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THE

SCIENCE AND AET

MIDWIFERY.

WILLIAM THOMPSON LUSK, A.M., M.D.,

FBomAom OF oBflrnenuos avd tiic disxaskb op women aivd childrkn ih ths bbllxvitb bobpital

MKDICAJL CX>LLW>B ; OOHBnXTIIfO PHTBICIAlf TO THS MATSBiriTT HOSPITAL ; TISITINO PHTBXOIAX

TO THB SMBBOBKCT BOflPITAL; OTHJMOL06IBT TO THB BBLLBVUB HOSPITAL; PBLLOW

OP THB AMBBIOAlf OTHJCOOLOOIOAL BOOZBTT; OOBBBSPOIfBTirO PBLLOW OP THB

OBtlRBXOAL BOCnETDBB OP BDCIBVBOH ABD LONDON ; BTO., BTC.

WITH NUMEROUS ILLUSTRATIONS.

This hook u theprop^rffj of
COOPER MEDICAL COLLEGE,

SAN fflAf40IS00. OAL.

and in wof to ht^ remold fi^^m the
Libr'f'tf fuK'.'i htf Oi'jt p'Tson or
fiudtr '/' .J .' ■ '-'' (•■"■uf^'rer.

NEW YORK:
D. APPLETON AND COMPANY,

1, 8, AND S BOND 8TBEET.
1884.

c6rTKI0HT BT

D. APPLETON AND COMPANY,

1881.

FORDYCE BARKER, M.D., LL.D.,

IN BSOOGXITION OF HIS EMINENCE

A8 A WBITEB, TEAOHKB, AND PHT8I0IAN,

AND IN OBATEFUL AGKNOWLEDOMBNT

HIS QBNEBOSITT TOWABD THE T0UN6EB MEMBEBS OF HIS PB0FES8I0N,

C^ §ook is $tbkaie)^,

WITH THE AFFECTIONATE BEOARD OF HIS FBIEND,

THE AUTHOR.

ITUs hook is the property oj
COOPER MEDICAL COLLEGEt

, SAN FRANOISCO. CAL.
aind \$ not Uf he mnor''d fn^m the

PREFACE.

In the preparation of this work, my purpose lias been to present
to the reader a fair statement of the changes which have been made
by modem investigation in the views entertained respecting the
physiology and pathology of pregnancy, labor, and childbed ; and
I have endeavored to show that with advancing knowledge the art
of midwifery has ceased to rest upon empirical rules, and is already,
with rare exceptions, the natural outcome of scientific principles.
To insure accuracy, I have spared no pains to subject the doctrines
taught to rigorous clinical tests ; and I have everywhere sought to
supplement and correct my own personal. experiences by tlie re-
corded observations of others.

Because of tlie strangeness of much of tlie new obstetrical litera-
ture, I have considered it desirable to make copious references to
recent authorities. At the same time, I hope that tliese references
may prove of service to such as desire to examine for themselves
original sources of information. If I have given special promi-
nence to the labors of German investigators, it has not been due to
a lack of appreciation of valuable contributions from other foreign
and home sources, but because, with large hospitals and with state
encouragement, the obstetrical writers of Germany have of late
years occupied a vantage-ground of which, to their credit, they
have been prompt to avail themselves.

To make room for the results of recent scientific investigation,
much of purely historical and controversial matter usually found in
obstetrical treatises has been omitted.

Ti PREFACE.

Special stresB has been laid upon the operations of midwifery
and the influence exerted by the more common varieties of con-
tracted pelvis in the production of anomalies pertaining to preg-
nancy and labor.

In reviewing the field of practice, I have not found it possible
to discover any natural line of division between obstetrics and gy-
nsBcology. No man merits the reputation of a good accoucheur
unless he possess a thorough appreciation not only of the immediate
dangers but of the far-reaching consequences of the faulty practice
of his art ; nor can his equipment be looked upon as otherwise than
defective unless it include an ability to repair surgical injuries at
the time of their occurrence.

In'submitting this work to the critical judgment of the medical
profession, it is my earnest hope that the principles which have
governed my own practice may prove a safe guide to others.

41 EaBT TmRTT-FOlTBTH STREET,

SepUmber, 188L

PREFACE TO THE SECOND EDITION.

The short time that has elapsed since the appearance of the
first edition of this work precludes any attempt at extensive
revision. I have, however, taken the opportunity afforded by
the call for a new impression to correct errors, to make a few
changes in the text and illustrations, and to enlarge the index.

Apra to, 1882.

ITus book is the property oj
COOPER MEDICAL COLLEGE,

SAN rRANClSCO. OAt.
onrf is not to W remo9^ from the
l/ibrary Ikutmi h^ o,kff person #r

tinder antf prdtxt wliuiever.

CONTENTS.

PH7SI0L00ICAL ANATOMY.

CHAPTER I. PAOT

Fkmalb Oboajts of Genkbation ...••. 1

The pudendum. — Labia majora. — Clitoris. — ^Labia minora. — Vestibule. — The bulbs
of the Testibule. — Meatus urethne. — Sebaceous glands. — Mucous glands. —
Vaginal orifice. — Hymen. — ^Vagina. — ^Vessels of yagina. — ^Uterus. — ^Fallopian
tubes. — Ovaries. — ^Vessels of uterus and its appendages. — ^Nerves of uterus. —
Lymphatics. — ^DeTelopment of the female organs of generation. — ^Arrests of
deyelopment

PHYSIOLOGY OF THE OVUM,

CHAPTER n.

Detelopment of the OvtTM . . . . . . .33

The Graafian follicles and the ovum. — Discharge of the ova from the ovary, and
the formation of the corpus luteum. — The migration of the ovum. — Fecun-
dation. — Changes taking place in the ovum subsequent to fecundation. —
Nourishment of the embiyo. — ^Thc allantoic and chorion. — The deciduaj. —
The placenta; its development and structure. — Formation of the umbilical
cord. — The amniotic fluid.

CHAPTER III.
Development of the Fcetus . . . . . . .59

Area germinativa. — Primitive trace. — Dorsal plates. — Tubus roedullaris. — Cerebral
vesicles. — Chorda dorsalis. — Vertebral plates. — Abdominal plates. — Central
plates. — Development of the bony skeleton. — Development of the intestine,
face, lungs, liver, pancreas, bladder, heart. — Development of footus in suc-
cessive months of pregnancy. — Foetus at term. — Fetal cranium. — The atti-
tude, position, and presentation of the foetus.

PHYSIOLOGY OF PREGNANCY.

CHAPTER IV.
Chakges effected in the Maternal Oboanism bt Pkeonanct . . 82

Changes in the sexual apparatus and neighboring organs. — Changes in the uterus.
— Explanation of apparent shortening of cervix. — Changes in the vagina,
vulva, abdomen, navel, breasts, nipple. — Functional disturbances of bladder.
— Constipation. — Gildcma. — Changes effected in the entire organism.

viii CONTENTS.

CHAPTER V. FAOK

The Diaokobis of Pbsonahoy . . • . . .95

Signs of pregnancy. — Sappresaion of menses.— Nausea. — Saliyation. — Breasts. —
Increase of abdomen.— Changes of the os and oernz. — Quickening. — Bal-
lottement. — ^Fetal heart-beat — ^Uterine bruit — Funic souffle. — Interrogation
of the patient. — Methods of physical examination. — Inspection of abdomen.
— ^Palpation. — ^Auscultation. — ^Tbe vaginal touch. — Distinction between first
and subsequent pregnancies. — Diagnosis of death of foetus. — ^Duration of
pregnancy. — Prediction of day of confinement from date of last menstrua-
tion. — Date of quickening. — Size of uterus.

PREGNANCY.

CHAPTER VI.

The yAKAOEMENT OF Pbbonanoy . . . . . .115

Hygiene of pregnancy. — The disorders of pregnancy. — The blood-changes of preg-
nancy. — Pernicious ansemia. — Hydnemic oedema. — Varicose yeins. — ^Nausea
and vomiting. — Heart-bum. — Insalivation. — ^Pruritus. — ^Face-ache. — Cephalal-
gia. — ^Insomnia.

LABOR.

CHAPTER VII.

The Physiolooy of Labob and its Clinical Phenomena . .122

Causes of labor. — Uterine contractions. — Action of labor-pains upon the uterine
walls. — Contraction of ligaments. — ^Action of abdominal muscles. — Action of
vagina. — ^The pain of labor. — General influence of labor-pains upon the or-
ganism. — Precursory symptoms of labor. — First, second, and third stages of
labor. — Duration. — ^Action of the expellent forces.

CHAPTER Vni.
Mechanism of Labob . . . . . . . .139

Anatomical factors. — ^Anatomy of pelvis. — Sacrum. — Coccyx. — Ossa innominata,
— The ilia. — ^The pubes. — The ischia. — Articulations of the pelvis. — Sacro-
iliac articulations. — Symphysis pubis. — The pelvic ligaments. — Obturator
membrane. — Sacro-sciatic ligaments. — Inclination of the pelvis. — ^The pelvis
as a whole. — ^The pelvic planes. — Plane of the brim. — Plane of the outlet —
Planes of the cavity. — Ischial planes. — Pelvic axis. — Differences between
male and female pelvis. — Differences between the infantile and adult pelvis.
— The soft parts of the pelvis. — The perineal floor. — ^The head of the foetus
at term. — Sutures and fontanelles. — The diameters of the fetal head. — Tlie
articulation of the head with the spinal column.

CHAPTER IX.
Mechanism of Labob. — {Continued.) . . . . .167

Presentations: natural, unnatural, normal. — Vertex presentations: frequency, po-
sitions. — Manner in which head enters pelvis. — Positions. — Normal mechanism
of labor. — Descent and flexion. — Rotation. — Extension. — External rotation.
— Expulsion of the trunk. — Abnormal mechanism (vertex presentations). —
Mechanism of occipito-posterior positions. — Configuration of the head in ver-
tcx presentations. — Molding. — Scalp-tumor. — Diagnosis of vertex presenta-
tions.

CHAPTER X.

Mechanism of Labor. — {Continued.) ..... 182

Face presentations. — Frequency. — Causes. — Mechanism. — Descent and extension.
— ^Rotation.— Flexion. — External Rotation. — Abnormal mechanism. — Configii-

CONTENTS. ix

FAQE

ration of head. — ^DiagnoBiB. — PrognosiB. — Treatment. — Brow presentations. —
Breech presentations. — Causes. — Diagnosis. — Mechanism. — Irregular mechan-
ism. — Configoration. — ^Prognosis. — Treatment.

CHAPTER XI.
Conduct of Nobmal La30b ....... 202

Preliminary preparations. — ^Examination of the patient. — Management of the first
stage.— Management of the second stage. — Preservation of the perimeum. —
Delivery of the shoulders. — Tying the cord. — Third or placental stage. — ^Care
of patient after delivery. — ^Treatment of perineal lacerations. — Anaesthetics
in midwifery.

CHAPTER XII.
Multiple Pbeonanoiss akd thbib Management . . . .221

Frequency. — Origin. — ^Varieties. — Acardia. — Weight. — Unequal development. —
Superfetation. — Diagnosis. — Labor. — Presentations. — Simultaneous entrance
of both diildren into the pelvis. — ^Locking. — ^Prognosis. — Conduct of labor.

THE PUERPERAL STATE.

CHAPTER Xin.
The Phtsioloot and Manaoement of Childbed .... 280
The puerperal state borders closely upon pathological conditions. — Post-partum
diilL — ^Temperature. — ^The pulse. — General functions. — ^Retention of urine.
— ^Loes of weight. — Involution. — Separation of the decidua. — Closure of the
sinuses. — The cervix. — ^The vagina. — Position of uterus. — After-pains. — ^The
lochia. — ^The secretion of milk. — Anatomical considerations. — Milk-fever. —
Composition of milk. — Diagnosis of the puerperal state. — The new-bom in-
fant. — Changes in circulation. — The navel. — ^Tumor upon the presenting part.
— Digestion. — Skin. — ^Icterus. — Loss of weight. — Management of puerperal
state. — Sleep. — Passing urine. — ^Visits of physician. — Washing the vagina. —
Diet. — Laxatives. — ^Nursing. — ^Duration of lying-in period. — Care of new-bom
infant. — ^Bath. — Cord. — Nursing. — Wet-nurses. — Artificial feeding.

THE PATHOLOGY OF PEEGXAXCY,

CHAPTER XIV.
Accidental Compucations. — Abnormalities of the Uterus . . 241)

Variola. — Rubeola. — Scarlatina. — Scarlatina puerperalia. — Cholera. — Typhus, ty-
phoid, and relapsing fever. — Malarial fever. — Icterus. — Cardiac diseases. —
Pneumonia. — Emphysema, chronic pleurisy, and empyema. — Phthisis. — Syphi-
lis. — Chorea. — Surgical operations during pregnancy. — Double uterus. — Ante-
version and antefiexion. — Retroversion. — Retroflexion. — Prolapse of uterus
and vagina. — Hernias.

CHAPTER XV.
Di.heases of the Decidua. — Diseases of the Ovum . . . 270

Endometritis decidua: 1. Chronica; 2. Tuberosa; 8. Catarrhalis. — Anomalies of
the placenta. — Anomalies of form ; of position ; of development ; of circula-
tion. — Placentitis. — Degenerations. — Syphilis. — Anomalies of the amnion and
of the amniotic fluid. — Hydramnion. — Deficiency of amniotic fluid. — Anoma-
lies of the umbilical cord ; torsion ; knots ; hernias ; coilinp; of the cord ;
cysts ; stenoses of vessels ; marginal implantations. — Ilydatidiform mole.

CHAPTER XVI.
The Premature Expulsion of the Ovum . . . . .291

Causes of abortion. — Disposition to abortion. — Immediate causes. — Symptoms. —
Moles. — Incomplete abortions. — Diagnosis. — Prognosis. — Treatment. — Pro-

X CONTENTS.

PAOS

phylazifl. — Arrest of threatened abortion. — Treatment of inevitable abortion.
— ^Treatment of neglected abortion. — ^RemoTal of fibrinous polypi — ^Treat-
ment of miscarriage.

CHAPTER XVII.

EZTSA-UTBBIKE PfiEONANOY ....... 809

Definition. — ^Tubal pregnancy. — ^Pr^nancy in rudimentary comu. — ^Interstitial
pregnancy. — ^Tubo^ibdominal and tubo-OTarian pregnancy. — Ovarian preg-
nancy. — Abdominal pregnancy. — Symptoms. — ^Terminations. — Diagnosis. —
Treatment, in cases of early ge8tation.---Cases of advanced gestation (foetus
living). — Cases of gestation prolonged after the death of the foetus.

OBSTETRIC SURGERY.

CHAPTER XVIII.

The Induotion of Pbematube Labor ..... 326

Induction of premature labor. — Indications. — Contracted pelvis. — Habitual death
of foetus. — Diseases which imperii the life of the mother. — Operation. —
Catheterisatio uteri. — Intra-uterine injections. — Rupture of membranes. —
Mechanical dilatation of cervix. — ^Vaginal douches. — Tampon.— Choice of
methods. — Care of the child. — ^Artificial abortion.

CHAPTER XIX.

Forceps ......... 384

History. — ^Varieties of forceps ; short forceps, long forceps. — Action of forceps.
— Indications. — ^Preparations. — ^Forceps at outlet. — Operation ; introduction ;
locking; tractions; removal. — ^Forceps at brim; operation. — Axis-traction
forceps. — Forceps in occipito-posterior positions ; in face presentations.

CHAPTER XX.
Extraction is Foot and Breech Presentations .... 354

Extraction in pelvic presentations. — Attitude of the physician. — ^Prognosis. — Posi-
tion. — Extraction of trunlc. — Extraction by the feet ; by the breech. — Man-
agement of the cord. — Liberation of the arms. — Exceptional cases. — Extrac-
tion of the head. — Smellie's method. — Veit*s method. — Head at brim. —
Prague method. — ^Forceps to the after-coming head,

CHAPTER XXL
Version ......... 866

Cephalic version. — External method. — Combined method. — Busch. — D'Outrepont.
— ^Wright. — ^Hohl. — Braxton Hicks. — Podalio version. — Bi-polar method. —
Internal veraion. — Neglected version. — Use of the fillet.

CHAPTER XXIL

Craniotomy and Embryotomy ...... 877

Craniotomy. — Indications. — Operation. — ^Perforators. — Method of perforating. —
Extraction after perforation. — Forceps. — Cephalotribe. — ^Action of the ceph-
alotribc. — Objections. — Application of the cephalotribe. — Cranioclast. —
Crotchet and blunt hook. — Cephalotomy. — Embryotomy. — Exenteration. —
Decapitation.

CHAPTER XXIIL
CiBSAREAN Section. — Operations of Thomas and Porro . . . 899

CaDsarean section. — History. — Indications. — Operation. — ^^Vftcr-treatment. — Prog-
nosis. — Operation of Porro. — Operation of Thomas.

CONTENTS. xi

THE PATHOLOGY OF LABOR.

CHAPTER XXIV. p^„

AXOMAUSS OF THB EXPELUCNT FOROBS . . . .419

PNdpitate labors. — ^Tardy labors. — ^Irregular pains in the first stage of labor. —
Treatment of protracted first stage. — Irregular pains in the second stage. —
Treatment of protracted second stage. — On the use of ergot in labor. — Ir-
regular pains in the third stage ; treatment — ^Painful labors : from hysteria ;
from riieamatism ; from intestixial irritation ; from inflammatory changes.

CHAPTER XXV.

CONTRAOTKD PeLYBS ........ 482

Varieties. — Frequency. — ^Dia^osis. — Pelvic measurements. — Forms of the con-
tracted pelvis. — Justo-mmor pelves. — Flattened non-rachitic pelves. — Rachitic
flattened pelves. — Generally contracted, flattened pelves. — Irregular forms.
— ^Pseudo-osteomalacia. — Scoliosis. — Kyphosis. — Influence of contracted pel-
res during pregnancy and labor. — Influence upon the uterus. — Influence upon
the presentation. — Influence upon the pains. — Influence upon the first stage
of labor. — Influence upon the mechanism of labor. — Effects of pressure upon
the maternal tissues. — Influence upon the fetal head. — ^Effects of pressure
upon the integuments ; upon the cranium. — Prognosis.

CHAPTER XXVI.
Trbatment op Contbaotkd Pelves ...... 460

Cases of extreme pelvic contraction, rendering delivery per vias naturales impos-
sible—Gases indicating craniotomy or premature labor. — Cases where ex-
traction of a living diild at terra is possible. — Premature labor. — Version.
— Forceps. — ^Expectant treatment.

CHAPTER XXVn.
Rabk Forms op Pklvio Distortion . . . . . .481

The Naegele oblique pelvis : morbid anatomy, etiolo^, diagnosis, mechanism of .
labor in, prognosis, treatment. — The icyphotic pelvis : morbid anatomy, etiol-
ogy, diagnosis, prognosis. — Scolio-rachitic pelvis: anatomical characters. —
Robert's pelvis: anatomy, etiology, diagnosis, prognosis. — Spondylolisthetic
pelvis: anatomical characters, diagnosis, prognosis. — Funnel-shaped pelvis.
— Osteomalacia. — Pelvis narrowed by exostoses. — Divided symphysis.

CHAPTER XXVIII.
Abnormalities op the Sexual Groans ..... 500
Atresia of the genital canal. — Vulvar atresia. — Vaginal atresia. — Cystocelc. — Rec-
tocele. — Retention of urine. — Impacted calculi. — Vaginal hernias. — Cystic
degeneration of the vaginal wall. — Vaginismus. — Echinococci. — Uterine atre-
sia. — Conglutinatio orificii extemi. — Cicatricial atresia. — Rigidity. — Throm-
bus of the cervix. — Symptoms of atresia. — Note on treatment. — Tumors. —
Fibroids. — Cancer. — Ovarian tumors.

CHAPTER XXIX.
Abnormalities of the F(etus which offer an Obstruction to Delivery, 513
Premature ossification of the cranium. — Hydrocephalus. — Encephalocele. — Hydro-
thorax. — Ascites. — Other causes of abdominal distention. — Tumors of the
trunk. — Monstrosities. — Double monsters. — Acardiaci. — ^Anencephalous mon-
sters. — Abnormal positions. — Spontaneous version. — Spontaneous evolution.

CHAPTER XXX.
Eclampsia ......... 526

Definition. — Clinical history. — Prognosis, pathology, and etiology. — Treatment.

xii CONTENTS.

CHAPTER XXXI. ,ao.

POBT-PARTUM H^MOBBHAOE AND RETAmBD PlAOENTA . . . 589

Normal agencies for checking hannorrha^. — Diatarbances of contractility, of re-
tractility, of thrombua formation. — Treatment — Method of securing contrac-
tion and retraction. — ^Treatment of cerebral ansemia. — ^Retained placenta.

CHAPTER XXXII.

Placenta Previa. — Accidental H^emobbhaoe. — Inysbsion of the

Utebus ......... 552

Situation. — ^Varieties. — ^Frequency. — Causes of hsemorrhage. — Clinical features. —
Prognosis. — Diagnosis. — Treatment — ^Accidental haemorrhage. — InTersion of
the uterus.

CHAPTER XXXIII.

RuPTUBES OF tue Genital Canal . . . . . .564

Rupture of the uterus. — ^Etiology. — Pathological anatomy. — Symptoms and diag-
nosis. — Treatment. — Prophylaxis. — ^Treatment after rupture. — Rupture lim-
ited to the peritoneal covering of the uterus. — Perforation from pressure. —
Laoerations of the vaginal portion. — Laceration of the vagina. — Laceration
of the vulva. — ^Thrombus of the vulva and vagina. — Rupture of the pelvic
articulations.

CHAPTER XXXIV.

Pbolapse of the Funis, etc, ...... 582

Prolapsed funis. — Asphyxia neonatorum. — Collapse and sudden death during labor
and childbed from thrombosis, from embolism, and from entrance of air into
the circulation.— On the extraction of the child in case of death of the
mother in pregnancy or labor. — Tympanites uteri.

DISEASES OF CHILDBED.
CHAPTER XXXV.

PUEBPERAL FeVEB ........ 602

Frequency. — Pathological anatomy. — Endocolpitis and endometritis. — Metritis and
parametritis. — ^Pelvic and diffused peritonitis. — Phlebitis and phlebo-throm-
bosis. — Nature of puerperal fever.— -Clinical history. — Symptoms of endome-
tritis and endocolpitis ; of parametritis and perimetritis ; of general perito-
nitis ; of septicaemia lymphatica ; of septicaemia venosa ; of pure septicaemia.

CHAPTER XXXVI.
PuEBPEBAL Feyeb. — {C<nitinued,) ...... 630

Causes. — The atmosphere. — Relations to zymotic diseases. — Season of year. — So-
cial state. — ^The prevention of puerperal fever. — ^The treatment of puerperal
fever. — ^Vaginal and uterine injections ; opium ; leeches ; laxatives ; quinine ;
salicylate of sodium ; veratrum viride ; digitalis ; alcohol ; cold. — Treatment
of pelvic exudations.

CHAPTER XXXVII.

PrERPEBAL Insanity.— Phlegmasia Alba Dolens. — Diseases of the

Bbeabts ......... 652

The insanity of pregnancy, of childbed, of lactation. — Phletj^asia alba dolens. —
Defective milk secretion. — Galactorrhoea, — Sore nipples. — Subcutaneous in-
flammation of the breast. — Submammary abscess. — rarcnchymatous mastitis.
— Galactocele.

LIST OF ILLUSTRATIONS.

nawM PAoa

1. The external parts of generation (the thighs are separated so as to place the

parts upon the stretch). (Losehka.) 2

2. Lateral Tiew of the erectile structures of the external organs of the female (from

Kobelt), two thirds ^ 3

3. Front view of the erectile structures of the external organs of the female.

(Kobelt.)

4. Section through the female pelris. (Kohlrausch modified by Spicgelberg.) 8

6. The Tagina (exposed in its entire length by the remoYal of the posterior wall).

(Denle.) 9

6. Complete genital organs of the female. (Bcigel.). ^ . 10

1, Virgin uterus. (Sappey.) 12

8. Virgin uterus opened posteriorly. (BandL) 13

9. Uterus of a woman who has borne children. (Bandl.) 14

10. SecdoQ through the mucous membrane of a normal virgin uterus, magnified about

forty diameters. (Kundrat and Engclmann.) ^ 17

11. Section through uterus showing cavity. (Weber.) 17

12. Posterior lateral view of the uterus, with portion of lig. latum, oviduct, and ovary.

(Henle.). 18

18. Section through Fallopian tube 19

14. Section through ampulla (thirty diameters). (Luschka.) 20

15. Longitudinal section of ovary from a person aged eighteen (eight diameters).

(Henle.) 21

16. Arterial vessels in a uterus ten days after delivery. (Luschka.) 22

17. Uterine and utero-ovarian veins (plexus pampiniformis). (Sappey.) 24

18. Nerves of the uterus. (Frankenhaeuser.) 26

19. Rudimentary sexual oigans. (Luschka.) 28

20. Uterus and its appendages in the foetus at the end of the fourth month (natural

size). (Courty.) 29

21. Uterus unicornis from a young child, posterior aspect. (Pole.) 20

22^ Double uterus and vagina from a girl aged nineteen. (Eisenmann.) 80

28. Uterus bicomls, double cavity and double vagina, from a girl seventeen years of

a[ge. (CJourty.) 31

^4. Uterus oordiformis, double natural size. (KiLssmaul.) Gl

25. Uterus septus bilocularis. (Cruveilhier.) 82

26. Section of Wolffian body, with rudimentary ovary (embryo of chick, fourth day

of incubation). (Waldeyer.) 3S

27. Vertical section of an ovary of a human foetus thirty-two weeks old. (Waldeyer.) 3 i

28. Portion of vertical section through ovary of bitch. (Waldeyer.) 85

29. Ovum from a Graafian follicle m the rabbit (Waldeyer.) 36

xiv LIST OF ILLUSTRATIONS.

riaim paob

80. Spermatozoa from the human subject (magnified eight hundred diameters).

(Luschka.) 41

31. OTum of the nephelis Yulgaris, showing retraction of Titellus and the penetration

of the spermatozoa through the vitelline membrane (magnified three hundred

diameters). (Robin.) 42

32. Segmentation of the ovum. (HaeckeL) 48

S3. Blastodermic vesicle from the uterus of the rabbit (Bischoff.) 44

34. Section through area germinativa in the egg of a rabbit, showing the thickening

of the ectoderm (ect.) at that point, as contrasted with the ectoderm of the

blastodermic vesicle beyond the area germinativa (v^.). (Eolliker.) 45

35. Area germinativa, from the ovum of a rabbit, enlarged about ten diameters.

(Haeckel.) 45

36. Transverse section of egg in early stage of development. (Dalton.) 46

87. Transverse section through the embryo of the chick a few hours after the com-

mencement of incubation 46

88. Transvei*se section through the embryo of a chick at the end of the first day of

incubation (magnified twenty diameters) 47

39. Transverse section through the embryo of a chick on the second day of incuba-

tion (magnified one hundred diameters) 47

40. Section through the ovum of chick after development of umbilical vesicle 48

41. Diagram showing early stage in development of amnion 49

42. Diagram showing completion of the amnion and formation of the chorion 49

43. Human embryo, at the third week, showing villi covering the entire chorion.

(Haeckel.) ", 50

44. Formation of permanent chorion 50

45. Human embryos, at the ninth and the twelfth week. (Erdl.) Facing 50

46. Formation of decidua, first stage 51

47. Formation of dccidua, completed 52

48. Diagram showing the branching of the villi and the connection of the larger

trunks with the placenta. (Langhans.) 54

49. Diagram of uterus and placenta in the fifth month. (Leopold.). 56

50. Area germinativa, from the ovum of a rabbit (enlarged about ten diameters).

(Haeckel.) 59

51. Development of the nervous system of the chick. (Longet.) 60

52. Development of spinal cord and brain of human subject (Longet.) 60

53. Transverse section through the embryo of a chick at the end of the first day of

incubation (magnified twenty diameters) 61

54. Human embryo between the twenty-fifth ind twenty-eighth days, showing the

visceral arches. (Coste.) 68

55. Mouth of embryo of thirty-five days. (Ck>ste.) 64

56. Mouth of embryo of forty days. (Coste.) 64

57. Development of the lungs. (Longet) 65

58. Heart of embryo chick in the earliest stages of formation. (Remak.) 66

59. Diagram of heart and first arterial vessels. (Quain.) 67

60. Area vasculosa. (Bischoff.) 68

61. Diagram of the vascular arches, with transformations giving rise to the perma-

nent arterial vessels. (Rathke.) 69

62. Diagram of the fetal circulation. (Flint.) 71

63. Fetal head, side-view. (Hodge.) 77

64. Fetal head, viewed from above. (Hodge.) 77

66. Attitude of foetus in uiero. (Tamier et Chantreuil.) 78

66. Appearance of vaginal portion in primipara ; end of ninth month. (Taylor.). . . 87

67. Appearance of cervix in multipara ; ninth month. (Taylor.) 88

LIST OF ILLUSTRATIONS. xy

fWVSB PAOB

68. Showing the ocmTexity of the anterior wall produced by the weight of the ovum. 89

69. Diagram representing changes in the cerrix resulting from pressure of child's

head on anterior waU. (Lott.) 90

70. Diagram from computing pregnancy. (Schultze.) 112

71. Scfaoltae diagram 113

72. The mucous membrane of the uterus. (Engelmann.). 124

78. Transverse section, dotted line representing shape of uterus during a pain.

(Lahs.) 127

74. Lcmgitudinal section, dotted line representing elcTation of fundus during a

pain. (Lahs.) [ 127

76. Diagram representing the changes in the thickness of the uterine walls during

Ubor. (Lahs.) 128

76. Section through a frozen corpse. Stage of expulsion. (Braune.) 181

77. The uterus and parturient canal. Foetus removed. (Braune.) 182

78. Longitudinal section through walls of uterus in eighth month of pregnancy.

(Bandl.) 186

79. Sacrum and coccyx (anterior surface) 140

80. Section of sacrum and coccyx 141

81. Os innominatum, before consolidation. (Luscbka.) 141

82. Outer surface of os innominatum 142

83. Inner surface of os innominatum ... 143

84. Section through the left sacro-iliac articulation (natural size). (Luschka.). . . 144

85. Section of symphysis. (Luschka.) 144

86. Front view of pelyis, with ligaments. (Quain.) 145

87. Transverse section through pelvis, to show the sacro-sciatic ligaments. (Tar-

nier et Chantreuil.) 146

88. Section showing the inclination of the pelvis according to Naegele. (Tamier

et Chantreuil) 146

89. Diagram showing oscillatory movements of sacrum. (Duncan.) 148

90. Anterior half of the pelvis 148

91. Posterior half of the pelvis 149

92. Diameters at brim. (Martin.) 160

93. Diameters at outlet. (Martin.) 160

94. Section showing the inclination of the pelvis according to Naegele. (Tamier

et Chantreuil.) 161

95. Axis represented upon a vertical section through a plaster cast of the pelvic

cavity. (Hodge.) 1 62

96. Vertical section of a female infantile pelvis. (Fehling.) 163

97. 98. Diagrammatic representations of sections through the infantile and adult

pelves. (Schroeder.) 154

99. Pelvis covered with the soft parts, with removal of bladder, uterus, and rectum 166

100. Section of pelvis, showing the pyramidal muscles. (Tamier et Chantreuil.). . 167

101. Section of pelvis, showing the intemal obturator muscle. (Tarnier et Chan-

treuil.) 168

102. Muscles of the perineal floor, as seen from the abdominal cavity 168

103. Antero-posterior section of the perineal floor. (Tamier et Chantreuil.) 169

104. Muscles of the perinaeum. (Henle.) 161

105. The parturient canal. (Hodge.) 162

106. Lateral view of fetal skull. (Hodge.) 168

107. Fetal head, as seen from above. (Hodge.) 163

108. Antero-posterior and vertical diameters of the fetal head. (Tamier ct Chan-

treuil.), 166

109. Diagram showing transverse diameters of fetal head. (Tamier et Chantreuil.) 165

xyi LIST OF ILLUSTRATIONS.

rravBi PAoa

10. Figare iUuBtrating the mechanism of labor in oodpito-antcrior deliveries.

(After Schultae.) 110

11. Vertex presentation; child surrounded by amniotic fluid. (Tamier et Chan-

treuU.) 171

12. Attitude of fcetns. (Bibemont.) 116

18. Figure illustrating Uie mechanism of labor in ocdpito-posterior positions.

(After SchultM.) i 178

14. Outlines showing diiferencc between head of child at birth and four days sub-

sequent to delivery. (Budin.) 179

15. Figure showing shape of head in occipito-posterior doliTcries. (Tamier et

Chantreuil.) 180

16. Method of performing external palpation. (Tamier et Chantreuil.) 181

17. Attitude of the head in face presentations. (Rib^mont.) 185

18. Engagement of the head in face presentations. (Tamier et Chantreuil.) 186

19. Mechanism of face presentations. (Schultze.) 187

20. Face presentation, chin to the rear. (Hodge.) 187

21. Outline of head bom with face presenting. 1£8

22. Same head five days later. (Budin.) 188

28-1 25. Diagrams showing Schatz's method of conyerting face presentations into

vertex presentations 191

26. Outline of head after delivery, the brow presenting. (Budin.) 192

27. Brow presentation, subsequently converted into that of the face. (Maternity

Hospital.) 198

28. Presentation of the breech. Left dorso-anterior position. (Tamier et Chan-

treuil.) 196

29. Illustration showing lateral inflexion of the trunk during delivery of the breech 198

80. Showing shape of head in breech presentations. (Budin.) 200

81. Showing the effect of premature tractions upon the cord. (Schultze.). .:.... 216

82. Showing normal position of plaoenta. (Duncan.) 217

33. Author's case of acardia 222

84. Twin pregnancy, both heads presenting. (Tamier et Chantreuil.) 226

85. Twin pregnancy, head and breech presenting. (Tamier et Chantreuil.) 227

36. Mammary gland. (Liegeois.) 288

37. Section through acinus from breast of a nursing woman. (Billroth.) 289

88. Knot of umbilical cord. (Leyman.) 280

39. Insertio velamentosa. (Lobstein.) 282

40. Hydatidif orm mole 284

41. Ovum, with imperfectly developed decidua ; outer surface of vera. (Duncan.) 293

42. Uterus, with basis of a fibrinous polypus after an abortion. (Frankcl.) 297

43. Tubal pregnancy. (N. Sommer.) 811

44. Pregnancy in mdimentary comu. (Kiissmaul, observed by Heyfelder.) 812

46. Interstitial pregnancy. (Hennig.) 813

46. Bifurcation of tubal canaL (Hennig.) 814

47. Forceps of Chamberlen 336

48. Forceps of Smellie 336

49. Levret's forceps 337

60. Naegelc's forceps 338

51. Simpson's forceps. 388

62. Hodge's forceps 889

63. Introduction of blades 343

64. Blade adjusted to the head at outlet 344

66. Method of making tractions 846

66. Position of operator when head is on perineeum 347

LIST OF ILLUSTRATIONS. xvii

wKumm PAo>

157. Forceps ^plied to head at brim »49

158. Taylor^s narrow-bladed forceps 350

159. Author's modification of Tamier's forceps 302

160. Taylor's method in mento-posterior positions of the face 864

161. Method of seidng both feet. (Scanzoni.) 367

162. Method of seizing the breech. (Scanzoni.) 358

163. Combined traction upon mouth and shoulders. (Chailly-Honor6.) 363

164. The method of extracting the trunk 864

165. The Prague method of extracting head. (Scanzoni.) 365

166. Chin arrested at symphysis. (CIiailly-Honor6.) 865

167. D'OutreponVs method, modified by Scanzoni 868

168. Version in head presentations. (Chailly-Honor6.) 372

169. 170. Version in transyerse presentations ; direct method of seizing feet. (Braun.) 373

171. Method of reacliing an extremity by first passing the hand around the breech.

(Scanzoni) 874

172. Brann's repositor 375

173. Catheter used as repositor. 876

174. Scissors of Smellie 878

175. Simpson's perforator 879

176. Blot's perforator 879

177. Hodge's craniotomy scissors 879

178. Thomas's perforator 379

1 79. Trephine perforator 380

180. Operation for perforating the child's head 881

181. Cephalotribe of Blot 884

182. Cephalotribe of Scanzoni : 385

188. The author's cephalotribe 386

184. Simpson's cranioclast 889

185. Braun's craniocUst. 390

186. Head of child after delivery with the cranioclast. (Simpson.) 800

187. Meigs's craniotomy -forceps (modified by Professor I. E. Taylor) 892

1 88. Crotchet 893

189. Dr. Taylor's right-angled blunt hook 893

190. Segment removed by the Tamier forceps-saw. (P. Thomas ) 894

191. Braun's decapitating hook 896

192. Braun's method of decapitation 396

193. Embryotome of P. Thomas 397

194. Embryotome adjusted around the neck of the child 398

195. Method of extracting foetus in the Caesarean operation. (Stoltz.) 403

196. Baudelocquc's pelvimeter 434

197. Schultze's pelvimeter 435

198. Normal inclination of the symphysis pubis. (Spiegelberg.) 437

199. Diminution of angle between symphysis and pelvic brim 437

200. Increase of angle between symphysis and pelvic brim 437

201. Specimens from the Wood Museum (Bellevue Hospital) 410

202. Flattened rachitic pelvis. (Wood's Museum.) 442

203. Small symmetrical rachitic pelvis. (Wood's Museum.) 44ft

204. Pseudo-osteomalacia. (Naegele.) 445

205. Scoliosis. (Litzmann.) 446

206. Pressure-mark upon skull. (Dohm.) 457

207. BsLne of skull 471

208. Method of employing supra-pubic pressure. Head in the pelvic cavity. (Mundc. ) 472

209. Naegele oblique pelvis. (From specimen in the Wood Museum.) 481

xviii LffiT OF ILLUSTRATIONa

210. Specimen of kyphotic pelyifl. (Litzmazm.) 486

211. Specimen of scoUo-radiitic pelvis. (Litzmann.). 488

212. Robert's pelyis. (LambL) 490

213. Spondylolisthetic pelvis. (Kilian.) 491

214. Osteomalacia. (Specimen from Wood's Museum.) 495

216. Osseous tumors filling pelvic cavity. (Naegele.). 498

216. Author's case of acardia 620

217. Birth with doubled body. (Chiara.) 624

it 18. Neglected shoulder presentation. Section through frozen corpse. (Kleinwilchter.) 626

219. Diagrams representing relaxed and contracted uterus. (Breisky.) 640

220. Bimanual compression of uterus. (Breisky.) 644

221. Diagram showing the unavoidable placental separation as a consequence of cer-

vical diUUtion. 654

222. Diagram showing dangerous thinning of the lower segment, owing to the non-

descent of the head in contracted pelvis. (Bandl.) 666

228. Case of ruptured uterus (anterior surface) 667

224. Retraction in a case of shoulder presentation. (Bandl.). 671

226. Roberton's repositor 687

226. Specimens of micrococci. (Dol^ris.) 618

TliU book w the propei tj .;^

COOPER MEDICAL COLLEGEt

SAN FHANCISOO. CAL.

and M vof ht /*#* r^mor^d from the
Libvirr.f /; , /*#/<? 1/ person or

finder ^: ' t --j-.t ^ ,'»ui'rrer

THE

SCIENCE AND ART OF MIDWIFERY.

PHYSIOLOGICAL AIS-ATOMY.

CHAPTER I.

FEMALE ORG AM OF GENERATION.

^Tbd poden^m. — Lnbia majora. — Clltorit. — ^Labb mtnora. — Vestibule.— The bulbfl of
the TCfltibule,— Hofttufl ur«thr£B. — Sebaceous glnnds.^ — Mucoui gliiads, —Vaginal ori-
fice — Hjroen, — Vagina, — Ve»8cte of ragintt, — Uterus.— Fallopian tybes.— Ovaries.
— Veaseli of ut^rua and lu appendages. — Ncrvea of uterus. — Ljmpbatica. — Devel-
opment of tbc femivle organf of generation. — ^Arresta of development,

TffE female organs of generation may be properly divided as fol-
llows: 1, The external parts, or pudetidum, and the vagina^ 2. The
I uterus^ Fallopian tubest and ovaries.

The external parts and vagina are chiefly concerned in the act of
Icoptilatiou, As they likewise constitute the channel tkrough which
I the child passes during parturition, a knowledge of their anatomieul
Ifftmcture becomes of importance to those who would practice the ob-
fstetric branch of medicine.

The internal organs, i. e., the uterus. Fallopian tubes, and ovaries,
loume obstetrical importance in connection with the parts they play
in goitation. Thus, the ovary furnishes the germ from which the
new being is developed. The Fallopian tube receives the germ, and
COHTejra it to the uterus. In the uterus, the fecundated germ ob-
^taiufi the nutritive materials necessary for its subsequent growth and
^Telopment.

L Tub Extcekal Parts of Gekeratiok and Vagina,

Tha Pudendum, — ^The pudendum comprises all those parts which
are perceptibUf externally. It includes the mons Veneris, the labia,
f clitoris, the nymphae^ and the hymen. It is situated at the lower

PBYSIOLOGICAL ANATOMY.

opening of the pelvis, and has a wedge-shape, whence the term am-
nus, i. e», emi^ua. Its base ia formed by the mons Vemris, a fatty J
cushion, abundimtly supplied witli hair, which covers the eymphysis 1
pubis. As it follows the curvature of the lower portion of the tmnk,
iti extreme inclination of the pelvis it is sometimes direct-ed so far
biickward aa to render difficult the introduction of the speculum and
the accompliiibment of the sexual act. It is divided in the median
line by the rima pudendi, which extends from the mons Veneris to the
periijieum. Upon etich side of tlio rima there are two longitudinali
slightly curved, and rounded folds of integument, which rest upon
cushions of adipose areolar tissue* These folds constitute the so-called

Fia; 1.— The external partfl of ireneratlon (the thtirh« are »cpanitec1 no ab to p!ac« the pATti j
upon the sitrrtch). 1, Ifthia mnjcirft; 2^ ^huis elitoridl^; 3, 3^ Oio nymphie; 4, pm'pntunaj

gljinds of Duvcrouy \ 9, tubcrculum voginiL^ ; 10, meutuii urethrse. (Luiidikii.J

labia majora, which, like the mons Veneris, are covered, though to a
less extent* with hair. In healthy young women they are firm and
full, while in deteriorated constitutions, and in advanced life, tbey
become wrinkled and pendulous, from diminution of the adipose
tissue.

The labia majora act as a sort of valve, which closes the orifice of
the vagina, whence the term vulva — i. e., valva, the folding-door of
the ancients. When the labia are full and well rounded, they are ap-
proximated closely together, and form the tmlva connivens. With the

FEMALE ORGANS OF GENERATION.

as of adipose tissue, a gaping of the flaccid labia ensues^ and forms
the vulva hiajtM,

The labiti offer an external and internal Burfacc, The outer sur-
l&oe presents the usual characteristics of tegumentary tissue, and is
t abundantly supplied with large sebaceous glands. The inner surfaoe
is in all respects like a nuicous membrane, except that it possesses
sebaceous glands in place of mucous follicles. The subcutaneous tia-
ene is composed of connective tissue, rich in elastic elements, and con-
taining fatty lobules continuous witli the underlying adipose struct-
ure» It furnishes support to an abundant venous plexus, to which
the turgescenee of the labia in pruritu^ and under sexual excitement,
is mainly due. The existence of conti*actiIe elements has never been
demonstrated.

The two extremities of the vulva have been designated, respec-
tively, the anterior and posterior commisaures of the labia ; but these
terms, so far as they convey tlie idea
of connecting bands between the la-
bia^ are incorrect* for Luschka*ha3
shown that the labia are directly eon*
tinuous with the mons Veneris in
front and the perinieum behind.

The f.lHoris is a small, elongated
body, situated just beneath the so-
eaned anterior commissure. It re-
sembles the penis in form and struct-
ure, but differs in possessing neither
corpus gpoDgiosum nor urethra. The
clitoris is divided into the crura, the
corpus, and the glans. The crura
ize long, spindle-shaped processes, at-
tached to the borders of the ascend-
ing rami of the ischia and the de-
scending rami of the pubis. The cor-
pu$ is formed by the junction of the
crum in the median line, just beneath
the pubic arch. Even in a state of
extreme erection, it does not normally
exceed an inch in length. Hhc glans
is the rounded, imperforate extremity,
dim

Fio, 2

T.nttm) vicn'of the erectile struct-

I tml oroniLs of tliti fo-

it). two thinU. Tho

■ -V' been iiijwted^ ttiid

the? skiij uud tuiKt^un mcmDmnc' hnTD

>XH*n roinnved, a, biiilbua vestlbuli ;

r ' - f vein*^, nnnnxl tho para in-

, g'^i'"^ L'litondU;y^ eor-

1 i:^ ; A, dor?iftl vt in ; /, right

crUH ditoiulii*; m^ vcisti buhim ; n,

right gl&Dd of BurthoUn or Duveniey.

During erection it attains the
n pea. The cutieular covering of the glans is of
ap<. i is covered with papillfe, part of which contain

Teiaelji, and part, nerve-endings similar to those found in the nipple,
and termed by Krause ** terminal bulbs'* {EmUKolbm), The nerves

^ LvscHSAf ^* D!« Aastomie des fnenschlichcn Bcckeiu,^* p. 407.

PHYSIOLOGICAL ANATOMY.

of the clitoris are more fully developed than the corresponding neiTes
in the penis. The clitoris is regttrded iis the seat of the yoluptuous
Bensations experienced by the female during copulation.

The labia minora are two nurrow, reddiuh, moist folds of mucous
membrane, situated between the labia majora, with which they are
coutinuuiis by their outer surface* The inner surface is continuous
with the mucous membrane of the vestibulum. They are, sometimes,
termed likewise the nymphm, Nymphw vocanfur vcl quod i^int mslU
iatis prcBsideSy vel quod sponsum primo inter mitiant^ vel quod aquis
prosiKentibus prwHini (Plazzonus),* or, as Sir Charles Bell words it
in his ** Anatomy/' *'The most modest of the uses ascribed to them
16 that of directing the stream of urine,*' When the rima pudendi is
narrow, as in virgins, the labia minora are concealed and protected by
the labia majora. In the vulva hians, the labia minora acquire, from
exposure to the atmosphere, a dirty-bluish color, and take on the prop-
erties of the cutis. In Hottentot and Bushman women, they some-
times reach the length of eight inches, and constitute the so-called
'* Hottentot apron.'*

Each labium minus splits anteriorly into two folds, of which the
outer joins the corresponding one of the opposite side to form a cover
for the clitoris, the prmpuHum cUioridis, The lower folds converge
to meet bene-ath the lower border of the glans cHtoridis, and form the
frenulum of the clitoris. This attachment serves to bring the clitoris
forward into contact with the penis, as the labia minora are pressed
inward during copulation.

The labia minora meet posteriorly, in most instances, and form a
thin circular band, thefrefiulum vulvm or fourchetie. The fourchette
has usually been regarded as the posterior commissure of the labia
majora, but this view Lusehka has shown to be incorrect* f

The veaiibuium is the angular space bounded by the labia minora
and the vaginal orifice.

The Ifulbi vesdhuli vagincBy the bulbs of the vaginal vestibule, are
two curved, leech-shaped masses of reticulated veins, situated between
the vestibulum and pubic arch of each side. Eobelt has shown that
they correspond to the two separated halves of the male bulbus ure-
thrsB- They are composed of erectile tissue, and measure, when dis-
tended with blood, a little over an ioeli in length. As the head of the
child passes through the vulva during parturition, these bodies are
pushed for^'ard to prevent their being compressed between the head
and the pubic arch. Still, rupture does sometimes occur, and then
the hEemorrhage leads to the formation of thrombus of the labia ma-
jora. The upper ends of the vaginal bulbs are rather pointed, and
communicate, by means of a small plexus, the pars intermedia of

* Lt'soncA, ** Die Aimtocme dea menschliclien BeckeES," Tubingen, 1 864, p, 40S.
f Uid., p. 404.

FEMALE ORGANS OF GEXERATIOX,

Kobelt, with the vessela of the glana clitoridis. Through this connec-
tion the blood is pressed^ during venereal excitement, by the reflex

Fie, •.— Fromt Tiew of iha emotilo irtruetiires of tlit* extomal oTjrariB of the fi>iTtii1o (Kobftlt).

^ ' '' " " = l: r, clitorw; D^ L'limil of the clitoris; E, bulbj F^ c^tnsirictor

: ]»ilbir nf the chtwris ; H, dorwil vein of the olitonn ; I^ int<iir-

M, lublik mii:ui~^.

.omiDunicuiion with the ubtumtor vein; K, obturutor vein ;

contractiona of tlie moscnlus constrictor cunni, from the turgid
bulbs into the glans of the clitoris.

Tbe meatm urtfhrm is Bitnated in tlie median line, at the lower
jiortion of the vestibular space, about three quarters of an inch from
the glatifl of the clitoris. It is surrounded by a ring of muscular libers,
which keep it closed under ordinary circumstances. These fibers cause
m pnckering of the mucous membrane, which is easily recognized by
the experienced finger, and serves as a guide for the Introduction of
the cathuter,

Sehacrous ghmth are found in great abundance in tlie tissues of
tbe nrmphae, wliere they furnish a fatty, yellowish-white niaterial,
poisetting a peculiar odor. This material, when accumulated beneath
tbo prepueo of the clitoris, constitutes the smegma prwpuiiiy so com-
mon in women who neglect the niceties of the toilet

The mueaus glaufh of the v\ilva are divided into the glandulaa ves-
tibnlares majores and the glandulre vestibulares minores.

The glandnlcB vestibulares minores are from five to seven in num-
ber, and are irregularly distributed in the neighborhood of the meatns
urethme. They are of the compound racemose variety, of about the
gi^e of pi^ppy-seed, and poss^ess short, wide ducts with large orifices,
Tyler Smith says that one of these lacunae may be enhirged suf-
ficiently to admit a small-sized catheter, leading the operator to

PHYSIOLOGICAL ANATOMY.

suppose that he has reached the bladder, while the instrument is really
in a cul-de-sac,*

The glandulm vestibularcs vmjores were first diseovered in the
human aubjeet by Bartholin, and bear Bometimea his name and some-
times that of Duverney. They arc two in number, of the size of a
pea, and of a reddish-yellow color. They are situated behind the pos-
terior extremities of the bulbi vcstibuh', which, however, they partially
overlap. They are of the compouTid racemose variety, and their acini
open into a duet a little over a half-inch in length, wide at its begin-
ning, but which narrows toward its orifice. The duct takes an oblique
course along the inner side of the vaginal bulbs, and tern^inates in
front of the hymen, at the angle which the hymen or its remains (the
canmculfe rayrtiformes) makes with the walls of the ve,stibule. The
glands of Bartholin secrete a yellowish, adhesive fluid, which is poured
out freely during coitus, and preparatory to the passage of the child
at the time of labor. This secretion, by rendering the parts moist
and slippery, serves to protect the mucous surfaces from mechanical
injury. An abundant secretion may likewise be caused by erotic
dreams, or, in fact, by any form of sexual excitement. They are
more developvd in young persons than in those of middle life, and in
old age they seem in some cases to disappear altogether.

Tlie orificium vaginw is bounded by the labia minora and the ves-
tibule. It differs greatly, both as to size and appearance, in young
children, m virgins, in women accustomed to sexual intercourse, and
in those who have borne children.

In virgins, the vaginal orifice is partially closed by a thin fold of
mucous membrane, termed the hymen. This fold has usually a
cresccntic diajie, with its concave border looking toward the urethral
orifice, so that a small opening is left anteriorly for the escape of the
menstrual fluid. There are, however, a number of other less common
varieties, of which the following ai-e the most important: 1. The
livmeu annularis, with a small central opening. 2. The li}Tnen cribri-
formis, with a number of small openings. 3. The hymen imperfora-
tus^ which completely occludes the vagina, and occasions retention of
the menses. 4. The hymen fimbriatus, from its resemblance to the
fringed extremity of a Fallopian tube. This variety possesses med-
ico-legal importance, from the possibility of its being mistaken for a
normal ruptured hymen.

The thin tissues which constitute the hymen are usually lacerated

by the first complete coitus. Laceration, however, is not, in all cases,

the necessary result of sexual intercourse. There is a young girh

aeteen years of ago, now under treatment for amenorrha'a in the

■^terine ward^ of the Bellevuo Hospital, who possesses a perfect hymen,

the opening of which is of the ordinary size, yet so distensible is its

♦ W. Ttlkr Suim, ** Manual of Obstetrics,*^ p. %%.

FEMALE ORGANS OF GENERATIO.V.

tiasae that a medium-sized (one inch) Fergusaon speculnra has been
repeatedly introduced, for purposes of explorntiun, without in tlie
slightest degree affecting its integrity. Hy rtl mentions a specimen of
the female genitalia preserved in Meckera museum, at Halle, where
the hymen is perfect, though the woman had given birth to a seven-
montlis child,*

We are indebted to Schroedcr for having pointed out that the fleshy
eminences, known as the caruneul® myrtiformes, are the result of
child-bearing, and not, in the rule at least, of sexual intercouree.
Coitus simply causes a solution in the continuity, at one or more
points, of the free border of the hymen. The pressure of the child's
bead, however, during labor causes necrosis and sloughing of the
heretofore persistent though lacerated hymen, of which, sulxsequently,
the familiar, isolated elevations of mucous tissue about tlie vaginal
orifice furnish the only visible traces, f My own experience is entirely
eonfirmatory upon this point. In the examination of young nullipa-
roos prostitutes, who enter the Bellc^Tie Hospital for uterine dit^orders,
I have always found a torn hymen, but, in no cajse, carunculae myrti-
fonnes.

The Vagina.— The vagina is a membranous canal, connecting the
nterus with the external parts of generation. It runs in an oblifiue
direction fonvard from it;s attachment at the cervix to its orifice at the
Tttlva. When not artificially dilated, its anterior and posterior walls
are in contact with each other. The lengtli of the vagina, owing to its
extiaordinary distensibility, is usually greatly over-estimated. Admit-
ting considerable variations, dependent upon weight, position, etc., of
the ut^ms, two and a half inclies for the anterior, and a little over
three inchea for the i^osterior wall may be accepted as fair avenige
meaaarements. J The vagina is placed between the ix^ctum and blatlder,
and U more or less intimately connected witb both those organs. In
its tipper fifth, the vagina is separated from the rectum by the cul-de-
nor of Douglas, From thence downward, the rectum and vagina form
a common partition, the septum recto-vaginale. Above the pelvic
floor, a layer of connective tissue continuous with the pelvic fascia
QDites the rectum and vagina together. Below the pelvic floor the
t3ni€>n of the two organs is immediate. Luschka limits the term
am recto-vaginale " to this lower half of iho common wall.**

1 ae upper half of the anterior vaginal wall is attached to the blad-
der by means of loose connective tissue, while the lower half is insepa-
mblc from the tissues about the urethra. The partition thus formed
bctwcH^-n the nrethra and vagina is termed the septum urethro'Vaginule.

■ Utetl, " Htndbucb der lopogxaphJ^chen Anatomie," Wlcn, 6te Auflagc, Bd. ii,
f Scaxoi^ta, ** Schwingenchaft, Gebiirt, und Wocbcnbctt," Bonn, i6*i7, p. 6.
i LcUdfiUk, ** DiQ Anfttouiic dcB meDnch lichen BcckenA,'* Tiibingcn^ 1864, p. 888.

p. 161

PnrSIOLOGICAL ANATOMY.

The fornix^ as the upper part of the vagina is termed, eBcimlea
the vaginal portion of the cervix in such a way as to extend at least
twice as high upon it^ posterior as upon its anterior aspect. The
vaginal walls, when not distended artificially, are directly applied
to the vaginal portion of the cervix.

vfVr:

H^iv'^i

V.t.^

;igi'^

[<^/i

'^S?t^j

'J^U

hf--

•^i

-^^

Fro. 4. ^Section thrcmph the feirado pel via. 1, rectum ; % ntcrus : 8^ cxcaTntio Tccto-ote-
nnft K'u!-ciif-«ftc ot'Douplas^- 4, cxcavatio vesico-utcrina ; 6, bladder; GjClttom; T, ttfe*
thru ; b| symphyab) ; 9, sphincter anl ; 10, vagiuii. (KoMrauach modified by S|*ici|]pl-
borg.)

The structure of the vaginal walla ia not identical in all parts of the
canal In thenpper portion the internal snrface ia nearly smooth, and
the walls measure from a half a line to a line in thickness. They are
composed of a mncons membrane, a muscular coat, and an external
connective-tissue sheath, or kiyer. The latter is highly elastic, and
affords support to the vaginal blood-vessels. The mui^ealar fil>er8t
which are of the involuntary variety, run in both a longitudinal and

FEMALE ORGANS OF GENERATION*

^n-

One

txansrerse direction, and are so interwoven together that a dissection
into distinct strata ib impossible.

The connective-tissuo and muscular layers gradually increase in
thickness as they approach the vaginal orifice. A circular bundle of
Toltintary fibers, the sphincter vagijuB of Luschka, surrounds the lower
extremity of the vagina and urethra. The contraction of this sphinc-
ter not only acta upon the vaginal orifice, but likewise serves to close
the urethra by compressing it against the septum urethro-vaginale.*
The vaginal columns are two thickened ridges, which occur in the
^jnedian line, upon the anterior and pos-
erior walls, at the lower portion of the
igina. The anterior column is more
'prominent, in the rule, than the poste-
rior. It is often divided into two por-
tions by a longitudinal furrow. In these
^thickened ridges the muscular fibers pos-
I a trabecular arrangement and inclose
oflUioota from the venous plexus. Tlie
-^umns thus present a cavernous stnict-
ure. They are not, however, endowed
with ercctility. When turgid with blood,
they serve to close the vagina, but the
resistance they offer, like that afforded
Lby a filled sponge, is easily overcome, f
fThe mucous membrane covering the col-
nmjis is greatly thickened, and abun-
|4antly supplied with vessels.

The vagina is likewise furnished with
transverse ridges {erisiw, not rufjcB — they
are not wrinkles), which are more fully
developed upon the anterior than upon
iio posterior wall In virgins these
hdg^ possess a nearly cartilaginous con-
istauce. Any relaxing agency, such as
thronic catarrh* child-bearing, and the
ike, serves to efface them, and render
the vagina smooth.

The roncous membrane of the %"agina
ii covered with numerous vascular pa-
Lpilla?, which, under certain conditions, es-
f pecially those pertaining to pregnancy, may reach such a degi-ee of devel-
opment as t« communicate to the finger a distinctly granular sensation.

• LrmciiKA, **Die AnAtomie dea niPTiscliUcben Beckens/' Tubinpen, 1864, p. 387.
f QfjiLE, " QADdbuch der EJogewrciddchre dt'3 Munstben," BrflunacLweig, 18t>6^ p.
4»0.

Oil-
Fro, 6*^Tho va^n«i (cxpo«d in ito
entire len^h by the nniiavid of
tl»c [Kisterior wallK C*^, orifid-
uni uffthne ; 0»€y onfidum utc-
rio nnj -extern uni ; B, ii«wilon of
wutl lit the foniL\ vugioos. (Uon*

FEMALE ORGAXS OF GENERATION,

Though there are no secreting glands, the vagina is covered, even
in periods of repose, with a thin layer of acid mucus. Under sexual
excitement, and during motistniation or pregiiancj^ the amount of
this secretion is largely increased.

The hyiiogastrie, the uta'ino, the vesical, and the pudendal arteries
all Bend branches to the vagina. The pulsations of the uterine artery
may sometimes be felt through the upper part of the vaginal walls.
During pregnancy the*?e pulMtions arc always so distinctly marked as
to constitute a good inferential sign of that condition.

The veins form a close plexus around the vagina. Like all the
pelvic veins, they are without valves, and are therefore peculiarly sub-
ject to stasis from anything that interferes with the return circula-
tion. Blood-stasis, with enlargement of the vaginal veins, communi-
cates a deep-pnrijle color to the vagina. As the requisite conditions
are fulfilled during gestation, Jacquemin and Kluge proposed to (e-
clude this coloration of the vagina, which they compared to wine-lees,
among the signs of pregnancy. It occurs, however, tliough perhaps
to a less intense degree, in prolapsus uteri, in cases of pelvic tumors,
and the like. As free intercommunication exists between the vaginal
plexns and the plexuses distributed to the pudendum, the rectum,
the bladder, and the uterus, a disturbance in the circulation of any
one of thciie organs is necessarily attended with some degree of circu-
latory disturbance in all the contiguous organs.

The general relations of the external and internal organs of genera-
tion are admirably given in Fig, 6, which we have borrowed from Beigeh*
It represents the complete generative system of a virgin (natural size).

II. The Utebus, Fallopian Tubes, and Ovaries.

The Uterus, — The uterus in the virgin ditlers somewhat in shape
and size from that of a woman who has borne children. The following
description is intended to apply to the nulliparous uterus only: In
outwiird form the uterus has been compared to an inverted, wide-
Df}cked flask. It is flattened antero-pogteriorly. Its average length
a in the neighborhood of two and a half inches, though its dimensions
Tary to a very considerable extent. It is divided by a tolenxbly well-
dctlned constriction into two parts of nearly equal length- The upper,
Imrger jjortion possesses an anterior, flattened, and a posterior, convex
cnrface. It is limited by three borders. The upper border is moder-
ately convex. The lateral borders are convex above and concave be-
low. Tlic Fallopian tubes pass into the uterus at the junction of the
upper and lateral borders. The width of the uterus at this |K)int is
about one inch and a half. The lower portion has a spindle shape^
and measures about a half-inch in its widest diameter.

* Bfiatd., **Die Kr&tikheitcD dea wciblichen Geschlcchtcs,** Erlangcii^ 1S74, Bd. i, p.

13 PHYSIOLOGICAL AXATOiTT.

All the lower, gpindle-shaped portion of the utems is termed the^
eervixy or neck. The portion of the uterus comprised between tho
neck and t]ie Fallopian tubes is called the carpus or body. The
segment situated above the Fallopian tnbes is distinguished as the
fundus. C

/3^1

'mm

IV;

Fm. 7, — ^Virtfin utcntei. A, anterior view; B, mMmn socHon t C, Interal Bection fSap-
jjev). A^ 1, body; 2, 3^ anclrw; S^ojmxj 4, site of the os internum; 5^ viicrinal por-
tion of the «?rvix; ff^^ cxtcniul o^i; 7, 7, vnpna, B, 1, 1, pff^fllc of tho antcnor nurface;

2^ ve^ioo-uU'rino culHle-f*iuo • ,t. »J profllo of tho jiostennr'wurfHcc : 4^ hndy ; 5^ nock; <5»
isthmiLH ; 7^ cavity of ihe body : 8, cnviti of thi? cirvix ; Vi^ oa mtemunj ; 10, anterior
lip of the OS externum; 11^ fxwterior lip'; 12^ 12, voginft. C^ 1, cavity of the body;
2, laterftl wull * 8, 8U]Tflrior wall; 4, 4^ comua; 5^ oh intcmnin; 6, cavity of the cervix;
7, urbor viUa of Uio oervix ; 8, o* oxtemuiii ; 9, 0, vogint.

The lower extremity of the cervix projects freely into the vagina,
and forms the portio vaginaJiSy the vaginal portion. It possesses a
transverse aperture, measuring from a half a line to two lines in width,
termed the external orifice, or morc frequently the m tincm^ from a
fancy of the anatomists that it resembled the mouth of a tench. The
08 tincre is bonndod by two thick lips, of which the anterior is abso-
lutely lonp:er than the posterior. As, however, tho distance from the
external orifice to the vaginal insertion is about half as great anteriorly
as posteriorly, a sensation is communicated to the finger, when an
examination is made per vaginam, ns though the anterior lip were
really the shorter of the two. This absolute superior length of the
anterior lip, combined with the natural oblique direction of the uterus,
causes the external orifice to look nearly directly backward, a fact
which is readily recognized when tho organs are examined in situ by
means of a Sims^s speculum.

Upon lateral section, the uterus is fonnd to be provided with a
cavity, in which the upper portion or cavity of the body is to be dis-
tinguished from the lower portion or canal of tho cervix, Tho catnty
of ihe body presents a triangular shape with convex borders. The two

FEMALE ORGANS OF GENKRATTON,

Lupper angles communicate bj a small opening, hardly large enough to
lit a fine bristle, with the canal of the Fitllopian tubes. At the
Idwer angle is situated the aft internum^ a circular orifice, large enough
admit a uterine sounds which forms the internal anatomical limit
l)etween the body and the cervix. The canal of the cervix has a fusi-

m^%

fto, a, — ^yii|^ Uteroi opened poeteHorly, showing nt vl , .-I , Che c» mteinum ; at £? #, os exter-
num; P^ pcntouual falda. (Bimdl.)

form shape, and is included between the internal and external orifices
already described. Its inner surface is characterized by two longitu-
idinal ridges, occupying the anterior and posterior walls, from which
branching processes extend obliquely upward, giving rise to an appear-
mnce which justifies the title — arbor viim uferina.

In women who have borne children, ilie uterus measures three inches
in length, of which nearly two inches belong to the body and one to
the cerrix* There is increiised convexity of the fundus. The distance
^littweeii the insertions of the Fallopian tubes measures over two inches,
width of the cervix, at its junction with the body, measures one
inch. The uterus thus assumes a pyriform shape. The cavity of the
ntems loses its triangular character, and assumes a more ovoid ap-
pearance. The external orifice no longer forms a smooth transverse
kdepreasion, but its edges, lacerated by childbirth, communicate the
[impression of a rounded, puckered surface.

When a profile section is made through a perfectly healthy unim-
lated uterus, its walls are found in actual contact A cavity does
therefore, naturally exist
The uterus is so situated in the pelvic cavity as to possess a largo

PHYSIOLaGICAL ANATOMY.

degree of mobility. Its lower extremity projects, as we have Been,
into the vagina. The siipra-Tagioal portion of the cervix is attached
anteriorlj to the walls of the bladder. That portion of the uterus
which extends freely into the pelvic cavity is covered by a reflection
of the peritonaeum, precisely as though the uterus had been pushed
from below upward into the peritoneal sac. Thus the peritonjBuni
covers the uterus anteriorly and posteriorly. Its two surfaces meet at
the lateral borders of the uterus, and thence spread outward to the
ilia of the respective sides* These peritoueal folds divide the pelvic
canity into two nearly equal halves, and are termed the Ugamenta iata^
or broad ligaments.

Two peritoneal folds, containing a few contractile fibers derived
from the muscular tissue of the uterus, pass forward from the uterus
to the bladder— the plicm vesieo-nierinw. These folds form the sides
to a space, limited anteriorly and posteriorly by the bladder and uterus,
termed the excavatio vesico-uterina. { Vide Fig, 4, p, 8. )

Upon the posterior surface, the peritoneum descends down not
only over tlie entire supra-vaginal portion of the uterus, but over that
portion of the vagina which covers the posterior lip of the intra-vagi-
nal portion. Thence it curves upward, and becomes continuous with

m^A

MAi

Fi«. 9, — T7t«rua of ti wDmftn who hns borne children, J^ J, ttie jxntlon of the uterine cftxnty
OOTTOspctiidin^ to the peritomml fbldiif P/ JI^ £\ oa iDtcruuiu \ t^fx^ CiXtemum. (Handle)

the peritoneal investment of the rectum, Thus a deep ciddtsac is
formed between the uterus and tlie rectum, known as the ezcavaiio
recio-uierina, or cul-de-sac af Douglas, Two lateral folds of peri-

FEMALE ORGANS OF GENERATION.

tomeum likewise pass from the uterus to the rectum, which form aides
to this space, the plicm recio-uterince. These folds inclose in their
tree borders contractile mnscnkr fibers, derived fi*om the uterus and
Tagina* The plicse recto-uterinae pass backward, near the rectum, to
the neighborhood of the second sacral vertebra. As the muscular
fibers they contain fulfill the function of maintaining the uterus in a
state of normal anteversion, Luschka proposes that tliey should be
termed the retractores uteri,*

The peritonaeum covering the uterus is an exceedingly delicate
membrane. In front it is so adherent to the subjacent tissues that it
can not be removed by dissection without tearing. Behind, on the
contrary, it is connected with the uterus by a loose areolar tissue, and
caa be easily stripped up by the finger. On this account infiamraa-
tory processes are attended with more pain when situated anteriorly
than |>ogiteriorly*

Though it may be proper to speak* in a general way, of the uterus
aa occupying a position coincident with the axis of the superior pelvic
Btiuit, it must be borne in mind that, in reality, its position is largely
influenced by the neighboring organs. Thus, a full bladder pushes
the fundus backvirard. A fuU rectum shoves the cervix forward.
When bladder and rectum are both evacuated, the action of the re-
tractor muscles in the recto-uterine folds produces a limited amount
of anteversion*

The uterus is composed of muscular fibers of the un striped variety,
arranged in bundles and united together by delicate processes of con*
nective tissue. The arrangement of these muscular fibers has been
chiefly studied in a^Jvanced pregnancy, when three separate layers may
be readily distinguished :

1. The superficial hiyer^ which covera the anterior and posterior
surfaces of the uterus like a hood, while the sides are loft free. It
possesses a membranous thinness, and is intimately adherent to the
peritoneeum. It furnishes longitudinal fibers to the external muscular
layer of the Fallopian tubes. From the posterior surface its fibers
ocmverge to form the Ugamenium ovarii, a broad band, measuring
about an inch in length and a fifth of an inch in width, which passes
from the upper lateral portion of the uterus, between the layers of the
broad b'gainent, to the ovary. From the anterior surface a similar
bundle of a round form, the ligamenium teres, passes tli rough the in-
guinal canal to the symphysis pubis, where its fibers terminate in the
CKinnectivG tissue of tl>e mons Veneris. The ligamentuni teres is four
t0 five inches in length, and, in the unimpregnated uteims^ when tlie
ftttiduii is depressed below the pelvic brim, runs in a curved direction,
outward, and forward, to ^ain the internal

apward.

mgumal rmg.

• LrvcHix, ** l>ie Atuktomlc dca wctbJicben Beckcns," Tubingen^ 1864, p, SOI. It is
tdflit Uiat, bj drftwing the ccirix backward, the fundus of the uterus ii thrown forwftnL

PHYSIOLOGICAL ANATOMY.

%, The median hyer^ which constitutes the great bulk of the
uterine walls* It is composed of longitridinal and transverse fibers,
which, in place of being armnged in distinct strata, as is the rule in
other hollow muscles, form an intriente interlacement, in the meshes of
which are contained the vessels of the organ* The longitudinal are in
part derived from the lower transverse libel's, and pass downward to be-
come continuous with the longitudinal fibers of the vagina, and in part
are longitudinal from the beginning, but are closely interwoven with
the transverse fibers. As they descend to the cervix, they gradaally
diminish in bulk, and terminate by fine processes in the connective
tiasue directly underlying the mucous membrane of the vaginal portion,

3, The inner layer, composed of circular fibers, continuous with
the circular fibers of the Fallopian tubes above and those of the vagina
below* This* like the external layer, is extremely insignificant in size.
It represents the vestiges of the early development of the uterus from
the filamenta of MuUer. A special re<?nforcement of the muscular fibers
around the internal orifice of the cervix, constituting the so-c&lled
** sphincter," is admitted by most anatomists.

Upon the outer surface of the cervix, just at the point of the vagi-
nal attachment, there is a well-developed layer of transverse muscular
fibers. Circular vessels, imbedded in a loose-meshed connective tissue
containing wide lymphatic spaces, surround the cervix at the same
point. Thus a ridge is formed, which is greatly augmented in sue
during pregnancy.

In the cervix, the connective tissue exists in the form of well-differ-
entiated fibers of the ordinary variety. In the body of the uterus, a •\
similar loose-meshed, wavy connective tissue is found in the external <
layer, where it sends processes between the muscular bundles, and eur-
rounds the vessels. In the median layer, rings of connective ticsue .
accompany the vessels, while fibers of the finest description ])enetratd ^
between the muscular bundles. Fine fibers, of a like character, but
more abundant, are found in the inner muscular stratum, whence they
pass directly into the connective tissue of the mucous membrane.

The mucous membrane of the uterus is divided into that lining the
body and that which lines the cervical portion, between which char-
acteristic differences of structure exist.

The mncouH membrane of the body is smooth and soft. At the
fundus and upon the sides it measures about ^ of an inch in thick- '
ii€88, but is thinner in the vicinity of the tubes and the cervical por-
tion. It is covered, under normal conditions, with a thin layer of
transparent alkaline mucus. When examined with a magnifying-glass
its surface presents a perforated appearance, due to the openings of the
uterine glands. These glands are of the tubular variety, have a sinu-
ous course, and are oftentimes divided below into two or three separate
blind extremities. They extend, in the rule, through the entire tliick*

FEMALB ORGANS OF GENERATION.

hiu. li>, — feiftction throii|t{h
tin- mucotiit iiK'iubruiK* ol'
a nonim! virjin uterus,
iiiujernidcd about forty

Eiiif t^l rauiin ) . ^^ m ueoiLi
mcBibmno; i>^gUQd»;

loui^ng to die mt^^m&l

I of the macons membrane^ and, in rare inatancesi ponc^trate into
tha mttscalar tissue of the uterus. Tliey possess a delicate basement
membrEne, composed of spindle-shaped cells,
which dovetai] into one another like the en-
dothelium of the capiIJark»s and lymphatics.*
They are lined by cylindrical cells which are
said ta poaseas cilifld. The mucous membmno
of the body of the uterus possesses an epitheli-
um of the ciliated variety, whieli produces a
ourreut in the direction of the Fallopian tubes, f
A very irregular capillary net-work, with
delicate walls^ extends between the glands, and
pnees near the free surface into venous radi-
cle, which furnish during menstruation the
ionrce of venous haemorrhage.

The intermediate space is filled up by a
oonnective-tissue mesh-work, composed of fine
pfooesses and spindle-shaped cells, whose nu«

clei impart to hardened specimens a granular
appearance. Leopold J claims for this mesh-
work the significance of lymph-sinuses. The
close attachment of the mucous membrane to
the muscular tissue is explained by the direct
continuity of the connective tissues of the two
structures.

The mttcou.^ membrane of the cervix is of a
yellowish-red color, of a firm consistence, and
jjossesses the penniform ridges already described.
It is therefore readily distinguished, both by
the eye and the touch,* from the red, smooth,
velvety strticturo of the mucous membrane
lining the body. At the time of puberty, it
possessed a ciliated, cylindrical epithelium,
which extends down to within from two to three
lines of the os externum. ^ Simple gland-tubes,
and glands with multiple cnh-dc-sac, are found
upon the crests and sides of the ridges and
upon those portions of Uie cervical canal in
which ridges do not exist. Thc^e glands are,
. .i." 7ww^r> ' genetically considered, simple inversions of the

^ Lvaroi.n, ** Die Lymph s^^fiaw dot aorranlcn mcUt Bchwangerta Utenii," ** Arch,
t Uyiwk.," Bil, ?i, 1S73, Jlcft I, p. fS.

t V. HTRicKm, "Die Lcbrc dcr GewcWu." Ldpsic, 1871, art. "Ulcniii," too Dr, R
€taiM4K, pJK 1173 tf* w^. t Qp- "'•t ^ ^7>

• Lot?, '•Zor AnatonUe tmd Hiysiologl^ dcr Ccrrlx Uteri," Erlangcn, 1872, p. 17,
t

PHYSIOLOGICAL ANATOMY.

m aeons mptnbranc, and are lined by ciliated epithelium* When the
neck of one of tltese glands becomes obstructed, the secretion accu-
mulates, and forms the gtraw-colored vesicles which have been termed
the OYula of Naboth* Papillary structures, of elavate shape, are very
numerous in the lower half or third of the canah According to
Lott,*a section through one of these papillae is not to be distinguiehed
from a section through one of the smaller folds of the arbor vit©
uterina. The cervical mucous membrane affords thus an extensive
Beeretory surface, furnishing an alkaline mucus, which possesses im-
portant physiological functions in connection with conception, preg-
nancy, and labor.

The FaUopian Tubes. — The Fallopian tubes, as the history of their
developments goes to demonstrate, are, strictly speaking, integral por-
tions of the uterus, A glance at Fig. 13, p. m, will serve to make
apparent the continuity between the tisanes of the uterus and those
of the Fallopian tubes. It will be noticed, too, that the canal of the

Ori'

Oft

Fio, 12. — Posterior kterftl view of the uterus ( UJ, ), with pardon of lig. liittim (L.l.\ oviduct,
and ovarv, Od^ mthtDUS ; Od\ampul\a,\ J^ infufidibtiUitD ; O.a.^ oe^tium ubtloiuiimle ;
F.o.^ fijnbria ovaricjii; O^ ovarium • L.o.^ lig. ovurii ; Z.».o., lig, iufUiicUbuio-ovaiieum ;
Z,f.^.}%* uif\iiidibulo-pelvieum; ibf pnrovarium. (Hcole.)

latter communicates directly with the uterine cavity. Tlie Fallopian
tubes moasure from three Uy four inches in length. They are included
between the folds of tlie broad ligament at its upper border. As they
pass outward from the uterus they follow a somewhat sinuous course,
and gradually increase in width and thickness. The free extremity
an opening communicating with the abdominal cavity, the

* Loe, eU,, p. 20.

FEMALE ORGANS OF GENERATION.

ogHum abdominale^ which is large enough to admit a email gaose-
quiU (2'), whereas the uterine opening does not exceed ^y of an
inch in diameter. Henle designated the inner, narrower hall,
which runs a comparatively straight course, the isthmus, and the
Ottter, sinuous, dilated portion the ampulla of the tube. A number
of ragged^ Iringe-hke processes snrronnd the ostium abdominale,
whence the name fimbriated extremitff of the lube. These fringes
received likewise from the mediceval anatomists the name morsus
diaboli from a supposed resemblance to the root of the scabiosa euc-
cissa, the peculiar apj>earance of which was ascribed by the sujier-
stitious to a bite the devil gave it in a fit of anger at its beneficent
action in the maladies that affect the human race.* One of the fim-
bria? (F,o.) ig rather longer than the rest, and is attached to the outer
angle of the ovary.

The muscular walls of the tubes are composed of unstripcd fibers,
Bimilar to those described as existing in the uterus. They are ar-
ruiged in two layers : one, longitudinal, continuous with the external
layer of the uterus; and the other, circular, continuous with the
circular fibers of the inner uterine layer. Galvanization of the tubes
earner contractions of a vermicular character*

Between the muscular walls and the peritoneal covering there is a
connective-tissue layer, which gives support to a rich plexus of blood-
TDssels.

The mucous membrane of the tubes is extremely vascular* and has

Flo. 13.— Sectlou through Fnllopian tubo, (Richnrcl,)

ft ciliated epithelium, which produces a current in the dii'ection of
Uie Qtems. It preacnts numerous longitudinal folds, which are much

• OvRTt, ** TopogiuphiicJie Anotomic,** Wlcii, 186Bj M «, p, 210.

PHYSIOLOGICAL ANATOMY.

more complicated in the ampulla than in the isthmus. In the ampulla
these folds possess an arborescent character, as may be seen in the fol-
lowing figure :

Fio. 14. — Section throiii^h amtjiiUn (thirty dmraoUTs). a^ submuoom ti»sue; 6^ tntiseuliir
loyef ; i*, hcroim ewitiiig ; <i, mucoiis oiemlu'jme ; *, *, vt s.«cls ; 1, 1^ little foldi*. Te5*embUn|f
Vtllo?titi^ whttt t-etii in pmotilc ; 2^ a, louirititiluuiil tblds of larger hiixij with numoroLui
acceosory (olds; 3. 3, little folds, uniti-'d to^^utlicr bo oa to form u sort ol caoivUcukr net-
work. (LtuicUka.)

Tte OvBries. — The ovaries are two flattened, nearly ovoid bodie?,
situated, according to the usual description, between tlie layers of the
broad ligament Tliey measure from one to one aiid a half inch in
length, from three fourths of an inch to uu inch in breadih. and from
a third to a half inch in thickness. Each ovary is comiectcd with tho ^
uterus by a muscular band about an inch in length and a fifth of
inch in width, termed the ligamenhim ovarii.

Previous to puberty the ovaries present a smooth surface, but after
maturity they become uneven and corrugated from the enlargement, \
rupture, and cicatrization of the Graafian foUicles,

Although the ovaries are said to be of ovoid shape, in reality one^
border is miicli more convex than tlie othen The comparatively
straight border is attached to the posterior surface of the an tenor
layer of the broad ligament. The posterior layer of the broad liga-
ment is apparently reflected over the entire ovary, with the exception
of the attached border, at which point the hilum, or opening, is situ-
ated, through which the spermatic vessels, which are included between

FEMALE ORGANS OF GENERATIOK.

the folds of the broad ligament, find entrance into the substance of
the Ofgati. AValdeyer claims that the peritonfeum ceases abruptly at
the base of the ovary. He states that jiisst where the rejection is snp*
poaed to take place, microscopic sections sliow that the epithelium of
the serous membrane is replaced by one possessing a cylindrical char-
acter. In dccordance with this view, then, the surface of the ovary
would have to be classed with the mucous nither than with the serous
membranes, and should be regarded as tcxturally in continuity rather
with the lining of the Fallopian tubes than with the peritonaeum,*

When the broad liga-
ments are removed from
the body, and held as near-
ly as p3S5ible in the natural
position, the convex border
of the ovary looks down-
ward. If the broad and
eTarian ligaments are, how-
ever, put upon the stretch,
the convex border rises and
looks directly backward*

The ovaiT is found, upon
section, to contain a fibrous
stroma, the arrangemen t of
which can be best under-
stood by reference to the
accompanying excellent il-
histration from Heule.

Externally, the ovary is
MUTOunded by a fibrous
eoatiog, the so-called iuni'
m Muginm, In the first
tiireo years of exi.stenee,
baweT^r, the albuginea is
wonting. Even in a state
of complete development, Fio. ^
it can never be stripped ot!
aa a separate layer, but is
alwap intimately adherent
to the subjacent tissues.

Beneath the albuginea the parenchyma of the gland is further
divided into an outer cortical and an inner medullary substance.

The medullary substance has a spongy texture, and is of a reddish
^loT. It contains an abundance of blood -vessels^ the branches of which

• Waildbteb, "Etewtock iind Nchcacicrstock," Strieker's **Hjindbuch tier lx:hre dcr

iiHlinal Boction uf ovary fmm a persoQ
I fri::ljt dJumi'tiJi^), i, atbuffiiicft ; 2^
Hi = r of cortical portion; a, vcllulflr layer

of ctjiticj*! portioD ; 4, ni(H]ttllarv iiiibfltiinco ; B.
loose connective lt«j»uc Ijctwccn tlio flim liiytim of
iJj medul Itiry bu bfttuaoo. ( lloule. )

PHYSIOLOGICAL ANATOMY.

pursue a spiral course. The cortical mibgfancB is of a grayifih oolor.
In it a multitude of small follicles^ of the utmost fanctional impor-
tance, lie imbedded. The precise descriptiou of these follicles will be

given in connection with the sub-
ject of ovulation. The stroma of
the cortical substance is nowhere
sharply distinguished from that of
the medullary portion. The fibers
of the stroma, for the most part,
radiate from the center toward the
circumference* Just underneath
the albuginea, however, the con-
nective tissue of the cortical sub-
stance presents a felted arrange-
ment This portion is termed in
the illustration (Fif^. 15), the fibrous
layer, in contradistinction to the
more central portion, which is large-
ly composed, in the neighborhood
of the vessels and the follicles, of
round and spindle-shaped cells.

The Vessels of the Uterus and
its Appendages,— The uterus re-
Fio. 16.— Amrifti v«s«;l» in a uterufl'tcii ccives its arterial supplies from th© .
dftva lifter deUvc.n';thc<mcraiiiMumed following sourccs : 1, The arhHa\

forward^ »o as U> rrej*eiit tlie posterior . ** , f •■?*#«» i

aspect. 1. ftindu)* ui<?ri ; 2^ va*riiiui ix>r- titer ifia hypogaMHca. This artery,
tube*; 5, right ovfirj' ; 6, abdomimi nor- ^ ^^ ^^me implies, IS derived from^

ta; Y, art. mosonterica inf. ; 8, 8 art. the hypogastric. It first pursueS ftl

&, iirt. iliiicii couaiiiunij* ; K\ tat, tiiaea downward course to reach the vagi-

cxt. 1, 11, nrt. hvf>o^a»tritit i 12, urt.
utcrina hvpogastnca, (Lufidikti.)

nal fornix, where ita pulsations
may be felt during pregnancy.
Thence it curves upward between the folds of tlie bro^id ligament, and
follows a tortuous course along the lateral borders of the cervix and
corpus uteri. It distributes small branches to the fornix vagina?, and
large ones to the uterus. The uterine branches are, in part, distrih*
utcd to the surface of the uterus, and, in part, penetrate the muscular
tissue, to form a thick capillary network immediately under the uter-
ine mucous membrane. Of surgical interest is a circumflex branch,
which unites the arteries of each side with one another. The situation
of this branch is just at the junction of the cervix and body. During
pregnancy other anastomotic branches are developed,* As the preg-

^ IlYiiTt disputcii tlie fonniitiaii of anastomoses during pregnancy, and ttatca that in
Ibe pregnant aa well as in the non-pregnant uterus none but capillarj communicntion ex-il
\b\a betvrcea the arteries. lijrrtl^ ^* Topographlsehe Aimtomie,'' Wiea, 1865, Bd, ii, p^
194.

7E1CALB ORGANS OF GENERATION.

nant nterus is situated directly under the abdoniinal walls, the arterial
munnurs are at certain points distinctly appreciable, and furnish the
auscultatory §ign of pregnancy improperly termed the '* placental
bruit.** 2. The arteria uterina aorika^ or internal spermatic artery.
The origin of this artery is situated about two and a half inches above
the bifurcation of the aorta. It pursues a serpentine coui-se, and, in
places, makes spiral tunvs, which are specially marked during preg-
lumcy. It descends obliquely downward under the peritonaeum to the
carity of the peWis, and then ascends between the folds of the broad
ligaments to reach, by its branches, the ovary, the Fallopian tube, and,
by its main trunk, tlio side of the uterus* where it forms a direct com-
munication with the art. uterina hypogastrica.

This communication between the aortic and hypogastric uterine
arteries serves to maintain a continuous blood -current during gesta-
tion. The situation of the uterine artery within the pelvic cavity,
aod its exposure to pressure, would render it, were it the sole source
of blood-supply, an extremely unsafe dependence. It is well to note
here, that when pressure is made upon the aorta, after childbirth, with
a view to chi^ckmg post-partum hsemorrhage^ the manipulation fails to
affect in any way the blood-stream which pours into the uterus from
the aortic uterine branches.

The beautiful injections of Rouget * have demonstrated a peculiar
disposition of the aortic uterine branches, as they penetrate the body
of the uterus. Instead of dividing, as they branch, dichotomously,
tbey bre4ik up, on reaching the vicinity of the Fallopian tubes, into
from twelve toeigliteen arterial tufts, of which each branch is twisted
in spiml foruu These tufts of vessels are so aggregated together as
fre<|uently to cover the angles of the uterus.

The tmns of the nterus form a net- work, which traverses the
uterine tissues in all directions. As their walls are intimately adher-
ent to the muscular tissues of the uterus, they remain patulous upon
aection, and, when enlarged by pregnancy, are termed ** sinuses."
Bouget likewise describes tsvisted, tangled venous ducts, which often
form spirals like those described in the arteries. The same authority
claims that the ultimat^s divisions of the arteries communicate with
the venous sinuses by very fine vessels, measuring from yia*^ ^^ Vt*^
of an inch, instead of by capillary networks.

The retuni-currents of the uterus empty into two venous plexuses :

1. The plexus uferinus. This plexus receives its blood from the
atenn9 alone. It extc^nds between the folds of the broad ligament^
and emptier into the hypogastric vein.

2. The plexus pampiniformis. The plexus pampiniformis derives
its blood from the uterus, the Fallopian tubes, and ovaries. Its vessels

* Bm^orr, ** Rrchcrdi«8 aur lea Org&ncs £rcoiiloft do U Fctnme,^' "Jour, de k FhjaU

rHYSIOLOGICAL ANATOMT.

combine to form a single trunk, the vena gpermatica in tenia, which
follows the coarse of the artery of the same name, and empties, on
the right side, into the vena renalis, on the left, into the yeua cava.

12 13

^ 17. — Uterine nnd titcro-ovfirian veins (plcxim pnmpinlf«r>rmis), 1^ uteniB wen from the
front \ itj* liirht liulf i-^ oovtitid by tlie ixritoTiiuuiu ; up'vii the left half injiv be fw«u tho
pli!XtH uf ut*?n>-MVuriiui vi'Xtxn (im*>nmi iipermiitie ) ; G, i]tc'n>^Divarian vcfflcti covered Uy
peritobiiMjria ; 7^ thu mme weaevh cxiio«4€d; 8, ti» 8, vcitia fiom the FaUopiun lul>e; 9,
venous plexus of the hiluiu ovarii; 10^ uterine vein; 11, uterin^e artery; lii, vcnona
ploxus, covering the Iwrden* of the uteru*; IS, anobtomoeica of tliQ uterine with tho
nieitM>varittii vein (int^ i»poniiatic)« (Suppcy,)

The arteries of the ovari/ are derived, as we have had ocea8ion to
notice, from the internal spermatic, penetrate the medullary substance,
at the hilum ovarii, and describe a spiral course. The arterial branch-
es anastomose within the ovary, and form an interlacement, including
spaces, which become smaller and smaller as the surface of the gland
is approached. The veins start as radicles from the cupillaries, then
rapidly eiilarfre, and present a varicose appearance. By their anasto-
moses they form a plexus, which includes spaces of very irregular
size. The blood is then taken up by vencais trunks, which run parallel
to the arterial branches, and terminate finally in the interned sper-
matic vein (termed by Sappoy, Fig. 14, the utero-ovurian vein).

Upon the basis of the foi*egoing description,* Rou^et draws a par-
allel between the structures of the penis and those of the corpus uteri,
and claims identity between the two organs* One feature, however, of
the erectile tissue, as generally understood, is wanting in the uterus,
viz., a dense, fibrous sheath, a tunica albuginea, inclosing the erectile
organ, limiting the degree of its distention and enhancing its tor-
gidity.

As ex]ierimental proof that the uterus possesses erectile properties,
Bouget has sho^Ti that, wlien an injection is forced by the spermatic
artery, in the dead subject, so as completely to distend the vessels of
the body of the uterus, the latter becomes elevated in the pelvis, and
makes a movement similar to that performed by the penis during
venereal excitement.

• ItouGCT, " Rccherchcs sur los Organcs ^rcctilca de !a Fcmmc," " Jour, de k Physi-
ol ," t i, pp. 838 «< Jwy.

■

FEMALE ORGANS OF GENERATION.

It is, howcYer^ obvioua that the forcible distention of the Tessels of
a flaccid uteinis, in which the muscular walla are dejirivcd of their
normal tonus by death, does not necessarily represent the phenomena
produced during life by the turgescence resulting fi-om either ovula-
tion or the sexual orgasm. Unfortunately, so far as the body of the
uterus is concerned, the difficulties iu the way of direct observation
upon the livin^j subject have hitherto rendered the settlement of this
point impossible.

With regard to the cervix uteri, we have physiological as well aa
auatomic-al reasons for admitting a certain kind of erectility. To bo
sore, a tunica albuginea is wanting. It is, therefore, not an ideal erec-
tile organ* But it is among the occasional unpleasant experiences
of gynascological priictice that a simple digital examination, made for
the purpo^ of a diagnosis, may evoke the venereal orgasm. Precise
obeervaticns as to the phenomena presented by the accessible portion
of the uterus dnring the orgasm have been furnished by Wernich,*
Litzmaun,t and in one remarkable ciise by Beck, J wliich leave very
little doubt that strong erotic excitement is attended by a rif>idity of
the cervix, which produces an impression upon the Ungcrs similar to
thai imparted by the glans of the male organ during erection.

The following anatomical peculiarities of the cen^ix uteri are fnr-
Dished by Henle : The walls of the vessels (arteries, capillary branches,
and veins) are characterized by an extraordinary development of the
circular layer of muscular fibres. For instance, in vessels measuring
from Y^ to Y^ of an inch, tlve diameter of the bore is scarcely one
third the diameter of the entire vessel. The arrangement of the ves-
sels is likewise peculiar. In the labia uteri na, especially within the
muscular tissues, small branches pass directly down to the mucous sur-
fBOe, These branches pur?uc an undulatory course, are parallel, and
run at nearly equal distances from one another. Just beneath the
mucous Burfaco in like manner the veins arise and make their way up-
ward parallel to the arteries, and with the same orderl}' arrangement.
The capillary connections between these veins and arteries are situated
just beneath the epithelium, where they form looped projections into
thi^ pupil he. In the plicfe palmato? the general direction of the vessels
lit likewise jierpendicular to the surface. In commenting upon these
faetii, Henle remarks that there is nothing in the situatiou of the
srterial walls tliat would call for their special development, i%s they arc
not particularly exposed to external pressure. *' Where, however/* he
Mji, *• extraoniinary means are employed in maintaining contraction,
eartraordinary relaxation and dilatation arc possible." He, therefore,

• WfjucicH, **Dic Erectioiwritliipkcit dca unteren Uterus- Abscbnittes," "Beitr, jmr
G«barUb. und Oyntw^^k.;* UJ, i, p. 2yd.

f WA03fKB*« *• llandwoi-tcrbucb dtT Fbysiologic," Bd, iit, p. 53*

I B9C%, ** Qew do ihe Spcrmaio«oA cater the UieniA ? '^ '' Am. Joyr. Obst./* Not<, 1674.

PHYSIOLOGICAL ANATOMY.

premises, as at least probable, " that the changing degrees of contrac-
tility m the finer vessels may serve to impart a sort of capacity for
erection, or» at least, tnrgescence, to the cervical and vaginal portion *'
— an anatomical deduction sustained, as we Lave seen, by physiologi-
cal observation.

A similar attempt on the part of M. Ronget to constitute an erec-
tile organ out of the ovary ia disposed of by Sappey as follows :
'* Erectile tissue ia formed by large, short, anastomosing capillaries.

\ik.

Fio. 19.— Nerves of thfi utenw. v4. plexus otr^rinu* miisTius; ^, pk3ni« hrpojTi*»triPM»;^
corvicail ^rifflinn. 1, Biierum: 2, itictum; 3, bliiddtir; 4, utoms; S, ovary ; 6» tttti
of F&llopioa tube. (Fraaktiuliuouacr, )

supporting mnscnlar trabecule, and into which open the ultimate
divisions of the arteries ; bnt in U»e bulb (the vascular portion of the
ovary) there are neither dilated capiUaries, nor areolae, nor trabecnlffi.

FEMALE ORGANS OF GENERATION.

The aualogT signalized by M. Rouge t is therefore much more appar-
ent than real."*

The Nerves* t — Tlie nerves of the uterus arc derived from the gan-
gliated cords of the sympathetic system, through which important
c« ' tris are formed with all the abdominal viscera. Just at the

hi -ni of the aorta there is a broad band of nerve tissue termed

the pitxus uterinus magnus^ formed by the coalescence of filaments
from the spermatic ganglia (two pairs of ganglia, situated upon each
side of the inferior mesenteric artery) and tilaments derived from that
portion of the aortic plexus which is distributed mainly to the supe-
rior mesenteric artery (plexus mesentericus superior, Frankenhaeuser).
Abant an inch and a half beiow the bifurcation of the aorta it divides
into two strands, the plexus hypogastrici^ which pass right and left
around the rectum to the uterus and upper portion of the vagina.
The hypogastric plexuses receive nerve branches from the lower lum-
bar and three tipper sacral ganglia. Fpon the sides of the rectum
they divide each fnto two portions, of which the smaller passes directly
to the posterior and lateral walls of the uterus, wdiilc the larger con-
mbute^ to the formation of the cervical ganglion.

The cervical ganglion is a krgo plexus, which measures during
pregnancy two inches in length by one and a half inch in breadth.
It i^ formed by the concurrence of filaments from the hypogastric
plexus, the three upper sacral ganglia, and the fii*st, second, and third
aacrat nerves. The cen'ical ganglion siipplies the entire utenis, and
eepeciaUy the cervical portion, with nerves. Examined with the naked
eye, these nerves are soon lost sight of as they penetrate the walls of
the uterus, but their ultimate filaments have been traced by Fmnken-
haeuser, in microscopic preparations, to the muscular element, where
they ap}>arently terminate in the nucleus of the fibre-cell.

The Lymphatics. — We have already had occasion to notice the
probttl>le existence of Ij^nph-spaces in the uterine mucous membrane.
In the muscular tissue of the uterus, lymph-spaces are found in the
delicate connective tissue which unites the muscular bundles together.
Kegular lymphatic vessels are found in the connective tissue wiiich
accompanies the arterial trunks into the uterine parenchyma. A net-
work of lymjihatic vessels, with dilated and constricted portions, and
provided with valves, exists beneath the serous coat. The lymph-
spaces of the uterine mucous membrane communicate, by funnel-
shaped depressions, with the lymph-spaces and lymphatics of the mus-
eiilar strata. Just beneath the external muscular layer, upon the
lateral borders of the uterus, are largo receiving vessels, into which
empty the lymphatics from both the subserous and uterine vessels.

• •* TVdU d'Analomi*?/' Paris, 1871, l. b, p. 691.

f Por lalot snd ntosl coinplute accouni^ vide FjUKKCxaAirsBK, ^'Dlo Nerren d«r
' Jeiis« 1847.

PHYSIOLOGICAL ANATOMY.

The lymphatics of the cervix pass to the glands of the pelvic cavity,
while those of the border and fundus follow t!ie course of the plexug
pampiniformis to form connections with the lymphatics of the lumbar
region.*

Development of the Female Generative Organs. — Three
connected structures make their appearance on either side of the
spinal column, at an early period of fetal existence^ which need to be

understood by those who would gain a
clear idea of the developed organs of
generation in the female. Tliese struct-
ures are the Wolffian bodies, the ducts
of Muller, and the rudimentary organs
which are destined at a more advanced
period to become the ovaries.

The Wolfflaa bodies are oblong glan-
ly^ dular structures^ terapoi-ary in chanicter,
which are thought to perform, in tho
embryo, the excretory function of the
kidney. They possess duct«, situated at
the sides, which converge together below
the Wolffian bodies to empty into the

], epijiiil column; »J""» ^^^ gcnuaus,
bodie*; f), pliinda TwO OrganS, di

destined to become the

Fio. 19, — Euditnontary scxtinl oi^n*.
The interniil orji^imft rcpicsc'titcd
ot the Hcverjth week of tetiil Hte ;
the external orirans Ixlori^ to a
later pcnotl, ],

Sy 3j Wolffian Ixjdie*; f), pUinda TWO OrganS,

destined U> become the ovaries in . ? i.i - av

the ft'oiaie, the U'^iiek-s* m the ovanes, make their appearance upon the
ri't' % Mlf?"cf"n?iL^^f; ii^ner side of the Wolllian bodies. They

ment5 <d Mulkr; H, bl udder; 0* '

tubcrtie, formiiijrrtbe rudimfiit or possess at first an elongated, but snbse-

cither the clitoris or ncub: 10, ., ^

fokU, det^Lined i^j fonn the Uhm quently assume a more oval appeamnce,
majoraOnthoraaiethefiorotuin); The ducts of Midler are secondary

11, &mus uro-giiDiUlis; lii, utius. , , , i .

(Luiidika.) formations, and arc produced by an in-

version of the peritoneal epithelium, be-
ginning near the anterior end of the Woltfiun body and thence extend-
ing downward parallel to the Wolffian duct^. (Kulliker.) Below
they pass Bpirally forward, where they meet in the raediun lines to
dcscand together to the sinus uro-geni talis. By the eighth week ih«
lower portions of the filaments, which are in appo ' ' *■ "?
another, fuse together, and furnish the first rudimc^
and vagina. The free portions of the filaments f
tubes. Both uterus and vagina are at first divid*
a common partition- wall, which di8a])peara aubs'
upward.

The uterus, at tho fourth month of fetal li:
tnices of tho early origin trom the

Gynack,," BJ. vi, Heft I» pp, i
ei&a,*' T&bingtcQ, lUi, p. 87«l.

FEMALE ORGANS OF GENERATION.

undeveloped. The ridges of the arbor vitaB uterina, which are con-
fined at a later period to the cervix, extend the entire length of the
nteinis. A depression at the fundus
marks the point of union between
the ducts of Miiller. Two cornua,
or homsy are thus distinguishable
upon the external surface of the
uteras. About the eighth or ninth
month the convex fundus is devel-
oped, and the cornua disappear ex-
ternally, though all through life they
are traceable upon the inner surface
in lateral sections of the uterus {vide
Fig. 13, p. 19).

Before the differentiation of sex
has taken place, the external organs
of generation present the following
appearances : Two ridges, or folds,
surround a central opening (sinus

uro-genitalis), which either unite to form the scrotum of the male,
or develop into the labia majora in the female. Where these folds join
together above, there is a small projecting body, or tubercle, destined
to become the penis or the clitoris. In either case the lower surface

Fio. 20.— Uterus and its oppcncU^pes in the
foetus at the cud of the fourth month
(natural size). A^ external view : a, a,
ovaries, relatively larcCf nearly as long
as the oviducts ; b, \ the Fallopian
tubes (oviducts) \ e, <?, round lipaments ;
d, uterus ; e, vogrno ; /, vaginal orifice.
Ify interior view : a, rami of the arbor
vitie, extending to the fVindus of the
uterus ; 6, vaginal portion of uterus ; c,
vagino. (Courty. )

Fio. 21.— Uterus unicornis from a young child, posterior ospcct (Pole), a, uterus unicornis,
left half of uterus undeveloped ; b. ri^ht Fallopian tube ; c, left Fallopian tube, excep-
tionally present; d, dy ovaries, «, bladder. (Courty.)

of the tubercle is furnished with a groove. The margins of the groove
extend along the sides of the sinus uro-genitalis, and, in the develop-
ment of the female type, become the labia minora. The sinus uro-
genitalis affords a common aperture for the bladder and internal or-
gans of generation.

Abxobhalities of the TJtebus. — An arrest of fetal development

PHYSIOLOGICAL ANATOMT,

gives rise to a number of deTiations from the ordinary uterine type, of
which we borrow from Courty the following as of direct obstetric
importance.

L Uterus Unicornis, — The one-homed uterus results from the
atrophy or incomplete deyelopment of one of the filaments of MuUer,

Flo. 22. — Double ut4?ru8 tmd va^na froin a girl a^od nineteen (EiRenromm). o, doubla
va^rml oriiice witli doul>]e hymen ; b^ meatus^ urctlmr; c, ditom ; </, urethra; ^ <», tli6
double vai^iiifl* jf,/, uterine oriUces ; ff, g^ eervie*! fMr^rtions; A, A, bodic* and eomu»;
t. »\ ovurica ; ir, i, Fallopian tubes ; /, f , round Ugaments ; m, m, broad ligamoiita,
(Courty.)

while the other continues its evolution. We then have a uterus which
is composed of a single lateral half, possessing generally but one Fallo-
pian tube.

2. Uterus Duplex, or Bidelphys.— Both filaments of Miiller are
developed, but do not become united together. Thus two distinct
uteri are produced, of which each represents in reality the half of a
normal uterus.

, g^^l ^ftirni bioomiu^ doul»k' cavity and douldc va^na, frnm a prl seventeen jreiiTB of
IP, ^ llki two comuiL (SchrrKKlcr.)

7ia. S4.— Utenu oordifomtU, doublo natitral lisD. (Kuasmmi].)

PnrSIOLOGICAL ANATOMY.

3, Btems Bicornis.— Partial union of tlie filuments of Miiller takes
place^ but without reachiug the ordinary level indicated by the inser-
tions of the round ligaments. The upper portion of the uterus is
thus divided into two horns, separated by a furrow from one another.

4- Uterus Cordiformis.— Tiie uterus remains of the fetiil type in-
dicated in Fig. 17, Instead of a complete development of the fundus,
the hitter remains depressed, and presents an appearance remotely
resembling the heart of a playing-card.

5. Uterus Septus Bilocilaris. — Complete union of the two fila-
ments of Muller hjis taken place, but the common wall, formed by
their coalescence, persists. We thus have two distinct uterine cavities.

IB^rl

Jfjo. 25. — UtcruB H ptiis bllociilftris. Double iittrus, with pitnpk vii^nnn^ peen (Vom the front.
Ldl walls more dcvclofiod in couscquunco of prtgiiuucy, t Cruvcilhicr. )

The septum may extend the whole length of the vagina, and give rise
to a double vagina ; or absorption of the vaginal septum and a portion
of the uterine septum may have taken place, so that we may have a
double uterine cavity with a single cervix, uterus sefni-partitus^

DEVELOPMENT OF THE OVUM.

PHYSIOLOGY OF THE OVUM.

CHAPTER IL

DEVELOPMENT OF THE OVUM.

Th« GnAfim follicles and the onim. — Diichftrge of the ota from tbc orarj, and tho
foniiAiloii of the corpus liitenm. — The iDigtution of the ovum, — Fecundation, —
Ohiagei taking place in the orum subscqiicDt to fecundation. — Nourishment of the
e m br y o . — The aUantoui and chorion.^ — The dcciduip. — The placenta ; ita development
mxkd itructure, — Fonuattou of the uniblUeal cord. — The amniotic Uutd.

The pbysiology of the ovum comprises its genesis, derelopment,
and dkoharge from the ovary* its fecundation, and the entire senca
of mbsoqitent changes by which the simple structure of the germ
becomes converted into a complex organism preifcnting the specific
dunoteriatics of the parent.

ft«. til. — Sc<1idn of Wolftton body, with rudimentary ovary (embryo of chick , fourth day of

** ^> ''•' - "I -^y ♦ y^ Miction of Wolffimi duct; a, o, thickened cpHhe*

inoilMllon'
Uuni; >, o
orfm^ m^ Til

Iv flta^ in dcvclopnieni of ovary ; <?, O^ primordial

iv flta^ in dcvciopnieni of o
LiU of abdomen, (Woldeyer,)

The following account of the history of the ovum is derived from
Icyor's now tolerably familiar work.*
TmJ GuAAFiAK Follicles and the Ovum. — In the embryo

♦ *• Elemiock und Nehcneierstock^" Steiceer's " HandbucU dor Lebrc von den Gewe-
■«** UI|»»ic 1A71 ; **eiervtock uud Et/' Lcipaic, ISTO.
8

PHTSIOLOGY OF THE OVUH,

of tlie chick, by the fourth day of incubation, the Wolffian body
is covered by eylindrical epithelium, contrasting sharply with the
flattened eelis of the peritonfeum. Soon afie^, a thickening of the ,

ij»i

' v-

Fio. S^.^Vcrtical flection of ftn ovary of a bummi fcctua thirty-two Trwjkn old. a, a, fptth©^
liuro; hy 6, latest developtjd epk"hclifll ccIIb^ situated iii the t^pUhclml layer; <•, trftboculic
of cotinectivfl tij^uti which have jient^tnitecl bit^a the epitheliftl layer; «, «, primortliul fol-
licles Rumminltvl liy fine cwnnective-tiBiiiie cells ; /, gwuj* of iml>edded epitlielial cells,
{iiuoJL^ which nuiv c« dl-^tinjjruishcd cortain ones of large hijb© (primordial ova) ; g^ gr&ou-
lar celb of llisi. ' (Wflldeyer.)

epithelinm becomes noticeable on the inner side, and forms the
earliest trace of the ovary. Kext, a small rounded elevation, rich in
cells, and derived from the intergtitial tissue of the Wolffian body,
makes its api>earance underneath the thickened epithelium. The epi-
thelium is destined to form the Graafian follicles and ova ; the pro-
liferated connective tissue furnishes the vascular stroma of the ovary.
Between the fourth and fifth day, certain cells already indicate their
destiny as future ova, by their size, their rounded shape, and large nu*
clei. The further development of the ovary is the result of the muhi-
plication of the epithelial cells and the continued growth of the stroma.
As the connoctive-tisBue processes grow outward and penetrate between
the cells, tiie latter gradually become imbedded in the stroma. Thus,
the connective-tissue processes assume a trabecular arrangement, the
meshes of which are filled with cell-masses of a nearly cylindrical shape,
which hang together in the form of a net-work. Among the imbedclcdj
cells, the large ones already noticed are termed *' primordial ova,** Thfl
smaller cells remain small, and arrange themselves like epithelium'
around the larger ones. In the course of development, the interpene-
tration of the connective tissue continues, until each primordial ovum
is ctmtainud in its own separate partition. These partitions, with the
included cells, are rudimentary Graafian follicles. Two distinct o^Ti,
within the same Graatlan follicle are of rare occurrence. As the ova
enlarge, and tlie epithelial cells multiply* an irritative action is set up
in the surrounding stroma. Au increase in vascularity results, and a

DEVELOPMENT OF TEE OVtTM.

young connective tissue is deTeloped about each epithelial colle<!tioii.
As the foUicle growg, the outer layer becomes fibril kited. Thus around
each Graafian fallicle a distinct envelope is formed, termed by Baer
the theca folliculif consisting of an internal vascular coat, the tunica
propria^ and an external fibriUatcd coat, the tunica fibrosa.

Each primordial ovum is at first encircled by a single layer of
cylindrical cells. Ctradually new layers form, in which the OYum lies
imbedded. Afterward, at a point remote from the ovum, a crescent-
shaped opening makes its ap{>earance, which becomes filled with a
clear fiuid derived from transuded serum, and possibly in part from

^ r

maf ^

f9 _p,,rt|rrti of n^rrfW! wv'finti through ovary of hitdh a^ epithelium of ovary ; 6, b^

f ' ■ ^; <:^, niatiinj fi'lUclva i f,fljscti»proliyiijru», with ovum ;

ii' folliL'le: f/, tuujtja dl>roisa Mhculi; A, tunico propria
u , , ^ (W^ttldcyer.)

[di«tnt4?gratod epithelium. A heap of cells remains about the ovum,
land forms the discus prolifferus. With the increase of the follicular

PHYSIOLOGY OF THE OVUM,

fiuid/the cylindrical cells are pressed against the membnina propria,
and form a third coating, or luyer, termed the memhrana granulosa.

A glance at a transverse sectiun through the ovary of a mature
mammal exhibits follicles of diffei*ent ages. To recapitulate :

The youn^ follicles arc composed of primordial ova, surrounded by
epithelium, and iml)edded in the ovarian stroma.

The fully developed follicles possess a vesicular character. They
are surrounded by a coiinective-tissue wall (theca follieuli), which is
composed of two layers (tuDica propria and tunica Obrosa), The tunica
propria is lined by cells (memhrana granulosa) which are gathered in
heaps (discus proligenis) around tlie ova. The discus proligcnia is
seated sometimes superficially, sometimes in the deepest portion of the
follicle. Each ovum is fiurroanded by a special layer of cylindrical
epithelium (epithelium of the ovum)*

Ilenle estimates the entire number of Graafian follicles in each ovary
at thirty-gjx thousand,*

Fio. 20.— mm from a GraoAan follicle in the rabbit. <x^ epithelium of ovum : &, Jtona mdi-
ataa. jKjIlticidu; c, germiuutive vfriielo ; d^ gonnioutiva spot ; «, viUilliis. (VViddejrur.)

The ovum J at the time of it^ discharge from the ovary, is no longer
a simple cell, composed of ordinary protoplasm, but presents the fol-
lowing characteristic peculiarities : It is of large size. In the human
female the o%nim measures about ^hf of an inch. It possesses a thick,
transparent envelope^ termed the vitelline membrane, or, from the man-

* HxKLZ, ^' UoiulbQcli dcr Eingoweidelehre,*' Btntmacliwcigf 1$0G, p. 4iS.

DEVELOPMENT OF THE OVUM.

iier in which it transmits light, the zana peUucida* The zona jwllu-
eida was formerly thought to be due to a thiekening of the cell-mem-
braoe. It is now more commonly regarded aa something gnpenidded
to the primordial ovum. Probably the attached portions of the radiate
oeUft which surround the ovara in the discus proligerus contribute to
its formation. The appearances in Fig. 29 represent, according to
Waldeyer, these cells undergoing a cuticular transformation. The
fine lines which may be seen, when high magnifying powers are used,
•xe, be believes, unclianged filaments of the original protopkiam,* The
thickiiett of the zona pellucida is from ^ to ^ the diameter of the
oTiim.

The bo<ly of the ceU becomes the vitellus or yolk of the ovum. It
po wo a oe s contractility and other proixTties of ordinary pmtoplasm* It
hat m Tiflcid consistence, and is opaque from the presence of very tine
gnmuJes and globular vesicles

TSie nucleus of the cell becomes converted into a large, clear, col-
orlen ▼esicley known as the germinative vesicle. The nucleolus per-
nsta m a dark, probably solid, body within the germinative vesicle,
where it is known as the germitutiive spot,

DtSCHABGE OF THE OvA FROM THE OVART, AXD THE FORMATION

THE Corpus Luteum, — We have already seen that the number

Graafian follicles within a single ovary is estimated at thirty-six

hoQsuid. The formation of these follicles is^ in great degree at

completed during the antenatal period of existence. Previous

puberty, however, they remain in a quiescent condition. With

advent of puberty the ovaries assume functional importance,

surface of the ovary, if examined at this time* is no longer

Ih, but studded with small vesicles. These vesicles are nothing

than the enlarged Graafian follicles, which, as they become dis-

aded by their fluid contents, approach the periphery, theu the

mica iilbuginea, and form rounded, translucent prominences. By

1 disappearance of the blood-vessels and the lymphatics,

in the wall of the foUicle, the macula or stigma folliculi,

I left exposed

id' ' ' of the ovum is due to the conjoint action of a fatty
It: he cells in the walls of the mature follicle and the

nation of the corpus luteum.

eorpus luteum begins by an abundant cell-proliferation, in.

iiich both the follicular epithelium and the tunica propria paiiici-

ie. Vascular arches push forth into the cavity of the follicle, and

ftirthcr encroach upon the already crowded space. Finally, a

it ia ifsached at which the follicle ruptures, and its contents, in-

Ibe omm, are discharged. When the Graafian follicle has

• WjiLPitTint, " Ekrstoek utid Nebeacierstockf^' StniciccR's " Handbuch der Lt-hrc ?og

POYSIOLOGY OF THE OVUM.

reached inaturity, the congestion, occurring at the time of the menses,
operator imquestionably in a most effective manner to the accomplish-
ment of this result.

Immediately following the rupture of the Graafian follicle, blood
is effused into its cavity* The active proliferation of the cells of the
membrana granulosa continues. At the same time a process of disin-
tegration ensues. But, in place of a degenerative product, the disin-
tegration furnishes a granular^ vitellus-like substance of a yellow color.
Examined by the microscope, in addition to the granular mass, glob-
ules may be recognized, which are not precisely fat, but correspond to
the globules contained in the vitellua of the ovum.

While the above-mentioned process is going on, an abundant trans-
migration of white corpuscles from the vascuhir network surrounding
the follicle takes place, wliicli lift up the granulosa cells, with the
pseudo-yolk substance, and press them toward the center of the fol-
licle. Along with the young wandering cells (white corpuscles), Tascu-
lar offshoots, like small papillce, push out from every side into the
ej)itlielial and vitellus-like masses. As the larger vessels form more
marked projections, they give to the corpus luteum a folded ap-
|>earanee.

