NLn DDSfllEBS fl LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL I * \„ vs. -. y*v ^ * 1 /\^l o Aavaan ivnouvn iNOiaiw to Aavaan ivnouvn indioiw do Aavaan ivnouvn jnuioiw do \ i k\&■■ C( A i;'( '■? 4* » to IIS I £ I M I THE SCIENCE AND AKT OF MIDWIFERY. BY WILLIAM THOMPSON LUSK, A. M., M. D., PROFESSOR OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN IN THE BELLEVIJE HOSPITAL MEDICAL COLLEGE; CONSULTING PHYSICIAN TO THE MATERNITY HOSPITAL; VISITING PHYSICIAN TO THE EMERGENCY HOSPITAL; GYNECOLOGIST TO THE BELLEVUE HOSPITAL; FELLOW OF THE AMERICAN GYNAECOLOGICAL SOCIETY ; CORRESPONDING FELLOW OF THE OBSTETRICAL SOCIETIES OF EDINBURGH AND LONDON ; ETC., ETC. WITH NUMEROUS ILLUSTRATIONS. NEW YORK: D. APPLETON AND COMPANY, 1, 3, and 5 BOND STREET. 1882, mih mi COPYRIGHT BY D. APPLETON AND COMPANY, 1381. TO FORDYCE BARKER, M.D., LL.D., IN RECOGNITION OF HIS EMINENCE AS A "WRITER, TEACHER, AND PHYSICIAN, AND IN GRATEFUL ACKNOWLEDGMENT OF HIS GENEROSITY TOWARD THE YOUNGER MEMBERS OF HIS PROFESSION, (Cbis §Sook is glcbitateltr, WITH THE AFFECTIONATE REGARD OF HIS FRIEND, THE AUTHOR. B PREFACE. In the preparation of this work, my purpose has been to present to the reader a fair statement of the changes which have been made by modern investigation in the views entertained respecting the physiology and pathology of pregnancy, labor, and childbed; and I have endeavored to show that with advancing knowledge the art of midwifery has ceased to rest upon empirical rules, and is already, with rare exceptions, the natural outcome of scientific principles. To insure accuracy, I have spared no pains to subject the doctrines taught to rigorous clinical tests; and I have everywhere sought to supplement and correct my own personal experiences by the re- corded observations of others. Because of the strangeness of much of the new obstetrical litera- ture, I have considered it desirable to make copious references to recent authorities. At the same time, I hope that these references may prove of service to such as desire to examine for themselves original sources of information. If I have given special promi- nence to the labors of German investigators, it has not been due to a lack of appreciation of valuable contributions from other foreign and home sources, but because, with large hospitals and with state encouragement, the obstetrical waiters of Germany have of late years occupied a vantage-ground of which, to their credit, they have been prompt to avail themselves. To make room for the results of recent scientific investigation, much of purely historical and controversial matter usually found in obstetrical treatises has been omitted. VI PREFACE. Special stress has been laid upon the operations of midwifery and the influence exerted by the more common varieties of con- tracted pelvis in the production of anomalies pertaining to preg- nancy and labor. In reviewing the field of practice, I have not found it possible to discover any natural line of division betM'een obstetrics and gy- necology. Xo man merits the reputation of a good accoucheur unless he possess a thorough appreciation not only of the immediate dangers but of the far-reaching consequences of the faulty practice of his art; nor can his equipment be looked upon as otherwise than defective unless it include an ability to repair surgical injuries at the time of their occurrence. In submitting this wTork to the critical judgment of the medical profession, it is my earnest hope that the principles which have governed my own practice may prove a safe guide to others. 47 East Thirty-fourth Street, September, 1881. CONTENTS. PHYSIOLOGICAL ANATOMY. CHAPTER I. Female Organs of Generation ...... The pudendum.—Labia majora.—Clitoris.—Labia minora.—Vestibule.—The bulbs of the vestibule,—Meatus urethra?.—Sebaceous glands.—Mucous glands.— Vaginal orifice.—Hymen.—Vagina.—Vessels of vagina.—Uterus.—Fallopian tubes.—Ovaries.—Vessels of uterus and its appendages.—Nerves of uterus.— Lymphatics.—Development of the female organs of generation.—Arrests of development. PHYSIOLOGY OF THE OVUM. CHAPTER II. Development of the Ovum ....... The Graafian follicles and the ovum.—Discharge of the ova from the ovary, and the formation of the corpus luteum.—The migration of the ovum.—Fecun- dation.—Changes taking place in the ovum subsequent to fecundation.— Nourishment of the embryo.—The allantois and chorion.—The deciduae.— The placenta; its development and structure.—Formation of the umbilical cord.—The amniotic fluid. CHAPTER III. Development of the Fcetus ....... Area germinativa.—Primitive trace.—Dorsal plates.—Tubus medullaris.—Cerebral vesicles.—Chorda dorsalis.—Vertebral plates.—Abdominal plates.—Central plates.—Development of the bony skeleton.—Development of the intestine, face, lungs, liver, pancreas, bladder, heart.—Development of foetus in suc- cessive months of pregnancy.—Foetus at term.—Fetal cranium.—The atti- tude, position, and presentation of the foetus. PHYSIOLOGY OF PREGNANCY. CHAPTER IV. Changes effected in the Maternal Organism by Pregnancy . Changes in the sexual apparatus and neighboring organs.—Changes in the uterus. —Explanation of apparent shortening of cervix.—Changes in the vagina, vulva, abdomen, navel, breasts, nipple.—Functional disturbances of bladder. —Constipation.—(Edema.—Changes effected in the entire organism. Vlll CONTENTS. CHAPTER V. PAGK 95 The Diagnosis of Pregnancy . Signs of pregnancy.—Suppression of menses.—Nausea.—Salivation —Breasts.— Increase of abdomen.—Chan-es of the os and cervix.—Quickening.—mi- lottement.—Fetal heart-beat.—Uterine bruit.—Funic souffle.—Interrogation of the patient.—Methods of physical examination.— Inspection of abdomen —Palpation.—Auscultation.—The vaginal touch.—Distinction between nrst and subsequent pregnancies.—Diagnosis of death of foetus.—Duration ot pregnancy.—Prediction of day of confinement from date of last menstrua- tion.—Date of quickening.—Size of uterus. PREGNANCY. CHAPTER VI. The Management of Pregnancy . . . . • .115 llygiene of pregnancy.—The disorders of pregnancy.—The blood-changes of preg- nancy.—Pernicious aiwemia.—Hydremic oedema.—Varicose veins.—Nausea and vomiting.—Heart-burn.—Insalivation.—Pruritus.—Face-ache.—Cephalal- gia.—Insomnia. LABOR. CHAPTER VII. The Physiology of Labor and its Clinical Phenomena . .122 Causes of labor.—Uterine contractions.—Action of labor-pains upon the uterine walls.—Contraction of ligaments.—Action of abdominal muscles.—Action of vagina.—The pain of labor.—General influence of labor-pains upon the or- ganism.