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CopnuaarsD 1882.
Bt GBOSS & DELBBIDGE;
JUrighUnterved,
JimOBUTT, BEHKUXa k CO.^ KLICniOTTFERS, CRICAQO.
0. R. blahuhx^ ft oo.( prihtkrs.
CHICAOO.
ANDSBSOIT, BANBEI? * CO., BINDERS.
CHICAGO.
■ • • .• • •
: •::;: .V.
••• •••• •• •••
TO
PROF. R. LUDLAM.
In ooDsideratioii of your high attainments as a gyn-
aoologist and obstetrician; in acknowledgement of your many
UlidneBaes; and as a token of tiigk personal regard^
THIS BOOK IS DEDICATED TO YOD.
Whateyer of merit it possesses is in great measure attrib-
utable to you, inasmuch as it would never have appeared bat
for your wise advice and hearty encouragement
That the work as completed may receive your endorsement,
is the fond hope of
The Authob.
Chicago, Oct 20th, 1882.
66987
PREFACE.
1 have beeu prompted to prepure this work by a conviction of
the existence of an tirgent demanii for a treatise on the Science
Rud Art of Obstetrica, in our School of Medicine, which should
emboiiy the advance*; recently laade, and set forth the distinctive
characters of oiu* therapeutics in a rational and practical manner.
Treatment in obstetrical practice in a great menaure is me-
chanical, and does not involve the extensive application of thera-
peutioAl resources. It is true that by the jutUci(.)ua use of
Lomwojtfithic remedies labvn* may often be divest^nl of its patho-
logieul features; yet we must beware of expecting too much.
We cannot reasonably hoi>e to ilex an extended fuetal head, to
amplify i)elvic diameters, to reduce iiitra-uterinc* hydi'ocephalus,
to effect version, or to arrest uiiuvoidabie hemon-hage by the
most carefully afliliated remedy; and the sooner the ejihcro of
reme«li^*d action can l)e settled, the 1>etter for us and the prin-
ciples which we represent Tlie vautage-grovind which we hold
consists in lair ability to reduce the number of cases demand-
ing interft-reiifo to a minimum, and to remove from the path-
way of the partui'ient and pueri)eral woman all unnecessary diffi-
culty and danger.
In preparing u practical and reliable work of this kind, it is
always found necessary to draw largely from the wnting and
ex]>erieni^ of c)tlier8. In doing so, I have endeavored to award
doe recognition, and have sought to appropriate only the most
Tsloable and practical trutlis.
(i.)
Thougli the matter has been prepared with the greatest care,
important omissions and glaring errors will doubtless be dis-
covered; on account of which, in advance, I implore the read-
er's most gracious forbeco'ance.
To numerous friends I would return my hearty thanks for the
many aids and encouragements afforded; and to my enterprising
publishers, for their excellent and energetic performance of the
mechanical part of the work.
SHELDON LEAVITT, M. D.
CHiCAab, Oct 20th. 1889
CONTENTS.
PART I.
AMATOMY AUD PHYSIOLOGY OF THE FEMALE
ORGAKS.
CHAPTEB I
QENEBATIVE
rAOa
. 26
TwBcHm OF THE rEL\ns ...
General form uf Ihe IVIvi». — The os InnoTuinatam: — iw nutcr surface.
— its inner surface. — The iw Ilium. — The as IflchiouL — The o»
PobiA. — The Sacram. — The Coccyx.
CHAPTEf{ 11.
TgK Pelvic Abticulationb ...... 32
The HyraphvsU Puhia.— The Sacro-iliju? SynchondroseJi. — Mechuuicol
iCrlation^ of the Sttcrum- — The t^ui-TotJocicygciil Joint. — Ahntirmal
Ueviatious.— The Pelvic Ligauieuu- — Movcmeut*! of the Pelvic
Articulations. — The I'elviBas a WhoU*.— Mt-Murementa of the Pel-
Tia. — Int'linnMon of the PelviH. — Hori^^ontal l'lan<'« of the PeU'is. —
Axis of thf PortUTieut ^'uunl. — The InclinnI Planes. — Male and
Fcsuale Pelvis.
CHAPTER III.
Tub PfcMAi.c External GENKRATiVE Oroans . .47
Ihrtaion Ar<*onlinp to Fiim-tion und Situation —The Monst Venerhi. —
The V'ulvn.— The Clilorii*. — The Labia Minora.— The Vestibule. —
The ViiKiiittl Orifice.— The Hymen. — (iirum-tila' Myrtil'omies. — The
Fiwsa N'aviculuri^.— The S«cret4)ry Appjinitua.— The Vulvo-vagiuttl
Oluuda.— The Bulbi Ve»tibuli — The Vayimi,— The Ptfriueum.
CHAPTEU IV.
TlfK FrMALE ISTERXAL GeKICHATIVE OROAIfS . . . .61
The L'tcruB. — Tlie Pt*rine Li^uTuentn. — The Uterine Cavity, — Structnre
of the Uterus:— the miucular etructnre — the mncoiu nnrfacc — the
uterine KlHndB—tlif uterine vw*hH8 — the uterine nerves — the lym-
phatK-Ji. — Ahnorniulitu-» of the Uterus.
CHAPTER V.
TjW FtMALE IXTEBTiAi. GcNEBATivE Oroans.— fOmhnw^d) . 73
The Fallopian Tubv.- Tlie Ovariefl: the Graafian foLliclefl.— the OTule.
— ▼enels and nervw of the ovary. — The Intra-pelvic Muaclefi.—
The Mammary Glands.
(uL)
ir OONTENTS.
PART II.
PBEQNANC7.
CHAPTEK I.
Dktblopuent of the Ovum .83
The Corpus Lnteam of Menstraation. — The Cotpoa Lutenm of Preg-
nancy.— Migration of the Ovum.— Fecandation.— Course of Spermat-
ozoa to Point of Fecundation.— Changes in the Ovum after Fecun-
dation.— Souroee of Nouriahment. — iSe Chorion. — The Allantois. —
The Decidoa. — The Placenta: — general description — functions —
changes preparatory to separation.— The Umbilical Cord.— The
Liquor Amnii.
CHAPTER 11.
Development or the Embbvo and F(etus .101
• In the First Month. — Second Month.— Third Month.— Fourth Month. —
Fifth Month.— Sixth Month.— Seventh Month.— Eighth Month.—
Ninth Month. — Circulation of Blood in the Foetus.— The Cranium.
— The Sutures and Fontanelles.— Diameters of the Foetal Cranium.
— Heads of Male and Female Children. — Attitude, Presentation and
Position of the Foatos. — Presentations and their Causes. — Position.
— Diagnosis of Presentations and Positions.— Examination^ vagi-
nam. — Diagnosis of Presentation and Position by Abdominal Pal-
pation.— Diagnosis of Presentation and Position by Auscultation. —
Diagnosis of Twin Pretniancy by Auscultation.- Diagnosis of Sex
from Rapidity of Foetal Heart.
CHAPTER III.
Changes in the Matebnal Organism that abe Wbouoht by Pbbg-
NANCY ......... 125
uterine Changes : — in situation — inclination of its longitudinal axis-
cervical position — siae and texture of the cervix. — Vaginal and Vul-
var Changes. — Changes in the Mamme. — Other Tissue Changes. —
Abdominal Changes. — Relation of the Uterus to Surroundine Parts.
— Functional Disturbance of Keighboring Pelvic Organs. — Changes
in the Blood.— Formation of Osteophytes.- MiscellajQeous Changes.
—The Permanent Changes.
CHAPTER IV.
The DiAGNORisoF Prkgnancy .... . 139
Classification of the Signs. — Subjective and Objective Signs. — History of
theOase. — The Menstrual Flow. — Pregnancy in Women who do not
Menstruate. — " Mornini^ Sickness." — Unreliability of Subjective
Symptoms. — Menstruation During Prejniancy. — Objective Symp-
toms.— Inspection. — Palpation : — cervical softening — foetal move-
ments— abdominal enlarfcement — hatlottement. — Percussion. — Aus-
cultation :— the foetal heart — the uterine souflle.- Tabular Arrange-
ment of the Signs of Pregnancy. — Differential Diagnosis. — Diagno-
sis of Foetal Death.
CHAPTER V.
The Dubation of Pregnancy . .161
A Study of Comparative Physiology. — The Minimum. — The Maximum.
— Prediction of Date of Confinement : — the date of quickening — the
sixe of the uterus.
CONTENXa
CHAPTER VI.
ItetTDOCYBSIS ......... 159
F&be, Spurioiu or Phimtoni Pregnancy. — Condition* of Development. —
EUoIogy.— Symptoms.— Diagnosis.— Treatment.
CHAPTER VII.
The Patholoov of I'regkancy . . . . i$4
£xti%-at«nne Prcignancy : — ovarian — tubo-ovarian— abdominal — inter-
stitial- tubal.- Pregnancy in Rudimentary Comu of a One-homed
Uterus.— Rarer Vanelit.-« of Extru-Vterimr Pregnaney.— Uterine
Changes in Extra-Uterine Pregnancy —t?yniptoms.—TeVmiuution8,
— Diaipiosis.- Treatment : — in casen ofreevnt imprcynaf ion— puncture
of the 904' — injretions into the sac — elytrolouiy — use of electricity
— laparotomy- t«Af* oj advanced gratation, tfu-fcctM ttiHiivinff — cases
of gtMtation pTohttytd after death of fatus — gestation in bi-lobed ute-
nia. — Missed Labor: — treatmeul.
CHAPTER VIII.
The Patholoot oy PBBOKAi^cy:— < Ctyntinued.)
Premature Expulsion of the Ovum. — Predisposing Causes: — atrophy of
uterine mncoos membrane — hypertrophy of uterine miK-ons mem-
brane.— Proximate Causes : — hyi»enjcniin of the uterus. — Symiitoms!
early aliortions — later ubortious. — luc-<inij!lele Abt'rtion : — diajinusis
of incomplete abortion — mi-mbranefl ex]>elle(l. ta-tus retained — ex-
pnlsioD of one fa'tua in twin pregnancy. —Diuifnasis of Abortion. —
Prognosis — Treatment: — preventive irraiment — -promotive trratment : —
the taniimn — emptying the uterus— how to remove the secaudines
— fiatiseptic precuutiona — neglected
182
CHAPTER IX.
Patholoov op thk Decidva akd Ovitm ..... 206
Endomotriti.4. — Patholojry of Ihe Chorion: — hydatidiform drffencratton^^
canse**— symptoms and eourse — diagnosis- treatment.— Pntholopy of
the Placenta: — fonn — size — situation— degcnenil ions aud new foruio-
tiouH — other morbid elates — syphilis of the placenta— nTwpIexy and
inflammation. — Pathohipy of the Amnion: — hydrtimnios — etiolojiy—
signs and symptoms — diagnosis — progniieiM— t-fltet on labor — ireat-
nient — dejintncy of omitiottc jtuid — unomtiUe* of appenrnnee of the
/lyuorrtmwii.— Pathology of the Cord :— knots — torsion — (*oiling —
cysts— heniia- — calcareous de]><»Hiti# — stenowis* of vessels^aiiomalies
of insertion. — Pathology of Ihe Fu'tus :— infUimmiition» — blood dis-
eases transmitted through the mother — syphilis — measles and scar-
latina— malaria and lead poisoning — dropaii-si — effects of violt-nce —
intrauterine amputations — monstrosities — death and retvjiiion —
niummitirntion — mucerution. — Moles: — the mole of abortion — tho
fleshy male.
CHAPTER X.
Di&CAses AiCT> ArrrnENTS of PKEr.NAXrv .... 231
Hyirietie of Pregnancy. — Deningements of (he Pigestive System : — prog-
nosis— treatment — chance of hnbitation. air and scenery — local uter-
ine treatment — medicinal treatmcnt^the prodnction of al>ortion—
minor gastric disorders.— Pruritus.— Fai*e-ache.--Cei)halftlgiii.— Insom-
nia.— Awcmia:— treatment.- Albuminuria : — causes — effects — prog-
nosis— symptoms — treatment — advisability of induced labor.— Cho-
rea.—Hysteria. — Paralysis. — Syncope. — Painful Breasts.— Pain in
Tl
CONTENTS.
the Side. — Puiu in the Abdomen. — Leuoorrhoea. — Odontalgiik —
Crampa. — Inj uriea.
CHAPTER XI.
Diseases and accidkn'ts of Pbegnanl-y.— {CbM^imwrf.) . 236
Constipation.— Diorrhcpa. — Vesical Irritation. - Cough.— Dyspnoea. —
Uemurrboids. — Anti'versiun and Antellexiuu of the Uterue. — iietro-
TersioD and Xietroflvxiou of the L'tenw. — Prolapse of the Utenia. —
Hcruia of the (Iravid Uieraa. — Surgical Operations in Pregnancy. —
Cardiac Diseiutea. — Eruptive Fevers : — variola — scarlatina. — Contin-
ued Fevers. — Mahirial Fevers. — Pnciuuonia. — Phthisis. — Syphilis.
PART III.
LABOR.
CHAPTER I.
Causes op Labob '. . . . . . - .273
The Expelling Powers. — Tlie Uterine Contraelious. — InfluLnce of the
Pains of I*fllK>r on the Organwm. — C-ontractionsof the Uterine Liga-
ments.— The Vaginal Contractions. — Abdominal Aid.— The Pains of
LalHjr.
CHAPTER H.
CLIXICAL COITRSE OK Laboh, axi> Its Piikn'omena . . 383
The Stages of Labor. — False Lobor-paina.— The First Stage. — Tlie Mech-
anism of Dilatation. — The Second Stage. — The Third Stage.— Dura-
tion of Lalwr. — The Hour of Lnlwr. — Inflneuce uf the Tide on Par-
turition.
CHAPTER in.
The Manaoement or Normal Labor .....
Preliminary Arrangements. — Response to Calls. — Armninentarium. —
How to Approach the Patient. — The Examination.— Has Labor
Begun? — False Labor-pains. — Patient's Bed and Dreas. — Position of
the Patient. — The Ph^siciiiirs Attendanct; During the First .Stage. —
Bearing Down. — Treatment of the Mcntbranrs. -The Second tStoge.
— The Useof Antcstheiics. — Indications fur Interference, — Emptying
the HladdtT. — iTieareenition ol the Anterior Uterine Lip. — Support
of the Perineum. — Episiotomy. — Frequency of Pcriaeal Ku^iture. —
Varieties of Rupture.— Delivery of the Shoulders.— Treatment 01
the Cord:— early and late ligation.— The Thinl Stage.— C^red^'s
Method of Plaoentnl Delivery.- The Combined Metho<l.— Manual
Compression of the Uterus. Post-partum Care of the ^^oman. —
The Binder. — Therapeutics.
CHAPTER IV.
Use of Avasthbtics in Midwifkby Practice . . . .323
In Cases of Nortnal Labor.— In Operative Midwifery, — Eulea for Admin-
istering.
CHAPTER V.
The Mechan'tsm of Labor . , . .331
Various Positions of the Foetna.— Theory of Classification.— Basis ot
Clossiilctttiou. — Relative Frequency of Poeitinufi. — Points of Coinci-
CONTENTa ^^^ TU
leace Between the Varioua Positions: — vertex presentation — face
pretttltacioD — breech presentation.
CHAPTER VI.
Thx Mxchakisx of Labor. — [Continued.) ... .340
Vertex Pteeoatation. — Relative Freqnency of Vertex Present ations. —
Kelfttive Frequeuuy of First Po»itiou. — Condition at the Beginning
of Labor. — Mechanisni of the First Position: — descent and flexion —
direct descent — passage through the pelvis — rotation — paaaage
through tht! outlet— restilution—expuJsionut' the trunk.— Mechanism
of the Second Pneilion.— Mechunisni of Occipito-posterior Position^:
— bigD rotation — conversion iuto occipito-anierior po8iiion.s.- Caput
8uc<»daDeutn. — Couliguratiou of the Uead in Vertex Presentation.
CHAPTER VII.
Tut: Mechanism or Labor.— (CbnrinuMf.) . . . 35J
Face Prracntation. — Character of Labor. — Canses of Face Prfflentation.—
Relative Frequency of Positions.— Aleohnnisin of the First Position.
— descent and extension — rotation — Ilex ion. — Foriu of the CYa-
niiitn in Facti I*rcscntation. — Proj^jni^flm. — The Set-ond Positifin. —
Thiril and Fourth Pusitious. — Trciitment : — conversion into vertex
pit^eutatiuu — when the face does not en^a^e the brim — petaistent
meato-jKMtcrior positions.— Brow PretientattoD.
CHAPTER Vin.
ThS MethaKISM of LaboU.— (Continurtt.) ..... 365
Pelvic PresentatioD. — Fretiueucy. — ProKnoHis. — Causes of Ihfantile Mor-
tality.— Etiology. — Mechanistu of Firet and Second PoMtions of the
Breech : — descent— rotjition — eximlsiou. — Mechanism of the Third
and Fourth Positions. — Footliug PresMsntation. — Treatment of the
Anns in Head-last Caaes. — Brcathiny Space for the Fretus when the
Head is Reluined. -Forceps to the .\rter-coming He.id. — Form of the
Heud in Pelvic Presentation. — MnnaKcment of Pelvic Presentation.
--^Juestion of Cephalic Version.— Expulsion of the Truuk.—Extroc-
tidb of the Head.
CHAPTER IX.
MeCHAKism OF Labor. — {a»ii/iHi4«<l.) ... .374
^rse Presentation.— FTequeiicy.— Various Positions. — Cansea. —
oda. — Protjuoeis. — StHmlanfons Evolution. — SiHrnlaiit-ouH Ex-
IsioU: — Treatment :— favorable moment for o|K;ratin^ — prt-.serva-
tion of the memhrane.s -version.- Death of the Fu^iis.- l.'Huided
enuiuatiaiL — Com|ilex Pre.f<eniuuoiis ; — baud with the head — feet
hands — head, Imnd and foot.
CHAPTER X.
Labor UKxnKKEn DrFFirt'LT oh DANGEBotis by Anomalies of the
EXFELl.ENT F<mi'ES . . . .387
Pfccipilate Ijibor— rterine tnenia or Weak Labor : — causes — symptoms
— Irrntmcnt : -therapeutics — use of forceps in — third stage of labor
oomiilicaicd by iuerlta,
CHAPTER XL
OitsTKrcTEn nv Matehxai. Soft Parts . . . .-395
Kigi<lity of the Cervix Uteri :— symptoms — trfatmeni .-^ — use of dilators —
maniml dilatation^inciaion— use of the forceps — craaiotoniy — ther*
^m
CONTENTS.
apeatics. — Ut«riQe Tetaooid CVmstrittion i — cbaracter of the stricture
— diagnosis- Irerttnietit. - Agf^lutinuiion oi' the Kxtenml Uterine
Orifitt;. — Complete Ublitcraiion oi the Cervical Cuuul. — Tumelactjon
aud Iiirarcemliou ol' the Anterior Lip.— Cftninoniu ot the Cervix. —
Cauliflower Tumors of Uu- Ccrvix.^Tlirombus of the Vulva and
Vagina. — C'ystocelc. — Inipuctiun of Fceeei* iu the Kecluni.- Kieto-
cele. — Veskal Calculiw. — Difl'use Swelhu^. — Uuyieldiug iiyiuen. —
Uterine Polypi.— Tumors oflhe Oviiry.- KiKiJ I'erincum. — "Hotlen"
Periu^uiu. — treatmcHt : — iuimedialv periiiuuirhui)hy.
CHAPTEK XII.
Labor Oiwtrt cted by So.me Unitsual Condition of the Mateb-
NAL Osseous SxRrcTiiREs ..... . 4ia
Large Pelvis. — RymmetriraUy Contacted Pelvis.— Flattniod Pelvia —
Flattened, Generally Conlnit-ted. IVlvis, — Irnmihir Kntlutie and
Maltiecwlfon Pelvis.— Oldiqnely-Cont rat- ti.d Pelvis. — I'lntleniu^ of
the Saenini. — Kxag^eraled Curve of the Sneruni- Funuel-shaped
Pelvis. — InfiUltile Type of Pelvis*.— Detoniiities from Spimil Curva-
ture.— Kohert's Amhylosed and Trunsvirsely Contrjuted JVlvig. —
8|>ondylolisthotie Pelvis, — (l*;tco-.'4Jireonia and ExoMoKiJi.— Other
08Heou« Tiiinoi^ and Prouiiucnees.— .\lisenee ol tlie Synipbysis. —
Tho Chief CauM*.-* of !Vlvic* DeRmnity. — I'«*lvinietry-- Jnlltieuce ot
Pelvic Conrrartton on tht- rti-ruA Durinp Prt'^nnucy. — Intlnenet' nf
pelvic Contraelion ou Presfiilatiou. — IiiHneuee of Pelvie Contrac-
tion on I.,abijr-painfi. — Influcnec of Pelvic Contrpctimi on the Firft
Strt^e of Lahor— KtJert of Pressure on the Soft Tipsues.^Ffleet of
Pressure on theCliildV Heail. — Pnij;nosi8 of Pelvic Deformity.— In-
duction of Abortion in Kxtrenie ivfomiily. — [nduelion oj" j*rema-
ture Labor. -When to Intcrtere. Cases Wherein delivery oCa Liv-
ing ChiM is Pi*.-*ible. -Ca-M-s Wht-n-in a Living Cndd Cannot l>o
Boni.— Cjises Wherein Extraction Through the Natural l^aasages is
Impossible.
rilAn'KRXIIT,
Labor Rendeueu Diffk ri.T or Daxgkuoijh iiy .Some Uxusual Con-
IHTION OF TIIK FffiTlfH OR ITS APPENOAiiEs .... 433
Plural Pregnancy : — urnuigement of the niembnincfl — iy>nditinn8 attend-
ing development - miinanemeut of lirsl Itiith — dtlay after birth of
first child — Imked iwin.s— double mnnMers. Intra-l'lerine Il^dro-
cepakw: — diagnosis— head-last cases — tn':itni»*ni.- Hydrolhorax. —
Ascites and Vesical UistcUHion. — Other Abn<)rmalities :~crauial d©-
forniities^arge fcctuses— dorsal disjilacement orthearm.
CHAPTKk XIV,
Labor Renoered DrrnrrLT «»u nAXoERoi^s by Si)ME Unusual Con-
dition OF THE FfETrn OK ITS .\I'1'KM>A«KS— [ CoNflHUr//.) . . 447
Placenta Pncvia: — ^varietiea — fiviiueucy — rausea of the hemorrhage —
tivniptonis — diagnosis — prognosis — fntifmrut : — the qucM ion of favor-
ing fo'tal expuluiou -mcHlcs of prom<plin;: labor— evacuation of the
liquor amuii— the vaginal tampon — complete separation of the pla-
ceiUu — (lartial srparalinu— treatnunt whi-n the o» is either dilated
or dilatable. — Prolapw of the Funis ;— frequency — pronnosis — canaea
— sinnrt — h;w pulsation ceased — prevrntive treatment — postural
treatment— artificial reposition— Ircalnient when reposition fails. —
Accidental Hemorrhage :~il8 character — causes— varieties— symp-
toms of external hemorrhage — symptoms ofiutenuU hemorrhage —
treatment.
CHAPTER
OTUCS DimCCLTIBS ASt» DASQKJtH AjtlHltiQ IX THE FlBST AKD SbC-
ostD Stages op Lauor ...:...
Hupture of the Uteruii: — tteat and dwrocter — etiology — BymptoiuH —
Drognoeii* — rreolmm/ ;— conipurative ri'salte of varioua metbods,—
LAcetmtion of the Cervix. — Lacerution of the Vagina. — Liicerution
of the Vertibale.
477
CHAPTER XVI.
DiFricDLTiEs Axn Danoeks Arihino jn the Third Stage of Labor. 484
I'oBt-jiarUini lleuiorrhiigc— Causes. — Premonitory Symptotuft. — General
Symptniiw.— Sceondur^* Hemorrhage. — Prognoaia. - Treatment :—
hemorrha>:e of the fir«t degree — hemorrhage of the second dejfre© —
brmorrha^fe of the third clegr4*e — treatment of concealed hemorrhage
— hecondary hemorrhage— therapeutics.
JCHAPTEK XVII.
DlTnCTLTI E8 AKD DANGERS AKIBINO IN THE THIRD STAOB OF LaBOB.
—{CkmtintuH.) 501
Retained Plaeenta.— Actite Inversion of the Uterna i^caupes— symptoms
— ^iagnoeis — treatment. — Asphyxia Neouatitruni :— morbid ftnntnmy
— diagnosis and pri^iosif* — treatmt'vt : — Sylvester's method of urtiti-
eial reeplration — Mareball Hall's — Sclirteder's — Kchultze's — Uow-
Md'CL
CHAPTER XVin.
OlBCTXTBIC OPEBATIOVS
Indnction of Premature I>ahor ;^ rupture of the membranes — dilatation
ofjtheeervix — intra-uierine iujfctions — eathetvrizaliou of the uterus
— Kiwineh's douche — introduction of foreign bodies into the vagina.
— Induction of Abortion.
6U
CHAPTER XIX.
fTnwixo ........ 514
CooditiouA Calling for the Operation,— Favorable Conditions. — Cephalic
Version.— Podalic Version. — Combined Method. — The Internal
Metho«l.
CHAPTER XX.
FOBCKPfi .........
Hi»tory.— Tlie Short Fnroepe. — The Long Foreeiis. — Designatiooa of the
Bludra. — Action of the Foreeps. — Modeif nf Application: — the pelvic
— iJie (Tphalir.- f'onditions culling for the Forfe]j8. — The Prelimi-
narieH. — Tlie Applieutiou.—Traetion.— Removal.— Forceps in Occin-
jto-^iofttrrior Positions.— Forcep'4 iu Face Pre*ientotion. — Forceps in
Krvi-t-b Presentation. — Forceps to the Altei-coming Head.
535
CHAPTER XXI.
JIlXaBOtwrmiK IXSTUUME.N'ftt AXP 0PEft.iTItiN8
Th* Ve«-ti*— Tbr HInnt Hook- — Hypodermic Injections. — Catheterism.
— Transinsiou of Blood: Ihc immediate melhml— rhemicjU preven-
tloo of coagulation — deflbriuation of the blood.— TrausAision of
Hllk.
641
C0NTEKT8.
CHAPTEK XXII.
Opekatioxs Invoi-vino Destruction or the Fcirrrs . . 548
Craniotomy:— itJ5 sphvre — frequency of employment — inntntmrnU cm-
piotftii ; — the pcrl'iirator— Ihi- crotchet — craniotoni^' fon.-c|>8 — Ibe cm-
DioclAAt — the fi'phalolribe— fompnnitivf nieritnof cephulotri|isyand
craniocUisin — i.-omiKU-alive inerit« ureruniotomy and C'lcsiircan sec-
tion.— Embryotomy : — (lec:ipitution — extraction of th« ixnly aiidaub-
quunt delivery of the head- *-vi-«;erat ion.
CHAPTEK XXIII.
C.SBAUBA'S SECTIfiN — POHRO'S OPKBATION — LAPARO-ElYTROTOMT—
Rymphysotomy ..... 558
Cesarean Section on the Living Woman.— Cnuscs nC Diath after the Op-
eratioq. — American and En(ilif»h Stutistim. — Tht' t »peration. — lien-
oral Conftiderations. — Preliminaries, — Kxamiun^lious. — Form of the
Uterus. — Advisnltilily of Operalinn Early.— The Im'isi<sn».— Extriic-
tion of the ChihI. — Closure of the Wounds. -After-care of the Pa-
tient.— Post-mortrmCa'sareanSeclion. — Porro's Operation. — Laparo-
elytrotomy. — Symphysotoni.v.
PART IV.
TBE PVERPERAL STATE,
CHAPTER I.
Phksomeka and M.^n'auement of the Pt ebperal State . . 579
Mortality nf Childbirth. — Phenomena Suceeedinp delivery.— Post -par-
turn Blood Changes. — Pulse Changes. — Moi.*ture of the Skin.— Tem-
perature.— Uteriuo luvtduiion. — The E.xiretiot..*— Chanyes in I'tcr-
ine Mucous Menilmme. — Vairjnal Chanpfs. — Tlu; Lochiu.— The Ijic-
teal Swretion : -therapeutics. Means for Arresting the LarTeal Se-
cretion.— After-paint*. — Necessary Atteniiont^ tu Puerperal Women.
— The Physician's Visits. — Uegimeu. — The Bowels. — Time for Get-
ting Up. — Core of the Child.
CHAPTER II.
TnE Pl'ERPEBAL DlSEABEB .589
Fhle^natiia Dolen.«: — «ymptomK — etiology — patholopy— treatment. — Pu-
erperal Mania.— Puerperal Insanity.— Insanity of LociatioD.
CHAlTEK 111.
The PTERPEBAI.DlSEAaKS.— (CtfliflMMny.) ..... 590
Causes of Sudden Death During I^aUjr and the PneriH'ral State: — pul-
monary thrombosis and rniboHsni— iiyncope — death fnim entrance
of air into the veins.— Defeclivc Laoleal Secretion.- Depressed Nip-
ples.— Excessive Lacteal Secretion. — Sore NippU-s.^—Mastitis Puer-
peralis : — Htrncturea involved — nymptoms — causes — treatment.
CHAPTEK IV.
ThkPcerpebal Diseases.— I Omiinufrf I .....
Puerperal Eclampsia. — Etiology and Pathologj-.^^ymptoma. — Diairno-
sia. — ProKnobis. — Treatment : — preventive — curative — therapeutical
resources.
CONTENTS. a
CHAPTEK V.
THlPcrXBPEaAL DlSKASBS.— (CbiaintMd.) . . .617
PoerpeTal Fever. — (Puerperal Septicsmia, Sapnemia, Pysemia.)—
Pathological Anatomy. — Autogenitic Sepsis.—HeterogeDetic Sepsis:
cadaveric poiaoning — erysipelas — scarlatina — infection from other
pnerperal women. — Manner of Conveying the Contaginm. — Symp-
toms:— endometritis and endocolpitis — parametritis, perimetri-
tis and general peritonitis — septicemia, lymphatica and venosa —
pure septicaemia. — Preventive Treatment. — Curative Treatment. —
Palliative Treatment — Regimen.— Use of Antiseptic lo^jections. —
Belief of l^ympanites.— General Therapeutics.
LIST OF ILLUSTRATIONS.
norms. paok
1, The right os innominatiim,— outer surface, • • • • 26
2. The right o9 innomiiiatiim, — iuner surface, - - - . 27
The anterior surface of the sacrum, ---••- 31
"4. Section of the symphysis pubis, 82
6. Section through the left sacro-iliac articulation, - - - 83
6. Diagram showing the oscillatory movement of the sacrum, - 88
7. The articulated pelvis, 38
8. Sliowing the diameters of the superior strait, - - . - 39
9. Showing the diameters of the outlet, ------ 40
10. llanes and axis of the pelvis, 42
11. Pelvic angles, .-.--------43
lU. Numerous horizontal pelvic planes, and pelvic axis, - - 44
13. Axis of the entire partiuient canal, ------ 44
14. Section of pelvis,— inner surface, 45
lo. Male pelvis, -.---------45
16. Female pelvis, -----
17. lateral view of the erectile structures of the external generative
organs. --..-.----. 43
18. Tl»e external female generative organs, 49
19. Figure showing the hymen, -.-..., 51
90. Figure showing the hymen, --51
21. Vascular supply of vulva, ------.- 53
2i. The vagina (after removal of posterior wall.) - - - - 64
Si. Section of female pelvis, 56
^.M. Muscles of the perineimi, ----.-.-as
JB. The external aiul intenial generative organs, - - - - 60
S6. Anterior view of virgin uterus, --62
ft. Sectionsof virgin uterus, ..--.--- ei
SH. Muscular fibres of unimprepiiaied utenis, 65
29. Developed muscular lihn^s from the gravid uterus, - - - 66
80. Section of uterine mucous membrane, with glands, - - - 67
81. Arterial vessels in uterus ten days after deliver)-, - - - 68
Si. Xen'es of the uterus, ---------89
83 Uterus with double cavity, and slight deviation of form, - 70
(xiiL)
Xir LIST OF ILLDSTRATIONa
34. Uterus septus bilocularis, ..-.--.-71
85. Double uttnaa aud vagina, -------- 72
S6. Ovary and Fallopian tube, --------73
87. LongituiUnal section of an ovary, ------ 75
88. Portion of vertical sertion through ovary of bitch, - - - 76
89. Section of Graafian follicle, 77
40. Uterine and utero-ovarian veina, 78
41. Section of pelvia showing the pyramidal muscles, - - - 79
42. ilammary gUiud, ------..--81
43. Spermatozoa, .-_-,.--.. 97
44. Bifurcation of tubal canal, ------. .g9
4o. Stiige of segmentation *if the yolk, 90
46. Stage of segmentation of ilie yolk, -.--.- 90
47. Stage of segmentation of the yolk, - 90
48. External surface of ovum, slmwin^; area genninativa, - - 91
49. Stage of embiyouic development, 92
50. Stage of embryonic development, -•- - - - - -92
51. numan embryo at the third week, with chorionic villi, - - 93
5:2. ForiDaliou of the ilccidua reflexa, Ursfc stage, - - - - 95
ea. Fivrmatiini nf the decidua reflexa, compIet*'d, - - - - 95
64. Flap nfdecidiia retlexa turned down, disclosing the ovum, - 96
56. Placei.tiil villus, magnified, --__.-- 97
56. Fo'tal surfuce of the placenta, -98
57. U'terine surface of the placenta, 99
58. Section of uterus and placenta in the fifth month, - - - 100
59. Ovum and embno, -...----- 102
80. Ovum at live months, --------- 103
•61. Diagram of the f anal circulation, 108
62. The vertex, 109
63. Posterior view of the cranium, - - 109
64. Lateral view of fcetal liead, -- 110
«5. Attitude of fffitus in utero, HI
60. Situiilkm and surroundings of the fcettiB, 114
Hi. Fij^ire illuBtrating abdomiuid palpation, _ _ - - 117
Bti, Figure ilhistiiitiug abdominal pidi*iition, 117
HO. Figure illustrating abdominal palpation. - - - - ijs
70. Figure showing the U>cations of the f(etal heart-sounds, - - 119
71. Location of heart-sounds in linst position of the vertex, - 120
72. T^>catiou of heJirt-sounda in lirst iK»sition of the face, - - 120
73. Location of heart^sounds in first position of breech, - - 120
74. Location of heart-sounds in dorso-anterior position of trans-
verse presentation, '-- 120
75. Location of heart-sounds in twin pregnancy, - - - - 120
76. Cervix uteri at the end of third month, 128
77. Cenix uteri at the beginning of lifth month, - - - - 128
78. l^ulging of anterior uterine wall from pressure of fcetal head, 129
79. Cervix uteri at the end of eighth montli, 130
80. Cervix of a woman wlio died in ttie eighth month, • - - 180
81. Cervix uteri beyond the seventh month, ----- 181
Bl.
as.
97.
va.
9U.
101.
«».
KM.
106.
wr.
UK
loe.
IIU.
tti.
tt2.
US.
Ill
lU.
118.
IIT.
116.
U9.
ISO.
la.
ir
fc?
1.
u>,
lA.
127.
U55.
LIST OF ILLUSTEATIONS, XV
Appearance of the areola in pregnancy. - - - - - 133
l^iteral view of Uie enlarged aUlomeu at the sixth month, - \iA
Lateral view of the enlarged abdomen at the ninth mouth. - 134
J>ize of the uterus at various stages of pregnancy, - - - 158
Abdomihiil pregnancy. 16ft
A Uthopfl'iiion. .---_---__ jct
ntprstitial pregnancy, 167
Tubal pregnancy, ---169
Tubal pregnancy. 170
Pregnancy in a rudimentary comu, ------ 171
Ovum with imperfectly developed decidim, .... 184
Fterns with basis of a fibrinous polypus after an abortion, - 190
Tlieovum forceps, --------- 199
Sieman's intra-uterine curette, 302
Pirn's intra-uterine curette. 202
Vertical section of pelvis, showing uterus tliawu down witli
the volsella, 204
Loomis' placenta forceps, --. 205
Schnetter's jilacenla forceps. 206
Smalt hook and lever. 306
UvjKTlrophied decidua laid opei». -.---- goe
Uvdatidifoim mule, ---218
llydatidifurui mole, placental origiu. . . . - . 213
Fauy degi'ueralion nf the placeula, 219
Knot uf the umbilical citrd, 238
Knot of the umbilical cord, 235
Hernia of the cord, 227
Intra-uterine amputation. 230
Relative size and inclination of the uterus at the close of gesta-
tion, 258
Betrottexion nf the gravid uterus, 268
Soft nibber catheter. 201
The uterine mucous membrane. 275
Section of uterus, sliuwing fan us iu membraues, - - - ^85
Sri-tion of a Frozen body at the close of the first stage, - - 247
The piirltirH'tit canal. -------- - 288
Tiir titi-ruH and parturieul canal, fietus removetl, - - - 291
DiMensiou i»f the pcrineimi, 2113
Xoniud mode of separation and expulsion of the placenta, 2li/i
Modrof sepanition and expulsion of the placenta when tractitui
is made on t fie cord, -----••-- sns
TlievaginaJ touch. ----- 302
Method of perineal support, 31S
I ...... , -PS of the umbilical cord, 318
ire knot^ -.._-..-. ajg
' M^i. ^ method of placental deliver}'. ------ 321
Inversion of jdaccnta from traction on the cord, - - - ,^$22
Allis* ether Inhah'r, - 331
Cbuliolm's ether iulialer, 331
itf
xn
LIST OF ILLU8JBi.XI0NS.
129. First position of the vertex, - - ' - - ^ ^ - ZM
130. Second position of the vertex, ------- 8»4
131. Third position of the vertex. 334
132. Fourth position of the vertex, - 834
133. First position of tlie breecli, 835
134. Second position of tlie breech, ------- 335
136. Third position of the breech, --.------ 335
186. Fourth position of the breech, 335
137. Fonrtli position of the feet, -------- 330
138. Tiiird posititin of transverse presentation, - - . - 330
139. Second position of tranrfverse presentation, - . - - 337
140. First position of the vertex, ------- 33a
141. First position of the breech, 838
142. Second position of the vertex, ------- 339
143. Second position of the breech, ------- 339
144. First position of t!ip vertex, ------- 343
145. Lateral obliquity of llie head in the pelvic cavity, first position, 345
146. Leveni^e aetion of the fa*tal head, 346
147. Head approiu'hin(r llie Diitlel in the first position, - - . 347
148. The mechanism of labi>r in the Urst position, - - - - 347
149. Second position of the vertex, ------- 348
150. Third position of Uie vertex. ------- 349
151. Fourth pi>Bition of the vertex, ------- 349
152. Third i>o3ition of the vertex seen from above, - - - 350
153. Occipito-posterior lermiualiou of the third position of the ver-
tex, ------------ 351
l.W. Outline of fo'tal liead at birth, 354
155. Outline of fa*tal head four days after birth, - - - - 354
156. Form of the head in vertex presentation, ----- 355
157. Face presentation at the *)iitlet, nienttHposterior position, - 356
168. EngHgement of the liead in face presentation, - - - - 353
169. Meclianism of face presentjition, first position, - - - 359
160. Mento-anterior terniinnlion of face presentntiim, - - - 361
161. Diagram illustratiiij? .Sclmtz's method of converting face into
vertix prest^nlutions, -..---._-
162. Diagram illustrating Sclialz's method of converting face into
vertex presentations,, ---.-_.--
163. Diagram illustrating Schalz^s method of converting face into
vertex presentations, ---..---- 363
164. Menlo-posterior termination of labor, 3<34
105. Outline of heatl, broift- presentation, ------ 3»}5
166. First position of the breech, 363
167. Expulsion of the trunk in breech presentation, - - - - 368
168. Birth of the stioulders in lueech presentation, - - - 370
IfiO. Third position of the breech, 871
170. Completion of rotation and extraction of the head, - - 372
171. Footling presentntion. --- 373
172. Shape of the hea<l in pelvic presentation, - - - - 374
173. Ventral presentation, .-- 376
36^H
LIST OF ILLU8TBATI0N8. XYU
174. Section of uterus showing foetus in transyerae presentation
within the membranes, ---.--,■ 377
175. Dorso-anterior position of transverse presentation, - - 378
176. Dorso-posterior position of transverse presentation, - - - 379
177. Ann presentation, --_---,_■ ggo
vm. spontaneous expulsion, from a frozen specimen, - - - 381
179. Spontaneous expulsion, tirst starve, .-«... 862
18U. Spontaneous expulsion, second stage, ------ 883
181. Running noose on the foot, .--.-.- 887
UEL Complex presentation, ---------387
188. Cystooele obstructing lal>or, -...--. 404
184, Small cervical polypi, 407
185, Labor impeded by a uterine polypus, . • - - . 408
186, Labor impeded by ovarian tumor, -•--,- 409
1S7. The llattened pelvis, 414
188. ^lalacosteon pelvis, ---------- 415
189. Isabel Bedman's pelvis, -.--.... 416
100. Obliquely distorted pelvis, -.------ 417
191. Flattening of the sacnim, --..---- 4itj
IBS. Exaggerated sacral curve, -------- 418
19B. Robert's pelvis, --. 419
IW, Spondylolisthetic pelvis, - - -• 419
195. Pelvic exostosis, -.-,, 410
19H, (ireenhalgh's j>elvimeter, --- 403
197. Manual pelvimetry, -.------. 424
19& Change of cephalic form, from molding in ditScult head-last
cases, 430
198. Change of cephalic form, from molding in dilllcult head-last
cases, - 430
9N>. Transverse diameters of the bead, as viewed from above, - - 431
aoi. Molding of the head at the brim, 432
aOi Twins in utero, -- ---436
flua, ilead-lofking, -------.-. 433
AM. Uead-Iocking, 439
flix Double monster united laterally, ------ 440
atHj. Double monster imited anteriorly, ------ 441
917, llydrocephiilic head at the brim, ------ 443
anti. Jlydrorephalie head, front view, ------- 444
flj». Mode of perforating the head in pelvic presentations, - - +46
^0, Acrania. front view, -----.---- 445
fil. Acrania, lateral view, -.. 440
SIS. Dorsal dispUicement of the arm, 447
SIS. Varieties of placental implantation, ----- 449
214, O-nlral placenta pra?via, --------- 463
S15. Prohipse of Uie funis, --------- 466
tie. Incliualiou of the nterua in dorsal posture, ----- 469
217, Tostural treatment for prolapse of the funis, - - - - 470
218. Irregular uterine contra<'tion with retention of the placenta, - 502
_S19. Incipient inversion of the uterus, ------ 604
xnii
LIST OP ILLUSTRATIOHa,
220. Commencpment of inversion of the cervix uteri, - - - 504
221. Version by conjoint manipulation, first stage, * • - 518
222. Version by conjoint manipulation, second stage, - . - 6i9
223. Version by conjoint manipulation, third stage, ... aa)
224. Version in lieud prpsentation, -----.. 522
£25. Version in transverse presentation, ---.-- 523
22fi. L'ne of running noose on thefoot, - - - - - - 523
227. Tumingby the noose, 524
22M. ( 'liaml>erlen's forceps, --------- 525
229. Davis' forceps, ----. 526
280. Comstock'B forceps, ----- 527
231. Build's forceps, 627
2!i2. Simpson's forceps, .-.-• 53?
283. Elliot's forceps, - - 628
234. Hodge's forceps, 628
235. Hale's forceps, ---------- gaS
2S6. A'edder's forceps, 629
237. Leavitt's forceps, ------.--. 539
238. Taniier's forceps, - 680
2in>, Forceps at the brim, pelvic mode, ---.-- eai
240. Forceps in tlie cavity, cephalic mode, 532
241. Introduction of the Iift^t blade. 635
242* Showing tiow the bead is usually seized in the cephalic mode of
application, --- ___ 53^
243. Folding vectis, Wl
244. Ryeraon's vectia, ----- 542
245. Taylor's blunt hook, W3
240. Soft rnblier catheter, 644
247. Manner of holding the catheter, - 544
24«. Fryer's instnunent for Immediate transfusion, - - - 5j(j
24U. Allen's transfuser, 647
::o<J. The '-skin cup," 648
251. Tliomas' perforator, 65Q
252. Blot's perforator, ----- 651
253. Blunt hook and crotchet, 6S1
254. Thomas' craniotomy fon:epa, 651
255. Use of the craniotomy foR-eps, 552
256. Simpson's craniiwlast, -------- 553
SIT. Lusk's cephalotribe, --------- 654
258. Fretal head crushed by the cephalotribe, 554
259. Decapitating hook, 668
2(j0. Mode of ushig the decapitating hook, 557
2*il. The Oiesareaii operation, 660
2(i2. The clinical thermometer. -------- 675
203. Pulse and temperature diagram, 676
INTRODUCTION.
Dfar Doctor: —
If one physician more than another has an especial interest
in the publication of new and practical works on Obstetrics, it
is the busy gynaecologist, whose daily and nlniost hourly duty it
is to remedy the consequences of ignorant and nioddlesomo mid-
wifery. On this point alone, if there were no other, I am ready
li> congratulate you on the timely issue of your excellent treatise.
Through the more thorough education of the profession in this
important branch, it will be an honor U> the school from which
itoomes, ami also to our literature. Based uxkju your experience
in the obstetric clinic of our hospital, and iu private practice;
adapted to the real needs of the pupil and the practitioner;
abounding in reeoorces that are designed to anticipate and tn
■vert the risks of gestation and of parturition, your lxx)k is cer-
taizJy destined Uy be useful even beyond the scope that you have
marked out for it
Aa an old teacher of midwifery, who ia proud to have had the
training of »i> many excellent obstetriciaiiH, yourself included, I
am particularly pleased with the cleamesa antl the fullness ^vith
which you have given the obstetric anatomy of the pelvis and of
the foetal head, and with your treatment of the mechanism of
Inbor. These subjects are indispensable, and are more certain
to be thonjughly mastered if they are well presented by the
bctnrcr and the author. It should l>e indictable at the common
Wv for any one to pretend to the f\mction of an accoucheur who
(xix.)
XX
INTRODUCTION.
is ignornnt of the mechanism of labor, whether normal or ab-
normal. »
In your especial chapter upon the different presentations and
positions, the method of comparison and the means of illostra-
ti*m that you have employed, have put a very difficult subject in
a clear and practical light I know of zio author in any language
who is so free from confusing his readers in this regard. This
kind of instruction is the small coin that the practitioner will
need, and must carry witli him to tlie parturient chamber. If in
these matters **all mystery is defect/' and I believe it is, you
certainly deserve credit for your remarkable ploiimess and per-
spicuity.
In the light of recent and promising developments in the phys-
iology and pathology of pregnancy, as they are related to
obstetrics and gynecology, your discussion of this department
of your general subject has au added interest. Conception,
nidation, the formation of the decidun and of the placenta, the
growth of the embrj'o and then of the foetus, and the local and
general changes in tlie maternal organism consequent upon ges-
tation, are carefully considered, anil thoroughly illustrated by
the cuts that accompany the t«xt
The chapter on the attitude, presentation and position of the
foetus, with their diagnosis, is a fitting and excellent prelude to
the study of labor and its management. These pages abound in
the evidence of clinical drill and demonstration, and of a careful
study of the whole subject, with an idtimate desire to preserve
the result in a ready and available form. They embody the
teachings of the best obstetricians without the sacrifice o^ your
own individuality. The innovations are modest and suggestive,
and they will doubtless prove acceptable.
I am glad that in the treatment of the hsemorrhages incident
to delivery you have taken such pains as the subject really de-
mands. For it has seemed to me to be very wrong, not to say
INTRODUCTION.
XXl
criminal, to pass over this f earful contingeijcy so lightly as is the
custom with some of our mociern authors. Post-partum hamor-
rhages are always bad enough, bat iu their unavoidable and
accidental forms they deserve all the consideration that you
have given them. Our students and practitioners should be
forewarned and forearnie<l against them. Your text is in evi-
dence that my earnest preaching u^wn this subject in former
years has not been iu vain; and it will awaken the right kind of
&n echo among our responsible workers everywhere.
In operative midwifery, especially your treatment of the use
and application of the forceps, the indications and contra-
indications, the mechanism and mocius operandi of these instru-
ments, are very carefully and practically considered. The fact
that the forceps have been abused, and that iu the hands of the
ignorant they have wrought a great deal of mischief, is no argu-
ment against their intelligent and skillhil employment And the
fact that you have so often and so successfuHy applied them
apoD the living subject for the benefit of our college classes has
enabled you to put the matter all the more clearly, in these
pages. For it is sometiraes an immense advantage for an author
lo have rehearsed his part to a crowd of competent and interest-
ed witnesses, before committing himself to the printed page,
and yuur readers vnW get the beuetit of this drill on your part
U your directions are carefully and intelligently followed there
will l>e little danger of harm from the resort to tliis very use-
fol and indispensable in8truu>eni
Version in your hands, with the aid of external manipulation,
ia an excellent and available obstetric resource. The conditions
that require it in one or anotber of its forms, and the directions
giv«n for its performance are clearly stated and practically set
forth. Your excellent illustrations of this process of voluntary
evolution furnish one of the most attractive and useful features
of the book. The aid to turning by the proper postural treat-
xxu
INTBODUOTION.
ment, and the relative importance of version by the vertex^ when
it is practicable, are properly emphasized. These obstetric ma-
nipulations deserve a plain desci'iption, and a thorough illumina.
tion, BO that, in an emergency, the phjrsician who is forced to
make them may have good counsel at hand in an author who
haa not buried hia meaning under a heap of word-rubbish. You
have succeeded in giving the most e:£p]icit and available direo-
tiouB possible for this and other fonns of manual midwifery.
I have looked over your fresh, uncut i>Bge8 for the little items
which tell whether one has written from experience, and with a
view to assiHt his readers, or merely ^'ith tlie idea of making a
book And I have been pleased to find that you havn given the
most careful instruction as to the introduction of the catheter,
the resuscitation of the asphyxiated infant, and kindred subjects.
I also find a painstaking description of pseudocyesis, and a care-
ful differentiation of tnie fr(»m false hibnr pains. These minor
matters answer for your fidelity, and will Ije extremely useful
My own idea is that, in these latter days, the consideration of
tlie puerperal state should be taken from our works on obstet-
rios and gynaecology, and devoted to separate treatises. ,The
subject is too large and too important, and, both on account of
its immediate clinical history, and of its far-reaching conse-
quences upon the health of women, merits a more careful and
thorough consideration thiin most teachers and writers on these
tctpics can afford to give it. For this reason I would have pre-
ferred that the space you have given to th«> puerperal diseases
had been devoted to obstetrics. But others may tJuuk differ-
ently; and the busy practitioner may choose to have the mate-
rial pertaining t*** child-Wd included in the same volume. Brief
as your discus.sion of the. subject necessarily is it will be a Croil-
BGnd to many a poor doctor and to many a poor mother who is
in need of help.
Of the general therapeutics of the work I shall be excused
INTEODUCTION.
nUl
from saying very mnch. The indications that you have given
and emphasized are simple and practical. There is a commend-
able absence of iine-epun theorizing, and of controversy, and a
cahn, straightforward commendation of the remedies which the
general professional experience has often tested, and upon which
we must continue to rely until we are certain of having found
something better. It is still a question in obstetrics, as it is in
gyn»oolpgy, where surgical interference should end and thera-
peutical means should be exclusively depended upon. TJutil this
question is settled we will surely do well to present the claims
of both these kinds of resource as fairly as possible, and then
leave it to the judgment of the practitioner to adapt the one or
the other, or both, to the case in hand.
Without a further reply to your kind and touching dedication,
permit mp, ray dear doctor, to thank you most heartily, and to
wish you an abundant measure of success and prosperity in your
doable capacity of teacher and physician.
R. LUDLAM.
Chicago, Nov. 3, 1882.
THE
SCIENCE AND ART OF OBSTETRICS,
PART I.
ANATOMY AND PHYSIOLOGY OF THE FEMALE
GENERATIvk ORGANS.
CHAPTEE I
Anatomy of the Pelvis.
Tho i>olvis IS a part of tlie liumnii Ixxly, u knowledge of "which
is of the highest vahie to tlio ohritetrician. Indeed, so essential
is a comprehensive and explicit acquaintance M'ith it, that with-
ctiit thoroiij^h conversance with its structure and relations, no
one is (jualitied to practice midwifery with any degi'ee of satis-
faction to either himself or his patrons.
The p*4vis constitutes a bony case or basin, within, and upon
which, are all the organs directly concerned in the process of
repnxluction. Not only this, but through the canal which it
firms, the fwtus passes in the act of parturition.
ComiKmeiit Parts of the Pelvis. - In tho adult, it is composed
of four distinct bones, namely: the two ossa innomlnaiaj the
facnun and tlie atccjfj'. The o.ssa innomimila are united ante-
riorly, and, from their peculiar foriii, constitute the anterior and
Ittteral walls of the pelvis. Posteriorly thtjse btmes articulate
with the $a4yrumy which is interjxjsed between their extremities.
26
ANATOMY OF THE PELVIft.
The coccyx is joined to the sacrum inferiorly in such a manner
AS to continue and anuplete the lutter*8 structure.
Tlio OS iunominiituiu is formed by the union of three part-s
the i7fuiii, ischium and pubis, the |ierfect fusion of which gives
to the bone a fc»nu unlike that of any other in the human frame.
Owaeoua union uf the imrts ia completed about the twentieth
year.
The Os Iniiominatum. This bone is so irregular in shape,
tliat a description of it, however carefully given, w(juld utterly
fail U) convey to the mind a clear conception of its anatomical
ehartictias, without the aid of a sijecimeii or drawing. It is
truly tJie nameless bone. It is formed of three part«, distinct in
the infant and young child, united at the acetabulum, at ixrsi by
cartilaginous, Imt eventually by osseous structures. The lines
of junction form a figure resemblijig the letter Y. but, after ojm-
pleto <^sification, they become almost wholly obliterated.
These three jMjrtions of tlie os innominatum have been named
1 . the OS IMVM, hip, or hitunch hoiu; 2 • the os ISCHICM, or sit-
iing bone, aud S . the 08 Ptruitiy pecien or ttharc hone.
Flo. 1
The rijclit im lunoninvjiiim. — uutrrsozlbcr
Itjs ontor snrfkcf, Th«* chief oMi^tric interest in conni
tion with tht' innominnto Ikiuo is dinvttsl U> its inner surl
28 AKATOXY OF THE PELTI&
known as the anricalo-articnlar surface. These featnies being
given, no farther study need now be made of the ob innomina-
tum as a whol& Its several parts, however, are worthy further
attention.
The Os Ilium. — This is the larger of the three, of a triangu-
lar shape, situated superiorly, and, with its fellow of the oppos-
ite side, forming what is called the false pelvia It presents an
irregular, convex, external surface, with elevations and depres-
sions which afford attachments for the glutei muscles. Its op^
posite or internal surface is smooth and concave, forming a fossa
for the broad, flat iliacus intemus muscle. It is Tinited to the
other parts of tlie innominate bone at its lower anterior margin,
by what is termed the body or base, which is thicker than other
parts. The ilium being broad and flattened, forms an aJa or
wing. Its superior margin, thickened into a lip for the attach-
ment of certain muscles, is termed the crest Upon the promi-
nent anterior margin there are two eminences — one above, and
the other below, known as the anterior superior, and anterior
inferior spinous processes. The body of the bone is divided
fn.>ni the wing on the inner surface by a well-defined ridge,
which forms part of the ilio-pectineal line, and marks the
lx>undary of the true pelvis.
The Os Ischium. — This bone is situated anteriorly and in-
foriorly to the ilium, and is joined to it at the acetabulum by its
IhhIv. Pn>jpcting fonvard and upward from the base, which is
tho thickest and strongest part of the structure, is a thinner por-
tion, ill*} ai<iTft(ling ranuts. This is united to the descending
raiiuis of tlio pubis, and aids in forming the obturator foramen,
and pubic arch. Between the two extremities of the ischium is
a tliick, strong iK>rtion, projecting downwards, and constituting
tin* most inferior port of the pelns. This, from its form, is
called the tulH»n)sity of the ischium. Pointing downwards, back-
wards and inwards from the body of tlie bone, is a point of con-
sitli'rabl*^ obstetric imiK>rtance, since it has been termed "the
kfv U> tho mechanism of labor" — L e., ihcsphwof ihe ischium.
The Os Pubis.— This is a light, V shaped bone, situated most
aiit<Tiorly, articulating with the ilium and ischium at the acetab-
ulum, and with its fellow anteriorly. The body of the bone, at
its acf^tabular articulation, is the thickest part, while from tliis
30 ANATOMY OF THE PIXVI&
pyramid, with the apex downward, its base forming a seat or
plinth, on which rests.tlie last lumbar vertebra. The seams be-
tween the several vertebrsD thus united, are distinct^ and tlie
edges of the bones form prominences easily felt on vaginal
examination. The sacrum presents six surfaces for study, all of
which are, in their main characters, of some interest to the
obstetrician. The bone is bent somewhat longitudinally, and
slightly so from side to side, witli the concavity looking inwards.
Its superior, inferior and lateral surfaces are articular. The
superior surface, or base, articulates with the last lumbar verte-
bra by means of an inter-articular disk of cartilage, and tlius
forms the lumbo-sacrnl or sacro-vertebral joint The interven-
ing cartilaginous disk, from being thicker anteriorly than
posteriorly, causes the base of the sacrum to project more tlian
it otherwise would. This part of the bone, thxis rendered pro-
minent, is knoT^Ti as the promontory of the sacrum. The
superior portion of either lateral surface articulates witli the
ilium to form the ih'o-sacral sipwhomh'osis, Tlie small, tliin
apex articulates with the coccyx below, and thereby forms the
sacro-coccygeal joint
Looking at the inner surface of the bone, we discover on either
side of tlie Ixxlies of the fused vertebra?, four oj^nings, formed
by the transverse processes. These are tlie sacral foramina, and
transmit the anterior sacral nerv-es, which contribute to the for-
mation of the great sciatic nerve, that x>ssses down the outside
of the thigh. The concavity formed by the sacral curves is known
as the hallow of the sacrum. This surface of the bone is compar-
atively smootli, thereby favoring on easy passage of the foetus
through tlie pelvic canal.
The outer surface presents an entirely different aspect, being
rough and tuberculous. In the median line are the spines of
the vertebrae, while on either side are discovered ox>enings
which correspond to those on the inner surface, and which sen^e
to transmit the posterior sacral nerves. The roughness of the
posterior surface serves a wise purpose, since the tubercles give
tirm attachment to ligaments and muscles of much power and
imixjrtanc^ The entire bone is penetrated longitudinally by
the spinal canal, which contains the terminal nerves of the spi-
nal cord, known as the cmtda equina.
32
ANflTOlCY OF THE PELVIS.
CHAPTER n.
The Pelvic Articulations.
Having viowecl the sepnrate !>oi3es which make np the pelvis,
we may now consider the articulations which result £rum tlieir
association. We shall notice, L the symphysis pubis; 2. tlie
ilio-sacral syncliondrofies; 3. the sacrooxrcygeal articulation, in
each of which the obstetrican ^ill take interest
The Symphysis Pubis is the articulation situated directly
in front, and resulting from the approximation of tlie two pubic
lx»ne8. The articular surface of the bones is but small, since
tlie bone itself at this jjlace is com|>aratively thin- This surface
is invested with fibro-cartilage, which is thickened anteriorly.
where tlie siu^ace comes in contwct with its fellow, and thinned
jvosteriorly, so as to leave a space, which is lined by a synoviid
membrane.
Fin. i.
Bectiou of the Synipbyais Pubis.
The bones thus articulated form an arch, called the pabic
arch, the crown of which is directly at the symphysis. It is
highly important tiiat the student bear in mind the existence,
situHtion and form, of this arch, inasmuch as under it the foetal
occiput glides in favorable terminations of vertex presentations.
A shortening of the span of the pubic arch ojjerates to increase
*HE PELVIC AKTIOTLATIONa
33
• ^^^^"^pth anteriorly, and addfi greatly to the difficulties
^:rvs of piirturitiou.
The Ilio-Sacral or Sacro-IIiae, Synchoiulroses. — Attention
has already been directed to the auriculo-articular surfaces
of Utth the ilium and sacrum, the junction of wliich makn tlie
j«.»int under tt:)nsideration. The lx)nes once in position, we have,
then, two synchondroses (so called) the right and the left. The
articolar surfacet* are, in the recent subject, covered with fibro-
cartilagee, and there is found between tlieni, an in the other jiel-
ric articulationRt a serous nienibrane, which becomes most distinct
iluring tlie latter part of pregnancy.
Fro. 5.
Section through the leA nucrD-iliiic articulation. (Xfttural size.)
M<)chankal Relations of the Sacrum.— If we regard the
as does Dr. Matthews Diuican,* as a strong transverse
I, curved on its ant^^rior surface, witli its extremities in con-
tact with the corresponding articular siurfaces of the ossa in-
nominate, important mechanical relations are sustained by the
** Rcneari'liea in Olxsletricw,*' p. (57.
34
ANATOMY UK THE TELVIS.
iliosAcral fiynchondroeee. The weight of the body is trRns-
luitted to the iniioiuinnte bones, and through them to the ace-
tftbula an<i femurs. Counterpressure is tliere applietl, and the
reeolt is an imix>rtant mixlifying influence on the develojiment
and shape of the jjelvitn.
The Sacro-Cocey^eal Joint. — This is a ginglymoid joints
formed by tlie articulation of tlie bones from which its name id
derived. There is no doubt that by means of it considerable
mechanical advantage to hihuT it* derived- Wlieii the long
diameter of the head in its descent rotates into the conjugate of
the j>elvio outlet, the latter diameter, by mnvemont backwanl of
the coccyx under pressure, is capable of amplifying the neces-
sary dimensions, and thereby fiicilitating fcetal escape. This
lovement, however, is not confine<l to the joint itself, but is
'ueniUy shared by the |x>inte of ossiticntion of which the coccyx
is made up. Tliis is especially true of the second and third and
fii'st and second i>iece8.
The articular surfaces here are likewise coivered with cartilage,
and l)etween them is found a serous membrana
Abnormal Deviations,— Relaxation, or violent disruption of
the pubic joint and of the ilio-sacral syiichondroses has been
described by several. The most pronounced symptom in such
cases is the difliculty, or im]x>ssibility, of sitting or standing
erect There is generally pain or uneasiness in the pelvic region,
and a sense of weakness and unsteadiness in the bt>nes. Relief
can usually be afforded by a tight bandage alK)ut the hi[»s. This,
and absolute rest, constitute the best treatment Inflammation
and suppuration of the [lelvic joints is an occasional occurrence.
^Vllen recognized, the pent up matter should be drawn away, and
constitutional treatment adopted.
Anchylosis of the sacro-coccygeal joint, and premature ossifi-
cation of the separate pieces of the coccj'x, may take place, and
give rise to much delay, difficulty and suffering during descent
of the head. Such anchyhtses liave }>een known to snap under
pressure, with a report which was audible. During instru-
mental delivery a rupture of the kind may take place, and thus
permit the rapid completion of the process. In all such cases a
certain amount of attention should be bestowed on the repara-
THE PELVIC LIGAMENXa
35
tive process, to pr<*veut reunion of the parts with tho coccj-x in
mn uunatoral position.
The LigamentH of the Pelris.— These are by no means few
uixi nomber, when those whicii are in close relation to the articu-
Hntioas are included. Tlie stfrnjihysis j^abis receives strength from
ligaments stretcheti from one bone to the other on every side of
the joint We therefore have superior and inferiorp inner and
nuter ligaments. Of these, the postej-ior is a layer of fibres
of little strength ; the superior is connected with a band of fibres
which arises from the spine of the pubis, and conceals the irreg-
ularities of the crest of tlie bone. The [interior is a layer of
irregular fibres passing across from one side to the other, and
|cn>Bsiug obliquely the corre6ix>nding fibres from the other side;
f^xd the inferior, triangular, or subpubic ligament is so thick,
and so formed by its attachments to tlie mmi of the pubes, as
tn give smoothness and roundness to the subpubic angle, and
thereby to facilitate the passage of the foetus.
The ligaments which stay the ilio-sacral st/nchondroses are so
arrongeil as to give the articulation great strength. The ]x>sfe*
n'or sacro-th'ac Ugnmaii consists of strong iiTegnlar bands of
fibres, which pass from the overhanginj? p4^rtif>n of the ilium, to
the oontiguona rugged projections on the lateral surface of the
sitfram. One of these bands, prolonged from the posterior su-
perior iliac spine, to the third or fourth vertebra of the sacrum,
in ft direction dififerent from the other fibres, is known under the
name of the inferior, or ohh'qncy sftcro-ilific ligament. The an/e-
ricnr sacro-xliac ligament is a simple fibrous lamina, extended
tnuiflrersely from the sacrum to the os innominatum. It is rather
an «xpansi(»n of the periosteum, than a true ligament The
superior sacro-iliac lignjurnt is a very thick fasciculus, pasaing
transversely from the base of tlie sacrum to the posterior i>art of
the inner surface of the bone.
Theft© synchondroses are strengthened also by the sacro-sci-
ftlic ligfimfrtiixj — greater and lesser. The greater or fjosferior,
vrw^ from the posterior margin of the ilium, including the
poitfrrior inferior spine, and from the lateral surface of the sa-
cnun and coccyx. It is broad and fiat, but its fibres converge as
tbpy pasB downwards, and forwards, to be inserted into tlie inner
TOiWf of Oil* ischial tuberosity. Tlie fmtf^ittr or smaller sacro-
jcidlir hycirnpn/ is triangular in shape, but shorter and thinner
ANATOiry or the pelvis.
tUau the other. The origin of its base ia blended witb that of
the greater, but is less extensive, and its apex is attached to the
8pine of the iHchinm.
These ligament* transform the sciatic notch into two foramina,
the grcaier and ihe lesser sacrchsciaiic Through the former of
these pHfis the pyrifonnis mnscle, the great sciatic nerve, and the
ischiatic and pudic vessels and nerves. Through the latter i)a8s
the obturator int«mus muscle, and the internal pudic vessel and
pudic nerve.
The function of these ligaments is tersely put by Leishiuan* as
follows: — "They act, as has already Ix^en mentioned, by pre-
venting the displacement of the apex of the sacrum upwards and
backwards, an accident which, without tlieir aid, the very oblique
position of that bone woidil, in the erect posture, be likely to
engender; and therefore, in this sense, they strengtlieu the sacro-
iliac articulation. But, in addition to this, they close in, in some
measure, the large irregular opening which constitutes the ouU
let of the pehns, forming, at tlie same time, the framework of
those soft structures which constitute the floor of the pelvis,
which exercise a very imi>ort*int influence on the progress of
labor; and which act also by aflording an efficient and elastic
support to orgHiw which would otherwise be liable to frequent
displacement doi»*nwards."
The ligaments which strengthen the lumbosacral joint are
6imilar to those wliich join one vei'tebra to another. The ante-
rior common vertebral ligament passes over the surface of the
joints, and we also And the ligamentn sub-flava and the inter-
spinouB ligaments, as in the other vertebrne. The articular pro-
cesses are joined h)getlier by a fibrous capsule, and there ia also
A pecoliar ligament, the lumbosacral, stretching from the trans-
verse process of tlie last lumbar vertebra, on each side, and at-
tached to the side of the sacrum and the sacra-iliac synchon-
drosis. Note should also be made of the jlnt-lumbar h'gntneni,
which passes from the apex of the last lumbar vertebra to the
thickest portion of the iliac crest
The ligaments of the 9acro'Coccy{)eal ariiculaiion require but
brief notice. The anterior ligament consists of a few parallel
fibres which descend from the anterior part of the sacrum to the
corresponding face of the coccyx. The posterior sacro-coccj'geal
■"System of Midwifery." p. 40.
MUVEttKNTH OF THE PELYJO BONES.
37
is flat, triflngiilftr, broader above than below, and of a
dark color. Aribiug Crom the mar(^u of the inferior orifice of
tbe eacral canal, it descends to, and is loBt on, the ^ihole poste^
rior surface of tbe cocojtc. It aids as well in completing the
cnnal behind. These ligEimeuta seem to elubraue the entire
joint in a kind of capsule.
A few words remain to be said regarding the obturator W^^
iD«*nt or membrttue. As has been elsewhere stated, this struct*
ore is stretched over the obtiirat4->r foramen, abn<iBt closing it, a
UdaII opening only being left for the passage of the obturator
ressels and nen'ea. It may be said uf this nieiubrune, however,
that it 18 rather on aponeurosis than a ligament
lurenients of the Pelvic Articulations.— There is a popu-
lar notion among people of nearly all natii»nH» and has Iteeu
from time out of mind, that, during labor, there is extensive
movement and separation of the pelvic bones. It has been ques-
tioned by many capable of forming an intelligent opinion on tho
Hibject, that, with a single exception, any movement or divarica-
tion occoTB. Action of tlie coccyx on the sacrum has been ad-
mitteil, but motion of the bones at the other joints haa been
doubted- The ctnisenHus of opinion, however, among the best
aatliorities, endorses the conviction that movement of the sort
-fion, does take phu-e. At the symphysis jmbis the
;:r5 are softened, and, under pressure, there is slight sepa-
ration. At the 8aci*o-iliac synchcmdroses similar relaxation of
lijrauientous ntmctures wcurs, the articulm* surfaces ai'e sun-
di-rtNl in a minute tlegree, and tlieii there is {K'rformed an oscil-
lation of the sacrum on its transverse axis. The sacro-sciatic
ligiimeiits share iu tlie general relaxation, and thereby give
greater freedom to the actioiL Zaglns* first called uttontion to
the fact that, notwithstanding the intimate union of the bones at
f' '-iliiic articulation, they still jx^ssess a certain degree
lity. In man he found, that under cerUiin conditions,
a« ill defecation, the oscUlatiou amounted to about a ]jisx^ Dr.
JTfttlhews Duncan describes a similar, but exagg*' ' - • > f
'ifcs taking place in the parturient woman, nn
advantages thereby afforded, and the conditions wl
Thn^ at tiie beginning of labor, as the head enters
•"MaulMy Journal ol" Mwl. Scieact," Sept- 1831.
38
ANATOMY OF THE PELVia
■woman instinctively prefers to sit, to walk, or, if to lie, to do bo
witli the lower limbs eiteuded, jxjaitions which favor the rotation
backward of the sacral base, and consequent increase of the con-
jugate diameter of the brim.
But when the head reaches
the pelvic floor, and begins
to engage the outlet, there is
a manifest dis}HJsition of the
woman to bend the budy for-
ward, and flex the thighs, Citn-
ditions which favor extension
of the conjugate diameter of
the inferior strait by a rota-
tion of the sacrum on its trans-
verse axis.
UiufttHtii hhowtug the uacillator; move
luout of thc> sacrum.
The Pelvis ah a Whole. — Having made a somewhat detailed
Fi«*. 7.
Tile art icn]&U*d Pelvis.
study of the several bones, joints and ligaments, which contrib-
ute to form the pelvis^ let us now view it as a whole, ami note it»
40
ANATOICY OF THE PELVIS.
Measurements of the Pelris.— Before proceeding further,
the student will do well to ftimiliarize himself with the dimen-
sions of the pelvis. In giving these, certain terms will be used
which require definition-
Referring now to figure 8 we have a diagram of the superior
strait, or pelvic brim; a~b represents the antero- posteriory or
conjugate (iiameter, the poles being the symphysis pubis and
sacral promontory; c~d designates the tratwi^rsc diameter; f-e
shows the leff-obliqup diameter, the jjolea resting at the right
acetabulum or ilio-pectineal eminence, and tlie U*ft sacro-iliac
synchondrt)8i8; /-c marks out the right -ohliqiie diainetRr, the
poles being found at the left ilio-pectineal eminence, or left
acetabulum^ and the right sacrtv iliac synchondrosis.
Witli regard to exact dimensions we should recollect that they
C4m scarcely be given with any degree of confidence, inasmuch
as actual measurements are found to be so various. It is only
by taking the average diameters of a large number of pelv(
that we can arrive at a clear comprehension of pelvic dimensions.
Fici. 9.
Bhowin^ the DinTneUre of the Outlet.
But what is of vastly greater importance than exact figures for
the student of obstetrics to remember, are the relative measure-
ments. In the figures, which follow, reference is had to the
drietl pelvis, divested of all soft parts save ligaments.
THE PELVIC DIAMETEBi
fore sabmitting the figures, however, a word is required
witL regard to the oblique and conjugate diameters of the pelvic
cavity and outlet In the instance of the former, one pole
neoe66ari]y reete on the sacro-eciatic ligament*}, and hence is not
fixecL This is also true of the conjugate of the outlet* one pole
of wliich diameter rests on the tip of the coccyx, and this, as has
been explained, is pressed more or lese backwardfi during de-
scent of the foetal head
The following will then approximate the actual diameters, in
inches^ of the true pelvic cavity, and of its superior and inferior
straits: —
Co^juffnie. TVawAfTTw;. Ohlujuc
Brim, or superior strait 44 5^ 5
t^iviiy 5f 5 (3})
Ontlrl .. 5to« i\ (4})
Other peU-ic measoremeutfi are also submitted: —
Clrrnmfervntial miswuremem *jf the brim 17
H«w»iir«mcnt from tli«: Aucriil pntmoutorj lo the eviitn* of the ocetabulutii,
or the Uio-]><-'<*1iHeal eiiiincnce 3^
Between the wjclwit piirt oi* iliac < Tej*U lOJ
** " MDtcriar »ui)cnor ilhvr spines lOj
*' " Tront of symphysis aud sacral spinre 7
From the diameter of the true pelvis, as given, it will be
obs^rve<l that ut the brim the conjugate is the shortest, and the
transverse the longest In tlie recent subject, however, these
relative diuieusions are changed. The transvei'se diameter, fnun
encrottdiuient of the psoto and iliac muscles, becomes shorter
than the oblique. Moreover, on account of the presence of the
Wiclnm on tlie left side of the sacral promontory, the left oblique
diameter la rendered shorter than the right
Inclination of the Pelvis. When the pelvis is placed upon a
fiul *urfacr, so that the ischial tubers and coccygeal tip are
Imtught upon the same plane, we do not get an accurate idea of
tiio position which this part of the skeleton really occupies in
tiie living, erect subject "Without entering into a narrative of
llw iViff(*rent notions which have from time to time been held on
^kftuhjpct, it will answer practical purj)09e8 to say that the pel-
t\«iaHfipUic«'d thiit in tlie erei^t pi-^sititm, what are termed its
WiriioiiUil plauoB, Bostiiin a marked inclination- This is an im-
^^irtimt orinsklenilion, and should be clearly comprehended.
42
ANATOMY OF THE PELVIS.
Now it liAs been found that, while the inclination of tlio pel-
vis vari<*a in clifferent j>e?8ons, and in the same |)ers<m at differ-
ent times, tiie general pitch of the plane of the superior strait is
at an angle (>f rt«y fiO*^, and the plane of tlie inferior strait, l>efore
recession of the a»ooyx, is at an angle of say 11*^ with the hori-
zon. Tlie high practical value of these items of information
"will be clearly discerned as we procee<l.
Fig. 10.
CMCYX
QISMED BACK
flBSTCTRTCAL eONJUUTI.
MOBtZOtf.
riANC or OUTLET
Planes of the Pelvis. It is not difficult to demonstrate what
is meant by pelvic planes. That of the superior strait would be
well represented by a piece of card-lx>ard fitte*.! into the irregn-
lar outline of this apertui'e. In a section of the i>elvis, the plane
of the brim woidd be represented by a line drawn from the su-
perior margin t»f the pulieH to the promontory of the sacrum. A
piece of rard-bojinl fitt^Ml into tlie iuitiet, so that one side of it
would rest on the point of tlie coccj-x, and the op|x»site side at
the crown of the pubic ardi, extending betwe^^n thei^u■'hial tul>erB,
woiUd represent the plane ot tl»e outletw Tliis plane, in a sec-
tion like that in figure 10, would be represented by a line dniwu
from the sub-pubic margin to the tip of the coccyx.
THE PELVIC AXIS.
43
Other jjIhiirs, without number, may be created within the
cavity, by carryinir funvard the lines representing the
A. B. Horizon
C. D. Vertiiiil line.
A. D. I. Adk1<' of inclinntioD of
pelvis to horizon, f-'qaal to 60".
It. I, C. Angle of iudinution of
|H>lviR to spinal colamn, equal
to l.V)'.
C. L J. Angle of incUnalioa of
Bacriim tospinulooUimn.cqunl
to i:w°.
K. F. Axis of poUis inlet.
r.. M. Mid plane in the middle
iine.
N. Lowest point of mid plane
of iiichium.
planes of the 8uj>erior and inferior straits to the point of inter-
fiectioD, and from this, as a focus, radiating other lines through
pelvis, as shown in figure 12,
^xh of the Parturient Canal. The axis of the parturient
canal is its geometrical centre. To demonstrate the axis of a
,peiect cylinder wotild not be tiiificult, but the parturient canal
^carity of irregular dimensions, ^^-ith diameters short in one
and long in anotlier, and a depth much greater posteri-
rly than anteriorly. The axis of the brim would be representetl
J* line dru^vn through its centime, perpcn<liculurly to its plane,
vLich would extend from the umbilicus to the coccyx. The
oi the outlet of the Injny pelvis intersects this, and extends
■m the promontory of the sacrum through the geometrical
itre of the plane in question.
Whnt is known as the "curve of Cams," was at one time
'|K»ee<i to represent tlie axis of tlie pelvis. It is formed
\nng manner: The compiisses are expanded so that
wh«i one point is placed at the midtlle of the posterior surf ace of
tine ijrinphysis, the other will rest midway upon the conjugate di-
44
aKatoxi of the pelvis.
ameter. The latter point is then made to describe a onrre through
the pelvic canal, and the line restd^ing is the curve sought For
practical purposes this will answer, yet it cannot be regarded
as the real pelvic axis, since the posterior wall of the cavity
has not a uniform curve. It is only by creating a large num-
ber of artificial planes like thpse represented . in figure 12,
and determining the geometrical centre of each, that we ap-
Fio. 13.
Fro. 12.
proximate exactness. A line drawn through the centres of such
planes, from pelvic inlet to outlet, would be found to describe an
irregular parabola, which would represent the true axis of the
pelvic canal.
It must not be supposed that the plane of the bony outlet
truthfully represents the plane upon which the foetal head passes
the vulva. The yielding 1)6^0 floor is greatly stretched, and if
the posterior boundary of the plane be the posterior vaginal
commissure, we discover that the plane would form with the
horizon an angle of 75® or 80®. This is fully set forth in
THE PELTIC A3US.
45
igare 13; rt^t is the newly fonnetl plane of the vtilva, r is the
mas. and e Uie line representing the axis of the parturient
cuttL
FTfi. 14.
The Inclined Planes. — When
we look nt a section of the pelvic
canal, like that here shown, we ob-
serve that the lateral wall is easily
di^aded into two parts, by a line
extending, naturally from the ilio-
pectineal eminence to the ischial
Bpine, 6-a. That j)art of tiie bone
in front of the line looks slightly
forward ; that behind the line looks
slightly backwani These are the
anterior and posterior inclined
\plane3 of the ischium, supposed by
many to determine the rotation of
the foetal head in the pelvic cavity.
lale and Female Pelyis. — With dried specimens before us,
h is apparent, even on a cursory comparison, that there is a
Fig. 15.
between the male and female palvis. In order to ren-
Ibe rariations explicit in detail, the following contrast has
been drawn :
4G
ANATOMY OF THE TELVIS.
Fio. 36
Comparison of the 3Iale and Female Pelvis.
FEMALE.
I. All the bonis are I'umpnrRtively
Jijjht in stnictHre. Jiiid the points for
mus«'uliir attachment are only mode-
r.itfly (li'veIu|K?d,
'2. Tlio iliac wings are widely spread,
m that when awn fn>m (x't'oio, ihc
hromi expHiise ol' tlie iliac t'oaaiii cumea
plainly into view.
3. Thoiwhial ttiborosities are wide-
ly scparal^-d. ;«> o-s to jjiie :i transverse
diamvtcr at iho outlet of 4^ inc-hcfl.
4. The flnh-puhtc angle is obtnse
(90° to 100'*). and the spuu of the arch
brood.
5. The pelvic cavity !» wide nnd
shallow, and the twctional area of the
brim and outlet about equal.
6. The Hacrnni is broad, and its
promontory* moderately prominent.
7. The obturator foramen are trian-
gular in ibmi.
8. The spines of the ischia have a
aaoderate projection into the pelvic
cavity.
MALE.
1. AU the bones arc comparatively^
heavy in structure, and the p^iints for
muscular uttnchmentA are well devel-
oped.
9. The iliac wings not so widely
spread.
3. The ischial tuberosities com-
paratively near, yovinf* a tninsverse
diameter at the outlet of say 3 j or 4
inche«.
•t. The sub-nnbic angle ia acute (70
to 75"), and the span of the arch nar-
row.
5. The pelvic cavity is narrow and
deep, and the sectional areaoft lie out-
let cfHi^iderubly below that of the
brim, giving to the pelvia a funnel
shape.
(i. The sacrum is comparatively nar-
row, mul tlie promontory very prom-
inent
7. The obturator foramen are more
oval ia »hftpe.
8. The ischial spines ore remarka-
bly prominent.
THE EXTEltNAL GENEBATIVE OROANS.
47
Those diifrrences between the male ntul female i>elvifl aro
probably the result of the growth and deveiopment of tho female
internnl genenitivfl organs, fiituated within tho true pelvis.
Scbxoeder, in pnK>f of this, calls attention to the fact that iu
Wiimen witli congenital defects of these org»ins, and in women
who have had b<jth ovaries removed iu early life^ the general
form of the pehis is masculine.
CHAPTER III.
The Female External Generative Organs.
Division Aeronlinir io Function anil Situation.— The female
gf'ntTfitive oryjins linvt^ been divided ncc/:)rding h) Bitnation and
fimction into rartenia/ and infertml organs. The external organs
arp till »se whieli are in ^new externally, nud together constitute
ike pntiemlum^ They are concerned mainly in the copulative
BCt, but til rough them passes the fcetus in parturition. They
OODflist of the mims veneris, the ^'ulva, tlie vagina and the j)cr-
The internal generative organs are concerned mainly in
Lacing the ovum, developing and ultimately expelling it
ley consist of the ovaries, the utenxs and the Fallopian tubes.
The Mons Veneris, — This is a cuahion-like eminence situated
lUnn^tly upon the symphysis pubis and the horizontal pubic ramL
It i.s c()ui|M>s<'d mainly (»f adipose and fibrous tissue, and serves
AS a protection to the parts during sexual intercourse. At pu-
berty it ilevelopa a growth of hair, the area thus covered fonn-
M pyramid with the apex at the vulva. Numerous sweat and
lurt glands are found to open on its integument
The Vulra.— The vulva is maile up of a variety of parts. The
Ittbia mnjitrtt ore two rouutled folds of connective tissue contain-
iog ti variahle amount of fat, elastic tissue, and smooth muscular
fthn«. They originate anteriorly, at the posterior margin of the
oiniLs veneris, and, lying side to side, extend posteriorly, and
finiUly unite at the anterior margin of the perineum to form the
posterior commissure of the vulva. The margins which lie in
•Qoittct, and the entire inner surfaces, are covered with mucouB
Aiemhrane, wliile the external surfaces are provided with ordi-
48
AJiATOMY OP THE PELVIS.
nary integunifini They are broad and flat in front, i, e., at the
anterior commissure, but thin and narrow posteriorly. The in-
t*^gument for a certain distance from the mons reneria is
thinly covered with hair, and is provided with a considerable
nunilmr of sweat and sebaceouR glands. Tlie external labia, or
labia majora, in the mature virgin, conceal the other vulvar
structureB, but in women who have borne children they ai'e not
so close, and between them may be seen the labia minora. In
young girla also, and old women the labia minora protrude.
The Clitoris.— Soparating the labia niajora we find just be-
hind the anterior \iilvar commissure, a small elongatetl Ixxly,
called the clitoris. On careful examination, it is found to resem-
ble the penis in form and structure, and like the male organ is
the seat of the aphrodisiac sense. It tliflers from the penis in
ha^nng neither cori)U8 spongiosum nor urethra. It is dindod
into the cruia, the a^rpus and the glans. The cmi'a are long,
Fir.. 17.
Lateral view of the erectile struclures
of the female external or^;ans. The aWiu
and mucouB oieiubnuie have beeu re-
movcnl iind the l)l»od veaacls iniecteil, n.
hullms vt'Stihiili ; v. plexiisnr veins cnlled
the para intermedia; *. gluits ditoridis;
/. corpus clitoridis; A. dorsal vein ;/. ri^ht
erus rlitoridis; m. vestibulum; n. right
gland of Bartholin or Duvemey.
spindle-shapetl processe.s, attached to the borders of the ascend-
ing rami of the ischia and the descending rami of the pubes.
The corpus is formed by the junction of the crura in tlie med-
ian line, just l^eneath the j)ubic arch. The glam is the rounded,
imperforate extremity. During erection the clitoris attains the
size of a small pea. The mucous membrane covering of tlie glans
is of a pale, red color, and contains papillfe, part of which are
provided with vessels, and part, nerve endings, similar to those
found in the nipple.
THE EXTERNAL GENERATIVE ORGANS.
Fio. 18
49
Tb« ^xtenial orinitis. fr. labia m^jora; ^, ve«ti bale; c, posterior commb-
■m and foorchette ; rf, |»erintiam ; e, anas.
50
ANATOMt OF THE PEtVlS.
The Labia Minora.— The labia minora, or nymphce, are two
fohla of umc<:»us uiomliraue. which arino on either side from the
centre of the int<?mal surface of the labia majom. They extend
forward, forming fokla of coiisiderable breadth, and tinaljy unite
at the clitorb As tliey approach tliis organ they bifurcate, the
posterior branches being attached to the cliturin, and the anteri-
or uniting to form a sort of prepuce for the organ. In Bome
women, even in middle life, the labia minora become quite
elongated, and protrude a considerable distance. This is
especially true of some of the ne^o races. As elsewhere stateti,
in adult ^^rgins tliey are ct)vered by the external labia, but in
women who have borne chikben. in the aged and in young girls,
they show themselves in the rimd pudendi In young girls and
virgins, the mucous membrane covering their surfaces is of a
light pink shade, but in otJiers it is brown, tb*y, and like skin in
appearance. The mucous membrane is provided with tessellated
epithelium, and a large number of vascular papillro. On their
inner surfaces are a large number of sebaceous glands, which
secrete an otlorous. cheesy matter, that serves for lubrication and
prevents adhesion of the folds.
The Vestibule.— The vestibule is a efmooth, mucous surface,
triangular in form, with its B.pe\ to the clitoris, lying l>etween that
organ and the anterior margin of the vaginul oritice. It is
bounded on eitlier side by the folds of the nymphao, and
I>osteriorly by the vaginal orifice. The muc^jus membrane of
the vestibule is smooth, and unlike the mucous membranes of
other vulvar parts, is destitute of sebaceous glands. There
are a few muciparous glands opening on its surface. At the
centre of the base of the triangle formetl by tlie vestibule,
is situated an oijening, the location of which should be famil-
iar to the physician, namely, the vwatus un'narins or mcgius
ureihrw. From this external opening ihc ureihra posses
upwards and backwards under the pubic arch, in the tissues
which form the anterior vaginal wall, a distance of about one
and one-half inches, to the bladder. It is composed of mus-
cular mid erectile tissue, and is remarkably dilatable. With tlie
finger in the vagina, it can be plainly felt in the situation des-
cribed.
Vaginal Orifice. — The opening of the vagina is directly be-
hind tite vestibule. Its lateral boundaries are the labia minora
THE EXTERNAL QENEBATIVK OUOANH.
51
for but a sliDrt distance, and the labia majora in the main. Its
posterior bi)un(hiry is the fotirchetie. In an imdilated state it ia
a mere fissure, which varies considerably in size.
Fui. ID.
FIO. 20.
Figures showiog different forma of the hymen.
The Hymen is a structure of variable thickness and strength,
situated j ust within tlie vagina, and was formerly regaitlod as a
seal of wginity. When intact, and of ordinary form, it serves as
a complete bar to mtroception of the male t»rgnn, but it is fre-
quently ruptured in infancy or childhood from accidental
caxuses^ When incomplete, or an(jrajilt)us in stnicture, scscual
congress may be held, and impregnation follow, without its
destruction- There are bIbo well authenticate<l c^ses on reconl,
of pregnancy existing in women with this part not only of usual
proportions, but with only small perforatioiia It is generally
cresentic in form, with the free border turned toward the
(Ukteriur vaginal M'all. In the main its structure is such, being
chietiy a fold of mucous membrane with some cellular tissue and
moscular fibres, t4:>gether with vessels and nerves, *that it yields
readily to firm pressure. In other cases, however, in6tea<l of
being thus constructed, it is firiu and strong, requiring an in-
cision to displace it. Anomalies in form are not uncommon.
* Budia hu sbown that it is really n purl of the vAeinnl orifice. ** Pragrca
lUdical," 1879. Noa. 35, etc. ** Coolracblatt fOr Tyniik." vol. iv. p. 12.
52
ANATOMY OF THE PELVIS.
Instead of presenting a free border anteriorly, it may be pro-
yided with a central opening of differing size, or there may be a
number of small openings, rendering it cribriform. Cases of
imperforate hymen are also mot
Carunculse Myrtiformes. Tliese are small deahy tubercles,
from one to five in number^ situated about the vaginal orifice.
They are generally regarded as remains of the ruptured hymen.
*Schroeder does not concur fully in this opinion. " In primi-
parse/* he says, " portions of the torn hymen are suffused witli
blood (during labor), ami deBtroyed by gangrene, ho that in the
vulva some varty, or tongue-like projections remain. (Caruncu-
liB myrtiformes. ) His views are supported by Lusk and others.
The Fossa Narlcularis.— In women who have never borne a
child there still rDmains a fold of mucous membrane at the
posterior margin of the vaginal orifice, which has been termed
the fourchette or frajnum. Situated between this and the
jwsterior vulvar commissure is a little fossa, calle<l the fossa
navicularis. In nearly all first labors the fourchette is torn.
The Secretory Apparatus. — Sebuceous gUimU are most
abundant in the tissues of the nymphae, where they furnish
a fatty, yellowish-wliite material, pwesessing a peculiar odor.
This material, when accumidated beneath the prepuce of the cli-
toris, constitutes the smegma prepntv, so common in women
who neglect the niceties of the toilet They are also present, as
stated, though in fewer numbers, on the mons veneris, and labia
majoro. Mitciis gkmds^ five to seven in number, are found
irregularly distributed about the meatus urinarius. They are
of the compound racemose variety, about the size of a poppy-
aeed, and possess short, wide ducts with large orifices. They
are of aid to the beginner in locating the meatiis urinarius for
cathoterism, tliough Tyler Smithf says that one of these single
lacnnffl may be sufficiently dilated to admit the point of a small-
sized catheter, thus C()nstituting a deception and snare.
The Vulvo-Yaginal Glands were first discovered by Bartho-
lin, and have been called "the glands of Bartholin.*' The name
of Duveney has also been attached to them. They are two in
number, of the size of a small bean, and somewhat resembUng it
in shai^e, of n reddish-yellow color. They are situated near the
* Muiaal of Midwifery, p. 102.
fManual of Obstetrics, p. *2:2,
EXTEBNAL GENERATIVE OBOj
63
posterior part of the vnpnftl orifice, behind tlie posterior extrem-
ities of the bulbi vestibali, which they partially overlap. They
are oonglomerate glands, and are the analogues of Cowper's
glands in the male. Internally they are of a yellowish-white
color, and composed of a number of lobules separated from each
other by prolongations of the external envelope. The several
lobules give origin to separate ducts, which unite in a common
canal about half an incJi in length, which opens in front of the
attached edge of the hymen in virgins, and in married women
at the base of oiio of the caruncuLfi myrtiformes. They secrete
a yellowish adhesive fluid, which is freely poured out during coi-
tus and labor. Its office is a protective one, as it renders the
macDOs surfaces moist and slippery. They are more developed
in young girls than in women of middle life, while in old age
they in some cases disappejir altogether.
The Bnibi Yestibuli. The bulbs of tlie vestibule are two
curved, leech-shajwd masses of reticulated veins, about un inch
in length, situated between the vestibule and pubic arch on
Fig. 21.
Vascular snpply of Vuhu. \Al'U*r Kobelt,)
A pnl.U; K. B. iiM'limm; C. ditoria; D. Klund of the cliUiri*; E. bnlb;
F ' tiiuscio of the vulva; G. left pillar of the clitoris; H. dorsal
*f> ' lilorin; M. labia oitnura.
either side Thoy are covered internally by the mucous mem-
brane, and embraced on the outside bv the fibres of the constric-
ANATOMr OF THE PELVIS.
tnr vagiuff} muscle. Kol»lt claims that they correspond to the
two Beparato<l halves of the male balbus urethna The ant^^rior
ends, which are rather small, are connectetl by means of the
pdt'y intrntirdia with the glans clitoridis. It is by meaus of
this erectile tissue that erection of the clitoris takes place. The
bliXMl, during sexual excitement, is pressed through thii« cunnec-
tion by the reJlex action of tlie rausculus constrictor cunni, from
tlie turgid buH^ into the glans clitc»ridis. These highly erectile
tissues are supplieil with bli>iKl from the internal pubic arteries.
The Vagina.— This important part of the female generative
apparatus is by some classed with the internal genitals, but it is
hero cx)nsidere^l as an external organ.
It is a cylindricAl membranous tul»e,
extending from the vulva to the uterus,
and is sometimes called the yuIvo-
uterine canal. It i^ .situated in the
pelvic cavity, with the bladder ante-
riorly, and the rectum posteriorly,
and, when put upt>n the stretch, ex-
teniis from the vulva to the superior
strait, following pretty closely the
general curve of the pelvic axis. The
walls, wliile strong, are soft and }'ield-
ing, and He in contact, Inking ilat-
tenod from before backwarfls. There
has been considerable discussion over
the length of this organ, and it is quite
certaiai that the ineahuremente given
by some are excessive. When not
drawn forcibly out to its greatest
length, it can be fully explorwl with a
finger measuring three or three and a
hidf inches; but, when at its maximum,
the length is probably four to four loid
ahalf inches— ix>K8ibly live. Its nif^ns-
urement varies greatly in different
women. The cannl is Ht>metimea very
short, its length being only one and a
half or two inoht^ It is united to the bas-fond of the bladder
The va({ina, IvSU^r rvmov*!
uf pttMrrlor wall). On. nu'n-
tiui uriiiiirius. (>««•, ex tcrnol
o* uteri, ij, ♦teclinn of wjtil at
th*; Ibrnix vaftinir, (Henle».
THE EXTERNAL GENERATIVE ORGANS.
or>ndentied aretdur tissue, while the urethra is situated in its
ix^rior wall. Behind, it is connected witli the rectum, in its su-
perior jxixt, by a doable fold of peritoneum, and in its inferior
pi>rtian by areolar ti.ssue. Its lateral l>orders afford attachment
ttl>ove to the broad ligaments, and below to the pelvic areolar
tissue and some venous plexuses. The superior extremity, or
fornix, embraces the cervix uteri in such a way as to give a
SHpra-vaghtal portion^ find an intra^vagiiKtl jtftftiorL The su-
perior boundaries of the vagina in thus folding upon them-
fielves to embrace the nock, fonn a circular groove or cul-de-sac,
deflcribed as the anterior ami ix>sierior varjinal cul-de^ncs.
The posterior is generally double the depth of the anterior.
TTie orifice of ihe vaqina is bounded by the labia minoro and
vestibule. It differs considerably in size and ap{)earanc^ in
young girls, in virgins, in women accustometl to sexual ntor-
oourse, and in those who have borne children. Most of theri
faHfi have already been |X)Lnted out Erroneous ideas arc nome*
\xax^A derived from the vagina being described as a tube with ni;
ext^^mal oijening. It is a tube or canal, but one whose walls
normally lie in contact
The vagina is composed of an external, a middle, and a
mcwous coat The external consists of cellulartissue, which con-
Bectfl it anteriorly with the bladder an<l uretlira, laterally with
the levator ani, and posteriorly witli the rectum and peritoneum.
The walls are not of unifonn thickness. In the upper part of
llie cnnal the internal surface is very smooth, and the walls are
*inly half a line to a line in thickness. The external cellular tis-
«Tip coat is very elikstio, and affords n fine l>ed for the vaginal
hluMlvesLsels. The middle c^mt is muscular, the fibres being of
till* involuntary variety. Tliey nm in both longitudiiuil and
tnmarerse directions, and are so interlaced that a dissection into
wparste layers is imi^ossible. The connective tissue and raus-
cnlur Ifiyera incrt^aso in tliickness as they approach the vaginal
uriW, Lusclika* has descril>ed a circular bundle of voluntary
filjre«, the spliinrirr raijimv surrounding the lower extremity ol
liie raginn ami uretlira. The action of this muscle not only nar-
Wiwstlijj vaginal orifice, but likewise serves to close the urethra
by oomprpfitting it against the urethro- vaginal septum. The mid-
Olo Oi»t (it the vagina is dense and fibrous like the proper tissue
'" W« «iMiomt> itt wm«chiichin iktknut," Fubingcn, 1804. p. 387,
66 ANATOMY OF THE PELVIS.
of the nterufl, and is ctrntmuous with it at the os and cervix
uteri. Cruveilhier, and other anatomists, have compared it to
the dartos. The maoous lining of the vagina has, uix>n the lower
portion of its anterior and posterior walls, two thickened ridges,
which are found in the median lina These are termed the col-
inmice nigarum or vaginal columns. The anterior is more prom-
Fin 23.
Section of female pelvis. 1, rectum. 2, uieiii«. 3, col-ae-sac of Douglaa.
4, vemco-nteriDC Hpace. 6, bladder. 6, clitoris. 7, urethra. 8. sympbysis..
9, sphincter aoi. 10, vagina. (Kuhlraunch moiititied by Spiegelberg.)
inent than the jwsterior, and is sometimes divided into two
portions by a longitu<Iiiial furrow. From these two columns pro-
TRK EXTEBNjIL OENEHATIVE ORGA-NS.
57
j^nSldaof mucous membraue at nearly rigiit angles, wliicli are
he;v>'ier and more numerous in the lowermost part of the vaginal
cbbaL The riigtx^ or cristce, as eome prefer to call them, are
mwt distinct in virgins, less si> in women who are accustomed
to seiutvl intercourse, and ore nearly absent in women who have
borne children. The vagina also becomes smooth in virgins
iift€ir the time of child-bearing has passed. The designs of these
mncons folds are to afiord increased sensational are^, and more
(i&rticalarly to provide against rupture of the vaginal mucous
membrane during the immoderate distention which takes place
iu lobor. According to Henle,* the muscular fibres of the
nginal columns poesees a trabecular arrangement, and inclose
o&li'.iots from the vaginal plexus. Though thus constructed, the
columns are not proj>erly erectile. When tui'giil with blood,
they cloee the vagina, but the resistance they offer is not for-
midable, since, like a siMiugf, they are easily compresseiL Mic-
roecDpical examination discloses- a large number of vascular paj*-
iUa studding the mucous membrane of the vagina, which under
wrtain conditions, as those of pregnancy, become greatly en-
larged, so that to the exmuiniug finger they seem hard and
mu^ Writers have frequently describetl the vagina as con-
tfci^ f: numbers of mucnus ft)llicleK, h> which \a attributed
III* a of the muciui which lubricates the vagina. It has
Bov become a conWction (unsettled, Imwever, by some doubt,)
Uuitthoro are no secreting glanvls. Dr. Tyler Smith, who was
vfmoi the first to deny their existence, saj-s:t "The mucus
rfllio vagina is, I believe, pro<Iuced by the epithelium, and con-
fer ' ' ,sinn and epithelial partit^les." This thin layer of
*"' . J» covers the vagina even in peritxls of repose, is, as
WW peiintetl oat by M. Donne and Dr. Whitehead, distinctly
wid. Under sexual excitement, menstruation, and during par-
^itiDu, the amount of the secretion is greatly increased.
Tlio lining coat of tJie vagina resembles ordinary skin almost
•* ' "lua'us membrane, and in cases of procidentia, where
" \ •'» it becomes converted intii dermoid tissue. Tlie
'Npiukl mucous membnme is covered with squamous epithelium,
Mfcl i» reflectetl over the vaginal portion of the cervix and ob
atm
^''Smmihmch rfrr KtagrxetideUhre rfcj» JfrnwA^n," Brnunschweig, 1866, p. 4S0.
♦ UrtQm on OlMtUtrirft, p. 37.
58
ANATOMY OP THE PELVIS.
The vagina is abundantly supplied with vessels and nerves.
The blood is derived from tlie internal iliac artery, and retiuus
by means of corresponding veins. The arteries form an intri-
cate network around the tube, and eventually end in a 8ul>-mu-
cons capillary pJexus, from which t^'igs pass to supply the papilla'.
These in turn again give origin to the venous radicals, which
unite into meshes, freely interlacing with each other and form-
ing a well-marked venous plexus.
The Perineum.— Tlip perineum is one of the most important
structures in connection with the female generative apparatus,
and Jionce merits most careful study. It is situated l)etween the
Fui. 24.
CLiTORtS.
RETHRA.
CONSTRICTOR
CUNNI M.
TRAHSVEHSUS
Mnitcleftnr !lir IViiiuMim
posterior vaginal commissure and the anus below, and between
the vagina and rectum above. It presents three surfaces for study,
namely, the vaginal, oxtending upwanls from the |X)9terior vulvar
THE BOTBIUX OENZBATITE OBOANB.
5y
oommiafiure for a distance into the recto-vaginal septum, the
rfy^tal surfaces extending from the margin of the anus upwards
into the recto-raginal septum, while the third is that which
stretcheB externally between the p^jsterior vaginal commissure
tnd the anus. The lant i^ that generally considered, and me^is-
oree about one inch in length.* During labor this is greatly
iDcreaned. The j>erineum is a body of considerable thickuess,
but during expulsion of the foetal head it [.becomes gi'eatly
thinned and elongated, so that the measurement given, is in many
esceedod.
Hie stmctnre of this Ivvly is chiefly skin, celhilar tissue,
mtiscalar fibres, and mucous membranes. The arrangement of
the peiineal muscles deserves notice. They are inserted by at
J««st one extremity into tendonous structures and fasciie. This
is true of th*^ sphincter ani, levator ani, coecygei, trauHversi per-
periuaei. erectores clitoridis, and sphincter vaginpp. The fibres
vhic'h are jtssuciate<l tt) foriii these several muHcles^ are indis-
tinct when compared ^ith other muscles, and are mixed up with
» pood dead cjf elastic dartoid tissue. The peculiar constructiou
<jf tlip- jt^rineura is what gives to it the quality of distensibility,
wliich is manifeiitei.1 duaing parturition-
The most important structure which forms a part of tlie per-
uM'Tun, is the levator-iuii muscle. Tliis muBcle has a double
rtructure, is attaclied anteriorly i^y the inner surface of the luKlies
Mul horiiiDntal rami of Uie pubes, and its lateral halves to the
tolinous arch of the pelvic fascia, which stretches from the
inner Kinler i>f the [mbes to the ischial spines. The fibres of
the masclt^s stretch anteriorly downwartl and inward to the sides
of Uie lihu]ih?r and. rectimi, and are inserte^l ix)8teriorly into a
fcpTntmous raphe, which extends from the tip of the coceyx to the
iKtiUQ. llie fibres extending to tlie rectum bec*.)me blended
with those of the external sphincter, while those in relation with
(hengina are situated l>eneath the bulbs of tlie vestibule, and
llto ootwtrictor cunnL The ischio-coccygeus, a small musch^ is
by eooie included in a description uf the levator auL It requiies
i» detailed notico.
• Tostcr, P. P. ** Anat. of the UtcniB and its Surroundings." " Am. Jour,
J«tnimrv. 1h«i.
Fxa. a&
A. port io v»;;in:»lis. B, corpus utfri. C,
(liirt. I), Kullopian IiiIh^s. K, fimlrria'. F, ovarii
O, paruvuriii. H. rutiud li^imenta. I, vaginn.
K, labia nuijont. L, labia minora. M, clitoris.
N, liymcu. (flvigcL)
THE IKTEBNAL QENEKATIVE OBOANS.
61
The levator ani and coccygeus muscles are of nearly membraji-
tiiimiess, and derive their chief strength from the strong
les of the internal pelvic fascia, to which they are closely
Attached
- The other mnscle? which contribute to form the [>erineal fl(»or
«re uf slight obstetric importance. They are chiefly the i^chio-
caremosi, tlie constrictor vaginfe, and the transversi perinaei.
The ishio-cavernosi muscles form a sheath about the crura of the
ditiiria The cuustrict<^>r vagina* is made up of two sniftll lateral
mnscles wiiich lie u])on the outer side of the vestibular bulbs,
and Bum)und the ^nilvar orifice. Tlie trausversi perinaei mus-
cles are small, triangular, thin muscles, passing from the innei*
fiidee of tlie ischia, uudemeath the constrictor muscle, to the
FJiif' of the vagina and rectum.
It remains to be said of the perineal Ixxly that it occupies, as
stated, the spac** ]>etwoen tlie vaginn and rectum, and in a sagit-
ul section preeente a tri-angular 8hai>e, with a convex vaginal,
And concave rectal, surface. It extends up the recto-vaginal se[)-
tam, nearly half the length of the vagina.
The functions of the perineum are chiefly two: 1. It olosea
llie lower outlet jxjsteriorly, so as to prevent prolapse of the
pelvic viscera; 2. it admits of distension when necessary, and,
by its elasticity, 8i>eedily resumes its former condition.
CHAPTER IV.
The Inti^rnal Female Generative Organs.
The Uterus. — About this wonderful organ more obstetric
inthreet cecntres than about any other in the female economy. It
* petr-ahapod, flattened somewhat antero-posteriorly, and bent
•lightly on its longitudinal axis, its concavity looking forwaixls.
riie atoms in the virgin diflfers in shaje and size from that in
^ woman who has borne cliildren. In the description, which
fcDowR, reference is made only to the nulliparous organ. Its
length varies from two, to two and a half inches, its average
62
ASATOMT OP THE PELVIS.
breadth at the widest point is about one and a half inches, while
its thickness is about three quarters of an inch. Its upper
border is moderately convex, and its lateral borders are convex
above and concave below. At the points of junction of the
lateral and superior borders, the Fallopian tubes pass into the
uterus. The points are called antjles or contua. The lower
portion of the organ is spindle-shaped^ and has a width of say
half an incL
By reason of its peculiar fomi tlie organ is naturally di>nde<l
into two portions of nearly equal length. The lower portion is
called the cemixy or neck- The upj>er piirtion is 8ul>di\'ided, and
that part lying below the Fallopian tubes is known as the corpus
or body, wliile that situated above the Fallopian tubes is
distinguished as the fundus^
The lower {>art of the cervix is em-
braced by the upper extremity of the
vagina, and this intro-vagiual end of
the cervix is known as the vagituil
poHion, The remainder of the cer-
vix, which lies above or without the
vagina, is distinguished as the supra-
vnginnl jxirtion. At the lowermost ex-
tremity of the cen'ix there is a sliglit-
ly transverse aperture, calleil the ex~
termd o.-*, or os //nort% It is very
Binall. mfvisuriiig not more than two
liue-s in width, and sometimes scarce-
ly admitting tlie point of a small uter-
ine sound. Tliia uterine mouth is
providetl with two thick rounded lips,
the anterior being a little the longer.
In the adult female the utems is
situateil in the true pelvis, between
the bladder in front and the rectum
behind- In the non-pregnant condition it is wholly within the
pelvic cavity, the fundus being below the plane of the superior
strait Tlie mechanism, by which the organ is held in position,
should be thoroughly comprehejided. Lying, as it does, approx-
imately in the axis of the pelvic canal, it is to a certain extent
AnU'rior view of Virgin
Uterus, (Sappeyi. I. body. 2,
2, angli^H. ',i, cer%'ix. 4, »it«
of OH iiitenium. 5, v:i(ciuul
portiou uf ctTvir. 6, oxlcrnul
08. 7, 7, vagiaa.
THE INTERNAL GE>'£IUTIVE ORGANS.
63
gupportecl hy the vaginal walls and columns, while the latter de-
rive much <»f their supporting power from tho perineal body.
The Uteriue Li^aluents, £rom their peculiar arrangomont,
give to to the organ a cout^iderable freedom of movement, while
in health, they serve to prevent serious deviations of position or
situation. Most of these are formed by folds of the great serous
membrane which i*Tni>s the pelvic viscera, namely, the periton-
eom. This membrane, after covering part of the posterior sur-
fiu^flof the bladder, is retlected ujxin tlie anterior face of the
otrrtis, covering a greater share of its superficies. It then passes
tirer the fundus uteri, and down the posterior surface, dipping to
a cuusiderable depth, anil forming posteriorly to the upper part of
theragina a serous pmeh, bounded laterally by folds of the peri-
toneouL This pouch is the cul-de-sac of Douglas, and the folds
of i^ritoneam which form its lateral boiindaries are the retro-
nterine, or utei-o-sacral ligaments. Anteriorly to the uterus —
that is, between the uterus and bladder— is a shallow ix)uch with
similar ligamentjus boundaries formed by the |>eritoneum, the
litter being known as the vesico-uterine ligaments. The peri-
toneum being a broad sheet orapron, forms by its duplicaturea
IS it passes over the pelvic organs as described, broad-folds upon
bf»lh sides tif the utenia, Btretchiug from this organ to tlie [)elvic
»nll, known as the liijanienta Ma or brand lujrtmvttfs. These di-
vide tlie pelvis into two cjivities— the anterior of which lodges
UiH hlmlder, and the posterior, the rectum. The superior border
of cite Inroad ligament is free, and extends fn»m the angle of the
att^nis to the iliac foesa. The two serous folds which constitute
till- l.irnnd ligament, are separated by a IiHtse, and very extensible,
luuHllutoil cellular tissue^ continuous with the proper fascia of
the pelvis. The broad ligaments disapi)ear during gestatit>n,
thftir twi) lamime assisting to cover the anterior and iwsterior
tweaof the enlarge*! uterus.
Tkff round ligaments, or supra-pubic cords, are structures
vliirli differ eutire'ly from those just described, being evidently
c^atianuori ^i*ith the uterine tissues. They arise from the upi)er
^Wof the uterus, and extend transversely, and then obliquely,
' until they pass through the inguinal rings, and
' .:.; the cellular tissue of tho mons veneris and labia,
lu pftiteing through the inguinal rings each is invested with a peri-
*"Oft«l sheath calte<l the cmud of Nude, Their upper portion ia
64
ANATOMY OF THE TEL VIS.
made up solely of the \ui9tnpe<i variet}' of rausciilar tissue; but,
as they deaceml, they receive strijied fibres from the traimvers-
alis muscles, and the (X)himns of the iuguiual rings. They also
contjiin elastic and couiiective titisne, and arterial, venous and
nervous branches, the first being derived from the iliac or cre-
masteric arteries, and the last from the genito-crural nerve.
The uterus thus held by ite ligaments is in a freely mobile
state, it l>eing a wise provision for pi*otection from injury tliat
might otherwise arise from violent physical 6X6x1^00, falls, jars,
C
B. median soctioii ol vir^cin iivorus. C, trauavorae scctiou, fSapp«^y). B, l,li
pnifileol* the anteriorsurfaw. 2, vesico-uterinc-ctil de sac 3, 3, profile of poste-
rior siiriiu'e. 4, btwly. 5, neck. 6, isthmus. 7, cavity of the body. 8, cavity
of the con'ix. 9, os internum. 10, ant. Up of os ext*Tnnra. 11, post<'rior lip.
12, 12, vajzina. C, 1, c;ivity of the Ixxly. 2, lateral wall. 3. superior wall.
4, 4. eomna, 5. as int4'rnum. 6, cavity of theecrvix. 7, arbor vtlae. b,a»
externum. 9,9, vnginn.
and other disturbing occurrenoes. As previously stated, its
longitudinal axis corresponds pretty closely to the axis of the
j>elvic canal, but the^ fuiitlus of the organ is, iu inoBt cases*
slightly inclined to the right
The rterine Cavity.— Lateral section of the organ discloses
B ca\'ity corresponding in form to the uterus ^^ewpd as a whole-
Its widest niefisurenient is at the superior angles, where minute
orifices mark the openings of the Fallopian tubes. The narrow-
est point is at the junction to the body and cervix, at which
TUE IXTEHNAL GENEUAXn'E ORGANS.
65
ISSe the cavity is a very narrow passage, distinguished as the
^IIiUtoaI OS. Between this jxiiiit and the os tincin there is a wider
channel, known as the cervical cnjtal. A converse longitudinal
section reveals but a small cavity, with the anterior and posterior
wallA lying in contact
NtrartUTfi of the Uterus.— Tliree principal structures enter
into the com|>ositiun of the uterus— namely, peritoneal, muscu-
lar, and mur<iufi. The manner in wliich the peritoneum invests
the organ has been <lescribed with suilicieut minuteness for prac-
tical purposes. Almost tlie entire organ is covered by this mem-
brane. The investment at tlie sides is less extensive than else-
where, since the peritoneal folds w^parate a shoi-t dist/iuce below
tlie Fallopian tubes, and there the nerves and vessels which su|>-
ply the organ gain entrances. Tlie peritoiieuiu, as it covers the
upper portion of the uterus, becomes firmly adlierent to it, while
below it is more loosely connected.
The Mnsrular Structure. — The proper tissue of the uterus
is of a grayish color, and is very dense in structure, creaking
Fio. aa
Mosrnl;tr fibres of nnimprcticnalcd uU'rns, (Fttrre). n, fihres anited hycon-
Bwtiu' tissue. 6. sopnmtc tlhrva and uUinifiitttry cori'iWH'U*.
like cartilage under the scalpeL The oenix is generally less
firm tLan the body, a condition resulting, as M. Cruveilhier
believes, from the body and fundus being the more frequent seat
of sanguineous fluxions. Under physiological, as well as patho-
logical conditions, the tissue presents a more marked redness,
^ is more supple.
The uterine tissue is clearly fibrous in character, but the
B^tore of the fibres has been a subject of spirited debate. The
""^iCToftoope appears to have ended the dispute by showing them
to i>ft clearly muscular. This is further shown by the develop-
ment that takes place during pregnancy, the uterine inuHCular
™wa becoming large and powerful It is certain then that the
66
ANATOMY OF THE PELVIS.
Fig. 29
proper uterine tisBue is chiefly muscular, but the fibres in the
non-pregnant organ are condensed or atroph-
ied, so that their true character is in a meas-
ure concenleti In the latter condition of the
organ, the direction of its muscular fibres can-
not bo satisfactorily made out. They cross
and re-cross, as every examiner has found, in
an almost iuextriciible manner. Inasmuch,
then, as the muscular structure of the uterus
can be satisfactorily studied oidy during preg-
nancy, its farther consideration will be de-
ferred.
The Mucous Surface.— The existence of
any mucous membmue whatever on the inner
surface of the uterus, has been c^uestioued by a
number, and even recently by Dr, Snow
iu-vfioiu-ti jnM«culari3e(,t ♦ ^.j^^ insists that what has been so re-
flbrcH ironi thu gravid . , - x, • in ti.
«i»Tus', (Wagner, t garded 18 nothing more noi less than soften-
ed proper uterine tissua Authorities in general, however, do
not concur in this belief, but agree that it is essentially a
mucous membrane, differing from mucous membrane in other
parts ehieiiy in l)eing more intimately associated with tlie
subjacent stnictures, in consequence of possessing no definite
connective tissue fnune work of its ovni. Us color is pale pinL
lis thickness varies considerably in different parts. Towards
the middle of the lx>dy it constitutes al>out one-fourth of the
thickness of the entire uterine walls, being from one-eighth to
three-si xteeutlis of an inch in depth. Like the uterine walls
themselves, it thins off rapidly tt>wards the internal os below,
and the Fallopian tubes alx)ve. In the cervical canal it is thick
and more transparent than in the body of the uterus. Within
the cervix the uterine mucous membrane IcHJses many of its char-
acteristics. On the anterior and j_x »sterior surfaces <»f the canal is
a prominent perpendicular ridge, with one less distinct on each
side, from which extend ridgon at acute angles. Theee from their
appearance, liave been calletl tJie arbor nVci?, pennifann rugip, and
palmre plicatie. Like tlie vaginal ruga', tlmy are mpst distinct
ui \*irgins, and are indistinct after child bearing. The mucous
• ObeU't. Trans., vol. xiii., p. 294.
INTERNAL GENEl
OBOAN&
fi7
of the uterus in a normnl condition, is covered with a
^thin layer of transparent alkaline mucus.
The rterine Glands.— With the aid of a magnifj'ing glass,
the general structure of the uterine mucous membrane is clearly
oeen. It is maile up in part of c<inuectiv6 tissue, which is
directly continuous with the connective tissue of the muscidar
coat, in which, as a bed, are a large number of tubular, or utric-
nlar, glands. About forty-five of them are cont(iine<l in a sjMice
one-eighth of an inch square. These glands have a sinuous
wunse, often divide below into two or three separate blind
extremities, and are about one b^o hundred and twentieth of an
inch in diameter. As a rule they penetrate the entire thickness
r»f raucous membrane, and in some instances even dip into the
muscular tissue. Their basement membrane is composed of
•piniUe-shaped cells, which dove-tail into one anotlior. Their
free surface is covered with cylincbiwil cells, jxis^eHsiug cilije.
The mucous membrane itself jM>ssesHes an epithelial covering, of
the ciliated variety, which is believetl by Bome to protluce a cur-
rent in the direction of the Fallopian tubes.
The glands of the cervix, {glands of No-
hoik, ) cover the entire area of the cervical
canal, from the internal os to the bordere of
tlie external. They differ from those found
within the uterine cavity. Like them they
are cylindrical, but terminate in a nnuuled
cul-de-sac, lentil-shapetl. These glands are
so numerous that, according tt) Dr. Tyler
Smith, " on a mcxlerate c<>mputtition, under
a power of eighteen diameters, ten thousand
mucous follicles are visible in a well-devel-
oped nulliparous organ." " Those glantls,"
says Dr. Lusk, "aie, genetically consid-
ered, simple inversions of tlie mucous mem-
brane. find are lined by ciliated epithelium."
Obstruction of the neck of these glands gives
rise to straw-colored vesicles, which have
. been called the ovula of Nalwth. The pen-
JWiion a.ron».|/«t.. ^^if^'™ rug»e give to the cen-ical canal an
res «ittowiii)i rjivity. n, extensive secretory surface, whicli funushes
ind glimdular struct- ^ ii,„i:«« *»i-,^«ii^
Bni.1 [lUhtx). an alkaline mucus.
Fiii. 30.
68
ANATOMY OF THE PELVIS.
The Tessels of thp Tteras.— The uterus receives its bl
from two sources, viz.: 1. the t\vo ovariftn, or sperniati<
arteries, and 2. the two nteriue. The origin of the ot^aHm
arteries ia Hb<>nt two-aiul-a-half inches nlxjvo the aortic bifurca-
tion. They pursue a serpeutine course, descentliug obliquely
do\mwariis under the fieritoueum to the i>elvic wivity, and thei
ascending between (he foUls of the broad ligaments. Tliey then
reach by their main trunks the sides of the uterus, and communi-
cate with the uterine aiteries. The uterine arteries are derived
from tlie lij-pogastric. Tlieir course is at first to tlie vaginal
fornix where they give the "vaginal pulse." Thence they cur\*e
upwards between the folds of the broad ligament, and imsa in a|
tortuous C43urse over the lateral borders of the utprinecer^nx and
body. By means of a circumllex branch at the junction of cervix^
and corpus uteri, the arteries of each side communicjite.
Fui. .11.
Arterial vesaela in a nterus teu days after delivery. The posterior aspect \i
shown. 1, fundus uteri; % vaginal |tortion; 3, 3, round ]i>{amont; 4, 4, fal-
lopian tul)es; n, right ovary: (>, nlMloni. aorlu; 7, inf-nicsi'nteriL' art; 8,
spermatic arteries 9, coiniuou iliac. 10, txt. iliac; II, hypogupt. art.
The veiyis of the uterus f onn a network through all the uterin
tissues. They are so intimately related to the latter that they
remain open after section. They enlarge during pregnancy to
THE nrrEBNAL FEMALE OEKEKATIVE ORGANS.
69
fiirm "sinuses." The blcxxl, collected by the veins, is caiTietl
iiitotwti vrnous pU\raseSf namely: the ulrrtHc. Rud patuju'inftfrm,
Tk> latter returns blood trom the uterus, Falh»pian tubes and
m*arie6, but the former from tlie uterus only.
Fir., na
yZrr^f nf tht iitrnirt. A, p1i<xU8 uterinuK ma(j;TiiiM; Tl, plexus hypogastxicDB;
C- .:itiKlii>iL l.iwicnim; 2. rvuttim; 3, hUuldcr; 4, ut<unui; 6, ovary;
6. ' ol' Fallopimi tu1>c. (Fnuikcuhacuser.)
Ihe I terine Nerves, — Frankenhaeuser.* who is probtibly the
ktecit and best authority, srtys that the nerves of the uterus are
*Dit Nerren dcr G«>»lirmutter," Jc-nn, 1-^(17.
70
ANATOMY OP THE PELVIJB.
derived from the gangliated cords of the Bympathetio system,
through which iiuportant comxectioas are formed with all the
abdominal viscera. Tlae nerves supplied to the organ, when
examined without the aid of a lens, are soon lost to sight in the
uterine walls, but in microscopic preparations, Fraukenhaenser
has traced their ultimate filaments to tlie muscular element,
where they appear to terminate in the nucleus of the fibre-celL
It is a conviction of some that there exist in the uterus certain
ganglionic centres of indejiendent nervous action, like those
found in the walls of the heart.
The LymphatiC8. — Lympli-spaces iilH)und in the uterine tis-
sues, and regular lymphatic vessels are found in tlie connective
tissue about the arterial trouks in the parenchyma. Beneath
the x)eritonenm is found a real network of these vessels. Large
receiving vessels lie just beneath the external muscular layer on
either side of the organ, into which the lymph fi'om both the
subserous and uterine vessels is poured. The lymphatics of the
cervix
Uterus with double cavity, tvnd slight deviation of form.
BeTelopTiient. — In the embryo the uterus is formed by the
fusi<jn of the two ducts of Miiller, or the efferent tul)es of the
ruilimrntarj^ generative apparatus. Uiwrn thus uniting, tlu> par-
THE INTERMAL FEMALE OEXERATIYE OKOA^S.
71
tJtioD between the two is absorbed, and the organ is then pos-
aeesed of but a single cavity. In different stages of development
tiiere is acoortlingly an organ of various shape.
AbnormalitfeK of the Uterus.— The various abnormal con-
ditions of the uterus and vagina which are occasionally met, are,
Fiu. 34.
Cieraa wptos hiloculariiii. I>ntil»le iiUtus, wttli mii^U- vugimi, r>eoii fb>ni the
IKkiL httX walls mon* clfvHoiH*d in i'onfle<iiirnc<* orpreguanry. (Criiveilhicr.J
ill the main, the result of arrested devoUipment. After the canal
or ducts of Miiller have united tt> form the rudimentary uterus,'
if the partition shtmhl remain, the result is a donhlo or bifid
tderns. This may be true of an organ presenting little differ-
ice in form from Uiat of the normal uterus, as shown in figure
or the organ may present an external api^^arance Avhich cor-
mds U> its internal anomalies, as in ligure 34. The parti-
tion may not exist alone in the uterine cavity, but extend down-
wnnLs 'ind form a double vagina as well.
The folUtwing constitute the main varieties of abnoTTnalitiea
met: 1. The uterus unicornis^ or single- horned uterua In that
cose tlje organ presents but a single lateral Imlf, and generally
72
ANATOMY OF THE PELVIS,
boH but one Fallopinu tube. 2. The Duplex Ulerus, — Two dis-
tinct uteri are produced, each of which, represents a half of the
Fio. 35.
T>oii>>le nUTiw tim! vaKina from a girl um^ niaetten (Kn*eniminn). a, double
va^)lull orilice witli doiibli' hyuu-ii ; &, meatus iitvlliru;; c, rlitoris; d, uri'lhm;
*, *, llif Hoiible vagina ; J\/. iit«Tiin- orifiit'-s; g, g^ eiTvit-jil purtiitns; A. A, IwHlies
uml corrum: i\ i, ovum*H; Jt ^-, Fttllopiou tubis; lyl^ ruuml ligumoute; m^ m,
liroad lipimeutti. iCuiirty.)
normal utorus. 3. The Uterus BicoiviiH.—Th'm results from
paj'tial uniuu of the ducts of Muller, giving to the upper part of
tLe orgau two horns, divided by n furrow. 4 The Uierus Cor^
diformis. — Thisj aa its name indicates, presents the form of a
heart as ordinarily re[)resented cm playing cards. 5. The Ute-
rus Sephis Bilocnlnria—Xl man in this case is complete, but the
septum persists, as representeil in figure 34
^^
THE INTERNAL FEMALE QEN£KAT1"\'E 0110AN8.
73
CILVFIER V
The Internal Female Generative
Organsr— (CokTiNCED. )
The Fallopian Tubes, or Ovidiirts.— These are the infundil)-
nJa or iiigluvieH whii^h tjike up niid convey the ova from tlie
oraries to the uteiine ca%it)% as well as transmit to the ovaries
the fecundating principle i)f the male. They ineasure from
three to four inches in lengtli, and extend from the upper angles
of the uterus to the ovaries. Their course is along the tipper
margins of the broad ligament«, lieing covere<l by the peritoneum
Fiti. ;«».
Od' U*
'\
\
\
i.a
o
u
Oi«T Mjil FullopittD mh*. (i li, Funoiji'i" tube ; o, ovury ; o a, fimbriated
■Wrtmity of thf tulic ; p o, parovarium.
•imihirly to the uterus. They may justly be regarded as inte-
P^i portions of the latter organ. The Falloj>ian tubes are tmm-
P^UhnpeiL and terminate near the ovaries in a comparatively
^"^•ful, fringed end, called the Jlvihrifiivd virlrcmiftfj or mors^is
^toholi This free extremity communicates with the abdominal
c*vity. One of these fimbriie is atUiched to tho outer angle of
u
ANATOMY OF THE PELVIS.
the ovary by a fold of peritoneum. It is 8upi>osed tlint during
the menstrual nisus these fimbriie apply themselves firmly tii the
ovary, in order to receive the escaping ovula Its uterine ex-
tremity presents an opening known as the osUum uien'nuni,
which is 80 small that it will scarcely admit n bristla These
tul>e8 ai'e remarkably movable, so that they are not only capable
of applying themselves to those parts of their respective ovaries
frc»m which the o^Tile is to come, but, as is now believed, U>
stretch themselves to opposite sides to receive an escaping ovule.
In some cases there are found to exist sujiemumerary fimbriated
extremities which communiciite "with tiie tube at some distance
from the main extremity. In the bfxHes of twenty women, se-
lected at random byM. Gustave Richard, tliis anomaly was found
five tiujf^s.
The walls of the tubes are composed largely of unstriped mus-
cular fibres, arrangeil in two layere — one longitudinal, and the
other circidar. By virtue of these the tubes have a vermicular
or peristaltic action. Between the muscular and peritoneal layers
is a web of connective tissiir*, uhicli gives sup]>ort to a rich
plexus of bltKxivesselB. The mucous membrane lining the cavity
of the tul)e is liighly vascular, and is provided witli ciliated epi-
thelium, which is said to jiroduce a current in the direction of
the uterus.
The Ovaries- — These are regarded as the essential organs of
geueratitm in the female, since they provide the germ which is
made fi'uitful by cout^jct with the mnle fecundating principle.
They are the analogues of the testes, and, up to the time of
Bteno, wore called "testes mnlieris." They are situated on
eitlier side (»f the uterus, within the pelvic cavity, and are at-
tachtMl to that organ by muscular bauds about an inch long,
called the ovaruni h'gawcufs. They arc small, oval, flattened
bodies, broader at the end distant from the wcimb, their meas-
urements being alw»ut an inch and a half long, alu^it three-quar-
ters of an inch in breath, and three-eighths to h-nlf an inch in
thickness. They are situateil between the layers of the bn^d
ligaments, the i>osterior layer being reflected over the entire or-
gans, save at the atbiched l>orders, at which jwints openings ex-
ist for transmission of the si>erraatic vessels. They lie beneath,
and somewhat behind the find)riated extremities (»f the Fallo-
pian tubes. Besides the jieritoneal coat, they have V>eneath it
THE INTEBKAL TEMALE OENEIfATIVE ORGANS.
uiother* the tunica aJbuginea. This covering is bo intimately
Hdlierent to the subjacent tissues that it cannot be stripped o£
k the first three years of life it is entirely absent.
Fio. 37.
UTiKitndinnl section of on ovary froin n pirl einhU'pn years old, 1. Alba-
JWn^: % tthrotifl Ittytr of cortical p(»rtifm ; 3, crlluliir layer of cortical ix)rlion;
^oiedtill»ry )4u>M<t4Uiit: ; 5. looee oonnective tiHsiic.
IV^neiith the albnj^inea the parpiicliyma of the organ lias /in
tnjlt^r corficai, and an inner wefluUfWff subsfttnrr. The fonuer is
of II (fmyiiili fol(»r, and is nmde up of interhieed fibteH of con-
i'' tissue, containing a large number of nuclei. It is in this
^t'U^ture that the Graafian follicles and ovides are fouiul. The
»tUir exist in immense numbers in various stages of develop-
ment, from the earliest periods of life. The stroma of the
owtical sul>sUmce is at no place sharply distinguishetl from tiiat
'•f liift uicflullary. In figure 37 the outf^r portion is termed tlie
fitifotiB layer, t*i distiuguish it from the in(jre central portion.
AITATOMT OF THE PELVtS:
there Iwing a differejicse in ite structure. The meduUftrj' buH-
stanoo has a reddish color, given it by its numerous vesselii. It.
Fro. 38.
t
V',-'
•s.
V'
*
t>
//
^.
\
A
A-
\
i-^
Portion of vertical section thmufsh ovary of hitch. «, epithelium of ovnry-,
i, h, tubnlus of ovary ; r, yoiiuj; follicles: rf. imitnrc lollieles; p. di.vus proli^
iTus, with ovun» ; /, opilhrliutn of weciind ovum in Mime tbllk'le ; jr, tiinicA
tibroHu foUicu]! ; A, luuicji propria foUiotili; i, meuilmina punuhiMi. lAVul-
dcycr.)
oonsiets of loose connective tissue, v-itli some elastic, and
muscular. Rouget* and Kisf claim that the greater part of the
ovarian stroma is formed of muscular tissue.
• Journal do Phywol., Vol. i, p. 737.
t SchnltM'a Arch. f. Mikrocop. Anat., 1865.
THE INT:iiK>AX. FEMALE GENiCBAXIYK OltGANB.
77
The iiraaflaii Follicles, or owsocs.— Waldeyer, and others,
from (mus-takiiig research, have found that the Graafian foU
r ■ formed, ut an early period in fcetal life, l>y cylindrical
i. i. us of the epithelial covering i)f tlio ovary, wliicii dip into
Uie 8ul)stance of tlie gland. These tabular filaments anastomose
^irith each Dther, and in tliem are furmed the ovules, which are
sloped from the epithelial colls lining the tubes. Portions
become dindetl from the rest of the filamentft, and form the
^Graafian follidea Acceptmg this vievr the ovides must l>e re-
as liigldy developed epithelial ■ cells, derived primarily
fnnn the surface of the ovary.
The number of Oraafiau follicles ia immense, tlie ovary at
birth being estimated to contain not leas than 30,000; Honle*
•wtimates tliem at 3<),000. No new follicles are formed after
birtli, but development and destruction are constantly p>iiig on.
[£,.oourbe, but u small pro|x>rtion of the entire number ever
Fio. 39.
f
niAtillAMMATU- SKt'flUN OF (iKAAFIAN FOT.MCI.E.
I, Dvuni ; 2 memhrana Rnuiulosa ; a, external nivmbrane ol" UrniUinn ibilirle ;
■ vtseeU; 5, ovarian strouA ; 6, cavity of GruufiaD follicle; 7, exteruiU cov-
Mi; •>/ ovarj.
reach maturity. The greater part of these follicles are not
risible to the naked eye, but under the microscope they come
plainly into view.
The structure of a ripe Graafian follicle is 1. an investing
membrane, consisting of tT^'o layers. Tlie external, or iitniai
JBnrmn, is formed of connective tissue, and is highly vascular.
The internal, or lunica propria^ is also composed of connective
tiasne, bat contains a large number of fusiform cells and
• UCXLC, " Haudbuch tier Eiuyowpidilchre," 1800, p. 476.
78
THE ANATOXY OF THE PELVIS.
numeroufi oil globules. These two layers are really formed of
condensed oyarian stroma. 2. The meinbr ana granuloaot con^
sisting of stratified columnar epithelial cells. Near the clroam-
ference of the ovisac is 3. the mmle, around which are oongre-
gaied a large number of epithelial cells, forming what is known
as the discus proligcrus, 4. Transparent fluid fills the re-
mainder of the follicle, with three or foiir bands, or retinacula
of Barry, stretched through it^ and attached to the opposite
walls of the cavity. In some yoiing folliclee the ovule fills the
ejitire cavity.
Fio. 40.
I'teriue ami uUTo-ovarian veins ipiesu3 papinilormis). 1, aiprnsfleen from
the frout ; il» rinhl half is covenxl by the piTitoavum ; u|)on the left half uiay
l»e M-en tlie plexus of utoro-ovariun vciiw (internal •t|K;rmatic) ; 6, nteroovarian
ver^els c<neretl by ]>eritiiueum ; 7, the same vesspls exposed ; 8, 8, 8, veins Irom
the Fallopian tube; 9, vt-uou* plexiui of the hiliini ovarii; 10, uterine vein ;
11. uterine artery ; lij, venona plexuis covcrinjc the Iwrderw of iJie utrrtiK; 13,
aoaMtouioHeifl of the uteriue with the utero-ovarian vetu ^iiit. spermutic.u
The Ovule. — The ovule is a roundetl vesicle, about 1-120 of an
inch in diameter. At tlte time of its discharge from the ovary it
is no longer a simple cell, composed of ordinary protoplasm, but
presents tlie following characteriBtics: It has a thick, transparent
envelope, termed tlio riirlliiie mcmhrmWf or zona pi'lluciiku The
body of the cell is the vtivUus or yolk. It poesesses the proper-
ties of ordinary protfiplasiii, has a viscid oonsistenoe, and is
opaque from the presence ot very fine granules and globular
vesicles. The nucleus of tlie cell beoomes converted into a
large, clear, colorless vesicle, called the germinative vesicle^
The nucleolus persists as a dark, probably solid body, within the
germinative vesicle, where it is known as the germinaiivc sjx4.
The ovule is attachetl to some part of the internal surface of the
Graafian follicle
THE INTRA -PELVIC MUSCLES.
70
Teesels and Nerres of the OTary,— The arteries of the ovary
■TV «l«^rived from the interaul spermatic, euter at the hiluin and
peDebate the medullary substauce in a spiral course. The
linuxrhes freely anastomose, and form nn interlacement Be-
tween the vessels, thus connected, are spfices, wliich become
smidler and eninller as they approach tlie surface of tlie glantL
The V4:ins begin as railicals, raj^idly enlarge, and have a varicose
appennuiee. A plexus in formed by luuiatoraottis, including
.*l>nce3 of varying sizes. Their blood is then conveyed by veins,
following the arteri;d brfinches, to the internal H]>ennatic vein-
Lymphatics and nei*ve8 exist, but tlieir mode of termination is
m>t undersUKxL
Thi* Ititru-pelvic Muscles. —Certain muscles which encroach
u;k'Ii tlie pelvic space shoxdd l>e mentiouetL The iliac muscles
accupy the entire iliac fossa?, the fibres converging below, and
Fiu. 41.
SACRUlCb
pmimAusji
SocUou of Fehii*, Hhowhi;; Ihe pynuuiihil muai^les.
piii^iiig under Ponpail's ligaments, and becoming united to the
^lers of tlje psoiB muscles. These muscles cushion the iliac
^'«s;n, and tliereby afford a soft support for the gravid uterus.
Tlie great p^om and the iliac muscles encroach more or less
uihin the transverse pelvic diameter at the brim. By virtue of
tk'ir femoral insertions, these muscles servo as flexors of the
*^'gK while, in addition, the iliacus hcIshshu alxluctor, and tha
P*»« acts as a flexor of the pehns upon the spinal column.
The pyramidal muscles close the sficnMJciatio notch. Tlieir
80 THE AKATOaiT OF THE PELVIS.
shape is triangular, the base presenting a series of digitations,
which find insei-tion upon the lateral jwrtions ©f the anterior sur-
face of the sacnun, along the outer bonlers of the four inferior sac-
ral foramina, and the upper portion of the sacro-sciatic ligament
After crossing the greater sacro-sciatic foramen, and emerging
from the pelris, they terminate in a tendon, which is inserted
into the trochanter major.
The obturator internus mnscle arises from the circumference
of the obturator ft.>ramen, and the inner siu'face of the obturator
membrane. Its converging fibres form' a tendon, wliich x>asses
out through the lesser sacro-sciatic f(.>ramen, and is inserted into
tlie digital fossa uf the great trochanter. None of the intra
pelvic muscles occupy mudi 3f)ac6 in tlie i^elric cavity.
The Maniiuary Glandn. — ^An account of the female generative
organs would be incomplete Tiithout at least a brief reference to
the mammary glands. They are two in number, of the com-
poxind racemose variety, are situate on either side of the
sternum, over the i)ectoralis major muscles, and extend from the
third to the sixth rib. They are ©mvex anteriorly, and flatteneil
jwsteriorly. Their size is found to vary considerably, chiefly on
account of the difference in amount of adijx)se tissue which
tliey ct»ntain. During pregnancy they increase greatly in size,
owing to hypertrophy of tlie glandular structures. Anom-
alies in numl)er, shape, and iK)sition, are occasionally ol>-
servecl Tliey n re C( nt^red 1 >y a fine, supple skin, and a
layer of adiiH)S9 tissue, whicli increases in thickness toward
the i)eriphery. The glandular mass is made up of from fifteen
to twenty-f<mr h)l)os, tliese l>eing sulxlirided into lobules, con-
structed of ftriin\ or minute cul-de-sacs. The acini open into fijio
cuuidiculi, which unite until they form a large duct for each lobe.
The ducts in turn unite until they foim a still larger duct coni-
nioii to the lol)e, wliich oi)ons on the sui-face of the idpple. The
latter canals are known as ffalaciojihonis, or luciiferous diicfs.
They enlarge as they reach the space beneatli the areola tt^ form
the ifiuus of Ihc dtici, measuring from one-sixtli to one-third of
an inch in diameter. In the nipple, their diameter is from one-
twelfth to ono-twenty-fifth of an inch. Tlie openings on the
nipple are from one-sixtieth to one-fortieth of an inch in diame-
ter. The accini are lined with a single layer of small polyhedral
cells, becoming more cylindrical near tlie canalicnlar ducts. The
TH£ HAMMAIIY OLAKOS.
81
ntuxk ducts are liuecl ivitli low, cylmdrical cells, and are provided
with noii-striHteil wustrular fihres, wLicb wmtraot uud produce a
free d»jw of the eecretioii during lactation.
VUi. 4-2.
Mamniwy i^and. n, nipple, tin* cfiilml portion of which is n'traotod ; hi
■jwlft; r, ?, r, c, r, lobules of thrt gliind ; 1, ^inus. or dilntnl portion of one ol
•« *i«:Urtrott!j dncts ; % extremitirH of the lactiferous ducU*. (Liegeoia.)
The nipple is situated at the summit of the mamma. It is a
('otucal projection, varying greatly in size. Dopresaed nipplee
we ofU'u met, which is a condition generallyt though not
'l*«ysdue to natural causes. Its surface is covered ^vith papillaa,
** thel)ase9 of which open the lactiferous ducts. Upon its surface
We alao tlie oi}ening8 of numerous sebaceous follicles, the eecre-
tionaof •which protect and soften the integument chiring [aeta-
ta. Beneath the skin are muscular fibres, mixed with con-
***ctvYe atwl elastic tissues, vessels, nerves and lymphatics. Ir-
ritatuiu of tho nipple causes contraction and hardening, owing to
"muscular ftction.
T^i' rjrw/a ifl a circle which surrounds the nipple, of a color
<«wriu(; frum the other integument It is pink in virgins, and
82 THE ANATOMY OF THE PELVIS.
is provided with from fifteen to thirty f oUidee, which imder cer-
tain conditions poor out their secretions and moisten the areola.
A band of muscular fibres is found beneath the integument, the
action of which is to compress the lactiferous ducts, and thus
favor the fiow of milk during lactation.
The mammse receive their blood supply from the internal
mammary and intercostal arteries, and are provided with lym-
phatics, which open into the axillary glands. The nerves are
derived from the intercostal and thoracic branches of the bra-
chial plexus.
PART II.
PREGNANCY.
CHAPTER I.
Development of the Ovum.
Inasmnch as this branch of obstetrics is of theoretical, rather
thAii jiraotical vidue, to the student of luidwifery, and Bince the
study of it has b<^en diligently pursued by a few, under most
faTomble auspices, and the results of their investigations re-
cordod, the author has taken the liberty to draw freely from va-
rious authorities on the subjcot, sometimes in their own words,
without, in every instance, giving the credit wlxich may seem
to he due.
Tlie anatomy of the ovary with its Graafian follicles and
omles has alreatly been givea The formation of the Graafian
follicles is in the main corapleterl during the ante-natal period
of existence. Until abt^nt the time of pul)erty they remain in a
qniescent state, bat with its advent they begin to assume func-
tional imp<.)rtance. The surface of the ovary, when now exam-
ineil, is found to be uo longer smooth, but studde<l with small
aloTAtions. These elevations are cf\used by the enlarged Graaf-
ian follicles, which have approached the i)eriphery, and now
being diftt^nded by their Htiid ctmt-ents, form mmidtHl, translu-
ceut prominences. From disappearance of the blood-vessels and
lymphatics at tlie [H)int of pressure, a weak HjMjt in the wall of
the follicle is formed, called the macula or sfigtna folUcnlu
The discharge of the ovum is due to the conjoint action of a fatty
degeoeration of the walls of tbe mature follicle, and tlie develop-
ment of the following changes: The follicle becomes congeste<l,
ftnd the vessels coursing over it loailed with blood, while, at the
•Bine time, the ovarian covering l>ecomes so thin, that the eleva-
tion preeents a bright red. color. Laceration of some of the capilla-
(83)
84
THE PHVSIOLOaY OF THE OVUM.
rics ill the inner coat takes plucc, and a certain quantity of blood
escapes into the cavity of tlie follicle. By these means the dis-
tension is gi'eatly increased, until at last, under the additional
stimulus of sexual excitement, or without it, rupture occurs, and
the ovule is set free. Whether laceration takes place befoi-e,
during, or after menstruation, is still an unsettled question- Tliin-
ning of the follicular and ovarian walls goes on at one and the same
time, and final rupture takes place simultaneously. It is prolv
able that laceration is furtlier promote*! by growth of tlie inter-
nal layer of tlie follicle, which increases in thickness l)efore
rupture, and assumes a characteristic yellow color, from the
numl>er of oil-globules which it ccmtains. Contraction of the
muscular tibres in the ovarian stroma is also supposeti to have
an influence in the production of laceration. As rupture occurs,
the fimbriated extremity of the Fallopian tube is ch>sely applied
to the ovary, receives the freed ovule, and starta it on its way to
the uterine cavity.
The Corpus Luteuni of MenHtrnation. — At the moment of
rupture, or immediately after it, an abundant hemorrhage takes
place from the vessels of the follicle, by which its cavity is filled
witli bl<KxL The blood soon coagulates ami the clot is retainetL
The a|>erture through which the ovule escai>es is often not more
than one-fortieth of an inch in diameter. If the follicle is now
incisefl Longitudinally it will be seen to form a globular cavity,
one-half to tliree-quart^^rs of an inch in iliameter, containing a
soft, dark coagulum. lying loosely withui it An important
change soon begins. The clot contracts and expresses its se-
rum, which latter is al)sorbed by the neighboiing parts. The
coloring matter of the 1>Kxk1 is also, to a great extent, absorbed,
so that, at the end of two weeks, a diminution of color is x)en»ep-
tible. The membrane of the follicle becomes thickenetl and
convoluti'd, and encroaches on the cavity. At the end of iliree
weeks tlie follicle has become so solidified that from its color it
receives the name of oorpua hiftnim. It still continues in rela-
tion with the ruptured 8ix>t on the surface of the ovary, traces of
which yet remain. On section at this time it presents the
ap|)earance of a convoluted wall, and a central coagulum. The
ct^iaguluiu is semi-transparent, of a gray, or light-greenish color,
more or less mottled with red. Tlie wall is about one-eighth of
an inch thick, and of a yellowish or rosy hue. The entire cor-
rnZ COBPCS tCTEUM OF PJIEGXANCY,
ptM may be easily enacleated from the ovnriaii tissue. After
Ui^ tiiird week active retrograde changes begin. The whole
body undergoefl a process of partial atrophy, until at the end
of the fourth week it Is not more than three-eighths of an inch
in its longest diameter. The color of its walls has also changed,
it being a clear chrome-yellow. After this peritxl, the process
of tttrr>i)hy and degeneration goes on rapidly, until at the end of
eight or nine weeks, the whole body is represented by nn insig-
nificnnt cicatrix-like spot, less than a quarter of an inch m its
longest diameter, in which the original texture of the corpus
luteom can be recognizeii only by the ])eculiar.foldingand color-
ing of its constituent parts. It disappears entirely in seven or
eight months.
The Corpus Liitcnni of Pregnancy.— The foregoing shows
thut the mere presence of the eorj>u9 luteum is no evidence that
pregnancy has existed, but only that a Graafian follicle has been
ropturetl and an ovulo discharged. There is n difference between
the i^irpns luteum »if pregnancy, and that of menstruation, and
yet the difference is not essential or fundimental. It is, proj^rly
iking, only a difference in the degree and rapidity of their
Felopment. It will not be necessary, therefore, to enter ujw)n
a lengtJiy description of the ajipearances and changes, but only
to note some of the more salient [xiints. At the end of the first
month, the convoluted wall is bright yellow, and the clot still
feddish. At the expiration of two months, instead of being
reduced U^ the condition of an insignificant cicatrix, it is seven-
fflghtlis of an inch in diameter. When six months have passed
it is still as large as before; the clot has become fibrous and the
cnuvoluted wall paler. At the end of utero-gestation. it is about
bill! an inch in diameter; the central clot is but a radiating cica-
trix, and the external wall is tolerably thick and convoluted, but
ha** K»st its bright yellow color. The cor]>u8 luteum <tf preg-
ttuury is often termed the Irue, and that of menstruation the
/oise.
The Migration of the Ovum.— But a small proportion of the
OT» in each ovary ever meet with the conditions retpiisite for
fruition. Many doubtless perish in the ovarian stroma, wldle
otbtitrft are doubtless lost in the abdominal cavity, as we learn
from the occurrence of extra-uterine pregnancy, The precise
86
THE PHTSIOLOGY OF THE OTTM.
oonclitioBs wliicli determine the passage of the o-\iim through;
the oviduct to tlie uterine cavity, are still shrouded in obscurity
The theory that by virtue of its erectility the Fallopian tube at
the proi^>er moment is brought int*:) relation with the ovary
through its fimbriate*! extremit}% is hai'dly a tenable one, since
it has been demonstrated that the tube is not possessed of
erectile tissue. Rouget* found that injection of its vessels after
death did not communic-ate to it tJie sliglitest change of form or
placa Experiments upon the muscular fibres of the tubes has
brought no better results, as galvanization prodnce<-l only vermi-
cular contractions, which did not affect the jx^sition of the
fimbriiat Moreover, when we reflect on the situation and sur-
roundings of these tubes, it becomes difficult Uy understand how
it is pi>ssible for them to execute any very extended movements.
The theory ad\'anced by Henle that the ovum is drawn into the
Fallopian tube by cuiTents prcxluceil in the serum by the
ciliat^l epithelium, which covers l»oth the external and internal
surfaces of the fimbria?, appears to be gaining favor. Failures
of the ovum to enter the tube are probably common.
While the ovum is in the outer portion T)f tlio tube, progress is
made only by the aid of the cilife; b^t when further advanced on
its way to the uterus, additional ft>rce is supplied by the circxdar
muscular fibres.
Fecundation,— Conception, fecundation, and impregnation,
are terms all of which imply fruitful contact of the male audj
female elements, so that n new organism comes into existence.
The pre4?iRe jx>int at which this takes place has l3eeu the subject
of much speculation and research. It has been pretty clearly
demonstrated that it cannot be within tlie uterus, inasmuch as it
takes the ovum a pcritKl exceeding ten days t<:» reach the uterine
cavity, and an unfecundated egg cannot sustain life for bo long a
time. Abdominal pregnancies seem to prove the ix^ssibility of
fecundation at tlie ovary. But, when we reflect uix>n the rarity
of such j)regnancies, and the strong probability of the frequent
failure of the e8cni)eil o^Tim to enter tlie Fallopian tube, we are
* Rorr.ET" 1^8 Orpines Erertilcsrte la Fcmme/' Jour, dc la Pbyftical. t. i.
1&5H. p. xn.
t UvuTi. ''IlftndlnK'h dor Tojwgraphi.Hclu'n Anatomie." Wicu, 1805. Bd
ft, p. '210.
I Leisiimax, "Hystom of Midwifery,*' p. !)«.
FECUNDATION.
87
infer that fecundation at the ovary is anomaloue, Henle
has directed attention to the fact that the outer part of the tube,
poBBeBsing arborescent folds, is especially designed as a re-
ceptacle for the seminal fluid The congested cf>ndition f>f the
iDUcoos membrane, its canalicular structure, and the contractions
of its muBonlar fibres, all seem intended to further the intimate
itact of the spermatozoa with the ovum after it has reached
situation.
The fecundating principle of the male is secreted in the testes
hi puberty, and is called the semen or seminal fluid. During
sexiial congress the semen is ejaculated with considerable force
by the fibres of the vasa deferentia and tlie special muscles which
luind the vesicuhe serainalea and the prostate glantL It thus
rhes the upper part of the vagina, and doubtless sometimes
even the cerncal canal, from which situation the spermatozoa
ascend to tlie p«"tint of contact with the female ovum. It is,
however, an established fact> that deposit of the seminal fluid
deep in the vagina, is not an esHential condition to impregnation,
for pregnancy has been found coexistent with imperforate
hvmen.
The semen is a thick, glutinous,
wliitibli, albuminous fliiitl, heavier
than water, and emitting a char-
acteristic odor. AVhen placed un-
<ler a jjoweiful lens it is found to
consist of a large number of small,
o%'al, flattened bodies, measuring
not more than 1-6000 of an inch in
diameter, provided with t-fiils wliich
taper gratlually to the finest point
The entii-e spermattjzoou measures
Sperinatoxoa. from 14J0O to 1-400 of an inch.
Th<:*se bodies do not passively float in the seminal fluid, but
niuve about witJi a lasliing, undulating motion as though
emlf»ved with volition. The appearance of independent life,
which they manife^^t, was wliat led Kolliker to cinnpure them
to ciliated cells, and gave the erroneous notion that they were
ftXMmalcoles. The name sjiermaiozoa, which they bear, is sug-
gi«tive. Henle, in his '* Haudbuch der Eingeweidelehre," al-
leady referred to, has estimated their speed at an inch in
Fia. 13.
88
THE PHYSIOLOat OF THE OVUM<
seven-and-a-balf minutes. It is doubtless to the spermatozoa
that the semeu owes itH fecaudating power. Neither is thia
faculty speedily lost, for examinatioDs have demonstrated the
vitality and activity of these bodies withiu the female generative
organs eight and ten days after ejaculation. If, then, the
spermatozoa are absent from the seminal iiuid, aa in debility or
old age, impregnation is impossible, and it iB their absence from
the semen of hybrids that rendere tliese animals sterile.
Our knowleilge of the process of fecundation is very limited,
the fact only l^eing known that the spermatozoa ]>enetrate the
vitelline membrane, and then dissolve in the vitellus. Various
tlieories of penetration have been advanced. Barry, in 1840,
tliought he hatl discovered an opening in the zona pellucida of
tlie rabbit, which appeared to be designed for passage of the
Bjjermatozoa. Kebler confirmed the discovery of such an open-
ing, and cftllpd it the micropyle, and its existence is now gener-
ally admitted in the instances of fishes, mollusks, insects, eta
Robin* has made some very interesting and instructive observa-
tions u{x>n the ova of the iiepheUs milgaris, or common leech.
Ho found that the spermatozoa in their movements aroimd the
ovum assumed a i>erpentlicular or oblique ilirection to the ^ntel-
line membrane. At one point penetration of this membrane
could be distinctly obsen-ed. At the end of an hour the pene-
tration had ceased, and then a little bundle of spermatozoa could
be seen arrested, jwirtly within and partly without the ovum.
They continued to move in the clear, limpid fluid surrounding
the vitellus, for a time, but after fifteen or twenty minutes their
movements grew slow, and in about t\^o hours had altogether
ceaseiL It was then found, by counting the number remaiiiing,
and comparing it with that of the sjjermatozoa which entered, that
some had disappeare<L They had l>eeu absorbed directly into
the vitellus, to sei*ve for its fecundation.
Conrse of Hperniatozoa to Point of Fecundation. ^The
movement of the spermatozoa through the uterus and Fallopian
tnl>e is proba!)ly effected by various agencies. Pirst: By the
imdulatory motions of the 8|>erraatozoa themselves, although it
is diiBcult to comprehend why these should pn)pel them in any
* " M^raoire sur lea Phenomt^nes qui »o passcnt dans I'Ovule Avant lasesmexii-
ation du VitcUua.'* Hobin, Jour, dc la I'hysiol. t. v., p. 67.
CBANO£$ IN THE OVUlf AFTEE FECCKDATION.
89
definite <lirection. Secondly: By the action of the cilite of the
t|iiUieliuui lining tije jiassages. Thiiclly: Muscular peristaltic
roQtractiuns. It is highly iu^probable that their course is through
iLe channel said, by Mauricean, De Grnaf, and others, to exist in
the uterine walls. It is quite i>robable that such a canal exists
unly as an anomaly.
Fio. 4-J.
Bifurt'.iii(iu of tubiil ciuiiil. — (Heuuig.)
Changes iu tho Ovum After Feciin<Iation.— It should be
preiuieeii that our kuowleilt^'O of what takes place in tho t)viuu of
Ihe human female is derived mainly from analog)*; but from the
itndies in ci>mparative jjhysiology ililigently prosecuted V»y a
lew, it is quite probable tliat tlie changes described in the foU
kfiring pi^res are wortliy of credence.
One of the earliest clianges which has been observed is the
di>: ice of the gprminal reside. This may occur, how-
fv '. :a« r fecundation has taken place or not, but, in an im-
pimgQuted oAum, the etubri/o cell is formed in its place. Inas-
much as tl»e entire time coiisume<l in the migraticm of the ovum
to tin* uterine cavity is upwarils of ten days, it is assumed that
mae of these changes take place while yet it occujues the outer
Ihinl of the Fallopian tube. In this part of the tube the zona
p^lincida bect)mes somewhat thickcne<l, the germinal si>ot ditt-
Afipears, and its place is supplied by the embryo cell, while the
'Ttellufi l>ecomea somewhat condensetL Before tlie egg enters
tile uterine cavity the more remarkable changes begin by seg-
weniation^ ar ch'^tmye of ilie jjolk. Their first step is the forma-
tion ijf a deep furrow, wliioh, by extension, «Kin completely di-
ndt« thu yolk. TJiese halves are likewise divided by a similar
90
THE PHYSIOLOGY OF THE OVUM.
process, so that four spheres result Nor does the segmentation
stop here, but it goes on until the entire yolk has been converted
into a finely, granular mass, which has been well compared to a
mulberry. It should l>e understood that this segmentation also
includes the embryo cell or nucleus, so that every granular cell
resulting from the subdivision has its nucleus. From this gci'in
morulay or mass, the whole organization of the embr^'o is gradu-
ally evolvecL
Now begins another imi)ortant change. A clear fluid accumu-
lates in the centi'e of the mass, and gradually increases in quan-
tity, until finally a greater part of the original cells are flattened
Fio. 4.'».
Fl(i. Ki.
Fits. 17.
^ SiuTossivi- stii<>i-K orM>:ini'iitiiti<iii ol'tlio v«lk.
and ch>soly crow(le<l to the surface. AVe now have a vesicle,
calhnl the hhu^ftKh-nrn'r rr's/r7*», and the flattened coll Avail is
known as tln^ hlnsf<pilrrnn'(' wrmhjutnr. It is found now that by
absorjitioii, tlie dinn-usions of iho ((vuju havo been incroasod
from n diameter «»f l-.")(Hli to 1 2i)tli of an inch.
TluTc are sonio nf tli*' colls, forniod by the original segmonta-
tioTi, wliit'Ii do not t^iko ]iart in the formation t»f the blastotler-
niic uuMiibrantN and thoy accnninlato ami lio together atono s]Hit
just beneatli the irieniltrane. Tlien, l\v i>eriplieral extension,
these cells (gradually s])read over and line the inner surface of
the blastodermic nicnibrane, therei»y giving to the ovum a second
membrane. Tlio <mter layer of the }>lastcHlennic membrane is
accordingly termed the rrfnth-niK and the inner layer the rnit}-
tlrnu. The zona i>ellueida is now called the chorion^ and there
is formed between it and the blastodt^nnic membrane a thin
layer of fluid. During the formation of the entoderm, a Vu'ight
round s]X)t is observed in the eetnderm, which, as fmiher obser-
vation shows, marks th<* plaei* at which all the more important
processes connect»Ml with embryonic development take j)laco,
and is termed the ttrrti (jrrunHaiirn. Tliis is formed l>y the ng-
CHINOES IN THE OVUM AFT£K FECUNDATION.
91
Fig. la
^"•>-S^^^;^-
ation ctf the originnl segmentary cells. It at first presents
_ mogi'ueous appearance, but it soon develops in its centime
M dear space, oalle<V the area pcUncidti^ bounded by a dense
layer of cells. The area pelliicidn, at first circular, becomes
oral, and there funus in its centre a dark oval spot, termed tlie
emhryofiic »fH)L A longitudinal furrow, or shallow groove, then
its appeariince in the embr>onio spot, which has been
the prhniUve irme, the borders of which are called the
dorsal plates. It constitutes the earliest indication of the oere-
biro-epinal canaL
A third intermediate cell-layer
has meanwhile formed, termed
the mesoderm, lyiiig between the
ectoilerm and the enttKlenn. In
this layer are developed the primi-
tive blood-vessels, which, as they
*leveIop, give to tlie area germ-
iuativa the name of nrva rattru-
haa. Later the mesoderm divides
into two distinct layers, gi>'ing to
the embryonic structures, at one
st^ige, four distinct layers.
