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Full text of "The Science and Art of Obstetrics"

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SCIENCE AND ART 

OP 

OBSTETRICS. 

BY 

SHELDON LEAVIOT, M. D., 

Profe^OT of Gynecology in IM Chicago ilortieopathic Medical College: 
formerly Profeaaorof Obstetrics in Hahnemann Medical Col 
lege, Chicago; CoTisulting Gynecologist to the Bapttsf 
Hospital, Chicago, and Vie Silver Cross Hospi- 
tal, Joliet; Member of tlte American Insti- 
tute of HoTueopathy, etc, etc. 



THIRD EDITION. 
Bktibbd add Bnlarokd. 



CHICAGO: 
HALSEY BROS. CO. 

1901 

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CartaioBT, IBOl. 
By HAL8BY BBOS. CO. 



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PREFACE TO FIRST EDITION. 



I have beeD prompted to preparethiBwork by a conviction of 
the existence of an urgent demand for a treatise on the Science 
and Art of ObstetricB, in our School of Medicine, which should 
embody the advances recently made, and set forth the distinct- 
ive characters of our therapeutics in a rational and practical 
manner. 

Treatment in obstetrical practice in a great measure is me- 
chanical, and does not involve an extensive application of thera- 
peutical resources. Itistruethat by the judicious use of homeo- 
pathic remedies labor may often be divested of its pathological 
features ; yet we must beware of expecting too much. We can- 
not reasonably hope to flex an extended foetal head, to amplify 
pelvic diameters, to reduce intra-uterine hydrocephalus, to 
effect version, or to arrest unavoidable hemorrhage by the 
most carefully affiliated remedy ; and the sooner the sphere of 
remedial action can be settled, the better for us and the pnnei- 
plea which we represent. The vantage-ground which we hold 
consists in our ability to reduce the number of eases demanding 
interference to a minimum, and to remove from the pathway 
of the parturient and puerperal woman all unnecessary 
difficulty and danger. 

In preparing a practical and reliable work of this kind, it is 
always found necessary t-o draw lai^ly from the writing and 
experience of others. In doing ho, I have endeavored to award 
due recognition, and have sought to appropriate only the most 
valuable and practical truths. . 

Though the matter has been prepared with the greatestcare, 
important omissions and glaring errors will doubtless be dis- 
covered, on account of which, in advance, I implore the reader's 
most gracious forbearance. 

To numerous friends I would return my hearty thanks for 
the many aids and encouragements afforded ; and to my ent«?r- 
prising publishers, for their excellent and energetic performance 
of the mechanical part of the work. 

SHELDON LEAVITT, M.D. 

Chicago, October 20, 1882. 



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PREFACE TO SECOND EDITION. 



The first edition of this work has been out of print for about 
three years, during which time I have economized the spare 
moments, gathered from busy days, in preparing for this edi- 
tion. So difficult has it been for me to find the necessary time, 
that,. had it not been for the clamor of students, and the 
encouragement given by brother practitioners of sincerity and 
judgment, I fear the task would never have been finished. 
Whetlier the work, as now presented, will meet the needs, and 
fulfill the expectations, of those for whom it is intended, or not, 
they may rest assured that it represents a great amount of 
labor and earnest effort. 

When I came to review the first edition, more than three 
years ago, so many changes and additions were found needful 
that I at once resolved again to undertake thedrudgeryinsepa- 
rable from a thorough revision of a work of this size. What 
is herein presented has been fully reduced to manuscript, and 
reset, hundreds of pages being displaced by entirely new mat- 
ter, and not a single page being re])roduced without change. 
The size of the work has been augmented by upwards of one 
hundred pages, the therapeutic hints have been increa«ed in 
number and perspicuity, recent methods have been intro- 
duced, imperfect cuts have been improved and some excellent 
ones added, until we are able to send out an entirely remodeled 
and reconstructed book. 

I have bestowed unusual pains on the index. Much medical 
lore lies hidden in text-books for want of suitable facilities for 
revealing it to the busy practitioner. It has been my aim to 
make every important subject readily accesBible, Furthermore, 
the names of all authorities mentioned in the work have been 
indexed, together with the topic in connection with which they 



I gratefully acknowledge special help in important details. 
The appendix consistj* of an excellent article on Antiseptic Mid- 
wifery prepared for the work by Prof. L. L. Danforth, M.D., of 
New York. The chapter on Puerperal Fever was written by 
T. Griswold Comstock, M.D., of St. Louis, and the therapeutics 



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Preface. 

of Syphilis Dm-iiig PregnaDcy by Prof. T. S. Hoyne, M.D., of 
Chicago. Some valuable Btatistics and wibr suggestionB were 
furnished by George B. Peck, M.D., of Providence, and in pre- 
paring the index I was aided by Prof. F. H. Honberger, M.D., 
of Chicago. In addition to help bo direct, rendered by these 
well-known gentlemen, 1 am indebted to Profs. Phil. Porter 
and George R. Southwick, and others, for valuable suggeBtions. 

Notwithstanding the great care taken in its preparation, 
I am painfully conscious of numerous defects which mar the 
book, some of them plainly traceable to my lack of proficiency 
in literary composition. There are doubtlees many glaring 
omiBsions in the matter of therapeutics, while again some of 
my recommendations will not meet the approval of those who 
regard mere medication bb abundantly adequate for all exi- 
gencies. 

In conclusion I reaffirm my implicit confidence in the efficacy 
of the indicated remedy for the correction of abnormal condi- 
tions which may reasonably be expected to respond to mere 
medication. 

SHELDON LEAVITT, M.D. 
148 Thirtv-sitentii Stbkit, Chicago, 
Ha; 1. 1892. 



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PREFACE TO THIRD EDITION. 



A revision of this work waa again undertalcen in response to 
an urgent demand from students and practitioners in various 
parts of the country, the former edition having been out of 
print for three years. 

In rec<^nitloa of the growing conviction among those who 
give special attention to this department of practice, that ob- 
stetrics is not only to be regarded as a branch of surgery, but 
that it should be followed only by those who are familiar with 
the details of approved surgical procedure and possess some 
degree of surgical instinct, 1 have given special prominence to 
features which have a s^jrgical aspect. It must be evident to 
those who have given the subject attention, that the innovations 
in obstetrical practice during the past decade or two have been 
chiefly along surgical lines. 

Advanced ideas concerning the pathology of pregnancy, par- 
turition and puerperalit^, have also been introduced. Several 
chapters of new text have been added, t<^ether with many new 
illustrations, with a view to making the work still worthy a place 
in the foremost rank of text-books in homeopathic schools. 

SHEIiDON LEAVITT, M. D. 

Chicago, Nov. 10, 1900. 



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CONTENTS. 

PART I. 
ANATOMY AND PHYSIOLOGY OF THE FEMALE PELVIC ORGANS 

CHAPTER I 

ANATOMY OF THE PELVIS. **! 

Component Parts op the Peltih — The On ixnominodim — The 0« 
Ilium— The Oi /«cftium— The 0» PubU— The 0» Sacrum— The 0* 
Cotxyx. 

, CHAPTER II. 

THE ABTICULATI0N8 AND GENERAL CHARACTERS OF 

THE PELVIS 7 

The Symphysis Pubis— The Sai-ro-iliac SvNcitoHDRosBs— Mechan- 
ical Relations OP THE Sacrl'u — The SAcRo-coccYr.EAL Joint— 
The LtoAUBNTS op tub Pelvis — The Pelvis as a Whole — Dimen- 
sions or THE Pelvis — Inclination op tub Pelvis — Planes op 
THB pBLyu — Axis op the Pabtubient Canal — The Inclined 
Planes — Male and Female Pelves. 

CHAPTER III. 

THE FEMALE EXTERNAL GENERATIVE ORGANS. ... 30 

The VLLVA-The Labia Wi«on— The C/i(ori»— The >'m()6w^— The 

Vaginal On>fcr— The Hymtn—Tht, Fotsa NavicttlarU—The Sterelory 

Jpparatv»— The Bnlbi Ve»libali—1be, Vaoina— The PBBiNBtrH. 

CHAPTER IV. 
THE FEMALE INTERNAL GENERATIVE ORGANS, ... 34 
The Uteehb— The Uterine Ligamenl*~Th6 Uterine Cavity—Structurf 
of the Ulerut. — AbnormalilieK of the Vterut. 

CH.\PTER V. 

THE FEMALE INTERNAL GENERATIVE ORGANS-Continued, . 48 

The Fallopian TiBES— The Ovaries— The (Jrnoyfaii FoUicies—Vft- 

»el» and Nfrrft of the Ororj- The Intsa-felvic Mi'scles— The 

Mamhaei Glands. 



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PART IL 
PREGNANCY. 

CHAPTER I. 

'impregnation and development of the ovum, . 67 

The Corpus Luteuh op Msnbtbuatioh — The Corpus Luteuh op 

PHEONANCY-^The MlflttATlON OP THE OvUM — FrCUKDATION — COURHK 

op Spbrmatosoa to Point op Fecundation — Ciianoieh in the 
Ovum Apter Fecundation— Sou bcbb op Nourishment— The 
Chorion— The Allantois- The Decidua— The Placbnta— The 
Umbilical Ooud — The Liquor Amnii. 

CHAPTER II. 

DEVELOPMENT OF THE EMBRYO AND FtETUS, .... 76 
In the First Month — Second Month — Third Month — ForRTH 
Month — Fiptb Month — Sixth Month — Seventh MoNTH-^EmnTH 
Month — Ninth Month — Circulation op the Blood is the Pietus 
— The Cranium — Attitude, Prbbkntatiom and Position op the 
F<BTiis — Presentations and their Caubea — Position. 

CHAPTER III. 
CHANGES IN THE MATERNAL ORGANISM WROUGHT BY 

PREGNANCY 90 

Uterine Changes — Change in Situali<m — Inclination of He Longitudi- 
nal Axit — Change* of Cervical Poeilion — Changei in the Size and 
Texture o/ the Cervix (7«m— Vahinal and Vulvar Chanobs— 
Changes inthbMammx — Chanobb intheUtebine Appendaobs — 
Abdominal Changes — Disturbancb op Neighboring Oboanb 
PBOM Pbessure — Ckanoes in the Blood — MiacRLLANBOus 
Changes — The P^bhanekt Changes. 

CHAPTER IV. 

THE DIAGNOSIS OF PEEGNANCY 104 

Ci.A88ir-icATioN OF THB Signs — Subjective Symptoms — Hiilory of the 

Cate — The Jlffn»(ruul Flow — Morning SinkneM — Unrelinbility of Sub- 
jective Symptomg — Objective Symptoms — Tnepection — Palpation — 
Percutiion — AueciiUation — DippERBNTiALDiAaNosis— Diagnosis op 
FtETAL Death — Proofs op Former Pbkqsanct and Labor— Diag- 
nosis OF FlETAL FRESRKTATION AND POSITION BY ABDOMINAL AUS- 
CULTATION — Diagnosis op Twin Pregnancy through Avsfii.TA- 
TION— pIAONOSIB OF SCX PBOU RAPIDITY OF IBS FtSTAL HSABT. 



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CHAPTER V. 

THE DURATION OF PREGNANCY 127 

TheHiNiMuu — TheMAziitiiu — PrbdictionofDatb or Con tin km kht 
— The Date op Quickening — Fbxdiction op Timb or Labor pbok 
Si z a or Utbrub. 

CHAPTER VI. 

PSEUD0CYE8I8 ISO 

Conditions or Dbvblofhbkt — Etioloqv — Symptoms — Diaonobis — 
Teeatmbnt. 

CHAPTER VII. 

EXTRA-UTERINE PREGNANCY, 140 

OvAEiAN Peeonancy— Falbb Ovarian, or Tubu-Ovakian, Prbq- 
KANCY — Abdominal Pbeonancy— Inteebtitial Prbohancy — 
Tubal Pbeonascy — Pekgnancy in a Rudihbntart Horn or the 
Utbeub — Rarbe Variktibs — Symptoms or Extra-ctkeine Prbg- 
KANCY — Teekination — DiAO NOBIS — Trbatmbht — Caaei of Recent 
Impregnation — Puncture of the Sac — Injeetiont into the Sac — £lee- 
(Hetty — Laparotomy — Treatment After Rupture — Caiet of Advanced 
Oettalion, the Fcetui StUl Living — Operation through the Vagina— 
Catet of Oeitation Prolonged After Death of the Fatui — Missed 
Labob — IVeatmenl. 

CHAPTER VIII. 

PREMATURE EXPULSION OF THE OVUM 169 

Gausbs or kBOBTiQu—Prediipoting—OvulaTjf— Maternal— Immediate 
— Symptoms — Incomplete — Expulsion op One F<xtus ik Twin 
Prbonancy — DiAOMOgis — PEoaHOBis — Tbbatmbmt — Preventive — 
Promotive — Neglected Catet. 

CHAPTER IX. 

PATHOLOGY OF THE OVUM AND DECIDUjE, 185 

Endombtbitib— Patholoot opthe Chobion — Cantet of Hydatidiform 
Degeneration — Symplomi and Courte — DiagnoH* — Prognotit — IVeal- 
ment — The Placbnta — Site — Situation — Degenerations and Neat 
Formationt—Syphilit of the Placenta — Apoplexy and Inflammation 
of the Placenta — Htdbahniob — Sigm and Symptomt — Diagnorii — 
Termination — Prognoiie — Effect on Labor — Treatment — DBriciBNCY 
or THE Amniotic Fluid — Anomalies or the Amniotic Fluid — 
Pathology or the CoaD—Toriion— Coiling — CytU— Hernia — CaU 
eareout Depont* — Stenotit of the Veeeelt — AnomalouB Iniertion — 
Pathology op the Fcbtub — Infiammalione — Fever* — Syphilix— 
HydrocephaluM — Plettrity, etc. — Intro-uterine Amputations — Mon- 
itrotitiei— Death and Retention of the FatM — Putrefaction— Mwnmi- 
jlcation— JlfaMrotton— 'Jfoki, 



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CHAPTER X. 

DISEASES AND ACCIDENTS OF PREGNANCY 2 

The HvoiBNt OP Prbonamcy — Dbrancbiibnts of the Diobbtivb 
SvHTBM — Ptvalibm — pHURiTca — Inbomma — An«mi4 — Albi'mi- 
\UBIA — Caimei — Symplotiu — Effect* — Prognotit — r«iicimii*oiiii — 
TrfolBient — The ifiVt Di<(—7Vrap?uli>j — Chorea — IIystbria— 
Paral¥B[8—8yscopb— Painful Mamk*— Lellorrikka — Odos- 
tai^ia — Craupb— Traumatic Com p Lie ationb— Const: pati oh— 
DiARBHCBA — Vesical Irritation — CoooH — Dvbpkwa — Hbhor- 

CHAPTER XI. 

THE DISEASES OF PREGNANCY— Continued 2 

Dibplacehbnts of the Gravid Utbrur — Anterenioni nnd Anlr- 
flexiom — JteiruvertiotM — ItHrriJtexiemt — Prolifne — Cardiac Dibbabeh 
— Eruptivb Fbvbbb — Variola — Scarlatina — Continued Fevrrb — 
Typhoid — Malarial — Psbumonia — Phthibis — EBvaiPBLAn — Svpiii- 
Lie— Utbrine Rheuhatibu— Inbanitv of Prbo n a ncy—£( i'o%y~ 
Diagnotia — Prognotis — Trralmenl — Eclampsia — Frtqueiiey — Eti- 
ology — Pathological Anatomy — Prodromaia — The Seizure — Diagwttia 
Ocewrrtnee and Mortality — Treatment, 



PABTm 
LABOR. 



CHAPTKR I. 

CAUSES AND CHARACTER OF LABOR a 

The Causes op Labor — The Expblliho Powkks. 

CHAPTER 11. 

CLINICAL COURSE AND PHENOMENA OF LABOR, .8 

The Staokb of Labor— The Firxt Stage—Tbe Merkanitm ofDilatati/m 
— Rupture of the Membranet — The Second Staoe — Morementt of the 
Pelvic Arlicalationt — The Thikd Staob — Duration of Larob — 
The Hour of Labor. 

CHAI*TER III. 

THE MANAGEMENT OF NORMAL LABOR. 8 

Prbliminahy Abranqembntb — Armambs'tarium — How to Approach 
THE PATiKNT^The Exami.vation- Has Labor Broun?— False 
Labor Painb— Fatikht'b Bed and Dress— Pobition ow thi 



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COXTBNTS. I 

Woman— First St.iok — Bearing Down — Treatnifnt of the Mem' 
branfi — The Second Stags — Bearing EfforU — The V*e of Aneitktl- 
iet — Indieationt for Interference — The Prevention of Laceratum — 
Frequency of Laceration — Extent of Rupture — Treatment of the 
Cord — Early and Late Ligation — The Third Stage — Delivery of 
the Placenta by Exprettion — The Mixed Method — Manual Comprei- 
tionofthe Uterui — Immediate Repair of Laceration» — Pobt-pabtum 
Cabb of tkb Woman— The Binder — Oeneral TherapeuUct of Labor. 

CHAPTER IV. 

USE OF ANESTHETICS IN MIDWIFERY PRACTICE, 3 

Obstbtrical Anestubsia- Subqical AKBSTHKeiA— Rclbs vor Ad- 

HINISTEBINQ AnEBTHETICB. 

CHAPTER V. 

THE VARIOUS POSITIONS OF THE FCETUS 3 

The Theory of Clabhification — The Basib of Clashificatiok — 
The Relative Fbequencv op Positionb — Points op Goikcidbhck 
Between the Vabious Positionb. 

CHAPTER VI. 

VERTEX PRESENTATIONS 4 

Relative Frequency of Vertex PRbsENTATioNB — Mechanibh c 



Labor is the First Position — Expulsion of the Trunk — Mb- 
ciiANtSM OP TDK Second Position — Mechanism of Occipito-pob- 
TBRioR Positions — Oaplt Sitccedanruh— Conftoubations of thb 
Head in Vebtei Pbbsbntatiok— DiAONoaia of Positions, etc. 

CHAPTER Vn. 

FACE PRESENTATIONS 417 

Relative Frequency of Positions — Form of Oranivm in Face 
Pbbbbntation — Peognosis — The Second Position — Third and 
Fourth Positions — Conversion of Face into Vertex Presenta- 
tion— Manaoemest WHEN THE Face does not Enter the Brim— 
Pbbbibtbnt Mento-postsbior Positions— Bbow Presentation. 

CHAPTER Vni. 

PELVIC PRESENTATIONS «7 

Frequency — Prognoeib — Causes of Infantile Mortality — Etio- 
logy OF Pelvic Presentation — Mechanism op Breech Prebbhta' 
TioN IN Firbt and Sbcond Pobitiohs — Mechanism of Breech 
Pbebentatioh in the Third and Fourth Positions — Footling 

PREBENTATION CoN FIG CHAT ION OF THE HHAD IN PbLVIC DELIVERY 

— Manaokment of Pelvic Presentations — Expulsion of tbb 

TBDHX— EXTBACTIOH OF TBI HKAO. 



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CHAPTER IX. 

TBAN8VEB8E PBE8ENTATI0N *42 

FBBQCEHcr— CaV8K8— DiAoiiosia— Pboonosis— Tubatmbmt — Com- 
PLKX Pkbbsktatio.nb. 

CHAPTER X. 

PRECIPITATE LABOE, 4H 

WEAK LABOB 466 

Causes— SvMPioMa— Trbatmbkt— The Forcbps ih Inbbt Labob— 
Tbbatmbnt Of TiiiBD Staox Comflicatso by Ikbbtla- 

CHAPTER XI. 

PARTURIENT ANOMALIES EEFEEABLE TO THE MATERNAL 

SOFT PABT8 483 

RiaiDiTY or THE GMKvis^Symptam* — Treatment — UtbbinbTbtanoid 
CoNeTRicTioM — Diagnoiii — TreatTntnt — Atrbbia or tub External 
Utbrink Orificb — Couplbtb Obliteration op the Cbbvical 
Cahal — TuuBFACTioN AND Incabcbbation op the Antbbior Lip — 
Cabcikoka op tbb Cbbvix — Thrombub of the Vaoina and 

V U I, V A C y BTOCE LB— BbCTOCBLB — VbSI CAL CAI^ULV 8 DlFF USE 

BwELLiNQ — Unvibi.diho Hihen — Utbbihb Polypi — Ovariait 

TUMOBB — RlQIDITY OP THE PeBINEUH. 

CHAPTEE XII. 
PARTURIENT ANOMALIES EEFEBABLB TO THE MATERNAL 

OSSEOUS STRUCTURES 478 

Depobhitieb of the Pblvib — Large Pelvii — SymmetrieaUy-contracUd 
Pelvit — Flattened Pelvii — Flatlened, Generally Contracted Pelvit — 
Irregular Rachitic and Malacoateon Pelvii — Oblique Oval Pelvit — Flat- 
tening of the Pelvii — Exaggerated Curve of the Sacram — Funnel-ihaped 
Pelvis — Infantile Pelvit — Deformitiet from Spinal Curvature — The 
Anchylotie, Trantveriely-eontracted Pelvit — Spondylolittheiic Pelvit 
— Otteo-iareoma and Exottatii — Other Oiteoui Tumors and Prvjec- 
itoiw— The Chief Caiuet of Pelvic Deformities— Diagnosit — Influence 
of Pelvic Contraction on the Uterui During Pregnancy — Influence of 
Pelvic Contraction on Fatal Pretentatio^i— Influence of Pelvic Con- 
traction on LaboT-paifit — Influence of Pelvic Contraction on the First 
Stage of Labor— Effect of Pressure on the Soft Pelvic Tissues — Effect 
of Pressure on the Child' t Head—Prognosis— Tkbatmskt— Induction 
of Abortion in Extreme Deformity — Induction of Premature Labor in 
Deformed Pelvi»-~Whtn it Interference During Labor Advisable t — 
Traction Force Applied After Version, ivith Reiultt — The Forceps 
and Version Compared — Gates in which a Full-term Living Child 
Cannot be Rom, but Delivery through the Natural Pottages is Ad- 
visable — Cases wherein Extraction Through the Natural Passages 
Appears to be ImpoitibU, 



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CHAPTER Xm. 

PARTURIENT ANOMALIES BEFEEABLE TO THE F<ETU8 OR ITS 

APPENDAGES COl 

FhtiRAi^FRBanAiicr— Arrangement of the Mtmbranu — Conditi(m$ At- 
tending Intra-uterine Development — Labor in Plural Pregnancy — 
ifanagement of the Firtt Birth—Delay after Birth of FirM Child— 
Locked Twint — Double Maneterg — Intba-uterinb Hydbocepralub 
Bydkothokai — Abcitib and Vbsigai. Dibtbhbiok — Other Ab- 
KORif ALiTiBB — iMtge Fatutet — Doreal Ditplaeement of the Arm. 

CHAPTER XIV. 

PARTURIENT ANOMALIES REFERABLE TO THE F<ETUS OR 

ITS APPENDAGES— Continued 616 

Uhatoidablb Hbmobbbaob — Placenta P&xtia — Varietiet — Fre- 
qaencp — Cauiei of the Hemorrhage — Symptom* — Diagnotx* — Progno- 
tii — Treatment — Treatment Before Moderate Dilatation of the 0» — 
Treatment After Moderate Dilatation of the Ot — Peolapbb op thb 
Fdmb — Prequenci/ — Prognotie—Cauiei — Signi — Treatment — Acci- 
dental Hbhobkhaqb— J(« Character— Caute*— Varietiet—SgMp' 
tome — ProgwH it— Treatment, 

CHAPTER XV. 
OTHER PARTURIENT ANOMALIES ARISING IN THE FIRST 

AND SECOND STAGES OP LABOR 662 

RupTUBB oy TiiK VrxRVt—Time—Caiue — Symptome — Prognoiit— 
Treatmenl-Laceralion of the C«rt>ii— Lacbeationb op thb Vaoisa. 

CHAPTER XVI. 
PARTURIENT ANOMALIES ARISING IN THE THIRD STAGE OF 

LABOR, 562 

Post-partum Hehorrhaqb — Premonitory Symptom* — Genernl Symp- 
tome — Secondary Hemorrhage — Prognoeu — Treatment. 

. CHAPTER XVII. 
PARTTJRIENTANOMALIES ARISING IN THE THIRD STAGE OF 

LABOR— Continued, 679 



CHAPTER XVIII. 

OBSTETRIC OPERATIONS, 691 

iKDUCTtoK or Pbeuatubb Labor— In diction or Abortioh. 



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CHAPTER XIX. 

OBSTETRIC 0PEBAT10N8— Continued, E 

TuRNiNO — Couditiont Calling /or the Operation — FavorabU Condition* 
— Cephalic Vertion — Podalic Vertion. 

CHAPTER XX. 

0B8TETBIC OPERATIONS— Continued, C 

The Forceps — The Short Foreept — The Long Forcepi — Salirnt Fea- 
ture* of the InnlrurtKtU — Axii-traction Forcepi — Deiignationt o/ the 
Bladet — Action of the Foreept — Mode* of Application — Condition* 
Calling for the Forcep* — The Preliminariei — The Application — 
Traction'-Forcept in Occipito-posterior Potitiom — The Forerp* in 
Face Preientation* — Vie of the Forcep* on the Breech — The Forcep* 
to the After-coming Head. 

CHAPTER XXI. 
MINOB OBSTETRIC INSTBUMENTS AND OPERATIONS, . t 

The Vkctia— The 
TEUiax— Mode of Perfc 

CHAPTER XXII. 

OPERATIONS INVOLVING DESTRUCTION OF THE FOiTUS, . . i 

CRJkVioTOUY~-Frequency~Iti Sphere— Th6 Perforator—The Crotchet- 

Craniotomy Forcep* — The Cranioclatt — The Cephahtribe — Rrlatire 

Value of Different Mode* of Reducing Cephalic I)imen*iont — Embry- 

OTOH Y — Decapitation — Evisceration. 

CHAPTER XXIII, 
OBSTETBIC LAPAROTOMY AND SYMPHYSEOTOMY, . . . ) 
G^BSARBAN SKCTioK—T!te OpOTotion— Jfler-eaTe of the Patient— Po»l- 
mortem Caiarean Section — Post-mohtbm Dklitkrv turough tiik 
Natural Pabsaqkb — Pobro'b Operation— Syupbtheoto my. 



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PART rv. 

THE PUERPERAL STATE. 



CHAPTER I. 

PHENOMENA AND MANAGEMENT OF THE PUERPERAL STATE, 

PUBRPBRAL MOBTAUTV— PhBSOMBNA BlCfBEDING DbLIVBRY— The 

Pulie — Pott-partum Blood Changes — Trmperaturt — Uterine Involu- 
tu>u— After-pains— The Excretioni — Change* in the Uterine Mucoui 
Membrane— Vaginal Changei — The Lochia — The Lacteal Secretion—^ 
Makaobmeht of thb Bsbasts in Non-nusbing PtiEBPBKs — Gbn- 

ERAL AtTBNTIOK TO THE PuERPBRAL WOMAN — The PhYBICIAM's 

Visits— Retbntioh of Ubinb — RiaiMBN— The Bowels— Tihb fob 
Qbttino Up. 

CHAPTER II. 

THE PUERPERAL DISEASES, U 

Sdddbn Dbatk Durino Labor and tbk Poebpbbal State — Pat- 

monarjt ThromboBii and Embolism — Syncope— Entrance of Air into 
the Veins — Violent Emotions — Organic Heart Lesions — Defective 
Lactkal Skl'Rbtion — Deprbbrbd NippLKs — EscBBBivB Lacteal 
Skcbktion — Sorb Nipplbs — Mabtitib Fl-bbperalis — Etiology and 
Symptom atology — Path ology — Treatmen i. 

CHAPTER III. 

PUERPERAL SEPSIS T 

Symptoms of Pukrpebal Ikfection— Btiolooy— The pATHOasNic 
HicROBKB Capablb OF Pboduciho Local Inflammation and Ges- 
KRAL Systemic Infection nHRN Introduced in the Genital 
Canal — The Hanneb in which Pathogenic Organibhb Find an 
Entramck into the Genital Canal— The Bbhatiob Of Patho- 
genic Micro- Organ IBM 8 when Introduced into thk Gknitai. 
Canal or Dbpobitbd upon its Entranck— Pathoi/>oicai, Anatomy, 
Stmptomatologt and Diagnosib of the Various Manifbbtatiohs 
OP Septic Infection — VTilvitis and Sneolpilis — Endotaetritit, Met- 
ritis, and Salpingitis — Peritonitig^Uteriiu PMebitis— Phlegmasia 
Alba Dolent — Bapraaia—Malaria — Treatment, Pretiriitite — Prac- 
tical Antisepbis in Hobpitals- Dibinfection of Wards — Disin- 
fection of Patibntb — Disinfection of Doctors and NuRSffs — Dis- 
infection OP M ATE R I a1£— Disinfection of Instruments— Prepa- 
ration ov Sutures and Liqatdres — Antiseptic Conduct of Labob 

— SUBBBIJUBNT CaRE — PRACTICAL ANTlflKPBlB IN DoMICILIABT 

Practice— Antiseptic Attkntioni> Dei^>be and Dl'bino Labob— 



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V Contents. 

The Ltino-In Rook— The Bed— Stsbilizatiom of MaTsbuu — 
The PiTtiNT— The NuiiaB— The AccoucBEnB— The Imbtruubntb 
^—Little Slips which Nclujt the Most Complbte Preparations 
— Treathbnt, OuratiiM — Aeoniu — B^/idonna — OaUemvim — Anen- 
ieutti — Mw. Cor. — Serum-therapy — HyperleuJateytotit — Saiint In- 
futiona—Burgieal Iat&nentu>7t. 



APPENDIX. 

CHAPTER I. 

THE OBSTETRIC EXAMINATION, , . 

Prepartum Bxaminaticn, 

CHAPTER II. 

OBSTETRIC POSTURES, 

The Bffeel of ImpnUe — Potiliont A$tiimedfor Cowtenienee of Aeeouehevr 
in Non-cjm-ative Catet—Poitures Favorable to Labor. 

CHAPTER III. 
INFUSIONS OP NORMAL SALT SOLUTION, 

CHAPTER IV. 
THE SPINAL SUBARACHNOID METHOD OP ANESTHESIA, . 



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THE • 

SCIENCE AND ART OF OBSTETRICS. 



PART L 

ANATOMY AND PHYSIOLOGY OF THE FEMALE 

PELVIC ORGANS. 



ANATOMY OF THE PELVIS. 

An acquaintance with the anatomy of the Temale pelvis ie 
indispensable to an intelligent coinprehenHion of the details of 
theScieiieeand Art of Obstetrics, and ought to be insisted upon 
as aprelirninary to the study of this branch of medicine. Anat- 
omy is, in truth, the A B C of medicine and surgery, and 
our progress in the latter will largely depend on our knowledge 
of the former. 

The pelvis constitutes a bony case, or basin, within and 
upon which are all the organs directly concerned in the i)rocefis 
of reproduction. Not only this, but through the canal by 
it formed, the foetus passed in the act of parturition. 

Component Parts of the Pelvis.— In the adult, it is com- 
posed of four distinct bones, namely, the two ossa mnoimimta, 
the sacrum and the coccyx. The ossa innominata are united 
anteriorly, and, from their peculiar form, constitute the ante- 
rior and lateral walls of the pelvis. Posteriorly these bones 
articulate with the sacrum, which is interposed between their 
extremities. The coccyx is joined to the sacrum inferiorly in 
such a manner as to continue and complete the latter's 
structure. 

The Os Innomimatum.— This bone is formed by the union 
of three parte, the iUum, ischium and pubis, the perfect fusion 
of which gives to the bone a form unUke that of any other in 
the human frame. Osseous union of the parts is completfd 
about the twentieth year. The bone is so irregular in shape, 
(IJ 



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Anatomy of the Pelvis. 



that a description of it, however carefully given, would utterly 
fail to create in the mind, without the aid of a S|)erimen or 
drawing, a clear conception of its anatomical characters. It is 
truly the nanielesB bone. It is formed of three parts, distiuct 
in the infant and youufr child, united at the acetabulum, at first 
by cartila^nous, but eventually by osseous, structures. The 
lines of junction form a figure rcHembling the letter Y, but, after 
complete ossification, the evidences of primary individuality 
become almost wholly obliterated. 

These three portions of the os innominatum have been 
named: 1. The os ilium hip, or haunch bone; 2. The as 
ischium, or sitting bone ; 
and 3. The os pubis, pecten 
or share bone. 

Outer Surface.— The chief 
obstetric interest in con- 
nection with the innominate 
bone is directed to its inner 
surface. 

Upon its outer surface are 
attached certain muscles, 
some of which render in- 
direct aid in parturition, 
but are not indispensable 
to its easy performance. 
Powerful abdominal mus- 
cles find attachment to the 
crest of the ilium, which, 
with those springing from the tuber ischii and contributing to 
the structures forming the )>elvic floor, exercise considerable 
influence* over the parturient act. 

Looking at it« outer superficies we observe the broad, flat 
ilium, the bent ischium, and the projecting pubis, while at the 
point where these several parts are united, is the smooth, round 
depression known as the acetabulum, or' cotyloid cavity, intd 
which is received the head of the femur. We also notice in the 
dried specimen an ai>erture situated l)etween the pubis and 
ischium, which, in the recent subject, is fille<l, or covered, with a 
membrane or ligament, which gives to the opening its nacie, 
the obturator foramen. 

A small aperture only is formed superiorly, which serves to 
transmit the obturator vessels and nerve. 




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COMPOKENTS OF THE PELVW. 3 

Inner Surf/ice. — Bringing under view the inner surface, we 
observe that the bone is divided into a superior and an inferior 
part, by a ridge which traverses it transversely, Thisistermed 
the ilio-pectiuea] line, talcing its name from the iliac and pubic 
portions of the os innominatum. On the lower and posterior 
part of the ilium is a roughened, ear-shaped surface, being the 
portion of bone which articulates with the sacrum, known as 
the auricular surface. These features being given, no further 
study need now be made of the os innominatum as a whole. Its 
several parts, however, are worthy further attention. 

The Os Ilium, — This is the largest of the three, triangular 
in shape, situated superiorly, and, with its fellow of the oppo- 
site side, forming what 
is called the false pel- 
vis. It presents an 
irregular, convex, ex- 
ternal surface, with 
elevations and depres- 
sions which afford at- 
tachments for the 
glutei muscles. Its op- 
posite or internal sur- 
face is smooth and 
■concave, formi ng a 
fossa for the broad, 
flat iliacus intern us 

muscle. It is united Fio- 2. — The right Ob Innomin&tum. 

to the other parts of (Iniier surtace.) 

the 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 fiat, forms an ala, or wing. Its 
superior margin, thickened into a lip for the attachment of cer- 
tain muscles, is termed the crest. Upon the prominent anterior 
margin there are tyvo eminences — one above, and the other 
below — known as the anterior superior and anterior inferior 
spinous processes. The body of the bone is separated from 
the wing on the inner surface by a well-defined ridge, which 
forms part of the ilio-pectineal line, and marks the boundary of 
the true pelvis. 

The Os Ischium.— The bone is situated anteriorly and infe- 
riorly totheiliuin,and is joined to the latter at the acetabulum. 

Projecting forwards and upwards from the base, which is the 



4 Anatomy of the Pelvis. 

thickest and strongettt part, of the structure, iu a thiuiier por- 
tion, the at^cendiDg ramuH, whidi is united to the descending 
ramuB of the pubiti, and aide in forming the obturator foramen 
and pubic arch. JJetween the two extreniitieB of the icichium is 
a thick, strong portion, projecting downwardsandoonstltutiug 
the inoBt inferior part of the pelvis. This, from its form, is 
called the tuberosity of the ischium. Pointing downwards, 
backwards and inwards from the body of the bone, is a point of 
considerable obstetric importance, which has been termed " the 
key to the mechanism of labor," i, e., the spine of the ischium. 

The Os Pubis.— This is a light v^haped bone, situated moat 
anteriorly, articulating with the ilium and ischium at the ace- 
tabulum, and with its fellow anteriorly. The body of the bone 
at its acetabular articulation is the thickest part, while from 
this there extends forwards and inwards a thinner part which 
is the horizontal ramus. The articulation of the pubis with its. 
fellow of the opposite side is called the symphysis pubis, and 
from this part of the bone there stretches downwards, back- 
wards and outwards a thin plate, the descending ramus, which 
joins the ascending ramus of the ischium. The superior margin 
of the pubis forms a continuation of the ilio-pectineal line. 
Near the symphysis pubis is an elevation, the spine of the pubis, 
to which is attached Poupart's ligament, and dose to it the 
pectiiieus muscle. The pubis by its anterior articulation forms 
that important pelvic feature the pubic tirch. 

In figure 1 is shown the outer surface of theosinnoniiiiatum. 
(1) is the ilium, (2) the acetabulum, (3) the crest of the ilium, 
(4) the anterior sui)erior spine and (5) the anterior inferior 
spine of the ilium, (16) the horizontal ramus of the pubis, (19) 
the spine of the pubis, (20) the obturator foramen, (15) the 
ascending ramus of the ischium, (14) the tuberosity of the 
ischium. 

Figure 2 shows the inner surface of the os innominatiim. (1) 
is the articular surface of the ilium, (2) the ascending ramus of 
the ischium, (3) the spine of the pubis, (4) the anterior supe- 
rior and (5) the anterior inferior spine of the ilium, ((i) (7) the 
posterior, superior and inferior spines of the ilium, (8) the sci- 
atic notch, (10) the iliac fossa, (12) the ilio-pectineal line, (13) 
the spine of the ischium and descending ramus of the pubis, 
(20) the obturator foramen. 

The Bacui'm, or Busilnrp. — It is difficult to understand why 
this bone should have received a name indicating a quality 



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Components of the Pelvis. 5 

of holinesH,— for sacrum meana holy, — and that so general 
an idea of sanctity should have been connected with it in 
ancient times, by many different nations. It may be related in 
Bome way to the belief current among the Jews that "there is a 
Minall bone in the body which is indestructible, and which at the 
reHurrection will gather about it, as to a center, all the other 
parts of the body and rise bodily into everla«ting life." 

The sacrum is a triangular bone, forming the base or lower 
termination of the apinal column, and binding together the 
os«a innomiuata. It is composed originally of five separate 
rudimentary vertebrae, of graduated sizes, whi^h by their junc- 
tion resemble a pyramid, with the apex downwards, its base 
forming a seat or plith, on which rests 
the last lumbar vertebra. The seams 
ibftwesa the several vertebrae thus 
united, are distinct, and the edges of 
+he bones form prominences easily felt 
on vaginal examination. 

The sacrum presents sis surfaces 
for study, all of which are, in their 
main chariicters, of some interest to 
the obstetrician. The bone has a 
<lecided curve longitudinally, and a 
slight one from side to side, with the 

concavity looking inwards. Its supe- ^^J? 

rior, inferior and lateral surfaces are ^^ 

articular. The superior surface, or Fio- 3.— The anterior surfsce 
base, articulates with the last lumbar "' ^^^ Sacrum, 

vertebra by means of an inter-articular disk of cai-tilage, and 
thus forms the lumbosacral, or sacro-vertehral joint. The in- 
tervening cartilaginous disk, from being thicker anteriorly than 
posteriorly, causes the base of the sacrum to project more than 
it otherwise would. This part of the bone, thus rendered promi- 
nent, is known as the promontory of the sacrum. The superior 
portion of either lateral surface articulates with the ilium to 
form the iliosacral syncbondroftis. The small apex articulates 
"with the coccyx below to form the sacro-coccy/^al Joint. 

Looking at the inner surface of the bone, we discover on 
either side of the bodies of the fused vertebrtp four openings, 
formal by the transverse processes. Thesearethesacral foram- 
ina, and transmit the anterior sacral nerves, which contribute 
to the formation of the great sciatic nerve that passes down 



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6 Anatomy of the Pelvis. 

the outside of the thigh. The cavity formed by the sacral 
curves is kuown as the hoUow of the sacrum: au important 
feature for the student to remember in conuection with intra- 
pelvic auatomy. The surface of the hone is comparatively 
smooth, thereby favoring an easy passage of he fcstus through 
the pelvic canal. 

The outer surface presents an entirely different aspect, being 
rough and tuberculous. In the median line are the spines of the 
vertebrse, while on either side are discovered openings which 
correspond to those oa the inner surface, and which serve to 
transmit the posterior sacral nerves. The roughness of the pos- 
terior surface serves a wise purpose, since the tubercles give 
flrm attachment to ligaments and muscles of much power and 
importance, especially those which serve to maintain the erect 
posture. The ontire bone is penetrated longitudinally by 
the spinal canal, containing the terminal nerves of the spinal 
cord, which, from their bundle shape, are known as the cauiJa. 
equina, or horse's tail. 

The Coccvx, or hackle-bone, ie small and composed origi- 
nally of fourrudimentary vertebrae, which do not become ossified 
into one piece until middle life. In shapeit somewhat resembles 
the sacrum, and isso articulated as seemingly to form a part of 
that bone. It may be regarded as the tail-bone of the species. 
Like the sacrum, it is turned base upwards, and apex down- 
wards. 

Two styloid processes project from the posterior lateral sur- 
faces and rest upon the back part of the apex of the sacium, 
thus preventing too great repi^essioii of the point of the bone 
during descent of the foet'is. There are corresponding cornua 
on the opposing part of the sacrum. The curve begun by the 
sacrum is so far extended by the coccyx that the latter bone is 
made to form part of the floor. Its apex represents the pos- 
terior pole of the conjujrate diameter of the outlet, which diam- 
eter is considerably amplified during expulsion of the fcetus 
by a recession of the apex, through movement at the sacro- 
coccygeal joint. 



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Articulations op the Pelvis. 



CHAPTER II. 



Having viewed the separate bones which make up the pelvis, 
we may now consider the articulations which result from their 
connection. We shall notice, (1) the symphysis pubis; (2) the 
ilio-aacral syuchondrosee, (3) the safro-coccys^al articulation ; 
in each of which the student of obstetrics will take interest. 

The Symphysis Pubis ie the articulation situated dii-eotly in 
front, resulting from the approximation of the two pubic 
bones. The articular surface of the bones is small, since the 
bone itself at this place is comparatively thin. The surface is 



Fia. 4.— Section of the SymphysiB Pubis. - 

invested with fibrocartilage, thickened anteriorly where the 
surface comes in contact with its fellow, and thinned posteriorly 
so as to leave a small space in which is a synovial sac. 

The bones thus articulated form an arch, called the pubic 
arch, the crown of which is directly at the symphysis. It in 
highly important that the student bear in mind the existence, 
situation and form of this arch, inasmuch as under it the foetus 
passes in parturition. A shortening of the span of the pubic 
arch operates to increase the pelvic depth anteriorly, and add 
greatly to the difficulties and dangers of parturition. 

The Ilio-Sacral or Saciio-Iliac Synchondroses.— Atten- 
tion has already been directed to the auricular surfaces of both 
the ilium and sacrum, the junction of which makes the joint 
under consideration. The bones once in position, we have, then, 
two synchondroses (so called), the right and left. The arti(;ular 



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8 Anatomy of the Pelvis. 

surfaces are, in the recent subject, covered with flbroeartilages, 
and there is found between them, as in the other pelvic articu- 
lations, a Hynovial membrane, which becomes more distinct 
during the latter part of pregnancy. 

Mechanical Relations of the Sacrl-m.— If we r^ard tlie 
sacrum, as does Dr. Matthews Duncan, as a strong transverse 
beam, curved on its ant^erior Burface, with its extremities in 
contact with the con-esponding articular surfaces of the ossa 
ionominata, the important medical relations sustained by ttie 



ilio-sacral Ryncliondrosia at once becomes apparent. The 
weight of the imdy is transmitted to the innoniinatt^ bones, and 
through them to the femurs. Countei-pressure is applied, and 
there is thus exerted an important modifying influence on the 
development and shape of the pelvis. 

The SACRO-roorYOEAL Joint.— This is a ginglymoid joint, 
formed by the articulation of the bones from which its name is 
derived, and by means of it labor dei-ives considerable mechan- 
ical advantage. When the long diameter of the head, in its 
progress through the i>elvis, rotates into the conjugate of ttn- 



Articulations of thic Pelvis. 9 

pelvic outlet, the latter diameter, by movement backwards of 
the coccyx under prewture, is so amplifled ap to afford greater 
facility for escape of the foetus. This movement, however, 
is not confined to the joint itself, but is generally shared by the 
points of ossification of which the coccyx is made up. This is 
especially true of the second and third, and the first and sec- 
ond s^roents. 

The proximal surfaces here, ae at the other articulations, 
are covered with cartilage, and between them is found a serous 
membrane. 

Anchylosis of the sacro-coccygeal joint, and premature ossi- 
fication of the separate pieces of the coccyx, may take place, and 
give rise to much delay, difficulty and suffering during descent 
of the head. Such anchyloses have been known to snap under 
pressure, with an audible report. Anchylosis of this joint con- 
stitutes an impediment to labor, and may necessitate forcible 
rupture through instrumental delivery. In all such cases a cer- 
tain amount of attention should be bestowed on the reparative 
process, to prevent reunion of the parts with the coccyx in aa 
unnatural position. 

The Ligaments op the Pelvis.— These are by no means 
few in number, when those which are in close relation to the ar- 
ticulations are included. Thesymphysis pubis receives strength 
from ligaments stretched from one bone to the other on every 
sideof the joint. We therefore have superior and inferior, inner 
and outer, ligaments. Of these, the posterior is a layer of fibers 
of little strength ; thesuperior is connected with a band of fibers 
which arises from the spine of the pubis, and conceals the 
irregularities of the crest of the bone. The anterior is a layer 
of irregular fibers passing from one nide to the other, and crosa- 
ing obliquely the corresponding fibers from the other side ; and 
the inferior, triangular, or sub^pubic ligament is so thick, and 
so shajwd by its attachments to the rami of the pubes, as to 
give smoothness a.ud roundness to the sub-pubic angle, and 
thereby to facilitate passage of the fcetus through the pelvic 
canal. 

The ligaments which stay the ilio-sacnil Kviichondrosee are 
so arranged as to give the articulations great strength. The 
posterior sacro-iiiac ligament consists of strong irregular bands 
of fibers, which pass from the overhanging portion of the ilium 
to the contiguous rugged projections on the Iat«ral surface of 
the sa<TUin. One of these bands, prolonged from the }X)sterior 



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10 Anatomy of the Pelvis. 

superior iliac spine to the third or fourth vertebia of the- 
sacrum, in a direction different from the others, is known under 
the name of the inferior, or oblique, sacro-iliac ligament. 

The anterior sacro-iliac ligament is a simple fibrous lamina, 
extended transversely from the uacrum to the os innominatum. 
It is rather an expansion of the periosteum than a true liga- 
ment. The superior sacro-iliac ligament is a very thick fascicu- 
lus, passing transversely from the base of the sacrum to the 
posterior part of the inner surface of the bone. 

These synchondroses are strengthened also by the sacro- 
sciatic hgaiinents, — greater and lesser. The greater, or poste- 
rior, arises from the posterior margin of the ilium, including 
the posterior inferior spine and the lateral surfaces of the sacrum 
and coccyx. It is broad and flat, but its fibers tonveige asthey 
pass downwards and forwards to be inserted into the inner 
surface of the ischial tuberosity. The anterior or small sacro- 
sciatic ligament is triangular in shape, but shorter and thinner 
than the other. The origin of its base is blended with that of 
the greater, but is less extensive, and its apex is attached tothe 
spine of the ischium. 

These ligaments transform the sciatic notch into two foram- 
ina, the greater and the lesser sacro-sciatic. Through the 
former of these pass the pyriformis muscles, the great sciatic 
nerves, and theiscbiaticand pubic vesselsand nerven. Through 
the latter pass the obturator internus muscles, and the internal' 
pubic vessels and nerves. 

The functions of these ligaments in tersely put by Leishnian 
as follows: "They act, as haa already been mentioned, by pre- 
venting the displacement of the apex of the sacrum upwards 
and backwards, — an accident which, without then- aid, the very 
oblique position of that bone would, in the erect position, be 
likely to engender; and therefore, in this sense, they Ktrengthen 
the sacro-iliac articulation. But in addition to this, they close 
in, in some measure, the large irregular opening which consti- 
tutes the outlet of the pelvis, forming at the same time the 
framework of those soft structures which constitute the floor 
of the pelvis. The floor thus constructed exercises a very im- 
portant influence on the progress of labor, and at the same 
time affords an efficient and elastic support to organs whitrh 
would otherwise be liable to frequent displacement down- 
wards." 

The ligaments which strengthen the lumbo-sacral joint are 



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Articulations of the Pelvis. 11 

similar to those which join one vertebra to another. Tlie 
anterior common vertebral ligament passea over the surface of 
the joints ; and we also find the liganienta sub-flava and inter- 
spinosa, as in the other vertebrte. The articular processes are 
joined together by a fibrous capsule, and there is also a special 
support given by the lumbo-eacral ligament, which stretches 
from the last lumbar vertebra on ea«h side, and is attached to 
the side of the sacrum and the sacro-iliac synchondrosis. Men- 
tion should also be made of the ilio-lumbar ligament, which 
passes from the apex of the last lumbar vertebra to thethicksst 
portion of the iliac crest. 



Fii). 6.— The articulated Pelvis. 

The ligaments of the 8a.cro-coccygeal articulatlou require but 
brief notice. The anterior consists of a few parallel fiberswhich 
descend from the anterior part of the sacrumtothe correspond- 
ing face of the coccyx. The posterior sacro-coccygeal ligament 
is fiat, triangular, broader above than below, and of a dark 
color. Arising from the margin of the inferior orifice of the 
sacral canal, it descends to, and is lost on, the whole posterior 
surface of the coccyx. It aids also in completing the canal 
behind. These ligaments seera to embrace the entire joint in a 
kind of capsule. 

A few words remain to be said regarding the obturator iiga- 
meut or membrane. As has been elsewhere stated, thisstruc- 



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12 Anatomv of the Pelvis. 

ture in stretched over the obturator foramen, almost closing it, a 
Htnall opeoiug only being left for the passage of the obturator 
vesHi^lM a:]d nerve. It is spoken of as a ligament, but it is thin, 
and in structure resembles an aponeurosis. 

The Pelvis as a Whole.— HaWng made a bomewhat detailed 
.8tud,v of the several bones, joints and ligamenta which con- 
tributt! to form the pelvis, let us now view the structure as a 
whole, and note its remarkable characters. And as we do so, 
first of all we observe that by means of the peculiar form given 
it b_v the ilio-pectineal line and sacral promontory (which con- 
stitute the HUi>epior strait, or [ielvic brim), the pelvis is natu- 



Fni. 7.— Showing the Diameters ot the Superior Strait. 

Tally divided into superior and inferior parts, the former being 
t4'rmeil I he fiikf pplvis, and the latter the true pelvis. In the 
living or recent subjert. then, the false pelvis is bounded ante- 
riorly by the abdominal walls, Interally by the broad flat wings 
of tiie ilia, posteriorly by the lumbar vertebrae and the pos- 
terior portions of the ilia, and inferiorly by the plane of the 
superior Htrait. The tnie pelvis is bounded posteriorly by the 
sacrum, laterally by the ischia and bodies of the ilia, ante- 
riorly by the pnbes, superiorly by the brim of the pelvis, or 
superior strait, and inferiorly by the outlet, or inferior strait. 
The broad expanded alfe of the ilia, the ischial tuberosities, the 
fiaoral promontory, and the pubic ai-ch, are all iieeuliarities of 



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Anatomy of the Pelvis. IS 

the structure that should be noticed. Within the true pelvic 
cavity, the hollow of the sacrum, formed by the curve of that 
bone, and the ischial splnee, demand B|)ecial attention. 

We shall shortly enter upon a more minute study of the 
pelvic cavity, a part replete with interest, since it is the home 
of the unimpr^nated uterus jmd appendages, and through it 
passes the fcetus on its way to light and liberty. 

Dimensions of the Pelvis.— Before proceeding further, the 
student will do well to familiarize himself with the diniensiona 
of the pelvis. In giving these, certain terms will be used whicbi 
require definition. 



Fio. 8. — Shovring the Diameterg of the Outlet, 

Beferring now to figure 7, we have a diagram of the superior 
strait, or pelvic brim: »-6 represents the antero-posterior, or 
conjugate diameter, the poles being at the symphysis pubis and 
sacral promontory; c-ff designates the transverse diameter; p-f 
shows the left-oblique diameter, the poles rewtiiig at the right 
acetabulum or ilio-pectineal eminence and the left sacro-iiiac 
synchondrosis; f-e marks the right^oblique diameter, the poles 
being found at theleftilio-peetineal eminence, or left acetabulum, 
and the right ssicro-iliac synchondrosis. 

With regard to exact dimensions, we should recollect that 
they can scarcrfy be given with any degree of assurance, ina«- 
much as actnaJ measurements are found to be so various. It is 
onlybytakiagtheaveragediamet^ersof alarge number of pelves 
that w« can acquire a clear idea of pelvic dimensions. But 



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14 Anatomy of the Pelvis. 

what is of vastly greater importance than exact figures for the 
etudent of obetetrics to remember, are the relative meaaure- 
meuta. 

In the figures which follow, reference is had to the dried 
pelvis, divested of all soft parts eave ligaments ; but before sub- 
mitting them a word is required with regard to the oblique and 
coujugate diameters of the pelvic cavity and outlet. In the 
instance of the former, one pole necesHarily rests on the sacro- 
ficiatic ligaments, and hence is not fixed. This is also true of 
the conjugate of the outlet, one pole of which diameter rests on 
the tip of the coccyx ; and this bone, as has been explained, is 
pressed more or less backwards during descent of the fietal 
bead, thereby lengthening the diameter. 

The following will then approximate the actual diameters of 
the true pelvic cavity, and of its superior and inferior straits: 

ConlDgkte. TMnsvarn. Obllqna. 

Brim, or inperlor Btrait . 11.6 cm. 4^ in. 18.4 cm. 5}4 io. 13.7 cm. In. 
Cavity . . . . 18.4 « 6Ji " 12.7 " 6 " 18.4 " OH " 
OaUet 5 to « " 12 " 4S( « 1> " *% " 

Other pelvic measurements are also submitted : — 

Circumferential measurement of the brim 17 

Measurement from tbe sacral promontory to the center of the 

acetabulum, or the ilio-pectineal eminence .... 3<^ 

Between the widest part of itiac creatB 10^ 

Between the anterior superior iliac epinee 10^ 

Between the froDt of symphisis and sacral spines .... 7 

From the diameters of the true pelvis, as given, it will be ob- 
served that at the brim the conjugate is the shortest, and the 
transverse the longest. In the living subject, however, these 
relative dimensions are changed. The transverse diameter, 
from encroachment of the psoae and iliac muscles, be<5omes 
shorter than the oblique. Then, on account of the presence of 
the rectum on the left side of the sacral jiromontory, the left 
oblique diameter is slightly diminished. The result of these 
changes is that the right oblique becomes the longest diameter, 
and hence the long diameter of the head is most frequently- 
found in it. 

Inclinatiox of the Pelvis. — When the pelvis is placed upon 
aflat surface, so that the ischial tubers and coccygeal tip are 
brought upon the same plane, we do not get an accurate ideaof 
the position which this part of the skeleton really occupies in 
the living, erect subject. Without entering into a narrative of 



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Planus of tub Pelvis. 15 

the different notions which have from time to time been held, 
it will answer practical purposes to say that the pelvis is so 
placed that, in the erect position, what are termed its horizon- 
tal planes sustain a marked inclination. This is an important 
■fiact, and should be clearly apprehended. 

Now it has been found, that, while the incHnation of the pel- 
vis varies in different persons, and in the same person at differ- 
ent times, the ^neral pitch of the plane of the superior strait is 
at aB angle of say 60 degrees, and that of the inferior strait, 



FiQ. 9. 
before recession of the coccyx, about 11 degrees with the hori- 
zon. The high practical value of these items of information 
will l)e clearly discerned as we proceed. 

Planus op the Pelvis. — It is not difficult to demonstrate 
what is meant by pelvic planes. That of the superior strait 
\>ould be well represented by a piece of cardbotird fitted into 
the irregular outline of this aperture. When viewed in con- 
jugate section, the plane of the brim would be represented by a 
line drawn from the superior margin ofthepubes to the promon- 
tory of the sacrum. A piece of cardboard fitted into the outlet, 
so that one side of it would rest on the point of the coccyx, the 
opposite side at the crown of the pubic arch, with its lateral 
borders extending between the ischial tubers, would represent 



16 



Anatomy op the Pelvu 



the plane of the outlet. This nlane, in a eection like that in> 
figure 9, would be repreaeuted by a line drawn from the sub- 
pubic margin to the tip of the coccyx. The change produced by 
recesnion of the coccyx is also well shown in the eame figure. 

Planes without number may be created within the pelvic 
cavity by carrying forward the lines representing the planes of 
the superior and inferior straits to the point of intersection, 




and from this, as a center, radiating other lines through the- 
pelvis, as shown in figure 10, 

Axis op the Pahtuhient Canal. — The axis of the partu- 
rient canal is its geometrical center. To demonstrate the axis, 
of a perfect cylinder would not be difficult, but the parturient 
canal is a cavity of irregular dimensions, with diameters short 
in one part and long in another, and a depth much greater pos- 
teriorly than anteriorly. The axis of the pelvic brim is rep- 
resented by a line drawn through its center perpendicularly t*> 
its plane, which, if extended, would touch at the umbilicus and 



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Planes of the Pelvis, 17 

the coccyx. The axie of the outlet of the bony pelvis intersects 
this, and extends from the promontory of the sacrum through 
the geometrical center of the plane in question. 

A good deal has been aaid by obstetrical writers about the 
"curveof Carus," and students should be made to understand 
its practical significance. It is formed in the following manner : 
The compasses are expanded so that when one point is 
placed at the middle of the posterior surface of the symphysis, 
the other will rest midway upon the conjugate diameter. The 
latter point is then made to describe a curve through the pelvic 
canal, and the line resulting is the curvesouglit. For practical 
purposes this will answer, yet it cannot be regarded as the 
real pelvic axis, since the posterior wall of the cavity haa not a 
uniform curve. It is only by 
creating a large number of arti- 
ficial planes like those represent- 
ed iu figure 10, and determining 
the geometrical center of each, 
that we approximate exactness. 
A line drawn through the center 
of such planes, from pelvic inlet 
to outlet, would be found to de- 
scribe an irregular parabola, per- 
fectly demonstrating the true 
axis of the pelvic canal. 

It must Dot be supposed that 
the plane of the bony outlet 
truthfully represents the plane 
upon which the ftetal head parses 
the vulva. The yielding pelvic ^'*'' ^^' 

flooris greatly stretched, and if the posterior boundary of the 
plane be established at the posterior vaginal commissure, we 
discover that the plane forms with the horizon an angle of 75 
or 80 degrees. This is fully set forth in figure 11 : a-6 is the 
newly formed plane of the vulva, ris the anus, and e the line 
representing the axis of the parturient canal. 

The Inclined Planes.— When we look at a section of the 
pelvic canal, like that here shown, we observe that the lateral 
wall is easily divided into two parts, by a line extending from 
the ilio-pectineal eminence to the spine of theischium b-a. That 
part of the bone in front of the line is inclined inwards, down- 
wards and forwards, while that behind the line is inchned in- 

(2) / - I 

LjM_. A'OOgle 



18 



Anatomy of the I'elvis. 



wards, downwards and backwards. These are the auterior and 
posterior ioclined plaues of the ischium. They Bu»tain very 
important i-elatioris to the mechanism of rotation of the firtal 
head in the pelvic cavity, as will be shown in a suimprjuent 
chapter. 

Male and Female Pelves.— With dried specimens before ub, 
it is apparent, even on cui-sory comparison, that there is a dif- 



FiG. 18.— Male Pelvia. 

ference between the male and the female pelvis. In order to 
render the variations explicit in detail, the following contrast 
has been drawn : 

MALE AND FEMALE PELVES COMPARED. 



1. All the bones are comparative!; 
li|;hC in structure, and the points 
for muscular attaclimente are only 
moderatelj developed. 

2. The iliac wings are nidel; 
spread, so that when seen from 
belore the broad expanse of the 
Iliac foBste comes plainly into view. 

3. The ischial tuberosities are 
widely separated, so as to );ive a 
transverse diameter at the outlet of 
4^4 inches. 



1. All the bones are comparatively 

heavy in structure, and the points 
for muscular attachments are well 
developed. 

2. The iliac wings are not widely 



3. The ischial tuberosities are co 
paratively near, giving a transve 
diameter at the outlet of say 3"^ 
4 inchea. 



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Male and Female Pelvis. 



lU 



4. Tbe aub-pub[c angle is obtuse 
<90° to 100°), and span ot the arch 

5. Tlie pelvic cavity is wide and 
ahallow, and tlie sectional area of 
the brim and outlet about equal. 



6. The sacrum is broad, and its 
promontory moderately prominent. 



4. The sub-pubic angle Is acute 
(70° to 75°), and the span ot the 

6. The pelvic cavity is narrow 
and deep, and the sectional area of 
the outlet considerably below that 
of the brim, giving to the pelvis a 
funnel shape. 

0. Tbe sacrum is comparatively 
narrow, and the promontory very 
prominent. 



Fio. 14.— Female Pelvis. 

7. The obturator foramina are 7. The obturator foramina are 
triangular in form. more oval in shape. 

8. The spines of the ischia have a 8. The ischial spines are remark- 
moderate projection into the pelvic ably prominent. 

cavity. 

These differences between the male and the femalo {wlvis are 
probably the result of the growth and development of the 
female internal generative organs, situated within the true 
pelvis.. Srhroeder, in proof of this, calls attention to the fa^'t 
that in women with congenital defects of these oronns, and in 
women who have had both ovaries removed in early life, the 
general form of the pelvis is masculine. 



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Anatomy of the Pelvib. 



CHAPTER III. 

THE FEMALE GEXERATIVE ORGANS. 

The female generative organs have been divhied according- 
to situation and function into external and internal organs. 
The external organs are those which are in view externally, and 
together constitute the pudenda. They are concerned mainly 
in the copulative act, but through them emerges the ftetus in 
parturition. They consist of the mona veneris, the vulva, the 
vagina and the perineum. The internal generative organs are 
concerned-mainly in producing the ovum, developing and ulti- 
mately expelling it. They consist of the ovaries, the uterus, and 
the Fallopian tubes. 

The Monh Veneris.— This is a cushion-like eniiiience tiitu- 
ated directly upon the symphysis pubisand the horizontal ))ubie 
rami. It is composed mainly of adipose and fibrous tissue, 
and serves as a protection to the parts duriri;j sexuiil inter- 
course. At puberty it develops a growth of haii-, the area thus- 
covered forming a pyramid, the apex ofwhicli is at the vulva. 
Numerous sweat and sebaceous glands are found opening on 
ita integumental covering. 

The Vulva. — The vulva is made up of a variety of parts. 
The labia niajora are two roun<led folds of connective tissue 
containiug a variable amount of fat, elastic; tissue, and smooth 
muscular fillers. They originate anteriorly, at the posterior 
margin of the mons veneris, and, lying side to side, extend pos- 
teriorly, uniting at the anterior margin of the perineum to form 
the posterior rommissure of the vulva. The margins which he 
in contact, and the entire inner surfaces, are covered with mu- 
cous membrane, while the external surfaces are provided with 
ordinary int^ument. They are broad and flat in front, i.e., at 
the anterior commissure, but thin and narrow posteriorly. The 
integument for a certain distance from the mons veneris is thin- 
ly covered with hair, and is provided with a considerable num- 
ber of sweat and sebaceous glands. In the mature virgin these 
external lips conceal the other vulvar structures, but In women 
who have borne children they are not so close, and fron> 
between them peer the labia minora. Tn young girls and old 
women the lubia minora are also prominent. 

The CuTOitis.— Separating the labia majora, we find jusb 



Cocwic 



Female Generative Organs. 



21 



behind the anterior vulvar commissure, a small elougated body, 
called the clitoriB. On careful examination, it is found to re- 
semble the penis in form and structure, and, like the maleur^an, 
is the seat of the aphrodisiac sense. It differs from the penis in 
having neither corpus spongiosum nor urethra. It is divided 
into the crura, the corpus and the glana. The crura are long, 
spindle-shaped processes, attached to the borders of the as- 
cending rami of the ischii and the descending rami of the pubee. 

The corpus is formed by the 
junction of the crura in the me- ' 
dian line, in front of the sym- 
physis. The glans is the round- 
«d, imperforate extremity. The 
mucous membrane covering the 
glans is of pale-red color, and 
contains numerous papillee, part 
of which are provided with ves- 
sels, and part nerve endings, sim- 
ilar to those found iu the nipple. 

It is supported by a suspen- 
sory ligament which finds attach- 
ment to the anterior and inferior 
margin of the symphysis, while 

the nymphte encircle it in such a p,^ i6._L.teral view of the 
manner as to provide a prepuce ErectileStructuregofthe Female 
-and render its Hkeness to the External Generativ 
virile organ more exact. With 
such environment and anchor- 
age, it cannot, when turgid and 
■erect become very prominent, 
nor conspicuously display its 
true proportions. The entire or- 
gan measures about three- 
fourths of an inch in length. Its 
blood supply is received from the int<!mai pudie artery through 
the dorsal and cavernous branches ; its veins end in the vesico- 
urethral plexus; and it is provided with nerve communication 
through the internal pudic. 

The Labia Minoha.— The labia minora, or ny.mphse, aretwo 
folds of mucous membrane, which arise on either side from the 
center of the internal surface of the labia majora. They extend 
anteriorly, forming folds of considerable breadth, and finally 



(The skin and mucous membrane 
have been removed, and the 
blood-vesselfl injected.) a, bulbuB 
vestibuli. t, plexuaofveingcalled 
the pars intermedia, e, glane 
. /, corpus clitoridiB. k, 
dorsal vein. ', right crus clitori- 
die. m, vestibulum. n, right 
gland of Bartholin or Duvemey. 



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22 



Anatomy of the Pelvis, 



unite at the clitorm. As they approEiclithiaoi^anthe.v bifurcate, 
the posterior branehee beiug attaelied to the clitoritt, and the an- 
terior uniting to form a sort of prepuce for the organ. In some 
women, even in middle Hfe, the labia minora become so elon- 
gated a« to destroy the symmetry of the vulvar etructureg. 
TiiiH is especially true of certain negro races. As elsewhere 
stated, iu adult virgins they 
are covered by the external 
labia, but in women who have 
borne children, in the aged and 
in young girls, they show them- 
selves in therima pudendorum. 
In young girls and virgins, the 
mucous membrane covering 
their surfaces is uf a light pink, 
shade, but in others it is 
brown, dry, and like skin in ap- 
pearance. The mut^^us mem- 
brane is provided with teefeel- 
lated epithehum, and a large 
number of vascular papillffi. 
On their inner surfaces are 
numerous sebaceous glands, 
secreting an odorous cheesy 
matter, which serves for lubri- 
cation and prevents adhesion 
of the folds. 

"Among some of the Orien- 
tals," says Parvin, "the nym- 
phfe are quit* large, hindering 
the entrance of the penis, and 
their partial excision wa« the 
circumcision of females. Cu- 
vier states that in the sixteenth 
century missionaries in Abys- 



— Vulva of the Virgin. 



Jio. la.- 
greater lip of right Bide. 2, four 
chette. 3. email lip. 4, clitoi 
6, urethral orifice. 6, vestibuie- 
orifice of the vagina. S, hymen. 



orifice of the vuIto- vaginal gland, ginia persuaded their converts 
10, anterior commisaure of greater ^^ abandon the custom, but 
lips. 11. anal orifice. . , , , , 

as girls could no longer find 

husbands, the pope authorized a return to it." 

The Vkstibulb.— The vestibule is a smooth, mucous surface, 
triangular in form, with its apex to the clitoris, lying between- 
that organ and the anterior margin of the vaginal orifice. It 



Female Generative Organs. 23 

is bouuded on either side by the folds of the nymphse, and pos- 
teriorly by the vaginal orifice. The mucous membrane of the 
vestibule Is smooth, and, unlike the mucous membranes of other 
vulvar parts, is destitute of sebaceous glands. There are a few 
iiiuciparoua glands opening on its surface. At the center of the 
base of the triangle formed by the vestibule i« situated an open- 
ing, the location of which should be familiar to the physician, 
namely, the meatus urinaihui, or meatus urethrm. From this 
external opening the urethra passes upwards and backwards 
under the pubic aroh, 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 muscular and erectile tissue, 



Flo. 17. Fio. 18. 

Figureg showing different forms of Hymen. 

and is remarkably dilatable. With the finger in the vagina, it 
can plainly be felt in the situation described. 

Vagisal Okifice. — The opening of the vagina is directly be- 
hind the vestibule. Its lateral boundaries are the labia minora 
for a short distance, and the labia majora in the main. Its 
posterior boundary is the fourchette, and its anterior the vesti- 
bule. In an undilat«d state it is a mere fissure, varying consid- 
erably in size. 

The Hymen is a structureof variable thickness and strength, 
situated just within the vagina, and was formerly regarded ivs 
a seal of virginity. When intact, and of ordinary form, it 
serves as a complete bar to introception of the male organ, 
but it is frequently ruptured in infancy or childhood, through 



CiOOglc 



2i Anatomy of the Pelvis. 

accideDtal or other causes. When incomplete, or anomalous 
in structure, sexual cougress may be held, and impregnation 
follow, without its destruction. There is a specimen of the fe- 
male genitalia on exhibition in Meckle's museum, at Halle, from 
a woman who gave birth to a seven-months child, which shows 
a perfect hymen. There are also well autheuticated cases on 
record of pn^nancy existing in women with this part still not 
only of usual proportions, but with onl.v small perforations. 

It is generally erescentic in form, with the free border turned 
toward the anterior vaginal wall. In the main its structure is 
such (being chiefly a fold of mucous membrane with some cel- 
lular tissue and a few muscular fibers), that it tears easily 
under pressure. In other cases it is firm and unyielding, requir- 
ing incision to displace it. 

Anomalies in form are not uncommon. Instead of present- 
ing a free border anteriorly, it may be provided with a single cen- 
tral opening, or there may be a number of small openings. A 
fimbriated hymen is occasionally observed, which might easily 
be mistaken for one freshly ruptured. Instances of imper- 
forate hymen are also met. 

Carunculse Myrtiformes.—Th.&Be> are small fleshy tubercles, 
from one to five in number, situated about the vaginal orifice, 
commonly regarded as remains of the ruptured hymen. Bchroe- 
der does not concur fully in this opinion. "In prlmarse," he 
says, " portions of the torn hymen are suffused with blood {dur- 
ing labor), and destroyed by gangrene, so that in the vulva 
some warty, or tongue-like, projections remain." 

The Fobsa Naviculakih. — In women who have never borne a 
child there still remains a fold of mucous membrane at the pos- 
terior margin of the vaginal orifice, which has been termed the 
fourchette, or frienum. Situated between this and the posterior 
vulvar commissure is a little fossa called the lossa navicularis. 
Ill nearly till first labors the fourchette is torn. 

The SErRETOHY A fp a rat rs.— Sebaceous glands are most 
abundant in the tissues of the nymphre, where they furnish a 
fatty, yellowieh-wbite material, poBsesRing a jwculiar odor. 
This, when allowed to accumulate beneath the prepuce of the 
clitoris, confltitutes the smegma pnepntii.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 majora. Mucous glands, five to seven in number, are 
found irregularly distributed about the meatus urinarius. 



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Femai.k Gk.vkrative Organs. 25 

They are of the compound rftcemose variety, about the size of 
a poppy^seed, and possess short, wide ducts with large orifices. 
They are of aid to the beginner in locating the meatus urina- 
rias for catheterism. These la«un« may be sufficiently dilated 
to admit the point of a small-sized catheter, thus constituting 
a deception and snare. 

The Vulvo-Vaginal Glands -were&TBt discovered by Bartholin, 
and have been called "the glands of BarthoUn." The name of 
Duvemeyhas also been attached to them. They are twoin num- 
l)er, of the size of a small bean, and somewhat resembling it in 
ahape, of a reddish-yellow color. They are situated near the pos- 



Fio. 19.— Vascular snppi; of Vulva. (After Kobelt.) A, pubis. B B, 
ischium. C, clitoris. D, gland of the clitoris. £, bulb. F. coostrlctor 
muscle of the vulva. G, left pillar of the clitoris. H, dorsal vein of the 
clitoris. M, labia minora. 

terior part of the vaginal orifice, behind the posterior extremitiea 
of the bulbi vestibuli, which they partly overlap. These coii- 
glomerate glands are the analogues of Cowper's glands in the 
male. On section, they are found to be of a yellowish-white 
color, and made up of a numlier of lobules separated from each 
other by prolongations of the external envelope. The several 
ducts of the separate lobules unite in a common canal, about 
half an inch in length, which opens in front of the attached 
edge of the hymen in virgins, and at the base of one of the ca- 
runculfe myrtiformes in married women. They secrete a yel- 



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26 AXATOMY CF TliE PELV.'S. 

lowUh viacid fluid, which is freely poured out during coitus and 
labor, the office of which is to prevent irritatiou by renderiD^ 
the raucous surfaces moist and slippery. The glands are larger 
in youDg girls than in women of middle life, while in old age 
they in some cases altogether disappear. 

The Bulbi Vestibili.— The bulbs of the vestibule are two 
curved masses of reticulated veins, somewhat resembling a 
filled leach, about an inch in length, situated between the 
vestibule and pubic ai-ch on either side. They are covered in- 
ternally by the mucous membrane, and embraced on the out- 
side by the fibers of the constrictor vaginte muscle. Kobelt 
claims that they correspond to the two separate halves of the 
male bulbus urethree. Theanteriorends, which are rather small, 
are connected by meaiis of the pars intermedia with the glana 
clitoridis. The blood, during sexual excitement, is pressed 
through this communicating channel by reflex action of the 
muBcuIus constrictor cunni, from the turgid bulbs, thereby 
flooding the erectile tissue and hardening the clitoris. These 
vessels are supplied with blood from the internal pubic arteries. 

The Vagina. — This important part of the female genera- 
tive apparatus is by some classed with the internal genitals, 
but it is here considered as an external organ. It is a cylin- 
drical membranous tube, extending from, the vulva to the 
uterus, and hence is sometimes called the vulvo-uterine canal. 
It is situated in the pelvic cavity, with the bladder anteriorly^ 
and the rectum posteriorly, and, when put upon the stretchy 
extends nearly to the superior strait, following pretty closely 
the general curve of the pelvic axis. Its walls, while strong» 
are soft and yielding, and lie iu contact, being flattened from 
before backwards. There has been considerable discussion over 
the length of this organ, and it is quite certain that the meas- 
urements given by some are excessive. When not drawn 
forcibly out to its greatest length, it can be fully exi>lored with 
a finger measuring three or three and a half inches ; but, when 
at its maximum, the length is probably four and a half inchee 
— possibly five. Measurement variesgreutlyin different woraen. 
It is sometimes very short, the whole length being only one 
and a half or two inches. It is united to the bas-fond of 
the bladder by condensed areolar tissue, while the urethra is 
situated in its anterior walls. It is connected with the rectum 
in its superior part, by the double fold of peritoneum whiob 
forms Doi^las's pouch, and in its inferior part by areolar tis- 



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Femalk Gexehative Oiu; 



27 



flue. Its lateral borders are attached ahi)\(' to the broad 
ligaments, and below to the pelvic areolai- tisHua and some 
venous plexusee. The superior extremity, or fornix, encircles 
the cervix utei-i below its juiietion with the corpus uteri, thus 
giving to the cervix a supra-vag'mal portion, and aaintra- 
vaginal portion. The suiwrior boundaries of the vagina in 
thus folding upon themselveH to embrace the neck, form a cir- 
cular groove or cul-de-sac, described 
as the anterior and posterior vagi- 
nal cahdesacB. The posterior is 
deeper than the anterior. 

Erroneous ideas are sometimes ' 
derived from the vagina being de- 
scribed OS a tube with an external 
opening. It is a tube or canal, but 
one whose anterior and posterior 
walls are in contact. Its caliber 
varies in different parts, being least 
at the outlet. 

The va^na is composed of an ex- 
ternal, a middle and an inner coat. 
The external consists of cellulo- 
flbrous tissue, which connects it 
anteriorly with the bladder and 
urethra, laterally with the levator 
ani, and posteriorly with the rectum 
and peritoneum. The walls are of 
variable thickness. In the upper part 
of the canal the internal surface is 
smooth, and the thickness of the 
walls is only half a line to a line, 
while in the lower part it is much 
greater. The external cellulo-fibrous 
tissue coat is very elastic, and af- 
fords a fine bed for the vaginal 
blood-veflsels. The middle coat is 
muscular, the fibers being of the 
involuntary variety. They run in both longitudinal and trans- 
verse directions, and are so interlaced that a dissei'tion into 
separate layers is impossible. The connective tissue and mus- 
cular layers increase in thickness as they approach the vapinal 
orifice, the latter constituting two-thirds the thickness of the 



Fiii. -11.— The Vagina lat- 
er removal ot poBteriitr 
rail). Oti, meatus urinaritiB. 
*at, external oa uteri. B. 

BectioD of wall at the tornis 

vaginfe. (Henle.) 



28 Anatomy op the Pelvib. 

vagina. Luechka ha« described a circul€tr bundle of volun- 
tary fibers, the sphincter vagiuse surroundiug the lower ex- 
tremity of the vagina and ni-ethra. The action of this muscle 
not only narrows the vaginal orifice, but likewise serves to 
close the urethra by compressing it against the urethro-vaginal 
;septum. The sphincter va^use and the sphincter ani form a 



Fio. 21.— Section of Female Pelvis. I, rectum. 2, uterus. 3, cijl-de-sacof 
Douglas. 4, vesico-uterine space, 5, bladder. 6, clitoris. 7, urethra. 
8, symphysis. 0, sphincter ani. 10, vagina. (Kohlrausch modified by 

Spiegelberu.) 

figure of eight. The middle coat of the vagina is dense and 
flbroiiR, like the proper tissue of tlie uterus, and is continuous 
with it at the os and cervix uteri. Cruveilhier and other anat- 
■oniiwts, have compared it to the dartos. The mucous lining of 



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Female Generative Organs. 29- 

the Tagina, upon the lower portion of the anterior and poste- 
rior walls, in the median line, has two thickened ridges, termed 
the eoluinnsB rugarum, or vaginal columns. The anterior is. 
more prominent than the posterior, and is sometimes divided 
into two portions by a longitudinal furrow. From these two- 
columns project folds of mucous membrane at nearly right 
angies, which are heavier and more uumeroua in the lowermost 
part of the vaginal canal. The rugte, or cristse, as some prefer 
to call them, are most distinct in virgins, less so in women who- 
are accustomed to sexual intercourse, and are nearly absent in 
women who have borne children, and in those who have passed 
the child-bearing period. The purpose of these mucous folds is 
double— (1) to afford increased eensational area, and (2) more 
particularly to provide against ruptureof the vaginal mucous 
membrane during the immoderate distension which takes 
place in labor. According to Henle, the muscular fibers of the 
vaginal columns possess tralaecular arrangement and inclose 
oflshootsfrora the vaginal plexus. Though thus constructed, 
the columns are not properly erectile. When turgid with blood, 
they close the vagina, but the resistance they offer is not for- 
midable, since, like a sponge, they are easily compressed. 

Micn>scopical examination discloses a large number of vas- 
cular papillee studding the mucous membrane of the vagina, 
which under certain conditions, as those of pregnancy, become- 
greatlj- enlarged, so that to the examining finger they seem 
hard and rough. Writers have frequently described the vagina 
as containing a great number of muciparous glands to which 
is attributed the secretion of the mucus which lubricates this 
tube. It has now become a conviction (unsettled, however, by 
some doubt) that there are no secreting glands. Dr. Tyler 
Smith, who was one of the first to deny their existence, says: 
"The mucus of the va^na is, I believe, produced by the 
epithelium, and consists of plasma and epithelial particles." 
This thin layer of n>ucus which covers the vagina even in 
periods of repose, is, as was pointed out by M. Donne and Dr. 
Whitehead, distinctly acid. Under sexual excitement, men- 
struation, and during parturition, the amount of secretion is 
greatly increased. 

The lining coat of the vagina resembles ordinary siiin almost 
as much as mucous membrane, and in cases of procidentia, 
under external exposure, it becomes converted into dermoid 
tissae. The mucous membrane is reflected aver the vaginal 



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30 Anatomy of the Pelvis. 

portion of the cervix and oh uteri, whereon is everywhere found 
squamous epithelium. 

The vapiiia is abundantly supplied with vpHsels and nerves. 
The blood js derived chiefly from the anterior branches of tlie 
internal iliac through the vaginal arteries, but in part from the 
inferior vesical and internal pudic arteries. 

The arteries form an intricate network around the tube, and 
eventually end in a sub-mucous capillary plexus, from which 
twigs pass to supply the papillte. These in turn again give 
origin to the venous radicals, which, uniting into meshes, freely 
communicate with each other and form a well marked venous 
plexus. The lymphatics conduct to the lateral glands within, 
and the inguinal glands without. 

The nerves are derived from the hypogastric plexus. 

Thk Perineum.— The peri- 
neum is one of the most impor- 
tant structures in connection 
with the female generative ap- 
paratus, and hence merits most 
careful study. It is situated 
between the posterior vaginal 
commissure and the anus be- 
low, and the vagina and rectum 
above. It presents three aur- 
Pio. 22.— 1, vagina. 2, rectum. 3, faces for study, namely, the va- 
triangular notch or space into ^„^, extending upwards from 
"which penetrates the perineum. , ■ . 

the posterior vnlvar commis- 
sure for a distance upon the recto-vaginal septum, the rectal 
surfaces extending from the margin of the anus upwards upon 
the recto-vaginal septum, whilethe third is that which stretches 
externally between the posterior vaginal commissure and the 
anus. The last constitutes its base, and measures from an 
inch to an inch and a half in length. The perineum is a body 
of considerable thickness, but during expulsion of the f<i?tal 
head it becomes greatly thinned and elongated, so that the 
dimensions of its base, as above described, are greatly in- 
creased. 

The structure of this body is chiefly skin, ceflular tissue, 
muscular fibers, and mucous membranes. The peculiar ar- 
rangement of the perineal muscles deserves notice, they being 
inserted by at least one extremity into tendinous structures 
and fasciie. This is true of the sphincter ani, levator ani, 



Female Geserative Okgass. ^1 

coccygei, transversi periDtei, erectoren clitoridia, and ephiiicter 
va^nte. 

The fibers which are asBOciat'ed to form these several mu«- 
cles are comparatively indistinct and are mixed up with a good 
deal of elastic dartoid tissue. Such peculiar construction of the 
perineum is what gives to it the quality of contractility and 
distensibility, so notably manifested duiiug parturition. 



Fio, 23.— Kluscles of the Perineum. 

The most important muscle which enters into the structure 
of the perineum is the levator ani. This muscle has a double 
structure, is attached anteriorly to the inner surface of the 
bodies and horizontal rami of the pubes, and its lateral halves 
to the tendinous arches of the pelvic fascire, which stretch from 
the inner borders of the pulKS to the ischial spines. From this 
broad orisin the muscle extends downwards and inwards to the 
sides of the bladder and rectum, and is inserted posteriorly into 
a tendinous raphe, which extends from the top of the coecys t« 



Anatomy op the Pelvib. 



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Female Generative OitGANa. 33 

the rectum. The fibers extending to the rectum become bleuded 
with those of the external sphincter, while those in relation with 
the vagina are situated beneath the bulbs of the vestibule, and 
the constrictor cunni. The ischio-coccygeus, a small muscle, is 
by some included in a description of the levator aui. It requires 
no detailed notice. 

The levator ani and coccygei muscles are of nearly membra- 
nous thinness, and derive their chief strength from the strong 
tissues of the intenicJ pelvic fascia, with which they are brought 
into close union. 

The other muscles which contribute to form the pelvic floor 
are of less obstetric importance. They are chiefly the ischio- 
cavemosi, the constrictor vaginte, and the transversi perinset 
The ischio-cavemosi muscles form a sheath about the crura of 
the clitoris. The constrictor vaginiB is made up of two small 
lateral muscles which he upon the outer side of the vestibular 
bulbs, and surround the vulvar orifice. The transversi perineei 
muscles are small, triangular and thin, extendingfromtheinner 
sides of the ischia, underneath the constrictor muscle to the 
sides of the vagina and rectum. 

It remains to be said of the perineal body that it occupies, 
as stated, the space between the vagina and rectum, and in a 
sagittal section presents a triangular shape ba shown in figure 
22. It extends up the recto-vaginal septum nearly half the 
length of the vagina. 

The function of the perineum is to close the lower outlet 

posteriorly so as to aid in retaining the pelvic viscera, and yet 

to close it in such a way as to admit of distention of the outlet 

when necessary in a manner to insure but temporary dilatation. 

{«) 



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Anatomy of the Pelvis. 



CHAPTER IV. 
THE FEMALE INTERNAL GENERATIVE ORGANS. 

The Uterus.— About this wonderful organ more obstetnc 
interest centers than about any other in the female economy. 
It is pear-shaped, flattened somewhat antero-posteriorly, and 
bent slightly on its longitudinal axis, its concavity looking 
forwards. 

In the vii^n the or(;an differs in shape and size from that in 
the woman who has borne childrea. The nuUiparous uterus 



Fia. 26. — Normal position of the Uterus, with empty Bladder. 

varies in length from two to two and a half inches. Its aver- 
age breadth at the widest point is about one and a half inches, 
while its thickness is about three quarters of an inch. 
Richet gives the following dlmeiisioni^ : 

VertEfal diameter TraDBTer^e latra- 
luehes. Inchex. 

Virgins 1.7 .6 

Nullipara? 2.0 1,0 

Multipara 2.3 1.2 

Its average iveiglit is about 030 grains. 
Its upper border is moderately convex, and it« lateral bor- 
ders are convex above and concave below. At the points of 



Internal Genekative Organs. 85 

janetion of the lateral anti superior borders, being the angles or 
cornua, the Fallopian tubes joiu the organ. The lower portion 
of the organ is spindle-shaped, and has a width of say tliree- 
quarters of an inch. 

By reason of its peculiar form the uterus is naturally divided 
into two portions of nearly equal length. The lower portion is 
called the cervix, or neck. Theupper portion issubdivided, and 
that part lying below the Fallopian tubes is known as the 
corpus, or body, while that situated above the Fallopian tubes 
is distinguished as the fundus. 

The lower part of the cervix is. embraced by the upper 
extremity of the vagina, and this intravaginal end of the cer- 
vix is known as the vaginul portion. 
The remainder of the cervix, which A 

lies above or without the vagina, is 
distlDguished as the supravaginal ' 
portion. At the lowermost extremity 
of the cervix there is a slightly trans- 
verse aperture, called the external os. 
or OS tincse. In uulliparee it is very 
small, measuring not more than two 
lines in width, and sometimes scarcely 
admitting the point of a small uterine 
sound. This uterine mouth is pro- 
vided with two thick rounded lips, 
the anterior being a little the longer. 

In the adult lemale the uterus is 
situated in the true pelvis, between 

the bladder in front and the rectum Fm. SB,— Anterior view of 
behind. What we mean to say is, that Virgin Uterus (Sappej). i, 
in the non-pregnant condition it is "^r- 22. angips. 3. cervix, 
wholly within the pelvic cavitv, the ^' '"*"' °' "'ternum. 6. 
- , , . , , , , - , vaginal portion of cervix. 6, 

fundus bemg below the plane of the external ob. 7 7, vagina, 
auperior strait. 

The mechanism by wliich the organ is held in position should 
be well understood. Lying close to the axis of the pelvic canal, 
it is to a certain extent supported by the vaginal walls and 
columns, while the latter derive much of their supporting power 
from the levator ani muscle and the pelvic fascia. 

The Uterine Lioamenth, from their peculiar arrangement, 
give to the organ considerable freedom of movement, yet serve 
to prevent seriotis deviations of position or situation. Most of 



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36 .'^NATOMV OF THE I'ELVI8. 

tbeee are formed by folds of that great serous membraue which 
wraps the pelvic viscera, namely, the peritoueum. This mem- 
brane, after covering part uf the posterior surface of the blad- 
der, is redected upon the anterior face of the uterus, overlying- 
the greater part of its superficies. It then passes over the 
fundus uteri, and dowu the posterior surface, dipping to a con- 
siderable depth, and forming, posteriorly to the upper part of 
the vagina, a serous pouch, bounded laterally by folds of the 
peritoneum. This pouch is the cul-de-sac of Douglas, and the 
folds of peritoneum which form its lateral boundaries are the 
retro-uterine, or utero-saeral ligaments. Anteriorly to the 
uterus — that is, between the uterus and bladder — is a shallow 
pouch with similar hgamentous boundaries formed by the 
peritoneum, the latter being known as the vesico-uterine' liga- 
mentH. The peritoneum being a broad sheet, or apron, forms 
by its duplicatures, as it passes over the pelvic organs in the 
manner described, broad folds upon both sides of the uterus, 
stretching from this ovgan to the pelvic wall, known as the 
ligamentH lata, or broad ligaments. These divide the pelvia 
into two cavities — the anterior of which lodges the bladder, and 
the posterior the rectum. The superior margin of the broad 
ligament is free, and extends from the angle of the ut^us to 
the pelvic wall. The two serous folds which constitute the 
broad ligament are separated by a loose, and \ery exteuHible, 
lamellated cellular tissue, continuous with the proper surfaces- 
of the pelvip. 

The broad ligaments disappear during gestation, their two 
laminee assisting to cover the anterior and posterior surfaces of 
the enlarged uterus. 

The round liffaments, or supra^pubic cords, are structures 
which differ entirely from those just de8cril)ed, being evidently 
continuous with, and similar in character to, the uterine tissues. 
They arise from the upper borderoftheuterus, and extend trans- 
versely, and then obliquely, downwanis, until they pass through 
the inguinal rings, and blend with the cellulartiseueof themons 
veneris and labia. In passing through the inguinal rings each 
is invested with a peritoneal sheath called the canal of Nuck. 
Their upper portion is made up solely of the nnstriped variety 
of muscular tissue; but, as they descend, they receive striped 
fibers from the transversalis muscles, and the columns of the 
inguinal rings. They also contain elasticand oonnectivetissue, 
and arterial, venous and nervous branches, the first being de- 



Intkhnal Generative Okgass. 



37 



"rived from the iliac or cremasteric artei'ies, and the last from 
the geiiito-erural nerve. 

The uterus thus held by its llKamenta is in a freely mobile 
state, such being nature's wise provision to protect the organ 
ifrom injury which it might otherwise receive through violent 
^physical exertion, falls, jars, and other disturbing occurrences. 
•As previously stated, its longitudinal axis corresponds pretty 
"closely with the axis of the pelvic canal, but the fundus of the 
organ in most cases is slightly inclined to the right. 

The Uterine Cavity. — Lateral section of the organ dis- 
•closes a cavity in form somewhat like the uterus viewed as 
jsi whole. Its width ^ 

«t the superior angles, 
<(vhere minute orifices 
mark the openings of 
the Fallopian tubes, is 
;greatest, while the nar- 
rowest point is at the 
juiH4:ion of the body 
and cervix, at which 
place is the uterine 
isthmus. The cavity 
is here a very narrow 
passage, distinguished 
as the internal os. Be- 
tween this point and 
the OS tincie there is a 
wider channel, known 
as the cervical canal. 



Fios. 27 AND 2S.— B, Median section of Vir- 
gin Uterus. C, transverse section (Sappey). 
B 1 1, profile of the anterior surface. 2, 
An antero - posterior vesioo-uterine cul-de-sac. 3 3, profile of poe- 
section reveals but a terior aurface. 4, body. 6, neck. 6, isthmus. 
7, cavity of the body. 8, cavity of the cervix. 
9, OS internum. 10, ant. lip of ob externum. 
11, posterior lip, 12 12, vagina. C 1, cavity 
of the body. 2, lateral wall. 3, superior wall. 
4 4, cornua. 5 os internum. 6, cavity of the 
cervix. 7, arbor vitK. 8, os externum. 9 9, 



email cavity, with the 
anterior and posterior 
walls lying in contact. 

STRUrTUltE OP THE 

UterL's. — Three prin- 
cipal tissues enter into 
the composition of the uterus, namely, peritoneal, muscular, 
and mucous. The manner in which the peritoneum invests 
the organ has been descrilyed with sufficient minuteness for 
practical purposes. A good partof theeutireareaof this organ 
is covered by it. The investment at the sides is leas extensive 



vagina. 



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38 Anatomy op the Pelvis. 

than elsewhere, since the peritoneal folds separate a short dis- 
tance below the Fallopian tubes, and there the nerves aiid ves- 
sels which supply the organ gain entrance. The peritoneum, as 
it covers the upper portion of the uterus, becomes firmly adher- 
ent t-o it, while below it is more loosely connected. 

The Muscular Structures. — The proper tissue of the uterus 
is of a grayish color, and is very dense in structure, creaking 
like cartilage under the scalpel. The cervix is (generally lesa 
firm than the body, a condition resulting, as Mr. Cruveilhier 
believG8, from the body and fundus being the more frequent 
seat of sauKuinous fluxions. Under physiological as well a» 
pathological couditioiis, the tissue presents a more marlied 
redness, abd is more supple. 

The uterine tissue is clearly fibrous in character, but the 
nature of the fibers has been a subject of spirited debate. The 
microscope appears to have ended th« dispute by showing them 
to be clearly muscular. This is 
further shown by the develop- 
ment that takes place during' 
pregnancy, the uterine muscular 
fiber becoming large and power- 
ful. It is certain, then, that the- 

F,o.29.-i^«lar fibers of un- P'-^I'^'' ''*«""« *'««"« '« ^^'^8^ 
-impregnated Uterua (Farre). a, muscular, but the fibers in the 
flbera united b; connective ttssup. non- pregnant organ are con- 
6, separate fibers and elemenUrj densed or atrophied, BO that 
oorpuBoIei. their true character is in a meas- 

ure concealed. In the latter condition of the organ, the direc- 
tion of its muscular fibers cannot be satisfactorily made out. 
They cross and recross, as every examiner has found, in an 
almost inextricable manner. 

An attempt has been made to divide the muscular fibers 
into three layers, namely, (I) one in which the fillers take a 
longitudinal direction; (2) another wherein they are circular, 
and (3) a third in which they run obliquely. After patient 
study and reseai-ch, Bayer arrived at the following conclusions : 

1. The fundus is composed of— 

{a,.) A 8upei*ficial layer, the medium longitudinal fibers of 
■which pass from before backwards, while the lateral fibers are 
arranged in whorls around the insertions of the oviducts. 
These whorls pass from left, to right around the right tube, from 
right to left around the left tube, compared with the direction 




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I.NTERNAL GKNEKATIVE OKGA.VS. 39 

in which the hands of a watch move. A hood-like coverine; is 
thus formed, probably arising from the external lougitudiual 
layer of the oviduct, and of the round ligament. 

{b.) Of the deepest, or Bubmucoue layer, arranged in the 
same manner as the above, and derived from the internal 
longitudinal fibers of the oviduct. 

(c.) Of a middle layer, which is derived from the round and 
from the ovarian ligaments, a biotid band, anteriorly and 
posteriorly, on both Hides of the median line, passing in asagit- 



Fio. 80.— External Muscular Fibers of the Uterus. 

t-al direction. This is interlaced with transvorse bands from 
the circular fibers of the oviductH. Fibers from fheovarian liga- 
ment, in connection with the latter, surround the horns of the 
uterus in spirals and obliquely placed circulars. 

2. The posterior wall is formed by the circular fibers of the 
oviduct, by diagonal lamellte from the ovarian ligament, 
which pass inwards from above, and, finally, by the eccentric 
rings coming from the retractors, which penetrate all the 
la.vers. In this description the most superficial and the deejwHt 
longitudinal fibers originating from the oviducts, and which 



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40 Anatomy of the Pelvis. 

unite to form anteriorly and posteriorly a triangular muscle, 
are omitted. 

3. The middle part of the anterior wall may be divided 

into an extei-nal lonfptudinal layer, which arises from the mue- 

ciilar fibers of the round Hgament, united with the longitudinal 

fibers from the oviduct; a middle layer formed by the union of 

ciiTular fibers from the oviduct with the anterior rings of the 

retractors, and an internal longitudinal layer formed by the 

crossing anteriorly of 

the inner longitudinal 

fibers of the oviducts. 

4. In the lower part 
of the body the greater 
part of the walls is 
formed by muscular 
bands from the round 
ligaments. 

5, In the internal 
and external portion of 
the cervix, longitudinal 
fibPFB, which are the con- 
tiimation of the corre- 
sponding layers of the 
corpus, anteriorly and 
posteriorly puss iu the 
median line. BeflJdea 
these, the posterior wall 
of the cervix essential- 
ly consists of eccentric 
rings of the retractors, 
the interlacing fibers of 
which form other parts, 

and finally of fasciculi from the ovarian ligaments, which after 
passing longitudinally are inflected. 

In the anterior wall of the cervix only muscular lamellse, 
running diagonally toward the mucous membrane, and cover- 
ing each other like the tiles of a roof, can be recognized ; the 
fibers of the retractors are found more especially in the lower 
third, forming a compact muscular mass from interlacing with 
the radiating fibers from the round ligament. 

The Mucous Surface. — The existence of any mucous mem- 
brane whatever on the inner surface of the uterus has been 



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INTERNAL Generative Organs. 41 

<|ue«tioned by a number, and even recently by Dr. Snow Beck, 
who insists tJiat what has been bo regarded is nothing more 
nor less than softened proper uterine tissue. Authorities in 
^nerai, however, do not concur in this belief, but agree that it 
is essentially a mucous membrane, differing from mucous mem- 
brane in other parts chiefly in being more intimately aflso- 
ciat«d with the subjacent structures, in consequence of possess- 
ing no definite connective tissue frame-work of its own. Its 
color is pale pink. Its thickness varies considerably in dif- 
ferent partM. Towards the middle of the body it constitutes 
About one-sixth of the thickness of the entire uterine walls, 
being from one-twelfth to one-twenty -fifth of an inch. Like the 
uterine walls themselves, it thins off rapidly towards the in- 
ternal OS below and the Fallopian tubes above. Within the 
cervix the uterine mucous membraue loses many of its char- 
acteristics. On the anterior and posterior surfaces of the canal 
is a promhieut perpendicular ridge, with one less distinct on 
-each side, from which extend ridges at acute angles. These, 
from their appearance, have been called the arbor vitiB, penni- 
form nigre, and palmee plicatw. Like the vaginal rugae, they 
are most distinct in virgins, and are indistinct after child- 
bearing. The mucous surface of the uterus in a normal con- 
dition is covered with a thin layer of transparent alkaline 
mucus. 

The Uterine Glands. — With the aid of a strong glass, the 
general structure of the uterine mucous membrane is clearly 
seen. It is made up in part of connective tissue, which is 
■directly continuous with the connective tissue of the muscular 
coat, in which, as a bed, are a large number of tubular, or 
utricular, glands. About forty-five of them are contained in a 
space one-eighthof an inch square. These glands have a sinnous 
course, often divide below into two or three separate blind ex- 
tremities, and are about ,hr of an inch in diameter. As a rule 
they penetrate the entire thickness of mucous membrane, and 
ill some instances even dip into the muscular tissue. Their 
basement membrane is composed of spindle-shaped cells, which 
dovetail into one another. Their free surface is covered with 
cylindrical cells, possessing cilise. The mucous membrane itself 
possesses an epithelial covering, of the ciliated variety, which 
is believed by some to produce a current in the direction of the 
Fallopian tubes. 

The glands of the cervix (glands of Naboth) cover the 



42 



AXATUMY OF TUB PELVIS. 



entire area of the cervical canal, from the intenial os to the 
borders of the externah They differ from those found within, 
the uterine cavity. Like them they are cylindrical, but termi- 
nate in a rounded cul-de-sac, lentil-uhaped. These glaiidsare bo 
numerous that, according to Dr. Tyler Smith, " ou a moderate 
computation, under a power of eighteen diameters, ton thou- 
sand mucous follicles are visible in a well developed nulliparous 
organ." "These glands," says Dr. Lusk, "are, gfuetically con- 
sidered, simple iuveraioiis of the mucous membrane, and are 
lined by ciUated epithelium." 

Obstruction of the neck of these 
glands gives rise to straw-colored vesi- 
cles, which have been called the ovula of 
Naboth. The penniform rugte give to 
the cervical canal an extensive secre- 
tory surface, which furnishes an alkaline 
mucus. 

The Vessels of the Uterus. — The ute- 
rus receives its blood from two sources, 
, namely, (1) the two ovaiian, or sper- 
matic, arteries, and (2) the two uterine. 
The origin of the ovarian arteries is 
about two and a half inches above the 
aortic bifurcation. They pursue a ser- 
pentine course, descending obliquely 
downwards under the jieritoneum to the 
pelvic cavity, and then ascending be- 
j tween the folds of the broad ligaments. 

They then reach by their main trunks 
the sides of the uterus, and communi- 
cate with the uterine arteries. The 
uterine niteries are derived from the 
hypogastric. Their course is at first to 
the vapnnal fornix, where they give the "vaginal pulse." Thence 
they curve upwards between the folds of the broad ligament, 
and pass in a tortuous course over the lateral borders of the 
uterine cervix and body. By means of a circumflex branch at 
the junction of cervix and corpus uteri, the arteries of each side 
communicate. 

The veins of the uterus are valveless. but, hy anastomosis, 
they form a network through all the uterine tissues. They are 
so intimately related to the latter that they remain open after 



Fia. 32. — Section 
through UteruB, ehow- 
itif? cavity, a, and icland- 
iilar Btructures, d. (He- 
ber.) 



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Internal Okkekativk Okcans. 4a 

section. Duriog pregnancy they eiilar^ to t'orni "einuseB." 
The blood, collected by the veiue, is carried into two venous 
plexuses, namely, the uterine and jminjnniforiu. The latter 
returns blood from the uterus. Fallopian tubes and ovarii, 
but the former from the uterus <mly. 

The Uterine Nerves. — Frankenhaeuser saj's that the nerves 
of the uterus are derived from the gangliateU cords of the nym- 
pathetic system, through the medium of the hypogastric and 
cervical plexus, and by means of which important connectioua 
are formed with all the ab- 
dominal viscera. The nerves 
supplied to the organ, when 
examined without the aid of a 
lene, are soon lost to eight in 
the utenue walls ; but in micro- 
scopic preparations, Franken- 
haeuser has traced their ulti- 
mate filaments to the muscu- 
lar element, where they appear 
to terminate in the nuclei of 
the fiber-cells. Notwithstand- 
ing the denial of some anato- 
mists, it is now generally con- 
ceded that the cervix is sup- 
plied with numerous fllameute, 
even to the os tirioe. 

From experiments on rats, 
mice, rabbits, etc.. Rein con- 
cludes that there exists an 
essential nervous plexus. Iving posterior aspect is shown, i. fundus 
outside of the uterus, mainlv ".^«"- 2- '"K]"^! Portion. 3 8^und 
, ,,_ „ 1 ^. ; iigamentH. 4 4, Fallopian tubes. 5. 

in the cellular tissue surround- right o^ary. e.abdom. aorta. 7, inf. 
ing the vagina at the point mesenteric art. 8 a, spermatic ar- 
where the hypogastric plexus teries. 9, common iliac. 10, ent. 
anastomoses with filaments of '■'«<=■ ". hypoftast. art. 
the sacro-uterine nerves. Many ganglionic cells are found in 
it, lying for the most part along the course of the principal 
nerve branches which go to, and come from, the plexus. The 
upper limit of these cells is at the beginning of the tubes ; the 
lower limit is lost in the vo^nal plexus. No fil»er, either from 
the hypofiraetric plexus or from the sacral nerves, goes to the 
uterus without first passing through the uterine plexus. 



Fia. 33. — Arterial Vessels in a 
i len days after Delivery. The 



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44 Anatomy <n- the Pei.vih. 

The Lymphatics.— hymphs^acee abound in the uterine tis- 
suea, and r^ular lymphatic vesaels are found in the connective 
tisHUe about the arterial trunks in the parenchyma. Beneath 
the peritoneum is found a real network of theee veHsels. Large 
receiving vessels lie just beneath the external muscular layer on 



Via. 81.— Nerves of the Dterua. A, plexus uterinus magniu. B, pUiiu 
Ik^pogtutrlcuB. C, cervical ganglion. 1, sacrum. 3, rectum. 8, bladder. 
4, ui«raB. G, ovATj. S, extremity of Fallopian tube. (Frankenhaeiuer.) 



either side of the organ, into which the lymph from both the 
subserous and uterine vessels is poured. The lymph vessels 
from the upper part o( the vagina and lower cervix lead to glands 
on the pelvic floor, whence they proceed to the next system of 
glands in the bifurcation of thecommoa iliacarteries and thence 
to the lumbar glands. Lymph vessels from the uterine body 
pass out through the mesosalpinx near the ovarian attachments 
and up the suspensory ligament to the lumbar gland.s; or they 
course down the round ligaments to the deep inguinal glands. 

DeveiX)pment. — In the embryo the utorua is formed by the 
fusion of the two ducts of Miiller, or the efferent tubes of the 



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Internal Gi:nerative Orgaxs. 



Fig. 85.— Uterus with double cavity, and ilight deviation of form. 



Fig. as. — Uteras SeptOB Biloculsris. Double uterus, with single vagina, 
eeen from the front. Left walls more developed in consequence of preg- 
aaucf. (Cruveilbier.) 



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46 Anatomy of the Pelvis. 

rudiinentaiy geiierative apparatus. Upon thus uniting, the 
partition between the two is absorbed, and the organ is then 
left but a siiijrle i;avity. In different stages of development 
there is aceordingrly an organ of varying shape. 

Abnorm.\litif;» op the Uterus. — The various abnormal 
conditions of the nteniB and vagina which are occasionally met 



Flo. 37.— Double Uterus and Vagina from a Girl Ag&d Nineteen (Ersen- 
tnann). a, doublft vaginal orifice with double hymen, h, meatus urethrte. 
c, clitoris, d, urethra, f e, the double vagina. //, uterine orifices, i; i;, 
cervical portions, h h, bodies and cornua. i i, ovaries, it k, Fallopjao 
tubes. 1 1, round ligamentB. m ni, broad ligaments. (Court}'.) 

are, in the main, the result of ari'ested development. After the 
canal or ducts of Miiller have united t(t form the rudimentary 
uterus, if the partition should remain, the result will be a 
double or bifid uterus. This may be true of an organ pretwut- 



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Ikternal Generative Orqanh. 47 

ing little difference in form from that of the normal uterus, as 
shown in figure 35, or the organ may present an external ai>- 
pearance which roiresponda to its internal anomalies, as iu 
figure 36. The partition may not esist alone in the uterine 
«avity, but extend downwards, to form a double vagina as 
well. 

The following constitute the main varieties of abnormalities: 

I. The Cterus Unicornis, or single-horned uterus. — In that 
case the organ presents but a single lateral half, and generally 
has but one Fallopian tube. 2. The Duplex Uterus.— Two dis- 
tinct uteri are produced, each of which represents a half of the 
normal uterus. 3. The Uterus Bicornis. — Thisresultsfroni par- 
tial union of the ducta of Miiller, giving to the upper part of the 
ot^an two horns, divided by a furrow. 4; The Uterus Oordi- 
formis. — This, as its name indicates, presents the form of a heart 
as ordinarily represented on playing cards. 5. The Uterus 
Septus Bilocularis.— Union in this case is complete, but the 
septum persists as represented in figure 36. 

Obstetric DmsiON of the Uterus.— For obstetric analysis 
we may divide the uterus into two segments, an upper and a 
lower, the dividing line being the contraction ring of Baudl. 
The superior section embraces that part of the uterus which 
takes an active part in the expulsive efforts. Bandl's ring is 
located at about the lower line of peritoneal attachment, and in 
the uterus at full development is at or near the plane of the i>el- 
vic inlet, 

"Thetrue retraction ring of Bandl," says Reynolds, "whether 
we believe it is situated at the level of the internal os or above it, 
is, at all events, always due- to passive distention and thioning 
of the less powerful lower portion of the uterus by the active 
contractions and retraction of the more powerful upper part; it 
is frequently developed in the presence of a normal or excessive 
quantity of liquor amuii, and when se6n in a pure state, is due 
solely to the action of the longitudinal, and not at all to that of 
the circular, fibres, 

"It is felt clinically as a mere ridge in the uterine wall, is in 
no sense a constriction ring, and, like the general retraction of 
a dry uterus, it is the necessaryresultof exhaustion of the uter- 
ine muscle by a too long continuance of labor in the face of an 
obstacle. " 



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Anatomy of the Pelvib. 



THE FEMALE IXTERSAL GEXERATIVE ORGAXS— Continued. 

The Fallopian Tubes, or Oviducts.— These are the homo- 
Ic^ues of the va»a differentia of the male. They are the 
infundibula or insluvies which takeup and convey the ova from 
the ovaries to the uterine cavity, aa well aa transmit to the 
ovaries the fecundating principle of the male. They measure 
from three to four inches in len^h, and extend from the upper 
angles of the uterus to the ovaries. Their course in along the 
upper margins of the broad ligaments, being covered by peri- 



Fio. S8. — Ovary aod Fallopian Tube, o d. Fallopian tube, o, ovarj, o a, 
fimbriated extremit; of the tube, p o, parovarium. 

toneum similarly to the uterus. They may justly be regarded 
as integral portions of the latter organ. The Fallopian tubes 
are trumpet-shaped, and terminate near the ovaries in a com- 
paratively broad, fringed end, called the fimbriated extremity, 
or morsue diaboli. This free extremity communicates with the 
peritoneal ca\ity. Oue of the fimbrise is attached to the outer 
angle of theovary by a fold of peritoneum. It issupposed that 
dcring the menstrual nisus the fimbriae apply themselves 



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Inteunal Gkxerative Okgaxs. 49 

firmly to the ovary, in order to receive the escaping ovuie. 
These tubes are in the upper part of the broad ligament, where 
they cau be felt as hard cords. The uterine extremity of the 
tube presents au bpenini; known as the ostium uterinum, which, 
owing to its small size, will scarcely admit a bristle. 

The tubes are so remarkably movable that they are not 
only capable of applying themselves to those parts of thwr 
respective ovaries from wliich the ovule is to come, but, as is' 
now believed, to stretch themselves to opposite sides to receive 
an escaping ovule. 

In some cases there are found to exist supernumerary fimbri- 
ated extremities which communicate with the tube air some 
distance from the main extremity. In the bodies of twenty 
women, selected at random by M. Gustave Richard, this anom- 
aly was found five times. 

The walls of the tubes are provided with a peritoneal, a 
muscular and a mucous coat, — the muscular predominating. 

The last is arranged in two layei-s — one longitudinal and 
the other circular. By virtue of these the tubes have a ver- 
micular or peristaltic action. Between the muscular and peri- 
toneal layers is a web of connective tissue, which gives support 
to a rich plexus of blood-vessels. The mucous membrane lining 
the cavity of the tube is highly vascular, and is provided with 
ciliated epithelium, which is said to produce a current in the 
direction of the uterus. 

The. Ovaries.— These are regarded as the essential or- 
gans of generation in the female, since they provide the germ 
which is madt' fruitful by contact with the male fecundating 
principle. They are the analogues of the testes, and, up to thft 
timeofSteno, were called "testes muiieris."' They are situated 
on either side of the uterus, within the pelvic cavity, and aio 
attached to that organ by muscular bands about an inch lon-r, 
called the ovarian ligaments. They are small, oval, flattentnl 
bodies, broader at the end distant From the womb, their ineiv 
Hurements being about an inch and a half long, about three- 
quarters of an inch in breadth, and three-eighths to half au 
inch in thickness. They are situated between the layers of the 
broad ligaments, the posterior layer being reflected over the 
entire organs, save at the attached borders, at which points 
openings exist for transmission of the spermatic vessels. They 
lie beneath, and somewhat behind, the fimbriated extremities 
of the Fallopian tubes, 
W 



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50 



Anatomy of the I'elvib. 



Besides the peritoneal coat, tbey Lave beneath it another, 
the tunica albngiuea. This covering i» so intimately adherent 
to the subjacent tiBsuee that it cannot be stripped off. Id the 
first three years of life it is entirely absent. 

Beneath ttie albugineti the pai-enchyma of the organ has an 
outer cortic&l and an inner medullary substance. The former 
Is of grayish color, and is made up of interlaced fibers of con- 
nective tissue, contain- 
ing a large number of 
nuclei. It is in this 
structure that the 
Graafian follicles and 
ovules are found. The 
latter exist in immense 
numbers in various 
stages of development, 
from the earliest peri- 
ods of life. The stro- 
ma of the cortical sub- 
stance is at no' place 
sharply distinguished 
from that of the me- 
dullary. The medul- 
lary substance has a 
reddish color, given it 
by its numerous ves- 
sels. It consists of 
loose connective tissue, 
with some elastic, and 
muscular. Rouget and 
Kis claim that the 
greater part of the 
ovarian stroma is 
formed of muscular 
tissue. 

The Ghaafian Fol- 
licles, or OnsAcs.— The Graafian follicles are formed at an 
early jieriod in foetal life, by cylindncal indigitations of the 
epithelial covering of the ovary, which sink into the sub- 
stance of the gland. Portions in this manner become infolded 
from the rest of the tubules, and form the Grnafian follicles. 
The ovules are developed from the epithelial cells which 



Fio. 89. — Longitudinal Section of an 
Ovary from a Girl Eighteen Yearn Old. 1, 
albuginea. 2, fibrous layer of cortical por- 
tion. 3. cellular layer of cortical portion. 4, 
medullary substance. 6, loose connective 
tissue. 



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ISTEUNAL GeNEIIATIVE ORGANS. 51 

line the tubules, derived priraarily from the surface of tbe 
ovary. 

The number of the Graafian follicles is immense, the ovary 
at birth being estimated by FouUb to contain not less than 
30,000, and by Henle 36,00o. The ovary at birth contains its 
full quota of follicles, and, during the menstrual epoch, develop- 
ment and destruction are constantly going on. Of course, but 



Flo, 40.~Portioii o! Vertical .Section tlirouf-h Ovary of Bitch, a, epi- 
thelium of ovarjr. b b, tubules of ovary, c. young follicles, d, mature fol- 
licles, f, discus proligerus, witli ovum, /, epithelium of second ovum in 
same follicle, g, tunica fibrosa folliculi. h, tunica propria folHculi. t, mem- 
brana granulosa. ( Waldeyer, ) 

a smalt proportion of the entire number ever reach maturity. 
Few of these follicles are visible to the naked eye, but under the 
microHcope all come plainly into view. 



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52 AXATOMY OF THIC PKLVIS. 

The structure of a mature Graafian follicle is, 1, an investing' 
membrane, consisting of two layers. The external, or tunica 
fibrosa, is formed of connective tissue, and is highly vascular. 
The internal, or tunica propria, is also composed of connective 
tissue, but contains a large number of fusiform cells and 
numerous oil globules. These two layei's are i-eally formed of 
condensed ovarian stroma. 2, The membrana granulosa, con- 
sisting of stratified columnar epithelial cells. Near the cir- 
cumference of the ovisac is the ovule, around which are 
congregated a large number of epithelial cells, forming what is 
known as the discus proligerus. Transparent fluid fills the- 
remainder of the follicle, with three or four bands, or retinaoula. 
of Barry, stretching through it, and attached to the opposite- 
walls of the cavity. In some 
young follicles the ovule fills 
the entire cavity. 