—Precursory symptoms of labor.—First, second, and third stages of labor.—Duration.—Action of the expellent forces. CHAPTER VIII. Mechanism of Labor ........ 139 Anatomical factors.—Anatomy of pelvis.—Sacrum.—Coccyx.—Ossa innominata. —The ilia.—The pubes.—The ischia.—Articulations of the pelvis.—Sacro- iliac articulations.—Symphysis pubis.—The pelvic ligaments.—Obturator membrane.—Sacro-sciatic ligaments.—Inclination of the pelvis.—The pelvis as a whole.—The pelvic planes.—Plane of the brim.—Plane of the outlet.— Planes of the cavity.—Ischial planes.—Pelvic axis.—Differences between male and female pelvis.—Differences between the infantile and adult pelvis. —The soft parts of the pelvis.—The perineal floor.—The head of the foetus at term.—Sutures and fontanellcs.—The diameters of the fetal head.—The articulation of the head with the spinal column. CHAPTER IX. Mechanism of Labor.—{Continued.) . ]q>j Presentations: natural, unnatural, normal.—Vertex presentations: frequency po- sitions.—Manner in which head enters pelvis.—Positions.—Normal mechanism of labor.—Descent and flexion.—Rotation.—Extension.—External rotation —Expulsion of the trunk,—Abnormal mechanism (vertex presentations)__- Mechanism of occipito-posterior positions.—Configuration of the head in ver- tex presentations.—Molding.—Scalp-tumor.—Diagnosis of vertex presenta- tions. CHAPTER X. Mechanism of Labor.—{Continued.) Face presentations.—Frequency.—Causes.—Mechanism.—Descent and extension —Rotation.—Flexion,—External Rotation.—Abnormal mechanism.__Confi cxtrcrnity supporting muscular trabeculae, and into which open the ultimate divisions of the arteries ; but in the bulb (the vascular portion of the ovary) there are neither dilated capillaries, nor areolae, nor trabecule FEMALE ORGANS OF GENERATION. 27 The analogy signalized by M. Rouget is therefore much more appar- ent than real."* The Nerves.f—The nerves of the uterus are derived from the gan- gliated cords of the sympathetic system, through which important connections are formed with all the abdominal viscera. Just at the bifurcation of the aorta there is a broad band of nerve tissue termed the plexus uterinus magnus, formed by the coalescence of filaments from the spermatic ganglia (two pairs of ganglia, situated upon each side of the inferior mesenteric artery) and filaments derived from that portion of the aortic plexus which is distributed mainly to the supe- rior mesenteric artery (plexus mesentericus superior, Frankenhaeuser). About an inch and a half below the bifurcation of the aorta it divides into two strands, the plexus hypogastrici, which pass right and left around the rectum to the uterus and upper portion of the vagina. The hypogastric plexuses receive nerve branches from the lower lum- bar and three upper sacral ganglia. Upon the sides of the rectum they divide each into two portions, of which the smaller passes directly to the posterior and lateral walls of the uterus, while the larger con- tributes to the formation of the cervical ganglion. The cervical ganglion is a large plexus, which measures during pregnancy two inches in length by one and a half inch in breadth. It is formed by the concurrence of filaments from the hypogastric plexus, the three upper sacral ganglia, and the first, second, and third sacral nerves. The cervical ganglion supplies the entire uterus, and especially the cervical portion, with nerves. Examined with the naked eye, these nerves are soon lost sight of as they penetrate the walls of the uterus, but their ultimate filaments have been traced by Franken- haeuser, in microscopic preparations, to the muscular element, where they apparently terminate in the nucleus of the fibre-cell. The Lymphatics.—We have already had occasion to notice the probable existence of lymph-spaces in the uterine mucous membrane. In the muscular tissue of the uterus, lymph-spaces are found in the delicate connective tissue which unites the muscular bundles together. Regular lymphatic vessels are found in the connective tissue which accompanies the arterial trunks into the uterine parenchyma. A net- work of lymphatic vessels, with dilated and constricted portions, and provided with valves, exists beneath the serous coat. The lymph- spaces of the uterine mucous membrane communicate, by funnel- shaped depressions, with the lymph-spaces and lymphatics of the mus- cular strata. Just beneath the external muscular layer, upon the lateral borders of the uterus, are large receiving vessels, into which empty the lymphatics from both the subserous and uterine vessels. # " Traite d'Anatomie," Paris, 1874, t. iv, p. 691. •f For latest and most complete account, vide Frankenhaeuser, " Die Nerven der Gebarmutter," Jena, 1867. o8 PHYSIOLOGICAL ANATOMY. The lymphatics of the cervix pass to the glands of the pelvic cavity while those of the border and fundus follow the course of the plexus pampiniformis to form connections with the lymphatics of the lumbal ^Development of the Female Generative Organs -Three connected structures make their appearance on either side ot the spinal column, at an early period of fetal existence, which need to be understood by those who would gam a clear idea of the developed organs of generation in the female. These struct- ures are the Wolffian bodies, the ducts of Miiller, and the rudimentary organs which are destined at a more advanced period to become the ovaries. The Wolffian bodies are oblong glan- dular structures, temporary in character, which are thought to perform, in the embryo, the excretory function of the kidney. They possess ducts, situated at the sides, which converge together below the Wolffian bodies to empty into the sinus uro-genitalis. Two organs, destined to become the ovaries, make their appearance upon the inner side of the Wolffian bodies. They possess at first an elongated, but subse- quently assume a more oval appearance. The ducts of Muller are secondary formations, derived from the Wolffian ducts. They begin as longitudinal seams upon the latter, and finally, by deepening of the furrows, become separated, and form solid filaments, which pass spirally around the Wolffian ducts, and meet in the median line to descend together to the sinus uro-genitalis. These solid filaments next become hollow. By the eighth week the lower portions of the filaments, which are in apposition with one another, fuse together, and furnish the first rudiments of the uterus and vagina. The free portions of the fila- ments become the Fallopian tubes. Both uterus and vagina are at first divided into two parts by a common partition-wall, which dis- appears subsequently from below upward. The uterus, at the fourth month of fetal life, presents distinct traces of the early origin from the ducts of Muller. The fundus is * Leopolh, " Die Lymphgefasse der normalen nicht schwangeren Uterus » « Arch f Gyn,rJ:V.Bd"Ti,i?»t1, ?