-. , _.. Brieflv it may be said tliat the
Willi arra tjmntnativn. ectoderm 18 concerned in tlie for-
miilion of tho epidermis, hair, nails, the ghuidular structures
ol the skin, the brain, the spinal cord, the organs of special
•wise, and, it is snpposeil, in that of the genlto-urinary system.
Thp imter stratum of the mesixlerm gives origin to the coruim,
U*«» muscles of the truiJc concerned in moving the Ixxly, and the
tkelebon. Tlie inner layer of the mesoderm provides the mus-
coUr and fibn MIS tissues of the digestive tract, the bhK>d, the
W'»"d-vi-8st'Is and the blood-glands. The entoderm supplies the
^pitLeliom liaiing the walls and glands of the inteBtinos.
^hou a tmusverse section ni the primitive tmce is placetl
niidw o micTosc*:»pe, its characters are readily recognized, while
Ij'sieath the furrow a cylin<bacal organ kno\^ni as the chonln dor-
'k irmy he seen. It is alwut this structure that the vertebra
tually form. The latter Ixxlies themselves are derived from
^ longitudinal chords, separated by a cleavage from the por-
ticRu of the intermeiliate layer next to the chorda dorsalis on
/
92
DEVELOPMEKT OF THE OVUM.
either sida The peripheral jmrtioiis of tlie mesocierm are now
termed the lateral or abiiominal plates. The dorsal plates con^_
tinue their development until they meet La the median lui^|
forming a tube kiio^^Ti as the tubus me<Iallaris, the cavity withi^^
which is formed the centi*id nervous system.
The mesoderm, which at this point has been fused into a single
layer, now separates into hvo strata, united by their inner bor-
ders and tliereby form what are known as tlie yncstmfen'c folds.
The opposite extremities of the inner stratum of the mesoderm
curve inward, and tijinlly unite to form tlie intestine, while at
the same time, they iuolose tlie entoderm. The closure in tl
case is from front to rosr, as well as from side to side, but d<
not include the entire blastcKlerraic vesicle, a considerable por-
tion hanging liuring tlie early months to the body of the embryo,
called the umbilical vesicle. Finally the ectoderm and the
outer sti'atuui of the mesixlfrm cui*%'e forward and inward to in-
close a long cavity, which surroumls the intestines. This cavi-.
ty is eventually divided by tlie diaphragm into thorax and a1
domen.
riu
Fl«. fiO
The embryo as thus far formetl gradually moves toward tho
center of the ovum, wliile there rises nl)out it on every side, foltls
made up of tlie ecttxlerra and the outer layer of the mesoderm.
Between the latter and the iimer stratum, is a collection of fluid.
The process of de[)ression goes on. and tlie folds of the ecto-
derm, now cnHed the amniolic folds, aj»proach ch>ser and closer,
until eventually they meet The partitions are subsequently
broken down, and there is formed a cavity, called the amniotio
80CKCES OF NOUBISHMEST.
93
cariiy, with iis outer sac termed the amnion. This cavity fills
vilh flxiiii knovru aa the irntcrs^ or liquor timnt'L
Between the chorion and amnion is often found a gelatinous
fluid, traverseti Ly minute jilaiueutous processes, cidletl the r'//ri-
form fiodif, oTc<n'pns n'liruh'. It sometimes exists in considej-a-
ble quantity, and near the en<l of pregnancy may 1>e discJiai'ged
by rupture tif the decidua and chorion, and give rise to the sup-
imeiition that the -waters (liquor nmnii) have escaped.
Sourt'es of Nourishment-— Tho ovum, during its passage
tlinnigh the FalK>i)ian tube, is increased iu size by absorption
from 1-125 of an inch tti from l-r)0 to 1-25 of an inch. Tlio
structure previously nlladed to as the umhiUrrd vesicle is lined
by the entcnlerm^ and is c*jvere<i by tlie inner sti'atum of the
m«sodenxL Its cavitj*. wliich at first communicates with the
intestine, slmiu becomes separated by ttbliteration t>f its passage,
but remains attached to the intestijie by a pedicle. When once
lodge<l within the ca^-ity of the uterus, the ovum begins to draw
its nourislimeut fn>m the mucous membrane liiiiiij:; that organ, at
firet by mere absorption through its walls, and later tlirtmgh the
Dtenvplacental circuhdion. In onler to obtain a clear idea of
total nourishment, and hence of further embryonic development,
Fiti. ol.
^^
ITiimcii emHi-yo»t Ibe iliirtl wt-ck, with villi of the cborioD.
it becomes necessary to enter into a more intimate acquaintance
wth certain stractares to which allusion has already been made.
94 DEVELOPMENT OF THE OTUH.
Th© Chorion. — The chorion is the external membrane which
envelops the ovum. Originally it consists, as stated elsewhere,
of tlie vitelline membrane, or zona pellucicla. Soon after the
ovum enters the uterus this part develops amorphous villi, M'hich
serve to anchor the ovum to the uterine mucous membrane.
When once the amnion has been formed by the meeting of the
folds of the blastodermic membrane over the back of the em-
bryo, and the absorption of the partitions between them, the
outer layer of the blastoderm remains ft>r a time in relation to
the existing chorion; btit the latter, so far as it is a ventage of
the zona j)ellucidn, disappears, and a new chorion, as it were, is
formed from the ectoderm. The new chorion in turn becomes
covered with a growth of non-vascular villosities, which are not
solid, but hollow. These villi develop rapidly in size and num-
l>er, by a process of gemmation, so that at the close of the third
week the entire ovum presents ujwn its outer surface its charac-
teristic shaggy aj>i>earance.
The AUatitois. — During the third week a new organ is devel-
oi>ed, by metins of which provision is miule for supi)lying the
rapidly increasing nutritive demands of the embrj-o. This < >rgan,
which establislies vascular connection between the embryo and
chorion, is termed the alUmlois. It l>egins ns a sac-like projec-
tion from the jx)sterior extremity of the intestine, while yet the
umbilical vesicle is nn orgon of ct^nsiderable size. It is com-
lK)sed of two layers derived from the entoderm, and the inner
layer of the mesoderm, which Btxm unite to form one membrane.
It at first is provitled with two arteries and two veins, but later
the vein on the right side becomes obliteratetL These are the
same vessels as are afterward found in the fully-developed um-
bilical cord. Before the close of the fourth week the allantois
reaches the chorion, and then begins to spread ujx>n it and form
a vascular lining. The chorion and allanti^is now become fused
into a single membrane, ami constitute the pernunieni chorion,
the outer surface of which is calleil the exochorion, and the in-
ner the endochorwn. During the development of the allantois
the umbilical vesicle dimhiishes rapidly in size, until at the end
of the sixth week it is no larger than a pea.
As develoi>ment of the ovum advances, its surface becomes
less and less vascular, except near the place where the allantois
THE DECIDUA.
95
originally Anchored to the choriou, uud there vaBCularity ia rap-
iiily inoreafteiL At other places the villi of the choriou also
atrophy and disappear^ until, after a time*, the greater portion
Kif the uvnni becomes entirely free of vilh^sities, wlule about one-
third of its surface is covered with a thick, shaggy growth. This
ts tite site upon which the placenta is ultimately formed.
Flti. .V*.
J ■•rni;»iuni <>I tlu' DiH-itluii Krflexn. (First l^tagc).
The Decidua,— The decidua is comiKised of three tlistinct
portionA, namely: The decidua \em, the decidua reflexa, and
decidna 8ert)tina. The Dwiihta Vmui is notliing more nor
i tlian tlie mucouB membrane lining the uterine cavity. The
Dtxfduu Reflvjcn is a struct ore formed from the uterine mucous
Fl«. fKt.
Formation of the Deridua Reflexa L-ompletecl.
ttembrane. which, when completed, closely envelops the ovum.
Betw*K*n these two jwrtions there is at first, over a greater part
of ibe surface, a deciiled interBpace, filled with viscid, opaque
mncoa; but after a certain degree of development has been at-
lett the eidnrged ovum brings the two surfaces int<i close
itact, and they s«x>n l>ecome united The Ut'cidud Sentfina
i» nufrely that part of the uterine mucous membrane on which
the ovum rests, and which, eventually, is covereil by the
pljicenta.
Whi^n first formed, the decidua vera is a hollow, triangular
p, having three openings into it, being those of the Fallopian
96
DEVELOPMENT OF THE OVCM.
tubes and os uterL It continues to develop, by hyiiertntpliy, up
to the third month, nnd tlien ntrophy l^egins, and the process is
continued until it becomes thin and tramspureut 'When fully
develoi>ed, it presents, under a lens, oharact^i's which clearly es-
tablish its identity as hyi)ertrophied uterine muci>us membrane.
The formation of the deoidua reflexa is an interesting study. As
elsewhere remarked, tiie ovum, on reaching the uterine cavity,
fiiuls the mucous membrane in nu hyi>ertro[)hied audcouvolutod
Btate, so that the cavity of the organ is well nigh obliterated. It
therefore forms ensy attachment in a fold near the \Knui of en-
trance, and the rapidly-f'-^nued villi of tiie zona pellucida sorxe
to retain it The mucous membrane at the base of the o^nim be-
gins to si>rout about it» and extends luitil, aft<»r a time, the ovum
is completely inchised. Up t*> tlie third month, it shoiild be re-
memberetl, the decidua vera and decidua reflexa are not in c<:»n-
tact, since this fact has an iuip(^>ri4Uit l>eai"ing on the question of
Fi<i. •>!. 8Ui)erfcetation. Nrar fhr
dose of prr(7?iaHC^ the decid-
ua (l)oth layers now forming
cne meml»rane) l>ecomes al-
tered in api^earance, and is
fibrous and thin. Fatty de-
generation seta in, its vessels
iinil glmids are obliterated,
and it becomes easily separa-
ble innn the uterine walls.
The Placenta.-The villi
of the cln»ri<»ij are sent down
intothetissuest>f tlie decidua,
whence is derived tlie nutri-
ment so necessary to projM^r
development of the ovum.
After the vascular relations betAveen the embryo and perman-
ent chorion have b*^n formed, the area of nutritive sujiply is
greatly diminiBhed by atrophy of the villi of the chorion over
about two-thirds of its surface, and the tJiinniugi as well,
of the decidua reflexa, and obliteration of its vessels. As
a result of these chnngea, the whole process of emliryonio
supply and waste becomes concentrated at tlie decidua sero-
tina. The villi of the chorion at this ]X)int become arranged
Flap of necidiirt Ucflcxu turntrddown,
diisc'lfwing tlir nvuiii.
PLACENTA^ VILLI.
97
in tnftB, sixteen to twenty in number, the villi theniBelves multi-
ply, and ft tliick, soft, 8i:»ongy mass results, which constitutes the
foetal portion of the placenta. Within the transparent walla of
the villi the contained vessels may be seen under the micro-
scope, ilist^ndetl witli blood, and presenting an appearftnee
eouiewhat resembling tliat of a loop of small intestine.
These capillaries are the terminal ramifications of the um-
bilical arteries and vein, \nth terminal loops contained in the
digitaUuiis of the villL From the accompanying cut it will be
Fia. 5i5.
rilK-i'ltlill VillUB.
ISf each arterial twig is HCt'ompanied by a corresponding
V'-iioTis brancii, the two uniting to form the terminal arch or
^■P* By this means the bLxnl of the foetus is brought very
1W« the blood of the mother, but without coming into actual
oowtftct with it This condition is veritied by utter inability to
f'lrre any fluid into the maternal circulation, by the most oare-
fclijoouduoted injections through the foetal vessels. The exist-
ence of lymphatics, or nerves, in the placenta, has never been
(leraoustrated.
Tbo spaces between the villi of the placenta, which have been
98
DEVELOPMENT OF THE 0\XM.
demonstrnt^tl to be fiinuses in which circulates maternal blood,
extend tliroogh the whole tliickuess of the organ, closely embrac-
iiig all the ramifieatictna of the fintal tufts. The essential com-
position of the placenta when fiilly developed is nothing but
bloodvessels.* All the tissues wliich it originally contained have
di8aj)i>eareil, save the bloocivessels of the fcetus, associated with
and adherent to the larger blocKlvessels of the mother.
Ueneral Description. — The placenta upon examination as a
whole, is found to be a soft, sixtngy mass, of nearly a circular
form. It m*»asures about seven and n half inches in diamotor,
is about an inch in thickness at the insertion of the umbilical
Fio 5n.
Fcetal snrruce orilt« placenta.
cord, and has an average weight of about sixteen oance& Its
fcetal surface is smooth, nml, tlirotigh the amnion which a:tvei'8
it, can be seen the vessels rmliating in every direction over the
surface of the organ. The uterine surface lias a rougliened,
spongy feel, and is divided into n number of lobes, correspond-
ing to the foetal tufts, or cotyledons, before described. The lat-
•DaLTOX. " Treatise on Knnian Physiology," 1871, p, 646.
THE PLACEKTA. 99
ter are penetrated by curled arteries from the uterufi, which
convey the maternal blood into the laconm or biuubos be-
tween the foetal tuft^. The bhx)d returns to the uterus by the
coronary vein on the margin of the placenta, and tlie sinuses in
the septa between the cotyledons.
Ftu, 57.
Uterine surrace of the placenta.
Fnnctlons.— "The placenta," says Dalton,* "must accord-
ingly l*e regarded as an organ which performs, during intra-
uterini? life, <ifficea similar U) those of the lungs and the intes-
tiiies ftfter birth. It absorbs nourishment, renovates the bh »od,
•D'l discharges by exhalation various excrementitious matters
^hich originate in the pHK-ess of foftal nutrition-"
AbnontialHws of fonn are often met The organ is some-
titoes dividefl into distinct parts; while, again, smaller supple-
mentsry placentae, or placenite succcidurice, may be found around
'"TrmtiMC on Htininti PhyBioIOK^," 1^*71, p. nvx
IDO
DEVELOPMENT OF THE OVt'M.
the niaiu mrisa. "Wheu this condition exists, one of the jmrts is
liable to be left beliiml, exp«.>8iug the woman to dangers of sep-
tic infection and secondary hemorrhage. The luubilio^d cord,
instead of being attached to the centre of the organ, may be at the
margin, in which case it is termed battledore placenicL
Fiu. 58.
V CH
Ct Aw
L\' ' '■'
8rction nCuttiTiM and pUriMila in l)u* lit^h month Ch tliorinn ; ^m. aiiiiiinn
V. villi ; L. Incnntc ; 5. norutiun: A R. areolar : V. small luipriesj. — [I^oojxtld.]
The term iuxcrtio valnmeniosa is applied when the umbilical
vessels extentl for stmie dist^uice through the membranes l>efore
reaching the placenta.
OiangfK Preparator>* ♦<> Separation.— These changes are of a
degenerative, nature, consistiug chietly in tlie de|x»sit of calcare-
ous matter on its uterine surface, and fatty degeneration of the
villi antl decidua sen^tina. Should tliese changes be either pre-
mature or excessive, death of the foetus will l>e likely to ensue.
The calcAreous deposit is sometimes wi marked that the uterine
fiorface of the organ feels rough like a grater.
The Vnibiltral Cord.— This is forme<l by elongation of the
pedicle of the allantois, and obliteratit»n of its cavity. When sf)
constructed it consists of the following parts: the amniotic sheath,
which entirely surrounds it, except at one point, where a small
slit gives egress to the petlicle of the shrunken umbilical vesicle;
SMBIIYO AXD F4ETUS.
letwo nmbilical orterios, and one vein; the remains of the ped-
icle of the ombilical vesicle; the remains of tlie pedicle of the
allantoifi; and liiinlly the gelfttiue of Wharton.* It is nsually
ftboat the thickness of the little finger, but varies greatly, its
circomferenco tle|x*ntling mainly on the qnantity of Whnrtqn's
g<elatine. Owing to the greater length of the right artery, the
vessels in their Hpiral ctnu*Be generally olwerve tJio direction
!n>n) right to left, the vein forming on axis about which the
arteries curl. Tlie average length of the cord is twenty-two
inch«*s, but it has been obsorvetl as short as three inches, and as
long as five or six feet The coril, us a rule, is possessed of con-
siderable strength, as may be demonstrated by traction made
npon it for the pnrjxjse of ])lacentAl extraction. Still, in some
QBBea, slight traction wtII cause it to part One extremity is
firmly attached tc» the umbilicus, and the other is woven into the
tisfiut»s of tlie placenta. No nerves or lymphatics are said to
exist in it*; stnicture. \
The Liifiior Anuiii. — Tlie amniotic fluid is supposed to result
ni&inly from the exudation of serum from a fine capillary net-
vfirk of blixnlvessels developeil just beneath the anmicjii, in that
jinrtof the chorion wliich covers the pkcenta. In the latter half
of jwgnancy tliis network of vessels diBapi>ear8. The tiuid is
tl'»obtless increased in quantity by urine, voided by the foetus
dufing its iutra-uterine existence.
CHAPTER IL
Development of the Embryo and Fcptus.
iVn ticcount of tlie development of the ombryr* and fo^tns be-
longs I>roi>erly to physiology, and allusion 1o it ken? is dosigziedly
^«t The t«rm embryo is proj>erIy applied to the product of
tODCeptiou n]) ti> the close of the third montii tjf uteru-geatfition,
*ft«r which time tlie term foetus ought to be substituted. Em-
™7oltH5y, Bttvo for the light which comparative physiology throwB
QlJ*m it^ l<, in tlie human, shroudeil in much obscurity. The
"Plu^ituuilies aff(.»rded for the examinatioii of bodies, dead in the
wly Binges of pregnancy, ore very limited, and it is probable that
•Tlieiiftly ktulMice of muooid tusqe in a normiil orgau.
102
DEVELOPMENT OF THE OVUJL
our acquaintance with the Bubject moBt continue to be made
mainly tLnrngh study of the process in animals.
Kio. 59. In the First Month.— The
embrj'o in the tirst month of
gestation is a minute gelatinous
and semi-transparent mass, of a
grayish color, presenting to tlie
unaided eye no definite trac4?s
of either head or extremities.
The entire ovum measures but
oiie-foui'th of an inch, and the
embryo one-twelfth. During
the next week it doftbles in di-
_ mensions. The amnion is fully
Ovum and Kmitryn. devolopetL Nourishment is de-
rived from the umbilical vesicle. Tlie allantois reaches the
periphery of the o>'um. but the vessels do not yet penetrate the
villi. At the close of the moutli, the ovum is about the size of
a pigeon*s egg. It weighs about forty grains. The embryo is
about three-fourths of an inch in extreme length, and alxiut one-
third inch in direct menaurement The ovum is so small that
it reaiiily eac'^ipes notice in alwrtions, g<*nernlly passing with
a coagulum.
Second Month. Ecker describes an embryo of eight weeks.
It measured two-thirdt* of an inch in a direct line from the head
to the fiiUilal curve. The ovum itself was alx^nt the size of a
hen*B egg. The independent circulatory system of the embryo
wfiB l>egiunmg to furm. Tlie amnion was distended with fluid,
and ill contact witli the chorion. The umbilical vessel Mas
greMly reduced in size. Ossification had l>egun in the lower
jaw, and the rlavicle.
Third Month,— The embryo weighs from 70 to 300 grains, and
measures from 2J to S^ inches in length. The forearm is w^ll
formed, /md the fingers are discernible. The head is relatively
large, tlie neck sei)arat«»s it fn>m tbe trunk, and the eyes are
prominent The chorion has lost most of its villi, and the pla-
centa is formed. Points of ossification a|Ji>ear in most of the
b«»nes. Thin membranous nails appear on the fingers and toes.
Fourth Month. —The fcetus weighs five or six ounces, and ia
about six inches long. Its sex can now be determined. Distinct
THE FtETUS.
103
rements are visibla The convolutions of tlie brain are be-
to £onu. Ossification is extending. The placenta is
lI in size, and tlie cord is about twelve inches h^ug. The
is one-fourth the length of the whole l>ody. The sutures
and fontanelleH are widely separated. Hair begins to appear
on the scalp.
Fifth Month.— Fcetal weight has increase*! to twelve ounces,
unil lezjgtii to alKjut Um iiu'hes. The head is still relatively large.
Fine hair ( lanugo) appears over the whole body. Foetal move-
inemis can be felt by the mother.
Fig. 60.
Omm :it five mniitim.
Sixth Month. — Weight about twenty-four ounces. Fat is
^winti in tlie Bubcutaneoiis cellular tissue. The testicles are
rtil! in the abdouiinal cavitv. The clitoris is prominent Hair
lOi
DEVELOPBCENT OF THE OVUM.
is darker and more abundant The membrann pupillaris existe^^
but the eyelids separate. If bt»ni at this time it breathea freely,
but life is retained only a few hours, with few exceptions.
Seventh Month.— Weight from three to four pounds; length
fourteen or fifteen inches. The skin is wrinkled, of n red color,
and covered with vernix caaeosa. The tefeticles have descended
into tlie srrotuni. Tiie foetus is now viable.
Eighth Month. — Weight from four to five pounds; length
sixteen to eighteen inches. Development is now rather in thick-
ness than in length. The nails are nearly perfect The roeui-
braua pupillaris has tlisapi>eareii. Tlie lanugo is disappoariug
from the face. The navel has gradually approaclie<l the centre
of the Ixxly, until now it has nearly reached that median point.
Ninth Month, or At Term. -At the end of pregnancy the
fcetus weighs nu average of six and a half or seven ptiunds. and
measuren alxiut twenty inches in lengtli. If we were to tiikethe
weights of children as given by mothers and friemls, this aver-
age would be greatly increaseiL Out of 3,CHM) children delivered
under the care of Cazeaux, at different charities, but one reached
ten pounds.* Of 4,000 chiJtlren delivered at La Maternity, one
only weighf^l twelve pounds. (Lachapelle. ) The birth of one
has recently been recordetl,t whtfso weight wfis twenty-one
pounds. Probably the largest fivtus on record w;is that born to
Mrs. Captiiin Bates, the Nt>va Sct»tia giantess. It was l>orn iu
Ohio, and its weight is said tt) linve been nearly twenty-four
pounds. Children have been bom at maturity, and lived, whose
weight was only onf^ ix>uniL The average weight of mature
males is greater than that of females.
At birth tlie foetus is covered with remix caseosa, a whitish
Bul)stance conij>*>sed of a mixture of surface epithelium, down,
and the prtiilucts of the sebaceous glands. During intrti-ut^rine
life it serves as a protection fur the skin agftiust the amniotio
flui<l. It can l>e thoroughly removed only by preceding the use
of water with a fi*ee ijumctiou.
Circulation of the Blood iu the Fcetus.— The following is a
brief, but yet explicit, rcsumeoi the footaJ circidation. Blootl is
conveyed through the uml)ilicid arteries, whicli are terminations,
or branclies, of the iliac arteries, to the placenta, where, within
***Theonnic«J and Prartiml Midwifery," Am. Ed., 1878, p. 216.
tBrit. Med. Jour., l\'b. 1. 1879.
THE FtETAL CIBCrLATION.
105
the villi of the chorinn, the interchanges with the maternal blcKxl
take \}\ace. After being thus renovated and recharged with oxy-
gen, it collects within the umbilical vein from innumerable
braQchea, and pusses back through the umbilical cord to the
Uver, The blood thus returned to the foetus is, in a sense, arte-
rial, and that which passetl through the umbilical Hrteries, v^n-
oos; but it is ill a mtxlifietl sense only. After reacliing the liver
on its return from the placenta, a part of it circulates through
the liver, while the rest pasises through the ductus venosus into
the inferior vena cava, and both these streams cominiugletl cou-
tinue on to the riglit auricle. The two colnmns of blood— that is,
the bhKwl [Missing into tlie vena cava from the hepatic vein, aud
from the ductus venosus, join the stream which has been collected
from the lower part of Hie body, and mix with it In early foetal
life the inferior vena cava ojx'ns at the septum of the auricles
into both cavities, though the chief part of the blood enters the
Itift, owing to increase<l development of the Eustachian valve.
Sultsequently this valve becomes smaller, and by the increased
develupmeut of tlie valve gujmliug the fyr^meuovale, the cur-
rent is turned more and more into the nght auricle. In this
cavity the blood is partly mixed with that which enters from the
Bn\i&rior vena cava, imd a part of it desceuils into the right ven-
tricle, whence it passes, in part, through the pulmonary ar-
tery into the lung tissue. No proper pulmonary circulation
biiring >et been established, only about half the blood contained
in the right v(*ntricle enters the pulmonary artery, whilst tho
other half enters the descending aorta through the ductus arte-
no«Q& The imperfectly de veloi)ed pulmcmary veins convey to
the left auricle but a small quantity of blood, the chief supply
Wing receiveil from the right auricle through the foramen ovale,
Ujroogh whicli passes the main stream fn;tm the inferior vena
cttva. From the left auricle the blood, which is semi-arterial,
desc/inds into the left ventricle, and thence into the first division
of the aorta* By virtue of this movement the head and upper
extrttuities are supplied through the carotid and subclarian ar-
te-ries witli tlie blood which has been but little deteriorated in
ii|nality, and escape the more venous current from the right ven-
tricle through the ductus arteriosus.
At the birth of the foetus there occurs a profound revolution
hi the circulation. Air now enters and expands the lungs, and,
106
DEVELOrMEST OF THE OVrH.
Fia. fil.
a)7Uf/af
iwram of the Fa-Ul ««"!»<<<»•
THE FCETAX CBANIUM.
107
a result, blood begins to pass freely into the pulmonaiy cir-
oulatiozi. The blood received inUj the right ventricle is now
forced through the pulmonary system exclusively, the ductus
arterioeos at once closing. After passing through the lungs and
being oxygemited the blootl flows in greatly increased quantity
into the left auricle. It is presumed that in the latter cavity
the alood pressure is considerably increased by cessation of the
phtoent&l circulation, while, through moderation of relative eup-
plr» the pressure in the right auricle is diminished, by means of
which changes, the valve of tlie foramen ovale is enabled to close.
As a result of these modifications, more especially in conse-
qcumce of closure of the ductus arteriosus, the arterial pressure
in the descending aorta is greatly diminishe<l, and were the
lilacentu left uiiseparated from the child, the long placental cir-
culation could not be maintained. The blood still left in the
oord soon coagulates, and circulation therein is effectu*dly ar-
re6tei.L The ductus venosus also contracts on complete estab-
lishmeut of the pulmonary circulation. Tlie foramenovale_
sometimes remains open for a short time; but, after its closure,
owing to the peculiar construction of its valve, and the greater
blood pressure in the left auricle, there is no intercommunica-
tion l>etweeu the blooil of the two cavities.
The rranitini. — The general anat<imy of the foetal head is of
much greater value to the obstetrician or student of midwifery,
Ihau that of any other part of the iMKly. Apart trom Hh dimen-
ftions, the chief anatomical peculiarity of interest is that of the
khalic; bcmes, and more es}>ecially of the calvaria. These
les, are not firmly ossified at their contiguous margins in tlie
fcetus, F)ut are joined liK^eely by membrane or cartilage, for-
liung above by their united margins sutures, or commissiireSf
Aitil ffrtihtru'lles. This arrangement permits the bones auider
fiircible pressure to overlap, and tho licad thus to be moulded
to correspond to the size and shape of the channel through
it has to pass. Since this change in form of the head
only the vault of the cranium, the more deh'cate organs
in the base of the brain are protected by iinyielding osseous
tftractoresL
All ftcqoaintance with the characters of the foetal cranium is
of the greatest service in furnishing the data from which to cal-
culate the position occupied by the part as it presents in labor.
108
DEVELOPMENT OF THE UVCM.
The Sutures and Fontanelles,— The sagilial suiure extends
along the vertex, l>etweeu the auterior aud posterior fontouelles,
and is formed by the junction of the two parietal bonea Run-
ning forward in the same line, anteriorly .from the anterior fon-
tanelle, is a short seam known as the frontal suiure. The coro~
nal suture is formed by junction of the edges of the two parietal
bones and the frontal, and hence extends over the heml in a lat-
eral direction, constituting the anterior transyerse suture of the
vault of the cranium. The himt>d<ndnl suiure is the line of de-
marcation between the occipital aud two parietal bones, extend-
ing transversely across the head, and forming a tigure which re-
sembles theOreek letter ^Vt from which its name is derived. ^
the other oommissures of the festal cranium we have no special
obstetric interest
Ossidcation of the craninl bones at birth is incomplete, espec-
ially at the margins w^hich ai-e thus approximattnl, and as the
l>oues have only membranous, or, at the most, cartilaginous union,
mouliliug of the head and overlnpping of the bones, under the
necessary compression, is generally accomplisheil by the natural
efforts with facility, and thereby great mechanical advantage is
gained.
The comers, or angles, of the bones, as thus approximated,
are obtuse, especially at the junction of the coronal, sagittal and
frontal sutures, through deficiency of osseous structure, and
hence there are gaps formed anteriorly and iX)steriorly, whicJi
are terrae*^l ftmtancUejs. The largest of these is the anterior fon-
innellej or bregmri, which is formeii by the concurrence of four
seams, namoly: the two branches of the coronal, the sagittal and
the frontal, giving to the opening a lozenge shape. The larger
part of the gap is in front i>f the direct line of the coronal suture,
and is sometimes continued some distance into the frontal bone
in the line of tlie frontal sutiue. The pmterior fofiian/'Ue is very-
much smaller, and, in general, is hardly entitled to the designa-
tion, since it would be scarcely possible to observe any pulsation
there. Its shape is characteristic, and is rendered still more
distinct during labor by depression of the occiput, whereby
the limbs of the x are made pr<:)minent As will be noticed fur-
ther on. the occiput, in the greater proportion of cases, is tume<l
toward the pnlns, and hence the posterior fontanelle is the one
more easily felt by the finger in making an examination daring
THE FCETAL CBiUnUM,
109
Too mncb emphasis cannot well be put on its character-
namely its j^ Hhapo, and the ooncurrence of only three
oommifisures (the two branches of the lambdoidal and the sagit-
). The anterior fontanelle is lozenge-shapetl, and has four
itores concurrent, as stated; but what most markedly distin-
guishes it during an examination, is the existence of the notch,
more or less distinct, in the frontal bone. These characters will
not at first \ye readily recognized by the student, but rei>eated
examinations will render them familiar.
Fig. 62. Fig. ea
^^»
The vert<;x.
PosUirior view of the craniam.
Diameters orF«etal Cranium. — Familiarity with the relative
diameterB of the foetal head is essential to an intelligent practice
d midwifery. Thc»8e of most imp<^rtance are: 1. The occipito-
nitil^ measurement l)eing taken from the occipital protuberance
to the point of the chin, the average giving five and one-half
inches. 2. The occipUo-froniaU from the occiput to the centre
of the forehead, on a line with the frontal eminences, four and
Uiree-quart^^rs inches. 3. The cervico-brcgmafict one i>ole being
at the foramen magnum, and the other at the posterior margin
of the anterior fontanelle, alx>ut three and one-half inches. 4.
The bi'parieialj the two poles of the diameter being the parietal
emijieuces, three and three-quarters inchea 5. The bi-iemporal^
being the measurement through the ears, three and one-half
inchee. 6. The fronio-menl(tl^ from the apex of the forehead to
tLe cMn, three and one-half inches. 7. The bi-malar, through
the malar liones, three inches. 8. The suh-ompUo-hrecjfnaiiCt
pole being say one-half an inch below the occipital protuber-
110
DEVELOPMENT OF THE OVUM.
ance, and the other at the anterior fontanelle. three and one
half inehea Others might be added, but tlxose given comprise
most of the diameters cx>ncemed in the meclmnism of labcir.
Putting these figures in tabular form, they are as followe :
Ucipilo-menUJ 5j in^jho,
Otvipito-trouUil 41 »»
Cervico-lirr^intic , ;ji *«
Sab-occipito-bregmatic 31 *•
Bi-parietAl ^ ;m «
Bi-Tvmponil •n n
Fronto-mr ntui „ ^^ 31 u
Bi-malur 3 w
Without pausing now to di-
late on the change of diameters
which is effected in different i)re-
seutHtion8and()08ition8, it ought
1^ to be mlded that these averages
were taken from heads which
traver8e<J the parturient canal
in occipito-anterior positions
of vertex presentations. Dr.
Jjnmes* has shown by diagrnms
made from heads immediately
Lateral view of heocl, with diuuH-tcrs. ^^^^ delivery, that, in difficult
and protracted labor, the longer diameters may be increased
more than an uich, as the result of lateral compression by which
the bi-parietal diameter is reduced to correspond with the bi-
temporal.
Heads of Male and Female Children.— There are some gen-
eral ctJUrtideratitms in relation t-o the size of the fcctnl heml which
must not be overiookeiL On taking the average measuremeuhi
of a large number of male heach^, and comparing them with those
of an equal number of female heads, it becomes evident that the
former exceed the latter. Sir Jas. Simpson t attributed to this
fact the increased difficulties and dangers attendant on the birtli
of male childnm. This influence he believeil to be so marke<i,
that he made a careful estimate of the mothers and children lost
in Great Britiau during three years, as the result of slightly
♦ObBtet. Tnin*. vol. vii.
t Selected Ohatet. Works, p. 363.
PBESENTATTOS AND POSITION,
111
increased cranial development in males, at about 46,000 infante
and between 3,000 and 4(K)0 mothers.
Attitude, Presentation and Position of the Fcptns.— From
the eariicBt period in pregnancy the foittis in tlie uterus con-
forms itself to the shape of the organ, in the cavity of which it
is placed. Its adaptation to a bent and flexed attitude is clearly
disclosed early in embryonic life. While yet it floats freely in
^ liquor amnii, and is not at all pressetl by the uterine walls,
the oorregf>ondence of the embryonic with the fuital ovoid is wor-
thy oi notice The flexed attitude becomes more marked as preg-
Fio. 65. nancy advances, and at the close of
gestation the fcetus is found with
the spinal column bent forward,
the clun on the chest, the arms flex-
ed at the elbiiws and the forearms
laid on the breast. The thighs are
bent on the abdomen, the feet ex-
tended so as to oome in contact with
tlie legs, and the latter, like the
forearms, often crossed This at-
titude enables the foetus to occu-
py the minimnm amount of space,
find gives to it the form of an ovoiJ,
with the larger t*nd represented by
the head.
Presentations and their Cau*
ses. — The ix)sition of the foetus
with respect to the ilirection of its
long flxis,cttnstitutes what is known
»s present at ion. When the ce-
phalic jxile of the longitmlinal dia-
meter is dependent, it is a cephalic
presentation. When the knees.
M or breech lie over the os uteri, the i^elvic iH>le of the
long diameter presents, and hence it is called a i>elvic pre-
•entatioa Finally, when neither pole of the long diameter
jataente, it is a transverse presentation. In more than nine
Biiitare cases out of ten the cephalic extremity forms the pre-
•flotation, and various theories have been advanced in explanation
of the phenomenon. NotM'ithstanding the attention bestowed
luuadr of lUc Foetus ia Utero.
112 DEVELOPMENT OF THE OTUX.
on the subject, and the profound research to which it has given
rise, the mystery remains but partially solved. It does not an-
swer the claims of science to let the question rest merely on the
plea of the suitability or desirability of such condition for the
facile consummation of the reproductive process. Manifestly there
is a cause, the influence of which is felt from an early period of
fcetal life, the ultimate cflfect of which is discovered in tlie won-
derful adaptation of means to ends in the mechanism of labor.
Hipi)ocrates appears to have originated the idea that, until the
seventh month of gestation, the foetus occupies a sitting posture,
with the vertex turned to the fundus uteri, and that then a com-
plete change of presentation is effected, as a preparation for ex-
pulsion. The smaller percentage of cephalic presentations in
miscarriages j)robably suggested this notion. Aristotle referred
the frequency of head presentations to the laws of gravity,
which is a theory still tenaciously held by some. To test this
gravity doctrine, Dubois* experimented by suspending dead
foetuses^ of different ages, in a vessel fflled with water, and found
that not the head, but the back or shoulder was the part which
rested on the lx>ttom. He accordingly denietl the influence of
gravity, and advanced the theory of instinctive or voluntary foe^
tal movements to ex])lnin the phenomenon in question. Simi>-
8on,+ too, repudiated the theory, and substituted that of reflex
foetal movements. Others have attributed the i)henomenon to
uterine contraetii^ns. J)r. Matthews Duncan has done more than
any other recent observer to elucidate the 8ubject.J In numer-
ous experiuK^nts made by him, in which foetuses rec<>ntly dead
were nlhnved to float in a bap; fllled with salt water, of a sj^ecific
gravity corrosjHWKling clos(*5y to that of the liquor amnii, it was
seen that the hnad lay low**r than the breech, and tliat the right
shoulder (from the increased weight of that side due to the sit-
uation of the liver) lookeil downw*inls. This appeared clearly
to demonstrate that the centre of gravity lies nearer the cephal-
ic than the jjelvic extremity. *'The i>osition (presentation) of
the foetus at the full time is," says Dr. Duncan, " in the great
♦DirBois. " Memnire snr la oanw lU'^ presentations do la t6te." Mem, tie
I'Acad . Koy. de Meti. tome ii. \r^'SX ]». 265.
t Simpson. "Olistetric Work.-*/' vol. ii. p. 81.
t"01»tot. Researelies," p. 14.
I'BESE>TATION JkSD TOSITION.
113
mass of oa6ee» fixed and determined about the ond of the seTenili
month of pregnancy. This arises from the fact that about thrt
time the size and shape of the uterus become bo nearly and
closely adapted to the size and form of the fcetus, that it cannot
change the position of its truuk in any material degree. After
this time the position of the foetus must be determined by grav-
tation, for it is imjx>ssible to conceive its reposing in any »»ther.
"All the knowledge wc poBsess of the position (presentation)
of the foetus, after it has entered the second half of pregnancy,
leads us to believe that its head lier ordinarily lowest Before
the seventh month it is still capable of having its position in
ntero changed, by changes merely in the attitude of the mother,
and probably it possesses the power of effecting tem]x>rary changes
at legist, by its o\^•n unaide^l movements. Bnt the foetus is gen-
erally in a state of repose, and not producing motions in its
limbs or l»ody. In this state of repose, in n tliud of nearly its
own specific gravity it is im|X)SBible to conceive of its maintain-
ing any poeition but under the infiuenoe of gravity. Its ix>sition
must at all times be mainly, if not entirely, caused and deter-
mined by statical circumstances. It is tjuite conceivable, that
while still comparatively free in the uterus, it may, by virtue of
its vcrj- easy mobility in the dense liquor amnii, change its ]x)Bi-
tion. If this occur at a time when its ilimensions are beginning
to approximate to tliose of tlie uterus, having overcome some
resistence of the uterine walls by the force of its own muscular
efiortiif, or otherwise — as by accidents to the mother — it may not
gmvitate back to its old and ordinary position, and thus a pre-
atural presentation may l3e produced. The uterine walls are
en'where smooth and glabrous, and rounded; and the foetus
liee in its cavity with its legs, its chief organs of locomotion,
clevfltoii; circumstances which appear to render its maintenance
of any position but that of graviUtion a greater feat than ever
was performed by a rope dancer. With all the advantages of
ita new circumstjinces, the child after birth cajinot assume or
OBaintain a new ix^sition. How much less could it be expected
do so in the uterus, and under circumstances so disadvantage
cms for the fulfiDment of such a function. Those authors who,
nith Dubois, strive to prove that the jK>Bition of the foetus is
determined by its own motions. Lave first to prove that it oould
uriiiinfaiiTi any position whatever against gravity, veithout sucIl
lU
DEVELOPMENT OF THE OVCJL
coueiant efforts as voluntary musclert are incapable of, and of
the actual presence of which no evidence cnn be furnishetl"
Without entering further into a consideration of this question,
it may be adde<l tliat cephalic presentation of the fcetus is not
probably referable wholly to any one cause, but a combination of
causes, in which gravitation* uterino contractions, and reflex
movements all hf*ve an influence.
Position. — By tliis ttrra we desi^ to fiignify the' relation of
certain determinate ix>int8 in the body of the foetus to the uter-
ine walls. Care nm&t be taken n<»t t<.> confound the two terms —
presentation and j>:>8itit)n. To simplify an nnderstaniling of tlie
various positions, we shall re-
gard the dorsal surface of the
ftetus aa the cardinal feature
from the direction of which to
tlesignate pc»sition8. And still
it will Ih? obser\ed, when this
subject is treated at length, that
fK-teitions are often designateil
by the direction of the oocipnt
in vertex- presentation, and the
chin in face presentation, as. for
example, right oc^ipito-anterior
position, left meuto-poeterior
IKTsition, and bo on. Full con-
siileratiou of this subject will
bo biken up in another chapter.
Changes of position are fre-
qtient in pregnancy, antl, very
likely, like j)re8entation8, take place, when not subjected to con-
trary influences, in a large measure through obetlience to la\vs of
gravity. This is not mere speculation, for close observation has
Bubetantiatecl its truth. AVhen the woman is in the erect posture,
the axis of the uterus is presumed to correspond closely with the
axis of the plane of the superior strait, and hence forms with the
horizon an angle of about thirty degrees. There is generally a
little deviation to the right It is also slightly twisted, so that
ita left lateral surface looks somewhat forwanL Therefore, when
the woman is erect, the anterior uterine wall is not only inclined
at the angle mentioned, but the left side drops a little lower than
Situation iintl ■<urronnding8 of tUe
fa*tua ill ul4.'ru.
PBESENTATIDN AND POSITION.
115
^glit If these facts receive iittention, we will readily dis-
T tlxat when the child rests on the incline, with the head de.
pendent, that tlie heaviest part of the body will gravitate to the
lowest surface, and hence we most frequently get a position with
the back turned to the left, and somewhat forward, and. for mani-
fest reasons, this is more likely to be true in the uterus that has
previously experienceil the distension of pregnancy.
With the woman in the dorsal decubitus the long uterine axis
is still at an angle with the horizon, and the child's weight is
thrown on the pt>sterior wall of the nterus, npon which the
heaviest part of the superior portion of the body would naturally
seek the lowermost surface, and woxild accortlingly be ilirected
to the assumption of a right doi-so-j>osterior ])osition-
These are prnetir^l considenitions, and well wortliy the stu-
it's thoughtful attention.
IMagnosiK of Fcptal Presentations and Positionn. — It is
highly important t<:) know, as early as pijssible after labor
set* in, the presentation and position of tlie foetus. If the pre-
fieiiiting part has been driven dovt-nward into the j)elvic cavity,
Kill the membranea have ruptured, this cnn usually be learned
wilhfjut much di^culty by a vaginal examination. But if de-
scent of the presenting i>art has not yet been acoompHshed; if
there is a tense and full bag of waters, and if the os uteri is but
partially dilated, and is reached witli dilhculty, such diagnosis
is not easily made in every instance, even by experta In a case
tliis kind it will be necessary to bring to oar aid the informa-
derivable from external examination.
Examination Through the Tagina.— In the vast majority of
ewQOO- positive information can be gained from vaginal explora-
tion alone; but in some instances its revelations, as ordinarily ob-
tained, are most unsatisfactory. One not thoroughly familiar
with the feel of the characters of the various presenting surfaces,
will do well to verify conclusions by external means.
The head is recxigni^ed from ita shape and hardness, which
differ from those of any other presenting part To the inexpe-
rieDoed these may not be wholly characteristic, for students and
joang practitioners have often mistaken the head for the breech,
mnd the breech for the head. The breech, when fairly crowded
into the pelvic brim, or c«rity, d<.>e8 give out a feeling of resist-
116
DEVELOPMENT OF THE OTTBJ.
anoe, wlitcli, to a casual examiner, is liable to prove deceptive.
An attentive obeen^er will rarely, or never, be misled. But these
remarks do not apply with equal force to both varieties of <je-
pLalic presentation, since the vertex possesses characters not aft>
Bociated -with the face. The vertex will be distinguished mainly
by its sutures and foatanelles. As the £uger is passed through
tlie OS uteri and rests upon a fontanelle, it is most frequently the
posterior, and it will be recognized by its ^ shape, which is gen-
erally easily felt. From the apex of this figure, the finger passes
along the sagittal suture to its extremity, where the anterior fon-
tanelle will be found- The face will be recognized from the feel
of mouth, nose, chin and eyes, though those features will be con-
siderably obscured by the pressure to which the part is sub-
jected, and the consequent tuinefuetion. Such presentation is
more likely to be confounded with breech presentation than any
other, and diiTerentiatiuu must be made by a detailed study of the
parts, as the fingers are swept over them.
When the peMc end of the fcetus is turned to the os uteri the
feet or knees may be in advance, or, what is more frequent, the
breech presents.
The characters of this part can sc^irccly be mistaken. At first
one natis only is found, but, when the os uteri opens, the other
is felt, and tlie deft between the two. The genitals, the j)oint of
the coccyx, the anus, and the rudimentar>- spines of the sacrum,
puss under inspection, miiting to declare the character of the
presentation.
In transverse presentation, the precise suiiace upon which the
examining finger falls can generally be made out, though not al-
ways with facility. The side would be recognized from feeling
the ribs, and the shoulder would be distinguished by the scapula,
the vertebrsB, and its own j>6culiar contour. In early examina-
tion the presenting part may lie entirely out of reach. This is a
diagnostic fact of much value.
Upon examining per vaginam in these cases, we find, when
the feet or knees present, that, early in labor, diagnosis is many
times a matter of some difficulty, inasmuch as an extremity is
felt, but it moves l>efore the finger, and will not admit of careful
study. Later, however, it comes within reach, sometimes sud-
denly, by rupture of the membranes, and esojipe of the liquor
amniL The foot would be distinguished mainly by the toes and
PEB8ENTATI0N AilD POSITION.
117
heel, imd the knees would be known from their size, and the ob-
tuseacBS of their ptjints.
When the presentation is either transverse or pelvic, the bag
af waters is generally larj^er and longer, and may render thor-
ough exploration nnusunlly difficult In vertex presentation,
when tlie bug is large and tense, its feel is liable to mislead the
ines-perienced to suppose the breech or the face is presenting.
Flo. 67.
DiA^osls of Presentation and Position by Abdominal
Pftlpatton. — This subject has received ctnisiderable atteution of
late, and lis value duringpregnanoy, for the purpose of diagnosis,
has been clearly demonstrated. Dr. Paul F. Munde * has fur-
nished li inoHt interesting and valuable paper on the subject, with
oome very excellent illustrations. Dr. Depaulf has likewise
given aome in]])ortaut instruction concerning its value and meth-
ods, with iigures
According to the writers mentioned, and others, a little prac-
tice will enable one to elicit by means of nixlominal palpation,
■v-aluftbli? information concerning both the presentation and
Am. Jnnr. 0(w., vol. xii, p. 512, etc.
t " Vt^mM de clinique ObeU-tricale." 1872-1878, p, 21.
PHE8EMTAXI0N AN1> POblTlCafc
iiy
W
By striking the tipi of the fingers suddenly inwards
At the fundus, the hard breech can generally he made out, or the
head^ if there, sffl more easily. It is also possible, as a rule,
fto feel the foetal limbs, especially on proTokiug morements.
WhflO the foetus lies in a transverse presentation, diaguofiia is
ilBl leea difficult The long fcetol axis being thrown across the
abdomen, gives \^^ the part a feel wholly different from that found
iu connection with other presentations. The rounded mass of
the heml can be easily felt in one iliac fossa or the other, or at a
jxjint still above.
Diat^noHis of Presentation and
Position by Abdominal Auscul*
tation. -This is another means of
diagnosis not properly valued or
under8to(^>d by obstetric practition-
ers. For general purposes the un-
aided ear will answer very well;
but for the diagnosis of presen-
tation and position, the stetho-
scope is a necessity, as without it
the summum of intensity of the
Kounds cannot l>e circumscribed.
The most common location of the
foetal heart 8i}unds is on the left
side below the uujVnlicus: 1. Be-
cause tiie back of the child is most
frequently turned toward the moth-
er's left, and 2. Becauae the head
generally present^ at tlie ns uteri.
The tirst fact, then, to be kept in
mind is that when the fcetal back
is turned toward the left side of
the mother, the heart- sounds will
I* most diatinctly audible on that sida The just inference
tfl be taken frtim this is not that the position is ueces-
wrily a left dorso-anterior one, though it is more likely to be.
It may l>e a left dorso-p^sterior position, with but a moderate
iScLiuation backwards. Accordingly we conchido that when the
Boands of the foetal heart are most distinct on tlie mother's left
Mdfi^ the position is eitlier a left dorso-anterior, or a loft dorso-
_ at + <!*** loititions of
lao
DEVELOPMENT OF THE OVUM.
posterior poBiiion; in other words» it is a first or a fourth posi-
tion, with the probabilities stnmgly in favor of the former. If
Fm. 71. Fro. 71 Fio. 73.
Locution ofthv
heart sou iids.
firet i>o8ition of
the vertex, at-|-
Firsr pcwiiion of
the face. Locji-
tioii of ht*art-
Hounds indicated
Fitst poeitioti of Uie
hret*ch. L ocatiou
of heart-sounds ia-
dioated by +•
heard most clearly at a point an inch or more below the line
of the umbilicus, the woman being near term, it is a cephalic
Flo. 74. Fia. 76.
Dorao-nntcriur podl-
tiou of tranaverw.' pro-
B(^Dt»tioii. {..nciitioii
of heurtHioaDda iadi-
cftted by +•
Twin ptvpnancy. Lo-
cution uf heart'»oundd
indicated by -\-
presontation ; if heard mofit distinctly at n point as high as the
umbilicus, or higher, it is a breech presentation. When the sum-
DIAGNOSIS OF TWIN PUEONANCY.
121
mom of intensity of the fcetal heart-beat is on the right side,
the poeition is either right dor&o-anterior, or right dor8o-i)OB-
terior; or» in other words, it is either a second or a third po-
sition, without regard to the presentation. But now, if Uie
point of btrongebt auiiibility in ou ur bek)W a line drawn trans-
versly across the abdomen al»cmt an inch below the umbilicus,
the woman being near term, it is almost certainly a cephalic pre-
sent^ition. If the sounds are most distinctly audible at a ix>int
above the umbilicus, the present-ation is almost certainly pelvic.
In transverse presentation the fcetal heart- is heard most forci-
bly on or near the median line of the abdomen, several inches
below the umbilicus.
IIUi;nosis of Twin Pro:?nancy, from AuKPiiltalion.— In
twin pregnancy the fci^tuses lie upou either side of the abdomen,
and from mere insfx^ction a diagnosis can sometimes be made.
The stethoscope will bo applied to one side, perhaps the left,
below tli« umbilicus, and the sounds there heiird counted by the
w»tcb. The investigation is still further pursued, and on the
uppnsite side of the abdomen, perhaps on a line with the first
ttoonils, Init more likely at a liigher i>oint> a foetal heart of a
different rhythm is heard, and its pulsations counted From
such an examination it becomes^ clear that there are two foetuses
in utero, and furtliormore that their positioas and perhaps their
pTe&entati*»n8, vary. The same principles nf diagnosis iff ]rre~
Betdalton atid position are here involved as in the instance of
sir. ' iiancy. In tliesame connection it should be lx)me in
mii 'iie dorsal surfaces in twin pregnancy, and the cephal-
ic exlremilies, are, as a rule, turned in opposite directions.
That is to say, the back of one fcetns generally looks toward the
molber's left, and that of the other toward her right; while the
head of one fcetus is usually turned toward the os uteri, and that
of the other toward the fundus.
The**e ideAS of presentation and jxisttion derivable from pal-
pation and auscultation, are not theoretical merely, but highly
practical, as the author has demonstrated in hundreds'of cases
within the Obstetrical Department of Hoimemaim Hospital,
Chicago, as well as in private practice.
Dlasmosls of Sex fVoni Rapidity of the Foptal Heart.— The
poesibility of determining with tolerable accuracy the sex of the
122 DEVELOPMENT OF THE OVUM.
foetus in ntero from the rapidity of the heart's action, has com-
manded the confidence of some, and is deserving of study. The
theory is founded on the clinical observation that the heart of
tlie female foetus exceeds in rapidity of pulsation that of the
male. That tliere is an element of truth in the theory, is plainly
shoTVTi by the reports of all who have given the matter attention,
but exi>erience of tlifferent observers, has, nevertheless, l)een far
from uniform. Steinbnch was correct in fortj'-five out of fifty-
seven cases which he examined, and Frankenhaeuser * made not
a single mistake in fifty consecutive cases. But other careful
observers fall far short of such marvellous success.
In studying the subject, one should not forget the influence of
botli maternal and Unial states nyxm tlie heart's action. It is
probably as true of intra, aa of extra-uterine life, that such in-
fluences much more frequently accelerate, than retard, the car-
diac contractions, and hence we often find the male heart simu-
lating, in point of rapidity, the female heart This aflbnlb a
rational explanati<m of the greater relative frequency of males
when the pulsations fall below 13oJ to the minute, than of fe-
males when the pulsations exceed that number. That disturb-
ance of tlie vital force of the foetus, and its reduction to a low
ebb, is exhibited in the pulsations, is clearly shown in obser\a-
tions carefully conducted. An instance of the kind npixjars in
the succeeding tables. The mother was in verj^ feeble health,
and, two months jirior to delivery, the heart of u male ftutus
which she lK)re was pulsating so rnpidly that it could scarcely
be followed - 172 times a minute. The child was still-born, near
term, «nd presented evid«»nc(M»f life having been extinct for sev-
eral dnys.
The author's i)ersonal observations in ninety-six unselected
cases gave an average pulsation of 18")^. The results of obsen^a-
tions, with this as th(i intermediate point in the si:ale, is given in
the accompanying table :
Mai.k. Femai-k.
Pulsations in i-xoess of VMi\ '3.'> 'J 4
I^lsutioiM 1h:I«\v i:ir>\ ;{.'> i*^
Total 00 ;SU
Averuge pulsatiuits (if inaU'S 131
Avorajrc pulsations ol" iVnial*^ 138
*"MoiiatJJSchr, f. Ocliiirt.sk.," Ud. xiv, p. IGl.
DIAGNOSIS OP BEX FROM HEART-SOrNDS.
Acconliiig to these figures, it will be observed that if diagnosis
of s<»x had been mmle in accordance with the tlioory of cardiac
rapidity alone, they would have been correct in only fifty-nine
out of ninety-six oases, or, in but Little more than sixty-{)ne per
cent of them.
As the proportion of males in these ninety-six cases is so far
in excess <>f females^ it appears that a comparative statement.
titutiug in some regards a mure ecjuitable showing, should
based on an equal number of males and females. In order to
present such a table, we have taken the entire number of females
(36), and compared it with a like uumber of mules taken in regu-
lar ortler from the records, first in chronological order, and
ndly in reverse order, with the following results :
CoMPAiiATrvE Statement of the F(Etal Heart-Sous'dr in
Thibty-Six Males, Taken in Chronological Ohoer from
the Author's Records, and Those of the Entire Thirtv-
Six Females in the Foregoinq List :
Coacfl wherelQ the palsationM exceeded the
average number of l^^ per minute :
Mules, 14 — a)M)ut 37 per cent.
Femules, 24 — u1>oui IKS per cenl.
Cmm wherein the puUatinnR feH below the
average number of 135^ per ininute :
Miilea, 23 — about 65 per crnt.
Females, 12 — ^about il5 per euul.
A CojfPARATrvE Statement, Similar to the Foregoing, the
Thirty-Six Males Being Taken from the Records in Re-
verse Chrosolooical Order :
Chk8 ifberein the pnlflHtionn exceeded the
average number of 135^ per niinnle:
Malus, 13 — altout 34 p^r cent.
Females, 23 — alrout 66 per oenl.
Cum wherein the pulsations fell below the
average number of 135i per minute:
Males, 23 — about 08 jier rent.
Females. 11— about 32 per cent.
These obserrations were made in hospital prnctice, and the
iQal proportion of male chiltlren is not easily explained ou
My other basis than the recognize^l j^reponderance of that aei
UDOog the illegitimate:
124
DETELOPMENT 09 THE OTUM.
Pulsations of Fcetal Heart.' Male. Female.
110 1 0
116 1 0
12(» 0 2
122 4 0
124 1 1
12« 5 1
128 :? 2
i:)o 10 1
132 5 3
134 5 2
1:J(J 2 3
i:jm 4 2
140 J) fi
142 r> 5
144 2 0
14« 1 1
14H 0 4
150 0 1
160 0 1
162 1 1
172* 1 0
Totals fiO 30
MoTiiER'A Auk.
14
16
17
Avebage Pilsations.
120
141
i:i6
Male.
... 0
... 1
Female.
1
2
IH..
14
i:!7
... 1
4
2
3
20
]:\K
H
4
21 .
i:t7
. . H
5
»>•>
!:«
13
2
2;(..
21
u:*y
i:i7
... 5
5
1
2
2."» .
i:to
2
1
2<i
1 u
1
1
27..
l-»(;
*>
0
•>M
VMi
... 1
2
2!»..
123
... 3
0
;»()
131
2
5
'.Vi .
VMi
1
0
:\\
i:u>
1
0
37. . .
3H
142
IW> ,
\'.i2
... 0
... 0
1
1
2
0
Totals.
...60
36
*Ca8C of dyinj; fcctiis before mentioned,
t Dying fwtu8 raised the average.
CHAKOES RE8CXTINQ FUOM rR£ONA>'CY.
125
CHAPTER IIL
The Changes in the Mutenial Organism tliat are
Wrought hy Pregnancy.
Following closely on tlie heelB of impregnation, changes are
begun in the maternal organism, a knowledge of which is essen-
tial to an intelligent view of the subject of utero-gestation, and
the skillful performance of obstetric duties.
rterine Changes. — Impregnation is followed hy increased
rascolarity of the litems. The mucous membrane becomes thick-
ened and convoluti^d, end there is begun the formation of the
important structures known as the decidun?. The textural
changes are buth numerous and great. New muscular fibres
fonn. The connective tissue processes, between the muscular
fibres, become more abundant The arteries assume a spiral
courae, and increase both in number and size, while the veins di-
late and form wide-meshed reticulated anastomoses. The reins
when examined se«^m to be mere canals of considerable size,
coursing through the uterine muscular tissues, particularly in
Ibe vicinity of the placenta. The lymphatics fonn numerous
plexttses in various parts, but especially at the fundus. The
nerres lengthen and tlucken, and sti'etoh inward to the canty of
the organ, on the surface of which ganglia are formecL
The general changes are equally well marked. The unirapreg-
naied uterus measures two ami a Iialf to three inches in length,
ADd weighs little more than an ounce. From these dimensions
ihe organ comes to weigh at the close of gestation twenty-four
ooBoeBr and to measure about twelve inches. Uterine growth
may be said to begin coincidently with development of the ovum,
and continue without interruption to the close of pregnancy.
126 CHANGES REBULTINa FROM PBEGNANCY.
Farre has fumislied the folloTving table of approximate uterine
dimensions for the several calendar months of ntero-gestation:
LvNOTU. Width.
E'nd of ihinl month 4$ — o inches. 4 inches.
End of foarth month 5j — Cinches. 5 inches.
End of fifth month 6 — 7 inches. 5) inches.
End of sixth month 8 —9 inches. G\ inches.
End of seventh month 10 inches. 7} inches.
End of eighth month 11 inches. 8 inches.
End of nintli month 12 inches. 9 inches.
According to Levret's fignres,* the virgin uterus presents a
surface of sixteen square inches, and the pregnant uterus at term
measures 339 square inches. Krause f says the uterine cavity
is enlarged by pregnancy 519 times.
The uterus in the early part of pregnancy is not enlarged from
centrifugal pressure exerted by the expanding ovum, as is Bho\m
by similar development taking place, even in extra-uterine preg-
nancy. In the latter mouths, the expansion is in great measure
mechanictd. The walls become thinned, and their thickness
varies from one-sixth to one-fourth of an inch. The muscular
layers become developed to a surprising degree, and are clearly
discernible. They are three in number: 1. The external layer
is thin and delicate, and is adherent to the i)eritoneum. 2. The
intermediate layer, heavy and strong, composes the greater thick-
ness of the uterine walls. This is made up of fibres that sur-
round the vessels, and interlacing circular and longitudinal fibres.
3. The inner layer, a frail structure, formed mainly of circular
fibres, suiTountls the orifices of the Fallopian tubes and the os
uteri internum.
As the utt^rus increases its dimensions, its serous ctivering is
put upon the stretch, and, with the advance of pregnancy, the
layers of the brouil ligament separate, until finally the Fallopian
tubes and ovaries lie in contact with the uterus.
In the early months, while yet the uterus is a pelvic organ, the
increase is rather in breadth and thickness than in length, so
that it is more splierioal tlian in a non-pregnant state. After it
leaves tlie jx^lvic cavity, development of the organ is more in a
longitudinal du*ection, so that it comes to assume an ovoid shape,
*ScAyzoifi, " Hundbuoh d*T (Sobnrtwhiilfe," p. 77.
tSPlEaELBKKU, "Handbuch di-r Gt-burtstthuliV," p. 51.
ITTEKINE CHANGES.
127
with the narrower estremity below, at the cervix and os. In tlia
fiftl) month, the uterus fills the hyjwgastriuni, and in the ninth
moDth its fundus reaches tlic epignstrium.
Change In Situation.— The first change is in a downward
directiuUf as a fesultof which, £rom it« close anatomical relations
U> the bhulder, and the connection, in turn, of the bladder to the
mubilicuB by means of the uracbus, there is abdominal flattening
lUid umbilical retraction. It is only after the gravid organ rises,
so that itt bulk in above tlie pelvic brim, tliatalxlominal increase
i* i»l»ser\'able This change in situation, which takes place at
the close of the third or l>eginning of tlie fourth mouth, is gen-
erally a slow one, and, when compiete<l, enables us to feel the
form of the organ in the hyiH)gaBtrium.
A few days before the advent of labor there is a slight subsi-
'Wuce. or downwiud movement of the uterus, very marked in
some women, but scarcely noticeable in othera The cause of it
is to be found chiefly in the extreme relaxation of the soft parts
which prece<les delivery.
The Inclination of its Longitudinal Axi».— Tlie fully de-
telope*! gravid uterus lies within the abdominal cavity, its cervix
ihrected downward and l>ackward, and its fundus upward and
forwanl There is also, in general, a slight latend obliquity, the
iAclinution most frequently being toward the right. Situated
iLofl, its anterior surface rests agninst the abdominal pariotes,
its long axis nearly parallel with the axis nl the plane of the
pelvic brim, thereby fttrniing with the horiz(^>u im angle of about
thirty ilegrees. It assimies the vertical line only when the woman
is la the semi-recumbent posture. From excessive relaxation of
tho abdominal parietes. a j>endulous ct>nditiou sometimes exist«.
rbancces of Cerviral Position. — The situation of the cervix
niTtot obviously depend largely upon the situation and inclihatiou
of the uterine iKxIy. Hence, in tlie early weeks of pregnancy,
the cervix is within easy reach of the finger. After the third
mooth it is higher, and situated s<i fnr posteriorly as sometimes
to place it almost beyond reach of the index and middle fingers.
Changes In the Size and Texture of the Cervix Uteri.—
le cervix shares in the hypertriiphy of the body and fundus of
tiw aterufi, but this change is generally comjdeted by the fourth
DiootL The increase in size is partly from an increased growth
aotl new formation of tissue elements, but more especially from
128
CHANQES BE8ULTING FROM PBBOKANCT.
Cervix uteri at the cud of third mouth.
the loosening of its strncture and distension of its tissues from
serous infiltration. The cervical vessels, under the stimulus of
the process going on in the uterine cavity, are dilated, and the
Fia- 76. result is hyi>er8Bmia of the part,
and consequent oedema. These
conditions in turn occasion a
physiological softening of the
tissues, first manifested in those
parts where there is least resist-
ance, that is, under the mucous
membrane on the lips of the os
externum, and from this jxnnt
continued jjrogressively upwanl
toward the os internum. The
cervical follicles are active, and
pour out their secretions, though
the formation of a " mucus plug," describeil by some authors,
is questionable. The orifices of these follicles are liable to occhi-
sion, in which case little sacs are formed, known as tlie ovules
of Naboth.
Most of the standard works on midwifery- allude to a progress-
ive shortening of the cer- vm. rr. ■
vix uteri whicli is 8U])]x>sed
to take place in pregnancy.
Stoltz, in 1820, queBtioned
the truth of this theory, but,
according to Dr. Duncan,
he M'as preceded by Weit-
brech in 1750. Various
post-mortem examinations
by others have clearly
shown that, c<mtrary to the
older teachings, the cervix
does not lose half its length
by tlie sixth month, twtv
thirds of it by the seventh,
and all of it by the middle
of the eighth. To l)e sure,
the part diws not present
the prominence which it once possessed, but the change is in
Cervix uteri at t>eKiii»iiif; of lifth month.
tTTEKlNE CHAKGES.
129
II of softening and elevation without coincidpnt
rdiort , , r ol)lit<'ration of the cervical canal by expausiun
of the intenxal ob uteri. We have insisted on the truth of this
[Jor yeais* as the result of careful examinations, and we are con-
'Tiiioed that, in tlie majority of cases, the internal os uteri does
not yield till lalxir suj>ervene8, or is near. According to Dr.
Fio. 7H.
8bo«rinff tb<* bulging of th? anterinr uterine wall from pressnre
ol' tin: liKlal hfa*l.
M&tthews Duncan, the change occurs during the latter half of
the niuth month, but, even then, the obliteration of the cervical
cwal appears to be due to the incipient uterine contractions
vliich preymre the cervix for Ialx>r. "The length." says Dun-
Pwi, "of the vaginal |X)rtion of the cendx, or the amount of pro-
jection into the vaginal cavity, greatly diminishes as the uterus
nses into the cavity of the abdomen."
This is fai' from being a constant phenomenon of pregnancy,
130
CfLVNQES BESULTING FBOM PBEGXANCY.
yet it is probably one of the causes of tlie mistakou ideas for-
merly entertained regarding cervical shortening. On making an
examination, the raginal portion of the cervix is found not to be
''i'» "y as prominent as usual, and, in-
dee.l, in some cjifies, even sc^u-ce.ly
to be felt, and the inference has
genendly been tliat tlie cer\'ical
Uxly has been annihilated. The
opposite result, as is well knonii,
is produced by depression of tlie
uterus, as in the early weeks of
pregnancy. This change ha&
led Boivin and Filugelli to re-
Cervix uteri at ciul Mf eighth month, gm-^i the cervix as lengthened-
It is probably true, however, that to actual measurement there
is a certain amountof cervical shortening, which takes place dur-
ing pregnancy, growing out of the physiological softening which
occurs; but it is not n shortenins consequent on relaxation of the
Flii. 80.
Cervix of a womuii wliu died iii the eighth month of preffUKticy. (After
l>uucan).
internal os, and infringement upon the cervical canal, as has been
supposed. Post-mortem, and careful vaginal examinations, have
CTCRIKE CHANGES.
131
Fio. PI.
clearly shown that the internal os nteri does not expand until
near the close of utero-gestation.
Another factor in the production of apparent shortening is
probably the bulging of the uterine wall anteriorly to the cervix,
hs on effect of downward prCBSure of the presenting head. This
condition, which, while common, though by no means uniform,
causes the os uteri to l)e directe<l backward toward the sacrum, and
gives rise at times, especially in late pregnancy, to considerable
liifliculty in reaching the part, and at the same time produces a
marked shortening of the anterior lip of the os uteri. By push-
ing the head ujjward, or by placing the woman on her knees and
elbow«, so tliat the head will recede, the cer\'ix is made to resume
ite normal situation and feel.
As pregnancy advances
the 08 uten liecomes more
and more patulous, but the
degree of expansion differs
in primipariB from that in
multii>iu-ie. In the former,
after the fom-th or fifth
montli, it gets slightly pat-
ulous, but will not receive
the end of tlie linger till a
much later i)eri(xl. Even
at the eighth or middle of
the ninth montli, the mar-
gin of the OS is pretty close-
ly contracted. Tlie cavity
of the cervix is wide, and
Cervix ut«ri»»cyoiui the (wvuDth montb. if the finger be pushed
through the external os, it readily passes to the situation of the
internal os.
In pluriparae the cervical changes are somewhat influnnced by
»e experiences of former pregnancies and labors. The cervical
does not assume the spindle shape, but rather resembles a
thimble. The os tiucje is more widely expanded, so that at the
seventh month the finger easily enters the cervical canal, and ai>-
pn^ttchee the internal os. At the eighth month the latter, as a
rule, has begun slightly to yield, though on one hand it may re-
main closely shut till the close of gestation, and, on the other, it
132
CHANGES BE8ULTIKG FBOIC FBEONAKCY.
may bo so widely expanded as to admit two fingers. Lusk^
mentions Uie case of a multipara whom lie had occasion to ex-
amine toward the end of gestation to determine the question as
to the safety of her making a railroad journey to a neighboring
city. He found the cervix soft, the head low, and the internal
06 dilate<l to tlie size of a dollar. Two weeks later, he was call-
ed to see her in the early stage of labor, and found that, under
the influence of uterine contractions, the canal i>f tlie cenix had
again closed.
Vaginal and YiilTur Changes.— In the vagina, changes takd
place ct>rrespon<li]ig in s<»iiie reganls to those in tlie uterus. Tho
muscular fibres bj-pertrophy; the vessels of the venous plexuses
increase in size, and imjjart a blue, or purple color, to the vaginal
walls. The mucous membrane l>ecome8 thickened, and increased
in length, so that though the vaginal tube is drawn upon by ascent
of the ut<?rua, the anterior of tlie vagina not un&'etiuently j>ro-
trudes from the vidviL The {>apinio enlarge and impart a rough
feel to the finger.
There is also turgescence of the vulva, pouting of tlie labia,
duskiness of the mucous surfaces, and abuuilant secretion of the
follicles.
Cbanges in the Mammie.— Before impregnation the breasts
are firm and nearly hemispherical; but during pregnancy they
increase in size, and present other changes which demand oon-
sideration. The phenomena observed in these glands are due to
swelling of the amnective tissue, development of glandular acini
along the course of the lactiferous ducts, and increased deposi-
tion of fat between the lobes. Enlargement of the organs is not
noticeable until tlie fourth month, though from an early period
In pregnancy there is a painful sensation of fulness in them.
The veins onlnrge and become nnusually distinct as they course
beneath the skin, and as distention fijially becomes excessive,
the cutis yields in places, presenting reddish or white lines like
those found on the alxlomen.
The nipples l>ecome turgid, prominent, sensitive, and, on slight
stimulation, erect The most diagnostic changes, however, take
place in the areola. Often as early as the second month the sur-
face of this part is soft and oedematous, and slightly elevated.
I
* " Science and Art of Midwifery," p. Sa
COAXOES IN THE BIAMM^
133
Tlie eebaoeoos follicles enlarge, and after a time moisten the
ai«olB with their BfUTctioiw. Ab<»ut tho midille of pregnancy,
discoloration, arising from a deposit of pigment, is noticeable.
It is more marked in women of dark comidexiou, and, from the
fact that it is more or less permanent^ the sign is of value mainly in
primiparsB.
Fxi. «2
7
fihowing the appeamnce of the areola.
In the latter months of pregnancy, about the border of the
arpola is observed a ring presenting a i>ecaliar aj)pearance, called
llw stxxmdary areoUi of Montgomery, The character of it is
betU'r depicted in tlie accompanying cut than in any written de-
scription. Briefly stated, it looks as tliough the color had there
Wu discharged by a shower of drops. Tiio appearance is due
U) the presence of enlarged sebaceous follicles devoid of pigment.
Other Tissue Changes.— The connective tissue interposed
l»tween the layers of the broad ligaments, and around the ute-
nij, becomes slightly infiltrated with serum. The lymphatics
»l«i) enlarge, from the increased work put upon them. Fat is
il«poaited in the subcutaneous tissues of the pelvic region, giving
to the hips increased breadth.
134
CHANGES RESCLTINQ FROM PREGNANCY.
Abdominal diansjes. — As the uterine development goes on,
the alxluiuiunl whUh are put upon the Btretch. and, in women
who are well nourished, are increased in thickness by the abun-
dant formation of adipose tissue. The umbilical ap]>earances
are altore<l from stage to staga At first, from causes l>t>fore
explainer!, there is marked retraction of the pari This becomes
progress! v*^ly h^ss, until, at the seventh or ei^lith mouth, it be-
gins to assume the exact counterpart of its former appearance,
by becoming prominent, from the pressure exeri^l from within.
Ab<lominal distention also gives rise to the formation of reddish
fitreuks, or striic, which, after deliverj% become bleached, so as to
resemble cicatrices. They are found more especially upon the
Fio »X
LfttcvalView ok tiixlh uioath.
Lateral view at ninth moath.
sides of the alKlomen, where they form sinuous lines, varying
in leugtli. They are due to an atrophic contlition of the skiu-
layers, to partial obliteration of the lymph-spaces, and to con-
densation of the connective tissne elements, which, instead of
BLOOD CHANQES.
13d
forming rhomboid meshes, run [)arallel to one another.* They
are merely the result uf disteutiou, and are not peculiar to preg-
nancy.
Bflation of the Fterus to Surrounding Parts.— Toward
the clone of gestation the uterus lies with its anterior surface
directly in ctmtact with the abtlominiU wuIIh, the intestines hav-
ing been crowded upward and backward until they surround the
uterus like an nrcli. Its lower anterior surface rests upon the
posterior surface of the symphysis pubis, and the lower uterine
gegment dips, to a certain extent, into the pelvic cavity. The
piist^rior nt^^rine surface lies in relation to the spine, by which
it is made to assume a slight lateral obliquity.
Functional Disturbance of Nelghborinsc Pelvic Orj^ans.—
The pivssure exfrt^ed by the gravid uterus creates fiiuctiimal
disturl>ances in the neighboring pelvic organs. Pressure on the
bladder, at its cervix and fundus, prc»duces a desire for frequent
micturition. The rectum and intestines generally become inac-
tive, and the resulting constipation is an annoying complication
of the pregiutnt state. Pressure on the sacral nerves causes
poina in the tliighs and legs; also cram]>8 and cUtHcult locomo-
tion. fEdema of the lower half of the body, and varicose eou-
dition of the veins of the legs, rectum and vulva, arise mainly
from presHuie, but partly from vascular fulness of the jnUvic
vessels, induct by pregnancy.
('han]E:es in the Blood. — Amongst the most important altera-
tms in tlie female or{j;Huism brought about by the pregimnt
ile, lire the changes which occur in the cii'culating iiui<L At
one tiiue it was a common notion that, during pregnancy, the
vonian was nearly always in a condition analagous to plethora,
and to this state of the vasculwr system were refenvd the many
ills of which pregnant women complain, such as headat^he, pal-
pitatioD, singing in the eai*s, and shortness of brenth. With
ihetie ideas of pathology, the treatment a[)plied was logical, re-
ift being had to active anti-phlogistic medication, low diet, and
laentlv to venesections. "We are told that it was not un-
• Btbiy.— "ThoCiwitrices of Pregnancy.*'— Trans. Am. Gyn. Soc'y, Vol. IV
134
CHANGES RESULTrwO FBOH PREGNANCY.
Abdominal Thangeft. — As the uterine development goes'on,
the abdoiiiinal whLIk are put upou the sti'eteh. aud, iu women
who are well nourished, are increased in thickness by the abun-
dant formation (vf adipose tissue. The umbilici appearant
axe altered from stage to stage. At fii'st, from causes beforei^
explained, there is marked retraction of the part This becomes
progressively less, until, at the seventh or eighth month, it l>e-
gins to assume the exact counterpart of its former appearance,
by becoming prominent, from the pressure exerted from witliin.
Abdominal distention also gives rise to the fonnation t»f reddish
streaks, or stiiaj, which, after delivery, l^ecome bleached, so as to
resemble cicatrices. They are fotind more especially upon the
Fio. 83.
Fio 84.
LatcralVicw at nixth muntli.
Lattiml view at uinib mouth.
Bides of the abdomen, where they form sinuous lines, varying^
iu length. They are due to an atrophic condition of the skiu- -rt
layers, to partial obliteration of the IjTnph-spaces, and to cxm
deusation of the connective tissue elements, which, instead
136 CHANQES BS8ULTINQ FBOJC FBEONAKCY.
common for women to be bled six or eight times daring the latter
months of gestation, and we have the record of cases wherein such
depletion was practiced as a matter of routine, every two weeks,
and sometimes much oftener.
Modern research appears to have conclusively demonstrated
that there is an increase in the quantity of the circulating fluid,
to correspond with the enormous vascular developmeni* The
increase is mainly of serum, but the number of white blood cor-
puscles, and the quantity of fibrin are both augmentecL On the
other hand there is a decrease in the number of red blood cor-
puscles, the quantity of albumen, iron and salts of the bl(X>d.
Inasmuch as there is an increase in the total quantity of blood,
the proi)er maintenance of the circulation would demand an in-
crease either in the fre<iuency of the heart pulsations, or in the
quantity of bkHKl forced into the large vessels with eacli cardiac
systole. Observation of i^regnant women tenches us that the
first alternative is not true, the action of the heart is not accel-
erateiL The C4)m]x>nsati()n, then, is in dilatation of the heart
cavities and hyi>c»rtr()phy of the left ventricle, the auricles and
right ventricle remaining unaflected As a result of these
changes, there is increase<l arterial tension, which impniis a full-
ness to the jnilso, formerly inisuiidorst<HxI. Acoonling Uy Duro-
ziezf the lienrt remains enlargetl duriug lactation, but is rapidly
diminished in size in wimien who do not suckle. In those who
have borne mnny chihlren the organ remains }>ermanently some-
what larger than in nulliparae.
Tarnier says that in women who have died after <]elivery, the
organs always slu>w signs of fatty degeneration. We are tolil
by (lassner that tlio whole IkxIv increases in weight during the
latter part of pregnancy, and this increase is somewhat beyond
what can l>e explained by tlie size of the wonib and its contents.
Formation of Osteophytes.— Thin lM>ne-Iike lamelhe, con-
sisting eiiietly of phosphate nn<l carlnmate of lime, are found
de|K>sited on the inner surface of the skull in rather more than
half the women who have died late in pregnancy, or soon after
* Vidt: *'UntersiuhuiiK<'n iibtT dif ISlutnR'iijje tracliliger Hiindc." "Arch. f.
(iyiiurk." Ikl. iv. i>. 1];2.
t Gaz. des Ilojiit. Ih«!H;
OTHEJl CHANOES.
137
delivery. These lamellie, which measure one-sixth to one-half
line in thickness, are by Kokitansky termed osicopht/fes. They
begin to fomi about the third montli, and are foand cliiedy upon
the frontal and parietal bonea They are not pecidiar to preg-
nancy, but are likewise often found in consumptives. .
Misfellaneous Changes. — The nen-ous system generally be-
cxiuiLts morri impretisiouublL!. There are alterati{>us in the intel-
lectual functions, changes in disp<:)aition and character, morbiil,
eftprieious appetite, tlizziness, neuralgia and Hym'ojw. Melan-
cholia is 8<jmetimes met, wlucli in women predisposed thereto,
isiionally enils in mania. The memory is often weakened,
^Slpt^cially when one pregnancy follows another in rapid succes-
iiixn. On the contrary, the nervous system sometimes becomes
calm and strong, and the woman experiences a peculiar sense of
well-being.
Hespirntiun becomes dificalt from mechanical causes, espec-
uilly at a time just previous to the subsidence of the uterus here-
ittl)ffnre «ilud*?tl U*, at which time, according to Dohrn, there is
lidiininntion in the vital capacity of tlie lungs. Tlie thorax is
mcrease*! in breiwlth, and diminished in depth.
Gastric disturlwnces are common in pregnancy. Nausea and
vimiiting, which, from tlieir most frequent occurrence in the
morning, have been called " morning sickness," are experienced
by the majority of women during the early weeks. Tiie anthor
bus founfL however, ujw^n cnreful inquiry of women presenting
tliRUi!*lvt»s for coiiMneiJietit in Hahnemann Hospital, that about
^'trty per cent of all cases entirely escape the annoying complica-
'' ' '* - Tierallylw'ginH at alxmt the sixth week of pregnancy^ and
f- >r from six days to 8i,\^ or seven weeks. In other
is«M!8 it is a C!i:»mplic^ition of later gestation. The appetite is
"ipricirtu.s the tongiiigs l)eing in some cases for even disgusting
tirtirj)^ of foi^i IncreHsP4l tlow of saliva is often a marked
;"'lt*'iu- The bowels are tMmietimes hxise, but constipation is
Jic'iv common.
It is not suriM'ising to observe that the health of women is
9<»aie«'hat impairoil during the first three months of pregnancy,
•ifter that time, liowever, there is generally uu improvement--
tifl appetite returns, digestion becomes more active, and assinn-
138 CHANGES REAULTIXQ FROU PREGNANCY
lation recruits the strength and increases the weight Gassner*
estimates the total increase at about one-thirteenth the entire
weight of the body.
Besides the pigmentation of the areola about the nipple, there
is discoloration of the linea alba of the abdomen, and at times
muculio appear on different ]>arts of the body, particularly the
face, but, as a rule, disap]>ear after delivery.
Certain changes in the urine have^ by some, been considered
pathognomonic of pregnancy. Tiiese consist in the formation
of a dei)osit when the urine is allowed to stand for a considera-
ble time, wliich has l)een called KieAfein. It is observed after
the second month of pregnancy, iintl up to the seventh or eighth.
From the fact that a precisely similar substance is sometimes
found in the urine of women who are not pregnant, esi)ecially if
aniemic, and even in the urine of men, it cannot \>e regarded as
a change i)oculiar to pregnancy.
The Permanent Changes.— The uterus after delivery does
not resume its nulliparous sha])e and sixe, but retains vestiges
of the condition through which it has passeiL The weight of the
organ is increased to alxmt an ounce and a half; the fundus and
IxKly are rounded externally; the cavity of the body loses its tri-
angular shape, and becomes much larger relatively to the cervix,
wliile the os internum is left somewhat agape. The mucous
folds of the cenix are in great measm'C obliterated, or. at least,
nre rendered indistinct, and the os externum is j>ateni Abdo-
mimd distentitm leaves indelible marks in the shai>e of the stria*
niontioned, which, from a reddish or br*.)wn color, become sil-
very-white like cicatrices. The pigmentation of the linea albn
is nr»ver wliolly removed. Tlie breasts gi^'e evidence of former
]>regnancy in tlu* existence of tin* silvery lines alluded to, and the
tliscoloration of the nreola which has, in a measure, remaint^l.
In addition t<» these clinnjjes tliere are d(»ubtless many which
mark a diilerence between women who have lK>rne children, and
those who liMV** not. but furtiier i-vidence is, in the main, refera-
ble Ui ])arturient elVects.
*"Monatss(hr f. (;churt-ik." \\i\. xix. p. 1.
THE OUONOSIS OF rBEOKANOY.
CHAPTEE IV.
The Diagnosis of Pregnancy.
The diagnosis of pregnnncy, from the obscurity nnd indeter-
minato character of early symptoms, and the weighty contingen-
des which iiang upon the expressed conviction arising horn
eiamination, is one of the mosttrjang duties which the physician
ifi ealle>d to perform. It is further iutensihed by the notion so
prevalent among people, that the signs of pregnancy, from the
first, are, or should be, to the trained and skillful observer,
clearly legible.
In moet cases wherein this interesting condition is snspected
to exist, the woman is within marital bonds, and diagnosis is
flcmgbt more from the promptings of curiosity than any other
oonsideratiou. Sneli women, as a role, are (cosily pacifie<l with
an equivocal answer. In other cases there is an entirely differ-
ent posture of ivffaii^ and diagnosis is requested not out of idle
cuririftity, or to satisfy a momentary whim, but from the pressure
dire forel»oding8. The woman Ls not under the safe protection
marriage vows, and, urgetl on by her fast-auginonting fenrs,
or 6timalate<l by an impngning conscience, she seeks positive
knowledge. Again the physician is consulted, not by the woman
hwrself, but by her friends. Parents, perhaps, witli, or without,
IwfHrt-aickening suspicions of their daughter's unchastity, desire
w Piplanation of the objVctive and subjective symptoms which
hftv»i come to their knowledge. In many such cases so much tle-
pe«da upon the diagnosis rendered, that an error will not be par-
'i*mRi. Tlie symptoms may be ambiguous, and a most careful
invfeatigation may not elicit conclusive evidence, but by the con-
Tictioa expressed the physician has generally to abide. No plea
of Living done as well as circumstances allowed, will atone for a
miitaten opinion- A confession of error will not bind up a broken
l»«art. nor restore the lustre to a tarnished reput-ation. Further-
non^ the physician is sometimes called npon for an opinion in
140 DIAGNOSIS OF PBEONANCT.
cases under litigation wherein alleged gravidity is an important
factor. Final adjudication in fixing responsibility, or in direct-
ing the iixheritance of proi>erty, may be determined largely by
the effect of his expert testimony.
Classification of the Signs. — The signs of pregnancy should
always be classified as relaiive or ^)rcs?tnip/tVe, and j^osifive cr
demofisfrahlc signs. Ujxjn one, or ujwn a number of the former,
nothing more substantial, affirmatively, than probabilities, of
various degrees of intensity, can be ijredicatecL An unequivo-
cal affirmative diagnosis ought never to be given. The presump-
tive evidence may be so strong in certain instances as to leave
few and feeble ])ossibilities of error, and yet experience teaches
the fallacy of drawing absolute conclusions from such data.
There are three signs which arc generally regartled as positive,
viis.: foetid movements, htilloiicmcni, and the soimdsof the foetal
heart By some teachers, however, the last alone is regarded as
unconditionally positive, ami thus we here teach.
Huhjective and Objective Signs.— In the diagnosis of preg-
nancy subjective symptoms should receive due consideration, but
objective symptoms must constitute <mr main reliance. Women
are too prone to dniw their conclusions from intuitions and men-
tal impressions, and as a result we sometimes have gravuUius
nervosity disconnected, i)erhiips, with even the most common and
essential physical indications of pregnancy.
History of tlie Case.— Items of inii)ortanco mny Iw gathered
from a recital of tlie history of the case, which should include
an account of the mode of development, and the order in which
the various observable and sensible signs were manifestetL
Tlie Jtlenstrual Flow ouglit to be carefully inquired after.
Tlicre may have boon a reguhir return of it throughout the suj)-
j)Osod pregnancy; or tliore nuiy Iw complete suppression. Should
the fonuer condition i)revail it will justly arouse suspicion. In
that case, ascertain wherein the catamenia deviate from a nor-
mal standard. If menstruati*)n has ceased, learn the circum-
stances under which it disappeared, and the jx^culiarities, if any,
which characterized the last two or three *'i>eriod8."
Pregnancy in Women Who Do Not Menstruate.— Cases are
on record wherein young women have <?onceived before the men-
strual function had lieen established. During lactation and sus-
pension of menstruation, impregnation often occurs.
INSPECTION.
141
I
'' Morning Sickness" — a sign of some valuf* — is largely sub-
jective, and c*inren»mg it strict iucjuiry shoultl be made. "When
it first felt ? At what times, and under what circumstances
it most troublesome ? How long did it kist ?
^Vlien tpiicknting is alleged to have taken place, try to fix the
ilate, and the precise sensations experienced.
Inreliability of Subjective Symptoms.— "With regard to
information thus elicited from women, it should be observed
that, while it afibrds valuable data to be used in constructing a
diagnosis, it is liable to be wholly fallacious. The menstrual
function may, or may not be suppressed, ami she may, or may
not hare experienced morning sickness and foetal qiiickening.
Facte are exb'emely lia!)le to be distortetl (not always purjKJsely)
by surrounding circumstances, and the woman's mental state.
Menstruation During Pregnancy.— It is not very uncommon
for a woman to menstruate once, twice or thrice after impregna-
tion, and cases are recordetl wherein the catamenia returned with
regularity throughout utoro-gestation. Various Uieories have
Iven advanced in explanation of the anomaly, but most observ-
wh now C4incur in ascribing the flow t*> its usual source- Tlus is
^reIlderell probable by the well established fact that the decidua
reflxa does not come into intimate relation with the decidua vera,
over the entire surface of the uterine cavity, until after tlie third
montL
Objet'iive Symptoms. — We must depend, then, almost wholly
on objective syuiptonis as a basis for diagnosis. The same com-
mon means <»f investigation are available here as in otlier cases
^liere physical examination is required. They arc — Inspection,
IWpation f inchiding "the t«:>uch"), Percussion, and Ausculation,
Om relative value of which, and the methods of most efiective
OM^ will be briefiy considered.
I Inspe<*tion.— Inspection will aid very materially in perplex-
ing c&des, in carrying the inquirer to a correct decision. The
form of a woman who has reached the fifth mouth of gestation
i« Qnite diagnostic even when purposely obscured i> a certain
d<?gree by the appnreL The experienced observer is often able,
by inspection of the form, to differentiate between pregnancy
and fiiinulating eruditions. Tlie precise outline of the gravid
Abdomen varies, bnt within limits which make all cases quite
142
DUON06I8 OF PaEGNAN'CY.
Bimilar. As we take n lateral view of a preguiint woman, the ab-
dominal enlargement ifi seen not t«i l>e equable, but its point of
greatest projection is near it» sujjoriur iMnuular)'. This pecul-
iarity becomes mf>re and more characteristic as pregnancy ad-
vances. The cause of this is obvious when we recollect the form
of the uterus, and the direction of its long axis, it being at an
angle with the horizon of about (50 ^ .
This latend view is of w»nsidr'niblo value in the diagnosis of
pregnancy. Mere circumferential measurements are of com-
paratively little importance.
A front viow also of the alidominal tumor, taken when the
woman is cither Ht^inding or lying, reveals diagnostic characters.
They ore more marked in the erect position. First should be
observed the absence of prominences and irregularities. It is
not uncomiucdi to find a difference btHween ti»o two sides in point
of fulness, but it is not c<»n£ued to a circumscribed area. This
is generally i)ro<luced by the presence of the fietiil trunk, as tho
writer has rc^peatedly demonstrat^L Then, too, the tumor aris-
ing from pregnancy is narrower, and more prominent along the
middle lijie, than is the pathological tumor.
S|>ecial alxlominal appearances, aside from enlargement, should
be remembere<L During the first few weeks of utero-gestation.
the abdomen, instead of being enlarged, is really retracted or
flattone<L This is especially true of tlie umbilical regiim. This
phenomenon has alreml^' been explained. The uterus, from its
uncommon weiglit, procee<ling in [virt from actiial increase in
size, but largely from vascular engorg^sment, sinks in the pelvic
cavity to an unnatural level, and in doing so drags u|Kjn tlio
bladder, which, in tuin, through the urachus, causes the retrac-
tion mentioned
The linen alba of tho abdomen, from a deposit of pigment,
loses its usual appearance.
Fcetal movements are often discernible. They are sometimes
closely simulated by spasmodic muscular action, when, as a
maans of differentiation, palpation affords {K>sitive aid
Inspection of the breasts is a valuable means of diagnosis, by
means of wliich the chaugea deKcnl>ed in the preceding chapter
will be observetL The appearance known as the "secondary
areola of Montgomery,'* should receive special attention.
The changes in the vaginal mucous membrane must be seen to
»ALPATJON.
143
I
»
\» Itiiowii. but wheu once familiar to the eye will afford cansiil-
embJe aid
The furegoing embrace an allusion to the principal applica-
tion* of tLis means of investigation. When intelligently em-
\i\t)\iHl it famit»he£ valaable aid iu perplexing cases.
Palpation, — If deprived of every sense but the tactile, the
physician would still retjiin the means for making a positive
diagnosis in nearly all cases t)f suspected pregnancy. This mode
of examination is in common use, and is highly regarded, yet
there are many, even among those lung in practice, who, from
]hck of adequate comprehension of its jKissibilities, do not value
it a» highly as they ought Alidominal palpation alone is suffi-
deat, in many ambiguous cases, to effectually dispel doubt. Li
early pregnancies it is not capable of such achievements, but
when combinwl with tlie vaginal t<iuch, it ]>ecomes a most valu-
•ble heljx L;iter. however, the uterus, with its developing fcetus,
rLies within easy reach of the hand, and udiuits of minute ex-
ftmiiuitiou. The fundus uteri is always easily distinguishable,
and iU height can be clearly determined. Its peculiar ft>rm,
with broad, even surface, is highly characteristic. Its lateral
Guperticies can al&ci generally be felt. If the examination is
pmlonged. the recurrent uterine contractions which aro going on
Iboiighoat tlie greater part of pregnancy, will be felt under the
bud; and <lnring tlieir prevalence, a pretty good outline of the
fnvi*! uterus may be distinguished. At tlie moment <^f con-
tnrtiun, Uie surface of the uterus which comes under examination,
»ben not defaced by fibrous growth, will convey to the hand
siimooth, regular feel. In the inter\^al8 between contractions,
vban there is no muscular resistance, it is possible after the
middle of pregnancy, to feel the foetal form through the uterine
walls. At this peridd, and later, there is in many cases so great
a rvlAtive rc<lundancy of liquor amnii as to admit of remurkublw
foeia) mobility. Tlie head, if not presenting closely at the brim,
M it frequently at this season is not, may easily be moved from
oDBsido <>f the abdomen to tlie other. In a modified degree this
is aIi»o trufi of the extremities and trunk. The foetal movements,
whetiier spimtaneous or elicite<l, are easily felt by the pali>ating
If the abdominal walls are thin, as jn women of spar-^
it, p&Ipotion is capable of affording highly satisfactory cv.-
Opon which to base diagnosis.
144
BlAOyOeifl OF PBEGSANOY.
In many cases, by deep pressure, the alxlomiiml walls helow
the umbilicus cau !>e liepressed until the fijigexs touch the spine,
in which case the ph>-sician may rest assured that there is no
pregnancy, or that it has nut advanced beytJiid the thu'dor fourth
ujonth. If in making such au attempt, resistance is at once en-
countered, tliorongh examination by deep pressure and conjoint
touch should be made, to loarn the nature at it
"The touch'' is a highly efficacious mode of examination, and
one wiiicii, in casas at all ddubtful, ought never to be neglected.
By means of it several imjwrtant signs may be elicitetL In the
parly weeks, the uterus, as before ol»ser\'Bd, lies lower in the
lielvic cavity than during a non-pregnant state. This condition
by itself would be of no signitafance, and, at liest, is but a Feeble
relative sign. After the third month, the uterus having risen stj
that its bulk lies above the pelvic brim, the cervix is elevated
and turne<i backward toward the rectum, thnreby putting the
roof of the anterior vaginal cuUle-sac on the stretch. This is a
valuable relative sign when found as a concomitant of other
affirmative contlitions.
('errical Softening. — The raarkwl changes in the cervix uteri
which begin soon after impregiiation and gradually progress to
full consummation, have been descril>ed elsewhere. At the close
of the eighth or ninth wi*ck the li[»3 of tlie iis, uteri communicate
to the examining finger a slight sensation of softness, at that time
dup, j)pjhaps, in the main, t*» turgescence and tumefaction of the
IMirt, Itutdoubtless attributable, in a measure, to si^ecial i)hysiolog-
ical softening of the ut«rine ne<*k, <lej)eudent on oUier causes. The
process begins at the lowermost i»art and progressi^'ely as-
cends. Au examination made at the sixth montli discloses soft-
ening to the extent of half its length. Not until near tlie close
of gpstation is the process completeiL The gradually hicreasing
expansion and dilatability of the os nU^rl which accompanies the
cervical softening, ought to l>e kept in mind during examination.
The iH>ritMl at which the internal i»s uteri gives way, so that
the cervical canal becomes part of the uterine cavity admits of
some diversity of opinion. It is the author's conviction ( else-
where expressed), based upon special observation of many cases,
that it is not brought about until, or very near, the beginning of
labor, and frequently not until pains have been present for some
time. If this is true, the progressive shortening of the cervix
generally described is more ap|tarent than real.
PEBCU8SI0N.
145
rnsiOD Las bc*eii nimie Uy the fliagnostir value ol conjoint
fiataiiiDtion, / c, alKiomintil palpation employed in connection
with the Taginal touch. By such manipulatiLin it is possible to
f.irrn an approximate estimate of the size of the uterus, and
lieDoe the prolj.ilnlity or improbability of pregnancy. It should
beindalged with due caution, as harshness is liable to produce
tnmi unvelcome results.
There is a form of vaginal, or bimanual ex.amination, the era-
pliirment of which, at certain stages, will disclose a sign of
piegnancy by some reganled as pc^sitive. namely, iKiUoffemeitf,
ll c«i: be pnicticed by both hands upon the alxlomen. To do so
tbevoman must be placed on her side, one of the operator's
IuukIs resting above, and the other below the abdomen as she. lies.
By u Budden movement of the hand beneath the foetus, the latter
nifty be displaced or tossed, and the imjmlse of its return com-
municated to the keen sense of the operator.
Vaginal bnHotiemeni is performed by placing the woman on
her back in a eerai-recumbent posture, and then, with two fin-
gers in the vagina, tlie uterine wall just interiorly to the cervix
is given a sudch'n push in the direction of the long uterine axjs.
This propels tlie foetus away from the lower uterine segment,
I'tit it H(K»n sinks again in the li(juor amnii, and the gentle bip
of its contact with the uterine tissues may be felt When clearly
ehcited, it is regarded as a positive sign of pregnancy, but owing
tf- the skill and experience required to successfully practice the
mamtuvre, it has here been classed as a relative sign. It can-
not be employeti with satisfaction earlier than alxjut the close of
the fourtli month, nor later than the seventh.
Uleruie fluctuation may sometimes be felt, according to Dr.
;h/ by conjoint manipulation— the hand on the abdomen,
two fingers in the vagina; but the delicacy of the sign ren-
iier» il nniehable for geneial use. It is recommended as a
iDe&us ot ejirly <Liagnosis.
Perciis-ilon,— This means of diagnosis fills but a small niche.
Tb*. ttUhimen in real gravidity gives, on jjercussiou, soumls
mo«t]> flat, always dull. Should resonEince be obtained over the
site ot tlie enlargement, it may jiLstly Ije regarded as almost con-
chifiive evidence of non-jiregnancy. It can be employe*! to oon-
* Bffitteb Mctlicai Jnumal, vol. ii., 1.47:t.
146
DUOKOBXS OF PBE02iA^*CY.
firm other indicntiona, but as a means of positive diagnosis it
possesses no merit
Auscultation. — When Mayor, of Geneva, tentatively applied
his ear to tl»e alxkmien of a prej^nnt woman In the hope that
he might hear foetal movements, and disw^vereil the inaudibility
of these, bnt heard the unmistakably clear sounds of the foetal
heart, he brouglit ^^nthin command n means of diagnosis at once
easy of application and unequivocal in inchcatiun. The fo-tal
heart-beat is (he jxisitive sign of pregnancy.
Tlie sounds have been compared to those oi a watch under a
pillow, but an infinitely better idea of them may be obtaineil by
listening to the heart of a new-born child. They were first heard
by Mayrn* with the unaidetleflr, hut we ought not to infer from
this that immediate ausculation is preferable. The auth<^r has
repeate4lly demonstrated the superiority of the nwMiiate mode.
The dtjuble stethoscope gives best satisfaction. The instmmeut
may be applied by firm or by light pressure, the latter lieing
preferable. To properly do this it should be placed on tlie a}»-
domen in such a way that it Mill rest evenly, and lightly, aaid
then the fingers entii'ely remove<l. iS*)unds can tlius be heard
which would otherwise be abs<:>lutely iuauilible. This method of
using the stethoscope requires considerai)le practice to obtain
the best results.
The area of audibility depends mainly on the ]X)sition and
present/ition of the foetus. The sounds are conveyetl to the ear
mtwt intensely by rnilld tissues or substances; hence they are
most distinct when the trunk of the fcetus, at a point near the
heart, comes in contact with the uterine walls, ami tlie uterine
walls are in turn brought firmly agninst the aUlomiual parietes.
A dors<vanterior position of the f(jetu8 is most favorable for
transmitting the impulse. The area of audibility varies consid-
erably in extent. Li one case the sounds can be heard over
nearly the w^hole abdomen; wiiile in auotlier they are circum-
scribed to a small space. When audible over an extensive area
there is always a point where the snmmum of intetisiitf is reached.
Since the left dorso-anterior position of vertex presentation is
the most frequent, the sounds of the fcetal heart, are t>ftener
heard on the left side below the umbilicus. When the child is
in the fourth position, the sounds are also on tlie left side. In
second and third positions, on tlie nght side. In cephalic pres-
AUSCULTATION.
147
I
entatlon tJie area of audibility is lower than in pelvic presenta-
tiuu.
Th«» rapidity of pal&ation varies greatly, the average being
ablaut 134 Ijeatfi pfsr niinnt^^
Observers are not in accord regarding the period in pregnancy
it wJiich the fcetal heart is firwt audible. Practice will enable
one lijitener to detect it at an earlier age than another of less ex-
perience. De Paul says he has heard the sounds at the eleventli
Naegle could not tlistiugiiish them before tlio eiglitocnth
*eek, and lus exfierience in thia regard is a counterpart of the
tTfroge skilled practitioner.
Wbil was fonnerly termed the "placental souffle," and re-
gimled as a certain sign of pregnancy, is now more appropriately
known as the uterine, or abdominal stiulHe. This hruii inste.-ul
of proceetling from the utero-plncental circulation, and marking
tW placental site, is probably occasioned by the uterine and ab-
dofflinal circulation, the vessels of which in places nre subject to
pTftBure, and emit a blowing or purring sound. Lnrge alxlomi-
ntl tamors, disconnected with pregnancy, also give nse to the
fiiae, or a similar hrttit. It may l>e modified, or entirely ar-
w«ted. by the pressure of the stethoscope.
A» a sign of pregnancy, it doubtless possesses some value, but
ii must not be admitted as a certain sign, and under no circum-
cttQced is it to l)e regardwl as pnM^f of tlie life of ilie foetus. It
kjkiw woll understiXKl that by auscultation of the abdomen of
» pregnant woman, we may hear the pulsations of the fcetfil heart,
ami the bruit de souffle ; in some cases ftetal movements and the
souiHe. The first named is a pretty constant sign of preg-
; the second is of value only when it is certnn that the
wortinn has no other disense which can possibly give rise to it;
while tlje third and fourth are so rarely audible in one instance,
9o Anibignoos in the otlier, as to be of little real value.
following summary of the signs of pregnancy may prove
148
THE DIAGNOSIS OF PBEQNANCT.
'lAL DIAGNOSIS.
ud
BifTerential Diagnosis. — The 8ul»JL'ct of the diagnosis of
prt*gn:uicy would be far from complete without a few observa-
lioixs on tlifferential diagnosis. It would be imjxjsHible to mention
in a short chapter all tliose various couditious which are liable
to be mistaken for pregnancy.
When there is an enlarged abdomen which raises a suspicion
of pregnancy, combined internal and external examination is
highly important U|x>n employing it a tumor of some sort may
be discovered, but, if extra-uteiine, by careful manipnlatioD of
the cervix the uterus can generally be mnde out as a distinct and
free organ, Avith walls which are not greatly distended To pass
the uterino s<3und is rarely iiecessuj"y, except to render assurance
duubly sure. If serioiLs doubts are felt, it would be an xmjusti-
fiable act. The feel of the lower uterine segment, in coimection
n ith other signs, is diagnostic. From the second to the fourth
month the gravid uterus is peculiarly soft, wlule, if tmnors are
pre**ent, it is harder. In htematonietra it is firm, but elastic, and
lauy even give Huctuation. In chronic inflammation, the uterus
is aomotimes rather soft, but usually it is much hanler than in
jjr^guaucy. Then, tcnj, if inflammation exists, other s^inptoms,
fuch as ten<lerness and ]min, will strengthen diagnosis. In both
h*iunl<»metra ami iiitorstitial tibroicb*. there is greater firmness of
the utiTiue tissues, and tlie cervix disappears catly. Diagnosis
in some cases may still be uncertain at the first examination, but
i\i** liipse of a few weeks will clear up the doubtful [Kiints.
Sluiald the fibroids fonn knobby projections, as tlicy most fre-
quently do, abdominal palpation would contribute the requisite
wriiiiiity ity the diflVrentiation.
.Vn exact diagnosis of pregnancy is often impossilile even at
th*» Uiird month, but again it may be made with a reasonable de-
p»y i>f certiiinty. If the organ is found slightly anteflexed, and
ciTTttipfUiding in size to the ]>robable periixl of gestation, not
ptinful to manifiulation, of a peculiar 8t)ftness, and, moreover,
tfi»« woman healthy, though her menses liave not appeareil dur-
Hiij the lime, then, every probability leads to the one conclusion.
iTie inexperienceil, however, will act a wise part to make their
' '_'r*'»His with a ilistinct reservation.
A I !\ hubsiHiuent periixl difleientiation of the physical condi-
tion becomes less <litlicult, quickening, hallottement and the fcetal
Leart-tfouutls cleai'ing away all doubt. But, at the fourth or fifth
150
DlAQNOStS OF PB£0NANCY.
month, though the absolute signs of pregnancy are absent, as in
the instance of dead ovum, or uterine mole, development of the
organ has gone to so great an extent that the real condition may
be determined with the utmost certainty.
In those cases where pregnancy exists in connection with mor-
bid conditions, the former is sometimes overlooked, not so much
because the symptoms of such a state are absent, as that they
are not so prominent as those of the diseased conditions. The
latter are generally discerned without difficulty, and further in-
vestigatioJi is neglectetL In these complicated cases, sliould
there he a suspicion of pregnancy, repeatc«:lc;ueful examinations
will either o»^»ufirm or remove it; and no measures should be
ad*>pted for the treatment of disense in women, which would be
prejmlicial to the pregnant state, without the }>osaibility of such
a state receiving due consideration.
Diagnosis ot Fu'tal Death.- -This is a highly important
conrtideratiiiu- The circumstances which may give rise to a sus-
picion that the fcetus is deatl are: 1. Absence of fcetal movements.
2. Ahsence of the foetal heart-sounds. 3. Diminished size and
increasetl softness of the uterua 4 Flaccidity of the mammse.
5. Hensntiiiu of weight and coKbioss in the abdomen. 6. Debil-
ity anil general ill feeling.
Concerning the first, we need not hesitate to declare it wholly
urjrt^!ifd>le, and. when once active uterine effort has begun, it is
devoid of significance. With respect to tlie second, it should l>e
Uiiderstood that in certain cases the sounds of the fcetal he-art
are inaudible for a considerable periotl, while yet the child is
vigorous. The physical signs three and four, may depen<l uixm
causes which do not involve foetal death* while numbers five and
six, being subjective symptoms, ore ot verj' slight relative value-,
"Certainty of death having taken place," say^ Scliroeder,* "is
obtained only when the os is ojien and allows the h>ose cranial
boues to be felt distinctly; also when the sounds of th^ fcetal
hftart, which, in the absence of other pathological conditions can
always !« distinguished by a repeated itiveful rj-amimiihn, can-
not bo heard."
Signs of Ftptal Death Evinced Daring Labor. — After labor
has begun, the signs of foetal death have reference only to the
n-tUflauA] of Midwifory." Applton A Co., 1@73, p. 63
DfBATION OP PBEQNANCY.
151
^
^
child itself, and they are generally so clear as to dispel all donbt
1. Tlie results of auscultation are almost conclusive, since, dur-
ing parturition, the conditions favorable for the transmission of
the foetal heart-sounds are at their best, and can hardly fail to
be Bucoeasfully made use of by even a novice. 2. On the head
of a dead foetus no caput succedaneum is formed. The presence
of such tumefaction is conclusive evidence of life, as it is tlie
effect of long-oontinued pressure, ami circumscribed arrest of
the circulation. 3. The sc^lp of a dead fcetus is flabby and soft;
the iKines are movable, and overlap more than usual; their edges
feel sharp, and on pressure commuuicate to the fingers a grating
sensation. The heads of poorly-nourished, but liviug chihlren,
sometimes present these peculiarities. 4 The presence of meco-
iiiom. and the escape of thin, slimy, ulTensive liquor amnii af-
ford atlditional proof of death.
If tl»e breech presents, the sphincter ani is relaxed, and does
Cjnntract on the finger. The epidermis is blistered, and is
easily rubbed off with tlie finger, if the child has been dead
mon» than a <lay or t^vo. This is also true of other surfaces.
If the face presents, the lips and tongue are flabby and mo-
Uonless. In arm j>reseutatious, there is no swelling, no lividity,
uti motion, and no warmth. In prolapse of the funis, the cord
is flaccid, cohl and pulseless.
CHAPTER V.
The Duration of Tregnancy.
Thin is a subject which has elicited much study and diBciis-
•i^ii. In settling it. on a tiim, scientific basis, the main obstacle
*^been the impossibility to ascertain tlie precise date of fer-
^<'«*itiis- In hospital practice, the majority of women entered
'or ci)nfinement are living outside the conjugal relationship;
liate Ixjen leading lives of repeated exposure to impregnation,
*«d are unable to offer positive testimony as to the date of con-
option, even if so disposed to do. Others, both in and out of
152 DIAGNOSIS OF PKEGNANCY.
hoBpitAl wftllfl, who are unmarried, profess to have been guilty
ot luit a niiigle misstep, and are prepared to give precise dates;
])at may we not justly withhold from such our full credence,
since it is probable that shame prompts them to withlioltl a state-
ment of indiscretions which nature has finally amplified before
tlie eyes of all? The marrietl state presents obstacles to al)so-
luto calculation fully as great as those just enumerated. On ac-
count of these difficulties in the way of trustworthy observation,
it has beccmie customary to l>ase calculations on the date of the
lust menstruation. The fallacies associateil with such figures
are conspicuous. First, the date of tlie last menstrual return
cannot l)e held to represent the real time of impregnation, or
even of insemination, in more than a very small percentage of
cases, since sexual congress <luring menstruation is avoided ]>y
lH>tli parties to the act Mor(H>ver, the time of insemination does
not corresj>ond to the date of impregnation, inasmuch as the
time c^>nsumed by the spermatozoa in journeying from thr
vagina to the point of contact with the ovum represents a ])erio4l
varying from a few liours to a few days. Again, it is admitted
by physi()logists that fertile coitus may lx>th precede and succeed
the menstrual n^turn, by a few days. Should it i)recede, tli<*
flow whicli was so near may be prevented, and a miscalculation
muile by basing the figures on the date of the last ni(»nstruati<>n.
Or, the fiow mny come on at tlie usual time, in a feeble and brief
way, even though iniprefrnntion has existed for several diiys.
Allusi«»n should hen' be nuuh^ also to those anomalous cases
wherein conception is succeeded (nr two, three, or four numths
by rej^uhir menstrual retin*ns. Hence it appears tliat, at best,
such a ItMsis of calculation is not settled nor reassuring.
\V*' ^athi'r stnne infttnriati»>n on the average daraticin nf i>re}j:-
nanev from a study of c<miparative pliysidhtj^y. Valuable ob-
servations liav(* been made in tht* case of C4»rtain dianestic ani-
mals, in wliom one coitus c*>inciiles witli tlu^ ]>eriod of rut. In
IHllI, M. Tessi*»r submitted to the Academic des Sciences, at
Paris, the n^sultsof a serit^sof investigations of this nature, which
are worthy attention. The following is the tabular statement:
or 11(» Cows:
1 1 (alvrd lictw.'i'ii thr "JHst and the ''(Mttli *lny.
.VI " '■ " 'Jiiilth " LMith '*
(iS •• " o^dh '• -JiKHh '*
DCRATIOX OF FREGNANn, 153
(lestAtion in cow& is bu^ little mort- protractv*! than in womoB,
nod according to this table, founded on exact obsurvations, there
WM lui extreme difference in diirution of pregnancy tiniounting
to 67 days. Lord Spencer mmle a series of observati6DS of a
tdmilar nature in the aise of mares.
Of lOaHikREs:
3 Fooled on the ailth day,
1 *• " 314th "
1 " " 325th "
1 ;woth "
2 ■' *■ 3:WHh "
47 " l»etwe«D the 34inh anil lHHnh day.
25 35«th " 3fl(Hh "
21 " " " 3(K)th " 377th "
1 '" on •' au-lth day.
In neither of these tables has allowaneo been naatle for the
itingency of premature labor, wliich probably wdens the ex-
but when a reasonable nujnl>er has been deducte<^l, on tho
igth of tliis presumption, there stiU remains evidence of
lely variable results. It may be said in favor of the tables as
t^ihibitod, tliai, in the animals meiitione<I, it is Iti^hly j)robab]e
that the iufluences generally regarded as productive of prema-
turi* lalxtr were not as numerous nor as jxiwerful as those to
wUich women are subjected.
Dr. Reid collected thirty-nine, and Dr. Montgomery fifty-six
oises, in wliich pregnaiicy was calculated from a single coitus,
with the following results:
^citL Moal£;onier>. Total. Duration.
0 1 I 3« weeks, or 252 days.
1 2 'A , 37 weeks, or 259 du>s.
6 2 8 38 weeks, or OfiH d.-iy.s.
7 10 17 ...39weeke, or 27:J duys.
16 23 40 40 woeks, or 280 days.
2 9 11 41 weeks, or aj*? duys.
3 8 11 42 weeks, or '34 days.
2 2 4 43 weeks, or 301 days,
Wlile there are grave doubts of the accuracy of many of theso
ai«»»i, and hence of the table as a whole, some of them aie worthy
vnmt implicit credence. Dr. Montgomery relates the case of a lady
who went to the sea-side in June, 1831, leavujg her husband in
tyiTD. He visited her for the first time November 10th, and re-
154 DURATION OF PREONANCT.
turned to town on the succeeding day. She quickened on the
29th of January, 1832, and was delivered August 17th, exactly
two hundred and eighty days from the time of the last sexual
intercourse, which was precedetl by an interval of nearly five
months. Considering the remarkable care and precision exer-
cised by these ol>servers, it seems probable that the results, as
shown. n]>i)roximnte very clt>sely the real facts. Acconling to
them, there is a wide variation in the duration of pregnancy. In
addition to the alx)ve, there are several oases recorded where de-
livery of what api)eared to he. fully-develoi>e<.l children occurred
as early as 2G0, and as late as 284 days after a single coitus, so
that we are led to conclude that pregnancy daea not run a course
with uniform limita
Schlichting* has e\amine<I 4;')() cases in which tlie day of cop-
ulation was known, and in which the children were full term.
He foimd an average duration of 270 days, but the extremes
were very wide.
But as it is rarely j)«>sHible to determine the date of fertile
coitus, the ciilculation aii<l exi)erienee of the duration of preg-
nancy must rest chiefly on observations, the starting i)oint of
which is the last dny of the last menstrua. Dr. Merriman has
accordingly conducted nn<I recorded a series of investigations,
which are hero tal,)ulated. Of the l.V) mature births observed
by him:
5 wtrc (UIivi'i'»'tl in tlie .'J7tb wot-k ti.V»th to ri.^iuli <l:iy.
I(J " " " :W{h :2fM«h to '2(!(ttli '"
t31 ■' '■ " :J!Uh * -^tiTth t.) 'J7:u\ -
■Ui " •• '■ Intli ■■ -iTItli t(» :i"^>th "
•J'^ •• •■ * -list •• •»"'ls| to *J^7th "
I- ■' - " r.M •i-'-th 10 r2J»-lth "
U •■ " '• \.U\ '* -iitrith to :{(>lst '*
.'> " *' Uih " ...the latest lHin*r the :MH>th day.
A <lirt'i*r('iu'f of iirty-oiic d;iys between oxtremes is here sIiomtl
Dr. Jan»os llriil hn^ j^iven ii table of .500 cnses, in which the cal-
culation is iiUn from tlio last dny of menstrurtion. Of these;
•i:j were diln . p-,! in tin- :i7th week '3r>">lh to '2.>l>th day.
■H ■• :i-<th *• 2f>0ih to iifJftth **
>^1 " '■ '• :«tth '■ OfiTth to e7:ld **
l;ll '* '■ lOtli " ^Tith to -2^inh "
ll--i " \Ut •■ -^-^Ist to 2J?7th "
\n-h. 1". <;yn. xvi., >, p. :»:>I.
DUIUTION or PREGNANCY.
155
83 wtrt delivered in i\w 424 week 28Hth to '2fl4th day.
a? " " " 43d " -'yoth to aolat "
8 « " " 4Uh > SCWd to 308tb "
6 •* " " 45lh *• 309th to 315th •»
The difference l>etween extremes is here sixty days. With
these, and other equally reliable facts before us, we are led to
the ouDclusion that the average duratiun of pregnancy is in the
vicinity of 278 days, though the variations are extensive.
The Miiiiiuiiin. -It ia interesting and imixirtant to know
wh&t is the shortest time within which a child may be bom alive,
Biul huve a fair chance of Ufa In cases of contemplated indue*
tinuof premature labor for conservative purjioses, the minimum
tiineidlowrd tlie ftetus is 230 U^ 250 days, but cases are on record
in which life h/^s been sustained when birth took place at a much
earlii^r periixl. The following table by Dr. Montgomery will
pruvc of interest because of the information ou this subject
vliich it affords:
3(a
lairr Datk nr
Mkwss <:oKvtv'n.
1 OcL B OcL »
8 Aug. 34
S Jnly'i-J
marriwl
Bnrm.
Apr. 3
Mar. 3
IH'riATIOS
orOEST'N.
5 M. 10 D.
5 " 21 "
Days. Survival dpCbiuj.
Ifil Twelve honra.
174 A wetk.
J:ui. 19 5 '* 27 " 180 131 days.
Apr. 10
Apr. 1
4
B Apr. 1(1
«
7 Jan.3l
6 Jiiiieri
9 Oct. 24
10 Aim'i'i
The Maximum.
e '* 1S3 Seven weeks.
Oet. Ifi 0 " 0 ** 188 Eleven ycATS.
CHI. 10 6 * 13 ** 103 Doing well «nL afterward.
Auk- 14 6 ■• 10" 100 Thirty yenra.
iJre. tn G " 18 " IIW Two years.
May 10 0 " 19 " lOtt Eleven dtiys.
Mar. 18 6 " 21 " 2tll Thirteen yrars.
-That pregnancy is sometimes pr4>tractedbe-
ycmd tlie tisual p>eriod s«M»ms now an estttblisLetl fact. We are nev-
rrf' ' *-<ld that little more than fifty years ago opinions very
d I . * 'HI tht»se whicii nt»w prevail were held by tlie best obsti-
tricKAiM. In the Gardner peerage case which eame before the
H»'>a-'*<? of Lords, England, in 1825, Drs. GtK>ch and Da%'is, and
Sir C Cbirk, testified that, in Llieir judgment the period of 280
days wa« never exceeded. Subsequently, with a view to ascertain
the ex 5 i- of tliose who were most likely to have jHii<l par-
tkrulftr i-'tt t4i the subject, upwanls of forty of the most
eminent oljstf^tricpnwtitionerB in Lond<m, Dublin and Edinburgh,
applied to by Dr. Reid. The large majority of these ex-
156 DCBATION OF PBEGNAXCY.
pressed a firm convictiou as to the occasioual extension of tlie
usual period of pregnancy by a few days beyond 280. Several
had met with one or two cases of protracteil gestation, out of
many huntlred, on the exact data of which they could rely;
others, who Imd not kept notes of tlieir cases, could not offer
positive testimony, but had no doubt tliat in some cases, tlie
period had l)een extended. Some, who hatl had extensive private
and hospital practice, stated that they had never met with an
undoubted case of protracted gest^ition; while two affirmed their
strong conviction that no case ever exceetis the 280th day from
conceptit)n, and one, that it is never carried ]>eyond the ninth
calendar month.
Without permitting this subject to take up totr much space, it
may be remarkeil that there are on reairtl undoubtetl cases of
pn>trftctod gestation, though they are probably rarely met. The
most eminent teachers and practitioners of the day admit the
probable truth of the projx>sition. Many of the cases adduced
are valueless, ])ecauKe founde<l on insufficient data, but cases
have been reix>rted which merit our acceptance.
Prediction of Date of Confinement.— Tlie average duration
of gestation after cessation of the menstrual flow has been found
to he 278 days. Various metluxLs of calculation have been sug-
gested, and sundry peri(xloscoi>es and tables have been given,
with a view to facilitate tlie predictii>n, and make it more accu-
ratt-i than it could be without them, some of which are based on
an average of 278 and some of 280 days.
Dr. Matthews Duncan, who has d(*vote<l much study to the
prediction of tlie time of hibor, has given a method of calcula-
tion, based on an averagt* of 278 days, whicli is A'ery convenient
and j)racticHl. His rule is: **Fiml the day on which the female
ceast»d to menstruate, or the first day of being what she calls
'well.* Take that day nine months forward as 275, unless Feb-
ruary is includ<Ml, in whicli case it is taken as 273 days. To this
add three days in tlie former case, or five if February is in the
count, to make up the 27H. This 278th day should then be fixed
on as the middle of the week, or. to make the prediction more
accurate, of the fortnight in wJiich the confinement is likely to
occur, by which means allowance is made for the average varia-
tion of either excess or deficiency."
Naegele*B method is to figure from the first day of the last
W OF PKEGNANCY.
157
meostmal periixi, and thon count fonrnrds nine raontlis, i>r back-
wards throe months, and to this date tuldseveu days to complete
the period of 280 <lay8.
Tlie foUowiug table by Dr. Protlieroe Smitii. is easily com-
prehended, nud is probably fully as sei-viceable as any.
TiVBLE FOR Calculating the Peiiiod or Utebo-Gestatiox.*
1 Nlve
Calkxuab Mun-thb.
Tev Lusar Mokths.
From
To
Daya
To
l)»ys.
J an nary 1
September 30
273
October 7
280
F.f.rtiary 1
tkrlolM-r :?1
273
XovfnibiiT 7
280
Marrb 1
NovemU'r :}0
275
Dcfcralier 5
280
April 1
Decemher 31
275
JuDimry 5
280
)liy 1
JuDuary ^1
270
Frbraury 4
280
June 1
Fehrunry 2fl
273
Miirtli 7
280
JnW 1
Mnrtli 31
274
April 6
280
AtU.'UBt. I
April 30
273
May 7
28l»
^'■jit4inber 1
May :n
273
Juuc 7
2M(»
tVlMlMTl 1
Juiwm
273
July 7
280
SosciuIrt 1
July ;JI
273
August 7
280
Drtrnibcr 1
Aiigiiut 31
274
September 6
280
The Date of Qukkenin^.—When it is impossible to obtain
the date of the Inst mtMistrual i>erioil, if the time of quickening
am be ascertained, it is customary to add twenty-two weeks for
ths puqxise of deterraining ' the proximate day of delivery.
But <|uickeuiug is n sign of pregnancy which does not always
devi'lop in tlie eighteenth week^ and the extreme variution ju its
uuaifestation in different women and diflereut pregnancies, ren-
ders this methol of calculation a vei*y uncertain one.
Prediction of Time of Labor from Size of Tterus. -From
Bbdominal ]>alpatii)n we may gather important data a|>on which
to venture a prediction of the time of expected confinement Ac-
c»>nliug to common bedside teaching, the utems in the second
month is of the size of an orange; in the third month, of the
wae of a child's head; in the fourth month, of the size of a
'The aI>ov<» ohstctric ** Roft«1y RvckoDer/' coufiists of two oolumns, one of
(^<:iiilAr. Ihi* otbet of limur inuDths, and iimy l»e ri*ad as follows : A patient
■■•ceiuwl to inruBtruatr on July 1: horconfinpnic-nt may be pxpcct<!d ni soon-
^ nKiiit Marcb 31, ithr rnd o/ ninr caimdfir months.) or at laU'St un April 6,
\i^tndof trn funar montAAi. Another baft ceased to me^nstrualt^ on January
**! hfT ixm]hi«ni«*nt may l>e expected on September 30, plus 20 daya ftt« end
^ «^ taJendar monthx | nt wwnest ; Oi" on October7, plus 'iO days I thfi end ofirn
noiUAjtl at latest.
168 DURATION OF PREONANCT.
man's head,* and can be felt above the symphysis pubis. In
the fifth month, the fondos of the nterus rises to a point mid-
way 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 or three fingers above the naveL
Fig. ft>, In the eighth month, it rises half-
way between the navel and the epi-
gastrium. In the ninth month, it
— * reaches the epigastrium. In the
* tenth month, two or three weeks
before confinement, the uterus sinks
■fl downward and somewhat forward,
g so that its upx)er level corresptmds
very nearly to that of the uterus in
the eighth month.
The fallacy in this mode of des-
cribing the progress of uterine
development, as discovered through
the abdominal parieties, is that
the navel is not a fixed point, and
its distance from the symphysis is
Size of the uterus at Various^ yj incrense<l up to ft late
Penwis of Pregnancy. . i- .
l^erunl m i)regnancy. A more accu-
rate manner of describing the hoiglit of tlie fundus ia followetl
by Spiegolbergt witli tlie following results :
From tlie *2*2d to the 2(ith week 8.1 inches.
Frcini the 'i-J^i to the '^th week 10] inches.
Fruni the *22d to the :K»th wwk 11 inches.
From the *J*Jd to the ;!'2U and :K»d weeks IIA iuchet*.
From the ±h\ to the ;Mth week V2 inehcH.
From tlie :I*Jd to the lioth and :W»th wtfks I'ii ineliea.
From the "i'-id to the 37th and :JHth weekn i;{ inches.
From tlie 2*Jd to the 3(Uh und 40tli weeks 13| iucheH.
The size of the uterus varies greatly in different women at the
same stage of gestatiiin, but the nlK>ve average measurements
are somewhat excessive. From accurate recordetl observations
*The alwunlity of this statement ir seen when we cov|inre it with the
figures given hy Dr. Farre, on page V2fi.
f'Lehrhuch der Gel>," IJd., ii., y. 11'*.
159
le oy tne~anthor, tho figures wliich approximate the true
trage mure closely ore those which follow :
Pfum the I6th (o Uie 30th week 6 «0 ej mch««.
From the AHh lo the •i4th week 7 to 8 inches.
Fruni itir 24lii to llur '^Md, wi-ek OJ U) 10 inchos.
Fmni the '2Hth to tiie ;V2(1 werk lu to 101 ituhea.
FmrntbeXid to the :«ith vnrek 11 to Hi iuchea.
From the 36th to the 40th week 13 to 12^ iuehee.
The facte here presented may aid materially, when taken in
connection with other conditions, in Hxing ujjou the probable
tiiQQ of delivery.
CHAPTER \T
Pseudoeycsis.
Pseudocyesift— /a/«r, spurious, or pfutntom prrgnancy—h&n
K ' * ■*! by one a** a "mental ilelusion, rebultiuf; in a false
i!on of Ixxlily sensations, experienced for the most
pwt in the abdomen." It may be more justly regarded aa
» deluwiry oonvicticm of pregnancy, based upon, or giving rise
lu. symptoms whi^'h, in some inst*inces, closely resemble th<:rse
of pregwincy. It is not a dceting notion, but a fixed idea, which
isBometimea so vivid as not only to cause the woman both to
ttiisinterpret and to generate Kymptoma, but also to umlergo a
^mcarrence of phenomena, presenting striking resemblances to
M purturitiou. A similar mentid impressirtn may leml a
*oman u* l>elieve that she is the subject of an abdominal ttunor.
Cwe shouJd be taken not to confound spuritms pregnancy with
"'alsfi (•i)ncei)tion." Hinc<^ there is a wiile difference between the
**o states, the latter being nothing more nor less than molar
|'ri»gnftuey.
l^r. Matthews Duncan directs attention to the fact that some
"f the lower animalH, such as bitches, exhibit signs of spurious
r^rtorition- Ile\iewing tho subject of pseuilo-pregnancy, in his
terse and lucid manner, he very pmperly, as we believe, em-
160 SPURIOUS PREGNANCY.
phasizes the thought that distinction ought to be made between
those cnsos whore tliero is merely spurious pregnancy, and those
in which the patient's A'ivid imagination, strong with the delu-
sion, carries her to a culmination of the supposed pregnancy
in fancied or spurious lnlK)r. . Dr. Reamy mentions a case where
not only was a midwife kept two nights Avatchiug by the ]>ed8ide
of a woman who was the subject of phantom pregnancy; but a
practitioner, doing a largo business, actually shared with the mid-
wife for several liours, the honoi of suj)porting the i>erineum.
Both declared tliat not only worf* the pains scA'ere, but the peri-
neum actually bulgetl from wlmt was supiK)sed to be the foetal
head.
Conditions of Development. -The anomaly of spurious preg-
nancy is observed in wtunen of various ages. Dr. O'Farrall
mentions a case which i»ccurred in a girl of only thirteen years.
Dr. Churchill records t»ne which happened in a young lady of
seventetni.* Sir J. Y. Simpson, who was t!ie first to give a de-
* Till* nMiiarka)>I(> iiiHuriicr of mind over l«Mlily statrn. rviiuiuj; itscirin the
iU'veh»piiirnt of jihysical nijins of iiroijiiancy. i» so well ilhistratiKl in tho fol-
lowing case, n-porlt'd >>y l>i. Keaniy, tliat we fjivc it in full ; "' A l>oantirnl au«l
rflincd girl, :iU ycaix of aju'. from an atljoininj; Stjitv. wn8 platt'd umlcr luy
rhargc. Slio imaginnl that, on artTtaln night, s|>(TitiiMl andi-lrarly (It'&ignalod
oironniKtantially tohrrniotlur and a married sister. Iht r<Hmi had Ix'en entered
hy Xvitt men. one <»f whom had ehhirolornied. and the other rnimil her. She
had read a few days hefon- a falsi* iind sensational artide detailing the particu-
lars of a similai iitriH-ity. When 1 examined her fonr months after her snp-
jKw^ed i>i'egnancy had <Henrred, she was jiale. amemie, nervons, amenorrhival.
Her <-ountenan<'e was tin- i)ietnre of despair. .\t tinn'S the abd<mien was large,
then deeidedly flat. Themainnne were >wo)Ien. and eontained milk. She snf-
fcred Irom nansea every nnnning. and wa*. eons<*i(>ns that tor the pa>t few days
Hhe had felt violent, movi-ments in the ahdonten. The friends were, ennstantly
in dread tiiat she .might eonunil snieide. l-Vmiginons tonics with generous
diet, hathiui;, air, exercise, etc.. were tried withont avail. Her general health
did not itnproM', and no argument or asinraitee rould eonvinceher of her de-
lusion. On every other suhjeet she was jMrfeelly rational. Finally, after live
months fnun the dale of Iier Knpi«wed pregmniey had ehqwed, I tiK>k into her
room a munakin, the arti<-iila1ed hony and ligamentous jwlvis. with Sehultz's
olwtetrical plale.s. 1, l»y thi^ means, sneceeded in demonstrating to her the im-
poasibility of pregnanev at live moniliN advaneennnt without greater alidomi-
iinl enlargement. I sjH^nt in this demonstration at least an hour, going over
nnd over the ground. It wa.** in the presmee of her mother. Sucwss rewan.U»d
me. She was tronvini-ed iif her deltision. The fear never retnrneil. She gaiued
eighteen ]Mmnds in wi'i«;ht in ilire,- weeks. The menstrual funetiou was at
o'lre estahlished,"
ies OF 81
iril
irt«*d description of spurious pregnancy, olucidate its causes,
and prescriF»e it* treatment, thinks the complaint ns frequent
during the first year after marriage, as at any other time. Dr.
Montgomery t>elipves it to be most frequent at tlie climacteric
(tehod. Melancholy iuatnncA?H of the kind have Iwen ohscn'ed
in aged spinsters nitd widows, who liad long passed the meuo-
pttose, in whom life was rendered intolerable by reason of the
hamiwing delusion.
Etiolcwry. -The excesses of early marrietl life, and the physi-
cal and psychical chanfjps incident to such a peritxl in a woman's
histur)*, afford, in the susce]>tible, an excellent basis upon which
Ut fraioe a false conviction of pregnancy. The same is also true
"f Ui^ disturbed physical and menUl equilibrium attendant on^
tilt! ohmiicteric f>erio<l. It seems clear, also, that a conscious-
tt««s ifl tlie unmarried of having been exposed to the risk of im-
|>r«t£^Rtii>n. and the impugnings of a guilty conscience, contri-
bute tci settle and fix the uuploasant delusion.
The latter may operate as jwwerful predispouentsto the phys-
ical fintl mental states and symptoms wliich point so signiti-
Mntly tn a pregnant condition; but it is probable that in many
ttwtences there is a transposition of cause and effect. In one
'^wnple, the physical symptoms which characterize the case, are
'Itiiiblless the result of a previous mental state, being physical
i'lpri'sHions and sequences of a settled delusion, while in another,
tb-iu^'utfl] impression is, as in real pregnancy, c^:>nsecutive on
<»i*#rvi'd physical coutlitions. In the httter instance, it is doubt-
1<^ true that the bodily state is modifie<i in great meas-
w** In- tiio r^xited ncttion which originated from physical
phpQomona. Dr. Simpson says that "the aggregate of the B^\Tnj>-
^a which we clasfl under the designation of spurious preg-
"wncy b women, is in some way or other dei)endent upon the
'^'i^Ugeij which occur in the ovaries and in the uterus at the j>e-
fW of menstruation." Another carefid observer remarks that
* It will W found that in most i)f those* persous who fancy them-
^"^ pregnant, there is a maiked derangement of the circulo-
"*y» dig»?»tive and nervous systems, either one or all being usu-
*UyimpUpat)>d."
SyaiplomH.— The phenomena observed in spurious pregnancy
■** turthy a careful study. In the majority of cases, there is
QnngQ^ flftlnlence, and some TiTiters have accordingly attributed
162 SPUBI0U8 PBEGNANCY.
tbe abdominal symptoDss manifested, to this circumstance. Simp-
son does not incline to that view, but regards the phenomenon
of alxlominal distension, as probably dependent " on some aflfipc-
tiou of tlie diaphragm wliich is thrown into a state of contraction,
and pushes the bowels downward into the abdominal cavity.**
Tliere is tympanites; but it is not evident from reported cases
that either tbe area of resonance, or the percussion note, differs
essentially from that often met in the non-pregnant state. In-
creased prominence of the abtlomen, in some cases can be justly
atti'ibuted to deposition of adipose in the abdominal parietes
and tbe omentum.
The movements, wliicli so closely simulate those of the fcetus,
are probably protluced in some cases by ftlatus in the intestines;
but they are oftener due to spasmodic muscular action. Dr. B. F.
Betts relates a case whennn tlie movements were so vigt.>rous as
to be discernible through tlie clothing. Uix)n examination oi
the abtlomen, he ftiund the cause to be spasmoilic contraction of
the redns (ihdoniinis.*
In some cases the alxlomen is swollen to an extreme degree,
but these are exceptions to the rule. In palpating, the hand
may meet with resist^mce, but it generally arises from contraction
of the broail, flat miiscles of that region. In a few roix>rted in-
stances there has l>oen a certain anitmnt of tumefaction, which
assumed tbe outline of a j)r»^gnant uterus.
Pseudo-pregnancy nmy continue for only a few weeks, and then
wholly vanish, or it niny jM^rsist for seven. nint% twelve t»r evon
eighteen months, — perhaps longer. The similarity of wmie of
the manifestations to those of certain nervous disorders of a
hystericnl type, sliould n!»t be overKniked. The str*»ng mental
impression, tlie exaggeration ttf s«'nsatii>ns and e<m<lition.s, the
Hatulency so often observed, anil the state of nervous exaltation,
are all of this nature.
* ** By an application of the palmar surfari' of the hands to the ulMloniinal
walls," Kjiys the I)o«tor, *' tin; recti musi-lcs were founU to !«; irn^gularly con-
tnu'tinj;, .•«> as to appear at first :ls tlHiuifh they were presscil out liy the. niovo-
nienlH of a child in titerf), at irregular iut4'rvuls. From an inH[H>(*tion, it wuh
iuiix>ssihlc' todiHtinjtuisli these cnntractihns from the real movements ofa iVvtus,
but by pal|mtion, the tendouoiis attaehnientt of the muscles to the brim of the
pelvis were felt to lie stretched. a> fronii stmn;: museuhir contracti(ms."
Duosoais or spcbious pregnancy.
163
Vla^SOTts. — The diaguosis of pseudocyesis will vary in relia-
bility accordii]g to tliu peri(xl of development whicl\ has been
rQa4;luxl at the time of examination. In early gestation we have
relative signs only, ui>on which to base our convictions, and these,
though in certain combinations they may leatl with strong prob-
ability to conclusions, afford, after all, nothing more than pre-
snxDptive evidence. A notion of existing pregnancy takes pos-
BOBBion of a woman, and she presents iierself for diagnosis.
Qestaticin, if begiui, is two or three montlis advanced. Some of
the relative signs of that cx>ndition are found, giving color to the
presumption, but the judicious physician will not express an
tmqoalified opinion. On the contrary-, there may be an absence
of the most common presumptive signs of pregnancy, yet an
aueqaivocal diagnt)si8 of m)n- pregnancy would be unwise. At a
Uter peritxl a physical examination ought to yield unmistakable
results- Abtlominal distention, due t«i a tumor of some sort,
may create in the woman's mind a conviction of pregnancy not
easily eradicable. Consecutively, symptoms closely resembling
tbo6e of pregnancy may l^e develoi>e<L In such cases the trinity
of signs [lathounonionic of the real condition, namely: fretal
movements. baUotinttent nnd the foetnl heart-sounds, will go far
to clear up the doubttid |>oiuts in the case.
It is not always possible to make a s^itisfactory examination in
icAseof doubtful pregnancy, without first bringing the womaiL
ttntitr anaesthetic inlluences. ^Vlien this has been done, since
I')' it flatulency will be in great measure overcome, muscular
tp6&tti subdued, and sensibility annulled, the abdomen will olTer
no resistance to deep palpation, nor the vagina to thorough ex-
pluraiiun, affording thereby conditions the most favorable for
diagnosis. Mention should also be made of the want of sym-
ciptryand completeness in the order of development and mutual
f^'Iation t^f the signtt. There is a lack of harmony in the assem-
Wagcof the phenomena, an irregularity or defect in the sequence,
^p grouping, or the character of the symptoms, creating in the
iibwrver an impression unlike that derived from a clinical study
<rf tlifj signs of real pregnancy. This is especially true with
f^iird to menstruation. Rtirely is the menstrual function sus-
penilftii for nine months. It is also worthy of notice that move-
ments, inferential! y fcvtal, in many of these cases are felt much
«sriier than in tht^e of real pregnancy.
164 EXTRA-UTEBINE PBEOXANCT.
Treatment.— The delusion which enthralls the woman in
these interesting cases is not always easily remoyed If she
has confidence in her medical adviser, she will be persuadid,
perhaps reluctantly, to cast away her erroneous notions. It
may be necessary for him to point out and elucidate the prem-
ises uiK>n which his conclusions rest, but such an appeal to her
reason will generally avail In those cases where the con-
viction of pregnancy was derived from logical conclusions based
ui}on insufficient data, there may not be marked physical im-
provement, even after the delusion has been dispelled, \i'ithout
suitable medicinal treatment If there was antecedent menstrual
suppression, pnlsalilla, ajtis, sulphur, or some other remedy may
be required to regulate functional activity in the generative
sphere. If the digestive api>aratus is disordered, clit'na, lycopo-
dium, 7ntx nmiica, iiux moschafa, or carfjo vegriahilis, may be
needed. Here, as elsewhere, an endeavor should be made to
ascertain the {>athological condition upon which the train of
symptoms depends and then to seek the similimum of the case
n» a whole, by individualizing as closely as possible. By dis-
tin<i;uishing between the sequence and dependence of mental
and ]>hysicnl symptoms, and by tlie use of rational and medicinal
means, we luay reasonably hope for the best success.
CHAPTER VU.
The Patliolos?y of Pregnancy. .
Extra-l'terino Preirnanfv, -Pregnancy has few occurrences
associated with it, more <lisHstr<)us in their results, than the
develoi)nient of the tn'um outside the uterine cavity. After
coitus, the spermatozoa make their way with a certain degree of
rapidity through the uterine cavity and Fallopian tubes toward
tlio ovaries. Fecundation, as has before been stated, may occur
at almost any point on tJie route, in the uterine ca^dty, in the
Fnlloj)ian tubes, or at the ovaries; the most frequent point of
contnct between the male and female elements probably being
OTAitlAlf AND ABDOMINAL TEEaijANCY.
165
in the outer tkird nf the tubes. After impregnation, the ovum
may be arreBted in its progress tovrard the uterine cft^ity, and
development take place, at the ovary, in the abdominal cavity,
or in the tube. Accordingly we have ovarian, abdominah ami
tuind pregnancy, besides some minor varieties, the names indi-
the Bitaation of the developing ovum^
•fan P^e^^lancy. — Careful observers have put upon rec-
'ernl cases wbere fecundati(jn and devehipmeiit c»f the
ovum took place within the Graafian follicle. When this occiii's^
Uie follicle may close, and development go on outside the peri-
tonral cavity, or the ovum may work its way tlmmgh the aper-
tnie resulting from rupture of the follicle, and thus come even-
tually to Mi", chiefly within the peritoneal cavity.* From the
amount of ilistension to which the sac is subjected, rupture
Qjtiintly takes place Muthin the early weeks of pregnancy. Sucli
»D occurrence di>e8 not always prove fatal to ovular development,
for the sac walls are sometimes strengthenotl by adhesicms to
the peritoneum covering adjacent viscera, and gestation goes on.
Falne or Tubo-Orariun Pregnancy.— When the ovum is
inwU'Al in tlie fimbriated extremity of the tu]>e. the cyst struc-
tnro is composed partly of the fimbriiB of the tube, and partly
o( ovHriau tissue. This makes develoi)meut less confined, and
tli*^ pregnancy may continue, without laceration, to an advanced
period, or even to term. This form much more nearly resembles
tbdominal, than ovarian pregnancy. The placenta is usually
dweloped in the pelvic cavity. When none of the investing
«tnictnre8 are ovarian, it is termed Uibo-abdominaL
Abdominal Pregnancy.— The etiol(»gy of alxiominal preg-
MDcy remains in doubt. It probably arises in some cases from
tbe impregnated ovum being dropped directly into tlie periton-
^ cavity, in other instances very likely it is a secondary out-
P*Mh from tlie tubal and ovarian forms. Dr. Barnes believes
^** it is never primarily abdominal, because of the difficulty of
OQOoeiving how so small a Ixxly as the ovum should \m able tofis
rtfielf on the smooth siirface of the peritoneum; but a contrary
opinion is entertained by most authorities. Some have supposed
tltttaWominal pregnEincy may originate from impregnation of an
ovule already lying in the peritoneal cavity, by sx>ermatozoa
•ft'tcH. Aimal. de Gyaecc, July, 1978.
166
EXTBA-UTEKINE PIlEONANCY.
wliicli have found their way thither. From all that has beei
observed, it is highly pn)bable that it is no uncommon thing fur
Fio. 8G,
AbdominKl Pregnjincy.
an oxxile to fall into the peritoneal cavity, and there, after an
uneortrtin time |>eriHh, without giving rise to any disturbance^
But when, from fertilization it does survive, a connective tissi
IJioliforation is set up which surrounds the ovutu with a vasca"
lar Htic. The latter often attiiins a thiekness nearly as great as
that of the uterine walls. The chorion villi sprout, form ad
luests to the sac, and other structures, and eventually devehip a
placenta* Tl»e walls of the sac and the ovum generally deveioi
jmri 2*(t^^i'^t awd extend into the alxlominal cavity, forming
hesions it* tlie intestines, the mesentary and omentum.
In unusual cases the ovular development pn;>ceeils without the
formation of pseudo-membranes, the coverings of the foel
being only the amnion and clu»rion.
Rupture of the UvU\\ coverings sometimes tfilces place in ab-
dominal, in ovarian and in tubal pregnancies, and the foel
passes into the nlnhmiinal cavity. Death (if the fcptus general
follows, but, in other instances, development is continued by
the fi>rmation of a new sac. When ftetal death succeetls such
nil acciilent, the child may l>e converted into a lithopiediou, or the
vascular C4)nnective tissue sun'ounding it may preserve the soft
structures fi>r years. The precis'* seat of attachment in alv
doniinal i)regnancy varies considerably. The placenta has be<
ice^j
"4
:;tac|flM
;h)p ^1
th^j
al^i
lUrEUSTrriAL rUEONANCY.
107
fonod fixed to most of tbealxlominal viscera, to the intestmes, to
Fly, ir?. the iluic fossa aud to the structures
witliiu the tjnie pelvis. Its most fre-
queut site is the retro-uterine space.
Interstitial Pregnancy.— When
development of the ovum takes place
ill the uterine portion of the tube,
the tenu *' interstitial prc^iancy/' b
employed. This j>oi*tion of the tul)e
is about seven hues in length. From
hyjxTtr*iphy of tlie muscular walls a
Bu« is ftirined al)out the o^*am, which
projects fiom the involvetl angle of
the uterus. Ovuhirdeveloj>ment, how-
ever, is so much more rapid than tiie
musculfti', ruptuie jjenerally occurs
before the fourth month. lu one re-
»• the uterine wbU did not give way, ami tlie ordinarj-
Km. «8.
A LiiborsHlion.
Interstitiitl PrvgDAncy.
• n<f RpKioKt.BBEO. - I.ehrlnich der CebimshiUf," p. 313
168
KXTBA-UTEHISE PREGNANCY.
period of utero-gestation was exceeded by a month, when
foetus was removed by laparotomy.
When the fecundate*! ovum is arrested near tlie out^r boun-
dary of the uterine part of the tube, as development procetnls,
the tumor escnpe^ mainly into the tube, pro<lncingwhat has been
called iuho-lnlersiitial pregnancy. When development takes
place on the borders of the uterine ca\'ity, the resulting tumor
may crowd through the Fallopian oi>ening, and lodge in the
uterus, only \m be finally expelled as in ordinary abortion.
Tubal Preernancy.— This is the most frequent form of extra-
uterine prpgnan(!y, and properly eoiniirises the forms describeil as
"interstitial," tubo-ovariaa," and '*tubo-abdominal." The cause
of this anomaly is found many times in catorrhal affections of
the tubes, involving a loss of tlie ciliated epithelium which cov-
ers the mucous membrane, and doulitless more or less tumefac-
tion, with consequent reduction of tlie calibre of tlie canal. In
otlier cases the o\Mm may be arrested in its progresH by flex-
ions and conatriftinns (if the tube, resulting from adhesions and
inflammatory bum^Ls. In rare instances it is due to the existence
of small polypi. In a number of cases the corpus luteum has
been found in the tivary upon the opixisite side from that suf-
fering from the abnormal development, showing tliat the ovum
must have migrated from one side to the other, or that its
vitality under ct»rtain conditions is preserved for n longer period
than is generally supposetL
After arrest, the chorion soon begins to develop villi, wliich
engraft themselves into the mucous membrane of the tube, and
serve as anchors to the o\'um, and channels for supply of its
necessary nutriment. The muooua membrane becomes hyper-
trophied, veiy much like that of the uterine cavity in normal
pregnancy, so that a sort of jjtjeudo-decidua results. The pecu-
liar characters of the mucous lining of the tube afford for the
ovum but a feeble hold, and lience hemorrhage from lacera-
tion of the villi can very easily occur. If e«rly rupture does
not take place, a spurious placenta, wholly of festal origin, may-
be said to develop. Thn \'illi penetrate to the muscular structure
of the duct, where they are sometimes sunouuded by large
vessels. The muscular ooat of the tube soon becomes hyper-
trophied, and, as the size of the ovum increases, the fibres are
scimrated so that the ovum protrudes at certain jmints throi
TCBAL PREaNANCY.
169
and there it is covered by the stretched and attenuated
(US and peritoneal coats of the tube.
At the beginning of preg- F^o. 80.
uiinoy the walls of the duct
weliypertrophied, bntsiib-
lequently thoy are
tliinned by the pressure ex-
€rt(Mi by the developing
orum. Rupture generally
resulu within the first three
mouths, the site of it being
tt the point of least resist-
ance, which, in quite a per-
centage of case6, is at the
kicitiou of the phicPuta.
hfnih usually follows ruji-
larc, t»itlier immediately
fwm acutf* internal hem-
wrriiftge, or secondai'il}
from poritonitia
lUpture of both ovum
Mhl tal)e walls may take
pW, when the fcetus will
^''&\f^ iut<i tho abdominal
Cavity; there may be rup-
*wp of the tube only, suc-
c^e<i by passage of the
^^Tun bto the cavity; or,
^ly, tiiere may be a
BJ'ire favorable termina-
hoii. in which theovumre-
O'Abs in the tube, where Tubal Prcgunnt-y.
itBerves as a tampan, ami diminishes the hemorrhage.
Nature here manifests its conservative temlencies, for when
***PniaJ death does ni>t speedily ensue after rupture, false
o«nbrimeg are formed about the foetus, or the entire ovum, and
rt tliu» beixtmea encysted
The lulie may rupture at a point where it is not covered by
pftntoneuuit in which case there is escape of the ovum and
170
BXTBA-UTERIXE PttEOXAA'Cr.
effusion of blood between the folds of the broad ligament Thi
la known as eiCra-poritoneal pregnancy.
Flu *M»
Occasionally in\'m\ pregnancy, from the excessive tliicknes
of the mnscnlar walls, gocss oti to full tf*rni.
Preunanry in the Riulimentury Coruu of a One-Horned
Fteriis. — The resemblance between this and tubal pregnancy
so close that the most careful examination mil rarely enable
distinction to he made daring life. After death, the only cer-
tain guide is afforded by the situation of the round liganien
whicli, in tubal pregnancy, is between the sac and the utem
and in tlie mdimentjiry horn lies outside the saa Develo
ment in a rudimentary comu does not result in so early a ru
ture as in the iustunce of tubal pregnancy. Tlie point o
laceration is at the apex of the comu, where tlie walls are tliiu-
nest Koeberle* mentions a case wherein foetal death oocurr
n
* KtEDEBLE, "Cof. TI«1h1 .'' Ifi66. Ko. 34.
k
PBEGSAJ^OY IN BCDIMKNTAKY C0BNC7.
171
$t the fifth month, and the product of conception was conyerted
into A lithofMedion. Tumerf relates one in which pregnancy
went on to full term.
Fio. 91.
Pregnnncy iu a ruUinjenlary cornu.
}T Tarietles, — Among the rarer varietieeis that in "which
»n^ placenta is in a norma! situation witliin the uterine cavity,
and tbe fcetua within the Fallopian tube. In another form
the foetus ia found iu the abdominal cavity, and the placenta in
tbfi atems, the two being connected by an umbilical cortl run-
t TCRXKR, " Edlnb. Med. Joar.," May, 1866. p. »74.
172 ESTBA-UTERINE rKEONANCT.
ning through the oviduci The latter variety of cases has been
called the tifero-iuho-abdominal Another rare form is known
as the sub-pcritoneo-pelvic, in -which the ovum, from failure or
inability to get within the tube, slips between the folds of the
broad ligament, and there develops.
rterine ChangeH in Extra-Uterine Pregnancy. — During
the develojjmont of a foetus outside the uterus, changes, more or
less markal, have been observed in that organ. They consist
chiefly in iucreaseil vaisculurity, in marked increase in size, and
in tlie charactorirttic thickening and hypertropliy of the mucous
membrane. But these symptcmis are of short duration, since
the stimulus esKential to their continuance, such as is supplied
by entrance and imphuitution of tlie fecundated ovum, is want-
ing. Its bulk and vascuhirity are soon restored to nearly the
normal standard.
Symptoms of Extra-l'terine Pregnancy.— In the early i>aii;
of sueli a state thore are few, if any, symptoms, which differ ma-
terially from those attending normal pregnancy. The woman
may enjoy health, unsettled (»iily by gastric disturbances so com-
m<»n to gestation. Menstruation is interrupted in only alxtut
lifty per coiit. of th«' cases, though it is linally sui)pressod in
most instances, where tlie condition is not brought to a close }>y
rupture of tlu' SHC. There is generjilly some alHhiminal pain,
usually constant, !>ut sometimes intermittent, within a circuui-
scribt'd area. Often previous to ruptiire, ttr, in alxlominal jjreg-
nnneie«, th<' dejitli of the fo.*tus, in addition tt» tlie other sufter-
ing, the woman experiences uterine pain of a bearing character.
In othiT cases tiiere is very litth* to attract attention t** the case
until tlie moment of rujiture. As the »>vum increases in size,
s<.)me discomfort may arise froni pressun^ exerteil by the tumor
against otiier structures. Changes in the breasts and morning
sickness are of conmion (K'currence. After a time the tumor
may be felt, which resembles the gravi<l uterus, but which is
situated a little to one si<l(» of the median line. Quickening and
the fcetal heart-sounds are soon discovered.
Terminations. — M. Deseimeris, who has written a memoir on
this subject, states that rupture takes place in more than three-
fourtliB of all cases. In tubo-uterine pregnancy it occurs, in tlie
main, before the close of the second mouth; in tubal, in the
TERMINATIONS.
173
fourth month; in ovarian pregnancy, lat^r, and in abdominal
preguancy not until tlit» eighth <»r ninth month, Tlie mnst iioiu-
iiHtn termination then, by far, is ruptoire, —rupture of the foetal
Oi^mhranes nUme in abdominal pregnancy, and of both sac and
DiHmbranes in other forms.
Rupture is often preceded by the bearing pains alluded to,
which may continue for liours. These suddenly cease; the tu-
iDiir diminLshes in size; and then follow yawning, languor,
(niiiting, Clammy perspiration, rapid pulse, intermittent vomiting,
ci)l|jij>se^ and occasionally acute mania. These symptoms are
Mici.'t'wied by death, or. the bleeiling being arrested, the woman
rallies and escapes immediate danger. Still, defith may follow at
M interval of some days, purely as the result of hemorrhage.
A pretty large percentage of cases survive these perils, and the
fifitus remains, perhaps for years, without bringing about fatal
rPSTiIta When fcetal death occurs prenous to i-npture, the ovum
tUHV uniiergo a degenerative process by means of which it is
mnTerted into a mole, or a lithopsedion. In other cases it under-
g(»6 mummification.
The immediate dangers of rupture are succeetled by others
fiqttally grave. As a result of rupture, severe peritoneal inflam-
luatioD ft>llowa Shoukl tlie natural powers withstand this forc-
ible ouset, the results of the intiammatiou may be accounted
^vomblev inasmuch as j>8eud*>-membrane8 are forme<l from co-
•ipiliihli' IjTiiph, which exercise a conservative influence l'>y shut-
"^guffthe o\nim from the peritoneal cavity. In the cases where
nipture is not followed by peritonitis, Schroeder says the move-
wt'utaof the f(¥tus within its membranes may give rise to such
^teuae Buffering as to bring about death from exhaustion- In a
certain proportion of cases, the foatus dies early, a suppurative
^Miiniafion in the sac is set up, and death results from general
r*"ntoaitis, or from profuse suppuration. Shoidd the woman
«Mvi?e, in consequence of low intensity amd meagre extent of
•w *ction, fistulous openings to other hollow viscera may Ije
^ttecl, through wliich the sac contents may gradually l>e elirai-
*o»tei The opening is extremely liable to l)e into the large intes-
fi^ Bometimps through the abdominal walls, and rarely into tlie
ami bladder. At best^ the process of elimination is
fWiwaely slow. For weeks or months, portions of the more
stible foetal structures, such as bones and teeth, are dis-
174 EXTRA-UTERINE PREONANCT.
charged. During this discharge of debris the iBflammatory
action in the cyst goes on, and is probably intensified by the
admission of air, or the contents of the viscera with which the
sac communicatea Irritative fever BU{>ervenes, and death from
exhaustion or blood poisoning is a common result.
Sometimes the before described inflammatory changes do not
occur, as the result of foetal death, and then the fluid contents
of the sac are reabsorlied, and the walls collapse. The soft
tissues of the foetus undergo a si>ecies of degeneration, closely
allied to atlipoccrc. The fluid [mrtions are afterwanls absorbetl,
so that the l)0]ies, lime Iniuelliu, and incrustations on the walls of
the sac remain. In other cases the foetus becomes mummified,
presenting its shape and organs to the minutest detail. A foetus
which has uu<lergone tliese changes is calleil u lithopfe^liou, and
it may remain for years without serious inconvenience to the
woman.
Otiier conditions unite to bring about death, as for example;
pressure of the tumor upon <»ther structures, giving rise to in-
tolerable suffering, and interfering with the projjer performance
of t>rganic functions.
Rupture is sometimes obviated by early death of the ovum.
In such a case there is retention for a considerable time, w^ithout
hemorrhage, or peritoneal inflannuution, but the remains are
likely to be finally eliminated by a pnwess of ulceration similar
to that bef(>i'<» di»scribed. In rare instances there has been
retention, without great dis<romfort, for a peno<l of thirty, forty
or (»ven fifty years. Women in some of these cases have lK*en
the subjects of rt^peatetl pregnancies, terminating in a natural
manntn*, without in any way interfering with the extra-utt^rine
f(etus.
"If ])ri'gnaney got»s on without accident or hindrance till the
('lost' of the juM-iod which t»rdinarily nuirks utero-gestation,
piiins etnne on, which are i)eriodie, and which are described by
women who have und(*rgone n«)rnial lalxn*, hs jM'ecisely similar
to those ntteiiding tiiat pnuM'ss. * These i)ains,' says Burns,
* usually begin in tlie sac, and thtni the uterus is excitetl to con-
tract and disi'iiarge any fluid it c(mtains.' This uterine effort nt
the clos(^ of th(! ninth month, is a i)hysiological fact of &ur})ass-
ing interest."
Diagnosis. — In the diagnosis of extra-uterine pregnancy, there
DIAGNOSla Ul EXTKA-DTEKINE PKEGNANCY.
176
are iLree puLuts to lie esUblislied: 1. The existence of the
(ximnion sigus of pregnancy. 2. The emptiness of the uterine
cavity, and 3. The presence of ft tumor in close contiguity to
jtbe ntems. Diagnosis is attended with much difficulty, and the
Jbest practitioners have been deceived.
The diagnosis (jf abnormal pregnaiicy, eBjiecially of the tubal
variety, is a matter of great and increasing imjwrtaiice, since
luodt^m surgerj- has made it piis.siblo to avert the almost certain
death which awaits the patient. But the symptoms are obscure,
aini Hi only a small percentage of cases are susi>icions aroused
oiDwrning the normal character of the pregnancy till rupture
suddenly occurs. The existence of a hemorrhagic discharge,
appearing after the eighth week, is of some significance. There
aw Also paroxysmal pains, radiating from one iliac fossa, which
arc often Bttributo<.l by the woman to flatulent tbstension of the
uit«6tines, and thus pass from notice. If then we meet a case
presenting tlie symptoms of eai'ly pregnancy, in which there is
i'T»'gttlar hemorrhagic dischso-ges, accompanied by abdominal
|«in. our suspicions would justify a demand for a careful csani-
"iatioii, when the real nature of the case may be discovered
A raginal examination made at such a time would reveal the
titPmi! somewhat enlarged, its cervix slightly S4>ftentMl, and the
^ist^iuoe of a j)eri-nterine tumor. Wlieii sitmited Ittw. the use
•>f ftJnjoint manipulation will enable one to make out the form,
witif'Hfl the fluctuation in the sac. In the absence of peritoneal
*'lh^ions, hdUftlfrmrui of the entire tumor can bo made out.