In a state of complete development the corpus lut-euni consists of
— L The pseudo-yolk substance, mingled with effused blood. 2. The
thickened layer of the granulosa cells, mingled with yolk-subatance.
It is this layer which, to a great extent, forms the folded, yellow por-
tion of the corpus luteum. 3. The vessels which, with the wandering
cells, push from all directions into the epitlielial masses. As these
vessels reach the center of the follicle, a complete interpenetration of
the connective tissue and einthelial elements of the corpus luteum
results, and the foldings become indistinct.

Finally, absorjition of the vitellus-like substance occurs ; the last
vestiges of the effused blood are converted into blood-crystals ; the
arterial vessels degenerate ; the epithelial masses and the connective-
tissue mesh-works disapi>ear gradually, until at the last only a white^
stellate cicatrix remains.

If the ovnm is discharged without impregnation talking place, the
corpus luteum readies its maximum size at the end of three weeks,
and then begins to decline, until, at the end of two months, it is re-
duced to an insignificant cicatrix. But, when conception occurs, the
changes in the corpus luteum take place more slowly. The corpus
luteum reaches a higher state of development. Its increase in size
continues for two months. It then remains stationary up to the end
of the sixth month. During the last three months of pregnancy it
gradually loses its bright-yellow color, grows smaller, but still measures
one half of an inch in diameter at the end of the period of gestation.*

♦ DiLfON's " Trcaliae oq Human Pb/siologj," rbikdelpbla, 1861, pp. 564 ei ae^.

DEYELOniENT OF THE OVtTM. 13^3

The coq>u8 luteum of pregnancy is often termed the trm corpua
iin, to distinguish it froni the moro triviul variety which is pro-
by the rupture of a Graafian follicle at a menstrual period.
ie latter has been termed i\\^ false corpns luteum, because it is found
Jin virgins, and does not constitute a sign of preexistent pregnancy.
The Migration of the Ovum* — The number of ova in each ovary has
estimated by Henle at thirty-six thonsaiul Only a small pro-
ion of them, however, meet with the conditions requisite for frni-
ItioD. It is probable that many ova perish while still aorrounded by the
itroma of the ovary. The history of extra-uterine ju-egnancies teaches
\\L% that, in some instances at lea^t, the ovum, after its discharge
am the Graafian follicle, escapes into the abdominal cavity. It,
therefore, becomes an interesting subject of inquiry as t<j the conditions
which ordinarily determine the passage of the ovum from the ovary
Kinto the Fallopian tube of the corresijonding side. It will not do to
■«3^me, as is usual, a peculiar erect ility of the Fallopian tube, which
Benables it to ap])Iy its funnel-sliaped extremity to the ovary, just at
Hthe moment of the rupture of the Graafian follicle. Setting aside the
Binherent improbability of the existence of such a degree of intelligence
m the timbriact as would lead to the exact adaptation of the tube to
the precise point at which tlie OYum is to be discharged, it has been
[proved that the Fallopiau tube possesses none of the characteristics of
erectile tissue. Injections of its vessels after death do not communi-
ute to it the slightest change of form or place.*
Muscular action has also been often invoked to explain the assumed
fmanner in which the fimbriae seize the ovary, but galvanization of the
ibes. practiced upon criminals recently executed, produces only ver-
Imicular contractions, which do not affect the position of the fimbriae, f
(indeed, when we remember the position of the Fallopian tubes in the
|ielvis^ and bear in mind that they are at all times necessarily subjected
\Ui the pressure of the intestines, it becomes dtfilicult to understand
liow they can exeente any very extended movements,!

In the absence of direct experimental proof, the suggestion of

• Eof^OTT/'LeA Orgmnea firectiles dc !a Femrae," "Jour, de la Physiol/* t i, 1858, p.

f ETtbtx^ **HM'ib«ch der topographi^cbcn Anatomic," Wicn, 1885, Bd. ii, p. 210*
J OisiLS, ** Haodbuch dor Eingeweidelehre,'* Braunschweig, 1866, p. 470. Rouget
\*h **Orgati«i ferectilos/* "Jour, de la Phfsiol/* 1858) has studied with great care
Mi« arrangt^meut of the muacular fiberfl situated bctreen the peritoneal layers of the
nm\ IriniinenU Thcsic fibers are directly continuouB with the delicate external muscular
aifrr of the uiefutJ* t^^rtain of them are bo dititributedf ficeonllng to Houget, a» to pro-
\ bj ihdf contraction a direct approximation of the fimbrifu to the ovary. Ilealc re*
> by Hfft? of criticism, that more strcas rni^ht l>c laid upon ibese fibers were thcj
^iit«d to the Fallopiati tubes alone. A?, howcTer, they spread likewise over the
, ibtfir ptobabk action would consist in drawiog both o? ai7 and tube toward the

PnTSIOLOGY OF THE OVUIC,

Henle that tlie passage ot the ovum into tlie Fallopian tube is due to
the currents produced in tlie serum by the ciliated epithelium, which
covers both the external and internal surfaces of the fimbria?, is, on
the score of probability, entitled to the most consideration* One of
the fimbriaa (fimbria o varies, Fig. 12, p. 18) is, as wc have already
seen, permanently attached to the lower angle of the ovar)% It is
likely that the ovum, discharged from a Graafiim follicle, is floated
down by the peritoneal serimi toward the lower and outer border of
the ovary, where a sufiicient current is present to insure ita being
caught up and conveyed into the iufundibulum tiihse, FailuiTS on
the part of the ovum to reach its destination are, in all probahility,
not uncommon. Support is given to the theory of the importance of
the cilia3 in influencing the migmtion of the ovum by the observation
of Thiry,* that in batrachians, wiiich have the o\iducts fixed to the
abdominal walls, and eituated at a diatanco from the ovary, during i
the rutting period little pathways of ciliated epithelium form in the
peritonaeum, which collectively converge toward the openings of the
tubes, f

While the ovum remains in the ampulla, or dilated portion of the
tube, its further progress is at first dependent upon the movements of
the ciliae ; but, after the isthmus is reached, an additional proi>elling
force is furnished by the circular muscular fibres, which possess a peri*
staltic action*

Fecundation* — The precise point at which fecundation takes place
hm been variously ascribed by authors to the tubes, the ut^erus, and
the ovary. Tlie occurrence of fecundation within the uterus may be
rejected, as it has lx?en sufiiciently demonstrated that the passage of
the ovum to the uterus requires a period exceeding ten days in the
human female — a period far exceeding the extra-ovarian life of the
o\^im, when not vivified by the contact of the male element of geneni-
tion. Abdominal pregnancies prove certainly the possibility of the
ovary becoming the seat of fecundation, but their extreme rarity would
lead us to infer that, so far as the human female is concerned, in
whom it is fair to believe tlie ovum not uncommonly fails to enter the
tube, the phenomenon is unusual. A priori reasoning leads us, how-
ever, to regsu'd with Henle the ampulla, with its arbcjrescent folds, as
6j>ecially designeil for a receptacle of the seminal fluid. The conges-,
tive condition of the mucous membrane, its canalicular structiUMJ, and

♦Oftttinger ** Nachricbten/* 1862, p. Ill,

f Cft&es of the complete migration of the ovum from the ovary of one lide to ihc
Fnlloplim tube of the opjKisite eitlc arc not reatlily explained by any hir^othesis. Yet the
oocwrrencc of such ca*es is iindoubtod. Prcgnnncy» for infitance^ may exist where ther«
is complete absence or closure of the FaHopian tube upon the same side with the corpus
lut4*um. For the literature of tho BUbJQCtf Pido ScitROEDSft's '^Lebrbuch der Gcburts-
hiilfe/* 4tis Auflagc, p. 22.

DEVELOPMEXT OF THE OVtrM.

Fio, 80.^ — Spermatozoa fWrni tlie bii-
iiirtn sulyect (magiiiflfd omhi bun-
dred diumotera}. (Luachluu)

the contractions of the muscular fibres, all seem int/ended to further
tie intimate contiict of the spermatozoa with the ovum after H has
cached this situation.*

The semen, contact with which is essential to the fecundation of
y^he OTum» is a tliick^ viscidi albuminous fluids of a whitish color, and
^ft peculiar odor, which has been compared to that of the raspings of
^Bone. When examined by the microscope, it la found to contain nu-
^Hoerous minute anatomical elements, termed spermatozoa. Each spcr-
Bltaatozoan consists of an oval head and a
^long filiform extremity or tail. The
hesid is flattened, and measures about
^tV^ of an inch in widtli. Wlien seen
in profile^ it presents a pyriform appear-
aD£e. The entire spermatozoon meas-
es from j^ to xh^ ^^ ^^ ^^^^^ ^^
agth.
The spermatozoa do not simply float
the seminal fluid, but possess tiie ca-
nity of moving from place to plueo,
though endowed with volition. lu-
lled, as the observ^er ^qe them advance,
w eingly, and now in shoals, now div-

wn, and then rising again to the surface, now avoiding some

Ic, or skillfully picking tlieir way between masses of epithelium,

difficult to resist the conviction that they are really, what tliey

long supposed to be, distinct organisms capable of a certain de-

of voluntary action. But there is little doubt, at the present

that the undulatory movements of the tail, which furnish the

'- ir force, are due to purely molecular tissue-changes, similar

which give rise to the amceboid movements of protoplasm or

e oscillations of the liair-like processes of ciliated epithelium.

^enle estimates that the spermatozoa travel at the rate of an inch
en and a half minutes. It is to these bodies that the semen owes
fwnndaling power, but only so long as they retain the faculty of
lotion — a faculty which has been found to exist in full force, within
, the female genital organs, eight to ten days after ejaculation.!
^K Our ki ' ' ^f^ of the process of fecundation is limited to the fact
^Biat the - '»zoa penetrate through the vitelline membrane, and

^Hbrn disstolve m the vitellus.

^" In 1840 Martin Barry described a point in the zona pcllucida (vitel-
line membrane) of the rabbit, which appeared to him to be an opening
dedgned for the passage of 8]»ermatozoa. At first embryologists jiro-
iKMittced Barr}'*s descriptions to bo based upon an illusion, but since

• Wwn.m^ " Hftndbuiib dcr Emgewcidclchre/* 1866, p. 476.

{ LrKCim^ ** Die AnAtomie ded menschlicbeo Bcckens/' Tubmgcn, 1864, p. 273.

FnYSlOLOGV OF THE OVUM.

then the existence of such an opening, tenned later by Keber the
micropifltu has boon abundantly demonstrated, at least in the ova of
liahes, muUysks, insect^,, etc.*

A Tery interesting series of observations, connected with thia gnb-
jeet, have been made by M, Robin wpon the ova of the nepkeUs vul-
garis, or commuu leech. The earliest token of the maturity of the
ovum consisted in the disapiiearance of the gerrainative veaiele. At tlie
same time a retraction took place in the viteihis, which became tbci^eby
reduced one sixth to one fourth in size. At firiit the removal of intc^mal
pressure, conscf|uent upon thia retraction, led to a wrinkling of the vitel-
line membrane. Afterward, however, a clear, limpid flaid. probably in
part exuded from the vitellus and in part derived by endosmosis from
external sources, filled up the intervening spaee^ and caused the wrin-
kles to diiiaj)pean The qijermatozoa, in their movements aronnd the

ovum, assumed a perpendicular or
oblique direction to the vitelline
XJ //'///i^^^^^^^^^J^^^ «« membrane. At one point in the

^ i^/^^J^sHHI^H^uM:^^^^ membrane the penetration of these

liodies could be distinctly observed.
At the end of an hour the penetra-
tion had ceased, and then a littlj
bundle of spermatozoa cou Id be seen
arrested, partly within and partly
without the ovum. In the clear*
limpid space surrounding the vitel-
lus, the spermatozoa continue*! to
move about actively for a time, but
in fifteen to twenty minutefl their
movementa began to grow slow, and
in a couple of hours had ended alto-
gether. A comparison, by actual count, of the spermatozoa now re-
maining, showed that a certain number of those which bad found
entrance into the limpid space had disappeared. They had been
absorbed directly into the vitellus, to serve for its fecundation. f

^^>^^_^x^

Flo. 31,— Ovum ni Uic iJi'f»}H*li!* vulimm,
^howinu rclraotion of vii«'llus nm! the
l^iiutrntion of the uptnutttozoii thmuirli
the vitcUinc nicriihratio (niftimifiod
three hundred dkmiuUjrb), (Kobiu.)

CHANGE.S TAKIKQ PLACE IX THE Ovi M SlBSEQtTENT TO FECUN-
DATION.

In describing its anatomy, we have noted tlmt the ovum was orig-
inally a simple cell, possessing contractility and other properties of liv-
ing matter. The ova of certain of the gponges, whicli do not pos.«cssa
zona pellucida, move about under the field of the microscope by

♦ Vide 5Iu.NF.-EDWARDa, *' l^^ons dc la Physiologic/* t, vili, Frtris, 18t3, pp. 86i rf
g» ; WAtOEYKB, ** Eiei j»tfKk utid Nt-benoJerstock,'* St ickkr^^ " tlaudbiirh/' p. 854,
f ** Mi^raoire stjr leu, Plienoiiitnefi qui sc pas^ont dans VOvulc avaut la SegttienUtioD dii
YitelJufi," RomHf ** Jour, de 1a Physiol,," L t, pp. 67 el ntq.

MVELOPMENT OF THE OVUM.

jWeTj ing mat finger-liko processes, pi'ocisely like the ordinary nmoeba.*
CoDtncti]e movements of the vitellus witliin tlie zona pelliicida have
been described by Robin in the ova of the leech and other low orders
of animal life.t

B<?fore the ovum leaves the Graafian vesicle, or soon after its dis-
ehttf^ from the ovarj% the gerroinative vesicle disappears. As this
diMppearanee has been observed mostly in the impregnated ovnm, the
phenomenon has been generally attributed to the penetration of the
spermatozoa, bnt Robin regards it m simply a sign that the ovnm has
reached maturity, and has become apt for fecundation. It occurs
equally within the nnfeenndated •Yum*t

The first decided indication «f the changes effected in the ovum by
contact with the male element af generation, and a sign, too, conclusive
af fecundatian, is the spantaneaus appearance of a round nucleus in
the center ml the viteUas, This nucleus is recognisable fifteen to thirty
I hours after fecundation. In appearance it so closely resembles tlic
original germinative vesicle that, for a long time, it was erroneously
I regarded as such.

^_ Almost immediately after its production, the vitelline nucleus sub-
^^Bdtvidej into two nuclei. By a similar process of cleavage* the vitellus
^H likewtso separates into two halves. The nuclei act as central points

Fia. S?.— eccmcntatioD of the ovum. A^ the ovum divided into two colh ; B, the two cells
divided loto four; (.\ the four t-c^a djvidfd into oi^ht ; i>, ty ivpealod neuineutaJt^oa, the
arum liaa beoouMi * rtiuod, mulUfry-sliiipod mosB— the mansta. (llacckel.)

of attmction, around which collect the molecular and viscid portions
[of tlie protoplasm. In this manner the original cell is converted into
two new cells, exactly resembling one another, and both lying near
togctlirr witliin the vitelline memhrane. To this cleavage of cells the
u»rm Mft/mfniafion has l>een a])j»lied. By a continuation of the process,
the two new cell* are ccm verted into four, the four into eight, and so on
I in £iiceession until, firuilly, a great multitude are generated, all cloiiely
mtiwded together, and giving to the ovum a mulberry appearance,

• IIjorcKJCL, '• Amhropogcnie," Lcipnic, 1874, p. 112.
1 1 Jj^* Cl/., pp. \00 ft teq,

«, **Sor U Production du Koy&u Mtellin,'* ** Jour, de la Phyaiol/* L r, p, 815.

PHYSIOLOCfY OF THE OVUM.

whence the term morula has been apph*ed to the ovum at this stage of
its dovelopmout.

A clear llyid next accumnlatcs in the center of the morula, at first
small in amount, but gradually increasing in quantity until finally
the cells are pressed to the surface. Thus the morula is converted
into a globular vesicle, termed the blastodermic vesicle (Fig, 33).
The walls of the latter are composed of a single layer of cells, which
form a continuous membrane, termed the hinsiodermic membrane. By
the absorption of fluid in its transit through the Fallopian tube, the
ovum is iiicrejised, upon the completion of the blastoderm ic membrane,^
from jItj of an inch to from -^^ to ^y of an incli in diameter*

All the cells resulting from the segmentation of the original >itel-
lus do not, however, take piurt in the formation of the bhi^todermic
membrane. If we carefully examine the blastodermic vesicle, just
after its development, we find, at one point upon its surface, a dark,
round spot, which is caused by an accumulation of a portion of the
cleavage cells upon the inner surface of the membrane. In profile tliis

spot presents a semicircular projection
within the vesicle.* By peripheral ex-
tension, its cells gradually spread over
and line the inner surface of the blasto-
dermic membrane* Thus the ovum be-
comes encompassed by two cell-mem-
branes, termed respectively the outer and
the inner layer of the blastodermic mem-
brane. The outer layer of the blosto-
dermic membrane is likewise termed tb'
ectoderm^ in distinction from the inoei
layer, or entoderm.

At the same time a stratum of fluid
forms between the external layer of the
blastodermic membnine and the chorion^
as the zona pelhicida is now called. Be-
fore the completion of the entoderm, a
bright, round spot makes it^ apj>eaninee
upon the surface of the bla^odermic ves-
icle. This spot marks the point at which
all the more important processes connected with the devchipment of
the embryo tako place, and is termed the area germinativa. At the
outset, it diflfers from other portions of tlie blastodermic vesicle solely
in the increased thickness of the cells composing the ectoderm. Those
of the entoderm remain unchanged.

FlO.S9. — ^BUwtodennJc vesicle IVom
the uterus of the mbbit. o,
chorion ; h, cvlb, rtisulting fn>in
f»c|fmentation, form id p a niiiyjlo
laver linin^r tnc chorioti — these
cells havp beivtme beKOj^foaol
frtsm reciprocal pressure ; c,
liciif> of cells rcmain'mii witliin
the blftj-totkniiic vesicle iiaer
Iho formfllion of Ute bla^t^xicr-
mic meiubmne* (BidchofT.Ji

* Thp theoTT of nii^choff and others, that the area perminativa is dertloped at thii
point, ia not supported by the recent in^ci^tigiilitjna of Kidlikcr. — Alukrt KolLIEEK,
**£Dtwickcluiigs-Geschlcht€;' crate HitlXlc, p, 2*27» Lcipsic, 1876.

PEVEI>OPMENT OF THE OVUM.

Tho area germinativa has later an oval shape, with a bright center
and a dark border. The clear center is termed the area pellucida^ and
the darky thickened border the area opata {Fig, 35),

•y

«#»f

_5f

, ft«. M,— -^

iiph nrcfl pCTmi"fttivB in Uie egg: of u rubl>1t» showing the thickening of
i at t[iat point, us coDtrtuitod with tho ectodiirm of tho blufltciiicrji^c
* urea genuinutiva {rg.), (KOllikor,)

^m!':

Subsequently a third, intermediate, cell-layer, termed the meso-
I derm, is developed between the ectoderm and the entoderm*'* In

the mesoderm are developed the

primitive blood-vessela, with the
[growth of which the area opaca
ibeoomes known as the area vas-

Finally* the mesoderm separates
[ into two distinut strata, so that
, the embryo, at one stage, is com-
h1 of four distinct layers.
Without entering minutely into
the ffubject, it may be well to
*\Ht^ according to common
nice, these layera are as-
(stimed to have tho following rela- fi^.
^tiona to the ulterior development
>f the body :

Th€ outer layer, or ectoderm,
Bcemed in the formation of
epidermis, hair, nails, the
jFtnictures of the skin,
J, the spinal cord, the organs of special sense, and perhaps in
that of the genito-nrinary system.

The second, or outer, stratum of the mesoderm gives rise to the
' corium, the muficles of the trunk (those concerned in the movement
of the hotly), and the bony framework.

The third, or inner, stratum of the mesoderm supyjlios the muscn-
hr and fibrous tissues of the digestive tract, the blood, the blood-ve»»
\mUf and the blood-glands.

* Aooonling lo KulHkGr, the ogUb of the mcsod^nn tire derircd solely from the pro-
I ll^ftllfa of tbotte of tho ectoderm : '' £titwkkelutigii-G^ ^blehtc/' ^tc AuJa^c, p. 208.

85. — a o. area opaca ; a p^ area Pt-'nu-
cidn ; with bejrirmini? fonuntlon of em-
bryo fnjm the cmhiyonic ^pot. From
the ovuEp of a rabbit on the nintli day.
Owing to tho advanct'd stago of develop-
ment, the area pellucida ha^ loet ita
pritnithe shape, and presenti the ap-
pearnnoe of i^ couiitriclud ovoid. (Kol-
Uki;r.)

PHYSIOLOGY OF THE OVtTM,

The inner layer, or entoderm, furnisher the epitlielinm lining the
walls and glands of the intestines.*

About the time the area germinativa loses its circular form, and
becomes of an oval shape^ there appears in the middle of the area

pcllucida a large, dark» oval spot, produced
by the multiplieation at that point of the
cells belonging to tbe outer and inteme-
diate layer, and ti^rmed the embryonic spot,
or by some autliors the protomma, because
it represents the most primitive stage
the development of the embryo. The oval"
shape of the embryonic spot is suggestive
of the future distinction between the head
and the posterior extremity, the larger
end corresponding to the former, and the
smaller to the latter. Then, of a sudden,
there appears in the middle of the embry-
onic spot a delicate line termed the prim-'m
Hive trace, which divides it into two later*
al halves. The primitive trace consists of
a groove or furrow, bordered by two ridges,
termed the dorsal plates^ and formed by
a thickening of the external layer. The dorsal plates may be readily
nnderstood by reference to the transverse section (Fig. 36), taken
from Professor Dal ton's "Treatise on Human Physiology.**

Upon microscopic examination of such a transverse section, the
embryo m found to be composed of three layers, wiiich, in the verte-
brata, are united together in the median line. The iutennediate layer

fn h

¥in. 3fl,— Trans vcrfto section of
egg in early «^tagc of dGvelop-
roGDU 1] ext«raiil and mcdlim
Itkyen of blafttodertuic mem-
brane ; 2, 3, donol pljit€« ; S,
internal layer ot blDstorleruiio
membraDel ^Dalton.)

Fio. 37.— Tranftverw' Hoc-tion Uimufh the embryo uf the chick :i few hours after the (y»m«
mcncemcnt of incubiithm. A, oxtcrnid Inyer of the bhiht^Klermic membrune; w, cxtcrnnl
i^truttiin of ititt'nDCcUiitt' IftVi-r ; /, mientw.1 striituin of intcnn4>diat« layer ; d, mu^ma]
byerof thffl blaatodcnuk* muntbnuie ; «, primiCiva trneo or furrow; ar, djoi'dtt doi'&alitf.

(mesoderm), which possesses the greatest thickness, already presents
the appearance of two closely connected strata. The primitive trace
may be recognized in the middle of the upper sui^face, and the dony^I
plates are seen rising up as low ridges. At the same time, just hQ-
neath the furrow, a cylindrical organ, l^nown as the chorda dormlintj
becomes separated from the cell-mass. The chorda dorsalis owes its

♦ EiECKEL, " Antbropoir«nic," p. 218.

DEVELOPMENT OF THE OVUM.

tit

importttncc to the fact that it is around this cylindrical body that the
|vert4?bne subsequently form. The vertebra? themselves are derived
[im two longitudinal chords,
ited by a cleavage from the
IportiuQg of the intemiediuto layer
luc^xt to either side of the chorda
The periphenil portions
lof the intermediate layer are now
Itermed the lateral or abdominal
\plaU», Meantime the dorsal
plates continue to grow, and, by
curving toward one another, final-
ly meet in the median line, so as to form a closed tube, the tuhn^
iuOariif, in which ie developed the central nen^ous system. [Thus
will be noticed that the organ through the agency of which the
^dividual is brought into contact with the external w^orld k primi-
bvely derived from the extenial blastodermic layer (ectoderm).

fto. S8,

Din^niui] wjprofientiiijsr tranavereo
ftection thmuffb the embryo of a chick at
the end of fiio firet djiy' of incubation.
m^ dorHiit rUtctt ; M, ehortln dorsallb ; t,
vertebral cLonk ; a p^ abdomiDAl plAtcs.

fffn.

■^:-^:>;'^-^-;-:::^

k m. — Transverse section throiig'h the embrro of a chick on the second dav of innibatimi

(m«tfiiificd otic hundred diametcrt*). t m,' the dorsal platen have closerf to |<jrt*to t<4btts

^nilarU : *^ -. >, »;^-, ^.^tii ^\^f^ outer or ctitoncouB iajrcr (r) \» broken otf; eh.

horda; c, a />, tlic abdnniinial plnte^^ have BQ|tanitcd Into on extemul

\ lAteiTiiiii I lit m to fono the uieM^uteric folds.

intermediate layer (mesoderm) now separates into an internal

^nd external stratum, the existence of which, it has been noted, was

[idicsited at un earlier stage. These two struta remain united by their

mcr borders, and form later at the point of union the mesenteric

The outer extremities of the inner of these strata now curve

. and finally unit^ togetlier to form the intestine* They in*

at the mme time the internal hiyer of the bkistodermic mem-

limne (entoderm), The closure, unlike that of the dorsal plates,

take« place from front to rear, as well as from the two sides. The in-

ti'stinal tulie is thus formed from tlie inner stratum of the mesoderm,

rhich fnrnirtheH the fihro-muscular tissues, and from the internal

bUstodermic layer (entoderm), fnjm which the glandular struct ui*es

arBi derired* A portion of the hhistodermic vesicle is, however, not

i ' * 1 in the intestinal tube, btit hangs, during the early month-* of

*♦ from the hmly of the embryo, and is termed the umhiliral

rmcie {u r)* Finally UiC outer or cutaneous layer of the blaistoder-

PnTSIOLOGY OF THE OVUM.

mic membrane (ectoderm) and the outer stratum of the mesoderm
(the fibro-museular layer of the trunk) curve forward and inward so

as to inclose a long cavity, the
ccelum, which surrounds tiie in-
testine. This cayity in mam*
nials subsequently becomes divid-
ed by the diaphragm into thorax
and abdomen.

The body of the embryo, seen
in profile, at the time these
changes are going on, possesses
a thickened anterior, or cephalic
portion, and a tapering posterior
extremity. It manifests at an
early period a tendency to elevate
itself above the level of the area
germinativa. The back becomes
arched, and the extremities ap-

Fio. 40. — Section through the ovum of chick
after development of umbilical vesicle.
c A, chorda dorsalis ; t m. tuba medulloris ;
o m, outer layer of mesoderm, from which proximate toward OnC another.
»«fonned,the bony skeleton, tho blood- pj^j^ ^^^^^^ ^^^^^^^^ ^^^ ^^

vessels, and large muscles of the trunk ;
edj ectotlerm ; tnt, intestimd tube,
formed from the inner stratum of the
mesoderm and the entoderm (ent)- « r,
umbilical vesicle, continuous with intes-
tine ; a p, abdominal plates, formed from
the outer stratum of the mcsodcnn and the
ectoderm. Eventually the abdominal plates
meet to inclose the cavity of the trunk
(thorax and abdomen) ; a fn, amnion,
formed from ectoderm and outer stratum
of the mesoderm ; e, zona pellucida ; /.
outer lamina of the amniotic iolds, derived
from the ectodenn.

strata of the mesoderm, and sep-
arates them from one another.
Of these the outer stratum forms
a union with the cutaneous layer
so as to produce a single mem-
brane, folds of which rise at the
same time from the extremities
and sides of the embryo, and en-
compass it with an outer wall or
parapet. In the process of growth these folds approach one another
over the dorsum of the embryo, and finally unite together. Thus
a sac, including the embryo, is formed, termed the amnion, the cavity
of which subsequently fills with fluid.

NOURISHMEXT OF THE EmBRYO.

It now becomes a matter of importance for us to consider the
sources from which the embryo receives the nutritive materials requi-
site for its further growth and development.

We have seen already that the ovum, in its passage through the
Fallopian tube, is increased in size by absorption of albuminous ma-
terial from -f Jy of an inch to from ^ to ^ of an inch.

In describing the formation of the intestinal tube, it was noted
that a portion only of the blastodermic vesicle was included by the
curving inward of the inner stratum of the mesoderm, while a portion,
known as the umbilical vesicle, hung from the abdomen. The um-

DEVELOPMENT OF THE OYTm.

Fio. 41,— DiiL^'^raiii a bowing wirly
ein^ 1Q developtiictit of timiiion.
(t, o« externa] liiycr of bJiiitti>(icr-
mic roembrunf^f ri»mg^ up over
the doiNum of cmbrjo to form
the amniotic foltL»; /> , allantoii ;

bilical vehicle is lined, like the intestinal tube, by the inner layer of
the blastodermic menibmne (entoderm)^ and is covered by an exten-
ffiom of the inner stratum of the meso-
derm* At first the cavity of the vesicle
comfnnnicates with the intestine, and
coQiributcs by its contents to the nour-
isblt»ent of the embryo. This arrange-
ment, however, is only temjiorary. The
pft^Mtfli rery eoon becomes obliterated,
Mid tJie remains of the iinibilieal yesiele
hang downward, attached by an imper-
Tious pedicle to the intostine.

From the time the ovum has passed
into the uterus, however, it derives it
tnaiii Dutritivo supply from the mucous
membmne of that organ, at first by sim-
plcj jib!5ori>tion, and afterward by the for-
mation of the placenta, an organ through
which the blood of the foetus circulates,

pparated from that of the mother by the thinnest of partitions.
the party -wall there pass to the fcrtus all the materials
r for existence and growth, and from the fcetus the excreraenti-
imis principles representing the waste which is incident to vital action.
There is nothing in physiology more interesting than the proeosa
by which the circulation of the fcetus is brought into close relation

with that of the mother. It in-
cludes tlie consideration of the
allanMn, the chorion^ the decldua,
and finally the joint product of
them all, \'iz.^ the placenta.

The Allantois and ChorioE,—
The chorion is the external mem-
brane that invests the ovum. Be-
fore the formation of the amnion
it consists simply of the zona pol-
hicida or vitelline membrane^ As
the ovum is received into the ute-
rus, the vitelline membrane be-
comes covered with amorphous vil-
li, which help to fix the ovum in
the utennc cavity.

After the completion of the am-
nion by the closure of the amniotic
hUa, it remaim for a time attached to the outer lamina of the ecto-
a, at the point wh«fiie the fold^ m»ret o\{'x th<? hack of the embryo-

-Thi

>>.oi

i'^tintil* ti'ill of

lofi-
t tho

k.'»i< Ttn UIII4 I i-MxinciiF :ifi;iiiii»uc tottls ;i

L BnAliloia ; H^ unibUtr-itl vc^tdii.

PUYSIOLUGY OF THE OVUM,

tfi

Fia, 4^.— fTtimnn embryo, nt the third wcok, show
ing vilU covcrmg Uwj entire chorioD. (llucckei.)

The outer lamina meantime expands until it comes in contaot with

the vitelline membrane, which then disappears. Thus the outer

lamina becomes m turn the
external covering or chojioB.
Tlie new chorion, like the
one it snperjjeded, is speedily
covered by a growth of non-
vascular viliosities. These
villosities are not solidt but
hollow, like the finger of a
glove. They soon reach an
e?£traordinary development.
New villi sjirout upward
from the chorion, the older
ones pu8h out buds nnd
lateral offshoots, so that al-
ready in the third week the
entire surface of the ovum
ia covered with a dense for-
est of villi, presenting the
most delicate and graceful
characters,
Wc have just noted that the umbilical vesicle was a temporary

stnicture, and only for a brief period of physiological importance.

Meantime a new organ is developed, by means of which a vascular

connection is cFtablished between the embryo and the villi of the

chorion. This organ is termed the

aUantoii<. The allantois begins as a
HC-like projection from the posterior

Extremity of the intestitie, at the time

when tlie tunniotic folds rise up in

the form of an embankment around

tlie embryo [vide Fig, 41). At this

time the umbilical vesicle is still very

large* The allantois, like the um-
bilical vesicle and the intestine, h

comjiosed of two layers derived re.

meetivelv from the internal layer c»f

Oie bhistodermic membrane (ento-
derm), and the inner stratum of the

mesoderm. It speedily becomes va4>- Fio,

cular, and increases rapidly in size.

The inner surfaces of the sjic soon

adhere together^ so as to form a single membrana In the couni© of

the third weeV^fuiail^nloit(r^iiehas thcoiiori^li, over which it spreads

44,--l, oxocb Orion; 2, btontod^tmic
chorion; w, uiultiliail vtwicle-, cr, am-

DEVELOPilENT OF TEE OTUM,

and forms a complete vascular lining. According to the usual accep-
tation, the Tcssck of the allantois everywiierc penetrate into the YJlli
of the chorion. Then the chorion and allantois fuse together and form
by their consolidation a compound niembrane termed the permanent
chorion* At first the embryo is connected with the vascular chorion
by two arteries and two veins. The two arteries persist as the ar-
teries of the umbilical cord. One of the two veins disappears^ while
the other becomes enlarged in proportion, and forms the umbilical
vein.

With the growth of the ovum its surface diminishes in vascularity,
except in the neighborhood of tlie attachment of the allantoic vessels,
at which point tlie viUi incrciise in stae and prnftision. Over the rest
of the ovum the villi atroph\^ and disappear. Thus the greater portion
of the chorion becomes smooth, while about one third of its surface is
covered with a thickened, shaggy portion, destined to contribute to
^Hie formation of the placenta.

The DecidusB,— When tfie ovum passes from the Fallopian tubes
into the uterus, it finds the mucous membrane prepared, by certain
changes, for its reception. These clvanges, as sliown in a specimen ex-
amined by Dr. Engelmann,t in the first month consisted of a ten-fold
iDcreafie in thickness (two fifths of an inch). The tissues were intensely
Tascular, and the entire mucous membrane w^as thrown into convolu-
tions. The thickening was mainly due to an increase in the elements
composing the inter-glandular
connective tissue. This was moi-c
especially the case in the upper
layers, where the cells were like
those of young connective tissue.
A soft, pulpy stato of the mu-
cous membrane was occasioned
by an augmented production of
the amori^hous in ter-cel hilar substance which characterizes connective
tissue in the embryonic state.

It is tills thickened^ vaseuJar, softened mucous membrane which
furnishes the decidua vera.

The oviUB, soon after its entry into the uterus, finds a Ixlgment in

I of the folds of the decidua vera. This takes place usually in the
pr portion of the uterine cavity, upon the posterior wall, near one
of the tubal orifices.

The point of attachment between the o>Tim and the decidua is dis-

JiQ. 46. — Fonottion of decidua, fli^tfitBgo.

boater portion, derived from the ect«»deriii, furnishes the epithelium, ane? is called
rioii, while the inner vaAculnr supfi*cc furnished by ihc allaatoia b entitled tb«

t ExaiUlAX^, ** llucmuB Membrane of the Utcrua," *'Amcr, Jour of Obstet./' May,

PHYSIOLOGY OF THE OVCM.

Pio, 47.— Fnrmftiion of dm<lua comp lettni. rt, rltwitlufl ro-
fltijoi; 6| dtitHdua veru ; c, dccidua scrotum.

tingnished as the decidua scrotina. It is physiologically important a^
the site of the placenta.

The ovum is not simjdy adherent. It lies, as it were, imbedded in

the tumefied membrane,
folds of which grow up
around it and finally
meet so as to inclose it
in a cavity of its own,
shut off from tlie gener-
al cavity of the uter-
us.*

The folds of mucous
membrane which inclo^
the ovum are termed the
decidua reflexa.

The space between
the decidua vera and reflexa is filled by opaque, viscid mucus.

The Placenta. — The villi which cover the chorion become imbedded
in the soft tissues of the decidua, and derive, by absorption, imtritive
materials from the circulatory system of the mother, ^Vfter the for-
mation of the permanent chorion, by the extension of the allantois to
the inner surface of the egg, the allantoic vessels convey the absorbed
materials directly to the embryo* At first, absorption t4ike9 place from
the entire circumference of the chorion, but with the enlargement of
the ovum there ensues a thinning of the reflexa, with obliteration of
its vessels. At the same time the villi cease to grow over that portion
of the chorion in contact with the reflexa, and the whole process of
exchange between foetus and mother becomes concentrat^^d at the de-
cidua serotina. At this point the chorion, in place of l)ecoming bare,
is covered with an infinite multitude of villi, which enlarge, lengthen,
and, by sending out lateral offshoots, as^sume an arborescent appear-
ance. The villi are arranged in tufts, sixteen to twenty in number,
which together form a soft, spongy mass, and constitute the fetal
portion of the placenta.

The uterine mucous membrane, in which the villi lie imbedded,
contributes likewise its share to the make-up of the completed pla-
centa. The structure of this so-called maternal portion of the or-
gan has been the subject of much dilTerenco of opinion. Indeed, an
inteliigible idea of its anatomy can hardly be conveyed without a
preliminary cousideration of certain points connected with its devel-
opment.

* Leopold, in his acrount of the iitcriDc miicous membrane^ adopts Reichcrt's Ttew^ of
the fonnatioQ of the reflexa, viz., that, owing to the Icsa rapid increase iti the growth of
ihe acrotinA, the ovum becomes buried in the thitkeiiing of the vera. — ( Vide ** Studien
&ber die Uteruischleimbaut/' etc., "Arch. f. Gynaek.," Bd. xl, p. 455.)

DEVELOPMENT OF THE OVUM.

Thus, the Tilli are often erroneoiisly described as penetrating direct-
ly into the glandular gtructnres of the adjacent uterine mucous mem-
brane. Professor Turner has, however, conclusively shown that, in all
the leea complicated placental forms throughout the animal kingdom,
the depressions or crypts into which the Tilli dip occupy the soft,
palpy, interglandular tisisues. Engelmann further draws attention to
the large siase of the terminal sprouts of the villi in the human placenta,
which would render their entrance into the glandular tubules, unless
by a mere exceptional chance, a mechanical impossibility. Moreover,
Friedlander* has demonstrated, as will be again noted hereafter, the
pergi4?tence of the enlarged flattened glands in the serotina even after
the separation of the placenta at childbirth. It may be deemed,
therefore, as fairly settled that the maternal portion of the placenta is
derived from the tissues occupying the spaces between the glands, and
not from the glands themselves.

In the fuarey the relations of the villi to the uterine mucosa are of
the simplest character. With a little force it is possible to draw the
villi from the crypto, which, on vertical section, are seen to be
cup-like depressions between the glands. The crypts are surrounded
by a dense capillary plexus, and are lined by epithelial cells. The
epithelial cells are partly columnar, like those covering the mucous
membrane of the uterus in the unimpregnated state, while others
are 60 swollen out that their length but little esceeda their breadth,
while others are of irregidar shape. Transitional forms prove the
derivation of the irregularly shaped cells from ordinary columnar eju-
ibelium«t

In the airangement just described, it will be seen that the villi,
containing the vessels communicating with the.fcetus, dip into cryptfl
in the titerine mucous membrane* The cr}^t-walls are highly vajycu-
lar, and are lined with epithelium. There is, therefore, no direct com-
mmijeation lietween the fetal and maternal blood-vessels. The crypts,
bowever, elaborate a secretion, termed by Haller uterine milk, which
contains fatty, saUne, and albuminous matters dissolved in water. The
QieriDf} milk is, therefore, well qualified to serve as a nutrient mate-
rial, and is without doubt absorbed by the villi for the benefit of the
fa^tui.(

^ WKtttitATinwKt " UntersuditrngK^n ilbcr den Utcmv," 1870 — Uvber die Tnnenfllidic
4m D(i*rai po»t ptrtum, " Airk f. GytmeV Bd. ix, p. 2*2, 1876, FricMlliiiider'i
ol>«errfttloci* lure been ooafinii«<l by Kuodrat tiiid Engelmami^ Langhans, and Leo-

f Piroftf^aor TmufEE, '*Thc Strwcture of the Placenta," "Jour, of Anat. and Pliyai-
«l," fol, I, p. IS6,

} Tlw Qtcrin« milk can not he obtained from the placenta of the mare unmixed with
iIM f d ' t tioos from tl^e u(«rtn« glands. The analyses of Professors Preroitt, Schtosi-
t^fie«f( afid Oamgcc were marie upon a fluid derived from polycotyledoaoua placentic,
-^Vidt '♦Slruclure of the Phiccnla," p, 176,)

PHYSIOLOGT OF THE OVUM.

In the cat, the villi of the chorion have the form of broad, sinuous
leaflets, whieh, about the completion of one half the period of gesta-
tion, are so interlocked with the crypta that the two surfaces can not
be disengaged from one another. Vertical sections show that the walls
of the crvpts closely follow the sinuosities of the villi in such wise as
to form an intimate investment for them. Injections of the maternal
capillaries show them to be dilated to two or three times the size of
the capillaries in the fetal villi.*

In the human placenta the relations of the villi to the uterine mu-
cous membnnie differ somewhat at different stages of development.
Thus, (ft Jirsi^ the empty cylindrical villi simply sink into the soft,
pulpy, interglandular spaces, JVt'xi, as the villi sprout and become vas-
cular and arborescent, projections, formed from the proliferation of
the superficial portion of the serotina, grow around the offshoots and
branching processes. At tin's time we distinguish in the placenta a
fehil portion, the placenta fwtalw, composed of the villous tufts of the
ovum, and a uterine portion, the placenta uierina, derived from the
tissues of the scroti na.

In the third and fourth months the union of the fetal and maternal
tissues is very intimate. But, sub.^cquently, the growth of the uterine
tissue does not keep pace with that of the villi, so that the mature
placenta is almost altogether a fetal organ. A layer of uterine mu-
cosa, not exceeding ^ of an inch in thickness^ covers the surface of
the placenta after delivery. Between the cotyledons, however, thin
partitions from the serotina extend downward for a considerable

■.H^'

Fw. 48*— Dijitfniin Khowin^r tlio brimeliinfi' ol' tlie villi und ide crmnectii m of the lan>er t

with the placenta, rt, chorion ; ^, prinmrj tnmk, wiib radmtu bniDcbes (c); d^ the t^r-
tiiifjr bmnchua*, which cither tlireetfy^ or atU-r previous division {d}, i^t'iietratc ibo pla-
centa mAtcma {/). The free tennioul tiUt« (tf) are indicated only at » few points.
(Laughatus.)

distance J though never, except near the hordera, as far as the cho-
rion.

Sections throngh the hardened placenta show that the main villous
trunks divide at a short distance from the chorion. The secondary
branches assume a radiate direction, from which proceed tertiary
* TvKSER, op. Hi,, pp. X56, 166,

DEVELOPMENT OF THE OVCM.

branches, which terminate in club-shaped extremities and bury them-
iTea in the serotina. From these tertiary branches fine lateral ones,

laTing a dendritic arrangement, are given off, and till the spaces be-
tween the tertiary trnnks.

Many of these lateral tufts are attached directly to the serotina^

nd fill up in part the intervalbetween the larger radiate branches;
others, again, float freely in the blood-currents derived from the ma-
ternal vejssels,*

The precise origin and nature of the vascular a^aees between the
villi have been a prolific subject of discussion. In the early months,
we saw, the scroti nal projections extended deep down between the
rUli, and contained largely dilated capillaries ; and yet afterward
every trace of these vessels is found to have disapj>eared throughout
the entire placenta, except in the thin layer of the placenta uterina,
where the endothelium, or inner lining, may still be detected. The
most probable supposition is, that the vessels have become eroded
and finally destroyed by the growth of the villi, leaving the blood
to flow unimpeded through the intervillous spaces. A delicate layer
of epithelium may, indeed, be found upon the villous trunks and
tufts ; but these, it is sufficiently established, belong to the villi,

I and arc derived from the exochorion.f Whether these cells essen-
lially modify the interchange between the fetal and maternal cir-
tuUtions, can only be a matter of conjecture. The fact that cer-
Uiin medicinal substances, such as iodide of potassium and salicylic
acid, wiien administered during the latter days of pregnancy, may be
found in the blood and secretions of the foetus, whereas others, as
woorari and perhaps mercury, have not been so found, renders some
action on the part of the cells, aside from simple osmosis, at least
probable. J

The Structure of the Fully-developed Placenta.— The placenta, after
Is removal from the body, is found to be a soft, spongy mass, of a
mewhat oval shape. It measures upward of seven and a half inclies
m its longest diameter* is from two thirds to an inch in diameter at
he point of insertion of the funis, and weighs about sixteen ounces.
U internal surface is smooth, and is covered by the amnion, through
hich the vessels, communicating with those of the funis, can be seen
iQ their distribution over the surface of the organ, previous to plung-

' Lakqhahk, **Zur Koimtniss dcr men^chlichon Placenta,*' "Arcli. f, Oynack.," Bd. !»
imo, p. Sit; f/Jr, also, K6t*u&icn, ** EntwickelungaGcdcbiuhto " ; Leopold, "Dcr Bau
itr rimcentii," "Arch, t. Gyuaek.," Bti. xi, 1877> p, 443,

f K6LU%%n, " EntwickolunirsGescUiehte," 2te Auflagc, p. 3Sa ; Leopold, '* Der Bau
itr PUcenU," " Arch. I. Gynaek ," BtJ. ni, p, 467,

I Vidt FicnUKS ''Zur Lohfc dcr Stoffwechsel," "Arch, f. Geburtsk./' Bd. \%, p, 313;
BcatCKB, "Ztjichr. f, Geb.- uod Frauenkrankheiten^" Bd, i^ p. 477; GrssKROw, **Arcli.
■"1 GebflitikV* Bd. B, p. Ul\ SctiAVtmsmn utid SrAiiH, '^ Jahrb. der Kinderhdlk,/*
tfi«f Jftbrg., p. 13.

rHYSIOLOGY OF THE 0\TIM,

ing into the tissues beneath* The uterine surface has a peculiar, gran-
ular feel, and is divided into a nural>er of lohes, corresponding to the
ivtdl inft& or cotyledons already described. It is covered with a soft,
thin membrane, which sends septa or jmrtitions in between the cotyle-
dons. This n^iembrane is simply the product of the surface layer of
the scroti n a.

Curled arteries from the uterus penetrate the cotyledons, and con-
vey the maternal blood into the spaces or kcunte between the fetal

llllllllill

CXr Am

, L->

!l ^

m \ _ ^

Pio. 49. — Dm^mni of uterufl and placcntA in the fifth month. Ch, chorion ; Am^ »mm<m;
r, villi; X, IftcuoiB; S^ aerotimi; AE^ areolar; * , b'^"*'^ urieries. (Leoiwld.)

tuft^. Through these epaces the blood flows in a sluggish current,
and is conveyed hack to the uterus by the coronary vein upon the mar-
gm of the placenta, and by means of sinuses situated m the septa be-
tween the cotyledou8, and continuous with the venous sinuses of the
nterine walls.* The fetal tufts which thus bathe in the mothers
blood receive, through the umbilical arteries, the blood wiiich comes
from the fo>tU8 darkened with carbonic acid. In the ultimate rami-
tications of the villi, the arteries communicate by an arch or loop with
a corresponding branch of the umbilical vein, whicli returns to the
child red, arterial i zed bloody

♦ For nflRrmative evidence of the exiatenee of ptaccntAl liicuniE>, ride P^ofes86r
TuRNEii, "Stnicturo of the Human Placentu," *'Jour. of Anat. und PhjjioL/* toL
vH, p, 120. Fo, too^ Profe.<9ot" Dalton*b ingenious infiation of the tnteni1lou9 spiicea
with iiir, "Treati!«<* on Iluniftn Phyiiiology," 1867» p. 615. For objection^ the «1at>ortt«
|iapep of Braxtos Iticfes, In the Loudon ** Obstet* Trans.,'* vol xiv, deserves careful
perusal.

f Vide ejqieHmenis of Zweiffl, '* Die Respiration dcs Fojtus," ** Arch. f. roaek^*'
Bd. Ix, p. Hm. S«ef tlso, B^rard^ t. tii, p. 422, exp«cnmeiits of LegaUoId,

BEYELOPMENT OF THE OYVU.

But the placenta is not simply a respiratory organ. The rapid de-
relopment of the ovum, from a simpk' cell of microscopic size to the
proportions of the infant at birth, argues as surely that the relations of
Ithe blood-currents in the placontA enable the fcetus to derive from
the mother all the proximate principles required for the building
up of tissue, the differentiation of organs, awd the performance of
fanetion.

Then, too, the fa?tus has been shown to have a tcmpemtore of it-s
owiiy Bomewhat higher than that of the mother.* This production of
Koat is necessarily attended with destruction of tissue. Of this there
jfleTidence in the presence of urea in the bladder and the amniotic fluid,
|There can be little question, however, but that the placenta furniahcB
I chief channel through which the devitalized products are dis-

The Formation of the Umbilical Cord,

To understand the strncture of the cord, it is well to bear in mind
I various particulars connected with its development. At the time
the alluntoia first appears as a sac-like projection from the intes-
&, the embryo is hardly more than an appendage to the umbilical
Ifle, The larger size of the latter directs the allantois over the
&rior extremity of the fc£'tiis. By its growtli and extension, the
Ilantois reaches the chorion, and forms a sort of pedicle, by means of
rhich a vascular communication is established between the embryo
ind the |»eriphery of the ovum. This pedicle is the first indication of
Ihe nmbilieiU cord. Its vessels become reduced to two arteries, the
irobilical arteries, and a single vein, the umbilical vein. Meantime,
Ihe nmbilical vesicle diminishctf in size, and finally shrinks to a mere
hre^* The amnion fills with fluid, exuded probably from the l>ody
[>f the fu?tns, and continues to expand, so that often by the end of the
and month it comes in contact with the chorion. f In this way, it
forms a reflection over the pedicle of the allantois, which it invests
like the finger of a glove. Finally, the structure of the cord is com-
pleted by the formation of an elastic substance, termed the (jelatme of
[Wharion, which cons^ists of conncctivc-tissne elcmeots inclosing large
con^iiining amorphous matter. The gelatine of Wharton fiinc-
lionally st^nc-s to protect tlie vessels of the cord from compression*
\l u formed by hyjiergencsis from the outer layers of the amnion
nd the allantois, both of which are derived from the intermediate
ftjcr, described in the development of the foetus [vide p, 74). The

• Wc«FTTO, *' Ccber tlie Eigonwiirtne lier Keuf^^eborn^n," " Berh kUri. Woch.,** Nr 87,
'lW9 ; Aixxcty/* Uebcr tiie Teinp^ratur dca Kinder ira Uteruis/' ** Arch. f. iiynaek," Bd,
I, ^ ut.

f Vide Hchhkb'b " Gmvid Uterus/* plate xxxtii, Fig. t ; Ecixr, " leon, Fhjslolog,;*
pltx# ttiiU, Fig* 7.

PIITSIOLOGY OF TOE OVUM.

intermediate lujer furnislies, likewise, the connective tissue of the
body.

The f ully-deTeloped cord consists, therefore, of a sheath from the
amnion, the geUitine of Wharton, the nrabilrcal vein and arteries, and
traces of the nmbilical vesicle,* and the pedicle of the allantois.t It
averages twenty iiiclies in Icngtli, though it 1ms been olx^erved as long
as seventy-five inches, and us short as three inches, J A long cord
predisposes to the formation of coils about the neck, body, and h^mhs
of the fo?tiis. It is usually of about the size of the little finger,
but is very variable, it^ circumference depending chietly upon the
quantity of the gelatine of Wharton. The artcriea arc so twisted
as to form spiral turns around the vein, and, owing to the superior
length of the right artery, in mo?t cases in the direction from right
to left. As an anatomicid peculiarity, may be mentioned the fact
that the walls of tlic arteries arc only slightly thicker than those of
the vein.

The Amniotic Fluid,— The origin of the amniotic fluid in the earlier
months of gestation is not known, the most probable suggestion being
thai it is simply exuded from the tissues of the foetus. After the for-
mation of the placenta, a capillary network, connected with the vessels
of the umbilical cord, is developed just beneath the amnion in that
portion of the chorion which covers the placenta. From these vessels
a transudation of serum takes place into the cavity of the amnion.*^
After the first half of pregnancy has been reached, the cajjfllary net-
work disappears, Tlic continued increase of fluid in the amnion in
the later months of gestation is due to the accumulation of urine,
which the ffetus passes intermittently during intra-uterine existence. ||
The composition of the amniotic fluid corresponds to its double origin.
In addition to water it contains albumen, urea, and the saline sub-
stances which are found in serum and urine. Its quantity varies usu-
ally bet\xeen one and two pints, of which nearly one half is contributed
durincr the last three lunar months.^

* ScHtTtTZE, '*Dft8 Nabclblaschcn, ein constantp? Gcl»ikk\" etc., Ltlpsle, 1861.
f AaLFCLD, ** Die Allimtois des Mou^chen," '■* ArvU. f Gynack*," IkL x^ p. 81.
J ** Lthrbuch dtr GcburtshiilfeJ* vnn OUo Spiegelbprji, p. S2.

• JtNCBLUTU, *' Ueitra?^ atur Lcbre vom Fmchtwasser/* Irmug. Dissert,, Bonn, 1869.

I GrssEROw, '* Zur hehre vom Rtoffwecbael des F»rtus," '* Arch, f. Gynnck./* Bd. Ill,
p, 268, 26!*. pRocBowNicE, " Beitrigc zuv Lcbrc votu FruclitwiiH.'jer und &cjncr Ent»
bung;^ " Areb. f. Gynaek.;' Bd, li, p. 804.

-& Gdbsehow, I. <:., p. 269.

DEVELOPMENT OF THE FCETUa

CHAPTER III.
DEVELOPMENT OF TUE F(ETUS,

Ar«ft giMminallTa. — PrimiiiTc trace. — Dorsal plfltes. — Tuba mcdulJaris. — Cerebral vcil-
elci.— Chorda dor^alU,^ — Vcrtehral platce. — AbcJomiDal plates. — Central pUtes. — De-
relopmcnt of tbe bony skeleton. — DeTelopment of the mtcsiinc, face, luDgs^ Uver,
pancreas, bladder, heart. — ^Development of fmtus in Buccesaivc montha of pre|;*
nancy. — Fwtua at term. — Fetal craniuni. — The attitude, position, and prcdentution
of the foetiifl.

TiTE study of fetal development belongs properly to works on
physiology, and to them the reader is referred for completeness of
detaiL The following ennmeration of the principal facts in embryol-
ogy has, howcTer, been intrmluced by the writer, in tfio belief that it
will be useful for reference to both tbe student and practitioner of
obst^^trics.

First in order will be remembered the segmentatioD of the ovum,
the formation of the blastodermic membrane, and the development
of the area germinatiya by the
aecumulation of cells at a llm- , :— ^ —

ited point upon the inner sur-
of the blastodermic mem-
me. An inner blastodermic
layer b formed by the peripheral
extension of the cells at the area
germinativa* Between the outer
and inner layers a third or inter-
mediate layer makes its appear-
ance* This third layer is con-
fined to the area germ i cat iviu
Sub^qtiently its peripheral por-
ttotis further separate into two Ym,
etrata. In yertebrate animals a
umon of these separate layers
exists at the point at which the
apiaal column is to be deTelo|M3d.
At Srit the area gcrminutiva is
a round disk with a cUmr cen-
ter, the arm pellucida, and a dark border, the area opaca, but aft-er-
wafd becomes of an oval shape. In the middle of the area pdludfJa
a '' ' q:»ot, termed the embrtjnnie spoty is formed by the rapid

miii , ion of cells, and is directly concerned in the formation of

I tbe embryo.

In the middle of the embryonic spot there suddenly appears the
pciinitive trace, a furrow bordered by two ridges, the dorsal plates,

Ofi

%^'

o. 50.-

ftTPrt t^jHtt>n • a p^ arm pollu*
r rmiition or cm-
pot. From

dda ; with 1
bryo from r

the ovum ot u the ninth day

Owhi^ to the iulvuiKiiii j^^tage of develojv-
ment, the urea i>eilucida hm lo«t tt«
prioiitlve shApe, and prefMsnts the ap-
peamnoe of a couAtrictcd ovoid, (Kul-
fikerO

PHYSIOLOGY OF THE OVUM.

which finally meet above so as to inclose a cylindrical space, viz., the

tubus medullaris. From this closed tube is developed the nervous bj^s-
tem^ at first in the form of a cord, uniform in size. Soon, however, a
dilatation takes place in the anterior extremity, at first single^ but af-
tenvard by two annular constrictions, divided into three communicat-
ing compartments termed the cerebral vesicles. The first of these is

Flo. 51, — Bcirelopmcnt of the nervDus my^tvm of the chick fljonj/et). A, the two priinHtra
halves of the nervous sjatem twonty-rbur hours nfttr Incuhtttion ; B, the »iitue thirty -sbt
hours* nfter; C, the aamc at a moro advanced etapo. c^ the two iirimUive halves of the
vortcbjw; d imtenor dUatation of the neuml coiiat ; h, lumbar ouWji^iiient ; 1, 2^ Sj an*
terior^ middle^ and infenor cerebral vesiclea ; a, fi%ht flacteaing of the anienor vesicle ,
o, iomuitian of the ocular vceiclcs*

further subdivided into two compartments to form respectively the
cerebral hemispheres and the optic thahimi ; the second primitive
vesicle ia developed into the tubercula quadrigemina, or centers of
vision* The third or posterior primitive vesicle is divided into two
secondary vesicles, the anterior to form the cerebellum, the posterior
to form the medulla oblongata, and the pons Varolii (Flint).

Fw. B2.— Development of spinal oord and brain of human Bubjoct (Lon(rct)* A, bmm fitia
ipinol cord at seventh week, B, more advanced fttai^o ; i, spinal cord ; */, enl i^ f]

tne Hpinat oorti with ita anterior curvature; <". cereMIum ; <«, tubercula nun
/, optic Uialamua ; ff^ cerebral hemiBpher&«. C, bruin and spinal cord at tlc\ u...
■8 in foregoing ; p, optic nerve of the left side, C\ vertical section of the precedin^^.

Lumbar and brachiiil enlargements likewise form at the points at
which the nerves are given off to the upper and lower extremities.

In the very earliest stages of development, there appears, just be-
neath the primitive groove, a cylindrical body, tapering at both extrem-

DEVELOPMENT OF THE FCEIVS.

Fm. 53. — DiajcTflin representing tran9vorR« nee-
tion throikgb the i^mbiyo of u ehiek at th«
end of the fii>t duy of inciibalion, m^
tlor^ial plates ; eh^ eborda doraalie ; r, v*3r«
tobml dioixU ; a />, ubdomiual plates.

I, of a cartilage-like consistence, and extending the entire length
of the embryo. This organ is termed the chorda dorsalis (ch,y Fig.
53). It is a temporary structure, but of great interest from it^ sus-
taining an intimate relation in the vertebrate classes to the produc-
tion of the bony skeleton.

Upon either side of the chorda dorsalis, and running parallel to it,
two longitudinal masses {vide Fig, 53) are separated of! from the cen-
tnd portions of the intermediate

layer. They are sometimes termed -jn^ ^

the primitive vertebral platefl,
though they are more properly
columns. They are concerned

the formation of the verte-
%i», the muscles of the back,
and the origin of the spinal
nerves. The two peripheral por-
tions of the intermediate layer

genre to close in the great cavities of the body, and hence are termed
tJie abdominal plates {a, p, ).

In iU earlier stages the anterior half of the embryo is occupied by
the cerebral vesicles. At this portion, the division into vertebral and
abdominal plates does not take place. The intermediate layers, here
termed the cerebral plates, fold together over the vesicles, and invest
them with a simple membranous eapanlc, from which are derived the
buues, the muscles, and the integunients of the head.

In the posterior half of the embryo, the vertebral plates, soon after
their formation, separata into a number of cube-shaped segments (C,
Fig, 51)* These close together above and below ai-ound the cord,
to form the primUive vcriebrw. Those portions of the vertebral plates
which unite beneath the spinal cord include between their borders
the chorda donalis. Around the cliorda dorsalis as a center is devel-
oped! the cartilage from which are formed the bodies of the vertebne.
The chorda dorsalis for the most part disappears as the bony frame-
work is developed, so that at birth only a trace of it^ earlier existence
^to be recognized in the intervertebral cartilages.

The spinal column is formed from the inner portion only of the
vertebral plates. The outer portions, we have seen, form the dorsal
muscles and the roots of the spinal non'cs. If the vertebral plates do
not close over the dorsal as|)ect of the ftPtus, the l>ony rings which
include the sjiinal canal renuiin incomplete. When, as sometimes
Ipfiens, fi*om arrest of devolapment, this condition exists at birtli,

u-like protrusion of the membranes and cord takes place, consti-
' luting the afTcction known as ffpina bifida.

While these changes are taking ]ilaee upon the upper aspect of
the embryo, a shallow groove apiiears just beneath, and parallel to, the

rnYSIOLOGY OF THE OVUM,

chorda dorsalis. At this point the two inner layers — inner blasto-
dermic layer (pntoderm) and inner stratnin of the intermediate layer
(mosoderm)^^lose hitcrally, and from front to rear, so as to form a
cylindrical tube with blind extremities. Tliis tube, the tubus ifUeji-
iinalis, 8ti!l, however^ possesses an open comrannication with the urn-
biJieid vesicle, which at this time is very large. But afterward, as the
embryo increases in size, the canal becomes obliterated, and the um-
bilieal vesicle, w'hich has ceased to be of physiological importance,
hangs from the endiryo by an imfwrforate card. From the tubus
intestinalis are derived all the viscera of the pleuro-peritoneal cav-
ity, with the exception of those connected with the genito-urinary
system.

The openings at the mouth and anus into the intestine are the result
of eecondary processes. The oral orifice begins as a pit-like depres*
sion in the membranous envelope covering the bead. The depression
continuously dee|>eTis, until it finally comes in contact with the upper
end of the intestine. Then absorption of the intervening tissues takes
place. The intestine, lined by the internal blastodermic membrane,
unites with the external layer. Even in adult* life the sharp distinc-
tion between the epithelia of the buccal cavity and the d'sophagns
points to the difference in origin of their respective mucous mem-
branes. By a similar process the anus is produced, and a communi-
cation formed with the lower extremity of the intestine. When from
arrest of development the anal depression does not occur, or does not
reach the intestine, the malformation known as imperforaie anus is
produced.

In the rear of the buccal cavity, and upon each Fide of the neck,
four slit-like openings make their apfiearance, which possess an in-
terest from the fact that, though temporary in the higher vertebrates,
and devoid of physiological imjiortancc, they represent permanent
structures in fishes, viz,, the hranehia?, or organs of respimtion. These
opc^nings arc termed the insci^al clefis. They include between them^
four sickle -shaped processes termed the msceral arches^

The buccal cavity is at first a large orifice, or cloaca, communicating
with the anterior extremity of the intestine. But at a very early
period there likewise appear, in the frontal region of the embryo, two
funne]-€haped depressions termed the nasal fossw, which constitute
the first indications of the olfactory organs. The nasal fossfe are at
first widely separated from one another, and do not communicate with
tiie ond cavity. In the closure of the latter to form the moutlu a
projection, termed the frontal or infer muxiUary process^ is pushed
downward from the frontal wall. From the right and left lower
borders of the intermaxillary process two secondary minor processes,
termed tlie incisor processes, form, which bound the inner surface of
the nasal iossm. At the same time, two oflfshoots from the frontal wall

DEVELOPMEXT OF TOE F(ETUS.

curl around the outer surface of the fossa^* In this way, in the place

of the nasal fo^^sro, two grooved ciitmls are produced, open below,

which lead directly into the oral

mvity. The growtli of the nasal

offshoots gives to the intertnax-

iUary process a split or notched

appearance.

The upper jaw is completed
by the pushing out from the
central ends of the maxillary
(upper visceral) arch of two con-
ical growths (5, Fig. 54)^ which
apprtYach one another in the me-
dian line. As they do so they
include between them the inter-
maxillary process, and funiisli
the floors of the olfactory canals.
The lateral pressure brings into
apposition the divergent halves
of the notched surface of the
intermaxillary process. The na-
ftal passages, which at fii*st were
widely apart^ come into close
contact. The eyes, too, which
were situated at the sides of the head, are moved to the front until
; tlieir axes look directly forward, and parallel to one another.

The intennaxillary bone, to which subsequent to dentition the
tipper central incisor teeth are attached, is derived from the intormax-
iWnry process. The superior maxillary processes not only furnish the
8U[)erior maxillae, but the material from which the sphenoid and

tine bones are derived.

Ha re- lip results from an arrest in the development process just
de^ribcd. The lip, like the jaw, is formed by the union of the inter-
maxilkry with the superior maxillary processes. In case of the failure
of either superior maxillary process to unite with the intermaxillary
proci'&i, a fissure is formed to the side of the median line. This is
lermed single hnre4ip. An arrest of development upon both sides
gives rise to double hare-lip. Sometimes the separation is not confined
to the lip, but extends to the bony structures of the jaw. The ca.'^e is
then said Uy l»e one of rampHatted hare-Up,

The roof of the mouth, or palaihie arch, which separates the mouth
from Uie mxsal passages, is derived from two horizontal plates, spring-
ing from the inner surfaces of the sujierior maxillary processes. These
plated approach one another, and finally fuse together in the median
line* An arn'st of development upon one side gives rise to chfi palate ^

Flo. 54. — TluTnan crjibno U ; ..^. .. .... ;,, k.iilv-

fltYh nod t^setity-ciifhtli davn, showing tho
V bee ml iirchcs (7, 8, 9). (tJoftte.)

PnYSrOLOGY OF TUi; OVUM*

The vomer, which fonns the vertical paiiition of the nare*, is de-
rived from the intermaxillary process.

With the formation of the superior maxilhiry process, the residue

C>'

Fio. r^.— Moutii of embryo of tliirty-flirc dayj* (Coste). 1, fronul proccBS wldi^ly «li»pc*! at
its inlt'Hor rrfirtlt^n ; J, 'J, inctsor processes produced by this sloping; 8, 8, no^t^LU ; 4,

lower Up nnd muxilla^ ibnntjd by tlie union of iho inl'tirior looxilliiiy pFooca*; 5^ 5, *iupe^
rior maxillary proceniie^* i iL nioutli ^ 7^ fttut a^pc»ranco of cloaur© of iuimiI foiMB; 8, 8^
f rnt appcamneo of the two Luilvefi oi; tue palatine arch; 9, tongue; li>, 10, oyei; 11, 1^,

13, visceral arclics.
Fio. 50v

iipftcaranoe
fomjcd ■

Mouth of embryo of forty days (Costo). 1^ first appearance of the notw; 2, S, Hr?
ranoe of bIjb iA doso ; 3, closure boneath tlie nose ; median portion of upjwr li
d bv tbo union of tbti inde^or proocaaea, a Uttlo aoCch in the median tine indtcatin

first

lip

tcatmi;'

the primitive wjiamtiori of the two proocs»(» ; fi, % fiupeiior maxilkry pro«»f*e* j <!» »K
gmovc for the devcloonjitit iif tbo lachrymal ?iic and tne nasal catial; 7, lower bp ; 8,
m.otith ; H, ^^ the two lateral halves of the palatine arch.

of the upper visceral arch {%nd^ 4, Fig. 65) becomes known as the

inferior maxilkry process. From its base are derived two little bones
of the ear, viz., the malleiiB and incus. The outer portion is con-
verted into a cartilaginous band, termed the cartilage of Meckel, which
unites with its neighbor of the opposite side. Upon the outer surface
of the cartilage of Meckel is formed the permanent structure of the
lower jaw.

From the second visceral arch are produced the stapes, the styloid
process and ligament, and the lesser coniua of the hjoid bone. The
third areh forms the body and greater cornua of the hyoid. The
fourth arch in the embryo appears to be a purely rudimentary organ,
which docs not develop into permanent etnicturea.

The lungs aixj derived from the anterior portion of the intestinal
tube. At first they consist of a single small sac which grows from
the tube just posterior to the visceral arches. Afterward the sac be-

DEVELOPMENT OF THE FCETUS.

lifurcated below and forms two lateral halves (A). Each half
diTides and subdivides after the manner of a racemose gland to form the
hing (C and D), The upper portion of the sac elongates and is de-

"^'li^A-v

Fio, ST. — Development of Um lungs (Lonifet). A, B, deveJopmeat of ibe liings, ftrt^r Eathkc ;
Cf D, histologicardcvQlopQient of the liingB^ aitor J. MCiUer.

Teloped into the trachea (B). From the anterior portion of the intestine
h formed the oesophagn?. The opening of the trachea into the oesopha-
, gu« becomes the rima glottidis.

Poaterior to the lungs (passing from front to rear) there forms a
indle^ehaped dilatation in the intestinal tnbe. This dilatation is the
flfst rudiment of the stomach. Afterward it assumes an oblique posi-
tion by a movement of the upper portion to the left, and the lower
extremity to the right. By the unequal deyelopment of the left side
of the spindle-shai>ed dilatation the fundua and greater curv^ature of
the stomach are formed.

Below the stomach the intestinal tube increases rapidly in length.
At firat it forms a loop, attached by the mesentery to the spinal col-
umn, and projecting by its convex surface into the umbilical vesicle.
Afterward it is thrown by its rapid growth into numerous folds and
convolutions* Finally, the distinctions between duodenum, ilium, and
jejunum become apparent. Previous to the closure of the abdominal
walla a portion of the intestine protrudes at the umbilicus, A persist-
ence of this condition up to the time of birth produces congenital
hernia.

The liver begins as two saccular projections from the duodenum.

[These afterward fuse together to form a single organ. The openings

lof the sacs into the duodenum constitute the bile-ducts, which are at

[flret doable, but subsequently unite to form a single canal The

fibmuiicoat of the liver and the vessels are derived from the inner layer

of the mesoderm. The lobules are produced from branching processes

of the internal or glandular layer (entoderm). The growth of the liver

in at firxt rapid. By the third month it fills nearly the entire abdomen.

Afterward, by the growth of the stomach and otiier abdominal riscera,

I liver is pushed over to the right side. Although its subsequent

1 10 lew out of proportion to the entire body, it is even at the end

I of pregzuuicy relatively much larger than in the adult*

PHYSIOLOGY OF THE OVITIL

Fio. 68,^ — Hoart of embryo chlok in tlio ear-
\\G»t stijgtjs of formiition (Rcmttk). A^
ttctorior half of embryo afltir twenty -
eight to thirty hours of incubfttioij ; 2?,
orter about thirty- six houni of iucuba-

tion. 1, 1, veins; 2,
tiide; i, aortic bulb.

Aurick ; 8, ven-

In like manner the pancreas is developed from a blind procesai^
springing from the left eide of the duodenum. The pancreatic dnct

19 at first single, though afterward
A B it often becomes double.

The terminal portion of the in-
testine is at the outset straight.
With its subsequent growth, how-
ever, it is thrown into folds and
geparates into a longer portion, the
colon ; and a shorter portion, the
rectum.

The bladder is formed from the
portion of the allantois which is
closed in by the abdominal pktes.
The allantois, it wit! be remem-
bered, begins, like the lungs and
the liver, as a blind process spring-
ing from the intestinal wall, but is
situated at the posterior extremity
of the tube. At the outset, there-
fore, both intestine and bladder
open into a common cloaca. Afterward, however, a transverse septum
forms between the geni to-urinary and anal openings.

In the beginning of life the vascular system is extremely simple.
The heart is at first spindle-shaped, and composed entirely of cells.
It then aseumes an S-shape, and becomes hollow. Fluid accumulates
in the cavity. Single cells detach themselves from the walls and float
in the fluid. These are the earliest blood-cells, and contain nuclei.
In like manner the vessels are at first solid round cell-cords, which be-
come hollow, fill with fluid, and furnish nucleated cells. It is inter-
esting, physiologically, to note that the heart pulsates long before the
muscular fibers appear, and when it is composed entirely of simple
cells,*

The anterior extremity of the heart is connected with the arterial
system. The posterior or caudal extremity receives the venous blood.
The heart soon becomes bent upon itself, and projects forward on the
ventral aspect of the embryo, and to the right side. As the bending
increases the arterial and venous ends approach one another. Two
slight constrictions divide the heart into three compartments, which
ojien into one another. "The first, next to the veins, is termed the
auricular portion, the middle one is the veniricular^ and the last,
which is the primitive arterial trunk, is named the bulbus arterioims "
(Quain). Fig, 58*

The bulbua arteriosus divides into two branches, which convey the

* A, Kot^LtKER, " Entwiekclttngs-Oeschichte,^' 2ie Auflagc, p. 169,

DEVELOPMENT OF THE F(ETUa

blood from the heart upward to tbe first (upper) Tisceral arch* At
this point, which corresponds to the future base of the brain, they
curre backward and then take a downward course in front of tlie
chorda dorsalis* These two branches of the bulbus arteriosus are
termed the superior vertebral arteries. They are likewise known as
the aariic arches. Beneath the level of the heart they unite for a short
dlstimce to form a common trunks which in turn again divides into
two branches, termed the inferior vertebral arteries. These latter run
parallel to one another, on each side of the future vertebral column, to
the caudal extremity of the embryo.

I.s^-

k 50— Dwrara of heart antl first arterial vcasebt fOuainV A, at a jperiod oorrespondimr
i,^. it... tki^^ .;^ii Of thirty-oi^hth hour of incuWlon; B and </, at the forty-eighth

I >n. 1, If primitive veins: 2, auricular part of heart ; 8, vcntricuW part;

-* . '>. 5, aftrtic arches — in C\ tneir ccKalesoencxs it dhown at a ; in B^ below the

I Xi-^-^y, r '\ Hm- s^x^rmd aortic arch id fonnud, and farther down this dotted lines indicate the

S<«tTtjon of'thfl sucoetNilinx arehca ; 6*, 5\ coDtinuation of main vcs^cla (inferior vertebral) ;
y $, omphalo-ixwacDtoric arteries.

lo their course the inferior vertebral arteries give ofl branches which
Mre at first limited to the area germinativa by a circular vein, termed
the Wnuir lerminaliH. The veins, which return the blood to the embr)^o,
oceup; a lower stratum than the arteries, and empty into two Bhort
tniiikx, communicating with the auricular extremity of the heart.
Kafaoequently the sinus terminalis disappears, and two arteries, die*
tSQ^blied by their superior size^ pa^s beyond the limit of the area
§erminativa, now termed the area vasculosa^ to extend over the sur-
fioe of the umbilical Tesicle. These vessels are known as the - * om-
pkiUihmesenieric** or *^ vitelline'^ arteries. At first four, but after-
wnrd two veins, Ix^artng the same name as the corresponding arteries,
return the blood to the embryo. Finally, the two omplialo-mesenterio
arteries and veins are replaced each by a single trunk, so that the en-

PHYSIOLOGY OF THE OVUM.

tiro Titclline circulation is maintained by a single artery and a single
vein.

According to this arrangement, the simple cylindrical heart, during

Fio. 60*— Arw VABCttlosa (Bi»ohoir)< a. a^ h^ Binui} termiDalk ; e. omplialo*iueeeoienc vein
df heart; «i/i/t posterior Teitebral ttitonca*

its systole, drives the blood into the vertebral arteries, by which il ia
distributed to the different re^ons of the embryo, and especially to
the walls of the umbilical Teaicle* There it becomes charged with nu-
tritive materials, and is conveyed hack to the heart during the dias-
tole by the omphalo-mesenteric veins. In the transition from the vi-
telline to the allantoic or placental circulation, corresponding anatom-
ical changes take place in the entire vascular system. Of these tha
more noteworthy are as follows : L The single ventricle of the hearth
becomeg separated into two compartments by the gradual growth of a
partition from the apex to the auricular portion. At the end of the
second month the partition is complete, and the heart eonsiste of two
ventricles and a single auricle. Next a partition extending from the.
base toward the ventricles divides the single auricle into a right and^
left compartment. This partition, imlike the ventricular one, is in-
comi)lete posteriorly, leaving an opening* the foramen ovale^ which
persists throughout the entire period of fetal existence. A thin cres-
centic fold, termed the Eustachian valve, is attached to the anterior |
border of the orifice of the inferior vena cava. The Eustachian valve'
divides the right auricle into two unequal portions, and directs the

DEVELOPMENT OF THE F<ETT:?S.

«0

r/H'

fp"

blood from the inferior cava, which lies behind it, through the fora-
men oTale into the left auricle. At the same time the blood from the
superior cava, passing in front of the foramen ovale and the Eusta-
chian valve, pouTB directly into the right ventricle. A thin cres-
centic valvular fold, termed the valve of the foramen ovale^ grows
from the posterior surface of tfie auricles to the front. It is situated
a little to the left of the foramen ovale and projects into the left auri-
cle. By its action the blood is allowed to pass undisturbed from
right to left, while it effectually prevents any regurgitation from left
to right

2. Meantime, beneath the aortic arches, there forms a series of
Taacular loops, corresponding in number and situation to the vi&ceral
arches in the sides of the neck of the foatus {vide B, Fig, 59). They
do not all, however, exist contemporaneously. A number of them
atrophy and disappear. On the right
side the third and fourth, counting
from above downward, and on the left
side the third, fourth, and fifth, alone

^ist, reserved for a gyx^cial destiny*
after the formation of the sep-
tam in the ventricular portion of the
hearty the bnlbus arteriosus divides
into two distinct vessels, of which one
(B) communicates with the right, and
the other (A) with the loft ventricle.
The left division (A) communicates
with the second of the series of loops
(cotuiting from below) formed be-
tween the ascending and descending
portions of the aortic arches. The
loop on the right side (4) becomes
the subclavian artery ; that on the
Vdt enlargeti and forma the arch of
the aortju The right division of the
bulbus arteriosus (B) opens into the
ft rat vascular loop on the left side.
This loop gives off branches (/?) to the
Ittiiga and becomes the pulmonary ar-
tery. That portion of the loop situ-
ated beyond the pulmonary branches continues during fetal life in
ojM»n communication with the aorta, and is termed the ductus arfe-
rimuM (d). The lower portion of the vertebral artery on tlie left
•ide becomes the permanent aorta, while that upon the right side
phioe and disappears. Tlie ascending branches of the primitive
^ archea furnish the common and externa! carotids (c e). The in-

llpnr

FiQ. «1, — DuiirniTO of th« roBcular arches,
with trKQtiformatioQa givW rise to
the pcmumcnt artedftl vosaelA (Rath-
ke). Tite auptic bulb is divided into
A^ the ascending part of the aortio
apcJi ; and f, the pulmonary part.
The vasculoj* arehc« ani nujuftred 1,
2, 8, 4, fi, from below upward, p,
]>ulm0iiary brand les ; d, ciuetya arte-
riostia j e f., external carotidM ; c t\
and c i\ latumal carotids.

ffifHOLOGT OF THE OV0M.

temal carotids (r i) Bxe formed from the third Yasctilar loops and a
portion of the vertebriil arteries,

Tho umbilical arteries at first take their origin from the inferior
vertebral arteries, and afterward from the hypogastric or internal iliac
arteries.

Tho umbilical vein enters the abdomen at the navel, and thence
passes to the lower gurface of the liver : it gives off a number of
branches to the left lobe, the lobus quadrat us, and the lobua Hpigelii.
At the transverse fissure it divides into two branches, the larger of
which empties directly into the portal vein, and supplies the right lobe
with umbilical blood ; the other passes to the inferior vena cava, and
is termed the ductus venosus. Thus the gi'eater portion of the regen-
erated blood, brought by the umbilical vein from the placenta, first
pasaes through the liver before entering the general circulation of the
foBtuSy while the lesser amount empties at once into the inferior vena
cava. Ab, however, with the advance of gestation, the relative dispro-
portion between tlie hepatic trunks and the ductus venosus is in-
creased, toward the end nearly all the blood from the placenta has to
make the circuit of the liven

Thus the inferior vena cava carries to the right auricle, in part»
blood from the lower extremities charged with effete matters, and,
in part, placental blood, eitlier received direct from the umbilical vein
throagh the ductus venosus, or after Itaving previously traversed the
liven

In the fcetus the currents of blood through the heart are especially
adapted to the unexpandcd condition of the pulmonary organs. Previ-
ous to the first respiratory act at birth, the lung is small, and, were
the entire contents of the right side of the heart, as in the adult, at
once discharged into the pulmonary vessels, intense engorgement with
rupture of the capillaries would ensue. This danger is, however,
averted by the anatomical peculiarities already stated. Thus, in the
early months the blood from the inferior cava, in place of empty-
ing from the right auricle into the right ventricle, passes directly
across the right auricle, guided by the Eustachian valve, through the
foramen ovale to the left auricle, and thence to the left ventricle. Aa
the heart contracts it enters the aorta, and is distributed by the large
yeesols which spring from the latter to the head and upper extremi-
tiea. The blood returned from the upper portion of the body by the
superior vena cava enters the right auricle, where it passes in front of
the Eustachian valve into the right ventricle. A commingling of the
current.^ from the superior and inferior ven^e cavae in the right auricle
is almost completely [prevented in the earlier months by the Eustachian
valve. With the advance of gestation^ however, a gradual disappear-
ance of the Eustachian valve takes place, so that a part of the blood
from the inferior cava enters with that of the superior cava into the

DE7SL0PMENT OF THE FCETUS.

right Tentricle. The contraction of the right ventricle forces the blood
into the pulmonary artery, which distributes an insignificant quantity
to the lungs, while the main current passes through the ductus arteri*

Jhtbnonar^ Art.

Formmen OvaU.- *^

Might Auric • VmU. Opmi^.^-

pnhmmmy Art,
Ufi Auride.
Ijtfi Auric, 'VaO.

HqfoUe Fem.,

Braneha of the f'--..lAiier.
Umbiiieal Vnn-^ l _ "

to the Liver.

Ihi£im Vmonta,

- V*

Jhtemal liiae Arteriet,
Fio. 6S.— Diognun of the fetal oiroulAtion. (Flint.)

rmSIOLOGT OF THE OVUM.

OBUB into the aorta, by which it is distributed to the lower portion of
the body.

Thu8 it will bo noted that at all times provision is made for sup-
plying the head and upper piirta of the body with regenerated placen-
tal blood- On the other hand, the lower extremities are for a time
almost entirely supplied with hlood which has already fed the tissues
and received the waste of the upjier portion of the body. As preg-
nancy, however, advances, with the disappearance of the Eustachian
valve, a small measui'e of placental blood is likewise distributed to the
lower portion of the body. This is in unison with the well-known
fact that the relative development of the lower extremities increases m
the end of gestation is approached.

With the cessation of the placental circulation at hirth, the um-
bilical vesselii close, with the exception of the umbilical arteries* which
remain pervious at their lower portion and constitute the vesical arte-
ries. After the establishment of respiintion, the blood from the right
side of tlie heart makes the circuit of the lungs and returns to the left
side by the pulmonary veins. The ductus arteriosus then contracts
and disappears. As the left auricle fills %vith blood, the pressure closes
the valve of the foramen ovale. Occasionally, however, the foramen
ovale remains oy»en after birth, and allows a portion of the venous
blood to pass from the right to the left auricle. We have tlien one
form of the condition known 'as cyanosis neonatorum^ an a^ection
characterized by intermittent attiicks of dyspncpa, blueness of the sur-
face of the body, and depression of the tempeniture.

Development of the Fcetl's in the Successive Months of

Pregnancy.

It is customary to reckon the duration of pregnancy at two hun-
dred and eighty days, and to divide that f^pace into ten months of
twenty-eight days each. As it is often a matter of importance that an
accoucheur should be able to judge the age of a prematurely expelled
embryo or fa'tus, the following particulars concerning the changes in
each month are furnished as a guide to the formation of an opinion.
In the writers experience all rules regard ing the age of the ovum
possess, however, nothing more than an appr4jximative value, owing
U) the very great normal variations in the rapidity of development in
different individual cases.

First Month. — At the end of the second week, the embryo is rep-
resented by the embryonic spot, which has assumed a biscuit-shape.
The dorsal plates are developed. The entire ovum measures one fourth
r>f-an inch, and the embryo one twelfth of an inch. A week later the
embryo has doubled in length, and presents as special features a curv-
ing of the back, an enlargement of the cephalic extremity, with rudi-
ments of the three higher organs of special sense, and the appearance

DEYELOPMEXT OF THE FCETUS.

of the Tiaceral arches. The amnion is fully developed. The emhryo is
nourished by the umbilical vesicle. The allantois carries the vesselfi
from the embryo to the periphery of the ovum, but the vessels do not
penetrate the villL An ovum described by Waldeyer, exactly four weeks
old, was of about the size of a pigeon-egg, and three fourths of an inch
Img by two thirds of an inch broad. It weighed upward of two scru-
ples* The embryo nieasured nearly one third of an inch in length, or
four fifths of an inch in length following the dorsal curvature from
the top of the cephalic extremity lu the end of the coccyx. The head
of the embryo presented the primitive cerebral vesicles. The eyes were
in the side^ of the head, and the ears posterior to the eyes. Beneath,
the visceral arches were well marked* Four bud-like processes indi-
cated the beginnings of the anterior and posterior extremities. The
miestine, with anal and oral openings, was formed. The cord was
short and thick, with a single vein and two artmes. The amnion waa
only moderately distended, and space still existed between the amnion
and chorion. The umbilical vesicle waa tolertibly large.

Second Month. — An embryo described by Waldeyer from the sixth

to the seventh week measured about one inch in length, following the

dorsal curve. Another in the eighth week described by Ecker meas-

, tjred two thirds of an inch in a direct line from the head to the caudal

eurve.'* The ovum itself was of about the size of a henWgg. The

amnion at the end of the second month is distended with fluid and in

contact with the chorion. f The villi become abundant near the im-

^plantation of the umbilical cord. The umbilical vesicle is greatly

reduced in size, and hangs from the embryo by a slender pedicle*

^ The umbilical cord is increased in length, but its vessels do not yet

l^sfiome a spiral direction. The umbilical ring is small, though still

attuning loops of int-estine. Ossification begins in the lower jaw

iod clavicle. The three divisions of the extremities are clearly indi-

^fiated«

Third Month. — Toward the end of the third month the ovum me^is-
F^re« ni.^ariy four inches in length. The embryo is between three and
Ihrf^ and a half inches long, and weighs about an ounce. The chorion
haa lofit in great measure its villosities. The placenta is formed,
though of small size. The cord lengthens, and forms spiral turns,
Tiie neck now separates the head from the trunk. The development
of the rib« distinguishes the thorax from the abdomen. The mouth
i§ closed by the lips, and the nasal separated from the oral cavity by
the palate. Points of ossification appear in most of the bones. Thin,
' membmne-like nails appear upon the fingers and toes. The scrotum
and labia majoni begin to form from cutaneous folds. The penis and
clitoris do not differ from one another in lengtli.

^ SriEdELDKRO, '* LcbrliUL'h dur GcbuitsUulfc/* p, 84.
f Xotf. eU^ p. §4,

PHYSIOLOGY OP THE OVUM.

Fourth Month. — Toward the end of the fourth month there is an

increase of size and thickness in the placenta. The cord is increased
to two or three times the length of the fcetus, and has become thicker
from the formation of the gelatine of Wharton^ The foetus measurei
four to six inches in length. The weight is estimated all the way be-
tween two and four ounces. The head of the fcetus is one fourth the
length of the entire body. The bones of the skull are partly ossified.
The sutures and fontanelles are widely separated. The mouth, eyes,
ears, and nose assume their proper shape. The sex is distinguishable,
the skin firmer, and hair begins to form upon the scalp. The foetus
makes slight movements with its limbs.

Fifth Month. — The fcetus measurea from seven to ten inches in
length, and weighs nearly ten ounces. The head is still relatively
large. The face, however, is wrinkled, and wears a senile aspect
Fine hair (lanugo) appears over the w^hole surf ace of the body. The
fetal movements are now distinctly felt by the mother.

Sixth Month. — Near the end of the sixth month the foetus is eleven
to thirteen inches long and weighs about twenty- three ounces. The
deposition of fat in the subcutaneous cellular tissue begins. The eye-
lids separate. A fcetus born at this time breathes feebly, but in the
course of a few hours dies.

Seventh Month. — The foetus measures fourteen to fifteen inches,
and weighs in the neighborhood of thirt^^-nine ounces. The skin is
still wrinkled, of a red color, and covered with vemix caseosa. Chil-
dren bom between the twenty-fourth and the twenty-eighth week
move their limbs and cry feebly at birth, but in spite of every care
they die in the course of a few hours or days.

Note.- — Ahlffld has recently Btig^csttHl Ihc inquiry tm to whether the AAiumption, that
children bom before the completion of the twentj-eigbth wc«k nece^arily periflh, U Dot
too arbitrary. Many practitioners have observed instoDcea of the sunrlral of a premature
child which, both from the data obtained from tbc parents and from all the indicatioiw
presented by the child, they, at the time of birth, had placed within the Umlt rc^rded ms
hopclcsa* Ablfeld has cuUed a number of such cases from the published literature of the
subject. Granting the many sources of error which would lead us to accept such cases
with caution, it none the less seems incumbent upon us to regard Ahlfetd^s advice, aod
look upon every child which respires at birth a9 one whose life may [Kkssibly be preeerred
by suitable care. It may be that the skepticism of medical men may be in port the oaoBe
of the unfavorable results,*

Eighth Month, — The fcetus measures sixteen to seven t-een inches,
and weighs upon the average about fifty-two ounces. The papiUary
membrane disappears ; the hair of the head increases in thieknesa ; the
lanugo begins to disappear from the face ; the nails are harder, but
do not yet reach the tips of the fingers. Usually, in boys, a testicle
may be felt in the scrotum ; the navel is situated nearly in the center

^ AsLFELD, " Uebcr tmzertSg uod sehr fi uhzciUg geborcno Friiohte die am Leben
UUeben," " Arch. 1 Gynaek.," Bd, vUl, p. 194,

DEVELOPMENT OF THE FCETUa

of the child's body. With care, the life of a child born within this
period may be preserved.

Ninth Month. — The length is between sixteen and a half and seven-
teen and a half inches ; the weight is about sixty-four ounces ; the
body becomes rounded and the face more comely, losing its wrinkled,
antiquated aspect ; the bones of the head bend easily, and the lanugo
begins to disappear from the body. Children at this period are loss
energetic than at full term, deep a great part of the time, and are
prone to die with lack of careful attention.

Tenth Month.— In the first two weeks the foetus measures eigh-
teen to nineteen inches, and weighs about seventy-seven ounces,*

For convenience of reckoning from memory it is sufficiently accu-
nie to a^ume the length of the child in the third and fourth month
at respectively three and four inches. In the fifth, sixth, seventh,
and eighth months close approximations to the average length may be
obtained by doubling the number of months. In the ninth and tenth
months the length may be placed respectively at seventeen and
eighteen inches.

The FoBtus at Term* — In the child at birth the body is well rounded,
and the ekin has lost its deep-red coloring ; the fine down (lanugo)
biBy for the most part, disappeared ; the nails project beyond the fin-
ger-tips ; in the male the scrotum contains both testicles, and in the
[fctoale tlie labia majora are in contact. In the fifth month the sur-

f ot the fetal body is covered by the vernix cmeom^ a whitish sub-
composed of a commingling of surface epithelium, down, and
( the products of the sebaceous glands. This coating probably protects
the akin during intra-ttterine life from the i>enetration of the amniotic
fluid. The amount of this substance upon the body is very variable
at birth, when it is chiefly found upon the back and flexor surfaoea
of the extremities.

Children at term cry lustily soon after birth, move their limbs
ttmiy^ and nurse when put to the breast. In the first few hours they
paas urine and the so-called meconium, a mixture of intestinal mucus
with epithelium, epidermis cells, lanugo, and bile, which gives to it a
bloiek or bn>wniah-gTeen color, f

The average length at birth is from twenty to twenty-one inches.
"Tie average weight seems to bo, in some degree, de|>endent upon race

♦ The wcjghtfl and naciaurcs are taken fmm Hecker'a averagef, based on 486 obscrra^
Bi. ( Vid0 ** Monit^schr I, Geburt«^k.;" Bd. xxrii, 180(>.)
ObtfcrrationB of Foaaer showed similar faults. (" Lchrbucb dcr Ooburtahulfc/* Ton
Oifo SrikoELBCJifl, IB 77, p. B6,)

Ahlfefd obtniniNl considcrBbly larger iTcrap^es from 260 obserrationii in which the
, dftto of rcinifptton could be determined. (^' DcMimmungi^n der Groa&e und des Altera dcr
iJrwOiC rur der Gcbiirt," " Arch. f. Gynaek.," H, 1871, p. SfiL)

) Zwnrct^ " UQi«!r9ucbuDgcn tiber daA Meconium/* ^ Arch, f. Gjnack /' Bd. vit^ 1875

PHiSIOLOGY OF THE OVUM.

peculiarities. Scanzoni* found, in nearly 9,000 births, an ayeraga
for both sexes of nearly seven pounds, Ingerslev,f in Copenhagen,
from statistics based upon 3^450 births, arrived at nearly the same
results. Hecker.t in Munich, out of something over 1,000 births,
obtained six and fonr-tift!is pounds as the average ; while Fesser,* in
Breslau, found it only six and a ball pounds. Bailly [ likewise reports
the average weight as something less than seven pounds. The weights
of 200 infants horn in the Belle vue nos]>ital gave to the writer an aver-
age of seven and two tliirds pounds for the two sexes. The boys
averaged seven aud nine tenths pounds, and the girls seven and one
third poundsp Three fourths of the mothers were of Irish birth, one
fifth were bom in America, while the remaining fraction was divided
between English, Scotch, and Oerraans, The largest child weighed
eleven pounds. Ingerslev's largest child weighed ten and three eighths
pounds ; Hecker found two weighing between ten and eleven pounds ;
La Chapelle, out of 7,000 cases, found thirteen infants weighing ten
pounds, but none exceeded that limit. Credible histories^ of children
weighing from twelve to sixteen pounds? are extant; such children
have generally been still-born. Waller, however, reports a case of
a living infant delivered by him with forceps, which weighed fifteen
pounds fifteen ounces, ^ The size of the child is influenced in especial
by — 1, The sex. Boys average a greater weight than girls, 2. The
number of pregnancies. The children of pri mi parse average less than
those of multipara*. The increase in weight of children in each succes-
give pregnancy is progressive, though tliis law is liable to interruption
where pregnancies follow one another too rapidly, or in cases in which
there is a change of sex. In the latter instance the variation is to the
disadvantage of the female born in succession to a male.J 3, The age
of the mother. Duncan found the greatest weight in children bom
of mothers between the twenty-fifth and twenty-ninth years; J Wer-
nich, between the thirtieth and thirty-fourth years.} 4. The constitu-
tion and health of the parents. By some, too, the size of the father
is supposed to exercise an influence upon that of the child.

The Fetal Cranium. — Except in children of exaggerated size, the

♦ ScANZONi, ** Lcfarbuch der Gcburtshiilfe," p, 96,

t l»a«iiSLi?'ts " On the Weight of Ncw-Wni Cbildren," "Obstct. Joar/* ui. 18t«,
p. 706.

t ** Klinik der Geburtekimde,'' ii, 1S6I.

• SpiEGELiiERU^ *' Lchrbiich dcr Geburtshiilft?," p. S6.

I Bailly, " Xouvcau Dictionnaire,'* t. xv^ art, ** Fa*tu8»*' p, ft.

^ Nakoell^s *'Lcbrbucli iler Gcburttiihulfe" bparbcUetTon Grcuser, Stc Auflii^p, 624.
^ WALLtft, London **Ob»tet. Trans. /' vol. i, p. 309.

J WiiENicH, **Ueber die Zunahme dcr weiblicben ZeugUDgsfMbigkeit," **Bcitr, zar
Gcbuttsh.;' Bd. 1, p, 3,

% DtJscAN, " Fecundity, FcrlilStyi and SteiiUty/* p, 53.
J Loe. ^.^ p. 10.

DEVELOPMENT OF THE FCETDS.

Ibead IB the most Toluminous and unyielding part which has to traverse
tlie parturient canal.* The diameters of the head and the physical
characters of it^s bones are chiefly of importance in connection with the
mechanism of labor. Their consideration may, therefore, be conven*
ientlj postponed to the study of that subject. A knowledge, how-
ever, of the general stractnre of the skull is essential to the diagnosis
of pregnancy.

The face is very small in proportion to the cranium. The latter

1 consists of the two frontal bones, the two parietal bones, the occipital

[bone, the temporal bones, and the alaB of the sphenoid bone. At

birth these various bones are not, as in the adult, directly articulated

together, but are united by means of fibrous bands, termed suiures.

mlim^

fV>-

Fto. (^. — Fetal heftd, side-view.
(Uod^)

Fio. 64. — Fetal bead, viewed from
abovo* (Ilodgo.)

lich ossification subeerjucntly takes place. It is important to be-
familiar with the following sutures : 1. The frontal stduref
^tween the frontal bones, 2, The sagittal suinre, between the two
ietal bones. 3. The coronal suture, between the frontal and parie-
bones. 4, Tlie lambda suture, between the occipital and two parie-
tal tiones.

^Tien three or more bones meet together^ the rounded angles of
he bones offer at the point of concurrence a deficiency of osseous sub-
•taiiee» which is closed by fibrous membrane similar to that which
forms the sutures. These membranous interspaces are termed /bw/a-
ilbt. Two of these, the large anterior and the small posterior fonta-
^f are of immediate obstetrical interest, as they, with the sutures,
li»h the guiding points which enable the examining finger to
iet«rmtne, in advanced pregnancy, the position of the child*s head.
^The large fonianelle, or bregmatic space (bregma, the sinciput),
ipies the gap between the parietal and frontal bones. It possesses
a lozenge-8ha|>e. Its anterior angle is continuous with the frontal
gatart* ; its posterior angle with the sagittal suture ; and its lateral
angled with the two halves which compose the coronal suture. Its
aut^" '1e is much longer than the posterior angle.

'i '// foniant'lle is situated at the junction of the occipital

rith the parietal bones. It is of a triangular shapo, and, as its name

* Ia tmlkjr ffaildren, tbe ihouldcrs tomeiimefl offer the greatest dlfUculties in delivery.

PHYSIOLOGY OF THE OVUH.

indicates, of small size. As a rule, it no longer exists at birth,
owing to the complete ossification of the angles which form it.

The anterior fontanelle may be recognized by the finger, during
labor, by its large size, its lozenge ebape, and by its four converging
sutures which cross one another at right angles. The posterior fon-
tanelle, on the contrary, is small and triangular ; the sagittal suture
forms, with the lambda snture, an obtuse angle on either side, and
terminates at the occipital hone. During the descent of the child's
head into the pelvis, the occipital bone is frequently depressed beneath
the parietal bones^ which tbna form a relief, along which the finger
readily passes to the site of the small fontanelle, even when the latter
no longer exists as an open gap or space.

The ATTrruDE, Presektation, akd Posmoif of the Fcetus,

^le afiUude of the fcctus in uiern is as follows : The spinal column
J8 bent forward, the chin is inclined toward the chest, the arras are

bent at the elbow, and the forearms
are crossed upon the breast, the thighs
are flexed upon the abdomen, and the
feet extended so as to come in contact
with the legs, which, like the fore-
arms, are often crossed. By this ar-
rangement the foetus assumes the
smallegit bulk, and presents an ovoid
form, of which tiie head furnishes the
smaller enA.
, I By presentaiion we understand

\ I that portion of the foetus which oc-

enpics the lower segment of the ute-
rus. By the determination of the
presentation, we are enabled to decide
upon the relation of the axis of the
r . r child to the long diameter of the nte-

.^ iVi\ I rus. When these two coincide, either

of the two extremities of the child,
viz., the head or the breech» becomes
the presenting part. When the long
diameter of the child corresponds to
the oblique or transverse diameter of
the nterus, the shoulder becomes the
presenting part.

Though head-presentations form.
during labor, by far the large majority of all cases (ninety-six per
cent,), changes of position are very common during pregnancy. The
frequency of the^e changes is in inverse ratio to the advance of preg-

Fio. 65.— Attitudo of fcettis in vt4t^,
(Tarukr ct Chantreuil,)

BEVELOPMEKT OF THE FCKTUS.

occurring with diminished frequency in the later months. In
Itiparse they take place oftencr than in^primiparse. In multiparae
they occur not rarely shortly before birth, while it is exceptional in
primiparse for them to take place in the last three weeks of pregnancy.
Great ingenuity has been exercised to account for the preponderating
freqaency, at the time of labor, of head-presentations* Hippocrates
taiaght that, during the early months of pregnancy, the fcetus occu-
pied a sitting posture, with the head uppermost. In the seventh
moDth^ however^ it made a complete turn or eomersault preparatory to
tt« exit from the womb, an act accomplished by the voluntary efforts
of the child. Aristotle referred the head*presentations to the laws of
[gravity, a theory which has always had many adherents and is still
ively defended at the present day.*

Dubois t made a serious breach in this doctrine by showing that if

he allowed a dead foetus, of any jieriod between the fourth and ninth

mouthy to sink in a vessel filled with water, it was not the headt but

[the back or right shoulder which first reached the bottom. Dubois

feupon denied the influence of gravity, and referred the head-pres-

itions to instinctive or voluntary movements on the part of the

taa, designed to bring it into a position best adapted for intra*

Iterine domicile^ or for parturition. He likewise argued against the

fpiTitation theory, that in premature births, and in children who die

m uiero^ pelvic and transverse presentations are very common, a fact

^Uut would be inexplicable were gravity the sole or chief force in opera-

ioR. Simpson I agreed with Bubois in ascribing the cephalic pres-

ions to fetal movements, but, in place of the instinctive or

itary movements of Dubois, substituted, in an argument of ex-

trnofdioary ingenuity, a theory of reflex action. Thus, the frequency

of malpositions in the first six months of pregnancy was explained by

Ibe spheroidal shape of the uterine cavity, which allows of unrestrained

fetal movements. In the latter months, however, as the uterus as-

muned a more ovoid shape, it was only when the child was situated in

the uterus with the head lowest that a physical adaptation l^etween

f(^iUf; and uterus existed* In case, from any cause, therefore, a devia-

i_tJon from this, the normal position, took place, the pressure upon

be cutaneous surface of the child, by the uterine wall, would give rise

-motory movements of an adaptive kind, calculated to restore

rAlltirbed presentation. Duncan ^ and Veit succeeded in partially

• Vfdt MstoncaX part of C^hnstcin^B paper entitled ** Die Aetio]ogi<j dcr nonnalcD Kin-
' lIonat»»cb. f. Gebtiitsk,/' Dd. xxxi, p. 142.

^ HunotM, ** ll^moire <mr la cause dcs prdBcntationB de la tfll«,'' *' M^ni. de TAcad, R07,
d« V^;' iumc ii, 1833, p, 265.

) SntmoK, *' AUilude and Positions of the Fwtua In Utcro;'* ^* Obstetric Work«/*
«dll«>d bf PHcalley and Storer, toI, il, p. 81,

• DcKCAii, *'Besearcbcd in Obsteuics/* p. 14. Veit, Scanxoai't "Beltriigc," Dd. iv,
^ t7H

PHYSIOLOGY OF THE OVtTM.

rehabilitating the gravitation theory by showing that, notwithstanding
Dubois's experiments, the center of gravity lies much nearer the ce-
phalic than the pelvic extremity of the child. They found that a
fresh foetus immersed in a saline fluid possessing nearly the same spe*
eific gravity as the fcetus, in place of sinking upon its back or side to
the bottom of the vessel, assumed an oblique direction in the fluid
with the right shoulder looking downward.* They, therefore, con-
cluded that the fa^us, lying upon the inclined plane furnished by the
uterine walls^ would naturally assume a similar position, were no other
forces operative to interfere. Finally, we have the opinion of Cred^^ of
Kristeller^f and of Braxton Iliclis, | that the contractions of the preg-
nant uterus adapt the position of the feet us to the form of the uterus.
Now, each one of these conflicting ideas undoubtedly represents a
portion of, but not all, the truth. It is certain that all the influences
cited do exist, and it only remains for us clinically to assign to each its
relative value. In the early months of pregnancy, the spheroidal
shape of the uterine cavity, the small size of the fcetus in comparison
with that of the uterus, and the large proportion of amniotic fluid, all
allow the foetus the greatest measure of mobility. At this time the
position of the child must be influenced by the active movements,
which are felt by the mother subjectively often as early as the four-
teenth week. As, usually, during the first half of pregnancy even,
the shoulder and head are turned downward, it is fair to ascribe this
position to the laws of gravity. The frequency of malpresentations in
premature laboi's is explained in part by the tardy dilatation of the
cervix and the mobility of the foetus, which render easy the displace-
ment of the head from its first position, under the influence of preset-
ure exerted upon the axis of the child's body. Malpresentationo
are more frequent in the case of a dead ftetus than in the living,
but Duncan has shown that in the dead foetus, owing to post-mortem
clianges, the center of gravity often shifts toward the pelvic ex-
tremity. With the advance of pregnancy, as the longitudinal ex-
ceeds the lateral growth of the uterus, the child adapts itself to the
long axis of the uterus ; and the further pregnancy advances the more
complete the adaptation becomes. When from any cause or condition
the correspondence between the fetal and uterine axis is disturbed^
compression of a portion of the cutaneous surface of the fwtua results.
Reflex movements, especially in the lower extremities, are excited,
which restore the faHus to that position in which it enjoys the most
complete freedom from discomfort. Often, too, the uterine walls resent
tlie pressure of the foetus, and, by their contractions, serve to maintain
the body of the child in the uterine axis.

* On ftccoimt of the liver upon tVie ripht side.

I yidf Sell foederis " llntidbueli der Geburtahiilfe^*' Ate Au^Ogc^ p* 47*

t Hicks, " Contractions of Fregnant Utemt," " Obstet Tr»oa.,** p. 894.

DEVELOPMEXT OF THE FCETUS.

In cases of hydramiiios the conditions more nearly resemble those
which exist in early pregnancy ; hence malprescntations occur with
greater frequency, favored by the mobility of the foetus in the surplus-
nge of amniotic fluid. Per contra^ when, iia is the case toward the
end of normal pregnancies, the foBtus nearly fills the intra-uterine
0{Mbce» the movements are very restricted, and displacements rare.

lo primi parous women, the pyriform shape of the uterus in the
Ufcer months is most marlced, and as a consequence the head of the
child is usually held by the uterine walls in the pelvic cavity. In
nmltipara^, on the contrary, owing to the relaxation of the uterine
parietes, it is usual for the child, in obedience to the laws of gravity, to
lie somewhat obliquely in the uterus, with its head resting upon one of
the iliac fo6sie. As soon as labor begins, however, the uterine con-
y^ctiona carry the head to the axis of the superior strait of the pelvis.

The changes in the fetal presentation are not, however, confined
to simple conversions from an oblique to an upright direction, or to
ghiftings of position in obedience to laws of gravity. But even in ad-
ranced pregnancy a breech-presentation may become a head-presenta^
tion, and vice versa,* P. Muller reported a case in which the fcBtua
made ffix such revolutions within five days, f Now, it can not be sup-
posed that the difficulties wliich the foetus must encounter from the
lesigtance of the short transverse diameter of the uterus could be over-
come by such comparatively feeble forces as gravity, or reflex adap-
tive moTcments, or partial uterine contraction. In Miiller's case the
chaogee, if the mother*8 story be correct, must have taken place, not
grmdualiy, bat suddenly, and by the vigorous movements of the child's
limb& The character of the movements, whether spontaneoua, or
refiex, or instinctive, remains, of course, a question requiring further
inrestigation.

^y position is designated the relation of a determinate point in the
body of the fojtua to the uterine walls. In head or breech presenta-
^oiii» the back of the child is most commonly turned to the left, which,
beoee, is termed the first position. The back turned to the right is
known ss the second position, and occurs with much less frequency.

In the Orst position the back is usually directed somewhat ante-
riorly, while in the second position it is turned rather to the rear-
la shoulder-presentations the back is usually directed to the front,
Ohttngos of position are frequent in pregnancy, and take place, when
other influences do not prevent, in obedience to laws of gravity. When
the woman stands erect, the axis of the aterns is continuous with the
axia of the superior strait of the pelvis, and forms with the horizon an

• ScBlOKDm, "Schwang. Geb. u. WochcDbctt," Bonn, 1867, p. 21 ; StrffULTZX, ''Un-
%m%. ftbfr d«n Weche<>l cter Lag«," etc, Ldpfiic, 1868; Fabbbxhscb, Bcrl. **Bdtr%e sur
Ock oad GfTiAipli.,*' lid 1, p. 4U

\ 8eAii%09ira *'12ftxiabucb der Geb./* 4t6 Auflage, p. 128.
6

PHYSIOLOGY OF PREGXANCY.

angle of thirty-five degrees. The uterua does not occupy exactly the
median line, but lies more to the right It is also twisted Blight! j
upon its axis, so that the left lateral portion is directed somewhat to
the front In the upright position, therefore, tlie anterior wall of the
uterus not only forms an inclined plane, hut one, too, with a down-
ward drop toward the left side. Now, if these relations be borne in
miud^ it will be readily seen that the child, resting upon the inclined
plane furnished by the anterior wall, with its right shoulder look-
ing downward, must, if left to itself, turn with its back to the left
aide of the uterus. In the recumbent posture, the axis of tlie ute-
rus forms with the horizon an angle of thirty degrees, and the down-
ward Blope is to the right side. The child, now resting upon the
inclined plane furnished by the posterior wall, with its right shoulder
looking downward, would naturally turn with its back to the right
side of the uterus. These considerations are not purely theoretical, as,
when the conditions have been such as to allow the foetus latitude
of movement, the changes indicated in the fetal position foDowed
changes in the attitude of the mother.*

PHYSIOLOGY OF PREG:N'A:srCY,

CHAPTER IV.

CffAJfGES EFFEOTED W THE MATERNAL ORGANISM BT PREGNANCY,

Ch&ngca in the sexual appamtua and neigb boring organs-^^bangea in the uterus. —
Explanation of apparent shortening of cervix, — Changei in the vagina, rulva, ab-
domen^ navel, broaats, nipple— ^Functional disturbances of bladder. — Coostipatioa,
— (Kdcm Oh,— ^Changes effected in the entire organism.

ChAKQES OCCUKRIKG IN THE SeXUAL APPARATUS AND NeIGHBOB-

iNO Obqans.

The pre^ant state is signalized bj the nutritive energy imparted
by the fecundated ovntn to the goncrative organs and to the viscera
in their vicinity.

The n terns, from the inception of pregnancy, increases in vascu-
larity. Its mucous membrane becomes soft and thickened. The
museuhir fibers are increased seven to eleven times in length, and three
to five times in width. During the first five months new muscular
fibers are developed, especially upon tlie inner layer of the uterua.
• Hi*siNo, Scanzoni^s •* Beitrilge," Bd. rii, p. i>9.

CHANGES IN THE MATERNAL ORGANISM BY PREGNANCY. $3

The delicate connective-tissue processea, between the muscular fibers,
become more abundant, and, toward the termination of pregnancy,
digplay distinct fibrillae. The yessels increase in number, length, and
circumference. The arteries, as we haTe noticed, assume a spiral
course, and in places communicate directly with the Tcins. The veins
are dilated, and form, espocially in the placental region, wide-meshed
net-works. The walls of the veins are intimately united with the
mtiscular walls of the uterus, and form, when divided, open-mouthed
canals* The lymphatics, starting from the spongy tissues of the lin-
ing nmcous membrane, traverse the muscular structures, and are
gathered up by abundant plexuses, which are distributed especially
over the fundus and sides of the womb. The nerves increase in length
and thickness, and gi-ow inward toward the uterine cavity. UiJon the
inner surface of the uterus ganglia may be observed,* The ganglion
oervicale, which measures in the non-pregnant condition three fourths
of an inch in length and one half an inch in width, is now an inch
and a half in breadth, and possesses a length of two inches.

These textural changes are accompanied by an enormous increase
in the volume of the uterus. The weight of the latter in the virgin
state is about an ounce, while toward the end of pregnancy it weighs
in the neighborhood of two pounds. The increase in the bulk of the
oteros is progressivet The following table, by Arthur Farre^f fwr-
nifihes approximate measurements for the different months of preg-
nascj :

Lwiffth, Width.

End of 3d month 4^-5 inches, 4 inches.

*^ 4lh " 5M *' 5 "

** 6th ** 6 -r " 54 "

** 6tU " 8-9 »' 6J **

»* 7lh •* 10 " 7* "

« gth ** 11 ** 8 '*

" 9th " 12 '* 9 **

According to Levret, the surface of the virgin uterus measures six-
teen isrfittare inches, while that of the pregnant uterus at term measures
Ibree hundred and thirty-nine square inches,! The uterine cavity is
wMM by Krause to be enlarged five hundred and nineteen times.**

The enlargement of the uterus is not due, in the beginning of
prDgiuincy at least, to the pressure of the expanding ovum, for the
Mme changes occur during the first four months in cases of extra-
uterine pregnancy. In the latter months, however, a mechanical

* Bnxi7m.BC]to, " Handbuch der Ocburtsbiilfc," p. 60.

f ** Ojrclop«dla of Anmtomj ind Pbysiologj/* article " Utcrui aud its Appeadiigcs,"

J Vidt ScA!iEuNT, " Htttidbucb dt?r Oeburtflhiilfe," p. 11.

• Vide SnsuJCLiieJtu^ " Uaodbucb dcr GcburUhiilfc/* p, 51.

PnYSIOLOOT OF PREGNANCT.

gtretcliing is probable^ as the walls become thinned and conform to
the size of the oYum. At term, the walls are not of nniform tliickneBSp
but vary between one sixth and one fourth of an inch.

In advanced pregnancy three muscular layers are distinctly marked.
They consist of— 1. The external layer, which covers the uterus like
a delicate veil, and which is intimately adherent to the jK?ritonaeum ;
2. The midd!e layer, which makes up the bulk of the uterine walls —
it consists of circular fibers surrounding the vessels, and circular and
longitudinal fibers, which interlace with one another ; 3* The inner
layer, composed mainly of circular muscular fibers, which form con-
centric rings about the orifices of the tubes and os internum.* The
third, like the first layer, is feebly developed. The existence of a dis-
tinct sphincter muscle at the oa internum is admitted by many anat-
omists, and questioned by others. The clinical evidence in its favor
is strong. According to Kreitzer*s investigations, the museular fibers
amund the os internum lu all the layers have a more or less transversa^
direction.}

With the growth of the gravid uterus, the peritoneal coat is put
upon the stretch, and, in places, a thickening of the serous membrane
takes place by the formation of new tissue-elements. At the sama*!
time, the folds of the broad ligaments gradually separate, so that
toward the end of pregnancy the ovaries and Fallopian tubes are in
close contact with the uterus*

The growth of the uterus is confined chiefly to the body, the cervix
participating only to a slight extcmt. In the early months, the in-
crease is rather in the antero-posterior and lateral diameters than in
the longitudinal diameter. As a eonsequeoce, in the rule, it is not
until the fourth month that the fundus can he felt through the ab-
dominal walls above the symphysis pubis. In these earlier months
the normal antelkxion of the uterus is increa^sed by the weight of the
coqius uteri. In the fifth month the uterus fills the hypogastriura,
and in the ninth month reaches the epigastrium. During the lasiJ
two weeks, however, tlie uterus sinks somewhat into the jielvic cavity* "*
At the same time the fimdus of the uterus sinks downward and for^
ward, so as to stand about three inches beneath the lower extremity
of the sternum.