The Ovule. — The ovule is a 
rounded vesicle, about tU of 
an inch in diameter. At the 
time of its discharge from the 
ovary it is no longer a simple 
cell, composed of ordinary pro- 
toplasm, but presents the fol- 
lowing characteristics : It haa 

a thick, transparent envelope, 
Fio. 41. — Diaerammatio section , , ., ., ,,- , 

of Graafian FoUicIe. 1, ovnm. 2, t«™«» ^^^ ""^^"'^^ wewbmDe, 
membrana (jranulosa. 3, external or zona peUuCida. The body 
membrane of Graafian follicle. 4. its of the cell IS the vitellus, or 
veBselB. 6, ovarian stroma. 6,cavity yolk. It possesses the proper- 
ot Graafian follicle. 7, external cov- ^-^^ ^f ordinary protoplasm, 
enng o ovary. ^^^ ^ viscid consistence, and is 

opaque from the presence of very fine grannies and globular 
vesicles. The nucleus of the cell becomes converted into a 
large, clear, colorless vesicle, called the gerniinative vesicle. 
The nucleolus persists as a dark, probably solid body, within 
the germinative vesicle, where it is known as the genninative 
spot. The ovule is attached to some part of the internal sur- 
face of the Graafian follicle. 

Vessels anh Nerves of the Ovary.— The arteries of the 
ovary, derived from the internal spermatic, enter at the hilum 
and penetrate the medullary substance in a spiritual course. 
The branches freely anastomose, and form an interlacement. 



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Intehnal Gknehative Organs. 53 

Between tUe vessels thus connected are spaces, which become 
smaller as they approach the surface of the gland. The veins 
begin aa radicals, rapidly enlarge, aiiastoinoBe and form an 
erectile plexus. Larger veins then convey the blood through 
channels following the arteries, to the internal spermatic vein. 

Lymphatics emerge at the bilus, and are conducted to 
the lumbar ganglia. 

The uerve supply is from the ovarian plexus. 

The Intra-Pelvic Muscles.— Certain muscles which encroach 
upon the pelvic space should be mentioned. The iUac mnscles 
spread over the entire iliac fosate, but their origin is chiefly 
marginal. The musclescondenee below, pass under Poupart's 
ligaments, aud become united to the psoee muscles. These 
muscles cushion the iliac fossa, aud thereby afford a soft 



FiQ. 42. — Uterine and Utero-ovarian Veins (Plexue Pap in i for mis). 1, 
ateruii Been from the front; ite right half is covered by the peritoneum; 
upon the left half ma; be seen the plexuB of uteroHjvarian veins (internal 
spermatic). 6, utero-ovarian veeseig covered by peritaneum. 7, the same 
veasele eiposed. 8 8 8. veins from the Fallopian tube. 9, venous plexun 
of the hilum ovarii. 10, uterine vein. II, uterine artery. 12, venous plexus, 
coverinf; the borders of the uterus. 13, anastomoses of the uterine with 
the uteroHDvarian vein (int. spermatic). 

support for the gravid uterus. The great psoee and the iliac 
muscles encroach more or less upon the transverse pelvic diam- 
■eter at the brim. By virtue of their femoral insertionR, they 
serve as flexors of the thigh ; while, in addition, the iliacs act 
.as abductors, and the psose as flexors of the pelvis upon the 
apinal column. 

The pyriformia muscles close the racro-sciatic notches. 
Their shape is triangTilar. the base presenting a series of digita- 
tions, which find insertion upon the lateral portions of the 
anterior surface of the sacrum, and the superior margin of the 
eacro-Bciatic ligament. After crossing the greater sacro-sciatic 



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54 AXATOMY OF THE PeLVIS. 

forameD, aud emer^ng from the pelvis, they terminate in 
a temjon which iu inserted into the great tpoohauters. 

The obturator intemuB muscle arises from the circumference- 
of the obturator foramen, and theinuersurfaceof the obturator 
membrane. Its converging fillers form a tendon, which passes 
out through the lesser sacro-Hciatic foramen, and is inserted 
into the digital fossa of the great trochanter. None of the 
mtra-pelvic muscles oi-i-upy much space in the pelvic cavity. 

The Mammary Glands.— An account of the ffiimlf genera- 
tive organs would be incomplete without supplementiirv refer- 
ence to the mammary glands. They are two in number, of 



Pig. 43. — Section of Pelvla, shon-ing the Pyramidal Muscles. 

the compound racemose variety, are situate on either side of 
the sternum, between two layers of superficial fascite, over the 
pectoralis major muscles, and extend from the third to the sixth 
rib. They are convex anteriorly, and flattened posteriorly. 
Their size varies considerably, chiefly on account of the differ- 
ence in amount of adipose tissue which they contain. In most 
women the right breast is larger than the left. Owing to hyper- 
trophy of their glandular structures, during pregnancy they 
increase greatly in size. Anomalies in number, shape and posi- 
tion are occasionally observed. They are covei-ed with a tine, 
supple skin, and a layer of adipose tissue, which increases in 
thickness towards the periphery. The glandular mass is made 
up of from fifteen to twenty-four lobes, these being subdivided 
into lobules, constructwl of acini, or minute ciil-flps/ics. The 
acini open into fine canaliculi, which unite until they form a 



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Intkrxal Generative Organs. 55 

large duct for each lobule. These ducts are confluent, forminfr 
a Btill larger caual for each lobe, which opens on the surface of 
the nipple. The latter canals are kuowti as galnctophorus, or 
lactiferous ducts. When they reach the space beneath the 
areola they enlarge to form the sinus of the duct, measuring 
from one-sixth to one-third of an inch in diameter. In the 
nipple, their diameter is from cue-twelfth to one-twenty-fifth of 
an inch. The openings on the nipple are from one-eixtieth to 
one-fortieth of an inch in diameter. The acini are lined with a 
single layer of small polyhedral cells, becorningmorecylindrical 



Tra. 44.~Snperaamerai7 Mammsa. (Hint) 
nearthecanalicular ducts. The main channels are lined with 
low, cylindrical cells, and are provided with non-striated mus- 
cular fibers, which contract and produce a freeflow of the secre- 
tion during lactation. 

At the summit of the mamma is a conical projection, vary- 
ing in diameter from a quarter to half an inch, called the nip- 
ple. Its surface is covered with papillse, between which open 
the lactiferous ducts. Upon its surface open also numerous 
sebaceous follicles, the secretions of which protect and soften 
the integument during lactation. Beneath the skin are mus- 
cular fibers, mixed with connective and elastic tissues, vessels, 
nerves and lymphatics. Irritation of the nipple brings about 
turgescence and excites muscular action, which causes c<mtrac- 
tion and hardening. 



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56 Anatomy of the I'elvis. 

The Areola is a circle which surrounds the nipple, of a color 
difFerinff from the other integument. It is pink in virgiuH, and 
in provided with from fifteen to thirty follicles, which pour out 
their secretions to moisten the areola. A band of muscular 
fibers is found beneath the integument, the nction of which. 



Fio. 4&, — Mammar; Gland, o, nipple, the central portion of which is 
retracted, h, areola, c c c c c. lobules of the K'l^nd. 1, sinus, or dilated 
portion of one of the lactiferous ducts. 2, extremities of the lactiferous 
ducts. (Liegeois.) 

when stimulated, is to compress the lactiferous ducts, and thus 
tavor the flow of milk. 

The mammie receive their blood supply from the internal 
mammary and inteiTostal 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 brachial plexus. 



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PAET II. 
PREGNANCY. 

CHAl'TER I. 
nrPREGNATION AXD DEVELOP.VEXT OF THE OVU.V. 

Inasmuch ae this brauch of obstetrics iet of theopGtical 
rather than practical value to the student of widwifery, and 
since the study of it has been diligently pursued by a few, under 
most favorable conditions, and the results of their investiKfu 
tions have l»een made the common property of the profeesion, 
the author has taken the liberty to draw freely from various 
authorities on the subject, sometimes in their own words, with- 
out, in every instance, giving explicit credit. 

The anatomy of the ovary with its Graafian follicles and 
ovules has already been given. The formation of the Graafian 
follicles is in the main completed during the ante-natal period 
of existence. Until about the time of puberty they remain in « 
quiescent state, but with its advent they b^n to assume func- 
tional importance. The surface of the ovary, when now exam- 
ined, is found to be no longer smooth, but studded with 
small elevations. These elevations are caused by the enlarged 
Oraafian follicles, which have approached the periphery, and 
being distended by their fluid contents, form rounded, translu- 
cent prominences. From disappearance of the blood-vessels 
and lymphatics at the point of pressure, a weak spot in the 
wall of the follicle is formed, called the macula or stigma fol- 
lifuli. The discharge of the ovum is due to the conjoint action 
of a fatty degeneration of the walls of the mature follicle, and 
the development of the following changes: The follicle l)ecomes 
congested, and the vessels coursing over it loadefl with blood, 
while, at the same time, the ovarian covering l)ecomes so thin 
that the elevation presents a bright red color. Laceration of 
some of the capillaries in the inner coats takes place, and 
a certain quantity of blood escapes into the cavity of the folli- 
cle. By these means the distension is greatly increased, until 
at last, under the additional stimulus of sexual excitement, or 
(5?) 



58 PREG.NANCY. 

without it, rupture occure, aud the ovule is net free. Whether 
laceration takes place before, during or after nienstruation is 
still an unsettled question. Thinning of the follicular and 
ovarian walls goes on at one and the dame time, aud final 
rupture takes place simultaneously. It in probable that lacera- 
tion is further promoted by growth of the internal layer of the 
follicle, which increaaes in thickness before rupture, aud is given 
a characteristic yellow color by the number of oil-globules 
which it contains. Contraction of the muscular fibers in the 
ovarian stroma is also supposed to have an influence in 
the production of laceration . As rujiture occurs, the fimbriated 
extremity of the Fallopian tube is closely applied to the ovary, 
receives the freed ovule, and starts it on towards the ute- 
rine cavity. 

The Corpus Luteum of Menstruation.— 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 with blood. The blood soon coagulates and the clot is 
retained. The aperture through which the ovule escapes is 
often not more than one-fortieth of an inch in diameter. If the 
follicle is now incised longitudinally, it will be seen to form a 
globular cavity, one-half to three-quarters of an inch in diame- 
ter, containing a soft, dark coagulum lying loosely within it. 
An important change soon begins. The clot contracts and 
expresses its serum, which latter is absorbed by the neighbor- 
ing parts. The coloring matter of the blood is also to a great 
extent absorbed, so that at the end of two weeks a diminution 
of color is perceptible. The membrane of the follicle becomes 
thickened and convoluted, and encroaches on the cavity. At 
the end of thi-ee weeks the follicle has become so solidi- 
fied that, from its color, it receives the name of corpus 
luteum. It still continues in relation with the ruptured spot 
on the surface of the ovary, traces of which yet renmin. On sec- 
tion at this time it presents the appearance of a convoluted 
wall and a central coagulum. The coagulum is semi-transpa- 
rent, of gray, or light-greenish color, more or less mottled with 
red. The wall is about one-eighth of an inch thick, and of yel- 
lowish or rosy hue. The entire corpus may be easily enucleated 
from the ovarian tissues, -Vfter the third week active retro- 
grade changes begin. The whole body undergoes 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- 



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Development op the Ovum. 59 

color also of its walls has now changed to a clear chrome yel- 
low. After this period the proeesa of atrophy aud degeneratioik 
goes on rapidly, until at the end of eight or nine weeks the^ 
whole body is represented by an insignificant cicatrix-like spot, 
leas than a quarter of an inch in its longest diameter, in which 
the original texture of the corpus luteuin can be recognized 
only by the peculiar folding and coloring of its constituent 
parts. It disappears entirely in seven or eight months. , 

The OorpuB Lutemn of Pregnancy.— The for^^ing shows 
that the mere presence of the corpus luteum is no evidence that 
pregnancy has existed, but only that a Graafian follicle 
has been ruptured and an ovule dischai^ed. There is a 
difference between the corpus luteura of pregnancy and that of 
menstruation, and yet the difference is not essential or funda- 
mental. It is, properly speaking, only a difference in the 
degree and rapidity of their development. It will not be neces- 
sary, therefore, to enter ujion a lengthy description of the ap- 
pearances and changes, but only to note some of the more 
salient points. At the end of the first month, the convoluted 
wall is bright j'ellow, and the clot still reddish. At the expira- 
tion of two months, instead of being reduced to the condition 
of an insignificant cicatrix, it is seven-eighths of an inch in di- 
ameter. When six months have passed it is stHl mt large as 
before; the clot has become fibrous and the convoluted wall 
paler. At the end of utero-gestation, it is about half an inch in 
diameter ; the central clot is but a radiating cicatrix, aud the 
external wall is tolerably thick and convoluted, but has lost ite 
bright yellow color. The corpus luteum of pregnancy is often 
termed the true and that of menstruation the fnlfie. 

The Migration of the Ovum.— But a small portion of the 
ova in each ovary ever meet with the conditions requisite for 
fruition. Many ignobly perish in the ovarian stroma, while 
others, as we learn from the occurrence of extra-uterine preg- 
nancy, are doubtless lost in the abdominal cavity. 

The precise conditions which determine the passage of the 
ovum through the oviduct to the uterine cavity, are still 
shrouded in obscurity. The theory that by virtue of it« 
erectility the Fallopian tube at the proper moment is brought 
into relation with the ovary through its fimbriated extremity, 
is open to criticism, since it has been demonstrated that the 
tube is not j)OH8eased of erectile tissue. Rouget found that in- 
jection of ite vessels after death did not communicate to it the 



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60 PttEG.VA-NCY. 

slightest chao^ of form or place. Experimeuts upon the mus- 
cular fibers of the tubes has brought no better results, as gaU 
vauizatiou produced ouly vermiciilar coutradictious, which did 
not affect the poHition of the timbi-i^. Moreover, when we reflect 
on the situation and surrouiidiugs of these tubes, it becomes 
difficult to uuderstand how it is pos«ible for them to execute 
any extended movements. The theory advanced by Henle that 
the ovum is drawn into the Fallopian tul>e by currente pro- 
duced in the serum by the ciliated epithelium, which covers 
both the external and internal surfaccH of the fimbrise, appears 
to be gaining favor. Failures of the ovum to enter the tube are 
probably common. 

While the ovum is in the outer portion of the tube, progress 
is presumed to be made by aid of the cilia'; bat when further 
advanced on its way to the uterus, additional force in supplied 
by tlie circular nmHoular fibers. 

Fecundation. — Conception, fecundation, and impregnation, 
are terms all of which imply fruitful contact of the male and 
female elements, so that a new organism comes into existence. 
The precise point at which this takes place has been the subject 
of much speculation and resesrch. It has been pretty clearly 
demonstrated that it cannot be within the uterus, inasmuch 
as it takes the ovum a period exceeding ten days to reach the 
uterine cavity, and an nnfecundated egg cannot sustain life for 
so long a time. Abdominal pregnancies seem to prove the pos- 
sibility of fecundation at the ovary. But, when we reflect upon 
the rarity of such pregnancies, and the strong probability of 
the fre*juent failure of the escaped ovum to enter the Fallopian 
tube, we are led to infer that fecundation at the ovary is 
anomalous. Henle has directed attention to the fact that the 
outer part of the tnl)e, possessing arborescent folds, is espe- 
cially designed as a receptacle for the seminal fluid. The con- 
gested condition of the mucous membrane, its canalicular 
structure, and the contractions of its muscular fil)ers, all seem 
intended to further the intimate contact of the siiermatozoa 
with the ovum after it has reached this situation. 

The fecundating principle of the male is wcreted in the testes 
at puberty, and in called ihti semen, or seminal fiuiti. During 
sexual congress the semeu is ejaculated with considerable force 
by the fibers of the vasa differentia, and the special muscles 
which surround the vesiculie seminales and the prostate gland. 
It thus reaches the upper part of the vagina, and doubtless 



Development op the Ovim. 61 

sometimes even the cervical canal, from which eituatiou the 
spermatozoa ascend to the point of contact with the female 
ovum. It is, however, an established fact that deposit of the 
seminal fluid deep in the vagina is not essential to impr^na- 
tion, for pregnancy has been found co-existent with imper- 
forate hymen. 

The semen is a thick, glutinous, whitish, albuminous fluid,, 
heavier than water, and emitting a characteristic odor. When 
placed under a powerful lens it is found to contain small, 
oval, flattened bodies, measuring not more than juVir 
of an inch in diameter, provided with tails which taper 
gradually to the flnest point. The entire spermatozo5n meas- 
ures froni 5-1-5 to :riir of s-" inc^- These bodies do not pass- 
ively float in the seminal fluid, but move about with a lashing,, 
undulating motion, as though endowed with volition. The ap- 
pearance of independent life, which they manifest, wa£ what led 
Kolliker to compare them to ciliated cells, and gave the erro- 
neous impression that they were animalcules. The name sperma- 
tozoa, which they bear, is suggestive. Henle, who has given 
much study to the subject, has estimated their speed at an inch 
in seven-and-a-half minutes. It is doubtless to the spermatozoa 
that the semen owes its fecundating power. Nor is this faculty 
Speedily lost, for examination has demoustrated the vitality 
and activity of these bodies within the female generative 
organs, eight and ten days after reception. If then the sperma- 
tozoa are absent {rom the seminal fluid, as in debility or old 
age, impregnation is impossible, and it is their absence from^ 
the seminal fluid of hybrids which renders these animals sterile. 

Our knowledge of the process of fecundation is very limited, 
the fact only being known that the spermatozoa penetrate the 
vitelline membrane, and then dissolve in the vitellus. Observa- 
tions o,n the lower animals appear to prove that penetration of 
the ovule by one spermatozoon is not only adequate, but con- 
stitutes the usual order. Others may gather about, and pene- 
trate a certain depth, but one only enters the protoplasm and 
creates the vital contact. Various theories of penetration 
have been advanced. Barry was the first to discover sperma- 
tozoa within the zona pellucida of the rabbit's ovum ; and his 
discovery has since been confirmed. Hensen found that the 
spermatozoa began to penetrate the rabbit's ovum about thir- 
teen hours after coitus. 

Barry also discovered an opening in the zona pellucida. 



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•^3 Pregnancy. 

8eemtngl.v designed as a point of entrance for the Bpermatozoa ; 
and Kebler confirmed the diseoverj-, 

Kobin, who made some very interesting and instructive 
observations upon the ova of the nephelis vulgaris, or common 
leech, found that the spermatozoa, in their movements around 
the ovum, assumed a perpendicular or oblique direction to the 
vitelline membrane. At one point penetration of this membrane 
could be diBtiactly observed. At the end of an hour the peae- 
tratjon had ceased, and then a little bundle of spermatozoa 
could be seen arrested, partly within and partly without the 
ovum. They continued to move in the clear, limpid fluid sur- 
rounding the vitellus, for a time, but after fifteen or twenty 
minutes their movements grew slow, and in about two hours 
had altogether ceased. It was then found, by counting the 
number remaining and comparing it with that of the sperma- 
tozoa which entered, that some had 
disappeared. They had been ab- 
sorbed directly into the vitellus, to 
serve for its fecundation. 

CouKsE OF Spermatozoa to 
Point op Fecundation.— The 
movement of the spermatozoa 
through the uterus and Fallopian 
tube is probably effected by various 
agencies. First: By the undulatory 
F.o. 46.-Sperraatozoa. motions of the spermatozoa them- 
selves, although it is difficult to 
-comprehend why these should propel them in any definite 
direction. Secondly: By the action of the ciha of the epithe- 
lium lining the passages. Thirdly: By muscular peristaltic con- 
tractions. "It is probable," says Hirst, "that once the sper- 
matozoa have reached the neighborhood of the ovum their 
movements are controlled by some substance excreted by the 
egg and diffused in the liquid bathing it. In some of the lower 
plants (ferns and others) the male elements are motile anthero- 
zoids; if a capillary tube containing a weak solution of malic 
acid be immersed in water containing antherozoids, the latter 
swim towards the opening of the tube. The malic acid, slowly 
diffusing through the water, controls the movements of the an- 
therozoids, so that their cilia lash in a manner tending to drive 
them to the place where there is most malic acid. It has also 
been found that malic acid is excreted by the female organs of 




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Dkvblopmext of the Ovum. 63 

these plants. Some similtir process may occur in the higher 
animaU and lead to a swarming of spermatozoa around the 
egg." It is highly probable that their usual course is not 
through the channel said by Mauriceau, De Graaf/and others, 
to exist in the uterine walls. 

Changes in the Ovum After Fecund ation.— It should be 
premised that our knowledge of what takes place intheovum of 
the human female is derived mainly from analogy; but from the 
studies in comparative piiysiology diligently prosecuted by a 
few, it is quite probable that the changes described in the fol- 
lowing pages are worthy of credence. 

One of the earliest cbangeu which has been observed is the 
. disappearance of the germinal vesicle. This may occur, how- 
ever, whether fecundation has taken place or not; but, in an 



Flo. 47.— Bifurcation of Tubal Canal. (Heiinig.) 

imprt^rnated ovum, the embryo cell is formed in its place. 
Inusntuch HB the entire time consumed in the migration of the 
ovnra to the uterine cavity is upwards of ten days, it is 
assumed that some of these changes take place while yet it 
occupies the outer third of the Fallopian tube. In this part of 
the oviduct the zona pellucida becomes somewhat thickened, 
the germinal spot disappears, and its place is supplied by the 
embryo cell, while the vitellus becomes somewhat condensed. 
Before the ^g enters the uterine cavity, more remarkable 
changes begin by segmentation, or cleavage of the yolk. Their 
first step is the formation of a deep furrow, which, by extension, 
soon completely divides the yolk, These halves are likewise 
divided by a similar process, so that four spheres result. Nor 
does the segmentation stop here, but it gotw on .until the entire 
jolk has been converted into a finely grannlar mass, resem- 



6i Pregnancy. 

bling in that particular theraulberry. It should be understood 
that this segmentation also includes the embryo cell, or 
nucleus, so that every granular cell rtsulting from the- sub- 
division retains the elements of the original vitellus. From 
this germ morula, or mass, the whole organization of the- 
embryo is gradually evolved. These cells grow in many dif- 
ferent ways ; some elongate into ttbers, others remain Hphericnl ; 
"sorae excrete around them a lai^ amount of intercellular 
substance and make cartilage, boue, and connective tissue; 
others make little intercellular substance. In some of them 
contractility of the original egg-protoplasm is intensified and 
they become rauscle-fibei-s. Others lieconie so modified in struc- 
ture that they almost or quite lose the contractile power pos- 
sessed by the ovum, but developing to a high degree its irrita- 
bility, or faculty of being easily changed by exterual influence. 



Figs. 48, 49 and 00. — SucceBBive stages of Segmentfttion of the Yolk. 

they become nerve-celis or the end-organs of nerve-fibers in the 
retina and other sense apparatuses. Some cells l>ecome dis- 
tinctly secretory, others excretory; some become horny, and 
as epidermis, hairs, ami nails, serve to protect the oi^anism. 
The general result is that from a set of similar cells, formed by 
the division of a single cell, the oiisperm, there is developed 
that heterogeneous mass of gronps of cells, each with distinc- 
tive modes of growth and with spe<-ial physiological properties, 
which constitutes the tissues and organs of the adult human 
body." The whole pro<-esK of segmentation is completed in the 
rabbit within about seventy hours. 

Now begins another important change. A clenr fluid accu- 
mulates in the center of the mass, and gradually increases in 
quantity, until a greater part of the original cells become flat- 
tened and closely crowded to the surface. We then have a vesi- 
cle, called the blastodermic vesicle, and the flatteneil cell wall 
is known a« the blastodermic membrane. It is fnund now that 



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Development op the Ovum. 65 

b,r absorption, the dimensions of the ovum have been increased 
from a diameter of 5's to ^V of an inch. 

All the cells formed by the original segmentation do not 
take part in the formation of the blastodermic membrane. 
Those which ai-e left accumulate and lie together at one spot 
just beneath the membrane, where by peripheral extension 
they gradually spread over and liye the inner surface of the 
blastodermic membrane, thereby providing for it asecoud, or 
sub, layer. The outer layer of the blastodermic membrane is 
accordingly termed the ectoderm, and the inner layer the ento- 
derm. The zona pellucida is now called tlie chorion, and there 
is formed t>etween it and the blastodermic membrane a thin 
film of fluid. During the formation of the entoderm, a bright 
round spot is observed in the 
ectoderm, which, as further ob- 
servation Hhows, marks the place 
at which all the more important 
processes connected with embry- 
onic development take place, and 
is termed the area gemiinativa. 
This is formed by an aggrega^ 
tion of the original segmentary 
cells. It at first presents a homo- 
geneous appearance, but there 
soon develops in its center a 
clear space, called the area pel- 
lucida,, bounded by a dense layer ^'°- Bi-— External Surface of 
of cells. The area pellucida, at '^'•e Ovum, with ^rfaGfrm.>.a(ii-a. 
first circular, becomes oval, and there forms in its center a dark 
oval spot, termed the embryonic spot. A longitudinal furrow, 
or shallow groove, which has been termed the primitive trace, 
the borders of which aie called the dorsa! plates, then makes 
its appearance in the embryonic spot, constituting the earliest 
indication of the cerebro-spinal canal. 

A third intermediate cell-layer has meanwhile formed, called 
the mesoderm, lying between the ectoderm and the entoderm. 
In this layer are developed the primitive blood-vessels, which, 
as they develop, give to the area germinativa the name of area 
vascalosa. Later the mesoderm divides into two distinct 
layers, giving to the embryonic structures, at one stage, four 
distinct layers. 

Briefly, it may be said that the ectoderm is concerned in 



66 Pbegnancy. 

the formation of the epidermis, hair, nails, the glandular t>truc- 
turee of the skin, the brain, the spinal cord, the organs of eptxrial 
sense, and, it is commonly supposed, the geuito-uriuary system. 
The outer stratum of the mesoderm gives origin to the corium, 
the muscles of the trunk coucerned in moving the body, 
and the skeleton. The inner layer of the mesoderm provides 
the muscular and fibrous tissues of the digestive tract, the 
blood, the blood-vessels and the blood-glands. The entoderm 
Bupphes the epithelium lining the walls and glands of the 
intestines. 

When a transverse section of the primitive trace is placed 
under a microscope, its characters are readily recognized, 
while beneath the furrow a cylindrical organ known as the 



Fro- S2. Fia. 68. 

chorda dortiHlis may be seen. It is about this structure that 
the vertebra* eventually form. The latter bodies themselves 
are derived from two longitudinal chords, separated by a 
cleava^ from the portions of the intermediate layer next 
to the chorda dorsalis on either side. The peripheral portions 
of the mesoderm then l>ecome the lateral or abdominal platen. 
The doi'sal plates continue their development until they meet 
in the median line, forming a tube known as the tabus meilullit- 
ris, the cavity within which is ultimately elaborated the central 
nervous system. 

The mesoderm, which at this point has been filled into a sin- 
gle layer, now separates into two strata united by their inner 
borders, and thereby forms what are known aw the mesenteric 
folds. The opposite extremities of the inner strntum of the 
meeoderm curve in wai-ds, and finally unite to form the intestine, 



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Development op the Ovum. 67 

Tfhile at the aame time they encloae the entoderm. The closnTe 
in this case is from front to rear, as well as from side to 
aide, but does not include the entire blastodermic vesicle, a con- 
siderable portion of which, called the umbilical vesicle, during the 
«arly months is connected to the body of the embryo. Finally 
the ectoderm and the outer stratum of the mesoderm curve 
forwards and inwards to inclose a long cavity which sur- 
rounds the intestines. This cavity is eventually divided by 
the diaphragm into the thorax and the abdomen. 

The embryo as thus far formed gradually moves towards the 
center of the ovum, while there rises about it, on every side, 
folds made up of the ectoderm and the outer layer of the 
mesoderm. Between the latter and the inner stratum is 
a collection of fluid. The process of depression goes on, and 
the folds of the ectoderm, now called the amniotic folds, ap- 
proach closer and closer, , 
until eventually they meet. 
The partitions are subse- 
quently broken down, and 
there is formed a cavity 
called the amniotic cavity, 
with its outer sac known as 
the amnion. This cavity 
mis with fluid commonly 
spoken of as "the waters,^' or liquor amnii. 

Between the chorion and amnion is often found a gelatinous 
fluid, traversed by minute filamentous proeeBses, called the 
vitriform hotly, or corpus reticule. It sometimes exiatK in con- 
siderable quantity, and near the end of pregnancy may l»e dis- 
charged by rupture of the decidua and chorion, and thereby 
ffve rise to the supposition that the waters {liquor amnii) have 
escaped. 

Soi'BCES OF Nourish M EXT .—The ovum, during its passa^ 
throu<<h the Fallopian tube, is increased in size by absorption, 
from j^ of an inch to from j>, to ^ of an inch. When once 
lodged within the cavity of the uterus, the ovum bf^ins to 
draw its nourishment from the mucous membrane lining that 
organ, at first by mere absorption through its walls, and later 
through the utero-placeutal circulation. The structure previ- 
ously alluded to as the umbilical vesicle, lined by the entoderm, 
and covered by the inner stratum of the mesodei-m, doubtless 
contributes to embryonic uourishment. Ite cavity, which at 




68 Pregnancy. 

flp8t communicates with the intestine, soon beeoniee separatetl 
by obliteration of its pa8»ag:e, but remains attaelied to the in- 
testine by a pedicle. In order to obtain a clear idea of fcBtaT 
nutrition and of preceding embryonic development, it becomes- 
neceBsary to enter into a more intimate acquaintance with 
certain structures to which allusion has already been made. 
The Chorion. — The chorion is the external membrane which 
envelops the ovum. Originally it coneists, aa elsewhere stated, 
ot the vitelline membrane, or zona pellucida. Soon after the 
ovum enters the uterus, this part develops amorphous villi 
which serve to anchor the ovum to the uterine mucous mem- 
brane. When once the 
amnion has been formed 
by a meeting of the folds 
of tlie blastodermic mem- 
brane over the back of the 
embryo, and an absorp- 
tion of the partitions be- 
) tween them, the outer layer 
of the blastoderm for a^ 
> time remains in relation to 
' the existing chorion ; but 
the latter, so far as it is a. 
vestige of the zona pel- 
lucida, disappears, and a 
new chorion, as it were, is 
formed from the ectoderm. 
Fio. 65.— Human Embryo at the third The new chorion in turn 
week, with Villi otth«ChorioD. i^^^es covered with a 

growth of non-va«cular villosities, which are not soHd but 
hollow. These villi develop rapidly in size and number, by a 
process of gemmation, so that at the close of the third week 
the entire ovum presents upon the outer sui-fa^e its character- 
istic shaggy ap^tearance. 

The ALLAXTOI9.— During the third week a new organ is 
developed, by means of which provision is made for supplying 
the rapidly increasing nutritive demands of the embryo. This 
oi^an, which establishes vascular connwtion between the 
embryo and chorion, is termed the allantois. It begins as a 
sac-like projection from the posterior extremity of the intes- 
tine, while yet the umbilical vesicle is an organ of considerable 
size. It is composed of two layers derived from the entoderm. 



Developmekt of the Ovum. 69 

and the inner layer of the inesoderm, which soon unite to form 
one membrane. At first it ie provided with two arteries and 
two veins, but later the vein on the right side becomes oblite- 
rated. These are the same vessels which are afterward found 
in the fully developed umbilical cord. Before the close of the 
fourth week the allantois reaches the chorion, and then begins . 
to spread upon it and forhi a vascular lining. The chorion 
a,nd aliantois now become fused into a single membrane, and 
constitute the permanent chorion, the outer surface of which 
is called the exoehorion, and the inner the endochorion. Dur- 
ing the development of the aliantois the umbilical vesicle 
'diminishes rapidly in rela- 
tive size, until at the end 
of the sixth week it is no 
larger than a pea. 

As development of the 
ovum advances, its sur- 

face becomes less and less p„ 56.-FormBtion of the Decld^a 

vascular, except near the Eeflexa. (First stage.; 

place where the alian- 
tois originally anchored 
to the chorion, and there 
vascularity is rapidly in- 
•creased. At other places • 
the villi of the chorion i 
also atrophy and disap- 
pear, until, after a time, 
the greater portion of 
the ovum becomes bare, 
while the remainder re- 
tains its villi in full devel- 
opment. Thisis the siteatwhich the placenta ultimately forms. 

The Dbcidua. — The decidua ie composed of three distinct 
portions, namely, the decidua vera, the decidua reflexa, and 
the decidua 8er<»tina. The decidua vera (or uterine decidua) is 
nothing more nor less than thealtered mucous membrane lining 
the uterine cavity. The decidua itiflexa (ovular or epichorial 
decidua) is a structure formed from the uterine mucous mem- 
brane, which, when completed, closely envelops the ovum. 
Between these two portions there is at first, over a greater part 
of the surface, a decided interspace filled with viscid, opaque 
mucus ; but after a certain degree of development has been 



Fio. B7,— Formation of the Deciduft 
Reflexa completed. 



70 PREGNAKCY, 

attained, the enlarged ovtim bringe the two surfaces into close 
cootact. The decidua serotina (or placental decidua) is 
merely that part of the uterine mucous membrane on which the 
ovum rests, and which, eventually, is covered by the placenta. 
When first formed, the decidua vera is a hollow, triangular 
sac, having three openings into it, l)eing those of the Fallopian 
tubes and os uteri. It continues to develop^ by hj-pertrophy, 
up to the third month, and then, owing to preseure, atrophy 
begins; the blood-vesselH disappear, a fatty degeneration sets 
in, but the Ptructure is not completely altered till gestation 
ends. The process is continued until it becomes thin and trans- 
parent. When fully developed, 
it presents, under a lens, char- 
acters which clearly establish 
its identity as hypertrophied 
uterine mucous membrane. 
The formation of the de- 
I cidua reflexa is an interesting 
study. As elsewhere remark- 
ed, the ovum, on reaching 
the uterine cavity, finds the 
mucous membrane in a hy- 
pertrophied and convoluted 
state, so that the cavity of 
the organ is well nigh obliter- 
Fig. 68.— Flap of Decidua Reflexa ated. It therefore forms easy 
turned down, diiicloBing Ovum. attachment in a fold near the 
point of entrance, and the rapidly formed villi of the zona 
pellucida serve to retain it. The mucous membrane at the base 
of the ovum begins to sprout about it, and extends, until, after 
a time, the ovum is completely inclosed. Up to the thiiti 
month, it should be I'emembered, the decidua vera and decidua 
refiexa are not in contact throughout, since this fact has an 
important bearing on the question of superfoetation. By the 
close of pregnancy the decidua reflexa, like the decidua vera, 
becomes greatly altered in appearance, and from asimilar cause. 
It is then very like the decidua vera, with which it blends, and 
from which careful dissection only is able to separate it. 

The Placenta. — The villi of the chorion are sent down 
into the tissues of the decidua, whence is derived the nutri- 
ment so necessary to proper development of the ovum. After 
the vascular relation between the embryo and permanent 



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Development of the Ovum. 



71 



chorion have been formed, the area of nutritive auppl.v is 
erreatly diniinwhed by atrophy of the villi of the chorion over 
ubout two-thirds of its suri'ace, and the thinning, as well, of the 
decidua refltjxa, and obliteration of its vessels. Pari passu with 
these chaiigfis, the whole procpsB of embryonic supplyand waste 
becomes concentrated at the decidua serotina. The villi of the 
chorion at this pointbecome arranged in tufts, sixteen totwentj 
in number, the villi themaelveB multiply, and athiek, soft, spongy 
mass results, which constitutes the foetal portion of the pla- 
centa. Within the trans- , ^ 
parent walls of the villi 
the contained vessels 
may be seen under the 
microscope, distended 
with blood, and present- 
ing an appearance some- 
what resembling that of 
a loop of small intestine. 
These capillaries are the 
terminal ramifications of 
the umbilical arteries 
and vein, with terminal 
loops contained in the 
digitations of the villi. 
From the accompanying 
cut it will be seen that 
each arterial twig is ac- 
companied by a corre- 
sponding venous branch, 
the two uniting to form 
the terminal arch or loop. 



Fiu. 59.— Placental Viilua, magnified. 



By this means the blood of the 
foetus is brought very near the blood of the mother, but does 
not come into actual contact with it. This fact is verified by 
utter inability to force any fluid into the material circulation 
by the most carefully conducted injections through the firtal 
vessels. 

The existence of lymphatics, or nerves, in the placenta, has 
never been demonstrated. 

The spaces between the villi of the placenta, which have l>een 
demonstrated to be sinuses in which circulates material blood, 
extend through the whole thickness of the organ, closely 
embracing all the ramificutions of the fuetal tufts. Theessen- 



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Flo. 60— Fretal Burface of the Placenta. 



e surface of tlie I'lacetita. 



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Development of the Ovum, 78 

tial compoeition of the placenta when fully developed is noth- 
ing but blood-vessels. All the tissues which it originally 
contained have disappeared, save the blooii-vesBels of the 
fietus, associated with and adherent to the larger blood-vessels 
of the mother. 

General Description. — The placenta, upon examination ae 
a whole, is found to be a soft, spongy ma^s, of nearly circular 
form. It meaaures about seven and a half inches in diameter, 
about an inch in thickness at the insertion of the unbilical 
cord, and hae an average weight of about sixteen ounces. Its 
foetal surface is smooth, and, through the amnion which covers 
it, can be seen the vessels radiating ia every direction over the 



FioR. 62 AND 63. — Specimeng of Placentte SuccentaHatfc. (Auvard.) 

snrface of the organ. The uterine face has a roughened, 
spongy feel, and is divided into a number of lobes, correspond- 
ing to the foetal tufts, or cotyledons, before described. The 
latter are penetrated by curled arteries from the uterus, which 
convey the maternal blood into the lacunie or sinuses between 
the foetal tufts. The blood returns to the uterus by the coro- 
nary vein on the mai^n of the placenta, and the sinuses in the 
septa between the cotyledons. 

Functions. — "The placenta," says Dalton, "must accord- 
ingly be regarded as an organ which performs, during intra- 
uterine life, offices similar to those of the lungs and the intes- 
tines after birth. It abworbs nourishment, renovates the 
blood, and discharges by exhalation various excrementitious 
matters which originate in the process of fuetal nutrition." 



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74 PREG.VANCY. 

Abnormalities of form are often met. The or^an is some- 
times divided into distinct parta; while, again, similar supple- 
mentary placentiB, or placenta? Bnccenturiatte, may be fonnd 
around tbe main mass. When this condition exists, one of the^ 
parts is liable to be left behind, exposing the woman to dan- 
gera of septic infection and secondary hemorrhage. The umbili- 
cal cord, instead of being attached to the center of the orp-an, 
may be at the margin, in which case it is termed battledore 
placenta. 

The term jasertio valamentosa is applied when the umbilical 



Fm. 64.— Section ofUteruB and Placenta in the fifth month. CA. chorion. 
I. amnion. I', villi. L. lacunie. S. aerotina. Ar. areolar. I', small 
CLeopold.] 

vessels extend for some distance along the membranes before- 
reaching the placenta. 

Clmnf^efi Preparatory to Separation. — At about the eighth 
month the giant cells .of the serotina, until this time in con- 
tact with the veins, begin to penetrate the vessels, and by 
their presence constitute foci of coagulation. These, together 
with a varying amount of fatty and calcareous degeneration, 
prepare the placenta for easy separation in labor by the con- 
traeting uterus. 

The Umbiucai- Cord.— This is formed chiefly by elonga- 
tion of the pedicle of the allantois, and obliteration of its 
cavity. Thus constructed .it consi.itB of the following parte: 
the amniotic sheath (which entirely surrounds it, except at 



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Dkvelopment op the Ovum- 75 

one point, where a small slit pves egress to the pedicle of the 
shruDken umbilical vesicle); the two uinbilical arteries, and 
one vein; the remaius of the pedicle of the umbilical vesicle; 
the remains of the pedicle of the allantois; and finally the 
gelatine of Wharton. It is usually about the thickness of 
the little finger, but varies greatly, its circumference depend- 
ing mainly on the quantity of Wharton's gelatine. Owing 
to the greater length of the right artery, the vessels in their 
spiral course commonly observe the direction from right to 
left, the vein forming an axis about which the arteries curl. 
The average length of the cord is twenty-two inches, but it 
has been observed as short as three inches, and as long as 
five or sis feet. As a rule, it possesses considerable strength, 
as may be demonstrated by traction made upon it for th& 
purpose of placental removal. Still, in some cases, slight 
traction will cause it to part. One extremity is firmly attached 
to the umbilicus, and the other to the placenta. No nerves 
or lymphatics are said to exist in its structure. 

The Liquor Amnii. — The amniotic fluid is supposed to result 
mainly from the exudation of serum from a fine capillary net- 
work of blood-vessels developed just beneath the amnion, in 
that part of the chorion which covers the placenta. In the 
latter half of pregnancy this network of vessels disappears. 
The quantity varies greatly, and diminishes alter the fifth 
month. When in excess of three pints, the condition is one of 
hydrops amnii. 



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DEVELOPMEST OF THE EMBRYO J.VZ) FCETl'S. 

An account of the development of the embf.vo and f<Btus 
belcvnpt properly to phveiology, and alluRion to it here is 
■deBig;iiedly brief. The term embryo is properly applied to the 
product of conception up to the close of the third month of 
utero-gpBtation, after which time the term fuetus ought to be 
substituted. Embryology, 8av*> for the light which compara- 
tive physiology throwa upon it, is, in the human, shrouded in 
much obficurity. The opportunities afforded for the examina- 



Fio. 66. — Ovum ot seven 
Fia. 85. — Ovum and Embryo. weeks. <NBtural BJee.) 

"tion of bodies, dead in the early Btages of pregnancy, are 
very limited, and it is probable that our acquaintance with the 
subject must continue to be made chiefly through study of the 
process in animals. 

In the FinsT Month. — The embryo, in the flret week of ges- 
tation, is a minute gelatinous and semi-transparent mass, of a 
grayish color, presenting to the unaided eye no definite traces 
of either head or extremities. The entire ovum measui-es but 
one-fourth of an inch, and the embryo one-twelfth ; but during 
the next week they double in dimensions. The amnion becomes 
ftiUy developed. The allantois reaches the periphery of the 
ovum, but the vessels do not yet penetrate the vilK. At the 
close of the month the ovum is about the size of a pigeon's 
«^, and weighs about forty grains. The embryo is about 
three-fourths of an inch in extreme length, and about one- 
third of an inch in direct measurement. The structures have 



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Development op the Porrus. 77 

so little bulk that, when raptured, they easily escape attention, 
in aborttone, generally passing with a coagulum. 

Second Month. — At eight weeks the ovum is about the size 
of a hen's egg, and the well developed villi of the chorion are 
still imbedded in the decidua throughout. It weighs from 180 
to 300 grains. The embryo is about two-thirds of an inch in 
length from head to caudal curve; its independent circulatory 



FiQ. 67.— Ovum at five months. 

system ib forming; indications of theexternal generative organs 
are visible ; and ossification has begun in several parts of the 
body. 

Third Month.— The embryo weighs from 300 to 400 grains, 
and measures from 2% to S% inches in length. The forearm is 
well formed and the fingers are discernible. The umbilical cord 
is about 2% inches in length. The head is relatively large ; the 
neck separates it from the trunk, and the eyes are prominent. 



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78 PREGNA?rCY. 

The chorion has lost most of its villi, and the placenta is 
formed. Points of ossification are present iumoatof thebonee. 
Thin membranous nails appear on the fingers and toes. Sex 
may be determined by presence or absence of a uterus. 

Fourth Month. — The ftetus weighs five or nix ounces, and ie 
about 8ve inohes long. Its sex is more distinct. Movements 
are visible. The convolutions of the brain are beginning to 
form; ossification is extending; the placenta is increasing in 
size, and the cord is about twelve inches long. The head is 
one-fourth the length of the whole body. The sutures and 
fontanelles are widely separated. Hair begins to appear on 
the scalp. If born, the foetus may live three or four hours. 

Fifth Month. — Foetal weight baa increased to ten ounces, 
and length to about nine inches. The head is still relatively 
large. Fine hair (lanugo) appears over the whole body. Fcetal 
movements can be felt by the mother. If bom, the fattus can 
live but a few hours. 

Sixth Month. — Weight about twenty-four ounces; length 
about eleven inches. Fat is found in the subcutaneous cellular 
tissue. The testicles are still in the abdominal cavity. The 
clitoris is prominent. Hair is darker and more abundant. 
The mambrana pupUlaria exists, but the eyelids separate. If 
born at this time the foetus breathes freely, but life is retained 
only a few hours, with rare exceptions. 

Seventh Month. — Weight from three to four pounds; length 
fourteen or fifteen inches. The skin is wrinkled, of red color, 
and covered with vemix caseosa. The testicles have descended 
into the scrotum. The pupillary membrane disappears. If 
younger than twenty-eight weeks it is not likely to live. 

Etohth Month. — Weight from four to five pounds ; length 
sixteen to eighteen inches. Derelopmeut is now rather in thick- 
ness than in length. Tlie nails are nearly perfect. The lanugo 
is disappearing from the face. The navel has gradually ap- 
proached the center of the body, until now it has nearly 
reached that median point. The cranial bones are easily mould- 
ed under pressure, a point to be remembered, as bearing on the 
question of induced labor in pelvic deformity. 

Ninth Month, or At Term. — At the end of pregnancy the 
fi£tus weighs an average of six and a half or seven pounds, 
and measures about twenty inches in length. If we were to 
take the weights of children as given by mothers and friends, 
this average would be greatly increased. Out of 3,000 children 



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Development of the Fjetus. 79 

delivered under the care of Cazeaux, at different charities, but 
one reached ten pounds. Of 4,000 chiidren delivered at La 
Maternite one only weighed twelve pounds. (Lachapelle.) The 
birth of one has recently been recorded whose weight was 
twenty-one pounds. Probably the lai^est foetus on record was 
that born in Ohio to Mrs, Captain Bates, the Nova Scotia 
giantess. Its weight is said to have been nearly twenty-four 
pounds. Children have been born at maturity, and lived, 
whose weight was only one pound. The average weight of 
mature males is greater than that of females. 

At birth the foetus is covered with vernix caseosa, a whitish, 
tenacious substance, composed of a mixture of surface epithe- 
lium, down, and the products of the sebaceous jrlands. During 
iatra-uterine life it serves as a protection for the skin against 
the amniotic fluid. It can be thoroughly removed only by 
preceding the use of water with a free inunction. 

Circulation of the Blood in the Pcstus.— The following is 
a brief, but yet explicit, r^unie of the foetal circulation : Blood 
ia conveyed through the umbilical arteries, which are termina- 
tions or branches of the iliac arteries, to the placenta, where, 
within the villi of the chorion, the interchanges with the ma- 
ternal blood take place. After being thus renovated and 
recharged with oxygen, it collects within the umbilical vein, 
fi'om innumerable branches, and passes buck through the 
umbilical cord to the liver. The blood thus returned to the 
foetus is arterial, and that which ])a8sefl through the umbilical 
arteries, venous ; but it is so in a modified sense only. After 
reaching the liver, on its i-etum from the i)la.centa, a part of it 
first circulat^es through the liver, and then passes out through 
the hepatic veins, while the rest goes through the ductns 
venosuK into the inferior vena cava, and both of these streams, 
uniting iu this vessel, continue on to the right auricle. The two 
columns of blood, that is, the blood passing into the vena cava 
from the hepatic vein, and from the ductus, join the stream 
which has been collecte*! from the lower part of the body, and 
mix with it. In early ffletnl life the inferior vena cava opens 
at the septum of the auricles into both cavities, though the 
chief part of the blood enters the left, owing to the increased 
development of the Eustachian valve. Subsequently this valve 
becomes smaller, and by the increased development of the valve 
guarding the foramen ovale, the current is turned more and 
more into the right auricle. In this cavity the blood is partly 



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Fio. 68.— Diagram of the Foetal Circulation, 

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Development op the F(BTue. 81 

mixed with that which eoters from the superior veaa cava, and 
a part of it descends into the right ventricle, whence it passes, 
in part, through the pulmouary artery, into the lung tissue. 
No proper pulmonary circulation having yet been estabHshed, 
only about half the blood contained in the right ventricle enters 
the pulmonary artery, whilst the other half enters the descend- 
ing aorta through the ductus arteriosuB, The imperfectly 
developed pulmonary veins convey to the left auricle but a 
small quantity of blood, the chief supply being received from 
the right auricle through the foramen ovale, through which 
passes the main stream from the inferior vena cava. From the 
left auricle the blood, which in semi-arterial, descends into the 
left ventricle, and thence into the first division of the aort-a. 
By virtue of this movement the head and upper extremities are 
supplied, through the carotid and subclavian arteries, with the 
blood which has been but little deteriorated in quality, and 
escape the more "venous current from the right ventricle 
through the ductus arteriosus. 

At the birth of the foetus there occurs a profound revolution 
in the circulation. Air now ent-ers and expands the lungs, and, 
as a result, blood begins to pass freely into the pulmonary cir- 
culation. The blood received into the right ventricle is now 
forced through the pulmonary system exclusively, the ductus 
arteriosus at once closing. Afterpassing through thelungs and 
being oxygenated, thebloodflows in greatly increased quantity 
into the left auricle. It is presumed that in the latter cavity 
the blood pressure is considerably increased by cessation of the 
placental circulation, while, through moderation of relative 
supply, the pressureon the rightauricle isdiminished, by means 
of which changes the valve of the foramen ovale is enabled to 
close. As a result ofthese modifications, more especially in con- 
sequence of closure of the ductus arteriosus, the arterial press- 
ure in the descending aorta is greatly diminished, and were the 
placenta left unseparated from the child, the long placental 
circulation could not be maintained. The blood still left in 
the cord soon coagulates, and circulation therein is effectually 
arrested. The ductus venosus also contracts on complete es- 
tablishment of the pulmonary circulation. The 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 between the contents of the two cavities. 
(6) 



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Pregnancy. 



The Cranium.— The general anatomy of the ftetal head is of 
much greater value to the obstetrician or student of midwifery 
than that of any other part of the body. Apart from ita dimen- 
sions, the chief anatomical peculiarity of interest is that of the 
cephalic bones, and more especially of the calvarium. These 
bones are not firmly ossified at their conti^ous margins in the 
foetufl, but are loosely joined by membrane or cartilage, forming 
above, by their united margins, sutures, or commissures, and 
fontanelles. This arrangement permits the bones under forcible 
pressure to overlap, and the head thus to be moulded to cor- 
respond to the size and shape of the channel through which it 





has to pass. Since this change in form of the head affects only 
the vault of the cranium, the more delicate organs in the base 
of the brain are protected by unyielding osseous structures. 

An acquaintance with the characters of the foetal cranium 
is of the greatest service in furnishing the data from which to 
calculate the position occupied by the part as it presents in 
labor. 

The Sutures and FontaDelles.— The sagittal suture ex- 
tends along the vertex, between the anterior and posterior 
fontanelles, and is formed by the junction of the two parietal 
bones. Running forward in the same line, anteriorly from the 
anterior fontanelle, is a short seam known as the frontal 
suture. The coronal suture is formed by junction of the edges 
of the two parietal bones and the frontal, and hence extends 
over the head in a lateral direction, constituting the anterior 
transverse suture of the vault of the cranium. The lamhdoidai 
suture is the line of demarcation between the occipital and 



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DeVELOPMEXT of TBE F(ETD8, , 83 

two parietal bones, extending transversely across the head, 
and forming a figure which resembles the Greek letter A, from 
which its name ia derived. In the other commissures of the 
ftetal cranium we have no special obstetric interest. 

Ossification of the cranial bones at birth is incomplete, 
"especially at the margins which are thus approximated, and 
as the bones have only membranous, or, at the most, cartila- 
ginous, union, moulding of the head through overlapping of 
the bones under the necessary compression is generally accom- 
plished with facility by the natural efforta, and thereby great 
mechanical advantage is gained. 

The rorners, or angles, of the bones, aa thus approximated, 
are obtuse, especially at the junction of the coronal, sagittal 
and frontal Butnres, through deficiency of osseous structure, 
and hence there are gaps formed 
anteriorly and posteriorly, which 
are termed fontaneliee. The 
largest of these is the aaterior > 
fontanelle, or bregma, it being 7 
formed by the concurrence of I 
four seams, namely, the sagittal, 
the frontal, and the two branches 
of coronal, giving to the opening 
a lozenge shape. The larger part 
of the gap is in front of the Fio. 71.— Lateral viaw of Head, 
direct line of the coronal suture, with indicated Diameten. 

and is sometimes continued some distance into the frontal 
bone in the line of the frontal suture. The posterior fontanelle 
is very much smaller, and, in general, is hardly entitled to the 
designation, since it would be scarcely possible to observe any 
pulsation there. Its shape is characteristic, and is rendered 
still more distinct during labor by the depression of the 
occiput, whereby the limbs of the A are made prominent. As 
will be noticed further on, the occiput, in the greater portion of 
cases, is turned towards the pubis, and hence the posterior 
fontanelle is the one more easily felt by the finger in making 
nn examination during labor. Too much emphasis cannot 
he put on its characteristics, namely, its A shape, and the 
concurrence of only three commissures (the two branches of 
the lambdoidal and the sagittal). The anterior fontanelle 
is lozenge-shaped, and has four sutures concurrent, as stated. 
The angle is much more obtuse ; bat what most markedly 




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84 Pbeonancy. 

diatinguiBbea it is the ezistencA of the notch, more or lens dis- 
tinct, in the frontal bone. These charactera wiH not at first 
be readily recognized by the student, but repeated examina- 
tions will render them familiar. 

Diameters of Fcetal Oacium.— Familiarity with the rela- 
tive diameters of the fcetal head is essential to an intelligent 
practice of midwifery. Those of most importance are : 1 . The 
occipito-mental, measurement being taken from the occipital 
protuberance to the point of the chin, the average giving five 
and one-half inches. . 2, The occipito-froutal, from the occiput 
to the center of the forehead, on a line with the frontal 
eminences, four and three-quarters inches. 3. The cervico- 
brc$;matic, one pole being at the foramen ma^am, and the 
other at the posterior margin of the anterior fontaiielle, about 
three and one-half inches. 4. The bi-parietal, the two poles of 
the diameter being the parietal eminences, three and three- 
quarters inches. 5. The bi-temporal, being the measurement 
through the ears, three and one-half inches. 6. The fronto- 
mental, from the apex of the forehead to the chin, three and 
one-half inches. 7. The sub-occipito-bregmatic, one pole being 
say half an inch below the occipital protuberance, and the 
other at the anterior fontanelle, three and one-half inches. 
8. The bi-malar, the poles being at the outer margins of the 
malar bones, three inches. Others might be added, but those 
given comprise most of the diameters concerned in the mechan- 
ism of labor. Putting these figures in tabular form, they are 
as follows : 

loches. C»Dtlm«Eree. 

Occlpito-meDUl 5^ = 14. 

Occlplto-froDtal 4% = li. 

Cervioo-bregmaUo S"^ = 8. 

8ab-occlplto-btegmatlc 8>^ = 9. 

Bi-parletal 3^^=9.7 

Bi-Mmporal 3^ = 9. 

Froato-mental i% = 9. 

Bi-malar 3 = 1.7 

Without pausing now to dilate on the change of diameters 
which is effected by difFereiit pi-eRentations and positions, it 
ought to be added that these averajies were taken from heads 
which travei-sed the parturient canal in occipito-anterior 
pomtions of vertex presentations. Dr. Barnes has shown by 
diap^'ams made from heads immediately after delivery, that, in 
difhcult and protracted labor, the longer diameters may be in- 



Development of thk Fcetub. 



85 



creased more than an inch, 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 Cluldreu. — There are some gen- 
eral considerations in relation to the size of the foetal bead 
which must not be overlooked. On taking the average nieaa- 
uremeuts of a large number of male heads, and comparing them 
with those of an equal number of female heads, it becomes evi- 
dent that the former exceed the 
latter. Sir JameH Simpson at- 
tributed to this fact the increased 
difficulties and dangers attendant 
on the birth of male children. 
This influence he believed to be so 
marked, that he made a careful 
-estimate of the mothers and chil- 
dren lost in Great Britain during , 
three years, as the lesult of slightly 
increased cranial development in 
males, at about 40,000 infants, and 
between 3.000 and 4.000 mothers. 

Attitude, Presentation and 
Position of the PoetuB.— From 
the earliest period in pregnancy the 
fcetus in the uterus conforms itself 
to the shape of the oi^an in the 
cavity of which it is placed. Its 
adaptation to a bent and Hexed 
attitude is clearly disclosed early in 
embryonic life. While yet it floats 
freely in the liquor amnii, and is 
not at all pressed by the uterine 
walls, the correspondence of the embryonic with the foetal ovoid 
is vForthy of notice. The flexed attitude becomes more marked 
as pregnancy advances, and at the close of grestatioa the ftetus 
is found with the spinal column bent forwards, the chin on the 
chest, the arms flexed at the elbows and the forearms laid on 
the breast. The thighs are bent on the abdomen, the feet 
extended so as to come in contact with the legs, and the latter, 
like the forearms, often crossed. This attitude enables the foetus 
to occupy the minimum amount of space, and gives to it the 
form of an ovoid, with the smaller end represented by the head. 




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86 PBEGNAKCy. 

Presentations and theih Causes.— The poaition of the fctu» 
with respect to the direction of its long axis, conBtitutes what 
is known as presentation. When the cephahc pole of the 
lon^tudinal diameter is dei>endeiit, itisa cephalic presentation. 
When the knees, feet or breech lie over the oa uteri, the pelvic 
pole of the lonRdiameter presents, and hence it is called a pelvic 
presentation. Knatly, when neither pole of the long diameter 
is in advance, it is a transverse presentation. la more than nine 
mature cases out of t«n the cephalic extremity forma the pre- 
sentation. Various theories have been advanced in explanatioit 
of the phenomenon, but notwithstanding the attention be- 
stowed on the subject, and the profound research to which it 
has given ri^e, the mystery remaina only partially solved. It 
does not answer the claima of acience to let the question reet^ 
merely on the plea of the suitability or deairability of such con- 
ditions for the facile consummation of the reproductive pro- 
cess. Manifestly, there is a cause, the influence of which is felt 
from an early period in fcetal life, the ultimate effect of which 
is discovered in the wonderful adaptation of means to ends in 
the mechanism of labor. Hippocrates appears to have origi- 
nated the idea that, until the seventh mouth of gestation, 
the foetus occupies a sitting posture, with the vertex hurned 
to the fundua uteri, where it ia held by bands from the- 
umbilicus, and that then, as a preparation for expulsion, a 
complete change of presentation ia effected. The smaller per- 
centage of cephalic presentations in miscarriages probably 
suggested this notion. Ariatotle 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 fcetuses, of different 
ages, in a vessel filled with water, and found that not the head, 
but the back or shoulder, was the part which rested on the bot- 
tom. He accordingly denied the influence of gravity, and 
advanced the theory of instinctive or iuvohmtarj' fuetal move- 
ments to explain the phenomenon in question. Simpson, too, 
repudiated the theory, and substituted that of reflex fietal 
movements. Others have attributed the phenomenon to uter- 
ine contractions. Dr, Matthews Duncan has done more than 
any other recent observer to elucidate the subject. In numer- 
ous experiments made by him, in which ftetuseB recently dead 
were allowed to float in a bag filled with salt water, of a specific 
gravity corresponding closely to thatof the liquor amnii, it was -< 



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DEVKLOPMKNT op THK FlETUS. 87 

seen that the head lay lower than the breech, and that the right 
shoulder (from the increaaed weight of that side dae to the sit- 
uation of the liver) looked downwards. This appeared clearly 
to demoDStrate thatthecenter of gravity lies nearer the cephalic 
than the pelvic extremity. " The position (presentation) of the 
fcetus at the full time is," says Dr. Duncan, " in the jrreat mass 
of cases, fixed and determined about the end of the seventh 
month of pregnancy. This arises from the fact that about that 
time the size and shape of the uterus become so nearly and 
closely adapted to the size and form of the foetus, that it caunot 
change the position of its trunk in any material degree. Aftei- 
this time the position of the foetus must be determined by gravi- 
tation, for it is impossible to conceive its reposing in any other. 
"All the knowledge we possess of the position (presentation) 
of the foetus, after it has entered the second half of pregnancy, 
leads us to believe that its head lies ordinarily lowest. Before 
the seventh mouth it is still capable of having its position in 
utero changed, by changes merely in theattitudeof the mother, 
and probably it possesses the power of effecting temporary 
changes, at least, by its own unaided movements. But the 
foetus IB generally in a state of repose, and not producing 
motions in its limbs or body. In this state of repose, in a fluid 
of nearly its own specific gravity, it is impossible to conceiveof 
its maintaining any position but under the influence of gravity. 
Its position must at all times be mainly, if not entirely, caused 
and determined by statical circumstances. It is quite conceiv- 
able, that while still comparatively free in the uterus, it may, 
by virtue of its very easy mobility in the dense liquor amnii, 
change its position. If this occur at a time when its dimensions 
are banning to approximate to those of the uterus, having 
overcome some resistance of the uterine walls by the force of its 
own muscular efforts, or otherwise — as by accidents to the 
mother — it may not gravitate back to its old and ordinary 
position, and thus a preternatural presentation may be pro- 
duced. The uterine waJls are everywhere smooth and glabrous, 
and rounded; and the fffitus lies in its cavity with its legs, its 
chief organs of locomotion, elevated, circumstances which ap- 
pear to render its maintenance of any position but that of 
gravitation a greater feat than ever was performed by a rope 
dancer. With all the advantages of its new circumstances, the 
child after birth cannot assume or maintain a new position: 



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88 Pregnancy. 

how much lesB could it be expected to do so in the uteruft, and 
uuder circumstaneeB bo dieod vautageoue for the fulfillment of 
Buch a function! Those authors who. with Duboiw, strive to 
prove that the position of the Jbetus is determined by its owu 
inotiouB have first to prove that it could maintain any position 
whatever against gravity, without such constant eiTorts as 
voluntary muscIeB are incapable of, and of the actual presence 
of which no evidence can be furnished," 

The law of foetal accommodation, formulated by Pajot, 
should be accredited with considerable influence in the determi- 
nation of presentation. "When one solid 
body is contained in another.'' says he, "and 
if the latter is alternately in astate of motion 
and of repose, and if the surfaces are rounded 
and smooth, the included body constantly 
tends to accommodate its shape and dimen- 
sions to the shape and capacity of the contain* 
ing body." 

Without entering further into a consider- 
ation of this que*4tioD, it may be added that 
cephalic presentation of the f<£tU8 is not 
probably referable wholly to any one cause, 
but a combination of causes, in which gravi- 
Fro 73— The fcetal t^ti^n, uterine contractions, and reflex move- 
Ovoid, ments, all have an influence. 
PosiTiox. — By this term we design to signify the relation of 
certain determinate points in the body of the foetus to the uter- 
ine walls. Care must be taken not to confound the two terms 
— presentation and position. To simplify an understanding of 
the various positions, we shall regard the dorsal surface of the 
foetus as thecardinal feature from the direction of which to des- 
ignate positions. And still it will be observed, when this sub- 
ject is treated at length, that positions are often designated by 
the direction of the occiput in vertex presentation, and the chin 
in face presentation, as, for example, right ocdpito-anterior 
position, left mento-posterior position, and soon. Full consid- 
eration of this subject will be taken up in another chapter. 
Changes of position are frequent in pregnancy, and, we suppose, 
like presentations take place whea not subjected to contrary 
influences, in a large measure through obedience to the law of 
gravity. This is not mere speculation, for close observation 




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Develoi'MENT of the F(etu8. 89 

has Hubetantiatecl its truth. When the woman is in the erect 

posture, the axis of the uterus is presumed to correspond closely 

with the axis of the plane of thesuperior 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 its left lateral 

surface looks somewhat forwards. 

Therefore, when tlie woman is 

«rect, the anterior uterine wall 

is not only inclined at the angle 

mentioned, but the left sidedrops 

a little lower than the right. 

"The deviation of the uterus 
during pregnancy," says A uvard, 
"designated by authors gener- 
all.y under the name of lateral 
obliquity, is not due to a true 
inclination of the organ during 

gestation, but to an apparent Fio. 74.— Situation and aurround- 
inclination. '"8^°' ^^^ P'*'="« '" ^'*''o- 

" It is not, in fact, an inclination of the uterus towards the 
right side or towards the left side, which is the cause of this lat- 
eral obliquity, but a want of equality and of parallelism in the 
development of the two halves of the organ. 

" Wheu there is a true inclination, it ia secondary to this ap- 
parent inclination; it is due to the fact that the uterus is drawn 
aa a whole towards the side most developed,'-' 



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CHAPTER III. 



Following closely on the heeln of impregnation, chauges are 
begun in the maternal organism, a knowledge of which i» 
essential to an intelligent view of the subject of utero-geata^ 
tion, and the Bkillftil performance of obstetric duties. 

Uterine Ohanges.— As soon as impregnation takes place 
Nature sets herself at work to prepare a nidus for the nestling 
which is about to enter the uterine cavity. The first noticeable 
change is an inci-eased determination of blood to the uterus, 
one of the effects being an augmented thickness and rugosity of 
the mucous lining. As the fecundated ovum enters from the 
tube it is arrested by one of these folds, and the uterine mucosa 
rapidly rises and envelops it. This movement is the initial 
phenomenon looking to the formation of those important 
structures, elsewhere described, which are to enclose the ovum 
and ultimately be discharged with it, namely, the deciduee. 
Thetextural changes are both numerous and great. The mus- 
cular fibers increase in length and s<miewhat in breadth, while 
new elementa are also added. Connective tissue is correspond- 
ingly developed. The three layers of muscular fibers running in 
different directions, which cannot be demonstrated in the non- 
pregnant uterus, become more and more patent. The arteries 
assume a spiral course and increase both in number and size, 
while the veius dilate and become wide-meshed reticulated 
anastomoses. The latter vessels form valveless canals or 
sinuses of considerable size, which intercommunicate, coursing 
through the muscular tissues, especially in the vicinity of the 
placenta. The lymphatics become more numerous and form 
plexuses in various parts. The nerves are correspondingly 
developed, and ganglia are found on the inner surface of the 
organ. 

The volume of the uterus is augmented, development being 
almost wholly confined to the body and fundus. This increase 
in bulk is due in part to hypertrophy of the walls, but also to 
distension from development of the ovum. The muscular 
changes which have been mentioned constitute the most essen- 
tial elements in the production of augmented weight of the 



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Changes in the Orqanibm. 91 

oi^aD. The walla themselves are not materially altered in 
thicknees. Uterine ^owth may be aaid to b^n with preg- 
nancy and continue to ite close: and yet it can scarcely be 
r^arded as uniformly pn^ressive. At different periods of 
gestation increase in size seems to be arrested, and then, after 
brief intervals of rest, development may be unusually active. 

Levret's figures give us as the area of the vii^n uterus 16 
square inches, and that of the pregnant uterus at term 339 
square inches. Ki-ause says the uterine cavity is enlai^ed by 
pregnancy 51!) times. Fajot says if some observers find the 
uterus at full term measuriug 15.7 inches through its greatest 
diameter, others find it only 12 to 14 incheN long, including 
fundus, body and cervix. Following are his average measure- 
ments. 

Vertical diameter 14.6 

Transverse diameter 10.2 

Antero-poBterior diameter ».& 

Circumference at tbe level at the Fallopian tubes 27 to 28 Inches. 

Cazeaux gives the following as the usual dimensions of the 
uterus at the principal periods of pregnancy : 

Vertical Diameter, TriDaTerae, AntSFD-poftcrior^ 
Incbei, iDcbeg. iDchea. 

Third month . . . 2^ 2% i^ 

Fourth month ... 8^ SJi 3?^ 

Sixth month ... %% 6'^ 6^ 

Ninth month . . \2%-\\% 9>i 8-9>i 

Farre has furnished the following table of approximate 
uterine dimensioDS for the several calendar months of utero- 
gestation, which we regard as nearer correct: 

LeiiKUi, WIdlb, 



End of third month 



*H-6 



End of fourth month 6!^-6 

Knd of fifth month 6-7 

End of sixth tnonth S-9 fli^ 



6>^ 



End of seventh month . 
End of eighth month 
End of ninth month 



7X 



As the uterus increases in dimensions, its serous covering is 
put upon the stretch, and, with advance of pregnancy, the lay- 
ers of the broad ligament separate, until finally the Fallopian 
tubes and ovaries lie in contact with tbe uterus. 

In early months, while yet the uterus is a pelvic organ, tha 



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»2 



Pregnancy, 



increase is rather in breadth and thickness than in length, as 
will be seen from Cazeaux's flgnres. making the organ more 
spherical than in a non-pregnant state. After it leaves the 
pelvic cavity, development of the organ is more in a longi< 
tudinal direction, until it comes to assume an ovoid shape, 
with the narrower extremity below, at the cervix and os. 
In the fifth month, the uterus fills the bypogastrium, and, 
in the ninth month, its fundus reaches the epigastrium. 

Change in Sit- 
tiATioN. — The first 
change is in a down- 
ward direction, as a 
result of which, from 
its close anatomical 
relations to the blad- 
der, and the connec- 
tion, in turn, of the 
bladder to the um- 
,. bilicus by means of 

■y^ ^^u. the urachuR, there is 

■ ' -■ abdominal flattening 

and umbilical retrac- 
tion. It is only after 
the gravid organ 
rises, so that its bulk 
is above the pelvic 
brim, that abdominal 
iuci-ease is observ- 
able. This change in 
situation, which takes 
place at the close of 
the third or begin- 
ning of the fourth 
Fig. 76.— Height of Cervix and Fundus Uteri at nionth, is usually a 
different weeki of pregnancy. (Schultze.) ^,^^^ ^^^^ ^^^^^ ^^^ 

completed, enables us to feel the form of the organ in the hypo- 
gaatrium. 

A few days Ivefore the advent of labor there is a slight subsi- 
dence, or downward movement of the uterus, very marked in 
some women, but scarcely noticeable in others. This dropping 
of the fundus is caused chiefly by the extreme relaxation of the 
soft parts which precedes delivery, to distension of the lower 




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Changes in the Obqamhm. 03 

uterine segment, and to a slight abridgment of the uterine 
' lonj^tudinal diameter. 

The Inclination of its Longitudinal Axis.— The fully de- 
veloped gravid uterus lies mainly within the abdominal cavity, 
its cervix directed downwards and backwaids, and its fundus 
upwards and forwards. There is also, in general, a slight lateral 
obliquity, the inclination most frequently being towards the 
right. Situated thus, its anterior surface rests against the ab- 
dominal parietes, its long axis nearly parallel with the axis of 
the plane of the pelvic brim, thereby forming with the horizon 
an angle of about thirty degrees. It assumes the vertical line 
only when the woman is in the semi-recumbent posture. From 
excessive relaxation of the abdominal parietes, a pendulotis- 
condition is sometimes induced, 

Changes op Cervical Posi- 
tion.— The situation of the 
cervix must obviously depend 
largely upon the situation and 
inclination of the uterine body. 
Hence, in the early weeks of 
pregnancy, the cervix is within 
easy reach of the finger. After > 
the third month it is higher, and f ' 
situated so far posteriorly as 
sometimes to place it almost 

beyond reach of the index and ^"'- ^^■-^^"J''* Y^l" "* "^"^ "^ 

.J J, „ the Fourth Month, 

middle nugers. 

Changes in the Size and Textuhe of the Cervix Uteri.— 
The cervix shares in the hypertrophy of the body and fuiidusof 
the uterus, but this change is generally completed by the 
fourth month. The increase in size ie partly from an increased 
growth and new formation of tissue elements, but more espe- 
cially from the loosening of its structure and distension of its 
tissues from serous inflltration. The cervical vessels, under the 
stimulus of the process going on in the uterine cavity, are di- 
lated, and the result is hyperemia of the part, and consequent 
cedema. These conditions in turn occasion a physiological soft- 
ening of the tissues, first manifested in those parts where' there 
is least resistance, that is, under the mucous membrane on the 
lips of the OS externum, and from this point continued progress- 
ively upwards towards the os internum. The cervical foUicles 
are active, and pour out their secretions, though the forniatioa 



94 



Pregnancy. 



ofa "mucuBplug," described by aome authors, IB questionable. 
Tlie orifices of these foUicIeB are Uable to occlusion, in which 
case little eacs are formed, known as the ovules of Naboth. 

Most of the standard works on midwifery alhide to a pro- 
gressive shortening of the cervix uteri which is supposed to take 
place in pregnancy. Stoltz, in 1826, questioned the truth of 
this theory, but, according to Dr. Duncan, he was pi-eeeded by 
Weitbrech in 1750. Various post-mortem examinations by 
others have clearly shown that, contrary to the older teach- 
ings, the cervix does not lose half its length by the sixth month, 
two-thirds of it by theseventb, and all of it by the middle of the 




Fio. 77. — Cervix Uteri at beginning 
of the Fifth Month. 



Fig, 78.— Ceirix Uteri at close 
of the Eighth Month. 



■eighth. To be sure, the part does not present the promi- 
nence which it once possessed, but the change is in the direction 
of softening and elevation, without coincident shortening 
or obliteration of the cervical canal by expansion of the 
internal os uteri. We have insisted on the truth of this 
for years, as the result of careful examinations, and we are 
convinced that, in the majority of cases, the internal os uteri 
does not yield till labor supervenes, or is near. According to 
Dr. Matthews Duncan, the change occurs during the latter half 
of the ninth month, but, even then, obliteration of the cervical 
-canal appears to be due to the incipient uterine contractions 
which prepare the cervix for labor. "The length," says 
Duncan, "of the vaginal portion of the cervix, or the amount 



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Changes in the Organism. 95 

of projection into the va^nal cavity, greatly diminJBhes as the 
■uterus rises into the cavity of the abdomen." 

This is a pretty constant phenomenon of pregnancy, and is 
probably one of the causes of the mistaken ideas formerly 
entertained regarding cervical shortening by supposed yielding 
of the internal os. On making an examination, the vaginal 
portion of the cervix is found not to be as prominent as usual, 
and, indeed, in some cases is even scarcely to be felt, and the 
inference has generally been that the cervical body has been 
annihilated. The opposite effect is produced by depreeaion of 



Fm. 79.— Cervii of a Multipara who died in the Eighth Month of 
Pregnancy. (Duncan.) 

■the uterus, as in the early weeks of pregnancy. This change 
led Boivin and Filugelli to r^ard the cervix as-lengthened. 

It is probably true, however, that to actual measurement 
there is a certain amount of cervical shortening, which takes 
place during pregnancy, growing out of the physiological soft- 
ening which occurs; but it is not a shortening consequent on 
relaxation of the internal os, and infringement upon the cervi- 
cal canal, as ha« been supposed. We insist that post-mortem, 
and careful vaginal examinations, have clearly shown that the 
internal os uteri does not expand until near the close of utero- 
^eetation. 

.\iiother factor in the production of apparent shortening is 



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96 Pheonancy. 

probably the bulging of the uterine wall anteriorly to the cer- 
vix, as an effect of downward pressure of the preBenting head. 
This condition, while common, though by no means uniform, 
causes the os uteri to be directed backwards towards the 
sacrum, and gives rise at times, especially in late pregnancy, to 
considerable difficulty in reaching the part, and at the same 
time produces a marked shortening of the anterior lip of the os 
uteri. By pushing the head upwards, or by placing thewoman 
OD her knees and elbows, so that the head will recede, theoervix 
is made to resume it« normal situHtion and feel. This bulging 
of the lower uterine segment and backward displacement of 
the OB, has, at times, been 
mistaken for anteflexion of 
the uterus. 

As pregnancy advances, 
the OS uteri becomes more 
and more patulous, but the 
degree of expansion diflers 
in primigravidffi from that 
in multigravidfe. In the 
former, after the fourth or 
fifth month, it get« slightly 
patulous, but will not re- 
ceive the end of the finger 
till a much later period. 
Even at the eighth, or mid- 
dle of the ninth, month, the 
margin of the os is pretty 
closely contracted. Thecav- 
ity of the cervix is wide, and if the finger be pushed through 
the external os, it readily permeates the canal. 

In pluriparee the cervical changes are somewhat influenced 
by the experiences of former ppf^ancies and labor. The cervi- 
cal canal does not assume the spindle shape, but rather 
resembles a thimble. The os tincee is more widely expanded, so 
that at the seventh month the finger easily enters the cervical 
canal, and approaches the internal os. At the eighth month, 
the latter, as a rule, has be^un slightly to yield, though, in one 
instance, it may remain closely shut till the close of gestation, 
and, in another, be so widely expanded as to admit two fingers. 
Lusk mentions the case of a multipara whom he had occasion 
to examine towards the end of gestation to determine the 




Changes in the Organism. 9T 

question of safety in making a railroad journey to a neighbor- 
ing city. He found the cervix soft, the head low, and the 
internal ob dilated to the size of a dollar. Two weeks later, be 
was called to see her in the early sta^ of labor, and found that, 
under the influence of uterine contractions, the canal of the 
cervix had a^ain closed. 

Va^ol and Vulvar Changes.— In the vagina, changes 
take place corresponding in some r^ards tothosein the uterus. 
The muscular fibers hypertrophy ; the vessels of the venous 
plexuses increase in size, and impart a blue, or purple color, to 



Fio. 81.— Showing the appearance of the Areola. 

the vaginal walls. The mucous membrane liecomes thickenpfJ 
and amplified, so that though the vaginal tube is drawn u|K)ri 
by ascent of the uterus, the anterior wall of the vagina ocea- 
sionally protrudes from the vulva. 

There is also turgesceuce of the vulva, pouting of the labia, 
duskiness of the mucous surfaces, and abundant secretion of 
the follicles. 

Changes in the MammsB.— Characteristic changes take 
place in the breaeta of such value in the diagnosis of pregnancy 
as to merit close attention. Tingling and slight sensiti vtMiess 
are the first indications of change here. These symptoms arc 
soon supplemented liy an uiic<unfortuble senseof teusiou, which 



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M Pregna.vct. 

precedes the external eridenceB of enlargement. Increase in sue 
<]oe8 not often become noticeable until the fourth month, 
thoDf^fa from an early period in pr^j^ancy there Ih a painful sen- 
sation of fullness. The veins enlarge and become unusually 
distinct as thej course beneath the nkin, and as distension 
finally becomes excessive, the cutis yields in places, presenting 
reddish or white lines like those found on the abdomen. 

The nipples become turgid, prominent, sensitive, and, on 
■light stimulation, erect; but the most characteristic changes 



Fio. 82.— Lateral view at Sixth 
Month. 

take place in the areola. Often as early as the second month 
the surface of this part is soft-, (edematous, and slightly ele- 
vate. The sebaceous follicles enlarge, and after a time moisten 
the areola with their secretions. About the middle of preg- 
nancy, discoloration, arising from a deposit of pigment, is 
notii-eable. It is more marked in women of dark complexion, 
and, from the fuet that it is more or less permanent, the sign is 
of value mainly in primigravidie. Colostrum can usually beex- 
prrssed from the nipples as early an the tenth or twelfth week. 
In the latter months of pregnancy, about the border of the 
areola is observed a ring presenting a peculiar appearance. 



CHANGK6 IS THE ObGANIBM. 99 

called 'the secondary areola of Montgomery. The character of 
It can be better understood from the illustration on page 97 
than from any written description. Briefly stated, it looks as 
though the color had there been discharged by a shower of 
■drops. The appearance is due to the presence of enlarged seba- 
-ceous follicles devoid of pigment. 

Changes in the Uterine Appendages.— The ovaries eo. 
large and rise with the broad ligaments; the Fallopian tubes un- 
dergo hypertrophy and lose theciliee from their epithelium ; the 
folds of the broad ligaments separate and become bypertrophied, 
and the enlarged round ligaments, owing to greater uterine 
■development posterioriy, are united 
to the uterus at the junction of the 
posterior four-fifths with the an- 
terior one-fifth of the lateral uterine 
surfaces. 

Abdominal Changes. — As uter- 
ine development goes on, the 
abdominal walls are put upon the 
stretch, and, in women who are well 
nourished, are increased in thick- 
. nesB by the abundant formation of 
adipose tissue. The umbilical ap- 
pearances are altered from stage to 
stage. At first, from causes before 
explained, there is marked retrac- 
tion of the part. This becomes „ „. „ , , .... 

. , ■^ , ., Fis. S4.— Pendaloui Abdomen, 

progressively less, until, at the 

seventh or eighth month, it begins to assume the exact coun- 
terpart of its former appearance, by becoming prominent, 
owing to the pressure exerted from within. Abdominal dis- 
tension also gives rise to the formation of reddish streaks, or 
striee, which, after delivery, become bleached, so as to resemble 
cicatrices. They are more abundant upon the sides of the 
abdomen, where they form sinuous lines, varying in length. 
They are due to an atrophic condition of the skin-layers, to 
partial obliteration of the lymph-spaces, and to condensation 
of the connective tissue elements, which, insfftad of forming 
rhomboid meshes, run parallel to one another. They are mere- 
ly the result of distension, and are not limited to pregnancy. 
Relation of the Uterus to Surrounding Parts. — Toward the 
«lose of gestation the uterus lies with the anterior surface 



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100 Pregnancy. 

directly in contact with the abdominal wallB, the intestines 
having been crowded upwardo and backwards until they sur- 
round the uterus like an arcli. Its lower anterior surface 
rests upon the posterior surface of the symphyiis pubis, and 
the lower uterine s^ment dips, to a certain extent, into tlie 
pelvic cavity. The posterior uterine wall lies in contact with 
the eipine, by which the fundus is slightly deflected to one side. 
DUtiirbance of Neighboring Organs from Pressure. — 
The pressure exerted by the gravid uterus creates functional 
disturbance in the neighboring pelvic organs. Pressure on the 
bladder, at its cervix and fundus, producesa desire for frequent 
micturition. The rectum and intestines often become inactive, 
and the resulting constipation is 
/ "u. ''■ '^'^ — X fl-n annoying complication of the 
pregnant state. Pressure on the 
I sacral nerves causes pains in the 
\ thighs and legs; also cramps and 
difficult locomotion. Traction on 
the uterine appendages causes pain 
in the hypogastric and inguinal 
r^ons, (Edema of the lower half 
of the body, and varicose condition 
of the veins of the l^s, rectum and 
• vulva, arise mainly from pressure, 
but partly from vascular fullness of 
the pelvic vessels, induced by pr^- 
nancy. In the latter part of preg- 
nancy, pressure on the stomach is 
annoying. The renal circulation may likewise be impeded. 

Changes in the Blood.— Amongst the most important altera- 
tions in the female organism, brought about by the pregnant 
state, are the cliatiges which occur in the circulating fluid. An 
attempt has l>een made to overthrow the common notion that, 
during pregnancy, the woman is nearly always in a condition 
analogous to plethora, and to prove the fallacy of referring to 
this state of the vascular system some of the many ills of which 
pregnant women complain, such as headache, palpitation, sing- 
ing in the ears, and shortness of breath ; but the attempt litis 
not been altogether succetisful. With these ideas of pathology, 
the treatment formerly applied was not illogical when viewed 
from thestandi>oint of the dominant school, resort being had 
to active antiphlogistic medication, low diet, and frequently to 



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Changes rN the Organism. 



101 



veneHectioii. We aretold that it wasoot uncommon for women 
to be bled six or eight times during the latter months of f^esta- 
tion, and we have the record of cases wherein such depletion 
was practiced as a matter of routine every two weeks, and 
sometimes much oftener. Such treatment is unquestionably 
wrong. 

It appears to have been conclusively denionstrated that 
there is an increase in the quantity of the circuFating fluid, a 
little in excess of that demanded by the enormous vascular de- 
velopment. 

The inrreaee is mainly of serum, but the number of white 
blood corpuMcleH, and the quantity of fibrin, are both aug- 
mented. On the other hand, there is a decrease in the number 
of red blood corpuscles, the quantity of albumen and iron of 
the blood. 

For the first six months fibrin diminishes in quantity, and 
for the remaining three it increases up to the point of 
hyperinosis. 

Following is an extract from tables showing the relative 
qnantities of the before-mentioned constituents: 



Red globules in pregnane; 
Albumen .... 
Fibrin ..... 



6.76 gr. in 2^ Ibe. dried blood 



Red globules in he&lth; man 141 .1 
Albumen .... 69.4 
Fibrin .... 2.2 

Iron 8.4 gr. i 



1 2.'3' Iba. dried blood 



Inasmuch as there is an increase in the total quantity of 
blood, the proper maintenance of 
the circulation demands an in- 
crease either in the fi^uency of the 
heart pulsations, or in the quantity 
of blood forced into the large ves- 
sels with each cardiac systole. 
Observation of pregnant women 
teaches us that the first require- 
ment is not met: the action of the heart is not accelerated. 
The compensation, then, is in dilatation of the heart cavi- 



B6. — Sphygmographio 
Tracing of the normal PuIbq 
in a Pregnant Woman. 



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102 Pregnancy. 

ties and hypertrophy of the left ventricle, the auricles and 
ri^ht ventricle remaining unaffected. As a result of these- 
chauges, there is increased arterial tension, which imparts 
a peculiar fullness and strength to the pulse. According to 
Durosiez, the heart remaiiiB enlarged during lactation, but 
. is rapidly diminished in size in women who do not suckle. Id 
those who have borne many children the oi^n remains per- 
manently somewhat larger than in nullipara. 

MiscellaneouB Changes. — The nervous system generally 
becomes more sensitive. There are alterations in the intellec- 
tual functions, changes in disposition and character ; morbid, 
capricious appetite, derangement of the senses of taste, smell 
and sight, and oftendizziness, headache, neuralgia' and syncope. 
Melancholia is sometimes met, which, in women predisposed 
thereto, occasionally ends in mania. The memory is weakened, 
especially when one pregnancy follows another in rapid succes- 
sion. On the contrary, the nervous system sometimes becomes 
calm and strong, and the woman experiences apeculiar senseof 
well-being. 

Respiration is rendered difficult from mechanical causes, es-. 
pecially at a time just previous to the subsidence of the uterus 
hereinbefore alluded to, owing, as Dohrnhas shown, to diminu- 
tion in the vital capacity of the lungs. The thorax is increased 
in breadth and diminished in depth, whilediaphragniaticaction 
is greatly impeded. 

Gastric disturbances are common. Nausea and vomiting, 
which, from most frequent occurrence in the morning, have 
been called "morning sickness," areexperienced by the majority 
of women during the early weeks. The author has found, how- 
ever, upon careful inquiry of women presenting themselves for 
confinement in Hahnemann hospital, thataboutforty per cent, 
of all cases entirely escape the annoying symptom. It gpn- 
erally begins at about the sixth week of pregnancy, and con- 
tinues for from six days to six or seven weeks. In other cases 
it forms a complication of lat^^r gestation. The appetite is 
' capricious, the longings being in some cases for even disgusting 
articles of food. Increased flow of saliva is often an accompa- 
niment. The bowels are sometimes loose, but constipation is 
more common. 

In view of the tumult of incipient changes going on, we can- 
not wonder that the health of women is somewhat impaired 
during the first three months of pregnancy. After that time, 



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Changes in the Oroanibm. 103 

however, there is generally aa improvement. The appetite 
returns, digestion becomee more active, and assimilation re- 
cruite the strength, and increases the weight. Gassner estimates 
the total increase at about one~thirteeath 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 maculee appear on different parts of the body, particu- 
larly theface, but, as a rule, they disappear after delivery. 

Certain changes in the urine have, by some, been considered 
pathognomonic of pregnancy. These consist in the formation 
of a deposit when the urine is allowed to stand for a considera- 
ble time, which haa been called kiestei'n. It in observed after 
the second month of pregnancy, and 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, 
especially if anaemic, and even in the urine of men, it cannot be 
regarded as a change peculiar to gestation. 

The Pennajient Changes.— The uterus after delivery does 
not resume its nulliparous shape and size, but retains vestiges 
of the condition through which it has passed. The weight of the 
oi^an is increased to about an ounce and a half; the fundus 
and body are rounded externally ; the cavity of the body loses 
its triangular shape, and becomes much larger relatively to the 
cervix, while the os internum is left somewhat agape. The 
mucous folds of the cervix are in great measure obliterated, or, 
at least, are rendered indistinct, and the os internum is patent. 
Abdominal distension leaves indelible marks in the shape of 
the striae mentioned, which, from a reddish or brown color, 
become silvery-white like cicatrices. The pigmentation of the 
linea alba is never wholly removed. The breasts give evidence 
of former pregnancy in the existence of the silvery lines alluded 
to, and the discoloration of the areola, which has, in a measure, 
remained. In addition to these changes there are doubtless 
many which mark a difference between women who have borne 
children, and those who have not, but further evidence is in the 
main, referable to parturient effects. 



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CHAPTEE IV. 
THE DIAGXOSIS OP PREGNANCY. 

Owinx to the obscurity andindpt«nninate character of earl.v 
symptoDiB, and the weighty contingencies which hang upon 
theexpreBBed conviction derived from examination, the diog- 
noBis of pregnancy ie one of the most trying duties which the 
physician is called to perform. It is further intensified by the 
notion, so prevalent among people, that thesigns of pregnancy, 
from the first, are, or should be, to the trained and skillful ob- 
server, clearly legible. 

In most cases wherein this interesting condition is suspected 
to exist, the woman is within marital bonds, and diagnosis is 
sought more from the promptings of curiosity than any other 
consideration. Such women, as a rule, are easily pacified with 
an equivocal answer. In other cases there is an entirely differ- 
ent posture of affairs, and diagnosis is requested, not out of 
idle curiosity, or to satisfy a momentary whim, but from the 
pressure of dire forebodings. The woman is not under the safe 
protection of tnarriage vows, and, urged on by her fast 
augmenting fears, or stimulated by an impugning conscience, 
eheseekspositiveknowledge. Again: thephygician iscousulted, 
not by the woman herself, but by her friends. Parents, per- 
haps, with or without heart-sickening suspicions of their 
daughter's unchastity, desire an explanation of the objective 
and subjective symptoms which have come to their knowledge. 
In many such ca^es, so much depends upon the diagnosis ren- 
dered, that an error will not be pardoned. The symptoms may 
be ambiguous, and a most careful investigation may not elicit 
conclusive evidence, but, by the conviction expressed, the physi- 
cian has generally to abide. No plea of having done as well as 
circumstances allowed, will atone for a mistaken opinion. A 
confession of error will not bind up a broken heart nor restore 
the lustre to a tarnished reputation. Furthermore, the physician 
is Rometimesealled upon foran opinion in cai^es under litigation, 
wherein alleged gravidity is an important factor, and final 
adjudication in fixing responsibility, or in directing the inher- 
itance of property, will be determined lai^ly by the character 
of his expert testimony. 



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DiAiiNOfcis OF Pheonancy. 105 

Claasiflcation of the Signs.— The signs of pr^nancy should 
always bextlassifled ae ivlstive or presumptive, and poeitive or 
demonstrable signs. Upon one, or upon a number of the 
former, nothing more substantial, affirmatively, than proba- 
bilitiee, of various degrees of strength, can be predicated. An 
unequivocal affirmative diagnosisought never to be given. The 
presumptive evidence may be bo strong in certain instances as 
to leave few and feeble possibilities of error, and yet experience 
teaches the fallacy of dramng absolute conclusions from such 
data. There are four signs which may be regarded aH positive, 
Datnely, foetal movements, ballottemeut, tliesouuds of thefcetal 
heart and recurrent uterine contractions. By some teachers, 
however, the third alone is looked upon as unconditionally posi- 
tive, and this ia what we formerly taught. 

Subjective Symptoms. -*-In the diagnosis of pregnancy, 
subjective symptoms should receive due consideration, but 
objective symptoms must constitute onrmaiu reliance. Women 
are too prone to draw their conclusions from intuitions and 
mental impressions, and as a result we sometimes have gra- 
viditas nervosa, disconnected, perhaps, with even the most 
common and essential physical indications of pregnancy. 

History of the Case. — Items of importance may be gath> 
ered from a recital of the 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 mani- 
fested. 

The Menstrual Flow ought to be carefully inquired after. 
There may have been a r^jular return of it throughout the 
sappoeed pregnancy ; or there may have been complete sup- 
pressioD. Should the former condition prevail, it will justly 
arouse suspicion. In that case, ascertain wherein thecatamenia 
deviate from a normal standard. If menstruation has ceased, 
learn the circumstances under which it disappeared, and the 
peculiarities, if any, which characterized the last two or three 
"periods." 

Pregnancy in Women who Do A'b( Menstruate. — Cases are 
on record wherein young women have conceived before the 
menstrual function had been established; while again, during 
lactatioR and suspension of menstruation, impregnation often 
occurs. 

Menstruation During Pregnancy. — It is not very uncommon 
for a woman to menstruate once, twice or thrice after iiapre^- 



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106 Pregnancy. 

nation, and cases are recorded wherein the catamenia retained 
with r^ularity throughout the full term. 

Durosiez observed that menstruation is more likely to per- 
sist in womeo affected with mitral stenosis. The flow ia these 
anomalous caaes differs from the normal in either quantity or 
quality, and is not often regular in its appearance. The source 
of the blood is probably the cervical canal, though in tlie early 
weeks it may come from the uterine cavity. 

"Morning Sickness"— a sign of some value— is largely sub- 
jective, and concerning it strict inquiry should be made. When 
was it first felt? At what times, and under what circum- 
stances, was it most troublesome? How long did it last? 

When quickening is allied to have taken place, try to fix 
the date, and the precise sensations esperieueed. 

Unrebability of Subjective Symptoms.— With regard to- 
information thus elicited from women, it should be observed 
that, while it affords 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, and she may' or may 
not have experienced morning sickness and fcetal quickening. 
Facta are extremely liable to be misconstrued or misrepre- 
sented through either the woman's untruthfulness or mistaken 
convictions. 

Objective Symptoms.— For our diagnosis we must depend, 
then, almost wholly on objective symptoms. The same com- 
mon means of investigation are available here as in other cases 
where physical examination is required. They are, inspection, 
palpation (including "the touch"), percussion, and ausculta- 
tion, the relative value of which, and the methods of most 
effective use, will be briefly connidered. 

Inspection. — Inspection will aid very materially.in perplexing 
cases, in carrying the inquirer to a correct conclusion. The ab- 
dominal contour of a woman who has reached the fifth month 
of gestation is quite diagnostic, even when pui-posely obscured 
to ft certain degree by the apparel. The exj>erienced observer 
is often able, liy inspection of it, to differentiate Vietween preg- 
nancy and simulating conditions. The precise outline of the 
gravid abdomen varies, but within limits which make all cases. 
quite similar. As we take a lateral view of a pregnant woman, 
the abdominal enlargement is seen not to be equable, but its 
point of greatest projection is near its superior boundary. This 
peculiarity becomes more and more characteristic as pr^nancy 



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Diagnosis op Pregkancy. lOT 

advances. The cause of this is obviona when we recollect the 
form of the uterus, and the direction of its long axis, which .is; 
at an angle of about 60 d^rees with the horizon. 

This lateral view is of considerable value in the diagnosis of 
pregnancy. Mere circumferential measurements areofcompara- 
tively little importance. 

A front view also of the abdominal tumor, taken when the 
woman is either standing or lying, reveals diagnostic charac- 
ters, more marked in theerectposture. P^rstshould beobserred 
the absence of prominences and irregularities. It is not uncom- 
mon to find a difference between the two sides in point of full- 
ness, but the elevation is not confined to a circumscribed ai-ea. 
This is generally due to presence of the fcetal trunk, aa the 
writer has repeatedly demonstrated. Then, too, the tumor 
arising from pregnancy is narrower, and more prominent along 
the middle line, than is a pathological enlargement. 

Special abdominal appearances, aside from enlargement, 
should be remembei-ed. During the first few weeks of ut<TO- 
gestation, the abdomen, instead of being more prominent, is 
really retracted or flattened, and especially in the umbilical 
region. This phenomenon has already been explained, but we- 
repeat: The uterus, from ite uncommon weight, proceeding in 
part from actual increase in size, but largely from vascular en- 
largement, sinks in the pelvic cavity to an unnatural level, and 
in doing so drags upon the bladder, which, in turn, through 
the urachua, causes the retraction mentioned. 

Along a narrow line, extending from the nmbilicus to the- 
pubis, there is darkening, the shades varying frwm light brown 
to black. 

F<etal movements are often discernible. They are sometimes 
closely simulated by spasmodic muscular action, when, as a 
means of difl«rentiation, palpation affords positive aid. 

Inspection of the breasts is a vaJuable means of diagnosis, 
by means of which the changes described in the preceding chap- 
ter will be observed. The appearance known as the "second- 
ary areola of Montgomery" should receive special attention. 

The purplish hue in the vt^^nal mucous membrane must be 
seen to be known, but, when once familiar to the eye, will afford 
considerable aid. 

The foregoing embraces an allusion to the principal appH- 
cations of this means of investigation. When intelligently 
«mpk>yedj it furnishes valuable helpto unravel perplexing cases. 



108 Pregnancy. 

Pai-pation. — If deprived of every sense but the tactile, the 
ph.vBician would still retain the meaua for making a satiefac- 
tor,v diagnosis in nearly all cases of suspected pr^aancy. This 
mode of examination is in common use, and is highly 
regarded, yet there are many, even among those long in prac- 
tice, who, from lack of adequate comprehension of its possibili- 
ties, do not value it as highly as they ought. Abdominal palpa- 
tion alone is sufficient, in many ambiguous cases, effectually to 
dispel doubt. In early pregnancies it is not capable of such 
achievements, but when combined with the vaginal touch it 
becomes a most valuable aid. Later, however, the uterus, 
with its developing foetus, rises within easy reach of the hand, 
and admits of minute examination. The fundus uteri is always 
easily distinguishable and its height can be clearly determin^. 

The uterine form, with broad, even front and lateral super- 
flees, is highly characteristic. If the examination be prolonged, 
the recurrent uterine coutractionB which are going on through- 
out the greater part of pregnancy will be felt under the hand ; 
and, during their prevalence, a pretty good outline of the 
gravid uterus can be distinguished. At the moment of con- 
traction, the surface of the uterus which comes under examina- 
tion, when not defaced by fibrous growths, conveys to the hand 
a smooth, regular feel. 

In the intervals between contractions, when there is no mus- 
cular resistance, it is possible, after themiddle of pr^Tiancy, to 
feel the foetal form through the uterine walls. At this period, 
and later, in many cases there is so great arelative redundancy 
of liquor amnii as to admit of remarkable foetal mobility. The 
head, if not pres^ting closely at the brim, as at this season it 
frequently is not, may easily be moved from one side of the 
abdomen to the other. In a modified degree this is also true of 
the extremities and trunk. The foetal movements, whether 
flpontaneous or elicited, are felt by the palpating hand. If the 
abdominal walls are not too thick, palpation is thus capable 
of affording highly satisfactory evidence upon which to baae 
diagnosis. 

If pregnancy be absent, then by dee]) pressure the abdominal 
walls in the hypogastric region can be depressed until the 
fingers touch the spine, in which case the physician may rest as- 
sured that there is no pregnancy which has advanced beyond 
the third or fourth month. If in making such an attempt, re- 
sistance is at once encountered, thorough exploration by deep 



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DiAGXOeiS OF PltEGXANCY. 109 

abdominal pressure and va^Dalindigitation should be madfto 
ascertain the nature of it. 

"The touch" is a highly efficacious mode of examination, 
and one which, in cases at all doubtful, ought never to be u^- 
lected. By means of it several important signs may be elicited. 
In the early weeks, the uterus, as before observed, lies lower in 
the pelvic cavity than during a nou-pr^^iaut state. This con- 
dition of .itf+lf would bo of no significance, and, at best, is but 
a feeble relative sign. After the third month, the uterushaving 



Flo. 87.— Bimanual Eiamination in the DjagnosiB of Pregnancy. (Martin.> 

riaen so that its bulk lies above the pelvic brim, the cervix is 
elevated and turned barkwarde towards the rectum, thereby 
pufctingthe roof of the anterior vaginni cul-de-sac on the stretrh. 
This is a valuable relative sign when found as a concomitant of 
other presumptive symptoms. 

A few years ago Hegar described a sign of pregnancy, of ser- 
vice in the early weeks, which bids fair to become generally 
recognized as positive. It is of special value inasmuch >m 
hitherto we have had nothing but relative sigiis upon which to 
base dia^uoais until near the middle of gestation. 

In the early weeks, development of the uterus is confined 
pretty closely to the body and fundus, and expansion i» 



110 Phegnakcy. 

greater anteriorly and posteriorly than laterally. At the same 
time while softening m just beginning in the lower part of the 
vaginal cervix, it in proceeding more rapidly in the supra- 
cervical uterine walla, bo that there is soon a zone of uterine 
tiBBue at the uterine isthmue, which, to the touch, is softer and 
more boggy than the structures above and below. Then, too, 
as a r«iuU of these changes, it is found that the uterine wall 
there becomes more prominent, bo that the cervix feels as 
though it were set on the inferior surface of a small sphere. 
TliiB gives us, aa among the first changes in form, that which 
causea the uterus to lose ita pear shape, and the body of the 
organ to become more spherical. 

These changes can best be recognized through rectio- 
abdominal, or recto-vaginal touch, while the uterus is de- 
pressed in the pelvis by means of abdominal pressure. 

The sign is available as early as the fifth week of preg- 
nancy. 

The marked changes in the cervix uteri which b^n booq 
after impregaatioD and gradually progress to full conBumma- 
tion, have elsewhere been described. At the close of the sixth 
or seventh week the lips of the os uteri communicate to the 
examining finger a slight sensation of softuess, at that time 
due, perhaps, in the main, to turgescence and tumefaction of 
the part, but doubtless attributable in a measure to physio- 
logical softening of the uterine neck, dependent on other 
-causes. The process begins at the lowermost part and pro- 
gressively ascends. An examination made at the sixth month 
discloses softness to the extent of half its length, but not until 
near the close of gestation is the reduction complete. The 
gradually increasing expansion and dilatability of the os uteri 
which accompanies cervical softening, ought to be kept in mind 
during examination. 

The period at which the internal os uteri gives way, so 
that the cervical canal becomen part of the uterine cavity, 
admits of some diversity of opinion. It is the author's convic- 
tion (elsewhere expressed), based upon special observation of 
many cases, that it is not brought about uutil, or very near, 
the banning of labor, and frequently not until pains have 
been fbr some time present. 

Allusion has been made to the diagnostic value of conjoint 
examination, i. e., abdominal palpation employed in connec- 
tion with the vaginal touch. By such manipulation it is poBsi- 



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Diagnosis of I'ueuxancy. Ill 

ble to form an approximate estimate of the size of the uterus, 
and hence the probability or improbability of pregnancy. It 
«bould be indulged with due caution, as harshness is liable to 
produce most unwelcome results. 

There is a form rif vaginal, or bimanual ezatnination, the 
employment of which, at certain stagee, will disclose a sign of 
pregnancy by ub regarded as positive, namely, b&IIottement. 
It can be practiced by both bauds upon the abdomen. To do 
so the woman must be placed on her side, one of the operator's 
hands resting above, and the other below the abdomen as she 
lies. By a sudden movement of the hand beneath the foetus, 
the latter may be displaced or tossed, and the impulse of it« 
return communicated to the keen sense of the operator. 

Vaginal baUottement is performed by placing tlie woman 
on her back in a semi-recumbent posture, and then, with two 
fingers in the vagina, the uterine wall just anteriorly to the 
cervix is given a sudden push in the direction of the long uter- 
ine axis. This propels the foetus away from the lower uterine 
s^ment, but it soon sinks again in tlie liquor amnii, and the 
;geotle tap of its contact with the uterine tissues may be felt. 
When clearly elicited, it is regarded as a positive sign of preg- 
nancy, but it requires skill and experience succeesfally to prac- 
tice the man<euvre. It cannot be employed with satisfaction 
•earlier than about the close of the fourth month, nor later 
than the seventh. 

Uterine fluctuation may sometimes be felt, according to Dr. 
RoHch, by conjoint manipulation — the hand on the abdomen, 
anil two fingers in the vagina; but the delicacy of the sign ren- 
ders it unreliable for general nse. It is recommended as a 
means of early diagnosis. 

Percussion.— This means of diagnosis fills but a small niche. 
The abdomen, in real gravidity, gives, on percussion over the 
uterus, sounds, mostly flat, always dull. Should resonance be 
obtained at the site of the enlargement, <it may justly be 
regarded as almost conclusive evidence of non-pregnancy. 
It can be employed to confirm other indications, but as a 
means of positive diagnosis, it possesses no merit. . 

AuscuLTATiox. — When Mayor, of Geneva, tentatively applied 
his ear to the abdomen of a pregnant woman, in the hope that 
he might hear fietal movements, and discovered the in audibility 
of thefie, but heard the unmistakably clear sounds of the foetal 
heart, he brought within command a means of diagnosis at 



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112 pREtJNANCY. 

oiice easy of application aud unequivocal in iudication. The- 
fcetal heart-beat is the poeitive sign of pregnancy. 

The flounde have been compared to those of a watch under a. 
pillow, but an infinitely better idea of them may be obtained 
by listening to the heart of a new-bom child. They were first 
heard by Mayor with the unaided ear, but we ought not to 
iafer from this that immediate auscultation is preferable. The 
author has repeatedly demonstrated the superiority of the 
mediate mode. The double stethoscope gives best Katisfoction. 
The instrument may be applied by firm or by light pressure, 
the latter beinf; preferable. To properly do this it should be- 
pla^cd on the abdomen in such a way that it will rest evenly 
and lightly, and then the fingers entirely removed. Sounds can 
thus be heard which would otherwise be absolutely inaudible. 
This method of using the stethoscope requires considerable 
practice to obtain the best results. 

The area of audibility depends mainly on the position and 
presentation of the foetus. The sounds are conveyed to the ear 
with the greatest facility by solid tissues or substances; hence 
they are most distinct when the trunk of the foetus, at a point 
near the heart, comes in contact with the uterine walls, and the 
uterine walls are in turn brought firmly against the abdominal 
parietes. A dorso-anterior position of the fistus is most favoi-- 
able for transmitting the impulse. The area of audibility varies 
considerably in extent. In one case the sounds can be heard 
over nearly the whole abdomen, while in another they are cir- 
cumscribed to a smalt space. When audible over an extensive 
area, there is always a point where the sammuni of intensity is 
reached. Since the left dorso-anterior position of vei-tex pre- 
sentation is most frequent, the sounds of the ftetal heart are 
oftener heard on the left side below the umbilicus. When thp 
child is in the fourth position, the sounds are also on the left 
side. In second and third positions they are on the right side. 
In cephalic presentation the area of audibility is lower than in 
pelvic preeeiitation. 

The rapidity of pulsation varies greatly, the average being 
about 135 beats per minute. 

There is want of unanimity among observers regarding the 
period in pregnancy at which the ftptal heart is first audible. 
Practice will enable one listener to detect it at an earlier statii; 
than another of less experience. I)e Paul says that he Iinw 
heard it at the eleventh week. N'aegle could not distinguislb 



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DiAGNUSis OF Pregnancy. 113 

it before the eighteenth week, and his experience in this regard 
corresponds to that of the avera^ skilled practitioner. 

What was formerly termed the "placental souffle," and 
regarded as a certain sign of pre^aney, is now more appropri- 
ately known as the uterine, or abdominal, souffle. This bruit, 
instead of proceeding ftx>m the utero-placental circulation, and 
marking the placental site, is probably occasioned by the 
uterine and abdominal circulation, the vessels of which in 
places are anbject to pressure, and accordingly emit a blowing 
or purring sound. Large abdominal tumors, disconnected 
with pregnancy, also give rise to the same, or a similar, bruit. 
It may be modified, or entirely arrested, by the pressure of the 
stethoscope. As an indication of pregnancy, it doubtless pos- 
sesses some value, but it must not be admitted as a certain 
sign, and under no circumstances is it to be regarded as proof 
of foetal life. 

It is now well understood that, by auscultation of the ab- 
domen of a pr^nant woman advanced beyond the fourth 
month, we may hear the pulsations of the fetal heart, the 
bruit de souffle, and occasionally ftetal movements and the 
fuuic souffle. The first named is a positive sign of pr^- 
nancy; the second is of little value save when it is certain 
that the woman has no other disease which can possibly give 
rise to it ; while the third and fourth are, on one band, so rarely 
tbudible, and, on the other, so ambiguous as to be of little real 
worth. 

The summary of the signs of pregnancy, which appears on 
page 114, may prove serviceable. 

Differential Di^nosis.— The subject of the diagnosis of 
pregnancy would be far from complete without a few observa- 
tions on diflerential diagnosis. 

It would be impossible to mention, in a short chapter, all 
those various conditions which are liable to be mistaken for 
pregnancy. 

When there is an enlarged abdomen which raises a suspicioQ 
of pregnancy, combined internal and external examination is 
highly important. Upon employing it, a tumor of some sort 
may be discovered, but, if extra-uterine, by careful manipula- 
tion of the cervix the uterus can generally be made out as a 
distinct and free organ, with walls which are not greatly dis- 
tended. To pass the uterine sound is rarely necessary, except 
to render assurance doubly sure. If serious doubts are felt, it 



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X14 l'REGXAS('Y. 

would be ail unjustifiable act. The feel of the lower uterine 
segment, in connection with other signtj, is diagnostic. From 
the second to the fourth month the gi-avid uterus is peculiarly 
soft, while if tumors are present it ie harder. In htematometra 
it is firm, but elastic, and may even g;ive slight fluctuation. 
In chronic infiaiiitnation, the uterus is sometimes rather soft, 
but usually it is much harder than in pregnancy. Then, too, 
if infiammatiun exists, other symtonis, HUch as tenderness 
and pain, will strengthen diagnosis. Diagnosis in some cases 
may still be uncertain at the first examination, but the lapse 
of a few weeks will clear up the doubtful points. Should the 
fibroids form knobby projections, as they most frequently do, 
abdominal palpation would contribute the requisite certainty 
to the diflerentiation. 

An exact diaguosis of pregnancy is often impossible even at 
the third mouth, but again it may be made with a reasonable 
degree of certainty. If the organ is found slightly anteflexed, 
and corresponding in size to the probable period of gestation, 
not painful to manipulation, of a peculiar softness, and, more- 
over, the woman healthy, though her menses have not appeared 
during the time, then, every probability points to the one 
conclusion. The experienced, however, usually act a wise part 
by making their diagnosis with a distinct reservation. 

At a subsequent period, differentiation of the physical condi- 
tion becomes less difficult, quickening, ballottement and the 
fuetal heart-sounds clearing away all doubt. But at the fourth 
or fifth month, though the absolute signs of pregnancy are 
absent, as in the instance of dead ovum, or uterine mole, devel- 
opment of the organ has gone to so great an extent that the 
existence or non-existence of pregnancy can be determined 
with much precision. 

In those casea where pregnancy exists in connection with 
morbid 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 investigation is neglected. In these complicaticd cases, 
should there be a suspicion of pr^;nancy, repeated careful 
examinations will either confirm or remove it ; and no meai<- 
ures should be adopted for the treatment of disease in women, 
which would be prejudicial to the pr^:nant state, without the 
possible existence of such a state being excluded. 



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DlAUXOSIS OF PltKGNAXCY. 



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Diagnosis op Pregnancy. " 115b 

The following from Hirst ia a fitting conclusion: 
"A positive diagnosis of pregnancy before the sixth week is 
fanpossible, and the diagnosis may be only presumptive until 
the foetal heart-sounds can be heard and foetal movements are 
felt. 

"Clinictilly, the signs of pregnancy may be divided into those 
-of three trimesters, or ireriods of three months each. It is use- 
less for the practitioner to look for certain signs in one trimes- 
ter only available in the next. First tHmeater. — In this period 
"the following signs of pregnancy are available : Enlargement, 
-change in shape and bc^giness of the uterine Imdy, soft cervix, 
-enlargement and functional activity of the breasts, Hegar's 
sign, cessation of menstruation, nausea, and vomiting. The 
■second trimester will exhibit, in addition to the above, enlarge- 
ment of the abdomen, intermittent contractions of the uterus, 
feeble foetal movements, ballottement, fcetaJ heart-sounds, and 
blue discoloration of the vaginal mucous membrane. In the 
third trimester all the symptoms just enumerated become more 
easily appreciable. The outlines of the fcetal body are dis- 
tinguishable by abdominal palpation, and the presenting part 
-may be felt through the roof of the vaginal vault " 



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116 PREGNASCY. 

Diagnosis of Foetal Death.— This is a highly importcuit 
consideration. The circamstancefl which may give rise to a 
auBpicion that the foetas is dead are: 1. Absence of foetal mov(»- 
ments. 2. Abseoce of the foetal heart-sonnds. 3. Diminished size 
and increased softness of the utems. 4. Engorgement, succeeded 
by flaccidity of the mammte. 5. Sensation of weight and cold- 
Dess in the abdomeo. 6. Debility and general ill feeling. 7. 
Peptonuria. 

CoDceming the first, we need not heeil ate to declare it wholly 
unreliable, and when once active uterine effort has b^run, it is 
devoid of signiScaoce. With respect to the second, it shonld be 
understood that iu certain cases, the sounds of the ffetal heart 
are inaudible for a considerable period, while yet the child » 
vigorous. The physical signs, 3 and 4, may depend upon 
causes which do not involve foetal death, while numbers 5 
and 6, being subjective symptoms, are of very slight relative 
value. Sign number 7 is said to be quite constant. 

"Certainty of death having taken place," says Schroeder^ 
" is obtained only when the os is o})en and allows the loose 
cranial bones to be felt distinctly ; also, when the sounds of the 
foetal heart, which, in the absence of other pathological condi- 
tions, can always be distinguished bya repeated careful esami- 
natioD, cannot be heard." 

SignsopFietal Death Evixced Dimxo Labor.— After labor 
has begun, the signs of foetal death have reference only to the 
child itself, and they are generally so clear as to dispel all doubt. 
1. The results of auscultation are almost conclusive, since, dur- 
ing parturition, the conditions favorable for the transmissioa 
of the fiBtal heart-sounds are at their best, and can hardly fail 
to be successfully made use of by even a novice. 2, On the- 
head of a dead ftetus no caput succedaneum is formed. The 
preeeuce of such tumefaction is conclusive evidence of life, as 
it is the effect of long-continued pressure, and circumscribed 
arrest of circalation. 3. The scalp of a dead foetus is flabby 
and soft; the bones are movable and overlap more than 
nsnal; their edges feel sharp, and on pi-^sure communicate to 
the fingers a grating sensation. The heads of poorly nourished, 
but living children, sometimes present these peculiarities. 4. 
The presence of meconium, and the escape of thin, slimy, offen- 
sive liquor amnii, afford additional proof of death. 

If the breech presents, the sphincter ani is relaxed, and does 
not contract on the finger. The epidermis is blistered, and ia 



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Diagnosis of Pregnancy. 117 

easily rubbed ofi with the finger, if the child has been dead 
more than a day or two. Thie ia also true of other Burfaoee. 