« ^ ^ 5 LUSCHKA' "DiG Anat°mie des «h'lichen Be'ck! ens," Tubingen, 18oo, p. 378. A 9 ^\ /0 H /£ Fig. 19.—Rudimentary sexual organs. The internal organs represented at the seventh week of fetal life; the external organs belong to a later period. 1, spinal column; 3, 3? Wolffian bodies; 5, glands destined to become the ovaries in the female, the testicles in the male; 6, Wolffian duct; 7, fila- ments of Muller; 8, bladder; 9, tubercle, forming the rudiment of either the clitoris or penis; 10, folds destined to form the labia majora (in the male the scrotum); 11, sinus uro-genitalis; 12, anus. (Luschka.) FEMALE ORGANS OF GENERATION. 29 undeveloped. The ridges of the arbor vitae uterina, which are con- fined at a later period to the cervix, extend the entire length of the uterus. A depression at the fundus marks the point of union between the ducts of Muller. Two cornua, or horns, are thus distinguishable upon the external surface of the uterus. About the eighth or ninth month the convex fundus is devel- oped, and the cornua disappear ex- ternally, though all through life they are traceable upon the inner surface FlG- 20.—uterus and its appendages in the 1,1 ,• o 11 / • 7 foetus at the end of the fourth month m lateral sections of the uterus (vide (natural size). A, external view : a, a, ovaries, relatively large, nearly as long as the oviducts; b, o, the Fallopian tubes (oviducts); c, c, round ligaments; d, uterus; e, vagina; /, vaginal orifice. B, interior view : a, rami of the arbor vita?, extending to the fundus of the uterus; b, vaginal portion of uterus ; c, vagina. (Courty.) Fig. 13, p. 19). Before the differentiation of sex has taken place, the external organs of generation present the following appearances : Two ridges, or folds, surround a central opening (sinus uro-genitalis), which either unite to form the scrotum of the male, or develop into the labia majora in the female. Where these folds Join together above, there is a small projecting body, or tubercle, destined to become the penis or the clitoris. In either case the lower surface Fig. 21.—Uterus unicornis from a young child, posterior aspect (Pole), a, uterus unicornis, left half of uterus undeveloped; b, right Fallopian tube; c, left Fallopian tube, excep- tionally present; d, d, ovaries, e, bladder. (Courty.) of the tubercle is furnished with a groove. The margins of the groove extend along the sides of the sinus uro-genitalis, and, in the develop- ment of the female type, become the labia minora. The sinus uro- genitalis affords a common aperture for the bladder and internal or- gans of generation. Abnormalities of the Uterus.—An arrest of fetal development 30 PHYSIOLOGICAL ANATOMY. gives rise to a number of deviations from the ordinary uterine type, of which we borrow from Courty the following as of direct obstetrical importance. . , 1 Uterus Unicornis. —The one-horned uterus results from the atrophy or incomplete development of one of the filaments of Muller, Fig. 22.—Double uterus and vagina from a girl aged nineteen (Ersenmann). a, double vaginal orifice with double hymen; b, meatus urethra;; c, clitoris; d, urethra; e, e, the double vagina; //uterine orifices; g g cervical portions; h, h, bodies and cornua; (bou^T8' FalloPlan ^bes; /, I, round ligaments; m, m, broad ligaments; while the other continues its evolution. We then have a uterus which is composed of a single lateral half, possessing generally but one Fallo- pian tube. 2. Uterus Duplex, or Didelphys.—Both filaments of Muller are developed, but do not become united together. Thus two distinct uteri are produced, of which each represents in reality the half of a normal uterus. FEMALE ORGANS OF GENERATION. 31 Fig. 23.—Uterus bicornis, double cavity and double vagina, from a girl seventeen years of age. c, cervical portions united together, presenting the appearance of a single cervix; d, d, the two cornua. (Courty.) Fig. 24.—Uterus cordiformis, double natural size. (Kiissmaul.) 3o PHYSIOLOGICAL ANATOMY. 3 Uterus Bicornis.-Partial union of the filaments of Muller takes place, but without reaching the ordinary level indicated by the inser- tions of the round ligaments. The upper portion of the uterus is thus divided into two horns, separated by a furrow from one another. 4. Uterus Cordiformis.—The uterus remains of the fetal type in- dicated in Fig. 17. Instead of a complete development of the fundus, the latter remains depressed, and presents an appearance remotely resembling the heart of a playing-card. 5. Uterus Septus Bilocularis — Complete union of the two fila- ments of Muller has taken place, but the common wall, formed by their coalescence, persists. We thus have two distinct uterine cavities. Fig. 25.—Uterus septus bilocularis. Double uterus, with simple vagina, seen from the front. Left walls more developed in consequence of pregnancy. "^Cruveilhier.) The septum may extend the whole length of the vagina, and give rise to a double vagina ; or absorption of the vaginal septum and a portion of the uterine septum may have taken place, so that we may have a double uterine cavity with a single cervix, uterus semi-partitus,. DEVELOPMENT OF THE OVUM. 33 PHYSIOLOGY OF THE OVUM. CHAPTER II. DEVELOPMENT OF THE OVUM. The Graafian follicles and the ovum.—Discharge of the ova from the ovary, and the formation of the corpus luteum.—The migration of the ovum.—Fecundation.__ Changes taking place in the ovum subsequent to fecundation.—Nourishment of the embryo.—The allantois and chorion.—The deciduae.—The placenta; its development and structure.—Formation of the umbilical cord.—The amniotic fluid. The physiology of the ovum comprises its genesis, development, and discharge from the ovary, its fecundation, and the entire series of subsequent changes by which the simple structure of the germ becomes converted into a complex organism presenting the specific characteristics of the parent. Fig. 26.—Section of Wolffian body, with rudimentary ovary (embryo of chick, fourth day of incubation). WK, Wolffian body ; y, section of Wolffian duct; a, a, thickened epithe- lium ; z, duct of Muller; E, early stage in development of ovary ; 0, 0, primordial ova; m, mesentery ; Z, lateral wall of ovary. (Waldeyer.) The following account of the history of the ovum is derived from Waldeyer's now tolerably familiar work.