In the upright posture the uterus, in advanced pregnancy, rests
upon the anterior abdominal walls. As, in the intervals of contrac-
tion, the uterus is a mere eac with fluid contents, it becomes flattened
from front to rear, aud the width increases at the expense of the dis-

• For ft minutp dewription of the intricate mranf^cnipiit of tTio mufloiiiar fibers %n thaj
difFcrcnt lavcrB of the uteru?*, vuii H^lid, " Rechcrchcs gur les dispositionB des fib
musciiletisea de rut^rua dfivellopeesi par la groescasc/' Pttriii, 18ti4,

f KniiTXicR, '*Anftt» Uoters,, iiber die Musculatur der aielit ftchwaiigcni Gubirmut^
ter,*' "St. Pct^rsb. med. Ztscbr.," 1871, Heft ii, p» 113»

CHANGES IN TUE MATERNAL ORGANISM BY PREGNANCT.

tanoe from the fundus to the symphysis pnbis. In the horizontal
position* in which the uterus rests upon the vertebral column, its
length is, on the contrary, increased and its width diminished. In
the upright position, the intestines occupy the space posterior to the
Qtertts. In the dorsal position, the intestines lie chiefly upon the
sidcts, but partly too in front of the uterus.

During the first three months of pregnancy, the pyriform shapo
of the uterus is preserved. During the succeeding three months, ow-
in^ to the relative increase in the lateral and antero-posterior diameters,
the body gradually assumes the appearance of a flattened spheroid.
After the sixth month the longitudinal diameter again preponderates.
As the dilatation of the uterus takes place more rapidly in its upper
than in its lower segment, the cavity of the organ assumes, under
BOfmal conditions* an oval shape, with the narrow end pointing down-
waid, corresponding to the ovoid shape of the foetus in head-presenta-
tions* It was long taught and believed that this change of shape,
occnrring in the latter months of pregnancy, was duo to the gradual
I unfolding of the cervix uteri from above downward, which thus con-
i tributed to the enlargement of the uterine cavity. It is, however,
[probable that, with rare exceptions, the cervix uteri maintains its com*
t plete integrity up to the commencement of labor. The enlargement
I of the uterus, necessitated by the development of the fcetus, results
chiefly from the growth and distention of the fundus and posterior
uterine wall.*

The cervix uteri participates in the hypertrophy of the entire
uterus. Its development, however, is completed by the fourth month,
and 10 the result not so much of increased growth or new formation
af ltaBae*element9 as of the loosening of its structure and swelling
from serous infiltration. This latter is the consequence of a hvpera?mia
I of the cervix, which results from the passive relaxation and dilatation
tof the cervical vessels. It occasions a i>hygiological softening of the
which first manifests itself in those portions of the cervix
'where the least resistance is encountered, viz., beneath the mucous
membrane beginning at the os externum, extending outward through
the mufctilar structures of the vaginal portion, and afterward upward
lt<iward tlio os internum. f The follicles of the cor\ncal mucous mem-
tbrane furnish a thickened secretion, which fills the cervical canal, and
forms what is known as the ** mucous plug/' Frequently the orifices
kf the follicles become occluded. The follicular sacs then fill with
|tfapir own secretion, and project from the mucous surface as tlie ovules
l^if Naboth. Erosions about the os externum are rarely absent in ad-
vanced pregnancy.

• For the contrary Ticwy* maintained by Bandl^ vuU note, p. 28^ wrtide " Labor,**

\ Lan, "Zur Anatomie uod Physiologicj des Cervix Uteri,'* Erlangen, 1872, pp

PHYSIOLOGY OF PREGNANCY.

With the advance of pregnancy an apparont shortening of the cer*
vix take3 place, at first confined to the vaginal portion, but afterward
inTolving the entire organ. The earlier explanation of this phenomenon,
and one which still meets with very general acceptance, assumes that,
after tlie sixth month, a gradual unfolding of the cervix from above
downward takes place, which contributes to the enlargement of the
uterine cavity. In this manner space is provided in correspmndcnee
with the rapidly increasing growth of the foetus. The etn^ngth of
this doctrine hiy, in a great measure, in the seemingly confirmatory
evidence afforded by digital explorations.

In opposition to the current opinion, Stoltz, in his inaugural thesis,
published in 182G,* maintained that the internal os remained closed up
to the last two weeks preceding delivery, when, indeed, under the in-
fluence of painless contractions, the eflacement of the cervix, described
by earlier writers, did in fact, at least in pnmiparap, take place* Stoltz
explained the apparent shortening of the cervix as the result of a
spindle-shaped dilatation of the cervical canal, causing an approxima-
tion of the external and internal orifices. In 1859 Duucanf furnished
corroborative evidence of the general correctness of Stoltx^s view, by
means of two dissections of uteri derived from women who died re-
spectively in the seventh and eighth months of pregnancy. In thesai
casee the length of the cervix uteri had undergone little or no change^
consequent upon pregnancy, Duncan, however, in common with
Stoltz, admitted that, duriug tlie latter days of gestation, incipientj
uterine contractions of a painless nature may lead to the opening ofi
the internal os. In 1863 he showed that Stoltz's discovery had beeai
anticipated by Weitbrecht in 175a| In 186^ Professor I. E. Taylor,*
of New York, stated, what is without doubt true in the majority of
cases, that the cervix remained closed, and retained it^ entire length uf
to the very beginning of active lalH>n In evidence he offered the re-^
suits of four post-mortem examinations made upon women dying from
accidental causes during the first stage of labor. | In 1873 I found in
the dissecting-room a woman, seven months pregnant, who had died
in the first stage of labor, but after dilatation of the cervix had well
advanced. The bag of waters, in the form of a cylindrical sac two
inches in diameter, protruded into the vagina. Both the cervic-al
orifices were distinctly defined ; the cervix was equally expanded
throughout its entire extent ; and the head rested above the os inter-
num. The cervix clearly formed no part of the uterine cavity, but

* *^ Sur les dlff^rGnts ^t&ta du col dc Fut^nis, mtd& pHndpalement sur les changemcnta
que la gestation ct raccoiicbemcnt lui font djiTOiivcr" Strai'boiirg, I826»

f *' On the Cervix Uteri in Pregnancy," ** Edinburgli Med. Jour.," vol W^ 1850, p. 774*

I Vitk *' Edinburgh Med. Jour,'* September, 18G3.

« Tatlor, " On the Cervii Uteri," "Am. Me^. Time?,'* June 21, 1862.

I Vide likewise cmae of Aagua McDonald, ia '* Edinburgh Med. Jour.," April, 1877.

CHANGES IN TUB MATEHNAL ORGANISM BY PREGNANCY.

merely as a communicating passage between the uterus and

Tigina. Dr. Taylor has made some very interesting observations upon

f action of the cervix during labor, using for the purpose a large

Wim, %%* — ^AppMranoe of vogmal portion in primipani ; end of ninth month. (Taylor.)

(tliree to three and a half inch) cylindrical gpecnlum, by means of
which the entire process can he freely witneseei In multif>aroiis women
be has seen the head descend during a pain bo as to produce complete
oblttaration of the cervix, and then recede, leaving the latter with the
same appearances as existed previous to labor,*

While the non-shortening of the cervix baa been fairly demon-

stnitedj it is not so clear that the os internum remains closed in all

^aea op to the beginning of lahor. Certainly there are rare excep-

ItioQa to the rale, Litzmannf reported a case in whieli the mem-

[ bimnea were found, at the time of labor, attached to the cervical wall

sronnd the jieriphery of the os externum* In a few instances I have

hod an opportunity, during the la^t period of pregnancy, to deter-

I mine by touch the dilatation of the oa internum. The cervix, how-

[erer, did not expand in such a way as to become continuous with the

I uterine cavity, hut remained distinct and apart, preserving its inde-

[pendent existence. How far such a dilatation is due to painless labor

[it in impossible to say. Muller J regards it rather as the result of the

• "li<id. Record," October 18, 1877.

f ** 0M Verbalten deft Cervix Uteri in dcr Schwangcrichaft/* **Arch. t Gynaek./' Bd,
' X, p. ISO,

I " rntcrmichiiiig<*n fiber die Verkdnung der Vci<;inal portion in den Ictsten Mooatea
d«r Gnvidiliit " i Scmwool'i ** Beitri^,** Bd. v, U. 2, 1869, pp. 300 et mj. Mailer does
Mi, bewcver, esdode the pOMible action of utcHoe contractiona.

rHTSIOLOGT OF PREGNAKCT.

pressure of the head upon the softeaed cervix. I had once oceasion
to examine a multipara toward the end of gegtation, to determine the
question m to the safety of her making a railroad journey to a neigh-
boring city. I found the head low, the cervix eoft, and the os inter-
num clearly dilated to the eize of a dollar. Two weeks later I was
called to see her in the early stage of labor, and found, under the
influence of the uterine contractions, the canal of the cervix had
again closed.

Tho apparent shortening of the cervix is unquestionably due in
part to the swelling, incident to pregnancy, of the vaginal mucous
membninc, and of the vascular, loose-meshed tissues surrounding the
cervix at tlie vaginal junction. But, in addition, a noticeable differ-
once may be observed between cases in which the head occupies the pel-
vis and those in which it rests upon an iliac fossa. In the latter the
cervix is found, both by the epeculam and by the touch, to have pre-

Fio. <i7. — Appcaranoc of cervix id iDulti|)ara; nintli montli* (Taylon)

erved its entii^e length. In the former, on the contrary, the antmolj
lip is often obliterated, while the length of the canal and the posteric
cervical wall remain unchanged.

In explanation of this phenomenon, it is to be bonie in mind that
in the upright position the uterus forms with the horizon an angle of
thirty-five degrees. Tho weight of the ovum, resting upon the in-
clined plane of the utenia, increases the convexity of the anterior wall,
and the head of the fcetus, when it enters the pelvic cavity, does not
fall directly upon the os internum, but somewhat in front, producing,
in accordance with the laws of gravity, a bulging of the anterior lower
segment Upon vaginal examination the head is felt, therefore, low

Hiowxif aud covered by tho uterine walls, while the cervix is directed
backward^ not always in the median line, and is often reached with
difficulty, because the finger, in passing to it, has first to make the

CHANGES IN THE MATERNAL ORGANISM BT PREGNANCY.

[s^— Sbowing tho ctmvejtity of the imtcrior wall prodoccd by tlie weight of the ovum.

etnmlt of the child's head. The bulging, produced by the hitter,
dhcea the angle between the anterior lip and the vaginal wall, while
the posterior lip remains unchanged. The canul of the cervix assumes
a nearly vertical direction, and when examined with care, with due
regard to the pby Biological softening of its tissues^ is found to have
preeerved its normal length. By pushing the head away from the
cerrix, or by placing the patient in the knee-elbow position, so as
to »llow the head to recede, the anterior lip resumes ita normal di-
meaBiana,^

In the vagina changes take place corresponding to those in the
uteruB, thongb, of course, less in degree. The smooth muscular fibers
hjpertropliy ; the vessels of the venous iilexus increase in size and im-
part a blue color to the vaginal walls ; the mucous membrane heeomes
thickened, and furnishes a more abundant secretion. The mucous
Dembrane likewise increases in length, so that, in spite of the fact that
i» liftcul upward by the elevation of the uterus, the anterior vaginal
not unfreqnently protrudes from the vulva, Tho papillse swell

[ impart a granular feel to the finger*

The vulva becomes turgescent, the labia gape apart, to the mucous

• l\ HVLhKk, op, etL, p. 842.

LoTT, *• Verhnltcii dos Cervix Uteri walireiid cjcr Schwangerachttft/* p. tl.
L £. Tatt-oo, " Non-«hortenhi{» of the Cervix during Gestntion," "Med. Record,''
' la, 1S17, p. M(S, with vcrt»al statement of the author conccraing the results of
I of pregaftat women in the genu- pectoral positioii.

90 PHTSIOLOGT OF PREGNAKCT.

Biirface the enlargement of the Teins and Tenons pleznses giyes a
dusky hue, and the follicles secrete abundantly.

The connectire tissue between the layers of the broad ligaments
and around the uterus becomes succulent from serous infiltration.
The lymphatics, which conrey away the waste engendered by the rapid
tissue-changes in the pelvic organs, enlarge in conformity with the
increased labor thrown upon them. The hips broaden from the de-
posit of fat in the subcutaneous tissue of the entire pelric region.

FiQ. 69.~Diagram representing changes in the cervix resulting fix)in pressare of chUd'a

on anterior wall. (Lott)

With the growth of the uterus the abdomins^ walls are put upon
the stretch, and, in well-nourished individuals, are increased in thick-
ness, by the more abundant formation of adipose tissue. By the fifth
month the navel begins to diminish in depth, and about the seventh
month becomes level with the skin. During the last two months the
navel often is everted by the pressure of the uterine tumor, and forma

CHANGES IX TDK ilATHRXAL ORGANISM BY PREGNANCY.

a roimded elcYation. Another consequence of the stretcbingof the
abdominal walla is the formation of reddisii, bluish, and at times of
white glistening streaks (strias), which do not disappear after delivery,
thongh they lose their coloring. They rarely fail in the last third of
pregnancy. They are found moat abundant upon the lower lialf of
the abdomen, especially upon the sides, whert! they form curved, sinu-
OQfi Ltties. They are due to an atrophic condition of all the skin-lay-
ers, to partial obliteration of the lymph-spaces, and to a eoudensation
of the connective-tissue elements, which, in place of forming rhomboid
meshes, run parallel to one another,* Striae are produced likewise in
pathological distentions of the abdomen, and are not peculiar to preg-
nancy. Similar streaks form upon the nates and upon tlie anterior
and posterior surfaces of the thighs. They may occur, too, indepen-
dent of pregnancy, as in the rapid development of the hips at puberty.
Piunfnl sensations at the costal insertions of the abdominal muscles
are oft^n experienced during pregnancy. They occur more commonly
in multiparie, and, owing to the preiTonderancc of the right lateral
position of the uterus, with greater frequency upon the right side.
Sometimes the recti muscles are separated from one another, Tliis is
specially liable to take place in contracted pelves, and in women of
small stature, in whom, on account of the insufficient longitudinal
diameter of the abdominal cavity, the uterus is forced to make for
itself the space requisite for its development to term at the expense of
the abdominal walls.

The mammary glands, previous to gestation, are firm and nearly
hemispherical. During pregnancy the breasts increase in volume, and
present characteristic changes in structure and consistence. These
changes are due to a swelling of the connective tissue of the organ,
the development of glandular acini along the course of the lactiferous
ducts^ and tbe increased deposition of fat between the lobes. The
enlargement of the breast often begins in the second month, and he-
comes noticeable between the fourth and fifth months of gestation.
With the development of the glandular structure the breasts possess a

I knotty, uneven fe^l, more marked at first about the periphery of the
^and thence proceeding gradually toward the nipple. The veins
and form a tracery beneath the skin. Early in pregnancy,

IfnUoi^ of the breasts, and pains, shooting toward the axilla, aix? often
expefieneed. As the breasts increase in size* the cutis yields in many
women about the periphery, where the tension is greatest, whereby
bluish. whit4?. nr reddish lines, like those remarked upon the abdomen
and thighs, make their appearance.

The nipple becomes elongated, is more sensitive, and enters readily

I into an erectile condition. Changes in the areola are justly regarded

• BcsKT, ** Tbc Cioniticei ol Pi^goaocj,** "Tpmib. of the Am. Gyua)c* Soc," vol Iv, p,
I HI,

PHYSIOLOGY OF PREGNANCY.

as among tho most important oidences of the existence of pregnancy*
Often as early as the second month the areola has a soft, CBdematoafi
feel, and is raised above the level of the surrounding skin. The seba-
ceous follicles, ten to twenty in number, enlarge, and bedew the sur-
face with moisture. By the middle of pregnancy a circle, due to pig-
mentary deposit, is formed aroiuid the nipple, the coloration of which
depends in part, though not altogether, upon the complexion of the
individual J being usually more intense in brunettes than in women
with fair hair and delicate skins. In the negress the areola is jet-
blacky while in the albino it is of a delicate rose-color (Montgomery).
The diameter of the i>igmented circle averages from an inch to an inch
and a !ialf , though it sometimes greatly exceeds the figures mentioned*
In the latter part of pregnancy there oft^n forms around the outer part
of the areola a so-called secondary areola, consisting of scattered round
gpots, presenting the appearance as though, to use t!ie language of
Montgomery j^ the color had been discharged by a shower of drops. ^_
This peculiarity is due, for the most part, to the presence of enlarged^^^f
non-pigmented sehaceoos follicles.

The pressure of the gravid uterus gires rise to functional disturb*
ances in the neighboring organs of the pelvic cavity. The capacity
of the bladder is diminished, and, as a consequence, increased fre-
quency of urination results. In some women, when the bladder is
moderately full, the mere act of coughing or sneezing, or the upright
posture*, produces involuntary discharges of water. Constipation is
common, due not so much, however, to mechanical obstruction as to
diminished intestinal action. In the latter months of pregnancy,
pressure on the sacral nerves gives rise at times to numbness of the
extremities, neuralgic pains, cramps, and hindered locomotion, (Ede-
ma of the lower half of the body and varicose dilatation of the veins
of the legs, the rectum, and vulva* are referable partly to pressure and
partly to the increased vascular fullness of the pelvic vessels induced
by pregnancy.

CnAKOES EFFECTED IJf THE ENTIRE ORGANISM.

Corresponding to tho enormous development of the vascular ap-
paratus in the gravid uterus, there is an increase in the total quantity
of blood in the circulation.* Thus a sort of plethora is formed, which,
however* is serous in character. The red blood corpuscles, the albu-
men, the iron, and the salts of the blood are diminished, while the
white blood corpuscles, the fibrine, and, above all, the water of the
blood, are increased. These changes are explained, in part at least, by

* This assert! on, wbtch is simplj the formal statetneiit of a phjsiologicftl necesdtft
hfts bean eiperiiin?nrJiHy proved to be correct id bitches by Spiogelberg and Gscheidlio.
Vide ** Untarsuchyngea UlKsr die Blutmvnge trachiigcr Hiinde," '* Arch, t Gyoaek.," Bd.
iv, p, 112,

CHANGES IN TOE MATERNAL ORGANISM BY PREGNANCY.

the demands made upon the maternal system by the growing foBtus.
With increased waste in the orgiLnism, m evidenced by an augmenta-
tion in the carbonic acid and urea eliminated, there is usually dimin-
ished capacity to take and assimilate food. How far these causes are
operatire in producing the aboye-mentioned conditions is shown by the
alight degree of hydra^mia, or the entire absence of blood impoverish-
ment, in women who possess during pregnancy good appetites and
excellent digestions, and who, at the same time, are able to procure an
abundance of nutritious food,*

Aa a necessary corollary to the increase of the total blood-supply
in pregnant women, the maintenance of the circnlation would require
cither greater frequency in the contractions of the heart, or that the
entire quantity of blood entering the ventricles during the diastnle
should be increased, Kow, it is known that the frequency of the pulsa-
tions of the heart remains unchanged. For the alternate contingency,
however, the dilatation of the cavities becomes a necessity. For the
same reason the arterial tension is increased, imparting a fullness to
the pulse, which was formerly regarded as an indication for venesec-
tion. The interposition of the enlarged and multiplied vascular chan-
nd^ in the pelvic organs increases the labor thrown upon the heart, in
tMpoase to which an eccentric hypertrophy of the left ventricle takes
placet

Pregnancy increases the size of the thyroid gland. In districts
where goitre is endemic, and in women in whom a predisposition al-
ready exists, pregnancy may produce a temporary form of the disease,
or furnish the starting-point of the permanent affection. J

In rather more than half the cases of pregnancy, thin bone-Hko
UmeUie, consisting chiefly of phosphate and carbonate of lime, meas-
uring from one sixth to one half a line in thickness, are found deposited
il|K>n the inner surface of the skulL These plates have been termed
»phytes by Hokitansky. They occur after the third month, and

> found chiefly upon the frontal and parietal bones, especially along
the eotirse of the sulcus falciform is and the arteria meningea media.^

We have already noticed the increase in the carbonic acid discharged
by the lungs during pregnancy. Andral and Gavarrot found the mean
consumption of carbon hourly in pregnant women equaled 8 grammes

• Il4»V " Dii« lUut dcr SchwEngereji," " Arch, t Gynaek,/* Bd. i, p. »6l. Vide ibid,,
for new eupcri meats rt'lnti^c to the dimmution in the salts and iron (hjematii)) of the
^lood, and for facts rt'lmivo to iDcre&§«d deatmctive as^imUadon.

f For the rcstdu o( Larcher aod other French mvcatigatom upon thia point, vide
Jpolin, '* Tniitil' ooioplct d* accouchement," p. 3S3.

I U T41T, ** Enlargement of the Thyroid Body," " Obstct, Jour, ol Gr. Brit, and Ire.,**

• FdftOTW, ** IlandhtH'h der patholoj?, Anat,," Bd, ii, p. 945. These osteophTte« ftro
not peeolSar to prr g:nancy ; they likewise occur commonly in consmnpiivea. " Notiveau
mOL lie Cbir. et dc MM.,'" 1 irJl, Art '' GToseeaao/*

PHYSIOLOGY OF PREGNANCY.

instead of 6 '4 grammes, as in menstnmting women. The thorax is
increased in breadth and diminished in deptli, a condition which
becomes reversed after deliYerj. There is usually, toward the end at
least, a diminution in the vital capacity of the lungs.* Subjectivelv,
there is often experienced, especially in primipara?, a sense of oppressed
respiration during t!ie latter months of pregnancy. This feeling is
relieved, however, to a considerable extent, when the uterus, in the
last two to three weeks of pregnancy, sinks downward and forward-
Very few pregnant women escape altogether troubles of digestion ;
of those the most common are nausea and vomiting, due to si>asmodic
contractions of the stomach and diaphragm. The nausea and vomit-
ing usually occur on waking in the morning, i, e., with an empty
stomach, more rarely after meals. In a few cases, these gastric dis-
turbances take place only three or four times in the beginning of
pregnancy, upon the first suppression of the menses. Usually, how-
ever, they recur daily during the first three months, and then gradu-
ally disappear. In the early period of pregnancy, the appetite is, as
a rule, capricious, like that of chlorotic women. Some are said to
crave unusual and even disgusting articles of food (longings). An
increased secretion of the salivary glands is often a noticeable symptom.
The bowels are more commonly constipated. In a few, however, diar-
rhoea takes place, often about the time of the month when the woman
would, if not pregnant, have her menstrual flow*

It is not surprising that in the first three months of pregnancy
many women lose their flesh and color, have dark circles about their
eyes, and wear a drawn, haggard look ; but after the third month, or
later, after fetal movements have been felt, the appetite returns, the
digestion becomes more active, the nutrition is improved, and an in-
crease of weight in normal cases takes place, which can not be accounted
for simply by the growth of the ovum. According to Gassner*s esti-
mates, the average gain in the eight months amounts to five and a
half pounds, in the ninth month to three and a half pounds, and in
the tenth month to about three and a quarter pounds. The total
increase he found not far from one thirteenth of the entire weight of
the body.f

We have already noticed the pigmentation of the areola in speaking
of the changes produced in the breasts of pregnancy, Tlie forehead
likewise at times becomes covered with dirty-looking brownish patches,

• Dohm found that in fiiity per cent, tlicre was a marked diminution in the Titnl ca-
pacity of the luQgB of women in tbo latter pnrt of pregnancy, as compared with that of
tlio aamc women tested twelve to fourteen dAvs after delivery. " ?a\t Keontntss der
EinSiissc3 von Schwangerarimft nnd Woehenbott nuf die ritale Capacitat der Lungen,"
** Monatssehr. T Geburtgk.," Bd. xxviii, 1806, p. 457. Earlier obflerrations^ not entirely
in accord with tho?e of Dohni^ were mnde by FabiuB and Wintrich. Vide SpxcOKtaERO^
♦* Lclirbuch der GeburtsbiiMe/* 1877, p. 03.

f " Monataachr* t Gebuttsk.** Bd, zix, p. 1,

THE DTAGNOSTS OF PREGXAKCT.

rticli may extend over the entire face, especially over the eyelids, the
at of the nose, and the upper lip. These spots, with the disfigure'
aent they occasion, rarely remain permanent, but, as a rule, disap-
pear shortly after confinement. Similar discolorations are often oh-
^rred about the external organs of generation, upon the abdomen,
id, with considerable coostancy, along the linea alba and around tlic
ibilicns.

Owing to the increased arterial tension, the urine is more abuodant
and watery. Albumen in the urine is not an infrequent occurrence,
due, probably, in the milder cases^ to transitory catarrhal affections
of the bladder,*

The nenrona system becomes more impressionable. The whole
character frequently undergoes a change. The most amiable of women
are liable to become fretful, peevish, and unreasonable, Tiio spirits
are often depressed, especially in the earlier months, when the general
latrition is most impaired. The melancholia in women ali^eady pre-
lispoaed to insanity may terminate in mania. The memory is gen-
"erally weakened, especially in women who have home a number of
children in rapid succession. On the other hand, nervous women
iometimes lose their nervousness, and, exceptionally, there are individ-
uak who experience during pregnancy a peculiar sense of well-being*
Seiiralgic affections are common (face-ache, toothache, etc.) ; local
anieethefiia and paresis occur at times ; the senses are often disordered
|(jiyctalopia, amaurosis, amblyopia, deafness, perversions of taste and
aell) ; pruritus is sometimes troublesome ; and, finally, pregnant
"women are subject to attacks of dizziness and syncope.

CHAPTER V.

TITE DIAGNOSIS OF PREGNANCY.

rpftt^ncy. — Suppression of menses, — Kausca.— Salivation.— Brcosts,^ — Increiwc
abdomen. — Chftngos of the oa und cerrii.'^Quickenmg. — BanoUement. — Fetal
lMtfi4>e»t. — Uterine bnilt. — Funic souffle.— Iftt^rrogation of the pntlcnt, — Methods
of physical examinatioo. — Inspection of abdomen* — Palpation. — Auscultation. — The
v«g(n*l touch. — Distinction between first and Bubscqucnt pregnancies. — Diagnosis of
ill of fdjtus, — Duration of pregnane?. — Predietion of day of ooafinenieut from
\ of laai noeostniation* — Date of quickening. — Size of uterus.

A THOROUOH familiarity with all the Bigns which lead us to the
lition of pregnancy is an essential part of the outfit of every
ticiag physician. The reasons for this are obvious. Mistakes as

• KALfuroACiii ** UcbcT AlbnminuHe und Erkmnkungcn der Hamorgane in der Fort-
de." 'VArck t Gjnaek.," Bd. Jii, p. 1*

priYSIOLOGY OF PREGNANCY,

to the diagnosia of the pregnant state can neyer he covered up. They
therefore inevit^hly snhject the author of them to criticism and ridi-
cule. But, apart from personal considerations, it is to he remembered
that, in the practice of hoth medicine and surgery, the caexistence of
pregnancy not infrequently modifies materially the prognosis and
treatment* Moreover, it is one of the most grateful functions the
physician is called upon to perform to he ahle to dissipate nnjust
suspicions of pregnancy, which sometimes cloud the reputations of
perfectly pure women. On the other hand, the writer has known
many cases of grievous wrong and injustice done to the innocent by
a careless, hasty, and incorrect decision on the part of the medical
examiner. The so-called *^ signs of pregnancy" are based upon the
physiological changes which t4ike place in the ovum, and the changes
wrought by the growth of the ovum upon the maternal organism.
Many of the signs^ therefore, posseas little weight, and serve only to
draw attention to the possible existence of pregnancy. A number of
the signs taken together furnish cumulative evidence of the proha-
hility of pregnancy. There are, however, single signs, which, taken
individually* make pregnancy probable ; only a few possess a positive
significance. Hence the rule that the physician keep ever in mind
possible sources of error, and, in cases of doubt, that he maintain a
prudent reserve in the expression of his opinion.

The diagnosis of pregnancy depends upon an acquired facility in
the menttd grouping of symptoms in the order of their respective
weight, and upon a familiarity with all the methods by which objective
symptoms can be determined.

We have, therefore, to consider :

1. The signs of pregnancy, with their limitations and possible
sources of error.

2. Methods of physical exploration.

3. The differentiiil diagnosis of pregnancy.

The Signs of Peeqnancy,

The sitppression of the menses is, to most women who have been
e3q>osed to impregnation, the tirst warning of the occurrence of con-
ception. Certainly, where they have been previously habitually regu-
lar, this sign rarely leads them into error. Still it is by no means
reliable. To estimate it at its true value, it is necessary to bear in
mind the numerous aberrations to which the menstrual function is
subject. In married women a retardation of the menses for a few
days, or even two or three weeks, is not an nncommon occurreuce.
These retardations are not unusual in newly-married women, in whom
the disturbance appears to follow the novelty of t\m matrimonial rela-
tion. Again, they may be the result of colds, fatigue, and mental
emotions. In the unmarried, who, by reason of imprudent oonduct»

THE DIAGNOSIS OF PREGNANCY.

►Te had occaaion to fear pregnancy, a retardation sometimes occurs
the result of pure appreliensioo.
The cJiuaes of amenorrhom do not need to be specified here. They
are operative in the married m weO as in the nnmarried. The family
^^hv^cian, however, cognizant of the peculiarities and temiieramenta
^Kf his patient^^ will easily recognize such conditions, and separate
^^piem from the cessation of the menses induced by pregnancy. Should
^Tmy doubt exist, of course it would be proper to ensiiend judgment,
and await the advent of other symptoms before expressing an opinion.
Pit»gnaQcy, while it suspends ovulation, the usual concomitant of
menstruation, ia not incompatible with a periodic flow% ivhich may
ahecure the diagnosis. When conception occurs immediately prior to
a menstrual period, it frequently does not arrest the discharge, though
usually diminishes the amount, A few women have periodic dis-
dnring the first two or three months of pregnancy, and, in
(ly mre cases, throughout its entire duration. Authors liave like-
recorded instances of women whose habit it was to menstruate (?)
only during pregnancy (Montgomery). In all such cases it is prob-
Ic that the haemorrhage is of cervical origin. In one instance my
letid Br. L. M. Yale, of this city, verified the presence in the cor-
caual of a small mucous pul>^>us, with the removal of which
trouble disappeared. In mentioning these deviations from the
^andard, it is necessary to invite the student to view them in proper
tive. They are of extremely rare occurrence, and the physician
ot often fall into error who maintains a skeptical attitude toward
supposed i)regnancy in which apparently normal menstruation

to continue.
imen who arc habitually irregular, or in whom' the menstrual
are absent altogether, the question of the existence of preg-
1^ often in the early months a very puzzling one. There are
now and then patients who .menstruate only at long intervals. If they
ODOO suspect pregnancy, they are apt to simulate other corroborative
; or, on the other hand, they may proceed far in gestation with-
the slightest misgivings of their true condition. In such instances
hy.^ician, unless he bases his opinion on purely objective symp-
b at times drawn into error, which places both himself and his
.tient in a ludicrous position*
In the ?amo category are to be placed cases of pregnancy occurring
nursing women before the return of the menses, in young girls
the appearance of menstruation, and in women who have ap-
tly pitted the climacteric.
Among i\m sympathetic disturbances, those of the stomach i>08sess
"flia greatest diagnostic importance. Nausea and vomit inf/, occurring
tt^odally in the morning, and following suppression of the menses, are
ligiis to which the women themselves, and the laity in general, attach
t

98 PHYSIOLOGY OF PREGNANCF.

great Taluo. They are, however, sometimes absent in pregnancy, while
thej are present in a variety of other conditions. They are notablfe
fi*atiires of chlorogis, where they are likewise often associated with sm-
j>en8ion of menstmatian^ Uowever, after eliminating other morbid
causes^ they are always suspicions s^Tnptoms in women who, in their
sexual relations, have exposed themselves to conception, and who
never experienced similar sensations in tlie nnimpregnated state.
Abundant salivation possesses a similar significance,*

Tingling sensations and swelling of the breasts, turgescence and
pigmentation of the areola, tlie development of the glandular follicles
around the nipple, enlargement of the superficial veins, and the secre-
tion of milk, are valuable though not infallible signa of pregnancy,
Thn.s, puinful sensations and sympailietic swelling of the bi^easts may
dci>end upon pathological conditions of the sexual organs. To be of
importance, they should be persistent and progressive. The coloratioa
may be the relic of a previous pregnancy. The other changes in the
areola rarely lead us into error wlien they are present, but I have
often noted their entire absence. I liave likewise noted cases where
there was entire absence of milk in the breasts until aft^r confinonient
Numerous and very curious instances of milk in the breasts of the
non-pregnant have been recorded. The importance of these excep-
tions is greatly lessened by tlie fact that milk rarely appears in preg-
nancy before the development of other signs which enable us to make
the diagnosis certain.

Increase in the size of ihs abdomen during the child-bearing period
always suggests the existence of pregnancy. But it is to be remem-
bered that it is not invariably of uterine origin. Thus, it may result
from ascites, fVom an excessive deposit of adipose tissue in the abdom-
inal walls, from tympanitic distention, and from various abdominal
tumors having no connection with the uterus. If the enlargement
proves to be due to a uterine tumor, we have then to exclude fibroids
in the earlier months, subinvolution, and the increase of size often
associated with peri-uterine inflammations. The absence of uterine
enlargement, in women supposed to be several months pregnant, pos-
sesses, of course, absolute value in the way of purely negative testimony.

The changes in the os and cervix uUri are of great value in decid-
ing the question of pregnancy. They con^tist of softening and u>dema-
tons swelling of the cervix, velvety character of the mucous mem-
brane, associut^d with increased cervical secretion. In primiparm the
external orifice, instead of offering the sensation of a transverse slit,

* A pellicle, formed upon the aurface of the urioe, twentyfour to fortj^i^bt liotirs
after emi^^ion^ wtis once rog^Ardedl as of ^eit dia3:ni>stic value. It receive*! the name of
kicatcino, and has been found to consist of a proteine sub^^tance, triple phosphates^ funjrf,
tnd infu-Moria. It is not invarifibly present in the tii-inc of pregnant womeiL It tnaj
oeotir At other times, and bad cTea been found in the uiine of the male

THE BUGXOSrS OF PREGNANCY,

circular. In multiparao the tip of the finger penetrates to a
greater depth than in its former state, Durini^ the first two months
the changes are rarely eufficiently marked to distinguish them from
oonditions that ohtain at or near the menstrual period*

Quickening is tl»e terra used to designate the earliest moYements of
the fcBttu perceived by the mother. They are at first slight, and have
been compared *'to the tremulous motion of a little bird, held in tlie
hand " (Montgomery), ifodern investigations plaee the time at which
the fotiis first begins to employ its muscles at about the tenth week.
It i% however, somowhat rare for these movements to excite the at-
IrotioQ of the mother before the sixteenth to the eighteenth week*
though experienced matrons may recognize them at an earlier peri-
od* HypersBsthetic women do so, I should say, as a rule* Tlie clear
stfttements of intelligent women leave me no reason to doubt that they
attay feel life as early as the twelfth week. At first the sensation is
ilttt of a flutter or tap, but the intensity of the movements m increased
an pregnancy advances. They are rendered more active by a long fast,
and by certain positions in bed. For considerable periods during the
ly they disappear altogether. Occasionally they may be suspended
' days or weeks at a time, without the life of the child having be-
»e necessarily compromised. Cases have been cited in which women
re n©Tcr recognized the feeling of quickening throughout the entire
jod of pregnancy. Dropsy of the amnion and ascites are said to
obscnre the sensation of the fetal movements.

The subjective impressions of women as to quickening require,
(.bowtTer, to be received with reserve. Instances are not infrequent
pre sterile women* misled by their i.'?kgQT longings for maternity,
not only deceived themselves, but have succeeded in beh-aying
itr medical advisers into error by their confident assurances of hav-
Ir ' ■ 'Uy felt the movements of the child in the womb.

movements* on the other hand, when recognized by the
ileal export, furnish oonclusivo evidence of pregnancy. These
lTement« may be active or pamive, Acfhfe movements may be de-
aA hy the eye, or by immediate contact. They seldom as.-'umo
Bch di>iinctness Ik? fore the sixth month, though this is not in-
iably ihe rale* (Thus, a patient of mine, the mother of six chil-
ftx* ahortcd at the fourth month. The ovum was expelled on the
'I She gave birth on the 25th of Deeeniher following*
months later, to a full-term child. In tlie latter part
kJuljr the movements were clearly appreciable to both the sight and
ich.) At first Uie sensation is that of a simple pat or throb* but in
sixth and seventh month the limbs may he felt to escape from
Jer the hand with a rolling or gliding movement In the hist two
cinthj, in women with lax abdominal parietes, it is sometimes pos-
ijbfe to wizc with the fingers a limb of the foetus, especially when it

100

PHYSIOLOfiY OF PREGK.1^XT.

chances to form a project ion recognizable through the intermediate
coverings. The fetal movements have been closely simulated by the
irregular and spasmodic action of certain of the abdominal muscles.
In the cfOebrated case of Jounna Soiithcote, who at the age of sixty-
four chiiraed to be with child by tiie Holy Ghost, Dr, Reece says, **I
felt something move under my hand, possessing a kind of undulatory
motion, and appearing and disappciiring in the same manner as a
f cetus. " *

BaUoUenient is the tenn applied to the passive movements commu-
nicated to the fcetus by the physician. It may be performed either by
impressing the uterine contents with the two hands, laid upon the
alHlominul wall, so as to cause the intervening body to float between
tlium ; or by introducing two fingers into tlie vagina and pushing them
Buddcnly against the lower segment of the uterus just anterior to the
cervix. When this is done, the head, if the presenting part, is made
to bound away from tlie fingers, to drop down again in a few moments
upon them with a gentle tap. Vaginal ballot tement can sometimes
be practiced successfully as early as the latter part of the fourth month*
Ballottemcnt is to be regarded as positive proof of pregnancy, as thoro
is no other condition in which a solid body is found floating in the
uterine cavity.

The ansetiUatory signs consist of the tderine bruit and the sounds
of the feial heart. The discovery of the latter was made by M, Mayor,
a surgeon of Geneva, as appears by the following not43 contributed by
tlie editt^rof the *' Biblioth^Miue Universelle,'* in speaking of the comph
rendu, made by Percy, June 29, 1818, to the Academy of Sciences^
upon the memoir of Latinnec relative to auscultation : "This observa-
tion reminds us of one made by SL Mayor, which has appeared very
interesting to us in its connection with the art of midwifery and legal
medicine. He has discovered that it is possible to recognize with cer-
tainty whether a child is living or no, by applying the ear to the ab-
domen of the mother of the child ; if the child is living, one can hear
rery well the beatings of it^ heart, and distinguish them from those of
the maternal pulse." f Time has served only to confirm in the most
complete manner the accuracy of this statement. The heart-sounds
of the ftetus, when once clearly heard, are now regarded iis the most
valuable of the signs of pregnancy, and conclusive eridence that the
child is alive. They are, like those of the mother, distinctly double,
and have been aptly compared by Kergaradec to the tic-tac of a watch.
They are much more rapid than the correspoiKling sounds in the heart
of the mother, oscillating between 121) and 100 per minute. They
may be temporarily increased in frequency by movements of the mother,
and by both the active and passive movements of the child. At tho

♦ MoNTOovKnv, "Sign* of Prcf^iancy/' second cdUion, p. 144.
t JopLnf, **Tniit6 coraplct d^acoouchemcnt,'* 18^7, p. 410,

THE DIAGNOSIS OF PREGXAKCY.

101

ginning of a pain, especially after rupture of the membrane, the

irt^soands often become more fi-eqiient ; on the other band, they

sme slowed during the height of the contraction, and may even for

moment cease altogether, either in consequence of the compression
[the child's body, or as the result of the disturbimce produced in the

?ntal circulation. In the interval between the pains, the average
Kjuency is usaally restored. If at any time the freijueney of the
ift-beat permanently either rises above or falls below the normal
?ni^e, the child's life is to be regarded as endangered. As the fettd
[!uIation is entirely independent of that of the mother, there is no

^t relation between the rapidity of the pulsations of the fetal and
fttemal hearts. However, in the febrile affections of the mother,

health of the child may become coincidently deranged, with re-
Iting increase in the frequency of its heart's sounds. In genenil, the
beort beats more frequently in girls than in boys, a cireumstimce prob-

ily owing to the average smaller size of the female at birth. In
y obeervations, Frankenhaeuser * found the average in the boys was
I, irhile that of the girls was 144, lie believed, therefore, that it
iild prove possible to predict the sex of the child in utero three
iDths previous to confinement. Subsequent experience has demon-
»tcd» however, that proplieeies based upon the frequency of the
irt-beats are at best of only approximative value, and that it is the
part of wisdom to i-eserve a prognosis which may he falsified by time*
^H The fetal heart njay generally be made out by the eighteenth to
^K twentieth week. Under favorable circumstances it ha?* been de-
Hetod aa early as the tifteentli to the sixteenth week. It is usually
^raid over the dorsum of the fcptus ; in face-presentations, on the
ocmtimrr^ it is heard mo*t distinctly over the anterior surface of the
ihorux. The sound is often obscured by the thickness of the abdomi-
wsIU in fat women, and by an excessive amount of amniotic fluid.
bea the dorsum of the fcBtus is turned posteriorly, it may be absent
t>gQther. It is customary, therefore, to make frequent examinations
in terra Is Ik? fore decidiug, in consequence of its failure, upon the
Itb of the child.

The uterine brnii is a blowing sound synchronous with the maternal

It resembles strongly the souffle heard in aneurismal tumors,

md Tarien greatly in quality and intensity. It is apt to be louder in

nuirkcidlj anaemic women. During uterine contractions it possesses

more of a musical character ; at the height of a pain it may disappear

: vther. It may be modified by the pressure of

- t^d altogether. When firitt discovered by Ker-

(1833), it was attributed to the ut-ero- placental circulation* and

rfiitrefore termed the placental bruit As, hoivever, it was found

lopCCTtft two or three days after delivery, it became evident that the

• "Monataachr, f. Geburtak,," Dd. xiv, p. 161,

102

PEYSIOLOGT OF PREGNANCY.

sound must bo of uterine origin. It is now the generally accepted be-
lief that the sound is produced in the ascending branches of the arteria
uteriiia. Rotter* and Rapiu have shown that, in pressure along the
course of the arterv, both when made through the abdominal walk
and through the vagina, a vibratory thrill may be experienced by the
touch, whieh corre^sponds to the sounds heard in auscultation.

It is seldom heard before tlie fourth month* Spiegelbergf states
that, in women with lax abdominal parietes, he has gucceeded, by
pressing the stethoscope, placed above tlie symphyBis pubis, deep down-
ward so as to reach the sidca of the lower i*ortion of the uterus, in
detet'ting tlie murmur m early as the eighth to the ninth week. As a
sound similar to the uterine bruit may sometimes be detected in uter-
ine fibroids, lis value as a distinctive sign of pregnancy is thereby
grea t ly i m pal red ,

A hi&siing sound sjuchronous with those of the fetal heart is some-
times heard in auscultating the abdomen. This sound is referable to
the umbilical cord^ and is termed tlie funic souffle. Its etiology is a
nuitter of conjocture. As it is oidy found in fourteen to fifteen per
cent, of cases examined, it possesses moderate value m a sign of preg-
nancy,

InterrogatioB of the Patient. — In all cases of presumed pregnancy
it is customary to commeuce an investigatiou by preliminary inquiries
as to the existence of the more important subjective symptoms. As
such are to be regarded the suppression of the menses, the so-called
*' morning-sickness/' salivation, pricking sensations and lancinating
pains in the breasts, enlargement of the abdomen, and quickening.
As we have already seen, however, none of these symptoms are i^ally
decisive. PatienL^, by their statements, may in ix^rfect good faith lead
the physician into error ; or, where they have an interest in practicing
deception, may deny the existence of incriminating symptoms alto-
gether. It is, therefore, often necessary to supplement the testimony
of i)atients by the evidences to be obtained by a clinical examination.
Ordinarily the vaginal touch suffices. In a few cases of doubt it may
be necessary to possess one's self of all the objective signs before arriv-
ing at a conclusion.

Methods op Physical Exploration.

The patient may be examined in the upright or recumbent posi-
tion. In the upright position, the phyeician may first examine the
breasts, with reference to the existence of the changes characteristic
of pregnane y. With the eye he takes note of the a?dema and discolor-
ation of the areola, the development of the follicles, the secondary
areola, and the increased size of the organ. To distinguish from the

* RoTTKR, ** XJebev filhlbare^ Uteri ngerausch, •* Arch. f. Gjnaek.,
f " LeLrJ>ach dur Gcb./* p. 104.

p. 639.

THE DIAGNOSIS OF PREGXANCY. 103

[ilargement of the breast due to adipose tissue, he looks for the pres-
aoe of developed veins upon it^s sitrface, and with the touch recog-
'liizes the knotty, uneven feel produced by the development of the
glandular tissue. By pressing the breast near the nipple between the
^fthumb and index-finger the presence of milk may be determined.
^B Au examination per vagitrnm is sometimes mude in the upright
^■kosition, in cases where the physician desires simply to rapidly ae-
^nuaint himself with the condition of the generative passages and the
^Rower portion of the uterus. The patient either stands with the feet
apart, or with one foot raised upon a stool, while the physician, kneel-
ing before her, encircles her hips with the left arm, and witli the right
hand, ^uissed beneath the elotliing, makes the reqniHit^ exploration.
This method furnishes incomplete results, and is apt to oflend sensi-
tive patients. It possesses no advautages over that in the recumbent
position, and is rarely resorted to except in the hurry of office
practice.

Although for certain purposes it may prove advantageous to choose
be lateral or knee-chest position, in all ordinary cases it is advisable
I eiamine the patient upon her back, as being most convenient for
9lk external, internal, and conjoined exploration.
In the dorsal position the body should be as nearly horizontal as
sible, with the head and shoulders resting upon a pillow, and the
bighs flexed at right angles to the body, and separated from one another.
In this way the greatest possible relaxation of the abdominal walla
and of the perinaeura is attained. Corsets, or other articles of apparel
mterfering with freedom of investigation, should be removed. The
woman should be covered with a sheet, and the clothes reflected up-
ward so as to expose the abdomen. Where actual ins|iection is not
oeo^sauy, it is well to draw the chemise smoothly over the abdominal
waUs to avoid offending the modesty of the patient. When it is of
importance to survey the external surface, care should be tiiken to so
armngc the sheet as t^ cover the pubic region.

Innpvctton of the aMonien enables us to recognize its form and
ihape, the coloration of its surface, the strife due to distention, and
■■M|eondition of the navel. A flattening of the abdomen at tlie um-
^HIBiil region, with bulging at the sides, would lead to the suspicion of
asdtei, A depression of the navel is incompatible with advanced
pttgiiAiiejr* Fetal movements are sometimes visible through the ab-
domtnal {larietes.

Palpation of the abdompn enables us — 1. To recognize the size,
p, and consistency of the uterine tumor, and to distinguish it
^m other intnir abdominal growths ; 2^ To ascertain, in advanced
nancy, the pn*senco of the ftrtus. In a very large number of
juilpiition alone serves to establish the existence of pregnancy,
b, however, only after the third month of pregnancy, when the

104

PHYSIOLOGY OF PREGNANCY.

fundus titori can be felt above the gymphjsis pubis, that this method
of exploration becomes availuble.

In its pei-formance the physician Btands by the side of the patient,
and irith the tips of his fingers rapidly traverses the abdomen from
the pulK'S upward. In this way he takes note of the thickness of the
abdominal walls and of the general position of the nterus. The latter
may then be outlined by pressing the abdominal walls inward to the
sides of the iiteriig, with the uhiar borders of the two hands. The
uterus is then steadied with one hand, wJiiks with the other, intermit-
tent pressure is made to determine the eousistence of the tumor. In
pregnancy, after tlte second month, the uterus becomes soft and elas-
tic, a condition that increajses with the growth of the ovum, so that,
toward the end, palpation often furnishes an obscure sense of fluctu-
ation. TJie physician should next turn his face toward the feet of his
patient, and make deep pressure above the symphysis pubis to the
luwer borders of t!ie uterus. Ue should here seek to discover the vi-
bratory thrill, which may sometimes be detected along tlio course of the
uterine arteries. At the same time, in head -presentations (after the
sixth month), a hard, round body can generally be felt, and made to
float to and fro between the examining fingers of the two hands. In
thin persons, with relaxed abdominal and uterine parietes, it is pos-
sible, in the later months, to tnice upward the back, the breech, and
the extremities of the fojtus. During the progress of the examina-
tion in advanced pregnancy, the movemento of the child are usually
excited, and are readily appreciated.

The Differential Diagnosis op Pregnancy,

The differential diagnosis between pregnancy and other sources of
abdominal enlargement is, in most cases, not difficult. In subperi-
tuneal fibroids of the uterus, the unevenness of the surface and the
hardness of the tissues are distinctive. But it must be remembered
tliat fibroids, though they commonly cause sterility, do not actuall}^
exclude pregnancy. In the rare cases in which fibroids and pregnimcy
coexist, the diagnosis for a time may be doubtful.

It is, therefore, important, where any uncertainty exists, to ab-
stain from the use of sounds and to await the result of a future exam-
ination. In a few weeks' time the rapid growth of the pregnant utc-
rns, quickening, ballotteraent, and the fetal heart will furnish the
necessary data for establishing the distinction.

Ovarian cyst*, in the early stages of their growth, occupy a posi-
tion to the side of the pelvis, and are hardly likely to be confounded
with the pregnant uterus. When, however, by their increase in size,
they fill the abdomen, the histor}^ of ovariotomy shows that, without

a full and complete examination, siicii a mistake is possible. Where
0¥Brian cyets are complicated by pregnancy, the latter has been at
Umes OTcrlooked, simply because it was not so much as suspected,
Thui?, a young servant-girl was sent to me some yeai-s ago to consult
me relatiTc to the nature of an abdominal tumor. The diagnosis of
urarian cyst wa3 readily established. A year later she sought the ad-
\ of a surgeon, formerly of this city, who counseled its removal,
laving obtained her consent, he made the usual incision in the median
B, and exposed, to hia horror, the pregnant uterus. He afterward
ned that the girl, having been assured that conception was impos-
\ on account of the ovarian disease^ had yielded to the solicitations
her lover. Finding herself pregnant, she purposely concealed her
>ndition, and had sought the operation when seven months advanced,
the hope that a fatal issue would cover her shame. The ovarian
inior was left untouched, and the wound was quickly closed. The
\ died, however, a few days afterw^ard. In this case, the undoubted
ace of an ovarian cyst and the reputable character of the girl
combined to disarm suspicion.

In ovarian cysts there is, on paljiation, ordinarily greater distinct-
nes of fluctuation than in the gravid uterus. The diagnosis is,
^Boweveri mainly based upon the presence or absence of the usual signs
^bf pregnancy.

^H Thick layers of fat in the abdominal walls and ascites could
^Rardly be mistaken for pregnancy, though they may serv^e to obscure
^Bpal{iation.

^K Tympanitic distention is recognized, in part, by the character of

^^he percussion-note, and, in part, by demonstrating the absence of the

iit4jrine tumor. The latter is accomplished by directing the patient to

make alternate deep inspirations and prolonged expirations. The phy-

Man then places tlie left hand upon the abdomen. During the long

dspimtion he remains passive ; with the expiration, he presses with

he fingers of the right hand, placed obliquely against those of the

?ft, in the direction of the spinal column. With the recurrence of

irimtion, he holds steadily the ground previously gained. During

be following expiration further progress is made* and thus by succes-

■Te advances, in case no intervening body prevent^?, the liaud is made

to sink inward until the vertebra? are felt,* In eases of undue sensi-

i?enf«et of the abdominal walls, chloroform may be administered to

amplete anaesthesia. Some patients, by means of contractions of the

linal muscles, succeed in producing the semblance of a tumor,

may even be mapped out with the hands applied to the abdo-

Thcsc so-called ** phantom tumors "occur most commonly in

women who are earnestly desirous of becoming mothers.

> Ttluflbto mcUiod U borrowed from Professor SniatLD erg's " Dlagnodc der Eier-
■todcminoppfi," VoIlunaim*i **&}4mm1. kiln. Tortr./* No, SS.

106

PHYSIOLOGY OF PREGNANCY.

They an? eminently calculated to entrap tlie imwary, if the examina-
tion be confined to the iibdomcn» or to listening to the patient's sub-
jective symptoms. They flatten down and disappear under chloroform,
or when the attention is distracted during the course of an inrestiga-
tion.

AuacuUafion furnishes the most certain evidences of the existence
of pregnancy. The stethoscope may be employed, or the ear may be
applied directly to the abdomen. To hear the fetal heart requires a
certain amount of practice, but the art can be readily acquired, As
the sounds are, at best, of feeble intensity, the utmost stillness in tiie
neighborho€d of the patient is necessary for this appreciation. They
are always heard with great difficulty before the end of the sixth
month. There is no sj^ecial point at which they can be invariably dis-
tinguii^hed. In head or breech presentations, with the back of the
fcetus curved and in contact with the uterine wall, the sounds are most
clearly to l>c made out over its dorsal aspect. In face-presentations,
on the contrary, the anterior surface of the child is pressed against the
nterine walls, and the sounds are heard with the greatest distinctness
over the chcist. As in the last three months of pregnancy the cephalic
presentations, with the back to the left, preponderate, the heart-sounds
are oftenest heard in a line extending from the anterior superior spi-
nous process to the umbilicus. When the back of the child is turned
to the right, it is likewise directed somewhat posteriorly. The heart-
sounds are then less accessible, and therefore ajjpear feebler. Care
must be taken not to confound with tlie fetal heart the conducted
heart-sounds of the mother, or the aortic pulse. Thick abdominal
walls, or abundant amniotic fluid, may interfere with the recognition
of the heart-sounds. Wlien the back of the child is turned to the
rear, orduringa uterine contraction, they may disappear altogether.
If the child bo living, however, repeated examinations will not fail to
detect them, Tlie uterine souffle is heard with maximum inten^ii
to the sides of the uterus. In the early months it is to be sought lor
near the median line, just over the symphysis pubis.

Thfi vaf/inal iouch enables one to effect an examination of the
genital canal and that portion of the uterus which is contained within
the pelvic canity. The accoucheur should accustom himself to use
either hand with equal ease, and t^ conduct an examination upon
whichever side of the bed his patient chances to be lying. The index-
finger sliouM he anointed with cold cream, hird, butter, Taseline, oil,
or simple soni>-and-w^ater, to make its introduction into the vagina less
painful. As the hand is piissed under the clothes, it is a good plan
to cover the index with the thumb and remaining fingers, to prevent
its soiling the patient's wearing-apparel. The patient should now
be told to separate her knees widely, while the index-finger glides
forward over the perintifum to the introitus vaginas. Kote should be

THE DIAGNOSIS OF PREGNAXCT.

107

?re of the size and direction of the orifice, and the degree
resistance afforded by the externa! part^. Where there is much
hair about the pubes, the introduction of tJie index-linger into the
TogiBii iif greatly favored by separating the htbia with the fingers of
the other hand. As the finger enters the vagina, it is well tu notice
the urethra, the condition of the rectum (whether filled with fseces),
the length and width of the vagina^ and the amount of lubricating
eecretion furnished by the vaginal walls. To explore the anterior half
of the pelvis, close the unemployed fingers upon the palm of tlie
haad, direct the palmar surface of the index-finger to the front, and
preas upward to the presenting part. In the early niontbe, ]*lace the
unemployed hand upon the abdomen above the symphysis pubis, and,
by conjoined manipulation, make out the size, shape, and consistence
of the utenis. If pregnancy is sufliiciently advanced, ballottement
may be produced. To reach the cervix, the finger should be next
turned to the rear. Many practitioners now prefer to extend the
previously closed fingers, and press them opened against the peri-
rneum* Should the cervix not be readily reached, the examination
filiould be made with both the index and middle fingers. If tlie mid-
dle finger is introduced slowly and wuth care, it gives no additional
pain, and increases the reach by nearly an inch. The actual distance
to the cervix miiy be diminished by placing the closed hand under the
extremity of the sacrum, so as to diminish the degree of pelvic incli-
nation. It is often necessary to resort to this measure when, toward
tlie end of pregnancy^ the cervix is situated unusually high up and is
directed well to the rear. With the touch, we recognize the size and
tfaieknef^s of the cervix, the length of both the anterior and posterior
walls, the shape of the os, and, if open, the character of the cervical

The rectal touch is only necessary where there is obliteration of the
Tagiiui, a condition which doee not exclude pregnancy, but it is some-
limeB usefully resorted to in other cases to complete information ob-
laincMl by vaginal exploration.

The speculum, though it funiishes us with a view of the coloration
of iJio vagina, a most valuable sign, is rarely employed as a means of
diagno^iid.

DliJTtNCTIOK BETWEEN FlRST AND SUBSEQUENT PREGNANCIES,

111 women who have once completed the full term of ntero-gesta-
tion, the imprint* left by the pregnant state are indelible, and easy to
recognize. As it is sometimes a matter of foreusin importance for a
]ihyiieian to be able to distinguish between first and subsequent preg*
nanciep, it is desirable for every practitioner to make himself familiar
with the characteristic ditferences between ifie two conditions.

In primiparm the abdominal integuments are firm and tense, so

108

PHYSIOLOGY OF PREGNANCY,

that it 18 difficult to map out through them the underlying uterus,
or to feel the head, the breech, or the limbs of tlie child. The striie
found upon the abdomen, the nates, and the thighs, appear late in
pregnancy, and have a reddish-brown or slaty color. The breasts are
full, firm, and sensitive to pressure. The labia arc in apposition, and
the fra?iuilum is intact. The hymen is torn, but each fragment re-
mains attached in its entirety to the introitus vaginse. The urethra
is hypertrophied, and ap^Tcars as a cylindrical body, of a reddish-blue
color, in the vaginal orilice. The vagina itself is narrow, with dis-
tinct transverse ridges, and oftentimes possesses a granular feel, from
the enlargement of the papill*. The vaginal portion of the cervix
18 soft. When the head enters the pelvis, toward the end of preg-
nancy, sliortening of the anterior lip takes place. The os externum
is closed, or, not infrequently toward the close of gestation, admits
the passage of the extremity of the examining finger. It then feels
like a round apening, with smooth borders, and a sharp inner edge at
the |>oint where it joins the cervical mucous membrane. The eervicul
canal has a spindle shape. The head, in the latter months, as a rule,
sinks into the pelvis, and bulges the vagina.

In women who have already borne children^ the skin of the abdo-
men is loose, wrinkled, and can be gathered into folds by the hands.
Tlie uterus is likewise relaxed, and through its walls can be felt, in
many cases, the projecting parts of the fa?tus. T!ie uterus is easily
defined. In addition to the striiE upon the abdomen, noted in primi-
parn?, many of older date, possessing a shining white or silvery ap-
pearance, can be made onL The breasts arc flabby, pendnlous, and
marked with eilvcry lines. The vulva gjipes open, and wears a bluish
aspect from the development of the superficial veins. The fra^nulum
is usually found to liave been lacerated. The carunculie myrti formes
alone remain as vestiges of the hymen.* The vagina is smooth, from
the obliteration of the transverse ridges. Swelling of the vaginal
papillae is exceptional. The cervix is swollen, and has a cylindrical
mther than a conical shape. At times it is like a cone, with the base
downward. The os is open, and admits the extremity of the finger.
This patulous condition is due to lacerations of the cervix, which are
the inseparable concomitants of child-bearing. The lacerations differ
greatly in degree, but are rarely difficult of recognition. As they are
situated usually on the sides of the cervix, they convert the os into ti
wide, tmnsverse slit, bounded by a well-defined anterior and posterior
lip. The cervical canal has a funnel-shape, narrowing above. In the
ninth month {tn some cases earlier) the finger passes readily through
the 08 internum to the child's head* The latter rarely descends into
the pelvis before the advent of labor, but either is situated at the
brim; or resta upon one of the iliac fossce.

• Vide p, 7.

THE DIAGNOSIS OF PREGXANCY.

109

It ghould be added, finally, by way of caution, that while the pres-
of the foregoing signs si^eaks plainly in fiiTor of tfjc existence of a
iotiB pregnancy, their absence is not absolutely incompiitible with
the occurrence of a premature labor, or even, in rare cases, with the
delivery of a small fcetus at full term,

Thb Diagnosis of the Death op the Fcetus,

The presence of a dead child in utero may be inferred where
ive movements arc not elicited by palpiition, or where the heart-
fiounds* after repeated trials, can not be made out. As we have seen,
ft nninber of conditions sometimes combine to temporarily render it
impossible, even when the child is living, to obtfiin positive results
by auscultation, A decision should not, therefore, be based upon the
resmlte of an isolated examination.

In the earlier months, previous to the period when the fetal heart
be heard^ the death of the fcetus is rendered probable by flabhinesa
diminution in size of the uterus, by a flaccid condition of the
bfoastg, and certain subjective sensations experienced by the mother,
such m languor, chilliness, bad taste in the nioutli, and the feeling
of m weight like a foreign body in the hypogastrium. Certainty is
obtained when, through the open cervix, the cranial bones can be
ie out, and are found loose and movable within the integuments.

The Duration of Peeo nancy.

There is no question, in obstetrics, upon the solution of which so
much ingenuity has been expended as the determining of the normal
donition of pregnancy. Inasmuch as it has proved impossible to
sdcertatn the precise moment in which concepttou (i* e., the fertilizing
of the ovum by the spermatozoa) takes place, it has been customarj
to aaaume as the starting-point for the reckoning of gestation either
the date of the last menstruation, or that of a single fruitful coitus.
It would seem at first as though the latter would lead us to more
nearly accurate results. But, aside from the fact that the distance
of time between insemination and conception is avowedly variable,*
it is only in rare cases that the particular coitus which has resulted
in pregnancy can be definitely ascertained, Duncan collected 46 eases
in which connection took place during a single day only, and found the
time to the da1;jD of parturition was 275 days, Ahlfeld» from
ly^is of 425 cases, obtained an average of 271 days.f In 108

* DtrxcAii, " Fecundity, Fertility, tnd Sterility," BtHX^nd edition, pp, 488, 435.
^f ** Ocobadituiigeii liber die Dnucr dcr Schwcmgerachttft/^ *' Monai^sdir. t Geburtsk,,"
lElsiv^, p, S08. Ahl/eld'^ actual reckoning gave un avcrug« of 269 91 day?, but
ikli w»j nftcnrani corrcon?d by LSweohardt, who fotind Ahlfeld'** tftbica really f«r-
aiihcd tD iivenige of 270*d4. Vide Lowrnbaiu^t, *'Die Berechnung und Daucr der
WiwingpfitchAft," "* Arch. f. GycAck./* Bd, ill, p. 458.

PBYSIOLOGY OF PREGNANCY.

cases furnished by Ilecker the arera^ was 273 '5^ days.* Veit pub-
lished 43 cases, with an average of 2 70 "42 dayg.f In 63 cases of Faye's
the average was 270*^64 Undoubtedly many of the cases included in
these tables are o£ questionable reliability ; two of them, indeed, in
which confinement is reported to have followed coitus, respectively
in 329 and 330 days, evidently belong to the realm of fable* Assnra-
ing, however, that the size of the tables serves to nearly neutralize
specific inaccuracies, the small value of the averages obtained, as a
means of predicting the date of confinement, is shown by the wide
differences between the terms of gestation in the individual cases of
which the tables are composed. Thus, in Ahlfeld's table there existed,
between the longest and shortest gestation, a difference of 09 days ; in
Hecker's, a difference of 63 days ; and in Veit's, a difference of 30
days» In the breeding of domestic animals, in which conception, as
a rule, follows a single act of sexual congress, similar vanations are
common. In the now familiar observations of Tessier, Krahmer, and
Spencer, the average duration of gestation in rabbits is 31 days, the
variation 8 days ; in sheep, pregnancy averages 151 days, and the
variation amounts to 26 days ; in cows, the average time of gestation
is 283 days, but calving may occur between the 18M and the 356th
day ; in mares, the average time is 347 days, but foaling may occur be-
tween the 287th and the 419th day.*

However, Ahlfeld's tables show that the bulk of confinements vary
within narrow limits. Of 653 women, in 15'93 per cent, delivery oc-
curred in the thirty-eighth week; in 27*56 percent., in the thirty-
ninth week ; in 26*19 per cent, in the fortieth week ; and in 10*01
per cent., in the forty-first week. In other words, more than half the
cases occurred in the thirty-ninth and fortieth weeks, and 80 per cent.
between the thirty-eighth and forty-first week inclusive. Of the re-
mainder, 14 per cent took place prior to the thirty-eighth week, and
were probably influenced by the many operative accidental cauges
w^hieh favor prematurity. Of the G per cent, reported as occurring
later than the forty-first week, a considerable number are of question-
able authenticity. Gestation protracted beyond the two hundred and
eighty-fifth day is certainly of very rare occuiTcnce, j

* Ahlfkld, op. eit., p. 20S.
\ Ihhl, p. 210.

t Other tables may be found in Montgoukut, " Signa of Pro^ancjr," Beoond editioti,
pp, 403 c(»eq.

• Vide Ahlfeld, op, cit, p. %H\Bt. Cvh, ** Trail6 d*obBt^triqu<j Tdt^riniiirc,'' pp. 107
dteq.

I Many cases of apparent pTotrftct4*d gestatioii find their explanation in the fact that
conception may occur just prior to the menTitnititiori period succecnlitig to that from which
the count is made* III one instance, m which a lady was confined three hundred and MX
days after the tast menatnml period, the statement was volunteered that for twenty days
following menstruation " preeaulKoos " against pregnancy bad been resorted to.

THE DIAGNOSIS OF PREGXANCY,

111

Prediction op the Day op Confinement.

In all Bchemes for predicting the date of confinement, it is custom-

to throw out, as defying calculation, the exceptional cases^ which

II mach below or greatly exceed the usual average. No sclieme is

er likely to be devised which will insure accuracy with regard to the

day upon which labor will occur. In every Bcheme it has been assumed

thsi errors of from four to five days are inevitable. Moral emotions,

fiitigue, attacks of indigestion, mechanical causes, and the like, are

recognized as liable, toward the end of gestation, to preci]>itate labor

at any time. But a vast deal of ingenuity hm been expended in the

endeaTor to reduce ordinary errors within the naiTowcst limits.

The Last Henstmation* — Now, it has already been remarked that it

uf only in rare eases that the day of conception (i. e,, insemination) can

be utilized. In all calculations of the duration of pre^ancy, it has

been customary, therefore, to select the menstrual period as the start-

ing-lK>int. As the days immediately following menstruation are those

in which conception usually occurs, the end of menstruation has been

opt^ by some as the most suitable point of departure. Alilfeld

imated that 35 '55 per cent, of married women conceived on the

t day of menstruation, and that 88 '44 per cent, conceived within

elve days, counting from the first of menstruation.* Experience

shown, however, that there is no single day in the intermen*

mal period in which conception may not occur. Jewish women,

deed, who are forbidden sexual intercourse by the Mosaic law during

enstruation and the seven days following, are pi-overbially fruitful.

> wen hard t haa shown that, though in two women conception follow

I jn each a single act of coitus, occurring the same number of days after

menstmation, there is no necessary correspondence of the date of eon-

^ftDemont in the two. f

^H As, therefore, there is little to be gained by estimating the day of
^Bdnflnement from the probable day of conception, it has become the
^IwQal rule to reckon from the first rather tHan from the la^t day of
menstruation, especially m mo6t women exercise more care in presorv-
uig the record of the former date.

From the days of Hippocrates, it has been customary to regard

gnancy as extending over ten lunar months, or ten menstrual pe-

uf twenty-eight days each. In accnrdance with this idea, Nae-

J proposed a ready method of computing two hundred and eighty

Ij^ from any given date, which has since his time lK*en geuemlly

adi^pted. This consisted in counting forward nine months, or, what

amcHinted to tho same thing, counting backward three months, and

ihsQ adding seven days (in leap-years, after February, six) to the date

* ABt.nn.l>, op. cif,, p. 191, f Op. Hf., pp, 461 d Mty*

% NjueatLi, *' Lehrbuch dcr Geb./* nchter Auflage, p. 132«

112

FEYSIOLOGT OF PREGNAKCT.

cliosen as the starting-point of the calculation, Nacgele selected the
first day of the lost nicnstrnation- His method is, of course, equal! j
applicable* wlicn the day of cessation is preferred as the point of de-
part urc. For seven months in the year Naegelc'e method is ahsolutely
correct. In February, however, four days, in December aud January,
five days, and in April and September, six days only are required to
complete two hundred and eighty days. Tables may l>e found in most
physicians' visiting lists, by means of which the two hundred and
eiglity days may be determined at a glance. The following circle of

i)\

,i^»*

30.

Jul.

'^/z

S-

V5i|U

''-r-/vvp|.|£-o30

O**'

Fia. TO. — Biugnim for oomput'mg prognoncy, (Schu)tzc.)

Schultze is based upon Naegcle*s method. The figures between th©'"
rfidii show tlie exact number of days to be added for each of the
months BeveraOy, The figures in paren theses arii to be employed in
leap-year.

Unfortunately, the supposition that labor comes on after the ex*
piration of ten menstrual periodti of twenty-eight days each is correct
for only a small number of ciuses, so that it has been found necesi?ar)^
to shift the ground somewhat to the position that the normal duration
of pregnancy covers ten menstrual periods. The instability of the
reckoning would then find its explanation in the common experience
that ten consecutive periods of exactly twenty-eight days each are rare
even in the most regular of women. Although ovulation is suspended
during pregiuincy, at the return of the menstrual epochs the existence
of an ovarian influence ui)on the generative organs may be clearly
traced in many individuals. At such times a sensation of fullness is
often experienced in the pelvic organs, associated in some women with
an awakening of the sexual appe^e. At such times, too, there has

ippettfce. At

THE DIAGNOSIS OF PREGNANCY.

113

been obsenred a tendency to miscarry^ bo that it becomes incnmbent
upon sensitiye^ impressionable females^ predisposed to abort, to espe-
cially aToid either reflex or mechanical sources of disturbance during
the continuance of the state under notice. When the ovum reaches
maturity, the recurrence of the tenth menstrual epoch furnishes local
conditions in a peculiar degree faToring the production of labor.
Ldwenhardt * found it was possible to calculate the duration of preg-
nancy in twenty-two individuals with tolerable accuracy, by assuming
that ten menstrual periods represent not two hundred and eighty days,
bnt ten times the length
of time between the
last menstrual period
and the one immediate-
ly preceding it. In no
case thus calculated did
the error exceed fiye
days, a degree of exact-
itude unattainable by
the method of Naegele.

The Date of Quick-
ening. — When the date
of the last menstrua-
tion can not be obtained,
it is customary to reck-
on the time of labor
approximately by add-
ing twenty-two weeks to
the date of quickening,
which is assumed to oc-
cur in the eighteenth
week of pregnancy. The
extreme yariatiou, how-
eyer, in the time at
which quickening oc-
curs in different indi-
yiduals renders this
method of calculation a
very uncertain one.

The Size of the Uterus. — As the increase of the uterus is progres-
sive, its size is sometimes used in determining approximatively the
period to which gestation has advanced. According to a rude for-
mula, commonly employed at the bedside, the uterus is, in the second
month, of the size of an orange ; in the third month, of tlic size of a

• ** Die Berechnmig und die Dauer der Schwangerachaft," " Arch. f. Gynaek.," Bd.
ill, p. 476.

Fio. 71. — Schultwj diagram.

114

PHYSIOLOGY OP PEEGNANCY.

child^B head ; in the fourth month, it can he felt ahove the symphysis
pubis. In tlie fifth month, the fundus of the utenia risefi to a point
midway between the symphysis and the navel. By the sixth month,
it reaches the level of the navel. In the seventh month, it should be
the breadth of two to three iingers above the navel. In the eighth
month, it rises half-way between the nave! and the epigastrinm. In
the ninth month, it reaches the epigastrium. In the tenth month,
two to tliree weeks before confinement, the ntenis sinks downward
and somewhat forward, so that its upper level corresponds very nearly
to that of the uteruB in the eighth month.

In the foregoing calculation most of the data are obtained from the
relation of the fundus to the navel. Bnt the navel is not a fixed point*
Spiegelberg found the distance between the upper border of the sym-
physis and the navel varied in different women as much as six inches.*
The average distance from the symphysis pubis to the fnndus of the
uterus in the different months of pregnancy he found was —

From tLe 22d to the 26th week • 81 ioches^f

" " " 28th week. 10^ "

" ** " 80th week U **

** ** " 82d and 88d week Hi "

" »* " 84th week 13 "

** ** ** 86th and 3Cth week 12i **

" " *' STth atid 38th week 13

** *' ** Sflth and 40th week... 13J *'

But the size of the uterus is subject to considerable variations, due
to the size of the child and the amount of the amniotic fluid.

♦ "Lchrbuch der Geb./* Bd. ii, p. 115,

f These men bu rem en t a exceed cora«iderably tbomj furnished by Fftrre, p. 83. The dis-
crepandea arc due m part to the extent of individual variation^ and in part to the fact
tbat they were made with a tnpe-mcasure, Tliua, Ahlfcld, employing the cyrtom^tre of
BAudclocque, found the dii^tanee from tlie symphysis pubis to the fundus only tea and a
half inches m the fortieth week. Ahlfeld found the length of the child to be nearly
double the distance between the head and breech when the child assumed the attitude
nsual in the y tenia. To determine the date of pregnaocy, he proposed to ixiea^ui^ the
axis of the r<jptua in tUero^ by means of a cyrtoro^tre, one extremity of which, passed into
the Tagina, rested upon the child's head^ while the other was extended to a mark upon tl>e
abdominal wail corresponding to the breech. He then Bought to establish the length of
a eliild at each week of pregnancy. His tables show, however^ such TariiittonA in the
size of children bom in the game week as to impair the practical value of the method
Vide AnLrxLD, '* Bcattmmung der Gros&e und des Alters der Frucht Tor der Geburt^^
" Afch. t Gynaek./' Bd. ii, p* 353,

THE MANAGEMENT OF PREGNANCY,

115

PREGKAl^CY,

CHAPTER VL

THE MANAQEMEKT OF PREO NANCY.

Hj-^ietie of prdgnancj. — The diaordera of pregnaucy. — The blood-dmnges of pregnancy*
— Pemicioii* anemia,— HydrsemLc ixdema, — Varitose veins,— Nausea and vomiting,
— Beart^bum, — Insaliviition. — Pruritua, — Faue-aehe. — Cepbalftlgia, — InflomDia^

Ix Studying the effects of pregnancy we saw that, besides the local
elianges in the sexual apparatus and the disturbances produced by
pressure, the organism had to adapt itself to a variety of new condi-
tioDB, of which the most conspicuous were alterations in the quality of
the blood and increase of ita quantity^ with additional work thrown
[upon the lungs and kidneys, and reflex derangements of the nervous
ituid digestive systems. The physiological condition of the pregnant
woman approximates so closely to what would be regarded m patholog-
ical at other times that the necessity arises for the patient to carefully
observe hygienic rules, while the physician often finds himself called
'upon to exercise his art in restraining distressing symptoms within
limits consistent with the healthy progress of gestation.

The HygieBe of Pregnancy. — During the pregnant state, the in-
1 elimination of carbonic acid by the lungs is necessarily associ-
(ated with increased consumption of oxygen. This respiratory activity
I mokes an abundance of fresh, pure air a matter of prime importance.
\Ab a role, therefore, a rural neighborhood is more conducive to nor-
1 pregnancy than large cities. To be avoided are smallj close, heated

, confinement in-doors, and crowded assemblages.

The dietary should embrace all nutritious, easily-digested articles

of food. The natural tendency to acidity, heart-burn, flatulence, and

ct>lic is apt to be increased by indulgence in the products of the frying-

Lpan and the dainties of the pastry-cook and confectioner. The eon-

I'Saming desire for unwonted articles of food, which is customarily

I termed "longings," I have never yet witnessed, and am tempted to

itcgBrd a« in a great measure mythical. A good appetite is the best

rMft^giiani against moat of the discomforts of pregnancy. Owing, how-

ever, to the activity of the assimilative processes, a very moderate ap-

ite ia not incompatible with a considerable gain in weight. A very

appetite is not normal during pregnancy, and ref|uirc3 to be

allied.

The dn?s8 ghonld be loose and easy. Garters and tight corsets

boald be diiK^arded. When the projection of the abdomen removes

PREGXANCT.

the folds of the dress from the lower limbs, flannel drawers reaching
to the waist should be worn as a protection,

Geiitleexerci.se, not pushed to the verge of fatigue, should be en-
couraged* Walks and drives m the fresh air are the best means of
fostering sleep and maintaining the appetite and general assimilative
processes. Violent exereise^r on the other hand, is liable to produce
miscarriage. It is stated that the predisposition to miscarriage is
greatest at the third and seventh month. Throughout pregnancy
special care should be observed at the recnrrenco of the menstrual
epochs. Long railway Journeys at such times are a frequent cause of
trouble. Marital relations, though not absolutely to be prohibited,
should he of infrequent occurrence. Excesses in the newly married
are a eijmmon source of abortion.

The skin should be kept in good condition by frequent bathing, as
by its eliminative action it is capable of relieving the kidneys of a j^or-
tion of the work thrown upon them. The increased vaginal secretion
renders it important for the woman to frequently wash tlie external
genitals. The vaginal douche is a source of comfort to many women.
but the quantity injected should not exceed a pint of wat^r, and should
be introduced elowly, with every precaution in the way of allowing
au immediate reflux to take place.

The increased irritability often observable in pregnant women calls
for the greatest forbearance and gentleness on the part of those who
are brought into close contact with them* Their unreasonableness id
not to be cured by either impatience or stern treatment It is the
product of nervous derangement, and is to be regarded as due rather to
physical than to moral fault.

The Disorders of Pregnancy. — Among women reared amid the
refinements of civilization the entire period of pregnancy is very fre-
quently attended with a great deal of discomfort. The attempt to
relieve the disorders of pregnancy seriatim^ it should be stated in a
general way, is a vain undertaking, and is a good method to beget hys-
teria by fixing the female's attention upon minor ailments. The best
medicines, in a large proportion of cases, are amusements and occu-
pations calculated to produce a forget fulness of self, When^ how-
ever, the disorders of pregnancy advance beyond the stage of dis-
comfort to that of actual suffering or danger, every effort should be
put forth for their relief or mitigation.

The Blood-Changes of Pregnancy, — The most important changes
consist in the loss of red corpuscles and albumen. The former, as
the oxygen -carriers to the tissues, are illy spared from the economy.
Wlien they have undergone destruction to any material extent, the
cell-elements^ whose vitality is intimately associated with the power to
take oxygen from the blood, suffer from inanition, and the starved
cells waste or fill with fatty molecules. These changes are of noces-

THE MANAGEMENT OF PREGNANCY.

IIT

pity followed by lose of weight, muscular prostration, impaired func-
Eional activity of the secretory organs, and increased nerve irritability,
a consequence, the appetite fails, the digestion is weakened, neunil-
fic pains develop, and even moderate muscular exertion is attended ^ath
fort and followed by a sens?e of fatigue ; vertigo, loss of memory, aud,
ievere cases, chorea, liysteria, and insanity, may result from the
deranged condition of the nerve-centers ; attaekg of syncope, palpi ta-
tioDit^ and pTsecordial oppression point to feeble heart-action ; the arte-
rial tension is lowered and venous hypersemia results ; and, finally, the
aant blood, deprived of its albumen, in place of inviting endos-
aotic current^s, transudes through the walls of the vessels, giving rise
CBdema and dropsical effusions, Gusserow* (1871) called attention
the fact that the anaemia of pregnancy might progress to such an
ctreme as to produce a fatal termination.

The treatment of antemia is largely prophylactic. Light, air,
noderate exercise, good food, regulation of the bowels, cheerful society,
ad an occasional respite from household and family cares, will always
be the main checks to its extreme development Iron, though of little
aTail in repairing losses which have already taken place, is of the ut-
most value in limiting the progress of the malady. Iron reduced by
hydrogen, in three-grain doses, either alone or combined with a fiftieth
of a grain of arsenic, has rendered mo most service in this affection,
should^ however, be continued witliont intermission for weeks at a
in order to obtain the fnll advantsige of it^ beneficent action,
I I]C|nid forms of iron, so useful at other times, I have rarely found
Ulermtol for a lengthened period in the pregnant state. In weakened
I of the stomach, when the latter revolts at beefsteak and mutton,
ly assimilated albuminoid articles, such as milk, soft-boiled eggj^,
id sc™i)ed raw or underdone meat, should be administeix*d in small
it frequently repeated portions. Where the marasmus is extreme,
and the rectum tolerant, the stomach may be relieved of a part of \ta
dnty by the use of nutritive enemata prepared in accordance with the
• familiar prescription of Leube. In the pernicious form of anromia,
luBserow tried transfusion^ but without success. He recommended,
fore, the resort to premature labor. In a ca^e which occurred to
hospital practice, before my attention was drawn to Gusserow's
MMJt I employed the latter method after consultation with my col-
le^jpUML The patient made a slow but apparently sure progress tow-
ard reoaTi?ry» until, at the end of a month, slie managed, in the tem-
pomy absence of the ward nnrse, to get out of bed and make a
iy metA of corned-beef and cabbage. Vomiting set in, followed
eollapse, which proved fatal in a few hours. This pernicious
orm of amemia* though not confined to multipane, develops most

♦ Grmnow, ** Uebcr hochgradigstc Anaemie Schwangcrer/* " Arch, t Gjnnck.," Dd.
il^^tlS.

118

PREGNANCY.

frequently in women who have borne many children in rapid sue-
cession p

A not unusual result of bydnemia consists in a swelling of the
lower extremities, beginning at the ankles, and thence extending up-
ward and invading often the labia, the vagina, and the lower segment
of the uterus. When not associated with kidney complications, this
fl?dema ia rarely dangerous, though often the source of extreme dis-
comfort. In some caacs of oedema of tlie vulva, tlve labia may attain
to tlie size of a man's head, and become nearly diaphanous from the
Beroua infiltration. When tlio distention is extreme, gangrene may
threat4?n and make it necessary to resort to puncture. In lying-in
hospitals this should he done with every antiseptic precaution. With
fj'ce drainage established, the swelling rapidly subsides. In a half-
dozen cases which I have thus far treated in this manner, premature
labor has followed in the course of two or three days, a coincidence of
such frequent occurrence as to make it necessary to employ puncture
with circumspection.

(Edema of the lower extremities seldom disappears entirely before
confinement, though relief is sometimes experienced in the last month,
when the fundus of the uterus falls forward* Slight degrees, such bs
swelling limited to the feet, making it necessary for the woman to go
around in old shoes or her husband's slippers, do not require treat-
ment. Where, however, the skin of the limbs becomes tense and
painful, warm cloths should be applied, diaphoresis if possible should
bo induced, tonics should be administered, and the patient be kept in
a recumbent position, or with the extremities raised d VAmhicaine^
llydragogue cathartics, by still further impoverishing the blood, tend
to aggravate the difficulty.

Varicose Veins. — ^Varicose veins occur with greater frequency in
multipara? than in priraipara^. So long as the large veins are not
involved, they possess slight significance. The saphena is always first
affected, then tlie lateral branches upon the inner surface of the leg
and thigh, especially ju?t above the knee,* and less commonly the
veins of the vulva. Dilatation of the haemorrhoidal veins is a very
frequent occurrence.

The treatment of varicose veins is limited to the adoption of meiUK
ures to prevent their inci"ea8e, and to provide against the dangers of
rupture. The first indication is best ful Oiled by regulation of the bow-
els and the wearing of elastic stockings. The subcutiineons injection of
one to two grains of ergotine in solution has been recommended, and is
re|>orted not to awakfen uterine contractions. As the danger of rupture
is not speculative (Spiegelberg f reports two cases of fatal haemorrhage

* PniOELBEHO, lo€, ciLj p. 250,

f Ibid.^ p. 250« For a cotnplcte tUseuBftloti of the subject, vidtf **0ea vuieee diet t*
femme enceinte," ''Tbeee d'Agr^g&tioo," jwr lo Dr. P. BuDtn.

THE MANAGEMEXT OF PREGNAXCT.

119

from this cause), the patient should always be proyidcd with a com-
preaa and baudage, which she should be taught to apply herself in case
of a sudden emergency before professional aid can be obtained.

Nausea and Vomiting. — There ai*e few known therapeutical agents
which have not at one time or another been essayed as remedies for
the nausea and vomiting of pregnancy. Some of them have even en-
joyed for a time high repute as specifics, but the sobering effect of
experience has invariably served to dispel illusive hopes, the most suc-
oeosfui of them proving uncertain, and of benefit to only a limited
class of patients. It is usually, therefore, the part of prudence to do
nothing for the minor degrees of the affection, such as the ordinary
rooming-sickness, or even for continuous nausea, so long as the inges-
tion of food and the general nutrition of the patient are undisturbed.
For these cases Seyfert's advice to let the wife go home on a visit to
her mother, implying the value of changed surroundings, furnishes a
serriceable hint in the way of practice. When, however, the distress-
ing symptoms continue after the first three months, and perceptibly
tend to exhaust the vital powers, every resource should be tried in
turn^ in the hope that some one of the many in repute may prove of
service as a means of warding off impending disaster,

I^At the outset of any systematic plan of treatment for pregnancy-
Tomiting, it is essential that the physician should inspire his patient
with confidence in his ultimate success. ' Care should be taken to reg-
ulate the bowels, as constipation invariably aggravates existing gastric
disturbance. If* in the early months, the uterus is found retroverted
or retroflexed, it should be replaced in the knee-chest position, and
ihe recurrence of the displacement should be prevented by a suitable
IMMary. A speculum examination should be made of the cervix* and,
•lioiild it be found eroded, the raw surface should bo bni??hod at inter-
^ikof from two to three days with a ten-per-ceni, solution of nitrate
of silver. In quite a number of cases a mitigation of the distress is
obtained by applying the faradaic current to the pit of the stomach ;
m others, the ice-bag applied to the cervical vertebrae affords a con-
■idermble measure of relief. The inhalation of oxygen has likewise
been tried by Pinard with success. To many, ice-cold effervescent
drinks are grateful. Dr. Fordyce Barker recommends carbonic-acid
wmtifer containing a drachm of bromide of potassium to the siphon. Dry
dtampagiie is of assistance to a comparatively small class, but more
[often 1 have found it revolting to a squeamish stomach. Of medicinal
I suhnitnite of bismuth and the oxalate of cerium possess the
I application. Usually I order ten grains of the former, com-
bined witli five to ten grains of the latter, to be taken ten minutes be-
fore eating. In cases of gastric eataiTh, my favorite is the tincture of
nua vomica given in ten-drop doses before meals. Drop-doses of
I PowIer*i solution at meal-time are said to exert considerable inffuenoe

120

PREGNAXCT.

in allaying stomach irritability. A twelfth of a grain of morphia giVen
h}^odermically or by the mouth will frequently aid the retention of
food by tlie stomach, but may lead to the formation of the opinm«
habit, Simmons, of Yokohama, recommends the injection of thirty
grains of chloral per rectum morning and evening, a practice of which
Bichardson advises further trial* After eating, digestion may be
promoted by ton grains of pepsin, given alone or with either the dilute
muriatic acid or Horsford'g acid phosphate, f

li the foregoing measures prove of no avail, the patient should bo
made to take small quantitiea of easily digested food, such as milk
and lime-water, Vakntine^s beef-juice, or the pulp scraped from
raw or underdone beef, at hourly intervals, while rest in bed is main*
tained for the purpose of avoiding the slightest unnecessary waste of
tissue.

When the vomiting is literally uncontrollable, a rare event in
cases where the pliysiciau commands the full cooperation of his
patient, and death from starvation tlireatens, there remains as an
ultimate resource the artificial induction of abortion, or premature
labor. Before, however, proceeding to this last extreme, it is proper
to remember that, in many cases, the vomiting stops spontaneously
after the termination of the third month, or, when more persistent,
after the sixth month of pregnancy ; and that furthermore, where
practicable, it should be the rule to postpone measures for emptying
the uterus until after the child has become viable. Now, where it is
necessary to mn in tain the Btrengtli of the patient for two or three
weeks only in the hope of obtaining a living child, or a natural sub-
sidence of the disorder, rectal alimentation is capable often of ren-
dering excellent service. t Milk, eggs, and defibrinatcd blood ^ may
be u&ed for this purpose, though I have found nothing so effective as
the beef and pancreas preparation of Leube. || Dr, Henry F, Campbell

♦ RrCHAiiDsON, " Iljdrfflte of Cbloral in Obstetric Practice/* ** Trans, of the Am.
GjTMec Soc.,'* Tol. i, p. 247.

t Dr. E, CopuMAN rccomnicnds dilatation of tlie os externum and cerTical cadoI with
the indci-fin^cr. The latter should be passed to the first Joint, btjt not up to the os ia-
temum. Thia method, which bears Dr. Copcman^s ii4mc\ is regardcvt by its author as
inftt!liblc. It has Ukcwi^^e received the cnthuAioiJiic indorsement of Dr. Marion Bims.
—("Arch, of Med.;' vol. JIL)

I Dr. BtTBEY, in an article published in the *' Am. Jour, of the Med. ScL " (1879, pp.
112-117), recommends Btomoch-rcat, nutritive eoemata^ and the rectal adminidtraiiaQ
of bromide of potasfiUmL

* To prcTent decomposittoD^ Dr. A. H. Smith advises the addition of a grain and a
half of chloral to each fluidouuce of the blood.

I LEiTBB'g formula consists of five to ten ounces of finely-chopped becf^ to which
should bo added one third ita weight of finelj-minced pancreas (pig or ox). The mixture
should be treated iii a mortar with five oudocs of lukewarm water, and reduced to a
thick Boup (FosTicR*g " Clinical Medicine," p. 24). Not more than fcmr to six ounces
ahould be given at a time, nor more froquently than once in four hours.

THE MANAGEMENT OP PREGNANOT,

121

related a case where a patient of his was nourished for iifty-two days
by rectal alimentation alone.* Such cases, however, are very rare,
owing, in my experience at least, to the fact that in time the rectum
becomes intolerant of the presence of the injected materials. As the
induction of abortion, or premature labor, always subjects the operator
to criticism, and as its jierformance ia by no means unattended with
risk to life, it is advisable to share the responsibility with an experi-
euced professional coUejigue.

Heart*buni. — Ileart-bum becomes distressing in the later months of
pregnancy. It can rarely be cured before delivery; but may* in most
eases, be palliated by carbonate of magnesia, or half-teaspoouf ul doses
of aromatic spirits of ammonia.

SaliTation. — Excessive flow of saliva to the extent of two to three
qoarts in the course of the day has been observed. For this dis-
order small doses of atropia, the twelfth of a grain of pilocarpine, and
the fluid extract of viburnum pruuifolium have been severally recom-
mended.

Pruritus. — Pruritus, without any visible affection of the skin,
sometimes occasions in pregnant women an unendurable degree of
suffering. When general, a temporary relief may be obtained by plac-
ing the patient in a prolonged eoda4iath, and subsequently rubbing
the entire surface with vaseline* Very commonly the itching is con*
[fined to the distended abdominal walls. In such cases, cloths wet
'with camphor-liniments, with the addition of chloroform (lin. saponis
j eomp.» 3 V ; chloroformi, 3 j), or a solution of carbolic acid ( 3 j ad Oj)
[applied t4> the itching surface will usually allay the irritation for the
jtime. In pruritus of the vulva, in addition to local external applica-
Itions, great pains should be taken to cleanse the vagina with solutions
of borax or carbolic acid. A half-pint slowly injected into the vagina
may be employed twice daily, without risk of provoking labor. If
[th© itching results from an acrid discharge proceeding from an ulcer-
cervix, the application of nitrate of silver or the introduction
jght of a cotton plug soaked in a solution of tannin in glycerine
(ae. taniuc., 3j : glycerinse, 3 j) will usually afford relief.

Fftdl^acfae. — Neuralgia of the fifth nerve is a common affection in

prcgQUt women. It can often be quieted by the external application

of ttoonite, chloroform, or camphor liniment. Should these or kindred

lemedjes fail, it is best to resort at once to the hypodermic injection

[of morphia* 'The recurrence of pain, as the effects of tbo morphia

||iaj§8 away, can in most cases be prevented by giving to the patient

I once in four hours from three to five drop doses of the fluid extract of

i^laemium, suspending its administration so soon as the slightest in-

[dicatioQ of ptosis is produced. Croton-chloral, in from two- to five-

♦ fl, P, CiMMiELL, "Rectal AUmenUtion in Pregnancy," "Trans, of the Am. Gyn.

122 LABOR.

grain doses hourly^ has likewise proved effectiye. Bartholow advises
not to push the remedy beyond fifteen grains. Lindner (''Arch. f.
Gynaek./' Bd. x\i, p. 312) recommends ten grains at a dose given at
bedtime.

Cephalalgia. — Headache should be treated according to the canse.
Constipation should be removed, and iron should be given when the
headache is dependent upon anaemia. If of malarial origin, I have
never hesitated to give quinine in large doses, and have never yet ob-
served its acting as an oxytocic. When parely ol reflex origin, the
guarana-powder, the diffusible stimulants, and the entire range of
nerve sedatives are indicated. Unfortunately, there are no fixed roles
by which, in a given case, the appropriate remedy can be invariably
selected.

Insomnia. — Troublesome sleeplessness may toward the end of preg-
nancy reduce a woman to an unfavorable condition for encountering
the perils of childbirth. The main reliance should be placed, where
possible, upon moderate exercise, upon bromide of potassium, chloral,
camphor and hyoscyamus, and codeine. The ordinary forms of opium
should be placed under the ban, on account of the fatal facility with
which the opium-habit is acquired. Even in ordering the less ob-
jectionable hypnotics, care should be taken against their continued
employment. With proper caution, however, their occasional admin-
istration for the purpose of breaking a morbid » habit is to be com-
mended.

LABOR

CHAPTER VII.

TffE PETSIOLOOr OF LABOR AND ITS CLINICAL PHENOMENA.

Causes of labor. — ^Uterine contractions. — Action of labor-pains upon the uterine walls. —
Contraction of ligaments. — Action of abdominal muscles. — Action of yagma. — ^The
pain of labor. — General influence of labor-pains upon the organism. — Precursory
symptoms of labor. — First, second, and third stages of labor. — Duration. — ^Action of
the expcllcnt forces.

Under the term labor are comprised all the physiological and me-
chanical processes by means of which the extrusion of the OYum from
the maternal organs of generation is effected. As the term implies
exertion, its application is restricted to the parturient efforts of yi-
yiparous animals. The duration of pregnancy varies widely in the

niYSlOLOGr OF LABOR AND ITS CLINICAL PHENOMENA.

different classes of the animal kingdom. The occurrence of normal
labor is coincident with the maturity of the faetus. This, in man, is
fotmd to correspond very nearly to tlie interval between ten menstrual
periods.

Causes of Labor,

Speculation as to the proximate causes of labor have so far proved
profitless. The following particulars comprise the extent of our
knowledge of the conditions which prepare the way during pregnancy
for the final expulsive efforts :

1, During the first three months the growth of the uterus is more
rapid than that of the ovum, which is freely movable within the uter-
ine cavity, except at its placentiil attachment. In the fourth month
the reflexa becomes so far adherent to the chorion that it can only be
separated by the exertion of some slight degree of force, and the am-
nion ia in contact with the chorion. After the fourth month the
chorion and amnion are agglutinated together, though even at the ter-
mination of pregnancy they may with care be separated from one
another. After the fifth month the agglutination of the decidua vera
and reflexa takes place. In the second half of pregnancy the rapid
development of the ovum causes a corresponding expansion of the
uterine cavity, the uterine walls becoming thinned, so that by the end
of gestation they do not exceed upon the avenige two to three lines in
thickness. The vast extension of the uterine surface is not, however,
simply a consequence of over-stretching, a fact shown by the circum-
stance that the uterus toward the close of gestation is increased nearly
twenty-fold in weight, and by the histories of extra-uterine fetations,
in which, up to a certain limit, the uterus enlarges progressively* in
spite of the non-presence of the ovum. The augmented weight of
the uterus is the result of the increase in length and width of the indi-
Tidual muscular fiber-cells, the extreme vascular development, and
the abundant formation of connective tissue. Up to the sixth and a
half month there has further been observed a genesis of new fiber-
cells, especially upon the inner uterine surface. According to Ranvier,
the smooth muscular fibers become striated as the end of gestation is
leachod.*

The precise manner in which the distention of the uterus is aecom-
pltthed has as yet not been demonstrated, ^1 priori only two possibil-
iliei are apparently admissible, viz., either the individual stnicturio
elements are stretched after the manner of elastic bands, or a rear-
inent of the muscular elements takes place in such wise that a
1 proportion of tfie Hbcr-cells, instead of lying, as in the begin-
ning of pregnancy, parallel to one another, gradually, with the ad-
vance of gestation, are displaced, so that the ends only are in juxtii-
position. It is probable, though not proved, that toward the close
# ri«ii TAmjttm ot CHAifTAKtrf t^ '' Traitd de r&rt des Acoouchcmcnts,** p. 203.

134

LADOK.

the thinnitig of tbe valla is tbe result of both conditions. Bearing
these premises in mind, it becomes a disputed question as to whether
one of the causes of labor is not to be found in the reaction of the
uterus, as a hollow muscular organ, from the extreme tension to which
its fibers are ultimately subjected. Countenance to the affirmative
side is afforded by the tendency to premature labor in hydramnion and
multiple pregnancies, in which a high degree of tension is reached at
a period considerably antedating the complete development of the
foetus.

2* There is a perceptible increase of irritability in the uterus from
the very beginning of gestation. Indeed, the facility with which con-
tractions may be produced by manipulating the organ through the
abdominal walls has been put forward by Braxton Hicks as one of
the distinguishing signs of pregnancy. This irritability is especially
marked at the recurrence of the menstrual epochs, and becomes a more
and more prominent feature in the latter months, when spontaneous
painless contractions are ordinary incidents of the normal condition.

3. Tlie researches of Fried! tinder, Kundrat, Engelmann, and Leo-
pold have demonstrated that the decidua vera of pregnancy is dis-
tinguishable into an outer, dense, membranous stratum, composed of
large cells resembling pavement epithelia, probably metamorphosed
cylindrical cells, and an — in appearance — ^underlying mesh-work,
formed from the walla of the enlarged decidual glands. It is in
this spongy layer that the separation of the decidua takes place, the

Ft8. 72.— The muoouB fnerabrimc of the uterus. A. amnion ; B, reflcxa ; /?, decidua v«r« ;
i>, R^ ^limdulAr fipocea of the lower stn&tutii ; J/, luudculjir atructure of iitent*. (Eogisi-
cumti,)

fundi of the glands persisting, even after the expulsion of the OYtun.
By many, a fatty degeneration of the cells of the decidua has been
observed toward the end of pregnancy, but Leopold^ Dohrn* and
Langhans have shown that this is not of constant occurrence.* The

♦ Lfionji.0, "Studice abcr die Schleimhaut," etc., "Arch. f. Gynaek.," Bd. %i p. 49.

pmrsroLOGY of labor and rrs clinical phenomena.

125

tmbecalse which inclose the spaces of the net- work diminish in size
with the advance of pregnancy. Thus, while they measure at the
foanh month about -j^ of an inch in thickness, they become gradu-
ally reduced in the subsequent months to j^ of an inch, a change
which materially facilitatea the peeling off of the decidual surface.*

4» From the fifth month onward, large-sized cells make their
appeftmnce in the serotina^ especially in the neighborhood of thin-
willed vessels. The liirgest of these so-called giant-cells contain some-
tiniM as many as forty nuclei. Though a physiological product, they
jeaemble for the most part the so-called specific cancer-cells of the older
writerB* They are of special obstetrical interest from the fact observed
by Friodlander, and confirmed by Leopold,! that they penetrate the
Dterine sinuses from the eighth month, and lead to coagulation of the
blood, and to the formation of young connective tissue, by means of
which a portion of the venous sinuses becomes obliterated before labor
begins. The subtraction of these vessels from the circulation tends to
iliGErease the amount of the venous blood in the intervillous spaces of
the placenta.

5. It is proper to recall here the fact that the nerve-filaments of the
uterus are derived in principal measure from the sympathetic system.
The large cervical ganglion, which in pregnancy measures about two
inches in length by one and a half inch in breadth, receives, however.
In addition to the sympathetic fibers, filaments from the second, tliird,
and foorth sacral nerves.

Physiology has as yet left unsettled the question as to the main
channels of the motor impulses which are conveyed to the uterus during
labor. One of my hospital patients, with paralysis of the lower ex-
tn^mities, retention of urine, and loss of power over the sphincter-ani
mUBcle, had a perfectly natural though painless labor. The cause of
the fwiralysifi was obscure, the patient subsequently making a complete
recovery. JacquemartJ reports a similar case, in which tho paralysis
was due to partial compression of the cord at the level of the first
dorsal vertebra. On the other hand, Schlesinger * has shown that the
•ym pathetic is not the only motor nerve, as reflex movements of the
titeru9 follow stimulation of the orgim when all the branches of the
aortic plexus have been carefully divided.

A mot^jr center for uterine contractions has been proved to exist in
Ihe medulla oblongata. This center is excited directly to action by
ansmio conditions, and by the presence of carbonic acid in the blood
conveyed to it. Vivid mental emotions may either awaken or suspend

• B)nncL»4ji9, "The Muoout Membrane of the Tlerus," p. 45.
f Op. ftt, pp. 191, tt ttf,

I TAXunta et Cu^imuetrii*, " TraiU dt Tart dcs ttccoiieh«mcnl»,*^ p. 229.

• Oua nod ScaueuHQis, StHcl(cr*d ** Wiener mcKl JahrbucV 1S71«

i2e

LABOR.

Keflex movementa of the uterus may be provoked by stimulating
the central end of any of the spinal nerves, a fact which serves to ex-
plain the consensus long recognized as existing between the breasts
and the organs of generation. Wlien the gpinal cord is divided below
the medulla oblongata, this phenomenon is no longer observed. Direct
etimuli to the uterus, however, determine contractions independently
of the medulla oblongata, the spinal cord then acting as a reflex center.
The presence of asphyxiated blood in the arterial trunks acts a^ a-
phjsiological stimulus to labor.* By the separation of the decidn^J
from its organic connection with the uterus, the ovum acts aa
foreign body, and, as is well known, speedily awakens uterine move-
raenta. Finally, Kehrer f has shown that, when a eomu is removed
from the uterus during labor, rhythmic contractions of the mt
cular fibers will continue from a half-hour to an hour after eepara*
tion, provided only the tissues bo kept moist and at a suitable tern-
peniture.

The following theory of the causes of labor is offered, not beeauae^
of its completeness, but merely as a means of grouping the foregoing
facts together in the order of their relative importance. The advance
of pregnancy is associated with increase in the irritability of the uterus,
a property most pronounced at the recurrence of the menstnial epochs.
By thinning of the partitions between the ghmdular structures the
way is prepared, as the time for labor approaches, for the easy separa- ]
tion of the dense inner stratum of the decidua. The ready resj^onad j
of the uterus to stimuli reflected from the peripheral extremities of tho
spinal nerves, to direct local irritation, and to the presence of blood
surcharged with carbonic acid in the uterine vessels, explains the fre-
quency of painless contractions for days, or even weeks, in gome eases,
previous to labor. To these means of exciting uterine motility there
should be added, in all probability, the reaction of the uterine muscle,
from the tension to which it is subjected by the growth of the ovum,
and to circulatory disturbances in the cerebral centers sometimes
effected by vivid emotions. Frequently repeated uterine contractions,
without partial separation of the decidua, are hardly comprehensible
after the decidua vera and reflexa are brought into close contact with
one another. Such a physiological separation would, of necessity,
when of suflicient extent, by converting the ovum into a foreign body,
furnish an active cause for the advent of labor, in the same way that
labor is prematurely excited by a similar separation when artificially
induced, ' Thus, by tho time the development of the fostus is com-
pleted, all things are in train for its expulsion. When other causes
do not early operate as determining forces, the increase of uterine

♦ r7ife ScHLKSi^fOEn^ Strieker's " Wiener rued. Jfthrbuch," 1S73.
+ Kkkrcr, " Bcitrage xur verglekheiide und eiperimcutellen Gcburtakaade,** Ste«
Heft, p. 48.

PHTSIOLOGT OF LABOR AXD ITS CLINICAL PHENOMENA. 127

irritability at the recurrence of the menstrual epochs probably ac-
counts for the ordinary coincidence of labor with the tenth cata-
menial date.

Physiological Phenomena of Labor.

The Uterine Contraotions. — The uterine contractions are entirely
independent of yolition. As in other organs composed of smooth
muscular fibers, each contraction at the beginning is slow and weak ;
gradually it reaches the point of greatest intensity ; the acme con-
tinues for a brief period, and then, finally, is followed by complete
relaxation. Each complete excursion is termed a labor-pain. Peri-
staltic moyements have been obsenred in animals with two-homed
uteri. A similar action, proceeding from the fundus to the cerrix,
has been sometimes assumed for the human subject. The peristaltic
waye, however, if, indeed, it exists, extends so rapidly that it is best
to consider the uterus as a hollow muscle, which contracts simulta-
neously in all its parts. As labor advances, an increase in the length
and the force of the contractions is developed. The stronger the
pains, the shorter is the interval between them. The average normal
duration of a labor-pain is about one minute.

The Action of Labor-Pains upon the Uterine Walls.— During the
intervals between the pains, it is well known that the uterus possesses
an ovoid shape, and is fiattened antero-posteriorly by the pressure of

Fio. 73. — Trans verne section, dotted line
representint; sliape of uterus during
a pain. (Lahs.)

Fio. 74. — Lon^ritiidinal section, dotted
line reprej^cntiny elevation of fun-
dus) during u pain. (LaliH.)

the abdominal walls. During the pains, however, the uterus, as it
closes upon the fiuid contents of the ovum, assumes a more nearly
globular outline. As a consequence, the transverse diameter is dimin-
ished, and the antero-posterior increased in corresponding j)roportion.
By this change, the uterus, which had previously rested by its i>08te-

128

LABOR.

rior surface ux>on the spinal colnmn, rises upward bo that its fundus
produces a bulging of the anterior abdomiual walls.

Inasmuch us the lower uterine segment progressively ditnlnighes
in thickness toward the cervix^ its walls offer less resistanco to the
pressure of the ovum, and thus are stretched downward during each
pain. While, in contractions of the uterus, the lower segment is
thinned, the diminished hulk of the contracted organ leads to an
increase in tlic Hiickness of the walls of the body and fundus**

The Goatractioiis of the Dteriie Ligaments. — Structurally the mn^
cular fibers of tiio round and broad ligaments are in dirc*ct continuity

with tlie external muscular layer of
the uterus. As would be anticipated,
they contract simultaneously with that
organ. In contracting, they fix the
uterus at the pelvic brim, while the
round ligaments serve additionally to
incline the fundus forward.

The Action of the Abdominal Muft^^
cles.^ — The contraction of the abdomi^^f
nal walls is a powerful auxiliary to the
expulsive action of the uterus. At
the beginning of labor, the contrac-
tions are voluntary, but, as labor ad-
vances, they become more and more
reflex in character, until, in many
women, the disposition to press dur-
ing each pain assumes the form of an
uncontrollable impulse. The mechanism by which these auxiliary
forces are called into play is as follows : As, toward the acme of the
pain, the fundus uteri is elevated and lifts up the abdominal walls, the
woman takes a deep inspiration, the glottis closes, and the diaphragm
contracts. The latter pushes the intestines downward, and thus aids
in raising the uterus to a posi tion nearly perpendicular to the pelvic
brim. All the expiratory muscles then enter into active contraction.
Meantime, the laboring woman secures fixation of the trunk by Had-
ing points of support for the upper and lower extremities. By these
leans thQ capacity of the abdominal cavity is greatly diminished,
id tlie uterus is compressed not only by the adjacent muscular cover-
ings, but by the entire mass of inclosed viscera. The effect is twofold :

1. Tliere i-csults an augmentation of the intra-uterine pressure.

2. A portion of the contents of the large vessels of the trunk is
forced to the extremities. To this cause is attributable the flushed,
congested appearance of the face during labor-pains. As the intra-

* For inoDt of the following deductiond the writer id mdebted to Dr. Lmju*b infenious

work, entitled " Die Tbeori^ der Gcburt."

Fio. 7S.— Biftjifriiiu representing tho
change in tlie tlnekueMH of tho
uterine wftlla durin^f lubor. (Luha.)

PHYFIOLOOT OF LABOR AND US CLINICAL POENOMENA.

12a

abdomiDEl preesure ia not brought to bear upon the organs within the
i ' ivic cavity, hypenemia of the yagina and the eontigiiona tissues
. uwg. An a consequence, the channel through which the head has
to pass, as labor advances, becomes infiltrated with serum, and offers
less resistance to the presenting part. At tlie same time the glandu*
hit gtructures are excited to increased action, and the lining mucous
membrane becomes lubricated by the secretion which is freely poured
out

The Influence of the Vagina in Parturition. — As the head advances
tlirough tht* cervix, the vagina at first opposes an obstacle to its fur-
tht*r progress. After, however, the largest circumference of the child
haij* pjL'i^d through the genital canal, the contractions of the vagina
aid somewhat in the expukiou of the after-coming extremities and of
I be placenta.

The Pains of Labor. — The painful sensationa, which are the accom-
{Kuiiment of the uterine contractions, begin in the lower uterine eeg-
metiL Tliey are at first esiJeciaUy felt over the sacrum, whence they
radiate to the rectum and the bladder, across the abdomen, and down
the thighs. In the beginning of hibor, tlie sensations are dull, and of
a bcaring^down character. As labor advances, however, the pains
increase in acutone^s, and in many persons reach an unendurable de-
gree of ge verity. They are mainly induced through the compression
of the uterine nerves by the contractions of the muscular tibers. Tho
^verity of the pains is consequently proportioned to the resistance
to be overcome* At first, as has been stated, confined to the lower
Dgment of the uterus, the pains subsequently invade the body and
be fundus. The sufferings of the female increase with the mechani-

dUtention of the cervix, especially with that of the external orifice,
ad finally reach the point of supreme agony as the head passes

9Ugb the vagina and vulva, which are abundantly supplied with

Ittive spinal ner\es.

Though no labor is absolutely painlesst* where the first st^ge is slow
ad the resistance of the soft parts slight, the suHering may become
comparatively insign ill cant.

Lifluence of the Pains upon the OrgEniam,— During each pain the
arterial pressure is increased ; the freqnency of the pulse rises until
1 is reached, when it slowly declines to the normal point ; the

r ^ »ns are slowed during the pains, owing to the contraction of

the abdominal walU, but are more rapid in tlie pauses as a consequence

the general nmscuhir exertion ; the temperature rises progressively
lurwg labor. but» as a rule, within narrow limits ; and the uriuary
ion, in consequence of the increased arterial pressure, is aug-

• Namklk, "Lchrbuch dor Gvb.," p. 168.

ISO

LABOR.

The Clinical Course of Labor.

Precursory Symptoms, — About the thirty-ninth week of pregnancy
it is usual for the entire uterns to sink somewhat downward into the
pelvis, while the fundus falls forward, Tliis change of position is
followed by congiderahle relief to the respiration, and to previously
existing gastric disturbances. At the same time there is experienoed
an increased difficulty in locomotion ; the a^dema of the lower extremi-
ties is aggravated ; the intra- pel vie pressure causes a frequent desire
to urinate, and predisposes to the development of hceniorrhoids, espe-
cially where, as is the rule in primipara^, the head likewise deaeenda
deep into the pelvic cavity. Indeed, in primiparje the changes of
position are more pronounced than in women who have passed through
repeated pregnancies. As gestation draws to a close, a copious glairy
secretion is poured out from the cervix, the vagina relaxes^ the labia
majora become swollen, and the vulva gapes open. For a variable period
preceding the advent of labor, painless contractions occur at irregular
intervals. These so-called dohres presaf/ientes are the ordinary prelude
to labor in multiparie, though they are often inappreciable in primi-
parae. They very commonly begin in tlie evening hours and continue
till toward the middle of the night. Very often they are associated with
a dragging sensation between the Bacrum and symphysis, and a feeling
of tension in the abdominal region, Sometimes they expand the oa
intenmra to a considerable extent, but never in such a way that any
portion of the cervical canal contributes to the enlargement of the
uterine cavity.

Actual labor has been divided, as a matter of clinical convenience,
into three stages^ as follows :

First stage, or stage of dilatation of the cervical canal.

Second stage, generally termed the stage of expulsion, comprising
the period from the dilatation of the cervix to the expulsion of the
child.

Third stage, or stage of the placental delivery,

L The First Stage—Dilatation of the Cervix,— The advent of trae
labor is characterized by painful contraetiotis, which render the patient
restless, and disiiose her either to bend forward with clinched hands,
or to seek some firm support for the sacrum to ease her giifferings.
TTmially, in the beginning of labor, women prefer the sitting posture,
which enables tliem to press with the forearm against the sacrum dur-
ing the pains. The pain of labor begins with the dilatation of the
intc?rnal os. In true labor the dilatation progresses gradually. As the
OS internum opens, the contractions cause the membranes to descend
and press upon the cervical canal. TVith the advance of labor^ the
pains increase in intensity and frequency. During their persistenco
the external os is put upon the stretchy so that tlie border becomes thin

PHYSIOLOGY OF LABOR AND ITS CUNICAL PHEXOMENA.

131

and eharply defined** A6 the pain subsides, the os relaxes and the
membraTies retreat Each new pain increases the dilatation, and forces
e membranes somewhat deeper. The softening, the relaxation, and
e hjrpersecretion of the soft parts become more and more decided.
As the borders of the os yield to pressure, lacerations form, which
tin^ the mucous discharges with blood. When the dilatation has
leacbed a certain limit (usually by the time the diameter of the exter-
nal OS is three to three and a half inche^s), the protruding membranes
remain tense in the intervals betw*ecn the pains, and are then ready for
rupture. After rupture, which usually occurs spontaneously, the water

132

LABOR.

finally become so far dilated that cervix and yagina form one continn-
0E8 canal*

In ease the piTsenting part does not thoroughly tampon the lower
aegment of the uterus, a more or less complete escai>e of the entire
amniotic fluid may follow the rupture of the membranes. As a role,
the tear in the membranes takes place in the most dependent point
of the convex portion which constitutes the bag of waters in the cer-
vical canal. Sometimes?, however, the rupture takes place above tbo
cervix, wliere there can be a gradual escape of fluid in spito of the
perj^istence of tlie bag of waters.

If the membranes rupture before the dilatation of the cervix k

pancreas

,^/-

Tenulo..

pJAcenu

W'lU

. 0. mei. iupw

V. port.
f . rvii. tin.

orlt tub .

orlf. ut tnL^

V4»lca ^
oril ut. cxL ^

"y'^

orif ot. int,

nrethm-

Flo. irT.— 'The uterus and parturieDi ctuuil. Fcetus removed. (Braune.)

complete, the head descends and acts as a dilating wedge. In rare
cases the rupture of the membranes, if left to nature, does not occnr^
and the ovum !iuiy descend in its integrity to the vulva. In such in-
stances the membranes sometimes rupture in the neighborhood of the

TOYSIOLOGT OF LABOR AND ITS CLINICAL PnExVOMENA.