If the face presents, the hpe and tongue are flabby and 
motionless. In arm presentations, there is no swelling, no 
lividity, no motion, and no warmth. Id prolapse of the funis, 
the cord is flaccid, cold and pulseless. 

In rare instances cadaverous rigidity has been observed. 

Proofs of Former Pregnancy and Labor. — The permanent 
changes wrought by pregnancy and labor, which remain ae evi- 
dence of the ordeal, should be remembered. 

The int^^ment covering the abdomen, which has once been 
stretched by development that went to full term, never again 
wholly regains its tenseness, but, even daring a certain degi-ee 
of redisteusion due to a second pregnancy, it may be gathered 
in rolls by the hand. The silvery lines found upon it never dis- 
appear, and the new marks which may be added are, when 
fresh, of a purplish color. 

Discoloration of the areola about the nipple is more or lees 
permanent, and such appearance observed in the early weeks of 
gestation should be regarded as signiScant, since it is not 
found primarily among the early signs. The mammse them- 
selves lose their original hardness and regular outline, often 
becoming decidedly flaccid. 

Uterine changes are marked, especially in the crervix, which 
remains permanently enlarged and the os ranch more patulous 
than formerly. Its cone shape is lost and it becomes more 
cylindrical. Owing to overdistension and slight laceration, the 
OS presents an irr^ularity of surface which makes it quite dis- 
tinctive. 

The vulvar opening is larger and the canineulse myrtiformes 
are developed. 

With a knowledge of these permanent changes in mind we 
shall usually have little difficulty in determining the question 
of former pregnancy. Yet it must ite remembered that these 
changes are the result of gestation which goes to a late period, 
and hence their absence is not positive evidence that pregnancy 
has never existed. After miscarriage at the third or fourth 
month, none of these evidences would be found, save perhaps 
those in the os uteri. 

Diagnoaia of Fcetal Presentations and Positions.— It is 
highly important to know, as early as possible after labor sets 
in, the presentation aiid position of the foetus. If the prcscnt- 



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1 ! 8 PREGNAXCY. 

ingpart bas been driven downwarda into the pelvic cavity, and 
the membranes have ruptured, they can usually be learned by 
a va^nal examination, without much difficulty. But if descent 
ofthe presenting part has not yet been accomplished; if there 
IB a tense and full bag of waters, and if the os uteri is but 
partially dilated, and is reached with difficulty, such diagnosis 
is not, in every instance, easily made even by experta. In a case 
of this kiud it will be necessary to bring to our aid the informa- 
tion derivable from external examination. 

Examination through the Vagina. — In the vast majority 
of cases positive iuformation can be gained from vaginal 
exploration alone ; but in some instances its revelations, as ordi- 
narily obtained, are most unsatisfactory. One not thoroughly 
familiar with the feel of thf» characters of the various presenting 
surfaces will do well to verify conclusions by external means. 

The head is recognized fi-om its shape and hardness, which 
differ fi-om those of any other presenting part. To the inexpe- 
rienced these may not be wholly characteristic, forstudenta and 
young practitioners have often mistaken the head for the 
breech, and the breech for the head. The breech, M'hen fairly 
crowded into the pelvic brim, or cavity, does give a feeling of 
resistance, which, to a casual examiner, is liable to prove 
deceptive. An attentive observer of course will rarely, if ever, 
be misled. But these remarks do not apply with equal force to 
both varieties of cephalic presentation, since the vertex pos- 
eessescbaractersnotassociated with the face. The vertex will be 
distinguished mainly by its sutures and fontanelles. As the 
finger is passed through the os uteri and rests upon a fonta^ 
iieile, it is most frequently the posterior, and it will be recognized 
by its A shape, which is generally easily felt. From the apex of 
this figure the finger passes along the sagittal suture to its 
extremity, where the anterior fontanelle will be found. The 
Jace will be recognized from the feel of mouth, nose, chin and 
eyes, though these features will be considerably obscured by the 
pressure to which the part is subjected, and the consequent 
tumefaction. Such presentation is more likely to beconfounded 
with breech presentation than any other, and differentiation 
must be ma(]e by a detailed study of the parts, as the fingers 
are swept over them. 

When the pelvic end of the foetus is turned totheos uteri, the 
feet or knees may be in advance, or, what is more frequent, tbo 
breech presents. 



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DlAQNOSIS OF PREGNAKCY. 119 

The features of this part can scarcely be mistaken. At 
-first one natJs only is lound, but, when the or uteri opens, the 
other is felt, asd the clefb between the two. The genitals, the 
point of the coccyx, the anus, and the rudimentary spint^of the 
sacrum, pass under inspection, uniting to disclose the character 
of the presentation. 

In transverse presentation, the precise surface upon which 
the examining finger falls can generally be made out, though 
not always with facility. The side should be recognized from 
feeling the ribs, and the shoulder by finding the scapula and 
■vertebree, and by its own peculiar contour. In early examination 
the presenting part often lies entirely out of reach. This is a 
diagnostic fact of much value. 

Upon examining per vagiaam in these cases, we find, when 
■the feet or knees preeent, that, early in labor, diagnosis is many 
times a matter of some difficulty, inasmuch as an extremity 
is felt, but it moves before the finger, and will not admit of 
tactile study. Later, however, it comes within reach, some- 
-times suddenly, by rupture of the membranes, and escape 
of the liquor amnii. The foot is distinguished mainly by the 
toes and heel, and the knees are known from their size, aJid 
obtuseness. 

When the presentati'oo is either transverse or pelvic, the ba^^ 
of waters is largerand longer," and thorough explorationcorre- 
-spondingly difficult. 

Diagnosis of Pkesentation and Position by Abdominal 
Palpation. — This subject has received considerable attention 
of late, and its value during pregnancy, for the purpose of 
diagnosis, has been clearly demonstrated. Dr. Paul F. Mundd 
has fulTiished a most interesting and valuable paper on the 
-subject, mth some very excellent illuBtrations, Dr. De Paul has 
likewise given some important instruction concerning its value 
and methods, with figures. 

According to the writers mentioned, and others, a little prac- 
tice will enable one to elicit, by means of abdominal palpation, 
most valuable information concerning both presentation and 
position of the fcBtus. Examination ought first to be with 
reference to the direction of the long uterine axis. If that corre- 
sponds closely with the longitudinal axis of the woman's body, 
the presentation must be either cephalic or pelvic. By spread- 



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ing the bauds over the uterus, a Bense of greater resist- 
ance and fullness can generally be felt more to one side or the- 
other, which represents thesituationof the foetal bai-k. By dee[^ 



palpation with a single band on the hypogastrium, the head of 
the foetus, if preseuting, can be felt, and recognized by its form 



and hardness. By striking the tips of the fingers suddenly 
inwards at the fundus, the breech can generally be made out, or 
the head, if there, be felt still more easily. It is also possible, ia 



Diagnosis of Pregxancy. 121 

most cases, to find the fiBtal limbs, especially on provoking 
movements. When the foetus lies in a transverse presentation, 
diagnosis is still leas difficult. Thelong fetal axis being thrown 
across the abdomeii, gives to the part a feel wholly different 
from that found in connection with other presentations. The 
cephalic globe can easily be fingered in one iliac fossa or the 
other, or at a higher point. 

Diagnosis of Presentation and Position by Abdominal, 
Auscultation. — This is another means of diagnosis not 
profterly valued or understood by obst^'tric practitioners. For 
general purposes the unaided ear will answer very well ; but for 



the diagnosis of presentation and position, the stethoscope is a. 
necessity, as without it the summum of intensity of the sounda 
cannot be circumscribed. The most common location of the- 
foetal heart-sounds is on the left side below the umbilicus, 
1. Because the back of the child is most frequently turned to- 
wards the mother's left, and 2. Because the head commonly 
presents at the os uteri. The first fact, then, to be kept in 
mind is that when the fcetal back is turned towards the left side- 
of the mother, the heart-sounds will be most distinctly audible 
on that side. The just inference to be drawn from this is not 
that the position is necessarily a left dorso-anterior one, though 
it is more likely to be. It may be a left dorso-postmor poni- 
tion, with but a moderate inclination backwards. Accordingly 
we conclude when the sounds of the foetal heart are most dis- 
tinct on the mother's left side, that the position is either a left 



122 Preonancy. 

doreo-anterior, or a left doreo-poeterior position; in other 
words, it is a first or a fourth position, with the probabilities 
strongly in favor of the former. If heard most, clearly at a 
point an inch or more below the line of the umbUicus, the 
woman being near term, it is a cephalic presentation ; if heard 
most distinctly at a point as high as the umbilicus, or higher, 
it is a breech presentation. When the summum of intensity of 
Ihe fi£ta] heart-beat is on the right side, the position is either 
right dorso-anterior.orrightdorso- 
posterior ; or, in other words, it is 
.either a second or a third position, 
without regard to the presentation. 
But now, if the point of clearest 
audibility is on or below a hne 
drawn transversely across the ab- 
domen about an inch below the um- 
bilicus, the woman being nearterm, 
it is almost certainly acephalic pre- 
. sentation. Ifthe sounds are most 
distinctly audible at a point above 
the umbilicus, it is equally certain 
that the presentation is pelvic. 

In transverse presentation the 
foetal heart is heard moat distinctly 
on or near the median line of the 
abdomen, several inches below the 
umbilicus. 

Diagnosis of Twin Pregnancy 

through Auscultation.— In twin 

pregnancy, the fcetuses lie upon 

Fio. 91— Showing at +■ the either side of the abdomen, and 

most common locations ot the (-j.^^ jj,gpg inspection a diagnosis. 

total Heart-Bounda. ^^ sometimes be made. The 

stethoscope will be applied to one side, perhaps the left, below 

the umbilicus, and the sounds there heard counted by the 

watch. The investigation is still further pursued, and on the 

opposite side of the abdomen, perhaps on a line with the first 

sounds, but moi-e likely at a higher point, a fnetal heart of a 

different rhythm is heard, and its pulsations counted. From 

such an examination we infer with great confidence that there 

are two fiptuses in utero, and furthermore that their positions, 

and i>erhap8 their presentations, vary. The same principles of 



Diagnosis of Pbeonancy. 



dia^osis of presentation and positiou are here involved, as in- 
the iuBtance of single pre^ancy. In the Bame connection it. 





Fia. 92.— First poBi- Fio. 93.— First poel- Fio. 94.— First posi- 
tion of the Vertex, tion ot the Face. Lo- tion of the Breech. 
LoostioD of heart- cation of heart-soands Location of hearts 
sounds indicated b; +• Indicated by +. sounds indicated bj +• 




Fio, 96.— Twin Pregnancy. Lo- 
cation of beart-sounda indicated 
by+. 



Fio. 96. — Dorso- anterior posi- 
tion of Transverse Presentation. 
Location of heart-aounds fpdi- 
cated by +. 

shoold be borne in mind that the dorsal surfaces in twin pr^- 
luuicy, OTB, as a rule, turned in opposite directions. 



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124 Pregnancy. 

The presentations are also different in about forty per cent, 
of twin pregnancies, so that the heart-sounds are most fp&- 
queiitl,v found at corresponding heights on the abdomen. 

These ideas of pre.'>entatioii and position, 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 Hahnemann Hospital, 
Chicago, as well as in private practice. 

D^nosia of Sex from Rapidity of the Pcetal Heart.— 
The possibility of determining with tolerable accuracy the sex 
of the foetus in utero from the rapidity of the heart's action, 
has commanded the confidence of some, and is deserving of 
study. The theory is founded on the clinical observation that 
the heart: of the female fcetue exceeds in rapidity of pulsation 
that of the male. That there is an element of truth in the 
theory is plainly shown by the reports of all who have given 
the matter attention, but experience of different observers has, 
nevertheless, been far from uniform. Steinbach wa*i correct in 
forty-five out of fifty-seven cases which he examined, and 
Fran ken hiPuser made not a single mistake in fifty consecutive 
cases. But other careful observers fall far short of such mar- 
velous success. 

In studying the subject, one should not forget the infiuence 
of both maternal and foetal states upon the heart's action. It 
is probably as true of intra- as of extra-uterine life, that such 
influences much more frequently accelerate than retard the 
cardiac contractions, and hence we often find the male heart 
simulating, in point of rapidity, the female heart. This affords 
a rational explanation of the greater relative frequency of 
males when the pulsations fall below 1351i to the minute, than 
of females when the pulsations exceed that number. That dis- 
turbance of the vital force of the foetus, and its reduction to a 
low ebb, is exhibited in the pulsations, is clearly shown in 
carefully conducted observations. An instance of the kind 
appears in the succeeding tables. The mother was in very 
feeble health, and, two weeks prior to delivery, the heart of 
a male fcetus which she bore was pulsating so rapidly that it 
could scarcely be followed — 172 times a minute. The child waa 
still-bom, near term, and presented evidence of life having been 
extinct for several days. 

The author's personal observations in ninety-six unselected 
cases gave an average pulsation of ISoH. The results of obser- 



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DlAOXOSLS OF PREOXAXCY. 125 

Tationa, with this ae the iotermediate poiat in the scale, are 
^ven in the accompanying table: 

Hale. Female. 
Pulsations in exceBS of 18G>i ... 26 24 

Pulsations b«low 135,i^ 30 12 

Total 60 36 

Average pulsations of males . .... 134 
Average pulsations of females .... 138 

According to these figures it will be observed that if diag- 
nosed of sex had been made in accordance with the theory of 
cardiac rapidity alone, they would have been correct in only 
fifty-nine out of ninety-six cases, or in but little more than 
sixty-one per cent, of them. 

As the proportion of males in these ninety -six cases is so far 
in excess of females, it appears that a comparative statement, 
constituting in some regards a more equitable showing, should 
be 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 number of males 
taken in regular order from the records, first in chronological 
order, and secondly in reverae order, with the following results: 

COMPAKATITE STATBMBNT OF THR F(ETAL HeaBT-SOUNDB IN ThIBTT-SiT 
HaLBS, TAKEN IN ChBONOLOGICAI. OsDER FROM THR AuTHOR's RsCORDB, 
AMD THOSE OP THE ENTrRBTHIRTr-SIX FbHALBS IN TRB FoRBOOINQ LlST : 

Cases wherein the pulsatiouB exceeded the 

average number of I35X per minute ; 

Males, 14— about 87 per cent. 
Females. 24— about 68 per cent. 
Cases wherein the pulsations fell below the 

average number of 135i, per minute: 

Males, 22 — about 65 per cent. 
Females, 12 — about 36 per cent. 

A Comparative Statembnt Similar to "phb Foregoiko, the Trirtt-six 
Males beino taken from the Records in Reverse Ohrokolooical 

Cases wherein the pulsations exceeded the 

average number of 136,'^ per minute : 

Males, 13 — about .S4 per cent. 
Females, 26 — aboul 66 per cent. 
Casea wherein the pulsations tell below the 

average number of 136"^ per minute; 

Males, 23— about 68 per cent. 
Females, 11— about 32 per cent. 



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126 



Pregnancy. 



These observationB were made in hospital practice, and th» 
unusual proportion of male children is not easily explained on 
any other basis than the recognized preponderance of that sex 
among the illegitimate : 

PnlBatlona of vbIb Fon.is PnlH«tlon« of 

FixMl He«r(. ""*■ """«■ Foetal Heart. 



Male. Female. 



Male. Female. 



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DnRATioN OP Pregnancy. 



CHAPTER V. 

TffE DURATION OF PREGNANCY. 

This is a subject which has elicited much study and discas- 
sioD. Id settliog it on a firm scientific basis, the main obsta- 
cle has been the impossibility to ascertain the precise date of 
fertile coitus. In hospital practice, the majority of women 
entered for confinement are living outeide the conjugal relation- 
ship; have been leading lives of repeated exposure to impr^> 
nation, and are unable to offer positive testimony aa to the 
date of conception, even if so disposed to do. Others, both 
in and out of hospitals, who are unmarried, profess to 
have been guilty of but a single misstep, and are prepared to 
give precise dates ; but we must withhold from such full cre- 
dence, since the motive prompting them to misrepresentation is 
so powerful. The married state presente obstacles to absolute 
calculation fully aa great as those just enumerated. On 
account ofthe difllcnlties in the way of trustworthy observa- 
tion, it has become customary to base calculations on the date 
of the last menstruation. The fallacies associated with sach 
figures are conspicuous. First, the date of the last menstrual 
return cannot be held to represent the real time of impr^na* 
tion, or even of insemination, in more than a very small per- 
centage of cases, since sexual congress during menstruation is 
avoided by both parties to the act. Moreover, the time of 
insemination does not correspond to the date of impregnation, 
inasmuch as tbe time consumed by the spermatozoa in journey- 
ing from the vagina to the point of contact with the ovum 
represente a period varying from a few hours to a few day-i. 
Again, it is admitted by phystolos^sts that fertile coitus may 
both precede and succeed the menstrual return, by a few days. 
Should it precede, the flow which waa so near maybe prevented, 
and a miscalcalation made by basing the figures on the date 
of the last menstruation. Or the fiow may come on at the 
usual time, even though impregnation has existed for several 
days. Allusion should here be made, also, to those anomalous 
cases wherein conception is succeeded for two, three, or four 
mouths by regular menstrual returns. Hence it appeai-s that, 
at best, such a basis of calculation is not settled nor reaasuriug. 

We gather some information concerning the average dura- 
tion of pregnancy fi-om a study of comparative physiology. 



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128 Pregmancy. 

Valuable observations have been made in the case of certain 

domeHtic animala, in whom one coitus coincides with the period 

of rut. In ISllt, M. Tessier submitted to the Academie des 

Sciences at I*aris the results of a series of investigations of this 

nature, which are worthy of attention. Of 140 cows — 

14 calved between the 241st and the 266th daj. 

63 " " " 269th " 280th " 

68 " " " 280th " 290th *• 

6 " " " 290th " 308th " 

Gestation in cows is but little more protracted than in 
women, and according to this table, founded on exact observa- 
tions, there waa an extreme difference in duration of pregnancy 
amounting to 67 days. Lord Spencer made a series of obser- 
vations of a similar nature in'thecase of mares. Of 102 maree — 

8 foaled on the 3llth d&j. 

1 " " S[4th » 

1 *' " 825th " 

1 " " 826th " 

2 " " SSOth " 

47 " between the 840th and 360th day. 

26 " " " 35flth " 360th " 

21 " " " 860th " 877th " 

1 " on " 894th day. 

In neither of these tables ha« allowance been made for the 
contingency of premature labor, which probably widens the 
extremes ; but when a reasonable number has been deducted, on 
the strength of this presumption, there still remains evidence 
of widely variable results. It may be said in favor of the tables 
a« exhibited, that, in the animals mentioned, it is highly prob- 
able that the influences generally regarded as productive of 
premature labor were not as numerous, nor as powerful, as 
those to which women are subjected. 

Dr. Reid collected thirty-nine, and Dr. Montgomery fifty-six 
cases, in which pregnancy was calculated from a single coitus, 
with the following reBiilts: 

Total. DuntloD. 

1 ... 36 we«'ks, or 252 days. 

3 . . . 37 " 259 " 



2—66 4—95 



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BUBATION OF PbEGNANCY. 1S0 

"While there are grave doubts of accuracy \n mauy of 
these eases, and hence of the table as a whole, some of them 
are worthy of moat implicit trust. Dr. Montgomery relatesthe 
case of a lady who went to the sea-side in June, 1831, leaving 
her husband in town. He visited her for the first time Novem- 
ber loth, and returned 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 preceded by 
-an interval of nearly five months. 

Considering the remarkable care and precision exercised by 
"these observers, it seems probable that the results, as shown, 
approximate very closely the real facts, and from them we learn 
that there is a wide variation in the duration of pregnancy. In 
addition to the above, there are several cases recorded where 
■delivery of what appeared to be fully developed children occur- 
red OS early as 200, and as late as 384 days after a single 
■coitus, so that we are led to conclude that pregnancy does not 
run a course with uniform Umits. 

Sehlichting hasexamined 456 cases inwhich the day of copu- 
lation was known, and in which the children were full term. 
He found an average duration of 270 days, but the extremes 
were very wide. 

But as it is rarely possible to determine the date of fertile 
'CoituH, the calculation and experience of the duration of pr^- 
nancy must rest chiefiy on observations, the starting point of 
-which is the last day of the last menstruation. Dr. Merriman 
has accordingly conducted and recorded a series of iuvestiga- 
"tions, which are here tabulated. Of the 150 mature births 
■observed by him — 

6 were delivered in the 37th week , 255th to 259th day. 

16 " " " Bfith " , . , 260th to 266th " 

21 '• " " 39th " . 2finh to 273rd " 

46 " " " 40th "... 274th to 280th " 

28 " '■ " 4l8t " . . 2m8t to 287th " 

18 " " " 42d "... 2R8th to 294th " 

11 '■ •' " 43d " . . 295th to 30lBt " 

6 " " " 44th " the latest being the 306th daj. 

A difference of fifty-one days between extremes is here 
sib-onn. Pr. James Reid has given a table of 500 cases, in which 



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the calculation is also from the laet day of menetruation. 
Of tbeae— 



were delivered 


n Che 37th week . 


. 256th to 269th day 


" " 


•' 3fith 




2«0Ch to 266th " 


" 


" 89th 


•* 


. 267th to 273d '• 


" " 


" 40th 


'• 


. 274th to 2a0th '' 


". 


" 41it 


" 


. 28Ut to 287tb " 


" " 


" 42d 


" 


. 28«th to 294th " 


" 


" 43d 


" 


. 21(5th toaOlBt " 


" " 


" 44th 


" 


302d to 308th " 


" 


" 46th 


" 


. 309th to 316th " 



The dififerenee between extremes is here sixty days. With 
these, and other equally reliable facts before as, ive are led to 
the couclusion that the average duration of pr^:nancy is in the 
vicinity of 278 days, though the variations are extensive. 

The Mimmuh. — It is interesting and important to knoiv 
what is the shortest time within which a child may be bon> 
alive, and have a fair chance of life. In cases of contemplat<>d 
induction of premature labor for conservative purposes, the 
minimum time allowed the fcetus is 230 to 250 days, but cates 
are on record in which life has been sustained when birth took 
place at a much earlier period. The following table by Dr. 
Montgomery will prove of int^erest because of the information 
on this subject which it afTords : 



Lut Date of 

HSDMl. CODCep'D 


Birth. 


DanttloD 
otGesfn. 


D»F. 


Survival ol Child. 


Oct. 9 Oct. 9 


Apr. 3 


B M. 10 D. 


161 


Twelve hours. 


Aug. 24 


Mar. 8 


D " 21 " 


174 


A week. 


July 22 


Jan. 18 


6 " 27 " 


180 


131 days. 


nmrried 














8 " 


183 


Seven weeks. 


Apr. 10 Apr. 10 


Oct. 16 


6 " 9 " 


189 


Eleven years. 


Apr. 1 


Oct. 10 


6 " 18 " 


193 


Doing well 6 m. art«rwBrd 


Jan. 81 


Aug. 14 


6 " 16 " 


196 


Thirty years. 


Jun. 12 


Dec 27 


6 " 18 " 


198 


Two years. 


Oct. 21 


May 10 


6 " 19 " 


199 


Eleven days. 


Aug. 22 


Mar. 18 


6 " 21 " 


201 


Thirteen years. 



The Maximum. — That pregnancy is sometimes protracted 
beyond the usual period seems now an established fact. We 
are nevertheless told that little more than fifty years Ekgo 
opinions very different from those which now prevail were held 
by the best obstetricians. In theGardner peerage case which came 



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Duration of Pregnancy. 131 

before the House of Lords, England, in 1825, Dr«. Gooch and 
Davis, and Sir C. Clark, testified that, in their judgment, the 
period of 280 days was never exceeded. Subsequently, with a 
view to aacertain the experience of those who were most likely 
to have paid particular attention to the subject, upwards of 
forty of the most eminent obstetric practitioners in Ijondon, 
Dublin and Edinburgh, were applied to by Dr. Reid. The large 
majority of theseexpresseda firm conviction as to theoccaaional 
«xtension of the usual period of pregnancy by a few days be- 
yond 280. Several had met with one ortwo caaes of protracted 
gestation, out of many hundred, on the exact data of which 
they could rely ; others, who had not kept notes of their caaes, 
could not offer positive testimony, but had no doubt that in 
some cases the period had been extended. Some, who had had 
extensive private and hospital practice, stated that they had 
never met with an undoubted case of protracted gestation; 
while two affirmed their strong conviction that no case ever ex- 
ceeds the 280th day from conception, and one, that pregnancy 
is never carried beyond the ninth calendar month. 

Without permitting this subject to take up too much space, 
it may be remarked that there are on record undoubted casee 
of protracted gestation, though they are probably rarely met. 
Many of the cases adduced are valueless, because founded on 
insufficient data, but cases have been reported which merit our 
acceptance. 

There are many careful observers who put no credence in 
a11(^;ed examples of prolonged gestation. " We therefore say," 
remarks Charpentier, " with all other authors, that prolonged 
pregnancy, the foetus being alive, does not exist as a physiologi- 
cal condition. It exists only in cases like the following: I. In 
extra-uterine pp^nancy ; 2, In cases of dead foetus retained in 
utero, as in instance of abortive ova; 3. Finally, in cases 
where a dead foetus is retained by obstacles to parturition 
seated at the cervix. Even in such cases, prolonged pregnancy 
is very exceptional," 

Prediction of Date of Oonflnement.— The average dura- 
tion of gestation after cessation of the menstrual flow, haa been 
found to be 278 days. Various methods of calculation have 
been suggested, and sundry periodoscopes and tables have 
been given, with a view to facilitate the prediction, and make 
it more accurate than it could be without them, some of which 
are based on an average of 278 and some of 280 days. 



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1S2 



Pregnancy. 



Dr. Matthews Duncan, who has devoted mocft stuJy to tha 
prediction of the time of labor, has given a method of calcula- 
tion based on an avera^ of 278 days, which ia very convenient 
and practical. His rule is: "Find the day on which the female 
ceaeed to inenBtruate, or the first day of being what she ca11» 
' well.' Take that day nine months forward as 275, unless Feb- 
ruary is included, in which case it is taken as 273 days. To tbis^ 
add three days in the former case, or five if February is in the- 
count, to make up the 278. This 278th dayshould then be fixed 
on as the middle of the week, or, to make the prediction mopo 
accurate, of the fortnight in which the confinement is likely to- 
occur, by which means alloweuce is made for the average varia- 
tion of either excess or deficiency. 

Naegele's method is to figure from the first day of the last 
menstrual period, and then count forwards nine months, or 
backwards three months, and to this date add seven days to 
complete the period of 280 days. 

The following table by Dr. Protheroe Smith is easily under- 
stood, and is probably fully as serviceable as any : 



Table 


FOB Calculating tkb 

NlME CALBNDiR MOKTHB. 


Period 


Of Uteeo-Gkbtatiom. 

TKK Ltl.NjkB UONTHI. 




From 




D«y«. 




Day.. 


January 1 . 


. September 30 . 


. 273 


. October? . 


280 


February 1 


October 31 . 


273 


November? . 


280' 


March 1 . 


. November 30 . 


. 275 


. December 5 


280 


April 1 


December 31 


275 


January 5 


28ft 


May 1 . . 


. January 31 


. 276 


. February 4 


280 


June 1 


February 28 


273 


March 7 . 


280 


Julyl . . 


. March 31 . . 


. 274 


. . April 6 


280 


AuKUBt I 


April 30 . . 


273 


. May? . . 


280 


September 1 


. May 31 . . 


. 273 


. . June? . . 


280 


October 1 


June 30 


273 


July 7 . , . 


280 




.■ July 31 . . 


. 273 


. August 7 . 


280 


December 1 


August 31 . . 


274 


September 6 . 


280 


The ibove ob 


tetrlc ■• Re.<ly Reekoner 


■ conilst* 


of "two tolumoa, one oJ ta 


endar. 


the niber of luasr 


months, and may i>e rend 




: A patient hu ceaied to me 




Me on July 1; he 






r«d of 




j»,orftl.ate9tA|.rI18((fl 


rnd»/(n. 




vnaea 




anuHirSO; her eon flu em « 




expected on September 90, 


1us» 


d»rB((ft*™d(./m 




est; or o 


October 7. plUi ao day. (Me 


M<i/ 



The Date of Qt'ickexing. — Even when it is impossible to 
establish tlie date of the last menstrual period, the time of 
qnickeninp; can sometimes be recalled by the woman, in which 
case it is customary to add twenty-two weeks for the purpose 



CiOOgle 



Duration of Pkegxancy. 



133 



of dGtermining the proximate day of delivery. But quickening 
is a sigii of preguanry which does not always develop in the 
eight«euth week, and the extreme variation in its manifestation 
iu different women and different pregnancies, renders this 
method of calculation a very uucertaia one. We have heard 
patients declare that movemeuts were felt in certain pr^^au- 
cies au early as the third month, while others were not conscious 
of them until the fifth or nixth month. 

Prediction of Time of Labor fi-om Size of Uterus.— From 
abdominal palpation we may gather important data upoa 
which to venture a prediction of the time of expected confine- 
ment. According to common bed- i 
side teaching, the uterus iu the I 
second month is of the size of an \ 
orange ; in the third month, of the \ 
size of a child's head ; in the fourth \ 
month, of the size of a man's head, / 
and can be felt above the syin- / ^ 
physis pubis. In the fifth month, / 
the fundus of tlie uterus rises to a / 
point midway between the sym- / 
physis and the navel. By the sixth I 
month it reaches the level of the \ 
navel. In the seventh month, it \. 
should be the bi-eadth of two or \ 
three fingers above the navel. In \ 
the eighth month, it mounts to a Fro. 97.— Size of the Uteras 
point half-way Iwtween the navel at yarioua perioda of preg- 
and the epigaKtrium. In the ninth °*n<^y- 
month it reachett the ppiga.strium. In the tenth month, two or 
three weeks before confinement, the uterus sinks downward 
and somewhat forward, bo that its upper level corresponds 
very nearly to thnt of the uterus in the eighth month. 

The fallacy in this mode of describing the progrcKS of uteiine 
development, as discovered through the abdominal parietes, is 
that the navel is not a fixed point, and its distance from the 
symphysis is stetidily increased up to a late period in preg- 
nancy. .\ more accurate manner of describing the height of 
the fundus is followed by Spi^!;elberg with the following results : 




From the 22d to the 2Ath week 
" " 22d to the 2«th week 
" " 22cl to the 30tb week 



S'i inchei. 



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Prom the 22cl to the S2d and 33d weeks 113^ jncbet. 

" " 22d to the 34th week ... 12 

" 22d to the S5th and 36th weeks . 12>i 

" 22d to the 87th and SStfa weeks . 13 

" 22<i to the 39tb and 40th weeks . ISJi 

The size of the uterus varies greatly in difTerent women at the 
same Bta^ of ge8t>ation, but the above average measurements 
are somewhat excessive. From accurate recorded observations 
made by the author, the fibres which approximate the true 
average more closely are those which follow : 

From the 18th to the 30th week 6 to S}^ inches, 

" 20th to the 24th week . . 7 to 8 

" " 24th to the 28th week . 934 to 10 

" " 28th to the 32d week . . 10 to 103^ 

" 82d to the 36th week 11 toll>^ 

" 86th to the 40th week . . 12 to 12>^ 

The facts here presented may aid materially, when taken in 
connection with other conditions, in fixing upon the probable 
time of delivery. 



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PSEl'DOCYESIS. 



CHAPTER VI. 
PSEnDOCYESIS. 



pHeudocyesis— false, spurious, or phantom pn^ancy — ^has 
been defined by oue as a " mental delusion, resulting in a false 
interppetatiou of bodily sensations, experienced for the most 
part in the abdomen."' It may bo justly regarded as a 
delusory conviction of pregnancy, based upon, or giving rise to, 
symptoms which, in some instances, closely resemble those of 
true gestation. It is not always a mere asaumption which will 
readily yield to the force of an ordinary negative from the 
medical attendant ; but a settled conviction, strong enough to 
divert the course of nervous impulses, and thereby magnify or 
develop presumptive symptoms of pregnancy, and, sometimes, 
even parturition. A similar mental impression may lead a 
woman to believe that she is the subject of an abdominal 
tumor. 

Care should be taken not to confound spurious pregnancy 
with " false conception." since there isa wide difference between 
the two states, the latter being nothing more nor less than 
molar pr^nancy. 

Dr. Matthews Duncan directs attention to the fact that some 
of the lower animals, such as bitches, exhibit signs of spurious 
parturition. Reviewing the subjectof pseudo-pregnancy, in his 
terse and lucid manner, he very properly, as we believe, em- 
phasizes the thought that distinction ought to bemade between 
those cases where there is merely spurious pregnancy, and those 
in which the patient's vivid imagination, strong with the delu- 
sion, carries her to a culmination of the supposed pregnancy 
in fancied or spurious labor. Dr. Beamy mentions a case where 
not only wa« a midwife kept two nights watching by the bedside 
of a woman who was the subject of phantom prt^ancy, but a 
practitioner, doing a large business, actually shared with the 
midwife for several hours, the honorofsupportingthe perineum. 
Both declared that not only were the pains severe, but that 
the perineum actually bulged from what was supposed to be 
the foetal head. 

Conditions of Development. — The anomaly of spurious 
pregnancy is observed in women of various ages. Dr. O'Far- 
rall mentions a case which occurred in a girl of only 



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130 Preonancy. 

thirteen years. Dr. Cburcliill records one which happened in a. 
young lady of eeventeen." Sir J. Y. Simpson, who was the- 
flrst to give a detailed description of spurious pregnancy, eluci- 
date its causes, and pi-escribe ite treatment, thinks the com- 
plaint is as trequent the first year after marriage as at any 
other time. Dr. Montgomery believes it to be most frequent at 
the climacteric period. Melancholy instances of the kind have- 
been observed in aged spinsters and widows, who had long 
passed the menopause, in whom life was rendered intol- 
erable by reason of this harrowing delusion. 

Etiology. — The excesses of early married life, and the phys- 
ical and psychical changes incident to this period in a woman's 
existence, afford, in the susceptible, an excellent basis upon 
which to fi-ame a false conviction of pregnancy. The same is-- 
also true of the disturbed physical and mental equilibrium at- 
tendant on the climacteric period. It seems clear, also, that a 
consciousness in the unmarried of having been exposed to the 
risk of impregnation, and the impugnings of a guilty con- 
science, contribute to settle and fix the unptensant delusion. 

The latter may operate as powerful predisponents to the- 
physical and mental states and symptoms which point so im- 
pressively to a pregnant condition; but it is probable that in 
many instances there is a transposition of cause and etfect. In 
one example, the physical symptoms which characterize the 
case are doubtless the result of a previous mental state, being 
physical expressions and sequences of a settled delusion, while 

fitates, evIurlnK Itself In tbe develop- 
ilrated In the folloKlugcaae, reported- 
Hiid reflncd Klrl. 30 yenreof age,froTn< 
She Ininxlued tliat.Du Bcerlsln Dlnht, 
her mother snd a married sister, ber 
ad rhlorofornicd and the other ruined 
snBstlaiiiil arUi-Ie detalHiiE Ibc panic- 
uUrn of a similar utriiolty. When I eiamlued her loiir moiitha after her siippased 
prefinaDCy hod Dcriirred. she waii pale, anienilc, aervous. amenorrhceal, Uei (^ountenanee 
waa the picture of deB|«iIr. At time* the abdomen was large, then decliltdly flat. The 
mammffi were swollen, and contained milk. She HiifTe red from nausea everj moniliiKanil 
waa conaclotiB that for the past Few dayn she bad felt violent movemenlK In the abdomen. 
The friends were eoniitantly In dread that she mlnht commit suicide. Ferrnnlnous Ionics 
ivith ttenerouadlet.tiathliiK. air, exercise, etc.weru tried without arall. Iter general beallh 

every other subject she was iwrfectl; railoaal. Finally, after Hve mouths from the dale of 
her supposed preciiancy had elapsed, liook Into her room a manikin, [he articulated bony 
and ll(-»mentou9 [■elvis. with Sc hulli's ohsletrlcal plates. 1, by (his means, succeeded In 
demonstrating to her the [mi>oHslbIlltr of preinancy at five months' ndvancemenl with- 
out greater abdominal enlar)cement. I spent In thU demouKtrstlon M leait an hour, ttoiD^ 
over and over (he sround. It was Id the presence of her mother, Snccesa rewarded me. 
She was convinced ol ber delusion. The fear never returned. She gained eighteen, 
ttounda Id weight In three weeks. The menstrual function was at once established." 



Joining State, wa 


s placed 


uude 


my charge. 


Hed and clearly 


eslgnsie 


el re 


imstantially 


had been enterc 


1 by two 




one of whom 


She had read a 


ew days 


tfor 


a false and 



Pbeudocyesis. 13T 

iD another, the mental impreeBion is, as in real pregnancy, con- 
secutive on observed physical conditions. lu the latter in- 
stance, it is doubtless true that the bodily state is mudifled in 
great measure by the rooted notion which originated from 
physical phenomena. Dr. Simpson says that ''the a^regate 
of the symptoms which we class under the desigiiatiou oi' spu- 
rioua preRnancy in women, is in some way or other dependent 
upon the changes which occur in the ovaries and in the uterus 
at the period of menstruation." Another careful observer re- 
marks that " it will be found that in most of those persons who 
fancy tlieinselves pregnant, there is a marked derangement of 
the circulatory, digestive and nervous systems, either oue or- 
al! being usually implicated." 

Symptoms, — The phenomena observed in spurious preg- 
nancy are worthy a careful study. In the majority of cases,, 
there is unusual flatulence, and some writers have accordingly- 
attributed the abdominal symptoms to this condition. 
Simpson does not incline to that view, but regai-ds the phe- 
nomenon of abdominal distension as probably dependent 
"on some affection of the diaphragm which is thrown into a 
stateof eontra<'tion,and pushes the bowels downwards into the- 
abdominal cavity." There is tympanites; but it is not evident 
from reported cases that either the area of resonance, or the- 
[>ercussion note, differs essentially from that often met in the 
non-pregnant state. Increased prqminence of the abdomen in- 
some cases can be justly attributed to deposition of adipose \a 
the abdominal parietes and omentum. 

The movements which so closely simulate those of a foetus 
are probably produced in some cases by flatus in the intestines ; 
but they are oftener due to spasmodicmuscular action. Dr. B. 
F. Betts relates a case wherein the movements were so vigor- 
ous as to be discernible through the clothing. 

" By application of the palmar surface of the hands to the 
abdominal walls," says the doctor, "the recti muscles were 
found to be irregularly contracting, so as to appear at first as 
though they wei-e pressed out by the movements of a child in 
utero, at irregnlnr intervals. From an inspection, it was im- 
possible to distinguish these contractions from the real move- 
ments of a foetus, but by palpation, the tendinous attachments 
of the muscles to the brim of the pelvis were felt to be stretched, 
as from strong muscular contractions." 

In some cases the abdomen is swollen to an extreme degree. 



138 Pregnancy, 

but these are exceptions to the rule. In palpiitiog, the hand 
may meet with resistance, but this genertjly arises from cod- 
traction of the broad, flat muscles of that rejrion. In a few 
reported instances there was a certain amount of tumefaction, 
which assumed the outUne of a pregnant uterus. 

I'seudo-pi'egnancy may continue for only a few weeks, and 
then wholly vanish, op it may persist for seven, nine, twelve or 
even eighteen months — perhaps longer. The similarity of some 
of the maiiifestatioDS to those of certain nervous disorders of a 
hysterical type should not be overlooked. The strong mental 
impression, the exaggeration of sensations and conditions, the 
flatulency so often observed, and the state of nervous exulta- 
tion, are all of this nature. 

Diagnosis. — The diagnosis of pseudocyesis will vary in pre- 
cision according to the period of develojiment which has been 
reached at the time of examination. In early gestation we have 
relative signs only upon which to base our opinions, and these, 
though in certain combinations they lend strong probability to 
our deductions, afford, after all, nothing more than presump- 
tive evidence. A notion of existing pregnancy takes possession 
of a woman, and she presents herself for diagnosis. Gestation, 
if b^un, is two or three months advanced. Some of the rela- 
tive signs of that condition are found, giving color to the 
presumption, but the discreet physician will not express an nn- 
qualifled opinion. On the contrary, there may be an absence 
of the most common presumptive signs of pregnancy, yet an 
nnequivocal diagnosis of non-pregnancy would be unwise. At 
a later period a physical examination ought to yield unmistak- 
able results. Abdominal distension, due to a tumor of some 
sort, may create in the woman's mind a conviction of pr^- 
nancy not easily eradicable, and symptoms closely resembling 
those of pregnancy follow on apace. In such cases the quar- 
tette of signs pathognomonic of the real condition, namely, 
foetal movements, ballottement, ftetal heart-sounds and rhyth- 
mical uterine contractions, will go far to clear op the doubtful 
points. 

It is not always possible to make a satisfactory examination 
in a case of doubtful pr^nanry, without first bringing the 
woman under aneesthetic influences. When this has been done, 
since by it flatulency will in great measure be overcome, mus- 
cular spasm subdued and sensibility annulled, the abdomen 
will ofier no resistance to deep palpation, nor the vagina to 



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PSEUDOCYEaiS. 139 

thorough exploration, affording thereby conditions the most 
favorable for diagnosis. 

Mention ahould also be made of the aaymmetry, and incom- 
pletene88 in the order of development and mutual relation of 
the signs. There is a lack of harmony in the assemblage of 
the phenomena, an irregularity or defect in the sequence, the 
grouping, and the character of the eymptome, creating in the 
observer an impression unlike that derived from acliiiical study 
of the signs of real pregnancy. This is especially true with 
r^ard to the menstrual function, which is rarely suspended for 
the entire period. It is also worthy of notice that movements, 
inferentially ftetal, in many of these cases, are felt much earlier 
than those of real pregnancy . 

Treatmbnj. — The delusioD which enthralls women in these 
interesting cases is not always easily removed. If a subject has 
confidence in her medical adviser, she will be persuaded, thojgh 
perhaps reluctantly, to cast away her erroneous notions. It 
may be necessary for him to point out and elucidate the prem- 
ises upon which his coaclusions are based, and such an appeal 
to her reason will generally avail.- In those cases where the 
conviction of pregnancy was derived from logical conclusion* 
based upon insufflcient data, theretnay not be marked physical 
improvement, even after the delusion has been dispelled, with- 
out suitable medicinal treatment. 

If there was antecedent menstrual suppression, Pulsatilla, 
caalopbyllam, apis or sulphur, may be required to regulate 
functional activity in the generative sphere. 

If the digestive apparatus is disordered, giving rise to flatu- 
lence, china, lycopodium, nux vomica, nux moscbata, or carbo 
vegetabilis, may be needed. 

If marked physical diHturbance is found, we are more likely 
to unravel the tangled case by giving the symptoms arising 
therefrom a dominating influence in aselection of remedies. In 
the absence of these, or if we have good reason to believe that 
Ainctional disorder is due to psychic influence, then the men- 
tal Bymptoma ought to be given more weight. 



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The Pathology of Peecsnamcy. 



CHAPTER VIL 
THE PATHOLQOT OF PRBOSASCT. 

Ectopic or Extra-Uterine Pregnancy, — The true pa. 
thoIt«y of pelvic lesions, and the relative frequency of its 
various phases, have been greatly elucidated during the present 
generation. At an earlier period, ectopic pregnancy, with a 
pathology well understood, -was supposed to be a rare condition, 
and one which involved tremendous risks to the subject of it 
But the facilities for the study of intra- pelvic conditions affotded 
by modern gynecological surgery have disclosed the relative 
frequency of this anomaly, and modern methods have reduced 
its mortality to a small percentage. 

EnOLOGY . — The etiology of ectopic pregnancy cannot be ab- 
solutely determined until we have farther positive knowledge of 
the usual site of impregnation and the conditions attendant 
upon the ordinary migration of the ovum through the tube. 
Reasoning from analogy and the phenomena accompanying 
pregnancy in its various forms, physiolt^sts, with few excep- 
tions, are inclined to the opinion that the fertilizing principle of 
the male comes in contact with the ovule either in the outer 
third of the tube or at the ovary. Under ordinary conditions it 
is presumed that the impregnated ovum migrates from this 
point through the tube to the uterine cavity and there becomes 
implanted. The forces which impel the ovum to such a course 
are said to be movement of the cilise of the tubal upithelium and 
the peristaltic action of the tube aided by intestinal t>eristalsis, 
gravity, respiration, capillary attraction, and voluntary muscu- 
lar movements. 

The unimpregnat^d ovule may be dropped into the periton- 
eal cavity, or, what is probably far more common, it may be 
taken up by the fimbriae of the tube and conveyed to the uterine 
cavity, whence it escapes with the menstrual fluid. The physio- 
logical process by which the tube obtains possession of the 
ovule is not altogether clear. It is hardly probable that the 
fimbriae are spasmodically applied to the ovary at the proper 
time and in the proper place so that the ostium of the tube shall 
receive the matured ovule as itescai)es; nor is there good reason 
to believe that the ovule is ejected from the Graafian follicle with 
energy; yet in some manner the prehensile act is accomplished. 



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Extra-Uterine Pregnancy. 141 

It may be that the ovule is carried along' like driftwood on a 
^rnall stream of sticky fluid, with the single fimbria which is 
attached to the ovary serving as a guide, until it reaches its des- 
tination; or it may be that this imjiortant structure is able to 
make selection of methoda to conform to varying: conditions. 

Ectopic pregnancy is the result of anomalous action at some 
point, due in one instance to an unusual condition of the tube 
and in another to peculiarities of the ovum itself. As it escapes 
from thefoUicle the ovule is immersed in a structureless granu- 
lar layer of protoplasm which probably serves a purpose in its 
final lodgement. An anomalous condition of the ovule may have 
an effect upon this granular layer unfevorable to normal action. 
It is quite possible also that unusual size of the ovule is not in- 
Irequently a factor in its permanent lodgement within the tube. 
Ectopic pr^nancies in general, however, find their etiological 
factors in pathological conditions of the tube itself, amongwhich 
may be mentioned malformations of the tube, occlusions result- 
ing from inflammation or compression, and torsion. 

Vabieties: — Tubal pregnancy constitutes the main varied, 
tiiough abdominal and ovarian pregnancies have been described. 

OvAEiAS Pri-jgxascy. — Careful observers have put upon 
record several cases where fecundation and development of the 
ovum took place within the Graafian follicle. When this occurs, 
the follicle may close, and development go on outside the peri- 
toneal cavity, or the ovum may work its way through the 
aperture resulting from rupture of the follicle, and thus come 
eventually to lie chiefly within the peritoneal cavity. From the 
amount of distension to which the sac is subjected, rupture 
usually takes place within the early weeks of pregnancy, and 
the ovum enters the peritoneal cavity. Such an occurrence 
does not always prove fatal to ovular development, for the sac 
walls are sometimes strengthened by adhesions to the perito- 
neum which covers adjacent viscera, and gestation goes on. 

False Ovariax, or Tubo-Ovaiuan, I'hegnancy. — When the 
ovum ig arrested in the fimbriated extremity of the tube, the 
■cyst structure is composed partly of the fimbriae of the tube, 
and partly of ovarian tissue. This makes development less 
confined, and the i)regnancy may continue, without rupture of 
the sac, to on advanced period, or even full term. This form 
much more nearly I'esembles abdominal than ovarian preg- 
iian<:y. When none of the investiug structures are ovarian, it 
is termed tvbo-abdoiitiiial. 



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The Pathology of Pregnakcy. 



Fia. 98. — Abdominal Pre^ancf. 

Abdominal Pre6nancy. — The etiology of abdominal pr^- 
nancy remaiiiB in doubt. It probably arisen in some cases 
from the impregnated ovum t>eing dropped directly into the 
peritoneal cavity, but in moat instances very likely it is a 
secondary out^growth from the tubal and ovarian forms. Dr. 
Barnes believes that it is never primai-ily abdominal, because of 
the difficulty of conceiving how so small a body as the ovum 
should be able to fix itself on the smooth surface of the perito- 
neum. The view is warmly supported by several close students 
of ectopic gestation. Some have supposed that abdominal 
pregnancy may originate from impregnation of an ovule 
already lying in the peritoneal cavity, by spermatozoa which 
have found their way thither. From all that has been observed, 
it is highly probable that it is uo uncommon thing for an ovule 
to fall into the peritoneal cavity, and there, after an uncertain 
time, perish, without giving rise to any disturbance; but when^ 
from fertilization, it does survive, a connective-tissue prolifera- 
tion is set up which invests the ovum with a vascular sac, 
thereby forming a decidua reflexa of peculiar construction. The 
latter often attains a thickness nearly as great as that of the 
uterine walls. The chorionic villi sprout, form attachments to the 
sac and other structures, and eventually develop a placenta. 
The walls of the sac and the ovumgenerally developpari/>assii, 
and extend into the abdominal cavity, forming adhesions to- 
the intestines, the mesentery, the omentum, the uterus and 
other structures. Occasionally the ovular development pro- 



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Extra-Uterine Pregnancy. 143 

ceeds without the formation of peeudo-membranea, the cover- 
in^s of the foetus being only the amnion and chorion. 

Kupture of the tnetal coverings nsually takes place in extra- 
uterine pregnancy,and the fcetus pane- 
es into the peritoneal cavity. Death 
of both embryo and mothei* generally 
follows, but, in other instances, the 
woman surviving, development is con- 
tinued by the formation of a new sac. 
When foRtal death succeeds such an 
accident, the child may be converted 
into a lithoprodion. or the vascular 
connective tissue surrounding it may 
preserve the soft structures for years. 
The precise seat of attachment in 
abdominal pregnancy varies consider- 
ably. The placenta has been found 
P.O. 99.-A Lithop^dion. ^^^' «* different times, to most of the 
abdominal viscera, to the iliac fossa 
and to the structures within the true pelvis. Its most frequent 
site is the retro-uterine space. 

Tubal Pregnancy. — Tubal pregnancy is by far the most 
common primary form. It embraces the "interstitial," the 
"tubo-ovarian"and the "tubo-abdorainal" varieties. Abdomi- 
nal pregnancy is sometimes engrafted upon what was originally • 
tubal pregnancy, the developing ovum being extruded at an 
early stage into the peritoneal cavity. Corresi>onding to the 
particular part of the tube occupied by the impregnated ovum, 
and, therefore, most directly involved in the gestation process, 
we have interstitial, isthmic and ampullany pregi^ancy. 

Interstitial, Pmegnancy. — When development of the ovum 
takes place in the uterine portion of the tube, it is called "inter- 
stitial pregnancy." This portion of the tube is about seven 
lines in length. From hypertrophy of the muscularwalls a sac 
is formed about the ovum, which projects from the involved 
angle of the uterus. Ovular development, however, is so much 
more rapid than the muscular, that rupture generally occurs 
before the fourth month. 

When the fecundated ovum is arrested near the outer bouri- 
dary of the uterine part of the tube, as development proceeds 
the tumor escapes mainly into the tube, producing what has 
been called tubo-ijUerstitial, preffnancy. When development 



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144 The Pathology op Pregnancy. 

takes place on the borders of the uterine cavity, the resulting 
tumor may crowd through the Fallopian opening and lodge in 
the uterus, only to be finally expelled as in ordinary abortion. 

ISTHMic Pregnancy, — Isthmic pregnancy may occur at any 
point between the ampulla of the tube and the uterine insertion. 
In these cases the tube wall may be thinned' within a particular 
area, or at first uniformly hypertrophied. The posterior wall 
is regarded as the weakest. 

Ampullary Pregnancy, — ^AmpuUary pregnancy is the most 
common tubal variety. When development involves that jmrt 
near the fimbriated end, the ovum pushes outwards toward the 
peritoneal cavity (tubo-abdominal), or in the direction of the 
ovary (tu bo-ovarian), 

Intraugamentol's Pregnancy. — WhUe intraligamentous 
pregnancy most frequently occurs as the result of downward 
rupture of the tube walls, it is sometimes developed through 
gradual thinning and final disappearance of the tubal covering, 
development going on between the layers of the broad ligament. 

Developmental Phenomena. — After arrest at any point 
in the tube, the chorion soon begins to develop villi, which 
engraft themselves Into the mucous membrane, serving as 
anchors to the ovum, and as channels for the supply of its 
necessary nutriment. The mucous membrane becomes hyper- 
trophied, very much like that of the uterine cavity in normal 
p^'^nancy, so that a sort of pseudo-decidua results. The 
peculiar characters of the mucous lining of the tube afford for 
the ovum but a feeble hold, and hence hemorrhage, from 
separation of villi, is easily brought on- If early rupture does 
not take place, a spurious placenta may develop, which 
resembles the normal placenta in some particulars, the rudi- 
mentary villi of which may be surrounded by maternal vessels 
of some size. The muscular coat of the tube soon becomes 
hjpertrophied, and, as the size of the ovum increase.s, the fibers 
are separated so that the ovum protrudes between them at cer- 
tain points, and is there covered by the stretched and attenu- 
ated mucous and peritoneai coats of the tube. Or the muscularis 
atrophies at a jiarticular spot and soon yields. 

Rupture of the attenuated walls of the tube occurs most 
frequently during the fourth month, and the ftetus is cast into 
the peritoneal cavity. The attachments to the tube are so frail 
that the ovum has been known to escape unbroken, while again 
the tube has given way, but the ovum has pushed but x>artl)' 



Extra-Uterine Pregnancy. 145 

fhrough the opening. In neglected cases death usually follows 
rupture into the peritoneal cavity, either immediately from 
hemorrhage, or secondarily from peritonitis. 

When maternal death does not speedily ensue, false mem- 
branes may be formed about the foetus, or the entire ovum, and 
it thus become encysted. 

The tube njay rupture at a point where it is not covered by 
peritoneum, in which case there is escape of th^ ovum and 
«Susion of blood between the folds of the broad ligament. This 
form is now known to be relatively frequent, and is attended by 
diminished shock. 



Fio, 101.— Tubal PregDaDcj. 

In extremely rare instances, tubal pregnancy, owing to 
excessive thickness of the muscular walls, goes on to full term. 

Rarer Varieties. — Among the rarer varieties is that in 
"Which the placenta is in a normal situation within the uterine 
cavity, and the fuetus within the Fallopian tube. In anotiier 
form the foetus is found in the abd(Huinat cavity, and the pla- 
-centa in the ut«rus, the two being connected by an umbilical 
■cord running through the oviduct. The latter variety has been 
called the utero-tubo-abdomina/. Another rare form is known as 
the 8ub-peritojteo-pelm; in which the ovum, from failure or inabil- 
ity to get within the tube, slips between the folds of the broad 
ligament, and there develops. 

Uterine Changes, — During the development of the fcetus 
outside the uterus, changes, more or less marked, have been 



146 The Pathology op Pregnancy. 

observed in that or^an. They are substantially those accom- 
panying normal pregnancy in its early weeks, and are chiefly 
increased vascularity, marked increase in size, and the char- 
acteristic tluckening and hypertrophy of the mucous mem- 
brane. 

A true decidua is formed quite like that of early pregnancy» 
which is anbsequently cast off, though sometimes in fragments. 

The cervix softens slightly, but the internal os does not 
yield. These symptoms are of limited development, since the 
stimulus essential to their continuance, such as is supplied by 
entrance and implantation of the fecundated ovum, is wanting. 
Its bulk and vascularity are soon restored to nearly the normal 
standard. 

The uterus is more or less displaced by the extra uterine 
growth, so that the cervix, instead of being found far back in 
the pelvis, as it commonly is in normal pregnancy, is pushed 
forwards. The uterus is more elevated than in the early weeks 
of a normal pregnancy. 

Symptoms, Subjective. — The early symptoms of extra- 
uterine pregnancy are not characteristic. There is often noth- 
ing to distinguish the condition from one of normal pr^fnancy 
until the signs of rupture appear. Usually, however, the woman, 
experiences severe pain in the hypogastric and ovarian region, 
beginning a few days or several weeks after a fertile coitus. 
This pain constitutes the most distinctive feature of the condi- 
tion, and is so severe as of itself to possess decided pathological 
significance. It is often so agonizing as to create profound sys- 
temic disturbance, with symptoms of shock. In rare instances, 
when, as in abdominal, and in occasional tubal pregnancy, the 
gestation proceeds to term, little pain is felt till near the close. 
The temperature may be slightly elevated; sometimes there 
is great heat, and the general health is much imx>aired. 

Objective. — Menstruation is interrupted in about fifty per 
cent, of all cases. In any event it is likely to be irr^ular. De- 
cidual casts of the uterine cavity are sometimes extruded. There 
is often an irregular sanguinolent discharge which may substi- 
tute the regular flow. Just prior to rupture of the tube there 
may be a bearing or pressing sensation, followed after rupture 
by the alarming symptoms of threatened collapse, and the de- 
velopment of an hematocele in Douglas cul-de-sac, or a hematoma 
in the broad ligament 



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Extra-Uterine Pregnancy, 147 

In those cases where the gestation proceeds, fcetal move- 
ments become [miiiful, and unusually distinct to the palpating 
hand. 

Termination. — In seventy-five per cent, of all cases left to the 
natural processes there is rupture. In tubo-uterine pregnancy 
it usually occurs before the close of the second month; in tubal, 
in the fourth month; in o\'arian pregnancy, later, and in abdom- 
inal pregnancy it may continue for an indefinite period. The 
most common termination then, by far, is rupture — rupture of 
the foetal membranes alone in abdominal pregnancy, and of both 
sac and membranes in other forms. 

The duration of the different varieties of extra-uterine preg- 
nancy is shown by the following tables from Charpentier, which, 
though old, are a truthful presentation of the facts: 



In nineteen cases of interstitial pregnancy, 
OeetBtion lasted 4 weeks in one case. 
" " about 3 monthB in 2 ca 

" " 3 months in 12 cases. 

" "4 months in 3 cases. 

" ''5 months in 1 case. 

In eighty-eight cobsb of tubal pregnancy, 

Gestation lasted 4 to 6 weeks in 3 cases. 
" " 4 to 6 we«kB in 17 cases. 

" " 6 to 7 weeks In 9 cases. 

" " e to 8 weeks in 13 cases. 

" " 2 months in 4 oases. 

" " 8 months in 17 cases. 

" "4 months in 11 cases, 

" "5 months in 4 cases. 

" " 6 months in 2 cases. 

" "7 months in 2 cases. 

" "9 months in 6 cases. 

In thirty-nine caaee of ovarian pregnancy, 



" "6 months In 6 cases. 

" "7 months in 3 cases. 

" "9 months in 4 cases. 

Rupture is often preceded by the bearing pains alluded to, 
■which may continue for hours. These suddenly cease; the tumor 



148 The Pathology op Pregnancy. 

diminishee in nize; and then follow yawning, languor, faintin^r 
clammy perepiration, rapid pulse, vomiting, collapse, and 
occasionally acute mania. These Bymptoms are sucweded by 
death, or, the bleeding being arrested, the woman rallies and 
escapes immediate danger. Still, death may follow at an 
interval of some days, purely as the result of hemorrhage. A 
moderate proportion of eases survive these perils, and the 
foetus remains, perhaps, for years. Kupture into the folds of 
the broad ligament is not always attended by the symptoms of 
sbock, and may even escape positive recognition. 

When ftetal death spontaneously occura^or is brought- about 
by artificial means previous to rupture, the ovum in the early 
weeks will be almost wholly rtimoved by absorption, while at a 
later period it may undergo a degenerative process by means 
of which it is converted into a mole, or a Itthoptedion. Inflam- 
matory action may ensue, followed by suppuration, with 
ulceration into the hollow viscera or the peritoneal cavity. 
The immediate dangers of rupture are succeeded by others 
equally grave. As a result of rupture, severe peritoneal inflam- 
mation follows. Should the natural powers withstand this 
forcible onset, the results of the inflammation may be accounted 
favorable, inasmuch as pseudo-membranas are formed from 
coagulable lymph, which exercise a conservative influence by 
shutting off the ovum from the peritoneal cavity. In case 
rupture is not followed by peritonitis, and embryonic life is 
preserved, as development proceeds the movements of the fcetus 
within its membranes often give rise to most intense suffering. 
In a certain proportion of cases, the fcetus dies early, asuppura- 
tive inflammation in the sac is set up, and death results froin 
general peritonitis, or Irom profuse suppuration. Should the 
woman survive, in consequence of low intensity and meagre 
extent of the action, fistulous openings to other hollow viscera 
may be formed, through which the sac contents will gradually 
be eliminated. An opening is extremely liable to make its way 
into the large intestine. It may even penetrate the abdominal 
walls, or, rarely, the vagina or the bladder. At best, the pro- 
cess of elimination is extremely slow. For weeks or months, 
portions of the more irreducible foetal structures, such as bones 
and teeth, continue to be discharged. During this tedious ex- 
trusion of debris the Inflammatory action in the cyst goes on, 
and is probably intensified by the admission of air, or the con- 
tents of the viscera with which the sac communicates. Irrita- 



Extba-Uterine Pregnancy. 149 

tive fever supervenes, and death from exhaustion or blood 
poisoning is a common result. 

The phenomena attending those cases in which gestation is 
protracted to full term are sometimes quite striking. Partu- 
rient efforts are estabUshed which resemble very closely those 
of normal labor, the pains of which are said to be excellent 
counterfeits of those which characterize that process. 

Diagnosis. — In the diagaosia of extra-uterine pregnancy 
there are two important points to be established: 1st, exist- 
ence of the common signs of pr^^naacy; and 2d, emptiness of 
the uterine cavity. To these we may add, in all but interstitial 
pregnancy, a third point: the presence of a tumor in close prox- 
imity to the uterus. Diagnosis is a matter of transcendant im- 
portuice, since modem sui^ery has made it possible, in a con- 
stantly iucreasmg ratio of cases, to avert the otherwise almost 
certain death which awaits the patient; but the symptoms are 
obscure, and in only a small percentage of cases are suspicions 
aroused concerning the normal character of the pregnancy till 
rupture suddenly occurs. 

The existence of an irregular hemorrhagic discbarge, ap- 
pearing after the eighth week, is of some significance; also the 
paroxysmal cramp-Uke pains, radiating from the ihac fossa, 
which are often attributed by the woman to flatulent distention 
of the intestines. In any case presenting these symptoms, a 
critical examination should be made. 

In order that the investigation shall be conducted in an 
orderly and satisfactory manner, the three points to be estab- 
lished should be kept constantly before the mind. After a care- 
ful study of the symptoms, both objective and .subjective, should 
there be reasonable doubt concerning the diagnosis, it will be 
well to make a search for decidual cells. The presence in utero 
of a decidual membrane without any of the ovular structures, 
would be confirmatory e\-idence. It is manifest, however, that 
as this condition of affairs cannot be determined without resort 
to curettage, those cases only are eligible to such exploration 
which furnish reasonably conclusive evidence of ectopic pr^- 
nancy. To obtain the specimens the curette should be used in 
the ordinary manner, and careful search be made. 

Before proceeding to a thorough physical exploration in a 
case wherein ectopic pregnancy is strongly suspected, the 
patient and examiner ought to be prepared for immediate oper- 
ative procedure, as the necessary manipulation is liable to rup- 



liiO The Pathology of Pregnancy. 

ture the sac. Besides, should the dia^osis be established be- 
yond reasonable doubt, it is well to operate without delay. 

The chief difficulty arises not in connection with the recog- 
nition of the ordinary signs of pregnancy, but in determining 
the question of uterine emptiness. To settle this point, when 
other indications of ectopic pregnancy are relatively distinct, 
the examiner is fully warranted in using the uterine sound. 

The third point of importance is recognition of a swelling at 
the site of the fruit sac. This is not difficult when it really ex- 
ists; but in the relatively infrequent form of tubal pregnancy 
known as the "interstitial," such a swelling does not exist. The 
absence of an adventitious growth makes the recognition of the 
particular form of ectopic pregnancy peculiarly difficult. 

After rupture of the sac into the peritoneal cavity, the at- 
tending symptoms, concluding a history like that before men- 
tioned, render diagnosis a matter of no great difficulty; but 
when rupture is into the folds of the broad ligament the symp- 
toms are more likely to be confounded with those of pelvic in- 
flammation with resulting exudate. 

When rupture of the sac occurs early in pr^uancy, the 
flow of blood may be moderate, and the physical sigoB only 
those of ordinary hematocele. Later rupture gives rise to 
symptoms of extensive internal hemorrhage, and presents a 
ghastly percentage of deaths. 

In abdominal pregnancy the form of the abdomen will be 
observed to differ from that of normal gestation, enlargement ' 
being more in the transverse direction. In the latter months 
the form of the foetus can be felt with remarkable distinct- 
ness. The cervix is somewhat softened, but often displaced, 
and sometimes fixed by perimetritic adhesions. Conjoint touch 
may enable the examiner separately to distinguish the uterus 
from the bulk of the tumor, and demonstrate its nearly norm^ 
non-ftregnant size. 

When extra-uterine pn^ancy goes beyond the fourth 
month without occurrence of rupture, whether originally tubal 
or uot, with rare exceptions, either an ovarian or abdominal 
pregnancy should be assumed to exist. 

Treatment. — The mode of treatment will be determined 
largely by the degree of development which has been attained, 
the condition of the foetus, and the health of the woman. For 
the sake of perspicuity and convenience, we divide non-ruptured 
cases into three classes: 1. Those which have not ad\'anced 



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Extra-Uterine Pregnancy. 151 

beyond the limits of a few weeks. 2. Those wherein gestation 
is well advanced, and the fcotus is still living. 3. Those in 
which pregnancy has been prolonged after f c»tal death. 

Treatment Before Rupture or Abortion. — In the man- 
agement of cases before the appearance of rupture symptoms, 
a metliod was formerly prevalent which took the distinctive title 
of "American," to distinguish it from that In vogue among for- 
eign obstetricians and gynEecologists. The Americem method 
<»>n8i8ted in destruction of ovular vitality by means of the elec- 
tric current, ultimate care of the product of conception being 
committed wholly to the natural processes of disintegration, ab- 
sorption and encystment. But in the evolution of the surgical 
idea this method has been relegated to obUvion, and extirpation 
of the misplaced ovum has become the uniform method. 

Avenue of Scrgical Approach. — Since surgical interven- 
tion ^as become the accepted rule of practice, the chief contro- 
versy among surgeons has grown out of the divisions of senti- 
ment respecting the preferable avenue of approach; but even 
with respoct to this there is an evident convergence of opinion 
and practice, so that rules of procedure, which represent with 
tolerable accuracy the concensus of opinion, may now be form- 
ulated. 

The chief consideration which commends to conscientious 
operators the vt^inal route for removal of an ovum and its re- 
lated structures prior to rupture, is that of increased safety; 
but there can be no rational doubt that the advocates of it have 
not the same It^cal standing in the presence of a case of this 
nature that all would be willing to concede them under certain 
other conditions. There is a close analogy to be noted in the 
element of danger between the early stage of ectopic gestation 
and the early stage of appendicular inflammation. In either 
case the fatality incident to operative procedure at the oppor- 
tune moment, when undertaken by an experienced surgeon, is 
very light. 

Over against the possible advantage accruing from the dimin- 
ished shock and lessened danger of a vaginal operation, is the 
facility with which the ovum and implicated structures can be 
approached from the abdominal side, with the patient in Tren- 
delenburg's position. Through even a moderately spacious 
opening in the abdominal parietes it ia not only possible to 
manipulate the tube, big with possibilities of no innocuous 
nature, and to make the necessary excision, but also to bring 



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152 The Pathology of Pregnancy, 

every part under visual survey, and to do the required work 
directly under the eye. The advantage residing in conditions 
of so favorable a nature, in my opinion, far outweigh the sUght 
gain which may ensue from diminished shock. 

Par be it from us, however, to decry a skillfully executed 
vaginal procedure. We are weU aware that bj' placing the 
woman in a modified Trendelenburg posture, with the thighs 
flexed, broad retractors anteriorly and posteriorly, and the roof 
of the posterior vaginal cul-de-sac well exposed, it is quite pos- 
sible to enter Douglas' pouch, and, in favorable cases, bring 
down and tie off the distended tube. Nor are we ignorant of 
the possibility of making an incision behind the cerviat, sepa- 
rating the layers of the broad ligament, rupturing the gravid 
tube with the finger, emptyii^ the sac and draining the cavity. 
That such procedures sometimes produce most gratifying re- 
sults we do not question; but, let us add, we are not unmindful 
of the complications which are liable to be encountered in their 
practice. The large tube may have formed some very close 
alliances with contiguous structures, so as greatly to embar- 
rass the operator in his attempts to bring the growth within 
reach of the deft fingers which would encircle it with a ligature 
and safely excise it; or the hemorrhage may be so free after 
making a filler dissection of the peritoneal layers of the liga- 
mentum latum and removing the offending ovum, as well nigh 
to defy control. 

Technique op the Abdominal Operation Before Rcp- 
TLTtE. — The abdomen is opened as for other tubal lesions, with 
the patient in the Trendelenburg position, and an inspection 
made of the involved structures. Adhesions are carefully bro- 
ken up, until the parts to be ablated can be isolated. A com- 
mon method of extirpation corresponds to that adopted by most 
surgeons for removal of the appendages, the tube and ovary 
being encircled by ligature en masse and the condemned part 
amputated; but a preferable method consists in tying the ova- 
rian artery, near both the pelvic and uterine junctions, cutting 
out the tube and overatitching the peritoneal margin of the in- 
cision, 80 as to control hemorrhage, to limit the possibility of 
fresh adhesions, and to insure quick repair. 

Technique of THE Vaginal Operation Before the Rup- 
ture. — When the vaginal operation is performed, the woman is 
placed in the lithotomy position, but with the head lowered, 
this being in fact a modified Trendelenburg posture. The 



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Extra-Uterine Pregnancy, 153: 

uterus IS drawn gently downwards by means of a volsella, and' 
an incision is made with knife or scissors, behind, but close to,, 
the uterus. If, now, the intention is to penetrate the broad 
ligament and avoid the peritoneal cavity, which may sometimes 
be done, as in evacuating a pyosalpinx, the incision is extended 
a little further in a lateral direction, and the finger made ti> 
burrow its way, with as great care as the necessities of the case 
will allow, until the gestation sac has been entered and the ovu- 
lar structures have been carefully removed. Into this cavity, 
after thorough irrigation, sterile gauze is lightly packed to in- 
sure drainage and prevent hemorrhage. Or, to pursue a differ- 
ent course, Douglas' pouch may be directly entered, adhesions 
about the site of ovular development, if any, may be carefully 
broken up, and the tube and ovary drawn into the vagina, liga- 
toped and amputated. We fear to leave such a case without a 
gauze drain, but usually remove it at the end of twenty-four- 
hours. If in the progress of the latter operation extensive ad- 
hesions l>e found and annoying hemorrhage arise, it may lie- 
come wise to complete the operation through an abdominal 



Tubal Pregnancy, the Only Primary Form./— AUusion 
has tiius far been made to tubal, as the only form of extra- 
uterine pregnancy, from which it will be correctly inferred 
that we regard this as the primary form in nearly all instances. 
The evidence of ovarian and primary abdominal pregnancy is 
stm inconclusive, but that a tubal pregnancy may become ab- 
dominal, in consec[uence of tubal abortion, is undeniable. 

Though there are some observers of much experience who 
■allege that theovum does not become fertilized in the outer third 
of the tube, the preponderance of evidence appears to be in favor 
of tbe«ffirmative view. Lawson Tait and others hold the ex- 
treme view that normal pregnancy always takes place in the' 
uterine cavi^, and that successful fertilization in the tube is a 
rare ezcej)tioii and constitutes the true etiology of extra-uterine 
gestation. The causes of arrest of a migrating ovum on its way 
to the uterus are not altogether clear, though various explana- 
tory theories have been put forth. But when arrest occurs in 
the outer part-of ihe tube, and development ensues, the trumpet 
shape of the infuodibulum offers much encouragement to ulti- 
mate esGape'Oflheovum from its narrow confines into the free 
peritoneal cavity. The symptoms accompanying such a change 
■of base are£ommon(y those which follow rupture of the tube» 



154 The Pathology of Pregnancy. 

though less inteose, with the addition in many cases of the usual 
subjective signs of uterine abortion. The patient may even 
have more or less uterine hemorrhage. 



Flo. 102. — Diagram Bhowliigf pelvio hematocele posterior to the nteraa, 
which ia crowded forward with tbe bladder behind the symphysU pubis, while 
t le rectum is compressed behind agalDst itie sacrum (Sliene). 

Though it is quite possible that 
all ova are not taken up by tbe 
tube and passed on toward the 
uterme cavity; and though, in 
fact, it is quite probable that 
many are dropped into the free 
peritoneal cavity, reUable evi- 
dence that they may there become 
■ impregnated is yet to be adduced. 

Treatment op Interstitial 
Pregnancy. — Kelief of intersti- 
tial pregnancy, when recognized 
before rupture, should be under- 
taken by dilating the cervix and 
carefully using theuterine sound. 

In those cases wherein the ab- 
domen has already been opened, 
such an effort will be suppliment- 
ed by manipulation of the sac. 
Treatment op Ectopic Pregnancy After Ri'pture or 
Tubal Abortion.— The proportion of cases recognized prior to 



Fio. lOS.— Decidual cast of tbe 
uterine cavity [n extra- uterine preg- 
nancy (Zwelfel). 



Extra-Uterine Pregnancy. 155 

tabal rupture or abortion is relatively smalL The physician re- 
ceives an urgent call to a woman and finds her suffering .pain in. 
the abdomen and pelvis, vitha small and rapid pulse, depressed 
temperature, pallor and other indications of shock. Vaginal 
examination may disclose some fulness of Douglas' pouch, and 
abdominal palpation and auscultation may reveal the presence 
of a free exudate in the peritoneal cavi%. 

When the rupture is in a downward direction into the broad 
ligament, the symptoms are not severe, and the true nature of 
the case may for the time escape detecUon. 

But even in such instances the time arrives, early or late, 
when, by the development of signs of shock, due, perhaps, ta 
secondary rupture, or by continued pain and disability, atten- 
tion is finally drawn to the true nature of the case. - 

The Period op Eupture. — The tubal walla cannot bear the 
strain put upon them by a pregnancy much in excess of three 
moHtlis. Tait declared some years ago that he had never seen 
a case where there was good evidence that the pr^nancy had 
advanced beyond twelve weeks. 

THBPATHOLoaYopKuPTURE. — As the resultof confinement 
of the developing ovum within the narrow limits of the tube, en- 
largement far ontetrips compensating development of the tube 
structure, so that in lime the confining walls become so attenu- 
ated that they can no longer maintain their Integrity. More- 
over, the normal villi penetrate, and thereby wealien, the mus- 
culature of the tube, thus hastening the accident 

When rupture takes place, the ovum may remain and con- 
tinue development downwards between the folds of the broad 
ligament, if the laceration occur on the lower side, or outwards 
into the peritoneal cavity if the opening &vor such a course 
Though the ovum be not expelled, its vitality may be destroyed 
and it undergo molar transformation. More commonly the sac 
is ruptured and the embryo extruded, when it ultimately be- 
comes wholly absorbed; or it undergoes mummificaUon, macer- 
ation, decomposition, or is transformed into a lithopedian. 

Hemorrhage nniformly follows rupture. When the bleeding 
If into the peritoneal cavity it is often so profuse as of itself to 
become a grave menace to life, though we are not justified in 
attributing the ensuing symptoms of profound shock wholly or 
mainly to vascular depletion. In certain cases shock is clearly 
due to peritoneal invasion by even moderate hemorrhage, a fact- 
to be remembered an having an important bearing on the ques- 



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156 The Pathology op Pregnancy. 

tiou of surgical intervention in the face of persistent de- . 
pression. 

When the bleeding is into the broad ligament, it is limited 
by lack of space. 

Peritoneal hemorrhage forms a hematocele, and extra-peri- 
toneal extravasation creates a hematoma, Elither of these, if 
not too extensive, may nndergo absorption; or it may become 
infected through the tube or bowel and result in pelvic abscess. 
A hematocele usually forms behind the uterus, pushing it.ap- 
wards and forwards, A hematoma closely embraces the uterus 
JateraUy and crowds it to the opposite side. 

Tubular abortion presents symptoms, both subjective and 
objective, so closely resembling those accompanying rupture, 
that an abscdute diagnosis cannot be hoped for, nor is it of par- 
ticular importance, inasmuch as the required treatment Is sub- 
stantially the same in both instances. When the occurrence is 
early and complete, the accompanying hemorrhage is usually 
sjRirii^, and passive in character. At a later period in gesta- 
tion it may of itself become a grave menace to life, and, when 
incomplete, is liable to recur. 

Prognosis. — Under expectant treatment the mortality from 
extra-uterine pregnancy is appalling. "It is but too true, I 
fear," says Goupil, "that we are authorized in saying that all 
the cases of lutra-peritoneal hemorrhage arising from extra- 
terine pregnancy end in death. In fact, all the cases that I 
have quoted terminated in death. Generally it has taken place 
in a few hours or days, and although death has been delayed for 
six months, it is wholly exceptional." Recent statistics are 
hard to obtain owing to the relegation of the expectant treat- 
ment to the oblivion which it deserves. An idea of the actual 
figures may bainferred from Parry's collection of one hundred 
and forty-nine caseB with one hundred and forty-flve deaths. 
It is possible that these figures do not represent the true mor- 
tality, as various other forms of intra-peritoneal hemorrhage 
v.'ere formerly r^arded as the cause of pelvic hematocele, 
whereas now detection of such a condition is regarded as prima 
fiicieevidence of either a ruptured tube from ectopic pregnancy, 
or a tubal abortion, though this fact could not materially alter 
then. 

When the rupture is in a downward direction, so that the 
hemorrhage is confined by the peritoneal duplicatures to the 
broad ligament, the Immediate dangers are not great Such a 



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Extra-Uterixb Pkegxancy. 157 

rapture often produces so slight an effect upoa the sympathetic 
nervous system as ta escape recognition as a marked crisis in 
the patient's patholo^cal history. Iawsou Tait maintains that 
circumscribed hemorrhage from a ruptured tube in ectopic 
pregnancy is always eztra-peritoneaL Whether this annuncia- 
tion is true or not, the fact remains that primary hemorrhage 
in these cases cannot well be extensive, but repeated secondary 
hemorrhages are liable to occur. 

The resulting hematoma remains as a source of much dis- 
turbance, usually reducing the woman to a state of chronic in. 
vaJidism, which yields only to surgical mediation. 

The pr(^nosis of surgical treatment, when the case comes 
early under surgical care, is highly encouraging. The rescue 
which such management elctends to womanldnd in this perilous 
exigency marks an era in obstetric practice. It is undeniably a 
great life-saver. 

Operation During Shock. — Shock is the surgeon's teteTwxVe. 
To avert it, and to tide his patient over it when present, com- 
mand liis most sturdy efforts. The woman in whose body a 
Fallopian tube has ruptured from ectopic gestation, usually 
finds herself suddenly precipitated into the very shadow of 
death. In such an environment the physician recognizes his 
line of duty as leading primarily in the direction of judicious 
stimulation of the vital powers, and such a reUef to the oppressed 
nervous centers as shall avert the fatal result which often seems 
imminent. In such efforts he is likely to be successful, pro- 
vided the hemorrhage, which is the most energetic, but not the 
sole factor in the production of the alarming symptoms, has 
spontaneously ceased. But, with the torn vessels still emitting 
the life fluid, he can scarcely hope for a satisfactory effect from 
the best directed endeavors. 

"A novel suggestion comes from Sippel, who advises placing 
the patient in the Trendelenburg position if seen at the time of 
rupture, so that the blood cannot accumulate in the pelvis, but, 
being distributed among the intestines, is exposed to a larger 
absorbing surface, thereby avoiding shock, hematocele, and 
finally operation. " — (Frankenthal.) It should be added thatthis 
position would also favor arrest of the hemorrhage by diminish- 
ing blood pressure in the i)elvis, and thus encouraging the for- 
mation of coagula in the mouths of the bleeding vessels. But it 
must be conceded that no treatment designed to arrest an in- 
'ternal hemorrhage of the character indicated can be reUed upon 



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158 The Pathology of Pregnancy. 

to act with absolute precision and certainty. And then, in cases 
where the depressing eflfectsjjf shock are manifest, we are un- 
able to determine at once whether tlie threatening symptoms 
are due to a progressing, or to an arrested hemorrhage. In the 
matter of differentiation we are in the dark, aud, while waiting 
for light, the patient may sink beyond the possibility of restora- 
tion. 

Conservative surgery points with no equivocation to the wis- 
dom of retaining in force the rule which makes it the duty of 
the medical attendant to rally the patient, if possible, l>efore 
subjecting her to operation; but it should not constitute an ab- 
solute prohibition of surgical mediation in those cases where it 
becomes evident that shock is deepening, and that the patient, 
without rehef from such mediation as radical measures may be 
able to afford, however unpromising, is Roomed to death. In our 
opinion we are not extending to a patient the fuU measure of 
benefit which modern methods are capable of affordii^ when we 
allow her to sink and die before our eyes on the plea that the 
Ufe forces are too exhausted to sustain the vital strain of 
attempted surgical relief. If the woman is not actually in 
articulo mortis, we should not hesitate, in such a refractory 
case, to hastily prepare her, open up the abdomen, feel for and 
compress the ovarian artery, both near its pelvic and uterine 
junctions, so as immediately to control the hemorrhage, tie the 
artery at these points if the woman's vitahty will allow, pull 
out such coagula as readily present, introduce gauze drainage, 
and close the wound ab<jut the drain. If the patient's vital ener- 
gies should be fast waning, we would leave the forceps on, with- 
out tying the artery, introduce the drain and hastily suture the 
wound to the required extent. But while doing this an assist- 
ant should infuse within the median basilic vein sufBcieat salt 
solution to bring the pulse to reasonable size and strength- 
Rapid work of this nature offers a degree of encouragement 
which more than justifies its adoption. 

Ruptured Interstitial Pregnancy. — Should the case 
prove to be one of interstitial pregnancy, an attempt should be 
made to clean the cavity at point of rupture and suture the 
uterine wall so as to close it. It may be necessary temporarily 
to use clamps on the broad ligament to control hemorrhage 
while this is being done. 

The Anesthetic — It is in those cases of extreme and per- 
sistent shock, if anj'where in the whole category of situations. 



BlxTRA- Uterine Pregnancy. 158a 

demanding surgical interference, that we should lay aside 
prejudice and choose the anesthetic which may possess, per* 
haps, but a mere shadow of rational advantage over another 
which we might elsewhere more commonly use. It is quite prob- 
able that chloroform depresses the vital energies more than 
ether, and it is also probable, as commonly asserted, that it in- 
duces cerebral anemia, which constitutes one of the chiefest 
dangers inseparable from these cases of shock. At the same 
time we should not forget that it is more agreeable to take, and 
more prompt in its action, than ether. We confess a pre- 
dilection for chloroform, and have never seen ill effects from 
an administration of it when undertaken with suitable precau- 
tion and care. But, with a patient in a condition of shock, such 
as we find in cases of ruptured tube from ectopic gestation, 
with the accompanying hemorrh^e, the conditions are peculiar 
and the facilities for safe administration of chloroform are not 
always at command. It requires far more skill and discre- 
tion for its safe administration than does ether, and since 
in such cases but the minimum quantity of any anesthetic 
is required, ether is probably to be preferred. At the same 
time we should not hesitate to begin with a few inhalations 
of chloroform, which are usually sufAcient to bring about a 
moderate degree of anesthesia, and then change to ether. 
By pursuing this plan the stege of excitement will be greatly 
shortened, or entirely avoided, thus measurably economizing 
time and strength. 

Rupture which Calls for CoNSERVATrvE Treatment.— 
"When it is evident, from a minimum degree of shock, a circum- 
scribed hemorrhage and the situation of the extravasation, that 
the case is one of intrarligamentous rupture, conservative treat- 
ment is to be adopted. Surgical opinion is unanimous on this 
point. The immediate danger is but slight, subsequent events 
are within the scope of attentive observation, and, should oper- 
ative intervention ultimately be indicated, the vaginal route and 
a conservative operation may be all that the conditions demand. 
It is quite true that, until radical relief be offered, there is dan- 
ger of secondary hemorrhage, but it does not exist as a menace 
80 pronounced as to outweigh the dangers associated with early 
operative interference. 

Another condition in which we are warranted in pursuing a 
Fabian policy after rupture is that presented in a case already 
somewhat ancient, one which, for example, has passed the criti- 



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158b The Pathology op Pkeonancy. 

cal primary ata^, and now, by its appearance, gives enconrage- 
ment to the hope that absorption is rapidly progressing, and is 
likely to become complete. 

Tubal Abortion. — Since the symptoms ol tubal abortion 
with escape of ovum and blood into the peritoneal cavity cannot 
be differentiated from those of rapture prior to operation, it is 
sufficient to say ttiat treatment by section, either va^nal or ab- 
dominal, Is called for. 

Hematobia REQuntma Secondary Operation.— Rupture 
downwards, with hemorrhage into the broad ligament, since it 
does not often produce alarming symptoms, nor expose the 
woman to immediate danger, does not call for primary surgical 
intervention. Subsequent operation may be required should 
secondary hemorrhage occur, fcetal life and development con- 
tinue, or the absorptive energies be unable to remove the rup- 
ture debris. Hematoma of full proportions which defies ab- 
sorption, in a patient whose vitality is below par, sometimes 
becomes infected, with resulting pelvic abscess, which requires 
vaginal incision and drainage. When the vitality of the ovum is 
retained, and development continues, the indication for opera- 
tive interference becomes unequivocal, and, unless such a case 
be taken in an early sta^e, the abdominal approach is to be pre- 
ferred. In cases of secondary hemorrhage the symptoms re- 
semble those of hemorrhage from primary tubal rupture, and 
are to be treated in a similar manner. 

Infusion or Normal Salt Solution.— Before enterii^ 
upon a discussion of the technique of operative procedure for 
the rescue of women suffering the effects of rupture of the ad- 
ventitious matrix of an ectopic pregnancy, we venture a few 
words on the expedient of infusing salt solution, which has be- 
come an adjuvant of inestimable value in the management of 
such cases. 

The pulse of a woman who has recently experienced an acci- 
dent of the nature mentioned is characteristic of shock, there 
being almost total loss of tension and volume. That this condi- 
tion is not referable wholly to blood-loss has been shown by the 
disclosures resulting from abdominal incision. This conclusion 
we are the better prepared to accept in view of the shock which 
we have seen follow operations which involved but slight loss of 
blood. In either instance the alarming symptoms are probably 
due in great measure to the demoralizing effect of profound re- 
flex irritation of the nerve centers. But the surgeon, in ad- 



Extra-Uterine Pregnancy. 158g 

mlttmg the truth of this postulate, is not placed in a position 
which lays him under aacred obligation to make an impossible 
discrimination before deciding the question of alimenting the 
supply of circulatory fluid. The condition upon which the lack 
of arterial pressure greatly depends may be one of deep vascu- 
lar stttf^natiou, especially in the abdominal region; and to in- 
crease the quantity of circulatory fluid, so ss to give the heart 
something upon which to act, may be of profound importance 
to that wavering organ and the vital, interests which it repre- 
sents. 

Two methods of infusion are presented: the direct and the 
indirect. In practicing the former, a vein, which is usually the 
median basilic, is chosen as the channel of entry. An incision, 
an inch long, is made, the vessel is carefully picked up and 
encircled with two hgatures, placed a short distance apart. 
"Hie point of the glass tip is introduced through a nick made in 
the vessel, between the ligatures; the outer ligature is tied; and 
that surrounding the point of the tip is tightened. A small 
aseptic douche bag, provided with a transfusion tip, is all the 
apparatus required. To provide against iujectii^ air, the point 
is introduced while the stream is flowing. The temperature of 
the fluid should be from 105 deg. to 110 deg. F., as some heat is 
lost in transit. The quantity thrown into the vein at one time 
should be varied to suit (individual requirements, the criterion 
of adequacy being the condition of the radial pulse. 

On removing the tip, it is well to tie the ligature with a pro- 
visional knot, and to close the wound with provisional sutures, 
as it may be found necessary to repeat the operation several 
times. 

The immediate effect of infusion is usually tranquilizii^ and 
reviving. There appears to be but slight danger of accident 
when the operation is done with reasonable care in the matter 
of technique. 

The indirect method of infusion consists in introducing the 
fluid into the arealar tissue by means of a small aspirating needle 
attached to the apparatus employed for direct infusion. The 
sit© most commonly chosen for puncture is the submammary 
re^oiL 

While the fluid thus indirectly introduced does not immedi- 
ately enter the circulation, still, when the vital energies are not 
at too low an ebb, the effect is surprisingly prompt. The quan- 
tity injected should be determined by the rapidity of absorp- 



laf^D The Pathology op Pregnancy. 

tion, and the circalatory effects. There is practically no danger 
of snrcharging the vessels in titiis manner, as nature will refuse 
to accept more of the fluid than she can comfortably utilize. 

It is well to remember in connection with infasion and trans- 
fusion, that the kidneys act as a safety valve upon the quantity 
of fluid introduced, provided their functional activities have not 
been seriously impaired, by excreting any surplusage of Qtiid 
which may have been introduced. It is observed tliat these 
oi^ians are often excited to phenomenal activity after a free in- 
fusion. 

As serviceable as infusion of saline solution has proved to be 
in rescuing women from the perils which environ them as the 
result of tubal rupture, it is of superlative importance only 
when resorted to at the opjwrtune moment Were we to under- 
take by such means to remove the symptoms of impending dis- 
solution, with a design to avoid operative intervention, we should 
be likely to precipitate our patients into a still more desperate 
condition. So long as ruptured vessels are left agape, the 
restoration of arterial pressure by infusing water into the cir- 
culation means but renewal or increase of hemorrhage, which 
still further diminishes the quantity of blood necessary to sus- 
tain life; but it is plain that the system needs something more 
than mere fluid to preserve, even for a short time, its essential 
physiological activities. After profuse hemorrhage the quan- 
tity of residual blood essential to the preservation of life, when 
reinforced by saline fluid in adequate quantity to supply the 
vessels, probably varies considerably; but in every case there 
is a point of depletion, which, when exceeded, reduces the case 
to a state of hopelessness. 

In preparing for operation before the removal of shock, or 
in any case where there has been recent hemorrh^e, or where, 
from other cause, the vital functions have been decidedly re- 
duced, it is the part of prudence to have at hand not only an in- 
fusion apparatus and a sufficient quantity nf normal salt solu- 
tion, but also an assistant, prepared to infuse at a moment's 
notice. When the pulse b^ins decidedly to weaken, in a case 
of this kind, it is wise not to delay infusion tUl the operation be 
completed. Bhould the patient be temporarily revived by it, 
and later the pulse begin to fail, the injection is to be repeated 
until permanent results be obtained. 

This subject is further discussed in the Appendix. 



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ElxTRA- Uterine Pregnancy. 158e 

The Abdominal Operation After Primary Rupture. — 
The patient should be prepared as thoroughly as the exigeacles 
of &e case will permit, and every proTiaion made for her com- 
fort and safety. The incision should be ample enough to allow 
free manipulation, the position of the patient being preferably 
Trendelenburg's. On Qpeniug the peritoneum, coagula will 
usually posh outwards, together with more or less bloody serum, 
to the alarm of those unaccustomed to anch emergeacies. It 
may be that the hemorrhage is still going on, and, in any event, 
immediate search is to be made for the point of rupture. On 
bringing this to view the question of existing hemorrhage is at 
once settled, and, if it still continues, a temporary clamp is at 
once applied. If the woman's condition be fair, it ia well to clean 
up the peritoneal cavity quickly but thoroughly. But if, on the 
contrary, her condition be precarious or bad, thia cleaning up 
process ought to be omitted, only the larger coagula being 
quickly drawn away. The ovarian artery is then to be Med at 
its uterine junction, as well as near the pelvic wall, when the 
tube and ovary are safely trimmed out by means of the scissors. 
It will take but a few moments longer to whip over the raw 
e^es of the broad ligament, thus leaving the case in excellent 
form. 

As suggested earlier in this article, the condition may be so 
desperate as to justify nothing more than application of a clamp 
to the ovarian artery on either side of the rupture point, fol- 
lowed by closure of the wound about the protruding forceps. 

Instead of treating the case in this manner, some Uttle time 
may be saved by drawing up the tube and ovary, applying a 
ligature en masse, as is done by most operators in removing the 
appendages, and trimming off the mass as close to the ligature 
as safety will allow. If the peritoneal cavity has been well 
cleaned, there is no occasion for use of drainage, and the ab- 
dominal wound will be promptly closed. On the contrary, if it 
has not been deemed safe to remove many of the coagula, it is 
probably better to introduce a gauze drain. 

Inasmuch as the symptoms of tubal abortion are indis- 
tinguishable from those of rupture, the abdominal cavity may 
sometimes be opened and an abundance of coagula found, but 
no discoverable laceration. In such a case it is only necessary 
to make sure of controlling further hemorrhage by as simple 
means as possible, to clean up well and close the abdominal 
wound. ' 



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158p The Pathology of Pregnancy. 

The Abdominal Operation for Pelvic Hematocele. — In 
-what appear to be uncomplicated esses, it is sometimes thooght- 
advisable to follow the vaginal route, but the abdominal approach 
is oftener deemed preferable. After opening the abdomen, the 
adhesions are carefully broken up and the peritoneal cavity is 
gentiy but thoroughly emptied. If the adhesions have been 
numerous and firm, and especially if Uie hematocele has under- 
gone suppurative change, drainage is advisable. Our own 'pre- 
ference under these circumstances is for drainage throngh the 
vagina; but many prefer to make it through the abdominal 
wound. 

The Vaginal Operation After Rupturr — The first ques- 
tion to be settled in connection with the vaginal operation is that 
respecting the advisabihty, on one hand, of doing a radical oper- 
ation, involving hysterectomy, or, on the other, of making th» 
surgical work as conservative as the most scrupulous, could 
dictate. The cases which call for operation through the vagina, 
it will be understood from what has been said, are not those of 
primary rupture, but rather those wherein rupture has not 
taken place, or wherein the rupture has been intra-l^mentary. 
It is not often that it is deemed wise to remove the uterus in a 
case which still remains intact; nor do we frequently find it- 
wise to do BO radical an operation in post-rupture cases. But 
occasionally there are complications, which, in consideration of 
peculiar environments, point to such a procedure as the prefer- 
able one. There is no question that the total operation is often, 
simphfied by vaginal hysterectomy, especially when performed 
by enucleation or ligature, as access to the lesion is thereby 
faciUtated. When this form of operation is decided upon, its 
performance differs in no essentials from that of hysterectomy 
undertaken in connection with pelvic abscess. 

The method of doing a conservative operation before rupture 
has been described earlier in this article. 

A conservative oi)eration undertaken for the resulting symp 
toms of intra-ligamentary rupture, requires a brief description. 
It is well in these cases to place the woman in the Ut^otomy 
position, with the head lower than the hips. The vaginal vault 
is exposed in the usual manner and a post-cervical incision 
made close to the uterus. The chief care is to avoid unneces- 
sary opening of the peritoneal cavity, and, to accomplish our 
purpose, we find it necessary to extend the incision laterally 
from the cervix, being careful not to allow the knife to i>enetrate. 



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ElXTRA-UTERrtTE PREGNANCY. 158g 

deeply, for fear of wounding the uterine artery. From this 
point onwards the disaection is made by means of the linger, 
which is burrowed into the mass in aach a way as to separate 
the layers of the ligament, uatil the cavity is reached. When 
once entered, the opening should be made sufficiently large to 
admit of free access. By means of the fingers the contents of 
the cavity are then broken up so that they may be easily re- 
moved. On taking away the finger there is usually a free dis- 
charge of coagula. Upon reintroduction of the digit the embryo 
and its membranes can usually be removed without especial 
difficulty. If it be found that development has been going on 
subsequently to primary rupturG, and especially if the foetus 
has attained a size corresponding to a three-months' develop- 
ment, it may be deemed imprudent to forcibly separate and re- 
move the placenta whose formation at that stage of advancement 
has become quite complete, and whose removal ia liable to 
occasion severe hemorrhage. In one such case the author was 
constrained to leave it, applying suitable drainage, until ulti- 
mately it came away piecemeal, the 'woman making an excellent 
recovery. 

In all the author's cases of vaginal section for pelvic abscess 
and ectopic pregnancy, gauze drain^e has been employed with 
most gratifying results. 

Cases of Advanced Gestation, the Fcetus Still Living, 
— Most women suffer during the progress of such an abnormal 
gestation, from attacks of circumscribed peritonitis, from great 
sensitiveness to fcetal movements, from recurring uterine hem- 
orrhages, from emaciation and from depression of the vital 
powers. With the occurrence of labor-like efforts, peritonitis 
is apt to be relighted. Considering all the dangers to which 
both woman and child are exposed under the expectant plan oi 
treatment, it has been proposed that an early operation be per- 
formed, with a view to rescuing the latter from certain death, 
without materially increasing the risks sustained by the former. 
But the results of such operations have been of a disheartening 
nature, the chief source of danger being found in the hem- 
orrhage which necessarily follows removal of the placenta. On 
the other hand, when the placenta is permitted to remain, sep- 
tic poisoning and fatal hemorrhage are liable to occur during 
the process of elimination. The difficulties are made still more 
formidable by the situation of the placenta, in a considerable 
.percentage of cases, on the line of incision. 



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158h The Pathology of Pregnancy. 

Fcetal dangers are never to be lightly considered in obstetric 
practice, and therefore when, in ectopic gestation, the child 
attains viabUity, it is unjust unnecessarily to defer intervention, 
as fuetal life is continually exposed to great risk. 

On opening the abdomen the placenta is sometimes found to 
be so situated as to admit of comparatively safe removal. But 
should its relations be such as to involve extreme risk of uncon- 
trollable hemorrhage, it would better be left, the cord being cut 
short, the organ well covered with sterilized gauze, the sac wall, 
if possible, sewed to the lower end of the wound, and the trail- 
ing gauze so placed as to constitute a drain. The risk of septic 
infection in an operation so unavoidably conditioned, is very 
great. 

A method of treatment advised by a few consists in cutting' 
the cord short and closing the wound over the placenta, trusting 
t» resolution for a favorable outcome. 

Cases op Advanhed Gestation Prolonged after Death 
OF THE FcETua — In these cases it is generally thought ad- 
visable to wait, carefully watching the patient, until the symp- 
toms become grave, or there is positive indication of the chan- 
nel through which elimination of the fcetus is about to take 
place. If relief is to be found through the vagina, it will be 
shown by bulging of the cyst in or about this organ. An open- 
ing may be effected by the natural efforts; in which case it 
ought to be artificially enlarged to a size which will admit of 
fcetal exit. Should the opening be into the intestines, the dan- 
gers and difficulties attendant on expulsion become so great that 
celiotomy should be at once performed. 

It is obvious that the presence of a dead foetus seriously 
compromises the safety of the woman, and the suppurative pro- 
cess which is liable to ensue inevitably reduces her to a de- 
plorable condition. In view then of the success which has 
attended surgical interference, on one hand, and the extreme 
dangers of waiting, on the other, oparative procedure is ad- 
visable. 

With respect to the time for th3 parfirminceof celiotomy in 
these cases, a clear notion is of much importance. The time 
of fcetal death is to be carefully noted with a view to delaying 
a sufficient time to provide for obliteration of the placental ves- 
sels. Schroeder removed the placenta without loss of blood 
three weeks after cessation of fcBtal movements. De Paul oper- 
ated four months after foetal death, and lost his patient from 



Missed Laboii. 15Bi 

placental hemorrhasfs. There is no doubt that the process of 
obliteration of the placental vessels is rapidly effected in some, 
and is slowly effected in others; hence, under the circum- 
»tances, unless interference be urgently demanded, it is ad- 
visable to defer operative measures, treating the patient aymp- 
tomatically, until several weeks have elapsed, at the end of 
which time they may be undertaken with good prospect of 



The operation is then analagous to removal of an ovarian cys- 
toma. In the absence of forbidding complications the entire 
gestation sac, with its contents, will be removed. 

Missed Labor- — "An extremely rare and curiouEi phenome- 
non has been occasionally observed, in which, the fcetus remain- 
ing in utero, labor has not come ou at the usual time, and the 
remains of the fcetus may be retained for a considerable period, 
or di8Chai^:ed piecemeal by the va^^na, without, for a time at 
least, eerioiittly aflTectingthe health of the mother." This has 
been called " missed labor." 

Muller, after investigating forty-five cases of alleged missed 
labor, concluded that there does not exist an authentic abser- 
ration of retention of the fcetus within the womb beyond the 
term of ordinary pr^nancy. By many they are i-egarded as 
instances of extra^uterine pregnancy. 

For the most part, death of the foetus is followed either by 
premature expulsion, very soon after life is extinct, or by the 
occurrence of abnormal development of the foetal envelopes, 
and a perversion of the natural energies, culminating in molar 
pregnancy. In the rare cases above alliiiled to. neither of these 
occurrences is oliserved, but the ftPtus becomes mummified, or 
disintegrated, and its remains are retained in utero for months, 
or even years. The cause of this is supposed to be absence of 
uterine irritability, obstructed labor, and unusually close adhe- 
sions of the placenta. In many cases uterine expulsive action 
is set up, but, after a time, it ceases permanently, or is renewed 
at intervals, for days, weeks, or even months. Whenever the 
ovum perishes and is kept in the womb for a time far in excess 
ofthe period of normal uterogestation, whether molar changes 
take place, the foetus is disint^rated and discharged piecemeal, 
or becomes mummified; indeed, whether any decided post- 
mortem changes take place or not, they constitutfl an instance 
of what has been known as "missed labor." Manget reportsan 
■observation by Langelott of a caw in which the foetus perished 



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158j The Pathology of Pregnancy, 

in the fifth month, and was not expelled until the twelfttt 
month, in a mummified condition. -Johns obser\'ed two cases 
in which the fcetnses died at the sixth month, and were not bom; 
till five and six months respectively after their death. Olshau-: 
sen reports a case of retention of a mummified three-months foe- 
tus for eight-and-a-half months. McMahon relates a case in. 
which a foetus of four montiis was retained for eighteen monthH, 
and was then expelled, inclosed in a compressed placenta which 
evidently bad continued growing for some time after foetal 
death. The calcified or mummified fcetus is said to have been 
retained many years. Fcetal bones have been discharged from 
the uterus where they had been incrusted for years. 

In rare cases of prolonged retention, the foetus becomes the 
seat of fatty and calcareous d^eneration, in which case it is 
designated by the term "lithopsedion. " The subject of misstrd 
abortion is considered in another place. 

TVeatment, — When a woman has presented .undoubted si^ris 
of pregnancy, hEiH passed bytheperiodof maturege8tation,nnd 
evinces indications of fetal death, followed by disint^jat ton 
or mummification, it is clear that something ought to be done- 
to effectually rid the system of the depressing influences ta 
which it is subjected. This can be done only by securing thor- 
ough uterine evacuation. 

We should begin by seeking a remedy which covers the 
eymptoms. It will probably be found among the antipsorics, 
aud is likely to be sulphur, calcarea carb., silic'm, or arsenicum. 
If the carefully chosen remedies fail, we may afford relief by 
mechanical and manual means, but it should not be undertaken 
unless the condition is seriously disturbing the health. But if 
active interference be required, the lower numbers of a set of 
graduated steel dilators may at first be used, aud when suffi- 
cient dilatation has been secured to admit of its easy introduction 
we may employ Allen's dilator, and finally a Barnes' bag, fur- 
ther to expand the os. When it has thus been opened, the oper- 
ator should proceed much as he would in abortion, rely- 
ing mainly on the placenta forceps or small blunt hook, and 
finally the curette, as a means of complete delivery. If putrid 
masses be taken away, the uterus, after complete evacuation, 
should be washed out with a mild antiseptic solution. This 
operation, like all others, ought to be performed throughout 
under antiseptic precautions, and followed with a few doses of 
Hrnicn. 



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PREMATfRE EXPULSION. 



CHAPTER VIII. 

PREMATURE EXPULSION OF THE OVUM. 

Premature expulsion of the product of conception may take 
place at any moment prior to the time when the ftetus presents 
all the evidences of maturity, and the process has received dif- 
ferent desiguatioDS according to the stage of pregnancy at 
which it occurs. Interruption of pregnancy during the first, 
three lunar months is termed abortion; during the fourth, 
fifth, sixth and seventh months, that is, from the time when 
the placenta is AiUy formed to the date of viability, it is called 
mmc&niage; and from that time to the close of the thirty- 
eighth week it is known as prem&ture labor. While these are 
the t«chnical distinctions, the terms abortion and miscarriage 
are used int»t^hangeably by many, and, as we believe, with 
perfect propriety. 

The term fcetus, according to osage, is 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 doubtless greater in 
the early weeks of gestation, when the union between the cho- 
rion and decidua is imperfect, as hemorrhage is apt to occur and 
fill the space between them, thereby cutting ofi* communication, 
between the mother and child. 

Obstetrical writers do not agree as to the relative frequency 
of abortion. Hegar reckoned one abortion to every eight or 
ten full-time deliveries, while Devilliers sets them down in the 
proportion of one to three or four. The statistics of Whitehead 
show a proportion of about one to seven. Probably thirty- 
seven out of every hundred mothers experience abortion before 
they attain the age of thirty years. 

OaoBBB of Abortion. — The causes of abortion, miscarriage 
and premature labor, are, in the main, of slow, but cumulative 
action. The uterus is a patient oigan. It will bear a good 
deal of abase, neglect and interference, and with the greatest 
reluctance does it finally exhibit resentment. It is the mother 
oi^an, and in the quiet forbearance and self-flacrificing^ 
devotion to the new being which it nourishes, it is a reflection 
of the maternal mind. Evil infinences set themselves at work 
and gradually undermine the vitality of the ovular structuret*. 



] 60 Pregnancy. 

and render insecure the placental attachments to a d^ree 
which finally enables a very little accideot to precipitate 
expulsion. 

As lon^ as there is life in the inchoate being so carefully 
wrapped up in the membraDes, the uterus holds on with sur- 
prising tenacity; butwhen that is from any cause extinguished, 
the enveloping organ begins to gather force with which to effect 
its expulMon. Tliese are the phenomena most commonly ob- 
served; but in a certain pero^ntage of canes, the uterus is 
excited to expulsive effort before foetal death oecnrs. 

Predisposing Causes. — Death of the foetUB is sometimes the 
result of direct or indirect violence ; but it is oftener due to slow 
pathological changes in the embryonic or the maternal struc- 
tures directly concerned in nutrition. 

When death overtakes the embryo or foetus, it at once 
becomes a foreign body, and with conservative sense the womb 
sets at work to bring about complete evacuation. The villi of 
the chorion in early pregnancy, and of the placenta at a later 
period, undergo atrophy and fatty degeneration, and when the 
ovum is thus loosened from its moorings, uterine contractions 
are set up and expulsion is accomplished. 

A small embryo, if long retained, may become disintegrated 
in the amniotic fluid, and thus disappear. 

In early abortion the sac fi-equently comes away intact ; but 
at a later period it rarely does. 

OvuLAEV Causes.— These include the various diseases and 
accidents affecting the foetus and its envelopes, details of which 
need not here be given. 

Maternal. Causes. — Abortion often finds its predisposing 
causes in morbid couditions of the deciduse. Among these are 
(1) atrophy, and (2) hypertrophy of the uterine mucous 
membrane. 

The endometrium, instead of affording a generous reception 
to the impregnated ovum, and snugly enclosing it, in some 
cases spreadH an abnormally thin decidua, with the result, a 
small placenta. In other cases the decidua reflexa is not com- 
pleted, or may utterly fail of development; in which ease, 
covered only by the chorion, the ovum is suspended from the 
serotina. 

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 pedicl« 



PlIEMATURt: ExPfLSION. 161 

which it forms. Thia has received the name of cervical pr^- 
nancy. It ia chiefly the rigidity of the os interiium and the 
cervix which i-etains the ovum, and heuce it is an occurrence 
more common in primiparte than in multiparee. In some 
instancee, however, the stren^h of the pedicle is sufficient to 
prevent.further descent, even when the os is patulous. 

Endometritis with consequent thickening of the mucous 
membrane is a frequent cause of abortion, from the fact that it 
^ves rise to structural changes in the placenta. A placenta 
thus involved may fail to wupply to the fcetus requisite nourish- 
ment, or the weakened vessolB of the decidua may rupture and 
produce sanguineous effusion between the membranes. 

In retroversion, which is recognized as a common cause of 
abortion, the endometritis is probably the chief fa^^tor in 
bringing about the untoward result. 

lnt«rstitial and submu- 
cous fibroids, by preventing 
equable development of the 
uterine walls, and by en- 
croaching on the uterine 
cavity, may be the means 
of exciting expulsive action. 

The results of former cel- 
lular or peritoneal inflam- 
mation may prove seriously 
inimical to continued ges- 
tation, through the irrita- 
tion caused by adhesive 
bands and thickened para- 
uterine (*tructures. 

It is custoniarv to place F'o. 104.— Ovum with tmperfectly 

syphilis at the head of causes developed Decidua Reflexa. 

of premature fnetal death, and after it follow pernicious auEemia, 
chronic metritis, and endometritis. Dr. Fehling has shown 
that this result very frequently results from kidney dis- 
eases of the pr^^ant woman. In all the eases referred to, 
idbuminuria occurred, partly as the result of parenchymatous 
nephritis and partly as theresultofagenuinecontractiuu of the 
kidneys. After death of the foetus the albuminuria increased 
rapidly. In the pla<«nta may be observed deposits due to in- 
larctiou, so-called fibrinous wedges, the result of au ischemic 
necrosis. 



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102 FlUiaNANCY. 

Acute diBeastiB, eapecially those creating high temperatures, 
are liable to result in abortion. 

Napier lays emphasis on neuralgia as a predisposing cause. 
Following are his conclusions : 

1. Neuralgia and abortion are frequently associated. 

2. In certain cases of " habitual abortion,'' neuralgia invari- 
ably manifests itself as the first symptom, attacking cranial or 
spinal nerves remote from the uterus. 

3. If treatment relieves the pain there is a strong probability 
that uterine disturbance will not commence, or, if already there 
have been contractions, these will cease. 

4. Neuralgia, while perhaps most common in the rheumatic, 
occurs in diflferent types of patients: in the aneemic, dyspeptic, 
or malnourished ; or in the overfed, indolent and plethoric. 

5. Abortion sometimes evidently results from the reflex irri- 
tation associated with the neuralgic paiu. 

6. Acute neuralgias occurring in pregnancy may not in any 
way interrupt healthy gestation. 

7. When severe facial, cervical, or other neuralgia yields to 
treatment, even though the embryo be dead, uterine contrac- 
tions and emptying will not occur for days, perhaps weeks. 

8. The trifacial, occipital, and cervical nerves are most com. 
naonly affected ; but brachial, intercostal, lumbar, and sciatic 
neuralgias are also met with. 

9. Acute gastric irritation is associated with neuralgia 
and abortion. Pregnancy sicknesB, although very severe, 
seldom causes miscarriage; but gastrodynia, which is some- 
times accompanied by salivation and a constant feeling of 
nausea and depression, not infrequently precedes acute neu- 
ralgia, which eventually causes uterine irritation and ends in 
abortion. 

In many cases it is impossible to trace the cause of the oc- 
currence to any abnormal conditions of either the fietus and its 
envelopes, or the maternal generative organs. In such women 
there doubtless exists a condition of nerve irritability, which 
readily reflects irritation proceeding from physical or psychiced 
sources, with force sufficient to produce powerful premature 
uterine action. 

Immeriatr Causes of Abortion. — The immediate causes of 
abortion arise in general from the maternal side. No changes 
on the part of the ovum, save those of forcible separation of 
the attachments, or rupture of the membranes, could bring 



Premature Expulhiow. 163 

about the rcault. The aiaternal influence, however, is strong 
and uDmistskable, and is often exerted, willingly orunwillingly, 
with the effect to inteirnpt pregnancy. 

Uterine Congestion. — Active or passive congestions of the 
uterus are probably the most frequent prozim ate causes of abor- 
tion. In those cases wherein influences have been silently at 
work to weaken the relations between the ovum and decidua, any 
circumstance which is capableof determining an unusual quan- 
tity of blood to the organ is capable of causing extravasation, 
separation, and premature expulsion. Hyperemia excited by 
an BCCompliBhment of the menstrual cycle, fevers, inflanunation 
of the genitalia, excesses in coitus, hot foot-baths, the use of 
certain drugs, unusual physicalexertion, valvular heart-lesions, 
obstructions of the pulmonary or portal circulation, may be 
the means of precipitating expulsive action. Under conditions 
of uterine hyperemia, a very slight motion or jar, vomiting, 
coughing and straining, to nay nothing of falls, injuries, and 
violent emotions, are capable of hastening the fall of the unripe 
fruit of the womb. 

The significance of pre-existing remote causes, associated 
with accidental occurrences, is clearly shown in many i-ecorded 
cases. When the connections between decidua and ovum have 
not been weakened by the occurrence of any of the changes be- 
fore mentioned ; in other words, when the woman in all her 
generative tissues is in ahealthystate, most powerful influences 
of a baneful nature are often suffered, without interruption of a 
normal course of gestation. I-'alls from considerable heights, 
giving rise to severe contusions and fractures, have repeatedly 
occurred to pregnant women without causing abortion. Dr. 
Pagan tells of an instance in which his coachman drove directly 
over a woman who was in the eighth month of pregnancy, in- 
flicting upon her serious injuries, and still gestation proceeded 
in a regular manner to term, and terminated in the birth of a 
healthy child. M. Gendrin speaks of a young lady who was 
thrown from a chaise over the horse's heful, by the animal fall- 
ing in his career. The lady was then five months prq^nant, but 
the accident did not prevent her from reaching her full term. 
Cazeaux met a case precisely similar in the wife of a notary liv- 
.ing near Paris. Women, with a desire to rid themselves of a 
developingovum, sometimes resort to most desperate measures 
without success. 
Matthews Duncan mentions a case wherein an intra-uterine 



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164 Pregnancy. 

Btem pessary waa introduced and worn for some time duriug- 
pregnancy, without exciting miscarriage. A woman seven 
montha pregnant, jumped from a third-story window to th& 
pavement below without BufTeriiifr abortion, though she broke 
both her lege and arms. Operations of all degrees of severity 
have been performed with immunity from the result in question. 
Limbs have been amputated, ovaries have been removed; the 
vaginal pori:ion of the cervix uteri has been cut off, and sub- 
mucous flbroids have been taken away by laparotomy. 

Symptome of Abortion. — Early abortion may, and doubt- 
less does, occur, in many cases, with symptoms differing but 
little from those attending a return of the monthly flow . There- 
are pains in the sacral and hypogastric regions, and bearing 
sensations in the pelvis, with a rather free flow of blood, and 
then the whole ovum may be discharged, enveloped in a clot, 
thereby utterly escaping notice. In other cases the sac is 
raptured by the uterine contractions, the embryo escapes 
unnoticed and the membranes soon follow. 

In either cane there is generally but a moderate loss of 
blood ; but the rule in not without its exceptions. In a certain 
proportion of iuHtances, even in the early weeks of pregnancy, 
the hemorrhage attendant on the occurrence is remarkably pro- 
fuse, and occasionally even alarming. Still the practitinnernmy 
comfort himseif and patient with the i-eflection that in early 
abortion, under intelligent management, this symptom is more 
alarming than dangerous, since women who are the subjects 
of it not only survive, but rarely suffer serious impairment of 
health or strength. 