* The Graafian Follicles and the Ovum.—In the embryo * " Eierstock und Nebeneierstock," Strickee's " Handbuch der Lehre von den Gewe- ben " Leipsic, 1871; "Eierstock und Ei," Leipsic, 1870. 3 34 PHYSIOLOGY OF THE OVUM. of the chick, by the fourth day of incubation, the Wolffian body is covered by cylindrical epithelium, contrasting sharply with the flattened cells of the peritoneum. Soon after, a thickening of the e e S J Fig. 27.—Vertical section of an ovary of a human foetus thirty-two weeks old. a, a, epithe- lium ; b, b} latest developed epithelial cells, situated in the epithelial layer; c, trabecular of connective tissue which have penetrated into the epithelial layer; e, e, primordial fol- licles surrounded by fine connective-tissue cells ; /, groups of imbedded epithelial cells, among which may be distinguished certain ones of large size (primordial ova); g, granu- lar cells of His. (Waldeyer.) epithelium becomes noticeable in the median line, and forms the earliest trace of the ovary. Next, a small rounded elevation, rich in cells, and derived from the interstitial tissue of the Wolffian body, makes its appearance underneath the thickened epithelium. The epi- thelium is destined to form the Graafian follicles and ova; the pro- liferated connective tissue furnishes the vascular stroma of the ovary. Between the fourth and fifth day, certain cells already indicate their destiny as future ova, by their size, their rounded shape, and large nu- clei. The further development of the ovary is the result of the multi- plication of the epithelial cells and the continued growth of the stroma. As the connective-tissue processes grow outward and penetrate between the cells, the latter gradually become imbedded in the stroma. Thus, the connective-tissue processes assume a trabecular arrangement, the meshes of which are filled with cell-masses of a nearly cylindrical shape, which hang together in the form of a net-work. Among the imbedded cells, the large ones already noticed are termed " primordial ova." The smaller cells remain small, and arrange themselves like epithelium around the larger ones. In the course of development, the interpene- tration of the connective tissue continues, until each primordial ovum is contained in its own separate partition. These partitions with the included cells, are rudimentary Graafian follicles. Two distinct ova within the same Graafian follicle, are of rare occurrence As the ova enlarge, and the epithelial cells multiply, an irritative action is set un in the surrounding stroma. An increase in vascularity results and a DEVELOPMENT OF THE OVUM. 35 ring of young connective tissue is developed about each epithelial col- lection. As the ring grows, its outer layer becomes fibrillated. Thus around each Graafian follicle a distinct envelope is formed, termed by Baer the theca folliculi, consisting of an internal vascular coat, the tunica propria, and an external fibrillated coat, the tunica fibrosa. Each primordial ovum is at first encircled by a single layer of cylindrical cells. Gradually new layers form, in which the ovum lies imbedded. Afterward, at a point remote from the ovum, a crescent- shaped opening makes its appearance, which becomes filled with a clear fluid derived from transuded serum, and possibly in part from Fig. 28.—Portion of vertical section through ovary of bitch. «, epithelium of ovary ; b, b, tubules of ovary ; c, young follicles ; d, mature follicles ; e, discus proligerus, with ovum ; epithelium of second ovum in same follicle; g, tunica fibrosa folliculi; h, tunica propria folliculi; *, membrana granulosa. (Waldeyer.) disintegrated epithelium. A heap of cells remains about the ovum, and forms the discus proligerus. With the increase of the follicular 36 PHYSIOLOGY OF THE OVUM. fluid, the cylindrical cells are pressed against the membrana propria, and form a third coating, or layer, termed the membrana granulosa. A glance at a transverse section through the ovary of a mature mammal exhibits follicles of different ages. To recapitulate : The young follicles are composed of primordial ova, surrounded by epithelium, and imbedded in the ovarian stroma. The fully developed follicles possess a vesicular character. They are surrounded by a connective-tissue wall (theca folliculi), which is composed of two layers (tunica propria and tunica fibrosa). The tunica propria is lined by cells (membrana granulosa) which are gathered in heaps (discus proligerus) around the ova. The discus proligerus is seated sometimes superficially, sometimes in the deepest portion of the ovum. Each ovum is surrounded by a special layer of cylindrical epi- thelium (epithelium of the ovum). Henle estimates the entire number of Graafian follicles in each ovary at thirty-six thousand.* Fig. 29.-Ovum from a Graafian follicle in the rabbit, a, epithelium of ovum • b zona radi- ata; c, germinative vesicle; d, germinative spot; e, vitellus. (Waldeyer.) The ovum, at the time of its discharge from the ovary, is no longer a simple cell, composed of ordinary protoplasm, but presents the fol- lowing characteristic peculiarities : It is of large size. In the human female the ovum measures about ^ of an inch. It possesses a thick transparent envelope, termed the vitelline membrane, or, from the man- * Henle, " Handbuch der Eingeweidelehre," Braunschweig, 1866, p. 483. DEVELOPMENT OF THE OVUM. 37 ner in which it transmits light, the zona pellucida. The zona pellu- cida was formerly thought to be due to a thickening of the cell-mem- brane. It is now more commonly regarded as something superadded to the primordial ovum. Probably the attached portions of the radiate cells which surround the ovum in the discus proligerus contribute to its formation. The appearances in Fig. 29 represent, according to Waldeyer, these cells undergoing a cuticular transformation. The fine lines which may be seen, when high magnifying powers are used, are, he believes, unchanged filaments of the original protoplasm.* The thickness of the zona pellucida is from -^ to ^ the diameter of the ovum. The body of the cell becomes the vitellus or yolk of the ovum. It possesses contractility and other properties of ordinary protoplasm. It has a viscid consistence, and is opaque from the presence of very fine granules and globular vesicles. The nucleus of the cell becomes converted into a large, clear, col- orless vesicle, known as the germinative vesicle. The nucleolus per- sists as a dark, probably solid, body within the germinative vesicle, where it is known as the germinative spot. Discharge of the Ova from the Ovary, and the Formation of the Corpus Luteum.