133

child's neck, and the head is born covered with the so-called **caiil,"
u e., with the detached portion of the membranes, which old nurses
regard as significant of good hick. In still rarer cases, where the
fcBtiis is small and the amount of amniotic fluid limited, the entire
OTtun may be expelled without rupture of its cove rings*

2. The Stage of Expulsion. — After the short pause which follows
the mptnre of the membranes, the paina become stronger and more
frecjuent, and are now powerfully reenforccd by the involuntary con-
tractions of the abdominal mugcles, which, though previously not
tirely inactive, have played only a subordinate part With each
in the head now makes perceptible progress, retreating, however, as
e pains decline. After tiie head has passed tlie pelvic outlet, and is
vered only by the Foft parLs, the perinfeum bulges outward, the labia
pe, and a portion of the head makes its appearance at the vulva.
s within the pelvic canal, with each pain the head advances, and puts '
e perinteum upon the stretch, receding somewhat in turn iis the pains
bside. The pressure upon the rectnm leads to the evacuation of
contents. Finally, the thinning of the perineum reaches a point
bich the sutnres can be readily felt through its structure ; the re-
in of the head ceases ; the anus assumes an oval shape ; the
orifice of the vulva looks forward and upward ; the urethra is pushed
against the symphysis pubis ; while, as the circumference of the head
in the neighborhood of the parietal bosses engages in the vnlva, the
labia and fraenulnm form a thin circular band, through which, dur-
ing a pain or the contraction of the abdominal walls, the head makes
iu way, nsnally leaving behind moderate lacerations of the fnenu-
or anterior portion of the perina?um. The same, or the succeed-
g fiain, leads then to the expulsion of the trunk; The birth of the
lid is followed by the outpouring of the amniotic fluid, which, as
rale^ escapes colored with blood from the site of the wholly or par-
ly detached ]»Iacenta,

The Placental Period, — The placental period embraces the time
tlic birth of the child to the delivery of the placenta and mem-
bmoea.

After the birth of the child, the recession of the blood from the

) brain, which follows the diminution of the intra-abdominal pressure,
ftfteo protluces a sense of faintness, and sometimes temporary syncope.
ffhe mpid evacuation of the uterus is at times, too, succeeded by a chill,
irhich, however, does not betoken the onset of fever, hut is the result
pf vafio-motor disturbance, and the loss, through the expulsion of the
phi Id, of a source of heat-supply- Most women, however, experience
i netful feeling of comfort and repose. This sense of quietude lasts
anywhere from a few minutes to a quarter of an hour, when the con-
trsoiioniK return, which detach the placenta, and force it into the vagi-
I on. The separation of the placenta takes place in the meshy, lamel-

134

LABOa

lated layer which is formed in the serotina by the thinned, elongated
walls of the gland-tubules, the dense cell-layer of the maternal por-
tion remaining adherent to the placenta. As the maternal ressela
are necessarily torn across, some hiemorrhftge follows the detach-
naeiit. The hsemorrhage ie, however, speedily arrested by the con-
tractions of the ntems, which both compress the Tossels and furnish the
conditions favorable to the formation of fibrinous clots in their distal
extremities. When the mechanism of expulsion is left to nature, the
placenta descends by its edge into the vagina, while premature trac-
tions upon the cord cause it to present by its fetal surface at the cer-
vical orifice. When once in the vagina, the expulsion is completed by
the action of the abdominal muscles, sustained by the retraction of the
muscles which form the floor of the pelvis.

According to Gassner,* after confinement the female experiences,
BS a consequence of the expulsion of the ovum, of the exhalations
from the lungs and skin, from the discharge of excrements, and from
htemorrhage, a loss of weight equivalent to one ninth of that of the
entire body.

Duration of Labor, — Spiegelberg found, in 50G labors, the average
for primiparjB was 17 hours, for multiparaB 1% hours. In primipan©
past the thirtieth year Hecker found the average 21*1 hours, while
Ahlfeld in 82 women over thirty -two years of age obtained an average
of 27-6 hours,!

In ordinary normal labor the second stage lasts about two hours in
priiniparaB, and about half aa long in raultiparee, though in the latter
the resistance is frequently so slight that a few pains sufiioe to com-
plete the delivery.

According to Kleinwachter,! the time at which labor-pains begin
occurs most frequently between ten and twelve o'clock in the evening,
Si)iegelberg^ states that the maximum frequency of births takes plac^
between twelve and three o'clock in the morniug.

The Action op the Expellent Forces.

Haying considered separately the action of the uterus, the uterine
appendages, and the abdominal mnscles during labor, there remains
for us to combine these factors together, and to show in what manner
they contribute to the end of all parturient effort, viz., the expulsion
of the ovum.

In the first place, the contractions of the uterus are intermittent.

* Gasskwk, ^ Ucbcr d, Terftnd<>mngeii des Kdrpergewichtes b. SchiraDg., Gebar. and

Wochncr," *' MonatuflcUr, t (jebtirtdk./* lix, p. 18,

+ BpiKOErtiERO^ ** LehrbucV^ pp. 134, 135.

t KtEiNWACHTiiR, "Die Zeit der Geburtsbcgiimcs," **Ztsclir* t Goburtah.," Bd* i, p.
230.

• SpiiGW-Biao, " Lehrbuck" etc.. p. 186.

PHYSIOLOGY OF LABOR AKD ITS CLINICAL PHEXOMEXA,

135

When ihej lose their rhythmical quality, and become continuous, they
ceiise to belong to the domain of pliy^jology. It is only during the
aet of contraction that work ig performed. Whenever the alternating
relaxation ceases^ and the uterus passes into a condition of tonic con-
traction^ no work is accomplished, and the pains are ineffective.

The uterus is a hollow muscle, which, during a pain, cloaca down
upon its contents. If all parts of the uterine walls were of equal thick-
ness, the contractions would be entirely expended upon the periphery
of the ovum, and, as the contents of the latter are practically incom-
pressible, the effort would he resultless. If, however, the walls were
80 constructed that the thickness varied in different regions, the periph-
eral compression exerted during a pain would be followed by a bulg-
ing at the points of leAst resistance, provided the thinned tissues pos-
tered the property of elasticity. Now, the unequal development of the
uterine walls and the elasticity of the uterine tissue-elements are both
anatomical facts. Thus, the fundus and the lower uterine segment
Mm materially thinner than the intermediate portion. Indeed, the
Itttier is often two to three times as thick as the lower segment.* As a
fcmlt, therefore, of these conditions concentric pressure of the fluid
contentd of the ovum is followed by an increase in the longitudinal
dkuneter of the uterus. While the convexity of the fundus is un-
4{neslionably increased during a pain, the effect of the latter is chiefly
manifested in the distention of the lower segment. Various causes
combine U) produce this result. Near the cervix the tissues are not
alone thinner, bat the fibers run for the most part in a more nearly
longitudinal direction, and therefore offer a weaker resistance than
that afforded by the close interlacement of both circular and longitu-
dinal fibers which prevails in the fundal and upper uterine zones.
Tben, too, as was pointed out by Lahs,} the lower segment sustains,

• la 1876 Btnd) (** Uebcr da* Verlmltcn de» CteniB unci CcmTc in dcr Schwftnger*
I wihrtnd dcr (Icburt " ) called attention to the thmiied condilion of the lower
» «Cgni«Qt, cnendiog from what had previously been regarded w the cia Internum
i ioat to ds iticb«« upward, and terraiuating abruptly In m mtiicular ridge upon the
f nufiee. Tbift Hdgc, under th« same ol the Hui; of Bnndl, ha:^ been the subject of
on. Bandl regards it as the true ob Internum, nnd the tlunued lower sog-
l as the tipper portioQ of the i?cr\'tcal caual which has been opened by the ^owth of
the antm. What k ntually reganled as the anatomical cerru, he iDsistft^ U dimply the
' ficfibieiit portion of the original canaL This re rival in a new form erf the old
r daetHiie hni been bitterly attacked, and aa hotly defended. The diacuasion f uma
cUdlj upon the tnte Umit of the cervical mucouB Diembranc, but upon this point the
ahmtitiriBf of anatomists arc at wide Tarlance.

Far recent publieatioiis in fa^or of BandFs tiows, wide Kt^fTirsE, "Arch, t dynatk,/'
Dri. iB, IL 3; MiaciiiND ond Bandl, ihid.^ Bd. kt, H. %, In favor of the preserration
af IIm eervix during pregnancy, ri4f MtrLLsn, ibnl.^ IM. ilii, II, 1 ; Lanohans und M&ller,
Bl. liv, IL 2; Saxokii, H. 8 ; TuiEt>E» "Ztschr. f. Geburtsh. und Gjnaek./* Bd. It, IL 2;
HcD ogAUi, ** dwlet. Jour of Or. Brit, and Ire..*' July, 1877.
'0i« Thooiitt disr Oeburt,'* p. 116,

isa

LABOR.

^-^

C'fK

in the ordinary positions assumed by the female, the entire weight of
the superimposed ovum with its fluid and solid contents ; and, finally,
the pressure, transmitted from the abdominal nmsclcs, t^ikes a direc-
tion from a1>ove downward.

Bo far, for the sake of siniphcity, we have regai*ded the uterus as a
closed fiiic, possessing walls of unequal thickness. In reality the lower
segment terminates in an opening^i the canal of the cervix, which,
though at the hegiuning of labor of small size, and otiering consider-
able resistance to the pressure of the ovum, is capable of sufficient dis-
tention to permit the exit of the fa4u8.

The dilatation of the cervix is partly mechanical, and partly the
effect of certain organic changes which have already received cursorf^
mention.

The mechanical dilatation is the result of — 1. The pressure of the
ovum upon the lower uterine segment, which forces open the 08 in-
ternum, and unfolds the cervix from above downward*

2. The retraction of the uterus, an important property, which
requires brief description. While each contraction of the uterus is

followed by rolasation, and a
period of repose, a gradual
change is continually going on -
in the length and arrangement'
of the muscular fibers. In the
thinned lower segment the fibere
are stretched, and separated
from one another. In the upper
portion, on the contrary, they
shorten, and change their posi-
tion in such a way that those
which previously had only their
extremities in contact assume
a more nearly parallel arrange-
racnL The walls, therefore, in
tlie upper zones, thicken and
shorten, especially in the lon-
gitudinal direction. The limit
between the thinned lower seg-
ment and the upper thickened
zones is marked by a distinct
ridge termed the ring of UandL
It is to the changes in the ute-
rus which take place above the
ring of Bandl that the term re-
traction is appHcable. As the retraction is progressive, it leads to a
gradual withdrawal upward of the uterine walls, in consequence of

ik^..

Fio. 78. — Lonj^tudinftl sedition tL rough walls of
uterufl in eitrhtli month nf pre^BOcv ( Bntidl),
a^ ring of Biuidl ; h^ os intcnium ; a^ c« cxtor*
num.

?HYSIOLOGY OF LABOR .IKD ITS CLINICAL PrTEKOMENA.

137

which the lower segment is not only put upon the stretch during the
paiii% bnt, toward the end of the period of dilatation, is Bnbjected to
a greater or less degree of permanent tension. Then, too, as the ring
of Bandl moves upward, the longitudinal fibers of the lower segment,
by reason of their insertion in part at least into the vaginal portion,
exert a direct influence in dilating the cervical canal.

3* When the abdominal mascles contract, the uterus is pressed
downward into the pelvic cavity. The descent is, however, limited
by the attachment of the uterine ligaments, and the adjacent organs.
Bat the resistance afforded by the uterine attachments exercises a pe-
ripheral traction upon the cervix, and thus tends to draw its walla

The normal dilatation of the cervix is, however, by no means a
matter of pnre mechanical distention. If the canal which forms the
communication between the vagina and the uterus were simply an elas-
tic tube, it would of necessity retract down upon the neck of the fa^tua
after the passage of the head, and thus a new distention would be
required to permit the passage of the shoulders. Indeed, the condi-
tions of an elastic tube are not unfrequently realized in versions,

> where an attempt is made to extract the foetus through an im-
perfectly dilated oa ; in which case, after the disengagement of the
shoulders, the cervix is apt to close upon the neck, and arrest the

I delirery of the after-coming head. That this complication does not
I happen as a rule is due to the fact that in natural labors the me-

► cbanical expansion is associated with certain organic changes which
I leader the cervix soft and distensible, and at the same time diminish

Ha retractility. The basis of tlie organic changes consists in the serous
infiltration of the lymphatic interspaces, which separates the tissue-
eleiiienl«i and deprives them of t!ie resistance afforded by the force of
eobesioti* The main factor in the production of the softening of the
cenrijt is an active hyperaemia, which the cervix shares during preg-
nancy with all the pelvic organs, and which during labor is greatly
enhanced by the diminished pressure to which tlie parts below the
pelvic brim are subjected. We have already noticed how, during the
acme of a pain, the contents of the uterine vesaels are forced into the
Teeaeli^ of the intrn-pelvic viscera.

In normal head jjresentations the organic changes are in a special
degree farthered by the formation of what is known as the bag of
wateri. As the head descends into the lower uterine segment, the
contraction of the muscular fibers around its largest circumference
$DfmrnU^& u layer of fluid from the contents of the uterine cavity. At
^flnst thi^ layer becomes tense only during a pain. With the descent
[ti^e head the tension increases, and the '* bag of watet^ " is formed.
^tbe abdominal pressure is not operative below the pelvic line, and
the intra-uteriue pressure is arrested in a measure by the child's

138

LABOR

bead, in tliat portion of the uterus which lies below the circle of
cephalic compression, hyperemia, serous infiltiiitioii, and softening fol-
low as necessary corollaries of the anatomical conditions. The value
of the bag of waters in dilating the cervix is due, therefore, not only
to the hydrostatic pressure it exerts, but to the manner in which it
favors the development of the organic processes described.

Thus far we have considered the expellent forces as acting upon
the ovum as a whole. Many authorities accept in addition a direct
pressure of the fondna upon the breech of the child, which is transmit-
ted through the spinal column to the cephalic pole. A little reflec-
tion, however, will show, m Lahs* ha^ pointed out, that so long as the
ovum contains any measurable quantity of fluid, or at least more than
enough to till the fetal intei-spaces, the immediate contsict of the
bi*eech with the fimdos is hardly possible. To be sure, Alilfeld f de-
termined; by direct measurements, that there was an actual increase of
about one and a half inch in the distance between the two poles of
the child in head-presentations during the height of a jiain, Schroe-
dert attributes this ext<»nsion to the lateral compression of the fcetus,
which results from the diminution of the transverse diameter of the
litems during contraction ; but it is evident that lateral pressure would
equally produce an elevation of the fluid contents of the o\Tim, and
thus, as tbe fundus assumes a spherical shape, prevent the impinge-
ment of the breech. Moreover, it is not easy to see how, so long as
the fo?tn8 is surrounded by a fluid medium, any effective propiikive
force can be transmitted through a flexible column like the spine. It
is certain that, in the intervals of the pains, manual pressure upon the
breeeh through the fundus simply bends the fetal body, and deflects
it from tlie vertical direction. Even if during a pain the lessening
of the uterus in the transverse diameter bindei-s this movement to
some extent, the increase ant^ro-posteriorly would stiU leave ample
BiKice for lateral incurvation.

The descent of the ovum is followed necessarily by increased ten-
sion of the bag of waters. Under a pressure, estimated by Duncan *
as varying, according to the resistance of the membranes, between
four II and thirty-seven and a half pounds, rupture occurs. The cervix
then usually closes, but remains dilatable ; i. e., it yields readily to
pressure, and offers no resistance to the advancing head.

The x>re5sure exerted by the united action of the uterine and ab-
dominal walls requisite to accomplish delivery, according to the eati-

• tjuiB, "Studicn zur Gcburtskunde/* "Arch. f. Gynaek.," Bd, iir, p. 195.
t ABLiTEJ-n, ** Arch. f. Gjnaek./' M. ii, p. 807.
t St^nnoEDER, *' Lchrbuch dcr Geburtshiilfc,** ttte Aufl,, p. 166.
" DrNrAH» "K(?scurcbe3 in Obatt^tries."

I UiBKSiONT, *'Rechercheii expdninpntales »ur b r^sUtnnoe, etcUf des membimnGS d«
Voaal htimmin,^* p. 36^ pkcoa the mimmam resist&iioe at fifteen and three fourtha pounda.

MECHANISM OF LABOR. 189

mates of Schatz,* based upon manometric observationSy Taries between
BBTenteen and fifty-fiye pounds, f Although the methods by which
both the results of Schatz and Duncan have been obtained possess
defects, which the authors themselves make no attempts to conceal,
they are quoted as furnishing approximations to the truth.

CHAPTER VIII.

MECHANISM OF LABOR,

AnAtomiad factors. — Anatomj of peWis. — Sacrum. — Coccyx. — Ossa innominata. —
The Uia.— The pubes. — The ischia. — Articulations of the pelvis. — Sacro-iliao articu-
lations. — Symphysis pubis. — The pelvic ligaments. — Obturator membrane. — Sacro-
sdatic ligaments. — Inclination of the pelvis. — The pelvis as a whole. — The pelvic
planes. — Plane of the brim. — Plane of the outlet. — ^Planes of the cavity. — Ischial
planes. — ^Pelvic axis. — Differences between male and female pelvis. — Differences be-
tween the infantile and adult pelvis. — The soft parts of the pelvis. — ^The perineal
floor. — ^The head of the foetus at term. — Sutures and fontanelles. — The diameters of
the fetal head. — The articulation of the head with the spinal column.

The mechanism of labor comprehends the movements of adjust-
ment, by means of which the foetus accommodates itself to the dimen-
sions of the bony pelvis and to the variations in the direction of the
parturient canal. Its study is, therefore, properly prefaced by the
enumeration of a series of anatomical details relating to the pelvic
ring and the soft tissues which form the floor of the pelvic basin, and
to the structure, the diameters, and the reductibility of the fetal head.

The Anatomy of the Pelvis.

The following description includes only such points as are of direct
obstetrical interest :

The bony pelvis is formed by the union of the sacrum and coccyx
and. the two ossa innominata.

The Sacrum. — The sacrum is a curved quadrilateral bone, inserted
like a wedge between the ossa innominata. Like a wedge, it is broad
above and tapers toward its lower extremity. It is composed of a
central vertebral portion, and two outer masses termed the alse or wings.
The central portion, as its name implies, is really a continuation of
the spinal column. In early childhood it consists of five distinct ver-
tebrae with well-defined joint-surfaces and intermediate cartilaginous
disks ; but, with the completion of the growth, the whole becomes con-
solidated into a single piece by the inter-articular deposition of bone.

♦ Vxdt ScHROEDKRf ** Lchrbuch," 6te Aufl., p. 158.

t PoLAiLLON, " Rechorchcs sur la phy siologic de Tut^rus gravide," p. 38, estimates
the minimum pressure at twcntj-thrcc pounds.

140

LABOR.

The bony union is confined chiefly to the outer circumference, and is
marked by ridges termed the I (new (ransversm. The base of the
Bacmm articalates with the laat lumbar vertebra^ with which it forms
a projecting angle. It possesses a conyex anterior surface, termed the
proraontorj, which Juts forward and encroaches upon the pelvic space.

From the sides of the central j^iece tliere extend two triangular
portions of bone, termed the alie or wings. Under normal conditions
they are symmetricaL They are dereloped upon each side from three
independent nuclei, w^iich make their appearance near the bodies of ^
the three upi>cr vertebrae. They are supposed to have the morphologieul
significance of ribs. In the course of this growth they fuse together,
except at the points of junction of the bodies of the vertebrae, where
they leave between them open spaces or foramina, for the passage of
the spinal nerves.

The sacrum in the female is about four and a half inches wide, and
from four to four and a half inches long, when measured from the pro-^
montory to the lower extremity. The sacrum possesses two curves J

PftOMOKTORY^

ARTICULAR'
SURFACE.

-ALA,

S^^VCRTEflRA,

-ItHEA
rRANSVCRSAUS,

'FORAMEN.

Fio. Vft.— Sacnun and cocqyx (aiitcrioir furfaoe).

one, less marked, from side to side, and the other extending from above
downward. The depth of the latter is greatest just below the upper
border of the third vertebra, where it measures a little over an inch.

Upon the posterior surface we notice a canal, continuous with the
spinal canal, Which runs tlie entire length of the sacrum, but is incom-
pletely closed at the fifth vertebra, giving rise to a slit-like opening,
termed t!ie hiatus sacrah's* In the middle line the spinous processes
coalesce into a vertical crest for the attachment of the erector spin®
muscle. The posterior lateral masses are formed by the fusion of the
transverse processes, and their consolidation with the anterior struct-
ures. Next to the vertebrae, however, spaces are left between the

MECHANISM OF LABOR.

141

processes for the passage of the posterior sacral nerves. Opposite the
three upper yertebne, the outer border k known us the tuberosity of
the sacrum. It possesses a roiiglieoed surface, to
which are attached the sacro-iliac ligaments.

The upper portion of the side of the sacrum
is famished with an ear-shaped articulating sur-
face termed the superficies auricularis.

The Coccyx. — The coccyx is composed of four
mdimentary vertebras, which progressively dimin-
ish m size from above downward. It possesses as
a whole, therefore, a triangular shape. It is at-
tached to the extremity of the sacrum by a hinge-
joint, and is pushed backward during defecation,
and in childbirth as the liead passes the pelvic
outlet It is only when anchylosed that the
cocoTX assumes obstetrical importance. „ „ . .

The Oasa Innominata.— Each os innommatum imd coccyx.
may be roughly compared to a figure eight, of
which the upper and larger portion slants upward, outward, and back*
ward, while the lower smaller division inclines downward and inward.

I Up to the ago of puberty it consists really of three bones, which are
connected at the acetabulum by cartilage of a Y-shape. These three
bone^ are termed respectively the ilium, the ischium, and the pubes^
names which are subsequently retained for convenience of description,
in spite of the fact that in adult life the separate parts become solidly
united^ by the deposition of bone-tissue, into a single continuous piece.

, fn,^Os inDOmiiiAtutQ, before consoUdntion. 1| il'mm ; 2, UehJtim ; S, pubea.

The ili/w portion hm an external surface marked hy a number of
rOQghened lineii, to which are attached the three glutwil muscles. The
inner larface la excavated and forms the so-called iliac fossa^ which

LAOOIt

contains the internal iliac muBclo. The fossa is bonndcd below by the
linea arcurttii interna, a convex ridge which contributes to form the
brim of the jielvisi* The upper border or crest of the ilium pofiaeeses
an S-shaped curve, the anterior extremities of which are directed in-
ward. The crest of the ilium terminatog, front and rear, iu bony
prominences, termed respectively the anterior and posterior superior
spinous processes. Beneath the upper spines, and separated from them
by curved indentutions, aro two lower, less sharply detined projections,
termed the anterior and posterior inferior spinous processes. Behind
the iliac fossa is situated an ear-shaj>ed articular surface, the super-
ficies auricularis, which corresponds to the surface of similar name
described upon the sides of the sacrum*

CREST.

AMT^SCP

LCSSCR
SCIATIC NOTCH

TuamosiTy

OrtSCHIUM,

Fm. 8S. — Outer Burfaoe of oa iocomioatum.

The pubic portion consists of the body and two rami. The body
presents upon itii inner border an oval surface, which articulates with
the pubic bone upon the opposite side. The superior border is fur^
nishcd with a rough crest^ terminating in the projecting spine. - The
upper, or, as it is usually designated, the horizontal ramus, possesses
a ridge, the pecten pubis, extending from the spine and becoming con-
tinuous with the linea arcuata of the ilium. The linea terminalis, or
boandary-lino of the pelvic brim, is generally known as the ilio-pec-
tineal line, from its sources of origin. Near the Junctiou of the ilium

MECHANISM OF LABOR,

143

and OS pubis is situat43<l a slight elevation, the ilio-pectiDeal eminence,
whichy however, according to Luschka,* belongs entirely to the pubic

QHfsr*

SUPEPFICIES

SCIATIC NOTCH t

^erm SFIHE OF ISCHIUM.
^LESS£R SCIATIC HOTCH

.Of

|«*g

Icf

^UBCAQSITYOr ISCHtUM.
Fiok 68.^iiiier nurfiiee of os innomiattum.

bone. The descending ramus helps to bound the obturator foramen,

and to form the pubic arch. The ischium completes the lower portion

the o« innominatum. It consists of two rami, which, with the rami

f the pubic bone«, include the obturator foramen. It contributes about

wo fifths to the formation of the acetabulum ; from this the descend-

ramus drops yertically downward, and thence curves forward, and

forms the ascending ramus, which unites with the descending ramus

the pubes. At the point where the descending ramus hooks forward

^thent is a thickened projection, termed the tuberosity of the ischium,

upon which the body rests in the sitting posture. Upon the posterior

[border of the descending ramus there is a sharp spine, projecting

Dward, which plays an important part in the mechanism of labor,

the posterior inferior spinous process and the spine of the

there is a deep incurvation, termed the great sciatic notch ;

bile a imaUer incurvation, between the spine and the tuberosity^ is

lown m the small Hoiatic notch.

The Pelvic Articulations. — ^The articulations of the ossa innominata
with the sacrum are usually termed the sacro-iliac 8}Tichondrose8, The
irior articulation of the innominate bones with one another is known
«ymphyiiifl pubis.

* LotoaEA, ** Bio Anatomic des meoschlichca Bcckeiu/* p. S6.

IfECHANISM OF LABOR,

145

upon the ligaments distriliated front and rear, and particularly upon
the very numerous and closely interwoTen bundles extending from the
tuberosities of the sacrum to the roughened portions, or tuberosities,
of the ilia, which project posteriorly beyond the articulation.

The gymphyBifi pubis is likewise supplied with a small cavity, only
the |K>sterior portion of which possesses a synovial membrane. Tlie
fibro-cartilage hetween the articulating surfaces of the bones is thicker
in front than behind. The anterior ligaments are more developed than
the posterior ones, and allow no movements of importance to take
placT in the non-pregnant condition.

The Pelvic ligaments. — In addition to the ligaments which have
already been noticed as contributing to the solidity of the joints, the

*^^ 't'flM^^?^

ANTERIOR SACRO -ILIAC'
LIGAIi£Nr.

UtO-FEMORAL-
LIGAMENT.

3 SCI/me

' JiGAMENf.

SYMPMYaiS PUBISr
1 OBTURATOR J^EMBRAhtC.

Ym. 86. — Front vkw of polvia, with ligaments. (Quatn,)

following help to close in the pelvis. Across the obturator foramen is
itretche<l a fibrous septum, complete except where a small opening is
lafl for the passage of the nerve and vessels.

The great saero-sciatrc ligament extends partly from the lower bor-
der of the sacro-iliac articulation, aod partly from the lower border of
\ihB aacram and coccyx to the tuberosity of the ischium* The small
[ BM!iXMiciatie ligament lies in front of the preceding, and extends from
[the side of the sacrum and coccyx to the spinous process of the
[i^ichtum. These two ligaments close the large and small sacro-sciatic
notches, and convert them into two foramina, which bear the same
name.

The Inelination of the Pelvis, — The plane of the brim of the pelvis
mu formerly supposed to run nearly parallel to the horizon, whence
10

MECHAJOSM OF LABOR,

147

the pelvis backward is only prevented by the strong ilio-femoral
igaments (Fig. 86), Whatever, therefore, serves to relax the ligaments
in question dinunishes the angle of inclination, while positions that
increase the natural tension cause the pelvis to asaitme a nearly vertical
attitude. Experimentally Meyer found that the pelvic inclination was

[ diminished to the greatest extent when the thighs were moderately
eparated and rotated slightly inward, while its increase was due to four
conditioDs: closing the knees, stretching the legs widely apart, exter-
nal rotation, and exaggerated internal rotation, Naegele endeavored
U> ascertain the normal inclination upon the living subject, by deter-
miniiig the distance between the extremity of the coccyx and an hori-
aontal line drawn from the lower border of the symphysis, and then
placing the bony pelvis in a position conforming to the measurement
thus obtained. He found in this way the mean inclination wbjs nearly
SO**, a result explained by the fact that tlie method of measurement

I Tendered a separation of the knees, and consequently an increase of
iion of the ilio-femoral ligaments, a matter of necessity,*

MoVESfEKTS AT THE PeLVIC AkTICULATIONS*

At the symphysis pobis during gestation the fibers which compose

(its fibro-cartilage become infiltrated with serum, and the ligaments

I elongate, so that at term the distance between the articular surfaces of

] the pubic bones is increased twofold, Budin has shown that if the

patient, when the finger is introduced into the vagina, and pressed

upward against the lower border of the symphysis, be made to walk,

an elevation of the ramus upon the side of the extremity in motion

<ain be distinctly recognized. In the rule, this mobility is most

.marked in women who have borne a number of children, f

Zaglass first pointed out that, in spite of the close union at the
riacro-iliac articulation, a certain degree of mobility between the sacrum
I and iliac bones existed. Thus, in defecation, when the body is thrown
i forward, the promontory is tilted toward the symphysis, and the in-
ferior extremity of the sacrum is thrown backward, thereby enlarging
the outlet of the pelvis. Matthews Duncan describes similar move-
ments, only exaggerated in extent, during pregnancy, and points out
how they practically contribute to facilitate labor. Thus, at the be-
(ginning of labor, as the head enters the brim, the woman naturally
to sit up, to walk about, or, if in bed, to recline with the
Ktremities extended, positions which favor the rotation back-
warf of the upper portion of the sacrum, and the consequent increase
of the antero-prist^^rior diameter at the superior strait. As tlie head,
however, descends to the floor of the pelvis, the patient instinctively

* 5kqiftoniCR, " I^eBrbucb der Gcbartaliinfc,** 6te Au6^ note, p. 7 ; KftegcTci 8te Aafl*,
f TAUtiss at CiLiNxmiciL, " Traitd de Vtai dea Aceoucheni<mi!r,*^ p. S30«

movemcats of encrum. (Dimcao.)

148

draws up ber Icnees, throws the body forward, and during a pain
contracts the abdominal muscles. In this way ehe succeeds in tilting
up the pubes, in pressing tlie promontory forward, and in rot4iting

the point of the aacrum backward,
m as to perceptibly increase the con-
jugate diameter at the pelvic outlet.
The Pelvis as a Whole.— The
pelTis is divided by the linea termi-
nalis into an upper and lower por-
tion.

The upper, or, as it is usually
termed, the large pelvig, is composed
of the lumbar vertebrae and the up*
j>er surfaces of the wings of the sa-
crum behind, the spreading portions
of the ilia upon the sides, while the
anterior segment is closed in by the
muscles of the abdominal parietes.
In shape, the bony part of the large ])elvis has been compared to tlie^
rim of a barber *s basin, Obstetrically the iliac fossae are of int
inasmuch as they furnish
shelves upon which the head
of the foetus in multiparaa
commonly rests during the
latter part of pi-egnancy. The
inclination of the ilia to the
horizon, the shape of the
crests, and the distance be-
tween them, togetlier with
the distance between the two
anterior superior spinous pro-
ceases, are important points
for study, because they fur-
nish data upon which valu-
able inferences ai-e based in cases of pelvic deformity, relative to the
shape and dimensions of the pelvic canal.

It will be remembered that the crests of the ilia possess an S-shape^^^
curve. Normally, the widest distances between the crests measure toi^H
inches ; the distance between the anterior superior spinous processes
measures nine inches.* The slope of tlie inner surfaces of the ilia issuch
that an extension of the lines drawn from the crest to the linea termi-
nalia would meet in the neighborhood of the fourth sacral Tertebra,

^ * A» DO two pelves poRsess precisely tbe fiAme dimeiiBio&s, pelvic meA^urementfl nrr
gireo aomewbftt differently by authors. They arc obtained cither by Inking the mean of
a large number of pelves (a method whicb fumishes fractions difiicuk to remember^ bus

Fio, ^O.— Anterior half of the pelvis.

MECHANISM 01 wABOR

14D

V JJ«

The inferior or gmall pelvis comprises the portion below the liuea
l^rtninalis. It ig formed by the sacnim, the coccyx, the lower por-
tion of the ilia, the ischia and pubes, the obturator membrane^ and
I the saero-aciatic ligaments. Together the foregoing inclose a basin-
like cavity, which, though open below in the .skeleton, is closed in
' by soft parte in the living subject The posterior wall, formed by
tbe sacrum and coccyx, measures five inches in a direct line from the
promontory to the apex ; the anterior wall at tbe symphysis pubis mea-
sured one and three quarters inch; the lateral walls, from the linea ter-
minalia to the tuberosities of the ischia, measure three and three quar-
ters inches. The posterior wall is cui'ved ; the symphysis pubis slopes
downward and inward, so as
to run nearly parallel with
the two upper sacral vertebne ;
the rami of the pubes approach
one another at an angle of Q5^
to 100*^ and unite beneath the
^niphysis in the form of an
ai€b, the arcuB pubis ; the side-
walk are solid in front where
they are constituted by the
uchia, while behind the great
sciatic notch is closed only by
soft structures and the sacro-
sciatie ligaments. The transverse diameter, owing to the incline of
the side-walls, nsirrows toward t!ie outlet.

The Planes and Axes of the Pelvis, — The eccentric forms of the
pelvic bjnes render it extremely difficult to convey a clear impression
of the nature of the pelvic inclosure. As a means to this end it is
customary to study a series of planes drawn at different levels through
the pelvic walls, which serve to show the changes in tbe shape and
dimensions of the bony canal at selected points of ob8er\'ation. By a
phwe is meant simply a mathematical surface, without reference to
depth or thickness.

The upjjer and lower openings are both somewhat contracted, and
hence are termed re8i>ectively the superior and inferior straits, while
the space between is denominated the cavity of the pelvis.

The first plane requiring our attention is that of the sujRTi or strait
or brinu It is bounded by the linea terminalis, and bus an elliptical
contour, with a depn^'ssicm po8t4}riorly, produced by the projection
uf the promontory of the sacrum.

Fio. 91.— Poeterior hnlf of the pelvis.

olTfTini; no tpccW idTiatagcs In the w»t nf aecumo?), orb? telecting us the normd stand-
mnl «tllier a whole number, or, where fmciiotis arc neccasary^ the nearest half or quarter
•pffwosinwling to the mc&n aTcrftf^o. The latter plao recommeads itself m proctioc eqimJly
«a 1^ Mora of uiilitj aud convenienoc.

150

LABOR,

The dimensions of each plane are determined by measuring the
antero-posterior, the transverse, and the two oblique diameters.

LoisrANnEBrrwrEH

1 THE CRESTS fOOi

_roi9TANCE eETW£tM
ANTSUP.BP PROC.SIII.
'SACHO-COTViOID^

^OBUq.UE'OIAMrrER B\H.

; 4^111.
Fio. 92.— DuunctCR of the brim.

The antero-poBterior, or, as it is generally termed, the conjngate
diameter, extends from the upper border of the gymphysis pubis to the
promontory. Its length is four and a quarter inches. About two*
fifths of an inch bidow the upper border of the symphysis is sitnatM
the obstetrical, m distinguished from the anatomical, conjugate. The
length of the former, owing to the thickening of the pubic bones^ iij
reduced to four inches*

The transverse, eometiraes termed the bis-iliac, diameter is the
widest distance between the ilia. It measures five and a quarter
inches.

The oblique diameters extend from the ilio-pectineal eminences to i
the opposite sucro-iliue articuUitions. The distance between the points

mentioned is five inches.
The right oblique diameter ia.
the one directed to the right'
acetabulum, and the left to
the left acetabulum.

The axis of the superior
strait is represented by a line
drawn peqjendicular to tlie
center of the plane. The
extension of this line fallsj
below upon the extremity of '
the coccyx, and above strikes
the abdomen near the umbil-
icus (vide Fig, 94). The circumference of the brim is very nearly
sixteen inches.

The inferior strait proper, or outlet of the pelvis, is bounded by
tho Bub-pubic ligament, the pubic rami, the ranii and tuberosities of
the ischia, the sciatic ligaments, and the coccyx. Owing to the pro-

*-,4y#ii

Fio, »3,— DkmcFtors of the outlet.

MECHANISM OF LABOR

151

ion of the ischia, the surface of the pelvic outlet is rendered con-
'tpx, or, j>erhap3, is better dDscrib<?d by supposing it to be composed
of two obtuse-angled triangles with apices at the symphysis and coccyx,
and with a common base formed by a line drawn through the ischia.

The antero-posterior diameter extends from the lower border of
the symphysis to the extremity of the coccyx. It measures three and
three quarters inches, though, when the coccyx is pushed backward,
the distance may be extended to four and a half inches.

The transrerse diameter* between the inner borders of the tnberoa*
ities^ measures four and a quarter inches;.

a?^

'CONJUOATC

-AXIS or

OUTLCT.

eOGCVX .

HORIZON.

nrtMtQ BACK

fbtt, flk— SpGtioD thowtiig the iaclUution of tbo pelvis according to Nuegole. <T&mier el

fUMEOr OUTLET

ion of the

Owing to the elasticity of the sciatic ligaments, the oblique diam-
oCeni are not regarded as of obatetrical importance.

The axis of the inferior strait, when the coccyx is not disturbed,
itrtkes the promontory. When the coccyx is pushed backward, a per-
pendicular line drawn from the center impinges upon the lower bor-
der of the first sacral vertebra.

The circumference of the inferior strait measures thirteen and a
half inches.

The ihAyic cavity or canal possesses an irregular, cylindrical shape,
eonitricted somewhat above at the superior strait, and narrowing rap-
idljat the pelvic outlet Below the brim, the dimensions are in-
CfiittBed considerably by the concavity of the sacrum. Thus, a plane
phasing through the lower portion of the 8}TnphysiB pubis, and across

152

LABOR.

.r^\

■\

tlie upper margins of the acetabula» to the junction of the second and
third sacral vertebrae, gains three quarters of an inch in the conjugate,
while the transverse diameter is barely one fourth of an inch less than
the transver^ diameter of the brim. The narrowing at the outlet is
most marked in a plane drawn so as to intersect the spines of the
ischia and the extremity of tlie sacrum. At the level indicated, the
distance between the spines {transverse diameter) is but four inchaSt
and the antero-posterior diameter four and a half inches.

The sciatic spines divide the pelvic cavity into two unequal sec-
tions. In the larger, anterior section, the lateral walls slope toward
the symphysis and arch of the pubes, while posteriorly the walls elope
in the direction of the sacrum and coccyx. The declivities in fronkp
of the spines are termed the anterior inclined planes of the pelvis, ovei
which rotation of the occiput takes place in the mechanism of normal

labor. Behind the spines the Literal

slopes arc known as the posterior inclined

planes. Meeting together in the median

line of the sacrum^ they constitute a sort.

of vault, into which the face is turned i

after rotation is completed.

The general direction of the pelvic
cavity is best shown by a line represent-
ing the axis of the bony channel. It
should, however, be stated in advance
that the so-called pelvic axis of obstjetri-
cal writers is not to be construed as the
median line of a cylinder in a strict
mathematical sense, but is really intended
to indicate very nearly the coui-se which
a round body like the fetal head would naturally pursue in its
course through the parturient canah In practice it is convenient
to follow the suggestion of Hodge, and draw a plane from the supra-
pubic ligament backward to the sacrum, and parallel to the plane of
the superior strait. This second pamllel would intersect the middle
portion of the second sacral vertebra. Inasmuch as the pubic walls
run nearly parallel to the upper portion of the sacrum, the axis of the
cavity included between the two planes may be rc^garded as continu-
ous with the axis of the brim* Below the second phme, owing to the
curvature of the sacrum, the axis describes a nearly circular course,
with intersecting planes radiating from the lower border of the sym-
physis as a center. Further on it will be shown that the axial curve ia
continued beyond the bony canal by the distended tissues which form
the floor of the pelvic baain.

Differences between the Male and Female Pelvis, — In the male the
hones of the i>elvis are thick and solid ; the brim is triangular in

Ft<»* 95. — Axis repreacnted upon a
vertical ueotioii tbrougli ji platstcr
oaat of fch^pei vie cavity. (Ilodgc.)

MECHANISM OF L.VBOR.

153

I shape ; the promontory projecting ; the cavity deepi and sloping in-

waid like a f annel ; the sacrum long, narrow, and moderately curved ;

and the arch of the pubes is formed at an angle of from TS'' to 80^.

In the female, on the contrary, the bones are lighter and more delicate

ill coutimr, therein corresponding to the inferior muscular develop*

[lent of the sex ; the brim, owing to the less marked jutting inward

>f the promontory, has an elliptical outline ; the diameters, both

^anterioposterior and transverse, are increased ; the pelvic inclination

is more pronounced ; the sacrum is wider and more concave ; the

tuberosities of the ischia are wider apart ; the angle of the arch of the

pubes meafiures from 90° to 100° ; and the entire depth of the pelvis

fis diminiis^hed. As a result of the increased transverse diameter in the

'female, the trochanters are at a greater relative distance from one

[another, and are directed somewhat obliquely to the front. This

[peculiarity brings the knees in close proximity, and accounts for the

characteristic feminine gait.

The configuration of tlie female pelvis, though unfavorable to
rapid locomotion, is, in a special
degree, adapted to render possible
the birth of the child. A female
jjelvis approximating in tyjie to
that of the male gives rise to a
Yariety of dystocia of a very formi-
dnblo character.

Differences between the Infan-
tfle and Adult Pelvis.— In the in-
fantile pelvis the promontory occu-
pies a relatively higher position
above the upper border of the ^ym-
phj9i3^ the last lumbar and two
upper sacral vertebra? possess a
moderate convexity — i, e. , the
promontory does not project for-
ward, as in the adult ; the sacrum,
after miming a straight course, be-
gins to curve forward first at the
ff>tirth vertebra ; the aim are slight-
ly develoi>ed ; the inclination of
tlie ilia more nearly approaches tlie
I perpendicular ; the S-shaped cui-ve
i of the crests is barely indicated,
thcfe bi'ing but slight difference
in tlie distances between the crests

and anterior superior spines ; the conjugate diameter in proportion to
I tht! transverse is increased ; the side- walls converge toward the outlet ;

Fio.

H. — Vertical Bcction of a fbronle iufkn-
tUtj i»ehb. (FehlitJg.)

154

LABOR

the pnbic arch is formed at an acute angle ; and the distance between
the spines of the iscbia is greater than the tranaverse diameter of the
outlet.

Distinctions pertaining to sex are but slightly accentuated. In
the female, tlie gacnim, owing to the smaller size of the yertebrae, is
narrower than in the male ; the aide- walls are higher ; the symphysis
lower ; the iliac incline approaches more nearly a rertical line ; the
pubic arch is less acute ; and the transverse diameter is increased.

The most important agent in effecting the changes which char-
acterize the adult pelvis is unquestionably the weight of the trunk.
Owing to the wedge-shape of the sacrum, and the shelf-like ledge
which projects from the lower surface of the iliac articulation, no dis-
placement can take place in the direction of the long axis of the au-

FiAft. 97, 9S.— Diugmxnmati^ ropresentatioiui of eoctioufi Oirougli th« infMitilo ftnd

pelves. (Sdiroeder,)

ricnlar surfaces. But, when we bear in mind the inclination of the.
pelvis, it is obvious that pressure from above mnst act upon the
crum likewise in a downward, forward, and inward direction. Now, i
the sacrum were, as it is sometimes represented, the key-stone of the
pelvic arch, it^ position would he fixed between the ilia. We owe to
Duncan,* however, the demonstration that this view is incorrect* and
that in reality the sacral articulation slopes backward and inward in
the direction of the median line* The fact that the sacrum does not
under pressure drop from the arch is due to the strong sacro-iliac
ligamcuts, which hold it in position as part of the bony ring. The
ligaments do not, however* prevent the sacrum from sinking forward
to a limited extent into the pelvic cavity, as is shown in the projection
backward at maturity of the tuberosities of the ilia, whereas in the
infantile pelvis the dorsal surface of the sacrum is level with the pos-
terior superior spinous processes,

♦ DuKCA»» " Resenrches in ObstetiicB."

MECHANISM OF LABOR.

155

As the line of graTity of the traak falls in front of the sacrom,
[the weight from above presses the promontory forward and inward
toward the symphysis pubis. At the same time the rotation backward
of iha sacral apex is restrained by the sciatic ligaments. The natnral
eifect of these two simultaneously operatiye forces, acting at a period
when ossification is still incomplete, is to increase the sacral curve,
and consequently to shorten the distance between the upper and lower
, ends of the ba^. As a result, the height of the promontory is dimin-
ished, the pelyic brim and outlet become constricted, aud the dimen-
j Fions of the pelric cavity are increased. The upper portion of the
I sacrum, in rotating forward, drags upon the posterior ligamentous at-
tachments of the ilia. This traction would, were it not for their union
at the symphyses, and the pressure of the heads of the thigh-bones,
ct^om the ossa innominata to revolve around the sacral articular sur-
faces, like doors upon their hinges. As a result of the antagonistic
action of the symphysis and the sacro-iliac ligaments, however, the
Oflfia innominata bend at the point of least resistance in front of the
aacnxm, and in this way an increase takes place in the transverse at the
expense of the antero-posterior diameter.

The sexnal differences are attributable to differences in the char-
acter of the pelvic contents and the external sexual organs, to differ-
eoce^ in muscular development, and to certain distinctive peculiarities
[of growth. Thus, in the female eunuchs of India, described by
Boberta,^ there were absence of vagina and complete atrophy of cellular
[tiBStie in the genital organs ; at the same time the pelvis approximated
[to the male type, and, in place of the pubic arch, the rami of the
I and ischia appeared as though they were in contact at the site
' occupied by the vagina.
In fetal life, the female sacrum, owing to the smaller size of the
fertebr®, is narrower than in the male. Subsequently the more rapid
growth of the alae becomes the cause of the increased width which
chaiacierizes the sacrum of t!ie female at maturity. The larger cir-
cQinfefenco of the brim in the female is due partly to this difference
[ in the width of the sacrum and partly to the greater length of the
\mem innominate.

Tkt Soft Parts of the Pelvis, — Prefatory to the history of the im-
pregnated o\nm, we have already considered the more important pei-
ne raoera concerned in generation and parturition. In studying the
I ipechaniBm of labor, it is, however, necessary in addition to recall —
1. The soft tissues which encroach upon the pelvic space; 2. The
stTueturcs which close in the openings of the pelvis, and convert it
iota a basiD-like cavity.

1. The diameters of the brim are diminished eoraewbat by the
tlio-pdoaB muscles. The iliac muscles proper occupy the entire surface
^ Vide Tilt, ** Uterine «Jid Ovarian lufiam motion," p. 68.

156

LABOR

of the internal iliac fossae. The fibers coBTerge below, and. pasging

beneath Poupart's ligament, become united to the borders of the psoaa
muscle. The pelvic portion affords a soft cushion for the support of

VEWA CAVA-

-AORTA,

P80A£ MUSCLE.

PfllMmVE fHAC.t
V£1N,

%^'>^
^:\^)

^PKIMITIVC

IXTmNAllUACyElK,'
lUAC MuseU

Acra
of-

^EXTERNAL

\tLIAC.
llHTERNALtUM;

EXTEftMAl OBTURATOR NUSCLE ,

Tio, 99.— Pelvis oover^ witk ibe soft pftrt«, with removal of bljiddcr, uterus, and i

the gravid utenis. The great psom muscles fill out the spaces upon
the sides of the promontory. They take their origin from the latcnil
surfaces of the bodies and traus^^erse processes of the four upppr lum-
bar and the la^st dorsal vertebrae. They cross the pelvis panillel to the
linea innominata, which, however, they slightly overlap. They taper
below, and, pjissing beneath the femoral arch, terminate in a tendon,
which is iusei-ted into the small trochanter. These two muscles flex
the thighs upon the abdomen. The iliac muscle likewise acts as an
abductor, and the psoas serves to flex the pelvis upon the spinal col-
umn. The ilio-psoae muscles diminish the transverse diameter nearly
a half-inch, so that the latter becomes very nearly equal in length to
the oblique diameters. When the limbs are extended and the muscles

MECHANISM OF LABOR

157

are rendered tense, the influence they exert in lessening the pelvic
space is somewhat greater than when they are relaxed by flexing the
legs npoD the thighs.

The large arteries and veins at the pelvic brim do not undergo com-
pre^on doring labor under normal conditions. When, however, con-
siflerable disproportion exists between the pelvis and the child*s head,
the effects of presanre are sometimes manifested in the swelling of all
the soft tissues within the pelvic cavity — a swelling which, in turn,
enhances the difficulties of delivery.

2. The open spaces of the pelvis, which are closed in by soft
partBt are the great sciatic notches^ the obturator foramina, and the
pelric outlet.

SACRUM.

PYRAMIOAUIM

Tin. loa.— 6«ctioti ttf pdvii, ihowing the pyramidid musdes. (Tu-aier ot Clumtretiil.)

Tlie closure of the sacro-sciatic notches is effected by the pyramidal

loicles. The pyramidal muscle has a triangular shape. Its base

eJi^ntd a stories of digitatians which are inserted upon the lateral

[>rt]on9 of the anterior surface of the sacrum, along the outer borders

' of the four lower sacral foramina and the upper portion of the sacro-

iCiAtio ligament. It then crosses the large sciatic foramen, and,

{Mising outward, terminates in a tendon, which is inserted into the

^ large tn>clianter.

The tibturator foramen is covered by the internal obturator mus-

The latter is attached to the quadrilateral surface which corre-

idtf to the cotyloid cavity, to the circumference of the foramen, and

the inner surface of the obturator membrane. Its fibers converge

I farm '. which passes through the lesser sciatic foramen, and

lienee i.- 'l downward and backward to the digital cavity of the

liDobADter*

MECHANISM OF LABOR. 159

of two symmetrical halves^ attached in front to the inner surface of the
body and horizontal rami of the pubes^ and laterally to the tendinous
arch of the pelvic fascia which stretches from the inner border of the
pubes to the spines of the ischia. Its fibers slope anteriorly down-
ward and inward to the sides of the bladder, between and to the sides
of the bladder and rectum, and posteriorly are inserted into a tendinous
raph£, extending from the extremity of the coccyx to the rectum.
Its rectal insertions become confounded with the upper fibers of the
external sphincter ; those of the vagina are situated beneath the bulbs
of the vestibule and the constrictor cunni. The ischio-coccygeus is a
small triangular muscle, by many included in the description of the
levator ani. It is situated between the latter and the pyramidal mus-
cle, and in front of the small sciatic ligament. Its base is attached to

THREE LAYERS OF
THE PERINEAL FASCIA

Fig. 103. — Antero-poeterior section of tho perineal floor. (Tamier et Chantrenil.)

the sides of the coccyx and lower extremity of the sacrum ; the inser-
tion of the apex is at the spine of the ischium.*

The upper surface of the levator-ani and coccygeal muscles is con-
cave. The muscles themselves are flattened, and of nearly membra-
nous thinness. Alone they are capable of affording but feeble support
to the superimposed viscera. They are, however, above closely at-
tached to the strong tissues of the internal pelvic fascia, which pos-
sess the qualities of elasticity and toughness.

The internal pelvic fascia is attached to the upper border of tlie
superior strait where it meets the fascia which lines the iliac fossae,

^ The ooccYgens muBcle is strongly deyeloped in caudate animals, and enables them
to more the taU kteraliy.

160

LABOR.

and the transverse fascia of the abdominal walls* It covers the py-
ramidal and the upper half of the obtarator muscles. In front it de-
scends from the symphysis to the neck of the bladder, and forms the
pabo-vesical ligament From the linea terminalis to the areas t-en-
dineus t!ie fascia upon the side- walls is firmly attached to the perios-
ieum. The tendinous amh marks the line at which the fascia leaves
the pelvic walls to form the inner lining of the levator and cooeyge-al
muscles.

The upper surface of the internal pelvic fascia is covered by the
peritoneum, with wliich it is connected by loose connective tissue*

The fascial coverings beneath the levator-ani muscle are divided
into a posterior and anterior portion by a line drawn between the two
ischia.

The posterior portion consists of a single layer. It starts from the
sacro-seiatic ligaments and the tuberosities of the ischia ; thence it
mounts upward over the inner surfaces of the ischia and the obtura-
tor interuus muscle to the tendinous arch, which it contributes to form,
and from the tendinous arch is reflected at an acute angle over the
inferior surface of the levator-ani muscle. The space thus limited
between the side- walls of the pelvis and the levator ani is termed the
ischio-rectal excavation.

The anterior portion, or perineal fascia proper, fills the space be-
tween the bis-ischiatic line and the arch of the pnbes. It is composed of
three layers* as follows : L The deep perineal fascia* which covers the
lower surface of the levator ani ; 2. The median perineal fascia, sep-
arated from the former by a narrow interval, and inclosing the puddc
vessels and nerves; 3» The superficial perineal fascia which forms,
with the median layer, a shallow compartment in which are lodged
the superficial muscles of the perimeum, the bulbs of the vagina,
tlie vulvo- vaginal glands, and the rami of the chtorb. Each one of
these organs, except the latter, is, moreover, enveloped in a special
eheath, derived from prolongations of the upper surface of the apo-
neurosis.

The superficial perineal muscles are of slight obstetrical importance.
They are the constrictor vaginae, the ischio-cavemosi, and the
versi perin^ei.

The constrictor vaginae consists of two small lateral muscles, sita-
atcd upon the outer sides of the vestibular bulbs, and surrounding the
vulvar orifice. Posteriorly the extremities of the main muscle start
from the perioeal fascia at a point nearly midway between the sphinc-
ter ani and the ischia, while a small bundle only is connected with the
sphincter ani itself.* Above, the convergent ends separate into a
superficial and deep portion. The superficial portions terminate in i
tendon which unites them together above the dorsal vein of the clit
* Lu9CQK>, *' Aantomle dcd men&ehtlchen Bedcena/* p. 899.

MECHANISM OF LABOR.

161

Tis ; the deep portions pass between the upi>er ends of the bulbs and
the clitoris, and are likewise united by an aponeurosis.

The action of the muficio consists chiefly in compressing the veins

f^l

,, CLITORIS.

-URETHRA.

iCONSTHlCTOI?

TRANSVERSUS

rERfNAEL

Fio. 104.^Ma!»deft of the perlmeam. (Henle.)

e^iiwud by its tendon, and in thus enhancing the turbidity of the
ef^tile apparatus. It is in no sense a sphincter muscle, though, by
pmaing the turgid bulbs inward, it may narrow the vestibule of the

The ischio-cavernosi muscles form a sort of fihro- muscular sheath
about I he crura of the clitoris. They aiB united together above by an
aponearosis which crosses the posterior extremity of the body of the
During sexual excitement these muscles are capable not only
apressing the crura, thereby forcing the blood toward the body
[bl the clitoris, but, through the pressure exerted by the aponeurosis
the dorsal vein, they help to retard the return of the blood from
^turgesccnt organ.

T1m5 transversi pcrinaei muscles are small, triangular, flattened
mnacles which pa^ from the inner sides of the ischia, underneath the
DOBllfictor muscle, to the sides of the vagina and rectum. When the
11

162

LABOR.

perinfleiim is lacerated, these muBcles tend to produce gaping of the
wound, and to interfere with union bj first intention.

A mere enumeration, such as has been given, of the thin, flat, mus-
cular and aponeurotic etructores of the pelvic floor affords, however,
a very incomplete idea of the trne anatom j of the lower portion of the
parturient canal. Both as regards form and function, the role of the
connective tissae which fills out all the available interstices between
the different organs, the different muscular groups and the bony walK
is of the highest importance. It is to this tissue that the perineal
body occupying the space between the vagina and rectum owes its ex-
traordinary distensibility. In a Sfigittai section, the i»erlneal body
presents a triangular shape, with a convex vaginal and concave rectal
surface.* Laterally it spreads out to the rami and the tuberosities of
the ischia. In height it extends upward ncai*Iy one half the length of
the vagina. Between the border of the anua and the posterior com-
missure of the vulva, tiie external portion, which forms the base of the
triangle, measures on the average an inch in length, f When the head of

Fio. lOD, — Tliu piirtLuricat camil. (Hodge,)

the child, during labor, descends below the level of the bony walls,
it bulges the pcrin^-euni and stretches it from four to five inches in the
antero-posterior direction. Both the length and degree of curvature
of the pelvic canal are thereby increased, the soft parts posterior to

♦ TnoMAS, **Tlic Femnlc Perinipum," etc., "Am. Jotm of Obstct/' April, 1880,
t Foster, F. P., "* Anatomy of the Uteriia aod U« tjairouiidiog?,*' " Am. Jour, ei
ObsUW January, 1880.

MECHANISM OF LABOR,

163

* the TulTft forming a gutter-like extension, the axis of which is con-
tinaoas with that of the pelvis.

The Head of the Fcetus at Term,

The liead U the part which presents the greatest mechanical diffi-
culties in the passage of the ftT?tus through the parturient canah It
is, therefore, important to become familiar with its shape, its diameters,
and the modification it undergoes during labor.

In studying the fetal head we distinguish the face and the cranium.

The face is of little importance in normal labors. It ma}', how-
crer, be here incidentally noted, what is sometimes of consequence in
extreme degrees of pelvic contraction, tliat the distance (two and a
half inches) between the malar bonea possesses but a slight degree of
r^actibility.

In the cranium we distinguish again between the upper compresai-
' ble portion or vault and the lower incompressible portion or base of
the skolL The vault is composed of the frontal and parietal bones
and the gquamouB portions of the temporal and occipital hones. The
Imee is formed by the union of the ethmoid, the sphenoid, the petrous
portion of the temporal bones, and the basilar portion of the occipital

: lO^^Latonl view of fctul

Flo. lOT.^Fetol hmd. w sean from
above. (llod^\)

ThB Sutures and Fontanelles* — The flat Ixjnes which form the vault
» arc thin and imperfectly ossitied, consisting, indeed, of little more than
' Ihe diph>c. InsU^ad of union by serrated osseous borders, they are
I beUi in their relative positions by the periosteum and dura mater,
^bidi oome into contact with one another and form membranous com-
betw*een the bones. Where more than two bones meet at a
"ghren point, the ossification is apt to be incomplete, and spaces are left,
eoTered only by membranes, termed fontauelles.

The sutures to which it will bo found necessary to make constant
[ioe are the following : the frontal suture, situated between the
iijted halves of the frontal bone ; the coronal suture, between iho
frontal and parietal bones; the sagittjil suture, where tlie parietal hones
meei at the t-op of the cranium ; the lambda suture, so called from its
mtmblmnco to the Greek letter of that name^ between the triangular

164

LABOR.

portion of the occipital and the posterior borders of the parietal
bones.

At the point of intersection of the frontal » the sagittal, and the
coronal sutures the incomplete ossification of the frontal and jmnetal
bones leaves a large open space of a rhomboidal shape, termed the an-
terior or large fontanelle, or sometimes simply the bregma. Of the
four sides, the anterior are longer, often extending for some distance
between the bones of the os frontis.

The posterior or small fontanelle is situated at the junction of
the 8agitt*il and lambda sutures. It is formed at the meeting of three
bones, viz., the two parietal and the occipital, and possesses a triangu-
lar shape. In very many cases the ossification of the bones is complete
at the time of delivery. Its site then is indicated by the angle formed
by the {losterior borders of the parietal bones, beneath which, as a
consequence of labor, the occipital bone is usually found depressed,

Budin has recently demonstrated that the squamous or triangular
portion is attached to the basilar portion of the occipital bone by meaofl
of a bund of cartilaginous and fibrous tissue. A sort of hinge-joint is
thus formed, which permits veritable movements of flexion and exten-
sion to take place.*

The flexibility of the cranial bones, the sutures, the fontanelles,
and t!ie fihro-cartilaginous bands of union, together enable very con-
siderable changes to take place in the diameters of tlie fetal head
daring the progress of labor.

The Diameters of the Fetal Head.— The diameters of the child's
head are a series of imaginary lines extending between fixed points^
selected so as to indicate the dimensions of the largest segments which,
in the different positions and presentations, engage in the pelvic canal. _
We distinguish diumeters running in the antero-posterior^ the trana^^J
verse, and the vertical directions*! ^^

The an tcro-posterior diameters arc : 1. The occipito-mental ; 2, The
occi pi to-frontal ; 3. The sub-oceipito-bregmatic.

The occipito-mental diameter extends from the highest point of
the occiput to the chin; J the ocoipito-f rental, from the occiput to
the root of the nose ; the sul>occipito-bregmatic, from the junction
of the occiput with the neck to the point of intersection in the large
fontanelle of the coronal and sagittal sutures.

The transverse diameters are : 1. The bi-parietal ; 2. The bi-tem-
porul ; 3. The bi-mastoid.

♦ BrDiN» ** Dc k THc du Ftptup/' p. 72.

f The points of de]»ariurc of the fonowing diameters have been tdopled from Budin^a
cicelkut monograph, ftlrcftdj quoted.

I The ocdpLlo-mentfil diameter is usimlly referred to fts the loiDgcst one of the bend.
According to Budin, the true mmirmim diameter is eitiiiiited between the chin mod ft T»ri-
iible poiat In the tine of the sagittal suture above the oocipttt.

MECHANISM OF LABOR,

165

The bi-parieial diameter stretches between the two bosses or pro-
toberaBces of the parietal bonea ; the bi-temporalt between the extremi-

OCCtPITO^MOtTAL-

kr«DHT(HIENTAU

^OCCrPITOfRONTAL.

SUB-QC»PlTO-Bfl£GMAriCl

ncERVICO^REGMATrC-
FlOw 1O0W — Antiiro-poateiior utd vertical dimnetera of the fetal bead. (Tftmifif ot Chjuitreui] . )

[ ika of the coronal Butures ; the bi-mastoid, between the mastoid pro-
1868 ni the base of the skull.

The vertical diameters are : 1. The fronto-mentjil ; 2. The cerrico-
' 'bngtnatic.

The fronto-mental diameter extends from the top of the forehead

to the point of the chin ; the cervico-bregraatic, from the middle of

the lar^e fontanelle to the upper portion of the neck near the larynx.

In famishing standard measurements of the foregoing diameters

it ia of coarse understood that no two heads present precisely the same

dimendons. As a rule, m shown by Sir J. Y. Simpson, the heads of

^hojs are larger than those of girls. In selecting type-cases it will be re*

ijoanbefGd too^ that^ owing to the plasticity of the head^ in none are the

Bt-PARI£TA1.

BI-TCMPORAU

f 10, 109. — ^Dtogimm fthowing tnuuTene dlameteri of fotftl bead. (Tnrnior ct Clumtreuil,)

f
duuneters completely normal immediately after the transit through
the generatiTO paasagGS. Unless^ therefore, the child is deliyered by

166 LABOR.

CsBsarean section, sufficient time should be allowed to elapse after de-
livery before the measurements are made, to permit tho head to return
to its natural shape. Again, as in the measurements of the peiyis,
the figures selected to represent the normal average should be such 86
admit of convenient recollection.

DIAMETERS OF FETAL READ.*

Occipito-mental diameter 5^ inches.

Occipito-frontal " -H "

Sub-occipito-bregmatic diameter SJ "

Bi-parietal '' SJ "

BUemporal " SJ <«

Bi-mastoid " 8 *'

Fronto-mental " 3J "

Cervico-bregmatio " 3} "

The circumference of the head, from the chin to the vertex, using
the latter term to express the highest part of the skull, without refer-
ence to any fixed anatomical point, is about fourteen and three quar-
ters inches. The circumference at the sub-occipito-bregmatic diameter
is but thirteen inches.

The Articulation of the Head with the Spinal Column.— The move-
ments of the occiput upon the atlas are extremely limited, those of
extension and flexion, which the head executes so readily, taking place
for the most part in the articulations of the cervical vertebrae. Move-
ments of rotation are performed at the articulation between the axis
and the atlas. In practice, the head can not be turned with safety to
either side beyond a quarter of a circle, though, when rotation is per-
formed slowly after delivery, it may sometimes be earned to such an
extent as to enable the face to look directly backward. The insertion
of the spinal column at a point nearer to the occipital than the frontal
extremity of the child's head is of supreme importance in the further-
ance of the mechanical processes of labor. It converts the head into
a lever, consisting of two unequal portions. When the head, there-
fore, encounters circular resistance in passing through the obstetric
canal, pressure transmitted through the spinal column causes the de-
scent of the occipital short end of the lever, while the pressure upon
the forehead from the side-walls flexes the chin upon the thorax, the
degree of flexion depending upon the size of the canal through which
the transit is made.

* The diameters piven are based upon the table in Tarnier and Chantreiiil, which
were aTcragcd from measurements taken with great precision in forty-four cases.

MECHANISM OF LABOR. 167

CHAPTEE IX,

MECHANISM OF LABOR,-^CorUinu€d,)

Prwentatfoos : nttaral, uxmatuTal, normal. — ^Vertex presentations : frequency, positions.
— ^Manner in which bead enters pelvis. — Positions, nonnal mechanism of labor. —
Descent and flexion. — ^Rotation. — ^Extension. — External rotation. — ^Expulsion of the
trunk. — ^Abnormal mechanism (vertex presentations). — Mechanism of ocdpito-poster-
ior positions. — Ck>nflguration of the head in vertex presentations. — ^Molding. — Scalp*
tumor. — ^Diagnosis of vertex presentations.

The mechanism of labor — ^i. e., the manner in which the foetus
passes through the parturient canal — varies with the presenta-
tion.

The presentations are classified, in the first place^ with reference
to the position of the foetus in relation to the axis of the uterus. In
cases where the long diameter of the foetus coincides with that of the
nterus, we have further to distinguish presentations of the head and
presentations of the pelvic extremity.

Head presentations comprise those of the vertex, brow, and
face.

Pelvic presentations offer two varieties, viz., breech presentations,
and foot presentations.

When the long diameter of the foetus crosses the axis of the uterus,
there is produced a transverse, or, after the operation of uterine con-
tractions, a shoulder presentation.

Vertex, face, and pelvic presentations are included in the category
of natural labors. Brow and shoulder presentations are termed unnat-
ural, as, with few exceptions, they are not terminable except by the
resources of the obstetric art.

Vertex presentations alone are to be regarded as normal, as they
only realize the mechanical conditions compatible with the highest
degree of safety to both mother and child.

In the following pages it is purposed to associate with the descrip-
tions of the mechanism of labor, in the various presentations and posi-
tions, an account of the means of diagnosis, and the treatment suited
to the special cases under consideration, instead of placing diagnosis,
mechanism, and treatment in chapters distinct from one another.
The writer believes, from long experience in teaching, that what is thus
sacrificed in the way of systematic completeness is more than compen-
sated by the clinical advantage of keeping in close proximity the prin-
ciples of obstetric art and the rules of practice directly deducible from
them.

Precedence of description is given to the vertex presentation as
representing the normal type of labor.

168

LABOR,

Vertex Presentations*

Id 93,871 births, collected from private practice, Spiegelbcrg found
that m over ninety-seven per cent, the cranial vault presented.* The
buck of the child in utero is directed in about seventy per cent, of
caaee to the left, and in thirty per cent, to the right, side of the mother.
The fronto-occipital diameter of the head measures four and a half
inches. The diameters of the pelvic brim, after deducting the soft
parts, are nearly as followa :

Transverae diameter of brim ,4} to 5 inches. ^

Oblique " " , . . , .4} to 5 iachea. /

Antero-pORterior diameter of brim (mini mum diameter y

aboat one third inch below the crista pubis) 4 mcbcs, ^

Thus it will be seen that the fronto-occiptal diameter of the bead]
may, a't the brim, enter the pelvis without meeting with any special
resistance in either the transverse or oblique diameters. In the conjn-
gat-e diameter, on the contrary, this is not possible. Transverse posi-
tions, where the conditions are normal, are of very exceptional occur-
rence, though they form the rule in flattened pelves. TamierJ
suggests that this infrecjuencj is partially explicable on mechanical
grounds. The long transverse diameter of tlie pelvis, he says, is,
owing to the projection of the promontory, situated in a line consid-
erably posterior to the point at which the sagittal suture nonnally
meets the conjugate. When the head, therefore, enters the pelvis in a
transverse direction with both parietal bones upon the same plane, the
fronto-occipitid diameter corresponds to a shortened chord subtending
two points of the pelvic ring in front of the anatomical transverse
diameter ; in point of fact, therefore, the latter, at the site of engage-
ment, is less thim either of the oblique diameters J In flattened pelves
this ditHculty does not exist, as, in place of both pkrietal bones entering
upon the same level, the posterior is turned toward the corresponding
shoulder, the anterior dipping obliquely into the brim (lateral obliquity
of Naegele), an arrangement by which the long diameter of the head
IB brought into correspondence with the long diameter of the pelvis.

At the time when the sagittal suture is accessible, and it is possible
to observe with correctness, the antero-posterior diameter of the head
is found to approximate to one or the other of the pelvic oblique diam-
eters.

It is customary to classify the positions of the head with referenoe'
to the direction of the occiput. Most English authorities admit four
varieties, viz. :

The right occipi to-anterior {E. 0. A.), the right occi pi to-posterior

• gpiEOELnKRQ, •» Lehrbucfe der Gebttruhillfe," p. 148,

X Tardier et CaANTaiiiL, ^*Trait6 de TAri dca Aooouchemeats,^' p. 405.

MECHAXISM OF LABOR.

160

(R 0* ?•), the left occipi to-anterior (L, 9, A-), the left occipito-pos-
terior(L. 0. P.),

Naegele first called attention t# the fact that the head occupiea^ in
an overwhelming propter tien of cases, the left oblique diameter ; that,
therefor^t when directed t« the left, tlie occiput is turned to the
cotyloid cavity, and, when directed to the right, it looks toward the
Bacro-iliac synchondrosis.* This peculiarity probably results from the
fact that the uterus is usually rotated in such a way upon tho spine
that the right side inclines obliquely backward, while the left side is
turned somewhat to the front.

In practice it is convenient to take simply into acctunt, in the first
place, the question whether the occiput is turned to the right •r t^ the
left, and then to observe specifically whether it occupies a p#8iti#n in
front or to the rear of the transverse diameter.

At the beginning of labor the head, surrounded by the lower seg-
ment of the uterus, is commonly found at the brim or resting upon
an iliac fossa in multiparie, and below the brim, within the pelvic
cavity, in primiparse. The direction of the head, as regards its vertical
axis, depends upon tho degree of resistance afforded by the contigu-
ons ntcrine tissues. In the softened, relaxed condition often ob-
cenrable in multiparas toward the close of pregnancy, the two fonta-
nelles are not infrequently situated upon tho same leveh Where the
lower uterine walls are firm and slope toward tlie os intenium, the
weight of the chihl's body, transmitted through the vertebral column,
de]>re8seB the occiput. At the same time the sloping uterine walls,
acting upon the frontal extremity of the child's head, direct the chin
toirard the thorax, thus producing a state of semi-flexion.

The Nokmal Mechanism of Labor,

The mechanism of labor in head presentations is usually described
BM consisting of a series of acts, termed respectively descent, flexion,
fotation, external restitution, expulsion of the trunk-

A familiarity, not with the names of the various acts, but the things
the names represent, is essential to the judicious prosecution of the
obiietric art

Descent and Flexion. — Descent and flexion go liand in hand, and
fihoold be associated in thought as they are in reality. It is evident,
whenever the head encounters tho resistance of tlie obstetric canal*
the force transmitted through the spine to the foramen magnum will
omsi^ the fle!<cent of the occiput, and thus flexion will result. The
degree of flexion, however, is proportioned to the extent of the action
of the walU upon the frontal extremity of the head, and therefore is

^ Wlum the hc?a«J h paid to occupy an oblique diameter, this 18 not intended to bo
fllid«ritood tu « mfttbematicsi] arnt^c. The vspressiou iuipliea aimplj tlhiit the be«d is
J<tol»il from t2i« tf«QSvtfr»e diameter

170

LABOR.

Tariftble in dififereBt subjects and in different portions of the canal
Tliis will best be shown by considering the two acts in conjiuiction.
The descent of the child's head through the cennx ja effected bj

^,^-

^HT*

Fid. 110.— Figura inuBtrating tho mechiuil'^m uf lubor in occipito-iuiterior ddiveiics (aftrr

ScliultzeJ.

the pressure of tlie uterus during contraction upon its entire contents.
While not denying the possibility of the transmission of a certain
amount of propulsive energy from the uterine walls through the trunk
of the child to the head, it is necessarily of feeble force, as the flexi-
bility of the spine and the smoothness of the breeeh prevent the latter
from finding a suitable point d'appni against the vaulted fundus* The
head is, however, subjected to the driving force of tlie fluid medium
with wliich the foetus is surrounded. As the pressure is proportioned
to the height of the fluid, in the case of partial flexion, the force
directed agiiinst the depressed occiput is greater than that exjiended
upon t!ie frontul extremity. This condition not only promotes the
continuance of head-flexion, but contributes to its increase as the
head in its descent meets with the resistance of the cervical canal.*

The head enters the pelvis in the axis of the brim, with thebi-
parietal diameter paralJel with the planes of the su])erior strait. This
direction it maintains until arrested by the curvature of the sacrum
and by the floor of the pelvis.

In its transit through the cervix, it is usual for the head-flexion to
* Lahs, "Die Tlieorie der Geburt," p. Itf9.

MECII.1NISM OF LABOR.

171

become complete — u e,, for the cIu'd to sink until arrested by contact
with the chest. Exceptions to this rule are found in eases where the
head is unusually small, or where, as is sometimes the case in rtiulti-
pane» the cervix, after rupture of the membranes, is so softened and
diktable as to offer slight hindrance to the advancement of the head.
It is well for the beginner to keep constantly in mind that flexion is
not in any sense an active movement. It is always a movement of
accommodation, the end of which is the successive substitution of a
shorter diameter for a previous longer one, so soon as the latter has
encountered sufficient resistance to arrest its further progress. The
mechanical advantjiges of flexion are obvious when we recall that the
average length of the sub-occipito-bregmatic or maximum diameter of
the flexed head (three and three fourths inches) is three quarters of an
inch less than the occipi to-frontal or maximum diameter of the head
when midway between extension and flexion. Again, the maximum
circumference of the flexed head (thirteen inches) is one and three
fourths inches less than one measured about the extremities of the
occipi to- frontal diameter. These measurements, which are represent-
ative of the natural state, are, however, far from expressing Hie full
extent of the differences which exist after the plastic head has under-
gone the molding processes incident to labor {vide p. 178).

Fio. 111. — Vtirt«x pfotontatUm ; cliild eurrouDded by •nmiotio fluid* (Pin&rd.)

A further advantage of flexion is thus described by Professor Pajot :
**Tlio to*Ui*, in iU entirety, is to be regarded as a broken, vacillating
iod» poaaeised of mobility at the articulation of the head and trunk ;

173

LABOR,

but a solid thns disposed presents conditiona unfaTorable to the tran^-
migi^ion of a force acting principally upon one of it^ extremities ; it
follows, therefore, that previous to flexion the uterine action* pressing
upon the pelvic extremity to promote the advance of the foetus, is lo
in great measure in its passage from the trnnk to the head, by rea^d
of the mobility of the latter ; but the cephalic extremity, once fixed ^
upon the thorax, is most advantageously disposed to participate in the
impulse communicated to the general mass of the fo?tus," * How, al-
though we have seen that, in its descent through the cervix, the head
ig for the most part propelled by the direct action of the fluid pressure ;J
just in proportion to its advance into the pelvis, the propulsive foiwl
exerted during a contraction operates more and more exclusively upon
the trunks until the conditiona mentioned by Professor Pajot are com-
pletely realized.

After Ibe head is once released from the environment of the eer-
vieat canal, a i^liglit movement of extension may follow, provided the
resistance offered by the vagina is less than that of the cervix* In
many cases, on the contrary, where dilatation is complete at the time
of rupture of the membranes, the head may pass through the cervix
with scarcely any change in its direction, flexion taking place first
when the head encounters the resistance of the sloping pelvic walls and J
the |)erineal floon

Rotation, — The head, as wo have seen, follows the axis of the su-
perior strait until arrested by the extremity of the sacrum and the
perineal floor. As it nears the latter, the curvature of the sacrum ap-
proximates the posterior wall to the sagittal suture. Upon vaginal
examination, the linger comes in contact with the anterior half of the
head as the presenting part It is not, however, on that account to
be assumed that the head is inclined laterally toward the posterior
shoulder, though the sensation produced deceptively favors such a
theory* f

When the head has once reached the perineal floor, its further
progress is associated with the most interesting of the mechanical acts
of labor. The occiput, whether previously directed to the anterior or
posterior extremity of an oblique diameter, turns forward under the
arch of the pubes, until the sagittal suture occupies very nearly the
antero-posterior diameter of the outlet. The utility of this movement
is obvious. Owing to the inward slope of the side-walls of the pelvis^

* Pajot, '* Dictioniiftire encydopd^iqae dcs sdencei mfidicalen," t i, p. S82, quoted
by Tamier ct Chantreuil, p. 639,

f With the tt|ipaix;tit obliquity it h probable that a certain amouttt of real obliquity
oocxiata. A^^ even in extreme ^exion^ the lateml tnoYoments of the head are not intei^
fered with, it is hardly to be expected that the bend, when arrested at the perineal floor^
'would continue to roaintaiu a right line with the spine» The movement po^s^ssca^ how* ^
ever, no fipecial signifieancc as a factor in the mccbanism of labor, and lt« mentioa if \
umplj th« addition of a needless detail to an alrcadj BulBcientlj complex process.

JIECHAKISM OF LABOH,

178

the distmice between the ischia is but four and a quarter inches, and
between the spines four inches. If, in nnskillfiil forceps operations,
the bead, preyious to rotation, is dragged through the transverfio dtam-
eter of the pelvis by main force, it becomes enormously flattened and
lengthened in the direction of the trachelo-bregmatic diameter, the
child's life is endangered, and the soft parts of the mother are jeop-
ardized. When, howeTer, rotation is completed, the bi-parietal diam-
eter (31 inches), which ia capable of sustaining a considerable degree
of lateral compression, engages in the transverse diameter of the pel-
ris ; at the same time the sub-occipito-hregmatic engages in the con-
jngste diameter- The latter, though measuring but three and three
fourths inches, may be extended t« fcur and a half inches by the
pressing backward #f the tip of the ctccyx.

The conditions for tlie forward r#tati#n of the occiput are — 1.
Flexion ; 2. Gead labor-pains ; 3. A firm perina?um.

In either of the occipi to-anterior positions rotation is not difH-
colt to understand. The convergent anterior inclined ])lanes furnish
smooth surfaces upon which tlie occiput glides downward and forward
to the front The rigid ischial spines direct the forehead to the eacro-
ectEtic ligaments, which determine the backward movement corre-
sponding to that of the occiput in the front part of the pelvis.*

Jf. Pajot expresses the law which governs the rotation movements
in the following terms : ** When a solid body is contained within an-
other, if the receptacle (contcnanf) is the seat of alternations of move-
ment and rt»pose, and its surfaces are slippery and but slightly angular,
the contained body will tend increasingly to accommodate its form
and dimensions to the form and capacity of the receptacle*" f

In occi pi to-posterior positions, the rotation of the occiput forward
ijj, at the fii-st glance, a puzzling phenomenon, as the inclined planes
oi the pelvis, the ischial spines, and the law of accommodation, pre-
Tiouily invoked by way of explanation, should determine the rotation
of the occiput, not to the front, but to the sacra! cavity* The follow-
ing experiment of Dubois, however, throws considerable light upon
the principal conditions of success: '*ln a woman who had died a
short lime previous in child-bed, the uterus, which had remained
flaccid and of large si;5e, was opened to the cervical orifiee, and held
by aids in a suitable position above the superior stniit; the fcctus of
the woman was then placed in the soft and dilated uterine oritice in
the right occipito-posterior position. Several pupil-midwives, pushing
tb* ' ^ " 'i\ readily caused it to enter the cavity of the pelvis ;

mu ^ 1 was needed to make the head travel over the peri-

neum and clear the vulva ; but it was not without astonishment that
WTB saw, in three successive attempts, that wlien the head had traversed

• LiufrBiiiif, *'Tbe MtHshcmism of Parti irition^*' p. tC.

f lUioxx^ ** yioooiiimo(i«t)oa en qbst^trique," Hd!e IntroductloiL

174

LABOR.

the external genital organs, the occiput had turned to the right ante-
rior position, while the face had turned to the left and to the rear; in
a word, rotation had taken place as in natural labor. We repeated the
exi>eriment a fonrth time, hut as the head cleared the vulva the occi-
put remained posterior. Then we took a dead-born fastus of the pre-
vious night, but of much larger size than the preceding ; we placed it
in the same conditions m the first, and twice in euccession witnessed
the head clear the vulva after having executed the movement of rota-
tion. Up^ju the third and following essays, dehvery was accomplish
without the occurrence of rotation ; thus the movement only ce^
after the pcrinajum aod vulva had lost the resistance which had made
it necessary, or, at least, had been the provoking cause of its accom-
plishment." *

This interesting experiment shows that it is unnecessary to assume
a vis veriens, or rotation force, in the uterus itself, A certain amount
of light is thrown upon the action of the perineal floor by the clinical
fact that it is always tlie most dependent portion of the presenting
part which rotates to the front. A moment's reflection will show that
rotation, therefore, takes place in such a direction that the sloping sur-
face of the child's head is brought into correspondence with the down-
ward slope of the perioa?um. Thus it sometimes happens, in occipito-^j^^
posterior positions, that moderate extension occurs, so that the l&rgot^^^
fontanelle is felt below the plane of the small one. In this case, the
head rests with it^ entire length upon the perineal floor ; its move-
ments are of necessity restrained within narrow limits ; and» if exten-
sion |>er8ists, the pressure of the opposing isch to-pubic ramus directs
the forehead under the arch of the pubes. When, however, the bead
is well flexed it no longer corresponds to the perineal plane. The occi-
put then ghdes downward, and is projected forward by the elastia
pelvic floor until the anterior imnetal boss is forced between the ischio*
pubic rami. As the occipital end of the flexed head descends down*
ward and forward toward the pubic arch, the frontal extremity en-
counters the resistance of the pelvic wall near the ileo-[)ectineal emi-
nence. If the pressure upon the head were in all parts equal, no fur-
ther progress would now be possible. But it is not equal. The back-
ward pressure applied to the frontal portion of the head is exerted
upon the long end of a lever, and works, thercfore, at a greater mechan-
ical Advantage than that directed against the occiput, f At the same
time, if the anterior wall bo divided by a lino drawn on a level with
the lower margin of the symphysis, we find that in the sujierior divis-
ion the general pelvic pressure diminishes from before backward, while,
below the line indicated, pressure diminishes from behind forward.
Now, in accordance with the mechanical principle that, when a body is

♦ Maqtel, " De raccomoKKlation en obat^triqae/' quotatlont p. 98.
f Tahiixr et Chaxtriuu., " Tniit6 de Tart dea accouchenoGBts/* p. 644.

MECHANISM OF LABOR.

175

Bnbjected to yarions pressures, the moyement will take place in the
direction of the least pressure,* we find that the frontal portion, which
lies above the sub-pubic plane, turns backward, while the occiput, which
lies below, turns under the arch of the pubis.

It must not be supposed, in imagining the results of rotation, that
the moyement continues until exact coincidence of the sagittal suture
and the conjugate is reached. Leishman endeavored to measure the
divergence between the two after the head had escaped from under
the pelvic arch, by stretching a cord over the surface of the head from
the lower border of the symphysis to the coccyx. He found that in
left occipital positions the cord crossed the lamhdoidal suture about an
inch to the right of the small fonta-
neUe, and thence extended forward to
the middle of the opposite orbit, in-
tersecting the median line at or near
the anterior fontanelle.f

In emerging from the pelvis, the
two tnbera parietalia do not pass out
at the same time. In place of this,
the head rolls upon its side, so that
in left occipital positions the presen-
tation is formed by the upper and pos-
terior part of the right parietal bone,
and in right occipital positions by the
corresponding territory upon the left
parietal bone.

Extension. — As the head clears the
inferior strait it distends the i)erinae-
um, and converts it into a groove,
which directs the occiput toward the
vaginal orifice. With the descent of
the head the jierinaeum lengthens ; be-
tween the i)ains the perinsBum retracts,
and the head recedes. A gradual soft-
ening results from the continuance of
this play, and, with diminished resist-
ance from the perinseum, the occiput
descends along the anterior j^lvic wall, the trunk enters the cavity, and
the neck finds support against the os pubis. Flexion continues until
the occiput engages between the pubic rami. When the resistance of

Fio. 112.— B, short end of the head
lever ; B F, long end of hetul lever.
(Tamier et Chantreuil.)

• Stcprenson, " On the Mechanism of Labor," ** Obstet. Jour, of Gr. Brit, and Ire./'
October, 1S78, p. 405.

t LuKHMAii, ** The Mechanism of Parturition," p. 84. It will be readily understood
that, fai right occipital positions, the cord should pass from the left of the small fonta-
nelle fonrard to the right orbit.

1T6

LABOR.

the anterior bony wall ia no longer encountered, the surface of the
child^s head glides forward upon the pcrinfeam, as upon an inellBed
plane, and deftcribes a eirele heneath tbepel?ie arch, of which the sub-
occipito-bre^matic diameter forms the radius.

The extension of the head, which is an essential featnreof the fore-
going movement, is the resultant of two forces — derived, first, from the
uterus ; second, from the jkjIvic floor.

The uterine action is transmitted in the axis of the 8ui>erior strait
With the occiput fixed beneath the pubic arch, and the neck
against tlie inner surface of the pubes, the propulsive force is expent
upon the frontal extremity of the head, and this causes the eeparation
of the chin from the thorax* So soon as the forehead passes the apex
of the sacrum, the recoil of the coccyx and the elastic perinaeum drives
the fronto-occipitid diameter forward to the vulva, which now looks in
a nearly vertical direction* When the bi-parietal diameter has once
passed the vaginal orifice^ the perinjeum rapidly retracts, and, as it
glides over the face, the occiput is thrown sharply and rapidly upward
against the pube?.

External Rotation.^Aftor the birth of the head, the face, no
longer supported by the perinoeum, sinks toward the anal region. At
the same time, or with the recurrence of a pain, the head makes a
quarter-rotation, the occiput turning toward the thigh corresponding
to the side to which it was originally directed (right occipital posi-
tion, right thigh ; left occipital position, left thigh), and the face
to the internal surface of the opposite thigh. This movement is
partly a restitution of the head to its normal direction, and partly is
due to a coiTesponding rotation of the shoulders in the pelvic cavity.
To understand the mechanism of external rotation it must be borne
in mind that, in the movement of rotation performed by the head in
its transit through the pelvic canal, the trunk participates to a dimin-
ished extent only. Thus, Schatz * found, in the frozen gection made by
Braune through the cadaver of a woman who died in the second stage
of labor, where the head had originally occupied the right occipito-
posterior position, that the deviation between the pelvic extremity and
the head was measured by an angle of thirty degrees, and between the
head and trunk, on a line with the shoulders, by an angle of thirteen,
degrees. After the release of the head from the vulva, the torsion
ceases* and tlie fetal parts resume their natural relations to one an-
other. The head, therefore, turns slightly to the side, as it accommo-
dates itself to the direction of the shoulders. This first movement is
termed * " restitution," and is much less marked in oceipito-antcrior than
in occi pi to-posterior positions. The shoulders assume an oblique posi-
tion, until, encountering the sloping pelvic planes, the anterior shoul-
der rotates forward, and the bis-acromial diameter approximates to
♦ SCHAT«, "Arch. f. Gynaek.," Bd. vi, p, 41«r

MECHAKTFM OF LABOR.

the antero-poeterior diameter of the outlet. The internal rotation of
the shoulders uauallj takes place suddenly, and in accompanied by the

I corresponding movement of the child's head.

ExoessiTe rotation is sometimes observed. Thus, the shoulders, in
place of turning to the antero-posterior diameter, may continue in
movement until they occupy the oblique diameter of the opposing
side, the posterior shoulder coming to the front. This necessarily
causes faulty external rotation of the head- It occurs most frequently
in occipi to- posterior positions.*

Expulsion of the Trunk, — After rotation, the antonor shoulder
pofflwa under the arch of the pubes j the trunk, as it is driven down
from above^ becomes bent laterally, and the posterior shoulder glides
forward upon the perinaeum to the commissure of the vulva ; both
Ehoulders then make the exit from the vaginal canal simultaneously.
In the dehver}* of the shoulders, the bis-acrominl diameter is usually
g4>niewhat oblique. The expulsion of the trunk, owing to the previous
dilatation of the passage, follows with rapidity ; the body executes a

I f^tral movement until the hips engage at tlie outlet ; during the
birth of the pelvis, however, the bis-iliac diameter rotates so as to

I approximate to the line extending from the coccyx to the pubea,

Abxoriial Mechanism op Labor, (Vertex Presentatiok.)

In the proper performance of the various mechanical acts of labor,
it is necessary that the diameters of the fetal head approximate to
those of the canal through which it has to pass. A very large pelvis^
or a very small head, may become disturbing factors by leading to
imperfect flexion and rotation. In either case, with a lax perinteum
and gaping vulva, the head may be born in any of the diameters
of the pelvis. Head-births in either an oblique or transverse diam-
eter are, however, extremely rare. They are attended with unusual
difficulty, as the occiput has to traverse a longer course than when
directed forward under the pubic arch.

The most important of the irregular forms results from the rotar
tion of ihe occiput, in occipito-posterior j^osifcions, backward into the
hollow of the feacrum.f The chief condition of its production is a

ial extension of the head, the forehead then turning anteriorly, in
^accordance with the law that the most dependent portion of the pre-
tcating part is moved to the front

The Mechanism of Occipito-posterior Positions. — When the occiput
turns backward, it rests upon the anterior surface of the sacrum and
upon the perineum ; the forehead and the anterior fontanelle distend

• Donvit, •* 0eber die Urrachen fehlerhaftes Drehung der Schaliem," et©.» ♦* Arch, f,
GjfMek^'^ Bd. ir. p. 8r,8.

t PLATy4iteMiite« that Dr. Uvcdftle West found the frwiuency of this backward rotation
ma ioiitt flni«5ft U> the hundred in ocdpito-tKWterior positions, Anicrkftn edition^ p, 26S.
12

178

LABOR.

the Tulva, If tbe rotation is incompleto, the anterior parietal, or adja-
cent frontal bones, are seen at the rima pudendi ; and, as the frontal
portion is bom, the occiput sweeps forward to the perineal commissure*

tih

■W

Fro. IW* — Figure iUuMtmtiog the mechoTiiRm nf labor in occipito-postericr olur

After the occiput makes its exit, the neck rests upon tbe perinaeum,
while tbe bead swings backward, describing a circle, of which the sub-
occipito-bregmatic diameter forms the radius.

DeliT?ery in these cases is apt to be tedious, and often demanda the
aid of forceps^

COI^FIGURATIOK OF THE HeAD IN VERTEX PRESENTATIONS.

During labor the Tarious head diameters of the fostus undergo ex-
tensive modification as they are subjected to tbe resistance of the par-1
turient canal. Of these tho most important is tbe diminution of the
gub-occipito-bregmatic, tbe oecipUo-frontalt and the bi-tem|)oral diam*
eters, with compensatory elongation taking place in a line mnnii
from the chin to a point in the sagittal suture situated between tbe
apex of the occipital bone and the large fontanelle (maximum diame-j
ter of Budin). The plastic changes mentioned are rendered possibl
by the presence of the footanelles, the width of the sutures, the plia-
bility of the sagittal borders of the parietal bones, the depressibility of
the 08 frontis, and the joint-like movement between tbe squamous an3:|
basilar portions of the occipital bone. As a consequence of these ana

MECHANISM OF LABOR.

179

tomical dispositiongy pressure from above inclines the frontal bones back-
ward, while the resistance encountered below shoves the occipital bone
in a forward direction. These movements are rendered possible by

Flo. 114. — Outlinos showing difference between head of child at birth (1) and four days sub-
sequent to deliveiy (2). (Budln.)

the depression of both frontal and occipital bones beneath the adjacent
borders of the parietal bones ; at the same time the dragging thus ex-
erted uiK)n the latter, front and rear, increases the curve of the cranial
vault along the line of the sagittal suture. The sharpness of the bend
at the summit of the curve is more or less pronounced, according to
the rigidity of the channel through which the head passes. In cases
of birth with the occiput to the rear, the head is often drawn out to a
great length, the occiput forming an almost vertical line with the
neck and shoulders, while in front the forehead and parietal bones
slope upward to the vertex in nearly the same plane. (Fig. 115.)

The contour of the head is still further modified by the formation
of the caput succedaneum, or scalp-tumor, a swelling developing upon
the portion of the presenting part which is subjected to diminished
pressure from the obstetric canal, and which in consequence becomes
the seat of venous hyperemia, oedema, and extravasation. The forma-
tion of the tumor is usually preceded by a wrinkling of the scalp indic-
ative of the stronger compression above. It may be produced within
the cervical canal, but is then usually of insignificant size, and of
small practical importance. Indeed, it may even form previous to
rupture of the membranes in cases where the separation of the bag of
waters from the contents of the uterine cavity is complete, and where,
we have seen, the water-pressure below the line of cervical contact
with the head is less than the intra-utcrine pressure above. Usually,
however, it is developed after the head reaches the pelvic floor, at the

180

LABOR.

outlet of the vagina, the situation upon the scalp often enabling one
siibsoriuent to delivery to diagnose the position the head had occupied
within the pelvic canal.*

A voluminous scalp-tumor is, as a rule, the result of compression
from the bony canal, and forms, therefore, in normal pelves, below
the narrowing of the inferior strait. In generally contracted pelves,
however, where the resistance of the bony canal is encountered at the
brira, the formation of an enormous scalp-tumor may precede the en-
trance of the head into the pelvis.

According to Deissautjf the scalp-tnmor is usually of larger size
when situated upon the anterior surface of
the head, partly because of the greater laxity
of the tissues, and partly because of the longer
duration of labor when the forehead is di-
rected to the front. Its length may vary
from a half-inch to two inches or more^. In
extreme cases, where the labor has been pro-
longed, there is sometimes found, associated
with the scalp-tumor, a separation of both the
periosteum and the dura mater from the un-
derlying segment of the cranium.

Diagnosis.— The diagnosis of cranial pre»-
entatione by external palpation is usually not
difficult. The head is recognized by its hard-
ness, its rounded form, its separation from
the trunk by the neck, and the ease with
which ballottement is produced. Sometimes,
by pressure upon the cranial bones, a pecul-
iar parchment-! ike crackle is elicited, which is perceptible even through
the abdominal parietos.| The breech, on the contrary, is of uneven
shape, of smaller size, and of softer consistence ; the feet are found in
close proximity ; ballottement is obscure on account of the broad con-
nection between the breech and the trunk. Under favorable condi-
tions the back presents upon one side of the uterus a broad, palpable

Fio. 115.— FiifurtJ f*bowing
»hfkY>Q of Jicad in oociT»itx>-
poeterioT Jelivcncis, (Twr-
nier et CbttutreuU.)

♦ Tha tumor forms in left ocdpi to-anterior posiiioikB upon tlic superior posterior angle
of the right pariota! bone, cncroftching somewhat upon the small fontanelie and the ocd*
put; in right occipjto^anterior positions^ upon the correspondin?; point upon the left Bide
cjf the cranlunL In occipito- posterior deliveriea the tumor develops cpon the anterior
superior angle of the parietal bone tortied to the pubie arch^ and encroaching upon the
large fontanelle^ and even ujwn the frontal anture. If Ihe head-rotation Is complete, and
Ihe head is detained for a long period at the vulva^ the tumor maj occupy the median
line, and thug obscure the diagnosis.

I Takkicr et CHANmELirL, p. 686.

i Fasrender, " Monatsschr. f. Gebiirtsk.," Dd. xiiiii, p. 435. Dr. P. F. ^fnnd^ has re-
cently furnished an excellent rimime of the subject of diagnosis bj external exanunatioo,
in an essay teimcd ** Obstetric Palpinilon.'*

Flo. 119.->ll«Ui«d«f performing extemul pfttpati#n. (PmiutL)

SRrection of the feet, whicli are situated upon tlie abdominal side of
the child.

Upon examination made per vaginam the head is felt as a hard,
roand, smooth body, characterized by the sutures and fonfcaiielleB, and
sufficiently large to fill tlie space of the pehis. Before the nipturo of
the membranes, investigations should be conducted in the intervals be-
tween the pains, i. e.» while the membranes are lax and deprcssible. If
the head is high, and retreats before the examining finger, it should l>e
steadied by counter-pressure applied to the fundus uteri through the
Abdominal walls.

The autnree and fontanelles are best made out after ruptnre of the
membranes* In passing the extremity of the index-finger backward
oviT the cranium toward tlio sacrum, the eagitUl suture k usually en-
countt^rcd. At the extremities of the sagittal suture, the two fontanel les
are perceived, distinguishable from one another by the differences in
Kute and shape. In exceptional cases, the extreme compression of the
bones of the ekuU may render the large fontanello scarcely recognizable ;

182 LABOR.

in others, again, the presence of membranous spaces in the line of the
sagittal suture, fissures at the apex of the occipital bone, or the exist-
ence of ossa triquetra near the site of the small fontanelle may cause
perplexity, and lead to errors in the diagnosis of head positions. It is,
therefore, well to bear in mind, as special marks of distinction, that the
small fontanelle furnishes the meeting-point of three sutures, while
four sutures meet at the large fontanelle.

The sagittal suture pursues a straight course, forming a right angle
with the coronal and an obtuse angle with the lambda suture. An-
teriorly it is continuous with the frontal suture ; posteriorly it ends
abruptly at the occipital bone. The lambda suture, which is the only
one liable to be mistaken for the preceding, is distinguished by its cur-
yilinear direction, by the greater thickness of the parietal borders, and
by the depression of the occipital beneath the parietal bones.

When the sutures are masked by the presence of a large scalp-tumor,
it is still possible in most cases to diagnose the position, by pushing the
finger up behind the symphysis pubis and feeling for the ear.

CHAPTER X.

MECHANISM OF LABOB-{C(nUinued),

Face presentations. — Frequency. — Causes. — Mechanism. — Descent and extensioiL — ^Rota-
tion. — Flexion. — External Rotation. — Abnormal mechanism. — Configuration of
head. — Diagnosis. — Prognosis. — Treatment. — Brow presentations. — ^Brecch presenta-
tions. — Causes. — Diagnosis. — Mechanism. — Irregular mechanism. — Configuration. ~~
Prognosis. — Treatment.

Face Presentations.

In facial presentations, in place of the normal attitude of the foetus,
the chin is extended, the occiput is reflected against the neck, and the
face with the frontal portion of the skull occupies the entrance to the
pelvis. It is not a very common anomaly, having occurred, according
to Pinard, 320 times in 81,711 confinements at the Matemite in Paris,
or, in round numbers, once in 250 cases.*

Causes. — The causes of face presentations are imperfectly known.
Clinical observation has, however, succeeded in connecting the exten-
sion of the head in the pelvic canal with a variety of predisposing con-
ditions. To Ahlfeld f we are indebted for a collection of associated
events derived from a careful analysis of well-observed cases. From
these, the following are selected because of their more palpable con-
nection with the phenomenon in question :

* Charpentier, " Contributions k T^tude des pr6sentation dc la face,** p. 16.
\ Ahlfeld, " Die Entstehung dcr Stim- und Gcsichtslagcn."

MECHAMSM tF LABHR.

183

Hon of the chin froin the chest, resulting fr#m ctngemtal eu-
largement of the thyroid glaiid ; from increased size of the chest in-
terfering with flexion ; from stricture of the cervix about the neck of
the child, the uterine walls adding to the circumference of the thorax;
firom the mobility of the foetus, either because of its small size or from
exoeis of amniotic Enid ; from oblique positions of the child and of the
utems, especially in cases of rapid escape of the amniotic fluid ; and
from coiling of the cord around the head of the foetus. Hecker*
lays great stress uptn the shape of the child's head, and has endeavored
to establish a connection between face presentations and unusual
length of the occiput. Tt be sure, after birth in face presentations
the hind-head is tften found to nearly equal in length the anterior
portion, and it is easy to see that, were such the case at the beginning
of labor, the question of extension or flexion would always be in sus-
pense ; but^ in most cases, the shape is the effect rather than the cause
of the presentation. Still, Heeker and others have reported instances
where the elongation, instead of proving temporary* persisted after de-
livery, and therefore it was fair to assume had existed as a pre-natal
condition*

The resiatanoe encountered by the occiput, which converts partial
into complete exteuflion of the head, may be furnished by either the
uterine or the pelvic walls*

Most writers ascribe great importance to oblique positions of the
tmiu3 and of the uterus in the etiology of face presentations. In mul-
tipane^ the former are not uncommon during pregnancy, tlie head
then resting upon an iliac fossa. As a rule, however, the first pains
straighten the foetus, the narrowing of the uterus in its transverse
diainetor serving to press the brooch toward the fundus and the head
into the pelvis. So long as the back of the child is directed down-
ward» the rectiOcation would inevitably be followed by head-flexion.
When, however, the back is turned toward the fundus, and the change
to the veHical attitude is not readily effected, the pressure of the ad-
^^ jacent uterine w*all may, during contraction, act in a special degree upon
^P the occiput, and direct it backward toward the neck, while the fore-
^F ' ' rjks forward into the brim of the pelvis. This movement is
^^ mponu-y, anil, with the descent of the child, the resistance en-

^BCf^untered by the forehead may exceed that met with from the occiputi
^BmA thus in the end flexion may follow in the ordinary manner. If,
^mprever, the extension continues, a point is finally reached at which
tho pro|>elling force is exerted specially in the direction of the chin,
now converted into the short end of the lever, and the face presenta-
tion becomes complete. In the same way, extension may be produced
when the occiput is arrested at the linea innomiuata, an accident most
occur in transverse narrowing of the pelvis, and, again, in
* Hkcue, ** Veher die Schidelfonn bei GeaichuUgcu."

184

LIBOR.

flattened pelves when the bi-parietal diameter is arrested hy the con-
tracted conjugtitc. The meclianiam of head-flexion may ]ike\f]3e be
interfered with by a prolapsed extremity encroaching npon the pelvic
space.

In lateral obliquity of the uterus, the curvature of the uterine
canal favors the production of face presentations when the back of
the child conforms to the convexity of the lower surface, as the pro-
elling force, which is transmitted in the axis of the uterus, then
sses aJono^ the anterior aspect of the foetus, and increases the ten-
dency of the forehead to descend.

While in vertex presentations the left dorsal positions are nearly
three times as frequent as the right, in face presentations the difference
is very small,* Both Duncanf and Sohroeder J ascribe this relative
preponderance of face presentations with the chin directed to the le
to the constancy of right lateral obliquity of the uterus,

Ahlfeld ^ mentions further that it is not infrequent for extensic
to take place within the pelvic cavit}^ the arrest of the occiput reiull
ing from an unusual projection of the spines of the ischia.

The Mechanism of Face PiiESEinrATioKs.

As in vertex presentations, the dorsum of the child may be tume
to the right or the left side. The position of the face is usually de
ignated by the direction of the chin. We distinguish, therefore :

Right mento-iliac positions (chin to right ilium) ;

Left mento-iliac positions (chin to left ilium).

Most frequently the face occupies the left oblique diameter of tho
pelvis. The common positions are, therefore, the right mento-iliac
posterior, and the left mento-iIiac anterior ; still, it is by no means_
rare for the face to enter the pelvis transversely, probably because
the frequent association of face presentations with a narrowing of
conjugate, #

Descent and Extension, — These two movements, like descent and
flexion in vertex presentations, are conjoined— not distinct from
another. At the brim, the large fontanelle is easily reached, while
the chin is inaccessible. As tho vertebral column is situated, in face
presentations, nearer to the chin thai! the occiput, extension is ao-
jmplished in obedience to the same rules which produce flexion in
Vertex cases. With the descent of the head through the pelvic chai

* Statistic? are a** wt not BufficienUj numerouB to determine the question a* to vKid
positign actually occurs most frequently. Dubois and D^sormeaux (** Dictionnairu," in
thirty voluraofi^ p. 3ft4) reported eighty-five coses. Of these, in forty-five the chin was
rurnod to llic right, while in tblrty-eight it was directed to the left. Dr. A, Waltbcr
(VVinckcrs " Beridite," Cd. iii^p. 312) reported from the Dresden Lying-in Itifitit\ii« thirty^
one cases. Of those, the chin was turned to the left twenty-one timefl, to the right ten tin

f DmiCAV, " Edinburgh Obstet. Trans.," voh ii, p. 108.

^ ScDitocDiai, '* Lcbrbuch der Gcburtshiilfe/' p. 182. * Ablfeld, he. tit,, p. i

MECHAXISM OF LABOR

n©!, the chin sinks deeper and deeper, while the occiput is pushed

backward aiid pressed firmly against the dorsal surface of the child.

The degree of extension at the different stages of the descent is mead-

ured by the relative positions of the chin and tht* large fontanellc.

H The engagement of the head is usually slow and accomplished with

Hdi£Rculty^ owing to the fact that

^hhe neck and posterior portion

^of the head enter the excavation

at the same time. The descent

of the head is normally limited

|tiy the length of the child's neck,

it is only in the case of a

rery small child, or exceptionally

oomy jielvis, that the head and

ipper portion of the thorax can

pnter the pelvis simultaneously.

When the face reaches the pei-
ne floor, a slight degree of lateral
(^bliqaity is produced, the cheek
lirected toward the pubes advan-
ag domewbat more rapidly than
he one turned to the sacrum*
Rotation.— When the chin has
daecende^l along the lateral or
erior wall of the pelvis un-
lil the thorax reaches the linea
iinnominatdf further progress is
'only rendered possible when the
chin rotates forward and engages
beoieatb the arch of the pubes.
The mechanism of chin-rotation
is the i^ame portrayed in vertex presentations. When extension is com-

Kikte, the chin, as the most dependent portion, glides downward and
brward upon the perinasum, and the malar bone is pressed between
he pnbic rami. We have seen already that the pressure above the
mbic arch diminishes from before backward, while below it dimin-
lihes fn>m behind forward. In accordance with the mechanical prin-
|dple, that a body subjected to various pressures moves in the direc-
tion of leaat pressure, the chin or deeper portion turns to the front,
irhih! the eraniaJ vault rotates into the hollow of the sacnim. To
|tlit0 movement the unequal length of the two extremities of the
i*Ter, mcaiiuring from the malar bone to the top of the forehead on
imd from the midar bono to the chin upon the other, con-
tii important degree.*

* TAJtmxR et CoAirrattJtL, loc ciX, p. OflB.

^'^{/,

Fro, 117.— AttitiKie ol' the heacl in fboenreiwi-
tutlo OS . ( Hi li^moot.)

186

LABOR*

Flexion, — After rot^ition, the cliiii emerges beneath the pnbic arch,
the shoulders press upon the base of the skull, the perinaenm becomes
rounded by the cranial vault, and, finall}% as the head performs the
mOTement of flexion in obedience to the forward impulse imparted by
the perinsenmj the chin rounds the symphysis, while the mouth, the
nose, the brow, the vertex, and the occiput appear in succession at the
posterior commissure of the vulva.

External Rotation, — Wlieu tlio delivery of the head is complete,
the shoulders rotate into the antero-posterior diameter of the fielvis,

FiQ. lIS.—Eiigii^iiiinit of Uie bofttl in fa<!0 preseDtadons. (Tttrnlfir et Ch&ntreulL)

the chin turning in correspondence, in right mento-iliac positions, to
the right thigh ; in left mento-iliac positions, to the left thigh.

Abnobmal Mechanism.

In a foetus of small size, the face may, when it meets with slight
resistance from the perineum, be bom in any of the pelvic diame-
ters. Instances of spontaneous delivery without anterior rotation of
the chin are, however, extremely rare. The egress of the face in the
transversie diameter is possible in a shallow, rachitic pelvis, flattened
in the conjugate at tlie brim, and wide between the ischia at the out-
let. The head emerges with the chin resting upon one of the ischio-

188

LABOR.

At full ierm^ the face presenting, spontaneous deliyery in mento-
posterior positions is not practicable. This becomes evident when m

reflect that, owing to the
length of the sacral inD,
the chin can not desoend
to the fonrchette witboat
an incredible flattening ol
the cranial yault and the
simultaneous entrance of
the chest into the pelvic
cavity. It is claimed, how-
ever, that when the headii
small and compressible it
may stretch either the »
cro-sciatic ligaments when
oblique, or the perinsnm

Fia. 121.-0utline of head bom with face prescDtiiig. ^^^ ^^^^^ ^^^ ^^^^

ty of the sacrum, to an extent sufficient to permit the descent of the
occiput beneath the pubic arch, and the conversion of the face into i
vertex-presentation.

Configuration of the Head in Face Presentations.

In face presentations, the vault of the cranium is flattened, so
that the sagittal suture runs from fontanelle to fontanelle in nearly an
horizontal line ; the squa-
mous portion of the occip-
ital bone is pushed back-
ward, while in both the
occipital and frontal bones
the convexity is increased.
As a result, there is an
augmentation of the trans-
verse, the occipito-frontal,
and oceipito-mental diam-
eters, while the sub-occipi-
to-brcgmatic is diminished.
The maximum diameter
either corresponds to the
oceipito-mental, or termi-
nates posteriorly at a point

below the apex of the oc-

oiiiiif * ^^°* ^22.— Same head five days later. (BudixL)

The sero-sanguineous tumor, which forms upon the presenting part
as a consequence of the diminished pressure, occupies the lower portion

* BuDiN, he. ciLf p. 77.

MECHANISM OF LABOR. 189

of the malar region, and the comer of the month (left mento-iliac
position, left cheek ; right mento-iliac position, right cheek) in mento-
anterior positions, and the upper portion of the malar region, and
eyen the eye, in mento-posterior positions. The integuments of the
cheek assume a blackish-blue color ; the tumefaction of the lids is
such that at birth the eyes are closed, and sanguineous effusions are
found upon the ocular conjunctiva ; and the mouth, when involyed,
becomes swollen and distorted, so that suction is sometimes interfered
with for scYeral days after birth.

Diagnosis. — At a time when a portion of the head still remains
aboye the level of the pelvic brim, it is not infrequently possible to
form a diagnosis from external manipulations alone. Thus, by making
deep pressure with the tips of the fingers above the symphysis pubis,
the cranium may, under favorable circumstances, be recognized upon
one 'side of the pelvis, together with the sharp angle formed at the
neck between the occiput and the dorsum of the fcetus. As the
heart is heard vnth greatest distinctness over the anterior portion of
the chest in face presentations, confirmatory evidence of the latter is
afforded by detecting the presence of the fetal extremities, and the
heart-sounds upon the same, instead of, as in yertex presentations,
upon opposite, sides of the trunk.

Upon internal examination, the distinct peculiarities are a high po-
sition of the presenting part, a flattening of the vaginal fornix, and,
through the intervening tissues, the recognition of the smooth forehead,
contrasting with the uneven surface of the face. Through the dilated
cervix the finger detects the forehead, the bridge of the nose, the nostrils,
the orbits, the malar bones, the alveolar processes of the jaw, the mouth,
and, when extension is complete, the pointed chin. Instances have,
indeed, been recorded where, in advanced labor, the distorted face has
been confounded with the breech, the inexperienced observer mistaking
the swollen cheeks for the nates, the malar bones for the ischia, the nose
for the tip of the coccyx, the cedematous eyelids for the scrotum, and
the mouth for the anus. Such an error is best avoided by deliberation
in exploring the presenting part. With proper care the smooth fore-
head, the bridge of the nose, the hard orbital borders, the chin, and
especially the mouth, through which the jaws can be felt, afford suffi-
cient data for a correct diagnosis.

Prognosis. — ^According to the statistics of Winckel,* the mortality
of the children in face presentations amounted to thirteen per cent.,
while that of the mothers reached as high as six per cent. Thus,
though spontaneous delivery is the rule in face presentations, the
dangers to both mother and child are considerably greater than in
yertex presentations. The causes of the less favorable prognosis are
to be looked for in the increased peripheral head measurements, which
• WwcKEL, "Pathologic der Geburtshaife," p. 89.

LiBOR,

engage successively in the different planes of the obstetric canal, and
consaqaently from the increased reciprocal pressure exerted between
the head and the soft parts^ and partly from the compression of the
Teins of the neck by the anterior wall of the pelvis. Though the
average length of labor does not much exceed that of normal pre»eD-
tations,* the duration is more readily affected by minor digtuThanceB,
such as weak pains, moderately contracted pelves, and rigidity of the
obstetric canal. At the same time, the prolongation of labor in these
cases is attended by more disastrous consequences, and calls more
frequently for the resources of art to complete the delivery.

Treatment, — The first rule in the treatment of face presentations i«
to carefully avoid prematurely rupturing the membranes. The face is
ill adapted to serve the purpose of a dilator to the cervical canal^ and
early rupture is apt to be followed by complete escape of the amniotic
fluid — ^^an accident always to be dreaded, bnt specially serious in face-
presentations, where the umbilical cord is exposed to pressure between
the anterior surface of the child and the uterine wall. Examinations
made with a view to diagnosis should, therefore, be conducted with
great care, during an interval between the pains, and their repetition
should be avoided when the requisite information has once been ob-
tained. During the progress of the first stage of labor, it is recom-
mended to place the mother upon the side toward which the chin of
the child is turned, with a view of favoring extension and rotation.

Because of the uncertainties of the prognosis in face presenta*
tions, many manoeuvres have been proposed for the conversion of the
latter into normal presentations. The manipulations chiefly recom-
mended consist of either pushing up the face, or drawing down the
occiput, by the fingers passed through the cervical canal. Though
occasionally successful, they have been diaconntenaneed by most ob-
stetric writers, because experience has shown the results to be by no
means commensurate with the dangers incurred. Schatz f has^ how-
ever, suggested a rational plan for reducing the extended head by
external manipulations only, which avoids the objections to the earlier
methods. His manoeuvre consists in restoring the normal attitude of
the body by flexing the trunk, and leaving the head to resume spon-
taneously its proper position as it f^inks into the pelvis. It is per-
formed by seizing the shoulder and breast with the hand through the
abdominal walls ; then lifting the chest upward and pressing it bock-
ward, at the same time steadying or raising the breech with the other
hand applied near the fundus, so as to make the long axis of the child
conform to that of the uterus, and, finally, pressing the breech directly
downward. As the child is raised, the occiput is allowed to descend,

♦ Waltheh, WiNOtEL'a •* Bcricbte," Bd. iit, p. 315.

t ScHAXZ, *'I>ic Umwacdlung voa Geaiditslage/' etc., " Arck L G}Tiack^" Dd^ ▼, p.
S18.

MECHAXrSM OF LABOR.

191

and thien^ as the body is bent forward, head-flexion is produced by the
refiistanoe of the Bide-walla of the pelvis. Sclmtz illustratea these
moTements by the accompanying diagrams, Ifj owirig to its elevation,

.:«)

Fto*. 1S^IS& — Dlagrmzia showing Sch&tz'i method of <x:»DVcrtln:j lucu prostsnlutiona into

vertex preMutatious.

tlio bead tends to moye to one side when backward pressure 18 made
upon the chest, the place of the pelvic wall may be supplied by cx-
iem&l presgure exerted by an assistant. The time for attempting this
ma&jpnlatioQ ia previous to the riiptnro of the niomhranes. The
roqmsitos for success are experience in mapping out the fetal out-
hnei by external palpation, and the absence of abdominal and uterine
imtnhility. Aft^T rupture of the membranes, great care must be
eit njind in vaginal explorations, to avoid injuring the eyes, or exciting
promature respiratory movements by allowing air to enter the mouth.

If the chin remains persistently directed to the rear, rotation may
•ometimcd be promoted by either pressing forward with two fingers
upon the lower jaw, or by pushing the forehead backward and upward,
to produce a deep descent of the chin. To be efTective, either ma-
mpolalaon should be executed during a pain. Hodge advocates the
fecttf * and others a blade of the forceps, as of use in correcting mento-
IMioricir positions. As a rule, however, good pains and complete ex-
lemioti ai>e the C(mditiona most likely to effect the forward movement
of tlie chin. It is practically of importance to bear in mind that
Urdy rotation is characteristic of face presentations. The treatment,
in cases where all measures prove ineffective to secure a favorable
eliange at positiun, and dangers accrue from delsty to either mother or
cbt]dr belongs to the domain of operative midwifery.