Ah soon as the ovum, whether whole or in fragments, has 
been conii)lete]y extruded, there is usually an end to the bleed- 
ing, and but a short period of time is consumed in uterine 
involution. But in earl v, as well aw later, abortion, the jiresence 
in utero of any part of the product of conception, whether it be 
embryo or envelopes, is opt to continue the hemorrhage. There 
may be temporary cessation, but the flow again i-eturns to de- 
clarethnt the abortive jirocess is incomplete. 

Later abortions pre.sent more pronounced characters. The 
pains are more severe, the flow more profuse, and the effect on 
the woman more profound. For some time before these symp- 
toms set in, prodroniuta are generally experienced consisting of 
fullness and weight in the pelvis, sacral pains, frequent mirturi- 
tion, and a mucus or watery discharge. These, followed by 



PREMATUBE EXPULSION. lliS 

recurrent paine and hemorrhage, indicate a threatened abor- 
tion. There may be but a Blight discharge at any time during 
the progress of the case, but in every instance there is h'ability 
to exhausting and even dangerous hemorrhage. The peril, to 
life from the blood lose is not great, but the baneful effects of 
a sanguineous depletion, such as is now liable to be suffered, 
are not speedily remedied. The tenor of the woman's general 
health may be seriously impaired for months, or even years. 

In a typical case of abortion occurring about the third 
month, the ovum is extruded without rupture, in which ca«e it 
passes into the vagina, with the embryo viwble through the 
thin membranes, and the imperfectly formed placentaattached. 
The uterus, then being empty, contracts down, and the hemor- 
rhage is at an end. In abortions occurring after the third 
month, it is uncommon for the ovum to come away entire; but 
the membranes are ruptured, the ftetus expelled, and the secun- 
dinee are retained. During the period of retention, which may 
be prolonged, the woman is in constant danger of profuse and 
Hudden loss of blood. After the abortiveact has been finished 
by complete evacuation of the uterus, hemorrhage is an unusual 
occurrence; but in rare cases, owinf; to a depraved state of the 
system, to intra-uterine growths, or to imperfect involution, it 
becomes an annoying complication of the puerperal state. 

Incomplete Abortion. — Retained secundines, whether in 
early or later abortion, are apt to prove a source of much 
trouble. Here, as iu labor at full term, after expulsion of the 
foetus the uterus is disponed to take a season of rest ; but, un- 
like the latter, this rest is usually prolonged. We may some- 
times vainly wait hours or days for renewed action, while 
caaes are by no means rare in which vigorous uterine contrac- 
tions never return. 

The comparative comfort of the woman will lead her to 
believe that the process is complete, and a physician may not 
be consulted until serious symptoms are developed. Violent 
hemorrhage may at any time ensue, or in default of that, sep- 
ticeemia may be set up. In many cases the physician does not 
reach his patient until the foetus has been expelled, and theclots 
which generally follow are falsely assumed to be the afterbirth. 
The patient or friends being deceived by these, the physician is 
informed that everything has come away, and as all evidence 
baa been destroyed, the confident statement of the attendants 
is liable to make him the dupe of credulity. 



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160 Pregnancy. 

The Diagnosis of Incomplete Evacaation becomce a point of 
great nicety, in those ca^eH where the extruded matters have alt 
been preserved, as well as in those where they have not. When 
the ovum is discharged with ita membranes inta«t, it is not 
diflictilt to arrive at a positive conclusion; but this dttes not 
always occur. The placenta, or decidual mass, is relatively larf;i 
The size of the embryo, at an early period, may be represented 
by the last phalanx of the little finger, or a Lima bean, while 
the afterbirth, when spread out, is as large as one-third of the 
hand. In some cases the secundiDes are expelled or extracted 
in fragments, and a retained portion is easily overlooked. It 
follows that absolute certainty can be attained only by careful 
exploration with the finger. 

Cases are oil record in which the order of expulsion was re- 
versed. The membranes were ruptured and expelled, uterine 
action ceased, and the foetus was retained. Dr. No^gerath 
mentions a case in which the membranes were expelled at the 
fourth month of pregnancy, and the foetus was retained for 
aeveral weeks. In the interval between the expulsion of the 
membranes and birth of the foetus, the woman was in a com- 
fortable state. Dr. Chamberlain relates a case in which the 
membranes were expelled, but the foetus continued in utero for 
twelve weeks. Dr. Peaelee had a similar case in which the 
foetus tarried three months. In the last two cases the women 
manifested symptoms of retention of a part of the ovum, there 
lieing hemorrhage and irritative fever. 

The following observations by Spiegelberg concerning in- 
complete abortion merit most attentive study : 

1 . Most frequently hemorrhage continues at intervals, spon- 
taneous elimination gradually taking place, as through retro- 
grade changes, portions of the retained membranes become 
successively loosened from their attachments to the uterus. 

2. In exceptional cases the hemorrhage ceases for a time en- 
tirely. For days, weeks, and even months, the woman apjiears 
quite well, then suddenly strong contractions, accompanied by 
profuse hemon-bage, usher in the elimination of the fo-tal de- 
pendencies. 

Lusk says, in a case of his own, three months elapsed froji 
theocourrenceof the first hemorrhage, which took pla^e towards 
the end of the third month, and waj* quite insignificant in 
amount, before the abortion was completed. Meanwhile, as 
there were progressive abdominal enlargement, supposeil 



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Premature Expulhion. ' 167 

•TjuickeniDg, and milk in the brea»ta, the threatened abortion 
was believed to have been arrested . 

Total retentioQ with a long interval of quiet is supposed to 
proceed from an unbroken relationship between the placenta 
And the uterine walls, by means of which the former, though 



Fio. 106.— Uterus, with baeia of a Fibrinous Polypus after an aLortion. 
( Prankel. t 

functionally inactive, continues to receive nutrient supplies from 
the uterus. The retained secuudinea, if not removed by arti- 
ficial means, have a strong impulse to come away at a men- 
-strual period. 

3. Of more fi-equent occurrence than the foregoing, is the 
putrid decomposition of the retained portions, Itoccurs chiefly 
incases where there is more or less complete loss of organii: 



168 Phegnancv. 

connection between the placenta and the uterus. Decompom- 
tion of the non-adherent portiooB is produced hy the introduc- 
tion of air during the escape of the embryo, or through the 
subsequent passage of the finger into the uterus, or where 
portions of the ovum bang down into the vagina, by ab- 
sorption of septic matter from the vagina upwards into the 
uterus. As a result of putrid decomposition, the woman is 
exposed to8eptictemia,andinflectiQii ofthrombiatthe placental 
site. Fatal results are, however, rare, as decomposition isusu- 
ally a late occurrence, setting in, as a rule, only after protective 
granulations have formed upon the uterine mucous membrane, 
and after complete closure of the uterine sinuses. Continued 
fever, with intercurrent attacks of hemorrhage, is, however, 
set up, but finally passes away with the gradual discharge 
of the decomposed particles,' while the threateiiiug symptoms 
subside. Still, now and then septic proceescs lead to an un- 
favorable termination. Local perimetritic inflammation is a 
common event. 

4. Where there is a certain degree of relaxation with enlai^e- 
ment of the uterine cavity, the fibrin of the extravasated blood 
may become deposited about any uneven surface within the 
uterus, and give rise to a polyshaped body, suggestive in its 
mode of development of the stalartiteformations in calcareous 
caverns. These so-called fibrinous polypi generally develop 
around the debris of aa abortion, such as retained bits of de- 
cidua, placental remains, and portions of the foetal membranes. 
In some coses, likewise, thrombi projecting from the placental 
site become the base of a loosefibrinousattachment. Placental 
polypi give rise ultimately to bearing down pains, and inter- 
current hemorrhages. They may even decompose, and endanger 
life by septic absorption. 

Expulsion of One Fietub in Twin Pregnancy.— In twin 
pregnancy one ovum may be blighted and expelled, and the 
other retained till completion of the full term of utero-gesta- 
tion. A most interesting case of this kind was reported by Dr. 
E. Chenery, A woman at the fifth month jiresented the usual 
symptoms of abortion, and a fcetus in its envelopes, together 
about the size of a common open-fared watch, wag expelled. 
T'pon making a vaginal examination the head of a much lander 
fcptuB was found protruding through the ob uteri. This was 
seized by the fingers for the purpose of extraction, but it escaped 
and returned to the uterine cavity. The physician, supposing 



Premature Expulsion. 169 

"that expulsion waa then a necessity, gave ergot, but the os con- 
tracted, and the uterus refused to act. When the full term of 
pref^nancy was accomplished, expulsion took place in a normal 
manner. 

Another case of similar kind was reported by Dr. Stanley 
P. Warren, of Portland, Maine, in 1887. Other cases are on 
record. In general, however, in multiple pi-egnancy, the uterus 
is entirely evacuated without a long interval of repose. 

Diagnosis. — Contemplation of the symptoms of abortion 
an related would lead one to suppose that diagnosis of the 
approaching occurrence should not be attended with much 
di^culty. Still, in many cases this is not true. The woman, 
perhaps, has evinced her pregnant state by the usual symp- 
toms, and now hemorrhage and pain indicateitethreatened eon- 
«lasioD. The case is clear, and diagnosis unequivocal. But 
we often meet women who are worshiping at the shrine of the 
goddess Isis. So extremely desirous are they to present th^r 
husbands with heirs, that every possible sign of pregnancy has 
been magnified as a support to fond hopes, and the symptoms 
now presented, though really those of a menstrual return, are 
-construed to be signs of abortion. Therearewomen of opposite 
-desires and tendencies who will minimize every true symptom, 
and thus mislead themselves, as well as those who are sum- 
moned to their aid. Then there are ^hose nnfortunate females, 
many of them girls scarcely out of their teens, who, having 
fallen prey to the wiles of designing men, use every endeavor 
to conceal the evidences of guilt. Among the number are found 
.some to whom we would scarcely dare impute wrong-doing, and 
who thereby disarm suspicion. The onlysafe coursefor the phy- 
-sician to pursue is to insist upon an examination per vagin&m 
in all cases where, from the symptoms, there appears to be the 
least possibility of threatened, orpartialiycompleted, abortion. 
The diagnosis is based upon the presence of pain, hemorrhage, 
■dilatation of the cervix, and descent of the ovum. If the os 
has become patulous, the ovum may be felt, when the demon- 
stration becomes complete. In all cases of pregnancy, the 
occurrence of hemorrhage, even unaccompanied by other 
symptoms, ought to be accepted as a probable evidence of 
threatened abortion, and every precaution accordingly exer- 
cised. 

It is impossible to make out with certainty, fi-om mere sub- 
jective symptoms, the existence of pathological changes in the 



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170 Pregnancy. 

ovum and deciduee which prepare the way for abortion. Deatlt 
of the embryo may be inferred from the signs given in anothor 
chapter; but positive knowledgecan be obtained only at alat^^r 
period. 

Whenever the discharged substances have been preserved, 
the physician should carefully examine them with a view to 
discovering every possible trace of the ovum. The clots may 
be broken up in cold water, and solid substances wholly freed 
from extraneous matters. The ovum, when unrupturiMi, is 
generally found surrounded by layers of coagulated blood, and 
may easily be overlooked. If the discharged substancee have- 
not been preserved, and the os uteri will not admit the point of 
the finger, it may be impossible to determine at once whether 
complete evacuation has been effected or not. Forcible mea£- 
nres are not justifiable for mere diagnosis. The occurrence of 
further pain and hemorrhage would constitute strong evidence 
of retention, and dilatation of the osmay be necessary as a pre- 
liminary to extraction of the remaining substances. 

Prognosis. — Of prognosis as regards the foetus, of course 
nothing need be said. The maternal mortality from abortioa 
is not great, but the pernicious effects on health are very 
decided. More feebleness and suffering proceed from thissource- 
than from labor at term. Women frequently urge, as an ob- 
jection to continuing the pregnant stats, that their Iiealth is so- 
feeble as wholly to disqualify them to endurethe strain of preg- 
nancy and labor, but assume that interruption of pregnancy 
will protect them from subsequent physical ailments. The 
minds of women ought to be disabused of such erroneous no- 
tions. The hemorrhage which usually accompanies premature- 
. expulsion of the ovum does not often destroy life, but it so re- 
duces the strength, and hence the powers of resistance, as to- 
create inviting subjects for the inroads of disease. 

Criminal abortion is quite another thing, and if we could 
gather reliable statistics concerning the results of it, the mor- 
tality would be shown to be very heavy. The professional 
abortionist frequently makes of himself a professional execu- 
tioner. 

Treatment.— The treatment of abortion is : 1 . Preventive ; 
2, Promotive; and 3. Remedial. 

Preventive Treatment.— This involves (a) general and 
special prophylaxis, and (b) the arrest of threatened abortion. 

The pregnant woman, and especially she who hap alreadj 



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Premature Expulsion. 171 

suffered one miscarria^ or more, should attend most scrupu- 
looBly to the observance of general sanitary rules. Over-in- 
dulRence and over-exertion are particularly to be avoided. No 
amount of exercii:<e should be laid out for pr^aant women 
indiscriminately, for what may justly be regarded as moderate 
exercise in one case, will far exceed the endurance of another. 

Women who have had repeated abortions, at or near a 
certain period in pregnancy, must be guarded with the greatest 
care. 

It is sometimes advisable to put them ia close quarantine, 
and even in bed, for a time, though no threatening symptoms 
have arisen. When the period at which, in individual cases, an 
interruption of pregnancy generally occurs, has been sa^ly 
passed, the woman's r^traints may be gradually relaxed, until 
they have been reduced to a minimum. So strong a propensitiy 
is sometimes generated by recurrent abortions, that the unex- 
pected arrival of a friend, a vinit to the table, or even a strong 
odor, may be sufficient to bring on thp accident. 

For these discouraging cases of habitual abortion we would 
especially recommend the following remedies : 

Snlpbar for women who are thin and feeble, with dry skin 
and poor complexion. Very sensitive to vaginal examination. 
Sense of wealtness in genitals. They have usually menstruated 
sparingly. 

Araenhum iod. for scrofulous women, especially those who 
have, or have had, eczema. The skin is easily irritated. 

Calcarea carb. is likewise suited to scrofulous Bubject«, 
especially those with fair skin, light hair and rotundity of form. 
They give an account of habitually profuse menstruation. 

Caalophyllum when the woman has suffered from myalgia, ; 
is a poor sleeper; has a history of "female weakness." 

Sepia. — We regard this as one of the best remedies for use in 
these cases, especially in nervous, sensitive women. Complains 
of much bearing towards genitals ; cannot sleep well. 

Kali iod., mere, iod., nitric acid, and other remedies, may be 
called for when there is asyphilitic taint. 

The treatment of chronic and a<;ute disease in general, of 
which the woman may be the subject, is also included in 
prophylaxis, but methods of treatment and the selection of 
remedies are modified so little by the patient's pr^nancyasnot 
to demand extended consideration here. The same may be said 
also of accidents, from which pregnant women are not exempt. 



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172 Pkegnanct. 

Since strong emotions, which in a non-pr^nant state could 
do no harm, are capable of prodncing, during gestatjoo, most 
Rerious consequences, they ought to receive attention. After 
violent anger, colocynth and ehamomilla are of considerable 
service. When anger or vexation is associated with fright, 
aconite may be employed. It is also of service when, after 
fright, a state of apprehension and dread remains. Opium also 
has the reputation of effecting favorable results after fright. 
To avert the evil effects of grief we can probably do no better 
than to administer ignatia or phosphoric a-cid. 

After a bruise a few doses of arnica ought not to be omitted. 
A strain generally excites uterine action by rupture, to a certain 
extent, of the utero-placental relations; still, good may occa- 
sionally be done by th« timely administration of rbas toxico- 
dendron. 

After marked symptoms of threatened abortion have ap- 
peared, the first point to be settled is, whether the abortion 
ought to be, or can be, prevented. In general, the physician 
should firmly and conscientiously be in no way accessory to 
abortion, and only when he is convinced that the foetus isdead, 
or that discharge is inevitable, should he assume the responsi- 
bility of promoting the act already bf^un, or passively permit 
the consummation of it. This principle vf action, closely fol- 
lowed, given considerable scope for the employment of prevent- 
ive measures, wien once the expulsive forces of the uterus have 
been aroused. 

Little time should be lost in getting the woman into a bed. 
which has coot, pleasant, and quiet surroundings. Her cloth- 
ing ought to lie removed, and loose garments substituted, at 
the earliest practicable moment. If the hemorrhage is profuse, 
the hips may be raised by something laid directly under them, 
or, bett<?r still, by setting the foot of the bed upon blocks. In 
a certain percentage of cases, perfect repose of body and mind 
is the only essential, but when painful uterine action has been 
excit<ed, when the hemorrhage is profuse, or when a passive flow 
has existed for some time, further means of prevention will be 
required. The si mitimum of the case should be sought, and if 
found, it may quiet the pains and arrest the flow in a magical 
way. 

There are a few remedies which we have found of frequent 
service at such a time : but let us not foi^t that, whenever any 
remedy is called for by clear indications, whether its special 



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Premature Expulsion. 173 

:»i>)iereof action 1b the geoerative, or not, it should be admla- 
iatered. 

Sabina is a prominent remedy, especially in threatened 
Abortions about the third month of pregnancy. The hemor- 
rhage is rather profuse, of a bright red color, and is accom- 
'paiiied with clots. Ita action is more prompt and efficient in 
nervous, hysterical women, but need not be limited to such. In 
tlie absence of clear indications for some other remedy, we do 
■well to employ this. 

Secale cor. is best suited to thin cachectic women, and to 
late abortions. The flow is passive and more likethe menstrua) 
dischai^. The pains are not very vigorous, but rather pro- 
tracted . 

Caalophyllum. — The pains are spasmodic and pressive, but 
the flow not necessarily profuse. The woman is uneasy and 
j<enaitive. Tremulous weakness. 

PulaatiUa, — Especially for mild, tearful women ; but irrita- 
bility of temper is sometimes a good indication. Id those 
-cases where the sudden spurts of blood are unusually profuse, 
with only a moderate flow in the intervals. 

Viburnum.— It has been highly extolled by some. Our own 
■experience with it has been- very limited, and we are aware of 
no special indications for ite use. 

Ipecac. — When the hemorrhage is profuse, and blood bright 
red. It is more likely to be efllcacious in womei* with a history 
of profuse menstruation. 

Gratifjing results are often obtained from the above rem- 
edies. To them we may add aconite, with its great fear of 
death, and of stir, or bustle; nux moschata. with its hysterical 
symptoms and syncope; beUadoima, with its bearing-down 
sensation, and bright red blood, which feels hot to the parts 
over which it flows: apis, with ite stinging, tearing, aching 
ptun ; and f^ehewiuin, with its pains running up the back. 

In old-school practice, opium constitntes the great reliance 
for the prevention of abortion in these instances where threat- 
'ening symptoms have arisen, and there is no sort of doubt 
that it proves efllcacious in many cases which would otherwise 
culminate in expulsion. This fact should not be ignored, and, 
when other remedies do not produce prompt results, we need 
not hesitate to avail ourselves of the benefits derivable from a 
discriminative use of the dnig. The most eflloacious mode and 
form of administration is the hypodermic injection of morphia. 



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174 Pkegnancy. 

ODe-eighth to one-fourth grain will generally be an adequate- 
dose. Begin with the mtDimum quantity, and repeat it if 
neceesary. 

In every case of threatened abortion occurring during the- 
first three months of pregnancy, a careful examination ought 
to be made to ascertain the eituation and position of the- 
uterus. In some instances the symptoms depend upon retro- 
flexion and retroversion, and they often quickly disappear 
when, upon placing the woman in the knee-chest position, and 
carefiilly' using the fingers, or the elevator, the organ is re- 
turned to its Dovmal position. 

It is evident that preventive treatment is not suitable to 
all cases. The consummation of the process is sometimes 
clearly inevitable from its very incipiency. For a considerable 
time there may have existed evidence of the sulwidenc-e of the 
normal developmental activities, resulting, doubtless, from 
fcetal death. The usual symptoms of pregnancy have become 
less pronounced ; there is a sense of weight and bearing in tbe- 
pelviB, associated with a feeling of coldness in the abdomen, 
and sometimes a vitiated vaginal discharge. The woman is ill 
in body, and distressed in miud. In such a case interruption of 
pregnancy should never be prevented. On the contrary, ca8e» 
which at first appear to be preventable, may, by a persistence- 
and an aggravation of symptoms, ultimately pass the bounds, 
and become unqualifiedly unavoidable. 

The signs of inevitable abortion are, profiise hemorrhage^ 
with regularly recurrent uterine pains, dilatation of the osexter- 
num, descent of the ovum, and rupture of the membranes. 
While we cannot concur in the opinion expressed by some 
authors that rupture of the membranes is not proof positive 
that abortion is inevitable, we would caution against too hasty 
a presumption of its inevitability. Scanzoni has reported a 
remarkable case in which a woman was seized with profuse 
hemorrhage from the uterus in the third month of gestation ; 
numerous clots were discharged, and all hopes of preventing 
the threatened occurrence were dissipated ; erffot 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 passively for three weeks, a weak solu- 
tion of perchloride of iron was injected; but, despite ail 
interference, the pregnancy continued, and uickening waa 
experienced six weeks later. 



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Premature ExpuiiBion. 175 

Promotive Treatment.— When the case has advanced be- 
yond the Hinit where preventive treatment is available, the 
exJBtiDg conditions do not always favor immediate adoption of 
efforts at uterine evacuation. The ob uteri, or, indeed, the 
entire cervical canal, may be so small that it will not admit a 
single finger, while the uterus is pouring out blood in alarming 
quantities. In such an emergency something must be done at 
once to protect the woman from the serious consequences of 
excessive depletion, while the cervix is given additional time for 
expansion. In some cases dilatation may be speedily efTected 
with the finger, if the uterus is kept within rea^h by firm press- 
ure upon its fundus. If the ovum, in early abortion, is found 
intact within the os uteri, no interference whatever should be- 
practiced, in the absence of urgent indications, for fear of rup- 
turing it, and thereby complicating the delivery. 

If the uterus cannot be emptied and the hemorrhage con- 
tinue profufie, we may think best to pack the vagina. 8till, in 
our own experience we have seen no inexorable demand for the 
tampon, and therefore we never use it. At best it is a danger* 
0U6 expedient, and, unless we have at hand material for the 
pur[>OBe which we know to be strictly aseptic, we intend never 
to resort to the operation. The best material for a tampon i» 
doabtless iodoform gauze. This should be cut into a long strip 
and gradually crowded into place, tlie near end being left at the 
vutva, so as to admit of eaay removal. 

In the introduction of a tampon much ditficulty will be ex- 
perienced, and great suffering inflicted, unless the precaution is 
observed to separate the labia and retract the perineum with 
the fingers of one hand, or by means of a speculum, while the 
article employed is being passed by the other hand. This sub- 
ject is considered at length in another chapter, to which the 
reader is referred. 

Before introducing a tampon, the vagina and vulva should 
be thoroughly washed with a disinfecting solution, and no 
tampon ought to be allowed to remain in situ for more than 
twelve consecutive hours. It can be renewed at the end of that 
time, if necessary, the precaution being taken to cleanse the 
vagina with an antiseptic solution after its removal. The 
ovum often passes into the vagina, when the tampon is taken 
away. If it does not, dilatation may be sufficiently advanced 
to enable the operator easily to remove the foetus and envelojMit* 
in an unbroken state. 



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176 Pbeonancy. 

As soon as dilatatioD is great enough to admit of interfer- 
ence with a reasonable prospect of immediate success, it should 
be undertaken. In default of this condition, another vaginal 
plng.if required, may be introduced fortwelve hours, but the use 
of this expedient for a period much in excess of twenty-four 
hours, is not to be recommended. The vagina becomes irri- 
tated, more or less blood decomposition ensues, and septic 
matters are generated. 

In the practice of many excellent obstetricians the tampon 
is frequtntly used ; and J^et, as before said, we regard it as an 
■ expedient to be avoided when the indications can be met by 
remedies and other innocuous means. "During the course of 
an average practice of over a quarter of a century," says my 
•esteemed friend, Dr. Henry A. Minton, of Brooklyn, "I have 
never resorted to the tampon ; I have never had occasion to, 
the carefully selected reme<iy has always given such prompt and 
satisfactory results that nothing more was called for," 

Emptying the Vterua.~The eecundiues, as well as the ovum, 
require removal, and this is uot always accomplished with the 
utmost facility. The ovum or placenta forceps have been 
recommended, and cau sometimes be successfully used, but 
cannot be regarded as safe except in those cases where the part 
retained protrudes from the os uteri. As will be seen in a sue* 
■ceeding paragraph, the fingers afford the safest and best means 
■of extraction. 

In miscarriage the fcetus is extremely apt to present by the 
feet, and the utmost care and discretion must be exercised to 
avoid parting head and trunk. This is not an uncojumMi acci- 
dent, though by no means an insignificant one, as a retained 
head is not always easily extracted. In removing the foetus, as 
likewise in getting away the placenta, the operator ought to 
work about the mass, loosening first one side and then the 
other, so that it may not be torn. 

In these rare ceibcs wherein the nipmbranes are expelled and 
the fcetus retained, the latter should be extracted without un- 
necessary delay. A fretiis left behind would give risetothesame 
dangers as a retained placenta, namely, hemorrhage, and 
septic poisoning, and the rules of practice regarding unexpelled 
wtnindines would apply with equal force to an unexpelled 
fo-tus. In the latter case the operation is attended with fewer 
ilifficulties than in the former. 

It may occasionally happen that the symptoms of abortion 



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Phemature Expul8[on. 17T 

culminate in the expulsion of one f(Btu8 and its membranes, 
while yet another child, with intact membranes, remains in 
utero. In such cases the physician should assume the expectant 
attitude, and patiently await developments. If there are no 
discernible signs of fcetal death, and no further abortive etforta, 
there surely is noexcuse for interference. But should symptoms 
of miscarriage continue, or again become manifest, or should 
foetal death or disruption of the membranes be discovered, 
delay ought to be brief, for the woman's interests are best 
subserved by speedy delivery. 

In twin pregnancy, the membranes of the first child may be 
broken before foetal expulsion, and remain behind. In such a 
case we should discreetly await the natural efforts, indulging a 
hope that the placenta will be extruded wibhoot serious dis- 
turbance of the uterine relations of the second child. Nature 
failing to accomplish this, and no untoward symptoms arising, 
the case, kept under strict surveillance, may be permitted togo 
undisturbed. It is evident that the existence of twin pregnancy 
is rarely recognized until interference has gone so far as to in- 
sure complete evacuation of the uterus. 

When once the embryo or Ketus is expelled, the case has not 
always reached its climax of difficulty and danger. Indeed, in 
many instances serious difficulty is now first met. Expulsion 
of the ovum entire is not au infrequent occurrence in early 
abortion ; but in other cases the embryo is first extruded, to be 
followed without much delay by the secundines. In later preg- 
nancy this sometimes occurs, but in the main, the phenomena 
differ in some important respects. The abortive process goes 
on in a regular way until foetal expulsion has been accom- 
plished, when uterine efforts cease, and the placenta is retained 
for an indefinite period. Nor is such retention generally for a 
few moments only, as in labor at full term, but it is prolonged 
anil fwrsistent. 

Wkat gives to such a condition a serious aspect is, that< 
there grow ont of it eert-ain dangers, namely, hemorrhage and 
septiofenna. After labor at full term, the placenta, on account 
of certain degenerative changes, is more easily separable, and 
m*y fee -either expressed -or extracted. When letained after 
abortaon, the ntenrs is too small "fc© admit of successful expul- 
■mon'oftbe placenta by abdominal pressure, the umbilical cord 
is too frail "bo beartrectioTi, and the vulva, cervix, aud uterine 
cavity, ai« mot sufficiently <eKjpaiided to admit the hand. These 



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178 Pregnancy. 

are the conditions which render retention of the placenta after 
abortion a matter of BO great moment to both physician and 
patient. 

When and How to Remove the Senuntiines. — When the 
placenta ia retained it sometimes becomes a point of gi-eat 
nicety to decide when to operate for ite removal, and unlesa 
one haa settled rules of practice for his guidance he will be likely 
to stumble and vacillate in a very enibarrassing way. Physi- 
cians are not in perfect accord with regard to the treatment 
of these cases, and the consensus of opinion is not easily 
gathered. Many advise against early interference, preferring 
to wait honrH, or even days, for natural expulsion. Others 
insist upon the advisability of immediate attempts to remove 
the retained secundines, even though the operation prove to be 
difficult. 

The placenta proper is not formed until the third month of 
pregnancy, but the proper embryonic envelopes of an earlier 



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Fig. 108.— The ovum Forceps. 

date constitute a mass several times larger than the embryo 
itself, and require treatment varying but little from that given 
the placenta. We find, however, that the uterine cavity and 
cer\'lcat canal are so small at an early period in pregnancy, 
that the finger is not afways available, in which case interfer- 
ence should not be pushed to extremes, unless hemorrhage 
becomes troublesome, or there is intimation of septic in- 
fluences: and then, the finger failing, the curette should be care- 
fully employed. Such masBPs left in utero, being small, do not 
often create serious disturbance ; but they ought not to be left 
for an indefinite period. A safe rule of practice is to resort to 
the curette without much delay when there are persistent indi- 
cations of incomplete abortion. 

In abortions of tlie third and fourth months, the ti-eatment 
should differ from this in some important respects. The 
placenta is now formed, and must be removed; but when? 
and how? 

The question " wlien " is one which merits more than a brief 



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PitEMATunE Expulsion. 179 

answer. It haa engaged the attention of obstetricians for 
many years, and haa been diacussed with much fervor. For- 
merly the practice was to follow the expectant mode of treats 
meDt, keeping careful surveillance of the patient, and interfering 
only when serious symptoms began to manifest themselves In 
1883, Dr. T. Johnson Alloway, of Edinburgh, in a communica- 
tioD to the American Journal of Obstetrics, took strong 
grounds in favor of immediate removal, in such cases, of the 
retained secundines. In the same number Dr. Paul F. Muude, 
being incited thereto by Dr. Alloway's communication, went 
over the subject iu a thorough manner, alid unhesitatingly 
advocated a similar treatment. The following excerpt is from 
that aT-ticle, the italics being ours : 

"The future safety of the patient demands that the secun* 
dines should be at once removed after expulsion of the foetus, 
in every case of abortion in which such removal can be accom- 
plished without force sufficient to injure the woman." In the same 
journal, during the succeeding year, two other articles appeared 



■an 

Fia. 107.— LeavJtt'B uterine Curette. 

favoring the same treatment, one by Dr. S. Henninjnvay and 
the other by Dr. G. N. Acker. We also observe that Dr. Egbert 
H. Grandin, in hiBtranblationof Gbarpentier'sexcellenttreatise, 
advocates the same treatment. 

This has been our own method of maQagement for ten or 
twelve years, and we have had no reason to regret its adoption. 

On the other hand, a large number of excellent obstetricians 
etill favor the exi)ectant plan, and in pursuing it, allow the 
placenta in some cases to remain for two or three days. 

Immediately after expulsion, or extraction of the fcetus, the 
crrvical canal ought to be examined, and if expansion be great 
enough to admit the finger, the placenta should at once be re- 
moved. With ore hand on the hypogastrium the uterus can be 
pushed down into tlie pelvic cavity, and its contents thus 
brought within i-each. when by gentle manipulation the entire 
mass may be removed. If the cervical canal will at first admit 
the finger nearly or quite to the internal os, gentle endeavor 



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180 Pregnancy. 

will soon overcome resistance. We have otten oeen surpnued 
to find the finger easily penetrating the cervical canal, when, to 
a superficial examination, the os seems quite too small 
to receive it. If neither dilatation nor moderate dilatabiiity 
exist, the operation should be delayed for a time, though the- 
placenta ought not to be permitted to remain longer than 
twenty-four hours, unless violence in its removal would be 
unavoidable. 

The chief exceptions to the foregoing rules arise in conuection 
with those cases wherein the woman has either been greatly 
reduced by hemon-ha^, which has temporarily ceased, or is in 
a state of extreme nervous erethism. Either of t^lese conditions 
would contra-indicate interference. In the former ease the- 
patient must be kept under strict observation, while time is- 
given the natural energies to recuperate. Cliina, or some better 
indicated remedy, should meanwhile be ad mtnistei-ed. Inevent 
of recurrence of the hemorrhage the placenta should at once be 
removed. For the nervous irritability which may stand in the 
way of immediate interference, the most effective remedies are 
actxR racemose, caulophylhun, ignatia, hyoscyamus, Rsarum, 
camphor (2^), cofka, stramonium, kali hrom., or even chloraf 
hydrate. 

Delay in excess of twenty-four hours ought not, as a rule, to- 
be permitted. Bring the patient carefully under the influence- 
of an aneeethetic, and proceed with the necessary operative- 
measures. In truth, it often happens that wheu the placenta is 
18 retained, the woman, especially if of a nervous organ- 
ization, is thrown into a condition of extreme nervous 
excitability, which cannot be wholly relieved while the placenta 
remains. 

In abortions at the fifth month, operative procedures should 
not be delayed longer than ten or twelve honrs. In abortions- 
at the sixth month, we should not wait longer than two or 
three hours. 

There are remedies which contribute a certain amount of 
aid towards expulsion of the uterine contents in these cases of 
incomplete abortion, and among them stands pre-eminently 
Sabina. China has been spoken of in high terms by some. If 
enough blood has been lofit to produce an effect on the pulse or 
sensorium, this remedy will be peculiarly suitable, PulsatHIa 
has rendered good service in many cases. The»e remedies may 



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Premature Expulsion. 181 

faJl to expel the placenta, and yet, by encouraging uterine 
act.ion and consequent dilatation of the cervical canal, render 
efficient aid to extractive measures. 

In a moderate percentage of cases we succeed with difrital, 
or even instrumental, effoi-ts at removal, without an antes- 
thetic; but, in most instances, it is either advisable or neces- 
sary to resort to it. 

Abortions at tbe fifth and sixth months can usually be' 
terminated by delivery of the placenta as in labor at full term. 
It may be necessary to introduce the half-hand ; but ourexperi- 
ence Hub not led us to think so. 

When the placenta has been removed in fragments, or when, 
in the absence of positive knowledge of what has been extruded, 
the finger is introduced for exploratory purposes, the rough- 
ened endometrium may lead one to suppose that something 
still remains. It is only by most painstaking examination 
that the truth can be elicited. 

The placenta is sometimes so closely adherent to the uterus 
that removal of the entire maaa, even in fragments, is impossi- 
ble, and there remains the danger of hemorrhage and septi- 
caemia. If profuse hemorrhage should at any time occur, water 
at a temperature of say 118° to 122° Fahrenheit, injected di- 
rectly into the uterine cavity by means of a syringe throwing a 
gentle stream, free from air. is a most excellent means of over- 
coming it. There is little or no danger connected with this use 
of hot water, provided the os be lai^ enough to permit free 
escape of the fluid injected. 8ueh an injection ought never to 
be made by other than the medical attendant or a skillful 
nurse. A hot vaginal douche often answers well to keep the 
flow within bounds, and it may be resorted to before using the 
intra-uterine douche. 

Similar injections have been given with excellent results for 
hemorrhage consequent on total retention of the aecundines, 
substituting the tedious and painful use of the finger, or instru- 
ments. In most cases the uterus is stimulated to immediate 
contraction, and, when the cervical canal is sufficiently ex- 
panded, the result is usually placental expulsion and arrest of 
hemorrhage. 

When by the means described we are unable to depress the 
uterus far enough to admit of digital or instrumental extrac- 
tion of the placenta, we may cause the organ to descend by 
means of the volsella. Abortions are much more frequent in 



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182 Pregnancy. 

multigravidse than i» primigravidfe, and it is chiefly in the 
latter, aud in thote whose abdominal walle present an un- 
usual thickness of adipose tissue, that the fingers, aided by 
abdomiual pressure alone, will fail. In these exceptional cases 
we may seize the cervix with the volsella, one with a slight curve 
being preferred, passing one blade within the oh for about half 
as inch, and plciciug the other upon the outer aspect of the 
cervix at a corresponding level. With a hold thus obtained, 
the uterus may be drawn down without injury either to it or 
its ligaments, and held by one hand, while we operate with the 
other. If other instruments are used, care of the volsella most 
be given to an assistant. 

Precedence and preference are by scftne given the placenta 
forceps and the small blunt hook em a means of extracting the 
placenta; but most operators prefer the Angers. Still there 
are cases in which, from our inability to bring the uterine cavity 
within reach, or from the shortness of the fingers, the instru- 



FiQ. 108,— Leavitt'a placenta Hook. 

mente mentioned are capable of rendering efficient aid. 
aration of adherent portions of the placenta should never be 
entrusted to instrumental means, unless the sense^^ided 
fingers utterly fail. The placenta forcejM are constructed with 
slim shanks, and sometimes spoon-like blades, the inner surface 
of the latt«r being roughened, so as to afford a firm hold. In 
order to pass the instrument, the fingers of one hand should be 
laid in the vagina, with their points at the os uteri, and along 
their palmar surface the instrument can be directed into the 
uterus. With the handles well back against the perineuni, the 
blades are separated and an effort made to inclose the placenta. 
This is an operation which requires some skill, and, like many 
other obstetric procedures, is more easily described than suc- 
cessfully performed. Extreme care should be exercised to avoid 
traumatism. When the placenta is taken hold of, forcible 
traction ought not to be made, as its fragile structures are 
easily broken. By gentle rotation of the instrument, first one 
way and then the other, associated with moderate traction, the 
retained part can sometimes be delivered in one mass. 



Peemature Exptii£ion. 183 

About twelve years ago the author designed a placenta hook 
"which is figured on page 162. He made much use of it for a 
time and found it of service. But since that time he has 
learned to value the curette so highly, that, for some years, he 
has used no other instrument to clear the uterine cavity of its 
■contents. Accordingly, with a view to reducing the size of the 
obstetrician's armamentarium he does not hesitate to recom- 
mend dependance on the curette alone in emptying the uterus 
after abortion. 

In nearly all instances bleeding ceases as soon as the uterus 
is fully evacuated; and when it persists, especially if it come 
in little gushes, at intervals, we may be quite sure that a frag- 
ment of the ovum, or a*hard coagulum, remains behind. The 
finger should be again passed, if the cervix will admit it, and 
every part of the uterine wall examined. If anything be found 
it must be removed. If bleeding still continue, as it will rarely 
do, the cavity should be thoroughly curetted. 

Neglected Cases. — The most threateniug emergencies which 
the physician is called to meet, sometimes grow out of the neg- 
lect of women to avail themselves, in season, of professional 
care. It is assumed that the abortive act has been consum- 
mated, until, after the lapse of days or weeks, serious symptoms 
are manifested. A passive flow haa existed for some time, 
when suddenly the blood gushes forth so profusely that the 
woman's life-forces are speedily brought low. A physician is 
hastily called, and he finds bis patient exsaniruine and synco- 
pal. The flow has temporarily ceased. Reflecting upon her low 
«tate, and realizing that the last few drops are thosewhicb kill, 
his ^ood sense tells him that the present is no time for interfer- 
ence. The voice of a wise monitor whispers: "To disturb 
those clots may be to kill," and he wisely heeds it. He revives 
his patient by judicious stimulation, and the administration of 
china-, while a constant watch is kept to prevent an unobserved 
renewal of the flow. Should it occur, he will remove the secun- 
dines without delay ; but in its absence, time for recuperation 
4>f the vital forces is ^ven, and then the case is terminated 
without danger. 

In another instance the placenta, through neglect, is suffered 
-to remain in utero. After a time certain ill-feelings are experi- 
enced : there is a chill, the pulse is accelerated, the temperature 
rises; then follow headache, backache, fetid dischai^ee. pros- 
tration, and all the signs of what has been called irritative fever. 



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184 PitEGNANCY, 

A physician is called in to explain the slow "gettii^ 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. 

More frequent use of the curette, under strict antiseptic 
precBtitions, is recomniended. 

(For detailed description of the use of the curette see a 
later chapter.) 



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Pathology op the Uterine Mucosa. 



CHAPTER IX. 

PATHOLOOT OF THE OVUM AND DECIDV^. 

The physiological changes which take place in the uterine 
mucouB membrane as the result of impregDation, sometimes 
pass the usual bounds and become pathological. It appears 
probable that abortion not intrequently owes its origin to such 
a cause. 

EJndometritis. — This may be either acute or chronic. The 
latter variety of the aflection is divided into three distinct 
forms, namely, 1. Endometritis decidua chronica difTusa; 2. 
Endometritis decidua tuberosa et polyposa, and 3. Endome- 
tritis decidua catarrlialis. 

The causes of the first form probably depend, in a great 
measure, on endometritis which antedates conception. Syphi- 
litic infection, excessive physical exertion, and fcetal death, 
with retention, are also set down as etiological factors. The 
anatomical changes wbicli take place consist in thickening and 
hardening of the decidua, resulting from diftlise development of 
new connective tissue, and proliferation of decidual cells. The 
-decidua vera and decidua reflexa may be separately or jointly 
involved in the processes, and changed in whole or in part. 
According to Duncan, the hypertrophied decidua always pre- 
sents evidence of fatty degeneration, uneqaatly advanced in 
different parts. When the changes are wrought in the latter 
part of pregnancy, they pursue a notably chronic course, are 
limited in extent, do not involve the placental decidua, and 
pregnancy does not invariably suffer interruption. Premature 
expulsion is caused in these cases by death of the ovum from 
imperfect nutrition, or by the exciting of reflex uterine action. 
The ovum, after death, generally retains its connection with 
the decidua for a time, and finally the diseased decidua 
and attached ovum are expelled. The decidua is a thick 
triangular fleshy mass, and has attached to some part of its 
inner surface, the blighted ovum. Expulsion is apt to be a 
«low process, owing to the adhesions which have formed be- 
tween the decidua and the deeper uterine tissaes. If thesa 
include the placental decidua, much difficulty will be experienced 
in natural separation, and the case is liable to be complicated 
by profuse hemorrhage. 



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186 Pheonancv. 

The causes of tbe second variety of chronic endometritie are 
obscure. Virchow r^arded syphilis as one of theni. Gusserow 
says that when conception closely succeeds delivery, the re- 
cently formed vascular uterine mucous membrane may take on 
abnormal proliferative processes. This variety of endometri- 
tis and the succeeding pathological changes are limited, with 
rare exceptjons, to the decidua vera, and prefer for their loca- 
tion the anterior and posterior walls of the cavity. "The 



Fro. 109.— TuberouH subchorial hematomata of the decidua CWalther). 



uterine surface of tbe decidua is rough, and covered with 
coagulated blood, while the entire mucous membrane is ex- 
ceedingly vascular. Upon that surface of the decidua which in 
directed towards the ovum, are situated large excrescences or 
elevations, the prevailing isliape of which is polypoid. They 
may, however, appear in the form of nodules, of cones, orlioBs- 
like projections, provided with a broad, non-pedunculated base. 
Tlieir height is from oiie-quarter to one-half inch, and theirsur- 
face is smooth, very vascular, and devoid of uterine follicles. 



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Pathology of the Utkrisk Mucoka, 187 

The latter, however, are plainly visible on the mucous mem- 
brane intervening between the polypoid outgrowths, but they 
are compressed, and their orifices constricted or obliterated by 
the pressure of whitish, contracting bands of newly developed 
connective tissue. Similar fibrous bands surround the 
blood-vessels. On section, the larger prominences sometimes 
appear permeated with coagulated blood, and narrow, cord- 
like bands of hypertrophied decidual tissue occasionally form 
bridge-like connections between neighboring polypi. The uterine 
follicles are, in some cases, filled with blood-clots. The epithe- 
lium is often absent from the uterine surface of the decidua, 
except around the orifices of the follicular glands, and the 
deeper decidual tissues contain large numbers of lymphoid 
cells. The cells of the decidua reflexa frequently undergo fatty 
degeneration. The placental villi may show hypertrophy of 
their club-shaped ends, or be the seat of myxomatous growths, 
in which cose their cells are granular and cloudy. The fietus is 
generally dead and partially disintegrated. This form of 
endometritis decidua is, coiitiequently, usually accompanied by 
abortion, which occurs predominantly at an early stage of 
pregoan cy . ' ' — Lues. 

The third form of chronic endometritis attacksmultigravidee 
ofbener than primigravidse, and runs a comparatively mild 
coarse. It has been termed bydrorrhcea grRvidarum, by 
which is meant a collection of yellowish watery albuminous, and 
sometimes bloody, fluid between the decidua refiexa and vera, 
which is discharged at intervals during pregnancy. Many theo- 
ries have been formed regarding it,8 etiology. Some have re- 
garded the discharge as due to rupture of a cyst between the 
ovum and uterine walls. Baudelocque thouKht it proceeded 
from transudation of the liquor amnii through the membranes, 
while Burgess and Dubois believed it depends on rupture of the 
membranes at a point distant from the os uteri, Mattel has 
referred it to the existence of a sac lietween the chorion and 
amnion. A single discharge doubtless occasionally proceeds 
from the two last-mentioned causes, but repeated loss must be 
referred to other sources. Hegar's theory, that it is the result 
of abundant secretion from the glands of the uterine mucous- 
membrane, which accumulates between the decidnaand chorion, 
and escapes through the os uteri, is probably nearer the truth. 
The real pathological changes which take place are vascularity, 
hyperemia, and hypertrophy of the interstitial connective 



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188 PREONANCY. 

tis-sue. and of the glandular elemente of the decidna. The in- 
flii mmation involves the decidua vera by preference, but may 
Biinultaneously affect the decidua reflexa. The fluid which re- 
Kiilta is thiu, watery, muco-jmrulent, or sero-sanguinoleiit, re- 
sembling the liquor aninii both in color and odor. When no 
obBtacle to its free escape m iuteiposed, its diecharge is contin- 
uous, but when it is confined, a considerable quantity may col- 
lect, until finally the reeiHtance is overcome, and there is a 
sudden and copious discharge. It is often expelled at night 
while the patient is sleeping, very likely by reason of uterine 
(ontraction. In some cases even a pound, or more, of the 
fluid is thus lost. Hydrorrhoea gravidarum is observed at 
all periods of pregnancy, but most frequently in the latter 
months. It often occurs as early as the third month. 

Diagnosis involves differentiation between it and rupture of 
the membranes, escape of fluid sometimes confined between the 
amnion and chorion, and escape of fluid emanating from the 
hypertrophied decidual glands. The chief point of differentia- 
tion between hydrorrhoea and escape of fluid from the space be- 
tween the amnion and chorion, is that in the latter case there 
is but a sinjrle discharge, while in the former there is either con- 
tinual draining or repeated gushes. It is not always easy to 
distinguish l)etween hydrorrhoea and escape of the liquor amnii. 
In the former we find that pains are absent, the os uteri un- 
opE>ne(l, and ballottement can be made out. If the membranes 
are ruptured, labor is quite certain to ensue, though cases of 
long retention after rupture have been recorded. A repetition 
of the discharge, and continuance of pregnancy, will materially 
aid in clearing up the diagnosis. Hydrorrhoea, though apt to 
cause alarm, rarely presents serious phases, though Veit says 
that the uncontrollable vomiting of pregnancy is sometimes 
attributable to it. The pregnancy i.^ rarely interrupted, and the 
woman feels rather relieved by the discharge. During the exist- 
ence of this form of endometritis the general health of the 
woman should be as well maintaiued as possible, 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 shall be most likely to 
find the siniilimum, are ampnicuin album, I.ichesis, natrum mu- 
riRticuni, mprcnrius, calcarea carb, and sulphur. If uterine con- 
tractions supervene, the utmost quiet must be insisted upon, 
and eaaloph^Hatn, Pulsatilla,, or viburnum administered. 



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Pathology of the Ovi-m. 189 

Pathology op the Chorion. — The only affection of the 
chorion that has yet been described is that form of degenera- 
tive change which reeulta in the developnient of what is known 
at) vesicular or hydatidiforni raole (cystic disease of thechorion, 
hydatidifonn degeneration of the chorion). It is of rare occur- 
rence. Madame Boivin saw but one case in 20,375 delivered. 
Before the time of Cmvelhier, the vesiclps which ctiaracterrze 
this morbid product wei-e, from their close resemblance, sap- 
posed to be real hydatids. 



Fig. no.— Hydatidifonn Mole. Fio.lll.— Hydatidiforni Mole. 

(Placental origin.) 

Thpre is a little disagreement concerning the structures 
involved in the myxomatous degeneration here considered, 
rareful dissection disclosing the villi of the chorion in various 
stages of change ; but still there is not perfect accord concern- 
ing the histological element* affected. Heinrich Miiller locates 
tlie affection in the external membrane covering the villi. 
Mettenheinier maintains that a cystic transformation of the 
cells of the interior of the villi is the essential pathology. His 
views are also shared by Pajot. Virchow locates the morbid 
change in the villi and holds that what fluid there is, is simply 
the intercellular tissue fluid. His views have been most com- 
monly accepted. The resulting vesicles vary in size from that 



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190 Pbeonasct. 

of a millet seed to that of a walnnt. The vesicular fluid con- 
tains muBtn, but the large cysts a lees quantity than the 
smaller. All the villi are not iavoWed in the morbid process. 
Development in by gemmation or budding, not fioni single 
stems, but mainly from vesicles already formed . They fi-equent- 
ly a^r^ate a considerable mass and present the general 
appearance represented in figures 110 and 111. 

When degenerative development b^ns in the first month of 
pregnancy, as indeed it usually does, the d^eneration iuvolves 
the whole chorionic surface. Death and absorption of the 
embryo may ensue, leaving the amniotic cavity entirely free 
from solid matters. If the placenta has already been formed, 
degenerative changes do not go beyond this structure, and if 
sufficiently extensive to destroy the fcetns, the remains of the 
latter are found in the amniotic cavity, which sometimes 
contains on excess of fluid. If only a few of the placental 
cotyledons are implicated, the foetus may continue its func- 
tional activity for a time, and even reach perfection. The 
morbid changes generally take place within the decidua sero- 
tjna, but that boundary is sometimes exceeded. Volkmaun 
reports a case in which the d^enerative process invaded the 
uterine blood sinuses, and, by pressure, led to so extensive an 
atrophy and absorption of the uterine walls, as to leave only a 
thin septum between the mole and the peritoneal covering of 
the organ. "The cavity formed by this process of erosion in 
the uterine parenchyma was larger than the uterine cavity 
proper, and presented intersecting trabeculee resembling the 
columnee carnese of the cardiac ventricles." Such results, how- 
ever, probably depend on a morbid condition of the uterine 
walls, proceeding ^om malnutrition. Similar cases, with fatal 
" results, are reported by Schroeder. 

Sometimes the adhesion of the mass to the uterine walls is 
very finu, and may interfere with its expulsion. Nutrition 
of the altered chorion is carried on through its connection with 
the decidua, which also is often diseased and hypertrophied. 

Causes of Hydaticliform Def^encration. — The etiology of this 
disease has evoked considerable discu88ion. Ruyech, Scanzoni, 
Hewitt and others nmintnin that thp<'hnn):ce8 in the cliorionic villi 
which charactenzi' it ai-e always pnH-edwl by pmhryonic death. 
In support of this view allusion has been made to the fact that, 
in nearly all oases, the embryo hen been eutirely absorbed, and 
also to the oorasional occurrence of hydatidifoi-ni d^eneratinn 



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Patholooy of the Ovum. 191 

of the chorion of a dead foetus in twin pregnaTicj, while that of 
the living one remains healthy. That the excitiug cause of the 
degenerative changes is often, if not usnally, a morbid ma- 
teroal condition, seems likely from ita repetitioii in the uanie 
woman, by its co-existence with endometritis, or with extensive 
uterine flbromata, and by the existence in most cases, according 
to Underhill, of a cancerous or syphilitic dyscrasia in Che- 
mother, But still better evidence is found in the clinical obser- 
vation that myxomatous changes have been observed involv- 
ing a part of the placenta M'ith a living child. In Germany the 
opinion prevails that the cause of these degenerative changes is- 
found in endometritis. If this be accepted, we nmst conclude- 
that the d^enerative changes generally precede and produce- 
foetal death. The disclosure of the true pathol*^y of hyda- 
tidiform degeneration has disposed of the question, formerly 
mooted, of its occurrence independently of impregnation. 

Symptoms and Coarse. — Cystic disease of the ovum may 
exist for a time without developing any symptoms of sufficient 
prominence to draw attention. Later it is observed that the 
ordinary course of pregnancy has been changed in some impor- 
tant regards. Some of its most common symptoms may disap- 
pear, bat such changes are by no means const-ant. The most 
prominent sign of the existence of perverted development 
ctmsists in a failure' of correspondence between the uterine en- 
largement and the computed period of utero-gestation. Thus, 
at the third month, the uterus may be found as high as the 
umbilicus, or higher. On the other hand, if the cystic develop- 
ment began early, the organ may be decidedly smaller than at 
a corresponding p<^riod in normal gestation. There is more 
general disturbance of the health than there oughtto be, nausea 
and vomiting being apt to become excessive. Lumbar and 
sacral pains are prominent and distressing in proportion to 
the rapidity of the abnormal growth. About the third month, 
sometimes eariier, there begins a more or less profuse watery 
and sanguineous discharge, generally at intervals, which re- 
sembles currant juice. These losses doubtless depend on break- 
ing of one or more of the cysts, and escape of the contents, 
brought about by painless uterine contractions. Though not 
usually excessive in quantity, they are sometimes so profuse 
and frequent as to reduce the woman's vital forcewtoa low, and 
even dangerous, condition. In the discharge are also found 
portioDS of cysts, and sometimes masses of considerable size. 



192 Pregnancy. 

Expulsiou of the de^uerate masB usually takes place before 
the sixth month, but it may be delayed beyond the usual period 
of mature utero-gestation. As in the case of ordinary abor- 
tion, the hemorrhage ceases after the uterus has been com- 
pletely evacuated, but retained portions of the tumor may give 
riBe to protracted and profuse bleeding. The entire maas ie 
sometimes expelled enclosed in an unbroken deciduu. 

Diagnosis.— This will i-eet in part on subjective eymptoms, 
such as the sensations accompanying foetal death ; but mainly 
on objective symptoms. 

The uterus an felt through the abdominal walls sometimes 
presents irregularitien, but such as do not closely resemble 
foetal outlines, and the organ imparts to the examining hand a 
peculiar boggy, or doughy feel, with sometimes distinct fluctu- 
ation. On examination per vaginaw, the lower uterine seg- 
ment is found to present similar characters. Ballottament 
yields negative results, and foetal movements are not felt, 
though they may be simulated by uterine contractions. The 
sounds of the foetal heart are diminished in intensity in the 
early stage of degenerative change, and subsequently quite lost. 

In these cases where the cystic degeneration implicates but a 
part of the ovum, diagnosis cannot always be made with any 
certainty, unless we observe that duet of characteristic signs, 
rapid increase of uterine development and the peculiar dis- 
charge in which whole vesicles are at times found. Absence of 
the more important signs of normal pregnancy should be given 
due weight. 

Prognosis. — The character of the prognosis in cases of hyda^ 
tidiform mole is governed lai^ely by the frequency and violence 
of the accompanying hemorrhages. It is reassuring in the 
majority of cases, as far as it regards the mother; but the life 
of the foetus is, of course, almost invariably sacrificed. 

Treatment .—The treatment differs but little from that pre- 
scril:)ed for ordinary abortion, and consists, in' the main, of 
measures calculated to control the hemorrhage, and promote 
expulsion of the degenerate product of conception. Manual 
and instrumental non-interferenoe is generally advised until 
uterine action is excited, unless threatening symptoms are 
meanwhile developed. When contractions begin, the tampon 
should beused, if called for byprofuse hemorrhage with inability 
to deliver, and uterine action sustained by appropriate rem- 
edies. 



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Pathology of the Ovum, 19S 

Under the ezpectaat plan of treatment there is considerable 
danger to be apprehended from sudden and violent hem- 
orrhage ; therefore, unless arrangements of the best sort can be 
made for prompt professional attention, the question of im- 
mediate interference merits thoughtful consideration. Dilata- 
tion may be began with tents, and afterwards continued with 
the finger, or with the dilators of Molesworth, Bamee or Allen. 
The remaining steps of the operation will be easy. With the 
fingers the mass is removed either whole, or in fragments, and 
the main difficulties of the case are soon overcome. Since there 
is sometimes fiim adhesion of the cystic mass to the uterus, 
very energetic attempts at complete separation should be 
avoided. 

The Placenta.— The usually rbund or oval shape is not 
always preserved, but it maybecrescentic, orhoree-ahoe shaped, 
or have an irregular form, and be spread over a considerable 
surface, in consequence of an unusual number of the chorionic 
villi being concerned in its formation. That anomaly of form 
which deserves special mention, is the one in which a supple- 
mentary placenta exists. This is known as placenta succen- 
turia, the accessory developments being due to the persistence- 
of isolated villous groups, which form vascular connections 
with the decidua vera. They are of consequence, inasmuch a» 
they are liable to be left in utero, and give rise to hemorrhage. 
Hobl says they always form at exactly the junction of the 
anterior and posterior uterine walls, and the portions of 
placenta on each side of the line become nearly separated. 

Size. — Placentse varj' also in size, the dimensions of the 
organ bearing a pretty constant relation to that of tlie child. 
Hypertrophied placentae occur chiefly in connection with hy- 
dramnioB, and consist of a genuine parenchymatous hyper- 
plasia, the foetus being dead and shriveled. In some cases tl e 
organ is remarkably small, which condition is referable (o 
defective development, to premature involution, or to hyper- 
plasia of the connective tissue, with subsequent contraction. 
It should be borne in mind, however, that the dimensions of 
the placenta are modified by the state of the placental vessels. 
When the latter are empty, the organ is small, and when 
filled, it is greatly increased in size. 

When true atrophy of the placenta existe, the vitality of the 
foetus is sure to be more or less impaired. Whitaker believes 
that atrophy of the organ depends either on a diseased state 



194 Pregnancy. 

of the chorionic villi, or of the deoidua in which they are im- 
planted. The latter is supposed to be the more common cautte, 
and it consists iu hyperplasia of the connective tissue of the 
deeidua, which presscH on the villi and vessels, and results 
in atrophy. Placentee have been fouad in a state of 
atrophy though the tissue of the organ itself showed nothing 
peculiar. ^ 

Setuation. — The most frequent situation of the placenta is 
At or near the fundus ut«ri, close to the orifice of the Fallopian 



Fio. 112. — Fattjr Degeneration of the PlacentK. 

tube, on one side of the uterus or the other, but it is occEtsion- 
ally implanted elsewhere, as, for example, over the internal os, 
as in placenta prtevia, and at various points in the abdominal 
cavity in connection with extra-uterine pr^nancy. 

Degenerations and New Formations. — The most common 
form of d^eneration is the fatty, which may be circumscribed, 
or diffused. It is normally present in a mature placenta, and 
in probably a change which facilitates the final separation of 
the organ. When it occurs early in pregnancy it is often 
responsible for premature completion of the occurrence which 
normally takes place at a later period. Its CAuse is doubt- 



Pathology of the Ovum. ' 195 

Icsa referable to tissue changes which interfere with i)roper 
nutrition, proceeding, perhaps, in the first instance, from the 
^vonlan's state of health. Syphilis, doubtleos, in Rome cases, 
has an influence in its production. The placental tissues often 
present yellowish masses of different sizes, which consist largely 
of molecular fat, penetrated by a fine network of fibrous tissue; 
but true fatty degeneration has a predilection for the chorionic 
villi. The latt4;r, on careful examination, are found to be 
altered in their contoor, and loaded with fine granular fat- 
globules. 

Other morbid states of the placenta are: 1. Amorphous 
calcareous deposits, which are found on the uterine surface of 
the placenta, iA the decidua serotina. Sometimes these are 
isolated grains or needles, sometimes calcareous masses. They 
are composed of amorphous carbonates and phosphates of 
lime and magnesia. The process Bometimes extends to the 
ftetal portion of the placenta. When the change begins in the 
latter part, it is generally limited to it, and afiects the small 
blood-vessels of the villi, attacking first their tevrainal ramifi- 
•cations, and gradually implicating the trunks. 2. Deposits of 
pigment, usually attributable to alterations in the heemo- 
globin of extravasations, found within the blood sinuses or 
villi of nbrmal placentee, are sometimes excessive. 3. (Edem- 
atous infiltration of the placental tissue is sometimes observed. 
According to Lange, it occurs only in convection with hydram- 
nios. 4, Cysts are frequently found near the center of its con- 
•cave surface, and vary from a few lines to several inches in 
diameter. Cysts of considerable size have been found also on 
the foetal side of the placenta, but below the amnion and 
■chorion. Their contents are solid and liquid. The amnion, 
covered with pavement epithelium, forms the cyet wall. A 
reddish, cloudy, thin fluid, makes up the contents. Ahlfeld re- 
gards the cysts as liquefied myxomatous formations. They 
may also develop from apoplectic foci. 5. Circumscribed 
tumors areoecasionallyTound on the fcetal side of the placenta, 
beneath tbe amnion. Spiegelberg tells us that these are fibrom- 
atous or sarcomatous in character. They sometimes attain 
considerable size. Myxoma of the placenta, consisting in 
hyperplasia of the villi, and myxoma fibrosum placenta, char- 
acterized by the fibroid degeneration of the basement mem- 
brane in isolated villi, are the chief remaining varieties of 
placental neoplasms. 



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196 Pregnancv. 

Syphilis of the Placbwta,— According to Charpciitier, 
Fraiikel, in concert with Waldeyer and Kolaezek, was tlio fii-st 
to give serious attention to the subject,. He collected fifteen 
cases of syphilis transmitted from the father, wherein nothing 
more than hypertrophy of the villi could be found. When the 
mothers were diseased, the lesions were more complex. Follow- 
ing were his conclusions : 

1. There is syphilitic placenta, presenting characteristic 
features. 2. It is found only in cases of congenital or he- 
reditary foetal syphilis. 3. The seat of the l^on differs when 
the mother is effected from that when the virus is merely car- 
ried by the spermatozoa to the ovule. In a cane like the latter, 
the placenta is d^enerated, thefa^tus is diseased, the villi of the 
ftetal placenta are filled with fat.granules, while their vessels 
are obliterated and their epithelial coVjerings either thickened 
OP absent. In case the mother is tainted, one of these con- 
ditions may be present : 1. If the mother is infected during the 
copulative act, syphilitic foci often develop in the maternal 
placenta. 2. If the mother is syphilitic before impregnation, 
or soon becomes so, the chances of the placenta being healthy 
are about even. 3. If the mother is not infected till she has- 
passed the seventh month, both foetus and placenta escape. 4. 
Inoculation of the foetus during delivery has not been estab- 
lished . 

Apoplexy and Inflammation of the Placenta.— Hemor 
rhage into the placenta sometimes takes place from congesl ion. 
of the utero-pln cental vessels, proceeding from disturbances in 
the mother's vascular system. The extravasalion may be into 
the placental parenchyma., into the serutina, or into the uterine 
sinuses. Extravasation is due mainly to morbid chonget; in 
the decidual vessels, often as the result of placentitis. Thr 
blood coagiila undergo the ordinary retrogressive meta- 
morphoses. Occasionaliy cystic, fatty, or calcareous d^reuenv 
tion takes place. The hEematomata by pressure may interfere 
with proper nutrition of the ftetus, and result in its death. 

Placentitis has been alluded to by some authors as a com- 
mon disease, and various pathological changes have been at- 
tributed to it, such as hepatizations, purulent deposits, and 
a<ihesions to the uterine structures. Its existence is now 
disputed by many, who contend that the morbid changes 
alluded to are due simply to retrogressive metamorphoses in 
coagula. "What has been taken for intlammatioR of the 



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Pathology of the Ovum. 197 

placenta," saya Robin, "is nothing else than a condition of 
transformation of blood-clots at various periods. What baa 
been regarded as pus is only fibrin in the course of disorgaDiza- 
tion, and in those cases where true pus has been found, the pus 
did not come from the placenta, but from an inflainiiiatioii of 
the tissue of the uterine vessels, and an accidental deposition 
in tbe tissue of the placenta." Other writers affirm its ex- 
istence, and assign to it etiological relations with metritis nud 
endometritis. According to their view the inflammation origi- 
nates in the serotina, or in the adventitia of the ftetal arteries, 
generally producing granulation titisue, which, from contrac- 
tion, produces compression of the placental vessels, which, in 
turn, may result in their obliteration, and lead to fatty de- 
generation of the villi. Should the inflammatory 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 tbe foetus. 
It rarely results in suppuration. 

HydranmlOB. — The chief pathological condition of the am- 
nion is that in which the liquor amnii exists in excessive quan- 
tity, known as hydramDios. 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 foetus, morbid symptoms are developed. Dr. 
Kidd limits the term to cases in which the amnion contains 
more than two quarts of the liquor amnii; while Charpentier 
says " All anthors agree that w hen the quantity exceeds 32 or 
48 ounces, there is dropsy of the amnion." 

SioNS ANU Symptoms. — These manifest themselves chiefly in 
the direction of overdistension of the uterus, the effects of which 
first become noticeable at the flfth or sixth month, when the 
abdominal development may be nearly as great as that of 
normal pn^nancj, at full term. The distension ultimately be- 
comes so great that various distressing symptoms ensue, such 
BA palpitation of the heart, dyspnnea, neuralgia and oedema of 
the labia and lower extremities, epigastric distress, dysuria, 
nervous disturbances and painful locomotion. The bowels are 
usually constipated, sleep is disturbed, the spirits are depressed, 
and, in some cases, delirium, and even eclampsia follow. 

In the latter part of gestation, under the influence of so great 
distension, the abdomen assumes a peculiar shape, which, how- 
ever, is mainly an exaggeration of the abdominal outline de- 



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198 Pregnancy. 

scribed in the earlier part ot thin work. What we mean by this 
IB, that the derelopment is mainly in front, while the sides are 
relatively flattened. The outline of the utems can easily be 
felt, thpre may be no marked eridenee of fluctuation, though 
this is not a conHtant sign, while the walls are extreiiioly teuse. 
Foetal movements are iudiBtinct, and sometimes unrecognizable. 
Vaginal ballottement cannot be successfully practiced in every 
instance, on account of the soft oedeiiiatous condition of the 
Dterine tissues. Palpation of the overdistended abdominal 
walls is painful, and in some cases cannot be borne. 

DiAQNOsiB. — In some cases of hydramuios, differentiation is 
attended with some difficulty. First of all, we should endeavor 
to recognize the existence of pr^^ancy, having done which, we 
will have to distinguish between several possible conditions, 
namely, twin pregnancy, ascites accompanying pregnancy, and 
ovarian dropsy associated with that condition. In uncompli- 
cated twin pregnancy, the form of the utems would differ in the 
dii'ection oF lateral expansion and anterior flattening, while 
the sounds of the foetal heart would be heard. Fluid in the 
peritoueal cavity, again, would give rise to lateral expansion 
and ftuctuation, while anteriorly the foetal outline would be felt. 
Ovarian dropsy, in ai^sociation with pregnancy, is a rare com- 
plication, and might present some difliculties. However, the 
ovarian growth would be pushed to one side by the enlarged 
uterus, thereby giving to the abdomen an uncharacteristic ap- 
pearance. Foetal movements and the fcptal outlines would be 
felt, and to both palpation and auscultation there would beevi- 
dence of lateral uterine displacement. The diagnosis of coex- 
istent hydramnios and ascites is difficult. Fluctuation would, 
perhaps, be felt all over the abdomen, but whether within or 
without the uterine cavity, is, at the moment, not easily de- 
termined. Fluctuation will be more distinct upon the sides, and 
the characteristic form of hydramnios alone, will belost. Aid to . 
diagnosis is afforded, by the rhythmical contractions of the 
uterus, though they are felt less distinctly than in normal 
pregnancy. Vaginal examinatfon will afTord some evidence ot 
an excess of amniotic fluid. 

Termixatiox. — Premature expulsion of the foetus very often 
happens as the result of foptal death, of placental separation, 
or of overdistension of the uterus. The latter condition ren- 
ders uterine action feeble, and hence the first stage of labor is 
greatly prolonged. Should uterine inertia prevail in the third 



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Pathology of the Ovum. 199 

stage, hemorrhage is liable to ensue. In general, however, upon 
rapture of the menibr^,nes and escape of the amuiotic fluid, 
vigorous contractions ensue, and lead to precipitate expulsion. 
Involution is apt to be slow and imperfect. 

Phoonosis. — In four cases out of thirty-three collected by 
McClintock, the women died after labor, theresult beingattrib- 
ntable to their debilitated state. Foetal mortality is very 
great. Nine of the thirty-three children were born dead, and 
ten died within a few hours. 

The Effect on Labor. — Even in those cases wherein the 
amniotic fluid is excessive in quautity, bnt still not sufficiently 
so to acquire the title of hydramnios, the effect on labor is to 
create feeble uterine action, and cause delay. The effect is more 
marked in the first stage of labor, since, at its close, the mem- 
branes usually break. 

Thkatment. — For the disease itself no remedy has yet been 
found. Should the mother's condition become distressing and 
perilous, the physician will feel called upon, in the interest of 
his patient, to puncture the membranes and draw ofl" the liquor 
amnii. Inasmuch, however, as this procedure is sure to be fol- 
lowed by foetal expulsion, it ought to be postponed as long as 
the woman's safety will permit. Playfair suggests the possi- 
bility of puncturing the membranes with a fine aspirator needle, 
and modifying the (H8i:en8ioD by drawing off the fluid only in 
part, thereby affording relief without bringing on premature 
labor. Disturbance of the mother's heart is one of the symp- 
toms most urgently calling for interference. If during labor 
the excessive distension of the uterus retard dilatation of the 
■OS, the membranes should be ruptured, and the amniotic fluid 
permitted to escape. The unusual danger of post-partum 
hemorrhage, which threatens in these cases, ought to be borne 
in mind, and the best precautions adopted. 

For such women, the homeopathic physician will think of 
antipsoric remedies, and will select those which, from special 
aymptonis, seem best indicated. . 

Deficiency of the Amniotic Pliiid.— When the liquor amnii 
is deficient in quantity foetal movements are restricted, and 
hence are liable to cause unusual pain to the mother. Direct 
pressure of the uterus on the foetue is liable to cause deformity. 
The amnion not being separated from the foetus in the early 
part of pr^mancy, abnormal amniotic folds and adhesions 
between the amnion and foetus may form. Foetal deformity 



200 



Pregnancy. 



and intra-uterine amputation may result from mechanical com- 
pression by the foBto-amniotic bands thus formed. 

Anomalies of the Amniotic Fluid. — The amniotic liquor 
does not present constant characters. Instead of being limpid, 
and of an inoffensive odor, it may be thick and emit a dis- 
a^^reeable smell. The cause of these variations is not fully 
anderstood. 

Pathology of the Oord . — The average length of the cord is 
about twenty-two inches, but there are extreme variations, the 
maximum length being about one hundred and eight inchec, 
and the minimum about three inches. When unusually long, 
the cord is liable to complicate pregnancy by becoming tightly 
drawn about the neck or limbs of the foetus. In this way intra- 
uterine amputation 
is probably some- 
times performed, 
and by a similar 
process foetal life 
may be destroyed. 

Knots.— Knota of 
the umbilical cord 
are found once in 
two hundred caaes. 
They are doubtless 
produced by the fcetus in its movements passing through loops 
in the cord. Those formed during parturition are loose, and 
in any case, if there is the usual quantity of Wharton's gela- 
tine in the cord, little harm is likely to result from a knot 
made at such a time. AVhen formed during pregnancy, their 
long continuance, and the consequent absorption of Wharton's 
gelatine occasionally produo; fatal results. 

Torsion. — A certain amount of torsion is frequently ob- 
served, and without consequent evil results; but occasionally 
it is so extensive and strong as to destroy foetal life. It occurs 
most frequently about the middle of pregnancy. The arteries 
of the cord take a spiral direction about theumbilical vein, and 
this very arrangement serves as a protection to the circulation ; 
but a few twists are sufficient to interrupt it. Torsion is 
supposed to result from rotation of the fcetus on its longitudi- 
nal axis, but whether it happens during fcotal life, is a moot 
question. Martin claims to have demonstrated that the effect 
is not from active foetal niorements, but is a post-tportem 




114.— Knots of the Umbilical Cord. 



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Pathology op the Ovum. 201 

occorrence. In eupport of thie, Schauta advanceB the foUowing 
propoBitloDS : 1. The large uumber of twists generally found 
indicate this, because auy one of them is capable of producing 
fietal death. 2. It is improbable that the healthy cord can suffer 
«uch torsion, inasmuch ascompensatory reverserotation would 
be caused by its elasticity, 3. Twenty-five artificially-induced 
twists in thecoi*d caused rupture. As high as three hundred 
■and eighty torsions have been found in a single funis. 

CoiLiNo OF THE CoBD, — The umbiHcal cord is often found 
■wound around the neck or other parts of the foetus. It is ob- 
served in one out of every eight or ten cases. As high as seven 
turns about the neck have been observed, though it is rare to 
'find more than two. When rapidly formed they may lead to 
immediate death of the foetus. They are especially liable to 
complicate delivery. During descent of the child, the loops 




Pio. JIB.— Torsion of the<;or4. (Martin.) 

-which were at first but moderately tight, are drawn upon, and 
thus strangulate the child before the complication is recognized 
and relief aflForded. Strangulation probably occurs more 
»lowly during intra-uterine life, owing to gradually increased 
tension of the coils. In this manner the foetal head has in some 
instances been nearly amputated. From shortening of the 
■cord thus produced, there may result anomalous positions, 
premature reparation of the placenta, retardation of labor, 
4Lnd even fntal death. 

Cysts of the Cohd are sometimes observed. They are 
formed within the amnion, and are the result of liquefaction 
■of the mucoid mass, or by accumulation of serum between the 
■epithelial layers of the allantois. 

Hernia. — Protrusion of a loop' of intestine into the umbilical 
■cord, from errors in development, are occasionallj met. In our 
own prcictice we have encountered the condition but once. 



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302 Preonancv. 

HeTDJa may occar in otherwise well-developed foetuses, but it is 
frequently associated with other deformities, such as stricture 
of the rect>um, imperforate autis, distortion of the lower limbs 
or of the genitals, resulting, in the main, from traction of thedis- 
placed Tiscera on adjoining parte. The hernial sac is composed 
of the amnion and the peritoneum, and its contents are con- 
volutions of the intestines, though other orgaiis are sometimes 
included to such an extent as to leave the abdomen nearly 
empty, i 

Calcareoits Deposits have been found inthecordsof fffituscB 
presenting evidences of syphilis. 

Stenosis of the VESSELS.^-Atheroma, and consequent 
thrombosis, have been known to give rise to stenosis of the 
ambilical arteries. In syphilitic foetuses, chronic phlebitis, with 
the new connective tissue developed in connection with it, may 
produce stenosis of the umbilical vein, and occasionally of the 
arteries. 

Anomalous Insertion. — Anomalies in the distribution of the 
vessels of the cord are often met. The insertion may be int» 
the margin instead of the center of the placenta, and then tbe- 
latter organ is known as battledore placenta. The cord i» 
sometimes found to separate before reaching the placenta and 
spread its vessels on the membranes, in which case it is known 
as inaertio valamentosa. 

Pathology of the Fcetus. — Comparatively little is known 
of the diseases to which the foetus is liable, but enough has been 
observed to teach ub that it may suffer from nearly as great a 
variety of pathological states as the young child. Death of 
the fujtus is Id such a manner often compassed. Following are 
some of the ailments which are known to attack the unborn : 

Inflammations of various parts have been known to ezist„ 
the peritoneum being a common seat of attack. The pleura 
and lunge have often been found involved. 

Fevehs are transmitted from the mother, and the foetua 
doubtless at times becomes idiopathically their subject. When 
the mother suffers from smallpox, she usually miscarries, and 
the foetus is most commonly observed to be infected. 

Syphilis is a diseaae from which the fcetus does not escape. 
Premature labor and foetal death are common resulte of the 
affection. The evidences of involvement of the offspring are 
not always patent at birth, but a careful examination post 
partum, or a thoughtful consideration of the symptoms subse- 



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Pathology op the Ovum. 203 

qaently developed, in living childreo, disclosee the true disturb- 
ing cause. 

The Bensitiveness of the fcetUs to certain poisons is sbowu in 
the numerous reports of lead and malarial poisoning. M, Paul 
collected eighty^ne cases in which there was evidence in dead 
fcetuses of the toxical effects of lead. In some instances the 
foetus was affected while the mother escaped. 

Among dropsies, hydrocephalus is the most frequent, but 
not the only, form met. The fluid distends the ventricles, and, 
OB a result, there is expansion and thinning of the cranium, the 
bonee of which are widely spread. Ascites and hydrothorax 
ar« now and then met. The following foetal diseases, among 
others, have been reported : Pleurisy, Bcirrbas, tubercles, pneu- 
moDta, calcareous deposits, peritonitis, scariatina, measles, 
enteritis, worms, calculus, jaundice, rickets,caries, necrosis, con- 
wlsions, hemorrhages, et«. Tumors of various kinds, and in 
different situations, have been observed. Tamier reported a 
meningocele larger than acbild's bead, and large cystic growths 
have been found attached to the nates, thorax and other parts. 

The child may suffer from the effects of violenck. Extensive 
lacerations, and contusions in various parta of the body, have 
been observed. lutra-uterine fractures have resulted from 
injuries, but there is no doubt that spontaneous fractures do 
occur, and are nearly always multiple in the same foetus. 
Chaussier speaks of a child bom in 1803, after a rapid and eaay 
labor, who had forty-three fractures, even the cranial bonee 
being involved. He also repoi-ts a case in which a child was 
bom after an extremely short and easy labor, presenting feeblR 
signs of life, and living but a short time, upon whom were 
found one hundred and thirteen fractures. The causes of such 
anomalies are not well understood, but are supposed to be due 
to arrested development of the bony structures. 

Intra-utebine Amputations. — Another phenomenon equal- 
ly remarkable, is that of amputation of fcetal extremities. 
Numerous cases of limbs deprived of a portion of their con- 
tinuity have been reported, in which the stump presented 
evidences of traumatism. Medical records show cases in which 
the whole four extremities were wanting, as shown in figure 13 (i. 

The cause of these conditions merits much attention. Such 
amputations are commonly explained by assuming that they 
are the results of gangrene; but Reuss holds a different view. 
It does seem that the gangrene theory is untenable, iiias- 



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204 Pregnancy. 

much a8 such a degenerative change ranoot take place iii the 
aljseuce of atmospheric air, though there may be an equally 
destructive process. 

A certain number of these amputations probably result 

from coiling of the cord about the extremities; and another 

of the most common causes is the constriction of fibrous 

bands or folds of the amnion. But in many instances none of 

these causes have been 

at work, and heuce their 

etiology is shrouded in 

obscurity. 

Foetuses who suffer 
intra-uteriue amputa- 
tion are usually stiD- 
bom. 

The amputated part 
issometimee found lying 
in the amniotjc cavity, 
and follows the child in 
' delivery. More frequent- 
ly the amputated por- 
tion dinintegrates and 
disappears. But this 
•ean occnr only when 
amputation has taken 
place at an early period 
of development. When 
separation is effected at 
alaterperiod.the part is 
not only found, but cica^ 
trization of the stump is 
often incomplete. Rudi- 
mentary toes are found 
on the stump, which are believed by some to be aboi-tive at- 
tempts of nature at reproduction of the lost parts. 

Monstrosities.— Deviation from the ordinary process of de- 
velopment, results in the productionof monsters. Thesubject is 
one which might very properly here be considered at length, but 
it is so extensive that we shall attempt toglveouly its outlines. 
Our observation in this direction has been very limited, and 
we follow Charpentier, who, in turn, quotes mainly from Saint- 
Hilaire. 



Fig. I1«,— Intra-uterine Amputations. 



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Pathology of the Ovum. 205 

Monsters are divided into two grand claesep, namely, simple 
tind composite; the former being made up of elements of a 
'Single foBtua, and the latter of elements of more than one. 

SiMPLK MoNSTEiiB. — In these there is either absence of indi- 
vidual elements, oi" unnatural distribution of them. They have 
been divided into three varieties, nq,mely, autosites, ompha- 
loHites and parasites. The first are capable of sustaining life 
for a time after birth; the second can live only in the uterus; 
and the third are morbid productions, having their seat either 
in the uterus or ovaries, 

^utosites have been divided again into varieties according 
to the character and seat of the abnormal development. Ectro- 
nielic foetuses are such as lack one or 
more limbs, but do not include cases 
of intra-uterine amputation. Pho- 
-comeles are those wherein atrophy is 
limited to the middle segments of the 
limbs, the feet and hands being well 
■developed. Hemimeles are foetuses 
with rudimentary feet, hands, and 
forearms or l^s. Ectromeles are 
those wherein arrested development 
includes all the segments to about an 
«qual degree. In symmelic fcetuses 
there is a anion of two limbs of the 
same kind. They are symnfelic when 
the fused legs have only one foot, 

Sirenomeles are where the fused limbs Fm- 117,— Aoephalic Faatut. 
terminate in a point without a foot. Celosomic foetuses have 
more or less complex eventration of the genito-urinary organs 
and various viscera. These aregiven various names according 
to the character of the abnormality. 

Exencephahc fastassa are characterized by badly formed 
brains which are only partly enclosed by the skull. They are 
■divided into notencephalic, proencephalic, podeneephalic, hy- 
pereneephalic, iniencephalic. Exencephalic fcptuses are charac- 
terized by the presence of the brain almost entirely outside the 
ukull. Pseuden cephalic f(Btu"e8 are entirely wanting in brain 
matter. The vault of the skull is absent. The superimposed 
mass is email, of a deep red color, provided with interlacing 
vessels, separated only by debris of brain matter, Anence- 
phalic foetuses differ from the last named mainly in the absence 



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20tt Pregnancy. 

of the fuDgoid tumor. There is arrest of development through- 
out the entire vertebraPeanal. Derencephalic foetuaee differ from 
the anencephahc in the absence of so extensive a fissure of the- 
vertebral canal. 

Cyclocephalic faituses are anomalous in the absence of naeal 
appendages, and in misshaped eyes. These are often associated 
with other abnormalities. Five varieties have been described : 
ethnocephalic, ceboeephalic, rhinocephalic, cyclocephalic (true), 
atomocephalic. 

Octocephalic frntases. — These are derivatives of the cyclo- 
cephalic, with more marked tendency to atrophy. Their most- 
characteristic feature is an approximation of the ears. Five- 
varieties are described: sphenocephalic, octocephalic, edoce- 
pbalic, opocephalic and triocephalic. 

" Omphalogites. — There are many varietaes of these, and, in. 
view of their variety, bot a brief mention will be made of them. 
Paracephalic fcetuses are those in which the characteristic 
feature is the head, which is only a mass at the upper part of 
the trunk. Acephalic f<£tu8es have uo head, bnt a mere anatom- 
ical trace of it. Antdic foetuses have sometimes been called 
Bcardiac. They constitute almost an indeterminate mass ot 
varying form. They are termed parasitic. 

Composite Monsters. — There are many varieties of these.. 
They are twins practically complete, with separate organic ac- 
tion, but with united bodies. When joined back to back, they 
are called pygopagi ; when united by the heads und look in the- 
same direction, they are termed metopagi; and when joined 
head to bead, but facing in opposite directions, they are known 
as. cephalopagi. Monomphalic Itetuses are united at the 
trunkal surfaces, and present the following varieties : xipho- 
page, sternopage, ectopage and hemipage. 

SjnephaJic Fwtuses. — In these there is fusion of the heads. 
They are always of the same sex. Following are the varieties : 
janiceps, myopes and synotes, 

MoDocepbalic Fcetuses are those in which one head, without- 
trace of union, surmounts two bodies. 

Deradelpbe. — In these the bodies are united above theumbili- 
CUB, and separated below. If there are four pelvic limbs and 
two thoracic, the monstrosity is termed thoradelphe. Iliodelphe 
are those with one head and neck, two thoracic limbs, one body 
below the umbilicus, and four pelvic limbs. Synadelphe are^ 
those with one head, single trunk, four arms and four legs. 



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Pathology of the Ovom. 



207 



Syaomic Fatuaea. — Id theee there is fusion of the two trunks^ 
but the heEuls arenot iDVoIved. PBodymes have a single pelvis 
and two lower limbs. XyphodymeB have a fusion involving 
likewise the lower part of the thorELX. In derodymes fusion of 
the bodies ia throughout the entire 
length. 

MonoBomic Fcetases.—ln these 
there are two heads npon a single 
body. The varietieB are, atlo- 
dymes, miod.vmes and opodymes. 

Complex Parasitic Monsthobi- 
TIE8. — Here there is fusion of two 
beings, but one haii undergone such 
arrest of development that it could 
not sustain independent existence. 
.They are exceedingly rare in the 
haman species, and do not deserve 
extensive mention in a work of this 
character. Among the varieties are 
heteropage, heterodelph, hetero- 
dyne, heterolicus, polygnathus, 
epignathos, hypognathus, aug- 
nathus, pygomelus, gastromelne, 
cephalomeluB and melomeius. 

Death and Retention of the F(etu8.— Expulsion of the 
fbetus does not, in all cases, immediately follow death. If the 
placenta does not separate fixtm the nterus, its vitality may 
remain, it« development continue, and expulsion thus be de- 
layed. When the 
placenta does be- 
come separated, 
whether as cause 
or effect of foetal 
death, retention is 
probably due to 
diminished irrita- 
bility of the refiex ^'•*''' ■'^^ *"'* 120.— MonoKunata. (Cbarpentier.> 
nervoas centers which preside over the aterine energies. Re- 
tention due to uninterrupted utero-placental relations, ia rarely 
prolonged beyond the ordinary period of utero-gMtation, 
while retention referable to diminished reflex irritability may 
be indefinitely protracted. 




Fio. 118.— Pygopajti. (Char- 
pentier.) 





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308 Pbeonancy, 

Whea the fcetna is retained, and' the membranes continue 
intact, themost important changcHare mummification, macera- 
tion, and calciflcation. If the membranes are broken before 
or soon after fcet>al death, mummificatioD may reeult, or cal- 
careous d^eneration follow. If air gains entrance into the 
uterine cavity, putrefactive changes are apt to take place. 
Mummification having b^un, putrefaction does not set in. 

Putrefaction. — This cannot take place unless air finds 
entrance to the uterine cavity. The conditions then met 
are those most favorable to its development, namely, mois- 
ture and heat. It often proceeds with great rapidity, so 
that surprising changes occur within a few hours. McGlintock 
says be has observed the abdomen become quite tympanitic be- 
fore delivery in cases where death did not occur until after the 
beginning of labor. The changes resemble those which take 
place in the body of a person who baa drowned : i. e., the abdo- 
men swells with ga«, the deeper tissues of the body become 
'Oedematous, the emphysematous connective tissue crepitates 
when pinched, and a horrible odor is emitted from the body. 
■Sonietimee the uterus becomes distended by the gas generated 
in the process of decomposition, emitting it at intervEils, which 
■condition is known aa physometra. The woman sufTers chilli* 
nees, elevated temperature, and a sense of general illness, and, 
unless relieved from the source of infection, the process may 
terminate in death. 

Mummification. — It becomes necessary to explain what is 
meant by mummification, and what are its causes. "At the 
second period of intra-uterine life is a particular change, entirely 
distinct in form from those which precede or which follow. The 
embryo, endowed with greater force of resistance, provided 
with an oiinseous frame, frail and incomplete, it is true, but 
nevertheless solid, composed of newly organized elements, which 
already have a fixed texture, does not liquefy ; it preserves its 
first form, exc^t its volume, which suffei^s a proportional re- 
duction. This is mummification, withering, emaciation, con- 
traction, drying up of the authors. The tissues, yet soft, are 
■condensed under the influence of the prolonged maceration in a 
saline fluid ; they are diminished in volume, reduced to athinner 
layer, in a word, shrivelled up. The color also changes very 
rapidly; it becomes dull, gray, yellowish, tarnished, and as if 
■cachectic, contrasting clearly with the normal color, a brilliant 
<lark rose. The quantity of sangnineons fluid exuded into the 



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Pathology of the Ovum. 209 

different Berous cavities is very small, very dark, and the rose 
color of the eye-humors hardly marked." 

It is most frequently observed in foetuses with inadequate 
blood-supply, a condition growing out of constriction of the 
umbilical cord. From preference, it attacks those dying during 
the middle stages of gestation, and especially a single fcetus in 
twin pregnancy. When one mummified and one living foetus 
occupy the ut>erine cavity, gestation usually preserves a toler- 
ably normal course and expulsion of the living and the dead ia 
deferred until theclose of theordiuary period of utero-gestation. 

Maceration. — ThiH is a process of slow deeom position, and 
by it an embryo may be entirely dissolved. A foetus, on the 
contrary, preserves the outline of its organs and general form, 
but granular degeneration and disintegration of its anatom- 
ical elements takes place. The epidermis first yields to the 
process. It rises in the form of blebs or vesicles, which fill with 
a reddish, sero-sanguinolent, or clear serous fiuid. There is 
also infiltration of the corium, which has a brownish-red ap. 
pearance resembling the lees of wine. The subcutaneous areolar 
and adipose tissues are also oedematous. There is no odor, no 
gas, no cadaveric tint, and the process never gives rise to septic 
symptoms in the mother. Viewing the body as a whole, it is 
observed to be flaccid, and, from its oedematous condition, may 
be molded by pressure into grotesque shapes. (Edema is most 
apparent over the cranium, abdomen, feet, hands and sternum. 
The cranial sutures are separated, the articular surfaces pushed 
apart, and the periosteum is detached from the long bones. 
Dark blood is fonndinthe vessels, and bloodyseruni in the serous 
cavities. The brain is pulpified, and all the visceraaresortened. 

Moles. — Of these, one variety — the hydatidiform — has al- 
ready been described, and of the other varieties, but a brief con- 
sideration will be required. Mules have been divided into two 
general classes, one of which is termed false, and the other true, 
the element of distinction between them being that the true 
mole is always consecutive on impregnation, and' the false is 
not. Hence, in a work of this character and scope, we shall 
consider the former class only. 

True moles are divided into three general varieiies, namely : 
1. The mole of abortion, or the blighted ovum. 2. Thecame- 
ons, or fleshy mole; and 3. The hydatidiform mole. The last, 
of these having been described, the flrst two varieties only re-. 
main for consideration. 



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210 PRUONANCY. 

Tbe Mole of Abortion, or mola eanguiDOBa, is the blighted 
ovum, within which post-mortem changes have just begun, and 
the mans has not yet been materially altered, save in the direc- 
tion of extravasation of blood and dissolution of the embryo, 
whose vital resistance, until death, had been sufficiently potent 
to preserve its integrity. Many years ago Smellietook occasion 
to say that ''should the embryo die (suppose In the first or 
second month), some days before the ovum is discharged, it 
will sometimes be entirely dissolved, bo that when the secun- 
dines are delivered there's nothing more to be seen. In thefirst 
month the embryo is so small and tender that the dissolution 
will be performed in twelve hours; in the second month, two, 
three,' or four days will suffice for this purpose." In case foetal 
death occurs in more advanced pr^nancy, degenerative and 
disintegrative changes are wrought in a relatively short period, 
tuid the mass, when expelled, may not disclose its real character 
except to closest scrutiny. 

Tbe Fleshy Mole. — The conditions which giverise to the forma- 
tion of the carneouB mole are substantially as follow : As the 
result of some sudden or violent exertion, one or more blood- 
vessels give way, and as the blood is extravasated, it acts in a 
mechanical way to influence separation of contiguous parts, 
with most> potent results. The embryo perishes from wrLnt of 
nntritive supplies. A similar effect may be produced by apo- 
plexy of the placenta, elsewhere considered. Extravasation is 
sometimes between the chorion and decidua, and even within 
the amniotic cavity, and results in embryonic death. 

Consecutive on such occurrences there is, most frequently, 
speedy expulsion ofthe ovum, but occasionally it remains for a 
considerable time, and undergoes certain change by which it in 
converted into a fleshy mass. Theeffused blood becomes decol- 
orized, the blanching proceeding from center to circumference, 
and, according to Scanzoni, the Hbrin is transformed into cellu- 
lar tissue, by which means communication is established be 
tween the external lining of the ovum and the uterine tissues,— 
and thus further development is made possible. It is highly 
probable that complete separation of the ovum from the uterus 
never takes place in these cases, but, through the adherent 
parts, vascular communication is continued and amplified. De- 
generative changes take place chieflyin the decidua vera, though 
the chorion and amnion are sometimes more or less involved. 

These masses seldom exceed an orange in size, but their full 



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Patbology of the Ovum. . 211 

development, from the very nature of the case, is quite rapidly 
aocomplished. They may continue in utero for three or four 
months, but eventually the organ is excited to contractioa, and 
expulsion takes place, unattended, as a rule, by any remarkable 
symptoms. 

Little need be said with reference to the treatment of such 
«ases. There are a few remedies which have the reputation of 
promoting the e^pulaion of moleH, but whether the reputation 
has been fairly earned is a matter which we have not thus far 
been able to determine. The truth is, that, apart from the 
hydatidiform mole, which was previously considered, these de- 
generate products of conception are not often recognized, and 
hence women who are the subjecta of them rarely fall under 
treatment until the process of expulsion is well under way. 
When uterine efforts at expulsion have once strongly set in, the 
form of promotive treatment, described under the head of abor- 
tion, is then applicable. We should use such means, whether 
they be fingers, instruments or drugs, as will safely hasten the 
process. For specific indications we refer to the chapter on 
abortion. If, from the symptoms, we should be led to believe 
that the uterus contains a mole, we may safely, and efTectually, 
resort to such remedies as cakarea carb.,sihcea,, sulphur, sepia, 
caulophyllum, sabina, aecale, and sometimes others, according 
to specific indications. 



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DISEASES AND ACCIDENTS OF PREGNANCY. 

When we reflect upon the profound impresBionH made on the- 
female organism, and the extensive changes wrought in it by 
pregnancy; and furthermore, when we recollect that this con- 
dition exempts a woman from few of the ordinary ills of hfe,, 
we shall ceaae to wpnder that there is a pathological, as well 
as psychological, side to the subject. 

The Hygiene of Pregnancy. — At the risk of transposing- 
the conventional order of discussing pathological states, we- 
have chosen, at this point, to offer a few observations on the- 
general management of pregnant women. 

The general health is frequently already disturbed, and the- 
system in an enfeebled state, when pr^nancy is established. 
The woman at once enters on the trying experiences of early 
gestation, and, attributing nearly all her symptoms to the 
physiological changes being wrought in her organism, viewing 
them also as in great measure essential features of her con- 
dition, she is prone to neglect proper attention to hygienic 
rui^. Though the advent of pregnancy find her in excellent 
health, she is extremely liable, while under the influence of sub- 
sequent ill-feeling, to neglect proper precaution in the way pf 
attention to saiiitarj' details which would materially mitigate 
existing suffering, and aid in preparing her for an easy and safe 
termination of gestation. 

We have seen many women so overcome by the nervous dis- 
turbances and gastric ailment-s of the early part of preg- 
nancy, as to seek close conflnement at home, and sometimes 
even to take to their beds. This, of course, isaltogether wrong. 
At that very time, fresh air and moderate exercise are of the 
greatest value. Those who spend their days mainly in the open 
air, and their nights in well-ventilated rooms, are tided over the 
distressful weeks of pregnancy in greater comfort than those 
who pay no regard to such sanitary essentials. Throughout 
pregnancy a woman ought to spend as much of her time in the 
open air, without walking or riding to the extent of produc- 
ing excessive fatigue, as the condition of the weather will per- 
mit. The health and strength of both mother and child are- 
greatJy promoted by so doing. 



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Hygiene. 213 

The'diet should be re^lat«d to suit the peculiar require- 
ments and Bensibilitiefl of the woman, and ought to embrace 
most nntritious and easily-digested articles of food. It ie uot 
our purpose to give a complete bill of fare, but to indicate cer- 
tain articles which most commonly agree with the requirements 
and the peculiar sensibilities of women under these trying cir- 
cumstances. Patients are differently constituted, and have 
been so variously trained with respect to gastronomies, that 
many will prove heedless of our best advice, even though made 
emphatic. Some of them assume that it is a matter of no con- 
sequence what they eat, while others have derived from their 
friends or relatives certain harmful notions which they do not 
care to give up. 

Certain articles of food are peculiarly suited to the condi- 
tions which prevail in the early part of pregnancy which would 
be liable to disagfee'in late gestation. In the early weeks the 
gastric symptoms are chiefly nausea and vomiting; while in the 
latter weeks they ai*^mainly those growing out of compi-ession 
and a changed character of the gastric secretions, puring the 
early period, unless the stomach is unusually sensitive, women 
may choose their food from among the following articles: 
mutton-broth, chicken-broth, oysters, clams and fish. When 
they have theretofore agreed, the following may also be eaten : 
beef, mutton, chicken, game, ^igs, stale bread, oat meal, rice, 
baked potatoes, spinach, macaroni, greens, celery, green peas, 
lettuce, asparaguH, oranges, grapes, and stewed fruit. Desserts 
should, in most Instances, be avoided. 

There are doubtless many harmless thin^ not included in 
this list, while, on the other hand, many of those which do ap- 
pear will not in all cases prove innocuous. In late pregnancy, 
as we have before said, compression and a changed character of 
the secretions constitute the most distressing factors of the 
gastric symptoms, and the diet should be modified to meet ex- 
isting conditions. Very likely the upward pressure of the 
enlarged uterus, in interfering with proper action of the 
stomach, and sometimes even changing its fonn, has much to 
do with the woman's discomfort. But even here, careful atten- 
tion to diet will go a long way towa.rds relief. At this period, 
all articles of food which will increase the fermentative ai-tion 
soeaaily set up, ought to be avoided. Such are mainly those 
containing starch, sugar and fat. Some patients derive con- 
siderable benefit from indulgence in lettuce. Aerated bread, in 



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214 Pregnancy. 

preference to all other, ought to be eaten. In considering 
various pathological states to which the pr^poant woman is 
liable, we may have occasion to say something further od this 
subject. 

The pregnant woman requires not only an abundance of 
fresh air and good food, but also a certain amount of physical 
exercise. It muBt not be violent, nor carried to the production 
of excessive fatigue, as thus only shall we build up rather than de- 
stroy the best effects. Walking in the open air and riding in 
an easy vehicle, are conducive to good digestion and refresh- 
ing sleep. Although it is not commonly recommended, we 
truly believe, that carefully r^ulated calisthenics are decidedly 
beneficial. These ought to include breathing exerases, in which 
abdominal respiration is employed but not overdone. In this 
way all the muscles of the body can be invigorated and pre- 
pared to do good service in the propulsive efforts of labor. By 
abdominal respiration the abdominal muscles are given 
strength and tone which they will not otherwise acquire, — an 
important consideration, as we can see when we recall the part 
these structures play in the propulsive act. In women who 
hsrve menstruated with regularity, it is well to regulate physical 
exercise so that it will not be excessive at what would be the 
menstrual period but for th'> interruption occasioned by preg- 
nancy. This precaution derives special emphasis from the 
peculiar proneness to miscarriage at the completion of 
monthly cycles. 

Kexual indulg:ence, always moderate, ought, during preg- 
nancy, to be interdicted at the recurrence of these periods. 

The free but judicious use of water is beneficial. Frequent 
sponge baths, followed by brisk rubbing, contribute to the 
vigor and tone of the general system. They should be taken in 
a warm room, and, in case of feeble women, ought to be given 
by an attendant. The vaginal douche may be employed, but 
the stream should be-feebie and the quantity of water mod- 
erate. 

The mind of the pr*«j:nant woman deserves even more atten- 
tion than the body. It is highly important that her surround- 
ings l>e of the most agreeable nature, and the mind thus 
metintained in the greatest possible state of tranquillity. When 
left to herself she is very apt to fall into morbid moods, and, at 
times, to sufier distressing mental perturbation. It lies upon 
the physician and the friends of the woman, as an obligation. 



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Diseases and Accidents. 215 

to show her the bright side of life, and to maintain a cheerftil 
and hopeful spirit. Primigravidee are often astoniahed to find 
labor so painful. It is to them a revelation, but a revelatioD 
which should not be made in advance. "Sufficient unto the 
-day is the evil thereof." It is far better to fill the mind of the 
pregnant woman with bright images and agreeable prospects, 
since bj such mana^ment the tedium of gestation becomes far 
more bearable, and theoutcome much less distressful. If possible, 
prevent her from being brought into contact with women who 
take exquisite delight in harrowing the aouls of unsophisticated 
young married women just entering upon maternity with a re- 
H»tal of the perils and suffering which await them at parturition. 
If despite the most judicious management our patients in early 
and middle pr^^ancj do become depressed and disheartened, 
they ma}' be indulged in a pleasant trip by rail or other easy 
■conveyance, to home or friends, and thereby, for a time, be 
^tten oat of the monotonous cycles of ordinary domestic 
life. 

The entire period of utero-gestatiou to some women ia one 
of physical and mental distress, and from it they finally emei^ 
with a sense of joy akin to that experienced by the prisoner 
who is set free after long confinement. The ailments from which 
they suffer are various, oftentimes relievable by medication, or 
a change of scenery ; while in certain Instances they cannot be 
made to give way, though every intelligent effort be put forth to 
anbduo them. 

Vrinarj Tests. — At varying intervals in the latter part of 
pregnancy careful tests of the urine ought to be made, both as 
to quantity and constituents. Diminution of the diurnal ex< 
cretioD usually precedes albuminuria. Various conditions, 
amoDg which are atmospheric temperature and the amount of 
fluids drunk, have an important bearing on the quantity of 
urine voided, and these should be given due consideration. The 
presence of any albumen, or a diminution of the quantity of 
urea much below 500 grains, in a woman weighing 140 pounds, 
should be regarded with suspicion. 

Derangements of the Digestive System.— The most 
prominent derangements of the digestive functions, referable 
chiefly to sympathetic irritation, are kausba and voMrriNG. 
Thev are the common accompaniments of pregnancy, and un- 
der ordinary circumstances can hardly be considered as ailments 
requiring medical attention ; but occasionally they are so ex- 



216 Pregnancy. 

ceesive and long continued as to lead to inanitioD, extreme 
debility, and even death. Veit attributes the uncontrollable 
vomiting of pregnancy in many cases to endometritis. Id some 
cases the sickness is limited to the morning hours, at which 
time the smallest quantity of food is rejected, while later in the 
day it may be borne with impunity. From these circumstauc8» 
the uauBea and vomiting of pregnancy have been designated 
" morntDg sickness." In other cases, the woman feels constantly 
sick, and the mere smeU of food may bring on a paroxysm of 
vomiting. 

These distressing accompaniments of pr^,^ancy are not 
experienced by all women, but about forty per cent, of them 
escapesuch disturbance altogether. They usually begin about the 
sixth week, and continuetill the closeof the third month. Some- 
times, however, they immediately follow conception, and con- 
tinue until the end of pregnancy, while in other women they do 
not appear until the patient has reached the latter months of 
gestation. 

It is surprising to observe how severe aud protracted may 
be such gastric disturbances in some cases without producing 
emaciation or excessive debility, while in other instances the 
vital forces are thereby brought to a low ebb. Grave cases are 
characterized by a dry coated tongue, pallor aud distress of 
countenance, excessive nervous irritability, tenderness of the 
epigastrium, great restlessness, and general heat. In worse 
cases there is elevated temperature, with rapid, small and 
thready pulse. Want of nourishment soon reduces the woman 
to a state of extreme emaciation. The breath becomes foetid,. 
and the tongue dry and black. Profound exhaustion, with 
low delirium, follows, and, in the absence of relief, death soon 
ensues. 

The prognosis in nausea and vomiting of pr^nancy, though 
the affection should assume a grave form, is generally hopeful; 
but such cases create much anxiety. Gueniot collected 11 ft 
cases of this form of the disease, out of which forty-six died; 
and out of the seventy-two who recovered, in forty-two the 
symptoms ceased only when abortion, either spontaneously 
OP artificially induced, had occurred. Upon the termination 
of pregnancy the symptoms sometimes at once disappear, and 
the digestive and assimilative processes soon become active 
and vigorous. 

Treatment,— It is of prime importance to regulate the diet 



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Diseases and AcaDENTS. 217 

of women Buffering from morning sickness. A few mouthfiils 
■of food, or a cup of coffee, taken in the morning before rising, 
many times proves of decided benefit. Food should be taken 
in small quantities and at short intervals. Ice cream thus 
-eaten will sometimes be retained when nothing else can be. 
FCoumysa, when fancied by the patient, is a remarkably good 
food. Special articleH can be selected from the list given under 
the head of the Hygiene of Pregnancy. The woman's caprices 
should be considered in the choice of food, but should not be 
allowed to betray one into injudicious selections. The boweis 
■ought, throughout pr^nancy, to be kept open. 

In some cases, where other forms of treatment prove una- 
vailing, and the patients are greatly reduced, a change of habi- 
tation, air and scenery, especially from a poorly ventilated 
house in the crowded part of the city to a rural situation, is of 
the greatest benefit. 

Since it is clear that the nausea and vomiting of pr^nancy 
Are mainly dependent upon changes going on in and a.bout the 
uterus, the attempt has been made to reduce the irritability of 
the organ by local treatment. Morphia, in the form of supposi- 
tories, and belladonna applications to the cervix, have been 
recommended, tbe former being in some ca^ee of apparent 
benefit. The cervix has been burned with caustic, and bitten by 
leeches, in the vain endeavor to overcome the obstinate sick- 
ness. In the latter months, gentle dilatation of the cervical 
canal to a slight degree only, has been attended with beneficial 
results. Dr. Grailey Hewitt believes that in q uite a lai^ per- 
centage of cases tbe disorder depends on uterine deviations, and 
can be cured only by their rectification. This may be true and 
the suggestion should lead to a careful examination in all ob- 
stinate cases. If retroverted, a Hodge, or an Albert Smith 
pessary, properly adjusted, can be safely worn. During: the 
employment of local treatment a woman should be required to 
rest more than usual in the reclining posture. 

Galvanism, in some cases, has afforded relief to distressing 
nausea and vomiting. The current ought not to be directed 
through the uterus, but one pole may lie on tbe epigastrium and 
the other on the nape of the neck. 

Ether spray upon theepigastrium will in someinstancesdecid- 
edly allay these distressing symptoms. 

Production of vesication over the fourth and fifth dorsal 
TertebrflB will often afford great relief. Tbe same may be said 



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218 Pregnancv. 

of the glycerioe tampon, and of the well-fitted abdomiDal sap- 
porter. 

The list of remedies which mar be found useful in this condition 
is long, but there are a few especially prominent. 

Ipecac should be given when the nausea is the predominant- 
Hjmptom attended with vomiting of bilious matters, undigested ' 
food, and large quantities of mucus. 

ArseDicanii when the vomiting occurs after eating and drink- 
ing, and there is faintness, and excessive prostration of the. 
vital forces, 

Nax vomica, for real morning sickness ; bitter, sour eructa- 
tions; vomiting of sour mucus and the ingesta. Also, for ex- 
cessive nausea, with the feeling that she would be better if she- 
could vomit. 

Tabacam, in those caees where there is nausea, with faint- 
ness and deathly pallor, relieved by being in the open air. 
Vomiting of water, acid fluid and mucus. 

PsoriBum is suited to obstinate cases, especially in women 
presenting the psoric diathesis. 

Pulsatilla., especially when the vomiting comes on in the 
evening or night. The appetite is capricious, the woman crav- 
ing beer, acids, wines, etc. Much eructation tasting of the' 
ingesta. Specially suited to mild, tearful women. 

Acetic acid, when there is sour belching and vomiting, with 
profuse water-brash and salivation. 

Colcliicuw, when the following symptom is well marked : ex- 
cessive nausea, even to faintness, produced by the odor of flsh, 
^gs, meat, etc. 

Bryonia, when the nausea and vomiting are brought on or 
decidedly a^ravat^d by the least motion. Teratram album is 
well suited to the same symptom. 

Pbospboric acid, a few drops of the dilute acid in a half glass 
of water, aud a teaspoonful every two hours, is often of the- 
greatest service. Its special indications correspond pretty 
closely with those given above for acetic acid. 

Sulphur. — Nausea, without vomiting, with faint sickish. 
spells during the forenoon. 

Almost every remedy in the materia medica has been recom- 
mended, and we doubt not that there are cases to which they 
are severally suited. 

HvPEREMEsm. — When the vomiting is absolutely uncon- 
trollable — as it will rarely prove to be when the patient fully 



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Diseases and AcciPENTe. 210 

co-operates with her phynician in the effort at cure — and fatal 
results Beem tinminent, there remains as an ultimate resource, 
the artificial interruption of pr^nancy. In considering this ex- 
pedient r^ard should be had tor the clinical fact that, in most 
instances, the threatening symptoms disappear at about the 
close of the third month. It is an operation which is liable to 
sabject the physician to criticism, and, as it is attended with 
considerable risk, it should never be undertaken upon the re- 
sponsibility of a single attendant. 

There seems to be no doubt that some mothers have been 
saved by the induction of abortion in such cases, in all proba- 
bility many have been lost for want of it, while some probably 
owe their death to it. The success of the operation demands 
that it be performed before prostration has become so threat 
that the patient cannot rally. The obvious indication is to 
diminish uterine tension, without delay, and the preferable 
mode of doing this is to puncture the membranes with a uterine 
sound or stiff catheter, and allow the amniotic fluid toescape. 
Prof. C. Braun, of Vienna, reports a ctise of hyperemesis to 
which he was called, in which the woman was supposed to be 
moribund. The physician in charge had resolved on the induc- 
' tion of premature labor as a last resort. Dr. Braun decided to 
bathe the intra-vaginal portion of the cervix in a ten per cent, 
solution of nitrate of silver. This was done and the surface 
quickly dried to prevent further cauterization. An hour after- 
wards the patient enjoyed and retained a meal of roast beef 
and there was no subsequent vomiting. 

Braun says he has never, in all his vast obstetrical practice, 
seen a case of death from hyperemesis. In an obstetrical ex- 
perience extending over many years, we have never seen more 
than two cases in which the symptoms became so uncontrollable 
as to cause us seriously to think of this operation. Further- 
more, we believe that homeopathic literature will show very 
few cases wherein the induction of abortion became necessary 
in order to control nausea and vomiting. In France, where 
abortion is frequently induced for the relief of these symptoms, 
the vomiting is arrested in only about forty per cent, of all 
cases, while t«n per r>ent. of them terminate fatally. 

Other Qastric Dibohders. — Anorexia, or want of appetite, 
and even a loathing and disgust for food, is a prominent dis- 
order of the stomach, especially during the early mouths of 
gestation, but, under the influence of gentle exercise, pure air, 



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220 PBfiONANCY. 

HaliibriouH suiroandingB, and judiciouB 8el«btion of food, it will 
generally disappear. The remedies which are most likely to 
afford aid are the following: 

Nnx vomica, when there in irritability of temper ; exceeding 
seDsitiveneBa to every imprefisioD, and constipation with fre- 
quent ineffectual urging to stool. 

Ipecac when associated with distressing nausea, with, or 
without, vomiting. 

Antimoniam tartarinam affords help when there are vomit- 
ing of mucus, sense of weakness, bad humor and pale face. 

Antimoniam crudem is the remedy when there are white 
tongue, unusual activity of the muciparous glands in various 
parts, and no thirst. This remedy ia pre-eminently suited to 
women who have gastric catarrh. 

Colchicam, with its strong characteristicof extremeaversion 
to the odor, or even the mention, of food, is an excellent 
remedy. There is no thirst 

Other remedies are natnim mariaticum, china, puIsatiUa 
and cyclamen. 

The patient may be annoyed also with acidity of the stom- 
ach and heartburn, for which nax vomica, calcarea, natrum 
mariaticam, salpliar, or phosphoric acid iB\\ke\y to prove effl- 
caciouB. We have oftener obtained relief from arsenicam jod. 
than any other remedy. Temporary relief will often be afforded 
by a swallow of pure glycerine, or a half-teaspoonful dose of 
aromatic spirits of ammonia. Flatulent distension may be 
removed by carbo veg., china, lycopodiam, nux vomica or 
&rgentum nitricum. 

Neuralgia of the stomach is sometimes very distressing. If 
attended with nausea, ipecac will often relieve; if of a cramp- 
ing nature, dux vomica; if the stomach feels as though dis- 
tended with gas, carbo veg., belladonna, or better still, atropin 
au/ph., is often of service. Hot fomentations should be applied 
to the epigastrium. 

The caprices of appetit<',P0 often met, seldom require medica- 
tion, but may serve as valuable indications for the selection of 
remedies in the treatment of other morbid conditions. 

To enable the practitioner to select the indicated remedy 
with greater precision, we have adapted from Dr. George W, 
Winterbum's repertory the following : 



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DiSEAHES AND ACCIDBNTB. 



GASTRIC AILMENTS. 



4aUlt]r, olc. pul. cbin. nux. phoB. ■ul. 

crb. arn. chm. ly. kli-c. nit-a. 

Btm. nat-m. fer. Bul-a.jih-a. tart. 

pet. io. grph. ip. lacfa. bell. amb. 
SlaiTliM. with, ars. ip. ver. phos. 

lacb. bell, tart. col. 
IMaldns, after, arg. vet, pul. ail. bry, 

nuz. am. chin. fer. rhs. chm. ac. 
SaUnc, after, ars. brj. clc. eye. dig. 

lacb. mere, nat-m. nnz phoe. pul. 

Bil. Bul. ver. crb. ammc. con. fer. 

bjo. ly. eep. nit-a. in. atm. pet. 

nat-c. kli-c. io. grph, cbm. an. 

— during, pul. kll-c. mere. ver. ler. 

crb. dig. mag-m. Bar. 

— — relievet, aep. pbos. eaba. 
XraotaUoiw, nat-m. crb. bry. an-t. 

nnz. hep. con. am. aul. thj. atm. 
Terb. chin. alu. ver. bell, kli-c. 
mere, mur-a. sep. sta. pet. grph. 

— bitter, nux. an-t. sep. chin. pul. 

aro. bell. ver. scil. gra. mere. 
Bul-a. thj. bry. 

— hamijig, io. ph-a. cth. 

— eonttant, lach. sul. coo. 

— empty, sul. con. bry. hep. crb. nux. 

lacb. cauB. phoa. sep. ver. ammo, 
bell. sta. mere, kli-c. nat-c. rha. 

—fetid, sul. 

— food, lasting of, put. crb. ail. an-t. 

con. pboB. ammc. cbin. amb. thj. 

nat-m. ly. chel. 

— greaty, crb. 

— ineffectual, pfaos. caua. con. amb. 

Bul. crb. pul. 

— lovd, behhing, con. pet. 

— painful, phos- sep. pet. cocc. saba. 

orb-a. 

— rancid, thj. 

— relieve!, lacb. 

— tall, Bta. 

— lour, But-a. nat-m. chm. crb. alu. 

nui, ly. phoB. amb. pal. kli-c. 
pb-a- sn. to. asa- chin. 



SraotaUona Meompaalvd toy breathitig 
impeded, gra. 

— chett pain. sn. 

— eotic, chm. 

— hawking, cup. 

— improvement, lacb. 

— gtomach-aehe, phoa. 

— throat conttricted, nuj. caue. 
Bmctatloiu ooonrrlas, 

— drinking, after, tar. ars. mez. 