BidhitU'7H*^9tt of the ftfitua can be detected by the end of the
^'onb montiL There we various conditions which give rise to
pliysica! sigus of a similar kin<l, such as small ovarian and dbroid
^wrK, or even hajmatocele, and hence tlie difliculty of differ-
^^ti\ dingnosis.* ^
h view of the desirability of early recognition of extra-uterine
pwpiimey, it is justiliable, when the other evidence in favor of
* A ciirirni* example of the diflirulttfs ol (liiipnosU i& recorded hy Joiilin, in
whkfli lluiftiiiT, iiiiil sii ortit'veu ul l he most 8killt:d obHt<'trici.TnH of Pari-s,
■•'•■'Ion Ujc eiiftleucf of tfxtra-uu-rine pn^jin;iue>, and ha<J, in oonsnitiilion,
■"cUooed on operation, when the case terniinuti'd by ubortiou. and proved to
'• » lutnral prrginiocj.
'■'rfr Playkaiu. "System nf Midwifrry," p. 173.
176
EXTrtA-UTEnrS'E rREGNAXCY.
the condition is strong, to pass tlie utorine sound to demo
tlio absence of intni-uterine development
When rupture of the sac occurs early in pregnancy, the fl
of blood may ho moderate, and the physical sigiis be only tho;
of ordiuar}' hu?matucele. Later ru[»tiu-e given rise to sympt^jms
of extensive internal hemorrhage, and, as a rule, is speedily l
lowe<l by dontli.
In abdominal pregnancy the form of the &l>iomen will
observed to differ fi'om that of normal gestation, it being gener
ally more developed m tho transverse direction. In the latter
mouths, the form of the fcetus can be felt with remarkable dis-
tinctness. The cervix is somewhat softened, but often displaced,
and sometimes fixec' by peri-metric adiiesions. Conjoint touch
may enable the examiner to feol the uterus distinctly separatt
from tho bulk of the tumor, and demonstrate its neai'ly normal
non-pregnant size.
"When extra-uterine pregnancy goes beyond the fourth mon
without occurrence of ruptui-e, with rare exceptious, either
ovarian or abdominal pregnancy may be assumed to exist
A means of diagnosis of considerable value is based upon the
contractility of the uterine muscular fibre in response to stimu-
lation. If extra-uterine pregnancy exists, fi'iction with the hand
over the tumor will excite ctuitractions in the uterus, which hav
no effect on the size or form of tlie tumor itself.
As a final mtxlo of examination in doubtful cases, the worn
may be anfestlietized, and deep and thorough bi-manual manipu-
lation resorted to. Under such contbtions the finger may be
jmssed into the uterine cavity, into the rectum or into the blad-
der,* the risk bein^' assumed by the physician, of its proving to
be a case of uterine prof^uancy, and its resulting in miscarriage.
Treatment. — The mo<ie of treatment will be detenuined
largely by the degree of development which has been attained,
the condition of the fcetus, and the health of the woman. For
the sake of i>er8picuity and convenience, we make three classes
of cases, viz.: 1. Those which have not advanced beyoml the
limits of a few weeks. 2. Those wherein gestation is well ad-
vanced, and tlie foetus is still living. 8. Those in which preg-
nancy has been jirolonged after foetal death.
be I
lal j
i
he :
tu-
nd j
ive J
•Da. NcEGOKliATii. 'Am. J. Olw.,'' Muy 1875.
TREATMENT OF EXTBA-UTERINE PHEONANCY.
177
I, Cases of Recent Impregnation, —It has l>een obsened
timt, wbeu, £rt>ui any cause, embryimic life is destroyed, recov-
ery often ensaes. Following this hint, it has been proposed as
ri mode of treatment t<7 atlopt lueiwiires which will compass this
resiilt This hoii been doue in some eases mfch good results, and
the methods employed were puncture of the sac^ injections of
morphia, and other solutions, olytrotomy, and the induced cur-
rent
Punrtnre of the Sac is generally effected by introdncing an
pxuloriii^ needle, a trocar or an aspirator needle, throuf»h either
the vaginal or rectal wall, and drawiug off the liquor amuii. The
rtsolts of this mode of treatment have not been wholly satisfac-
tory, and fatal effects have several times been prmluced. lu
moet of the cfisea, if not in all of them, iiowever, an ordinary tro-
<ar was employed, whieli necessarily admitted air- We can
brvlly believe that a small aspirattir nee<lle could prcMhice serious
Pteulls. Niuuerous instances of recovery have been put on
rwonL
Iiyectlons Into the Sac. — Joulin ♦ was the originator of this
niHthod, and he proposed injections of 5uli)hate of atropia.
Friftlreich afterward following the suggestion with success.
Morphia was subsequently employed by him with more satisfac-
tftry results. The site of puncture is the al)dominal or the VEiginal
VRllft. When the needle has once entered the sac, a few drops
''f the liquor amiiii are withdrawn and tiieir place supplied by
th'* KjJution of morphia. The operation should be repeated
*wiry second day, untd evidences of success are diaoemible.
Wylrotoniy.— Dr. Gaillurd Thomas f f)pened a cyst from the
T'lgiiiu by means of an incandescent platinum knife connected
^thiigTilvam>-cautery appai'atus. Through the ojieniiig made
oytht'kuife the foetus was removed, and in attempting to extract
tli^ phuvnta, hemorrhage was set up which was controlled with
"»e greatest difficulty. Septicemia followed, but the woman sur-
^^M. Dr. Thomas, in the last editi<m of his work on Diseases
^^ Women, recommends to cut through the sac with Paquelin's
cautery knife, remove the fcetus, but allow the placenta to re-
**""»i Mid then fill the sac with antiseptic cotton, which should
J^rtT-Dt. *' Traits romplet des aocouchenicnU," p. 968.
♦S'» York Mwl. Jour., June, 1H75.
178
EXTUA-UTEBINE PBEQNANCY.
1
be removed every tliirty-six liourB. The operation is de^igni
however, only for cases which, from the severity of tlieir sym]
tomB, demand immediate action.
The L'seof Electricity. — The induced current passed through
the ovum is a safe and effective mode of destroying the cmbryu^^
One pole of tlie buttery should l>e passed into the rectum, againfl^|
the tumor, and the other placed two or three inches above PouJ
part's ligament, on the alxlominal wtdl. The full force of an
ordinary battery of a single cell, employed for a few minutes, at
intervals of twenty-four hours, for several days, will effect the
purpose.
When rupture of the sac takes place, treatment should ha^
for its object tlic arrest of internal hemorrhage, and tl»c removi
of the effects of shock If the vital forces of the woman
not too low, an ice-bag may be npi>lie<l to the abdomen. Vei
hot applications will answer l>etter in case great depression ex-
ists. Compre^sitm of the aort^i, and a sand bag u]k>u the alnlo^^
men over the site of the ovum, have also been recomuiende^^|
The patient should l>e placed in a cool, (juiet jilace, stimulants in
small quantities administered and often repeat-ed, if roquire^^^
cmd, in the absence of other s|>ecial in<licatiou8, chitia given. I^M
will be a wise policy to follow these with several doses of (womft*^
in anticipation of the peritoneal iuHammation ^-hich is likely t^^
ensue. ^|
Laparotomy. — Since rupture of the tube is attended witb
fatal results in the vast majority of cases, Kiwisch and others
have advised abdominal incision, and ligature of the bleeding
vessels, remttvid of the sac, and clearing of the j>eritr»neum.
Still, the operation has not yet been performed, and the expec^i
tant plan of treatment prevails. ^|
2. Cases of Advanced Gestation, the Foetus Still Living.—
Most women suffer during the progress of such im abnormal
gestation, with severe, but brief attacks of peritonitis, from great
sensitiveness to foetal movements, from reciuTing uterine hemor-
rhages, and from emaciation nnd depression of the vital powers^^
With the occurrence of lab*)r-Hke efforts, peritonitis is apt to ti^H
excited. In view of all the dangers to which both the Voma^^
and child are exposed, under the expectant plan of treatment, it
has been proposed that an operation l>o performed early, with a
view to rescuing the latter from certain death, without adding to
ntEATMENT OF EXTBA-ITTERIXE PREONAJfCY.
179
risks sustained by the former. But the results of such ope-
»us have been of n cLiBheurteuiiig imture. Tlie chief Bouive
of (Linger is fouiid in the hemorrhftge which necessarily follows
removal of the placenta. On the other hand, when Uie placenta
Lsporiuitted to remain, septic poisouing and fatal hemorrhage
itfp liable lo occur during the process of elimination. The diffi-
cnlties are made still more formidable by the situation of the
(tbictiutn, in a ooDfiiderable percentage of cases, on the line of
iucisiozL
:{. (*a5es of Gestation Prolonged After Death of the
FfftUH.— When the ftetus is dead, no attempt sliouhl be made
to remove the product of conception during the existence of labor
]iiiiii5, as the thingers would be thereby uimocessarily enhaucetL
It IB generally thought advisable to wait, carefully watching tlie
patient, until the symptijms become grave, or there is jKisitive
icationof the channel through which elimination of the fretus
lEhout to take plac^. The latter will be sliown by bulging of
tlK^cyst in or about the vagina. An o{)ening may l>e effect**d by
tiie natural eflforts, in which case it may be artilicially enlarged
to a sizfi which will admit of fcetal exit. Should tlie opening be
othe intestines, tlie dangers and difficulties attendant on ex-
lioD are so great that gastrotomy would be justiiiable.
It is obvious that the presence of a dejid fcetus seriously cx)m*
!»»»mi*es the safety of the woman, and the suppurative process
which is liable tfj ensue, inevitiibly reduces her to a deplorable
ojuilitinu. In view, then, of the success which has attended
^<^»iulHry laparotomy, on one hand, and the extreme dangers of
*^lii»g. i>n tJie other, operative interference seems to be a justi-
fiable prxMjedure. Oat of thirty-three cases collected by Lilz-
aifcnn, twenty-four of which were between 1870 and 1880, there
»er(- tiititHeeu recoveries. It will be observed that the two great
^nu<^ns which attend the primary operation (that made during
ttttJil lift- 1— bem(»rrhage /md septiciemia, — are in this oj>eratiou
ff*^i\)' DiiKliiieii, the former by gradual thromlwisis and ol)lit-
*»ation ci( the maternal vessels which follow the cessation of the
»o^l circulation, and the latter by the iMJssibility here afforded
for Ihft removal of the entire ovum, or the speedy subsequent
■"l*i*tion and extraction of the placenta.
"^'tli rt'si>ect to the time for the performance of secondary
**iwirutomy, a clear idea is of much importance. The time of
180
iaS8£D LABOB.
foetal death should be carefully notetl, and our object should be
to dehiy a sulficieiit length of time to provide for obliteration of.
the placental vessels. Schroeder removed the placenta without
losH of bl*Kxl tliree weeks after cessation of fffibd movements.
DePaul operated four months after fcetal death, and lost his
patient from placental hemorrhage. There is no doubt that the
process of obliteration of tlie placental vessels is rapidly effected
in some, and slowly in others, and hence, under the circum-
stances, when we can delay, it is advisable to p*3stpone opera-
tive menacres, and treat the patient symptomaticall v The woman
should receive an abundance of fresh air and nourishing fo«>d,
while in the absence of more specific indications arsetiicum
ought to be administered. Should marked septic symptoms be
developed, they should be regarded as a signal for interference,
as delay would certainly be fatal.
The operation itself should begin with an incision along the
lineal alba, as in otlier cases. If no adhesions are fountl between
tlie cyst and surronuding structures, it should be turned out
through the incisicm, before rujjture, and stitched to the cut
Ku'dors of the abdominal wall. The placenta, unless it occupies
the site of the incision, or unless it separates at once spontane-
ously, should he permitted to remain. The cord should \>e
placed in tlie lower part of the wound, which will be left open
for it, and for antiseptic injections.
Gestation in a Bi-lobe<l I'terus.— The history of these cases
corroHponds so closely to tliat of tubal pregnancy, as tti require
but little notice. As elsewhere stated, they cannot be differen-
tiated tiuring life, and only by careful examination post-mortem.
The chief difference in their clinical history is, that in cornual
pregnancy ruj)tiire generally occurs a little later than in
tubal, on account of the greater distensibility of the part
Hissed Labor. — "An extremely rare and curious phenome-
non has been (xrcasionally observe<l, in which tlie foetus remain-
ing in utero, labor has not come on at the usual time, and the
remains of the foetus may be retained for a ocmsiderable period,
or discharged piecemeal by the vagina without, for a time, at
least, seriously affecting the health of the mother." This has
been called ''missed labor."
For the most part, death of the foetus is followed either by
MISSED LABOB.
181
^matore expnlsion, very soon after life is extinct, or by the oc-
eurrence of abnt^nnal development of the fcetal euvelopee, and a
penroraion of the nataral energies, culminating in molar preg-
nancy. In the rare cases above alluded to, neither of these oc-
currences is observeti, but the foetus bec^rtmes mummified, or dis-
I integrated, and its remains are retained in utero for mouths, or
fc\en years. The cause of this is supposed to be absence of
uterine irritability, obstructed labor, and unusually close adhe-
tioms of the placenta. In many cases uterine expulsive action
is set up, but, after a time, it ceases permanently, or ia renewed
at iutervals, for days, weeks, or even months. Whenever the
ovmn perishes and is kept in the womb for a time far in excess
of the (leriod of normal utero-gestation, whether molar changes
takii place, the fcetus is disintegrated and discliarged ijiecenieal,
or becomes mummified; indeed, whether any decided post-mor-
;ee take place or not, tbey constitute an instance of
?l»l>or. Mauget* report* an observati^^m by Langelott of
acaaein which the foetus perished in tlie fifth month, and was
not expelled until the twelfth month, in n mummified condition.
Johubt obsen'ed two cases in which the ftetuses died at the sixth
mimlh, and were not born till five and six months respectively
*fter tkeir death. Olshausen J reports a case of retention of a
ffloiimiitied three months* fcetna for eight-and-a-half months.
McMalion S relates a case in which a fictus of four months was
Waintxl for eighteen months, and was tlien expelled, inclosetl in
*tt>iDprea8ed placenta which evidently had continued growing
for tome time after fa?tal death. The calcifiwl or mummified
wAw is said t<> hare been retained many years. Foetal bones
MTfr b*H»n tlischorg«^d from tlie uterus years after conception.
A. Halloy aud H. Davis rep<:>rt the case of a woman who, in the
«*^«i<l Liilf of her pregnancy, had a brownish discharge from
"1^ VHgina, aud occasionally lost i>utrid fieshy masses, at times
•^opanietl with bones. Four years later tlie os uteri was ar-
*^"'^ly dilated, and eighty-six bones removed in two sittings.
In rure caaos of prolonged retention, the foetus becomes the seat
•BlKsi^ Pmct., B. iii. Cl^ntva, IfiOG, p. 814,
♦ Ottbl. (joart.. J, Aug . 1855, p. 63.
*M< Chir. rtoview. No. 8», Jan., 1870, p. 278
182
ilBOBTION.
of fatty and calcareous degeneration, in which caee it is design
nated by the term lithopa&dion.
Treatment. — When a woman» who has presented the rational
signs of pregnancy, passes by the period of mature gestation,
and evinces indications of foottd death, followed by disintegia-
tion or mummification, it is clear that something ought to be
done to eflectnally rid the system of the depressing iullueuces to
which it is subjected This can be done only by securing thor-
ough titerine evacuation. Measures which might answer admi-
rably in ordinary pregnancy to accomplish the purfjose, such as
KiwiHch*8 dou(rhe, would very likely here prove unavailing. The
operator should accordingly I>egin by passing a small springe or
lamimuia tent int*) the cervical canal, followed after a time by a
larger one, and finally, if necessa]-y, by several. When the oa
has thiis been opened, he should proceed much as he would
in abort.ion, using, from preference, his fingers, but, if necessary,
the placenta forceps or small blunt htxik, as a means of extrac-
tion. If putrid masses be taken away, tliQ uterus, after complete
evacuation, may be washed out with a mild antiseptic solutiou.
This <>i)eration, like all otbers, ought to be performed tJirough-
out under antiseptic precautious, and followed with a few doses
of arnica.
CHAPTER VHL
The PrtMimturo Kxpulsion of the Ovum.
Premature exjiulsinn f>f flie product of conception may take
place at any moment prior to the time when the foetus presents
all tlie evidences of maturity, and the process has received dif-
ferent designations according to the stage of pregnancy at which
it occurs. Interruption of pregnancy during tlie first three lunar
months • is termed ahorfkm; during the fourth, fifth, sixth and
seventh month, that is. from the time when the placenta is fully
formed to the date of viability, it is called miscarriage, and
• Some sny, during tho first /«mr lunar months. Vidf Leishnian. p. ;J67.
C\C8E8 OP ABORTION.
183
*
trota that time to the close of the thirty-eighth week it is known
as prenmiure labor. While these are the technical distinctions,
the terms abortion and miscarriage are used iuterchangei.bly by
many, and, as we conceive, with perfect propriety.
The term Foetus, according U) usage, ia not applicable to the
product of conception until the termination of the third month
of gestation. Till then it is known as the Embryo.
The liability to premature expulsion is donbtieas greater in
the early weeks of gestation, when the union l>etween the chorion
and decidua is imperfect, as hemorrhage is apt to occur and till
the space between them, thereby cutting off communication be-
twepD die mother and child
Obstetrical writers do not agree as to the relative frequency of
abortion. Hegar reckoned one abortion to every eight or ten
fnll-time <leliverie8, while Devilliers sets them down in the pro-
pifrtion of one to three or four. The statistics of Whitehead
filiour a proportion of about one to seven. Probably thirty-seven
uut of every hundred mothers experience abortion before they
ftiljlin the age of thirty years.
PredispoNins Caumes of Premature Interruption of Pre?-
nuDpy.— The causes of abortion, miscarriage and premature
U)u,T, are, in tlie main, of slow, but cumulative action. The
»ay is us\ially prepared, either by changes gradmdly effected in
tli« ovum, or by certain pathological states of the maternal organ-
**m. lusidifais agencies having finally undermined the vitality
i>f the ovular structures, and rehdered insecure the placental
'■ liments, circumstances which would othei'wise have been
tivi^ly innocuous, are then sufficient to precipitate premature
'> at expulsion.
la the fitudy of the etiology of abortion it becomes obWous
tiiftt (ranse and effect are not always clearly discerniljle. It seems
fTtwa, however, that, in some cases, disease of the dionnn leads
tlift wiy t.> fwtal death, while in others, chorion changes are con-
•^H'^t on that occurrence.
I^th i.f the ftfitus may be due to direct violence, such as
«ck* and blows uf»on the abdominal walls; to indirect violence,
••Wis, or fltraixis; t<i tlisease of the foetal appendages; to tlis-
*M«a! the decidua, esi^ecially those which induce hemorrhage;
!■ '. iiriln nitt'ctioris; to i)Iethora. or, on the other hand, ameraia.
i;. Eiiii-^of (amine, great numbers of women alxirt Deatli of
184
ABORTION.
the foetus is folloTTOtl sooner or later by expulsion of the uterine
contents. In the early weeks, delay in some cases results in
dissolution and absorption of the embryo. Foetal death is
usually foUowetl by atropy of the villi, and fatty degeneration
of tlie placenta. The ovum is thus rendered a foreign botly, and
after the lapse of a certain length of time, which varies largely,
contractions of the uterus are excited. Before formation of the
placentit, theo\'um is frequently espelled without rupture. Sub-
sequently, such an occurrence is rare. When the membranes
give way, and the pressui'e upon the inner surface of the uterus
is removed, hemorrhage, more or less profuse, usuaDy folJo\^'s,
and Ci^ntinxies until complete evacuation has been eflfected.
Abortion often finds its predisposing causes also in changes in
the decidua alone. Among these are: 1. Atrophy, and 2. Hy- -
pertrophy of the uterine mucous membraue. ^H
!. Atrophy of the Uterine Mucous Membrane.— The endo-
metrium instead of afi'ordLng a generous reception to the im-
pregnated ovum, and snugly enclosing it, in some cases spreails
an abnormally small decidua serotina, with the result of a. small
placenta. In other cases the decidua reflexa is not complete*!,
or may utterly fail of de-
velopment, in which case,
covered only by the chiv
rion, the ovum is susi^end-
e<l from the sorotiiia.
In either case, the ovum,
instead of being at once
expelled by the uterine
contractions, may be forced
downwards to the cervix,
and there remain for a
time nourished by the ped-
icle whidx it forms. This
has received the name of
cervdeal pregnancy. It is
chiefly the rigidity of the
OS internum, and the cer-
vix, which retains the ovum, and hence it is an occurrence more
common in primipara^ than in multiparie. In some instances^
Ovum with imperfectly developed dcddiia.
CArSES OF ABORTION.
185
I
L to affect i(
hoirerer, the strengtii of the pedicle is sufficient to prevent
further descent, even when the os is patulous.
2. Hypi*rtrophy of the I'terine Mucous Membrane.— En-
dometritis with consequent thickening of the mucooH membnine
wa[rei|ueut cause of abortion, from the fnct that it gives rino
to affections of the placenta. A placenta thus involved may fail
tft supply to the foetus requisite noui'ishiaeut, or the weakened
of the decidua may rupture and pnxluce sanguineous
between the membranes. In retroversion, which is
recognized as a common c«use of abortion, the endometritis is
imOxibly the chief factor in bringing about the untoward result.
Rigidity of the uterine walls, as from the preseueo of inti'a-
ttoml fibroids, preventing proper expansion, may excite efforts
UsWtion. Expausitm may also be hindered by i)eriU>Deal ad-
hf^onj?, or the changes which result fi*om i>elvic cellulitis,
h many rases it is imi>ossible to trace the cause of the occur-
Bttii'e to any abnormal conditions of either the ftttus and its
*lope*>, or the maternal generative organs. In such women
ttere doubtless exists a condition of nerve irritabiJit>% which
wfliiily reflects irritation, proceetliug from physical or psychical
ftiirces, ?iith forco suiticient to produce jx>werful premature
^rm action.
Inmiwiiate i'anses of AI>ortJoil.— The immediate causes of
*l»"rtiun arise, in general, from the maternal side. No changes
hi the ovum, save those of forcible separation of the ovum from
it* attachments, or rupture of its membmnos, cotild scarcely
bnug ttl^jut the result. The maternal influence, liowever, is
*frviig and anndfitakable, and is often exerted, \villingly or un-
willingly, witli the effect to interrupt pregnancy.
Hyperemia of thi* Gruvid I'ternK.— This is pmbably the
ni"«t fir-tjuent proximate cause of abortion. In those cases
*'>'*reiu influences have been silently at wtirk to weaken the re-
l*tioDfcbetwe<'n the ovum and decidua, any circumstance which
tecapfthlQof determining an unusual qtiantity of bkuKl to the
•tf^n, ifl eAi>ublo of cimsing extravasation, separation, and pre-
nJAturoexptilsion. Hyperiemia excite<l by an accomplishment of
™ BwiUitnnil cycle, fevers, inflammation of the genitalia, ex-
^■•■u* b coitus, hot foot-baths, the use of certain drugs, unusual
pBfwctl «xertion, vahTihii- heiirt-lesions, olwtructions to t1 *
m
186
ABOBTION.
ptilmonary or portal circulntion, may one nntl all load to rupture
of the decidual vessels, und couBequent exti'avasatiou of BIlkhL
Under conditions of uterine hyperwniia, n very slight motion or
jar, vomiting, coughing and straining, to say nothing of falls,
injuries, and vii>lent emotions, are capable of precipitating the
foil of the unripe fruit of the womb.
The significance of pre-existing remote causes, associated with
accidental occuiTences, is clearly shown in many recorded cases.
When the coniiections between decidua and ovum have not bee
weakened by the occurrence of any of the changes before men-
tioned; in other words, when the woman in all her generative tis-
sues is in a healthy state, most powerful influences of a baneful
nature are often Bufiere<l, without interruption of a normal course
of gestation. Falls from considerable heights, giving rise to se-
vere contusions and fractures, have repeatedly occurred to preg-
nant women wltliont causing HlK>rtitm. Dr. Pagan* tells of an
instance in which his coachman (b*ove directly over a womiiu
who was in the eighth month of pregnancy, inflicting upon her
t^erious injuries, and still gestation pnKee<led in a regular man-
ner to term, jind terminated in the birth of a healthy cliiliL M.
Gendrinf speaks of a young lady who was thrown from a chaise
over the horse^s head, by the animal falling in his career. The
lady was then five months jtregnantj but tlie accident did not i>r6-
vent her from reaching her f idl term. Cazenux met a case pre-
cisely similar in the wife of a notnrj' living near Paris. Some
women, with the dt^ire to rid themselves of a developing ovum,
resort to most desijernte measures without success. Physicians,
without a knowledge of existing pregnancy, liave passe*! the uter-
ine sound, and swe])t it about in the uterine ca\'ity, and have even
introduced and left an intra-xiterine stem pessary, without produc-
ing premature expidsion. J
Symptoms of .\hortion.— Early nborticms may, and doubtless
do occur, in many cases, with sympt*-'ms differing but little from
those attending a return of the monthly tlow. There is some
pain in the siicral and hypogastric regions, and bearing sensa-
tions in the pelvis, with a rather free flow of blood, when the
♦ ViiU Lkishman. "%sU'm of Midwifrn.-;' p. 362.
t Vidn CAKBAVX, "Thwniicul and l»nw'tit:al Midwifery.'' Am, Ed^p. 5G7.
"V: \,i . I '-\-!" Ill of Midwifery,*' Am. Kri., p. 240.
BYMPTOMS or ABORTION.
187
>le OTTun may be diacliarged, enveloped in a clot, and thus ut-
terly escape notice. Oftener, however, the ovum is broken, and
the liquor amoii is lost before expulsion. The embryo follows,
and ultimately the socundines, the latter when opened some-
what resembling the placenta of later pregnancy. In either case
there is generally but a moderate loss of blood ; but the rule is
)t without its exceptions. In a certain proix)rtion of instances,
m in tiie early weeks t:>f pregnancy, the lii^morrhage nttemiuut
on the occurrence is remarkably profuse, and occasionally even
alarming. Still the practitioner inny comfort himself and |)atient
with the reflection that this symptom is more alarming than dan-
gerous, since ivomen who are the subjects of it not only survive,
irat rarely suffei serious imjmirment of health or strength.
Astux)n as the oatuu, whether whole or in fragments, has been
completely extruded, there is usually an end to the bleeding, and
bat nsliort periotl of time is consumed in involution. But iji
early, as well as in later aUirtion, the presence in utero of any
Iitrt iif the product of conception whether embryo, or envelo]>e8,
ift »pt to continue the hemorrhage. There may lie temponiry
QMsatioD, but the flow again returns to declare that the abortive
prowTSB is incomplete.
Uter Abortions present more pronounced ehai'ucters. Tlie
l«iM are more severe, the flow more profuse, and the effect on
the woman more |>rofound. For some time before tliese symp-
t"itts set in, prodri)ma are generally experienced in the shape of
MlneRS and weight in the |>elvis, sacral pains, fiequent micturi-
tiiai,aml a mucus or watery discharga These, followed by re-
m1 jinim^ and hf'm<irr]iage, indicate a threatened aliortion.
iiiny be but a slight discharge at imy time during the pro-
BWBftof the case, but in every instance tJiere is liability to ex-
liftUHtiiig and even dangerous hera»>rrhage. Tliere is prt)bably
litilt^reul peril t«^ life, imt the baneful effects of sanguineous de-
|>l»?tiun are not speedily remedietL The tenor of the woman's
K«»nil health may be seriously impaired for months, or even
In •» typical case of abortion occurring about the third month,
Miin is extruded witliout mptnr", in which case it passes
liu* vagina, covered by the decidua vera, or drags the in-
'1 iliHuilna after it. The uterus then being empty, contracts
*i*/wa, nul the hemorrhage is at an end. A small afterbirtli, with
188 ABOBTION.
shrunken nmbilical vessels, is usually found In abortions oc-
curring after the third month, it is uncommon for the ovum to
come away entire; but the membranes are ruptured, the foetus
expelled, and the secumlines are rettiinecL During the periotl of
retention, which may be prolonged, the woman is in constant
danger of profuse and sudden flow. After the abortive act has
been flnisheil by complete evacuation of the uterus, hemorrhage
is an unusual occurrence. In rare cases, owing to a depraved
state of tlie system, to intra-uterine growths, or to imperfect in-
volution, it becomes an annoying complication of the puerperal
state.
Incomplete Abortion. — Betained secundines, whether in
early or later abortion, are ajjt to prove a source of much trouble.
Here, as in labor at full term, after expulsion of the foetus the
uterus is disposed to take a season of rest; but, unlike the latter,
this rest is usually prolougeiL AVe may sometimes vainly wait
hours or days for renewed action, while cases are by no means
rare in which vigorous uterine contractions never returiL
The comparative comfort of the woman will lead her tol)elieve
that the pnwess is complete, and a physicinn may not be con-
sulted until serious symptoms are devoloi^ed. Violent hemor-
rhage may at any time ensue, or in <lefuult of that, septieanuin
may bo s(*t up. In many cases tiie physician does not reach his
pntient until the fcetus Iins been ex]>elle4l, and the clots wliich
generally ftillow aro nssumed to be the afterbirth. In that case
he is informed that everytJiing has come away, and as the evi-
d*Mice has been destroyixl, the intelligence of tlie attendants is
given undue credit, Skoi)ticisni is hen* connnendal>le. The phy-
sieiun ought to institute a thorough exploration, if it can pru-
dently be done, or he should act on the theory of partial reten-
tion.
The Diai^nosis of Incomplete Kvacuation becomes a jx^int
of groat nicety, as well in those cases where the extruded mat-
ters have all been i>reserved, as in those where they have not^
When the ovum is dischargtHl with its entire membranes intact,
it is not difficult to arrive at a positive conclusion, but, in abor-
tions aft<^r the third month, this does not often occur. The pla-
cental or decidual mass is relatively hirge. The size of the em*
bryo may be roi)rosent<'d by the last phalanx of the little finger,
or (I Lima bean, while the uftt^rbirth, when spread out, is as large
IC£B(BBAKES EXPELLED — FOETUS BETAIXF.D.
189
half the hand. In same cases the secundiiies are expelled or
extracted in fragments, and a retained portion is ejinily ovftr-
luukfld. Absoiuto certainty can be uttaiued only by a careful ex-
ploration •uith the finger.
The Beusations experienced by the woman liave some diag-
no6tic value. These are of a nervous kind, an<i aie felt most
noticeably about the head. It is a RiH>cie3 of nervous erethism,
U^yond the power of description, attended with some headacliei
and a general unrest These sjTuptoms usually persist until full
rncuation of the uterus has been accomj>lished.
The existence of hemorrhage, esj^ecially when it occurs in
nmll or large gushes, is a further indication of incomplete evac-
TiatioD.
Membranes Expelled,— FiPtus Retained.— Cases are on rec-
onl iij which the order of expulsion Avas reversed. The mem-
branes were ruptured and expelle*.!, uterine action ceased, and
t' ' ' - was rftuiiietL Dr. Nooggernth* mentions a case in
uieuibranes were expelK-d at the lourt h mi mth of preg-
nancy, and the foatus was retained for several weeks. In the
jntiTval I^etween expulsion of the membranes and birth of the
?lU6, the wnman was in a comfortable stiite. Dr. Chuinbcrlain f
relfttes a case in which the membranes were expelled, but the
fa*tufi continuecl in utero for twelve weeks. Dr. Peaslee hud
ft similar case in which the fcetus t'lrried tliree months. In the
Iwt two cases tlie women manifestetl symj^toms of retention of
ft part of the ovum, tliere being hemorrhfl;:;o and irntative fever.
The fiilldwiug observations by BpiegelbergJ concerning in-
<y*mj)Ietc alxjrtion. merit most attentive study:
L Miwt frtHjuently hemorrhage continues at inter%'als, sponta-
JifH-tufi elimination grailually taking jjlace as, through retrograde
•^lugps, portions of the retained membranes become successively
*«»seiied in their att^ichments to the uterus.
2. In exceptional cases the hemorrhage ceases for a time en-
^^i^ly. For days, weeks, and even months, the woman appears
n^tewell; then suddenly, strong cxintractions, accompanied by
profuge hemorrhage, usher in the elimination of the foetal de-
'Am. Juur. Oba., vol. iv., p. 551.
iAm. Jour. OIm^ vol. iv., p. 5r>2.
: I'ide LrsK. *' Scipnce and Art of Miclwifery," p. 206,
190
ABORTION.
pendencies. Lusk says, in a case of his own, three monfl
elapsed from the occurrence of the first hemorrhage, which took
place toward the end of the third month, and was quite insig-
nificant in amount, before the alx^rtion was completed. Mean-
time, as there were progi-essive abilorainal enlargement, 8uppt)setl
quickening, and milk in the breasts, the threatened abortion was
believed to liavo been arrested. Total retention, with a long
interval of repose^ is thought to be due to complete adherence
Fi«. 93.
L'tenu, with btisb oi' u tibriuuuif |M>lypu8 uUer uti uburtiun. (Frunkel.
the placenta, which continues to receive nutrient supplies from
Uie uterus. He believes that a menstrual (leriod is the usual
INCOMPLETE EXnaSlUX Ut TWINS.
101
le at which the discharge of the retained membranes takea
pUce«
y 3. Of more frequent oticurrence than the foregoing, is the pu-
V trid (lecomjiositinn of the retained portions. It occurs chietfy
in castet^ where there is more or less complete loss of organic
ttmiiection between the placenta and tlie nterua Detsoraposition
of the non-ailhereiit portions is produced by the introduction of
ftir during the escape of tlie embryo, or Uiroixgli the subsequent
puBage of the finger into the uterus, or wliere portions of tlie
oTunj hftug dow^l into tlie vagina, l>y aljsorption of septic matter
fntm the vagina upward into the uterus. As a result of putrid
decomposition, the womuu is exfjosed to septiciemia, and infec-
tiiinof thrombi at tlie placental site. Fatal results are, however,
rare, as dec4im[n»sititm is usually a late occm'rence, setting in, as
a rule, only after protective granulations have foruied upon the
uteriii'' mucous memhnmo. ami nfter the complete closure of tlie
aUfrioe sinuses. Continued fever, with intercurrent attacks of
liemorrhage, is, however, set up, but passes away finally with tlie
gnwlual discharge of the decmnposed particles, while the threats
puing bymptoms subside. Still, now ami then septic processes
lend to an unfavorable terminatitm. Local perimetric inllamma-
tioo is a common event.
4 Where tliere is a certain degree i»f relaxation m ith enlarge-
mcriit of the uterine cavity, the fibj'in ul the extravusated bl<x>d
^fty liecome deposited alxjut any uneven surface within the
^tunis, and give rise U^ a ]>o!ypus-Khai)od twxly, suggestive in its
nii>(le(»[ development of the sUdactite formations in calcareous
cavenw. Tliese so-calleil fibrinous polypi generally develop
witind the rirhrts of an aKirtion, such as retnine<:l bits of decid-
^ pincental remains, iiml ixirtions of the foetal membranes.
In Some cases likewise, thrombi projecting from the placental
Mt<»beo(»me the biuse of a hxjse fibrinous attachment Placental
Nypi give rise ultimately to bearing-down pains, nnd intercur-
p?at beiuorrliages. Tliey may even decom|}ose, and endanger
life by septic absi)r])tion.
Expulsion of One Fcrtus in Twin Preg:nancy.— In t^rin
pi^gimiicy one ovxkm miiy 1m? bliglded and expelled, and the other
wtained till oi^mpletion of the full term of utero-gestation. A
*>*«* btereating case of this kind was reported by Dr. E. Che-
192
ABOIITION,
rr-
nery.* A woman at tlie fifth niontb presented tho usual symp-
toius of abortion, and a foetuji in its envelojit^H, together abou^i
the size of a common open-faced watch, was expelle<L I-^pol^H
making a vaginal exauiination the ht^ad uf a much larger foetu^^
was fuimd protruding tlinrngh thf* os uteri This was seized h}
the fingers for the purix)se of extraction, but escaped and
turned to the uterine cavity. The pliysicinu supixwing thi
expulsion was then a necessity, gave ergot, but the os eontracted^i
and the uterua refused to act When the full term of j^regnanc^H
was accomplished, expulsion t<x)k jjlace in a normal maiuiei^^
Other cases are on record. In gen«nal, lutwever, in multiple
pregnancy, the uterus is entirely evacnate<i without n lojig inter
val of rejjose.
Diagnosis. — Cont-omplation of the sjinptoms of alK^rtion
related would lead one tt; supjxjse Uiat ilingnosis of the approach-
ing occun't^noe should not be attended with much dirticultv.
Still, in unuiy cases this is not true. The woman, perhaps, h
evinced her pregnant state by the usual symptoms, and n
hemorrhage and pain indicate its threatened conclusion. The
case is clear, and diagnosis luicquivocal. But we often meet
women who are wor8liij)ing at the shrine of tlie goddess Isis.
So extremely desir^>us Jire they to present their husbands with
heirs, tliat every possible sign of pregnancy has bet-n magnified
as a supf)ort to fond hopes, and the 8)^nJ?tom8 now presented,
though really those ftf n incnstrnal I'etum, are cunstruetl to be
signs of abortion. Tliere are women of op|)osite desires and
tendencies who will minimize eveiy true symptom, and tlins
mislead themselves, and those who are summoned to their aid
Then there are those unfortunate females, nmuy of them girls
scarcely out of their teens, who, ha^dng fallen a prey to the wiles
of designing men, use every endeavor to conceal the evidences
of guilt Among the number are sometimes found th<^e t*i
whom we would scarcely dare imput« wrong doing, and who
thereby disarm suspicion. The only s»d^e course for the ])hyHi-
cian to pursue is to insist upon an examination jnrr vayinam
all cases where, from the symptoms, there ap|>eai*8 tol)etliele
possilulity of threatened, or ]iartially completed, Abi:»rtion. The
diagnosis is based upon the presence of jmin, hemorrhage, dil
M
'h^
■sioa Med. UQtl Sitrj!. Jour. .Vpril. 1K71.
phoqnosis.
loa
of the cervix, and descent of the ovum. If the os has
fotue ]>atiilims, the o^niin may l>e felt, when the tltMnonfitrii-
tion becomes c<}U]}>lete. In all eases of pregnancy, the c»coiir-
reuoe of helU4ln•hHg»^ even iiTiarronipaniod l)y other eymptoms,
uaght to be accepted as a probable evidence of threatened
abortion, and every precaution aeeordiugly exercised.
It is impossible to make o\it with certainty, from mere sub-
jective symptoms^ the existence of pathc ihigicnl changes in the
oTiim and deciduie whicli prepare the way for abortion. Death
of th»? embryo may be inferred from the signH given in another
chapter; but positive knowleflge can be obtained only at a later
Whenever the di.schargeil substances have been preserved^ the
physician should carefully examine them witli a view to discov-
ering every possible trace of tlie ovum. The cluts mny l>e bro-
ken up in cold water, and solid substances wholly freed from ex-
tnmeoua matters. The ovum, when unruptured, is generally
Inund surroondeii by layers of coagulated blood, and might
easily Ije overlooktxl. If the discharged i^ubsfcances have not
bcfu preserved, and the os uteri will not admit the point of the
finiTpr, it mny Ix' impossilile to determine at ouce wliether com-
plel« evacuation has been effected or not Forcible measures
>^ u<»t justitinble for mere diagnosis. The occurrence of fur-
ther pnin and hpiuorrhage would constitntt* strong e^^deuce of
reltmtiiiu, an<l tlilation of the i)S may be necessary as a prelimi-
^ l<» extraction of tlie remaining sul^stances.
Prognosis. — ** The prognosis takes cognizance, of c^^urse, of
th'* results to the mother only. In the tirst place, it may l>e laid
'l'>^ii iu the way of broad, general statement, that all cases of
! 'iiUiiKius abortitm {k e, excluding criminal cases), not com-
ll. vitrei with other morbid conditions, are, under suitable medi-
^ j^i'liince, devoid of danger. But, in the r*Pcoud place, it
•"^i»tt»e borne in mind that the statement is only true with tlie
'^nations tliat limit it, for in point of fact, the actual number
"' titaths from abortion is by no means inconsiderable. Thus,
*li*dt'«ths fn>ra tlus cause rejwrted to the Bureau of Vital Sta-
^ticftof New York city, between tlie years 1867 and 1875, in-
"^ire, were one hundred and ninety-seven, a number which
^^ short in all probability of the truth, by reason of the many
*=i'>?anmtancett which precisely in this condition tempt to con-
194
ABORTION.
cealment The total number of deaths daring the Batne peri*
from metria was, according to the reporta rendered, 1,947, Hegar
reckons one abortion to ever}' eight or ten full-time deliverie|j^|
If this proportion be correct, it wouhl seem to show tliat th^^
mortality fiom abortion is hardly second to that fiom puerperal a
fever itself. fl
"Death, as a consequenceof criminal abortion, is especially fre^^
quent M. Tardieu found that in one hundred fuid sixteen sue]
cases of which hewasable to ascertain the termination, sixty wom<
died. But even in sixjntaneous citses death may take place fronT
hemorrhage, from septicjeniia, or from iH»rit*mitis. In many
caaes the fatal termination is fairly attributable to the ignorance,
the imprudence^ or the willfnlneKs of the patient How far the
dangers of abortion may be neutralize<l by proper medical as-
sistance is best shown by the statistics of large hospitals. Thus,
I gather from the repoi-ts issued by Dr. Johnston, during his
seven ytnrs mastership of the Rtttimda Hospital, in Dublin, that
in two hundred and thirty-four cases of abortion treated in that
institution, tiiere was but one death, ami that not from p\ieq>e-
rnl trouble, but fri»m mitral disease of the heart Bellevue H^>s-
pital is the receptjicle 'annually of n t-olerably large number of
women Huffering from incomplete ab<»rtionf*. many of whom enl
the hospitjd in a very un()r(>mising con<lition from either exci
Bive hemorrhage or septic decomposition of the retained jx>r-
tions of tiie ovum. Yet, of the many cases whose histories I
find in the record books of the hospital, all have ended in r6-_
covery."— LusK.
Treatment. — The treatment of abortion is: 1. Preventive
2. Promotive, and 3. Remedial. '
Preventive Treatment.— This involves (a) general and spec-
ial prophylaxis, and (b) the arre-st of threatened ftlK>rtion.
The pregnant woman, and es|x^cially she who has jilreatiy suf- i
fered one miscarriage, or more, should attend most 6crupuloasl]d|
to the observance of general sanitary rules. Over-intlulgence^
and over-exertion are particularly to be avoided. No amount of
exercise should l>e laid out for pregnant women indiscrimi-
nately, for what may justly l^ regarded as moderate exercise f<
one, will far excee<l the endurance of another.
Women wht^ have had repentotl al^ortions, ot or near a certain
period in pregnancy, must be guarded with the greatest
it«ad
r-
I
M
6^
TREATHENT,
195
fl 18 sometimes mivisnble to put them in close qnornntino, and
(.Teu in bed, for a time, though no threatening symptoms have
aritieiL When the period at which an interruption of pregnancy
gt'Lfmlly oorours in an individual case has passed, the woman's
restniinte may be gradually lessened, until they laave reached a
uiinimunL 80 strong a propensity is sometimes generated by
Tecarrent abortion, that the unexpected arrival of a friend, a
Tiwi ti:» the table, or even a strong rwlor, may be sufficient Uy
tiring on the accidentv
The treatment of certain constitutional dyscrasije, as well as
(•hronic and acute disease in general, of which the woman may
Iw the subject, is also included in prophylaxis, but methods of
tipatment and the selection of remedies are niotiified so little by
Jbfi patient's pregnancy as not to demnnd special considerati(»n
The same may be said also of accidents, from which preg-
ien are not exempt
inoe strong emotions, which in a non-pregnant state could
no harm, are capable of producing, during gestation, n»ost
wnuus consequences, they ought t<^ receive attention. After
viiili'nt anger, colocytifh and chamomtlfa are of considerable Bi*r-
'ire. When auger or vexation is associatetl with fright, aronife
nw>)' be employed. It is also of service when, after fright, a state
"^ apprtilicnsion and dread remains. Opitnit also has the repn-
Wjottof effecting favorable results after fright To avert the
"^1 efi^ctfi of grief we can probably do no better than to atbnin-
^Vr ujnatui or phtMphoric iicid.
After a bruis<^ a few doses of arnica ought not to l)e rmiitted.
A strain generally excites utenne action by rupture to a cer-
^iii«*ttput of the utero-placent^d relations; still gotnl may occa-
iKmally be done by the timely administration of rhnft foJ-iciKlru-
After marked symptoms of threatened abortion have appeared,
'*»»^ fiiHt point to be decided is whether the abortion ought to be,
^ «wi Ik', prevente<l In general, the physician shouhl tirmly
"^^ couHcientioutily be in no way accessory to alx»rtion, and only
^ben be ia convinceil that the fcetus is dead, or that discharge is
'"•^blft, ahould he assume the re8|><>n8ibility of promoting the
'*'* ilrfindy begun, or passively permit the consummation of
^ ITaift principle of action, closely followed, gives considerable
196
ABORTION
scope for the employment of preventive measoree, when once tlie
expulsive forces of the uterus liave been aroused
Little time should be lost in getting tlie woman into a bed,
which has cool, pleasant, and quiet surroundings. Her clothing
must be removeil, and Ujose gaixueuts Bubbtituted, at the earliest
practicable moment. If the hemorrhage is profiise, the hips
may he raised by something laid directly under them, or, better
still, by the foot of the bed set upon blocka hi a certain per-
centage of cases, perfect repose of body and mind, is
all that is required; but when uterine action has been fairly
excited, wlien the hemorrhage is profuse, or has existed for some
time, further means of prevention will be required. The simili-
mum of the case should be sought, and, if found, it may quiet
the pains and arrest iUi' Hdw in a magical way.
There are a few remedies which are of frequent service at such
A time, but whenever any remedy is called for by dear indica-
tions, whether its special sphere of action is the generative, or
not, it should be administered.
Sabhia is a jnoniinent remed,v, osiweially in threatened al>or-
tions lihtyni the third mouth of pregnancy. The hemorrhage is
rather profuse, of a bright red color, and is accompimied with
clota Its action is more prompt and efficient in nervous hyster-
ical women, but need not be limited to such. In the absence of
clear indications for some other remedy, we do well to employ
thia
St'caJe cornnium is best suited to thin cachectic women. The
blood is dark and unooagulated. PuUaiillu should be adminis-
teretl in those cases wliere the flow ceases for a time, and then
returns with greater vigor. It is best mlapted to mild, tearful
women. Cauhjthtjllum is the remedy when the pains are spius-
ruodic and prossive, worse in the back and loins, vnih evidence
of feeble uterine contractions. Slight flow; vascular excitement;
tremulous weakness.
Gratifying results are sometimes obtained from the above rem*
edies. To them we may add iteoniie, with its great fear of death«
and of stir, or bustle; nux moschata, with its hysterical sjTup-
toms and syncope; and belladonna, with its bearing-down sensa-
tion, and bright red blood, which feels hot to the parts over
which it flows.
In old-school practice, opium constitutes the gnsat reliance for
TfiEATMENT.
197
pTev**ntion of abortion in tliese instances where threatening
eyuiptooib Lave firiHeii, und there in uo Bort of doubt that it
proves efficacious in many coses which would otlierwise culmi-
imtt* in. expulsion. This fact should not l>e ignored, and, wlien
other remedies do not produce prompt results, we need not hesi-
tftte to arail ourselves of the benefits derivable from a discrimina-
tive nse of the <li'ug. The most etHcaeioos mode anil form of
administration is the liypodermic injection of morphiiu One-
eighth to one-fourth grain will generally be an adequate dose.
B^nu with the minimum quantity, and repeat it, if necessary.
In i^very case of threats tied aU>i*tion occurring during the first
three mouths of pregnancy, a careful examination ought to be
i:j ' -rtain the situation and ix)sition of the uterus. In
"•' ui^s the symptoms depend upon retroflexion audretro-
wsion, and they often quickly disappear when, upon placing
tlie VDOi/m in the knee-chest position, aiid carefully using the
finfere, or the t^lt»vat4>r. the organ is returned to its normal posi-
tbn.
It is evident that preventive treatment is not suitable to all
Wiw. The consummation of the process is sc^metimes clearly
a«^tahle from its very iucipiency. For a considerable time
^fl»W(» niuy have existetl evidence of the subfsidence of the normal
'lopmental activities, resulting, lioubtless, from fietjd death.
Tk' iwuol symptoms of pregnancy have become less pronounced;
"J^rf- U n sense of weight and bearing in the pelvis, associated
^lUi a feeling of a^ldness in the abdomen, and .sometimes a viti-
"W Tugiual ilischarga The woman is ill in Inxly, and distressed
^ mind In such a case interruption of pregnancy should never
I* l>riTeuted. On the contrary, cases which at tiret appear to
l« preventable, may, by a [jersist«nce and an aggravation of
*!Ti>Iitom*. ultimutely pass the bounds, and become unqualifiedly
wi*vi,i,lnl)hi.
Tlie ii^n of inevitable abortion are profuse hemorrhage, dis-
^■'S'' of clot« from the uUtuh, dilatiition of the os externum,
'■^^ut uf the ovum, and ruptuie of the membranes. While we
■ iiJDirnr in the opinion expressed by scjme authors that
I H' of the membranes is not proof jxwitive that abortion is
ii^' vitahlo, we would caution against Uxt hasty a presumption of
Its inevitability. Scanzoni* has reported a remarkable case in
•" Ulilncb der <;obMrt^h6Ife," Wien, 1^67, p. 83.
198 ABORTION.
which a woman was seized with profuse hemorrhage from the
uterus in the third month of gestation; numerous clots were dis-
charged, and all hopes of preventing the threatened occurrence
were dissipated; ergot was given in full doses, the vagina was
packed for many hours, and a sound was passed into the uterine
cavity. After the hemorrhage had continued actively and pas-
sively for three weeks, a weak solution of jwrcliloride of iron was
injected; but, despite all interference, tlie pregnancy continued,
and quickening was experienced six weeks later.
Promotive Treatment.— AVhen the case has advanced l^eyond
the limit where preventive treatment is availiible, the existing
conditions do not always favor the immediate adoption of efforts
at uterine evacuation. The os uteri, or, indeed, tlie entire cer-
vical canal may })e so small tliat it will not admit a single finger,
while the nterus is jxmriiigout bUKxl in ulanning quantities. In
such an emergency sometliing must he done at t»nce to protect
the woman from tlie serious consequences of exci>ssive deple-
tion, while the cervix is given additional time for expansion. In
some cases dilatation may l)e si)eedi!y effected with the finger, if
the uterus is kept within reach by firm pressure uixm its fundus.
If the ovum, in early nl>ortion, is found intact within the os
uteri, no interference whatever should be practiced unless the
How iissunies seritms phuses, for fear of rui)turingit. and thereby
coiuplicutinj^' the delivery.
The Tani|mn.- Articles *»f various kinds have been recom-
mended for vaginal tampons, but it matters less whnt is used
than how it is used. A poorly np|)lied tampon is worse than
none. If strips of silk, Iin»'n or muslin are emi)Ioyed, th«*y
sliould be smeared with cosnioline or bird, and pusheil, one nt a
time, into tlie vagina, until the latter has been well pMcked.
Charpie, or raw cotton, when propt^rly used, makes a most eJli-
cient tani|)on. Tlu* chief t-sscntial in any case, is to thoroughly
distend the ui>])er i)ortion of the va*^ina, and tightly pack the
space about tin* cenix. but to-tlo this requires the greatest care.
A number of pieces of size sui1al)l(' fi»r introduction may be j)re-
j>ared by l>eing dipped int^) a disinfecting soluti(m, and the fluid
then expressed. About eaoh of tlu^se a string should l>e tied,
by means of which extractittn can 1m^ effected without pain. One
t>f these at a time can be dei)osited, at first near the cervix, until
TUEATMENT.
199
ihe vagina is well filled. The early pnrt of this operation can
In^st be (lone tliroui^h a Kpeculum. A roller bandage makes a
gotxi tampon, and admits of easy removal. The same is true of
ip-wieking, recommeudeU by Dr. F. P. Foster.*
In the introduction of a tampon much difficulty ^^-ill be ex-
perienced, and great suffering iuHicted, uule^is the precaution is
observed to separate the labia and retract the perineiim with the
fingers of one hand, or by means of a speculum, while the arti-
cle employed is being piissed by the fingers of the other hand.
This subject is considered at p'eater length in another chapter,
^l which the rea<ier is referred.
Before introducing a tampon, the vagina should }>e thoroughly
wftsbed with a disinfecting solution. No tamixm ought t«> l)e
(illuwiHl to remain in situ for more tlian twelve cimsecutive hours.
It can be renewed at the end of that time if necessai*>'. The
lirn'ftntion should be observed to cleanse the vagina with nn
ftntLicptic solution after removal of the taru])on. The ovnm
i'ft»*ji passes into the vagina, when the tampon is t^iken away.
If it does not, dilatation may be sufficiently advanced to enable
Ui« operator to easily remove the fcetus and envelopes in nn un-
broken state
Arsood as dilatation has advanced far enough to admit of
int*^rfereuce with a reasonable prospect of immediate success, it
1 he. undertaken. In default of this condition, another
-^iixid plug, if rtHjuired, may be introduced for twelve hours,
hoi tlie use of this exi>edient for a period much in excess of
hreuty-fnar hours, is not to be recommended. The vagina be-
mtn^A irritjiteii, more or leas blood decomposition ensues, and
t matters are generated.
Th« ovum ibrtTitfi.
Imt^ad of resorting to it at all, some prefer to use sponge
t» cu In case the tampon has been employetl for the above
■ ^ V M(^l. Jonr." .Tniin, iHflO.
200
ABOKTION.
limited period, and the conditions whicli originally called for
have not disappeared, resort may be liad to the Bjxjnge tent
This cannot be safely left so long as the vaginal tanapon, and if
its position is maintained, its usefulness will in a measure l>e
lost iji tbe space of a few hours, lis removal should be followed.
by the vaginal douche*
recom^j
canJO^H
retjiin^l
Emptying the Uterus.— The secmidines, as well as the ovu
require removal, and this is not always accomplished witli tfi
utmost facility. The ovum t>r [ilacenta force[>s have l)een recom^
mended, and can sometimes be successfully used, but
be regarded as safe except in those cases where the j>art retjiia
ed protnides from the os uteri. As will be seen in a 8uccee<ling
paragraph, the fingers aflord the safest and best means of ex-
traction.
In miscarriage the foetus is extremely apt to present by the
feet, and the utmost care and discretion must be exercised to
avoid severing its head and trunk. This is m)t an uncommon
accident, though by no means an iusiguihcant one, as a retained
bead is not always easily extracted. In removing tbe foetus, as
likewise in getting away the jjlaceuta. tbe of)erat^ir ought to
work nlxmt the mass, loosening first one side and tlien theotheT^
so that it ma^' not be torn.
In those rare cases wherein the membranes aro cxpollpd
the fcetua retained, the latter should be extracted without un-
necessary delay. A foetus left l»ehind would give rise t-o the
same dangers as a retainetl placenta, viz.: hemorrhage, and sejv
tic ]>oisoning, and the rules of practice regariling unexpelled
Becundines, would (ipply with equal force to unexpelled fcetus.
In the latter case llie operation would be attended with fe
diiliculties than in the former.
It may occasionally happen that the symptoms of aborti
oulminaie in the expulsion of cmo fa'tua and its membran
while yet another child, with intact membranes, remains'
utero. In such cases the physician slioukl assume the expectant
attitude, and patiently await developments. If there are no
disoeniible signs of fcetal death* and no further abortive eflforts,
there surely is no excuse for interference. But should symp-
toms of miscarriage continue, or again become manifest, or
should fa'tal death or disruption of the membranes be tliacov-
■^1
an™
WHEN AND HOW TO UKMOVE THE SECCNDLHES-
201
a&i, dela)" ought to be brief, for the woxoan's interests are best
BubbtTTed by sj^eedy delivery.
In tvin pregnancy, the membranes of the first child may be
broken before foetal expulsion, and remain behind. In such a
case we shoiJd discreetly await tlie natural efforts, iiululj^ng tJie
hope that the placenta will be extruded without serious tUsturb-
imceof the uterine relations of the second child. Nature failing
to accomplish this, and no untoward syiupt4.»m8 arising, the case
mPBDwhile being keptimder strict Bur\-eillance may be permitted
to go undisturbed for a day or two^ but longer delay would l»e
mivise. It is e>-ident that the existence of twin j>regiiancy is L
tvcly recognized until interference has gone so far as to insuroj
complete evacuation of the uterus.
When once the embryo or foetus is expelled* the case htis not
(J»ny« reached its climax of difficulty and danger. Indeed, in
ninny instances seri*Mis difficulty is now first met Expulsion of
tijeovum, entire, is not an infrequent occurrence in early abor-
U*m. In other cases the embryo is first extruded, to be followed
^H-.iit much delay by the secundines. In later pregnancy this
'•m times occurs, but in the main, tlie phenomena differ in srtmo
important r«*8i>ect8. The abortive process goes on in a regular
*'»y until foetal expulsitm hns been accomplished, when the ute-
rine efforts cease, and the placenta is retained for an indefinite
!>ww»L Nor is such retention generally for a few momenta only,
** in labor at full term, but it is prolonged and j)ersistent
Wlmt gives to such a condition a serious aspect is, that there
gMwontuf it certain dangers, viz: hemorrhage and septiciemia,
-WterlttlH>r at full term, tlie placenta, on accoiuit of certain de-
giMii'ralive changes, is m(jre easily separable, and may l>e either
•Jlirftswd or extracted. When retained after alwittion, the ute-
'Ti'*i»tfiosnuiIl U) admit of successful expulsion of the placenta
".^ |TP9Bure, the umbilical cord is too frail t<j l)ear traction, and
w*^ vulva, cervix, and uterine cavity, are not sufficiently erpjinded
^'»ilmlt the haml. These are the ctiuditions which render re-
*^tttjim(.f the placenta after abortion a mutter of so great mo-
'^t t.) |>(iih physician and patient.
^h»'n am! How to Remove the Sccundines. — When tJie pla-
ottiU in rt*tttined it somotinu^s becomes a point of great nicety
w 'ipadh when Uj operate for its removal, and unless one has
202
ABOBTION.
tfafl
adoptetl for his guidance rules of practice hy which to regular
Fig. 9\ Fio. 9fi. his conduct, he will be likely to stumble and
^^k vaoillnto in a very embarrassing manner. The
W^m profession are not in perfect accord with regard
1^ to the troatuient of these cases, ami the con-
' Beiisu^ of opinion is not easily colIeeteiL Mioiy
advise against early interference, preferring to
wait hours, or even days, for natural expulsion.
Others insist upon the advisability of immediate
attempts to remove the retaLue<l seeundines, ev<
though the operation prove to be diMcult.
The t>]aceutji pniper is not formed until
third month of pregnancy, but the proper em-
bryonic envelnpos of an earlier date constitute
a mass several times larger than the embryo it-
self, and recpiire treatment varying but little
from that given the placenta proper. We finiL
however, that the uterine cavity and cervical
canal are so small at an early period in preg-
nancy, that the finger is not always avtiilable,
in which case interference should not be pushe^H
Ut extremes, unless !iomt)rrhaKe becomes tronble^^
some, or there is intimation of septic intlu-
euces; and then, the finger failing, the curettfS
may be employe^!, but with the utm<^>3t careT™
The mass left in utero l)eing small, will not of-
ten create sei'ious disturbance, but will harm-
lessly disiiiti^grate and escape in the dischar{
In nborti<»ns of the third and fourth montl
the treatment shouKi he slightly at variance
with this. The placenta is n(»w formed, and
must be removed; but when? and how? Im-
mediately after expulsion or extraction of tl
foitus the cervical canal ought to l>e examin<
and if expansion is great enough to admit tl
Qjiger, the placenta should at once be removed.
There is no excuse for delay. With one hand
on the hyi)ogastrium the uterus can be pushed
down into the pelvic cavity, and its contents
Riu?sTum!uterinc thus brought within reach, when, by gentle
curt'ttes.
-gea^
ithiH
ncT^
ind
[m- I
i
WHEN AND .HOW TO BEMOVE THE SECUNDlNEa
203
msDipnlatinn, the entire mass can generally be removed If
the cervioul canal will (ulmit the finger, nearly, or quite, to the
internal os, gentle endeavor will soon overcome resistanca If
neither dilatation nor moderate dilatability exist, the operation
fibfuld be delayeil for a time; but the placenta ought not U) be
permitted to remain longer than twenty-four hours.
The chief exceptions to the foregoing ruJes arise in oonnec-
tioawith those cases wherein the woman haa either been greatly
rwiaced by hemorrhage, which has temporarily ceased, or is in
a state of extreme nervous erethism. Both those conditions
tuuld contra-indicate interference. In the former case the
patient must be kept under strict observation, while time is given
tbe nutural energies to recuperate. China may meanwhile be
Hdmiiiistered- Should hemorrhage set in, the placenta should
atitQoe be removed. In the latter case, effoi'ts ought to be made
tonicHlify tlie nervous excitability, before resorting to interfej-
*^*«. The most effective remedies are aetata rttcrmosa, i(jnaii<i,
htjitsrynmus, asarutn^ camphor (2\}^ coff*^'(h sfra7Hon{um,kalt
''TOW., or even rhlm^al htfdrafe. Delay in excess of twenty-four
honre ought not, as u ruU^ to be i>ermitteiL Bring the [>atient
carefully under the influence of an anaesthetic, and proceotl with
the necessary operative measures. In truth, it often liapi>en3
tiwt when the placenta is retained, the woman, espwially if of a
fiervous organization, is thrown into a coutlition of extreme ner-
eis excitability, which cannot be wholly relieved while the
I^ota remains,
Tmction on the cord should not be made in such cases, be-
<«U9e it will not be of the least service, and will almost certainly
^wult in tearing the cord away, thereby removmg what is fre-
Mtt'ully a valuable guide to the finger in further attempts to re-
i^vt» 111*, placenta.
In ftlhirtions at the fifth month, operative procedures should
ii"t be delayed longer than ten or twelve hours. In abortions
^ tb#^ Bixth month, we need not wait longer than two or three
houm
Hxiralsion of tho placenta may sometimes be brought about
by •wimioifttration of pnlsadUa, china or sabiiia.
'ii Miy oust* when the os utori is t<.>o small to at once admit
thefiiifpor, gentle, yet persistent endeavor, will usually be offoct-
^■^ If, owing to spasm of the circular fibres of the os uteri) or
201
ABORTION.
th
1
extreme BensitivenesB of the woman, extraction of the pin-
cannot be effected, an anaesthetic shonkl be admiui&iter
Otiier means will rarely be reqiured- In abortions at the fifth
and sixth months, the uterus is so large that three or four fin-
gers may have to be introduced to bring the operation to a su
cessful conclusion.
Wben the placenta has been removed in fragments, or when,'
in the absence of positive knowledge of what has been extrudedj
the finger is introduced for exploratory purjKJseH, the oonvoiu
endometrium may easily lead one to snpjwse that somethin
still remaius. It is tmly by most painstaking examination that
the truth can be elicited.
The placenta is sometimes so closely adherent to the uter
that removal of the entire mass, even in fragments, is imj)o5
bie, and there remains the danger of hemorrhage and septica?
If profuse hemorrhage should at any time iiccur, water at a?
temperature of say llO'^ or 115° Fahrenheit, injected ilirectly
into the uterine cavity by means of a sjTinge throwing a gen
stream, free from nir, is a most excellent means of overcomin
it There is little »)r no <langer connected witli tJiis use of hot
water, p^n^-ided the os is large enough to permit free escape
the fluid injecteil.
Piu.97.
n^
Similar injections ha'
beeu employed with excell
results for hemorrhage co:
sequent on total retention of
the secundines, substituting
the tedious and painful use
the finger, or instruments,
a goodly proportion of
the uterus is stimulated
immediate ct^ntraction, result-
ing in placental expulsion and
arrest of the hemorrhage.
When by the means dea-
cribed we are unable to
press the uterus far enoa
Vfrtioftl section of pelvis, sliowing ulerus to mlmit of dimtal extraction
drawn <Iowti with the volsclla. - ,, , .
or the placenta, we may cause
the organ to descend by means of the volseUa. Abortions
uting I
Liseo^J
caa^^l
?d ^
lea- ii
A
WHEN AND HOW TO REMOVE THE 8E0CNDINEB.
205
P
m much more frequent in raultigravid, than in primigrnvid,
wxunen^ and it is chiefly in tlie latter cIush, and in those whose
alxlominai walls present an unusual thickness of adipose
tissue, that the fingers, aidetl by abdominal pressure, will fail.
But Lu these exceptional cases we may seize* the cervix with tJie
volBells, one with a slight cune being prefered. One blade
sboold be passed within the os lor about half an inch, and the
other rest upon the outer as].>ect of tlie cervix at a corresponding
IweL With a hold thus obtained, the uterus may be drawn
dijwn without injury to either it or its ligaments, and held by
one hand, while the fingers of the other are passed into the cav-
% nf the organ, to explore and evacuate it.
Prece^ienoe and preference are by some given the placenta for-
t"*"!*, and the small blunt hook, as a means of extracting the j^la-
*'fnta;but the vast majority of operators prefer the fingers. Still
'If '*• are cases in which, from oui* inability to bring the uterine
^;iuiy within reach, or from tlie brevity of tlie physician's fingers,
ill* lUbtrumentB mentioned are capable of rendering efficient aid.
S<ivvration of adlierent portions of placenta sliould Jievrr be
witnisted to instrumental means, unless the sense-guided
^.'*•^s utterly faiJ. The placenta forceps are constructed with
Flii
Loomis' PiawDta Forceps.
FlO. 99.
iT
Schnetter^K Ploceutu Forceps.
*^ shanks and sometimes spoon-like blades, the inner surface
"I the latter l>eing roughened, bo as to afford a firm hold, other
J*tV>n« are like those in figures 98 and 99. In order to pass
^ »Dittnunent, the fingers of one hand should be laid in the
206
ABORTION.
vagina, with their points at the os uteri, and along their palmar
surface the instrument should be directed into the uterus. Wit^^_
the haudles well back against the perineum, the blades are sepa^H
rntc<i antl nu offort made to inclose the placenta. This is an
operation wliicii reiiuires soiue skill, and, like manyuther obstet-
ric procedures, is more. easily described than performed* Ex-
treme care shoidd be exercised to avoid traumatism. When the
plac<>nta is taken hold of, forcible traction ougiit not to be roadt
as its fragile structures are easily broken. By gentle rotation
the instrument^ first one way imd then the other, assfK'inted wH
moderate traction, the retained part may often be deliver
entir& ,
Fio. 100. Small blunt hooks for similar use have be<
couKtructed, and are more practical instruments
than the placenta forceps. Such an aid may beim-
proviaed as follows: Take a piece of pretty stiff
inm or copt>er wire, and bend it in the middle until
the two ends iu*a brt^ught together. The loope^H
extremity thus formed should be turned over abou^^
half an inch, in the sliape of a fenestrated hook.
This may \ye introducetl similarly to the plac^enl
forcei>s, and delivery performed by a eeriea
traction efforts upon different parts of the retain<
mass. An instrument consisting of a small hook
and lever, like that shown in figure 100, is sonn
times serviceable in these cases.
lu nearly all instances bleeding ceases as soon
the uterus is fully evacuated, and when it persist
esi)ecially if it comes in little gushes, at interval
we may be pretty sure that a fragment of the ovum,
or a hard coaguliim, remains behind. The finger
should be again passed, if the cervix will admit it.
and every part of the uterine wall examined. If
anything is found it must be removed- Should
bleeding still continiie, as it will rarely do, the cavity
may be gently scraped with the curette.
When this is faithfully done, hemorrhage is al-
most certain to cease; but, owing to constitutional
Small hook Peculiarities, such treatment may now and then be
and lever. inadequate, and special medication be requin
I
K£OL£CTED CASES.
207
In the absence of well-flefineil indications for some other
retoeily, r/ii'w/ is to be givi:*n Fulsaitllaj secatcj cauloph^jUnni^
»ud phosphorus are often of service. The favorable outcome
of miscarriage, as of labor at full term, deponda almost wholly
on a proper manual and instrumental conduct of the case, and
does not often require extensive therapeutical measures. To
ilepend upon the latter in the emergencies which abortion pre-
seDtfl, U> the neglect of other and better means, is, like a similar
proceeding in post-partum hemorrhage, the very height of folly.
Anti-Septic Precautions. — The varioxis measures which have
Wi»ii recommended for the conduct of abi>rtion in different stages
"( the process, should always be employed un<ier antiseptic pre-
wntjons. Neither the fingers, nor any instrument, ought to be
intriHlaced into the uterus, or even int<^ tlie vagina, without
fiftt l>eing thc^roughly cleaned and disinfected To do otlier-
^ise is to subject the woman to increased dangers, and do all
concerned a grievous wrong.
N^'clected Cases. — The most threatening emergencies which
tli^ I%si('ian is called to meet, sometimes grow out of the neg-
Iwt of Women to avail themselves, in season, of professional care.
It is assumed that tlie abortive act has h>een consummated, until,
«it>>r the lapse of days or weeks, serious symptoms ai*e mani-
'•st^NL A passive flow has existed for some time, when suddenly
tiielilood gnsiios forth so profusely that the womnn's life force3
^^ s[H^dUy brought low, A physician is hastily called, and lie
fe»fe his {>atient exsangubie and syncopal The flow hi\s temi>o-
fxrily Willed, Reflecting u|X)n her low state, and realizuig that
^"•littt few droj>s are tliose which kill, his good sense tflls him
"*t the present is no time for interference. The voice of a wise
2>o!iitor whisj>ers: "T(* disturb those clots may be to kill," and
w wisely heeds it He revives Ids patient by judicious stimu-
'^^tm.antl the aibuinistration of china^ while a constant watch is
"pt tt» prevent an unobserved renewal of the flow. Should it
°*^i lit* will remove the secuudinea without delay; but in ita
'**na, lime for recuperation of the vital forces is given, and
"*^ the case ia terminated without danger.
^ 'Ujotber instance the placenta, through neglect, is BuflTereil
wrwttain b utero. After a time certain ill-feelings are experl
*'^- there is a chill, the pulae iB accelerated, the temperature
208
rATHULOGY OF THE DECIDUA AND OVUM.
rises; then f<^llow headache, backache, fetid discharges, proB-
tratiou, aud all tlie HiguH of what has l^en calleil iritative fever.
A physician is called in to explain the slow "getting up," and
recognizes the alarming condition of his patient He does not
hesitate nor delay: — the uterus is at once emptied and washed
out with a disinfecting solution. This treatment is generally
followed by marked and immediate improvement; but sometimes
the poisonous matters have been absorbetl in so great quantities,
and suitable treatment has been so long delayed, that the patient
cannot be rallied.
CHAPTER TX.
Pathology of the Deeidiiu and Ovum.
[la-
The physiological changes which take place in the u
mucous membrane as the re-sult of impregnation, sometimes pass
the usual bounds and become pathological It appears prolm-
ble that abortion not ijifrequently owes its origin to such a
cause.
Endometritis.— This may be either acute or cJironic. 1
latter variety of the affection is divided into three distinct forms^
viz: 1. Endometritis decidua chronica diffusa, 2. Eudom4'tri-
tis decidua tuberosa et polypoea, and 3. Endometritis decidua
catarrlmlis. ^H
The causes of the first form probably depend, in a great mea^V
tire, on endometritis which antedates conception. Syphilitic
uifection, excessive phyBical exertion, and foetal death, with
retention, are also Hf^t down as eti(>l<»gical factors. The anatom-
ical changes which take place consist in thickening and harden-
ing of the deciduu, reKultiiij^ from tUffuse development of new
connective tissue, and proliferation of decidual cells. The
decidua vera and decidua reHexa may bo separately or jointly
involved in the processes, and eliang^d in whole or in pnrt
According to Duncan,* the hypertrophied decidua always pr
DrxcAN, " RrfWHirehe'* in OhstHries," p 2(13.
EITDOMETHITIS DECIBUA.
209
cmtBOvidence of fatty degeneration, uue(|imll)' advanced in dif-
erent ports. When the changes are wrought in the latter part
of idTgnancy, they pursue a notably chronic course, are limited
b extent) or do not involve the placental decidua, and pregnancy
Fio lt)l
Hypertropbied Decidua laid open: ovuiu at the fuDdus.
''wjj not invariably suffer interruption. Premature expulsion is
woKvl in iheHG caaea by death of the ovum from imperfect
nutrition, or by the exciting of reflex uterine action. The ovum,
""'•r ilenth, generally retains ite connection with the decidua for
B miigth of time, and iiimlly the diseased decidua and attached
'*^^^ are expelled. The decidua is a tliick triangular fleshy
'"'**», and hna attached to B«>nie part of its inner hurfnce, tlie
''"litiUid ovum. Expulsi<»n is apt to be a slow process, owing to
"i*- uilLeeious which liave formed between the decidua and the
*^'i*r uterine tissues. If these include the placental decidua,
®^b tUfliculty will be experienced in natural separation of the
210
PATHOLOGY OF THE DECIDUA.
organ, and the case is liable to be complicated by profuse fiem«
orrhage.
The causes of the seoond variety of clironic endometritis are
obscure. Virchow regarded syphilis as one of them. Gusserow
says that when oonc€'[)tu)U clos<?ly succeeds delivery, the recently
formed vascular uterine mucous membrane may take on abnor-
mal proliferative processes. This viiriety of endometritis, and
the pathological changes wliich result, are limited, with rare ex-
ceptions, to the decidua vera, and prefer for their location tlae
anterior and posterior walls of the cavity. **The uterine surface
of the decidua is rough, and c*-»vered with ct>agulated 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 prev
ing shape of which is polyjxiid* They may, however, appear
tlie form of nodules, of cones, or of bt)88-like projections, pnv
vided with a broad, non-peduuculafcetl base. Their height is
from one-quarter to one-half inch, and their surface is smooth,
very vascular, and df^vi»id of uterine follicles. The latter, bow-
ever, are plainly visiblu on the muctms membrane intervt;ning
between the polypoid outgrowths, but they are compressed, and
their orifices constricted or obliterated by the pressure of whit-
ish, contracting bands of newly developed connective tissue.
Similar fibrous bauds surround the blood-vessels. On section*
the larger prominences sometimes appear permeated with coag-
ulated blood, and narrow, cord-like bands of hypertrophieil
decidual tissue occasionally foi-m bridge-like connections Im?-
tween neighboring polypL The uterine follicles are, in some
csases, fiiletl with blood dote. The epithelium is often absent
from the uterine surface of the decidua, except around the ori-
fices of the follicular glands, and the deeper decidual tissues
contain large numbers of lymphoid cells. The cells of the de-
cidua reflexa frequently undergo fatty degeueratioii. The pla-
cental villi may show hypertrophy of their club-shaped ends, or
be the seat of myxomatous growths, in which ?Aae their cells are
granular and cloudy. The foetus is generally dead and partially
disintegrated. This form of endometritis decidua is, conse-
quently, usually accompanied by abortion, which occurs pre^
dominantly at an early stage of pregnancy."— LusK.
The third form of chronic endometritis attacks plurip
lNIX>lC£TJEaTI& DECIDUA.
211
ler than primiparjB, nnd runn a cnnipnratively mild coiirsa
h hfts been termed htjdrorrhcca fjraviddrum, by which is
B6ftut a discharge of a clear watery Huid at iutervals during
pTPgnancy. Many theories have l>eeii formed rogartling its eti-
oltJgy. iSome have regarded the discharge as due to rupture of
d cybt between the ovum and uterine walla Baudelocque thought
it proceeded from transudation of the liquor aninii through the
membranes, while Burgesii and DuUiih beiioved it depeudH ou
rapture of the membranes at a point distant from the os uteri,
lei has referred it tt> the exiHteuce of a sac between the chorion
amnion. A single (lischarge doubtless occasionally proceeds
from the tvro last-mentioned causes, but re])eated loss must be
■ed to other stmrces. Hagar's theory, that it is the result of
ulaut secretion [rom the glands of the uterine mucous mem-
bmce* which accumulates between the decidua and chorion, and
(•capes through the ob uteri, is probably nearer the truth. The
W*l patholo<;ical changes which tfdce ]>hioe are vascularity, hy-
phemia, and hypertrophy of the interstitial connective tissue,
ami of the glandular elements of the, decidua.* The inflamma-
tinn tSTolves the decidua vera by preference, but may simulta-
uwosly nflfect the decidua reflexa-f The lluid which results is
thin, watery, mueo-purulent, or sero-sangninolent, resembling
the liquor amnii Ixjth in ctdor and odor. When no obstacle to
its free eacape is interposed, its discharge is continuous, but
»bFn it is cjulined, a considerable quantity may collect, until
finally the resistance is overcome, and thoro is a sudden and oo-
louTte discharge. It is often eij>elled at night while the patient
» sleep'mg, brought alnrnt, very likely, by uterine contraction.
bi*r)me ca.ses even a pountl, or more, of the fluid is thus lost
Hyll^)rrhtea gravidarum is observed at all j>eritKls of pregnancy,
k^l it is mtjfit frequent in the latter months. It often occurs ae
*wl) as llie third month.
Diiignusis involves differentiation between rupture of the
tt<?mbnuHVi, the escape of fluid sometimes confinetl between the
*ttmoD and chorion, and escape i»f fluid emanating from the hy-
r^rtroplac^l d^-cidual glands. The chief point of differentiation
'^twi'en hydrorrhcea and escape of fluid fn^m the space between
tbe unnioii and chorion, is that in the latter case there is but a
*SrnaKLBtBa; ^'OrburUhulfe,** p. 303.
♦ScitaKiisu; "Oelmrtfihulfff.'» p. 394.
2U
PATHOLOQY OF THS CHOBION.
single dischBTge, while m the former there ib dither continual
draining or repeated gubhes. It is nut always easy t<> distingni^h
between hydrorrhcea and escape of the liquor amniL lu the
former we find that pains are absent, the os uteri unopened, and
iHiUolicnieitl can lx» made out If tlie membranes are ruptured,
labor is quite cert*iin to ensue, though cases of long retention
after rupture have been recnnlfKl. A repetition of the discharge,
and continuance of pregnancy, will materially aid in clearing up
the diagnosis. Hydrorrhcea, though apt to cause alarm* pre-
sents no serious phases. The pregmincy is rarely interrupted,
and the woman feels rather relieved by the discharge. During
the existence of this form of endometritis the general health of
the woman should be as well maintained as {lot^sihle, by strict
observance of hygienic principles. Sexual intercourse, vaginal
douches, and all {possible sources of local irritation should be
avoided. The remedies among which we will l>e most likely to
find the siniilimum are arsp7iicum alburn^ 1<tcht*8iSj natrum luu-
riaiicnm, vwrcurinSy (xilcnrea curb, and sulphur. If uterine
contnictii)ns supenenf*, the utmost quiet must l>e insisted upon,
and ctiulophyUuni, puhatilla, or vihumum administered
Pathology of the rhorion.— The only affection of the cho-
rinu that has yet been described is that form of degenerative
change which results in the development of M'hat is known as
vesicular or hydrdkiiform 7nok\ (cysUc disease of the chorioji,
hifduiifomi defjencraiian of ihe chorion.) Before the time of
Cruvelhier, the vesicles which characterize this morbid product
were supposed to be real hydatids. Since his researches, others
have confirmed the conclusions now held, and it is at present
regarded as established, that the essential j)at}iological process
involved in the production of the vesicular mole consists in a
proliferative degeneration of the chorionic villi There ia
hypertrophy of the investing epithtdinm, of their connective
tissue cells, and of their mucoid intercellular substance. As a
result there are formed a large numl)er of translucent vesicles,
containing a clear limpiil tluid, which closely resembles the
liquor amnii, but contains more mucin. The vesicles vary in
dimensions from those of a millet seed to th(.>se of a walnut, and
form masses of considerable siza Small collections are more
frequently met than tliose of large size. The larger cysts cim-
tain less mucin than the smaller. All the villi are not involved
BTDATIDIFOKM l^EGENEnATlU.^.
213
in Ihe process, and tlie normal tissue which intervenes between
the vesicle!?, gives to the mass an appearance which somewhat
roeemblea a bimch of grapes — the intervening normal tibsues
' .; their connecting stems. Close examination widens
ty, since the process of development is one of gem-
tuntion, not from single stems* bnt mainly from veBicles already
formetL When degen»^rative development begins in thefirstmouth
of pregnancy, as indeed it nBually d(>es, before atrophy of the
eboriouio \Tlli begins elsewhere than at tlie site of the forming
plac«*utn, the degeneration will involve its whole surface. Death
mill id)M>rption of the embryo may ensne, leaving the amniotic
cavity entirely free from solid matters. If the placenta has
ily lieen formed, degenerative changes will involve its struct-
only, and if suUicieully extensive to destroy the foetus, the
iMsmiiis of the latter are found in the amniotic cavity, which
stiinetimes contains an excess of liquor amnii. If only a few of
tl»e jjlacental cotyUulonH are implicated, the DfctoH may continue
existence and growtli, and reach a certain ilegree of perfec-
Fi»i. Mf2. Fig. UVS.
Ujdatidiform Mole.
Kydiitidifonn Mule (plao«nlal origin).
boo.' These changes generally take place within the decidua.
2U
PATHOLOGY OF TOE CHORION.
but that boundary is sometimes exceeded Yolkmann* reports
a ciUMi in which the degenerative process invailed the uterine
b]o<^)d-6inu&es, and, by pressure, led to so extensive an atrophy
and absorption of the uterine walls, as to leave only a thin sep-
tum between the mole and the peritoneal covering of the organ.
"The cavity formed by this process of erosion in the uterine
paroncliyina was larger than the uterine cavity proper, and pre-
sented intersecting trabecule resembling the columnse camese of
the cardiac ventricles." Such results, however, probably depend
on a morbid condition of the uterine walls, proceeding from mal-
nutrition. Similar casesj with fatal results, are reported by
Schroederf.
Sometimes the adhesion of the mass to the uterine walls is
very firm, and may interfere with its expulsion. The nutrition
of the altered ch«>rion is carried on through its connection with
the tlocidua, wliich also is often liiseasod and h)i>ertrophied-
Causes of Hydatid iform Degeneration.— The etiology of
this disease has evoked considerable discussion. Some have
supposed thatthe changes in tlie chorionic villi which character-
ize it, are also preceded by embryonic death. In support of tliis
view allusion has been made to the fact that, in nearly all ouses>
the embryo has been entirely absorbed, and (l1s*3 to the occjLsioual
occurrence of hydatidiform degeneration of the chorion of a dead
foetus in twin pregnancy, while that of the living one remains
healthy. That the exciting cause of tlie dogt^nerative changes is
oft«^n, if not usually, a morbid maternal condition, seems likely
from its repetition in the same woman, by its oo-esistence witli
endometritis, or with extensive uteruie fibroids, and by the exist-
euca in most pases, according to Un<Ii*rhill, of a cancerous or
6y]>hilitic <lyscrasia in the mother. K this be acceptetl, we must
conclude tliat the degenerative changes generally precede and
produce foetal death. The disclosure of the true pathology of
hydatidiform degeneration has disposed of the question, form-
erly mooted, of its occurrence independently of impregnation-^
The theory of vesicular moles prooeetling from a retained frag-
ment of placenta is now regarded as having been clinically
•VoLKMANN, " Virchow's Archiv.," Bd. xii, p. 528.
IMauden, "Obstetrical Jour." Vol. viii, p, 42.
BYDAXIDIFOUM DEOENERATION.
215
iM >iy the best clinical evidence, yet some very
)ng tebfeimony in its favor stands upon the records.*
Mtildpane are the subjects of yesicuiar moles much oftener
lii&D primiparai. TIuh appears to proceed from advanced age,
TBllier than from repeated pregnancies. The degenerative
ebinges generally bej^iu dnring the iirst month; while, according
Ui Underhill.t the latter part of the third month is the extreme
limit within which the disease can originate.
S}m|it<inis and Course. — Cystic disease of the ovum may
jttLst for a time without developing any sjTnptoms of sufficient
linence tf> draw atteutiou. Lnter it is observed that the
onlinarj' course of pregnancy has been changed in some impor-
tant regartis. Some of its most common symptoms may disap-
paiT, bnt such changes are by no means constant The most
promiitent sign of tlio existence of jierverted development con-
nstfl in a failure of corresi)onde«ce Itetween the uterine enlarge-
oeDl and the computed period of utero-gestation. Thus, at the
tliird month, the ut*>ruH may be found as high a« the umbilicus,
Of higher. On the other hand, if the cystic development began
"TnkiDK ^** view of the etiology of this disease, it is obvious that it is
V'Bfitlly connected with x>regnaxiey, luid that there is no yalid ground for
■uinUliiiiig, Bw has sometimt^ been done, thnt it may occur independently of
w««»lrtiiin. It is jQst possible, however, that trne entozoa may form in the
If* of ihe uterus, which being esjtelled jit-r vtujinom, mi|;ht 1k' t;ikeu
tht rr«ultA fit rystir diseusf. and thuK givti ris*' to ^roiinillt'Ks .^usjiieionB us
"^lif }n()t'iii'ft ohAstity. Hfwitt hua related one case iu which true hydatids,
«Bit*Ut formed iu the liver, hiwl extended to the peritoneum, and wtn- alKtut
**t»iw through ihe Ta^inn at the tinm of death. This occurred in :in nnmnr-
^ wnmaa. One or two other examples of true hj'dntidj* forming m the suli-
•»>» of the nluras are also recorde*!. A very interesting case is also related
"jlUwiti, iu which undnuhttHl acepfaalocysts were expelled from the utems
"'•HUlcnt who nUinintely reet»ven'd. A careful examination of the cyst and
UkfontoitK wtinldsthiiw their true nature. as the echin'XfKrui head**, with tbeir
•■WWeiiftlic booklets would 1m> discovernhle by the niicros4*ope.''
-j^ihic that unfounded saiHpicions uiipht ariw from the fact of a
f- ■■ lUK Lt muwi of hydatids lon^j after imprejo»a*if>n. In the ease of a
•lilu«,(,r womdn living apart from her husband, serious mistakes might thus
" **ile Tliiti h]is iM-en siM-cially pointed out by McClintoek, who snysi
^^ytUijdi ttiiy be retained in utero for many months or years, or a portion
^h oinif Im rxpelled, and the residue may throw out a fresh crop of vesicles to
'* 'iMiargrd on a future occasion.' "—/*/ffy/ai>, " Syrtan of Midwifery,'* Am,
flJUtetOoantle;* Jan., 187f), p. IG.
216
PATHOLOOr OF THE CHORION,
early, the organ may be decidedly sranller tluin at a corre8p)on<
ing i)priod in normiil gestation. There is more general disturb-
ance of the health than there ought to be, naasea^fl^_X0Bftiiil4L
being apt to become excessive. Lumbar and sacral pains are*
prominent and dibtres&lng in proportion to the rajiidity of tlie
abnormal growth. About the third month, sometimes earlier,
there begins a m<ire or less profuse watery and sanguineous tlis-
charge, generally at intervals, which resembles currant juice.
These losses doubtless depend on breaking of one or more of the
cysts, andescape of the contents, brought about by painless uter-
ine oontractions. Though not usually excessive in quantity,
they are sometimes so profuse and frequent as to reduce the
woman's vital forces to a low, and even dangerous, condition- In
the discharge are also found jwrtions of cysts, and sometimes
even masses of considerable size.
Physical exploration discloses important signs. The uterus,
as felt through the abdominal walls, sometimes presents irregu-
larities, but which do not closely resemlile fcetal outlines, and it j
imparts to the examining hand a peculiar boggy, or doughy feel,
and sometimes distinct Huctuation. On examination pi'r ra(jintt77t^
the lower uterine segment is found to present similar characters,
Balloilemeni yields negative results, and fcetal movements are
felt, though they may be simulated by uterine contractions,
sounds of the ftftal heart are diminished in intensity, or
quite imperceptible.
Expulsion of the degenerate mass usually takes place bet
the sixtli raontli, but it may Ije delayed beyond the usual jjer
of mature utero-gestation. As in the case of ordinary ab«jrtio:
the hemorrhage ceases after the uterus has been completely ev
uated, but retained i^>rtious of the tumor may give rise to p
trocted and profuse bleeding.
Diagnosis. — In those cases where the cystic degenerati<
implicates but a part of the ovum, diagnosis cannot always be
made with any certainty. The chief reliance as a l>asis
diagnosis, are the rapid increase of uterine deveh)pment,
th*' peculiarities of the discharge, in which whole vesicles are
at times found- Absence of the more important signs of norm
pregnancy should be given due weight.
Prognosis, — The character of the prognosis in c«ses of liy-
datidiform mole is governed largely by the frequency and violeni
ire ■
HTDATIDIFORM DEGENERATION.
217
o{ tho accompanying hemorrhages. It is reassuring in tLo ma-
jority of cases, as far as it regards the mother; but the life of
the fcftas is, of course, ahnost invariably sacrificed.
Treatment.— The treatment differs but little from that pre-
6cril>?J for ordinary abortion, and consists, in the main, of
mwtfnres calculated to control the hemorrhage, and prt>m()te
expuLsioD of the degenerate product of conception. Non-inter-
lerenc** is generally ailviseil until uterine action is cscit^Hl, unless
itening symptoms are meanwhile developed. When cou-
badiouH begin» the taminm should be useil, if calli^d for by
prnfuse hemorrhage, and uterine action sustained by appropri-
ite remedies. Under the exjmct^int plan of treatment there is
liderable danger to be apprehended fnim sudden and violent
kmorrhage; therefore, uidess arrangements tif the best soii;
am be made for prompt professional attention, tlie question of
iinuiftlinte interference merits thoughtful consideration. Dila-
tati(i!i may be begun with tents, and afterwards continued with
tlie linger, or with the dilators of Molesworth, Barnes or Tar-
iii«. The remaining sie\)s of the ()i>eration will be easy. With
tiifl fiflgers tlie mass is removed either whole, or in fragments,
suJ tlib raaiji difficulties of the case are soon overcome. Since
there is souietinies firm adhesion of the cystic mass to the uterus,
^^ry^^uergetic attempts nt conij>lete separation should be avoided.
After delivery has been affectetl, the uterus ought to be washed
'"itwitlia;? antiseptic solution. If severe hemorrliage should
^*^^^ hot water intra-uterino eneraata may 1m? used vnih l^enetit
t^Jtain remedies have been said to promote the expulsion of
^l*% though their real efficiency for such a purpose is open to
wiabt The most prominent of these are ftrrnimy hnli carh.^
V^UnilUn, mhina, silicea, sulphur, merenrius, and nafrum carh,
'^•"jQld one of these remedies, or any others, l>e indicate*! -by
""y p^)minpnt characteristics, it should be administered. For
iw lirtmorrhage which in these cases occasionally follows deliv-
'^S> thH Bamo indications should be obsen'ed as in a similar
<^iirr^ne(> after abortion, or even labor at full term.
^*MhoIoi;y of the Plm-enta.— The pathology of the placenta
'^RHuhjt^ot of the great*>st importance, and has in late years re-
*'^«*l c^msiderable attention from obstetricians.
^wm.— The form of the placenta varies considerably. Its
218
PATHOLOGY OF THE PLACENTA,
tii^j
usually round or oval shape is not always preserved, but
he crescentic, or horse-shoe shajKjd, or have an irregular
frjmi, and be spread over a considerable surface, in consequence
of an unusual nuwlwr of the churiuuic villi beiu'g concerned in i
formation. That snomaly of form which desei-ves special me
tiou» is the one in which a supplementary placenta exists. This
known as jAcicenta suceentariaia^ the accessory devolopmen
being due to the persistence of isolateii villous groups, whi
form VHsculnr connections with the decidua vera. They are o
consequence, inasmuch as they are liable to l>e left in utero» and
give rise to persistent j>ost-imrtum hemorrhage^ Hohl says they
always form at exactly the junction of the anteritir and posterior
uterine walls, and the poiidons of placenta on each side of
line become separated.
Size. — PIacent*e vary also in size, the dimensions of the or-
gan bearing a prett>' constant relation to tliat of the child. Hy-
})ertrophied phicentte occur chieHy in connection with hydram-
nios, and (sousist of n genuine parenc}iymat*:)us hyperplasia, the
foetus being dead and slirivelled. In st^me cases the organ is
remarkubl}' small, which C4^>nvlitiou is reft* mble to defective de-
velopment, to premature involutitm. or to hyjierplatiia of its con-
nective tissue, with subsequent contraction. It should be borne
in mind, however^ that the dimensions of the placenta are modi-
fied by the state of its vessels. When the latter are empty, th
organ may appear small, whicli when filled would l>e greatly in-
creased in size. Wlien true atrophy of the placenta exists, tlie
vitality of the foetus is Rure to be more or less impaired Whit-
taker* believes that atrophy of the organ depends either on
diseased stjite of tlie chorionic villi, or of the decidua in whi
they are implanted. The latter is 9up]>ose4l to be the more oo
mon cause, and it consiKtn in hyiJerplnnia of the connective t
sue of the decidua, which i>resses on the %'illi and vessels,
results in atrophy.
Situation,— The most frequent jiituation of the placenta is
or near tlie funilns uteri, close to the orifice of the Fallopian
tube, on one side of the uterus, or the other, but it is occasion-
ally implanted elsewhere, as, for example, r>ver the orifice of the
I tube, over the internal os, as in placenta prievia,
;^
Jour OIm. " Yi"*! iii, )p '?"J!t.
IttXiENERATIONS AND NEW FORMATIONS.
219
st various j-»oints in the abdominal cavity in connection with ex-
tra-nterine pregnancy.
Degenerations and New Formationfl,— The most common
(orm of degeneration is the faiUf, which may be circumscribed,
(ir (liflFused. It is normally present in a mature placenta, and ia
probably a change which facilitates the final separation of the
organ. When it occurs early in pre-gnancy it is often regarded
MA premature completion of the occurrence which always nor-
mally takes ]>lace at a later period. Its cause is doubtless ref-
erable to tissue changes which interfere with proper nutrition,
|iroceeihng, ]>erhaps, in the first instance, from the woman's
atate of health. Syphilis, doubtless, in some cases, has an in-
Fm. 104.
Ffttty Defccnemtion of the PlacentA.
m its production. Tlie placental tissueB often present
pio^ah masses of different sizes, which consist largely of mo-
i^ular fat, peuoti*ateil by a fine network of fibrous tissue ; but
^' ^e tatty degeneration has a predilection for the chorionic
^'"^ Th« latter, on careful examination, are found to bo al-
220
PATHOLOoy or the PLACENTA-
tered in thoir contour, and loaded with fine granular i
bules-
Other Morbid States of the placenta are: L Amorpho
calcareous (ieposiis, which are found on the uterine surface
the placenta, in the tle<Mdmi 8**rotina. The process sometira
extends to the fcetal p<jrtiou of the placenta. When the chnn
begins in the latter part, it in generally limitetl to it, and affec
the small bicKxl-vessels of the villi, attacking first their termin
ramifications, and grndufilly implicating the trunks. 2. Dep«.>s-
itsof pigment, usually Fittributal>Ip to alterations in the hsemoglo-
bine of extrarasatious, fouml within the blood-sinuses or Wilt c^h
normal placentie, are soniptimes excessiva 3. (Edematous in^l
filtration of the placental tissue is sometimes observed. Accord-
ing to Lange, it twcurs only iti connection with hydramnios.
Cysts are frequently found near the centre of its concave b
face, and vary from a few lines to several inches in ditunete
The amnion, covered with pavement epithelium, forms the cy
wall. A reddish, cloudy, thin iluid. makes up the conton
Ahlfeld* regards tLe cysts as liquified myxomat^^nis formations.
They may also develop from apoplectic foci. 5. Circmnscril)ed
tumors arc occasionally found on the fcetal side of the placenta,
beneath the amnion. S])iege]berg tells us that these are fibro-
matons or sarcomatous in character. Myxoma of the placenta,
consisting in hyi>erplasia of the villi, and myxoma fibn3sum pla-
cenla\ charaet^M'ized by the fibroid degeneration of the liasrment
membrane in isolated villi, are the chief remaining varieties of
placental neoplasms.
HyphilEs of the Placenta.— Placental syphilis, which only
exists, aco^rding to Frankel, in connection with cougeuital or
here<litiiry s\-])biliB, involves the maternal portion of the pla-
centa, when the mother is affected either before or soon after
conception, and pnMluces gummatous proliferation of the de-
cidua, characterized by the development of large-celled connect-
ive tissue, with occasional accumulations of y(^unger cells,
When the infection is conveyed by the father to the foetus
alone, or to both mother and fcetus, pathological changes occur
as the result of a chronic inflammatory process, embracing pro-
liferation of the cells and connective tissue in the tUH, with sub-
• " Arob. of GynAi*," vol xL, p. 397.
i^l
PLACENTITIS.
221
sequent obUteration of the vessels, often complicated by the
nurked proliferation and hardening of their epithelial covering.
"The affected villi become swollen, cloudyj and thickened,
while their epithelium undergoes proliferation and cloudy Rwell-
ing. The parench}-ma of the villi is. filled with lymph-cells, and
the vessels are either oompressed or obliterated. The bhuxl-
snoses are gradually encroaclied upon by the villi, the foetus
(.lies from lack of adequate nutrititni, and the villi undergo fatty
dogenerntion. Portions of tlie healthy placental tissue, which
often inten'eues between the diseased parts, may be the seat of
extravasations. "^Lvsk.
Placental Apoplexy and Inflammation.— Hemorrhage into
the placenta sometimes takes place from congestion of the utero-
placental vessels, proceeding from disturbances in the mother's
>^iiscular system.* The extravasation may l>e into the placental
IHvrenchema, into the serotina, or into the uterine sinxises. Ex-
travasation is due mainly to morbid changes in the decidual
TOssels, often as the result of placentitis. The blood o^agula
uadergo the ordinary' retrogressive metamorphoses. Occasion-
ally cystic, fatty, or calcareous degeneration takes place. The
ii«niatomata by pressure may interfere with proper nutiitiou of
ttefcEtns, and result in its death.
Placentitis has l>een alluded to by some authors as a common
^ttease, and various pathological cimngea have been attributed
wit, such as hepatizations, purulent deposits, and adhesions to
^fi Uterine structurea Its very existence is now disputed by
^^y, who contend that the morbid changes alluded to are due
fiimply to retrogresaive metamorphoses in coagula. " What has
'•et*n token for inflammation of the placenta," says Robin, **i8
*iotliiiig else than a condition of transformation of blood clots
*^ various periods. What has been reganled as pus is only
fiWin in the course of disorganization, and in those cases where
trdft pug has been found, the pus did not come from the placenta,
"Qt from an inilammation of the tissue of the uterine vessels,
^^ an accidental deposition in the tissue of the placenta,"
Jther writers affirm its existence, and assign to it etiological
^*'*tioiis with metritis and endometritis. According to their
^lew tbe inflammation originates in the serotina, or in the ad-
^fttitia ot the fcetal arteries, generally producing granulation
***2?oav . pict. de Mtfd. et dc Chirnrg. Prat." vol. xiviii, "Placenta." p. 63
222
PATHOLOGY OF THE AMNION.
iiicu
tissue, which, from contraction, prcnluces compression of tne
placental vessels, which, in turn, may result in their obliteration,
and lead to fatty degeneration of the villi Should the inHam-
matory action be recent, the friability of the new granulation
tissue may result in retention of parts of the placenta.
Placentitis is sometimes accompanied with hemorrhages which
prove fatal to the foatus. It rarely results in suppuration.
Hydraiuulos— The chief pathological condition of the
niou is that in which the liquor amnii exists in excessive qnan*
tity, known as hydramm'os. This term should be restricted,
however, to those cases in which the amount of fluid is so large
that, by its pressure on the uterus, the abdominal or thoracic
viscera, or the fcetus, morbid symptoms are developed- Dr.
Kidd * limits tiie term to cases in which the amnion containa^—
more than two quarts of the liquor. ^M
Etiology. —The precise cause is still a matter of doubt, but
it probably depends upon a variety of morbid conditions, affect-
ing either the mother or the foetus. It is more common in
multipaDi! than in primiparaj, and in the vast majority of cases,
the foetuses are females. It mL>st commonly results from morbid
states of the foetus, and particularly from mechanical disturb-
ances of the circulatit)u, either iu the placenta or cord. Kus
nerf relates a case in which the anomaly resulted from obstruo
tion of the umbilical vein, resulting from hepatic diseasa The
thtiory that the disease is of a purely local origin has been adv
cated by some, and it is certainly favore<l by the fact that when
the condition is met in twin pregnancy, one ovum only is found
to be affected.
The fcetus is very often dead and shrivelled, and the placenta
enlarged and oedematous. Still, we have no reason to infer that
death of the foetus is always consequent on the morbid condition
in question. McClintock collected thirty-three cases, in nine of
which the children were still-born, and of those born alive, ten
died within a few hours. J
8igU8 and Symptoms.— The excessive uterine and abdominal
distension which results from hyilramnios makes locomotion
• '' Ou the Diugiiasia of Dropsy ot the Amaion," Proce«liug8 of the Ol
Btet Society of Dublin, May 11, 1H7S.
1 " Arch. f. Gynack.." B<i x. 1870. p. 134.
t "Discas, p. 383.
4
[oa
223
diiBcultaml paiufiil. Its effects are chiefly mochfinicalj aiui are
first noticeable Ht the fifth or sixth month. In advanced stagea
the dJfitreBs which resaltB from it is great: — the diaphragm \h
forceil upwards, compressing the hmgs and displacing the heart,
tljos prxxlucing dyspnoea, and cardiac palpitation; neuralgia
a&d uedema of the labia and lower extremities result from cf^>m-
profision of the jjeh-ic nerves and vessels; direct compression
of the stomach produces disb'ess after even a small meal; while
ascites may resiUt from ob8tructit>n of the jxjrtal circulation.
liigl)ection and palpation reveal great distention nf the alnlo-
meu, in ad vHnce<l cases. The outline (if the uterus can l>e easily
felt, aud there is unusual evivlcnoe of fluctuation, while the uter-
ine and abdominal walls are extremely elastic and tense. The
foetal moveiuents are not so easily felt by either tlio woman or
&e exnminer as in normal pregnancy, though there is greater
fff^tm uf action. The sounds of the fcetal heart are scarcely
othlible. When tlie k»wer uterine segment is felt by the finger
jfr vagina m^ the resistance of the presenting part, is found to
be leas firm thtwi usual, though the uterine walls are firm and
feni*. Premature expulsion of the foitus very often supervenes
&B the result of foetal death, of placental separation, or of over-
*libtpUiiiou of the uterua The latter condition renders uterine
wtiitu feeble, and hence the first st^ge of lalx»r is'greatly pro-
loDgnrj. Shotthl uterine inertia prevail in the third stage, hem-
<»rrli(\ge is liable to ensue. In general, however, up<jn rupture
'f the membranes and escape of the amniotic fluid, vigorous
<^Hitrrictiuns ensue, and lead to precipitate expulsion. Involution
^^ apt to be slow, and imperfect.
DitUj^osLs. — In real hydramnios, diagnosis is not often at-
I'-mW vritb much difiiculty. It is to be distinguished from
twill iircj^uMncy. from ascites, and from ovarian dropsy. In
t»u> pregnancy, the foetuses can easily be felt, and the fa*t«l
licarl-H(»mids are distinct, while tlae uterine walls, though tense,
^* ' I the evidences of distension from solid matter. As-
■ recognizeil by the sujK^rficial situation of the fluid,
^'? tlie depth of palpation required to feel the uterus, by the
* " * hie of dropsical efl^usions in other parts, and by the evi-
' licitetl from palpation, that the fluid changes its lx>unda-
'i*! u^ w^rrespond to tlie various positions of the woman. (Ka-
™n (lro[»Ay may be distinguished from hydramnioB by the
224
PATHOLOGY OF THE AMNION.
gpnernl history of the casft, the y>oint whence abdominal enli
luent proceeded, and tlie absence of the most common signs of
pregnancy. Dr. Kidd calls attention to the fact that the position
of the uterus, whether the organ is gi'a^nd or non-gravid, is
usually low in the pelvic cavity, wlien an ovarian tumor exists,
while in hydiamnios it is so high as to be reached per vagtnam
with difficulty.
ProgiiosiH.— In four cases out of thirty-three collected by
McClintock, the women died after labor, the result being attrib-
uted to the debilitated state of the women who were subjects of
the anomaly. Fa?tal mortality is very great Nine of the thirty-
three chiltlren were bom dead, and ten died within a few hours.
Effects of Amniotic Dropsy on Labor.— Even iu those cases
wherein the amniotic fluid is excessive in quantity, but still not
sufficiently abundant to acquire tlie title of hydramuios« the
eflfect on labor is to create feeble uterine action, and cause dela
Tiiis effect is more markeil in the first stage, since at its cl
the membranes are usually broken-
Treatment. — For the disease itself no remedy has yet be
found. Should the m(»ther's c/)nditi()n become iiistressing a
perilous, the physician will feel calleii upon, in the interest
his patient, ta j)uncture the lucmbranes, and draw off the licju
omniL Inasmuch, however, as this procetlure is sure to be fol-
loweil by foetal expulsion, it sliould be postjumed as long as the
woman's safety will peruiit. Playfair* suggests the possibility
of ]mneturing the mpTtibranes with a tine n.spirator needle, aiul
modifying the distention by drn\*nng off only a part of the tluid,
thereby affording relinf without bringing on premature la])or.
Disturbance of the niotlier's heart is one of the symptoms most
urgently calling for interference. If, duniig labiir, the excessive
distention of the uterus retards dilatiition of the os, the mem-
branes should be punctured or ruj>tureiL and the amniotic fluid
permitted to escape. The unusual danger of jxjst-partum hem-
orrhage, which threatens in such cases, ought tt) l>e lM>rne in
mind, and the best precautions adopU^d.
Deficiency of Amniotic Fluid.— When the liquor amnii
deficient in quantity, foetal movements are greatly restricte
and are liable to cause the mother much discomfort, from t
^
SyrtPin of I
"Am. Ed., 1889, p. «d.
KNOTS OF THE UMBILICAL OORD.
225
I
difttinctneas with which they are felt From tlie same cause,
[ire^sfire of the uterus upon the foetus may result in deformity.
U the amnion is not separated from the foetus by a considera-
ble Amoont of fiuid, in the early pai't of pregnancy, abnorjual
anmiotic folds, Hud adhesions Iwtween the amnion and the foDtus,
may take place. Fcetal deformity, and intra-uterine amj^uta-
tiou, from mechariic^-il compression by the so-called foeto-anmiot-
ic bonds thus formed, may be caused.
Anomalies of Appearance of the Liquor Anuili.— The am-
niotic liquor dors not present constant characters. Instead of
brting limpid, and of an inoffensive odor, it may bo thick, and
emit a disagreeable smell. The cause of these variatious is not
weD understood.
Pathology of the I'lubilical lord.— The average length of
the umbilical cord is about twenty-two inches, but extremes in
both directions are exceedingly wide. Its minimum is al>out three
inches, 'ind its maximum about one hundred and eight inches.
The cord, when unusually long, is liable to complicate preg-
nancy by getting tightly <lrawn about the neck <»r limbs of the
foetus Intra-uterine amputation is probably occasionally per-
formed by the pressure of the cord about an extremity, and
foBtal life is sometimes sacrificed in a similar manner.
Fui. loi;.
Fui. 107.
Kuota of the I'mbilicttl Cord.
Knots. — Knots on the umbilicnl cord are found once in two
liaudriN] cases. They result, in general, from the foetus, in its
movemeutft, passing through loops of the cord. Knots formed
daring parturition are lo<ise, and easily untied. In any case, if
there is an average amount of Wharton's gelatine in the cord,
226
PATHOLOGY Or THE mTBILICAL CORD,
case^H
Dro-
no barm will pnibahly result from any knot which is likely to
be tied. Knots formed during pregnancy, from their long con-
tinuance, and the coubequent abBorption of Wharton's gelatine,
occasionally produce fatal results.
TorHiou, — This is a more serious and frequent complication
of prpgnuncy tliun tlie formation of knots. It winaiHta in such
an extreme rotation of the cord that the circulation is impede<L
It occurs must frequently after tlie middle of pregnancy, and, aftiH
Spiegelberg assures us,* in the seventh month. Martin ha^^H
shown t tliat the occurrence is not, as a rule, attributable, as has
been supposed, to active movements of the foetus. He found
that, in a giMnl share of the Bases in which fcettil death has l)eeu
rationally attributable to torsion, the pathological conditions ac-
companying death from such a cause hare been absent,
therefore arrived at the conclusion that torsion was in such
a 2>osi-mcnie7n occurrence, resulting from foetal rotation pro-
ducfld by matemfil movements. These views have l>een supjxjrted
by several other obsen'ers, among whom Schauta J is the most
recent, who bases his conclusions upon three projwsitions, viz:
1. Upon the large number of twists generally found, while any
one of tliem is capable of producing foetal death. 2. Ujk>u the
improbability of extensive torsion in a healthy cord, inasmuch
as compensatory reverse rotation would be caused by its elas-
ticity. 3. Upon the fact that even twenty-five artiliciidly-in-
duced twists in a healthy cord causetl rupture. He reports one
case in which there were three huntlred and eighty torsions of
a single cord Torsion occurs more frequently in long cords»
ami in multiparoua women. Itti seat is usually near the umbili-
cus. Trombi are often found in the vessels, and cystic degener-
ation in the cord* In the foetus are observed general oedema.
Coiling of the Cord,— The umbilical cord is frequently found
coiled about some part of the foetal body, most frequently the
neck. This appears to be true in ten or fifteen per cent of all
cases. The number of such turns may reach six, or even seven,
though more than one is an uncommon occurrence. "When rap-
idly developed, they may, in rare cases, lead to sudden interrup-
•"Lehrbuch,"p. 350.
t" Ztschr. t Oebortsh. n. Gynaek/' Bd. iL, HeA. 2, 1878, p. 346.
X " Arch. f. Gynaek," Bd. xvii,, Heft. 1, 1881, p. 20.
HERNIA OF THE CORD.
227
th© umbilical cii'culation, and consequent death of the
Should the coil be but moderately tense .at first, it
gete tighter as the foetus develops, until oonipiesHion may be-
eome great enough to interfere with the vascular supply of the
and eventually load to its entire death and Be[)aratiou. In
ler cases, tlie combiue<l pressure of the cord, and of the slowly
member, may interrupt the umbilical circidatiou, and
lace fcetal death. From a tense coil of the cord about the
:t the head of the fcotua has sometimes been almost ampu-
fcile<L When tlie cord is coiled about the fcetus at birth, partu-
tition is ocwisionally impeded. Dr. George T. Elliot reports a
owe in which the head refused to enter the brim on account of
1 cord rendered short by two turns al>out the fcetal neck. The
forcepswere applied, and labor completed with tlifficulty. From
ai^riening of tlie cord thua pro^luced, there may result anoma-
positione, premature separation of the placenta, retarded
and even fcetal death.
Cynts.— Cysts of the cord are occasionally observed. They
Itinn within the amnion, and are produced either by liquefac-
rt(;. 108.
Heruia uf the Cord.
•wn of the mucoid tissue, or by accumulation of serum between
tt« epithehal layers of the allantois.
Hernia,— By hernia of the cord is meant the escape from the
228
PATHOLOGY OF THE UMBILICAL COBD.
abdomen, at the umbilicus, into the cord, of some or all of the
flbdoniinul viscera. It arises either l!rf>ui arrested embryonic
development, or the faiJkire of the intestines, which were orig-
inally situated outside tlie alxiomen, to enter the cavity. Although
hernia may t)ccur in otherwise normally developed fcetuses, it is
uflualiy accomj)anied by other deformities, such as stricture of
the rectum, imperforate anus, or distortion of the lower limbs
and of tliR gpnitals, resulting from ti'aotion of the tlisploced vis-
cera on adjoining parts. The hernial sac is composed of the
amnion and the peritoneum, and its conteuts ai^e convolutions of
the intestines, though other organs, as the liver, kidneys, spleen
and stomach are sometimes included, leaving the abdomen nearly
emi)ty.
Calcareous Deposits have been found in the cords of foEntusee
presenting e\'idenceR nf syphilis.
Stenosis of the rmbilical Vessels,— Atheroma, and subse-
quent thrombosis, sometimes give rise to stenosis of the umbil-
ical arteries. Chronic phlebitis, through development of new
connective tissue, may i)roduce stenosis of the umbilical vein,
and occasionally, of the arteries. The latter process is usually
referable tti syphilis.
Anomalies of lusertlon. — Anomalies in the distribution of
the vessels of tlie cord are of common occurrence. The oord
may be inserted into the odgo, inst^^nd of the center of the pla-
centa, in which case the organ has receivetl the designation of
hnifh'dorc pkwenia. It may separate before reaching the pla-
centfL, and its vessels traverse the membranes, in which case the
anomaly is sjjoken of as hiseriio valamt*niosa. Traction on a
cord so insei-ted would be manifestly dangerous to the integrity
of its structures.
Pathology of the Foetos. — Comparatively little is known of
the diseases which attack the foetus in utero, though there is
abundant evidence tlmt they are numerous, and often fatal
Following are some of those which have been observed:
InflHiiiniaiions. — Various organs are attacked, the peritoneum
being one of the structures most frequently involved. The
pleura and lungs are also subject to inflammation.
Blood Diseases Transmitted Through the Mother.— It
been found that various eruptive fevers ore transmissible to th4
foetns through the ranther. When a pregnant woman
P(ETAL SYPHIUB.
229
conflnent small-pox, abortion generally results, and the
tus has often presented evidences of baring had tbe disease.
8f philis is a disease from which the fcBtus does not escape.
PreEoatxire labor, and fcetal death, are common resuUs of tlio
affection. The evidences are not always patent at birth, but a
c&reful esiimiuatiou posi-moriem, or attentive consideration <if
[the subsequent symptoms in living children, discloses the true
fisturbing causes.
leasles and Scarlatina are both known to affect the child in
nti?ro.
lataria and Lead Poisoning are also of frequent occurrence.
M. Pnal • has cited eighty-one cases in which the latter induced
dflith of the child. In some instances the fcetus was affected,
fkile the mother escaped.
Dropsies. — Hydrocephalus is the most common, but not the
«dr form met The fluid distends the ventricles, and as a re-
iult there is expansion and thinning of the cranium, the bones
i which are widely separated Ascites and hydi'othorax are
'Wibionally observed.
Tim foetus in utero is probably exempt from few diseases.
Tlw following, among others, have been reported; Pleurisy,
"orrhas, tul)ercles, i^neumonia, calcareous deposits, peritonitis,
fliJfritis. worms, cralculus, jaundice, rickets, caries, necrosis, eon-
Tul»ions» hemon'liages, etc Tumors of various kinds, and in
•fiffpr^nt situations, have been observed. Tamier has reported
ttt-mngooele larger than a child's head, and large cystic growths
kwe been found attached to the nates, thorax, and other
pvtfl.
Effects of Violence. — Accidents to the mother may involve
bBtna, so as to leave permanent marks, without interrupting
Extensive lacerations and contusions in various
of the body have been observed. Intra-uteriae fractures
>iQpttm(^ result from injuries, but there is no doubt that spo?j-
frttclures also occur, and are nearly always multiple in
e fcetus. Chaussier mentions a child bom in 1803, after
pid and easy labor, which had forty-three fractui-es, even the
I bones l>eing involved. He repwrts another case in which
bom after an extremely short and easy labor, pre-
"•Aftli. O^n. de M^iL," 1860.
230
PATHOLOGY OF THE FlETDB.
senting feeble signs of life, and which died iu a Bbort time, upon
whom were found oue hundred and thirteen fractxirea The
causes of such anomalies are not well understood, but are prob-
ably due to arrested development uf the bony stmctures.
lutra-L'terine Amputations.— Another phenomenon equally
remarkable, is that of complete or incomplete amputation of
foetal extremities. Numerous cases of limbs deprived of a por-
tion of their length, have been reported, the stump jiresenting
Flo. 109. evidences of traumatism. Cases are
known in which the whole four extrem-
ities were wanting.
The cause of these conditions has re-
ceived much attention. Reuss,* o*mtrary
to the opinions of some, believes that
gangrene is not the cause of such sc^
lution of continuity, inasmuch as he is
convinced that gangrene in the unrup-
tured ovum is an impossibility, because
there is no access of oxygen.
The cause of this singular lesiou is
supposed by some to be due to coils of
the umliiliciil cord aroxmd the limb, and
thin ]±^ lik<'ly the (explanation in a small
percentage of cases. The most common
cause IS probably the constriction exerted by fibnms liamls,
or by folds of the amnion. It should be remembered, how-
ever, that these bauds are not always present, and the etiolog}'
of spontaneous intra-uterine amputation, is therefore rendered
obscure. It seems clear that it is not always due to the me-
chanical effect of a constricting agent, but in some cases it may
arise from a deep-seated locjil lesion, and from the constriction
exerted by ext-eusive cicatricial action.
The amputated part is sometimes found lying in the cavity of
the amnion, and follows the child in delivery. More frequently
the separated portion has disintegraUn! imd (hsappeared. This
can only occur, however, when amputation has taken place at an
early period of development When separation is effected at a
later period, the part is not only found, but cicatrization of the
liu...
AnipuUUion.
* ScuDZoni*B Beitriigc, 1669.
DEATH AND BETENTION OF THE FCETCS.
2:31
stamp is often incomplete. Rudimentary toes are sometimes
foQZKl on the stumps which are believed by some to be abortive
efforts of nature at reproduction of the lost parts.
Monstrosities.— Deviations from the ordinary process of de-
Telopment frtfquently result in the production of monsters. The
subject is one which might very properly be considered here,
bat it is so extensive tiiat we cannot attempt to give even its
OQtUnes.
Death and Retention of the Fopt us.— Expulsion of the
foflii* di>e.s not, in all cases, immediately follow its death. If the
placenta does not separate from the uterus, its ntality may re-
main, its development continue, and expulsion thus be delayed.
\en the placenta does become separateil, whether as cause or
[uence of fcetal death, retention is probably due to diminished
initability of the reflex nervous centres which preside over the
titorine energies. Retention due to uninterrupte<I utero-placen-
td relations, is rarely prolonged beyond the ordinary i)eriod of
ttteru-gestation, while retention referable to diminished reflex
inntahility, may be indefinitely prolonged Liebmann* believes
tLftl all case^i of retention which exceed the normal term i>f
pregnancy owe their continuance t*"* such a cause.
^y\wu the foetus is retaine*.!, and the membranes continue in-
tact tbe most im|)4>rtant changes are mummification, macera-
tion, fatty degeneration, and calcification. If the membranes
wv broken, before or soon after foital death, mmuraificntion
may r»*iiult, or calcareous degeneration may follow. If air gains
^Jitrauce into the uterine cavity, putrefactive changes are apt to
take place. Mummification having been begun, putrefaction
don not set lil
lummiHcatian. — It becomes necessary to explain what is
by mumniitication, and what are its causes. *' A mummi-
»tns is flattened from compression. Its viscera are of soft
ixnunstexicy and of small dimensions. Its surface is shrunken.
The perit^meal and pleural cavities contain a scanty and discol-
ored fluid. The subcutaneous areolar tissue has disappeared.
and tlie akin lies in direct contact with the musclea The pla-
oacta, which w drj', yellowish, and tough, is the seat of fatty de-
jfeaeration, and ecmtains the residue of old extravasations."
*" Bictrag X. G^burtoh, u. Gyoaek." Bd., iii., 1874, p. 59, 63.
232
PATHOLOGY OF THE F{ETDS.
It is most frequently observed in foetuses witli inadequate
blood-8upply> n couditiou often growing out of constriction of
the umbilical cord. From preference, it attacks foetuses dying
during the middle stages of gestation, and especially a single
foetus in twin pregnancy. When one mummLded and one li\ing
foetus occupy the uterine cai'ity, gestation usually preserves n
tolerably normal course, and expulsion of the living and the dead
is deferred until the close of the ordinary [>eri(xl of pregnancy.
Maceration. — An embryo may be entirely dissolved by the
process of mummification. In the case of the fopttis, il^ general
form, and the outline of its organs, are preserved, but granular
degeneration and disintegration of their antatomical elements
takes place. The epidermis is the first to yield to the process.
It rises in the form of blisters, or vesicles, which are lilleil with
a reddish, sero-sanguinolent, or a clear serous fluid. There is
also infiltration of the corium, wliich has a brownish-red parch-
ment-like appearance. The subcutanedus areolar *ind adii>ose
tissues are also oedematous. Viewing the body as a whole, it is
observed to be flaccid, and, from its oedematous c{mdition, may
be molded into curious shapes by pressure. The oodema is
most apparent over the cranium, abdomen, feet, hands and
sternum. The cranial sutures are separated, and the ai'ticular
surfaces pushed apart. Tlie i)eriosteum is detacheil from the
long bones. Dark blooil is found in the vessels, and bloody se-
rum in tlie fierrmw cavities. The brain is pulpified, and all the
viscera are softened. In some cases a species olfaily degenera-
iiori eusues.
The placenta of a foetus undergtiing maceration is almost des-
titute of blood, soft, and easily broken. The cord is cylimbi-
cal, smooth, spongy, and inelastia At the foetal end it is
brownish-red and club-shai>ed. The liquor amnii has a sweet-
ish and sickening, Ijut not putrefactive odor. It is turbid, and
of a greenish color, from admixture with it of meconium and
aero-sanguinnlent fluid. The membranes retain their strength
and consisteuey fur a considerable time, but finally swell, soften
and <]arkeu.
The rapidity with which the process of maceration proceeds
varies within considerable limits, and no positive data concern- |
ing the time of fcetal death are afforded by the changes which ^
are observed.
MOLES.
233
Bnge* says that inacerateil fcetuses fire expelled before the
tlurty-first week, ui seveuty-five per cent, of all cases. It is a
ognificnnt fact that the presentation ir* nearly one-half of all
tsacli caaes Is either transverse or breech.
loles. — Of these, one variety— the hydatldiform^has ul-
K*dy been described, and of the other varieties, but a brief
jBBsideration will be required. Moles have been divided into
wo general classes, one of which is termed /(t/se, and the other
'rtK*, the element of distinction between them being that the
tnip mole is always consecutive on impregnation, and the false is
DoL Hence, in a work of this character and scope, we shall
ttinwdor the former class only.
True moles are dividerl into three general varieties, namely;
L The mole of abortion^ or the blightetl ovum. 2. The carne-
Btt, or fleshy mole ; and 3. The hydatidiform mole. The last
tLfwe having been describeil, the first two varieties only re-
in fur consideration.
The Mole of Abortion, or mola sanguinosa, is the blighted
"nun, within which post-mortem changes have just begun, and
liitimosa has not yet been materially altered, save in the direc-
*tou uf extravasation of bhxKl and dissolution of the embryo,
*lMi8e vit^il resistance, until death, had been sufficiently potent
^'^progerve iis int<>grity. Many years agoSmellie took occasion
*"wy tliat **,ehould the embryo die (suppose in the first or sec-
tounth), some days before the ovum is discharged, it will
times be entirely dissolved, so that when the secundines
■"o delivered there's nothing more to be seen. In the fii'st month
^*?mhry<J is so small and tender that the dissolution will be
P*rfi)rme<l in twelve hours; Ln the second month, two, three, or
*OBr days will saifice for tliis purpose." In case fcetal death
^^^ir^ m more advanceil pregnancy, degenerative and disinte-
IK'^tivc* clianges are wrought in a relatively short period, and the
'^'■•N wlien expelled, may not disclose its real character except
**> cWst scrutiny.
T"l>t? Flt^shy Mole.— The conditions which give rise to the
""fiMtion uf the camoous mole, are substantially as follows;
*^8 the result of siinie sudden or violent exertion, one or more
hlu.jd.vessela give way, and as the blood is extravasated, it acts
" tnt r firb. 0. Oyn." Bd. L, Itcft. 1, IftT?, p. 5S.
234
DISEASEfi AND ACCIDENTS OF PREGNANCY.
P 18 1
in a mechanical way to influence Beparation of contiguous pai
with most potent results. The embryo perishes from want
nutritive supplies. A similar effect may be produced by a]
plexy of the placenta, olsewhore considered. Extravasation is"
sometimes between the chorion and decidua, and even witliin tl
amniotic cavity, and results in embryonic death.
Consecutive on such occurrences there is, most frequentlyf
spefedy expulsion of the ovum, but occasionally it remaijis for a
considerable time, and luidergf^s certain changes by which it is
converted into a flesliy mass. The effused blood beconjes decol-
orized, the blanching j^'oceeding from centre to circumference,
and, according to Scanzoni, the fibrin is transformed int<j cellular
tissue, by which means communication is established between
the external lining of the o^^im and the uterine tissues, — am
thus further development is made possible. It is highly prol
ble that complete separation of the ovum from the uterus never^
takes j)lace in these cases, but, through the atiherent parte,
vascular communication is continued and amplified. Degener-
ative changes t^ike f)lace chiefly in the decidua vera, though thtt|
chorion and amnion are sometimes more or less involvetL ^J
These masses seldom exceed an orange in size, but their full
development, from the very nature of the case, is quite rapidly
accoinplishecL They may continue in ul^ro for three or four
months, but eventually the organ is excited to contraction, and
expulsion takes place, unatt*:'nde<l, as a i-ule. by any remarkable
symptoms.
There is little or no treatment required. In expulsion, tlie ,
case assumes the character of an abortion, and similar principles
of treatment should l>e adoi>te<i.
and^
CHAPTER- X.
Diseases and Accidents of Pregnaincy,
When we reflect upon the profound impressionfl made u\mh
the female organism, and the extensive changes wrought in it
HYOIENB OF PREONilNCY.
by pregnancy; furthermore when we recollect that this condi-
ti«m exempts a woman from })ut few of tlie ordinary ills of lifc^
wp viU cease to wonder "that there is a pathological, as well as
ph)^iological, bide of the subjet^t.
The Hygiene of Precjnancy.— At the risk of transposing
the conventional order of discussing pathological states, we here
insert a few ol>servation8 on the general management of tlie
pregnant state. The importance which attaches to the obaer-
vaai-e of sanitary rules during pregnancy, has not received
aumgh attention. The augmented elimination through the
lan^ of carlionic acid, necessarily increases the demands for
oiyt,'en.Hnd the acceleration of respiration, makes an abundance
«ffreshftira matter of the highest importance. To confine
apTf^ant woman within the hountls of a few rooms, with an
wvusLcmnl walk or drive o\itside, is unwise, if not cruel. So far
tekr necessary duties, her physical strength, and the weather
*ill jMrmit, she should spend lier days very largely in the open
«r. ami her nights in well-ventilate<l rooms.
The diet must l>e regulated to suit the peculiar requirements
w*i sensibilities of the individual woman, but should embrace
**«! nutritious, easily-digested, articles of fotxl. The stomach
^ niTely in a condition to profit from the eating of pastry and
^fections, and they should be scrupulously avoided. Women
"Ught not to suffer themselves to be led into eating what t<^> a
"'^)nuhle mind must seem harmful, by what are termed '*Iong-
^S^'^ and no jxjssible effect on the fa?tus can result from self-
'^''ninL A goixl appetite, indulged by the supply of a reason-
'"*'** quantity of wholesome food, is the best guarantee of a
''*^ilthy and well-formed child. A vonicious apj>etite should be
'^trained, and a feeble one encouraged-
^^xt in importance to fresh air and good food stands physical
^eroise. This should not be violent, nor carried to fatigue,
* '^king in the open air, and riding in an easy vehicle will aid
K*^Kliiin, and induce refreshing sleep. In the case of women
have formed the habit of aborting at a certain stage of
'^^Krumcy, rest should l>e enforced iintil the dangerous periofl
I>ftS9e(L It has been found that there is often a predisposi-
^^^ to abtirtion at the time when, but for interruption, the
^**«knwl return would have been experienced, and hence tliis
Period during which special precaution should be observed.
236
*8 OF PBEONANCy.
Sexual pleaaures ought to be indulged in strictest moderation.
The free, but judicious use of water is beneficial. Frequent
Bponge baths, followed by brisk rubbing, will keep the skin in
good condition, and give tone to the entire system. The vaginal
douche may be employed, but the stream should be feeble, and
the quantity of water used at one time not in excess of a pint
The entire perit>d of utero-gestatiou in some women is one of
physical and mental distress, and every effort should be ma
to lighten the load of suffering. The ailments from which th
suffer are various, sometimes relievable by medication, at other
times yielding to a change of scenery or circumstances; while
in certain instances they will not relax their hold despite every
effort to disLulge them,
Deriin^eiiuMits of the Digestive System.— The most prom-
inent derangements of the digestive functions, referable chiefly
to sympatlietic irritatiun, are nausea tuid vomiting. They are
the common accompaniments of pregnancy, and under ortliuary
circumstances can hardly be considered as ailmenks requiring
metlical attention; but occasionally tliey are bo excessive and
long continued as to lead to inanition, extreme debility, and
even death. In some cases the sickness is limited to the morn-
ing hours, at which time the smallest quantity of food is rejected,
while later in the day it may be Ixirno with impunity. From
this circumstance the nausea and vomiting of pregnancy have
been derfignated "morning sickneBs." In other cases, the wo-
man feels constantly sick, and the mere smell of food may brin
on a |>ai'0xyBm of vomiting.
This distressing accom]>animent of pregnane}' is not expert
enoed by all women, but about forty per cent of them escape it
altogether. It usually begins al>out the sixth week, ami contin*
ues till the close of the third month. Sometimes, however, it
immediately follows conception, autl continues until the end of
pregnancy, while in other women it does not appear until the
patient has reached the latter months of gestation.
It is surprising to observe how severe and protracted may be
such gastric distui'bancea in some oises, without i>roilucing ;
emaciation or excessive debility. In other instances the vital
forces are tlierehy bn^ught to a low ebU Grave cases are char-
acterized by a dry coated tongue, palor and distress of oounte- ^
nance,excessive nervous irritability, tenderness of theepigastriun^^
KAtTBKA A»D VOillTING OF PREGNANCY.
237
grent restlessness, and general beat. In worse cases there is
elevated temperatnre, vrith rapid, small and thready pulse.
Want of nourishment soon reduces the woman to a state of ex-
treme emaciation. The breatli becomes fetid, and the tongue
dry ftnd black. Pmfouud exliaustion, with low delirium follows,
and, in the absence of relief, death soon ensues.
The Pro^osis in nausea and vomiting of pregnancy, though
the affi^tiou sliouhi ansume a grave fonn, is generally hopeful;
bat sooh cases create much anxiety. Gueniot collected 118
cues of this form of the disease, out of wltich forty-six died;
and out of the seventy-two that recovered, in forty-two the Bymj>-
tuuffi only ceased when alxirtion, either spontaneously or artifi-
ciftlly induce<l, had occurred.* Upon the termination of preg-
Dauey the sj'mptoms sometimes cease at once, and the digestive
aiid assimilative processes soon become active and vigorous.
Treatment. — It is of prime importance to regulate the diet
of women suffering from momlnj; sickness. A few mouthfuls
<^f fnod, or n weak cup of coffee, taken in tlie morning l>efore
nsiug, is sometimes of decided benefit Food should be taken
in small quantities, and at short inten-ols. Ice cream thus eaten
frill s<jmetimeB be retained when nothing else can be. Kou-
luyss. when fancied by the patient, is a remarkably good f*Kxl.
fifirlt'y-water, oatmeal gruel, blanc-mange, beef, mutt<:in, and
diic'kpu broth, and essence of beef in small quantities, are
'"""ug the articles from which selections should from time to
t^ue 1)6 made. Tlie caprices of tlie woman Blunild have an in-
Huenoe over tlie choice of food, but should not be permitted to
wtray one into uuwise action.
('hange of Habitation, Air and Scenery. — In some cRses,
*l"Te other forms of treatment prove unavailing, and the
P'^tifJita are greatly reduced, a cliange of habitation, air and
*ceni'ry, esjiecially from a poorly-ventilated house, in the crowd-
^1 Jwrt of a city, t^i a rural situation, is of the grtmtest benefit
W»l Treatment. — Since it is clear that the nausea and
**>mitujg of pregnancy are mainly dependent upon changes go-
*^ff t>n in ftnd about the uterus, the attempt hns been made to
f^ace the irritabilitj' of the organ by local treatment. Morphia
•i^tATrrATX. **RyBtora of Midwifery." Atn. Ed.. IWO. p. 180.
238
DISEASES AND ACCIDENTS OF PKEQNANCY,
in the form of snppositorieb, and belladonna applicationa to tl
cervix, have been reoommenJed, the former being in K*>uie cases
of apparent benefit The cervix has been burned with- eavflf^
and bitten by leeches, in the vain endeavor to overcome the ob-
stinate sickness. In the latt€*r months, gentle dilatation of the
cervical canal, to a slight degree only, has been attended M^ith
beneficial results. Dr. Grailey Hewitt believes that in quite a
large percentiige of cases the disortler depends upon uterine de- „
viations, and can be cured only by rectification. This may l^H
true, and the suggestion shtmld lead tti a careful examination^
in all obstinate cases. If retroverted, a Hodge, or Albert Smith,
pessary, properly adjusted, may be safely worn. During the
employment of local treatment the woman should be required
rest more than usual in the reclining posture.
Electricity has, in some cases, afi*onled relief to the distr*
ing nausea and vomiting of jiregnancy. Both the continue
and interrupted currentn have been employed.
Medicinal Treatment,— The list of remedies which may
found serviceable in the treatment of the nausea and vumitii
of pregnancy is long; but there are a few which are especially
prominent These are:
IpeaiCy when the nausea is the predominantly distressini
feature, attended with vomiting of bilious matters, undigested
food, and largo quantities of mucus.
Arsenicum^ when the vomiting occurs after eating and di
ing, and there is faintuess, and excessive prostration of the vii
forces.
Nxix voinicQy fur re^l morning sickness; bitter, sour eru<
tiona; vomiting of sour mucus, and the iugesta. Also, for ex-
cessive nausea, with the feeling that she would be better if she
could vomit
Tabacum^ in those cases where there is nausea, with faintnees
and deathly pallor, relieved by being in the open air. Vomit-
ing i>f water, acid tiuid, and mucus.
PithaiilUi, especially when the vomiting comes on in
evening, or night The appetite is capricious, the woman crav-
ing beer, acids, wines, etc. Much eructation, testing of the
gesta. Specially suited to mild, tearful women.
Acetic acitf, when there is sour belching and vomiting, wXJ
profuse waterl>nisli and salivation.
M
ii^^ij
NAUSEA AND VOMITIXO OF rBEOSAACY
2519
Cokhicunty m cases when the symptom is well marked of ex-
cessive nausea, even to f amtnoss, produced, by the odor of fish,
eggs meats, etc.
Bnjoma^ when the nausea andTomitiug are brought on or de-
ciiifiily aggravateil by the least motion. Vendrum album is
well Huited to the same symptom.
Phosphoric acid (dilute), a few drops in a lialf-glass of water,
» teahptjonf ul every two hours, is often of great service. Its
ipecinl indications are similar to those given above for acetic
acid.
Almost every remedy in the Materia Medica has lieeu reeom-
memled, and we doubt not that there are cases to which they
may severally bo suited
The Production of AlM>rtion,— When the vomiting is abso-
lately aucoutrolluble — as it will rarely prove to be when the
Itttit-at fully co-oiK?jates with her physician in the effort to cure
(md fatal results seem imminent, there remains, as an ultimate
^si^iirce, the artificial interruption of pregnancy, Regard must
l«bul, however, for the clinical fact that in most instances the
fe&timing symptoms disapjX'ur at alxtut the close of the third
ttiouth. It is an openitiou which always subjects the physician
to criticism, and aa it is attended with considerable risk, it
fiiitili] never be imdertakeu upon the responsibility of the at-
ttQtliiig physician aloha
There seems to be no doubt that a few mothers have been
mini by tlie induction of labor in such wises, and in all proba-
"ility many have been lost for want of it The success of the
*'I»*imliou demaiuLs that it l>e i)«rf(>rraed Ix^fore prostration has
TO>me so great that the jjntient cannot rally. The obvious in-
*^iitiou is to diminish uterine tension without delay, and the
prt-ferable mode of doing this is to puncture the membranes
^^ a uterine sound or stiff catheter, and allow the amniotic
^'li'i to escape.
»rof. C. Braun,* of Vienna, reports a case of hyperemesis. to
»Qich he was called, in wliich tbo woman was Kup|K>sod to l>o
"^rilittiuL The physician in charge had resolved on the intluc-
nn nf premature labor as a last resort Dr. Braun decided to
wttiie the intra-vaginal portion of the cervix in a ten per cent
""Mlgem. Wcin. Med, Xeii.,*' 1882.
'240
DISEASES AXD ACCIDENTS OF PREQNANCT-
solution of nitrate of silver. Tliis was done, and tlie surf
quickly dried, to prevent further cauterization. An hour aft
wards the patient enj<>ye<l and retained a meal of roast veal, an
there was no subsequent vomiting. Prof. Braun says he has
never, in all his vast obstetrical jiractice, seen a case of death
from hyperemesis. In France, where abortion is frequently in-
duced for the relief of these symptoms, the vomiting is arrested
in only about forty per cent. o{ all cases, while ten per cent of
them terminate fatally,
Other CSBstric Disorders. — Anorexia, or want of nppetit<»7
and even a loathing and disgust for food, is a prominent ilisorder
of the stomach, especially during the early months of gestation;
but under the influence of gentle exercise, pure air, salubrious
surroundings, and judicious selection of foo4l, it vail generally
disappear. The remedies which are most likely to afford aid ore
ntix vomica, ijH'.c<ic, iaiiar eynetic, nairutn muriuticum, colchict
and pnhaliUiu
The patient may also l>e annoyed with acidity of the stomach
and heartburn, for which nn:r vomica, calcnrea carb., nairuyn
muriaiicnm, sulphur, or phosphoric acid is likely to prove eftica-
cious. Temporary roHof will often bo afforded by a swallow of
pure glycerifw, or a half teaspoonful dose of aromafic sjn'rits
of ammonia. Flatulent distension may be removed by can
veg,y china, hjcopotUum, nux vomica, or argenimn niirium, Nei
ralgia of the stomach is sometimes very distn^nsing. If attended
with nausea, ipecac will often relieve; if of a crami>ing nature,
mar-vomica; if the stomach feels as tliough distende4l by gas,
carbo reg. Belladonna, or better still, airnpine, is often of ser-
vice. Hot fomentations should l>e applied to the epigastrium,
and, if relief is not obtained in response to the treatment given, a
minimum dose of morphia maybe given hyixKlermically.
The caprices of appetite so frequently observed do not of
require medication.
Ptyalism, or excessive flow of saliva, is occasionally asso-
ciated Avitb pregnancy. In a few cases the secretion has amounted
\a^ two or three quarts in the course of a day. The remedies
best calculated to relieve, are mercurius, carbo vegeiabelis^ acetic
acid, heUadonna. If there is disgust for food, and vomiting of
mucus, iarUir emetic.
axe
t^J
PRUIUTUS.
241
Pruritus. — Diatressing itching, witliout a risible affection of
th»! skin, somf tiiueg tormente pregnant women beyond all en-
dorance. The affection may be limited to the distended ab-
duminal wralls; in other cassa the vulva anil vagina are the seat
of the itching. In many instances, it is doubtless a reflex ner-
vooa symptom, in others, it depends on an irritating vaginal
discharge, and again, on asearides. When the vulva and vagina
are llie [)artfl involveil. the vagina should l)e syringed out twice a
day with a solution of carl>olic acid or borax, and the vulva
wubed with the Rama If dependent on asearides, a wash
wmpoeed of an infusion of tobacco, or garlic, may be ust'd.
When the alxlominal surface is the sent of Uie trouble, tempo-
rwy reUef may be obtained from the local use of chloroform
liniment, or a solution of carb*.>lic acid. The principal remedies
«« /wrox, ( which should be used both locally and internally, )
rmium, jJaftna^ and sepia,
Farp-ache.— Neuralgia of the fifth nerve is often experienced,
*nd atropine, Mlaflomia, at'senictinl^ or gelsrtniumj will genei-ally
rplieve it 8h<»uld the indicated remedies fail to afford relief,
'**>rtiuay be bad to the external application of aconite, chloro-
'■^ or camphor liniment The continued use of hot water is
^>nit'times a gre^tt aid.
Cephalalgia.— The reme^ly may be selected according to the
ff-Utiving symptoms: Bursting or splitting headache, — bryonin,
AffiiJuMis every morning with a violent bursting headache, — 7ia~
'''"ffl mur. Sense of great fullness of the \\endt~ hclhitionmu
Ht'wl fiHjIs much too large, — nuo' vomica, gehemium, aconite^
iVmnnnm. Fullness and heaviness in the forehead, — lu'lUidonna^
'"■^«»« uUk Determination of blood to the head, with thn>b.
^iiiK headache, — IwlUidonna. Sensation of great expansion,
I'hiellyof head an<l face, — anjrnfrum nUricum. Pressing head-
**'lu' itwin lH)th siiles, as if the head were in a vice, — mevcurius.
"f*»'ifttl pain in the vertex as if the brain were crushed, after
''^i»R-coiitinued grief,— phosphoric acid. Piercing, throbbing
l*ui iu the forehead, worse from motion, — acow//p. Pain of a
'lull, heftvy. throbbing character, mainly in the forehead, worse
***w eating, — kali hick. Beating hea^lache, most violent over
^^ ^y^.—'kichfisis. Throbbing headache after excessive deple-
^*n,*-<^Aime. Headache from eating a little too much,— «?ij:
"^•cWa. Beating headache, seemingly in the middle of the
24-2
DISEASES AND ACCIDENTS OF PBEaNANCY.
bor.
II
brain, — calcarea carb. Beating headache in the occiput,— .'«f7>ia,
lusuinniu. — Continued sleeplessness is not only diBtressing to
the patient, but it is liable to so reduce her vital energies that
she is poorly prei>ared to undergo the violent strain of labor.
Moderate exercise, pm'e air and frequent baths, will geuer
bring the needed rejKJse. Certain remedies will aid:
Sleeplessness, — acicea r(ic.yhyoscyamus, coffea, cwdaph yll
Sleeploasness and restlessness, —</.coni/<^, tirsenicum alhu
Drowsy during the day, sleepless at night, — sulphur. Cannot
sleep after 3 A. u., ideas bo crowd on the mind, — nux vomica.
Cannot sleep after 3 A. M., — calcarea carh Cannot sleep beca
of involuntary thoughts, ™C't/«2r«* carL, chiruL Sleepy,
cannot sleep, — Mhfhmna.
Blood Changes of Preguaney.*— lie most important changes
consist in the loss of red corpuscles and albumen. The former,
as the oxygen carriers of the tissues, are illy spared from the
economy. AA'Iieu they have undergone destruction to any ma-
terial extent, the cell elements, whose vitality is intimately asso-
ciated 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 necfessity followed by loss of weight, mus-
cular prostration, impaired functional activity of the secretorj-
orgauH, and increased nerve iriitHy)iIity. As a conse<juence, Uia^
appetite fails, the tligestion is weakened, neuralgic pains <level
and even moderate muscular exertion is attended with effort, an
followed by a sense of fatigue; vertigo, loss of memory, and, in
severe cases, chorea, hysteria, and insanity, may result from the
•deranged condition of the nerve centres; attacks of 6yncoj>e,
palpitations, and precordial oppression |x>int to a feeble heart
action; the arterial tension is lowered, and venous hy|)enemiA
results; and finally, the stagnant blood, deprived of its albumen,
in place of inviting endosmotic currents, transudes through the
walls of the vessels, giving rise to oedema and dropsical effusions.
Guaserowf (1871) called attention to the fact that the antemia
of pregnancy might progress to such an extreme as tt> produce
a fatal termination.
The Treatment of ausemia is largely prophylactio. Ligh
*LrsK. "Roicnce and Art of Midwifory," p. IIB.
t " Ueber bochgradigste Anicmie fcichuangerrr." " Ardi. f. Gvaack
p. 2ia.
BLOOD CHANGES OF PBEONANCX.
243
moderate exercise, good food, regulation of the bowels^
jrful society, and an occasional respite from household and
iamily cares, will always be the main checks to its extreme de-
Telopnwfnt In weakeuetl states of the stoiuach, when the latter
revultii at beefsteak and mutton, easily assini i latetl albuminoid
uticles, such as milk, soft-boiled eggs, and scraped raw, or on-
derdune, meat, should be administered in small, but frequently
rqieated portions. Where the marasuiua becomes extreme, and
the rectum is tolerant, the stomach may be relieved of a part of
its duty by the use of nutritive enematn. In the pernicious
form of ausemia, Guaserow tried transfusion, but without suo-
oea He therefore recommended a resort to premature labor.
The p(»micious form of amemia, though not confined to multi-
pwii-, de-\-elojM5 most frequently in women who have borne many
children in rapid succession.
A Dot unasual result of hydnemia consists in swelling of
the lower extremities, beginning at the ankles, and thence ex*
trading upward, and often invading the labia, the vagina, and
the lower segment of the uterus. Wlien not associated with
odne^v complications, this anlema is rarely dangentua, though
uEten the source of extreme discomfort In some cases of cede-
lOf the vulva, the labia may attain to the size of a man'shead,
become nearly diaphanous from the serous infiltration.
»\im the distention is extreme, gangrene may threaten, and
ttake puncture necessary. If free drainage is established, the
swelling rapidly subsides.
^lema of tlio lower extremities seldom disap]x;ars entirely
twforf! c<.)nfinement, though relief is sometimes experienced in
t^«lftst mouth, when the fundus of the uterus falls forward.
Slight degrees, such as swelling limited to the feet, making it
*tt»8sary for the woman to go around in large shoes, do not re-
spire treatment When, however, the skin of the limbs becomes
t*n»e and painful, warm cloths should be applied, diaphoresis, if
P^iwible, should l>c induced, and the patient be kept in a recum-
^t position, or sit with the extremities raised.
The medicinal treatment consists in the administration of one
WBioTeof the following remedies, maintained for a conaidera-
Dw tune, since beneficial effects are not at once manifested.
"pTPUTii, in one of its several forms, is most frequently em-
P">J*d with good results. The metallicum is often used, as well
244
DISEASES AKD ACCIDENTS OF PBEONANCY,
as ferruin et Btryohnia citrfttte, and ferrum phospboricmn.
Pulsaiilla is capable of aflfording aid in these cases, especially
when the attack is of tlie tnildei" typa There is constant chilli-
ness, cokbiese, and paleness of the skin; coldness of the feet; ir-
regular jjultje, and paljntfition of the heart; want of appetite;
vertigo, especially on rising; mild, weeping mood, or excessive
irritability.
Nux vomica, when indigestion is a troublesome feature, and
there is constipation, or small loose stools, with urging.
Numerous other remedies will be found usefid, such as hclo'
niaSt j^^tospharus, cyclamen, calcarea carb., sulphur, etc.
For the dropsical symptoms, we will find help in arscnictim
alhutn, apisviel, hellcbonis, or apoctpiutn caiu AVhen limited to
the feet and legs, bryonia may bo the remedy.
Albnminuria. — Acide Brtghrs Disenso. — Albuminuria, asso-
ciated with pregnancy, was little known by the profession until
witliin about thirty years. Roger, in France, and Ijever, in
Great Britain, were the first to direct attention to its intunnte
relationsliip to that appalling complication of pregnancy and
puerperality, viz: eclampsia. For many years it was believed
that convulsionH ocrcurring in the pre^^iiant or puerperal woman
were always j)receded by, and in a measure dependent upon, al-
buminuria. But recently it has been shc^n that this is not
true, for in some Ciiaes albumen is not present in the urine
until after the con^'ulsionb have begun; while in otlier cases it
does not appear at alL
Albuminuria is also associated with other afTections to which.
the pregnant woman is subject — as, for example, puerperal
mania, vertigo, headache, and certain forms of paralysis, either
of the nerves of s{^cial sense, as in the instance of amaurosis, I
or of the spinal system. The relation which it bears to these
diseases is not yet fully understood. It shoidd always be re — '
garded with apprehension, and vigorous efforts made for its^
removaL '
Causes. — Albuminuria in a pregnant woman is not a rare m — ;
currenoe. Blot and Litzman met with it in twenty per cent ' — — j
all cases examined, which is, however, far above the estimate I
other authors. Dr. Fordyce Barker thinks it occurs in ab(^^^
ALBUM INUJIIA.
245
I
one out of twenty-five cases, or four per cent.,* and Hofmeirf
fouml it in 137 out of 5,000 women delivered in the Berlin
Clinic, which, represent about 2.74 per cent In most cases it
ilisttppears soon after delivery, and hence the causes ux>on which
itdepends must be temporary. It follows, therefore, that ulbu-
[ut-u in the urine of a pregnant woman, while it justly arouses
wnsiderable anxiety, does not always assume the grave iraport-
&uc« tliat it does in the non-pregnant state. Lohlein, from the
rwnrtl of thirty-two autopsies made upon eclamptic women,
found in eight that dilatation of one or both ureters co-existed
with renal disturbances. How far this has a bearing on the de-
Telo[nnent of unemic mtmifestations remains t<3 l)e seen.
The blood changes already described as taking place in preg-
iwncy, may have a causative relationship to albuminuria. Still,
it i» observed that in the worst cases of anaitmia during gestation,
nihumen is rarely found in the \irine.
UisBupposed by some that albumen in the urine is due to
ftjugflstion of the venous cii'culatii>n of the kidneys, caused by
Bi*i'lijiuic/d pressure of the renal v€*;sels by the gravid uterus.
Tlii.-i may be true of some cases, but, in general, it cannot be re-
pwtiwl us the only, or the chief cause, as similar pressure is ex-
^tftl by uterine and ovarian tumors without producing such an
NjDipUiins.— One of the most common symptoms of albumin-
*^\n is anaaarcu. which is a iL'opBical condition of the subcuta-
*^**ous cellular tissues. This is ospecinlly raauLfest in the ei-
'^^mities, and face, and sometimes becomes excessive. Gixlema-
■•^tis swelling of the feet and li'gs is observinl in a large proiK>r-
^oa of pregiiant women, though it is associateil with the albu-
***ii»ttrift in only a small i)ercentage of crises. Sometimes the
**M8ai«a spreads until it finally Ijecomesgenered, and the woman
K*>>«entB n pitiable «u>i>ect
There are also many nervous symptoms connected with albu-
'■^inoria, such as vertigo, cephalalgia* dimness of vision, spots
***'ore the eyes, and nausea. The appearance of such symp-
wniain a pn>gnant woman, whether there be coincident oedema,
Khould elicit a thorough examination of the urine both
illy and microscopically.
• iBL Joar. Oba^ July, 1878.
t Berlin K\in. Woch., H*<pt., 1878.
246
DISEASES AND ACCIDENTS OF rKEQNAXCY
The Effects of Albuniinarfa. — The various diseases associ-
ated, either as cause or effect, with albumen in the urine, require
separate consideration, inasmuch as some of them are among
the most dangerous complications to which a pregnant woman
is liabla Some of these have been alluded to as symptoms of
albuminuria, such as cephulalgiii, vertigo, and paralysis; but that
which stands out most prominently is eclampsia. Tlie precise
mode in which the last ujimed disease is produced will be con-
sidered when we come to discuss in detail the cause, course and
treatment of it in another chapter.
Proji^nosis. — The danger to mother and child in connection
with albuminuria in pregnancy is not slight Goubf^jTe esti-
mated that forty-nine per cent, of priinipane who manifest the
diseased condition, and who escape eclampsia, die from morbid
results tniceable to the albuminuria. Hofmeir found tliat out
of forty-six cases reported by liim, only one-third had eclam])sia,
thtmgli one-half died. Including botli ncuto and chronic cases,
Braun estimates that only sixty in the hundred develop uriemic
convulsions. Hofmeir foiuid in five thousand births recordtvd
upon the l>ooks of the Berlin Clinic, 137 crises of nephritis en-
terexL Out of tins number only KM patients were attacketi with
e-clampsia. Prof. Bamberger* reports from autopsies of the
"allgemeinen Krankenhaus," in twelve years, 2,430 coses of
Bright's disease, of which 152 were found in puerperal and
pregnant women, viz: 80 acute cases, 56 chronic cases, and 16
cases of atrophy. Pueri)eral eclampsia was recorded in 23 of
them,
A modifying condition has been shown by Bailly to exist, viz:
that not rarely albuminuria in pregnant women disappears
for SBvaral hours, and then reappears, so that it may hap{>en that
on examination is made during the short perioii when the urine
ceases to be albuminous. It should be Inime in mind, however,
that it is the renal insufficiency, and not the albuminuria which
causes urremia and convulsions. The mere absence of albumen
from the urine does not even exclude the existence of Briglifs
disease.
C(uivulsions occur more commonly in primipane than in nnil-
tiparie, esi)ecially in elderly primipai-sB, in twin pregnanciea, in
•"fcher Morbus Brifthlii uml seine Bi^xit-hunjzcji zn iuiJ«rcn Kniiikhcil«n."
Volkman's SuTTinil. Klin. Vnrtr.." No. 173, p. I.=V41.
.BusfiNrniA.
247
lomen with contractPd pelves, and in connection with the cle-
lirery of male children. They may occur epidemically iu c<mi-
a^ence of atmospheric conditions, which probably interfere
wilb the functions of the skin, and thus indirectly increase the
labor thrown upon the kidneyK.
Tendency to Produce Abortion.— Besides the risk which
accmes to the motlier from the liability to eclampsia, albuminu-
ria strongly predisposoa to alx>rtiou, no doubt on account of the
im|)erfect nutrition of the foetus by blood impoverished from the
drain i)f albuminous materiuls through the kidnoyH. Thirt fact
i^^Gii been observed by many writers. A go<xl illustration of it is
^M.jen by Tanner,* who states that out of seven womeji he at-
^•^uilfHl. ftuflering from Bright's disease during pregnancy, four
,e».lt»rtwl, one of them three times in succession.
Character of the Urine.— Contrary to the common belief
long patients, the mere physical appearance of the urine as
cloudiness, ropiness, eta, has very little significance, so
as concerns the presence of albumen. The urine is generally
ity, and highly colored, and, in addition to the albumen, es-
rially in cases where the morbid condition has existed for
le time, we may find epithelial cells, tube casts, and oeca-
-^^^^ttUy, blood corpuscles.
Treatment. — Iu order to gain the best results from'the treat-
'^t iif puerperal albuminuria, and prevent so far as possible
occurrence of impending c^ioA^ilsions, it becomes the duty of
* m»»diwd attendant to examine closely every c/ise which pre-
j*^^*tfl suspicious symptoms. In the greater share of cases, how-
1^^^^, he is not consulted until eclampsia has attacked his patient,
**^ hhe is in parturition.
The tn»atmont must of course be modified to meet the various
^^^^cations presented by individual cases. The stage of the
'^"^'p'^Hluctivo process in which she is, namely, — pregnancy, labor
''^ imr-rpenility, the severity of the symptoms, and tlie cause of
^eu). are all important considerations. I£ tlie cause of the
i^baminnria is trnceable to pressure of tJie gravid uterus on
sarrounding organs, thereby producing hypenemia of the renal
secTPtory apparatus, treatment ought to be varied in some es-
fipAtials from tliat which would be employed when albumen in
•"Slgxw »nO DiMUMD of Pn^tDaucy,** p. 428.
248
DISEASES A3ID ACCIDENTS OF PREQXANOY.
tlio urine is referable U^ a differeut cause. Agiiin, a slight trace
of albumen, with no pending oonstitutional disturbances, would
not require the same heroic treatment that might be indicated
when convulsions threaten the patient's life.
Homujopathy has providwl ub with remedies which have a
most salutary effect on this disease. Among them mercurius
corrosivus occupies the highest place. Prof. IL Ludlam ♦ says
of it, " Experience has led me to place groat confidence in the
mercurius cori:uBi\'Tia. I have prescribed it very frequently to
fulfill this precise indicatiou, and it has seldom disap|)ointed
me.'* ♦ ♦ ♦ "The idea which I dosi^ to convey is not that
this, or any other remedy, is an absolute specific for ante-par-
turn convulsibility. There is no real prophylactic ot puerperal
oclnmi)siH. But if in one case in ten you can recognize incipi-
ent syniptomt* of this dreadful disease, and avert 1^ you should
know how to do it."
Arstt'Hivum is often a valuable remedy. The oedema is obser-
vable in the face, esiH^cially about the eyes; the countenance is
pale, and the thirst intense.
Aj^is is indicated by similar symptoms, but there is generally
absence of tliirst
Phosphoric acid and npocynnm cann.^ have also been used
with benefit. The latter may be given with better effect by hy-
podermic injection, the fluid extract being employed.!
Besides tJiese remetlies might 1k» mentioned hellcboruSt fere-
hijithina, phosphorus, and many otiiers.
The Advisability of Induced Labor.— In ol>stinate cases,
the question of iiulucing lalx»r, as a means of relief, is forced
upon us. Hofmeu' is in favor (.»f the oj>eratioD, and believes
that it does not hicreaso the risk of eclampsia, while it may
altogether avert an attack. It has been advocated by others.
On the other hand, Spiogelberg is opposed to it, and Fordyco
Barker J thinks it shoidd only be resorted to "when treatment
has been thoroughly and perseveringly trifnl without succeBs for
the removal of symptoms of so grave a character that theiV con-
tin uauce would result in the death of the patient" Plnyfair§
* **Di8€aM8 of Women." 1H81, p. 21>9,
t Fahnestock, "The cliniqiie," vol. 1, p. 331,
t 'Am. Jonr. Oi>s." July. 187H.
I "System of Midwifery," p. 201.
CHOBEA DCBTNO PBEGNANCY.
249
Myg: "liifliiot easy to lay down any definite ralea to ^de
our decision; but I should not hesitate to adopt this resource in
aQ cases in which the quantity of albumen is considerable, and
progressively increasing, and in which treatment has failed to
kssen the amount; and, above all, in every case attended with
threfttening symptoms, such as severe headache, dizziness, or
liissrjf sight The risks of the operation are infinitesimal com-
pared to those which the patient would run in the event of puer-
peral convulsions sepervening, or chronic Bright's disease
becoming established. As the operation is seldom likely to be
indiciiteil until the child has reaohoil a viable age, and as the
lUnmiDuria places the child's life in danger, we are quite justi-
fad m ouusidering the mother's safety alone in determining on
ifc performance."