During head-expulsion caution must be used in supporting the
perinii?am, in order not to injure the neck by too strong forward
pf^mum Jigninst the anterior wall of the pelvis.

192

LABOE.

It is safe ta assure the bystanders that the distortion of the face
and the extension of the head after delivery will disappear spontane-
ously in the course of from twenty-four to forty-eight hours.

Brow Presentations.

In brow presentations the head oecupies a position intermediate
between flexion and extension. Of necessity every face presentation
has become such aft^r first passing tbrough the frontal stage. A tem-
porary dip of the hirge fontanelle in the earlier period of labor is by
no means uncommon. With the advance of the head, however, the
resietanee encountered usually causes the complete descent of either
the chin or the occiput The causes of brow presentations are^ in the
main, the same as those given for presentations of the face, vix., ob-
liquity of the nterns and foetus, enlargements ol the neck and thorax,
contracted pelvis, and excessive mobility of the foetua.

The diagnosis is made by recognizing the apex of the foreheed
in the pelvic canal, with the orbits and the root of the nose upon one
side, aDd the large fontanelle and parictul bones upon the other. At
tlie brim the frontal suture is usually transverse, but becomes oblique
in its progress toward the pelvic outlet.

A email head may pass tbrough a roomy pelvis, the brow present-
ing, withoul injury to either mother or child. In the mechanism of
delivery the forehead turns to the front and appears at the vulva, the
upper maxilla resting against the symphysis, and the cranium lying in
the hollow of the sacrum and upon the perinieum. The exit is accom-
plished by the cranial vault
first sweeping forward ovi
the perinseum ; the upp
jaw, the mouth, and the
chin afterward making the
\ \ appearance beneath

symt>hysi8 pubis.

Sometimes, though i
ally only when the forceps!
U8cd. the head may be delif^
ered in the transverse diam*
eter. In spontaneous caaes
the superior maxilla finds %
point of support against one
ifichio-pubic ramus, while
the cranium rotates trans-
versely through the vulva. When the face turns posteriorly, delivery
of a living child is scarcely possible.

The configuration of the head is very strikingT The swelling of
the integuments extends from the root of the nose to the upper angle

FiO. 12G.-

-OuLliiie of head afttT delivery, the brow

MECUANISM OF LABOR

193

tbe large fontaneUe. The forehead is nearly perpendicular, while
the parietal and occipital hones form a elope which inclines downward
and backward. The mcnto-frontnl and sub-occi pi to-frontal diameters
are increased, while the distance between the chin and a point in the
igittal guture anterior to the oceipnt is diminished. Tliesc changes
[tipart to the head a triangnlar shape. The peculiar formation is ex-
iained by the compression of the occiput between the pelvis and the
surface of the child, and the compensatory elongation which
place in the direction of the forehead.
The prognosis is lesa favorable than in vertex pre&entationa, but ia
means so einister as is popularly supposed. Many cases of
brow presentations become converted into face or vertex pres-

K^Brow prca^c&toiu>ti, subflcquently converted loto that of Uxo fiioo,* (MutcmUj

ilosiiiUl.)

entatioDS daring the progress of labor; many are delivered spantane-
ottilj or bj the aid of the forceps. Craniotomy is rarely called for.

Aitt.7Xi.o r**Dic Entstehung Steiss- und Gosifbtslagen") fumiahea twenty*
m% raaea to whirh the result to both mother and child is j^ven. FRiTsrn (** Klioik
d«r flUtBirlioheQ gebort^hQjflicheD Opcmtionen," p. 45) gives the histories of seven
Bn>i3r (*' T^te du Foetus,'* p, 53) the history of one ease. In the thirty-
» dftlt verier there were two raati*riijil dentlm ; in one of the fatal coses ooxolgio
iilillqii0 ^Itis existed tiB a complication. In the other the brow spontaneoaslj
Awiiffil into a face presentation. There were ten apontrtocous deliveries, the
trow ])ir«t«ittin£r, irith four dead children, but one died previous to labor. Tlier^
w«% ten QASea of apontaaeouo delivery in whieh the brow during delivery be-
iOEMi eonT«rt«d into either a face or vertex pre«eQt6Uo&, Of these one child died.

• Uecortrr of both nuitlier aad child. (From drawing of A. H. Fridenberg.)
18

194

LiJ30B.

Fourteon child r€E were extracted with the forceps, nino with the brow preeent-
iog, of which two were dead, one from prolapsed tnm^ and one which hod died
before iRborj five, after cod version into face or vertex presentations, with no
deaths. Tbii», of the tiiirty-four chlldreo, there were seven deaths, but of these
four onlj eould be attributed to the presentation.

From the foregoing, it is evident that the duties of the accoucheur,
in the presence of brow presentation, should be confined to efforts to
direct the labor to a favorable termination by one of the paths indi-
cated by Nature, At the brim, previous to engagement, the dip of
the anterior fontanelle is often temporary, in many cases eiraply sig*
Bifying a narrowing in the upper conjugate. For this reason it is
evident that version, ao frequently recommended with a view to the
substitution of diameters more conformable to those of the pelvis, is
to be regarded as of questionable value. Early in labor it does not
better the prognosis, while at an advanced stage, when self -correction
is no longer probable, the dOficulties of its execution exclude it from
the list of practicable measures.

Manual attempts to convert a brow presentation into one of the
face or vertex possess more legitimate claims to favor. The method
of Baudelocque consists in seizing the head with the entire hand
introduced into the vagina, lifting it to the brim, and then drawing
the occiput downward with the fingers until flexion becomes com-
plete. The procedure was bitterly opposed by ChaiUy,* who urged
against it, in addition to the frequency of failure, the dangers of uter-
ine rupture, of prolapse of the cord, and the inconveniences arising
from the early evacuation of the amniotic fluid. There is no question
of successes by this measure, but the concurrent risks ought to limit
its employment to cases of absolute necessity. Thus* it would be proper
to make the attempt when brow presentation b complicate delivery in
Justo-minor pelvis, or in persistent mento-posterior positions, as in
these cases craniotomy is the only alternative. Complete aniesUiesta
facilitates reduction ; while elevating the head, firm counter-pressure
should be made at the fundus uteri, f

Occasionally the conversion of the brow into a vertex or face pres-
entation may be effected by pressure exerted during a pain upon re-
spectively the occipital or frontal extremity of the head. In bringing
down the vertex, the movement should he aided by external pressure
made with the disengaged hand above the brim of the pelvis. When
a face presentation is desired, the woman should be made to lie during
labor upon the side to which the child's abdomen is directed, and upon
the side to which the back is turned when the descent of the vertex is
aimed at.

* Chaillt-Hosorf., " Traitd pratique des aeeotiohcraeDta," p. 783.
t Vide Parrt, "On the Use of the Ilntid to correct Unfavorable Preflcntatioii«|" i
*♦ Am. Jour, of Obfiict.," toL viii, p. ISa

Schatz^ recommends, with the xiew to the production of a face
presentation, the introduction of two fingers into the child's mouth,
^und making traction on the superior maxilla.

When the head shows a disposition to reyert to its original position
so Boon aa pressure or traction is suspended, the forceps should be
applied^ and traction made in such a manner after reposition as to
hold the head in the direction sought for*

In case the brow presentation is irreducible, the labor should be
allowed to continue as long as compatible with the safety of the
mother. Owing to its plasticity, the head often adapts itself in the
Bost surprising manner to the unfavorable diameters of the pelvis, so
tiat, eTen when spontaneous delivery fails to take place^ the forceps be-
smes available. In mento-posterior positions, charts should be made
Nrith the fingers, or the vectis, to rotate the chin forward. In fixed
mento-posterior positions, the use of the forceps is impossible, and the
conversion of tbe brow into a face presentation does not lessen the
mechanical difficulties of delivery. The only artifice by which the
hfe of the child can be saved consists in bringing down the occiput,
and producing a vertex presentation. Failing in this mancpuvre,
^craniotomy becomes inevitable. In all cases of brow presentation, if
H|he child is dead, craniotomy is iudicated in the interest of the mother.

mo
■iha

^BcOE

Breech Pbesektations,

In breech presentations the attitude of the child is primarily
the same as in those of the vertex, though, owing to a variety of
CttOfleflv such as voluntary or refiex movements and the action of
gamtjt especially after rapture of the membranes, the extremities
mMj advance in front of the breech, and give rise secondarily to
pftfientations of the foot or knee. Sometimes one extremity may
booome prolapsed, while the other is retained in its normal position ;
flgpin^ it may happen that, after the rupture of the membranes, the
t^ which had previously been in close proximity to the breech, are

hod upward, so that the limbs become extended parallel to the
terior surface of the child's body. None of these changes, how-
ever, materially affect the mecbanism of delivery.

Pinard f found in 100,000 cases of confinement 3,301 presentations

the breech, or in the proportion of one to thirty, but, excluding
premature births, the proportion was reduced to one in sixty-two.

Causes* — The causes of breech presentations are to be sought for
toatnlj in the absence of the conditions which ordinarily determine
le prvarDtations of the hearl, or which interfere with the fixation

the fcHus, Tlius, the production of breecli presentations is favored

• Schatx, "Die Umwandlung Ton Gciichtalage «a HinterUnuptslftge/* etc., " Ardi. f.
Bjaarli^" Od. ▼, p. 928.

fiiit4
ev<

LABOR.

by an excess of amniotic fluid, by lax uterine walls, and by coTit
tions of the pelvis. They are more common in miiltiparae than
primiparap. Of the 3,301 cases collected by Pinard, there were 1,3
primiparj© and 1,954 multiparte, though the entire number was nearlj
equally divided between the two classes.* Finally, they occur witf
greatest frequency of all in twin pregnancies, and during the expu
sion of premature and dead children. Of 32,264 children from tb
statistics of Hegar and Spiegolbcrg; f ^^^ were the product of nmltipl
pregnancies, and «j50 were premature. Of the former, 227, or 25 ]
cent., and of the latter 14S, or 22*4 percent., were delivered byth
breech, though we have seen that the ratio of breech prc&eutatioa

t--

^u:i,

Wi&. 1S8. — FrcsenU^tioQ of tlie breech. Left doreo-onterior pogition. {PinanL)

to the entire number of births does not exceed the proportion of oi|
to thirty.

Diagnosis. — By external palpation the recognition of the bead ]
the fundus uteri furnishea the chief diagnostic sign. Fpon \'agiil
examination, the presenting part, as in face presentations, is usua
high up, and reached with difficulty. The bag of membranes is
to be of large size, owing to the imperfect closure of the lower uter
eegment by the small breech, often descending through the can
where the cervix is rigid, in the form of an elongated pouch. Tliroi]
the membranes, upon pressing the foetus downward during the int

Vid4 TASKiKfi Gt CuAimtnTiL, p. 4<^5.

f SriiOKLBEBOi ioe. oY., pw ItL I

MECHANISM OF LABOR. I97

val between the pains, the breech is felt as a soft, irregular body, and
with care it is possible to recognize the coccyx, the sacrum, the ilia,
and sometimes to feel tapping movements from the feet. After
rupture, the nates, the cleft between the nates, in boys the scrotum,
the anus, the feet when accessible, the coccyx, the sacrum, and the
ilia, furnish the necessary data for an exact diagnosis. The pressure
of the uterus upon the breech frequently occasions an evacuation of
meconium. The latter is thick and consistent, thereby differing from
the meconium passed in vertex cases by a dying foetus, which is
ordinarily thin from admixture of amniotic fluid. When the nates
are much swollen they may be confounded with the cheeks in a face
presentation, an error, however, easy to avoid, if the examination be
made with deliberation, and the principal points of difference between
breech and face already given {vide "Face Presentations," p. 189) are
borne in mind.

The foot, as compared with the hand, is longer and narrower, the
toes are shorter, of nearly equal length, and continuous in a straight
line with the sole, the ankle-joint is less flexible than the wrist, and is
distinguished by the malleoli and the pointed heel. As the outer bor-
der of the foot is thin and rounded, while the inner edge is thick and
hollowed, it becomes possible to recognize which of the feet is under
examination.

The knee is distinguished from the elbow by its larger size, by the
patella, and by the spine of the tibia.

The Mechanism of Breech Presentations.— The position in breech
presentations is defined by the direction of the back. Thus, we have
right and left dorsal positions. Usually the hips occupy one of the
oblique diameters of the pelvis. According, therefore, as the back is
turned anteriorly or posteriorly, we distinguish right and left dorse*
anterior and dorso-posterior positions.

The cervix dilates slowly, especially when the feet are in close
proximity to the breech, and increase the bulk of the presenting part.
The latter is pressed downward into the pelvis until the perineal floor
is reached. Here, owing to the shortness of the pubic wall, the ante-
rior hip is felt with great distinctness, while the cleft of the nates lies
near the curved sacrum. These anatomical relations give rise to the
impression of an exaggerated degree of lateral obliquity. At the peri-
nseum the breech glides forward and rotates upon its long axis, so that
the bis-iliac diameter nearly corresponds to the lower conjugate. In
the movement of rotation, it is always the anterior-lying hip, irrespec-
tive of the position of the trunk, which moves to the front. At the
outlet one hip engages beneath the arch of the pubes, the other rests
upon the coccyx and perinseum, while the sacrum is directed toward
the tuber ischii. As the shoulders enter the pelvis in an oblique
diameter, the trunk of the child becomes somewhat twisted by the

108

LABOR.

rotation of the breecb. The anterior buttock makes its appearance at
the Yulva, while the posterior distends the perinaeum. As rotation is
rarely complete, tlie forward trochanter usually finds its point of fiuj*-
porfc against the nearest ischio-pubic ramus. During the advance of
the breech, the lumbar region undergoes a certain amount of lateral
flexion, owing to the forward movement imparted to the posterior hip
bj the coccyx and elastic perinaeum. The degree of flexion is, how-
ever, limited by the rigidity of the lumbar portion of the vertebral
column. When the posterior trochanter reaches the commissure of
the vulva, the perinaeum retracts, and in gliding backward directs the
breech still farther to the front.

■f^

Fw. 189,— lUustxation showing lateral iatlcxion o! the trunk duntig dcUvery of the 1

After delivery, the breech rotates into the oblique diameter it
originally occupied, this external rotation bringing the transve:
diameter of the hips into correspondence with that of the shouldei
The uterine contractions continuing, the abdomen and base of the
thorax slowly make their appearance ; the thighs are then delivered,
and the arras, folded upon the upper portion of the thorax, emerge
from the vulva. The shoulders, which enter the pelvis in an oblique
diameter, are delivered in the conjugate, the anterior shoulder rostiij^H
beneath the pubic arch, while the posterior shoulder sweeps over t^H
perinaBum.

The head enters the pelvis in an oblique diameter, with the chin
flexed upon the thorax. The expulsive efforts as the chin reaches the
perinfieura are followed by the rotation of the occiput to the pubes, and

MECnANISM OF LABOR

of the face into the hollow of the sacrum. At the outlet the neck ia
supported by the arch of the pubes, the face rests upon the perina?iimt
and the large fontanelle is felt at the coccyx. Under the iuEoence of
pressure from the abdomen, the brow sinks deeper and deeper, and is
pushed by the soft parts of the pelric floor still closer to the thorax.
The occiput then revolves beneath the pubic arch, and the chin, the
mouth, the nose, the brow, the large fontanelle, and finally the occiput^
appear in snccesgion at the commisfiiire of the vulva.

Irregulaiitiee in the Mechanism of Breech Presentations.— Though
IS by no means rare for the breech to enter the peh^s with the
Drum turned to the sacro-iliac spichondrosis, the rotation, begun
the passage of the hips through the vulva, usually continues in
iie same direction until the back revolves to the front ; or, after a first
ight retrograde movement, the rotation forward takes place as the
boulders engage at the outlet Still, cases do sometimes occur in
rhich the back remains posterior during the whole period occupied by
expulsion of the trunk, and in which consequently the head entera
be |>elvis with the face directed to the puhes. Even here, however,
ii* very common for the occiput to eventually rotate forward, and for
iehvery to follow in the ordinary manner. Should, on the contrary,
be occiput remain in the hollow of the sacrum, spontaneous delivery
occur in either of two ways: 1. When no tractions have been
upon the extremities, the head reaches the outlet with the chin
p11 flexed, tlie neck resting upon the commissure of the vulva, and
( brow braced against the arch of the pnbes* The birth of the head is
[len accomplished, as the neck pushes hack the perin^Bum, by tlie suc-
give descent of the face, the cranial vault, and the occiput. With a
igid perinffium, or an immovable coccyx, owing to the considerable de-
grve of flexion which this movement necessitates, unaided delivery may
he rendered impossible* 2* If, during the transit of the head through
Uie pelvis, extension occurs, the chin may be arrested at or above the

trmphpis pubis. In this position pressure from above pushes back
l^brow, so that the face looks upward, and the occiput is turned to
PP bottom of the pelvic excavation. During delivery the occiput
glides orer the ixsrinseum to the fourchette, and the small fontanelle,
le cinnial vault, and the face escape in succession through the vulva.
^t h only possible for this method of delivery to take place ei>ontAne-
hf n either the head is small or the iwWis roomy, and the soft
I devoid of rigidity. In artificial extraction of the head, it is
proper to hear in mind and to imitate the natural order in expulsion.

In prefienUitfons of the foot and knee, the breech, if of small size,
may pa^^ the vulva in an oblique or transverse diameter, rotation fol-
lowing later during the passage of the trunk,

KxceAiiive rotation is not uncommon* both head and trunk some-
jmes describing a half-circle. This occurrence is most fre<iuently ob-

200

LABOR.

served in cases where the posterior extremity presents, while the ante-
rior buttock is caught above the pubic wall, the prolapsed limb then
rotating, as a rule, to the front.*

The Configuration of the FiBtus in Breech Deliveries. — ^During the
descent of the child through the genital canal, more or less swelling is
developed upon that portion of the presenting part which is subjected
to diminished pressure. This swelling varies, according to the du-
ration of labor, from a slight cedema to a large, intensely discolored
tumor. It is usually seated upon the anterior buttock, but often in-
vades the genital organs, especially the scrotum, which at birth may
present a bluish-black color, and be of double the usual size. The ex-
tremities, when near the breech, may also show signs of discoloration.
The head has usually a characteristic round shape. This is due,
according to Spicgclberg,f to the pressure exerted by the genital canal
upon the circumference of the head, while, at the same time, with the
absence of pressure from above, there is produced an increase in the

convexity of the cranial
vault. Two cases reported
by Hecker,t in which the
length of the occiput was
comparable to that found
in face presentations,
show, however, that the
original shape of the head
counts for something in
the appearances presented
after delivery.

Prognosis.— As regards
the mother, the prognosis
in uncomplicated cases
docs not differ materiaOy
from that of vertex cases.
Where manual extraction
becomes necessary, there
is always, however, increased danger of lacerating — 1. The cervix ; 2.
The perincBum.

Lacerations are apt to follow attempts to drag the after-coming
head through an imperfectly dilated cervix. The prognosis is
more favorable, therefore, in cases where the membranes do not
rupture until after dilatation is completed. It is also better in pel-
vic presentations, where the bulk of the breech is increased by the
addition of the extremities. In footling cases, when the membranes

* Vide KiJSTNER, "Die Stciss- und Fusslagcn," p. 21.

f Spieoelbero, lo€. rtV., p. 176.

t IlECKJJi, "Arch. f. Gynaek./' Bd. xi, p. 348.

130. — Showing? sliapc of head in brocch presenta-
tions. (Budin.)

MECEANlSil OF LABOR.

201

ten

Pthe

rupture prematurely, the smaner size of the pelvig and its rapid de-
nt through the eervix imperfectly prepare the way for the subse-
it passage of the liead. A stricture is, therefore, liable to form
the neck of the child, and, as the spasm docs nat yield to force,
.6 result of violent tractions is to sacrifice the integrity of the cervix,
to extent of the laceration being proportioned to the power exerted.
lacerations of the perinteum occur where with rigidity of the tis-
snofl it becomes necessary to introduce the Imnd to release the arms,
or the interest of the child demands tlie speedy delivery of the head.

The prognosis for the child is, ou the other hand, extremely unfavor-
ttWe. According to the etatistica of Dubois,* the mortality in full-
t4»rm childi-en is as one to eleven » while in vertex presentations the
portion is as one to fifty. The chief cause of this largo death-rate
the pressure to which the cord is subjected between the child and
te aurface of the utero- vaginal canal, especially after the navel appears
at the vulva. The pressure i.s exerted principally at tlie orifices of the
ttteruB and the vagina, and is i-aised to the point of greatest danger
after the head has become engaged in the pelvis. Other sources of
ril arise from prolapse of the funis and the coiling of the latter
and the body of the child, and from the complete escape of the
lotic fluid in premature rupture of the membranes,

.tment* — Eariy in labor, with the membranes intact, it is desir-
Ic, in cunsideration of the unfavorable prognosis for the child, to
and perform cephalic version by exteraal manipulations. In case
I failure to bring down the head, pains should be taken to preserve
lie membranes until dilatation is completed. To this end unneces-
exami nations should be avoided, the patient should be placed upon
ttde and cautioned not to strain, and, when the membranes tend
form an elongated poach, counter-pressure may be employed by
a moderately distended Barnes's dilator introduced into the
After rupture of the membranes it is best to remain passive.
[n the intijrest of the child, it is desirable that the expulsion of the
nk should tiike place slowly. Bringing down an extreniity, as a
rophylactic measure in order to secure a good handle in ease of sub-
nt delay, is a questionable procedure. By this niaucruvre a path
ned for tlie descent of the cord, and the mechanism of delivery is
tsiyrbccL When the hips appear at the vulva, the attending physi-
aq nhonld be ready to extract in ca^e of emergency. The patient
ttould, therefore, if lying upon the left side, be brought near the edge
i iho bed ; if upon the back^ she should be placed across the bed with
e hips well over the edge. She shonld be instnicted to bear down
uring the pains. The lateral flexion of the lumbar portion of the
nink should bt^ sustained by the hand applied to the perina*um. The
, uji it advances tli rough the vulva, should be wrapped in a warm
* Dy&oni, *'M^m. de VActtd. Roj. de MM.," vol ui, p. 4^0.

203

LABOR

clotli and raised upward. When the cord appears, it should be drawn
gently downward in tlie direction of one of the recesses to the side of
the promontory ; in case the cord passes between the thighg of the
child, it should be released by slipping it over one hip* From this
time on, the pulsations of the cord should be carefully watched, and,
in case of failing Htrength, extraction should be resorted to.

With one hand the physician now supports the body of the child
while with the other ho should make sustained and gradually increa
ing pressure upon the fundus uteri. The patient should be exhor
to strain, and bring into play all the auxiliary muscles concerned in"
expulsion, During the passage of the arms, the lateral flexion of tfae
body should be promoted by raising the hips and supporting the pen-
nauim* After the engagement of the hcad» it h desirable, if poasibli
to commit to the hands of a skilled assistant the maintenance of th
Bupra-pubic pressure. When the face reaches the coccyx, the phj
cian should raise the body of the child toward the abdomen af
niotljer. By this manoeuvre the occiput is pushed upward by the
pubic wall, and the chin brought forward to the vulva. The deliver
of the heatl is then speedily accomplished by pressing tlie forehea
forward with two fingers applied to the perinteum in front of the i
cyx, or introduced into the rectum. By then keeping the head flexe
lacerations of the perinfeum are best avoided.

AVhen the occiput is turned posteriorly, the body should be rah
if the chin is arrested at the symphysis, and depressed when flexion
complete.

CHAPTER XL

CONDUCT OF NOHMAL LABOR

PreUrainary preparations. — Examination of th© patient. — MaDagcmcnt of the first steg
— Management of tUe second ata^, — Pre94?rvation of the perinseuro. — Delivery of 1
Blioulders, — Tying the cord, — Third or placental utage. — Care of patient after delii^
ery. — Treatment of perineal lacerations. — Aofosthetica in midwifery.

It 19 hardly an exaggeration to state that the greater proportion of
the sins of midwifery practice are comTnitted in the management
norma 1 labors. It ia equally easy to full into errors of comniissicin ai
errors of omission. It is as necessary to know when to abstain as
when to interfere. It is an old but always good rule, not to meddle
with the physiological performance of a function ; but the rule* when
applied to obstetrics, presupposes a thorough familiarity with the
phys^iologieal processes of childbirth, and the contingencies to whicfc
women in parturitton are exposed. There is no sen^e in reposing
blind, uni'easoning confidence in the powers of Nature, Indeed, legil

CONDUCT OF NORMAL LABOR

203

imaie groands for interference arc liable to arise in the simplest
laboiB* The attitude of the medical attendant should be one of watch-
ful expectancy. He should be ready, if needful, to assuage pain, to
I fareet-all dangers, and to limit the duration of suffering,
H Preliminary Preparations. — When summooed to a patient, the pby-
^hiciau should go armed to meet the sudden emergencies of obstetrical
H^raetice. His armamentarium should include a silver catheter, an
^English catheter of small size for use in asphyxia of the new-born
^^child, a pair of forceps, needles and needle-holder, and silk or wire for
BiuiureSy a Daindson syringe, with long nozzle for uterine injections,
BSuid an hypodermic 6)Tinge. lie ehould go provided with chloroform,
VlEagetidie'8 solution of morphia, ergot, the perchloride or persulphate
of iron, and a small vial of sulphuric ether. At the house, ice, brandy,
and hot and cold water, should be had in readiness.

As it is not uncommon for women, especially among the poorer
^hclasses, to test the experience of young physicians by asking details
^Melative to tlic arrangement of the bed upon which the confinement is
^■to take place, it is trusted that a few words upon the subject will not
'1)6 regarded as entirely superfluous.

The bedstead should not be too low. If against the wall, it should
be moved out, so as to allow easy access from both sides." The bedding
fihould consist of a hair mattress or of a straw palliasse. Feather-lieda
are an abomination. Over that portion of the mattress upon which
the woman exi^ecU to lie, a rubber cloth, or other imiwrvious material,
ihonUi be spread. Next to the water-proof, nurses usually lay a folded
woolen comforter or blanket to absorb the fluid discharges. Tlie whole
then covered smoothly with a sheet, and a second sheet, fuldod in
everal thicknesses, is laid beneath the hips of the patient. All these
|>reparations are designed to limit the soiling of the bedding to a cir-
ptimscribed space* and to facilitate the removal of the discharges after
termination of the delivery.

Examioation ot the Patient.— The first duty w^hich devolves upon
be phvs^ician in the lying-in chamber is to examine his patient, and to
Inform the family if **'all ia right *' — i. e., whether the bead presents,
and no unusual obstacle to delivery exists. It ia a good plan to em-
ploy external palpation in every ease where no opposition is made, as,
^ven where the diagnosis by ordinary vaginal exploration is clear and
putublct no opportunity should be lost to jierlect one's self in
ing out the foetus through the abdominal and uterine walls,
riie ability not only to recognize the presenting part, but the position
f entire fa^tus in the uterine cavity, is, in many cases of difficult
r, a passeesiou of priceless value. During the manipulation of the
abdomen, fetal movements should be carefully noted* If absent, aus-
■ eultjttion should be practiced to ascertain whether the child is still
lif^ The internal examination shgukl take cognizance of the condi*

S04

LABOR,

tion of the Tulva and perinaBam, the state of the reotiim and bladder,
the length of the vagina, the degree of dilatation and softening of the
cervix, the amount of cervical and vaginal secretion, the hardness of
the chiUfs head* and, if the membranes are not ruptured, the qiianti
of amniotic fluid. It is customary to begin the examination during an
interval between the pains, but it is often convenient to continue the
investigation during the pains, in order to judge of their efficacy and
character.

The history of tlie case should embrace the length of prenoi
labors, the health during pregnancy, the number of times the womj
has been pregnant, and whether in the present instance she has ad-
vanced to full time. Inquiries should bo made as to when the laboi
pains commenced, as to their frequency and situation^ and if tl
membranes have ruptured.

After the examination of the patient is ended, the pliysician is et«
pected to express an opinion m to the probable duration of the labor.
It is, however, necessary for the responses upon this point to be
guarded and Delphic* In general terms, when the pelvis is normal,
the head well flexed, the vagina short, and the cervix and perinffiui
are dilatable, an easy and rapid labor is to be anticipated ; while»
contra^ with a small pelvis, tardy flexion, a long vagina, and rigid
of the uterine and perineal orifices, a tedious period of waiting is to
assumed. Of course, too, labor is, as a rule, much longer in prirai-
|>ar^ than in women who liave previously borne children. Moreover,
with few exceptions, the result depends in a special degree upon the
energy and persistence of the jiains, Tlie latter, liowever, repreeent
always the uncertain element in the calculation. If the pains a:
good, therefore, the reservation should be made that, for a short laboi
they rau8t continue as at the beginning; while, if weak and powerle^
it should be stated that better pains will be needed to bring the
to a speedy conclusion.

Makagemext of the Fibst Stage of Labor.

The duties of the physician during the first stage of labor are,
normal cases, extremely simple, lie should from time to time, say j
hourly intervals, repeat the examination, with a \iew to inform hit
self of the progress of dilatation* He should caution his patient
pass her urine frequently. In case of retention, he shonld draw
water with a catheter. When the head is low down, the urethra of
follows its convexity. The introduction of the straight female cath€
ter may then be extremely diflicult. Many re*eommend in such cas
a silver male catheter to which a suitable curve has been given. I na
by preference the English flexible catheter, which is passed easily, pr
vided the end is guided by the index-finger, through the anterior va
nal wall, to the point of contact between the head and the sj-mpbya;

aai,

CONDUCT OF NORMAL LABOR

205

pubis. A flattening of the tube by pressure tb an extent causing
'obliteration h not likely to take placo unless the catheter be smaU ur
has become over-pliable from long use.

If, at the time of examination, the rectum is found clogged ^ith
faeces, an enema should be ordered. A disposition on the part of the
it to bear down during the first stage of labor elumld be di^
gd, as wasting her strength without possessing any counter-
licing utility* The patient should be encouraged not to take to
. at the outset of labor. In the upright or sitting posture, gravity
'aids the fixation of the hea^ and promoters dilatation.
I As the end of the lirst stage approaches, however^ the woman

^kiould undress and lie down* as the pains, after rupture, as a rule^
^BoUow one another with rapidity, and make locomotion difficulty To
HmToid soiling, the night-dress should be drawn well up under the arms.
Tidy nurses pin a folded sheet around the hips of their patients to
arrest tlie soaking of fluids upwards

Bapture of the membranes is, as a rule, a gjiontaneoug act. Yet

ftfUiti enough something may be done in the way of shortening labor,

IJimcturing the membranes so soon as cenical dilatation is com-

Thoy have then fulfilled their physiological mission, and their

^miatence simply retards the advance of the child's liead* Artificial

iitpifure is ea.'^ily effected by means of a straightened hairpin, passed

|ii the groove between the index and middle lingers of the examining

to the amniotic pouch. The puncture should be made during a

at a time when the membranes are tense and separated from the

Bed|> by a deep layer of fluid.

MANACfEMENT OF THE SeCOKD StAOE OF LaBOR.

he management of the second stage of labor calls for considerable
Bt on the part of the medical attendant. It is incumbent ui>on him
make frequent examinations, to determine the degree of rapidity
which the descent of the head takes place. So long as the ad-
is regular, he should abstain from interference. Should the
pains slacken, however, lie should not allow the dumtion of the second
glage to exceed the physiological limits. It is not easy to define ex-
^aeUy what is implied in the expres^^ion "physiological limits." As a
^hnli^^ a very rapid second stage is not physiological, as it endangers the
^Hntc^rity of tbe vagina and {lerinjeiim, and predisposes to post-parium
^Ka'tiiorrluige. Still, now and then labor is ended by a single pain af l^r
^^ rupture of the membranes^ without detriment to the mother. Of
jotmrsef s^uch cases are extremely uncommon in primiparae. They re-
|uire an unusually distensible condition of the soft parts, and an ex-
flinary degree of resiliency in the ntenis. On the other hand,
xm of the head, after its descent into the pelvic cavity, leads, if
\ continued, to pathological changes in the tUsues of the canal

206

LABOR.

and of the outlet It is usual, therefor6» unless the head is small or
t!ie pelvis roomy, to use the resources of art to terminate labor when
the head remains stationary at the perineal floor after two hours of
effort. It is desirable, therefore, when the pains are weak and ineffec-
tive, to utilize all the simple adjuvants which experience has shown to
possess real efficacy in increasing the acti\ity of labor.

Changes of posture increase tlie power of the pains temporarily*
When head-flexion is incomplete, it has been recommended to place
the patient upon the side toward which the occiput is turned. Others,
again, claim that the descent of the occiput is best effected by plac-
ing the mother upon the side toward which the chides forehead is
directed. In point of fact, either posture frequently leads to the
desired result, simply because the change from the dorsal to the
lateral position is apt to be followed by a temporary addition to the
uterine force. ^

In many women, owing to defective innervation, or to insufficient
development of the muscular structures of the uterus, it is of great
moment that the expulsion of the child be aided by the voluntary
pressure of the abdominal walls. To be sure, in most cases, the reflex
impulse to bear down is imperative ; but in others, where the impulse
is feeble or held in abeyance by the dread of the patient lest she in
crease her gufferings, it becomes the duty of the physiciau, in
labors, to see to it that all the auxiliary forces are brought into plaj
To this end he should instruct his patient to fix her pelvis, either
pressing her feet against the foot-board of the bed, or by drawing i
her knees and resting tliera against an assistant, who assumes the \m
tion best adapted to furnish the requisite support. Then the nt
or other suitable person, should grasp the woman *s hands, so
enable her to fix her thorax and to bring all the expiratory muscli
into full exercise. Often, when the agony is intense, the patiefl
can be induced to strain with her pains, if her sufferings are fir
dulled by small doses of chloroform* When the head is on the per
mrum, the physician may further expulsion by rubbing the abdomen
to excite pains, and by pressing upon the breech through the fun-
dus.

During the second stage the patient's posture should be left in
general to her own volition. The physician should accustom himself
to conduct labor with equal facility, no matter whether the w^oman
lies upon her side or upon her back. j[The left lateral position, affected
by English accoucheurs, is very convenient at the time of delivery,
especially when there is occasion to support the perin«eum, and whcre^
owing to the flatness of the nates, the vulva is scarcely raised
dorsal posture above the level of the bedding.

♦ Lahs, *'Dio Thcoiic der Oeburts.," Bonn, 181% p. Ul.

CONDUCT OF NOBMAL LABOR.

207

The PRESEEVATION OF THE PERIN^UM*

By far the most delicate task whicli the physician has to fulfill
toward his patient in the expulsion stage consists in so regulatiDg the
exit of the child's head as best to avoid perineal lacerations. It is
needless to state that such lacerations, unless of slight extent, entail
upon women a variable degree of subsequent discomfort and suffering.
When the perincBum is examined with care after labor, a practice which

Iehonld be invariable with a conscientious attendant, the frequent oc-
enrrence of more or less extensive rupture of its tissues is a matter of
posy contirmation. Statistics of their frequency are of little value,
much depending upon individual skill in management Olshausen*
Imports, as the result of the preventive measures adopted at the clinic
En Halle, during a period of ten years, 21*1 per cent of perineal in-
juries in primiparie and 4*7 per cent in muUipane, These percent*
ages did not include slight tears conllned to the f rfenulum. He regards
16 per cent, as hot too high an estimate for the absolutely unavoidable
lacerations, due to defective distenaihility of the perinaeum, and to the
disproportionate size of the child*s head.

The aim of prophylactic measures should he to develop the elas-

cJty of the soft parts to the fullest practicable extent, and to cause the

lead to pass through the disteoded orifice of the vulva by its smallest

iameters. Preliminary softening of the perinajum is best accomplished

>r the continuous but not too rapid descent of the presenting part.

be relaxation^ as a rule, begins earlier and is more complete in mul-

ipar^ than in primiparae. In a few cases the soft parts will already

lave ceased, by the end of the first stage of labor, to offer any effec-

ve harrier to delivery. The distensibility of the soft part^ may be

fairly inferred from the presence of a copious discharge of glairy mucus.

When rupture takes place, the vaginal mucous membrane is the

firel structure to give way. In the ordinary form, the perineal body

llStn fixmi tlie commissure backward to the rectum. In rare cases, a

emtml perforation may result, and tlie child be expelled through a

rent situated between the vulva apd the anus.

When the head l>egina to make the perinfeum bulge, the physician
abould be on the alert, and inform himself during eacli conlraction of
the strain to which the parts arc subject-ed. At first it is only neces-
sary to rest the hand lightly upon the perina?um. Direct pressure is
to be avoided, except when the perina?iim is stretched to a membranous
tbipiaeas, and the diinger of central perforation threatens. As the head
beg:]iis to distend the vulva, the tension at tlie fraenulum should be
fully gauged by a finger introduced between the labia. Measures
avert rupture may be classified under three headings, viz.:

• OuauvmXt ** UclMsr Dammvcrletzuog und Damtnschutt," Volkiawin^s " Sttmml. klin.
Toitr.,**Ko.il, p. 80O.

LAIQJL

1. Those designed to check the exit of the head before the fullest
ex])ansiou has becm secured, and to prevent expulsion daring the acme
of a pain, when the borders of the orifice are most rigid.

2. Measures which impart an upward movement to the head, with
a view of making all unoccupied space beneath the arch of the pubei
available.

3. Measures which favor exjiulsion during the interval between the
pains, or at ieasl^ after the acme has subsided.

In ordinary cases Hohl's method, recommended by Olshausen,* has
rendered me excellent service. It consists in applying the suppiirt,
not to the perinaeum, but to the presenting part. To this end the
thumb should be applied anteriorly to the occiput, and the indei and
middle fingers posteriorly upon that portion of the head which lies
nearest to the commissure. The unconstrained position of the hand
enables the operator to exercise effective pressure in the direction of
the vagina^ while the posterior fingers favor the rotation of the head
under the pubic arch. The patient should at the same time be directed
not to hold her breath during the pains, except when they are weak
and powerless. Where the impulse to bear down is irrcsistible, chlo-
roform should bo given to annul the excessive reflex irritability.
Under the mo^t gkillfiil management, hiceration is liable to occur,
unless the physician is able to control the action of the auxiliary ex-
pulsive forces.

8o soon as the bi-parietal diameter passes the tense border of the
vulva, the perinieum retracts rapidly over the face, and the expnlsion
of the head is completed. It is during this period that laceration is
most apt to occur* This danger is, however, greatly lessened if the
heiid ia made to issue through the orifice after the pain bus subsided,
and when the soft parts are in a relaxed and dilatable condition* To
accomplish this, in many instances where the resistance to be over-
come is slight, it is sufficient for the woman to hold her breath during
an interval between the pains, and voluntarily call into play all the
muscles of expiration. In the larger proportion of cases, however,
these efforts are futile, because of the comparatively feeble motor-force
brought into action.

An excellent method of manual delivery w© owe to Ritgen,t which
consists in lifting the head upward and forward through the mlva,
between the pains, by pressure made with the tips of the fingers
upon the perimeum behind the anus, close to the extremity of the
coccyx. Of course, the method is only available after the head has
descended sufiiciently for the pressure to be exerted upon the fronted
region.

* OLsnArsEN, loe. «V,, p. 366.

t Olsuausen, *' Ucbcr Dammvcrlctzung mid DaramschutK," Volkmaim's " Sammlimg^**
No. 41. p. S6d.

CONDUCT OF NORMAL LABOR. 209

Rectal expression has lately found warm advocates in Olshausen*
and Ahlfeld^t The manoenyre consists in passing two fingers into the
rectum toward the close of the second stage of labor, and hooking
them into the mouth or under the chin of the child through the thin
recto-Taginal septum. By pressing the face forward and upward, the
normal rotation of the head beneath the pubic arch can be effected,
and delivery can be accomplished between the pains at the will of the
operator.

When rupture is felt to be imminent, mock-modesty should be dis-
carded, and the parts imperiled should be unhesitatingly exposed to
view. If, owing to its excessive elasticity, the occiput, in place of
being directed forward to the vulva by the perinaeum, distends the
latter so that central perforation threatens, the hand should be applied
in such a way as to give direct support to the stretched tissues and to
guide the bead upward to the outlet. If, on the other hand, the
danger arises from defective elasticity, the physician, standing to the
right of the patient, with his face toward the foot of the bed, should
puB the left hand between her thighs and press the head upward and
inward, during each pain, with the thumb and*two fingers, as previ-
ously described. At the same time, the movement of extension, should
it threaten danger to the parts, should be hindered by pressing back-
ward upon the frontal region, through the perinaeum, with the disen-
gaged hand.

Dr. Goodell X recommends hooking two fingers into the anus, and
drawing the perinsBum forward during a pain, to remove the strain
from the thinned border of the vulva, and to promote the elasticity of
the tissues.

Fasbender* places the patient upon the left side ; then, standing
behind her, he seizes the head between the index and middle fingers of
the right hand, applied to the occiput, and the thumb thrust as far
into the rectum as possible. By this manoeuvre the head is held under
complete control, the rectal wall hardly affecting the grip in any ap-
preciable manner. During a pain the progression and extension of
the head are readily prevented. During the interval between the
pains, by pressure with the thumb through the rectum and the poste-
rior portion of the perinaeum, the head can be pressed forward and out-
ward at the will of the operator.

Between pains, I have been in the habit, in cases of rigidity, of
alternately drawing the chin downward through the rectum until the
head distends the perinaeum, and then allowing it to recede. It is as-

* See Ahlpeld, " Da« Dammschutz Vcrfahren nach Ritgen," " Arch. f. Gynack.," vi,
p. 279.

f Loc. at.

X GooDiLL, "Am. .Tour, of the Mod. Sci.," January, 1871.

• Fasben'der, " Ztschr. f. Geburtsh. und Gynack.," Bd. ii, H. 1, p. 68.

210

LABOR,

toniehing how offcen apparently the most obstinate resistanoe can be
overcome by the simple repetition of this to-and-fro movement, the
part^ rapidly becoming soft and distensible. Of course, it should be
diecontiDned the moment contraction begins, and care should be taken
to effect delivery after uterine action has subsided.

With judicious management the nnmberof unavoidable laceratiatui
can he restricted to a small proportion of cases. Still there are indi-
vidual peculiaritioa which will now and then render abortive the best
prophylactic measures* In this category I have already alluded to a
primitive lack of development of the maternal parts, to unusual size
of the child*s head, and to the excessive rigidity of the perinaeam in
primipane, esfiecially after the thirtieth year. In addition, should be
mentioned cases where the pubic arch is diminished by the approxi-
mation of the pubic rami, or where the tissues have been rendered
friable from chronic osdema, from a varicose condition of the veins,
from condylomata, from syphilitic sores, or from inflammatory infil-
tration consequent upon undue prolongation of the second stage of
!abor» Lticerations are more frequent in oceipi to- posterior positions,
and in the delivery of the after-coming head, where hasty extraction
is demanded in the interest of the child.

When, in the judgment of the physician, rupture of the perinseam
seems inevitable, he is justified in making lateral incisions through the
vulva to relieve the strain upon the recto-vaginal septum. To this
operation the term episiotomy is applied. By it not only is the danger
of deep laceration through the sphincter ani prevented, but, owing to
their eligible position, the wounds themselves are capable of closing spon-
taneously ; whereas, when laceration follows the raph§, the retraction of
the tranaversi perintei muscles causes a gaping to take place which inter-
feres with immediate union. As, however, every wounded surface is a
source of danger in childbed, episiotomy should never be performed
60 long as hope exists of otherwise preserving the perineum. It is
essentially the operation of young practitioners* the occasions for its
employment diminishing in frequency with increasing experience.
The chief resistance encountered by the head is not at the thin border
of the vulva, but is furnished by a narrow ring situated half an inch
above, and composed of the constrictor cunni, the transversi perinaei,
and sometimes of the levator ani muscles. Incisions should be made
during a pain, when the ring becomes tense and rigid, and is easily
recognized with the finger. As it is not desirable that the head should
be driven suddenly through the vulva during the act of operating, the
time selected for performing episiotomy should be at the commence-
ment or close of a contraction. The division of the rigid fibers may
be accomplished by means of a blunt-pointed bistoury, or a pair of
angular scissors. So far as practicable, the incisions should be con-
fmed to the va^na, and should not exceed three quarters of an inch

CONDUCT OF NORMAL LABOR,

in length. In cases where the head is on the eve of expulsion, the
bistoury may be introduced flat between it and the vagina, half an inch
miteTior to the commissure, and the section made from within outward.
Care, however, should be taken at the same time to avoid severing the
external skin, by drawing it as far hack as possible,* In central per-
foration it is best to divide the band left attached to the vulva, as its
preserratioB ia of no advantage.

The Delivery of the Shoulders. — After the expulsion of the head,
mucus should be wiped from the mouth and nose» and cleared from
the throat with the finger should laryngeal rdUs indicate an embar-
r&sament of the respiration. If the cord is found coiled around the
neck, it should be loosened by drawing upon the placental end until
the shoulders can pass readily through the loop. Should this be found
impossible, either because the cord is unusually short, or because it is
wound several times around the body, a ligature should be applied,
the cord should be cut between the ligature and the placenta, and de*
livery should be hastened by manual efforts.!

In the majority of cases the shoulders are expelled spontaneously.
Still, it IS a good plan to expedite the descent by pressure made with

' the left hand at the fundus of the uterus. Care must be taken lest

[ the lower shoulder convert a slight tear in the perinaeum into an ex-
ive laceration. The right hand should therefore be applied to the
aaBum in such 9. way as to lift the shoulder upward, and at the same
time furnish a bridge over which it can glide in its movement forward.
Sometimes after the passage of the head a deep vaginal laceration co-

lexifits with an intact condition of the external parts. The shoulder
then tears through the skin, and a complete rupture ensues. Olshau-

' ten recommends, in cases where rupture is imminent, to turn the shoul-
ders so that they clear the vulva in an oblique or transverse diameter.
II, after birth of the head, the child does not breathe, and asphyxia

lihfeatens, the physician should rub the uterus with the hand through

I the abdominal wall, to excite a pain, during which he should urge the
ptttieni to press down, and thus aid expulsion. The most common
hindrance to delivery consists in an arrest of the upper shoulder be-
neath the pubes. Usually its release is readily effected by seizing the
sides of the head with the two hands and drawing directly downward,

[ It ifl rarely neooesary to raise the head subsequently, or to hook the
finger into the armpit to extract the posterior shoulder.

Tying: the Cord. — When the cord is torn across, as sometimes hap-

Ipeoa in street-births, no haemorrhage takes place from the lacerated
Of course, this occurrence deprives the physician of the

' OLSRAtim, loc, tit., pp. 373, 87$,

\ Taiuiicii recomniends dividing the cord, and then compressing Che pFoxifnal end be-
I the tfaiaiDb md the index -fingvjr. Tho proiiioikl end Ls dktingnbhcd bj the flpont-
E «C fbt two ombiliG&l artcrjea.

212

LABOR.

power of clioosmg the point at which the division shall be made. As
it is desirable, for the sake of convenience, to fcnever the cord about two
inches from the navel, it is the custom in all civilized countries to cut ^
it with scissors, and to prevent htemorrhage by tlie application of
Hgature, Almost any material may be employed for tlie latt-er purpos€
though nothing is so handy as the narrow flat bobbin which mostj
nurses keep in readiness. The ligature should be applied tightly, and
the cut surface should subsequently bo examined once or twice by tbe^
physician before leaving, to make sure that the arteries are suffi-
ciently compressed to prevent oozing from taking place. The cord
should be held in the hollow of the hand at the time of its dividon,
to avoid the possibility of including accidentally any portion of the
child between the blades of the scissors. Commonly two ligatoiea
are applied, and the cord is severed between them, though the ques-
tion of one or two ligatures is, except in twin pregnancies, of trifling
importance.

In practice it is very desirable that the physician should understand^
the physiological difference between the effects of the early and the
of the late application of the ligature. The custom, as regards tbtl
point, has been by no means uniform. The ancients deferred the lig^J
turc until after the expulsion of the placenta. Mauriceau, Clement
and Deventer followed the same plan, but employed artificial ei
dients to comj^lete the third stage of labor rapidly.* The eommoD
practice at the present day is to tie the cord immediately after the
birth of the cliikL Still, there have not been wanting in recenl(
times warning voices against precipitate action, Nagele advised wait
ing until the pulsation of the cord had ceased ; Braun f first descril
the changes from the fetal to the post-natal circulation, and then says s
" This stupendous process should be taken into considemtion in tli0
treatment of every case of labor, and because of it the cowl should
never he severed or tied so long as pronounced pulsations can be fel|
near the navel.'' Stoltz| noticed that, ** after the child has rospir
well, division of the cord is followed by an insignificant loss of bloody
while, after immediate sectioUt blood escapes in abundance.'*

In 1875 Budin, at that time interne at the Mafceraite of Paria
undertook the following experiments at the suggestion of Professoi
Tarnier : In one series, the cord was tied immediately after the birth
of the child, and the blood which escaped from the placental extrem^
ity was measured ; in the other, the quantity of blood was determine
in cases where the cord was not tied until several minutes after de
livery. By a comparison of the results thus obtained, he found tha

* BiTDiN, " A quel motnent doit-on op^ror la Ugature du cortkm ombiUonl ? *' *' Public
cationa du ' Prop;Tfea Medtcal \" 1876,

f Bradn, *'Le.hrbuch der Geburtshiilfc," p. 192.

J Stoltz, art, " Accouche meat nuturcl," ** Nouvcau Dictlonnolre/^ p* 288.

OOKDCCT OF NORMAL r^BOR.

213

the average amount of placental blood was three ounces greater in
the first than in the second series of experiments.^ Welcker estimated
the entire quantity of the blood in the infant at one nineteenth the
reight of the body, which would amount, in a child of seven pounds,
to BIX ounces. To tie the cord immediately after birth would there-
fore be equivalent to robbing the child of three ounces of blood which
would otherwise pass into its cireulatiom This startling result has in
Uie main been abundantly confirmed by subsequent observers. Two
years later (1877), Schucking, extending Budin's experiments by
weighing the child at birth, and tlieu observing the changes that took
place up to the time of the cessation of the placental circulation, found
I that the child gained from one to three ounces in weight by delay. It
rtain that these amounts do not represent the entire increase, aa a
ion necessarily escapes observation in the interval that must elapse
before the weight can be ascertained.

There is a difference of opinion as to the mechanism by which the
transfer of the blood from the placenta to the child takes place. Ac-
cording to Budin, the principal factor in the accomplishment of the
result is thoracic aspiration. With the first breath, the afflux of blood
^ the lungs develops a " negative pressure " in the vessels of the larger
circulation, so that a suction force is exerted upon the placental blood,
which continues until the equilibrium is restored. To tie the cord
Iprematurely, therefore, is to cut off from the child a supply of blood
for which the establishment of the pulmonary circulation had created
a physiological need.

Bchuckingtf on the contrary, maintains that, after the first inspira-
thoracic expansion cea^ies to operate as an active force^ and that
[the main agent which drives the blood from the placenta through the
[ttmbilicAl vein is the compresKion exerted by the retracvtion, and, at
intervals, by the contractions of the uterus.

The diiference in the theoretical standpoint of these two observers
yf il importance, for, if the movement of blood to the child

I thoracic aspiration, the quantity which enters its circula-
tion will not exceed its requirements ; while, if the movement is due
'i0 uterine compression, the question arises as to whether the forcible
truirfasion thus accomplished is compatible with the child's safety
ud welfare. The ultimate decision will depend partly upon experi*
mental and partly upon clinical observations. Provisionally, the caae
fltotids as follows : The manomctric obse^'vations of Ribemontt show
that the pressure in the umbiliciil arteries is uniformly greater than that

* Iliniur« S&e. dij.

f Boit&ciu»o, *' Znr Physiologie dcr Nachgcburtsperiode,*' " Deri, kiln, Wocb,/' Kos.
mil % 1M7.
t Hiainoifr, ** Reehetob^ tur la tension du sung dam lea TUMetux du foetus et da
4," •* Arch, do ToooU" October, 187»»

214

LABOR

in the umbilical vein ; during a eeriGs of deep inspirations and cxpi-
rationsj the blood in the umbilical vein is subject to marked oscilla-
tions ; after the pulsations of the cord have ceased, the uterine con-
tractions alone are insufficient to propel the placental blood through
the umbilical vein to the infant. Again, Budin (discussion upon
Ribemont*s paper), in a breech-delivery, compressed the cord at the
vulva as far as possible from the navel ; at birth, the vein was dis-
tended with blood, but with the first inspiration it was instantlj^
emptied* Thoracic aspiration does, therefore, exist as an opemti^
force. On the other hand, Schucking found that when the placenta*
was rapidly expelled by Crede's method, so as to remove it from the
influence of uterine retraction, the pressure in the vein was sligbtl]
lessened, and the total amount of blood transferred to the infant
greatly restricted.

According to the clinical observations of Budin, Ribemont, and
Schucking, infants which have had the benefit of late ligation of tha^
cord are red, vigorous, and active, whereas those in which the cor
is tied early are apt to be pale and apathetic. Hofmeier,* Rib6mont
Budin, and Zweifel f have shown that the loss of weight which occur
in the first few days following confinement is less in amount and (
shorter duration when the cord is not tied until after the pulsatiooB^
have ceased.

There appear to be no harmful results to the child, growing out of
the practice of late hgation. Porak, indeed, reports two cases of dark
vomiting, two of melaena, and two with sanguineous discharges from
the vagina, which he is convinced wore the result of the practice ; but
the extensive trial to which it has since been subjected in the principal
lying-in institutions of the Continent have sufficiently demonstrated
that it is exempt from danger.

In late ligation^^ the amount of blood retained in the placenta and
the increase in the weight of the child differ materially in different
casesyj a difference which seems to indicate that, so long as the plaoea-j
tal circulation is left undisturbed, the amount of blood passing to thf
child will be meai?ured by its needs. In a case of Illing's,'^ on th©"
other hand, after the placenta had been expressed from the uterus, its
contents and that of the cord were forcibly squeezed into the circula-
tion of the child, and death followed from over-distent ion of the heart.
Forak and Georg Violet | claim that there is a special predisposition

• "Der Zeitptinkt dcr Abnabolung," etc, "Ztachr. f. Geburtsh. u. Gynaek./* Iv, 1, p.
114.

+ ZwEmcL, '* Centralbl. f Gjnaek.," No. 1.

% See WiENiR, *' UeWr die Einflusa der Ahnabelun^ieit auf den Bltitgehall do
Pkcenta,** •- ArcK f. Gynnek," lir, 1, p. 84; also, MgYER, *'CentralbU f. GjnaclL,"
lSt8, No. 10. ^ ** Inaug. Diss.," Kid, 1877.

I Gitono Violet, " Ueber die Gelbaucht der NeugeboreneD uad die Zcit der Abiiabe-_
lungi" ViBcaow'a "Archi?,*' Ixix, 2, p. 3G8«

CONDUCT OF NORMAL LABOB,

315

to ictems in cbUdren when the cord is tied after the placental circula-
tion has ceased. Violet attributes the di&coloration, not to bile-pig-
nienty but to a rapid disintegration of the excess of blood-corpusclea,
jHeloty he says, found, ou tlie tirst day after the birth, a difference of
fume hundred thousand corpuscles to the cubic millimetre between
cases of late and those of early ligation, while on the ninth day the
difference fell to three hundred thousand. Others have failed to
uatiee any characteristic icteric discoloration peculiar to late ligation.
iKeither Porak nor Violet attaches any pathological significance to the
symptom.

The outcome of the foregoing observations may fairly be stated as
follows :

1. The cord should not be tied until the child has breathed vigor-
ously a few times. When there is no occasion for haste arising out of

I the condition of the mother, it is safer to wait until the pulsations of
* the cord have ceased altogether.

2. Late ligation is not dangerous to the child. From the excess of
I blood contained in the fetal portion of the placenta, the child receives
rinto its system only the amount requisite to supply the needs created

by the opening up of the pulmonary circulation,

3. Until further observations have been made, the practice of em-
[ploTing uterine expression previous to tying the cord is questionable.

4. In children bom pale and anaemic, suffering at birth from syn-
cope, late ligation furnishes an invaluable means of restoring the equi-
librium of the fetal circulation.

Kakagement of the Third ob Placental Stagb of Labor.

The duties of the physician in the third stage arc to guard against

arrhage^ to promote uterine contractions, and to further the ex-

bon of the placenta. These objects are best fulfilled by manipula-

Ftioius through the abdominal walla. Tractions upon the cord should

riiot be re-sorted to before the placenta begins its descent into the

, Tugina. The method, at present in vogue, of expressing the placenta

by neizing the uterus through the abdominal coveringB, is associated

iodiiKtluhly with the name of Crede, for, though the value of friction,

: kneading, and compression, was appreciated, as their writings show,

Mtturiceau, Robert Wallace Johnson, Joseph Clarke, Busch, Mayen

nd otijers,* it remained for Cred6 to elevate placenta! expression to

Ifae rank of a recognized procedure of obstetric practice.

Credo's method consists essentially in applying at first light and
afterward stronger friction to the fuudus of the uterus until an ener-
getic contraction is obtained ; at its height the utt*rua is grasped so
lltat the fnndus rests in the palm of the hand, with the fingers to the

* Ibr libtoHcftI refcr«fi«e«, vidt Riol, '^D^UvraacQ par ezpreuioii,** G. lU0Olt|
IMQ; McjtJii, ""Obdlotrio Pupation/' p, lOS.

216

LABOR.

front. The exercise of circular compression forces the placenta from
the uterus, or in case of failure the process may be repeated until the
object is iiccomplished. It is true that the expulsion of tlie placenta
will, as a rule, occur spontaneously. The unaided uterus is, how-
ever, liable to relax, and become the source of hasmorrhage ; or, where
the delivery does not take place speedily, it may, on the other hand,
close down, so as to imprison the placenta within its cavity* The gn^at
merit of Credo's method is, that by maintaining retraction it prevents
haemorrhage, and by promoting speedy expulsion it guards against
the dangers of retention.* When systematically practiced, the bug-
bear known as adherent placenta is the rarest of accidents. The prac-
tice is not difficult, and is devoid of danger. To be successful, how-
ever, expression should be practiced only during a contraction, and the
propulsive force should be directed from the fundus downward in the
axis of the ut4*ru8. Spiegelberg f lays great stress on exercising com-
pression of the uterus from the moment the head emerges from the
vulva, and not waiting until the delivery of the child is ended. By
so doing, general contractions are maintained, and the detachment of
the placenta promoted.

The evidence of the expulsion of the placenta is furnished to the
operator by his feeling the anterior and posterior uterine walls in con-
tact with one another. By then pressing
the uterus downward in the axis of the
brim, it is often possible to drive the pla-
centa into the vagina and through the
vulva. There is no objection, however*
at this stage, to expediting delivery by
drawing upon the cord downward and
backward, while at the same time the
ut^^rine pressure is maintained. The ex-
traction of the placenta should take place
slowly, to avoid tearing the mem bran ei^
As the placenta passes the yulvs it should
be made to revolve so as to twist the mem-
branes into a cord, which should be with-
drawn with the utmost care* If the mem-
branes are felt to give way at any point.
the fingers should be introduced, if neces-
sary, into the vagina to seize them abiive
the site of the laceration, and the re-
moval should be ])roceeded with by gen-
tle manipulations.
When the mechanism of pliu^ental delivery is not interfered with
by premature tractions upon the cord, the placenta descends edgewise
• RtOL, he, d/., p, 34, f SFreoKLBKttG, " Lehrbticb,'' p. 191

^x*a:.^';<.

''K

^^* ^>

Fto. 131.— >Showm£^f the cfTcot of
proniflturii tmction» upon Oio

cord.

CONDUCT OF NORMAL LABOR.

21T

ibrough Uie cervix, and its expulsion is effected with the loss of but
a trifling amount of blood** Wlien extraction, on the contrary, is at-
I tempted previous to descent by pulling upon
^Bfthe oerdy the central portion of tlic placenta
^Bb dragged into the cervix, while the bor-
^PUers are inverted in such a way as to form a
^^ cup-like cavity. This disturbance of the
normal mechanism not only increases the
difficulty of delivering the placenta, but
c&usee the latter to exercise a suction force
which increases the haemorrhage, and at
imes even is capable of partially inverting
las uterine walls. Now and then* where
16 occlusion of the cervix is complete^ it
ay be found impossible to effect delivery
ithout first iutrodueing two fingers, and
looking down the margin of the placenta,
m to allow air to paaa above into the uter-
cavity.

Cabx of thb Patient after Delivery*

As the danger of haemorrhage does not „ ,, . . .

, 1 ?i 1 ,1 1 ■ ii rio. 132. — Showmff normal poRi-

uirmys end wuh placental expulsion, the Uon of pUocuta. (Duncau.)

fihyncian should be ready t^i sacrifice, even

simple casesi at least a half-hour to close observation of the subse-

it behavior of the uterus. The weight of the hand laid above the

iphysis pubis is usually sufficient to maintain a safe degree of re-

itJtkin, Should, however, the uterus become lax, and lose its out-

Bne, the physician should grasp it in hia hand and knead it firmly

mill a contraction is excited, lo this way he not only guards against

orrbage, but, by preventing the formation of clota, he diminishes

inttipar£C the severity of the after-pains.

ilixt physicians seek additional security against haemorrhage by

inititering ergot, wliich, as is well known, favors tonic retraction of

f nterufl. To tbiti there is no objection, provided the ergot be given

itificqnent to the expukion of the placenta. When given, bs is com-

at tlie time of the passage of tlie child's head, it is liable

\ts effect prematurely, and thus to give rise to hour-glass

^ninictiou. The rarity of the uceident is no argument in favor of

|li> jMjpularity of the practice, in the face of tlie serious complication

which it iii capable of giving rise. When the physician judges it is

to Busjicnd the proi>hyhictic pressure upon the uterus, he should

^mx thai all the 6<>iled clothing lie removed from beneath hia patient,

and that the nurse wash the genitalia gently but thoroughly. Nothing

• MxTTilKwv DnMCAlt, *• Bdinburgh Med. Jour.," April, 1871.

218

LABOIt

does so much to caase speedy diBappearanoe of the sorenosa of the ex-
ternal parts as perfect cleanlmess. In hospitals a vaginal douche of
warm carbolized water should be combined with external ablutions.
The periuajum should then be carefully examined, and, if lacerations
are discovered, the physician should make himself acquainted with
their extent and importance.

The application of the hinder after delivery is one of those points
in practice about which men of large experience entertain a difference
of opinion. In my stadent-days in the Hopital des Cliniquea in Paris,
the binder was dispensed with. A folded sheet was. however, laid
across the abdomen, it having been found that a certain amount of
pressure was necessary for the comfort of the patient. This plan
com{>elled her to lie upon her back, and thus had the disadvantage
of restricting freedom of movement. Careful observation has failed^
however, to show me a single good reason why the binder should be
discarded. When properly applied, it adds greatly to the woman's
comfort, and enables her to turn at will upon her side. My own pref-
erence is for a piece of unbleached muslin wide enough to reach below
the hips.

In adjusting the binder tlie physician should pl^e himself to the
right of the woman ; he should seize the near end between the thumb
and two fingers of the left hand, while with the right hand he draws
the farther portion smoothly over it. The two ends should then be
held with the left hand, and the pins, which should preferably be of
large size, should be inserted with the right. The process should be-
gin below, and be followed upward at intervals of about two inchei^H
These details are given because the writer remembers his own embapH
raasment arising from his inability to get information upon this trivial
subject in the early days of his practice. Moreover, as many women
are somewhat tenacious of having the binder first applied by the physi-
cian, to know how to do it with address is not an indifferent aooom-
plishment. Many place a compress made of a folded towel above the
symphysis pubis. This addition usually serves no better purpose than
to displace the uterus to one side. The toilet of the patient is finally
completed by laying a warm folded napkin at the vulva to receive the
loehial discharge.

Treatment of Perineal and Cervical Lacerations.— It is needless,
we have already stated, to invade the domain of gynaecology to expl
the serious after-results of neglected perineal and cervical lacerations.
During childbed, open wounds in the course of the genital canal are a
source of danger from septic infection, and, even when kept clean by
frequent carbolized douches, retard the progress of recovery. The art
of closing lacerations of significant extent by suture deserves, there-
fore, to be acquired by every obstetric practitioner. While in hospital
practice the results as regards immediate union are widely variable,

CONDUCT OF NORMAL LABOIt

219

md often, in consequence of atmoBpheric conditions, are negative, in
properly conducted labors occurring in private practice, where the
hygienic conditions are favorable, failure to obtain union is a rare
exception. The details of the operative procedures will be given in
connection with the pathology of labor (mde p. 576).

Kains,

An^sthetics in Midwifery.

The value of aniesthetics in certain irregularities of the labor-
in eclampsia, and in most midwifery operations, is no longer a
tnftiter of discussion. The benefits fi'om their employment in such
cases are palpable and beyond dispute. As to the right, however,
of a woman to have her sufferings assuaged in ordinary normal labor,
lere is by no means unanimity of opiniou. To be sure, the old ob-
tions raised in Sir James Simpson*s day that labor-pain is a salutary
manifestation of life-force> that anaesthesia gives rise to paralysis, to
L^entonitis, to puerperal mania, to haemorrhage, to pericardial adhe-
^Kons, to indecencies of language and behavior^ and that it contravenes
^Hie word of God, are now known to be unfounded or imaginary. Still,
^^lere is no doubt that the vast majority of medical men refrain from
the use of anosthetics in ordinary labor, either from vain apprehen-
sioDS or because some incident in their practice has led them to sus-
pect that^ in spite of statistics, they are not devoid of objectionable
or dangerous properties. In my own experience during the last sixteen
' JWB thcTe have been comparatively few cases in which I have not
Hied chloroform or ether in some stage of labor. The result of my
I i^perienoe has been to make me a warm advocate of their wider em-
ployment on the one hand, while proclaiming the necessity of caution
in their use upon the other. It seems to me that the hesitancy mani-
toted regarding their general adoption is due, in large measure, to the
liel that few practitioners give themselves the trouble to master the
neeenary f nodus operandi^ to stndy the limitations of their usefulness,
or to learn the conditions of their safe administration. It should be
slesilfiistiy borne in mind that the giving of an^esthetica in labor is an
art to be acquired — a very simple one, perhaps, but the practice of
which admits of neither ignorance nor carelessness.

As in ordinary surgical practice, anse^sthetics are contraindicated by
organic affections of the heart and lungs,

Bxcept in the prolonged insensibility required for difficult obstet-
rical operations, I think the preference should be accorded to chloro-
form rather than to ether. The former possesses the advantage of
ing more agreeable, more manageable, and more rapid in its action,
Anasathesia, not narcosis, is the object aimed at, and the dulling
the eensibihiy is much more readily effected by chloroform than by

Afl a rule, chlorofonn should not be administered during the first

220

LABOR.

stage of labor, partly because of its tendency, when given at too early
a period, to weaken the contractions of the uterus^ and partly because
protracted anaesthesia has a tendency to impair the cardiac force. To
this rule there are, however, numerous exceptions* to which we shall
have occasion to revert in connection with the consideration of irregu-
lar labor-j^aius.

If the pains in the second stage are of feeble intensity, it is best to
withhold tlie anaesthetic ; if of normal strength, chloroform may be
given, but at first only in small doses and during the continuance of a
pain. The anaesthetic should not be pushed to the stage of complete
unconsciousness until the head begins to emerge at the vulva.

Chloroform can be conveniently given upon a folded handkerchief.
The latter should be held near to, but not in contact with, the reBpir-
atory passages. The best diluent for chloroform, as was long ago
Bt4ited by Sir James Simpson, is atmospheric air. If the handkerchief
be laid directly across the nose, instant suspension of respiration may
result. A minor evil is the cutaneous irritation produced by placing
the chloroform in direct contact with the lips and mouth.

At the beginning of each pain the patient should be directed to
tiiko a number of deep inspirations. During the acme of the pain the
expiratory efforts which are then called into play prevent the inhala*
tion of any considemble amount of the anEesthetic*

When the head presses upon the perinieum, the handkerchief should
be intrusted to the nurse, but the administration to the end should be
directed and strictly supervised by the physician.

When chloroform is first given, it is common for the pains to
become weakened, but this suspensive inliaence upon the uterus
is usually temporary. Exceptionally, however, the weakness of the
pains may continue, and render it necessary to withhold the anses*
the tic. In still rarer cases the pains remain inefficient after the anaes-
thesia has subsided. On this account it seems to me certain that those
who use chloroform habitually will find themselves compelled to report
to the forceps with somewliat increased frequency. A tardy labor, due
to uterine inertia, will likewise call for additional vigilance during the
Etage of placental expulsion, to forestall the occurrence of haemorrhage.

The immunity enjoyed by women in childbirth against the acci-
dents which sometimes occur from ansesthesia in surgical practice u
not absolute, hut dependent upon its cautious and intelligent adminis-
tration. I once narrow^ly escaped losing a patient in the Bellevue
Hospital, upon ivhom I designed to perform version, in consequence of
my house-physiciun suddenly crowding a paper funnel containing a
towel wet with chloroform over the respiratc^ry passages.

Chloroform should not be given in the third stage of labor. The
relative Siifcty of chloroform in parturition ceases with the birth of
the child. After delivery it favors the relaxation of the utoras, and

MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 221

predisposes to haemorrhage. Moreover, after the nteras has been
emptied there is always an increase of blood in the large vessels of the
abdomen, and a corresponding recession of blood from the head.
NoWy it is known that the quantity of chloroform which one day is per-
fectly tolerated by an individnal in health may prove fatal on the suc-
ceeding day» in case of the intervention of any considerable loss of blood.
Cerebral anaemia, from any cause, increases the risk of ansBsthesia.

In lengthy operations requiring prolonged anaesthesia, ether, as has
already been intimated, should be preferred to chloroform.

CHAPTER XII.

MULTIPLE PREGNANCIES AND THEIR MANAGEMENT,

Reqiiencj.-* Ori^n. — ^Varieties. — Acardia. — Weight. — Unequal development. —Superfe-
tation. — ^DiagnoBifl. — Labor. — ^Presentations. — Simultaneous entrance of both children
into the pel?i8. — Locking. — Prognosis. — Conduct of labor.

The term muUipU pregnancy is used when more than one germ
are simultaneously developed. Twins, the most common form, occur
in the proportion of one to between eighty and ninety births ; triplets
in about the proportion of one to seven thousand ; quadruplets and
quintuplets are of extreme rarity. No authentic example of over five
children at a birth is on record. An instance of quintuplets I have
once witnessed. In the Prussian statistics of Von Hemsbach and
Veit, based upon thirteen million births, the number of twin pregnan-
cies amounted to 150,000. Of these, in 50,000 both children were
boys ; in 46,000 both were girls ; and in 54,000 the children consisted
of a boy and a girl.

Twins may develop either from two distinct ova, discharged from
the same or from distinct Graafian follicles, or may both originate from
a single ovum. If two Graafian follicles rupture, the ovaries will
offer two corpora lutea. In some instances a corpus luteum has been
found in each ovary ; in others, both are situated in the same ovary.

In the case where twins develop from two ova, each fa3tus is con-
tained in its own. chorion. If the ova are imbedded in the decidua
at sufficiently distant points, the placentae w^ill be separate, and each
ovum will have its distinct rcflexa. If near one another, the placentae
are often united at their borders, each, however, maintaining its inde-
pendent circulation. In some cases the two ova lie so close together
that tliey are encircled by a common rcflexa.

When twins are developed from two centers of development con-
tained in the same ovum, the placenta, the chorion, and reflcxa are, of
course, common to both. In most instances, each foetus is contained

MULTIPLE PREGNANCIES AND THEIR MANAGEMENT,

tion of the lees favored fcBtns, then arrostiug it, and 6nallj causing it
to reverse its direction. The heart atrophies, and an acardia is pro-
daced, which is eimply an appendage to the healthy fcetus. The cir-
colatioQ in the ac^urdia takes place as follows : Venous blood from the
heddthy fcetus is conveyed by the umbilical arteries to the placenta ;
the farce of the fetal heart driven the stream through the communi-
cating branches to the umbilical arteries of the less favored twin ; this
force is, however, insuflicient to carry the current to the upper parts
^of the body, which are, therefore^ not developed. The favorable posi-
^Hon of the lower extremities for receiving the blood from the umbili-
^Kal TOflsels explains their continued though imperfect growth and de-
^|f9lopnfient^ The blood carried to the fcetus by the umbilical arteries is
^ returned by the umbilical vein.

According to Ahlfeld,* a division may take place in the formative
miAerial contained within a single area germinativa. This division
may be complete, and thus produce separate twins inclosed in the
same amnion, which not only are of the same eex, but bear to one
another through life the most striking similarity as regards appear-
aDce, physical peculiarities, and both mental and moral characteris-
^^^es ; or it may be incomplete, and thus give rise to conjoined twins,
^Hr one of the numerous forms of double monsters, f
^V In tripleta it is common to find one child derived from an indepen-
^Hfent ovnra, and two from a single ovum. In a case of quadruplets
^BBpoiied by P. Mailer^ two ova were simi»le, wliile the third contained
^'two embryos. The children in the single ova were of the female,
I while those in the double ovum were of the male sex.

The average weight of the individual children in multiple preg-
^janciea is less than that of children born single. This is partly due
^■o the frequency with which the excessive distention of the utems
^BBUnes the exciting cause of premature delivery, and partly t4y the
^BHk^us fact that the maternal organism is rarely capable of furnishing
f the nutritive material requisite for the complete growth of more than

a gingle child.
I Twing often exhibit at birth a remarkable disparity as regards both

six© and development, a disparity unquestionably due to local condi-
tions. A striking example of this is shown in a case related by
Schult2C.* One child, at the time of delivery, was nearly if not quite

* Arch.

^H ^ AntixLo, ** 0ic Entstebung dcr Boppclbildung und der homologen ZwUltnge/^
^K OjniAek.," m. it, p. im.
^V f Sdmltw, on iht other hand, contends thnt the double EDan9ter» are deriTcd from the
I^^Mon of t»o embryo* developed upon the blastodenmc vesicle at pointa close to one an-
dfcf, SoictTiif '* UcberZwiHlngaschwaugcrschftft,'^ YouiMxVH'a "Samm. kiln. Vortr **

t F. UfLLKB, ** Ebe Vicrling's Geburt," "Ztschr. t Geburtsb. und Ojnaek./* Bd. Ui,

• 8gbi;u«E| lot, o^, p. 800*

LABOR.

mature, while the other presented the appearances of a rix weeks'
fcetus. As both ova were enveloped in the same reflexa, their develop-
ment must have begun at nearly the same time.

Sometimes one foetus dies, and yields to tlie more fortnnate broth-
er the space and the nutritive material which would otherwise have
fallen to his share. In such a case the ovum and the contained fa?tiis
may he compressed by the surviving twin, and he flattened against the
uterine wall, giving rise to the so-called '^ftetus papyraceus ** ; or ii
may degenerate into a mole ; or the aborted ovum may be expelled,
while the living foetus advances to the fnll term of gestation,

Yery rarely, where the twins are both living, but have undergone
unequal development, the stronger child may be delivered firsts while
the other remains in the uterus, and is bom after wrecks of delay, dar-
ing which, under more favorable conditions, it makes good the defi-
ciencies due to its retarded eyolution. The most remarkable cases of
this kind occur in the uterus duplex. Professor Fordyce Barker n?-
lates an instance in his practice where, in a double uterus, a matare
living male child was born on the 10th of July, 1855, and on the 22d
of Seitteniber following the mother gave birth to a full-term living girl.

Histories like the foregoing are often adduced in support of the
theory of what is known as superfetation, a theory which supposes
that, after conception has once occurred, a second gestation may result
from a subsequent coitus. That this is possible, if two ova are de-
tached during the same menstrual period, seems to be est^iblished by
authentic accounts of negro women giving birth to twins, showing tlie
evidences of a paternity derived in one from the black and in the
other from the white race. That impregnation can tiike place at tn*o
periods distant from one another must be regarded as an inadmissible
hypothesis, until physiologists shall succeed in demonstrating in a sin-
gle instance, by the presence of cor]3ora lutea of different ages, that
ovnlation ever occurs during pregnancy.

Diagnosis, — The diagnosis of multiple pregnancy is rarely to be
made out with absolute certainty. Unusual size of the uterus, with
exaggeration of the symptoms which result from pressure, would nat-
urally lead to inquiry on the part of the physician, as it is certain to
excite apprehensions in the mind of the pregnant female. Size, how-
ever, furnishes hut an uncertain criterion, as it may he equally due to the
presence of a very large child, or to an excess of amniotic fluid* More
trustworthy information is to be obtained from palpation and auscul-
tation. Thus the recognition of a number of distinct fetal part^ and
the exclusion of hydramnion would render tlie diagnosis of twin prt*g-
nancy probable. The outlining of two fetal heads at a distance from
one another would make the diagnosis certain. When the fetal heart
is heard at two remote points, and the sound is found to die away in
the intervening spaoe^ it is justifiable to conclude that the sound at

MULTITLE PREGNANCIES AND THEIR MANAGEMENT. 225

%llKi point has a separate origin. If the two heart-beats are counted
at the same time by different observers, and are found not to corre-
grpond in frequency, a twin pregnancy is established beyond dispute.
After the birth of the first child, the presence of the second is deter-
mined by the size and consistence of the uterus, and the perception of
fetal i>art3 both through the abdominal walls and tlie vagina.

The recognition of triplets and quadruplets is, of course, ai^tended
with even greater difficulties than that of twins.

Labor in Multiple Pregnancies, — We huve already noticed the fre-
quency of premature labor in multiple pregnancies. Of one hundred
and ninety-two twin births reported by Heuss* from the Wurzburg
clinic, fifty-one did not complete the full term of prestation. In one
of tlicse abortion resulted from small-pox, in another from syphilis,
in two cases premature labor was induced artiUcially, in the others
kbor occurred spontaneously — in one instance at the seventh month,
in tlie others in the ninth and tenth months.

Twin labors are usually easy. The first child is delivered m in
simple labors, and, except in faulty presentations, is followed shortly
by Ihe second. The interval varied, in seventy-four of Reuss's cases
which terminated spontaneously, from five minutes to one and a half
hour. In seventy-nine per cent, the interval was less than an hour,
Aa the stage of dilatation is completed at the time of the expulsion of
the first twin, a protracted interval is occasioned purely by weakness
ind ' " " ncy of ihe pains.

I ^ /enta? are usually expelled after the birth of the second
child ; now and then the placenta of the first child precedes the birth
of tiie second ; again, the second child may not he boni until after the
deliverj* of its placenta. When the placentie are united, a portion may
be torn off and expelled with the first child, while the remainder is not
thrown off until after the birth of the second, f The placental stage
18, owing to the relaxed state of the uterine widls, apt to be of longer
dttmtion than in simple labors, and calls for the exercise of special

\ CMie to guard against the occurrence of haemorrhage.

Presentations in Twin Labors, — Spiegelberg J furnishes the follow-
inp ' ' 1^ rived from 1,138 deliveries, of which 899 were taken from

i Kli ' r and 203 from Reuss :

Both heads preisentlng. , , 558 or 43 per cent.

Head and breech preiMjnting. 861 *' 31-7 "

Both pelvic preaenttttions 98 '* 8*0 "

Heid and tran^ verse profteotations. 71 '* 6-18 "

Brv^ffch iinil traOHverao , 40 '• 444 "

Bath tnuiiversi.^ , 4 " Q'U *'

• Rsina, "ZuT Lehrc Ton den Zwillinji^en/* '* Arch, t, (lynaek,/' Bd, iv, p. 123,
f I'hk gniQOKtitKitu, "* Lcbrbucb dcr Ucburteliulle," Bd. l, p. 203.

22(1

LABOR.

f^.-.

Fie. 134.--Twm pregnaney, Loth liduls prcftuBtmg. (Tumler et dmatrouil.)

The transverse presentations are mostly geeoBdary, conee^jiient
upon the roominess of the uterine cavity and the sudden eacape
the amniotic fluid. Version is, of course, in such eaeoB easily
formed.

The SimultaEeoTis Entraiice of Both Children into the Pelvis, — Th^
consideration of the various complications to which this anomaly gii
rise belongs properly to the domain of pathology. To avoid, howevc
needless repetitions, they may, for convenience' sake, he properly i
fiidered in the present connection.

TfVheo both children present at the brim previous to the rupture <
the membranes, it usually happens that, with the escape of the ami
otic fluid, one of the twins descends into the pelvis, while tlio secoB
glides to one side. The result is identical, whether the twins are coS
tained in a single or in separate sacs. If interference is called for
because of delay, the amnion, or one amnion in case there are twq
should be ruptured, and the nearest presenting part brought into tl
pelvis, while the other is, at the same time, pushed out of the way.

MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 227

If head and breech present^ the head Bhoold preferably be allowed to
descend first.

It may happen, howeTer, that, after rapture, both children may
descend into the pelvis so close to one another as to hinder each the
other in its further progression. This locking of the twins, as it is
termed, may take place in one of two ways, viz. :

1. In double vertex presentations, delivery may be impeded by the
pressing of the second bead into the neck of iJie more advanced foetus,
or, after the birth of the first head, the second may enter the pelvis
and arrest the advance of the thorax. Obviously this difficulty could
only arise in a case where both heads were of unusually sm^ size.
The diagnosis has rarely been made previous to the birth of the first
head. The treatment consists in the artificial extraction of one head
after the other, and then delivering the body of the first child. Cra-
niotomy is usually not necessary. The prognosis as regards the chil-
dren is extremely unfavorable. Beimann * reports six cases in which

Fio. 135.— Twin pregnancy, head and breech presenting. (Tamier et Chantreml.)
• RinLunr, " Am. Jour, of Obrtet.," 1877, vol i, p. 68.

LABOR.

the fate of the children was ktiown. Of the six first-born, one sur-
vived ; of the six last-bom^ two survived* Kcimami, in commentin
on these figures, remarks, ** The child whose head first enters the
vis is in great danger, because, not only is its neck squeezed by
head of the second child^ thereby producing cerebral hyperemia, bai"
its umbilical cord is exceedingly liable to be compressed by the bodj
of the second child. '''

2. When one child presents by the breech, the other by the vertei
the former, because of its smaller size, is apt to descend first into ti
pelvis. No difficulty is then experienced until the neck is bom. In
case, however, meantime the head of the second child has entered the
pelvis, further progress may be rendered impossible, a lock resulting
either from the overlapping of the chins, or of the occipital portion
of the two heads, or from the pressure of the face of one child int|
the neck beneath the occiput of the other. By lifting the body of 1
child, and introducing the half-hand into the vagina, the diagnosis
rendered easy.

In a large, roomy pelvis, if the pains are good and the childr
small, spontaneous delivery may take place. In a number of cases (
this kind which have been reported, the head of the second child wi
bom first. In a few instances, it has been found possible to push
the second head. Operative measures consist in applying tlie foree|
and extracting the second head, and afterward, if neceesary, the ;
In case of failure, craniotomy remains as an ultimate resort. The fir
child is rarely born living. Of twenty-six children, the fate of whic
was ascertained by Reimann, only three survived. The prognosis
the second child is more favorable. Of twenty-nine cases, Reimai]
reports nineteen survivals. Naturally, therefore, the perforation
the first head would be preferred, were the matter one purely of ele
tion, but the operation is very diflicult, and does not remove the oh
stacle, for even the diminished head can not pass the one already
occupying the pelvis.* In the cases so far reported, where decapita^
tion of the first child has been performed, the operation has not prove
successful in saving the life of the second.

The possibility of one twin sitting astride the other when
verse requires mention, because of the perplexity that may arise aa
the diagnosis, unless the hand is introduced into the lower segment
of the uterus to determine the exact relations of the twins to oc
another.

Prognosis, — The prognosis, both aa regards the children and tl
mother, is much more unfavorable than in simple labors. Statistic
on this point are valueless, as much depends upon the conduct of i
physician. As regards the children, the increased mortality resnll
from prematurity, from unequal development, and from the fre(jueiiQ
* Eeimakit, he, tt/., p. 61.

MULTIPLE PREGNAKCIES AND THEIR MANAGEMENT,

of malpositions and malprescntations, requiring operative interferenoe ;
as regards the mother^ the mortality and euseeptibility to puerperal
diseases are augmented by the excessive distention of the uterus, the
extent of the placental wound, the feebleness in many cases of uterine
retraction after delivery, and by the operations which grow out of the
anomalies to which labor in multiple pregnancies is subjected.

Conduct of Labor In Multiple Pregnancies.— The management of
multiple pregnancies does not differ essentially from that of ordinary
labor. Aiter the birth of the first child, the placental end of the cord
fihoold in all cases be tied, on account of the frequency with which
anastomoses are found between the vessels of the placentse, A period
of repose should then be allowed, to enable the uterus to retract down
upon the remaining ovum. During the birth of the second child,
every care should be taken to follow the uterus with the hand, and
redoubled precautions should be observed against the occurrence of
haemorrhage, to which tiie woman is exposed both on account of the
large size of the placental wound and the disposition to relaxation,
Ibcpreesion should be employed to force the placentoa into the vagina.
When both descend at ouce» if it is necessary to make tractions, both
cords should be drawn upon, simultaneously or in alternation, to find
which placenta is most easily removed. When the placenta followB
the birth of the first child, it should be left untouched until the ad-
vent of the second. Vigilance after delivery should be long observed.
We have already noticed that the leugth of time between the ex-
^j ohiun of twins situated in separate membranes rarely exceeds an
Bpcmr* When, therefore, there is a longer delay in the delivery of the
^beoocid child, measures should be employed to excite pains, and the
^raienibranes should be ruptured. In case of a premature child deliv-
ered with its own placenta, cases of continued development, in utero^
^ni the remaining child, would point to the policy of abstention. In
stances where more than two children are contained in the uterus,
tie anomalies of position are more frequent, and the danger of haemor-
ia still further enhanced.*

* SrixaKLOEROj *' Lehrbucb/* pp. 206, 207,

230

TBE PCTEEFERAL STATE.

THE PUERPERAL STATE-

CHAPTER XIIL

TBE PETBIOLOQY AND HANAQBMENT OF CHILDBED,

The puerpcrril fltatc borders doeelj upon pmthological conditions. — PoBt-paitum chill—
Teroperattirc. — The puls€. — Oencraf runctiooa^ — Rcieution of urine. — Loss of wcighu
— InvolutiuQ. — Separalioii of the decidua. — Closurt; of the sinuae?. — The cerrU.—
The vagina. — Position of uterus. — Aftcr-pain5,^The locliia, — Tlie secretion of
milk.^ — Anatomical considerations. — Milk-fever.— 'Composition of milk. — Diagaosii
of the puerperal state, — ^The new-born infant. — Changes in eircnlaiion. — ►The nnvd,—
Tunjor upon the presenting part. — Digestion —Skin. — Icterus. — Loss of weig^L^—
Management of puerperal state. — Sleep. — ►Passing urine. — Vbits of phjaician. —
Washing the vagina, — Diet» — Laxatives. — Nursing. — Duration of lying-in period. —
Care of now-born infant.-^Bath.— Cord.-*Nursiog. — Wet-nursca. — ^Artificial feeding.

The puerperal state occupies the border-land between liealth and
disease. Though in a strict sense physiological, it offers a Tariety of
conditions, as Schroeder* has pointed out, which, at other times, and
under other circumstances, would be regarded as pathologicai Thus,
the exfoliation of the decidua, and the copious serous transudatiaq
with the abundant formation of young cells which accompaniog
development of the n^w mucous membrane, w^ould elsewhere be
garded as characteristic features of catarrhal infiammation. The acuj
degeneration of the uterus presents a phenomenon wliich, when
peated in any other organ of the body, would prove speedily fat
The thrombus formation in the open placental vessels possesses
corresponding physiological analogue* Again, the torn vessels may
lead to haemorrhage, while the traumata which CTen in normal lab
result from parturition, the ease with which deleterious materials
absorbed by the wide lymphatic interspaces, the serous infiltration
the pelvic tissues, the exaggerated size of the lymphatics and veic
create a predisposition to innumerable forms of disease. The nic
of the balance between normal and morbid conditions renders it j)ecT3
iarly necessary for the practitioner to make himself familiar with
physiological limits of the phenomena of childbed.

Post-partura Chill. — The exertion of labor is followed by a sense
comfort and repose. Often after the birth of the child, a chill sets -
in of greater or less intensity, but of short duration, and of no pr
nostic importance. It is to be accounted for by the disturbance of i
equilibritjm between the internal temperature and that of the external
Burface. Thus, toward the end of labor, and for a short period sub-
Be<iuent to delivery, the loss of heat is increased by the evapor

* ScHROinEK, " Ilandbuch dcr Gcburtshtilfe," Gte Aufl., p. 21ft,

THE PnYSIOLOOY AND MANAGEMENT OF CHILDBED.

231

from the lungs and skin, and the cessation of muscalar effort This

eoolmg proeesa is, however, speedily arrested by tlie contraction of the

cutaneous arterioles. During the period which intervenes until the

external and internal temperatures rise to relatively equal levels^ the

patient experiences chilly sensations, or a distinct, well-defined cbilL*

^This phenomenon is more frequent in hypei*festhetic women and in

^■those whose skins are bathed in profuse perspiration^ especially where

Hfhere hajs been some necessary exposure of the person durin^^ the ex-

^P|>ulsiou of the head or of the placenta. Under the influence of a

warm, dry bed, the chill at once subsides.

Temperature* — A rise of temperature follows the parturient act,
I aresaging one and a half degree in primiparte, and one degree in mul-
Hftipans* This elevation contiuues during the first six days, with, bow-
^'ever, morning remissions and slight evening exacerbations. It is moat
pronounced in the first twelve hours, especially when they coincide
with the normal evening increment. In the following days the high-
. point is usually reached at five in the afternoon, while tlie lowest
Aperature is found between eleven and one in the early morning,
ature of 100 J ° belongs within physiological limits. My own
e-tables confirm amply the opinion of Schroeder, that a
rke above 100^® is by no means incompatible with a generally satisfac-
tory condition of the patient, Schroeder attributes the increased heat
production to tlie combustion of organic substances which attends the
iiiTolution of the uterus. To this are to he added, as provoking causes,
reaction of small wounds in the course of the genital canal, and
I disturbances attendant upon the establishment of lactation, f
Tlie Pulse. — lo contrast to the increase in tlic temperature, the
[ often exhibits a remarkable diminution in frequency, in perfectly
1 cases ranging between sixty and seventy beats, but not unfre-
itly dropping to a still lower level, and may even sink to less than
arty pulsations in the minute. This slowing of the pulse is of favor-
f prognostic import. It is known to be associated with diminished
tension, I and has been attributed to a variety of not very sat-
isfactory reasons, such as the sudden removal of the utero-placental
fMsels from the circulation, entailing a less degree of labor upon the
t» rejwse in bed, and disturbed action of the pneumogastric nerves.
It U usually most marked on the second or third day, and does not
to be specially influenced by the establishment of lactation.
Qneral Functions. — During tlie first week tlie skin is active and
»i£t ; the patient is, therefore, sensitive to temperature changes, and

• Fon^t^a, ** Klin, Beobnchtungcn uber den EiafiuBS der lodteo Friichte auf die MuU
pf.** "Afck t Gyimck.," Bd. vii, p. 15L
f Vfde f^^HMOitDKR, " Pchwttiigcrachaft, Gcburt und Wochenbett," pp. 168-177 ; Spiegici.-
,"Uhr4i«cli," p. 210,
\ IliTMftO, ** U«bur die PUlae der WochDcrtttacn," ''Arch, t Gjnack,," Bd. xij, p. 1 14.

232

THE PUERPERAL STATE.

is eubjoct to profuise perspiration when warmly covered or during sleepl

The appetite is lessened, the thirst is increased* the bowels are slug-
gish, and the urine abundant* In spite of the li^lit diet and repose^
in bed, the amount of urea eliminated is but slig-htly dirainishe
Sugar in the urine is ob^rved at the time of the establishment of '
tation. It disappears goon afterward, to reappear, however, whcnev
the milk production is in excess of its consumption.* The diabel;(
is, therefore, due to absorption, f

Retention of Urine,^ — In the first day or two following confinement,
retention of urine is a common occurrence. It results, according to
Schroeder» from the increased capacity of the bladder following the re-
moval of pressure from the gravid uterus. Many women, who suffer
from retention when reclining, are able to voluntarily urinate when
raised to a sitting posture, probably because of the greater facility with
which, in the latt^er case^ the pressure of the lax abdominal parietes can
be exerted upon the bladder.

Loss of Weight. — Owing to the rapid retrograde changes in the
pelvic organs^ the discharges from the genital passage, the increased
Becrctiona of the skin and kidneys, combined with limited ingestion <
food, the loss of weight in the first week amounts to from nine to \
pounds, on roughly speaking, to about one twelfth the weight of
body. I

Involutiou.^ — The processes by means of which the uterus retomsto
its non-puerperal condition are inaugurated at the commencement <
labor. During the rapidly following contractions of the uterus tb
cell'clement.s are consumed, while, at the game time, the compressio
of the nutrient vessels cuts off fresh supplies from the oxidized pr
toplasm. The fatty degeneration of the muscular fibers continn^
after the expulsion of the ovum. The contractions which bear
name of after-pains point to the continuance of muscular cells capab
for a time of functional performance. Grail ually, however, the pr
teine suU^^tances are converted into fat^, which undergo absorption
Whether t!ie enormously enlarged colls of pregnancy ever entirely dis-
appear is gt ill an open question. In the fourth week young cells of
new formation make their appearance upon the external layer of the
uterus, from which eventually a new uterus is developed. Thus de-
struction and reparation go hand in hand. In from six to eight weeks,
the process described rciiches its completion. The lochia then cea
and, in women who do not nurse, menstruation returns (Schroeder),

Immediately after birth the uterus weighs upward of two ponnc
in two days the weight falls to a pound and a half ; the uterus is seve

* JooAWNorsKT, ♦*Ut?ber den Zuckergehalt im Hame der WacbiieriiiiiGtv'^* *^ AT«iu j
GynaeU,/* Ud, vil, p, 448.

f SriEOEtuEnai loc. «Y., p. 212.

THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 233

to eight inches in length and about four and a half inches broad ; the
walls are from an inch to an inch and a half in thickness ; at the end
of a week the uterus weighs a pounds and is fiye to six and a half inches
long ; at the end of two weeks the weight is three fourths of a pound,
the length five inches, and the walls hardly a half-inch in thickness.
Of course the individual yariations from these averages are very great.*
In six w^ks the process usually reaches the end, though the uterus
remains ever after somewhat larger and more rounded than in nulli-
parsB (Spiegelberg).

Separation of the Deoidua.— With the expulsion of the ovum the
outer portion of the decidua vera for the most part adheres closely to the
reflexa, while the meshy portion, with the fundi of the glands, remains
attached to the uterus. The adherent portion consists of empty areolar
spaces, of gland septa, of lymphatic spaces and blood-vessels, while
only the fundal extremities are lined with glandular epithelium, f As,
however, the line of demarkation rarely takes place throughout the
entire decidua at any fixed level, fragments of the outer, more com-
pact layer may frequently be found here and there clinging to the inner
sur&ice of the residual membrane. {

The uterine cavity is covered and in part filled with at first a bloody
and subsequently a muco-sanguinolent fluid containing blood and mu-
cus corpuscles, and decidua-cells in various stages of degeneration.

At the end of a week the mucous membrane measures at most from
a half to three quarters of a line in thickness ; the inner surface has
become smoother from the disintegration and exfoliation of adherent
shreds ; the glands, owing to diminished size of the uterus, are pressed
closer together, and assume a more nearly perpendicular direction ; the
gland-epithelium extends upward along the gland-walls to the surface
of the membrane ; the interglandular spaces are filled with lymphoid
cells, with blood-corpuscles, fat-granules, and epithelial cells, in a state
of fatty degeneration. As the regenerative process goes on, fine capil-
laries without walls form in the interglandular substance, so that the
latter presents the appearance of granulation-tissue. By the third week
these vessels of new formation stretch upward to the surface of the
mucous membrane, and by the sixth week the development of the vas-
cular network is complete. In the second week the lymphoid cells begin
to dissolve, and thus the glands are brought into near contact with
one another. Spindle-shaped cells of young connective tissue are found
between the glands in the second week, and with continued connec-

• BoRNiR, " Ueber den puerperalen Uterus " ; Sinclair, " Measurements of the Uterine
Cavity,*' "Trans, of the Am. Gynaec. Soc.," toL iv, p. 231.

f Lbofold, *'Studien iiber die Uterusscblelmhaut/' etc., '* Arch. f. Gjnaek./* Bd. xii, p.
180.

X K&STVSR, *'Die Losung der muttcrlichen Eihftute," ** Arch. f. Gynack./' Bd. xiu, p.
422.

2M THE PUERPERAL STATE,

tive-tissue proliferation the flattened tubules are drawn upwiid, And
assume a perpendicular direction. The epithelial cells at the moutlii
of the glands, wliich at first formed sepamte islets, approach one an-
other as the glanda assume their normal positions, and by actiYelf
multiplying spread from the circumference until they form a coniiu-
uoiis lining to tiie wounded surface.

As regards the principal features, the changes which take place at
the placental site arc the same as those described elsewhere within the
uterine cavity. Immediately after delivery, liowever, the surface pos-
iesses an uneven aspect, witli elevations where the septa of the gerotina
had penetrated between the placental cotyledons, and with intervening
depressions. The mouths of the torn vessels are closed by thrombi,
and large vessels are irregularly distributed beneath the attached resi-
due of the mucous membrane. The process of regenei-ation Jit tlie
placental site takes place somewhat more slowly than elaewhere within
the uterus.

Closure of the SiEuses. — By the eighth month of pregnancy, i
been mentioned, a poHton of the sinuses beneath the placenta are oblit-^
crated by the emigration of giant-cells which cause coagulation of the
blood circulating tlirough theni. After delivery, the blood stagnates
in the intact vessels in such a way that at first the inner walls are
covered with fihrine, while the center contains fresh red blood. The
walls then thicken by proliferation of the endothelium, and lymph-
and blood-corpuscles penetrate into the coagulated layer. Finally* the
thrombus fills the entire vessel, spindle-shaped cells radiate from the
eudothelium, and with the development of young connective tissue a
gradual shrinkage takes place* which, however, proceeds slowly, so that
four to live mouths after birth the placentid site is still distinguish-
able,* According to Engelmann, pignientaiy deposits in the tissue of
the mucous mcmbnme are almost conclusive evidence of recent deliv-
ery, as after menstruation they are not found, probably on account
of the superficial character of the hiemorrhage.

The Cervix,— The cervix speedily resumes after delivery it^ normal
size. At first it has a soft and pulpy feeh The os internum (ring of
Bandl) forms a resistiiiit ring, which constitutes a well-defined boun-
dary between the corpus and cervix uteri. This ring varies in size in
different subjects, but is always sufficiently ojjen to permit the intro-
duction of two fingers. Beneath, the walls are thrown into ti-ansver«e
and longitudinal folds. The os ext4?mum is usually torn, especially
upon the sides, and the thickened labia roll outward. The length of

* LEoroLD, *' Stiid 1(^11 fib or die Utenii«>cliloimhatit," etc., " Arcli. f. Grnack,,'* Bd. sil,
p. 109; EN*o«t.\tANN, *'The Mucous Monibrano of the Uteruft/' **Am, Jour, of Otistei.,^
May, IS7fi ; SnK(iKLfiKim» "Lchrbuch," p. 2H ; SctmouoEn, ** Lohrbtieh/* p. 222; KtsTSriK,
"Die Losung der ntiiitcrlicben Eihaute/* eta, **ArclL L GyniciL," Bd. atiii, p. 428;
FwEDLANOKR, ** Arcli* f . Gjnack-," Bd. ix, p. 22.

TIIE PHYSIOLOGY AND MANAGEMENT OF CHILDBED.

235

the canal measarea two and three quarters inches, and upward. At
ihe end of twelve hours the distinction between the ceryix and vagi-
na is clearly marked, and the os internum is bo far closed that a cer-
tain amount of force is refiuisite to pass two fingers into the uterine
cavity. The contraction of the os internum renders the longitudinal
folds more pronounced in the upper portion of the cauaL From thia
time on, the involution of the cervix advances rapidly. At the end
of twelve days the canal is shortened to an inch in length. Aa the
longitudinal muscles contract, the plicaa palmatfc become distinct as
transverse ridges. The longitudinal folds, with the exception of the
anterior and posterior ridge which belong to the plict'e palmatae, dis-
appear with the retrograde changes which take place in the mucous
membrane. The os externum long remains patulous, and permits the
linger to pass to the oa internum for a period varying between the sev-
enth and fourteenth days. The anterior lip is thicker than the poste-
rior, and is frequently the seat of erosions and granulations. The
involution of the vagimil portion is not completed until after the ex-
piration of five to six weeks.*

The Vagina* — The vagina during the first few days is soft, smooth,
and relaxed, and requires from three to four weeks to regain its nor-
mal dimensions. The contniction and involution proceed more rajv
at the introitus than above in the neighborhood of the fornix,
longhy owing to the presence of lacerations, it remains, with few
iceptions^ permanently wider than in women who have never borne
lehildren.

Position of the Uterus. — Immediately after the expulsion of the
fQta the contmcted uterus is felt through the abdominal walls as a
»olid body, of a flattened, pyrifonn shape. When both hips are
on the same level, and both bladder and rectum are empty, the uterus
is found in the median lino with tlie fundus between the symphysis
nd the navel. At the same time the weight of the body and the
laxity of the abdominal walls lead to a moderufce degree of ante-
Urine in the bladder and feeces in the rectum give rise to a
ID amount of lateral displacement, and now and then to a torsion of
Qlenu upon its long axis. As in pregnancy, the fundus of the ute-
ia thua generally, though not always, directed to the right, and the
border looks to the front. The mean elevation of the fundus above
m sjTnphysis is about four and one third inches, the width of the fun-
as 18 Upward of four and a half inches, and the length of the entire
t^nne cavity, aa measnred by the sound, is in the neighborhood of six
ch&3* The dimensions of the uterus are somewhat less in primiparse

• Lorr, "Znr Anstonaie untl Physiologic der Cervix Uteri" pp. 87 H «7- ; Borkkr^
*tr«licrileA puerpcrBlni Utoni0," p. 47, 9tatoB that at thi' vnd of the e^^cultd week the
m permito the pssMgi) of (he tinger in about half the cases, bul la doseii lo al^
[ uf the third week.

BOXIOQ.

230

THE PUERPERAL STATE.

than in maltiparaB, A full bladder pushes the fnndua upward, and
increases the longitudinal diameter of the organ. Bomer has obaerred
an inerease from this cause amounting to three and a half inches.

A diminution in the size of the uterus is apparent in most ca«es in
the course of the first twenty-four hours. An actual increase is either
pathological or due to the abo re-mentioned influence of the bladder.
The dimiDUtion is most marked in the first twenty days, but after-
ward progresses at a slow rate* About the tenth day the fundus sinks
below the level of the symphysis pubi«, and the posterior surface of
the anbflected uterus occupies the plane of the brim**

AfteF-Pains. — ^The reduction of the uterus' in the first few dajrs rf
the childbed period is in the main the result of contractions, termed
after-pains, resembling tliose of labor both as regards the hardening
of the uterine walls perceptible through the abdominal coverings, and
the nature of the dolorous sensations which they evoke. The after-
pains stretch over a period varying from one to four days. Their
duration and intensity are in inverse proportion to the duration and
activity of the preceding labor. On this account they are more pro-
nounced in mnltiparae, while they are often absent subsequent to a
first delivery. They arc intimately associated with the permanent re-
traction of the uterus, and are therefore to be regarded as a normal
and favorable phenomenon. They are especially prominent in cases
of over-distention of the uterus, as, for instance, in cases of twin preg-
nancies and hydranmios. Suckling the infant produces reflex contrac-
tions of a somewhat intense character.

The Lochia. — The discharges from the genital passage consequent
upon delivery are termed the lochia. At first the latter are composed
of pure blood with coagula of fibrine, but after a few hours the wound-
ed surface of the uterus furnishes an abundant exudation of a semus,
alkaline fluid, which washes away in its descent the secretion from the
cervix and the vaginal mucus. For the first two or three days the
lochia are of a red color {lorJiia rubra) from the commingling of bJood,
while upon the third, fourth, and sometimes upon the fiftli day* as the
sanguineous elements diminish, they present a pale-red color (lochia
serosa). As constituents we find under the microscope oeryical and
vaginal epithelium, blood and mucus corpuscles, bits of decidua, and
Bometimes shreds of membranes and of the placenta. The organic con-
stituents consist of albumen, mucine, the saponifled fat^, and a variet)-
of saline matters. From the fifth to the seventh or eighth day the dis-
charge continues thin, but the blood-corpuscles become less abundant,
while there is an increase in the pus-cells and fatty globules. In the

♦ BoRNEB, loe. eit ; CiiEni, *^ BcitrJtjico ziir Bestimniun^dei' DonoalBn La^ der geBimdeQ
Geb&rniuUer," "Arch, t Gynack./* Bd. i, 1870, p, 84 ; Ppaxx^ch, " Ucbcr die SinfluttS
dcr N«chbar43i^iie auf die Lago imd lavoltilioa der puerperalen Utcnia," ** Arch. f. Of-
naek.," Bd. iii, 1872, p. 827,

THE PHYSIOLOGY AND MANAGBMBNT OF CHILDBED. 237

second week the discharge becomes of a grayish-white or greenish-yel-
low color {lochia alba seu laciea), and of a creamy consistence. It
contains chiefly pus-corpuscles, yonng epithelial cells, spindle-shaped
connective-tissue cells, fat-granules, free fat, and crystals of choles-
terine. The reaction is neutral or acid. Gradually the discharge
diminishes, becomes transparent, and finally assumes a normal appear-
ance. After the fourth day the odor is recognizable, and the lochia
are found to contain bacteria, indicatiye of decomposition. In the
Taginal secretion the trichomonas vaginalis is likewise present. To-
ward the end of the first week, and especially after leaving the bed,
fresh blood often makes its appearance.*

The quantity of the lochia varies with the peculiarities of the indi-
vidual. It is, as a rule, greater in multiparse, in women who do not
nurse their children, and in those of flabby fiber, who habitually men-
struate abundantly. The mean quantity, according to Oassner, of the
lochia cruenta or rubra (to fourth day) amounts to nearly two and a
fourth pounds ; of the lochia serosa (to sixth day) to rather more than
nine ounces ; and of the lochia alba (to ninth day) to six and two thirds
ounces : so that the entire amount lost during the first eight days
reached the total amount of nearly three and a quarter pounds.

The Secbetion of Milk.

Anatomical Considerations. — The breasts, which furnish the secre-
tion of the milk, are two large glands of the compound racemose vari-
ety. They are covered by a fine, supple skin and a layer of adipose
tissue, which increases in thickness toward the periphery of the organ.
The mass of the glandular substance is composed of from fifteen to
twenty-four lobes, which in turn are subdivided into lobules made up
of a greater or less number of acini, or cuh-de-sac. Fine canaliculi
start from the latter, and unite together to form the canals of the
lobules. These again anastomose, to form a principal canal for each
lobe, termed the lactiferous duct. The lactiferous ducts terminate at
the nipple by small openings measuring only from one sixtieth to one
fortieth of an inch. Each duct, as it passes downward, enlarges in the
nipple to one twenty-fifth or one twelfth of an inch in diameter, and
beneath the areola it presents an elongated dilatation, from one sixth
to one third of an inch in diameter, called the sinus of the duct
(Flint). The spaces between the lobes are filled with adipose tissue,
and the various elements which constitute the mammary glands are
united into a single mass by a dense connective tissue continuous with
that of the subcutaneous layer. The acini, which are merely rudimen-
tary in the non-pregnant state, are lined with a single layer of small
polyhedral cells, assuming a more cylindrical character in the neighbor-

• Vide ScHBOiDER, ^'Lehrbuch," etc., ftte AulL, p. 226 ; Sphqelbibo, "Lehrbncb,'' {x
218.

Mf THE PUERPERAL STATEL

hood of the canalicular ducts. The main ducta are lined with lor
cylmdrical cells, and contain in their walls non-striated muscular fibers^
tiie contractions of which are the cause of the epurting of the milk in
lactation.

jiiSf^?'

Pio. 1S6*— Mammary pland. a, nipnlo^ the oontml portion of which Is retracted ; 5»
0, <r, c, c, Cy lohula* of the gkmd: 1, ulnua^ or flilntud portion o( oue ol' tiie
duoto \ S, extremitiea of tho kctilbrvits duota. (LiogeoU.)

During pregnancy the breasts enlarge in consequence of the swelling
and increase of the connective tissue, the accumulation of fat between
the lobes* and the multiplication of the acini, which fill with fatty glob-
nlea resulting from the disintegration of the lining epithelial cells.
The changes in the secretory apparatus give rise to irregularly dis-
tributed nodular cords, which, however, at first are most distinct at
the periphery, and thence advance toward the center of the organ.
With continued development a lactescent fluid is produced, which
either exudes spontaneously from the nipple or is diacharged by press-
ure.

Milk-Fever. — About the third or fourth day of the childbed period,
the turgescence of the breasts is suddenly increased, and they become
full, tense, nodular, and sensitive to the touch. The axillary glands
enlarge, and radiating pains are ex]>erienced in the arm and shoulder.
The intensity of the mammary congestion varies in different individ-
uals. It is more pronounced in women who postpone nursing their
children until after the secretion of milk is fully established. In ex*

THE FHTSIOLOGT AND IIANAGEMENT OF CHILDBED.

239

ceptional cases it may be absent altogether. Since the general intro-
dnction of the thermometer into practice, and the better understanding
of the causes of febrile temperatures in the puerperal state, the exist-
ence of a distinct milk-fever referable to functional disturbances in
the breasts during the period in question has been found to be an en-
tirely exceptional occurrence. The temperature tables, which have
been kept with great regularity for the past ten years in the Maternity
Hospital of this city, prove that under normal conditions the tempera-
tures of the third day do not rise above 100^^. With this sub-febrile
increase there is, indeed, often conjoined considerable general dis-
turbance, indicated by slight chilly sensations, headache, anorexia,
and a quickened pulse, which, however, disappear in the course of
twenty-four hours, with profuse perspiration, and an abundant secre-
tion of milk. Most writers regard the higher temperatures which are
sometimes found associated with extreme turgescence, tenderness, and
reddening of the mammae, and which subside when the latter are

Fxa. 1S7. — Section through adnuB from breast of a nursiiig woman. (Billroth.)

partially unloaded, as dependent upon a non-suppurative form of
parenchymatous inflammation.

Composition of Milk.— Milk is composed of a fluid portion, and of
formed constituents, the first derived from the blood, and the second,
termed the milk-globules, from the epithelial contents of the acini.
In the production of the milk-globules, the gland-cells actively multi-
ply, and become filled with granular particles, which gradually coa-
lesce to form drops of fat. Subsequently the nuclei and the contours
of the cells disappear, so that the latter consist of mulberry-shaped
aggregations of fat-drops held together by the remains of the cell-pro-
toplasm. The epithelial elements thus metamorphosed are termed

S40

THE PUEHPERAL STATE

colostrum-corpuscles. They are found sparingly distributed in tlie
crude, imperfectly formed secretion known as colostrum, which is fur-
nished by the breasts of women who have been but recently confined.
Finally, the fat-globules ol large and' small size separate from one an-
other, and form an emulsion with the fluid transuded from the blood»
a process aided, according to Kehrer, by the diffusion through the iiaid
of the residual protoplasm of the cells.*

Colostrum is a watery, semi-opatjue, mucilaginous fluid, containing
yellowish streaks composed of fat-globules and fatty-degenerated cells
which hang together in stringy masses. It is distinguished from true
milk not only in the physical characteristics mentioned, but in tlie
greater proportion of sugar and inorganic salts it contains, and in the
fact that it coagulates upon boiling. It possesses laxative qualities,
which render it of use to the infant in aiding the removal of the me-
conium.

Perfectly formed milk contains from 2*5 per cent, to 7*6 per cent
butter in emukion, and from 3*2 per cent, to six per cent, milk-sugaf
in solution. Both of these substances arc directly manufactured by
the gland-structures. It possesses likewise a proteine substance termed
caseine, which fluetimtea in quantity between one, threo^ and four per
cent, Kehrer maintains that it is not held in the milk in solution,
but is composed of particles derived from cell-protoplasm which are
diffused through the fluid. The salts in the milk amount to 0'14 per
cent.t

Tlie Diagnosis of the Puerperal State.— The diagnosis of recent d(y_
It very is baj^ed upon the physiological conditions which, we have i
characterize the puerperal state. Thus, the abdomen is flabby
wrinkled, with pigmented linea alba, and is traversed by white and
lines ; tlie breasts are full, tense, and nodular, and ^^ecrete milk or"
colostrum ; the areola about the nipple is discolored ; the uterus is
enlarged, anteflexed, palpable through the abdominal wall, and is ex-
cited to contract by pressure ; the vulva is swollen, the labia gape
apart, the hymen is ragged, the perinaeum is distensible, and in recent
cases lacerations, in older ones ulcers or granulating wounds* are found
about the vaginal orifice ; in the smooth, lax vagina there is observable
the absence of the columme rugarum ; the cervix is soft, wide below
and narrowing above, with the labia often torn and contused ; when
the finger can be passed into the uterine cavity ^ thrombi may be ffi
at the placental site ; finally, the lochia are hardly likely to be cq
founded with hemorrhages or discharges from non-puerperal cans

Buring the first two weeks an approximative estimate may be :
as to the date of confinement by bearing in mind that just after deli ve
colostrum is found in the breasts, the lochia are bloody, and the laceJ

• Kehrer, " Zur Moqibologic del Milch-Giiscinfl," '
f SpULam.DeBO, he. eit,^ p. 22K

Arch, f. Gyimk," Bd li, p. L

TEK PHYSIOLOGY AND MANAGEMENT OF CHILDBED.

241

tions aboat the vulva present a fresh appearance ; that during the fol-
lowing dajs the IcKsliial secretion changes first to a seroiig and then to
a puralent character ; that the uterus gradually diminishes in size,
the fundus at the tenth day ainking below the upper border of the
gympbysis, while the os internum remains patulous to the tenth day,
usually impassable for the finger after the twelfth day.

The New-bork Infant.

With the first inspiration the thorax expands, and air fills the
alveoli of the lungs ; at the same time the blood passes from the right
«ide of the heart to the capillaries of the pulmonary organs, and is
lotumed arterialized to the left side of the heart. As a consecjuenoe
of the establishment of the pulmonary circulation, the ductus arteri-
osus contracts, the foramen ovale closes, and the left ventricle under*
goes eccentric hypertrophy. As a consequence of the diversion of a
port of the blood-currents to the lungs, the pressure in the aorta sinks,
and the circulation in that portion of the umbilical arteries which lies
ODtaide the navel ceases, while thoracic aspiration empties the umbili-
cal vein. The cord dries from the cut surface toward the navel, and
drops off on the fourth or fifth day. The line of demarkation forms
at the termination of a capillary network which extends upward upon
tlie cord to a distance of from throe to four lines from the skin. When
the cord drops off, a wounded surface is left, which heals in a few

M The swelling upon the presenting part subsides mostly in twenty-
lour to forty-eight hours. The head slowly resumes its normal
ahape — a process completed, probably, in the course of two to three
weeks.