— eating, vhen, nat-o. pet. ol. Bar. 
after, nat-m. bry. chin. ars. crb. 

ver. pboB. lacb. mere. nux. sil. 
clc. tbj. Bul. 

meat, ro. 

— hytteric persons, ru. 

— milk, after, nat-m. eul. chin. 3sn. 

— morning, early, val. crc. , 

— night, lach. buI. 

— smoking, Bel. 

Bvtniiif, in, pul. phos. eye. an. bII. 
lat, from, pul. ctb-a. aep. dra. eye 

thj. nit-a. 
Heartburn, clc. sul-a. cap. nat-m. 

am-c. saba. zn. amb.io. ly. crc. 
Hsartlnmt. eontinaally, lob. 

— mealt, during, mere. 

— sugar, from, zn. 

HlosonCh, ign. ac. atr. byo. nus. pul. 
sul. bov.bell. bry. am-m. mag-m. 
nus-m. eep. coB. clc. are. cup. 
mur-a- nit-a. ver. grpb. mere. 

— painful, teu. 

— spasmodic, nux. str. bell. 

— violent, nux. ly. cic. 
Hiooonsli ooenrrlns, 

— breakfast, after, zn. 

— drinking, after, lach. 

— eating, while, mere. teu. 
after, ver. hyo. cyc. mere. 

— evening, in, Bil. 

— motion, causes, crb. 

— n("jjA(,ar8. 
Loatblns. gra. sen. rat. mag-c sec. 



lau. a 
- beer, after, mur-a. i 



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LoatMns — Con lintttd. 

— mealt, afUr, ip. sara. 

— night, rat. 
■Uk. from., clc. aul. 

MonUnc, tarly in, dig. sal. sil. nux. 

grph. an. crb. arr. kr. bar. ly. 

phoa. chm. lach. 
llBO<nu ditordert, pul. ang. chin. 

mere. aul. cap. bell. fp. ver. rha. 
BaoMa, ip. an-t. nuz. tart. aul. 

Dat-m. hep. orb. eil. ver. ign. 

grph. an. caue. pbos. sta. alu. 

arn. bell. bry. chin. dig. lach. 

mere. ph-a. ru. Bcp. Btm. eul-a. 

■ec. nit-a. pet.kli.cup.amb.bar. 

kr. 
-- afternoon, in, ran. 

— air, in, ang. bell. 
rtlievtd, ly, 

— hreakfiut, after, chm. 
btfort,ip. 

— coffee, after, chm. cap. 

— cold, effecU of, cocc. 

— conitant, frequent, ip. nux. crb. ail. 

1;. nat-c. kli. ver. Bcil. mag-m. 
ph-s. 

— drinking, when, nux. 
— i — relieve*, phoa. 

eating, after, nux. pul. aul. Ter. 

aep. rha. grph. phoa. nat-m. eye. 

tDA«n, kli. ver. pul. £er. crb. 

coco. 

— — reiietiM, aep. kli. phos. 

— eggt, odor of, cloh. 

— eEening,{n, pul. eye. 
— egei, when elniing, thei". 

— fat, caueei, pul. orb-a. dra. gep. 
a» /rom, eye. tar. 

— injuriet, after, rha. bry. arn. pul. 

ehel. 

— mitk. from, clc. 

— morning, early, ip. nuz. ail. an. 

ver. grph. erb. am. dig. kli. aep. 
phoa. 

— mod'on, ara. pul. kli. crb-a. 

— moi»e,frigkt, ther. ign. 
—^riding, from, cocQ. pet. aul. nux-tn. 

aep. sta. 

— »intting,ii!hen, led. 



— throat, fell trt, ph-a. 

— walking, when, kli. 
in air, alu. 

— wine, from, an-t. 
Nanasa aeoompanled br, 
~ angtiitik, kli-c. ign. 

— backache, pul. 

— bittemet* in mouth, bell. 

— ehillineu, ang. pul. kr, 

— colic, pul. cup. 

— df/tpnaa, ang. 

— ear», humming in. Be. 

— eruetationi. cocc. Be. spfg. 
— face, pale, pul. 

gray, mag-m. 

hot, ang. 

red, Ter. 

— fainting, arn. bov. ly. 

— hunger, epig. mag-m. 

— loathing of food, with, bell. hell. 

lau. 

— lying dovm, when, ara. ph-a. 

— thirtt, ver. 

— water in mo\Uh, flow of, pet. 
Hlsbt, at, are. rha. aul. ofain. pboi. 



M, food, crb. phoa. nux. 
lach. aul. ly. bry. tart- clc. grph. 
put. aara. aul-a. zn. bell. Ign. hep- 

— acrid, can. are. tatt. 

— bitter, arn. Bars. gra. nus. te 

— bloody, nux. 

— drink», of. aul. 

— food, of digetted, phoa. aul. ly. 
chm. bry. ign. lach. con. thj. fer; 
nux. mag-m. ctli. 

— green lubttance, ara. grph. 

— milk, of, ly. tart. 

— ealty, aul-a. 

— tovr, phoa. aul. grph. ly. nat-n- 

— tweetigh, ac. p!b. 

— watery, plb- gra. 

— yellow >vbgtance, cic. 
BafnrglUtloD occnrrliif . 

— drinking, after, mere. 
mitk, clc. crb. ly. 



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DiHEASEB AND ACC[DENT8. 



BacttrdUtton OMmxibig— Continued. 

— eating, lach. ver. bry. nux. tan. 

asa. fer. 

— night, cth. 

— Hooping, when, cio. 

— walking, mag-m. 

BstoUnc, ip. bell. nux. srn. Btm. 
mere. plb. bry. asa. tart. op. 
■aba. XD. nat-m. 

— bread cautet.cbin. nit-a. 

Bldlac, twinging, cooc pet. fer. bor. 

etch. lil. ly. Bul. 
Wna food cautei, crb. ac. an. bep. 

lacb. Bul. nat-m. 
IwMta, mere. zn. ac. 
Tomltlas, ars. ip. pul. nux. ver. chm. 

arn. bry. eec. sep. lacb. mere. ly. 

cauB. cln. bell. ign. kli. nat-m. 

nux-m. ail. tart. eul. 

— acrid, ip. 

— albuminout, a.n. jat. ip. ver. 

— bUiout, an-t. nux. chm. pul. ara. 

ac. chin. bry. sep. phos. ip. cln. 
lach. ver. mere. drs. coff. bell. ly. 
aul. col. ign. 

— black, ver. ara. chin. nux. ip. phoa. 

dc. pet. Hul. plb. 
ttaini, ar-n. 

— bloody, ler. ac. am. phoa. fp. pul. 

Btm. are. beU. clc. hyo. 

— bluuA, cup. 

— brovn, ara. bi>. 

— (front, vhitl hat been, ara. ver. ail. 

byo. phoa. ip.ciu. 
— food, of, nux. phoa. buI. ara.ip.pul. 
ail. aep. dtK. cle. bry. chm. aec. 
fer. grph. hyo. 

— gelaHnout, ip. [ac. pet. 

— gretn, ara. ver. pul. lach. plb. col- 

— mncut, are. jat. ip. ver. 

— mtU, Bam. cet. 

— pileh-lilee, ip. 

— iaIt,io. Bil. 

— tliint/, pul. die. bell. dra. aul. ip. 

ara. mere. an-t. ohm. bor. cin. 
fgn. gaj. cin. dig. , 

— (Our, chm. phoa. pul. aul. nux. ara. 

bell. chin. fer. tart, aul-a. caua. 
bor. ph-a. 



ymaUUg^Continued. 

— eweetiih, kr. 

— urinoue, op. 

— violent, cup. lach. ver. tart. ara. 

nux. bell. plb. io. moa. 

— vialery, caua. dra. bry. bell. ip. jat. 

aul. 

— ytUowith, ara. kli. 
Vomttlac aaoompanlad by 

— agony, ara. 

— anguifh, BQg.kli. 

— backache, pul. 

— chiltiitrtt, pul. 

— eoHvuliiont, op, cupi. 

— diarrhaa, ara. ver. ip. belL pboa-. 
' . col. lach. 

— drowtineti, tart. 

— eructatiom, mur-a. nit-a, 
— /ain(injj, clc. 

— f(Btid breath, Ip. 
— face, pate, pul. 

— ttomach-ache, ara. cup. nux. phoa.. 

ver. ip. dig. ac. op. 

— tweat, ip. kli. aul. 
cold, cam. 

— thirit, ip. 

— weakneii, ver. ara. Ip. 
Tomltlas oeenRlac, 

— drinking, after, chin. ver. ara. ail.. 

fer. chm. bry. nux. 

— eating, after, ara. phoa. nux. aul. 

pul. fer. dig. ac. aep. am. ver. sil. 
hyo. ac. ip. 
when, pu]. rha. 

— evening, pul. [moe. 

— morning, early, nux. lach. ara. dra. 

— motion, after, ara. bry. nux. ver. 

ther. 

— night, at, pul. arai fer. phoa. nux. 

Bul. cbin. all. 

— riding, tvinginff, cooe; pet. fer. are. 

— improper food, from, puL ip^. an>t. 

aux. bry. aul. 

— ttooping, after, Ip. 
VaUBK. lach. 

VaterbraiUi, clc. aepi crb. pul. aul. nux. 
ara. nit-a. rha. nat-m. bar. ip. ly. 
bell. pet. 

— aeidt, after, pboi. 



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224 

iraMrbrajli — Cnatinwd. 

— alUrnaU dayt, ly. 

— drinkxTig, after, tep- nit-a. 

— eating, after, ail. lul. 



irttMtnM^b— Continued. 

— evening, in, eye, 

— morning, sul. 

— night, gtpb. crb. 



AeUns, klf-e. ign. con. mere bell. 

nus. aul. sep. 
Aerid/eeltnjT, hep. 
AU*a 171, ««n«« o/ totnething, ere. sng. 
Angnlili, wttA, cbm. nuz. crb. apig. 

— from, ars. chm, eup, nux. ver, ooflf. 

see. cio. str. 
Aslautl^uuJiiChin. crb. nux. 

u /«(ftn!7, jkt. ars. aee. oaua. str. 
r, o/, bell. 
I, wilA, boT. 
BalUMlng. »enie of, ph-a. 
Beaten, at if, euph. Ma. 
Sendlnc double, kal. 

r^iier^a, chm. 

Bmns in, moe. etr. 
BUtMiuH tn, cup. 

— mouth, ly. 

Xloated, an. kli. nux-m. 

Sorlnf , nat-s. >ep. an. 

BnilMd, at if, DUX. aaa. 

XamloK. are. phoe. cio. lacb. nux. lep. 

earn. crb. sul. dig. bry. cap. eapb. 

zn. eec. cth. mere. l&u. nit-a. 

— co'iting hunger, grpb. 

— with vomiting, jat. 



OblUlnHi, with, pul. 
tOutUat. nux. 

OlawUif. aul-a. cocc. orb-a. nux. 
Ctdd feeling, pho«. rhs. chin. cap. ars. 
Bp. cleb. lau. bar. 

— drink! relieve, pho«, 

— from, crb. Ij. caua, aul-a. 
Ctaia. with, cup. col. 

— (Di'lft tpatmt in chett, lep. ver, 
OonitrlcUott, nux. bu). nit-a. aep. alu. 

plat. phoH. 
OMTDBlon, ifnc of, iod. nux. 
Cramp, kli-c. an-t. grph. pul, nat-m. 

olc. byo. caus. atm. 
Orawllug in, lact. pul. 
Oattlng, cio. nat-o. 



OntUnc — Continued. 

— lowardt tpine, aep. 
DaUlltr, olc-p. nat-m. aaba. 
OMpaiT, with, aa-t. 
OlarrliiBa, pul. etm, 
DlaMiuli>&, ly. rat. hell. 

— before eating, cro. 

— lente of mng. 
DnCEliu: in, tente of, mere. 
DtKwiat pain, bry. 

Dyapnaa, nux-m. phoa. rhs. nux. 
Sat, must, grph. 
Znotlona, chm. col. nux. crb. 
TSxa-vtJ feeling, ign. fp. 
Bmotattoni, ars. atm. mag-c. 

— evening, pul. sop. ly. pbos. erb. 
BxtMialon. tente of, mng. 
Ftrmantatioa, in, crc. 
Platnleiica, crb. lach. china. 
FiUHt, after, orb. 

Full feeling, kli-c, chin. nux. lach. kli, 
nux-m. dap. pbos. sul. dig. pet. 
rhe. graph, bar. arn, ly. eye. boy. 
cast. hell. moH. nat-B. 

FnUneai, at from undigeiled food, ko. 

Oaatralfla, nux. orb. put. ac. aul.cocc. 
bell. elc. etm. bis. amme. bry. 
con. ign. ly. aep. nat-o. ail. nux-m, 
mag-c. lach. grph. dap. chia 
chm. cauB. an-t. ar-n. eup. pet. 



— hytteric pertont, ign, gra. mag-c. 

— lou ofjluidt, r-auted, chin. nux. crb. 

— portal congestion, nux. orb. 

— ealt, from, crb. 

Oriplng. Bil. phoa. nux, pul. nat-m. 

8ul-a. caua. clC. 
Oroanlna, moaning, with, nux. ara. 
OnzilliiK, flu. kli-i. an. lob. verb. mens. 

— when drinking, thj. cin. lau. cup. 
Hsat. tente of, ara. sep. chin. 

— head, with, caud. 



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DiBEABEa AND ACCIDENTS. 



22& 



HyaWrle pertont, ign, coce. nux. 

mag-c. 
JwplBff, »mtat\(m of, cro. 
■onlBg, eartjr, oKt-ni. an. eta. nnx. 
M« — a. dig. are. nux. orb. ttm. nat-tn. 

aul. ip. mere. 
mdtt, at, phos. grph. nux. crb. sul. 

WvBlbfingert, vnth, \j. 

HuBbuM, ttnte of, cast. 

PalB in chett, teitk, am. bdI. 

— itomach, clc. nux. am. bry. ver. 

■pig. 
ValpttaUou, wifA, nux. lye. 
Pntoftloat pain, If. ign. hyo. 
tnt M %t upon, when, 1;. bry. gii. nux. 
nat-m. pnl. 
It fool on ground, tvktn, brj. 
*, ly. nux. rhs. aep.bie. nat-m. 
chm. sil. pul. pboB. grph. crb. 
bell. bep. ign. gra. cic. ripfc. 
plat. an. bar. clc. cauB. die. ip. 
lach. far. nat-c. plb, sta. rho. 
»totu,(ufrom, nux. ign. chm. laob. 
mere. aep. spig. 

:e Tbrabblsc. 



Afttling, ip. 
B««Umulmb, cth. [caua. 

Bollluc. Tumbling, phos. crc. verb. bell. 
SenaltlTen*!! to contact, sul. dux. bry. 
clc. ly. laeb^ hep. 

— to pTeimre of clothing, ly. bry. nux. 

clc. iul. hep. spig. 
•OM, pain <u if, nux. bry. lach, 

mteUng in, s«p. rhs. nit-a. bry. clc. 

kli-e. 
Itrlotaie, at if, nux. pbos. 
awallowliic, when, bar. 
Bv«lU&s, tense of, bry. 
Throiiiiliic, al, pul. nux. aaa. eep. 
Tonclwd, wh^n, phos. «ul. bar. nux. ar»_ 

bry. clc. nat-c. splg. mere. cnp. 
TwlaUnc >en»ation, nat-m. 
tnoarattr* pain, crb. nat-m. rhs. 
Tiolant pain«, arg. ver. cup. pboB. hell^ 

lach, plb. Ip. 
TomltlaK, ip. an. ver. nux. cup. pbu. 

op. bry. pnl. dig. 

— relievet, hyo. 

WalUBC, tehile or afttr, sep. clc. pliM^ 
WatOT, o> ij^full of, mil. pbe. 
- « of, ign. dig. 



Ptyalism, or ezcesBive flow of saliva, is frequently a88ociat«(T 
with pregnancy. In a few cases, the secretion has amounted to- 
two or three quarts in the course of the day. The remedies- 
beet calculated to relieve are those which follow : 

BeJ/flrfonoa.— Much mucus in the mouth; great flow of 
saliva; violent con8trict.ion of the fauces; violent constrictive- 
pain at the scrobiculum; long'lasting gastralgia; continual 
pressure to urinate ; passage of scanty urine ; frequent pamage- 
of pale, watery urine; violent pressure and bearing down 
towards the sexual organs ; prensure in the cardiac region . 

Coccnlas. — Running of saliva from the mouth; choking con- 
striction in the throat; ga^tralgia; watery urine is passed in 
large qnantities at short intervals. 

Ctoniom.— Salivation ; faucial and gastric spasms; constric-^ 
tive pain in the stomach with seusation of coldness in thestom- 
ach and in the back; very frequent urging to urinate and 
scanty passage; crampy pains in the lower portion of the 
abdomen. 



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*22Q Pbeqnancy. 

Natram m or. —Constant collection of water in the mouth, 
compelling her to spit frequently; constrictive gast'ralgia 
with sensation of colduesa in the stomach and back; 
pressure in the abdomen every morning; pain as from a load 
in the abdomen, or as though everything would be torn apart 
while walking ; pressure and bearing down from the side of the 
-abdomen towards the sexual organs, in the morning, compel- 
ling her to rest quietly; frequent passage of profuse, hot urine, 
with violent urging, as often as every half-hour, even while 
•drinking less thau usual ; pressive pain in the cardiac region in 
1;he morning, 

iVax vom. — Fi-equent collection of saliva in the mouth; 
-asthmatic, constrictive oppression across the chest while walk- 
ing and ascending; cardialgia and convulsions: constrictive, 
•oppressive pain in the stomach ; continuous pain in t^e stom- 
ach ; frequent ineffectual urging to stool, even after a sufilcient 
evacuation; bearing down in the abdomen towards the sexual 
■organs; painful, ineffectual iit^ng to urinate; increased quan- 
tity of urine, exceeding in amount the quantity that was 
■drunk ; pain in the abdomen and bearing down towards the 
■sexual organs while walking in the open air. 

Secale. — Increased secretion of saliva; severe pressure in the 
^stomach without loss of appetite; ^^tralgia; urination is 
-accomplished with difficulty, with frequent urging thereto; in- 
•crea«ed passage of watery urine. 

Veratrum. — Salivation ; inuch tasteless water runs into the 
mouth; crampy constriction in the pharynx, and gagging; 
■cardialgia; violent pressure in the scrobiculum ; pressure in the 
-cardiac region ; pressive pain in the bladder ; palpitation of the 
heart. 

Kahjod. — 1" has proved efficacious in manyobstinatecases. 

Other remedies arejaborandi, mercurius, and acetic acid. 

Pruritus. — Distressing itching, without visible affection of 
■the skin, occasionally torments pregnant women beyond all 
■endurauee. The affection may be limited to the distended 
Abdominal walls, and, in other cases, to the vulva and vagina. 
It is moat frequently a reflex nervous affection ; atother times 
the result of irritating vaginal dischai^es ; and again the eff^t 
of aacarides. When the vulva and vagina are the parts in- 
volved, the vagina should receive a douche, made up of water 
in which liaa been put carbolic acid, borax or hydrastis, and 
the vulva washed with the same. What some regard as a still 



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Diseases and Accidents. 227 

l>etter wash is aqua mentbee piperitee. If dependent on ascari- 
-dee, a wash composed of an infueiou of tobacco or garlic may 
be used. 

A mild galvanic current, with the anode at the vulva and 
the cathode on the Bacrum, will sometimeB relieve. When the 
abdominal surface is the seat of the trouble, temporary relief 
may be obtained ftvm the local use of chloroform liniment or a 
solution of carbolic acid. The principal homeopathic remedies 
are borax (which should be used both locally and internally), 
coaiam, platina, sepia, graphiteB, petroleum, tarantula, and 
coWnsoiiia- 

It may be that the distregsiiig itching is chiefly in the ure- 
thra, in which case injection of a two per cent, solution of 
cocaiae affords immediate relief. It will require a few, but not 
frequent, repetitions. We have been driven to the use of this 
remedy upon the vulva and within the vagina, in a few in- 
stances. 

Pace-ache.— Neuralgia of the fifth nerve is often experienced, 
and atropin, belladonna, arsenicam or gelsemiuin will gener- 
ally relieve it. Should the indicated remedies fail to afford 
relief, resort may be had to the external application of aconite, 
chloroform or camphor liniment. The continued use of hot 
water is sometimes a great aid; and the galvanic current is 
■often efficacious. 

Cephalalgia. — The remedy may be selected according to the 
following symptoms : 

Bryonia. — Bursting or splitting headache ; dryness of mouth 
and lips. 

Natram mur. — Awakens every morning with a violent head- 
ache. 

Actssa rac— Pain over either eye, or in. the eyeballs. 

Belladonna.— ^nae of great fullness of the head. 

Nax vomica,gel8emiaw, aconite, glonoinum.—Headfeelsmnch 
too large. 

Belladonna, bryonia, oak. car6.— Fullness and heaviness of 
the forehead. 

Belladonna. — Determination of blood to the head, with throb- 
bing headache ; right-sided headache. 

Argent, nit. — Sensation of great expansion, especially of the 
head and face. 

Mereurias. — Pressing headache ^om both sides as if the 
khead were in a vise. 



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328 Pregnancy. 

Pbo8. acid.— Dreadful pain io the vertex aa if the brain were 
crushed. 

Aconite. — Piercing throbbing pain in forehead, worse from 
motion ; brain feels as though it would press out at fore- 
head. 

Kalibicb. — Pain of adull, heavy, throbbingcharacter.maiDt;* 
in the forehead, worse al^r eating. 

Lacbesis. — Beating headache, most violent over the eyes. 

Cbiua. — Throbbing headache after excessive depletion. 

Glonoinam. — Throbbing in the temporal arteries. 

iVux mosehata. — Headache from eating too much. 

Calcarea carfc.— Beating headache, seemingly in the middle 
of the brain. 

Sepia. — Beating headache in the occiput. 

In every case of severe headache in pregnancy the urine- 
ought to be tested for albums, and to determine the quantity 
of urea, for fear that an unpainnent of the renal function lie» 
back of the symptom. 

Insomnia.— Continued nleeplessness is not only distressing 
to the patient, hut it is liable so to reduce her vital energies as 
to render her poorly prepared to undei^o the violent strain of 
labor. Moderate exercise, pure air and frequent baths, will 
generally bring the needed repose. Certain remedies will aid : 

Actma rac., byoscyamus, cotka, caulopbyllam. — Sleepless- 
ness. 

Aconite, arsenicuw alb. — Sleeplessness and restlessness. 

Sulpbar. — Drowsy during the day ; sleepless at night. 

Nax voitt. — Cannot sleep after 3 a.m., ideas so crowd upon 
the mind. 

Calcarea carb. — Cannot sleep after 8 a.m. 

Calcarea carb., cbina. — Cannotsleep because of involuntary 
thoughta. 
■ Belladonna. — Sleepy but cannot sleep. 

The last remedy, in our experience, is indicated oftener than 
any other. 

AncBinia. — In our account of the changes wrought in the- 
organism by prq^nancy, we entered somewhat in detail int-o an 
account of the blood-changes which take place, and to that we 
now refer for the pathology. As the result of these changes, 
symptoms of a more or less aggravated nature develop, vary- 
ing in degree to correspond with the extent of deviation from> 
the normal type. Within limits, the changes may be regarded 



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Diseases and Accidents. 229 

as normal, but when they become exceS6iye,tbeorf]:aiii8m BbowB 
signs of enffering and deterioration. The red blood corpuscles 
being reduced in number, if the diminution continue, the cell 
elements suffer, and finally waste, or Sll with fatty molecules. 
Then follow loss of weight, muscular prostration, impaired 
functional activity of the secretory organs, and increased nerve 
irritability. All the functions of the body are impaired, and 
the patient, unless the morbid changes became arrested, soon 
sinks to death. While such a termination is not impossible, 
the deterioration and disintegration are usually brought under 
control, and the patient is ultimately restored to a fair degree 
of health. 

This distressing condition is much more easily prevented 
than cured. Preventive treatment lies in the direction of obedi- 
ence to the laws of hygiene governing both mind and body. 
" Light, air, moderate exercise, good food, regulation of the 
bowels, cheerful society, and an occasional respite from house- 
hold and family cares, will always be the main checks to its 
extreme development." 

As a result of hydraemia, there may be extensive oedema, 
which gives rise to much discomfort, and requires special atten- 
tion. When it is extreme in certain parts, gangrene may 
threaten, and puncture be required. If the skin of the lower 
limbs becomes painful from great tension, application of hot 
cloths will afford some relief. 

Medicinal treatment consists in the administration of one or 
more of the following remedies, the action of which should be 
prolonged, since beneficial effects are slowly manifested. 

Ferrnm, in one of ite several forms, is most frequently era- 
ployed with good results. The metallicum is often UBed, as well 
as iermm et strychnia, citrate, and Arrant pbospboricam. 

Pui!sati7/a is capable of affording relief in some of these cases, 
especially when the attack is of the milder type. There is con- 
stant chilliness, coldness, and paleness of the skin ; coldness of 
the feet ; irregular pulse, and palpitation of the heart ; want of 
appetite; vertigo, especially on rising; mild, weeping mood, or 
excessive irritability. 

None of the foregoing remedies have been in our hands as 
serviceable as arseDicam jod. The arsenicum album may do 
as well in most instances. When these remedies are indicated, 
there are pallor, more or less cedema, restlessness and a sense 
of weakness. 



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ayo Pregnancy. 

A'ux vomica, when indigestion ie a troublesome feature, and 
there is constipation, or small loose stools, with urging. 

Numerous other remedies will be found useful, such as 
belonias, phosphorus, cyclamen, calcarea carb., sulphur, etc. 

For the dropsical symptoms, we find help in arsenictim 
album, apis meh, heUeboras and apocynum can. When lim- 
ited to the feet and legs, bryonia may be the remedy. 

Albuminuria. — Albuminuria, associated with 'i>re^ancy, 
was little known by the profession until within about forty 
years. Roger, in France, and Lever, in Great Britain, were the 
first to direct attention to it« intimate relationship to that ap- 
palling complication of pr^nancy and puerperality, eclampsia. 
For many years it was supposed that convulsions occurring iu 
the pregnant or puerperal woman were always preceded by, and 
in a measure dependent on, albuminuria. But more recently it 
has l)een shown that this is not true, for In somecases albumin 
is not present in the urine until after convulsions have begun; 
and again it does not appear at all. 

Albuminuria is also associated with other affections to which 
pr^nant women are subject, as for example, puerperal mania, 
vertigo, headache, and certain forms of paralysis, either of the 
nerves of spet^ial sense, as in the instance of amaurosis, or of 
the spinal Hystem. The relation which it bears to these diseases 
is not yet well understood. It should always be regarded with 
apprehension, and vigorous efforts made for its removal. 

Blot and Litzman met it in twenty per cent, of all cases ex- 
amined, but this is far above the estimate of other authors. 
Dr. Fordyce Barker bebeves it occurs in about one out of 
twenty-flve eases, or four per cent., and Hofmeir found it in 137 
outof 5, OOOwomen delivered in the Berlin clinic, which represent 
about 2.74 per cent. In most cases it disappears soon after 
delivery, and hence the causes upon which it depends must be 
temporary. It follows, therefore, that albumin in the urine of 
pregnant women, while it justly arouses considerable anxiety, 
does not always assume the grave importance which it does in 
the non-pregnaut state. 

Causes. — The origin of this disorder is usually sought in the 
conditions of pregnancy, but beyond thispointopinionsgreatly 
diverge. The blood-changes already described as taking place 
in pr^nancy, may have a causative relationship to albumi- 
nuria. Still, it is observed that in the worst cases of aneemia 
during gestation, albumen is rarely found. 



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Diseases ASjy Accidents. 231 

It ie supposed by Bome that albuiuin in the urine is due to 
eongestiou of the renal vessels by the gravid uterus. This may 
be true of some cases, but, in general, it cannot be repfardeii sb 
the only, or even the chief, cause, as a similar pressure is ex- 
erted by iiterine and ovarian tuinors without producing such 
au effect. 

The increased arterial tension doubtless constitutes an im- 
portant causative factor. All careful observers have found it, 
much above the normal. Fancourt Barnes believes it possible 
to predict "with almost absolute certainty, albuminuria, with 
its usual puerperal complication, eclampsia," from the in- 
creased and increasing vascular tension. 

In a certain number of instances, albuminuria antedates 
pr^^ancy. "When this is true, there is during gestation nearly 
always an aggravation of the pathological condition, 

Sympthms. — One of the most common symptoms of al- 
buminuria is oedema, which is a dropsical condition of the 
eubcutaneons cellular tissues. It is exhibited especially in 
the extremities and face, and sometimes becomes excessive. 
■(Edematous swelling of the feet and legs is observed in a large 
proportion of pregnant women, though it is associated with 
albuminuria in only a small proportion of them. Sometimes 
thecedema spreads until it becomes general anasarca, and the 
woman presents a pitiable aspect. 

There are also many nervous symptoms connected with 
albuminuria, such as vertigo, (cephalalgia, dimness of vision, 
spots before the eyes, and nausea. The appearance of such 
symptoms in a pr^^ant woman, whether associated with 
■cedema, or not, should impel the physician to a thorough chem- 
ical and microscopical examination of the urine. 

The Effe<:T8. — The various diseases associated with albu- 
men in the urine, either as cause or eflfect, require separate con- 
sideration, inasmuch as some of them are among the most 
dangerous complications to which a pregnant woman is liable. 
Several of these have been alluded to as symptoma of albu- 
minuria, such as cephalalgia, vertigo and paralysis; but that 
which stands out most prominently is eclamTssia. The precise 
mode in which the last named disease ie produced will lie con- 
sidered when we come to discuss in detail the cause, course and 
treatment of it in another chapter. The acutest cases are 
most hopeful. Those in which albuminuria sets in early are 
extremely liable to become chronic. 



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232 Pregnancy. 

We have before said that albumia appears in the urine- 
of womeo sufTering from puerperal mauia, and variouB forms of 
paralysis ; but whether as cause or efTect, cannot be positively 
stated. 

Prognosis. — The danger to mother and child in connection 
with albuminuria in pregnancy is not slight, Goubeyre esti- 
mated that forty-nine per cent, of primipariE who manifest the 
diseased condition, and who escape eclampsia, die from morbid 
resulta traceable to the albuminuria. Hofmeir found that out 
of forty-six cases reported by him, only one-third had eclamp- 
sia, though one-half died. Including both acute and chronic 
cases, Braun estimates that only sixty in the hundred develop 
urfemic convalaions. Hoftneir found in five thousand births 
recorded upon the books of the Berlin Clinic, 137 ca«es of 
nephritis entered. Out of this number only 104 patients were 
attacked with eclampsia. Prof. Bamberger reports from 
autopsies of the " allgemeineu Krankenhaus,' in twelve years, 
2,430 cases of Bright's disease, of which 152 were found in 
puerperal and pr^^nant women, namely: 80 acute cases, 56 
chronic cases, and 16 cases of atrophy. Puerperal eclampsia 
was recorded in 23 of them. 

A modifying condition has been shown by Bailly to exist, 
namely, that not rarely albuminuria in pr^nant women dis- 
appears for several hours, and then reappears, so that it may 
happen that an examination is made during the short period 
when the urine ceases to be albuminous. It should be borne in 
mind, however, that it is the renal insufficiency, and not the 
albuminuria, which causes urasmia and convulsions. The mere 
absence of albumin from the urine does not even exclude the 
existence of Bright's disease. 

Convulsions occur more commonly in primiparee than in 
multiparee, especially in elderly primiparte, in twin pregnancies, 
in women with contracted pelves, and in connection with the 
delivery of male children. They may occur epidemically in 
consequence of atmospheric conditions, which probably inter- 
fere with the fiinctions of the skin, modify the peripheral 
circulation, and thus indirectly increase the labor thrown on 
the kidneys. 

The danger of eclampsia is decided and unmistakable; but 
besides this, owing to imperfect nutrition of the fietus, by ma- 
ternal blood impoverished through loss of albumin, there 
is manifested a strong tendency to abortion. This fact has 



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Diseases and Acx^dents. 233 

beeu observed hj many authors. A good illustration of it is 
j^ven by Tanner, who states that out of seven women he at- 
tended, suffering from Bright's disease during pregnancy, four 
aborted, one of them three times in succession. 

The urine usually presents the common indications of serious 
renal involvement, namely, scantiness, high color, epithelial 
cells, tube-casts and occasionally blood. 

Conclusions, — Leopold Meyer, from observations upon 
1,124 pregnant and 1,138 parturient women, draws the follow- 
ing conclusions: 

1. In 1,124 non-selected cases of pregnancy, he found albu- 
minuria in sixty-one cases (5.4 per cent.), in twenty-two of 
■which he also found casta 2 per cent.) 

2. Albuminuria with casts occurred a little oftener in those 
'Cases where albuminuria appeared for the first time in the 
earlier months of pr^nancy than in those where it appeared 
later on. 

3. The £ige of the women had no influence in regard to the 
frequency of albuminuria. 

4. Albuminuria with and without casts occurred most fre- 
quently between the lOlst and 170th days and between tlie 
first and fourteenth day before parturition, 

■ 5. Of those women who had not albuminuria 1 9.7 per cent. 
had premature labors ; of those with albuminuria but without 
casts 27.7 per cent. ; of those with albuminuria but with casts 
41.2 per cent. 

6. Of pregnant women who had albuminuria without casts 
55 per cent, were free from it, and healthy during labor; of 
those who had albuminuria with casts only 12 per cent, had no 
albuminuria when at full term. 

7. Of 1 ,138 parturient women,25 per cent, had albuminuria 
wthont and 12 per cent, with casts. 

8. Albuminuriaduring parturition wasalittle more frequent 
in the primiparte than in the multiparse. 

10. Albuminuria without casts, which was only observed 
during labor, and did not exist before, disappeared as a rule 
rapidly. 

11. Albnminuria with casts, disappeared as a rule rapidly 
after parturition, generally after the 4th day. Yet occasionally 
it perHisted longer, especially if it had existed during preg- 
nancy. The age nor the number of pr^nanciee had any infln- 
ence on the course of the disease. 



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284 Pregnancy. 

12. Of the women who had not albuminuria 1.9 per cent, 
had 8tiil-born children. Of those with albuminuria but with- 
out casts, 2.1 [}er cent, of those with albuminuria and i-aKts, 
2,9 per cent. 

Treatment, — It is extremely desirable to recognise this dis- 
ease in its jncipiency, and in order so to do, everj' case which 
presents suspicious symptoms ought to be carefully examined. 
It is a lamentable fact that, in the lar^r number of instances 
in general practice, the medical adviser has no knowledge of 
the woman's condition until convulsions set in. 

Treatment should bemodified to meet thevarioaeindications 
presented by individual cases. The stage of the reproductive' 
process at which the woman has arrived, namely, pregnancy, 
labor or puerperality, the severity of the symptoins, and the 
cause of them, are all important considerations. If the cause- 
of the albuminuria is traceable to pressure of the gravid utems 
on the surrounding organs, thereby producing hyperemia of 
the renal secretory apparatus, treatment ought to be varied in 
some essentials from that which would be employed when albu- 
men in the urine is referable to a different cause. Again, a 
slight trace of albumen, with no pending constitutional dis< 
turbances, would not justify the same heroic treatment which 
might seem indicated when convulsions threaten the patient's, 
life. 

Frequent examinations of the urine ought to be made with 
special reference to ascertaining the quantity of albumeu and 
urea. A woman weighing 140 pounds ought to excrete 500 
grains of urea every twenty-four hours; and when the quantity 
falls much short of that in a given case, uremic symptoms are 
liable to develop. 

The prominent indications for us to follow are, to diminish 
the tendency to renal congestion, and to bring the blood into 
its normal condition. 

The Milk Diet.— The r^ulation of diet is one of the most 
essential features of treatment. All obstetricians agree in 
recommending milk as the exclusive article of food. Tarnier 
gives the following rules for guidance, to be adopted as soon as- 
the albumen appears in any considerable quantity in theurine: 

First day, a quart of milk, with two portions of food. 

Sc^nd day, two quarts of milk, with one portion of food. 

Third day, three quarts of milk, with one-half portion of 
food. 



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Diseases and Accidexts. 235 

Fourth and following days, four quarts of milk, or milk uO 
' lihitaiu, without other food or drink. 

In severe cawes, if prodromata of eclampsia appear, put the 
patient at once on three or four quarts of milk per day. The 
influence of the milk diet is never slow in manifesting itself, and 
in eight to fifteen days after beginning this treatment, the al- 
buminuria is diminished very considerably, or even cured. 

This diet will not be equally well borne in all cases; but by 
judicious management, and the use of indicated remedies, it 
will nearly always become tolerable. 

Therapeutics. — Homeopathy has provided us with remedies 
which have a most salutary efTect on this disease. Among them 
mercurius corrosivus occupies the highest place. "Ex|)erience," 
says Dr. Ludlam, "has led me to place great confidence in the 
mercurius coprosivus. I have prescribed it very frequently to 
fulfill this precise indication, and it has seldom disappointed 
me, " " • The idea which I design to convey is not that 
thie, or any other remedy, is aii absolute specific for ante- 
partum convulsibility. There is no real prophylactic of puer- 
peral eclampsia^. But if in one case in ten you can recognize 
incipient symptoms of this dreadful disease, and avert it, you 
should know how to do it." 

Arsenicum is a valuable remedy. The cedema is observable 
in the ftice, especially about the eyes; the countenance is pale; 
the thirst intense; the patient restless; the urine scanty and 
passed with difficulty. 

Apis. — Urine scanty and high colored, albuminous, and con- 
taining uriniferous tubules and epithelium; oedema of face, 
bauds and lower oxtremities; cedematous eyehds; great pros- 
tration in association with pale waxy skin; drowsiness with 
restlessness; irritation of bladder; frequent desire to urinate, 
with the passage of only a few drops; no thirst; patient tear- 
ful and absentminded. 

Gloaoimim. — Abundant, highly albuminous urine, tthich she 
must rise at midnight to pass; urine high-eolored, and bum- 
ing. In connection with these indications of renal fullness, we 
have, as corroborative symptoms, the violent headaches pecu- 
liar to this drug, congestion of the head with paleness of the 
face, throbbing felt with every pulsation of the heart, at every 
step or jar; blood mounts from neck, throat and chest.— 
TTom occiput to eyes; pressure from within outwards in both 
temples; brain feels too large and as if it would burst, impelling 



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236 Pheonancy. 

her to hold both hands to the sinciput ; laborious action of the 
heart; the patient in bad humor. 

Helonias. — Albuminuria during pregnancy. Urine profuse, 
clear, and light^coloved ; frequent desire ; urine barns ; heat and 
pain in the region of the kidneys, so that their outlines ran 
thereby be traced ; aching ajld tenderness of the kidney, weari- 
ness, languor and weight in the region of the kidneys : general 
malaise, unusually tired ; drowsy, sleepy, melancholy mood. 

Cantbaris. — Not often indicated in the ordinary albuminuria 
of pregnancy ; but may be the only remedy when acute neph- 
ritis occurs, or when an acute attack is engrafted upon a neph- 
ritis already existing. Urine turbid, scanty and containing 
mucus, easts and shreds. Pains in the loins and abdomen, with 
pain on urinating, and with constant desire. Convulsions, with 
<Bdema. 

Antimouium tartaricum. — Patient io bad humor; urine 
brownish-red, scanty, turbid and of stmng odor. Blood con- 
tains urine. Associated with these conditions of the urine, the 
gastric derangements peculiar to the remedy are sometimes 
observed, such as vomiting of mucus, belching, disgust forfood, 
and salivation. There may also be bronchial catarrh, dyspnoea, 
and pulmonary oedema consequent on uremic oppression of the 
nerve centers. The face is pale, and the tongue is white. 

Arnentum nitricam. — Urine sufficient in quantity, but it 
contains a relatively large quantity of albumen. 

Colcbiciim. — Pain in renal region, frequent urination, but 
diminished excretion; weakened memory, clouded intellect, 
mental depression, occipital pressure. This remedy frequently 
doiw excellent service. 

ffif>//«ifjorus.— Frequent desire, with scanty urine. 

Pbospbnnis. — Albumen, and exudatiou cells in the urine. 

Terebintbina. — Urine scanty, dark and albuminous. 

Kalmia, is oftt^n useful, though in the recorded provings 
thpi-e are no indications of its value in kidney affections. By 
virtue of its power over the heart, and secondarily over the 
kidneys, its use has been followed by good results, especially 
when gn^atand persistent aching painsinthelimbnwere present, 
without evidence of local inflammation. 

Induced Labor for- Alhuminurin. — .\llu8ion is sometimes 
made to this as " Schroeder's method." In obstinate cases the 
question of resort to this operation is forced upon us. Hofmeir 
bplieves that it does not increase the risk of eclampsm, while it 



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Diseases and Accidents. 237 

may altogether avert an attack. The operation has been ad- 
vocated by others. On the other hand, Spi^elberg opposes it, 
and Fordyce Barker thinks it should be resorted to only "when 
treatment has been thoroughly and perseveringly tried without 
eucceBS for the removal of symptoms of so grave a character 
that their continuance would resultin the death of the patient." 
'■ Wb discard," says Charpentier, "the question of premature 
labor for the fbllowing reasons : 

"1. The success which we have had with the milk diet issuch 
that we believe all other treatment UHeless, particularly when 
the milk diet is carefully and Bufficiently observed during preg- 
nancy, and soon enough to produce its effects. 

"2. When the albuminuria is slight, the interruption of 
pr^nancy appears useless, the gravity of the accidents which 
occur in pregnant women, who are at the same time albumi- 
nuric, being, in general, in direct relation with the amount of 
albumen. 

"3. When albuminuria produces serious symptoms, it de- 
pends upon, not only pregnancy, but also a serious renal 
affection, which may progress after confinement, and cause, as 
the observations of Hofmeier prove, the death of the patient. 

"4. Labor, as we have seen, has a marked influence in the 
production of albuminuria and of eclampsia; and, as the in> 
duction of premature labor, and with still mure reason, abor- 
tion, always requires a certain length of time, the result may 
be that, during this time, the patient may be placed in a condi- 
tion still more unfavorable than that in which she already is, 
by the mere fact of the albuminuria from which she is suffering. 

" Finally, although it is true that, in a number of cases, al- 
buminuria has disappeared after the death of the fcetus, and 
the real cessation of pregnancy, there are many other instances 
in which it has reappeared at the onset of labor, accompanied 
or not by eclampsia." 

"It is not easy," says Playfair, "to lay down any definite 
rules to guide our decision ; bnt I should not hesitate to adopt 
this resource in all cases in which the quantity of albumen is 
considerable, and prt^ressively increasing, and in which treat- 
ment has failed to lessen the amount ; and, above all, in every 
case attended with threaticning symptoms, such as severe 
headache, dizziness, or loss of sight. The risks of the opera- 
"tion are infinitesimal compared to those which the patient 
Tould run in the event of puerperal convulsion') supervening. 



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288 Preoxancy. 

or chronic Bright's diBease becoinin^ established. As theox)era- 
tion ia seldom likelj to t>e indicated until the child has reached 
a viable age, and as the albuminuria places the child's life in 
danger, we are quite justified in considering the mother's safety 
alone in determining on its ))erformance. " 

We believe few cases, if properly managed, will prove intrac- 
table to the milk diet and suitable remedies, but in those which 
do, we should not hesitate to bring on prematai-e labor, and 
bafiten it to a close. 

Chorea. During Pregnancy.— Cfiorea gravidarum.— This, 
fortunately, is a rare complication, and occurs chiefly in young, 
nervous women, a large percentage of whom have had chorea 
in childhood. It most frequently sets in during the third, 
fourth or fifth month. Among the recognized causes, apart 
from heredity, are anfemia, profound emotions and repercusi-ed 
eruptions. The mere irritation arising from normal develop- 
ment of the ovum in certain susceptible women, may constitute 
an efficient cause. 

Its prognosis, in cases bronght under suitable treatment, 
does not appear to hi-, as grave as some authors would lead us- 
to believe. Btill it must be regarded as a serious affection. Dr. 
Barnes compiled fifby-six cases, of which number seventeen 
died. Its danger is not to life alone, for it appears that the 
disease is quite liable to leave permanent impairment of ihe- 
mental faculties. It has also an unquestionable tendency to 
excite abortion and premature labor, and hence to sacriflce- 
fietal life. 

Treatment. — Special eifort should be made to protect the 
patient from all possible sources of irritation, and to render her 
surroundings as pleasant as possible. Good food, fresh air, 
r^ular baths, followed by brisk rubbing, and such exercise as 
she can bear without great fatigue, are the general indications 
for treatment. " There are nervous conditions which simulate 
ehorea,"writesDr. Ludlam," that yield readily tosuch remedies 
as beUadonna, ignatia, coffea, nux vomica, agarinus, and cuprum, 
under appropriate indications. These states are temporarj', 
and often depend upon avoidable en uses. They areeaeily cured." 

Spasms of chorea caused by fright, require aconite, ignatia, 
opium or cuprum. 

When proceeding from suppressed eruptions, cuprum acPti- 
eum, sulphur, caJcarea carb., arsenicum and causticam are the- 
remedies from which selection should be made. 



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Diseases axd Aa-iDKSTFi. 239 

When the cauBe remains latent the remedies from which to 
choose are veratruni viride, beUadomm, Pulsatilla, sepia, 
sabiiiB, gelsemium, tarantula and caulophylluin.the particular 
indications for which will be found mainly in the mental and 
physical traitB, taken in connection with collateral manifesta- 
tions. 

If, in apite of our remedies, the paroxysms inci-eaae ia severi- 
ty', and the patient's strength appears to be exhausted, counsel 
agreeing, labor may be induced. The choreic manifestations, 
usually terminate with complete evacuation of the uterus. 

The propensity of chorea to recur in succesHive pregnancies 
should be remembered, and precautions of the best character 
adopted. 

Hysteria. — Well-marked hysteria is not commonly observed 
in pregnancy, though many women evince symptoms of a ner- 
vous character, which, in some respect*, resemble it: hence we 
find that authors have little to say about it. Such symptoms 
are more prone to appear in the early part of gEstation, and 
may condense into distressing convulsions. Indigestion, exces- 
sive fatigue, loss of sleep, and a variety of occurrences and con- 
ditions, operating on a nervous system very sensitive, and 
already a little out of tune, may so confuse its action as to set 
the various functions to work at cross purposes. 

Mere remedies, however well suited to the case, are hardly 
sufficient. The disorder being largely emotional, the patient's 
mind has to be brought under subjection, not by harsh, but by 
the gentlest possible, measures. Anything which is calculated 
to strike the fancy, to divert, overwhelm or control the emo- 
tional elements of her nature, if not brought to bear with too 
much force and energy, will have a beneficial effect. These cases 
are exceedingly difilcult to handle, and demand the exercise of 
our best judgment and keenest tact. The judicious employment 
of frifrtrion, electiicity, bathing and exercise, is to be recom- 
mended. Even hypnotiBra may be cautiously employed. Elec- 
tricity ought to be used with great caution, for fear of exciting- 
uterine action. 

Among the remedies most frequently employed are the 
following : 

Ignatia. — This remedy most happily affects women of n 
nervous t«mperament, of dark hair and eyes, of quick mental 
faculties, and with an inclination to low spirits. They are 
ezceedinoily sensitive to the discomforts and inconveniencpK of 



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240 Pregnancy. 

their state, and may quietly grieve, or become greatly vexed 
over them. 

PahatUIa. — The temperament here is not necessarily ner- 
vous, but there are the delicate Bensibilities, light complexion, 
fair skin, and mild e.ves, — most frequently blue. The weeping 
mood is characteristic. The temper is sometimes petulant, but 
the tears are quite likely to soften its effect. 

Caulophyllum. — We have found this a very useful remedy, 
but its characteristics are not clearly defined. 

Nux moschata. — The woman, instead of being excessively 
sensitive to impressions, is quite the opposite. She is inclined 
to stay within doors, and takes but little interest in what is 
going on about her. The mental faculties are dull, the memory 
weak, and drowsiness is well marked. 

Nux vomica,. — This remedy acts chiefly on the spinal cord, 
and the effect is excitement. The mental traits are character- 
istic, there being irritability, dislike for work and disgust for 
life. The temperament is masculine, but nervous. We have 
not often found this an indicated remedy. 

MoBchus. — Women of excitable disposition, melancholy 
mood, with a tendency to coldness. It is especially valuable 
for its immediate effects upon hysterical paroxysms. 

Gelsemiani. — Sometimes of service when there are depression 
of spirits, restless sleep, aching in the limbs, weakness and 
trembling. 

Many other useful remedies might be mentioned, but those 
named have in our hands proved most beneflcial. 

Paralysis.— Pregnant women seem peculiarly liable to vari- 
ous forms of paralysis, but more especially hemipl^a and 
paraplegia, the former being more frequent. The subject is too 
extensive for anything more than brief mention here. In a 
general way it may be said that the disease seems in many 
cases to be associated with albuminuria and urajmia. 

Many modern authorities advise the induction of premature 
labor in cases wherein paralysis appears in connection with al- 
buminuria; but the results of the milk diet and homeopathic 
medication are so satisfactory that the advice should be re- 
ceived with caution. Upon disappearance of the albuminuria 
the paralysis usually improves. If it persist, the induced cur- 
rent, friction, bathing, and a continued use of the homeo- 
pathic remedy, usually prove effectual. For the relief of 
_paraly6i8 not associated with, or dependent upon, albumi- 



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DlBBASES AND ACCIDENTS. 241 

nuna, the ioductioa of premature labor would be manifestly 
improper. 

The results of homeopathic medication, wheu aided by the- 
milk diet, are in the main so satisfactory that the cases of pa- 
ralysis dependent on albuminuria, calling: for the induction of 
premature labor, are few. The remedies of greatest service- 
have already been fz^iven under the head of " albuminuria," and 
need not be repeated here. If we are driven to the induction of 
labor, or if it comes on naturally, without relief of the para- 
lytic condition, the remedies which will be most beneficial are 
nujc vomica, gelseminw, mercurius cor., Arsenicum, sulphur and 
calcarea carb. 

Syncope. — Attacks of syncojie, while not very common, are- 
experienced by pregnant women. They oftener occur during- 
the first three trying months, when all the functions are more- 
or less disturbed, and the nervous system so very sensitive to- 
every impression. The attack is not often a fully-developed 
fainting fit, and hence consciousness is not entirely tost ; yet 
the patient may lie with dilated pupils, feeble pulse, and in semi- 
consciousness, for several minutes, or much longer. 

In the way of treatment, lay the patient on her back, withi 
the head low ; supply plenty of fresh air, and give ammonia, 
amyl nitrite, or spirits of camphor, by inhalation. If the at- 
tack be prolonged, a sinapism to the precordia will be found of; 
good effect. Select a remedy according to the symptoms ; 

Aconite, eact. granfi.— Palpitation of the heart. 

Arsenicum. — Debility or prostration. 

Bryouia. — Great thirst and drinks much cold water. 

{^mphor. — Very weak pulse; coldness of the whole body.. 

<^sr6o veg. — Eructations, 

ChamomilJa. — Irritability ; dimness of vision ; nausea. 

China. — Cold perspiration ; ringing in the ears. 

CoeculuB indicas. — Paralysed feeling in all the limbs, with 
trembling. 

Digitalis. — Pulse slow and irr^ular ; cold sweat. 

Ignatia. — Much trembling. 

Nax Tomif^.— Vomiting; trembling. 

Sepia. — Feet and hands cold as ice ; flushes of heat. 

Stramonium. — Painting; pale face. 

Veratrum alb. — Cold sweat upon the forehead. 

Painful JSamiZHB. — ^The changes which are began early in 
TpKf^aajac^ to pre^iaM the niaioiiue for activity, always excite 



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242 Pkegnakcy. 

more or less dietresB, sometimes amouuting to real pain. The 
aufTeriiig i» more intense in tlioee cases where the breasts have 
been systematically compressed with corsets and pads. 

Inunctions with warm oil, and the application of poultices 
when the pain is severe, will afford considerable relief. 

Bryonia, when the pain is sharp and stitching, the breafits 
sensitive to toueh, and the pain increased by the jar of 
walking. 

BelladonuH, when there are redness, heat and induration, 
■with distensive pain, 

Phytolacca, when the glandular structures Reem to be in- 
volved in inflammatory action, and the pain is intense. It 
may be applied locally with additional benefit. 

Pain in the Side,— During the fourth or fifth month, and 
sometimes later, women often experience pain under tfae false 
ribs, on one side, or both. Nux vomica will generally relieve in 
a few days. Bryonia, belladonna, arsenicum, canlophyllijni 
or Pulsatilla may be required. 

Pa,in in the Abdomen. — As the result of the excessive disten- 
sion to whi<;h the abdomen is subjected, there is more or less 
pain, depending in severity on the original tenseness of the 
abdominal walls, the d^ree of distension and the sensibility of 
the patient. 

Inunctions of cosmoline, vaseline or some other oleaginous 
substance, is helpful. 

Sepia, if the abdominal walls are exquisitely sensitive to the 
touch. 

Coniuni, if there is pain in the abdomen after going to bed, 
ameliorated by rising and moving about. 

Leucorrbcsa. — The wonderful physiological changes going 
on in the pelvis during pregnancy, necessitate a strong deter- 
mination of blood to this part of the body, and excite into 
activity every function. Hence, the natural secretions of the 
glands are increased in quantity, and require attention only 
when they become excessive. The secretion which appears in 
the form of leucorrhoea is mainly from the cervical glands, but 
the vaginal and vulvar glands also contribute. It is sometimes 
very copious and occasionally acrid, in which latter case the 
whole genital tract may be hot, swollen and painful. The irri- 
tation, if comnmnicated to the urethra, will create frequent 
and painful urination. 

To control this annoying symptom, rest from sexual iudnl- 



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Diseases and Accidents. 243 

gence, and a daily enema of tepid water, are often all that is 
required. In other cases the discharge is pertinacious. 

Pulsatilla,. — The discharge is thick white mucus, and is 
extremely irritative. 

Hydrastis. — Irritative leucorrhtBa, with coexistiuf; iudiges- 
tion and debility. (A mild solution of the ordinary fluid 
extract, or, what is better, the "fluid hydrastis," should also 
be used as a va^nal injection.) 

Mercurius. — Yellowish, purulent leucorrhoea, producing sore- 
ness of the parts. 

Arsenicum. — Thin burning leucorrhoea. 

Graphites. — Profuse leucorrhoea, especially in a scrofulous 
subject. 

Odontalgia.— Toothache often proves to be a real torment 
to women during pregnancy. It may set in immediately after 
irapreguation, and continue, at short intervals, throughout 
pregnancy ; but in general it proves to be quite amenable to 
treatment. 

iS^pJa has long sustained the reputation of being the most 
aerviceable remedy in this annoying affection. 

Belladonna, if there is determination of blood to the head, 
with either paleness or redness of the face. 

Mercurius is the remedy when the affected tooth is carous, 
the pain more severe at night and the tongue somewhat coated 
and presenting the impression of the teeth about its margin. 

Stapbisagria for women with a rheumatic diathesis, teeth 
dark, carious and apparently uncared for: the pain is worse 
when the tooth is touched, especially by hot things ; also worse 
when out of doors or drawing cold air into the mouth, and 
worse at night. 

Coffea for oversensitive, nervous women, the pain sudden and 
violent, and the mental faculties active. 

Pulsatilla, when it b^ins in the evening and continues 
through the nighty especially in women of mild temper, with 
inclination to tears. 

Nux vomica. — The pain is increased by fresh air, wine, coffee, 
cold, and mental labor, and diminished by warmth. Shooting 
in the teeth and jaws, extending into the bones of the face and 
head, with a grinding, pressing or drawing in the decayed tooth. 

Plantar maj. is an excellent remedy. 

Kreoaotum, that prince of remedies for toothache, should 
not be forgotten. 



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244 Preunancy. 

The selected remedy may be tried for an hour or two, but, in 
a very painful attack, if Bome relief is not then afforded, it 
should be exchanf!;ed for another. 

When other means for relief have failed, palliative meaenres- 
are in order, among which are brushing the gums with Bpirtts- 
of camphor, applying equal parts of alcohol, chloroform and 
ether, use of the galvanic current, plug^ng a carious cavity 
with cotton saturated with a strong solution of cocaine, etc. 

There is no doubt that pregnancy predisposes to caries, and 
the latter condition of the teeth may necessitate mechanical in- 
terference, such as extraction, filling, etc. "There is much 
nnreasonable dread," eays Playfair, "amongst practitioners- 
as to interfering with the teeth during pregnancy, and some- 
recommend that all operations, even stopping, should be post- 
poned until after delivery. It seems to me certain that the suf- 
fering of severe toothache is Hkely to give rise to far more- 
severe irritation than the operation required for its relief, and 
I have frequently seen badly decayed teeth extracted during 
pregnancy, and with only a beneficial result." 

Oramps. — Pregnant women are often annoyed by cramps m 
the abdomen and limbs. 

Veratrum album, taken before going to bed, will generally 
prevent them. Dr. L. A. Phillips says that ammonivm mnri- 
aticum has, with him, proved to be almost a specific for them, 
especially those occurring in the legs. Nax vomica or coSea 
may be given to nervous, sensitive women. Secale, cuprum and 
BtrontJana carb. are also of benefit. Gelsemium seems well 
suited for relief of cramps in the abdomen. 

Traumatic Complications of Pregnancy.— Among the 
questions which confront us is that concerning the risk of 
premature expulsion of the product of conception, arising from 
traumatism, whether accidental or surgical. The chief danger 
arises from reflex effects on the uterine muscular fibers, ex- 
pressing themselves in immoderate contractions ; but there are' 
other dangers, namely, destruction of fffital life from maternal 
hemorrliage, and likewise from maternal toxeemia. 

In considering the first of these risks, we ought to recollect 
that the uterus is not at rest during gestation, but is in rhyth- 
mical contraction. Throughout the greater part of pregnancy, 
this organ, as we can easily demonstrate, never wearies of con- 
tracting and relaxing, at tolerably regular intervals. Labor 
itself is but an intensification of this action. This truth beings 



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Diseases and Alx^dektb. 245 

rew^nized, we readilyaee with what facilityirritation applied to 
certain parts of the body may.by reflex actioo, augment uterine 
energy, and precipitate expulsion of the immature OYum. 

The womb, like otherorgans, responds much more promptly 
to irritation existing in one part of the body than in another; 
and therefore extensive traumatism can be inflicted with com- 
parative impunity over certain areas, while rapid effects follow 
interference with others. Then, too, in some women the reflex, 
function is on the qni vive, while in others it is extremely 
lethai^c. Little experimentation is required to determinethat 
stimulus applied tothemammee.the external genitals, the anus, 
and the uterus itself, quickly excites the uterine muscles. Ac- 
cordingly it has been found that operations involving these 
parts are more frequently followed by abortion. 

When women are in a state of health, and free from morbid 
disposition, normal pr^^aiicy is not easily interrupted. Mat- 
thews Duncan mentions a case, wherein an intra-uterine stem 
pessary was introduced, and worn for some time during preg- 
nancy, without excitiuj; miscarriage. A woman seven months 
along in gestation jumped from the third story window to the 
pavement, without sufTeringlossof theovum, though shebroke 
both legs and both arms. Operations of all degrees of severity 
have been performed with immunity from the result in ques- 
tion ; limbs have been amputated ; ovaries have been removed ; 
the vaginal portion of the cervix uteri has been cut off, and sub- 
serous fibroids have been taken away by laparotomy. Aye, 
when women, such as the subjects of these accidents and opera- 
tions, set about procuring abortion, they, and their accesso- 
ries, are sometimes driven almost to desperation by the futility 
of their efforts. On the other hand, a slight strain, or an 
insignificant wound, in certain women, is sufficient to precipi- 
tate uterine evacuation. In a woman who has no disturbance 
of functional activity, no depreciation of vital energy, and no 
morbid predisposition to miscarriage, pregnancy is interrupted 
only by certain efHcientcausesoperatingat afavorablemomeiit. 
To such patients irritation may be applied for a brief period, 
without harmful effect ; and it seldom becomes overpowering 
unless unusually prolonged. They may fall down stairs, or 
they may be incised in vital parts, and still hold tenaciously to 
their immature progeny. But even such women will finally 
yield, though with reluctance, to the force of reflex energy set in 
action by long-continued cumulative irritation. 



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246 Pregnancy. 

AgaJD, the monthly molimeD iB not wholly snppresaed during 
pregnaocy, but only ander restraint: and influencefl which, at 
other times, would be innocuous, are, at that particular period, 
capable of doing serious harm. For this very reason women 
with a propensity toward miscarriage, require to be held in 
check, or put into strict quarantine, at such times. But what 
can be said of those who, ft'om a shght shock, a high step, a 
long walk or a stirring emotion, to say nothing orsevere trau- 
matism, cast their untimely Iruit? They make large drafts on 
our time, our patience, our ingenuity, oar tact, our skill, our 
discretion and our sympathiefi, even in their best estate. 

Apart from reflex causes of abortion proceeding from acci- . 
dental or surgical injury, we ought not to forget that uterine 
evacuation may be brought about ft*om harm accruing to the 
fietus through maternal blood-loss, uterine congestion and gen- 
eral maternal toxsmia. Prior to the operation or injury, the 
woman may be aneemic, so that a sparing loss would so impair 
fffital nutrition, already low, as to extinguish life. Again, 
strong uterine congestion may rupture some of the finer 
decidual vessels, and destroy the functions of so large a pari 
of the placenta, that foetal life can no longer be sustained. 
Finally, inasmuch as fuetal blood is aerated by the maternal 
blood through the process of oamosis, it follows aa a necessary 
consequence,, that fwofound toxKuiia of the mother has a 
marked effect on the unborn child. The latter cab bearacertajn 
d^xee of contamination without fatal results, but, as with us 
in vitiation of the atmosphere by poisonous gases, when that 
certain point is exceeded, it falls a prey to the baneful influence. 

To recite cases wherein serious operations were performed 
during utero-gestation, without interruption of its course, 
would profit little. They are by no means numerous in the 
prnctice of any one physician, and sound deductions can 
sonreely be drawn from my records, or those of any other ob- 
stetrician. Cohustein. who devoted considerable time to the 
study of this subject, was enabled to rollect sufficient data to 
entablish a fair view of the danger of miscarriage, which awaits 
upon serious traumatism. He says that, in 54.5 per centum of 
all ca»es, pregimncy goes on to a natural termination. An 
evidence of the wonderful tolerance exhlbifed by somepregnant 
women, we may cite the case mentioned by Frommel, in which 
a sub-serous fibroid, with a sessile base, occupying considerable 
of the uterine wall, was removed. Convalescence was pr& 



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Diseases and Accidents. 247 

"tracted by iodoform poisoning, but preijnancy continued an 
■uninterrupted course. Tlie physical state of his patient, and 
her environment as well, must have been of the most favorable 
kind. 

Treatment. — Beflez effects can be greatly diminished by the 
•employment of anesthetics, and, that, too, without special 
•danger to the foetus. Ether is oftenest the chosen agent, but 
we are convinced that its effect on the child is more peraicions 
■than that of chloroform. Thelatteranestheticseemapeculiarly 
adapted to the pr^nant woman, and, by general agreement, 
ite dangers in midwifery practice are but a remove Irom perfect 
«afety. Then, too (and this is a consideration of some weight 
in this connection), vomiting is less \\ke\j to result from its 
Administration. 

The best prophylactics are the antipsoric remedies, and, in 
our opinion, prominently, sulphur and caJearea carb. Tempera- 
ment anil general physique are the best indications upon which 
to base our selections. 

Salphur, for women of nervous temperament, inclined to 
be thin and narrow-chested. Skin rough, sense of weakness 
through the pelvis, flushes of heat and frequent faintness. She 
lias a previous history of sparing fiow at the month. 

Cakarea carb. — Leuco-phl^i^atic temperament, lair com- 
plexion, inclined to stoutness. Clumsy; feet cold and damp. 
Previous history of profuse flow at the month. 

There are many other remedies for use before and after 
traumatism, among which should be mentioned arnica, byperi- 
-cam, cauJophyllam, secale (neither of the laat two lower than 
the 3^), Pulsatilla, araenicum, geJsem'ium, china, etc. More- 
over, we would not hesitate to appeal to opium for its sootjiing 
-effects after severe traumatism, provided there were urgent call 
for it, just as we would to chloroform or e^Aer during theopera- 
i;ion. 

Under homeopathic care, both before and after operative 
procedure, the probability of uninterruption of pregnancy is 
rendered decidedly more promising. 

OonBtipation. — This annoying complication of the pregnant 
-state owes its existence not so much to the pressure exerted by 
the gravid uterus, as to diminishpd intestinal action. One very 
important factor in its production is doubtless the sedentary 
tiabits of women at such a time. When constipation exists, 
neglect of the bowels may give rise to foecal accumulationd. 



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348 Pregnancy. 

Bometimea of enormous size, which occasion great pain, and 
endanger premature interruption of pre^ancy. If such a con- 
dition be allowed to complicate labor, it may eerve an a serious 
impediment to descent of the foetus. 

Proper attention to the action of the bowels will prevent 
large accumnlations, and do much to overcome the habit of 
constipation. Begularity of going to stool ought to be enjoined 
upon the woman, together with a choice of diet which will not 
include the more constipating articles of food. Fruits, iu their 
season, should be recommended, graham bread, figs, and such 
other articles as are known to have a laxative elfect upon the 
bowels. Sipping a balf-pint or more of water, as hot as can be 
taken, thirty or forty minutes before each meal, will improve 
digestion and act as a gentle aperient. If, in spite of treatment, 
and the observance of such habits, the bowels still remain cos- 
tive, an occasional enema of water, soap and water, or olive oil 
and soapsuds, will afford temporary relief. A teaspoonM of 
glycerine, as an enema, is very effective. 

Aconite. — Much thirst ; fear of death. 

Alumina. — Scanty, hard stool. 

AgancuB m. — Loud rumbling in the bowels. 

Arnica. — Flatulency; colic, foul smelling flatus. 

Belladonna. — Flatulency; obstruction of the bowels; much 
tendency of blood to the head; red eyes; intolerance of light; 
flushed face ; heat in the head. 

Bryonia.— }Avxih thirst; rumbling in abdomen; irritable; 
mouth and hps dry ; hard stool. 

Carbo veg. — Flatulency, with colic and rumbling in bowels. 

C&usticum. — Constipation ; rumbling in the bowels. 

China. — Flatulence with colic; rumblings. 

Conium. — Much vertigo. 

Grapbitea. — Hard stool; itching blotches about the body; 
-colic. 

Ignatia. — Empty feeling at the pit of the stomach ; mmb- 
ling. 

Kali carb. — Unsuccessful desire for stool. 

Lycopodium. — Rumbling and gurgling; incarcerated flatu- 
lence. 

MercuriuB. — Salivation ; gums sore. 

Natrum mur. — Hard stool; rumbling of fiatusandincarrera- 
tion ; headache on awaking in the morning; aversion to bread; 
fiore places in mouth. 



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Diseases and Acodekts. 249 

yitric acid.— Hard stool ; bloody stool ; much flatas. 

Nux mosci.— Dryness in mouth and tongue; stool slow and 
difflciilt. 

Nux vom. — Flatulence. 

Opium . — Sleeplessness. 

PAos.— Blood with the stool. 

Pbosph. Bcj'd.— Flatulency ; stooihard. 

PJum6um.— Constipation, with colic; stools composed of 
little balk like sheep's dung ; flatulency ; colic. 

Pulsatilla. — Bloody stool. 

Sepia.— Stool difficult; flatulency, with loud rumbling in the 
a.bdomen. 

DiarrhoBa.— This is a less frequent complication of the prq?- 
nant state. Simple looseness deserves no particular attention ; 
but frequent, watery, painful movements should be checked, as 
a continuance of them is liable to excite strong u'terine effurts 
at expulsion. Light food, taken in Hinall quantities, aad re- 
pose of body and mind, ought to be prescribed. 

Pregnant women are exposed to the same influences which 
occasion diarrhoea in the non-pregnant, and, in mentioning 
a few remedies, we would not be understood as regarding 
them peculiarly suited to diarrhoea during pregnancy, though 
we have found them very serviceable for it. They are named in 
the order of their usefulness. 

J/oee.— Feeling as if the stool could not be retained, but 
most drop involuntarily; rumbling in the bowels; generally 
good appetite. 

Ahimina. — Tenesmus; stools bloody and scanty; urine can 
be passed only with the stool. 

Amenicam. — Bloody or involuntary stools; very weak, least 
motion causing great fatigue ; worse after eating or drinking; 
great thirst, 

Bryonia. — Much better when quiet; thirst; worse when the 
weather liecomes warmer. 

CbamomiUa. — Nightly diarrhoea with colic; very irritable 
■temper; stool small, frequent, smelling Hke rotten eggs. 

CheUdoniam. — Stools pasty or watery, bright yellow ; lighter 
colored than usual; light red or brown. Patient craves hot 
drinks. 

China. — Stools contain undigested food ; yellowish ; painless. 
Diarrhcea worse at night, after eating and at night. 

Colocjntli. — Pappy stools, with or without burning at the 



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250 Pbegnancy. 

antia; may be preceded by colic; sometimes teneamna: stools 
yellow, brown, bloody or fcreeDisb. 

Dulcamara. — Diatrhcea worse after every cold change in the- 
weather. 

Gelsemiam. — Dlarrhcea arising from depression or anxiety 
of mind. 

Hyoscyamus. — Frequent, slimy stools ; yellow watery, pain- 
less 

Ipecac. — Greenish stools, accompanied by much nausea. 

Kah carb. — Stools profuse, with much weariness or severe- 
pain in lower part of abdomen ; insufficient. 

Memurius. — Stools greenish, bloody, slimy, corrosive; tenes- 
mus and frequent urging; perspiration. 

Pi ospZiorus.— Stools watery ; general debility. 

Veratrum alb. — Stools profuse, watery ; cold perspiration ; 
colic before movement. 

VeBical Irritation. — Yesical disturbances are common dur- 
ing pregnancy. They are more marked during the early and 
the latter parts of the terra : the former due chiefly to hyper- 
eemia of the pelvic organs which characterizes that stage of 
gestation, and the latter proceeding in great part from the 
mechanical compression exerted at that time. The symptoms 
are frequent deeire to urinate, with pain, burning, and sorae^ 
times itching. 

If the ailment becomes distressing, and treatment proves 
unavailing, an examination per vaginam should be made, and 
if the difficulty proves to owe its existence to mechanical causes 
which can be remedied, careful interference may be practiced. 
When there is nothing more than irritation, and the desire is 
fi^uent and distressing, we have often used a steel sound, of as- 
large size as the meatus can easily receive, with excellent effect. 

Treatment. — This ailment is sometimes so distressing that 
we feel justified in tpving here a brief repertory of symptoms : 

DieCHAROI OP URINE. 

I>UlaiilI,(iccm.,aIuni.,api«,arj7.n.,arn., From atoDf , camph., opium, rhtwn, 
art., aur., benz. ac., caclus, campk,, tecale, thuja. 

can. ind., can. tat., caps., erol., duU., From cold, cold drinks, dule., nit. ae. 

eTig.,eup.puTp.,geU.,helon.,h«par t., From epaamodic contraction ot tfaft 
hyoi., Hth.e., lye, mag. m., meph., neck of the bladder, Aye*. 

mere, mur. ac, not. m., nit. ac, After dinner and supper, nuz m. 

ntir m., opium, pareira, plumb., ran. After exertion, nux m. 

b., rheum, rhui I., tecale, sepia. All day, mepA. 

tlram., rulpk., tereb., thuja, lineum. Especially in the morning, ttpia. 



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Diseases asd Accidents. 



r UKINE COBTJKUBD. 



, with pain and beat, nil. ac. 
With urging to etool, nose tn. 
Can paai onlj by straining at atool. 

Must press bo that anus protrudes, 

Alternate dysuria and enuresis, geU. 

DlmlBlalMd, hyper., hreot., Ud., lob., 

TMX.,pod., rkut, tab., lenega, itram., 

DTlbUlng, agar., am., bem. ac., brom., 
bry., can. ind., cautt., tali 6rt>m., 
mix v., petr., phtmb., ulen., ipig.. 

During motion, without sensation, 

bry. 
At beginning of stool, kali b 
After stool or urine, lelen. 
After urinatiag, can. ind. 
With burning after urinating, brom. 
With burning at meatus, ipig. 
No pain, tan., ttram. 
In spite of urging no stream forms, 

la Drops, actm., apit, aTn.,bry.,caetu», 
camph., eanth., catul., clem., eoleh., 
drot.. dulc., ettp. pttrp., hell., lachn., 
mere, mere, c, nuxm., ntix v.,plumb,, 
piili., rhiiM, labina, tart., tep,, tpig., 
ilaph., ttram. 

Sensation as if drops came from 
bladder, tep. 

When moving, without sensation. 

When sitting, puU. 

When walking, puU. 

With frequent desire, apit, cup. 
purp. 

With much burning, caetut, nttx v. 

With great pain, mtrc. c. 

With tearing, nux v. 

InoTM j sd. acet. ac, aeon., agn., atnb., 
berb.,cah.p., earbo a., carbo v., caul., 
etc., etna, coleh., tup. purp., euph.. 
Ml., hyd., tali j., kob., Ud., til., lob., 
mag. c, nice., tnarutn., mere. j. r., 
mere, e., nal, m., pho».,p«U., rheum, 
rhod.,tenega, tqtiilL, UU.,ther.,uttil., 
eafcr., veral. v. 



With headache and profuse sweat; 

vomiting, aeon. 
With sense of weakness, cafe. p. 
With unquenchable thirst, kali j. 
With thirst for large quantities. 

With sweat on bead, hands and feet, 
or forepart of body, phot. 

iBtwropted, earbo a., elem., con., led.. 
meph., op. 

With burning during the interrup- 
tions, clem. 

From spasm at neck of bladder, op. 

Painful, aeon., mtc, apii, aur., bapt., 
ealad., camph., can. ind., can. 
canth., capi., croL, date, orig., eup. 
purp., fluoT. ac, gelt., hell., helon., 
nth, c.,lyc., mag. c.,merc. c, mur 

nuar p., olean., pareira, plumb., 

t.,tab., tart., tereb. 
After cold drinks, dulc 

Dinner and supper, nux m. 

Exertion, nuxm. 

Jolting ride, eup. purp. 
Alternating with enuresis, gelt. 
Irritating, aart. 
Very, eup. purp., pomm. 
With heat, nit. ac 

Micturition, vomiting and purging 
from spasmodic contractions, 

Profnss, aeet. ac, act., leth., agar., aloe, 
alum., amm. c, amm. m., org., art., 
awr., bary. c, bell., bit., bry., caeL, 
edlc. p., can. ind., eepa, chel., cic, 
coff., cot., cyel., erolal., drot., erig., 
eup. perf., eup. purp., euph., Jerr., 
gelt., glon., guai., ham., hell., helon., 
igii.,iTit, kalib.,kalic.,kalij.,talm., 
kreot.,lith.c.,mang. acet.,merc.j.fi., 
nuz.,ffiur. ac, nal. a., not. m., oUan., 
Qxal. ae.,phot., phot. oc.. phyt.,Tumfx, 
tab., tamb., tang., tart., telen., til., 
tp>g.,ttan., ttaph,, ttram.,»ul,,larax., 
tereb., thuja, verat. a., vibur., xanth. 

During night, amm. m., arg. m. bary. 
c, phot, ac., tang., tart., ttram., 
tulph. 



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DIBCHABOE OP DB1M>— CONTINUED. 



Dfstarbing sleep, [i(ft. e. 
In alternoon, rumex. 
In morninK, ambra, tmz. 
Followed by dull pain in region of 

kidneys, ambra. 
NervouB affections, alum. 

Nervous women, xanth. 

Spasms, ttram. 
Passed witbout sensation, tan. 
Pale, evp.perf. 

Relieving baokacbe, gelt., lye. til 
Very often, eupft. 
Very profuse, eup. purp., hell. 
With frequent discharge, ar«. 

Headache, terat. a., pibur. 

Hysteria, lulpk. 

Sense of weakness, calc. p.,ferr. 

Thirst for large quantities, not. m. 
Batalned, aeon., apii, apoe.. am., art., 

arum, aur., bell., bem. oc-, campk., 

eanlh., cavtl., eic, dale, ham., hell., 

hepar, hyot., illic, taur., milUf., op-, 

puit., rftui, ruta, tab., tec. 
After exertion, ai^. 



From atony, muscular, hell. 
Cold, aeon. 

Contraction of spbincter.op. 
Exertion, am. 

With bacLacbe, rhvt. 
Constipation, canlh. 
Pain, canth,, ruta, Bart. 
Pressure in bladder, aeon. 

Boantj, nbrof,, aeon., act., sic, ai'Ian., 
aloe, alum., aiit. t., apii, apoe., am., 
art., anim, aur., bapt., bell., bfrb., 
brom., bry., eamph., canth., eard. 
mar,, cham.. china, clem., eoec, coleh., 
erotal.,eiip., eycL, dig., drot., dule., 
eup. per/., eup. purp., fiuor. oc, 
graph.,ham.,hell.,hyot.,hyper.,ipee., 
irit, kali b., kali brom., kali e., kob., 
lil., lilh. c, lye., mtre. j. ft,, mere, e., 
mur. ae., myriea, nal. »., nit ae., ntuc 
m., op., petr., phot., phyl., pior., 
ptelea, ptili., rvla, tang., tart., lelen., 
tgtiill., itann., ttaph., lereb., nttil., 
terat.a., vernt. v. 

With no uneasiness, apoe. 



WB>N NOT DBINATtHQ. 



Burning pain in forepart of uret 
which compels to urinate. 



Gutting in urethra between micturi- 
tion, with frequent urging, tnang. 



Cutting and stinging in urethra. 

Fleeting pain in bladder, benz. ae. 
Pressure in forepart of urethra as if 

to urinate, can. «al. 
Stitches along urethra, can. tat. 



Aching in back, ameliorated by 
urinating, lye. 
In bladder./uor. ac. 
Bladder, aching in,^uor. oe. 

Burning in, /nor. ae., rheum. 
Bladder, burning in and cutting, 
from neck of to fossa navicu- 
laris, cant A, 
Pain in region of, phyl. 

Worse in right, ttashesof, (if A. e. 
Pressure on, nux v. 
Burning in kidneys, rAeum. 
In bladder, can. ind., canth., clem,, 
fluor. ac., rheum. 



In bladder, from neck to fossa 

navicular is, eanUi. 
In urethra, can. ind., can. tat., 

canth., clem., fluor. ac. 
Cutting from neck of bladder to fossa 

navicularis, canth. 
Kidneys, burning in, rhrum. 
Pressure on bladder, nu:! v. 
Stinging in Uretha, can, ind. 
Ureters, violent pain indirection of. 

Urethra, burning, can. ind., canth.. 



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Diseases and Accidents. 



DUBINO UBIHATION. 



Abdomen, pala in lower, agn. 
Aching of b&ck, ant. e. 
Anus prolapsed, mur. ae. 
Constriction of neck of, cactut. 
Pain in, ant. t.. phyt. 

Violent, ant. t. 
Pressure in, laehn. 
Smarting and burning in, eup. 

purp. 
Spasm in, ataf,, op. 

Interrupting flow, op. 
Stitcbesln.naf. m. 
Tenesmus of, lith. e. 
Throbbing in neck of, during 
straining to urinate, dig. 
Burning in kidneys, rktum. 
In bladder, tham., eup. purp., 

And smarting, eup. purp. 
Neck of, eanth., cluim. 
And cutting to fossa navi- 
cularie. eanth. 
In urethra, aeon., aloe, ant. e., ant. t., 
arg. n., an., bapl., cact., calr., can. 
ind., can. int., eapi., earbo an., 
eauit., cham., elem., eup. purp., 
glon., helon., hepar, ign., kali b., 
kali F., lachn., mag. 






.,nit.a 



., nux m., nux v.,ptor., 
rhettm, $ab., itaph., thuja. 
And soreness, carbo a. 
With gonorrhcea, Ihaja. 
With discharge of urine in 
drops, eacl. 
In meatus urinariui, can. tat., 
eineh., puh., tep., eulph. 
And smarting backwardi, can. 

rat. 
During bloody urine, puU. 
Chills, rigors, »tram. 
Constriction of neck of bladder. 

Cutting in urethra, ant. c, caust., 
guai., mur. ac, ntix m., op., pior. 

Hnmorrhoids protrude, kali e. 

Kidneys, burning in, rheum. 

Meatus urinarius, burning at, during 
bloody urine, pult. 



Itching at, preceded by urgent de- 
sire, petr. 
Pain in hips, berb. 

Thighs, pawro. 

Kidneys, agn. 

Burning, rluum. 

Bladder, ani. t.,phyt. 

Urethra, ealad., lith. c. 
Pain in urethra at meatus, eing, 

Glbns penis, oral. ac. 
Pressure in bladder, lachn. 
Prolapsus ani, mur.ac. 

Recti, valtr, 

Shuddering along spine, ni(. oc. 
Smarting and burning in bladder, 
eup. piirp. 
In urethra, cole A., rup. purp.,graph., 
ign., kob., mag. c, mere. c. not. m., 
nit. ac.,ptdea, lep. 
Of vulva, nof. m. 
Soreneas in urethra, carbo a., hepar, 

ign. 
Bpasm in bladder, oia/. 
In neck of, interrupting flow, 
op. 
Stitches In bladder, not. mur 

Urethra, can. tat., graph. 
Stool, atVan., aloe, alum., canlh., mur. 

Urging to, aloe,alum., eanth. 

Straining and prolapsus recti, 
valer. 

Tearing in urethra, nuz v. 

Tenesmus of bladder, lith. c. 

Thighs, pain down, pareiro. 

Throbbing in neck of bladderduring 
straining to urinate, dig. 

Drsthra, bnmlac, aeon., aloe, ant. c, 
ant. (., arj. n., art., bapl., fact., 
calc., can. ind,, can. lat., capt., 
carbo a., cauBt., eham., elem., eup. 
purp., glon., helon., hepar, ign., 
kali b., kalic, loch., mag. c, merr. 
C, mur. ae.,Tial. C, no(. m., nat.t., 

pior., rhtiim, tab., ttaph., thuja. 
Gutting, an(. c, eanth., guai., mur, 
ac, nux m.,op., ptor. 



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DURIiie CBINATION— CONTIVrKD. 



Smsrting, eoleh., eup.purp^ graph., 
iffrt., tob.. mag. c, mere. c.,na,t. m., 
nit. ac, pUlea, tfp. 
As if raw, colck. 

StiDgfng, can. ind. 



Urethra, atitflhes, can. »at., graph. 

^Tearing, nwr v. 
Urging and protapauB recti, vaUr. 
VariceB protrude, tali c. 
Vulva, Bmarting and soreness, nat. ny 



APTBB UBINATION. 



AebiDg of back, relief aft«r, lye. 
Bladder, achiog ia.fiuor. ae. 
Sense of fullness continues, dig.i 

eup. purp., rvia, $taph. 
Spasmodic in neck of, extending to 
thighs, puU. 
Burning, ant. t., brom., can, sat., 
canth., capt., con., fltior. ae., trit, 
tali b., kali c, Ud., mag.m., nat. c, 
nat. m., staph. 
And cutting from necic to fossa 

naviculsris, canth. 
With dribbling, hrom. 
Cutting, canth., lye, nat. tn. 
Desire continues, herb., hov., tcnega, 

itann., staph. 
Fullness in bladder, sense of, con- 
tinuee, dig., eup. purp., rtda, 

Even after frequent urination, 

eup. purp. 
And feeling aB if moving up and 
down at every step, rvla. 
Headache, relieved by profuse uri- 
nation, gels., sxL 
Jerking and cutting in urethra, lye. 
Lancination in abdomen, relief fronn, 

Pain, severe, sars. 
Spasmodic, in neck of bladder, ex- 
tending to thighs, pul«. 

Sexual organs excited and sense of 
weakness, herb. 



Shooting to abdomen, tarar. 
Soreness in urethra, carbo a., liepar. 

Spasmodic pain in neck of bladder, 

extending to thighs, pul*. 
Spasm of bladder, ataf. 
Stitches and lancination in abdo- 
men, relief from, carho a. 
Urethra, burning, ant. t, brom., can. 
sat., canth., caps., con., ftuor. ac, 
iris, kali b., kali c, led., mag. m., 
nat.e., nat. m., staph. 
In glandular portion, continu- 
ing long after, kali 6. 
Cutting, canth., lye, nat. m. 
Drop remained, Bensation as [f, arg. 
n., kali b. 
Running down, thuja. 
Jerking, lye. 

Smarting, borax, caps., HI., ptelea. 
Stinging, can. ind. 
Stitches, kali b. 
Straining, mur. ac. 
Tenesmus, mur. ae., ni(. ae. 
Urging, mur. ac., nit. ac. 
Urging continues, berb., bov., senega. 

Urine were still flowing, sensatioa 

as it, «tbtir. 
Weakness and dullnesa relieved 

after, irreb. 
Benae of, and excitement of, 

berb. 



Ooiigh. — In addition to the more comnion disoasee of the 
respiratory tra«t, from which pr^naut women are notexempt, 
there is a Bpasmodic cough, doubtless of reflex origin, which 
sometimes proves most distressing. It bears a resemblance to 
whooping-cough, and may become so violent, and the par- 
oxysms so frequent, ae to excite abortion. 



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DiBEASEB AND ACCIDENTS. 255 

Aconite for a few days, followed bj nax vomica, has proved 
efflcacious. If the coagh is worse in the evening and night, 
belladonna. If attended with vomiting, ipecac. Cimicifu/fa 
and aepia are sometimea indicated. Other remedies are bryoma^ 
pbosphoruB and coniam. 

Dyspncsa. — Oppressed respiration, not always amounting- 
to real dyspnoea, may arise from reflex causes, but real diffi- 
culty of breathing most frequently proceeds either from upward 
pressure of the uterus, or from heart disease. 

When it is clearly a reflex condition, moscbuB, nux moscbftta 
and lobelia are likely to afford aid. Nux vomica in these and 
other cases, on special indications, will be found of service. 
When dependent on heart disease, strophantbus, digitalis and 
cactus are better remedies. We have recently given great relief 
in a case of mitral insufficiency, by the use of spongia,. 

Sleeping with the head and shoulders elevated will be found ' 
to have an ameliorating effect on the distress. 

HemorrhoidB. — Pressure of the gravid uterus on the hem- 
orrhoidal veins, accompanied, asitoftenis, by a loaded rectum,, 
ultimates with facility in the production of piles. Coincidently 
with this dilatation of the rectal veins, varices in other parts,, 
such as the vulva, vagina and lower extremities, are often ob- 
served. Distension may become so great as to produce rup- 
ture, ^ving rise to va^nal or vulvar thrombus or hematocele, 
a condition which will be described in another place. The hem- 
orrhage resulting from such an accident is sometimes profuse. 

Hemorrhoids may be kept within bounds, and thus much 
suffering averted, by securing, without 14ie use of purgative 
remedies, a daJIy movement of the bowels. Much can be done 
to favor this, as observed under the head of "constipation," 
by regular efforts at stool. 

Belladonna. — Piles so sensitive that the woman eaanot bear 
to have them touched ever so lightly ; the back feels as though 
it would break ; throbbing headache. 

Aloes. — The piles protrude, and are not and sore, attended 
with bearing-down sensations. 

Hamawelis. — Bleeding hemorrhoids, with burotng, soreness, 
follness and weight, with tendency to rawness. The local use 
of the aqueous extract is very beneficial. 

Nnx vomica.— Ib of greatest service to women of sedentary 
habits, and thoue who have been accustomed to the use of 
cathartics. 



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256 Preqnancy. 

iSi?/37a.— The piles come down with even a soft stool ; feeling 
of beariugand Btraiaingin the rectum; oozingof moisture from 
the rectum ; soreness between the nates. 

Salphar.—lt is suitable to jriles of all descriptions, and 
should be given when any of its general characteristic symp- 
toms are found, 

CoUimonia,. — This is one of the best remedies. Sensation as 
of sticks, sand or gravel, in the rectum. Worse in the evening, 
better in the morning. 

jEscu}uB hipp. — Blind and painful hemorrhoids, sometimes 
slightly bleeding; severe pain across the back and hips ; feeling 
as of a stick in the rectum. 

Other remedies sometimes required are, aconite, &pis, alu- 
mina, caJcarea carb.,. graphites, leptandria, nitric acid, Pul- 
satilla. 

An operation for radical cure of hemorrhoids during ges- 
tation is not advisable; but should they remain permanently 
protruded after the puerperal period has passed, they may 
be excised, with proper precautions, or otherwise cured. 

Varices. — The veins of the lower extremities, in certain 
women, become varicose, and sometimes painful. When this 
is true, an elastic stocking gives considerable comfort. 

A varicose condition of the vulva can be kept in check by 
the moderate pressure of a soft pad held by a T bandage. 



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DlSBABES OF i^REONANCY. 



CHAPTER XI. 
DISEASES OF PREGNANCY— Continutd. 

Displacements of the Gravid Uterus.— The gravid uterus 
is liable to diBplacement, and th6 occurrence forma one of the 
BeriouB complications of pr^nancy. 

Antbversions and Anteplexions. — There is much to be- 
found in homeopathic literature on this subject, and one would 
be led to suppose that it is not only a common occurrence- 
during pregnancy, but that it is a frequent and serious cbmpli- 
cation of labor. This error proceeds from a want of clear 
comprehension of the normal incliuation of the longitudinal 
uterine axis. The plane of the 
pelvic brim lies at an angle of 
about 60° with the horizon, 
and it is generally supposed 
that the long uterine axis is 
coincident with, or lies parallel 
to, the axis of this plane, which 
would give the fundus uteri, as 
is seen in the Sgure, an iucli- _ 

nation forward more marked Fig. 121.— Relative Bi«e and in- 
tban many suppose. The nor- clination ot the TJterug at the c1ob» 
mal anteversion of the impreg- "^^ GeBtatfon. 
nated uterusis, at first, sometimes exa^erated by the increswed 
weight of the gravid uterine body, but the deviation is usually 
rectified by the gradual development, and upward movement, 
of the organ. In rare cases the deviation continues after the 
fourth month, and produces tenesmus of the bladder, dysuria, 
or incontinence. The condition, when once recognized, is- 
readily overcome with, or without, an abdominal supporter. 
A pessary would be of no sei-vice. 

A similar position of the uterus in late pregnancy forma 
what is known as pendulous abdomen, which is referable to 
inadequate abdominal support, proceeding from relaxation of 
the parietes, separation of the recti muscles, or to the cicatrices 
left from operations or iujuries. Curvature of the spine, and 
contracted pelvis, favor its production. Cases are on record 
wherein the recti muscles were separated, and the uterus was. 




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■258 Pbeonancy. 

•anteverted between them, covered ODly by fascia and intega- 
ment, nearly tn the kuees. 

Treatmebt clearly consistB in the reduction of the displace- 
ment, and the application of a firm abdomiual bandage. 

RKTROVEiiaiON. — This is aow r^arded asacomparatively in- 
frequent form of uterine displacement durinf? pregnancy, and 
when spontaneous rectification does not occur, thedevelopment 
of the organ forces it into a.fiexed condition. 

Retroflexion. — This is an uncommon occurrence in women 
for the first time pr^nant. It may arise during pr^nancy 



Pig. 122.— Proien lectloii of retroTerted uterus of three and a hftif to tonr 
fnonthB. Dea'h from rupture of bladder. 



■from the same causes which produce it in the non-pregnant 
state, such as a fall, or undue dieteuBion of the bladder and 
rectum; bnt sometimes it is doubtless due to displacement of 
the ortcari which antedates conception. 

With the advance of pregnancy the uterus generally 
straightens and clears the pelvic brim, without serious incou- 
veiiience. This spontaneous rectification is uot so apt to occur 
in chronic cases as in recent ones, because tissue tonicity is 
gi-ciitly impaired. In many cases the fundus does not ascend 
above the sacraJ promontory at the usual time, but remains 
incarcerated In the pelvic cavity, when the condition which was, 



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Diseases of Pbeonancy. 259 

perhaps, at first, one of retroTersion, now becomes partial re- 
troflexion, by means of which the uterine cavity is divided into 
dtverticuli op pouches — an anterior and a posterior. 

The symptoms of incarceration embrace dysuria, or even 
complete retention, Tesical tenesmus, incontinence of urine, 
painful defecation, constipation or obstipation, severe sacral 
and lumbar pains extending into the thighs. In grave cases, 
«mesi8, and all the other symptoms of ileus, may be developed. 
At any time during incarceration, abortion may occur, followed 
by relief of the thi-eatening symptoms ; but should it persist, 
metritis, parametritis and peritonitis may ensue with fatal 
njfiult. Death may also result fi-ora pathological processes set 
up iu the bladder by retention and decomposition of urine. 
These are cystitis and gangrene, which, in turn, give rise to 
septiceemia or vesical rupture. The retention may lead to 
urtemic poisoning, and thus to death. 

The diagnosis of retroflexion and incarceration of the uterus 
is not often difficult. As the physician passes his finger along 
the vagina, in order to reach the os uteri, he will find that it 
impinges upon an elastic swelling along its posterior and supe- 
rior border, lessening and changing the course of the latter, 
and if pregnancy be advanced to the fourth or fifth month, 
completely filling the cavity of the lower, or true pelvis. The 
cervix uteri, if discovered, will be found behind or above the 
posterior or inner face of the symphysis pubis. On abdominal 
examination, the fundus uteri cannot be felt above the pelvic 
brim. By bimanual examination, the alternate relaxation 
and contraction of the gravid uterus can be made out, and 
■diflerentiation 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 also give important data. 

The distinction between an incarcerated uterus aud an 
extra-uterine pregnancy is sometimes difficult, necessitating a 
thorough and careful bimanual examination, aided, in cases 
of abdominal tenderness, by the employment of an anes- 
thetic. 

Treatment. — In these trying cases delay is dangerous, owing 
to the progi-essive increase in size of the uterus, and the per- 
nicious effects of long-continued pain and physical disturbance. 
The object to be held in view, is a return of the fundus uteri to 
a situation above the pelvic brim. But before attempting the 
operation there are certain preliminaries to be observed, the 



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260 Preqnancy. 

first of whicli is thorough evacaatinn of the bladder and rec- 
tum. For the 'purpose of drawing the uriae there is no instru- 
ment superior to tb» soft rubber catheter, of Huiall size, as the 
urethra is too greatly altered in its course and calibre by the 
compression to which it is subjected to admit of the safe use of a 
stiff catheter. Even with this instrument v/s may sometimes 
utterly fail, in which case puncture of the bladder, if distension 
exists, may be practiced above the symphysis pubis by means 
of a small needle of the aspirator. 

Another preliminary to the operation in cases of real uterine 
incarceration is the induction of anesthesia, and the placing of 
the woman in the Sims' latero-prone position. The knee-oliest 
position should be prescribed if no anesthetic is used. The 
operation itself is performed by introducing four fingers into 
the rectum, and pushing upwards on the fundus uteri. Dr. 
Barnes recommend* 
turning the fundus- 
to one side, so as tO' 
avoid the sacral pro- 
montory. Repeated 
efforts may have t-o 
be made to achieve 
complete success. 
Mere evacuation of 
the bladder and rec- 
tum, and the influ- 

P.G. 123.-Soft rubber Catheter. «"•=« O*" gravity 

brought to bear 
through the assumption of the knee-elbow, or knee-chest posi- 
tion, will be adequate in some eases to bring about complete- 
reduction. This result may be still further promoted by retrac- 
tion of the perineum with the fingers or by Sims' speculum, 
and the admission of air into the vagina. 

An instrument has been devised by Dr. H. N. Guernsey, 
which serves an admirable purpose in the accomplishment of 
difBcultr redaction. It consists of a curved rod of steel, upon the 
end of which is a hard smooth ball, about three-fourths of an 
inch in diameter. The instrument is provided with a suitable 
handle. "As soon as a case of this form of displacement is 
clearly diagnosed," says the J)octor, "if the urine or feces are 
retained, the nsual means should be at once adopted for their 
evacuation. The patient should then be placed on the bed^ 



the rectum, and pushing upwards on 



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Diseases of Phkgnancy. 201 

near its edge, upon her knees and elbows, 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 
convex surface of the rod upwards, then gently pressed till 
within the sphincter, when the handle should be slightly ele- 
vated, so as to bring the ball against the anterior wall of the 
rectum. The instrument is now to be firmly and carefully 
pressed up the rectum, when the ball will elevate the fundus, 
care being taken to raise the handle of the instrument more 
and more ae progress up the rectum is made: and presently the 
uterus will r^ain ite normal position immediately posterior to 
the symphysis pubis," 

It has been recommended that a Hodge pessary of large 
size be introduced into the vagina, after reduction of thedisloca- 
tion, and allowed to remain until the uterus haa reached a 
size which precludes the possibility of a return to its former 
position. Others advise simple lateral decubitus, without the 
use of a pessary. The after-treatment includes also careful 
attention to the bladder and rectum, neither of which should 
be permitted to become loaded. 

It occasionally happens that replacement of the uterus is 
prevented by inflammatory adhesions, or by the secondary 
swelling of the displaced organ, in which case the induction of 
abortion is the only recourse. Mechanical obstacles to the 
ordinary methods of arousing uterine action are here met, and 
the accomplishment of the object in a tolerably safe manner 
will tax one's ingenuity and skill. The introduction of a 
uterine sound, or a flexible catheter, is rarely practicable. Dr. 
P. Miiller, in a case of complete retroversion, resorted to the 
following ingenious expedient, a knowledge of which may be of 
benefit to others. He cut off the end of a male silver catheter, 
and after having bent the extremity, he hooked it within the ' 
cervixuteri, which waslookingupwardsand forwards. Through 
this artificial channel he passed a piece of catgut, and left it 
between the membranes and uterine wall. In twelve hours the 
foetus was expelled. If our efforts to pass a foreign, but in- 
nocuous, substance within the uterus prove unavailing, the 
organ may be punctured through the vagina with an aspirator 
needle, or a fine trocar, and a portion of the liquor amnii with- 
drawn, with but slight risk to the woman, if done under 
strict antiseptic precautions. This is a sure method of bring- 
ing on abortion. 



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2G2 Pbegxancy. 

Prolapse of the Uterub. — We have already directed atteu- 
tion to tbe norma! descent of the gravid ut«n]8 during the 
early weeka of gestation ; but we have now to mention the 
descent beyond the physiological boundB there described, when 
it becomes pathological. Hut«r, who, in 1860, collected all the 
recorded cases, makes the following division : 

1. The gravid ntenis being prolapsed, reduces itself during 
the first months, and pregnancy and labor follow their usual 
course : 5 cases. 

2. The prolapse is not spontaneously reduced. Its artificial 
reduction and -support must be undertaken : 8 cases. 

3. Reduction cannot take place, because of incarceration: 
3 cases. 

4. The prolapse causes labor before term : 7 cases. 

5. Prolapse occurs in the second'half of pregnancy, and per- 
sists to term and during labor : 3 caaes. 

6. Prolapse occurs just before or during labor as term. In 
such a case, prolapse may not have existed prior to labor, or, 
if it did exist before, was spontaneously reduced during early 
pregnancy; or the prolapse was reduced and the utjertis sup- 
ported by a pessary : 16 ca«es. 

7. Prolapse occurs during pregnancy and labor: 15 
cases. 

8. Prolapse existed before impregnation, but became pro- 
nounced during labor: 16 cases. 

These give a total of 73 cases. 

In women predisposed to prolapsus, the condition is easily 
brought about in. the early weeks of pregnancy. In thosecases 
wherein prolapsus existed before impregnation, the condition 
may not only continue, but become aggravated during early 
gestation. It is found to exist more frequently in multigravidte 
in whom the process of uterine involution after former labors 
had not become complete, A prominent exciting cause is trau- 
matism, under the power of which great strain is put upon the 
natural uterine supports. 

The disturbancps to which this sort of displacement gives 
rise, vary in severity and character with the stage of pregnancy 
at which it occurs. Should the condition remain unrectified, 
the bladder and rectum become irritated, and there is a feeling 
of weight in the anus, and of painful tractions in the groins, 
lumbar region and umbilicus. A fretid discharge is set up, 
change of position does not relieve the sufiering, and a state of 



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DiSEAJSES OF Prkgnancy. 263 

-maraamus ie liable to superveae. An intensitlcation of these 
symptoms goea on uutil abortion ensues. 

IVocidentiiiissoinetimes simulated by cervical hypertrophy. 
When this involves the intra-vaginal portion, the elongated 
neck may, from its mere length, be forced downwards to such 
an extent, that the oa will lie between the labia, and there be 
subjected to constant friction and atmospheric irritation. The 
result can easily be predicted. In view of the prognosis under 
these circiimstancefl, and considering the prejudicial influence 
which such a pathological state would naturally have on the 
woman's general health, as well as the prf^nancy itself; cervical 
amputation has sometimes been practiced, without interrup- 
tion of pregnancy. 

Prolapsususually rectifies itself as pregnancy advances; but 
it may, in many cases, be thought beet to elevate the womb 
from time to time with the finger, but always in a most gentle 
manner. Such treatment, if followed by a season of rest in 
bed, will be found most serviceable. 

When prolapse is complicated by vesical distension, it may 
be necessary to use the catheter for t^tmporary relief; but this 
instrument ought to be discarded if simple expedients can pos- 
sibly be made to accomplish the desired end. 

When the developing uterus becomes incarcerated in the pelvic 
cavity, in a state of prolapse, the condition is somewhat tike 
that of incarceration with retroversion or retroflexion. If un- 
relieved, abortion is sure to ensue, and therefore reasonable, 
but not violent, attempts should Iw made to push it above the 
pelvic brim. If such efforts are not attended with success, 
abortion ought to be artificially induced before the tissues have 
been long compressed. 

Oardiac Diseases. — We have elsewhere noted the circula- 
tory changes incident to pregnancy, prominent among which 
are alterations in the relative constituents of the blood, the 
fibrin being increased and the red corpuscles diminished, while 
the total quantity of blood is greatly augmented. We should 
here allude also to cardiac hypertrophy and increased arterial 
tension. Accordingly we are not surprised to observe that 
pregnancy appears to hasten the development of cardiac 
leeuons. The latter vary in seriousness with their form. Myo- 
carditisinterfereswith the development of cardiac hypertrophy, 
compensatory for the increased blood supply and, in some 
instances, pre-existing valvular lesions. Endocarditis shows a 



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364 Pbbonancy. 

stroncr tendency to aaBume the fatal nloerative form, while 
perJcarilitis has no marked effecton thenormal course of utero- 
gestation. The chief duii^r in these cases lies in the direction 
of interference with the necessary hypertrophy which pref^ancy 
imposes ; while another element of danger is found in the 
rapidly changing degrees of vascular pressure brought about 
during labor, by intermittent uterine and general muscular 
action. 

The early weeks of pregnancy are comparatively free frour 
indications of cardiac disturbance; but when once developed 
it rapidly augment*) in intensity, and the woman thus afflicted 
rarely goes to term. The distressing symptoms point to^ 
pulmonary congestion andcedema, — occasionally to pneumonia' 
and pleurisy. The most serious valvular lesions, here, as iw 
the non-pregnant state, are 1. Mitral Ktenosis, and 2. Aortic- 
insufficiency. In those cases wherein the pathological con- 
ditions have developed during pregnancy, when once the' 
disabled heart haa weathered the storm of parturition, the' 
abnormal symptoms usually subside ; but, wheu pregnancy has^ 
merely aggravated pre-existing disease, the patient is extremely 
liable to sink during the puerperium. This latter clinical fact' 
was recently made peculiarly impressive to us by the death of a 
patient, three days after delivery of two seven-raonths foetuses, 
in whom there was decided tricuspid insuSlciency. 

Women who are the eubjecto of serious cardiac lesions ought 
not to be encouraged to marry. 

The existence of pregnancy will not materially modify the" 
treatmentof thesecases. Thepatieut must have plenty of fresh 
air and good food, but excesses in both should be scrupulously 
avoided. 

In our medication we should select remedies mainly from 
among the antipeorics, and the patient's early history should 
be carefully scrutinized for indications. 

These diseases constitute no contra-indicataons for the use 
of anesthetics, though they ought to be given with unusual 
caution. 

Eruptive Fevers.— MEABI..E8 is inft^uent, not more than 
two-score of cases having been reported. In those instances 
where they did not appear, they manifested a strong tendency 
to become hemorrhagic, and to excite metrorrhagia which 
terminated fatally to both mother and child. Pneumonia 
is a frequent and dangerous complication. Abortion nearly 



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DiSEAHEB OF PitEGNANCY. 265 

always takes place. The mortality arising from this disease in 
high ; but attacks occurring in the early months are not as 
dangerouH as those encount«Fed at a later period. 

Variola, among eruptive fevers, is the most frequent and 
dangerous of them all. The dangers arising from an attack 
are augmented as the woman advances in pr^iniancy, hence we 
may regard it as a fortunate clinical fact that the disease shows 
a preference for the early months. The ordinary perils of such 
an attack are here increased by a strong tendency to abortion 
and profuse hemorrhage. The disease itself may, after abor- 
tion, assume a hemorrhagic type. The more severe forme of 
the disease prove almost invariably fatal to both mother and 
■child. In one series of twenty-nine cases of all degrees of severity, 
tabulated by Meyer, five died and nine aborted. In another 
series of forty-seven cases, eighteen died and twenty-two 
aborted. When the disease assumes a mild, or discrete, type, 
itfi course is generally favorable, though abortion often en- 
dues. 

Scarlatina.— Cazeaux never saw a case of this disease in a 
pr^^ant woman. Olehausen, after thorough search, was able 
to collect only seven cases while he found one hundred and 
thirty-four in puerpene. A striking peculiarity of the disease 
as it appears in connectiou with the pregnant state, is its long 
period of incubation. The disease, under other conditions, 
displays peculiar whims in this respect ; but, in some instances 
where it has appeared in pregnancy and puerperality, the lapse 
of time between exposure and development has been astonish- 
ingly great. For instance, a woman in the early months may 
be exposed to the contagion, and temporarily escape its 
baneful influence at the time only to fall a prey to the disease 
in the puerperal state. 

As a result of the disease in pregnancy, miscarriage always 
takes place, and, in the larger nnmber, death ensues. 

Apart from the mauagement of threatened or accomplished 
abortion, the disease requires treatment, differing in no essen- 
tials from that of other cases. 

Continued Fevers. — Typhoik.— Pregnancydoes not exempt 
from attacks of the various continued fevers, nor does it seem 
seriously to modify their course, save in the one particular of 
added miscarriage. Out of seventy-two cases of typhoid fever, 
sixteen aborted ; and out ot sixty-three cases of relapsing fever, 
pregnancy suffered interruption in twenty-three. 



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266 Pregnancy. J. 

As in the eniptive diseafies, so here, these fevers are more 
likely to attack women in the early part of the t«rm. Foetal 
dangers, arising through abortion, are sufficiently expressed 
in the figures just given ; while the maternal perils are increased 
chiefly by the abortion which is so liable to ensue. In serious 
types of the diseases, danger is augmented by the uterine hem- 
orrhage which may occur without immediate interruption of 
pregnancy. 

No special observations concerning treatment are necessary, 
excepting to notice the unusual demand for the tampon in view 
of the greater danger of excessive hemorrhage, and the in- 
creased difficulty of controlling it. 

Malarial. — The revulsive effect of pfegnancy brings out 
latent dyscrasiee and lurking poisons, malaria among the 
number; yet the organism, at such a time, does not seem to be 
a fertile soil for its development. When malarial symptoms 
are manifested, their paroxysms assume either an anticipating 
or ti retarding tendency, being very irregular in appearance- 
Rarely the type is pernicious in character. Even though pro- 
tracted in its stay, malarial fever seldom results in abortion. 
"When labor supervenes during the fever, the paroxysms may 
be temporarily interrupted, only to return a few days post- 
partum. The interruption is not infrequently for alonger period. 

Araeaicnm. — This remedy is one of the most valuable, espe- 
ciallyin cases of ancient infection. We find it peculiarly suited 
to the irr^^lar type of the disease, 

Natnim m. — In the 30' trituration, we have found this a 
most effective remedy, especially when the paroxysm occurs 
in the forenoon. 

Pukatilla. — When the paroxysm comes on late in the after- 
noon, or in the evening; not well marked in all its stages; 
temperature does not mount to a great height; and there is- 
little thirst. 

CAJna.— From this reniedy in potency, we have observed no- 
speciut eflfect; but there are cases, especially those of recent- 
origin, which seem to demand quinine in appreciable doses. 

There are many other most excellent remedies, even a list of 
which would occupy too much space for insertion in such a 
work as this. Cases which do not readily respond to the 
selected remedies, demand special search for a similimum. 

Pneumoma. — This is always a serious disease, but doubly 
ao when it occurs during pregnancy. The danger here arises^ 



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Diseases of Pregnancy. ^67 

not because of a, special enfeeblement of the vital forces, or any 
peculiarity of the constitution during pregnaucy; but because 
of the extreme danger of the added complication of abortion. 
Among all the inflammations involving the parenchyma or the 
envelopes of the various organs, no one is so liable to excite 
abortion as this. Grisolle reported four cases of his own, and 
collected eleven others, out of which number four aborted a few 
days after the onset of the disease, and ouly one escaped 
serious symptoms. 

Pneumonia in pr^nancy is unquestionably a remarkably 
fatal disease. Grisolle reports a mortality of 92.8 per cent.; 
Rican, 35,8 per rent.; Bourgeois, 7 per cent.; Wernick, 21.1 
per cent.; Uhetelain, 39 per cent. Dr. George B. Peck, in 1887, 
collected the experience of nineteen physicians, which showed 
a mortality, alike for mother and child, of 14.28 per cent. 
The same statistics, however, establish the comparative inh-e< 
quency of the disease^ 

The strong tendency to abortion is probably referable to a 
combination of causes, among the chief of wliich are, the 
hyperpyrexia, the intensity ot general reaction and the par- 
oxysnis of cough. The cause of maternal mortality has been 
a moot point, and is not yet fully settled, but it is fairly refera- 
ble "to coexisting hydreemia,and to theinability of the poorly 
nourished heart to restore the balance of a pulmonary circula- 
tion disturbed by the consolidation of lung-tissue nnd by the 
consequent impermeability of large capillary areas." The im- 
mediate cause of death is pulmonary cedema. 

The induction of premature labor is not to be considered in 
connection with the management of this disease, since statis- 
tics plainly show that it greatly augments the dangers. In Dr. 
Peck's tables before alluded to, we find that, out of 82 wonion 
who suffered miacarriage during the disease, 58 died ; while out 
of 74 who did not abort, only sixteen died. Still, if labor 
has already l)egun, it should be hastened as rapidly as may 
seem advisable. Under judicious homeopathic treatment we 
look for far better results than have thus far crowned old- 
school management. 

Aconite may be of some service at the very beginning, pro- 
vided it is indicated by its three prominent symptoms; heat, 
thirst and reatlessness, but not otherwise. We do not sympa- 
thize with that practice which prescribes aconite at the beg:in- 
ning of every acute attack of disease accompanied by fever. 



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268 Pbegkakcy. 

Yeratnim vir. may likewise aifford some aid, provided the 
Attack is violent, the fever high and the pulse hard and bound- 
ing. 

Bryonia.— This ie the remedy from which we may expect the 
best results, even in the incipiency of the diseaae. Its provings 
furnish us with a better picture of the diseasethan any other 
in the whole Hst. It corresponds to the most tborooghly 
fibrinous nature of the eiadation. The fever, the thirst, the 
sharp pains, worse from movement, and the cough, all consti- 
tut*i good indications for this remedy. 

PhospboruB. — "Experience," says Hughes, "hasshown that 
it is difficult to define i(s sphere of userulness, and that it may 
either come in (as Jousset recommends) to renforce bryonia 
when that medicine is not telHng, or from the outset when the 
latter is not specially indicated, with the utmost advantage." 
When the exudation is being slowly absorbed, and the respira- 
tion is stitl accelerated, the patient complaining of a sense of 
oppression of the chest, this remedy will do good service. 

Arsenienm. — The temperature is elevated, the patient 
thirsty, restless, and sleepless. Also with a low temperature, 
and indications of sinking vitality. 

Antimonium tart. — Much rattling of phlegm on coughing 
land breathing, but much difficulty in loosening it. Especially 
serviceable during the stage of i-esolution. 

Among other valuable remedies are, beUadonna, carbo veg., 
cuprum, lycopodjmn, mercurius, sanguinaria., and rhva tox. 

Phthisis. — Contrary to the commonly accepted befief, it 
appears that pregnancy, in the majority of cases, hastens the 
progress of phthisis, and precipitates its development. The 
latter is true, of course, ehiefiy of those women who have an 
heredity, or a strongly-acquired tendency to the disease. Out 
of twenty-seven cases collected by Grisolle, twenty-four showed 
the first symptoms of tlie dtHease during gestation ; from which, 
together with other data, we are led to believe that pregnancy 
does not exert a protective infiueuce against the development 
of this dieoaee. Oanlard reports thirty-two cases in whicb the 
condition was aggravated, and collected eighty-four in which it 
originated during pregnancy, and was evidently aggravated by 
it. In advanced stages of the disease women are not susceptible 
to impregnation. A woman with inherited tendencies to the 
disease, may escape it in a first, and possibly, second preg- 
nancy, but fall a prey to it during a subsequent gestation. 



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Diseases op I'keg.vaxcy, 269 

When those suffering from this disease pafls safely through 
pregnancy and parturition, their vital forces are extremely 
reduced. They supply but little milk to their children, who 
are nearly always feeble, poorly-nourished, and who inherit 
consumptive tendencies. Lebart says that the influence of 
pre^ancy is not only most decided, but his statistics show 
that inheritance of the disease tendency is strongly marked. 
Following are hia conclusions : 

1. Latent tuberculosis in young girls most often appears 
after inarri^^ as the result of pr^nancy. 

2. In ezceptioual caaes the health of tuberculous women 
is not affected even by repeated pregnancies, though in some of 
these the children are feeble, and a certain proportion die early. 

3. Advanced phthisis usually prevents conception. In- 
■cipient phthisis does not prevent it, and the pregnancy goes on 
to term. 

4. Abortion, pregnancy and the puerperal state determine 
the development of phthisis in at least three-fourths of the 
cases. 

5. Children born of phthisical mothers are generally feeble, 
and often develop scrofulous symptoms and then tuberculosis. 

It is fortunate for such women and their offspring that they 
have little milk, as they are thereby obliged to resort to-other 
aourcen of nutritious supply for their children, thereby econo- 
mizing their own remaining strength, and saving their children 
from imbibing milk poorly calculated to well-nourish and to 
furnish the necessary elements for future constitutional vigor. 

Women possessing tendencies to phthisis should be dissuaded 
from entering the married state, as their interests, and those 
of society, will be best subserved by their never becoming 
mothers. 

How much good can be done for such patients is problem- - 
atical, but during gestation they ought to be well fe<l, and 
receive Rrseaicam jod., phosphorus, iofUam, sulphur, or other 
indicated remedies. 

