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Full text of "The Science and art of obstetrics"

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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 — 
m ani ml 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 foramen ovale_ 
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 

116 1 

12(» 2 

122 4 

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 

14« 1 1 

14H 4 

150 1 

160 1 

162 1 1 

172* 1 

Totals fiO 30 



MoTiiER'A Auk. 

14 

16 

17 


Avebage Pilsations. 

120 

141 

i:i6 


Male. 

... 

... 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-»(; 


*> 





•>M 




VMi 


... 1 


2 


2!».. 




123 


... 3 





;»() 




131 


2 


5 


'.Vi . 




VMi 


1 





:\\ 




i:u> 


1 





37. . . 

3H 





142 

IW> , 

\'.i2 


... 

... 

1 


1 
2 






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. 

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 " ** 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 " 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, Hega r 
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 
iu aJ ^ 



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 
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 mod a , 
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. 



r eanu , 



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 c