Soon after birth the meconium is discharged from the intestines,

fl in a few days the evacuations assume a feculent character. The
duetion of pepsin in the stomach, and the secretion by the pancreas
a fluid capable of emulsifvnng fat^ and digesting album moid sub-
new, rt^ider tlie assimilation of milk practicable. The kidneys
rrote an abundance of urine of a low specific gravity.
About the third day an exfoliation of the epithelium begins, which
nuiititained for a week, or even a longer period. During this time
hypera?mia of the skin is very marked, and imparts to it a red
yr, which as it fades pusses into a yellowish tint. The breasts in
Ih mxes swell very commonly, become red and sensitive, and yield
yn pressure a serous, milky fluid.

Icterus of tbe new-boni infant is a pretty common affection.

occurrence is, however, largely influenced by local conditions,

Porak plaeod the frec|uency at eighty per cent, among the chil-

bom in the? IlOpital Cocliin in Paris ; Kehrer, in the vti&t mater-

im of Vienna, at sixty-eight |>er cent ; Ebstein, in Prague, at forty-

242

THE PUERPERAL STATE.

two per cent ; while West declares it is a rare phenomenon at the
Rotuntla HospiUl in Dublin. Tt develops usoally upon the second or
third day^ and ends, as a rule, by the sixth to eighth day. Kehrer*
has shown statiatieally that it occurs more frequently in boys, in pre-
muture infants, in the children of primiparae, and a^ a consequence of
malpresentations. It is likewise promoted by atelectasis, by intes-
tinal affections, by depressing the temperatnre of the child, by insof-
ficient feeding, and, in a word, by all the variotis pathological condi-
tions and nnfavorable hygienic iniiuences intensifying or giving an
abnormaldirection to the ordinary changes which take place in the
blood (Ebstein). Its frequency in lying-in hospitals is probably cod-
nected with a septic infection, for which the wounded surface at the
navel furnishes the point of entry* It does not appear to be dependent
upon gfistro-duodenal catarrh, upon a narrowing of the bile-duct^ or
uiK>n retention of meconium. The faeces are stained with bile, while
bile-pigment in the nrine is of exceptional occurrence. On the other
hand, in all the tissues of the body, and most abundantly in the kidnej*»,
pigment-crystals and yellowish- red amorphous granules are found de-
posited in greater or less quantities. These pigment-bodies are presum-
ably not products of the liver, but result from tbe disintegration of
blood-corpuscles, their accumulation in the organism dei>ending either
upon the rapidity of the processes of destruction, or upon obstructed
elimination by the kidneys. An expectant treatment ia the only ra-
tional one. Laxatives are unnecessary, and perhaps harmfiiKt

Owing to the discharge of meconium and urine, and the limited
amount of sustenance at its disposal, the new-born infant experiences
a loss of weight in the first two to three days, estimated at from seven
to eight ounces. After the second or third day the loss is gradually
recovered, so that between the fifth and eighth day the weight at
birth is reached. The loss of weight is greater in the children of
primiparsB than in those of raultiparie, in artificially nourished in-
fant^j and where the immediate application of the ligature to the
at birth has been resoi'ted to.

The Management of the Puerperal State,

Sleep, — After every precaution has been taken against hfemorrho
after the patient has been washed carefully and placed uiK)n clean, <
bedding, and after the baby has been bathed and dressed, it is very i
sirahle that the mother should enjoy a few hours of refreshing slee
To this end the room should be darkened, and absolute stillness
forced. The crying of the baby, the affectionate salutation of frienc

♦ Kehrkr, "Studien iiber den Ictcnia Nconatoram/* "Jnhrbuch f. Faediatrik,'* BcLI
p. 71, 1871.

t EDSTEtK, ** UebCT die GelbBucht b«i neagcborencn Eindern," Volkniann*ft ** i
trtn. Vortr.," No. 180.

THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED,

243

^Br the tidying of the room bj household Marthas^ often becomoB the

Ularilng-point of nervoas restlessness, whicli is with difficulty over-

^'ccine by the aid of the strongest soporifics. Should the mother feci

faint and exhausted, she should be allowed a cup of hot tea orbouilloa.

In multipara it is well to leave with the nurse some form of ano-

lyne, to be administered in case sleep is interrupted by the frequent

currence and severity of the after-piuns. Opiates, while they lull

pain, do not, after labor, arrest those physiological changes in

iie uterus with which the after-pains are associated.

Passing Urine, — As the natural impulse to urinate after delivery
very feeble, even when the bladder is full, the nurse should be in-
tructed to solicit the patient to pass water in the course of eight or
c*n hours. The act of urination should be performed upon the back,
firhich of course necessitates the use of the bed-pan. To bo sure, there
are a good many women who are able to pass water without ditlicuUy
the Bitting posture, who fail in the attempt when recumbent. Still,
be risk of exciting haemorrhage by placing tlio patient upright, during
tie first four or five days after delivery, is always sufficient to control
paction of the careful physician. The physician should make it a
i to visit his patient within twelve hours from tlie time of confine-
ment. He should then inquire, not only whether she has passed
rater, but ascertain the quantity voided. If the quantity has not
ied three to four ounces, he should introduce the catheter and
make sure that the bladder is completely emptied, In cases of reten-
ion, the urine should bo drawn at least three times in the twenty-four
Before using the catheter, the external parts should be care-
ally washed, to avoid conveying the lochia into the bladder, as the
kichial discharge after the first day is liable to excite cystitis. In
Atix>dncing the catheter beneath the bedclothes, the urethral orifice
readily be detected by first feeling for the tumefied urethra with
lie index-finger of the right hand through the anterior vaginal wall,
nd then following it in a forward direction until the meatus is
^f^ached.

yislts of the Physician. — The physician should see his patient at

least once daily during the first week following confinement. During

^Ihe first four days it is my custom to make both a morning and even-

tieit, not only for the purpose of noting carefully the pulse and

lure, but to be sure that my patient is not made a victim to

itional prejudices and superstitions of the monthly nurse.

the phyaician will take the trouble to call occasionally upon his

&tH?nt subsequent to the first week, to insure the unretarded progress

pf puerperal convalescence, he will do much to circumscribe the field

)f»lo;rieal practice.

Directions, — Great pains should be taken to keep the air
of the lying-in chamber fresh and pure* If the room is warm, the

244 "^HB PUERPERAL STATE.

patient should be lightly coyered, owing to the tendency daring
childbed to profuse perspirations. There is no foundation for the
prevalent belief that it is dangerous to comb the hair of a puerperal
woman. Nothing contributes so much to the removal of soreness,
and the healing of wounds in the genital canal, as cleanliness. Every
morning the external parts should be washed carefully, and at least
twice daily the vagina should be syringed with some warm disinfect-
ant lotion. My own favorites are, for the first three days, an infu-
sion of camomile or a saturated solution of boracic acid. After the
third day, when decomposition of the lochia is apparent to the sense
of smell, carbolic acid ( 3 j ad Oj) should receive the preference.

Diet. — The diet should be selected with reference to the physio-
logical requirements of the patent. Thus, during the first three days,
when, as a rule, the patient is thirsty, and is indifferent to solid food,
the diet should consist of gruel, milk, milk-toast, and tea, to which
may be added clear soups and bouillon should more stimulating ali-
ments be called for. It is equally desirable on the one hand to avoid
exciting colics and catarrhal affections of the stomach by too early
resorting to a substantial regimen, and on the other to remember that
the speedy establishment of an abundant milk secretion is apt to be
hindered by subjecting women to a process of semi-starvation. After
the bowels have moved on the third or fourth day, the normal appetite
usually returns. All easily digested articles of food, such as soft-
boiled eggs, chicken-broth, small birds, steak, chops, and the like,
according to the taste of the patient, should then be allowed. Cooked
fruits are of service in overcoming the natural constipation of the
puerperal period. The popular prejudice against fish and vegetables
containing a large amount of nitrogenized substances seems to me
well founded.

Laxatives. — The canonical practice of administering a laxative on
the third day is of unquestionable utility. Very few women escape
from an accumulation of fecal matter during the last weeks of preg-
nancy — an accumulation which is often enormous in quantity, and
which creates a predisposition to puerperal affections. The remedies
selected should, however, be adapted to the peculiarities of the indi-
vidual. In some women an ordinary injection of soap and olive-oil
in water suffices to procure an adequate evacuation ; in others the ob-
ject is fulfilled by the milder laxatives, such as the compound rhubarb
pill, a claret-glass of Hunyadi-J&nos water, or the compound licorice
powder of the German pharmacopoBia ; while in obstinate cases a calo-
mel purge, or some such combination as the post-parium pill of my
friend Professor Barker,* will be found requisite. Castor-oil I give only

• Ext. colocynth. comp., 3 j ; ext. hyoscyami, gr. xv ; pulv. aloea «)c., gr. x ; ext. nuc
vom., gr. V ; podophyUin, Ipecacuanha, ftA, gr. j. M. Ft. pil. (argent.) No. x!L Of these,
two usually act efficiently and without causing pain.

THE PHYSIOLOGY AND MANAGEMENT OF CIULDBER

245

in cases of seTcre colic, either alone or combined with fifteen drops of

laudannm. In hapmorrhoids complicating puerperal convalescence, I

add my testimony to that already given by Professor Barker m to

tie specific curative effect of half-grain doses of aloea administered

light and morning.

NursiDg. — Every healthy woman should nurse her child at least
I through the puerperal period. The advisability of continuing lacta-
Ition subsequent to the resumption of household duties must depend
[upon the question as to whether the mother is in a position to make
the necessary sacrifices to the interests of the child. When the do-
mestic and social demands upon her time and thoughts arc nnmor-
► oos and pressing, lactation is apt to be imperfect, and the child will
lnot thrive. Humanity, in such cases, requires that the child be sur-
adered to a wet-nurse. Nursing may be rendered impossible by a
of milk, by flattened, misshapen nipples, and by the health of
^mother. It should be prohibited in phthisis, in epilepsy, and in
Gssee of syphilis contracted shortly before the birth of the child.

The child should be applied to the breiist after the mother has
rested, and within the first twelve hours following the end of labor.
Soon after birth the child seizes the nipple eagerly, and, though the
quantity of nourishment obtained is small, it is infinitely better

I adapted to the child's needs than the catnip-teas and sweet-oil which
jDonthly nurses employ as substitutes. The early application of the
cliild to the breast benefits the mother by promoting the contractions
mild the involution of the uterus, and by lessening the painful disten-
tion of the breasts which oocurs at the time when the function of lac-
tation is fiiUy established,
I As the child sleeps for the most part during the first few days of
existence, no rule can be laid down with regard to the frequency with
which it should be placed to the breast. Afterward it should be ac-
[ customed to some regular routine. 80 long as the etoraach is of small
and regurgitates a portion of its food, the interval should not
I A couple of hours. From an early period, however, the child
' ahould be accustomed to sleep six hours at night, which gives an op-
portunity for the mother to recuperate her strength. This discipline
b of course not practicable where the child sleeps in the same bed with
the mother. After six months the cfiild should not nurse oftenor
^than five or six times in the twenty-four hours.

The breasts should he suckled in alternation. The nipples should

pfully washed both before and after nursing. The addition of

Die acid to the water prevents the development of fungi. The

extremo sensitiveness of the nipples at the commencement of lactation

ha greatly relieved by applying constantly to them a rag wet

tlw liquor plumbi suhaceiaL^ in the proportion of ateaspoonful to

i tumbler of water. For a few days a metallic shield over the nipples^

246

TUB PUERPERAL STATE.

tt> prevent tlie robbing of the night-dress or the bedclothes, is a Bouroe
of comfort.

DiuratioB of Lying-iii Period. — Most women expect permlBBion to be
given them to sit up upon the tenth day. Ttiere should, however, be
no fixed rnle abont leaving the bed which does not take into account
the individuality of the specific case, Not to leave the bed before the
tenth day is a safe rule in normal pnerperal convalesoence ; but, whe
there are wounds to heal by granulation, a much longer period of tin
may be necessary. Garrigues* expresses his conviction that *' the up
right and sitting postures ought to be carefully avoided until involutio
has proceeded so far that the uterus has receded from the anterior wu
of the abdomen and returned to the pelvic cavity" — a rule whicij
would allow one woman to sit up in a week, while another would
kept in bed two weeks, or even longer- The continuance of the lochij
rubra should serve as a warning against a change to the upright pod
tion. The first attempt at getting up should be tentative. The ]
sumption of household duties should be postponed until the patieia
can walk about without fatigue or backache. When the abdomina
walls are greatly relaxed, a well-fitted bandage should be worn for
weeks subsequent to delivery.

TnE Care of the New-born Infant.

As the new-born infant possesses feeble powers of resistance
cold, the first bath should be iiinety-eight degrees, or nearly that
the body. The vernix caseosa should be softened by oil or fat^inun
tion, and gentleness employed in its removal. The child should the
be gently dried in soft, warm cloths, and carefully examined wit
reference to any possible defect of formation or development. The
cord should be wrapped in an oiled nig, and held in place upon tli
left side by a flannel bandage, After the cord has separated, th
wounded surface should be dressed with a carbolic salve until the dis-"
charge ceases, f The dressing of the child is the province of the nurse^
and varies considerably in the different social ranks. Cleanliness
fresh air are essential to healthy development. To avoid aprue^
mouth of the child sliould be washed with cool water each time aft
nursing.

Selecting a Wet-Nurse, — Should the mother be unable to nurse 1
child, a wet-nurse should be urgently recommended. In selecting

♦ Gasiuiques, **Rest after Delivery/' *' Am. Jour, of Obstct.," October, 1880, p. 86L
f Dr. Goodell bgitx^s the cord, after it hoB betiu cut as UBtial, betweeti the thumb aod
forefinger of the k*ft hond, near tbe navel, and then strips ofF the gvlatine of WharioQ
with the thumb and forefinger of the right hand. The procure ftt the narel h ne
temporarily fiuapcndi^d where the mtemal portions of the Teasels oollapBe, The cor<i|
thereupon Bubjected to a second strlppiD^, tied in the usual manner, and left free witho
any dressing whatever. The rpsuit is, that !t Bcparates without any bad ameU. ( Vuk
Parry'a note, Leiahman'a ** Midwifery/' third American edition, p. 608.)

THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 247

liitteTy an exaniinatioii should be made with regard to her constitution
and health. The physician gbotild, by inspecting the throat, the legs,
the glands of the neck, and, if possible, the genital organs, exclude
the existence of a gyphilkic or strumous taint A nurse should bo
between twenty and thirty-five years of age, and should present all the
sppearances of good health. The gums should be red and t*rm ;
the breasU should preferably possess a pyriform ahui^e, and should be
marbled with blue veins ; it is not necessary that they should be large,
but they should be firm, elastic, and nodular from abundance of glan-
dular atructure ; the nipples should be well formed, prominent, and
free from cracks and erosions ; the milk should flow easily, and not
be too bluish in color. The age of the milk should bear some corre-
spondence to that of the child to be suckled. Aside from the question
of adaptability, it is obvious that, w here a great discrepancy exists, the
milk of the nurse is liable to fail before the time of weaning is reached.
One of the best tests of a nurse's capacity is the appearance of her
owtt child- If the latter is plump, with well-rounded limbs, and with
a healthy skin and mucous membranes, the presumptions are in her
faTor, even if she does not present in her own person, as Jacobi sport-
ively suggests, '* a combination of Aphrodite, Athene, and Psyche."
When a choice has once been made, a change should not be recom-
mended without a fair trial. It is by no means uncommon for a nurse
but recently separated from her child, placed among strangers, and
introduced to a foreign mode of life, to temporarily suffer from a dimi-
nution of the lacteal secretion, the milk returning in a brief period
under the infiuence of kindness, habit, and a nourishing regimen.
Moderate exercise is necessary for the maintenance of health. The
nne should be allowed to drink milk freely, but malt liquors should
prohibited, at least until toward the close of lactation.
Artifleial Feeding. — If it is impossible to procure the services of a
et-nuree, or if the aversion of the parents to wet-nurses as a class
profit unconquerable, artificial alimentation must be tried. It is un-
qtiailionable that many babies thrive fairly when brought up on the
bottle. For success, scrupulous cleanliness, punctuality, intelligence,
flod experience are requisite. The beautiful roundness of outline, the
Mm msff and the easy dentition of infants at the breast are, however,
rmrdy attainable by those who are brought up by hand. Bottle-fed
m&nt0 are apt to be lean, to be subject to attacks of indigestion, and
to mfler from nervous dii^turbances when teething. If cow's milk is
tiaed as a substitute for human milk, the experiment is more likely to
^ p rove a succscss in the country, where the milk can be obtained fresh
Hmiomtng and evening, than in the city where milk is, of necessity,' at
^Beast iwelre hours old at the time of delivery, and thirty-six hours
wold before a fresh supply can be obtained. My own experience inclines
to faTor employing, where it is practicable, milk from one cow,

248

THK PUERPERAL STATE.

especially if the caw is selected with reference to the child's tndlTidQ
aHty, precisely in the same manner as a wet-nurse would be selected. |
The fitness of the milk to the child is to be determined rather l)yi
experiment than by analysis* In a general way, however, it is well to
remember that the milk of a very young cow ia deficient in fat-glob-
ules, while that of an old cow is apt to err on the side of excseaite
richness, and that either extreme is equally liable to tax the infantik
organs of digestion.

The difference in the digestibility of human and cow's milk is depeQ
dont npoD a difference in the molecular arrangement of the caseine ?a
eties they respectively contain. The acid of tlie stomach precipitat
human cai^eine in the form of ffoccnleut shreds, while that of the eon
milk is converted into firm, solid masses. Now, of the two forms it hii
been experimentally proved that the former ia much more soluble in the
gastric juice than the latter. With many physicians the favorite plan
for neutralizing this objection consists in substituting cream for milk
(diluted at first with three and afterward with two parts water [Bie-
dert] ), and thus to reduce the quantity of caseine to minimum pro-
- portions ; but this diet, by confining the child ahnost entirely to the
hydrocarbons, to the exclusion of the prot^ine constituents, has neve
seemed to me in practice, even when well borne, to meet the full tiasii
requirements of a growing child. After many trials of this mixtn
which found a warm advocate in the late Professor Childs, of
city, I have finally returned to milk of good standard quality, stirrin
it before using to distribute the fat-globules evenly between the dif-
ferent layers, and adding to it water proportioned to the age of the
child, beginning with eight tablespoonfuls of milk to eight of water|_
increasing the one and diminishing the otlier a tablespoonful at
time as rapidly as the digestive organs exhibit a toleration of th
change. The water does not, of course, alter the chemical constitutioii
of the caseine, but aids digestion by provoking an increased flow of the
gaetric juice, and incidentally contributes to alleviate thirst (Jacobi),

City milk should be boiled to prevent fermentation, an unneces
practice when milk can be obtained fresh night and morning, Inst
of plain water, Jacobi has pointed out the utility of using some snfc
_ ace ** which by its physical consistence is able to hold the casein€
'clots in suspension, thus protecting the stomach from irritation, whilj
they are being prepared for dissolution." I have been in the habit of
following out to this end his earlier suggestion to employ an indif-
ferent substance, as gum-arabic or isinglass for very young children^^
and afterward a thin decoction of oatmeal or barley, according to th^|
tendency of the child to constipation ordiarrhiPik ^^

Condensed milk is pojuilar with many pliysicians, becanae children
with whom it agrees fatten upon it, and suffer but little from indi^
tion and loose passages. The large amount of sugar it containa

ACCIDENTAL COMPLICATIONa— ABNORMAUTIES OF THE UTERUS. 249

fits it, however, for prolonged use. I have seen a number of children,
exclnsively fed upon it, after passing through apparently a blooming
infancy, develop symptoms of rickets at the end of their first year.
I have, however, been in the habit of allowing its habitual use during
the first three months of existence, and in the city during the hot
months of summer.

Whatever the preparation selected, it should be warmed, before it
is given to the child, to blood-heat A small quantity of salt, and a
grain or two of bicarbonate of soda, or a tablespoonf ul of lime-water,
should be added to the infant's food, the former to promote assimila-
tion, and the latter to neutralize any free acid the milk may chance to
contain. When artificially reared, many children do not gain flesh,
in spite of apparently healthy digestion. I have often derived great
benefit after the third month from the addition to each bottle of a
tablespoonful of Ldfflund's Liebig's food for infants. Presumably the
various forms of malt extract now so popular in this country would
serve the same purpose equally well.

The bottle from which the child is fed should be scalded each time
that it is used, and should then be filled with cold water to which a
little soda has been added. The tube and mouth-piece should both
be washed, cleaned with a brush, and allowed to soak in cold water,
in the intervals of feeding. Unless every precaution is taken to prevent
the development of fungi, a bottle-fed infant will never prosper.

THE PATHOLOGY OF PEEGl^TAl^CT.

CHAPTER XIV.

ACCIDENTAL COMPLICATIONS,- ABNORMALITIES OF THE UTERUS.

Variola. — Rubeola. — Scariatina. — Scarlatina puerperalia. — Cholera. — Typhus, tjrphoid, and
relapsing fever. — Malarial fever. — ^Icterua. — Cardiac diseases. — Pneumonia. — Emphy-
sema, chronic pleurisy, and empyema. — Phthisis. — Syphilis. — Chorea. — Surgical oper-
ations during pregnancy. — Double uterus. — Antcversion and anteflexion. — Retrover-
sion. — ^Retroflexion. — ^Prolapse of uterus and vagina. — Hernias.

The pathology of pregnancy includes the various morbid condi-
tions which exercise an unfavorable influence upon pregnancy, whether
of maternal or fetal origin.

The maternal diseases comprehended under this title may consist
of simple exaggerations of normal disturbances, a class which has,
however, already received attention in connection with the chapter on

250

THE PATHOLOGY OF PREGKANCT.

tlie jnanagemetit of pregnancy ; accidental complications which mate-
rially infiuence the circulation or the integrity of the j>elvic orgaus :
and, tinuUyj, diseases of the uterus and the uterine appendages which
endanger tlie health of the ovum, or pave the way to its expukion.

The pathological processes which affect the oYum may be primaiTp
or may result secondarily from maternal disturbances.

The hseraorrhages of the first half of pregnancy and the prema-
ture expulsion of the ovum are ordinariiy the result of fetal or mater*
nal disease. Their consideration » therefore, forms a fitting conclusioD
to the subject-matter in hand.

The management of the haemorrhages occurring in the second half
of pregnancy requires a preliminary knowledge of the operative pro-
cedures of midwifery. Its consideration will therefore be postponed
until the principles governing the conduct of difficult labor have un-
dergone discussion.

Morbid states which exercise an unfavonible influence less during
pregnancy than after the development of labor will, to avoid double
mention, be considered in connection with the pathology of the latter
process.

Accidental Complications of Pregnancy.

Variola attacks pregnant women more frequently than any
other eruptive fever, and, although it manifests a preference for tho»
in whom pregnancy is not far advanced, its type is severer and its
prognosis graver when it affects women near their confinement

Variola is, unless of a mild form, a peculiarly dangerous eompliwh
tion of pregnancy, greatly imperiling the life of both mother und
footug,* through its tendency to metrorrhagia and abortion.

When the disease pursues its course without producing abortion, the
child may present characteristic variolous cicatrices, or the latter may
be absent. Occasionally the child remains unaffected by the disea^
until after birth, and may, sometimes, escape it altogether, Burtttg
epidemics of variola, women may, without manifesting other symptoms
of infection from the variolous poison, give birth to premature chil-
dren, who remain unaffected with the disease. Children sometime*
suffer from variola either before or soon after birth, while their mothers
enjoy complete immunity from the disease. f

The healthy child of a mother affected with variola, or of one vac-
cinated during pregnancy, may be insusceptible to vaccinia for some
time after birth,!

* McTBR, " Ucber Pocken, helm wciblichen Geschlecht," Berlin. ** Beitr. s. Oeburtslu,"
il, 1873, p. 197.

f BtiiROKiJKR^ ** Lehfbiich d. GeburtsU,/^ p. 364,

t BpiKQKLBKao^ ** Geburtek/* p. 26& ; Mai Runoe, " Die acute InfectiODskmnkhciten m
&tiologia«hG Bcsdehung zur Sctiwaiigerscbaftsuntcrbrcchiing/* Volkmann^s *' 8:uimiL klin.
VortrV'No. 174, p. 137«.

ACXTOENTAL OOMFLICATIQNS.— ABNORMALITIES OF TOE UTERUS. 251

ti It is advisable that all womeD, becoming pregnant during an epi-
mic of Yariola, should be immedititelj vaccinated.
Buboola is an infrequent compliciition of pregnancy, but is seriouB
^ aocotmt of its tendency to become hjemorrbagic and to produce
introrrhagia, fatal alike to mother and child. Pneumonitis is a very
frequent and dangerous complication of puerperal rubeola.

Scarlatina is a less frequent complication of pregnancy than vari-
ola, attacks primiparaB by preference, although not exclusively, and
manifests a decided tendency to develop itself in the puerperal state,
■en when infection baa taken place in the earlier months of preg-
Bncj. Okbausen* waa able to collect from all the medical literature
KluB disposal only seven cases of scarlatina occurring during preg-
^Bicy, while the number of cases taking place in the puerjieral state
^pounted to one hundred and thirty- four.

In the majority of recorded cases infection is, known to have been
only posisible at a time more or less remote from the confinement, and
tbe tardy development of the disease is, therefore, most rationally
leferred to a prolonged period of incubation, extending in some in-
stances over weeks or months.

AssTuning the correctness of this theory, we must infer that some
imknown condition unfavorable to the development of the scarlatinous
pQusoQ exists during pregnancy and is removed by parturition.

The mortality of scarlatina, occurring in pregnancy and in the
pfoarperal state, varies notably in different epidemics, although it is
iisiuilly high.T Attacks occorriog immediately after confinement are
more fatal than those developed later.

The stage of invasion may be entirely absent or may exist for one

I two days before the appearance of tfie eruption. When present, it

Kfaaracterized by intense febrile movement, emesis, and nobible con*

ion of the face* Usually, however, the earliest announcement of

I attack consists in the sudden development of the eruption on all

of the body. The eruption soon assumes a characteristic livid

por, which is usually retained until the fatal issue, should the latter

par within a week.

The pharyngitis and tonsillitis are either very mild or entirely ab-

It. DiarrhcBa is a frequent and dangerous complication. Aside

the abovo-mentioned peculiarities, puerperal scarlatina presents

important Taxations from the clinical history of ordinary scarlet

pr. The lochia! discharge, the lacteal secretion, and the uterine

rolotion are unaffected by the disease.

• OifliiArsKy, " FotCTauch, iib. d. CompUc, dcs Pucrp. m. Scarlat. u. d, fwg<maniitc &
Jw/* *' Arch. f. Gynaek.," is, 1876, p. 16& j Bhaxtok Hit its, '' Ttohb. of the ObsteL

(f Iknham mw onljr on« recovery In dghi u»d Hicks otil; four recoveries in e%htocii
, wblk McCUalook bad but ten f utal tcbuIu m tbirtj-four c^scb.

TOE PATHOLOGT OF PREGNANCY.

Antipyretic measures, particularly cool baths, are indicated in pro*
portion to the intensity of the febrile movement* Cathartics are to
be avoided, because of the inherent tendency to diarrha»3, alluded to
above. Stimulants are to be fearlessly employed when asthenic iymp-
toms arc developed.

Scarlatina Puerperalis. — Some authors have applied the designation
" scarlatina puerperalis '* to an infectious disease which, although le-
eembling scarlatina, is still said to be identical with or closely related
to puerperal fever. The theory advwated by them is based upon the
fact that, in the eases upon wbich their deductions are founded* the
angina was trivial in character ; the attacks occurred, usually, witkin
three days after confinement ; infection with scarlatinous poison could
not, in the majority of cases, be established ; the rat*.^ of mortality waa
very high, and i>eritonitis and cellulitis were often revealed on autopsy
Olahausen* concludes with appiirent justice, af t^r a careful review of
the reasons for and against the introduction of this new disease into
obstetric nosology, that the grounds for it-s esbiblishment are insufiB-
cient, and that the cases of so-called ** scarlatina puerperalis" are noth-
ing more than ordinary cases of scarlet fever, modified by the eoBOomi-
tant puerperal condition, but in no way akin to puerperal pyemia
or septicaemia. It is worthy of note that scarlatina and paerpend
fever may, in rare instances, occur in combination withont mutually
affecting their respective signs and symptoms, Braxton Hicks f advo-
cates the extreme theory that a puerperal woman, when infected with
scarlatina, develops puerperal fever, and that persons other than lying-
in women, contracting the disease through intercourse with the puer-
peral patients, are attacked by scarlatina of the usual form.

Cholera. — The predisposition, on the part of pregnant and puer-
peral women, to cholera Asiatiea is not usually decided, but variea
with different epidemics, and is more marked in cities than in the
country. Women are most liable to an attack of cholera in the latter
half of pregnancy, particularly in the seventh and eighth months, and
the prognosis is gravest for cases occurring at those periods. The
prognosis is almost necessarily fatal in the ciise of children born before
the ninth mouth. J The intensity of the disease is somewhat mitigated
by the existence of the puerperal state. Slight attacks of cholera may
take their natural course without prejudicial effects upon mother or
foetus, but the disease frequently results in abortion or premature
delivery, due, in part, to haamorrhagic metritis. The pathological
uterine conditions observed in the cases recorded by Slayjansky* com*

♦ R, OLSHArsEN^ loe. at.

t Brjlxtos Hjck5, '' Trans, of the Obstet. Soc. of Lon.ion," 1S71, pp. 44, 75.
X XJeb il. Eiiifluiia d. i\ nuf Sohw. «. Woclienbett/' ** Moaalsschr. t Oeburtsk," 1S68,
xxnii^ p. 60.

* Slavjansky, " EticJometrit. deciduiiUs bflGm. bci CholenikrtLiiken," "Xrcb, t Gynaek*,"
iv, 1872, p. 293.

ACCTDENTAL COMPLICATIONS.— ABNORMAUTIES OF THE UTERUS. 253

prised roaghening of the inner surface of the nterns by dark-yiolet
shreds of the decidua yera^ nnmerons extravasations permeating the
mucous membrane, which remained intact in some places and was
ulcerated at others, besides the presence in the uterine cayity of coagu-
lated bloody pus, and shreds of the uterine mucous membrane.

The placenta foetalis presented granular degeneration and almost
complete disintegration of the epithelium covering the villi. Both
pathological processes above described conspire to induce the death of
the foetus, which then, in common with coagula and inflammatory
products in the uterine cavity, acts as a foreign body and produces
abortion. Schroeder* refers the death of the foetus to asphyxia pro-
duced by changes in the maternal blood which interfere with the pla-
cental respiratory function. The clinical history of cholera is not
materially affected by coexisting pregnancy, except in so far as uterine
symptoms are concerned. Eclampsia sometimes occurs, and irregular
uterine pains may persist for several days without producing abortion, f
Cholera does not specially predispose to puerperal diseases, nor does
it afford protection against them. Lactation, whether commencing or
already established, is not markedly affected by cholera, although the
lochia are often almost suppressed.

The treatment is conducted upon general principles. The artifi-
cial induction of premature delivery has had many advocates on ac-
count of its supposed tendency to ameliorate the prognosis, but has
now fallen into disrepute, although judicious measures to hasten par-
turition, already begun by Nature, are regarded as justifiable.

Typhus, Typhoid, and Belapsing Fevers.— These fevers more fre-
quently complicate the earlier than the later months of pregnancy,
and affect the prognosis more seriously at the former epoch, owing
to the greater tendency then existing to protracted post-partum
hsBmorrhage.| They may also, rarely, complicate the puerperal
state.

Typhus fever manifests a less marked tendency to the induction of
abortion or of premature delivery than either typhoid or relapsing
fever, probably because it is less frequently accompanied by metrorrha-
gia.* It, however, occasionally produces these results, thereby essen-
tially increasing the danger of a lethal termination. I

Typhoid fever is frequently, and relapsing fever almost constantly,
accompanied by abortion or by premature delivery induced by profuse
uterine haemorrhages,^ and thus greatly endanger life. The clinical
history and the treatment of the fevers in question are unaffected by

♦ Schroeder, "Lehrb. d. Oebartsh.," 1872, p. 365. f Hbnnio, he. eit.

t Wallichs, *' Monatsscbr. f. Gebartsk.," zxx, H. it, 1867, p. 253; Spieoelberg
•* Handb. d. Geburtsh.," p. 260.

• ZUELZER, " Monatsscbr. f. Geburtsk.," xxxi, H. tI, 1868, p. 419.

I Walucbs, op. A^, p. 261. ^ Zuelzer, o/>. ei7., p. 424.

254

TH£ PATHOLOGY OF PREGNANCY,

coexisting pregnancy except ia so far as symptoms and indicationa
having reference to the oeciirrence of metrorrhagia, abortion, or pre-
mature delivery^ are concerned.

Malarial Fever, — Malarial fever is not a very frequent complicstio
of pregnancy, perhaps because the latter secures a certain freodoij
from exposure to the malarial poison. Women who have previonsl
experienced malarial fever, and who have been considered cured of 1
disease for several years, often suffer a relapse during subsequent pr
nancies.* Attacks occurring under these circumstances may be
garded as acute exacerbations of a chronie malarial disease which hai
remained latent for a certain time. Malarial fever does not produce
abortion except in rare in3tanoea,f even when the febrile phenomena
persist up to the termination of pregnancy. Parturition suspends the
periodic paroxysms, supposing them to have continued up to oonfine-
ment, possibly owing to the loss of blood dependent on delivery*
During the puerperal state, however, particularly in the second and
third weeksj the paroxysms usually return or a latent malarial cachexia
may manifest itself in the manner previously alluded to. j The disease
maybe communicated to the foetus, as has been proved by the detec*
tion of the characteristic pathological appearances induced by mala-
rial poisoning in the spleen, and hj the discovery of malarial pigmeiii-
granules in the blood and skin of children dying before or immediately
after birth.*

Hubbard | reported an interesting case of intra-uterine malarial
fever of the tertian type, in which the fetal movements were entirely
suspended during the maternal paroxysms, and returned during tbe
intermissions. The woman was confined during an intermission. On
the following day the mother and child had a simultaneous paroxysm.
Quinia was now administered, with the result of curing both moth
and child — the latter obt^iining the antiperiodic through the mediu
of the mother's milk.

The usual course of malarial fever is altered by coexisting preg*
nancy. Intermissions are usually wanting, and the fever become
continued or remittent, the chills occurring irregularly*'^ Eveii thd
cases which most nearly approximate the usual malarial course shoi
a tendency to anticipation or retardation of the paroxysms. The fever
may assume a pernicious character, ita tendency in this direction beii
accounted for by the nervous prostration and ansemia attendant uf
the puerperal condition. Quinia best controls the febrile phenome

• Robert BAR^rES, '^Traoa. of the Am, Gju. Soc," 1876, p. 144.
f Max Runge, Volkraanii-s " Samml klin. Vortr./' Na 174, p. 10, 18Y6.
t SprEOELBERO, ** Geburtsh./* p. 251. *> Kax Rcxqk, loc, dL

I HuBiiJna>| ** Edinburgh Med. Jour./' June, 1866,

^ Mkndkl, *' Intermittens wahread Scliwangerachaft uud Wocbcnbett/* ** MoQAti
Oeburtak.," Bd. xiiit, H. i, p. 10.

AGCmENTAL OOMPLICATIONS,— ABNOEMALITIES OF THE UTERUS, 255

[hat must be given in large doses, since the powers of digestion and of

mmilation are seriously impaired by the puorpenil state,*

Icterus. — Icterus, although a phenomenon of rare occurrence dur-

in^ pregnancy, is interesting and importiint on account of its tendency

<^ precede or to accompany the fatal pathological changes and symp-

^matic events connected with acute yellow atrophy of the liver. It

*s ordinarily assumed that this grave general disease is developed

^tt>m a form of icterus which, when complicating pregnancy, uanally

Ijaa etiological relations identical with those of simple ohstruetivo or

*<Msalled hepatic jaundice, although the causative condition frequently

eludes observation. The development in pregnancy of icterus termi-

mting fatally is, also, sometimes due to the lesions of phospliorus-

poisoning. Davidson f attributes the fatal influence of pregnancy

upon the course of simple icterus to the three following causes : 1.

The impairment of the renal excretory function, due to the passive

Dgestion produced by uterine pressure upon the renal veins. This

tiolcgtcal factor operat-es by causing the retention in the blood of the

[>rb€d biliary acids, which, according to the investigations of

rraobe and others, are of themselves capable, even when present in

the blood in moderate qmmtity, of producing acute yellow atrophy.

■9. The hydra?mia of pregnancy, which renders the system less capable

^^pt reeistance to toxic agencies. 3. The impairment of cardiac activ-

^■l5» duo to the retention of the biliary acids, which still further com-

^Bromises renal el i mi native action. Icterus often produces abortion by

^Rfidtroying the life of the feetus. The causative connection between

ictenu and fetal death has been proved by the intense icterus of the

deed fcDtus, by the detection of biliary acids in its blood, and by the

eselo^ion of other causes. After abortion a previously benign icterus

mjr ipeedily develop all the characterii^tic lesions and symptoms of

e yellow atrophy. J Under these circumstances, the sudden advent
& fatal symptoms may be accounted for by the anaemia and hy-
ia induced by the haemorrhage accompanying parturition. As-
^■liBiiig the correctness of the above-mentioned deductions with refer-
Htooe to the usual etiology of fatal icterus compheating pregnancy,
^pt^ must admit the urgent indication in these cases for measures cal-
^^[ilat4?d to facilitate the elimination of the biliary acids from the blood
bj iBfltoring the normal excretory function of the kidneys. An early
resort to appropriate measures might, partially or entirely, prevent the
aocoinubition of the poison upon whoso presence such baneful results
ire beltered to depend.

• Bahkicr, id a paper lenncd ^* Puerperal Malarial Fever " {" Am, Jour, of Obstct,**
April, tsSOK furnishes a most Taluable addltioa to our knowledge of tbo symptoma
•Old IfVAlmont of this dificase.

t Da wtmnyi, "Hooat^dchr f, Geburtsk," Bd, xix, U. vi, 1867, p, 4G5.

I Baaomn, ** Lehrbuch d<^r Gcburisb.," p. SOd.

sde

THE PATHOLOGY OF PREGNANCY.

Cardiac Diseases,— The various effects produced upon pregnancy
by coexisting heart-di.sease depend entirely upon the seat and character
of the cardiao aflfection. Wiiile the resulti^ of myocarditis are R?ri-
ouB, because of its interference with tlie development of cardiac hyp&t-
trophy adequate for the comj^ensation of existing valvular lesions, and
acute endocarditis, occurring during pregnancy, shows a marked ten-
dency to assume the fatal ulcerative form,* pericarditis has no percep-
tible effect upon the normal course of utero-gestation.f Oironic en-
docarditis often produces disastrous results, which may, in general
terms, be accounted for by the fact that an amount of cardiac hrp.-r-
trophy completely compensatory for preexisting valvular legions i^ m
longer able to overcome the increased arterial and venous presfinre
prevailing during pregnancy, or to adapt itself to the sudden variations
in vascular tension due to the parturient act. The augmented arteri&l
pressure which calls for increased cardiac activity is referable, in part
t^ the newly developed utero-]>lacental circulation* It is also attrib-
uted by some authors to the actu^il pressure of the gra\id uterus upon
the aorta; while SpiegelbergJ believes it to be me-asurably due to
the plethora of pregnancy, and to the limitation of the intra-thoracnc
space by the encroachments of the diaphragm. An important source
of varying and perturbed heart-action is, moreover, found during labor
in tlie suddenly changing conditions of pressure produced by the alter-
nriting uterine contractions and relaxations with the correspomling
violent respiratory efforts.

Spiegelberg * refers the symptoms of aortic insufficiency or stenosis,
which are usually most marked in the later months of pregnancVt
solely to cardiac disturbances due to increased arterial tension, and
disappearance of these symptoms, after birth, to the restitution of
normal pressure. He considers the grave symptoms of mitral disea
often presenting themselves soon aft-er confinement, as referable to \
cessive distention of the right heart with blood forced into it from \
coDtraeted uterus. Fritsch | opposes this view, and attributes
morbid phenomena of mitral di.sea»se to the accumulation of blood
the abdominal vessels recently released from the pressure of the graf
uterus, and to the cardiac paralysis resulting from an insufficie
blood-supply and consequent defective nutrition of the heart.

The hydrfBmiaof the puerperal state may contribute to the impair-
ment of nutrition, and thus cooperate with the above causative agen-
cies in the production of cardiac paralysis.

♦ Ledkrt, "BcUr, zur Casuistik tier Herz- um! GefasskrankhDJten im Paerjieriuni,"
"Arch. f. Gyimok./* Bii. iii, 1872, |>. y0.

t PoRAK, '* Do I'infl. reeip, de In gro«a€iB»e et d<»s lual, de cceur," 1880, p, 92l

X SriEGKLBEEo^ *' Amli. f. GyiiJiek./* ii, 1871, p. 236,

^ SwEGKLPERo, '* Ucbcr d. Comp. dos Puerp. in. chron. Hcntkr./* ibid., ii, IS71, p, 23$.

I FftiTSCti, " Die GefahrcD d. Mitralisfcblcr," ibid., vlU, I8t6, p. SSI.

ACCIDENTAL COMPLICATIONS.— ABNORMALITIES OF THE UTERUS. 257

I The symptoms of aortic valvular disease are usually manifested

during the latter half of pregnancy. They consist in palpitations,
^dyspnoea, and, in extreme cases, abortion or premature delivery.
^■hould pregnancy proceed to a normal termination, the symptoms are
^Aggravated by parturition, but disappear speedily after it. Mitral
PValTular lesions, if slight or completely compensated for, may not
manifest their existence by any rational symptoms. If, however, the
I compensation be inadequate, the patient's life may be greatly and
' Bometimes suddenly endangered by the occurrence, either before
or after confinement, of extreme pulmonary congestion and cedema,
incites, albuminuria or metrorrhagia. The fo?tus may die in ukro,
the result of metrorrhagia or of impaired nutrition due to defi-
nt oxygenation of the maternal blood. Children whose mothers
the victims of cardiac disease are often imperfectly developed, and
isposed to untimely death. The prognosis is based upon the gen-
coudition of the patient. It is impaired by coexisting pulmonary
i, tending to obstruct the circulation in the lungs, as well as by
diseases of other vital organs. Mitral lesions are of more grave signifi-
canoe than those at the aortic orifice, and mitral stenosis is particularly
dangerous.^

Women with cardiac disease of any considerable gravity should be
dimiaded from marriage. The indications for medicinal treatment
lie Uie game as for cardiac diseases uncomplicated by pregnancy.
Cliloroform should be administered with special caution, if at all, dur-
ing parturition. The artificial induction of abortion or of prematuro
Mirery may be justified by the occurrence of symptoms menacing the
aether's life.

Acute Lobar Pneumonia. — Pneumonia attacks women less fre-
foentlj than men. Its rat© of mortality is, however, much larger
aoioflg the former. These facts should be remembered by investigar
t oTO of the reciprocal relations between pneumonia and pregnancy, in
^Krier that the influence excited by the former upon the latter be
^Hot exaggerated. Pneumonia is an infrequent complication of the
Hpregnant state, but affects the course of the latter very prejudicially. f
f Although a pneumonia of large extent may terminate in complete
»Tory, without having endangered the life of mother or fcptus^J it
ten produces abortion or premature delivery, the frequency of these
Iti increasing in direct proportion to the duration of pregnancy.
ty|»e of the pulmonary inflammation is also more severe in
lo latir stages of utero-gestation, and parturition exerts an unfavor-

* FbftAX, op, fit^ p, Uii\ Fnrrsm, op. nV., p. 383.
f VAsmmintM, " Cebcr P. aU Schwangcrscli. Complicate/* ctc.» '* Bdtrilg z. Geburtah,/'
inu, aiUgnber,, p. 54.
{Gimaow, "Fo, b. ScHwingcron;* "Monilaschr. f. Gcburtsk.," xxiti, H. ii, ISfiS

THE PATHOLOGY OF PREGNANCY,

able effect upon women in proportion as their pregnancy is far ad*
vanced**

It was formerly believed that pneumonia, occurring during preg-
nancy, owed its fatal character chiefly to the encroachments of the
gravid uterus upon the intra*thoraeic space, and to the consequent
interference with the necessary compensatory increase of functional
activity on the part of the healthy lung-tissue* Later investigations
having not only shown the fallacy of this theory,f but even rendered
probable an actual increase in the intra-thoracic space during preg-
nancy, J the fatal character of intercurrent pneumonia is referred to
coexisting hydraemia, and to tlie inability of the poorly nourished
heart to restore the balance of a pulmonary circulation disturbed by
tlie consolidation of lung-tissue and by the consequent impermeability
of large capillary areas. Pulmonary oedema, resulting from progr?i-
sive cardiac asthenia, directly induces the fatal issue. Parturition
itself, whether naturally or artificially produced, greatly imperils the
woman's life ^ by making exorbitant demands upon the already failing
heart-power and by aggravating existing hydraemia. Abortion, when
occurring under these circumstances, is referred to fetal death caused
by detieient oxygenation of the maternal blood, by placental ansmia
produced through an inadequate supply of blood to the left heart, ami
by the abnormally elevated maternal temperature, || From the fatal
results of parturition in pneumonia we conclude that the induction
of abortion or of premature delivery, in ordinary cases, is unjustifi-
able.^ Should labor» however, have already begun, its termination
must be hastened by all available means. Oar further treatment most
consist in efforts at strengthening the heart's action. Brandy and c-ar-
bonate of ammonia, digitalis and quinia, deserve the most con6dence
for the fulfillment of these indicationg, Wemich recommends cautioaa
venesection, for the relief of extreme dyspnoea or cyanosis, and pro-
poses that the collapse to which bloodletting may lead be combated b|
ti*ansf usion* ^

Emphysema, Chronio Plearisy, and Empyema,— These affections \
dangerous complications of pregnancy, in that they produce car
dilatation, and prevent the heart from successfully adapting it^ activity
to the varying conditions of vascular tension obtaining in parturition
and the puerperal state. The induction of abortion or of premature
delivery may be indicated by the existence of these diseases, ])ravido
the mothers strength has become so impaired as to incapacitate
for continued utero-gestation.

• WKRmcH, *• Beitrftg. z. Get>tirtBh.," iii, 18H, Sltzgsb., p. Q6.

f OuasKROw, op. eii.y p. 68.

t WuiifiCH, Berlin, **Bcitrig. z. Gcburtab.," li, 18Y8, p. 249.

^ FxsnENDKK, op, rU., p. 56, | SriEOKLUKitrt, ** L«hrbi. d. Qeburtoh.," p. ]

A Wkbiucb, op, ci(.^ p. 2fll. SciooicDttt, "■ Lebrb, d. GebttrUk/' p. \

ACCIDEKTAL COMPLICATIONB.—ABNORILILITIES OF TDE UTERUS, 259

PhtMsis. — It was formerly erroneously held that pregnancy afford-
ed immunity against pulmonary phthisis. This view may have been
based upon the clinical fact that the progress of preexistent phthisis
is Bometimes retarded by the supervention of pregnancy.* This re-
sult is observed, according to Lebertjf in only a small proportion of
cases. In the majority of instances pregnancy not only hastens the
i of actually existing phthisis, but precipitates its development.
ae latter result ia of especially frequent occurrence in those heredi-
ilj predisposed to the disease, or in such persons as may have re-
from a previous attack. These effects of pregnancy upon the
Bvelopment and course of phthisis are most manifest between the
twenty and tlxirty years, although they are not infrequent be-
\ the ages of thirty and forty. The advanced stages of phthisis
inception, but the same is not true of its earlier periods. The
1 state often favors the development of phthisis, particularly
in those hereditarily predisposed to it, and usually hastens the fatal
^pue of the disease if it have already manifested itself. In very ex-
^hptional instances, however, parturition and the postpartum state
^kert a favorable influence upon the course of phthisis. It often
^lapjiens that women with inherited tendencies to phthisis may escape
it during their first pregnancy, only to become its victims in a later
ooclI Although women with progressing phthisis may pass through
tlie parturient and puerperal states in safety, they are greatly prostrated
thereby, and rarely have sufficient milk to nurse their children. They,
moreover, often experience abortion or premature delivery. The chil-
drtii of such women are usually puny and feeble* They are slowly
and imperfectly developed and are predispf:)sod to pulmonary disease.
Prophylactic treatment affords the only encouraging prospects of sue-
eem in the cases under consideration. Girls w*ith suspected hereditary
pfiedtfipOfiition to phthisis should, accordingly, not marry, as they
ghoold not become mothers. If they do bear children, they must never
nxam them.

Syphilis. — When syphilis, which is a frequent complication of preg-
lumcy, is contracted at the beginning or during the course of the latter,

Kis characterized by intense initial and by unusually mild consecutive
tnptoms.^ The duration of the incubation is, ordinarily, about two
lekRy but may be protracted to six weeks. The initial lesions, which
art more extensive than in women who are not pregnant, may involve
tbe vagina, cervix, labia, nates, and thighs. They embrace swelling,
reddemog and excoriation of the mucous membrane and skin, oedema^

• WnuRcn, " Berlhi. Beitr&g. z. Geb.," ii, 1873, p. 251,

f Lanr, ** Tithes Tab.d. weibUclL G^achlechtsorgane;' •• Arch, f, Gynaek,/* ir, 1872.
p, 4€f . I SniauLDEHG, " L<?hrb, d. Gcburtsh./* p. 266.

■ fUoMUTio, '* Dcbof d. Yeriaof d. 8. bei SohwwigerBchaft," ** Wiea, med. Ppbmc," xlv.

THE PATHOLOGY OF PREGNANCY.

eczema, follicular abscesses, and even necrosis of connective tiasueL
These intense inflammatory processes may be referred to increased
nutrition of the parts, and to the mechanical results of friction be i
them. The secondary symptoms are of a mild type, consisting t
of general glandular induration, papules on and around the gemt4iid|
and scales on the palms and soles. Mewis * states that the occurreoee
of piirttirition has a favorable effect upon these lesions, usually result-
ing in their disappearance* Erythema, pharyngitis, alopecia, iritis,
and febrile movement are either absent or slightly marked, Pregnanl
women owe the mildness of their secondary symptoms to amelioration
of t!ieir general nutrition. Syphilis exerts a very prejudicial inftuence
upon t!ie product of conception. If either parent be affected with
genera! syphihs at the time of the coition resulting in impregnation,
syphilis is coramnuieated to the foetus. It is almost equally impos-
sible for a fcBtua poisoned by the paternal reproductive element to
infect a healthy mother. Provided the mother were untainted at tbe
time of conception, syphilis contracted by her during pregnancy can
not be communicated to the f'oetug. If the father be sy{>hilitic, the
infection of the ovum is accomplished by the diseased spermaiozoida.
If the mother be constitutionally tainted, the ovum is already poi-
soned. Should both parents be the victims of general syphilis, each
equally bequeaths the disease to the offspring.! The syphilitic poison,
therefore, will not traverse the septa intervening between the fetal
and the maternal vascular systems.J In rare exceptions to this general
rule the mother contracts the disease by so-called choc en retour,*

A progressive and continuous diminution in the intensity of fetil
syphilis, directly proportionate to the length of time which has elapsed
Biuce the contraction of the disease by the parent who communicated
it, is observed in cases unmodified by treatment. Parents wh<«e
syphilis is allowed to pursue its natural course retain the capability
of transmitting the disease to their offspring for varying periods,
the average length of which is ten years. Latency of the parental
Byphilis does not secure immunity of the foetus from the disease,
although it diminishes the probability of its transmission. Parents
with tertiary sjqihilitic symptoms may or may not communicate the
disease to their children, according as the poison whose original pr
ence produced the gummata is still retained in the system, or
been eliminated by nature or by mercurials. | In accordance with
varying intensity of the hereditary influence, the foetus may either
perish iw uteroj its death resulting in abortion orprematare delivery.

• Mewi.% '^SypUiUs coD^enitV "Ztachr, f, Geburtsh, u, Ojniiek.,** It, 1879, 1^ p, 6t.

f Kassowitz, "Die Vcrerbiiog d. SjpMUa," Strieker's "Mod. Jabrb./' p. 872.

t KASsowirjc, loe. cit.^ p, 425,

^ FoXjntBL, ** ITebftr PUcctttiirjyphiUa/' ** Arch, t Gynaek./* ?, 1878, p. 44.

I &AA80WITZ, op, cU,, p. 451.

ACCIDENTAL COKPUCATIONS.-^AB NORMALITIES OF THE UTERtTS. 261

maj be born alive but destined to die early, or may manifest the dia-
esse only at the expiration of periods varying from weeks to years.
Conception occurring during the first yeare after the parents' infec-
tion with syphilis almost invariably terminatea in abortion or premar
tor© delivery, the causes of which are either the vitiated nutritive
procesBefl of the foetus, the increased maternal temperature due to
gjrphilitic fever^ or syiihilitic degeneration of the fetal placenta, con-
sisting, according to Mewis,* of iuflammatory changes in tlie tunica
intima of the blood-vessels. Similar pathological changes are said^ by
tlie same author, to occur in the intima of the umbilical vessels* The
pathological conditions observed in syphilitic disease of the placenta
are either granular degeneration of the placental villi, with obliteration
of the blood-vessels, or the morbid changes designated by the names
endometritis placentaris gummosa and endometritis decidualis.f (For
a more detailed account of placental syphilis, vide chapter on placental
diseasea.)

Every pregnant woman who, at the time of conception, is or has
been affected with constitutional S3ri>hilis, should be promptly subjected
to a thorough mercurial treatment, preferably by the method of in-
onction. This is desirable, even when no present symptoms are de-
tectedf with reference to the prevention of the frequently disastrous
inflaenoes of latent syphilis. If, however, the disease be contracted
during the later months of pregnancy, the treatment may consist of
palliative measures, until after parturition, since no harm will result
boni the maternal 8y]>hili8 to the fetal life. Local primary or sec-
ondary disease of the genitals should receive appropriate treatment, in
order that the child be not infected during delivery-
Chorea in Pregnancy. — Chorea, which is a rare complication of
pr^nancyt affects primiparsB by preference* particularly those possesa-
tDg an hereditary predisposition. Barnes J was able to collect only fifty-
nx and Febling ** only twelve additional cases from the whole domain
at obstetrical literature.

Organic cerebral lesions are assumed by Spiegolberg || aa estab-
lished causes of the disease. In regard to other etiological agencies
wide diversities of opinion prevail. According to Goodell,^ the
choreic movements are of reflex nature, and are referable to im-
paired nutrition of the central nervous system, incident to the hydra&-
mia of pregnancy. The association of chorea and organic cardiac
di aoo a o has been frequently observed, and the discovery, in certain
eaaas^ of fibrous vegetations upon the mitral and aortic valves accounts
isamption, by some authors, of embolism as a cause of chorea.

, he, tii,, p. 43* | Faankkl, op, tU,^ p, 62.

t B^yurcs, *^Tnn^. of the Obst^t, Soc. of London^'' %, 1S60, p. 141
• nmuno, *MrclL f. Qyiuek.," rl, 1874, p, 137. | Spieqkldebo, **Lehrb.,»* p. 256.
^ G<K)tiictX| TAiQ. Jour, of ObBt«t.,*' May, U1Q, p. 140.

THE PATHOLOGY OF FREGNANCT.

Barnes* discountenances this view, and calls attention to the probable
causative agency of myelitis. Terror and other intense emotions maj
act as exciting cansos of chorea.

Choreic movements occurring in pregnancy do not differ from
those attending the disease in the nnimpregnated state. They are
usually bilateral. In most cases the muscular contractions manifest
themselves in the earlier months of pregnancy, and continue until
delivery is accomplished. In rare instances they are arrested at the
beginning of parturition. In still more exceptional cases the contrac-
tions may either cease before delivery or persist during the post-partum
state. Transitory albuminuria and diabetes mellitua are occasianal
unex]>luined complications of chorea gravidarum, and the phosphate
and urates of the urine are present in abnormal abundance. Abortion
and premature delivery, due to the repeated suecussion of the uteruA,
ai-e of very frequent occurrence.

Chorea exerts a prejudicial influence niK>n the course of preg-
nancy,! having interrupted it in about one half tlie recorded cases.
Death of the mother resulted in seventeen of the fifty-six cases
collected by Barnes, J The lethal termination was usually re&rabld
to the exhaustion consequent upon protracted muscular exertion, or to
hemiplegia secondary to grave cerebml or spinal lesions. The Hfe of
the child is less frequently sacrificed, but it is itself often affected
with chort^a.

The treatment consists in the administration of iron and quinine,
and the lowering of the reflex excitability by the prolonged use of the
bromide of potassium. During the attack, chloroform, chloral, and
the subcutaneous injection of morphia have proved Berviceable. When
palliative remedies prove fruitless, in view of the perilous nature of the
afiEection, artificial labor or eTcn alx*rtion is indicated.

Surgical Operations during Pregnancy. — Massot ** concludes, from
the observation of a considerable number of cases, that ordinary .twr^-
cal operations do not interfere with pregnancy unless they materially
and permanently disturb the uterine circulation, or call into activity
the uterine muscular force by reflex irritation. This will, most
frequently, be the result of operations upon the external or inter-
nal genital organs, Cohnstein | states, as the result of his Fesearehejt,
that, after operutions and injuries, pregnancy reaches a normal
termination in 54-5 per cent, of all cases. Interruption of preg-
nancy was, in his cases, determined : (a) by the period of pregnancy

• Babiibs, he, eit^ p. 17t». f Goopeli., ** Am. Jout. of Obstet.," toI. Tiii, p. 1«8.
t Babnks, ** Tran3. «f tlie Obatet, Boc of London," x, IS 69,

* Massot, '* Uebcr d. Einfiua« traumat. Einwirk. auf d. Verlauf dor SchwiuigerBdiaft,^
Schmidt'd *' JahrK," 1874, 164, p. 206.

I Cohnstein, **Uebcr chirurg. Op. bei Sobirangereii," Yolkmwm^i "SuDtal. kilo,
Vortr,,'' No. m, Un, p. 493, "

ACCIDENTAL CX)MPL1 CATIONS.— ABKOR MA LITIES OP THE UTERUa 263

when the operation took place, occurring more frequently as the result
of ffurgical measures resorted to in the third, fourth, and eighth
monthd ; (6) upon the seat of the operation, resulting in two thirds
of nil coses, from operations upon the genito-urinary organs ; (c) upon
the extent of the wound^ following aniputiitions^ exartieulations, and
orariotoniies with great relative frequency ; (d) upon the number of
children, occurring in multiple pregnancy with uniform regularity.
Age seemed to exert no causative influence. Abortion directly results,
under these circumstances, from reflex irritation^ or from fetal death
referable to hiemorrhage or to septic poisoning on the mother's part.
The prognosis, so far as the mother is concerned, depends upon the
tame when delivery occurs. The mortality ordinarily attending de-
liTery, if at term, is insignificant ; for abortions and premature de-
li reries it amounts, according to Cohnstein, to thirty'tbree per cent
The most frequent causes ol the mother^s death are shock, iieritoni*
ti% septicaemia, hsemorrhage, and oedema pulmonalis. In view of the
manifest danger from openitions of any magnitude* it may be stated
aa a general law tljat surgical measures not absolutely indicated by
the existence of pathological conditions liable to aggravation by
didayed interference should be postponed until after confinement
Tboee morbid conditions, however, whose development is hastened
hj pregnancy, or whose existence offers mechanical obstacles to par-
rition, must be early subjected to operative interference. This re-
k applies with special force to carcinomatous growths in any part

f the body and to intra-pelvic tumors.
The time of operation should not coincide with the menstrual
h of pregnant women, as abortion is more likely to occur at that
nod,* For a similar reason it is recommended that the third,

fourtli, and eighth months should be avoided. JVIassot is of the opin-
ion t that anseathetics, when employed during ojieratious on pregnant
vomen, exert rather a favorable than a prejudicial effect upon fetal
life by diminishing reflex irritation.

^^^H Abnormal Coxditioks op the Uterus.

^^^Bbonble Uterus. — Double uterus occurs under various forms. The
^Bterufi and cervix may be double, the vagina remaining single. The
^B|H|||a uterus may have a single cervix opening into an undivided
^mPB The uterus, although double, may have a single cervix open-
ing into a double vagina, the septum beginning at the os internum ;
nr nlefti8y oervix, and vagina may be double throughout.

All these forms permit of normal utero-gestation on either side
or on both sides simultaneonsly, provided that each half of the genital
be aufificiently developed. If, however, the dividing septum ex-

• 8rt«airt.BtRa, " LchrK d. Gcburtah,/* p. 268.

THE PATHOLOGY OP PREGNANCY.

tends quite to tlie Yaginal entrance, simultaneoug pregnancy in each
horn IB exceedingly rare.*

II pregnancy occur in only one side of a double uterus, a decidua
vera is developed In the other side, and expelled at the end of pr
nancy. Double uterus is less readily diagnosticated during pregnane
than after or before it, but ia usually recognized with facility. A
double vagina is not necessarily indicative of doable uteros, but if
two vagina? are found, each containing a cervix, the presence of double
uterus may be safely assumed. If a double cervix terminate in an un-
divided vagina, the uteraa may or may not be double. When preg-
nancy exists in only one horn, the uterine development is manifestlv
unilateral, and the existence of an unimpregnated half may be deter-
mined by combined manipulation or by the uterine sound. In these
cases presenting a double uterus with a single cervix and vagina, the
diagnosis rests chiefly upon unilateral uterine development and de-
pression of the fundus and body corresponding to the septum. The
form of a double uterus is most plainly manifest during the contrac-
tions accompanying and succeeding parturition.! It is still undecided
whether double uterus be a cause of abortion and of premature de-
livery. Ordinarily, however, the symptoms and course of pregnancy
are unaSected by this malformation* The complete functionid inde-
pendence of the two segmontB ii demonstrated by the fact that in
twin pregnancies parturition is frequently not simultaneously accom-
plished by them* In the case of unilateral pregnancy, the ratio of
head to breech presentations is, according to Schatz, as twenty-one to
two. Tedious labor may result in cases of double uterus, from uterine
atony^ referable either to imperfect muscular development of the preg-
nant horn, to its deviation from the normal |>elvic axis, or to obstruq
tion produced by the unimpregnated horn. Fosi-parium ha?morrha
may result from uterine atony or from attachment of the placenta 1
the septum, whose imperfect development prevents its firm and thor-"
ough contraction.

Ante version and Anteflexion. — The normal ante version of the un-
impregnated uterus is exaggerated by the increased weight of the
gravid uterine body, but this deviation is usually rectified by the
gradual development and upward movement of the uterus. In excep*
tional caj^es the anteversion persists after the fourth month, and pr
duces vesical tenesmus, dysuria, or incontinence. No evidences
uterine incarceration are, however, observed, and the comparatively
trivial symptoms are relieved by regulating defecation, replacing the
fundus, causing the patient to assume the dorsal decubitus, or by ad-
justing an appropriate pessary.

• ScHROEDER, '* Lchrb. d. Gebartsh.," p. 3T0.
f ScHJLTX, ^' MHtb. ftus d* Letps. G^t.-klinik
1871, p. 207.

1. Pobklmik," *^ Arcli. f. GjAftek.^**]

AOaDRNTAL CO^IPUCATIOKS— ABNORMALITIES OF THE UTERUS. 265

In the later stages of utero-ge«tation, anteversioo combined with
Sexion may again occur, and produce the deformity known as
lulous abdomen* It is, then, chiefly due to the inadequate sup-
port ailorded to the uterus by the abdominal parietes. The failure of
their sustaining power is referable to their relaxation — ^which is most
marked in multipane — to separation of the recti muscles^ or to the
yielding of old cicatrices produced by operations or injuries* The dis-
placement is also favored by lordosis of the lumbar vertebrae, and by
contracted pelvis, which prevent the normal descent of the uteims. In
extreme cases of pendulous abdomen, the uterus, having separated the
recti, descends, covered by fascia and skin, almost or quite to the
kiiees> and seriously interferes with locomotion. Its pressure also pro-
doces cedema of the abdominal wall, vesical tenesmus, and pain in the
distended cutimeous tissues. These eymptoms are relieved by repo-
fiition of the uterus, and by the application of a suitable abdominal
bandage.

Betroversion. — Retroversion, a comparatively infrequent form of
diysplaoement in the unimpregnated uterus, usually rectifies itself dur-
ing the earlier months of pregnancy. Should spontaneous restitution
not occur, the fundus being detained below the promontory until after
the third month, the cervix bends upon itself at an acute angle, and
ihe retroversion is transformed into a retroflexion*

Betroflezion. — Retroflexion occurs infrequently in women who have
not borne children, but often renders sterile those who are tlius aiect-
ed* It ig one of the moat common uterine displacements in women
who have borne childreo^ though it does not, in their case, ordinarily
prevent conception. When conception occurs in a retroflexed uterus,
the latter usu^y risea from the pelvis, and assumes a position of ante-
version at the fourth month. In many cases, however, the displace-
jnent produces congestion of the uterine mucous membrane, metritis,
Eld abortion. In still other cases the fundus does not ascend above
be promontory at the uaaal time, and either the symptoma of retro-
txion with incarceration arc slowly developed, or that form of retro-
mon known as partial retroflexion, or retroflexion in the second half
pregnancy, occurs. This consists in the division of the uterine
irity into an anterior and a posterior diverticulum or pooch. The
■ior diverticulum is produced by tlie more mptd upward dcvelop-
it of the anterior uterine wall, which is subjected to comparatively
ight pressure and contains the larger part of the foetus. The poa-
iot uterine wall enters predominantly into the formation of the
erior diverticulum, and usually contains the fetal head. This
peculiar form of uterine displacement may be spontaneously rectified
dttring pregnancy, or may persist until delivery, producing no impor-
t4Wit nymptoms except vesical and rectal tenesmus, with dysuria and
painfiil defecation. In the latter case it materially interferes with par-

2G6

THE PATHOLOGY OF PREGNAN^CT.

tnrition, inasmuch as the cervix, which is displaced upward and for-
ward behind the symphyj^is, is not situated in the pelvic axis, and the
posterior diverticulom is forced by the uterine contractions against
the perinieum and poaterior vaginal wall. Even at this stage Nature
may restore the uterus to its normal position ; but, in default of gpon-
taneous restitution, it must be replaced by forcing up the posterior
diverticulum with the hand introduced into the rectum, while the an-
terior pouch is displaced downward by pressure upon the abdomen and
by traction applied to the cservix ; or, where version is practicable, by
bringing down the breech, room maybe made for the relea^ of the
imprisoned licad.

Retroflexion of the Gravid Uterus, with Incarceration.— Although
this form of retroflexion is usually developed in the gradual manner
above described, it may, in rare instances, bo rapidly produced by sud*
den abdominal compression or concussion.

The symptoms, which are in either case essentially the same, differ
chiefly in the varying rapidity of their development, and result from
the pressure of the displaced uterus upon the intra-pelvic visoor
tissues. They embrace dysuria, eventuating sometimes in con .
retention of urine from urethral compression, vesical tenesmus, incon-
tinence of urine, painful defecatioo, constipation, or obstipation, vio-
lent sacral and kunbar pains, which radiate into the thighs, and in
grave cases emesis, with all tlie other symptoms of ileus. Abortion,
followed by spontaneous restitution and recovery, may occur even at
this stage. Should incarceration, however, persist, violent metritis,
parametritis, and peritonitis may lead to a fatal issue. In rare cases,
gangrene of tlio uterus or vagina may be induced, A lethal termina-
tion may also indirectly result from pathological processes in the blad-
der occasioned by retained and decomposing urine. These morbid
processes consist in cystitis, sometimes complicatt*d by diphtheritic and
gangrenous inflammation of the mucous membrane and of the deeper
vesical tissues, which may lead to septicaBmla or to rupture of the blad-
der. Death may, moreover, result from passive renal congestion and
ura?mia.

The diagnosis of uterine retroflexion with incarceration is based
upon the foregoing elinical history; the fluctuating abdominal tumor,
from which large quantities of urine may be obtained by the cathet^^
or by puncture; the a?deraa of the \Tilva ; the presence in Douglad^l
cuMe-sac of a tumor presenting the chanicteristic consistence of uter-
ine tissue ; the position of the cervix and meatus urinarius behind the
symphysis ; and t\m distention of the perinanim by the fundus uteri.

The distinction between an incarcemted uterus and an extra-uterine
pregnancy is sometimes difficult, necessitating a thorough bimanual
examination, aided, in caaiss of abdominal tenderness, by the employ-
ment of an anaesthetic.

ACCIDENTAL COMFLICATIONa— ABKORMALITIES OF THE UTERUS. 267

The replacement of the uterus, which, of course, is the objective

>int of treatment, should in all cases be preceded by the evacuation

lof the bladder. This is usually accomplished without much trouble

by means of a sharply curved male eiithetor, and by remembering that

'^the urethra is ordinarily deflected somewhat to one side, Veit,* in an

experience of from seventy to eighty cases, found catheterization

always practicable. Where intelligent effort is attended by failure,

^puncture is allowable. To this end an aspirator needle, which, how-

^kver, should not be of too small caliber^ should be passed through the

K»bdominal walls at a point about three inches above the symphysis.

Vl& practice this operation has thus far proved devoid of danger,

though the possible risk from inf Itration of urine should acf as a

Peheek to its rash employment
[ The replacement of the uterus should he attempted with the patient
•Q«esthetized, and in the Sims latero-prone position,! Pressure upon
the fundus should be exerted by four fingers introduced into the va-
gina or rectum, Barnes J recommends tilting tJie fundus to one side,
8o as to disengage it from the projection of the promontor}\ It may
hsppen that the first attempt may be only partially successful, while
m renewal of the manipulation after twelve to twenty-four hours may
lead to complete reduction (Veit). It is possible that, after empty-
J ^iiilf the bladder and rectum, spontaneous reposition may take place;
Hfcut the expectant plan is hardly to be recommended, botii because of
^■fe^Biicertainty and on account of the prolongation of the patient's

In exceptional cases the replacement of the uterus may be prevent-
ed bjr inflammatory adhesions, or by the secondary swelling of the dis-
phtf>ed organ. The induction of abortion then becomes imi)erative,
etiher by tlie ordinary methods or by puncture of the uterine walls.

The introduction of a uterine sound or a flexible catheter is rarely
practicable. In a case reported by F. Muller,* where the retroversion
waft complete, with the fundus upon the perinjeum and the cervix
looking directly upward, Muller resorted to the following ingenious
expedient : He cut off the end of a male silver catheter, and then
bent the extremity into a hook. Having succeeded in passing the lat-
ter into the cervix, he introduced a piece of catgut through the tube
bvtwv^n the membranes and the uterus. After twelve hours, during
which the catgut was left tn siiUf the fcetus was ex|>elled. It catheter^
itation can not be accomplished by either of the foregoing methods,

* Tnr, " U^bef dl« Retroflexion der Giib&niiuttcr b den fpfttcrcn Schfrangerscfa&f is-
mamink," Volkminn'i " S*mmL klin, Vortr.;' No. 170, p. 1363,

f U 90 aaiBfllietiiO if OMd, the kueo-cUedt poeition maj be tried in difQcult replace-

I llAii5m, "Obitetrlc OpcratJonB," third Ameriean edition, p. 27ft,

• P. UeLLB, **Zur TUempie der Betroversio Uteri grftvjdi,'' " Beltr. zhr Oeburlih.,"

Bd la, p< tr

208

THE PATHOLOGY OF PREGNANCr.

pencture of the uterus with a fine trocar, and with antiseptic pr
tions, has proved a tolerably safe procednre, and, by the withdrawal of"
a portion of the aniniotie fluid, a certain means of provoking abortion.

Prolapse of the Pregnant Uterus. — In rare inatancea the normal
pregniiiit atcras becomes prolapsed during the eiirly months, throng
mechanical violence, and ita sudden displacement may lead to abortio
through uterine congestion and hsemorrliage. Ordinarily, however,
procidentia uteri is only observed, during pregnancy, when it hofl
antedated conception, and it is most frequent in mnltiparae. A slight
pro lapse disappears tempomrily with the ascent of tho nt^srua. A
well-marked procidentia, however, as a result of which a part or the
whole of the uterus haa been extruded from the vagina, is often* at-
tended by symptoms of incarceration terminating in abortion. There
is no recorded instance of procidentia in which pregnancy persisM
until the time of normal delivery, in a uterus lying wholly without
the vagina. Procidentia uteri is simulated by hypertrophy, either
of the supravaginal or of the infravaginal portion of the cervix.
This pathological condition is unattended by grave results, unless
lead to rigidity of the os uteri, tedious delivery, and uterine inertii
If excessively developed, however, the portio vaginalis may be
formed into a pulpy, polyp-like mass, which, by its constant frictio
and irritation, produces abortion* It should not be mistaken for pr
lapse of the uterus, as efforts at reposition may produce irritation gaffi*
cicntly severe to induce premature delivery. Amputation of the hyper^
trophied cervix {performed during the third month does not necessa-
rily disturb pregnancy, and is indicated, in aggravated cases, because
of the possible prejudicial influence of cervical hypertrophy, onmo
fied by treatment, upon utero-gestation and parturition.

When prolapse, even of slight extent, exists in a pregnant uter
the normal ascent of the organ should be encouraged by the avoidanc
of exertion, and by careful regulation of defecation and micturition.
In more pronounced cases the uterus must be replaced and sustained
by a suitable tampon. Spiegelberg "^ advises the use of a cotton tampon,
soaked in glycerine, and held in position by a perineal bandage, an
renewed at short intervals. Caution is necessary in the reduction
the uterus, lest the fundus be caught beneath the symphysis and t
procidentia converted int^3 a retroflexion. When incarceration base
curred, and the parts are much swollen, their volume may be rednc
by scarification, after which reposition must be attempted. Should
it fail, abortion should be induced before the incarceration has irrepa-
rably compromised the vitality of the pelvic tissues.

Prolapsa of the Vagina,— A slight degree of vaginal prolapse oecui
more frequently in pregnant women than does uterine prolapse. Ca
of more complete prolapse of the vagina are, however, almost iuva
» gpiKOiLBEao^ " Gebiirtahulf«,*» p, 278.

AOCIDBNTAL COMPLICATIONS.— ABNORMALITIES OF THE UTERUS. 269

ftblj attended with procidentia uteri* The anterior vaginal wall is
qsqaUj alone involved in the prolapse, although the posterior wall
may descend alone, or both walls become eimultaneously prolajised.
This displacement produces traction upon the bladder and rectum,
resulting in irritation of these organs and of the vulva. During par-
turition, moreover, the prolapsed vagina offers an impediment to
delivery, and may, therefore, be subjected to an amount of pressure in-
compatible with the maintenance of its vihdity. The treatment con-
nsts in producing regular alviue evacuations, and in sustaining the
vagina with cotton tampons and a ])crincal band, or with the latter
alone. Daring labor, pei-sistent efforts at rcjiosition of the prolapsed
vagina must be made between the pains. Should these attempts prove
effectual, the vagina must be sustained in proper position^ nnlil the
descent of the head has occurred. If reposition be impossible, the
forceps must be resorted to in order to prevent the disastrous results
of excessive pressure on the vaginal tissues» and traction must be so
applied as to avoid injury of the anterior vaginal wall*

Hernias of the Pregnant Uterus.— Although hernias of the unim-
pregnated uterus are very rare, they still occur much more frequently
than those of the gravid uterus. The most frequent forms under
which they present themselves are the umbilical and the ventral.
Femoral and inguinal uterine hernias, as well as hernias through the
foramen ovale and the great sacro-sciatic foramen, also oecnr. The sac
of a ventral hernia is often formed by the yielding and dihitatlon of
extensive cicatrices in the abdominal wall, such as result from ovari-
otomies and gastrotomies, or by the separation of the recti muscles.

Femoral and inguinal uterine hernias are either congenital or are
produced by ovarian or omental hernias, between which and the uterus
adhedons exist. Pregnancy has been obser\'ed to occur most frequently
j^in inguinal uterine hernias, next in umbilical, and least frequently in
femoral hernias.* It has never been discovered in a uterus which had
laped through the foramen ovale or the greater sacro-sciatic foramen,
Dgnancy occurring in inguinal or femoral uterine hernias is uni-
ioimly terminated by abortion or by premature delivery. The diag-
Is readily made if due regard be paid to the absence of the uterus
its natural situation, to the shai>e and consistence of the hernial
tomor, to the physical signs furnished by auscultation and percussion
it, and to the displacement of the vagina toward the site of the
^mia.
r Wlrcn the heniia is recognized at an early date, the utenis must, if
able, be restored to its normal position, and there retained by an
ftppropriate trnaa. Should attempts at reposition be onsucccssful,
Soial abortion should bo induced, as it will otherwise occur sjion*
Eiosly at a later date, and under less favorable conditions. When
• Spiioklbeko, "Geburtflh," p. 2S0.

270

TOE PATHOLOGY OF PEEGKANCT.

the product of conception has already attained a large size, repositbfl
and delivery, whether spontaneous or artificial, are rarely accoinplishe
unless the constricting hernial ring be previously divided. Even
latter procedure may prove ineffectual, in which case hysterotomy 1
the last resort.

CHAPTER XV.

DJ$£AS£8 OF TBE DECWUA,— DISEASES OF TEE OVUM,

EmdoTTietntb docidoa : L Chromeik; 2. Tulverosii; 3, Catdrrbalifl^ — Anomalies of tlie
centn.-^Anomaliefi of form ; of position ; of devolopmcnt ; of circulation,— Pliccn*^
litis,— 'Dcgeiicraiiotis.'-'^jptiills. — Anomalies of tlic ninaion and of the amniotic
iluid, — ^Hydramnioti. — Deficiency of amniotic fluid. — Atiomalii^a of the timbiHcd
cord; torsion; knots; hernias; coiling of the cord; cysts; Btenoses of reudi'i
marginal implantations. — Qydatidiform mole.

Endouietritis decidua. — The normal congestion of the uterine'
coua membrane attendant upon conception, and resulting in the foi
tion of the decidua, may, under the irritating influence of Tarioua
exciting causes, develop into endometritis. The inflammation may be
either acute in character, as is often the ease in cholera Asiatica and
other infections diseases,* or may pursue a chronic course, presenting
itself in the three distinct forms about to be considered :

L Endometritis decidua chronica diffusa.— The causes of this foi
of endometritis are not usually readily discoverable. It is believed
be sometimes developed from an endometritis antedating conceptioi
It is also referred to syphilitic infection,! to excessive physical e»
tion,t and to secondary inflammation resulting from the death of
foetus and its retention in the uterine cavity,*^

The anatomical changes characteristic of this form of endometritis
consist essentially in thickening and induration of the decidua, due
to a more or less diffuse development of new connective tissue, and to
proliferation of the decidual cells. Cyst^ have been observed in the
hypertrophied decidua by Hegar and Mftier*|| Kaschewarowa dii
covered newly developed and hypertrophied involuntary miiscu!
fibers in the substance of the decidua.^ Extravasations into the hy|]
trophied decidual tissue are of frequent occurrence. ^ The decidi
vera or the decidua reflexa may be separately or joinOj involved in

* Slatjanskt, " Arch, t Gjnaek./' ir, p. 285,

f FRANKgL, '* Arch, t Gynaek./* v, 1873, p. 53.

t KAScnEWARowA, Vlrchow'e ** Arch.,'* 1868, vol xliv, p. 113.

» SciiROEDER, *' Gehurtsh./' sixth editioni ^ 392.

I SrmaeLBEao, '* Gi^burteh./* p. 3Dl.

^ Kascbewahowa, loc. ciL, p. 111.

( EiQiwanon und HkOAR, '* Monatseclir. f. Geburtek.," toL xiii^ 1S68, p. lei.

DISEASES OF THE DECIDUA.~DISEASES OF THE OVUM. 271

these pathological processes, and may be affected throughout a part
or the whole of their extent. When the hyperplasia of the mucous
membrane is deyeloped in the later months of utero-gestation, pursues
a notably chronic course, is limited in extent, or does not involve the
placental decidua, pregnancy may proceed to a normal termination.
When, however, the endometritis appears early, assumes an acute or
hs&morrhagic type, is attended by partial separation of the decidua, or
/hvolves the placental decidua, it frequently induces abortion or pre-
mature delivery, either by causing the death of the fcBtus through in-
terference with its nutrition,* or by exciting reflex uterine contrac-
tions. Parturition may, in either case, be protracted by the slow
separation of the decidua, between which and the deeper uterine tis-
sues adhesions have been formed by the newly developed connective
tissue and muscular fibers. If the placental decidua be involved in
the morbid process, the placenta may be separated with difficulty, and
its slow expulsion be attended by copious haemorrhages.

II. Endometritis deoidua tuberosa et poljrposa.— The etiology of
this variety of decidual inflammation is involved in obscurity. Syph-
ilis was regarded as a causative agent by Yirchow, who first described
the degenerative changes under consideration,! and preexistent endo-
metritis is also supposed to occupy a causative relation to them. Gus-
serowj suggests that conception occurring soon after delivery may
excifce the recently formed vascular uterine mucous membrane to ab-
normal proliferative processes. It is doubtful whether the latter are
ever secondary to irritation produced by the death of the foetus.* In
Ahlfeld's cases the inflammation was apparently idiopathic.

The pathological processes peculiar to this variety of endometritis
are usually observed in the decidua vera alone, and manifest a prefer-
ence for those portions of the decidua corresponding to the anterior
and posterior uterine surfaces. In some cases, characterized by absence
of the decidua vera, the decidua reflexa is found involved in the mor-
bid changes. The latter consist in marked thickening of the entire
decidua referable to proliferation of the interstitial connective tissue
and to extensive hypertrophy of the decidual cells, which are provided
with nuclei of enormous size. Occasional free nuclei occur.) The
uterine surface of the decidua is rough and covered with coagulated
blood, while the entire mucous membrane is exceedingly vascular.
Upon that surface of the decidua which is directed toward the ovum
are situated large excrescences or elevations, the prevailing shape of
which is polypoid. They may, however, appear in the form of nod-

* Klbbs, **Monats8chr. f. Geburtok.," 1S66, toI. xxtii, p. 402.
t Ahlfeld, " Arch. f. Gynaek./' vol. x, 1876, p. 178.

X GnssEROW, " Monatssdir. f. Gynaek./' toI. xxyU, 1866, p. 828.

* ScHROKDER, " Geburtsh./' sixth edition, p. 898.
I GussERow, /oc. a/., p. 822.

272

TOE PATHOLOGY OF PREGNANCY.

iiles, of cones, or of boss-like projections provided with a broad, noE-
peduncalated base. Their height is from one quarter to one half aa
inch, and their surface is smooth^ very vascular, and devoid of uti*riii^
follicles. The latter are, however, plainly visible on the mucous mtoi-
brane intervening between the polypoid outgrowths, but they are ooin-
pressed and their orifices constricted or obliterated by the pre«si
of whitish, contracting bands of newly developed connective tissi
Similar fibrous bands surround the blood-vessels. On eection, 11
larger prominences sometimes ajjpear permeated with coagulated bl
and narrow, cord -like bands of hypertrophied decidual tisssue occasio]
ally form bridge-like connections between neighboring poly7)i. Tl
uterine follicles are» in some cases, filled with blood-clots. The e]
thelium is often absent from the uterine surface of the deeidua excel
around the orifices of the follicular gland»,* and the deeper decid
tissues contain hirge numbers of lymphoid cells. The cells of
deeidua reflexa frefinently undergo fatty degeneration. The placen
villi may show hypertrophy of their club-shaped ends, or be the
of myxomatous growths, in which case their cells are granular and
cloudy. The ftptus is generally dead and partially disintegrate
This form of endometritis deeidua is, consequently, usually ac^coi
panied by abi)rtion, which occurs predominantly at an early sta^
pregnancy.

IIL Endometritis deeidua catarrhalis*— HydrorrlicEa gravidaram.—
This form of uterine infiamniation is less intense than the two vari^
ties just described, affects pluriparje more frequently than primipai
and seems to stand in etiological relations with hydraemia, Tl
pathological processes involved in the disease are vascularity, hypei
mia, and hypertrophy of the interstitial connective tissue and of
glandular elements of the deeidua. f The inflammation involves tl
decid im vera by preference, but may simultaneously affect the 4
cidiia reflexa. t The most striking symptomatic occurrence is due to
the glandular h}^vertrophy, and consists in the escape from the uteris
cavity of a thin, watery, muco-purulent or sero-sanguinolent liqui
which resembles the amniotic fluid both in color and in odor. Pro-
vided that free exit be afforded to the secretion, its discharge is effected
gradually and in small quantities. Should, however, obstacles to
continuous evacuation be encountered, either in the usual adhesi
between the deeidua vera and reflexa or in impenetrability of the
internum, the secretion, having accumulated between the deeidua
the clioriouj forces a passage through the deeidua reflexa and is
charged in considerable quantities. In some cases even a pound
more of the liquid is thus suddenly evacuated. J Small quantities

♦ Hkoar, " MoQalR»chr. f. Geburtsk./* irol wil, 1863^ pp. S00» 429.
f Sjfieoeldebo, •* Geburtshiilfe," p. 302.
I ScmoEDEit, " Geburtahulfe/' p. S04.

iJfl

DISEASES OF TOE DECID0A,^DISEASES OF THE OYUM.

273

the eecretion are often obaerred aa early as the third month. The
mar© abundant discharges occur only in the later periods of pregnancy,
wdare often attended by slight uterine contractions, which may, in
exceptional cases, become so severe as to induce abortion or premature
delivery.

The diagnosis inTolves differentiation between a discharge emanat-
bg from the hypertrophied decidual glands and the anie-parium es-
cape of a fluid which sometimes accumulates between the amnion and
chorian. The latter discharge, the quantity of which may be so large
M to simulate hydramnion, differs from that of hydrorrhoea gravida-
nim in that it occurs only once.* The escape of the decidual secretion
might be mistaken for that of the amniotic fluid, which may be easily
dirtijignished by the fact that it immediately precedes delivery. The
tj^stment should embrace analeptic and tonic measures as well as the
cirefal avoidance of vaginal douches and of all local irritation tending
to produce abortion. Should uterine contractions accompany the es-
cape of the decidual fluid, appropriate anodyne treatment must be
I idopted.

Balaxation of the Pelvic Symphyses.t — This condition, which consists
(ja an excess of the ordinary physiological softening at the pelvic artic-
ulations, may permit of such a degree of mobility between the pelvic
ones OB to effectually hinder locomotion. This is usually accompanied
pains in tlie ligaments of the joints affected, in the thighs, and in
be lumbar region. Its existence is easily recognized. Tlius, motion
the symphysis pubis becomes apparent if, with the patient in an up-
light ix)6ition, she be made to throw the weight of the body upon each
in dternatiou, while the accoucheur holds the symphysis between
\ thumb and two fingers placed within the vagina. Motion in the
ncro-iliac joint is perceived by seizing the crests of the ilium and get-
ting the patient to move forward. In the recumbent posture, move-
mtntft at either the pubic or saero-iliac joints may be recognized by
mmOM of the vaginal touch, upon extending or flexing the femur.

The great relief afforded to all the symptoms in such cases by means
of a firm binder makea it most desirable that the possibility of its oc-
i ' should be always borne in mind where the patient walks with

I y during the latter mouths of pregnancy, or subsequent to the

childbed period. The first case I witnessed at the Bellevue Hospital
was altogether a mystery to me, until the nature of the disability was
pointed out by Professor Barker. The patient was in the last month of
jvegnancy, bad been six weeks in bed, unable to move, though appar-
cntl/ otherwise in i^erfect healtli. A rude bandage, constructed of
canvas and made to lace in front, furnished a good support, and ena-

* flraBocumtii, o/». dt., p. 503,

f Ssnxnrn, '^ On Itclaxntioa of the Female Pclrlc Sjmphysea/^ " AmcdcftQ Jounia]
orObattttla," February, 1870; Baauji, '^Puerperal Diaeaaea," p. 198.
IS

274 THE PATHOLOGY OF FBEGNANCT.

bled my patient to stand and move around without fnconyenience.
She ha^y at the end of gestation, a good confinement, and subsequently
recoyered without a trace of her preyious difficulty.

In childbed a towel-binder is capable of rendering good senrioe.
During pregnancy, or during the period of puerperal conyalescence,
where frequent changes of the bandage are not necessary, Martin's
girdle, consisting of a solid metal ring surrounding the whole pelyis,
has been strongly recommended. In a case I haye recently had to treat,
where the relaxation became manifest after deliyery, I employed a pair
of strong breeches, furnished me by Philip Schmidt, instrument*maker,
of this city, which were carefully fitted to the thighs and hips of the
patient, and were made to buckle in front and lace behind. The appa-
ratus proyed to be light, comfortable, and answered eyery requirement

AkOMALIES OF THE PlACEXTA.

1. Anomalies of Form. — ^The usually round or oyal placenta may
be of a horseshoe or other irregular shape. The superficies depends
upon the extent to which the yilli form yascular connections with the
decidua. In general terms it may be stated that the thickness of the
placenta is in inyerse proportion to its surface extension. Placentsd
Buccenturiatse, small accessory placental deyelopments, are due to the
persistence of isolated yillous groups, which form yascular connec-
tions with the decidua yera. PlacentsB spuriae consist of circum-
scribed deyelopments of yilli, the decidua not participating in the
growth. A placenta membranacea is a broad and thin yascular mem-
brane produced by a diffuse proliferation of the yilli oyer the entire
oyum, forming yascular connections with the refiexa or, where the
latter is absent, with the yera.

2. Anomalies of Position. — The placenta may be attached oyer
the OS internum, thus constituting placenta preyia, oyer the orifice of
the Fallopian tube, or, in connection with extra-uterine pregnancy, at
yarious points in the abdominal cayity.

3. Anomalies of Development.— An hypertrophied placenta is ab-
normally large in proportion to the size of the foetus, occurs chiefly
in connection with hydramnion, and consists of a genuine parenchy-
matous hyperplasia. A small placenta is referable either to defectiye
deyelopment, to premature inyolution, or to hyperplasia of its connec-
tiye tissue, with subsequent contraction.*

4. Anomalies of Circulation. — Haemorrhage into the placenta is
sometimes produced by congestion of the utero-placental yessels, due
to disturbances in the mother's yascular system, f The extrayasation
may, rarely, be intra-placental, may occur into the sorotina, thus con-
stituting utero-placental apoplexy, or may take place into the uterine

* Whittaker, "Am. Joar. of Obstet," August, 1870, p. 229.

t " Nouv. Diet, de M^d. et de Chiraig. Pmt.," toL xxviii, " FUcenta," p. 68.

DISEASES OF THE DECIDUA.— DISEASES OF THE OVUM. 275

mnnses. In the last case, thrombosis of the placental sinuses is said
to haye occnrred.* Placental haematomata are the aboye-mentioned
collections of coagulated blood in yarioos stages of disintegration.
The causes of the hemorrhage are, chiefly, morbid changes in the de-
cidual yessels, often referable to placentitis. The extrayasated blood
usually experiences the ordinary retrogressiye metamorphoses. It
sometimes undergoes cystic, fatty, or calcareous degeneration. The
pressure upon the yilli produced by the hsematomata impairs the
nutrition of the foetus, and may cause the death of the latter.

OBdema of the placenta, a morbid condition usually attributed to
derangement of the fetal or umbilical circulation, is characterized by
abnormal pallor, with increased size, friability, and succulence of the
placenta^ due to serous infiltration. The morbid anatomical changes
consist essentially in cystic dilatation in and between the yilli, ac-
companied sometimes by extrayasations.

5. Flaoentitis. — The subject of placental inflammation is still in-
yolyed in obscurity. Many authors dispute its yery existence, con-
tending that the morbid changes hitherto referred to placentitis are
simply due to retrogressiye metamorphoses in extrayasations.! Other
writers affirm its existence, assign to it etiological relations with me-
tritis and endometritis, t and describe its pathology under the fol-
lowing heads : {a) Congestion ; (b) Hepatization and induration ;
(c) Suppuration.* According to the latter yiew, the inflammation
originates in the cells of the serotina or in the adyentitia of the fetal
arteries, and results generally in the formation of new granulation
tissue, either nodular or diffuse, which, by contractions, leads to com-
pression or obliteration of placental yessels and to consequent fatty
degeneration of the yilli. Haemorrhages also occur upon the fetal
placental surface, and fibrous adhesions, forming between the de-
cidua and the uterine wall, may lead to the retention of the placenta
after deliyery. Should the inflammatory process be of recent date,
the friability of the new granulation tissue may cause sei)aration and
retention within the uterus of small parts of the placenta. The
haemorrhages sometimes attending placentitis may destroy the foetus
and induce abortion. Suppuration, circumscribed or diffuse, is a rare
result of placentitis.

6. Degenerations and New Formations.— (a) Fatty degeneration
of the placenta, circumscribed or diffused, may result from retrograde
changes in extrayasations. When developed early in pregnancy, it is
sometimes regarded as a premature completion of the fatty degenera-
tion normally occurring at the end of pregnancy, and may be due to

♦ Slatjansky, " Areh. f. Gynaek.," v, 1873, p. 860.
t Whittakkb, loe, «£., p. 240.

X ScBROBDER, ** Geburtsh./* 6te Aufl., 1880.

• " NouT. Diet de MM. ct de Chir.," loe. cU., p. 61.

THE PATHOLOGY OF PREGNANCY,

gyptilis or scrofula, (b) Amorphoua calcareous deposits are frc^j

and are almost invariably found on the uterine placental surface* id
the decidua serotina. Thence the process may extend to the fpUl
portion of the placenta. When the calcareous change begins in the
fetal tissues it is confined to these, and affects the small blood-Tet8sels
of the villi, beginning in their terminal ramifications and gradnal-
ly involving their trunks, (c) Pigment deposits, resulting nsuallj
from alterations in the hsemoglobine of extravasations, are found in
both healthy and diseased placentie within the blood-sinuses or villi
(d) Cysts are of frequent occurrence in the placenta. They are found
near the center of its concave surface, and vary from a few lines to
several inches in diameter. The cyst- wall is formed by the protruding
surface of the amnion, which is covered with pavement-epithehimu
The cysts contain a reddish, cloudy, thin fluid, Ahlfeld* regards tLe
cysts m liquefied myxomatous formations. They may also develop
from apoplectic foci, (p) Tumors, Circumscribed tumors, 6broiii
or sarcomatous in nature J are found on the fetal i?ide of the pla.
beneath the amnion. They are produced either by fibroid transforma-
tions in the villi, or by cell proliferation in the decidua. Myxoma cf
the placenta, consist! Dg in hyj^erplasia of the villi, and myxoma fibro-
sum placentiT* characterized by the fibroid degeneration of the base-
ment-tissue in isolated villi, are the chief remaining varieties of pla-
cental neoplasms.

7. Syphilis of the Placenta,— -Placental s}7>liilis, which only exists,
according to FrankeljJ in connection with congenital or hereditary
fetal e}"philis, involves the maternal portion of the placenta, when the
mother was infected either before or soon after conception, and pro-
duces gummatous proliferation of the decidua, characterized by the de-
velopment of large-celled connective tissue, with occasional accumukr
tions of younger cells.

When the infection is conveyed by the father to the foetus alonCj
or to both mother and ftetus, pathological changes occur as the result
of a chronic inflammatory process, embracing proliferation of the cells
and connective tissue in the villi, with subsequent obliteration of the
vessels, often complicated by the marked proliferation and hardening
of their epithelial covering.

The affected villi become swollen, cloudy, and thickened, while
their epithelium undergoes proliferation and cloudy swelling. The
parenchyma of the villi is filled with lymph-cella, and the vessels are
either compressed or obliterated. The blood-sinuses are gradoally
encroached upon by the villi, the foetus dies from lack of adequate
nutrition, and the villi undergo fatty degeneration. Portions of the

* At!J.fTLD, '* Arch. f. Gynaek.,'* toI. %\, p, 897.

f SriEGELBEIIO^ op. ctt^ p. S46.

i Feakkkl, »♦ Arch. f. Gynack.." r, 1873, p. 51

DISEASES OF THE DECIDUi DISEASES OP THE OYXJU.

277

ilthy placental tissue, which often intervene between the diseased
Af may be the seat of exiravasationB*

Anomalies of the Amnion and of the Amniotic Fluid.

L Hydranmion. — Inasmuch as the amount of the liquor amnii
iT&ries considerably within normal limits, the term hydramnion should
[be leatricted to those cases in which the amount of fluid is so large as
I to produce morbid symptoms by its pressure upon the uterus, the ab-
fdomina] and thoracic viscera, or the fcetu^.

Etiology. — The causes of hydramnioii embrace varied morbid con-
fdifcioiis, affecting either the mother or the fcetua. Multiparse are more
to it than primipara?. It is a noteworthy fact that the
\ are females in the large majority of the cases, Schroeder as-
»• that McClintock collected thirty-three cases, in only eight of
the foptuses were males. The occasional causative connection
ctween morbid maternal states and bydramnion is proved by the fact
the foetus is sometimes free from disease while the mother is
:ited with sypliilis. Tlie existence of lymph-channels between the
Jotic cavity and the uterine mucous membrane furnishes further
oandB for the assumption that maternal disease may induce hydram*
bf In most cases, however, it results from morbid states of the
Ittts^ and particularly from mechanical disturbances of the placental
umbilical circulation. Kiistnert relates a case in which hydram-
Biazi waa produced by obstruction in the umbilical vein, resulting
from hepatic disease. The pathological placental process, leading to
obitructed umbilical circulation, consists often in hypertrophy, the
filli of the chorion being thickened and CEdematoua. The decidual tis-
Ptes are sometimes the seat of inflammatory proliferative changes. The
ftaolt of these diseased conditions of the membranes is an abnormally
faurge secretion of liquor amnii, wUh diversion of an undue share of
the nutritive material destined for the foetus, and the consecpient atro-
phy or death of the latter.

^finptoms and Signs. — The distention of the uterus, and the conso-
qtwsiit abnormal expansion of tlie abdomen, produced by bydramnion,
pesnlta in an impediment to locomotion, and produces discomfort or
actual pain by traction upon the abdominal parietes. Tlie diaphragm
i§ forced upward, and, encroaching upon tlie thoracic space, compresses
the longs and displaces the heart, thus }jroducing dyspncea and car-
diac palpitation. The urine may become scanty and albuminous from
impeded renal circulation. Neuralgic pains and cedemaof the labia
and lower extremities are produced by compression of the i>elvic nerves
mod veseeb. Dyspeptic symptomji result from direct compression of

278

THE PATHOLOGY OF PREGXAKCY.

the digestive organs or from reflex irritation of them. Ascites may
be produced by obstruction of the portal circulation. Physical exiim-
ination rcYeals, in advanced cases, an immensely distended abdomen.
The ntems, which can be easily mapped out by palpation and percuB-
eion, is tense, elastic, and obscurely fluctuating. The fetal cardiac
sounds are faint or imperceptible. The foetus changes its positioa
with unusual rapidity and facility, Cumbincd manipulation shows
the lower segment of the uterus to be elastic and tense, while tli«
fcetua can not be readily felt by the finger placed in contact with the
cerrix. Pregnancy accompanied by bydramnion seldom reaches iU
normal termination, delivery being prematurely induced by death of
the foBtus, by separation of the placenta, or by OTer-distention of the
uterus. The first stage of labor is abnormally prolonged, becun^ of
the comparatively feeble contractions of the expanded uterine walls.
Labor may become precipitate in the second stage, owing to the sad-
den escape of the amniotic fluid ; and uterine inertia, in the third
stage, frequently results in posi-parium haemorrhage. Involutioa is
apt to be protracted and incomplete.

DiagTiosis. — llydramnion may be mistaken for twin pregnancy,
but is easily excluded by the rational symptoms, by the tenseness of
the uterine walls, by the feebleness or absence of fetal heart-sotmdai
and by the ditSculty ex]>erienced in jwrceiving the fetus on palpatioiL

Prognosis. — The prognosis for the child is fatal in nearly thirty
per cent, of the cases. For the mother it is favorable, although the
risk of post'par turn hiemorrhage is considerable.

Treatment* — The treatment embraces the application of an abdom-
inal supporter and the injunction to refrain from active physical ex-
ertion. Grave disturbances of the mother's heart indicate the induc-
tion of premature delivery, which should, however, in the interest of
the child, be delayed as long as k consistent with maternal safety, la
parturition, the membranes should be punctured if the accumulated
liquor amnii retard the dilatation of the cervix. Puncture must be
performed in the interval of the pains, in order that the waters may
escape gradually and leave the position of the child unchanged. After
the expulsion of the placenta, the usual prophylactic measures against
pmi'partum ha^morrha^^e must be promptly adopted.

IL Abnormally Small Amount of Amniotic Fluid.— The quantity
of amniotic fluid may, even in some cases of advanced pregnancy, be
so limited as to render the uterus unusually small and firm, and to
limit the freedom of the fetal movements* Under these circum-
stances, the movements are so plainly perceptible to the mother as to
be the source of positive discomfort.

An abnormally small quantity of liquor amnii is, however, only of
importance in the earlier stages of fetal development. If the amnion
be not then separated from the ieetus by an adequate amount of fluid.

I m bi

DISEASES OF THE DECIDU A.— DISEASES OF THE OVtTH, 279

inormal amniotic foldings and adhesiona between the amnion and

[Q surface of the fcBtus may take place*
The so-called fceto-amniotic band*? * thus formed may, by mechani-
cal compression, result in various fetal deformities, or in spontaneous,
intra-uterine amputation.

Anohajjes of the Umbilical Oord.

I. Torsion. — Torsion consists in such a rotation of the umbilical
pd npon its longitudinal axis that its vessels are thereby rendered
nearly or quite impermeable. It occurs most frequently in foetuBes
which have advanced beyond the middle period of normal utero-gesta-
don, particularly, according to 8piegelberg,f in those of the seventh
month. It is, however, often met with in fcetuses of an earlier age,
Until a comparatively recent period, authors have unreservedly attrib-
uted torsion to active movements on the part of the foetus, and re-
ed it as the cause of the lattera death. Martin | has shown that
lis theory is untenable for the majority of cases, because the patho-
igicdl conditions which result from fetal death induced by torsion,
hether rapidly or slowly produced, are almost invariably absent.
ese morbid anatomical processes embrace rupture of the umbilical
blood-vesselB, and extravasations, for cases of sudden origin, and con-
^ion, with oedema^ for those more gradually developed. Martin,
;< fore, concluded that torsion was a po^t-jnortem event, resulting
from rotation of the foetus produced by maternal movements. Rage ^
aaraeeily advocated the same view, and suggested the various morbid
changes due to syphilis, endometritis placentaris, and sub-placental
hamarrhage as the cause of fetal death in cases which subsequently
developed numerous torsions, 8c!iauta | appears as a recent champion
of the same theory, although be admits that loose torsions, incapable
of fiToducing actual stenosis of the umbilical vessels, may often occur
dunng the life of the fcetus. He bases bis belief in the posi-jmriem
oecnrreQce of torsion — 1. Upon the large number of twists often pre-
aeoting themselves, any one of which would have involved the death
af the fcrtus. Even granting the original torsion to have been of ante-
m4tri0m origin, the others must then have occurred after death* 2*
l/pon tlio improbability of the formation of verj^ numerous torsions in
a healthy cord, inasmuch as its elasticity would lead to compensatory
lererse rotation, 3. Upon the fact that even twenty -five artificially
indaced torsions resulted in rupture of the normal cord from excessive
tmm&n, Schauta regards the cysts found in connection with some

• Flhw?, "Arch. f. GyunckV* Bd. ii, nil, p. 318.
4 gptiojcuiiriia, " Lebrbuch,'* p. SBO.
} Ujumn, ** Zt«chr. t Geburtsh. u. Gjnaek," Bd. ii, Heft 2, 1S78» p. 846.

• RroK, ihid,, Bd. Hi, Hcfl 2, 1878, p' 417.
I 8C1U0TA, ** Arch, t Qjnmek,;' Bd. ivii, Heft 1, 1881, p. 20.

280

THE PATHOLOGY OF PREGNANCY,

toraions as insufficient proof of their anie-fnortem occurrence. To^

gioDS are more frequently present in the umbilical cords of male thaa
m those of female foetuses, and are eometimes surprisingly nuraerous.
Schauta reports a case in which he observed three hondred and eighty
rotations of the cord on its longitudinal axis. It occurs by prefereaee
in maltiparte, probably on account of the greater latitude atfordedlor
fetal movements. Unusual length of the cord favors its occuirencet
for a similar reason. The seat of the torsion is ordinarily in close
proximity to the umbilicus. It occurs but rarely at the placental end
or in the center of the cord. The umbilical vessels are usually nearly
occluded at the seat of the torsion, but still j^ermeable. Thrombi
varying consistency are often found in the vessels. Sero-sanguinolei
fluid in the abdominal cavity of the foetus, oedema, and cy^itic dej
oration of the cord, are also pathological conditions frequently ati
ing torsion.

11 Knots. — Knots in the umbilical cord, which occur onoe in
hundred ca^ses, may result from the passage of the fcetus through
twisted loop of the cord, whether the passage be effected during pr^-
nancy, by the spontaneous fetal movements, or at term, by the ui
inc expulsive efforts or by the manipulations of the accoucheur, Kn<
fonned during parturition are loose and easily untied. They are un-
attended by any diminution in tlie gelatine of Wharton, Those oc*

curring during pregnancy ai-e more close-
ly and firmly drawn, and more difficult
to loosen, than the former variety. The
cord is partly or completely denuded of
the gelatine at the seat of the kn<
and plainly shows the location of tl
latter, after its solution, by well-marked
indentations. Knots in the cord,
either variety, are comparatively im
uiticant, although a tightly contracted
one, in a thin cord, may occasion grave
or even fatal disturbance of the umbili-
cal circulation,
IIL Hernia* — ITernia of the umbilical cord consists in the escape
from the abdomen, at the point of insertion of the cord, of some or all
of the fetal abdominal viscera. It is due either to arrested embryonic j
development, which prevents the complete closure of the abdominal |
cavity, or to the failure of the fetal intestines, originally situated out*
side the abdomen, to enter the same. Hernia of the cord may occ^^
alone, in otherwise normally developed foetuses, but is usually accod^f
panted by other deformities, such as stricture of the rectum, impe^"
forate anus, or dist-ortions of the lower limbs and of the genitals, pro-
duced by traction of the displaced viscera upon adjoining parts. The

WiA, 188.— Knot of umbUical cord.
(LeymftQ.)

DISEASES OF THE DECIDUA.~DISEASES OF THE OVUM. 281

contents of the hernial sac, which is composed of th^ amnion and of
the peritonasam, are usnally convolntions of the intestine, or these
with a portion of the liyer, idthough the kidneys, stomach, and spleen
are sometimes also extmded, leaving the fetal abdomen nearly empty,
lY. Coiling of the Cord. — Windings of the umbilical cord around
the foetus, occurring during pregnancy, Tary in their results with the
rapidity of their formation. When rapidly developed they may, in
rare cases, lead to sudden interruption of the umbilical circulation,
and to consequent death of the foetus. Should the coils be gradually
formed and firm, the extremity embraced by the cord increases, by its
own growth, the tightness of the constricting ligature. The latter
slowly lessens the caliber of the vessels supplying the extremity con-
cerned, and finally, occluding them, produces death of the limb. Ab-
sorption of the soft and hard parts of the extremity may result from
the cord's unyielding pressure,' and the limb be thus completely
severed from the trunk by so-called spontaneous amputation. In cer-
tain cases the combined pressure of the cord and of the slowly grow-
ing member may suffice to completely arrest the umbilical circulation,
and thus produce the death of the foetus. Should the neck be encir-
cled by the cord, death will soon ensue, attended, in some cases, by
almost complete amputation of the head. Ceilings of the cord around
the foetus occurring at birth are of little importance unless they be
numerous. In that case they lead to a shortening of the cord, and
produce anomalous positions, premature separation of the placenta,
retarded second stage of labor, and even death of the foetus from inter-
ference with the umbilical circulation.

V. Cysts.— Cysts of the umbilical cord, within the amniotic sheath,
are either produced by liquefaction of mucoid tissue or by accumula-
tion of serum between the epithelial layers of the allantois.

VI. Stenosis of Umbilioal VesselB. — Partial occlusion of the um-
bilical vein, at the placental insertion, produced by new connective
tissue resulting from circumscribed periphlebitis, is sometimes ob-
served, but is not sufficiently marked to impede the umbilical circula-
tion. Stenosis of the umbilical arteries is occasionally produced by
atheroma and subsequent thrombosis. Stenosis of the umbilical vein,
and, more tarely, of tho arteries, may also result from chronic phlebitis
characterized pathologically by the growth in the intima of spindle-
shaped and round cells which, later, develop into new connective
tissue. This process, which is usually referred to hereditary syphilis,*
may extend into the muscularis, and even invade the adventitia. The
result of the stenosis of the uterine vessels is, of course, prejudicial to
the foetus in direct proportion to its grade of development.

YII. Calcareous Degeneration. — Calcareous deposits have been
observed in the cords of syphilitic foetuses.

• Uewu, •'Ztachr. f. Geburtob. v. GjiiuIl;* Bd. It, Heft 1, 1S79, p. 62.

384

THB PATHOLOGY OF FREGKANOT.

&^3 ^mM

f^\

•4

ill*"

placenta be already formed at the beginning of the cystic degenerap
tion, the villi having already become atrophied upon that part of the
chorion not participating in the dcTclopment of the placenta, the

neoplasm is confined as a rule to
the latter, although cysta, erident-
ly owing their origin to Tilli which
have not undergone atrophy, Borne-
times occur upon the smooth sur-
face of the chorion. Should the
hydatid if orm mole be of sufficient
extent, under these cireumBtances,
to destroy the foetus, the more
less disintegrated remains of
latter are found in the amnio:
cavity, which sometimes contaii
an excels of liquor auinii. If oi
a few of the placental lobes or
fiingle cotyledons be implicatedi
the growth of the foetus may in
he disturbed, A healthy foetus
occasionally develoi>ed side by side
with a hydatid mole,* The hyda-
tidiform mole is usually contained
within the decidua. In an inter-
esting case reported by Volkmann, however, f the degenerated villi
had invaded the uterine blood-sinuses, and by pressure led to
extensive an atrophy and absorption of the uterine walls as to lea^
only a thin, transparent septum between the mole and the perito-
neal covering of the organ. The cavity formed by this process Q^m
erosion in the uterine parenchyma was larger than the uterine Cii1^|
ity proper, and presented numerous intersecting trabeculm resembling
the columnse camea3 of the cardiac ventricles. The destructive ch]
acter of the cystic degeneration is attributed in such cases to bo]
unknown morbid condition of the uterine walls, probably the result
malnutrition. Schrocder J refers to two similar cases, in one of whii
the cystic degeneration was attended by fatal peritonitis and the 01
by rupture of the uterus, and death from hsEmorrhage into the peri*
toneal cavity.

XL Etiology.— PrimiparaB are less frequently affected by the hydatid
iform mole than multiimra?, although the actual number of pregnaneii
seems to exert a less marked predisposing influence than advanci
age. The cystic degeneration usually occurs during the first mou\

♦ Spiegelberg, " Lehrbuch," p, 839.

f VoLtMANN, Virchow'B *' Arcbiv/' Bd. xli, p, 526.

% ScBEOKDBR, " Lehrbuch/* p, 420.

I'lo. MO.— Srieeimen fh>ni liydatitlilbnn mole,
m the Wood Miw^uai.

bung
soxofl

at«fl

rhicfH

DISEASES OF THE DECIBUA^^DISEASES OF THE OVUM.

285

of ntero-gestiition. According to UnderhilJ,* the latter part of the
third moDtli is the hmit within wliich the disease can originate. That
the exciting cause of the hydatidiform mole may be a morbid maternal
coadition is rendered probable by the repeated recurrence of the dis-
ease in the same patient, by it^ coexistence with inflammatory deeidiud
difioiise, or with extensive uterine fibroids, and by the presence, in the
majority of cases, according to Underbill, f of a cancerous or syphilitic
dyscrasia on the part of the mother. If the origin of the degeneration
be maternal, a^ it probably is in most instances, the degeneration of
the chorion antedates and produces the death of the foetus. On the
other hand, the fact that the morbid growth may owe its inception to
fcetal disease seems demonstrated by those cases in which, ^is has been
•lietidy Btated, a healthy fcetus may be developed in the same amniotic

tenTity with a hydatidiform mole. This view is further supported by
thoee cases in wiiich death of the foetus is attended by bo insignificant
a& amount of chorionic disease as to render its active causative agency

»in the death of the fcjptus highly improbable. Spiegolberg J is of the
Opinion that the hydatidiform molo does not result from death of the
embn^o, and that its cause is often to be sought in an abnormal devel-
opment of the allantois. The establishment of the true pathological
(jelations of the hydatidiform mole have led to the abandonment of
the once prevalent opinion that the neoplasm might be developed
independent of conception. The theory tliat a portion of retained
placenta might become alTected with the hydatidiform disease has also
been refuted by accumulated clinical evidence.

Ill, Symptomatology, — A leading sign of the hydatidiform mole
^nsistfi in a failure of correspondence between the uterine enlarge-
Dent and the computed period of utero-gestation» The uterus is
Hy larger at any given stage of pregnancy than it naturally would
in the course of normal gegtation, but may bo decidedly smaller in
^•tho€e cases attended by early demise of the embryo. Lumbar and
eacral pains are prominent and distressing in proportion to the rapid-
ity of uterine development. The uterus imparts a peculiar doughy
feeling to the palpating fingers, and in rare instances plainly percep-
tible fluctuation. Individual parts of the fmtus can not be distin-
guished through the uterine walls. The lower segment of the uterus
ifl remarkably tense. Ballottement yields negative results and fetal
moTements are absent, although they may bo closely simulated by uter-
ine contractions. The fetal cardiac sounds are diminished in inten-
eity or are quite imperceptible. There is ^ discharge from the uterus,
githsir eomtant or intermittent^ consisting of disintegrated and unrupt^
Qted oyatBy cystic fluid, and blood, which, although usually not exces-
mref may be so much increased by uterine contractions^ induced by

*Th€ Hyditidiform Mole,"
, he, dt.^ p. 6.

Obetct. G

{ SrUQELDElta,

JaQUBrv, 187ft, p, 10,
' Leiirbueli," p. 333.

sss

THE PATHOLOGY OF PREGNANCT,

over-distention, as to seriously impair the general strengtli, or even to
induce death from exhaustion.

Abortion is usually produced by the mole before the sixth month,
but the expulsion of the neoplasm may be delayed until the normal
period of parturition, or even until a later season. The hsBmorrhagftj
and the characteristic discharge cease after the complete exjiulsion (
tlie tumor, but retained jxjrtions of the same may give rise to i>rotractfl4l
bleeding. It is often impossible to distinguish the local signs pr&-*
dnced by the expulsion of a large bydatidiform mass from those ob-
served after normal delivery,

Diagaosis. — In eases of limited cystic degeneration it is often
impossible to diagnosticate bydatidiform mole. The eymptoms upon
which, in well-marked cases, the diagnosis is to be based are rapid in-
crease in the dimensions of the uterus, the presence of obscure fluctu-
ation, the impossibility of obtaining the fetal heart-sounds, or of
grasping any of the fetal members, negative result of ballot teTneni, and
uterine contractions, attended by the mucous or muco-saoguinolent
discharge containing the characteristic cysts.