Erysipelas. — Idiopathic erysipelas is much more disposed 
to attack the face than any other part, but even there is com- 
paratively infrequent in pregnancy. We have never seen a 
casp, and few obstetriciane have reported examples of the dis- 
ease. It would appear that pregnancy serves, not as a positive 
protection against the disease, but as measurably preventive. 
Its course is not materially altered bj' the woman's condition. 



save in the one particular of the added complication of abor- 
tion which is prone to occur and thereby increase the gravity 
of the progBosis. Tlie fatality is about equal to that of 



Treatment of the disease proper is substantially that of 
cas<« disconnected with pn^^ancy. 

lielladoana stands in the front rank, being indicated by the 
cerebral fullness, throbbing hecidache, elevated temperature, the 
dermatitis, etc. Heat without thirst we have always found a 
strong characteristic. 

Apis mel. — Swelling and redness of the skin ; stinging and 
burning. Little or no thirst. 

Rhus tox. — Part red and swollen, headache, dry mouth and 
much thirst, symptoms worse at night. The appearance of 
vesicles on the inflamed surface is a strong indication for this 
remedy. 

Other remedies are, arsenicum, aconite, mercurins, puisa- 
.tilJa and hepar sulphur. 

Syphilis. — With this disease in pr^cnancy we have had but 
little experience, and as the subject is so satisfactorily consid- 
ered by Charpentier, we quote from him as follows: "All au- 
thors agree in admitting the influence of oyphilison pregnancy, 
and of pregnancy on syphilis ; but there is a particular 'actor 
which imparts to this mutual influence special forms — the age of 
the syphilis. 

"1, Sometimes a woman is pregnant when she contracts 
syphilis, and the infection can then occur either at the begin- 
ning, during the first months after conception, or during the 
latter months. 

"2. Sometimes a woman becomes pregnant at the same 
time that she contracts syphilis. The infecting coitus haa also 
been fruitful. 

"3. Pregnancy occiirn in a woman who is healthy and in 
good condition, and who has never presented, nor does she 
then present, any evidence, old or recent, of Byphilie, but whose 
husband has possessed, or still possesses, a syphilitic diathesis. 

"4. Pregnancy occurs in a woman affected by syphilis at 
a time more or less remote; it was not treated, and the woman 
presents, or does not present, traces of it. 

"In the first place, what are the evidences of syphilis nmst 
often met with in the pregnant female? According to ail the- 
authors who have studie<l the disease thes" are esijecially the 



Diseases of Pregnancy. 271 

primary and secondary manifestations. The tertiary, on the 
contrary, are rare. These manifestations are greatly influenced 
in their course, and in their character, by ^^tation. This in- 
fluence of pregnancy is manifested in two ways, either locally, 
or generally, and both chancres and syphilides are subject to 
the disturbing circulatory effects which exist in the pr^naiit 
woman, and which result in either passive or active congestion. 
According to Fotirnier, pr^nancy complicates the pox by adil- 
ing to it its own anaemia, its depressing influence, its neuralgic 
tendency, disorders of nutrition, etc. As regards the local 
manifestations, syphilis predisposes to the development of 
mucous syphilides, which assume great importance. The in- 
duration is slightly marked, being a simple hardened ncale- 
parchment chancre ; but, while in the non-pregnant woman the 
duration of the chancre does not generally exceed from four to 
Ave weeks (rarely more, often less), in the pregnant female the 
mean duration of the chancre is about two months and twenty 
days. 

" According to Fournier, mucous papules are not only very 
common, but they develop in pregnant women a remarkable' 
exuberance, assume rapidly the budding, v^etating, or hyper- 
trophic variety, and often form actual tumors, which invade and 
distort the entire vulva. Moreover, they are ahvayH more- 
rebellious than usual, and disappear more slowly. Syphilitic 
olcers are quite frequent in pregnant women; they are livid, of 
a violet color, excavated, and are rendered still deepei* by the 
vascular turgeacence of the parts. They usually persist for a 
longer or shorter period, and often tend to progress, It is 
sometimes extremely difficult to cauBe them to cicatrize before 
delivery. While the duration of syphilides, in the non-pregnant 
state, varies from two to two-and-a-half months, it varieH from 
three to three-and-a-half during pregnaTicy. Gu^rin, who agrees 
with Fournier on this point, affirms that during pregnancy the 
mucous patches increasein number,and grow in spite of geneml 
and local treatment as long as the pregnancy continues; or 
that if they disappear for a short time, they have a great 
tendency to return, not only on the genitals, but also on the 
fauces, tongue, and lips. Their persistence, according to him; 
proves that treatment is not so effective as it is in the non- 
pr^nant condition. 

•'The Influence of Svprnus on Pregnancy.— Although the 
Influence of syphilis on pregnancy is unquestioned, it is, liow- 



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'272 Pregnancy. 

ever, not absolute, and varies with the conditions aceordiOK to 
which syphilis appeara in women. The important feature iethe 
frequency of abortion and premature delivery. Among 657 
ayphiliticfemiiles, 281 miscarried, while 426 were delivered at 
term of li\ing and dead children. But as we have Been, four 
cafes may be presented, and we must cousider here: 

" The father alone is syphilitic. The mother has never pre- 
:8ented, nor does she now present, any manifestations of nypbilis. 
The idea of direct transmiesion from the father to the foetus, 
without participation on the part of the mother, which was 
opposed for some time, has been defended by Trousseau, Diday,< 
Bourgeois and many others. It remains to-day incontestible, 
and we have observed numerous cases. 

" As regards maternal syphihs, we have seen that (1) the 
woman may be afTected before conception ; (2) syphilis and 
pregnancy may begin simultaneously; (3) syphilis may have 
been contracted after conception, at a period of pregnancy 
more or less advanced. 

"1. Syphilis existing Before Conception. — A syphilitic woman 
who becomes pregnant is far more predisposed to abortion than 
« pregnant woman who subsequently becomes syphilitic. This 
is especially observed in cases of repeated abortion, am] it is 
now a classical fact that all accoucheurs, both in France and 
abroad, with a few exceptions (happily rare), advise that, when 
successive abortions are observed in the same woman without 
apparent cause, she should be put on antisyphilitic treatment, 
and that, too, notonly when DO specific manifestation is present) 
but even when she has not shown any. 

" When the pregnancy advances to term, (1) thechild maybe 
born healthy and in good condition, and remain so (this is 
exceptional); (2) It may be healthy when born, but may, 
during the first three months after birth, rarely later, show 
symptoms of syphilis (quite frequent) ; (3) It may show 
symptoms of syphilis from its birth, and may then either 
succumb quickly (the rule), or may be cured by appropriate 
treatment (the exception) ; (4) Although apparently healthy 
when born, it may die within a few days, either by reason of its 
fr-eble condition in consequence of premature delivery (often), 
or from convulsions (when delivered at term). 

"2. Syphilis and Conception are Concomitant. — Here, too, 
abortion is the rule, or at least delivery is often premature, and 
in cun^equence of the rigid treatment to which -the mother is 



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DiBBABES OB^ PREGNANrY. 273. 

subjected, the child may, in exceptional cases, be born healthy 
(or without evident traces of ayphilis), and then, as in the 
former instance, may either be cured or may succumb. 

"8. Syphilis is Contracted After the Fourth or Fifth Month- 
of Pregnancy.— In this case the danger is lees, Abortion does 
not take place, but delivery is often premature, and when the- 
foetus reaches full term it may frequently be born healthy ; or it 
may be apparently healthy when bom, but may present syplii- 
litic symptoms within two or three months after birth. 

"^.Finally, the Woman Contracts Syphilis Only at t he- 
Termination of Pregnancy.— Then the danger is almost nil; 
pr^fnancy is concluded in the ordinary manner at term by the 
birth of a living, healthy child. It is during the secondary 
stage, that is, from the fourth month to the second year of this- 
period, that maternal syphilis seems to predispose to abortion. 
But. a« we know, syphilis may be active at the end of three, 
four, five, SIX years, or even longer. Those women are most prone ■ 
to abort who are affected with severeforms of the disease — those 
who, to use Fournier's expression, are affected ' rudement et vis- 
ceralement ;' butabortion may occur in all forms of the disease, 
eyen the lightest, and t« often the sole expression of the diatb' 
esis. 'There are a certain numbttr of women,' says Fourniw^ 
' who abort exclusively because of syphilis, without, at the" 
same tame, presenting, or having presented, for a period more- 
or less remote, any appneciable specific symptoms.' In his. 
opinion, tlien, even latent syphilis is still capable of causing' 
abortion. We sharo this conviction fully. 

" We see, therefore, that syphilis is one of the dieeases that ' 
deserves the ;grratesit attention on the part' of the accoucheur, 
and we realise iftfe full importance of treatment in the interest- 
of the TmUher tm 'well as the child. Some writers have neverthe- 
less ^n^rsted tlbat these ravages should be attributed, not to the 
'pox,ht/tto fts antidote, mercury. Such a view could not be too- 
•tftro'ngjly'dppofled, and all obstetricians a^jee with the syphilo- 
'giraph^rti In advising mercurial treatment during pregnancy, 
•ndt only "in the case of women who are actually affected by 
IQ'philis.'or who show evidences of it, but in every instance in 
which the father has had syphilis, and where there have beeni 
'repeated abortions without any known cause." 

We are not quite sure that many of the aggravated 
^yniptbms sometimes seen in the subjects of syphilis under old- 
-AehObl treatment, do not owe the aggravation, 4t 1?^t in part,. 

(18) 



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374 Pbeonancy. 

to the character of the treatment which they have received. 
At any rate, Buch cases are not with us so numerous. 

TitEATMENT.— That whlch follows wa« prepared by T. S., 
Hoyne, M.D., at our request, especially for this work. 

Ill the treatment of primary syphilis, mercarius cor. holds 
the first place, if mercury has not already been taken without 
benefit. A decided improvement should follow the adminis- 
ti-ation of this drug within four or five days, especially if the 
ulcer is superficial, with free secretion of thick pus, or in case 
the ulcer is spreading; and penetrating at the same time. 

MercuriuR jod. ffav. follows well if the former preparation 
does not alter the ulcer for the better. 

Cinnabar acts well in scjofuloua patients. 

Nitric acid always proves useful in persons who have ta,keii 
considerable mercury without benefit. The special indications 
are, easily-bleeding chancres ; superficial or elevated ulcer with 
zigzt^ edfrea, where no sifi^ns of central granulation are present. 

Arsenicum is a very important remedy, and one not to be 
overlooked when the chancre becomes gangrenous or phage- 
denic ; also for ulcers with proud flesh and bleeding edges ; and 
for ulcers with a copious, thin, ftetid discharge. 

In secondary syphilis the remedies which have proved bene- 
ficial may be grouped as follows : 

Ars., pbos., carbo veg., calc. carb., hepar sulph., ailicea, 
sulphur and kali carb. — Falling out of the hair. 

C^lc. carb., iodium, petroleum, si/icea, pbosphorua and snl- 
phur. — Cervical adenitis. 

Nitric acid, thuja, urg. nit., calc. carb., lacbesis and ansen- 
icum. — Ulcers in the mouth and throat. 

Nit. ap., arseoicvm, calc. carb., mercurias, phosphoraa, 
lycopodium and sulphur. — Erethema and roseola. 

Arsenicum, nit. ac., anrum, ars. jod., coral, mercurius, hep. 
sulph., phonphorns and phos. acid. — Squamous and scaly 
diseases. 

Hepar sulph., teUarinm, ailicea, sulphur, nit. ac, lacbesis, 
&nt. tart., graphites and mercurius.— Pustular diseases. 

In the tertiary form of the disease aurum is indicated for the 
afTections of the bonM of the skull with a suicidal tendency. 

Pbos. flcic/.— Low-spiritedness, with intense pain iu the peri- 
osteum of the bones. 

Silieea and kali jod. in scrofiilous persons, with ulcerations 
of the bones and fistulous opening. 



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Diseases of Preonancy. 275 

AsaftttifJa. — Cramping, jerking and drawing in the bones at 
night : nodes very sensitive to the toocb. 

Fiuoric acirf.— Burning and intermittent pain in tbe bones. 

I\'itric acid for exostoses in patients who have taken large 
-quantities of mercury, 

Rhus tox. — Rheumatic pains afi^rravated on first moving 
after rest, and on getting up in the morning ; paralysis of lower 
limbs. 

Carbo veg. — Lung complications, with loose rattling cough. 

Arsenicum. — Psoriasis palmaris and plantaris. 

Benzoic acid. — Intestinal complicatiouB, with copious, watery, 
:fiBtid diarrhwa. 

StHpbisagria. — Caries of the teeth ; ostitis and periostitis. 

Goitre. — Primary development during pregnancy is quite 
rare; but increase of antecedent goitre, both in size and an- 
noyance, is frequently noted. 

Iodine is doubtless the best remedy for goitre, though other 
remedies have cured many cases. We regard the galraoic cur- 
i-ent of electricity as very effective. 

Uterine Bheumatism. — We quote again from Charpentier: 
"Cazeaux and Gauthier have particularly called attention to 
this disease. Cazeaux considers it true rheumatism, but 
Oauthier regards it as identical with uterine neuralgia, which 
may also occur aside from pregnancy. Gestation produces 
modifications, however, in its course. Spiegelberg and Brauu 
do not believe in uterine rheumatism and consider it a« a result 
of either endometritis or metritis. 

^'Symptoms. — Among twenty-nine cases collected by Gau- 
thier, eighteen commenced during pregnancy, before labor, and 
eleven bt^an during parturition. The attack is never sudden. 
Before the appearance of uterine pain the patient complains of 
pains and contractions in the limbs and the trunk, of vertigo, 
palpitations and of syncope. Shortly afterwards, or at the 
same time, a continuous, dull pain, of variable intensity is felt 
in the sacrum the hypogastrium and the lateral abdominal re- 
gions. This pain is exaggerated by movements of the mother 
or of the fcetus. At the end of a few hours or days, the pain 
becomes suddenly violent, sharp, lancinating, and lasts from a 
few seconds to several hours, beginning at theuterus, radiating 
into the lower limbs, and extending to the bladder and rectum. 
On applying the hand to the abdomen, we And that its walls are 
not the seat, and that the pain is uterine and not so limited aa 



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276 - Pbeonancy. 

ID ordinary neuralgiaa. Almost always one of the surfaces or 
sides of the uterus is the chief seat of the pain. The pain is 
generally fixed, but may be mbbile, the fundus uteri being^ 
usually less affected than other regions. The women experience 
aseusation of spasmodic constriction, due to uterine contrac- 
tion, perceived by both patients and obstetrician during the 
earlier months. The uterus, in fact, grows hard. Sometimes 
it is smooth and sometimes nodular, from partial contractions. 
When the organ is large we can appreciate these changes Id 
form, which may, in certain cases, produce an annular trans- 
verse constriction. The latter may be partial, and involve 
different parts of the uterus, including the cervix, and may oc- 
casion, according to the case, either rigidity, or rapid dilatation 
of the cervix; 

"Gauthier admits two forms, one acute, febrile, and one 
ehrouic, apyretic form. The former may succeed the latter or 
may present momentary acute exacerbations. Uterine rheu- 
matism occurs most frequently at term and during labor, at 
which time it may become the cause of dystocia. It may be 
developed after labor, either immediately or after a few hours. 
It then causes spasmodic uterine contractions, which lead to 
retention of the placenta. Finally, it may occur later yet> 
after fifteen days, as in a case ofNeucourt. 

"The usual complications are neuralgic or rheumatic pains 
in certain vescera, in the muscles or in different nerves, particu- 
larly the vesical and rectal nerves. Luroth has seen a case of 
rheumatic meningitis, and finally, there may be muscular pains 
in the face, the neck, the arm, the shoulder, the thoracic walla 
and the lower limbs. 

"Very prone to relapse, this affection may recur several 
times, during or after pregnancy. The intervals vary from two 
or three days to several weeks. An individual attack varies 
from a quarter of an hour to twelve days, at the longest, hut 
in general it does not exceed twenty-four or forty-eight hours. 
The disease may reappear in successive pregnancies. It may 
end in recovery, which is the rule ; in a chronic condition, in 
metritis and in eclampsia. 

"1. InSaeme upon Pregnane j.— When the attacks have 
lasted a certain time, and have been violent, they are followed 
by uterine contractions, and may thus provoke labor. But it 
is not always so, and Wigand quotes a case where the cervix 
dilated, and the bag of waters formed; when everything was 



PwEASES OP Pregnancy. 277 

arrested, labor ceased, the os closed, the oervix regained its 
former length, and pregnaucy went ou its course. Sometimes 
thu pains simulate labor without inducing it, and they may 
■ occasion faulty presentations. 

"2. InHuence upon Labor. — Uterine rheumatism impedes 
labor, and sometimes even renders the spontaneous expuUion 
of the foetus impossible by interfering with the pains, by pro- 
ducing spasm of the cervix, and hj preventing the woman from 
making voluntary expulsive movements. 

"3, InSuence upon the Puerperal Functions. — By causing 
tetanic uterine contractions it may produce dystocia, or may 
occasion hemorrha^ by inducing uterine atony, which may ba 
followed by metritis or by perimetritis. 

" Causes.— These are difficult of detection. The disease may 
appear under all circumstances and at any stage of pregnancy. 
Gauthier saw it begin in twenty-nine cases, as follows : 



In the first five monthR, 6 times. 



In the MCODd month 
" " third 
" " fourth " 
" " fifth 


11 
3 

1 
1 


'• " Bixth 
*• " seventh " 
" " eighth *' 
" " ninth 


2 
4 

6 
12 



"Meiasner r^ards rheumatism as a neurosis of ut^inne sen- 
sibility and motility, caused by peripheral irritation, and 
particularly by cold. 

" The predisposition increases as the full term approaches, and 
is notably augmented near the time of labor. 

"Pro^/ios/s.— Although not fatal to the woman, uterim- 
rhenmatism is still serious because it may occasion abortion c»r 
premature labor, or by retarding and complicating labor it 
makes the condition of both mother and child much less favor- 
able. It is particularly disagreeable when developed at the end 
of pr^nancy, because of its tendency to recur several times 
Iwfore confinement, even when it does not interrupt pregnancy. 
In these cases it almost always recurs during parturition, which 
it renders long and difficult." 

Treatment.— The homeopathic medication of rheumatism 



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278 Phegnancv. 

ia not as satiBfactory aa we might winh, and yet by means of it 
we are frequently enabled to make some brilliant cures. 

CauIophyUum. — This we regard as one of the very beet rem- 
edies for the treatment of rheumatic conditions during pr^- 
nancy, and it is probable that, on account of its virtues in this 
direction, it has acquired a reputation for producing painless 
labor. Many of the false labor-pains which precede the true, 
and cause so much annoyance, are due to a rheumatic condi- 
tion of the uterus, and caulophyllum, when syatematically 
administered for a few weeks prior to labor, removes this, and 
leaves nothing but the labor-pains pure and simple to be suf- 
fered. Its control over after-pains, in certain cases, is probably 
due to a similar action. It is a remedy which we always use in 
the fluid extract. 

Arnica, is often serviceable, especially when the muscles feel 
lame and sore as if they had been bruised. 

Bryonia is indicated by its usual characteristics of a^^-ava- 
tion on motion, sharp, tearing, drawing pains, usually worse in 
the morning and from touch. 

Rhus tox. — Soreness and stifTness of affected parts ; worse 
during rest ; during cold, damp weather, and at night. 

These are tlie leading remedies, but other valuable ones are: 
ciniiciivga, colchiciim, mercurius, Pulsatilla, ranunculus, rhodo- 
dendron and sulphur. 

Women suffering from uterine rheumatism ought to be 
placed under the influence of an anesthetic aa early in labor as 
their safety will justify, and the delivery hastened as rapidly as 
the conditions will allow. 

Insanity of Pregnancy. — During the latter part of 1888, 
and the eai-ly part of 1889, Dr. H. H. Crippen published an 
article in sections, in The Homeopathic Journal of Obstetrics, 
under the above caption, so complete in detail, and so excellent 
in character generally, that for this entire account of the 
Insanity of Pregnancy, I have drawn almost wholly from the 
article named. 

"More than two years ago," says Dr. Crippen, "in writing 
on thin subject, I stated that, 'in selecting the title Insanity of 
Pregnancy for this paper, 1 have been guided by two reasons: 
first, that I might include all conditions pertaining to the 
mental aberrations arising from any of the exaggerated physi- 
ological influences affecting the child-bearing woman; and 



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Diseases of Pheqnancy. . 279 

second, that the term puerperal mauia, usually made to include 
all these conditions, is a misleading one, as many cases belong 
to the class of melancholia as to mania.' To-day I find myself 
supported in this view by Charpentier, who includes ia the dis- 
-eases of pregnancy, the insanity of pregnant women, insanity 
developed during labor, during the puerperinm, and during 
lactation, and further says: 'True puerperal mania, we admit, 
will manifest itself three or four weeks after labor, but it seems 
impossible for us to separate it entirely from the insanity of 
the pregnant or of nursing women. We therefore include 
these forms in our study.' From conception to the end of 
lactation we have a period marked by a series of physio- 
logical crises, and insanity, therefore, whether associated with 
the pregnant state, with parturition, or with lactation, is 
merely consequent upon a sequence of events that arise from 
pregnancy directly, or have that condition as their antece- 
dent." 

Before discussing symptoms, we will rapidly review the 
-statistics. 

"1. The Proportion of Insane Patients Occurring Among 
PregDant, Parturient, or Nursing Women. — The statistics are 
not only hard to obtain, but are also very untrustworthy, 
chiefly on account of noraeuclature." Crippen then gives the 
Jollowing table: 

Charpentier's statistics Among 6,700 found 41 cases. 

Columbia Hospital " 1,149 " 8 " 

Freedm«a'B Ho«pltal " 680 " " 



That is .529 per cent., or 5.29 cases out of every thousand. 
Even allowing that this is a higher estimate than the percent- 
age of cases occurring in private practice, there is still a great 
discrepancy between this and Fernald's statement that, at the 
lowest estimate, at least one out of every thousand lying-in 
women becomes insane. 

" 2. The Extent to which Insanity is Dae to Causes Relating 
to Pregnancy. — During the winter I spent at the Bethlehem 
Royal Hospital, I found that out of 561 female patients, there 
were 58 ceises, or 10.3 per cent." According to other sta- 
tistics which follow, the percentage is raised to 7.83. 



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280 Pbeonancy. 

8. Relative frequency of the caaes during pregnancy, durinf? 
the puer|>erium, and during lactation : 

Kumber ol cuea. PKci>*n<:y- Paerpeiium. LurUtioti. 

Palmer 19 a 8 12 

Eaquirol 92 M 3« 

. Hanwell (Connolly) 43 4 28 13 

Maodonnld 66 4 44 IK 

Manrf 310 27 180 103 

TukB 1B6 28 73 54 

Leidesdorff 20 « 14 

Crippen 68 7 47 4 

Total 768 78 444 243 

"1. Insanity During the Period of Pregnancy.— Beeidvn the 
physical disturbaaces caused by changen taking place in the 
constantly increaaing bulk of the ut«rus, we are all fantiliar 
with the various modifications in the tastes, habit«, and tero- 
perament of a pregnant woman. To what degree such chanf!;«s 
belong to the ' borderland of insanity' (so happily treated of 
by Maudsley), it is difficult to say. A slight derangement of 
the physical processes may produce eccentric longings, ufTect 
the emotions, the intellect, or the will, or change the habit of 
life, BO that those who were energetic may become indolent and 
laay, while others may become irritable, with a tendency to the 
perpetration of unusual acts. Besides the perverted longings 
and hysterical affections, the unstable conditions may anioimt 
to moral perversions, such as dypsomania or kleptomania, 
which in some cases may be gradually developed, and in others 
suddenly and irresistibly implanted. The proportion of caaes 
of insanity occurring during' pregnancy has already been shown 
to be comparatively small, being not nearly as common as- 
those at or following childbirth. In mj' list of 58 caaes, the 
seven that occurred during the period were all found to have 
their oripn during the latter months. In the earlier months 
excessive vomiting produces great exhaustion, and to this 
physical weakness, combined with a neurotic tendency, or to 
the latter alone, may be due those extraordinary longings and 
nervous symptoms, that, passing beyond the limits usually 
met with, become insanity. This may pass oflT to reajjpear 
after delivery, or may continue in an unbroken course through 
pregnancy to parturition, or beyond it, but the majority of 
cases ultimately recover. 

"2. The Period Beginning with Liihor and Endinff with tbe 



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Diseases of Pregnancy. . 281 

Locliifll Discharge. — Physiologically the pains of labor may 
often start consiflerable mental disturbance, and from this 
instability it is that casea of this period are more numerous 
than those of the two other periods combined. In Inj expe- 
rience, nearly seventy per cent, of the cases of insanity of 
pregnancy appear dnrinfi^ this time. This is the period in which 
the term puerperal insanity may be applied to the mental un> 
soundness. With this group I have included miscarriafce, of 
which I have the histories of seven cases. They differ but little 
from those of labor at full term, except, perhaps, in the partic- 
ular that complications exist, such as severe flooding, or that 
there might have been a shock as a causation of the premature 
delivery and likewise of the weak-mindedness. 

"The type of insanity varies much. In my own experience 
melancholia and acute mania predominate, the former slightly 
in excess." 

"Those cases of emotional, morbiQ, objectivp impulses, 
marked by homicidal and suicidal propensities, are of more 
interest in a medico-legal point of view. They are usually as- 
sociated with aversion to the children or to the husband, or, on 
the other bund, the impulse to destroy life may be the result of 
a delusion. That such cases are common are recognized by all. 
An analysis of my list of cases shows that sixteen were suicidal, 
nine homicidal. The refusal of food is a serious consideration, 
and cases are constantly coming to the hospital in an ex- 
hausted condition fix>m the lack of sufficient 'means of forced 
feeding at home. 

"Some cases are apathetic from the beginning; take no no- 
tice of' husband or child ; ^ave a dull vacant look ; are dirty in 
their habits and tend to lapse into indifference to their sur- 
roundings; so that, unless we succeed in arousing their torpid 
mind, they pass into a condition of dementia. 

■"As to temperature. Dr. Campbell Clark, of Kdinburgh, 
draws attention to four types of temperature curves observed 
among twenty casee: (a) 'A moderate and uniform increase 
i» uncomplicated cases." (b) 'A periodicity of increase and 
decrease.' (c) 'A uniformly high evening temperature with 
well morning remission in phthisical cases.' (d) '.\ i>ersistent 
high temperature pursuing an erratic course.' His commenton 
these differences in temperature curves is worthy of note. A 
significant addendum to the above statement is that cases of 
the (c) and (d) types died. 



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282 Pregnancy. 

"3. Insanity Due to Lactation. — ThiB condition is UBually 
aasociated with exhaustion after prolonged nursing, or it may 
appear in a weakly woman unable to stand this extra tax 
upon her strength after having passed through the puerperal 
state. So that the term over-lactation is relative, depending 
purely upon the accompanyiDg conditions. 

"In these conditions the physical exhaustion leads to men- 
tal idepreBsioti. To the exhaustion are due the anemic appear- 
ance, the shortness of breath and the sleeplessness ; while the 
uneasy feelings the patient experiences lead to delusions and 
hallucinations of sight, hearing or smell. Naturally enough 
the depressed state of the mind tends to delusions of unworthi- 
nese, so that the usual condition is that of melancholia. 

"Ktiolooy. — Primarily we may look upon the mental aber- 
ration as dependent upon an overthrow of that unstable 
conditiou of mind which arises from causes associated with or 
following pregnancy, but there are many important secondary 
considerations to berefeiTed to in this relation, since thedisease- 
presents, in so many cases, a double, a triple, or even multiple 
combination of causes. We may look u|>on the causes as pre- 
disposing and exciting, or again as moral, social, and physical; 
but rather than confuse by attempting any dividing line, it is 
preferable to consider each one separately, 

''Heredity. — The influence of heredity in predisposing to 
insanity is becoming well recognized. In consequence of a 
sameness of conditionB of long duration in the past, tissues 
may receive modifications that produce a proneness to suffer in 
a particular manner when exposed to ordinary exciting causes. 
In the instances which we are connideriug, the nervous system 
has been ewpecially influenced in the particular direction t« be 
pointed out under the discussion of pathology. 

" In my exj)erience, twenty-three out of flfty-eight cases had 
a family hintory of insanity ; in eight cases the mother had 
suffered from insanity, and in one cane there was the remark- 
able hiHtory of daughter, mother and f^andmother, ail having 
puert»eral mania. In seven casey phthisis existed in the family, 
and in thi-ee there wns a history of cancer. 

"Closely associated with heredity, as a predisposing cause, is 
the history of previous neuroses in the patient. In the histories 
of thirty-six ont of flfty-eight cases, there existed previous 
nervous disorders varying from convulsion to derangements 
of the mind. These cases include fourteen having previous 



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Diseases of Pregnancy. 283 

attacks of insanity during pregnancy, during the puerperium 
or during lactation, of which eleven were second and three 
third attacks. 

"Number of Pregoancws. — Most authorities affirm that 
primiparee are most subject to the diseatie. In my own experi- 
ence the proportion of primiparse to multiparas was twenty-six 
to thirty-two. The special point to be emphasized is that cases 
having children rapidly are liable t« suffer from exhaustion. 

"Age. — The following table will show at a glance the pro- 
portion oocurring at different ages: 

number From 15 M From U to From 35 to From 30 to From 3& to OveTtO 

of cues 90 ]>«Bn 35 yean 90 jean 35 re are 40 years years 

ObMrrer. reported, of age. of we. of age. of age. of aite. Qfa^e. 

CloaBton... 60 3 16 29 9 12 

Marce 56 1 13 17 13 5 6 

Savage ....207 49 67 44 29 18 

Crippen. ... 58 1 16 17 12 9 3 



" From this table it would appear that those in the earlier 
periods suffer most from this condition, but, since at this time 
fecundity is greater and the proportion of births greater, I 
believe that the tendency to insanity increases with age; for, 
with increasing age, we fiud women leas able to bear the trials, 
worry and exhaustion of pr^iiancy, parturition and lacta- 
tion. 

"Qualitative Changes id the Blood. — A perverted condition 
of the blood quickly exercises a marked effect upon the function 
of the cerebral cells, and while I believe that the quantitative 
change in the blood-supply to the brain is most often the 
pathological condition, yet there certainly are eases of insanity 
of the variety under discussion that are due to a physical 
deterioration of the blood. Thus, in consequence of defective 
nutrition in the exhaustion produced by lactation, or by ill 
conditions of existence — a^ overcrowding, bad air, ineufflcieiicy 
of food, intemperance — we may find both predisposing and 
exciting causes." 

Dr. Crippen mentions Sir J. Y. Simpson's claim that albu- 
minuria is a prominent factor in the production of insanity of 
the sort under consideration, and adds that "though this 
extreme view of Sir J, Y. Simpson has not met with general 
acceptance, it must not be put aside, and [ have intentionally 
dwelt upon it with the idea of emphasizing the fact that 



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284 ' Pregnancy. 

frequent analyses should be made of the urine of pre^ant 
women." 

"There still remains for discussion a multitude of minor 
causes both predisposing and exciting. Miscarriage, that may 
or may not be followed by hemorrhage and exhaustion, is the 
cauHC of a considerable number of cases. Exhaustion may be 
dependent on excessive vomiting in the early months of preg- 
nancy, upon prolonged labor, upon severe hemorrhage at 
parturition, or may be dependent on over-lactation. The use 
of chloroform has been blamed as an exciting cause, but I have 
no history of such a case. It is also possible that forceps have 
a share in the causation, but as such there are very few cases 
on record. 

"The Frendi claim that mothers of illegitimate children are 
very liable to puerperal insanity. 

"Pregnancy especially, of all these periods, renders women 
more sensitive, nervous, eretfaistic, and excitable. At such a 
time an unkind word or look, indifference, or even thought- 
less neglect on the part of the husband, weighs with a heavy, 
burden upon an already unstable mind. In the case of melan- 
cholia, the weight of sorrow presses energy and will out of 
place, and the whole intellectual life revolves around one 
painful fixed spot. Anxiety, with the dread and peril of labor, 
may produce a self-consciousness, passing into a morbid stattt. 
So varied are the causes that one hardly knows where to draw 
the line, and to add to the difficulty, it is rare to find causes 
acting singly ; more often they are multiple. 

"DiAONOBis. — It is unnecessary to Hpeak of the diagnosis of 
the insanity of pregnancy or of childbed, except that it is 
essential to differentiate acute puerperal mania Irom the so- 
called pueriwral phrenitis and from the delirium of puerperal 
fever, 

" We distinguish puerperal meningitis at* ii distinct disorder, 
that may Ik- differentiated from acute mania by the contracted 
pupils, the intense headache, the high temperature, and the 
rapid progi-ens of the disease towards collapse. Onthecontrary, 
in acute puerperal mania, the pupils are usually dilated, the 
headache is not a prominent symptom, and the temperature 
seldom reaehes a high degree except when complications are 
present. The premonitory symptoms of acute mania are also 
distinctive, and have existed for a longer time preceding the 
marked onset of the disease. Some singular change of manner 



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Diseases of Pregnancy. 285 

■or mode of thought, or querulousnesa with incoherent talking, 
coniiionly appears before the violence of the attack. 

" Prounobis.— It appears to me that before so much attention 
was paid to puerperal fever and to puerperal septicffimia, many 
cases of puerperal mania must havehadthesecouditioiisascom- 
plications. Certain it is that the death-rate was greater than 
it is at the present day. Under Esquirol, in La Salpetri^re, out 
of ninety-two cases, six died, or one in fifteen. Of Dr. Burrows' 
fifty-seven eases, ten died, or one in six. Of LeidesdorfFs twenty 
cases, ini»»<liecl. Webster saw five deaths in one hundred and eleven 
cases, .\nioug fifty-eight cases in my Own experience, one died. 

"Hesides prognosis as to life, we have the question of recovery 
of the mental faculties. Generally it is believed that the ter- 
mination iH favorable, and this is borne out by statistics. Dr. 
Webster states aa the result of his observation that 'three in 
every livf caaes of puerperal insanity may be eon*ldently ex- 
pected t-> recover within a year.' Two-thirds of Eequirol's 
cases wpiv cured within the first six months after the eom- 
mencemfiit of the attack. Of Dr. Palmer's nineteen cases, 
fourteen had recovered after four months' treatment, and two 
were ronvalescent. Of the thirty-five cases recovering und^ 
Dr. Hurrows' observation, nine recovered in the first month, 
five recovered in the second month, five in the third, three in 
the fourth, two in the fifth, four in the sixth, one in the seventh, ' 
two in the eighth, one in the ninth, one in the fourteenth, a-nd 
one in the twenty-fourth month. Dr. Burrows continuing, says 
that one rwovered after three years, two after four years, one 
after six jears, and one after seven years, and that he never 
met with one permanently fatuous from insanit^y. 

'■In making up one's prognosis it is well to bear in niiud the 
brief aphorism of Gooch, which still holds good after more 
than half a century has elapsed. Briefiy stated this is, that 
jicute rrmnia is a less durable disease than melanoholin : it is 
more danf;f>rous to life, but less dangerous to reason. 

" It renmins but to say that insanity may follow upon puer- 
peral fever ns after any other acute exhausting disease, and 
that the tt^rmination depends much upon the condition of dc 
bility. Suicidal tendency, too, is dangerous to life, more 
especially where morbid impulses exist, than where there are 
delusions prompting the patient to destroy her life. To some, 
then, tlif prognosis with regard to lifp depends on complicn- 
tioDs,and if death occurs it is moreoftenfromsecondary causes. 



286 Pbegnancy. 

"In all forme of inflanity there exists a tendency to future- 
attacks after recovery, and we have this well marked in the- 
conditions under conHideration. This tendency must be given 
due weight in prognosiB, and especially must it receive careful 
thought if there is a family history of neuropathies. But a 
previous attack does not necessarily imply that the next preg- 
nancy will be followed by an upset of the mental balance; cases 
are cited in which the first attack waa before marriage and the 
next not until after the eighth child, and again, where patients- 
have suffered after the first and third, third and fifth, or fourth 
and sixth pregnancy." 

Treatment. — Passing by general considerations with re- 
spect to the question of removal to an asylum, the sanitary 
BurrouudingH, the quality and quantity of food, as well as the- 
methods of administration, we shall here give only the medi- 
cinal treatment, which is set forth by Dr. Ci-ippen in a most 
perspicuous manner. 

"Aconituni. — Melancholia following excitation produced by 
fear. The morbid state of the mind approaches dementia in 
lack of courage, confidence, and energy of character, Moans- 
and lamentations ansing from the apprehension that her death 
is near. She becomes positive of the date of herdeath. Weak- 
ness of memory; loses the faculty of remembering dates. Ex- 
pression of terror and imbecility in the countenance. 

"In mania accompanied with febrile condition. P'itfulmood; 
at times in furious delirium, again in full possession of the 
mental faculties. Delirium, especially at night. 

"Actiea racemosa. — Melancholia following labor. A heavy 
cloud of misery hangs over the patient. Dr. E. M. Hale places 
great strcMS on the syuiptoin of sleeplessness as a key-note. 
and gives also as characteristic symptoms: 'She was suspi- 
cious of everything and everybody ; would not take medicine if 
she knew it; indiflerent, taciturn; takfs no interest in house- 
hold matters; frequently sighs and ejaculates; great appre- 
hensiveness and sleeplessness. 

"Aurtim — Suicidal mania with dejected spirits. Religious 
mania; she howls and screams and imagines she is irretrieva- 
bly lost bf'CBUse she has neglected some duty. Aurum is 
■ seldom iTidirate<l in the melancholia of females. Platina will 
more often be found suitable in such conditions, arising from 
disturbances of the sexual organs of the female. 

" BelladoDna.— The wonderful effect of this drug over dis- 



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Diseases of PBEGUANtT. 287 

eases of women extends equally to the mental syniptoms 
arising from disturbances of tbe female genitalia. In its patho- 
genesis we find: foolish manner; immoderate laughter; sha 
sings merry but senseless songs: mania; she spits at those- 
around her; bites, strikes and tries to escape and hide herself;; 
delirium, which returns in paroxysms, first of a merry nature,, 
afterwards changing to rage, 

"Bromide of Potassium. — Dr. E. M. Hale gives the follow- 
iDg: 'Puerperal mania, when attended by ferocious or erotic- 
delirium. He advises its use in minute doses 3' to 6', in mental 
depression from cerebral aneemia or exhaustjou. The patho- 
genesis of kali bromatum is suggestive of dementia. 

" Cbamomilla. — Mental erethism. Angry and out of humor; 
cannot bear to be spoken to or interrupted. Slight irritations, 
of the mind produce great anguish and distress. Inclined to- 
be quarrelsome ; she seeks a cAuse for quarrelling. Irritability^ 
even amounting to incivility. 

"China. — Mania following hemorrhage or after prolonged 
lactation. E^tcessive sensitiveness of tbe whole nervous sys~ 
tem, debility, exhaustion, intolerance of noise; extreme anx- 
iety and apprehensiveness. The patient sees persons and 
objects on closing the eyes ; these disappear as soon as the eyes- 
are opened {cs,Ic. ost., bell.). 

" Cuprum aceticum. — Cuprum metallicum appears to have 
been a reliable remedy in mania in Dr. Jahr's experience, but I 
place greater confidence in theacetate, in the following condition : 
Mania appearing in paroxysms; confused look; at times she 
is in apparent full possession of her mental faculties, yet is liable 
t<.i paroxysms of howling, which come suddenly and unexpectedly, 

" HyoEcyainuB n/^r.— This remedy eeems especially ailHptpd 
to a^ute mania in which there is excitation without any evi- 
dence of inflammation. The symptoms as given by Faniiij::- 
ton will apply equally well for our purpose. 'The patient under 
such circumstances has many flexible notions, all arising from 
these morbid impulses. He imagines, for instance, that he is 
about to be poisoned. Possibly he will refuse your meflicine, 
declaring in angry tones that it will poison him. Or heimagines 
that he is pursued by some demon, or that somebody is trying 
to take his life. This makes him exceedingly restless. He 
springs out of bed to get away from his imagined foe. The 
senses, too, are disturtied. Objects look too large, or else are 
of a blood-red color. Sometimes objecte appear as if they were 



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288 Pregnancy. 

too flietinot; that is, they have an unnatural Hharpness of 
outline. The patient talka of Bubjectie connected with everyday 
life, jumping from one subject to another pretty much aa in 
lachi-sis; all this time the face is not remarkably red, possibly 
it is only slightly flushed. The pupils are easily dilat«d ; sleep 
is greatly disturbed ; the patient lies awake for hours. 

'■ 'At other times we find thedelirium returning anew and the 
symjitoms take another form. The patients are silly and laugh 
in a flippant manner. Sometimes, for hours at atime, they will 
have a silly, idiotic expression on the face. Again, they become 
lascivious, throw the covers off and attempt to uncover the 
genitals. The abnormal movements accompanying thesesymp- 
toms are rather angular ; they are not at all of the gyratory 
character of straroonium.' 

" IgDRt'm. — Melancholia; despairs of her salvation; imagines 
she has been faithless to her husband ; weeping bitterly ; tense- 
ness of the abdomen ; cold hands and ^t ; desires to be alone 
with her grief. 

" Litium ti/friaum.—hx comparison with sepia Dr. S. H. 
Talcott gives the following indications : ' Lilium and sepia find 
an important place in the treatment of depressed and irritable 
women. The troubles in such cases originate largely in the mal- 
performance of duty on the part of the generative organs. 
Both Uhuni and sepia cases are full of apprehensions and 
manifest much anxiety for their own welfare. In the sep/a cases, 
however, there are likely to be found raore striking and serious 
organic changes of the uterine organs; while the UUam case 
presents either functional disturbance or a very recent and 
comparatively superficial organic lesion, Lilium is more 
a|>plicable ti» acute caaes of melancholia where the uterus or 
ovaries are involved in moderate or Kubacute inflammation, 
and where the pa.tient apprehends tin* presence of a fataJ 
disease which does not in reality exist. The lilium patient is 
sensitive, hyiM-resthetical, tending often to hyHteria, She quite 
readily and Biiettlily recovers, much to her own surprise, as well 
as that of her friends, who have been made to feel by the patient 
that her case was hopeless. The sepia patient is sad, despairing, 
sometimes suicidal, and greatly averse to work or exercise. 
Thpif is, however, often a good reason for the patient's 
depression, for, too frequently, she is the victim of profound 
organii- li-sions which can, at best, be cured onl^ by long, 
patient, and perseveriug endeavor.' 



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Diseases of PnEoyANCY. 281) 

'■Opium. — Furious mania, with ijistortioti of the features, 
bloating and redneos of the face, bluish redness and swelling of 
the lipe. Exalted ima^nation ; frightful visions of ghosts, 
demons and horrid beaste. 

" Platina. — Very proud and haughty. Excitation of the 
sexual passions, with voluptuous crawlings and tinglings in the 
genitals, nymphomania. Melancholia; thinks she is pot fit for 
the world, is tired of life, but has a dread of death. The feeling 
of great [>ersonal superiority m the manifest cbaracteristic of 
this remedy. Persons are looked dowii upon as inferior and 
insignificant. She is out of sorts with the world, for everything 
BeemB too narrow. Objects about her look to be smaller than 
natural. 

"Pulaatilla. — Depression of spirits; sad, weeping mood; 
solicitude about her salvation ; disposition to suicide, but fear 
of death ; chilliness, flashes of heat, cold hands and pale face. 

" While the lachrymose symptoms of this remedy are. in the 
main, characteristic, the drug must be compared with othera 
that have the weeping mood. Among these we have ign&t'm, 
natrum war., stannvm and sepia. For the purpose of com- 
parison we may study Farrington with advantage. 

" The ignatia woman dwells upon her grief in secret ; she 
nurses her sorrows and keeps them to herself. In the words of 
Shakspeare, she lets ' Concealment, like a worm i' the bud, feed 
on her damask cheek,' This introspective mood is theopposite 
of Pulsatilla. The puIsatiUa patient makes known her grief to 
everyone who comes near her; she seeks sympathy; she is 
timid and yielding in her disposition. 

"This tender, yielding disposition, that likes consolation, 
diflere from natram inur., in which, with hypochondriasis, con- 
solation seems to make the patient worse. Attempts at 
consolation may even make her angry. 

"The Btannam patient is usually sad and lachrymose, just 
like Pulsatilla. Crying usually makes the patient worse. The 
woman for whom stannum is indicated is also nervous and 
weak. Stannum will come in as a prominent remedy in lung 
troubles complicating insanity of pregnancy. 

"Sepia also develops a state of weeping; anxiety with ebiil- 
litions;peevishill-faumor:solicitudeabout her health. But with 
all her lachrymose temper, she is easily offended and is incHned 
to be vehement. 

"Stramonium. — The mania of this drug may be of a wild or 
(IB) 



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290 Pregsancv. 

of a merry character. Delirium with bright, red face; the eyes 
have a wild and ewfTuaed look. Terrifying hallucinations; the 
patient sees animals springing up from every corner. Loqua- 
cious delirium ; at timen a merry mood ; at others she has the 
horrors. Laughing, singing, and making faces one minute; the 
next, praying or crying for help. Desire for company and for 
light, with fear of the darkness. 

"In comparing sframoD/wm, hyoscyamas and beJIadonua, 
Farrington says: ^Stramonium differs Irom belladonna and 
hyoscyamuB, The patient sees objects which seem to rise in 
every comer of the room and move towards him. He has a 
mania for light and company, which ia just the opposite of 
belladonna, is excessively loquacious and laughs, sings, swears 
and prays, almost in the same breath. The desire to escape is 
present ; there is sudden spasmodic lifting of the head from the 
pillow, and then dropping it again. He awakens from sleep in 
fright and terror, not knowing those around him. The motions 
that he makes are quite graceful and easy, although they may 
be violent. At times the body is bathed in a hot sweat, which 
does not give any relief to the patient. The desire to uncover 
is similar to that of hyoscyamus, but it is more an uncovering 
of the whole bt)dy than of the sexual organs. The tongue is 
often soft, taking the imprint of the teeth. Screaming in sleep, 
often with hiccough. The face is usually bright red, but not so 
deeply congested as in belladonna.' 

" Sulphur. — Despondency. Religious melancholia, with de- 
spair for her salvation; irritable and taciturn; slowness of 
body and mind during the day ; indisposition to do any labor. 
Mania ; she spoiln her things and throws them away, imagining 
she has everything in abundance. She imagines she has beauti- 
ful dresses; looks on old rags as beautiful dresses. 

" Veratrum album. — Furious mania. Wild shrieks, protru- 
sion of the eyes : bluish and bloated face ; anxiety ;frightened at 
imaginary objects; lasciviousness; lewdness in talk; endeavors 
to kiss everyone. Coldness of the surface of the body, with 
cold sweat on the forehead. 

" Veratrum viride. — Mania with arterial excitement. Eyes 
red ; pulse small but very frequent. This drag has been used in 
a rase of acute mania with curative effect after hyoscyarous, 
stramonium, veratrum album and hepar sulphur had been 
used in vain. The symptoms were: loquacity with exalta- 
tion of ideas, or an exalted opinion of her own powers; evOTy- 



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DISEA6E8 OF PRBGNANCY. 291 

tiling seems clear to her; what had formerly been mysterious 
to her, she now clearly anderataiids ; she does not want any 
medicine that will restore her to her former condition; some 
of the time she talks and laogha; on some days the langhter 
is quite constant; one day she talks a long time about one 
thing, and again changes that theme to another; will persist 
iu continual talk, without heeding what is said to her; will 
not answer questions ; does not like to be disturbed when she 
is t'jilking; she knows all that is going on about the house, 
and does not want anything said which she cannot hear; does 
not want to get up long enough to have the clothes changed ; 
head feels bad ; the eyes are red, but vision is not affected ; 
appetite capricious ; not much thirst ; pulse small and frequent. 
The remedy was used in tincture. 

"In one of Dr. Atlee's cases the patient was stubbornly 
silent, suspicious, and distrustful of those about her. She 
thought the physician had poisoned her, meditating her de- 
struction. 

Eclampsia.— All convulsive attacks during pregnancy, par- 
turition and puerperality, are not properly clnssified underthis 
heading, since some of them are mani&atetions of epilepsy, 
before present, and others incidental symptoms associated 
with other diseases. The true puerperal convulsion is an ex- 
pression of pathological conditions in which the changes inci- 
dent to pregnancy constitute essential factors. 

Puerperal eclampsia is an acute disease occurring in women 
in pregnancy, in labor, or in childbed, often sudden in its on- 
set, rapid in its progress, characterized by convulsions, with 
loss of sensation and consciousness, ending in coma. (Bailly.) 
The term eclampsia, signifying flashes of light, indicates the 
overwhelming force of the attack, and the lightning suddenness 
with which it often sets in. 

Fkequenty. — The average frequency of eclampsia is about 
one case in three hundred. According to the statistics gathered 
by Dr. George B, Peck, among twenty physicians of our school 
of practice, representing a total experience of three hundred 
and five years, flfty-one cases had been met. It is more fre- 
quently met among primiparee, especially in those well ad- 
vanced in years, in twin pregnancy, in women with contracted 
pelves, and in connection with the birth of male children. It is 
«ometime8 epidemic. 

Etiology. — The following theories respecting the conditions 



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392 Pkegxancy. 

which excite eclampsia in pregnancy and childbed have each 
had strong advocates, and each now has its supporters : 

Ist. Material change in the nervous centers and their envel- 
opes. 

2nd. Cerebro-spinal congestion. 

3rd. Reiiex irritation througli the spioal system, of T^hieh 
the point of departure is the uterus. 

4th. General or cerebral anaemia. 

5tli. Blood-poisoning, which disturbs the normal action of 
the nerve-centers. 

1. Eclampsia is Due to Material Changes in the .Xtrvous 
Centers and their En velopes. 

From experiments which have been made, it is cleaily jihown 
that the augmentation of blood-pressure alone is not Muificient 
to bring on the convulsions ; but the serous efTnsions which re- 
sult — iu otherwords, the cerBbral and spinal oedema — have been 
regarded by many as adequate exciting causes. 

2. Eclampsia is Due to Cerebro-Spinal Congestion. 

This theory was held by the older obstetncians. among 
whom is Dr. Hodge, who says that 'convulsions iu a large- 
proportion of cases arise from a congestion of the blood-vessels- 
of the brain, or from an actual efiTusion of serum or blood into 
its substance or cavities." It has been shown by more recent 
observers that the evidence of cerebro-spinal congestion and 
hemorrhage found in certain autopsies of women who died 
from eclampsia, is the result of the convulsions, and not the 
cause of them. 

3. Eclampsia is a Nervous Disturbance Set Up liy Reflex 
Irritation of the Spinal System, the Point of Ifepartiiif being 
the Uterus. 

This theory has had many advocates of acknowledged 
standing and repute, among whom are Dubois, Scanzoni. Mar- 
shall Hnd and Tyler Smith. "In conclusion," sayw Tyler 
Smith, "to give a. summary of the whole subject, tho true 
puerperal convulsion can only occur when the central organ of 
this system, the spinal marrow, has been acted upon by an 
excited condition of an important class of incident nerves, 
namely, those passing from the uterine organs to tlif spinal 
center, such excitement dejiending on pregnancy, labor, or the 
puerperal state. While the spinal marrow remains under the 
influence of either of thewe stimuli, convulsions may arise from 
two series of causes — those acting primarily on the spinal 



DiBEASES OF PUKONANCY. 293 

marrow, or centric causes; and, secondly, those affecting the 
©xtremitiea of its incident nerves— cnusea of central or pe- 
ripheral origin." When we reflect upon the remarkable uterine 
changes which are wrought by pregnancy, and the phenomena 
of {larturition, this theory certainly assumes significance and 
importance. "The answers to this theory are," remarks 
Parvin, "first, eclampsia may occur either before or after labor 
when the uterus is in complete repose, not the slightest mani> 
festation of an irritated conditiou; aiid, second, the uterine 
irritation being so much greater in primigravidat, they ought 
to be much more generally the subjects of eclampsia. It iH now 
generally held that while uterine irritation may, in some cases, 
assist in causing a convulsive attack, it is not the chief cause of 
the disease; or even if in a very few cases it may be the chief or 
only caune that can be discovered, it is inadequate to explain 
the majority of cases." 

4. General and Cerebral Ansemia are the Causes of Eclampsia. 
Some writers on the subject have regarded general an£emia, 

and others cerebral anemia, as the pathological condition upon 
which eclampsia is based. These authorities attribute the 
general aniemia in the main to the albuminuria which they 
assume to exist in all, or nearly all, cases. But our own obser- 
vations, as well as those of many eminent obstetricians, prove 
that albuminuria is by no means an esf^eutial antecedent of 
eclampsia. Charpentier has tabulated 141 cases reported by 
forty-five different observers, wherein there was no evidence of 
albuminuria prior to the development of the convulsive seizure. 
And since in a large percentage of cases no examination of the 
urine is made until after attention is drawn to it by the occur- 
rence of eonvulaiouB, the question has well been raised whether 
the albuminuria is the cause, or the sequence of the convulsions. 
The cerebral aiiGemia, which by some is regarded as an 
efficient cause of the seizures, is accounted for, in a measure, by 
irritation of the nerve-centers from circulation through them 
of vitiated blood, thereby giving rise to vaso-motor disturbance, 
resulting in contraction of the cerebral arteries. 

5. Eclampsia is Due to Blood-poisoning, which Renders the 
Vital Fluid Inefficient to Sustain Normal Action of the Nerve- 
Centers. 

Under this head are included mainly urfemia and am- 
monifemia. It is the most commonly accepted theory, though 
not one upon which we can explain all cases. 



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294 1*BEQSANCY. 

We caniiot give our exclusive endorsement to any one of 
thebe theories, inasmucb as we believe that there is no uniform 
pathology back of the phenomena. Indeed, it seems to us 
probable that each of these theories is capable of accountiu^ 
for a certain number of cases. 

Pathological Anatomy. —The lesions which .are met at the 
autopsies of women dead from eclampeiia are so numerous amd 
various that we may seriously question whether the dieeasehas 
any distinctive pathological anatomy. Sometimes they are in 
the brain, at others in the lungs, and again in the kidneys; 
hence it is impossible among th«4e to find one lesion which may 
be regarded as charactei'istic. Such able observers as Rams- 
botham, Velpeau, Scanzoni, Cazeauz, Kiwisch and Jacque- 
mire, have made a certain number of autopsies in such caees 
without discovering auy lesions. Braiin in one case found in- 
ternjeningeal apoplexy; in ten cases anemia and cedema of the 
brain and its envelopes. In forty-two autopsies made by 
Bevilliers. Regnauld, Lever, Hardy, Collins, McClintock, Rams- 
botham, Kiwisch andothers, there were ten cnses of hyperBsmia, 
four of aniemia, four of normal vascularity of the brain, seven 
of serous effusions in the arachnoid, five of ventricular hydrop- 
hieSj and twelve of apoplectiform extravasations of the brain, 

De Paul, Blot, Bailey, Mercier and Charpentier have noted 
cerebral hemorrhages, and Molas arachnoidal hemorrhages. 
Helm, Kiwisch and Braiin have observed hyperemia of the 
membranes, and meningeal apoplexy. Bloff noticed serous 
effusions in the spinal cavity. 

The alteratious most frequently observed are in the kidneys. 
These, however, are not constant, though in many casee they 
may be overlooked for want of thoroughness in the examina- 
tion, or inadequacy of the means employed. The morbid 
changes observed are mainly (1) hypenemia and slight exuda- 
tion ; (2) exudation and a certain amount of fatty degenera- 
tion; (3) atrophy. 

Dr. Alexander PiUiet lays great stress upon the hwmor- 
rhagie foci which are found in the livers of women after death 
from puerperal eclampsia. He infers that the hepatic lesion 
is primary, and that this pathological discovery must modify 
our opinions and our treatment of one of the gravest compli- 
cations of childbed. Twelve necropsies have been made by this 
obstetrician, and in all the characteristic changes in the livers 
weredetected. Thisseriee does not include any case of cholemic 



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Diseases of Pregnancy. 395 

eclampsia or hepatic aniemia of pregnancy and the puerperium ; 
and in the twelve, icterus, where it occurred, was slight, and ap- 
peared after the other distinct Bymptoms. The hemorrhagic 
foci in the tissues of the liver are uo mere product of simple 
engorgement of a vessel followed by rupture. There are asBO- 
ciated with complicated local pathological changes, minutely 
described by Dr. Pilliet. In certain respects these foci resemble 
similar appearances observed in the kidney in scarlatinal and 
ei'ysipelatous nephritis. The most cai-eful search, however, has 
failed to detect any bacteria in the foci in Dr. Pilliet's twelve 
cases. He maintains that since a distinct and severe lesion of 
the liver was found in every one of the twelve cases of death 
from puerperal convulsions, it is reasonable to suppose that 
the lesion is pathognomonic of the coiiiplicatiou in ques- 
tion. 

Effebt on Pregnancy. — This is nearly always decided. The 
morbid conditions existing in the mother and which lead up to 
the development of convulsions, together with the immediate 
effect of the strong convulsive action, nearly always prove de- 
structive to foetal life. Labor maynotimniediatelyen8ue,buti8 
not long delayed. Thedurationof laborissomewhatshortened 
by strong uterine action and the relaxation which follows the 
convulsive movements. 

Prodbomata.— An attack of puerperal convulsions is nearly 
always preceded by premonitory symptoms, the significance of 
which should be understood. They are not equally valuable as 
indices of the morbid state of the system. The patient suffers 
from sleeplessness, or an inclination to the opposite condition 
of drowsiness; there may be vertigo, vomiting, ringing in the 
ears, irritability of temper and lowness of spirits. None of 
these, however, are peculiarly indicative of threatened convul- 
sions; but when to them are added severe frontal headache, 
disturbance of vision and epigastric pain, we havethe premoni- 
tory symptoms well mapi»d out before us. 

The headache involves chiefly the sinciput, pain rarely being 
felt in the occiput. It at first is felt at intervals, after a time 
the intermissions become mere remissions, and when the ache 
becomes constant the eclamptic seizure is usually at hand. The 
headache may precede convulsions several days, or only a few 
hours, but is nearly always present for a time before the first 
paroxysm. 

Disturbances of vision are nearly as constant a forerunner 



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296 Pregnancy. 

of eclampsia. These are dimness of Biftht, as though a mist 
were befure the eyes, amblyopia, hemiopia and diplopia. 
Blurred vision is the most common, and occasions the patient 
great annoyance in the performance of her daily household 
duties. On attempting to read, the letters run together or ap> 
pear to be obscured by film before the eyes; on trying to sew, 
she can scarcely see the stitches. These ocular disturbances- 
increase in severity as the patient nears the eclamptic seizure, 
total blindness sometimes developing, and continuing for days. 
Severe pain in the region of the solar plexus is occasionally ex- 
perienced for a few hours before the convulsive attack. In a 
case which came under our care a few years ago, this epigastric 
pain came on severely about two o'clock in the afternoon, in a 
patient seven months advanced in pregnancy, and refused to - 
yield to remedies aided by various adjuvants, culminating 
about two hours later in the beginning of a series of convulsive 
seizures which terminated in death. The pain in this instance 
was evidently as severe as that attending an aggravated at^ 
tack of bilious colic. 

The SEizuRE.-'This commonly seLs in suddenly and vio- 
lently. The patient, totally unaware of the terrible experience 
before her, may be engaged about her ordinary avocations, 
when she suddenly falls to the floor with the muscles set in a 
tonic spasm. The head is usually turned to one side, and the 
eyes appear to be set as though gazing at a fixed object. The 
extremities are extended, the hands firmly closed with the 
thumbs under the fingers. The face becomes livid, and the 
pulse feeble and rapid. Consciousness and sensibility are wholly 
lost, and the pupils do not respond to light. The mouth is 
distorted aud usually deviates to the left. The convulsive wave 
extends from above downwards, and involves all the voluntary 
muscles. Whether the muscles of organic life are implicated or 
not is a matter of speculation, but from observations made by 
Braxton Hicks it would appear that the uterus sometimes 
shares in the convulsive action. The tonic stage is soon suc- 
ceeded by the clonic, wherein the body, by the irregular action 
of its various muscles, is thrown and jerked about in a most 
distressing manner. The lividity of the countenance becomes 
more marked, on account of the impeded respiration ; breath- 
ing is carried on in an irregular and imperfect manner, and 
through the set jaws frothy saliva is blown out with a bubbling 
sound. The muscles of the face act wildly, which, with the 



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l)iBE&8ES OP Pregnancy. 29T 

rapidly moving eyes, give the countenance a hideous expres- 
sion. It iB the most repulsive sight which the physician, who 
:get8 " behind the curtain " oftener than anyone else, is called to 
witneBfl. To see a woman in her beauty and strength thus dis- 
torted and disfigured in a moment, is enough to distrefis the 
moBt Platonic. The storm of convulsive action slowly dies 
•away. The movements become less violent, the Jividity fades, 
the eyes slowly close, and afterafewmoretwitchings of smaller 
tnuBcles, relaxation comes to the distressed body so recently 
Vrithing in the most extravagant manner. 

The duration of an attack varies from one to twenty 
minutes, and the eonvulfiive movement is succeeded by a period 
of coma more or less profound. In some instances conscious- 
ness returns soon aft^- the spasmodic oiovetnents cease, but 
generally after the lapse of a longer time. The patient may 
suddenly open the eyes as if in fright, and utter wild screams, 
soon quieting again into the unconscious state, or returning 
slowly to a comprehension of her surroundings, though not at 
first to the realization that an>'thing unusual has happened. 
As a rule, consciousness is restored by degrees, and memory of 
the occurrences preceding the attack returns after several hours. 
Even upon complete restoration to a normal condition, it is 
found that many of the incidents which occurred during what 
appeared to be hours of sanity preceding the seizure, have 
wholly escaped the memory. 

The first attack is nearly always succeeded at irregular 
intervals by others, unless eifective measures for prevention are 
At once adopted. Eclampsia may thus be arrested, in eome 
anstanoes, after a single attack, while again the most vaunted 
remedies will utterly fail. 

The paroxysms vary greatly in number. The average 
among those who recover is perhaps six or eight. The 
greatest number ever witnessed by Winckel in a case terminating 
favorably was seventeen. Among those ending fatally the num- 
ber may rise to one hundred and sixty. Between attacks the 
«oma, which results from cerebral congestion, becoipes more 
and more pronounced, deepening towards death. Even in those 
.-cases which recover, the patients may lie in a state of coma for 
hours. Death sometimee takes place during a paroxysm, but it 
«ft«ner occurs during the comatose stage, as the result of pul- 
monary oedema and cerebral apoplexy. When recovery ensues^ 
AS it does in the majority of instances, there is a decrease in the 



298 Preghancy. 

frequency, duration and iutensity of the parozyBms, followed 
by a deep, quiet sleep. 

DuGNDSiH. — To baae our diagnosis on the phenomena pre- 
sented by a fouvulsive seizure, would be unwise. The previous 
history of the patient, not only that immediately preceding 
the attack, but that also of the ante-pregnant state, should be 
learned, and be given due weight in making up our judgment. 

Special inquiry ought to be made concerning epilepticattaiks, 
since the phenomena of epilepsy are with difficulty diffei-en- 
tiated from those of true puerperal eclampsia. With the oiiHet 
of an epileptic paroxysm the patient utters a cry, which is 
usually absent in eclampsia; and after the former the suc«:eed- 
ing coma is more prolonged. 

Less difficulty is experienced in differentiating hysteria. 
During the attack consciousness is not wholly lost, the orderly 
course of the phenomena is broken, wild gesticulation nud 
admixture of emotional symptoms usually being sufficient to 
reveal the character of the attack. Moreover, instead of the- 
succeeding comatose state which follows the paroxysm of real 
eclampsia, evident consciousness is soon observed, even though 
it is sought to be hidden by the patient. 

OcuuKRENCE AND MORTALITY. — " Of the fifty-one cases under 
consideration," says Dr. Peck in his report to the American 
Institute of Homeopathy, in 1884, "in ten the convulsive 
attack anticipated labor; in thirty it manifested itself during 
labor, while in eleven it occurred not until after the entire com- 
pletion of parturition. In the first class four mocbers, forty 
per cent., perished, including one of whom it was at first sup- 
posed shewas merely threatened with abortion. (Oneof the sur- 
vivors suffered for a considerable time with puerperal insanity, 
but eventually recovered her wonted health,) Eight children 
were also lost, eighty per cent., one of which was the offspring 
of the patient just referred to; one the probable victim (though 
the fact was not positively stated) of a premature labor three 
weeks after the spasms, and one was already putrescent at 
delivery. In the second class eight mothers perished, twenty- 
six and two-thirds per cent., one of whom lingered six days 
after labor, and another succumbed to an attack of puerperal 
fever. Here but nine children were lost, or only thirty per cent. 
In the third class two mothers perished, or eighteen per cent. 
One of the survivors, who had six paroxysms within an hour, 
■was not attacked until twenty minutes after the birth of a 



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Diseases of Pregnancy. 299 

dead child. Combining we find a total loss of fourteen mothepe, 
twenty-seven and a half per cent., and sixteen childTen. omit;- 
ting thoee known to be dead prior to the seizure, or thirty-one 
and a third percent. The maternal mortality in cases occurring 
before or during labor is thirty per cent." 

The results of eclampsia must be held to vary according to 
the severity, frequeucy, duration and number of the paroxysms, 
as well as the period in the reproductive process at which the 
convulsions set in. Braiin says he has known but one patient 
to recover when attacked between the fourth and sixth months 
of pn^iancj, except where abortion took place. When several 
seizures are suffered, the life of the child is nearly always de^ 
Btroyed, as we have elsewhere intimated. 

Treatment. — Treatment of eclampsia should be considered 
under two heads, viz: Preveutive treatment and curative 
treatment. 

Preventive Treatment. — The prodromata of eclampsia ha^'e 
been mentioned, the most prominent of which were headache, 
disturbance of vision and epigastric pain. With these may be 
associated, as a still more threatening symptom, albuminuria. 
The first three symptoms are strongly significant, even when 
existing independently of albuminuria, and demand attentive 
consideration and faithful treatment. When there is albumen 
in the urine we are inclined to be influenced overmuch by this 
expression of pathological change to the neglect of other symp- 
toms which may not be dependent upon the albuminuria nor 
directly connected with it. The subjective, as well as the ob- 
jective, symptoms deserve to be accorded due weight, if we 
expect to give our patients the most perfect protection from the 
impending attack. It is under such circumstances as these thnt 
the value of our law of cure is able to manifest, with unusuiil 
force and beauty, its truth and efficiency. Of coursethewomun 
should be brought under the influence of good sanitary condi- 
tions, so that nature may not be handicapped in her efforts to 
restore the disordered system to perfect harmony. Among the 
remedies more especially suited to the cephahc, the ocular and 
the epigastric r^ons, when presenting the symptoms before 
mentioned, are the following: 

Belladonna. — This remedy covers the symptoms more 
thoroughly and more frequently than any other. The head- 
ache is chiefly in the sinciput, of a congestive, pressive, boring, 
throbbing, or even lancinating character, worse from stooiiing, 



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300 Pheqnakcy. 

from moTement in ^aeral, from lyinfE. The eyes bare dimnees 
of Tieion, bright sparks and flashes before the eyes, and doable 
visioD. This remedy also has the epigastric pain. Pain in the 
stomach, extending through to the spine, is one of its most 
characteristic indications. 

Gelsemium.—'We place this remedy as secondary only to 
belladonna for the premonitory sympt'onis of eclampsia. 
Neither of these has any special relation to atbnminuria, which 
may or may not be present. Our reference here is only to the 
symptomatology of the case, to follow which as a guide in the 
Belection of remedies under theKe circumstances wer^cardasthe 
safer and more effective course. The headaches of this remedy 
are chiefly in the occiput, while those accompanying other symp* 
toms of a premonitory nature in thesedangerous cases are usual- 
ly in the sinciput. Still the gelsewiam headache is not confined 
to the occiput, but this part of the head sometimes escapes 
while the sinciput sufTers. The headache is of a severe type, is 
accompanied with a aore bruised feeling, depression of the 
mental faculties, vertigo, dimness of vision from a haziness 
Ixtfore the eyes, diplopia, hemiopia and even total loss of sight. 
The remedy covers likewise the severe epigastric pain which 
sometimes pi-ecedes by a lew hours the convulsive seizure. 

Glonoianm. — Here is a remedy which does not correspond so 
closely with the symptoms of thesecases as nsually manifested, 
and yet one capable of affording relief in some instances. 
Among its indications are the following: Fullness in head as 
if all the blood had mounted to it; throbbing in front head ; 
crushing weight across forehead; pressure and throbbing in 
temples; holds head with both hands on the sinciput; flashes 
of light before the eyes; eyes red; and violent pains in the 
epigast-riura. Each of the above remedies has insomnia well 
marked, and this is often a most distressing symptom in asso- 
ciation with those already mentioned. 

Among other remedies which may be indicated by the more 
prominent precursory symptonls, are these, arsenicum, bry- 
ODJa, DUX vomica, melilotua and cicuta. 

Albuminuria constitutes one of the most threatening symp- 
toms, but its treatment has been described at some length in 
another place, and therefore requires no special consideration 
here. We may add, however, that the above-mentioned reme- 
dies, though not all of them peculiarly suited to the relief of 
albuminuria, as viewed from a physiological standpoint, may 



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DiSEASEH OK Phegkancy. 801 

jet afford perfect reeults in that direction, if specially iadicated 
by other Bjmptonis. Likewise, the remedies named under al- 
buminuria may cure the accompanying headache and other 
disturbances. 

Curative Treatment. — It will be modified more or less by the 
period at which the convulsions are developed. 

Whenedampsiasetsin during pregnancy, and the paroxysms 
are not brought aader control, the question of inducing labor 
has to be settled. The Gulvisability of the operation m advo- 
cated by some and denied by others ; and in the abnence of a 
settled rule of action, the question will have to be considered 
and settled in individual cases as they arise. It certainly ought 
not to be undertaken unlesu other measures have utterly failed, 
for the results of the operation, as thus far observed, are not 
reaaBuring. 

In many instances the uterus is excited to action by the 
convulsions, and dilatation of the os begins, the caae being 
resolved thereby into one of eclampsia during labor, to be 
managed accordingly. 

Convulsions which set in after labor has b^in have a tend- 
ency to recur until the parturient act is completed, and then to 
-cease. It is therefore advisable to ha«ten delivery by every 
obstetrical resource which is not inimical tothewoman'ssafety. 
During the ttrst stage the means at command arempture of the 
membranes, catheterization of the uterus, and manual dilata- 
tion ; and during the second stage, use of the forceps. In caee 
of malpresentation, or of a certain d^ree of contraction of the 
pelvic brim, it may be advisable to practice podalic version be- 
fore complete dilatation of the os uteri. 

" At the recurrence of the fit," says Dr. R. Lndlam," a thick 
piece of India rubber, or of soft wood, should be placed between 
the teeth, in order to protect the patient's tongue. She should 
iiot be held forcibly or firmly to the bed, but simply prevented 
from throwing herself on the flooror otherwise inflicting bodily 
injury. Too much constraint might increase the difilculty, and 
would do DO good. If she has an antipathy to the nurse, tbe 
husband, or anyone in the room, you had better send them 
out. And do not let bystanders give vent, in her hearing, to 
exclamations of fright and horror at the contortions of which 
they are witnesses." 

Thebapectics. — Among the curative remedies for this dis- 
-pase, none occupies so prominent a place as belladonna,. " No 



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302 PREU.NANCY. 

remedy," sftys Baehr, "responds to this disorder as completely 
as belladoQiia." The indications for its use, according to- 
Guernsey, are aa follows: She has the appearance of being 
stunned; a semi-con uciouHiiees and loss of tipetn^h; convulsive 
movements in the limbs and must^lei^ of the face; paralysis of 
the right bide of the tonjjue; difficult deglutition: dilated 
pupils; red or livid countenance. She may have pnleness mid 
coldness of the face, with shivering; fixed or convulsive eyes; 
foam at the mouth; involuntary escape of the ftecea and urine; 
renewal of the fits at every pain ; more or less tossing Iwtween 
the spasms, or deep sleep with grimaces; or starts and cries 
with fearful visions. The efficacy of belladonna has been 
repeatedly demonstrated. 

Cicuta virosa. — We have found but little reported experience 
with this remedy in eclampsia, but we believe it one of great 
promise. It has, as we have before shown, the symptoms which 
usually precede an onset of the convulsions, and from these 
alone would be well indicated ; but, in addition, it has loss of 
consciousness; facial distortion, either horrible or ridiculous; 
red, bluish, puffed countenance ; dilated pupils and insensibility 
of the eyes to light; eyes staring, fixed and glassy, or np> 
turned; convulsions, with loss of consciousneKS, frightful 
distortion of limbs and whole body. 

Gelsemium. — This has proved to Ite a remedy of remarkable 
value in this disorder. It is e8i)erialiy indicated when attacks are 
excited through i-eflex causes. One of its prominent symjitoms, 
sometimes observed as premonitory of an attack, is a large 
feeling of the head. The pulse is full, but not usually hard ; or 
it may be rapid and feeble. For some hours before the attack, 
and in the intervals, she is extremely dull, 

Veratrmn viride. — The strongest indication for this remedy 
is found in high arterial tension and circulatory excitement. 
Apart from these indications, it has been used, in great 
measure, empirically ; still it has done much good service. 

Following are indications for other remedies, many of which, 
when thereby chosen, have often proven efficacious: 

Argenticvm nit.— Seizures preceded by restlessness, and a 
sensation of general expansion, especially of head and face. 

Coccnius. — Convulsions following difficult labor, and those 
which appear to be brought on by changing position ; before 
the attack the patient complains of a sense of great weakness, 
especially of the lower limbs. 



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Diseases of Precnancy. 303 

Cuprum met.— Spaamu during pr^naiicy, of a clonic nature, 
banning iu one part and epreading; convulsions during 
parturition, with violent vomiting, or with every paroxysm 
oplBthotonoB, spreading of the limbs and opening of the 
mouth. 

G/oDoiflum.— Unconsciousness; face bright red, puffed; full, 
hard puke ; urine copious and albuminous. 

Helleborus. — Convuleions, with scanty urine; urine dark, 
floating dark specks, or albuminous. 

HyoscyamuB. — Shrieks, anguish, chest oppressed; uncon- 
Bciousnesa; jerking of every muscle in the body, including 
those of the eyes, eyelids and face; convulsions preceded by 
insomnia. 

Opium. — Convulsions during and after labor; drowsiness, 
open mouth, coma between paroxysms; convulsions which 
appear to have been excited by fi-ight or giief; stertorous 
respiration sets in soon alter convulsions begin. 

Pahatilla. — Convulsions following sluggish or irregrular labor 
pains; unconsciousness; cold, clammy, pale face; stertorous 
breathing, full pulse. 

Secale. — Labor ceases and convulsions begin. 

Stramonium. — Bright light, or conlact, renews the parox- 
ysms; arouses with a shrinking look, as if afraid of the first 
object seen. 

We do not feel that an account of remedial measures would 
be ample without allusion to other remedies than those already 
mentioned, and some, too, which, in their common use, aT& 
chiefly palliative. Our law of cure is probably universal in it» 
application, but it is still ho imperfectly understood in its d©. 
tails that, to rely implicitly and exclusively upon it, in the- 
presence of a dire emergency, is scarcely justifiable. These 
remedies which follow are not recommended to substitute 
homeopathic medication, but as mere expedients, by means 
of which to gain time for the selection and exhibition of the 
true similimum. 

As a temporary expedient, to prevent the early reeurrene& 
of a convulsion, chloroform may be used to the extent of com- 
plete narcosis ; but it is not a remedy whose action can safely 
be long maintained. 

Chloral hjdrate is a remedy which will produce an effect on 
the system similar to thatof chloroform, and may be continued 
for an indefinite period. In such cases it cannot well be admin- 



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304 Pbeonancy. 

istered by the month, but its effect can be as effbetualiy secured 
through the rectum. The bowel should be cleared through the 
iise of an enema, and then the chloral injected in the dose of 
isixty to one hundred grains. Thia may be repeated once, twice 
■or thrice, if neceesary, within a few hours. The uaual formola 
for the injection is : 

Nftv milk OE. iij. 

Egg ooe yolk. 

Chloral hjdrate gn. xc. 

To a homeopath this may seem like heroic dosing:, but for 
^he purpose named, a much smaller quantity of the drug would 
bave little efifect. 

Opium has been highly praised for its effect to quiet the 
[perturbed nervous eystem in these desperate cases. It is best 
■administered in the form of morphia by hypodermic injection. 
■One-fourth to one-half grain, in repeated doses, is sometimes 
used. This mode of treatment has received strong endorsement 
'from old-Bchocil authorities. 

Reliable statistics representing the results of various forms 
of treatment are not easily obtained ; but from all we can 
:gather on the subject, we are fully justified in saying, that, 
■a« between the two prominent modes of treatment upon which 
the old-school has learned to rely, namely, that by opium and 
that by chloral, the advantage appears to be on the side of 
-chloral. . 

We regard the hot wet pack as a most valuable agent in the 
treatment of eclampsia. Seemingly hopeless cases sometimes 
yield to it. It should be given by wringing out four blankets 
from hot water and wrapping all but the head in them. Upon 
the latter should be laid cloths wrung from ice-cold water. 

Under any form of treatment the mortality is appalling. At 
the same time later reporta indicate improvement in this direc- 
tion, proceeding largely, no doubt, from ,the growing custom of 
women to place themselves under the care of physicians during 
gestation. 

Use of Saline Solution. — Venesection is an old form of treat- 
ment for puerperal eclampsia, and in some cases it has been 
«fiicacious. Hemic toxemia constitutes the immediate cause of 
the seizure in a large proportion of cases, and a reduction of the 
contaminated circulatory fluid is capable of affording some re- 
lief to the oppressed nerve centers. But we cannot abstract 



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Diseases of Pbeqnancy. 305 

large quantities of blood without deliterious effects on the cir- 
culatory apparatus, for the heart must have an adequate supply 
of circulatory fluid In order to maintain its physiolc^caJ action, 
and modem thought has undertaken to work out a scheme of 
relief by means of infusion of normal saline solution. The 
median basilic vein of the arm is opened and the patient bled in 
varying quantitaeB, from four to twenty ounces,- according to 
evident requirements, and the loss is then supplied by iofasioa 
of the salt solution directly into the vein. 

The method has been but little tried, but, if preceded or fol- 
lowed by delivery, it offers some encouragement and is wortliy 
of consideration. 

I^rticulars of tins operation of Infusion will be found in an- 
other chapter. 

BelaxationandDisruption of the Pelvic ArticulationB.— 
Belaxation, or violent disruption of the pubic joint and of the 
ilio-sacral synchondroses, has been described by several. The 
symptom most characteristic of such cases is the difflp ulty, or 
impossibility, of sitting or standing erect. There is pain or 
uneasiness in the pelvic region, and a sense of weatcnees and uq-. 
steadiness in the bones, with a sense of relief afforded by a tight, 
bandage about the hips. Such a bandage, and absolute rest, 
constitute the best treatment. 

Inflammation and suppuration of the pehic joints are occa- 
sional occurrences. When recognized, the pent-up matter shouldi 
be drawn away, and constitutional treatment 4!iopted. 



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CHAI'TEK I. 

CAUSES AND CHARACTER OF LABOR. 

We have glanced at the pheoomena associated with impreg- 
nation; we have traced the growth and development of the 
fcetUB to maturity; we have considered the dineases and acci- 
dents to which the fcetus is liable ; the phenomena and manage- 
ment of its premature expulsion, and we now come tothatpart 
of our subject which treats of its expulsion at the close of 
mature utero-gestation, a period which, in the human female, 
is aoconiplished in about ten lunar months from the date of 
impr^rnation. 

The Causes of Labor. — " Speculation as to the proximate 
causes of labor," writes Lusk, who reasoos very learnedly on 
the subject, " have so far proved profitless. The following par- 
ticulars comprise the extent of our knowledge of the condi- 
tions which prepare the way during pregnancy for the final 
expulsive efforts: 

"1. During the first three months the growth of the uterus 
is more rapid than that of the ovum, which is freely movable 
within the uterine cavity, except at its placental attachment. 
In the fourth month the refiexa becomes so far adherent to the 
chorion that it can only be separated by the exertion of some 
8li;rht degree of force, and the amnion is in contact with the 
chorion. After the fourth month the chorion and amnion ore 
.iffglutinated together, though even at the termination of pi*^- 
nancy they may with care be separated from one another. 
After the fifth month the agglutination of the decidua vera and 
reflexa takes place. In the second half of pregnancy the rapid 
tlevelopment of the ovum causes a corresponding expansion of 
the uterine cavity, the uterine walls becoming thinned, so that 
by the end of gestation they do not exceed upon the average 
two or three lines in thickness. The vast extension of the 
uterine surface is not. however, simply a consequence of over- 
stretching, a fact shown by the circumstance toat the uterus 



SOS Laiiok. 

towards the close of geetatioD ia increased oearly twenty -fold in 
weight, and by tbehiBtoriesof eztra-uterine fi»tatioDS,ii)wbich, 
up to a certain limit, the uterus enlarges progreesivety, in spite 
of the non-presence of the ovum. The augmented weight of 
the uterus is the result of the increase in length and width of 
the individual muscular fiber-cells, the extreme vascular de- 
velopment, and the abundant formation of connective tissue. 
Up to thesixth and a-half month there has further been observed 
a genesis of new flber^cells, especially upon the inner uterine 
surface. According to Ranvier, the smooth muscular fibers 
become striated as the end of gestation is reached. 

" The precise manner in which the distension of the uterus iB 
accomplished has as yet not been demonstratod, A priori only 
two pofsibiliti<« are apparently admissible, namely, either the 
individual structure elements are stretched after the manner of 
elastic bands, or a rearrangement of the muscular elements 
takes place in such wise that a certain proportiou of the fiber- 
cells, instead of lying, as in the banning of pregnancy, paral- 
lel to one another, gradually, with the advance of gestation, 
are displaced, so that the ends only are in juxtaposition. It is 
possible, though not proved, that towards the close the thin- 
ning of the walls is the result of both conditions. Bearing 
these premises in mind, it becomes a disputed question as to 
whether one of the causes of labor is not to be found in the 
reaction of the uterus, as a hollow niuscular organ, from the 
extreme tension to which its fibers are ultimately subjected. 
Countenance to the affirmative side is afforded by the tendency 
to premature labor in hydramnion and multiple pregnancies, 
in which a high degree of tension is reached at a period consid- 
erably antedating the complete development of the fcetus. 

"2, There is a perceptible increase of irritability in the 
uterus from the very beginning of gestation. Indeed, the 
facility with which contractions may be produced by manipu- 
lating the organ through the abdominal walls has been put 
forward by Braxton Hicks as one of the distinguishing signs of 
pregnancy. This irritability is eepecially marked at the re- 
currence of themepstrual epochs, and becomes a more and more 
prominent feature in the latter months, when spontaneous 
painless contractions are ordinary inddents of the normal 
condition, 

"3. The researches of Friedlander, Kundrat, Engelmann and 
Leopold have demonstrated that the deciduavera of pr^:iiaiicy 



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Caubeb and Chaiiacter op Labor. 801> 

ie distingmshable into an outer, dense, membranous stratum, 
composed of large cells resembling pavement epithelia, proba- 
bly metamorphosed cylindrical cells, and an (in appearance) 
underlying meehwork, formed from the walls of the enlarged 
decidual glands. It is in thitt spongy layer that the separation 
of the decidua takes place, the fundi of the glands persiutiDg, 
even after expulsion of the ovum. By many, a fatty d^enera- 
tion of the cells of the decidua has been observed towards the 
end of pregnancy, but Leopold, Dohrn, and I^anghans have 
shown that this is not of constant occurrence. The trabecula> 
which enclose the spaces of the network, diminish in size with 
the advance of pregnancy. Thus, while they measure at the 
fourth month about 1.500 of an inch in thickness, they become 



Fig. 124— The Uterine Mucous Membrane. A, amnfon. R, reflexa. D, 
decidua vera. D R, glandular spaces of the loirer stratum. M, muscular 
structure. (Bnglemann.) 

gradually reduced in the subsequent months to 1.2500 of an 
inch, a change which materially facilitates the peeling off of the 
decidual surface. 

"4. From the fifth month onwards, large-sized cells make 
thmr appearance in the serotina, especially in the neighborhood 
of thin-walled vessels. The largest of these so-called giant-cells 
contain sometimes as many as forty nuclei. Though a physio- 
logical product, they resemble, for the most part, the so-called 
specific cancer-cells of the older writers. They are of special 
obstetrical interest from the fact observed by Friedlander, and 
confirmed by Leopold, that they penetrate the uterine sinuses 
from the eighth month, and lead to the coagulation of the 
Uood, and to the formation of young connective tissue, by 
means of which a portion of the venous sinuses become obliter- 



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810 Labor. 

ated before labor b^ns. The subtraction of these i 
from the circulatioii tends to increase the amount of thevenouu 
blood in the intervenoas spaces of the placenta. 

"5. It' is proper to recall here the fact that the nerve fila- 
ments of the uterus are derived, in principal measure, from the 
sympathetic system. The lat^ cervical f^anglion, which in 
pregnancy measures about two inches in length by one and 
a-half inches in breadth, receivea, however, in addition to the 
sympathetic fibers, the second, third and fourth sacral nerves. 

" Physiology has as yet left unsettled the question as to the 
main channels of the motor impulses which are conveyed to the 
uterus during labor. One of my hospital patienta, with i>a- 
ralysis of the lower extremities, retention of urine, and loss of 
power over the sphincter ani muscle, had a perfectly natural 
though painless labor. The cause of the paralysis was 
obscure, the patient subsequently making a complete recovery, 
Jacquemart reports a similar case, in which the paralysis was 
due to partial compression of the cord at the level of the first 
dorsal vertebra. On the other band, Schlesinger has shown 
that the sympathetic is not the only motor nerve, as refiex 
movements of the uterus follow stimulation of the organ when 
all the branches of the aortic plexus have been carefully divided, 

" A motor center for uterine contractions has been proved to 
exist in the medulla oblongata. This center is excited directly 
to action by anaemic conditions, and by the presence of carbonic 
acid in the blood conveyed to it. Vivid mental emotions may 
either awaken or suspend uterine contractility, 

"Reflex movements of the uterus may be provoked by 
stimulating the central end of the spinal nerves, — a fact which 
serves to explain the consensus long recognized as existing be- 
tween the breasts and the organs of generation. When the 
spinal cord is divided below the medulla oblongata, this phe- 
nomenon is no longer observed. Direct stimuli to the uterus, 
however, determine contractions independently of the medulla 
oblongata, the spinal cord then acting as a reflex center. The 
presence of asphyxiated blood in the arterial trunks acta as a 
physiological stimulus to labor. By the separation of the 
decidua from its organic connection with the uterus, the ovum 
acts as a foreign body, and, as is well known, speedily awakens 
uterine movements. Finally, Kehrer has shown that, when a 
cornu is removed from the uterus during labor, rhythmic con- 
tractions of the muscular fibers will continue from a half-hour 



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tlAtrsES AND Character of Labor. 811 

t-o an honr after separation, provided only the tigujues be kept 
Bioiat and at a suitable temperature. 

" The following theory of the causes of labor is offered, not 
because of its completeness, but merely as a means of groupiug 
the foregoing facte together in the order of their relative im- 
portance. The advance of pr^nancy is associated with in- 
crease in the in-itability of the uterus, a property most 
pronounced at the recurrence of the menstrual epochs. By 
thinning of the partitions between the glandular structures the 
■way is prepared, as the time for labor approaches, for the easy 
separation of the dense inner stratum of the decidaa. The 
ready response of the uterus to stimuli reflected from the 
peripheral extremities of the spinal nerves, to direct local ini- 
tation, and to the presence of blood surcharged with carbonic 
acid in the uterine vessels, explains the frequency of painless 
contractions for days, or even weeks, in some cases, previous 
to labor. To these means of exciting uterine motility there 
should be added, in all probability, the reaction of the uterine 
muscle, from the tension to which it is subjected by the growth 
of the ovum, and to the circulatory disturbancesin the cerebral 
centers sometimes effect-ed by vivid emotions. Frequently re- 
peated uterine contractions, without partial separation of the 
decidua, are hardly comprehensible after the decidua vera and 
reflexa are brought into close contact with one another. Such 
A physiological separation would, of necessity, when of suffl- 
«ient extent, by converting the ovum into a foreign body, fur- 
nish an active cause for the advent of labor, in the same way 
that labor is prematurely excited by a similar separation when 
artificially induced. Thus, by the time the development of the 
foetus is completed, all things are in train for its expulsion. 
When other causes do not early operate as determining forces, 
the increase of uterine irritability at the recurrence of the men- 
strual epochs probably accounts for the ordinary coincidence 
of labor with the tenth eatamenial date." 

The Expelling Powers.— The power by which expulsion of 
the fcetus is effected resides chiefly in the uterine muscular 
structures themselves. While this is true, every attentive clini- 
cal observer soon learns that much aid is afforded by the 
altdominaJ muscles, and a little by the feeble contractions of 
the vagina. 

TliP Uterine ContractioiiF. — The general form of the uterus 
towards the close of utero-gestfttion is oval ; but when in ^ 



312 Labou. 

Btate of contrattion the longitudinal and transverse diameters 
are diminished, while the antero-pt«terior is increased, render- 
inpT the organ more globular. One very marked feature of the . 
uterine efforts is their intermittent character, coming and go- 
ing at gradually narrowing intervals. The action is also peri- 
staltic, beginning at one extremity and sweeping to the other 
in a powerful wave of muscular energy. Whether this action 
proceeds from fundus to cervix, or from cervix to fundus, isstill 
s matter of dispute. It is said by most careful observers that 
the contraction sets in at the fundus and flows to the cervix, 
■whence it returns in a wave to the fundus, and this accords- 
with the author's observation. As the fingers rest against the- 
presenting head, the first indication of an approaching con- 
traction is found, not in the patient's uneasiness, nor in the- 
eontraction of the cervical muscles, but in descent of the- 
presenting part into the pelvis. We are often able to notify the 
patient of the coming pain before she herself is aware of its ap- 
proach. This clinical observation is good evidence that the 
contraction does not b^n in the cervix. We have also found 
that, if one hand be placed on the fundus uteri and the fingers 
of the other on the cervix, contraction will be first felt at the 
fbndus of the organ. 

Uterine contraction, of a forcible character, is nearly always 
a<ccompanied by pain, in the early stage of a cutting and saw- 
ing nature, in the second stage of a bearing and disruptive 
sort. At the same time it should be remembered that contrac- 
tions of a forcible kind only are usually painful, contractiona 
■without pain occnrring throughout the greater part of preg- 
Bancy without producing any unpleasant sensation. 

Uterine action rarely sets in with force and energy, but in an 
indolent and feeble manner, owing probably to the weakness of 
the stimulus exerted at the beginning. Slowly the contractions 
gather strength and energy, until, at the close, they become- 
terrific. The limit of intrar-uterine development having been 
reached, and the fcetus having become in a sense a foreign body, 
nature begins in a mild and hesitating way to suggest that it 
leave the nidus which it has outgrown. The repeated contrac- 
tions begin dilatation of the os uteri, the relations between th& 
uterus and membranes are more and more severed, and in this 
manner a stronger reflex action is excit«d. At a later period 
the stretched cervix, the distended vagina and vulva, and the 
compressed nerves, augment the action to an almost nnhear* 



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Causes axd Character op Labor. 813 

able deg^ree. At tbe beginniug the pains may be separated by 
an interval of an hour ; but as they iucreaee iu force they returu 
at shorter intervals, until, during the latter part of the propul- 
Hive Btage, they may be almost continuous. The avera^ dura- 
tion of a labor-pain is about one minute, or perhaps a little 
lees. Contractions come and go without consulting the will of 
the patient who is fortunate enough to be the subject of them, 
and are unresponsive to her volition. The motor centers of the 
uterus are located chiefly in the sympathetic ganglia. It has 
been su^;ested that the anterior sacral nerves may perform an 
inhibitory office. 

When the membranes are unruptured, the bag of waters, 
being the part in advance, is made to press at the os uteri and 
gradually eiipand it. If the membranes are ruptured, the 
presenting part of the foetus performs the office, and usually 
performs it nearly a* well. Prior to the beginning of labor the 
internal os yields to a considerable degree, so that a few jiains 
usually suffice to make the cervical canal a part of the uterine 
■cavity. The external os follows, and, before dilatation is com- 
pleted, the lips of the os become extremely thin from the 
stretching imposed upon them. After the bulk of the head 
passes the cervix, retraction of the os from the head rapidly 
follows, and the fcetus lies with its head in the vagina and its 
trunk in the uterus, the two cavities thus being opened to form 
a common canal. 

By placing the band on the globe of the uterus, as it con- 
tracts with force during labor, we may readily determine that 
tbe uterus displays much energy and contractile power. This 
power of the uterus is more sensibl^v felt when the hand is 
introduced into the oi^an for such a purpose as version, while 
the patient is not under the influence of an anesthetic. The 
contrsictious vary much in intensity, both in different cEises and 
in the various stages of the same case. Just what the degree of 
power thus exerted is in different subjects has long been a 
matter of curious inquiry, and attempts have been made to 
measure it. While the results of such researches have not been 
highly satisfactory, owing to the difficulties surrounding the 
investigations, they may be accounted valuable data. Dr. 
Matthews Duncan, after repeated experiment and study, found 
that the force required to rupture the strongest membranes, 
with an os uteri 4.50 inches in diameter, was about S~% pounds. 
He coUected. further, that, in ordinary labor, the propelling 



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314 Laror. 

force is from six to twenty-seven poands. la cases where un- 
usual effort is made, the propulsive powerexerted by the uterus, 
the abdominal walls, and the other forces at the woman's com- 
mand, may be increased to eighty pounds. I'oppel found that 
an average force of five pounds is required to rupture the mem- 
branes when the dilatation has attained a diameter of 1.9 
inches. He found that the average force necessary for expulsion 
of the foetus varies from four to nineteen pounds. Ribeniont'e 
experiments showed that when the diameter of the os amounts 
to 3.9 inches, the average pressure necessary to produce rupture 
is twenty-three pounds. Schatz, who entered into a thorough 
scientific investigation of the question, arrived at the conclu- 
sion that the power necessary to accomplish fcetal expulsion 
varied from seven to flfty-flve pounds. 

Effect of the Fains on Mother and Foetus. — One very marked 
eflFect of the uterine contraction is increasft of the arterial 
pressure. This probably grows out of the restriction of circu- 
lation through the ut«rine walls. But, since there is a great 
degree of nervous excitement associated with the movement, 
the rapidity of pulsation, instead of being diminished as usual 
in proportion to the degree of increaaed tension, is increased. 
The respirations are usually diminished in frequency, but some- 
times, especially in nervous sensitive women, the increase is 
quite marked. The temperature is slightly elevated, and the 
urinary excretion, in consequence of the arterial pressure, is 
augmented. 

The foetal circulation is decidedly affected by the uterine 
contractions, so that, during a pain, the heart-sounds are 
scarcely audible, even in those cases wherein they at other times 
are unusually distinct. This action onthe heart is attributed by 
Schwartz to an increased intra-cardiac pressure, by Schultze to 
slight asphyxia from placental compression, and by Kehrer to 
compression of the cranium and its contents. 

Viifrinul Contractions.— \9, the presenting part of the foetus 
passes through the os uteri and enters the vagina, it at first 
meets with resistance. Distension becomes so great as tempo- 
rarily to paralyze the force of the few muscular fibers of this 
tube; but, after the moment of greatest distension is passed, 
they regain a certain amount of the lost energy and contract 
down upon the receding foetus, and nltimately aid in expelling 
the placenta. 

Abdominal Aid. — The aid afforded by the abdominal mui^ 



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Causes and Character of Labor. 315 

clea has a marked effect, ou the progress of labor, but it is not 
iuvoked until the advent of the propulnive sta^re. The action 
of theae musclee differs from that of the ut«rii8, in that it is in 
a measure voluntary. Still, it is found that, at the height of 
a bearing-paiu, the action partakes of the nature of tenesmus, 
and becomes absolutely uncontrollable. Contraction of the 
abdominal muscles aids in the following way : The extremities 
are pressed against some firm support, or otherwise fixed, and 
the trunk is thus rendered firm ; then by deep inspiration the 
diaphra£!;m is pushed downwards while the abdominal muscles 
are held tense, and a powerful downward pressure is thus ex- 
erted ou the uterine contents. The aid thus afforded in of the 
greatest value in the aecomplishment of rapid and etfectual 
parturition. 

The Pains of Labor. — The location and character of labor- 
pains vary nob only with the parturient st^ages, but also with 
the woman's peculiarities. In sensitive women they are ex- 
tremely agonizing, and sometimes overwhelming; while in ■ 
those of more obtuse sensibility they are not so keenly felt. 
During the flrat or preparatory stage the pain is of a cutting, 
sawing or grinding nature, and is felt chiefly in the hypogas- 
tric, or lumbo-sacral region, or in both. From the back the 
pains radiate forwards and downwards into the abdomen and 
thighs. The hypogastric pains extend into the groins. Dur- 
ing the second stage of labor the lumbo-aacral region is, as a 
rule, the seat of greatest suffering, until, towards the close, it 
is traasferred to the sacrum, rectum, and vulva. The pains 
themselves are greatly changed during this part of labor, be- 
coming of a tearing, dist«usive, luxative character. Meigs 
offers some very excellent observations on this subject. " The 
pain felt in labor," he says, "is owing to the sensibility of the 
resisting, and not to that of the eitpelling, organs. Thus the 
eharp, agonizing and dispiriting pains of the commencement of 
the process, which are called grinders, or grinding- pains, are 
surely caused by the stretching of the parts that compose the 
cervix and os uteri and upper end of the vagina. Paius are 
rarely felt in the fundus and body of the organ; and nineteen 
oat of twenty women , if asked where the pain is, will reply that 
it is at the lower part of the abdomen, and in the back, — indi- 
cating, with their hands, a situation corresponding to the brim 
of the pelvis, and not higher than that, — a point opposite the 
plane of the OS uteri. When the pains of dilatation are com- 



31G Labor. 

pleted, and the foetal prenentatiou begins to press upon the 
lower part of the va^na, the pain will, of course, be frit there, 
and is finally referred to the sacral r^on, the lower end of the 
rectum and perineum. The lost pains which push out the 
perineum, and put the labia on the stretch, will of course be 
felt in those parts chiefly. The sensation, under these circum- 
stances, is represented as absolutely indescribable, and cer- 
tainly as comparable to no other paiu." 

Mei^ was an excellent clinical observer and teacher, but, in 
a fair view of all the facts, it does not seem probable that the 
foregoing ie altogether true. Reasoning from analogy, we infer 
that a forcible contraction of an organ like the uterus is, in 
itself, productive of more or less pain. This inference is justly 
derivable from a study of after-pains, and from violent con- 
tractions of other organs. There are other clinical observa- 
tions which throw some light on this question, among which 
we may mention the pheaomeuon of misplaced or metastatic 
labor-pains. In these cases, the pain, instead of being located 
in its usual place, is felt mainly, or exclusively, in other parts 
of the body. The bead, the eyes, the legs, or indeed almost 
any part, may be the point of attack. Dr. B. Fordyce Barker 
reported a case to the New York Obstetrical Society, a number 
of years ago, in substance as follows: ile recently attended a 
lady in her confinement who was in labor but two faount, 
though the pains did not seem at any time to center about the 
pelvis. There were no uterine pains at all, but, with each con- 
traction of the womb, pain was experienced in the legs. The 
pain was not localized, nor was there any muscular contraction 
of the legs. The same pain was produced in pressing off the 
placenta. Weigand relates a caae in which severe infra-orbital 
pain occurred with every uterine contraction. Dewees mentions 
one in which the pains were felt in the calves of the legs. 

Mattel attributes the lumbar pains to pressure of the utema 
against the spinal column, and Beau to lumbo-abdominai neu- 
ralgia, like that accompanying uterine troubles disconnected 
with pregnancy. 

The pains of labor increase in intensity an labor progresses, 
but, as a rule, those of the propulsive stage are borne with 
more fortitude than those of the firet stage. Lamentations are 
nearly always louder and more touching during the stage of 
dilatation, and the nervous symptoms are at this time more 
prominent. The reason for this is probably found in the 



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Causes and Character of Labor. 817 

absents of any appreciable advancemeut during this stage, and 
the coQeequent diacouragemeut growiug out of the feeling that 
all the pain is of no avail. The fa«t also that the effort is of 
an involuntary sort, has the effect to make the suffering more 
nnbearable than that accompanied by a strong voluntary 
struggle. 

The terms " forcible pains," " weak pains," " deficient pains," 
«tc., are commonly used to characterize different phases of the 
distressing process. It will be understood that the substantive 
"pain" is here synonymous with "contraction," Pain is merely 
the sensible evidence of uterine action. When the organ con- 
tracts with energy, the pains are usuafly severe; and when it 
acta feebly, the pains are correspondingly light. The terms 
■"vehement," "powerful," "forcible," "weak," "deficient," 
"inefficient." etc., are only relative, that is to say, they do not 
express a definite d^;ree of either quality or quantity. 



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CHAPTER II. 
CLINICAL COURSE AND PHENOMENA OF LABOR. 

The stages of Labor. — By what has preceded we have been 
brought to a point where it is proper to enter upon a consider- 
ation of the clinical course of labor in its normal phases. 

One cannot long be in the active practice of obstetrics with- 
oat observing that the process of parturition is very naturally 
divided into distinct stages, each characterized by its own 
peculiar phenomena, and the whole linked together into a 
remarkably uniform sequence of events, TUe first is in a 
meaaure a preparatory stage, during which the pains operate 
to open np the os uteri, and get things in order for descent of 
the foetus through the parturient canal. The second is the 
stage of propulsion, during which the foetus journeys through 
the pelvis and emerges at the vulva. The third comprises 
separation and expulsion of the secundines. The first stage 
ends, then, with full dilatation of the os uteri ; the second with 
complete expulsion of the fcetus ; and the third ^^'ith separation 
and extrusion of whatever of the product of conception and 
the immediate result of it is left behind. 

The FinsT Stage.— This properly be^ns with development 
of the first symptoms of actual labor, though the precise mo- 
ment cannot always be determined- There is a certain amount 
of preliminary action which has been very properly termed the 
preparatory stage. This is often well marked, while at other 
times it is so indistinct as to escape detection. 

One of the most common changes occurring toward the 
- close of pi-egnancy is what has been elsewhere alluded to as 
subsidence of the uterus, with a falling forwards of the fundus. 
When well marked, this change of relations and position is fol- 
lowed by considerable relief of the gastric disturbances which 
so often render the woman most uncomfortable in the. latter 
part of pregnancy. Locomotion may for a time be more difB- 
cult, while downward pressure of the uterus producpsafrequent 
desire to urinate, and often, to defecate. Proceeding partly 
from this cause, and partly from interference with the portal 
circulation by general intra-abdominal pressure, hemorrhoids 
are liable to make their appearance for the firet time, or, in old 
oases, become greatly aggravated. This subsidence of the 



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Phenomena of Labor. 319" 

uterus is commonly more marked in primiparEethan in multi- 
para, and hence we And the presenting head, covered by the 
uterine wallu, low in the pelvis more frequently in the former 
than in the latter. Subsidence of the fundus uteri is not 
brought about, however, wholly by a descent of the whole 
organ, but there is likewise a lessening to a small degree of the 
longitudinal measurement of the same, as though the oi^am 
were gathering itself for the final struggle. 

For a variable time before the advent of labor, the womaw 
usually observes a muco-sanguineous discharge from' th» 
vagina, accompanied by a sense of drag^ng in the Baci-mn>and 
pubis, and of tennion in the abdominal region. Moreover, as ai 
result of the painless uterine contractions which go on through- 
out the greater part of pregnancy, and an aggravation or 
augmentation of which constitutes labor, the cervical caitat 
may become dilated, in multiparee, to a considerable d^rea 
several days before labor. 

The moderate, intermittent, and usually painless, contrac- 
tJODS of the uterus, just alluded to, may in certain women of 
susceptible uatures, aud especially those of a rheumatic diathe- 
sis, give rise to pajn, and constitute what are known as falae- 
pains. These we believe to be the exceptional, rather than the 
«ommoR cause of these painful sensations. False pains are' 
HBuaHy irregular, often strong at first, but gradually becoming 
-weaker; are limited in extent, rarely dilate the os or protrude- 
the bag of waters, and are not generally accompanied by the- 
Binco-SEUiguiueous discharge which usually precedes real labor. 
They arise chiefiy from indigestion, cold, movements of the' 
fisbUR, and various other causes, and are dispelled by remedies 
calculated to remove the causes on which they depend. False 
pains arising from hyperesthesia of the sensitive nerves and 
occasioned by the uterine contractions peculiar to pregnancy, 
are best relieved by c&ulophyUam. Pulsatilla, arnica, bryoaia, 
and other remedies may be found useful. 

In a certain proportion of cases labor sets in abrnptly, with 
severe and quickly-recurring pains, but as a rule the onset is 
'gradnal, and the paJns are so far apart and so feeble that their 
real significance is not at first recognized. More painful con- 
trartions, however, soon ensue, creating restlessness, and 
causing all the phenomena pecniiar to labor. Women greatly 
■differin their sensibility to pain, and the positions which they 
ia88ame,'and'theii>ev^ei»eai8 which they make duriog labor are 



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320 Laboe. 

correspondingly diveree. Some instinctively seek the bed and 
keep it throughout the parturient act, others ])refer to sit or 
stand until the first sta^ is nearly finished, while others can 
scarcely be driven into a recumbent posture till the very close 
of the second stage. If sitting, the woman during the severe 
part of the first stage is usually disposed to throw the trunk 
of the body forwards as the pain conies on, resting her weight 
on the hands which press the thighs, or she bends backwards 
with the hands on the loins. The earlier paios rarely extort 
cries, but, when the os has reached a certain degree of dilata- 
tion, the suffering becomes bo severe as to create great restless- 
ness and bring out some exclamations of distress. Occasionally 
the woman's fortitude is so great, or the pain so slight, that no 
sound of distreBs escapes her lips during either the first or 
second stage. 

True labor pains usually manifest their impression on the os 
uteri without much delay, and therefore labor may be said gener- 
ally to begin with the first indication of expansion or reduction 
of this part, provided there is evidence of strong, recurrent, 
coincident uterine effort. The expansion then begun progresses 
gradually — sometimes rapidly, until the entire cervical canal 
becomes'large enough to admit of uterine evacuation. As the 
o8 internum opens, the contractions cause the membranes to 
descend and exert an expansive force on the cervical canal. 
During a pain the membranes become tense, and bulge through 
the opening to a greater or less degree, until, after a cert^n 
amount of expansion has been attained, they resemble the 
form of an old-fashioned watch crystal. This is true, however, 
only after the internal os has entirely yielded, and the edges of the 
external os have become thin from the pressure put upon them. 
As the pain subsides, the os relaxes and the membranes retreat. 
With the advance of labor, the pains increase in intensity, fre- 
quency and force, while uterine dilatation in usually progressive. 
Nausea and vomiting are not infrequent, and when present they 
add greatly to the woman's distress, though their effect on 
labor is often salutary. The softening, relaxation and hyper- 
secretion evinced in the soft structures, become more and more 
decided, and when the expansion has reached a certain limit, 
say a diameter of two and a-half or three inches, the protrud- 
ing membranes commonly rupture, and a considerable part of 
the liquor amnii escapes with a gush. Sometimes all the 
amniotic fiuid escapes as shown by the sequence, but usually a 



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Phenomena of Labor. 



321 



part of it is prevented from doing so by descent of the pi-esent- 
ing part, and is retained till final escape of the foetus. 

The pulse increases in frequency in proportion to the severity 
of the pain, its acceleration being determined by the exercise of 
muscular energy. This effect on the circulatory apparatus 
may be usefully employed, some say, as a gauge of the efficiency 
of the pains, for, the more marked and uniform the variation, 
the more effective the contraction. "When, however," says 
Hohl, "the rapidity of the beats subsides before approaching^ 
the maximam, the pain is too weak; or wheu the rapidity rises 




Fra. 126.— Showing v 

by sudden starts, the pain is a hurried one, and in either ceise its 
effect will be imperfect." The pulse acceleration, under an 
efficient pain of average duration, he represents by the follow- 
ing record of the several quarters of two minutes : 18, 18, 20, 
32: 24,24,22,18. 

This may all be true, but we have found the pulse of little 
value as a means of determining the efficiency of uterine action. 

The softening, relaxation, and hypersecretion become more- 
and more decided. The blood found on the examining finger 



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Fio. 126. — Section of a frozen bodyat the termination of the fir§t stage ol 
Xabor. The membranes are still intact, the cervix ia full; dilated, and ths 
head, occupying the second poBition, is in the pelvic cavity. 



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Phenomena of Lahor. 323 

and which tinp^s the mucufi, proceeds mainly from the decidua 
and the uterine walls with which it is. in contact, since the 
former, owing to a gi-adual giving way of the os uteri, is being 
torn away from its maternal attachments. After a time, the 
head, influenced by uterine contractions, descends into the 
cervix, the walls of which are separated until they lie against 
the pelvic borders, and thereby form, with the uterine cavity 
and vagina, a continuous channel known as the parturient 
canal. This, the first stage of labor, varies greatly in duratinu 
but ie genJerally completed in six or seven hours. It sometimes 
lasts but an hour, and on the other band, it is occasionally 
protracted to one, two or three days. 



Fio. 127.— The Parturient Canftl. 

The Mechanism of Dilatation. — It appears to be pretty 
penerally conceded that the so-called bag of waters acts as a 
kind of entering wedge, by means of which an equitable hydro- 
fltatic pressure is brought to bear in the direction of expansion, 
and that this is the mechaniem through which dilatation of the 
OS uteri is mainly effected. Ijeishman reasouR learnedly and 
forcibly on the subject as follows : " The first efficient contrac- 
1a"T having resulted in an opening of the os to a trifiing extent, 
and the tissues being sufficiently relaxed to admit of saris- 
fa«tory progi-ess, we are enabled to trace the process of dila- 
tation through all its subsequent stoges. As soon as the os 



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324 Labor. 

haa yielded to a certain extent, the membranee which are here- 
Beparated from their utei-ine attachment, commence to pro- 
trude in the form, first of a watch-glass, and then of the 
extremity of a pouch or baff, which has been termed the " bag- 
of waters." Following the operation of a very obvious law 
already alluded to, this phenomenon implies, primarily, an 
attempt, consequent on the uterine contraction, on the part 
of the waters, to escape in the direction in which resistance ia 
least. The special function, however, of this bag in to effect the 
further dilatation of the os, and we can conceive of no means 
which could be more admirably adapted to this object than the 
graduated fluid pressure which is thus brought to bear upon 
the OB equally in its whole circumference. It constitutes, in 
fact, in its action during a pain, a hydro-dynamic force, which 
acts at once safely and powerfully upon the whole of the oe." 

Theoretically this action of the bag of waters is very 
decided, but when we reflect upon all the conditions, we are led 
to doubt its practical effect. Moreover, every obstetric prac- 
titioner of much experience has surely observed that in many 
iDstances (we believe in at least thirty or forty per cent, of all 
cases) there is no well formed bag of waters, and, during a pain,, 
but little fluid can be felt between the unbroken membranesand 
the head. In such labors hydrostatic dilative force is neces- 
sarily an unimportant factor. These cases, combined with 
those in which early rupture of the membranes takes place 
either spontaneously or artificially, rendered quite true 
Cazeaux's remark. — "In general, it (dilatation) is very slow in 
the commencement of labor, but much more rapid towards its 
close." This statement he in another place explains by sayiug, 
"The foetus evidently has no part in the dilatation of the os 
uteri until the bag of waters is ruptured. It is not until after 
this event takes place that the vertex, by engaging like a wedge 
in the uterine neck, can hasten the dilatation niechanically ; and 
it is equally evident that in any other than a vertex presenta- 
tion, the presenting part being more voluminous and irregular 
than the head, cannot perform the same office, and therefore, 
ceteris paribus, the orifice will open more slowly." 

But in those cases wherein a bag is felt, what service does it 
render? This, of course, we are not able, even by the most 
careful experiment, to determine, since the conditions which 
exist in labor caunot beartifically duplicated. In considering 
the question it must be borne in mind that the entire liquor 



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Phenomena of Labor. 325 

amtiii is not available for the exertion of expansive force at the 
oa, owing to firm preseure of the head, during uterine contrac- 
tion, against the pelvic brim and the soft tissues thereabout. 
This may be demonstrated by rupture of themembranesduring 
a pain, even in instances of fully developed bags, the amniotic 
fluid confined below the head being the only part which then 
escapes. There are doubtless exceptions to this rule, as, for 
example, those instances in which the head does not descend 
forcibly against the lower uterine segment, and hence not 
against the pelvic brim, until after the first stage is consider- 
ably advanced. Another exception is found in those cases 
where pelvic deformity prevents a nice adaptation of fietalhead 
to maternal parts. But in general we find upon rupture of the 
membranes during a pain, that thebagofwatern, or rather that 
part of it within reach, empties itself, yet much of the amniotic 
fluid is left confined above the foetal head, and escapes in part 
by a continuous drain during the intervals of contraction, in 
part at the beginning of subsequent pains, but more especially 
after fcetal expulsion. Resintance being withdrawn, the pre* 
senting part pushes down, and, " at the height of the contrac- 
tion," OS Cazeanx says, "the flow is aiTested because the direct 
application of the head against the orifice stops it completely." 
"After rupture," says Lusk, also, "which usually oecurseponta^ 
neouflly, the water in front of the child's head escapes, though 
the greater part of the amniotic fluid is retained within the 
uterus by the valve-like pressure of the presenting part." We 
insist that these facts be borne in mind, and with them before 
us we will consider the theories of cervical dilatation usually 
advanced. 

"During the contraction," says Playfair, " the bag of mem- 
branes will be felt to bulge, to become tense from thedownward 
pressure of the licjuor amnii within it, and to protrude through 
the OS if it be suiBciently npen. The membranes with the con- 
tained liquor amnii, thus f;.rm a fluid wedge, which has a mont 
important influence in d^Uting tho os uteri. This does not, 
however, form the sole mechanism by which the os uteri is 
dilated, for it is also acted upon by the contractions of the 
muscular fibers of the uterus which tend to pull it open. It is 
probable that the muscular dilatation of the os is efiected 
chiefly by the longitudinal fUiers, which, as they shorten, act 
upon the os uteri, the part where there is least resistance." It 
is the fluid-wedge action of the bag of waters to which has been 



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82G Labor. 

attributed such potency ; and. bo fur aa it is related to early 
dilatation, we would not raise a dissenting voice. Butafterthe 
.08 has attained a diameter of, aay, two inches, the tumefied 
scalp and presenting occiput advantageously substitute it. A 
-part of the liquor ansnii having escaped, and a fair opening of 
the OS having been secured, the uterus is enabled to act with 
force on the ftetus, much as the fingers and thumb of the sur- 
geon would on the glans penin in retracting the foreskin for 
relief of phimosis. It will be undei-stood that we do not reject 
the theory of hydrostatic aid in dilatation: but we do claim 
that experience and re- 
flectiou have led to the 
conviction that it per- 
forms a very unimpor- 
p,Q J28, taut part in the latter 

half of the process. 
It will then be asked, "Why are labors complicated by 
early rupture of the membranes more protracted and danger- 
ous than others?" We reply that observers mistake in 
classing together all cases wherein rupture of the membranes 
takes place at any and every period before and during dilata- 
tion ; whereas a marked distinction ought to be made. When 
rupture takes place spontaneously before the first stage comes 
to a close, it most fi^quently occurs before the os has dilated 
to any extent, and while the woman is about the house or 
room, so that all, or nearly all, the amniotic fluid escapes, and 
the conditions thus 
become quite dif- 
ferent from thowe 
now being dis- 
„ 2- cussed . We often 

rupture the bag of 
waters after a certain amount of dilatation has been accom- 
plished and have but a small amniotic gush, and yet the effect' 
on labor is salutary. W© are fully convinced that beneficial 
effects as often follow when there in not a redundancy of liquor 
amnii, as when there is. If dilatation goes on till the expan- 
sion acquires a diameter of about two inches before the bag of 
waters discharges, the delivery cannot be set down as a " dry 
birth," and it is not thereby rendered more difficult and dan- 
gerous, but, on the whole, less so. 