Cborea During Pregnancy,— CT^rra gravidarum.— This is
iortanately a niro complication, and occurs chiefly in young,
irighly-nervous women, a large percentage of whom have had
tboTM in childliomL It is occasionally hereilitary. Anaemia is
• bftqaent cause. Sudden emotions and repercusse<l eruptioiis
Wttetimes induce it The mere irritation proceeding from nor-
mal lievelopment of the ovum, in certain susceptible women may
^i^tate a suiticient cause.
Its prognosis, under suitable treatment does not appear to be
w glwtiny art some writers would leatl us to suppose. Still, it
BQjrf be regarded as a grave affection. Dr. Barnes* compiled
fiftj'-eix cases, of which seventeen died. Its danger is not to life
•taw, for it appears that chorea is more apt to leave permiinent
JMntil disturbance when it occurs during pregnancy, than at
°tb6r times. It has also an unquestionable tendency to bring
iliortion or jiremature labor, and generally to sacrifice the
•'( the chilli
Tfwitmeiit.— The patient must be protected from all possible
*iww« of irritation, and her surroundings rendered as pleasant
'ft'i iHSreeable as may be. Good food, fresh air, regular baths,
uilluvnd by brisk rubbing, and such exercise as she is able to
^ we the general indications for treatment Prof. Ludlamf
■iy% "there are nervous conditions which simulate chorea, that
•*'Ofcttet, Trma.," toI. x.
Vlhuawof Womea," 1S81. p. 324.
J
250
DISEASES AND ACCIDENTS OF PREGNAKCY.
yield readily to such rf^medies as belladonu/i, ignatia, coffea, n
vomica, agaricus, and cuprum, under api)rupriato indicatious.
These Rtates are teuiiK)rui*y, and often de])end ujx)n avoidable
causes. They are easily cured.'*
Spasms of chorea, caused by fright, require aconite, igyuii
opium or cuprum.
When proceeding from suppressed eruptions, cuprum ac
cum^ sulphur, otthnrrn vnrh., itrscuicum and amsiicum are
remedies from which selection should be made.
When triiceable to no special cause, the remedies fn^m whiol
to choose are mainly vernirum viride, Mltnlonna^ pulsaiilla*
sejiiti, stifthut, tjilsrmiurn and ('(lulophylhvm, the i>articular indi-
cations for which will he found in the mental and physical traits,
and collateral manifeHtations, Aniesthetics are to Ije used only
as temjKvrary jialliatiTes, and rarely, even for this purpose, save
in the latter weeks of i>reguancy.
If, in spite of our remedies, the paroxysms increase in severity,
and the ijatient's strength api>ears to he exhausted, counsel
agreeing, labtir may be iiuliicetl. Evacuating the uterus gen
ally soon concludes tlie choreic manifestations.
The tendency fa) recurrenc-e of chorea in Huccessive pregnan-
cies should not be forgotten, and every precaution ought to
obsen'ed to prevent its development.
Hysteria.— Anthors do not say much alx»ut hysteria in preg"
nancy, except in its graver form of con^^dsions, yet it is by no
means infrequent in the early part of gestation. It is at this
stage, too, that hystericHl convidsions are most frequent. In-
digestion, excessive fatigue, or loss of sleep may bring on h
terical manifestations in tlie pregnant woman.
Mere reme<iios, liowever well-suitod to the case, are hardly
sufficient. The <lisorder l>eing chiedy emotional, the patient's
mind has to be brought under subjection, not by harsh, but by
the gentlest possible means. Anything which is calculate<l to
strike the fancy, to divert, overwhelm i»r c4>ntrol the ein*>tional
faculties, will have a beneficial influence. These ore excee<lingly
difficult cases to handle, and demand the exercise of tlie l.>est
judgment, and keenest tact The proper employment of friction,
electricity, animal magnetism, bathing and exercise, is to 1)6
reoommendecL Electricity ought to be used with great caution,
lor fear of exciting uterine action.
nn- '
no
Lus I
Ln-
%
PABAtTSlS AND SYNCOrE.
251
iong the remedies most frequently called for are igtuitic^
niur rno^ichutOj tjetscmium^ Mlationiia, cautitphyllumt secale,
plnjnbum, moschus, and nux vomica. The treatment between
pflroxysms must be regulated by the nature of the case.
Paralysis. — Prognnnt womon seem to be more liable to the
Tarious forms of paralysis than the unimpregnated. The sub-
ject, however, is too extensive for anything more than brief
mention here. In a general way it may be said that the disease
Gdems in manv cases to be associated with albuminuria, and con-
sequent on uremia.
Treatment. — Most modem authoritiea recommend that when
paralysis makes its appearance in a pregnant woman whose urine
ib loaded with albumen, that premature labor be induced without
delay. The c^useonce removed, the paralysis usually disappears
in Q few hours or days. If it should persist, the indnctnl cur-
reut, conjoined with friction, bathing, and the suitable homce-
opathic remetlies will genernlly be effectual. For the relief of
paralysis not asscKuated with albuminuria, the induction of pre-
nuihu'e labiir would be munifestly improper.
The resnlt of homoeopathic medication in the treatment of albu-
mimmn, are in the main, so satisfactt^ry, that the cases of parab
yaib dei>endent on its existence, which demand for tlieir relief
tlie induction of premature labor, are few. The remedies of
grwitcst service have already l>eeu given under the head of albu-
nunnria. If we are driven to the inducti4)n of labor, or, if it
eomee on naturally, without subsequent relief of the paralytic
<^dition, the remedies which will be most l>eneficial are nux
rowor;, gvlaeiiiium, sulphui% and calcarca carb,
l^fncope. — Pregnant women are remarkably subject to attacks
<^ f'iiiitTu*8s at various i)eriodfl of gestation, but more especially
during the first half of that state. The sj-ncope is not often
^''ry pnmouncetl, and hence consciousness is seldom entirely lost
Tlw ]«tif!nt, however, may lie with tlilated pupils, feeble pulse,
*"1 partial unconsciousness for several minuter, or much longer.
Trvatment* — Lay the jwitient on her back, with tho he*id low,
Supply plenty of freah air, and give ammonia by inhalation, in a
"^ Dot too concentratefl. Spirits of camphor may be U8e<l in
» like manner. If the attack is prolonged, a sinapism to the
252
DISEASES AND ACCIDENTS OF PREGNANCY
precordia, will be found of much effect. The inhalation of amyl
nitrite (threo or four drops) is oocasionally beneficial.
If the woman is feeble, melancholy, and weeps easily, ignaiia;
if lively, gay and passionate, chanwmilla; if morose and ill-
tempered, gets little exercise, and is constipated, nux vomica; if
the syncope is the result of exhausting disease or hemorrhage,
ch ina.
Painful Breasts.— The changes which are begun early in
pregnancy to prejmre the mammiD for activity, always excite
more or less pain. The suffering sometimes becomes acute^ and
almost insupportable, especially in women who have compressed
tlie breasts with corsete.
Treatment.— If tlie pain is very severe, and inBammation
seems threatened, tlie application of warm fomentations and
poultices will be found useful. Bryonia suits cases of prick-
ling and stitching pain. If there are redness, heat and indura-
tion, bi'lladotvui is the remedy. If the glandular structure ap-
pears to be involved in more or less iutlammat«ry action, phy^
iokicai is to be given, and applied externally.
Pain in the Side.— In the fourth or fifth month of preg-
nancy— sometimes later — women experience severe pain under
the false ribs, on one side, or l>oth. Nux j^oviica will generally
relieve in a few days. Brjfonia^ belLidontuit antenicuin, and
pulsaiilla are sometimes required.
Pain in the AlKlomen. — The excessive distension to which
the abdomen is 8ubjecte<l, creates more or less pahi. Inunc-
tions of Bweet oil or cosmoline will afford some relief. If the
abdominal walls are excessively sensitivo to the touch, sepin will
often prove beneficial.
Lencorrhcpa. — Owing to the extreme vascularity and hyper-
femiaof the generative organs during pregnancy, the occurrence
of leucorrhoea is more common than during the non-pregnant
state. The discharge is largely from the cervical glands, but tho
vaginal glands also contribute. The secretion is sometimes very
copious and acrid, in which case the whole genital tract and
vulva may be hot, swollen and painful. The irritation is often
communicated to the neck of the bladder, and produces frequent
and painful urination.
Treatment. — Best from sexual indulgence, and a daily enema
ODONTALGIA.
253
of tepid water is often all that is required- In other cases, the
discharge persists in de&auee of any bort of local treatment
FiilsaiiUa, — The discharge is thick white mncos, and is ex.
tremely irritative.
HydrcusiiH, — Irritative leucorrhoea, with co-existing indiges-
tion and debility. (A mild solution should also be used as a
Taginal injection.)
Jlfercwnws.— Yellowish, purulent leucorrhcea, producing sore-
ness of the parts.
Arsenicum, — Thin, burning leucorrhcea,
Qilontalgia. — Many women are tormented during pregnancy
witli UH>thache. Tliis sometimes begins with almost the mo-
ment of conception; in other cases not until a much later period.
The most serviceable remedy for this painful affection in a
pregnant woman, is probably sepia. If there is determination
of blood to the head, with either redness or paleness of the face,
bMttionfUL If the aching tooth is affected with caries, sitipky-
SQffria and mercvriitit are the remedies. If the pain is very
sodden and violent wffe.a. If most violent at night, and the
cheek is swollen, viercurius and chtrmomiUa. When it begins
in the evening and continues through the night, pulsafilhu If
the pain is increased by fresh air, wine, coffee, cold, an<i mental
labor, and diminished by warmth ; if there is also a shooting in
the teeth and jaws, extending into the l>onea of the face and
Lead, with a grinding, pressing or drawing in the decayed tooth,
niLX vomicti. The medicine may be trietl au hour or two, but if
relief is not then afforded, it should generally be exchanged for
another.
There is no doubt that pregnancy predisix)Bes to caries, and
the latter condition may necessitate mechanical interference,
namely, extraction, filling, etc. "Tiiere is much unreasonable
dread," says Playfair,* " amongst practitioners as to interfering
witli the teeth during pregnancy, and some recommend that all
operations, even stopping, should be postponed until after de-
livery. It seems to me certain that the suffering of severe tooth-
ache is likely to give rise to far more severe irritation than the
operation required for its relief, and I have frequently seen
• "System of Midwifery," Am. Ed., 18S0, p. 195.
254
DISEASES AND ACCIDENTS OF PBEONANCy.
badly decayed teeth extracted daring pregnancy, and with only
a beneficial result"
CrampK. — Pregnant women are often annoyed by cramps in
the abdomen, feet and legs. For these, verairum (ilbum, taken
before going to bod, will generally suffice. Nttx vomiva or
coffea may be given to nervous, sensitive women. Seaile and
cuprum are also of l>euefit. For cramps in the abdomen gelse~
mium is especially well suited.
Iiguries During Pregnancy-— Injuries, which, in a noi
pregnant state, woidd excite no alarm, occurring during uten
gestation are liable to assume threatening phases. A slight mil
step, a sudden jar, or a light strain, may arouse the latent nter^
ine energies, and precipitate premature expulsion of the o\'um-
Again, a woman will suffer most serious mishaps without evi^|
dent disturbance of the even tenor of a normal pregnancy^*
Mauricoftu tells of a woman in the seventh month of gestation
who fell from the ^dndow of a house, ami, besides extensive
bruises, broke one of the bones of the forearm, and dislocated
the wrist, M-ithout suffering miscarriage. Tyler Smith sj^eaks
of a woman who, in throwing some water from a window, lost
her balance and was procipitated into the street below. Both
thighs were brttkeu, but she did not abori Ovariotomy, and
other major Burgical operations, are frequently performed
pregnant women without loss of the protiuct of conception.
Treatment. — Much the same plan of treatment should
adopted as wouhl bo suitable to a non-pregnant woman. Reist^
for a varying length of time, must be enforced, soiiroes of irrita-
tion removed, fractures dressed, pain allayed, fears quieted, and
ehock overcoma For bruises, arnica will be used. If nervooiHJ
and weak from the fright, ignaUa. If there is excited circula- '
tion, restlessness, heat and auxiet>% (iconifr. Should tiiere l^e
throbbing carotids, injected conjunctivfe, and exalteil sensibility
of sight and hearing, Mhnhmna. If symptoms of threjiten
alwrtion super\'ene, and refuse to give way before indicat
remedies, a full dose of m<irphia may be given by the month,
half the quantity may be injected into the tissues, and repeated,'
if necessary, at suitable inter\als. By thus allaying mental ex-
citement, and quieting reflex action, the emergency may be suc-
cessfully met Extensive separation of the ovnm from its uter-
ina
1
iiy
]
COS8T1PATI0N ASD DURBHCEA;
255
iw sndiorage may have been effected in which case the abor-
tiivpruoefis will not suffer permanent arrest
CHAPTER XL
Diseases of Pregnancy.— (CoNrmcED.)
Constipation. — Tliis frequently annoying a^mplicatiou of the
pregnant state, is owing not so much to thn pressure exerted by
tbepravi*! uterus, as to dimiuished intestinal action. The sed-
enUry life led by most pregnant women doubtless contributes
to its production. Neglect of the bowels sometimes leads to
fecal accnmulations, occasionally of enormous size, which give
rise to spurious labor paiais, and mechanical obstruction during
ptftnrition.
Trpatment. — A regular habit of going to stool twice daily
fibottJd l>e formed, and nothing permitted to interrupt it. Fruits
Hi th(Mr season, graham breail, tigs and such otlier articles of
•**t U have a tendency to relax the bowels, shouhl be eaten.
Utt drinking of a glass of pure cold water, or of sorat; approved
•uneral water, in the morning on rising, together with adequate
^'•nise w-ill be found lieneticial. If, in spite of treatment, and
tap oli&ervance of sucli habits, the bowels still remain costive,
w 'Occasional enema of water, soup and wator, or olive oil and
*^p5ads will afford temporary' relief.
If intb the constipation there are headache, weight in the anus
«iul frequent ineffectual desire, ntw t^omiea slKudd be given. If
"'"Stools are hard and dry. as if burnt, brifonia: constipation
^Ij excessive tlatnlence, h/ropmliiini ; when there is complete
H^ctivity of the lower bowel, and the stools are round, hard and
"•w, optum; constipation complicated with hemorrhoids, ooZ-
'^^fmuL Srpia cc has been rf?c<^mmended as a specific for the
^'Urtiptttion of pregnant women.
"i»rrha*a. -An opjMJsite ootid i Hon of the bowels is occasionally
•^ and its neglect may lead to irritation so great as to excite
iteriiie |>jLin0* Light food, in smull quantities, and repose of
256
DISEAMES AND ACCIDENTS OP PREONASCY.
body, should be recommended. The remedies are phosphoric
(icidf pulsaiilln^ ipecac, dulcnmara^ cluimomilla^ arsenieum, or
even mercurius.
Vesical Irritation. — Owing to its situation, the bladder is
peculiarly liable to functional and mechanical disturbance, ac-
companied by a frequtMit desire t-o urinate. During the first few
weeks, and the last two or three, this is most marked. There are
sometimes much pain and difficulty attending micturition, when
nux vomica will generally afford some relief. If there is invol-
untary escape of mine, with tenesmus, cavipJtor. In the case
of feeble, impreHsible, timid women, jnilsntilhj.
If the ailment becomeB distressing, and reme<Hes fail to afford
much relief, on examination ]ier vagimim should be made, and
if the difficulty is found to be dependent on mechanical condi-
tions which can be changeil, careful interference should be
practicecL In rare cases we may be driven to the use of opium
suppositories in the vagina.
('ough. — Besides the ordinary diseases of the respiratory
tract, from which the pregnant woman is not exempt, she is
sometimas troubh^i with a spasmmlic cough, doubtless of sym-
pathetic origin. It not unfrequeutly resembles whooping-cough,
and may become bo violent as to excite abortion.
Aconite for a few days, followed by nux vomica, has proved
efficacious. If the aiugh is worse in the eveidng, and at nighty
helliulomuL If attended with vomiting, ipecac. Sepia often
has a decided influence over it Other indicated remedies are
hryonio^ phosphorus^ and cottirnth
Dyspnu»a.— In some cases this arises from upward pressure of
the graved uterus, with consequent irritation; and in others it
proceeds from reflex causes.
When due to the latter, loftclia, moschuSt or niu moschnfa are
likely to afford relief. Nux vomica in these, and other cases, is
often of service. If the face is flushed, and the head heavy,
belladonna or aconife may relieve. Arstenicum is sometimes
efficacious. Hysterical dyspnoea will require the remedies else-
where named.
Sleeping with the head and shoulders elevatetl will be found
to have an ameliornting effect on the distress.
Hemorrhoids. — The pressure of the gravid uterus on the
HEMORRHOIDa
267
hemorrhoidal veins, accompanietl, as it often is, by a loaded
state of tbe rectum, not infrequently gives rise to piles. Coin-
cidently with this, dilatation of the rectal veins, varices in other
pwts, such as the vulva, vagina and lower extremities, are often
observed. Distention may become so great as to produce rupt-
nre, giving rise to vaginal or vulvar thrombus or hsematoceley
▼hich will he doscribed in anothor place. The hemorrhage re-
sulting from such an accident is sometimes profuse.
Trealnieiit. — Hemorrhoids maybe benefited by a regidar, gen-
riJe, daily evacuation of the b<:>wel8. Much may he done to favor
Js» as observed under the head of "constipation," by having
■tated periods of going to stooL
Therapeutics. — Belladonna. — Piles so sensitive that the wo-
*>Uin cannot bear to have tliem touched ever so lightly; the back
f "BeJe as though it would break ; throbbing headache.
^loes. — The piles protrude, and are hot and sore, attended
■th hearing down sensations.
Jlainanielis, — Bleeding hemorrhoids, with biirning, soreness,
^Xillness and weight, with tendency to rawness. The local use of
_*-l^^ aqueous extract is very beneficial.
-A'rtr votnicit, — Is of greatest service to women of sedentary
Ll)iiA. and those who have been accustomed to the use of ca-
"^-^^rtics.
Sepia. — The piles come down with even a soft stool; feeling
"^ ^.aring and straining in the rectum; oozing of moisture from
^ rectum; soreness between the nates.
Sulphur. — It is suitable to piles of all descriptions, and should
gi\ien when any of its general characteristic symptoms are
«^VMid
CoUinsonia. — This is one of the best remedies. Sensation as
^^^ sticks, sand or gravel, in the rectum. Worse in the evening,
^^^%:ter in the morning.
~^^9CuIhs Hipp,— Blind and painful hemorrhoids, sometimes
^■^i^htly hlee<Ung; severe pain across the back and hips; feeling
of a stick in the rectum.
CDther remedies sometimes required are, ae-oniiej apis, alum^
. calcftrra carh., graph iies, lepiartdrt'a, niiric aeid, pnlsalilla.
-An o|>eration for radical cure of hemorrlioids during ges-
ion is not advisable; but should they remain permanently
***X5tnided after Uie puerperal period has been passed, they may
DISEASES Ain) ACCIDENTS OF PREONANCY.
be excised, with proper precautions, or cured by an occasional
injection into their substance of a mixture of ergot, carboli^H
acid and glycerine. ^H
For the varices of the lower extremities, an elastic stocking
may be worn. Those of the vulva may l>e kept in check by thng
moderate pressure of a soft pad held by a T bandaga ^|
Displannnents of the I'terus.— The gravid uterus is liable
to displacement, and its occurrence forms one of the serious
complications of pregnancy.
AnteTerslons and Anteflexions. — There is much to be foun
in homoeopathic literatiire on this subject, and one would be led
to suppose that it is not only a common occurrence during preg-
nancy, but that it is'^a frequent and serious complication of
labor. This error proceeds from a want of clear comprehension
of the normal inclination of the longitudinjil uterine axia The
plane of the pelvic brim lies at an angle of about GO^ with th^^
horizon, and it is generally supposed that the long uterine axi^|
is comcidt^nt with, or lies parallel to the axis of this plane,
which WLJulil give the fundus uteri, as is seen in the figure, an
inclination forward more marked than many suppose. The nor-
mal antevGi'sion of tlie impregnated uterus is, at first, sometimes
exaggerateil by the increased weight of the gravid uterine btxly,
Kio. 110. but the deviation is usually rec-
tified by the gradual devekip-
ment, and upward movement, of
the organ. In rare cases the
tleviation continues after the
fourth mouth, and produce^j
tenesmus of the bladder, dysi^H
ritv, or incontinence. The con-
dition, when once recognizetl, is
readily overcome with, or with-
out, an abdominal supporter,
pessary would l^e of no servii
A similar position of the uterus in late pregnancy forms what
is known as pendulous abdomen, which is referable to inade-
quate abdominal support, proceeding from relaxation of the
parietes, separation of the recti muscles, or to the cicatrices left
from operations or injuries. Curvature of the spine, and con-
Relative Hize ami mi'linatiOD uftlie
uterus ut th*? cioee of gestation.
in-
HETnOKLEXION,
259
tnded pelvis, favor its procltiction. Cases are on record wherein
tbe recti miwcles were separated, and the uterus was ante verted
between them, covered only by fascia and integument, nearly to
Treatment clearly consists in the reduction of the displace-
ment, and the application of a firm alxlominal bandage.
H*trOTersion, — This is now regarded as a comparatively in-
frnjaeDt form of uterine displacement during pregnancy, and
»heu B[x:intaneous rectificatif>n does not occur, the development
of the organ forces it into a flexed condition.
Retrofli'xtou. — This is an uncommon occurrence in women
for the tirst time pregnant It may arise during pregnancy
Fjg. in.
f»tjile,
RHrotlcxion of the gravid utcraa.
>m the same causes which produce it in the non-pregnant
U such as a fall, or undue distension of the bladder and rec-
tom; bat sometimes it is doubtless due to displacement of the
organ which antedates conception.
With the advance of pregnancy the uterus generally straight-
6110 and clears the pehic brim, without serious inconvenieuca
This spontaneous rectification is not so apt to occur in chronic
UB in recent ones, because tissue tonicity is greatly im-
260
DlSEAftl
FT8 OF PBEGNANCY,
paired- In mnny coses the fundas does not ascend above the
sacral promontory at the usual time, but remains Incarcerated
in the pelvic cavity, when the condition which was, perhaps, at
first, one of retroversion, now becomes partial retroflexion, by
means of which the uterine cavity is divided into diverticuli or
poaches — an anterior and a posterior.
The symptoms of incarceration embrace dysuria, or even com-
plete retention, vesical tenesmus, incontinence of urine, painfal
defecation, constipation or obstipation, severe sacral and lum-
bar pains extending into the thighs. In grave cases, emesis,
and all the other symptoms of ileus, may be developed. At ajiy
time during incarceration, al>ortion may occur, followed by re-
lief of the threatening symptoms; but should it persist, metritis.
parametritis and peritonitis may ensue with fatal result Death
may also result from pathological processes set up in the blad-
der by reteutiou and decumpoaition of urina These are cysti-
tis and gangrene, which, in turn, give rise to septicemia or vesi-
cal rupture. The retention may lead to urremic poisoning, and
thus to death.
The diatjnosis of retroflexion and incarceration of the uterus
is not often difficult. As the physician passes bis finger along
the vagina, in order to reach the os uteri, he will find tbat it
impingos uix>n an elastic swelling along ite posterior and supe-
rior border, lessening and changing the course of the latter, and
if pregnancy be advanced to the fourth or fifth month, com-
pletely filling the cavity of the lower, or true pelvis. The cervix
uteri, if discovered, will be found behbid or above the ix>8terioror
inner face of the symi)hysi8 pubis. On abdominal examination,
the fundus uteri cannot be felt above the pelvic brim. By bi-man-
nal examination, the alternate relaxation and contraction of the
gravid uterus can be made out, and difierentiation thus made
between the body and fundus of the uterus, and a swelling of a
different kind in the same situation. The clinical history of the
case will idso give imjxirtant data.
The distinction between au incarcerated uterus and an extra-
uterine pregnancy is sometimes difiicult, necessitating a thor-
ough and caroful bi-manual examination, aided, in cases of ab-
dominal tenderness, b}* the employment of an aniesthotia
Treatment* — In these trying cases delay is dangerous, owing
to the progressive increase in size of the uterus, and the per-
BETKOFLEXION OF THE UTEBU8.
261
Didoofl effects of loug-continued pain nnd physical disturbance.
The object to be held in view, is a return of the f undue uteri to
a situation above the pelvic brim. But before attempting the
operation there are certain preliminaries to he observed, the
nret of which is thorough evacuation of the blatider and rectum.
For the purpose of drawing the urine there is no instrumeut
8EDperior to the soft rubber catheter, of small size, oa the ure-
FIG. 112.
Soft Rubber 0801614^.
thra is too greatly altered in its course and calibre by the com-
prefifiion to which it is subject, to admit of tlie safe use of a stiff
oatheter. £ven with this uistruiueut we may sometimes utterly
fail, in which case puncture of tlie bladder, if distension exists,
m$:y be practiced above the symphysis pubis by means of a
B&all needle (^f the aspirator.
Aikother preliminary to the operation in cases of real uterine
iDcarreration is the induction of anfeHthesla, ami the placing of
the woman in the Sims* latero-prone position. The knee-chest
position should be prescribed if no aniesthetic is used. The
operation itself is performed by introducing four fingers into
the rectum, and pushing upward on the fundus uteri. Dr.
B«mi^* recommends turning the fundus to one side, so as to
aftiitl the sacral promontory. Repeated efforts may have to be
mado to acquire complete success. Mere evacuation of the blad-
der aod rectum, and the influence of gravity brought to bear
Quoogh the assumption of the knee-elbow, or knee-chest posi-
liofi, xoay be adequate in some cases to bring about complete
•"Obatetric OpenitioiiB;* Third Am. Ed., p. 27fi.
262
DISEASES AND XOCIDENTS OF PBEONANCY.
reduction. This result may be still further promoted by retnic-
tion of the f>eriiieum with tlie fingers, or by Sims' B|)eculum«
and the admission of air into the vagina.
An instrument has been devised by Dr. H. N. Guernsey,
whicli serves nn admirable purpose in the accomplishment of
difficult reduction. It consists of a curvKi rod of steel, upon the
end f>f which is a hard smooth ball, about three-fourths of an
inch in diameter. The instnunent is provided with a suitable
handle. " As soon ns a case uf this form of displacement la
clearly diagnose<l," says the Doctor,* "if the urine or feces
are retained* the usual means should l>e at onoe adopted for
their evacuation. The patient should then be placed on the
bed, near its edge. \i\Mm her knees and elljows, so that the force
of gravity may assist in the reduction. The ball of the instru-
ment, well lubricated, is to be brought to the anus, with the t\>n-
vex surface of the rtMl upwards, then gently presseil till witliin
the sphincter, when the handle shouM be slightly elevHte<l, so
us to bring the ball against the anterior wnll of tlie rectum.
The instrument is now ^> be firmly and carefully pressed up the
rectum, whpii the ball will elevate the fundus, care being taken
to raise tlie haniUe of the instrument more and more as i)rogreaai
up the rectum is made; and presently the uterus will regain its
normal position immediately posterior to the symphysis pubis."
After reiluction of the dislocation, it has l)eeii recommended
that a Hodge pessary of large aizt: l>t> introduced into the va^na,
and allowed te remain until the uterus has reached a size which
precludes tiie possibilty of a return to its former position.
Others advise simple lateral decubitus, with* mt the use of any
pessary. The after treatment includes also careful attenti<iu to
the bladder and rectum, neither of which should be permitted
to become loaded.
It occasionally happens that replacement of the uterus is pre-
vented by infiammator)' adhesions, or by the secondary swelling
of the displaced organ, in which cjise the induction of alx>rtion
is the only recoursa Meelianical obstaolee to the ordinary
methods of amusing uterine action are here met, and tbe mxrom-
plishment of the object in a tolerably safe manner will tax one's
ingenuity and skill. The introduction of a uterine sound, or a
•" Guernsey's 01»stetric«." p. 116.
PB0LAP8E OF THE UTERUS.
263
fcdble catheter is rarely practicabla Dr. P. Mtlller,* in a case
of complete retroversion, resorted to the following ingenious
e^Mdient^ a knowleilge of which may lie of beuefit to others :
He cut off the end of a male silver catheter, and after having
beat the extremity, he hooked it within the cervix uteri which
Wfi looking upwards and fowards. Through this artificial cLau-
mI he passed a piece of cat-gut, and left it between the mem-
bnoea and uterine wall. In twelve hours the fcetus was ex-
pelled. If our efforts to pass a foreign, but innocuous, substance,
vithin the uterus, prove unavailing, the organ may be punctured
through the vagina with an aspirator needle, or a fine trocar, and
a|vrtion of the liquor umnii withdrawn, without much risk to
the woman, if practicecl under strict antiseptic precautions.
This is a sure methtxl of bringing on abortion.
Prolaps<» of the rieriis. — We have' already directed atten-
tion to the normal de.scent of the gravid uterus during thp eai'Iy
'ftckBof gestation; but in some cases physiological bounds are
I*«8wJ, and decided prolapsus, and even procidentia may be
pfodiiced.f Abnormal downward displacement of the organ
produced during pregnancy is generally the result of mechani-
nl vitdence. and its result is often abortion, brought about di-
Wctly by uterine eongi*wtion and hemorrhage. It is most fre-
^o'^iit in multiparie, (uul, in a certain proportion of coses, the
iB'»U|ip.nB antetlates the pregnancy in which it is obser\'ed-
The disturbances to which this sort of displacement gives rise,
^y m severity and choi'acter with the stage of pregnancy at
^hieh it occurs. Should the condition remain unrectified, the
Wadder and rectum l^ecome irritated, there is a feeling of weight
in the ftnus, and jiainful tractions in the groins, lumbar regions,
wni ambilicua. A foetid discharge is set up; no change of posi-
tion rolifives tJie suffering, and a state of marasmus is liable to
wperreuiv These symptoms become intensified, until, gener-
ally, sufficient irritjition is create<l to bring on abortion.
P^x•identiB uteri is simulated by hypertrophy of either the
''^pru, ur intra-vaginal jxirtiou of the cervix. Excessive devel-
"*7.nrTlieropi<' der Ketroversio Uteri gravidi." "Beitr. Zur Geburtah."
tVinuuer ^vide Caxeanx), p<?ported a rase of complete protudcntia of the
l*n»l uteniA, the entire organ lying belwivn the thighs.
264
DISEASES AND ACCIDENTS OF PREGNANCY.
opment of the intra-yagisal p>ortioD of the cerrix is sometimee
transformed into a pulpy-like moss, and, as a consequence of
constant friction, abortion is brought on. This hypertrophied
condition of the enlarged cervix appears to exercise a prejudi-
cial effect on utero-gestation and parturition, and amputation of
the part is sometimes resorted to, during the third month, with-
out interrupting tlie course of pregnancy.
Prolapsus is generally spontaneously rectified as pregnancy
advances, but in some c^ess it becomes necessary to gently, but
firmly, manipulate the organ, and restore it to a normal situa-
tion. After such reduction, perfect rest in bed should, for a
time, be enjoined. The vesical tlistention which is liable to
complicate the anomaly, should be relieved, if necessary^ by the
use of the catheter. Resort to this instrument may often be
avoide<l by the woman assuming the dorsal decubitus, with ele-
vatt^d liips, for the act of urination.
Wliere there is actual incarceration, scarification should be
jierformed, and reposition attempted. If reduction cannot be
accomplished, abortion should be induced before compression
of the pelvic tissues has l>eoome excessive, or has been lon|^
oontiinnnl.
Hernias of the Pregnant Uterus. — These are true eventra-
tions, resulting from extreme relaxation of the abdominal walls,
and may very properly l)e classiiied with what has been de-
scribed as auteversion ot the gravid uterus. The anomaly is
fortunately a rare one. The most frequent forms are the um-
bilictxl and the ventral. Femoral and inguinal uterine hernias,
while exceedingly rare, and hernias tlirough the foramen ovale,
and the great sacro-sciatic foramen, have been kno\^Ti to occur.
Ventral hernias often form, from separation of the recti muscles,
and occasionally from the yielding of extensive cicatrices resolt-
ing from abdominal incisions.
Certain of thpse forms are many times congenital, such as the
femoral and inguinal, and those through the foramen ovale and
greater sacro-sciatic foramen. The latter two, however, should
not here be considered, as pregnancy was never known to occur
in a uterus which had escaped tlirougli one of these openings.
Diagnosis is not often attended with much difficulty, when dne
attention is given to the form and development of the hernial
tumor, and the absence of the uterus from its usual place La
SITROICAL OPERATIONS DCBIUG PBEGNAi^CY.
265
the pekUf together with vaginal tractiou toward the displaced
orgazL
In the way of treatment of these vexing anomalies, reposition
occupies the most prominent place. It is rarely practicable,
Ijftwever, unless the condition is discovered in its incipiency,
tfaoQgh in a case related by Ruysch, a midwife, by raising the
turaor, succeeded in returning the foetus into the abdomen, after
expulfiive efforts had begun, and the delivery was effected &a
Pregnancy occurring in inguinal and femoral uterine hernias
alwiiys terminates in alx)rtion or premature laU^r. When rejx)-
sitioa attempted in the usual manner, fails, it may sometimes
8tiin»e accompilished by di\nding the hernial ring. Tliis would
M«^*ely be a justifiable procedure, except in coses well advanced-
lUluction by the ordinary measures failing in an early stage,
ttlK>rtion should be induced, and thus the dangers attendant upon
fuitbftr development, and ultimate expulsion, averted.
In every instance, after successful reduction of the dislooa-
tioa. its return should be prevented by a well-adjusted truss.
Suri^ical Operations During Prefi?nancy. — Mnssot* con-
clodeft, from the observation oi a c<:)nsiiierable number of cases,
that urrliujiry surgical operations do not interfere with pregnancy
utilG*s they materially and ]>ermanently disturb the uterine cir-
c«lhtion, or call into nctivity the uterine muscular force by reflex
irritAtion- This will mo5t frequently be the result of operations
Dpua tlip pxternal or internal genital organs. Ct)hnsteint states,
the result of hia researches, that after ojierations and injuries,
pregnancy reiiches a normal termination in r)4.5 per cent, of all
cuea Interruption of pregnancy was, in his cases, determined;
{^j by tlie jieriod of pre^ancy when the operation took place,
ocCTUTing more freciuontly as the result of surgical measures
resorted to in tlu* third, fourtli, and eighth months; {h) upon
the sefkt of the operation, resulting in two-thirds of all cases,
fitim opf'riitit)ns n|Hin the genitivurinary organs; (c) upon the
eiteut of the wtnind, following amputations, exarticulations, and
ovariotomies with great relative frequency; (d) upon the num-
•■■ r«b»r d. KtnfltiM traamat Einwirk. aufd. Verlaafdcr SchwongercheA."
8rhmidl'« ".rnhrb..' 1h74, 1G4 p. 2fi«.
f " I 'r*»rr lOiirurg. Op. t»ci, Schwaugerca." Yolkmaiui*» " Samiul. Klia. Vortr."
266 DISEASES AND ACCIDENTS OF PBEGNANCV.
ber of cliildren, occurring in multiple pregnancy with uniform
regularity. Ag(? seemed to exert no cauBatiTe influence. Abor-
tion directly results, under these circumstances, from reflex
irritation, or from fcetal death, referable to hemorrhage, or to
septic poisoninj: on tlio mother s part. The prognosis, so far as
the woman is t'oncerned, tlepeiids upon the time when delivery
occurs. The mortality «)rdinarily attending delivery, if at t<>rm,
is insignificant; for abortions and premature deliveries it amounts,
acotirding U* Cobnstein, to thirty -three percent. The most
frequent causes of the mother's «leath are shock, |)erit.onitis,
septicjinnia. hemorrha'^e, and tedcrma pulmonalis. In view of
the manifest danger from opcrntinns of any magnitude, it may
be stated as a general law. thatsurgicid measures not abs<jlutely
indicated by the existence of ymth< (logical c^niditions, liable to
Hggravati<»ns by dehiyed interfereiico, should l>e postj^meil until
after contineirieiit. Tlicise morbid contlitions, however, whose
deA-elojiinent is hasteiu'd by pregnancy, or wlu»se existence oflers
meclianicnl nl>stach's to ]>arturitioii, must be early subjected t<>
operative iiifrrfereuce. This remark ap])lies with special f«)rce
to careiiuniiatous gn»T\'ths in any i)artt)f tlie Ixuly. and to intra-
pelvif tumors.
Tin- time ol* <>])*'nitioii shouhl nut cninciilt' with the time of
tiM' su.-pcndeil nn'iistni;il cporh, as jibortion is more likely to
ocfur at tli.'it period,* I'll!' ;i slinihir reason it is n-comniendod
that tl-c third. I'unih aiid fi^hlli nifniths shonhl ]»e avoidi-d.
Jla-sot is ««f til'' i>iiiiii'ii "'' that aiia-^tlieties. wli^n oinploy*^!
<birin;^ oprratioi!-; on pn-Lriiant wnnn'ii. cxi-rt ratlicr a favorable,
than M |.rt'jailici;!l. •■\\W\ upon fatal lil\-. by diminishing reJh'X
iri'itatio;i.;[;
rardiae Diseases. Tlic^e afTeoiiini:- vary in seriousness with
thfir I't-nii. lM\iM;ir.iiti> iiit»Trfn-< with the di'Vi-lopment i>f rar-
iliac h\ |"'i'troj)|iy. i-i»nipcii-!i!orv I'ov r\if^ting valvular lesions.
KndiM-arditi*i in |»rci:naiii'\ sli-iwsa .-^tro|l^ it'ndency to fissunio
the fatal uln-rativi- form, while [M-rirarditls lias no marked etl'ect
upon the nuriiial iMinr>e nf utero-gotritiun. The i-liief I'lement
of daji^er ill tl'( -'• e;i-e> j,^ iln- in'cosity which exists for hyi)er-
tropliy of the oTLiaii t" <-'niii*-n>ate iln- increased arterial pros-
*Si'n:(;r.i.r.i;i:ii. " I,< ln'i. i! W l'iiit>li.." p.'iiis.
•f- Mar*S(t1. lor, rit., \i. \*ii~.
I }'itit:. I.UffkV Miil\\ir<r\. p. 'i'S.':
EBUmVE FEVERS.
267
sue. Another important element of danger is the varied and
pertarbed henrt-aetion fonnd during labor, under the suddenly
changing cou^litione of pressure produced by the alternating
nttrine oontractioua and rolaxatiouo.
Out of twenty-eight cases of cardiac disease during pregnancy,
PTjllet'tetl by Dr. Angus MacDonald,* sixty jiercenL proved fatal
The ^^loptoms of serious cardiac lesions do not generally appear
nalil after the middle of pregnancy, imd gestation rarely advances
U>term. The symptoms, when severe, usually show themselves
in the form of pulmonary congestion, pulmonary cedema, with
(wcnsional pneumonia and pleurisy. The most serious vahnilar
U-vioim seems t*i bo here, as in non-pregu(^it conditions, 1. Mi-
trui Htenosis, and *i. Aortic insufficiency. After pregnancy ter-
miimtes, and the terrible strain of parturition is safely ])assed,
tJi** s)Tn[)t(>m9 usually disnj)]3ear, though when the caso has
wv^loped threatening patliological conditions before lalx)r, the
■woman is liable to sink during pnerperality. Foetal nutrition is
wjrt ti» bec<3me impaired t*3 a marked degree, resulting in iinper-
f^'X (ifivelopinent, and death soon after birth.
Wi>inen who are the subjects of cardiac tlisease of any degree
cf gravity, should bo encouraged to remain single. The treai-
itof the cardiac lesion will m>t bo materially modified by the
ice of pregnancy. T|je symptoms must be carefully stud-
wcl and the isimilimnm chosen. Snnitarj^ regulations are of the
Ughri^t importance. The patient should have plenty of fresh
tdr and nourishing fcKNl, though great precaution should l>e ob-
■enwd not to overload the st^^^nuach. Exposure to cold, and all
forms of over exertion must be avoided. Aii;i'sthotics may be
ero|>l<tyeil daring labor, — preferably chloroform — but with on-
tfatnal caution.
Eruptive Fevers. — The ])regnant woman is not exempt from
to Ruch cont*igi<m. Mritsh^^ is not infrecjuent, and it
serious ft*niur<*H in quite a percenttige of cases. It
seemfi to manifest a tendency to become hemorrhagic and to
pr. * '>»'trorrh«gifi, tenuinuting fatally txi mother and child*
Pi I is a very frequrr-nt and dangerous ^implication of
the disease in pregnancy. Abortion is not on uncommou result
of Use disorder.
• •KJbtttet. Joiir.," 1877.
DISEA8E8 AND ACCIDENTS OF PnEGNANCY.
Yariola^ of the eruptive fevers, is most frequently met, and is
withal, the most disastrous in its results. It attacks from pref-
erence women who are in the early stages of pregnancy, but its
onset later in gestation is attended with greater danger, con-
stantly augmented as it nears parturition. The dangerous as-
pects of the case are found in the tendency to metrorrhagia and
abortion which is usually manifested. The severe and confluent
forms of the disease are almost certainly fatal to both motlier
and child. When variola is of a mild form, and esi>ecially when
modified by recent vaccination, its course is generally favorable,
though abortion often ensues.
Scarlatina. — A striking peculiarity of this disease is that ita
contagion does not always excite immediate diseased action in
the pregnant woman, but occasionally its force api>ears to l>e
felt only after th(^ lapse of a considerable time. For example, a
woman, even in the earlier months of pregnancy, may be ex-
I)08ed to the disease, but temporarily escape its baneful influ-
ences only to fall a prey to it in the puerperal state. Olshausen,*
aftei' tliorougli search, was able to collect only seven cases
Ecarlatina in pregnant women, while he found one hundred
thirty-four in puerr»erre.
The mortality from the disease occurring in pregnant women,
is high. This tUsorder does not appear to be materially altered in
its general characters by the existing pregnancy, and ita usual
treatment requires no important additions.
Continued F^yern,— (Typhus, Ttjphoid, and Relapsing
T>ern. ) Pregnant women are Ijable to attacks of any of the
continued fevers, which do not appear to be aggravated by the
pregnant condition, but, when severe, are apt to provoke alxir-
tion. Out of seventy-two cases of typhoid, sixteen ab*>rte<l; and
out of sixtj'-three cases of relniming fever, pregnancy wbja inter-
rupted in twenty-three.
Tliese forms of fever are more likely to attack women in the
earlier months of pregnancy, and their eflects vary with the
form of fever present. Typhoid fever is frequently, and relaps-
ing fever almost uniformly, accompanied by abortion, or prema-
ture labor consequent on profuse uterine hemorrhagea Accord-
♦OrsnArsEN. "Untcreuch. uh. d. Compile, des Pnerp. m. Searlat. u. d*
SOgenanntcS. puerperiilis." '* Arch. f. G.vna<?k.." ix, ief76, p. 16S-, BuAX:
HicKS. " Tnuis. of tbe Obetet Soc Loadou," voL xvii
?n,«
BOf I
lon^
din j
iuaJ ^
PNEUMONU.
269
ing to Schweden, one of the chief soiirces of danger to the
fcetus in such conditions, is the hyperpjTexia.
The treatment of these cases is not essentially altered by the
cOensting pregnancy.
Malarial Fever.—This oonapHcation of pregnancy is not often
observed. When the poison lurks in the system from former
infection, it is often lighted up during recurring pregnancies.
This form of fever does not often result in abortion, even though
I>ersi8tent in its stay. The occurrence of labor interrupts the
paroxysms for a time, but, in the second or third week of the
puerperal state, they are apt to return. Tlie paroxysms manifest
either an anticipating, or n retarding tendency, being very irreg-
nltiT in their appearance. The fever sometimes takes on a per-
nicious type, and requires energetic treatment It has been
sviggested by Dr. Fordyce Barker, — and the suggestion is a for-
cibleone, — that, in the adininistratiou of remedies, regard must
l>e had to the impaired powers of digestion and assimilation.
Pneumonia. — Of all the acute inlQammations of the envelopes,
c>T of tlie parenchyma, of the organs, pnnumonia is one of the
tt^cwt likely to pnxluce abortion or premature labor.* Grisollef
reported four cases of his own, and collected eleven others. Of
tlie*ie fifteen women, ten had not reached the sixth month, and
f«^ur aborted a few days after the onset of the disease. Only)
<^tie, whose pneumonia was limited, ^recovered without serious I
^luptonifi.
It seems clear from these data that pneumonia, occurring in
pvcgn&ncy, is a remarkably fatal disease. The same facts, how-
^''r, fstablish the comparative infreijuency of the complication.
The strong tendency to abortion is probably attributable to the
importance of the organ directly involved, the gravity of the
■iiaeoae, the hyperpyrexia, the intensity of the general reaction,
*n<I tlie numerous sympathetic disorders which it pnxluces in
^U Ujp functions, much rather than to the paroxysms of cough-
ing. The caii.se of the maternal mortality is not altogether clear,
W it is probably referable to the coexisting hydnemia, and to I
the inability of the poorly nourished heart to restore the bal-/
ance of pulmonary circulation disturbed by the consolidation of
•CaJOACX. "Theoret. and Pract. Midwifery.'
fAtth, 04n dc M<^d. vol, xiii, p. 398.
Anu Truiuflation, p. 448.
270
DISEASES AXD ACCIDENTS OF PREONAKCY.
lung-tisBue, and by the consequent imponneability of largo caj?
illary areais.* (JEdema of the lungs, resulting from weakened
heart action, is the immediate cause of death. The occurrence
of alx)rtiou or premature lalxtr during the dise^ase, greatly aug-
ments tiie dangers, and we should recollect this if the question
of the induction of premature evacuation of the uterus is sug-
gested. If labor has already begun, every reasonable effort
sJiouId be made to accelerate delivery.
Under judicious homoeopathic management we look for better
results th.'in have lieen obtained from other forms of tieatmeni
The remedies should be adapted more especially to the pul-
monary condition, and are those most commonly employed in
treating the disease wliSnTnot associated ^th pregnancy. '
Phthisis.— Contrary to the generally accepted belief, preg-
nancy, in the majority of cases, hast^?ns the progress of phthisis,
and precipitates its development The latter is true, of course,
chiefly in tliose women wlio have an herediUry, or a strongly-ac-
quired, tendency t<i the disease. Out of twenty-seven cases of phthi-
sis coUecteil by Grisolle,t t^^-enty -four showed the first symptoms
of the disease during gestation; from which facta we are led to
conclude that pregnancy does not exert a protective inlluence
against the development of this tUsease. Women in the advanced
stiiges of phthisis are not susceptible to impregnation. Spiegel-
berg J says that women with inherited tendencies to the disease,
often escape it daring their first pregnancy, only to fall under
its baneful iiifiuences in a subsequent one. When such women
pass through pregnancy and parturition in safety, their vital
forces are extremely rediiced, and they have little or no milk for
their children, who are nearly always feeble, poorly nourished,
and inherit consumptive tendencies.
It is fortunate for such M-omen that they have little mOk,
they are tliereby obliged to resort to other sources of nutritious
supplies for their ofifij>ring, and thereby economize their remain-
ing forces. Girls possessing tendencies to phthisis shoidd be
dissuaded from entering the married state, as their interests, and
those of society, will be best subserved by their never beouming
mothers.
*M
*LVSK. '• Science and Art of Midwift-ry," p. 258.
t"Ob6tet Journal," 18T7.
t " Lclirb. d. GeburtBh.," p. 226,
8YPIULI8 IN PXIKOXANCY.
271
Syphilis. — Primary syphilis seems to luxuriate in pregnant
-omen. The periL«l of incubation is not limited to two weeks,
trut may }ye six weeks, or even longer. The lesions are more ex-
t.eiisivc than in the non-pregnant, and may involve the vagina,
c^rrvL, labia, nates, and tJiighs, and consist oC swelling, redness,
es.<^natiou, an^l ulceration of the inucoos membrane and skin,
oeclt^ma, eczema, follicular alwoesses, and even necrosis of con-
netlive ti^ue. Tlie 8ec<:tndary symptoms aro unusually mikl,
ct-msistiug, in the main, of ghuidular induration, papules in va-
rioiLH purt», hut especially about the genitals, and psoriaais of
Vho [HihuA and soles.
The ravages of syphilis are experiencetl more particularly by
thpfietus. If either i>areut, at the time of fertile intercourse,
i^^i^fferi»g from general syphilis, the i>oison is communicated
lt> the product of conception. The infection thus transmitted
to the fcetns is not often communicated by the f(t?tus to t!ie
lu'rtliw. Furthermore, tlie woman who contracts tiie disease
flibscquentJ^ to impregnation, /. c, while carrying the fcetus,
«nuot infect the latter. In other words, tainted spermatozoa
n^iy infect the ovum, without the womnn at any time l»ecomiug
iftftfted, find an ovum which was fi'ee from taint at tinie of im-
P*T?imtiun will not bec<.»me infected by subsequent maternal
<^trRctiou of the <liseasc, for the syphilitic poisim will not
tmvGrse the septa between the foetal iiud maternal vascular sys-
^Tas>. If botli jMirents are the victims of general syphilis at the
tininof impregnation each communicates the jjoison to the off-
spring.* Exceptions to the fiuegoing rules nre rare.
ft must m)t be iuferre<l, however, that every chOd bom of
inflected j>ftrenta will present evidences of the disease in ques-
li"a Indeed, it seems prolmblo that such is not the most fre-
'juent resnltt Legentlre. in discussing tlie question of the
iaiejit condition of syphilis in the parents, and of its influence
opon the child, says that out of (>3 jtatients who came under his
observation, there were 14 who had G^ children during the iu-
terrftl l.ietween primary and secondary stages. Of this nundjer,
35 died with<»ut ever manifesting any signs at infection. The
Arerage ftge of the children at the time of death was seven
,^KAmowi'n. "IHe Verenbungd. Syphilis," Strieker'* " Me<l. Jahrb,"
979L
f CAZEAirx. "TheorrL and Proct. Midwifery," p, 542.
272
DISEASES A>D ACCIDENTS OF PBEQNANCY.
years. All the surviving cliildren (33) enjoyed good healUi, thJ
mean of their ages being seventeen years.
The conditions under which it proves transmissible, varies con-
siderably. When the disease is allowed to proceed, unmodiBed
by treatment, the poison may never be wholly eradicateil; but
the liability of transmitting it to the ofispring seems to be lost
after an average period of ten years. Because the disease is
latent, it must not be inferred that there is no danger of infect-
ing the ofi^pring, though it is admitted that such a condition
diminishes the probability of communicating the infection. The
foetus may perish in utero, or it may be born alive only to die
early. The disease does not always declare its existence under
two years from date of hirth. Children begotten during the
first two or three years after infection of either parent, are al-
most sure to be expelled prematurely.
Women who at the time of pregnancy, or within a year or ti
previously, Imve suffered from syphilis, will be less liable to en-
tail the disease on their offspring, if given mercurius for a time,
at intervals during pregnancy. In old-school practice, mercu-
rial inunctions ai*e regarded as most beneficial When tte dis- ,
ease Lb contracted during pregnancy, and there are primary o^H
secondary sores about the genitals, care should be exercised 1^^
protect the foetus from infection during delivery.
w^^
PART Til.
LABOR.
CHAPTER I.
We have traced the growth and development of the foetus to
otturity, have cnnsidered the diseases and accidents to w]iich it
isH&ble, the phenomena and management of it-H premature ex-
palsion, and we now come to that part of our subject that treats
^ its expulsion at the close of mature utoro-geatatiou, which
peri(H], in the human female^ is completed in alH>tit ten lunar
fflonths from the date of impregnation.
ClMes of Labor.^Tho folh>wing observations by Lusk on
tiiis subject are so clearly and learnedly set forth, that tbey are
W transcril)ed almost i7j;7Ki//m rt UUrrdlhn* Speculation aa
t«the proximate causes of labor have so far proved profitlesa
^y following particulars c^>m prise the extent uf our knowledge
of tlie conditions which prepare the way during pregnancy for
^Hnal expulsive efforts:
!• During the first three months, the growth of the uterus is
ni"w rapid than that of the ovum, which is freely movable
•nthin the nt*>rine cavity, except at its placental attachment In
tlif* fourth month the reflexa becomes so far adherent to the
chorion that it caji only be separated by the exertion of some
lOij^'ht degree of force, and the amnion is in contact with the
ckuion. After the fourth month, the chorion and amnion are
Agglntinated together, though even at the termination of preg-
flftncy the one may with care be separated from the other. Af-
ter the fifth month, the agglutination of the deeidua vera and
roflexB taken jjlace. In the second half of prognEincy, the rapid
fjevelopraent of the ovwrn causes a corresponding expansion of
tCWC. " Science and Art of Midwifery," p. 123.
273
274 LABOR.
the uterine cavity, the uterine walls becoming thinned, so that,
by the end ot gestation, they do not exceed, upon the average,
twi) or three lines in thickness. The vast extension of the uter-
ine surface is not, however, simply a consequence of over-
stretching, a fact shown by the circumstfiuce that tlie uterus, to-
ward the close of gestation, is increased nearly twenty-fold in
weight, and by the histories of extra-uterine foetations, in which,
up tf> a certain limit, the utei*us enlarges progressively, in spite
t»f the non-presence of the ovum. The augmenteil weight of the
uterus is the result of the increase in length and width of the
individual muscular libre-cells, the extreme vascular develoj)-
ment, and the abundant formation of connective tis.sue. Up to
the sixth and a half month there has further been observed a
genesis of new libre-cells, espooially u|)ou tlie inner uterine sur-
fnce. Acot»rding to Ranvier, the smooth muscular fibres bec<^nie
striated as the end of gestation is reached.*
The jn'ocise manner in which the distention of the uterus is
accomplished has as yet not l>een demonstrated. A priori oidy
two ix>ssibilities are apiwireutly admissible, viz: either the indi-
vidual structure elements are stretcliod after tlie manner of elas-
tic bands, or a rearrangement of the muscular elements takes
jjlace in sTK'h wise that a ctM-taiu ijroj)ortion of the tlbro-cells, iii-
sh'ad of lyiri*:. as in the In'-^uniiiji: of pregnancy, parallel to ouv
another, grMduiiliy, with the n(hance of gestation, are displaced,
so that tht^ (Mulri only are in jnxtaix)8ition. It is probable,
tlutugh nnt ]»n>v«'(l, that t<»ward the close the thinning of tho
wall is the result of both euinlitiinis. 13oaring in mind those
premises, it becomes a disputed question as to whether one of
the causes of laUtr is not t4> \h\ found in the reaction of the
uterus, as a holhiw, mus<Milj'r organ, from the extreme tension to
which its libres are ultiniati'ly subjeettMl Countenance to the
aftirmativi' siile is all'orded by tlie t<^iidency to prematui'e lal>or
in hydramnios and multijile pn^giiancies, in which a high de-
gree (tf tension is r(Nichod at a p(^riod cttnsiderably in advance of
the compL'tt? devolopmont of the fo-tns.
2. Theni is a pereeptibh* incn*ase of irritability in the uterus
from the very beginning oi gestation. Indeed, the facility with
which contractions may be produced by manipidating the organ
* Vidr Takn[EU kt CiiANTitKni,. "Trails do 1 'Art des AccoiU'hments,"
p. *ia;t.
THE CAUSES OF LABOR.
275
thnn^b the nb<lominal whIIs, has Iwen put forward by Braxton
Hickfl Hs uiie of the i.iistiiiguishing signs of pregnancy. This ir-
ritubility is especially marked at the recurrence of the mensti-ual
•hi, and becomes a more and more prctmineut feature in the
llhtUr lUduMis, when spoiitanei^ms painless contractions ore ortli-
ury iDciileuts of the normal condition.
X Tlifl researches of Friedlauder, Kundrat, Engelmann, and
Lft:>piild, have demonstrated that the decidua vera of pregnancy
is distLiigaishable into an outer, dense, membranous stratum,
onni|x^fie<l uf large cells resembling pavement epithclia, prol>ably
tWibmorphosed cylinilrienl cells, and what appetirs to be a sub-
jawnt mesh-work, formed fr<mi the walls of the enlarged decid-
^\ glauds. It is in this s|>ongy layer that the separation of tlie
tlwiJoa Uikes place, the fundi of the glands persisting, even of-
Fio.iia.
"** t^trrtiif MiH-onft Meinhrane. A. Amnion, /f. KeflexjL D. Decidua
^'!T^ D. K Glundular Spaces of- the Lower Stratum. ST. Muscular
t^lnirturr. — K?cnEi.MANX.
•^tbo oxpulaion of the ovum. By many, a fatty degeneration
^ til.. p**Ilit c»f the decidua has been observed towaid the end of
ti^^imuo*: l*ut Leopold, Dohm, and Langhans have shown that
"io is not of constant occurrence.* Tlie trabeciiJre which in-
*** Iho si>ace9 of the net-work, diminish in .si^se with the ad-
**«<» of jiregnnncy. Thus, while tliey measure at the fourth
*^tli ftl^jut 1-500 of an inch in thickness, they become gradu-
*^y »<luoe<l in the sul>sequent months to 1-2500 of an inch, a
'UftMLD. "Stndicn nbcrde do Stilileimhoot," etc, "Arch. f. Oyna«k."
276
LABOR.
change which materially facilitates the peeling off of the decid-
ual surface. *
4 From the fifth month onward, cells of large si^e make their
appearance in the serotina, especially in the neighborhood of
thin-walled vessels. The largest of these so-called giant-cella
contain sometimes as many as forty nuclei Though a physiolog-
ical product, they resemble for the most part the so-called spe-
cific cancer-cells of the older writers. They are of special obstet-
ric interest^ from the fact observed by Friedlander, and confirmed
by Leopold.t that they penetrate the uterine sinuses from the
eightli montli, and load to coagulation of the blood, and to the
formation of yt>uug connective tissue, by means of which a por-
tion of the venous suiuses becomes obliterated before labor be-
gins. The subtraction of these vessels from the circulation tends
to increase the amount of renous blood in the intervillous
spaces of the placenta.
5. It is proper to recall here the fact that tlie nerve-filamentfl
of the uterus are derived in principal measure from the symjia-
thetic Bystem. The large cervical ganglion, whi<^h in pregnancy
nieasui'es aK'mt two inches in lengtli, by one and a half inches in
breadth, receives, however, in ad*lition to the sympathetic fibers,
filaments fi'om the second, third juid fourth sacral nen'es.
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 Lusk's hospital patients, with
paralysis of the lower extremities, i^etention of mine, and loss of
power over the sphincter-ani muscle, had a X)ertectly natural,
though painless delivery. Thecauseof the paralysis was obscure,
the patient subsequently making a complete recovery. Jacque-
martj reports a similar case, in whicli the paralysis was due to
partial compression of the cord at the level of the first dorsal
vertebra. On the other hand, Schlesingerg has shown that the
sympathetic is not the only motor nerve, as reflex movements of
tlie uterus follow stimulation of the organ wlien all the branches
of the aortic plexus have been carefully divided.
'Knqelmanx. "Ttic Mucous Membrane of the Uteros,** p. 45^
top. ci/., p. 492,et»t((.
JTahnier et Chantreitii,, " TraU<? de TArt dca Accouchmenta," p. 2Q9.
JObeb und Schlesixqeb, Strieker's " Wiener med. JaLrbach," 1872.
rsES OP LABOK.
277
A motor centre for uterine contractions Las been proved to
mst in the medulla oblongata. Tliis centre is excited diiectly
to action by antemic conditiouB, and by the presence of carbonic
acid iu the bkxxl conveyed to it. Vivid mental emotions may
eithur awaken or suspend uterine conti'nctility.
Keflex movements of the uterus may be provoked by stimulat-
ing tJie central end of any of the Hpiiml nerves, a fact wliich
eerres to explain the consensus long recognized as existing
between the breasts and tlte generative organs. Wlien tlie spi-
nal oord is divided below the medulla oblongata, tliia pheuome-
DtJH is no longer obfc^er^'ed. Direct stimuli Uj the uterus, how-
fver, determine contractions independently of the medulla oblon-
gatA, the spinal cord then acting as a retlex centre. The pres-
ence of asphyxiated l)l(>od in the arterial trunks acts fls a physio-
logical stimulus to labor.* By tlie separaiiou of the decidua
!miij its organic I'onnection with the nt<>rus, tlie ovurn acts as a
Ueign body, and, as is well known, speedily awakens uterine
movementsw Finally, it 1ms been shown by Kehnerf that, when
.itvTnu is removed from the uterus during labor, rhythmic con-
tJiu'tiiins of the muscuha* hbres will contiime fn)m a half-hour to
w hmu- after separation, pro^nded only the tissues be kept moist
«ul nt ft 6uital:»le temperature.
TLcfollowiug tiieory of the causes of labor is offered, not because
"' itfi completeness, but merely as a means of grouping the fore-
l^'iiig faetii toj^'ether in tlie order of their relative imiwrii-tance.
Ti»»' 'nlvance of pregnancy is associat^ed with increase iu the ini-
t^lniity of Uie uterus, a pro|)erty most pronoimceil at the recur-
tvm) of the menstrual ejxichs. By thinning of the pai'titions
ww(M*u the glandular structm'cs the way is prepared, as the
titoe for labor approaches, for the easy separation of the dense
^w 8ti*atum of the deoidua. Tlie ready resj)4»nse of the uterus
togtimnli reflected from tlie peripheral extremities of the spijial
flwvte, to direct local irritation, and to the presence of blood
WI^•hrl^ped with carbonic acid in the uterine vessels, explains
ti'^- frptj[uency of painless contractions for days, or even weeks,
^ *Jine cases, previous to lalwr. To these means of exciting
***r"ie motility, there should be added, in all probability, the
'J'Wciii-in,RSlN*GER, PtrickpT'a " Wiener med. Jahrhnch," ier73.
iwitrajic zut vergleichcudr uud expi<nmitnt«lleD Geburtskiuide," 2te8 Hefti
278
LABOK.
i
Ion.
pes.
reaction of the uterine muscle, from the tension to which It w
subjected by the growth of the ovum, and to circulatory disturb^
nnces in the cerebral centres sometimes affected by vivid em<
tious. Frequently ropenteil ntenne contractions, without partial
separation of the deculun, are hardly comprehen.siblo after tl
decidoa vera and retiexa are brought iut<^> close contact with oi
another. Such a physiological sepamtion would, of necessityT
when of suflicieut extent, by convertiug the ovimi into a forei
body, furnish an active cause for the advent of labor, in the sai
way that labor is prematurely excited by a similar separnti*
when artificially induced. Thus, by the time the developmei
of tbe foetus is completed, all things are in train for its expulsion.
When other cjiiL'^eK do not early operate as det^^rmiuing ft^rces,
the increase of ntenne iiTitability at the recurrence of the meii^
strual epfxihs, probably accounts for the ordinary coincidence
lalxjr with the tenth cat^imenial date.
The Expelling Powers. — The powers which unite to ex]
the foetus, are to a great extent, vested in the uterine unstrii>ed
muscular fibres. Auxiliary aid is afforded by the vaginal and
nlwlominal uiuycles. ^j
The Uterine Contractions.— The uterine muscles act in snc^^
a way that with each contraction the shape of the orgau is more
I »r less altereiL Its general form toward tlie close of gestation
oval, but wliile in a state of contraction, tbe longitudinal
transverse diameters are diminished, wliile the antero-posterior
is increased, giving the organ a globular shaj^e. Uterine actio
Ls always of an iiitermittiag character, the intervals at first l>eii
wide, but grndually lessened as partiiritit>n proceeds. The o<m-
traetiou is of a peristiUtic natui'e. Beginning at the fundus
exteuds downwards like a wave till it reaches the cervix ntei
and then returns again to tite fundus, during which time the^
uterus remains in a state of lu'm contraction. This i>pristaltio
wave, however, extends so rapidly that the organ may be justly
regarded as a hollow muscle which coiitnicts simultaneously
all its pai-ts. The action is generally acct.>mpanie*i with pain,
first of a cutting and sawing kind, and later of a bearing and dis-
ruptive nature, though some women pass through [)arturition
with very little suffering. With regard to the direction and
gin of the contraction waves which pass over the uterus, it shoi
be added that there ia a lack of concord among obstetriciai
n i^^
-ior '
i.^
m- ■
^h~
tic
CTEBINE CONTBACTIONa
279
Wine believing that the contractions of the uterus do not begin
in the fondos, but in the os uteri, and pass from one extremity
to the other. It is clAimed by such thut the os uteri is lirst felt
tt (wntract, and then follow evidences of extensiou upwards of
Uip action. This, however, does not at all accord with the
fiuthor's experience. As the fingers rest against the presenting
lieatl, the first evidence of uterine action commuuicattHl thrctugh
the iense of touch, is a descent of tlie part, showing clearly that
the oontraction begins at the distal pola Anotlicr pi>iut wortliy
of obeervation is that when the uterus goes into a 8tat« of ctm-
tr»cti(jii, if <ine baud be i)lac(*il over the fundus, wliilo the other
fi^ls the cervix, it will be noticed that hardening is first felt at
iLt^ hmdufl, followed by contraction of the os uterL
Asintlie case of almost all unstriped muscular fibres, reflex
wtion following upon irritation is gradtial. and varies in intensity
Mul doration atvonling U^ the degree of irritation. A certain
uiiomitof irritation is necessary to cause a contraction, and as
the stunalui* is at first mild, the resulting contraction is also fee-
We. Moreover, the inter^^d between contractions is long, as
uritDf'time is required Ut accrunjulate the necessjiry sum of stim-
ulfltioa Witli the increasing separation of the membraijes from
■' wall, and escape of the liquor amnii. the irritation la
I the uterine action gains in strength and diuration,
wi tlie intervals are much aV>breviatecL At the acme of tlie
pnrpiilKive Ktago. the stiundation is so considerable that the oon-
triw'liiiuH are broken only by short pausea The stronger the
pwnft, the shi>rter the uiter\'al l>etween thenu The average uor-
fiJul duration of a hdxn* pain is little less than one minute. In-
wuiach am tlie mot*:>r centres of the uterus are located mainly in
«» symiwithetic ganglia, the action is involuntary. Contractions
'■'■■ ' J.' without regard to the voliti<m of the woman whose
- to sntlei- tliem. Mental excitement has been observeil
^" Iwve n mwlifying effect, and it has been suggested that the
•'iWrior sacral nerves may [)erfr)rni an inhibib^iy office.
Tilt presenting part of the fcetus, or the bag of waters, is
'mtftl by the contractions of the uterus against the internal os
ii**!'!, t> fiirciVily distend it. The cervical canal thus becomes
■ part of the uterine cnvity, and then tlio external os is expanded
h ft siinilar mechivuism. As dilatation of tlie os proceeds, its
iMigiutt become tlunner, until they are almost mombranouB,
280
LABOR.
when finally retraction from the fcetal head takes place
uterus aud vagina now form the fully expanded parturient canaU
and expulsion of tlie foetus proceeds.
Uterine contractions vary much in intensity, both in differe
cases, and the various stagefi of the same case. Attempts ha
been made to approximately measure the different degrees of
force exerted in tlie accomplishment of pai*tttrition. While the
results of such researches and experiments have not been highl
satisfactory, tliey may be accounted valuable data. Dr. Matthe
Duncan, after repeated experiment and study, foiuid the for
requisite to rupture the strongest membranes, \ntli an ob uteri
4.50 inches in diameter, was ohowt I^TJ lbs. He collects, furth
that, in ordinary lalx)r, the propelling force is from six to twen
seven ix>unds.* In cases where unusual effort is made, the p
pulsive power exerted by the uterus, the abdominal walls,
tlie other forces at the woman's command, may be increased
eighty pounds.f The combined jjaiiurient energy has been cal-
culated by Schatz.J at from seventeen to hfty-five pounds. ProL
Houghton's estimates are far in excess of thesa
Influence of the Pains on the Organism.— During a p
the arterial pressure is increased; the pulse is accelerated seve
beats per minute until the acme is reached, when it slowly di
clines to a normal [xiint The respirations are generally slow
though they are sometimes considerably acceleratetl. especial
in nervous, sensitive women. Tlie temperature is slightly el
vatetl, aud the uiinar>' excretion, in consequence of the iiicreai*
arterial pressure, is augmented.^
Contractions of tlie Uterine Lifi:ainents.— Structurally, the
muscular fibres of the romid and broad ligaments are eontinua-
tions of the external muscular layer of the uterus. As would be
anticii)ated, they contract simultaneously w\{h. that organ. In
contracting, they fix the uterus at the pelvic brim, while
he
1
• *• Thf 8tronp««i mrtnbmno found in the experiments indicated, by the ji
Bnrereipiired t« burst it, an extruding force of 37i lbs. We muy tbcrcfo
tbiuk, sufely venture to assert, iw a highly probable coucluBiuu, lliat the great
ms^ority of labors are completed by a propelling force not exceeding 40 I
" Kesearuhes in Obaletrics," p. 319. Duncan.
+ " Researches in Oba.," p. 32:1.
X Vide SCHBOEPEB. 'Lehrhuch/' 6te Aufl-, p. 15a
2 Naeoelk. " Lehrbuch der Oeb./' p. 163.
ABI>OMINAL AID.
2»1
In^tigampntB serve additionally to incline the fundus forward*
The Taginal Contractions. — As the foetus passes tlirough
the 05 nteri into the vagina, tlie latter organ at Urst resists its
progress, bat tlie walls xdtimately exjMiud to receive and transmit
Ihe body that seekf exit The tube tJien at first not only does
Dot facilitate labor, but actually impedes it; but after the greatest
diameter of the fcetus has passed the spliincter vugime, expulsion
is nrnterially aided by contractions of that muscle. The same
fibres also aid in extruding the secundinea
Abdomiual Aid. — The aid afforded by the abdominal musoles
hu a marked effect on the progress of labor. This action differs
horn that of the uterus, in that it is largely voluntary; still, at
tbe lu*ight of a pain, the veliemence of uterine action provokes
fttind of general tenesmus, which is irresistible. Abdominal
preanire acts in the following way: The extremities are pressBd
I0u]t9t some firm support, and the trunk is thus fixed; by deep
tMlHration the diaphragm is pushed do^\Tiwards; the abdominal
ttitiBolfcs then contract, and the diaphragm, wliich desceuLls still
fetber. jwrtly from ite own contraction, but chiefly by the pow-
tn of tlie expiratory muscles, exerts an equable pressure
abdominal contents. Abdominal aid, however, cannot
feexerteil in an effective manner until there has l)een some de-
ituf the uterine tumor, as the w^itraction of the transversalis
;lp would manifohtly operate as a constriction, without de-
^Wedly promoting expidsion. Aid from the abdominal muscles
"lid not be evoked until the propulsive stage has been iuaa-
rstftl, when it will prove most helpful.
The Pains of Labor, — The location and character of labor.
I*ii» vary not only with the p*irtiirieut stages, but also with the
w^mian's pecnliaritios. Duriiig the first stage, or st-ago of uterine
liilata^n, the suffering is of a cutting, sawing or grinding nature,
*«! is generally referred to the hypogastric^ or Inrabo-sacral
'"gion, or to both. From the back, tlie pains ra<liate forwards
"^ downwards, into the abdomen and thighs. The hy]>ogastrio
puns extend into the groins. During the second stage of labor,
"«' InmlHi-s^nTal region is, as a rule, the seat of greatest suffer-
n*. until, toward its close, it is transferred totheHacnun, rectnm,
ttd mlva. Tlie pains themselves are greatly changed during
tluB part of labor, being of a tearing, distensive, laxative charao-
282
LABI IK.
ter. Dr. Meigs* offers some very excellent ol)8en'ations on
topic. "The pain felt in labor," Le says, "ifi owing ti» the
bility of the rosisting, and not to that of the expelling organs.
Thus the shai'p, agonizing and dispiiiting pains of the commence-
ment of the prooeftH, which are called grinders, or grinding |mins.
are surely caused by the stretching of the parts that c^impose the
cervix and os nteri and upper end of the vagina. Pains are
rarely felt in the fundus and btxly of the organ; and nineteen
out of twenty women, if asked where the pain is, will reply that
it is at the lower part of tlie abdomen, and in the back. — indicat-
ing, with their hands, a situation corresponding U» the brim of
the pelvis, and not higher than that. — a point oi)fx)8ite the plane
of the OS uteri. WIumi the pains of dilabition are completeiiaud
the foetal presentation begins t4» press upon the lower pail of the
vagina, the pain will, of coui-se. be felt there, and is finally
referred to tlifi sacral region, the lower end of the rpt-tum, and
perineum. Tlie last pains, which push out the ]jerinoum, and
jmt the hd»ia on the stretch, will of course l>c felt in those parts
chiefly. Tlie sensation, under these circunistances, is repre-
sented as olhsolutcly iudcscribable. and cpi-tainly as comparable
to no uther pain."
In a fair view of all the facts, it does not seem probable that
the foregtnng is altogether true. Beasoniug from analogy, we
Conclude that a forcible contraction of an (jrgan like the uterus
is, in itself, productive of moi-e or less pain. This inference is
justly derivable from a study of after-pains, and from violent
contractions *)f other organs. In this o<innection tliore are other
data of unpoitance. The pheuomefton of misplaced or mf.'/fi.s'-
iafiv hifxn-jiriins is occasittually observed. The pain, instead of
being in its usual hwations, is felt mainly, or exclusively, in
other parts of the tnidy. The head may be the point of attack,
the eyes, or the legs, indeed almost any pari Dr. R Fordyce
Barker reported a case to the New York Obstetrical Society,! in
substance as follows : He recently attended a lady in her con-
finement who was in labor but two hours, though the pains did
not seem at any time U^ centre about the pelvis. There were no
uterine pains at all, but with each contraction of the wornb, pain
leras experienced in the legs. The pain was not localized, nor
**Bystem of Obs.," ie*W. p. 2S1.
tAm. J. Obs.,Vol iv,p.7*>7.
ra£KOfiC£NA or uoioiu
2ba
was there any mnscular contraction in the legs. The same pain
was produce<.l in pressing off the placenta. Weigaud relates a
case in which severe infra-orbital pain occurred with every uter-
ine contraction. Dewees mentions one in which the pains were
felt in the calves of the legs. A very interesting example of
misplaced labor-pain is reporte<l by Prof. R. Ludlam, and made
a iGit for some instructive remarks.*
It will be clear from what has been said regarding the nervous
TOpply of the uterus and other pelvic c»rgau8, uuder its proper
head, that the organ may act in a regular and orderly manner,
vbile the pain incident thereto may be reflected to other and
distant parts.
Tlie terms " forcible pains," " weak pains," "deficient pains,"
etc, are or^mmonly used. The substantive ** pain" is lt«re syn-
tinymoua with " contraction." Pain is merely the sensible evi-
dence of uterine action. When the organ acts with euerg^', the
pains are generally severe; and when it acts feebly, the pains
aw oorrespondingly light The terms " vehement," "powerfnl/*
"ftiTciblo." "weak," "deficient,'* "inefficient," etc., are only rel-
ative, that is t4> say, they do not express a definite degree of
<ither quantity or quality.
CHAPTER n
Clinical Course of Laboi\aiid its Plienoineiia.
The Stas^eft of Labor.— Having given the physiological facts
^counection w*ith lalxir i>ains, we may now i)roceed tf) describe
^eoliuiwil course of a natural labor, with the vertex presenting.
Careful observers of the sequence of events in labor have not
Medt4> notice that the process is very naturally divided by
"16 plif>nomeuH presentetl, intothree'stagos, namely, the ^/'s/, or
P^^fmratory siagt% in which expansion of the os uteri is effected*
*^dtbe parts prepared f*u' descent of the head through the par-
turient canal; the second, or propulsive siage, during which the
♦^Di^easen of Women." 1881, p. 328.
284
PHENOH£NA OF LA^OR.
foetus is espellwl; and the third, which comprises the separatioa
and expulsion of the secundines. The first stage endft» then,
with full dilatation of the os utert* the second beginning there
and closing with expulsion of tlie fa?tus, and the third terminat-
ing with c'jjmplete evacuation of the uterus.
The Preparatory Stage. — The first stage of parturition is
said to begin with the fiist symptoms of actual lalx>r, but the
exact moment when this occurs is not always easily determinetL
There is a certain amount of preliminary action which has very
properly been termetl the pn*para(ory siatfe. This is sometimes
well marketl, while at tjther times it is so indistinct that it escapes
notice* One of the most common changes occurring toward the
close of pregnancy is what has l>een elsewhere alluded to as sub-
sidence of the utei*us, vnth a fulling forwanl io a certain extent
of tile fundus. This change of situation is followed by consid-
erable relief to respiration, andt*> the gastric ilisturbances which,
are so liable to atHict the woman in the latter weeks of preg-
ziancy. Locomotion is made more difficult, the downward press-
ure of the gravid uterus pHnluces a frequent desire to lU'inate^
and» often, to defecate. From a similar cause, hemorrhoids are
many timeH either developed or aggravated. In primipara; the
presenting head generally lies lower within the peine cavity
than in inultiijane. For a variable time before tiie advent of
real Iai>or-pains, there is usually a muco-sanguineous discharge
from the vagina, and premonitory' pains and aches are experi-
enced, esfjecially by niultipani\ The woman feels a sensation
of dragging in the sacrum aud ]>ubis. and of tension in the ab-
dominal region. As a result of the (Miinless, or slightly painful,
uterine contractions, which are observe*! throughout the greater
part of ])regnancy, and an aggravation or augmentation of which
constitutes labor, the cenical caiiid may be dilatetl to a consid-
erable extent, in multiparas for days, or even weeks, before
labor.
False Labor-Pains. — The mo«lerate, intermittent, and usu-
ally painless, contiactions of the uterus, just alludeil to, may in
some women of susceptible natures, give rise to suffering, and
constitute what are known as false pains. These, however, wo
believe to bo a comparatively infrequent cause of the sensations
thus designated. False pains are usually irregular, often strong
at first, but gradually becoming weaker; are limited in extent.
THE FIRST STAGE.
285
rarely dilate the os or protrude the bag of waters, and are not
generally accompanied by the muco-suuguineous discharge be-
fore mentioned as preceding real labor. They arise from indi-
geetiou, cold, moyements of the fo^tiis, and various other causeSf
b)it are usually relieved by rest, and the administration of oauL
vj)h\iUuf}iy puhatilld, or other remedies calculated to remove the
cause upon which they depend.
The First Stage. — In a certain proportion of cases labor may
Bet m abruptly, with severe and quickly-recurring pains, but as
a nile tbe onset is gradual, and the pains so far apart as to
aubiuit to nothing more than a little uneasiness, leaving the pa-
tient in doubt as to their real signilicance. Painful contractions,
Iwwever, soon ensue, making the woman restless, and diH{Kising
no. 114,
^'^ fthowiag the fiBtns, inclcwcd in ibt nicmhraoes, with expanding oe
uteri.
"f either to bend forward with clinched hands, or to seek some
^ WpjMjrt for the sacrum in the vain hope to find relieL But
*0D]en greatly <liffer, in their natural sensibility to pain, and
•Wf power to endure it Some will toss nbout with every uter-
286
PHENOMENA OF LABOK.
ine contraction, and evince the most intense agony, while others
will utter scarcely a groan. The cases of i>ainless labor are few
indeed, while instances of terrible suffering are numerous.
It is both interesting and instructive to observe the various
positions taken by wonieii in tlie different stages of labor. In
the early part of the pai-turient act, the sitting posture is most
commonly chuseu, with the huuds pressed ujkjh the hips during
a pain, while the body is bent somewhat backward.
The pains of labor may Ite said to begin with the dilatation of
tlie internal os, and the expansion there begun, progresses gradu-
ally until the entire cervical canal becomes large enough to nd-
uiit of ex]mlsion of the uterine c^mtents. As the oh internum
opens, the contractions cause the meinbnmes to descend and ex-
ert an expansive force on the cervical canal. During a uterine
ooutractiouj the membranes are observed to lx»come tense, and
to bulge, until, after a certain amount of expansion has been at-
tained, in shape they resemble a watch crystjil. This is true.,
however, only after the internal os has entirely yieldetl, and the
e«1ge8 of the external os are thinned from the pn^sure put u]>on
them. As the pain subsides, the os relaxes, and the membranes
reireai With the advance of lalK>r, the pains increase in in-
tensity and frequency, and uterine dilatation is usually progres-
sive. Nausea and vomiting are not infrequent, but when pres-
ent, add gieatly to the woman's distress. When not too pro.
longed, they need not be regarde<i as at all alarm big. The soft-
ening, relaxation and hj']:)ersecretion of the soft structures be-
come more and more decided, and when the expansion has
reached a certain limit, say a tliameter of two and a-half or
three inches, the protnitling membranes generally rupture
spontaneously, and a considerable part of the liquor amiui es-
capes with a gush, but a certain iK)rtion of it is generally re-
tained by the presenting head, which acts as a ball valve at the
pelvic brim. If they do not, the attendant usually finds it ad-
visable to rupture them.
The pulse generally iucreaseB in frequency in proportion to
the severity of each pain, only to decline again in the interval.
This effect on the circulatory apparatus may be usefully em-
ployed as a guage of the efficiency of the pains, for the more
marked and uniform the variation, the more effective the pain
fliM
PHENOMENA OF LABOR.
Flu. n&.
287
CttllorA,
Sup. 3Zcc«titrft
V.P«ri.tt
CttOaTIUa
ncctiiiii
Liquor A»nH
Suction of a firoseu body nt tht* terniinution of the first '*\mtf. of lal>or. The
maiinlwnrr ar« still intutt. the cernx is I'lilly dilated, und thv head, ocrnpy-
iag the arcoDd positioD, i» iu thv p&lvio cavity.
288
PHENOHEMA OF LABOB.
which causefl it "When, however," says Hohl,* "the rapidii
of the beats subsides before approaching the maximani, the pain
is too weak; or when the rapidity rises by sudden starts, the
pain is a hurried one, and in either case its effect will be imj>er-
fect" The piUse acceleration, under an efficient i>ain of average
duration, he represents by tlie following record of the several
quarters of two minutes:
18, 18,20,22: 24,24,22, 18.
Contrary to the teaching of some observers, our experience
has taught us that the effect of uterine contractions on the fcetal
Fro. IHi
The Ptirturient Canftl.
heart is usually one of retardation rather than acceleration.
The softening, relaxation, and hypersecretion become nw
and more decided. When distension of the os becomes ex<
• Vide LErpHMAS'fl "System of Midwifery," p. 253.
IMfa^
THE MECHANISM OF DILATATION.
289
>ii(;ht lu(remtioii8 <wcur, the blood from which, together
wiat from ruptured decidual lelatious, oozes fi*om the geni-
tal tissore, or staius the examining fingers. After a time the
head, influenced by the uterine contractions, descends into the
cenrix, the walls of which are Heparatetl until they lie against
the pelric borders, and thereby form, with the uterine cavity
ml vagina, a contiuucjus channel known as tlie j)arturient canal.
This, tlie first stage of labor, varies greatly in duration, but is
geDerally completed in six t>r seven hours. It sometimoa lasts
hot an hour, and, on the other hand, it is occnsioually protracted
to oDe, two f»r three days.
The MH'haiiism of Dilatation.— It appears to have been
fffetty generally c<.)nceiled that the so-called "bag of waters"
ute BB a kind of entering wedge, by means of which an equable
faydmsiatic pressure is brought to bear in tbe direction of ex-
pwisinn. and that this is the mechanism through which dilata-
tion of tlio OS ut43ri is mainly offectod. Leinhinau* reasons
leametUy and forcibly on the subject as follows: "The first
efficit^nt contraction having resulted in an o{)eniiig of the os to
atrilluig extent, ami the tissues being siifticiontly relaxed to ad-
mit of satiaf actory progreas, we are enabled to trace the process
of dilatation through all its subsequent stages. As soon as the
06 lias yielded to a certain extent, the membranes which are
here separated from tlieir uterine attachment, commence to pro-
IiIp in the form, first of a watch-glass, and then of the ex-
dty of a pouch or bag, which has been termed the 'bag of
imierB.* Following the operation of a very obvious law already
tllnded to, tliis pheuomen<5n implies, immarily, an attempt, con-
Mqaeot on the uterine contraction, on the part of the waters, to
€«caj>e in the direction in which resistance is least. The special
fttiiction, however, of this bag is to effect the further dilatation
of the OS. and we can conceive no means which could be more
fedmirably adapted to this object than the graduated fluid pres-
miPB which is thus brought to bear upon the os equally in its
whole circumference. It constitutes, in fact, in its action dur-
ing A pain, a hydro-dynamic force, whicli acts at once safely and
powerfully upon the whole of the os." Theoretically tliis action
of the bog of waters is very decided, but when wo reflect upon
•" Hy*ti^m of Midwifery," p. 254.
290
PHENOMENA OF LABOB.
all the circmnsiances, including the non-existence of the
wuterH iu a large share of cases, in which labor progresses fa^
vorably and rapitUy tlirough the first stage, we are led to oo
elude that the mechanism of os tlUatation deecrilietl, is no
altogether the tnie one. The chief discrppancy probably lies
in attributing the main expansive force to the pressure of the
bag of waters, instead of the fa^tal head, or othe?r presenting
part. Dilatation of the os is sometimes considerably accelerated
by early rupture of the membranes, and escape of the liqui
amnii.
The subject is further elucidated by Lusk.* "The dilatation
of the C4?rvix,'* he says, **i8j>artly mechanical, and partly t
effect of certain organic changes which have already receiv
cursory mention.
The mechanical dilatation is the result of — 1. The pressure
the ovum uixju the lower uterine sepraont, which forcps ope
the OS iutprnum, an<l unfolds tbe cervix from above downward.
2. The retraction of the uterus, an important property whi
requires brief description. While each contraction of the u
rus is followed bj' relaxation, and a period of repitse, a gradii
change is continually gating on iu the length and arranjjement
the muscular fibres. In the thinned lower segment the fib
are stret^hpd, and 8ei>arated from one aiiotlier. In the upj
poi-tion, on the contrary, they shorten, and change tlieir
jiosition in such a way that those which previously had only
their extremities in contact, assume a more nearly parallel
arrangt^ment The walls, therefore, in the upper sion
thicken, and shorten, especially in the longihulinid direction?
The limit between the thinned lower segment and the upper
thickened zone is marked by a clistinct ridge termed the ring of
Bandl. It is to the chimges iu the uterus which t^ike place
above the ring of Bandl that the term retraction is applicable.
As the retraction is progressive, it leads to a gradual withdrawal
upwards of the uterine walls, in consecjuence of which the
lower segment is not only put upon the stretch during the }>ain3,
but, toward the end of the period of dilatation, is subjected
a greater or less degree of permanent tension. Then, too,
the ring of Bandl moves upward, the longitudinal fibres of
oi^n
es
lie
lei ,
•"Science and Art of Midwifery." p. 136.
THE lUCUANltiM OF DILATATION.
291
»ginent^ by roason of their insertion in part at least into
rt4jiiLal purtion, exert a direct iulluence in dilating the cer-
\cn\ eanaL
"3, When th<> abdorainal muBcIes c<»ntract., the utenis is pressed
fWDward into the {nlvic cavity. The descent is, however, lim-
il by the attachment of the uterine ligaments, and the adja-
orgau& But the resistance afforded by the nteriue attach-
exercises a j)eripheral tractit^u upon tlie cen'ix, and thus
!ndi9 to draw its walls asunder."
Fio 117.
1%. eot'IUs
0. IOCS. Ill [k
tfLblb
The utenu And paTtnrient canal, — foetas rnmoved.
Rnpture of the membranes usually occurs spontaneously, as
sUiedf »bout the close of the first stage, marking a oomplete
292
PHENOMENA OF LABOR.
dilatation of the os uteri; Init when unufinally toiigh, thpy may, n
neglected cases, continue to surround the foetus till after its
expulsion. A child thus enveloped is said to be bom with a
" cauL" What is even more common, however, is a rupture of
the membranes at the point where they surround the neck, and
a retention of the detached portion over the face, constituting a
"veil," which old nurses regard as a sign of good luck.
The Second Stage, or Stage of Propulsion.— At this staged
the OB is completely dilated and somewhat retracted bo as scarcely
to be felt The pains begin to assume a diflereut character.
The uterus c-on tracts more closely on the fcetus, and pushes it
downwards into the peUac cavity. The woman now begins to-
feel the presence of a solid body which must be expelled, and^
she accordingly bends every endeavor to tlxe consummation of
tlie undertaking. The pains are now really much more painful,
but the consciousness that they are acaimplishiug something
seems to infuse both stiength and fortitude. The powerful pro-
pulsive efforts made by the woman are termed '* bearing down»**
propulsive, or expulsive, and hence tlie name often given to this
stage of labor, n*unely, the proiniUivc^ The resistance encoun«
tered in the first stage has been removed by the completion ol
dilatation, and now the pelvic brim, the vnried relative diameters
of the pelvic cavity, the pelvic door, vagina and vulva, resisfc
rapid progress. If the j>ains are powerful, ami the resistance
great, tumefaction uf the f<jetal scalp is likely to ensiie at the
l>oint of li^just rt^histaijce, such a Bwelliug being known as the
**capnt SHCcedanenm,** Each pain causes the head to descend
lower and lower, until it comes to press against and distend the
perineum. The head advances during a pain, and recedes aa
tlie pain passes off, but makes a sensible gain each time. The
recession is a wise pnn'ision of nature to prevent continuoua
pressure at any one place, as well as to obviate too rapid disten-
sion of the soft structures. The rectum becomes flattened, and
its contents expelled by the advancuig head. Such pressure and
distension open the anus to a considerable extent, and thin and
elongate the perineum. As the foetal head enters the pelvia
brim, with the occipital pole of its long diameter in advance, a
condition of firm flexion of the chin on the sternum is enforce*!.,
The long tliameter of the head, lying in an oblique diameter of
the pelvis, a movement occurs in the pelvic cavity, by mei
THE SECOND STAGE.
293
uliicL llio long diameter of the vertex Ls brought into the conju-
gate of the outlet. This movement is termed rotation, and the
tiiue for its accumplishmeut is when the head is pressing firmly
dnst the pelvic floor, and the perineum b thereby made to
The vulvar opening is put more and more upon the
ftretcbf as the head emerges; the woman gathers her energies
for every pain, and preeses as forcibly as her strength will per-
mit; while now and then she gives vent Ui her terrii>le suflerings
in an agooizing cry. The straining efforts of the woman are in
imeasare under her control. They are intensified by her inflat-
iftg ber lungs, and forcibly holding her l>reath, while she bears
dtiwu; but by opening the mouth ami giving expression to her
feeliat's in cries, the abdominal muscles are relaxed, and the
itnuning effr»rt« moditietL The head finally passes the vulva,
odthe woman experiences a great -sense of relief, which is soon
feurbetl by » pain tliat brings the Fa*tal iMMly wholly into the
wirliL The expulsion of the child is followed by the outpour-
t^of the amniotic Buid, which is generally reddened by blood
Fio. 116.
Distension of the Perineum (Hunter.)
"""* the Teeaels lacerated by partial or complete separation of
I** ptaoonta. The pains then cease, and the relief experienced
^*4e woman is most delicious. Some compare their feelings
■* * rod foretaste of heaven, or give expression to their exper-
^^^^ ia other words equally glowing and emphatic.
^ diiration of the second stage of labor is exceedingly varia-
2M
PHEKOUENA OF LABOR.
ble. It is occasionully completed in twenty or thirty minutes,
while in many coses it lasts several hours.
The Third Stage.— The placenta is sometimes separated dur-
ing the latter part of the second stage, and follows the fcBtus,
being expelled by the same contraction which terminates tliat
part of labor. This, however, is rather unusual, the i>henomena
of the third stage being such as are below described. The third
stage of labor begins immediately after complete expulsion of
the foetus. Contrary to the generally-received opinion, it is
attended witli moi-e real danger to the woman than eitlier of the
others mentioned. It is during this part of labor that the vas-
cular relations between foetal and maternal structures are sev-
ered, and on the perfect and harmonious action of the natural
forces, closure of the uterine sinuses is effected, and the woman
protects from fatfd hemorrhage.
Birth of the child is often followed by syncopal sensations,
arising from recession of blood from the brain, occasioned by
removal of the intra-abdominal pressure. Soon after comple-
tion of the third stage women occasionally 'suifer a chill, or,
what is of more frequent occurrence, a protracteil nervous tre-
mor, entirely out of proportion to the chilliness felt. This how-
ever need cause no apprehension, unless distressingly severe, or
long-continued, as it is merely the result of vaso motor disturb-
ance, and the loss, through foetal expulsion, of a source of heat^
supply.
Tliere is usually an interval of repose, of varying duration,
followed by one or more uterine contractions of some force,
which suitice to expel the retained secuudines. In unassisted
cases the placenta may be expelled into the vagina and lie there
for hours, or even tlays. The contracting uterus follows the
foetus during expulsion, until after close of the third stage it
will be found like a hard ball, in the hypogastrium. TliLs action
of the uterus cviuses separation of the placenta, detachment
occurring in the meshy, lamellated layer whicli is formed in the
eerotina by the thinned, elongated walls of the gland tubules,
the dense coll-layf*r which forms the maternal j>ortion remaining
adherent to the placenta. As such separation involves rupture
of the maternal vessels, some hemorrhage always follows the
detachment, but is rarely profuse, inasmuch as the very c^udi-
TH£ TEIBD STAGE.
295
which serve for separation of tlie placenta, likewise com-
press the broken vessels, and control the escape of blood,
Fm. 119. Fio. 120.
W)(l rxputaiou uftbc plac'en>
ta.
Mode of sepanilion and ex-
pulsion when traction is znade
on the cord.
Much (^mphasiH has of late been put u])on tlie mechanism
"'piflcoutal expulsion as elucidated by Dr. Matthews Duncan
'ui'^ 'itbi^rs. It is lield by tliem, — and their views are now gon-
'''»lly ftrcepteil,— that wlien no traction is put upon the umbili-
^ cord, the placenta issues from the uterus eilgewise, though
*'ittay be folde*! longitudinally; but when it is drawn out by
™ion on the cord, inversion occurs, and, from the suction
"^^'^n tlius irapiirted, the difficulties of delivery and tlie dan-
ilfiTiut bmnorrhngp are augmented*
Gastmer* found that after conhnement, the female experiences,
*B a aiDsequence of the expulsion of tlie ovum, of the exhalations
^fii the lungs and skin, from the iliscliarge of exci*emente, from
**S(jf bltHKl. and from other depletions, a loss of weight equiv-
alent to one-ninth of that of the entire body.
"Cflber d. Vchindcrnnf^ndes Korpergcwichtea b. Schwaug., Gebar, and
''■Awf/' Honataschr. f. U«huruk., xijs, p, IS.
296 PH£NOK£NA OF LABOR.
Duration of Labor. — Labor differs so greatly in duration that
it is almost impossible to deduce from observation any impor-
tant truths concerning its length. It may be said, however,
that, in general, it is longer in primipane than in midtipane, on
account of the greater Ih'mness of the soft structures. It is also
observed that, other things being equal, the pains and difficulties
of first parturitions increase with age. The relative depth of
the pelvic cavity has a modifying influence upon labor, and
accordingly it is found that very tall women pass through the
ordeal witii less facility than others. On the contrary, short,
stout women, with considerable adipose tissue, also suffer long
IftlKirs, owing to the firmness of their tissues, and the presence
of an unusual quantity of fat in the pelvic cavity. The charac-
ter of lalwr is subject to modification l>y the position and pres-
entation of the ftetus. Presentaticm of the face for example, is
attended with greater difficulty than that of the vertex, antl an
occipito-piisfa^rior position is more unfavorable tlian an occipito-
ant<»rior. Otlier nu)difyiug conditions are often found to exist,
as the presence of various tumors, and the contraction of the
pelvic diameters, etc.
People are prone to think that it is within the power of the
pliysician of skill and learning, to foretell tlie exact duration of
labor, a thiiit:, by the way, wliidi he is not capable of doing.
Th(^ j>aiiis may be vigt>rnus, tlie tissues relaxed, and oveiythiiig
jwogrossing in a satislactory way, wlion the uterine contractions
may siuLltMily \veak(»ii. or ultt-rly rcas*' for many hours, or some
othor unfiirtunatc <Kvurr**iu*t' may interpose Ui interrupt the
regular cDurse of nature.
Wlien the woman can bo trutlifully assured that everything is
fav(>ral)l(', it is iiu*unib<'nt upon him todischarg«» his obligation.
To tlie iniiH»i'tunate {iitju'al - *' Doi-tor, how soon will it be over? " it
is better to ovadc positive reply. I'he duration of lab<tr, while it
may be ]>redicted with eonsideiabh* accuracy in a certain num-
In^r of cases, manifestly deju'iuls up<m so many contingencies,
that trutlifxil predictions should nt)t be attenipted, and. in gen-
eral cannot l>e made. Tlie relative duration of tlie first and sec-
ond stages is by some stated to l>e in tlie i)roi)ortion ot two 4»r
three Uy om;, but others believe it is nearer four or five to one,
the first stage being the longer. It is sometijnes much shorter
than the second.
THK HOm OF LABOR.
297
The Hour of Labor.~Tho larger number o! births is said to
Uke place in the early morning boms. West* observed that
out of 'J019 deliveries, 780 occurred between 11 p. in. und 7 (l m.;
662 from 7 a m. to 3 p. m. and 577 from 3 j>. m. to 11 p. m.
Kieinwachter t tells us that labor-pains usually set in be-
tween 10 or 12 p. m. Spiegelberg J believes the maximuui fre-
quency itf birth is between 12 and 3 o'chuik.
The lufluf uce of the Tide on Parturition.— Dr. C. G. Raue
in 18(>5 § called attention to this subject, and reported his obser-
vations in thirty-four cases, in which, with a single ex('e]>tion,
he found that birth took place at high tide. Dr. T. S. HoynG||
found in seventy-five cases but four exceptions.
Or. M. M. Walker has prepare<l a paper on the subject for the
Hum. Med. Society, of Penn., (Sept 1882,) with a re|>ort of 200
casf«, from which the following figures, by the Doctor's courtesy,
h.M* been t^i.keu :
Naoilfrr bvrn during; wilar und lunar flood tides combined^
" Bolar Uond,
" luDur flood,
TWft] Vau during the flood tides,
'* ebb lidt's. und at otlier tiraes.
Urtroinrntal cu#cs imd extrmtions. - - ^i. or i:) jrfr cent,
ThRccA^'it born durini; tbv adminlfltration of an iiiitcstlu'tic. without iaatru-
*nAid aid. and inclmUM! m iln* ulMjvt: liibic, urfum-d us fitllowM : one during
'^•iftoUrand Innj*r flood. <mf during lunar flood, and one during ebbtide.
Tti-si' tMii linndred consecutive castas occurred I'roiu Nov. 1(^74 to Aug. 1881.
43.
52.
i:W, or (Ki pw cent.
42, or 21 per cent.
' iBiirican Mi-du'iil JonrntU. 1854.
tWftcit der Geliurlshtj^inuf**, " Ztschr, f. Oebort«li, Bd. 1 p. m,
I Uhr»)ui-h. etf.. p. 105.
{*'Halineinunnittu Monthly," vol. L
I^Tlie Cliaiqae," vol U. p. 400.
298 THE HANAaKWENT OF LABOK.
CHAPTER m.
The Management of Normal Labor.
Having given a brief account of the phenomena iLsually ob-
served in labor of a normal character, it Ijecomes necessary to
offer some observations on tJie management of the various
stages of the parturient process. So wisely has nature adapts
moans to ends, tliat the act throughout is generally one which
roquii'ofl but Htth* directit»n, and still less assistance, from the
medical attendant. So true is this that we might add that, in
the vast majority of c-nses, as hapi)y and satisfactory an issue
results under the c^ire of an uneducatetl, but experienced, at-
tendant, aft under the conduct of tiiose consummately learned,
and higlily skilletL But irregularities in the parturient act nro
liable to arise, in tlie niunag(Mn(»nt of which the highest attain-
mouts ire (essential Complications when they are met, howevf^r,
cannot be sut'cessfully uiastert'd witliont a thorout^h acquaint-
ance witli the plu'iioniena of tlu» normal process wiiich have al-
ready boon ih'scribod.
Preliminary Airaiit^ements. Within tho scope i>f those
su^i^ostions ret^'unlinj; the mai»a;:;oniout of laUir. should be in-
oludoil mention of otTtain pi'i-Iiniinaries, resi>oetin^ which women
oCteu rofjuiro some ndviee. In their proper jdace, observatiiins
respeotini^ exorcise and care of the lH>wels have been made, but
we ouj^ht hero to aild that the Wi»nian should ^ivt» es])ecial atten-
tion to the obsorvauoe i»f those. In no oase shouhl the custom-
ary Kto(tl bo n(^*ih'cted when labor is at hand, and if there is the
slightest tendency to constipation, as soon as pains are ex]>eri-
encod a larj^e onoina shonld bo taken and the Ixiwels emptied,
which will faciliiafe fotal expulsion, and at the same time ren-
der the necessary attentions of the accoucheur less disagreeable.
Under the same lif^ad. wo may call the physician's attention
to the advisability of evr^r holding himself in readiness to attend
HOW TO APPBOACH THE PATIENT.
299
midwifery cases, in order that no unnecessary delay may ensue.
It is true that in the majority of iuKtances there is no occasion
for hattte, but in many cases successful results are dependent
nwiuly on the physician's promptitude in responding to the ur-
gent call
Prompt Kesponse to Calls,— The practitioner will often be
subjected to the annoyance of being calleil l)ef()ro labor has ac-
tually begujj, but this fact should make him none the less atten-
tire nnd prompt It is of the highest importance that abnor-
mfllitii*^ of foetai form, presentatioii, or position, and unfavora-
ble maternal conditions, be recognized at the earliest possible
ffiumFut, since this places the accoucheur in a position to lei-
earely ilotermine tipon a phm of treatment^ to jn-ovide himself
with the lw*st facilities, and t4)ch«x)se tlie most desirable moment
l'»r interference.
Armamentarium. — If the case to which he is called is likely
toU^ ilifficult. the forceps and the perforator may I)© cairie^l.
Indcc*!, if tlie call is to take him a ctmsiderable distance from
domf, it is the part of prudence to take along such instruments
M may be required in emergencies. The physician in active
obstetrical practice will do well to provide himself with a bag
IT case of obstetrical instruments, which should include a good
pair of htifj forcf^jtSj a perfornt4:>r, a pair of cmniotomy-forceps,
• croiohet, a right-angled blimt hook, a dec^jpitoting hook,
tod A soft rubl»er catheter, lieside these he should have a
packet-case of instruments, a hyp<xierraic syringe, and a quan-
tity of chlorofitrm. He should provide himself also with a case
OcHit&iniug, in addition to the most common homoeopathic rem-
^&% a reliable preparation of fluid extract of ergot
Mow to Approach the Patient.— There is no subject con-
iwcled with midwifery practice, instruction concerning which
WottKl be more acr.ei)table than this, and yet it is one uim)u which
vtry little satisfactory' instruction can l^e given. The fact is, that
tbi> etiquette of the Ijing-in-chamber is founded upon the same
Bf-tieral principles of deportment which govern the polite rela-
lioiiB ut life. Gentlemanly demefinor is alx>ut all that is re-
quirwl to insure mutually agreeable contact The caprices of
Woman during lalwr ore greatly augmented in number and vol-
4
300
THE MANAGEMENT OF LABOfi.
ume, anil thfi mrmt considerate conduct on the part of the phy-
sician will sometimes be met witii repulse.
Women in parturition watch every movement, and mark every
word of their medical attendant, so that his tact then, as per-
haps at no other time, is put to a crucial test Xor can their
likes and dislikes, their opinions and their whims, be put into
one general class juid treated alike. Here, as elsewhere, to in-
sure the best results one must indiWdualize, and he who <loes so
best, will achieve the most perfect results.
The following advice, given by the erudite and urbane Dr.
Bhindell,* is thoroughly practical and sejisible: **If yon jira
well known to your patient," he says, "on reaching the house
j'ou will be welcx>me to her apartment; but if you have not fre-
quently seen her before, nor attended her on former occasions,
I would recommend you not immediately to pass into her cham-
ber. Not hnvitiy her full confidence, by your presence you
might agitate her, and in tliese cases it is projser to avoid every-
tliing tliat may produce commotion of the nervous system. It
is better, therefore, that the accoucheur retire into some adjoin-
ing room, where he may see his lady patroness, the nurse, who
has generally a great many foolish things to say, all of which he
may as well hear with patience and l)onhommie. When the
shower of worils is blown over, or when Mrs, JSpeaker rejoctantly
pauses to draw breath, dexterously seizing the auspicious mo-
ment, you may make inquiries res]iectiug the progress of the hi-
btir, the condition of the bladder, the state of the bowels, and so
on; questions which, in ordinary cases, may with more delicacy
be proposeil U^ the nurse than to the patient herself. Should
you chance not to be a dear man, a pious man, a good kind crea-
ture, or, still worse, should the lady be pettish, and declare you
to be a brute or a physiologist, so that for these manifold of-
fences she never, never %vill^never can see you — you may re-
main in the house, as the female *' nei^cf^* in these oases comprises
but a small portion of eternity, perhaps on an average, some
one or two hours, and when caprices and antipathies are a little
subdued by the pains, your presence will be cordially welcome.
Now, then, the pains being severe, after you have entered the
room, you may make your examination, ^ud if you fiml the labor
•" Blundell'a Midwiferj'/' l^% P- 96.
THB EXAMINATION.
301
rapiiily atlvftncing, you must remain at the bedside lest the child
sLcmld come into the world in your absence."
The £xan]lnation.~Wbeu Bhall it be madB? The stage of
mbancemeut which appears to have been reached, is the most
determinate element. When the phyfiician reaches his patient
bIk) may l)e experiencing the very first dilating pains, or she
nuiy already have progressetl into the second or jirDpuIsive part
of labor. In the latter instance, an examination cannot be made
ioo aeon, while in the former, there would be no occasion fol
IttBta Unluckily, the existence of these vai'ious conditions can-
tiot ill every case be determined. It is possible, as a rule, to
dutiiigoish between the first and second stages of labor by ex-
tHTiwl signs, as, for example, the peculiar pains of each; but it
does not follow that there is no urgency fur an examination l>e-
cause the os is not supposed to be wide open, nor that there is
•n inexorable and immediate demand for it because real propul-
eiou has begun. The l>est counsel is, not to be so precipitate in
iiecessarj investigations as to shock the patient, or betray trep-
idation ; and on tlie contrary, not to permit undue caution or
ooMtraint to carry one to the oppcjsite extreme; but to act delib-
erately and discriminately, keeping in mind the desirability of
»cogni2Euig the important features of every case through a thor-
*^li vaginal examination, as early in labor as practicable.
The finger is generally recommended tn be introduced during
*I»in; but it is far preferable to do so in the interval between
P"^ and to continue the examination during a contraction.
The patient need not be restrictetl to any one position for the
Purpose of examination. Women are extremely restless during
'^^T, and in frequent changes seek relief. They assume all
*^ftsof pfistures, and resort to all kinds of ex|)edient«, and one
Biuatdeal in an accommodating way. Let the woman remain
^"feturbed by any considerable change, and she will evince less
"'eisioD to the necessary touch. The allusion is now to cases as
«>«y ore ordinarily met When for operative purposes, an ab-
•o^ote diagnosis of the exact presentation and position, and the
tt)ndition ot the parturient canal in obscure cases, becomes
•swtitial, the position most favorable f^r differential distinctions
'^ttld be prescribed This is generally upon the back, near
tiieodgeof the bft<l, so as to permit the use, with equal facil-
ao2
THE MANAG£M£NT OF LABOR.
ity, of either band Sometimes the os uteri and presenting
part are broiiglit nearer the tingers when the decubitnft is laterni.
Cursory examinations are of little value. In the practice of
obstetrics, as well as in all other affairs, " what is worth doing at
all, is worth doing well" None of us possess supernatural
powers, and therefore ought not to assume celestial airs. It
takes time to make a thorough exploration.
Nothing is more annc tying to a woman of delicate sense than
a bungling attempt to pass the finger. A hint worth remember-
ing i.H that the vaginal orifice lies but slightly in front of a line
from one ischial tuberosity to the other. Whether the woman
lie on her side, or on her back, the hand may l>e passed in a
careless maimer against the tuber to locate it, and thus ensure
proper direction to the fingers.
Vut 121.
The vngiuui tx>ucb.
The points to be observed in a careful examination are the
conditions of the vulva, bladder, rectum and vagina; the sixe
and relative state of the os and cervix uteri; the general loca-
tion of the presenting part, its character and position; the con-
dition of the foetal membranes, and the general capacity of the
pelvis, at the brim, in the cavity, and at the outlet
EXTEItNAL EXAMINATIOX.
303
Frequent examinationB should be avoided as they tend to
irritBte the \Tilva, and cause the woman, if senaitive, unnecessary
suffering. Yet, no matter how painful they may be, they should
be mude often enough to nr(|uaint the physician with the pro-
gress being made. A single finger may answer, but two Ungera
should, as a rule, he employeil. In every instance they should
be smeared with some bland lubricant before introduction.
External Examination. —Examination of the abdomen by
pfilpation should not be omitted, and if there be a serious doubt
(xinc^^miug the presentation, single pregnancy, or fcetal life,
ausculiition should be practiced- A superficial manual examin-
ation of the ubtlomen, rapidly made under the clothea, is a
oommwi practice; but it is advisable to go furtlier and make a
systematic, scientific and accurate manipulation, by which we
may Hsoertaiu the existence of pregnancy, the foetal position,
pret^ntntion, approximate size and general c/^ndition, and the
rtjations of the uterus. Concurruig heartily in what Hoist says
oatbe Buhject of bimanual examinations,* that ** a detailed dis-
niasioiiof this methtnl of examination is necessary to the com-
(ileteness of a text book," we have elsewhere considered the
•^ubJHct at some length.
Has Labor Bes:iin !— As a rule when the physician is called,
t^f^re Ls no doubt as to the commencement of thw delivery.
Oft^n Le is not summoned till the middle of the process, and
H^ii examination finds tlie os uteri ojien, the liquor amuii dis-
cii«rg(Hl, and the heod of the fcetus approximating the outlet
1" other cases, however, the existence of what Ijave been de-
^nhed as false labor pains, leads the woman to believe that
Parturition has made some progress, when in reality it has not
wgnn. Careful attention to a few clinical liiiits will confer the
*iU)wledge and acumen necessary to differentiate the real signs
0^ Inbor. With the finger, or fingers, in the vagina, observe
during a pain, whether there is any descent of the presenting
pwt, or distension of the bag of waters, and other sympttims of
^fitiblo uterine conti'actions. Observe further, as the pains
<^'ine and go, whether there is progressive uterine dilatation.
Mere openne<)s of the os uteri is no affirmative evidence. There
Btilrj»»r zur «ivn. ii firli , \>n;7. ji. 9.
304
MANAGEMENT OF LABtJK.
ion o^^
s fre^
nm-
is & diffei'eDCG between real dilatjition of tlie os. such as com«i
from incipient labor, and an open state of the part. For weeks
prior to delivery there is sometimeB expansion to the extent of a
quarter of a dollar, or even more. An incrensing exptifUiion of
the 08 ut^ri denotes the e^stence of real parturition. Tlie
decisive indications of labor are then, 1. The advance and
treat of the presenting part; 2. The tension and relaxation
the membrane; and, '6. Above all, the progressive expansi
the uterus.
Other, less decisive, indications of labor are an open and
laxed state of the vulva, accompanied with a more or less
flow of mucus, or mucus and blood; also rhythmical pains return
ing every ten, fifteen, twenty or thirty minutes.
False Labor-pains.— Women, as they approach the cl
of utero-gestation, often suffer witli pains which sii^ulate,
measure, those of labor. Believing that real travail has be
they Huminou the [jhysioiaii to their bed-side, to whose annoy-
ance an investigation develops no substantial evidence of incipi-
ent parturition. "False alarms" of this kind are by no
means infrequent, and are sometimes repeated by the same
woman.
Thr aymjiioms of false labor-jmins vary to correspond wi
the causes whereon they depend. The pain is often located
the umbilical region, and is cloni'ly referable to the enlar
uterus. The ovarian region is sometimes its seat, and again
is felt in the hypogastriiuu, in which case it most closely sim'
lates the pains of real ]alK>r. Finally, it is occasionally felt m
severely in the lumbo-sacr^l articulation, and extends down
wards into the thighs.
False labor-pains are, as a rule, continuous, but still may
sent exacerbations. In some instances they are intermi
but irregular in recunence, while occasionally they come
go with the rhythmiis of true pains.
Causes. — Spurious labor-jmins owe their origin to a variety o£
causes. Undue distension of the uterus and abdomen may
set down as one of them. This may operate in a two-f<ild man
ner. 1. The very distension may create a bearing, tensive feel.
ing in the pelvic region, especially in the latter half of the ninth
month, when there is usually more or less subsidenoe of the or-
iown*
itteifl
e ai^H
FAX6E LABOB FAINS.
305
gun; 2. The normftl contractions of the nterus • which regu-
liuly recur throughout tlie greater part of i>regnancy, may
lieaime painful as a result of the great tissue strain which
exists.
Apnrt from unusual distension, there is, in the few days which
jirpcede lalnir, groat pressure downwards of .the gravid organ,
vtiich is capable of creating not only vesical and rectal irrita-
tiou, but a certain amount of real pain.
Women of delicate organization, and those whose strength
has been impaired by disease, are liable to Buffer from neui*algia
effecting the pelvic and a^Klomiiml viscera. Pains of this char-
Mtarare often intense, and sometimes observe a degree of regu-
Iwity in recurrence.
Id some cases, what are termed false labor-pains may be due
to rbeamatism, though probably it is not a common cause. The
wti^ras being rendered exquisitely sensitive by its rheumatic or
rheumatoid state, cannot painlessly untlergo the distension, the
Jtrefigure, and the slight contraction, to which it is physiolog-
ically subject.
Very likely false labor-pains are frequently excited by reflex
rtiosea Irritation t^.xists at some point, — commordy the stomach
or U'wels, — and is reflected to the uterine region, giving rise to
suffering resembling that of incipient parturition.
Diatjfums. — The physician ought to be able to discriminate
*ith pxactitude between the genuine and the spurious, as he
»iiay thereby protect his professional credit, and save his patient
Ml unnecessary amount of distress Beputable and generally
cfmfjptent physicians, have been victims of error in such cases.
A (Mtrrect diagnosis is not always made with facility. Single
^vmptoms are not decisive: a sound opinion must rest on the
^>btlity cif signs.
Perspicuity in differentiation between spurious and genuine
lahoNpains is best attainable by a close comparison like that
viiich follows:
'BgJLXTos UiCKB, "Obrt. Tranfl.^ v. 13.
306
THE HANAO£M£KT OF LABOB.
TRtTK.
1. Most freqaeoUy felt in lumbo-
sacral aud liypogaBtric regions.
2. Pnins rarely constants
3. Pains always recur with regu-
larity.
4. Pains quil« unifurui in dura*
tion.
5. PaiDS at ttrst far apart, and fi-e-
ble. jjnidually lieconuug more Ir6-
quent and severe.
6. Pains geueraUy preceded or ac-
companied by a mucouti, ur muco-
aanguineoleut disriiarge (Vom tbe
vagiua.
T. Tbe internal os is fonnd to bare
yielded partially , or fully, aud tbe
cervical body to bave disupiKtared.
8. Tbe uterus during a pain con-
tracts wilb force*} and the xucmbranes
bulge.
9. Tbe OB uteri b found to be di-
lating.
FALSK.
]. Sometimes felt in Inmbo-sarnd
and byp<>g]uttric regions; ooca&i<io*
ully in inguiniil, but ottcnest in uiu-
bilieal rv^'um,
2. Pains olVn constant, sometime&
remittent, but rarely intermittent.
3. Fains genenlly irregular.
4. Pains generally very nnrquiU
in duration,
5. Pains continuons, remittent, or
intfrniittent with sbort interraU,
tbcir intcDHity observing no regular
iucrease.
6. Pains occasionally accompanied
by a mncous discbojge from ibe vag^
ina.
7. The internal os sonietimea found
closed, and tbe cervix distinct.
ft. There may be uterine contrac-
tion,* but it is not forcible, and the
mrndiranefl, if ibey can be fell, are
but slightly, or not at all, aflect*^].
9. The OS is not dibiting, though
occasionally it is somewhat patulous.
Treahnerd. — If the pains are severe, tho woman ought to be
placed in the recumbent posture, in a quiet room, and every an-
noyance attentively renioveiL Search may t!ien be mode to
ascertain if the pain is not reflected from some distant point, and
if snch a cause is found, it must, if possible, be romovetL
Local treatment vnW afford much relief, especially inrheunwi-
tic and neuralgic cases. Hamamelis or warm spirits may be
freely applied to the abdomen. Unctuous applications will
greatly relieve the feeling of over-distension, aud consequent
suffering.
When the pains observe a decide<l periodicity, like those of
labor, aiulophyllum in a low potency is very effectual in many
*Pl.AYFAlB, "System of Midwifery " p. 142. "After the uterus is sufll-
cieutly large to be felt by palpation, if tbe baud be placed over it, and be grasp-
ed without u.*»ing any friction or pressure, it will be observed to distinctly
hanlen in a manner that is quite characteristic.''
l*ATIENT'S BED AND DKE8S.
307
casea Some physioiauB regard it iih a real apecifio. WTien
there is epasmodic pain, or when the woman suffers in the ova-
rian region, esjiecially at night, and ih restless and luieasy, pul~
9niilU% should be given. Aetata racemosa is peculiarly service-
able in rheumatic or rheumatoid conditions. Belludmma, and
its active principle airopia^ arn especially suited to the pains
when of a neuralgic character. Nux moschaia: spasmodic,
irregular pains; tlie patient has lirowsy, faint spells,
Nitx i^mica may be required when the pains seem to depend
on gastric irritation.
Arsenicum album: when there is gastric irritation and thirst:
the pains are sharp and distressing.
The Patient's Bed and Dress.— These arp matters with
which the physician generally has little to do, as tliey properly
belong to tlie nurse or other female attendants. It is wise, how-
ever, for the physician to be prepared to supervise them, when
in emergencies, he is appealed to. The bed should not be very
»oft; — the best is a good hair mattrass upon a tit^k filled with
fttrmw or hutiks. A soft rubber, or oil cloth, should be laid over
the mattrass, and a sheet spread upon it. A folded sheet should
also bo placed under the woman's hips. Instead of spreading out
the sheet, it may be pinned nlxjut the hips, her chemLse and
nightdress having been rolled up, for protection. During labor
the amount of covering may be regulated to suit the patients
wifiheB, unwise exposure being avoideii.
Tlie lying-in cliamber sliould be as large and airy as the house
affords, and provided with good facilities for heating, if the h\\x>T
cccur in a oool seaBon*
•
Pusitiou of the Woman. — If the room is warm, there is no
▼alid objection to the patient walking or sitting as her inclina-
tion may suggest, in the early part of lalx^r; but this should
not be |»ermitted after the second stage is fairly inaugurated.
She ought tlien to be confined to her bed. When the presenting
part has descended low int4:) the pelvic cavity, and the pains are
strong, on no account should she bey>ermittedt<iri6e. Thecom-
presaion exerted by tlie liead, or other presenting part, may
create u tenesmus of both bladder and rectum, and frantic re.
qacsvts be made for the pri^nlege of using tlio clmml)or vessel.
This, however, shotdd not be permitted, for fear of a sudden
308
THE HAKAOEKBNT OF LABOR.
terminRtion of the expulsive Hct, while the woman occupies an
attitude unsuitable for proper protection of mother and child.
The Physician's Attendance During the First Stage.—
During the first stage of labor the physician ought not to be in
oonfitant and close attendance, as such attention would raise too
liigh the woman's expectations of speedy delivery. The physician
himself will find frequent, and somewhat prolonged, absence
from the nx»ra a grateful relief from the oft-repeated query, of
both the patient and her friends, regarding the duration of labor.
To give non-committal, and yet satiBfactory answers, is no easy
task. His absence, too, will give the woman time and opportu-
nity to use the chamber-vessel, or visit the closet, a thing which
she should lie encouraged to oHe.n do during this stage. If at
any time there should be evidence of much urinary accumula-
tion, with inability to empty the bladder in a natural way, the
catheter ought to be employed.
Bearing Down. — "Women are generally encouraged by the
nurse, and other bystanders, to bear down with force whenevor
a pain returns; but in the first stage of labor this should l>e
utterly ilisi'ouragmL The practice is not only uselefls, but hurm-
fuL In the second stage only con decided aid be derived from
abdominal efforts, and earlier exertion tends to exlxaust the
patient's strength without adequate compensation.
Treatment of the Membranes. — Upon making a vaginal ex-
aminatjcm aft-er labor has fairly begun, there is oft«n, but not
always, to be felt protruding into the os uteri during a pain, a
tense disk of membrnnes, termed the bag of irafcrsy or the hag
of vteiubrancs. It is the practice of some to break this bag,
and allow the liquor amuii to escape, early in labor, under the
belief that progress is thereby acceleitited ; but the most aj>-
proved treatment is to refrain from so doing until full dilatation
of the OS has been accomplished. The latter conduct is generally
recommended on the theory that the bag of waters, by the
hydrostatic force which it exerts, aids very materially in the
process of dilatation. It is found, however, that, in a large per-
centage of cnses. tliere is no distinct bag of waters at the 08
uteri, and yet dilatation proceeds in just as satisfactory a man-
ner. Again, in c-ertiiin cases wherein the jihenomena of the tirst
stage are slowly and tediously manifested, rupture of the mem-
ft^Ml
THE SECOND BTAQE.
309
fcraneswill often greatly accelerate tlie natural prooesses. Still,
we will probably do well to adhere, as a practice, to the old rule,
aod refrain from rupturing the niembrHueB until the stage uf
Bif*rine dilatation has been ctiiupleteti If rupture of the mem-
Innee is not easily accomplished with the finger, the effort being
nuuie during a.^viin, a straightened hair-pin, a probe, or a stiff
catheter may be carefully used.
The Second Stage. — Thus far we have treated mainly of tlie
datiet* of the accoucheur during the first stage of labor. But
with complete dilatation of the os utori the first stage closes,
and is succeeded by the second, or propulsive, stage. The x>i'e-
cisr* moment of complete dilatation is not always easily recog-
nized. Indeed, there api^ears to be some dissonance of opinion
with reference U) what constitutes full dilatation. We are left
lo infpr from most descriptions tliat complete expansion is not
aecompli$ihe<l until the i>s has passed out of reach of the exam-
ining finger. What we have to say here with reference t«> the
management of the second stage of labor is fully applicitble,
Lowi"VPr, t4:> a perioil which somewhat precedes entire retraction
of the OS uteri. For practical purposes, then, we may reganl
the first stage of labor fairly closed when the os is widely ex-
aiul the presenting part, proper, and not alone the caput
eum, protrudes, during a pain, to a A^ertain extent,
tfaroogb the os uteri.
Baooura^e Bearing Efforts.— The phenomena of the second
■tftge ore distinct and ptn-uliar. Tiie woman is now disposed t<^
briug into action her abdominal muscles, and with each severe
l<i make a strong bearing effort. This action, unless vehe-
t b<'yond measure, ought to be encouraged, and every facility
>nled for its proper direction and utilization. While she
pies thp dorsal position, the physician may sit beside the
4>r upon it, and hold one hand of his patient, while st)me
one on the opposite side holds the other. The feet may be braced
agiliiifit the fo<:tt-bf>ard directly, or through the intervention of a
doo], box, or chair; or, what will answer as well, the woman's
knees may press against the shoulders of her assistants. Now,
Ly ' L;ing her to close her mouth, to hold her breatli, and
to i 1 l)eardown, very effective work mny be done. When
Ijin^ on her side, both bauds may be held by an assistant, while
lier lauMA rest against his or her chest. Such counter-traction
310
iTAKAGEMENT OF LA£OK.
requires the semcea of a strong person. Between pains the
woman should be permitted to take perfect rest If descent
proceetls rapidly, the fingers of the accoucheur should be kept
within the vagina, and the case carefully watched; but if slow
progress is made, an occasional examination only, is for a time,
reqiured.
The pains of the second stage are in some respects more sat-
isfactory to the patient, tlian those of the first stage, inasmuch
OB they appear to be more effective; but the real suffering ex-
periencetl in tins part of labor is far more intense. The woman
becomes restless and impatient, and makes frequent inquiry as
to how soon labor will terminate, at the same time fleclaring
that she can endure the suffering no longer. Great tact is here
required to maintain the patient's courage fuid confidence. The
manifestation of the slightest perturbation by the physician, is
liable to create a panic among the patient and her friends. Few
wordtt, fitly chosen, spoken with eAideut comiK»sure, are far bet-
ter than long explanations, or much talk on any pretext whatever-
The Tse of Aniesthetics.— The general subject of anees-
theticH during labor will elsewhere bo discussed, but we may
here take occasion to say that, in the latter part of the propul-
sive sbige, wlien the pains become almost unbearable, there is
no well-founded objection to be raised against the mmlerate use
of chloroform. A few drops may be ]X)ured on a handkerchief,
and when a jiain is due, the woman may take a few inhalations,
with the effect to somewhat benumb the sensibilities without
prtnlucing narcotism. Such administration of a ginxl article of
chloroform is almost wholly devoid of danger, and nmy be con-
tinued ff)r several Itours, if needed. A little instruction given
the inu'se will enable her to use the anaiosthetic, to tJio ex-
tent mentioned, with safety. The intensity of suffering en-
dured by women in labor varies so considerably thnt chhiroform
should not be resorted to indiscriminately; but lot it l>e given in
those cases only wherein there is a strong demand for its sooth-
ing aid.
IiidirationR for Interference.— So long as there is progreaa
being made, we should abstain from interference. If the pains
slacken, or if delay of the head in the pelvic cavity arises from
any other cause, we should not allow the duration of the second
USE OF THK CATHETEn.
311
stage to exceed the pfaysioIogiciJ limits. A satisfactoi'y defini-
tion of what is implied by the phrase "physiological limits"
cannot easily be given, since ita boundaries are not invariable,
and require to be set in each individual case. It should be re-
tflGmbered that i)re8sure of the head ujjon the soft tissues of the
pelWc canity, leads, when prolonged, to pathological changes in
the tissues of tlie canal and outlet. It is a ^vise rule of practice
not to permit the head of a relatively large child to remain sta-
tiiumry in the pelvic cavity for a period in excess of two hours.
But before resorting to instrumental delivery, the aid of other
ineiins should be invoked.
Feeble pains are sometimes intensified by changing the
3 |>ositiun, Rs from the hack to the side, or vice versa.
ler flexion of the foetal head is sometimes thereby effected
When that part has desceuded to the perineum, cipidsive action
niay \)& excited by kneatling the abdomen, or by pressing upon
the fundus uteri
Tijeof the Catheter, — There is sometimes considerable dis-
tension of tlie bladiler daring the second stage, accompanied
?itb utter inability t<» urinate. This distressing condition must
^ ouce be removed by means of the catheter. The use of the
ifistmiuent is s*>metinie9 attended with a>UHiderHbIe ilifficuUy,
oviiij; Ui the pressure of the head against the neck of the blad-
der, and n change in the directitm of the urethra arising from
ttceaftiTo compression imd partial prolajjse of the anterior vo-
^iBol tissues. On these accounts the best instrument for use is
tbe soft rubber ciitlieter of medium size.
iHcarcHratlon of the Anterior Lip of the Os Tteri.— As
tli'^heail descends in the pelvis, the anterior lip of the os uteri
If soiuiftimes caught and held between the head and the pubis,
*^l nihy thereby become a manifest impediment to the progress
of labor. Unless there is excessive* tuniefnctioii of the pai% in-
t^rferenoe is seldom required. Rigby fleclartis all attempts to
pwah it idwve the pehic brim not only futile, but decidedly ob-
jedioriable, since iuflamrnation is liable to he set up. This dic-
tum iH not accepted by all. "Any attempt," says Leishman,*
^raddy or forcibly, to push up the anterior lip, even when it
'SjrsUin orMidwireo'." Am. Ed,. 1H73, p. 2ti9.
ai2
TH£ MilNAGEKENT OF hABOU.
exists as a manifest impediment, should certainly be avoided;
but we are bound to add that, in many raises, it may be pushed
beyond the head with perfect safety, and in this way the im-
petliment to delivery may be at once obviated." The attempt
should be made in an interral between pains, and the part sus-
tained until the recurrence of another contraction serves to
maintain it in a situation beyond the reach of pressure.
tSupport of the Periueum.— One of the most delicate tasks
which the physician is called up<m to perform during ialK>r is to
so regidate tJie exit of the head as to prevent perineal lacera-
tiou. The means adopted to prevent laceration, prior to Smel-
lie's day, consisted mainly in the use of emollents and lubri-
canta He advisei! dilatation of tlie vulvar ojM»ning. Puzos
advocated the use of both lubricants and dilatation. In 17^1,
Professor Hamilton, of Edinhurgli, recommende<i the use of lu-
bricants, and extenial perineal support, from the moment when
the structure began ta bulge until full expulsion of the chilcL
From that time to the present, most writers on obstetrics have
recommended sonje f<;»rm of Kupport for the |>erineuTa- A few,
for example, Leishnian,* advise against all fii-m external sup-
port, as not only ueedless, but in some cases absolutf^ly injuri-
ous. He accepts Tyler Smith's theory, that, by external sui)-
port, the uterus is excited, thmugh reflex action, to greatej
energy at the very time when a contrary effect is sought " The
practitioner, however,^* says Leishmnn, "who never puts his
haml to the perineum, will, we firmly l>elieve, have fewer cases
of ruptured perineum in his practice than he who admits sup-
port in any form as flpplicnble to every case of labor." » • •
" We do not think, in reference to this subject, that we take an
exaggerated view of the case in looking upon it as a relic of
* meddlesome midwifery/ in which we presume, by irrational
and bungling interference, to dictate to natura" He says, also:
" And be it remembered always, that, do what we may, rupture
of the perineum will, in a certain proportion of cases, as is ad-
mitted by every one, occur."
Ritgenf advises pressure of the finger tips upon the pelvic
flotir behind the anus, close to the extremity of the coccyx.
•"System of Midwifery." Am. Ed., 1873, p. 271.
tOij^HArsEN, "Ueber OammverleUnng und Dammftcfantz," Volknuam*a
"Sumnilung." No. 41. p. :JfiO.
PERINEAL PUOTEOTION.
313
Bectal expression is receiving hearty support from n number.
This is effected by passing two liii^crn into the rectum t^jward
Uie close of the second stage of labor, and hooking them into
iLe mouth, or under the chin of the child, through the thin sep-
tum l)*!tween the vagina and rectum. By carefully operating,
thy liewl can thus l>e rotated and extended between pains, and
itlivery in some cases effected.
Fui \ttJ.
H«thO(l of finppnrttug the perineum.
Dr. Qoodell • advises that the fingers be hooked into the anus,
*0il iLe perineum be drawn forward, so as to remove the strain
frtiB> the imjwrilml posterior vulvar commissure, and at the
••"M time promote elasticity of the tissues.
pMbendert would have us practice a very novel and effective
P'^^ure. The woman is placed on her left side, and the ope-
f**"?. standing behind her, seizes the fcetal head between the
\d niiddlo fingers of the right hauil at the occiput, and
le thunkb int*i the rectum as far as possible. This gives
iiai oontrol of the heatl, the rectal wall offering but little resist-
In the interval l>etween pains the thumb can l>e made to
the head forward and uutward, without injury to the tis-
•-Am. Joar. of the Med. Scl." Jun'y 1871.
f ^UM^hr f. G<?burUh, mid Gynaek,"IW. ii, H. I, p. 58.
314 THE MANAOEHENT OF LABOR.
In certain cases, 08|)ecially primiparse, the head, instead of
being deflexjted well forward, under the pubic arch, from the
resistance offered by the |>erineum, presses directly uix)n tliis
body with such force as to threaten central rupture. When
this condition is obsen'tni, direct 8upi>ort to the i>erinettm by
the whole hand must l>e given, in an upward and forward direc-
tion, so as to carry the occiput as closely as {>ossible under the
pubic arch, antl at the same time establish and maintain firm
floxitm of the head.
The accoucheur should not limit himself to tlie practice of
a single mode of i)erineal sujjport, — or, more proj>erly, — ])orineal
pr<3tecti(>n. The form of treatment suited tt) one case will not
Ih? the best for all cases, nor should we discard tlie more commcm
methods ai linn pressure in an upward and forward direction,
under the impression that reflex uterine action w^ill thereby be
excited. From careful observations, freipxently made, we are thor-
oughly convinced that, practiced with an aim to carry the hend
well under the pubic arch, and maintain firm flexion, gooil results
will fiijlow.
The free applie^iti<m of emollients and lubricants to the peri-
neum, intornally and externally, is an imiK>rtaiit part of treatment.
For tliis purpose wiiriii »>il, or cosmolino, are tt) be jireferred.
Proper management of this stage of lalwr includes ch>so
attention tlirt)ughout, to the coiulitinn of the perineum, and tlie
j)reveiition, by manual resistance, of siithlen and ft>rcible oxpul-
siitii of the lii^ad. If ihe conditions are such as ti) jnit but little
strain on ilie vulvar opening, eneri^etie measures for protection
will not Ih' re(]uired. The piiysieian tiught in every case to l>t»
j)n'pMreil to ail'ord the most suitable form of relief whenever the
eniergcney may ])resent.
Kpisiotoiiiy. Hut. we in.|uire, can anything be done to pn*-
serve from serious injury a perineum wliicli, by reastm of an
anomaly in eonstruction, or which, tlirough want of relative
]>roportion betwe»'n tlu' dimt^isions of the fcetus ami vulva, is
very certain to suHVr l:u*eration? In I8:)() Von lUtgen published
an article* in wliich he reconimentled seven small incisions on
each side of tlie vaginal orilice. to be made at the moment of
greatest disteusi*>n. No incisitai was to extend more than a line
*"N('Ui' Zfilscnrilt Inr Cf Inirt^kinidi-." iii riami.
EPISIOTOHra.
315
in depUL By tliis means he claimed that au increased vulvar
circamference of two inches could be gained. The deptli and
ehnnK*t4?r of the incisions have been changed by others, and, as
wp l>eUeve, the character of the operation improvetl. Attention
Lbs l)een directed to the fact observed by everj' attentive prac-
titioDer. that the chief resistance enoounteretl by the head is not
at the thin border of the vulva, but at a narrow ring situated
Lalf RD inch above, reprementtHi posteriorly by the fourchette,
Md oom^KiBed mainly of the constrictor cunni, the tranaversi
p«rin»i, and sometimes, of the levator ani muscles. It hds been
scoardingly recommended that the incisions be made through
these rigid fibres, by means of a blnnt-pointod bistoury, or a
pair of angular scissors. We are told that, so far as practicable,
the ineisions should be confined to the vagina, and sliould not
etoeed three-quarters of an inch in length. In cases where the
iiwd is about to be expelled, and firm pressure already exists,
the bist*iury may l>e carefully introduced, upon its side, lietween
it and the vagina, half an inch in front of the commissure, and
till* section made from within outward. The external skin
^lioulfl not be included, and it may be protected by drawing it
Wk before cutting.
Ill this connection it should be remembered that serious per-
ineal rapture is nearly always along the course of tJie raphe,
owing to tlie relative weakness of the part, and the existence of
H (Minmissure.
The increased danger of septicemia has been urged against
the operation, but the objection is void of much force. The
choi4V> is b*^twcen several slight clean incisions, and one gaping
ruf^ture. It may be saitl for the incisions, that they are situa-
t^ laterally, are shallow, andtogetlier do not present a gi'eater
ar*» of nl^orbiug surface than the central rupture which follows
the exjioctunt plan. Tlie latter, too, owing to its location, is
more exfrnsed to t^ie discharges which carry most of the noxious
germs, and from its deptli, us observed by Dr. Fordyce Barker,
permits the lochia to approach ** an abundance of blood-vessels,
and chains of lymphatic glands."
By this operation, not only is the danger of complete lacera-
tion of the i>erineum prevented, but, owing to their eligible po-
sition, the wonndB generally repair spontaneously, while in cjise
of rupture along the raph6, retraction of the transversi perimei
316
TU£ BCANAGEMENT OF lABOB.
muscles causes tlie wound to gape, and prevents immediate
union.
LHceration of the ppriiieum often takes place during passage
of the shoulders. »Some authors insist that the shoulders cause
the accident oftener than the head While this is probably an
error, the fact that tliey frequently give rise to the accident
shoidd lead the practitioner to adopt every precaution in
trocting them. Descent of the hand by the side of the neck,
and the subsequent pressure of the elbow as it passes the vulva
with a snap, are the prolific cause of the accident Attention
to the mechanism of extraction will here afford greater protec-
tion than ])erineal supi>t)rt, however Avell applied.
Frequency of Perineal Laceration.— According to Scl
der's experience, the frenulum or fourchette is ruptured
sixty-one primiparaj out of tlie hundred. More extensive lacj
ation takes plact; in thirty-four and one-half per cent, of fti
labors, and nine per cent of others.
OLshausen found the j>erinenni rupturetl in 21.1 per cent
primiparre. and 47 per cent of muUipaiw.
Winkel in 11.5 per cent of all cases.
Hildebrandt in 7.2 per cent of all cases.
Von Hecker in 30.(1 per cent of all cases.
Extent of Rupture,
ties of perineal rupture. A mere margin, involving only thi
fourchette, may be t<jm, or there may l>e Inctratiou of the en-
tire perineal body, so as to make the rectum and vagina oi
horrible hiatu.^. Between these extremes are various degreej*^
Perineal rupture has been divided int*:» clnsses acconling to va-
riety and extent of the te^r. The most simple classification is
that which separates cases into complete and inwimplete rup-
tures. Wlien the laceration extemls through the sphincter
ani into the rectum, it is termed complete, while anything short
of that is called incompleie, This^vill answer general purposes,
and where it is deairnble to be more explicit, these classes may
be made to embrace the following degrees of destruction, as
named by Dr. Tlionias:
Superficial rupture of the fourchette and perineum, not in-
volving the sphincters.*
* "When the anterior edge of the perinonm alone U referred to, as for ii
stance, in n lurunition not amounting to halt' .in inch in linear extent, it
called the fonrchette." — Db. MatiheW!* UiNt AN.
-Tliere are various degrees and varii
r>ELn"ERy ok the HHOtTLDKRR
317
Rnphire to the spliincter ani
Ruptiirc till uogb tLe epkiucter ani. -
Kupture tlirougii the sphincter ani, and involving the recto-
TBgiiud septum.
DfliTery of the Shoulders.— When tlie hend hns finally
cletired the \ti1vh, the secretions should be wiped fruuj tlie
iiQ&t and mouUi of the foetus, and examination then made to as-
certain whetlier the umbilical cord is alxiut the neck. If the
ami is found, it should be lut)seued by di'awing carefully ajxin
it, until it can kie slipped over the head, or, failing in this, dur-
ing extraction it should l>e passed over the foetal shoulders, so
fts tu avoid strangulation of the child, and unnecessary and
b»nuful traction- If the cord is evidently to*i short to admit of
8iich treatment, or if there are several turns about the neck, two
iigjitttree may be hastily applieil, and the cord severed between
tiiem. After so doing, however, extraction must not be delayed,
or the foetus will perish.
In most cases the shoulders are expelled without aid. Bnt,
ihoQJi] there be delay, slight traction may be made on the head,
*Mlean assistant presses with some force on the fimdus uteri.
^ben the movement of expulsion begins, the operator's hand
fibould be placed at the postenor vulvar commissure, and the
Kboalder raiswl with some force, as a protection to the peri-
i^fiUflL As the aim, or elbow, of that side j>asses, special pro-
t<'Ctive effort, sliould be made.
\i iwKm as the child is expelled, the little finger of the ope-
'itor gLouhl be passed into the tliroat, and the face turned for-
'Tird, BO as to clear the part of mucus.
Treatment of the Cord.— It is obsened that when, fi-om any
catise, tlie umbilical cord is torn in twain, as B4imetimes acci-
dentally happens, there is little or no hemorrhage. It has been
''^nud also that, in many cases, the cord may l>e cut with scis-
*>rB. and no ligature applied, without the occurrence of any ex-
**tttive blood-loss. These, and other considerations, have led
^^^ to recommend and practice non-ligation of the cord, as an
otlhiary mode of treatment We have given the practice a
pretty thorough test in Hahnemann Hospital, and have found
^"»t, if we will but await the cessation of pulsation in the cord,
*^ niay be cut without fear of hemorrhage, and the case do welL
318
THE HANAQEMENT OF Z.ABOR.
It is probably a mode of tr«mtment which will eventually be-
come common, since it ai>pears to possess some advantages, but
Fio. 123. the rule of practice is yet strongly in favor
of the ligature. Some practitioners lay
much Btress on tlie qufdity and texture of
the material used for ligatures, but a string
of almost any firm material may be em-
ployed. The knot should Iw fibout nn inch
and a half .from the umbilicus, and tightly
drawn, so as to prevent the jK>ssibility of
hemoiThage. A ligature l(M)sely applied
is worse than none. In tightening it, the
two thumbs shoidd be placeil back to back,
and tlie knot mmle tirm by turning them
inwards. If direct traction is made, break-
ing of the string uiny give rise to umbilical
injtiry fmiii the severe ami sudden strain
which is likely to be given. A second lig-
Fiture should tlieii be applied on the side to-
ward the placenta, »inil the &>rd be severed
Shnwin;! I>i>:iittires of between. Tiie last ligature is applied
the Umbilical Cold. chiefly for the purpose of protecting the
bed nn<l clothing from uiniecessarj- soiling. In twin pregnancy
it is employed as a preventive of [jcxisihle blood-loss through
vascular relations lietweeu tlie plucentn. The form of knot to
be used is the reef, or square knot, as
shown in tlie accompanying figure. In
such a knot tlie ends of the ligature lie
across the umbilical cord, instead of
parallel to it, ob in the ordinary knot
Early and Late Lifirfttion.— The most
TheSqaorv Kuot. <lesirable moment at which to tie the
cortl is a matter worthy consideration.
The common practice is to ligate it immediately after foetal erpul-
sion. The errors of such a practice had been pointotl out by
several, when Butlin, in 1875. at the suggestion of Dr. Tar-
nier, made the following observations. In one series of experi-
ments the c-ord was tiwl immediately after birth of the child,
and the blood which flowed from the placental end was meusureil;
Fin. l-,»4.
EAOLY AND LATE UQATION.
319
in the other series, the quantity of blood was likewise deter-
mined in cases where the cord was not tied until after the lapse
of tieveral xuinutes. By a comparison of the results thus ob-
tlified. he found that the average amount of placental blood was
Ifcwe ouiic€*8 greater in the first than in tlie second series of es-
perimeDts.' Melcker estimated the entire quantity of blood in
tb infant at one-nineteentii the weight of the btxly, wliich in a
ilnld weighing seven pouncls, would amount to sLx ounces. In
Wil ScbOcking in similar experiments first weighed the child
11 birth, and then observing the changes which Uxtk place up to
UiH moment of cessation of the jilacentnl circulation, found tliat
H gained from one to three ounces in weight by the delay. An
tllowanoe should also be made for the p<»rtiuii which escapes
t»h«irTalion in the interval before the weight is taken.
What brings alxiut the b'ansfer of tlie bliwMl from the pla-
ctnta to the child Is nn unsettled question. Bndiu believes that
*itb the hrst inhi]>inition, tlie inci'eased How of bl(H>d to tlie
lunga sets up a negative pressure in tJie vessels of the systemic
circulation, so that a suction force is exerteil uiKm the placental
Wwiii, which oomlition is maintained until the equilibrium is
1 Ipiii estfiblished. To tie the c<.»rd at tmcv, therefore, prevents
iaeuleqiiate supply of the demands creatotl l>y functionnl pul-
■ny activity. SchOeckingt takes a different view, maintain-
Hig Hint, after tlie first breath, thoracic aspiration ceases to
outotitute an active energy, and that the main force which ojie-
^k»\i} cause a transfer of the bh»od, is the compression exortinl
"} Uir retraction, and, at intervals, by the contractions of tlie
iitpfas.
^'tfrn clinical observation and experimental research, the just
«>J»»d«sii»n is that there is an element of tnith in both these
thwries concerning the c^use of the phenomenon in question.
^'^ral observei-s have shown that the loss of weight which
^^^'^Ws in the first few days after birth is loss, and the period of
("•is shorter, wheuUie ligature is not applied until pulsation
lothftoiird has censed, and the children are more likely to be
'•ingoroufl, and active. This may also explain some of the
"^n«. " A quel moment doit-on op^rer la ligntnre da cordon ombilical.**
t*iiorHh>8ioIogie dcr NchgcburttiiK-nodc," "Bcrl. Klin. Woch.*» Nob. 1
320 THE MANAGEBCENT OF LAfiOB.
advantages claimod for nDii-ligation of the funis, inasmuch as
pulsation generally ceases l>efore tlie scissors are used. As soon
as pulsation does cease, the cord ought to be cut, or ligatured.
Dr. N. Andrejew* gives the results of his observations in
ninety-three full-term children of healthy parentage, and nursed
by the mothers. It was shown that the children in whom the
cord was tied early (one to one and a half minutes after birth,)
suffered less physiological loss of weight, and more readily in-
creaseil in weight, than those in whom the cord was tied late —
two minutes aftef the cessation of pulsation in it The physio-
logical time at which to ligature or cut the oord appears to be
as stated, iiiiinediately upon cessation of the pulsation in it
The Third Stafl:e. -After separation of tlie child it will be
handed to the nurse, or some lady assistant, to be washed and
dressed, while the physician attends to the duties of the third
stiige, which have reference now to promoting uterine contrac-
tion, the i>revention of hemorrhage, and the expulsion of the
l)lHcenta. . To remove the placenta, when it is not soon expelled
by the natural efforts, the old method is to make traction on the
cord, at first in the axis of the superior strait, and afterwards in
the axis of the inferior strait. Such treatment, however, through
the oontral insertion of the cord, generally inverts the placenta.
This of itself could do no i>ossible harm, but it has been claimed
witli n tjood show of reason, that such traction creates a certain
amount of suc*ti(tn at the jjlacental site, which is liable to pro-
tlui'c licniorriiaf^c. It is claimed that inversion of the uterus has
in a ft'W liistaiiceK Ikmmi producfd by a similar cause.
(rede's Method of IMarental Kxpression.— To obviate this
(lnnj:j('r, a iin)do of plactMital dtiliv^Tv has h^m recommended by
C'n'(M.T and is now practiced ])y a Inr^'O number of obstetricians,
whicli consists in a|>])Iyin^ a r/s // Icnjo, instead of the old n's a
froHfr. It is piiu^tifctl liy ^'ras])in<3: tin* fundus uteri with the
hand in such a way as to pn'ss wtM Ix^hiiul it, and then making
firm pressure downwards and liackwards in the axis of the su-
perior strait. Tlie result is not ohtaiiu'd alone by the manual
force applie<l, hut the uterus is stiumlated to contract by the ab-
dominal manipulation.
'*.IalirI)oh. iTir Kimililkmlc-. xvii.. ->.
"f Mnnulsscliriri I'm (■rl>iirt>k'iili-, \vi, :i:'.7.
DELIVERY OF THE PLACENTA.
321
Immediate efforts at expulsion are recommended by Bome,t
but f"ir the physiological reasons mentioned imder the head of
'• Early and Late Ligation," delay is preferable. In any case it
is l)e8t at first to apply light,, and afterward stronger, friction to
tlie fundus uteri, until an energetic contraction is established.
ITHe most approved way seems to be for the physician to place
iiand over the fundus, exerting only sufficient j)resRure to
lintoin uterine contraction and guard against hemorrhage,
moving the hand about from time to time in gentle friction, until
ateriue action is excited, when he should make firm and equable
pressure in a directiitu downward and backward, until extrusion,
at lejisi into the vagina, is effected. If the first strong effort is
an^accessful, it should l>e rej>eated during the succeeding uterine
i-'« mtraction. When delivery is c^mspleted in this way, the pla-
(^eutft is usually found non-inverte<.l, as in those cases in which
expulsion is effected by tlie natural effort-s.
VUi 1-i.v
Showing Crede'i* luednKl of ildivering Ihe pliureiita.
The Combined Method of Placental Delivery.— Though
^"^tle's mode of delivering the plaw^nta seems simple and easy,
^*Uy have in practice, found it extremely difficult. This is
^^bably owing, in most instances, to deviations from tlie pre-
***^V)ed rules, while in others it has probably occurred maiidy
**^ough fear to apply the necessary amount of pressure. The
^HptKciRlJtKlui. * lAlirlnK-li," p, VJ2.
322
THE MANAGEMENT OF LABOE.
author has found much greater satisfactiou in combining the
two geuerHl modes of placenta delivery, namely, pressure on tlie
fundus uteri, and traction on the cord. We believe this mode
of treatment free from any serious objections, while it provea
remarkably effective and easy. A short hold should be takeu
on the cord, within the vagina, so that traction can be mode
a line apprt)ximatiug the axis of the brim, and with the tlisen
gaged hand simultaneous pressure is exerted on the fundus
uteri.
It will occasionally be found that
occlusion of the cervix is complete,
and the placenta cannot be brought
away without iii*st introducing two
tijigers and hooking dowTi the margin
(»f it, so as to admit a certain amount
of air.
Extraction of the placenta should
be slowly effected, to avoid tearing
the membranes. The latter are usu-
ally left trailing in the vagina after
birth of the placenta, and in order
to secure their complete removal it is
best to twist thorn into the form of
a rof>e, and extract them with the ut-
most care. After expulsion or extmc-
tion of tlie placenta ami membranes,
the physician should see that the
uterus remains well contracted. In
most cases we find that organ firmly
oondensed in the hypogastrium, in a ooudition known as " can-
non-ball cxmtraction.*' i
i
I
I
Inversion of placenta
trad ion on ibt* <-onl.
from
Manual Compression of the Uterus, — Throughout the third
stage of labor, and fc)r a varying period thereafter, the hand of
the physician, 4)r some trusted assistant, should rest upon the
fundus uteri, at the same time exerting some degree of pressure,
If, after placental delivery, tlie organ manifests a decideil
tendency to relax, friction and kneatling of the abdomen should
be practiced, to excite uterine contraction. This sort of treaU:
ment should in no CEise be omitted, as its influence u|x>n the'
^
N
POeT-PABTUM CARE OF THE WOMAH. 323
stage of labor, and the puerperal state, is decidedly salu-
After removal of the placenta, the perineum should be thor-
oughly examiued by means of the thumb in t!ie vagina, and a fin-
ger in the ruetuiu. Tactilt^ oxamination is more modest, and is
fully as satisfactory as visual.
Post-partum Care of the Woman.— The general condition
of the woman, and the special state of the uterus, should be
ctrefully watchetl for some time after delivery. First of all she
should lie warmly covered to prevent the occurrence of chilling.
The manual attention given the uterine oontraction, l^efore men-
tioned, should be maintained in simple cases for at least fifteen
minutes after placental delivery. The pulse will alsti furnish a
criterion from whidi to draw valuable conclusions. If it is
•found to \)e rapid, the case requires undivided attention so long
as it thus continues, while if quiet and regular, little anxiety
Deed be felt Tlie pliysician should in no case leave his patient
"W-ithin the first half hour after delivery; and if hemorrhage has
V>cen threatened, he should stay much K»nger.
The atbuiuistration of arm'cfi should be begun immeiliately,
^.ad, ill the absence of more specific indications, ought to be
^^ontinued ho\irly during the first twelve hours, or longer.
When the hand is removed from the uterus, the nurse, and
^^ther assistants, should withdraw tlie soiled clothes, and make
^le patient as clean and comfortable as possible, without mnch
^disturbance. It is a gtxxl practice to have the nurse also wash
<Dut the vagina with a very gentle stream of carbolate<l wami
'^ater, the jxiint of the tube being introduced into the vagina
W)ut a short dist^ince.
The Binder. — The use of the binder is a point in practice
■^ver which there has been much discussion. Some practition-
ers of much repute believe that it is not only valueless, but ptwi-
tirely harmful, and utterly discountenance its use. Every care-
ful observer, however, must admit that a certain amount of
pressure is essential to the patient's perfect comfort After
labor women feel as tliough they "were falling to piecea," and
the binder, if it does no more, certainly contributes greatly to
tlieir comfort To completely fulfill the requirement, the binder
mnst be properly applied. A narrow bandage will not keep its
place, and is liable to do more barm than good. Its width will
324
TH£ MANAGEMENT OF LABOR.
9. '
lacM
? is
i
vary somewhat in differeut cases, but the average BboaI<
about twelve inches, and it should cover the entire abdomen.
To do this it must be brought well down over the hips. Almost
any material will an^twer tbe purpose, bat a strong piece of un-
bleached muslin is j^referable. By some, a pad, consisting of a
large napkin, or small folded towel, is placed over the hypogas-
trium.
To make a neat and effective application of the binder is
thing not easily accomplished by the novice; and yet every phy-
sician ought to jKisaess the necessary skill. To prt)perly pi
it under the woman's hips, requires the services of at least t
"When this is done, tlie physician should hold the end noA
him between the thumb and fingers of the left hand, if he
standing to the right of his jwitient, and of the right hand if
stands on her Inft, while he draws the opposite end tightly ovi
it^ and applies the first pin in the aide U>ward the vidva. Se
or eight i)ins should be used, and when fully ft])p!ieA the binde
should be free from T^Tinkles. The woman's toilet is completetl
by placbg a warm napkin at the vulva to receive the discharges.
If now comfortable, and her pulse quiet, she may l>e left by
the physician in the care of her nurse, who if not well ac-
quainted with her duties should receive explicit instruct iiins.
Therapeutics. — In the course of normal labor there woidd
seem to be but few occasions for the use of remedies; but un-
pleasant 8>Tnptoms are sometimes associated with the usual
phenomena, and without being essential parts of tlie parturient
action, are amenable t<j the suitable remedy. We therefore here
apj>end tlie folk>wing indications:
Labor-Pains.— /fi^^fWeri/, e/c— Violent and frequent, but
inefficient, aconite.
Too weak, not regular: ceihusin.
Violent, but inefficient: arniciu
Tormenting, but useless, in the beginning of labor: caulophyU
lum.
Short, irregular, spasmodic, patient very weak, no progress
made: caul.
Spasmodic and irregular: coccuhts.
Spasmodic: cwiat, femtw^ puhniilUu
THEBAPEUTiCH OF lABOB.
325
8{>iism(Hlic, cutting across from left to right, nausea, clutoli-
icg atxmt the navel: ipecac.
SpaKmo<lic, painful, but ineffectual: jp/a/(«a.
Spasmodic, they exhaust her, she is out of breath: sHfunnum.
Spaamoilic and ilistressiug, tearing dovm the legs: cham.
InsuiHcient, violent backache, wants the back pressed, bearing
down from the back into the pelvis: kali e.
Distressing, but of little uj>e, cutting pains across the alxlo-
meu: /j/iok.
Ineffectual, of a tearing, distressing character, they do not
eeem t<> be properly located: actimi.
Severe, but not effective, she weeps and laments: coffecu
UVrt^', FiiUt*, Dvjicieni.— False, labor-like pains, sharp pains
across abdomen: acfcra^ va/il
Pains weak or ceasing, wants to change position often, feels
bruised: ttT^iiai.
Weak or ceasing, will not be covered, restless, skiu cold, cc^w-
jfhor, c e.
Deficient or absent; she has only slight periodical pressure
on the sjicrum, amniotic tluidgone, os uteri spasmcnlically closed*.
belltuUmncu
W^nk or ceasing, with great debility, especially after violent
disease, or great loss of iluids: airb. v.
Pains become weak, ilagging, from long-protracted labor, caus-
ing e&liaustion; patient thirst)', feverish: cauL
Cease, from hemorrhage: chintt.
Ceasing, with complaining loquacity: coffea.
Weak, or accompanied with anguish; she desires to be rubbed:
n<iirum w,
Fidse or weak, spasmodic^ irregular, drowsy faint spells, with
weak pains: mix m.
Deficient, irregular, sluggish: pulsaiiUa.
Weak and cejising: ihuj<i.
Deficient, with os soft, pliable, dilatable: usfHago.
Sappressed, or too weak : secale.
Cease, coma; retention of stool and urine — from fright: ojuiuwi,
S/ron//.— Excessively severe: coffeuy mut t\
Too prolonged and powerful: secale.
Effect on Patient*— Labor- pains make her desperate, she
326
THE USE OF ANiESTHETIOB.
jping:
4
■8 and ■'
would like to jump from the window, or dash herself down:
arum iry.
During pain she must keep in constant motion, with weeping:
lycojymUum.
Cause fainting: mtx i%, i^rat alb, puis*
Ciiuse urging to stool, or to urination: nux v.
Excite suffocative or faint spells, must have the doors"
wind<JWH (»pen: jjulsaiilla.
Exhaust her; she faints on the least motion: verai a.
Cause weeping ami lamenting: cojfea.
Location and Cour.se. — Pains principally in the back: can
Pains worse in the back: nux v.
Pains worse in the abdomen: puhaiUla.
Pains ruu ui>ward: lyropodinnK
Pains like needles in the cervix, especially with rigid os;
lophylhim.
Special and peculiar Symptoms.— Canliac neuralgia
partm*ition: acUtea,
During labor cannot boar to have her hamlK touched: chh
With every uterine contraction, violent dispuotea which seei
to neutnilize the lalxir-pains: loheiiu.
Labtir progresses slowly. i)ains feeble, seemingly from sad
feelings, and forelxHiings: nnL vwr.
Cessation of labor-pains; retention of stool and urine, ofteu
from fright: opium.
Contractions interrupted by sensitiveness of vagina and vtil'
plaiimt^
CHAPTER IT.
Use of Ana&atliotics In Midwifery Practice.
In treating the subject of aniBsthetics in obstetrical practi<
we should divide cases into two general classes: L Case^
normal labor, wherein we seek merelj-- to mitigate the ordinal
pangs of childbirth, and 2. Cases of an abnormal, or tinusi
nature^ wherein operative interference is mloptwd-
ANaSTHETIOa IN NORBfAL LABOR.
327
1. fases of Normal Labor. — The use of anspsthetics in
normal Jabor, diflera essentially frtm) its omploymeul elsewhere,
in the design of its employment, and the extent to which its ac-
tion is carried. We aim in such cases not to wjmpleiely annul
sensibility, and subdue muscular resistance; but merely to mod-
ify the agony associated with the propulsive stage of labor.
When from purpose or accident the nuiesthetic influence is jjer-
mitted to exceed this limit, new dangers arise, and fresh compli-
cations are met. To accomplish our purpose, continuous inha-
lation is not required, and should n(^t he i>ermitted, but the
lethean vapors ought to be applied just before and daring the
pains.
The form of antesthetic best adapted to such purposes is un-
quentionably chloroform. It is more 8i)ee<ly. pleasant, and
energetic in its effects than ether, and in parturition it has prove<l
to be quite as safe. In surgical practice its effects have occa-
sionally proved fatal, but when ailmiuistered during labor, ac-
conling to the directions which follow, scarcely a death has
resulted.