Prognosis. — The prognosis of hydatidiform mole is determined
chiefly by the frequency and the violence of the attending hflemor-
rhages. It is not extremel y unfavorable in the majority of caaes.
The existence of the peculiar form of cystic degeneration described
as the interstitial, intra-parietal, or eroding variety would , howevg
naturally render the prognosis exceedingly grave- The fatalilj
of this class of cases results from their tendency to produce a ml
tare of the uterus complicated by intra- peritoneal hfemorrha
peritonitis, or septicaemia. The life of the foetus is almost invariable
sacrificed,

Treatment,^ — The treatment is restricted to measures calculated to
control htpmorrbagej and to promote the expulsion of the dis
mass. Most writers recommend non-interference so long as the
rua remains passive. When, however, contractions set in, the vagit
should be tamponed, and ergot given in full and repeated doses, until
the mole is expelled entire. The expeebint plan is, however, not d^
void of danger. In one case, where the patient stiflfered from labor-
pains for several hours before I saw her, the loss of blood was exces-
sive. I succeeded in removing, with the hand, through the patulous
cervix, an enormous quantity of cysts, sufficient to fill a wooden pail.
This wm followed by good contraction of the uterus and arrest of the
hiemorrhage, but the patient died two hours later from shook au
anosmia. Unless, therefore, the patient is so placed that professioni
assistance can be obtained at a moment's notice, the propriety of
lating the cervix so soon as the diagnosis has been established ma
well be considered. Dilatation should be effected by the finger, or by
the dilators of Molesworfch, of Barnes, or of Tamier, rather than by

SES OF THE DECtDUA,^DISEASES OF THE OVUM.

887

tentSi becaiue of tlie tendency of the latter to increase the dangers of
leptieaBiniiL

After expulsion, or after the manual removal of the hydatidiform
cjBt&, the uterus should be washed out with antiseptic fluids, or, in
case of hiemorrhage, its inner surface should be swabbed with the per-
cliionde of iron. The irrigatiori of the uterine cavity with water, to
irhJch only sufficient pcrehloride of iron has t>een added to give it a
^'Tine-colori has often a powerful styptic effect. Underhill recom-
mends the continued employment of ergot after delivery, and, in
ct^aes of persistent haemorrhage, the occasional introduetiou of the
Wninaria tent, and, if necessary, the employment of Thomas's dull-
Wire curette.

Retention, m Utero, of the Dead FcETua

The causative conditions producing retention of the dead foetus
ire not invariably identical. If the placenta remain adherent to the
^ DteroB after the demise of tlie foctuis, the continued vitality and unin-
^lerrapted development of the placenta sufficiently explain the fetal
etention. When, however, all connection between the placenta and
he ut4?ru3 has been severed, retention is probably referable to the
liminished irritability of those reflex nervous centers which control
^ex|iulsive uterine efforts. The duration of retention produced by
sion of the placenta, in cases of single pregnancy, is protracted
until such time m morbid placental processes impair the vitality of
th*t organ and induce it^ separation. In multiple pregnancies, at-
tended by deuth of one or more of the fcetuses, tlie latter are usually
expelled with the healthy feet us at term* They are, however, gome-
f^timea expelled earlier, and, in rare instances, later than the normal
^■to&tnSy and it may in general terms be stated that retention produced
^Biy placental adhesion very rarely exceeds the natural period of gesta-
^P^ioii. Betention due to diminished irritability of the reflex centers
^bny be indefinitely prolonged. Liehmann * is of the opinion that all
^5dmw of retention protracted beyond the normal term of pregnancy
belong in thU category.

The pathological changes which the foetus undergoes when retained
the uterus after its death vary with the condition of t!ie membranes :
II Ibeir int-egrity be preserved, the most important pathological fetal
onditions resulting from the retention are mummificatioii, maceration,
degeneration, and calcification*! 2. If the membranes be rupt-
un after the death of the foetus, or if their rupture be the
the termination of fetal life, that form of degeneration to be
untly descritx^d as mummification may ensue ; calcareous degenera-
tion may, as in the first instance, result io the formation of a lithopas-

^ lammAXK^ ^BcttrAg s. G«buri^h. u. Gvnack./' M. iii, 1874, pp. Ad, 68.

288

TOE PATHOLOGY OP PREGNANCy.

dion, or, m the event of the entrance of air into the uterine caritr.
the fetal tissues may undergo putrefactive changea. If mummification
has already occurred, putrefaction does not take place.*

Mummfication. — Mummification ia most frequently obserTed in f(^
tuses whose death has apparently been the gradual result of inanition
from inadequate blood-supply, this insufficiency of the nutritiTC fluid
being often referable to torsion or constriction of the umbilical cord.
Mummification affects, by preference, fcatuses dying during the middle
stages of gestation. Liebmann f suggests that this fact may be con-
nected with the augmeQted rapidity of endosmosis, due to the
percentage of saline ingredients then present in the amniotic flui^
or to the fact that torsion and stenosis of the cord are most liable
occur at tliat period of pregnancy. Mummification occurs chiefly
connoetion with twin pregnancies, { one footua being fully develo]
while the other becomes mummified. In this case the presence of
dead fcetus does not usually excite expulsory uterine efforts before
normal termination of pregnancy is reached, when both foetuses
simultaneously delivered. In certain rare instances the mummifii
foetus may be expelled either before or after the healthy one^ but
delivery is unattended by ha&morrhage or other unpleasant comphi
tion. When mummification affects a single foetus, the ret^ention
Buppoeed to be due to abnormally intimate connection between t1
placenta and the uterus. Symptoms closely simulating those of abo^
tion occur, but they subside before the product of conception is ei-
pelled, and probably even before the rupture of the membranes. The
foetus then becomes mummified, while the vitality of the placenta is
not impaired. Under thege circumstances the retention is never pro-
longed beyond the normal period of gestation, and is thus distinguished
from those cases of retention owing their origin to so-called ** missed
labor."

A mummified foetus is flattened from compression. Its Tiscera are
of soft consistency and of small dimensions. Its surface is shrunk
The peritoneal and pleural cavities contain a scanty and discoloi
fluid. The subcutaneous areolar tissue has disappeared, and the si
lies in direct contact with the muscles. The placenta, which is
yellowish, and tough, is the seat of fatty degeneration, and contains
residue of old extravasations.

Maceration. — The placenta of a macerated foDtus is ansBmic,
and friable. The cord, in which the vessels are permeable, is cy
drical, smooth, Rpongy, and inelastic. Its coils have disappeared,
is club-shaped at the fetal extremity, and its color is brownish-red.
The amniotic fluid has a peculiarly repulsive, sweotish, and sickeni

♦ Spixckluero, **Lehrb./* p» 367* f Likbhakn, op. cU.^ p. 54

I McCall, *' Tmnsiictiona of FhikdelpliiA Obatetrical Society," *' American Joam^_of
Obstetrics and Diseamw of Women juid Ubildren," vol iriii, p. 554.

DISEASES OF THE DECIDUA.— DISEASES OF THE OVUM. 289

odor^ unlike that of putrefaction. The flaid is rendered turbid and
of a greenish-yellow color by the admixture with it of sero-sanguino-
lent fluid, and of meconium. The membranes, which retain their
normal consistence for a long time, finally become friable, swollen, and
discolored. A foetus of only one to two months may be completely dis*
solved by the process of maceration. If the foBtus be more mature, its
general form and the outline of its organs are preserred, but granular
degeneration and disintegration of their anatomical elements are every-
where present. The epidermis is first affected by the process of macer-
ation. It is separated from the corium by the formation of vesicles,
similar to those of pemphigus, which contain either a reddish, sero-
sanguinolent, or a clear serous fluid. The corium is inflltrated with
the same fluid, and presents the appearance of brownish-red macerated
parchment. The subcutaneous areolar and adipose tissues are reddish
and (edematous. The oedema is most apparent over the cranium, the
abdomen, the feet, hands, and sternum. The entire body is flaccid,
and assumes, under the influence of external pressure, curiously dis-
torted shapes, being distended at some points, and depressed or flat-
tened at others. The cranial sutures are separated, the joints are
disarticulated, and the periosteum has become detached from the long
bones. The vessels are filled with dark, grumous blood. The serous
cavities are distended with bloody serum. The brain is transformed
into a grayish-red pulp. All the viscera are inflltrated and friable, the
uterus and lungs preserving their normal consistence longer than the
other organs. Pigment masses and fat-crystals are deposited in many
organs. Sometimes the accumulation of fat is so abundant that the
term faity degeneration is applicable to the process of its deposition.
No trustworthy inferences can be drawn from the appearance of macer-
ated foetuses as to the cause of their decease, since the gross patho-
logical conditions are identical under all circumstances.* Apparent
variations are due to the respective periods of retention. The rapidity
with which the process of maceration occurs is variable, and its extent is,
therefore, no criterion of the time at which the fetal demise took place.

Seventy-five per cent, of macerated foetuses are expelled, according
to Euge,f before the thirty-first week, and transverse or breech-pres-
entations occur in nearly one half of all the cases.

The cases in which the dead foetus is retained in utero after the ex-
piration of the normal period of gestation differ in symptomatic events
and pathological conditions from those already considered. In these
cases the death of the foetus may have occurred either in the earlier or
in the very latest stages of pregnancy, and the retention may extend
over months or years.

The term missed labor is applied to those cases in which, the uter-
ine expulsive efforts having been ineffectually made at full term, with-

• BuoE, *' Zeit. f. Geb. u. Gyn.," Bd. i, Heft 1, 1877, p. 58. f ^^d, p. 70.

seo

THE PATnOLOGY OF PREGKANCY.

out other result than the escape of the waters, the uterine eoDtracU^
finally subside, letiYing the fictus still in utero. The causes of mis^
labor usually cited are abnormal absence of uterine irritability, or of
that residing in the refiex neryous centers, obstructed labor, a»d un-
usually close adiieaions of the placenta. The pathological processes
presenting themselves in cases of long-continued retention and of
missed labor vary with the entrance of air into, or exclusion of air
from, the uterine cavity.

If the atmosphere have free access to the uterus, the fcetns under-
goes putrefactive changes. The soft parbi, having been liquefied, es-
cape, leaving the osseous framework of the fcetus in utcro. This may
also be gradually and partially disintegrated, liquefied, and expelled,
but its complete evacuation is not often effecti^d by Nature's processes.
If, however, the cervix be narrow or unyielding, the coutinuous press-
ure of some projecting and pointed bone may penetrate ita tissues and
force an exit through the vagina, rectum, or anterior abdominal wall
A similar irritation and penetration may induce suppurative metritis,
and, eventually, fatal peritonitis, or septicsemia.

If the air be excluded from the uterus, in cases of retention indefi-
nitely prolonged, the fo?tua either becomes mummified, and, forming
intimate connections with the uterus through the medium of inflam-
matory products, remains in ukro without giving rise to any syinj
toms, or it may produce by constant irritation suppurative metric
with abscess formation and the escape of pus externally. Acceea 1
ing been thus afiforded to the air, putrefaction and its confieque
will then ensue.

In rare cases of prolonged retention* the foetus becomes the 6eat<
fatty and calcareous degeneration. In the latter case it is designai
by the term lithopcedion.

The retention of the dead foetus is comparatively devoid of dang
Even if decomposition or putrefaction of the foetus occurs, the pp
uots of disintegration are usually eventually eliminated without •
fatal result, by natural efforts or by the intervention of obstetrical art
Heiu * recommends the colporynter and the internal administration^
ergot as effective means for secnring the expulsion of the feettia*
place of the colporynter, a large Barnes dilator, introduced inta I
vagina and filled with fluid, may be employed,

* ilEiN, " Bcitr, zur Geburtshwlfe," Bd. ii, p, 172,

THK PREHATUBE BXPULSION OF THE OVUM. 291

CHAPTEB XVI.

TEE PREMATURE EXPULSION OF THE OVUM.

GanseB of abortion. — ^Disposition to abortion. — ^Imroediate causes. — Symptoms. — Moles.—
Incomplete abortions. — Diagnosis. — ^Prognosis. — Treatment — Prophylaxis. — Arrest
of threatened abortion. — Treatment of ineritable abortion. — ^Treatment of neglected
abortion. — Bemoral of fibrinous polypL — Treatment of miscarriage.

When pregnancy is intemipted^ during the first three months, by
uterine contractions leading to the expulsion of the ovum, the term
abortion is used ; in the fourth, fifth, sixth, and seyenth months, i. e.,
from the formation of the placenta to the time the child becomes
yiable, it is proper to speak of the accident as immature delivery, or
miscarriage ; and, finally, a confinement occurring from the twenty-
eighth week, the earliest period of viability, to the thirty-eighth week,
when the foetus possesses every indication of maturity, is distinguished
as premature delivery.

This purely artificial division is justified by practical differences
in the symptomatology and treatment of the groups thus separately
designated.

Causes which lead to the Pbehatubb IjirrEBBUPnoK of Pbeo-

NANCY.

The underlying causes of abortion, miscarriage, and premature
delivery are the same. Causes of abortion are rarely of sudden occur-
rence. Usually the way is prepared, either by changes taking place
in the ovum, or by certain pathological conditions affecting the
mother. In either of these ways a disposition to abortion is pro-
duced. When once, as the result of morbid changes, the attach-
ment of the ovum to the uterus has been rendered insecure, causes
usually inoperative suffice to determine uterine contractions and the
time at which the expulsion takes place.

The Disposition to Abortion.— The disposition may be due prima-
rily to any disease of the chorion, of which we have an example in
syphilitic degeneration of the villi (vide p. 276). In most cases, how-
ever, death of the foetus precedes and leads to disease of the chorion.
The causes of abortion resolve themselves, therefore, in large measure,
into the causes which produce death of the foetus.

The death of the foetus may be due to direct violence, as kicks and
blows upon the abdominal waUs ; to diseases of the fetal appendages
(cord, amnion, chorion, placenta); to diseases of the decidua, especially
those which give rise to haemorrhage (before the complete formation
of the placenta, the separation of the decidua from the uterus inter-
feres with the nutritive supplies which go to the foetus) ; to febrile

292

THE PATHOLOGY OF PREGXANCT.

aflFections, in wliieli death results either from the high temperatun?,
from associated diseased coDditiona of the decidua, or, as ia certain
acute iafectious diseases, to the direct transfer of the poison from the
mother to the faetus ; and, finally, to excessive anasmia. Ansemia de-
veloped hy pregnancy rarely affects the child. In acute anffimia from
profuse haemorrhage, the child may die from asphyxia. In times of
famine great numbers of women abort The disposition to abort ob-
ficrved in corpulent women is probably due to the fact that the blood
is insnfticrent in quantity and quality to supply the wants of the
growing ^hild.

The death of the fcetns is followed by the expulsion of the o\Jim,
not usually at once, but after a longer or shorter period of time. Be-
fore the third month, in snch cases of delay, the embryo, which con-
sista of hardly more than a heap of cells, may become macerated, a»d
absorption may take place after the death of the embryo. Except in
cases of hydramnion, partial collapse of the ovum ensues. As soon as
the fcetua dies, the circulation which passes from the fcBtus to the cho-
rion and placenta is suspended. The villi then become obliten^ ^
and undergo fatty degeneration. The deetdua is affected by the h;iM
process. With the diminution in the volume of the ovum, contrac-
tions begin* The villi, loosened in their attachments to the deeidui
are drawn out ; and the decidual vessels, exposed and subjected to in
creased pressure, rupture, and hemorrhage results. The uterine con-
tractions are awakened and exercise an expulsive force upon the ovud
which in its descent expands the cervix from above downward, an
passes finally into the vagina. In the first three months the ovum is
not infrequently expelled with membranes unruptured. From the
end of the third month onward such an occurrence is rare, though I
have seen an instance which happened in the sixth month. In the
early months the expulsion of an intact ovum is associated with incon-
siderable haemorrhage. When the membranes give way, the embryo
and the fluid contents of the amnion escape first. With the removal
of the comi>res8ion exercised by the ovum upon the inner surface of the
uterine walls, haemorrhage occurs, which continues, as a rule, until
the complete expulsion or removal of the membranes and placenta.

Aside from the death of the fcetua, w4th consecutive changes in
the chorion and decidua, and diseases of the fetal appendages leading
to death of the foetus, the predisposition to abortion may be the result
of primary defects or changes in the decidua alone. Of these changes
we recognize :

1. Atrophy of the Uterine Mticous Membrane, — ^The insufBcie
development of the mucous membrane exercises an injurious influenq
upon the development of the ovum in cases only in which the scroti
and the reflexa arc involved. An abnormally small and undevclop
serotinaJ surface may give rise to a small placenta, or the serotiQa

THE PREMATURE EXPULSION OF THE OVUM. ggs

attachment may be of such limited extent that the mere weight of the
OTam drags it downirard and converts it into a long, narrow pedicle.
At other time^, the rcflcxa may be but partially developed, or may fail
altogether^ and then the ovum, covered only by the chorion, Imngs by
a pediculated attachment to tlie serotina.

In both these cases, the oterine contractions, in place of at once
effecting the expulsion of the ovum, may force the ovnm into the^

cervix, where it may remain
for a time, nourished by the
long pedicle, but arrested in
its further descent by a con-
tracted 08 externum. To these
cases the term cervical preg-
nancy has been applied. The
cervix, according to the month
of pregnancy, is more or lesa
spherically distended, and the
1!^ l^^^r '.K t >i. .1 J 1 J corpus uteri above contract*

Fia. 141, — Ovum^ with imperfoctly developed ^

sionsw As tlie cause of this con-
dition lie^ chiefly in rigidity of the os externum, it occurs most fre-
quently in primipara*. Even with a patulous os, though rarely, a cer-
Tical pregnancy may be produced by the resistance and firmness of
the pedicle attaching the ovum to the uterus.*

2. Hypertrophy of the Mucous Membrane, — Thickening of the mu-
cotts membrane is the result of endometritis, and may lead to abortion
in either of the following ways : The several forms of endometritis
(tnV/r p. 2tO) may give rise to affections of the placenta* and thus prove
fatal to the fa?tus, or the thinned, dilated vessels of the diseased de-
ddna may rupture, and produce sanguineous effneiona between the
membranes

The frequency of abortion in displacements of the uterus is prin-
cipally dependent upon associated endometritis. In anteflexion of the
uterus, sterility is common, but endometritis and abortion are rare.
In retroflexion, on the contrary, while there is slight obstacle to con-
option, the congestion of the uterine walls and the altered conditions

the uterine mucous membrane render abortion a frequent occur-

ice.

Bigidity of the uterine walls, which interferes with their due ex-
pansion, mixy lead to premature uterine contractions* In this way an
mbedded fibroid or carcinoma may ultimately become sources of abor-
Ex|)ansion of the uterus may likewise be hindered by old peri-
»xieal adhesions or pelvic cellulitis.

• W. Sciti}Lti)f, " Ucber cervical Schwangerachafi^** ** Ztacbr. i Geburtth. und Gy-
0d VLi, VL % p. 40d.

294

THE PATHOLOGY OF PRBOyANCT.

Fmally^ there remains a class of women in whose cases it is ii
Bible to detect either disease of the ovum or of the genital organs, yet
in whom abortion occurs, dependent, eo far as our present knowled|
goes, upon certain personal conditions of nerve irritability. Phrsie
and psycliical soorces of excitement, which would be of small momeo
in some women, in them suffice to interrupt pregnancy.

Immediate Causes of Abortion. — Changes in the ovum, other tb
rupture and escape of the amniotic fluid, rarely lead at once and di-
rectly to abortion. The proximate causes which induce contractions,
and the throwing oflf of the ovum, reside for the most part in the ma-
ternal system. They consist of :

!• Bypermmia of ike Gravid Uterus, — ^Wh en the predisposing canaeB
have operated to weaken the attachments of the ovum to the decidiui,
anytbing which determines the blood-currents to the uterus is liabh
to produce extravasations of blood around the ovum, and awaken ut
ine contractions. Because of this fact we surround patients predis-"
posed to abort with every precaution during the periodic menstrual
congestion that not even pregnancy altogether suspends. Fevere, in-
flammatory affections of the genital organs, excesses in coitus, ho
foot-baths, valvular hcart^lesions, obstructions to the circulation
the lungs and livor, may each lead to rupture of the decidual vessel]
More frequently rupture follows jars to the body from vomiting, oougti
ing, and straining, from railroad-journeys, from violent exercise, from
falls, and the like.

The importance of separating the predisposing from the immedia
causes of abortion is shown by the impunity with which often
fectly heiilthy women, with no abnormal conditions of the generatii
organs, set all the usual restraints at defiance with the intent to int
rupt an undcsired pregnancy, M* Brillaud Laujardi^ro relates th
case of a peasant who took his wife, while enceinte, behind him
horseback, and started off with her at full gallop with the view of cau
ing her to miscarry. Having thus thoroughly shaken her, hedropp
her suddenly to the ground without slackening his speed. ITiis brut
mancBuvre he repeated twice without the least success.* On the other
hand, women, eager for offspring, after an abortion, sometimes lay
undue stress upon slight imprudences, and make them the sources of
morbid self-reproaches, which it becomes one of the functions of the
physician to allay.

2. Ukriiie Contra^iionSf produced by Influences which ac4
rectly through the Nerves, — Of this we have examples in the contr
tiona awakened by frictions of the uterus through the abdomi
walls, in the reflex contractions produced by stimuli applied to
breasts* and in those excited by strong menUl emotions.

Symptoms,— As the detachment and expulsion of the ovum can iio|_
♦ T. Gaixard, '* De ruTortcment au point de vue mfidioo-Ugal,** PiirU, p. %i.

THE PREMATURE EXPULSION OF THE OVUM.

2d5

My take place without rupturG of the decidual or plaoental ves-
bwmorrhage becomes the constant and necessary result of every
Abortion^ In the first two months the ba?morrhage resembles that of
a pTofust menstruation. Pain is present, in part due to uterine con-
gestion, in part to the expulsion of blood-clots through the imperfectly
expanded cervix. The latter pains resemble those of obstructive dys-
menorrhoea. These symptoms last from four to five days. As the
oTnm passes away nnnaticed, enveloped in the clots, or piecemeal
with the decidua, women are apt to regard these early abortions as the
normal recurrence of a retarded menstrual period* J

After the third month prodronial symptoms lire rarely wanting.
Among these may be mentioned fullness and weight in the pelvis, sa-
cral pains, frequent micturition, periodic labor-like pains, and a mu-
coQS or watery discharge. Tbese, followed by haemorrhage, indicate a
tlueatened abortion. The haemorrhage, if slight, may cease, and the
pregnancy go on undisturbed. Usually, however, the haemorrhage
increasos in amount, or after a brief cessation recurs. Contractions
fict in, which become more and more pronounced, until finally the ovum
is expelled.

Iji a typical case of abortion, in which the ovura is thrown off
Titerine retraction and htemorrhage unite to effect the progres-
Bparatiou from below upward of the decidua from the uterine
inin& The ovnm then, covered by the reflexa and the detached de-
cidua, is graduaOj' pressed downward, and dilates first the os internum,
next the cervix, and finally tlie os externum. The ovum passes into
the vagina, covered by the decidua vera, or drags the inverted decidua
after it The emptied uterus then retracts down, and the haemorrhage
eeaoon. The aborted ov^im is surrounded with coagulated blood. In

t»e Bret three months, when the death of the embryo has preeeiled by
little time the completion of the abortion, every vestige of the em-
bryo may be found to have disappeared. Sometimes, in, the third
month, a small placenta with shrunken umbilical vessels may now and
then he met with.

iWhen the extravasation of blood upon the uterine surface of the
ra is considerable in amount, the vera is sometimes broken through,
d the bU>od eflfused between the vera and reflexa. Extravasation
may likewi^ie take jilace between the reflexa and chorion, either in
oonaequenoe of the rupture of the reflexa, or from a haemorrhage start-
ing from the placenta, which findia its way along the outer surface of
^iie chorion* and dissects away the reflexa. The pressure upon the
Hirum, unless it has previously undergone collapse as a result of the
Btath of the embryo, lejids to rupture and escape of the amniotic fluid.
^Tho retained fetal and maternal membranes, with the intervening lay-
ers of coain^ated blood, form a mass termed a mole. When the blood
ooigttia Br0 fresh, the mass is termed the moia sanguinea (blood-

296

TOE PATHOLOGT OF PREGN.INCY.

mole), and when of older date the mola mrnosa (fleshy mole). The
cavity, which is lined by the amnion, has usually an irregular surface,
It is very exceptional for extravasations to break through both chorion
and amnion^ and thus form clots in the amniotic cavity itself. Hole* i
seldom exceed an orange in size, and usually are expeUed between |
the third and fifth month.

In cases whore abnormal adhesions attacli the vera and serotina to^
the walk of the uterus^ retained portions of the maternal membrana [
may remain after the ovum is expelled. In another cla8s> and this it]
the rule after the third month, the fetal members rupture, and tbei
embryo escapes with the liquor amnii. While ordinarily the re-
tained portions quickly follow the discharge of tlie ovum or embryo,
it frequently happens that the uterus retracts upon its contents, thd
cervix closes, and a period of repose follows. There is then produced
what is commonly known as an incomplete abortion.

luoomplete Abortion. — The various contingencies arising from the«
cases of incomplete abortion are thus truthfully depicted by Spiegel- 1
berg:*

1. Most frequently hssmorrhage continues at intervals, spontaneoaij
elimination gradually taking place as, through retrograde changes, poi*
tions of the retained membranes become successively loosened in thei|
attachments to the uterus.

2. In exceptional cases the haemorrhage ceases for a time entirely.
For days, weeks, and even months, the woman appears quite well
Then suddenly strong contractions, accompanied by profuse hflemor-
rhage, usher in the elimination of the fetal dependencies. In a case
of my own, three months elapsed from the occurrence of the first
hsemorrhage, which took place toward the end of the third month,
and was quite insignificant in amount, before the abortion was com-
pleted. Meantime, as there were progressive abdominal enlargement
supposed quickening, and milk in the breasts, the threatened abortio
was believed to have been arrested. Total retention, with a long
tcrval of repose, is thought to be due to complete adherence of tU
placenta, which continues to receive nutrient supplies from the uterus.
Spiegelberg believes that a menstrual period is the usual time at whic
the discharge of the retained membranes takes place.

3. Of more frequent occurrence than the foregoing is the putri3
decomposition of the retained portions. It occurs chiefly in
where there is more or less complete loss of organic connection betwe
the placenta and the uterus. Decomposition in the non-adherent pol
tions is produced by the introduction of air during the escape of the
embryo, or through the subsequent passage of the finger into the ut
rus, or, where portions of the ovum hang down into the vagina,
absorption of septic matter from the vagina upward into the utert

• BrtsoiLBiBO, **Lebrbiicb der Geburtsliulfe," Jnhr 1877, p. 87t.

TEE PREMATURE EXTULSION OF THE OVUM.

29T

i a result of putrid decomposition, the woman is exposed to septicaB-
'^twa, and infection of thrombi at the placental site. Fatal results are,
Wever, rare, as decomposition is usaaliy a late occurrence, setting
in, as a rule, only after protective granulations have formed upon
the uterine mucous membrane^ and after the complete closure of the
uterine sinuses. Continuous fever, with intercurrent attacks of haem-
orrhage, is, however, set up, but passes away finally witli the gradual
diacharge of the decomposed particles, while the threatening symp*
toms subside. Still, now and then septic processes lead to an unfavor-
ible termination. Local perimetritic inflammation is a common event.

i^^'

r >

FiA. tlS.—UteruA, with bft«k of a fibrinom^ poljrpuA after im abortion. (FrAnliol.)

4. Where there is a certain degree of relaxation with enlargement
af the uterine cavity, the fibrine of the extravasated blood may become
deposited aliout any uneven surface within the uteruSp and give rise to
m polyp tiihdiapod body, suggestive in ita mode of development of the

208

THE PATnOLOGY OP PREGNANCY.

stdaciite fonnutions in culcareouB cayems.* These so-called ^brinoiu
polypi generally develop around the debris of an abortion, such as
retained bits of decidna, placental remains, and portions of the felal
membranes. In bo me cases, likewise, thrombi projecting from the
placental site become the base of a loose fibrinous attachment. Pli-
cental poly|>i give rise ultimately to bearing-down pains, and inter-
current haemorrhages. They may even decompose, and endanger life
by septic absorption.

The retrograde changes that take place in a aterus after an abo^
tion correspond to those which occur in deliveries at full term. Where
a suitable plan of treatment is not adopted, or where the importaDce ^
of care in the after-management is not adequately appreciated, sub- fl
involution is apt to follow. Of all sources of uterine disease, none ^
takes precedence of a mismanaged abortiom

Diagnosis.— The diagnosis is based upon the presence of pain,
hoemorrhuge, dilatation of the cervix, and the descent of the ovum. _
When the ovum can be felt through the patulous os, the demonstration H
is of course complete. A soft polypus may, however, present a decep-
tive resemblance to a small ovum. In all cases of pregnancy the exist-
ence of haamorrhage alone, even when disassociated from other symp-
toms, renders the probabilities of abortion sufficiently gre^t to call far
the exercise of every precaution. It is not easy to recognize pregnancy!
in the early months, but in doubtful cases the cessation of the meases '
should be regarded as presumptive evidence of its existence.

The diagnosis of these pathological changes in the ovum and d^
ciduae which pave the way lor abortion can not be made out witli
certainty from mere subjective symptoms. Such changes may
regarded as probable when the size of tfie uterus does not correspond
to the supposed period of gestation. Thus, if the uterus at the fifth '
month was no larger than is usual at the third month, the death of
the embryo with arrest in the development of the ovum would be
naturally inferred.

When the physician is summoned to a case of h«emorrhage occur-
ring during pregnancy, he should at once examine the clots, where
tiiey have been preserved, for traces of the ovum. The clots should
be broken up under water, and a careful examination made for floatin
fringes of villi* The ovum, when expelled entire, is usually envelop
in layers of coagulated blood, so that without thorough search it won
easily pass unnoticed. If the coagula have been thrown away, and
the physician finds upon his arrival the cervix closed, so that he can
not pass his finger into tlie uterus to explore its cavity, it may be im-
possible at once to determine whether the abortion has taken place
wholly or in part, or whether the entire o\nm still remains in uiero,

here

ould^

tinM

3pe9

oulfl

THE PREMATURE EXPULSION OF THE OVUM. 299

The subsidence of all symptoms pointSy as a rule^ to a complete emp*
tying of the uterus^ or to an arrest of the abortion^ thoagh in some
cases it precedes mole-formation. A renewal of the haemorrhage and
the absence of normal inyolution indicate the continuance of the ovum
in the nterus, or an incomplete abortion.

Prognosis. — The prognosis takes cognizance of coarse of the results
to the mother only. ^ In the first place, it may be laid down in the way
of broad general statement that all cases of spontaneous abortion (i. e.,
excluding criminal cases), not complicated with other morbid condi-
tions, are, under suitable medical guidance, deyoid of danger/ But,
in the second place, it must be borne in mind that the statement is
only true with the reservations that limit it, for in point of fact the
actual number of deaths from abortion is by no means inconsiderable.
Thus, the deaths from this cause reported to the Bureau of Vital Sta-
tistics of New York City, between the years 1867 and 1875, inclusive,
were one hundred and ninety-seven,* a number which falls short in all
probability of the truth, by reason of the many circumstances which
precisely in this condition tempt to concealment. The total number
of deaths during the same period from metria was, according to the
reports rendered, 1,947. Hegarf reckons one abortion to every eight
to ten full-time deliveries. If this proportion be correct, it would
seem to show that the mortality from abortion is hardly second to that
from puerperal fever itself.

Death, as a consequence of criminal abortion, is especially frequent.
M. Tardieu found that in one hundred and sixteen such cases, of which
he was able to ascertain the termination, sixty wqmen died. X But even
in spontaneous cases death may take place from haemoiThage, from sep-
ticsBmiay or from peritonitis. In many instances the fatal termination
is fairly attributable to the ignorance, the imprudence, or the willful-
ness of the patient. How far the dangers of abortion may be neutral-
ized by proper medical assistance is best shown by the statistics of
large hospitals. Thus, I gather from the reports issued by Dr. John-
ston, during his seven years mastership of the Botunda Hospital, in
Dublin, that in two hundred and thirty-four cases of abortion treated
in that institution there was but one death, and that not from puer-
peral trouble, but from mitral disease of the heart Bellevue Hospital
is the receptacle annually of a tolerably large number of women suffer-
ing from incomplete abortions, many of whom enter the hospital in a
very unpromising condition from either excessive haemorrhage or septic
decomposition of the retained portions of the ovum. Yet, of the many

* L0SK, ''Nature, Origin, and Prerention of Puerperal Fever/* *' Trmnsacdoni of the
International Medical Congresfi," Philadelphia, p. 830.

f Hboar, ''Beitriige zur Pathologie des Eies," '' Monatsschr. f. Geburtsk.,*' Bd. xzi
(supplement), p. 84.

% T. Gallaed, '*De raTortement au point de Tue m6dioo-Ugal," Paris, 1878, p. 48.

THE PATHOLOGY OP PREGXAXCY,

cases whose histories I find in the reoord>books of the hospital^ all
have ended in recovery-

Treatment. — The treatment is diTided into^l. Prophylaxis in esses
of habitual abortion j ^. Arrest of threatened abortion ; 3. Meant
adopted to avert the dangers of a progressing abortion.

Prophylaxis. — ^ Prophylaxis considers the cause which underlies, ia_
each case, the disposition to repeated abortion. One of the priDCi]
of these causes is syphilis in one or both parents. It is just in tb
cases that the triumph of the mercurial treatment has been most coi
plete. The treatment should be addressed to the parent affected, of
both parents should be subjected to the same treatment.

Among local conditions amenable to treatment may be mentioned
endometritis, displacements, and i>erimetritic inflammations. In re-
troflexions and retroversions, the best results often follow the replace-
ment of the uterus and the employment of a suitable jiessary. No
harm results from the use of pessaries during pregnancy. They shooldt
however, be watched, on account of possible vaginal irritation. After
the completion of the third month they should be removed^ as the
uterus then remains in place without artificial assistance. When back-
ward displacement of the uterus follows abortion, reposition aids nor-
mal involution.

In carcinoma and large fibroids, treatment is powerless* Where,
in such ca^es, sterility does not exist, hapi^ily for the mother, tb«
associated morbid conditions of the uterine mucous membrane And
the rigidity of the uterine walls lead commonly to the death of the
ovum and premature uterine contractions. Where a small fibroid in
the posterior uterine walls leads to sterility by the production of retro-
flexion, a pessary may, after replacement, at times be used with benefit

One abortion sometimes follows another in rapid succession in
newly married women. While the first abortion may have been dae
to some accidental cause, the sequence is often kept up by a morbid
condition of the endometrium, generated by the shortness of the inter-
val between the pregnancies, which does not allow the restoration of
the membrane to a normal condition. ( In such cases, a six weekif
abstention from sexual intercourse may be usefully enjoined»\

In certain diseases of the placenta, in which the respirarory func-
tion of the organ had suffered any marked diminution. Sir J, '^H
Simpson believed he had succeeded in averting the death of the foodV
by increasing the oxygen in the blood of the mother, through the ad-
ministration of chlorate of potash.^ ^lChlo^ate of potash may be given
in doses of twenty gntius, three times daily, for weeks at a time, with-
out injury to the mother. Though it has not always rendered me the
hoped-for service, the experience of other physicians, among whom I

* Sir J, Y. SiKPSoN, **Ob«totric Memoira," edited bj Priestlcj wad Siorer, Edmburgh,
1865, vol i, p. 460.

THE PREMATURE EXPUI^ON OP THE OVUM. 301

may mention Dr. Fordyoe Barker, appears faTorable to its employ-
ment.

In the class of cases in which abortion results neither from disease
of the ovum nor of the uterus, but seems dependent upon some pe-
culiar condition of nerre-irritability, the patient should not only avoid
every known means of awakening uterine contractions, but should
exercise the utmost caution at the recurrence of the menstrual epochs.
Especially at the terminations of the second and third months a week's
quiet in bed should be insisted upon. Dr. E. J. Jeuks * recommends
the vihmnupi pruni|aliBm in cases where the habit of aborting has
been formed. He writes : (' My mode of prescribing the vibumum is to
have the patient take from a half-teaspoonful to a teaspoonful of the
fluid extract four times a day, beginning at least two days before the
menstrual date, and continuing it not only during the usual period of
the menstrual flow, but two days longer than that discharge continues
when the woman is not pregnant I* From the fourth month onward,
the danger of the occurrence of dlnortion rapidly diminishes.

The Arrest of a Threatened Abortion.— Arrest may be accomplished
in cases in which the death of the ovum has not taken place, and
where the haemorrhage arises from a slight detachment only of the
decidua or placenta.

In every case of threatened abortion occurring in the early months,
a careful examination should be instituted to ascertain whether retro-
flexion or retroversion exists. In the genu-pectoral position, replace-
ment is easy. If the fundus is slowly raised by two fingers introduced
into the vagina, so soon as the horizontal line is reached the uterus
falls forward of its own weight. Replacement alone, in certain cases,
suffices to relieve the congestion which furnishes the immediate cause
of the abortion.

Pain in the back during pregnancy should be regarded by women
as a warning for them to temporarily abstain from their ordinary avo-
cations. With ever so slight a haemorrhage, they should at once be
made to lie down and keep perfectly still. Simple turning in bed may
start up fresh bleeding. Restlessness and mental excitement should be
allayed by opiates in full doses. Ice to the vulva, cold cloths to the
abdomen, and the internal administration of haemostatics are not indi-
cated. The fluid extract of viburnum prunifolium is recommended
by Dr. Jenks, in teaspoonf ul-doses every two or three hours, as long
as its use seems to be demanded, f The author's somewhat limited
experience has appeared favorable to the claims put forth for the
viburnum as a uterine sedative. Where the foregoing measures prove
successful, it is a safe rule to keep the patient in bed for a week after
the final disappearance of the threatening symptoms.

♦ Jenks, " Viburnum Pnmlfolium/* " Tnms. of the Am, Gyiueool. Soc.,*' ▼oL i, p. 180.
t JssKBf loe, «/., p. 130. '

TEE PATHOLOGT OF PREGNANCY.

In cases of ascertained death of the fcetua, and in those of meri*
table abortion, all measures calculated to retard the emptying of the
uterus should be at once abandoned.

In the first four months there are no unequivocal sig-ns of the death
of the fiotus. From the middle of pregnancy onward, death may be
assumed if, after repeated examinations, the absence of the fetal heart-
sounds and fetal movements is confirmed.

The signs of inevitable abortion are profuse haemorrhage, clots dis-
charged from the uterus, dilatation of the cervix from the descent ot
tlie ovum, and a patulous condition of the os externum. Other
symptoms consist of persistent uterine contractions, escape of the
amniotic fluid, and the presence of the embryo, or of portions of the
ovum, in the discharged clot^. How far the ordinary signs may, m
^Iven cases, prove delusive is shown by a remarkable one reported by
Scanzoni^ of a woman who was seized with profuse metrorrhagia in the
third month of pregnancy. Great numbers of clots were discharged.
As all hopes of saving the ovum were abandoned, ergot waa uaed id
large doses^ a t^impon was placed in the vagina for thirty-six hour?, a
sound was employed to explore the uterus, and finally, m the bleeding
continued for three weeks, an intra-uterine injection of a weak eola-
tion of perchloride of iron was resorted to. Eight weeks later the
patient quickened, and presented the distinctive evidences of a preg-
nancy advanced to the sixth month. ^

The Treatment of Inevitable Abortion.

In the treatment of inevitable abortion it is proper to distinguish
between cases of abortion proper and those of miscarriage* To avoid,
however, needless repetitions, it is only points of distinctive differeocG
to which at the close attention will be directed. The management of
premature deliveries differs in no respect from that of confinement ttl
term.

In the first two months little treatment besides rest in bed fori
few days is ordinarily re(|uired. In the exceptional cases, the t refit-
ment does not differ from that in the haDmorrhages of the non-preg-
nant uterus.

In the third month we distinguish — 1, Cases in which the oram
is thrown off entire ; 2. Cases in which the sac ruptures, SQd the
embryo escapes \^Hth the discharged fiuid.

1. When in the third month the ovum is thrown off withe
rupture of the fetal membranes, the haemorrhage" rarely assumes ^
gerous proportions. The uterine contractions press the ovum into
the cervix, which dilates and, in primipara?, becomes somewhat elon-
gated. As the ovum descends, the body of the partially emptied ul
rus retracts* The effused blood coagulates in thin layers between
• ScANzoNi^ *' Lpchrbuch der G*;bartsliUlfe," Wien, 1867, p, 83,

TnE PREMATtJRE EXPULSION OF TOE OVUM, 303

omm and the uteritie walls. The ovum forms a tampon, which fills
the cervix and restrains the h^eniorrhage.

No active treatment is, therefore, demanded, A vaginal douche
consisting of a pint of tepid water may be used twice a day as a meas-
ure of cleanliness. All attempts to disengage the ovum with the
finger should he avoided, as endangering its integrity. The vaginal
tampon is nnneecssary. It should only be used as a safeguard, whero
patienta live at a distance from medical assistance and can only be
visited at long intervals. As it is never certain that the rupture of
the ovum may not take place during the course of its expulsion, the
tampon may in such cases be employed in anticipation of a possible
increase of haemorrhage from sudden collapse of the membranes. In
multiparas the ovum seldom remains long in the cervix. In primiparee,
on the other hand, the tardy dilatation of the os externum may lead
to a retention of the ovum in the cervix, lasting for days. As this
condition is extremely painful, it is allowable to dilate the os exter-
num with the index-finger, or even by incisions through the ring of
circular fibers which furnish the cause of delay.

Small portions of the decidua vera sometimes remain attached to
the uterine walls after abortion. They commonly do no barm, but
are discharged with the lochial secretion.
I 2. When the sac ruptures, and the liquor amnii escapes, the re-

aioval of the pressure exerted upon the uterine wall by the intact
OTam is followed by profuse hemorrhage from the utero-placental
voesels.

The diagnosis of rupture may be made either from finding the

tmbryo in the clots, or, in the case of a dilated cervical canal, by the

direct examination of the uterine cavity. Although after rupture

portions of the ovum may still be felt, we miss the smooth surface

of the fluctuating amniotic sac. When the embryo can not be found,

and the cervix is closed, profuse lieBmon'hage alone would render the

oecurrence of rupture extremely probable,

^_ The principles of treatment in these cases are very simple. The

^■indications are, to check the haemorrhage and to empty the uterus,

^■la to the best methods of attaining these results, opinions widely

^B When cBses are treated with rest in bed, the internal administration
^^tf ergot, and cold cloths applied to the abdomen and \Tilva, the loss of
blcM>d is usually considerable, but the most of them terminate favor-
ly. In some, however, the haemorrhage may prove so severe as even
threaten life. Now, it is in every way desirable, for the future wel-
of tlie patient, to restrain tlic hemorrhage within the narrowest
The most effectual means of arresting the ha?morrhago is to
out the uterus. If, therefore, the physician at the time of his
finds the cervix sufficiently dilated to allow him to introduce his

aoi

THE PATnOLOGT OF PREGNANCT.

finger into the uterus, he shonld not hesitate at once to remore tie
retained portions of ovum. Tho operation does not require any con-
siderable amount of technical skill, wliile the immediate results are
in the highest degree satisfactory. The patient should be placed crosB-
wise in bed, with the hips drawn well over the edge. The legs should
be flexed and the thighs held, where assistants can be obtained^ at
right anglers to the body, to secure the greatest degree of relaication to
the periufEum and abdominal walls. The right index-finger should be
then passed into the vagina and through the cervical canal, while the
left hand, placed upon the abdomen, gradually presses the uterus down
into the pelvic cavity so as to bring it within reach of the examining
finger.* This portion of the act should be performed slowly, while
every effort is made to divert the attention of the patient. Hasty
manipulations invariably excite in the most willing of patients the
full resistance of the abdominal walls. When the point of the finger
reaches the os internum^ it is sometimes necessary to pause for a minute
or two» to await a sufficient degree of dilatation to allow the finger to
pass beyond the insertion of the nail When the right finger is used,
it should be made to pass upward with its dorsal surface along the le
side of the uterus to the opening of the Fallopian tube, thence i
the fundus to the right side. As the tip of the finger passes
upon the right side, it presses the detached ovum before it toward the
OS internum. By the time the finger has thus made the circuit of
the uterus, the ovum is pressed into the cervical canal, and thenc
passes easily into the vagina. With the left finger, the movement
exactly the reverse. The finger passes first, with its dorsal surface
directed to the right side, from the right Fallopian tube across the fun-
dus, and downward along the left side of the uterus. The only resists
ance the finger meet"? is at the placental insertion, where a oertain
amount of manipulation is required to complete the detachment, f
Where the uterus can not be pressed down within reach of
index-finger by force exerted above the symphysis pubis, it ia per
sible to introduce the hand into the vagina ; but, in such a case,
fingers are apt to become cramped, and all freedom of manipulatia
to be destroyed. A better means of overcoming the difficulty eonsifl
in the administration of an anflesthetic. In cases of extreme anieml
chloroform should be discarded as too dangerous. Ether, howeve
has often seemed to me, on the contrary, to possess a stimulating actio^
and its use to bo followed by increase in the volume and force of

♦ Professor A, R, Smpsox (** Tranaactiona of the Edinburgh Obat(?trio&l Sode^,**
iv, p, 227) pecommptKls drawing down the utcnis by mcaos of TolscUum-foroepf i
to the Anterior lip of the cervix* 1 have once seen eitrcni^ hsinorrhago follow tUs I
Dcpuvre (seventh month of pregnancy )» and now feci some hcaitatioii »boul JU cmpl
mcnt, mt least in the Inter months.

t Vide H&TiEii, " Compendium der gcburtflhaiflichcn Opcrationcn," p, %%.

THE FREMATUKE ^XPrLSlOK OF TOE OVFM.

305

puLae. The relaxation produced by the ansesthetic inakea it easy to
depress the uterus down to the pelvic floor, where it can he reached
with comparative ease. After the removal of the ovum, the cavity of
the uterus should be washed out with a stream of tepid carboiized
water, in order to bring away any small detached portions of the ovum
and decidua. In the manual extraction of the ovum, deliberation
and perseverance are the main elements of success.

If, when the patient is first seen by the physician, the cervix is not
sufficiently dilated to allow the finger to pass without force, the vagi-
nal tampon should be employed. The tampon restrains the haemor-
rhage, stimulates the uterus to contraction, and allows time for the
emplojrment of measures to rally a patient exhausted by profuse losses
of blood. The material of which a tampon is made is a matter of in-
difference, provided only it fills the vagina to its utmost capacity.
In cases of urgent need, a soft towel, handkerchiefs, strips of cotton
4sk>tht dampened cotton-wool, and the like, may be seized upi:)n to
meet a temporary emergency. The time-honored sponge, on account
af itfl porosity, is least deserving of favor* When, however, the phy-
sician proposes to leave his patient for a number of hours, the mere
hasty filling of the vagina through the vulva will not suffice. On
ihd contrary, the highest degree of safety can only be secured by the
eloaeflt observance of the rules of art.

The first essential of a good tampon is that it be carefully packed
around the cervix uteri* and till out the more dilatable upper portion
ol the vagina. This can be accomplished only by the aid of a specu-
Itim« The method I usually employ is one, the credit of which, so far
as the general features are concerned, I believe belongs to Dr. Marion
Sima, It consists in soaking cotton- wool in carboiized water, and
y then, after pressing out any excess of fiuid, in forming from the earbo-
' liaed cotton a number of flattened disks of about the size of the trade-
dollar* The patient is then placed in the latero-prone position, and
the perineum retracted by a Sims*s speculum. The dampened cotton
diskisare introduced by dre5sing-force|is, and, under the guidance of the
oye, are packed first around the vaginal portion, then over the os, and
Ibence the vagina is filled in from above downward until the narrow
portion above the vestibule is reached. No other plan of tamponing
with which I am acquainted can compare in solidity and effectiveness
with this. Its removal is accomplished by the detachment with two
Bogen of a portion at a time. Tiiis part of the procedure is moder-
ately painftil. Many methods have been suggested to overcome in the
removal the necessity of introducing the finger into the vagina- A
very ingenious one consists in attaching the cotton to a piece of twine
00 as to form a kite-tail, which can be withdrawn by simply making
liactions upon the extremity of the string left hanging outside the
fidTa* Professor L E. Taylor uses a roller-bandage. It is efficient,
SO

THE PATHOLOGY OF PREGNANCY.

and, like the kite-tail deecribed, can be easily remored. Dn P. P,
Foster* advises the use of the larap-wicking a^ a material for the
tampon.

Before the introduction of the tampon, the vagina should be thor-
onghly washed out. No tamfjon should be allowed to remain in the
yagina much over twelve honrs* Immediately after withdrawing the
tampon, before proceeding to the examination of the uterus, the vagi-
na should be clean&ed by an injection of tepid carbolized water (gr*
XXX ad Oj)* Often, after removing the tampon, the ovum is found ,
in the upper portion of the vagina or filling up the cervix* If this is
not the case, and the cervix is not dilated, po that manual extraction
may easily be performed, another tampon should be introduced.

It IB customary from the outset to sustain the action of the tampon
by the administration of ergot, either in the form of the fluid extract
{thirty drops every three to four hours), or of a solution of ergotin,
given hypodermically (ergotin, gr. xij, glycerinae, 3 j- Ten minims
twice in the twenty-four hours. In women with abundant adipose
tissue the injection should be made into the subcutaneous tissues of
the lower abdomen. In others, the outer surface of the thigh ghoold
be selected).

If the patient is collapsed from loss of blood after tamponing, opi-
ates, tea, and alcoholic stimulants should be administered, the hitter
in small but frequently repeated quantities, until the cerebral anamia
18 relieved and the capillary circulation restored*

If, after the removal, the cervix is found not to be dilated, a third
tampon may be introduced, and left in mtu for another period of
twelve hours. The employment of the tampon is not, however, to be
recommended for a period much exceeding twenty-four hours. Its
continued use is apt to irritate the vagina. In spite of carbolic acid,
it acquires an offensive odor. It generates septic matters, which, in the
long-run, creep upward through the cervix into the uterine cavity,
and produce decomposition of the ovum. I prefer, therefore, in cases
of undilated cervix, after twenty-four hours of vaginal t^imponing, to
resort to sponge-tents. The sponge-tent is most easily introduced
when the patient is placed upon her left side, with the perineum drawn
back by Sims's speculum, and the anterior lip of the cervix drawn
down and steadied by a tenaculum (Sims*8 method). The tent may,
however, in the absence of an assistant, be introduced, with the patient
on her back, by the aid of a pair of strong dressing-forceps. The tent
should be long enough to pass well up through the os internum.
Within six to twelve hours the tent should be removed, and, after a
preliminary vaginal douche, manual extraction be proceeded wiUi in
accordance with the rules already given.

In manual delivery, it is desirable to remove the decidua as well as
♦ Foflrai, " N, Y, Med. Jour.,'' Jimc, ISSO.

THE PREMATURE EXPULSION OF THE OVUM,

307

the OTurn, When the cervix is patent, this ie easy, as the decidua is
then detached from the uterine walJs, When the cervix is unchanged,
the detachment is usualJy incomplete. In such cases, it is advisa-
ble, therefare, to try first the tampon before the sponge-tent, as the
former stimulates the uterus to contract, and promotes the separa-
tion of tlie decidua, even when it fails to secure the discharge of the.
oTunx.

Inside the uterine cavity, ovum-forceps should be used with great
caution. I have discarded it altogether. In the first place, it is
dangerous ; in the second place, it is unnecessary. When, however,
the retained portions of the ovum have left for the most part the
uterine cavity, and occupy the cervical canal, the delivery may at
timefl be advantageously hastened by placing the patient upon her
side, and, with the cervix well brought into view by a Sims's spec-
itlam, applying the ovum-forceps, under the guidance of the eye,
within the cer\ix to the sides of the placenta (Skene). But great care
requires to be exercised not to break away the fragile structures and
leave material portions behind.

Under like circumstances, Hoening* recommended a modification
of Credo's method for expression of the placenta. With the patient
Ijring upon the back, the o|>erator, according to Hoening, should seek
to compress the body of the uterus between the left hand, laid above
tho iymphysis pubis, and two fingers of the right hand introduced into
tha Tagina. The measure is only practicable when the ovum has, to a
gretA extent, passed from the uterine cavity. As it is somewhat pain-
I ful, and requires for success lax abdominal parietes, it possesses a lim-
ited range of applicability.

Treatment of Neglected Abortion. — Where, following abortion, the
litems has once been completely evacuated, haemorrhage ceases, A
alight lochial discharge i^ersists for a few days during the period in
which tlie uterine portion of the decidua vera completes its period of
repair. If, therefore, a patient comes to ua two or three weeks aft^r
iho supposed conclusion of an abortion, with the story of recurrent
hemorrhages taking place, as a rule, whenever she leaves her bed and
awumes the upright position, it may be assumed, with an approach to
eertainty, that portions of the ovum still remain within tJxo uterus.
Oftentimes a fetid digchargo points to the fact that decomposition has
bean set up. The absoqition of septic materials may, furthermore,
become the source of chills, of fever, and of great uterine tenderness.
In most cases, with rest in bed, the contents are discharged by sup-
pnmtionp and recovery ultimately takes place, but only after a slow,
[protracted convalescence, during which pelvic cellulitis and pelvic

itonitis occur as not uncommon complications. lIiemorrhage8»

jtomtts, and aepticsemia may, however, bring the case to a fatal
* BosKiifo, ScanioDi'a " Bdtr&ge/' Bd. tII, p. 213.

308

TDE PATHOLOGY OP PREGNANCY.

issue. The remoTal of the retained placenta and membranes is there-
fore indicated, not only as a measure calculated to promote recoveir,
btit to avert possible danger to life.

With regard to the oi^eration for removal, the rules already given
are applicable. The following peeuliarities ehoiild, however, be borne
in mind. In case the retjiined portions are nndecomposed, the cervix
is usually found closed, and requires preliminary dilatation with the
Biionge-tent When decomposition has once set in, the os internum
will, as a rule, allow the finger to pass into the uterus,* When a
decomposed ovum is removed by the finger, a chill and a septic fever,
which rapidly disappear, however, are apt to follow in the course of
a few hours. This chill and fever result from the slight traumatic
injuries inflicted by the finger upon the uterine walls, whereby the
capillaries and lymphatics become oi>ened up to the action of the sep-
tic poisons. The fever ends in a short time, because the reservoir of
supply is removed with the debris of the ovum. If the uterine cavity,
after the operation, is carefully washed out with carbolized water,
the septic fever is often averted. The beneficial results following the
complete emptying of the uterus in these cases are so decided, that of
late years I have not allowed myself to be deterred from proceeding
actively, even when perimetritis and parametritis, in not too acute a
form, already existed. In practice, multitudes of examples show that
the products of inflammations situated in the pelvis do not become
absorbed so long as putrid materials are generated in the aterine
cavity.

The removal of a fibrinous polypus, owing to its smoothness and
the small size of the pedicle^ is often a Sisyphu8*6 task. The separation
can only be successfully accomplished when the palmar surface of the
index-finger presses from above upon the point of attachment. This
necessitates a choice of hands. Thus, when the polypus is situated
to the left, the right index-finger should be employed, and the left
index-finger, when the polypus is situated to the right. After the
detachment is complete, it is necessary to press the polypoid body
firmly against the uterine walls, and proceed with its withdrawal
slowly. If, as is sometimes the case, the poljrpns slips from under the
finger, the latter should be again passed to the fundus of the uterus,
and the attempt repeated. Small portions, not larger than a pea, can
be washed out by the uterine douche. When the polypus is situated
near the oa internum, the latter will be found patulous, but, when it is
well up within the body of the uterus, dilatation is a frequent prerequi-
site to removal.

For the removal of presumably small portionB of retained ovum,
especially in cases where, owing to inflammatory conditions, I have
hesitated to make the circuit of the uterine cavity with my finger,
* H0T£Rf *' Compendium dcr gebbiilfliolicn Opuratlonon," Ldpeilc, 18t4, p. Si.

EXTRA-UTERIKE PREGNANCY.

309

I have succeeded admirably by employing a tolerably firm Thomas's
wire curette.*

The Treatment of Immature Deliveries.— /owrM io seventh month.
— Distinctive of immature deliveries are ; painful periodic contrac-
tions, recognizable by the band applied above the eymphysis pubis,
rupture of the membranes and discharge of the fcetus, the complete
formation of the placenta and umbilical cord ; while in abortion the
uterine contractions arc obscure, the placenta \& rudimentary, and the
OTum is frequently expelled entire. In the treatment of immature
delirery, the tampon may usually be discarded. After rupture of the
membranes and expulsion of the fc«tus, the haemorrhage should be
controlled by grasping the fundus of the uterus in the hand through
the abdomen* and compressing the uterine walls firmly together.

The passage of the foetus opens the uterus so as to allow, in the
fourth and fifth monthg, the introduction of two fingers ; in the sixth
and seventh months, that of the half-hand. In case compression of
th6 atems does not arrest the hteraorrhage and expel the placenta, the
cord should be carefully followed to its insertion, to determine the
side upon which the implantation exists. If the placenta is implanted
upon the right side, two or four fingers of the right hand, according
to the degree of cervical dilatation, should be passed up along the left
side of the uterus, across the fimdus to the placental site. The de-
tachment should be effected with the tips of the fingers, and the pla-
centa pressed downward as the fingers descend along the right side of
the nterus. The left hand should he employed in the reverse direc-
tion, when the placenta is situated to the right

CHAPTER XVIL

EXTBA'UTERINE PREQNANVT.

litioDL — Tubcil pregnancy. — Pregnancy in rudimeotaiy cornu, — Int£?r8titial prognancy.
— TabcMibdomitml and tubo-oYarian pregnancy. — Ovariiui pregnancy. — Abdominal
pregnancy. — Syroptonu. — Tenninations. — Diagno.iia, — Trealmeni, incases of early
gaiiatioii,~€MO« of Adnaoed geatniiot] {fcetus JiTing). — Cases of gestaiioo pro-
looged aller the death of the fastui.

Aptbr coitus, the spermatozoa make their way through the Fallo-
piaii tubes to the pelvic cavity. It is possible, therefore, for the ovum
io become fecundated in any portion of the route from the ovary to

^ISxcKK, '» Med, Rpcord," 1875, p. 6t>; Munuk, ^^CcDtralbi t Gynaek.," 1878» No.
▼i, jK L The pAtietit tbould be placed in Sims*» position^ the peiiniemn should be drairn
httk irtih SSmaVffpeculutnf the cervix hooked down and steadied with a tenaculum, while
the eureU* la made to paas orer all portions of the uteiioe surface. AtUched bits of
placenta are recogniied by the reaiBtauce they o£Fef.

310

THE PATHOLOGY OF PREGNANCY,

the otenis. In exceptional ease^^ the ovum may, after fecundation, be
arrested in its travels, and undergo development at some point outside
of the uterus. To these fortunately rare cases the term extra-uiertne
pregnane^ has been applied.

The terms iukd, ovarian^ and abdominal pregnancy designate
different forms of extra-uterine development, and serve to express
the site of the attachment from which the growth of the ovum be-
gins.

Tubal Pr«gBanoy, — Tubal pregnancy is the most frequent of the
three forms. The ovum may find lodgment in any part of the tube.
The causes of this anomaly are to be sought for in catarrhal affections
attended with loss of the ciliated epithelium, dilatation, and, in some
cases, with the formation of hernial pouches, produced by the protm-
sion of the mucous membrane through separated bundles of the mus-
cular fibers ; or the ovum may be arrested by flexions and constriction*
of the tube resolting from adhesions and old inflammatory bands^
In a few instances a small polypus has been found filling up the calilxT
of the tube. Because of its connection with inflammatory prooesdes,
the occurrence of tubal pregnancy is often preceded by a long period
of sterility. When the obliteration is only partial, the spermatoEoa,
owing to their small size, are not prevented from reaching the arrest l4
ovum ; when complete, on the contrary, they can only gain access to
the o\Tim by first passing through the patulous tube, and then migrat-
ing across the rear of the uterus to the ovary or the open abdominal
end of the tube upon the opposite side. In a considerable number
of cases, the corpus luteum has been found upon the side opposite to
the tube containing the fecundated ovum. With the present pre-
vailing views,* this phenomenon is only to be accounted for by
the hypothesis of the migration of the ovum across the peritoneal
surface of the pelvis or through the uterus from one tube to the
other.

As the ovum develops, the mucous membrane of the tube thickens
after the manner of the decidua, and receives the club-shaped extrem-
ities of the villi. Until the formation of the placenta, the detachment
of the ovum is easy. Usually the two poles of the decidua-like cover-
ing are closed, though sometimes the uterine end remains open, and
in continuity with the raucous membrane of the tube and the decidua
of the uterine cavity, f A decidua reflexa is in any event extremely

♦ Matrhofer, " Ueber dio gclben Korper^ und die Ueberwandeniiig dea Eiea/* d«n!ei
the wbole doctrine of a distinet corpus Lutoum of pregnancy, and elairos thfti corporA lutci
lire found at states) Interrals, perhaps monthly, throughout the entire period of prcg-
nanc7, Leopold, " Die Ucberwandcrung der Eier," '* ArcU. f. Gynaek.," Bd. %n^ p» %i^
however, fotind that after tying the right tulns and after removing the entire left oirary
ia a couple of rabbiu pregnancy still took place.

+ L. Bandl, Billroth'a ** Handbuch der Frauenkrankheitcn/* 5te AUiiolm., art. ** Extra-
utejin&chwangerachaft," p. 44,

EXTRA-UTERINE PREGNANCY.

311

rare** The placenta ia purely a fetal organ. The villi j^enetrate to the
moK^ular structures of the fcube^ wliero they are occasionally surround-
ed by large vessels. Nowhere, however^ have they been observed to
liaTe broken through the walls of the matema! vessels, nor ie there
^any evidence of maternal blood in the intervillous epacea, such as is
(?iicved to exist in cases of intra-uterine development, f
With the beginning of pregnancy the muscular walls of the tube
hypertrophy, but they subsequently are stretched thin by the growth

5^(^

'-i^'

Fjo* 1«.— Tubd pregnuncy. (N. Sommcr.)

irf the omm* At an early period, usually within the first three
months, mptnro of the sac occurs at the point of least resistance,
which corresponds in many cases to tlie site of the placenta. With
rmre exceptions death follows rupture, eitlier immediately from acute
^mtemal haBmorrhage, or secondarily from peritonitis,

Hupture of the tube-walls may be associated with rupture of the
UTom and escape of the fcetus into the abdominal cavity, or the ovum

' paw intact into the peritonaeum ; or, finally (and this is the more
favorable termination), the ovura may remain in the tube, where it can
fierre as a tampon and diminish the extent of the haemorrhage.

Beoovery may occur in case of premature death of the embryo
before rupture takes place ; or subsequent to rupture, by the forma-
tion of false membranes around the embryo, or the entire ovum.

Exceptionally tubal pregnancy may, owing to an extraordinary
thickening of the muscular walls, advance to full term, 8j)iegelberg

fTB to tJiree instances of the kind — one reported by Saxti>rph, one

Ixnifio foimd in one hundred and fif\j reported cases a reflexa oientioncd in but
^Dit Knuiltbdleii der Eiieltera und die TubcnHcliwangcrschaft/* p. l&O).
f VidtCoxMAD and LAiroBAtra, "Tubenschwangerschaft," **Areh. f. Gjmaek,/* Bd.
fi, pv tftt ; aUo Liopoi.i>, ** Tubenschwangerachaft,^ etc., ihid.^ Dd. Jt, p. 263.

313

THE PATHOLOGY OF PREGKANCT.

by himself, and one by Fabbri.* Tlofmeierl likewise reports a case of
probably the same character.J

Rupture of the tube may occur in the portion not coTered by the
peritonaBum, Blood is tlien effused between the folds of the broad

Fio, lil.^PrepiaiKy in rudimentiiTy oomu. (Kf^RBomu!, observed by Heyfclder,)

ligament, and into the cavity thus formed the ovum may escape.
form is known as extra-peri toucal pregnancy.

Pregnancy in tlie Rudimentary Comn of a One-horned Dtems.—
This anomaly so clof^ely resembles the tubal form of pregnancy that
the diagnostic distinction can rarely be established during life. Eve
after death the only certain guide is furnished by the Bituation of th
round ligament, which in the rudimentary horn is found external to"
the sac, while in tubal pregnancy it lies between the sac and thfl!
uterus. In tubal pregnancy, however, rupture takes place, as a ml
during the first three months, while the rupture of the cornu occn

* SFixoti.iififtO, ** LebrbucU der Geburtsbiilfe," p. SI 2.

t Honmift, "Ztschr. 1 Geburtab. uud GjiMiek./* Bd, t, p. 115.

X Erj(8t Frankkl {'' Artfh, f. Gynaek.^^* Btl jeif, p, 20ft) collected twcDty^ii coses, i
ring between 1S75 loid 187^, of pure ttibal pregnancy, m which tbe diagnoeia waa
firmed by subsequent jek^^/- moWnn examination. Of thcee but seTcnt^^cn termmated la"
mpturG during the first three months. Of the remaining nine, two reached fuU tena
(SimpBon^s and Tinkered), one completed eight months of ^c^ation (Cullingwortb^a), one
Btji months (Doninger'a), one five montliis (Nctzcra and Blick**), and two four maatbj
I Fr^nkel'a and Netzers).

EXTIU-UTERISE PREGNANCY.

313

gomewhat later, usuaUy between the third and sixth month* In one
3, related by Turner,* pregnancy went on to full term ; the patient
lying of phthisis six months after labor, the dead child was found in
the left comu. Rupture takes place at the apex of the comu, where
tenuity of the walls is most pronoanced. Ko^berld f mentions a
J where the clnld died in the fifth month, and was converted into
a Hthopfedion,

Isterstitial Pregnancy. — The term intx^rstitial pregnancy is applied
Ottfloo in which the ovum is developed in the uterine portion of the
ftnbe. The latter measures about seven lines in length by one line in
iiameter. At first the muscular walls hypertrophy and form around
Ihe ovum a sac which projects from the upper angle of the uterus.
[As, ordinarily, the growth of the muscular tissue does not keep pace
'with that of the ovum, rupture occurs at an early period, usually be-
fore the fourth month. Rokitansky4 however, cites a case in which

Fia. 146.— Intentitkl pregnADCj. (Hemug.)

be thickened muscular walls resisted the pressure of the ovum to the
ixxA of gestation^ the child having been removed by bparotomy in the
^^nth month.

When the orum develops in the outer end of the uterine portion, it

• TcRjcni, "Eclmhiirj^h Med. Jour./* May, 1866» p. 974,

t K(KBKRf.K, "Gax* Hcbd.,'* 1866, No. 34.

% Vtdt SpiiotLiiitiio, " Lehrbucb def Geburtshllfc," p. 813.

314

THE PATHOLOGT OF PREGNANCY,

may grow partly outward into the tube. This form is termed tubo-
interstitial pregnaocy. On the other hand, when near the inner ex-
tremity, the ovum may dilate the ostium and pass into the uterine
cavity, and be expeDed after the manner of aa ordinary abortion.*
Another possible form of interstitial pregnancy is furnished by the
occasional existence of a canal, open at its two extremities, and appar-
ently a continuation or a bifurcation of the Fallopian tube, A case
reported by Dr. Gilbert, in the ** Boston Medical and Surgical Jour-
nal *' (March 3, 1877), where the head of the child could be felt just
above the os internum, covered by a thin mucous membrane, and in
which delivery was successfully accomplished by an incision through
the partition, probably belonged to this variety, A similar case, in

Fio. 146* — Biftircatiou of tubd canal* (Hcnnig.)

the practice of Dr, II, Lenox Hodge, is reported by Parry (o/). cii.i p.
266).

In the post-mortem examinations the distinction between an inter-
stitial pregnancy and one in a rudimentary cornn is not easy to make
out, as in both the round ligament lies to the outer side of the tnmor.
The chief points of difference consist in the fact that in interstitial
pregnancy the sac is separated from the uterus by a partition, while
in pregnancy in a rudimentary comu the two halves of the uterus
arc united by a muscular band, which is situated, not at the upper
angle, but near the oa internum, f

Tubo-Abdominal and Tubo-Ovarian Pregnancy* — When the ovum
becomes lodged near the trumpet-shaped extremity of the Fallopian
tube it grows outward into the abdominal cavity. Local peritonitis is
then set up, and plastic exudation is thrown out, forming an envelope

* In thia category we should certainly pUoe the case of Dr, Chnrlei McBurner (** New
York Med. Jour/* Marcb^ 1878, p. 273) and that of Dr, Cornelius Williftius, in the
Decemher nwrnbcr of the same journal (p, 58B), both of which Wfife followed by the reooT-
cry of the mother.

t SriEOELBiRo, ** Lehrbuch der Geburtehulfe," p. 815.

EXTRA^UTERINE PREGNANCT*

315

around the ovnm, which is likewise bounded by the contiguous or-
gans. In this way the ligamenta lata, the ovaries, the mesentery, the
intestines, the bladder, and the uterus, may all contribute to the
inyestment of the fetal membraoea. In case of rupture in the tubal
portion, inflammatory products may form, and limit the extent of
the injury. At first, owing to its weight, the distended tube drops
into the cul-de-sac of Douglas. In advanced pregnancy, the spleen,
kidneys, and liver may become involved, and form part of the sac-
walls around the ovum. Usually the placenta is developed in the
pelvic cavity,*

When the investment of the ovum is furnished by the tube and
the ovary, the term tubo-ovarian pregnancy is employed. The course
in either case does not materially differ from that of an abdominal
pregnancy.

Ovarian Pregnancy- — A number of well-observed cases are now on
record f where the fecundation and development of the oTum have
taken place within the Graafian fulHcle, the walle of the hitter and
the ovarian stroma furnishing to the growing ovum, in whole or in
part, a membranous envelope, like the wall of an ovarian cyst
Subsequent to fecundation the Graafian follicle may close, and the
ovum continue extra-peritoneal, or the ovum may gradually make its
way through the opening occasioned by the escajfe of the Gi*aafian
fluid, and thus come to lie eventually for the most part within the
peritoneal cavity. In either case, rupture of the sac takes place
usually within three to four months, though, when the sac- walls are
reenforced by adhesions to the peritoneal coverings of adjacent viscera,
the full term of gestation may he reached.

Abdominal Pregnancy. — The origin of abdominal pi-egnancies is
j miiettled. As no instances have been observed at an eiirly period
of development, it is not possible to say whether the fertilized ovum
drops into the peritoneal cavity on escaping from the ovary or during
ita migration through the groove of the long ovarian fibria, or whether
nettrly all cases of abdominal pregnancy are not really secondary out-
growths from the tubal and ovarian forme.

Wherever the ovum comes in contact with the peritomeum, a con-
neetive^tissue proliferation is set up» which surrounds it with a vas-
cular sac. The latter often attains a degree of thickness which renders
it oomparable to the gravid uterus (KJob). The walla keep paoe^ as
a rule, with the growth of the ovum, and, as they extend into the
abdominal cavity, form adhesions to the intestines, the mesentery, and
. omentum. It is claimed that organic muscular fibers have been found

• Vidt Baj(Ol, BUlroth'a " Bandbuch dcr Frauenkrankbeiten/* 6te Abschn., p. 47*

Vidt Sputottneno, ** Zur Casuislik der Ovurialscbwangerftchaft," ** Arch, f . Gynaek.,**
^iflf, p. 73; Lakoao, *'Zur Lehre von der Eierstockfiscbwangcrschiift," ibicL^ Bd.
xfUi pw iZt; 8cBlOII>ll^ " Lcbrbucb,^* 4te Aufl., p. SSO.

316

TOE PATHOLOGY OF PBEGNANCT,

in the sac, especially near the uterine attach menL In this Jform the
fcetua most frequently reaches maturity.

In rare casea the ovum develops free in the abdommal caTity, wiih-
ont the formation of pseiHlo-memhranes, the fcetus being surrouoded
solely by the amnion and chorion*

Still more remarkable are the so-called secondary abdominal preg*
nancies, where mpturo of the sac and the fetal membranes, whether
primarily eituated in the tnbes, the ovary, or the abdominal carity,
takes place, and the feetus passes into the abdominal cavity. tJeually
the child dies at or soon after the time of rupture^ but cases are re-
ported by Walter, Patena, and Bandl,* where it continued to develop
within the abdomen. The presence of tlie child excites an active pro-
liferation of connective tissue^ by means of which a secondary sac is
formed. If the child dies, it may either become converted into a
lithop^dion, or, through the vascular connective tissue by which it
surrounded, the soft structures of the body may preserve their int
rity for years succeeding the fatal ending.

There are, in addition to the varieties already mentioned, bistorioB
on record of the coexistence of extra-uterine and intra-nterine preg-
nancies, the latter occurring at the »ame menstraal period as the for-
mer, or subsequent to the death of the extra-uterine foetus, f

The Symptoms of ExTRA-irTERiNE Pregnancy,

The earlier symptoms of extra-uterine pregnancy do not materially
differ from those of the intra-uterine form* Menstruation usually
ceases, though not with the same regularity as in normal pregnancj
The recurrence of the monthly flow for one or two periods is not
uncommon incident. In some cases, too, a nearly continuous
eanguinolent discharge of moderate extent has been observed. Up to'
a certain point the h}"[jertrophic changes of the uterus take place in
the usual manner. The mucous membrane is converted into a de-
cidna, and a mucous plug fills the cervix. In general terms, the leng
of the uterus is greater, the closer the contiguity of the ovum to th
uterus. Thus, in interstitial pregnancies the length has been fonc
to vary between four and seven inches, in tubal pregnancies the ave
age enlargement is less than in the interstitial, and in the abdomln
leas than in the tubal form. In a few cases of tubal pregnancy thei
has been no increase in the size of the uterus. The extra-uterii
ovum may, in the course of its growth, drag the uterus upward, i
push it downward, forward, or sideways, according to the site of i|
development.

Characteristic symptoms of extra-uterine pregnancy do not occur
until the ovum has reached a certain degree of growth, and in son
cases not until rupture has taken place. Often preceding rupture, oi
* BAimL, loc, eii.^ p. 63. f 7&td, p. 6d.

EXTRA-UTERmE PREGNANCY.

317

in abdominal pregnancies, the death of the foetus, the patient suffera
from paroxysmal pains in the sac, and uterine pains of a labor-like
character. The latter are associated with a sero^saoguinolent dis-
charge, and are followed by the expulsion of portions of the deeidna.

The aymptoms of rnptnre are the usual ones of internal hff?mor-
rhBge, viz,, yawning, languor, fainting, clammy perspiration, rapid
pulse, intermittent vomiting, collapse, and acute anisemia. After the
death of the ovum these symptoms may cease and not return again ;
whereas, if the ovum continues to grow, there may be repeated attacks
of haemorrhage and local peritonitis, terminating finally in death or
recovery.

When the death of the ovum does not occur within the first three
to four months, the pressure of the tumor usually gives rise to dysuria
and constipation.

TerminatioiiB. — In tubal and interstitial pregnancies the usual
terminations are, as we have seen, rupture of the sac, ha&morrhage,
peritonitis, and death. It is well to bear in mind, however, that this
b not the history of all, a pretty large percentage ending in recovery.
Thus, a dead foBtua may be retained for years without furnishing the
impulse to a fatal issue. When the foetus dies previoua to rupture,
the ovum may degenerate into a mole, or the foetus may either undergo
mummification, or be converted into a lithopsedion.

In aMominal pregnancies, whether primary or secondary, the ovum
ror fu>tu8 usually excites a local peritonitis, attended with pain and
I fever, and followed by the production of pseudo-membranes, which
eiercise a conservative influence by shutting oil the ovum from the
peritoneal cavity. Indeed, in the exceptional instances wiiere these
infiammatory conditions do not develop, the movements of the foetus
within its own membranes may give rise to such intense suffering as
to cause the woman to die from exhaustion (Scbroeder),

In ovarian and abdominal pregnancies the child may die prema-
torely, or gestation may advance to full term. In the latter instances
labor*pains set in, the decidua is expelled, and the child dies during
the expulsive efforts. In the majority of cases the dead foetus excites
a guppurative inflammation in the sac by which it is inclosed, and the
patient dies either from general peritonitis or from profuse suppura-
tion. In favorable cmos, where the peritonitis remains local and the
iuppuration is tolerated, fistulous coniraunications may form with one
of the hollow viscera of the abdominal walls, through which the con-
tenia of the sac may be eliminated. Most frequently the opening
takes pUce into the large intestine ; quite often through the abdom-
inal walls ; more rarely into the viigina and bladder* In any case,
the process of elimination is glow, often lasting months and even years.
VITien the bones and soft tissues have all been discharged, complete
peeoTcrj may take place. In the larger proportion of cases, however,

318

THE PATHOLOGY OF PREGNANCY,

if Nature is nofc assisted^ tbe patient perishes from exhaustion and
blood-poisoning before the elimination is ended (Schroeder).

Sometimes the foregoing inflammatory changes do not occur as the
result of the death of the fcotus, in which case the fluid contents of the
sac are reabsorbed, and the walla collapse and come in contact with the
fetal cadaver. The skin of the latter, and at a later period the deep-
seated soft tissues, undergo fatty degeneration, and form a greasy sub-
stance, consisting of fat, lime-salts, cholesterin-crystals, and blood-pig-
ment. Afterward the fluid portions are absorbed, so that nothing
remains but the bones, lime lamellEe, and incrustations upon the walls
of the sac, or the fa?tus may shrink up like a mummy, preserring iu
shape and organs to the minutest detail (Spiegelberg). A foetus thus
altered is termed a lithopaedion. It may remain imbedded in connec-
tive tissue for years without injury to the mother. The lithop^dion of
Leinzell was removed in 1720 from a woman ninety-four years of age,
who had carried it for forty-six years. The presence of the lithopff-
dion does not prevent pregnancy from taking place.* In some cases it
may after years excite suppuration, a result which is fostered, according
to Spiegelberg, by pregnancy and labor. Eecovery may follow tbe
artificial extraction of the foreign body, or death may result from
inflammation and the discharge of pus.

Diagnosis.— 'The diagnosis of extra-uterine fetation is based upon
the existence of the signs of pregnancy, the excluBion of an ovum
within the uterine cavity, and the presence of a tumor external to the
uterus.

In tubal pregnancy, the symptoms up to the time of rupture are
often those of ordinary pregnancy. The existence of paroxysmal
pains, radiating from one iliac fossa, should excite the suspicions of
the physician and lead to a careful investigation. As these pains are
ordinarily associated with flatulent distention of the colon, they are aj»t
to be regarded as due to intestinal colic. Sero-sanguinolent discharges
from the uterus, and afterward the expulsion of portions of the de-
cidua, would, however, limit the diagnosis to a choice between mem-
branous dysmenorrhcea and the condition in question, the decision
depending upon the presence or absence of the menstrual, mammary,
and uterine signs of pregnancy. An examination per vagbmm^ after
the first five or six weeks, reveals tlie presence of a tumor to the side
of the uterus. When situated low down, whether in the cul^e-^ac of
Douglas, or to the sides of the vagina, by conjoined palpation its
ovoid shape, fluctuation in the sac, and, in the absence of peritoneal
adhesions, a ballottement of the entire tumor, can be made out, Bal-
lottcment of the foetus may be detected by the end of the fourth
month. Arterial pulsations in the vaginal walls beneath the tumor are
of suspicious im|>ort.

* ScBitOEi>£K, Op. cit^ ete Aufl.) p, 421.

EXTRA-UTERINB PREGNANCY.

819

Owing to the desirability of early recognizing an extra-utenne
pregnancy, when the evidence in favor of ita existence is very strong
it is allowable t^ demonstrate the empty state of the uterus by a care-
fal introduction of the sound, or, still more clearly, by introducing
the finger after preliminary dilatation of the cervix.

When the sac mptnres in the early weeks of pregnancy, the escape
of blood into the peritoneal cavity may be moderate and run the
conrse of ordinary haematocele. From the third to the fourth month,
rapture gives rise to symptoms of extensive internal haemorrhage, and
usually proves speedily fatal

With rare exceptions, when extra-uterine pregnancy exceeds the
fourth month without the occurrence of rupture, either an ovarian or
abdominal pregnancy may be predicated. After the fourth month the
oTum becomes of the size of the two lists, and it is sometimes possible
to make out the presence of feUil parts through the abdominal walls,
prorided the latter are not too thick. Of course, as pregnancy ad-
Tanees, the heart-sounds and the contour of the foBtus become more
distinct. The difference between intra- and extra-uterine pregnancy
may sometimes be established by frictions of the abdomen over the
tumor with the hand, as the uterus alone contracts in response to the
atimnlus.

If by the foregoing means the requisite certainty is not reached,
bimanual examination should be made under anseathesia. Sometimes
the diagnosis can only be decided by the introduction of the sound or
a finger into the uterus, the physician assuming the risk of premature
labor, should he find his supposition of extra-uterine pregnancy an
©nor*

Treatment. — The treatment of extra-uterine fetation varies in ac-
cordance with the stage of pregnancy and the condition of the foetus.
For the sake of convenience, we distinguish — L Cases of early gesta-
tioQ ; 2. Cases of advanced gestation (fcBtus living) ; 3. Cases of
fieitation prolonged after the death of the fo&tus.

1, Cases of Early Qestation, — The indication for treatment in
the early months is plainly the adoption of measures to destroy the life
of the foetus, and thus, by arresting the growth of the ovum, avert the
danger of rupture and hsemorrhage. Indeed, in this way we simply
foDow the plan marked out for us by Nature, spontaneous recovery
earomonty following the accidental death of the embryo*

The methods which have heretofore been employed to destroy the
OTum are puncture of the sac, injections of morphia solutions, elytrot-
omy, and the faradaic current.

Puncture of the Sac. — Puncture of the sac is usually easily effected
by the intToduction of an exploring trocar, through either the vagi*
nal or rectal wall. The operation is to be recommended on the score
of simplicity^ but has not been attended with very brilliant results.

320

THE PATUOLOGY OF PREGNAKCY.

Recoveries after puncture have been recorded by Greenhalgh, Tanner,
Stoltz, Jacobi, KcrborR*, and E. Martin (two cases). Fatal isstiei
from Bepticsemia and peritonitis followed puncture in the hand« of
Eouth, J, y, Simpson, A. Simpson, Mai*tin, Braxton Hicks, Thomas
(two cases), Conrad j Netzel, Hutchinson, John Scott, Gallard, and
DepauL Friinkel * withdrew nearly three filths of an ounce of amiii*
otic fluid from the eac without interrupting the course of pregnancy.

Injections of Solutions into the Sac, designed to destroy the Fctim.
—This method was first Buggested by Jouhn. \ He proposed injec-
tions of sulphate of atropia (one fifth of a grain, dissolved in a few
drops of water) into the sac by means of a long hypodermic syringe.
His suggestion subsequently was successfully carried into effect in two
cases by Friedreich,! "^^ Heidelberg. The needle of the syringe should
be introduced into the sac through the abdominal or vaginal walls, a
few drops of fluid should then be withdrawn, and its place supplied by
the solution containing the poison selected. Friedreich employed bj
preference a fifth of a grain of morphia. The operation should
be repeated every second day, until the diminished size of the o>iira
affords evidence that the result sought for has been aceomplisbal
The operation seems to produce but slight inflammatory disturbance,
and the maternal system has been found not to feel the influence of the
narcotic.

JElt/troiomi/, — Professor Gaillard Thomas reports a case where 1
cut into the sac through the vagina by means of the incandeseen
knife attached to the electric-cautery apparatus. The patient
rowly escaped with her life, but finally recovered. In the latest i
tion of his work on diseases of women, Dr. Thomas recommend
Paquelin's cautery brought to a red heat After cutting slowly
through the sac, he advises removing the ftfitus, but not the placent
and then fining the sac with antiseptic cotton, which shouki be :
moved once in thirty-six hours. He offers the operation only, hoi
ever, in cases where the severity of the symptoms demands immediat
action.

The Faradaie and Galvanic Currents. — Tlie transmission of ii
faradaic current through the ovum has proved a safe and efficienl
method for destroying the Hfe of the foetus during the first three
months of its existence. The application consists in passing one pole
ioto the rectum to the site of the ovum, and pressing the other upon
a point in the abdominal wall situated two to three inches above Pou-

* FiUKREL, "Zur DiagDOSlik und opcrfttire Behandluug dcr TubenacbwA&gerscli&ft,
"Arch. f. Gynftck.," Bd. xiv, p. 197.

f JortiN, "Trftitc complet des accoucliemetiLa,^' p, 968,

t CouNRTFJS, '' Beitrftg zur Scbwangcrschait nuafterliftlb dcr Gcbarmuttcr," **AtcIu
f, Gynack./' Bd. xiv, p. 355, Hen nig reports Hkewiae a case operated on by Efleb«rl6|
where profuBe hsemorrliage occurred. It 15 not stated whether the patieDt reoovered.
C* Die Krankheiten der Eilcitcr tind die TubenschwangerechaXt," p. 138.)

EXTRA-tJTERINE PREGNAKCT.

321

f& ligament. The full force of the current of an ordinary one-cell
&ry g^honld be employed for a period varying from five to ten min-
Ilea, The treatment should be continued daily for one or two weeks,
tiTttil the shrinkage of the tumor leaves no doubt as to the death of
the foBitus.

The successful employment of the faradaic current in extra-uterine
pre^ancy we owe to Dr. J. G, Allen, who reported two cases of
recovery through its instronientality in 1873* His first case occurred
in 1869, the second in 1871. Previously, in 1859, Burci had succeeded
in shriveling np the ovum, in a case of tubal pregnancy, with the
galvanic current transmitted through the tumor by means of two
aettpuncture-needles. In 1866 Dr, Braxton Hicks tried the faradaic
correni^ but abandoned it after the second application. Dr. Allen waa
•pparently in no haste to rejiort his triumphs, but appears to have
eutioned them incidentally in the course of a discussion before the
(Obstetrical Society of Philadelphia. So little pains did he take re-
1 garding his discovery, that the subjec^t was nearly forgotten, until a
t>cw success vfwA reported by Drs. Luvering and Land is, of the Starling
Medical College, in 1877, Since then, Landis has re|>orted a second
Cise of recovery, and one each has occurred in the practice of J. C.
fieevet* U. P. C. Wilson,! Harrison, and the writer. In three cases,
treated, one by Dr. McBurney,t one by Dr, C. E, Billington, and one
tliy Dr. Rockwell, the galvanic current, with one Imndred and twenty
iiptions to the minute, was employed with equally favorable
llt&»

The treatment in my own ease was begun at the end of the tenth
iF^ek^ dating from the last monstruation. The tumor was at that
ttXDG felt quite low down upon the right side of the vagina, fluctuation
distinct* and by conjoined palpation ballottement of the entire
could be produced. The diagnosis was confirmed by Dr, Gail-
l*rd Tliomas, who saw the case with me in consultation. At his sug-
gestion, I tried Allen's method, though skeptical as to any benefit to
be derived from it. As no |KTceptible eflfect was produced by the first
\$iam€e$^ and aa I believed rupture was imminent, I became ox-
ly anxious to make the vaginal hicision at once. In a second
ml tation with Dr, Thomas, I was, however, persumled to persevere,
mad iraa rewarded by finding, upon the tenth application, such dis-

Tfli iv

313. Allen's cafte is rcferrwl

♦ Rtmt, " Trans, of the Aroer, GyniDc. Soc,"
lio by Reeve.

♦ WiLxiK, ♦• Amcr Jour, of Obst^jt.," vd. iiii, p. 8»6.

} UcncRurr, ** Case of TuboJuteratklail Prcgoancy,*' " Neir York Med. Jon?.," toI
ixTii, p. 21X

♦ Verbal report of Dr. RoclcweU at the Coonty Society, In the diacuRnion following tbo
; i>f » pai>or by the ottllior on tlic '*Trcjilmont of Extra^Uterinc Prepiftncy/' In

MIcBitniey csMe two ippUcntions, m BiLUngtou's four, and in RocUwcirs » single
pplicAlion, auffirei) to dvalroy tbo embrya
21

832

THE PATHOLOGT OF PREGNANCT.

tinct evidences of suspended growth that I felt justified in learing the
case to Nature* The swelling has since nearly disappeared, and con-
▼alescence has progressed without interruption.

When the tiil>e ruptures without previous warning, treatment
bHouH he directed to the arrest of internal haemorrhage and the re*
moval of shock. An ice-bag applied to the ahdomen meets the first
indication, but it is to be employed with circumspection where great
depression already exists. Compression of the aorta, or a sand-bag
laid upon the abdomen over the site of the ovum, may prove of serrioe.
Tlie patient should be cautioned to maintain the most perfect quiet;
opiates should be administered, and stimulants should be given in
small quantities, but at short intervals. The subsequent treatment
should be that for peritonitis.

iMparotomy, — As, under careful managementi rupture of the tube
most often proves fatal, Kiwisch recommended in such cases to make
an incision four or fi\Q inches in length through the abdominal wall
along the linea alba. In order to be sure that internal haemorrhage
had really taken place, he advised, when the peritonaeum was reached,
to first make a small puncture, and to introduce a pipetto int^ the
abdominal cavity. If the presence of blood was detected, the perito-
naeum should then be laid open the length of the abdominal wound,
and, after tirst tying the bleeding vessels, the sac should be removed,
and the peritoneum carefully cleansed. Strange to say, intelligent as
these instructions seem, no one, in these days of abdominal surgery,
has so far had the hardihood to carry them into execution. The rea-
sons for tliis backwardness are probably to be found in the uncertain-
ties of fclie diagnosis, the risk of finding the sac hopelessly matted to
the adjacent viscera, the dislike for operating upon a dying woman,
and the fact that a considerable number of spontaneous recoveries
occur, either from the mummification of the foetus, or by the limita-
tion of the sanguineous eflfusion and the production of a cii^cumscribed
haematocelc.

2. Cmes of Advanced Oestaiion {Fmius living). — During the
progress of gestation, most patients suffer from transient though often
severe attacks of peritoneal inflammation, from pains caused by the
fetal movements, from irregular uterine hjemorrhages, from inability
to take food, and from the resulting emaciation and depression of the
vital powers. The occurrence of labor is apt to excite peritonitis, and
may be associated with separation of the placenta, hsemorrhagc into
the sac, and disruption of the sac- walls. These manifold sources of
danger have been advanced as grounds for early operative interference ;
and assuredly laparotomy, furnishing, as it does, an opportunity to
rescue the child from certain death, ought to enjoy the highest
degree of favor, provided its performance does not at tlie same time
increase the jeopardy in which the mother's life is placed. Ta de-

ESTRA-UTERINE PREQNANCT»

cide this point, it ia necessary to inquire as to the results thus far
obtutnod from its employment* Parry reported twenty cases of so-
called primary operations — i. e., operations performed during the life
of the child — ^by means of which eight children and six mothers were
eared. This, thongh not a particularly bnlliani showing, was thought
to famish encouragement to continued trial, witli the belief that ex-
perience would so far lead to improvements in methods of operating
and in the care of patients, as eventually to raise laparotomy for the
removal of an extra-uterine fcetus to the level of other forma of ab-
dominal surgery. An examination of Parry's table does not, however,
warrant his frequently qutted statement Five of the reported mater-
nal recoveries ought to be stricken •ut altogether.* For the sixth case,
that of Hooper (No. 14), it h simply stated that *' the cyst had burst
into the bowel/' and that the child was dead, Whetlier the death of
tlie child long preceded the operation, it is impossible to determine,
litzroann t furnishes the results of nine additional operations, with
only one recovery, viz., the now famous case of Jessup. Thus, in
twenty-four cases of primary operation, only one mother cert4inily sur-
Tived. If we admit Hooper's case, the result will stand twenty- two
deaths and two recoveries. If we accept Parry's statement as approxi-
mately correct — that in 490 cases of extra-uterine pregnancy, includ-
ing 174 cases of ruptured cyst, the mortality was 67*2 jier cent. — it is
evident that much remains to be done in the way of perfecting the
primary operation before its admissibility, except under des|K?rate con-
ditions, can be recognized. In ten cases reported by Litzmann, only
loor children survived the third day.

The unavoidable source of danger in the primary operation lies in
^ At impoesibility of removing the placenta* owing to the absence of
nj physiological contrivance to check haemorrhage from the maternal
ireesels. Even when the placenta is left in siiu, fetal hEemorrhages
maj occur during the process of its elimination. Again, in the pro-
portion of one case to six, the placenta has been found in the line of
tha abdominal incision*

• Fififo Paiat, " On Eitra-Uterine Prcgn&ncy,** p. 220. Cwe« B and « are the same.
TImj wwe found by Parry in difTepcnt journals^ in one case ascribed to Sohrcyer, who waa
Ibm filadpal in the operation, and in anather to Zwanck, who woj prcient as an assistant
LHiWiMiii, oa iecroipgly good grounds^ mamtaina that Scbrcycr fiituply performed Cic«arcan
McHoB iipoD a ooe4ioroed uterus.

In Be Coene*! case (No, 9) of twin pregnancy, one of the children passed into the
■MooiMS CATity through an opening in the utcrua formed by the gaping of the line of
vbIob at the aite of a prcvioua Cjvstirean sectioQ.

Ia Stiitter's case (Ko. 10), the operation was performed in the forty-fifth week, six
weeia after the death of the fcetm.

In Ramsbotham and Adams*a case (No. 11)« tlic frttis had l>een dead six montba —
•peratioQ In the Aftccuth to the Hixteenth month (LititrDAnn).

t Linuf A3(!«^ " Zur Fe^tstellun^ dur Indicationen fdr die Gastrotomie bcl 3GhwlU].gle^•
wdtmil aoatcrbalb der Geb&rmuttcr/'

THE PATHOLOGY OF PREGJ^ANCT.

The extraction of a living child through an incision in the Tagmal w^aU w«
reported by Dr. John King» of Georgia, in 1817. The uiother made an easy reoov-
erj* Camiibel! reports nine cajses, with the saving of five mothers and five obiJ-
dren. Parrj increasied thu ijuuiber to fifteen, with six recoveries- No recent
Buccesses have heen announced. Baiidl,* in 1874, operated under what be n>-
garded as most favorable conditions, but the jJi^tieDidied at the beginning of the
third day. The operation is only applicable to cases whore the stus h low
down in t!ie pelvis, and the presenting part can be easilj reached throngh tb«
Cful'de-ioc of Douglas.

3, Ca.'^es of Oestaiion prolonged after the Death of the Fwtus,^
It is an accepted rule not to operate in advanced extra-uterine preg-
nancy during the continuance of labor-painB^ as the expulsive efforts
at the same time diminish the chance of saving the life of the i' ''
and increase the danger of the mother. Opiates shotild l>e acii.
tercd and absolute rciit enjoined, with the view of hindering the separa-
tion of the placenta, an accident necessarily followed by haemorrhage,
and possibly by rupture of the sac.

After the death of the feet us, the most favorable result consists in
absorption of the amniotic fluid, continued shrinkage of the sac, and
the conversion of the foetus into a lithopsedion* More commoaly,
however, the foetus undergoes maceration, and the amniotic fluid, soiled
with meoonium and serum, etained with dissolved coloring-mattei]^
of the blood, becomes turbid and of a dirty-red, reddish-brown^ ,
or greenish-yeilow color. The patient suffers from attacks of
due to peritoneal irritation, from loss of appetite, vomiting, and
rhcea, from fever with irregular chills, from emaciation, and gene
prostration. Owing probably to the contiguity of the intastin
(Litzmann), septic germs are liable at any time to pass into tba
and excite decomposition. When an incision is then made to reroo
the foetus, the latter is found in a putrid condition, and the amnioti
fluid consists of a chocoJate-brown, purulent menstruum of greater or
less consistence. The nature of the changes that have taken placej
evidenced by foul odors and the escai>e of stinking gases. It is
viousj therefore, that the presence of a dead fcetus seriously conjpl|
inises the safety of its possessor. To be sure, many eases have been ]
corded where eventually snppurative proceases have led to the for
tion of fistulous openings communicating with the abdominal wa
the rectum, the vagina, and even the bladder, through which the flc
contents first escai>e from the sac, and afterward the piecemeal eliD
nation of the foetus spontaneously takes place. As, under the circnt
stances, the enlargement of the openings into the cyst, the removal of
the contents, and the treatment of the cavity like an ordinary abacefiii
are attended with but moderate risk (three deaths in twenty-nine casefi
of abdominal fistula, according to Parry), it has been proposed to posfc-

♦ BiLtnoTQj *' nandbutli der Frauenkranliheitcii," 5ie Abachn., p, 87»

EXTRA-UTERINE PREGKANCY.

a25

pone snrgical aid until Nature indicates the channel by which elimi-
nation is to be effected- This proposition, however, ignores the de-
plorable condition to which the suppurative process inevitably reduces
the patient, and the incidental dangers to life*

During the last decade^ the success of secondary laparotomy, as
distinguished from that )>erformed during the life of the foetus on the
one hand, and simple incisions designed to enlarge fistulous openings
on the other, haa been sucli as to warrant its being placed in the cate-
gory of justifiable operative procedures. In thirty-three cases collected
by Li tzmann (twenty-four between 1870 and 1880), there were ninc-
ieeu recoveries. Of the two dangers inherent to the primary operation,
iria., haemorrhage and septicEemia, the former is greatly lessened by
tbe oe^otion of the fetal circulation and by the gradual thrombosis
and oblileration of the maternal vessels, and the catting off of the
Uood-snpplies to the placenta. With the present perfection to which
antiseptic measures have been carried, the risks from septica?mia are
diminished though not entirely done away with.

The time for the performance of laparotomy is of some impor-
tance. All of Litzmann's patients which were operated u|>on during the
fir^t month subsequent to the deoease of the fcQtus (seven in number)
died, ivhile» in twenty-six cases operated upon at periods varying
from five weeks to a year after the decease of the foetus, there were
but seren deaths. The former mortality was partially due to the des-
perate condition of the patients, which determined the early date of
the operations, and in part to the occurrence of profuse hiemorrhages
from the patent mouths of tlie placental vessels. There are as yet
no signs known by which the time at which the obliteration of the
placental veeiels becomes complete can be a.'^certained. Schroeder re-
moTed the placenta three weeks after the cessation of fetal move-
menU without loss of blood, while a patient of Depaul expired f*%m
placental hemorrhage from an ojioration performed four months after
the foetus had perished. It is certainly evident that when the circum-
gtanoea admit of delay it is best to defer operative me^Lsures, and treat
tho patient eymptomatically, as Li tzmann suggests, with pure air,
nourishing food, quinine, and gentle laxatives, until the obliteration
of the maternal vessels has probably taken place. In case, however,
of marked septic symptoms, the opening of the f^ac ehould not be
layed, as the subsequent use of antiseptics at least is calculated to
(triin tlio pernicioua iuiuenco of the decomposing contents upon

entire organism*

Tlie operation for laparotomy should be performed with antiseptic

aiitiona. The incision should be made along the linea alba. In

the sac is not found adherent to the abdominal walls, it sliould be

to the cut borders of tho abdominal wound previous to open-

326

OBSTETRIC SUROERT.

less it oeonpieB the site of the incision. The wound should be clo
above and left open below for the passage of the cord, and the intm-"
duction of antiseptic injections.

No rulea can profitably be laid down as to the plana to be pursued
in the enlargement of fistulous openings. Each case must be treated
upon its own merits, and the surgical aid rendered must be i
to the individual peculiarities which characterize it

OBSTETRIC SURGERY.

CHAPTER XVin.

TBE UfDUCTION OF FEEMATURE LABOR,

Induction of preTnaturc kbor. — Indicationi. — Contracted pelTia. — Habf taal dcftth of I

— JJiseaHeB whicb imperil the life of tUc mother. — Operatioii.-^athetematlo otofi
— lutra-uteriue injectioiss. — RLipture of nicmbranca. — Mechanical dilatjition of oer*
vii. — Viigitiiil douches, — ^Tampon.— Choice of methoda, — Care of the child. — Artifi-
cial abortion.

The induction of premature labor is indicated in cases in which
the continuance of pregnancy, or delivery at full term, is associated
with risks to mother or child, or to hoth, which may be diminishe
by bringing iiregnancy to a close at an early |K^riod after the foetus
prepared for extra-uterine existence. The time at which the latt(
begins is usually placed at the twenty-ninth week. As, however,
preservation of the child at so early a date is an exceptional occurrenc
and as a large proportion of those which by tender care are made
survive the first dangers of immaturity perish in infancy, common
falling a prey to hydrocephalus or to intestinal derangements, the in-
terests of the child call for the postponement of the operation as !
as practicable. Where the choice lies with the physician, the pro^
cation of labor is usually deferred until the thirty-third or thi]
fourth week. The principal indications are :

1, Moderate Degrees of Pelvic Contraction, — In flattened pelves
measuring from two and three fourths to three and one fourth inche
and in equally contracted pelves under three and one half inches, li
passage of a full-term child is not impossible, though usually difficti
and dangerous. By inducing premature labor, however, owir
smaller size of the foetus, and esi>ecia!ly to the increased com]*?
of the fetal head, we are enabled to diminish the mechanical obstaoh

THE INDUCTION OF PRE31.iTURE LABOR

8S7

to delivery, and thus to improve the prognosifl for both mother and
child. To the mother the advantage from the operation is in all cases
decided, while to the child not mnch is gained in the extreme degreea
of contraction.

The time at which gestation sliould he interruptedl depends upon
the size of the pelvis and out estimate of the size of the fetal head.
The distance from the lower border of the symphysis to the promon-
tory should be accurately measured, and the side-walls of the pelvis
carefully explored, Schroeder*a measurementa show that the bipari-
etal diameter of the head is, between the twenty-eighth and thtrty-«ec-
ond week, about three and one fourth inches ; between the thirty-second
and thirty-sixth week, nearly three and a half inches ; and that after
the thirty-sixth week the increase is insignificant.*

One of the most important questions to be decided in reference to
the induction of labor is the period to which gestation has advanced.
But this, in the absence of wcll*do6ned signs, it is easy to miscalculate*
Physicians have been misled by the large size of the uterus in twin
piBgUAncies and hydramnion into provoking labor before extra-uter-
ine existence was possible.

Alilfeld has shown that the long axis of the foetus, when flexed in
mUrCf IB almost exactly one half its entire length in an extended position.
Ho proposes measuring the former with a Baudelocque pelvimeter, by
placing one extremity per vaf/itmm upon the child's head, and the
other upon a point in the abdominal walls over the fundus of the
atema at which the breech of the child is felt. Very nearly the same
results were obtained by measuring from the upper border of the
^mpbysis in place of passing the lower branch through the genital
canal. The following arrangement, based upon his tables, placea
hetore us in a practical way the result of his investigations, so far oa
they apply to the questions involved in the induction of premature
labor: t

I ^-"-^

Leofrth of ftBtm.

Bl-puteUl diameter.

DiinUoftofiMtMoqr*

r in inebei.

20 ioches*

18
16

Si iDcbeii.
3i

H
S

88-40 weoka.
35-37

• SoroAKDOt, " Lchrbiieh der Gcburtshiilfe," 4te Aufl., p, 2SB, It is to be

ihftt the btparicUl diameter is capable of a consitlerablc degree of compreMion,
and that it u usually tlu bitemporal rather tha^n the biparivtal diamctor which has %o
§mm iIm naiTDwcat tUameter of the pclrf^.

f The amognaient in modified from one furnished by Stahl ('* Geburtshulfliohe Ope-
ntlofialchrv,*^ p. 47)* Owin^ to indlTidual differences in the length of the fo^tua at the
Moe period of gestation, a oongidcmble source of error inheres to the Ahlfcld method of
OTOifnUatioiL 1 1 is, howerer^ much Icaa than tho«e to which estimates based upon iho
ifaa ol the uterus arc subjt.*vt.

328 OBSTETRIC SURGERY,

2. HaMiual Death of the Fmtus. — It has been proposed that, when
in Buccessive pregnancies the foetas perishes in utero during the latter
weeks of gestation, labor should be induced after the period of viability
has been reached, but before the time at which, according to prerious
experience^ the fatol ending was to be expected. This plan of treat-
ment does not apply to cases where death is due to syphilis, as a bett^
result is to be expected by subjecting both parents in advance to anti*
Bjphilitic treatment Little henetit, too, would be derived from pre-
mature labor where the death is due t-o organic diseaaes of the fcettii
But where death is the result of inanition, dependent ui>on maternal
amemia, fatty degeneration, faulty development of the placenta, or
alterations of the umbilical cord, the ojjcration is fully justifiabk

tWith the difficulty, however, of making the diagnosis and firing
the time when labor should be induced, there have been but few cases
in which the procedure has furnished favorable results,

3» Dimeaseji which imperil the Life of the Mother. — In these castt
the operation is primarily performed in the interests of the mother,
and is indicated, therefore, even when the child is known to have per-
ished. Sometimes, however, premature labor becomes a means of
saving the life of the child, which shares the dangers that threaten
the maternal existence. In this category belong especially chronie
' affections of the heart and of the respiratory organs ; enormous disten-
tion of the abdomen from multiple pregnancy, hydramnion, tumora,
and ascites, which occasion extreme dyspnoea ; pernicious aua&mia ; un-
controllable vomiting ; basmorrhages from placenta prsevia ; chorea ;
convulsions ; and nephritis, associated with excessive (Bdemo, In each
case, however, it is incumbent to carefully consider whether the spediil
condition is rcmdered more threatening by the existence of pregnancy,
and t^ weigh tlie question as to how far, for the time being, the dan*
gers are likely to be increased by the progress of labor.

Stehberger has proposed extending this indication to cases where
the preservation of the mother's life is hopeless, but in which prema-
ture delivery affords a chance of saving the life of the child-*

Operation,

A great number of methods have been proposed with the view to
provoke labor prematurely. 3Iost of them, however, such as the ad-
ministration of ergot, of fjuinine, or of jaborandi, the application of
electricity to the uterus, the stimulation of the vagina with carbonic
acid, frictions of the breasts, and the like, do not require anything
more than cursory mention. The following procedures alone i>0Bseas
any special claims to favor :

* SrsBBKiioEit, ^ Lex rogk imd kiinstliche FrCihgebuct^" *' Ardu t Oyi&Aek.,** Bd. i,
p. 465.

the

THE INDCCTnON OF PREMATURE LABOR.

CatheterizatioE of the Uterus.-— Thia method consists in the in*
actiozi of a cutheter, or, better still, an elastic bougie, between the
lembranes and the walls of the uterus, and leaving the instrument in
Hiu until active labor seta in. In performing the operation it is a good
plan to place the patient in a recumbent posture upon a iiard table,
with the hips brought near the edge, and the thighs well flexed upon
the body. Two fingers in the vagina guide the point of the bougie
into the cervix. The index-finger, passed to the os internum, then
follows the instrnment, and as it enters the uterus directs it to one
ide to prevent it from rupturing the membranes. In the case of
primipiiraB, preliminary dilatation of the ceryix may be secured, if
necessary, by the use of a sponge- tent or of the vaginal douche. The
boogie ehould be pushed slowly upward witli the disengaged hand,
and allowed to follow its own course, between the membranes and the
uteros. To prevent the instrument from slipping down, two inches
of the extremity may he left outside the cervix to find support against
the vaginal wall, A retentive tampon is rarely necessary.

The method is tolerably certain. In favorable cases labor follows
employment in the course of a few hours. Sometimes, however,
io action is set up during the first forty-eight hours, in wliich case it
id well to resort to other additional measures. Outside of unwholesome
hospitals, the use of the catheter or bougie to excite labor is not asso-
dated with any peculiar risks. The danger of detaching the placenta
bnot imminent, if the instrument be introduced slowly, iis, owing to
Ha eh&sticityy the bougie tends to make its way around the placental
margin. In maternity hospitals, however, it may serve as a point of
entry for miasmatic poisons, and thus be followed by local irritation
and pueri)eral septic affections. Because of this danger the solid
boagie is preferable to the hollow catheter. In all cases only a per-
tly clean and new inetrument should be used,
InjectioES between the Uterus and Ovum.— Cohen, of Hamburg,
in 1848 the separation of the membranes by injecting tar-
Hirongh a long-nozzled syringe made to penetrate about two
iChea within the uterine canity. The nozzle was furnished with a
extremity, and with o]>cning3 upon the side. He recom-
n i that the injection should be continued uutil a distinct feeling

of distention was experienced by the patient, which sometimes required
le employment of nearly a quart of the fluid (720 grammes).* This
hm 1x1X6 ^ince been modified by the substitution of an elastic catheter
T tlie metallic tube, and by the injection of a few ounces of simple
water (OS** Fahr.) in place of the aqua picea. In case of failure
with a single injection, it hm been recommended to repeat the pro-
are. Professor Lazarewitch has demonstrated that the nearer the
itation is e4irried to the fundus the more certain and speedy the
• {ktmsf, **Neac Ztsclir. f. Oeburtsk.»" Bd. %xi, p. UC

OBSTETRIC STJHOERY.

result He therefore employs a syringe with a central opening, i
passes it as near to the fundus as possible.*

When effieieutly performed, the method possesses the adyantage(
rapidly exciting uterine labor-pains. Kunne reports fifteen oasea in
which he resorted to it with complete success, lie cautions against
using force in injecting, and recommends^ as a means of avoiding the
passage of air into veins, the withdrawal of the catheter, and its i
introduction, in case a hiemorrhage should bet4>ken that the placeufii
had been impinged upon. Others have employed the method many
times with entire impunity. 8tiU, cases of sudden death have occurred
during it^ use, which have been referred to shock, to air getting int(
the uterine sinuses, and to rapture of the uterna. While, perh
the general results from uterine injections have not been less satii
tory than from the employment of other measures for inducing pr
mature labor, the suddenness of death in the fatal cases has had a det
rent effect upon its extended employment

Rupture of the Membranes*— This is the oldest of all the metho
now in U80. It is best performed by means of a simple apparatus de-
vised by the Freiherr Braun von Fernwald, consisting of a goose-quill
sharpened like a j^en and nicked upon its convex surface for the pas-
sage of a utiorine sound. Thus mounted, with its point guarded by
the sound, it can be introduced, without risk to the maternal tis
through the cervix to the ovum. Then, by simply pushing the qn
upward, the point is made to clear the sound and effect the punct
of t!ie membranes, TJie method is certain, though not always speedy
in its action. It is open to the objections which hold good in all cases
of premature discharge of the amniotic fluid. Hopkins recommende
as a mode to provide for the gradual escape of the liquor amnii,
ping the membranes with a sound at a distance from the os internal]
Rokitansky has shown^ from the statistics of Brann's clinic, that
hospital practice puncture of the membranes is the safest means of
inducing premature labor, diminishing as it does the chances of infec-
tion, which is the chief source of danger in all the measures where
the irritation is applied directly to the inner surface of the utenwi
Though in private practice I have never from choice selected tU*
method, I have witnessed many cases in which the membranes have
ruptured accidentiilly, and yet have failed to notice, either in the case
of the mother or child, the serious consequences which theory won
lead us to apprehend* It ia not adapted for the higher degrees
pelvic contraction or for cases wliere speedy delivery is desirable.

Mechanical Dilatation of the Cervix.— The dilatation of the cer
with 8i)onge-tents or laminaria is rartOy resorted to, except as prepan
tory to 'other meaiiures. While the expansion of the tent softens tl^
cervix and excites uterine contraction, the effect is quite frequent
♦ LAZAREWiTCHf *'TranJ. of the Obstct. Soc of London,'* 1^68.

THE INDUCTION OF PREMATURE LABOR.

ieni. To be sure, the action may be kept np by a succession of
lis gradually increasing in size, but such a plan denudes the cervix
its epithelium, and is apt to lead to septic infection*
The Barnes dilator is a most efficient aid in cases of induced labor.
fur the introduction of the Fmallest-sized bag, the cervix requires
I be sufficiently expanded to permit the passage of at least two fingers,
, useful chiefly as an adjuvant to other plans of treatment When
> bas fairly begun, however, the fluid pressure of the dilator upon
rii serves to strengthen the uterine action. When left in miu^
strument insures the development of good pains. It should,
be removed from time to time, if not forcibly exjielled into
[ina, and c^rbolized injectione should be employed to prevent
;ioiL So soon m the physiological softening of the cervix which
suits from labor has been effected, rapid dilatation can he advanta-
jufily employed. When the cervix is rigid, the rubber-bag is only
[ as a reflex exciter of paina. To be sure, the rigid cervix can be
forcibly dilated to almost any extent by hydrostatic pressure, but,
b a rule, it closes down to ita origin^ dimensions so soon as the
freesure is removed.

Tamier has devised a bag which can be passed upward through the
■prrix and distended in the lower uterine segment. It serves to par-
■ftlly detach the membranes, and excites by its presence active uterine
Hort& Its liability to rupture is the most serious objection to its
employment.

The Vaginal Douche. — The vaginal douche was introduced into
practice by Kiwisch, in 1846. It congists in directing a stream of
tepid water with considerable force directly agaiijst the cervix. The
stream may either be furnished by a Davidson's syringe, or a continu-
ous current from a tube connecting with a vessel placed at an elevation
above the patient may be used. The latter is the safer method. Tlie
large-€ized fountaiji-syringe, made to hold a gallon of water, is a very
convenient apparatus* The duration of each injection should be from
ten to fifteen minutes. At the outset, three douches in the twenty -four
biif9 suffice* Subsequently the frequency and duration should de-
Kud upon the degree of action excited and the urgency which exists
B^ bringing labor to a close. Twelve are about the average number
of injections required. lu pressing cases they have been repeated as
^ten as once in three trj four hours. The temjierature of the water
^11 ployed should be about lOG"* Fahr.

In using the douche the patient should be placed across the bed,
ad an India-rubber sheet should be so arranged under the hips as
» oonvey into a vessel beneath the water as it escapes from the vulva,
should be taken to avoid the introduction of air into the
ad at the beginning of each douche precautions should bo
lopied to aid the escape of the fluid. The forcible pressure of

OBSTETHTC SURGERY.

the Btream has beon known to drive air confined in the Ta^na into
the cervix* The game accident has followed imperfection in the valvea
of the syringe.

The douche acta by the warmth of the water, by stimulation of the
lower nterine segment, and by dilatation of the vagina. After the
donche bus been continued for a time, the latter is Bometimes dis-
tended so as to be nearly in contact with the pelvic walls.

The vaginal douche aa a means of inducing labor has of late yearj^J
fiillen somewhat into diarepote. It^ chief recommendation was th^H
supposed harmlessnesB of the procedure — a precious quality, to which
in reality it api>ears, however, to possess little claim. Numerous casei
have been reported where death has followed the accidental introdDC-
tion of air, and sharp peritoneal symptoms, according to Kleinwach-
ter,* have been known to result from the excessive distention of th<
vagina. The dangers referable to the latter cause increase with thftj
repetitions of the donche. At present its emplo}'ment is general!;
restricted to the preliniiiuxry dilatation of the os, or to the sushdning
of the action of other measures.

The Va^^al Tampon* — Braun introduced an India-rubber
furnished with a tube and a metal stopcock, which, under the Hi
of the colpeurt/nferj played a considerable rMe in obstetrical praetii
some dozen or more years ago. When filled with water in tlie vagii
it formed a painful and rather uncertain mode of inducing labor
IS now rarely employed except in haemorrhage and where it U desi
to prevent premature rupture of the membranes. Care should
taken to only modenitely distend the vagina, and not to continue
pressure for any lengthened period of time.