Dilatation of the ob uteri is in the main dependent on other 



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Phenomena of Labor. 327 

causes than hydrostatic pressure. "The procesB of dilatation 
of the OS is dependent," we are told by Meadows, " according: 
to the late Dr. Rugby, not merely on mechaDical stretching 
which the pressure of the membranes and the presenting part 
exert upon it, but also to the circular fibers being no longer 
able to maintain the state of contraction which they had pre- 
served during pregriancy; they are overpowered by the longi- 
tudinal fibers of thfi uterus, which, by their contractions, pull 
open the OS nteri in every direction." Cazeaux follows Desor- 
raeaux in attributing dilatation of the os largely to action of 
the longitudinal 
fibers. Tyler 
Smith r^^rded 
the OS a* pos- P,^ ^3^ 

seesed of both 

" dilatile and contractile " powers. He did not subscribe to the 
doctrine of equable and r^ular action of all parts of the 
uterus ; nor did he r^^ard contraction of the body and fundus 
of the organ as any more capable of overpowering the circular 
fibers of the cervix, than are the respiratory muscles of forcing 
open the little glottis in case of spasmodic closure. Moreover, 
he assumed that the individual muscular fibers of the cervix do 
not continuously surround the part, for if they did they would 
6e so stretched during passa^ of the ftetus that they could 
never r^ain their contractility. He believed in a peculiar 
arrangement of the 
muscular fibers, by 
virtue of which 
something more 
than a sphincter is 
formed, attribut- 
ing to the cervix 
dilative powers. 

Though questioned by mauy, this dual action of the os cannot 
positively be denied. Indeed, from the spasmodic expansion of 
the unimpregnated OS witnessed by Mund4, and several others, 
during sexual orgasm, the part seems almost unquestionably 
to possess spontaneous dilative as well as contractive energy. 
The three main factors concerned in dilatation ot the part 
we would then set down as, (1) mechanical action, primarily, 
of the bag of waters, and, secondarily, and more energetically, 
of the foetal cranium or otherpresenting part ; (2) contraction 




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828 Labor. 

of tbe loDgitudiual fibers of the womb; and (3) BpontaDeous 
ezpaoBive action of certain muMular fibers, not yet demon- 
strated, residing in or near the cervix. 

With respect tothefirst, it may beeaid that the bag of waters, 
in the early part, of the first stage of labor, plays a very useful 
role byinsinuating itself into the OS, as shown in figurel28,and 
gradually spreading it, much as would a rubber dilator as ap- 
plied by the gyneecologist. But long before expansion is com- 
plete this action loses its best effect (see figures 1.29 and 130),. 



Fig. 132.— Section shoving the FojtuB, inclosed in its membranei, with 
expanding Os Uteri. 

and may be advantageously substituted by the scalp and cra- 
nium of the child, as suggestively shown in fljrure 133. 

Concerning the second, little need l»e said, since all admit 
the powerful effect of the strong longitudinal muscles of the 
uterus. The oi^an l>eing thicker, and the muscular fibers more 
numerous, in the body, the weaker part is compelled gradually 
to yield, and thus, by degrees, expansion of the os is carried 
forward. 

Spasmodic contraction of even weak muscular fibers is 
hard to overeoine and this KometimeK seems especially true of 



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Phenomena ov Labor. 329 

tluCt ntTolVing the cervix uteii ; but, in a given case, when once 
•t is broken, tliere may be not only cheerful acquiescence ou the 
part 4^ the muscular fibers involved, but efficient aid afibrded 
iby them 'or their congeners. 

Ma^lMm of the Membranes. — After nide expansion of the 
■OS luteri aad the way is open for foetal descent, pressure becomes 
100 flbrong as usually to cause spontaneous rupture of the mem- 
<branes. When unusually tough, they may, in n^lected cases, 
■continue unbroken, and envelop the fcetus to the very close of 
the second stage. This can occur only when the placenta is 
■dragged loose from its moonngs, and is also extruded. A child 
thus enveloped is said to lie born with a " caul." "What is even 
more common, however, is a rupture of the membranes at the 
point where they surround the neck, and retention of the de- 
tached portion over the face, con- 
stituting a "veil," which old nurses 
r^i^ard as a sign of good lu<tk. 

The Second, or Propui^ve, 
Stage. — At this stage theos is com- 
pletely dilated, and somewhat re- 
tracted, so as scarcely to be felt. 
The uterus contracts more closely 
on the fcetus and pushes it down- 
wards into the pelvic cavity. When 
it reaches this situation the woman 
bt^DB to feel the presence of a Fig. 188. 

aolid body which must be expelled, 

and she accordingly bends every endeavor to the accomplish- 
ment of the undertaking. The pains assume a different char- 
acter. They are really much more painful, but the con- 
sciousness that they are accomplishing something seems 
to infuse both strength and courage. The powerful pro- 
pulsive efforts made by the woman are termed "bearing 
down," "propulsive," or "expulsive," hence the name, "pro- 
pulsive stage," often given to this part of labor. The 
resistance encountered in the first stage having been re- 
moved by the completion of dilatation, the pelvic brim, the 
varied relative diameters of the pelvic cavity, the pelvic floor, 
Tagioa and vulva. In turn resist rapid progress. When the 
pains are powerful, and resistance is great, tumefaction of the 
fietal scalp is likely to ensue at the point of least resistance, 
resulting in a swelling known as the "caput saccedaneum." 




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SSO Labor. 

The recurring contractiooB cause the head to descend lower and 
lower, until it comes to press a^inst and distend the perineum. 
The part advances during a pain, and recedes as the pain passes 
off, making a sensible gaiu each time. This to-and-fro move- 
ment is a wise provision of nature to prevent continuous pres- 
sure over any one pelvic area, a» well aa to obviate too rapid 



Fia. 134.— The UteruB and Parturient Canal. (Fcetna removed.) 

distension of the soft structures. The rectum becomes flat- 
tened and its contents expelled by the advancing head. 
Pressure ou the pelvic floor, and subsequent distension of the 
Tulva, open the anus to a considerable extent, and thin iind 
elongate^ the perineum. As the fcetal head enters the pelxic 
brim, with the occipital pole ot its long diameter in advance, a 
condition of firm flexion of the chin on the sternum is enforced. 



I'HCNOMENA OP LABOK. 'd'61. 

With theloDg diameter of the bead lying id an oblique diameter 
of the pelvis, a movement in the pelvic cavity is necessitated, 
by means of wbich the long diameter of the vertex is brought 
into the conjugate of the outlet. This movement is termed 
rotation, and the time for its accomplishment is when the head 
presses firmly against the pelvic floor, and the perineum is there- 
by made to bulge The vulvar opening is put more and more on 
the stretch a* the head emerges ; the woman gathers her ener- 
gies for every pain and pi-esses as forcibly as her strength will 
allow; while now and then she gives vent to her terrible suffer- 
ings in au agonizing cry. The straining efforts of the woman 
are in a measure under her control. They are intensified by in- 



Fio. 185.— Dlstenaton of the Perineum. (Hunter.) 

flfttion of her lungs and forcible retention of her breath while 
she exerts them; while, on the other hand, by opening the 
mouth and giving expression to her feelings In cries, the 
abdominal muscles are relaxed, and the straining eflTorts modi- 
fied. The head finally passes the vulva, and the woman 
experiences a sense of great relief, which is destined soon to be 
disturbed by a pain that brings the foetal body wholly into the 
world. Expulsion of the foetus is followed by an outpouring of 
the amniotic fluid, which is commonly reddened by blood from 
the vessels lacerated by decidual release and partial or com- 
plete separation of the placenta. The pains then cease, and 
the relief experienced by the woman is most delicious. It is the 
succeeding Heaven, the calm after the storm, the stillness aft^r 
the upheaval, the rest after a wearying warfare with a rclcnt- 



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332 Labob 

less opponeDt; and but for it labor would be absolutely UBen< 
durable. 

The duration of the second stage is exceedingly variable, be- 
ing largely dependent on the frequency and force of the pains, 
the form of the maternal pelvis, the condition of the soft 
structures and the size of the foetus. This stage of labor is 
occasionally completed in twenty or thirty minutes, though in 
many cases it lasts several hours, and but for iuterference would 
sometimes be prolonged indefloitely. 

Movements of the Pelvic Articulations . — There is a popu- 
lar notion among people of nearly all nations, and has been 
from time out of mind, that, during labor, there is exten- 
sive movement and separation of the pelvic bones. Many 
capable of forming an intelligent opinion on the subject, have 
cast much doubt on the claim that 
movement takes place at an articula- 
tion other than the sacro-concygeal. 
The consensus of opinion, among the 
best authorities, appears to be that 
slight movement of the sort in ques- 
tion, does sometimes, if not uniformly, 
take place. At the symphysis pubis 
the ligaments are softened, and, under 
pressure, there is a little sepnration. 
At the sacro-iliac eynchondroses simi- 
p ,3- lar relaxation of ligamentous struct- 

ures occurs, the articular surfaces are 
sundered to a minute degree, and then there is performed an 
oscillation of the sacrum on its transverse axis. The sacro- 
sciatic ligaments share in the general relaxation, and thereby 
give greater freedom to the action. Zaglas was the first to 
call attention to the movement at the sacro- iliac articulation 
in other than parturient conditions. He found, for example, 
that in defecation, the oscillation amounted to about a Hue. 
Dr. Matthews Duncan describes a similar, but exaggerated, 
movement as taking place in the parturient woman, and iudi- 
catas the advantages thereby afforded, and the conditions 
which favor it. Thus at the beginning of labor, as the head 
enters the brim, the woman instinctively prefers to sit, to walk, 
or, if to lie, to do so with the lower limbs extended, positions 
which favor the rotation backwards of the sacral base, and 
consequent increase of the conjugate diameter of the brim. 



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Phenomena of Labor. 833 

How often, in the early eta^ of labor, do we see the patient 
«it, during a paia, with her hands on her hips, and the 
shoulders thrown backwards. 

But when the head reaches bhe pelvic floor, and b^ns to en- 
gage the nutlet, there is a manifest disposition of the woman to 
bend the body forwards, and fiex the thighs, — conditions which 
favor extension of the conjugate diameter of the inferior strait 
by rotation of the sacrum on its transverse axis. 

The Thikd Stage. — The second stage merges into the third 
with full birth of the foetus; and occasionally the third stage 
is terminated by the same contractioo which ends the second. 
In general, the third stage is not brought to so speedy a close, 
but pursues a course marked by its own special phenomena. 
During this part of labor the intimate vascular relations be- 
tween mother and child are interrupted, and by orderly action 
■of the natural forces the necessary changes are safely wrought. 

This stage of labor haa its own peculiar dangers, which 
■frown upon the woman more ominously than those of any 
other. It is sometimes ushered in by syncopal sensations, 
-arisiDg from recession of blood from the brain, occasioned 
partly by sudden withdrawal of intra-abdominal pressure, 
partly from blood-loss, but more especially, we believe, from 
.general shock. This is usually short-lived, and the pulse be- 
comes Arm and slow, showing high arterial tension. As reac- 
tion b^ins, the patient often experiences a chill, or, more 
properly speaking, a marked nervous tremor, the shaking 
being out of all proportion to the chilliness. This need cause 
no apprehension, since it proceeds from mere vaso-motor dis- 
turbance which speedily rights itself. A certain amount of 
blood-loss is characteristic of this stage, and may be regarded 
as salutary. In a plethoric woman it may be quite profuse 
without harm, while in another half the quantity would be a 
misfortune. In setting the normal bounds we are then carefully 
to consider the varying states of our patients. 

After the second stage, there is usually an interval of repose, 
of varying duration, before the uterus resumes its activity. 
This is succeeded by contractions of sufficient force to detach 
and expel the secundines. In unassisted cases the placenta 
may be expelled into the vagina, and there remain for an in- 
-deflnite period. The contracting uterus follows the ftetus during 
■expulsion, and after extrusion of the afterbirth, condenses into 
■a hrm mass in the hypogastrium. Detachment of the placenta 



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334 Labor. 

takes place in the meshy, lamillated layer, which is formed in 
the serotina by the thinned, elougated wails of the gland tu- 
bules, the dense layer which forms thematerual portion remain- 
ing adherent to the placenta. 

Much emphaui^ has of late been put upon the mechanism of 
placental expulsion aa elucidated by Dr. Matthews Duncan and 
others. It is held by them, — and their views are now ^nerally 
accepted, — that when no traction is put upon the umbilical 
cord, the placenta issues from the uterus edgewise, though it- 
may be folded longitudinally; but when it is drawn out by 



Fio. 137.— Normal mode ot Fio. 138,— Mode of Separatioit 

Separation and Expulsion of and Expulsion when traction ia 

the Placenta. made on the Cord. 

traction on the cord, inversion occurs, and, from the suction 
action thus imparted, the difficulties of delivery and the dan- 
gers of hemorrhage are augmented. 

Gassner found that after confinement, the female experiences, 
as a consequence of uterine evacuation, of exhalati)ns from the 
lungs and skin, from the discharge of excrements, from loss of 
blood, and from other depletions, a loss of weight equivalent 
to one-ninth that of the entire body. 

Duration of Labor.— Labor differs so greatly in duration 
that it is almost impossible to deduce from observation auy~ 



Phenomena of Labor. 335 " 

importaDt facts concerning its length. It may be aaid, how- 
ever, that, in general, it is longer in primiparte than in inulti- 
paree, on account of the greater finnneHs of the soft Btructuren. 
It IB also observed that, other things being equal, the pains and 
difficulties of first parturition increase with age. The relative 
depth of the pelvic cavity has a modifying influence upon latmr, 
and accordingly it- is found that very tall women paws through 
the ordeal with less facility- than others. It is also true that 
short, stout wonieu, with considerable adipoee tissue, suf- 
fer long labors, owing to the firmness of their tissues, and the 
presence of an unusual quantity of fat in the pelvic cavity. 
The character of labor is subject to modification by the posi- 
tion and preaeiitation of the foetus. Presentation of the face, 
for example, is attended with greater difficulty than that of the 
vertex, and an occipito-poeterior position is more unfiivorable 
than an oceipito-anterior. Other modifying conditions are 
often found to exist, as the presence of tumors, contraction of 
the pelvic diameters, unusual size of the foetal head, etc. 

People are prone to think that it is within the power of the 
physician of skill and learning, to foretell the exact duration of 
labor, a thing, by the way, which he is not capable of doing. 
The pains may be vigorous, the tissues relaxed, and everything- 
progressing in a satisfactory way, when the uterine contrac- 
tions may suddenly weaken, or utterly cease for many hoars, 
or some other unfortunate occurrence intcT-pose to interrupt 
the regular course of nature. 

Tlie relative duration of the first and second stages is by 
some stated to be in the proportion of t-wo or thi-ee to one, but 
others estimate it to be nearer four or five to one. In properly 
managed cases, the second stage is never longer than the first. 

The Hour of Labor.— The larger number of births is said 
to take place in the early morning hours. West observed that 
out of 2019 deliveries, 780 occurred between 11 p.m. and 7 
A.M.; 662 from 7 a.m. to 3 p.m. and 577 from 3 p.m. to 11 
P.M. Kleinwachter tells us that labor-pains usually set in 
between 10 and 12 p.m. Spiegelberg believes the maximum 
frequency of birth is between 12 and 3 o'clock. 

Lunar Influence on Parturition. — Dr. C. G. Rane in lS(i5 
called attention to this subject, and reported his observations 
in thirty-four cases, in which, with a single exception, he found 
that birth took place at high tide. Dr. T. S. Hoyue found in 
aeventy-five cases but four exceptions. 



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S36 Labob. 

Dr. M. M. Walker prepared a paper on the subject for the 
Horn. Med. Society of Penn. (Sept. 1882), with a report of 
two hundred caaea, from which the following figures have been 
taken: 

Kumber born during lolar and lunar flood tldei combined, • • 42 
" " " solar flood, -....-.-52 

« lunar flood, - - - 38 

Total bom during the flood tides, .... 132, or 66 per cent. 

" " " " ebb tides, and at other times, 42, or 21 per cent. 

InstrumeDtal cases and extractions, - - - - 26, or 13 per cent. 

Three cases born during the administration of an anesthetic, without 
instrumental aid, and Included in the above table, occurred as follows : one 
during both solar and lunar flood, one during lunar flood, and one during 
ebb tide. These two hundred ooneecutire cases occurred from Nov. 1874 
to Aug. 1S81. 



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Management of Normal Labor. 



CHAPTER m. 
THE MANAGEMENT OF NORMAL LABOR. 

Having given a brief account of the phenomena usually ob- 
served in labor of a normal character, it becomes necesearv to- 
offer some observations on the management of the variouB. 
stages of the parturient process. So wisely has nature adapted 
means to ends, that tbe act throughout is generally one wliJchi 
requires but little direction, and still less assistance, from the- 
medical attendant. So true is this that we might add that, iU' 
tbe larger number of cases, aa bappy and satisfactory an i68ue- 
results under the care of an uneducated, but experienced, at- 
tendant, as under the conduct of those highly learned, and 
consummately skilled. But irregularities in the parturient act 
are liable to arise, in the management of which mere experience 
will not avail. To meet and successfully manage com plications 
as they arise, the accoucheur must have a thorough acquaint- 
ance with the phenomena of the normal process which have- 
already beeu described, and be otherwise well grounded od 
obstetric principles. 

Preliminabv Abhangbments.i— Within the scope of these- 
suggestions regarding the management of labor, Hhould be in- 
cluded mentiou of certain preliminaries, respecting which women 
often require some advice. In their proper place, observation» 
respecting exercise and care of the bowels have lieen made, but 
we ought here to add that the woman should give especial 
attention to the observance of these. In no case should the 
customary stool be neglected when labor is at hand, and if 
there is the slightest tendency to constipation, as soon as pains 
are experienced a large enema should be taken and the bowels 
emptied, which will facilitate ftetal expulsion, and at the same 
time render the necessary attentions of the accoucheur less 
disagreeable. 

Under the same head, we may call the physician's attention 
to the advisability of ever holding himself in readiness to 
attend midwifery ca«es, in order that no unnecessary delay 
may ensue, it is true that in the majority of instances there is 
no occasion for haste, but in many cases successful results are 
dependent mainly on the physician's promptitude in respond- 
JDg to the urgent call. 

PaoMPT iRESPOASE TO Callb.— The practitioner will often be- 



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338 Labor. 

subjected to the annoyance of being called before labor has 
actually begun, but this fact should make him none the less at- ■ 
tentive aud prompt. It is of the highest importance that 
abnormalities of foetal form, presentation, and position, and 
unfavorable maternal conditions, be recognized at the earliest 
f)Ossible moment, since this places the accoucheur in a position 
leisurely to determine upon a plan of treatment, to provide 
himself with the best facilities, aud to choose the most desirable 
moment for interference. 

Armamentarium. — If the case to which he is called is likely 
to be difficult, the forceps and the perforator may be carried. 
Indeed, if the call is to take him a considerable dist^ance from 
home, it is the part of prudence to take along such instruments 
as may be required in eraergeneiee. The physician in active 
obstetrical practice will do well to provide himself with a bag 
or case of obstetrical iuatruments, which should include a good 
paJr of long toi-ceps, a perforator, a pair of craniotomy-forceps, 
a crotchet, a right-angled blunt hook, a decapitating hook, 
two or three vulvar retractors, four pairs of bullet forceps with 
catches, full-curved suture needles of various sizes, a needle- 
holder, catgut, silk, iodoform gauze, and a new soft rubber 
catheter. Besides these he should have a pocket-case of instru- 
ments, a hypodermic syringe, and a quantity of chloroform. 
He should provide himself also with a case containing, in 
addition to the most common homeopathic remedies, a reliable 
preparation of fluid extract of ergot. 

How TO Approach the Patient.— There is no subject con- 
nected with midwifery practice, instruction concerning which 
would be more acceptable than this, Eind yet it is one upon 
which very little satisfactory instruction can be given. The 
fact is, that the etiquette of the lying-in chamber is founded 
upon the same general principles of deportment which govern 
the polite relations of life. Gentlemanly demeanor is about all 
that is required to insure mutually agreeable contact. Still, 
the caprices of women during labor are greatly augmented in 
number and volume, and the most considerate conduct on the 
part of the physician will sometimes be met with repulse. 

Womeninparturitionwatchevery 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. Nor can their 
likes and dislikes, their opinions and their whims, be put into 
one general class and treated alike. Here, as elsewhere, to in- 



Management or Normal Labok. 339 

sure the best results one must individualize, and be who does 
«o best, will achieve the most perfect results. 

The following advice, given by the erudite and urbane Dr. 
Blundell, is thoroughly practical and sensible: "If you are 
well known to your patient," he says, "on reaching the house 
you will be welcome to her apartment ; but if you have not fre- 
queutly seen her before, nor attended her on former occasions, 
I would recommend you not immediately to pass into her 
chamber. Not having her full contldence, by your presence you 
might agitate her, and in these cases it is proper to avoid 
everything that may produce commotion of the nervous sys- 
tem. It is better, therefore, that the accoucheur retire into 
some adjoining 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 bon- 
homie. When the shower of words is blown over, or when 
Mrs. Speaker reluctantly pauses to draw breath, dexterously 
seizing the auspicious moment, youmay make inquiries respect- 
ing the progress of the labor, the condition of the bladder, the 
state of the bowels, and so on ; questions which, in ordinary, 
cases, may with more delicacy be proposed to the nurse than 
to the patient herself Should you chance not to be a dear 
man, a pious man, a good kind creature, or, still worse, should 
the lady be pettish, and declare you to be a brut* or a physiol- 
ogist, so tliat for these manifold offenses she never, never will — 
never can see you — you may remain in the house, as the female 
'never' in these cases comprises but a small portion of 
«tpmity, perhaps on an average, some one or two hours, and 
when caprices and antipathies area littlesubdued 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, and if you find the labor rapidly advancing, 
you must remain at the bedside lest thechild should come into 
the world in your absence." 

The Examination. —When shall it be made? The stage oi 
advancement which appears to have been reached, is the most 
determinate element. When the physician reaches his patient 
she may be experiencing the very first dilating pains, or she 
may already have progressed into the second or propulsive 
part of labor. In the latter instance, an examination cannot 
be made too soon, while in the former, there would be no oc- 
casion for haste. Unluckily, the existence of these various con- 



840 La BUR. 

ditions cannot in every cane be determined. Tt is possible, as & 
rule, to distinguish between the first and second sta^^ of labor 
by external si^s, as, for example, the pecaJiar pains of each ; 
but it does not follow that there is do ui^ncy for an ezamioa- 
tiou because the os is not supposed to be wide open, nor that 
there is an iuexorable and immediate demand for it because real 
propulsion has begun. The-best counsel is, not to be so pre- 
cipitate in necessary iuvestigatioos as to shock the patient, or 
betray trepidation ; and on the contrary, not to permit undue 
caution or constraint to carry one to the opposite extreme; 
but to act deliberately and discriniinately, keeping in mind the 
desirability of recognizing the impiirtant features of every case 
through a thorough vaginal examiuation, as early in labor as 
practicable. 

The finger is generally recommended to be iiitroduced during 
a pain ; but it is far preferable to do so in the interval between 
pains, and to continue the examination during a contraction. 

The patient reed not be restricted to any one position for 
the purpose of examination. Women are extremely restless 
during labor, and in frequent changes seek relief. They assume 
all sorts of postures, and resort to all kinds of expedients, and 
one must deal in an accommodating way. Let the woman re- 
main undisturbed by any considerable change, and she will 
evince loss aversion to the necessary touch. The allusion is 
now to cases aK they are ordinarily met. When for operative 
purposes, an absolute diagnosis of the exact presentation and 
position, and the condition of the parturient ciiral in obscure 
cases, becomes essential, the position most favorable for dif- 
ferential distinctions should be prescribed. This is generally 
upon the back, near the edge of the bed, so as to permit the 
' use, with equal facility, of either hand. Sometimes the os uteri 
and pi'esenting part are more easily reached when the decubitus 
is lateral. 

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. lb 
takes time to make a thorough exploration. 

Nothing is more anuoving toawoman of delicate seusethan 
a bungling attempt to pass the finger. A hint worth remem- 
bering is that the vaginal orifice lies but slightly in front of a 
line from one ischial tuberosity to the other. Whether the 



Management of Normal Labor. Hil 

woman lie od her side, or on her back, the hand maj be passed 
in a careless manner against the tuber to locate it, and thus 
ensure proper direction to the fingers. 

The pointH to be observed in a careful examination are the 
conditions of the vulva, bladder, rectum and vagina; the size 
and relative state of the os and cervix uteri ; the general loca- 
tion of the presenting part, its character and position; the 
condition of the foetal membranes, and the general capacity of 
the pelvis, at the brim, in the cavity, and at the outlet. 

Frequent examinations should be avoided, as they tend to 
irritate the vulva., and cause the woman, if sensitive, unneces- 
sary suffering. Yet, no matter how painful they may be, they 
should be made of- 
ten enough to ac- 
quaint the physi- 
cian with the pro- 
gress being made. 
A single fingermay 
answer, but two 
fingers, should, as 
arule, beemployed. 
In every instance 
they should be 
smeared with some 
bland lubricant be- 
fore introduction. 

External Ex- 
amination.— Examination of the abdomen by palpation should 
not be omitted, and if there be a serious doubt concerning the 
presentation, the existence of single pregnancy, or the pres- 
ence of fcetul life, auscultation should be practiced. A super- 
ficial manual examination of the abdomen, rapidly mmle 
under the clothes, is a common practice; but it is advisa- 
ble to go further and make a systematic, scientific and ac- 
curate manipulation, by which we may ascertain the existence 
of pregnancy, the foetal position, presentation, approximate 
size and general condition, and the relations of the uterus. 
Concurring heartily in what Hoist says on the subject of bi- 
manual examinations, that "a detailed diucussion of this 
method of examination is necessary to the completeness of a 
text-book." we have elsewhere considered the subject at some 
length. 



Fig. 139.— The Vaginal Touch. 



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342 Labor. 

Has Labor Begun? — An a rule, wheD the physician is called, 
there is no doubt that labor has bep:un. Often he is not sum- 
moned till the middle of the process, and upon examination 
finds the os uteri open, the liquor amuii dischai^ed, and the 
head of the fcetus approsimating the outlet. In other cases, 
however, the presence of what have been described as false 
labor-pains, leads the woman to believe that parturition has 
made some progress, when iu reality it has not begun. Careful 
attention to a few clinical hints will coufer the knowledge aud 
acumen necessary to differentiate the real signs of labor. With 
the finger in the va^na during a pain, observe whether there is 
any descent of the presenting part, or disteuBion of the bag of 
waters, or other syniptoma of forcible uterine contractions. 
Olwerve further, as the pains come and go, whether there is 
progressive uterine dilatation. Mere openness of the os uteri 
is not conclusive evidence. There is a difference between real 
dilatation of the os, such as comes from incipient labor, and 
an open state of the part. For weeks prior to delivery there is 
sometimes expansion to the size of a quarter of a dollar, or 
even more. An increasing expansion of the os uteri denotes 
the existence of real parturition. The threedecisiveiudications 
of labor are, then, (1) advance and retreat of the presenting 
part; (2) tension and relaxation of the membranes; and (3) 
above all, progressive expansion of the os uteri. 

Other, less decisive, indications of labor are ao open and 
relaxed state of the vulva, accompanied with a more or less 
free fiow of mucus, or mucus and blood, and rhythmical pains 
returning every ten, fifteen, twenty or thirty minutes. 

False Labor-pains. — Women, as they approa<'h the close 
of utero-gestation, often suffer with pains which simulate, in a 
measure, those of labor. Believing that real travail has begun, 
they summon the physician to their bedside, to whose annoy- 
ance an investigation develops no substantial evidence of 
incipient parturition. "False alarms" of this kind are by no 
means infrequent, and are sometimes repeated by the same 
woman. 

The Symptoms of false labor-pains vary to correspond with 
the causes whereon they depend. The pain ie often located in 
the umbilical region, and is clearly referable to the enlat^:ed 
uterus. The ovarian region is sometimes its seat, and again it 
is felt in the hypngastrium, in which case it most closely simu- 
lates the pains of real labor. Finally, it is occasionally felt 



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Management of Normal Labor. 348 

most severely in the lumbo-socral articulation, and extends 
downwards into the thighs. 

False labor-pains are, as a rule, contiuuons, but may present 
exacerbations. lu some instances they are intermittent, but 
irregular in recurrence, while occasionally they come and go 
■with the rhythmus of true pains. 

^'awses.— Spurious labor-paine owe their origin to a variety 
of causes. Undue distension of the uterus and abdomen can be 
set down as one of them. This may operate in a two-fold 
manner. 1. The very distension may create a bearing, tensive 
feeling in the pelvic r^on, especially in the latter half of the 
ninth month, wlien there is usually more or less subsidence of 
the organ ; 2. The normal contractions of the uterus which 
regularly recur throughout the greater part of pregnancy, may 
be<-ome painful as a result of the great tissue-strain which 
exists. 

Apart from unusual distension, there is, in the few days which 
precede labor, great pressure downwards of the gravid organ, 
which is capable of creating not only vesical and rectal irrita- 
tion, but a certain amount of real pain. 

Women of delicate organization, and those whose strength 
has been impaired by disease, are liable to suffer from neuralgia 
affecting the pelvic and abdominal viscera. Paius of this char- 
artcr are often intense, and sometimes observe a degreeof regu- 
larity in recurrence. 

In some cases, what are termed false labor-paine may be doe 
to rheumatism, though probably it is not a common cause. 
TheuteruB being rendered exquisitely sensitive by its rheumatic 
or !-heumatoid state, cannot painleswly undergo the distension, 
the pressure, and the slight contraction, to which it ia physio- 
iogically subject. 

Very likely false labor-pains are frequently excited by reflex 
causes. Irritation exists at some point, — commonly the 
stomach or bowels, — and is reflected to the uterine region, 
giving rise to suflering resembling that of incipient parturi- 
tion. 

Dingnosis. — The physician ought to be able to discriminate 
with exactitude between the genuine and the spurious, as he 
maytliereby protect his professional ci'edit, and save his pa^ 
tient an unnecessary amount of distress. Reputable and gen- 
-erally competent physicians, have been victims of error in such 
caam. A correct diagnosis is not always mode with facility. 



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344 



Labor. 



Single symptoms are aot decisive : a sound opinioa must refits 
on the totality of signs. 

Perspicuity in differentiatjon between spurious and genuine 
labor-pains is beet att^aable by a close comparison like that 
which follows : 



1. Most frequently felt in lumbo- 
mcral and hypogastrio regions. 



2. Pains rarely constant. 

3. Pains always recur with regu- 
larity. 

4. Paine quite uniform in dura- 
tion. 

6. Pains at first far apart, and fee- 
ble, gradually becoming more fre- 
quent and severe. 

6. Pains generally preceded or 
accompanied b; a mucous, or muco- 
■anguinolent dischartte from the 
▼agina. 

7. The Internal os Is found to have 
yielded partially, or fully, and the 
cervical body to have disappeared. 

e. The uterus during a pain con- 
tracts with force, and the mem- 
branes bulge. 



1. Sometimes felt In lumbo-sacral 
and hypogastric regions; occasion- 
ally In inguinal, but oftenest in um- 
bilical region. 

2. Pains often constant, sometime* 
remittent, but rarely intermittent. 

3. Pains generally irregular. 

4. Pains generally very unequal 
in duration. 

5. Pains continuous, remittent, or 
intermittent with short Intervals, 
their intensity observing no regular 
increase. 

6. Painsoccaslonally accompanied 
by a mucous discharge from the- 
vagina. 

7. The internal os sometimea 
found closed, and the cervix distinct. 

8. There may be uterine contrac- 
tion, but It is not forcible, and the 
membranes, if they can be felt, are 
but slightly, or not at all, affected- 

9. The IS is not dilating, though 
occasionally it Is somewhat patulous. 



9. The OS uteri Is found to be di- 
lating. 

Treatment. — If the pains are severe, the woman ought to be 
placed in the recumbent posture, in a quiet room, and every 
annoyance attentively removed. Search may then be made to 
ascertain if the pain is not reflected from some distant point, 
and if such a cause is found, it must, if possible, be removed. 

Local treatment will afford much relief, especially in rheu- 
matic and neuralgic cases. Hatn&melis or warm spirits may be 
freely applied to the abdomen. Unctuous applications will 
greatly relieve the feeling of over-distension, and consequent 
suffering. 

When the pains observe a decided periodicity, like those of 
labor, caulopbyllum in a low potency is very effectual io many 



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MANA.G&MENT OP NORMAL LaBOR. 845 

cases. Some pliyuicians regard it as a real epecific. When there 
is BpasDiodic pain, or wheo the woman suifers in the ovarian 
refjfion, especially at night, and is restless and uneasy, pulsa~ 
tiUa ehuuld be given. Actisn racemosa is peculiarly serviceable 
in rheumatic or rheumatoid conditions. Belladonna, and its 
active principle atropia, are especially suited to the pains when 
of a neuralgic character. Nux moschata: spasmodic, irr^rular 
pains: t be patient has drowsy, faint spells. Nux vomica may 
be required when the pains seem to depend on gastric irritation. 
Arsenicum album: when there is gastric irritation and thiret; 
the pains are sharp and distressing. 

The 1'atiext'b Bed and Dress. — Thesfi are matters with 
which the physician generally has little to do, as thej' properly 
belong to the nurse or other female attendants. It is wise, how- 
ever, for the physician to be prepared to eupervise them, when, 
in emergencies, he is appealed to. The bed should not be very 
soft; — the beet is a good hair mattress upon a tick filled with 
straw or husks. A soft rubber or oil cloth should be laid over 
the mattress, and a sheet spread upon it. A folded sheet, or a 
wood-wool pad, should also be placed under the woman's hips, 
and another sheet should be pinned about the hips, thechemise 
and nightdress having been rolled up, for protection. During 
labor the amount of covering may be reg^ilO'tei^ to suit the 
patient's wishes, unnecessary exposure being avoided. 

The lying-in chamber should be as large and airy as the 
house affords, and provided with good facilities for heating if 
the labor occur in a cool season. 

Position of the Woman. — If the room is warm, there is no 
valid objection to the patient walking or sitting as her inclina- 
tion may suggest, in the early part of labor ; but this should 
not be permitted after the second stage is fairly inaugurated. 
She ought then to be confined to her bed. When the presenting 
part has descended low into the pelvic cavity, and the pains are 
strong, on no account should she be permitted to rise. The 
compression exerted by the head, or other presenting part, may 
create a tenesmus of both bladder and rectum, and frantic 
requests be made for the privil^e of using the chamber- vessel. 
This, however, should not be permitted, for fear of a sudden 
termination of the expulsive act while the woman occupies an 
attitude unsuitable for proper protection of mother and child. 

The Physician's Attendance Durino the First Stage. — 
During the first stage of labor the physician ought not to be in 



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346 Labor. 

constant and close att«ndance, as such attention would raise 
too high the woman's expectations of speedy delivery. Th* 
physician himself will find frequent, and somei<rhat prolonged, 
absence from the room a grateful relief from the oft-repeated 
query of both the patient and her friends regarding the dura- 
tion of lalior. To give non-cominittal, and yet satisfactory 
answers, is no easy task. His absence, too, will give the woman 
time and opportunity to use the chamber- vessel, or visit the 
closet, a thing which she should be encouraged often to do ilur- 
ing this stage. If at any time there should be evidence of much 
urinary accumulation, 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 whenever 
a pain returns; but in the first stage of labor this should be 
utterly discouraged. The practice is not only useless, but 
harmful. In the second stage only can much aid be derived 
from abdominal efforts, and earlier exertion tends needlessly to 
exhaust the patient's strength. 

Treatment op the Membranes. — Upon making a vaginal 
examination after labor has fairly begun, there is often, but not 
always, to be felt protruding into the os uteri during a pain, a 
tense disk of membranes termed the bag of waTet^, or the bag^ 
of membranes. It is the practice of some to break this bag, 
and allow the liquor amnii to escape, early in labor, under the 
belief that progress is thereby accelerated ; but the most 
approved treatment is to refrain from so doing until full dila- 
tation 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 percentage of cases, there is no distinct bag of watei-s at 
the OS uteri, and yet dilatation proceeils in just as satisfactory 
a manner. Again, in certain cases wherein the phenomena of 
the first stage are slowly and tediously maiiifest«tl, rupture of 
the membranes will often greatly accelerate the natural pro- 
cesses. Still, we will probably do well to adhere, as a practice, 
to the old rule, and refrain from rupturing the membranes until 
the stage of uterine dilatation has been completed. The bng of 
waters can be ruptured more easily during a pain, at which time 
the membranes become tense; and if it cannot be effected with 
the finger, a probe, or a stiff catheter should be carefully used. 



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Maxagement of Normal Laiiok. 347 

The Second Stage. — Thus far we have treiited mainly of 
the dnties of the accoucheur during the first Hta^ of labor. 
But with complete dilatation of the ob uteri the first stage 
closes, and is succeeded by the second, or propulsive, stage. 
The precise moment of complete dilatation is not always easily 
recognized. Indeed, there appears to be some dissonance of 
opinion with reference to what constitutes full dilatation. We 
are left to infer from most descriptions that complete expansion 
is not accomplished until the os has passed out of reach of the 
examining finger. What we have to say here with referenoe to 
the management of the second stage of labor is fully applicable, 
however, to a period which somewhat precedes entire retraction 
of the OS uteri. For practical purposes, then, we may i-egard 
the first stage of labor fairly closed when the os is widely 
expanded, and the presenting part, proper, and not alone the 
caput suceedaneum, protrudes, during a pain, to a certain 
extent, through the os uteri, 

ExcovKAGE Bearing Efforts.— The phenomena of the sec- 
ond stage are distinct and pecuHar. The woman is now dis- 
posed to bring into action her abdominal muscles, and with 
each severe pain to make a strong bearing effort. This action, 
unless vehement beyond measure, ought to be encouraged, and 
every facility afforded for its proper direction and utilization. 
While she occupies the dorsal position, the physician may sit 
beside the be<l, or upon it, and hold one hand of his patient, 
while someone on the opposite side holds the other. The feet 
may be braced against the foot-board directly, or through the 
intervention of a stool, box, or chair; or, what will answer as 
well, the woman's knees may press against the shoulders of her 
assistants. Now, by encouraging her to close her mouth, to 
hold her breath, and to pull and bear down, very effective 
work may be done. When the patient lies on her sitle, both 
hands may be held by an assistant, while the knees rest against 
the latter's body for a fixe<l support. Biicli counter-traction 
requires the services of a strong person. Between pains the 
woman should be permitted to take perfect rest.- If descent 
proceeds rapidly, the fingers of the a^'coucheur should be kept 
within the vagina, and the ca«e carefully watched ; but if slow 
progress is made, an occasional examination only, is, for a 
time, required. 

The pains of the second stage are in some respects more sat- 
isfactory to the patient, than thoseof the first stage, inasmuch 



348 Labor. 

8fi they appear to be more effective ; bat the real suffeiiitg ex- 
perienced in this part of labor is far more intense. The womau 
becomes restless and impatient, and makes fi-equent inquiry as 
to how soon labor will terminate, at the same time declaring: 
that she can endure the suffering no longer. Great tact is here 
required to maintain the patient's courage and confidence. The 
manifestation of tlie slightest perturbation by the physician is 
liable to create a panic among the patient and her friends. Few 
words, fitly chosen, spoken with evident composure, are far 
better than long explanations, or much talk on any pretext 
whatever. 

The Use of Asesthetich. — The general subject of anes- 
thesia during labor will elsewhei^e be discussed, but we may 
here take occasion to say that, in the latter part of the propul- 
sive stage, when the pains become almost unbearable, there is 
no well-founded objection to be raised against the moderate use 
of chloroform, A few drops may be poured on a handkerchief, 
and when a pain is due, the woman may takea few inhalations, 
with the effect to somewhat benumb the sensibilities without 
producing narcotism. Such administration of a good article of 
chloroform is almost wholly devoid of danger, and may be con- 
tinued for several hours, if needed. A little instruction given 
the nurse will enable her safely to use the anesthetic, to the ex- 
tent mentioned. The severity of pain sulfered by women in 
labor varies so considerably that chloroform should not be re- 
sorted to indiscriminately; but let it be given in those cases 
only wherein there is a strong demand for ita soothing aid. 

Indications for Ixtbrpeuencb. — So long asthere is progress 
being made, we should abstain from interference. If the pains 
slacken, or if delay of the head in the pelvic cavity arise from 
any other cause, we should not allow the duration of th^ second 
stage to exceed physiological limits. A satisfactory defini- 
tion of what is implied by the phrase "physiological limits" 
cannot be easily given, since its boundaries are not fixed, and 
they require to be set in each individual case. It should be re- 
membered that pressure of the bead upon the soft tissues of 
the pelvic cavity, leads, when prolonged, to pathological changes 
in the tissues of the canal and outlet. It is a wise rule of prac- 
tice not to permit the head of a relatively large child to remain 
stationary in the jielvie cavity for a period in excess of two 
hours. Rut before resorting to instrumental delivery, the aid 
of other means should be invoked. 



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Management op Normal Labor. 349 

Feeble pains are sometimes inteneifled by changing the 
■woman's poBitiou, as from the back to the side, or vice versa. 
Firmer flexion of the foetal head is sometimes thereby effected. 
When that part has descended to the perineum, expulsive action 
may be excited by kneading the abdomen, or by pressing upon 
the fundus uteri. 

Use of the Catheter. — There is sometimes considerable dis- 
tension of the bladder during the second stage, accompanied 
with utter inability to urinate. This distressing condition 
must at once be removed by means of the catheter. The use of 
the instrument is sometimes attended with considerable diffi- 
culty, owing to pressure of the head against the neck of the 
bladder, and a change in the direction of the urethra, arising 
from excessive compression and partial prolapse of the anterior 
vaginal tissues. On these accounts the best instrument for use 
is the soft rubber catheter of medium size, 

IsCjiRCKRATIOX OF THE ANTERIOR LiP OF THE Ob UtERI.— As 

the head descends into the pelvis, the anterior lip of the os uteri 
is sometimes caught and held between the head and the pubis, 
and may thereby become a manifest impediment to the progress 
of labor. Unless there is ezoessive tumefaction of the part, in- 
terference is^ldom required. Rigby declares all attempts to 
push it above the pelvic brim not only futile, but decidedly 
objectionable, since inflammation is liable to be set up. This 
dictum is not accepted by all. "Any attempt," saysLeishman, 
"rudely or forcibly, to push up the anterior lip, even when it 
exiatfl as a manifest impediment, should certainly be avoided ; 
but we are bound to add that, in many caaes, it may be pushed 
beyond the head with perfect safety, and in this way the im- 
pediment to delivery may be at once obviated." The attempt 
should be made in an interval between pains, and the part sus- 
tained until the recurrence of another contraction serves to 
maintain it in a situation above the limit of compression. 

The Preventiox of Vulvar Laceration.— Owing to the 
form and direction of the parturient canal, following as it does 
an irregular curve, the structures in that part of the curve 
which is least in accord with the uterine axis, and hence 
farthest from the line of propulsive energy, receive the brunt of 
the force, and are compelled to make the chief resistance. The 
included angle of the two siden represented by the line of pelvic 
entrance and the vulvar pltine upon which the foetus finally 
emerges, is practically a right angle, and hence the oelvic floor 



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350 Labor. 

is obliged to meet the descending head and deflect it in the- 
direction of least resistance, at the expense of considerable 
strain. It follows that the question of laceration of these 
structures is very largely determined by their strength and 
elasticity. 

We do not need to make many examinations to learn that 
there is a vast difference between perinea. Some are targe and 
thick and strong, while others are small and thin and weak. 
The former can resist a ^lowerful strain, while the latter are- 
capable of withstanding but little. Pass your finger during- 
labor along the vaginal surface of the perineum and pinch 
that body between the thumb and finger. 

In one case you find it thick and firm, bnt moderately long- 
as measured from the vulva to the auus, and evidently able to 
bear, without breaking, all the power which is Ukely to be- 
applied from above. Again you find a long, thin, moderately 
muscular structure, comparatively yielding, and clearly unable- 
to turn aside a body propelled against it with much force. In 
a third instance you find almost an entire absence of perineum, 
the recto- vaginal septum being but slightly thickened below, so 
that a shallow laceration would extend to the rectum. In a 
case like the first we have seen the head press firmly down on 
the jielvic fioor, the perineum resolutely resisting the strain for 
a considerable time, and finally turning the descending head 
aside and causing it to glide forwards through the vulva, whence 
it escaped without harm to the soft structures of this part, the 
integrity of which is so essential to the health of the generative 
organs. In cases like the second we have seen the long, thin 
perineum yield under much less strain, splitting to the very 
margin of the anus. I-astly, in a case like the third, we have- 
seen the deficient perineum left after dehvery still more deficient 
than ever. 

Danger of laceration is much augmented by unusnal length 
of the parturient canal below the bony outlet. During descent 
of the advancing head the soft tissues are pushed more or less 
in advance, and the greater distance required to be made by the 
head, and hence the more extensive the curve, the greater the 
danger to the perineum. This truth is to be borne in mind 
during our consideration of the proper measures to be adopt«'d 
for protection of the vulvar structures, and above all in our 
conduct of labor complicated by such a condition. 

At the moment of greatest distension, the very margin of 



Maxagbment op Normal Labor. 351 

theperiDeum at the posterior comiDissure is nearly ahvavH thin, 
and it ie evident that a reut once started is liable to Iteconie 
extensive. We are speaking now of cases left substantially to 
the natural movements. When a rent is bt^uu it draws the 
head away from the anterior boundaries, or, more properly 
speaking, diminishes the pressure against the crown of the- 
pubic arch, with a resulting extension of the laceration beyond 
the degree essential to easy escape of the head. This is a 
natural result of neglect on the part of the accoucheur to 
enforce the true principles of perineal protection about to be- 
en undated. 

Those who carefully examine the perineum during the 
moment of greatest distension have fre(]uently observed that 
there is usually a thin margin extending backwards only a 
limited distance, and then the examining finger comes upon a 
thick, firm, stroDg part, which appears to be the perineum 
proper. This thin portion is made up chietty of integument 
and mucous membrane, while the thick partis composed largely 
of muscular tissue. This is a favorable condition of things to 
find, but it does not exist in every case, and where it is absent, 
in a primipara, we ought to be on the alert. When it does 
exist, laceration, if it takes place at all, is likely to be limited, 
to the anterior thin part of the perineum, exceptionally 
extending into the muscular structures. In these cases the 
thick part of the perineal body serves as a boundary to the 
tear, casting the pressure back on the pubic arch which it had 
begun rapidly to leave. 

We are not among those who ascribe vulvar laceration ex- 
clusively either to the head or to the shoulders, nor are we dis- 
posed to unite with some in ascribing the accident more 
frequently to the shoulders than to the head. Still we are quite 
willing to admit that the perineum is often torn during passage 
of the trunk of the child. Obstetricians are quite accustomed 
to say that the trunk can follow wherever the head can go, and 
as a rule, so it can. Yet we have seen the head pass without 
injury to the perineum, and a laceration result from pressure 
of the foetal elbow as it slipped through the vulva. We are 
well convinced that more injuries to the periueuni and vestibule 
occur during passage of the head than of any other part; but 
next in frequency stand the fistal elbows. The shoulders them- 
selves rarely cause the accident. When the elbow of the child 
comes over the distended perineum, as it oft^n does, with a 



352 Labor. 

jerk, the structures which had previously resisted most heroic- 
ally may finally give way. 

The conditions which promote solution of continuity at the 
vulva are more especially met in the primipara. The intact 
fourchette, the narrow vagina and the resisting tissues are all 
of this nature. When once the vulvar orifice has been thor- 
oughly distended, it yields more readily a second time. More- 
over, though these structures are decidedly elastic, after 
thorough distension they never wholly regain their former 
tenseness. It therefore follows that we look for laceration 
mainly among women for the first time in labor. Still it does 
occasionally happen that the first child is premature, and 
hence small, while the second is of full term and much larger. 
Again, a former laceration may have been repaired, and the 
conditions met in a second or third labor prove as inimical to 
the perineum as those in the first. 

It should be remembered that the vulva may suffer anteri- 
orly as well as posteriorly. As the head emei^s ft-om the 
vulva, the vestibule can be felt with its thin, tense margin 
turned towards the head, ready to tear should much further 
strain be put upon it. This region is a common seat of injury. 
A laceration in this part usually passes to one side of the 
meatus urinarius, and when present is liable to make urination 
somewhat difilcult, and, occasioually, impossible. This is a 
more common cauRe of retention of urine after delivery than 
reflex spasm excited by lacerated perineum. 

The anatomical conditions being such as we have described, 
it is plain that rapid descent of the head aud sudden pushinf^ 
asunder of the contiguous structures, with forcible distension 
of the vulvar opening, are more likely to result in laceration of 
the parts involved than a dilatory accomplishment of the same 
parturient act. Here, as elsewhere, haste makes waste. Rapid 
changes in the human organism are accomplished at unusual 
risk. Nature's plan is the gradual one. The whole body can 
be broken down and renewed without pain or distnrbance if the 
work be done by degrees. Cyclonic movements are destructive. 

When the j)erineum is unusually long and comparatively 
yielding, it is subject to great danger, no matter whether pro- 
tective measures be adopted or not. Cases have been put on 
record wherein the descending head has steadily pressed on ita 
center to such a d^ree and for so long a time, that finally a 
false opening has been created through which the foetus has 



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Management op Normal Labor. ySJl 

emerged without rupture of either the posterior vaginal com- 
miBsure or the sphincter ani. To be sure this is a singular ac- 
cident, and fortunately rare. There is a form of laceration in 
such a perineum, however, worthy of special notice, of which 
I have recently had two or three marked examples, and which 
is doubttees of great frequency. It is not discovered through 
mere touch except in bad examples of it, and does not disclose 
itself to mere inspection unless the same be carefully made. 
Externally there may be no sign of injury, but upon retracting 
the perineum and opening the labia, we find the lesion in the 
form of a superficial rent along the vaginal surface of the 
perineum, occasioned probably by the head as it pushed heav- 
ily along on its way to the vulva. Though of but slight depth. 



Fias. 140, 141 AND 142.— Showing the difference in involved diameteTS 
between Flexion and Extension of the Head. 

it may be found, on lateral traction, to gape more than an inch. 
Such a laceration is not likely to be felt very profoundly in the 
way of weakening the natural supports of the pehic viscera; 
but it acquires importance by reason of its favorable situation 
for taking up septic matter during the puerperal stage. 

Now all these dangers are still further augmented by failure 
of the head, in its descent through the pelvis, to maintain itti 
position of firm flexion in vertex presentation, or firm exten- 
sion in face presentation. When such proper relations of the 
advancing head to the pelvis are not maintained, the longest 
diameter of the head, namely, the occipito-mental, is liable to 
be thrown into one of the pelvic diameters ; and since the former 
is greater than the latter, the head is likely to become incarcer- 



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'354 Labor. 

ated aiid-instrumental interference be required. Mere use of the 
forceps does not necesearily increase the perineal dangers, but 
the delay at that particular point, and final rectification 
through forcible fiexion, followed by instrumental delivery,doe8 
militate against p^^rineal integrity. But the head is far more 
frequently thrown out of proper position to a moderate degree 
only, in which case, though. incarceration may not ensue, un- 
usual demands will be made on the pelvic outlet, and the vulva 
in this way come to suffer. This anomalouscondition of things 
thus becomes a prominent factor in the production of perineal 
la^'eration . 

These are the main facts relative to causation of perineal 
rapture, plainly, but not nicely put; and now let us turn to a 
■consideration of the prophylaxis of the accident. The original 
method, of managing the head and shoulders as they passed 
the pelvic outlet was doubtless the expectant one, and some 
still adhere to it, "Hands off," they say, "and you will get 
better results than are obtained when attempts are made 
at prevention." When manual aid became the practice, 
it was almost the universal custom to "support the peri- 
neum." This ti-eatment was based on right principles, but 
was probably carried to unnecessary and harmful extremes. 
At anj' rate, there was a reaction from it, so that now a num- 
ber of the best obstetricians practice the let-alone method. Re- 
flex action is originated, they say, and the uterus is thereby 
excited to more energetic contraction, at the very time when 
modified action is sought. Of this we are not fully convinced; 
and, while we may not commend the more ancient method, we 
arn fully convinced that, properly used, some form of perineal 
protection is far better thau the expectant plan. 

Before we enter upon a discussion of the various methods of 
protection now in vogue, let us deduce the general principles 
upon which any form of perineal protection, in order to com- 
mend itself to the enlightened judgment of a practical obste- 
trician, should rpst. If we once get a clear Conception of these, 
we shall have little trouble in adapting different methods to 
varying circumstances. The true principles of perineal pro- 
tei'tion are four iu number, as follows: 

1. Prevention of too rapid progress of the head and after- 
torn ing shoulders. 

2. Maintenance of firm flexion of the head in vertex pre- 
sentation and firm extension in face presentation. 



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Management of Normal Labor. 355 

3. Deflection of the head from its movement- of direct 
■descent, causing it to hug the pubic arch ; and 

4. Relaxation of the vulvar Btructures so that the nei-essary 
dilatation may be obtained without too great strain on the soft 



The first may be accomplished by independent manceuvers, 
such as plain pressure againnt the head as it is forced down- 
wards by recurring uterine action; but it is much better to 
combine this with such measures as will carry into effect also 
one or more of the other principles. The necessity for this re- 
sistance ia at the pelvic outlet only, where there is likewise a 
demand for practice of the other principles. But better than 
all resistance is a wise modification of the propulsive energy, 
which may in a measure be accomplished by directions given 
the woman hereelf. Uterine action is not, but abdominal ac- 
tion is, in a measure, voluntary. ■ Under command of the will, 
abdominal action is often surprisingly powerful. To completely 
overcome it through an effort of the will is utterly impossible, 
but much can be done by enjoining voluntary propulsive effort 
and bidding the woman give vent to her agony in cries, while 
regularity of breathing should be maintained as far as possible. 
These measures alone may suffice, but in some cases it is advis- 
able to administer chloroform till the rigor of the contractions 
is broken and the head is thus brought under control. 

There are two, and only two, methods of protection for the 
perineum at the moment of greatest distension worthy of the 
name. The first is the old one of pressure against it with the 
flat of the hand in the direction of the pubic arch, and the sec- 
ond is that originally proposed by Fasbender. in the practice 
of which the head is grasped by the hand in such a way that 
the points of pressure are at the poles of the oceipito-frontal 
diameter. To do this either the thumb or the fingers will be 
passed into the i-ectum, according as the woman is on her side 
or her back. All other manual measures are fragmentary and 
undeserving to be called methods. 

Manual Protection of the Perineum. — The precise mode of 
support as applied by the flat of the hand, with the woman on 
her side, ia thUB desiribed by Parvin : 

"Supposing the patient to be lying on her left side, and her 
hips quite near the edge of the bed, the practitioner places his 
right hand so that the concave palm receives the convexity 
formed by the bulging perineum, the thumb is upon the right. 



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356 Labor. 

and tlie four fingers upon the left labium majus, while the fold 
between the thumb and index Hnger corresponds with the- 
anterior marg^in of the perineum, moderate resistance is made 
to the force driviiif^ the head against the perineum, and at the 
same time the head in gt^ntly pressed toward the pubic sym- 
physie; strong pressure is to be avoided, because, if the peri- 
neum be very thin, such pressureat this thinned part maycause 
a central tear. No napkin should be interposed between the 
hand and the perineum ; the hand is not applied until perineal 
distension begins, and the application is only during a pain." 
When the patient is lying upon the back these details ar& 



not observed, but the head is received into the palm of the- 
hand. 

This method of treating the perineum during expulsion of 
the ftetal head, greatly modified as it has been from the old 
mode, well applies threeoiit of four of the principles herein l)efore 
laid down, namely, resistance to too rapid advance of the head, 
maintenance of firm flexion, and elevation of the head well into 
the pubic arch. What are the objections urged against it? One 
objection alone, namely, that pressure, even interraittiagly, 
made against the perineum, excites the uterus to fury, through 
reflex action. Distended and benumbed as is the perineum at 
such a time, this stricture on the procedure is seen to be most 



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Management of Normal Labor. 35T 

■ridiculous. That the latter does save some perinea, either 
wholly or partly, we are well convinced. 

The second method to which allusion has been made, namely, 
that wherein the head is brought under control by being 
grasped over the poles of its long diameter, has a variety of 
modifications. The following, described by Hart, embraces 
three of the general principles which we have laid down : 

"All the attendant can do," hesays, "apart from the 
familiar means of relaxing perineal spasm by chloroform and 
hot applieatiouB, is to prevent the sinciput being forced down 
iu advance of, or faster than, the occiput. He restrains the 
foetal head from advancing too rapidly. He thus has always 
to get the occiput to lead, and to get it fully bom if possible. 
So far as I can judge, the best way of doing this ia as follows: 
With the patient lying, of course, upon her left side, the 
attendant places the thumb of his right hand, guarded by a 
napkin soaked in hot sublimate, in front of the anus and presses 
it gently there. The pressure is not in the direction of a line 
joining his thumb and the pubic arch, but nearly in that of the 
pplvic outlet. By this, descent of the sinciput is hindered, and 
that of the occiput is favored. When the latter is banning to 
pass under the pubic arch, the fingers of the same hand are 
pla<!ed between it and the apex of the arch, so that when 
the occiput has cleared the arch the fingers are passed towards 
the nape of the neck, and the head thus grasped in the hand, 
the thumb lying over the sagittal suture. This gives oue com- 
plete command over the head which is now engaging in the 
diameters between the nape of the neck, and forehead and 
face, and allows the whole passage with as little tear as pos- 
sible." 

Another variety of the same general method is set forth by 
I^usk as follows: 

"In ordinary ca»es Hohl's method, recommended by Ols- 
bnusen, has rendered me excellent service. It consists in 
applying the support, not to the perineum, but to the present- 
ing part. To this end the thumb should be applied anteriorly 
to the occiput, and the index and middle fingers posteriorly 
upon that portion of the head which lies nearest to the com- 
missure. The unconstrained position of the hand enables the 
operator to exercise effective pressure in the direction of the 
vagina, while the posterior fingers favor the rotation of the 
head under the pubic arch. The patient should at the same 



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358 Labor. 

time be directed not to hold her breath doring the pains, except 
when tbey are weak and poweriess." 

In Fasbeuder's method the patient is placed upon the left 
Bide, and when the head appears in the crowning stage, the 
index and middle fingers are applied to the occiput, and the 
thumb is pushed down into the rectum, which always stands 
open, and the head thus seized by the hand and brought under 
perfect control. 

Through use of these latter methods three of the principles 
of perineal protection are perfectly applied, and wecan but look 
upon them as excellent methods. 

tra.cs and Means for Softening and Dilating tlifi Vulva. — The- 
fourth principle is not an essential part of any method which is 
peculiarly adapted to the moment of final escape of the head, 
but is rather preparatory to the final strain. Relaxation of 
the perineum may be favored by a variety of expedients, 
among which the application of warm emollients occupies a 
prominent place. We have frequently drawn away the peri- 
neum from the foetal head between pains, and poured into the- 
space thus formed warm oil, with what seemed to us to be 
good results. Hot fomentations gainst the perineum are of 
utility. 

Besides such treatment, when he has special reason to fear 
rupture, the author exercises dilative pressure to the vulva 
during the latter part of the second stage. This sort of ma- 
nipulation should be begun before the head gets to preesinghard 
on the perineum, as considerable time is required to effect our 
purpose. The fingers lying in the vagina are pressed withsome 
force in a backward direction during the pains, and in this 
manner the vulvar opening is gradually expanded so that less 
time will be demanded when the head shall get to the outlet. 
The pressure should at no time be very forcible, lest we inflict 
unnecessary pain and begin a laceration which later may be- 
come extensive. The manipulation should at first be made 
coincidently with the pains, but later can be continued into the 
intervals between some of the contractions. The obstetrician 
who does not observe reasonable antiseptic precautions ought 
never to undertake this treatment. In fact, he who does not 
conduct his caries in a reasonably aseptic manner ouplit to 
have none to treat. 

A few yeare ago Dr. Goodell, of Philadelphia, recommended 
a practice intended to secure greater safety to the vulvar 



Masacement of Normai- Labor. 35& 

etpuetures- through perineal relaxation, the maaipulatioii being 
the very reverse of that which we have been deecribiup;. When 
the head is distending the perineum, it is hia plan to mitigate 
the strain at the posterior commissure by hooking the fingers 
into the anus and drawing the parts towards the pubic arch. 
The absurdity of such a recommendation is to our mind self- 
evident. The head is already pressing t.oo hard upon the peri- 
neum, and our aim should be to guide it forwards towards the 
pubic arch, and finally through it, as rapidly as we safely can. 
To do so with undue ha8t« would greatly endanger the peri- 
neum. A rent begun at it* margin through excespiveandrapid 
pressure, may easily be extended to serious proportions. This, 
of couree, we wish to avoid, but to gain relaxation at the 
posterior commissure at the expense of strong pi'eseure in what 
might be called the perineal hollow, is unwise. Far better is it 
to resist fai-ther advance (or a time, and then allow the head to 
make graduated pressure on the posterior commissure up to 
the moment of safe distension. Throwing the perineal body 
under the head, as it advances with each pain, does not serve 
promptly to prepare a safe exit for the presenting part, and 
seems to me like poor practice. It is postponing the evil mo- 
ment without changing its character. Advocates may urge 
that by prolonging the pressure on the perineum we piomote 
softening o( the part. This is quite true, but the part which 
most needs stretching, and that which comniand.s the whole 
situation, is the posteiior commissure, or rather that and the 
fourchette. The strong muscular part of the perineum can 
bear a powerful strain, provided the posterior commissure can 
be kept intact, or can be preserved till the head has nearly 
passed. But when, before the moment of greatest distension, 
the entering wedge is applied in the shape of atom commissure, 
the laceration is easily carried into the depth of the perineal 
body. 

Lusk mentions a practice which has given him satisfac- 
tion, that is also intended to secure relaxation of these parts. 
"Between pains," he says, "I have been in the habit, in cases 
of rigidity, of alternately drawing the chin down wards through 
the rectum until the hand distends the perineum, and then al- 
lowing it to recede. Itis astonishing how often apparently the 
most obstinate resistance can be overcome by the simple repe- 
tition of this to-and-fro movement, the parts rapidly becoming 
soft and distensible. Of coarse it should be discontiuaed the 



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360 Labor. 

moment contraction be^ne, and care should be taken to effect 
delivery after uterine action hafl subBided." Thie expedient is 
of some value and worthy of commendation. 

By meanH of the fingers, we have, in a number of instances, 
practiced expulsion of the head between pains. This can be 
done in the crowning; sta^ of labor by placing; the fingers be- 
hind the anus and pressing in the direction of the symphysis 
pubis ; but when no great descent has been attained, that is to 
say, when the head does not lie in the vulvar opening, proper 
pressure cannot be exerted without introduction of the fingers 



Fig. 144— Method of Perineal Protection (luring extraction of the Head. 

(Zweifel.) 

into the rectum. Such manipulation demands the greatest 
care, aa rough handling; might injure the recto-vaginal septum. 
We sometimes watch descent during a pain, with the fingers in 
the rectum, and as the contraction dies out and recession of 
the head begins, we hold it forcibly against the vulvar opening. 
Itisonly aft*'r repeated attempts thatexpulsion can be effected. 
The chief advantages derivable from this mode of delivery are 
found in the avoidance of the on-rush of propulsive energy, 
and the encounter of less resistance from muscular rigidity. 
An attentive obstetrician cannot fail to notice with what force 
the mii-!cles contributing to the formation of the pelvic floor 



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Management of Normal Labor. 861 

contract during the recurrent partorient efforts, while in the 
intervals they remain comparatively quiet. We need not add 
that this mode of delivery is adapted only to ca»ee wherein 
there is considerable interval between pains. 

There is some danger of laceration attending delivery of the 
sbouldere, but the only prevention lies in the exercise of care, 
drawing the body well forwards and keeping the elbow off 
the perineum, where it is so liable to tear the vulvar com* 
raissure. 

Episiotowy. —Bnt, we iaqoire, can anything be done to pre- 
serve from serious injury a perineum which, by reason of an 
anomaly in construction, or which, through want of relative 
proportion between the dimensions of the ftetus and vulva, is 
verycertain tosuffer laceration? In 1836 VonRitgen published 
an article in which he recommended seven smalt incisions on 
each side of the vaginal orifice, to be made at the moment of 
greatest distension. No incision was to extend more than a 
line in depth. By this means he claimed that an increased 
vulvar circumference of two inches could be gained. The depth 
and number of the incisions have been changed by others, and, 
as we believe, the character of the operation improved. Atten- 
tion has been directed to the fact observed by every attentive 
practitioner, that the chief resistance encountered by the head 
is not at the thin border of the vulva, but at the narrow riog" 
situated half an inch above, represented posteriorly by the 
fourchette, and composed mainly of the constrictor cannir 
the transversi perinsei, and sometimes of the levator ani 
muscles. It has been accordingly recommended that the 
incisions be made through these rigid fibers, by means of a. 
blunt-pointed bistoury, or a pair of angular seiBsors. So far 
aa practicable, the incisions should be contined to the vagina, 
and should not exceed three-quarters of an inch in length. 
Their depth will be determined by circumstances. In cases 
where the head is about to be expelled, and firm pressure 
already exists, the bistoury may be cai-eftilly introduced, upon 
its side, between it and the vagina, three-quarters of an 
inch in front of the commissure, and section made from within 
outward. The external skin need not be included, and it may 
be protected by drawing it back before cutting. Instead of 
several very shallow incisions, we now prefer a single deeper one 
on each side, at the points mentioned. 

In this connection it should be remembered that serious 



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303 Lahor. 

perineal rupture is nearly always alonp; the course of the raphe, 
owiug to the relative wealtiiesn of the part, and the existence of 
a commissiu'e. 

Increased danger of septictemia has been urged against the 
operation, but the objeotioii is void of much force. The choice 
is between two clean incisions and one gaping rupture. It may 
lie said for the incisions that they are situated laterally, are 
shallow, and together do not present a greater area of absorb- 
ing surface than the central ruptui-e which follows theexpectant 
plan of management. The latter, too, owing to its location, is 
more exposed to the discharges which carry nosious germs, 



Fio. 145.— Distension and Threatened Rupture of Perineum, a, fcctal 
head, b, perineum, showing linea o( incision to prevent rupture. 

and from its depth, as observed by Dr. Fordyce Barker, permits 
the lochia to approach "an abundance of blood-vessels, and 
chains of lymphatic glands." 

The incisions thus made should subsequently be closed with 
No. 2 catgut. 

Frequency of I'erinetil LaeeratioD. — According to Schroe- 
der's experience, the frenulnin or fonrcliette is ruptured in 
sixty-one primiparse out of the hundred. More extensive lacera- 
tion takes place in thirty-four and one-half per cent, of fir-st 
labors, and nine per cent, of others. 



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Management of Normal Labor. 



The following table, prepared by Schrenek, givee an idea of 
the frequency of rupture of the perineum 











Proportion of 


Frequ 


cniy 










Hildebrandt , . 356 


13.% 


19.7 


.18% 


Nippold . 




1011 


11.6% 


18.7 


2.2% 


Olshausen 






119 




21.1-4.7% 


4.7% 


Liebroann 






lOftl 


15.9% 


. 30% 


4.2% 


MewiB . 






1095 


19.8% 


81.8% 


5.8% 


Winckel 








20% 






Schrenek 






847 


21.4% 


36,6% 


8% 


Faabender 






800 


22.3 


34% 


10.6% 


Schroeder 






289 


27.7% 


54.6-37.6% 


9% 


LitzmanD 








27.e 







Extent of Rupture. — There are various degrees and varieties 
of perineal rupture. A mere margin, involving only the four- 
chette. may be torn, or there may be laceration of the entire 
perineal body, so as to make the rectum and vagina one horri- 
ble hiatus. Between these extremes are various degrees. 
Perineal rupture has been divided into classes according to va- 
riety and extent of the tear. The most simple classificatitjn is 
that which separates cases into complete and incomplete rup- 
tures. When the laceration extends through the sphincter ani 
into the rectum, it is termed complete, while anything short of 
that is called incomplete. "When the anterior edge of the 
perineum alone is referred to," says Matthews Duncan, " as for 
instance, in a laceration not amounting to half an inch in 
linear extent, it is called the fourchette." This laceration of 
the fourchette is not reckoned by all as involving the perineum 
proper, though when the term is made to include more than 
the anatomical feature known as the fourchette, we believe that 
it should be. One who has never picked up the f()ur angles of 
even a slight laceration, and thoroughly spread out the wound, 
will be greatly surprised, when he does so, at the extent of the 
raw surface. 

"Rotten' Perineum. — There is much difference in perinea as 
to their ability to withstand a severe strain. Every physician 
of experience has observed that moderate dilatation will atone 
time cause rupture, while excessive expansion, in another case, 
will be suffered without accident, Dr- Matthews Duncan sayp: 
"There is no doubt in my mind that, in certain cases, there k 



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864 Labor. 

what may be called rottennesa of tissne, whicb destroys tho 
power of the tissues to resist laceration or bursting. In some 
women, and occasionally, at least, very markedly intbesyphi- 
litic, this condition ia very easily demonstrated. It is a condi- 
tion also of many inflamed tissues, and this is exemplified in 
the perineum." 

The ordinary precautions at^ainst ruptured perineum have 
been considered at great length, because of their importance. 
There is nothing to be added. When we have faithfully applied 
them, we have done, in a protective way, all that it is possible 
for US to do, and yet the physician should not forget that, even 
when he has so done, his patients will occasionally suffer this 
accident. 

Delivery of the Shoulders. — When the head has finally 
cleared the vulva, the secretions should be wiped from the- 
nose and mouth of the fuetus, and examination tdeii made to 

ascertain whether 
the umbilical cord 
encircles the neck. 
If the cord be- 
found, it should 
be loosened by 
drawing carefully 
upon it, until it 

Pio. 146.— Showing ligatureg of the Umbilical +1, >, ^ 

Cord, and point of section. "^^'^ ^"^ °^^' **'"» 

failing in this, dur- 
ing extraction it should be passed over the fwtal shoulders, so 
as to avoid strangulation of the child, and unnecessary and 
harmful traction. The cord being too short to admit of such 
treatment, or there being several turns of it about the neck, 
two ligatures may be hastily applied, and the cord severed be- 
tween them. After so doing, however, extraction must not be 
delayed, or the foetus will ywrish. 

In most cases the shoulders are expelled without aid, But^ 
should there be delay, sliglit traction may be made on the head, 
while an assistant presses with some force on the fundus uteri. 
When the movement of expulsion begins, the operator's hand 
should be placed at the posterior vulvar commissure, and the 
shoulder raised with some force, as a prot<«^tiontothe perineum. 
.\8 the arm, or elbow, of that side passes, special protective 
effort should be made. 




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Management of Normal Labor'. 365 

As sooQ as the child is expelled, the little fing«r of the ope- 
rator should be passed into the throat, and the &ce turned 
downwards, so as to clear the part of mucua. 

Treatment of the Cord.— It is observed that when, from, 
any cause, the umbilical cord is torn in twain, as sometimes ac- 
cidentally happens, there is little or no faemorrUa^. It has. 
been found also that, in many cases, the cord may be cut wit'' 
scissors, and no ligature applied, without the occurrencenf any- 
extensive blood-loss. These, and other considerations, have led 
some to recommend and practice non-ligation of the cord, as- 
an ordinary mode of treatment. We have given the practice a. 
pretty thorough test in Hahnemann Hospital, and have found 
that, if we will but await the cessation of pulsation in thecord,. 
it may be cut without fear of hemorrhage, and the case do well. 
This is probably a mode of treatment which will eventually 
become common, since it appears to possess some advantages, 
but the rule of practice is yet strongly in favor of the ligature. 
Some practitioners lay much stress on 
the quality and texture of the ma- 
terial used for ligatures, but a string 
of almost any firm material may be 
employed. The knot should be about 
an inch and a-half from the umbilicus, 
and tiEMly drawD, .o as to prevent r„. ,„._Ti.„„;rK„ot. 
the poBHibility of hemorrhage. A ng- 

ature loosely applied is worse than none. In tightening it,, 
the two thumbs should be placed back to back, and the knot 
made firm by turning them inwards. If direct traction ie made, 
breaking of the string may give rise to umbilical injury from 
the severe and sudden strain which is likely to be given. A 
second ligature should then be applied on the side towards the 
placenta, and the cord severed between the two knots. 

The ligature on the placental eide is applied chiefly for the 
parpose of protecting the bed and clothing from unnecessary 
soiling. In twin pregnancy it is employed as a preventive of 
possible blood-loss through vascular relations between the 
placentee. The form of knot to be used is the reef, or square 
^ot, as shown in the accompanying flgure. 

Earl? and Late Ligation. — The most desirable moment at 
■ "which to tie the cord is a matter worthy of consideration. The 
-coraraon practice is to ligat* it immediately after fretal expul- 
«o«. The errors of such a practice had been pointed out by 




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366 Labor. 

several, when Budin, in 1875, at the suggeBtion of Dr. Tamier, 
made the:folloiviug observations. In one Beriea of experiments 
the cord waa tied immediately affcer birth of the child, and the 
blood which flowed from the placental end was meaaured : in the 
other series, the quantity of blood was likewise determined in 
ctises where the cord was not tied until after the lapse of several 
minutes. By a comparison of the reeultn thus obtained, he 
found that the average amount of placental blood was three 
ounces greater in the first than in the second series of experi- 
ments. Melcker estimated the entire quantity of blood in the 
infant at one-nineteenth the weight of the body, which in a 
child weighing: seven pounds, would amount to six ounces. Id 
1877 Schiicking in similar experiments first weighed the child 
at birth, and then observing the changes which took place up 
to the moment of cessation of the placental circulation, found 
that it gained from one to three ounces in weight by the delay. 
An allowance should also be made for the portion which escapes 
observation in the interval before the weight is taken. 

What brings about the transfer of the blood from the pla- 
centa to the child is an unsettled question. Bndin believes that 
with the first inspiration, the increased flow of blood to the 
lungs sets up a negative pressure in the vessels of the systemic 
circulation, so that a suction force is exerted upon the placen- 
tal blood, which condition is maintained until the equilibrium 
is again established. To tie the cord at once, therefore, pre- 
vents the adequate supplyof the demands ei-eated by functional 
pulmonary activity. Schiicking takes a different view, main- 
taining that, after the first breath, thoracic aspiration ceases 
to constitute an active energy, and that the main force which 
operates to cause a transfer of the blood is the compression 
exerted by the retraction, and, at intervals, by the contractions 
of the uterus. 

From clinical observation and experimental research, the 
just conclusion is that there is an element of truth in both 
these theories concerning the cause of the phenomenon in 
question. 

Several observers have shown that the loss of weight which 
occurs in the first few days after birth is less, and the period of 
loss is shorter, when the ligature is not applied until pulsation 
in the cord has ceased, and the children are more likely to be 
red, vigorous, and active. This may also explain some of the 
advantages claimed for non-ligation of the cord, inasmuch as 



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Management of Normal I>abor. 367 

puIsatioD generally ceases before the scissors are used. As 
aoon as pulsation doeH cease, the cord ought to be cut, or 
ligatured. 

Porak and Ribemont have latelv gone over this question 
thoroughly, and the general conclusions they have reached are : 
let. Tardy ligature ensures to the infant an extra quantity of 
blood, amounting to about two and a half ounces. 2d. The 
blood contained in the placental vessels is necessary to the circu- 
latory system of the infant. 3d. The cause of the entrance of 
this blood into the foetal circulatory system, is, in particular, 
thoracic aspiration. The pressure of the uterus is purely an 
Adjuvant and a secondary cause. 4th. Imine<liat« section, and 
bleeding from thecord, should not be practiced in caseof venous 
asphyxia of the new-born, 5th. Tnrdy ligature does not ex- 
pose the infant to any danger, whether immediate or remote. ' 
6th, The new-born, through tardy ligature, loses lessin weight, 
and regains what it does lose more quickly. 7th, The delivery 
of the placenta would seem to be facilitated through tardy 
ligature, 8th. Ligature and section of the cord should never 
be resoi-ted to until pulsation in it has ceased. 

The physiological time at which to ligate and cut the cord 
appears to be, as stated, immediately upon cession of pulsation 
in it. 

The Third Stage.— After severing the cord the child will be 
banded to the nurse, who should wrap it up warmly and lay it in 
some safe place, deferring the necessary attentions to it until 
after the mother has l)een cleaned up and made comfortable. 
Meanwhile the physician attends to the duties of the third 
stage, which have reference to the promotion of uterine con- 
traction, the prevention of hemorrhage, and the expulsion of 
the placenta. To remove the placenta, when not expelled by 
the natural efforts, the old method consists of traction on the 
4^ord, at first in the axis of the superior strait, and finally in 
that of the outlet. But, owing to insertion of the cord into 
the placenta near its center, this sort of ti-eatment is liable to 
create inversion of the placenta, causing it to pi-esent at the os 
uteri by its broad surface, and making delivery of it unneceo- 
sarily difficult. Moreover, it has been claimed, with good show 
of reason, that by traction on the cord and inversion of the 
placenta,, suction is liable to give rise to hemorrhage. Besides 
which, trartion of this sort haw been known to produce inver- 
sion of the uterus. 



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8G8 Labor. 

DELIVERy OF THE PLACENTA BY EXPRESSION.— A mftthod of 

placental delivery introduced by Crede a numbfir of years af^ • 
is at present commonly employed by many of the best obste- 
tricians. Tbis conuistti iii the application or a fis a tet^ by 
means of the hand applied to the uterus through theubdominfil 
wallH, instead of the old method of vis a fronte. For a few 
minutes after delivery of the foetus the hand is laid upon the 
fandos, and Blight friction made until the uterus is felt to con- 
tract with force, when, with the hand grasping the fundus as 
best it can, firm pressure is made in a direction downwards and 
backwards, i.e., towards the hollow of the sacrum. lathis 
manner the placenta can usually be expressed, though repeated 
attempts may be required. The effoit at expulsion is alnaya 
to be made coincidentally with uterine contraction. 

There are at present indications of a disposition on the part 
of many who have heretofore employed this method, to aban- 
don its exclusive employment, and adopt the mixed method, 
which is certainly better adapted to the general practitioner's 
use. 

Schroeder says : " I consider it the best procedure in the 
placental period, after the expulsion of the child, not to rub or 
press the uterus, but to wait quietly' until the diminution and 
ascent of the uterine body and the protuberance of the sym- 
physis indicate that the placenta is expelled from the uterine 
cavity, then, by gentle pressure, to expedite its passage 
through the vulva." 

The Combined or Mixed Method of Placental Delivery. 
— Though Credfi's method of delivering the placenta seems 
simple and easy, many have in practice, found it extremely 
difficult. This-is probably owing, in most instances, to devia- 
tions from the prescribed rules, while in others it has probably 
occurred mainly through fear to apply the necessary amount 
of pressure. The author has found much greater satisfaction 
in combiniug the two general modes of placeut^a delivery, 
namely, pressure on the fundus uteri, and traction on the cord. 
We believe this mode of treatment free from serious objections, 
while it proves remarkably effective and easy. Plain traction 
outside the vulva ordinarily suffices, but if delivery be not 
easily accomplished, a short hold should be taken on the cord, 
within the vagina, so that traction can I* made in a line 
approximating the axis of the brim, while with the disengaged 
hand simultaneous pressure is exerted on the fundus uteri. 



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Management op Normal Labor. 



Fio. 146.— Crede'B method of Expressing the Placenta, showing also Eplal- 
tttomf InciflioDa, photographed from nature (Dorland). 




Tio. 149. Delivery o( the Placenta by the Mixed Method. (After Auvard.) 



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370 Labor. 

It will occaaioually be found that the cervix is completely 
occluded by the mass, and the placenta cannot l>e brought 
away unlesB the fingei-s first be introduced and the margin, 
of it hooked down bo as to neeure the ideal presentation. 

Extraction should be elowly effected, to avoid tearing the 
membranes. The latter are usually left trailing in the vagina- 
after birth of the placenta, and in order to secure their com- 



Fia. 160. — Rotation of th« Placenta during Delivery to make a Cord of 
the Trailing Membranes. 

plete removal it is beet to twist them into the form of a rope, 
and extract them with the utmost care. After expulsion or 
extraction of the placenta and membranes, the physician should 
see that the uterus remains well rontracted. In most ca«es we- 
flnd that organ firmly condensed in the hypogaatrium, in a 
condition known as "cannon-bull contrartiou." 



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Management of Nqkmal Labor. ;171 

Majtual C0MPHE8810N OF TBE Utercs.— Tlirougliout tlie 
third std^ of labor, and for a varying period tliei-eafter, the 
hand of the physician, or some trusted asHietant, should ret^t 
upon the fundus uteri with a moderate degree of pressure. If, 
after placental delivery, the organ manifests a decided tendency 
to relax, friction and kueading of the abdomen should be 
practiced, to excite uterine eontractiou. This sort of treat- 
ment should in no case be omitted, aa its influence upon the 
third stage of labor, and the pueri:>eral state, is decidedly 
salutary. 

It is the practice in Carl Braun's clinic to apply gentle fric- 
tion to the fundus uteri twice daily for — ~-- 

the first two days after delivery. 

Immediate Repair of Lacera- 
tions. — After completion of the third / v 
stage, the cervix uteri and the vulvar 
structures ought to be carefully exam- 
ined for rente. Such cxaminaidon can 
be made of the vulvar structures only 
by painstaking insiiection in good 
light. Lacerations of the cervix can 
usoally be made out by means of the 
finger alone, but the lips of the ob are 
at this time so flaccid and irregular 
that sometimes iiiHjjection only can 
settle the question of their integrity. 
Rents are usually on the posterior 
surface of the vagina, alone, or in 
association with serious involvement fio. 161.— Inversioii of Pla- 

nf the n^rinoiim centa from TraclioD on 

ot tne pennenm. theCord. 

We are not aware that much has 
anywhere been said concerning immediate repair of cervical 
lacerations, but we have been experimenting considerably our- 
selves, and are thus far well pleased with the results of the 
operation. It is doubtless an a.dmissib]e o))eration in the 
hands of one who is accustomed to work of a similar kind in 
the vagina, but cannot yet be safely recommended to the gen- 
eral practitioner. In perfoi-ming the operation we introduce 
posteriorand lateral vulvar retractors, fasten a bullet forceps 
or double tenaculum into each lip at the angle of the wound, 
and, beginning at the upper angle of the laceration, close the 
rent with a continuous catgut suture. 



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S72 Labor. 

Care needs to be exercised not to break the cervix by means 
of the forceps, as the tissues are exceedingly soft' and easily torn 
With respect to the perineum, there can now be no reasonable 
doubt that immediate repair is not only advisable, but, in most 
uaaes, obligatory. To besure, in rare instances spontaneous re- 
pair takes place, but in these days of surgical precision, we are 
not justifiable in adopting the expectant plan of treatment. 
*' Hitherto it has been my custom to apply stitches in those in- 
stances only where solution of continuity wasconsiderable,"we 
say in a recent lecture, from which we here quote at considera- 
ble length, " and the loss of firmness to the pelvic floor seemed 
decidedly inimical to the 
maintenance of organs 
in their proper relations. 
This I now believe to be 
slovenly practice. We 
oughtnotto forget that 
there are other consid- 
I erations of a highly im- 
portant nature besides 
those just nientioued. I 
am fully persuaded that 
the time is coming, and, 
indeed, is not distant, 
when it will be regarded 
as the accoucheur's duty 
to make a careful exam- 
ination of the vulvaand 

Fin. 152,— Ifarffinal Presentation of the Pla- - ■ ,. , ,„ 

,r r f ui J n 1 . vagina immediately 
conta. If, uterus. 5, blood. /*, placenta. „ , , , . 

after labor, and repair 
with precision any rent which he may discover. Moreover, I 
b[-lieve y.^u will do well to follow this practice from the very 
bpfdnning. It will be somewhat embarrassing, and may be 
met with some criticism at first, but will become tolerated 
and at last sought. People are ultimat<^ly well pleased with 
the doctor who evinces care and consideration in the man- 
agement of his patients. Some of your colleagues and com- 
jietitors will cry 'nonsense,' but you will soon silence them 
by delicately pointing out in individual cases the unfavor- 
able results of the old expectant plan of management. The 
«ry of 'meddlesome midwifery' raised by some is getting to 
be stole. I do not believe that perfect license should be given 



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Management of Normal Labob 373 

every practitioner to do as he please; butlthinkthelinftsdmwn 
by Bome are altogether too hard and fast. I am not runnings 
breathlessly after the surgical idea, yet the conviction has 
taken fast hold of me that all of our- obstetrical cases should 
be treated in accordance with approved surgical principles. 
The science and art of obstetrics have advanced side by side 
with snrgery, and right there they hold their position. The cry 
of ' meddlesome midwifery ' was first raised by that man who, 
in his day, was the prince of obetetricians, Blundell ; but had it 
been heeded by all, the practice of obBtetrics would have re- 
mained where it then was, and ill-health and death after child- 
birth, though even how altogether too frei]uent, would have 
been as common as it then was. 

"Labor, they say, is a physiological process; and so it is. 
The effort, cOBstantly made by nature to prevent disease germs 
getting a dangerous foothold in our bodies, is a physiological 
one. and yet, when the struggle waxes warm and we begin to 
feel it, the movement is called pathological, and artificial aid is 
invoked. Who can draw a clear line between physiological and 
pathological processes? In other words, who can say when the 
physiological bounds are passed ? I^abor is truly a physiolo- 
gical process, in general, and the puerperal state is likewise 
physiological ; but certain pathological conditions are liable to 
be associated with them. My own conviction is that we are 
justified in aiding nature in her efforts, during the time when 
unusual efforts are required, so far as we safely can. After 
labor, if wounds large or small are found, standing as open 
doors for the entrance of infection, and as the possible poiuts 
of future irritation, I say close them under antiseptic precau- 
tions. Sew up the wounds which have been made in the per- 
formance of the physiological process of parturition, and you 
will do much to ward off the evil effects which stand ready to 
assail defenseless women at this critical period. 

"The conditions surrounding such cases are not altogether 
favorable for a practice of this kind, and it may take some 
force of character to follow it. Nevertheless, unfavorable 
enrironment is a poor excuse for neglect of duty. It very likely 
is a ease of first labor, and the woman, for a number of ago- 
nizing hours, has been receiving that astounding revelation of 
suffering common to unsuspecting primiparjB. At times she 
almost sank under the power of it; but bravely rallied and 
struggled to the close. She hopes to rest in the calm succeeding 



374 Labok. 

the storm, bat joa decree otberwue. The genital tract most be 
examined and all rents repaired. The friends say, ' Yes, to be 
sure. Poor child.' But the patient, weary aad worn, says 
' No, no. I can endure no more.' The friends say ' Yes/ but to 
one euiother they may add the damaging comment, ' There 
ought to have been no injuries.' All this, tboi^h unpleasant. 
ought not to deter. Do your duty. Finish op the case in a 
n-orkmaolike manner and you shall oItimat«ly have your 
reward. 

" I believe the details of this operation to be as important 
as those of any minor operation, and if the work is to be 
done at all, it ought to be well done. Surely, if there is a call 
for antiseptic precautions, it is right here. Look at the con- 
ditions. The woman has been in labor for several hours; the 
discharges hare bathed the volva, lying there exposed to the 
air, and doubtless undei^oing some change, while the fingers of 
the attendant have been passing in and out of the vagina from 
time to time during the whole period. It may be that feeces, 
as well as urine, have found their way to the parts, and thus 
in one waj- and another the conditions favorable to infection 
have been strengthened. The fact is, if we exi>ect to do a good 
piece of work it is just as essential to make elaborate prepara- 
tion for the immediate as for the secondary operatioo. That 
is not customary, I am free to admit ; but in this particular I 
would have you practice an innovation. I want you to go out 
from the college as thorough, painstaking, skillful obstetricians. 
"We want you to be all that yon seem, nod then we shall be 
j>n)ud to own you as our alumni. 

" In order that you may give these wounds proper att«ntton, 
I recommend aa a part of the r^ular obstetric outfit, the fol- 
lowing articles: Two tenaculum forceps; one short, but broad, 
[Krineum retractor; on© lateral retractor; several full-curved 
suture needle.s, an inch and a quarter to an inch and a half in 
length; a good needle-holder; plenty of formaldehyde catgut of 
various sizes; a large fountain syringe having a no^e provided 
with a stop-cock, by means of which the stream of water can 
be regulated; and a g(«>d rubber protection for the bed. These 
are in addition to the usual equipment If the rupture is com- 
plete, repair is to be undertaken with the greatest care. The 
sheet should be so arranged that it will carry the water and 
blood into a receptacle placed in front of the bed, Bince the 
bed is very yielding it will be necessary, in most instances, to 



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Management op Normal Labor. 875 

place a broad board of suitable lengrth upon the springs, beneath 
the mattress, and plenty of padding over it. Put the woman in 
position after she has been anaesthetized, and in the absence of 
assistants, fasten up the legs with a sheet folded cornerwise, 
tying it sufiBciently tight to keep the extremities out of the way. 
If she has been under an anffisthetic, we need but prolong its 
Influence. If but small wounds have to be sewed, an ansesthetic 
.may not be required. Turn on an antiseptic solution from the 
syringe and thoroughly wash the parts, including the Taf:iua. 
Use soap externally, and dry with a clean towel. With the 
jiecessary instruments at hand you are then prepared to operate. 

B^in upon the rectal side of the gap, and insert the stitches of 
No. 1 formaldehyde catgut one-fourth inch apart, including but 
little more than mucous membrane. In some instances the 
author has loosened the mucous membrane above the wound and 
has drawn it downwards over the rent, trimming its lower edge 
and stitching it so as to cover the gap. 

Having done this, a deep stitch is so placed as to take firm 
hold of the sphincter ani edges and brii^ them into apposition. 
Then separate the labia and ox>en the wound with tenaculum 
forceps BO as to expose the apex of the wound upon the vaginal 
surface, at which point suturing is now begun, the stitches 
taking hold of the walls of the laceration so as to close the wound 
without dead spaces. These sutures should be introduced as in 
^hnmet's perineum operation, in V form, with the points looking' 
downwards. 

Upon the vaginal side such lacerations are apt to follow the 
vaginal sulcus to the right or left. Accordingly, when they 
run into both sulci, the wound when closed resembles in form 
the letter Y. These stitches, when properly taken, will almost 
wholly close the gap between the vagina and rectum, only a few 
superficial stitches being required on the int^umental surface, 
sometimes not more than two. 

In complete rupture, the operation differs in no essentials 
from Uiat adapted to incomplete rupture, save in the particulars 
of rectal suturing and the deep stitch at the anal sphincter. 

It should be added, however, that for repair of an incomplete 
laceration it is not always necessary to make so elaborate prepa- 
ration, the parts merely being cleansed and the woman's posi- 
tion in bed shifted to a diagonal for the sake of convenience. 
For repair of a moderate laceration an ansesthetic is often un- 
necessary. Sntures introduced from the vaginal surface give 
but little pain- 



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376 Labor. 

Good resalts of primary perineorrhaphy are greatly de- 
pendent oa the attention given by the nurse to the 'wound. Our 
practice is to dry it and then dust it freely with boric acid, or, 
better still, aristol, and to instruct the nurse to keep it well cov- 
ered "with the powder and as dry as possible. Besides the ex- 
ternal cleansing, the vaginal surfoc^ should be gently wiped 
withabsorbentcotton, held in the jaws of dressing forceps, four 
or five times a day for nearly a week; and the patient should be 
kept much on her side. A gauze drain placed in the vagina is 
serviceable in the way of protection. 

Immediate repair is not always advisable. The lapse of a 
few hours, or even two or three days, is not inimical to operative 
procedure. If more than twenty-four hours old, the sur&oes 
ought to be freshened by scraping, and then united in the usual 
way. The author has obtained good results by operating thus 
a week after delivery. 

There are accoucheurs who prefer to wait twenty-four or 
thirty-six hours before closing the wound, beii^ convinced of 
more satisfactory results. Immediately after deUvery a woman 
is often so weakened as the result of protracted parturition or 
excessive blood -loss, that immediate repair of lacerations is in- 
advisable; in other instances the assistance at the accoucheur's 
disposal is so manifestly defective or deficient that postpone- 
ment of operative work is advisable. In connection with such 
cases it is well to remember that 
a deferred operation is far prefer- 
able to immediate work which 
mu.st be done under difficulties. 

There is no question of the ad- 
visability of giving attention at 
the same time to cervical lacera- 
tions, provided the conditions are 
favorable. These lesions are not 
so accessible, and, in the absence 
of suitable assistance, caonotwell 
l>e sutured. The difBculties at- 
tendant upoa immediate trach- 
izpoaed elorrhaphy are more pronounced, 
owing to the expanded state of the 
OS uteri, thefriabilityof tissue, thefree flow of blood.and lastly the 
diflftculty, except under close scrutiny, of even recognizing theex- 
istence and outline of such wounds, than those connected with 



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Management of Normal. Labor. 877 

the secondary operation. Accordingly, in the ordinary practice 
of obstetrics repair of cervical lacerations need not be under- 
taken immediately after delivery. When midwifery is given its 
proper place in surgery, and the laity learn that its practice can 
be best conducted under skillful surgical care, other than vulvar 
a,nd vEiginal lacerations can receive their due attention and the 
"welfare of women thereby be better conserved. At the present 
time there are many posing as competent obstetricians who do 
not understand the first principles of safe surgical procedure, 
and who are so lacking in confidence that they fear to open an 
abscess. It is to he hoped that the day is approaching when 
competency shall be found united with tact and complaisance in 
the person of accoucheurs, and when better discrimination shall 
mark the selections made by the patient and her friends. 



Fio. 164. — Antero-poeterior section, showing at e the beginning and at * 
the end of the Suturing in Complete Rupture. 
In order to repair a lacerated cervix the wound must be 
brought into view at the vulva. This can be accomplished by 
firm pressure on the fundus uteri, and use of retractors pos- 
teriorly and laterally. The comers of the wound are then taken 
hold of with tenacula and the sutures are introduced in the 
usual manner, beginning at the superior angle No, O formal- 
dehyde catgut, or No. 2 envelope catgut, is preferred. Cervical 
lacerations thus treated usually repair, though failures, due to 



,CiOO«,;le 



the retrt^rade metamorphosis going on in the uterus, are 
frequent. 



Fio. ISia. — Method of Rep&ir hy continuouB Sature, sometlmeg used. 

Poat-partum Care of the Woman.— The general condition 
of the woman, and the epecial state of the uterus, should be 
carefully wat<^hed for some time after delivery. First of all the 
patieut should be warmly covered to prevent the occurrence of 
chilling. The manual attention given to uterine contraction, 
before mentioned, should be maintained in simple cases for at 
least fifteen minutes after placental delivery. The pulse should 
be consulted, as it is a sort of criterion from which to draw 
valuable conclusions. If it is found to be rapid, the case re- 
quires undivided attention so long as it thus continues, while 
if quiet and r^ular, little anxiety need be felt. The physician 
should in no case leave his patient within the first half hour 
after delivery; and if hemorrhage ha« been threatened, he 
should stay much longer. 

The admiuifltration of arnica should be b^un immediately, 
and, in the absence of more specific indications, ouprht to be 
continued hourly during the first twelve or twenty-four hours. 

When the hand is removed from the uterus, the nurse, and 
other assistants, should withdraw the soiled clothes, and mako 



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Manaoeuent op NoRMAi. Labor. 371) 

the patient as clean and comfortable as posBtble, without much 
disturbance. It ia good practice to have the nurse also wash 
out the vagina with a gentle stream of warm water, the point 
of the tube being introduced into the vagina but a short 
distance, and everything being done under antiseptic pre- 
cautions. 

The BiNDBn. — The use of the binder is a point in practice 
over which there has been much discussion. Some practition- 
ers of much repute believe that it is not only valueless, but 
positively harmful, and utterly discountenance its use. Every 
careful observer, however, must admit that a certain amount 
of pressure is essential to the patient's perfect comfort. After 
tabor women feel as though they were "falling to pieces," and 
the binder, if it does no more, certainly contributes greatly to 
their comfort. To completely fulfill the requirement, it must be 
properly applied. If too narrow it will not keep its place, and 
is liable to do more harm than good. The proper width varies 
somewhat in different cases, but the average is about ten inches, 
the intention being to cover the entire abdomen. To do this it 
must be broughtwell down over the hips. Almost anymaterial 
will answer the purpose, but a strong piece of unbleached mus- 
lin is preferable. By some, a pad, consisting of a large napkin, 
or small folded towel, is placed upon the hypogastrium, beneath 
tlie bandage, and upon the contracted fundus uteri, but we do 
not advise its use. 

To make a neat and effective application of the binder is a 
thing not easily accomplished by the novice; and yet every 
physician ought to possess the necessary skill. Properly to 
place it under the woman's hips requires the services of two. 
When this haa been done, the physician should hold the end 
near him between the thumb and fingers of the left hand, 
while he draws the opposite end tightly over it, and fastens 
pin after pin. Seven or eight safety pins should be used and, 
when fully applied, the binder must be fi-ee from wrinkles. The 
woman's toilet is completed by plEicing awarm and thoroughly 
aseptic napkin at the vulva to receive the discharges. If now 
comfortable, and her pulse quiet, she may be left by the physi- 
cian in care of her nurse, who, if not well acquainted with her 
dnties, should receive explicit instructions. 

We cannot close this account of the general management of 
normal labor, without emphasizing the superlative importance 
of moat rigid attention to cleanliness. Make finre that in no 



380 Labor. 

possible manner septic matter reach the patient before, during, 
or after delivery. 

Therapeutics of Labor.— In the course of norma! labor 
there would seem to be but few occasione for the use of reme- 
dies, but unpleasant symptoms are sometimes associated with 
the usual phenomena, and without being essential parts of the 
parturient action, are amenable to the suitable remedy. The 
indications, as applied to labor, are, of course, purely clinical, 
as we have no record of extensive provings made during the 
parturient act. We here append the following indications as 
occasional guides to the right remedies : 

Labor Pains. — Inefficient, etc. — Violent and frequent, but 
inefficient: aconite. 

Too weak, not regular: wthusa. 

Violent, inefficient : arnica. 

Tormenting, but useless, in the beginning of labor: caulo- 
phyllum. This remedy rarely fails to produce a good effect. 

Short, irregular, spasmodic, patient very weak, no progress 
made : eaulophyllum, actwa rac., Pulsatilla. 

Spasmodic irregular: cocculua, Pulsatilla, eaulophyllum. 

Spasmodic : cansticnm, ferrum, Pulsatilla. 

Spasmodic, cutting across from left to right, nausea, clutch- 
ing about the navel: ipecac. 

Spasmodic, painful, but ineffectual : platina. 

Spasmodic, they exhaust her, she is out of breath: atannuni. 

Spasmodic and distressiug, tearing down the legs : cham. 

Insufficient, violent backache, wants the back pressed, bear- 
ing down from the back into the pelvis : kali c. 

Distressing, but of little use, cutting pains across the abdo- 
men: phos. 

Ineffectual, of a tearing, distressing character, they do not 
seem to be properly located : actipa. 

Severe, but not effective ; she weeps and laments : cof^a. 

Weak, False, Deficient. — False, labor-like pains, sharp pains 
across abdomen : actiea, caul 

Pains weak or ceasing, wants to change position often, feels 
bruised : arnica. 

Weak or ceasing, will not be covered, restless, skin cold : 
camphor, c. c. 

Deficient or absent; she has only slight periodical pressure 
on the sacrum, amniotic fluid gone, os uteri spasmodically 
closed : belladonna. 



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Management op Normal Labor. 381 

Weak or ceasing, with great debility, especially after ex- 
haustive disease, or great loss of fluids : carb. v. 

Pains be4?ome weak, flagging, from long-protracted labor, 
causing exhaustion ; patient thirsty, feverish: caul. 

Cease, from hemorrhage : china. 

Ceasing, with complaining loquacity : coffea. 

Weak, or accompanied with anguish ; she desires to be rub- 
bed : natrutn m. 

False or wea k, spasmodic, irregular, drow^sy faint spells, with 
weak pains: nax m. 

Deficient, irr^ular, sluggish : Pulsatilla. 

Weak and ceasing: thuja. 

Deficient, with ossoft, pliable, dilatable: ustilago. 

Suppressed, or too weak : secale. 

Cease, coma; retention of stool and uriue — from fright: 
opium. 

Stronff. — Excessively severe: coffea, dux v. 

Too prolonged and powerful ; secale. 

Effect on Patient. — Labor-pains make her desperate, she 
would like to jump from the window, or dash herself down: 
arum tri. 

During pain she must keep in constant motion, with weep- 
ing; lycopodium. 

Cause fainting: dux y., rerat. alb., puis. 

Cause urging to stool, or to urination : nax v. 

Excite suffocative or faint spells, must have the doors and 
windows open: Pulsatilla. 

ISxhauBt her ; she faints on the least motion : verat. a. 

Cause weeping and lamenting: coffea. 

TjOCATion and Couebe of Pains.— Pains principally in the 
back : cauaf. 
• Pains worse in the back : dux v. 

Pains worse in the abdomen: palsatilla. 

Pains run upward ; Ivcopodiiim. 

Pains like needles in the cervix, especially with rigid os: cau- 
lophyUum. 

Special and Peculiar Symptoms. — Cardiac neuralgia in 
parturition: acti^a. 

During labor cannot bear to have her bands touched: 
ebiaa. 

With every uterine contraction, violent dispncea which seems 
to neutralize the labor-pains : lobelia. 



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382 Laboh. 

Labor progresses slowly, pains feeblfe, seemingly from sad 
feelings, and forebodings : nat. mar. 

Cessation of labor-pains ; retention of stool and urine, often 
from fright: opium. 

Contractions interrupted by sensitiveness of vagina and 
vulva: platina. 



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Use of ANE8THET1C8. 



CHAPTER IV. 
VSB OP ANESTHETICS AV MIDWIFEE¥ PRACTICE. 

Id treating the subject of aneethetica in obBtetrical practice,, 
we should divide cases into two general classes : 1. Cases ot 
normal labor, wherein we seek merely to mitigate the ordinary 
pangs of childbirth, and 2. Gases of an abnormal, or unusual^ 
nature, wherein operative interference is necessitated. 

1. Cases of Normal Labor,— Obstetkical Anesthesia. — 
The use of anesthetics in normal labor differs esaentiaily from> 
its employment elsewhere, in the design of its employment, and 
the extent to which its action is carried. We aim in such cases- 
not completely to annul sensibility, and subdue muscular resist- 
ance; but merely to modify the agony associated with the 
propulsive stage of labor. When from purpowe or accident the- 
anesthetic influence is permitted to exceed this limit, new 
dangers arise, and fresh complications are met. To accomplish! 
onr purpose, continuous inhalation is not required, and should' 
not be permitted, but the lethean vapors ought to be applied 
JQst before and during the pains. 

The form of anesthetic best adapted to such pui-poses is 
unquestionably chloroform. It is more speedy, pleasant, and 
energetic in ite eifects than ether, and in parturition it has 
proved to be quite as safe. In surgical practice its effects have 
occasionally proved fatal, but when administered during labor, 
according to the directions which follow, scarcely a death has 
resulted. 

Parturient women are easily put under its influence to the 
extent required for immediate purposes: a few inhalations of 
its vapors, b^un just before the expected recurrence of a pain, 
and continued during it, being sufficient to allay excessive 
sensibility, and quiet the nervous erethism so often observed. 
The nurse, or some self-possessed assistant, is instructed to pour 
upon a folded handkerchief or napkin fifteen or twenty drops 
of the chloroform, and place it within about half an inch of 
the nose and moath, thereby giving free access to atmospheric 
air. We have found Esmarch's inhaler very convenient for the 
purpose. None of the chloroform should be permitted to touch 
the patient's skin, as the smarting produced by it would be 
liable to excite fear. It is a good plan to apply the chloroform 



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384 Labor. 

to the handkerchief soon aft«r the ciose of a pain, and then roll 
the latter tightly in the hand to prevent evaporation, until the 
pain is about to return. Otherwise there is liability to delay, 
and the patient is as greatly annoyed by the bungling work of 
the person in charge of the anesthetic as by the labor-pains 
themselves. By such administration of chloroform, conscious- 
ness is not interrupted. The patient may at the time declare 
that her Buffeiings are nearly as keen as before ; but when the 
labor is past, she will be enthusiastic in her praise of the virtues 
of the anesthetic. Women who have once taken it are not 
willing to be deprived of its soothing influences in subsequent 
labors. 

The usual objections raised against the use of chloroform in 
labor are not here forcible, since the effect is 80 moderate that 
it is not capable of materially modifying the pains, precipitat- 
ing post-partum hemorrhage, or producing any of the other 
ills sometimes attributable to a use of the drug when admin- 
ieijcred more freely. 

The period in labor when the use of an anesthetic should be 
adopted varies in diflerent cases. It is wise, however, to defer 
anesthesia until near the close of the oecoud stage. When once 
b^tun, its action must be maintained until the close of foetal 
expulsion, as the woman will not tolerate a suspension of the 
pain-soothing influences. Hence, to begin early involves long 
continuance. The most intense pain is suffered in the latter 
portion of the propulsive stage, and this part of labor, if any, 
ought to be lightened. In some instances of extreme excita- 
bility, and terrible suflering, the chloroform may, with perfect 
propriety, be earlier exhibited. 

a. The Use of Anesthetics in Operative Midwifery.— 
SuitGiciL A.VE6THE8IA. — The effect of the anesthetic, in those cases 
where operative procedures are necessary, is carried to a greater 
extent, and, possibly, involves the patient in greater danger. 
That there is a certain degree of peril to life associated with the 
administration of any anesthetic, no one will question, and that 
it is greater in the instance of chloroform, none who have 
familiarized themselves with the general subject of anesthetics 
will presume to deny. Every few weeks a case of death under 
chloroform finds its way into public print, thus giving strength 
to popular fear. And yet a careful analysis of such fatalities' 
generally discloses, as an efitcient cause of the accident, a fla- 
grant disregard of the rules laid down for the administratioD 



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Use op Anesthetics. 385 

of this potent, and hence dangerous, eubstance. The fatalities 
occarring in the dentist's chair largely preponderate, the 
patient occupying a semi-recumbent position, which is wholly 
at variance with the teaching of ali clinicians. 

Attention should be directed to the difference in point of 
mortality under anesthetics 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 
this is not true of midwifery. In fact, but fejv fatal cases in the 
latter branch of practice have ever gone upon record. The ex- 
planation of such divergent results is not altogether satisfac- 
tory, but we opine that it may be found in the increased cardiac 
energy growing out of the circulatory changes of pregnancy, 
elsewhere described. But whatever our theories rt^arding the 
cause, the truth remains, and has become familiar, even to the 
general public. 

Anesthetics are said to predispose to post-partum hemor- 
rhage, which is generally a complication directly dependent on 
atony of the uterine muscles. Extreme vascular fullness is 
maintained by the flaccidity of the tissues, while the exposed 
vessels at the placental site freely bleed. The effect of anes- 
thetics on uterine contraction is marked, as the author has re- 
peatedly demonstrated. This eflect is rather more decided in 
chloroform than in ether inhalation. A moderate degree of 
anesthesia may be produced without essentially modifying 
uterine action ; hut a^ the impression becomes more profound,, 
the contracting organ is partially or wholly subdued. If this- 
is the effect of anesthetics on the uterus during labor, when tbfr 
organ is stimulated to action by its contents, we should be^ 
prepared to find a corresponding condition protracted some- 
what into the post-partum stage. That we do find more or lesa 
relaxation after extrusion of the ffetus and secundines in such 
cases, is beyond question; and yet it is not so marked, nor s& 
persistent, as some suppose. Hemove the vapors from the 
woman's nostrils during labor, and the contractions which 
have been extremely feeble, or altogether absent, are soon re- 
newed. In like manner after delivery, when the more profound 
effects of the chloroform pass away, uterine atony generally 
gives place to a favorable tone of the muscular fiber. The re- 
sult is that hemorrhage of moment rarely ensues. Occasionally 
tiiere is a sudden profuse gush of blood soon after the placenta^ 
is removed, especially when the anesthetic influence has been 



38fi Labob. 

maintained to the very dose of the second stage, or longer; 
but hypogaBtric pressure, and moderate use of cold water, are 
nearly always capable of speedily arresting the flow. In the 
Hahnemann Hospital it is our custom, as a preliminary to the 
introduction of a class of students, to bring the woman pro- 
foundly under the influence of chloroform ; and though 
narcosis is irequently maiutaiued for a period of one and a 
half, or two hours, among the hundreds of women confined 
there during the past few years, not a single case of alarming 
hemorrhage has been met. Our practice is to keep a close 
■watch over the patient for a considerable time after delivery, 
and give attention to the first indication of trouble. Pressure 
is made on the fundus uteri for flfteen or twenty minutes after 
ftetal and placental expulsion, in ordinary cases, and longer in 
those presenting suspicious symptoms. If the uterus is felt to 
relax beyond a normal limit, and does not respond at once to 
abdominal pressure, the vulva is inspected, and, if necessary, 
cold applications, and manual irritation of the os uteri, are 
•employed. It is rare that more energetic measures are re- 
■quired. 

The question has often been asked — Does an anesthetic 
administered to the mother, produce any effect on the child in 
utero? We have been led by experience to give an affirmative 
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, though but a few 
minutes before birth it was proved by auscultation to be living, 
was still-born, and resisted all efforts at resuscitation. About 
forth-eight hours subsequently, dissection of it was begun by 
some students, and when the viscera were exposed, the odor of 
ether was distinctly recognized. 

In most instances, where the mother has been long subjected 
to anesthesia, the child is comparatively inactive for some time 
after expulsion. It is really uncommon for children bom under 
-such conditions to utter the cries so generally heard at the birth 
of children whose mothers have not been under anesthetic in- 
fluences. And yet, that decidedly deleterious effects are often 
produced, there is much reason to doubt. 

Dr. J. C. Reeve, in the "American System of Obstetrics," 
says that a careful study of the subject of accidents from 
■chloroform during parturition justifies the following state- 
<nents: 



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Use of Anesthetics. 887 

1. But one well authenticated case of death is on record 
-where the adminiHtration was by a medical man, and in that 
case no autopsy was held. 

2. Dangerous symptomB haveoccurred but avery few times, 
and then almost always from violation of the rules of proper 
^dminiBtration. 

3. The danger when chloroform is used only to the extent 
of mitigation or abolition of the suffering of childbirth 
is pi-actically nil; when carried to the surgical degree for 
obstetric operations, the danger is far below what it is in 
surgery. 

4. No proof can be famished that the parturient woman 
-enjoys a special immunity from the dangers of anesthetics, 
though factfl seem to indicate that such exists. Her best safe- 
guard lies in the care and watchfulness 

of the administrator. 

Rules for AdminlBtering Anes- 
"thetics. — The general rules for admin- 
istering anesthetics are pretty well 
understood, even by tyros, and still 
there is frequent disregard of them. 
The mode of administering chloroform 
■diflers materially from that of ether. In 
bringing a patient under the influence of 
"the latter, a cone, or an inhaler of some 
other form, is generally employed, which 
is .held closely down over the nose and 
mouth, so that all the atmosphere which 
enters the lungs is loaded with ether vapors, taken from the 
saturated sponge in the apex of the cone. Such a use of 
chloroform would be dangerous in the extreme. 

In the administration of chloroform the following rules 
should be observed : 

First: — The patient must occupy the recumbent posture. 
Second: — The article or apparatus by means of which the 
■chloroform vapors are conveyed to the patient, must be so 
placed or arranged as not to exclude a free supply of atmos- 
pheric air. 

TA/rrf;— Both respiration and pulse should be attentively 
observed from first to last. 

It has been repeatedly demonstrated that deviation from a 
^horizontal position augments the patient's danger. The 



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388 Labor. 

head ahonld lie in a line with the longitudinal axis of the 
trunk. 

The supply of atmospheric air must be more copious than 
that which is ^ven with ether inhalation. A folded handkerr 
chief, or napkin, is a convenient medium, on which should be- 
pou^d but a small quantity at a time, and then placed within 
one-half or three-quarters of an inch of the patient's mouth and 
nose. Esmarch's inhaler is more convenient and economical 
than any other means. The patient should be directed to 
breathe deeply and regularly, while fear and excitement ought 
trO be allayed as far as possible, by cheerful words and a calm 
bearing. The supply of chloroform may be renewed as often 
as circumstances seem to require, the intervals being varied to 
correspond with the woman's condition, and the facility with 
which anesthesia is produced. These are important considera- 
tions, since it is very certain that danger bears a marked 
relation to the intensity of the impression, and the rapidity of 
its production. 

Neither anesthetic should be administered without the 
closest attention being direct-ed to the pulse and respiration. 
When employed in normal labor for the purpose merely of dull- 
ing the sensibilities, this is hardly so essential, though it should 
not be forgotten that in other than midwifery cases, death has 
occurred, in quite a proportion of instances, at the very ban- 
ning of the anesthetic process. When carried to the extent of 
complete narcosis, the rule must be scrupulously adhered to, if 
one would keep within the bounds of comparative safety. Nor 
should these obaervations be intrusted to a person wholly 
unacquainted with the phenomena developed by anesthetics, if 
it is possible to secure the aid of one qualified to fill the posi- 
tion. To do otherwise is to subject the woman's life to unneces- 
sary risk, one's self to much solicitude, and to merited denunci- 
ation in case of a fatal result. 

After making the most elaborate provision for the adminis- 
tration of this powerful drug, theoperator should onnoftccount 
sufier himself to become oblivious to his patient's condition. 
When the operation is difficult, and attended with vexatious 
occurrences, one easily becomes so deeply engaged in the work 
immediately in hand as to remit his watchfutnesB over impor- 
tant concomitants — a state of mind against which he cannot 
be too guarded. 

We shall not here enter into an account of the symptoms of 



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Ube of Anesthetics. 389 

fatal caaee, or the treatment to be adopted; but for an extended 
discussion of these we refer the student to elaborate works on 
surgery and to Bpecial treatises. 
. " Chloroform is especially indicated — 

"1. In primiparee who are nervous and excitable, and in 
whom the pain may even cause delirium ; also in those with 
whom the labor is greatly prolonged, thus becoming a source 
of danger. 