Parturient women are easily put under its influence to the
extent require<l for present pui-poses, a few inhalations of its
vnjx)rs, begun just before the expected recurrence of a pain, and
continued during it, being sufficient Uy allay excessive sensibility,
d ijuiet the nervous erethism so often observed. The nurse,
or some Kelf-|MtssPssed M^^sistant, is instructed to pour upon a
folded handkercliief or napkin fifteen or twenty drops of the
chloroform, and place it within about half an inch of the nose
and mouth, thereby giving free access to atmospheric air. None
of the chloroform should be permitted to touch the patient's
flldn, as the smarting produced by it would be liable to excite
fear. It is a good plan to npply the chloroform to the handker-
cliief soon after the close of a pain, and then roll the latter
tightly in the hand to prevent evaporation, until the pain is
about tn return. Othenvise there is liability Ui delay, and the
pcitient is as greatly annoyed by tlie bungling work of the per-
D in charge of the amesthetic, as by the labor-pains themselves.
"By such juimtiiifitrntion of chhiroforni, c/insciousness is not im-
paireil, and the patient may at the time declare that her suffer-
ixigs are nearly as keen as before; but when the labor is past, she
is eoitiiosiastic in her praise of the virtues of the ansBsthetia
328
THE USE OF ANAESTHETICS.
Women who imve ouce tuken it, are not willing to be depriv'
of its soothing influences in subeeqnent labors.
The usoal objections raised against the use of chloroform in
labor, are not here forcible, since the effect is so moderate that
it is not capable of materiully modifying the pains, precipitating
post-partum hemorrhage, or producing any of the other ills
sometimes attributable to a use of the drug under different c
cumstauces.
The i>oriod in labor when the use of an aniesthetic should
ad*)pted, varies in different cases. It is wise, however, to def^r
luitil near the close of the second stage. When once begun, its
action must be maintainetl until the close of fuetal expulsion, as
the woman will not tolerate a suspension of the pain-stHHhing
influences. Hence, to begin <'arly, involves a long Cftntinuance.
The most intense pain is suffered in the latter portion of
pnjpulsive stage, and this part of labor, if any, ought to
lightened- In some instances of exti'eme excitability, and terri
ble Bxiffering, the chloroform may, with perfect propriety,
earlier exhibited.
2. The Ine of Antesthetics in Opi^ratire Midwifery
The effect of the amesthetic, in those oases where operative pr
cedures are necessary, is carried to a greater extent, and, possi
bly, involves the patient in greater danger. That there is a cer
tain degree of peril to life associated with the administration of
any auiesthelic. no one will question, and that it is greater
the instance of chloroform, none who have familiarized them-
selves with the general subject of ansesthetics will presume
deny. Every few weeks a case of death under chloroform fin
its way inti> public print, thus giving strength to popular fean
And yet a careful analysis of such fatalities generally disclosea,
as an efficient cause of the accident, a flagrant disregard of th
rules laid down for the administration of this potent, and hen
dangerous, substance. The fatalities occurring in the dentist'
chair largely preponderate, the patient cxscupying a semi-recum
bent position, which is wholly at variance with that prescrib
upon physiological priuciples.
Attention should bo directed to the difference in point of mor-
tality under anaesthetics between surgical and obstetrical
patients. In surgery we have many recorded cases of death,
and their number is being augmented from time to time; but
lis
1
its
OS
ice. I
th^
be^
AX^8THETIC8 £N OPERATIVE MIDWIFEBY,
329
tills b not true of midwifery. In fact, but few fatal cases in the
liitt<^r branch of practice have ever gone upon record. The ex-
planation of such divergent resuJts is not altogether satisfactory,
but it may be found in the increased cardiac energy growing out
o( th*? circulatory chungey t»f pregnancy, elsewhere doscril)e<L
KutvLfltever our theories regarding the cause, the truth re-
naiaa, and has become familiar, even to the general public.
AiticBthetics are said to pretllspose to post-partuin heraor-
rlwge, which is generally a complication directly dependent on
ttooy of tlie uterine muscles. Extreme vascular fullness is
mamtjiined by the llaccitUty of the tissues, wliile the expt)sed
'wsels at the placental site freely bleetl. The effect of anies-
\\w\i<s un uterine contraction is marked, as the author has re-
I^nUnlly demtmstrated. Tliis effect is rather more decided in
fthloroform than in ether inhalation. A moderate degree of
Wttthesia may l)e prfnluced withi)ut esseiitially modifying ntor-
U* Wtidu; but tis the impression becomes more profound, the
("ntnicting organ is partially or wholly sulxluecL If Uiis is the
>■? ' 'stlaetics on the uterus during Inlxir, when the organ
'^ :i ti> action by it.s content^s, we shouhl i>e prepared to
^ a orrespondiug condition protracted somewhat into the
i"fit-lnirtuin stage. That we do find more or less relaxation af-
*'''' extrusion of the fcatus and secundines in such cases, is he-
Tu&ij qne.ition; and yet it is not so marke<l, nor so persistent, as
^"'' -e. Kemove the vnpors fmm the woman's nostrils
'' II. and the contractions which have been extremely
"*^'l*. or altogether altsent, are soon renewed. In like manner
**« (Iftlivery, when the more profound effects of the chloroform
Bway, uterine atony gencnilly gives place to a favorable
^t» of the muscular fibre. The result is that hemorrhage of
^'mcDt mrely ensues. Occasionally there is a sudden profuse
*™*li f»f bliKJcl 8o<tn after the placenta is removed, especially
'uflQ the aiuesthetic in^uence has been maintained to the very
''JfHeof the second stage, or longer; but hyp<:ignstrio pressure,
•"^'1 HKxlerate use of c*)ld water, are nearly always capable of
^P<^-Hiily arresting the flow. In the Hahnemann Hospital it is
^citetom, aea preliminary to the introduction of a class of
iftnls, to bring the woman proftiundly under the influence of
'U'^rt'f orm ; and though narcosis is frequently maintained for a
P^nodof one and a half, or two hotirs, among the hundreds of
330
THE U8K OF ANESTHETIC**,
women confined theie during the past few years, not a smgie
case of alarming iiemorrJiage has been met Our practice is t<»
keep a close watch over the patient for a considerable time af-
ter delivery, and give attention to the first indication of trouble.
Pressure is made on the fundus uteri for fifteen or twenty
utes after foetal and placental expulsion, in ordinary coses,
longer in those presenting suspicions symptoms. If the ut<
is folt to relax beyond u normal limit, luid does ntit respoml
once to abdominal pressure, the viUva is inspected, and, if nec-
essary, cold applications, and manual irritation of the os uteri,
are employed. It is rare tliat more energetic measui
re(|uired.
The question has often been asked — Does an anffisthetic
ministered to the mother, produce any effect on the child
utero? We have been let! by experience to give an affirmal
reply. For example, in a difficult instrumental case which came
under the writer's care, wherein sulphuric ether was adminis-
tered for an uncommonly long time, the child, tJiough but a few
minutes l3<*fore birth it was proved by ausculbition t<j be living,
was still-bom, and resisted all eftorts at resuscitation. Al
forty-eight hours subse({uently, dissection of it was began
some students, and when the viscera were expo&ed, the odor]
ether was distinctly observetl.
In most instances, where the mother has been long subjected
to nntesthesia, the child is comparatively inactive for some time
after expulsion. It is reidly uncommon for children boni under
such conditions to utter the cries so generally heard at the birth
of children whose mothers have not been under anaesthetic in-
fluences. And yet. that decidedly deleterious effects are ofl
produoed, there is much reason to doubt
teM
nec-
ateri,
en^a^
am^
inis-
few
ving,
.bqjiy
]
Rules for Administeriug Anspsthetics.— The general t\
for administering anesthetics are pretty well understood, even
by tyros, and still there is frequent disregard of them. The
mode of administering chloroform differs materially from th&t
of ether. In bringing a patient under the infiuence of the lat-
ter, a cone, or aniuhaler 4>f some other form, is generally em-
ployed, which is held closely down over the nose and mouth, so
that all the atmospijere which enters the lungs is loaded with
ether vapors, taken from the saturated sponge in the apex of
nULES FOB ADMINI8TEBIN0.
331
^
»
Allis'Kthvr lubalcr.
Fro. 19V
oona. Such a use of chlorofonn would be dangerous in the ex-
trema lu its administration the following rules should be ob*
Benred:
Ficj 127. First: — The patient must occupy the
recumbent posture.
Second: — The article or apparatus by
means of which the chloroform vapors
veyed to the jmtient, must be so
■ ■ < )r arranged, as not to exclude a
moderately free supply of atmospheric
air.
Third: — Both respiration and pulse
should be attentively observed from first
to last
Deviation from a horizontal position
augments the patients danger, as has
been repeatedly demonsti*ated in fatal cases.
The supply of atmospheric air must be more copious than is
tfurded with ether inhalation. A fold-
fid handkercliief, or napkin, is a conven-
ient medium, on which should be poured
but a small quantity at a time, and then
placed within one-half or three-quarters
of an inch of the (latient's mouth and
sose. The j^atient should be directed to
breathe deeply nndroguliirly, while fear
and excitement ought to be allayed as
far as |Kissible, by cheerful words and a
calm bearing. The supply of chlor-
oform may Im renewed as often as cir-
camstances seem t*) require, the inter-
vals being varied to corresiKiud with the
woman's conditi<in, and the facility with
which ana?6tliesia is pnxlucecL These
•re important considerations, since it is
very certain tlmtdanprer bears a marked
relation Ut the int4?nsity of the impress- chisoliu's Ether inimier.*
ioiu and the rapidity of its production.
• Tl»is inhaler tnkt'8 up Httle room in the obstetriciU bag, or even the pocket,
«n4 is A TiT>' cunvriiKiit iiitirle to etirry.
332
THE MECHA5ISM OF LABOP
Neither ansesthetic should be admimstered without the closes
atteutiiiD beiiig directed to the pulse and resiiiratioii. Wh'
employed in normal labor for the purpose merely of dulling
sensibilities, this is hardly so essential, tliough it should ntjt be
forgotten that in other than midwifery cases, death hua occurred,
in quite a prox)ortion of instances, at the very beginning of the an-
lesthetic process. When carried to the extent of complete
cosis, the rule must be scrupulcmsly ndi»ere<i to, if one wo
keep within the bounds of comparative safety. Nor should th
c)bsei'\-ations be-intrusted to a person wliolly unncquaint/>tl wit
the phenomena developed by anaesthetics, if it is possible
secure the aid of one qualified to fill the position. To do oth
wise is to subject the woman's life to unnecessary risk, oneT
self to much solicitude, and to merited denunciation incase of
fatal result.
After making the most elaborate provision for theatlministra-
tion of this powerful drug, the operator shouhl on no arcnun
suffer himself to become oblivious to his patient's con^liti
When the o|)eration is difiicult. and attended with vexatioxis
occurrences, one easily becomes so deeply engage<i in the work
immediately in hand as to remit his watchfulness over im
tant concomitants— a state of mind against which he cannot
too guarded.
We shall not here enter into an account of the symptoms of
fnf.nl cases, or the treatment to be adopted; but for an extended
tliscuBsion of these we refer the student to elaborate works on
surgery, and to special treatises.
b^
■ed,
9 an- '
nafl^H
ouH
wit^^
M
oxii i
Hy
>tiH
CHAPTER V.
The Mcclianisni of Labor.
The Various Positions of the Fcetus.— This is a subjeo^i
which, to the student, is fxdl of difficulty, and to elucidate it j^H
no easy task. One of the most c^^nspicuous factors in the pn^^l
duction of confusion is the adoption of numerals to designate
the various positions which are met Every presentation has
four positions, which are designated by the numbers one, two,
POSITIONS OF TOE FCETUS.
833
tliree and foar. For example, the left occipito-anterior positiou
is the first, aud the right occipito-anterior is the second. The
ndoption of these designatious, it inuHt be confessed, is a saving
of aome words at the moment; but to give the student a per-
)icuoiid and comprehensive view of the different ixjsitions, aud
tlieir relations, demands an exhaustive, and» we may luld, unnec-
t&ary effort
As a preliiuiuury tu the study of this subject one must have a
clear conception of the cardinal features of the pelvis, which
Lnve been elsewhere i>4)inted out. With a knowledge of the
form of the pelvic brim, outlet and cavity, the situation of the
ileo-pectineal eminence and the acetabulum, and the relative
measxirements of the various diameters, and finally the bounda-
ries of the false and the true pelvis, one i^ prepared to under-
KUnd that which here follows.
The Theory of riasslficatlon.— The four positions into
which the various presentatidUH are di\aded, are bfised upon the
theory that tlie long diameter of the presenting part occupies an
oblique ix^sitiou with reference to the pelvis. That the theiiry
floes not hold true in idl cases, is manifest to every obstetric
practitioner. The long diameter is sometimes, though rarely, at
the brim, in the coiijugute of the pelvis; and again it occupies
the transverse diameter. In the latter instance it tdways rotates
into an oblique diameter, soon or late, and tnerefore becomes
one of the regular positions; while instances of the former are
80 rare as to make a single exception of no great imjx)rtance.
For praclic-ol, as well as theoretical purjx>ses, perspicuity would
leaf! ti» an approval of tlie division.
Wlien the vertex j»resents, the occiput is regai-ded as (he car-
dinal feature, since it is in advance, and from the direction it
asmunes, the positions are described, or numbered. With tlie
long diameter of the head in an oblique pelvic diameter, the lic-
ciput must be either forward and to the left, or backward and
to the right; fonvard and to the right, or backward and to the left.
When forward and to the left it is the first position; when for-
ward and to the right it is the second position; when backward
lod to the right it is the third position; and when backward
d ti> the left it is the fourth.
Wlien the face presents, the chin corresponds, so far as the
mecbanisin of labor is concerned, to the occiput in vertex pres-
334
THE MECHANrSM OP LABOR.
ent&tioD, and the direction of that part determines the position.'
"When backward liud to the right it is the first ]K»«itiou; when
Fia.139. Fkj. 130.
First PoeitiuD of the Vertex,
Fio. 131.
Second Position of the Vertex.
Fio. im.
Third Position of the Vertex. Foarlh Position of theVert«t.
backward and to the left, the second ; when forward and to the
left, the third; and when 'forward and to the right, the fourth.
THEOBY OF CLASSJFICATION.
335
\\Tien the pelvic extremity presents, one pole of the long
*"Wneter does not take precedence over tJio f»tliGr, since it is
ria.133. Fi(i i:u.
•^* r««. Position of the Drecch.
Fi(. KW
Kecoud Position of the Breech.
^*ittl PoiiitJon of the Breech. Fourth Powtioo ot the Itrcech.
\i&'^aU!rial to tfie easy and natural performance of the mechan-
Vgm uf Iftln^r whether the right or the left trochanter is turned
836
THE MECHASlfiM OF IJlBOB.
forward. Wlmn the bi-trochantcric diameter is in the left o1
lique pelvic diameter, aud the left hip is forward and t<> the
Vu) 137. right, it is the first pubition;
when in the right oblique tlia-
uieter, oud the right hip is
forward and to the left, it is
the second jx^sition ; when in
the left oblique and the right
hip is foi-ward and to the
ripht, it is thethia-d jx)sition;
u?ul when in the right oblique
diameter, with the left hip
forward and to the left, it is
the fourth iKwitiou.
When the foetua presents
transversely, four positions
luay also be describe<L If
the dorstim is forward, and
the hoatl lies to the right-, it
is the first |x>sition; if the dorsum is forward, and the head lies
to the loft, it is the second position; when the dorsam is back-
FiG. 139.
Fourth roMiliou ol the F«'t,
Third Position of TrAUSvcrae PrcAentation.
wnrd, and the head lies to the left, it is the third; and wh<
THE BASIS OF CLA88I?ICATI0N,
337
dGNnmm is backward, and the bead lies to the right, it is
Fig. i:e».
Second I'twitiuu uf TruiMvense rrcsentiiiion.
jfljGse are the four positions of the various j)resentations.
"'">' have been otherwise named by some autliors.
Tin, Basis of Classification.— It must not be supposed that
. ^ classification of pobititJUK is made ujhjh mere arbitrary prin-
'Pie«5^ though from the first study of it this may seem to be
y^^ Our attention has thus f*u" l>oeu addressed to the various
fj'^^i^es of the presenting parts, but we will now regard the po-
*^'*^ri of the trunk.
^ »t:ii respect to the direction of the back, it should be said
''^t» like the position of the head, it is not always oblique; still
*^*^^cal, as well as theoretical, purposes are just as well served
^ may say, are l)etter served — by assuming that it is. The
K ^lis (bis-Hfhrouiial) of the trunk forms a right angle with
long axis { occipito-frontal in vertex presentation, and
*^-0-mpnffl.I in face,) of the liead. Accordingly we observe
[ -. ^ the dorsarri of the foetus coincides with the occipital pole
\ . ^»i^ long diameter of the vertex, and the frontal {kAo of the
6 tliameter of the face. The bi-trochanteric diameter of the
»T *s is the long diameter of the presenting part, when the pel-
^ ^Od is in advance. In the first position of vertex presenta-
^^^^ the occiput lies to the left ilio-pectineal eminence, and con-
338
THE MECHANISM OF LABOR.
stitutes the left occipito-anterior position. Now, assumiiigr
we do, that thft fcctal btick correBponda in direction to the occi-
put, this position might well be designated as the left doi
anterior position of the vertex. Let ns now reverse the enc
and cause the breech to pre84njt in the first position, and
have the left dorso-auterior pr)sition of this presentation. We
will now return the child to the first position of the vertex, and
then, by extension of the Lead, t. e.y by tipping the head
PlO. 140. Fio. 141.
First Positian of the Vertex
First Pontion of the Brenib.
wards, we convert it into the first position of the face, and we
find that this may likewise be described as tlie left dorso-anto-
rior position — not of the vertex, not of the breech — but of th
face. Furthermore, we will now turn the head away from
brim and lay it in the right iliac fossa, and we have the
position of transverse presentation, which may also be desi
nate<i as left dorso-anterior.
What is true of tlie first position is also true of the secon
third, and fourth positions. In tlio second position the dorsum
of the foetus is forward and to the right, and it may be graphi-
cally described as right dorso-anterior. AMieu the head pre-
sents, it is right dorso-anterior position of the vertex or fac«
when the pelvis presents, it is right dorso-anterior of tliebreec
knees or feet; and when the presentation is of the side of
THE BASIS OF CLAS8TFICATT0N.
a39
ral, then briefly, it may still be designated as right dorso-
VT position. In the third position of any presentation, the
back of the foetus lies backward and toward the woman^s right;
and in the fourth position of any presentation, the dorsum is
turned backwards and toward tlie woman's left By such gen-
enjizatiou, we obtain a comprehensive view of the entire sub-
ject of positions.
Pik'. 1«. Fig. 143.
Second I'osition of Uiu Vertex.
Second Position of the Breech.
From what has been given on this topic we may draw the fol-
lowing conclusions:
First: That the underlying principle of classification is not
80 much the direction of the cardinal features of the presenting
Pwt, Hs the direction of the foetal dorsum.
Second: That the first and second positions of all presenta-
'ious, are dorso-anterior, — the first, left dorso-anterior, the sec-
<**l right dorso-anterior; and the third and fourth ptisitions are
"Wiiys dorso-posterior,— the thirtl being right dorso-poBt«rior,
*o4 the fourth, left dorso-posterior.
Tlitrd; That in the first and fourth positions of all presenta-
"0116, the dorsum of the fujtus ia directed toward the woman's
'^ft,— the first somewhat forwar<ls, the fourth somewhat back-
*«tU; and in the second and third ix>sitions of all presentations.
340
THE ICKCHANLSM OP LABOR.
the dorsum is turned toward the mother's right,— the second,
somewhat forwaids, the third, somewhat backwai'ds.
The Relative Frequency of Positions.— Of vertex presen-
tations the back of the child is directed to the left of the mother
in about seventy per cent of all cases. With regard to the fre-
quency of other positions there is much discordance of <»pinion,
but the author's exjmrieuce teails him to the conclusion that the
frequency of the several positions is in the order in which they
are numbered.
While tlie relative frequency of the various i>ositions cannot
yet be determuied for waut of recorded obw^rvatious, it appears
tiiat while in vertex presentations the dorsal surface of the ftk*tus
is turned toward the- mother's left in about seventy per cent of
all cases, in face presentations this position does not preponder-
ate.
Points of Coincidence Between the Varlons PosltionH.—
In vertex presctiialian the first and second positions agroe in one
particular, namely: they are both occipito-anterior positions; —
the fii'st lookiuR to the loft, the second to the right; and the third
and fourth agree in being occipito-posterior ]x>8itions, — the third
dii'ected toward the right, inid the fourth t<:tward the left The
first and fourth conesjxmd in being left occipital jx»sitions; that
is to say, the occiput in both instances is turned toward the left.
— in the fii*st, somewhat forward, in the fourth, somewhat back-
ward. The second and tliird are alike in the general direction
of the occiput,^both looking to the right,— tlie second turned
somewhat forward, and the third somewhat backwaixL Agfun«
the first and third agree in respect to the oblique pelvic iliame-
ter (right oblique) in which they lie, but the p4">les are reversed,
BO that the first is the left occipito-anterior position, and the
third the right oceipito-posterior. The second and fourth oor-
respond in similar respecta They occ^upy the left oblique pel*
vie diameter, the second being the right occipito-anterior, and
the fourth the left occipito-posterior position.
Face Presentation.— Briefly etatetl, the positions of the faee
coincide in certain particulars which are determined by simdar
principles of classification as are those of the vertex. Tlte fiist
and second are mento-posterior positions, the chin in the first
looking to tiie right, and in the second, to the left The thinl
POINTS OP COINCIDENCE, ETC.
341
lUid fotirtli are meuto-anterior jx^sitioiis, the chin in the third
being directe<l to the left, and in th«? fourth, t*^ the righ't The
first and fourth corres^xjud iu the lateral direetiou of the chin,
in tlip tirat it being backwards and to the right, and in the
Itmrth, forward and to the right The coinciileuce between the
)nd and third is similar, in the second the direction being
Wkword to the left, and iu the third forward to the left
Tbe first and third, and the secontl and foiu'th are alike in the
pelvic diameters occupied by the l(jug facial diameter, the first
being right mento-posterior, and the thinl, left mento-anterior;
■while tlie second is left mento-posterior, and the fourth right
iiienUi-anterior.
Br^erh Preseiitatfoii.— The first and second positions of the
hre*-ch aj^'ree iu that the right trochanter of tiie foetus looks
toward tlie left in the first position, somewhat backward, antl in
tlie second forward Likewise the third and fourth positions
r*^mi)ie one another in that the right trochant4?r is turned to
Uif! muther's right, iu the third position it being fonvard, andjn
tlie fourth backward. The first and third are identical in the
^iredionof the bi-trochanteric diameter (left oblique), but in
^© first |x»sition the right trocliaider is at the left ilio-sacral
fiyachuadrosis, and in tlie third is at the right ilio-pectineal em-
lUPiirt:, The secimd and fourth jiositious coincide iu tiie pelvic
diAiueter occupied (right oblique), but in the second the right
trtKihauter is at the left ilio-pectineal eminence, and iu the fourth,
•t Uw right ilio-sacral synchondrosia
CHArTER VL
The Mechanism of Labor,— (Continued.)
*^e mechanism of labor varies greatly with the character of
^P Presentation. The xarieties of these, and their positions,
bare already received attention, and but a few geuei*al remarks
^^ be made here witli regai*d to them. Vertex presentation
represents the normal type of labor, and is alone entitled to be
'^P'Jded as strictly normal The other varieties are relatively
342
THE MECHANISM OF LABOR
infrequent, nnd present characters which deviate from the'
nomena usually obsen^ed.
Vertex Presentations. — Some of the ancients believed that
the head paHsed through the pelvis in the same manner as a
semi-organized clot of blood, or a mass of hardened feces, with-
out reference to those nice laws oE flexion, rotation, extension
and restitution, now so well understood to have an important
bearing in every casa Others believe<l that the cluld Tjy its
own spontaneous e3bi*ts pushed its wny through the pelvis — that
it verily crept into the world. The origin of the present theo-
ries regarding the mechnuisui of labor may be traced to Sir
Fielding Oidd, who in 1742 published a work wliich ctrntained
8ome of the ideas still extant In 1771, Saxtorph, of Copenhageji.
and Solayrps de Renhac, of Montpellier, simultfineously, and
without mutual consultation or knowledge, published essays
which agreetl that in natural labor the long diameter of the
child's head enters the i)elvis in an oblique direction, and that in
a large prop<^)rtion of instances it occupips the right-oblique di-
ameter, the poles of which are the left ilio-pectineal eminence,
and the right ilio-sacral synchondrosis. Tlu'ough the strong
advocacy of Baudelocque these ideas were quite generally ac-
cepted, but certain erroneous notions crept in, and the matter
was finally cleared up and simpliHed by Naegel6, of Heidelberg,
in 1818.
Vertex.— The term "vertex" will be understood to signify
the upper surface of the head, but it may be well to say that by
it is meant the crown, or that part of the head embraced within
the limits of lines connecting tlie posterior fontanelle, the parie-
tal eminences, and the anterior fontanelle.
Relative Frequonry of Vertex Presentations, — Oat of 9.^.-
871 births collected by Spiegelberg, fj-om private prnctic<*, in
over ninety-seven |M?r ceni the vert<»x presented.* The proba
ble cause of this has already been considered.
Relative Frequency of First Position.— As elsewhere stai
the first position r)f the vertex is found in a very large pmportit
of caaes. The cause of this is not understood, but Simi>sun at-
Lehrburh der Otf-liwrtflhulfe,"?. 148.
MECHANIBM OF OCCTPITO-ANTKBIOR TOfllTIONa
343
trihates it to the presence of the rectum on the left side of the
p^iviu brim.
It has been suggested that it probably results from the fact
that the uterus is usually rotated in such a way upon the spine,
that tho right side inoliues obliquely b»ickward, while the left
side is turned somewhat toward the front
Conditions at the Bei^inning of Labor.— At the beginning
of labor, the presenting head, covered by the uterine tissues, is
found at the briiu, or below it, and occupies with itis long diam-
eter, an oblique diameter of tlie pelvis.
Conditions of the Fa?tus Which Favor Expulsion.— The
techanism of labor iii head presentations is usually descril)etl as
consisting of a series nf movements, termed, L descent, 2. flex-
ion, 3. rotation, 4 extension, 5. restitution.
A knowletlge of these, as they occur in labor, is highly essen-
tial to a proper comprehension of the mechanism of parturition,
and the intelligent practice of the obstetric art.
Mechanism of Labor in the First, or Left Uecipito- Anterior
Position, — It should be remembered that, in the first position of
le vertex, tlio lon^ diameter of the head cK'cupios the right
oblique diameter of the i)elvis,
the occiput lieing directed to
the left ilio- pectineal emi-
nence, and the forehead to
the right sacro-iliac synchon-
dritfiia The dorsum of the
fa?tu8 is thus brought to the
mother's left side.
Parallelism of the Bi-
partetal Plane to the Plane
of the I$rnn.— The head has
UHually been tlescribed as en-
tering the brim with tlie right
ptu-ietid eminence on a lower
plane than thf left; but this
idea is being abandonetl. The
plane of the brim and the bi-
parietal plane are probably
Vui. 1«.
First PofiitioD of tbi* Vi-rtcx-
fltit that moment coincident
THE MECHANISM OF LABOB.
Descent and Flexion. — Descent and fle^don are cU*s<»Iy allied
movemeuts. As the head descends and encounters the Ixjunda-
ries nf the brira, the force is such as to cause flexion. The long
diameter of the he^wl represents a lever, with the fidcrum at the
occipito-atantloid articulation, the anterior heiiog the lougarmand
the posterior the short It is clear then, that, as tlie head de-
scends and meets re-sistnnce at the brim, tlie force transmitted
through the spine will cause the descent of the occiput, ami efft^ct
flexion of the chin on the stenmm. The degree of flexion will
be proportioned to the extent of the action, aud the force and
extent of resistiiuce encountered.
IHreet Descent of the Head.— The descent of the head does
not, in the early part of its course, closely follow thp axis of the
pelvic canal; but the luovement is directly downwards and back-
wards in the axis of the brim, until it approaches the floor of the
pelvis, and meets there with resistance which turns it forward to
the pubic arch.
PassiVffe thronsrh the Pelvic Cavity.— As the head passes
through the cemx uteri, flexion usufdly becomes extensive, so
that Uie chin is pressed well upon the sternum. This in some
cases not l>einf^ requi.sito. does not occur, the head bt*ing unusu-
ally small or the cervix exceptionally soft and dilattdde. The
a<lvantage of this condition of flexion is plain, since it will l>o
seen that by means of it, shorter diameters are brought to beac^rf
u]K>n the pelvic dimensions. ^^|
A further advantage derived from hejid flexion has I)een de-
scribed by Pajot :* "The fcetus in its entirety may be regarded
as a broken, vacillating rod, which is moveable at tlio articula-
tion of tlie heafl and trunk, but a solid thus disposed presents
conditions unfavorable U) the transmission of a force acting i>ran-
cipally upon one of its extremities; it follows, therefore, that»
prenous to flexion, the uterine action, pressing ujion the jwlvic
extremity to promote the advance of the fa-tus, is lost in great
measure in its passage from the trunk to the head, by reason of
the mobility of the latter; but the cephalic extremity, once fixed
up«^n the thorax, is most advantageously diB|K>sed t*» participate*
in the impulse communicated to the general mass of the Ecstus.
* Quotc4l by TXttKIEE et CnANTRECIL, p. 639.
ICECHANI8M OF OCCIPITO-ANTEBIOB P0H1TI0N8,
345
Flo. 145.
The head, having acoompliBhed the movemoDt of direct de-
scent, aad having cleared itself from the trammelB of the cervix
abeh, becomefi again Bomewhat extended. But, as it thuB presses
oa the smooth pelvic door, tlie occiput very naturally glides in
the direction of least resist-
ance, flexiou is again fii'ia,
and rotation of the head oc-
curs, by means of which its
long diameter moves from the
right oblique to the conjugate
diameter of the pelvis, and
the occiput slips under the
pubic arch. The spines of
the ischia have been said to
act an important part in rota-
tion, but we are inclined to
deny them the title of " key
to the mechaniam of labor."
Since it is always the most de-
pendent port which rotates to
tlie Inmi, a moment's reflec-
tion will enable us to see that
such a direction that tlie
Sbovring the lutf^ml obliquity of the
■<»d with reterence to the horizon in
'^pelvic cavity in the first positioa.
^aUaon, therefore, takes place m sucn a
^ping surface of the foetal head corresponds with the incline
°f the perineum. The law which controls the movement of
y^ festal head known as rotation, is baaed upon the mechan-
^^ lirinciple that, when a body is subjected to pressure, itsmove-
^©nt will always be in the direction of least resistanca Hotation
** 'U^t always complete, the long diameter of the head still pre-
'^'^ing some of its original obliquity.
A.t the outlet there may be a certain amount of biparietal
™*Uquity, and accordingly the right parietal eminence is bom in
•■^ance of the left These obliquities, however, are of compar-
^■^ely little importance, and should not be regarded as essentials
^ the mechaniam of labor, as are the movements of flexion and
rotatioQ.
^assajere of the Head Through the Outlet-— Flexion at this
P*rtof labor should be Arm, so as to bring the Hhorter diameters
w the head into the strait At the same time the occiput glides
846
THE MECHANISM OF LABOR.
tmder the pnbic arch, and becomes the centre of another move-
ment which is now begun, viz., extension. The occiput being
fixed under the aroh, is preventeti. by the nape of the fcBtal neck,
from further advance, and the di-
Fio. 140. rection of least reaistence is chang-
ed, so that now the perineum is
distended, and by the movement
of extension alluded to, the head
posses the vulva.
ReNtitntion, or External Ro-
tation.—After birth of the head, a
movement of a c c o m m o <1 a t i o u ,
knt^wii as restitution, or external
rotation, takes place, wliidi is noth-
ing more than the fac<> turuing in
this case to the motiier's right
thigh. This change is efTect^yi
mainly by the shoulders which are
yet U> be delivered, the long, or
bis-acromial diameter of which now
seeks the pelvic conjugate. This
IK an imjx»rtant movement The
l<»ng diameter of the vertex, and
tho long diameter of tlie shoulders,
naturally assume dii-ections at right
angles to one auotlior. In the first
position, the vertex lies with it^
long axis in tlio riglit oblique dia-
meter of the pelvis, and the bis-
acromial axis in a converse direction. During rotation of the
head iji the pelvic cavity, the ix)8ition of the shoulders does not
materially change, and after the head escapes, it forsakes ite
constrauied position, and is restored Uy its original, nr, at least,
ite recent direction,— hence the name of the movement, — resti-
tution. But this does not complete the movement, for, no soon-
er has the head fairly escaped than the shoulders begin to ad-
just themselves to the outlet, by turning their long diameter in-
to the conjugate, and as this change oocors, the head is still
O. B. abort arm of head
B F. longons of head Lever
lever ;
■■
nCBANfM OP OCCIPirO-ANTEBIOR POSITIONS.
347
further rotated, until the face looks pretty squarely to the moth-
er's right thigh-
While this is the osaal phenomena, others are sometimes
Fki 1 17
The bead appnutchin^ the outlet in the Hrai poeitiOD.
Flo. 148.
The mechanism of labor in the first position.
^rved to Bubstitute them. It would occasionally appear that
'Oration of the shoulders does take place Bimoltaneously with
348
THE HECHAN1S3C OF LABOB.
that of the head, La which case the bia-acromial diameter comes
to lie at the brim, or in the cavity, in a transverse direction, and
when the shoulder rotation, preparatory to escape from the out-
let, comes to be made, the unusual direction is taken, and as a
result, the face is observed to turn toward the mother's left thigh.
The author has seen several marked instances of this kiniL
The term restitution has by some been limited to the first
of the movement described, while the balance is called external
rotation.
pai^^
ExpulHion of the Trunk. — After birth of the head there is
generally a longer or shorter rest, and upon the renewal of pain,
the right shoulder is directed foi'ward by the right anterior
ischial plane, while the left glides backward over the left poste-
rior plane, hito the sacral lioUow. This movement is often quite
sudden, and is accomplished only as the {>art actually passes the
vulva, which it munt do with a spiral motion. The botly is bent I
upon itself, and the left shoulder is driven downward until it
sht)wa at the pt^sterior commissure, when the right sHjxs under
the pubic arch, and finally both emerge almost simultaneously.
Fui. U'X If the arms are fiexeil, the el-
bows piias with a jerk, and some-
times produce laceration of the
perineum. The trunk easily fol-
lows tlie shoulders, and the en^i
tire body is speedily bom. ^|
Nerhanism of the Second,
or Right Occipito-Anterior
P4»Hitioii,— In the second posi-
tion of the vertex the long dia-
meter lies in the left oMiqup di
meter of the i^ehns, and the
put looks forward and to
right ilio-peotineal eminence,
ncptnbulum, and the foreliead
ward the left ilio-eacral
„ . „ . . chondrosis. The same a
Second Position of the Vertex. ^ . r
moremen^ are performed,
VIZ., descent, flexion, rotation, extension, and destitution; but
the directions are changed. Rotation in the pelvic cavity i»
MECHANISM OF OCCIPTTO-POSTEBIOE POSITIONS.
t49
from right to left, inBtead of left to right, and external rotation
takes place by the face turning toward ilie mother b left thigh,
instead of her right The left shoulder rotates from the left
side tS the piibic arch, whereas, in. the first position, the right
sboidder rotates from the. right side forwarda Further material
differences than these do not exist, and we accordingly omit a
detailed description of the mechanism of this position.
Flu. \:^}.
Via. 151.
Tbinl PiMition oC tin* Vertex. Fmirth Prwition of the Vertex.
Merhanlsm of the Oceiplto-Posterlor Positions.— Tlie oc-
dpito-posterior pc^sitions are the third and fourth, in the former
of which the occiput lies toward the right ilio-sacral synclion-
droBis. and in tlie latter to the left ilio-sacral synchondjosia.
The third position occupioB the same oblique diameter as the
first, and the fourth the same diameter as the second, but the
poles are reversed What creates the particular interest in con-
nection with these positions is the extensive rotation by which
the occiput is brought to the pubic arch. In occipito-anterior
positions, the rotation is but slight, and easily accomplished;
while in occipito-posterior positions it is extensive., and, from
the contingencies attending it, is not always properly performed-
Botation of the occiput forward is accomplished by the short-
ert route; the third position, during the performance of thisact*
becoming the second, and tlie fourth, the firsi
360
THE MECHANISM OP LABOR.
Ill exceptional} bat by no means rare, cases, the occipnl
owing to the existence of anfavorable mechanical conditions, is
thrown backwards into the sacral hollow. ' An oceipito-poste-
rior termination of labor is more difficult and dangerous than
Thin! pOKiliun ol' ilu- vtritx, jis M-m from nikovc
an anterior, l>ecause the head has in be subjected to greater
moulding, and even then longer diameters ore brought to bear.
The occiput in such a case, after much effort, slips through the
vulva, and rests upon the perineum, upon which, oa a pivot> the
head rotates in the movement of extension, until it ultimately
passes. The movements described as taking place in the first
{position, occur here also. Flexion is, or should be, firm; rota-
tion should take place as described; extension is observed at the
vulva, and restitution occurs after head expulsion- When ro-
tation is properly accomplished, the third becomes, as stated, the
secuud, and the fourth the first; from which point onward their
movements are identical. Wlien labor terminates in an occi-
pito-jMisterior position, the face of the child turns, in restitu-
tion, in the third position to the mother's left thigh, and in the
fourth, to the right thigh.
With regard to the wiuses which determine rotation forwa
of the occiput, the following experiments of Dubois will be
structive: **In a woman who had died a short time before
child-betl. the uterus, which had remained tlaccid, and of lar
size, was opene<l to the cervical orifice, and held by aids in a
suitable position above the superior strait; the foetus of the
woman was then placed in the soft and dilated uterine orifice in
the right occipito-posterior position. Several pupU-midwiTes,
pushing the fcetus from above, readily caused it to enter the
MECHANISM OF OCCiriTO-POHTERlOR l^CWITIOKS.
351
eaTity of the pelvis; much greater effort was needed to make the
head travel over the perineum and clear the vulva; but it was
not without aBtoniehment that we saw, in three successive at'
tempts, that when the head had traversed the external genital
organs, the oociput had turned U.) the right anterior position.
Fig. 153.
Oodpito-posterior tennioaiion oi' (he tliird positioa of the vertex,
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
experiment a fuurth time, but as the head cleared the vulva the
oociput remained posterior. Then we took a dead-bom fu>tus
of the previous night, but of much larger size than the pre-nM].
ing; we. placed it in the aame conditions an the first, and t^
in succession witneseed the head clear tlio vuIvh ■ '
executed tlie moyement of rotation. \J\mn the thira
ing essays, delivery was accomplished without the occorren
rotation; thus the movement only ceased after Uie p«rtoi
352
THE MECHAKI8X OF LAfiOB.
vulva had lost the resistance wliich had made it neoeesAry, oar,
at least, had been the provoking cause of its accomplishment"*
High Rotation.— "Rotation,'* says LeishmaD,t very truly,
** at an early stage of labor, Ijefore it is yet practicable to ascer-
tain the actual position of the head with anything like cer-
tainty, is probably of much more frequent occurrence than we
have any idea of. Few things are more familiar to the experi-
enced accoucheur than arotary or rolling movement of the head,
which he observes either during a pain or an interval, while it
is still high in the pehns. This is due partly to uterine action,
and partly to the movements of the foetus, and we have no doubt
tliat, by this means, many unnatural and faulty positions are
rectified even after labor has commenced; and we are further
entitled to assume that in this way many occipito-jRwterior po-
sitions are rectified at such a stage that their detection is ren-
dered impossible. It should always be rememhere<l that the
dorso, or occipito-anterior position of the child is the natural
one, and that according to which the irregular oval which it
forms is most conveniently disfiosed,"
Conversion of Occiplto- Posterior Into Occiplto-Anterior
Positions. — A ver>' important question of treatment may not
iua]>propriately be liere ojn^ith^revl, viz: the ix>8sibility, practi-
cability, and advisability of converting oc^ipit<>-fx>sterior into
occipito-anterior jiositions. The ex])erienceof ourselves, as well
as others, thoroughly Cf)nnnces us of the possibilitj' of so doing.
Whether, in all cases, it is an advisable tiling is anotlicr matter.
We believe, however, that when the head is still free above the
superior strait, it may nearly always be accomplished by manip-
ulation of the suitable kind. But sometimes, in order to ac-
complish it, the effort involves a certain amount of risk to the
woman, which it is not always advisable to incur.
Smellie, more than a century ago. executed such a change in
a difficult case, and thereby accomplished a result which '* gave
him great joy." The feasibility of the operation is advocated
by a goodly humljer of obstetricians of to-day. It is not aa
operation, however, which can be performed at every stage of
* Maktkl. '* T)e 1'««commodAtion en ohst^triqac,"* qtfotAtioQ p. 93.
t "Syntcxn of Midwifery," Am. Ed., 1873, p. 301.
OAPtrr SirOOEDANEUM.
353
but the possibility of its sucoesshil execution is limitetl to
two periods, viz: that of early labor, when the head is still free
above the pelvic brim, and that part of the seoond stage, wiien
the advancing occiput presses firmly on the pelvic floor. At no
other time should it be attempted. Attention to the ordinary
movements of the head will sometimes obviate any necessity for
interference. In the process of descent there is sometimes
manifested a tendency of the chin to leave the sternum, and the
head to be extended. To allow this condition to persist, is to
preclude the possibility of rotation forwards of the occiput by
the natural forces; while to enforce flexion is the only tiling re-
quired to secure the desired end In other cases, two fingers
under the occiput, and slight traction in an anterior or lateral
direction, during, as well as between, pains, vrUl bring about
rotation.
But in other cases, while the heml still lies above the brim, or
hut loosely engaged, it is deemed advisable to effect rotation.
"niflt being true, the forceps may be used, or not Rotation wifh
^p forcey* will be considered when we come to speak of forceps
'lelivery in occipito-postorior [Kisitions. l>r. Jno. 8. Parry* is a
^^ug advocate of manual rotation in these positions. He reo-
ommpnds the uitroduction of the well-oiled hand into the vagina,
^oJ the fingers through the os uteri. The head is then grasped
^ firmly as possible, and rotation effected, while with the oppo-
^^ hand, by external manipulation, the body is rot-*ited on its
^'^tudinal axis. The range of applicability of such treatment
*^^Uld be left to the good judgment of each individual practi-
Cft-put Succedaiienni.— ThiH is the name of the swelling
*bici forms on the fcetal head during lalx)r, as the result of
^^^^^i^l serum or blood, or both, into the tissues of the scalp.
1^ ^ not found on the head of a drad child.
^^ forms on that part of the liead which is subjected to the
V'^ pressure, and hence, at first, within the circle of the os
titei As labor advances, the area is extended, and more or less
LinotliBwl Its development is most marked as the head is l>eing
drivpn through the pelvic canal. In the first and fourth positions
ibe swelling is found on the right, and in the second and third i)osi-
•"Ato, Jonr. of Obfl.,'* vol. viii, p. 138.
854
THE KECHANISH OF LABOR.
tions, on the left parietal bona In oocipito-anterior poeitionB it
is located more posteriorly than in occipito-posterior positions
Confignrations of the Head in Vertex Presentations.—
The head of the foetus undergoes during labor a considerable
aiuount of moulding, by meauu of which the respective diame-
ters are greatly modified. The smaller the parturient canal —
the more difficult the labor, — the more extensive the change.
The most important modification is the diminution of the
Bub-occipito-bregmatic, the occipito-frontal and the bi-temporal
diameters, with elongation of what is generally regarded as the
occipito-meutal diameter, but which is, more accurately, the
diameter represented by a line drawn from the end of the chin
to a point on the vertex between the anterior and posterior
fontanelles, nearer the latter than the former.
Moukling is favored by the existence of fontanelles, the nature
and width of the commissures, the depressibility of the occiput
and frontis, and the mobility of the bones at their several artic-
ulations. As the result of pressure, the frontal bono re.cedes
beneath the parietal bones, the occipital bone is pushed forward
under the parietal, and, finally, one parietal bone laps over the
other. Moreover, the parietal bones themselves are somewhat
changed in form, the cranial vault being curved at the point in
front of the posterior foutanefle, hereinbefore alluded to, the
Km. I.S4. Fig. 155.
Outlines showing difiereocA between heiwl at birth fFig. 154.}, and four d«ys
subsequently iFig. 155.)
sharpness of the curve being determined by the closeness of the
labor, or, in other words, by the amount of compression exerted.
mi
FOBM OF HEAD IV VERTEX PBESENTATION.
855
When the head passes the onilet in an ocoipito-poeterior posi-
tion, the changes noted, are still more marked.
The outline of the head is etill further changed by the forma-
tion of the capat succedaneum.
Flo. 15«.
We may here add that this long-
drawn-out appearance of the head, in
general soon passes away without the
adoption of any special treatment to
correct it; but the change may be
somewhat accelerated, and perhaps,
rendered more pronouncetl, by gentle
pressure upou the poles of the occip-
ito-frontal diameter with the palms of
the Lauds.
Diagnosis of Positions, etc.—
This subject has been discussed in
Fom of the head in Tert«i another place, and does not here re-
pRteouition. quire mention.
CHAPTER VIL
The Mechanism of Labor.— (Continued.)
* ^ce FresentationR. — The face constitutes the presenting
P**^ once in about 250 cases.* ChurchiU's statistics make it
*>^^^^ a little of tener.
^^racter of Labor. — Labor in connection with face presen-
tation, while it may. in quite a proportion of instances, be ter-
inuiated by the* natural efforts, is generally far more tedious and
difficult than in vertex presentationsi and often presents compli-
*CBABPKSITJKk. ** Contnbntions a Tt^tade dea pr6flcnUtion de la face." p. 15.
866
THE KECHANIRM OF LABOK
cations of a most formidable nature. This is particnlnrly troe^
as will later be seen, in ootmection with mento-posterior poei-
tiona For these reasons, and the adilitional fact that it is a
presentation in which the dangers to both mother and child are
considerably increased, we have thought best to adopt the classi-
fication which places it among abnormal presentations.
Caases. — There seems to l>e l>ut little doubt that a large share of
face presentations are transformed vertex presentations. The
movement by which the latter is converted into the former ooti-
sists only in extension, and a variety of caoscs may operate to
effect the change^ Hecker * attributes many cases of face pfe-
sentation to unusual length of the occiput, and the theory
appears to be a plausible one. Other causes of exiension are
set down, as enlargement of the thyroid gland; increased size of
the chest preventing sufficient flexion of the head; and unusual
mobility of the ftetus, owing to small dimeusiona
Lateral obliquity of the foetus and long uterine axis, are sup*
Vto. 157.
Face presentation at the outlet, lUinto-iKwterior position.
posed by many to be an important factor in the etiology of these
presentations. Uterine action presses the head against the
^^'IMier die Scliiidel form bci UefrirlitKlnfcen/'
I
}
FACE PBE8ENTATI0S. 357
boundary of the pelvic brim, and tilte it backwards,
once extension passes the line of equipoise, the presenta-
tion becotnes penoanently established. Proper flexion of the
hesd may be prevented by the presence of a prolapsed extremity
which encroaches upon the pelvic space.
When, in lateral uterine obliquity, the dorsmn of the foetus
rorresponds with the lower surface, the propelling force con-
stantly increases the tendency to cephalic extension.
Relative Frequency of Positions.— Statistics are not yet suffi-
cieutly numerous to settle the question of the relative frequency
of tho various positiona There is doubtless but little difference
in point of frequency between left and right dorsal poBitions.
Nmrgf'Ife considered the first as the most frequent, in the ratio of
tventy-two to seventeen. Tyler Smith says that the "third and
fettrth facial positions are so extremely rare as hardly to be
iwth enumerating." There is, however, quite a lack of harmony
ttnong obstetric writers, for Leishman and others proclaim the
fourth position as the most frequent It is by no means rare for
the face to enter the pelvis, with its long diameter lying trans-
Tersely.
Mtrbanisiu of the First Position of the Face.— In the first
position of the face the occi pi to-mental diameter lies in the right
oblique of the pelvis, and the chin is directed to the right sacro-
^ synchondrosis.
For descriptive purposes we may divide the mechanism of face
pretentAtions into the movements which follow:
''irst movements — descent and extension.
Second movement— rotation.
Tiiird movement — flexion.
f*>ttrth movements— restitution and external rotation.
These we shall proceed to consider in the order of their occur-
rence in the first, or right mento-posterior position.
*^ttfeiit and Extension.— These two movements, because of
their almoet simultaneous occurrence, are described together
i**^ M were descent and flexion in vertex presentations. So far
u the mechanism of lab*:)r is concerned, the chin in face presen-
tfttiuna corresponds to the occiput in vertex presentations, and
banoe in well-marked instances of the former, we find the chin
siakiug lower and lower in tlic cavity, thereby greatly augment-
358
THE ICEGHANISV OF LABOR.
ing the exteneion. The degree of extension is ascertained
the relative situation of the chin and anterior fontanelle, both of
which can generally be reached. The head engages the superior
strait against mechanical disadTantages, and hence slowly. The
degree of descent which may l»e accomplished with some degree
of facility, is determined by the length of the child's neck, unless
the tliorax and shoulders chance to be small enough to permit
them to pass into the cavity.
The chin maintains its advanced position, owing to a mechan-
ism similar to that which causes tlie occiput to take the most ad-
vanced position in vertex presentation. The fronto-mental diam-
eter represents a lever with the short arm on the mental side,
and the long arm on the frontal side. Force is applied from
above, and of course the short arm descends.
Botatlon.— The exact amount of descent which the length ol
the neck will permit in these cases, depends upon the cdrcum-
Fit I. i.5y.
r
Engagement of the head in lace presentation {Tarnier et ChantTvaiL)
Bt&ncea. Experience toAches, that in most cases, the shoulders
FACE PBESENTATION.
359
not reBch the brim and engage it, until after the face presses on
the periueum. Farther descent is impeded, and rotation for-
ward of the chin, seems to be a necessity. In nearly all cases
the movement doee take place in a natural manner, and menacing
dangers are thereby averted. The chin in face presentations,
and the occiput in vertex presentations, in the movement of rota-
tion, act in obedience to a similar mechanism. The chin, being
in advance, ftrst oomea in conttict ^nth resistanoe at the pelvic
floor, and acting under the well-known law of mechanics, that a
body subjected to various degrees (jf pressure, moves in the di-
rection of least pressure, turns forward, while the cranial vault
i>e«b the sacral hollow.
Fio. 1 30.
MechanUm of fa(% presentation, first pof«itinD.(Sk^bnItz6.)
^ "* Uie oourse of rotation there is a complete change of posi-
^11 the first becoming the foiu-th. By means of rotation the
*^ ia Iffought to the pubic arch, and expulsion tliereby facili-
teted.
Abnormal Mechanism. —In a small percentage of cases, the
MUi. instead of pushing forward Ut the pubic arch, moves back-
'•'d into the wicral hollow, and labor terminates as represented
in figure 157. The effect of tliis is excessive stretching of the
360
THE MECHANISM OF LABOR.
neck of the fcetna, and of the vulvar BtmctoreB of the woman.
Unless the child hap{)ens to be relatively small, labor can scarce-
ly be terminated at all, without artificial aid.
The depth of the pelvis posteriorly, and the added length of
the perineum, will not admit of desoent of the chin over the |x>e-
terior vulvar commissuTP, without a surprising amount of cranial
fattening, and the entrance of the thorax to a certain extent into
the pelvic cavity. Cases have occurred in which, from unusual
smallness of the Lead, distension of the sacro-sciatic ligamentB
ha:^ permitted flexion to take place, and delivery thus to be
effected
Flexion.— In face presentation, the movement by which the
head parses the vuU'a is one of flexion. The chin engages under
the pubic arch, and remains flxed, while the forehead, vertex
and o<!ciput, successively sweep over the distended perineum.
Then occurs the final movement, — that of restitution, or external
rotation, the face in the first position turning towards the moth-
er's right thigh. The shoulders follow, and expulsion is speed-
ily accomplished-
Form of the Cranium in Face Presentation.— As the result of
excessive compression of the head in so unnatural a position, the
cranial vault is considerably flattened. The transverse, the occip-
ito-frontal ,iuid especially the occipito-mental diameters, are oonse-
quently increased, while the sub-occipito-bregmaticis diminished.
The tumefaeiiou of the presenting area is liable to be exoeashre,
so that the foetal countenance immediately post-partnm presents
an appearance scarcely human. Swelling is greatest in "
malar region.
Prognosis. — We have before alluded to the augmented dan
to Ix^th mother antl child in this variety of preseubitiom
Winckel • gives the mortality of the foetuses in face presentation
at thirteen per cent, and that of the mothers at six per cent
According to the same author, the average duration of lal>ordoe0
not greatly exceed that in the vertex presentations,! but protnuv
tion is attended by more dangerous consequences, and demands,
with greater urgency and frex^uency, the aid of obstetric re*
Bouroee.
•'* Pathologie'der Gebartshulfe," p, 88.
t •• Berichte » Bd. iii, p. 315.
FACE PRESENTATION.
861
^
The Heeond Position. — The mechanism of the second posi-
tjon is quite like that of the first, except that the tlirections are
changed. Botation takes place by the chin swinging around
from the left ilio-sacral Bynchondroeis to the pubic aroh. In
xnakLng the movemetit the second rotates into the third position,
from which point onwarils the mechanism is essentially that of
the third.
Third and Fonrth PositionH.— The first and second are re-
cognized as unfavorable positions, because the chin is directed
Fig \m.
Blento-anterior t^nniD.ttion of face presentatioxL
Ij^Awards, and the necessary rotation is extensive. The third
tBO fourth positions are favorable, because tliey are mento-ante-
riiv poeitiuna, and tlie necessary rotation is but slight. In the
362
THE KECHANISH OF LABOB.
latter, the chin, in its descent, strikes against one of the
inclined planes, and is directed forward under the pubic arch;
while in the former, even though the chin does usually rotate
anteriorly, much delay and difficulty are often experienced. A
backward rotation of the chin gives a termination the most uo-
favorable. ^M
Special detailed description of the mechanism of labor in otP
third uud fourtli poBitimis Ib not required, as it differs not at all
from that of the second and first positions, respectively, a£^|
partial rotation has taken place. ^^
Treatment- — The older obstetricians not only looked upon
presentations of the face as abnormal, but they deemed artificial
assistance necessary in all cases, the treatment being version,
when practicable, and instrumental delivery in neglected case&
An imix>rtm»t concern of treatment is to preserve inl
throughput the first stage, the bag of waters. This here
matter of more imix>rtjiuce than in vertex presentation, because
of the irregularity of the presenting part, and the likelilioodj
complete escape of tlie litpior Jimnii should rupture take pi
Conversion of Face Into Vertex Presentations.— This
matter worthy the closest attention. The manipulations
erally recommended are pushing up the face, or drawing doi
the occiput, by means of tlie liand passed into the vagina iind
cervical canal. Still the suggestion has not often been aci^|H
upon, owing to the tlifficulties and dangers accompanying nr
That it may be done without much effort in favorable caaee, i^e
author has, from experience, become convinced. There is, hi^M
ever, a considerable variation among cases in the call for suoT
interference. When the face presents in the first or seirond
sifcion, we have an imfavorable condition. In other words,
have an undesirable |)ositiiin of an undesirable presentation,
by flexing the heaii we convert the case into a desirable position
(occipito-anterior) of a desirable presentation, and the measure
of atlvantage to be derived from the change would mimpensate
for considerable effort and risk. On the other band, the third
and fourth positions of the face are favorable positions of ^M
unfavorable presentation, and by flexing the head we would odP
vert them into an undesirable position (occipito-posterior) of a
desirable presentation, and we would not be justified in assom-
)tracted or difficult manipulation.
afflP
IBg
pro!
CONVERSION OF FACB INTO VEBTEX PRESENTATION.
363
Xo attempt to change the presentation should be undertaken
after the head fairly engages the brim, unleas delivery by any
other method eeems impracticable, as the occipito-mental di.
ameter of the standard foetal head exceeds every pelvic diameter,
and incarceration would be likely to result
In some cases, by firm pressure, the head, even after some de-
scent has taken place, may be dislodged, and carried above the
brim, where flexion can be enforced.
Whenever such manual operations are performed the woman
sbnnid be undpr the relaxing influence of an ana^theria
The following method of manipulation, suggested by Schatz,*
will sometimes be preferabla We are directed to restore the
body to its normal attitude by flexing the trunk, when, we are
Wi the head will drop into its normal position in the brim of
t^f pelvis. To thus operate, we should seize the shotilder and
lireast through the abdominal walln, ami lift tliem upward, and
at the same time backward, while, with the opposite Land, we
steady the breech so as to make the long foetal axis correspond
*o the uterine axis. Finally, the breech and shoulders, or tho-
'^, are made to approach by downward pressure on the former.
Pio. 161. Fio. 162. * FiQ. 16i
P^^gnuna iUufltrating Schatz's method of convertuifE face into vertex preseu-
t4ition!«.
^^ing the body, as descril)ed, gives the occiput an opportunity
Die tmwandlUDg von Gesichtslage," etc, " Arcb. t\ Gynoek," Bd. v., p.
J
364
THE U£CHiLNISM OF LABOIL
to descend, and flexion of the fcetal body, accompanied by back-
ward and upward pressure on the chest, proiluces flexiou of the
head Schatz says that when the he^ lies high, any attempt to
enforce flexion by repression of tlie thtinix, sometimes causes
movement of the whole head, for want of resistance, and, in such
cases, the phice of the pelvic wall may be supplied by pressure
of the hand against the head through the abdominal walls. The
couditiouB friemlly to the practice of this manoeuvre are skill in
palpation, and the absence of abdominal and uterine irritability.
When the Face Does Not Enter the Brim.— When the face
refuses to pass the superior strait, operative interference is indi-
cated The character of the aid given will be determined by
tlie circumstances of the case. The hernl may be flexed by
Schatz*s metliod, or by the introduction of the hand into the
vagina and cervix, and the face thereby converted into a ver-
tex presentation; or podalic version may be practiced In either
case, the internal manipidation should be aided by dextrous ex-
ternal use of the opposite hand. Application of the forceps to
the face at the brim, is, in the main, impracticable and hazard-
ous, as the blades cannot well be applied to the sides of the
head, and to seize the face over the poles of its long diameter is
extremely dangerous to foetal life, from the pressure of one
blade on the throat, and compression of the large vessels and
nerves of the pari
PerHlstent Mento-posterior Positions. — Tardy rotation ap-
pears to be characteristic of face presentation, and a fair oppor-
tunity should be given the nat-
ural forces. The mechanical
condition most favorable to for-
ward rotation of the chin here
is firm extension, and by main-
taining it, we greatly augment
the probability of its occurrence.
The movement may be aided to
a certain extent by suitably di-
rected pressure against the fore-
head. If tliese simple methods
prove ineffectual, the forceps may
Meoto-posterior termination of be applied, and the he-ad care-
labor, fully turned in tlie direction
Fig. 164.
BBOW PRESENTATION.
365
wtfldi it "should take. If the long curved forceps be used,
they will nnpire removal and reapplication for completion of
the movement Every effort to bring forwaxd the chin should
be attempted during b pain.
Very strong support of the perineum, while favorable to pres-
ervation of that part, is dangerous to the child, from pressure of
the neck against the pubic arch.
Brow Presoiitation. — "When only partial extension takes
place, the brow Iwconies the presenting part Such presentations
most always be looked upon as of a most unfavorable nature, since
the long diameter presented, is the longest of the cranium. Four
positions are given, but, as the presentation is exceedingly rare,
and generally becomes transformed into either a face or a vertex
presentation, we shall not here describe them. If tlie head is
small, and the pelvis roomy, the labor may be finished witiiout
anosual diflBcnlty or injury to either mother or child. The Itead
passes by the cranial vault sweeping forward over the perineum,
followed by movement of the upper jaw, mouth and chin under
the symphysia
Treatment.— Treat-
ment consists first in at-
tempts to convert the
presentation into one of
either the vertex or face.
Baudelocque 6 method of
doing this involves the
introduction of the whole
hand, a thing to be avoid-
ed if [xjssibla Schatz's
method of operating in
face presentation may
here sen'e equally well-
The conjoint manipula-
Fio, 1G5.
tiioc ol head, brow presentation. (Budia.)
r
I
tton, one hand externally, and the fingers of the other in the
vagina, is sometimes successfully employed. Schatz * recom-
meods the introduction of two fiingers into the child's mouth,
• " Die tTmw&Ddliing von Gesichtslage zn Hinterhnnptelage," etc., " Arch, t
GynacV Bd. v. p, 32a
366
THE ICECUANISM OF LABOR.
and traction on the superior maxilla, for the production of a
face presentation.
CHAPTER YUL
The Mechanism of LaH)orr-(CoNTimjED.)
Pelvic Presentations.— Under the general designation of i>el-
vic presentation are included all those cases where the pelvis
precedes tJi«* trunk and head of the cliild m labor. Pelvic pre-
sentations are divided into those of the breech, knn'n and fecL
The mechanism of labor, however, is in all these substantially
one. From tlie time of Hippocrates until that of Ambrose Par6,
in the sixteenth century, delivery was regardetl as impracticable in
pelvic presentations, and the rule of treatment was to iutroduod
the hand, and turn by tlie head.
Frequency of Occurrence.— Breech presentation ia met
in alxjut 45 mature biitlis, while in premature labor and miscar-
riage it is of common occurrence. The lower extremities pre-
sent onoe in about 100 cases.
Pro}j:no8ls.— While labor in these presentations is not un-
usually dangerous to tlie mother, the peribof the child are greatly
augmented. The mortality in breech presentations is in the
proportion of about 1 death in 3J cases, and in footling presen-
tations 1 death in 2^ cases. Pelvic presentations in primipane
are attended with an extremely heavy mortality. Roberton •
says of footling eaaes, '*! do not remember having saved the
life of a child when the feet, in a first lalwr. formed the presen-
tation." The danger to the mother, in {>elvic presentation, is but
slightly increased.
Causes of Infantile Mortality.— The chief element of danger
in these cases is interruption of the foetal circulation by com-
pression of the cord. The foetus may be destroy^ by asphyxia,
arising also from another cause, namely, premature aeparation
* " Physiology ftnd Disease of Women and Midwifery,*' p. 457.
PELVIC PBE8ENTATI0N.
367
of flie placenta, followed by premature attempts of the foetus to
respire. Comprefision of the funis is rarely strong enough to
Bflriottfily interfere with the foetal circulation, until the pelvis and
most of the trunk have passed the vulva, and the bony cranium
presses it firmly against the pelvic walls. Premature eopara-
tioD of the placenta occurs as the result of contraction of the
ntems upon the descending head.
Delay of birth of the head ii* occasioned by insufficient dilata-
tion of the soft parts, the trunk not requiring as great expansion
of the OS uteri and vulva, as does the head.
Danger to the child is not confined to tlie moment when the
head lies at the brim, but compression of the cord may take
place at a later periotl, and premature separation of the placenta
16 more likely to be effected after the head descends into the
l)elvic cavity, but refuses to pass the vulva. Foetal circulation
iuten-upte<l, and respiration is impossible, as a result of which,
Ui from as]>hyxiu soon ensues.
Etiology of Pelvic Presentations.— It was supposed by the
older physicians, that the foetus sat upright in the womb ontil
the sixth or seventh month, at which time there occuiTed a 8u.d"
den overturning, aa the result of which the head l)ecame the
presenting part, and accordingly, breech presentation resulted
from the non-occurreuce of the acrobatic feat mentioned.
There is no doubt that breech presentation is sometimes the re-
sult of a peculiarity in the conformation of the uterus. Velpeau
mentions the case of a woman, who probably from such cause,
bad six consecutive breech deliveries. Pelvic deformity is also
a oaiisative factor. In a case reported by Dr. Randolph Wins-
low,* 8 colored woman, with a deformity of the pelvic brim, had
ten children, every one of whom presented by the breech.
Diagnosig. — Nothing need here be said with reference to
diagnosis, as the matter has been fully discussed elsewhere.
The Mechanism of Breech Presentations in the First and
Second Positions. — The first position of the breech is also
known as the left dorso-anterior position, and is one of the most
favorable. The breech dilates the os uteri with almost the same
facility as does the head.
* "* Am. Jonr. Med. Scienccs,">prU 1860, p. 444.
368
THE MECHANISU OF LABOa
Descent.— After the OS is so widely expanded as to permit
the breech to pass, umler the forcible propulsive action it sinks
to the pelvic floor, and approaches the vulva. Descent nsunlly
progresses but slowly, and dilatation of the os uteri and vagina
18 not required to be great, in order that the trunk may pre
oeed on its way.
* '*' ^""^ Rotation.— There is no ex-
tensive rotation in the pelvic
cavity, a&sociated with breech
presentation. In the first po-
sition the left trochanter lies
forward and to tbe right, and,
in rotation, it turns from the
right to the pubic arch. In
the second position the right
trochanter lies forward and to
the left, and, in rotation, it
merely comes to the pubic
arch. These are both dorso
anterior posi tions. In the
third position, the right tro-
chanter lies forward and to
the right, and in the fourth
the lef t trochantei lies forward and to the left Rotation in the
former position is from right to left« and in the latter
from left to right; but in no case is the distance traversed
extensive. And then, too, rotation, insignificant as it is, does
not often take place until the nates are pushing through the
vulva, and is only completed when the trunk has nearly passed.
Fiom inattention to the proper management of such cases, the
after-coming head may be permitted to descend, and enter the
pelvis in an occipito- posterior position, when cephalic rotation,
under unfavorable conthtions, becomes necessary.
Expulsion,— The anterior natis makes its appearanc-e at the
vulva, and the posterior pushes over the perineum. The ante-
rior trochanter finds a point of support undei th& pubic arch
nntd the opposite trochanter passes, when both descend, in a
forward direction, necessitating consideiable ficixion of tho body
in the pelvic canal. As tlie trunk passes, it ih well to have the
Firal Tuttition o( ihc Itreech.
BBEECH PRESENTATION.
36D
I
^
fingere rendy at the vulva to hook down the arms, which are
proDG to be thrown npwards. The anterior shoulder rests under
tbe pubic arch until the poeterior pusseB, and the head only
then remains.
Flo. 167.
Expnialoo oi tlie Trunk in Breech Presentation.
Theboad engages the brim in an ol)lique diameter, and usu-
*llv rith the chin upon the steraum. The inclined planes turn
"16 occiput forward as the head descends. The neck rests in
"*6 pnbic arch, and serves as a centre of motion, and as the
™'y is raised by the accouclieur, the face and sinciput pass the
"'Steaded perineum and the second stage is closed.
'^'h*' Mechanism of Breech Presentation in the Third and
Fourth Positions,— So far as the trunk and extremities of the
cuildare concerned, there is little diflference between the mechan-
ism of dorso-anterior, and that of dorso-posterior, positiona The
^»^^l I>articular in which they deviate has reference to theafter-
oomlng head. After expulHion of the trunk of the foetus, we ai'e
•pt in neglected cases, to find that the head engages the brim
'ith the occiput directed to one ibo-saeral synchondroBis, or the
370
TH£ MECHANIfiM OF LABOR.
other, and extensive rotation in the pelvic cavity ifi n^ceRBitated,
whlchj by the way, is often attended with some difficulty. This
FIO.168.
Birth of the Hhouldcra.
is a coiuplicatiou of lal>*r which may be obviated by proi^er
attention t<» the body in its desceut through the outlet When
the trunk and shoulders are of usual size, there is seldom any
necessity for close approach of the bis-acromial diaiueter to the
pelvic conjugate, at the outlet Bearing in mind tliis fact, if we
will but rotate the trunk on its longitudinal axis during the mo*
ment of its expulsion, the head, which still lies perfectly free
above the brim, will also rotate in compliance with the soggea-
tion thus offered, and as a consequence, this part enters the brim in
an occipito-anterior position. The rotation here advised should
a
BBEECH PREBENTATIOK.
3n
be neither rapid nor forcible; though we are of ten obliged to
accelerate the morement to a certain extent, on account of the
rapid progress of expulsion.
^i°- 16^ In those cases wherein, from a
combination of circumstances
beyond the physician's control,
the head enters the brim in an
occipito-posterior position, if
traction is not applied to the
trunk, the condition of heati flex-
ion will usually be maintained
Iiy the contracting uterus, and
if»tation will take place in re"
sponse to slight Huggestions from
the fingers of the accoucheur-
But this movement, and that al-
so of final expulsion, depends to
a very great extent on thorough
flexion of the head on the breast,
and the physician should en-
TiunJ PontioD of tiie Breech. f^j-ce it by proper manipulation.
trunk of the child, wrapped in a towel, should rest uixm the
toonvenient arm, while the fingers of the same hand are pass-
into the vagina, as far as the child's face. Pressure and trac-
h™ should then be made with the fingers in the canine
fobg.x', while at the same time tlie fingers of the opposite hand
exertapward and backward pressure on the occiput, and the body
IS Carried well forward, as in all cases of pelvic presentation,
nntil the head passes. If the fossje caninte cannot at firtst be
rciched, the fingers may be passed into the mouth, and traction
w»d pressure made on the inferior maxilla. This will answer
'^ry well in those cases where the fcetal head and the pelvic
^'W^ are in relative proportion; but in difficult cases, while the
fingers of one hand enforce flexion of the head, those of the
other most exert traction on the child's shoulders.
In some cases it may be found impossible to bring forward
tke occiput, and labor terminates with the occiput to the i)eri-
nwim, and the face to the pubes. There is the same necessity
here, as elsewhere, for firm flexion of the head, and while en-
forcing it in the mannex already d(?scribed, the body should be
372
THE MECHANISM OF LABOR.
carried baclrsrard, instcnd of forwonl, until, as the neck rcBta on
the posterior vulvar commissure, the face revolves about it as a
centre, and glides under the pubic arch.
Fig. 170.
Showing the Completion of Rotation, and Exlructiou uf the Head.
Footling Presentation. — It is unnecessary to give a detailed
account of presentations of the feet, since they agree in all es-
sential particulars with the mechanism of breech presentation.
Botation is delayed until the breech reaches the outlet The
head is delivered with greater difficulty than in the presentatioii
of the breech, since tlie foetus enters and passes the pehns, in
footling cases, in the form of a wedge, with the small end in
advanca
FOBM OF HEAD IN PELVIO PRESENTATION,
373
Trcatnidiit of the Arms. — Ordinarily, the physician experi-
ences but little trouble in bringing down the uima when they
aje extended upward by the side of the head, but occasionally
^^^' ^**- the movement is not easily
accomplished. The fingers of
the operator should be passed
under the pubic arch, and
over the anterior shoulder,
when the arm should be made
to descend over the anterior
surface of the child.
Breathing 8pace for the
Partus in Cases of Head
Retention. —When the head
cannot at once be delivered
from the pelvic cavity, and
the child is making eflforts at
respiration, the mouth may
be drawn well down to the
Presentation of the Feot. perineum by meanH uf the fin-
gers, and then an assistant may admit air to the foetus by in-
serting two fingers, and making forcible retraction of the peri-
neum and recto-vaginal sejjtiim. By this expedient, more than
OQp life has been saved.
Forceps to the After-Coming Head.— Some strongly con-
demu the use of the forceps for the purpose of extracting the
aftar-ooming head ; but there is no question that in some cases
Uiey an* of real service. They shoidd always be applied along
the ventral surface of the child.
Configuration of the Head iu Pelvic DellTery.— The ab-
?«of long-continued compression of the head in pelvic presen-
ion. leaves the part in a shape which differs greatly from that
observed in vertex and face cases. Instead of the long-drawn-out
a|>I»earance given it when the vertex is in advance, we have a
oharjict^^ristic roundness, due in part, as is believed,* to its cir-
wunforoutial compression by the pelvic canal, while absence of
decided resistance above, increases the convexity of the cranial
• SpieoeLBERG. " Lchrbuchr de G«bartshulft," p. 176.
374
THE ItECHAlOSM OF LABOB.
vault Still, the shape of the bead usually obBerred in pelvic
cases probably approximates the original form of the part
Management of Pelvic Presentations.— The practice of
Hippocrates, and his followers, of converting breech into ce-
phalic presentations, was succeeded by tbat ui bringing down
the feet This mode of treatment is now regarded as not only
undesirable, but, under ordinary circumdtancea, unwarrautable.
We should allow a breech presentation to continue as sucL, and
Fio. \n.
Shape of the Head in Breccli Fresentatton.
C. D. Bi'parietjkl diameter.
0. F. Occipito-froutal diameter.
not make the case still less auspicious by conyerting it into a
footling presentation. If the labor is proceetling but slowly,
the temptation may be strong to provide ourselves with a part
upon which to make traction, and hasten delivery. But the wi&e
man withholds Lis hand. After expulsion has gone so far thai
the trunk of the foetus is partially born, we may feel a strong
impulse to seize upon it and hasten the labor. But such inter-
ference with the uatuial phenomena and mechanism of pelvic
presentations would be liable to involve as in a tabarynth i>f
troubles, growing out of the extension of the arms alxivt- the
head, and a separation of the chin from the breasti with its lodge-
ment above the pelvic brim. When any traction effort whatever
is mmle, it should be carefully done, and ought to be supple-
mented by abilominal pressure.
THANSVEBSE PBESENTATIONa
375
The Qaestion of Cephalic Tersion.— Some have advised at-
tempts to produce cephalic version by external nianipulation;
but Bince it can rarely be successfully practiced, and the neces-
sary effort is liable to rupture the membranes too early and do
injuiy to the mother, we believe it an unwise procedure.
Expulsion of the Truuk.— As expulsion of the trunk takes
place, it may be received into a dry cloth, which has the double
advantage of providing warmth for the child, and a better hold
for the physician. As soon as the umbilicus is reached, the cord
should be drawn gently down, and carefully felt from time to
time. If pulsation in it continues good, delivery need not be
accelerated, but if it should fail, extraction must be hastened as
rapidly as possible.
Extraction of the Head.— The manner of effecting this has
been before suggested. The cliild, wrapped in a towel, should
rest on the most convenient arm, and the fingers on the canine
foessB enforcing flexion. Unless delivery is easily effected, an
assistant may make iirm oonipressinn on the fundus uteri, while
the woman is urged to make her best endeavor. The body must
be earrie<l well forward, if tlie case is occipito-anterior, and
well backward if occipito-posterior, with gentle traction. Flex-
ion of the hejul at the outlet, in occipito-anterior positions, is
sometimes better effected through the rectum. Expulsion of
thf head may also \>e facilitated by the fingers in tlie rectum.
Operative Measures. — Operative measures for relief will be
Ci>nsidered under the liead of "Operative Midwifery," and
nothing need here be said on the subject
CHAI TEB IX.
The Mechanism of Lahore Continued.)
Transverse Presentation. — In transverse presentation we
luve the longitudinal axis of the foetal oval lying across the
uterus, constituting a most unnatural and unavoidable case.
Viirieties of transverse presentations have been described by
some writej% such as ventral, and dorsal, as well as shoulder
878
THE MECHANISM OP LABOR,
and arm. The fact is, that in the early atage of labor, almost
any part of the trunk may constitute the presenting part; but
eiperienoe has taught that no matter what portion of the trunk
may lie over the os uteri at the beginning of labor, as the
Fio. 173,
Ventmi PresenUition.
advances, the shoulder or arm is quite apt to descend, and con-
stitute the presentation. Hence, in our remarks on ttie mechan-
ism of transverse presentations, what is said of shoulder and
arm presentations is substantially true of other forms of trans-
verse coses, and we shall accordingly limit our observations
thereto.
Freqiienfy.— According to the statistics gathered by Dr.
Churcliill, the arm or shoulder presents once in 231| cases. It
is much more frequently observed iu multipara than in primi
aroe.
The Tarious Positions.— The positions of the faetus
shoulder presentation have been described in another place, and
they do not need to be reviewed here. For purposes of treat.
ID 1
TBAR8VER8E PRESENT ATI ONS.
377
iMDt it is highly important that we iliBtinguiBh Haem^ as other-
vise we cannot act intelligently.
Causes. — The eaases of transverse presentation are not alto-
gttber clear. Any circumstance which may occur at the brim
io divert the head from its usual place, and turn it into one of
tlie iliac fosssB, constitutes an efficient cause; and this may con-
nstof a pelN-ic deformity; an unusual quantity of liquor amnii,
givm^'to the uteriis a form more nearly spherical; obliquity of
Fin 174.
^B*^*^ hiklf of utunu rvaioved, showing I'uetuit iu trauAverse presentation
within the membranes.
™ long aterine axis ; or premature expulsiv^^ efforts. The great
preponderance of transverse presentations among pluriparae,
would certainly give color to the tlieory of Wigand, that the
phenomenon is dependent on the form of the uterine cavity,
which is probably changed so that its transverse diameter ia
378
THE MECUANISJI OF LABOR.
augmented, while ite longitadiual meaeurement is diminished.
As to the time of its occurrence, it seems probable that in
some cases it takes place by a sudden moTement, during, or at
the beginning of expulsive efforts; while in other instances its
existence is known to have preceded labor by days or weeks.
DiagnnsiH. — The diagnosis of transverse presentation has
been considered, in a general way, in another place; but a few
observations may here be added. Abdominal jmlpation can
scarcely fail to reveal the transverse direction of the long axis
of the foetal oval. The enlargement is relatively broad, while
the fundus uteri is really below the height at which it is usually
found in ccphnlic and pelvic presonttitions. Deep palpation
also reveals the head in the iliac fossa. On vaginal examination
the presenting part lies unusually liigh, and in .some cases, nt
the beginning of labor can scarcely be reached. The stetho-
scope affords some aid. " If," says Cazeaux, " the vaginal
examination has resulted
in the recognition of a por-
tion of the fcetus which is
of small bulk, and if we
}>erceive the pulsation of
the heart in the hypc>gas-
trie region, we may almost
certainly conclude that it
is the superior extremity.
If we heard the heart at
the level of ttie umbilicus,
it would in all probability
be a leg." If the position
is a dorso-posterior one, we
will probably be unable to
Fid. 175.
Dorso-anterior {>ot(ition of the i'u)tu» in
transverse preacntutioii.
hear these sounds.
Prognosis,— In any case, the danger to both mother and child
is considerably augmented. The prognosis, however, will be
greatly modified by the stage of labor at which the case com*>s
under observation. From carefully collected statistics, taba-^
lated by Churchill, it appears that " out of 314 caaea of pi
tation of the superior extremities, 175 children were lost, or'
rather more than one half. Out of 282 cases, 30 mothers were
BP0NTANE0C8 EVOLUTION AND EXPCUBION.
379
DOTfK>>postenor poftition of the foetus in
tnuuveree iireseDUtioD.
iofit, or nearly 1 in 9.'' Statistica of more recent practice would
probably dhow n Blight reduction in the rate of mortality.
Hpontaneous Erolution.
—Spontaneous £ x p u 1 -
sion. — Symptoms. — Dr.
Kigby has given a graphic
picture of a case of trans-
verse presentation when
unassisted. " After the
membranes have burst/*
says he, "and discharged
more liquor nmnii than in
general when the head or
nat**8 prespnts, the uterus
contracts tighter around
the child, and the shoulder
is gradually pressed deep-
er m the pelvis, whde the pains increase considerably in
violence from the child being unable, from its faulty position,
to yield to the expulsive oflbrtsof nature. Drained of its liquor
Mniiii, the uterus remains in its state of contraction tiven during
thfc ifitervals of the pams; the consequence of this general and
contmnpd pressure is, that tht* fhild is destroyed from the circu-
lation iu the placenta being interrupted, Ihii mother bectjmes ox-
kaiuted, and inflammation and rupture of thij uterus and vagina
He the almost imavoidable results,"
So far as the mother is concerned the early jiart of labor ap-
pearbfobe natural and favorable; but after a time, varj^ing in
^*reiit cases, the symptoms of powerless labor supervoue, and
wileas aid is afforded, or unless the child is relatively small, or
h&s tKcome putrid, the woman will sink, and die undelivered.
Transverse presentations fhff(^r from the others before de-
scribed, in having no regular and uniform mechanism of labor;
but there are two movements occiisionally observeti, by virtue of
which nature has succeedeil in concluding the process of partu-
rition; these are spontaneous version or evolution, and what was
designated by Douglas as sponianeous expulaion. Both these
ooCTUrencses are extremely rare.
Sponianeous evolution or version, consists in a complete ver-
380 THE UEOHAMISK OF LAfiOB.
sion of the fcetus, begun by the escape of the shoulder from the
grasp of the pelvic brim, followed by descent of the tnink, and
finally the pelvis of the cliiliL This process is not nearly so
frequently observe<l, as that of sj^onlaneous expulsion, first de-
scribed by Dr. Douglas, of Dublin. In this the shoulder does
Showing a cftsenf transverse pT«8«Dlatiou wherein the U(|Uoramnii bus escaped*
the arm has desce-iided, and the shoulder is wexlged into the brim.
not recede from the brim, and give place to other parts, but it
descends until it rests under the pubic arch, where it is arrested,
and constitutes a centre upon which the body of the child
revolves, version thereby occurring within the |)€lvie cavity. "It
will be obvious,'* says Leishman,* "that such a mechanism as
this can only be possible under the same exceptional conditions
which permit of spontaneous evolution. For in this case thd
* LnanMAV, toe. eiL p. 337.
TREATMENT OF TRANSVERSE PRESENTATION.
381
breech rnnst pass the pelvic brim, which is already partly occu-
pied with the base of the skull — an occurrence which is mani-
festly impossible, if the relative proportion of the parts, mater-
nal and foetal, are in accordance with the normal standard.
Flo. 17"!
Spontaneous cxpulsiou. from a ivozcn 6\Kci\iit'n, by Cliiora.
The various stages of this important Tuovcmeiit nre made
inore explicit by the accompanying cuts, than could be duue by
*uy number of words.
Treatment.— In connection with the question of treatment,
^'> 'ait* point is of such iiui>ortanre us n recognition of the char-
^ater of the case at the earliest possible moment This involves,
too, not a mere diagnosis of transverse presentation, but a rec-
<»gn5tion, as well, of the position occupied by the foetus, for ujion
this the success of treatment will largely depend When sucli
knowledge is obtained at the beginning of labor, or soon tlicre-
ft^r we may look ujxjn the case with composure, knt»wing that
the isBue lies in great measure under our control. Both moth-
^ Mid chiM are still possessed of luiimpaireil vitality, and the
" i»f our treatment will be to interfere before the life forces
LaTi' seriously suflered.
The FarorabU* Moment for Operating.— There comes in all
flKMti cjises a moment which may he regardetl as opportune, and
382
THE MECUANIBM OF LAUUlL
linppy the accoucheur who discriraiuates it with exactitudes ^t
is prepared to apply the Huitahle ireatmeut with a vigorous ham
and wise judgment.
Spontaneoos vxpuldou (flret stage.)
Preservation of the Membranes. — It is of the utmost impor-
tance that the memhniue.s be presented intact up to the moment
of interference. This consideration will lead to careful vaginal
explorations, avoiding tlie moment of uterine contraction, and
anything more than motlerate pressure on the bag of waters.
Tersion. — Some form of version is re<iuired in all such p
seutations, save in rare and neglected cases, wherein the expul-
sive action has gone so far as to destroy all reasonable pros;
of success.
The various methods of practicing version will be diacui
in another chapter. We are only calle<l upon here to imli
the varieties of version which are applicable to transverse p
sentations. Cephalic version, or a bringuig down of the he
is suitable to some cases, and, under favorable conditions^ will
scarcely fail of success. This is best practiced by Dr. Braxtoa
Hick's method of conjoint manipulation.
J^
TBEATKfiNT OF TRANSVERSE rRESENTATION.
383
A method of delivery in transverse presentation hiisbeen prac-
ticed with success in a number of instances by Dr. R. Ludlam,
which consists of the knee-elbow position, oephalic version^ and
Fio. 180.
Spontaneous expnlitiuii (secood stage,)
^e application of the forceps. The cephalic version is greatly
''w^tated by the knee-elbow position, since the force of gravity
'IJmiiiiflhes the pressure upon the brim» and places the child in
s more mobile situation. When once the ceplialic version is
effected, the forceps are applied, with the woman still on her
Knees and elbows, thoogh perhaps not with the greatest facil-
''y- She is then permitted to resume the supine position, and
*«livery is at once effected. What was a formidable case, is from
"lattime forward an ordinary delivery with the forceps.
The fi)riu L»f version recommendf^d by most authorities is the
int*!mal jHxlalic^ which consists in tlie introduction of the hand
^Uiin the uterus, and the bringing down of the feet The con-
*htion8 favorable for the performance of tliis operation are, an
uitact state of the membranes, and dilatability, or dilatation, of
the OB oterL As the labor progresses in the first stage, it should
be attentively watched, and, if tlie membranes are preserved,
umI no serious symptoms are devpli>pe(l, we may safely await
884
THE BCEGHANI8H OF lABOO.
with patience, the xnomont of nearly complete dilatation. Shonld
the waters sooner escape, provided the o8 uteri is as large as a
half-dollar, and in a dilatable state, the operation should be un-
dertaken without unnecessary delay. ^^
The feet may sometimes be brought to the os uteri by tlfl^
method of conjoint manipulation, so highly recommended by
some. It is clearly the preferable mode, if the case is a suita-
ble one for its practice, as an operation, in the i>erformanoe of ^
which only two &ngers, instead of the whole hand, are intro- ^
duced, must invoWe less risk than necessarily attends the ordi-
nary procedure of tlrawing down the feet. Hence, unless the
conditions which surround the case offer no encouragement
whatever, it is advisable at first to attempt to effect our purpose
by the conjoint method, and, if that fails, we may tlien have re-
course to the more common method. Conjoint efforts should be
put forth as soon as the os uteri will mlmit two fingers, as delay
beyond that time progressively diminishes the chances oj
success.
But there is a class of cases quite different from these, in re-
gard to which apprehension will arise, and in the treatment of
which great difficulty will be experienced. "Though always
more or less dangerous," says Blundell,* in his earnest, eloquent
way, "the operation of turning may often be accomplished
easily enough, provide<i it be performed early enough, and cir-
cumstances conduce. Hence you will sometimes hear your ob-
stetric acquaintances triumphantly exclaiming — * For my part, I
always turn without any difficulty;' a declaration, by the way,
which evinces not their superior skill, but their small experienoe
in the nicer and more dangerous parts of practice. In consul-
tation, especially, we sometimes meet with cases of turning —
embarrassed at once with difficulties and dangers; the body of
the uterus is constricted about the foetus; the mouth and cervix
are more or less firmly contracted around the presenting part;
the passages are swelled, inflamed, and dreadfully irritable; the
patient, wearied with exertion, and desperate through suffering
cannot be persuaded to lie at rest upon the bed; and thus, som^
times, though rarely, a case is treated which might try the
N
Lectures oa tfae Principlet and Practice of UidTifery." t$4^ p> 154k
lTMEKT of TRAXSVEhSE PRESENTATION.
385
nerres and the muscles of even th«tsH minions of obstetric for-
tanrs to wLoho superlative skill all iliflifultiea givo way."
If the arm and hand have prolapsed, no attempt should be
Hiadc U) replace them before prm-eeding to operate. The woman
should be wirefully brought under the intluence of an aums-
tbetic, not only tt> prevent suffering, but to allay the irritability
o| the uterus, which wouUl interfere ^ith a speedy and relative-
1> eiisy Hccompliahrnent of our purposes. The tletails of the
operation will be given in another place. The necessity for the
utmost gentleness and caution slionld be kept coristantly in
mind, for *' wombs and women are not to be taken by assault'*
A thrust of the hand here is as fatal as a thrust of the
Itf yoiiet
Beath of the F<ptll?<.— If the physiciim, t»n being calUxI to a
c»«< of slioidder presentation, find clear evi<lence of f(etal
dftatli, be will be led t<t adopt a difierent method of treatment,
and one less hazardous t(» the wtmian. The signs in fjuestion are
stiiiocid, pulMt'less cord, if it can be felt, and exfoliation of the
skin as the result of incipient putrefaction. Evisceration is the
licfttiuent for such a ciisf
Inaided Termination." In many rare cases it may be ob\*i-
"ttsilml hdxiris about Ui l>e terminated by nature, thrt»ugh one of
Ibe movements previousI> described. During a pain, the cldld
i*"Wned tu move in such a way as clearly to reveal its design
Reflect either six>ntaneous evtjlution or expidsiou. Under such
^iwmnstances, the exi)ectant plan of treatment is the pro])er.
"If the arm of the foetus," says Douglas, ' should be almost
*Jotire]y protruded, with the shoulder pressing on the perineum;
^fi' Considerable |M>rtion ot its tlioras be in the li<dlow of the
**<^m, with the axilla low in the i>elvis; if, with this disposi-
tion, the uterine efforts be still jxjwerful, and if the thorax bt
fiirfod sensibly lower during the pressure ttf each successive
I'flUt, the evolution may, with great cunfidence, lnj expected."
Other Operative Frotedures.— AVhen all othei* means have
™Ic'(l to effect delivery, and when, in other cases, the fuetus is
Wftdinly dead, it may l)*^ decapitat<:^d, it may bo eviscerated, or
rt may be delivered through abdominal incision.
Complex Presentations.— The most common forms of ])res-
entAtion, ami even some of the uncommon varieties, have been
^
386
THE MECHANISM OF LABOR.
1 be
-m
JeiJ
tis-
1^
as 1
no. i
mentioned; but there are others of nire, though jwRsihl
rence, whereiu the presentation is comjxiund in character, as, for
example, when the hands and feet descend together. Most
complex presentations are modifications of transverse positions,
while in 6c»me, the long foetal and long uterine axes maintain
their parallelism. A description of one or two of them ^•ill be
briefly given.
Hand tctili ihe IlviHi —This is not an uncommon oc
renee, especially when the fcetus is relatively small as compareii
with tlje pelvic canal Labor will not become senomily imp
ed, provided the hand be prevented from descending to an^- ef?
tent Even in those crises in which the arm becomoK extended
by the side of the head, labor generally terminates in a satis-
factory manner; but should the hend chance to be relativ
large, the lol>or may be extremely difficult.
The suitable treatment consists in pushing up the arm, so
to obviate the compression which is othenvise liable to ensue.
In affording such relief, however, we should l>e c;ireful not ti
displace it backwanls, and thereby produce a still more awk
ward condition of things.
The Feet and Hands.— hoth feet and both bands may p
sent, or but one of each, and thereby form a variety of tra
verse presentation. The complication is sometimes still furth
increased by prolapse of the tind)ilical cord. Left t(» the na
ral efforts, the foot, or feet, after a time, are likely to recede, and
a shoulder to descend; or the presentation may nf>t change, bnt
be driven downward, and finally wedged intn the brim. To pre-
vent such an occurrence, the foot, or feet, should l>e seized, and
drawn down, while the hand is puslied upward, thereby com-
pleting the operation of version at the expense of but a slight
effort If tills is undertaken early in labor, no great diflicnltj-
will be experienced; but when attempted at a late period it may
utterly fail, or, at best, be acconij)lishod as the rewanl of a
strenuous effort In the latter class of cases, n fillet should be
attached by a running n<M.>se above the ankle, and jjersistent
traction made u|kui it, while the hand is pushed u]>w»rd, and.
by abdominal manipulation, the version aided. If such a pres-
entation is nMultred still more complicated by descent of the
funis, on attempt should Ixt made to send it back into the uter-
COMPLEX PRESENTATIONS.
387
ine cavity with the preseuting. but now receding, hand and arm,
failing in which, the case will be treated as one of prolapsed
hmis with footling presentatiou. Both the re]K:)sition of the
cord, and the completion of version, will be favored by putting
the woman into the knee-elbow position.
Fig. 1«1.
The use ol tbi; ti I let with a nmniiig noo«e.
Head, Hand and Foot — The head, hand and foot have been
found presenting together, and there has even been addeti pro-
lipeeof the cord, a condition represented in the accompanying
eat
pKBcntation ol beud, hand, t'ix>t and lbnia«
888
AXOMALIEB OF TilE EXPEU^ENT FOBCES.
Version is here again a necessity, and it should be undertaken
at the earliest practicable moment
Other forms of complex presentation might be mentioned* but
to do so would be useless, as their treatment is in accordance
with the principles already laid down.
Prognosis in Complex Presentations,— Any form of pre-
sentation which involves the performance of so serious an ope-
ration as podalic version, is always attended with increased risk
to both mother and child. The fatality obviously depends in
great measure upon the perifxl or stage of the parturient act at
which interfereuce ia practiced.
CHAPTER IX.
Labor Rendered Difficult or Dangerous by
Auomalles of tlie Expellent Forces.
In those cases wherein the natural forces are adequate to oTer-
come the resistance usually offered by the soft parts, or the bony
pelvis, labor is physiological. It may be rendered pathological
by a variety of anomalous conditions having reference to the
expelleut forces, the parts through which the fcetus must pass,
the fcBtus itself, as well as certain extrinsic elements which
enter as disturbing elements.
Viewed from aclinienl standpoint, we judge of pains (contrac-
tions) by the effects which they produce; but in practice we find
it convenient to consider them in connection with their effects on
the duration of labor, and accordingly we have 1. Precipitate
labor, and 2. Protracted labor.
In no two cases of labor do we obeerve the same oonditiona
and phenomena. Sudden and decisive changes occur at various
stages of what may be regarded as onlinary casea For exam-
ple : up to a certain px>int, a labor may progress with the utmost
regularity and facility, when suddenly the expulsive forces lan-
goiab-i and progress is at once arrested. On the other hand *
PRECIPITATE LABOR.
389
iardy action may be enddenly superseded by accelerated move-
ment, and the final expulsion be precipitate.
Precipitate Labor. — There are several degrees of precipitate
Ubor. In its milder forms it is generally attended with but
Blight inconvenience, and as little danger; but there are cases in
wtuch the contractions are so powerful, vehement, frequent, and
nncoatrollable, as to result in serious traumatism of the perine-
am, cervix uteri, and the body of tlie womb itself. The foe-
tu3 traverses the parturient canal with such rapidity as to
Wl on the street, or the floor, into the chamber-vessel or the
closet bowL In such cases the suffering endures but for a brief
Mason, but it is so redoubled in severity as sometimes to pro-
dttoeoonvulsions, apoplexy, and mania. The fall of the child in
cases of precipitate labor terminfiting with the woman in the
wect position, is usually broken by the cord, laceration of which
i& rarely followed by hemorrhage. The involuntary efforts of
tlw Toman are sometimes so intense especially when the vul-
^v structures are still unrelaxed, as to cause subcutaneous
^pbysema of the head and neck, to modify the utero-placental
Wculfttion, and even to fracture the fcetal skull, as well as to
r^t in lacerations of the tissues in and about tlie vulva.
Tie following remedies may be given, but we hardly have
time to get their action, in many instances, l>efore labor is
pfoui^'ht to a close. Chloroform may, very properly, be admin-
wtered to dimixiifili the vehemence of uterine and abdominal
sction.
Excessively severe labor pains, coffea, nitx vomica.
Labor pains too prolonged and powerful, secale.
Iterine Inertia, Weak Labor. — In some women there is a
lack of tone in nerve and muscular fibre which exercises a
"Dsrkwl influence on the character of the labor. " In women,
tnoreover,'* says Leishman,* " of this temperament, the ana-
^^nical peculiarities of the sex are generally well marked, and
uie ample and shallow pelvis thus offers a comparatively trifling
'distance to the passage of the child. If, however, we contrast
^th this the tall, vigorous and muscular women, we find that in
^l»e latter there is a very general tendency to the male type of
*Ld0 eiK, p. 566.
390
AJ(0XALI£8 OF THE EXPELLEKT FOB0E&
pelvis, involving a tardy passage of the child through the pelvic
canal. May we not infer that it is in some degree in compensation
for this that she is furnished with muscles so powerful, and con-
stitutional vigor so marked, to enable her to overcome the greater
resistance which in a feebler frame would constitute an insur-
mountable barrier."
We might with propriety include under the head of te
or prolonged labor, nil cases wherein the expulsion of the foetus
is unusually delayed, from whatever cause the delay may arise;
but in this place we shall speak only of labor protracted from
causes referable to deficient uterine force.
The average duration of labor is from eight to ten hours^
latter for primiparse. and the former for multiparaa. liabor may
be weak from the very beginning, or, as we have hinted, inertia
may suddenly develop in a case which, up to near the close of
the second stage, has been vigorous and active.
Causes.— In many cases inertia of the uterus is the result of
over-exertion during a protracted first and early second stage,
it being an expression of the complete exhaustion from which
the woman suffers. In a large number of instfinces it proceeils
from general debility, the woman's health having been impaired
by acute or chri)nic disease, or her general tone lowered by con-
stitutinnal fei^bleness. Rapid child bearing doubtless has a
marked effect in the same direction. Excessive and premature
uttirine retraction is an efficient cause in quite a percentage of
cases; and also adhesions of the membranes to the lower uterine
segment High temperature of the surrounding atmosphere
such as we get in the middle of a hot summer, also Las a de-
pressing effect Sudden and profound emotions, in the instance
of a sensitive woman are sometimes capable of weakening the
pains, or even of entirely suppressing them, though such
causes do not often mnintain their action for a lengthened period.
Over distension of the bladder, or rectum, and a condition of
inflammation in the abdominal viscera, may be reckoned among
the causes of this o*)raplication of labor. Hydramnios should
also be mentioned, its effects, however, being limited Uy the first
stage. The age of the patient has a marked influence. In young
girls there appears to be a pronenesa to weak and irregular uter-
WEAK LA£OB.
391
ine action, ftnd in those nearing the close of the child-bearing
period, powerless labor is by no moans an infrequent occurrence.
Symptoms,— Weak labor is manifested in the first stage by short
iod inefficient pains. They are offcen near together, but they
scarcely develop force before they cease. The os does not expand
SB it ought, and the woman becomes nervous and des[>ondeut.
Irregular action is liable to ensue to increase the difficulties and
paiafalness of the labor.
During the second stage, lalx)r may l)ecome inert. Perliaps,
while the head lies at the very outlet, the pains grow ineffi.
oieat, aud lose their expulsive character. From t}ie fact that the
l»erineum in some of these cases seems unyielding, delay is too
ofteu attributed to that condition; but good pains speedily dis-
pose of such a state.
Inertia of the uterus may continue even into the third stage,
iind thereby complicate placental delivery, as well as give rise to
profuse and dangerous post-partom hemorrhage.
Treatment. — The character of treatment will l>e controlled by
the stage of labor in which the inertia manifests itself, and the
eauBe of the occurrence. The condition of the bladder and rec-
tum should be investigated; the mental state and age of the
Woman considered; and the character of the presentation, and
state of tlie uterus, as regards retraction, passed under review,
Wben it evidently depends on excess of liquor amnii, uidess
tbere are «)ntra indications, the membranpi* may be ruptured,
"Dds part of the tiuid {>ermitted to escape. Adhesions of the
iDembranes to the lower uterine segment should be broken up
h' "weeping the finger about within the os uteri. A warm vaginal
iDjeokion will soraetijiies promote uterine contraction, favor the
physiological changes in the oen'ix, and mechanically distend
^* vagina. Barnes' bags are of service, but far better, and
'Uttre effective, we l>elieve is manual dilatation of the os, prac-
ticed with the utmost gentleness.
The following suggestion with regard to preventive treatment
<*' these cases should be remembered: — *'The moment we find
tile least evidence of flagging power," says Dr. Edis,* " of any
♦"Obrtct Jour." Vot vii. p. 236.
392
ANOMALIES OF THE EXPELLENT FOBCEa
cessation of pains, any intermittence in the regular beat, or an]
acceleration of the patient's pulse, or any general evidence of
the patient having had more than she can fairly compass, I think
we are bound in duty to assist the patient, and not allow her to
go on until she is in powerless labor."
In protracted second stage, resulting from inefficient uterine
action, expression may occasionally be effected, but aside from
homoeopathic remedies, our main reliance must be placed on the
forceps. Ergot will sometimes afford efficient, and, we believe,
harmless aid; but if the weak labor is the result of premature,
or excessive, uterine retraction, the unfavorable conditions will
be aggravated by it. If ndmiuLstered at all, the force, frequency
and regularity of the fcetal heart ought to be watcheil by means
of the stethoxope, and, should these indicate a serious disturb^—
ance of the vital force, the forceps should at once be applied. ^|
"Wlien the head, in cases of uterine atony, lies at the outlet* it
may usually be exp*:*lled by means of two fing(»rs, or the thumb,
in the rectum, combined with abdominal pressure.
Therapeutics. — Inefficient — Labor-pains violent, and fre-
quent, but iuellicient: acvnite.
Labor-pains too weak, but regular: CBthusia.
Labor-pains violent, but inelHcient: artiica.
Labor-pains tormenting, but useless, in the beginning of la
caulophtfUum.
Labor-pains short, irre^ilar, spasmodic, patient very
no progress made: caulophyllnm.
Labor-pains spasmodic and irregular: cocculus.
Labor-pains spasmodic: cansiicum, ferrum, puhafiUa.
Labor-puins spasmodic, rutting hcj'oss from left to right, naU;
sea, clutching about the navel: ijH*c<tc,
Labor- pains spasmodic, painful but ineffectual: platina.
Labor-pains spasmodic, they exhaust her greatly: siattnunL
Labor-pains spasmodic and distressing, patient irritable:
okaniomilhi.
Labor-pains distressing, but of little use; cutting pains acrosa
abdomen : pliosphorns.
Labf)r-paius ineffectual, of a tearing, distressing character,
seemingly not properly located: uctcEa,
I- '
I
WEAK LABOH.
393
Lfibor-pains severe, but not efficacious; she weeps and laments:
Weakf ^alse, Deficient. — Labor-pains weak or ceasing; she
WAUts t4^i change position often; foels lnuised: arnwa.
IjaKir-pains weak or ceasing; she vn]X not bo covered; restless;
sliio coldi camphorn.
Lalxir-pnins deficient or absent; Bhe has only slight periodical
j>ressure on the sacrum; amniotic fluid gone, os uteri spasmod-
■diUy closed; belhiiomicu
Lftbor-iiains weak or ceasing, with great debility, especially
».£tC't vii:»lent disease, or loss of animal fluids; carbo recj.
lifibor-pains become weak, flagging, from protract^<l labor,
jing exhaustion; patient thirsty, feverish; cauloplitjUum.
ibctr-pains cease from loss of blocnl: china.
Labor-pains ceasing, witli complnining loquacity: coffea.
Liibor-paiiifi gone, os widely dilated, complete atony: gelsetih-
Eun,
Libor-pnins weak, accompanied with anguish find sweat, and
ICtdre to l>e rubbed: noiruin mnr,
i-aUjr-pains spasnujdic, irregular; drowsiness: noirnin mur.
Labor-pains deficient, irregular, sluggish: pnhutiUa,
X^ibor- pains deficient, with OS soft, pliable, dilatable? tistHago,
Aiahir- pains suppressed, or too weak: secalc.
Lalxir-]iains cease, coma, retention of stool and urine-^from
'^iit: opium.
^«ilK)r-pain8 cease, or become weak, from anger: chamomilla
^L *-^bor-pain9 cease from excessive grief: iynniia.
^H^hf Forceps in Inert Labor.— There is occasion for the ut-
^^^^■t discretion in tlie use of the forceps in cases of weak labor
P*^ee<ling from real uterine atony. We should here distin-
€*ttfth between the latter condition and that of premature, or ex-
**^ivo uterine retraction. In the latter instance, the in.'itru-
^^^nt*) are not only called for, but there is little, if any danger,
•^^^uding their use. The same cannot be said of the former
'^JQ<lition- The head has <iest*euded into the pelvic cavity under
wip iiiHnence of fair pains; but, after a time, advancement ceases,
tiw'lwiins become feeble, and the case comes to a halt. Long
dftia,r uiuler such circumstances is not free from serious danger
3i)4
ANOICALIES OF THE EXPELLENT FOBCES.
to the wonmn, owing to continuotLs w^mprossion of the soft |>el'
tissues. Keccurse is had, perhaps, to various well-indicated
remedies, without relief. The uttnine energies are still tix)
broken to respond After & time the forceps are applied, and
the delivery finished without diflicidty; but, we find that the
uterus, instead oi assuming its usual cannon-ball coutractiQn|H
remains woak and nluggish, with the eflect to develop an nggni^l
vated attack of post^partum LemoiThage. The danger, then, in
all Bucli cases is, that the at4:>ny, with which tlie uterus is stricken,
will continue, and excessive bleeding result. There is little dan-
ger of such an ixwnrrence in connection witJi ]ab4ir rendered
weak by the premature, or excessive, retraction of the utei
alluded to alxjve.
Kow, if even moderate action of the organ is reneweil I»y
remedies administered, and the stimulus applied, we may CAI
tiously proceed with our forceps tlelivery. For. unless m com-
plete attmyexists.the very introduction of the instniment cnmnni-
nicates a stimulus of the most eflective kind, so that our traction
efforts are often fnuiul t<)l)e reinforced by uterine action, Beai
ing in miml the danirers which are most liable to arise, we fol
tify oTirselves against them by adopting sncli precautions us
descrit>ed in connection with tlin prophylactic treatment
post-partum hemorrhage.
Treatment of the Third Stage of Labor Coniplicateil hj
Vterine Inertia. The great danger which is jissociated wit
uterine weakness in the third stage of labor, is that of pust-p
tuui liemorrhage. A sluggish uterus in this stage is always
cause of much anxiety. Hemorrhage may set in early, tmu»
ately succeeding placental delivery, or it may not appear at
There should be no haste to deliver the placenta, and, ulxjve
no traction should be made on the cord. WitJj tJie hand firml
grasping the organ through tbe alMlominal walls, we slionid f<
a time maintain an ex|>ect.ant attitude, unless bloe<iing set*
We must watch and wait. Upon the supervention of prol
flow, or upon the occurrence of a uterine contraction, the pi
centid mass can be expellefl by Crede's method and the utei
afterward firmly hold. Under sach precautions as the8*^ shoi
the treatment of the third st^ge of j>owerleBS labor lie
ducted.
395
With n -weak third stage is often asssociated irregular uterine
ci)iitraction, as a result of wliicb there may be a constriction of
jiflrt of the organ, most frequently at one of its angles, but often
lit or near the site of the internal os, with firm retention of the
[ilAceuta. Relaxation of the structure usually takes place sjjon-
taneoUBly. but it may sometimes be hastened by the aihuiiuBtrn^
tionof the suitable remedy. Belladonna, (jvlsemium, or cuprum
are iuiiieated in a general way, and our choice l>etweeu tliem
will be based on the special symptoms observed- Chamomilla
i» indicated when the woman is irritable, thirsty, ami restless.
Qocculxis has also been found serviceable. The inhalation of a
few drops of amyl niiriie will sometimes relax the spasm. Un-
der do circiunstancea should such a patient be left, until the pla-
centa has been delivereil; for the muscular fibres of the Ixxly of
the uterus may relax before those of the lower segment, and give
^i-"^ to hemorrhage. Tlie forcible rediu'tion of an irregular con-
*^ction of the uterus should not be undertaken .sodu after de-
■fiveiy, unless alarming hemorrhage sets in. Patient waiting,
**^ntl careful prescribing, will uriually bring about tlie desirable
'^■sult After a reasonable time, however, a gentle endeavor
^^^y be made to get away the placenta, and the ]ilau to be fol-
">"Hred is thus stated by Lusk:* **Thc plan I have followed of
r^**t^ years, with uniform success, consists in introducing the in-
*^^3c and middle fingers, with the whole hand in the vagina, to
'«a^ pr)int of constriction. Then, by pressing the uterus do>vn-
^*"d, the fingers are brought in contact with the placental l)or-
V Now, it is only necessary to draw a single cotyledon
^^> the cnnal tt» render the further extmctiim a matter of cer-
^*-*rity. Under the pressure of the soft, jjlacental mass, the
l^^^^rturp relaxes slowly. By combining expression with slight
'<"tuin. tiie delivery is surely accomplished. The principal
ii^alty lif the operation lies in the manipulations needful t*i
ug the placenta at the outset to the point of stricture, but
•^^« difliculty can be pretty certainly overcome by pntience and
*'li^ iletermination to succeed. During the periotl of witlub'awal
Xhe operator should be content with a very slow progression,
Vt^>yHirtioned to the yielding of the tiasues; otherwise the pre-
*^»ititig ixprtion of the placenta tears away, when the labor ex-
Petided is lost"
■"The Sdentc and An oi" MulwiilTy," p. 430.
396
LABOn OBSTRUCTED BY MATERNAL SOFT PABT8,
CHAPTER XL
Labor Obstructed by Maternal Soft Parts.
Among the moat c5ommon obstruotions to lal->or fTom faulty con-
liitious of the 84:>ft parts of the mother, the following may
named: Rigidity of the oa and cervix uteri, arising from vai
OU8 causes; agghitinatiou and obliteration of the cervical cam
contractions and obstructions of the vagina; rigidity of
perineum; thrombus of the vagina and vtdva; vesical and reel
distension; uterine polypoid growths; ovarian and fibroid turn*
Rigidity of the Orrix Tteri.— Rigidity of the cervix ari<
from different causes, and is dependent on various patliologii
conditions.
1. It may come from incompletion of the physiological pi
oesB of softening, which takes place diuiiig pregnancy, ai
is tisually more or less pronounced in every case of premal
labor.
2. Abnormal rigidity of the os externum is often encotintei
in multi[)arjB a.s the result of genuine cicatricial processes.
3. Fibrous hypertrophy of the cerAncal body is occasion!
met This condition is especially obsei-ved in connection
prolapse of tlie uterus,
4 Carcinoma of tlie cervix, as mentioned in another p]
gives rise to most persistent rigidity.
5. In aged primipanc, atrophic degenerative changes in
cervical tissues, or hypertrophy of tho portio-vaginalis, ma]
the 08 reluctant to yiehL
■■' 6. A certain degree of rigidity of the cervix is observed
connection with general tonicity and firmness of tissue,
cially in young and robust primiparse.
7. Last of all, we have a condition vastly more common
any of the others, and which is most frequently signified when
RIGID 08 UTERI.
399
the term "rigid os" is employed; we mean a spastic state of^'»
circular fibres of the cervix; a trismus of the part; Bpasmo^
rigidity. The others are instances of mere passive rigidity, o^^^^^
DOD-dilatability. X
(renerally speaking, it is an occurrence which exists quite in-
dependently of any diseased condition of the parts, and is, in
fact, a purely functional lesion. It is found in various degrees
of intensity, from that which causes but slight delay, to the
more aggravated forms which yield unwillingly to the measures
adopted for their subjugation.
Symptoms, — In the more obstinate cases of tlie spasmodic
form, the os either refuses tt^ dilate at nil, or expansion advances
to the size of a silyer half-dollar or dollar, and remains un-
changed for hours, or, iu batlly inanaj^ed cases, even days, in a
thin, hard and unyielding condition, notwithstanding the force
exerted by the longitudinal and oblique fibres of the uterus to
overcome it. It occurs most frequently in premature labor,
W"Leu the cervix and lower segmeut of the uterus have not com-
pleted their physiological changes. It is commonly associated
fUso with malpreHentations, In some instances the Hps of the
OB become oedematous and hypertrophied, and to the finger seem
thick and tough, but the undilatability remains. The oedema-
tous condition alluded to occurs most frequently in stout pleth-
"ric women, at a time when the pressure by the head has been
l<>ng continued, especially after escape of the liquor amnii. It
should not lie confounded with a condition, somewhat similar,
^hich is often observed iu multiparas during the progress of
*iilntation.
This form of rigidity owes its origin to wmstitutional pecul-
^witiea, more especially a highly-nervous and emotional tem-
perament, which can scarcely bear the ordinary pains of labor.
*ne sufferings of a woman during the period in which hor cervix
^^riisin a state of rigidity, are often of the greatest intensity,
jnstaflin every tonic spasra of muscles in other parts of the
^y. Madam Lachapelle considered pain in the loins as a
^'iloable diagnostic sign of this condition. *'It would appear
"'"m reports, that, in the practice of some, labor is com-
I'lic&ted by rigidity of the os uteri in quite a large percentage
"' cases. Young practitioners are especially liable to such
HUCTED BY MATERNAL SOFT PARTS.
ht here they fall into error, and a]
e an examination j>er vaginam durii
le o8 uteri with hard and rigid lit
tis must be a rigi<l ob/ and they so
ited the condition of the part during '
Motions, it would have been found pliuble,
egree/'* ^^
\fter the pains have continued for a long time without mucl^H
tin^^
an^H
or any, progress of dilatation, they begin to lose their vigor; the
patient's tongue becomes spread with a dry, brownish coa
the skin hot, the pulse rapid, and the vagina and cervix hot
dry. Such symptoms are luistcncd by a dry l>irth, whether the
waters have escaped through spasmoilic or artificial rupture
the membranes.
Further consideration is given most of the other forms
rigid OS utt»ri a little further on.
Treutment. — Immetliate danger is not to be apprehend
from a rigid state of the oe uteri, and hence, there is nu gr'
urgency for more energetic measures than the administrati
of the indicated remedy. Later, if the condition perarst, ll
woman may bike a hot sitz bath, for a few momenta only,
a prolongeil hot water vaginal enema. In *lie treatment of oh'
school physicianH, opium is here regardt^d as the most precioua
remedy, and belladonna stantls second-
MoIesworthN Dilators, and Barnes' Bags.— When the he
remains high in the pelvis, and the membranes are unruptnn
the finger cannot be used to advantage, or the mode of digi
dilatation described below would be recommended. If our re
edies have failed, it will then be necessary to resurt to t
eattntehouc dilators of either MolesworUi or Barnes, to acoo
plish the necessary expansion. They are pi-ovided in differe
sizea The smaller ones should first be used, and substit
ted by those of larger size as rapidly as the expansion of the
OS will {)ermit.
Munual Dilatation.— In these cases of spasmodic rigidity
the OS uteri, digital dilatation maybe safely and efliciently pri
ticed. It should not be undertaken without first having res*)rt<
• "The Clinique," toI. ii, p. 397.
BIQID OH UTEHI.
399
UnuHtlicinalaid; but thatfailing, as sometimes it ^-ill, a careful,
skillful, persistent effort with the tingers wiii generally accoiu-
plidi the desired end. Es[>licit directiouH are not required; but
wt- may say that, ho Itnig :ui dilatation of tiie oh ia but slight, we
cm best operate by di'awing and pressing ou the lips, in various
tlirections, when room will soon he made for a second finger, and
tlien, by spreading the digits, further dilatation will be secured.
lucihion of the Cervix.— Faj/iHrW HifntrroUninf.—ll allotlier
meftus fail, as they rarely will, the cerrix uteri may l>e ijicised
in itu circumference, with a blunt-pointed bistoury, in three or
four places, to the depth of a quartc-r of an inch. Afterwards
tbe uatoral eftbrte will be sufficient to carry on the dilatation,
or it may be promt>ted by judicious use of the fingei*a
I se of the Fori-eps. -It is becoming the practice of the more
fctlvftiiced obstetricians to resort to the forcej>s in certain cases
»if rigid us uteri. Listead of following the old inile to await
Ml ililatiition lM?fore using the instrument, a restricti<:»n which
nould exclude the instruments in all these cases,— they resort
Vt the forceps in obstinate cases, as soon as the expansion is
'wnpli* enough to atbnit the blades. The oiM:»ration is especially
t'fillt^l for when, as often happens, a rigid os is associated with
pQcr|)eral eclampsia. In some cases it is wise to incise the os
More applying the instruments. In all crises wherein the fnr-
^p8 are employed before complete dilatation of the os, the
l*||Bgt care is necestwiry. The forcible words of Blundell • are
liftW iippropriate. *'The ^rand error yon are apt t** commit, in
'^'yng thn long forceps, is /orrr. In vnolent hands, the long for-
''^^PR is a tremendous instrument. Force kills the child; f<»roe
""Tiiaeft the soft parts; force occasions mortifications; force bursts
**ppn the neck of the bladder; force crushes the nerves:— beware
*>i fitrce, therefore; arie non viT A gentle, c-autious, but reso-
Itite (effort M'ith the forceyw;, in cases of rigid (»s which have re-
*'iste(l f.ther means, will generally be rewarded with success.
' ranlotoniy. — If there is considerable pelvic contraction, or
*"**n. ffLtm 'other chuses, the forceps are inadequate to effect
ufthvery, the accoucheur may l>e driven to the necessity of em-
ploying tliat t(?rrible instrument the perforator. Dr. A. K.
'*Uctqtr8on MidwilVry,'* p. 259.
400
LABOR OBSTECCTED BY UATERKAL SOFT TABTS.
Gardner * gives expression to the following sentiments respect-
ing the last two operations: "If, therefore," says he, "there be
any immediate necessity for any obst^ti'ic oi>eration, do it irre-
spective of the local condition; apply the forceps through au
undilated os; perform craniotomy through abut partially dilated
os; and even, if necessary, incise the os, in order to render an
operntifm practicable."
Therapeutics.— When the os uteri gets dry and sensitive,
with spasmodio. rigidity, and the woman restless and thirsty,
aconiie is the remedy.
When the oh is hard and unyielding from the irregular muscu-
lar action alluded to, without other and special indications, the
remedy which is most likely to afford relief is belkuUmna, By
physicians of all scrhooln of practice, this remedy has l>een re-
garded with great favor. Its local use has also been reoom-
mendecL Afropiti, the active principle of bellpdonnn, has also
been employetl, and doubtless in many cases with benefit It is
said by some to act with greater precision and energy, when ad-
ministered hyp«xlermical]y; and Dr. Henr>' S. Horton f bas de-
vised a syringe, with hooked nee*ile, for the purixwo of injecting
a solution of atropia into the tissues of the cenix itself.
The local use of ,both belladonna and atropia we regard as
rarely proilucing desirable results which cannot l>e obtained
from the administration of an attenuation by the mouth; while
poisonous effects are oft^n observed.
Gelsemium in lx>th attenuation, and fluid extract, or tincture,
bas been found of service in a certain number of caseft. By
some it is carried to the extent of producing toxical effects with-
out always obtaining relief of the spastic condition-
Caulophyllum has been highly extolled by others, and there is
no doubt that it is sometimes a most efficacious remedy.
When the patient is extremely irritable and restless. cha\
milla will often afford relieL
rterine Tetanoid Constriction.— It may occasionally hap^
pen duiiug labor, that progress is impeded by the occurrence of
a circular tetanoid contraction of a limited portion of the mo^
cular fibres of the uterus, above the internal os.
• Vide CfLIsox. "Text Book of Modem Midwifery/
t " Am. Jour. Uhs.," vol. li, |». 'M^2.
11.384.
mam
UTEBINE TETANOID CONSTKICTION.
401
fharacter of the Stricture.— Hosmer likens tne stricture to
a band of metal; Davis aaya the uterus is "as if a strong rope
hiui been tightly drawn around it;" and Gay says, "it felt as
liard as bone, and at first was mistaken for bone." Dr. Reamy
says: *' Nothing which I had ever encountered in ut<.triue con-
traction could convey any idea of the power of the constriction."
Dia&rnosis. — The stricture may sometimes be made out from
careful abdominal palpation, but we are liable to confound
the feel with that of premature and excessive retraction of the
ntfems, mentioned under the head of " Uterine Inertia." It will
be distinguished from that condition mainly by the general char-
Mters of the labor, which do not point originally to weakness, but
to obstruction. Then, too, vaginal examination does not reveal
premature disappearance of the os uteri from retraction over
tlio presenting part, though it must be remembered that this
does nut always accompany the anomaly mentioned.
Treatment. — The operations usually performed to overcome
tiLsfcructions have generally been resoi'ted to, but with most un-
Mtisfftctory results. Ctesarean section itself has been suggested.
Sttch cases are rare, and we are not aware of the success which
liHM fttteuded the use of homoeopathic remedies in their treat-
^mt, but we should expect good r&su\tGlrou\ belladojina, gelsem-
i«m, cnulo2>hyltum, and perhaps aconite. It may be that amifl
ffifritr ^-ill prove efficacious. Chloroform has failed to unlock
Agglutination of the Externa! Uterine Orifice.— There
Iwive been but a few cases of this form of obstruction rex)orteti
It is probably the result of intlammatory action, and has been
"t'JWD Ut (x^cur aftor cauterization employed for endo-cervicitis.
Though these adhesions resist firm uterine contractions, and
coubtitute a bar to labor, they may be broken up by the finger,
^ith a If)ss of but a few drops of blood,
Complete Obliteration of the t'ervical Canal.— This is an
^remely rare condition. It differs from simple agglutination
^^ the external os, chiefly in the greater strength of the adhesion,
"lenitive measures being required to overcome it.
Vaginal hysterotomy is tlie treatment required- If the site
of the original oi)ening can bo found, an incision should be
nutdo with a bistoury, in a transverse direction, to the extent of
4()2
LABOR OBSTRUCTED BY MATEIINAL SOFT PAHTS
Imlf an inch. Or, tlie uterine tissues may be picked up with
pair of toothed forceps, and then tlivided with scissors.
Tiiiiiefartioii and Incarceration of the Anterior Lip.—
When Jebcent of the liead beginn, as it frequently does, bef<
retraction of the cervicid ring has taken place, the anterior
of the oa uteri may l>eoome cf)mpressed and held between
head and pubes. This condition usually disappears spout*
ourily, without becoming excessive; but in occasional instan(
it will require relief.
Treatment consists in pressing upward the tumefied part, in
the interval 1)etween pains, and maintaining it iu a situatio^^^
aljove the brim, until the head descends far enough to prevei^H
its retnm. Blot mentions a case in which the tumor formetl by ■
the anterior lip, thus confined, was an inch and a quarter thic
and descended to the vulva, Tlie labor hatl to be temiina
with the ft>rceps.
Sanguineous tumors have in some cases re8ulte<l, which n\
rupturing, either during or after labor, have created serious, a
even alarming, hemorrhHges.
Tarcinoma of the Cervix. — The cervix uteri is oconaionally
the seat of cancerous degeneration dui'ingthe child bearing perio
and the result is extensive thickening and induration of
part Carcinoma of the cervix, even in an advanced stage, is no
b*ir to conception, though it will but oc^'asionally take place; aa
even then manifests a strong tendency to ultimate in fee
death and prenirtture expulsion. Pregnancy also causes rnpi
development ami prt>greB9 of the disease.
Delivery is sometimes absolutely and effectually obstruc
especially by the harder forms of the growth. In other
the cervical mass is fissureil by the necessarj' expansictn.
When the intervention of art is demanded, it may be fo
necessary to make repeated incisions tm the periphery of t
cancort)U8 mass. Subsequently the laWr may be termina
with the forcef)8, or the case left to the eflforts of nature. If,
after milking the incisions, the cervix is still too contracted
admit tJie forceps, — a thing which will but rarely occur,-
otomy is to be performed- Cazeaux ♦ thinks however, that.
■ no ^
Cazeatx, lor. dt. p. 7i»4.
THKOMBUS OF VULVA AND VAGINA.
iOd
far as tbe mother's risks are concerned, they are about equal in
cmnioti^my and G:«?sareiiii section; and since the former involves
certain death to the child, the latter is the preferable operation.
Caulifluwer Tumors of the Cervix. — Such tumors may arise
from either Iip» and by growth, finally cover the os. In the
pr«ictice of M. Nelaton, the internes of Lourcine Hospital mis-
took a Cauliflower escresonce of the cervix, with a pedicle an
inch and a half long, for au arm presentation, and sent for Nel*
utiin to perform version.
TMien these tumors are so large as actually to prevent fcetal
expulsion, they have, in fnvoruhle cases, been removed, while in
olhers, craniotomy and gastro-hysterotomy have been performed.
Thrombus of the Vulva and Tajtrina.— Effusions of blood
iulo the j>elvie cellular tissue, and the labiru ctmstitnte serious
Complications of lalxjr. In bad cases the effusion is not limited
Um small are;*, but it may extend f(»r a considerable distance.
Proi^nosis. — The dangers attending this accident of labor, are
wid t» bn less now than formerly, but still considerable. Out
of twenty-two crises reporte<l by Dr. Fordyce Barker, two died;
and out of fifteen reported by Scanzoni, one died.
Hjmptoius.— The accident is usually developed suddenly, and,
lu'wt fftHpiently, tow.inl the close of the seetind stage of lalK)r,
orimmetliately after fcetal exj)ulsion. Tlie woman experiences
nifre or less {)ain, and if the fingers are in the Miginn, the forma-
^i^-ti of the tumor is felt. 8*^)metimes hard and large like a small
><eUl head, for which it lias l>een mistaken. Distension may be-
come so excessive as to produce rui>ture, attended with cousid-
trabie hemorrhage. If much bh)od is lost, either into the tlirom-
W or at the site of it, the symptoms commonly attending ex-
c«s«ive dei)letioh areol>served.
The effused blood, if small in quantity, may })e absorbed; if
iter, there will be rupture, suppuration or slongliing.
Treatment. — If the tlirombus is large, it will act as a formid-
able obstacle to spontaneous delivery, and, until reduced, may
even forbid extraction with the forceps. In the latter case, free
inciaion shouKl l>e made across it, and the coagula turned out
Eb arrest the hemorrhage which follows, the wound shoidd be
:ed with styptic cotton, and digital pressure maintained.
404
LABf»B OBSTBUCTED BY MATERXAL SOFT PABTH.
If tLe thrombus is preserved. intact, or first develops
delivery, the physician should uot hast-en to adopt such
ment; but the expectant plan is then preferable. Recovery,
the eflFects of the accident will be more tardy under such t
mentf but, by adopting it, the dangers of hemorrhage and
ticsemia are diminished- Contrary opinions are held by 0
When rupture has occurred, or when the tumor has been infl
the resulting wound should be treated under strict antia
precautions.
Cystocele sometimes oomplicates labor and makes it ass
serious phases. The bladder, by descent of the head*
Fio. 183.
Cut showing cystooele. A n-presents ibe proUpaed bladder.
dividtHl into two compartments, and tlie lower one is pi
downward in advance of the head. This can occur, hoi
only as the result of inutteutioa to proper evacuatiun
VESICAL CALCCLCS.
405
viscus. If the part thus pressed upon ia considerably difttended,
im] does not receive euiUtble attention, it may offer decided r&-
sistance, and itself beoomo ruptured. It is maintained by
Mme that it is a condition not always chargeable to the medical
attendant, since occasionally it arises from prolapsus of the
bladder existing before, and independently of, pregnancy. We
tannot but feel, nevertheless, that when permitted to serioaely
complicate delivery, the physician is in a high degioo culpable,
i» an early vaginal examination ought to reveal the condition,
md afford an opportunity to remedy it
Treatment consists in passinjj: a soft rubber catheter, unless
compression prevents its use, when a male silver catheter should
be carefully introduced, with tbe cur^e looking t<^>ward the va-
gina. If neitlier instrument can be successfully used, the dis-
tended viscus may be punctured jn^r vatjinam, with a hypodermic
Dwdle, or the small needle of an aspirator, and relief thus
ftffurded. In such cases there is no rational excuse for failure
bytheftdoptiouiif judicious measures to prevent serious obstruc-
ta, or vesical rupture.
Impaction of Fflpces in the Rectum. — The presence in the
lectam of hardened fceces may constitute an obstacle to labor,
Scylmla; will be felt through the rGcU»-vaginul septum on making
adigilfll examination, and, when detected, should be removed by
repeated enemata. An accumulation of magnesian deposits in
womoa accustomed t« take this substance for the relief of heart-
bum, or as anaperient* is sometimes found. The extreme hard-
11*^ may at first give rise to the impression that there is a pelvic
pi(*tosis, but a careful examination will correct the error. Ob-
fttioate. cases may not yield to enemata, but require for their
reiuoTal A process of excavation.
RfCtocele. — The posterior vaginal wall, including the recto-
lal septum, may prolapse during lalx>r, but it can scarcely
titute a formidable impediment, unless hardened foecal ac-
[comnJatioufi are contained in the rectal pouch thus formed, Re-
loral of such offending matters is usually accomplished with
ity. '
Tesical Calculns. — This p^>mplication of parturition has been
lat in a large number of recorded cases. When tlie stone is
and it descends before the foatal head, labor cannot be
4(m
LABOn OBSTRUCTED BY MATERNAL BOFT PABTS.
finished without its spontaneous, or operative, removal. In any
neglected case, laceration of the bladder, and vesico-vaginal
fistula ore the almost certain results.
Diagnosis is readily made, for the stone, £rom its situation
and moveable character, cannot easily be mistaken for any nth^r
contingency of labor. These cases demonstrate the importance
of timely vaginal examination, for when the presence of the stone
is early detected, it can generally be passed above the pubes, in
which situation it is not so apt to produce mischievous results.
If the labor has advanced too far to admit of such treatment, or
if the size of the stone is too great, the rule is to perform the
ojiorfttion of lythotomy through the vagina. If time and oppor-
tunity are auspicious, lithotrity is in some cases the preferable
proco<luro.
DifTiise Swelling.— Swelling and tumefaction of the soft parts
of the parturient canal are liable to complicate expulsion. In
various forms of obstructetl labor, as for example, in deformed
pelvis, the long continued pressure, and the repeated uterine
ctmtractions and muscular effort, iore rise to tho complioation.
A Hiuiilar condition is sometimes noticed in connecti«>n with ordi-
nary labor, due, probably, to intense hyperemia and irritatit>n.
If excessive, hot water injections will bring about some reduc-
tion, but if the bladder and rectum are kept clear, little hfirm is
likely to ensue.
rnyieldin^ Hyiii*»n. — As mentioned in another place, women
occasionally become i)reguant thi'ough a cribroform hymen, aiid
in other cases through one possessing but a single small HfKur-
ture, and the structure, oTvnng to its unusual timghnoss, remain-
ing unbroken, forms an obstacle to delivery. Left to the natural
•course of events, the^sc membranes, however hard, woulil prtilvi-
bly be ruptured by the descending foetus; but more or less rlelay
and unnecessaiy paiii wt)uld be suffered. It is far l»etter to
dispose of them by making a crucial incision, before pressure or
strain has bewjuie excessive. It is probably iwtter still, wlion
such ooudithjus are i*ect>gnized during pregnancy, to make the
necessary incisions at once, as tliere is uo dungei*, and scarcely
any pain attending the ojieration.
I'terlne Polypi Obstructing Labor.— Polvpoid growths
springing from tiie uUtus at the os, the interior of the cf^nix.
UTERIKE POLYPr.
407
or the cavity of the uterus, when they exist in the non-pregnnnt,
commonly prevent conception; but there are exceptions to the
rule. In other cases they ore developed, or greatly augmented
during gestation, and at the beginning of labor emerge from the
OS uteri, and act as impediments to the iiatunil prtxM^sses, When
they arise from the lips of the os, they are usually of small
pmportions, and cystic character. Those which spring from the
interior of the cervix, or corpus uteri, are larger, and of a fibrous
natura
Small polypi ol' tlie cervix
The uterine contractions are sometimes forcible enough to
dt^tiudi them. Unless they are so large ami uuyiehling as to
constitute a i>ositive bar to delivery, they should not be removed.
Cvi^tie [M>lypi am lie punctured with an aspirator needle, or
a small tr<xyir, and their contents drawn off.
It it> (X'casi<jnuJly possible to push the tumor above the jjelvic
brim, out of the way of the jiresenting part, as has been demon-
strated in numerous instances. This is sometimes practicable,
even where the conditions are extremely unfavornbk>. Mr.
Spenoer Wells relates a case* wherein he was cidleti to perform
Ceesarean section, but succeeded in pushing the obstructing
tumor above the brim, when the fcetus passed with ease. Per-
eistent efft»rt, an<l consith*rabK^ force, are sometimes required,
when the impending dangers to both mother and child warrant
tlie procetlnre. Before attempting -the operation the woman
fihonld be deeply anaesthetized
If the tumor is hard, and ctmnot be pushed above the brim,
the next operations for consideration are enucleation and abla-
Obst«t. Trans.," vol ix, p. 73.
408 LABOR OBSTRCCTED BV MATERNAL SOFT PAKTa
tion. Such i^rowtLs usually have loose attachments, and, whi
witliin reach, can often be enucleated. If this is impracticable
they may be twisted off^ or removed with the ^craseur. 8honld
neither of these o]>erationfl be deemed exi>edient, the character
of further treatment will be determined by the amount of ob-
Bfeniction, the operations in their order being the forceps, crani-
otomy, and abdominal section.
Fio. 186.
LulHir impedrd X,y a ptilypuA.
Hemorrhage after delivery has f^enerally been regard*
strongly menaced in these cases, but fortunately it is m
common as might be expected.
Tumors of the Ovary Obstrneting DellTcry.— An ovarian.
tumor of any considerable size cannot descend into the peb
cavity, and hence will not become a seriouB obstacle to delivei
Tliose tumors which really do pncroach upon the sjjace wj
409
forms the parturient canal, are such as have preyionsly attracted
litde or no attention.
We Bhoold distinguish between cysts containing fluid, and
ifaose with only sobd matters. If the character o£ the tumor is
iloubtful, no serions injury will be inflicted by an exploratory
Fio. iwt
Labor olixtructed by ovaniin tumor.
pQDcturo with a fine aspirator needle, or small trocar. Pla3rfnir
wilected and tabulated fiftj'-seven cases of ovarian tumor ob-
•^^Wsting labor,* with the tolhjwing results: In thirteen, labor
»« terminated by the unaided natural powers, but, of this num-
^r. SIX mothers died. With these he contrasts nine cases in
which the tumor was diminished by ponoture. Tlie mothers all
lived, and six out of the nine children were saved. "The rea-
SOB," he says, "of the great mortality in the former cases is ap-
jwently the bruising to which the tumor» even when small
HhJOgh to allow the child to be squeezed past it, is necessarily
objected This is extremely apt to set up a fatal form of dif-
foiie inflammation, the risk of which was long ago pointed out
by Afihwell,t who draws a comparison between cases in which
socb tumors have been subjected to contusion, and strangulated
♦"Obstet. TTani.," vol ix.
tCNt7% HospiUl ft«portfi, toL ii.
410
LABOR OBflTRUOTED BY MATKKNj
hernia; and the oaufie of death in both is doubtlasa very similar.
This danger is avoided when the tumor is pimctured, so us to
become flattened between the head and the pelvic walls. On this
account^ I think, it should be laid down as a rule, that puncture
should be performed iu all cases of ovarian tumor engaged in
front of Uie presenting part, even when it is of so small a size
as not to preclude the possibility of delivery by the natural
powers."
In tive of the flfty-seven oases, the tumor was pushed above
the pelvic brim, aud the terminations were in every instanoe in
maternal recovery. It is a wise procedure in all those cases
where the contents of the sac cannot be evnouated by puncture,
to make a persistent, yet not harsh attempt, to return the tumor
to a situation above the pelvic inlet Such treatment will somt
times succeed even in unpromising cases.
Should l>oth puncture and rej)osition fail, or be out of the"
question, craniotomy Mould be preferable to any attempt at
livery with the forceps. In extreme oases, abdominal secti<
may be the only mode of extraction.
Rigidity of the Perineum.- Rigid os ut^ri has sometime?
associate*! with it, and augmenting parturient dangers and dif-
iiculties, a rigitlity of the perineum, which owes its existence
a like cause. In most instances, the hardnees is gniduallyove?
come, and the perineum escapes without serious laceration; but
sometimes the contraction is unyielding, and rupture the conse-
quence. In freneral, the structures of the pelvic floor and out-
let are soft^^iifd «luring lalxir, by plijrsiological processes, into a
condition of elasticity and ductility, and the perineum yields be-
fore the advancing head, to the necessary degTco, withoiit much
solution of continuity. On the contrary, we find that, iu so
instances, such softening does not take place, and, at the
pense of tlie intecrity of the tissues, the foetus is allowed to
Tlie latter condition is most frequently obsen'ed in primip
and hence perineal rupture most frequently occurs in first
bors. It is especially true of aged primiparfe; in whom tliere S
usually a non-ela.-iticity of the soft structures, unoimmon in
younger women. Old cicatrices, the results of former laceration,
may impart n firmness again dangerous to its int*?grity.
"Rotten" Perineum.— There is much difference in perin
!ne^^
BIOID PERINEUM.
411
»
¥
as to their nbility to withstand a severe strain. Every physician
of experience has observed that a moderate dilatation will at one
time cause mptnre, while an excessive expansion, in another case,
Till be suffered without accident. Dr. Matthews Duncan says:*
"There is no doubt in my mind that, in certain cases, there is
fflut may be called rottenness of tissue, which destroys the
power of the tissues to resist laceration or bursting. In some
women, and occasionally, at least, very markedly in the sj^ihil-
ilic, this condition is very easily demonstrated. It is a condi-
tion also of many inilamed tissues, and this is exemplified in the
perineum.'*
Treatment. — The ordinary precautions against ruptured
perineum, described under the head of *' management of natural
labor,'* need not be repeated here. Nor is there anything to be
idded, for, when we have faithfully applied them, v,'e have dune,
in a protective way, all tliat it is possible for us to do. And the
physician should not forget that, even when he has so done, his
patients will occasionally have ruptured perinea.
Immediate Perineorrhaphy,— The time for operating in
ciees of ruptured perineum has been much discussed, and va-
lioia opinions are still held- It appears however, that the
wight of testimony is in favor of the immediate operation-
^ consists in thoroughly cleansing the ■ ruptured surfaces,
wul bringing them Ujgether at once by strong sutures. The
Weults obtained have not been uniform, but these depend
^ a variety of conditions, prominent among which are
tke patient's surroundings, and the precise mode of operation,
hnmediate perineorrhaphy has proven itself unsuited to hospi-
W practice, the percentage of failures being very large; but in
private practice it has been quite otherwise.
The parts 8h«^»uld be thoroughly cleansetl with a soft sponge,
Md rags of torn tissue snipijed off before they are brought to-
gether. Silver-wire is preferable for sutures, and the needle
should be passed deeply enough to get a firm hold of the flaps.
Tery deep sutures are not required. Three or four to the inch
lid be tiiken, and after twisting the ends, they shoxdd be left
half an inch long, and turned backwards so as to prevent
The Ob-rtet. Jour," vol. iv., p. 4i
L2
LiBOR OBSTRUCTED BY MATERNAL 80FT PARTS,
irritation. The woman should then be placed on her side, with
the knoea padded, and tied together. The urine should be
drawn three or four times every twenty-four hours, during the
first five or six days, and the vagina syringed with a mild anti-
septic solution three times a day. The sutures can be re-
moved on the fifth day. The best dressing for the wound is a
soft piece of linen, saturated with dilute calendula tinoture.
When thus treated, the laceration will rarely fail to repair.
Some obstetricians recommend that even slight ruptures be
immeiliately stitched ; but we regard such treatment unnecessary,
alarming to the patient, and gratuitous self-impntation on the
physician's care and skilL The lacerations generally undergo
spontaneous repair, if only a little care be bestowed on them.
In such cases we will do well to follow the old plan of putting
the woman on her side, bringing the bandage well over the
thighs, to restrict motion, keeping her there for two or three
days, meanwhile drawing the urine as often as may be neces-
Bary. We may add to this a pad, nicely fitted to the perineum,
held in position by a T bandage. The most extensive niptures
sometimes spontaneously heaL*
* Dr. P. n. Lonie reported the following intercBting uase to the N. T. Ofasiei
ealSodety, l"Am. Jour, of Oba." vol. viiL p*625.)
"Some years ago two of my intimate professional acqnaiDtanc«s were iiit«^
ested in snch an exreptionul cuse. One was the late Prof. Geo. T. Elliot, the
other Dr. John G. ferry. The va;^na of this la«ly wa8 the smallr^t uod most
ri^id whidi Dr. E. had ever met with, which led him to caution her friends
that l.ioeratioD would probably occur. It became necessary to resort to the
forcepfl. and although he nsed the smallest and lightest in hifl possession, and
all the usual skill und care for which he was diatinguished, an appullintz lacer-
atioTi did tuvur, splitting the sphincter ani, and the rngina throughout it* whole
Imgih to the bottom of Douglaa' cul-de-sac" Thi« Uoention though not sewed,
underwt;ut perfect rc{tair.
%
:«^^
fi^^^
JUBTO-MTKOB PELVIS.
413
CHAPTER XI.
Labor Obstructed by Some ITiui^iial Condition
of the Maternal Osseous Structures.
Deformities of the Pelvis.— Without following closely the
Tiflual olasBitication of deformed pelves, we shall consider under
the above title, deviations from the common form and size,
whether the dimensions of the pelvic canal are uniformly
changed, or are contracted in particular dinmeters.
Lar^e Pelvis, — While the difficulties and pains of labor are
oonaiderably diminished in the case of enlarged pelvis, the dan-
gers are not correspondingly reduced. Mere facility of expul-
sion is not the most important consideration in connection with
labor. When the pelvis is too roomy, dangers and complica-
tious of a different sort are liable to arise. Tliese are such as
wpompany precipitate labor in general, and consist mainly of a
tlragging or forcing downward of Uie entire uterus, from want
of proper resistance of the pelvic walls, and hence rapid disten-
sion of the soft structures, the ooourrenoe of laceration of the
^rvix uteri, and the perineum. Among the dangers may also
0® mentioned strain and rupture of the cord from sudden expul-
Won of the foetus with the woman in the erect posture, and also
Dterine inversion.
Symmetrically Contracted Pelvifi, or Pelvis ^quabiliter
• Usto-MInor. — The general form of the pelvis may be eymmetri-
"^l the relative diameters remaining unchanged, but the structure
"® araall from equable contraction of all its diameters. These
Auditions constitute one of the most formidable obstacles to
'lelivery. Fortunately such pelves are rarely met They pre-
**ntan infantile tyi>e, and are doubtless occasioned by prema*
Wft arrest of osseous development
414
LABOR 0B8THUCTED BY PELVIC DEPORMITY.
.Flattened PelTls.— The peculiarity of this form of pelvis is
its shortenod conjugate diameter. The transverse measurement
remains nearly normal.
There ore two varieties, dependent on the causes which opera^^
ted in their production. The flattened, non-raohitic form is tU^f
most frequently met In it the sacrum is depressed and pushed
inward, between the two ilia. A great degree of contraction is
uncommon, the conjugate diameter rarely falling below three
inches. The cause of this deformity is not well a nderstood.
Lifting and carrying heavy burdens in early childhood, incom-
pletely developed rickets, and retarded development, in differ-
ent Cfises are regarded as sharing in its production.
Fiti. 187.
The Flattened, (Rtichitic) Pelvis.
In the rachitic form of flattened pelvis the bones are genei
erally rather small, but sometimescompact and thickened- The
ilia are flattened and spread. The sacral promontory is thrown
inward towanl the pubic 8ymph3\si8, and the base of the eacrum
depressed between the ilia. The sacrum has a sharp curve for-
ward, at or about tlie fourth vertebra. The sacmm also loses
its side to side ctu^'e. The transverse diameter of the brim is
about normal. The horizontal rami of the pubes are flattened,
and the acetabula are turned forward. The ischia ore spread,
and hence the jjubic arch is widened. Such a pelvis is contract-
ed at the brim, and widened at the outlet, while its depth is
diminished. Owing to depression of the sacrum, there is
sinking observable in the lumbo-sacral region.
I
I
IBBEGULAB EACHITIC AND MALAC08TE0N PELYI8. 415
The proximate cause of these deformities ie traceable mainly
to the weight of the superimposed body on the pliable bones.
J3ome of the changes, however, are probably congenital, some
dne to muscular action, and others to disturbacces of growth and
^rsistence of the fa'tal type.
Flattened, Generally Contracted, PeWte. — This variety
closely resembles the justo-niinor pelvis, and, durin*^ life, is not
tf^ften distinguishable from it The deformity is most frequently
(lae to racbitia
irregular Rachitic and Malacosteon Pelris. — Rickets usu-
f»Jly comes on before the child has begun ttj walk, and the weight
oi the body is thrown on the ischia iuHteiid of the acitabula.
;Malacosteon begins later in life, and the weight of the whole
tnink is transmitted to tlie tlilgh Iwinea through the acetabula,
Afl a resxilt of these varying conditions, a 4ieci*ied diii'erence in
Fio. IW.
Maliifcwii-oii I'l-lviw.
"ifr character of pelvic distoiiion is observed. The most fre-
quent of all the varieties of rachitic pelvis is that wherein the
*^»njugate diameter of the brim is shortened by projection for-
''fttlof the sacral promontory, accompanied, or not, by depres-
won of the pubes. Different varieties of distortion have been
<fe»cribed as "masculine," "lieart-shaped," and "figure of eight"
deformities of the brim, all of them, however, preserving the
general cUipiical form. In the malacosteon pelvis the general
416
LABOB OBSTRUCTED BY PELVIC DEFORMITY.
form is angular, oooasioned by the depressions at the acetabi
growing out of the conditions before meuiioned.
The characters of these two varieties of deformity are ofteft"
Fin. IWJ.
Iiui)m.*1 KcdiiiuitM J*etvi0.
blendetl. as shown in figure 189, which represents the pelvis
Isabel Redman, on whom Dr. Hall performed the Ctesarean
operation, September 22d, 1794 "These are,** says Leishman,*
"mere illustrations of possible variations, which might be infi-
nitely niiiltij)lied; but it is to be rcmeml>ered that a considerable
number of cases have been met with in which an undoubtedly
rickety pelvis presented all the more prominent characteristics
of malacosteon deformity.'* He also adds: "In so far as the
true mala(x>Bteou pelvis is concerned, it 1ms l>een well observed
by Stanley that there is no diminution in the actual circumfer*
ential mea.surement of the brim, and that the bones are of their
natural bulk and proportion, so that if their various doublings
were unfolded, the i)elvi8 would be restored to its normal di-
mensions and form. In rickets, however, this does not usually
apply, owing, as has already boen observed, to the partial arrest
•"SyBtem of Midwif*»rjf,*' Am. Ed., IftTTl. p. 4;M.
0BLK3TTELY CONTRACTED PELVIS.
417
of development whioh obtains during the courBe o£ the disease."
Obliquely Contracted Pelvis. — This distortion essentially
ooneiste in a deficient development and flattening of one side of
the pelvis, of an anchylosis of the sncro-iliac joint of the same
eide, and of a depression of the sacrum toward the latter, while
^lie symphysis pubis is thereby displaced so as to be nearly
opposite the sacro-iliac synchondrosis of the sound side.
Flattening of the Sacrum. — A relatively more common form
OUiqaely Disturted Pelvis.
^ pelvic deformity, sometimes associated with other distortions,
'^<1 again existing independently of them, is flattening of the
. ^^^u-iun. On account of such a deformity, the head may become
**-^arcerated in the pelvic cavity, and occasion much difficulty in
^livery.
lilxa^t^erated Curve of the Sacrnni.— The opix)site condi-
^^^n to that just described is cK^casionidly observed, consisting
* an exaggeration of the sacral ciir\'e.
Fannel*8haped Pelvis. — What has been termed the "fun-
^'il-shaped" pelvis, in its general appearance bears quite a re-
semblance to tlie male i)elvia. In such a B{>ecimen the diame-
ters of the pelvic canal diminish from above downward, and the
418
lABOB OB8TBUC3TED BV TELVIC BEFOBMITT.
head, when driven into such a pelvis, is liable to become impact-
ed, and delivery to bo attended willi considerable difficulty.
Infantile Type of Pelvis.— From arrest of development, the
pelvis occasionally preserves its infantile form, presenting a
greater inclination of the brim, and a reUtiveiy great conjogate
diameter at the brim.
Flu. lUl. Flo. 192.
Flattening of thr Sucrutii.
Exacgerated Sacrul Curve.
Deformitieft from Spinal Currature.— The shape of the
pelvis is considerably modified by spinal curvature, especially
in those cases which originate in infancy or childhood. Thus
kyphosis and scoliosis, both have their peculiar pelvic distor-
tions.
Robert's Anehyloseil and Transversely rontracied Pel-
vis,— In this deformity there is bi-Iatoral sacro-iliac anchylosis,
and absence or rudimentary development of the sacral lateral
masses. The sacrum is narrow, especially at the base, and both
its longitudinal and transverse concavities are nearly or qwte
obliterated- The sacrum is depressed, and the promontory is
tilted somewhat forward. The ilia are flattened; the descend-
ing rami of the pubes unite at an acute angle, and the ischial
tuberosities are approximatei The transverse diamet<>r»
throughout the pelvis are greatly diminished, and the pelvic
canal is increased in depth.
The cause of this deformity has not been satisfactorily ex-
plained.
mm
mmmi
OSSEOUS TUMORS.
419
Spondylolisthetic PelTis.— This is a i-are form of pelvic de-
formity, and consists chiefly in separation of the last lumbar
vertebra from the sacral base, and descent of the lumbar spine
Fig. 193. Fi«t. 191.
Robert's IVlvis, .Spuiui.vlolijslhflic Pelvis.
ito the pelvis, as shown in the accompanying cut The result
a groat reduction of the conjugate diameter.
O«teo-Sarcoma and Exostosis.— These growths are of com-
r>r->rativcly frequent occurrence. They may originate from any
of the osseous tissue of the pelns, but they seem to prefer
e upper third of the sacrum. The proportifins wliioli suoh a
S^*^wth may attain are well shown in the accompanying figure.
Fin. !!>.'». Pelves wliicli present these growths
are most frequeutly of the oblique-
ovate, or of the rachitic variety.
(It her Osseons Tumors and
Projections, — Pelvic deformity
may result from fractures uf the
pelvic bones, either by permanent
displacement, or by the formation
of extensive or numerous dejKJsits
of callus.
Cancerous disease of the pelvic
bones, prcxlucing tumors of some
size and consistency, may offer se-
rious obstructions to labor. Their
development is not confined to any
particular part of the pelvic structure.
PeWic ExoHlosis.
420
LABOR OBSTBUCTED BY PEL>aO DEFORMITY.
Osseous spicule sometiiues exist, especially ^t the znargiiifi of
the various pelvic articulations. The ilio-pectineal emlDence,
and the pubic crest and spine, maybe prolonged and sharp. All
of these conditions are apt, not only to impede labor, but to
create uterine laceration.
Absence of the Symphysis.— This rare form of pelvic d&.
formity, termed "split pelvis" by Litzmann, consists in con-
genital absence of the symphysis, its place being tilled by strong
fibrous bands extending between tlie opposed surfaces of the
pubic bones, or by the mttscles and connective tissue of the |>er-
ineum.
The Chief Causes of Pelvic Deformity.— The diseases which
constitute the main predisposing causes of pelvic deformity are
Bachitis, or Rickets, and Malaoosteon or Osteomalacia.
Rachitis, as we have said, is a disease of infancy, developed
most frequently during the latter half of the first year of liffe
It very rarely appears after the establishment of puberty. It
seems usually to rent on a scrofulous base, though it may be
developed through the supply of food deficient in certain ele-
ments necessary to healthy growth. The essential changes ob-
served in tlie osseous constituents consist in a deficiency of the
earthy matt-ers, and a retlundancy of the animal. But other
clmnges are also wrought, resulting in the formation of certain
new and semi-solid products. The deformities which ensue are
not confined to any particular p*»rtin!i of the Ixnly, but erexy
part is liable to suffer. A fact to be rememl^ered, as bearing cm.
the subject of pelvic deformity, is that rachitis is generally
attended by an arrest of groT^'th. The disease usually ends in
recovery, but the deformities which have been produced, though
sometimes slightly modifie<l by time, forever remain.
Malacosteon is in this country a rare disease.* While it agrees
with Rachitis in the particular of bone-eoftcning. it differs in
the fact that it is a disease of adult, rather than infantile lif&
• "The deformities of the pel via which wc have to contend with in this
country arc alnioat entiiely due to rickctH; some few are believed to l»e cozigeo'
ita!, or may result from ooxalgic distortion ; bnt cases of malacneteon, so com-
mon in some Earopcan localities^ are exceedingly rare, so niucJi so that many
of onr most experienced olwtetriciaus have never seon an example of thiAiIt>
Dr. Robt. r H.\nnis. Am. Jonr. 01»8^ vol. iv, p. 41)9.
DIAGNOSIS OF PELVIC DEFORMITY.
421
*
It is osuolly developed in the puerperal state, each succeeding
pregnancy being in some cases iitteiuled by a progressive devel-
opment of the disease. Tlie effects of the disefise may be ob-
served throughout the body, or they may be confined to individual
bonee. The pelvis and vertabrro are occaflioniilly the only parts
which suffer, especially when the disease develops in the puer-
peral state. According to Schroeiier,* the disefise is regarded as
an osteomyelitis, which, beginning in the centre of bones, ad-
Tances toward the periphery, the essential i>athological processes,
consisting in the absorption of calcareous matter, through the
Haversian canals, and the substitution of hypertrophic me-
dallary tissue for the softened osseous structures. The result is
that the bones become pliable and elastic, like rubber, and,
eventually, even of wax-like softness.
But there are other causes of pelvic deformity, among which
xnay l>e mentioned pelvic fracture witli permanent displacement
o£ all the bones; also the late establislnnpnt of pulw^rty. Until
tbeageof fourteen or fifteen years, the pelvis of the female
tiilfers in shaiw? but slightly, if at all, from that of tUo male; but
*^ soon as the girl has her first menstrual flow, the pelvis begins
**^ expand. If the appearance of menstruation is retarded to
^^« age of seventeen, eighteen or twenty, the Ix)ne8 of tlie pelvis
**^ve become firmer, and the articulations are anchylosed witliout
t*»*oper development having taken place, and without the pelvis
«Xa.riiig taken on the feminine characteristics.
IHai^nosiiit. — A positive diagnosis of |>elvic deformity can be
*^^j»ed only on a direct examination, but valuable data which
tH^int to' such a condition may be gleaned from inspection, and
|~i.e previous history of the woman. Whon tho infantile experi-
'*ices were such as usually accompany rachitis, and especially if
•*i€re ore patent physical deformities which may be referred to
i^txch causes, the case should he regarded vnih suspicion.
The history of previous labors may thn>w Home light on the
Subject, and, if there were connected with these, great difficul-
*^«6 and much suffering, we eliould sunpect [)filvic contraction as
•yijig at the bottom of it, and institute most thorough exploration.
The special appearances of the woman, unaasociated with her
Lehrbach," p. 613.
422
lABOB OBSTBUCTSD BT PELTTG DEFOBMITT.
history, may lend a strong probability to jielvic deformity. TL
are, briefly, a square Lead, pigeoD-brea£t, email stature, spinal cur-
vature, enlarged joints, and incurvation of the long bones of the
extremities.
tr^^
Exnci measurements can be made only by means of ins
ments constructed for the purpose, termed pelvimeters. Ntimer-
ous patterns have been devised, some of which are intended for
external, and others for intemal measurements, while some are
designed for either mode of use, Tlie internal dimensions are
those sought, no matter whether it be ascertained directly by
measuring the cavity, or indirectly, and less accurately, by taking
the external size of the pehds, and making allowance for the
thickness of its walls.
In nearly all forms of pelvic distortion, the conjugate diameter
is the one which is most contract^^d, and hence, the instruments
which have been devised, and the efforts which are generally
made, have for their more especial object the determination
that measurement.
14
For external use, Baudelocque's cabpers, is probably the
strument in most common use, though Schultze's is much em-
ployed- For internal use Goutonly's, Earle's and Greenhalgh's
are among the most prominent
AVliile it is only by means of such instruments that accurate
measun^ments can bfi taken, practical ends may be well served by
what has been termed manual pelvimetry. For the puipose
ascertaining the conjugate diameter of the brim, one or m
fingers are introduced, and the jKiint of the index finger ma
to touch the sacral promontoi-y, and tlie pait of the hand a
which the pubic arch rests, is marked by the thumb of the sa
hand or by the finger of the opposite one. The fingers are tl
withdi-awn, and the tlepth of introduction meaenrf^d. A s
traction from tliis of half an inch is supposed to give the r
conjugate diameter. Such measurement will be more accnrato
if (Jre^nhalgirs pelvimeter is used in the manner representt'<l
the accompanying cui
Another mode of manual measurement of the conjugate is
shown in figure 197, but it cannot be made so exact
The transverse and oblique diameters of the brim, may be a
1
INFLUENXE ON PREGNANCY.
423
proximately determined by introducing the four fingers of one
hantl and spreading them.
No special directions are required to determine the diameters
of the outlet of the x}elvi9, as they are bo immediately under
survey.
Fio. 196.
I •
0reeQhalgh*5 pelvimeter.
Inflaence of Pelvic Contraction on the Uterus During
"ffrguancy.^In the early months of pregnancy the contracted
pwTifl favors dislocation of the uterus backwards. It is held
down by the unusual projection of the sacral promontory, and a
rersiou is ultimately transfornjed into a £exiou.
434
LABOR OBSTRUCTED BY PELVIC DEFOBMITY.
In tlie latter months, the pelvic contraction, preventing di
of the lower uterine Hegnient covering the presenting party
maintains the organ in an unusually high situation, as a result
of whicht pendulous abdomen ia sometimes observed.
Fiii.197.
Manual I'elvimeteiy*
Influence of Pelvic Contraction on Fcptal Presentation
Faulty presentations nre relaiivoly frequent in contracted pelvea'
The high situation of the uterus, and its mobility, are the chief
factors in producing them.
Influence of Pelvic Contraction on Labor-pains.— Wheij!
insurmountable obstacles are encouutered by the natural forces,
the uterxis, from the vehemence of its contractions, is extremely
liable to rupture. There is also unusual danger of the organ
tearing itself from the vagina, by its excessive retraction.
i
EFFECT ON THE CHILD'b HFATl.
425
time muscular action beeoznee weak, and lingering labor may
sr^csolt from utter exhaustion.
Influenre of Pelvic Contraction on the First 8tage of
l^bor. — At the beginning of labor the head is high, and the
lower uterine segment protrudes empty through the brim. The
liquor amnii is driven downward with force, and still the os di-
lutes gradually. The membranes are quite apt to break prema-
-fc^^ely, when the ob and cervix, whicsh had been somewhat dilat-
^^^ by the bag of waters, seem again to retract. If the contrac-
-ft^^-cn is too great to allow the head to descend, the pains continue,
^^-nd no help is afforded, uterine laceration of some form,
^kfter a time, is almost certain to ensue.
Effect of Pressure on the Soft Pelric Tissues, When Con-
'action Exists.— The fcetal head is the only part which is
ible of producing injurious pressure, unless the arrest should
tend over a long period. In cxmtractexl pelves the most severe
ixijories are received at the brim. When the promontory is un-
ttilly prominent, and when there are spiculo;, or ctthor irregu-
lar pointa of pressure, tiie uterine tissues, which in the firat
stage lie l>etween the head and the brim, are often crushed and
thinned, and. at times, even perforated and torn.
Meet of the Pressure on the Child's Head.— The tumor
"*nDed on the fcetal cranium (caput succedaneum) is often large
*&<! bloody, and varies in location and form with the position
•nd character of the ci>ntracti(jn. Tlie heatl also presents local-
**d pressure marks, derived, in most cases, from the jutting
P'omonlor>'. They may be mere reddish lines, whioh soon dis-
appear, or they may be &o severe as to result in complete
wrnction of the tissues down to the periosteum. They are
j|tt»erally situated on the parietal bones.