Choiee of Methods,— From the foregoing it will be seen that no one
of the different proceedings mentioned is entirely free from objeetioB^H
Aside, however, from infection, a danger more especially dreaded i^^
maternity hospitals, and the avoidable accident of driving air into the
veins, the most serious difficulties against which we have to cont<»i
arise from the tardy dilatation of the os and the prolongation
hxbor. Any of the methods are good if only they act speedily. It is
advisable, therefure, in practice to follow the excellent advice of Dn
Barnes^ and divide the induction of premature labor int^ two stages,
in the first of which provocative, and in the second of which aceelera-
tive, measures should be adopted. In the former category should
placed the dilatation of the cervix with sx^nge-tonts, the vagi]
douche, and the catheterization of the uterus ; in the latter, dilatatii
of the cervix with the rubber bags, rupture of the menibnme^* ui
in case of delay, delivery w^ith forceps or by version.

The plan I have generally followed consiste in beginning in the
temoon with the vaginal douche, and following with the introductii
• ELfiiifWACBTim, " Pragtr Vicrtcljftbmcbrift," 1872, Heft I, p. W>.

THE INDUCTION OF PXtEMATURE LABOR.

333

af a solid bougie, to be left in tho nterus overnight. In many cases
labor IB excited in the course of a few hours. In the morning, if the
process is delayed, the vaginal douclie is refjeated. There are few cases
in which, toward the end of the twenty-four hoars, the cervix \s not
found softened and well lubricated with mucus. The dilators should
then be employed, the operator taking his time, as i^ermanent dilata-
tion is the object sought after. If the membranes come down well,
the dilator may be removed and the progi*es3 of the case left to Nat^
ure. Often it is advisable to adopt the plan of Dr. Barnes, ruptur-
ing the membranes when the cervix will admit thi*ee or four fingers,
and then dilating with the large-sized bag until the uterus ia opened
fully for the passage of the child. Finally, according to the condi-
tions pre.sent, tlie physician may cither await the termination of the
iiibor, or deliver by version or by lightly constructed forceps.

Care of the Cbild. — Premature infants possess slight powers of re-
sisting external agencies. They should immediately after birth bo
placed in warm cotton and kept near tlie fire. The customary baths
sliould posses a temperature of about 100° Fahr., or very nearly the
tem[>erature of the amniotic fluid. The chances of raising premature
infantd are greatly enhanced by feeding them upon the mother's milk,
whkh rfiould bo given by the spoon when tJie child is too feeble to
lake the breast. Before the thirty-second week tlie preservation of
the infant's life depends almost entirely upon the unremitting watch-
fnlnesa and zeal of a devoted nur^e or mother. In liospital.i, where
IIm»0 conditions fail, success in raising vciy premature children is of

I oocurrence.

Ahtificial Abortiok,

Artificial abortion ia justitiablo wlienever it offers the only hope of
\ laving the life of the mother. The morality of this general pn>posi-
I tion is unquestioned. It is not, however, by any means easy to deter-
I mine in a specified case whether the requisite conditions which render
llhe indaction of abortion a duty reidly exist.

The principal recognized causes for the operation which admit of
litUo dispute are : 1. Incarceration of the prolapsed or retrollexed
uterus when the dislocated organ can not be replaced. 2, Diseases of
pregnancy which immediately imperil life, and which have been vainly
combattnl by all the resources at our disposal. Of these diseases the
prominent is uncontrollable vomiting. Exceptionally the indi-
aon may arise in affections of the heart, lungs, and kidneys, where
the 8vmptom« are acute and peculiarly threatening.

The justifiability of abortion is, however, by no moans so clear
when the danger to the mother first arises after labor has actually
an. This is spc*cially the case in extreme degrees of j^lvic con-
etion, or where tUe presence of large tumors renders the parturient
GAoal impaiisable, as in those cases, by means of the Csesaroan section,

there is alwaya a probability of saving the life of the child, with a &ir
prospect of preserving the existence of the mother. It is considerwi
right, under such circumstances, after a dispassionate and colorless
statement of the facts^ to leave the decision to the mother and the
friends more immediately interested. When the operation is ptT^
formed for contracted pelvis, the following figures will show at hot
late a period it may be undertaken :

Ad terO' posterior diameter of peM«.

H inch.
H inch,
1 lack

lAtait period for Indodng Abortlai.

Beginmng of sixth month.
Beginning of fifth months
Four months and a half.

With less than an inch the difficulties of inducing abortion incm^Me
to such u degree as to make the operation rarely advisable, or indeed
even practicable.*

The induction of abortion is accomplished by puncturing the mem-
branes with a uterine sounds or by dilatation of the cervix with a
sponge-tent. In the early months the sponge-tent jwssesses the ad-
vantage of promoting the expulsion of the ovum entire. In the sixth
and seventh months the same means are available that have been
described in connection with the induction of premature labon

As to the choice of time when the operation should be performed,
opinions differ. Some prefer the first two months, on account of the
email mze of the ovum, and the slight development of the fetal tufts
at the decidua serotina. Others wait till the first three or four mouths
have expired, as the diagnosis of pregnancy is then certain, the execu-
tion of the operation easy,, and the detachment and expulsion of the
fetal appendages more complete.

OHAPTEE XIX.

Historj. — Varictiea of forceps ; short forwpp, long forceps. — Action of forccpi, — Indicm-
tionfi. — Preparations.^ — Forcepa at outlet. — Operation; introduction; lockhig; tmc^
tioos; remoTal. — Forceps At brSm; operation. — Axia-tiuction forceps. — Forceps la
f)cdpito*posterior positions ; in f soc predentationB.

History. — In 1647 Pet^r Chamberlen speak«, in a pamphlet written [
by himself, of a discovery made by his father, Paul Chamberlen, fori
saving the lives of infants during childbirth. The measure in the
possession of the Chamberlens was, however, withheld from the pro-j

• Di SoTRX, " DnuB quels ess cste-il IniliquA de proToqucr Vavorteinent f ^ F&ris, 187B, I

p. ft8.

FORCEPa 835

fession^ and utilized purely as a means of gain. In the early part of
the year 1670, Hugh Chamberlen, who enjoyed a great reputation as
an accoucheur, went to Paris in the hopes of finding a purchaser for
the family secret. Mauriceau, to test the value of Chamberlen's pre-
tenses, suggested that the latter shpuld attempt the delivery of a
woman with extreme contraction of the pelyis, upon whom he had
previously decided to perform the GsBsarean section. Ghamberlen de-
clared that nothing could be easier, and at once, in a priyate room,
set about the task. After three hours of rain effort he was obliged to
acknowledge his defeat. The woman died ; the negotiations for sale
were dropped ; and Ghamberlen returned with his secret unrevealed to
England. In 1672 Ghamberlen published a translation of Mauriceau's
work upon midwifery, in the preface of which he states : '^ My father,
brothers, and mjrself (though none else in Europe as I know) hare,
by Ood's blessing and our own industry, attained to and long prac-
ticed a way to deliver women in this case without any prejudice to
them or their infants, though all others (being obliged, for want of
such an expedient, to use the common way) do or must endanger, if
not destroy, one or both with hooks.** In 1688 Hugh Ghamberlen
went to Amsterdam and sold his secret to Boenhuysen for a large sum,
who in turn disposed of it to Buysch and others, and, as late as 1746,
it was the rule of the Medico-pharmaceutical Gollege, at Amsterdam,
that no one should practice midwifery without first obtaining the se-
cret measure, which was imparted by their examining body for a heavy
money consideration. In 1753 Jacob de Vischer and Hugo van de
Poll, who had acquired the secret from the daughter of a former pos-
sessor, made it public property, but the instrument turned out to be
the single-bladed vectis. Whatever doubts, however, this exposure
may have cast upon the nature of the Ghamberlen secret were set at
rest, in 1815, by the discovery in a former residence of the family, in
Woodham, in Essex, of a chest containing, besides letters and a variety
of patterns of the vectis, a number of pairs of forceps, fenestrated,
without a pelvic but with an excellent cephalic curve. Moreover,
Chapman, in a short treatise upon midwifery, published by him in
1733, stated that 'Hhe secret mentioned by Dr. Ghamberlen was the
use of forceps, now well known to the principal men of the profession
both in town and country." And two years later, in a second edition
of his work, he published an engraving of the instrument, which be-
came known as Ghapman's forceps, though it did not differ from the
one used by the Ghamberlens.

Since Ghapman's publication, the modifications made in the for-
ceps by obstetric practitioners have been exceedingly numerous. In-
deed, nearly every man widely engaged in midwifery practice finds it
convenient to possess his own forceps. With few exceptions, however,
the various patterns described by authors do not differ materially as

$36

OBSTETRIC SURGERY.

regards essential principles, but haye each some pecnliaritr of con-
struction which fits them to supplement a personal defect of the con-
trivcr, or to meet some special indication. The forceps is by no meang
a perfect instrument. It is imi>08fiible to constrnct it in such a way
as to cover every need. In cqnsniting practice, it ia convenient to
pofisesfi a number of forcepa for different emergencies. A good pair
for general use is necessarily a compromise between conflicting aims,
and requires, for successful use, experience and intelligence to coi
its deficiencies.

In selecting forcepa it ia well to bear the following points in minl^
We have first to distinguish between the long and the short forceps.

Short Forceps, — The original instrument of the Chamberlens fnr<
nishes the type of the short variety. By referring to Fig. 147, it

he seen that the Chamberlen forceps consii
of two levers, made to cross each other lib
a pair of scissors, with short handles, and
blades diverging just beyond the point of
articulation. The blades were fene;fitn»l
to lighten the instrument, and to enable thi
to seize the head with greater security- Thej
were furnished with a cranial curve, as has
been stated, but were straight when viewti
in profile. Though
somewhat rude in a|>-
pearance, they wore
capable of rendering
good service when tlie
head had once entered
the pelvic cavity.
Smellie, in place of the mortise lock of the
Chamberlen forceps, which required to be se-
cured by tipe or cord, invented the eaaily ad-
jus t^ed En glitch lock, and covered the handles
with wood and a durable coat of leather. The
handles were five and a half inches in length,
and the blades six inches. Short forceps, mod-
ified somewhat from the Smellie pattern, are
U(>ed by some practitioners at the present day.
It has been thought an advantage that they can
be concealed in the pocket, and slipped over
the child's liead without the knowledge of tho
patient or of the assistants. Smellie laid great
Btreas upon this point, and says, '*As women
arc commonly frightened at the very name of an instrument, it
advisable to conceal them as much as possible until the character

Flo, ur.

-Forceps of Cbflui'

Fio, 148.-

Forcci« of Stud-
lie.

FORCEPS.

asT

the operator is folly established." In these enlightened days, how-
ever, secrecy is no longer adyisable. Indeed, the forceps ought neyer
to be used without such exposure of the Tulva as will enable the opera-
tor to exercise every precaution for the preservation of the perinsBum.

Long Forceps.— Smellie tells us he found, in pelves with jutting-in
of the sacrum, that he could not push the handles far enough back-
ward to include between the blades the bulky part of the head, which
lay above the pubes.
He, therefore, to reme-
dy this inconvenience,
contrived a longer pair,
curved on one side, and
convex on the other.
Thus, at an early period
the necessity for long
forceps was experi-
enced. Smellie was
deeply impressed, how-
ever, with the dangers
of high forceps opera-
tions, and sought to di-
minish the risks inci-
dental to them by mak-
ing the handles short to
free himself, as he said,
from the temptation of
using too great force.

Levret, on the con-
trary, contemporane-
ously with Smellie, con-
jerted the forceps of
Chapman into a power-
ful tractor and compres-
sor. He retained the
iron handles, but rough-
ened the surfaces, and
made them slightly convex, to adapt them to the palms of the hand.
The articulation was effected by means of a pivot and a mortise. The
chief peculiarities, however, consisted in the weight and the length
of the instrument and in the extent of the pelvic curve. So far from
these features proving objectionable, they have been substantially
retained in modem French instruments.

The forceps of Smellie and Levret are the two type-forms from
which are derived the great number of the models in vogue at the
present day.

Fio. 149.— Levret's Ibrocps.

OBSTETRIC SUHGERY.

The Naegele forceps, erfcensively used in Germany, in its EDsb
features resembles the instrument of Sraellie, It is, however, two

inches longer, and there is less dii^
proportion between the length of
the handles and the blades* The
upper part of the bundles la fur-
nished with transverse ehoiildera,
hollowed out for the index and
middle fingers of the band which
exerts the traction force. The lock
is that of Bruninghausen, andcoD-
sista of a pivot, surmounted bji
flat button, which fits into a notch
upon the opposing blade.

The Simpson forceps poseeoei
a relatively short handle, with
transverse shoulders, and indenta-
tions for the fingers of the under
hand. The English lock is im-
proved by the addition of kneesor
projections to diminish its mobili-
ty. The cephalic curve, in place
of starting at the lock, is carried
away two and three eighths inches by straight, parallel shanks, am
arrangement which makes it possible to lock the instrument ontside
the vulva even when applied to the head at the brim, and which
enables the operator to bring the head to the floor of the pelria
without placing the vulva upon the stretch. The pelvic curve does
not exceed one inch and a half, I have been in the habit of recom-
mending this forceps to my classes of medical students on account

Flo. IS-O^ — Nii^lti^a foreepa.

Fto. 151-— Simp:»o«i's forcepn.

of the ease with which it can be applied, its solidity, and the slifR
markiugs it leaves, under ordinary circumstances, upon the child*i
lioad. It is, however, defective in compressive jiower. when sue
action is necessary.*

* The ioBtrument makers of this city »ro ftocuBlomed to make for me ftn instrameni
exactly copied from a pair of forceps brought by me from Edizibur^b in 1865. Many of

FOECHPS.

330

The forcops of Hodge, of Wallace, and of White, are extensively

^l in this country. Like those of French make, they have metal
dies, and a lock composed of a moTuble pivot, which slips into a
notch at the moment of adjustment. They are, however, much
lighter and of more graceful outline. The shanks are long and su-

Fia. 152.— Ho<Jgc*» fbrocpft.

, The blades are provided with wide fenestras, thronfi^h
the parietal bosses are intended to project I have tried each
of these instruments, and, though I cling to Simpson's forceps from
bahit, have found them extremely serviceable.

Fimilly, in choosing forceps, it is well to remember that, if there

are none which are absolutely perfect, there are few which are really

|ioar. Objectionable features are very short handles and thin, springy

bladee^ with sharp-cutting edges, A good pair of long forceps ren-

iBr^ the possession of short forceps a superfluous luxury,

^B Aetioa of the Forceps. — The forceps is primarily and essentially a

^BqIOC^ When properly adjusted, it serves as a handle by means of

inicli the head can bo withdrawn from the parturient canal. Many

taodle nt oi>erator8 are in the habit of combining with direct traction

^^^Kto-dde swaying of the forceps-handles with a view of determin-

^^^M alternate descent of the lateral surfaces of the cninial vault

fp donbt these so-called pendulum movements increase the extractive

power of the forceps. The increase is, however, obtained at the ex]>ense

fflf the maternal tissues. They should, therefore, bo discountenancecL

^m to the efficiency of direct tractions, I am able to speak from ex-

Hrience* At first insisted upon by the Vienna school, they have

Hand warm advocates in Matthews Duncan,* of London, and Albert

Smith, f of Philadelphia.

Tbo crofiaing of the forceps at the lock renders it impossible to

€km lkiv0C|M bcsriiig Simpson's name in tlils country have onl j a faint resemblimce to tho
odgfoal modeL

* PirKiuif, ^ Agiinst iht Pendtilum MoTcmcnt in worlting the Mldwifciy Fofoeps,"
••Triat. tjf the *)b«tct. Ax\ of Edinburgh," vol ir, p. 196,

f SiijTii, *'Thi* Pi^adnlum Leverage of Qb&tctrio Forcteps," ^^ Trans, of ibc Am. Qj*
asa Sm^** Yol. Hi, p. S«6.

840

OBSTETRIC SUBGERY.

resort to traction withoat, at the same time, exercising compresgifm
upon the child's head. When the forceps is applied laterally over
the parietal bones, moderate pressure is harmless to the child, mid
undoubtedly facilitates in some degree the act of delivery. When
the head 13 high in tlie pelvis before rotation is completed, the lateral
application is rarely possible. If the forceps is applied obliquely with
ODe blade over the side of the brow, and the other over the side of the
occiput, bulging takes place in the opposite oblique diameter — tk result
which tends to retard rather than to aid extraction. NeTerthelBO,
even at the brim some compressive force is necessary to seize the held
solidly, and to avoid slipping of the blades.

When the blades of the forceps are introduced within the nterai,
contractions are apt to be excited. This so-called dynamic inflaence,
tliough an ancillary property of the instrument, is often of consider-
able service in aiding delivery.

Indications. — It would be an unprofitable undertaking to enumerate
all the conditions which render forceps advisable. The indications for
their use may be summed up in two general propositions. The forceps
h applicable — L In cases where the ordinary forces operative during
hibor are insufficient to overcome the obstacles to delivery ; 2* Incasea
wliere speedy delivery is demanded in the interest of either mother or
child.

Both theso propositions ane, however, subject to the limitation
that, in the selection of the mode of delivery, choice should be made
specially with reference to the maternal safety. Fortunately, in the
great proportion of cases the intei-esta of both mother and child arc
identical

Preparations for Forceps Deliveries, — When it has been decided U»
deliver by forceps, it is a good plan always to place the patient cross-
wise in bed, with the head raised by a pillow, and with the hips well
over the edge of the bed. To be sure, many prefer, in simple eases, to
disturb tlie patient as little as possible, and pride themselves upon being
able to slip in the forceps and deliver without the seeming of an opera-
tive procedure. This trifling advantage is, however, more than coun-
terbalanced by the increased risk of injuring the vulva and perimeum^
when the operator is compelled to assume a constrained or awkward
position.

In this country, as in France and Germany, it is customary to
place the patient upon her back, whereas in England she is made to
lie upon her left side. The difference is not material. In the descrip-
tion to follow it will be assumed that the dorsal position is the ob
one likely to be selected*

At the beginning it is well, in most cases, to bring the patient eoiS^
pletely under the influence of an anesthetic. This I am accustomed lg_
do before changing the patient^s position. In easy ca^ea the aeconchf

FORCErS,

341

ean administer the ansBsthetic before operating, and then leave the con-
tiiiuance of the chloroform- or ether-giving to any intelligent bystander
who acts under his 8ui>6rvisitm* In difficult cases, however, it is bettor
t« send for a skilled assistant who is capable of taking entire charge of
the an^^thesia, that the operator's attention may not be diverted from
the work he ha^ in hand*

Before applying the forceps care should be taken to ascertain the
position of the head, and to make sure that the membranes have freely
ruptured. Forceps applied directly to the membranes might do harm
by causing a premature detachment of the placenta. The position of
the ce and the degree of its dilatation should likewise be determined.
In excessive ante version the he^id sometimes bulges out the anterior
wall of the cervix, and thins the cervical tissues to such an extent that
the sutures, the fontanelle, and contour of the head, can be distinctly
felt, as though the head had entered uncovered into the vagina ;
wlieread, in fact, the undilated os is situated high up, and with care
may be found looking backward in the direction of the sacrum. It is
only necessary to indicate the possibility of such a source of error to
injure the caution necessary for the avoidance of forceps applications
u> the cervix.

Ab a preliminary to all obstetrical operations, both bladder and
rectum should be emptied. The blades of the forceps should be
dipped in warm water to remove the chill from the steel, and should
be sroeared with some oily substance to reduce to the minimum the
fnction produced by their passage into the utero- vaginal canal.

Practically it is important to distinguish between forceps operaf
tiona at the brim and tlmse conducted after the head has entered the
carity of the pelvis. The latter are simple, safe, and easy of accom-
plishment, requiring only skill in the management of the periufeum ;
while the former belong in the category of capital operations, and call
tot a large degree of patience, experience, and obstetrical tact to bring
to a ffuooessful issue.

Fdreeps at the Pelvic Outlet. — The 8}>ecial indications for for-
when the head is low in the pelvis arc so-called rigidity of the
enm, stenosis of the vaginal orifice, and conditions demanding
iy delivery.
The condition termed rigidity of the perinieum is usually the sign
failing uterine action. So long as the labor-pains are good, the ex-
Bmal parts progressively soften and relax in preparation for the ad-
mg heaih If after the head reaches the floor of the })clvis the
I loie their expulsive character, the perina^um may be rigid simply
baoame the ordinary physiological forces whicli induce softening aro
aboent, or, in case softening has already begun, the periuiBum may
rigid from the sustained pressure to which it is subjected,
r contingency intermittent tractions made with forceps, in

842

OBSTETRIC SURGERT.

imitation of the natnral mechanism, furnish the Bpeediest aad
method of overcoming the resistance of the soft pnrt«.

Stenosis of the vulva is Bometimes the result of old cical
Oftener it is found where there is faulty direction of the child's
the vertex bulging the perin^eum in place of serving as a dilating
wedge to the \ailval orifice. The danger of central perforation of tte
perinaeom is hest averted by applying forceps and bringing the occi-
put well forward under the arch of the pubes. The commonest condi-
tions demanding speedy delivery are convulsions, exhaustion, and fe—
brile disturbances in the mother, and dangers threatening the lifeo^
the child. It is, however, of great importance to keep in mind ih&
relation that the prolongation of the second etage of labor bcftri to
these very dangers. So long as the head advances through the par*
turient canal by regular progression, the vagina pours out an abundant
secretion of mncns and relaxation takes place. If the advance of the
hearl is arrested from the dying out of the pains, or from other causes,
the continuous pressure exorcised by the head upon the soft parts pro-
duces venous stasis, cBdema, disappearance of the secretion, and final-
ly inflammatory infiltration. The genitals become therefore hot^ di7,
swollen, and friable, the intensity of the symptoms depending upon
the more or less close adaptation of the head to the bony walls of the
pelvic cavity. It is easy to understand that with tliese condition!; the
temperature rises and the pulse becomes frequent ; if the urethra is
compressed, retention of nrine with convulsions may follow ; while, ks
after-results, we may have phlegmasia extending to the pehic cellular
tissue and thence to the peritonaeum. Pressure too long continued
Cfm produce necrosis, and, as sloughing occurs, vesico- and recto-
vaginal fistulae. At the same time there is reciprocal pressure exer-
cised by the bony walla upon the child's head, and close retraction of
the uterus upon the foetus. The first cause may lead to retarded heart-
iK*tion and intra-eranial extravasations of blood ; while the second k
a fruitful source of asphyxia, owing to the diminution of the
blood-currents wliich circulate through the placenta.

In view of the foregoing, it will be seen that forceps is not
indicated in the presence of perils fully developed, but is of still
greater service as a prophylactic against the dangers of an undujy
lengthened second stage.

It is in vain to lay down well-defined rules as to the precise time
at which the forceps should be applied. Formerly it was advised to
wait for the advent of a thin, reddish-brown discharge. As the latter
simply consists of serum commingled with blood from overstrained
capillariesj it furnishes a sign that delivery has been delayed too long
Some counsel applying forceps two hours after the completion of the
first stage of labor, and proclaim longer waiting a useless barharity.
Clearly, however, it is not so much the length of the second stage of

second la
matag^H

not alone \

FORCEPa

848

labor which furnishes the indication for forceps, as the degree of the
reciprocal pressure exercised between the head and the pelvis. A Tal-
uable index to this pressure is furnished by the caput succedaneum.
In the second stage, a scalp tumor of large circumference can only be
produced by the circle of the bony pelvis. Such a tumor, increasing
in size, without any evidence of progress in the delivery, is a signifi-
cant evidence of pressure, and furnishes, therefore, the most reliable
indication for forceps.

Whether the ease with which forceps can be applied at* the outlet
and the safety which attends its employment justify its use as a

Flo. 158.— Introduction of blades.

means of saving the physician's time, or the patient from an addi-
tional half-hour of suffering, are questions which are at least de-
batable. I can only say that, with increasing experience, my own
practice has grown more and more conservative, and my own belief
is that true wisdom requires us to abstain from even trivial oper-
ations so long as Nature is able to do her work without our assist-
ance.

The operation consista of four acts, viz,: L Introduction of tba
blades ; 2. Locking ; 3. Tractions ; 4 Removal of the in»trunicnt

Introdnclion of Blades. — In introducing the forceps, each blade,
if a long one with pronounced pelvic curve, should be seised like i
pen near the lock, and should be held nearly vertically, with the ex-
tremity in correspondence with the slit-like opening of the vulva. In
the Simpson forceps, which possesses only a moderate pelvic curre,
the handle should bo lightly grasped in the half hand, and held at
the outset nearly parallel to Poupart's ligament Owing to the ar-
rangement of the lock, the left blade should be passed first* The
handle should accordingly be held in the left hand, while two or
three fingers of the right hand, inserted between tlie bead and the
vagina, serve to guide and guard the point during its introduction.
The passage of the blade should take place only during the inteniiU
between the pains. It is customary to pass each blade at first oppo-
site the sacro-iliac articulation, and then to change the direction is
required, after the point has reached the litiea terminal^.

In introducing the forceps-blades, the two curves of the instrument
should be borne in mind. By directing the handle toward the thigh
of the mother which corresponds in name to the blade, the latter is
made to glide over the convex surface of the child's head ; by sinking
the handle, the pelvic curve follows the axis of the pelvis* The two
movements should be made slowly, but simultaneously, and under the
guidance of the inserted fingers. But slight foroe is aecessary. The

FORCEPS. 845

duoed on the right side, under fche guidance of two to three fingers of
the left handy in accordance with the same general rules.

The cephalic curve of the forceps is intended to correspond to the
lateral surfaces of the child's head. When the rotation of the occiput
under the symphysis is complete, it is only necessary to sink the han-
dles to make the blades assume the natural position over the parietal
bosses. If the head is still in an oblique diameter, the forceps should
be applied in the opposite oblique diameter. When, therefore, the oc-
ciput is loft anterior, the left blade should be allowed to remain oppo-
site the sacro-iliac articulation, while the right blade, by sinking and at
the same time rotating the handle, is swept forward to the right ace-
tabulum. If the head is right anterior, the left blade is at once swept
forward toward the left acetabulum, while the right blade is allowed
to remain opposite the sacro-iliac articulation. If the sagittal suture
occupies the transverse diameter, the forceps should be applied in the
oblique diameter of the same name as the side toward which the fore-
head is turned. This is best accomplished by first applying the forceps
in the usual way ; then, leaving the occipital blade in the excavation to
the side of the promontory, with the guiding fingers inserted into the
vagina, direct the frontal blade forward toward the acetabulum. Dur-
ing this manoeuvre the handle should be held loosely. The forceps
will seize the head very nearly between the anterior frontal and the
opposite posterior parietal protuberance. The direct application of
the forceps to the sides of the head, with one blade beneath the sym-
physis and the other opposite the promontory, is sometimes practicsr
ble, but is undeserving of commendation.*

Locking. — When the occiput is rotated to the front, and the blades
are applied to the sides of the head, locking is a very simple matter.
The handles should be grasped in the full hand, with the thumbs
directed upward. Coaptation is secured by slight movements of the
blades as the operator sinks the handles downward.

When the head is transverse it is often, on the contrary, diflScult
to bring the separate parts of the lock in apposition. Under such
circumstances no force should be used, but the blades should be with-
drawn a little^ and the attempt made to adjust the lock by gentle
movements in reintroducing them.

After locking, a tentative traction should be made to ascertain
whether the head is seized securely. In bringing the blades together
some caution should be observed lest the hair of the pubes, or the
labia, become included.

* Tbe application of the forceps to the aides of the pelvis, without reference to the
position of the child^s head, has many warm advocates. That the head can he delivered
in this way is beyond all question. These so-called direct applications I practiced exclu-
sively for some years, and it was only gradually that I became convinced of the superi-
ority of the methods the description of which has been given.

of the left hand ebcmM be introduced int^ the vagina from time fc '^,
time, to determine tlie position of the forceps-blades^ and to estimat-
the amount of pressure npon the child's bead during tractions.

Steady trtictiona are preferable to pendulum or rotary ones. Trac
tions are most effective when made during a pain. This is specially
the ease when the rotation of the head is incomplete. However* in tlit^^
absence of pains, it is often necesgary to use the forceps as a substituu^
for, instead of a reenforcement of, the propulsive action of the uterua^
Pressure through the abdominal walls upon the uterus, made by j^
skilled assistant during tractions, is here, as in other obstetrical opera-
tions, an adjuvant of great value. Tractions should not be too pro^

FORCEPS.

a47

ed. When not made in unison with the pains, they shonld not
exceed one to two minutes in duration. The head should then be
lallowed to recede. Haste in delivery exposes the patient to the dan-
I gers of laceration and posi-partiim ha?morrhiige* Tjie alternate de-
motsit and recession of the head soften the external parts, and are the
beet means of overcoming rigidity. As the head advances, time should
be given for the uterus to retract upon its eontentsj for, when the
pains are deficient, retraction after the sudden emptying of the uterus
is apt to be imperfect or of short duration.

Tractions should at first be made downward, until the head has
descended below the symphysis pubis ; they should then be made in an
horizontal direction until the occiput appears at the vulva. When in
doubt about the direction, the handles should be held loosely during a

I pain, to serve as an index of the proper line of traction. If rotation has
not previously taken place, it may bo aided by the forceps, though rota-
tion usuaUy occurs spontaneously as the head descends. If the head
was transverse, the forceps requires to be readjusted after rotation, ei-
ther by removing the blades and then reapplying them, or by sinking the
bandle of the iK)sterior blade and raising the handle of the anterior one.
When the parietal bosses are in the act of passing through the
Tulva, tractions should no longer be made during the pains. The

;^DGp/

lfi». IW. — Po«itk>a of openilor when head u on perinflsuxa.

348 OBSTETRIC 8UR0ERT.

operator should stand to the right of the patient, and seize the handles
in the left hand. During the intervals of a pain, by alternately sink-
ing and raising the handles, the perinseum and yulTa can be gradually
dilated. So soon as the convexity of the perinfeum is marked, and
the parietal bosses press upon the commissure, it is better to sink the
handles during a pain, so as to flex the head to its greatest extent, and
cause the vertex to present. When the vulva is sufficiently dilated, it
is only necessary to raise the handles toward the abdomen to complete
the extrusion of the head, and finish the delivery.

Removal. — Although not generally recommended, it is always my
custom to remove the forceps so soon as the chin can be reached by the
index-finger introduced into the rectum. The extrusion of the head,
if it does not occur spontaneously, can then be easily effected, and the
blades of the forceps, though of no great thickness, still add something
to the distention of the vulva. The removal is accomplished by un-
locking and reversing the direction the handles followed in their intro-
duction. To avoid compressing the soft parts against the rami of the
pubes, I am accustomed to place two fingers of the unemployed
hand upon the upper border of the blade, and use them as a fulcrum
around which the blade should be rotated.

Foreeps at the Brim. — The safe conduct of the head through the
pelvic brim by means of the forceps is an achievement which requires
an accurate appreciation of the dangers to be avoided and the difficul-
ties to be overcome. The forceps as a means of accelerating delivery
is sometimes called for when the head is at the brim in cases of acci-
dental hffimorrhage, of placenta prsevia, of eclampsia, of pelvic ob-
struction, and in failure of uterine pains.

So long, indeed, as the head is movable at the brim, and version is
practicable, the latter operation furnishes the safer mode of delivery.
After the waters have drained away, and retraction of the uterus ren-
ders version impossible, a tentative application of the forceps may be
made to test the adaptability of the head to the pelvic canal. Persist-
ent attempts to drag the head into the pelvis by brute force, after
moderate tractions have failed to effect an advance, should be regarded
as criminal, exposing as they do the maternal tissues unavailingly to
injuries which are always serious, and which may prove fatal.

When, however, the head has become fixed, which does not occur
until after the engagement of its largest circumference, the difficulties
of forceps operations are greatly diminished. Still, dangers to the
mother arise from the fact that the blades have to be passed into the
lower segment of the uterus, where, owing to the extreme vulnerability
of the uterine tissues, lesions are only to be avoided by the patient
carrying out of a multitude of precautionary measures ; to the child,
from the rarity of the occasions which permit the blades to be applied
to the sides of the head, to which the cephalic curve is alone adapted.

FORCEPS.

849

Operation. — ^In introducing the forceps, the tips df the fingers of
the gaiding hand should be inserted between the child's head and the
cervix. In this way we insure the entrance of the extremities of the
blades into the uterus in place of into the cul-de-sac of the vagina. It
is generally customary to apply the forceps to the sides of the pelvis,
without reference to the position of the child's head. As a rule,
under the conditions mentioned, the head will be found to have
been seized obliquely — i. e., with the posterior blade over the parietal
boss, and the anterior blade near the coronal suture. Thus applied,
close approximation of the handles is impossible, and the tips are

FiQ. 167.— Forceps applied to head at brim.

correspondingly separated from one another. Considerable compres-
sion of the handles is necessary, therefore, to prevent the instrument
from slipping, the degree of pressure depending naturally upon the
extractive force requisite to advance the head. The adjustment of
the lock often requires considerable patience, and sometimes the
exercise of moderate force is necessary to bring the parts into juxta-
position.

Even when the instrument has been applied according to the
strict rules of art, it will be found not infrequently that the upper
border of the anterior and the lower border of the posterior blade will
project beyond the tissues of the scalp, and, unless managed with care,
the exposed edges are liable during extraction to cut deeply into the
soft structures of the parturient canaL

350

OBSTETRIC SUR6ERT.

When the cervix is only partially dilated, the forceps should be em-
ployed, not as an extractive instrument, but simply to bring the head
into the cervical canal to act as a dilating wedge, by means of which
the gradual and safe expansion of the os may be accomplished. If the
head be made to descend and then allowed to re-
cede at short intervals between the pains, in time
the cervix will be found to soften and yield in
the same manner as a rigid perinsBum ; whereas
the resistance of an undilated cervix can only be
overcome, when violent tractions are made, by
the production of lacerations extending to, or
even above, the vaginal junction. In seeking to
effect dilatation of the cervix through the forceps,
the utmost caution should, however, be observed.
At short intervals the finger should be slipped
into the vagina to note whether the tension of
the cervix is raised during tractions to danger-
ous proportions. Especial attention should be
paid to the condition of the parts during a pain,
as, when the uterus contracts, the os externum,
which previously was soft and dilatable, frequent-
ly forms a sharp, resistant border.

Dr. I. E. Taylor has devised a long, narrow-
bladed pair of forceps, capable of introduction
through a cervix measuring one and a half inch
in diameter, which he has used with advantage
in the manner above described at a very early
stage of labor.

In cases where it is necessary to expedite de-
livery, the resistance of the incompletely dilated
OS may be overcome by a number of incisions
about one fourth of an inch in depth, made with
a blunt-pointed bistoury passed between the cer-
vix and the child's head. It is very rare, how-
ever, that this otherwise trivial operation is really
called for.

In drawing the head through the superior
strait, the tractions should be made, as nearly
as the perinsBum will permit, vertically down-
ward. In doing this, however, care must be taken
lest the pelvic curve be brought so far forward
above the symphysis pubis as to subject the ma-
ternal tissues to injurious pressure. On the other hand, it is nec-
essary not to prematurely raise the handles of the forceps, as, in that
case, the head is simply crowded forcibly against the anterior pel-

Fio. 158.— Tnylor*B nar-
ro w-bluded* forceps.

FORCEPa 351

Tio wall. The best means of ayoiding these two difficulties is to ex-
ercise great patience, and be content with a very gradnal advance of
the heady as, by omitting anything like rude force, the risks arising
from misdirected tractions are kept within the limits of safety. Many,
indeed, seek to prevent the anterior pressure of the forceps, by placing
the left hand upon the lock, and using it as a fulcrum around which
rotation of the instrument is effected. As the right hand has then
to be employed at the same time to make tractions and to raise the
handles, the method requires both strength and expertness to be suc-
cessful.

In all high operations where the cervix is sufficiently dilated, I
can not too strongly recommend the ingenious forceps of M. Tamier,
which, by its construction and action, obviates to a great extent the
foregoing objections to the more familiar models.

M. Tamier's forceps possesses two original features : 1. The shanks,
in place of running forward continuous with the pelvic curve, are bent
backward, so that the handles, when placed horizontally, lie about
three and a half inches above the plane of the posterior curve of the
blades. This Tamier curve makes it possible to bring the blades well
forward in the sides of the pelvis without subjecting the soft parts
above, or the perinsBum below, to pressure. A transverse screw, cross-
ing the handles below the lock, approximates the blades to the sur-
faces of the child's head. 2. Two movable traction-rods are attached
to the lower curvature of the blades. These rods are curved to corre-
spond to the lower border of the shanks, to which, when not in use,
they are affixed by projecting pegs. When the instrument is adjusted,
the outer ends of the traction-rods are detached and inserted into a
socket^joint belonging to a strong steel bar with a dowiM^ard curve,
and furnished with a transverse handle which can be moved in any
direction by means of a universal joint. Tractions are made by means
of this transverse handle alone. As the head descends, the handles
proper rise upward and serve as an index to show the direction in which
the force should be exerted. By simply raising the traction-rods in a
line with the curved shanks, the blades of the forceps swing always in
the transverse diameter, and the head follows as nearly as possible the
axis of the ]ielvis. To one accustomed only to the familiar forceps,
the facility with which delivery can be accomplished by Tamier's in-
strument would seem hardly credible.

Mr. Stohlmann has modified for me the original forceps of Tamier
by making the blades much lighter, modeling them somewhat after
those of the well-known instrument of Wallace. This alteration makes
their application, especially in contracted pelves, or through an imper-
fectly dilated os, a much easier matter. In place, too, of the very
clumsy socket-joint into which the traction-rods are inserted, he has
substituted the key arrangement shown in Fig. 159, by means of which

353

OBSTETRIC SUKGERY,

the handle can be adjusted or removed in a few seconds of time. Tk\^c*
improvements do away, to a great extent, with the unhandinege of the
older model.

e\\

Fio, 159.— Author'B modification of Tirnier'a forceps.

As the solidity of the ghanks prevents the blades from spring
the amount of pressure upon the head requisite to keep the instrumeii
from slipping has b«en found in practice not to prove an element (
danger to the child.

When the head has boen brought to the floor of the pelvis, uu
the occiput has previously turned to the front, it is a good plan tor&*'
move the forceps and wait a little while to allow spontaneous rotation
to take place. Indeed, it is a question whether axis- tract ion forceps
shonid be employed at all at the inferior strait. Unless accurately
applied to the lateral surfaces of the child *8 head, the backward curve,
so useful at the brim, is apt to cut deeply into the posterior yagiuil
wall as soon as the converging soft parts embrace tightly the ndj
head. «i^

Forceps in Occipito posterior Positions,— So long as the
looks to the rear, it is the rule in midwifery practice to refrain fr
the use of forceps, which, of necessity, prevents forward rotation from
taking place. An exception to this rule, however, arises in cases
a near danger to either mother or child demanding speedy deliver
As attempts to rotate the occiput around to the symphysis by instru-
mental means are rarely successful, it is advisable under such circnE
stances to apply the forceps directly to the sides of the child's he
and to imitate during delivery the mechanism of labor in occipito-j
terior positions. If the sagittal suture occupies an oblique diamet^
the forceps should be applied in the opposite oblique diameter. As 1
head descends, the occiput should be turned into the hollow of th
sacrum. At first, tractions should be made directly downward until
the forehead has passed under the pubic arch, and the anterior foni|
nellc makes its api^arance at the vulva ; then, by raising the handle
the small fontanelle should be brought forward to the commissur6» and,
finally, as the vertex emerges from the vulva, the handles should be

FOBCEPa 858

'^"^ slowly depressed to aid the moyement of extension by which the

^ delivery of the face and chin beneath the pubic arch is accom-

plished.

Forceps in Face Presentations.— When the face is deep in the pelvis
and the chin has rotated to the front, forceps applications are easy and
do not differ materially from those in vertex presentation, except that
care should be taken to direct the blades far enough backward to se-
curely seize the occipital extremity of the child's head. Tractions
should be made in an horizontal direction until the chin has been
brought well under the symphysis pubis, when the handles should be
raised to lift the cranial vault over the perinasum. In oblique mento-
anterior positions, Spiegelberg advises introducing first the blade cor-
responding to the chin (posterior blade), as, in adjusting the second
blade and locking the forceps, spontaneous rotation usually takes
place.

In deep transverse positions, forceps operations should be deferred
as long as possible, as tardy rotation of the chin to the front is a physi-
ological peculiarity in face presentations. The forceps should be ap-
plied in an oblique diameter, with the concavity of the blades directed
to the side of the chin. Chin right, introduce the right blade pos-
teriorly, and bring the left blade forward to the left tuberculum ilio-
pubicum. An effort should then be made to rotate the chin to the
front. If the attempt prove successful, the forceps should be un-
locked, and the blades readjusted to the lateral sui^aces of the head.
Tractions when the face is transverse should not be attempted. The
wide separation of the blades makes it necessary to compress the han-
dles firmly to prevent slipping. When this is done, pressure upon the
neck and thorax is unavoidable, so that extraction withoai sacrificing
the life of the child is hardly possible.

In high transverse positions, forceps should not be used, as rota-
tion is not then permissible, and the blades, applied to the neck and
thorax on the one side and upon the cranium on the other, can not,
for the reasons just given, be safely employed in extraction. The
choice in such cases, when speedy delivery is called for, lies between
version and craniotomy.

In mento-posterior positions, the rotation of the chin to the front
by repeated applications of the forceps is inadmissible. In practice,
such efforts do not succeed, whilp they are calculated to inflict injury
upon both the mother and the child. Usually, if delivery becomes
necessary because of danger to the mother, craniotomy should be re-
sorted to. Smellie, Hicks,* and Braun, of Vienna, have, however,
each reported a case of forceps delivery by drawing the chin down over

* Hicks, *' On Two Cases of Face PreaentatioiiB in the Mento-posterior Position,**
'* Trans, of the Obstet. Soc. of London," vol. Tii, p. 56. Hicks likewise reports the
of Smellie and Braun.
23

354 OBSTETRIC SUR6ERT.

the sacram and perin»am, when the occiput and calvariam glided
underneath the pubes. In two cases, I. R Taylor * extracted the chil-

Fio. 160.— Taylor's method in mento-posterior portions of the flMse.

dren with straight forceps after bilateral incision of the perinsBum.
Unfortunately, both children were dead before the operation was un-
dertaken«

CHAPTER XX.

EZTRACTIOS IH FOOT AND BREECH PRESEIfTATlOm.

EztracUoii in pelyic presentationB. — ^Attitnde of the phjsidan. — ^Prognosis. — ^Position. —
Extrtction of trank. — Extraction by the feet ; by the breech. — Management of the
cord. — Liberation of the arms. — Exoeptional cases. — Extraction of the head. — Smel-
lie*s method. — ^Veit*s method. — Head at brim. — ^Prague method. — ^Foroeps to the after-
coming head.

We have already seen, in studying the management of breech pres-
entations, that the attitude of the phjrsician during deliyery, so long
as no immediate danger threatens either the mother or the child,
should be one of watchful observation. As a rule, the results to the
child are unquestionably more favorable when Nature does her work
unaided. Should, however, there be any faltering in the natural

* Taylor, ** On the Spontaneous and Artifidal DcliFery of the Child in Face Presenta-
Uons," " N. Y. Med. Jour.," Nov., 1869.

EXTRACTION IN FOOT AND BREECH FRESENTATIONa 856

forces, the phyBician should be in readiness to avert by prompt inter-
ference the perils which, in pelvic presentations, are associated with
delay. When an artificial breech-presentation has been produced by
internal version, immediate extraction is usually advisable, as the act
of version, when the entire hand has to be introduced into the uterus,
is apt to compromise the safety of the child.

Strong uterine contractions, a roomy pelvis, a dilated cervix, and
a relaxed state of the vaginal outlet are conditions highly favorable to
the success of the operation. Under such circumstances, artificial
delivery can be performed with celerity and ease. But these condi-
tions, however desirable, are not absolutely indispensable. Thus, ex-
traction is rarely indicated if the pains are good ; it is often necessary
to deliver before the cervix has reached the desirable degree of dilata-
tion ; and it is possible to drag the head of the child through a moder-
ately contracted pelvis without inflicting upon it any permanent in-
jury. There is always danger, however, in the last two cases, of
not being able to extract the child rapidly enough to save it from
asphyxia.

The prognosis for the mother is generally favorable. Still, lacera-
tions are apt to follow the forcible delivery of the head through the
undilated cervix.

Extraction is commonly performed with the patient on her back.
In easy cases she may occupy the usual position in bed, while the phy-
sician places himself at her side. If diflSculty is anticipated, the pa-
tient should be placed crosswise, with hips raised by a hard cushion,
and brought over the edge of the bed ; or, better still, may be placed
upon a table, as the operator is then enabled to draw downward in the
direction of the superior strait without kneeling before her. It is de-
sirable to have two assistants to hold the patient's knees. To one of
these should likewise be assigned the duty of making firm pressure,
during extraction, upon the fundus of the uterus. If ansBsthesia is
thought necessary, a third assistant will be required. The question
of ansBsthesia is not always easy to decide. Useful in unruly patients,
and where the entire hand must be passed into the vagina, its occa-
sional suspensive action upon the uterine pains and the loss of the
codperation which intelligent patients are capable of affording are
alloys to its beneficent action in stilling pain. My preference is to
ansBsthetize lightly at first, and then be guided by events as to whether
the insensibility shall be subsequently made complete or the patient
be allowed to return to partial consciousness.

As in all obstetrical operations, care should be taken to insure the
emptying of the bladder and rectum, and the operator should have in
readiness, in case of need, forceps, a soft fillet, warm napkins, hot and
cold water, and a small catheter, for use should the child be bom in
a state of partial asphyxia.

356

OBSTETRIC SITRGEBY.

The operation is divisible into three acts : 1< Extraction of
trunks as far m the Bhoulders ; 2. Extraction of the arms ; 3. Ex-
traction of the head.

FiKST Act : Extbactiox of the Trunk to the SHorLDiBSL

The extraction of the trunk ghould take place slowly* with paiwess
between the tractions, in imitation of the uterine expellent foree^^
Tractions are best made during the pains only, when the latter do no^
recur at too long intervals. It is desirable that the uterus be close! j^
retracted upon the eliild during the entire period of its expul^ioj
Where this does not ocenr, the arms are liable to be brushed upwar-^
to tlie sides of the eh i Id's head, the chin to become extended, and ilm «
mechanigm of the head-delivery to be disturbed. Hiemorrhage, toc^,
is more likely to follow hasty delivery than where the uterus has ha-^
time to pass slowly into a state of complete retraction. When, ther^?—
fore, it is necessary to extract during the intervals between the pains^
firm pressure should bo made upon the uterus through the abdomin^^
walls, so as to maintain them in close contact with the foetus. Stead^^^
.tractions are prcferuble to pendulum movements. Tractions should
be made downward and backward, in the direction of the superio*"
Btrait, until the breech meets with the resistance of the floor of the?
pelvis.

These general rules are applicable to every case of extraction*
Special differences of procedure result from the presentation of one or
both feet, and of the entire breech.

Extraction by the Feet,— If a single extremity presents, the foot
ehould be seized between the middle and index finger, with the thumb
upon the ^ole. It is not necessary to go in search of the second foot,
unless it crosses the first, or is reflected upward over the child^a back.
When the leg is drawn outside of the vulva, it should be wrappt^ in A
warm napkin, and grasped by tlie entire hand. Always, in seizing ^
hmb, the thumb should be directed upward and applied to the dorsal
surface. The napkin serves partly to prevent the hand from slippi
partly to protect the surface from air, which at times is eapabl
exciting reflex respiratory movements. Tractions should be made
downward, to avoid friction at the symphysis pubis. Until the |>et
is delivered, the child should be seized as near the maternal p
possible. Tlie hand, tlierefore, should be shifted upward as the 1:
ia drawn out of the vulva. Whichever extremity is seized rotates
ward under the symphysis pubis during extraction. So soon tm
breech reaches the peine floor^ traction should be made more in
upward direction, to facilitate the passage of the buttocks over the
perina3om. After the breech has cleared the vulva, the index-finger
of the free hand should be carefully inserted into the fold of the jkjs-
terior thigh, while the thumbs of both hands are placed upon the

EXTRACTION IN FOOT AND BREECH PRESENTATIONS.

367

sacrum. During the subsequent extraction of the trunk, the lower leg
falls from the vagina without special assistance.

FiQ. 161.— Method of sdang the breech.

If both extremities present, they should be seized so that the mid-
dle finger is placed between the feet, while the index and ring fingers
encircle the external malleoli. After they have passed sufficiently far
outside the Yulya, the left leg should be seized with the left hand, and
the right foot with the right hand. During extraction the normal
rotation of the child may be aided by dragging with somewhat greater
force upon the limb, which should be turned to the front.

Extraction by the Breeoh. — When the breech alone presents, it
may be thought best to secure a foot, previous to the descent of the
child into the pelvis, as a prophylactic measure, in case extraction
should subsequently be found necessary. In this event, with both
feet reflected upward, the hand should be passed over the anterior
surface of the child to the knee of the front extremity ; the thumb
should then be placed in the popliteal space, while four fingers grasp
the leg, flex it upon the thigh, and draw it down into the vagina.

S5d

OBSTETRIC StlBGERY.

This opemtioE is facilitated by placing the patient upon the side to
which the child's feet are turned.

After, howe?er, the hreech has once fairly engaged in the pelng,
the execution of this manoeuvre is no longer easy. The attempt to
bring down an extremity by the side of the breech in the pelvis n
liable to cause fracture of the thigh. Then, too, the introduction of
the hand is not always possible without the exercise of an unju^tili-
able degree of force. In such cases an attempt should be made to pasb
the foetus downward during the pains, by graduated pressure apoa
the fundus of tlie uterus. Should this measure prove insufficient,
manual extraction should be attempted. To this end the index-linger
of one hand should be inserted into the fold of the anterior thigh, and
traction made directly downward. By seizing the wrist of the hand,
which is hooked into the thigh with the disengaged hand, an inci^Ma^
of traction power can be exerted* Wliere the breech is low enoQj
down, both index-fingers may be employed — the one in the aDteri(

Fio. las.— Hetbo<l of Midog both fti«t.

and the other in the posterior groin. Extraction is then effected W_
alternately raising and depressing the pelvic extremity.

EXTRACnOK IX POOT AND BREECH PRESENTATIOXS. 859

Sometimes the resistance of the soft parts is such as to set all our
best efForts in the way of manual extraction at defiance. Then a beg-
garly array of alternatives present themselves to us. These are : 1.
The blunt hook, which should be passed upward in the direction of
the child's forward knee, and then turned and withdrawn so as to
bring the curved extremity into the groin. The blunt hook furnishes
a good hold, and may be used to materially further delivery. Some
contusion is, however, inevitable from its employment. Oreat care
must be exercised to see that the instrument is well placed. Should
it slip forward upon the thigh during tractions, the th^h-bone is liable
to be fractured. The risks to the child, from even its careful employ-
ment, are so great that the blunt hook is rarely used excepting where
the child is believed to have perished. 2. The fillet, formed of a silk
handkerchief, a skein of worsted, a wide strip of linen, or of any soft
material, which, when passed around the thigh, may be used to aid ex-
traction. In placing the fillet, one end may be knotted, or rolled into a
ball, and conveyed by the index and middle fingers around the anterior
thigh, or an English elastic catheter, having been first guided around
the groin, may be employed to draw the fillet into position. Before
extracting, pains should be taken to see that the fillet is smoothly ad-
justed, and fits well into the fiexure of the thigh. To its use it has
been objected that the fillet is apt to become twisted, and, when moist-
ened with the vaginal secretions, forms an uneven band capable of
cutting deeply into the tissues. While, however, these drawbacks
should admonish us to caution, the testimony is abundant as to the
serviceability and relative safety of the measure. 3. The obstetric for-
ceps may be applied to the breech, in cases where the latter rests upon
the fioor of the pelvis, and where the pains are insufficient to overcome
the resistance of the perinseum. The employment of forceps in breech
cases has been generally decried from theoretical considerations. The
experiences of Huter and Haake * have, however, been favorable. The
latter limited the use of forceps to cases in which the breech was
already in the pelvic outlet, and after complete rotation had taken
place. The forceps was applied with one blade over the posterior
thigh, and the other over the sacrum, with the extremity of the latter
blade just above the crest of the ilium.

Muiagement of the Cord. — So soon as the cord has passed beyond the
vulva, dragging upon the navel should be avoided by gently pulling
the cord downward into one of the recesses to the sides of the prom-
ontory until some resistance is experienced. Sometimes the cord is
found passing between the child's legs and up over its back to the
placenta. Then traction should be exerted upon the placental extrem-
ity, and an attempt made to slip the loop over the posterior thigh. In

* HttTEB» " Compendium der Cperationen,** Leipsig, p. 203 ; Haakb, ** Ueber den
Oebmoch der Kopfzangen car EztracUon,*' ** Arob. f. Ojiwek^" Bd. xi, p. 6&S.

360 OBSTETRIC SITR0ER7.

the rare cases of failure to obtain its release, and where the cord is
wound around the child's body, two ligatures should be applied, and
the cord be divided between them, whereupon every effort should be
put forth to complete the delivery as speedily as possible.

Second Act : Libekatiok of ths Abm&

When the Arms are flexed upon the Thorax.— After providing for
the safety of the cord, the pelvis of the child should be seized in the
two hands with the thumbs upon the sacrum. Traction should be
employed in a downward direction until the shoulder-blades make
their appearance. Then no time should be lost in liberating the arms.
If the latter are folded upon the chest, delivery is an easy matter. The
palmar surface of the corresponding hand is passed over the belly of the
child to the posterior arm (back to the right, right hand, and vice ver-
sa), while the extremities, wrapped in a warm cloth, are drawn in the
opposite direction. The forearm should be seized as near the wrist as
possible, and be brought down over the abdomen to the side of the child.

When the Arms are extended. — ^Unless, however, great care has
been exerted during extraction to keep the uterus by external press-
ure closely in contact with the foetus, the friction of the parturient
canal is apt to brush one or both arms upward to the sides of the
child's head. In such cases the difficulties involved in liberating the
arms are often very great. Here, too, owing to the increased amount
of space afforded by the curvature of the sacrum, an attempt should
first be made to release the posterior arm.

Release of the Posterior Arm, — This is best accomplished by draw-
ing the lower extremities strongly upward and to the side, thereby caus-
ing the posterior shoulder to sink deeper in the pelvis and to furnish
more room for the introduction of the hand ; then two fingers should
be passed along the side of the child to the elbow-joint, which should
be pushed sicross the face, and be brought down over the thorax.

In case the foregoing manoeuvre can not be rapidly executed, the
operating hand may be removed, and the extremities of the child may
be drawn in the opposite direction, while the hand which at first had
seized the feet or breech should pass upward over the abdominal sur-
face to the posterior elbow, and bend it, with two fingers in the joint,
toward the anterior pelvic wall.

Whether the hand be passed behind or in front of the child, it
should be introduced slowly and without force during the intermission
between the pains. Pressure should always be made at the joint, and
never upon the humerus. A forgetf ulness of the latter rule is apt to
produce fracture.

Release of the Anterior Arm. — As there is rarely space enough
between the symphysis and the shoulder to allow the fingers to reach
the elbow, it is customary after release of the posterior arm to rotate

EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 361

the trunk so as to bring the anterior arm backward into the cavity of
the sacmm. This is accomplished either by clasping the thorax in
both hands and rotating while pushing the thorax inward, or better
still by seizing the liberated arm, and drawing it upward under the
symphysis pubis. Indeed, the latter method has so far never failed me
in readily securing the desired rotation. (If the back is turned to the
left, the arm should be drawn upward idong the left labium majus,
and vice versa,)

Exceptional Cases. — The shoulders, in place of rotating into the
conjugate diameter, may enter transversely into the pelvis. If the
back then be turned toward the symphysis, the hand should be passed
over the abdominal surface in search of the arms. The space oppo-
site the sacrum renders this movement one of easy execution. When
the back is turned to the rear, so long as the arms are flexed, the hand
should search for them under the symphysis pubis. If, however, they
are extended upon the sides of the child's head, it is rarely possible to
push the arms forward between the face and the symphysis pubis.
An effort should be made, therefore, to bring one arm to the rear by
rotating the thorax with the hands. Michaelis succeeded twice in
similar cases without rotating the trunk, by passing the hand behind
the dorsal surface of the child and drawing the elbow backward and
downward below the side- wall of the pelvis, and then pushing the
forearm over the thorax.* I have repeatedly tested this movement in
passing the cadaver of an infant through a bony pelvis, and find that
it can be accomplished without producing fracture or dislocation.
Of course, during the life of the child the result may be different.

Sometimes, in rotating the shoulders, the anterior arm becomes
displaced backward, so that the forearm is thrown across the neck of
the child. When this accident is of recent occurrence, the release of
the arm may be accomplished by pressing the thorax of the child back-
ward into the genital passage, and rotating the body in the reverse
direction from that which produced the difficulty. If, however, trac-
tions have been made upon the child until the head has entered the
pelvis, the arm may become so compressed between the neck and the
symphysis pubis as to render its liberation a very difficult if not im-
possible task. Then every resource should be quickly tested to turn the
shoulder of the displaced arm to the rear, either by raising the released
arm, or by rotating the thorax, or by drawing upon the elbow. In case
of failure to obtain a speedy result, extraction may be attempted with-
out releasing the arm. To be sure, fracture of the humerus is thereby
rendered highly probable, but, if the bystanders are forewarned that
the risk is incurred in the interest of the child, they are generally
ready, where the life of the latter is preserved, to condone the injury.

In setting a fractured arm, soft pads should be bandaged upon the
* MiCHAKLis, ** Abhandlungen,*' Kiel, 18S8, p. 230.

362

OBSTETRIC SURGERY.

anterior and posterior surface to bold the extremities in position. The
posterior pad ahoiitd nm the entire length ol the arm ; the anterior
pad need not extend below the elbow. The arm should then be band-
aged to the thorax. In two or three weeks consolidation takes place.*
In performing artificial rotation, it is well to bear the warning of
Dr. Barnes in mind, Tiz,, *' That the atlas forms with the axis a rota-
tory joint, m constructed that, if the movement of rotation of the head
be carried beyond a quarter of a circle, the articulating surfaces part
immediately, and the spinal cord is compressed or torn,'* f ^^
should accordingly be taken to note, when a half-turn is given to tk
body, whether the head follows the movements of the trunk.

Third Act : Extra ctiok of the Head.

In the extraction of the head we have to distinguish — 1. Cases in
which the head has entered the pehis, and has only to overcome the
resistance of the perinsBum ; 2* Cases where the head is retained at
the brim by pelvic contraction, stricture of the os uteri, extemion oi
the chin, or insufficient expulsive action exerted by the uterus and
the abdominal rauscles.

1, Extraction of the head after it has entered the pelvis,

Smellie's Method.— -In the so-called Smellie's method the trunk of
the child is wrajjped in a warm napkin and placed astride the opem^
tor's arm ; the hand is then passed into the vagina, and the index aai
middle fingers are placed upon the fossae canina9 to the sides of tb^
child's nose. By tliis means fiexion of the head is induced. At th^^
same time, upward pressure is made with the fingers of the other han^^^
upon the occiput. Then by raising the trunk the face is rolled oat^
over the perinoeum. This method possesses the advantage of avoidin^^

the risks of injuring the child which are incident to the other proced

ures. It requires for its successful performance the cnrapletion or^
rotation, a small bead, and a lax perina^um.

Combiiied Traction upon the Chin and Shoulders.— In case the fores—
going plan is not followed by immediate success, the two fingers apo^ci
the fossae caninas should be introduced into the mouth, and, by pinjr*
ure upon tho alveolar processes of the lower jaw, flexion should \^^
accomplished. With the fingers of the other hand forked upon tt»^^
shoulders traction should be made, and as the head descends |t^^
body should be raised by the joint movement of the two arms, whe^"**-^
by the face sweeps over tho perinseum. By the combined metb*^^^^*^
there is obtained the greatest amount of traction force in combinati^ ^ ^
with the least degree of violence to the child. As the power is exerf:^^^
chiefly upon the shoulders, the fingers in the month are not likely
fracture the jaw, but, by keeping the chin flexed and drawing gen

• SpiKoiLBiBO, " Lehrbucb/' etc, p. 809.

t Barkis, ♦* Obst OpemUoiw," Am. ed., p. 210.

EXTRACTION IN FOOT AND BREECH PRESENTATIONa 368

upon ity the danger of twisting the neck, in cases where the rotation
of the face into the hollow of the sacrum is incomplete, is avoided.*

Fio. 168.— Comlnnod tnction upon month and ahooldoTB. (ChaiUj-Honorfi.)

When the occiput is turned into the hollow of the sacrum, and the
forehead is pressed against the symphysis, the process just described
should be reversed. As the fingers are forked over the shoulders, the
back of the child should rest upon the arm. With one or two fin-
gers of the other hand the chin should be fiexed. Tractions should
be made downward, so that while the neck rests upon the perinseum
the forehead rotates under the symphysis pubis.

Ordinarily, when the head enters the pelvis in a transverse direc-
tion, the occiput rotates to the symphysis pubis during extraction.
Should the head, however, remain with its long diameter in the trans-
verse diameter of the pelvis, a hand introduced into the vagina, with
the back to the sacrum and the fingers over the child's face, may
sometimes be successfully employed to rotate the latter into the sacral
concavity.

2. Eztraetion with the Head at the Brim.— Schroeder, and a con-
siderable i)ortion of the modem German school, employ combined trac-
tion upon the shoulder and chin for all emergencies alike, whether the
head be high, or after its entrance into the pelvis. As, however, the
life of the child depends ux)on the speedy extraction of the head, it is
well to become familiar with the various procedures, as, by passing

* The combined tnction npon the ohin and shonlden is in Gennanr known as the
Smellie-Yeit modified method, the latter haring warmly advocated the measure in 1868.
Chailly, howerer, long before spoke of its adoption in France, and attributed its introdno>
tion to Mme. La Chapelle.

364

OBSTETRIC SUROEBY.

yw.

rapidlj from one to another, a successful result is often obtained, when
failure might have followed ineffectual efforts in a single directioit ^^
The Prague Method owes its modern name to the advocacy olV
Kiwisch, Scanzoni, and Lange» all representatives of the Prague

school It was, however, nearly a c^n-,
tury earlier described by Pugh. W
consists in seizing the feet with on&l
hand, and directing the body of the [
child nearly vertically downward, T\x%\
fingers of the other hand are hooke
over the shoulders of the child, so i
the tips rest upon the supra-clavicolar
region. Traction is exerted by botlm^
hands simultitiieously. In the absence
of pains, external pressure upon tli«
head should be made by an assistaufl
through the abdominal walla,
should be taken to avoid twisting th
neck, and to preserve the normal reli
tions between the head and the should
dera. After the head has passed tb
brim, and fairly entered the pelvis, th
hand upon the neck should be em-^
ployed as a fulcrum, while the extren
ities are raised rapidly toward the ab
domen of the mother ; the frictio
from the inner surface of the symphys
pushers the occiput upward, and for
the face to descend into the hollow \
the sacrum and to sweep over the
rinieum.

When the chin is directed to tl
front, and at the same time is arrest
at the symphysis pubis, if the occiput
occupies the hollow of the sacrum, th^—
body of the child should, during th^J
tractions, be directed toward the abdomen of the mother^ so as to
cause the occiput to rotate over the perinjeum.

Forceps to the Aftercoming Head* — The forceps to the after-coming
head has been condemned by some and warmly approved by otheni^H
As, however, with its aid I have, in a number of instances, extracte(|
children alive in ca^s where the foregoing methods have failed me,
it is now my custom to have the blades duly wanned and ready to hand
before attempting manual extraction. The instrument is occasionally
of use in overcoming the resistance of a rigid perinfiDum in strongl]

Flo. IGi.-

-The nifth^xl of GXtmcting
the trunk*

EXTRACTION IN FOOT AND BREECH PRESENTATIONS.

365

built primiparse, but is chiefly indicated when both occiput and chin
are arrested at the superior strait. With the chin anterior, the forceps

Fig. 165. — ^The Prague method of extracdxig head.

should be applied under the back of the child, and the handles raised
so as to bring the occiput into the hollow of the sacrum. With the
chin to the rear, the forceps should be applied under the abdomen,

Fio. 166.— Chin arrested at symphysis. (Chaillj-Honor^.)

366

OBSTETRIC SURGERT.

and he used to draw the face into the sacrum. Where the arrest of the
head is due to stricture of the 09 externum or internum,, the farcepa
will sometimes bring the head rapidly through the ceryix, when trac-^
tion upon the feet only serves to drag the uterua to the Tuka.
stricture of the cervix, however, great care must \ye exercised to avoid*
laceration, a^ under no circumstances are extensive ruptures of the
lower uterine segment so apt to follow as in the forcible extraction j
of the after-coming head. The introduction of a large-sized catbeti
into the child's mouth and drawing back the perinseum have been!
found useful as temporary means of introducing air into the chUd*g
lungs, where delay attends efforts at delivery.

In extracting the after-coming head, the Tamier forceps is pa^
ticularly to be recommended.

CHAPTER XXI.

Cephalic Tcrslon» — External metbod — Cbrabiiied method, — Buach, — D'Oatr

Wright — Ut>hl. — Bmiton Hkkg.-^Podalic Tersion, — Bi-polar method. — ^iQlerotJ la
flion.^-Ni'giccted verBion. — Vm of the fillet

Version, or turning, is the term employed for the operatioMI
means of which an artificial change is effected in the presentation <
the child. It comprises the substitution of one pole of the foetus i
the other, and the conversion of an oblique or shoulder presentatio
into one in which the long axis of the f«tus corresponds to the ver
cd axis of the uterus.

It is customary to designate specifically the character of the versio
by mentioning — L The presentation to be changed* Thu8> version i
made from the head, the breech, or the shoulder, as the presenting'
part 2. The presentation to be effected* The term cephalic yersion
is used where the head is brought to the brim of the pelvis, and po-
dalic version where the feet are seized and the extremities made the
presimting part. 3. The method adopted by which version is accom^
plished. Tlie expression external version is applied to manipulatic
exclusively through the abdominal walls ; internal version, to the i^
troduction of the entire hand into the uterus ; and the corabir
method to cases in which both hands, the one externally and the otb^
with two to four fingers introduced through the os, cooperate togeth«

Cephalic Version* — When it is simply required to rectify a faul|j
presentation (shoulder or transverse), without reference to modif
ing circumstances, cephalic version nnqnestionably deserves the pr
erence. In practice, however, this method requires the concur

VERSION.

eo many favorable conditions that its emplojment is very limited.
r insUnee, there must be no complications which call for rapid
iiTery, It would be unsni table in prolapse of the cord and in
casee of placenta praevia. There should he nothing to prevent the
cliild*g head from entering the brim of the pelvia. It should, there-
lore, not be attempted in contracted pelves, A prolapsed arm, unless
Tiouflly replaced, would render the operation impossible. The
fhild should enjoy a considerable degree of mobility* An abundance
of amniotic fluid contributes much, though it is not indispensable, to
success, as, even after the rupture of the membranes, provided the
uterine walls are suflBciently relaxed, the head may bo brought into
the pelvis. Before rapture, excessive eensitiveness to manipulations,
and, after rupture, rigidity of the uterus stand in the way of success.
I The operation may be performed by either the external or the com-

^■fbined method,

^H Of the extenial methods the best is that which is known as Wi-
^fgand's (1807), which combines a suitable position of the mother, with
f manipulations through the abdominal walls. The mother is at first
I made to lie upon her back, with knees flexed, and with the abdomen
exposed or covered by some light material. The pliysician stands by
the side of the patient, looking in the direction of her face. He be-
gins by laying his hands flat upon the surface of the abdomen, and
seeks with the one the head and with the other the breech of the foetus.
During the intervals of the pains, by gentle movements of the two
hands working simultaneously, be strives to press up the breech and
anterior surface of the child and to bring the head into the pelvic
brim. Should the uterus harden, all friction movements of the
hands should cease, and the efforts of the operator be confined to
holding the foetus steady in the position previously produced. The
^^movement may be aided by turning the woman upon the side toward
^Blrbich the head is directed. As the fundus of the uterus sinks to the
^nide upon which the woman lies, it carries the breech of the child
^Pwith it, while the change in the uterine axis tends to throw the ce-
f phalic end in the opposite direction.

I When the head is once brought to the brim of the pelvis it may be

retiiined in situ, if the patient lies upon her side, by the band of an

ftwistant, or by a small, hard pillow pressed firmly against it. If the

patient lies upon the back, two compresses may be laid along tlie sides

of the uterus near the head, and a bandage applied to the abdomen to

eep them in position. When tho pains are regular and the cervix

airtially dilated, fixation of the head may be accomplished by rnptnr*

Lg the membranes and allowing the waters to escape. Until the uterus

is down upon the child » the head should bo held at the brim either

e two hands through the abdominal w^iills, or by tho thumb and

four fingers of one hand applied directly to the head through the cervix.

368 OBSTETRIC SURGEBT.

The more important of the combined methods are those of Buech,
D'Outreponty Wright^ Hohl, and Braxton Hicks. They have in com-
mon the simoltaneoos employment of the external and internal hand.
They differ, however, in detail. The methods of'Busch and D'Outre-
pont have now chiefly an historical interest Busch introduced the
hand corresponding to the child's head through the vagina and cervix,
while counter-pressure was made with the other hand upon the fundus

Fio. 167.— D*Outrcpont*s method, modified by ScanzonL

uteri. The back of the hand is at first directed to the front When,
however, its widest portion has passed above the symphysis pubis, the
back of the hand is turned to the concavity of the sacrum, and the fin-
gers are pushed up with care between the membranes and the uterus to
the head. The membranes are then ruptured, and during the escape of
the waters the head is seized by the fingers and thumb and drawn into
the pelvis, while the disengaged hand presses the breech toward the
median line. Every pains should be taken to prevent, with the fingers,
the prolapse of the cord, or of an arm,* during the escape of the
water. D'Outrepont seized the presenting shoulder between the thumb
and fingers of the hand corresponding to the breech, and, during the
intervals between the pains, pushed the shoulder upward and in the
direction of the breech until the head descended into the pelvis.
During this manoeuvre, D'Outrepont simply used the external hand
to support the uterus. Scanzoni recommended that it should be em-
ployed externally to press the head toward the pelvic brim.f

Wright's method differs from that of D'Outrepont, in that he em-
ployed, to seize the shoulder, the hand corresponding to the head, and,
while he pushed the shoulder, without lifting, in the direction of the

* SoAMZONi, **Lehrbuch der Geburtshulfe,*' 1867, Bd. Ui, p. 68. f Op. d/., p. 65.

YEBSION. 369

oorye of the nternsy he applied the remaining hand to dislodge the
breech and moye it toward the center of the nterine cavity.*

All the foregoing methods require for their successful performance
a movable foetus and a dilated cervix, conditions which render podalic
version safe and of easy execution. In practice, therefore, they have
never enjoyed any considerable degree of popularity. Of far greater
importance are the methods of Hohl and Braxton Hicks, which, pos-
sessing the advantage of requiring the introduction of two fingers only
into the uterus, can consequently be resorted to at an early stage of
labor. Hohl, like Wright, employed for internal use the hand corre-
sponding to the head. With two fingers in the cervix, he pushed the
top of the shoulder in the direction of the breech, and pressed the
head into the pelvis with the external hand. At the same time he in-
trusted to an assistant the task of seizing the fundus of the uterus be-
tween the palms of the hands, and directing it to the side toward which
the head was originally turned, f Braxton Hicks describes his method
as follows : ^' Introduce the left hand into the vagina as in podalic ver-
sion ; place the right hand on the outside of the abdomen, in order
to make out the position of the foetus and the direction of the head
and feet. Should the shoulder, for instance, present, then push it,
with one or two fingers on the top, in the direction of the feet At
the same time pressure by the outer hand should be exerted upon the
cephalic end of the child. This will bring down the. head close to the
OS ; then let the head be received upon the tips of the inside fingers.
The head will play like a ball between the hands, and can be placed in
almost any part at will. ... It is as well, if the breech will not rise
to the fundus readily after the head is fairly in the os, to withdraw
the hand from the vagina and with it press up the breech from the
exterior." I Lately, Hicks has proposed to employ the external hand
to alternately press the head into the os and the breech to the fundus.
His plan differs from that of Hohl, in that he operates with the patient
upon the side, and uses the left hand with the patient upon the left
side, and the right hand when she lies upon the right He likewise dis-
penses with an assistant*

Podalic Yebsiok.

Podalic version is indicated in the following cases :

1. The transverse presentation, where cephalic version is contra-
indicated, or attended with any considerable degree of difficulty.

2. In head presentations, where there is reason to suppose that the

• Wright, " Am. Jour, of Obitet.," vol. vi, part 1, 1878.

t Hohl, **Lehrbueh der Oelrartohalfe,'* 2te Auflage, 1862, p. 784.
X Hicu, ** Combined External and Internal Verflion,'' *' Trans, of tbe O^tet Soc of
London,** toI. t, p. 280.

• Hicks, ** Am. Jour, of Obatet," July, 1879, p. 093.

aro

OBSTETRIC SURGERY.

result would be favorably influenced by bringing down the feet
illustrations of such conditions, we have faulty presentations of the
head and face, prolapse of the cord and extremities, placenta pr
and contracted pelvis. The various contingencies which call for i
sion will be more closely considered in connection with the specia;
morbid conditions mentioned.

The operation may he performed by combined external and int
nal manipulations, or by the iDtemal hand alone.

The Bipolar or Gombined Method of Braxton Hicks.— In the 1
polar method of turning, the two hands operate simultaneously np
the extremities of the fuetii8. It may be carried out at will with ttej
patient upon the side or upon the back. The latter position is tlif 1
one which finds most favor in this country. The patient should hf j
placed transversely in the bed and the nates drawn to the edge. Tvo
assistants are required to hold the legs, which should be flexed and ro-
tated outward- As the beds in America are very low, where difficultj i
in operating is anticipated it is sometimes advisable to remove thtl
patient after she has been anaesthetized to a table covered with a blfti»- 1
ket or woolen comforter. Complete anaesthesia is useful asaramof^
of facilitating the introduction of the internal hand, and maintaining
a relaxed condition of the uterus. Care should l>e taken that both
bladder and rectum are emptied. Tlie hand selected for internil.
mauipulations should Ijo of the same name as the side to which th
the extremities are turned— i. e., feet to the right, right hand ; feet to"
the left, left hand.* The fingers should be brought together in tbe^
form of a cone. The back of the hand and forearm should be ^
lubricated with oil or lard. In passing the hand into the vagina, \
labia should be separated by the thumb and fingers of the diseng
hand. Entrance is effected by directing the fingers toward the
crum, and pressing backward upon the distensible perinaeum. In
stage of the procedure hasty action is out of place. Patience and gen-
tleness arc the prime re^tiisites. Two or three fingers only need to be
carried through the internal os. When the presenting part is reached^
the external hand should be laid upon the abdomen, and pr
brought to bear upon the breech. The two hands should then movel
extremities of the child in opposite directions. To quote Dr.
**Tlie movements by which this is effected are a combination of
tinuous pressure and gentle impulses or taps with the finger-tips t
the head (or shoulder), and a series of half-sliding, half-pushing ill
pulses with the palm of the hand outside/' When the breech is well
pressed down to the iliao fossa, the membranes should be ruptured

* Id Engknd ibe patient U deUven-d ujmD tlie Jeft Bide, ftod the left hand U <
monly introduced mto the va^nit. la Oemmny, when the patient lies upon the
side, the left hand is employed inside ; when upon the left side, the right biUMi
choice of hunda^ it will be Been, Ia not oi mutter of coincide rahle importance.

VERSION.

371

daring a pain, and a knee, which at this time is generally near the m
int^mtiin, shoal d be seized and hooked inio the vagina with the

Pngers. As the breech k brought into the pehns by tractions upon the
^g, the outer hand should be employed to pre^js up the head until the
ersion is completed.
The manipulations described are to be conducted during the inter*
Tala between the pains. Care should be taken not to hook down the
cord with the knee, When the lower extremities are reflected upward
^npon the body so that a knee is not attainable, tlie breech muy often
Hpbo brought down by a finger inserted into the fold of the thigh, or by
^pressure upon some part of the pelvis.
. The combined method of version, which we owe in all its essential

Ii^tures to Braxton Hicks, is one of the most important contributions
to obstetrical practice of the present century. It possesses the jirice-
1e89 advantages of enabling the physician to perform version early in
labor, and to accomplish the operation without in any way imperiling
the integrity of the uterus. The only prerequisit-es for success are :
safficient dilatation of the cervix to permit the passage of two fingei*8,
a certain degree of fetal mobility within the uterine cavity, and a
precise knowledge of the fetal position. After rupture of the mem-

»bmii6fi and escai>e of the waters the nperation becomed more ditBcult,
but is even then not always impraelicjible.

Internal Version. — In internal version the entire hand is introduced
into the uterus. It is necessary, therefore, that the cervix should be
solar dilated that the hand can bo passed without violence through
the cervical canaL Irregular uterine contractions require to be re-

■ lievcd by hypodermic injections of morphia, with or without the addi*
lion of atropia, or by the induction of complete anaesthesia. As inter-
nal rereion is not an indifferent operation, but may be followed by
inflammations due either to injuries of the maternal tissues or to the
introduction of infected air into the uterus, it should not be attempted
I until the impracticability of the combined method has been demon-
ttrated. It is applicable chiefly to cases in which a certain degree of
[ntcrine retraction has followed upon the escape of the amniotic fluid,*
The patient should be placed upon the back or side ; the bladder
[and rectum should be emptied ; and anaesthesia should be pushed
I until the action of the abdominal muscles is suspended. The exact
sition of the foetus should be carefully ascertained. The hand> well
^ilcHl upon its dorsal aspect, should be passed slowly, after the expini-

^ If tbo memhtmoeA am* intact^ and internal version h chosen in place of the b]'pr>Ur
, 009 ci throe plAna is open in practice: 1. Boer recommended pa^Hin*? the hand
wwmt the membmieA nui uterus to the feet of the child, nwl then ruptuHnjo; the ment-
I ; 8. UQter idled the feet of the child through the moinbmQefl, ftiid turnefl without
Qptnrittg ; S* Lerret ruptured the membranes at the o& uteri, And introduced the h&nd
dofiog the Ottlflow of the water. The third plan h the ene most deM<r?in(^ of faTor.

372

OBSTETRIC SURGERY.

tion of a pain, with the fingers formed into a cone, throngh the
and cerrix, opposite the sacro-iliac synchondrosis, upon the side of thr
child's feet. At the same time counter-pressure should be maintained
over the fundus uteri, to prevent rupture of the vaginal attachments.
If the uterus he^ne to contract, the fingers should be spread out, and
the operator remain passive until the pain subsides*

In head presentations, the hand employed should be always theooe
which corresponds to the side of the eliild*8 feet. In transverse presen-
tations, when version is performed soon after the rupture of the mera-
branes, before retraction of the uterus has taken place to any ex-
tent, the choice of hands is of lit-
tle consequence. This is especial-
ly true in the dorso-anterior por-
tion. Thus, when the child lice
with the head to the left, feet to
the right, and belly to the rear,
the right hand may be passed di-
rectly across the belly to the ex-
tremities of the child, or the left
Imnd may be made to pai^ from
the breech, along the surface ol
the thigh, to the nearest knee or
leg. By the latter method the
danger of mintaking an arm for
the leg is avoided. Should, in anj^
case, doubt upon this ecore aris
the characteristic differences b<*-^
tween the hand and foot should
guide us to a correct diagnosis.
Thus, the wrist enjoys greater mo-
bihty than the ankle, the fingers
are longer than the toea, the palm
is shorter than tlie sole, the posi-
tion of the thumb is peculiar to
the hand, and the pointed heel to
the foot.

Fiio» 168. — Vernon in head prcucntatiotia.
(Clmiay-flonoi^.J

In the lateral position, the i)atient should be placed upon the sid
to which the child's breech is turned, with the buttocks near
edge of the bed. Here, obviously, the ojierator, standing in the
rear of his patient, would use with the greatest facility the hai
corresponding to the side u]K>n which the woman lies (left side* rigll
hand, and ince twrsa). In dorso-pOHterior positions, especially, the j
vantages of such a selection are manifest

In easy versions, it is correct practice to bring down one foot or
knee only. When one extremity is left reflected upon the abdomeu.

VERSION.

a7a

the larger aize of the breech more fully distcnda the cervix, and thus
prepares the way for the subsequent passage of the child's head. In
difficult cases, or when rapid dehvery is to be effected, both feet should
be seized, A single foot ghould bo held at the ankle between the
thumb and fingers. When practicable^ the entire leg may be grasped
with the closed hand. When it is sought to turn by both feet, the
middle finger should be placed between them, while the ankles are
^held by the second and fourth fingers*

H Little importance gtiould be attached to the question as to which
Ve3dTemity should be selected » so long as the version is uncomplicatetL
W While in Genuany preference is accorded to the seizure of the lower
extremity, the superiority of turning by the more remote limb is gen-
erally advocated in England.

As in the bi-jKjlar method, during the traction upon the foot, the

^^OM, lf9f 170,^-Vereioii in trnasvorst* proscntatloiis ; direct method of seizing foet (Bmim.)

I external hand should aid version by pressure upward upon the head
I made through the abdominal walls with the disengaged hand.

When, in transverse presentations, the mcmbranea rupture, the

lower arm not unfrcqucntly becomes prolapsed into the vagina. As a

rule, this complication does not embarrass version, though it may prove

fm hindrance to the introduction of the hand. It is a good plan, in

L arm-presentations, to sHp a noose of tai>e about the wrist, which serves

[a twofold purpose, enabling us to draw the extremity up toward the

physii*, or back against the perinfeum, according as the hand is to

ed posteriorly or anteriorly, and to hold the arm to the side of

hhe child's body during the performance of version, thus avoiding the

S74

OBSTETRIC SURGERT,

difficultiea of arm delivery in the i>eriod of extraction. Dr, F. P.
Foster, in a case where the mobility of the child was unimpeded, used
the prolapsed arm aa an aid to version in the following ingenious
manner : The child lay with the back to the front, the head upon the
right iliac fossa, and the left arm presenting. With the right hand in
the vagina^ lie aeissed the arm, and pushed gently upward in the
direction of the humerus. In tbia way he succeeded in elevating,
the ceplialic pole until with the index - finger alone in the cenriij
uteri he managed to reach the breech of the child. With the poinl
of his "linger he gently urged this along to the mother's right dde, '

Fio. 171.— Mothnd of reaeliitig ia ttctreiDitj bj flist poBfldiigtlio iLmd iiroimd the I

and soon encountered the left foot, which he readily hooked down
into the vagina**

When, after rupture of the membranes, aid is not promptly ren-
dered, the shoulder becomes crowded into the pelvic brim. If the
pains are feeble the uterus may remain relaxed, so that houi-s after-
ward version may be readily jjcrformed. If the pains are good, how-
ever, as the waters escape the uterus retracts, until finally it bocon
rigidly applied to the surface of the foatus. This condition is kno«
to obstetricians as a neglected shoulder presentation. Version, unde
the circumstances, is embarrassed, partly by the difficulty of int
ducing the hand into the uterus to seize the foot, and partly by
fact that when tractions arc made upon an extreinity, in place of

♦ Foster, " On Pralapac of the Arm in TimnsTerse Presentiitioiis,** ** Amcr Jo
of Obsiei./^ vol ii, p. 208.

VERSION.

375

ctild tttming in uiero, both child and the closely applied uterus are
ftpt to move together.

In operating after the retraction of the uterus has become com-

Vlote, the physician should seek to effect the utmost relaxation by

puahing anaesthesia to complete insensibility. The hand should be

introdnced slowly and with the utmost gentleness. Precipitate action,

or Hn attempt to overcome the uterine resistant'c by force, may cause

fatal rupture. The extenial hand should make firm connter-pressure

Upon the fundus, to prevent the uterus from being torn from the

Ti^gina. The seizure of the lower foot is usually alone practicable.

Siiopeon* it is true, regarded the secret of succcfia in such cases as

<ie|>eading upon making tractions with the ujiper limb, as tending to

rotate the body of the child upon its long axi.^» and thus favoring the

reiease of the presenting shoulder from its imprii^onment. However

nttioDal all this sounds in theory, rotation within a rigidly contracted

tttems is easier to represent by diagram than to carry out in practice,

^he result of seizing the upper log is UHiually to cross it with its fellow,

and to twist tjie child's body so as to injuriously compresa the abdom-

tnul viscera. By making tractions upon the lower leg, the breech is

brought by the shortest route to the uterine orifice. To be sure, by

thig mano?n\Te the body of the child is bent laterally, but lateral

^^'xion dues the child no barm. In case^jf failure to effect version,

^ loose of tape may be placed upon the foot, and the band returned

^ Be«k the other extremity. When the foot is within reac^h, the

loop of the fillet, placed about the fingers, is

^•*ily conveyed upward to the ankle. When,

however, the foot is high up in the vagina,

^Ucsre the movement of the fingers is im-

P^*ftl» the loop from the lingers over the foot.

tiaciucttionably the most serviceable contriv-

^iic« to this end is the repositor of Carl Braun,

^hioh consists of a gutta-percha rod, sixteen

*^<^liC8 in length, with an aperture two Inches

^'^•aci, the extremity, through which the loop

^ ^ doubled tape is threaded. When in use

^'"S loop i^ parsed around the noo^o of the

^^^j and is then reflected over the end of the

Thus secured, the fillet is conveyed to

position aimed at. Then by loosening

^fidsof the tape, which during the upward

^"^"^^fment are held to the sides of the rod by

"*^ oj»enitor's hand, and )>y shaking the rod, the instrument is easily

^^^^■'^hed^ and can be withdrawn without ditficulty.

If the operator does not care to release the foot, because of the

tk&

Fid. 17t,— Bniuii*8 roixMitof.

376

OBSTETRIO SURGERT.

difSculties he has enooantered in getting possession of it, the fillet may
be noosed around his arm, and thence be pushed upward oyer the
hatid, to the seised extremity.

A deyice, which in many instances has rendered
me excellent seryice, has consisted of an ordina-
ry catheter threaded with a doubled piece of twine,
so that the loop projected from the eye of the in-
strument This loop, after inserting the stylet
into the catheter, I have used in precisely the
manner laid down for the employment of Braun's
instrument.

In case the second limb can not be reached, or
where traction upon both extremities fails to bring
the breech into the cenrix, an attempt should
be m^e to dislodge and elevate the presenting

yl^ 1 1 \ shoulder. This can sometimes be accomplished,
\ \\ \ in accordance with the suggestion of Professor
V" \ \ Ooodell, by bringing down the upper arm, and
turning the child upon its long axis; or, while
F 178— c«th tar used ^^^ T^ooaei foot is held out of the way by the at-
as repositor. tached fillet, the hand corresponding to the child's

head may be introduced into the vagina, and em-
ployed to press the presenting part away from the cervix. The.
raising of the shoulder should be gradual, and should be performed
with the utmost gentleness, as the danger of uterine rupture is pecu-
liarly enhanced by the thinned, overstretched condition of the lower
segment. Meantime a skilled assistant should support the uterus
from without, and aid the descent of the breech by rightly directed
pressure. Resolution to succeed, combined with patience in manipu-
lation, usually overcomes the obstacles presented by the most difiScult
cases.

In the few instances where failure follows all attempts to accom-
plish version, or where rupture is imminent, or where the child is
known to be dead, the obstacle to delivery may be overcome by
decapitation, and the removal of the head and trui^ separately.

CRAXI0T0H7 AND SlIBRTOTOMY. 877

CHAPTER XXII.

CRANIOTOMY AND EMBRYOTOUT.

Craniotomy.— Indications. — Operation. — ^Perforators.— Metiiod of perforating. — ^Eztrao-
tion after perforation. — Forceps. — Cephaloiribe.— Action of the oephalotribe.-— Ob-
jections. — Application of the cephalotribe. — Cranioclast.— Crotchet and blunt hook.
— Cephalotomy. — Embryotomy.-— Exenteration. — ^Decapitation.

Gbaniotomy.

Gbakiotomt includes all the yarioos operations employed to
reduce the dimensions of the child's head. Thus the term is applied
— 1. To the perforation of the skull, and the evacuation of the brain-
contents; and, 2. To the yarious procedures subsequently adopted
to further minimize and extract the cranial walls.

Indications for Perforation. — Perforation is resorted to, in cases of
mechanical obstacles to delivery, to overcome the disproportion exist-
ing between the child's head and the parturient canal. As the opera-
tion is performed solely in the interests of the mother, it possesses a
wider range of applicability when the child is dead than when still
living.

Perforation, in the dead child, is allowable in difiScult labors so
soon as temporizing becomes dangerous to the mother. The mere
SBsthetic advantage of removing by forceps an unmutilated child
ought not, if attended by any risk, to be allowed to weigh with the
physician against the welfare and safety of the parent.

If the child is alive, the question of perforation is one of the most
serious that falls to the lot of the conscientious physician. If the life
of the mother is at stake, and the sacrifice of the child is necessary to
her preservation, few would dispute at the present day the superiority
of the mother's claim to existence. Still, it is not sentimentality to
feel that it is an awful thing to destroy a living child before a clear
conviction is reached that conservative measures, which hold out the
hope of preserving both lives, are of little or no avail. The proper
position, however, of craniotomy, between the CsBsarean section on the
one hand and forceps and version upon the other, will be discussed
in the section upon the treatment of contracted pelves.

Operation. — When perforation has once been decided upon, there
should be no delay in its execution. By delay, the very object of its
performance, viz., the preservation of the life of the mother^ is im-
periled.*

The patient should be placed in the usual obstetrical position,

* Spiegelberg states that between the years 1870 and 1877, of thirty-three cases of
perforation, three terminated fatally, while in the prerioos five years in which the opera-
tion was performed, at a late period, of thirteen cases, seven ended in death.— <** Hand*
bttch der Gebartshiilfe," p. 888.)

378

OBSTETEIC SUBGERY.

with the knees flexed, and the hips drawn over the edge of the
Chloroform is not requisite. It is useful, however, as a means of mi'

ing the mother from painful after-memories. If the head is not fixed
at the hrim, it should be held firmjy in position by the hands of &q
aseistant, through the abdominal walls, or the child should be tiinjedij
and perforation performed on the after-coming head.

Complete dilatation of the cervix is not essential to the exectttiaii)
of the operation. If the object is simply to relieve the maternal soft '
parts from pressure, perforation may be performed at an early stage
of labor. When, however, it is intended to follow perforation bj -
immediate extraction, it is necessary to secure sufficient preliminary!
dilatation. In just this class of cases I have seen excellent re«ulij
from the employment of Dr. I. E. Taylor's long, narrow-bladed kh\
ceps, which can be passed through a cervix dilated to scarcely an inclij
and a half in diameter. They enable the operator to seize the headJ
and use it as a dilating wedge during and after a pain (m'de p. 350)j
If the cervix hangs empty in the pelvis, and the head can not
moved from the brim, Barnes's dilators are often of great senric^*^
Unquestionably in many cases less violence is done to the mother, i^j
simple perforation is resorted to, the brain evacuated, and the di^^|
tation of the cervix left to be accomplished by the pressure of th^^
gradually collapsing head. This method, however, exposes the mothe^^
to the dangers of septic poisoning, as, unless the pains should be goo^^
and delivery rapid, decomposition of the foetus in uiero speedily \
in after perforation.

Instruments employed in Perforation.— Most of the perfor
instruments in use in this country are patterned, with modification
after the scisBors of Smellie, Simpson's perforator is the one I
have been in the habit of employing. As compression of the
dies causes the separation of the perforating points, it can be \
managed with one hand. The projecting shoulders, just beneafl
tlie cutting portions, prevent the instrument from penetrating too \

Ffo. 174.^Sd«OBi of fioiallk.

into the skull. The edges and points of the blades are rounded, so tl
they are not liable to injure the soft parts of the mother during
operation. The chief objection to the instrument arises out of tbe
Bpecial measures of safety^ asj owing to it^ bluntnesa, considerable

CRANIOTOMY AND EMBBTOTOMT.

379

force has to be employed to penetrate the skull, which increases, of
course, the risk of slipping. A better instrument is that of Monsieur
Blot. It possesses a spear-point, which makes it effective as a per-

175. — Simp8on'8 perforator.

forator. The blades, when the instrument is shut, are superimposed,
and are not capabto of harming the maternal tissues. When the blades

Fio. 176.— Blot'd perforator.

are separated, after perforation has been accomplished, they readily
cut the bony structure of the skull. Hodge's craniotomy scissors can

f lo. 177.— Hodge's oraniotomy Bciasora.

be used as a perforator, and afterward to cut away portions of bone.
Dr. T. G. Thomas has devised a perforator with a gimlet-like extrem-
ity, which is intended to bore its way into the skull. The opening is

Fio. 178.— Thomos'B perforator.

38a

OBSTETRIC SITRGERY.

afterward enlarged by a knife which lies concealed and guarded in the
lio«3y of the instrument until required for use. Mechanicallj consid-
ered, Thomas's perforator is beyond reproach. It is, however, some*
what more ditiieult to keep in order than those previously mentiotid.
The Germans employ for the most part a long trepbiuing perfc^
rator^ which removes circohir segments from the scalp and the skull

Fio. 17D.— TrepMno perforalor.

The trephine leaves behind no splintered portions of bones, and ]
an opening which is not likely to close from overlapping ; but itm,
on the other hand, be used only upon the cranial vault.

Previous to practicing craniotomy, the bladder and rectum should
be emptied- The operator introduces his middle and index fingers into
the vagina, and presses them firmly against the most accessible poN
tion of the child's head. Great care, at this stage, should be eierti^ed
to gain an exact idea of the situation and the extent of the dilatation
of the cervix. The operator then seizes the handle of the perforator
in the right hand, and passes the pointed extremity, under the guiJ-
ance of the fingers of the left hand, to the region of the head at which
it has been decided the perforation is to be made. If convenientt *
suture or a fontanelle may bo selected, in place of the bony table of
the skull. The perforator should be pressed against the cranium with
a boring movement until the cessation of resistance warns the operator
that the bony incasement has been traversed. In cades where
skttll is unusually thick or hard, this part of the operation mav pr
a matter of some difficulty. Care should be taken to hold the in^
ment at right angles to the point of perforation, as otherwise it is i
to glance from the rounded surface of the head*

If the head, in place of being fixed in the pelvis^ is situated high
up, every precaution should be taken in the operation. The head
should be pressed firmly against the brim through the abdomen by afl_
assistant The perforator should follow the axis of the superior at
The point selected for perforation should be near the symphyaisij
the instrument is then much less liable to slip than if CArriod
ward toward the promontory. The fingers of the left hand fiho
keep constant guard upon its direction. Oftentimes, by way of
tection, the operator introducea the entire half-hand into the
After the perforator has penetrated the skull, the opening should '

CRANIOTOMT AND KMBRYOTOMY.

381

enlarged by compressing the handles and separating the cutting
blades ; then, allowing the latter to close, the instrument should be
semi-rotated, and a second cut made at right angles to the first. Be-

Fio. ISO.^Opention for perfomdng the child's hetd.

fore withdrawing the perforator, it should be moved about freely to
break up the brain-mass. The rapidity and completeness of the col-
lapse of the cranial walls are, in a measure, dependent upon the com-
pleteness of the evacuation of the cranial contents. Care too should
be taken to pass the perforator into the foramen magnum to break up
the medulla oblongata, and thus to insure the death of the child
before delivery. Sometimes it is advantageous to wash out the brain-
pulp by injecting a stream of water into the cranial cavity.*

In face presentations care should be taken to pass the perforator
through the frontal bones, or through an orbit. Where neither of

* Von Weber has shoim that no oephalotribe can folly decerebrate a perforated
bead, in general only the smaU part of the brain being eTacoated. He has likewiae demon-
itrated that a greater amount of compression can be aooomplished in case of a fully than
a partially decerebrated head. The head, therefore, that has been fully emptied can be
more easily extracted than one that has only been parttaUy deprived of its contents.

382 OBSTRTRIG SURGERY.

these points is, however, accessible, it is possible to make the open*'
ing through the roof of the month, behind the nasal fosssB.

The perforation of the after-coming head is always a matter of
considerable difficulty. The point of the perforator has to be inserted
obliquely in place of at right angles to the skull, and therefore is more
liable to glance. On theoretical grounds it has been recommended to
insert the instrument either between the occiput and atlas, or through
a lateral fontanelle. In practice, however, such niceties are rarely
observed. The operator simply passes the four fingers of the left
hand under the symphysis pubis, and, while the feet of the child are
drawn downward and backward by an assistant, the perforation is
made at any point behind the ear at which the manipulation can be
most easily effected. Chailly recommends hooking do?m the chin of
the child, and perforating, as in face presentations, through the roof
of the mouth.*

The trephine*perforator requires to be pressed firmly and steadily
against the parietal bone. Sometimes, when a large scalp-tumor
exists, it is necessary to make a preliminary incision through the
integuments. The trephine is not liable to slip, and is easily man-
aged ; as it can not be used either upon' the after-coming head or in
face presentations, and as it is difficult to keep clean and in order, the
less complicated lance-pointed instruments have, however, enjoyed the
preference in all countries outside of (Germany.

Extraction of the Child after Perforation.— Formerly, after per-
foration, a waiting policy was by many thought desirable. Osborne,
indeed, recommended that at least thirty hours be allowed to elapse
before delivery, in case craniotomy was performed upon a living child.
The grounds for favoring a temporizing policy were found in the
softening and relaxation of the sutures, and the ease with which flat-
tening takes place after putrefaction has once set in. At present,
however, it is customary to extract so soon as the condition of the os
renders it safe to resort to the necessary operative procedures. This
change in practice results from altered views regarding the dangers
due to mere protraction of labor, to fear of septic poisoning, and
finally to improved methods now at our disposal for the termination
of labor. Extraction may be performed by the forceps, the cepha-
lotribe, the cranioclast, the crotchet, or the blunt hook. In some
cases version may be employed with success. Each instrument, each
method, has its limitations, and its range of applicability. Usually, in
extreme disproportion, the operator finds it to his advantage to have

* Cohnstein recommendfl cuttfDg down upon the oerdcal and upper dorsal Tertebne,
and then opening into the spinal canal bj dividing the laminsD. Through the opening a
silTer catheter can be passed to the cranial cavity, and be used to break up the brain-
mass, which should be washed out through the canal by injections of water.-H( Vide ** Sin
neues Porforations Yerfahren," ** Arch. f. Oynaek./' Bd. vi, p. 606.)

CRANIOTOMY AND EMBBYOTOMY. 883

at hand a complete eqnipment, and to resort at different stages of
deliyerj to a sucoession of operative manoeuyres. The acceptance of
single measures and the wholesale condemnation of all others are cal-
culated in difficult cases to lead to embarrassment and failure. A
study, therefore, of the capacity of the rarious extractive instruments
employed to deliver the perforated head is essential to the formation
of correct judgment as regards practice.

Forceps. — The use of forceps as an extractive instrument, after per-
foration, is recommended by Tarnier as follows : " As the application
of forceps has often succeeded in our hands, we do not hesitate to say
that it is a good operation, applicable above all to cases in which the
pelvic contraction is not considerable. The forceps possesses the ad-
vantage of being in the hands of every physician ; it seizes the head
firmly, and, by pressing fche handles forcibly together, a sufficient evac-
uation of the cerebral contents is effected to secure a marked flattening
of the cranial walls. In making prudent tractions, one often succeeds
in extracting the head without any harm to the mother ; the danger
begins only with too violent tractions."* These remarks apply, how-
ever, to the powerful French forceps, which is capable of exerting
considerable compressive force. Hodge has found his forceps useful
under similar conditions, f The short handles and the great width
between the blades, in the English forceps, render it useless as a trac-
tor when craniotomy has been performed.

Cephalotribe. — On the 6th of June, 1829, Baudelocque, le neveu,
read before the Institut Royal de France a memoir upon a new method
of performing embryotomy. { He first pictured the dangers incident
to all operations effected with pointed and sharp-edged instruments
introduced within the uterus. From the statistics of the previous
sixteen and a half years in the ** Maternity," he showed that half the
mothers thus operated upon died, and that the shortest of these opera-
tions lasted three quarters of an hour. He then described an instru-
ment he had invented, which he termed the cephalotribe, and repre-
sented that with it he could crush in an instant the base and parietes
of the fetal skull, forcing the brain from the orbits, the nostrils, and
the mouth, the integuments at the same time remaining intact and
forming a sort of sac, which sufficed to prevent the edges of the fract-
. ured bones from inflicting injury upon the soft parts of the mother.
The author furthermore expressed his conviction that the cephalotribe
was destined to abolish and replace the perforator and the crotchet,
and that it could be employed successfully in pelves measuring but
two inches in the contracted diameter.

This early instrument was two feet long, and weighed over seven

♦ Tarnikb, " Diet de Medicine et de Chirorgie," art. " Embryotomie,'* vol. xii, p. fl«7.
t HonsB, '*0n GompreBrion of the Fetal Head," ** Am. Jour, of Obstet," May, 1S75.
t A. BAVVKJOcquKj ^'Bevite Mdd.,'* Aognat, 1829, p. 821.

384

OBSTETRIC SURGERY,

pounds; In shape it resembled the forceps* To the handles a enuik
waa attached, destined to approximate the enormous blades to one
another. The original cephalotribe has since been subjected to van-
ous modificationSj with a view chiefly to the removal of its repulgive
appearance* The observation of Chailly, in his "Traite pratiqae des
accouchementa/* 1842, that perforation should always precede cephft-
lotripsy, led spociully to the construction of lighter and more conven-
ient instruments. The dream of Baudclocque, that the cephalotribe
was destined to abolish the |)erf orator, has never been fill tilled.

The models in use at the present day vary considerably in weight,
the extent of the pelvic and cranial curves, and the character of the
apparatus for producing compression. These different varieties are
simply expressions of the defective working of the instrument itself.
The shape of the blades possesses the greatest importance practically.
It is to be borne in mind that the cephalotribe is designed to act both
as a crusher and as a tractor. Now, it so happens that whatsoever
tends to make it available in the one direction is obtainable only by
the sacrifice of some corres}>ondi ng advantaf,^e in the other. Thus, it id
evident that the greatest amount of crushing force is exercised whet^
the blades run nearly parallel to one another ; but, without a cranial
curvcy the bhides, in place of being a]iplied to the convexity of th^
child's head, open like scissors, and thus are liable to slip, if the in-^
strument is employed as a tractor. Again, as the blades are usually"
applied in the transverse or in an oblique diameter, it is necessary to
rotate the cephalotribe to make the flattened head correspond to th^
flattened pehic diameter. Rotation of the cephalotribe within tht^
genital organs necessitates an instrument without pelvic curve; and^
yet, where there is any considerable projection of the promontory, ^
straight instrument is apt to seize the head upon lis posterior aspect^-^
only, and thus the head is often forced from the blades, when com-
pression is used, like a cherry*pit, to use Cazeaux's simile^ from be-
tween the fingers.

Fio, 181.— Cephalotiibo of Blot.

Fig. 181 represents the French instrument of Blot, which is pro-
Tided with a good i>elvic curve, but the blades are in close approxima-

CRANIOTOMY AND EMBRYOTOMY.

385

tion to one another. In Scanzoni's cephalotribe, Pig. 182, the line of
greatest difference between the outer Burfaces of the blades is nearly
two inches. The inner surface of the blades is supplied with a longi-

Fia. 182.--Gephalotribe of SoioionL

tudinal ridge occupying the center, while the square extremities curve
sharply inward like pincers. The instrument possesses a pelvic curve
of two and three quarters inches. When the Scanzoni cephalotribe is
applied to the sides of the decerebrated head, the latter lengthens in
the axis of the instrument, but Mund£ reports that he has witnessed
the failure of the instrument to seize the head securely in the Wurz-
burg clinic, in three cases out of four. Pig. 183 represents a cephalo-
tribe made for me some years ago by Messrs. Tiemann & Co., which
has met with considerable favor in Ne^ York and its vicinity. It has
a cephalic curve of two inches and a quarter, measuring from the
outer surfaces of the blades.* The pelvic curve is three inches and

Fio. 188.— The author's cephalotribe.

two lines in extent. These measurements are similar to those of the
Prague instruments of Seyfert and Breisky. The blades are fenes-
trated and grooved upon the inner surfaces. The advantages of an in-
strument thus modeled are obvious. It is possible with its aid to seize
the head when movable above the pelvic brim. As the points ap-
proach each other closely after compression of the head is completeld,

* The advantages of making the blades parallel to one another are rather apparent
than real ; for, howeTer effectively compression with such an instrument may be applied,
the head acts as a wedge, producing a separation at the extremities proportioned to the
absence of the cephalic curve. Breisky and Seyfert have insisted that it is better to
transfer the greatest width between the blades from the extremities to the points at which
they oome into immediate contact with the child's head.
26

OBSTETRIC SURGERT.

the instrument becomes a perfect tra<;tor, holding the head as seci
as an ordinary forceps. Its construction is, however, virtuallj
abandonment of two favorite but chimerical ideas regarding the ca^
pacity and mode of action of the cephalotribe, viz., that it is C4ipable
of flattening the liead m that the latter can be drawn through a pel^
measuring but two inches in the conjugate diameter, and that
can be accomplished by rotating the instrument, as we have m<
tioned, m as to make the flattened head correspond to the Bhorteoed
diameter of the pelvis.

able

Tho actna] result of compression bj means of the cephalotribe was long
matter of dispute. Baudelocque^ with hh poDderous instrameDt, cUlmed
have been able to instantly crwsh the skull, incloding the base. Kilian* rel
that in his ihtit case of cephalotripsj lie succeeded in breaking up the skull
a ainjfle application into fifty-four piecea. Von Weber, however, made t largi?
number of expcrimeDta upon still-born children, emj^Joying for purp096$ tffooD-
parison instrtiracnts of varioiis patterns, and found that in no case did benw-
oeed in fracturing the bone^^ of the gkull. Even nfter the complete evacQitioa
of the cerebral contents the bones would bend, but did not fracture. The rerolt
was different, however, in casea where the cephalotribe was employed in <»et<
labor, where the head waa subjected at the same time to pressure from the ul
rine and pelvic walls. Under such circumstanc-es the bones certainly may bi
if they do not invariably. Fractures he found, in fact, less common than »m)/k
incurvations. Where a fracture took place in one bone it rarely extended W
contiguous ones, and, in general, contributed but little toward the actaal redae-
tion of the head, Winekel t presented tlireo heads to the Obstetrical Sodelj
Berlin, upon which the ceplialotribe had been used to facilitate delivery. C<
pression, in these cases, had been employed iu several diameters, and each tti
the cracking sound elicited could have led one to suppose that the bonoi wi
being reduced to small pieces, yet suhncquent examination showed that oalj
single bone, and that, usually, according to the position of the head, a pariet«l
bone, was bniken to any extent, while the opposite side, generally the hs»
cranii, was but sUghlly ruptured. Now, the greatest amount of corapneasion
effei'ted by the ccphalolrihe does not exceed two to two and a quarter iocbefc
The bizygomatic diameter, indeed, which measures three uchea, is not, id
dinary cephalotripsy, attacked at all4

It has always been objected to the cephalotribe that its application in
transveri^e diiimeter increases the length of the bead in the antero^post^
diameter, or precisely where the pelvis is the narroweit, and thos adds to
difficulty of delivery. This is no doubt true when the head is fixed in the pel
a fact which should lead ns to give the preference to other instrnments for
traction after engagement hm taken place. Above the brim, the ceplialol
seizes the head usually in an oblique diameter, so that the compensation t
place in the opposite oblique diameter. If the hea<i is seized in the tranfrei
diameter, it may easily be rotated into an obH^ue diameter. Sometime*

♦ KiUAN, ** Orf^an f. die gesammt. Mcdecia," Bd. ii, p. 279.
t WiNCKEL, **KepliaIotripsic/' *' Monntsschr, t Geburtsk.," Bd. xxi, p. 81.
t Fritscb, " Der Ke|>halothryptor and nr&un'a Cnmioelast," Volktuami'i '*Sb
klin. Vortr./* Ko. 127, p. 870.

CRANIOTOMY AND EMBRYOTOMY. 387

oompreflBed head rotates spontaneonslj^ so that the cephalotribe comes to occupy
the oonjngate, a thing obviously possible oulj in moderate degrees of contrac-
tion. Artificial rotation of the cephalotribe into the ooigugate is dangerous and
shonld nnder no circumstances be attempted. It mast he borne in mind that
the axis of the instrument is in a line between the upper border of one blade
and the lower border of the other, and not in one drawn transversely between
them. If spontaneous rotation occurs, the instrument should be removed, and
the cranioclast employed as a tractor. Extraction with a powerful instrument
like the cephalotribe can not be safely undertaken when the points of pressure
from the blades are the soft tissues between the symphysis and promontory.

Thus we find the cephalotribe nsefal in compressing the head
before it becomes fixed at the brim. It is, moFeover, advantageons
as a tractor in moderate degrees of pelvic contraction. With two and
three quarters inches in the conjugate, the limit for its safe employ-
ment is, as a rule, reached. Of course it is understood that other
factors than the pelvic diameters may influence the result. Thus,
much depends upon the size of the child's head, the resiliency of the
cranial bones, and the relations of the pelvic diameters to one another.
It is not disputed that the cephalotribe is capable, if force is used, of
accomplishing delivery through a smaller space than the one given,
but the severe injuries to the maternal tissues which the instrument is
apt to inflict, even when every caution is exercised, make its employ-
ment dangerous in the higher degrees of pelvic deformity.

In 1668 Pajot* published a paper in which he stated that, while in cases of
distortion, in which the narrowing did not exceed two and a half inches, cepha-
lotripsy was a favorable operation, requiring the exercise of no great amount of
force, and but two or three applications of the instrument, below that point he
regarded it as nearly as dangerous as the GflBsarean section. In the belief that
these results were due to rude attempts to drag an imperfectly reduced head
through the contracted space, he proposed that in all cases below two and a half
inches no tractions should be made, but, so soon as dilatation had proceeded far
enough to permit, perforation should be performed, whereupon complete dilata-
tion would occur more speedily, and cephalotripsy might be begun at an early
period of labor — a point in itself of considerable importance. While applying the
cephalotribe, one or two assistants should make counter-pressure over the pubes
to steady the head. The blades shonld be introduced as high as possible by de-
pressing the handles. After compressmg the head, rotation, if it has not occurred
spontaneously, should be cautiously attempted. The slightest obstacle should,
however, be the signal for suspending rotation and withdrawing the instrument,
when Nature usually brings about rotation with astonishing rapidity. The
instrument should then be reapplied, and the compression repeated. The same
process should be gone through with a third time, after which the woman
should be placed in a convenient posture, and given bouillon to drink. Then,
governed by the state of the pulse and the general appearance of the patient,
the quiet or excitement manifested, the weak or energetic character of the pains,
the cephalotribe should be applied two or three times every two, three, or four

* Fajot, '«De U c^phalotripsie r^p4t^ sans tractions,** Faris, 1863.

388 OBSTETRIC SURGERY.

honn, leaving the ezpnlgion of the foBtuB entirelj to Nature. M. P^ot has noTer
found more Uian fonr applioationa of this procedure necessary, while one or two
have generally sufficed. After the passage of the head, one or two applications
of the instrument are required, as a rule, to reduce the thorax. To he success-
ful, however, it is requisite that the operation should be resorted to at an early
period of labor, when, as a rule, not more than »z to eighteen hours are needed
for Nature to expel the uterine contents. Tractions should be employed only
in those cases to which one is called at a late period, after the powers of Nature
are exhausted. Objections to this plan of Piyot have been made as follows :
That there is risk of rupture of the nterus from the prolongation of the labor ;
that the uterus is exposed to injury from the spiculsa at the point of perforation ;
that, owing to the great rapidity with which decomposition takes place after
cephalotripsy, the bones of the skull are liable to become denuded of their cov-
erings; and, finally, that after a given period the membranes become so far
destroyed as no longer to protect the uterus from its decomposing contents.
Pajot replies by adducmg seven cases in which he employed his method. Five
of the cases were successful, and two terminated fatally. The highest degree
of deformity for which he operated was a case in which the contracted diam-
eter was something less than an inch and a half. The patient died from
ruptured uterus, due, according to M. P%jot, to attempts made previous to his
arrival to perform cephalotripsy with a badly constructed instrument. The
method of M. Pigot has never won the approbation of the profession, but, in
the absence of the necessary instruments to execute other preferable manoeuvres,
the success of its author recommends it for trial.

The application of the cephalotribe does not differ from that of
the forceps. Where perforation has been performed, spiculs of bone
should be carefully remoyed with the fingers. Confirmatory evidence
as to the direction of the head may be obtained by exploring the cra-
nial cavity with the finger, as, in this way, the exact position of the
base and vault may be determined. Great caution should be exer-
cised during the introduction of the blades not to injure the vaginal
or uterine tissues. It is not always easy to lock tlie instrument after
the blades have been adjusted. The left blade is easily placed, but
often the right blade is with difficulty brought forward to the cor-
responding transverse or oblique diameter. Compression should be
made slowly, and the opening made by the perforator should be care-
fully guarded lest cutting portions of bone protrude. Extraction
should take place under the guidance and protection of the fingers of
the left hand.

Sometimes the cephalotribe is used to compress and extract the
after-coming head in cases of moderate pelvic contraction. Under
such circumstances perforation is usually not a prerequisite. The
cephalotribe seizes the head securely, and acts with great power upon
the basis cranii. The increased diameters of the head accommodate
themselves more readily, too, to the long diameters of the pelvis than
in cranial presentations. When the head is retained in the uterus
after it has become detached from the body, it should be held by an

CRAKIOTOMY AND EMBEYOTOMT,

389

Btant through the abdominal walls, and steadied by a crotchet
introduced into the foramen magnnm, or fixed into an orbit, or in the
lower jaw. The cephalotribe may then be
applied to complete the extraction,

Cranioclast, — It is necessary to distin-
guish between two instrument^?, each of
wbich beiurs the name of cranioclast. The
original model was the device of Sir J. Y,
Simpson, and was intended by him to
:?f>lace the cephalotribe. It is substan-
tially a powerful pair of craniotomy-for*
cepg. The larger blade, which is intended
to be placed upon the outer surface of the
homA, m fenestrated and grooved. The
^ttialler one^ for introduction into the per-

^^«ated skull, is solid and supplied with

•*i^gei which fit into tlie grooves upon

^*^« apposite blade. The two blades artic-

**^liite by means of a button-lock. By a

^"^nsting movement, the cranioclast, when

^tiplied, can be employed to wrench oil the

^«jne3 of the calvarium, different portions

^t the ekull being seized successively with

^•iie riew of accomplishing that result As

^lie fractuied bones are covered by the

^salpt they are prevented from inflicting

^tijary during the subsequent course of de-
livery. But the cranioclast is not only of

*tlse in breaking up the cranial vault, it ia

likewise the most effective of all the in-

%tnuiients employed for extraction of the

Jierforated head.

The principal defect of the Simpson

fsnnioclast is that it attempts to combine Fio. iS4.—Biu]pson^» cranioclast.

in the same instrument the functions of

orueher and tractor. Now, as in the cephalotribe, the devices which

xniake it the most effective instrument in the one direction weaken

ltd utility in the other, Braun's modified cranioclast is intended to
serve purely m a tractor. All idea of its undertaking to break up the
ektiU ifl discarded. The work of compression and disarticulation is
left to the counter-pressure of the pelvic walls» and to the employ-
ment of craniotomy-forceps and the cephalotribe. The terra cranio
oelast is therefore a misnomer. Munde's proposed substitute of