—We have already seen that the number of Graafian follicles within a single ovary is estimated at thirty-six thousand. The formation of these follicles is, in great degree at least, completed during the antenatal period of existence. Previous to puberty, however, they remain in a quiescent condition. With the advent of puberty the ovaries assume functional importance. The surface of the ovary, if examined at this time, is no longer smooth, but studded with small vesicles. These vesicles are nothing more than the enlarged Graafian follicles, which, as they become dis- tended by their fluid contents, approach the periphery, then the tunica albuginea, and form rounded, translucent prominences. By the additional disappearance of the blood-vessels and the lymphatics, a weak point in the wall of the follicle, the macula or stigma folliculi, is left exposed. The discharge of the ovum is due to the conjoint action of a fatty degeneration of the cells in the walls of the mature follicle and the formation of the corpus luteum. The corpus luteum begins by an abundant cell-proliferation, in which both the follicular epithelium and the tunica propria partici- pate. Vascular arches push forth into the cavity of the follicle, and still further encroach upon the already crowded space. Finally, a point is reached at which the follicle ruptures, and its contents, in- cluding the ovum, are discharged. When the Graafian follicle has * Waldeyer, " Eierstock und Nebeneierstock," Stricker's " Handbuch der Lehre von den Geweben," Leipsic, 1871, p. 554. 3S PHYSIOLOGY OF THE OVUM. reached maturity, the congestion, occurring at the time of the menses, operates unquestionably in a most effective manner to the accomplish- ment of this result. Immediately following the rupture of the Graafian follicle, blood is effused into its cavity. The active proliferation of the cells of the membrana granulosa continues. At the same time a process of disin- tegration ensues. But, in place of a degenerative product, the disin- tegration furnishes a granular, vitellus-like substance of a yellow color. Examined by the microscope, in addition to the granular mass, glob- ules may be recognized, which are not precisely fat, but correspond to the globules contained in the vitellus of the ovum. While the above-mentioned process is going on, an abundant trans- migration of white corpuscles from the vascular network surrounding the follicle takes place, which lift up the granulosa cells, with the pseudo-yolk substance, and press them toward the center of the fol- licle. Along with the young wandering cells (white corpuscles), vascu- lar offshoots, like small papillae, push out from every side into the epithelial and vitellus-like masses. As the larger vessels form more marked projections, they give to the corpus luteum a folded ap- pearance. In a state of complete development the corpus luteum consists of —1. The pseudo-yolk substance, mingled with effused blood. 2. The thickened layer of the granulosa cells, mingled with yolk-substance. It is this layer which, to a great extent, forms the folded, yellow por- tion of the corpus luteum. 3. The vessels which, with the wandering cells, push from all directions into the epithelial masses. As these vessels reach the center of the follicle, a complete interpenetration of the connective tissue and epithelial elements of the corpus luteum results, and the foldings become indistinct. Finally, absorption of the vitellus-like substance occurs; the last vestiges of the effused blood are converted into blood-crystals ; the arterial vessels degenerate; the epithelial masses and the connective- tissue mesh-works disappear gradually, until at the last only a white, stellate cicatrix remains. If the ovum is discharged without impregnation taking place, the corpus luteum reaches its maximum size at the end of three weeks, and then begins to decline, until, at the end of two months, it is re- duced to an insignificant cicatrix. But, when conception occurs, the changes in the corpus luteum take place more slowly. The corpus luteum reaches a higher state of development. Its increase in size continues for two months. It then remains stationary up to the end of the sixth month During the last three months of pregnancy it gradually oses its bright-yellow color, grows smaller, but still measures one half of an inch in diameter at the end of the period of gestation.* * Dalton's « Treatise on Human Physiology," Philadelphia, 1861, Pp. 564 et scq. ' DEVELOPMENT OF THE OVUM. 39 The corpus luteum of pregnancy is often termed the true corpus luteum, to distinguish it from the more trivial variety which is pro- duced by the rupture of a Graafian follicle at a menstrual period. The latter has been termed the false corpus luteum, because it is found in virgins, and does not constitute a sign of preexistent pregnancy. The Migration of the Ovum.—The number of ova in each ovary has been estimated by Henle at thirty-six thousand. Only a small pro- portion of them, however, meet with the conditions requisite for frui- tion. It is probable that many ova perish while still surrounded by the stroma of the ovary. The history of extra-uterine pregnancies teaches us that, in some instances at least, the ovum, after its discharge from the Graafian follicle, escapes into the abdominal cavity. It, therefore, becomes an interesting subject of inquiry as to the conditions which ordinarily determine the passage of the ovum from the ovary into the Fallopian tube of the corresponding side. It will not do to assume, as is usual, a peculiar erectility of the Fallopian tube, which enables it to apply its funnel-shaped extremity to the ovary, just at the moment of the rupture of the Graafian follicle. Setting aside the inherent improbability of the existence of such a degree of intelligence in the fimbriae as would lead to the exact adaptation of the tube to the precise point at which the ovum is to be discharged, it has been proved that the Fallopian tube possesses none of the characteristics of erectile tissue. Injections of its vessels after death do not communi- cate to it the slightest change of form or place.