"2. In all cases in which there is a spasm, contraction, or 
rigidity of the neck or body of the uterus, Contra-indications 
are the absence of severe suffering, the existence of placenta 
pFBevia, general prostration, disease of the circulatory ot 
respiratory organs, cerebral disease, alcoholism, etc." 



Fio. ISO.— Esmarcb'i Inhaler. 



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THE MECHANISM OF LABOR. 

The VariouB Positions of the Fostus.— This jb a subject 
which, to the student, is full of difficulty, and to elucidate it is 
no eaay task. One of the most conspicuous factors in the pro- 
duction of confusion is the adoption of numerals to designate 
the various positions which are met. Most authors give to 
every presentation four positions, which are designated by the 
numbers one, two, three and four. For example, the left oc- 
cipito-an tenor position is the first, and the right occipito-ante- 
rior is the second. The adoption of these designations, it must 
be confessed, is a saving of some words at the moment ; but to 
give the student a perspicuous and comprehensive view of the 
different positions, and their relations, demands an exhaustive, 
and, we maj' add, unnecessary effort. 

As a preliminary to the study of this subject one must have 
a clear conception of the cardinal features of the pelvis, which 
have been elsewhere pointed out. With a knowledge of the 
form of the pelvic brim, outlet and cavity, the situation of the 
iliopectineal eminence and the acetabulum, and the relative 
measurements of the various diameters, and finally the bounda- 
ries of the false and the true pelvis, one is prepared to under- 
stand that which here follows. 

The Theory op Clabbipication,— The four positions into 
which the various presentations are divided are based upon the 
theory that the long diameter of the presenting part occupies 
an oblique position with reference to the pelvis. That the 
theory does not hold true in all cases, is manifest to every ob- 
stetric practitioner. The long diameter is sometimes, though 
rarely, at the brim, in the conjugate of the pelvis ; and again 
it occhpies the transverse diameter. In the latter instance tt 
always rotates into an oblique diameter, sooner or later, and 
therefore becomes one of the regular poaitions; while instances 
of the former are bo rare aa to make a single exception of no 
great imjiortance. For practical as well as theoretical pur- 
poses, perHpieuity would lead to an approval of the division. 

When the vertex preBents, the occiput is regarded as (fie cardi- 
nal feature, since it is in advance, and from the direction it 
assumes the poBitions are described, or numbered. With the 



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Mechanibu op Lasob. 8dl 

long diameter of the head' ia an oblique pelvic diameter, ttie oc- 
ciput must be either forwards and to the left, or btickwards and 
to the right; forwards and to the right, or backwards and to 
the left. When forwards and to the left it is the first position ; 
when forwards and to the right it is the second position ; when 
backwards and to the right it is the third position ; and when 
backwards and to the left it is the fourth. 

When the face presente, the chin corresponds, so far as the 
mechanism of labor is concerned, tx> the occiput in vertex pres- 
«ntation, and the direction of that part determines the 
position. When backwards and to the right it is the first posi- 
tion ; when backwards and to the left, the second ; when for- 
wards and to the left, the third ; and when forwards and to the 
right, the fourth. 

When the pelvic extremity presente, one pole of the long 
diameter does not take precedence over the other, since it is 
immaterial to the easy and natural performance of the mechan- 
ism of labor whether the right or the left trochanter looks 
forwards. When the bi-trochanteric diameter ia in the left ob- 
lique pelvic diameter, and the left hip is forwards and to the 
right, it is the first position ; when in the right oblique diame> 
t«r, and the right hip is forwards and to the left, it is the sec- 
ond position; when in the left oblique and the right hip is 
forwards and to the right, it is the third position ; and when in 
the right oblique diameter, with the left hip forwards and to 
the left, it is the fourth position. 

When the ftetus presente transversely, four positions may 
also be described. If the dorsum is forwards, and the head lies 
to the right, it is the first position ; if the dorsum is forwards, 
and the head lies to the left, it is the second position ; when the 
ilorsum is backwards, and the head lies to the left, it is the 
third ; and when the dorsum is backwards, and the head lies to 
the right, it is the fourth. 

These are the four positions of the various presentations. 
They have been otherwise named by some authors. 

The Basis op Classification. — It must not be supposed that 
the classification of positions is madeupon mere arbitrary prin- 
ciples, though from the first study of it this may seem to be 
true. Our attention has thus far been addressed to the various 
features of the presenting parts, but we will now regard the 
position of the trunk. 

With respect to the direction of the bock, it should be said 



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Fio. 157.— First position of the Vertex. Fig. 1B8,— Second poaition of the Vertex. 




189.— Third po8lti<m of the Vertex. Pig. 160.— Fourth poeition oi the Vertex. 



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Mechanism op Labor. 





Fm. Itl.— First position ot the Face. Fio. 163.— Second position of the Fwe. 




Fto. 16S.— Third position of the Face. Fio. 164.— Fourth position of the Face. 



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Fig. 166.— Firet ppaition of the Breeoh. FiQ. 166.— Second position ot the Breech. 





167.— Third position of tlie Breech. Fig. 168.~Fourth position of the Breeeb. 



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Mechanism of Labok. 



Fio. IS9. — Second position of Footling presentation. 




Fio.170.— Fourth petition Oi the Feet. Fio. 171.— Third position of Tr&nBverw 

presentation. 



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Fis. 172.— Second posttton of Tranevene Fia. 173.— Fourth potition of TransTerae 

presentatioD. presentation. 





Fio. 174.— First pOBition of the Vertex. Fio. 175.— Firat position of the Breeob. 



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Mechanism of Labor, 



397 



that, like the position of the head.it is not alwajsoblique; still, 
practical, as well as theoretical, purposes are just as well served 
— we may say, are better served — by asBuming that it is. The 
long axis (biB-acrotnial) of the trunk forms a right angle >vith 
the long axis (occi pi to-frontal in vertex presentation, and 
fronto-mental in face) of the head. Accordingly we observe 
that the dorsum of the fcetns coincides with the occipital pole 
of the long diameter of the vertex, and the frontal pole of the 
long diameter of the face. The bi-trocbanteric diameter of the 
pelvis is the long diameter of the presenting part, when the 




Fia. 177.— Second position d 
the Breech. 

pelvic end is in advance. In the flrat position of vertex presen- 
tation the occiput lies to the left ilio-pectineal eminence, and 
-constituteB the left' oecipito-anterior position. Now, assuming, 
as we do, that the fcetal back coiTesponds in direction with the 
occiput, this position might well be designated the left dorso- 
anterior position of the vertex. Ijet us now reverse the ends 
and cause the breech to present in the first position, and we 
have the left dorso-Einterior position of this presentation. We 
■will now return the child to the first position of the vertex, and 
then by extension of the head, i. e., by tipping the head back- 
wards, convert it into the first position of the face, and we 
£nd that this may likewise be described as the left dorso-ante- 



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89H Labor. 

rior positioir— not of the vertex, not of tbe breech— but of the 
face. Fnrthermore, we will now turn the heaxl away from the 
brim and lay it in the right iliac fossa, and we have tbe first 
position of transverse presentation, which may also be deeig> 
nated the left dorno-anterior. 

What is true of the first position is also true of the second,, 
third and fourth positions. In the second position the dorsum 
of the fcetus is forwards aud to the right, and it may be 
grai)hica11y described aa right dorso-anterior. When the head 
presents, it is right dorso-anteiior position of the vertex or 
face; when the pelvis presents, it is right dorBO-anterior of the 
breech, knees or feet ; and when tbe pi'esentation is of the side 
of the fcBtel oval, then it may still be designated the right 
dorso-anterior position. In the third position of any pre- 
sentation, the back of the fcetus lies backwards and towanls 
the woman's right, and in the fourth position of any presenta- 
tion, the dorsum is turned backwards and towards tbe womaii'» 
left. By such generalization, we obttiin a comprehensive view 
of tbe entire subject of positions. 

From what has been (pven on this topic we may draw the 
following conclusions : 

Ist. That the underlying principle of classification is not 
so much the direction of tbe cardinal features of the presenting 
part, as the direction of the foetal dorsum. 

2d. That the first and second positions of all presentations 
are dorso-anterior, — the first, left dorso-anterior, and the 
second, right dorso-anterior; and tbe third and fourth posi- 
tions are always dorso-posterior, — the third being right dorso- 
posterior, and tbe fourth, left dorso-posterior. 

3d. That in tbe first and fourth positions of all presenta- 
tions, the dorsum of the foetus is directed towards the woman's- 
left, — the first somewhat forwards, the fourth somewhat back- 
wards; and in the second and third positions of all presenta- 
tions, the dorsum is turned towards tbe mother's right, — tbe 
second, somewhat forwards, the third, somewhat backwards. 

The Kelative FbeqijEncy op Positions. — Dubois found the 
first position in 70.83 per cent., and the third in 25.66 Jjer 
cent, of all bis cases. Dr, Joseph G. Swayne, on the contrary,, 
out of ] ,000 cases had tbe first position in 792 (79.2 per cent.), 
tbe second in 152 {15.2 per cent.), the third in 19 (1.9 per 
cent.), and the fourth in 37 (3.7 per cent.). 

Out of 169 vertex presentations in our hospital practice^ 



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Mechanism of Labor. 399 

there were 118 of firot positioD, 35 of second, 7 of third and & 
of fourth. 

Points ofCoincidenoe Between the Various Position B.—Zir 
veiftex preaentation, the first and seconti positions agree in one- 
particular, namely, they are both occipito-anterior positions, — 
the first looking to the left, the second to the right ; and the 
third and fourth agree in being occipito-posterior positioiiH, — 
the third directed towards the right, and the fourth towards the 
left. The first and fourth correspond in being left occipital 
positions ; that is to say, the occiput in both instancefi is turned 
towards the left, — in the first, somewhat forwards, in the fourth, 
somewhat backwards. The second and third are alike in the 
general direction of the occiput, — both looking to the right, — 
the second turned somewhat forwards, and the third somewhat 
backwards. Again, the first and third agree in respect to the 
oblique pelvic diameter (right oblique) in which they lie, but 
the poles are reversed, so that the first is the left occipito- 
anterior position, and the third the right occipito-posterior. 
The second and fourth correspond in similar respects. They 
occupy the left oblique pelvic diameter, — the second being tlie 
right occipito-anterior, and the fourth thelefboccipito-i>o8terior 
position. 

Faoe Presentation. — Briefiy stated, the positions of the face 
coindde in certain particulars which are determined by similar 
principles of classification as are those of the vertex. The fii-Ht 
and second are mento-posterior positions, the chin in the first 
looking to the right, and in the second, to the ]eft. The third 
and fourt.h are mento-anterior positions, — the chin in the third 
being directed to the left, and in the fourth, to the right. The 
flrat and fourth correspond in the lateral direction of the chin, 
— in the first it being backwards and to the right, and in the 
fourth, fowards and to the right. The coincidence between the 
second and third is similar, — in the second the direction being 
backwards to the left, and in the third forwards to the left. 

The first and third and the second and fourth are alike in 
the pelvic diameters occupied by the long facial diameter, — 1 he 
first b^ng 'right mento-posterior, and the third, left mento- 
anterior; while the second is left mento-posterior, and the 
fourth right mento-anterior. 

Breech PreaeDtation. — The first and second positions of the 
breech agree in that the right trochanter of the foetus loiiks 
towards the left, in the first position somewhat backwards, and 



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400 Labor. 

in the second forwards. Likewise the third and fourth positions 
resemble one another in that the right trochanter is turned to 
the mother's right,— in the third position it being forwards, and 
in the fourth backwards. The first and third are identical in 
the direction of the bi-trochanteric diameter (left oblique), but 
in the first position the right trochanter is at the left ilio-sacral 
synchondrosis, and in the third is at the right ilio>pectineal emi- 
nence. The second and fourth positioDS coincide in the pelvic 
diameter occupied (right oblique), but in the second the right 
trochanter is at the left ilio-pectiueal eminence, and in the 
fourth, at the right ilio-sacral syDchondroBis. 



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Mechanism OF Labor. 



CHAPTER YI. 
THE MECHANISM OF LA BOB— Continued. 

The mechanism of labor varies greatly with the character of 
the preeentatiou. The varieties of these, and their positions, 
have already received attention, and but a few general remarks 
with regard to them need here be made. Vertex presentation 
represents the normal type of labor, and is alone entitled to be 
regarded as strictly uormal. The other varieties are relatively 
infrequent, and present characters which deviate from the- 
phenomena usually observed. 

Vertex Presentations.— Some of the ancients believed that 
the head passed through the pelvis in the same manner as a 
semi-organized clot of blood, or a mass of hardened fseoes, with- 
out reference to those nice laws of flexion, rotation, extension 
and restitution, now so well understood to have an important 
bearing in every case. Others believed that the child by its 
own spontaneous efforts pushed its way through the pelvis — 
that it verily crept into the world. The origin of the present 
theories regarding the mechanism of labor may be traced to Sir 
Fielding Ould, who in 1742 published a work which contaiuedl 
some of the ideas still extant. In 1771, Saxtorph, of Copen- 
hagen, and Solayres de Kenhac, of Montpellier, simultaneouBly,. 
and without mutual consultation or knowledge, published 
essays which agi-eed that in natural labor the long diameter of 
the child's head enters the pelvis in an oblique direction, and 
that in a large proportion of instances it occupies the right- 
oblique diameter, the poles of which are the left ilio-pectineab 
eminence and the right ilio-sacral synchondrosis. Through 
the strong advocacy of Baudelocque these ideas were quite 
generally accepted, but certain erroneous notions crept in, and 
the matter was finally cleared up and simplified by Naegele, 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 the posterior fontanelle, the 
parietal eminences, and the anterior fontanelle. 

Relative Feequency op Vertex Presentations.— Out of 
83,871 births collected by Spiegelberg, from private practice, in 



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402 Labor. 

over ninety-seven per cent, the vertex presented. Dubois, in 
2,020 deliveries at term, found 1,013 vertex presentations. 
Mme. Boivin in 20,517 births, found 19,810 vertex preeenta- 
tiona. The probable cause of this ha« already been considered. 

Beiative Frequency of First Po8itioD.—A.B elsewhere stated, 
the first position of the vertex is found in a large proportion 
of cases. The cause of this is not perfectly understood, but 
Simpson attributes it to the presence of the rectum on the left 
side bf the pelvic brim. 

It has been suggested that it probably results from the fact 
that the uterus is usually rotated in such away upon the spine, 
that the right side inclines obliquely backwards, while the left 
side is turned somewhat towards the front. 

Changes of Presentations and Positions. — The fcetus may 
change its presentation and position at any time during piq- 
uancy, but, of course, with less facility in the latter part of this 
period. Not rarely does such a change take place even after the 
beginning of labor, whether remedies have been administered 
with a view to effect a change or not. 

From extensive observations made by him, Schneder arrived 
at the following conclusions; 

1st. The fcetal presentation rarely remains motionless from 
the end of the seventh or the eighth month until the time of 
labor. In 113 women examined once only, change of presenta- 
tion was encountered in 31.86 per cent, of the cases. Primi- 
paree 30 per cent.; multiparee 36.36 per cent. In 56 woroen 
examined twice, change of presentation occurred in 59 per 
cent, of the cases. Primiparse 52 per cent.; multiparfe 66 per 
cent. In 33 women examined three times, change of presenta- 
tion was found, in 76 per cent, of the cases. , Primiparee 72 per 
cent.; multiparee 88.9 per cent. In 28 women examined several 
times, change of presentation was found in 89.3 percent, of the 
cases. Primiparee 89.3 per cent.; multipara 100 per cent. 

2d. The changes are less common in primiparee than in 
multipara. 

3d. They become rarer as we approach term. 

4th, Even when the head is fixed in the superior strait, 
change of presentation is pot^sible. 

5th. When the head ie completely within the leaser pelvis, 
change of position occurs in only 10 per cent, of the cases. 

6th. Changes are more common with contracted than with 
normal pelves. 



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Mechanism of Labor. 403 

The following table, taken frpm Sehroeder, will 8how the 
frequency and variety of these changes of presentations and of 
positioDS : 















All CUM 














Time.. 


iBt pwition of Vertex into 2d position of Vertex . . . 


60 


33 


17 


lat 








2d 




Breech... 


2 


1 




lit 


" 


" 


" 


Ist 


" 


Shoulder. 


3 


2 




iBt 




" 


" 


2d 




" 


2 


1 




2d 


" 


» 


" 


lat 




Vertex... 


71 


43 


28 


2d 


" 


" 


" 


lit 




Breech... 









2d 


" 


" 


" 


2d 




•■ ... 




2 




2d 


" 


" 


" 


lit 




Shoulder. 




S 




Sd 


" 


« 


" 


2d 




" 









iBt 

2d 


" 


Breech 


» 


iBt 

lit 




Vertex... 
Face 









2d 
2d 


■'.* 


." 


1 


iBt 

2d 




"Vertex... 




3 





2d 


" 


" 


" 


2d 













Itt 

2d 


", 


Face 


I 


iBt 
2d 




Vertex... 










Ut 


" 


Shoulder » 


iBt 


" 


" ... 




1 




iBt 


« 


" 


" 


2d 


" 


" .. . 




4 




lat 


" 


" 


" 


2d 


" 


Shoulder: 









2d 


" 


" 


" 


lat 


" 


Vertex... 




2 


2 


2d 


" 


" 


" 


2d 


" 


" 







6 . 




" 


2d 


" 


" ... 




2 






Conditions at the BeginniDg of Labor.— At the beginning of 
labor, the presenting head, covered by the uterine tissues, is 
aaoally found just above the brim, and occupies with its long 
diameter an oblique diameter of the pelvis. 

Conditions of the FestuB which Favor Expulsion. — The 
mechanism of labor in vertex presentations is usually described 
aa consisting of a series of movements, termed (1) descent, 
(2) flexion, (3) rotation, (4) extension, (5) restitutioD. 

A knowledge of these movements as they occur in labor is 
highly essential to a proper comprehension of the mechanism 
of parturition, and the intelligent practice of the obstetric art. 

Mechanism or Labor in the First, or Le>t Oocipito-An. 
TERioR, Position.— It should be remembered that, in the first 
position of the vertex, the long diameter of the head occupies 
the right oblique diameter of the pelvis, the occiput being di- 
rected to the left iHopectineal eminence, and the forehead to 
the right saero-iliac Bynchondrosis, The dorsum of the foetus 
is thus brought to the mother's left side. 



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404 



Labor. 



ParaUehsm oi the Bi-parieta} Plane to the Plane of the 
Brim. — The head has amially been described as entering the 
brim with the right parietal eminence on a lower plane than 
the left ; but this iden. is being abandoned. The plane of the 
brim and the bi-parietal plaiie are probably at that BtafE;e of 
advancement coincident. 

Descent and Flexion. — Descent and flexion are closely allied 
movements. As the head descends and encounters the bound- 
aries of the brim, the force is such aa to cause flexion. The long 
diameter of the head represents a lever, with the fulcrum at the 
occipito-atlantoid articulation, the anterior being the long arm 
~ and the posterior the 

short. It is clear, then, 
that,asthehead descends 
and meets resistance at 
the brim, the force trans-' 
mitted through the spine 
will cause descent of the 
occiput, and eflect flexion 
of the chin on the ster- 
num. The d^jee of flex- 
/ ion will be proportioned 
to the extent of the ac- 
tion, and the force and 
extent of resistance en- 
countered. 

Direct Descent of the- 
Head. — The descent of the 
Fig. 17B.-Fir8t position of the Vertex. ^^^^ ^^^ ^^^^ („ ^j^g 

early part of its course, closely follow the axis of the pelvic 
canal: but the movement is directly downwards and back- 
wards in the axis of the brim, until it touches the floor of 
the pelvis, and meets there with resistance which turns it 
forwards to the pubic arch. 

Passage Through the Pelvic Cavity.— ks the head passes 
through the cervix uteri, flexion usually becomes extensive, ao 
that the chin is pressed well upon the sternum. This movement 
not always being requisite, does not always occi]r,theexception 
being found in a small head, or an exceptionally soft and di- 
latable cervix. The advantage of this condition of flexion is 
plain, since it will be seen that by means of it shorter diameters 
are brought to bear upon the pelvic dimensions. 




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Mechanism op Labor. 405 

A further advantage derived from head flexion has been 
described by Pajot: "The foetus in it« entirety may be 
r^arded as a broken, vacillating rod, which ia movable at the 
articulation of the head and trunk, but a solid thus disposed 
presents conditions unfavorable to the transmission of a force 
acting principally upon one of its extremities ; it follows, there- 
fore, that, previous to flexion, the uterine action, pressing upon 
the pelvic extremity to promote the advance of the foetus, is 
lost in great measure in it« passage from the trunk to the head, 
by reason of the mobility of the latter; but the cephalic 
extremity, once fixed upon the thorax, is most advanta- 
geously disposed to participate in the impulse communicated 
to the general mass of the 
foetus." 

The head, having accom- 
plished the movement of direct 
descent, and having cleared 
itself &om the trammels of the 
cervix uteri, becomes again 
somewhat extended. But, as 
it thus presses on the smooth 
pelvic floor, the occiput very 
naturally glides in thedirectiou 
of least resistance, flexion is 
again firm, and rotation of the 
bead occurs, by means of which 
its loiig diameter moves from " 

the right oblique to the COnju- ^■«- l™— Showing the Uteral 

gate diameterof the pelvis, and obliquity of the Head with refer- 
", ,. , , ence to the horizon, in the pelvic 

the occiput slips under the cavity in the first position, 
pubic arch. 

The spines of the ischia have been said to act an importunt 
part in rotation, but we are inclined to deny them the title of 
" key to the mechanism of labor." Since it is always the most 
dependent part which rotates to the front, a moment's refiec- 
tion will enable us to see that rotation, therefore, takes place 
in such a direction that the sloping surface uf the foetal head 
corresponds with the incline of the perineum. 

The law which controls the movement known as "rotation" 
is based upon the mechanical principle that, when a body is 
subjected to unequal pressure, its movement will always be in 
the direction of least resistance. Rotation is not always com- 



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406 



Labor. 



plete, the loug diameter of the head still preserving some of its 
original obliquity. 

At the outlet there may be a certain amount of bi-parietal 
obliquity to the vulvar plane, and accordingly the right parietal 
eminence is born in advance of the left. The question of 
syuclitism of bi-parietal and pelvic planes merita but little 
study from any other than the specialist. 

Passage of the Head Through the Outlet. — Flexion at this 
part of labor should be firm, so as 
to bring the shorter diameters of 
the head into the strait. At the 
same time the occiput glides under 
the pubic arch, and becomes the 
center of another movement which 
is now b^un, namely, extension. 
The occiput being fixed under the 
arch, is prevented, by the nape of 
the neck, from further advance, and 
the direction of leaat resistance is 
changed, so that now the perineum . 
is distended, and by the movement 
of extension alluded to, the head 
passes the vulva. 

JtestitutioD, or External Rota- 
tion. — After birth of the head, a 
moveipent of accommodation, 
known as restitution, or external 
rotation, takes place, which is 
nothing more than the face turning 
in this case to the mother's right 
thigh. Thechangeiseflected mainly 
in deference to the shoulders, which 
are yet to be delivered, the long, or 
bisacromial, diameter of which now seeks the pelvic conjugate. 
This is an important movement. The long diameter of the 
vertex, and the long diameter of the shoulders, naturally 
assume directions at right angles to each other. In the 
first position, the vertex lies with its long axis in the right 
oblique diameter of the pelvis, and the bisacromial axis 
in a converse direction. During rotation of the head in 
the pelvic cavity, the position of the shoulders does not 
tnaterially change, and after the head escapes, it forsakes 




Fia. 180.— B, short 
head lever. B F, loog 
head lever. 



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Mecuanibm of Labor. 407 

its constrained position, and is restored to its original, or, at 
least, its recent direction,— hence the name of the movement,— 
restitution. But this does not complete the movement, for, no 
sooner has the head fairly escaped than the shoulders begin to 
■adjust themselves to the outlet by turning their long diameter 
into the conjugate, and as this change occurs, the head is still 
further rotated, until the face looks pretty squarely to the 
mother's right thigh. 

While these are the usual phenomena, others are sometimes 



Fia. 181.— External rotatroo ot the Head. 

observed to substitute them. It would occasionally appear 
that rotation of the shonlderB does take place simultaneously 
with that of the head, in which case the bisacromial diameter 
comes to lie at the brim, or in the cavity, in a transverse direc- 
tion, and when the shoulders rotate, preparatory to escape 
from the outlet, it pursues the usual direction, and, as a result, 
the face is observed to turn towards the mother's left thigh. 
The author has seen many marked instances of this anomalous 
movement. 

The term restitution has by some been limited to the first 



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part of the external movement, while the balance is called ex> 
temal rotation. The term external rotation may properly bi> 



Fio. 182.— The Head approaching the outlet in the flrat position. 

sppUed also to the anomalous movement just described, which 
is not strictly restitution. 



Fio. 183.— IlluBtratiDg the varlout fnovetnenta of the Head in the first 
position oi the Vertei. 

Expulsion of the Trunk.— After birth of the head there is 
generally a rest, and upon the renewal of pain, the right 
shoulder is directed forwards by the right anterior ischial plane, 



.CiOOgle 



Mbchanibm of Labor. 



409 



while the left glides backwards over the ]eft posterior plane, 
iQto the eacral hollow. Thie movemeDt is often quite eaddeo, 
and is accomplifihed only as the part actually passee the vulva, 
which it must do with a spiral motion. The body is bent upon 
itself, and the left shoulder is driven downwards until it shows 
at the posterior commissure, when the ri^ht slips under the 
pubic arch, and Anally both emerge almost simultaneously. 

If the arms are flexed, the elbows pass with a jerk, and some- 
times prodnce laceration of the perineum. The trunk easily 
follows the shoulders, and the entire body is speedily born. 

Mechanism of the 
Second, or Right Oc- /"^^'^ ">^\ 

ciPiTO - Anterior, Posi- 
tion. — la the second 
position of the vertex 
the long diameter lies in 
the left oblique diameter 
of the pelvis, and the 
occiput looks forwards 
and to tbe right ilio- 
pectineal eminence, or 
acetabulum, and the 
forehead towards the 
left ilio-sacral eynchon- 
-drosis. The same gen- 
eral movements are 
performed, namely, de- 
scent, flexion, rotation, 
extension, and restitu- 
tion ; but the directions are changed &om right to left, instead 
of left to right, and external rotation takes place by the face 
turning towards the mother's left thigh, instead of her right. 
The left shoulder rotates from the left side to the pubic arch, 
whereas, in the first position, the right shoulder rotates from 
the right side forwards. Further material diSerences than these 
do not exist, and we accordingly omit a detailed description of 
the mechanism of this position. 

Mechanism op the Oocipito-pobterior Positions.— The 
occipito-posterior positions are the third and fourth, in the 
former of which the occiput lies towards the right ilio-sacral 
synchondrosis, and in the latter to the left ilio-sacral synchon- 
drosis. The third position occupies the same oblique diameter 




Fio. 1S4.— Second poBltJon of the Vertex. 



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FiQ. 186.— Third position of the Vertex. Fio. 186.— Fourth poBJtion of the Vertex. 



Fio. 1S7.— Showing proper rotation of the Head in the fourth positioc. 
of the Vertex. 



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MiCCHANISM OF Labob. 411 

as tlie fir»t, and the fourth the same diameter as the second, 
but the poles are reversed. What creates particular interest in 
connection with these positions is the necessarily extensive 
rotation by which the occiput is brought to the pubic arch. In 
occipito-anterior positions, the rotation is short and easily 
accomplishGd, while in occipito-posterior positions it is long 
and diffienlt, the occiput sweeping around two-fifths of the 
circumference of the pelvic circle. Anomalous rotation oc- 
caaionally takes place, in which case the occiput la thrown back- 
wards against the perineum. Such a case as that to which we 
have just adverted, wherein the occiput persists in maintaining . 
a backward direction, is more difficult and dangerous than an 
occipito-anterior termination, because the head has to be sub- 
jected to greater moulding, and, even then, its longer diameters 
are involved at the outlet. The occiput in such a case, after 
much effort, slips through the vulva, and rests upou the 
perineum, upon which, as a pivot, the head rotates in the move- 
ment 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; rotation should take place as 
described; extension is observed at the vulva, and restitution 
occurs after head expulsion. 

When rotation is properly accomplished, the third becomes, 
as stated, the second, and the fourth, the first; from which 
pointonwardatheirmoveinentsareidentical. Whenlabor termi- 
nates in an occipito-posterior position, the face of the child 
turns, in restitution, in the third position towards the mother's 
left thigh, and in the foui-th, towards the right thigh. 

With regard to the causes which determine rotation for- 
ward of the occiput, the following experiments of Dubois will 
be instructive: " In a woman who had died a short time before 
in childbed, the uterus, which had remained fiticcid, and of 
large size, was opened to thecervical orifice, and lield by aids in 
a suitable position above the superior strait ; the fnetus of the 
woman was then placed in the soft and dilated uterine orifice in 
the right occipito-posterior position. Several pupil-mid wives, 
pushinf the foetus from above, readily caused it to enter the 
cavity of the pelvis ; much greater effort was needed to make 
the bead travel over the perineum and clear the vulva ; bat it 
was not without astonishment that we saw, in three successive 
attempta, that when the head had traversed the external geni- 
tal organs, the occiput had turned to the right anterior pnsi- 



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412 ' Labor. 

tion, while the face had turned to the left and to the rear ; in a 
word, rotation had taken plaoe as in natural labor. We re- 
peated the experiment a fourth time, but as the head cleared 
the vulva the occiput remained posterior. Then we took a 
dead-bom ftstua of the previous night, but of much larger size 
than the preceding ; we placed it in the same conditiono as the 
first, and twice in succession witnessed the head clear the vulva 
after having executed the movement of rotation. UpOn the 
third and following essays, delivery was accomplished without 



Fio. 188. — OccI pi to-posterior termination of the third position or the 

the occurrence of rotation ; thus the movement only ceased 
after the perineum and vulva had lost the resistance which had 
made it necessary, or, at least, had been the provoking cause 
of its accomplishment." 

High Rotation. — "Rotation," says Leishmari, very truly, 
" at an early stage of labor, before it is yet practicable to as- 
certain 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 a rotary or rolling movement of the 
head, which he observes either daring a pain or an interval, 



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Mechanism of Labor. 418 

wfaile it is Btill high in the pelvis. This is due partly to uterine 
action, and partly to the movements of the foetus, and we have 
no doubt that, by this means, many unnatural and faulty 
positiona are rectified even after labor has commenced ; and we 
are further entitled to assume that in this way many occipito- 
posterior poaitionH are rectified at such a stage that their de- 
tection is rendered impossible. It should always be remembered 
that the dorso, or occipito-anterior, position of the child ie the 
natural one, and that according to which the irregular oval 
which it forms is most conveniently disposed." 

Conversion of Occipito-posterior into Occipito-anterior 
Positions. — A very important question of treatment may not 
inappropriately be here considered, namely, the possibility, 
practicability, and advisability of converting occipito-posterior 
into occipito-anterior positions. The experience of ourselves, 
as well as others, thoroughly convinces us of the possibility of 
so doing. Whether, in all cases, it is advisable so to do is an- 
other matter. We believe, however, that when the head is still 
iree above the superior strait it may nearly always be accom- 
plished by manipulation of the suitable kind. But sometimes, 
in order to accomplish it, the effort involves a certain amount 
of risk to the woman, which it isnot always advisable to incur. 

Smellie, more than a century a^, 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 number of obstetricians of to-day. It is not an 
operation, however, which can be performed at every stage of 
labor, but the possibility of its successful execution is limited 
to two periods, namely, that of early labor, when the head is 
still free above the pelvic brim, and that part of the second 
stage, when 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 bead to become extended. To allow this con- 
dition to persist, is to preclude the possibility of rotation for- 
ward of the occiput by the natural forces; while to enforce 
flexion is the only thing required 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, will bring about rotation. 



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414 Labor. 

But a^aiD, while the hea4. still lieu above the brim, or bat 
loosely eugaged,it is deemed advisable to effect rotation. That 
being true, the forceps may be uned, or not. Dr. Jno. S. Parry 
is a strong advocate of manual rotation in these positions. 
He recommends the introduction of the well-oiled hand into the- 
vagina, and the tingere through the os uteri. The head is then 
grasped as firmly as possible, and rotation effected, while with 
the opposite hand, by external manipulation, the body is 
turned on its longitudinal axis. The range of applicability of 
such treatment should be left to the good judgment of each 
individual practitioner, as we are not prepared to commend sa 
radical treatment as a routine practice. 

Scaazoni's Method of Changing Cranial Positions.— T>t. Aly, 
in presenting this subject before the Obstetrical Society at 
Hamburg, recently, contended that abuse of the operation- 
brought it into discredit. He was of the opinion that a very 
valuable method waa being neglected, and, that in using it, 
Scanzoni's conditions and indications must be strictly observed. 
These are — 1. The operator must make an exact diagnosis of 
the position of the head. 2. The head must be deep in the 
pelvis and be well grasped by the forceps, with proper respect 
to any anomaly of the pelvis. 3. The mother or child must 
be in danger. This operation of Scanzoni consists in seizing- 
the head with a pair of straight forceps, and effecting forci- 
ble rotation far enough to bring the occiput somewhat 
forward. Among German authors, Winckel does not men- 
tion it in his text-book ; Spiegelbei^ warns against it, and 
Schroeder advised waiting till the head rotated, or extracting^ 
with the occiput posteriorly. In the discussion following. Dr. 
Lomer vehemently opposed the use of the forceps ae an instru- 
ment for rotating the head. He had seen a healthy yonng 
woman lose her life in consequence of it. The very fact that 
all modern obstetrical teaching opposed it, showed that others 
had experienced similar results. When a large head is fixed in 
the pelvis, the amniotic fluid having escaped, the head becomes 
moulded and conforms to the shape of the pelvis ; rotation of 
the head with the forceps, under these conditions, will either 
fail or be attended with severe injury to the mother. If 
extracted without rotation, the most severe maternal injury 
will be a deep perineal laceration. If the head be small or the- 
pelvis large, the head can be brought down to the floor of the 
pelvis in the ordinary maimer with the forceps. It will then 



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Mex^hanism of Labob. 415 

almost always rotate. If it should fail, Rit^n'a method is to- 
be emploj^ed. Prof Olshausen expressed the opinion that only 
those possessing exceptional skill should attempt the method. 
He remarked that introduction of a single blade and using it 
generally as a lever, was often sufficient to rotate the head. 

We give this subject further consideration in the chapter 
treating of the use of the forceps in occipito-posterior positions. 

Caput Succeuanbum. — This is the name of a swelling which 
forms on the foetal head during labor, resulting from effusion of 
serum or blood, or both, into the cranial coverings, or facial 
It does not form on the head of a dead child. 




Fio. 189.— Outlioe of foetal Head Fie. 190.— Outline of Head four 

after an ordinary labor,— Vertex days after birth, 
presentation. 

It develops on that part of the head that is subjected to the 
least pressure, and hence, at first, within the circle of the os 
uteri. As labor advances, the area is extended, and more or 
lees modifled. Development is most marked as the head is 
being driven through the pelvic canal. In the first and 
fourth positions it is found on the right, and in the second and 
third positions, on the left parietal bone. In occipito-anterior 
positions it is located more posteriorly than in occipito-poste- 
rior positions, owing to the ehiftied area of cranial exposure to 
diminished resistance; while in face presentation it distorts and 
deforms the countenance. 

CONPIGDRATIONB OF TBE HeaD TN VeRTEX PuBHBNTATION.— 

Since the cranium of the foetus is constructed of a number of 
bones, so articulated as to be capable of overlapping and 
moving under pressure, it follows that, in a close labor, this 
part undergoes a considerable amount of moulding, by means 



416 Labor. 

of which it8 respective diameters are greatly modified. The 
smaller the parturient canal, the more difficult the labor, — ^the 
more exteneive the change. 

Themoet important modification is diminution of the sub- 
occipito-br^matic, the occipito-frnntal and the bi-temporal 
diameters, with elongation of what is generally regarded ae the 
occipito-mental diameter, but which is, more accurately, the 
diameter represented by a line drawn from the end of the chin 
to a point OD the vertex between the anterior and posterior 
fontanellee, nearer the latter than the former. 

Under pressure the frontal and the 
occipital bones are depressed aod 
slide beneath the parietal bones, while 
at the same time one parietal bone 
overlaps the other. Moreover, the 
parietal bones themselves are some- 
what changed in form, the cranial 
being curved at the point in front of 
the posterior fontanelle, hereinbefore 
alluded to, the sharpness of the curve 
being determined by the closeness of 
the labor, or, in other words, by the 
amountof compressionexerted. When 
Tia. 191.— Form of the the head passes the outlet in an oc- 



Head in Vertex presenta- cipito-posterior position, the changes 
tion. after difficult labor. ^^^^ ^^ g^jji ^^^^ marked. 

The outline of the head is further changed by the formation 
of the caput succedaneum. 

We may here add that the long-drawn-out appearance of the 
head which has been subjected to extreme moulding to make it 
conformable to the calibre of the parturient canal, in general 
soon pa«8eH away without the adoption of any special treat- 
ment to correct it; but the change may be somewhat accele^ 
rated, and, perhaps, rendered more pronounced, by gentle 
pressure upon the poles of the occipito-froDtal diameter with 
the palms of the hands. 

DiACixosiB OF Position, etc. — This subject has been discussed 
in another place, and does not here require mention. 



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Mechanibm of Labob. 



CHAPTER Vn. 
THE MECHANISM OF LABOR.— Continued. 

Face Presentations.— The face constitutes the presenting' 
part, according to Hodge, once in about 250 cases, according 
to Spiegelberg, once in 824 cases ; according to Churchill, once 
in 231 cases ; according to LaChapelle, once in 217 cases ; and 
according to Depaul once in 175 cases. 

Cb&racter of Labor. — Labor in connection with face presen- 
tation, while it may, in quite a proportion of instances, be 
terminated by the natural efforts, is generally far more tedious 
and difficult than in vertex presentations, and often presents 
complications of a most formidable nature. This is particu- 
larly true, as will later be seen, in connection with mento-poste- 
rior positions. For these reasons, and the additional fact that 
it is a presentation in which the dangers to both mother and 
child are considerably increased, we havethought besttoadopt 
the classification which places it among abnormal presentations. 

Qa-uses. — There seems to be but little doubt that face pres- 
entations are most commonly transformed vertex presenta- 
tions. The movement by which the latter are converted into 
the former consists only in extension, and a variety of causes 
may operate to effect the change. Hecker atti'ibutes many 
cases of face presentation to unusual length of the head, and 
the theory appears to be a plausible one. Other causes of ex- 
tension are set down, as enlat^ment of the thyroid ^and, 
increased size of the chest preventing sufficient flexion of the 
head, contraction of the pelvic brim, and unusual mobility of 
the foetus owing to its small dimensions. Winckel says that 
thirty-three different causes have been suggested. 

Lateral obliquity of the fcetus and long uterine axis, is sup- 
posed by many to be an important factor in the etiology of 
these presentations. Uterine action presses the head against 
the lateral boundary of the pelvic brim, and, favored by direc- 
tion of the occiput towards the side of the uterine deviation, 
tilts it backwards. Such a movement would be favored by 
dolichocephalia, as suggested by Hecker. When once extension 
passes the line of equipoise, the presentation becomes pernia- 
oently established. Proper flexion of the head is sometimes 
prevented by the presence of a prolapsed extremity which en- 



41 8 Labor. 

croaches on the pelvic space, and tends at last to displace the 
Tert«z Iroai the pelvic brim. 

Relative Frequency op Positionb. — Statistics are not yet 
sufficiently numerous to settle the question of the relative fre- 
quency of the various positions. There is doubtless bat little 
difference in point of trequency bet<ween left and right dorsal 
positions. Naegele considered the first as the most frequent, in 
the ratio of twenty-two to seventeen. Tyler Smith said that 
the third and fourth facial positions are so extremely rare as 
hardly to be worth ennmerating. There is, however, quite a 
lack of harmony among obstetric writers, for Leishman and 
others proclaim the fourth position as the most frequent, while 
Charpentier unites with Naegele in putting L, M. A, in advance. 
It is by no means rare for the face to enter the pelvis with its 
iong diameter lying transversely. 

Mecoanism of the First Position op the Face, — In the 
firxt position of the face the occipito-mental diameter lies in the 
right oblique of the pehis, and the chin is directed to the right 
aacro-iliac synchondrosis. 

For descriptive purposes we may divide the mechanism of 
face presentations into the movemente which follow: 

First movements.^^escent and extension. 

Second movement, — rotation. 

Third movement, — flexion. 

Fourth movements, — restitution and external rotation. 
These we shall proceed to consider in the order of their 
■occurrence in the first, or right mento-posterior, [losition. 

Descent and Exteusioa. — These two moveraente, because of 
their almost simultaneous occurrence, are here described to- 
gether, as were descent and flexion in vertex presentations. So 
far as the mechanism of labor is concerned, the chin in face 
presentation corresponds to the occiput in vertex presentation, 
and hence, in well marked instances of the former, we find the 
chin sinking lower and lower in the cavity, thereby greatly 
augmenting cephahc extension. The degree of ext'ension is 
nj^certeined by the relative situation of the chin and anterior 
fontanelle, both of which can sometimes be reached. The head 
en-rages the superior strait against mechanical disadvantages, 
and hence slowly. The degree of descent which can be accom- 
plished with some d^jee of facility is determined by the length 
of the child's neck, unless the thorax and shoulders chance to 
be small enough to pass into the pelvic cavity. 



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Mechanism of Labor. 419 

The cbin maintains its advanced position, owing to a 
mecbanism similar to that which causes the occiput totalie the 
most advanced position in vertex presentation. The fronto- 
jnental diameter represents a lever with the short arm on the 
mental side, and the long arm on the frontal side. Propulsive 
force is applied from above, and of course the short arm is 
forced downwards. 

Rotation.— The exact amount of descent which the length of 
the neck will permit in these cases, depends upon circumstances. 

Observation teaches that, in most cases, the shoulders 
do not reach the brim, and engage it, until after the face 



Fio. 192. — Face preflentation at the outlet,— mento- posterior position. 

presses on the perineum. Farther descent is impeded, and ro> 
tation forward of the chin seems to be a necessity. In nearly 
«,I1 cases the movement does 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 rotation, act in obedience to asimilar mechanism. 
The chin, being in advance, first comes in contact with resist* 
«nce at the pelvic floor, and acting under the well-known law 
of mechanics that a body subjected to varied degrees of press-, 
lire moves in the direction of least pressure, turns forwards, 
M'hile the cranial vault seeks the pelvic floor. 

In the course of rotation there is a complete change of posi- 
tion, the flrst becoming the fourth. By means of rotation the 



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420 Labor. 

chin ia brought to the pubic arch, and expulHioD thereby 
facilitated. 

Abnormal Mechanism. — In a small percentage of casee, the 
chiu,iD8tead of pushing forwards to the pubic arch, moves back> 
wards into the sacral hollow, and labor terminates as repre- 
sented in figure 198. The effect of this is excessive stretching 
of the neck of the foetua and vulvar structures of the woman. 
Unless the child prove to be relatively small, tabor can scarcely 
be determined without artificial aid. 



Fia. 193.— Engagement of the Head in face presentation. (Tamier et 
ChantreuilO 

The depth of the x>elvi8 posteriorly, and the added length of 
the perineum, will not admit of descent of the chin over the 
posterior vulvar commiseure without a surprising amount of 
cranial flattening, and entrance of the thorax to a certain 
extent into the pelvic cavity. Cases have occurred in which, from 
unusual smallnees of the head, distension of the sacro-sciatic 
ligaments has permitted flexion to take place, and delivery thus 
spontaneously to be effected. 

Flexion. — In face presentation, with the chin to the pubic 
afct), the nioyeraent by which the head passes the vulva is one 



Mechanism of Labor. 421 

of flexion. The chin engages under the pubic arch and remains 
fixed, while the forehead, vertex and occiput, Buccessivel; sweep 
over the distended perineum. 

Restitution. — Then occurs the final movement, that of resti- 
tution, or external rotation, the face in the first position 
turning towards the mother's right thigh. The shoulders 
follow, and expulsion is speedily accomplished. 

Form of the Chanium in Face Pbesentation. — As a result 
of excessive compression of the head in so unnatural a posi- 
tion, the cranial vault is considerably flattened. The trans- 



verse, the oecipito-frontal, and especially the occipito-mental 
diameters, are consequently increased, while the sub-occipito- 
bregmatic is diminished. Tumefaction of the presenting area 
is liable to be excessive, so that the foetal countenance immedi- 
ately after birth presents an appearance scarcely human. 
Swelling is greatest in the malar region, because the early 
presenting area is usually found within it. 

Prognosis. — We have before alluded to the augmented 
danger to both mother and child in this variety of presenta- 
tion. Winckel gives the mortality of the foetuses in face pre- 
sentation at thirteen percent., and Parvin at fifteen. Mort-ality 



422 Labor. 

of the mothers vt at least twoorthree fold that associated with 
vertex presentation. The average daration of labor exceeds 
that in vertex presentation, while protraction is attended with 
more dangerous consequences, and demands, with greater 
urgency and frequency the aid of obstetric resources. 

The Seco.vd Position. — The merhanism of the second posi- 
tion is quite like that of the first, except that the directions are 
changed. Rotation taken place by the chin swinging around 
from the left ilio-sacral synehondroBis to the pubic arch. In 
making the movement the second rotatwii into the third posi- 
tion, from which point onwards the mechanism is essentially 
that of the third. 

Thikd axd Fourth Posftions. — The first and second are 
recognized as unfavorable positions, because thechin is directed 
backwards, and the necessary rotation is extensive. The third 
and fourth positions are favorable, because they are mento- 
anterior positions, and the necessary rotation is but slight. In 
the latter, the chin, in its descent, strikes against one of the 
anterior inclined planes, and is directed forwards under the 
pubic arch; while in the former, even though the chin does 
usually rotate anteriorly, much delay and difficulty are oft«n 
experienced. A backward rotation of the chin gives a termi- 
nation of the most unfavorable description. 

A special detailed account of the mechanism of labor in the 
third and fourth positions is not required, as it differs not at 
all from that of the second and first positions, respectively, 
after partial rotation has taken place. 

Tkeatmext.— The older obstetricians looked upon presen- 
tations of the face. as not only abnormal, but as always 
demanding artificial assistance; the treatment being version, 
when practicable, and instrumental delivery iu neglected oases. 
Later practice is more discriminative. 

An important concern of treatment is to preserve intact, 
throughout the first stage, the bag of waters. This is hei-e a 
matter of more importance than in vertex presentation, because 
of the irregularity of the presenting part, and the likelihood 
of complete escape of the liquor amnii should rupture take 
place. 

Oonversion of Pace into Vertex Presentations.— This is 
a matter worthy the closest attention. The manipulations 
generally recommended are pushing up the face, or drawing down 
the occiput, by means of the hand passed into the vaginal 



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Mechanise of Labor. 423 

and cervical canal. Still, the su^^tion has not commonly 
been acted upon, owing to the difficultiea and dangers accom- 
panying it. That it may be done without much effort in 
favorable cases, the author has, from experience, become con- 
vinced. 

But it must not be supposed that the demand for interfer- 
ence is laid with equal emphasis on every case. When the face 
presents in the first or second position, we have an unfavorable 
condition. In other words, we have an adverse position of an 
adverse presentation, and by flexing the head we convert the 
-case into a desirable position (occipito-anterior) of a desirable 
presentation, and the measure of advantage to be derived from 
the change more than compensates for considerable effort and 
risk. On the other hand, the third and fourth positions of the 
face are favorable positions of an unfavorable presentation, 
and by flexing the head they are converted into an adverse po- 
sition (occi pi to-posterior) of a friendly presentation, and we 
would not be justified in assuming the risk of a protracted or 
-difficult manipulation. 

No attempt to change the pr^entation should be undertaken 
after the head fairly engages the brim, unless delivery by any 
other method seems impracticable, as the occipito-mental 
diameter of the standard fcetal head exceeds every pelvic diam- 
eter, and incarceration would be likely to result. 

In occasional instances the head can be dislodged by firm 
pressure, even after a certain d^jree of descent has taken pla«e, 
and then it will be managed as in those cases where no descent 
has been made. 

Whenever such manual operations are undertaken, the 
woman should be put under t^ie relaxing' influence of an anes- 
thetic. 

The following method of manipulation, suggested by Schatz, 
is one of the best. Itis based on the assumption that, if the 
body be restored to its normal attitude, by flexing the trunk 
the head will drop into its normal position at the brim of the 
pelvis. To operate thus, we should seize the shoulder and 
breast through the abdominal wall, and lift them upwards, and 
at the same time backwards, while, with the opposite hand, we 
steady the breach so as to make the long foetal axis corresftond 
to the uterine axis, tonally, the breach and thorax are made 
to approach by downward pressure on the former. 

Raising the body, as described, gives the occiput an opportu- 



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424 Labor. 

nity to descend, and flexion of the fretal body, acconapanied by 
backward and upward pressure on the chest, produces flexion 
of the head. Scbatz says that when the head lies high, any 
attempt to enfoi-ce flexion by repression of the thorax, some- 
times causes movement of the whole head, for want of resist- 
ance, and, in such cases, the place of the pelvic wall may be 
supplied by pressure of the hand against the head through the 
abdominal wall. The conditions friendly to the practice of tbi» 
manoeuver are skill in palpation, and the absence of abdominal 
and uterine irritability. We recently succeeded with this oper- 
ation in a case where the liquor amnii had been drawn ofi' six 




FioB. 196, 196 AND 197— Diagrams illustrating Schatz'e method of 
converting Face into Vertex presentations. 

hours, and the face had engaged the brim. The child lived, antf 
the mother made an excellent recovery. 

Management When the Face Does Not Enter the Brim.— 
"When the face refuses to pass the superior strait, operative 
interference is imperatively demanded. It will be understood 
as unwise practice to await such effort without making a 
strenuous attempt to convert the case into a vertex presenta- 
tion ; but such efforts may occasionally fail. 

Inability of the head, thus extended, to pass the brim, puts 
the case in this category. The character of the aid to be 
given will be determined by the circumstances of the case. 
The head may be flexed by Schatz's method. or by introduction 
of the hand into the vagina and cervix, and the face thereby 
converted into avertex presentation; or podalic version maybe 



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Mechanism of Labor. 425 

practiced. In erther cane, internal manipulation should be 
.aided by dexterous external use of the opposite hand. Appli- 
-vation of the forceps to the face at the brim, is, in the main, 
impracticable a.nd hazardous, 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 iietal life, 
■owing to pressure of one blade on the throat, and compression 
■of the large vessels And nerves of the part. 

Persistent Mento-Pobtbrior Positions.— Tardy rotation 
.appears to be characteristic of face presentation, and a fair 
■opportunity to effect the movement should be given the natural 
forces. The mechanical condition most favorable to forward 
rotation of the chin is here firm extension, and by maintaining 
4t we greatly augment the proba- 
■bllity of proper rotation. The 
movement may be aided to a cer- 
tain extent by suitably-directed 
pressure against the forehead. 
If these simple methods prove 
ineffectual, the forceps should be 
applied, and the head carefully 
turned in the direction which it 
should take. If the long curved 
forceps be used, they will require 
removal and reapplication for 
completion of the movement, in 
order to avoid inversion of the 
instrumental curve and possible injury of the soft tissues. 
Every effort to bring forward the chin should be attempted 
'during a pain, but only after the head has evidently cleared the 
pelvic brim. 

Very strong support of the perineum, while favorable to 
preservation of that part, is dangerous to the child, from 
pressure of the neck against the pubic arch. 

Brow Presentation. — When only partial extension takes 
place, the brow becomes the presenting part. Such presenta- 
tions must always be looked upon as of a most unfavorable 
nature, since the 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 the head be small, and the pelvis roomy, labor may be 



426 



Labor. 



flaiehed without unusual difficulty ur injury eitherto mother or 
child. The head emerges from the vulva through firm prettsure 
of the cranial vault on the perineum, while the upper jaw, the 
mouth, and finally the chin, slip under the pubic arch. 

Treatment of Brow Pkesentation.— Treatment consist* 
first in attempte to con- 
vert the presentation in- 
to one either of the face 
or the vertex. Baude- 
locque'e method of doing 
this involves introduc- 
tion of the whole hand, a 
thing to be avoided if pos- 
sible, Schatz's method 
of operating in face pres- 
entation may here serve 
equally well. The con- 
joint manipulation, one 
band externally, and the 




I Head, — brow 
(Budin.) 



Fia. 199— Outline c 
presentatio: 

fingers of the other hand in the vagina, ia sometimes success- 
fully employed. Schatz recommended the introduction of two 
fingers into the child's mouth, and traction on the superior 
maxilla, for the production of a face presentation. It has noc 
been our misfortune to encounter a case of brow presentation 
tvhich coulJl not readily be converted into avertex presentatioa. 



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Mechanism of Labor. 



CHAPTER VIII. 

THE MECHANISM OF LABOR— ConHnved. 

PelTic Presentations. — Under the general designation 
"pelvic presentation" are included all those caaeB where the 
pelvis precedes the trunk and bead of the child in labor. Pelvic 
presentations are divided into those of the breech, knees and 
feet; but the mechanism of labor is in all these substantially 
one. 

Frequency of Occurrence, — Pelvic presentation is met 
once in about 47 mature births, while in premature labor and 
miscarriage it is of common occurrence. Footling presenta- 
tion is met once in about 100 cases. 

Prognosis. — While labor in these presentations is notunusu> 
ally dangerous to the mother, the perils of the child are greatly 
augmented. The foetal mortality in breech presentations is in 
the proportion of about 1 death in 4 cases, and in footling 
preseutations, 1 death Id 3 cases. The following comparative 
statistics of the Baden maternity are instructive : 

In 1883, (oroepB. Mortality : motherg, 1.97?^ ; infanta, 12 76?^ 

" " breech extractions. " " 2.4»% ; " 35.02% 

" 1884, forceps. " " 1.059^ ; " 10^% 

" " breech eztractions, " " 1*7% ; ' " 28.05% 

" 1885, forceps. " " 104% ; " 9.08% 

" " breech extractions. " " 102%; " 25.00% 

Pelvic presentations in primiparce are followed by an ex- 
tremely heavy fcetal mortality. Robertson sayfa of footling cases, 
" I do not remember having saved the life of a child, when the 
feet, in a first labor, formed the presentation." Danger to 
the mother, in pelvic presentation, is but slightly increased. 

Causes op Infantile Mortality.— The chief element of dan- 
ger in these cAses is interruption of foetal circulation by com- 
pression of the cord. The loetus may bedestroyed by asphyxia, 
arising also from another cause, namely, premature separation 
of the placenta, followed by prenatal attemptJ* of the foetus to 
respire. Compression of the funis is rarely strong enough se- 
riously to interfere with foetal circulation, until the pelvis, and 
most of the trunk, have passed the vulva, and the bony 
cranium presses the umbilical vessels against the pelvic walls. 

Separation of the placenta takes place in these cases, ns it 



438 



Labor. 



does in all others, as a result of the decided condensation of the 
uterus, but the action in head-last cases proves premature 
owing to delay in corapleting the delivery. Delayed birth of the 
head is occasioned by insufScient dilatation of the soft parte, 
the trunk not requiring for its passage as great expansion of 
the OS uteri and vulva as does the head. 

Danger to the child is not confined to the moment when the 
head lies at the brim, but compression of the cord may take 
place at a later period, and premature separation of the pla^ 
centa is more likely to be efifected after the head descends into 




Fig. 200.— Movemente of the Breech In flret poaition. 

the pelvic cavity, but refuses to pass the vulva, Fcetal circu- 
lation is interrupted, and respiration is impossible, as a result 
of which death from asphyxia soon ensues. 

Etiology op Pelvic Presbntationb. — It was supposed by 
the older physicians, that the ftBtus sat upright in the womb 
until the sixth or seventh month, at which time there generally 
occurred a sudden evolution, as the result of which the cephalic 
extremity became the presenting part. Failure to effect this 
movement explained the occurrence of pelvic presentation. 

There is no doubt that breech presentation is sometimes the 
result of a jteculiarity in the conformation of the uterus. 
Yclpeau mentions the case of a woman who, probably from 



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Mechanism of Labor. 429 

such cause, biid six consecutive breech deliveries. Pelvic 
■deformity ie also a causative factor. In a case reported by Dr. 
Randolph Winnlow, a colored woman, with a deformity of the 
pelvic brim, had ten children, every one of whom presented by 
the breech. 

Diagnosis.—Hothmg need here be said with reference to 
diagnosis, as the matter has been fully discussed elsewhere. 

The Mechanism of Biieech Presentations in the First 
AND Second Positions.— The first position of the breech is also 
^nown as the left dorao-anterior position, aad is one of the 



Fia. 201. — Expulsion of the Trunk in breech presentation. 

most favorable. The soft and easily moulded breech, preceded 
or not by the bag of waters, driven into the os ateri, as readily 
dilates that part as does the head. 

Descent. — After the or has expanded sufficiently wide to 
permit the breech to pass, it gradually sinks, under forcible pro- 
pulsive action, to the pelvic floor, and approaches the vulva. 
Descent is usually slow, but dilatation of the oh uteri and 
vjiqina is not required to be great in order that the trunk may 
proceed on its way. 

Rotation. — There is no extensive rotation in the pelvic 
<avity associated with breech presentation. In the first posi- 



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430 Labor. 

tion, the left trochatiter liee forwards and to the right, and, in 
rotation, it turns ft-om the right side to the pubic arch. In the 
second position the right trochanter lies forwards and to the 
left, and, in rotation, it merely comes to the pubic arch. These 
are both dorso-anterior positions. lu the third poBition, the 
right trochanter lies forwards and to the right- and in the 
fourth the left trochanter Ilea forwards and to the left. Rota^ 
tion in the former jxisitioD is from right to left, and in the latter 
from left to right ; bat in no case is the traversed distance 
extensive. Then, too, 
rotation, insignificant 
as it is, does not often 
take place until t he- 
nates have pushed 
through the vulva, and 
is completed only when, 
the trunk has nearly 
passed. 

From inattention to 
the proper manage- 
ment of dorso-posteri- 
or positions, the after- 
coming head may b» 
permitted to descend 
and enter the pelvis in 
an occipito-posterior 
position, in which case- 
cei)halic rotation, un- 
der unfavorable condi- 
Fio. 202.— Delivery of PoBterior Arm iq tions, becomes neces- 

Head-laet cases. (Zweifei.) onrv 

Ex pa Ision.— The anterior natis makes its appearance at the 
Tulva.and the posterior pushes over the perineum. Theantcrior 
trochanter finds a point of support under the pubic arch until 
the opposite trochanter pawtes, when both descend, in a for- 
ward direction, necessitating considerable flexion of the body 
in the pelvic canal. As the trunk passes, it is well to have the 
fingers at the vulva to hook down the arms, which are prone to 
be thrown upwards. The anterior shoulder rests under the- 
pubic arch until the posterior passes, after which the head alone 
remains within the vaginal embrace. 

The head engages the brim in an oblique diameter, and. 



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Mecbanibm op Labor. 



usually with the chin upou the sternum. The inclined planes 
turn the occiput forwards as the head descends. The neck rests 
in the pubic arch, and serves aa a center of motion, and as the 
hodjr is raised b.y the accoucheur, the face and sinciput pass 
the distended perineum, thereby completing the second eta^. 

The Mechanism op Bhkwh Presentation in the Third 
AND Fourth Positions.— So far as the trunk and extremities 
are concerned, there is little difference between the mechanism 
of dorso-anterior and that of dorso-posterior positions. The 
chief particular in which they differ has reference to the after- 
cominghead. After expulsion of the trunk of the foetus, weare 
apt to find, in neglected 
cases, that the head en- / 
gages the brim with the ,' 
occiput directed to one ' 
ilio-sacral synchondrosis ' 
or the other, and, in order f 
to secure a desirable ter- 
mination of the labor, 
extensive rotation in the 
pelvic cavity is neces- 
sitated, which, by the 
way, is often attended 
withmuchdifficulty. This 
is a complication which 
can usually be obviated 
by proper attention to 
the body in its descent 
through theoutlet. When F««- 2fl3.-Third podtion of the Brewh. 
the trunk and shoulders are of usual size, there is seldom any 
necessity for close approach of the bisacromial diameter to the 
pelvic conjugate, at the outlet. Bearing in mind this fact, if we 
will rotate the trunk on its longitudinal axis during the mo- 
ment of its expulsion, the head also, which lies perfectly free 
above the brim, will rotate, in compliance with the suggestion 
thus offered, and as a consequence, this part enters the brim in 
an occipito-anterior position. The rotation hereadvised should 
be neither rapid nor forcible; though we are often obliged to 
accelerate the movement to a certain extent, on account of the 
rapid progress of expulsion. 

In those cases wherein, from a combination of circumstances 
beyond the physician's control, the head enters the brim in an 




-433 Labor. 

occipito-posterior poBition, if traction is not applied to the 
trunk, the condition of bead flexion will usually be maintained 
by the contracting uterus, and rotation will take place in re- 
sponse to slight suggestions Irom the lingers of the accoucheur. 
But this movement, and that also of final expulsion, depends 
to a very great extent on thorough flexion of the head on the 
fcreast, and the accoucheur ought to enforce this attitude by 
proper manipulation. 
The trunk of the child, 
wrapped in a towel, 
should rest upon the 
most convenient arm, 
while the flugers of the 
same hand are passed 
into the vagina, as far 
as the child's face. 
Pressure and traction 
should then be made 
with the flngers in the 
canine fossee, while at 
the same time the fln- 
gers of the opposite 
hand exert upward 
and backward pressure 
on the occiput, and the 
body is carried well 
forwards, as iu all 
cases of pelvic presen- 
tation, until the head 
passes. If the fossae 
caninse cannot at first 
be reached, the fingers 
maybe passed into the 
mouth, and moderate 
■flexion force applied to the inferior maxilla until such time as 
a higher poiut can be reached. 

In some cases it will be found impossible to bring forward 
the occiput, and labor must terminate with the occiput to the 
perineum, and the face to the pubes. There is then the same 
neccKsity as at other times for firm flexion of the head, but 
while enforcing it in the manner already described, the body 



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Mechanism of Labor. 433 

Bhould be carried backwards, instead of forwards, until the 
Deck rests on the posterior vulvar i^ommissure, when the face- 
revolves about it as a center, and in so doing glides under the 
pubic arch. 

Footling Presektation. — It is unnecessary to give a de- 
tailed account of footling presentation, since the mechanism 
and mana^inent of it agree8 in all essential particulars with 
those of breech presentation. Rotation is delayed until the 
breech reaches the outlet. The head is delivered with greater 
difficulty than in 
breech presentation, 
since the foetus, when 
extended, resembles 
the form of a wedge, 
which in footling cases 
passes the pelvis with 
its small end in ad- 
vance. 

Treatment of the 
Arms. — Ordinarily, 
the physician experi- 
ences some trouble in 
bringing down the 
arms when they are 
extended upwards by 
the side of the head, 
and occasionally the 
manffiuvre is per- 
formed with the great- 
est difficulty. The 

fingers of the open- ^'''■^""^^i/''S ""'^^e^feV^^ '''*^'' 
atorshould l>e passed 

under the pubic arch, and over the anterior shoulder, when one 
arm at a time can be made to descend along the anterior sur- 
face of the child. 

Breathinn Space forthe Ftptus in Case of Pelvic Presentntion. 
—When the head cannot at once be delivered from the pelvic 
cavity, and the child is endeavoring to inflate its lungs, the 
month should be drawn well down to the perineum, where air 
can be admitted to the fietus by inserting two fingers and 
making forcible retraction of the perineum and recto-vaginal 
septum. This is a lertile expedient for saving fcetal life. 



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Labor. 



iPiffienf' Extraction of the After-com'mur Head.— The obeer. 
vatioDS whi'-h follow ha%-e refereoce to difficnit extraction of 
the h«a<l wbf-n it Iks io tbe pelric cavitv. and mnet not be 
nrKlfmtood an applicable to those cases of difficalt bead-laet 
caoeM wherein tbe obstacle to facial d^verj lies in contraction 
of the pelvi*; brim. 

The ordinary meaAores which snffice for a goodly percentage 
of [lelTic caHeri are Hometimes fonnd insufficient for speedy 
extratrtioD of tbe retained head, and rescue of the f<etns Irotn 
impendinfc danger demands a resort to some more efficient 
expMlient without unnecessary waste of time. Wfaeu theocdput 
is tnmed towards the pubic arch, an expedient of great 
efficiency is found in 
forcible traction at 
ri^t angles to the wo- 
man's body. Properly 
to secure this necessi- 
tates a position high 
above the patient, 
such as can be secured 
by standing upon the 
bed, when, by getting 
a firm hold of the 
child's feet through the 
interrention of a tow> 
el, the necessary trac- 
20ft.— Shape of the Head in Breech tion can be applied. 
pr««entktion. f D, bi-parietal diameter. By drawing on the 
O F. occipito-frontal diameter. ^^^j^y -^ ^^^^ direction 

the occiput in forced firmly against the pubic arch, and the 
resiBtance there encountered produces direct flexion of the 
head, thereby favoring safe exit from the vulva,. 

The amount of traction which may thus be safely applied 
cannot easily be determined. Dr. Goodell believes that he has 
put on one hundred pounds and delivered a living child, aud in 
two inntances we must have exerted nearly as much traction 
without injury. 

If this sort of treatment avails without the loss of valuable 
time, it iH well ; but if it avails not, then resort must be at once 
had to the forcepc. In order properly to apply the instrument, 
the fcetal trunk should be drawn quickly forwards, and there 
held while the blades are introduced. It goes without saying 




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Mechanism of Ladob. 435 

■that in thetse easee the operation should I* done with thw 
ntinoRt dispatch compatible with eafety. 

CONFIOI'RATION OF THK HEAD IN I'ELVIC DelIVKBY.— The 

absence of long-continued compression of the head in pelvi<: 
presentation, leaves the part in a shape which differs gi-eatly 
from that observed in vertex and face cases. IiiKt#ad of tht 
longr-drawn-oiit appearance given it when the vertex is in ad- 
vance, we have a characteristic roundness, due in part, as is be- 
lieved, to its cii-cumferential compression by the pelvic canal, 
while absence of decided resistance above increases the convex- 
ity of the cranial vault. Still, the shape of the head usually 
observed after deliveries in which the breech or feet constituted 
the presentation, probably approximates the original form of 
the part. 

Mas.vgf:.mext of Pelvic Pbebe.vtatiosb. — The practice of 
Hippocrates and his followers, of coiivertinjr breech into 
cephalic presentations, was succeeded by that of bringing down 
the feet. The latter mode of treatment is now regarded as not 
only undesirable, but, under ordinary circumstances, unwar< 
rantable. We should not make a breech case still less auspi- 
ciouB by converting it into a footling presentation. If the 
1aI>or is proceeding but slowly, the temptation may be strong 
to provide ourselves with a part upon which to make traction, 
and hasten delivery. But the wise man withholds his band. 
After expulsion has gone so far that the trunk of the fietus is 
partly born, we may feel a strong impulse to seize upon it and 
hasten the labor. But such interference with the natural 
phenomena and mechanism of pelvic presentations is liable to 
involve us in a labyrinth of troubles, not the least vexing of 
which an- extension of the arms above the head, and a separa- 
tion of the chin from the breast with its lodgment above the 
pelvic brim. When aii^' traction effort whatever is made, it 
iOiould be carefully done, and must be supplemented by abdom- 
inal pressure. 

Omphalic Version Before Labor. — There is a growing convic- 
tion among obstetricians, which has been strengthened in our 
school of practice by late contributions to the literature of the 
subject from the pens of Drs. R. N. Foster and G. E- Southwick, 
that the proper management of breech presentation consists, 
ill suitable eases, in conversion of the presentation into one ot 
the vertex before the advent of labor. After relating a typical 
case, Dr. Foster makes the following points ; 



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486 Labor. 

"First, that a breech presentation can b© converted, eome- 
times certainly, into one immensely preferable, at least two 
monthB before full term. The danger of delay is thus avoided, 
such danger being first that the waters may be discharged be- 
fore labor has commenced, and then change of position may bC' 
impossible ; and secondly, that the increased size of the fietus 
and the sinking down of the uterus, bo that the breech is deeply 
engaffed, may render version impossible even if the waters are 
retained. In such cases as the one here related, version secures 
a living child instead of a dead one. This is afBrmed on the 
ground of the second instructive point in the case, which is 
this: So far as can be dis- 
cerned, there is but one rea- 
son for the very bad results- 
of a breech presentation in 
the case of this mother; 
that reason is the peculiar 
shape of head which pre- 
vails in this family, alike- 
in the father and in the 
mother. 

"Obstetricians havelong- 
recognized the two varieties 
of head known as the 'do- 
iicho-kephalic' and 'brachy- 
kephalic,' or in plain Eng- 
hsh the 'long-heads' and 
Fia. 207.— Second position of the the 'short-heads.' Hut this 
Breech, which is a little below the division is incomplete. The 
brim of the pelvis. family head in this house- 

hold is neither long nor short, but it is exceedingly broad ; and 
it is this diameter, the bi-parietal, which presenting as it does 
to the shortest diameters of the pelvis &o(/i at the brim and at 
the outlet, constitutes in just such cases the most formidable 
obstacle to a rapid delivery of the after-coming head. It also 
endangers most effectively the circulation of the funis, from the 
moment the head reaches the brim until complete delivery. 
This style of head ought by analogy to be called the'platy- 
kephalic,' or 'broad-head.' 

" Now, given a well ossified skull, a male child, and a platy- 
kephalic cranium, together with a woman who will aJways 
present her children by the breech, and we havethe precise com- 



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Mechanism of Labor. 



43T 



bination necessary to explain the foetal mortality in this 
family. 

"And finally, so far as one case can be said to illustrate a 
principle in such matters, the experience here recorded shows 
the possible value of attempting version at a much earlier 
period than that usually advised." 

Dr. Southwick presents the subject in a comprehensive ^d 
convincing manner, furniehes some good cuts which are herein 
i-eproduced, and enters into a detailed descriptiou of the 
operation. 

It gives usgreat pleasure 
to quote at length from his 
article. " On account of my 
own experience," he says, 
"and from careful observa^ 
tion of the experience of 
others, I have sought for a 
remedy for cases likely to be 
difficult, and believe I have 
found it in version by ab- 
dominal and vaginal ma- 
nipulation about two weeks 
previous to labor, though 
I have performed it success- 
folly Ave weeks before labor, 
I have found the operation, 
as I perform it, to be very 
easy, requiring from five to 
ten minutes. It is painless, 
And I manage to talk with 
the patient, so that she is 
scarcely aware of what i 
being done. Indeed, she would not observe more than that she 
was being examined with some manipulation. 

" The preparations are identical with those for external ver- 
sion, a methftd which I have used with some success if the 
patient was not corpulent. I have found that the presenting 
part is apt to catch on the side of the pel™ (Fig. 207). requir- 
ing considerable effort to dislodge it, which was not always 
successful. 

" In order to meet this difficulty the writer now operates in 
the following manner, and will say here that while he is not 



Fio. 208.— Breech nlsed above the 
brim of the pelvis. Position of the 
External and Internal Hands in priMs- 
ing the breech to one side oC the pelvis. 



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LA.BOK. 



aware that any other physician operatfis in this way, or that 
there is a published account of it, no doubt there are mauy 
obstetriciaDH perfectly faniihar with the details. 

"I first direct the patient to He on her ba^k iu bed, un- 
dressed, in order to relax the abdominal niuBclee, with the 
kn<>?s drawn close up to the body and the shoulders and head 
well raised on pillows. I then thoroughly disinfect my hands 
and introduce the first and second fingers into the vagina, 
taking care not to enter the cervical canal. My first step is to 
gently press up the breech through the walls of the cervix, so as 
to raise the breech up just 
above the pelvic brim, and, 
if practicable, towards one 
aideof the brim, correspond- 
ing to the back of the child 
(Pig. 208). Holding the 
breech iu this position with 
the internal band, I apply 
the fingers externally to one 
side of the breech and easily 
coax, it to one side of the 
abdomen, corresponding 
with the back of the child, 
so that it will be in the posi- 
I tion in Kig. 210, hands ex- 
cepted. The head will move 
down correspondingly on 
the other side, and the ex- 
ternal hand can now coax 
it with a little sliding pres- 
sure into the brim of the 
pelvis and by occasionally 
pushing up the breech {Fig. 209). Should the head stick a 
little after the breech is pressed well to one side of the pelvis, 
the left hand must keep its position and hold the breech to one 
side, fu* it always tends to slip back, and the right hand is 
taken from the vagina and applied to the head of the child, as 
in Fig. 210. By pressing gently up on the breech aud down 
on the head, verHion is easily and painlessly accomplished. 
All manipulation is to be avoided during uterine contractions, 
whi(rh Hi-e recognized by feeling the \iterine muscle harden at 
intervals. The patient must relax her muscles as much as 



Fto. 209.— PoBitlon of the hands in 
performing Vagi no-abdominal Version 
after tite breech has been raised and 
pressed to one side of the pelvis. 



Mechanism of Labor. 439 

possible, and nothing is better to do this than to make her 
talk. It is easier to manipulate through thin abdominal walls 
than if they are very fat. 

" There is another way of performing this simple operation, 
which appears better theoretically ; but I have not employed it 
for this particular form of version, as it is more trying to the 
patient than the former method, which is bo simple.' 

"The principle is the same, only the patient is placed on that 
side corresponding to the child's feet. The operator stands 
behind her, introduces the hand nearest the genitals, presses 
up the breech through the cervix as before, and the head by 
force of gravity drops down 
as the breech goes up, till 
thechild is nearly in a trans- 
Terse position, when the 
head is pressed down as be- 
fore. 

"The question naturally 
arises, will the infant remain 
in its new position, and, in 
view of the child moving 
■about and naturally chang- 
ing its positionin the uterus, 
when would be the beet time 
to perform version ? 

"In regard to the first 
•question, I have kept the 
■child in position bv a couple 
of small folded towels on „ ^'"- 210- Method of perfominff 

, . , - ^ ■ 1 . External Vereion after diBplacement 

each side of the lower part „f ^^e breech, if that shown in Fig. 
of the uterus, which are se- 209 proveH inaufficient. 
cured by a moderately firm 

binder. In from twenty-four to fortj'-eight hours the uterus 
and child accommodate themselves to each other and the 
binder is unnecessary. 

"Thechild often changes its positionin pregnancy ; but in the 
lost month it is rare for any pronounced change to take place, 
BUcU B8 the substitution of a vertex for a breech presentation, 
or vice versa. I am of the opinion that about two weeks 
before the probable date of delivery is the best time to perform 
version. With the careful manipulation as described above it 
is difficult to ima^ne how any harm could follow. It would 



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440 Laboe. 

be possible for a careless operator to allow his flnger to slip 
into the cervical caoal and rupture the membraDes. This- 
would cause labor, which ought to be perfectly natural, 
though possibly more prolonged than if a fortnight later at- 
fuH terra. 

"The head brought down to the brim simply substitutes a. 
much more favorable presentation than that of the breech, and 
as such is subject to the same principles as if it were the primary 
position. After the first day the patient is up and around just 
the same as before, and will be confined at the usual term of 
pregnancy." 

These considerations 
serve to impress upon ub- 
the advisability of a careful 
external and internal exam- 
ination of every pregnant 
woman aweek or two before 
the advent of labor. 

Cephalic Version Daring^ 
Labor. — When once partu- 
rient efforts have set in, 
cephalic version cannot so 
easily be performed, and, 
save under extremeiy favor- 
able conditions, ought not 
to h« attempted. 
, Other Opera ti ve Meas- 

FiQ. 211.— PoBition ofFcetuBwhen ares. — Operative measures, 
version is complete. apart from those already 

mentioned, will be considered under the head of "Operative 
Midwifery," and nothing need here be said concerning them. 

Elzpulaion of the Trunk. — As expulsion of the trunk tak(» 
place it may be received into a dry towel, 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. 

Elxtraction of the Head.— The manner of effecting this has 
been before suggested. The child, wrapped In a towel, should 
rest on the most convenient arm, and the fingers on the canino 



Mechanism op Labor. 441 

fos8ee, enforcing flexion. Unless delivery ia easily efTected, an 
aHBistant may make firm compression on the fundus uteri, while 
the woman ia urg«d to make her best endeavor. The body must 
be carried well forward, if the case is occipito-anterior, and 
■well backward if occipito-posterior, with gentle traction. 
Flexion of the head at the outlet, in occipito-anterior positions, 
is sometimes better effected through the rectum. Expalsion of 
the head may also be facilitated by the fingers in the rectum. 



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CHAPTER IX. 

THE MECHAXISII OF LABOR— Continued. 

Transverse Presentation.— When the foetal ovoid presents 
by iieither extremity, but lies across the pelvis, we have what is 
known as "'transverse presentation." 

A number of varieties may be mentioned, such as ventral 
and dorsal, an well as shoulder and arm presentations. The 
fact is, that in the early stage of labor, almost any part of the 
trunk may constitute the presenting part; but clinical obser- 
vation has taught, that, no matt<>r what portion of the trunk 
may lie over the os uteri at the beginning of labor, as the case 
advances the shoulder or arm is quite sare to descend and 
constitute the presenting part. Hence in our succeeding re- 
marks on the mechanism of labor in these trying cases, the 
term " transverse presentation " will be understood as generic, 
and the principles of management suggested as applicable to 
every variety of it. 

Frequency. — According to Dr. Geo. B. Peck's statistics, 
transverse presentation occurs once in 115 cases, which agrees 
with Depaul's observations. According to Dr. Churchill, the 
arm or shoulder pi-esents once in 231!^ cases, but according to 
Dr. Peck, once in 180. It is much more frequently observed in 
multipara than in primiparte. 

The Variom Positions. — The positions of the foetus in 
shoulder presentation have been described in another place,and 
they do not need to be reviewed here. For the purpose of 
treatment, it is highly important that we distinguish them, as 
otherwise we cannot apply our treatment with intelligence and 
precision . 

Causes. — The causes of transverse presentation are not alto- 
gether clear. Any circumstance which may occur at the brim 
to divert the head from its usual place, and turn it into one of 
the iliac fossa;, constitutes an efficient cause; and this may con- 
sist of a pelvic deformity; an unusual quantity of liquoramnii, 
giving to the uterus a form more nearly spherical; obliquity 
of the long uterine axis; or premature expulsive efforts. The 
great preponderance of transverse presentations among pluri- 
parie, would certainly give color to the theory of Wigand, 
that the phenomenon is dependent on the form of the uterine 



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Mechanism of Labor. 443 

cavity, which is probably wideLed in its transverse diameter 
and diminished in its longitudinal measuremeiit. 

With regard to the time when the presentation becomes es- 
tablished, there is no uniformity. The change is sometimes 
wrought by a sudden movement, during, or at the banning of 
expulsive efforts ; while in other instances its existence is known 
to precede labor by days or weeks. 

DiApsoHis. — The diagnosis of transveree presentation hag 
been considered, in a general way, in another place ; but a few 
observations may here be added. Abdominal palpation can 
scarcely fail to reveal the transverse direction of the long axis 
of the foetal ovoid. The enlargement is relatively broad, while 
the fundus uteri is really below the height at which it is usually 
found in cephalic and pelvic presentations. Deep palpation also 
reveals the head in one of the iliac fossie. On vaginal examine^ 
tion the presenting part is found to lie so high that it cannot 
well be felt through the lower uterine segment ; and at the be- 
ginning of labor can scarcely be reached through the os uteri. 

The stethoscope affords some aid. " If the vaginal examina- 
tion has resulted in the recognition of a portion of the fiietus 
which is of small bulk," says Cazeaux, "and if we perceive the 
pulsation of the heart inthe hypogastric region, we may almost 
certainly conclude that it is the superior extremity. If we 
heard the heart at the level of the umbilicus, it would in all 
probability be a leg." If the position is a dorso-posterior one, 
we will probably be unable to hear these sounds. 

Churpentier's remarks under this head are so excellent thab 
we here quote them. 

"The finger comes upon a rounded part with a prominent 
osseous point, the acromion ; on following this part we recog- 
nize successively the scapula, its spine, and the clavicle. But to 
recognize these different osseous prominences requires great 
experience in the touch, and for our part there is a landmark 
which outweighs all the others, the axillary cavity formed by 
the arm on one side and the thoracic wall on the other. More^ 
over, this thoracic wall pr^tents a series of eminences and 
depressions arranged parallel to each other like the bars of a 
gate, which Pajot terms the intercostal gridiron. The ribs 
being thus recognized, we are sure of having the lateral plane 
of the foetus before us. Again, the axillary cavity bounded by 
the arm and the thoracic wall represents an angle, the point of 
which is necessarily directed towards the head. It is, therefore, 



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444 Labor. 

a certain means of indicatinf; the side occupied by the head in 
cases where it has not been discovered by palpation. The 
axilla is sometimes difficult to reach in dorBo-aiiterior cases, 
when the finger must be carried far back, and we can thus 
always recognize the ribs. In such a case we sometimes 
encounter the vertebral column of the foetus, which is marked 
by the row of projections formed by the spinous processes ; on 
following them, we reach the scapula. 

"The head being recognized, and the anterior or posterior 
location of the back determined by the facility with which the 
ribs may be reached, the diagnosis is complete ; that is to say, 
we know both the presentation and the position. 

" If we find — 

The head to the left, back anterior : ft is the right shoulder. 
" " " " " posterior: " " left " ^ 

" " " right " anterior: " " " " " 

" " " " " posterior: " " right " 

" If we know the presenting shoulder and the position of the 
head, the diagnosis is likewise complete. 

"If we find — 

Right shoulder, back anterior, the head must be od tbe left. 

■' " " posterior, " " " " " right. 

Left " " anterior, " " " " « « 

" " " posterior, " " " " " left. 

" If, on the other hand, we know the shoulder and the situa- 
tion of the head, the dia^osis is likewise complete. 
"If we find- 
Right shoulder, head to the left, the back must be anterior. 
■' " " " right, " " " posterior. 

Left " « « igft^ " " " posterior. 

" " " right, " " " anterior. 

"Hence, it is sufficient for us to know two terms of the 
problem to enable us to find the third. If instead of the 
acromial variety we have to deal with the cubital variety — iu 
other words, if the elbow is the most accessible part — ^its recog- 
nition is sufficient to establish the diagnosis. The elbow is 
characterized by the projecting olecranon, limited on its right 
and left sides by two other prominences, the epi-condyle and 
the epi-trochlea. The bend of the elbow is formed by the fore- 
arm and the arm', and it is only necessary to follow either one 
of these parts to convince us that it is the elbow we are touch- 
ing. The forearm will lead to the hand, recognizable by bdng 



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Mechan'ism of Labor. 445 

in the uxis of the arm, by the length of the fingers, the apposi- 
tion of the thumb, and the inequality of the fingers. In order 
to distinguish which hand we are touching, it is best to deter- 
mine the characteristics and the situation, and to substitute 
mentally our own for it. The one we can. as it were, superimpose 
upon the one felt will indicate whether it is the right or the left 
hand. This gives us the shoulder, or the elbow indicates the 
situation of the axilla; in either case the diagnosis is complete. 
Pajot advises, in doubtful cases, to make traction on the hand 
felt externally and compare it with one's own ; this will show 
whether it is right or left. 

"If the hand is outside the vulva, it is sufficient to compare 
it with either one of ours to show whether it is the right or the 



Fio. 212.— Dorao-anterior posi- Fig. 213.— Dorso- posterior posi- 

lion of the FcEtuB in Transverse tlon of the Fcetns fn Transverse 
presentation. presentation. 

left; but thereisamore scientific and equally reliable procedure. 
Take the protruding hand and turn it palm .upwards, the 
border inferior to the symphysis pubis ; the thumb will always 
be tamed to the thigh homonymous to the hand, to the right 
thigh in the case of the right hand, and vice versa. When the 
ahoulder is known, we need but follow the arm to reach the 
axilla, and thus the situation of the head and the diagnosis is 
complete. 

"When the hand depends ft-eely from the vulva, the arm in 
its natural attitude, simple inspection of the hand will complete 
the diagnosis. 

•'The hand gives us the shoulder; besides, the back of the 
hand always turns away from the side where the head is. This 



446 Labor. 

gives na two ternia of the problem, and we can find the third 
without difficulty and complete the diagnoBis. But examina- 
tion of the hand sufficee. 

"The hand gives us the shoulder; the dorsum of the hand, 
the situation of the head ; the direction of the thumb indicate 
the direction of the back ; for when the ba>ck is posterior, the- 
thumb points upwards from the symphysis. When the back 
is anterior, the thumb is directed downwards towards the- 
anus." 

Prognosis. — In any case, the danger to both mother and 
child is considerably augmented, yet the prognosis will be- 
greatly modified by the stage of labor at whicli tiie case comes 
under observation. From carefully collected statistics, tabu- 
lated by Churchill, it appears that "out of 314 cases of presen- 
tation of the superior extremities, 175 children were lost, or 
rather more than one-half. Out of 282 cases, 30 mothers were 
lost, or nearly 1 in 9." Statistics of more recent practice 
would show a great reduction in the rate of mortality. 

Unaided Termination. — Dr. Rigby gave a graphic picture of 
a case of transverse presentation when left to its natural ter- 
mination. "After the membranes have burst," says he, "and 
discharged more liquor amnii than in general when the head or 
nates present, the uterus contracts tighter around the child, 
and the shoulder is gradually pressed deeper into the pelvis, 
while the pains increase considerably in violence from the child 
being unable, from its faulty position, to yield to the expulsive 
efforts of nature. Drained of its liquor amnii. the uterus re- 
mains in its state of contraction even during the intervals of 
the pains; the consequence of this general and continued pres- 
sure is, that the child is destroyed from the circulation in the 
placenta being interrupted, the mother becomes exhausted, and 
inflammation and rupture of the uterus and vagina are the 
almost unavoidable results." 

In these days of enlightened midwifery practice such cases 
are rarely committed to the natural efforts, thus hopelessly 
handicapped; hence, what we know of them is learned chiefly 
from old reports. 

SpontnneooH Evolution and Spontaneous Expulsion. — Trans- 
verse presentations differ from the other presentations in 
having no r^rular and uniform mechanism of labor; but there 
are two mo\'ements occasionally observed, by the adoption of 
which nature ha«eucceeded in concluding the process of parturi* 



Mechanism of Labor. 



44T 



tion ; thtme are spontaaeoun version or evolution, and what wa* 
deHif^nated by Douf^las as spontaneous expulsion. 

Both have always been extremely rare. 

Spontaneous evolution or version couBists in a complete' 
version of the foetus begun by the escape of the shoulders from 
the grasp of the pelvic brim, followed bv descent of the trunk 
and pelvis of the child. This process is not nearly so frequently 
observed ae that of spontaneous expulsion, first descri^>ed by 
Dr. Douglas, of Dublin. In this the shoulder does not recede 
from the brim and give place to the other .parts, but it descends 
until it lodges under 
the pubic arch, where 
itconstitut'iB a pivotal 
point about which the 
body of the child ro- 
tates. This constitutes ' 
version within the pel- 
vic cavity, " It will be 
obvious," says Leish- 
man, "that such a 
mechanism aa thin can 
only be possible under 
the same exceptional 
conditions %vhich per- 
mit of spontaneous 
evolution. For in this 
case the breech must 
pass the pelvic brim, 
which is already partly 

occupied with the baae F'" ■ 214.— Showing a case of Transverw 
of the skull, an occur- P'-esentation wherein the liquor amnii has 
, . , . . eacaped, the arm has descended, and the 

pence which TS mam- shoulder i« wedged into the brim. 
festly impossible, if the 

relative proportion of the parts, maternal and fcetal, are in 
■occordance with the normal standard." 

The various stages of this important movement are made' 
more lucid and impressive by the accompanjing cute than 
■could be done by any number of words. 

Treatment.— No one point is of such importance as a 
recognition of the character of the case at the earliest possible 
■Boonrent. This involves, too, not a mere diagnosis of trans- 
"verse presentation, bat a recognition as well, of the position 



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448 Labor. 

occupied by the foetus, for upon this the succese of treatment 
will largely depend. When such knowledge is obtained at the 
beginning of labor, or soon thereafter, we may look upon the 
case with composure, knowing that the issue lies in great 
meaeure under our control. Both mother and child are still 
possessed of unimpaired vitality, and the aim of our treatment 
will be to interfere before vitality has been seriously reduced. 
In fact we ought to have such close supei-vision of pregnant 
women who propose to give us the managementof their labors, 
that the nature of the presentation shall in every instance be 
recognized before the day of delivery. 



Fio. 216.— SpontaneouB Expulsion. (First BtftgaJ 

The Favorable Moment for Operating. — Themostopportune 
time is before the advent of labor, when, by external manipu- 
lation, cephalic version can usually be performed after labor 
begins ; there likewise comes to all these cases a favorable mo- 
ment, and happy the accoucheur who discerns it with precision 
and is prepared to apply the suitable treatment with a vigor- 
ous hand, a wise judgment, and a courageous heart. 

Preservation of the Membranes. — It is of the utmost im- 
portance that the membranes be preserved intAct up to the 
momentofinterference. This consideration will lead to delicate, 
but nonetheless painstaking, digital exploration, which should 
be pressed only in the intervals between uterine oontractions. 



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-Mechamsm of Labor. 44& 

Version. — Some form of version ib required in such presenta- 
tions, save in rare and neglected cases, wherein the expulsive 
process has gone so far aa to destroy all reasonable prospect of 
success. 

The various methods of practicing version will be discussed 
in another chapter, and we are called upon in this place only to 
indicate the relative value of the different modes of performing 
it. Cephalic version, or a bringing down of the head, is siiita- 
ble to most of those cases in which there is eai'ly recognition of 
the unfavorable nature of the presentation, and, under favora- 



Pio. 216. — Spontaneous Espulaion. (Second stage.) 

ble conditions, will scarcely fail of snccess. This is best prac- 
ticed by Dr. Braxton Hicks' method of conjoint manipulation. 
A mode of delivery in transverse presentation has beeo 
practiced with success by some, which is merely a modifica- 
tion of the Hicks method, consisting of the knee-elbow position, 
cephalic version by conjoint manipulation, and application of 
the forceps. Cephalic version is greatly facilitated, in some 
respects, by the knee-elbow position, since the force of gravity 
diminishes the pressure at the brim and places the child in a. 
more mobile situation. When once cephalic version has l>een 
effected, the forceps are applied with the woman Btill on her 
knees and elbows, though the awkward posture does not permit 
it to be done with the usual facility. She is then permitted to 



450 Labor. 

turn upon the back, and delivery is wholly or partially effected. 
What was a formidable case is, fi-om the time of forceps appli- 
■cation forwards, an ordinary instrumental delivery fromabove 
the pelvic brim, through a partly dilated os uteri. 

The form of version most commonly practiced is the internal 
podalic, which consists in introducing the hand within the 
uterus and bringing down the feet, the conditiona favorable 
to which are an intact state of the membranes, and dilata- 
bility, or dilatation of the os uteri. ^ 

When either of the first two modes of version is to be 
employed, only moderate dilatation of the os is requisite ; but, 
when the lost mode is to be adopted, labor should be atten- 
"tively watched during the first stage, and if the merabrancB are 
preserved, and no serious symptoms are developed, we may 
safely await with patience the moment when dilatation will be 
nearly complete. Should thewaters soonereBcape,or should the 
pi'esentation be descending too rapidly into the embrace of the 
pelvis, then, provided the os uteri is bb large as a half-dollar, 
and in a dilatable state, the operation should be undertaken 
without unnecessary delay. 

The feet can sometimes be brought to the os uteri by the 
method of conjoint manipulation mentioned in connection with 
cephalic version. It is clearly the preferable mode if the case 
be a suitable one for its practice, inasmuch as an operation, 
in the performance of which only one or more fingers, instead 
of the whole hand, are introduced within the uterus, must 
involve less risk than that attending the older method of 
drawing down the feet. Hence, unless the conditions surrounding 
the ease offer positive discouragement to the conjoint method, 
it is advisable at first to make an attempt at version in that 
manner, and if it fail, then to have recourse to the more 
■common method of internal version. 

In any case wherein we have decided upon use of conjoint 
manipulation for the purpose of rectifying a transverse presen- 
tation, it ought to be undertaken as soon as the os uteri will 
Nilmit two fingers, as delay beyond that time progressively 
diminishes the probability of success. 

But there is a class of cases quije difierent from these with 
regard 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 



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Mechanism of La^bor. 451 

«a*"il J eDOugh, provided it be performed early enough, and circum- 
■Btimces conduce. Hence you will Hometimes hear your obstetrio 
aoquaintances triumphantly exclaiming — 'For my part, I 
always turn without any difficulty ;' a declaration, by the way, 
which evinces not their superior skill, but their amall experience 
in the nicer aud more dangerous parts of practice. In consul- 
tation, especially, we BometimeB meet with cases of turnings — 
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, iuflamed, and dreadfully irritable; the 
patient, wearied with exertion, and desperate through suffering, 
cannot be persuaded to lie at rest upon the bed; and thus, 
sometimes, though rarely, a case is treated which might try the 
nerves and the muscles of even those minions of obstetric 
fortune, to whose superlative skill all difficulties give way." 

If the arm and hand have prolapsed, no attempt should be 
made to replacethem before proceeding to operate, Thewoman 
should be carefully brought under theinfluenceof an anesthetic, 
not only to prevent suffering, but to allay uterine irritability, 
which would interfere with a speedy and relatively eaay accom- 
plishment of our purposes. The details of the operation will 
be given in another place. The necessity for the utmost gen- 
tleness and caution should be kept constantly in mind, for 
" wombs and women are not to be taken by assault." 

A thrust of the hand here is as fatal els a thrust of the 
bayonet. 

When the Foetus is Dead. — If the physician, on being called 
to a case of shoulder presentation, find clear evidence of foetal 
death, he will be led to adopt a difierent method of treatment, 
and one less hazardous to the woman. The signs in question 
are a flaccid, pulseless cord, if it can be felt, and exfoliation of 
the skin as the result of incipient maceration. For such cases 
evisceration is the treatment. 

Unaided Termination — In rare cases it may be obvious that 
labor is about to terminate without manual aid, by means of 
one of the movements previously described. During a pain, 
the child is observed to move in such a way as clearly to reveal 
itH design to effect either spontaneous evolution or expulsion. 
Under such circumstances, the expectant plan of treatment is 
the proper one. "If the arm of the ffetus," says Douglas, 
"*' should 1)6 almost entirely protruded, with the shoulder press- 



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452 Labor. 

ing on the periDeum ; if a coDsiderable portion of itfi thorax be- 
in theholloy of the sacrum, with the axilla low in the pelvis; if, 
with thia disposition, the uterine efforts be still powerful, and if 
the thorax be forced sensibly lower during the pressure of each 
Bucceesive pain, the evolution may, with great confidence, be- 
expected." 

Other Operative Procedures. — When all other means have 
failed to effect delivery, and, again, when the foetus is certainly 
dead, it may be decapitated, it may be eviscerated, or it may 
be delivered through abdominal incision. 

Oomplez I*re8entatioii8.— The most common forms of 
presentation, and even some of the uncommon varieties, have 
been mentioned ; but there are others of rare, though possible- 
occurrence, wherein the presentation is compound in character, 
as, for example, when the hands and feet descend together. 
Most complex presentations are modifications of transverse- 
positions, while in 
some, the long foetal 
. and Ibng uterine 
axes maintain their 
parallelism. A de- 
scription of one or 
r,o. 2X7.-The „.e ol th. Fillet with . ^^^ ^j j|_^^ „..„ ^ 
Running Noose. , . „ 

bnefly given. 

Hand with the Head. — This is not an uncommon occur- 
rence, especially when the foetus is small in comparison with the- 
pelvic canal. I-abor does not become seriously impeded pro- 
Tided extensive descent of the hand be prevented. But even- 
when the arm becomes thrown down beside the bead, the situ- 
ation does not constitute an effectual bar to labor, which, 
indeed, may still be terminated in a satisfactory manner. 
When from lack of room the complication becomes serious, 
suitable treatment consists in pushing up the arm by means of 
the half-hand in theva^ua. In affording such relief it behooves 
us to be careful to avoid displacing the arm backwards, and 
thereby producing a still more awkward condition of things. 

The Feet and Hands.— Both feet and both hands may pre- 
sent, t)r but one of each, and thereby form a variety of trans- 
verse presentation. Such a complication is sometimes etiil 
further increased by prolapse of the umbilical coi-d. Left to the 
natural efforts, the foot, or feet, after a time, are likely to re- 
cede, and a shoulder may descend ; or the presentation may not 




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Mechanism of Labor. 453 

cbaaf^, bat be driven downwards, and finaUy become wedged 
into the brim. To prevent such an occurrence, the/oot, or feet, 
should be seized, and drawn down, while the band is pushed 
upwards, thereby completing the operation of version at the 
expense of but slight effort. If this is undertaken early in labor, 
no great difficulty will be experienced; but when attempted at 
a late period it may utterly fail, or at best be accompliBhed as 
the reward of strenuoas and dangerous effort. In difficult 
cases a fillet ought to be attached above the ankle bya running 
noose, and steady traction made upon it, while at the same 
time the hand is pushed upwards, and the version further aided 
by abdominal manipulation. When such a presentation is 
rendered still more complicated by descent of the funis, an 
attempt should be made to send the cord back into the uterine 
cavity with the presenting, but now receding, hand and arm, 
failing in which, the case shonld be treated as one of prolapsed 
funis with footling presentation. 

Both reposition of the cord, and completion of version, will 
be favored by putting the woman into the knee-elbow position. 

Head, Hand and Foot. — The ht-ad, hand and foot have been 
found presenting together, and to these has even been added 
prolapse of the cord. 

Version is here again a necessity, and should be undertaken 
at the earliest practicable moment. 

Other forms of complex presentation might be mentioned, 
but to do so would be useless, since their treatment is in ac- 
cordance with the principles already laid down. 

Prognoaia of Complex Presentations. — Any form of presen- 
tation which involves the performance of so senous an opera- 
tion as podalic version, is always attended with increased risk 
both to mother and child. The degree of fatality obviously 
depends in great measure upon the stage of advancement in 
parturition at which interference is practiced, and the conse- 
quent difficulties which are encountered. 



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PARTURIENT ANOMALIES REFERABLE TO THE EXPELLEXT 
FORCES. 

Labor is said to be physiological in lifaose cases whereJD the 
natural forces are able to overcome the resistance usually of- 
fered by the soft parts, or the bony pelvis, without seriously 
injuring any maternal structure, consuming too much time, or 
considerably increasing the risk. It becomes pathological from 
entrance of a variety of disturbing elements referable to the es- 
pellent forces, the maternal soft structures, the maternal bony 
structures, the fcetus itself, and also various anomalous condi- 
tions. 

Patients judge tabor pains by their subjective effects, and 
they therefore describe "cutting pains," "grinding pains," 
"forcing pains," and so on. The accoucheur judges of them by 
their objective effects, and therefore describes " efficient pains," 
"propulsive pains," "unavailing pains," and so on. 

As the result of anomalous action of the ezpellent forces we 
accordingly have (1) precipitate labor and (2) protracted labor. 

In no two instances do we observe the same phenomena. 
Sudden and decisive changes occur at various stages of what 
may rightly be regarded as normal oases. That is to say, up 
to a certain point labor may progress with the utmost regular- 
ity and uniformity, the pains coming and going with clock-like 
precision, and dilatation proceedingwithoutheeitaney. Descent 
may begin, and proceed well for a time, and then there comes a 
halt which causes the patient to lose heart. Again, acase may 
proceed in a leisurely manner up to a similar period in the pro- 
cess, when suddenly theexpellent forces take on new energj' and 
bring the labor to an abrupt termination. 

Precipitate Labor. — There are several degrees of precipitate 
labor. In its milder forms it is commonly attended with but 
slight inconvenience, and as little danger. Such are the major- 
ity of easy labors. But there are cases in which the contrac- 
tions are so powerful, vehement, frequent and uncontrollable, 
as to result in serious traumatism of the cervix uteri, perineum, 
and even the body of the womb itself The f(etus traverses the 
l)arturipnt canal with such rapidity as to fall on the street, on 
the floor, into the chamber-vessel, or into the closet-bowl. In 



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Parturient Anomalies. 455 

cases like these the woman sufTers few paiDS, but they are so re- 
-doubted in severity as sometimes to produce convulsions, apo- 
plexy, and mania. When labor berminates with the woman in 
the erect posture the child's fall is usually broken by thecord, 
severance of which is rarely followed by hemorrhage. The in- 
volunta.ry efforts of the woman may be bo strong, especially 
when the vulvar structures are still unrelazed, and the pelvic 
floor offers strong resistance, as to cause subcutaneous emphy- 
sema of the head and neck, to modify the utero-placental cir- 
culation, and even to fracture the foetal skull, as well as to 
result in laceration of the tissues in and about the vulva. 

The following remedies may be given, but we do not always 
have time to get their action beforelabor is brought to a close. 

Excessively severe labor pains: coSea, dux vomica, caalo- 
pbylhim. 

Labor-pains too prolonged and powerful : secale. 

Chloroform serves to apply the brake more effectually and 
rapidly than anything else, and, if needful, it should be carried 
to the extent of deep anesthesia. 

Uterine Inertia. — Weak Labor. — In some women there is a 
lack of tone in nerve and muscular fiber which exercises a 
marked influence on the character of labor. "Id women, more- 
over, of this temperament," says Leishman, "the anatomical 
peculiartties of the sex are generally well marked, and the ample 
and shallow pelvis thus offers a comparatively trifling i-esist- 
ance to the passage of the child. If, however, we contrast 
with this the tall, vigorous and muscular women, we flnd that 
in the latter there is a very general tendency to the male type 
of pelvis, involving a tardy passa^ of the child through the 
pelvic canal. May we not infer that it is in some degree in com- 
pensation for this that she is furnished with muscles so power- 
ful, and constitutional vigor so marked, to enable her to over- 
come the greater resistance which in a feebler frame would 
constitute an insurmountable barrier." 

We might with propriety include under the head of tedious, 
or prolonged labor, all cases wherein expulsion of the foetus is 
unusually delayed, from whatever cause delay may arise; but 
in this place we shall speak only of labor protracted from causes 
referable to deficient action of the expellent forces. 

The average duration of labor is from eight to ten hours, 
the latter for primipar£e,and the former for multipara. Labor 
may be weak from the very beginning, or, as we have said; 



456 Labor. 

Inertia may develop in a case which, up to near the close of the 
second stage, has been rigorous and active. 

CAnsEa. — Uterine inertia finds iu general debility, — the result, 
it may be, of disease, — and in constitutional feebleness, a predis- 
posing cause. The immediate cause is most frequently attri- 
butable to over-exertion during a protracted first and early 
second stage, ut^^rine inertia being an expression of the complete 
exhaustion from which the woman suffers. Rapid child-bearing 
doubtless has a marked effect in the same direction. Excessive 
and pi-einature uterine retraction is an efilcient cause in quite a 
percentage of cases; and also adhesions of the membranes to 
the lower uterine oegment. High temperature of the surround- 
ing atmosphere, such as we get iu the middle of a hot summer, 
because of its depressing effects may be reckoned as a cause. 
Sudden and profound emotion, iu women of a highly nervous 
organization, is capable of weakening the pains, and even of 
temporarily suppressing them ; but the action of such a cause 
is not often sustained for a lengthened period. Overdistension 
of the bladder or rectum, and acondition of inflammation in the 
abdominal viscera, may be reckoned among the causes of this 
condition. Hydramnios should also be mentioned, its effects, 
however, being limited to the first stage. The age of the 
patient hasamarked infiuence. In young girls there appears to 
be a proneness to weak and irregular uterine action, and in 
those neariug the close of the child-bearing period, pon^erless 
labor is by no means an infrequent occurrence. 

Symptoms. — In the first stage, weak labor is indicnted by 
pains which come and go with tittle lees than uBual r^rularity, 
but which, while they may produce marked sensory impressions, 
further but slightly the parturient process. They are short, 
teasing and discouraging in character. When given an abund- 
anre of time they succeed at last in opening up the os uteri, 
and launching the woman, weary, worn and disheartened, into 
a powerless second stage. 

Then the rase drags. There is little propulsive energy in the 
contractions, and the woman cannot bring hei-self to the exer- 
cise of much voluntary effort. There may not be absolute ar- 
rest of the parturient process, but it proceeds so slowly that 
progress has to be meai^nred by hours. Left to itself, the case 
may ultimately culminate in spontaneous delivery, but occa- 
sionally it is overtaken by profound inertia, and requires arti- 
ficial aid. 



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Pabttjeient Anomalies. 457 

After tbe child is bom the same leiBare1.y movemeot contih- 
iies, and but for asBiRtaoce the placenta would likely tarry in 
utero for an indeflnite period. When once entirely empty, the 
uterus contracts in a listleBs, heeitatiog way, and, should there 
be in the patient a predisposition to hemorrhage, a serious ex< 
-ample of it is liable to develop, unless averted by wise prophy* 
lactic measures. 

Treatment. — The following suggestion with r^ard to 
preventive treatmeut of these cases should be remembered : 
"Tbe moment we find the least evidence of flagging power," 
«ay8 Dr. Edis, "of any cessation of pains, any intermittence in 
the regular beat, or any acceleration of the patient's pulse, or 
any general evidence of the patient having had more than she 
<an 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." 

The character of curative treatment will be determined by 
the causes contributing to inertia, and the stage of labor in 
which it is manifested. The condition of the bladder and 
rectum should be investigated, the mental state and age of the 
woman considered, and the character of the presentation, and 
state of the uterus, as i-egards retraction, passed under review. 
When it evidently depends on excess of liquor amnii, the mem- 
branes, iu the absence of contra-indications, may be ruptured, 
and a part of the fluid permitted to escape. Adhesions of the 
membranes to the lower uterine segment can be broken up by 
^sweeping the finger about within the os uteri. A warm vaginal 
injection will sometimes promote uterine contractions and 
favor physiological reduction of the cervix, Barnes' baf^ are 
■of service for opening the os, but far better and more eSective, 
we believe, is manual dilatation practiced with the utmost 
caution. 

In protracted second stage, resulting from inefficient 
uterine action, much aid can be afi'orded by properly directed 
manual pressure on the fundus uteri. It is better borne in 
labor which is prolonged through weakness of the expellent 
forces than in labor which is protracted by reason of re- 
sistance in front of the presenting part. In the latter case the 
energetic uterus resents interference, but in the former it 
invites it. 

Aid of this kind should be given by the palms of the hands, 
and pressure made in the direction of the long uterine axis. It 



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458 La DOR. 

need not be added that there is no iotention to supplant th» 
natural efforts, but to reinforce them. 

When the head, in eases of uterine atony, lies at the outlet, it 
can usually be expelleii by means of two fingers in the rectum, 
combined with abdominal pressure. 

Ergot has been commonly employed by the old school for 
the purpose of arousing the sleepy uterus, but even among its 
own practitioners the drug is falling into disrepute. In our early 
prEictice we also cherished a liking for it, but are now convinced 
that the outcome is likely to be more gratifying when strict, 
homeopathic indications are followed. 

The appended therapeutic hints are not intended to be specific- 
guides in practice, but mere finger-boards pointing to the 
possibly indicated remedies. In order to obtain satisfactory 
results from our remedies they must be chosen with due r^ard 
to temperament, constitutional traits, known systemic taints,, 
and the peculiar individual symjitoms of each case. 

Therapeutics. — Fneffident. — Labor-pains violent and fre- 
quent, but inefficient; patient says she canuot breathe; i» 
restless, anxious and impatient; aconite. 

Labor-pains too weak, but regular ; sethusia. 

Labor-pains violent, bat inefilcient ; feels lame and bruised; 
arnica. 

Labor-pains tormenting, but useless, in the beginning of 
labor; caulophylium. This is an excellent and frecjuently 
indicated remedy, especially in rheumatic patients. 

Labor-pains short, irregular, spasmodic; patient very weak; 
no progress made : caulophyUum. 

Labor-pains spasmodic and irregular, especially in women 
who have had great grief or anger: coccuIub. 

Labor-pains spasmodic: caustkam, ferram, Pulsatilla, mix: 
vomica. 

Labor-pains spasmodic, cutting across from left to nghtr 
nausea, clutching about the navel : ipecac. 

Ijabor-pains spasmodic, painful but ineffectual : platina. 

Labor-pains spasmodic ; they exhaust her greatly ; stannum. 

Labor-pains spasmodic and distressing; patient irritable: 
ehamomilla. 

Labor-pains weak and inefficient; patient weak; has slow, 
feeble pulse: canst., kali carb. 

Labor-pains distressing, but of little use; cutting paina 
across abdomen : phosphorus. 



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Parturient Anomalies. 45© 

Labor-pains JDeffectual, of a teariog, distressing character, 
seemingly not properly located : actwa. 

Labor-pains prolonged, but ineffectual : secale. 

Labor-pains severe, but not efficacious; she neeps and 
laments : coffea. 

Weak, falHe, deficient. Labor- pains weak or ceasing; she 
wants to change position often ; feels bruised : arnicSi. 

Labor-pains wealc or ceasing ; she will not be covered ; rest- 
less ; skin cold : cainphora. 

Labor-pains deficient or absent; she has only slight peri- 
odical pressure on the sacrum; amniotic fluid gone; OS ut«ri 
spaamodically closed : belladonna. 

Labor-paiuB weak or ceasing, with great debility, especially 
after violent disease or loss of animal fluids: carbo veg. 

Labor-pains become weak, flagging, from protracted labor, 
causing exhaustion; patient thirsty, feverish : caulophyllam. 

Labor-pains cease from loss of blood : cb'ma. 

Labor-pains ceasing, with complaining loquacity : coffea. 

Labor-pains gone, os widely dilated, complete atony: gel- 
semiam. 

Labor-pains feeble and inefficient; patient aneemic, weak; 
slow, feeble pulse : cauBticum, kali carb. 

Labor-pains weak, accompanied with anguish and sweat; 
desires to be rubbed: natmm mur. 

Labor-pains spasmodic, irregular: drowsiness: natmm mur. 

Labor-pains deficient, irregular, slu^ioh ; patient has light 
complexion, blue eyes, tearful mood : puhatiUa. 

Labor-pains deficient, ii-r^ular, slaggish; patient has dark 
hair and eyes: nux vomica. 

Labor-pains deficient, with os soft, pliable, dilatable: usti- 
logo. 

Labor-pains suppressed, or too weak : secale. 

Labor-paibs ceaBe ; coma, retention of stool and urine, from 
(right: opium. 

Labor-pains cease, or become weak, from anger : chaniomilJa, 
colocynth, coccnlus. 

Labor-pains cease from excessive grief : ignatia, cocculm. 

The Fobceps in Inert Labor.— There is occasion for the 
utmost discretion in the use of the forceps in cases of weak 
labor proceeding from real uterine atony. We should here 
distinguish between the latter condition and that of premature 
or excessive uterine retraction. In the latter instance, tlio in- 



460 Labor. 

Btruments am not only called for, but there Ib little, if any, 
danger attending tb^ir nee. Tbe same cannot be said of the 
former condition. The bead in a given case descends into the 
pelvic cavity under the influence of fair pains ; but after a time 
the pains become so feeble that progress is arrested. Long 
delay under such cireumstancee is not free from serious danger 
to the woman, owing to continuous compression of the soft 
pelvic tissues. Recourse is had, perhaps, to various well-indi- 
cated remedies, without relief. The uterine energies are either 
too broken promptly to respond, or, after a time, the forceps 
are applied and delivery finished without difficulty; but wttflnd 
that the uterus, instead of assuming its usual cannon-ball con- 
traction, remains weak and sln^^h, with the elfect to develop 
an a^ravated attack of post-partum hemorrhage. The dan- 
ger, then, in all such cases is, that the atony with which the 
uterus is stricken will continue, and excessive bleeding result. 
On the other hand there is little danger of such an occurrence 
in connection with labor rendered weak by the premature or 
excessive retraction of the uterus alluded to above. 

Xow,if before using the forceps, even moderate re-awakening 
of the organs be secured by refloedies and the application of 
suitable stimulus, we may proceed slowly with our forceps de- 
livery without incurring much danger of subsequent hemor- 
rhage. Unless a complete atony exists, the very introduction of 
the instrument communicates a certain degree of stimulation of 
the most effective kind, so that ourtraction efforts are often found 
to be reinforced by vigorous uterine action. The point which 
we wish to establish is that, bearing in mind the dangers which 
are most liable to arise, we should fortify ourselves against 
them by adopting such precautions as are described in connec- 
tion with the prophylactic treatment of post-partum hemor- 
rhage. 

TUKAT-MEXT OP THE ThIHD StAQE OF LaBOH COMPLICATED 

BY Utekixe Inertia. — The great danger H^sociated with 
uterine weakness in the third stage of labor is that of post- 
partum hemorrhage. A slug^sh uterus in this stage is always 
the cause of much anxiety. Hemorrhage may set in early, im- 
mediately succeeding placental delivery, or it may not appear 
at all. Thpre should be no haste to deliver the placenta, and 
no traction on the cord. With the hand firmly grasping the 
organ through the abdominal walls, we should for a time main- 
tain an expectant attitude, unless bleeding set in. We must 



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Parturient Anomalibb. 461 

wat<:h and wait. The recurrence of firm uterine contraction 
M'ill be taken as a si^al for delivery of the placental mass by 
pressure on the fundus, combined with moderate traction on 
the cord 

Followint; such a delivery the uterus ought to be tlrmly held 
for twenty or thirty minutes. 

With a weak third stage of labor irregular uterine contrac- 
tion is often associated, the fibers of a certain part acting more 
energetically than others and forming a constriction, most 
frequently at one angle of the uterus, but often at or near the 
site of the internal os, by means of which the placenta is 
■retained. The stricture does not often long persist, but it may 
be soon overcome byactionofthe suitable remedy. BelladoDna, 
gftlsemiuw, cuprum and cauIopbyUum are indicated in a general 
way, and our choice between them will be based on the special 
symptoms observed. 

Belladonna. — With this remedy the patient is disposed to be 
qaiet; is usually plethoric, and in good fiesh; withal, during 
the labor she may have complained of occipital headache. 

Gelseiniuni. — The woman desires to be left alone; is nervous 
and excited ; may be more or less hysterical. 

Cuprum. — Is especially suited to women who have a good 
deal of cramping of various muscles during pregnancy, and in 
whom the pains of labor take on a somewhat crampy nature, 
eBpecially in the early stage. 

Caulophylhim. — Patient weak and nervous, and the uterus 
sensitive to pressure. 

Many other remedies may be found serviceable, among 
which are — 

ChamomiUa. — The woman is irritable, thirsty and restless; 
desires fresh airt declares she cannot endure her distresses. 

CoccuJun. — This remedy is especially suited to women who 
have recently Wen greatly stirred by grief or anger. 

Amy! nitrite by inhalation is very effective in some cases, 
pnly a few drops should be inhaled, and even then with caution. 

Under no circumstances should a patient be left alone until 
the placenta has been delivered, for the muscular fibers of the 
bod