Profn^osis.— The prognosis will, of course, depend upon the
degree of deformity present. If the diameters are but slightly
iliminished, labor may be tedious and laborious, but neither th€
Btttemal nor foettil ri;*k is greatly increased; but if the doformity
considerable, the prognosis must be relatively grave. The
iftt^rnal mortality in these cases is at least twice as great as in
inl pelves. The foetal mortality is excessive.
426 LABOB OBSTRUCTED BY FELTIC DEPORMITT.
Treatment. — Even when there is but moderate contrsotion of
any of the pelvic diameters, labor is likely to be more tedious
and painful than in connection with normal pelves.
The details of delivery in cases of pelvic deformity will be
more fully discnssed when we come to consider the varioos
operations that may be required. When the fact of pelvic
deformity so great as to require the more formidable and
destructive op>erations to effect delivery, is known to the physi-
cian early in gestation, there are certain questions which will
arise, and which should be satisfactorily settled, with regard to
the induction of abortion, or of premature labor.
Induction of Abortion in Extreme Deformity. When
the contraction is so excessive that a viable child, of average size,
cannot be safely delivered, early abortion should be indnced.
The foetal life, in such a case, would not weigh a grain in the
balance, since the possibility of preserving it is out of thequos-
tion, and we are left to act in the interest of the mother only.
Nothing can be gained from delay, and hence the dictates of
wisdom would lead us to the artificial interruption of pregnancy,
as soon after it becomes manifest as may be possible. There is
no amount of deformity which can prevent the successful adop-
tion of some of the means for its accomplishment placed at our
disposal.
The Induction of Premature Labor in Deformed Pelreis.
"The induction of premature labor," says Playfair,* '*as a
means of avoiding the risks of delivery at term, and of possibly
saving the life of the chiltl, must now be stndieiL The estal>-
lished rule in this country (England) ia. that in all cases of pel-
vic dofornnty, the existence of which has been ascertained eitlier
by the experieucp of former lal)or8, or by accurate examination
of the pelvis, labor should be induced previous to the full pe-
riod, so that the smaller and more compressible hcnd of the
premature fcetus may pass, where that of the fcetus at term could
not. The gain is a double one, partly the lessened risk to the
mother, and iKvrtly the chance of saving the child's life.
The practice is so thoroughly recognized as a conservative
and judicious one, that it might be deemed unnecessary to arguo
» " System of Midwifery," Am. Ed,, 1880, p. 391.
TBEATMENT.
427
i
in its faTor, were it not that some most eminent authorities have
of late years tried to show that it is better and safer to the
mother to have the labor come on at term, and that the risk
to the child is so great in artificially induced labor as to
lead to the conclusion that the operation should be altogether
abandoned, except, perhaps, in the extreme distortion in which
the Csesarean section might otherwise be necetwary. Prominent
among those who hold these views are Spiegelberg and Litzmann,
and they have been supported, in a modified form, by Matthews
Duncan. Spiegelberg* tries to show, by a collection of cases,
from various sources, that the results of induced labor in c<m-
tracted pelvis are much more unfavorable than when the cases
are left to nature; that in the latter the mortality of the mothers
is 6.6 percent, and of the children 28.7 per cent, whereas in the
former the maternal deaths are 15 per cent., and the infantile
66.9 per cent Litzmann arrives at not very dissimilar results
namely 6.9 per cent of the mothers, and 20.3 per cent of the
children in contracted pelvis at term, and 147 i>er cent of the
mothers, and 55.8 per cent of the children, in artificially induced
premature labor,
"If these statistics were reliable, inasmuch as they show a
very decided risk to the mother, there might be great force in
the argument that it would be better to leave the cases to run
bechance of delivery at term. It is, however, very questiona-
ble whether they can be taken, in themselves, as being sufficient
to settle the question. The fallacy of determining such |)ointB
by a mass of heterogeneous cases, collected together without a
lareful nifting of their histories, has over and over ngain been
pointed out; and it would be easy enough to meet them by an
^Ual catalogue of cases in which the maternal mortality is al-
Diost nil. The results of the practice of many autliorities are
pVRn m Churchill's works, where we find, for example, that out
*rf 46 cases of Merriman's, not one proved fatal. The same for-
tttnate result happened in 62 ca-ses of Ramsbotham's. His con-
"•lusioD is, that 'there is undoubtedly some risk incurred by the
ttiother. but not more than by accidental premature labor,' and
this conclusion, as regards the mother, is that which has long
•go been arrived at by the majority of British obstetricians, who
A«h.f. Gyn.,"b. i. 8. 1.
428 LABOR 0B8TBUCTED BY PELVIC DEFOBMITT.
nntloubtedly have more experience of the operation than those of
any other nation. AVith regard to the child, even if the German
Btatistics be taken as reliable, they would hardly be accepted as
contra indicating the operation, inasmuch as it is intended
to save the mother from the dangers of the more serious
labor at term, and, in many cases, to give at least a chance to
the chikl, whose life would otherwise be entirely sacrificed The
result, moreover, must depend to a great extent on the method
of operation adopted, for many of the plans of inducing lalii>r
recommended, are certainly, in themselves, not devoid of dan-
ger, both to the mother and the child. It may, I think, be ad-
mitted, as Duncan contends,* that the operation has l)een more
often |)erformed than is absolutely necessary, and that the
higher degrees of pelvic contraction are much more uncommon
than has been supposed to be the case. That is a very valid
reason for insisting on a careful and accurate diagnosis, but not
for rejecting an operation which has so long Iweu an estiiblished
and favorite resource." The ideas of American obstetricians
do not materially differ.
Time for Inducing Prematnre Labor.— The operation once
decided upon, the period at which premature lalxir should be
induced is a matter of the greatest importance. The tables
which have been prepared to ilirect the physician in fixing upon
the suitable time, while theoretically clear and precise, are of
less value than we might expect them to be, because of the ex-
ceeding difficulty in estimating with accuracy the actual amount
of contraction which exists in diflerent caae& The table pre-
I)are<l by Kiwisch, which appears in various text-booka on ob.
stetrics. is as valuable as any:
]ncli<*t^.
Liues.
^™
When the Sucro-Pubic Diameter
is % and
6 or
7, indace labor at
aotii
WMk.
u
It
il
2, "
8 or
9,r
i(
il
3l8b
*•
H
u
"
la or
n.
H
11
3ad
11
II
i(
11
3, "
It
t(
S3d
»(
II
u
44
3, "
t
^
it
t(
XkX
«i
U
u
II
3, '
2 or
3.
II
"
34 th
t*
u
H
U
3, *
4 or
5.
11
It
35th
M
II
M
II
3, "
5 or
6r
11
II
3etfa
U
• " Edin, Med, Jotir.," July, 1873, p. 339.
mm
TBEATBCIO^T.
429
N
When ezpnisive action has been evoked, the treatment Bhould
be like that of labor spontaneously begun. In most instances
the natural forces will be found adequate to the emergency;
but in others the forceps, or turning, may be called for. As
the result of most deliberate and judicious treatment, these
cases may, in a large percentage of cases, be carried onward to
a conclusion favorable alike to mother and child.
When the conjugate of the brim is below two and three*
iourths inches, the chances of saving the child by premature la-
lior are too slight to be considered. Barnes has proposed in some
^uues to perform version in premature labor, especially if the
3)elvis measures less than three inches.
When is Interference Advisable?— When labor has once set
in, it becomes necessary, after a time, to decide upon the proper
JEXoment to adopt operative measures for the woman's relief. In
"fcJie minor degrees of pelvic deformity, it is always proper to give
*5atnre a fair opportunity; but, if the uterine efforts are ex-
^*^mely violent, we should be careful not to allow the case to
I>rogre8s to the point of exhaustion. When the head is small,
or the cranial bones unusually pliable, it sometimes happens,
^"ven in unpromising cases, that the head becomes so molded
^« "to pass with perfect safety to both motlier and child.
Cases Wherein Delivery of a Living Child is Possible.—
-■■II this category we mean to include flattened pelves with a con-
l^^&te of three inches and over, and justo-minor pelves with a
^^njugate of over three and a third inches. Below these figures,
wlivery of living children is rarely, if ever, possible. Our re-
^OTirces are here premature labor, craniotomy, forceps, and xer-
feion. Dohm collected some valuable statistics regarding the
Wbnent by induction of premature labor, in pelves presenting
^e above mentioned degrees of contraction, which give a
wTorable showing for the operation
In labor at full term the membranes should be most tenderly
cared for, to prevent rupture prior to full dilntation of the os
ntfiri. Obliquities of the uterus should bo considered, and poe-
taral and other treatment to overcome them resorted to. The
pains should be stimulated, when weak, and subduecJ when too
strong. When, after escape of the liquor amnii, and close of
the first stage, the head still refuses to engage the pelvic brim
430
LABOR OBSTRUCTED BY PELVIC DEFORMITT.
the disproportion may be assumed to be considerable. The nse
of the forceps un a head which is too large to become engageil in
the pelvic brim is hazardous in even the most skillfal hands, and
to be adopted with the utmost caution.* We should give the
natural efforts a fair opportunity, and if the head finally becomes
£xed at the brim, the forceps may be employed with every pros-
pect of success. But if nature is unable to accomplish fixation
within a reasonable time, of which the physician must be his
own judge, other measures should be at once adopteiL
Before proceeding to version we should be sure that the child
is living, l:>ecause tlie operation is to be made in its Ix^hulf. If it
be found dead, perforation is the suitable treatment Version is
indicated only when the fcetal hciart is pulsating with vigor, and
the pelvis measures between two and three-quarters and three
and a half inches in the conjugate, with progressively increasing
dimensions toward the outlet, and with an ample transverse di-
Bmeter. The advantages derivable from turning in such coses,
have been set forth by Sir Jas. Simpson, and his views have been
Bustained by others.
Fio. 198. Flo. 199.
Chooge of cephalic form, (Vom molding, in difficult lifcad-tast
It is but the revival of an old operation, but with its lim-
its clearly defined, and its advantages perspicuously set forth.
Simpson shows that the head viewed in transverse seotiun,
IB oone-shaped, its narrowest portion being at the base, rep-
resented by the bi-temporal diameter, and its widest part
above, represented by the bi-parietal diameter; the variation
*Dr. U. WUIiams has collected 119 canes reported since 1958, where the for*
eepB were applied to the head above the brim, and finds that nearly Ibrty per
cent, of the mothere, and over sixty per cent.of the children, pctrished.
■tt
TREATMENT.
431
in diameters being from one-half to two-thirds of on inch.
When the vertex presents, the broader part is in advance,
and if the pelvic diameters are shortened, much greater force
and much longer time will be required to drive the head
through, than in cases of pelvic presentation, in which the
leaser diameters descend in advance. Indeed, lie attempts to
show that, in some cases, nature may utterly fail to drive the
head through a contracted brim, and yet delivery be safely
acoomplished by version, with greater ease and less danger than
fa> the forceps.
Other advocates of the operation have evidently shown, by
:#izrther elucidation of the subject and the clinical application of
these theories, that it is possible
to deliver a living child by turn-
ing, through a pelvis contra*!ted
beyond the ix)int which would
I>ermit a living child to be ex-
tracted by the forceps. Goodell,
and some others, assure us that
a living child may be delivered
by version through a pelvis with
a conjugate diameter of two and
three-tjuarter inches. Other ol>-
stetricians of extensive experi-
ence, as, for exjimple. Barnes,
set the limits of the 4>i>eration at
*»«^ , ,. , , from three and one-fourth inches
■■-ne transverae di&m«tcr« of the
OB viewed from above. upwards.
>m a consideration of all the arguments advanced on both
^^es of the question, and the clinical cases reported, it appears
^^ be an established fact, that delivery of a living child may be
^^oompliflhed in some cases of pelvic contraction, wherein both
Mature and the forceps have proved inadequate to the task.
We should not lose sight of another mlvantnge to ho derived
from turning in nnyh cases, namely, that pressure on the head
it the brim, in the supra-pubic space, may be exercised by on
ttBifitant, and the extraction thereby greatly facilitated.
Ooodell and others place strong emphasis on the great advan-
tage of antero-posterior oscillatory niovenients given the fcetal
432
LABOR OBSTBrCTED BY PELVIC DEFORMITY.
body while trftotion is being put upon the legs.* By virtne of
it, a powerful leverage is obtained, wliicb must afford decided aid
in getting the head past the narrow strait It is mainly by
virtue of this that the extensive molding of the head repre-
sented in figure 201 is effecte<L
Fui. 'JfH.
Molding of tfae head ftt the brim lu diflieuU inuscsof extraction After version.
When the natural efforts are sufhcient, after due molding of
the head to force it into the pelvic cavity, further progress may
be obstructed, or the pains may become weak, either condition
bringing into requisition the forcejis.
It is manifest that perforation will be required when, aftor ver-
sion, we are unable to deliver the head, or when, in unchanged
presentations, the heJid cannot be delivered from the brim, the
the cavity, or the outlet, by means of the forceps.
rases in which a Full-term Living Child Cannot be Born—
but ilelivcrtj fh rotiffh the naiurnl passages furnishes the fx'^f chance
for ihe mother. We have atour command in this class of cases but
two operations, namely, craniotomy, and the induction of pre-
mature labc»r. The latter, of coTirse, cannot be performed, except
in those cases wherein the condition of the peh'is is recognized
for some time before the close of utero-gestation, and, hence, is
limiteti to only a certain proportion of the cases which we are
called to treat
The question of inducing premature labor has been elsewhere
considered, and does not require to be taken up here. Accord-
ingly we shall discuss the treatment of such cases only, au have
gone on to the close of normal pregnancy. " If labor comes on
*The wonderfal tensile strength of the neck is surprising. Dr. Ooodetl
(Am. Jnnr. OhA., vol. viii, p. 193), says that in one case he applied a trHctioa
forci? of 100 lbs. and yet il**Iiv*!rp(l u livinK cliild.
mbBi
TREATMENT.
433
at fall term," says Losk,* '* before craniotomy is proceeded to,
an attempt should be mado to gauge tlie degree of disproportion
between the head and the pelvic brim, for not only is it among
the bare possibilities that a living child may be expelled through
a pelvis measuring less than three inches, but it is to be borne
in mind that iu pelvic mensuration even the most expert may
make errors of a quarter of an inch.'* ♦ ♦ ♦ "Craniotomy
should not be performed 8o loug as the hope exists of saving the
life of the child" An approximate estimate of the size of the
bead can be made by palpation of the hypogastrium, conjoined
^th the vaginal touch. We may learn still more by passing the
iiatf-hand into the vagina, which, in such cases, is a perfectly
jQstitiable procedure.
Nor should we in this connection forget that in some forms of
J>elvic contraction, one lateral half of the brim is more capacious
^iian the other, in which case it may be possible to turn the ocoi-
P>iit» in head-first cases, to that aide, or, failing in such attempts,
'^^^ may, by performing version, secure a favorable adjustment
^^f the part to the anomalous outline of the brim.
Jn transverse presentation, version by the feet shoixld be un-
^^irtaken, whether there appears to be any possibility of saving
^*i^ child's life or not, and if extraction cannot be accompllBhed,
^^ ^ after-coming head can be perforated.
C^'ases Wherein Extraction Through the Natural Passages
K^pears to be Impossible.— In cases of extreme pelvic con-
ction, the natural forces are incapable of effecting delivery,
*icl art offers but little hope to either mother or child.
AVhen the degree of pelvic cnntraotinn is known in the early
onths of pregnancy, we are perfectly justifiable in producing
^^ abortion. If left till a late period in gestation, the only
I^^rations open to our election, are the Cresarean section and
***-E>aro-elytrotomy. We should not omit to say, however, that
.** a few instances, craniotomy has been successfully performed
^^ pelves with a conjugate of only one and a half inches. Dr.
-*^^aTy collected seventy cases of craniotomy in pelves measuring
^^o and a half inches, or under, but seven of them had finally
*^ V>e terminated by Csesarean section. Out of the whole num-
^», forty-three survived. Notwithstanding these comparatively
* ^8ei«oc« and Art of Midwifery," p. 464.
4M
LABOR OBSTBtrCTED BY FCETAL ANOMALIE&
favorable results, we believe that the operator of limited experi-
ence and skill} will be more likely to obtain favorable resulta
from gaetro-hysterotomy or laparo-elytrotomy, in such caseSy
than from craniotomy.
We should make a distinctioD between oases, by taking into
account the transverse measurement, since craniotomy can be
performed with much greater ease and safety in pelves with an
ample transverse diameter, than in those equably contracted.
CHAPTER XII
Labor Rendered Diflflciiit or Dangerous by Some
Unusual Condition of the Fcetus,
or its Appendages.
Plural Pre^ancy.— "In general, as we all know, women
present UH with a single child only; sometimes, however, they
favor US with two, tliree, four or five at a birth, and their gener-
ous fecundity may even exceed this number. Sennert relates
the case of a lady, who produced at once as many as nine chil-
dren, nor does this appear to be wholly incredible; and Ambrose
Par6 tells us of another lady, a co-rival of the former, I pre-
sume, who gave to our species no fewer than twenty children, I
do not say at a single birth, but in two confinements." *
Twins are produced in one case in eighty or ninety; triplets
in one case in seven thousand, and quadruplets in one case out
of many thousands. There are but a comparatively few instan-
ces on reoortl of five children at a single birth. The sex of
twins is divided, i. e. one boy and one girl, in about one-third of
all cases. Both fcetnses are boys in about thirty-five per oeni
of cases, and girls in about thirty per cent
Post-mortem examinations have shown that twin pregnancy
may result from impregnation of two ova from the same, or dif-
• BLrNDELL, Lectures on Midwifery, p. 364.
J
PLimAL PREONANCT.
435
ferent, Graafian follicles, or may originate from a single ovum
with double vitelluB. The ova may not only come from distinct
foUioles, bat also from different ovaries. Then, too, it is quite
probable that by snper-fpcundntion, or even by snper-fcetation,
twin pregnancy may be produced.
Snper-fecondation and super-foetation are defined by Scan-
aoni: the former being where a second impregnation succeeds
the first, after an interval of varying duration, but before the
formation of the decidua refiexa about the first ovum and tha
latter, where a second impregnation takes place after the first
ovum becomes completely inclosed by that membrane.
Arrangement of the Membranes in Plnral Pregnancy.—
When twins are developed from two ova, each foetus has its own
chorion and amnion, but the two may have a common decidua,
and the placentte be united by their borders. If the points of
original implantation be widely separate, the decidua refiexa of
each may be distinct, and the placenta as well. When the devel-
opment is from a single ovum, the placentie may be fused into
one mass, or there may be but a single organ with a bifurcated
cord. The decidua and chorion are common to both, and in
some cases the amnion as well Twins from the same ovum are
always of the same sex. In triplets it is common to find one
ciiild derived from an indei>endent ovum, and two from a single
one.
Conditions Attending Intra-nterine Development.— Twins
at birth often present appearances differing greatly both as to
eize and other evidences of development In other cases early
death of one embryo takes place, but the dead and the living re-
main together till the full period of utero-gestation has been
completed. As stated in another chapter, the dead foetus is
sometimes expelled, and without disturbing the uterine relations
of its mate. ' Very rarely, when lx)tti children are living, but
their rate of development has been different, the one which first
reaches maturity is expelled, and the other is retamed until ita
development has become complete. Just what bearing these
facte have up^m the question of super-foetation or super-fecun-
dation, we will leave for others to show.
L&bor in Plural Pregnancy.— The expulsion of the first foe-
436
LABOR OB8TBCCTED BY FCETAL ANOIIALIES.
his is generally attended with some unusual difficulty, the sec-
ond child more or less obstructing the usual mechanism of par-
turition. This is especially true when the first child presents
by the breech, since there is not only delay in the expansion of
the OS uteri, but in descent of tlie trunk, while the head delivery,
which in single breech cases is often most difficult, is here ono-
sually so, as little aid can be afftirded by the uterus.
Fio. 302.
Twins in Dt«ro.
Management ol' the First Birth.— But few special directions
are required for the management of the first birth. The cord
should be tied in two places and severed between the ligaturea,
so as to avoid hemorrhage in case there prove to be vascular
connection between the two placentfe. We have then to awaits
renewal of uterine action, and the rlescent and expulsion of tb^i"^
AM
J
PLrRAL PREONANCr.
437
second child should be managed much like a case of single
birtL
Delay After Birth of First Child. - In general, there
is a brief interval of rest between the expulsion of the tirst
child, and the renewal of uterine action for the expul-
eioa of the second. Ordinarily, this interval does not ex-
tend beyond a period of fifteen or twenty minutes, but in
some cases, hours, or even days intervene. In caae of un-
usaal delay, the plan of treatment has not yet become uni-
form in either theory or practice. Some regard any interfere
ejice whatever, having for its object the delivery of the second
<=Jail<L as "meddlesome midwifery,'* and to be discountenanced.
C>tliers recommend the physician, after the usual delay of fifteen
**»■ twent>' minutes, to rupture tJie membranes of the second
*^fcild. if the presentation is natural, and stimulate the uterus to
*^"^xxewed activity. Later, if necessary tt) expedite delivery, the
^^<1 of the forceps is suggested.
In case of transverse presentation, or of face presentation
^^-^i^erein rectification is deemed advisable, the necessary opera-
*^^=>xi, it is agreed, should be performed without unnecessary
^^lay.
If the presentation is either pelvic or vertex, the attendant
*^^^^d not go to either extreme, but give the uterus a reasonable
^*-^xie in which to recuperate its energies, in a measure, so that
*-^ Bpontaneous action does not ensue, the powers of the organ
^^*^ay be aroused by suitablo stimulation. If the membranes are
'^^ximptured, they may lM!brt»ken after an interval of say an hour,
^'"ten the case should be left to nature in the exf>ectation that
'^^■Uvery will s<xni Im? undertaken. Among the remedies suitable
^^^ the case at such a juncture of affairs, we may refer to those
Ki>'en under the head of uterine inertia. Slight stimulation of
****e womb may be attempted by careful manipulation of the cer-
^>^, and kneading of the abdomen. If, despite of those meas-
^^^^ expideive action is not set up, the forceps may be applied,
•'^^d delivery carefully effected, under the strict precautions
**>**iitioned in the observatitms on the treatment of uterine in-
^*tift. Version is here preferred by some, inasmuch as the parts
■*«ye been so well dilated by the passage of the first child, that
*tie conditions for success are remarkably auspicious. If the
438
LABOR OBSTRUCTED BY F(ETAL ANOMALIES.
seoond child present by the breech, and there appear to be an]
necessity for urging the delivery, the usual coBtom may be ig-»
nored, and the feet brought down. ^H
Locked Twins, — Dr. Barnes and others have called attention
to a complication of plural labor, which, while rare, should not
be disregarded. This consists in locking of the foetuses. When
both children present by the vertex, both heads sometimes ap-
pear simultaneously at the brim ; but they cannot be contained
Fio. '203.
2^
* Heml-toi'kiiig, (Burnea.l.
the pelvis at the same time, uuless the latter is unusually capa-
cious, in which case a very serious complication will be formerL
An example of this kind is given by Reimonn,* in which the
head of the first child was delivered with the forceps, and then
that of the second, those being succeeded first by the trunk of
the former, and then by that of the hitter. When both heads
are discovered at the brim, one should be pushed out of the way,
and the other, if necessary, secured by applying the forceps^
When one foetus presents by the breech, and the other by
head, a similar, and more common complication may arise*
•"Arch, of Gynaek," 1871.
LABOB IN PLDBAL PBEONAHCY.
439
showB in fignre 204. This conBtitntes a formidable obetrao-
tioii, aud, in a pelvis of ordinary size, is abBolutely insurmoimt-
able.
In sacli caaea it ia rarely possible to disengage the heads,
though thia should be the first endeavor. It may be occasion-
Fio. 204.
H ('ad-locking, ^TlameB).
ally possible to draw tlie second fcetus pa^t the first by means
of the forceps. Failing in such an attempt, the upper head may
be perforated, and then delivered, or it may be decapitated and
left in utero until after delivery of the lower head.
Double MoilHterH.— When the bodies of two fcetuses are par-
tially fused together, the management of delivery becomes a
440
LABOR OBSTRUCTED BT F<ETAL ANOKAXJES.
most respoQBible and difficult undertaking. Nature ia generally
equal to the emergency, as will be seen when we observe tbat
ont of thirty-one collected cases, twenty were spontaneously and
easily terminated. These reenlts are partially explainecl by the
fact that, in quite a number of such cases, labor is premature,
while in others, the fcctuses arc dead and somewhatdeooraposed.
The Mechanism of Delivery.— The mechanism of delivery
will vary acfordiug to the character of the anomaly, but the chief
Fio. 205.
Double Monster.
difficulty is usually in the delivery of the heads. In head last
cases it is of prima imjMjrtance to carry the bodies well forward
DOUBLE HOKBTEB.
441
the maternal abilouien, in rational attempts at delivery of
lite lipttdft, so that oue may enter in advance of the other.
1b head first cases, expulsion is commonly effected by the bo-
Fig. 206.
Double Monster Uniled Anteriorly.
dice performing a movement somewhat like that of Bpontane-
otifi evolution in transverse cases. The head and body of one
fcetns passes, and then ttie pelvis of the second in advance of the
head.
When delivery of living children is impossible, the body of
one most 1>© mutilntetl to make room for the escape of the other.
The result U* the motliors do(»s not appear to be so disastrouB
442
LABOK OBSTRUCTED BY F(ETAL ANOMALIES.
live
as might be expected Their dangers, however, are oonsidoi
biy augmented.
Intra-Utcrine Hydrocephalus.— Under this title we mean to
iucludo all tlio dropsies of the head, and all the extensive effii-
Bious or in^ltrationii of serum within or without the cranium;
but iuftflmuch as the latter are very rarely sufiiciently extensive
to constitute an obstacle to delivery, we shall couEne our obs<
vations chiefly to the internal variety.
HydrocephaluH iiitenius is a disease of rare occurrence.
4Ji,555 lubors, Madame Lachapelle observe<l but fifteen cases.
It must bo regardetl as a m(jst serious complication of la1x)r^
Out ttf Kevonty-fniir c^iwes collected by Dr. Keiller, of £di^^ri
bmgh, sixteen, ur a)x)ut twenty-one i>er cent were accompanie^^^
by uterine rupture. Nor is this the only danger to which the
woman is exposed. The head, wlien excessively developed,
stitutes an insuperabl*'. okstjiclo to delivery, the ut«»ru8 afi
a time becomes exhausted, and there supervene the dangers
tendant on uterine inertia, not least among which, in neglects
cust^H, is that of long-continued pressure of the soft peb
tissues.
Diagnosis. Phiyfnir says that " the diagnosis of intra-uterin?
hydrocephnlus is by ni> means so easy as the description in ol
stetric works would lead us to l^elieve." • ♦ ♦ " As a mal
of fact, the true natiu'e of the case is comparatively rarely i\\
c<»vered l^efore delivery; thus Chaussier found that in more thi
one-half of the cases ho collected^ an erroneous Sdiagnosia hi
been made."
Whenever the labor is difficult, without other appai-ent cam
thau tlie size of the fcetal head, our suspiciona should
aroused. These will be strengthened by separation of the ]iai
etal bones at the sagittal suture. A positive diagnosis caum
be made without introducing the hand into the vagina, and the
fingers into the womb; hence it should be regarded as not only
the privilege, but the duty, of the physician, in suspected cases,
—in fact in any case where the diagnosis cannot otherwise
be clearly established, — t<i thus pr*>eeed.
"The unusual size and dimensions of the head might be thi
ascertained," says Simpson* **but one source of fallacy is to be
^ .Select«ri, "Obrtat WotVii," p. 3R.5.
IXTBA-UTERINE HYDROCEPHALUS.
443
guanled agaiiibtf imuiely, that the sutures and fontanellds Are
not, as was usually described, always preternaturnily open and
'enlarged in hydrocephalic cases; foi* the crauinl bones are in
some instances, where the internal etFusion is groat, so largely
and abnormally developed ns to destroy this supposed pathog-
nomonic sign, Hn<i to form an almost complete osseous covering
£or the enlarged head/*
Chaussier found, as before stated, that in more than one-half
of the cases he collected an erroneous diagnosis had l)een made.*
In seventy-four cases collected by Dr. Thomas Keith, uterine
rupture *iccurreti sixtet*n times.
Fio. 2117.
Flydroct'phulif h«Kl at tho brim.
Head-last Casea. — Other than head |)resent«tion8 ai'e more
common in connection with hydrocephalus than any other con-
dition of the foetus, Ac^'ording to Scauzoni, out of 152 cases, 30
presented by some other part than the head In such a presen-
tation the diflicultieB of the case will not l>e realizeti until the
trunk has passed, and the head coraes to engage the superior
strait Tlie extraordinary cranial dimensions are recognized,
but the precise character of the complication ^vill not easily be
determined. The finger cannot be made to reach far enough to
444
LABOR 0B8TBDCTED BY FfETAL ANOMAIIES.
feel the peculiar features of hydrocephalus. However, if by
conjoint manipulation, — one hand on the abdomen and the fin-
gers of the other in the vagina, — the remarkable size of the head
ia made out, and further, if the body of the foetus presents the
shriveled appearance so generally observed in connection with
intra-uterine hydrocephalus, diagnosis may be made with eome
degree of confidence.
Fi*i 5no
Hydrocephalic hwul— front view.
Treatment. — The treatment in any presentation is to tap the
head by means of an aspirat<jr needle or small trocar, after
which dt^ivery may 1>g left to the natural efforts; it may be
termiuateil with the forceps or the cephalotribe; or version may
be performed as recommended by Schroeder. We do not recoil
from such an operation in cases like these, as we would under
other circumstances, inasmuch as hydrocephalic children rarely
live.
When the pelvic extremity presents, the head should be
foratetl behind the ear, a thing generally, but not invariably,
accomplished without much difficulty. Tamier relates a case
in which he divided the vertebral column with a bistoury, and
iiitroduce<l an elastic male catheter into the vertebral cunal,
through which he relieved the cranial distension.
.rol^
Hydrothorax. — This is a rare complication of delivery. It
is indicated by enlargement of the thorax, widening of the inter-
oostal spaces, and fluctuation therein. If distension is great
m
Fio.'joa
ASCITES.
euongh to prevent delivery, paracentesis thoracis must be per-
formed.
AHcites, and Tesical Distension. — Ascites is more frequent
Oian hydrothorax. It gives rise to abdominal distension and
fiuctoation. Descent is accomplished, and a part of the trunk is
ipelled, when labor is arrested by tlie presence of a large, soft.
liuctuating tumor, which
proves to be the distended ab-
domen. Tapping with an as-
pirator needle is the form of
treatment to be adopted.
Vesiciil distension cah rare-
ly be differentiated from as-
cites in an undelivered foetus.
If the pelvic extremity is the
presenting part, it may Ije
found practicable to pass a
small rubber catlieter, and
thus be enabled to distinguish
tho one condition from the
other. Otherwise the treat-
ment recommended for asci-
tes would here be suitable.
Other Abnormalities of
the Feet us, —Foetal tumors of
various parts, such as spina-
^^ode of perfontiDg the head in pelvic bifida, liydroencephalocele, or
dydro rachitis, as well as tu-
tors of the liver, spleen and kidneys, may obstruct laVwir, but
^^y are rarely large enough to do so. When their contents are
"^itl they should be drawn off^ if necessary; and in the case of
^^lid growths, evisceration may be required.
Other Deformities.— Other deformities of the foetus, such as
tlioee presented by theanencophalus, acephalus, and acrania, as
»ell as defective development of the thorax or abdominal parie-
bto, with protrusion of the viscera, are rarely capable of proving
ohstmctive to labor, but their anomalous features may render
diagnosis difficult, and often im()ossible.
LABOR 0B8TBUCTED BT F(ETAL ANOMALIES.
Large Feetuses. — While the nverage weight of the fcBtns at
birth isalxmt seveif ami a half ixnin<l6, it is often considerably
exceedetL What adds to the difficulties of lalx*r in such cases,
is the strong tendency of large children t<» unusual cranial firm-
ness and ussitication. The same general principles must control
Fio.210. the treatment, which are set
forth in connection with
pelvic contraction. If na-
ture is unable to complete
the delivery, on account of
undue size of tlie fietal
head, the forceps "wiD usu-
ally,—we may say, nearly
always, —be adequate to the
emergency. In rare cases
perforation will be requir-
ed.
Effect of Larffe Trunk
on the Profirress of labor.
— IrVhen the trunk of the
child is unusually large, if
delay occurs, it is nearly always in connection with the expulsion
of the shoulders. The delay at that point may be so prolonged
Fig. 211.
Dr. M. M. Walker's vixne ofsMTania-
truiit \ lew.
Dr. M. M. Walker's isae of Acrania — lateral view.
Bs to sacrifice foetal life. In a few recorded cases it has
nORRAL DISPLACEMENT OV AliM.
447
rcrana utterly imfx^ssible to extract the trunk without e^nscer-
iititui. (\)nsiderable delay is not very unusual. The hea<I jiuss-
e«, nnd tlien the uterus enjoys a season of re|K>Be. Meauwliile
foetal resj»inition is impossible, and the plaeentii, ctwin^ to uter-
ine eonilensatidii. may be separated, and the child fail tc» re-
ceive ite neceBSiiry supply of oxygen. It is plain that such a
oouditinit cjinnot long prevail without destroying fcetal life.
A woman was recently eoufuied by tlie author with her fourth
child. The three former children were ail still-born, and her
lue^lioul nttendajit, a man of skill and exj>erieni'e, informed her
that the cause of the stillness wns in eacli case long retention of
the trunk after expulsion of the heml. In the fourth labor a
like Cf)mplieati*)n arose, and only with the ^eatestdifllciilty were
the shuuhlers extracted iu time to save the life of tlie child, after
protracted resuscitatorj^ efforts.
T n*at III ell t.— Efforts at shoulder extraction, are., in such cases,
nindi* under most unfavorable conditions. The pelvic outlet is
usually Ao well tilled that the fingers cannot reach the axillu-S
while traction on the head is a dangerous procedure. The first
efforts should l>e to stiniulnte uti^rine contraction by abdominal
friction, and slight traction on the fot'tal head. These are usually
Fj<j. 21*2. sullicient. Should they fail, stronger traction
may be mach* on the he^id, but not to exceed a
few jHrnnds, while fi»rcible. but careful, alxlom-
inal pressure should be exerted by an assistant.
Hy such combined endeavors, success will nearly
always l)e achieveil. We should not omit U> say,
however, that rotation of the bis-acromial diam-
eter intf> the conjugate of the outlet, is here a
real necessity, and it may be favonnl at first by
rotary pressure of the fingers upon the shoul-
ders, BJid subsequently, by suitable ti'actlon with
the fingers in the axill». The blunt hook may
be of service in some cases.
Dorsal Displacement of the Arm.— In these
really difiicult cases the arm is applied to the
side of the head so that its bulk is added k> the
bi-parietal diameter, while the forearm is flexed at the elbow
and Uie hand lies behind the occiput
Ilur«U flixpliu'e'
Bi«nt of the Ann.
448
LABOR OB9TRU0TKD BY FffiTAL ANOMALIES
It is to be treated by hooking the fingers into the bend of the
elbow, and poshing the arm fomrard until it is finally made to
sweep over the chest
CHAPTER Xm.
Labor Rendered Diflicult or Dangeroas by Some
Unusual Condition of the Foetus or its
Appendages.— (Continued. )
UnaTOidabln Hemorrhage, Placenta Previa.— In order
that one may obtain a just conception of what is signified by
the term " unavoidable hemorrhage," it is essential tiiat he have
a lucid idea of the anatomical and physiological factors involved.
An exhaustive exposition of these is not here designed, and the
facts will be as concisely stated as clearness will allow.
In pregnancy as it ordinarily exists, the fecundateil ovum
upon entering the uterine cavity, lodges upon one of the shelvea
formed by the tumefied aud rugose mua)us membrane, in the
superior portion of the uterine cavity, and at this |X)int^ forms
its attachments. Development here pnweetls to full maturity,
and as the os uteri expands in parturition, and the foetus de-
scends, the placenta, because of its favorable situation, suffers
no necessary separation until after expulsion of the child, and
the consequent termination of its functional activity. In other
oases, happily few in number, the formative processes pursue an
anomalous course, ultimating in great suffering and periL The
little egg, heavy with possibilities, e8Ca|}ea the physiological
prehensile forces of the superior portion of the uterine cavity,
and sinks by its own weight to a lower i>oint, where it lodges,
and soon contracts its placental relations. As fcetal supplies
are all carried through the utero-placental circulation, a consid-
erable basis of supply is established on the lower segment of
the uterus. The relative proportions of the part are augmented.
^i^ito^l
isa
PLACENTA PRiEVU.
449
£rom both physiological and mechanical canses, small vessels
Ijecommg blood channels of remarkable size. The presenting
2>art, usually the vertex, rests down upon this, antl, when lalK)r
l^egins, and expansion of the os uteri sets in, there is more or
lees disruption of vascular relations. The placenta, an organ of
■^e utmost vascularity, occupies the lower uterine segment, and
<30Ter8 the internal os uteri, and as the maternal sinuses have been
jf ormed over and about the closed os, the very commencement of
^dilatation must begin the process of placental separation. Foetal
^expulsion cannot occur witliout dilatation of the os uteri, and the
«z>8 uteri cannot expand without rupturing blood vessels, and giv-
ing rise to hemorrhage, — hence the name — unavoidable hem-
^=>rrhage.
'''°*^'^- Varieties-— The placenta, as
a rule, is not situated precisely
over the centre of the lower seg-
ment of the uterus, but rather,
more or less to one side, — on the
right, or the left, anteriorly or
posteriorly. The nomenclature
of placenta prsevia correspond-
ingly varies. Thus we have 1.
Lateral placenta; 2. Latero-cer-
vtcftl placenta; and 3. Cervioo-
orifical, or Central placenta.
For practical purposes we may
make but two classes, the first
being termed partial, marginal
or incompMc, and the second
being known as iotalt central or
complete, placenta praevia.
Frequency.— Placenta pnevia
Varieties n{ placental attarhmenta. 18 a complication of pregnancy
£^.ftind:ji »^»^nt«;/).2>. lateral ^^^1 parturition which is en-
plAcmU; A. R. B. F. »*?at of cervico- countered oncB in about every
•rififal. or central pHc^uui. fi^e hundred cases.
Canftefl of the Hemorrhage. — The causes which are pro-
posed to account for the excessive hemorrhage in connection
450
LABOK OBSTRrCTED BY F(ETAL AX0MALIE8.
with placenta prpevia, have been matters of considerable dispute
The earlier, anil, usually, light losses, which are in intjst cnsen
sufiered, have been regarded by some as accidental. This may
l>e true in a small i>erceutnge of cases, but it can hardly be ac-
credited concerning the phenomenon in general The immediate
causes of the bleeding, which unavoidably takes place in pla-
centa prsBvia, were shadowe<l forth in tlie introductory obsen-a-
tions, but here we may give them form and shape. It is sal
that during the first five months of utero-gestation, deveh
mental energj*^ is exerted more especially in the superior portion
of the wurah, during which period the cervical region is but
slightly motiitied. Subsequently there is a change, we are toli
and very soon the cervical canal is encroached ui»n by the cJipi
ulation of the internal os, and that, for a considerable time
before labtir, the os externum is alone left for future dilatati
In supijort of this theory, progressive sliorteniug of the ce
uteri is cited. Hence» they say, as soon as the cervical canal
gins to expand, by reason of the submission of the ob internum,
small arterial twigs in the uten^-placentnl vascular system are
apt to be broken, and hemorrhage t(» result, but cotvgula soon
form and arrest the flow. This experience may be repeateil fn?m
time to time.
ion ■
>U^I
i^^
tic^l
TV^^I
I
We have elsewhere taken occjision to express our want of coj
ctirrence in the theory upon which this explanation rests. ^^
are convinced, from attentive observation of the phenomena in-
volved, that cervical shoi'tening is more apparent than real, and
that the internal os uteri generally preserves its contraction up ,
to, or near the beginning, of labor. Hemorrhage in these cases
may be due to the incrense<l strain put upon the lower uterin^^
segment after the sixth month of pregnancy, the uterine wal^^f
yielding to the force more rapitUy than the utero-plac^^ntal ves^^
sels, and thus giving rise to rupture of some of their bvigs, or
lesser vessels. It may be, too, that, in ]>hkcenta pnevia, the
anomalous development going on about it, may make the inl
nal OS more patulous than in normal crises.
But there comes a time when, through the rhythmical ni
contractions, the cervical canal becomes at first funnel-shape^
and afterward wholly expanded, and the external os >b left as
the tardy part As this moveinent b^ns, blood {;ui?Ues ft
»LACENTA PRiEVIA.
451
from mpture^l vessels, bxit whether the hemorrhage is from the
uteriue or the placenUil side, is still a question. It inuy be from
both. The weight of opinion »pj)ears to be that the blood is-
gnegt mainly from the uterine surface, though it cannot be de-
nied that strong evidence can be adiluoed in favor of the oppo-
site view.
Symptoms.— The imtient, perhaps, is lying asleep in bed, or
she may be uooupied in the performance of her household du-
ties, when suddenly the bloml bursts from the uterus, followed,
perchance, by faiutiug, and sometimes, though rarely, by death
itself.
In some women an occasional flow ooours for a number of
weeks before the onset of labor. It comes for a moment pro-
fusely, and then it disnpjiears, so that aid is not often socured in
time to be of particular service. The tinal hemorrhage sets in
similarly, and C4)ntinues with uneven progress until arrested by
well direct4?d treatment, or brought t<» a close by utter exhaus-
tion. In other cases, there is no warning whatever. Gestation
proci>ed8 in an uneventful course, and, full of animation and
hope, the woman is contemplating the near appi*oach of the time
when the restraints of pregnancy shall U^ removed, and the
trials and pains incident to its termination be succeeded by the
t«*ndt'r delights of maternity, when suddenly she is precipitjited
into despair, and jjerhaps death. There is a gush of fluid, which,
on inspection^ is found to l)e blood, and it pours forth in a sick-
ening stream- If it continues, the respiration becomes sighing,
the pulse rapid, feeble, and liually ulisent, tlie couutenauce
gets pallid, the extremities grow uneasy, syncope follows, and
even death. The torrent may six)ntaneousIy cease for a time,
ere these extreme symptoms are developed, and the worst will
seem to have passed, when a renewal of the flow ensues, and
death claims his victim.
For a time the uterus may act with its wonted energy, but ex-
cessive depletion is apt soon to paralyze its efforts. Occasion^'
ally labor hastens on its course, and if favored by a passive and
sparing flow, soon reaches a stage in which an incubus is laid on
the bleeding surfaces, and the pernicious bleeding is brought to
a close. In other cases, after the loss of a great quantity of
blood, the flow spontaneously ceases, and does not return, and
452
LABOR 0B8TBUCTED BY F(ETAL ANOMALIES.
r*»i I
labor thenceforth takes a normal course, niilesB complicated hf
great weakness.
These are exceptional cases, for when the tide of vital fluid is
not held in check by artificial means, or the conditions on which
it dependti are not rectified by jadioioua treatment, thefonnta
of life soon run dry.
In rare cases the placenta, through energetic uterine action^
is separated and driven down into the vagina, in advance of the
foetus. When this takes place before depletion has become too
excessive, the outcome is usually favorable.
Wben the case is of the incomplete variety, there is some-
times but a moderate flow at any time, and even that is soon
subdued by either natural or artificial means, and serious dan-
ger thereby averted This result is explained by the slight ex-
tent of necessary separation, and the early descent of the pre-
senting part into the pelvic inlet
ii^i
Diae^nosls.— However small a figure may be out by diagnoBis
in certain diseased states and obstetric conditions, it is here of
surpassing im{X)rtance. The perils of the emergency, and the
possibilities of treatment are too great, to tolerate anything lesB
than most coief ul and thorough search for the conditions
which hemorrhage before delivery depends.
The differentiation between accidental and unavoidable nera-
orrhage will be considere<l when we come to discuss the for-
mer complication of pregnancy,* but we may also here glance
at some of the more valuable iliagnostio points.
As soon as the hemorrhage is gotten \inder control, we should
investigate the history of the case, and learn under what oircu
stances the flow began, the possible influence of accident
developing it, and the iK>Bition of the Ixnly at the moment wh^i
it began. But it is only by making a thorough vaginal exami-
nation that a positive conclusion can be reached. The os will
generally admit the finger, not because dilated, but because of
its dilatable c-ondition, brought about mainly by the blood loss.
If the finger can l>e passed, we sliall almost always be able ^B^
feel some portion of the placenta. If the implantation is ced^^
* We arc weU aware thai it ia said that endo-KMrvicitw, with its sUghtf
bloodjr disoharges, may be oonfoanded with placenta pneria, but w« <«ii
scarcely crrdit the Htat^ment.
A
PLACENTA PR.tVlA,
453
tral, we shall find the cervical oanal covered by a thick, boggy
mass, which is readily distinguishable trom any part of the
foetus, and from a coagulum. By pressing upon this mass, we
may feel the resistance offered by the presenting part of the
foetus. When but a part of the placenta lies over the os, it will
be distinctly felt, and through the membranes attached to it» the
foetus will be distinctly made out. On account of a high sltua-
Fi«. 2H.
Cpntrol Pliicenta.
tion of the cervix, we may not be able to make a satisfactory ex-
amination witliout introducing the hand. There is also a sen-
satiou of thickness and vaBcularity about the lower uterine seg-
ment not observed in normal pregnancy. Furthermore, the re-
lation, in point of time, between the crimson gush and uterine
contraction, should be attentively observed, since their siniolta-
454
LABOR OBBTRPCTED BY F(ETAL AKOMALIEH.
)maii „
i
neons occurrence characterizes auavoidable, and not accident
hemorrhage.
Prognosis.— According to the calculation of Sir James Sii
son, based on an analysis of 399 cases, one-third of the moth(
and over (me-half of the children, wore k>st. But this eslii
does not fairly represent the results of modem treatment Out
of M cases recorded by Baraes, the maternal deaths were 6, or
1 in lOJ. Head estimates the maternal mortality at 1 in ^4
cases. The peril is far from being equally great in all caa^|
*'The question of safety in labors with unavoidable hemorrhag^^
says Meigs,* "is very much a question of time, —for if a woman
with central implantation of the aftrorbirth could, as some hi
done, ex|)el the child in one or two ht>urs. she would not hi
tim6 tii die, inasmuch as the involution power of the w<
would shrink the bleeiiing surface so si>eetii]y after the expul-
sion as to put an end to the Hooiliug at once, and so to all dan-
gers and alarm. On the other hand, where the woman contin-
ues in labor for fuur and twenty liours, she will probably die,
either bef*>re or soon after its concluaitm." ^j
The cause of the hea^'y foetal mortality is obvious when ^U
refifM't on the sources of su|)ply, and tht* entire or partial placC'D-
tal separation which occurs in connection with such cases.
Treatiiit*iit. — Upon clearly establishing our diagnosis^
shouhl carefully ctmsider the possibilities and probabilities]
the case, and lay out a plan of treatment
On reaching our patient, we should observe the general
of treatment for uterine hem<»rrhage. that is to say, we should
endeavor to allay feur, we shoxdd clear the chamber of nil
necessary company, and we should strictly enforce the hori
tal position, and the avoidance of any muscular effort If
advisable course of treatment is not at the moment cJenr, we tai
if necessary, at once Introduce a tjimpon to arrest the
Pressure upon tlie fundus uteri, which pushes the head firmly
against the bleeding plHcentji, is sometimes of service. T
question of treatment will ilepend somewhat on the i>eri(
pregnancy at which tlie bleeding occurs. If before the
term of gestation has been accomplishe<l, the question of far<
ing foetal expulsion has to be decided.
1 Ul^^
f tBp
•Meigs' Ob»t«tric», 4lh caition,p. 418.
PLACENTA PREVIA.
455
Tbe Question of FaToring Foetal Expulsion.— In 1866 Dr.
Greeuiiaigh, of Loudou, recommemled the iuduction of premn-
tnre labor in placenta prcevia, and though differing in tlieir
nioiles of procedure, obstetriciann have come to accept it as a
form of treatment highly practical Erect, as we may, the
strongest safe-guards, and yet the woman in whom the placenta
presents is constantly exposed to great perd. At any moment,
in waking or in sleeping hours, the torrent may gush forth, and
tJie vital forces bo speedily reduced to their lowest ebb. With
the best facilities for summoning aid, life is continually in jeop-
anly. But, by the induction of premature labor, the entire pro-
cess of pnrtni'ition is brought under tlie physician's personal
supervision, and the danger arising from hemorrhage accordingly
reduced to a minimum.
Over against these consideratioiiH must be set others of no
little weight. We allude first to the almost certain destruction
of the child which the operation involves. We should not ig-
n«ire the fuutul claims; but a fair and consistent view of tlieir
relative importiiuce must sulxirdinate them to the maternal
interests. In America it seems tt) have In^come a rule, and a just
one, too, we believe, to make the mother's safety in every jxiint
paramount to all other considerations. Nor should we in this
connection forget that while the induction of premature labor
is extremely hazardous to the foetus, the chances of its living
under the expectant f(^rm of treatment is no greater than of its
dying. The comparatively favorable results of the former
treatment are sJiown by Dr. King. Out nf twenty-nine cases re-
ported by him, there were twenty -three maternal recoveries, and
eleven children were saved.
**I think, therefore," says Playfair,* "that it may be snfely
laid down as an axiom, that no attempt bhould be made to pre-
Tent the termination of pregnancy, but that our treatment should
rather contemplate its oinclusion as soon as possible." We
may make the single exception of iliagnosis established before
the close of the seventh month, in which case we would be jus-
tifiofl in temporizing until a little later period, on behalf of
the child.
HodeH of Promoting Labor.— We have not here the same
• Pi.AvrAiR, foe. dtp, 401.
456
LABOR 0B8TKUCTED BY FOETAL ANOMALIES.
variety of means from which to choose that is offeretl unde:
otlier circumstances, inasmuch as it is essential that while we
provide for the stimulation of uterine contractions, and dilata-
tion of the OB uteri, we furnish an obstacle to the blee<ling
which is sure to set in. Instead, then, of Kiwisch's douche, and
otiier slow processes, which afford no protection from heme:
rhage, we are obliged to resort to other means. If the oa u
is very small, and the cervix is still hard in its npi>pr jwrtio
we will begin by carefully introducing a tent, tamponing th^
vagina to hold it in place. As snon as this has accomplish
its office, it sluiuld be withdrawn anil superseded by one
BaiTies' bags. The Iwig is iutnKluced in a Huccid state,
afterwonls dilated with either air or water, and left until it
be followed by another of larger size. If we are merely prom*
ing labor already begixn, we would be able to begin with
bags instead of the tent. Hydrostatic expansive force, thus a
plied, nicely simulates labor, and can hardly be regarded as i
|>osing serious danger. By filling the ob uteri, and following its
expansion, hemorrhage is kept within bounds, and labor is ra
idly i)romoted.
As soon as Llilatatiou has advanced to a certain extent, artifi-
cial extraction V>ecomefi possible. The precise degree of expa
Bion required, will depend on the state of the os with resjiect
dtlatability, and the mode of delivery proposed to be employ
The forcojjs can be used through an os uteri no larger tluin
silver dollar, and if the fcctal heatl can be gotten at, they are tb
preferable means. In other cases, and this is the most coxnm
treatment, turning may l>e practiced.
But the foregoing treatment 'is not always available, nor in-
deed successful, and other measures must be at our command.
%
Evacuation of the Liquor Amnii. — This expedient is by
Some regarded as almost uniformly efficacious. It is unanitab
if there is a probability of our being obligetl finally Uj reso
to podalic version. The favorable effect of rupture of the
membranes arises from increased uterine condensation, atitl
augmented presHure of the presenting part against the jilacenta
and the ruptured uterine vessels. To these should be added the
stimulus wliich is inqmrtpd to the uterus, and the oouseqaent
acceleration of the parturient process.
id
PLACENTA PH^VIA.
457
This operatiou is best performed by means of a stiff catlieter,
-^^hich, if uecesriary. may be passed directly through the pla-
<:?enta. Care should be taken not to wound the foetal head. The
evacuation should be pretty thorough, but not very rapid. Tem-
jporary ceasatitm of the streuiii, from the occurrence of uterine
<=?ontractiou, should not be token for full evacuation.
The Taglnal Tampon.— As soon ns the os uteri is thoroughly
«fMilatable, whether extensively dilated or not, delivery should be
-viandertaken. But in some cases this suitable moment for inter-
ference is greatly delayed, meanwhile the tampon seems to be
r— '^juired to control the hemorrhMge. It ought never t-o be al-
t^r^weil to remain unrenewed lunger than eight or ten liours, for
F'^earof septic poisoning from the rapid decomposition which is
L i «ble to ensue. To firmly iwick the vagina, and mnintfun the
:^-^ondition uuchangetl for many hours, is unwise; and it is like-
^t?^se indiscreet to use the tampon and neglect to watch for the
•^^corrence of unfavorable symptoms. It is the abuse of this
a^^3Kpedient which has aroused the oppxjsition to it which some
3.^5clare.
The indications for the tampon slumld not bo forgotten,
i^-*^*inely: delay of the time when extraction — manual or instru-
■^^^^^fc- ^-atftl — can be practiced, with meanwhile a profuse dow of
tfc^Xood.
The material best suited to the purpose has not been agreed
*-* X^'ii- but chai-pie, strips of silk, old liiion and muslin, raw cot-
^^^^^^:n, sponges and various other articles have been used. When
F^^**acticable, we should not forget to employ caoutchouc bags
**^ the OS uteri, as they not only act as good tampons, but greatly
^*<J ililatation, as well. An ordinary roller Vmndage is a most
*^'*^^xvement and effective article. It is both introduced and re-
** oved with comparative ease.
"To thoroughly pack the vagina, the no\'ice will find no easy
*^-^k. It may appear to be a simple operation, and would be if
^*^^ ostium vagiruc were only wide open. But when the material
^^t^d. whether it be muslin, silk, or charpie, is attempted to be
^^■feroduced, one piece ofter another, the difficulties of the case
*H become apparent The vulva must be <lilated, by means of
^^ fingers or a speculum. Sims' speoulnra answers best; but,
^i not at hand, let the fingers be used as perineal retractors, and
V
4o8
LABOn OBRTRrCTED BY FOETAL AXOMALTEfi.
the tampon cnn then be readily introdaced. Unless well appli^^
it is worse than Uiteless. ^|
The folldwiiig most efti'rtnnl mode of applying the tampon
was first rec<nmmeuded and practiced by Dr. Sims. " The
tient," says Dr. Paul F. Mund6, in his Minor Snrgir.(il Gtf\
oology, "(with empty rectum and bladder, ) occupies the left
era! prone ptiaitiou; S'jus* epeculuui is introduced and the ce]
exposed. All coagula and fluid bl(X)d having been carel
removed by the tlressing forceps and damp ctitton, a disk-sha]
tivmpon about two inches in diameter and one-half inch thicl
placed over the cei'vix. Another such tampion is rolled up and
placeil behind, another in front, and one on eacii si<le of cei
and a large tint one over all these. These tami>onB are re<
mended ]>y Emmet to be soaked in a saturateil solution of ah
and squeezed nearly tlry. I always carbolize the tomjious i]
one per cent solution, but think tlie alum solution a very g<
plan, as it contracts the vaginal |>oueh and thereby c*jmpret
the cenix- Occasionally it may *>e necessary to piu^h a i>ledg(
of alum cotton int*^ the corneal (umal and tlms arrest the heq^
orrhage until the whole tampon has been firmly place^L • ♦ ^|
Tlie first circle and layer of tampons having lK?en arranged, as
described, and the vaginal vault thus filled and the cer>ix ontu-
pressed in all directions, disk after disk of dampened carbolized
cotton is laid around the circle of the vagina, filling up the
centre at the last, and each disk and each layer is gently
firmly pressed down and packed tight with the dressing fon
or a whalelxme stick. This pressure should nlways 1>e nij
from the periphery t^tward tlie centre, or rather from the ani
rior vaginal wall towai-d the sacrum. As the cotton is tj
welded luid puHheil up, the n^orn thus made is Riled by-
pledgets, until the vagina is distended to its utmost and the ta
\ycyu has reached not only the fioor of the pelvis, but is parallel
with the pnbic arch. After a rtnal thomugh survey of the tamiHin,
and packing dowTi any louse parts, the dressing forceps hvdd
back the cotton firmly with wide-spread blndea» and the spe«
lum is carefully removed with points backward. Ci^nsideral
care is required nut i-culislmlgc the tami>on in the manceurre,
it is necessary after removal of the speciUam to fill the 8j>aoo
thus made by a fresh packing tight of the whole tampon, and
perhaps by several additional disks.*'
Liuld
PLACEJTTA PBiETU.
459
Separation of the Placenta.— This ia a mode of treatment
which has met \nth Home success and favor.
('Omplete Separation. — Entire separation of the placenta as
a mode of treatment in certain cases was first recommended by
Simpson. He advised it more especially, —
L When the child is deacL
2, When the child is not viable.
3. When the liemorrhage is great, and the os uteri is not yet
suflficiently dilated to admit of safe ttirning.
•4. When the pelvic passages are too small for safe and easy
turning.
5. When the mother is too exhausted to bear turning.
Pi. When the evacuation of the liquor amnii fails to arrest the
hemorrhage.
7. ^Micu the uterus is too firmly contracted to allow of turn-
ing*
This practice was basetl on the theory that the source of the
hemorrhage in placenta pra?via is chiefly the separated uterine
surface of the placenta; but without accepting the theory, in
certain cawes we mny find the operation a wise one. Complete
sepfu-atiou of the placenta, however, is not easily eflPect^ sinc^
the finger is not long enough to iiccoiupliKh it. It may be done
when necessary by introducing the half hand.
Partial Separation,— Barnes divides the uterine cavity into
three zones, or regions. When the placenta occupies the upper
zone, there will be no unavoi<hible hemorrhage. The same is
also true of the middle zone. But when the placenta is partially,
or entirely, in the lower, or cervical zone, expansion of the os
uteri to its full dimensions, involves mure or less separation and
conaequent loss of blood. If biit partially within the lower zone,
the placenta may not be entirely separated, but, after expan-
sion of the OS has !)een accomplished, contraction of the uterine
tissaes may take place and seal the exposed vessels, and no fur-
ther hemorrhage be excited by the remainder of the placenta
which lies al>f)ve the region of unsafe nttachment Dr. Mat-
thews Duncan f esUmates the limit of spontaneous detachment
• " SelertM Obstet Works.*
t •* Obstet. Trana.," vol. xv.
p. ca
460 LABOK OBSrnUOTED BY F(ETAJ- ANOMALIES.
to extend 2^ inches on every side of the centre of the oa ntei
On the strength of this theory Dr. Barneu has proposed a moda ,
of treatment which is doubtless efficient in many casea, tl^^|
description of which is given in his own words.* ^"
"The operation is this: Pass one or two fingers as far as
they will go through the os uteri, the hand being passed into
the vagina if necessary; feeling the placenta, insinuate the fin-
ger between it and the uterine wall ; sweep the finger round in
a circle^ so as to separate the placenta as far as the finger can
reach; if you feel the edge of the placenta where the membranes
begin, tear open the membranes freely, especially if these have
not been previously ruptured; ascertain if you can what is the
presentation of the child before withdrawing your hand. Com-
monly some amount of retraction of the cervix takes place after
this operation^ and often the hemorrhage ceases. • » ♦ If
uterine action return so as to drive down the head, it is pretty
certain there will be no more hemorrhage; you may leave nature
to expand the cervix and to complete the delivery. The labor,
freed ixom the placental complication, has become uatiiral." In
event of failure to arrest the flow by this means he recommends
the use of his *' uterine dilators."
A Full Bladder. — It is es{)ecially incumbent on the physi-
cian, in the tieutment of placenta prievia, to see that the bludd^^^
does not become loaded with urine. The jiatieut's anxiety an^H
fear, coupled with the pain and distress she suffers, may so ili- "^
vert her attention that the tliscomfort of a full bladder will b^_
disregarded. In no case, however, should she be permitted t^H
arise, or materially change her position in order to perform the
required act of micturition. It is far better to use n catheter. ^L
Treatment When tlie Os is Either DUated or Dllatabie.-S
We oome now to consider the means of effecting delivery when
once the os uteri has attained the state of dilatability which will
admit of artificial aid, other than that already describetL Th^'
character of the means suitable to the case will depend largelj^H
on the peculiar circumstances and conditions manifested in indi-^^
vidual instances. In a certain proportion of all CAses, the lalx>r,
&om the moment of uterine dilatation may be safely left to the
* " Obatetric Operations," 2d ed., p. 417.
PLACENTA TBiEVTA.
461
natural efforta The employment of the means for arrest or
prevention of excessive hemorrhage before recommended, will
often be so effectual as to obviate the pressing necessity for any
farther artificial interference. There is a point sometimes ob-
served in these oases, beyond which to go would perhaps consti-
tute '■ meddlesome midwifery." In the main, however, we find
it neoessary, in order best to conserve tlie patient's interests,
and rescue her from jeopardy at the earUe.st possible moment,
to complete the delivery as rapidly as is compatible with the
low state of the vital forces and the integrity of the tissues upon
which the strain in rapid delivery mainly falls.
£rgot has been recommended and saccessfally employed in
"those cases wherein uterine contractions are too feeble to force
"the fcetuB onward. We should refrain from exhibiting it if
'there still remains the possible necessity for version; if any ob-
.^Btacle to speedy expidsion exists, which would not be easily
^K>vercome by forcible contractions; or, finally, if the forceps are
^■Dot under ready command, so as to be employed^should delivery
i^till be prolonged.
The forceps, in dexterous hands, may be used early, and the
Oman thus speedily rescued from her perilous situation. The
nditions upon which the difficulty in using them in placenta
ravia mainly depends, are, the height of the presenting part,
he partial expansion of the os, and the inaccessibility of the
ead from the unusual location of the placenta.
It is always most difficult to apply the forceps to the head
rhen it lies free about the pelvic inlet. To do so it may be found
necessary to carry the half-lmnd into the vagina to give direc-
^n to the blades. The spiral sweep of the inatrument, as it
:iiter8, must be obseri'ed, in order ii acquire a firm hold of the
ead. which part might otherwise be so displaced as to prevent
^^ satisfactory application.
It is only under exceptional circumstances that we are justi-
^^^ in applying the forceps tlirough an incompletely dilated os,
^nd those attending unavoidable hemorrhage constitute an in-
*^Xaiice, They who have never passed the instrument through a
**njall OS, will find, on attempting to do so, that, in point of iliffi-
ciiltj% it far exceeds the ordinary introduction. To perform tlie
462
LABOU OB8TBU0TED BY F(ETAL ANOMALTEa
act with success, the details of application are reqmred to be
observed.
TLe placenta in these complicated cases, lying centrally, or
laterally, over tlie partially expanded os, is a serious obstacle to
this form of df?livery. If the implantation is central, we may
succeed in doing what has been done, i. e. in applying the instru-
ment directly through the placenta. To do so, an aperture
must first be made, of suilicient size to admit the blades, and
then we may operate much as we would through a simple nndi-
lated OS uterL In such a delivery, the placenta is likely to l)e-
come looseneil, and ha brought away, in advance of the descend-
ing fcetus, in which case the result will pnictically corres{xiud
to separation and extraction of the placenta.
Incomplete placenta pnevia is the form to which the forcej>s
are more particidiuly adapte^l, as it is usually possible to turn
aside tlie placenta, nnd reach the foetal head over its margin.
The fingers shmilil be slipped within the ob uteri, and the direc-
tion in which there is least attachment carefully sought Being
found, the placenta should l>e drawn aside, the membranes rup-
tui'ed, and the blades passed.
It is unwise, as a rule, to ajiply the forceps through a rigid os
uteri, but the co-existence of placenta prsevia sometimes consti-
tutes au exception. The hemorrhage may he continuous, and
still the OS, from exceeiling nervous irritability, is 8[>asm(xlioatly
olosed. The ordinary measures for relief are perha|>8 tritnl in
vain. If dilatation has reached a degree which^will admit of the
forceps beuig introduced, rather than suflbr longer delay we may
carefully pnx'eed to deliver. Traction shotild not be really in-
termittent in these cases, but rather remittent, to avoid the pos-
sibility of i-ecurring hemorrhage from a relaxation of the press-
ure imposed on the bleeding vessels during traction.
Version, as a preliminary to extractiim, in unavoidable hemor-
rhage, was first suggested by Ambrose Par^, and afterwanls
strongly advocated by GuUlemeau. At present it is the most
common mode of treatment, and some writers on the subject are
so emj^hatic in their endorsement of it as to teach that every
thought of placenta prfevia should have associated with it the
idea of version.
Version can be performed by bi-manual means, withimt in-
rifltfMfl
PIACENTA PREVIA.
463
troducing the hand into the uterine cavity, but they are not often
auitiible to these cases. Version, then, when npoken of in this
couuectioD, means iniemal j)odalic version. The conditions fa-
Torable to the pei-formance of the operation, iis enumerated by
Dr. Tyler Smith, are "u dilated or dilatable state of the os
uteri ; the retention of the liquor amuii, or a moderately relaxed
state of the uterus; a pelvis of average capacity; the absence of
djingerous esthaustion, or a temporary cessation of the hemor-
rlinge." *' Nothing," says Leishman,* "is of greater iraiKjrtonco
'than that the operation should bo attempted as early as possi-
He, for there can be ntKluubt that the great mortnlitj^ wliieh at-
^eDds these cases is due, in uo small degree, to an injudicious
^wt|>ectaut treatment, while the precious moments pass daring
'%^*Jiich alone we can save the |>atient*s life and that of her chiKL'*
in order, then, tt» improve the golden moment for operation, we
*iaiX5t bt* on the alert from the earliest manifestation of unto-
"^i^Ttl Bymptcmia. When a concurrence of the above mentioned
^«4.vttrable conditions is met, podalic version may be easily per-
'<^»»-ined; but the combination does not always exist, and then the
^iifticulties are \ioih. numerous and formidable.
There are two uKxles of perfonniug internal podalic version,
•differing in the precise manner of passing the hand. In one, the
**-«Mad is pressed gently into the vagina, and then through the os
"^i-teri, and the placenta which lies over it In the other, instead
**^ making an aperture Uw the hand through the placenta, this
^*^f?an is raised on the side of least attachment. . In case of com-
¥>lete placenta pntvia, the han<l is insinuated between the organ
^^<1 the uterine walls, and then between the thin membranes
'^^Hi the uterus, until a jxiint opposite the feet is reached, when
tiie sac is ruptured, and the extremities at once seized. Seri-
*-*^e, and perhaps unanswerable, objections to passing the hand
^3rouph the plncenta, as advocated by Dr. Rigby, have been
*"^i»e<l })y different obstetricians, and have been clearly epito-
***ijae<l by Dr. Dewees as follows :
**L In attempting this, much time is lost that is highly im-
l?**^»*t*nt to the patient, ae the flooding unabatingly, if not in-
***'®aaingly. goes on.
2. »*In this attempt, we are obliged to force against the mem-
■^-•c. erf*., p. 386.
^^
4M
LABOR OBSTRUCTED BY FCETAL ANOMALIES.
branes, so as to carry or urge the whole placentary mass toward
tJie fuudus of tlie uterus, by which means the aeparatiou of it
from the neck is increased, and, consequently! the flooding aug-
mented.
"3. Wlien the hand has even penetrated the cavity of the ate-
rua, the hole which is made by it ie no greater than iteelf, and, cou-
eequently, much totj small for the fcetus to pass through with-
out a forced enlargement; and this must be done by the child
during it« passage.
"4 As the hole made by the body of the child is not suffi-
ciently large for the arms and head to pass through at the same
time, they will consequently be arrested; and if force be applied
to overcome the resistance, it will almost always separate the
■whole of the placenta from its connections with the uterua
" 5. That, when this is done, it never fails to increase the dis-
charge, besides adding the bulk of the placenta to that of the
arms and head of the child.
"6. When the placenta is pierced, we augment the risk of the
child, for, in making the opening, we may destroy some of the
large umbilical veins, and thus permit the child to die from hem-
orrhage
" 7. By this method we increase the chance of an atony of the
uterus, as the discharge of the liquor amnii is not under due
control.
**8. That it is sometimes irapoRsible to penetrate the pla-
centa, especially when its centre answers to the centre of the os
uteri; in this instance much time is lost that may be important
to the woman."
Explicit rules for performing podalio version will be given in
another place, and we shall here indicate only the general out-
lines of the operation as performed in these cases.
By locating the sounds of the foetal heart, we can determine with
certainty toward which side of the mother lies the fcetal back,
and thus make choice of the hand with which the operation can
more easily be performed. Oiling the hand on its outer surface,
it is passed within the vagina, and thou slowly between the utems
and placenta, and later, the uterus and membranes, until it
reaches a point opp<isite the child's feet The membranes
should then be ruptured, the feet secured, and broucht down,
PB0LAP8Z or THE FUNIS.
405
uutil version has been fully wrought. After once the hand en-
ters the o8 nteri the hemorrhage is arrested by the plug which
occupies the part, viz: tirst the hand, then the wrist, then the
forearm, and, ultimately, with a reversion of this order, by the
body of the child itself.
Potialic version, always a formidable operation, is doubly so
in such emergencies, o'wing Ui the excessive depression of the
vital force by which, in most cases, it is preceded.
When examination discloses a presentation of the pelvic ex-
tremity of the child, whether it be breech, feet or knees, we may
vary somewhat the practice usually advised in such cases, by
bringing down a foot As the characters of the presenting part
in placenta pnevia are obscured by the interposed placenta, they
cannot generally be made out until the time for interference ar-
nvee, and the hand is passed into the vagina for operative pur-
poses. In pelvic presentation, we have, then, but to proceed
and bring down a single foot, or both feet
In the treatment of unavoidable hemorrhage during delivery,
or before, we can expect but little aid from drugs administered
in any form. If the woman's energies are broken, and the uterus
is inactive, by the exhibition of china^ pulsaHUay secaley cam-
phor, or caulophyllum, some help may be given. China ought
to be exhibited in every case of excessive blood loss. If the oa
uteri is spasmodically closed, belladonna, grlsemium, aoaniie, or
caulophyllum may mollify it But none of these remedies can
have direct influence over the hemorrhage itself, which consti-
tutes the alarming symptom.
After lalK>r, our remetlies will he of great service. Amir/iy if
promptly administered, alone, for a time, or in alternation with
china, it* ca]>able of averting serious ills. In the puerperal
state, unfavorable symptoms are unusually prone to appear in
these oases, and the remedy especially indicated will overcome
them, and impart a powerful impulse toward perfect recovery.
PbOLAPSE of the FtTNIfl.
Thifl is a complication which does not in any manner retard
the labor or make it diflScult, but what gives it significance is the
danger in which its occurrence places the foetus. A loop of the
oord descends by the side of the presenting part, and is liable
to severe compression between the fcetua and the pelvic walls.
466
LABOB OBSTBUCTED BY P{ETAL ANOMALIES.
The consequence of such an accident is serious intemipi
of the fcBtul circulation, and destruction of the child from asph.
la.
efl
Frequenry of Occurrence. — It is not generally regard*
of frequent occurrence, but it is probable that moderate prolap
takes place in some cases without detection, and results in feet
death. A loop of cord, may descend far enough to suffer ooi
pression at the superior strait, witliout being detected in an o
dinary vaginal examination. It has been observed once in 3<
Fit*. -215.
or 400 cases. Playfair and others have called attention to its n
markable prevalence in certain districts, which phenomenon
attributed largely to the unusual number of rachitic pelves i
such places. As between France, England and Germany, it
less frequent in France and most fre<quent in Germany, the n
apective figures being 1 in 446i, and 1 in 207J, and 1 in 156.
PBOLAPBE OF TU£ FCKIS.
467
Simpson believes that these national differeneeg are occanioned
mainly by the varying ptjsitione ija which women are placed dar-
ing labor, but thi.s interpretation of the cansative intlueuces
which are responsible for Buch widely different experiences,
Beems to lack the strength of probability.
FrognosiH. — To the fuetus, prolapse of the funis is one of the
znofit serious possible complications of labor. In ^^5 cases col-
lectetl by Dr. Churchill, 220 children, or nearly two-tliirds, died.
These, however, were mainly hctspital cases, and it may be that
in private practice tlie mortality is not quite so great.*
It is evident that compression of the cord is the main cause of
BO heavy a death-rate; but some authors attribute it in part to
partial loss of fluidity of the blood from being cliilled as it
passes through a loop of cord which protrudes fi*t>m the vulva.
Tliis effect of exposure has been questioned by many, among
them Madame Lachapelle, who says^f " I have-seen the cord
Lang out of the ^'ulva for several hours together without the
foetus suffering therefrom in anywise, Ijecause there was no com-
pression; and tills, in some of the cases, notwitlistandiug the
patients had c<»me n greater or less distance, eitlxer on foot or in
0ome vehicle, from their resident's to our hospital." The wri-
ter has likewise recently delivered a woman in whose case the
cord had been prolapsed for two or three hours, and when felt,
seemed cool and pulseless, and still the child, though feeble, was
easily revived
Mortality is neatest in vertex presentations, and least in
breech cases; the explanation of the varying results being the
greater force and duration of compression in one case than in
the other. It is also heavier in first, than in subsequent labors.
The Causes. — Prolapse of the funis results from a variety of
causes, among which are unusual length of the cord itself, a re-
dundancy of liquor amnii, irregularities of the pelvic brim,
obliquity of the long uterine axis, positions and presentations of
*Out of T43 cases compiled from rariotift onthoritira hy Scanxoni, only 335
of the children were saved. Oat of 302 cases of vertex presentation with pro-
Ift|«e of the Cunia, tabulated by another, only 76 children were saved.
+ Vide Cazbaux. "Theoretical and Pract. Midwifery," Am. Ed., 1878, p.
468
LABOR OBSTRUCTED BY F(ETAL AN0MAUE8L
the foetus which do not occupy the full outline of the pelvio
brim, and low attachment of the placenta. In the front rank of
proximate causes we must place sudden and rapid escape of the
liquor amnii. In must cases of labor, the presenting part
presses well down on the brim, and rupture of the membranes
during a pain is attended with escape of only that part of the
amniotic fluid which is confined below. But in other cases, the
presenting part does not rest at the brim with so firm and equa-
ble a pressure, and when the bag of waters breaks, a large part
of the liquor amnii escapes with a gush, and may bring down
with it a loop of the cord.
Signs of Funis Presentation.— Tlie signs of prolapse of the
umbilical cord are usually sufficiently well marked to make their
diagnosis easy. Descent is often so great that a loop of the cord,
three or four inches in length, protrudes from the vulva. Pul*
sation may be present or absent. ^NTien present it is sometimes
so feeble as almost to escape detection. If pulsation is distinctly
felt, this alone would establish the diagnosis If absent* the
twisted arrangement of the vessels, always plainly felt, or visual
examination, will remove all doubt When only a piece of the
loop can be felt at the brim, it might be mistaken for a finger or
toe, unless the examination were pressed. It seems hardly cred-
ible, but a loop of intestine, prolapsed through a rent in the
uterus, in more than one instance has been mistaken for the um-
bilical cord.
When only a knuckle of the cord drops down below the brim,
it is BO small that it may escape attention, and the child be sac-
rificed without any suspicion of danger having been excited.
Has Pnlsation Ceased *? — It is of the utmost im{x>rtanGe that,
in prolapse of the funis, we determine whetlier or not the cord
be pulsating, since if pulsation has actually been absent for say
fifteen minutes, we are safe in assuming the child to be past
recovery, and will resort to no interference on account of the
complication. Mere inability to at once detect ptdsatiou is not
sufficient ground upon which to rest the expectant treatment
It is remarkable how soft and indistinct are the pulsations in
some cases, as the author has recently had occasion to observe.
It should be remembered in this connection that an examination
of the cord made during a pain is liable to mislead, as compres-
PEOLAPaE OF THE FUNIS.
469
Bion at finch a time only may be Bufficiently great to interrapt the
circultttion.
Treatment. — Prolapse of the umbilical cord constitutes a real
emergency, inasmuch as even a brief delay in affording rehef
may be fatal. The obvious indication for treatment is, first,
prevention of prolapse, and secondly, relief of compression at
the earliest possible moment
Preventiye Treatment. — This has but a brief range of ap-
plicability. Before rupture of the membranes, in the first stage
of labor, the cord may occasionally be felt, coiled in atlvanoe of
the presenting poi't, and ready t*j descend as soon as rupture
occurs. In such a cuise the membranes shotdd be carefully pre-
served, and the woman placed iu a posture favorable to sponta-
ne«»u6 return of the cord to a less exixjsed situation. We allude
to the postiu-e alxtut to be described, wlncii is likewise of the
atmost value in attempt to reposit the cord after prolapse has
really tEiken place.
laciiiiotiou of iho uhtiw, in the ilorsal postnrp. fovoring d«M?ent of the cord
into the polvii*.
Postnral Treatment.— So long as the woman occupies a po-
sition on her side or back, the cord, from its very weight, will
manifest a strong disposition to return after every reixjsitioa
This tendency may sometimes be overcome by carrying it deeply
into the uterine cavity, but this involves the intnxluction of the
hand. "We should not hesitate," says Tamier,* "to carry the
•CAZKArx*9 Midwifery, Am. Ed., 1878, p. 833.
470
LABOR OBSTRUCTED BY FcETAL ANOMALIES.
hand up to the fundus of the womb for the purpose of leaving
the prolapsed portion in that part of tlie organ." It ixxiurrenl to
Dr. T. Gaillard Thomas to inyeil; the uterus, and thereby bring
the force of gravity in Uie. direction of the fundus, by placing the
woman in the knee-elbow, or, better still, in the knee-chest p*>si-
tion. The anterior uterine wall, is thereby made to form an
Fio. '217.
PosturaJ treatment for prolni^seof the cord.
inelinetl plane down wliich the conl slips. With the woman in
this posture it is in 8(»me ciises found that the force of gra\-ity
alone is sufficient to restore the prolaj^se^l cord, since the head or
other presenting part ceases to press firmly on the brim, and
nothing suffices to forcibly maintain the disjJacement Wlion
the funis has thus been j>lnced beyond the risk of eonii>ression,
if tlie OS uteri is large enougli, tlte forceps may be applietl, and
the l(ea<l drawii into the brim, tlius preventing a [M^fisible renewal
of the complication. If the forceps cannot well bo used at this
junchu'e, the head may be retaiiietl nt the l>rim by lirm hyi)<»jj:a8-
tric pressure, and the woman permitted to resume a less irksome
position. The ixjshiral treatment is suitable t4:i all cases wherein
there is any hope of restoring the cord to the uterine cavity; l>ut
it will usually have to be supplemented by manual and instru-
fiiental aid
Artiflcial Eeposition.^This should, in every instance, if at
all practicable, be performed with the woman in the knee-elbow,
the kneo-chost, or tlie serai-prone i^>ositiou. McClintock aod
PUOLAi'SE OF THE FUNIS.
471
Hardy reoommend the last positiou, with tLe woman on the side
opposite the prolapsed cord
The methods of repoeition vary greatly. Tarnier, as before
quoted, thinks it justifiable to carry the cord with the fingers as
high as the fundus uteri, while others regard even the hollow of
the neck, in vertex presentation, as too elevated* Unfortunately,
reposition, when thorougldy performed, is oft+»u extremely diiii-
crdt to effect, and frequently disappointing in its results.
Various instruments have been devised to aid in the manoeuvre,
but few possess them, and fewer still can successfully use them.
The fact is, that, in most cases, relief must be afforded without
the least delay, and tlie preparation of the ingenious means rec-
ommended in many text books, consumes the very time which
determines the issue of the case. Our own opinion is that in
those cases wherein successful re^wsitiou is at all possilile, tlie
hand is a better instrument than any yet devised, and witli it we
may more safely press the cord into tlie uterine cavity, and main-
tain it there. To effectually c^rry out this sort of treatment,
then, we ahoidd bear in mind the following points:
L The knee-elbow, or the knee-chest, position, for the womaiL
2. The use of the hand to return the oord, carrying it well into
the utc*riue cavity.
3. The immediate application of the forceps, or supra-pubic
pressure, to prevent a recurrence of the complication^
Treatment When Reposition Fails.— Efforts at complete
rejKJsitii^n often fail. More<iver, in a certain number of cases,
lalxtr has advanced too far to admit of a return of the oord to a
situation lugh enough to esc4ipe compression, and this, too, in
some instances, where there is gocxl ground for hoping to save
tlie child's life. Treatment will then in great measure Ije
controlled by surrounding circumstances. Nor should we for-
get that prolapse of tlip funis di>es not always necessitate pro-
tmctetl interruption of the foetal circulation. The cord may be
in a protected situation, and if it is not, we may be able to place
it there. If pulsation has not long been absent, and lalx)r is
progressing rapidly, it may bo completed in a natural manner,
in time to presence the fcetus. Again, if compression has not
• Platfaib. '* System of Midwifery," p. 330.
47a
ULBOn OBSTRUCTED BY F(ETAL AXOMALrES.
been long-continued, and the pelvic stmctnres are in a favora-
ble condition, the forceps may bo applied, and labor terminated
without delay.
If the head etill lies at the brim, and all efforts at reposition
of the cord have failed, we may have recourse to version.
Engelmauu ftJiind that seventy per cent of the children deliv-
ere<l iu this way were savetL This is a point of great nicety,
since the operation of podalic version augments the maternal
dangers. Statistics have not been gathered ujx>n which to base
a rale of action in such cases, and the matter is thus left entirely
to the judgment of the practitioner. If version can l>e effected
by the conjoint method, the olijeclions would be robbed 4>f tlieir
force; but, unfortimately, this mode of operating, at such a
time, is rarely practicjible. *' It is scarcely necessary to state,"
says Engelmann,* "what figures so plainly show, that version,
preceded by judicious postural treatment, is tlie methcxl to be
followed which promises most for the life of the child, in prolapse
of the cord, when complicating head presentations."
ACCIDKNTAL HeMOKKHAGE.
This is a variety of uterine hemorrhage regarding which but
little is found in the text books, or even elsewhere in obstetrical
literature; yet it is of sufficiently frequent oceurrence, anil in-
volves ample difficulty and danger, to merit more than passing
notice. Its character, causes, and_ treatment, ought to be fa-
miliar to the student of midwifery.
Its Character.— What does the term "accidental hemor-
rhage" signify? In one sense we may justly regard every
flooding as the result of accidental causes, but the designation
here made is speciiic. The elder Rigby, more than a hundred
years ago, clearly drew the linos of accidental hemorrhage, and
established its distinctions. Tlie term is employed more espe-
cially to differentiate between two varieties of hemorrhage occur-
ring at a like period in pregnancy, and presenting similar fea-
tures. Accordingly there are "accidental hemorrhage," and
** unavoidable hemorrhage," both encountered in the latter
months of ntero-gestation, and prior to foetal expulsion. The
former often proceeds Injm accident, and from this fact the des-
ignation is probably derived, A profuse flow of blood occurring
• Am. Jour. Obstct., vol, Tii, p. 355.
ACCIDENTAL HEMORRHAGE,
47a
parlier than the seventh month does not ELssume the title, but is
recognized as a symptom of threatened abortion.
The Relation of Fcetus and Placenta to the rteriis.— The
placenta is in its usual situation, high upon the body of the
uterus, or at its fundus, and the vascular relations of the several
parts differ in no essential particulars from those recognized as
uormaL There are, in general, no anomalies in the arrange-
ment of various parts, nothing perceptibly unusual in tho rela-
tions of the foetus to the placenta, or of tJio pUtcenta to the
uterus, which could possibly render the loss of blood in any
strict sense unavoidable.
The Causes. — The immediate cause of the hemorrhage is an
bcomplete dissolution of tlie utero-placental adhesiims, and the
wjuHequent exjx»sure of bleefling vessels. The remote causes —
Uiiit is to say, the causes proposed U* account for the placental
!?<^lMirutioa — are often untraceable. In a certain proptu'tion of
"wtances, the mainspring of the broken relationship is plainly
K^erable to accidental iniiuencea The woman has suffereil an
wiUHual physical strtun fj-om a sudden motion, from lifting a
beavy weight, or perhaps a light weight at disadvantage, from a
^ng walk, or from re-aching. Within a few moments, or liours,
a flow of blood seta in, and a c^ise of accidentfd liemorrhage is
fftpidly developed* A blow upon the abdnmen may ffdl on the
**itp iif placental attnchmeut, and partial sepamtinn be j^rfnluced.
Daring the latter part of pregniiuey the iitern-phuvntal rela-
tions are more feeble than at an earlier period, and it is surpria-
inpthat they are not oftener prematurely Hevered It is quite
probable that in some women the C4>nnection becomes so infmn,
that any unusual motion, or even ordinary locomotion, is suffi-
cient to sever it In this connection, it should be added that
lliis form of hemorrhage is a rare occurrence among young, ro-
bust women.
Vari<*tles.— There are two varieties of accidental hemorrhage,
ftwnt'ly: the ojjen, and the eoncealetl. In Inith the How is ooea-
sfionpil by partial separation of the placenta, and in both, blood
tt poured out between the fcetal envelopes and uterine walls. In
on*»ca8e it freely escapes throtifjh the os uteri, and in the other
»t meets lui obstacle and remains ijent up in the uterine cavity.
474
LABOR OBSTRrCTED BY FCETAL ANOMALIEK.
The effect on the patient is much the same in either case, thougli
concealed hemorrhage is attended with rather more danger,
from the fact that ita existence is not generally disclosed until
extensive depletion has resulted.
Symptoms of External Hemorrhage.— The symptoms of
the open variety are manifest, and generally exhibit diagnostic
characters. Whether preceded or not by an injiu-y or struin,
bleeding begins, and is not necessarily acc«)nipanied at first by
any other symptoms of |>remature labor. If the loss of blotxl M
but slight, it ought not to be dignified by tlifi title of hemor-
rhage. During pregiuincy, in nearly all stages, there is an occa-
fiional "show'* of bU)od, which possesses no special significjiuc-e.
In connection witli the How tliere may be pressure in the sa-
crum and abdomen, succeetled after a time by real recurrent
pain. When profuse hemorrhage sets in during paiiurition,
the uterine contractions generally become feeble, or entirely
cease.
Symptoms of Concealed Hemorrhage.— In the concealed
form, bU>od is discharged bet^'een tJie membranes and uteriiic
walls, or beneath the placenta, causing still gre-ater 8e|*firatioiu
The exuded fluid is sometimes confineil beneatlt the placenta,
which remains attached only at it-s margins. A nui'prising quan-
tity of blood is sometimes thus confined, causing cnusi<lernble,
and even dangerous, distention. Dr. W. Goodell collected 106
cases,' antl, from a study of theii' symptoms, deduced the follow-
ing marked signs: 1. An alarming state of collapse evincetl by
coldness of the surface, excessive pallor, feeble pulse, yawns,
sighs, dyspnwa, restlessness, retching, etc. 2. Generally, severe
pain in the abdomen. 3. Marked distension of the uterus.
4. When occurring duiing labor, nn absence or u feebleness <»f
uterine c«>utractions. In addition to these symptoms, there uiny
be dimness of vision and nyueope. Observing such signs, the
hand is place*l upiin tlie aUloinen, and remarkable ilistension is
found. Pressure may force away the obstacle from tiie cervix,
or separate the membranes or placental wherein the flow is ]K)t'k-
eted, and the pent-up blo*Td escape with a sickening gurgla
Madame Boivinf had little faith ui the possibility of conc<^Hl6d
•Am. JocT.Olw., vol. 1. p. 281.
t" M6moirc sar loa Ilcmorrliugieti latcrn«s de L'tTtcrua," p. 02.
ACCIDENTAL HEMOBBHAaE.
475
■addental hemorrhage. "I cannot believe," she eays, "that the
nieros, filled with the product of conception, can, at any stage
of gestation, admit bo considerable a voltune of blood, unless it
has been recently emptied, nor can the quantity be sufllcieut to
occasion the death of the woman." Velpeau entertained a simi-
lar ftpinion. Dr. Meigs* "never met with a sample of this kind
of bleeding." But facts are always more forcible than tlie^iriej^;
and the evidence of fatal cases put upon record is a sufficient
response.
Differential Diagnosis.— Little difficulty is generally expe-
rienced in difforentiating between Hccidental and unuvoiilable
hemorrhage, but in order to make the distinctions explicit be-
yond a doubt, tlie following comparison has been arranged:
ACCLDENTAL HEilOKHUAOE. UNAVOIDAHLE UEMOltUUAOE. .
1. Often preceded by a blow, strain,
or other tnjurv-
a. Mi>*»t frvqnenlly seta in moiltr*
•tely nDd, for a time, griuJuuIly in-
3. Tliere ift no hialory of prcvioaa
bemorrhogea of (ecvut occurreaue.
1. Karely preceded by an injury.
2. Generally oouies Auiidenly and
proOiE»eJy, buioDcu lustH only a^bort
tiiur.
y. Hi'morTlia|B«'8. hrieC, hnt frpe, in
a goodly numb**r ol' inntanees, *jccur
at intervaU alter tbo tillh or »Utb
month.
A. The dow ia more prolXuse during
a contraction.
5. The cervix and uterine walls aa
felt Ihroujfh tlie vu^^iua, are jiencnvlljr
thirk and Uuiiirliy.
G. If th«r tinker ia pafir^ed through
the rervieal ijiiial it gen<*rally comes
in L'untact with »ome [Kirt of the pla-
centa, which constitutes the present'
ing part.
Treatment.— Rest in a recumbent posture, perfect quiet, and
freedom from excitement and irritation, must be enforced. The
discreet use of cold may l»e sullicient to arrest the tlow, or greatly
modify it The |>ntient must \^ carefully guarded againt^tilisajv
pearance of the external hemorrhage, and the occurrence of a
c">ncenled discharge. If the placenta has separated uver only a
amall area, the treatment described may Ije fully mlequate. But
if a considerable surface of so great vaacularity has been ex-
po66d« more radical measures will be called for. It is manifestly
4. ir uterine contractions arc pres-
ent, the flow is more marked in the
tnt^Tvals.
5. The eervix ateri, and neighbor"
in^: uterine wiill^ aijpcar to be of
Doniial ihicknew and feel.
6. If the w* uteri will a<lmit tbo
Anger, Jie membranes may be felt^
and tlirou;£h them, as a rule, the pre-
Mrntliig fcetiil partti.
• **8y8t«m ol Oba.," p. 4 U.
4:76 LABOR OBSTRCCTED BY F(ETAL ANOMALIES.
desinible in accidental hemorrhage developed prior to the middle
of the ninth month, to overcome the threatening symptoms, and,
if possible, prevent premature labor. The tirst tiuestiou t'» be
answered here, as in threateutid abortion is, — *'ls expuLiion inev-
itable?" and if there is any likelihood of preventive measures
succeeding, endeavors shtmld be directed towiird arrest of the
symptoms by such means as will not tend tt* promote the expul-
sive process. These are few and simple, and have, in the main,
been indicated. Medicines can hardly be expected to have ajiy
direct control over the How. Bleeding vessels are exposed, and,
with the womb still distended by the product of conception, tJiey
cannot be constringed as they usufdly are under other cimditions.
The tlow ain be arrested, under the circumstances, by the for-
mation of clots which will seal the vessels. Drugs cannot be
expected to do that; but there is an indirect service which tbeVj^H
can render, and that is to s<H)th the nervous and vascular excitdJ^H
meat To accomplish this, the law of similars is our l*est guide,
thouf^h the use of morphia for the puriM»se ia not to be ison-
demne<l. The nervous tension may be subdued by coffea, stra-
rnonium, nclaea^ or i(piaiuiy and tlie vascular excitement by aco~
nitf, verairnm inn'rle, or i>erluips bellwinnnn. It should l)e
remembered al8<_>, that among the best sedatives at such a time,
are encouraging words, and perfect self-possession of the medical
atten»lant. Should he evince alftrm or excitement, his patient,
however placid before, will be inoculated with the prejudicial
ferment, and made less resinmsive to curative inlluencea.
Pressure on the fundus uteri will sometimes modify, or wbidly
arrest the loss. In applying it, much force must be avoided
through fear that all hoi>e of preventing premature lab*>r may lie
destroyed.
If foetal expulsion is clearly inevHable, the measures de-
scrilxni being inadequate to <:>vercome the tlow, or if the loss is
at all alarming, every effort should be directed towanl empty,
ing the uterus. In the conduct of a case up to the time whoa
preventive measures cease to be indicated, care is exei'cised to
preserve the membranes intact; but now as an approved, and, in
most instances, effective mode of treatment, they are punctureil
or torn, and the liquor amnii drawn off To do no more than
merely rupture the membranes may be insufficient, and hence.
ACCIDENTAL HEMORRHAGE.
aft^r proritling an tipening for escape of the amniotic fluid, it in
bettf*r, iK'tween pains, to crowd the presenting part away from the
brim Ut fiermit complete escape of the fluid By such an operation
the uterus is enabled to diminish its bulk, and by joint effect of
condensation and compression is often able to end the hemor-
rhage. "The puncture of the membranes," says Dr. Barnes, **is
the first thing to be done in all cAses of flooding suflicient to
cause anxiety before labor. It is the most generally effioacious
remedy, and it can alwayn be applied." Oooasionally the uterus
is sluggish, and rupture of the membranes is not folk>wed by
the favorable result sought. In that cnse it must be aroused to
action by kneading, by cohl appliciitions, by indicated homoeo-
pathic remedies, or even by ergot, pro>4ded the other conditions
are favorable. The tampon ought not to be used in such cases
unless it be inexorably demanded, and, if used at all, concealed
hemorrhage must be sedulously guarded against. An expedi-
ent far preferable to tamponing, is to firmly press the present-
ing pari into the pelvic brim, by means of the hands on the ab-
domen.
Delivery by the forceps, orpodalic version, should be effected
at the earliest practicable moment. If necessary, gentle manual
dilatation of the os uteri may be practiced, until the hand cjin
be introduced, or the instruments applied. The forceps are to
be preferred in case the vertex constitute the presenting part.
When once applied and traction begun, the special emergency
has passed, and the very presence in utero of the blades will be
likely to awaken the uterus to renewed activity, while at tlie
same time the head is being steadily drawn into and through
the pehnc cavity. If the forceps are not at hand, or cannot be
speedily obtained, or if the presentation is face or transverse,
then f)odalic version ought at once to be performed. If the
breech presents, we may depart from the ct)mmon rule of treat-
ment by bringing down a foot, and hastening delivery to the
extent of drawing the trunk into the pelvic cavity.
178
UTERDiE BUPTURE.
CHAPTER XIV.
Other Dlfflculties or Dangers Arising in the
First and Second Stages of Labor.
Rupture of the Uterus.— This most dangerous accident of
labor is fortunately a comparatively rare oocorrenca Bums
calculates tbak it happens once in 940 labors. Ingleby, once in
1,300 or 1,400; Cliuiclull once in 1,331; Lehmann. once in 2,433;
Jolly, once in 3,403; Ames, once in 4,883; and Harris, once in
4,000. In these calculations, however, we do not, of course, in-
clude n]]>ture8 of the intra-vaginal portion of the cervix uteri,
which is an exceedingly common occurrence. In their immedi-
ate oft'ects, the latter are rarely of mucli moment, though their
baneful influence on the health of women has been clearly de-
monstrated.
The Seat and Character of Laceration^.— Rupture of the
uterus takes place much less frequently in its upper part» and
the site of the placental insertion is rarely involved. The moet
oommon point of rupture is near the junction of the body and
neck, either anteriorly or posteriorly. In a few cases the cer\TX
has been torn away from the body of the organ in the form of a
ring.
The laceration does not ^ways inyol76 the entire thickness of
the walls. In some cases the peritoneum escapes, and, in other
instances, it is the only part that suffers. The extent of lacera-
tion is likewise variable. When complete and extensive, the
entire foetus and placenta, t4>gether with considerable blood,
may escape into the abdominal cavity. The direction of the rup-
ture varies greatly.
ETIOLOGY.
479
Etiolo^. — The predisposing causes are rather numerous,
ADil variable; the nature of souie uf tbeiu uot being clearly ap-
prehended. The occurrence of one or more former labors is
classed among them, and also advanced age. It seems clear, as
well, that there are certain alterations in the uterine tissues
which serve as predisposing causes of the accident. The -walls
of the organ, in some cases, have been found abnormally thin,
in certain parte. Morbid conditions of the mimcular fibres,
rach as accompany malignant and fibroid growths, the occur-
rence of fatty degeneration, and the consequences of blows and
euntusions, are likewise iucludetl among the strongly predispos-
ing causes. Dr. Traak,* who collected 417 cases, found tlie
eause of rupture reported in sixty-seven cases, and of the etiol-
ogy says: "We frequently find a diseased condition of the
uterus." Referring now to the sixty-seven cases mentioned, he
says: "Of ttiisnumlier there were thirteen healthy, twenty soft-
ened, twenty-one tliinned, one both thinned and softened, three
it some points thinned, and at otherH thickened, eight diseased,
one thinned and brittle." Then, too, pelvic deformity*, or the
existence of any formidiible obstacle to delivery, may excite ve-
hement action of the uterus, which in turn is capable of ulti-
mating in the rupture of its own tissues. Pelvic deEorniity also
gives rise to the accident, by compressing the uterine strictiues
between the jutting promontory, or symphysis, and the descend-
ing fcetal head.
The proximate causes of uterine laceration are mechanical in-
jury, and vehement uterine contraction. The organ, in a few
recorded instances, has been ruptured by falls, and blows, re-
eeived in the latter part of gestation The accident has als<j re-
sulted from violence, or unskillfulness, in the performance o!
eertain operations, as turning, and forceps delivery. The un-
usual force of the ut«rine contractions which have lieen found
io produce lacerations of the organ, in some well authenticated
instances have been augmented by the injudicious use of ergot
Jolly collected thirty-three such cases.
Threatening Symptoms. — In some examples of uterine rup-
ture, the actual occurrence of the accident has been prece<led
by premonitory symptoms, bat of an indefinite character. These
• Vidt "Am. Jour. Oba.," vol. »iv., p. 377.
480
UTEKINE RrPTimE.
have usually heeu described a.s acute, crampy pains in theh
gastrium; but, iu most iustaaces, no uucoiumuu symptoms Ixa
beeu observed.
Iiidieutious of Rupture.— The severity of the eymptoms ueo^
essarily depend iu great uteabure un tlio extent of the rupture.
A number of cases have been reported, in which subsequent evi-
dence of uterine laceration having taken place, has lieen found,
though the woman during labor presented no very alarming
symptoms. But there is usually a sudden^ sharp, and excruci-
ating pain, sometimes accompanied with a snap, audible to the
patient, and even U^ the bystanders. Then there is a recession
of the head or other presenting part^ if not already engaged in
the brim, and a sudden cessation of the recurrent contractions.
If tlie laceration in extensive, the child commonly passes throu
it int(5 tlip abdominal cavity, and its outline is easily tUsti
guishable through the abdominal walls. A coil of intestine
may prolapse through the laceration and descend into the va-
gina. The symptoms of collapse at once supervene, together
with a sudden gush of blood from the vagina, while the sounds
of the fcetal heart ce-ase.
The real character of the occurrence is in some cases masked
by the maintenance of strength, the presence of the presenting
part at the brim, and the continuance of fair pains. Dangerous
symptoms may not develop until after the lapse of some hoars,
or even days.
Prognosis.— The great majority of cases end fatally, but Dr.
J. M. Rose * has reported a case wherein uterine rupture t*x>k
place in four successive labors. Death may txicur from shock
or hemorrhage a few minutes after the accident, or may be p4ist-
poned for days, or even weeks, and ultiniaUily result from peri-
tonitis, septiciemia or pyjemia. A loop of intestine may be
Btrangulate<l in the fissure, or lie injured in re{K>sition. As will
be seen from the' following pages, gastrotomy has saved many
lives.
Treatment.— An important part of the treatment is of a
ventive kind, but this has been sufficiently considered iu
nection with the treatment of the conditions which p^dispose
to the accident.
m
Chimgo Me<l, Jrtiir, :*nd Kxam.,'* Aug. 1877.
TREATMKNT.
481
"Uterine rupture is a forinidable emergency, and requires
proini)t attention. If the eluhl has passed wholly or partially
into the peritoneal cavity, some advise that the hand at once be
introtluced, and, if the prospect uf delivery through the rent
appears to be at all encouraging, the attempt l)e made. The
child is seized by the feet, and extraction effected as rapidly as
the conditions will permit In di-awing the child through the
uterine rupture, there is great danger of bringing with it a loop
of intestine. This should be borne in mind, and an examination
be subsequently made for the purpttse of determining whether
that complication has been induced. It is proper that we add
right here, that there are very few crises on record of recovery
after tlie performance of this operation.
If the nterufl has contracted firmly so as to close and abbre-
viate the rent in the uterine walls, it may be clearly imjKissible
to deliver through the natural passages. If the body of the
claildlies but partly within the abdominal cavity, we will generally
stAcceed, unless the pelvis presents diameters which prevent ex-
fc**«ction without perforating or crushiug the head. In perforating
^-^-i* head, or applying the cephalotribe, the greatest care must be
^^^c^rcised, or it may escape the brim, and the ancliorage to the
J*<^:*dy thus }^e removed only to permit escape of the entire foetus
^*^"tti the alxlominal cavity.
li the head continues at the superior strait, and there are no
'■^surmountable obstacles to prevent, the forceps should be care-
*^-^>Jly applied, and the labor completed,
Jf there is no reasonable possibility of delivery p<?r vias naU
* *^<i/r5, we are left to choose between gastrotomy and tlie ex-
I*^-«tantplan of treatment, the latter of which modes, is practic«lly
*^ ^wmmit the woman to certain death. With respect U^ gastroto-
'^y we Ixtrrow from Playfair when we say that "of late years a
''^^*"ong feeling has existed that, whenever the child Jias entirely,
*^^ in great part, escajM^fl into the abdominal cavity, the operation
^^^ gastrotomy affords the mother a far better chance of recovery;
*^«1 it has now been performed in many cases with the most eu-
^^^^^araging results. It is easy to see why the prospects of success
**^ greater. The uterus being already torn and the peritoneum
^pened, the only additional danger is the incision of the abdom-
^^^ parietes, which gives us the opportunity of sponging out
[
482
UTERINE nrPTURE.
the peritoneal cavity, as in ovariotomy, and of removing all the
extravaaated blood, the retention of which so tierionely addb to
the dangers of the case. Another advantage is that, if the pa-
tient be excessively prostrate, the operation may be delayed
until she has somewhat rallied from the effects of the shock,
whereas delivery by the feet is generally resorted to as btxin as
the rupture is recognized, and when the patient is in the worst
possible condition for interference of any kind." Not only this
is true, but, judging from the results thus far obtained through
gastrotomy, we cannot but agree with Dr. Robt P. Harris,* who
says: "1 am fully of the opinion that we ought to go much
further than this, and operate in cases even where the child can
be readily delivered jicr i^'as nafurales, if there is a decided
rupture with escape of blood and liquor amnii into the abdom-
inal cavity, for the removal of the«e tluids is only second in
importance to that of the fcetua In corvico-vaginnl rupture
this is not so im{>ortant, as tliere is generally a naturfil drainage,
but where the body or fiindns has been freely rent, there is no
security equal to that of opening the abdomen and cleaning
it out"
Comparative Results of Various Methods of Treatment,—
The following table compiled by Jolly fumishefl a strong
proof of the comparative advantages afforded by gastrotomy:
COMPABATIVE RESULTS OF VARIOUS METHODS OF TBEATSTENT
AFTER RCPrniE OF UTERUS.
Treaimeat. Number of Cucst
^pectAnt plan. 144
ExtractioD per vitu naturaUs, 36*2
Uasirolouy. 38
The relative success of different methods of treatment haa
been collected by Dr. Trask, and is tabulated as follows:
(A) When the head and the whole or part of the body had
escaped into the peritoneal cavity.
(B) When the pelvis was contracted-
)cathB.
Recovericft.
Per Cboi. of Recoveries
142
2
1.45
310
Ti
UK
12
'26
B8.4
QASTROTOMY.
A.
B.
Saykd. Lost.
Savkd. Lost.
16. 4.
6. 3.
• Vide Playfaib'b " System of Midwifery," Am. Ed., 1880, p. 439L
TREATMEXT.
483
TURNING, PEBFOKATION, ETC.
A. B.
Saved. Lost. Bavkd. Lost.
23, 5<) 15. 30.
ABANDONED.
A B.
Saved. Lf>HT. Saved. Lost.
15. 44. 0. II.
Dr. Harris has collected forty cases of gastrotoDay after ute-
rine rupture, performed in this country, out of which number
tiitire were twenty-one women and two children saved.
L The chances of Buccess are much enhanced by the exercise of
^reat care in tlie performance of the operation, and wlien tliat is
^one w^e may reasonably hope t*5 raise the operation in point of
success nearer that of ovariotomy.
1 "We believe," says Dr. Trask, '' that a neglect of this mode
f ^of delivery has contributed much to the exaggerated estimates of
"^he mortality of this acciilent, which are so generally entertained,
^it is an operation requiring no little resolution nnd tme courage
'Zander the trying circumstances in whicli the physician is placed,
-^and consequently arises the need of settled principles of prao-
'fcice to guide one in tliis extremity." ♦ ♦ • « "jj^ short, as
^Q general rule, from whatever cause we might be led to anticipate
^a protracted and difficult delivery by the natural passages, gas-
^^ritomy will afford the best chance of recovery."
I The woman will require the most considerate treatment in the
^^uerperal state, differing but little, however, from that given
I^mtients who have undergone fatiguing lab*)r, or operative inter-
ference. Judicious stimulation will greatly aid in overcoming
"^he dangers arising from shock.
Lftceration of the Certix Uteri. — This part of the uterus
^^requently suffers laceration during the passage of the foetus;
f^^^indeed, there is no doubt that in the majority of cases there is
^^ere more or less solution of continuity. Traumatism is more
kble to result when instruments are employed, than in unaided
The significance of cervical lesions of this sort belongs,
does the treatment^ more properly to gyns&oology.
Lacerations of the Ta^ina. — Lacerations of the vagina occur
^3^^^ frequently. Indeed, slight ruptures are very common
■ISl
LACERATION OP TEB VAGINA.
accidents, but as a rule, they give rise to no serious Bymptoias,
aud hence escape attention. Severe injuries of the sort usually
come in connection with instrumental delivery. If the rupture
is deep enough to include the entire thickness of the septum,
anteriorly or posteriorly, the passage of urine or foocos is Likely
to prevent repair, and thus a vesico-vaginalj or a recto-vagitial
fistula result.
But fistulic more frecjuently result from long-continued com-
pression of the pelvic tissues by delay of the foetal head in the
pelvic cavity. In such cases the tissues become devitalized,
and as a consequence, a slough comes away within the first few
days succeeding delivery, followed by the evidences of fistula.
Treatment. — If lacerations of the vagina bxq known to exist,
they should l>e thoroughly cleansed several times a tlay for
three or four days with an antiseptic wash, to lessen the risk of
septic poisoning. If they involve the septum anteriorly, it will
be well to pass a rubber catheter, and allow it to remain for
four or five days, in order to protect the lacerat^il surfaces
from the irritation of the urine, in the hope that repair may
take place. Should such fistula? persist, as they usually do, tiie
w^oman must await relief from operative procedures, to be per-
formed at a later period.
Laceration of the Vestibule.— This accident is not an un-
common one, and it sometimes gives occasion to much annoy-
ance.* As a result of it, and the swelling and soreness to which
it gives rise, the woman is unable to urinate for a nunil>er of
days after labor, and use of the catheter is attended with un-
usual Piiffering.
* In only nin^ cones out of twenty-five exjunined by Dr. Matthews Duncan
was the vestibule untorn.
VAHIETIEH.
485
CHAPTER XV.
Difficulties and Dangers Arising iu tlie Tliird
Stage of Labor.
Post-purtuiu Hemorrhage.— Flootlings after delivery pre-
sent u variety of symptoms, and hence may be *livitled acconling
to their mauifestatious iuto several classes. Thus we have:
1. Eiterual hemorrhage.
2. CoucealoJ, or internal, hemorrhsga
3. Primary hemorrhage.
4- Secondary hemorrhage,
5. Heioonhage of various degrees, viz: First degree, Second
degree, Third degree.
1. When the How meets with no restraint, but passes the
ndvn, sometimes in sparing quantities, again in alarming
gushes, it ronstitntes external hemorrhage.
2. When, owing to some obstacle encounteretl at the cervix,
the bhK)d which fl(»ws from the uterine vessels is held in utero,
we term it concerJed hemorrhage.
In the same category may also be included that form of bleed-
ing wJdch e8caj)e.s the atteniion of tho.se under whose care the
woman has been placed, until a considerable pool has
formeil in the centre of the bed Such flooding is, aometimes,
but should never l>e. concealed from ^aew and knowletlge.
3. Wlien bleeding in any considprable quantity occurs within
Ihe first two or three hours after labor, it is regarded as primary.
4. When postponed until a later period, it is properly seoond-
ar\'.
5. Hemorrhage of the first degree is that wherein but little
486
POST-PARTtnC HEMORRHAGE.
reanu ,
blood is lost, though for a moment it may flow in a stream.
This occurs in perhaps ten per cent of ail labors.
Hemon-hage of the second degree is that which comes in
fuse gushes, and does not yield at once to abdominal pressure,
but requires the use of cold or hot applications for its arrest*
and even then, perhaps, manifests a disposition to return.
Hemorrliage of the third degree includes dangerous bleedings,
wherein the loss is excessive, and the prostration profound.*
The Causes of post-partura liemorrhage are yarious, and aa
an indispensable bases for intelligent treatment, require thor-
<jugh study.
1. Among the indirect or predisposing causes we may men-
tion/jr*7'//j//(i/f?/a/w>r. It is not altogether clear why a uterus
which has expended but a i>art of its nervous energy in esj>ul-
Bive effort should L>ecome atonic, and bleed profusely, as
as labor is brought to a close, and yet clinical exi>enoneo teac-
that it is a relatively frequent occurrence. Very likely the elTect
is produced by temporary exhaustion, arising from the intensi
of the labor while it lasts, musculai' inertia following here, as
does elsewhere, upon the hoola of violent exertion. Ctmtractio
may be remarkably powerful, but if not long continued, vital
force is sustained. In rai>iil hilH»r many times there is warcely
any real intermission between the pains, and occasionally but
slight remission, as the result of which strain, exhaustion event-
ually results.
2. Following unduly -prolongetl labor we sometimes get a si
ilor condition. Contractions having been forcible, perhaps,
intermittent, action is well sustained; but want of relative \
portion between the foetus and the pelvis, or the existence
some mechanical obstacle, resists advance for bo long a {leriod
that uiertia becomes a sequence. Action in such cases can gen-
erally be sustained for a long time, but the uterine muiicle«, li^a
*Dr. B.irDefl ha.s given us a very wientific ami practirul distioction hflwi
the int«aHity of syinptoniB, dividiug them into three degrees which w>rn»]i
with those aliovfdcATibed. In heiiuirihuKe of the fl n*t dcgrc*?, the diusiull
runctiuiiis mainlaiiKHl li)ta<!t. hut itsiLrtiun is diMinlm-d; in Ihut of thu xfioi
drgTff. Ihf diaaliiltie fonc in markedly diminished ; and in that of Uic iJiii
the diturtallic force is su3pendi'4l. (lutcnint. MM. Conj^ress..! "Am. Juur, Ol
vol. liv, p. im.
q>U^,
soc^^l
ic'he^^
1
i
n^
CAUSES,
487
Bunilar stmctlires in other parts. muBt> a£ter loug and vehemeut
effort, have a prolonged period of rest Labor being completed,
and the stimulus by which the uterus has been provoked to
action removed, it falls into atony at an unfavorable moment,
and is not easily aroused to renewed activity. Labor, in point
of duration, presenting either extreme, should then be regarded
as a predisposing cause of post-partum hemorrhage.
Beside the direct hemorrhage somotimes resulting from cer-
vical' rupture, there is no doubt that the accident occasionally
indirectly produces uterine relaxation, and consequent hemor-
rhage. This is probably not so pronounced respecting the pri-
mary, as the secondary, form of post-partum bleeding. It has
been shown liy Emmet and others, that proper involution of the
atems after labor is embarrassed or prevented by cervical fis-
Biire. The uterine cavity being accordingly more capacious than
normal, exciting causes combine to bring about congestion of
the organ and consequent blood-loss.
Flaccidity of the nterns after labor, and the bleeding result-
ing from it, are, doubtless, often the consequence of slovenly
practices, —a neglect of those iletfiils which should be matters of
routine in everj* case. Deliver}' is suffered t<:) take place while
Ihe bladder is distended with urine; the extended head is i>er-
initted Ut obstruct j)arturition for an indefinite time without any
attempt at rectification; the practice whirh nearly all cuueur in
Cum mending for every case, namely, pressure on the fundus uteri
during foetal expulsion, and aft+*r, is totally disregarded; or, fin-
ally, the placenta is prematurely extracted.
Constitutional dyscrasifle account for a small {)erceiitage of
Ottses. There is what has been termed the hemorrliagic diathe-
sis, or hemophilia, which strongly predisi^ses to Hooding. This
is generally ujiderstood to dei>end on an abnormal contlition of
the circulating fluid, which favors its escape from the blood ves-
sels, whether mptureil or not There is a condition closely
Rllied to this, wherein post-partum bleeding de|>end8, not so
much on an abnormal state of the blood itaelf. as upon constitu-
tional predisposition to lax muscular tone. Such women have
been termed ** bleeders," inasmuch as, though sometimes appar-
ently well nourished and vigorous, they suffer from tloodings in
488
POST-PAHTUM HF.MORRRAOE.
repented confinements to the extent of producing sjncope and
excessive exhaustion.
Repeated child-bearing predisposes to the accident, it rarely
occurring in first labors.
The proximate, efficient causes, are first, and most frequently,
nierine atony, flaccidUy^ irwriia.
In general, we find after expulsion of the foetus and placentA
the uterus contracting into a globular-dhaped mass which is felt
in the hypogastrimu, and whicli from its tirmness and form has
been termed the cannon-ball vonlractiofi. Such firm coudensa*
tion compresses the large blotKl-vessels of the organ, thereby
effectually preventing loss, and rapidly hastening permanent in-
volution. It is clear that this favorable state is brought about
by the muscular tone which the organ still maintains, despite
the severe strain to which it has been subjected. Now. when*
from any cause, this firm condensation of the blood-loeded
i trgun fails t4:> take place, the gaping vessels, at the site of pla- '
cental attachment, encounter nothing to restrain a free escape of
the warm life-fluid which they contain.
Probably ninety-eight per cent of all casee of post-parhun
hemorrhage owe their immediate origin to this condiliou <»f the
uterus, and hence it ought never to be out of mind in the con-
duct of labor.
There sometimes exist oliatacJes to the proper contraction of
the womb when delivered of the product of conception. A hiri^e^
accumulation of urine may interfere materially, not only by <li-
roct encroachment upon the space afforded the pehnc organs;,
but also by sympathetic action. Attention to the bladder dur-
ing and after labor is a matter which yonng practitioners, before
they have acquired routine habits, are extremely prone to neg-
lect
Tumors, generally fibroid, may thicken the walls, or en-
croach on the cavity of the ut«*rus, thereby preventing a com-
plete, safe, and equable condensation of the organ, and expoeing
the woman to serious, perhaps fatal, loss.
In certain instances Uiere is hemorrhage eacaping the mlva,
not very profuse at any time, but continuous, though the uterus
is firmly contracted. Failing to subdue it by ordinary means,
we learn, on careful examination, that it prooeeds from a laoera-
PREMONITOUY SYMPTOMS.
489
N
^
N
tion of tissiie involving a blood-vesfiel. The circular artery of
tbe cervix is sometimeB ruptured during pfisBugt? of the fo^tuH,
giving riae to considerable Banguineoos flow. The vestibule,
which sofierB a solution of continuity oftener than is generally
aappoaed^ occasionally bleeds profusely from iU lacerated sur-
faces.
Premonitory Symptoms. — Post-partnm hemorrhage some-
times gives notice of it;* approach, but the signs are so ambigu-
ous that they OBoally fail to l>e understood, and hence are of
trifling avail, Bbort, sharp pains, followed by complete utenne
relaxation, are said generally to presage tlie il1-(»ccurrencp.
8oaie light is shed on the probabilities by an acquaintance with
the woman's history, and by observation of her Itodily habit If
she gives an account of pre\'ious blee<lings, whether post-partum
or other; if menstruation has been habitually profuse; and final-
ly if the tissues of the body give general evi<lence of lack of
tone, we have reason to feur hemorrhage after delivery.
A rapid pulse was formerly regarded aH a highly Buspicious
symptom, and, so long as it continaed, the woman was thought
to be in imminent danger of the accident under consideration.
The same opinion is still held by many, but it appears to have
little ground in clinical experience on which to rest Dr. J.
Aahhurton Thompson • has made extensive and minute observa-
tions, and as a result thereof has been led to l)elieve that "tliese
notes justify a contradiction of the bare assertion that a pulse
which beats at or about a hundred shortly after labor prognosti-
cates inertia of the uterus. ♦ • ♦ These notes show that in
fact I have disregarded the pulse rate as a prognostic, or indica-
tion, of my patient's safety from hemorrhage." Dr. M. M.
Bradley j found in 300 cases that the pulse was from 50 to 130l
" From these obsenations." he says, ** I am not inclined to
attach much importance to the pulse-rate, either as a sign of
clanger, or of jx>8t-partum hemorrhage."
The degree of blood-pressure very likely has some influence
*o produce and maintain hemorrhage from the uterus after la-
^'^ and it is a physiological fact that with high arterial tension
ve most frequently have a pulse of but moderate rapidity.
•**0b6trt. Jour." vol. v., p. t86.:
f^^roL vii,p.&66.
490
P08T-PARTir« HEMOBRHAQE.
General Symptoms.— Hemorrhnge sets in as a rule ftc>oj
ftftor expulHion or extraction of tho placeutii, iiuil nearly alwa
•within the forty-five minutes immediately succeeding. O
Bionajly it begins when yet the secundiuea rtimnin iiudeliver
while the attendant is ^ving the child necessary attentii*
AVlien so occurring, the placenta is generally observed to be
the vulva, its separation from the uterine walls having prepar<
the way for bleedinf^.
If tlie hand restH uimjh the fundus uteri, as it ought in eve;
case, at this stage of delivery, coutractiou, which at first ma
have l>een good, is observed tt> relax, and the womb which w
easily felt Avhile in a cfindensed form, now escapes, so that i
outline cannot he clearly defined. It will l>e understood tha^
pressure upi»n the fundus is not necessarily made by tlie physi^
cion, as he has other duties that cannot bo delogato<i to a n
but the latter person, or even the woman herself, under sui
ble direction and supervision, may exercise the ne*^essary co
pression. It is when the hard globular e-ontraotion ceases,
danger of serittus loss of bhMKl begins, and at such a time^ espe-
cially in multiparrt), we di» well t*) be on imr guanL Ocaasioi
examination should lie made, either by touch or viaion, wl
there is any reason to suspect an unusual flow. To make su
of acciuate knowle<ige (xnicerning bluod-loHs after deliver^', it
well at once to apply a clean napkin, and then, by inspect]
this, we can basily determine with approximate certainty, t
auKmut of flow.
The bleeding generally N^gius suddenly, and often oeasea
suddenly. There may l>e but a single gush, or one may succ
another, and rapidly reduce tho woman. Sometimes the fiow
oomi>arativcly passive, but exceedingly persistent, B<»tbat in half
an hour there will be gi-ejit depletion. In bad caaes the bl
runs in a torrent, and rapidly drains the system.
In concealed hemorrhage after delivery, the womb, th
|}erhap8 at first firmly contracted, becomes flaccid; on im
ment, frequently in the form of acoaguluin. obstructs the flo
the uterus offers but feeble resisbmce, and bleeding gt>es
within. In case the hand is kept projjerly applied to the n
domen, and search made for the uterus by firm kneading, wh
it escaping the fwd, tliere is little likelihood of dangerous at
SYMPT0M8-
491
C(>a]e*i hezDonrhage. Jiad examples of hemorrhftge jire met iu
those cases wherein abdominal pressure is neglected, or the
bleeding begins a considerable time subsequently to labor, after
watchful care has ceased. There being no outward indication
of the flow, its occurrence is not often recognized until the effects
of tlepletion are manifested in the countenance imd feelings of
the woman. She will complain of great eKhaastion, and may
foil into a state of syncope. Alarmed at her con.lition, the phy-
sician feels her wrist ouly to find the pulse feeble and fluttering,
or not to discover it at all. The hand on the abdomen obtains
clear evidence of the uterus distended with blood, while firm pres-
sure causes it to gurgle foi*th into the bed.
There is a spurious form of concealed hemorrhage that is
manifested as a result of professional ignorance or inattention.
The ordinary precautions are disregarded— the fundus uteri is
left uncovered by the hand, none of the signs of bleeding
are watched for, and the accident is far advanced before the
guilty attendant is aware of its existence. Blood [tours forth
noiselessly, while tJie patient, reposing the utmost oontidence in
the skill of her physician, rests quietly, until she feels a deathly
sensation stealing over her, when she cjdls for help. On throw-
ing up the bed covering there is found, to the consternation and
ahame of her dull attendant, a great i>ool of bloo<].
The symptoms of i>ost-partum hemorrhage difler mainly in
intensity. There may be but a brief flow, producing no s^jecial
effect on the woman, and this is the sort which tlie young practi-
tioner so often meets, and which responds readily to a dose of
ipecac, or hclUtdmina^ In other instances, happily infi*eqnent,
the flow begins like the other, is a little more free, and is in-
dispo8e<] to surrender to the remedies mentione<,l. or to any other
potentized drug, but ultimately ceases, either from natural
causi^s, or manual treatment combined with refrigeration. In a
third class of cases, the flow comes suddenly, and si)\irts from
the %'ulva like water from a pump, waits for nobtMly, is unmind-
ful of drugs, does not yield to either cold or heat, and in the
absence of proper treatment hurries the patient on through the
various stages of loss, down to death. The extremities become
cold and damp; the ctmntcnance gets pale and ghastly; the pulse
rapid and small — perhaps intermittent; the limbs weary, and
192
POST-PAllTDM HEMOBRHAOE.
yet restless. There is sighing respiration, dimness of vieion,
and syucope. Later tlie whole body, and even the brecth, growa
coul; intense restlessness and jactitation, supervene; and deatii
ends the scene.
Primary hemorrhage occurs soon after lnb6r, generally within'
the first hour, and for this reason, among others, the physician
ought to remain with his patient during that time, Post-partam
hemorrhage in general is of the primary vai'iety.
Secondary Hemorrhage after labor at full term, is generally,
consecutive upon other symptoms which indicate a retention iu!
utero of a fragment of the seoundines, or a coagulum; the exist-
ence of interrupted-involution, or of midposition of the organ.
When the placenta is delivered in any case of labor, it ought
to be cfirefully Inspected to make siue that no part is left bo-
hintL If much traction force is applied to the cord, the bulk
of the organ antl membranes m«y l)e brought away, while a jxir-
tion, large or small, is left behind. Disintegration of sufh
fragment usually takes place, and the detiitus passes off in thi
lochia, without disturbance; but in other cases, hemorrhage re-
results.
Tliere is developed in rare instances a supplementary'^ placenta,'
placvnia sitcccniuriata, the connection between the organs being
marginal, and the smaller, or secondary one, may be left behind.
Any examination but the most minute, would scarcely be suffi-
cient tt) disclose the fact, and it comes to light only when hem-
orrhage, or septic symptoms with oflensive discharges, lead to
uterine exploration.
In few cases of secondary hemorrhage do we find the flow^j
extremely profuse. It is alarming on account of the period whei^^|
it occurs, the time for flooding presumably being past Still,^^
the patient occasionally evinces signs of great depletion, and
may present threatening symptoma
During the first few hours and days after delivery, even in
normal cases, the woman is in a state favorable to the develop-
ment of a variety of ills, and, among them, sudden and profuse
blood-loss. A powerfid disturbance of the emotional nature ia
sometimes an exciting cause. Great joy, anger, or fear is capa-j
ble of giving rise to serious, even fatal hemorrhage. Instancei
4
TBEATMENT.
m
of the kind have been placed on record, and stand a3 reminders
of possible occiirreuces.
ProgmosiH. — The remote effects of excessive loss, some of
which have been mentioned in another chapter, should not be
forgotten. A train of ills is liable to follow, and make misera-
ble an otherwise happy life. The immediate prognosis in most
cases is favorable. The great majority of women do well after
AotxlLng, and some authorities have accordingly taught that it is
more alarming than dangerous. There are always entailed a few
days of suffering from headache, prostration, and, may be, vom-
iting and purging. Then follow eouvalesenoe, and, in favorable
cases, perfect restoration. But the exceptions occasionally ob-
served, in respect to b«:»th immediate and remot^ effects, should
give to the favorable prognosis an air of seriousness.
The more remote results of hemorrhage are insanity, phleg*
masia, pelvic inflammations and general peritonitis.
Treatment, — Preventive, ireaiment is of the utmost conse-
quence, and yet it consists in the adoption of but few special
rules. The directions given for the conduct of normal labor
are generally sufficient of themselves, when scrupulously ob-
served, to prevent the occurrence of untoward symptoms after
delivery. If we make it a rule of practice to attentively observe
tlie progress of the head through the pelvic cavity, and see that
it follows those positions and movements which are favorable to
ready performance of the mechanism of labor, which in their
turn preser^'e the uterus from undue exertion ; if we keep the bla<l-
der empty; if, upon expulsion of the child, we apjjly an assist-
ant's hand to the contracting uterus, and keep it there, not only
to the close of the third stage, but for a considerable time tliere-
aftor; if, finally, we combine Cred6's method of placental de-
livery, with slight traction, if necessary, on the cord, we will
rarely indeed have thrust upon us for treatment a severe case oi
hemorrhage. Credo's method of placental delivery commends
itself, with much emphasis, to our adoption.*
* We may judge of the improvpmoni effected by tlie introdactioD of Cred6ll
plan of treatment, from the statiBtica of Pkwsi, (Wiener Mc-dicinische Wochen*
Bchrift, Nob. .3()-;i2, 1863,) who says that, in the Clinical wards at Vienna,
where the new method was in every infttiince adopted, the cases of poet purf
nm hemorrhofre amonnted only to 1.47 per cent., while in tho other wardj^
w'trre the old line of praflice was f.)Uowrd. they amounted to ^.W per cent.
494
POST-PAUTDM HEMORRHAGK.
Occasionally we will feel called upon to adopt more epeci
treutmeut for the prevention of iinpeuding danger. The womiin
perliaps Is a "bleeder/* and gives a history of a previous ti
ing of a most violent tyjje; or, it may be, without any such
tory, the uterus, from exhaustion of its overworketi powers of
endurance, toward the close of the propulsive stage manifests
unmistakable symptoms of inertia. In either case, ordinary
routine conduct may prove inadequate to avert the threatened
accident In such occasional instfinces justice to oar pationta
demands that we bring to bear f<:»rces better able to meet and
temper tlio crisis. The path(»logicftl wjndition of the uterus,
which we fear will be developed as soon as tliat organ has bee
emptied, is flaccidity of its walls, giving free escajw? t<» the bU
circulating within. Now, if there is any remedy which is oupa-^
ble of stimulating contraction, without at the same time eeri
ously harming the patient, in the name of humanity it ought to'
be given. Ergot of rye is capable of doing this ver>- thing in
the great majority of cases; but to get the effect, it must be a
ministered in appreciable quantities. A single dose of ono
drachm of the iiuid extract (Squibb*8 preferretl) may be give
by the mouth, or ten drops of the same may be injected dee
into the tissues. The latter mode of administration is to be p
ferred, as when so employed the drug act« with greater celerity^
certainty, and force.
The time to administer ergot as a preventive of post-portum
hemoirhage, is when the head lies at the pelvic outlet Delii
ery may be effoctoti by the forceps, or by the natural efforts, an
tlie placenta subsequently removed. By the time this is done
the drug will have produced its effect, and firm uterine con
tion will l>e established.
Those who fear to employ ergot in the manner preBcrilxHl, or
who look upon such an act as reprehensible in a homneopathic
practitioner, will prefer to search eagerly for charactf^ristic
symptoms of some attenuated drug. Special indications ma'
be found for pithnlilla^ chinOy canlophifllum, f^elscmi'inri, ustiUnjn^
or even secale\ and tlirough its emi)loymentthe desiretl end may
be attained.
Dr. McClintock advocates rupture i»f the membranes. "I
have adopted the precaution of ruptiuing the membranes," bi
TREATMENT.
495
Bays, "on very luuiiy oocasious, and am ful]y persuaded it is a
most valuable, and always u feasible auxiliary in tbe prevention
of flooding after ileliverj'." Dr. Dewees accounted it tbe prin-
cipal means to be relied on for tbe purpose of averting tbe ac-
cident*
In addition to tbese means, it is advisable to immediately ap-
ply tlie cbiUl to tbe breast Tbe close syinpatby between the
breasts aiad tbe uteiiis gives significance to tbe act
Tbe room occupied by the patient should be cool, and free
from a comjjany of noisy, excitetl women. Let everything be
done decently and in order, without confusion or agitation. TJie
physician, ab(»ve all, in such an emergency, should keep his emo-
tional nature in perfect subjection. He must not stop to pon-
der pcjssibilities, or probabilities, or to reflect upon his immense
respf»n.sibilities, for these will bo patent enongb. He is the pre-
siding genius, and the result largely depends on his executive
ability.
Heniorrhage of the First Dofftee.— Under foar, or excite-
ment, tlif youijg practitioner is liable to adopt too vehement
practices for the arrest of hemorrhages of the first degree. It
ehonUl be reuipmbered that the last stage of labor is always
accompanieil witli moi*e or less bUHwl-loHs, an<l if not remark-
ably profiise or prolonged, it need excite no alarm. To apply
ice anil snow to the abdomen, or carry it into the vagina; to dash
cold water over the alxlonien, and to i^ass tlie band into the
• The following hints on the pmphylaxiH of jMwt piirtum licmorrhagt^, hy T>r.
Pryor (Am. Jour. Obn.. vol. x., p. (iliH.): '* It is nni at all infrwjiient thai we
are calle^l to attend woniRn who have hud homorrhftge foHowiiijc their previ-
mi»contiuements, and who Ujok foiwitrrl l<o the rlosiMirfirftlAtion with (ear and
trvmbliog, the prMlispoHtng causes of hcmorrhugt durint: pregnancy and partti-
riliou being iutvusified by the hemorrhAgic diutbe^in. By guininj; their entire
»nnfideni« with the amurunce that wc pnawAH means of prevention almost in-
fikllible* we gain an mlvanto^e of no little vnlne a^ a meann nf prophylaxis.
Take a case where yon have reaHon to apprehend, or where hemorrhage has
ttt.'tually act in, apply » li^atnre or handage faltont an tneh in width) around
each extremity, aw ehwe U) the body op possible^ drawing them miflflciently
tight to arrest the return of venons blood without materially nffeetintf tbe ar
terinl drrnlation. then proce<'d with your other mechnnical an well a«
medicinal niccnta." Dr. Pryor puts prcftt confidence in this mode of prevent-
We treatment.
196
POMT-PARTCM HEMOHKHAOR.
womb for the purpose of checking Buch a flow, is not only un-
jiecessary, but jK>aitively unwise. The fundus uteri should be
pressed firmly with the palm of the hand, which may be mad©
cold by dipping in cold water, and in a moment the flow will
cease. We should not neglect this procedure for the purpose of
admmistering a remedy, however well indicated. The most
effective treatment must be adopted, or a slight loss may be
transformed into a profuse hemorrhage. The womb in such
cases seems a little undecided between contraction and expansion,
and requires V>ut a suggestion to determine its choice.
In this same class wo may properly mclude that variety of
heraorrliagfi wluoh tlepends on a Im^eration of the cervix or ves-
tibule. The flow is not profuse, but is persistent; and firm con-
traction of the uterus is f»bHerved to have little affect on it The
bleeding vessel sometimes requires a ligature, in order to apply
which to the cervix, the uterus must he drawn down by a tenao^
alum, or volsella, and the vessel secured. Torsion will answ
jufit as well it properly made in accordance with the usual di-
rections, viz: to seize the vessel firmly and make two or three
turns with the forceps. The aj>pli<',ation of cold, or if necessary
B styptic like the perchlonde of iron, will usufiUy answer every
purpose The vestibular bleo<ling is more easily oimtroUed than
the cervical; a piece o! ice or snow applied to the i>art for a
moment or two being sufficient to arrest it in nearly all c^i^^e^
Hemorrhage of the Second Decree. —The treatment for
fiooiling of the second degree is first, the use of coUL Cold
water is always procurable, and the hand may l>e plunged iuto
it. held there for a moment, and place<l on the abdomen with
firm pressure. If this does not excite contraction and arrest of
the hemorrhage, the other hand may \ye similarly dipi>e4l and
then carne<l into the vagina. Repeat the latter movement a num^
ber of times, if rwjuiretL
IVith the fijigers in the vagina, uterine contraction is some-
times excited by irritating the cervix uteri. Should anything bo
discovered at the oe, as, for example, a fragment of plftoenta, or
a coagulum, it must be removed.
The medicinal treatment for such an accident ought to l>e re-
garded as sul>sidiary to tlie mechanical, and yet most not be
despised. The sj>Bcial indications for remedies will be given ai
■m
TREATMENT.
497
tLe dose of thifl chapter. There can be no reasonable doubt of
the efficacy of the closely affiliated remedy in regulating the
disturbed vital action, and thereby subduing post-partum hem-
orrhage; but in view of the extreme liabilit>' to error in our
choice of remeiliGis, and the certainty with which other measures
can be employed, tiie latter should first be applied, and then re-
inforced, if necessary, by the former.
Hemorrhage or the Third Degree.— Hemorrhage of the
second degree by mismanagement or neglect, may exceed its
bounds and merge into that of the third. In managing the lat-
ter, firm pressure upon the fundus uteri must not be neglected,
for really this is tlie most irai>ortftnt i>art of treatment Every
effort shoidd be made to keep the uterus under the hand, and
well depressed toward, or into, the i)elvic cavity. No decided
intermissions should be allowetl, but a certain amount of knead-
ing will be lienefioial.
Cold water may l)e used as above indicated, or instead of it,
ice may be applied to the abdomen, and introduced through the
Tulva, or, if thought recjuisite, even uito the uterine cavity.
Snow may be similarly used Some have recommended pouring
cold water from a height on the abdomen, but the mlvisability
of so doing is questionable, save in the c^ise of warm, vigorous
women. Such refrigerati(»n woukl l>e too great for others. Much
harm may be done by an injudicious use of cold. Let it be
remembered that the action of refrigerants derives its efficacy
mainly from the first impresaion which it makes, and it ought
not to be long-continued-
The other extreme of temj>erature is just as fruitful .in good
results. Applied to the lumbo-sacral region, hemorrhage from
the womb is sometimeb speedily arrested by it Within the last
decade, liot water has been found a most efficient means for con-
trolling uterine hemorrhage, when injected directly into the
uterine cavity. There is little or no danger connected with the
operation, provided there is no obstacle to free escape of tlie in-
jected fluid. Immediately after labor, the os uteri is so open
tliat the water can easily flow away, and the uterus at such a
time will safely tolerate more than at any other. If the opera-
tion is undertaken, the nozzle of a fountain syringe may be
passed through the os uteri, and up well to the fundus, against
498
P08T-PARTUM HEMORRHAGE.
which the stream should be directed. Care ought to be exer-
cised to prevent the introduction of any atmospheric air- It is
said by many who have adojjted tliis mode of treatment, that as
soon as the stream of water, at a temi>erature of 115*^ to 120*^,
strikes tlie uterine walls, w^ntraetiou is excited, and the hem*
orrhagc ceases. There is, however, some adverse testimony. Dr.
Stedmau rejiorts having failed to arrest a violent flow by means
of it, being tinally driven to tlie use of i)ercLloride of iron. Hot
water doubtless arrests uterine hemorrhage by a double aciiun,
namely: by itp styptic, and by its stimulant effects.
One of the very best expedients for overa)ming such floodings
IB to introduce the hand into the womb. Some entertain a mor-
bid fear to perform such an act, but the fact is that, if gently
done, it is almost dovoid of danger. The 'soft pelvic tissues
have been contused and lacerated by ruthless operators, hut the
considerate will be guilty of no such harshness.
In these instances of dangerous hemorrhage, the hand is
carefully passed tlirougli the vidva and os uteri, until it reaches
the uterine cavity. Here, iusteiid of firm tissues, and a con-
tracted space, it finds remarkable flaccidity and considerable
room. The walls of the organ seem petmliarly soft ainl yield-
ing, being " folded together," as Cazeaux graphically remarl
*'like a piece of old linen."
The very presence of the hand communicates a stimulus to
the uterus, which is generally sufficient to excite contraction.
But this is not the only result which may be obtained by the o|>er-
ation. The relaxeil state of the organ is many times dei>endent
on the existence in utero of coagula, and firm condensation can-
not be acquired and maintained uiitil thej- are removetl. Ac-
cordingly it is set down as one of the most imjwrtant principles
of treatment, to ihormighhj evacuate ike uierus.
Ergot has been recommended as a remedy for all forms n
dangerous uterine hemorrhage, and yet there appears to lie litUd'
place for it here. Hemorrhage of the third degree generally
runs its course too rapidly for us to expect much aid from tlii
remedy, especially when administered through the mouth, nn(
the other degrees of hemorrhage do not require it
Despite the treatment above recommende<U flooding may con-
tinue, or be no more thau temporarily subdued, and for huch
TUEATMENT.
499
caseB we have farther trenhueut which has many times availed
to save lifa Styptic iutru-uterine injectious of variouB Bub-
stAuces have beeu recommended, but that which has afforded the
best aid is the perchloride of irou. This is used in strength
Tarying from one part of the iron to ten of water, to equal parte
of each, and even stronger. It should be thrown into the uterine
cavity, the pomt of the syringe being carried nearly to the fun-
dus of Uie organ. Before doing so, however, the utenia ought
to be cleared of coagnla and fragments of placenta. The action
of the iron is to cxia^^ate tho orj^anic principles of the blood,
and at the same time to have an astringent effect on the blood
vessela and surrouiuling tissues. This is a dangerous expedi-
ent, and must never be resorted to save under the demantls of
iue\orab]e necessity.
The supply of blood to the pelvie viscera may be modified by
firm pressure on the abdominal aorta. Tliis large blood vessel
can be easily felt by depressing tho abdominal walls on the left
side of the spinal column. Osmpression ought not t<> be long
continued, and should be made with great care. A temporary
arrest of the dow will give time for the formation of coagula in
the ruptured vessels, and aid greatly in permanently arresting
hemorrhage.
The caution elsewhere given may be repeated here — tlie phy-
sician must beware how he interferes in those cases^where the
loss has been excessive, but has temporarily ceased. It is the
iast ounce of blooil that kills. It may Ik.' that syncope has en-
sued, and the feeble circulation which characterises the condi-
tion has led to the formation of coagula. To excite the circuhi-
tum, or to interfere with the clois, may awaken renewed flood-
ing. Therefore withhold the hand, and attentively watcli the
casa Renewed strength, or renewed hemorrhage, will indicate
the moment for interference. The woman rallying sufficiently
to bear the stniiu, we may empty the uterus and wtinjulate per-
manent contraction. The hemorrhage returning, we may take
like action to effectually arrest it Therefore, when there is
Bjrncope, we shouhl not hastily )>egin stimulation, but guard
against complete cardiac failure. Should dangerous symptoms
ensue, stimulate well The hypodermic administration of sul-
phuric ether has proved extremely efficacious.
500
POBT-PARTUH HEMOBBHAOE.
The Treatment for Concealed Hemorrhage^ Post-Partam,
differs in no material respects from that already given for ex-
ternal bleeding. As soon aa the condition is recognized, the
distended uterus must be compressed with the hand from aboTe,
and the discharge of its contents enforced. The hand shoohl
then be introduced, and all retained coagala removed.
Secondary Hemorrhage requires 'the application of similar
principles of treatment, U being quite essential that the womb
be well emptied. This form of flow, depending, as it does in
many coses, on retaineii parts of placenta, will generally require
introduction of the hand, though if manifested at a considerable
interval from labor, the fingers only can be used. After remov-
ing a retained fragment of the aftei^birth, it is well to wash out
the nterinn cavity with u mild solution of carbolic acid, or some
other disinfecting fluid.
Forthe sub-involution existing in such cases, secale comuium
2 X or 3 X is probably the best remedy. Trillium or trillm is
nearly as eflicacious. Other remedies may be indicated by
special symptoms.
The following summary of treatment will be found
venient:
con-
Treatment. — Preventive, — Observe the rules for the conduct
of normal labor.
Rupture membranes before complete dilatation.
Give ergot by the mouth, or by hypodermic injection, just be-
fore the close of the second stage of lobor. Do not remove the
placenta too soon. If not naturally expelled, combine expre$'
sion with cjriraction for its delivery.
Curative. — Qetieral — Lower the head, and elevate the hipa
If necessary, practice auto-transfusion.
Have the room cool and quiet
Preserve a composed air.
Primary HemoTrhage—lst Degrec^Preaa on fundus uteri
with cold hand.
Avoid vehement practices.
2d Degree,— Vress on the fundus uteri. Irritate the cervix
uteri, and, if necessary, introduce the hand. Give the indicated
remedy.
*
i
TREATMENT.
501
3d Degree, — Press on the fimtluH uterL Befrigerate (in par-
ticular cases). Introduce the hand iiito the uterus, and remove
all cloto, etc. Administer indicated remedies. Use hot water
injections, and heiit to tiie lurabo-sacral region. Releutingly
inject styptics. Compress abdominal aorta. Do not needlessly
disturb clots when the liemorrhage has temporarily ceased. Do
not stimulate much unless necessary.
Curative. — Secondary Hemorrhage, — Empty uterus, and
treat as other forms.
Administer suitable remedies.
Honi(FOpathir. Therapeutics. — Iprmr is used more fre-
qnently, perhaps, than any other remedy in attenuation, for the
arrest of post-{Mirtum hemorrhage. It is indicated l)y a profuse
flotF: hlnttd bright red, *;)r clotte<l.
Brlhidonnn is said to bo an excellent remedy; and, like iiiecac.,
capable of c-ontrolliug bleedinf^ without mechanical or manual
aid The chief symptoms which call for it are profuse flow of
Ij^ilhl, red blood, which speedily eoagulafes. The blood feels hoi
^ ike parts.
Stibinn is indicated by a bright ml jUnr^ somotimes chtled.
It is often efficacious for profuse bleeding, with nu otlier special
indicjition. It is particularly serviceable when the flow is de-
pendeut on a retained fragment of the secundinea
Secnle is called for by hemiirrhage, especially in thin, cneheciio
tt^tmen, when ike flaw is dark, and conguUdcs slowly, or twi
aiall
Crocus, when the flow is dark and stiringy; worse from the
least exertiun.
Pulsatilkt and sabina are the beat remedies for secondary
hemorrhage when it depends on retained fragments.
602
BETAtKED PLACENTA-
CHAPTER xvn.
Difficulties and Dangers Arising in the Third
Stage of Labor-— (CoNTiNCED.)
Retained Placenta. — The placenta is often retained througii
unwise treatment of the third stage of labor. Witliout reference
to eftV>rts at expression, such as we have describoil as appropri-
ate in every case, mere traction is sometimeB made on the cord
witii the effect to invert the placenta, and bring it to the os uteri
in Buch a way as to prevent the entrance of atmospheric air, and
make tlft retentive jKJwers of the utenis ex-
tremely difficidt to overcome. Cre<i6's meth-
Oil is sometimes improj>erly attempted, and
instead of the uterus being pushed down-
wards iind biiekwanls in the direction of its
long axis, the fundus is presseil downwards
and fonvards against the symphyeis jmbiH.
Really udlierent placenta is a comparatively
rare occurrence; but tlien? are occasionally
well mtirked examples of it, traceable to for-
mer endometritis.*
IiTegular contrnctions of the utems are in
some instances the eflicient cause of retention.
Fig *218.
Irregular uterine
i hour-glass) con-
raction, with re-
tention of the plu-
centa.
Treatment.— When the placenta cnnuotb©ii*
gotten away by firm pressure of the uteruBv««
coupled with judicious traction on the cord,
within what may l>e regarded as a reasonable time, other meas— «
• When Cr*>d^ introduced his roothcMl. he declared that "' the fip«ctt« of acK
herrnt pliirenta wonld b«' »'4iri><l iiway.*'
TREATMENT OF RETAINED PLACENTA.
5D3
ures must be employed for long retention is a dangerous
eomplicutiou.
When the placenta is rdtained, it sometimes becomes a point
of great nicety to decide when you are to operate manually, and
when you are noi
Before resorting to artificial separation and extraction, we
should for a time try the effect of remedies, fitly chosen, and
meanwhile keep the case under attentive surveillance. The
most suitable remedies are pulsiiUlla and vhina^ and they may
be given singly or in alternation. Should special indications be
fouuil for any other remedy, let it be given. If the retention is
uot overcome by these various measures within an hour, we be-
heve it is wise, in the absence of eonti'a-indicating symptoms to
pass the hand partially or wholly into the uterine cavity for the
jiurfH>se of removing the after-birth. A digital examination will
imlicate the juivisable course to follow. The four fingers may
lie entered, if necessary, and if a border of the placenta can be
reached, it should be ilrawn down, when, if no morbid adhesions
^xist between that organ and the uterus, compression of the
latter and slight traction on tlie cord will suffice to secure de-
livery. Injection of the umbilical cord, to its full capacity, will
sometimes serve to arouse the uterus to c^^ntraction, and produce
separation of the placenta.
If such efforts fail, the fingers may be p)ished onward into
the uterine eavit}-, and separation undertfiken. By l)egiu-
ning at thp margin, we will generally soon succeed in our endeav-
ors. In some cases, however, small fragments of the organ are
fe> firmly adherent as to necessitate leaving them to be dis-
chargetl with the lochia. If every part of the placenta is adher-
ent, a thickened border should be wdected as the pt>int for com-
mencing the detachment.
If irregular uterine contractions are found, they should be
overcome by manual dilatation to a degree sufficient to admit of
separation and removal of the secundines.
After the adhesions are overcome, the placenta and hand
should not be withdrawn unless the uterus is disposed to con-
tract, and even then the organ ought to be followed down with
the abdominal hand.
The entire operation should 1>g performed without hurry, ad
604
TNVERHTON'OP THE UTERUS.
otherwise the uterine tissues may safFor from unnecessary trai
matism^ and, upon its completion. 8hoiild be succeeded by
warm disinfecting enema.
Acute Invernion of the rteriis.— This, by no means fre-
quent (uscident,* consists of a turning inside-out of the uterus,
BO that in well-marked cases the mucous surface of the fundus
protrudes tkiough the os into the vagina, or is even prolapsed
through the vulva. In other cases the action dc»es not proceed
to that length, but the fimdus is only depressed a Uttle way, as
represented in figure '219, and we accortlingly have complete and
xiici>mpletr inversion.
Firt. 219. PlQ. 220.
Incipient iuvcniion.
Showing thp commencement of in*
version of the cervix.
Causes* — There is no doubt that the accident in a certain
number of cases has resulted from immoderate traction made on
the umbilical cord for the purpose of extracting the placenta.
A similar c^iuse o{>cnite8 when the umbilical cord is very short,
and expulsion of the foetus produces trEictitm on it AJs*>, rarely,
when birth of the child takes pluce suddenly with the woman in
an upright position; the fundus being pulled down by the strain
* It WM ohflerred bnt once in' 190,800 deliveries At tbo Rotandn IToepitB]^]
London, and many physicians in extensive obstetrical practice neTcr see
case.
SYMPTOMS.
505
on the cord. It may arise also from inatteution to the condition
of the uterus while jn*ti8.siire is being exerted on the fundus ute-
ri for the purpose of delivering the after-birth. If the organ is
relaxed, its fundus may be indented like a hollow rubber b(dl.
Dr. Tyler Smith ♦ believes that the ncciviont may be occasion-
ed by irregular uterine contraction, independently of every
other circumstance.
Invernioii may begin at the cervix, instead of the fundus
ateri, as pointed out by Duncan, and in some cases become com-
plete.
Symptoms.— Dr. Momlows, who has met two cases of the
kind, gives tlie symptoms so clearly, and yet concisely,! that we
qui»te him here: '* Tlie symptoms of inversio uteri are gener-
ally prett)^ well marked, and are, always, of a serious and alarm-
ing character in pro|M»rtion to the amount or degree of inver-
sion; they have reference chiefly to the nervous system, which
giveH evidence of very severe sliock. Iji the slighter cases there
is great pain, of a dragging or bearing-down character, situate
diietly in the back and gri»ins, with more or less hemorrhage —
* the ])atient Buffers under an oppressive sense of sinking, with
nausea or vomiting, cold clammy sweats, feeble, iiuttering, or
nearly extinct pulse, faintings, or oven convulsions.' These are
tl»e kind of symptvims which always occur to a greater or less
extent; but ' the most universal symptom is a sudden exhaustion,
which coniPB on immediately after the inversion.' The amount,
both of tiie hemorrhage and of the paiji, varies: they are great-
er in the complete than in the incomplete version; and, as a
general rule, tliough the symptoms are less severe in appear-
ance in the latter than in the former, they are not so in reality,
for tiie shock to the nervous sj'stem has been so great that, in
some instances, the patient lias dietl almost immediately.
'*C>n examining the alKlomeu, we shall pmbably not be able
til feel the uterus at all, while per vaginam a round hard tumor
will l>e felt, whicli may be visible even l>eyond the extermil
parts. It is of a briglit red color, its surface being smooth and
bleeding; the size of the tumor wiU vary with the amount of in-
Tersion, and partly also with the time which has elapsed since
•**t.ecturc'a on Obstetrics," Am. Ed., p. r)M«.
t" Manila! of Miawifory, ' 4th VaI.. p. 437.
506
TNVERRIOX OF TRE UTERUa
it took place. In recent cases, there is generally a gooii deal of
swelling, possibly from the return of blood beiog prevented by
the narrow constriction of the now inverted ob."
Diagnosis.— The only condition with which acute inversion of
the uterus is very liable to be cuufountkul is that of uterine pol-
ypus. From this it will be distinguished by the absence of the
contracted uterus from the hypogustriuni, aiid the uttt*r inahilil
to pass the uterine souuiL Should the placenta remain adherent
as sometimes hapijeus, it would serve to dispel any doubt coi
cerning the inversion whicli might otherwise exist
Trpatinent.— The following we boiTow from Playfair:* *' Tlie
treatment of inversion consists in restoring the organ to its nat-
ural condition as 6o<^n as i^>o8sibla Every moment's delay only
serves to render restoration more difficult, as the inverted por-
tion becomes swollen and strangulated; whereas, if the attempt
at reposition be made immediately, tliere is generally compara-
tively little difficulty in effecting ii Therefore, it is of tlip
utmost imix)rtance that no time should be lost, and that we
should not overlook a partial or complete inversioiL Hence the
occurrence of any unusual shock, pain, or hemorrhage after de-
livery, without any readily ascertained cause, should always lead
to a carefid vaginal examination. A want of attention to this
rule has too often resulted in the exist^mw of pnrtial invorsidu
being overlooked, until its reduction was foiuid to bf diffic»Ut or
imjKJssible.
"In attempting U^ n^ducf a recent inversion, the inverteil jmr-
tion of the uterus should Ik? grasj^ed in the hollow of the humlT
and pushed gently and firmly upwards into its natural poflitioi
great care l>eing taken t*.* np[>l\- the pressure in the proper axis
of the i>eh-is, and U^ use ctniuter-pressure, by the loft hand,
the alxlominal walls. Barnes lays great stress on the importam
of directing the pressure toward one side, bo as Ut avoid the
promont<^ry of the sacrum. The common plan of endcavorin
to jrasli back the fundus first has been well shown hy McClu
tock to have the disadvantage of increasing the bulk of the mix
that has to be reiluce<I. and he aflvises that, while the fundus W
lessened in size by compression, we should, at the same time,
•**Sy8U'm of Midwifery," Am. Ed., 1890, p. 439.
TREATMENT.
507
endeavor to push up first the part that was less inverted, that is
to say, the portion nearest the os uteri. Should this be found
impossible, some oasiBtance may be derived from the manoeuvre,
recommended by Merriman and others, of first endeavoring to
push up one aide, or wall of the uterus, and then the other, al-
ternating the upward pressure from one side to the other as we
advance. It often happens as the hand is thus applied, that the
uterus somewhat suddenly reinverts itself, sometimes ^vith an
audible noise, much as an Indiei-rubber bottle would do under
similar circumstances. When reposition has taken place, the hand
should l^e kept for some time in the uterine cavity to excite tonic
contraction; or Barnes' suggestion of injecting a weak solution
of |>erchloridi> of iron may be adoptetl, so as to constrict the uter-
ine walls, antl prevent a recurrence of the accident.
" It is hardly necessary to point out how rtiiich these mancpu-
vres will be facilitated by placing the patient fully under the
mtluenoe of ^m aniehthetic.
"There has been much difference of opinion as to the manage-
ment of the placenta in cases in which it is still attached when
iuvorsi(m w^curs. Should we remove it Iw^fnre attempting repo-
eitjon, or should we first endeavor to rein vert the organ, and
8ul>Bequently remiive the placental? The removal of the pla-
centa certainly much diminishes the bulk of the inverted portion,
ftud, therefore, renders reposition easier. On tlie other hand, if
there be much hemorrhage, as is so frequently the case, the re-
moval of the placenta may materially increase the loss of blootL
For this reason, most authorities recommended that an endeav-
or should be made at reduction before peeling off the af ter-birtlu
But, if any difticulty be experienced from the increased bulk, no
time should be lost, and it is in every way better to remove the
placenta and endeavor to reinvert the organ as soon as possible.
•"Supposing we meet with a case in which the existence of in-
version has been overlooked for days, or even for a week or two,
the same procedure must be a4iopted; but the difficulties are
much greater, and the longer the delay the gi-eater they are
likely to be. Even now, however, a well conducted attempt at
taxis is likely to succeed. Should it fail, we must endeavor to
overcome the diflioulty by continuous pressure api»lied by means
of caoutchouc bags, distended with water and left in the vagina.
508
ASPHYXIA NEONATORrar,
It is rarely that this will fail in a comparatively recent cahe, autl
6uch only are now under conHideration. It is likely that by
prestiure applied in this way for twenty-four or forty-eight hours,
and then followed by taxis, any case detectcil before the involu-
tion of the uterus is completed may be successfully treated-"
Several cases are on record in which efforts at reposition w«
unsuccessful, but in which, nevertheless, spontaneous reposition
subsequently took place.
Suspended Animation, oe Asphyxia Neonatobcm.
Asphyxia of the foetus may be brought about in several wayaL<
While tlio child remains wholly in utero, its supplies of oxygen
are received through the uteri>-plaoental circulation; but when
expulsion has taken place, and in some cases even before it is
completed, they are obtained in the usual manner through the
pulmonary Htructures. Anytliing which may occur, then, during
intra-uterine life, to interrupt the utero-placental circulation, and
anything which may intervene, during complete or incomplete
extra-uterine existence, to ol>8truct respiration, may give rise to
asphyxia. Thus we have among the causes of intra-uterine
asphyxia, premature separation of the placenta, compression,
stenosis and torsion of the umbilical cord; and among the causes
of extra-uterine 8ti*angulation, the presence of mucus and fluid
in the throat and lungs. Long continuetl interruption of tlie
ftt'tal circulation, and the presence of mucus in the throat from
prematiu*e respiratory efforts, are the most common causes. We
should add, however, tliat piemature interruption, or lowering
of the fatal circulation, not only deprives the foetus of its ui
esaary suiDplies, but the very interruption stimulates respiratt^ry
efforts, which result only in filling the lungs with mucus, blood,
and liquor amnii, and thereby adding to the gravity of the caseb
"Experience has shown that pressure on the brain during la-
bor may be atteiulod by the nujst serious consequences tt» tlie
child. It remains to l)e seen in what way these unfavorable re.
suits of cerebral pressure can be explained. It may well l>e
doubted whether pressure U]x)n the medulla oblongata s*j irri-
tates it as to prcKluce the first inspiratory movement; at any rate,
proli^nged cerebral pressure, through irritation of the ^'agua,
felnckens the pulse and diminishes the irritability of the xne<lulla
oblongata lier.ause the exchange between the maternal and the
MORBID AXATOKY.
509
fcetal blood is impeded, and, consequently the blood circulating
in the fcetus is poorer in oxygen. By cerebral pressure, tliere-
fore, tiie child becomeB comatoee, and this may assume such a
degree that the usual irritations are no longer able to produce
inspiratory moveuienta The child is exposetl tt) such a danger
by compression of the head within a contracted pelvis, or by
the firmly compressed forceps."* Effusion of blood into the
hemispheres is well borne by new-born infants; but effusion at
the base of the brain is fatal.
Morbid Anatomy. — Schultze describes two stages — asphyxia
livida and asphyxia pallida f. In the first stage, tonicity of the
muscles remains, and roHex movements are easily excited. The
skin is dusky-red, the cutaneous vessels are turgid, and the eye-
balls protrude. The heart beats slowly, but forcibly. Sponta-
neous respiration is often set up, or can usually be easily excited.
In unfavorable cases the child soon passes into the second
stage.
In the second stage, or asphyxia pallida, the child is anaemic,
the body is cold and limp, and the sphincters are relaxed. Re-
flex movements cannot be excited. Pulsation is rapid and fee-
ble. If inspirat(Dry efforts are made they are feeble, and are not
participated in by the facial, nasal, or maxillary muscles. Re-
spiratory movements may, after a time, be established through
artificial stimulation.
Diagnosis and Prognosis.— SchultzeJ claimed to have proc-
licetl auscult{^on of intra-uterine respiration with success,
while many have heard the intra-uterine cry {ViKjiiHS uterinns),
Dimimahed frecjuency and force of the fa^tnl heart-sounds, per-
sisting during the internals between pains, indicates the begin-
ning of asphyxia. When delivery has Iwen pnrtially effected,
the failing pulse and the cyanosis give evidence of the condition.
Dr. Garrigues § reports a case of asphyxia wherein he practiced
artificial respiration for a period of two and a half hours before
the child made the first respiratory gasp. It died seven hours
• SCHKOKDEB. " Uhrbuch," p. 321.
t Scari.TZK. " Der Scheinlod Neugeborenen," Jeim, 1871, pp. 6, 130, 147.