* Muscular action has also been often invoked to explain the assumed manner in which the fimbriae seize the ovary, but galvanization of the tubes, practiced upon criminals recently executed, produces only ver- micular contractions, which do not affect the position of the fimbriae, f Indeed, when we remember the position of the Fallopian tubes in the pelvis, and bear in mind that they are at all times necessarily subjected to the pressure of the intestines, it becomes difficult to understand how they can execute any very extended movements. J In the absence of direct experimental proof, the suggestion of * Rouget, " Les Organes Erectiles de la Femme," "Jour, de la Physiol.," t. i, 1858, p. 337. f Hyrtl, " Handbuch der topographischen Anatomie," Wien, 1865, Bd. ii, p. 210. \ Henle, " Handbuch der Eingeweidelehre," Braunschweig, 1866, p. 470. Rouget {vide "Organes Erectiles," "Jour, de la Physiol.," 1858) has studied with great care the arrangement of the muscular fibers situated between the peritoneal layers of the broad ligament. These fibers are directly continuous with the delicate external muscular layer of the uterus. Certain of them are so distributed, according to Rouget, as to pro- duce by their contraction a direct approximation of the fimbriae to the ovary. Henle re- marks, by way of criticism, that more stress might be laid upon these fibers were they distributed to the Fallopian tubes alone. As, however, they spread likewise over the ovary, their probable action would consist in drawing both ovary and tube toward the median line. ■ 0 PHYSIOLOGY OF THE OVUM. Henle that the passage of the ovum into the Fallopian tube is due to the currents produced in the serum by the ciliated epithelium, which covers both the external and internal surfaces of the fimbriae is, on the score of probability, entitled to the most consideration. One of the fimbria (fimbria ovarica, Fig. 12, p. 18) is, as we have already seen, permanently attached to the lower angle of the ovary. It is likely that the ovum, discharged from a Graafian follicle, is floated down by the peritoneal serum toward the lower and outer border of the ovary, where a sufficient current is present to insure its being caught up and conveyed into the infundibulum tubae. Failures on the part of the ovum to reach its destination are, in all probability, not uncommon. Support is given to the theory of the importance of the ciliae in influencing the migration of the ovum by the observation of Thiry,* that in batrachians, which have the oviducts fixed to the abdominal walls, and situated at a distance from the ovary, during the rutting period little pathways of ciliated epithelium form in the peritonaeum, which collectively converge toward the openings of the tubes, f While the ovum remains in the ampulla, or dilated portion of the tube, its further progress is at first dependent upon the movements of the ciliae; but, after the isthmus is reached, an additional propelling force is furnished by the circular muscular fibres, which possess a peri- staltic action. Fecundation.—The precise point at which fecundation takes place has been variously ascribed by authors to the tubes, the uterus, and the ovary. The occurrence of fecundation within the uterus may be rejected, as it has been sufficiently demonstrated that the passage of the ovum to the uterus requires a period exceeding ten days in the human female—a period far exceeding the extra-ovarian life of the ovum, when not vivified by the contact of the male element of genera- tion. Abdominal pregnancies prove certainly the possibility of the ovary becoming the seat of fecundation, but their extreme rarity would lead us to infer that, so far as the human female is concerned, in whom it is fair to believe the ovum not uncommonly fails to enter the tube, the phenomenon is unusual. A priori reasoning leads us, how- ever, to regard with Henle the ampulla, with its arborescent folds, as specially designed for a receptacle of the seminal fluid. The conges- tive condition of the mucous membrane, its canalicular structure, and * Gottinger " Nachrichten," 1862, p. 171. f Cases of the complete migration of the ovum from the ovary of one side to the Fallopian tube of the opposite side are not readily explained by any hypothesis. Yet the occurrence of such cases is undoubted. Pregnancy, for instance, may exist where there is complete absence or closure of the Fallopian tube upon the same side with the corpus luteum. For the literature of. the subject, vide Schroeder's "Lehrbuch der Gehurts hiilfe," 4te Aurlage, p. 22. DEVELOPMENT OF THE OVUM. 41 the contractions of the muscular fibres, all seem intended to further the intimate contact of the spermatozoa with the ovum after it has reached this situation.* The semen, contact with which is essential to the fecundation of the ovum, is a thick, viscid, albuminous fluid, of a whitish color, and a peculiar odor, which has been compared to that of the raspings of bone. When examined by the microscope, it is found to contain nu- merous minute anatomical elements, termed spermatozoa. Each sper- matozoon consists of an oval head and a long filiform extremity or tail. The head is flattened, and measures about ^Vo of an inch in width. When seen in profile, it presents a pyriform appear- ance. The entire spermatozoon meas- ures from ■s-^o to ji-g- of an inch in length. The spermatozoa do not simply float in the seminal fluid, but possess the ca- pacity of moving from place to place, as though endowed with volition. In- Fig. 30.—Spermatozoa from the hu- deed, as the observer sees them advance, H dSSWS^t.)Un" now singly, and now in shoals, now div- ing down, and then rising again to the surface, now avoiding some obstacle, or skillfully picking their way between masses of epithelium, it is difficult to resist the conviction that they are really, what they were long supposed to be, distinct organisms capable of a certain de- gree of voluntary action. But there is little doubt, at the present day, that the undulatory movements of the tail, which furnish the propelling force, are due to purely molecular tissue-changes, similar to those which give rise to the amoeboid movements of protoplasm or the oscillations of the hair-like processes of ciliated epithelium. Henle estimates that the spermatozoa travel at the rate of an inch in seven and a half minutes. It is to these bodies that the semen owes its fecundating power, but only so long as they retain the faculty of motion—a faculty which has been found to exist in full force, within the female genital organs, eight to ten days after ejaculation, f Our knowledge of the process of fecundation is limited to the fact that the spermatozoa penetrate through the vitelline membrane, and then dissolve in the vitellus. In 1840 Martin Barry described a point in the zona pellucida (vitel- line membrane) of the rabbit, which appeared to him to be an opening designed for the passage of spermatozoa. At first embryologists pro- nounced Barry's descriptions to be based upon an illusion, but since * Henle, " Handbuch der Eingeweidelehre," 1866, p. 476. f Luschka, " Die Anatomie des menschlichen Beckens," Tubingen, 1864, p. 273. 