JScHri.TZK. ipp ciU V- '-"
3 "Am. .Tonr. Obs.;' vol. xi.. p. 8()2.
610
A8PBTXIA NEONATORUM.
later. Popptl Unmd thnt the mortality of asphyxiatetl children
in the first eight days after delivery is seven times greater than
that of the unasphyxinted, nud the mortality in the first week
in direct ratio to the duration and gravity of the symptoms at-
tending the asphyxia.
Treatinont.— There are three indications for treatment,* viz:
1. The child must be brought as rapidly as possible into a posi-
tion to inspire atmospheric air. 2. The inspired foreign botlies
must be removed from the air passages. 3. If the irritability of
the medulla oblongata has been so weakened that no spontaneoua^^fl
inspirations, or only very feeble ones, are made, tlie normal con-^H
ditiou of the central organ must be restored by artificial respi-
ration.
With respect to the first indication, no special directions are
necessary, as the various modes of accelerating labor have re-
ceived attention in other chapters.
Mucus may be cleared from the throat by inverting the body,
and passing the finger over the base of the tongue. For the pur-
pose of removing mucus and fluids from the trachea and bron-
chi, a soft cathot<ir or tracheal tuiie should be slipped along the
finger, and passed into the trachea, and suction by the mouth in-
stituted and maintained hr long as the tul>e fills. The mere
presence of the tube will often excite respiration, but, should it
fail, artificial respiration through tlie tube should be begun and
maintained as long as necessary, or until aD possibility of aav.
ing the child has disappeared.
In those simple cases where the child does not at once
breatlie, yet the heart and cord pulsate normally, a slap on tJie
nates, simple elevation and lowering nf the arms a few timt»Ss or
the sudden apr»lication of heat or cohl vnll suffice to arouse the
respiratoi*y forces.
The third intlication alluded to may be accomplished by sev-
eral methods.
Sylvester's Metho*!.— Tliis consists in drawing forwan! the
tongue, placing the infant <m its back, and extentUug the arms
alx)ve it*» head. This movement, which favors inspiration, is
then followed by bringing tlie arms do\^-n to the sides, and coni-
*8<HROKDKU. ojt. fit., p. 323.
HBTHODK OF ARTIFICUL UfiHrUUTlON.
311
Theso motions shonlf] be repeated about
preKsin^ the thorax, ^.....v,
twenty-five times per minute.
MarKhull HalTs Method.— Place the child in a prone poei-
tion, which favon* expiration by compressing the chest Then
roll it on to its right side, whicJi expands the thorax. These
movements should be repeated a like number of times per min-
ute 6A the foregoiiig. Neither of the prece<liug methods, as
they appear to us, are well suited to the revival of an asphyxi-
nte4l rliild, unless it should cbonce still to be seusitive to im-
pressions.
Schropdor's Method,— In this method inspiration and expi-
ration are prfKlucetl by alternately extftoding and flexing the
spine in the following way: *'TIie thorax can be diluted by
supporting the back, the head, pelvis and arms being allowed to
fal! backwards; a j>owerful expiration is then obtained by ImmuI-
ing the child over the abdominal surface, thereby compressing
the thorax."
SchuItzeN Method, —It consists of the following mnnipula-
tioos: The child is so held between the legs of the accoucheur
that the thumbs are ])laced upon the anterior surface of the
thorax, the index finger in the axilla, and the other fingers along
the back; the face of the child is turned away from the ac-
coucheur. The child, thus grasped, is then swung upwards, so
that the lower end of the trunk turns over towanl the accouch-
eur, and by bending the trunk in the region of the lumbar ver-
tebrse, the thorax is greatly compresseil. By such passive ex-
piratt»ry movements the inspired liquids pass abundantly out of
tlie respiratory opetiings. A very powerful inspiration is then
produced by extending the body of the child by swinging it
backwards, so as to return it Ui its previous ix>sition- In this
way exi)iration and inspiration are repeated until^they become
8[Kintaneou5.
Howard'H Method.— The child is laid on its back on the
operator's left hand, the ball of the thumb supporting the back
and extending the spine, thereby causing the shoulders to droop
and the head to bend downwanl and backward. The buttocks
and thighs are supported by the operator's fingers. The thorax
is then grasj»ed by the right hand, and by means of it, while the
512
INDUCTION OF PREBL^TURE LABOR.
left affords counter- pressure, the chest is compressed, and al-
lowed Ut expand, at the nite of from seven to ten times per
miuute.
After resi>iration has l>een estahlished, tlie chihl must be
watched until it has gained its natural red color, moves the
limbs actively, and cries with n loud voice.
CHAPTER XVIIL
Obstetric Operations.
The Induction of Premature Labor.— This operation may
be called for in the interest of either mother or child, or on be-
half of Ixjth. It may he employed with benefit in tiiree varie-
ties f>f cases: 1. In moilerate degrees of pelvic deformity. 2.
In habitual death of the fcetus. 3. In diseases wliioh imi)oril
the life of the woman.
Methods of Operatino,
There are a number of methods by means of which uterine
contractions can be provoked, lint they differ cctnsiderably in
their applicability to particular crts(^s, tlieir general efficiency
and their safety. Those which we shall mention are among the
m*>st approved.
Rupture of the Membranes.— This is Ae oldest method,
and is most easily performed. It is not well suitinl to cases in
whitrh speedy delivery is sought, as there is sometimes great de-
lay after rupture, l>efore the uterus takes on expulsive action.
Still, we may regard the method as certain. It is not always an
easy matter to rupture the membranes when the cervix uteri liee
high, and the os is pretty well closed. It is best done we 1>«-
lieve by the careful use of either a rather stiff a^und or a probe-
pointed catheter. It is desirable to have the liquor amnii escape
slowly, and to secure such a result, Hopkins has recommended
tapping the membranf^a with a sound at a distance from th»' 03
Mil
METHODS OF OPEIlATINa.
513
internum. Puncture of the membranes is regarded as one of
the f^ufest modes of inducing premature labor.
Artifkiai Dilatation of the jCervix I'teri.— Dilatation of
the cervix is usually begun by, means of tents, but extensive
exi)ansion can haidly be uccomplisLed ^ntb them: There are
objections to most of the i-ubber dilators oflered for sale, eluetly
on account of their danger of rupture, and irregular expansion.
Baruee' bags are excellent for cases to which they aie suited, but
oonaiderable dilatation is required as a preliminary to their use,
since the smallest cannot be employed tmtil expansion is great
enough to admit two fingers. Such means, if persisted in for a
time, are most effective; but they must be used with the utmost
caution. Tents should not be frequently repeated, or additional
ones crowded into place with force, for feai' of denuding the
cenical canal of its epithelium; u<»r should Barnes' diluU)r8 be
permittee! to keep up a constant and iwwerful strain for a great
length of time. If tlie cervix is in a condition of rigidity, great
force, even thougti hydrostatic, will result in harm.
Intra-rterine Injections, — Bor this purpose a gum elastic
catheter is introduced between the membranes and uterine walls,
f<»r a distance of about two or three inches, or further, and
through this a few ounces of water, at about the temperature of
the body, is injected. If the first injection fails to excite uterine
action, it should be followed by another. The use of tliis method
has several times been attended w^th sudden death, attributed to
entrance of air into the uterine veins, to shock, and to rupture
of the uterus, and hence has not been very pojjular.
Introdnction of a Catheter or Bougie.— In multipanethis
operntiun is |)erforme<l without great difficulty; but in primii>-
ano a certain amount of preliminary dilatation will often bo
found necessary, which may be accomplished with a single tent
well introduced. When ready to o|>erate the wojuau kIiouKI \tQ
placed npon the bed or table, with her hips at its edge. The
point of the instrument is then directed by a finger into the
cervical canal, and after it passes the internal os, it should \>e
tamed to one side so as not to puncture the membranes. No
amount of force should be used to urge it onward, and when it
cannot be further intro<luce<l, it ranv be left It is desirable to
514
INDUCTION OF PBKMATUHE LABOB.
leave only an ineli or two of the extremity protruding, as it
wonld othenrise extend through the vulva.
This operation is tolerably safe, is easily performed, and is
generally quite effective. Uterine action is excited within a few
hourR. It maybe adopted as on adjunct to some otlier means, as,
for example, Kiwisch's douche-, a description of which here fol-
lows.
Kiwisch^H Douche. — This process consists in directing a oom-
tinuous Btream of warm water against the os uteri by me-an? of a
tulK* connected with a fountain syringe, or an apparatus which
operates on the same principle. Some prefer the alternate use
of hot and CA)Id water. The injection should be repeated once
or twice a day, for ten or fifteen minutes at a time, until uterine
contractions are excited. Twelve are said to he aliout the
average number required In iirgent cases they may be em-
ployed every three or four ho urn; but the method is not well
adapts to cases in which rapid deliver)' is desirable.
This method has by some been changed, measures being taken
to prevent escape of the injected fluid from the vagina, with a
view to effecting anatomical detachment of the membranes from
the nteritie walls; Vint the iimovation has proved a dangerous
one. The operation as originally recommended is comparatively
free from risk, but is often extremely slow in its action. At one
time the methotl was an extremely popular one, but it has now
fallen into comparative disuse, except as a means of effecting
preliminary dilatation of the os.
Introduction of Foreign Bodie.^ into the Vagina,— Braun's
coliK'urynter, Goriors air pessary, and the onliuary tampon, have
been used as means of inducing premature labor. The effect is
excitation of reflex uterine action, and more or less mechanical
dilatation of the os uteri, with separation of the membranes.
These measures, while tolenibly safe and certain when carefully
employed, are not highly regarded by the most skillful physi-
einiis. The distension of the vagina should not be Excessive,
and must not be long-continued
liable to suffer.
or the vaginal tissues will be
The Induction of Abortion.— The physician is certainly
justifiable in inducing abortion whenever the operation offers thd
best chance of saving the woman's life, but only after doe con*
AAi
CONDITIONS CALLING FOR VEBJMOi'B.
515
siderAtJon. and when his conviction of its advisability has been
etreugthened by Cimiisel. The umiu conditiuns which imite to
demand the operation are: 1. Incarceration of the prolapsed
or retroflexed uterus, when the ditilucatiou cannot be reduced;
nnd 2. Diseases of pregnancy which greatly endanger life, and
which have refused submission to all carefully chosen remedies.
We believe it is equally justifiable to induce abortion in those
cases of extreme pelvic deformity, or of pehHc tumors, which are
quite sure to make the performance of abdominal section a ne-
cessity, should pregnancy l>e i>ermitted to go on.
The operation is performed by introducing a sound, and sweep-
ing it about in the uterine cavity; by introducing a soft cathe-
ter; or by the dilatation of the cervix with sponge tents.
CHAPTER XDL
Turning.
Taming consists in the performance of a manoea\Te by means
of which one presenting part is exchanged for another, as when
the head in a case of placenta praevia is converted into a footling
|)r«6ontation, or the shoulder in a transverse case is changed into
Q cephalic presentation. Two general varieties of turning are
priicticed, viz: the cephnlic and the pofluUc Among the an-
cients, cephalic version <:>nly, was practiced, under the mistaken
idea that labor could not well be terminated in any other than
bead presentation. The form of version now most popular, and
"which in geupral is more easily and safely performed, is the po-
dalic, which consists in bringing down the feet when some other
pari -presents, and thereby converting the case into a footling
presentation.
Conditions Calling for the Operation.— Turning is called
for in a variety of conditions wherein 8i)eedy delivery is requir-
ed, and especially those in which the necessity has developed or
been disclosed during the earlier part of the first stage of labor
616
TUKNINO.
Among the conditions demanding this sort of interference -we
may mention placenta pnevia, transverse presentations, certain
degrees of pelvic contraction, prolapse of the funis, sudden
death of the mother, and some coses of uterine rupture.
Conditions Favorable to the Operation.— In order that any"
form of version may be easily and safely performed, the os and
cervix uteri must be either dilated, or freely dilatable, and the
membranes either unruptured, or but recently broken-
Cephalic Version.^This form of version is but rarely prac-
ticed, chiefly for the reasons that it requires the concurrence
Bo many favorable ©jntlitions, and that the circuinstauces which
necessitate version are usually of so pressing a character as to
require the speedy termination of labor, a thing not always
easily accomplished in connection witli cephalic version. Still,
in some favorable cases it is the preferable mode of version.
The oi)eration can occasionally be practiced by external ma-
nipulation alone, but it usually requires the combined interna]
and external metiiod.
To perform the external manoeuvre, the woman should be
placed on her back with her hijis raised above the level of her
head and shouldei^s, so as to place the long uterine axis more
nearly in coincidence with a horizontal plane, and the knees ele-
vated The abdomen must be exposed or covered only with
some thin material By abdominal palpation the two |>oles of
the long foetal diameter, namely, the pelvic and cephalic, are to
be located, and the hands placed upon them. Oi)erating then
between pains, an attempt is maile to push upward the pelvic
extremity, and to bring the head into the pelvic brim. During
uterine action the only effort should l>e to maintmu the ad^'auce
obtained. The manoeuvre of external version may sometimes be
aided by turning the woman u^nm the side toward which the
head lies, but tlie position is unfavorable for manipulation.
After bringing the head into the brim, it may be retained l>y
suitable pressure made with the hand, but l>etter still if the oai
is dilated, by the application of the forceps; or the membranes
may be ruptured and the liquor amnii permitted to escape.
What answers a very good purpose, are pads applied to the
aides of the abdomen, along the line of the fcatal prominence,
and held in place by a well-adjusted binder.
PODAUO YER8I0N.
517
By the combined metbotl, that is, by the simultaneous use ttf
both external auti internal mauipulatioji, cephalic version it»
more easily performed. The method described and pructicetl
by Braxton Hicks is probably the preferable one. He prefers
the lateral decubitus, and uses the left hand when the patient is
cm the left side, and the right hand when she lies on the right
Bide. We quote htta as follows:* "Introduce the left hand
into the vagina as in [>odalic version; place the right hfiud on
the outside of the alxlomen in order to make out the position of
tlie fcetus and tlie direction of the head and feet Should the
shoulder, for instance, present, then push it^ with one or two fin-
gers on the top, in the tlirection of the feet. At the same time
pressure by the outer Imnd should be exerted upr»n the cephalic
end <»f the child. This will bringdown the hoadcluse tii the os;
then let the head be received ujxrn 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."
Anflpsthesia is neither necessar>', nor specially desirable for
the practice of version by the combined manipulation, and hence
the woman can Iw made to assume a position, which, in some
CBBBB, will be found to contribute to the successful practice of
the operation, namely, the knee-elbow position.
Podalic Version.— "The reasons why ptxlalic version bo rap-
idly displaced in public favor the ancient turning of the head,"
says Gliaon.t "h*^**"i to be chiefly on accoimt of its facility of
performance, and rapidity in the termination of labor, for it is
often very difilcult to seize, bring down and properly adjust, the
round, slipperj' head, by the old methotl of introducingthe hand
into the wt>tnb. By the modern external and bi-polar modes,
especially the latter, the difficulty and danger are so much less,
tliat tumingby the head, in transverse presentations partlcidarly,
will l>ecome more ^>opular. But where haste is necessarj', in
the latter presentation, as well as in all others adapteil to tom-
•" Combined External and Int«'rnal VeTsion," "Trans, of the Obstct Soc*y
nf Ixindon;' vol. v, p. 2:M).
t • Text-Book oi" Modern Midwifery." p. 510.
518
TU 11X150.
ing, po<lalic verbi<>n, and that too, in the regular way of intro-
ducing the hand inU) the womb, must be resorted to."
The operation may be performed by external manipulation,
by the combined method, or by the introduction of the hand
an<l tioisrare of the feet
Wigand, to whom we are mainly indebted for the introduction
of tlie exieitial method, considered it suitabfe only totranaverste
cases. It is practice*! so like cephalic version by external mani|>-
ulation, that it requires no special description.
First fttAfce of the comhined method.
Position of the Patient. — In practicing potlalic version in
any manner, tho position generally recoiumeuded by American
obstetricians is the dorsal. The patient should be so placed
that her nates lie near the edge of the bed, with her feet re.s-ting
on chairs, as in forceps delivery. The abdomen ouglit to lie un-
rorULIC VEHRIOK.
I
619
covered, or Lave over it only a sheet, a light chembe, or a night
cbess. The physician should stand betA^een his patient's feet
with his face toward her.
Tbe Combined External and Internal Method.— The posi-
tion and prenentation having been determined^ ami the bladder
and rectum emptied, the operation is performed much as is that
of cephalic version, the two poles of the fcetal oval being pushed
Flu. 23*^.
Se<*oiid stage of the combined method.
in opposite directions. The wlfole hand is never introduced
into the uterus, but it may be necessary to pass it into the va-
gina, on account of the inability to reach and handle the pre-
senting part. In some cases chloroform will l»e required The
pre-requisites for success are; Sufficient dilatation of tlie cer-
•m to permit the introduction of two fingers; a certain degree of
foetal mobility; nud a clear comprehension of foetal position and
presentation. After rupture of the membranes and escape of
TUKNTNO.
le waters, the operation becomes diiBcult, or even imprac-
!able.
I Internal Podalic Version.— This form of version, which was
Jrst practiced by Ambrose Par6, congists in iutnxincing the
Lud into the uterine cavity, seizing the feet and bringing them
Fio. 223.
Third Mtat^cuf lln* r(imbin»<l methotl.
lltrongh the os uteri and vulva, while tlic body is made to ro-
bte on its transverse axis. Sufficient dilatation is re<]uired to
idrnit the hand without force, an*l,8ave in those cases where the
itniost hastA^ is demande<l, the bi-]>iilar, or combined method,
ibouid first he tried. Internal iRxlalic version while still the
bost [popular mmle of turning, is rapidly giving way to the
ttlier methods, and may even now l>e said to be preferable
ihiefly in extremely urgent cases, and in ]>]acenta pra?viji, wliero
}ie hemorrhage during other nianipuhition could not l>e kept
inder control. It is the only practicable form of version when
be liquor amnii has been long dniined off, and a certain
^nount of uterine retraction has taken place.
After the preliminaries as regards diagnosis, position, the
ivacuation of the bladder and rectum have received attentipQiy
PODALIC VEBSION.
521
the woman has been drawn to the edge of the bed, and placed
under ansesthetiG influence, the physician Hhuald take a posi-
tion in front of his patient, with hand and bare forearm well lu-
bricated, with the exception of the palm, and proceed gently to
iiiBinuate his hsuid, the fingers slowly separating and expanding
tlie x>artt^ until it finally lies within the uterine cavity. When
practicable he should choose that hand, the palmar surface of
which, as it passes, corresponds to tlie ventral surface of the
foetus; but in transverse presentations this is a matter of com-
paratively slight importance, as by turning tlie woman Uiere is
no possible direction within the pelvis or the womb in which
either the right or the left hand may not be passed. If the
physician is not ambidextrous, lio shoulil use his most eflacient
hand, without reference to the foetal position.
In cephalic presentations the question of hands is one of more
importance, and the weight of experience favors the use of that
hau^l, tlie jialmar surface of which corresponds to the ventral
surface of the child; hence with the woman on her back, in first
and fourth ixisitions of the fu-tus, the left hand should be used*
and in second and third i)ositions, the right
After the hand passes the rulva, which it is enabled to do by
firmly repressing the perineum, it should pause for a moment
to examine more carefully the presentation and jxisition. Then
with the external hand upon the fundus uteri, the internal one
should be most gently urged through the os and cer^nx uteri.
If the membranes are now intact, it makes very little difference
whether we tear them with the fingers and then push onward
through them, or paas the hand between the membranes and
uterine walls until it comes into proximity to the feet, and then
effect the rupture.
If uterine action is at all forcible, the hand must be extende<l
and remain passive until the contraction passes away; but if the
uterine efforts are feeble, and almost continuous, as they some-
times are, sUiw, but resolute, progress may be insisted upon.
Obstetricians are at variance respecting the question of seiz-
ing one or both feet for the performance of version. The safe
rule of practice is to grasp both feet or knees if they lie within
convenient reach, es|>ecially if there is an urgent demand for
delivers* ; but, if l>otli limbs cannot 1^ easily seized, the most ac-
622
TUIlNTNa.
Vui. TZ\.
oeesible one ooght to be brought down without unnecessary de-
lay, and without subjecting tlie woman to the dangers of farther
search. If the demand for delivery is not a pressing one, and
both feet are within reach, we believe it advisable to take but
one, but to make ourselves sure that the one selected is the de-
sirable one. There is a positive advantage derivable from bring-
ing down but a single foot, or
knee, since by leaving one
still flexed uix^n the body,
greater dilatation of the oa
uteri, the vagina, and the vul-
va, is necessitated by the
iwssage of the pelvic portion
of the fcetus, and the diffi-
culties and dangers of head
extraction are thereby *ii-
miuished
That there is a difference
in desirability between tlie
two legs, we are fully convinc-
ed: and the prefernble on© is
that which lies U)wnrd the ab*
doininal parieties. The mi-
vantage in seizing tlus is
found in the gTHnter facility
with which the fcetus rotates
on its longitudinal axis, and
BO descends tliat the head en-
gages the pelvis with tlie ix?.ci-
Version in hcAci prnsonution j,^^ looking forward. This
advantage is oiejirly demonsti-able on the manikin. Yet this
is not a question of much prnctical importance.
In cases of turning in pelvic contraction, when extraction is
likely to be difficult it is regarded by some ns highly advisable
to bring down both legs; but the practical advantage of doing
BO, even there, is not obvious, since the rejected leg becomes free
before the shoulders pass the vulvn, and the special difficulty is
in connection with extraction of the head.
Unless care is exercised, the elbow is liable to be mistaken for
BUNNINO NOOSE ON THE FOOT.
523
the knee, and the hand for the foot; bnt ordinary attention will
prevent our falling into such an error.
Fro. 225.
Vereion in tmnsveree presentation.
WLilf* drawing down the f(x>t, or feet, with the internal hand,
an effort Bhuidd be made to push upward the head with the
external Before relaxing our hold on the feet we should
make Bure of the version, as otherwise the fietus is liable tube
restored tt^ its original position. If the head refuses to ascend,
a running noose of tape or other material which will not injure
Fio. 226.
Use ol'tbe mnninfi noose on the fool
the fcBtal tissues should be slipped around the fiM>t, and traction
made on it by one liaml, while the fingers of the other are used
within the os uteri to push the head upwards.
In Bome difficult cases of turning, it is unwise to relax the
■M
524
TCIINING.
hold of the foot for the purpose of putting a noose on it, as it is
liable to pass beyond reach, and occasion much trouble. In
that case the fillet may be noosed around the operator*s arm,
and gradually Hlij)ped upward, until it can be placed on the foe-
tal foot. If the version cannot be completed with one foot, the
other must be brought iIotvti.
When, in transverse presentations, the arm descends into the
vagina, it somewhat embarrasses version, but does not prevent
it. In such cases it is a good plan to place a noose of tape about
the wrist, which enables the o|>erator to control the arm, both
while his hand i>asses into the uterine cavity, and later, during
extraction of the trunk.
Completion of the Delivery.— When the desired change has
been effected, the question arises whether labor should be at
FUi
Taming by the noot^c or fillet.
once complete, or now left to the natural efforts. If there be
no urgent demand for deliver3% nature may l)e given a fair op-
portunity; but the woman is already anjpsthetized, and very
likely the pains are in great measure arrested, so that it would
seem most wise to proceed carefully and close the second stage
THE F0UCEP8.
525
of labor, for doing which no special directions are here re-
quired.
CHAPTER XX-
The Forceps.
The obstetrical forceps were designed and used by one Faal
Chamberlen in the early part of the seventeenth century. In
1047, Peter Chamberlen, in a little pamphlet publisiietl by him,
speaks of a discovery made by his father, Paul Chamberlen, for
Baving the lives of childreji during labor. It, however, remain-
ed a family secret, bringing its possessor immeuee gain, and did
not become public until 1733, in which year Dr. Chapman, in a
brief treatise on obstetrics, eaid that ** the secret mentioned by
Dr. Chamberlen was the use of forceps, now well-known to the
principal men of the profession, both in town and country." In
another edition of his work, published two years subsequently,
he gave a cut of the instrument, which was afterwards known as
Chaofaian's forceps. Since that day mollifications have been r&-
Chamberleu's Foreviw.
peatedly made, but, unfortiuiately, ** to innovate is not always to
improve/' and we accordingly find that, save in one or two par-
ticulars, the forceps of to-day are practicaDy but little l^etter
than the original blades of the Chamberlens.
The instrument, as at first designed, was for application to
526
THE FOBCEPa.
the bead when lying in tlie i>elvic cavity or at the outlet; though
it was sometimes used at the brim, yince tliat time the foroepa
have in some forms been considerably augmented in length,
with the design to provide an instrument ca^Mible of grasping
the head at the x>elTiG brim, or even above, and the result is that
we now have the long forceps and the short forays.
The Short Forceps.— The short forceps owe their brevity
chiefly to the abbreviation or entire absence of the shank, and
the shortness of the handle, the fenestrated portion of the in-
strument not being materially less than the same part of the
long forceps. The instrument is recommendetl mainly because
of its easy portability, and the possibility, in some cases, of rob-
bing the operation of forceps delivery in great measiue of the
formidable character which it is liable to present It is claimed
by some of their advocates that they may even be appb'ed with-
out the knowledge of the patient, a statement which seenos
scarcely credible. Most patterns of short forceps possess the
cephalic curve, but not the pelvic curve, — these being peculiari-
ties of construction shortly to be explained.
The Long Fprceps.— Since it has been found in practice that
the long forcops may be applied, not only at the brim> and above
FlQ. 229.*
Dttvis' Forcepa,
it, but also in the pelvic cavity and at the outlet, — in short, 1
the long forceps answer almost equally well the purposes of
short, most of the instruments at present manufactured are of
the long variety.
Without commenting on the different patterns of forceps
which we find in the instrument shops, we have become con-
vinced from use of a considerable variety, that, while we cling
THE LONG FOBCEPH.
527
instruments of a certain form, our preferences may proceed
largely from frequent u.se, f(»r there are few of the more promi-
nent varieties which are really poor. The features to be sought,
Pio. 230.
are handles ol moderate lenj^th; bhules as li^ht us are compati-
ble with great strength ; a cephalic cune sunicieutly acute to
Fiu. 231.
Simp8on*& Forceps.
hie the point of the blades to easily clear the sacral promontory,
without excessive depression of the shanks against the per-
ineum.
628
THE FORCEPS.
The Salient Features of the Instrument.— The blade of
the instrument is constructed with a fenestra varying in width,
and slightly so in general Bhape. This part of the instrument
FiO.233.
Elliot's Forceps,
requires to be strongly mmle, and none but tho Ix^t quality of
Bteel should be used in its construction. In order tt> give the
blade a firm hold ujion the head, it is provided with what is
Fig. 234.
Hotlge*a Fonwpfit.
termed the cephtilic curve. We believe with Dr. Laudis • that,
"with a proper liead-curve the tips of the blades will approxi-
mate to such an extent, when the instrament is applied, that
Fiii. 235.
Ifftlc*H Long Forceps,
traction upon the blades brings their distal end upon tlie fartlier
* " How to Use the Fomiw." p 95,
SALIENT FEATUBEH OF THE INSTRUMENT.
529
md of the head, so as to not only securely hold it, but also to
posh it onwards. When furceps are said to slip during their
use, one of two things is certain ; either the head-cnrve of the
Fio. 23«.
Vedder's Forceps,
instrument is insufficient, or the blades have not been properly
applied." Ho should hare added, perhaps, "or traction is not
ttiftde in the right direction." The pelvic cwrrc is a feature of
FIG. 237.
Leavitt^a Forceps.
the utmost importance. By means of it the forceps are more
easily applied, and extraction is more easily effected. There is
one disadvantage associated with it, namely, our inability to
630
IHK FORCEPS.
make traction in the line of the pelvic axis. To overcome this,
several expetlients have been resorted to, the moet prominent of
which is exemplihed in Tamier's aads traction forceps, a out of
which we herewith present
Pio.SSd.
Tornier'B Forceps.
The forceps are provided with a varietj^ nf handles. Hodge's"
and Comstock's, for example, have slim mebil liandles which ter-
minate in blunt htwks; but most other patterns have wooden
htmdles, provided at tlieir disttd extremities Avith shoulders or
rings, uptm or within which, the fingers may rest in making
traction. The wooden handles are far preferabla
Desic^natioiiH of the Blades.— In English text-books the
blades are spoken of as the male and female, and the upper and
lower. The latter designation has n double meaning, growing
out of the position of the woman. In English practice the ob-
stetric position is on the left sitle, and the lower blade when
lockeil with its mate is not only beneath or beliind the other, but
it is also, in the lower side of tlie pelvis when applied. In Amer-
ica the common, and most convenient designations, are the right
and le/L The right blade is naturally handled with tlie right
hand, and usually goes more or less into the right side of the
pei\T8; while the left blade is most conveniently handled with
the left hand, and commonly goes more or less into the left sid^
of the pelvi&
Action of the Forceps. — The forceps are primarily and es-
sentially tractors.^ Their action is also, in a modified sense,
* hVBK, ** Science and Art. of M id wifcrj," p. 339.
ACTION OF THE FOBCEPS.
531
lat of levers and compressorB. A certain amount of lateral
oscillation gives greater power to the instrument, and if made
without relaxation of traction efforts, and within moderate }ini-
itfl, it can do no harm. The antero-posterior, or **pump handle"
movemeiit, should never be executed.
Flo. 23a
The forcepa at the brim, by the pelvic mode.
The degree of compression exercised by the forceps should be
u» ilirect ratio to the force of the traction; the chief aim being
■
6H2
THE FORCEPS.
to retein a firm embrace of the head. When made slowly and in-
termittingly, the head of the foetus will bear a great degree of
oompression.
Modes of Application,— There are two modes of forceps ap-
plication, namely, the cf*]ihalic or oblique, and the pelvic or di-
rect. The former is used chiefly in the pelvic cavity, and at the
outlet; wliile the latter is employed more especially at the pelvic
brim and above it The cephalic mode is always preferable, so
far as fcetal interests are concerned; but out of deference to ma-
ternal interests it is not always advisable.
Fia. 240.
Forceps in the pelvic cavity, by the cephalic mode.
The Pelvic Application,— In adopting this we do not Btndy
CONDITIONS DEKANDIXa THE FOBCEPS.
533
the oranial position aud materially vary our application to suit
it, but we pass the blades into the sides of the pelvis. Since
this mode of application is used mainly in the high operations,
and inasmuch as the foetal head usually occupies an oblique pel-
vic diameter, the blades generally embrace the head over the
brow, on one side, and the mastoid process on the other. This
form of application is adopted because of the difficulty and dan-
ger associated with the blades on the sides of the head.
The Cephalic Application.— In this we study the position of
the fcBtal head, and vary our application to suit it^ the endeavor
always being to apply the blades to the sides of the head
Conditions Calling for the Forceps.— "It would be an un-
profitiible undi'rtakiug," remarks Lusk, " to enumerate all the
conditions which render forceps advisable. The indications for
their use may be summed up in two general propositions. The
forceps is applicable — 1. In cases where the onlinary forces oper-
ative during labor are insufficient to overcome the obstacles to
delivery. 2. In cases where speedy delivery is demanded in the
interest of either mother <jr child.
" Both these propositions are, however, subject to the limita-
tion that, in the selection of the mode of delivery, choice should
be made specially with reference to the maternal safety. For-
tunately, in the great proportion of cases the interests of both
mother and chdd are identical."
The Preliminaries.- When the operation has !)een decided
u|Km, it is advisable in most cases to aflminister an aujesthetic
before in any way changing the i)atient's position. An anesthetic
ift not absolutely required* aud some women object to it, prefer-
ring to sulier the? neoesaaiy [>ain rather than take what they re-
gard 08 an unneoessarj- risk. If the head lies in the cavity, or
at the outlet, the pain Hiteridant on forceps delivery is not suffi-
cuent to make the aufesthetie a necessity, and it may be omitted.
We would advise against partial aufrsthesia; either let it be en-
tirely omitted, or carried to the extent of complete narcosis. Its
Administration may be begun by the o]ierfttor, and subsf^quently
entrusted to an intelligent nurse, or other attendant, provided no
skilled assistant is at hand.
it is assumed that the l>owe1s and bladder have been recently
534
THE FOBCEPa
evacuated If they have not, a good enema should be adminis-
tered before beginning the amestheaia, and the catheter intro-
duced Ekfter the woman has been prepared for the operation.
The forceps should be thoroughly clean, and for a short time
before their use, should stand in a warm, antiseptic solution.
Meanwhile the membranes, if intact, should be ruptured, and
the woman turned so as to lie on her back across the bed, with
the hips well to the edge.
The Application. —We have found but little practical differ-
ence in the application of the forceps, Iwtween a high and a low
head, except in the adoption of the pelvic mode in one case, and
the cephalic in the other. A proper adjustment of the forceps
in one case is almost as difficult as in the other. When the
head lies low, it is within ea.sy reach, but the difficulty is in-
creased by the adoption of the cephalic mo<le of application.
When the head lies high, it is not so easily reached, but by the
pelvic mode the forceps are made to go easily intii place. The
oidy exception to be made is in the instances of marked pelvic
deformity, and a partially dilated os uteri.
The patient's feet now resting on tlie edge of the bo<i» or
placed in chairs and there held by assistants, the operator as-
sumes his place directly in front of the woman, and, having lu-
bricated the blafles, takes the left one in his left hand, holding
it between the thumb and fingers much as he would a peu^ and
introduces it a short distance, while he uses two or more fingers
of the opposite hand, resthig against the presenting surface, as
a guidi* to the j)t)int of tlie instrument. The bL^uie at this stage
will fonn alm»^st a right angle with the maternal body, the han-
dle looking slightly to the woman's right Now. rememl>ering
the double curve of the blade it is made to take a spiral swetfp.
the hnnille passing over the patient*s right thigh, nntil, in a high
application, the shank presses fij-mly on the perineum, A com-
mon mistlike is that of attempting to carry the hlmlo diroctly to
its place without first passing its point into the sacral hollow,
and then to ite proper position by a broad spiral sweep. In ap-
pljring the forceps to the sides of the head, the sweep of on<^
blade will be but slight, wldle that of the other will be unusu-
ally great, as will be sepn from a stiuly of figure 238.
The application of the second blade is similarly made, the in-
THE APPLICATION.
535
stmment being held in the right liand, and guidedby the left
In giving it the necessary sweep, the handle is made to pass over
the woman's left thigh.
Fio. Ml.
IntrodDction of the ftrei blade.
I^oth blades now being hi s//m, no diflaculty will be experienced
^^^ making them lock. If the adjustment is not accurate, they
^^«3ul<l be gently manipulated, but no amount of force should be
^*^*^ ployed to make tliem lock.
Traction. — The forceps once on, and locked, it next becomes
"*^^ operator's dutj* to effect delivery, and to do so safnly re-
qt».xres some knowledge concerning traction. Tlie handles of the
*^ ^Iniment should be heM in a convenient way, and so as not to
^^^rt toi great compression of the f<etal head. If the pains con-
"^^Xie, traction efforts should bo made coincidently with them, if
*'^*«*«iit, traction should take their place. But we usually find
^"^^t as soon as we begin to draw on the forceps, the uterus is
^^CiitiHl to action, and the vis nfronie is aided by the tyiaa fergo.
i^lM
53G
THE FORCEPS.
The force employed should at first be moderate, and afterward
stronger; but so long as the resistance is offered mainly by soft
structures, as, for example, an incomplet<^ly dilated cervix, t^r
vulva, the utmost caution must be exercised. In no CAse should
much traction be applied at the vulva, for fear of lacerating tlie
perineum.
The direction of ti'action will be
indicated pretty well by the direc-
tion of the handles in the inter-
vals between pains. In high op-
erations it is at first downwards,
and possibly a little backwards^
but as the head descends it should
be turned more and more for-
wards, until the handles at the fi-
nal i>asaage come to form ahuost a
right angle with the long axis of
the woman's body.
Removal of the Forceps. -
When the head is embraced over
the poles of its bi-j>arietal diam-
eter, there is no necessity for re-
moval of the forceps until after
complete delivery of the head;
but when, from adt>ption of the
pelvic rao<ie of npphcation, the
head is held over its occipi to- front-
al, or over an oblique diameter,
in performing rotation the head will carry the blmle^ into such
positions as to endanger the perineum posteriorly, and the ves-
tibule anteriorly, nnd we regaril careful removal of the in-
strument a wise precaution. Before diBphicing tlie forcej>9 the
head should be made to nearly reach the crowning stage, and
then, after removal, it can easily be delivered by Faslwnder's
manoeuvre, described in another chapter, .which ctmsists in plac-
ing the index and middle tiugers over the occiput, and then run-
ning the thumb as deeply into the rectum as |)ossible; having
done which, we may at will, with, or without, the assistance of
the natural forces, press the head through the vulva.
STiowiiij; how the head is ursn-
ally stized in the "cephalic appli-
cation."
THE rOBCEPfl IN OCCIPITO-POSTEBIOR POSITIONS.
537
Forceps iu Occipito-PoHterior Positions.— We are told that
"so long as the occiput looks to the rear, it is the rule of mid-
wifery practice to refraiu from the use of forceps, which, of
necessity, prevent" forward rotation taking place." * Moreover,
it is added: "As attempts to rotate the occiput liround to the
symphysis by instrumental means are rarely successful, it is ad-
visable under such circumstances to apply the fort-eps directly
to the sides of tlie child^s head, and to imitate during delivery
the mechanism of labor in occi])it(*-poHteri(>r positions. If tlie
sagittal suture occupies an oblique iliameter, the forceps should
be applied in the opposite oblique diameter. As the head de-
scends, the occiput should he turned into the hollow of the sa-
crum." We are convinced from exjjerieuce that it is ]>ossil>le to
do much better than this.
Accordingly, when there exists a demand for the forceps above
the brim, with the occiput looking more or less backward, we
bedieve it to be the operator's duty to endeavor carefully to ro-
tate the head, so that its long diameter will coincide with the
fcrftnsverse of the pelvis, before applying the instrument By
virtue of such a change he is eimbled, with ftie forceps in the
Bicles of the pelvis, to grasp the head in its long as.is, and ef-
f'©<:rtually prevent a backward movement of the occiput and, if
i*^»ciaisit©, to enforce proper rotation. On the contrary, when
tfa.e instrument is so applied without the observance of the pre-
c^^xition mentioned, the head is seized in one of its oblique di-
a-^Kxaeters, as has already been showii. and even slight compression
ii^posea the occiput to rotate into tlie hollow of the sacrum.
The change is so easily aceompliHhed in suitable cases that
e^jDlicit directions are not required. The head, as felt in the
l»>^ jxigastrium, should be pressed backwards, whilst the occiput
*^^^<3uld be drawn forwards with the fingers of the other hand.
Br««.-ving effected an alteration, the acquired position should be
"* *»-intained by firm and equable pressxire in the supra-pubic
'*f*^<*, until the forceps have been adjusted to the head. In de-
^'^"O^llof so doi)ig, it is very liable to revert to the original posi-
^^htter\*ation teaches that the head» when clearly above the
hrii3Q^ ifi not always freely movable, and then all prudent efforts
^*tU LrsK, Joe, «/., p. 353.
538
THE F0BCEP8.
tt) change its position will be utterly unavailing. To such easee,
including as well those in which the head lies in the 8U{>enor
strait, a dilTereut treatment is applicable. Tf the occiput is
turned more or less forward, or directly to one side, tlie physi-
cian has but to pass the blades according to the usual ilirections
for the pehdc application; but if it is more or less backwartl,
then, instead o( putting the blades squarely in the sides of the
pelvis, let him place them on the face and occiput, — a tiling, we
confess, not always easily done, — and therel»y embrace the heafl
over the poles of its occipito-fi'ontiil diameter.
When once the instrument is fairly adjusted, if tlie head is
found U^ be untixcd iu the brim, it may be gently raised, and
careftdly rotated from one oblique diameter into the other, but
the operator shouhi beware of violence. If such a movement is
not practicable, the liead should be drawn, with usual precau-
tions, to the pelvic fio^^r, and then, if the natural efforts are inel.
fectual, the desirable evolution can easily be enforced.
The forceps are occasionally required in the situations de-
scribed, but much oftener after the head has descended into the
j>elvic cavity. With respect to the mode of treatment l>est suit-
ed t4» the latter class of cases, a few years appear U> have wrought
a change in the opinion and practice of many excellent accouch-
eurs. The older authorities teach, and we believe with much
force, — that, when the liead lias in the polvio cavit)-, the forcoijs
should be applied in tlie diameter opposite to that occupied by
the long cranial dinineter. so that they will rest on the parietal
eminences. Some later writers, to whom allusion wiis made,
appear to prefer the pelvic mode of applicjition even there, in
adopting which the instrument will sometimes go to the side« of
the hea<l, but usuidly not. Tliese methiHlis may l>e equally well
suited to the class of cases most commonly met; but for third
and fourth |x>sition8 of the vertex, we call attention to a thinL
and, iu many in.stance8, a preferable mode. It would l>e super-
fluous to reiterate the disadvantages, in these poeltions, of the
blades Sipiarely in the sides of the pelvis. In pursuance of nn-
other mode tliey may be i>laced to the sides of tlie he^ul, but,
when so adjusted, tlieir curve is thrown towards the face, in-
stead of the occiput, and, when rotation takes place, they must
either be removed, at suffer inversion. To be brief, then, the
H
THE F0BCEP8 IN FACE FRE8EKTATION8.
639
reoommendatiozis made in connection ■with the head at the
brim may be adopted here, and, avoidingunnecessary repetitions,
we may say that, save in conspicuously unsuitable cases, the
blades should go over the face and occiput, and not be removed
until the he^d is ready to escape the vulva.
The Forceps In Face Presentations. — Application of the
forceps to the face when it lies high in the pelvis is not permis-
sible unless the chin is turned somewhat forward, and the blades
can be applied to the sides i>f the head. An application over
the fronto-mental diameter of the face should never be made,
and therefore, when the mental pole is not directed more or less
forward, the head lying at the lirim, or above it, our operative
resources, in case delivery is called for, are conversion of the
face into vertex preHGiitatiou, version, and craniotomy.
In mento-lateral. or posterior, positions, with tlie head in the
cavity or at the outlet, we believe the forceps may be used if
necessary, and forward rotation of the chin oflFected. In tine, if
the case seriously threatens to persist with the chin to the sa-
crum, we believe it to be a conservative operation for both
mother and child, to apply the forceps, and, operating with ex-
treme care, attempt to bring the part forward. The author has
8o done in one case, and that without harm. Tlie instrument
in that inatfince will require a double application, unless we chance
to have a pair of straight forceps. In the first application, the
pelvic curve of the instrument should look toward the forehead,
and after rotation has been effected as far as the transverse di-
ameter, it should be removed, and reapplied with the curve di-
recteii toward the chin. Rotation is then tct be slowly jierfonn-
ed, always coCi^ratiug with the pains, and luaintaiuing, at the
same time, firm ext<*nsii)n.
In mento-anterior positions no unusual danger attends the
forceps, provided they are always applied to the lateral surfaces
of the head.
If tlie physician is thoroughly versed in the mechanism of la-
bor, and comprehends the sphere antl action «»f the forceps, he
will be able to make the instrument perform faithful service for
him in most trying emergenciea
Use of the Forceps on the Breech. — Breech presentations
are generally aide<l, wiien aid Hppoiirs ia be required, by instru-
640
THE FORCEPS.
ments oonstracted for tlie purpose, uamely, the blunt hook and
the liilet By means of these, properly applied to the flexure of
the thighs, conBiderable force may be exerted aud delivery effect-
ed. But when we come to compare them, in all their essential
featuresi with the ordinary obstetric forceps, and reflect upon
the respective uses of each, ve discover that the latter instru-
meut is much better suited to a safe and easy delivery of the
presenting head, than are the former instruments to a safe and
easy delivery of the presenting breech. The fillet requires great
effort and consummate skill for its applit^ation to a breoch not
within easy reach of the fingers; and the blunt hook, while easi-
ly applied, is extremely liable to do serious injury to the fcBtal
tissues.
The ordinary forceps, though designed for the heatl. may be
effectively antl safely applied to the breech. Forceps of a pecu-
liar pHtt«5rn have beeu constructetl for this pur[>ose; but the com-
mon forceps, (the short straiglit forceps being preferable, we be-
lieve,) when adjusted to the sides of the foetal (^eU'is, that is to
say, over the i>*>les of the transverse pelvic diameter, are equally
harmletis nnd eflicacious.
The author lias made this use of the forceps in five cases, and
has been well satisfied with the results obtained.
From study, f*xi)erience and reflection, we have deducixl
following conclusions:
1. That the forceps may generally be used in breech presei
tations to better tulvantago thaii any other instrument, and wit
less danger than the blunt hook. '
2. As a prelimiiiary to the operation, it is esacutial that
position be unmistakably recognized-
3. The blades, when on, should embrace tlic pelvis over
poles of its transverse diameter, as a much better hold is therel
acquiretl, and d/uigerous pressure with the points of the insi
ment is thereby obviated.
The Forceps to the After-coming Head.— This is an oper-
ation but seldom required, and it has been sufficiently described
m another chapter.
JONOR OB8XETRI0 INSTRUMENTS AND OrBRATIOMS.
541
CHAPTER XXI.
Minor Obstetric Instruments and Operations.
Th© Vectis. — The vectis, or lever, was devised by Roonhuysen
of Holland, about thft tiine that the Chamberlens began to use
tbe forceps in Great Britain. Roonhuysen handed down the
secret to his sons and others, and it was eventually puichased by
I>r8. Visscher and Van den Poll, for 5,000 livres, and imparted to
tlie profession. The instniment was long popuhir, but it has
now largely fallen into di-suse, not because of its intrinsic worth-
lossnesB, but l>ecause it is so far eclipsed by tho forceps. By
some prominent authors it in not even mentioned.
The vectis greatly resembles a single blade of the straight
I forceps. Several patterns of the instrument are in use, two of
""^''liich are herewith given.
L
^^^^^ppp Foldiog Vectis.
^M Its Fses. — We believe that this instrument may be used to
^^^Tantage in a number of unfavorable conditions, and, since its
^■^*i ployroent does not necessitate the fonnalities of the usual in-
stcr-Tujiental delivery, less objection will be offered, and cases at-
^Xided with few outward indications of abnormality may 1»e
tB*'*^atly facilitated, which would otherwise be permitted to drag
542
MINOR OBSTETBIC IN8TBUMKNTS ANB OPKBATIONS.
safely employ it, and the difficulties attendiug its use are not so
great as we find in connection with the forceps, and hence the
ordinary practitioner will be more 'inclined to avail himself of
its aid.
Fio. 344.
aA\&MmH«iOD.
Kyerson H Vectia.
In many instances the forceps are said to be demanded when
tlio difficulty and delay in lalior has ansen from extension of the
fcetal head. The vectis is peculiarly well suited to just each
cases, and when, by its 8imi>le leverage and traction, the exten-
sion is overcome, labor goes on apace. In occipito-posterior
positions, when rotation is not disix>sed to take ]ilace in the de-
sirable direction, the vectis is capable of afibrding much assist-
ance, and by it tlie occiput may be brought forward. This is
true also of the chin in those most trying mento-poateiior posi-
tions of face |>re8entation.
The instrument acts as both lever and tractor. In exercising
its leverage powers we should be extremely careful not to make
any part of the i)elvic structures its fidcrum. Without n ful-
crum its leverage action cannot lie displayed, bat it must bo
supplied by one hand of tiie operator, wliile the other acts upon
the iKJwer arm of the instrument. A certain amount of traction
may be exerted by the instrument as it is pressed firmly against
the foital head, but it is awkward and generally inefficient.
Greater traction force can be applied when the fingers of the
operator are made t<3 take the place of the second blade.
The Blunt Hook. — This, like the vectis, is an ancient instru-
ment, formerly much used for extracting the fcetus in breech
m
m
FA88IM0 THE CATHETER.
543
presentatioQ, and occasionally in cephalic presentation attended
with delay in delivery of the shoulders. It is intended to be
hooked into the flexure of the thigh, or into the axilla, but it
is so apt to injure the foetal tissues that, for the extraction of a
living fcetus, it has fallen largely into disuse.
Fig. -245.
Taylor'BBInni Hook.
Hypodermic Injections.- Tli<>ut;h directiouB concerning: the
use of the hyixHlermic syringe do not properly.belong to a trea-
tise on midwifery, yet, since the employment of hyi>odermic
medication, and es|5ecially the sub-cutaneous injection of ergot is
herein recomnjeuded for certaiu couditionn, and furthermore,
inasmuch as some of oui* homoeopatliic remedies act much better
when BO employed, we offer the following hints:
1. Tlit^ lipst sites for puncture are the back of the arm, on a
line witli the insertion of the deltoid nmscle, and the abdominal
tissues near the umbilicus.
2. The ue,edle should be passed deeply into the tissues, so that
itH [H>int will iDe at least half an inch below the integument
3. The fluid should be slowly injected.
Catheterlsm. — This may l>e deemed scarcely worthy the title
of an (jbstetric operation, and still in many cases its difficulties
are such as to try the skill of even those of extensive ex|)erience.
The variety of catheters which is best suited to obstetrical prac-
tice in general is the soft rubber, lx)th l>ecHUse of its facility of
introduction and freedom from danger. Still, the gum elastic
and silver catheters generally answer the purpose.
Mode of Performance. — The catheter may be passed with a
Bicgle hand, or with both. When lx>th hands are used, the oper-
ator may stand by his patient's right side, and pass the tingere
of his left hand between her thighs, as she lies with the limbs
flexed, and locate the meatus, while with the opposite hand the
|>oint of the instrument is made to engage. Or he may stand
between the woman's feet, as she lies on her back, and pass the
Ufa
544
MINOR OBSTETRIC INBTRUMENT8 AND OPEKATIONB.
index finger of the left hand into the vatj^na but a sliort distance*
with its palmar surface looking upwarda. Now if the finger is
made to lie fiatly againnt the anterior vaginal wall, it will rest on
the urethra, while the meatus will lie close to the margin of the
vagina, just within the vestibule. By remembering these points,
introduction of the instrument will be gi'eatly facilitated. With
Fio. 246.
.Soa Rubber Cutheter.
the soft rulil>er catheter now hold in the other hand, between the
thumb and forefinger, the point of it can easily be made to catch
the meatus. If these instructions are followed, there is no oc43a-
sion to make any efibrt to locat<^ th« meatus with the point of
the finger, and thus render the eflfort more embarrassing and
difficult
When a single hand is used, the catheter should be held as
shown in Fig. 247. while the middle finger is made to rest just
ri(i. '^47.
Haoner of holding ihe catheter.
within the vaginal orifice, against its anterior margin, and the
poentus will be found directly nnder the point of the OAtheter.
^i
TKANSFU8ION.
545
It shoxild be remembered that Ihe meatus lies directly at the
ci'oicrn of the pubic arch^ and as the middle finger of the single
band, or the index finger in the doable hand operation, are
pre&sed against the urethra as it lies in the anterior vaginal wall,
they will easily feel the pubic arch, and thereby aecure fnrther
aid to introduction. Nor should it be forgotten that, when
the woman lies on her bauk, the catheter, in introiluction, should
be given a direction somewhat downwards and backwards.
To perform catbeterism skillfully requires considerable prac-
tice, but, above all, thorough aequatntuuce with the anatomy of
the external generative organs, and the details of the operation.
To expose the parts, and locate the meatus with the eye, is a
most indelicate and unnecessary proceeding.
The Transfusion of Blood.— A few words should be written
on the subject of transfusion of blood, an operation which,
though attended with many difficulties and discouragements,
and one which, through lack uf marked success, has not often
been employed, we cannot pass over in silence.
^ The operation dates back several hundred years, but it *iid not
^H come into prominent professional Tiotice until Dr, Blundell pub-
^H lisbed his work entitled, ** Besearches, Physiological and Patho-
H io^ical,'* in 1824.
^f The design of the operation is to supply to'a circulation which
i li£i.fi been greatly depleted, blood fri^m either a lower animal,
I fi'^^xierally a sheep, or another human being who is willing to
I *tt^ke the necessary sacrifice.
The great practical difficulty in transfusion has always been
***^ coagulation of the blood shortly after it leaves the body.
-**i<:zN->d in which fibrination has begun is not only useless for in-
J^*^'tic>n, but highly dangerous, as small coagula may enter the
^^^*^<^ Illation and cause embolism. To obviate this difficulty, three
^^-•i^x-ent methods have been adopted, viz. : 1. Immediate traua-
^^-**ic>n from arm to arm, without permitting the blood to be ex-
V*^**^^<i to the atmosphere. 2. Adduig to the blood certain chem-
^J^^*^ *-eagent8, which have the power to prevent coagulation. 3.
Re.
^*^^ovb1 of the tibrine, and injection of only the liquor san-
^^*-*^is and blood corpuscles.
^^fc« Immediate Method.— For the purpose of immediate
^^*^*^ fusion Dr. Aveling has invented an apparatus which woi
546
MIKOR OBSTETRIC INSTRUMENTS AND OPERATIONS.
much on the principle of a bulb syringe, without valves. One"
extremity is connectetl with a cauula inserted into the vein of
the person supplying the bluod, and the other into a vein of the
patient, and by operating it much like a syringe, anil making
the fingers serve for valves, the blood is .transfused. Dr. Fryer
has designed an InBtrument which in some respects, is an im-
Fia. 24a
Fryrr's instrument for immediate tninsfnsion.
provement on that of Dr. Aveling, and a cut of it is herein
sented.
fheraical Prerention of ('oafirnlation.— Dr. Braxton Hicl
who has been one uf the strtiiigest itdvocates of this meth<
projxjses to make a solutiun of three ounces of fresh phosjdiate
of soda in a pint of water, about six ounces of which are to be
added to the full quantity of blood to be injectetL Tliis prevents
ooognlation, and tlie injection of a certain amount of it has been
attended with soiue benefit; but the luethcHi does not recommend
itself to tho indorsement of a rational mind.
Defibrination of the Blood.— This is done by whipping
and then removing tho fihrine by stroining. The operation nee<
not be a hurried one, and the rapidity of tlie injection is a mi
ter easily controlled. It has boon successfully employed in
large number of cases, oppears to be attended with little dangi
and is most easily performed. It is the operation which coi
mends itself to the general practitioner, and may^ yet, in hie
hands, prove a blessing to mankind. Blood thus transfused has
been proved to become provided witli fibrine soon after eni
1
TBANSFUBION.
547
the circulation. The first injection need not exceed six or eight
Fifi. 249.
Allen's Transfuser.
^^^> afi, if necessary, it can be rei>eated.
5^
UIKOB 0B8TETRI0 INSTBDMENTS ASD OPEIIATIONS.
Allen*8 Instrument for Immediate Transfusion.— An in"
Btnunent for immediate trausfusion has been invented by Mr,
£. E. Allen, which works on an entirely new principle, and wliich,
in experiments, has shoA\Ti itself far superior to any other. By
means of it, coagulation of the blo*xl as it passes from arm to
arm is prevented!, and the velocity of the current is regalate<l at
will We are at present performing some exi^eriraents with the
instrument, and will be glad to answer any personal inquiries
with reference to it
Mr. Allen has also invented what he terms the "skin cup,"
which obviates the introduction of a canula into the vein of the
donor, and which, by simple mechanism, prevents the possible
entrance of air.
Fio. 250.
The " Skill Cup."
Transfusion of Milk. — The intra-venouB injection of fresh
milk, under conditions similar t-o those demanding the transfu-
sion of blood, was first practiced by Dr. Hodder, of Toronto. It
has since been experimented with by Dr. Thomas and Dr.
Brown-S6quard, and its efficacy has received their endorsement
The latter found, in his experiments on the lower animals,
that the milk was as efficacious as either fresh or defibrinated
blood, and its globules could not be found one half hour subse-
quently to the injection. Transfusion of milk certainly prom-
ises most excellent results. For a single injection eight ounces
are usually sufficient The milk should be warm, perfectly
fresh, and of good quality. To insure its freedom from foreign
matters, it should be passed through a fine piece of muslin. It
carried into the circulation by passing into a vein a small
OBANIOTOHY.
649
oacula, to which is connected n Bmall tnbo in relaldon with a ves-
sel containing the milk, which by its own weight is siphoned
through the apparatus.
Mode of Exposhi^ihe Teins Selected for Transfusion. —
This part of the (Operation is a most tielicate oue, rendered un-
usually so by the collapsed state of the vessels sought. The best
way to expose them is to pinch up a fold of skin at the bend of
the elbow, and transti^L it witii the knife, when upon opening the
wound, the veins will be found lying nt the bottom of it By
passing a probe under the vein it may be secured, and through
a small nick made in it, the caiiula can be passed. The appa-
ratus having been previously hlled witli eitlier blood or milk, to
prevent the intnxluction of air, the injection may be begun with
the greatest caution.
CHAPTER XXIL
Operations Involving Destruction of tlie Foptus.
Craniotomy. — Under the head of craniotomy are generally
classed all the operations, the performance of which involve mu-
tilation of the head of the fhiid. It is ou« of tlie oldest oper-
atiooa of midwifery, evidently having been practiced in the
time of HipiKJcrates.
Its Sphere, — Craniotomy is employed in those cases of diffi-
cult labor wherein neither the forceps nor turning can be effectu-
ally adopted. It is also ix-casionally had recourse to (though
not /iln^ays wisely) in certain contingent accidents which hapi>en
during i»arturition, as in some cases of accidental and unavoida-
ble hemorrhage, in some cases of convulsions, in certain cases of
uterine rupture, and in those cases of protracted labor in which,
from the neglect or ignorance of the physician in attendance, the
pelvic organs and tissues are brought into such a state from
preaanre, that delivery by other means would be extremely haz-
5S0
OBANIOTOMT.
ardous to the life of the woman. It is also employed in difficult
labor, when there is positive pvidence of foetal deatlL
Frequeucy of Employment*— From the statistics which fol-
low it will be seen that the frequency with which this operation
is had recourse to varies greatly among private practitioners,
hospital physicians, and the obstetricians of various countries.
Dr. Collins reports that, dmiiig his mastership at the Dublin
Lying-in Hospital, 16,414 women were delivered, during which
time craniotomy was performed seventy-nine times. Dr. Joseph
Clarke repf)rt« tliat, in 10,387 case of labor, craniotomy had
been performed forty -nine times. According to Dr. Churchill's
statistics, British practitioners resort to craniotomy once in 219
cases: the French, once in 1,205| cases; the Germans, once in
1 Q44A
iNSTBUatENTB EMPLOYED.
The Perforator. — There are many patterns of perforators,
but those illustrated in the accompanying cut*^ are among the
best. The instrument ought to bo well made, straight and
strong. It is the first instrument used in performing crani-
otomy, and, when proporly ctmstructed, can be employed with-
out danger to the maternal tissues. In cases of emergency, a
bistourj', or even a pockct-kidfe may bo used, if the head is in
the i)elvit! cavity.
The possibility of mistakes being made in cf>nnertion with
Fm. 351.
Thumiu* PcrfuRUitr.
perforation will be seen wlieu we say that the sacral promonti»ry
has been pierced under the supposition that ii was the fcetal
head.
The (Yotchet, — The crotchet is a hook, mnde of highly-tem-
pered steel, possessing a sharp point, the design of which is
fixation in some portion of the base of the skull, generally on
THE PERFOKATOIU
551
its internal surface^ by means of wliich traction may be made
For many y«ars it wag the only instrument used as an ex-
tractor after perforation. It is i)owerful in the hands of a
skillful operator, but a highly dangerous instrument when cm-
ployed by the ignorant or inexperienced. All forma of the in-
Fio, 252.
BIui'h l'error:iti»r.
Btrumeut are open to the serious objection of being liable to
slip, and wound either the maternal soft ports, or the hand of
the operator which nliould always be used as guard. It has
gone almoht inti» dinuae.
Pro. 258,
Blunt flmik Jind Crotchet.
I'raiiiotoin.v Forceps, — This instrument is used f<jr both ex-
tractive and destructive purposes. It is intended to lay hold of
Flu. '2oA.
Thomatt' Cramolomy Forceps.
the skull, one blade passing within the cranium, and the other
on the outside. AVith the hold thus obtained, forcible traction
can be miide, and, eavt? in cases of considerable pelvic contrac-
tion, extraction eil'ected.
In some instances, however, it becomes necessary after perfo-
ration, not only to break up and wash out the brain substance.
552
CRANIOTOMY.
but also by these forceps to remove the cranial bones in frag-
Flo. 256.
Use of the crauiotomy forceps.
ments. before the bulk of the head is sufficiently reduced lo
enable it to be drawn through the pelvic canuL
The Craiiioi'last. — The cranioclast may be regarded as a
pair of lurge <!rnniotomy forceps, which udiuirably answer the
purpose of delivery in many cases. The instrument designed
by Sir James Simi^soD is that most commonly employed in
Great Britain. In America tlie cranioclast is not oft^n nsed.
It t'onHibts of two l)la(les fastened by a button joint The ex-
tremities are shaped like a duck-bill, and are sufficiently carved
til give a firm hold of tlie head. The upper blade is provided
with a deep groove into which the other sinka
The female blade is applied outside the head, and the male
THE CEPHALOTRIBE.
553
blade is passed through the opening made by the perforator,
and then the cranial bones are all separately crushed liy the
forcible grasp of the instrument This having been done, the
crauiuclast is made to take a final hold, when it is turned u{M)n
Flo. 266. *^ ^^^^ ttxis several times, thereby
twisting the scalp, and expelling more
of its contents, after which extrac-
tion is easily effected.
The IJephalotribe.— In 1829, Bau-
delooque proposed a cephnlotribe for
crushing the crajuum in lalxirs ob-
Btructe*! by pelvic distortion. It was
used in France and on the Continent,
but was not adopted in England and
America till a much later pei'iod.
Thecephaloh'ibe is a large and jxjwer-
ful instrument, intended to grasp the
head, crush it, and then to extract it.
The instrument, as commonly con-
stnicted, resembles a largo and strong
pair of obstetrical forceps. It is suit-
ed to pelves distorted by rickets, rath-
er than malacostcon, and hence should
receive special favor from American
obstetricians. No rule can })e given
as to the amount of pelvic space re-
quired for its safe employment
Perforation is generally recomraond-
ed to be first perforraei I, though Bau-
delocquo regarded the preservation of
the integrity of the scalp as one of the
advantages of his method. The bhules
of the instrument are to be applied in
the same manner as tlie bladtts of
the long forceps in a high operation. Like the ordinary for-
ceps, the instrument may be api>lied through a partially ili-
latcil OS nt4^ri, wlien circumstances seem to demand the opera-
tion under such conditions. In order that the base of the skull
Simpaon'a Cranioclaat.
554 nRANIOTOMV.
may be reached, the bladee Bboold be deeply inserted. When
the bhides are in siiu, compresBiou is gradually applied by uieaiiH
of tlie screw. As the diameters of tlie head are dinnnished in
one direction tliey are increased in another, but, esce]}t in in-
stances of excessive pelvic contraction, this is a maitcr of no
great imix>rtance.
Fio. 257,
Lttsk'ft Cftphulotrilw
If necessary the instrument raay be carefully removed and ap-
plied so as to compress the head in its op{x>8ite diameter. Pajot
claimed to l>e able to deliver through i>elv«»8 contracted l>olow
two and oue-lialf inches by thus cruHliing the head in different
directions.
FiQ. 26b.
Pattal head nrnMhed by the cvphalotribe.
Before beginning extraction, the aperture made by the
forator should be examined to see that there are no projecting"
speculsp of bone.
Comparative Meritn of ('ephalotripsy and I'ranioclasm,—
The relative merits of the ccphalotribe and the cranioclas^
as instruments with which to briii^ a mutilated child through
a distorted pelvis, are not fully settled, but there appears
to be no doubt that the crauioclast enables as to extend the
CBAJ^IOTOMY AND CESAREAN SECTION,
556
limits qL safe delivery far beyond what would be admissible
with the oephalotrilw, as by meaus of it we may. aft^r partial or
complete remoyal of the flat bones of the cranium, tilt the chin'
downwards, and draw the ba»e of the head edgewise -through
the conjugate diametei* of the pelvis.
Comparative Merits of ('rauiotoniy and the ('jpsarean Sec-
tion.— Early Csesarean section appears to furnish as good ground
for hope, in cases of eictreme deformity, as craniotomy. Dr.
Harris* publishes a table of seventeen American cases in which
the oi>eration was performeil during, or at the close of the first
day of labor, which shows a mortality of a little less than thirty
per cent
Of 103 cases of craniotomy coming under the observation ol
Rokitansky. forty-one, or about forty per ceni, terminated fa-
tally.
Embryotomy, when Version Cannot be Effeeted. — Tlie
second class of destructive operations is that wherein mutilation
of other i>arts of the body than the heatl is performed. Embryot-
omy is most likely to be required in neglected cases of trans-
verHe presentittion in which turning caiuiot be efiected. Ouj*
choice at such a time lies between deccipiiation and rvisceraiiotu
Decttpitatlon.— This operation consists in severing the head
from the body, having done which, the latter can easily be with-
drawn V>y means of the arm, and subsequently the severed part
extrnctiMl. This is the oj>erfttion to Ik; preferred if the nt^^k can
b«i reached witliout much dithculty. Many instruments have
been densed for et^ectinp tlie ]>urpose, but what is known as
RamsUitham's decajntating lii>ok lifis met with much favor. Tit
use the instrnment it is slipped over the neck, and tlie part
divided by a sawing motion. The most difficult part of the op-
eration consists in gftting the linok *ivor the neck. To ijbviate
this difficulty, some have recommended the use of a spring, with
B string, which may l)e more easily paBse<l. By the siune mejins
the chain of an 6craseur may be drawn over, and the head tlitis
severed. A stiff male catheter rany also be employe<l instead id
a spring. The decapitating hook, though a goo<l instrument,
cannot he made 8ervic»>iiblo for tmy other puriM>se, ?ind as it is
Americftn JnuriKil Ut>* " V»h . 1>'72.
566
EMBBYOTOMT.
BO riirely required, few feel like providing themselves with ii
The 6cni8eur, however, is a surgical iuHtrument of relatively
froquent use, and with one of them every practitioner is expected
Fig. 35B.
Decupitaling ITook.
to l>p provided. It requires gentle manipulation to avoid
wounding the maternal tissues, and the greatest care must be
ext^rcised. Some prefer a pair of strong soissora, with which
they pierce the neck, and then divide the spinal column.
Extraction of the Body and Subsequent Dellrery of the
Head.— There is rarely much difiiculty ex]>erienced in getting
away the body. The arm is usually prolapsed, and by traction
on it extraction is effected. The head, still in utero, may Ih> held
at the brim, while the cej>halotribe is applieil, i^hich is generally
regarded as the preferable instrument for deliver5\ Collnj>se
of the head takes place by eacajK* of the brain through the
vertebral canal. The obstetrical forceps can sometimes be
need witli success. In other cases the head may 1^ perforated,
and then the crauiott>my ft)rceps em]>]oyiHl L*r extraction pur-
poses, one blatle being intro4luced within the perforation, and
seizing ujmju the cranial bt^mes, while the other is made to lie e«-
temally and exert counter pressure to secure the hold.
Evlsreration.— Our choice slinnld rest upon this oporation
only when decapitation cannot be practice*! In executing it
the thorax is jierfcmited at its most aoooesible point, luid the
opening made as large as ix)S8ible, in order that the Viscera may
be removed, and th*^ fivtal bulk thus decreased. The perforatiir
is swept about within the cavities, and tlie organs are thuB broken
up as much as possibli', pn^jwiratiry to their removal in frag-
ments. The thoracic and alxlominal caviti<*8 thus Ixing oi>enei
and to a great extent evacuated, the fcetus should be made ii>
perform an evolution, by means of which its i>elvic extremity de-
scends, and (h'livery is thu*i effecU'd. Tliis mt»vement may
ETI8CEEATI0N.
557
facilitated by division of the spinal colunm between the vertebra
by means of a stont pair of scissors, or even a knife, carefully
used, and then by ti'action with the crotchet, fastened on the
pelvic bones internally.
Fio. 260.
Mode ot asing the decapituiiug book.
^'Umber of coses have been recorded wherein neither decap-
558
C^SAEEAN SECTION.
itation nor evisceration could he successfully performed, and the
operator was driven to the performance of gastro-hysterotomy.
CHAPTER XXni.
Tlic Capsareaii Operation-— Porro's Operation
Laparo-clytrotoiuy"Sympliy80tomy.
Gastro-jiysterotomy, or the CaBsarenn section, consists of an
incision made through the abdominal and uterine walls for the
purpose of extracting the child.
The post-mortem oijeration was performed at a very remote
period of antiquity; but hysterotomy on a living woman waa
first practiced pixjbably not more than four centuries ago. In
the sixteenth century it bec<.>me so very frequent that a Domin-
ican friar, Scipia Merunia, was led to remark that it was as com-
mon in France as blood-letting in Italy.
Cfesarean Operation on the Living Woman,— This oj^era-
tion, regarded as one of the most fr»nuidiible in the whole range
of surgery, is now practiced whenever the uatunil passages
through the pelvis are so narrow, or so obstructed, that delivery
cannot otherwise be accom]>lished. The actual amount of con-
traction which calls for the operation is not agreed n\ioi\ by ob-
atetricians, and there is no doubt that other elements* beside
mere contraction exercise a decided influence over jiarticalar
cases in determining the necessity for the operation; as, for ex-
ample, the character of the instruments employed, and the skill
of tlie operator. The necessity for hysterotomy has been ob-
viated by some operators wliere the pelvic conjugate was only
one and one-half inches; and in the practice of others, it has been
demanded and jjerfnrraed, even in modem times, in pelves roe-as-
ming two and one-half inches in their antero-postorior diameter.
Causes of Death after the Operation.— The causes of
death after the operation, are hemorrhage, peritonitis, metritis,
RE8CLT8 OF THE OPEIUTION.
559
shock, Beptica^niin, and exhanstioD — being sabBtantially the samo
aa those following ovariotoray.
Denults of the Operation,— Ciosnrean section has not been
'ndod with Huch encouniging results in English as in Aineri-
practice. Up to January, 1881, there had been performed
in Great Britain and Ireland 134 CsBsarean eections, the resnli
being successful in eighteen jjer cent of them. The l)etter re-
Bults obtainod in American practice are shown in the following
table, prepared by Dr. R, P. Harris.*
TABL£ OF CJiSARKAN OASRH OPERATED T7PON IN THE DIFFER-
ENT H.TATES, SHOWING VEUY MARKED DIFFERENCES IN
SUCCESS.
S
WoMKN. 1
ClIlLORBM.
fi
tt
WllITl
Women.
Black \V,jnin.
Statks.
d
g
i
Q
^
^
s
a
Q
■
<
m
■^
<
^5
J3
^
5
>
Loui&iaua .
•20
h
15
11
9
1
19
5
14
New York...
14
11
3
lU
5
12
2
10
1
1
Alabama
10
7
3
8
2
3
7
6
1
Ohio
10
10
3
5
6
5
10
7
2
Pennsylvania.
1
Viru'inia
»
7
6
3
3
1
5
1
Illlil.lUli
6
<
4
2
5
1
MxaAlAHJppi ,. .
6
i
1
5
1
. .
2
Gcorjfia
5
5
. .
4
?
1
• •
MichiK^o
3
2
I
1
2
3
MiHOuri
3
3
. .
3
3
• •
.,
ArkAnooa
2
1
. ,
2
1
Cftlirornift . . ,.
3
1
I
2
2
Cnnnccticut, . .
2
1
1
. ,
, ,
1
Ulittois
2
. .
1
2
Iowa
2
2
1
1
1
3
2
1
, ,
Kfrnlucky
N. OirnliDa. ..
2
,.
2
1
1
. .
1
^IXCUDAID
2
2
1
2
Ji.ine
1
. ,
1
Jlar>liin(]
1
1
. ,
—MoiMat'huftctU.
. .
. .
. .
1
^3Jbw Jereey . .
1
1
^^^^. Hampshire.
1
1
• •
*^^ Carolina...
1
"" -ffcDnettc© ....
1
i
..
^^Kotttated....
IW
1
1
-.
1
••
•*
Total ....
70
50
68
62
64
5«
40
24
30
2fi
CiMa reported in medical jonmals, 65 ; recovered, 36=53 11*13 per ceni. of
Cmc8 obtained throagh correapondpnce, 55; reoorered, 15=27 3-11 per cent.
• " Am. Jour. Obi." Vol. xiv.. p. 347.
660
C£aAB£A^ SECTION.
Dwarfs from 3 a. to 4 ft. 8 in. high, tM ; recovered, 7. Whites, 5 ; blacks* %
While dwarfs, 17; black dwarfe,?. ShorU-fit white recovered, 3 ft. llj in^
black, 3 It. 9 in. Uterine sulurus used in '.20 ca&««, qI' which 7 recovered. Sil-
ver wire was used in 10, saving 5.
The Operation. — The following directions concerning the
performance of this very important operation we quote from
Dr. Thomas Radford,* who has performed hysterotomy quite a
number of times, and who from general surgical and obstet-
rical experience ia qualified to offer sound advice,
Fiu.261.
The Cceaareiui Operutioii.
General ronsiderations.— "The operation ought not to be
made one of display. There should only be a verj' few persons j
present, and the gjeatest quietude should be afforded to the pa-
tient Every cause likely in any way to create unpleasant emo-
tional feeling should be most carefully avoided. These mlea
were strictly observed in the two successful oases in which I
was engaged. It is of the first importance, to adopt all such
measures as will prepare the patient to undergo this operation,
by improving the general health.
* " Obwrrviitioiw on the Cieffarean Seolion, Craniotoniy, and other Ohst«trie
OpcrrttionH," p. 24. London, 18^0.
PUELIHINABIES.
ai;i
Preliminaries.—" The bowels should be emptied by a large
quantity of warm water thrown into the rectum and colon, by
an enema-apparatus with a long flexible tube (like the one used
to enter the stomach), so that its estremity can reach beyond
the great projection o£ the sacrum.
"The blndtler must also be emptied by a catheter, equal in
length to that used for the male. This organ is forced down-
wards and forwards, and lies under the deflected uterus, where-
by its cervix is lengthened and compressed upon the pubes.
This altered position of the bladder is particularly to be ob-
served during the latter month of pregnancy, in cases of pelvio
distortion from mollities ossium.
Exaniinations. — "Frequent examinations per rviginam have
been already shown to Ije extremely injurious; so that this prac-
tice should not be allowed. lu an exploration made to ascer-
tain the measurement of a distorted pelvis, the obstetrician is
compelled t^:> pass his hand completely, and as far as possible
into the vagina. Anxious to ascertain the state of the os uteri,
the presentation of the infant, and the exact available space in
the pelvis, he prolongs the operation, and often repeats it. And
when consultations are numerous (as is too common) in these
cases, serious mischief is inflicted on the pelvic organic and tis-
sue. By one effectual examination, every necessary informa*
tion can be obtainetL Tht^ interest of the patient is best secur-
ed by having only a limiteil number, (say two persons) in con-
sultation.
" The opcruiion should be pei'fm'med on the bed; so that the
patient may be kept as quiet as possible afterwards. In some
of the cases in which the woman was removed to a table, some
untoward circumstance happenecL
" The temperature of the room should be regulated, and a
genial warmth of the atmosphere maintained.
Form of the I'terns.— "The uterus projects more or less
forwards; and when the pelvic distt^rtion is caused by mollities
ossium, this organ assumes the retort shape. Its projection is
so great that its normal anterior surf ace rests upon the thighs of
the patient when she sits, so that the fundus necessarily stands
most foremost Before the incision is made, it is of the utmost
562
CESAREAN KECTION.
consequence to raise the deflected uterus up ; or else the f uudal
tissue, which abounds with large anast-omf^sing vessels, must un-
avoidably be divided • Neglect of this caution has, no doubt, led
U} the hemorrhage which happened in some of tlie casea A di-
vision of the structure of the upper part of the fundus of the
uterus must certainly interfere with the regular or efficient con-
traction of this organ, and thereby produce a ga*ping character
of the wound.
Advisability of Operating Early. — " When we contemplate
tlio mischievous effects of protracted labor, and review the uu-
fav)»rable condition in which most of the patients have been
brought by unwisely procrastinating the operation, we must at
once be convinced how import^int it is to j>erform it early. The
sooner the better it is had recourse to after it is determined
upon, either as one of election or one of necessity.
** When labor is rendered difficult by great distortion of the
pelvis, or by large exostoses, or by large tumors in its cavity,
some of those natural organic changes are not to be found
which would otherwise guide us, and enable us to judge of its com-
mencement and progress. To wait, then, in such cases as these
for the dilatation of the os uteri is not only a great mistake, but
also a very great evil; for, in most of tliem, tliis part of the
uterus cannot be touched, and, in general, very Httle dilatation
of it does or can talce place.
*'The dangers of delay, on e:jpectant grounds like these,
which so frequently hajipeued in the registered cases, ought to
guard us against waiting for those indications which cannot poB-
sihly be discovered, and in<luce us to operate early. As soon as
the labor is established, and before or immetiiattdy after the
membranes are ruptured is the most favorable time to proceed.
Great advantage accnies from adopting this plan; for the lenglli
of the uterine incision would relatively diminish in size, equal
to the diminution which takes place by tlie contraction of the
uterus. Another great advantage arising from this course is,
that the danger of protraction would altogetlier be avoided. It
is a well-known fact that little risk comparatively occurs before
the waters are discharged.
Placental Complications. — " Before the incision is made the
location of the placenta shoidd, if possible, be ascertained, in
664
CXS^BZAS 8ECXI0N.
oasness should be especially avoided. If the uterua be slowly
iBcised, the stimulus of the knife instantaneously throws thi«
organ in violent and irregular contraction, which separates the
placenta and entails mischief on both the mother and the infant
Every precaution having been taken, we ought to strictly ob-
serve the mottf), ' ciio ef tuto," The incision should be made
on the b(Kly of the uterus, because this portion of the organ is
eminently contractile, and ought to extend well towards the fun-
dus, but not into it. It ought not, however, to be carried too far
down into tlic c-crvix uteri, because this part possesses dilatable
properties which are unfavorable to a diminution in the size of
the wound.
Extrartion of the riiild.— "When the uterine incision is
completed, there should be no delay in withdrawing tlie infant
When it lies in its usual natural position, with the head over the
brim oi the pelvis, then the obstetrician should seize its legs
with the right hand, and pass his left cautiously and quickly
down go as to embrace the face on one side, or the hind part of
the head. By this mode a double ix)wer couKl l>e effectually
exerted; one of traction by the legs, the other by raising the
head upwards/*
"If the breecli offer at the incise<l uterine oj)ening, the practi-
tioner should seize it with his right hand and withdraw it, and
at the same time use his left hand as above mentioned If the
head lie in proximity with the incision, then it ought first to
brought forth, and. at the same time, he should pass one hand
cautiously forward ah^ng its body so as fairly to embrace the
breech, and act with both his hands as recommended abo^^ft.
These precautionary rules are suggested to prevent the grasping
seizure of the neck or the hips of the infant, as the case may be,
during its removal. One or two writers have urged that the
head of the infant should be always first extracted, on tlie
grounds of being safer for it, but a conditional practice, aeoord-
ing to its position in the uterus, is by far the best"
*'The head is most generally situated in the lower segment of
the womb, and, therefore, at some distance from the centre of
the incision. In order to bring it fairly to the opening, it woiUd
produce a great strain on, if not laceration of, the contracted
uterine tissue, and create nearly a doubling of the child upuu
CLO80BE OF THE WOUNDa
665
iteelf before it could be extracted. And as expedition is re-
quired, it would be found that the bulk of the head was not very
readily grasped with Bufficient Erinness bo as to ensure its speedy
withdrawal. Time would be lost, and imi^eiUments added The
placenta, with the membranes, should be also quickly extracted.
Prevention of Intestinal Protrusion. — ** Protrusion of the
intestines is very apt to occur during the operation; this becomes
very troublesome to the operator and distresyiug to the patient,
auil a considerable time is consumed in order to replace them.
This accident not only predisposes to remote mischief, but it
immediately tends to depress the vital (K>wera of ihe woman.
She feels faint and has a sense of sinking. Every care should,
therefore, he taken by the assistants to repress and retain these
viscera under the instruments by an extended application of both
hands on each side of the incision."
(iosnre of the Wounds.— "The advisability of closing the
uterine wound by sutures," says Playfair,* '*i3 a mooted point.
The balance of evidence is entirely in favor of this practice, f.s
temling to prevent the escape of the lochia into the peritoneal
cavity. Interrupted sutures of silver wire or carlxilized gut
may be used, and cut short;! or, as successfully practiced by
Si>enc-er Wells, n continuous silk suture may be applietl, one end
being passed through the os into the vagina, by which it is sub-
sequently withdrawn. Before closing the uterine wound one or
two fingers should be passetl through the cervix, to insure its
being patulous. A free esca|>e of the lochia in this direction is
of great consequence, and Winckel even advises the placing of
a strip of lint, soaked in oil, in the os, so as to keep up a free
exit for the discliarge.
** A ]>oint <tf great importance, and not sufficiently insisted on,
IB tlie advisability of not closing the alidominal wound until we
are thoroughly satisfied tliat hemorrhage is completely stopped,
since any escape of bloo<i into the peritoneum would very ma-
terially Wsen the chances of recovery. In a successful case
reported by Dr. Newman,J the wound was not closed for nearly
• " System of Midwifery," Am. Ed., 1880. p. 518.
t The cat^uL «nluw has proved a laili re. It dors not hold.
t *' OhstPt .^Trans.," vol. viii.
566
C^SABEAN SECTION.
an hour. Before doing so, all bltuxl nntl diBcharges should be
carefully removed from the peritoneal cavity, by clean, soft
spouges dipped in warm water. Th(> abdominal wound tihould
be closed from above downwards, by hair lip pins, wire or silk
sutures, which should be inserted at a distance of an inch from
each other, and passed entii*ely through the abiiominal walls and
tlie peritoneum, at some little distance from the edges of the
incisii^n, eo as to bring tlie two surfaces of the peritoneum into
conUict. By this means we insure the closure of the peritoneal
cavity, the opj)osod hurfuees adhering with great rapidity. The
surface of the wound is then covered with pads of folded lint,
kept in posititm by long strips of adhesive plaster, and the whole
covered with a soft tiauuel belt"
Antiseptic Precautions.— The operator cannot be too care-
ful to use every precaution to prevent septic infection. The at-
mosphere of the room must not become contaminated from tlie
presence of anybody or anything tJiat may c+juvey tlie (Hiisnu.
The hBn<ls of the operators, tlieir instruments and sponger,
must all be above suspicion, and be subjVcted to thorough
infection before coming in contact with the patient
After-Care of the Patient.— The care of the patient a
the operation diflfera in no essentials from that prescribed
women upt^n whom ovariotomy has been performed.
PosT-MouTEM Cesarean Section.
The Cesarean operation will mIso be advisHble in those cases
wherein women meet vriih sudden death during pregnancy or
labor, and a living child is left in utero. There can be n<i re«-
6<_»nuble doulit that many ehildi'cn have thus l>een saveij who
would othenvise have perished. The percentage of success in
these cases, however, U not so large as we might Im^ Wl to e^x-
pect Schwartz* collected 107 cases, out of which number nnt
one <']iild was saved. These, however, tlo not truly repr4*sont
the chances wliich the operation pives the child, for Duorr hits
tabulated fifty-five cases^ out of which uumlw^r forty resulted in
the delivery of living children. The lapse of time between the
maternal death and fcetal extraction was as follows: '* Between
• Monat. f. Oi'burt.. BUppI. vol., 1881, p. V2\.
t " rost-morlcm Dt-livcry," Am. Jour, Oba., Jan., 1879.
POST-MOliTEM OiEBABEAN SECTION.
567
1 and 5 minutes, including •immediately/ and *in a few min-
utes/ there were 21 cases; between 5 and 10 minutes, none; be-»
tween 10 and 15 rainntes, 13 cases; between 15 and 23 minutes,
2 cases; after 1 hour, 2 cases; and after 2 hours, 2 cnsea," The
last two cases did not long survive. Both these tables of cases
may probably be justly regarded as extremes, and therefore a
fair estimate of success may be made only by drawing the mean
between them. *
The Want of Success Attending; the Operation.— "The
reason that the want of success has been so great,** says Play-
fair,t "is doubtless the delay that must necessarily occur before
the operation is resorted to, for independently of the fact that
the practitioner is seldom at hand at the moment of death, the
very time necessary to assure ourselves that life is actually ex-
tinct will generally be sufficient to cause the death of tbe foetus.
Considering the intimate relations l>etween the mother and
chUd, we can scarcely expect vitjdity to remain in the latter
more than a quarter, or, at the outside, half an hour, after it has
ceased in the former. The recorded instances in which a living
child was extracted ton, twelve, or even forty hours after <lcath,
were most probably cases in which tlie mother fell into a pro-
longed trance or swoon, dming the continuance of which the
child must have been removed. A few authenticated cases, how-
ever, are kjiowu in wliich there can be no reasonable doubt that
the operation was performed successfully several hours after
the mother was actually dead.*'
The Operation. — The desirability of operating w^ith the ut-
most dispatch in such cases, has already been shown, but, since
the matenuil death was in some instances only apiMirent, the
operation should idways be performed with the same care and
caution /is if the mother were living, and no special directions
Deed be giveiL
•••prolmbly the child will survive the mother's a*?c'cast; longer, rjr/m«
paribuit. iu prop4.»rtioii to the suddeuuess of the womun*» dciith. 11* shp \ny
«ick, for n ronsidcrablc pi'rimi prior to death, th« uniouu! oC oxyjicn in the
blood at the niDiiieiit ot'ditwoluiion is presumably less than it would be at the
instunt ofKuddcD denih in a womau previouftly healthy." Dr. Underbill, vide
Jour. Obs., V. xi., p. G26.
t '* System of Midwifery," Am. Ed., 1880, p. 513.
568
rOHRO 8 OPEHATIOK.
Post- Mortem Dellrery Tlirough the Natural Passages. —
In some instances thia will be the j^referable mode of operating,
chiefly, liowever, out of deference to the wishes of friends of the
deceased mother. People in general do not look ^nth the 8ania^
feelings of horror on contused ns upon incised woimds. In
cases the chances of saving the ftjetus may be idmost as good by
version as by ab<loniinai incision; but success cjin be looked for
only in exceptional instances. If labor had gone into the
second stage before the maternal death to<jk place, the forceps
should be used without delay, in normal conditions of tlie j^el-
vie, in preference to the knife. Tliere are a Duml>erof recorded
oases of sponiaveous ea'pnlsirm after mafemal death,
PoBuo'a Operation.
Oophoro-Hysterectomy.— Porro's operation consists briefly,
in tJie removal, after the performance of the Cesarean section, of
the uterus and ovaries. It is a comparatively new oj>eration.
its first execution on a human Bubj<ot having taken place in
1868, by Dr. Horatio R, 8torer, of Bf>stou. The patient lived
sixty-eight hours. This operation, however, was not delilier*j
ate.ly planne<:I, and it was performed l:)ecause of tlie excessivi
hemorrhage arising from the uterine incision made in the Ci
sareau ojjerF^tiijn.
Prof. Etiwanl Porro, of Pavia, on tlie 21st of May, 1876, kav-
ing had encouraging results from the operation |>Grformefl on
some of the lower animals, hud the courage to i*emove the xiterus
and ovaries from a woman who had a rachitic pelvis, with a con-
jugate iliamet^r of one inch and a halt Both child and
mother were saved. Since that time the operation has l>een
perftirmod nearly one hundred times, and has resulted favora-
bly iu about forty i^er cent of all cases. In European oxi>eri-
ence, where the Cesarean section has been attended with an
aj^palling mortality', this operation has been performed with re-
markahle success.
The Operation. — Up to a certain point the operation differs
not at all from ortlinary hysterotomy; but after delivering the
child and placenta, the empty organ is lifted from the abdomen,
and the serrc-m^td of Cintrac is placed around the !i>wer seg-i
ment, just alx)ve the os internum, and the tissues constricted
until all hemorrhage from the uterine incision has ceased. The
POBBO'S OrEIiATIOK.
569
nteras is then severed with a bistoury, the etnmp brought out
through the abdominal wound and there held by strapping the
serre-yiicud to the patient'a thigh.
The oi)eration as thus performed by Porro has been modified,
Mtdler makes the abdominal incision large enough to lift the
nnpmj)tied uterus through, and then after makiug compression
above the cervix by means of the Eyinarch bonthige, or the wire
ecrastmr, tlie uterine inoision is made, and delivery effected.
This lutxlifitation is an important one, but in practice has t»een
fouTid applicable to only a certain number of cases.
The stump should be trimmed, and some regard it advisable to
apply freely to it porchloriile of iron. To sustain the pedicle
and prevent the ligature from slipping, two long steel pins should
be made to transfix the cervix and rest ujwn the abdominal walla
It 19 considered essential that this operation, like all <>thei*8
involving exposure of the alKloniintd viscera, b<!perfonn*?<l under
strict antiseptic ijrecautions.
On the advantages and results of the Porro operati(tn, Dr.
Robt P. Hams, wh(i is excellent authority, says:* "Examined
in all lis details in different countries, and under different cir-
cumshinces, I have formed the opinion that the Porro-Ctrsaroan
operation, performed undt^r the carbolic spray, and followeil by
proper drainage and the Lister treatment, will be found success-
ful to the wuhian in about one-half of all the cases of pelvic
deformity rt'cjuiring its perftirniance, that are brought for relief
to lying-ip hospitals. What it will accomplish in private prac-
tice, or in tlie United States, where but one Cresareun casein
twenty-eight has been in hospital, I am not prepared to say."
He also says.^ " I have no objection to the ijitr(Hluction of the
plans of Porro and Mttller, except that I am not convinced of
the necessity fur so doing. In our cities, where the requisite
uumb^T of a.ssistaut-s may l>o readily obtained, and in <mr hos-
pitals, the Porro methol is less objectionable; but in country
practice, I should prefer iiw old operation perftjrmed early, on
account of its requiriug but little manual aid, much less skill,
and far less time than thn new one. The patient is also slower
in recovering from gastro-hysterectomy than gastro-hysterotomy
* Vide GLI8AN. 'Text-book of Modern Midwifery.** |», 5r»I.
t "Am. Jour. Oh«.," voL xiv, p. 'M6.
570
LAPAKO-EL YTUOTOM V
as a general rale, the abdominal wound taking a longer iimo Ut
heaL"
Laparo-El3'trotoiny. - This is an operation which has Ik^pti
brought prominently to professional notice by Dr. T. Oaillard
Tbom^is, and is intended us ji Hubatitate, in some case^. for Uif>
Cicsarean operation. It consists in making an incision from a
jioiut an inch above the right anterior superior spine of the
ilium, witii a tsliglitly liowuward curve, on n line parnllel to Pou-
part'H ligament, to a point'oue and three-quarters inches above
and tt.) the outside of tiie s[iine of the pubis. In due^NMiing this
incision, the skin, the aponeurosis of the external oblique, the
fibres of the internal obIi(jue, and transversalis muscles are ili-
vided, and then tiie^ transversalis fjiscia, which is here dense and
separated from the peritoneum by a Inyer of connective tissue
containin;; fsit The superficial epigastric artery is divided and
must l>e taken up. When tiie perittMieum i.s reached it is cnre-
fuUy raist?d without being cut, so as to expose tlie upper part of
tlie vaginii, througli an iiurision in wluch the fu^tus is extracted.
Di incising the vagina there is great risk of hemorrhage. There
is also great danger of cutting the bladder and ureter, and to
avoid these the incision sliould be made nearly an inch and a
half b(d(»w the utenis, and in a direction parallel to the nreter
and the boundary line between the bladder and the vagina. The
right side of the patient is cliosen «'n account of tlie position of
the rectum on tlie left. The ojieration luis l)een performed but
a few times, is not suitable to all cases, and, owing to its diffi-
cultieg and special dangers, is not likely to l»ecome popular,
hence we shall not here give at length its various steps.
Synipliysotofny,— While this operation does not commend
itself to the g(»od sense of the obst^^ftricians of to-day, it should
not be passed over in utter silence. On account of the want of
success in Ciesaroan section as practiced a century ago, a sul>-
stitute for that oi)eratiou was anxiously sought and in 1768
Siganlt suggest^l sjonphysotiimy. This involves a division of
the symphysis pubis, with a view to sutlicient separation of the
innominate bones to admit of fcetal extraction. It was fi^und,
however, that even wide separatiitn of the bones at this articu-
lation, did not materially add to the facility c»f delivery. In
contracted pelvis, — the very pelves in which difficulty in delir-
SYMPHYSOTOMl'. ^71
ery was sought to be overcome by the operation, the conjugate
diameter is the one which offers the most formidable obstacle,
and this is not materially increased by the divarication. Dr.
Churchill concludes that, even if it were possible to separate the
articular surfaces to the extent of four inches, we should have
an increase of only from one-third to one-half inch in the con-
jugate measurement In instances of minor degrees of contrac-
tion, this increase might be su£5cient to allow the foetus to pass,
but the risk of the operation would be too great to justify its
adoption.
57-2
PART rv.
THE PUERPERAL STATE.
CHAPTER I.
Plienomciirt and Mana2:oinent of the Puerperal
State.
Importance of the Study. —"The key/* says Playfair,* *'l
tho iiiaiiagoni*:'ut of women after IhIwi*. and to the pn>p>er ande"
Btainliiif^ of the mmiy imjjortuiit dibeaaes wliich may then occu^
is to be found in a study of the pheuoiueua following delire]
and i>f the chaugeH goin^' on in the mother's system < luring tifl
puerperal j>eriotl No doubt uiitural lalwr is a pliysiologiwil and
bealtliy function, and during reourery from its eifecttt^ disease
should not occur. It must not be forgotten, however* that mme
of our patients are under physiohigically healthy eontiitiona
The surroundings of the lying-in women, the effects of civiliza-
tion, of errors of diet, of definitive ch>anlinesB. of exposure to
contagion, and of a hundred other conditions, which it is impos-
sible to appreciate, have most impi>rtantiufluenceson the results
of child>>irth. Hciuui it follows thnt labor, evemuider the most
favorable conditions, is attentled with considerable risk."
Murtality of Child-birth.— A large amount of statistii
ijiformation is at hand resjiecting the mortalit)' of woman in pi
turition anil the puerjjeral stiite, but it is largely from hi>spil
experience, nml, as is well known, does not represent with
•"SysUm of Midwifery," Am Ed., 1680, p. 5W.
PHENOMENA SUCCEEDING DEUVERY.
673
degree of accuracy the results of private practice. Dr. Matthews
Duncan,* and MeCIintock, t have both given us some valuable
figures, derived from various sources, from which it would ap-
pear that in Enf^liBh obstetrical practice the death rate is be-
tween 1 to 120, and 1 to 146. According to another report by
McClintt-wk,* he increased his estimate to 1 in 100. Playfair
has pointed out a source of error in these calcidations, which
should not be forgotten, viz: that they make no allowance for
deaths occurring from other causes than those attributable to
labor.
Phenomena Sneceediiiijj^ Delivery. — The phenomena suc-
ceeding labor may be divided into the normal and the abnormal
Under the latter head should be considered all those tliseased
conditions fco which the lying-in woman is subject; but at this
time WG shall exclude the latter division and confine our atten-
tion to the phenomena of a normal character which are most
commonly observed.
Immediately after delivery the woman usually sinks into a de-
lightful quietude of mind and body, which is in strong contrast
Tnth the stormy scenes of the close of the expulsive action.
This, however, is accompanied by a sense of profound physical
^depression, like that which is felt after any great muscular exer-
"ftion. There ia nearly always a certain degree of nervous shock,
"^•hich finds partial expn*ssion in tiie oxhaustion mentioned. It
is also manifested by the occurrence, in quite a percentage of
<2ases, of a chill, severe enough at times to produce a chattering
<^f the teeth. But these symptoms soon (lisa])penr, the nerves
Vjecome steady, and the skin warm and moist; a sleepiness comes
«Dver the patient, and after a short hut delightful slumber, she
bWakens, greatly refreshed. In connection with this season of
tpose, whicli many w*)men enjoy soon after the completion of
l^abor, it should be remembered that, during it, women are some-
times taken with lionKtrrhafre, and awaken to iinil tht'raselvee
^ery low from the blood-loss. There exists, then, a necessity
for watchfulness when sleej) follows within the first hour or two
nfter delivery.
* The "Mortality of Child-b«d." " Edin. Mod. Jour.." Nov. 188D.
t" Dublin Quarterly Jour.," Aug. 1869.
t** Brit. Med. Jonr.,'» Aur. lO, 1878.
■Eb^
571
PHENOMENA AND MANAO£X£NT OF PUKRrERALITY.
Post-partura BloofI ChangeH. -The changes in tiie blood in.
eident to utero-gestation, already described, have a deciiled in-
tiuouce over the paerporal stite. The hyperiiiiKsis whieh Al-
ready existed is now cousiderahly awgiuented by Uie changes
which folldw ilelivi'ry. Tho copious supply of bltHxl which has
been given the nterus is now turned into other channels, and
the involution uf tlie uterus, which now begins, throws into the
circulation a considerable quantity of effete matter, to get rid nf
which all the excretory ducU are opened, and all the elimiua-
tive processes are sec vigorously at work. These facts must be
Ixirue in mind as we advance in our study of the puerjieral con-
dition.
Pulse ("hantros.— When the fingers are placed ujmdu the wrist c>f
n woman recently delivered, tlie pulse is usually found t<i be
slow, regolar, an<l tiriu, indicating an increased aiterial pressure
— it being an estjvblished physiological fact that as lirterial
pressure is redu(M*d, the cardiac c<intractiona are acoelerate*l;
ami as it is increased, the heart's pulsations are diminishe<1 in
fre<|uency. In the ptierpiTal patient this condition is probably
occasioned by the smhlen nioilitication of the uterine circulation.
In many castas the pulse l>econies extremely slow* falling, per-
haps, to 50 or even 40 heats per minute. If. on the other hand,
till* ptdse, from any c^mse, laiconjes rapid, and continui^s so for
any length of time, the ca^ should be most carefully watched.
A temporary acceleration does n(»t often denote any 8|>ecial
change in the woman*s general condition, as the most trivial cir-
cumstance is capable of creating it In the wards of )ying*itt
hospitals, whore sp<?cial opportunities for such observations aro
iiilonkMl, this has l>een a common experienca It is also true, ns
stattMl by Plnyfair, that the occurrence of one bad case within
the knowledge or observation of other puerperal patients, has
usuiilly been obst^n'ed to send up their pulsa
Moisture of the Skin. — The activity of the skin, which was
diminished during gestation, now beoimes functionally excited,
and. in normal states, is always soft, and moist, especially dar-
ing the first week. Perspiration is sometimes excessive, and re-
quires attention. It is often accouii>anied by a miliary erup-
tion upon different parts, which, from its pric-kling, occasions
great amioyance, Cazeaux saya such eruptions were formerly
TEMPEBATUUE.
575
more commoD, as tiio msult »)f burdening the women with cov-
ering.
Temper atn re in the Puerperal State.— In this connection
we should idMj 8i>eak of tlie temperature of lying-iu women.
During hibor it is somewhat elevated, :is the result of the excess-
ive exertion put forth, and the general perturbation of both
mind and Ixaly. This cuuditiun cuntinues for a short time
after delivei-y, when it declines, and sometimes descends a little
l»eU>w tlie normal level. The fall is not often considerable. No
great elevation is often attained. Subsequently, an<l during
the first few days after delivery, thet'e is slight increase of ii*^at,
caused, doubtless, by nterJne involution, and the establishment
of the lacti^id secretion. Tliere appears, as a rule, to be no milk
fpver, sucli as is descril)c<l by tlie older authors, though tliero is
the aliglit increase of heat mentioned. Rapid, but temiKirary,
rises of tempernture. are often (ibserved in puerperal women,
wliicli may proceed from the most trivial causes. Unless an in-
crease of temperature is attended by other 8ympt<jms pointing
to complications of one kind or another, or unless the tonipem-
ture should continue on a high level, there is no occasion tor se-
rious apprehension.
Fi«. '262.
rrnnpiprTiiiij n/iijif "i|^^^jm| 'ij'Hi'f m; ' r^irrpi^-^
Tht' 1,-liiueul thermonit'UT.
The following diagram illustrates the temperature of a puer-
peral woman, taken morning and evening, daring the first ten
days, in whom no otIif*r unfavorable symptmis were manifestf^d.
In fact, the author is satislifd, from repeated observations, nmde
on ])erHona in their hours of quiet home life, that in conditions
which do not present any morbid symptoms whatsoever, the
temj>erature oftt^n attains \00 deg. F.
rterine Involution. — The uterus, after deliver)', tends to ro-
ttume its original volume, with an astonishing rapidity. Though
Uiis changi' does not occur with uniformity and precise regular-
ity, since various occurrences may serve to retard the action,
y6t we find tliat, in general, it observes the follo\ving course:
Immediately after expulsion of the foetus the organ contracts
firmly, and, as elsewhere stated, may l:te felt through thealnloiu-
576
PHENOMKNA aM> MANAGEMENT OF i'DEUPERAXn^.
inal walls, an u h^nl uifkss, like a cannon-hall. Alternate relaxa-
tions and contractions t*ike place at iut-ennls, and aid no doubt
in the phystologioal process of involution. Bxtreme relaxation is
a patliological state, and tends t<^ the formation in uteio of ooag-
ula, and in some oases peniiitu profuse hemorrhage. This con-
dition is also apt to load to the entrance of air into the uterine
cavity, favoring deoomposition and the liability to septic infec-
tion.
Fia. 2ti3.
Uitigram showing trmpenitiiri'' citrvcM. hImivo, and the pulse uurvfs, beloiv^ is
a uariuul piicrixTul c-a8v.
During the first two or three days subsequently the oi^n does
not diministi mnph in size; liut thereafter U»e rwluetion is usually
quite rapid- At tlit* i'liise of the hrst week it is found not more
than one and oue-hulf or two inches above the pelvic brim, and
three or four days tliereafter it cannot be felt through Uie ab-
dominal walla except by conjoint t4iut:h. lu many cases uterine
involution is arrested at about this iioint, and, as a r^ult, the
woman suffers from j)elvic discou3fi)i*t until the condition is di>^
covered, and by approjiriate treatment rectifietl In normal
cases complete involuti4)n is effected in six or eight weeks. The
progress of uterine diminution is grnphii^ully shown by HeschI,
from the weight of the organ at different perivnls. Immediately
after delivery he found that it weiglis 22 to 24 oz.; in one week
it is reduced to 19 to 21 oz. ; at the end of the sewmd week it
weighs 10 to 11 oz. ; at the close of tlie third week it weighs 5 to
7 oz.; and in eight weeks its weight is s little in excess of tliAt
which preceded the first pregnancy.
This slow redaction f)f the n*erus in some instances occurs
CIL\NOES IN UTEllINE MUCOVS MEMBRANE.
577
without producing imy paiii, or even discomfort; but in other
CBBes it gives rise t<^ what have been significantly termed nfter-
jHtintt.
InvtjlutioD K^nerally proceeds without interruption, but a vari-
ety of causes may interfere, such as too early physical exertion,
neglect of lactation, and laceration of the cervix uteri.
The Excretions. — The activity of the skin has been {pointed
out The urine also is secreted in large quantities, but difficulty
in voiding it is often exi>erienced on account of temporary pa-
ralysis of the vesical cervix, or from swellLug and occlusion of the
urethra. The rectum is for a time inactive, a condition not at
all inimical to the woman's well-being at this i>articular period.
Examination of the urine reveals a trace of sugar, varying in
quantity with tlie volume of the lacteal 8ecretif>n, Ijeing most
abundant when the breasts are distended, or when, from any
cause, the milk is not drawn.
Chancres in the l't**rine Mucous Membrane.— Without en-
tering into a detailed description of the post-partnm changes
occurring in the uterine mucous membrane, it may be said that
the cavity of the uterus is covered witii clots of bh'Mxl, beneath
which is a soft, moist, reddish-gray, friable Inyer, found every-
where except at the placental site. It is supinitied that this mem-
brane is formed by a new uterine mucous membrane in ])roce3S
of regeneration, after the fourth month of pregnancy. It does
not extend into the cervical canal, but the latter contains a glu-
tinous, transparent, and pinkish mucus.
The placental site is elevated, and presents a mammillated,
rouadetl, anfractuous surface, dotte<i over with coagula, which
are remove*! witli difficulty. The walls of the venous sinuses
e«})ecially at the placental site, are thickened and convoluted, and
contain a small blood clot, while their mouths are i)erfectly vis-
ibla
The cervical mucous membrane is not exfoliated. During
pregnancy it is sira])ly liypertrophied, and after labor the arbor
YitfB are discernible, though in a modified form.
Yaginal Changes, — The vagina is shortened, and diminished
in calibre, tlie rugro return, and the external orifice and vulva
Boon assume much their former api>earance. A strong contrast
578
PHENOMENA AND MAifAaEME>'T OF PrEJlPEHAim.
IB esfcablislied between the comliti(jiiH wliioh are observeil imiue-
diately after delivery and those now esttiblished.
The Lochia. — The discharges which esca^ie irom the vulva
Bfction of ft nterine sinus Irnm the ylaccntal aite nine weeks after deliTcry.
t Williams. (
after delivery are known as the lochia. The periotl of their con-
tinuance varies, but tliere is generally more or less discJinrge un-
til the uterus has returned to its iK»nnal, non-f)re(:^ant, size. In
some women, who do mtt uuree, they persist until meustruntion
returns. At first they are composed almost wholly of bhnKi,
botli duid ard coagulated. Clots of some size often acoumulnt4^
in the uterus and vagina, especially in multi]>arsp, and are dis-
charged, with a little Y»ain, durinp the first iweiity-four or for-
ty-eight hours. After the first day, tlie lochia consist of alx>ut
one-tlurd part red corpuscles, while the other matters are
chiefly whit© corjjuscles, blood seruru, nninerouB epithelial
cells, and mucus. After the second or third day the red corpus-
cles almost wholly disappear. As soon as the hicteal secretion
begms to be establifjhetl, the lochia are greatly diminishetl in
quantity, but soon again l>ccome )>rofuse, accompanied with
THE LOCHIA.
579
some blood, and later, pua corpuaclee; but tlie blood usually dis-
flpi)ear8 about tlie close of the first week. The discharge then
continues, yellowish-whito in color, and of somo. consistency. At
tins stiige it is sometimes called tlie "green waters."
Variations in (Quantity, etc.— The amount of flow varieg
mndeiy. Instead of grmluully diminishing, until final disappear-
ance within a feir weeibs, it sometimes continues profuse for
four or six weeks, without being accompanied by morbid sj-mii-
toms. A persistence, or occasiounl recurrence of a ssmguineous
dischaigo is ^'enerally indicative of irregular and imperfect
progirss of uterine involution.
The oilor of tlie discliarges at times is quite oiTensive, even in
those <^8es which ])rpsent no f»ther morbid symptoms. Such a
c<indition, however, sliouhl always be hx)l£ed uyKiU with susi)icitm,
sine** it may indicate retention of either some part of the secun-
dines, or coaj^^ula in which putrefacti\e changes have been set
up. The (huiger of infection may be iliminished by carefidly
eyringitij; the vagina, two or three times daily, wliile the oflfensive
odor coutinues, witli a mdd antiseptic solution. The lochia are
sometimes suppressed for an intei*vai, withtjut the t)ccurrence of
bad symptoms. In other crises morbid conditiims l>egin to ap-
j>ear, wliich, if properly treated, will tift^n be at once arrested.
The following indications will 1)4' found valuable.
Lochia suppressed by cold or emotion: ftcf <ra race.
Lochia suppressed, head feels as if it wimld bur.st: brt/ouitt.
I»chia RU) (pressed, followed by diarrhoea, colic and toothache:
ckam.^ enulojih.
Lochia suppressed, violent colic: nihictjnih.
Lochia .suppressed, from luiger or indignation; coluc^,
Ix>chin suppressed, with tympanitic swelling of the abdomen,
and iliarrha^a: cot(H\if,
Lochia sxippres8e<l by cold or dampness: dulcamara.
Lochia sujipressed from fright: opiunt, acwilie.
Lochia suj)pre8sed, with nyniphomania: verai. a.
Lochia scanty and oflensivo: uhj-. row.
Lochia scAuty, becoming milky; heat, without thirst: puis,,
sttr<t m.
Ijochia to*i profuse, with burning pain in uterine region: hri/-
Ottt(h
580
PHENOMBNA AND HANAOEMENT OF P0EBPERALITY.
Lochia profuse: miUefoUum, frUlium, chamomtlla.
Lochia profuse, excorinting, protracted: llUum,
Lochia milky, loo protracted: calc. carb.
Lochia long-lasting, thin, offensiTe^ excoriating, with numb-
nsss of the limbs: nirh. an.
Lochia vitiated and offensive; lasts too long, or often returns:
rJms tar.
Lochia protracted; great atony: cauloph.
Lochia protracted; drawing about ovaries; discharge fetid,
chc«sy, or purulent: china.
Lochia protracted, pi-ofuse, excoriating: liliuvu
Lochia acrid, fetid; great prostration : bapiisia.
Lochia offensive, feels hot to the parts.' fteUadonna.
Lochia brown, foul smelling: carh. reg. »
Lochia very offensive and excoriating; repeatedly almost ceases
only to freshen again; creosolum.
Lochia dark, \ery offensive; scanty or profuse; painless, or ac-
companied by prolonged bearing pain: needle.
Lochia offensive, irritating; sepia.
Lochia increased; pain in back when nursing: sxlicea.
Lochia return when she first gets about: acofiiff.
The Larteal Secretion. -The mammre for some time before
labor are furnished with a variable quantity of a peculiar duid
known as Cf>losinun, which contains a number of large granular
and tat corpuscleB, and some milk globules. Within the first
two or three days this is succeeded by the proper lacteal secre-
tion, the establishment of which is sometimes attended with a
slight acceleration of pulse and elevation of temperatxire. and
also some restlessness and headache, which condition was for-
merly termed the '^milk fever." These phenomena generally dis-
appear as stton as the secretion has been well established and
the breasts properly cared for. The profession is rapidly oc»m-
ing to believe that " there can bo little doubt that the impor-
tance of the Bo-cniled milk fever has been immensely «*xugger-
ated, and its existence, as a normal accompaniment of the
puerperal state, is more than doubtful/* Out of 428 cases re-
ported by Macan,* in 114 there was no rise of temperature. A
number of recent writers on the subject refer the phenomena
*** PabUn Jour, of Med. Science," Mft;. 1878.
THEKAPEUTIC8.
581
described to coincident septic iniiuences. Moreover, since they
apjieared to be much more commonly observed in tlie days when
the practice was to keep puerperal women on a low diet, it may
be that this element exercised a coutrt)lling intluence. From
careful observation, we are led to believe that the s^nnptoms in
qnestiim, when present, owe their existence mainly to the irri.
tation proceeding from over-distension of the breasts. Decided
relief is at once afforded by emptying them.
The lacte^il secretion does not make its appearance in every
cose. Whf*n, from any canse, n considernbly elevated temi>era-
ture follows closely upon delivery, the milk mny utterly fail to
appear. In rare cases, it would seem, as Du'bois has remarked,
tliat nature has left her work unfinished in some women. They
are ca]>nble of becoming mothers, and are able to provide suita-
ble nourishment for their chikben throURhout the periotl of ges-
tation, but their economy does not provide for their wont after
birth.
TherapeutiM. — Secrdion Ahmidanf. — Breasts greatly and
painfully distemled with milk: acei. uc.
Secretiim Unt abuudunt. culc. carb., umnixim, Pulsatilla.
Excessive flow of milk, causing great exhaustion: phijiol.
Scrtcfion Defirtrtif— Milk Bcaniy or absent; despairing sad-
nects: agnus c.
Deficiency of milk with over-sensitiveness, asafcet
Scanty secretion of milk* hrijonin,
Mammje distended, but milk scanty: calr. c.
Little, milk in mild, tearful women, presenting no morbid
fljTnptoms: pnlsaiilUi,
MiJk scanty or vitiatfd; child refuses it: mpvc.
Scanty milk, witli debility and great a]>ntliy: phosi, ao.
TLe secretion is not established; stinging in the breasts:
seciilv.
Insufficiency of milk, or entire failure to appear: uriica urens,
Qvalitff of SecrethtL^Miik watery and thin: ca/c. phoft.
Milk thin, blue; patient sad and despairing on waking: look.
Milk yellow and bitter, child refuses the breast: rheum.
Pain in the back on nursing; increase of lochia; flow of pure
blood Complains every time the child takes the breast: ailioeam
582
PHENOMENA AND MANAOEMEXT OF PITERPEIIALITY.
Means for Arresting the Secretion of Milk.— When from
any cause luctutiou is not perfoiiuecl, the breasts requke most
careful attention. Tliey are liable to become distendetl, heiite^i
and painful, and, if not properly treated, inilanunatiou and sui>-
puration may ensue.
We believe the best sort of general treatment of these patients
is the expectant one. It is unwise to tamper with tlie breasts
at all unless tliey bectjme hard and paiufuL Meanwhile Uiey
should be kept warm by the ap})]ieation of a layer of cotton,
over which may be laid a piece of oiled silk If the disten.sion
becomes excessive, it shoulil be jxirtially relieved by drawing
only a smfdl quantity of the secretion. If they l.)ecome hard and
lumpy the nurse should V>e instr»<'t*«l to freely aj)ply M'arm oil
and rub tliem in a gentle manner, always making the passes to-
ward the nipple. If in any case inflammation bcj^ins, hot fo-
mentations should l>e faithfully followetl, until tlie pain nn<l
Soreness disapiiear. A nutst excellent manner of applying tho
heat IB to take a basin of sufficient size, and line it with two or
ihrtto. tliicknessos of Hannel wrung out of water as hot as can l>e
borne, and then plaee it over the breast. By this means the
Lent can l>e retained for a long time.
In certain cases we may think best to subdue the functional
activity of the gland by the use (»f campliorntedoil. We l>elievQ
the use of belladonna plasters, as rec<:>mmended by some, unwise
practice.
The remetlies which give the best resnlts in the way of reduc-
ing the quantity of the secretion are hi'lladoimiu uriica urens,
and brtfonid. If inflammatory 8ym]^toms 3U))ervenG, the reme-
dies mentioned under the head *' Mammary Abscess" should Ije
employed
After-pains,— True after-pains are prcnhiced by uterine c*>n-
tractions, usmdly excite<l by the presence in utoro of coagula.
They occur much -more frequently in multipuno than in primip-
arse, because, in the former, the uterine cavity is larger, and
the rigidity and tonicity' of fibre observable in primipane haa,
in a measure, l>een lost They are to a certain extent preventa-
ble, and prophylactic means are those whicdi favor firm oontrao-
fcion of tho uterus, in which abtlominal pressure and knending
take a prominent place. The jmins generally begin soon aftor
TUEATMENT OF AFTER-PAINS.
683
delivery, and are reourrent, like those of labor. In exceptional
cases they are extremely severe^ Application of the child to
the breast, though a wise proceeding, increaseft the intensity of
the after-pains. Their period of duration varies, seldom being
protracted beyond two or three days. In some cases, after hav-
ing disappeared, they return for a time, and again leave after es-
cape of a retained coaguluiu. They are Kometimes so severe as
to extort cries, and are dreaded by many women almost as
much as the pains of lalx>r.
After-pnins should not be confounded with the pains accom-
panying peritoneal inflammation, and may generally be distin-
guished by the absence of high temperature and rapid pulsa
The uterus sometimes appears* to be in a condition of hyper-
{Bsthesia, wherein the intermittent contractions, which eJiarao-
terize the pueri>eral stnto, iinassociated with the presence of co-
agula, occasion luueh suffering. Dewees mentions a paiji of
frightful intensity which is experienced by some women in the
lower part of the sacrum, and in the coccyx. It V>egins soon af-
ter ilolivery, and, unlike real after-pains, it is coutinuooa
TreatmeMt. — When after-pains plainly depend on the pres-
ence in uteroof coagida, pressure judiciously applied to the fun-
dus uteri will sometimes afford relief, by evacuatiti^' the organ.
When of a neuralgic character, heat to the abdomen will be
found agreeable and beneficial.
There is no question that the prompt administration of
arw/ca, after delivery, has a modifying intiuence upon this va-
riety of suffering; while, in some cases, it serves as an efficient
prophylactic. Other remedies are often of great service, and
some of the indications for their use here follow:
After-pains extremely severe and long-lasting: aconite, nuxv.
After-pains too long, or too violent; worse toward evening:
jpuh.
After-pains too long and severe; though cold she dt>e6 not
wish to be covered: firralr.
After-pains of a cramping nature, often attended with cramps
in tlie extremities: cuprum.
After-pains worse in the groins; over-sensitiveness; nansea
and vomiting: acfcra rnc.
After-pains violent; return when the child nurses: arnica.
584
FHCN'OSIENA AND MANAGEMENT OP PUEBFEaALlTV.
After-paius, excited by the least motion, evezi taking a deep
inspiration: brijonitL
After- puius especially after long hard labor, Hpasmodic across
the hypogastrium, extending into the groins: canU^ph.
After-paiuH very distressiug, especially in women who have
borne many children: cupntrn m.
After-pains violent in sacrum and laps, with severe headache,
especially after instruniontid delivery: kyjtcricum.
After-pains Avith nmch sighing: ignniirt.
After-pains with great sonKitiveness of the abdomen: safmui.
After-pains of a severe bearing character, as if everything
were being forced out: btdlndi/niut.
After-jmins come and go suddenly; (especially gootl for neu-
ralgic pains:) ftellntionmt.
After-pains very distressing, and the patient extremely irrita-
ble: chamomHUi.
After-pains which produce a desire to defecate: nrur w
After-pains colicky, causing her t^i bend double: coloctf.
After-pains producing faiutness: n/u* cow., pidsdUUa,
After-pains worse at night; she wants the room waim, and
niurtt be AVi'll cftvcrod: rhm^ tax.
After-pains aecouii»anied with burning and Iwaring: ierebinth,
N>i*esHary Attentions to the I'lierperai Woman.— Tho pa*
erj^eral p/ilient requires plenty of fresh nil', without ex|K>siir©p
wholesome food, quietude, and cleanliness. In warm weather
tlie doors and windows should be oi>ened often enough to keep
the nir4)f the riMinj fresh ami pure, while everything alxiut the
Biiartiuent which tends to c*iut-nmiuate sh< add be scrupulously re-
moved. The room selecte^l for the confinement should not be
near a wator-cldset. or bath-room, and shouM have no sbitionnry
washlKiwl, as more or less ftmlness is emitted by all huch con-
nections witli a Fewer or c«ss-p<>ol. The beii should lie placed
so tliat the patient will mtt be in the line of n draft wlien the
doors and wimlows are openetl. In the cold seasouBtho temjH^r-
ature of the rof>m should be kept as even as jKissible, and should
approximate t55° to 7fK The vidva ought Ui \\& waslied witli
warm water soon after delivery, and the soiled clothes remove^L
On no account should the woman be permitted to lie with them
under her for several hours. The napkins will require frequent
changing.
THE physician's VISITS,
585
The PlijNician*s Visits, — The puerperal coudition is one in
which sudden uml alarming changes are liable to occur, and the
piiyaiciau should see his patient every day during the first week.
The interval between delivery and the fii-st visit ought not to
exceed twelve hours. At each visit during the first two or three
days, in uonual cases, iu addition t<^) the ordinary observations,
tlie uterus sliouUl be examined by placing the hand on the abdo-
men, the temperature taken, and the urinary and lochial dis-
charges inquired after. The condition of the breasts will also
demand liis attention.
The woman after lal>or sometimes finds herself unable to an-
nate, owing, in some coses, to temi>orary vesical pai'alysis, in
others to swelling of the ui'ethi'a, and occasionally to muscular
spasm. In such cases aconite will now and then afford speedy
relief. In case nf failure, hvlhuUmiKi may succeed. The reme-
dies should Ije given at intervals of only €i\^ or ten minutes, for
an hour. Cloths wrung out of hot water, and laid i)ver the vulva,
will ivccasionally give relief. But, in case both topical applica-
tions and internal remeilies fail, a soft catheter should be care-
fully passed. Subsequently it may be necessary, for a time, to
use the catheter night and morning. These are some of the
most iraportiint roiisiderntions in conTiection with puerperal
women, and must not be disregaided. We have lUrectetl special
attention t*» the foregoing remeilies, but the following may also
be found serviceable:
Retention of urine: ncojttie, hellt camphor, hifos.
Retention of urine with stitches in the kidneys: aeon., canfh*
Retention of urine without desire to urinate; nrs(*n.
Retention of urine with frequent ineffectual desire, or with
urging to st<:K>l: nttj' vom.
Desire to urinate, accompanied with great distress, fear and
anxiety: aconite.
Has to strain nt &t4>ol in order to annate: alumina:
Tenesmus of the bladder: mvrc. c.
Regimen. — The regulation of tlie diet of lying-in women has
been thoroughly revolutionized during the past few years. The
older cust^iim was to keep them on food of the lightest kind, and
in small quantities for several days succeeding delivery; but it
has DOW become customary to prescribe good nourishing food in
&86
PHENOMENA AND MANAGEMENT OF PUEBPEBALITY.
liberal quantities. Tliere is danger, however, of falling into an
error in tliia direction, and thereby destroying the l>enpfits
which are dorivahle from n well-regulated regimen. Our best
guide in the matter are the patient's feelings. If she has uo
apj)etite, it would l>e unwise to in&ist on a generous diet; but.
on the contrarj', if tlio appetite is gtHxl, we may safely l>e more
generous. Part of a cup of beef tea, a glass of milk, an egg
beaten up with milk, or some toast may be given soon after la-
lx)r. If there is a (lesire for it, a few mouthfuls of beef or
cldcken may be giviai aftt^r tlir* tirst tlay. When lacUition has
become establishml, the restrictions on diet may be almost
wholly removed, after cautioning tiie patient against over-load-
ing the stomach. Less care will be requiied in the case of ro-
bust women, than those who are ilelicjite; and, while we feed
the latter well, we should be exceedingly carefid about both the
quality and quantity of theii* food. Stimulants, as a rule, shouUl
be av* »i(letl,
The Bowels, — It is the custom in old-school practice to pro-
voke a niovoment of the bowels on the second or third day. and
to bring it about, recx)urse is generally had to cathartics of va-
rious kinds. This we cannot but regai'd with disfavor, both in
raepect to the time of movement, nnd the mode of eliciting it
In the latter days, or hours, of pregnancy, there is generally a
relasetl state of the bowels. When this is not true, an enema
should }>e givpn in the early part of labor, and thp reotuju en-
tirely emptied. This having occurre<l, there is no crying neces-
sity for further action during the succeeding four or five days,
uidess ineffectual desire is wxmer nmnifeste<l. On the fourtli or
fifth day a few dopes (jf 7iM.r ntmirti may l)e given, anil, if ni>c-
eesary, a full enema of tepid water and soap. If there is earlier
desire, without favorable result, it will be wise, in tlie aljsence
of inilammatoiy complications, to give a Hmall enema. If tlie
woman has been, or is, suffering fmm inflammatory action in the
pelvic region, the regulation of the bowels will require most
careful attention.
In exceptional cases the bowels are loose after deliverj-, the
treatment of which condition will be but little moilified by the
puerperal state.
Time for Getting rp. — Many women claim to feel as wef
TIME FOB QETTrKO UP.
687
and almost as strong, immediately afte? labor as before, and it
is impossible to impress them witb. the necessity of keeping the
bed for eight or ten days, as the prescription generally is. It
sliould be remembered, however, that this question of rest is the
most important one in connection witli either normal or abnor-
mal lying-in. The experience of the laboring women of foreign
birth, who generally get about on the tliird or fourth day, is
pointed to by some as evidence of the harmlessness of the prac-
tice of early rising from the puerperal bed "We admit that it is
not so much tlie danger of immediat<^ly serious effects that we
fear in such cases, as the weakness and derangementw which are
apt to ensue, and torture the patient for long months or yeai^s.
And when we have an intimate acquaintance with the physical
condition of those who disregard physiological laws respecting
the lying-in state, we find that they are laden with ailments, and
bear about with them the evil effects of their indiscTetions.
Still, the habit of kee]>ing the woman on her back for a week
or two following parturition* is a very injurious one. Sh** should
be allowed to sit upright to tirimite and defecate, and by this
means all coagula and retained lochia will be permitted to escape
from the vagina.
Dui'iug the first few days tlie puerperal woman should be
kept quiet, and free from annoyancf*; and no garrulous neigh-
bor should be permitted to disturb her repose of mind and
body. She will do well to keep her bed for nine or ten days, no
matter how strong or well she may feel; and for at least a week
subsequently, more than half her time should he spent in a re-
cmuljent postuie. If she will contentedly remain longer, so
much the1>ettor, as th<* normal |>o«t-paitum changes will l>emore
satisfnct-orily accomplisheiL In considering the question of rest
after delivery, the fact that the uterus does not complete its in-
volution under six or eight weeks, should bo kept prominontly
in mind; and that an early getting up is harmful, largely lie-
cause it interferes with the prompt and full accomplishment of
this physiological process.
There is but a single f urtlior caution to be offered in this con-
nection, and that is, that care be taken in the instance of feeble,
ner\'ous women, not to permit them to go to the opposite ex-
treme, and lie in bed too long. Some women require almost to
588
CARE OF THl
be driven out of bed. Every little discomfort is xnagniBed, and
made a pretext for acting the part of an invalid. The manage-
ment of such coses requires the most oonsujumate discretjon
and tact
Care of the Child.
The temperature of the room in which the chOd is to be washed
and dressed should not be below eighty degrees, and as the com-
fort aud well-being of the mother is not compatible with so
great heat, these attentions nhould be given in another room-
At the time of birth the child is covered with a layer, more or
less thick, of vernix caseosn, which cannot be easily removed
without first being treated to a thorough application of oil or
lard. The bath should not be prolonged, and at its close the in-
fant will be wrapped in flannel and laid aside for a time, or com-
pletely dressed. The stump of the cord should be rolled iu a
piece of raw cotton, or laid lietweeu folds of silk or old iineu,
and then covered by the flannel band. The condition of the
navel after separation of the cord will dejiend in some measure
upon the treatment bestowed at the time of birth. It is the
practice of a gomlly number of able practitioners to await the
cessation of pulsation in the c<»rd, or not, and then sever it with-
out applying a ligature. That the practice, if properly followed,
is a safe one, we are fully satisfied from o<iuHiderable experi-
ence. The cord should be held between the thumb and fingers
and cut with a pair of blunt scissors. If bleeding follows, the
stump should be held for a moment, and then stripj>e'd between
the fingers. As soon as bleeding has once ceased, the child, may
be considered safe. Still, like those cases wherein ligation is
practiced, it is wise to examine the stump occasionally during
the first lialf hoiu*. While we do not recommend this innovati<in,
we can see no rational objection to it. We have no question
that it is more in accordance witli physiological conditions, and ia
less liable to be followed by umbilical irritation and ulceration.
Should the navel beoome inflamed, or severely irritated, in
any case, we should enjoin perfect cleanliness, to be practiced
without friction, and with the application, if necessary, of lyoo*
podium.
The child will require no nourishment from the start but that
which it derives from the maternal breasts. The early secre-
m^tk
PHLEGMASIA DOLENS.
689
lion — oolostnun — has a laxative effect on the child's bowels,
whDe at the same time it affords some nonrishmeni It is ad-
visable, as a rule, Ui put the infant to the breast early, not only
for its own benefit, but also for the good of the mother. In
those unfortnnate cases whore the mother is unable to nurse her
child, or it is thought inadvisable for her to do so, we have to
provide either a wet nurse, or an artificial diet A discussion of
this subject we shall omit, and refer the student to special trea-
tises on the subjectf and to works on diseases of children.
CHAPTER 11.
The Puerperal Diseases.
Phle^riuasia Alba Dolens, or Milk Leg.— This morbid state
has attracted a great deal of attention and study, and yet opin-
ions differ respecting l)oth its nature and origin, though it seems
to be pretty generally mlmitted that the symptoms and pathol-
ogy of the couditioiis in question owe their existence to the for-
mation of thrombi in the peripheral venous system.
The disease is not limited to the puerperal state, nor even to
women, though these are the conditions under which it com-
monly occurs. It attacks by preference the left leg; but s*>me-
times it assails the right, and occasionally is bilateral.
The Symptoms. — The i>eri(Hl of invasion is most frequently
bediveen the end of the first fuid third weeks after delivery. The
real onset of tlie disease is generally preceded by a feeling of
great depression, restlessness, irritability, fever, and commonly
more or less pain in the uterine region. After a time, repeated
chilliness or a distinct rigor is experienced, accompanied, or
followed, by tlistressing pain, usually in the calf of the leg. The
pain is sometimes primarily felt in the ankle, knee, groin or hip.
When first exaiuined there is no reduews or swelling, but within
twenty-four hours the leg becomes a^dematous, white and shin-
ing. When the swelling begins in the groin or hip, its course
is usually downwards, but when the pedal extremity is the point
of first attack, its course is reversed. The swelling in some
cases does not extend above the knee. When the entire limb is
involved, the femoral vein is always hard, distinct and painful,
590
THE PUERFERM. DISEASES.
when touched by the finger. The paiiiH seem to follow the ooiii*rie
of the inflamed and obstructed veB&ek. OccaaioiiaUy the tmrk
of the vein cau be traced by on observable redness; bat the re-
verse of this is more frequently true. When the leg is the part
atfected, the veins on the inner side of the limb artd in the p*->l>-
liteal sijnoe are more particularly involved. Sometimes the lym-
phatics are also painful, and tlie inpruinal glands are eidargod
and sensitive. The limb, which at first would easily pit on pres-
sure, after a time becomes so distended as to admit of the pro-
duction of no such effect
Marked constitutional symptoms are also developed. The
pulse ranges from 100 to 150, and the tem}>erature from 10*2 ^
to 106 ^ . The tongue is rather dry, the stomach irritable, and
the skin, tliough hot, is usually moist The pain is so severe
that the patient can get but little sleep, and she is nervous and
irritable. The disease reaches its height in a period varj-iiig
from seven to fourteen days, and then begins gradually to decline.
The pain becomes less excruciating, and the tension of the liinb
less marked, while the pulse and temperature begin to fall. In
unfavorable cases, little vesicles appear in certain parts of the
affected niemlier, or over the whole of it In some cases the
lymphatic glands suppurate; abscesses form in the cellular tis-
sue, or the joints become the seat of inflammation mul fiU]>jiura-
tion. In rare cases, the symptoms, on declining in one of the
lower extremities. af)pear in one or botli of the upper limbs. In
any case, considerable time elapses ere the affected part regains
a aize which approximates the original In most instances there
remains more or less perumnent enlargement, and unusual ex-
ercise on the feet causes the member to swell- Patients who
have once suffered from the disease are prone to a recurrence of
it in subsequent confinements.
In the worst cases death may take place from exhaustion, or
may come suddenly from pulmonary obstruction due to ©m-
boliBm.
Etiology and Fatholoiery. — Mauric^au gave a very gootl de-
scription of the symptoms of phlegmasia dolens, the pathology
of which he regarded as "a retlux on the parts of certain humors
which ought to have been evacuated by the lochia." Puzoe sup-
posed them to bo due to an arrest of the lacteal seor^on^ and
a
FULEOHABIA DOLENS.
691
extravasation into the tissues of the affected limb. Many
sulxaeijueut theories were ailvauced, amou{; the most pc)pulHr of
which was that which attributed the sympttims tct some morbid
Ci>uditioxi of the lymphatic glands and vessels of the afifected
port
Subsequently, bat not till 1823. was tlie existence of coagula
in the veins, presumed to result from inliammation, pointed out,
which gave to the disease the uamo of "crural phlebitis." Dr.
R. Lee, on careftd dissection, fomid coagula als<j in the iliac and
uterine veins, from which fact he iufen-ed that the iliseaso be-
g^ in the uterine branches of the hypogastric veins, and ex-
tended downward to the femorala. He also drew attention to
the (tcctirrence of phlegraRsia dolens in connection with other
conditions which were liable to produce phlebitis, such, for ex-
ample, as cjircinoma of the cervix uteri. This theory is still
held by some.
Dr. ^lackenzie, and others, have since experimentally demon-
strated that intlanunation of the veins is not of itself sutticient
to proiluce the extensive thrombi which are found to exist, and
that inflammation shows no marked disposition tn extend along
the c*)urse of a vessel. The morbid conditions of the veins were
accortlingly attributed to an altered or septic state of the circu-
lating tluid.
Dr. Tilbury Fox* believes the thrombi to originate from either
extrinsic or intrinsic causes, the former being pressure from
tam»irs, and the like, and the latter: 1. True intiammat<.>ry
changes in the vessels, as seen in the epidemic form of the dis-
ease. 2. Simple thrombus, produced by rapid absorption of
morbid tluid. 3. The conjoined action of virus and thrombi, the
phlegmasia dolens itself being the result of simple thrombus,
and not of the inllamed ooats of the veins. The swelling of the
effected part he reganis as not atti'ibutable t<i oedema alone. Imt
to (inh^tna anil obstruction of tho lymphatics. The ellicient cause
«:>f these changes, he believes, is usually septic action originat-
ing in the uterus, produeiug a condition similar to that which
^▼68 rise to phlegmasia dolens in the non-puerj>eral state.
While no one of these theories can be adopted in its entirety*
*Ob«t«t. Trans., vol. ii.
592
THE rrERPEltJLL DISEASES.
we may regard the essential point in the pntbology of tliis dis-
tressing difcieasG, as tliroinbosis in tJie veins.
Treatnient.— *'The prophylaxis in this disease is very im-
portant'* We quote Dr. Joseph Amann.* If signs of fever
and pain in the limb appear, the patient sliould remain in bed,
receive no visits, and obser\'e strict diet. Every precaution
should be taken to remove all causes of excitement or irritation,
moral or physical.
** Axx important point is the position of the patient: she should
lie su that the leg of the affected limb is more elevated tlian its
thigL For this purpose, the leg should be laid on a soft, elas-
tic cushion, the knee Ijeiug bent."
It ifi well to rub the affected limb gently two or three times a
day with cosmoline, the passes all being made toward the trunk.
At other times it should be enveloped in cotton batting, and
covered witli silk.
After the period of acute tension has gone by, the leg should
be subjectoil t*) a careful examination for tlie puri)ose of ascer-
taining whether there is any circumscribed collection of pus,
and if found it should be freely evacuated. As soon as the
limb is in a condition to bear it, a roller bnndage should be ap-
plied from the toea to tlie hip. and renewed from time to time,
as long as there remains any oidema. The patient should not
be permitted to put her foot to the floor, until all evitlence of
the disease has disappeared.
The homoeopathic remedies specially suited to this disease are
few in number. When at tlie ^tiitsot the temperature runs up,
the skin is dry. the pulse rather rapid, and the patient restless,
we cannot do better than administer aconiir.
With similar sj-mptoms, and a full and hard pulse, showing
high arterial tension, verafmm viri^le mny be given.
Belladonna is probably the remedy from which we will derive
the most benefit after the first tweuty-four hours, especially if
the pains are sharp, the patient is less restless, and notso tlursty.
Often we >vill do well to continue this remedy for three or
four days, unless the symptoms point more directly to some
other.
• Klinik der Woclienbettkrankheiten. IRT?.
k
PUERPERAL MANU.
593
Bryonia will be found oi service when the pains are sharp
and shooting, and the suifering is greatly aggravated by every
movement
Puhaiilla should be substituted for, or given in preference
to, either belladonna or bryonia if there is no thirst, and the
temperament or mood is peculiarly mild and tearful. It should
also succeed either or both of the other remedies when the case
is not progressing favorably under their iutliieuce.
Hamainclis douljtloss has a decided influence over the ooiu'se
of the disease in certain cases, and should occupy a prominent
place among the remedies suited to it
Arsenicum^ sulphur, cakarea carb.y and other remedies are
sometimes called for.
Puerperal Mania.
The term "puerperal mania," is intended to include all those
oases of mental Hbf'rratipn occurring in connection witli the
pregnant, part'irieiit tind puerperal states, which might come un-
der the more comprehensive title of insanity. Such conditions
when developed during pregnancy are usually brought alxiut
by the hysterical temi>erament, by injudicious moral manage-
ment, by neglect of the excretory functions, by sudden shocks,
and by hereilitary prediBiH>Hition to inBanity. In parturition,
the agony of the occasion may be so intense as to arouse a
nerv'ous, excitable temperament to the very height of frenzy. It
i» more likely to occur just as the head passes tlie vulva, and in
primiparae. This form of insanity can generally be prevented
by judicious use of chloroform.*
Classifleatton. — The term puerperal mania is more especially
applicable, however, to that form occurring during the imerj>e-
ral state, and it is of this that we shall more especially speak.
We may conveniently divide it into two classes: 1. Putn*pt*r<d
insaniiy, proiwrly so called; that is, insanity which is developed
within the first two or tliree weeks after delivery; and 2. The in-
sanity of ladaiion. The former is the more frequent
Frequency. — As regards the frequency of these affections,
oat of 1,644 women iu the Bethlehem Hospital, 84 were
* Dr. Tyler 6mitb says he hru seen cafies vhich appareotly dependvd on tti«
Dse of large qnoatittes of cbloroform tluriug labor.
694
THE rUEBPERAL DlSEAfiES.
cases of puerperal origin; and of 1,119 cases in La SalpetriAre,
94 were cases of this kind.
Puerperal Insanity. — In this variety the attacK generally be-
gins within the first two or three weeks after delivery* and may
assume f\ melancholic form, or it may be acute, and attended with
violent deliriiuu, high fever and great constitutional disturbance.
The latter occurs much more frequently at a |)eriod soon after
deliverj', than the ft)rmor. Tuke found tliat all cases of acute
mania were developetl within tlie first sixteen days after deliv-
ery, and that all cases of melancholia developed themselves
after that time.
One of the first symptoms of the approach of acute mania is
ins(.)muia. Many times tliere is total want of sleep, and the
mental exJiaustion whicL rpsults doubtless adds to the severity
of the attack. Tlie countenance is flushed, the head aohes, tlie
eyes have an unusual lustre, and they rest with a wilii uneasi-
ness on objects l>eft>re them. The temper is irritable; the lacteal
secretion is diminished in quantity, and after n time totally sufv
pressei-l; and the memory is ilefective. The woman becomes lo-
quacious, and her ideas are constantly varying, and disconnected.
It often hapi>ens, however, that there is a fixed notion, or an im-
perfectly formed idea rimuiug through her incoherent talk, and
this is extremely apt to be of a sexual nature. The patient is at
times demure and morose, ami then again highly excited and
fairly raving. She may tear her clothes from her body. an<l at-
tempt self-<iestruction, or the life of others. She sometimes
bites, strikes /ind tears at n frightful rate, and again puts the
body through motions which indicate a nymphomaniacal condi-
tion. The temperature is always high, varying from lOl** to
105*^. The bowels are generally confined, the urine turbid, and
the tongue coated. Acute mania often accompanies pueri>end
septicaemia. It is also dex)endent in some cases on inflamma-
tion of the pelvic organs or the contiguous tissues, such as pel-
vic peritonitis, cellulitis, and metritis. It is occasionally associ-
ated also with inflammation in other and distant organs.
Acute mania, if prolonged, may finally take on tlie melan-
cholic type, and become intractable; but this form of the dis-
ease is generally iiliopathic. The advent is gradual, beginning,
PUEUPEBAL MANIA.
595
perhaps, with depression of spirits, insomnia, indigestion,
headache and other indications of physical derangement
Insanity of Lactation.— This generally proceeds from the
excessive drain placed upon the energies by over-luctation, in
the instance of women with delicate, highly nervous organiza-
tions, or of those whn Lave l>een reduced by illnesa The essen-
tial pathology is brain aniemia Such patients do not often pre-
sent the violent symptoms of those suffering from puerperal
mania, and when they do, the attack is usually of short dura-
tion.
Prognosis. — The prognosis of recent oases of puerperal ma-
nia and the insanity of lactation, is exceedingly liopefuL "It
is, perhaps," says Tuke, "f/ic most curable form of insanity.**
Its diu-ation is sometimes but a few days, especially in those
cases which follow puerperal c-onvidsions. " In a majority of
cases," remarks Barker,* "the mania gradually subsides with-
in a period of three weeks, more frequently earlier, and is fol-
lowed by a condition of partial dementia, with some delusions,
especinlly as regards i>ersonftl identity. These gradually disap-
pear, leaving a kind of iiit**lleetual biirrenness, like one waking
from a dream. From this condition, you may confidently hope
for ultinmt-e recovery. In some cases, the malady is prolonged
two or three or more months; but, if l>eyond six months, the
chances of recovery are very small. When death is the result,
it is almost invariably due to s<irae associated disease, as peri-
tonitis, or cellulitis, pueumouiu, and in some exccn^dingly rare
cases, phrenitis, the fatal result usually occurring in a very few
days."
Causes. — Hereditary tendencies exercise a strong predisposing
intluence, traceable more fret|uently to the female side of the
family. A condition of mental depression and physical exhaus-
tion favors its development Difficult lalx^r should also be classi-
fie<l among the prominent predisjjosing causes. Out of seventy-
three oases of Dr. Tuke, the labor was complicated in twenty-
three. To these may be added aniemia and eclanji)8ia.
Barker t has conclusively shown that mental and moral
* *' The Puerperal Diaeaaes," p. 175.
t Babkeb, loc. Hi. p. 177. et teq.
596
THE PUEHPEIUL DISEASES.
emotioiiB are the most common exciting cause of puerperal mania.
Morbid dread during pregnancy, insufficient to produce insanity
before delivery, may develop into mental derangement after it
81iame and fear of exposure in umuarried wonaen not unfre-
quently lead to it
Sir James Simpson attributed the development of puerperal
mania to a morbid state of the blood. Others have found its
origin in the peculiar state of the sexual system which succeeds
labor.
Treatment. — The general indications are for the supply of
good nutritious food, and plenty of sleep, to accomplish both of
which ie sometimes a matter of considerable difficulty.
Food that is known to possess an abundance of nutritious
elements and to be easily assimilated, should be prepared in the
most tempting form in order that the patient may be willingly
induced to take it There is little danger of over-feeding such
women. In some cases food is obstinately declined, when it
becomes necessary to forcibly administer it When given under
such conditions, it should be fluid rather than solid, both to favor
speedy digestion, and obviate the risk of choking the patient
But before resorting to force, every gentle and persuasive m«>au3
should be employed to overcome the obstinacy which is evinced.
Stimulants are not only of no service, but they are capable of
doing positive harm.
To calm the nervousness and excitement which induces the
insomnia, the well-selected homceopathic remedy is generally
adequate; but should our keenest discrimination and most intel.
ligent selections utterly fail to make the designed impression, it
will be a matter for each physician to determine whether he
shall resort to the hypnotics employed by old-school practition-
ers, or allow the symptoms to remain un8ubjugate<l. Opiatos
have not proved efficacious and have often done positive harTu.
The first eft'ect of a hypodermic injection of niori)hia is favora-
ble, but the symptoms are subsequently decidedly aggravated.
Chloral hydraie has thus far served the best purjjose, either
alone, or in connection with bromide of potassium. If given at
all, the dose should be from fifteen to thirty grains, to be ad-
ministered at bed-time. Its action is generally quite satisfac-
tory.
PUERPERAL KANIA.
597
The general care of the patient should be most considerate.
She must have a well- ventilated room, in a quiet pai-t; all undue
exertion shoidd be gently restrained; and the presence of any
person, or any thing, which ii'ritates or excites her, should be
interdictecL
With regard to the therapeutics of puerperal insanity it should
be said, that, inasmuch us the mental and moral symptoms are
oftentimes associated with, and probably the result of certain
inflammatory affections of different parts, antl in other coses the
c<msequeuce of excessive physical debility, they alone should
not constitute oui' guide to the selection of remedies, though
they should usually be given greater weight than any others in
our estimate of tlie relative value of symptoms. We should not
expect too much from our remedies, but their action must be
encouraged and sustained by the strict observance of hygienic
rulea
The following are some of the most prominent mental and
moral symptoms of the more common remedies:
MiHnl, etc. — Low spirited, out of humor, inclined to weep:
sulphur.
Strong disposition to sadness: lachesis, nafrum m«r., pulsa-
iiUiu sepiuy ignatia.
Despairing sadness, with milk scanty or suppressed: a gnus
cast.
Melancholy mood, looks on the dark side of everything: cans-
it'cum, (id(jea rac.
Sad alx>ut lier health and domestic affairs: sepia.
Mania arising from indignation or grief: colocynth.
Bad effect** from gi'ief, chagrin, unlmppy love: phoH. ac.
Desire to commit suicide: auruDh rhus iox., nux vomica.
Continual thought of suicide: ainitm,
Bestless; fears death, and predicts its time: aconiie.
Great fear of death and of being left alone: arsenicum aZ6.,
lycopodium.
Great anguish, extreme restlessness and fear of death: arsen-
icunij aconite.
Extreme fear of death; sleeplessness: coffea.
Fear of being poisoned : hyoscyamus.
Fears an internal incurable disease : Ulitivu
598
THE nmilPEKAL DISEASES.
Apprehends some misfortune: caicarea carb.
Starting and fear on awaking; stramojiiunu
Shuddering and dread aa evening draws near: caicarea carb.
Very irritable and wishes to be alone: 7iux vatn.
DesireH to l>o alone; tacitiirn, sad: ignatt'a.
Paroxysms of rage and fury: belhtdoinm.
Exceedingly irritable: hrifonia, chamomiUa, yiiur vomica.
Mania excited by anger; chamomilla, coloci/nth.
Mania from fright, with grief: <frheminm, ignaiia.
Mania from fright, witli indignation: avonife.
Apntliy; scanty lacteal secretion: phosphoric ac
Great indifference: jihosphoric acid^ sepia.
Indisposed to talk: 2>^'^^S2ihoric acid.
Taciturn, haughty: verahum alb.
Great loquacity: alrnmotntntu
Very haughty: plotiiuu
Gay, cheerful: lachesis^ crocus.
Lascivious furor, without modesty: hifoscyamtis.
Wants to kiss every one: ctrndrnm alb.
MeiUal Oppression, — Appears aa if stunned: belhuiotma.
Mania from fright, with sopor: opium,
C(mfusion of mind, - c-annot connect her thoughts: grlscmium,
baptisia.
M<'ni(d Afjiffdioth^'Sliinhi from fright, with vexation; circu-
lation exeite<l, rapid respiration: aconite.
Wild feeling in the head as though she would be crazy:
til in w,
IltdlucitialionSy DchisionSy Illusiofis, etc. — Imngines there is
another baby in bed requiring attention: jwirolriim.
Muttering; does not know her frifuds: hifoscyamtis.
Singing, delii'ium: sirnmoiiium, hf/oscyamns.
Unceasing talking, singing and imploring: stravimiittm,
Jjoquacious delirium, with desire to escape: belladonvta, airt^
viotitum.
Delirium, with friglitful figures and images before the eyea:
sirnmotiinm.
V\^on closing her eyes she sees pictures and all soria of
strange sights: pHhahlln*
CAUSES OF SUDDEN DEATH. 599
CHAPTEE III
The Puerperal DiseaseSr-(CoNTiNUED.)
Caases of Sudden Death During Labor and the Puerperal
State. — Death sometimes occurs suddenly during labor and in
the puerperal state, and may be attributed to a variety of causes,
among which the following stand most prominent:
Pulmonary Thrombosis and Embolism.— It is claimed that
the blood of a puerperal patient is in a hyperinotic state, and to
that condition is ascribed the strong disposition to coagulation
which has been observed. "In all the accidents and anxieties
of obstetric practice," says Meadows,* "none can compare with
the shock of the sudden death due to pulmcmary thrombosis. A
patient, apparently convalescing happily, is struck down with
scarcely a moment's warning." This accident is sometimes due
to detachment of vegetations from the cardiac valves, but of-
tener, as has been intimated, to a general blood dyscriwsia, which
predisposes to coagulation. A clot may form on the right side
of the heart, and extend to "the pulmonary artery, tlio coagula-
tion, it is said, taking place suddenly. The patient appears to
be doing well, when upon making some exertion, it may be but
raising the head, profound dyspnoea is suddenly developed, ac-
companied by most frantic efforts to breatlio, and faint cries,
soon followed by syncope and death. It is liable to occur not
only during the period immf^diat(4y succeeding delivery, but
even after the woman has l)egun to walk about.
It is plain that but little room is given for treatment in such
•'^Maniml of Midwifery," 4th Am. Ed., p. H7.
698
THE PVEUrEKAL DISEASES.
Apprehends some misfortune: calcarea carb.
Starting and fear on awaking: stramonium,
Shuddering and dread as evening draws near: calcarea oarh.
Very irritable and wishes to be alime: ni/j: vom.
Desires to be alone; taciturn, sad: ignaiUu
Paroxysms of rage and fury: belladminn.
Exceedingly in-itable: bryonin, chu mom ilia, mix vomica^
Mftuiii excited by anger: chtimotuilhi^ raloci/uih.
Mania from fright, with grief: grlsnnium, igiuxtia*
Mania from fright, with indignation; tironiie.
Apathy; scanty lacteal secretion: phosphoric Qc
Great indifference: phosphoric acid^ sepia.
IndisprMsed to talk: phosphoric acicL
Taciturn» haughty: vrrairnm alL
Great loquacity: siramoniunu
Very haughtj^: jtlaiimu
Gay, cheerful: lorht'in'.^^ crocus.
Lascivious furor, without mo<le8ty: hyosctjamus.
Wants tn kiss every one: vrrtdrujii alL
Menfcd O/^/jr^.ssiW. — Appeal's as if stunned; belladonna.
Mania from fright, vni\\ Si)jx>r: opium.
Confusion of mind,— cannot connect her thoughts: tjchcmium^
bcipiisin.
Meni<d AgiUdifm.—^h\i\n\ from fright^ with vexation; circa-
lation excited, rapid respiration: aconite.
Wild feeling in the head as tliough she would be crazy:
hliuw.
Hollucivtdiona, Drlnaionti, lUutiions, etc, — Imagines tliere ia
another baby in bed requiiing attention: peirolrutu.
Muttering; d»jes not know her friends: hijoscyamus.
Singing, deluium: airamoninm, //jyc/sr^r/mM^.
Unceasing talking, singing and imploring: siromotiiunu
Loquacious delirium, with desire to escape: belhdonna^ stra-
won in m.
Delirium, with frightful figures and images before the eyes:
»lrtimonium.
Upon closing her eyes she sees pictures and all sorts of
strange sights: pnlsnfilla.
CAUSES OF SUDDKN DEATH. 599
CHAPTEE in.
The Puerperal Diseases^( Continued.)
Causes of Sudden Death During Labor and the Puerperal
State. — Death sometimes occurs suddenly during labor and in
the puerperal state, and may be attributed to a variety of causes,
among which the following stand most prominent:
Pulmonary Thrombosis and £mbolism.— It is claimed that
the blood of a puerperal patient is in a hyperinotic state, and to
that condition is ascribed the strong disposition to coagulation
which has been observ^ed. "In all the accidents and anxieties
of obstetric practice," says Meadows,* "none can compare with
the shock of the sudden death due to pulmonary thrombosis. A
patient, apparently convalescing hnppily, is struck down with
scarcely a moment's warning." This accident is sometimes due
to detachment of vegetations from the cardiac valves, but of-
tener, as has been intimated, to a general blcMnl dyscrasia, which
predisposes tiy coagulation. A clot may ft)rm on the right side
of the heart, and extend to the pulmonary artery, the coagula-
tion, it is said, taking place suddenly. The patient appears to
be doing well, when ujxin making some oxerti<»n, it may he but
raising the head, profound dyspmva is suddenly developed, ac-
companied by most frantic efforts to broatho, and faint cries,
Boon followed by syncope and death. It is liable t-o occur not
only during the period imniodintcly succ(»eding dolivery, but
even after the woman has begun to walk about
It is plain that but little room is given for treatment in such
•"Mantxalof Midwift-ry," 4tli Am. Ed., p. 147.
602
THE rUEBPEBAL DISEASES.
riencefi the utmost difficulty in nursing, and on this account
niny, after a time, utterly reject the breast
In some of these cases the depression is due t-o anatomical de-
fects, and cannot be overcome; but in others it is the result i^f
pressure, and by manipulation and suction it is sot>n sufficiently
overcome for functional pui-j^oses. If the ilefect cannot be
rcmedieil, a glass nipple shiehl. with rubber tube, will often af-
ford a satisfactory metlium through -which the child may nurse.
Excessive Lacteal iSecretion.— This is known as gttkici</f'-
rhira, and Homelimes s<'rii>«sly intorfe!"es with Huccessfal laota-
tioTi. It is nut alone women of robust c^.^nstitution who are the
sul)jects of exeessivo secrotion of milk, but the weak and deli-
c^ite as> well, in whom, <jf cimrse, it is a ciuidition i»f frreatfr im-
|M>rt In the former the secretion may be whrtlosome, but in
the latter it is generally watery and innutritioiis, and* uuli^ss tLfs
morbid condition is forre<'t*»<l, serious i-fTrcts upon the Lealtli nrt^
likely to Ih* priKlnced. The woman begins t<^> sufl'er from weak-
ness, emaciation, insomnia, headache., and a h(^t of other un*
pleasant syinj»tttms, and is finally forced to relirupiish nursing.
Oalactorrh*en is in a mensuro under the contx*)! of remedies,
nnd the eflbct of these should l>e tried before dei>riving tlie in-
fant of the miit^nial breast. Those from which the great«*st
benefit is likoly tt) }>o derived are, culvnrcfx cnrh.. uronhmt. ftt*L
eoh'IUi and phtfinhuxxL
If the mother is unwilling' to wean her child, cert^n
may l.>e administered with salutary effect on her phs
tion. For the general weakness stii] prostration which she suf-
fers, c/uW/, (vi/crtre<i ;?/ios., 7>''<^J'Aoric f/c/d. and wrbo xrg. ore
the most useful.
To correct the quality of the secretion, cnlcurea phoft. may ba
given when it is watery. When the milk hK>ks thin and b]u<s
and the ]>atieut is sad and despairing on awaking,— //wA^W^l
Milk impoverished, bluish, transparent, strong sour tosta and
odor,— deficient in ciisein: ncvUc etc.
Sore Mpples, — In the early days of lactation, women are ofton
tormented with erosions, excoriations, chaps, fissures and cracks
of the nipple, giving rise in many cases to m<ist intolerable snlTer-
ing. The trouble generally begins with simple erosion, but may go
on from bad to worse, only to terminate in mammary abscess.
iS^
0gl^^
80&£ NIPPLES.
603
The affection is caused mainly by the friction of the chihUs
muuth in nursing, and may be oliviated by suitable care of the
nipples both before labor and during lactation. Cozeaux re-
gards the exposure of the nipples to cold, while warm and
moist, as one of the most frequent causes of the trouble. When
the st)reness is developed subsequently to the tenth day after
delivery, it is generally due either t«3 biting by the child, or the
cx>mmunication to the nipples of an aphthous inflammation.
When fissures have been formed, the irritation may be trans-
mitted from the base of the nipples to the cellular tissue, and
eventually to the glandular structure itself.
Treatment should be largely of a prophjdactic nature. Dur-
ing the latter uiontlis of pregnancy, the delicnt<? skin, covering
the nipple, may be hanlened by the frequent apx^Ucation of
astringent lotions, like strong tea and tannin. Sucli ]»recnntions
are paJticulorly appropriate to primiimne, "When lactation be-
gins, tlie nipples ought always tcj be sponged off with warm
wntftr after nursing, and gently dried, hs thf* secretions of the
child's mouth, if left^ are capable uf causing considerable irrita-
tion. Should erosion be set up, and refuse to yield promptly to
the measui'es adopted, the child should be made to nurse for a
time through a shield When cracks ami fissures exist, it may
l>e necessary in stime cases to touch the raw surfaces once or
twice with nitrate of silver.
The following remedies when administered on the strength of
the indicfitious given, will in many cases, without the use of any
adjuncts, be adequate to overcome the difficulty.
Nipples itch, burn, kn^kred: affaricus.
Nipples sore from nursing: aryrnhuit niL
Nipples ulcerated: calcurca carb.
Nipples ache, and feel sore: cfilcarrM phbs.
Nipples nearly ulcerated off, in neglected cases: castor equ.
Nipples bleed mucli, and ai*fe very sore: lycAjjwdium.
Nipples feel very raw and sore: mercitrius.
Nipples ulcerate eR8ily,and are very sore and tender: (iaiisticum.
Nipples inflamed and very sensitive: cfnimomiUa.
Nij>ples dark, brownish red; unbearable pain on slightest
^ttch; breasts full, skin hot, pulse strong: colchieuni.
604
THE PUEBPEBAL DIB£A£K8.
Nipples very sore to the touch; pain from uip])le to scapula of
Bauie side wbent?ver tlit» child nurses: tyroion tig.
Nipples painful, indamed, cracked: graphites.
Nipiiles very sensitive, will not bear contact with the clothing:
hclonias.
Nipples sore, Essored, or covei*ed with scurf; bleed eusily: ly-
copotVmm,
Nipples itch, and have a mealy covering: petroleum.
Nipples very sensitive: phylokicca.
Nipples sore and fissured, with intense suffering on putting
the child to the breast; pain seems to start from the nipple and
radiate over the wliole botly: phytolacca.
Nipples sore to touch, and sore and painfnl sptit under right
nipple: sunguinarm emu
Nipples are soro, they itch and bleed: aepicu
Nipples cracked across the crown: sepia^
Nip])les <lrawii in liko a funnel: itilicea.
Nipples cracked, after nursing they bum and bleed: sulphur.
Nipples painful during nursing, though thera is but little ap-
pearance of soreness: */i/u* cow.
Nipples in the first days of nursing feel sore as if bruised:
arniaL
Mastitis Pueiipekalis.
Strnctnres Involred.— The inflammation which attacks the
mamuiiLry gland in puerperal women, may involve either sepa-
rate iK>rtions of the gland, the entire organ, the siib-mamnmry
ct*unective tiBsm\ or the glands of the aretila. AVhen the paren-
chyma of the gland is the seat of the morbid change, the iufiam-
mution generally originates in the walls of the lacteal ducta, in-
vades the aciiu of the glands, and is apt to pass nipidly to the
stage of suppuration. These abscesses usually open spontane-
ously when loft to themselves, and end in complete reoovery.
Sometimes, however, fistulous openings remain for a long tinaeL
Occasionally milk nodules are formed, being indurated portionB
of the gland constricted and rendered useless by tlio pressure of
the hyperplastic connective tissue. Abscesses may become en-
cysted, and the pus undergo fatty or calcareous change; or they
may remain stationary for a time, but after a while give rise to
severe inflammatory symptoms. Wlien the sab-mammary ooq>
mt^^
MASTITIS PUEBPEBAIJS.
605
nective tissue is the seat of attack, the i>ii8 may burrow either
outwardfi or inwards. The gland becomes prominent, and ap-
pears to rest loosely on an elastic base. Much oedema is gen-
erally observable. When the follicles of the areola are the struct-
ures involved, they present fiirunculous appearances.
Symptoms. — The first symptom which attracts attention when
the parenchyma of the glaud is iuvolveil, is a nodule, hard, ir-
regular, tender, movable, and of variable size. The integument
is at first unchanged in appearance, but soon becomes red. As
the case prooeetls, the nodule enlarges; the axillary glands swell;
there is a chill, followed or accompanied by dull, piercing, or
throbbing pain, also loss of appetite, sleeplessness, and head-
ache. The integument gradually becomes prominent at some
particular ]>oint, o^demntous and purple; fluctuation is observed,
and, if left to itself, the pus after a time, is discharged through
one or more openings. Velpeau once found fifty-two eoUecliona
of pus in one mammary gland. Large cicatrices are often left.
The sjrmptoms generally abate after discharge of the pus, but
in some cases they become more violent, and pyiTemic conditions
may follow. When the infiammation is in the sub-mnmraary
connective tissue, the pain is often extreme, and movement of
the arm on the afi*ecte<l side rendere<l almost impossible. The
resulting abscesses often attain great size. Inflammation here
rarely undergoes resolution, but suppuration is the almost inva-
riable result.
Canses. — The causes of mammary inflammation may be traced
to exposure to cold, a blow, or other injury of the breast; tem-
porary engorgement of the lacteal tubes; strong mental emo-
tions, or, more frequently than all else, to irritation from fis-
sures or erosions of the nipples. In fifty lying-in women who
were afflicted with mastitis, Winckel* found but one wlio had
not suckled her child. The affection does not necessarily de-
velop during the existence of the fissures and erosions resulting
from Dorsing, but may appear from eight to fourteen days
after their complete cicatrization, or even later. The inflamma-
tion often creeps very slowly from the orifices of the lacteal
ducts toward the periphery of the gland. The assertion that an
• " WlBTOKEL, Pathology and Treatm. Childbed," Am. Ed., 1876, p. 380.
vm
THE PUERPEBAL DISEASES.
obstruction to the flow ol tlie milk is the moist common cause of
matititis is absolutely incorrect*
ParencliymatouH mastitis sometimes apijears in tlie course uf
puf*rperftl pytemia, and lias a depurator\' effect It may also de-
velop in the interlobular cellular tissue in case of metrophle-
bitis.
Sub-mammnry abscesses often develop siwntaneously as a pri-
mary affection, or secondarily on perit<»nitis, caries of the riba,
and perforation of a pleuritic effusion.
Treatment.— When mastitis appears in the course of pysB-
mia, attempts to arrest the process are not only useless, as a
rule, but absolutely unwise. Suppuration shoulil be hastened
b}' the application of poultices, and the administration of hcpar
sulphur. As soon as there is a ponsiderable accumulation of
pus. the abscess ought to be evacuatetL
Treatment of parenchymatous mastitis, disconnected with
pyH'niin, should l^e entirely different As sot^n as tlie first trai-ns
of inflammation are observed, energetic measures must l»e adopt-
etl Tlie child should be put to the breast at longer interyala,
and, if the iniiammation increases, should be taken from it en-
tirely; but nursing of tlie well gland may be continuetL Unless
engorgement should become extreme (a thing which is not
likely to occur), no efforts should be made to reuiove the secre-
tion. By such treutnient we admit that Hup]>ressiou of tlie milk
is almost certain to result, but that consequence is far prefera-
ble to mammary ahseoss. There need be no fear that, from
neglect to draw tlie milk, congestion of the affected breast "will
be f)rolonged and unfortunate results be promoted. Bubbing of
the breast should not be permitted.
In the early stage of the affection, hot fomentations should
constitute the main local treatment Into the hot water should
be put a small quantity of phi/iohicea tincture, and the cloths
changed often enough t<i be kept hot A g*>od mode of applica-
tion is to line a tin vessel of suitable size with tlie hot wooleu
clotlis, and then invert it over the breast The heat should he
as great as can be lx<me, and it should be maintained most <if
the time until the pain and soreness disappear, or the pruoeea
• WisfcKKL. he. eiL p. 381.
iB
MASTITIS PUEItPEltALIS,
607
has gone beyond the poiut of possible arrest. Under the faith-
ful, early uae of thene meaaures, together M'ith the indicated
remedy, mammary abbcesses will not be frequent.
When, in spite of all efforts to subdue it the inflammatory ac-
tion goes on, the general treatment should be ranch tlie same as
that bestosved on any other hirge abseesK, and the pus removed
at the earliest practicable moment In lancing a niamniHr)^ ab-
en^KS, tlie lowermost margin of tlie pun cavitj' should bo selected
as the site of the incision, and the opening should always be
made parallel to the course of the lactcfil tubei*, so as not to
sever any of them. Sub-mammary pus collections should be
evacuated on the outer margin of the glanil.
Tliis matter of lancing a mammary abscess, and subsequently
caring for tlie breast until it has beeu restoreil to a healthy state,
merits careful study. ''The oj.>ening of the abs<«>sses," says
Billroth,* "should always be done with a knife, and there is no
lulvantage in delay. Very great advantages are here ilerivod
from the antiseptic treatment The breast is first cleimed with
Boap. then WTished with n weak solution of carbolic acid, and an
incision one centimeter Kmg is to l>e made in the direction of
the radius of the breast The drainage tnbe is then inserted,
the pus withth'awn, the bn?ftst again bathed with the carbolic
iicid loti(»n, and the breast ciompressed fi'om all sides with anti-
septic gau^se.
** If the antiseptic precautions are fully carried out, one will
never see such cases as were common heretofore, in which the
breastB were undermined for months with abscesses, and the
woman suifered untold misery."
Firm and equable compi*ession shonld subsequently be exert-
ed by means of a bandage well applied. One which does not
exert uniform pressure is worse than none, and hence the neces-
sity for the grealost care. Some have recommended that each
turn over the breast l)e made fast and firm by the use of plaster
of Paris, the incision akme l>eing left uncovered. The bandfige
should be changed as often as seems necessary. Some prefer
tlie use of strijvs of adhesive plaster. Adhesive plasters are
now made puijiosely for such cases, and, when properly applied,
serve a very good puriH)se. Painting the breast with a thick
• "' Haiun*<ich diT Fraueiikrankheitcu."
608
THE PUERPERAL DISEASEH.
layer of collcKlif»n iramediately after lancing is a favorite method
witli some.
Our remedies have also a decided influence over tliis painful
affection, but they require to be chosen with great care.
E.rcesmve Secreiion. -Breafita greatly and painfully distended
with milk; abscess threatened: ncnUc acid.
Secretion of milk too abundant: ctilrarc^i rnrh., vrHnium^
'pulsodUn, pkijUjUweti.
Pains, Etc.j in Mammir. — Burning in the breasts: acUxu
rnvtnuosa.
Constrictive pains in the left mamma when the child nursea
the right: borax.
Griping, and sometimes stitches in the left mamma, and
■when the child has nursed she is obliged Ut compress the broast
with the hand, because it aches from being empty: bcffox.
Stitches as from nopdl»^s in tlie loft breast: couivm.
Cutting in left mamma through to scapula; sighing, short
breath: liliuvL
Cramp-like pain in left mamma, shoulder and fingers: Ulium,
Biu'ning, stinging pains: njns.
Burning pains; relief from motion: arsenlcum.
Tensive burning and tearing pnin: bryonia.
Pains antl buniing: calatrrd jthos.
Darting pains of nursing women; they arrest breathing, and
are worse from i)ressure: carho an.
Stitches in the breasts: creosofum, songuinaria^
Tnduratlon^ Influiiiniation, Suppuration, Etc. — Lfifl
Mammiv. — Lumpsdeep in left breast; aching pains: <tmm /ry.
Left breast inflamed, suppurating, with a feeling of fulltiees
in the chest; sensitive to cold air; scrofulous: cisius.
Either— Both Mrtmmtc— Burning, stinging, swelliug, hard-
ness, even suppuration: apis.
Breasts feel heavy, are pale, but hard and painful: bryonia.
Inflammation; sensation of fullness in the chest, over-sensi-
tivenesa to cold air: cactus,
Mammre sore to the touch: calcwea phos.
Suppuration; fine stinging in the nipples: camphora.
Hard, paiufid si>otB: earbo uti, phf/iolarca.
Swollen, inflamed (erysipelatous): carbo an.
MASTITIS PUEBPEBALIS. 609
Hard and tender to the touch; with drawing paioBi chamomilla.
Induration and inflammation: cisius.
Hard and swollen, with pain from nipple to scapula: croion
tig.
Swelling and induration: cuprum met.
Bluish, with blackish streaks, lancinating pains in the breast
and down the arm: lachesia.
Suppiiration of the mammee: sulphur, kepar sulphur, mercu*
rius, silicea, Phytolacca.
Swollen, hard, with sore pains; nipples ulcerated: mercurius.
Hard, red spots or streaks; fistulous openings, with burning,
stinging, and watery, offensive discharge: phosphorus.
Inflammation, swelling, suppuration: phytolacca^
"Broken breasts," with large, fistulous, gaping, and angry
openings discharging a watery, fetid pus: Phytolacca^
"Caked breast;" Phytolacca.
Swollen breasts; rheumatic pains extend to the muscles of the
chest, shoulders, neck, axillee and arms; pains change from place
to place: pulsatillay actcearac.
Breasts swell from catching cold, especially from getting wet;
streaks of inflammation; milk vanishes, with general heat: rhus
tox.
Suppuration; chilliness in forenoon; heat in afternoon:
sulphur.
Soreness of the follicles within the areola: calendula (topi-
cally.)
Chilly crawls over the mammse; guajacum.
Chilliness over the mammae: coc-culus.
Herpes of the breasts: dulcamara^
610
Tfi£ rUElifii^AL lilSEAbES.
CHAPTER IV.
The Puerperal Diseases.— (Continued.)
Puerperal Eclampsia. — This term is used to designate con-
vulsions associated witli, and directly or indii*ectly growing out
of pregnancy, parturition, and the puerperal ntate, cLanicterized
by unconsciousness, followed by comn. Convulsions due to
hystGria, true epilepsy, tmd cerebral lesions, since their connec-
tion with the physical states above mentioned is merely acci-
deniid, are not intended to be here included.
Eclampsia is fortunately a rare events occurring but about
once in five hundred cases. It is met more frequently in primip-
RTfe than in multipane, especially in elderly primipara', in twin
pregDnney, in women with contracted pelves, and in coiiLoctiou
with tlie birtli of male children. It is somotimes epidemic,
Etiolofiry.— The causes of eclampsia are still matters of dis-
pute?, which fact, in a mensure, accounts for the comparatively
ill success attending its treatment by physicians of all schools
of medicine. Many theories have been advanced, but that one
which attributes the manifestations to the retention in the sys-
tem of certain effete matters, is the one which has met with moet
genernl acceptance. The existence of albumen in the urine of
women sufleriiig from eclampsia was lii'st observed by Dr. John
C W. Lever, in 1842. Frerichs, in 1851, called attention to the
close resemblance between the convulsions occurring in preg-
nancy, and the unemic ctm^iilsions of Bright's disease, and drew
the conclusion that "true eclampsia occurs only in pregaaat
women suffering with Bright's disease.*' This view was soon
after sufn>orted by Braun and Wieger, and has come down, with
slight modification, to the present time.
ECLAMPSIA.
6U
With regftrd to the presence or absence of albumen, it shouIU
be remembered that no one can doubt that its presence is far from
being a constant sjTnptom of eclampsia; but this is compara-
tively unimportant, since the claim of most of those who sup-
port the lu-iemic theory is that the uraemia and convulsions are
not due to the presence or absence of albumen, but to the ex-
istence of renal insufficiency.
It is not uniformly held by later authorities that the renal in-
sufficiency is» in every instance, due to Bright's disease, for tlie
results of autopsies do not justify such a conclusion. The re^l
nature of the circulatory changes is not known, but some believe
that either the walls of the vessels are altered in such a manner
as to interfere witli the process of diffusion, or tJiat the calibre
of the vessels is reduced from redex action set up by penpheral
stiiuuhis. Color is given tlie lattt^r theory by Frankenhaeuser's
discovery of a direct connection, by means of the sympatlietic
nerve, between the ganglia of tiio kidneys and the nerve fila-
ments of the uterua
Frerifhs believed he had found the secret of the outbreak of
comTilsions in his theory of the development of carbonate of
ammonia in the blood fi-om the retained urea; but later research
has led to the conclusion that '* amnionitemia is to be regarded
as <me of the rarest causes of convulsions.'*
According to the Traube-Rosenstein theory, eclampsia takes
place in women rendered hydi*jemic by tlie loss of albumen, and
in whom sudden increase of the aortic pressure gives rise, first
to cerebral oedema, then secondary compression of the vessels,
and, finally, to acute anosmia. This theory is entertained by
many, but is rejected by others.
From a thorough consideration of the phenomena presented,
and the various theories which have, from time to time, been atl-
vanced, it seems probable that, in the greater share of cases,
nnrmia is the condition upon which convulsibility depends.
This may be due in one case to organic changes in the renal or-
gans, and in another to functional disturbance of their circula-
tion. Still, all anemic patients do not suffet from eclampsia;
and the efficient causes of the paroxysms are probably various.
The possibilitj', and indeed probability, of eclampsia being oc-
c^isionaUy provoked by peripheral irritation, sliould not lie over-
612
THE PUERPEBU. DISEASES.
looked. It appears quite possible that, in susceptible subjects,
an attack may be brought about through such n chubb, wiUiout
the co-existence of ursemia, while in uneniic patients, peripheral
irritation probably acts as a common exciting cause of the
Beizure&
SymptoniH. — Tlie symptoms of individual cases of eclampsia
are remarkably similar, difl'ering chietly in the intensity and du-
ration of their manifestations. Distinct precursory symptoms
precede the actual appearance of eclamptic convulsions in about
thirty per cent of all cases, consisting of headaches, nausea, diz-
ziness, muacAJi volUanles^ amblyopia, even amaurosis, pain in the
epigastrium, muscular tremor, mental depression or excitement,
laughing or crying, talkativeness, insomnia, etc. Such symptoms
usually last only a short time ; but may continue for several
days. In the majority of cases the attack suddenly seta in with
a loud cry, or the patient begins convulsive movements of some
part of tlie body, it may be an arm, and then another part
becomes implicated, until finally all the extremities are involved.
The arms and legs are violently twitched, or swung about, the
eyes, with dilated or contracted pupils, roll spasmodically, and
are not affected by light; the face is livid; the respiration is at
first panting, and then entirely arrested for a time, after which
it may be sterttirous. There is foam at the moutli; the teeth are
gnashed; the tongue is bitten; the pulse is rapid; and the tern*
perature rises.
In the interval between seizures, the pulse slackens its pace,
and becomeB fuller; while the respiration gets regular, but con-
tinues more or less stertorous. From this condition the i>ationt>
after a time, arouHes, but remains more or less dull or confused.
The number and frequency of the attacks vary greatly.
There may be but a single seizure, or the paroxysms may num-
ber twenty-five or thirty. Winckel says * that the greatest nmn-
ber he ever witnessed in a case which terminated in recovery,
was seventeen.
Death sometimes takes place during an attack; and again it
often occurs in the comatose stage from pulmonary oedema and
cerebral apoplexy. When recovery ensues, as it doea in the
♦Wii'CKKL, ** Pathology and Treatment of Child-bed," Am. Ed., lSf7«, p. 44a
ECLAMPSIA. "^^^i~ 613
innjority of cases, tliere is a decrease in the frequency, duration,
and intensity of the paroxysms, followed by u deep, quiet sleep.
DiagUOSiH. — Diagnosis of true eclampsia is not always easily
made. We ore obliged to form our opinions many times by the
method of exclusion- To this end, thereiure, we shoulil en-
deavor to learu whether the woman is subject to epileptic attacks,
or convulsions which are epileptiform in character. "With re-
gard to tlie symptoms of the paroxysms of puerperal eclampsia
and epilepsy, it should be known that they are not characterized
by widely different phenomena, and differentiation is exceedin^dy
difficult The intensity of the comatose stage is said to bi*
greater in eclampsia than in epilej)sy. In hysterical con%nd8iona
the consciousness is not generally lost, the attacks are less vio-
lent, there is no c^iati^se stage, and the patients weep, scream,
or laugh in the midst of the paroxysm.
Prognosis. — The prognosis is always serious, and more so
when the eclampsia jirccedes delivery. The relative results of
homoeopathic anduld-school practice cannot l>e stated, but tliey
wouKl seem to l>e decidedly in fa^*or of the former. Under the
latter, however, the percentage of recoveries has greatly in-
creased since the abandonment of repeated and indiscriminate
bleeding. The results of eclampsia must be held to Vary ac-
cording to the severity, frequency, duration and number of the
paroxysms.
Braun says he has never known but one patient to recover
when attacked Ijetween the fourth and sixth months of preg-
nancy, except where abortion has taken place.
When sevenil seizures are suffered, the life of the child is
nearly always destroyed.
Treatment.— Treatment of ecbimpsin may be very aptly con-
sidored under the two heads, preventive and curativa
Prei^eiiilve Treaiment — Whenever prodromi are observed, all
exciting causes of convulsions should be removed, and the
patient's surroundings mnde as pleasant and sanitary as possi-
bla Symptoms which will require special attention have l)eeu
considered by themselves in other places, and the most valuable
remedies for them indicat^^d. Among these symptoms we may
mention ins^^mnlM, cephalalgia, and nlbuminuriu.
f)14
THE POEBPEnAL DISEASES.
Curative irenimerd will be more or less modified by the period
at which the convuisions are developed.
When eclampsia sets in during pregnancy, and the paroxysms
are not brought under control, the question of inducing labor
has \m 1>o settled The advisability of such an opexation is ?id-
vociited by some, and denied by others, (uid will have tt:) be con-
sidered and settled in individual cases as they arise. It cer-
tainly ought not U) be undertaken without otlicr measures Iinre
utterly faile<l, as the favorable effects of the operation Lave not
been conspicuous.
In a Inrge percentage of instances uterine action is excited by
the convulsions, and dilatnti4m of the os uteri begins, by which
tlie case practically resolves itself into one of eclampsia dating
labor, and should l)e mnnnged accortlingly.
C'onvulsions which occur after lalv>r has begun have a ten-
dency to recur until the cf>mpletion of the parturient act. and
then to cease. Tt is therefore advisable to hasten the delivery
by every obstetrical rosf>urce Avhich is not inimiad to the
woman's safety. Tliese in the first st»ige consist in rupturing
Uie membranes, catheterizing the uterus, and employing manual
dilatation; and, in the second stage^ the iLsing nf tlie forceps.
"At the recurrence of the fit^" says Dr. Ludlam.* "a thick
piece of india rubber, or of soft wood, should l>e pUic<xl l)ctw*^en
the teeth, in order to protect the patient's tongue. She Bbt>ald
not be held Forcibly or firmly hi tlie bed, but simply prevented
from tlirowing herself upon the floor or otherwise inflicting bod-
ily injury. Too much constraint might increase the difliciiity,
ami would do no good. If she has an antipathy to the nurse,
the husband, or any one in the room, you hatl better send them
out. And do not let bystnndere give vent in her hearing to ex-
clamati<nis of fright and hoiTor ut the contortions of which they
are witnesses."
Therapeutical Resources.— "No rerae<ly" justly remwka
Biehr,t " responds to this disorder as completely asMladonnft.**
The indications for its use, acconUng to Guernsey, are as fol-
lows: She has the appearance of 1>eing stunned; a semi-oon-
sciousness and loss of speech; convulsive movements in the
^''Diseases of Women/' Fourth Edition, p. 260.
t " The acionce of Therapcutius," p. 1(W.
ECLAMPSIA.
615
limbs, and mascles of the face; paralysiB of the right side of the
tongue; difficult deglutition; dilated pupils; red or livid coun-
tenance. She may have paleness and coldness of the face, with
shivering; fixed or convulsive eyes; foam at the moutli; invol-
untary escape of the foeces and urine; renewal of the fits at
every pain; more or less tossing between the spasms; or deep
sleep, with grimaces; or starts and cries with fearful visions.
The efficacy of belladonna has be<3n repeatedly demonstrated.
Grlseininm has Y>roved to be a remedy of remarkable value in
tliis disorder. It is indicated in attacks brought on by periphe-
ral irritation as well as those occasioned by m'semia. One of
its prominent aymptoms, sometimes observed as jiremonitory of
eclampsia, is a large feeling of the Lead. The pulne is full, but
not hard We incline to the use of the tincture in doses of sev-
eral drops, a number of times repeated, if necessary.
Veratrnm vividc makes up the trio of remedies whicli are of
greatest service in the tieatraent of eclampsia. Its particular
indication is high arterial tension, or circulatory excitement.
To get the desired effect, it should also be used low, and in ap-
preciable doses.
Following are indications for other remedies: Seizuies pre-
ceded by restlessness, and a sensation of general expansion,
mostly of face and head: ar(j('jiti/m nit,
Convtilsions following difficult labor, and those which appear
to be brought on by changing ]K)Bition: corculus.
Spasms during parturition, with violent vomiting, or with every
paroxysm opisthotonos, spreailing of the limbs and opening of
the month: cuprum vtri.
Convulsions during pregnancy, of a clonic nature, beginning
in one jifirt, and spreading: ntprum met
Unconsciousness; fnce bright red, puffed; full, hard pulse;
urine copious and albunjinous: (jlrruohiuiu.
Convulsions, with urine scanty, dark, floating dark specks, or
albuminous: heUrltonis.
C<;nvulsions. shrieks, anguish, chest oppressed; unconscious-
ness: hyoscyamtis.
Convulsions during and after labor; drowBiness, open mouth,
coma between pwoxysms: opiunu
Convulsions following sluggish or irregular labor pains; un-
016
THE PUEBPEB^ DISEASES.
conscioufi; cold, clammy, pale face; stertoroas breathing, full
pulse: puhidillih
Labor cejises and convulBiomi begin: secale.
Convulsions with opisthotonos: secale.
Convulsions with copious sweat: sirarnonium.
Convulsions, with jerking of every muscle in the body, includ-
ing eyes, eyelids and face: hyoscyawus.
Convulsive twitches, especially after fright or grief: ignatia,
gelsemium, optuni.
Stertorous respiration continues from one spasm to another:
opiuHL
Bright light, or contact, renews the spasms: stirumonium.
Extreme degi*ee of nervous erethism: coffexh stramonitnn.
Excessive nervous sensibility: asarum.
For the insomnia which precedes eclampsiM: rnffc4i, aclcpxi
cauhjihylUnUy hjfoscyamus.
Awakens with a sluinkin^ look as if afraid of the first object
seen: siramoninm.
We do not feel that our tlesonption of reniotlial laeesiires is
what it ought to l>e, witlumfc allusion being lunile to ntliPr reme-
dies, which, however, we cannot recommend for adoption until
those homieopathically indicated have failed to niford the neces-
sary reUf'f,
ChUrrofirrm is regarded as of the greatest value in certiiin
cases, while in others, its influence has not j)roved beneficial.
Its atlministnition should be carried to the point of compMe
narcosisy but its action ought not to be very long sustained.
Opium und MorpkicL — These narcotics have been highly i)raii>ed
for their effect in eclampsia. The former should W given by tlio
mouth, and the latter by hypodermic injection. Doses of double
the onlinarj* size may be employed. This mtKle of treatment
has received very strong endorsement from old-school author*
ities.
Apoctfnum can,, by hypodermic injection of the fluid extr&cti
has bt'on employed ^vith excellent eflect in tme eclam[«ia by l>r.
C. 8. Fahnestt)ck.»
Chloral hydrate in doses of twenty grains, repeated sereral
«**The CUnique," vol. i, p. 321.
^^
PUERPERAL FEVER. 617
times within twenty-four hours, if necessary, in some cases also
controls the paroxysms.
CHAPTER V.
The Puerperal Diseases.— (Continued.)
Puerperal Fever, (Puerperal Septicaemia, SaprsBinla,
Puerperal Pyiemia.) — "The man of positive opinions on all
subjects is to be envied,'* says Glisan,* " because of the com-
fortable assurance that a firm belief or disl>elief in any doctrine
affords liim. But when among a number of learned and experi-
enced clinical observers in diseases of women some state that
puerjjeral or child-bed fever is essentially a zymotic disease pe-
culiar to puerperal women, as specific in its nature as typhoid
or typhus fever, or small-pox, and bears the same relations to
local concomitant patliological conditions as the ulcers in the soli-
tary glands and glands of Peyer do to typhoid fever, or the pus-
tules on the skin to small-pox; while others aflirm that the
disease is essentially a local infiammation like phlebitis, perito-
nitis, metritis, or lymphangitis, producing constitutional effects
of a secondary character; others again, that the malady is only a
form of pyaemia or septicaemia, modified somewhat by the puer-
peral condition of the patient; we must consider the nature of
puerperal fever as undetermined. The local infiammation theo-
rists are divided among themselves as to the seat of the infiam-
mation, and have been contending against each other so vehe-
mently, that from this cause, and the i)ressuro from without,
their hypotheses are fast declining in popularity. Latterly the
contention is chiefiy conducted between the zymotic and septi-
ceemic theoriea"
Lusk says :t " It has now passed the domain of dispute that
puerperal fever is an infectious disease, due, as a rule, to the
• "Text-Book of Modern Midwifery," p. 61^*.
t " Science and Art of Midwilery," p. 608.
B18
THE PUERPERAL DltTEASES.
septic inoculation of the wounds which result from the sepArn-
tion of the decidua aud the pas&age of the chihl through the
genital canal in the act of parturition." The statintical frequency
of septic pueri»eral di-seaaes is due doubtless to the length of the
parturient canal, and the extensive area, denuded in many placee,
over which the physiological excretions must pass in their escape,
as well OS with whicii the lingers and instruments are brought iu
contact during hibor.
The greater numlx>r of mtxlem observers entertain the c<^uvic-
tion that the infectious diseases of the puerperal state are of
septic origin; and tht* question of the identity of pueri>oral fever
and septicjemia or pyjcmia has become one mainly of definition.
Patholoi^ica] Anatomy.— The anatomical lesions with which
puerperal fpver is aHStx'iatetl are various, and the ritlanimatory
processes observed are rarely limited to a single tissue. Thft
following classification of lesions by Spiegellierg,* will be found
of the greatest utility.
1. Ivflammaiifm of ihe Gtmiial Mucouh Membranp, — Endo-
colpitis and endometritis.
(i. Superficial.
ft. Ulcerative (diphtlieritic.)
2. Injhftnmnihm af fhe lltTine Pareikchjvui^ ami of ihe Sub-
serous ami Pelvic OUulnr Tissue.
ft. Exudation circumhtribed.
h. Phlegmonous, <iiHused, with lymphangitis anil pyn'mia I lym-
phatic form of perit^mitis).
IJ. luJIfUHWiiiion of the Perihneuui coreriny the (JtertiA and
its yl/v"•"'^l.7r^^ -Pelvic perittmitis and diffiutetl peritonitis.
4. Phh'ltifis ('ff^^rhitt o.nd Pnra-uterina with formation of
thrombi, embolism, and pyjemia.
5. Pure St*piic<ymia. Putrid absorption.
Endocoipitis and Enthwcfritis.^Tiie passage of the fcetns
through the parturient canal nearly always results in lacoratioiu}
more or less extensive of some of the st^ft tissues, the nnwt com«
mon situations of which are the os uteri and vulva. After deliv.
ery it often hap|>ens that the e<lges of these wounds begin to
idcerate, giving rise ti> what has been called the "puerijeral
■"Utber das Weaen de« Puerperalfielwrs,^
Vortr.," No. 3,
VnlkuanD'H **SaiDml Klin.
PUEUPEBAL FEVEU.
619
nicer/' A freqnent location of ulceration is on the surface of n
ruptured poriripuru av frfimlum, though ulcers are occasionally
found in the vagina when the perineal laceration hag healed by
first intention. Tliese ** pxiorijoral ultN^rs," in advanced stiiges
are found to be covere<l with a brown isli -green layer, and ore
usually associated with cpdeniatouH swelling of the labia. In
favorable cases, under judicious treatment the deposit clears
away, and repair takes place by granulation.
The ulcers sometimes present diphtheritic appearances^ and
extend along the surface of tlie vaginal mucous membrane, or
even down the thighs, accompanied ^dth more or less oedema.
The mucous membrane of the vagina feels soft and infiltrated,
and being similar ta erysijielat^jus inflainnintinii in the skin, has
been termed by Virohow. erysipt'las itHilignum puerpvraU- in-
Extension of the process involves the uterine mucous mem-
brane, and, whei? intense, the inner surface of the uterus has the
ap|)enrance of severe catarrhal intlnmmation. Mortification
may ensue, in which case the comlititm takes on a diphtheritic
clianvcter. The superficial layers mortify in patches, and bc^twoen
the normal mucous membrane yellomsh-brown places are seen,
from which niasses of detritus can easily be Hcrnpe<l. In those
cases whoreii» the entire endometrium becomes invi^lved, there
will everywhere be foiuul. according to the state of the semus
triiusutlation into the organ, either brownish particles or a
smeary, chocolate-colored mass, after the removal of which the
deeper layers of the mucous mejnhrane, or the mus»MjIar fibres
themselves, are exposed. The placental sit^ also participates in
the changes.
The uterus itself becomes more or less involved, and it is
found either only slightly contracted, or its whole substance
cedeniatouB. In bad cases the lymphatics are disti'nded with
pundent matter, the origin of wliich contlition is sometimes
traceable to the unhealthy ulcers of the cervix.
The inflammation dt^es not usually exteud to the mucous
membrane of tlie Fallopian tul>es. Pundent saly)ingitis occa-
sionally takes place, and either by extension of the inflammJi-
tion or by rupture of the tube, peritonitis is excited.
Mt^irifis and ParamfirUitf. -[Pfln'r Celluliiin) — When the
620
THE PUERPERAL DISEASES.
endometritis becomes iiit*'iise, the parenchyma of the organ gen-
erally shares in the morbid processea This is mttnifestetl by
cedema, imperfect contraction, and a remarkable softness of the
tissues. When the endometritis extends deeply^ putrescentia
uteri is qiiite apt to result, and lead to perforation of the uterine
walls, thereby opening up the abdominal cavity.
From the connective tissue surrounding the vagina, or that
covering the uterus, the iniiamniatoiy pr<>cesB may extend be-
tween the folds of the broad ligament, and thence ascend to the
ilino foKsa. One side only is usually nffncteiL From the iliac
fossa, the inflammation spreads in ditfereut directions, but rarely
extends forward around the bladder.
In mild, uncomplicated cases, the process always terminatefl
in recovery, an<l the axlema speetlUy vanishes. AVhere the cell-
elements do not accumulate to any great extent, hardly a trace
of the disorder is left behind; but in other cases a haril tumor
remains, consisting of finely grnuular detritus, which may (.lida{>-
pear in a few weeks.
More intense infectitm is liable U^ result in neor* itic softening
of the subserous connective tissue, and the formation of a pu-
trid nbseess. In many cases i»f parametritis, thromb<:>si8 of the
lym])hatic vessels is friund within the inllnmed spot, which con-
dition Vircliow has shown to be in some degree a favorable in-
cident, since the occludeil vessels are prevented from carrying
the infectious substances^ and the extension of the morbid
changes is tliereby limited
By extension, the ovaries also beoome implicated in the in-
flammatorj* action; but ovarian abscesses thus originatuig are^
extremely rare.
Peritonitis.— Pelvic peritonitis may be said to consiflt, in
general, only in an inflammatory iixitation of the serous mem*
brane, attended with but little exudatioiu Sometimes pseudo-
membranes are formed, resulting in adhesions lietween the con-
tiguous surfaces of the pelvic organs; and when tliis occurs
cicati'icial shrinkage may cause n change in tlie position of the
organs, and create a variety of complaints. Allien the inflam-
mation is intense, suppuration may ensue, and the pus, when
encapsuled, is slowly absorbed. Pelvic peritf^nitis is liable, by
extensioio, to involve the whole serous membrane.
PCERPER.U- FEVER.
021
General peritonitis does not often follow endometritis; but
arises most fi*equently in the course of pariuuetritis or pelvic
peritonitis, in the following mnnuer: If the swelling in case of
parametritis is great, the dragging upon, and changes in the
position of the peritoneum cause an irritation wMch eventuates
in perimetritis, or pelvic peritonitis, which c<jndition, in fatal
cases, rapidly extends, and general peritonitis soon follows.
In relatively mild cases the |>eritoneunj, and especially that
part of it which invests the intestines, is iinely injected, and a
loose pseudo-membrane is formed, which, in recent c^ses, unites
the abdominal organs more or less firmly. The exudation is
sometimes very mtxlerate in quantity and free from pus cells;
while in other cases patches of pus, and thick membranes of co-
agulated fibrin are found. The liver and uterus generally have
a thick coating; the intestines are distended, and the diaphragm
U pushed upwards.
In the worst cases the exudation is not fibrinoiis, but brown-
ish and putrid in character, and the intestines have a dark,
brownish red apj)earance. They are always fatal.
Phlebitis Uterina and Para-uteriiia,— Inflammation is apt
to be set up in those veins which traverse tissues in or near the
uterus which ai*e infiltrated with purulent or septic matters. As
a result, the endothelium undergoes prt)liferation, and throm-
bosis is produced. A normal thrombus is in itself harmless,
and may in time become organized; but when pus or septic mat-
ters tibtain access to it, disintegration ensues, and the particles
are swept into the circulation. Wherever such emlx)li happen
to hxlge, inflammation is arouse<l, and abscesses result. The
thrctmbi sometimes extend, by accretion, toward the heart,
stretching from the uterus througli the spermatic, hj'pogastric,
and caramon iliac veins, to the vena cuva. Such a formation is
sometimes traceable back to tlie placental site.
Pnre Septicjemia.— By this term we designate a condition
arising in woman during the puerperal state, from the absorp-
tion into the system of septic matter, or organic material in the
process of decomposition. It probably differs in no essential
particular from surgical septicemia, and the local pathological
conditions which have been described are among its effect*.
Local inflammation does not always arise from extension of the
622
THE PUEnPEIlAL DISEASES.
process through continuity of tissue, but the inflammatiou of more
dJHtant tissues iin(i orgjms is createil in the same way im ill in-
fection after injuries of other parts of the body, and as in. sur-
gical diseases.
When the sepsis is intense, death soniGtiines rapidly ensues,
and the autopsy discloses to the unaided eye only a dark and
non-coRgulable state of the bliKnl, with ecchymoses of the vu-
rious tissues, and under tlie microscope is seen iinef gnuiular
iuliltration, fatty degeneration, or cell disintregration.
When the infection is not so intense, the vital organs are not
so ]Hi\verfully assaiUwl, and elevated temperntnrti is almost the
sole indication of general disturbance. In the aliseoce of fur-
Uier 6uj)ply of septic matter, these symptoms rapidly disapjjear;
but when the i>oisonou8 matter continues t<.»be absorbed in small
quantities, the fever is sustained, and inliammations of other
organs are likely to ensue.
We shall not attempt a description of all the pathological
changes rovonled in tlte post-mortem examination of women
dead from septiciomia following the course alluded t*^, and the
Hymi)tomB of which merge into those of pyaimia. It has been
suggested that the blood in these cases becomes so altered by
the infection, and loaded with soptici matter, that it is capable
itself of I'xciting inflammatory action wherever it may circnljite.
It has l>eeu ol>served that in some epidemics, the serous mem*
branes, in others the mucous membranes, in others, again, the
veins, and in still others the lymphatics, become prominently
affected. Abscesses may form in various organs and tissues aa,
the result of pysemic processes.
When the peritoneum has been inflamed, it is found more or
less extensively congestetl, spread over with l^-mph. and the in-
testiuee and alxlominal organs adherent to one another. In the
cavity will be found serum, sometimes clear, but at other times
mixed %vith I^Tnph, pus, and blood. 8imilar changes, after in-'
flammation, are found in the pericardium and pleura. Endom-
etritis is rarely secondary on general septic infection, and the.
anatomico-pathological changes arising from IocaI c^iusee, have'
been sufficiently described. Infection of the veins and lym-
phatics also usually arises from direct extension of the inflam-
matory' process.
PrEBPElUL FEVKIL
623
Channels of Absorption. -The inner surface of the uteruB,
especially at the placental site, an well as the vaginal and vulvar
Hurfaces in all puerperal women, affords most eligible absorbent
areas, and that through these septic matters reach the system,
has been cle^irly demonstrated There is reason to believe that
infection uiay, in certain cases, result from absorption of septic
matter tlirougli the mucous membrane of the vagina imd cervix
without there lieing any breach of surface.
Graiiulating surfaces an> not absorbing surfaces, and hence it
follows that infection unually takes place, if at idl, before repair
has fairly liegun.
The character anil sources of the septic matter constitute a
question which has been variously answereil, but not fully set-
tled. It is clear that in some cases thi* infection is from within,
find hence nuiofjmeiic, while in others it is from without, and
therefore heicvwn iwiic.
Auto^netir Sepsis. — Auto-infecti<m mny arise from auy
ctmdition with which is aHs<^>ciateil fjecomposition, either of the
tissues nf the woman herwilf, of the fiptns or of imy other re-
tained part of theproiluct of c^^nceptiou. As examples of these
we mny mention the altmghs of maternal tissue which result
from li>ng-ct>ntiuued pressure, ami retained portions of placental,
or even of membranes. That infection freipiently arises from
anch sources is beycmd question, and that it does not often occur
must l>e explained mainly on the ground of early granulation of
denuded surfaces.
Heterogenetlc Sepsln.— Infectious matters from without are
intr<MJuee<l iu a variety of ways.
Cftilrirrric Poi:ionhiff. — Poison is probably in some cases con-
veyed fnuu the dissecting room aud the autopsy table to partu-
rient and puerperal women. Semmelweiss pointed out the
diffei-ence in mortality among pueri)eral women in the two de-
partments of the Vienna Lying-in Hospital. In the department
attended by physicians and students the mortality was seldom
bel<»w fine in ten, while in that conducted solely by women, wlio
did not visit the dissecting rooms, the morbdity never exceeded
one in thirty-four. The number of deaths in the former de-
partment at once fell to that of the latter, when thorough disin-
fection was employed.
624
TFIE PCEBPEBAL DISEASES.
There seems IDiewise to exist a difference between people in
their liability to convey infection; for one practitioner wiil per-
forin frequent dissections and conduct numerous autopsies, and
yet carrj- on an extensive midwifery practice with roost satisfac-
tory* residtfi; while another from a single vLait to the disKwciing
or autopsy room will find tlmt he lias conveyed poison to Lis
parturient and puerperal patients. It should be remembered,
however, that the risk of conveying infection from a cadaver is
greater when the subject died fiom zymotic disease.
Erysipclds Infeeiion. — Exi>erience in private as well ns hos-
pital practice has conclusively shown that the infection from
crysipehis may lie communicnttMl by tht* [>liyHlcinn, or other per-
sons, passing from a patient suffering ^^'ith the disease, to the
lying-in ohauil>er. Still, such occurrences are comimratively
rare, and are probably met only in the instances of women p*Ds-
sessing peculiar susceptibility to the infection, and attendants,
medical or other, who ignore the ordinary usages of civilized
society by not thorouglily cleansing their hands. That er>'siiH'>-
las in a ])regnant and finally parturient woman does m»t always
add materially to tht» tuHuplicationsand dangers of the puerjiend
condition, was well illustrated in a case which occurreil in Hahn-
emann Hospital a few months since, A woman, during her nnto-
partum residence in the hospital, was attacked with erysipelas
involving mainly the face, after a pre\nous attack of di|»htiieria;
and during the existence of tlio former disease, passtnl through
labor. To the surprise of those acquainted with tlie cjiso she
made a good recovery.
Scarlnimal Infection, — Certain zymotic diseases possessing
symptoms peculiar to themselves, and quit« uniform in their
manifestations, may be so m*xlitied in a puerperal patient as to
differ in no essentials from the phenomena usually preseuteil by
ordinary septicaemia. This does nrtt appear to l>e true in every
case, for puerperal women dt), in some cases, manifest strictly
scarlatinal symptoms, rather than those of septicaemia, and why
the effects of thecontagium should be so widely divergent in dif-
ferent subjects, has not been clearly shown. We incline, how*
ever, to the belief held by many, that, if the contagium be ab-
sorbed through the skin or the ordinary channels, it may pm-
duce its characteristic sjTnptom», and run its usual c/^nrse;
PUEBPEIUL F£V£K. ^^^" C25
while if brought into contact with lesions of continuity in the
generative tract, it may act more in the way of septic poison,
and witJi such intensity that its specific symptoms are uot de-
veloped. Bpencer Wells says* that he has seen cases of surgi-
cal pyiemia, whieli he had reason to believe originated in the
scarlatinal poison.
Inff^riitm from Ofher Puerperal Women. — Epidemics of
puerperal fever outside of lying-in establishments have occurred,
in by fai* the greatest number of cases, in the practice of some
one physician or midwife, and they have generally been coh-
fined, therefore, to small districts, even in the large cities. Star-
feldt, of Co])enhagen, exjjresses the opinion that nurses most
frefjuently form the media for transmission of the contagion.
Distinction is made by some between sporadic au<I epidemic
cases, the latter l>eing regarded as far more infectious. In
either instance, however, the signs, seats, lesions aud rpstdts of
the disease are the same, and who can discriminate l»etween
their manifestations? A study of tlie history of puerperal fever,
in hospital and private practice, and a rational viqw of the ]>rolv
abilities, we believe cannot fail to lead one to conclude that the
infection is surely capable of being communicated from one
patient to another through various media.
How Lon^ do the Septic Matters B^tain their InfectiooK
Pr«pert!*»s? -Another imjxirtant question rolatf^s to the lenj^th
of time that one may carry infectious matters about him. Some
have claime<l that it is impossible for any one Ui infect a woman
in labor, in consequence of having performi*<l an autopsy, hav-
ing handled foul wounds, or having made a vaginal examination
of a woman suffering from x)uerperal fever, two or three weeks
previously. Schweninger l>elieve9 that the putrid fluid loses its
action after seven or eight months. Experimental research Uim
not settle<l the question, but it seems probable, as suggested by
Winckel, that such matters, by adhering to instnmients, etc.,
probably retain their infectious properties as long as vaccine
virus, I. e., for more than a year.
How IS the Coiitagluni Conveyed?— "In all cases where the
accoucheur has touched a woman in labor with his fingers or in-
• Vide pLAYFAre, loe. dt, p. 5©7.
62U
THE PUERPERAL DISEAtiES.
stniments," * says Winckel, "as well as with his clothing, and
has subjected her to repeated exanimations, we must, of neces-
sity, rather impute the trausmiasion of the infection to the
hands or instruments; firat, because the clothing is brought in
contact with the denuded surfaces in the rarest instances only —
and even then remains in contact with such a wound for a brief
spac^ of time— and linall\\ l>ecau8e the clothing is rarely so
thoroughly impregnated witli infexjtious matters as is often ob-
served in case of the hands. If the objection l)e urgetl, that the
disease may supervene, notwithstanding that the haints have
beiMi ciirefuUy clean.sed mid disinfected witJi chlorine water, or
a solution of permanganate of potash, or dilute muriatic acid«
the reply to this allegation is: that such washings, even if sev-
eral times rejieated, ore fai* from lx*in^ always thomugh; that
after numerous cleansings of this description^ the hands may
still retain an odor, from which it nuiy bo concluded that some
morbid matter is still adherent tct the dngers. It should not, on
tliis account, however, be inferred that it is any the less impor-
tant to wash the hands; this precaution should be uniformly
taken, although Ave can pronounce tlie result of the same to be
absolutely effective only when it has been many times repwit<Hi.
and all *>dor has disappeared. For this reason it is of the ^^at-
est im}>ortanee that accoucheurs of extensive practice, however
careful in these ablutions, should never make auU^imies, or, at
leaflt, should not attend a case of confinement for a number uf
days subsequent to such an examination, taking care even then
to avail tliemselves scrupulously of the most effective means of
disinfection."
Infectious matters mny be conveyed, then, by the hands or in-
struments of the physician, l»y the hands of the nurse and by
her implements, upon sponges, bed-pans and clothing, from
patients suffering from pueqieral fever, or any of the zymotic
diseases, and from various other sources.
Symptoms. — Puerperal fever is generally ushered in by
chilly Bensatit)us, or a well-defined rigor, on the second or tliirJL
day after deliyery; rarely later tlian the fifth day. The Byin|>-
toms vary greatly, according to the organs or tissues more jiar-
ticularly involved, but there is always elevati<m of temperature.
The Pathology and Treatment of Cliild-bed." TraiwlBtion, 187&
PUEBPEBAX FEVER,
627
ezUargement of the spleen, arrefited involatiou and seusitivenefis
of the uterus.
Following is a brief resume of the clinical features of the
local procenses:
Sympioms of Endomeiriiis and Endocolpiiis, — Uncomplicateci
catarrhal iutlanimatiou of the vagina and uterus is one of the
mildest affections to which the puerperal woman is subject, and
presents uo reliable symptoms, lix endometritis, involution is
retiu'ded, the after-pains are unusually severe, the lochia are
feii<l, and the uterus rather sensitive to p^e^isu^e. In eudocol-
pitis the discharge is thin and purulent, and imnation and def-
ecation are attended with }»ain and burning. If ulcers form at
the \-ulva, the labia ore swollen and sensitive. The temperature
in these cases seldom exceeds 102 ^ or 103 ^ . If the attack of
endi-unetritis prove severe, the discharge usuidly becomes brown-
ish and thick, but is sometimes quite serous, irritative and fetid.
The temperatuie may also rise to 104 ^ or 105 ^ .
When we proc-eed further we find that the symptoms of endo-
metritis and endooolpitis become merged into those of infection
of the whole organism.
Sympioim of Parametrttts, Perimetrium, and PeriioniUa. — The
symptoms which a<;company acute inflammation of the jjclvic
connective tissue are of great im portance. It Ls not ensy to dis-
tinguish between parametritis and perimetritis, l)ecauso the
pain associated with the former is generally oF sucli a character
as to indicate the implication of tlie peritoneum. In fact, it
must be very rare for one form to occur independently of the
other; and we accordingly include under the head of pai'ame-
tritis those cases, which, from the mmlerate pain exjwrienceii,
are more likely to belong there; while cases attended with in-
tense suffering, with evidence of limited peritoneal inilamma-
tiou, we include under the head of perimetritis and iielvic peri-
tonitia
Parnmeirifts usually sets in on the second day, the febrill"
symptoms being preceded by a rigor in some cases, while ii
others none is experienced. The temperature runs up quite rap
idly, and attains its height either on the first day of the attack
or the Bucceeiiing. It does not maintain a high level, but the
remissions are marked, and in some cases become real intermis-
628
THE PUERPEBAL DISEASES.
siona Occasionally the teniperaturo is at no time much abjve
a normal point; but generally it is highi and may reach 105 '^
and 106 o.
The pulse is usually accelerated to correspond with the ele-^
vated temperature; but ^^lleu the latter has remained low, the
former has, in some instances, been observed to become very fre-
quent— symptoms always to be regarded with Huspicion.
The pain experienced is a prominent subjective symptom, and
there is always sensitiveness to palpation, more especially on
one side of tlie uterus or the other.
Swellings are formed from infiltration of the cellolar tissue,
most frequently between the folds of the broad ligament, and
constitute the pathognomonic sign of the affection, disclosed by
conjoint touch* T^^e resulting tumor is not always lUstinct In
one case the exudation lies so closely to the side of the nteras
thiit the finger discovers only what npi>eare to be an uniismtl
thickness of the uterine structure on one side; and in anotb<:T
instance there is diflused exudation in the region of tlie intenial
OS uteri, extending backward, and thus almost eluding the feel.
The tumors nrf most frequently limiteil to one side, but in utii«>r
cases they are found on both sides, but differing in size. They
are often sitnnted so high as to be felt with the great^^st diffi-
culty, and this explains M'hy for so long a time they have l>eeu
overlooked, or at least their frequency been underrated. Occa-
sionally they extend so low as to encroach to a certain extent on
the vagina.
In somewhat rare instances the infiltration is especially ox-
tensive in (^ne iliac fossa or the other, in which case a vaginal
examination will not revefd its existence, but on al>dominal pal-
pation the tumor is felt in the situation alluded to.
After a time the contents of the tumors become more and
more inspissated, and in the space of a few weeks or monttis tyre
completely absorbed. Xlescirption of the exudation is accom-
panied with the symptoms of hectic fever; but in favoraV>le cas<«
lliese soon disappear, the temperature falls to a normal level, the
appetite returns, and health is soon restored. For n varying
period the uterus is drawn to one side and fixed; but these con-
ditions after a time disappear.
Besorption does not always take place, owing, in some
Mi
PUEBPEBAL FEVEB.
629
;kl the existence of external irrifcationB, and then the tumor rli-
sitniahea somewhat in size, becomes hard, and permanently
remains.
In comparatively rare instances suppuration ensues, the tu-
mor becomes soft and sensitive, hectic fever sets in, and after a
time the abscess perforates into the rectum, the vagina, tlie blad-
der, the abdominal cavity, or the uterus. Occasionally the pus
finds exit externally.
Pcrimeiriiis, — The symptoms of pelvic peritonitis so closely
resemble those of parametritis that the two diseases can scarcely
be distinguished; and» indeed, they are also clinically more or
less blended. Sharp pain, high fever, and tympanitic distension
of the lower abdomen are generally regarded as symptomatic of
inilammatiou of the pehac peritoneum. When these are well
marked, and the suffering is severe, should wo tirid, after the ab-
dominal sensitiveness has subsided, no objective signs of cellu-
litia, wo would be justified in regarding the case n^ one of ])elvic
peritonitis. Moderate fever, little pain and tympanitis, with
evidence of exudation into the pelvic cellular tissue, would be
goo<l gruuud for a iliagnosis of pure parametritis-
Perimetritis, or pelvic peritonitis, generally begins with slight
chilliness, or a marked rigor; but in some cases no such symp-
toms ore experiencetL Then follow pain and tenderness at tlie
sides of the uterus, accompanied with a rapid rise of tempera-
ture. These symptoms may continue for a time and tlien yield to
suitable treatment; or the.inllummation may extend and general
pt*rifnniiis follow. More frequently, however, the latter disease
arises from parametritis as a cousequeuce of pyiemic intoxica-
tion, in which cEise the early sympt»^ras much resemble those of
pelvic perit*:>niti8, but are more slowly developed The pain
increases in intensity, and is diffused over the abdomen; tym-
panitis is manifested, and may become excessive, giving rise to
dyspno-a; there is excessive sensitiveness tcj the least pressure;
and the most patient women give expression to their safferings
in cries and groans. After extensive exudation, the pain de-
creases in violence. Physical exploration is practiced with diffi-
culty^ but by means of gentle percussion we are sometimes able
to discover evidences of exudation, and mark its slow changes
of level upon turning the patient from one position to another.
630
THE rUERPEB&L DISEASES.
The febrile symptoms muy be slightly remittent, or tho flnct.
uatious of temperature extensive. Sometimes the temperature
follows ft very irregular course, rising in some cases to 106*^, and
in others it remains remarkably low.* The pulse is more ex»n-
Btaut, but it occasionally becomes rapid only toward the fatal
close of the disease. The pulse rises rapidly to 120, 130, or even
IGO beats per minute dnriug the actression and extension of the
inflammation. In fatal cases it becomes still more rapid, wliile
the temperature finally descends. Increased rapidity of the
pulse, occurring in connection with decline of the trmpcrnture,
is always a bad symptom. Tlie coimtonance has an anxious
expression; tlio forehead is cold and moist; the extremities are
also cold; and under s^anptonis of collapse the patient may sink
in a few hours.
Vomiting is usually present, though in some cases not eyen
nausea is experienced.
The mortality of puerperal peritonitis is very he-avy. Deatli
may occur in the early days of the attack, or even within thirty-
six hours.
When the disease terminates in recovery, the diffused exuda-
tion sdmetimes becomes eucapsuled, and the uterus agglutinated
to contiguous structures. These conditions may even then ulti-
mate in death, from suppuiation of the exudation, or the induc-
tion of a fresh attack of peritonitis. Even in favorable cases the
adhesions are apt to give rise to colicky pains, displacemeuts of
the utenis, and sterility.
Symptoms of St^ptk^cmia Lyinphaiica, and Vt>twsa, — Th^
septic infection will vary considerably in its manifestations ac-
cording to the channels through which it enters the system. In
■ Dr. Jncobi recently stateil Iwlbre the New York (.^bstetrirul S^Ractjr. tAm.
Jnur Obs., vol. xiv, ji, 12S.j, that ihe eleTutiou of tt'iupoTAturv vriu*. u very im*
pnrtuul nymptoiii, but tliitt hv bad lotit c'MntldL*m*r in U u« ouiMif tb« tniilD
.•iymiitomHol* |K*ritouiUs long iigo. He had seen n number of faUki catrs at
puritoDilis nitigiQir tbrough almost ever.v iv^e with rory little cleruUftu of trsi-
ptTiiturc up ti> tbo last lutiiute o{ Uf«. Hi^h ttmjterttinre wiw mor* tikfijf to bw
ttbitriit in crtju-f ir/wr** thrre ttttM lu'jttic poinomng. Il wus not iioeummon for m^p»1b
l-» lan n full course without an elo\*atcd temperature, or not nhnvt 101"= w lira*.
Dr Kminet snid at the same time, thftt the more maliiinunt thv form of p#r-
ilonitis. the more ceriaitilr would ever^' chorncteriatic saga he Ah«irnt, ant! ihat
this was due to blood poisoniiiK.
PUKBPEBAL FEVER.
631
a large proi)ortion of cases the lympLaties constitute such chan-
nels, and the sy mptoms which result are of tiie inobt pronounced
and dangerous kind. They appear Boon after labor and are
always introduced by a chill. The temi>ernture mounts to 104"^,
or higher, the pulse is small and freiiueut, the abdomen bec'i>raes
tympanitic, but not generally sensitiTe. dyspnoea is experienced,
and there may be bleeding at the nose. The perit'jneal effusion
is Hmall, or entirely wanting, the tongue is moist and coated, or
quite clean, and the bowels are sometimes loose.
In most cases the i)atient is drt)wsy, restless, and somewhat
delirious; she utters few complaints, and can only be induced to
give a rational response, by loud tones. She experiences a sense
of comfort, and has little idea of Iter low condition.
Pleurisy often forms a serious complication of the disease,
and is rarely single. It sets in witli the characteristic painsL
PericarditLs is not uncommon, but since it is usually dGvelojM'd
near the fatal close, its symptoms are generally overlooked. The
joints become the seat <^f suppurative inBaiumation, and the pain
and tenderness are often very great
The ]H*rcentapje of recoveries from ibis form of septic infec-
tion is sui^risingly small.
Venous sejiticiemia, or uterine phlebitis, arises from putrid
infection of the thrombus at the placental site. It sometimes
takes plat:e within twenty-four or forty-eight hours, but much
more frequently its invasion is insidious, and ap|>ear8 to develop
from a mild endometritis or parametritis. The rigor which
marks its approach is usually violent, — in some eases histijig for
hours. Tlien succeetl heat and perspiration, as in intermittent
fever, hut the temperature does not often snl>seqnently ilescfiid
to a normal level. The pulse usually xaries to corn'sj^ond with
the temperature.
Disintegration of the thrombus gives rise to omlx_ilism in dis-
tant organs, t^renting metastatic abscesses in the lungs, and otl»er
parta The temperature maintains a higher, and more constant
level, and the ])ulse bec»)me6 small and rapid. The patient be-
comes soporous, slightly delirious, has a dry skin and tongue,
■with a motlerately tympanitic alxiomen, though this last condi-
tion is often absent
The fatal result is usually posti>oned to the second or third
632
THE PUSRFErtAL DISEASES.
week, though it Bometimes occurs within the first few days. The
perc-entage of recoveries is Brnall.
Symphms of Pure Septic<pmi€i, — Experience has shown thai
in cases of iiitense septic infection deuth may take place in a
verj' bhtirt time, and that the post-mortem examination reveals
no other distinct chaiif^es than dark and nou-coagulable LUxkI,
and ecchymoses into various tissues. The temperature rises
rapidly, tlie pulse is nceelerated, the patient is delirious, and
afterward comatose, and death soon follows. In these cases the
vital forces are probably overwhelmed by the intensity of the
attack, before marke<l organic changes have had time to occur;
but we have other examples of what might be termed pure
septiciemia, followinp: n more protracted course, and yet evincing
no decided organic lesiouj?. A common instance of this is found
in tlio fever and other symptoms which result fixim the pre.so4ioe
in utenj of decomposing coagula or retained jjortions of the
after-birth. The treatment, wliich consists in the removal of
the offending substimces, is genendly followed by complete and
speedy disappearance of the unfavi>rahlo symptoms.
Preventive Treatment.— The conscientious physician should
not only himself adopt every reasonable precaution in his nec-
essary attentions to parturient and puerperal women tfv preveni
inoculation, or any foi'm of infection, but he should insist upoE
the ful(j]>tion, by others, of the strictest sanitary measures.
Tliat the neglect to do so resxdts most disastrously, has been dem-
onstratetl beyond a peradventure, while disinfecti<m has pi*oved
most salutary. The following statement of the results of ihe
adojttion of such measures in various maternities and hospitals,
where infecti^m is more especially ]i>oke<l for, must l)e couvino-
ing oven ti^ the most skeptical
Eraun von Femwald* reports 61,949 confinements, occurring
in sixteen years, in the Maternity Hospital of Vienna, out ol
which number there were 825 deaths from puerperal fever, a
percentage of 1.3. Dr. Johnston f reports from the Dublin
Rotunda Hospital, during seven years. 7,860 births, with H?,
deaths from metria, or l.OS per cent. WinckelJ reports for the
* " I^hrbuch der geaammtcn Gyniick/* p. 885.
t"ainical Reports," from 1870 to 1876.
I** BerichU uud Studicn," Leipsic, lfl74, p. 183.
i
PUEBPKKAL FEVER.
633
Lying-in Isfititation of Dresden 1.8 as the percentage of deaths
from metrift during 187'^, while in 1872 it exceeded 5 i)or cent,
the improvement being due to the exercise of greater prewiution
in avoid infection. In the Maternity Hiispital of Copenhagen
the mortality from metria, between 1865 and 1809. was *2.70 i>Gr
cent.; but between 1870 and 1874, Stadfeldt.* reduced it to 1.15
per cent. Dr. Goodellf repoi-ta, from tlxe Preston Hetreat, 756
cases of lalK>r, with only two deaths from septic disease. At Bres-
lau, out of 901 births, Spiegelberg J lost but 5 cases from puer-
peral fever. Buermann ij says that in the Hopital Lariboisi^re,
under M. Siredey, in 1877, the death rate was 1 in 145, and in
1878, 1 in 199; in tht* Hopital Cochin, under M. Polaillon, from
1873 to 1877, it was 1 in 108.7 ; and in the same institution in 1877,
there was but one death from puerperal causes, out of 807
dcliverieB.
The chief indications for effective prophylaxis are as
follows:
1. The prevention of tlie access of disease gerras, both before
and after labc»r, by the obsei-vance of antiseptic precautious. No
YOginal examination should be made without first subjecting the
hands to the action of soap and water, supplemented with tlie
nail-brush, and subsequently with a mild, carbolic acid solution.
The fingers should not be smeared with a lubricant which has
been stantUng o|>en in a sick nrnm, or int*^ wliich unclean fingers
have been thrust Cosmoline or vaseline should be used, \Jf
taking up some on the end of a clean knife-blade, and Tint by
putting the fingers into the box. Instruments should not be
used which have not l)een tlioroughly washtMl and disiufect-eii.
In hospital practice, or wherever there is unusual dantjt^r of in-
fection, it is well Ut place over the vulva, during labor, a cloth
well saturated with a disinfectant solution. After delivery the
utmost ch*anliness ought t<» l>e practiced. It is highly im]>ortant
that the soiled clothes be removed as soon as possible, the
Tagina carefully syringed out, and the vulva washed with a car-
* Les Mutt'Ttlities. leur nrganiKatiou ct adminiatnition." Copenli.ipen, 1976.
f "Oil thf Means Employed at the Prtstou Uelrcat for the Prevention nnd
TrcatraeDi of Pnerpernl DiBeasee," p. 13.
I " U'lirbuoh," p. 748.
4 " tteeherchcs sur la Mortalite des Femnie« en Couchea dans lea Hopitaux.**
Paris, ie7y.
634
THE 1»L'EK1^ERAL DISEA8E8,
bolic aci<l solutiun. The URpkins muftt be frequently changed.
We beliove aLwi that, iu uueiKuplicrattHl cases, uriuntieiD elioultl
be performed in tiie sitting pasture, wiiico tlie clots which form
ill the vngiim an* tluis, by tht*ir own weight, extruded. The
pationt's goneral aud special siirroundings should Ix^ of a sHiii-
taiy nature.
2. The dofitniction of iseptic genns wliich may have foiind en-
trance This win Iw^ lUme chieily by tht^ fret* use of autineptics,
more especially in the form of warm enemata— vaginal, and, in
some caHes. ut<*riue. Still, unless there are grave suepicione tif
the presence of disease germs, such injections j^hould not bo
often repeated,
8. The cli>sure of the open intra-nteriiif veiais, lymphatiiT«,
ttud, perhMjJs. Fallopian tuhes. 'To accomplish this, the utt-rua
most be induced to lirmly contiaot. The nie^isores and reme-
dies which favor such action have been mentioned in oilier
chapters.
Curative Trcatnieui.— The initiatory rigor we ai-e rarely
called uixm to deal with, inasmuch ha it is often libttent or but
light, and when severe, freijuently it is overl>efure we have time
t'j reach the beiLside. If we can cut it short by suitable medica-
tion, find other means, we ouglit t<i do so, inasmuch as the in-
tensity of the pyrexin, and the severity' of the suct^eedinj; or ac-
companying inHaniniatit)ns, l>e?ir n liertjun relation to the ilui-a-
tion of the rigur. During tlie chill, hrifotiia, vamphdro^ ftfrmHt\
vcratrtnn alhum. nr untrnicnw wlW probably l»e moHt suitable.
Hot drinks, nnd moderate 4juantitie.s of dijfutiible .stimulntitB,
may be given, while hot jars and bottles are applied to the body
aud extremities, and the amount of covering is increased.
As .HOtm an the reaction is established, aud the temperature
hoginp to rise, the choice of reuie«Hes will lie l>etweeu aconite^
iXfrairuTH vlndtu firllfukmnn aud arsmiemn. The indicatii»na
for acrniHv are. briefly, a drj', hot skin, agonizing resilee^neflB,
geneniDy intense thii^t, rapid pulse, anil HniJpreasetl lochia.
Vvrairnm viriilr has been used by -some pliy^toian^ and promi-
nently Dr. R Ludlam, for the pur|joRe of reducing the polae
and tempemture., it being given in every cnse when the teupera-
tnre goes above 102 ^ , and tlie puke is correfii^ntUngly acctf^ter-
ated Tlie special sjTnptoms regardeij as indications ft>r the
PUEBPEBAL FEVER. 635
remedy, are high temjjerature, and ftdl, rapid piilse. Arsenicnir.
is called for by extreme restlessness, burning pains, dry heat
with thirst, dry, parched lips, small, feeble pulse, and great pros-
tration. Belladonna: Heat, with moist skin, dullness and qui-
etness, excessive abdominal tenderness, suppression of the
lochia, redness of the face, delirium, sleepiness, without ability
to sleep, and generally little or no thirst.
Subsequent symptoms vary greatly, according to the local
lesion, and call for corresponding remedies, some of which we
give a little further on.
In those cases characterized by great prostration, witliout ex-
cessively high temi>ernture, wherein a profound alteration of the
circulating iluid has taken place, and reaction seems doubtful,
arHcnicum and secale have given most satisfactory results.
When peritonitis constitutes tlie most prominent localization
of the septic intoxication, arsenicum, bryonia, and belladonna
are frequently of service.
PalliatiTe Treatment. — For the pain of peritonitis in these
desperate cases it is inhuman to deny palliative measures; but
we should bew^are, in adopting thein, not to do our patient harm,
and materially lessen her chance of ultimate recovery. " For
the relief of the pain of peritonitis," says Dr. R. Park,* "poul-
tices have been prescribed as a routine. This is a practice, how-
ever, which the writer feels is highly dangerous, and cannot be
too severely dt^precated, as, if tlie pain l>e tlue to an incipient
peritonitis, it is amazing with what rapidity it spreads under the
fostering warmth of a hot poultice. Care mtist therefore be
taken to make as accurate a diagnosis ns possible of the cause of
the i^ain; but, at all events, to make sure it is not due U) an in-
cipient peritonitis. In cases where it can reastmably be con-
strued tt> be due to any other cause, as r, rj., painful and partial
uterine contractions, retention tjf lochia and <'lots, cellulitis, me-
tritis, etc., poultices vaW at once contribute to the relief of the
pain as a symptom, and, in some instances, to the removal of the
cause by resolution or su]>j)nrntion, etc. And, again, in cases of
comi)letely developed peritonitis, light and often-changed jwul-
tices are of infinite value for soothing of pain and promotion of
resolution under systemic treatment"
•"Glaf^!OW Mt'rtiral Jouriuil,'* Oct.. I^ho.
63R
PUERPERAL Dl
If the suffering in peritonitis is for a time extreme, we mny
regard the ndiuiuistration of morphia, preferably by hypoder-
mic injection, as justifiable; but if not unbearable, the prejudi-
cial effect of the drug should be avoided- In no case should its
use be long continued, and when once the disease is fully devel-
oped, poultices will afford sufficient relief.
Regimen. — The decided tendency of the disease to produce
prostration indicates the importance of sustaining the vital pow-
ers by an abundance of easily as^^imilated nourishment Various
forms of animal soups, strong beef-tea, and the yolk of eggs
beaten up with brandy, should he given at int-orvals of uc»t more
than two or three hours, in quantities as gi'eat as the patient can
well be induced to take. The digestive powers may be aided by
the administration of y)epRin- Nausea and vomiting are apt to
l>e j)rovoked by the ingestion of fo*Kl, though they frequently
arise without such an excitiug cause, and require medicati(»n.
Peculiar symptoms may point to particular and unusual reme-
dies; but those which are most likely to cx^ntrol the complica-
tion are arsemcum, bryonia, and ij>ecac,
A certain amount of stimulation will be found beneficial, but
it must be varied to correspond with the character of the symp-
toms present. When the temperature runs high, the pulse is
rapid and thready, there is much low delirium, tympanites, sweat-
ing and otlier indications of profound exhaustion, whisky or
braudy may for a time be given in teaspoonful doses every hour,
with good effect Larger quantities are sometimes used with
decided benefit
The Use of Antiseptic Iniection«.— When we have rea-son
to believe that retaint-d shreds of membrane, or adherent jM^r-
tions of the placenta, have given origin to the septic state, or
when there are evidences of ulcerative metritis, accompanied
with high temperature and the other familiar symptoms, intni-
uterine injections of a solution of carbolic acid have produced
decided improvement The favorable effect of such iujeclinnH
on the hj-perpyrexia is often most marked. When intra-uterine
injections are not indicattnl, or are thought to be inadvisable, the
vagina shouUl be syringed with n similar soluti<m. For such
injections a syringe like the Higginson or the Fountain, with
rUEKPERAL FEVER.
637
long tiibe should l>e used, as otherwise air is liable to l)e injected
into the uterine cavity, a thing always to be carefully avoided.
We look for favorable results from the hypoilermic injection
of phenic acid. The antiseptic effects of this remedy are un-
questionable, and its employment, according to D^ulat's method^
will doubtless prove most salutary.
Retained Fragments of Secundines.— HVliereitis suspected
that there is still in utero an rulheront placenta, foetid membranes,
a decomposing clot, or >'itiuted lochia, it becomes the physician's
first duty to explore the interior of tlie organ, and remove all
offending substances. To do this it will generally be ad>*isable
t<^> introduce ft>ur fingers, previously well smeared witli some
bland lubricant, into the uterus. This should be done under
anjpsthe^ia. Before removing the hand it is advisable to wash
out the cavity with a stream of warm cnrbolated water. If more
than two or three weeks have elapsed since delivery, but a single
finger can be introduced; but by means of that, with the half
hand in the vagina, the object can be effected. If tlie finger
cannot easily be introduced, the dull curette or small blunt hook
may be used.
Relief of Tympanitic Distension.— Tympanites generally
accompanies peritonitis, but it is often observed in connection
with other puerperal c<^^»nditions, and may require special atten-
tion. Arnica, lycopodiurn, china-, carbo vcg. (in ijoteney, or
charcoal in teaspoonful doses, ) or colocynih \\\\\ usually afford
relief; but should these remedies fail, a rectal tube mayl>e care-
fully introiluced, or tlie colon punctured in the right iliac fossa
with a large hyjwdermic needle. Before entering the needle,
a broad bandage should be passed around the body, so that
pressure may be brought to the aid of the paralyzeil bowels, in
effecting complete evacuation of their gaseous contents.
General Therapeutics.— .4cort//e.— High temperature, hard,
rapid pulse, dry skin, intense thirst, sensitive abdomen, shoot-
ing pains.
Arsenicum. — Burning, tlirobbing, lancinating pains; great
restlessness, anguish and fear of death ; thirst for frequent sips
of water, though they disagree; wants to be warmly covered-
Belladonna. — The pains are often of a clutching or clawing
638
THE PrEUI'EBAL DISEASES,
nature, though not always, ami come and go quickly. Sensation
of weight and bearing in the pelvis; tlirobbing hwidaclie, with
red face and eyes; raving delirium; lochia suppressed, or very
f(Ktid; the parts are exquisitely sensitive t<» the touch.
Bvifoniiu — Her eufleriugs are aggravated by the least motion-
She has splitting headache, dry, parched li|.>s, and considerable
thirst
Cfilcarca carb,--An occasional dose of this remedy will be
found beneficial in women of leucophlegmatic temperament
China. '\Y hen the attack succeeds jirofuse hemorrhage, this
remedy, unless previously administered, should always l»e given.
Creoiiofuni. — Is well suited to endometritis, with the usual
foetid discharges.
Kali vttrb. -The most marked symptoms of this remedy axe
the aiilrhimjj cutting, shooting, and darting pains. There are
great thirst and rapid pulse.
L«c/i<w/.s.— This is also well suited to endometritis. The hy-
jx)gustrium is very sensitive, and the lochia are foetid. She
always feels worse on awaking fmm sleep.
^Vn rom/Va.— The symptoms <.mly occasionally point to this
remedy. It should l>e given as anintr(Mlucti>ry remedy, if the
patient has been takuig drugs in quantities. Other sympU^ms
are heaviness and burning througli the i)elvic region; se\-ere
pnin in the liunbo-sacral regi(m; scalding and burning on urinat-
ing, with frequent desire. She is desjwndent, and sleej>less, or
has frightful dreams.
Rhus it KK —Ort^ixt depression of t lie vital forces crr^^ng oat
of the septic infection; delirium; dry tongue; extreme restless-
ness; cffejisive lochia; worse after midnight
SfVdle CO/*.— This remedy appears to be peculiarly well uidi-
cated in many cases of puerperal fever, and has rendei-ed good
service. The l(»chia are fcetid; the abilomen is distended, but
not vnry sensitive; and the urine is scanty. There are also of-
fensive diarrh(je»v deliiium, and sometimes vomiting.
Stilphur, — This excellent remedy shonld be udmtiiisterwl
in occasional doses, as it sometimes npjie^ars to gi\e point and
efticiency to remediesi well indicated by the pathology and symp-
lomatolog)' of the cass.
INDEX
Abdomen:
appearance of in pregnancy, liJ4.
pain in during pregnancy. :i52.
size of in pregnancy. 12(>, 157.
striaj ni>on in pregnancy. 134.
Abdominal pregnancy, 1(>5.
Abdominal muscles, action of in la-
lwr,281.
AMoramal tumors:
diagnosis of, from pregnancy. 149.
Abortion, 182.
artiUcial. 239, 2<i2. 42U, 514.
causes, 183.
dettnition of, 182.
diagnosis of, 192.
incomplete, 188.
moles of, 233.
symptoms of, 18*>.
treatment of, 194.
neglected cases of. 2U7.
of one fu'tus in twin pregnancy.
191, 2U*).
Abscess in mastitis, 004,
in phlegmasia dolens.o92.
suli-mammao'. (107.
Acci<lental iicmorrliage, 472.
treatment of. 47'>.
Accouclieiu-. armamentarium of, 2i«).
Acetabulum. 27.
Acephalus, 44'j.
Acrania, 44-').
Adlierent placenta. 5(t3.
After-pains. -')82.
Air, effect of entry into uterine ves-
sels, (iOO.
Air-passages, catheterization of in
asphyxia neonatorum, 510.
Albuminuria in pregnaticy, 244.
relation of to eclampsia, 346.
treatment of, 247.
Allantois, 94.
Amnion. 92.
anomalies of. 222.
dropsy of, 222.
Anenceplialus, 445.
Amniotic fluid. IK^.
excess of, 222.
deliciency of, 224.
Amputations, intra-uterine, 230.
Anaemia:
in i»regnancy, 242.
treatment of. 242.
Ansesthesia and amesthetics, 310,
:<27.
in eclampsia, <»1H.
in normal labor, 310. 327.
in o])erative midwifery, 328.
rules fiu" administering. iiiML
Anasiirca, maternal, 242.
Anchylosis of sacro-coccygeal joint,
:^4.
Animation, suspended, 508.
Antellexion, uterine, in pregnancy,
2.5S.
Anteversion, uterine, in pregnancy,
639
^H ^^^^^^^^^^^^^^H
^^K Antiseptic treatmeut of pueriittrul
^^^^^^^^^^^^^H
^H patients^ 636.
of pelvic brim, 43. ^^^^^^^
^H Aorta, compression of in post-p»r-
of pelvic outlet, 43. ^^^^^H
^^M tutu iiemorrtiago, Wt.
of pelvic canal, 43. ^^^B
^^m Arbor vittfr, m.
of parturient ctmal. 44. ^^^^
^H Area germinativa« 90.
Ballottemeut, U*}. ^^H
^H Area pelliicUla, 91.
Biisilaire, 2d. ^^^^
^H Area vaiiculosa, DI.
Hath of new-bom infant, 588. ^^^|
^H Ari-oUi.81.
iJaitledore placenta, 100. ^^B
^H chaiigeH of, in preiQ:naiicy, 133.
Bed, arrangement of for labor, 307, ^^H
^H secondary of Montgomery, 133.
Hinder, uses of. 323. ^^^M
^H Arm, preseittalion of, 37fi.
Hladder: ^^M
^H dorsal ilisplacemout of. 447.
calculus in, obstructing labor* 405. V
^H Armameularlumof obstetric physi-
dilatation of fcetal, 445. ^^M
^H ciaii.2U9.
Blastodermic membrane, 90. ^^H
^^H Articulationa:
Blastodermic vesicle, 90. ^^^H
^H pelvic, 31!.
Bliglited ovum, *J3&. ■
^^1 mobility of. in labor. 37.
Blood, changes uf, in pregnancy, 136 ^^^|
^^B relaxation of, in pi-egnancy. 37.
242. ^^M
^^M rupture of, :^.
alteration in after delivery, 575. ^^^|
^^1 Artideial n'spiration:
transfusion of, 545. ^^^H
^H Sylvester's method, 510.
Bluut hook, large, in breech present*- ^^^|
^H Marshall llall's metliod, .511.
tion, 54:2. ^^H
^H Si^hroedpr's method, oil.
small, in abortion, 306. ^M
^H Schiiltze\s method, fill.
B«)wels, action of, after delivery. 577, ^^H
^^H Howard's method, 511.
^^B
^H Artiticlal respiration lu asphyxia ne-
Breech presentation: ^^H
^^m onatonim, 510.
causes. 307. ^M
^H Ascites. fa'tAlt ubatructin^ labor.
conQguratiou of fcetal head in, 374. H
^H 446.
me<-hanlsm of . ,367. ^M
^B Asphyxia Tiennftti>nma. .^08.
thinners in, 366. ^^^H
^^M treatment of. rm.
rotation in, 368. ^^H
^^1 Astrin^enls, nse of. In poat-partum
forceps m, 530. ^^^|
^^1 hemorrhage, 409.
^^^1
^H Atony, uterine, in th« third atage of
aimlomy of. i¥), ^^^H
^H labor. 8!U.
anomalies itf, SO. ^^^|
^H Atresia, uterine, 401.
changes in during pregnancy, lSi,^^^|
^H Atrophy of uterine mucous mem-
diseases ^^^|
^H bi-ane, eauuing abortion. 144.
abscesses, 604. ^^^H
^H Attitude of tVetus, 111.
mastitis, 004. ^^^H
^H Anscnltalion. a.s a means of dia^jno-
pihkCtorrhcea, 602. ^^^|
^H sis of pregnauey. 146.
nipples, sore. 002. ^^^|
^H Auscultation, aa a means of diagno-
treatment of nipplea,6(Ki. ^^^^
^H 8ts of pobitiou and preseuta-
treatmeut of ma»titla. O))''- ^^^^
^M
Bregma, lOH. ^^M
^H AuHcullation. a^ a means of diagiio-
Brim of pelvis, 39. ^^^|
^^M sis of fwln preguancy, 121.
diameters of, 40. ^^^|
^H Auscultation, as a me^ms nf diaguo-
use of forceps at, 532. ^^^|
^^M sis of the aex of I'cetus, 1:^.
exti-action with head at. 376. ^^^|
INDEX.
641
Brow presentation, 365.
Oesarean section: 558.
indications for, 433.
preparations for, 560.
description of operation, 560.
prognosis of, as to the woman, 559.
prognosis of, as to the child, 559.
statistics of, ^9.
treatment after, 566.
post-mortem operation, 566.
results of, 567.
substitutes for, 568.
causes of death after, 558.
Cadaveric poisoning:
puerperal, 623.
Calcareous degeneration:
of foetus, 166,231.
of placenta, lOU.
Calculus:
vesical, obstructing labor, 405.
Canal, pelvic, axis of, 43.
of Xiick, 63.
Caput succedaneum, 292. 353.
Carcinoma of the cervix obstructing
labor, 402.
Cardiac diseases, complicating preg-
nancy, 266.
Caries of teeth in pregnancy, 253.
CarunculsB myrtiformes. 52.
Catheterization:
of bladder, .543.
of uterus, for premature deliv-
ery, 513.
of air passages in asphyxia neona-
torum, 510.
Cauda equina, 30.
Cellulitis, pelvic, 619.
Cephalic presentations, 333.
Cephalic version, 616.
mode of performing in transverse
presentation, 382.
Cephalalgia in pregnancy, 241.
Cephalotribe, 553.
Cephalotripsy, 553.
Cervix uteri, 62. [
artificial dilatation of for prema- ]
ture labor, 513. j
changes of in pregnancy, 127, 144. ,
atresia of, 401.
carcinoma of, obstructing labor,
402.
canal of. 65.
cysts of, 67.
mucous membrane of, 66.
glands of, 67.
rigidity of, in labor, 396.
incision of, 399.
lacerations of, 483.
1 lemorrhage from laceration of, 48&
Child:
asphyxia of, 503.
weight of, 104.
care of. 588.
Childbirth, mortality of, 672.
Chill, post-partum, 573.
Chloroform in labor, 310, 327.
in operative procedures, 328.
in eclampsia, 616,
effect of on pains, 329.
(*borea in pregnancy, 249.
Chorion:
formation of, 90.
permanent, 94.
villi of, 94.
degeneration of, 212.
Circulation of fietus, 104.
Cleavage of yolk, 89.
Clitoris, anatomy of, 48.
Coccyx, anatomy of, 31.
anchylosis of, 34.
mobility of, ai.
Coiling of funis, 226.
Colostrum, 589.
Commissures of vulva, 47,
Complex presentations. 385.
Cttnceptiou, 86.
Conllnement, prediction of day of,
156.
Conjugate diameter of pelvis,
true and false, in pelvic measure-
ments, 422.
Conjoined twins, 4S9.
Conjoint manipulation, version by,
519.
Constipation in pregnancy. 255.
Constriction, uterine, tetanoid, 400.
Continued fever in pregnancy, 369.
^H 642 ^^^" ^^^^^^^^^^^^^B
^^B (^uiitract^il peUis:
Crotchets, use of, 5.'i0. ^^^^^B
^^m dia^iosis of, 421.
Cystocele, obstructing labor. 104, ^^H
^^H labor iu . 42lt.
^^H
^H mmle of extraction in, 439.
cord. 227. ^^^B
^H Contractious, uterine* 278, ^1.
condurt of labor when complicated ^^^B
^^B vu^innl, 2SIK
by ovarian. 408. ^^H
^H Convulsions, puerperal, (JIO.
Death: ^^1
^H caiisfs of, 610.
apiiarent. of new-bom child, dOft. ^^H
^^K prognosis in, (113.
ffjctal. dia^tosis of. 15li. ^M
^^M treatment for. (il8.
real or appsu'out, of mother in pritg- H
^^1 Cord, ninbilical, liK).
nancy or lal)or, delivery of child ^B
^^B mode of l\iii^, 317.
in case of, 504i. ^^^^t
^^m unligutnred, 317.
sudden, of mother, in labor ao^^^H
^H[ di-essin^ of stump, oS8.
childbe<l. rm. "^^M
^^B coilitiK (>f< ^^•
Decapitation of f(BtU8, 385, SSS. ^^^|
^^K cysts of, ±.*7.
methods of, 5I>5. ^^H
^^H liemia of, i£i!7.
Decidua, 05. ^^H
^H stniouire of, 10().
retloxa, 95. ^^H
^^^^ manuRenient of, when about the
^^^H
^^^B
serolina. t)5. ^^^H
^^^H marginal insertion of. 100, 228.
sepaiation of, »6. ^^^B
^^^^H prolapse 4(VJ.
putlK>lu]k;y of. 20$. ^^H
^^^^F repotsitiun of, 409.
Decollator, &S5. ^^H
^^M tonsion of, 2'J'i.
use ^^^fl
^^K Cordiforiii uterus, 72.
Deformities, pelvic. 413. ^^^fl
^^M C<»rpu8 lutenm:
due to exostosis, 419. ^^^fl
^H
due to fi-actures, 421. ^^^|
^H fiiLse, »i4.
eontrartt'd ptdvis, 413. ^^^|
^H Corpus relU'ule, 93.
jx'lvis. 414. ^^^1
^H Cough in pn'unancy, 2S6.
fuiinel-sliapetl pehis, 417 ^^^|
^H Cramps in pregnancy, '26i.
N'aegele ohtiipie pelvis, 417. ^^^|
^^m Cranioi-hLHl, 552.
osteotualaoic i»elvis, 415. ^^^fl
^^1 Cmniotomy:
pseudo-oateouialacic pelvis, 416. ^^H
^^B eases requiring. .^9.
rachitic pelvis, 414. ^^H
^^M compnrutive merits of cej>haIotrii)-
Degeneration: ^^^B
^^H sy and cnuiioclasm. •>>!.
calcarei>us, of foetus. 168. :SI. ^^H
^^B deseription of ceptialotnp8y,633.
fatty, of fif tus. 232. ^^H
^^H frequetu-y of, 550.
hydatidlfonn, of chorion, 2]3w ^^^|
^^1 use of craniotomy forceps. 651.
^^^1
^^B perforators, .VX).
state of patient after, oTJt ^^B
^H metliod of pei-f orating, in head-last
contraction of uterus after. SJS. ^M
^^B ease». -144.
management of patient after, 5TS. ^M
^H contntsted with Ca'sarean section.
ner\'ous sbork after. .Ti-S. ^^B
^B
prHtlictiou of date of, ]5<V. ^^^B
^H crotchet in , 550.
sta.te of pulse after, f»74. ^^^f
^H Craniotomy forceps. 551.
weiiiht of uterus aflt-r, IS5, ^^B
^H Cranium, fi-etiil. 107.
post-mortern bv Osan^an sw-./Wft, ^^B
^H Gred(?'3 method of placental delirerv.
post-mortem through tutuial pa**^^^|
^^ S20.
sages, 50H. ^^B
INDEX.
643
Diameters of pelvis, 40.
of fcetal head, 109.
Diarrhoea in pregnancy, 255.
Diet, of the lyiug-in, .585.
Digital examination in labor, 801.
Dilatation, manual, 301, 3f)9.
Discus proligerus, 7S.
Diseases, etc., complicating pregnan-
cy:
abdominal pains, 252.
albuminuria, 214.'
anemia, ^2.
breasts, painful, 252.
canliac diseases, 266.
cephalalgia, 241.
chorea, 249.
constipation, 255.
cough, 256.
cramps, 254.
diarrhoea, 255.
displacement of uterus in, 258.
dyspna'a, 256.
endometritis, 208.
eruptive fevers, 268.
face-ache, 241.
haemorrhoids, 25<>.
hysteria, 250.
hydatidiform mole, 213.
insomnia, 242.
leucorrh(ca, 252.
ouilarial fever, 26!K
paralysis, 251.
pneumonia, 260.
pruritus, 241.
ptyalism, 24U.
rubeola, 267.
side, pain in, 252.
syncope, 271.
Byphilis, 271.
toothache, 253.
typhoiil fever, 268.
varicose veins, 257.
vesical irritation, 256.
vomiting, 137, 2:i6.
Displacements of uterus, 258.
Double uterus, 71.
Douglas, cul-de-sac of, fW.
Douche, vaginal,
for premature delivery, 514.
in puerperal state, 579.
Dropsies of foetus and membranes,
complicating pregnancy, 229.
Ducts of Miiller, 71.
Ductus arteriosus, 105,
Ductus venosus, 105.
Dystocia from foetus, 434.
Dyspnoea in pregnancy, 256.
Eclampsia:
clinical history of, 610.
etiology of, 610.
pathology of, 610.
prognosis in, 613.
treatment of, 613.
Ecraseur, use of for foetal decapita-
tion, 555.
Ectoderm, 90.
Electricity:
in vomiting of pregnancy ^ 238.
in extra-uterine pregnancy, 178.
EIytrotomy,170.
Embolism, 59t*, (i21.
Embrj'o cell, 89.
Embrj'o, delinilion of, 101.
Eml)ry*», development of, 101.
Embryotomy. .>>5.
Emesis:
in incarceration of retroilexed uter-
us, 260,
in pregnancy, 2:16.
Eudochorion, 04.
Endocolpilis, puerperal, 61S.
Kiidoinetritis.puerperal, 61s.
Endometritis in pregnancy, 20S.
Ent4»<lerni. i»0.
Epileptic convulsions, iti:!.
Episiotomy, 314.
Erirol, mode of administration. 1H4.
Eruptive fevers in pregnancy. 26s.
I'^rysipelas:
rt'lation of to puerperal lVv*'i*, 624.
Ether, use of, :^29, ImO.
Euslachian valve, IO-k
Evisceration, o-Vi.
Evolution, spontaneous, 379.
Exaniinatiou of parturient wtunen,
301.
Exanthemata in pregnancy. 2(»s.
Exochori4»n, *M.
^^^^^V 644 ^^^^^^ ^^H
^^^^^^H Exostosis, pelvic deformity from,
appearance of, at various stages^
^^^^H
development, 1f»2. H
^^^^^H Expelling powers of labor, 278.
circulation of. 104. i
^^^^^^H Kxpressioti of pliiceiita, 320.
changes in position and presenta-
^^^^^^H Extraction of f(jetu3:
tion during pregnancy, 113,
^^^^^^^§ in CEesorean section, 564.
position and attitude of, in uteiv,
^^^^^^^t in pelvic presentAliuns. 369, 375.
Ul-
^^^^^^^H in real or upparentdeatb of mother
cranium of, 107, j
^^^^^^^B in pregnancy or labor, 5ti6.
weight of, at term, 104. H
^^^^^^^m head . 375.
diagnosis of position of, 11& H
^^^^^^H Extra-uterine pre^ancy, 104.
by palpation, 117. H
^^^^^^^L abdiimiual variety of, lb5.
' by auscultation. 110. H
^^^^^^^B titl>a1 variety of, 166.
by vaginal examinatioQ, 115. ^B
^^^^^^^P interstitial.
viability of, 101. ^^M
^^^^^^H
dropsies of, 22». ^^H
^^^^^^ft tubo-abdominal, 168.
nutrition of, 93. ^^^B
^^^^^^^B tubo-ovarian,
of. 1.50. ^^H
^^^^^^B* treatment
deformities of. 445. ^^^B
^^^^^^H Face preseikUtion, 335.
paLliology of. 22S. ^^^H
^^^^^H
abdominal enlargement nf, -M^^^B
^^^^^^^B diuRTioKis
congenital hydroceplialus of,442ifl
^^^^^^^^ft mechanism of, 365.
fatty degeneration of, :£i2. H
^^^^^^^m mcnto-p(tsterior positions in, 8&1.
extraction of: H
^^^^^^^H io, 3410.
by breech, 540. H
^^^^^^^H conti^iiration of bead iD, 380.
in breech and foot preeentAtio^|
^^^^^^H treatment of, 3U2.
WJO. 375. ^
^^^^^^H Fallopian tubes, 73.
in craniotomy, ft50. fl
^^^^^^H Palse labor-paiu», 1^, 3M.
with forceps, 634. H
^^^^^^H Fatt> de^neration of ftjetus, 232.
heart-sounds of, 1 19, 121, 146. ■
^^^^^H Fatty defeneration of placenta, 219.
hydrothorax of. obstructiizs Ub^|
^^^^^^H Fecundation. 86.
444. ^^M
^^^^^^H
large, 446. ^^H
^^^^^^H oialariHl, in pre^ancy^ 2U0.
. maceration of, 232. ^^H
^^^^^^H milk, pieguancy, 5S0.
monstrosities of. 445. ^^H
^^^^^^^1 typhoid, in pregnancy, 2H8.
movements of, 141. ^^H
^^^^^^^m in pregnancy, 'JiH.
mummilication of. 2S1. ^^^fl
^^^^^^^B relapsing, in pregnancy, 208.
retention of. dead, 180, 231. ^^H
^^^^^^H puerperal.
syphilis of, 1^. ^B
^^^^^^^H
tumors of, obstrurttng Inbnr, 4^|
^^^^^^B diflerential diaRTiosis of, 148.
viability of. 104, h>% ^^B
^^^^^^H compUcutiug laUtr, 406.
violence, effects of on, 229. ^^^B
^^^^H
Follicles, Gruaaan, 77. ^^H
^^^^^^H use of, in breeob presentations. 640.
Foiitauelies, lus. ^^H
^^^^^^^^ use of, in version, 623.
F(H>lling pre-sentatian, 372. ^^^fl
^^^^H Flfxir, pelvic, 61).
Fommen ovale, 10^5. ^^H
^^^^B Foeces. impacted, obstructing labor,
otiturntorj^. ^^^H
^^^H
sacro-sciatic, 38. ^^^|
^^^^B
Forceps: ^^^|
^^^^H anatomy and physiology of, 101 .
action of, 530. ^^^B
INDEX.
645
application of, 534.
varieties of, 532.
head at or above the brim, 532.
head in pelvic cavity, 533.
or outlet. 533.
in occiptto-posterior
positions, 537.
to after-coming head, 510.
to breech, 539.
ceplialic mode of, 533.
pelvic mode of, 532.
in face presentation, 539.
craniotomy:
description of the operation, 534.
history of 525.
long, 52G.
in connection with rigid os, 399.
removal of the blades, 536.
short, 326.
salient features of, 528.
use of ansesthetics in connection
with, 533.
in uterine inertia, 393.
varieties of, 527.
direction of traction with, 535.
placenta and ovum, in abortion.
204.
Fornix, vaginal, 55.
I>>ssa navicularis, 52.
Fourchette, 52.
Practur**s;
causing pelvic deformity, 421.
intra-uterine, 229.
Fimdus uteri, 62.
Funis:
path<»logy of, 225,
care of stmnp of, 588.
coiling of. 22»».
cysts of, 227.
lientiiis of. 227.
knots in, 225.
marginal insertion of, 100, 228.
prolapse of, 4<}5.
Piuses, 407.
diagnosis, 4(i8.
prognosis, 467.
treatment, 4(>9.
stenosis of vessels of, 228.
torsion of, 22(}.
ligature of, 317,. 588.
Funnel-shaped pelvis, 417.
Galactorrhoea, 602.
Gastrotomy:
after uterine rupture, 482.
in extra-uterine pregnancy, 178.
Gastric derangements of pregnancy,
236.
Gastro-elytrotomy, 570.
(fastro-hysterotomy,55S.
Gelatine of AVhaiton, 101.
Generation:
anatomy of female external organs
of, 47.
anatomv of female internal organs
of, 61.
Genital (ranal:
ruptures of, 316, 478, 483.
uterine atresia of, 401.
Germinal (or germinative) vesicle,
78.
Germinal (or germinative) spot, 78.
Gestation, duration of, 151.
(Tlands, mammary:
anatomy, 80.
changes in produced by pregnancy,
132.
Glands, sebaceous, of uympha;, 52.
Glands, uterine, 67.
Glands, vaginal, 57.
Glands, vulvo-vaginal, 52.
(ilans c^liloridis, 4S.
Graafian foUicles, anatomy of, 77.
Graafian follides, physiology of, 83.
Gravidity, signs of, UO.
llajmatorele, ()b^tr^u•ting labor, 4a*t.
Ilamionlioids, in pregnancy. 25«i.
Hand, dilatation of os witli, :i91, 399.
Hand, manner of introducing in po-
dalic versittn. .")2I.
when t(» introduce for delivery of
placenta, i"»(K».
Head, fo'tal:
anatomy of, 107.
diatnt'tt'is of. UK».
various positions of. .":U.
presentations of. HI.
application of fon-fps to:
hi hcad-lirst cases. 'u'A,
G40
INDEX.
in head-last cases, 540.
configuration of in various pres-
entations and positions, 361,
360, 365, 373, 425.
at brim, forceps to, 632.
ill cavity, forceps to, 533.
at outlet, forceps to, 533.
clian^e of position of, by manipu-
lation, 537.
cliange of presentation of, by ma-
nipulation, 362.
flexion of, 344.
rotation of, 344.
extension of. ;Uf>,
restitiition of, 346.
scalp-tumor on, 292, JW3.
iulluence of sex on size of head,
110.
Headache in pregnancy, 241.
Head-last deliveries:
treatment of arms in. ri7.^.
breathnig space for foetus in, 373.
forceps in, 373.
Heart:
diseases of in pregnancy, 26(>.
changes in, wrought by pregnancy,
i:t(i.
Heart -sounds, ftetal, lUl, 121, 14t>.
Hcniopliilia. 4^7.
llt'iimri'lia^^^i':
accidculal, 472.
{•oiiccalcd iiilcrual, 474.
cxlcnial. 474.
trcatiin'iit of. 475.
tVoin crrvica! hicpratioii, IS"^.
from \(>nlpiilar ia(;fiation.4S9.
in alunlinii. I.s7.
in (!!:i('r!it;i pnrvia. 401.
po^t-paruiiii. is.-),
v;ii:('lit's of. |s.">.
catlM'S iif. iMi.
constitutional itredi-^posilion to.
4s7.
incnioniioi'v symptoms of. 4s'.i.
pn>i:iHt>is of. lici.
preventive Irealnieiit I'f, 4it:[.
• ■"Ueeiiled. I'-'U.
c ii-ealed, spurious. \U\.
<-iii;iiive treatment of, H).j.
compression of uterus in, 496,
497.
various modes of exciting uterine
contractions, 496, 497.
post-partum, secondary, 492.
treatment of, 500.
unavoidable, 449.
Hemorrliagic diathesis, 487.
Heniia:
of cord, 227.
of pregnant uterus, 2&4.
Hook:
blunt, large, 642.
blunt, small, 206.
deoitpitating, 555.
Hour-glass contraction, 502.
Hydatidiform degeneration of cho-
rion, 213x
treatment of, 217.
Hydramni(»s, 222.
as cause of tardy labor, 224.
clinical history of, 222.
treatment of, 224.
Hydrocephalus of foetus, 442.
as cause of tedious labor, 442.
conduct of labor in, 444.
Hydrorrhcea gravidarum, 211.
II>ih<iliu)rax. ftetal, 444.
IlNirieue of pregnancy. 'Zi-'i.
Hymen:
anatomy of, etc.. 51.
as an obstacle to delivery, 406.
Ilypertropliv of uterine muctms
membrane as a cause i.>f abort it m.
Is.').
Ilypoilermic injections, nuhle of giv-
ing. ■>43.
Uysicria during prejinaney. 254».
II\stfroti>my, vaginal. 4oi.
gastro, .'mS.
Mia. anatomy of, 2S.
Ilio-saeral syneliondrosis, Xi,
Impregnation, 8t>.
Incarceration:
of retroUexetl uterus. 2ti0.
Inertia of the nirrns. ;i^y.
treatment of. :;;ti.
Infant:
apparent death of. -'Ais.
INDEX.
647
new-bom, first attentions to, 558.
changes in circulation of, 105.
umbilicus of, 588.
Infectious diseases complicatiug
pregnancy, 2G8.
Injuries during pregnancy, 1254.
Injections:
hot water intra-uterine, for hem-
orrhage, 4i)7.
styptic, intra-uterine, for hemor-
rhage, 499.
in puerperal septicsemia, 636.
vagiucil, to produce premature la-
bor, 514.
to prevent auto-infection, 579.
hypodermic, method of giving, 54:>.
Innominate bones, 2t>.
Insanity:
of lactation, 595.
of pregnancy, 137, 593.
puerperal, 594.
transient mania, of labor, 593.
Insert io vahuuentosa, 100.
Insomnia in pregnancy, :i4:i.
Intra-pelvic muscles, 7!».
Inversion of uterus, 'liH.
Involution, uterine, 57"i.
Iron, injection of in i)()st-purtum
hemorrhage, 4!)1).
Irregular uterine contractions, dur-
ing labor, 400.
after labor, 501.
I»chia,planes of the, 45.
Ischia, anatomy of, is.
Joints:
movement of pelvic, in labor, :i7.
prlvic, 'A±
Kithieys. pathological cliauges of, in
eclampsia, 611.
Kiestein, i:^.
Knots of the funis, 22.5.
Knee presentation, avAi.
Labia majora, 47.
commissures of, 47.
oedema of, 243.
thrombosis of, 40:^.
minora, 60.
Labor:
abdominal muscles, action of in,
281.
anaesthesia in, 310, 327.
care of the woman after, 323.
causes of, 273.
contractions, vaginal, in, 280.
contraction of uterine ligaments
in, 2H0.
contratrtions, uterine, effects of, in,
278, 281.
duration of, 296.
diagnosis of, 3U3.
expelling powei-s, action of, 278.
has it begun, 30.'J.
liour of, 2!)7.
management of normal, 29S.
mechanism of, :i32.
induction of, 512.
in occipito-anterior position of
vertex, 34:*, »48.
in occipito-posterior position of
vertex, lU'X
in meuto-anterior positions of face
presentation, 3(n.
in mento-posterior positions of face
presentation, 357, 361.
in lu'ow presentation, IH>>.
in breech presentation, 367.
membranes, rupture of, in, 308.
missed, IH).
rational manag(>ment of, 298.
obstructe<i by uterine polypi, 406.
ol»structed by maternal soft parts,
:{!tii.
jiains of, character and source. 281,
pains, inlhience of on the organism,
2sO.
plicnomena of. 2S:{.
pains, falsi*, 2s4, ;io4.
posilit)n of patient during. 307.
pr('rii)itale, 3M*.
preliniiiiary |»rcparations for, 298.
pniloiigcd, ;{89.
protecrtioii of perineum in, 312.
protrarted. :iS9.
luematurc, 1S3. <
modes of inducing, 512.
stages of, 2.s;i.
648 ^^^^" ^^^^^^^^^^B
swelling.Oiffuse obstructing. -400.
Malaeobteon, as a eanse of pelvic d^ H
preiDoiiitory symptocub of, 384.
formity.42U. ■
pulse <lurinj^,l»G.
Malarial fever in pregnancy. 209. ^^^t
Uwraiteulics of , 324-
Mulfonnationfi of child, 445. ^^M
tedioii.s, :^8n.
Mamnne: ^^^|
tide, rclalirm of. to hour of. i!W;.
abscess of, OOL j^^H
uterine iigiuueuts, contfraction of,
anatomy of, 80. ^^^|
in,l^o.
auomaliea of, 80. d^^H
uteriue conlractiona in, 278. 281.
changes of in pregnancy, 132. ^^^|
\veak.:iSJ*.
scrfeti(»n of milk in. 5hu. ^^^|
Laceration:
pain in, during pregnancy. 258. ^^^|
ofwrvl3piiteri,48a.
Management of labnr« 208. ^^^|
of gonitul I'anal. 483.
Mastitis puerperulis. 6&4. ^^^|
of p(^rineiiiu, 310.
Mania, puerperal, oiKt. ^^^H
of iiteruH. 47H.
Manual dilatation of os, ."^1 , ^m. ^^H
of vestibule. 4&4.
Marginal insertion of cord, 100. ^^^H
of vesaels, 4.S8.
MealuH nrinarius, .50. ^^^|
LarijUion:
Measles in pregnancy, 307. ^^^|
t(L*i('riiv« Kecretion of milk \n„ tMM.
Mechurtism: ^^^|
L ttXLTHsive Heoretion of piilk in. 00:1.
of labnr. ;«2. ^^M
t fever of, .580.
abnurrual, in vertex presentatiuna. H
^^^ insanity of, ol^.
mi ■
^H iiiL'aiiH of arresting Becretion of
abnormal, in face presenutions. ■
^^M Uiilk in, o^.
35J).
^H I^iparo-elyti-oloiuy, o70.
occiplto-anlerior positions of
^H I*itparotuuiy, 17s, 4si>.
vertex, :i12,34.s.
^H LeuRorriKi'A in prfgnuucy, ^252.
occipito*pogt positions of
^H Lever (vectiA), .S4I.
vertex, 343.
^^H Leverage action of forceps. Sil.
of fiM-e prc'^' ■ ' ■•■ '••^. 355,
^^m Llptments. pt^lvie, Ho,
of bi-c^ecli I' Its. 306.
^H uterine. U3.
of brow preM iinit-iis.S'.W.
^H eontractions of tii labor, 280.
of transvLTse presentations, 875.
^H Linea alba, in pregnimcy, 142.
MelanctioUain pw?gnancy, 137.
^^H Liqtmr aiunii. iKt. 101.
.Memlnanea.artilicial rupture of, 308.
^^M anonialiea of. 225,
arlitii-ial riipHire of, to prevent
^H Lint*, ilto-pectineal, 27,.*{9.
piisl-parlum litu^«rrhagi?. 4WS.
^H Litliopffidion. Iti6, 174. 1H2.
pnnr'tnreof, to induce labor. ^12,
^^H Loehia:
puncturiiof, in aecidfulal lM>m<DT-
^^B vurtLHl clnirueter^ of. 67!^.
rluige, -(70.
^^M vuriiition in uniouut and duration
puncture of. in placenUi prmvla»
^H
450.
^^ft L<ickijig:
spontaneous nipture of, 261.
^^ft of ctiildT*en in multiple pregnancy.
MembiHue, blastodermic. W).
^K
Menstruation:
^H Lnmbo-sarral arliculation, 80.
ceftsation of. 14*'
^^1 Lying-in ix-riud, duration of, tj^.
during pregnancy. 141.
^^H J^ymplmtirs lit litems, inilammution
corpus luteum of. bi.
^H of. in piien^^'i')^! fever, 030.
Mes(HhMm,9l.
^^1 M:m^ration of fuaub, 2^2.
MeLiitiH, puerperal, 619.
^^^^^^^^^^^^^^^^^tNDEX. 649
n
^^^Milk:
Nymphffi, 50.
^J
^H defective secretion of, 601 .
sebaceous glands of, 60.
^^^1
^H exceaaive secretion of, 602.
Obliquely contracted pelvis, 417.
^^H
^H appearance of after delivexyi 560.
Obstructed labor, from—
^^^1
^H means of arresting secretion of,
abnormulities of foetus, 434.
^^^1
^1 582.
arm. dnisitl displacement of, 447.
^^^1
^1 Milk-fever, 580.
agglutination of 09 uteri, 401.
obliteration of cervica canal,
^^^H
^1 Milk-leg,. 58i>.
^^^1
^H Migration of ovum, 86.
401.
^^^^
^H Miscarriagv, 182.
ascites, foetal, 445.
^^^B
^m Hissed labor, ISO.
overloaded fietal bladder, 445.
^^H
^H
cystocele, 404.
^H uf aburt ion , 233.
conl, coiling of. 226.
^^^B
^^m cumtMituH, 233.
fteces, impacted, 405.
^^^M
^H sangniuosn, 233.
librous growths. 4O0.
^^H
^H hyOjitiUironn, 213.
liydrocephalus, fa'tal, 442.
^^^H
^^1 true and false, 2113.
hydrothorax, fa.»tal, 444.
^^H
^^H treatment <if, 23:<.
hymen, unruptured, 40fi.
^^^H
^^m MonHtroaitiea, 2:il, 44o.
monstrosities. 445.
^^^1
^^B Mon» veneris, 47.
from pelvic defonnity, 413.
^^H
^^m Montg(»mery, secondary areola of.
piMiueuui, rifiidity of, 410.
^^H
^H
pregnancy, multiple, 436.
^^^H
^^H Morning sickness, 137, 236.
rigid OS uteri, 3lW.
^^^1
^^H Mtfnsus (lial)oU, 73.
tumors:
^^H
^H Mortality of i-liild-1>ed, 572.
ovarian. 40H.
^^^1
^^H Mt'vi'ments, fietal. Ml.
uterine, 4(W.
^^^H
^^M Muooiis memlMune of utervis, 66.
twins, locked, 4.18.
^^^1
^^P Mnller'H ducts, 71.
Obturator ligament, 37.
^^^1
^V Multiple proKnancics. VM.
Obturator foramen, 27.
^^H
^H arrangement of membranes in, i3.i.
Occipito-posterior positions:
^^^1
^^H dingnosis of, 121.
difficult cases of. 34!».
^^^1
^^V causes of, 41^.
abnormal mechanism of, 350.
^^H
conduct of lab<ir, 436.
forceps in..j.'{7.
^1
inalwrtion, I'Jl.
conversirm of. Into anterior posi-
^^H
locking of children in, 489.
tions. :i.'»2.
^^H
Mumuiinculi'm, tVctal, 231.
Odontalgia, in pregnancy, ^TiS.
^^H
XiP^Me obliijoe |>*'lvis. 417.
<Ederaa:
^^H
Nausea tif pregnancy, 137, 230.
associated with eclampsia, 240.
^^^1
Navel, chanwtvrM of. in pregnaiK-y.
in pregnancy, 2W.
^^^1
i:i4.
of vulva, in pregnancy, 243.
^^^1
Navel of new-bom child, .388.
Oophoro-hystereclomy, 5iiS.
^^^H
N«r\'fs of uterus, 00.
Operations:
^^^H
Nervous sIkk^U after delivery, 573.
C'ajsarcan section, 558.
^^H
NiMiraluiu iu pregnancy, 311.
craniotomy, 549.
^^^H
Nipples:
embrjotomy, &>i.
^^^1
> cluingcH in during pregnancy, 132.
Forceps, 52'>.
V
depressed, 1(01.
for producing abortion, 230, 282,
H
sore, r«2.
420, 514.
H
Kntrition of fcetiLs, 93.
for inducing labor, 612.
■
1
J
G50
IKDEX
Porro's, 668.
Thomas', or Uparf>-el3rtrotomy, 570,
catbeterism, 543.
Organs^ generative, 47.
female^ auatomy of, 47.
changes in produced by pregnancy,
123.
OsttM.»malacia as a cause of pelvic de-
formity, 420.
Osteophytes, 136.
Ossjk innominata, 20.
L)9 uteri, VitL
auuluUnulioii uf, 401.
dllutatiou of in labor, 289.
causes of, 289.
imprisoned anterior lip of, in labor,
311,402.
Blow dilatation of iu labor, 397.
391.
manual dilatation of, 391, 399.
instniim-iUnl diluUtionof, 309.
riffidily of, 30tJ.
Os tinm'. »1J.
Ovarian:
pregnancy, 165.
tumors obstructing labor, 406.
Ovaries:
anatomy of, 74.
pliysiology of, SI.
escaiw of ovum from, 83.
tumors of in pregnancy and partu-
rition, 408.
vessels and nerves of, 79.
Ovaro-hysterectomy, 568.
Ovid»ict3, 73.
Ovuhition. 83.
Ovimj or ovule:
anatomy of, 78,
poBt-fecundativo changes In, 80.
escai>e from ovary, b3.
discus proligerus of. 78,
germinative spot itf, 79.
genninative vesicle of, 78.
migration of, 8o.
puthology of, :iOS,
prcmjilure expulsion of, 182,
Begmontation of yolk of, S9.
vitelline membrane of, 78.
vitcUusof, 78.
yolk of, 78.
Kona pellucida of. 78.
blighte<l,233.
Ovum and placenta forceps, use of,
aw.
Pains:
after-, 582.
in al)domen during pregnancy. 2.52.
irregular or inefficient in labor,
391.
labor, 381.
weak, 391.
effect of chloroform on,32B.
r*!il]>Htiou, alMloininul, tat a means of]
diagnosis of position and pre9-^
entation, 117.
Paralysis in pregnancy, 2-51.
I'ai*ametritis.r,i9.
Tarturieiil canal, axis of, 44.
Pathology:
of decidua and ovum, 208.
of pregnjuicy, ItW.
of labor, 388.
Patient, how to approach. 299.
Pntient^sbed and dress, 3U7.
Pelvis:
measurements of, 40.
exU'nuil,41.422.
internal, U. 422.
moile of taking in Hvbtg subject,
422.
in.struraents for. 4i2.
method of taking with the baud,
422.
deformity of, 413.
anatomy of, 25.
divisions of, 39.
differi'nce l>etween male and fe-
male, 46.
axesuf, 4^t,44.
movements and relaxAtlOD of joints
of during labor, 37.
ligaments of. 35.
causes of deformity of, 420.
MuUiction of premature labor in 6^
formity i»f, 426.
induction of abortion in deformity
of, 42»i.
^^^^^^^^^^^^^^^^^ ^^^^^» 651 ^^H
^H turning and forceps in deformity
positions of , 335. ^^^|
^1 uf, 429.
mechanism of, 368. ^^^|
^H craniotomy In deformity of, 432.
dangers in , 36tt. ^^^B
^H funuel-ahaped, 417.
use of forceps in, 539. ^M
^H CffiHarean section in deformity of.
mode of extracting head in, 375. H
^m
mode of applying the forceps, fi;i2. ^_^B
^H uniformly mntracted, 4ia.
Penttiform ruga;, 66. ^^^|
^H flattened^ 414.
Perforation: ^^^|
^^m flatt4^ned, generally contracted,
inatruraents for, ."viO. ^^^B
^H
extraction of cliUd after, 651. ^^H
^H imiformly enlarged, 413.
Perineorraphy. immediate, 411. ^^H
^H infantiU; ly[K) of, 418.
Perineum: ^^^^
^H mechanism and modes of delivery
incision of, in labor, 315. ^^^^
^H in deformed pelvis, 429^ 432,
laceration of, in labor, 81H. ^^H
^H 438.
support of. in labor, 313. ^M
^H prognuBiB of, 425,
rigidity of as an obstacle to labor, H
^^M planeB of, 42.
410. ■
^H nu^hitic, 41d.
rotten, 410. ■
^^M tmilacofit<H>n, 41*5.
Peritonitis: ^M
^H effect of deformity of on pains,
diffuse, 621. ■
^M 424.
[M'lvic, 620. H
^H obliquely contracted, 417.
puen^eral, 620. ^M
^H deformity uf ii.s a cause of prolapse
I'lii'uomena uf labor. 283. H
^H of funis, 467.
PblebitiB, uterine and para-uterfne, H
^M Robert's, 418.
■
^H effect of deformity of on presenta-
Phlegmasia alba doleiis, .^80. H
^B tion, 424.
IHithisis in pre^ianry, 270. ^M
^H effect of deformity of on labor, 424.
I'hysiciaii, atltniiance of, on puer- ^|
^H deformity of brirn u£ aH a cause of
peral women, oKV ^^^H
^H uterine traumatism, 425.
PtacenU, 96. ^^M
^H spondylolisthetic, 419.
apoplexy and Inflammation of, 221. ^^^^
^H deformed by—
anatomy of. IM. ^^^|
^H absence of symphysis, 420.
physiology of, 96. ^^^B
^H exost4>sis, 41<.>.
pathology' of, 90. ^M
^H f]:acture8,42l.
battledore, KHJ, 22S. ■
^H osteomalacia, 420.
delivery of, 320. H
^H rachitis, 420.
artiticial separation and removal H
^V sacral flattening, 417.
of, 502. ■
sacral curve, 417.
changes preparatory to separation, H
tloor of, .50.
KHJ. H
inclination of, 41.
expression of, 319. ^M
soft parts of, 47.
detachment of in normal labor, H
Pelvic:
294. ■
deformity, 413.
degeneration of, 219. H
cellulitis. Olfl.
development of, 90. ^^
organs, functional disturbance of
functions of, 99. ^^^^
in pregnancy, 1S.5.
inflammation of, 221. ^^^M
peritonitis, 620.
pnevin, 449. ^^^|
presentations, 360.
varieties of, 4*W. « ^^^|
^^^H ^^^V 653 ^^1
^^^^F tubo-lnterstitial, 168.
paraly8iain,251. ^^H
^ tubo-ovarian, 166.
pathology of, ItM. ^^^^
^^m fAC6-acbeiu,241.
percussion in, 145. ^^^^^^H
^H fevers, continued. In, 268.
permanent changes of, 138. ^^^^^H
^H foetal heart-fioundB in, 119, 121, 146.
phthisis in, 270. ^^^^^H
^H fundus, height of at varioua stages
pneumon ia in , 269. ^^^|
^™ of. 158.
protracted, 1.S5. ^^^|
r gastric disturbances of, 137, 236.
permanent changes of, 138. ^^^|
1 hemorrlioids in, 2&6.
pniritisin,24]. ^^^^^M
1 headache in, 241.
ptyalism of, 240. ^^^^H
^H history of symptomfl as data for
quickening in, 141, 157. ^^^H
^H dia^osis of, 144).
nibeola in, 267. ^^^|
^H hygiene of, 235.
scarlatina in, 268. ^^^|
^H hydraMnia, in,24;{.
side, pain in during, 252. ^^^|
^H hysteria during, 230.
signs of, 140. ^^^1
^^^ injiu-ies during, 2M.
spurious, IdO. ^^^|
^^M insalivation in, 240.
surgical operations during, 265. ^^^|
^^p insoiniLia in, 242.
syncope in , 251. ^^^H
^r inspection of the signs of, 141.
syphilis in, 271. ^^H
^K interruption, premature, of, 182.
tootliache in, 253. ^^H
^^M In rudimentary comu of a oue-
touch, vaginal, in, 115. ^^^|
^^m horned ut«rus, 170.
twin, diagnosis of, 121. ^^^H
^^M leucorrliiL'a 1u, 2^.
typhoid and typhus fevers compli- ^M
^^M maculse In, 138.
eating, 268. ^^H
^^^ malarial fever in, 2S0.
urine, characters of, in, 138. ^^^|
^^M mammary changes in, 132.
uterine displacements in, 2i8. ^^^|
^^P mammar}' pains in , 252.
uterine bruit (souffle), in, 147. ^^^|
management of, 235.
uterine textural clianges in, 125. ^H
mania in, 137.
uterine subsidence near close of ^^^|
melancholia in. 137.
^^M
mensti-ual suppression in, \M>.
nteras: ^^H
menstruation during, 141.
intermittent contractions of, as ^M
moniing sickness of, 1.S7, 236.
a sign of, 143. ^^H
movements of foetus in, 141.
prolapse of, in, 127. ^^^|
multjpk', 4^4.
change in size, etc., during,12fi. ^^^|
conduct of labor In, 436.
vagina, changes in, in, 132. 144. ^^B
diagnosis, 121.
varices in, 257. ^^^H
frequency of, 434.
variola in. 2G8. ^^H
locking of foetuses in, 438.
vesica] irritation in, 256. ^^^^
varieties of, 434.
vulva, changes in, in, 1.^ ^^^|
nausea and vomiting of. 137, 236.
without menstruation, 140. ^^^|
navel, changes of, in, 1"U-
Premature labor, 18:), 512. ^^^|
nervoua system, effects of, on, 137,
nipple, clianges of, in, 132.
l^emature labor in pelvio defonui- ^M
ty.426. ^^
(Bdema in, 243.
operations, surgical, in, 286.
in paralysis of preg.£5] . ^^H
osteophytes, formation of, in, 13fi.
Preparations for Uibor. .Ki?. ^^^|
OS uteri, changes of, in, 127, 144.
Presentotions, 111, 33i^ ^^H
palpation for diagnosis of, 143.
etiology of, 111. ^^H
^^^^ 654 ^^^^^P ^^^^l^^^^^H
^^^^H difference between presentation
definition of, 617. ^^M
^^^^H and position 1 14.
classiacation of lesions of, 618. V
^^^^B diagnosis of, 115.
nature of, 61 7. ^^U
^^^H pelvic, 306.
pathological anatomy of, 61& ^^H
^^^^H causes of, 367.
septicemia in, 617. ^^H
^^^^^P extradition of head in, H7o.
virus of, 62:i. ^^^|
^^^^M configuration of head in, 373.
c<mtaKium, how conveyed, 625. ^^B
^^^^1 liberation of arms in, 373.
clinical history of, GJti. ^^H
^^^^H positions of, 33fi,
causes of, 623. ^^^|
^^^H brow, md.
pleurisy in, 631. ^^H
^^^H face, 3od.
diphtheritir patcliea in, 619.
^^^^1 positions of, 333.
symptoms of eudocolpitis and of
^^^H causes of, 35<i.
endometritis In, 627.
^^^^^ forceps, iise of, in. o39.
symptoms of general peritonitiain.
^^^^H form of head in, 360.
029.
^^^^1 dia^osis of, 116.
symptoma of parametritis in, 627.
^^^H mechanism of, 355.
symptoms of perimetritis in, 629.
^^^H conduct of labor in, 362.
symptoms of septicaunia in, 632,
^^^H footling.
pericarditis in, 631.
^^^^B normal. 341.
erysii^eltts, how related to, 6^.
^^^^H uhntirmul, 341.
diet in, 630.
^^^^H slioulder.
treatment of, ^^^|
^^^^H podalic version in, 383.
preventive, 632. ^^H
^^^^1 cephalic version and forceps in,
curative, 634. ^^H
^^^1
palliative, 635. ^^H
^^^^^1 transverse, 375.
intra-uterine injections in, 6SB. ^^^|
^^^^^1 in twin pregnancy, 121.
vaginal injections in, 636. ^^^|
^^^^^1 complex , 385.
poultices in, 635. ^^^^
^^^H vertex, 342.
tympanites iu. 637. ^^H
^^^^H positions of, 833.
Puerperal mania, 593. ^^^B
^^^^^T diagnoHis of, IIK.
Piierpf>ra1 state, ^^H
^^r cause of preponderance of, 34iJ,
management of. 322,572. ^^H
^H Primitive trace, 91.
pulse in, 574. ^^^^
^^^ Prolapse;
bowels in , 586. ^^H
^^^^L of funis, 405.
temperature in, 675. ^^W
^^^^P of gravid uterus, 263.
visits of physician in, 585. V
^^^f Propulsive stage of labor, 292.
diet in, 58.^ ■
^H Pruritus in pregnancy, 241.
hygienic considerations in, 584. 1
lochia in, 578. ^^H
^H Paeudocyesis, 150.
after-pains in, 582. ^^^B
^H Ptyalism in pregnancy, 240.
getting up, time for, in, 588. ^^H
^H Pul>ea, anatomy of, 28.
uterine involution in, 576. ^^^|
^H Pubic arch, 20, 32.
uterine mucous membrane, ^^^|
^H Pudendum, 47.
changes in, 577. ^^^^
^H Pudcndi , rima, 50.
milk fever in, 580. ^^^H
^H Puerperal diseases, 589.
urination in, 585. ^^^H
^1 Puerperal eclampsia, ( vide eclampsia. )
sec^retion of milk in. 580. ^^H
^■^
means for arresting. 582. ^^^|
^H Puerperal fever, 617.
skin, condition of, in, 574. ^^^|
^^^^^^^^^^^^^^^ ^^^^^^ ggg ^^m
^H phenomena immediately succeed-
Sacrt>-iliuc articulation, 33. ^^^|
^M ing deliver)', 578.
Sacro-cocc> geal articulation, 34. ^^^^
^B vaginal douches in, 579.
anchylosis of, 34. ^^^|
^f vaginal changes i ii , 578.
Salivation in pregnancy, 210. ^^^|
^^ Pulmonary thrombosis, am.
Sapriemia, 617. ^^^H
i Pulse, Stat© of, after delivery, 574.
Scarlatina: ^^^|
^ft during labor, 286.
in pregnancy, 268. ^^H
^1 Pya?raia, in puerperal fever, 617.
in (jnerperatity,624. ^^H
^H Quickening, 141.
.Scyljulio ob.stnicting labor, 405. ^^^|
^H time of its occurrence, la?, 157.
Section, Ciesarean, 5o8. ^^^|
^M Rachitis, deformed pelvis from, 420.
post- partum, 566. ^^^|
^H Rectocele, 405.
Secret! on ^^^|
^H Kectiun, impaction of forces in. 4a5.
lacteal, deficient, 601. ^^^|
^M Repercussion, {vide ballott^ment,)
excessive, K02. ^^H
H
salivary, excessive, t^. ^^^|
^1 Repositor, uterine, 2fl2.
Segmentation of yolk. 89. ^^H
^H Respiration:
^^^1
^B artificial, methods of, for foetus.
Septicaemia: ^^^|
^1
in puerperal fever, 617. ^^^|
1 Restitution, movement of, 346.
channels of septic absorption, 623. ^^^|
^^ Retention:
auto-genetic and hetero-genetic ^^^|
^^ placental,. 'M'i.
forms of, 623. ^^^|
^1 foetal, ]uu.:Sl.
sources uf infection. 623. ^^H
^m urinary, 585.
treatment of, ([A2. ^^^M
^^ Retroflexion of gravid uterus, 350.
^^^M
\ Retroversion of gravid uterus, 25fl.
fcetal, diagnosis of during preg* ^^^|
^K Rigidity:
^^^1
^H of OS uteri, 306.
inlluence of, on size of fcet^il head, ^^^|
^M of periMPum, 410.
^^M
^H Rima pundendi, 50.
Shoulder presentations: ^^^|
^1 Rotation of fcetus:
mechanism (»f . 376. ^^^H
^M in vertex presentation, 293, 345,
pddalic version in. 383. ^^^H
■ 349, a52.
cephalic version and forceps in, ^^^|
^H in face, 358.
383. ^^M
^M in breech, 368.
Sinuses, closure uf, in puerperal ^^^|
^H Rubeola, in pregnancy, 267.
^^M
^H Rupture:
SkM^plussnesH, in pregnancy, 242. ^^^|
^M of perineum, 316.
Small-pox, in pregnancy, 268. ^^^|
^M of utenis. 478.
SoulHe, uterine, 147. ^^^|
^m of vagina, 483.
Spermatozoa, 87. ^^^|
^M of vestibule, 4^.
course of to point of fecumliiliuti, ^^^|
^M Sac, amniotic:
^^H
^f puncture of in extra-uterine preg-
Sphincter vaginie, 55. ^^^|
nancy, 177.
Spondylolisthetic i>elvis,4lf). ^^H
injcctiouH into, in extra-uterine
Spontaneous evolution and expul- ^^^|
pregnancy, 177.
sion, 379. ^^^1
Sacnim, anatomy of, 20.
Spot, germinative, 78. ^^^|
muvemo.nt of in labor, 37.
Spurious pregnancy. 150. ^^^|
^ mechanical relations of, 33.
Stages of labor, 283. ^^H
H 656 ^^^^^^1
EX^^^^^^^^^^^^^^^^^^^^^^^^^^^^H
^^m Stat«. puerpHt'iiU
mode of applylng^S^^^^^^^^^^B
^^^^^ management of, 57i;.
in abortion, 196. ^^H
^^^^^ pulse
in placenta prievia, 457. ^^^|
^^^^1 temperature in, 575.
tu induce labor, 514. ^^^H
^^^^H visits of pliysician in, Aa5.
Temperature after delivery, 575. ^M
^^^H dietiu, 58.5.
Tetanoid coostriction of the uterus, H
^^^H lochia in, 57a
400. ■
^^^^H after-pains in, 58t2.
Thrombosis: ^^^^
^^^^^1 closure of sinuses in, 577.
periplieral venous, 5Nii. ^^^|
^^^^B condition of skin in, 574.
cUiucal history of, 589. ^^^|
^^^^^H uterine involution in, 575.
treatment of, 602. ^^^^
^^^^^1 milk fever in, 5fS0.
puerperal, ^^^|
^^^^^M urination in, 58(i.
causing collapse and death, SWl ^^^|
^^^^1 Becretion of milk in. 580.
of vagina, 403. ^^H
^^^^H phenomena inimodrntely succeed-
of vulva, 403. ^^H
^^^^H in^' delivery, 573.
TooLluiche in pregnancy, 253- ^^^|
^^^^F vaginal douches in, 579.
Torsion of cord, 22(i. ^^^|
^^V Stenosis ot umbilical vessels, 22d.
Touch, vaginal, in pregnancy and ^M
^^B Stethoscope, maimer of using, 1-lti.
lal>or, 115, 301. H
Trace, primitive, 91. ^M
^^^^ Strait:
Tractions, on forceps, ^^^H
^^^^K superior. 30.
direction of, 635. ^^^H
^^^^H
time for making, 535. ^^^H
^^^^H inferior, 39.
on fa?tal b«>dy . 432. ■
^^^V
on tiead in delayed expulsion of H
^B Striae of pregnancy, \M.
slioulders, SKi. ^t
^H Styptics in post-portum hemorrhage.
Transfusion: ^^^|
^H 490.
of blood. 545. ^^^H
^H Snperfecundation, 435.
mode of performing. 546. ^^^|
^H Sui>erfcetution, 4.^5.
of milk, 548. ^^H
^^M Surgery, ohstetric, 612.
Transverse pn^sentatinus, S76. ^^^|
^H Surgical operations during preg-
causes of, ^^^H
^H nancy. 'Jiin.
pof^itiouB of, mi ^^H
^^^ Suspended animation, 508.
treatment of, 381. ^^H
^H Snturea of fo-tal cranium. 108.
^^H
^^H Swelling, diffuse, obstructing labor,
presentation of, 375. ^^^H
^m 406.
eximlsion of, 379. ^^^H
^H Symphysis pubis, 32.
Tubal pregnancy , liW. ^^B
^^H absence of. 41^1.
Tubes, Fallopian, anatomy of, 73. ^M
^^H anatomy of, 32,
action of tlieir (Imbnated ex%reml« H
^^a Symphysotomy, 570.
ties. 74. ■
^^B Syncope:
Tumors: ^M
^H in |tregnancy, 2Si,
dilTerential diagnosis of, from H
^^t in puerpcralit>', (iOO.
pi*eguancy, 149. H
^^M Synchondrosis, ilio-sacral, 33.
fcetal. irausing dystocia, 445. ^^B
^H Syphilis in pn^gtimtcy. 1*71.
osseous, deforming pelvis, 419. ^^H
^H Syringe, hypodermic, manner of
ovarian, in parturition, 408. ^^^|
^^m using, 543.
pnnunetritio, in puerperal fever, ^M
^H Tampon, 198.
1>2S. ^^1
IKDEX.
657
fibroid, in labor, 406.
phantom, 150.
Tunica albuginea, 75.
Turning, (ride version), 616.
Twins:
diagnosis of, 121.
conduct of labor with, 430.
locking of during birth, 438.
conjoined, 439.
in abortion, 191.
TympaniteH:
In puerperal fever, G37.
Typhoid and typhus fevers in preg-
nancy, 2(>8.
Umbilical cord, 100.
knots of, 225.
torsion of, 220.
coiling of, ^0.
ligature of, 317, 588.
prolapse of, 465.
hernia of, 227.
anomalies of insertion of ,100, 228.
dressing of, 588.
early and late ligature of, 3lM.
cysts of, 227.
marginal insertion of, 100. 228.
non-ligation of, ol7.
stenosis of vessels of, 22S.
Umbilical vesicle, 92.
Umbilical vessels, stenosis of, Z2H.
Umbilicus:
changes of, in pregnancy, I'M.
of infant, 5S8.
Unavoidable )ienit>nliage, 449.
Uni'mia an*! ecUunpsia, (HO.
Urethra, 60.
Urinary calculus, obstructing labor,
4('5.
Urine, peculiarities of during pn»g-
nancy, VoH.
albumen in, during pregnancy, 244.
necessity of drawing before using
the forceps, fii^A.
passing, in puerperal ity, 685.
Uterine:
elevator, 202.
Bouilie, in pregnancy, 147.
inertia, 389.
fluctuation as a sign of pregnancy,
145.
tumors, obstructing labor, 406. et
Uterus:
anatomy of, 61.
anomalies of, 71.
axis of gravid, 258.
ante version and anteflexion of, 258,
atrophy of mucous membrane, as
a cause of abortion, IHl.
bicornis, 72.
body of, 62.
cancer of neck of, complicating la-
bor, 402.
cannon-ball contraction of, 488.
catliete^ization of, 513.
cavity of, 64.
cervix of, 62.
contractions of, in pregnancy, 143.
contractions of, in labor, 278, 281,
clianges in cervix uteri,
during pregnancy, 127.
conliformis, 72.
corpus of, 62.
changes in form and size, 126, 157.
changes in situation, 127.
changes in tissues of, 126.
development of, 70.
dimensitms of, 01.
displacements of, during pregnan-
cy, 258.
double. 71.
fundus of, 02.
gland s of, 67.
hour-glass contraction of, 502.
height of fundus of, at different
stages, 120, 157.
hernias of gravid, 2()4.
hypertropliy of nuicous membrane
of, 185.
inclination of gravid, 127.
injections, into the,
tif hot water, 497.
of styptics, 499.
antiseptic, 6H6.
ituTliaof, :iS9.
inversion of, 504.
treatment of, 506.
658
INDEX.
involution of, after labor, 575.
laceration of, 478.
cen'ix of, 4s3.
ligaments of, 63.
lymphatics of, 70.
manual compression of, after and
during labor, 322.
mucous membrane of, 06.
muscular fibres of, m.
nen-es of, 09.
perforation of, from pressure. 479.
prolapse of gravid. 'M\.
regional division of. (i2.
Felations of, in advanced pregnan-
cy, ia5.
retroversion of gravid, 259.
retroflexion of gravid, 2^19.
rupture of, 478.
clinical history of, 480.
causes of, 47J*.
conduct of cases of, 480. |
septus bilocularis, 7:;. '
size of , at various stages of preg-i
nancy, 2<i, 157. |
Bituation of, change in during prog-
nancy, 127. ,
tumors of, complicating lab(»r. 400. i
tetauoiil const ricTiim of. 4(Mi.
utricular glands of. li".
unicornis, 71.
V(':^sclsor, G8.
wci.LTht of. after delivery. 12o.
Avails. lliicUness <if at close (tf i^es-
tation, 120.
Vagina:
anatomy of, .>|. '
chan^^es of. in pre^niancy, i:i2. 144. '
contraclion itf, in labor. 2m1.
ectliinuis of, "jfj.
dniil)li'. 71. I
glands of, 57.
exaniinaiion i)\\ ll.->. ;;(H.
Uu'cratioii of. 4X\.
sphincter of. .Vi.
orilice of, .',0. ."m.
tanipnn of. l!(s. i.-jt. .')l i.
thnnnhns of. -Jo:;.
walU of. .V),
niMcons nieinhraiie of. .y*.
Vaginal douche to induce labor, 514.
in puerperal state, 579.
Valve: Eustachian, 105.
of foramen ovale, lOtt.
Varicose veins in pregnancy, 257.
Variola in pregnancy, 208.
Vectis: action of, 541.
I use of, 641.
Veins:
varicose, in pregnancy, 257.
entrance of air into, as a cause of
sudden death after deliver)-. *iOU.
Vernix ciuseosa, 104. 588.
Version:
cephalic, 510.
bimanual, external, 516.
by conjoint manipulation, 519.
conditions favorable for, 516.
conditions calling for, 515.
anaesthesia m, 521.
choice of hand to be used, 5:!1.
in deformed pelves, 430.
in placenta prn^via, 461.
in tmnsvenM! presentation, 382.
in prolapse of fiuiis, 472.
in rupture of uterus, 481.
useof hllotin,o2;t.
neglected, 884.
podalic, 517.
podalic, external method, 518.
podalic, coiutjined external and in-
ternal, 519.
po<laIie internal. 520.
position of patient in, 518.
spontaneous. .'17!*.
\'ertex, :{42.
presentation, nieelianisni of. :i42.
eonlignration t»f head in, presen-
tation (tf. :\rA.
Itositions of, :i-i;t.
Vesicle:
Mastoderniic, 90.
gernilnative, 78.
uiuhilical. 92.
V<'sical irritation in pregnancy, 256.
vesical ilistension of the fa'tn.s,4l5.
Vesico-uterine ligaments, tiH.
\'esical calculus. 4lt-"i.
INDEX.
659
Vessels:
collapse and death from entrance
of air into, 600.
umbilical, stenosis of, 228.
Vestibule, 60.
bulbs of, 53.
glands of, 50.
laceration of, 484.
Viability, fcetal, 104, 155.
Villi of chorion, 94.
Visits of physician to puerperal pa-
tient, 585.
Vitelline membrane, 78.
Vitellus of ovimi, 78.
Vitriform body, 93.
Vomiting, of pregnancy, 137, 236.
in retroflexion of the uterus, 260.
Vulva, 47.
changes of, in pregnancy, 182.
oedema of, £13.
thrombus of, 403.
VulTO-vaginal glands, 52.
Weak labor, 389.
Weight;
of woman, increase of, in preg-
nancy, 138.
of fcBtus at term, 104.
of non-pregnant uterus, 125.
of uterus after delivery, 125.
Wharton's gelatine, 101.
Wounds of foetus, 229.
Yolk of ovum, 78.
Zona pellucida, 7ft.
Zymotic diseases:
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by their perusal.
"The work prcscnta the latest pnthologicfil data, the moat practiciil method
of troiUiiiff disoase lionui'opalhirally. nml u criliciil anwlysla of cuch cose
rclatf!fl. It is cminontly priictical nud dcnmnda llif iii*« of'wcll proved reme-
dica." — From the Unhnetnafimmi Monthly. Philarttlphin.
It conlaina the very l>C¥t and niDst rcliiihlp clinicnl experience in the nrac-
ticeof UonKUDpalhyof any work cjctaal iu Ihe profession. — yl. B, Snuill, M.
D.t ttttfie Chiciif/a Trifntnt.
I have CHrf?f»illy read the work nnfl hardly know whether I admire more,
the plain ihoroiiifh prt!holoj;:y nml diairnoj^is, or Ihe prnelicHl common sen?e,
honest irvatmenl set forlli. * * The Notes nf Dr. Ludlam ure in keeping
with our best Anu-rican aulhoi-ship— J". P. Dike, M. D.. NashtiUe. Tt-nn.
The book is of (^eal value to praclitionerfl and students of medicine- — «A.
W Dotclittg, M. I)., Dfiin uf the Neio York ITomtropiitKif Mfdieal CoUfyt,
I have reatl the work with ti ffreat deal of interpi*t and find it lobe eminently
practlcul. and of great value to the profession. — T. O. Comatoek, M. /)., 3i.
Xaitis, Afo.
I have sivnl eon m(I or able lime In examining Dr. Ludlam's translation of
Jouaset's Clinical Modieim* andrannot speak ton hi;?hly of it- Itfdls a place
In our literature whieli hnA hitherto always hrcn vacant — U. C. C'lapp, -U, i>..
Editor of the New Eiif/lmnf MftliaU Oazttte, BomU/h. M<u$,
GROSS & DELBRIDGE, Publishers,
49 MadUou St.. CHICAGO.
Mi
GROSS & BELBRIDGE'S Pcblicatioss.
Antiseptic Medication, or Declat's Method. — By Nicho.
Fkancir Cooke, M. D., LL. D. Emeritus Professor of TLe-
cry and Practice in the Hahnemann Medical College and
Hospital pf C^hicago. 128 pp. 12 mo. cloth, lb82. Price «LO(l.
Gross & Delbridge, Chicago, Publishers.
Thia is the first, and must continue to be for some time, the
only treatise on this -vitally important subject, in the English
language. It is plain ami practical. Though written only for the-j
physician, it cannot fail to attract attention from the intelligeul
layman every where. Especially will it be welcome to the sufferers
from CoNsiTMPTiiiN, Cancer, Pv.€MIa, Nbchosis and all forms of
blood-poisoning, and Malabuv.
For the matter of thiR volume Iir. Cooke confe»M>fl his l(irp« iQdebt«dn«as
Dr. D^trlat; but tlii* romarkable coivh of iubcrt^uIwU, fnnnT. ^'r''
cczpiuii, ftnd malftrial fevers rvcnnU'ti in the luttci li.ilf of thi* hook '
ori^nal. The only trwitise on the subject iu the lun^uavre. it must ;
full umJer tht* eye of every iutvUi>;ent phy^ieiuii, \iud the present i
therefore! Im? liniitetl to u deseripttoo nf its conteut«. Tht-se consist ni
duetion, which uol more lucidly «et» forth the leAchinpt of D^ciiil tiiaii it et-j
feetually UemoliKhes the diiiru^ fif his rivals, Leumire nud Lister; sonic renmrki
on I iintis«*ptie?t in genenil. jjiviug prcferrnce to phenie acid atu\ th?
protochloride of iron prejmred aecordinic to Houdreaux's method; Hnd un ex*
uniimiti'jn of phenie :u'id, both iu its rheminil uud ther.tpeiitit >' "'
gid»-.s nil this, we hIiV^? directions for the use of the [lyiKNl.-rni
l.'Lst, i\iu\ luutit intereiitiu^ of all to the hiity, whocuie llllh liO(\ i i
full aceonnt'* ijf 11 nunil>er of cases that have Iwen siiceess-fnlly tre:r
met IumI of IhVlal. The averjifre niKlicnl niun. who is inorr likely t.
OiirH to the voice of the sa^e than to tlie soii>£ nf the slreu, vilt.skiut ti):ht)]^
over the eases of cancer, and nay in Win eiisy, auiierior way. Ihnt not one of thna^
was a cjwe of true (yintrer. He will certjiiiily say this lo his own y.^
whose enliv^liteiinient it uuiy be well to mention that Dr. Cooke imih
Pnitessorof r>ia;:nosis. Ur. Cooke Im-^ be*'n wfindi-rfully fortiiu»l<- m m-
nf the iit-w n*niedy. hut he has thi< candor lo ;uhuit that he liufi not alwnji
Iktu victoriuufl. — The Chimgo Tribune, HvitL lltU, IWSJ.
" Anttaf ptic McdicAtion ■' in a muAll Tolnmc by Dr. N. F. Cooke, of the Hahne-
mann Mcilical rt)!lcye of this city, avowedly u incalisc on the thror>- and lurtho '
of Dr. D«^ehil, a recent visitor from the old world, which h:»VM rtiir.ieirtl » tri
deal of attention of late. It is pretty penemlly safe to - i
exaciLienition in almost anythio}! whieb lakes au sudden
enlhu!4iihsm, hot it most be said, front ha^itily ruuuinK Ihion^ * imiki _^ uu*
Vance shoots, that he makes out a pretty siroiic ease. * » -i •
Tlie subject-matter treated of in Dr. Cooke's iMtok Ijelom-^ c->i.rtM:inv i,. ilta
medical profession, and the volume can warcely fail to 1h
t/)all of that pTofeftsion not "hidebound,*' iis it is called, in i
It 14 clearly the work of an earne»t, thoii^l)tl\il, and MJtciittiic uiau, «•««!*
If nolhins else wa* known of the nnthor. — Chicago Timai, >*ept. llth, 19S2.
Sent free on receipt of price.
GROSS & DELBHIDGE, PiiblLsliers,
48 Madison St., CHICAtiO.
GROSS & DELBRIDGE*S Poblicationb.
Bow to Feed the Sick; or, Diet in Disease. By Charles
Gatchell, M. D. Second etiition, revised and enlarged.
12 mo. 160 pp„ 1882. Price $1.00.
This \vork is a very practical and timely volume not only for
those who are sick, but also for those ^vho are not really well, and
to whom the problem, "What shall I eat/' is of vital importance.
As introductory, the various forms of animal, vegetable and
inorganic foods are considered and their relative merits carefully
pointed out. The Chapters that follow are devoted to such prac-
tical subjects as IIow to feed yonr patients. Diet for Dyspepsia
with aids to Digestion, Diet for Constipation, llectal Alimenta-
tion, etc.; Diet in Consumption, Diet in Diabetia. Bright's
Disease. Gravel ; How to nurse the Baby, How to choose a Wet
Nurse, IIow to wean the Baby. How to feed the Baby, Diet for
Cholera Infantum. Diet for Travelers, Seasickness, the Corpulent,
Scrofula, Rickets, Scurvy, Chlorosis, Collapse, RheuraatiBm,
Asthma. Heart Disease. Alcoholism, Diarrhcea. Dysentery, Chol-
era, Diphtheria, Gastritis, Biliousness, etc. Diet for convales-
cents is a valuable chapter. Then follows a long and carefully
prepared list of recipes for the preparation of Beverages, Meats,
JBrothii, Soups, Breads, Gruels, etc., etc.
MlI.WAL'KKE. Witt.
•*I considtT your work on "Flow to Feed llie SU'k" to be the most
'pructioiU. uihI llienjforo tlio most useful, work on lliu subjcrt with wliicJi I
ftni aci|iiainLed. No physician should be without il; every nmihrr should
lave It.
Il is in use in uiuny uf the huusehuldif in wliidi I prac-tirc."
C. C. OJ.M^T^;D, M. D.
"This work is plain, practical and vuhmMe. It is renlly n cliniont ^iiidc
nn diet, nnd one the profc.Hsion will find rtliablc and correct." — I'niUtifitnU*
Medical Iiiceatit/utifr.
"Evidently much [nveMigntion. thought and carefulness have entered
Into the produrtion of this work, and we bejiev« it to be worthy a pitice in
every household." 3hf. Mugnet.
* * • "We hfivt* ciirefiilly exnminrd the work and shnll cheerfully
recommend il for fumilv use. The directions ub to what food und driults,
und modes of preparation are very judlrious." • • • • *
JanentiUe, Win. Resp. Yours, Dr. G. W. CHirncNDE.N a Bon.
Mti>w\L'Kr.K, Wis . Sept. 8. 18H0.
"Professor Gatcheirs "How to Feed the Sick" is the bef»t bonk on (ho
'fiUbjcct for the people. Il contains in I'M) pnges an nPtonishint- fitnount of
cundensed information nu a subkct of great iriiporianc-t'. and one Iml llllle
understood. Its style is admirable, pithy und to the point. The book has
.. uo paddiog about it, and deserves an immense sale,"
Sam'l Pottkb, H. D.
GROSS k OKLBinnOE, Polilisliers,
48 Mudison St., CHICAGO.
GROSS & DELBRIDGE'S Publications.
IX PRESS.
Practitioner's Guide to Uriualjsis. By Clifford Mitcheli,,
A, D., M. D., author of "Manual of Urinary Analysis," "ClinicJ
Significance of Urine," etc. 260 pages, illustrated. Price, $1.50.
The object of lliis work h to teaeh, whether any on«' be ereatly ex-
p«rleaced or not in the use of Chemicals and the Mirroscope. Hi* ninv bv it«
means Uam how to anal^vze n specimen of urine, examine any aoiiiment with
the microscope, and having done so ascertain the clinical ingnifi<ane4 ol BUCh
constituents ws have been found.
Thi Inlrndurtion ffitf\f morf dftaih in reffard to ffir.use of Vh«miciila and
the Microar^tpe ih^m any hwk on the Urine yet pubiithed. How to nun te«i-
lubes, pipettes, beakers— How to heat, boil, ami tiller urine— flow to collect
the urine of twenty-four hours What cbemioala are necessnrj' for an ex-
amination of urine and how to keep iliem— What cheraiciiU used stain the
skin orclolliing and how, if possible, to remove the Bl-tina — What chcmieaU
uavd are poisonous and what their antidotes — What chemical nppnratus U
necessary, with descripl ions— How to colled sediments for rhemicnj /malyftli
it desired — names of the component parts of the microscope— Uow to «X'
amino sediments ralcroscopieally and to use microehemical ro-a^enis— How
to take care of and clean the microscope— Explanation of metric system
cqtiivalonis, etc.. etc.
Part I. tells in concise lanpuage how to examine a specimen of urine
chemically and microficopically in the tthoTteat and timplcut manner: nny phy-
iifitin cm UJie tkf t/^fa hicen inUlUgfnHy nnd iifcurntriy. An nriirinHl and
most valuable feature of Part I. is the plan of inserting hen-
*'Clinica! Summary" explaining in concise terms the rlinifttl f<
all conHlitueuts thus far demonstrated. In t/i€Ar " Surhtnufirit" r'
ifiilljind /ii'iitM to Diagnonin lohich, if in othtr wi>rk* at uif, it/r unit'
gcorM of ptfp'f. The Mtudmt studying for ex-iniinaU on leiU fin'!
an intitUwtHe gi/nopniH How to detect and estimate alttumin aud UA\ if it l>o
of kidney origin— How sugar, bile, ihp contents of di-posits. ap blnod. pu«,
uric acid, casts, etc may be identified with nmiurnus cuts -} the
microBcopirjil appearance of ilu- contents of si'dinifnls. Tlie •. ud
estimation of normal constituents, as urea, sodium chloride, the , — ^ it:^,
etc. are described and hints given with reference to eiuculi.
Part II. is for the physician who is "studyini; up a case" and de»ir4*« an
epitome of the latest scientific knowled^ on the subject. phy-*>it)lot;ic«l.
f pathological, semioloiincal, micrfiscopical and chemical, dimprehenflive
ists are triven of diseases and conditions in which albumin. suu;ar. blood,
pus, casts, epithelia and other important constituents appear — trhen (hi
proonosiH in pufctrnble, wIuh doubtful. Complete description of tlic urine in
various forms of Bright's disease, in diabetes, in the oxalic acid and uric
acid, diathe-iis.'clc, etc. — part played by the normal constim. hn urea,
sodium chloride, phonphales. ele. in dist-ase. Normal urine, i y,
color, odor, reaction, specific gravity, amount of solids, etc is li. Lod
the Author's statistics on the daily amount collcctud for sixty tiyU luupccu-
tire days given. Abnormal urine is then similariy described and the effect
of poisons on it noted.
Thr mitre iidrunr^d Mtudftit wtU find in part II. a ehroniHe of latut •!/#-
cvverien in nrinnry pathology itnd Uie laUtt and moat improved rticthoda af
OAemical and Mie'rotcopical rfneufch.
A
of
jh
'to
GROSS & DELBRIDGE, Pablisherft,
48 Madison St., CHICAGO.
GROSS & DELBRIDGE'S Publications.
IX PRESS.
Lectures on Feyers. By J. B. Kippax, M. D., LL. B., Prof,
of Principles and Practice of Medicine in the Chicago
Homceopathic Medical College; Clinical Lecturer and
Visiting Physician to the Cook County Hospital ; Author
of " Handbook of Skin Diseases," etc. Octavo 600 pp.
The work will comprise thirty lectures, embracing every form
of Fever; their Deiinition, History, Etiology, Pathology and
Homoeopathic Treatment, making a most important and valuable
addition to our literature. In large type and;on the best paper.
LEOTUIIE I — FeverK. Introducti'iii Clif-iflrnt'on of KevtTH. Miasmatic, or Mala-
rial. Mia.'iiu .lic-Coritaj^ioiis ami C'ontugioiii*. Ttie Thurnnnmtry of Fcvi-rs.
LEtvruUR H -FpverM. Simple Conli'iufl Vovor. ■ .}fa'anal Ffwrs. Laws of
Maliirlu). .Mi-:i!<mutic Cieo^rraphicul Ui^lributinii, an I Iiiciibatioii.
TjKL'TL'ltK III. -Intt'niilrtfiit F«»v«r. -Iriimii'itpnt K»!V«r Dnllnition. Syn(»nym,
Tliptorii-al Nutice. Ktiolo;.'y. Clinical ini«tory. Typct* uf Inlennittent. MorDid Aualomy
and D;lTi:rinittal I)t:iguu»iii.
LRf-Tl'ItK I\'.— lnU'rniItt«nt Povcr (conthunMii, Complications and Sequela;.
Progruwis Chart of Oh;iraclcr;gliri* Prophylaxis. Titatmunt.
LECTlTltR v.— Uemittfiit Povor Deiinition. Synonym. Iliatorical Notice. Etlo-
Itigy. Clinical ili(«l(>ry. Mcrhiil Aii:it-imy.
KECTI'ltR Vl.-H«»iiiltt**nt F«v<t (I'ontimifd). Differential Dlasnuvis. Complica-
tion)* und S»^i|tii-lif. P 4i^iiohi» C h:irt of C'lirtnicteristicf. Tn-iitment
LECTt'ltK VII. IVrnlrlotiM .MHlnrlHl I-Vvt-r.— TH-flniiion Svnonyni. IIlvtoHral
Nolicf. Kri'doiry, iind ("linical Minffiry Typi s of I'miirinii-i Malarial FeviT. Dnniiou.
Morliid Anatomy. l.iiirer«nt:al l)i)i;rni)-i!t. ('nin|ili<'aiiiin- itiid .'^cqiiL-hi'. Prognosis. Chart
o( Cli!ira'"(!ri-tn''s. Treatint-nt. <-UrouiiT Malurinl Infc lion.
l.ECrniR VllI.--l>enK«»'. Ddliiiri.tn. Syintnvni. Ilisrortcnl Survey. Etioloirv.
Clinical Historv. Duration. Morbid .\iintoiiiy. lijirerential Diagiio^iy. Pio'gno.^if. ( hurt
of Clia ai-ii*ri?>tics. Tre:itinrnt. ■
LKrrt'RR L\ — Ilti.v Ffvor. Dcfliiition. Syii'inym. Ili-iory aiid StatiBtics. Etiology,
Ciinii-al lli-tory I>ilTeri;ntial l>ia:rniit<i«<. Pr 'Unosi-. lTi)pliyla>t-J*. Treatnient.
I-KCTl'WR X.-T.v|»lio-Sl!iliiri;il r*»v«»r. Definition. ."^yiiniiyTn Historical Notice.
Etiolnu'v. Type- uf Typh"~M-iia ial Fever, t'lin <al Ili-lory. 'Dnnilion.
LRi'Tl'lif-; XI.-Tvi»lio-M)il-«rl »l Fi'vt'r fe.nninned). Morbi-i Vmroiny. Coniplira-
tioiiHand Seqne le. Dilterenti.il Di;ii;ni>-i-. Prov;n<i.ii,x. *:liari «if t'liaraeteristlcs. Treat-
ment.
I,E<'Tri!K \\\. -llI:i»*niiitl«'-<'niitiiKiotirt Foverji. Ttjplnn-l Ft nr. Delluitinii,
Synonym. Ili-iiTV aiu! Maii-t;c-. EtioliL-y.
LKriTlir: XlII.-Typhnia F«v<T ir.intiniiud). Clinical History. Duration. Morbid
Anatoiiiy.
LKfTlItR XIV.— TypliolH r4'v<T n.-miiitniedl. '((niplieaticn-" und Scqiiehr. Differ-
ontial Dia-.'ini.-ir'. pMi'iiofin. l1i:iri of (!liiiiarteri!'lii s 'I'reatnieiit.
l.l'cTri.'K \'V - \VI oiv- I-Vvcr. D.-iIiiiti.iii. SyiHmym. ili-torv and StatUlics.
EtioioL'y. ''liTiival Ili»t(M'y. I iitT<-renti:i] l>hf_'iHi!<:»*. Mnrtiid Anatomy. ConiplicutiuuH and
bcqiielif. Pro:riio>i:'. *'harl of i'harai'tt;ri>iicj'. Tri-ainient,
The above selc(rti()ns from tlio taltle of coutonts will give tlie
reader soino idea of tin* valiu? of this new book. The work is now
in press and will be ready about January 1st. IHHiJ
GROSS k DKI.DRID(;K, Piiblishors,
48 MiuUsoii St.» CUICAGO.
GBOSS & DELBBIDGE'S Publications,
ly FIIESS.
A Compendium of Venereal Discuses, For Practitioners and
Sludeuts; being a condensed description of those nfTcotions
and their Homoeopathic Treatment. By E. C. Fiu>kus,
M. I)., Professor of Surgery in the HomcBOpatliic Depart-
ment of the University of Michigan; Surgeon to the
University Homcoopathic Hospital ; Author of "Science and
Ai'tof Surgery," "A Complete Minor Surgery," etc., etc.
About 112 pages. Octavo. 1883. Price $1.00.
"This compendium of venereal diseases has been prepared by
the author for the ni?e of practitioners and students of modicine,
as a eummarj' only of the recent investigations nnd advnnce viows
toupliing the various scquelif that follow in the train of these con-
tagious disorders, and to lay before the profession thr knowledge
of the present day gained by the use of comparatively small doses
of medicine in their treatment.
Believing in the "dualistic theory" that the origin of the
exciting virus which produces the local contagious ulcer, differs
from that which develops true py]»hilis. the terms chancroid and
syphilis are used to desigiuite these two essontially diatinct con*
ditions.
It is not intended that this little treatise shall take the place
of the larger works on venereal disenses, but that it shall he a
useful guide and a ready reference to the general practitiouer ; ft
synopsis of the more accurate and scientific observations lolely
gained in the therapeutics of these disorders.
As such it is committed to the profession, trusting that hu-
manity may lie benefited by its teachinj;s. and that homcBopathy
may receive the proper credit due it in (he more successful treat-
ment of these aiTections by attenuated medicineSi which oor
brefhrcn of the allopathic school are slowly and grudgingly
adopting." — Extract from Dr. FrankUng Prrfare.
GROSS & DELBltlDUEi Publishers,
48 Mudison St*. CHICAGO.
GROSS & DBLBRIDGE'S Publicatioks.
The Physician^s CoiideiiHed Accoiiut Book. An Epit-
■ omi^ied System of HooK-Kt^oping, avoiding the necessity of
Beparute Jouruui, Diiy Book and Ledger, combining system,
accuracy aud eany reference, with a luiniruam of labor. 272
pages. Price, $3,50.
The book fumUhes an entirely unique Bystem of keeping books
for physicians. No separate Day Book. Journal or Ledger is
required. The doctor's whole month's buhiiiess is spread out
before him on a double page, and each patron for the mouth hfia
a line all to himself. In posting the book for the month, there is
a coluuni of charges uLjuinbt eauh patient treated ; another oohinin
in which that patient's unpaitl balance of old account i.-^ brought
forward; another column totals due, cash paid, etc. Opposite
each name is a column for the patient's residence, street and
number, the year aud the mouth. The system is simple aud
plain.
■'The hook is ibc besl T over saw. Atl before your oyea. Have inad«
snme rolW'rlioris ulrciidy wliirh were f<^i'pfrtii«'n. bfcauiie not cecn. Kvory
phvbiciun Bhould liavc one" Cuaulks E. PtNKiiAM, M D..
WooOland. Cat
*' Oenttcijun : \ hnve iiiceived tlie Phy8icUu'» Condensed Account Book,
■jQVi.^ very much plL'&Mti witli U. I pi^noiince it njrand fturcL-ss."
J. DKiTUICK. M. D..
Pelrolia, Pii.
Gross & DEi.iiKHHiK,
GfntUmrn : The Account Book cnme to hand all rictat. After u trial wo
can truly say tlini \\v arw very much plcabed wirh ii, Ii U all any im'difal
man can udk in (In.' way of book keeping. By UHing cvt^ry oiIht linu wt: are
onal)led to keep u record of our pro«cripliont<. and we iliuB have a complete
[i»tur»* of our liusines^ before us. We have no hei»ilaliiin in rt-f.ommi'nding
it to tbu busy pracliiiouer Yours,
Drs. DAVFo</r«fc McKay.
Mt. Morris. N. Y.
•*Gnoii» A DEi.RnitMiF.
OenUrmru : llnvin^' used the Physician's Condensed Account Bouk for a
year past, I am pixum-i'd to spudk IntcUipontly as lo itJ* itw ■=' ' ' f titily
regard il an the i\f >tfw« uKm of book-keopmir Tor the biiKy i My
Mccouutti are alwuys in onl* r. It combinoN rtcruratv wilh <"..,. n,"
R. N. TooKEii. M. r>.,
Pn:iffS8or of DiseaM-H of i liddrcn,
ill ihe (.'hicngo Homu-opalhir (.'ullt-^,
The price of the Physician^s Condensed Account Book is
P3.50 net, and ^vi]I l>e sent per express on receipt of price.
GROSS & DELBRIDGE, Publinhers,
48 MaUisoii 8t.. CniCAOO*
088 & DEIiBBlDGE'S Pubi^icatiokb-
The Aneriem Hom«Bop«flile IHspeBsatoiy. Deaigned as a
' Texfr-Bool^ lor the FhTsieian, Pharmacist and Student.
Abont CGO pp. oetayo. Bliutrated.
TfaiB important work is written in a plain and concise manner
by a gentleman of laige experience as a pharmacist, and who
seems therefore to have fully comprehended the long felt want of
a reliable and scientific pharmacopoeia.
Indeed we can safely assert that this work will be to the
EbmcDopathib Behoof what the United States Dispensatory now
is to the Allopathic School, a de$ideratum,
''The American UomcBopathic Dispensatory"
was conceived, bom and bred as a pharmaceutitsal text-book, and,
as such, is intended for the dmggist, the student, and the physi-
cian. Inf brief, the contents are but a series of modem practical
paragraphs, each one of which is equally important. Not in any-
one instance is there any attempt made to contort or re-arrange
the subject matter of other Homceopatliic Pharmacopoeias, but
the work is wholly original and replete with practical informa-
tion.
It is the Book for Practical Instruction.
The volume will be an octavo of about 500 pages, printed on
the best paper, and bound in the best manner. Be sure and buy
no work on the subject until you have seen and examined " The
American Ilomceopathic Dispensatory "
All orders should be addressed to
GROSS & DE1BRIDG£> Publishers,
48 MadUon St., CHICAGO^
4
LANE MEDICAL LIBRARY
To avoid fine, this book should be returned on
or before the date last stamped below.
-.-N-^
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