42 PHYSIOLOGY OF THE OVUM. then the existence of such an opening, termed later by Keber the micropyle, has been abundantly demonstrated, at least in the ova ot fishes, mollusks, insects, etc.* _ . A very interesting series of observations, connected with this sub- ject, have been made by M. Eobin upon the ova of the nephelis vul- garis, or common leech. The earliest token of the maturity of the ovum consisted in the disappearance of the germinative vesicle. At the same time a retraction took place in the vitellus, which became thereby reduced one sixth to one fourth in size. At first the removal of internal pressure, consequent upon this retraction, led to a wrinkling of the vitel- line membrane. Afterward, however, a clear, limpid fluid, probably in part exuded from the vitellus and in part derived by endosmosis from external sources, filled up the intervening space, and caused the wrin- kles to disappear. The spermatozoa, in their movements around the ovum, assumed a perpendicular or oblique direction to the vitelline membrane. At one point in the membrane the penetration of these bodies could be distinctly observed. At the end of an hour the penetra- tion had ceased, and then a little bundle of spermatozoa could be seen arrested, partly within and partly without the ovum. In the clear, limpid space surrounding the vitel- lus, the spermatozoa continued to move about actively for a time, but in fifteen to twenty minutes their movements began to grow slow, and in a couple of hours had ended alto- gether. A comparison, by actual count, of the spermatozoa now re- maining, showed that a certain number of those which had found entrance into the limpid space had disappeared. They had been absorbed directly into the vitellus, to serve for its fecundation, f . 31.—Ovum of the nephelis vulgaris, showing retraction of vitellus and the penetration of the spermatozoa through the vitelline membrane (magnified three hundred diameters). (Robin.) Changes taking place in the Ovum subsequent to Fecun- dation. In describing its anatomy, we have noted that the ovum was orio-- inally a simple cell, possessing contractility and other properties of liv- ing matter. The ova of certain of the sponges, which do not possess a zona pellucida, move about under the field of the microscope by * Vide Milne-Edwards, " Lecons de la Physiologic," t. viii, Paris, 1873, pp. 361 et seq.; Waldeyer, "Eierstock und Nebeneierstock," St icker's " Handbuch," p 354 f " Memoire sur les Phenomenes qui se passent dans l'Ovule avant la Segmentation du Vitellus," Robin, " Jour, de la Physiol.," t. v, pp. 67 et seq. DEVELOPMENT OF THE OVUM. 43 pushing out finger-like processes, precisely like the ordinary amoeba.* Contractile movements of the vitellus within the zona pellucida have been described by Robin in the ova of the leech and other low orders of animal life, f Before the ovum leaves the Graafian vesicle, or soon after its dis- charge from the ovary, the germinative vesicle disappears. As this disappearance has been observed mostly in the impregnated ovum, the phenomenon has been generally attributed to the penetration of the spermatozoa, but Robin regards it as simply a sign that the ovum has reached maturity, and has become apt for fecundation. It occurs equally within the unfecundated ovum.| The first decided indication of the changes effected in the ovum by contact with the male element of generation, and a sign, too, conclusive of fecundation, is the spontaneous appearance of a round nucleus in the center of the vitellus. This nucleus is recognizable fifteen to thirty hours after fecundation. In appearance it so closely resembles the original germinative vesicle that, for a long time, it was erroneously regarded as such. Almost immediately after its production, the vitelline nucleus sub- divides into two nuclei. By a similar process of cleavage, the vitellus likewise separates into two halves. The nuclei act as central points Jp.2.—Segmentation of the ovum. Ax the ovum divided into two cells; B, the two cells divided into tour; PP- 461 et seV- X Naegele, "Lchrbuch der Geb.," achter Auflage, p. 122. 112 PHYSIOLOGY OF PREGNANCY. chosen as the starting-point of the calculation. Naegele selected the first day of the last menstruation. His method is, of course, equally applicable, when the day of cessation is preferred as the point of de- parture. For seven months in the year Naegele's method is absolutely correct. In February, however, four days, in December and January, five days, and in April and September, six days only are required to complete two hundred and eighty days. Tables may be found in most physicians' visiting lists, by means of which the two hundred and eighty days may be determined at a glance. The following circle of Fig. 70.—Diagram for computing pregnancy. (Schultze.) Schultze is based upon Naegele's method. The figures between the radii show the exact number of days to be added for each of the months severally. The figures in parentheses are to be employed in leap-year. Unfortunately, the supposition that labor comes on after the ex- piration of ten menstrual periods of twenty-eight days each is correct for only a small number of cases, so that it has been found necessary to shift the ground somewhat to the position that the normal duration of pregnancy covers ten menstrual periods. The instability of the reckoning would then find its explanation in the common experience that ten consecutive periods of exactly twenty-eight days each are rare even in the most regular of women. Although ovulation is suspended during pregnancy, at the return of the menstrual epochs the existence of an ovarian influence upon the generative organs may be clearly traced in many individuals. At such times a sensation of fullness is often experienced in the pelvic organs, associated in some women with an awakening of the sexual appetite. At such times, too, there has THE DIAGNOSIS OF PREGNANCY. 113 been observed a tendency to miscarry, so that it becomes incumbent upon sensitive, impressionable females, predisposed to abort, to espe- cially avoid either reflex or mechanical sources of disturbance during the continuance of the state under notice. When the ovum reaches maturity, the recurrence of the tenth menstrual epoch furnishes local conditions in a peculiar degree favoring the production of labor. Lowenhardt * found it was possible to calculate the duration of preg- nancy in twenty-two individuals with tolerable accuracy, by assuming that ten menstrual periods represent not two hundred and eighty days, but ten times the length of time between the last menstrual period and the one immediate- ly preceding it. In no case thus calculated did the error exceed five days, a degree of exact- itude unattainable by the method of Naegele. The Date of Quick- ening.—When the date of the last menstrua- tion can not be obtained, it is customary to reck- on the time of labor approximately by add- ing twenty-two weeks to the date of quickening, which is assumed to oc- cur in the eighteenth week of pregnancy. The extreme variation, how- ever, in the time at which quickening oc- curs in different indi- viduals renders this method of calculation a very uncertain one. The Size of the Uterus.—As the increase of the uterus is progres- sive, its size is sometimes used in determining approximatively the period to which gestation has advanced. According to a rude for- mula, commonly employed at the bedside, the uterus is, in the second month, of the size of an orange ; in the third month, of the size of a * " Die Berechnung und die Dauer der Schwangerschaft," " Arch. f. Gynaek.," Bd. iii, p. 476. Fig. 71.—Schultze diagram. 114 PHYSIOLOGY OF PREGNANCY. child's head; in the fourth month, of the size of a man's head, and can be felt above the symphysis pubis. In the fifth month, the fun- dus of the uterus rises to a point midway between the symphysis and the navel. By the sixth month, it reaches the level of the navel. In the seventh month, it should be the breadth of two to three fingers above the navel. In the eighth month, it rises half-way between the navel and the epigastrium. In the ninth month, it reaches the epigas- trium. In the tenth month, two to three weeks before confinement, the uterus sinks downward and somewhat forward, so that its upper level corresponds very nearly to that of the uterus in the eighth month. In the foregoing calculation most of the data are obtained from the relation of the fundus to the navel. But the navel is not a fixed point. Spiegelberg found the distance between the upper border of the sym- physis and the navel varied in different women as much as six inches.* The average distance from the symphysis pubis to the fundus of the uterus in the different months of pregnancy he found was— From the 22d to the 26th week........ " " " 28th week......... " " " 30th week........ " " " 32d and 33d week.. " " " 34th week. " " " 35th.and 36th week " " " 37th and 38th week " " " 39th and 40th week But the size of the uterus is subject to considerable variations, due to the size of the child and the amount of the amniotic fluid. * "Lehrbuch der Geb.," Bd. ii, p. 115. \ These measurements exceed considerably those furnished by Farre, p. 83. The dis- crepancies are due in part to the extent of individual variation, and in part to the fact that they were made with a tape-measure. Thus, Ahlfeld, employing the cyrtometre of Caudelocque, found the distance from the symphysis pubis to the fundus only ten and a half inches in the fortieth week. Ahlfeld found the length of the child to be nearly double the distance between the head and breech when the child assumed the attitude usual in the uterus. To determine the date of pregnancy, he proposed to measure the axis of the foetus in utero, by means of a cyrtometre, one extremity of which, passed into the vagina, rested upon the child's head, while the other was extended to a mark upon the abdominal wall corresponding to the breech. He then sought to establish the length of a child at each week of pregnancy. His tables show, however, such variations in the size of children born in the same week as to impair the practical value of the method. Vide Ahlfeld, "Bcstimmung der Grosse und des Alters der Frucht vor der Geburt," " Arch. f. Gynaek.," Bd. ii, p. 353. 8-J- inches, f 10^ " 11 " Hi " 12 " 12£ " 13 " 13i " THE MANAGEMENT OF PREGNANCY. 115 PEEGIA^CT. CHAPTER VI. THE MANAGEMENT OF PREGNANCY. Hygiene of pregnancy.—The disorders of pregnancy.—The blood-changes of pregnancy. —Pernicious ana?mia.—Hydraemic oedema.—Varicose veins.—Nausea and vomiting. —Heart-burn.—Insalivation.—Pruritus.—Face-ache.—Cephalalgia.—Insomnia. In studying the effects of pregnancy we saw that, besides the local changes in the sexual apparatus and the disturbances produced by pressure, the organism had to adapt itself to a variety of new condi- tions, of which the most conspicuous were alterations in the quality of the blood and increase of its quantity, with additional work thrown upon the lungs and kidneys, and reflex derangements of the nervous and digestive systems. The physiological condition of the pregnant woman approximates so closely to what would be regarded as patholog- ical at other times that the necessity arises for the patient to carefully observe hygienic rules, while the physician often finds himself called upon to exercise his art in restraining distressing symptoms within limits consistent with the healthy progress of gestation. The Hygiene of Pregnancy.—During the pregnant state, the in- creased elimination of carbonic acid by the lungs is necessarily associ- ated with increased consumption of oxygen. This respiratory activity makes an abundance of fresh, pure air a matter of prime importance. As a rule, therefore, a rural neighborhood is more conducive to nor- mal pregnancy than large cities. To be avoided are small, close, heated rooms, confinement in-doors, and crowded assemblages. The dietary should embrace all nutritious, easily-digested articles of food. The natural .tendency to acidity, heart-burn, flatulence, and colic is apt to be increased by indulgence in the products of the frying- pan and the dainties of the pastry-cook and confectioner. The con- suming desire for unwonted articles of food, which is customarily termed '-longings," I have never yet witnessed, and am tempted to regard as in a great measure mythical. A good appetite is the best safeguard against most of the discomforts of pregnancy. Owing, how- ever, to the activity of the assimilative processes, a very moderate ap- petite is not incompatible with a considerable gain in weight. A very large appetite is not normal during pregnancy, and requires to be The dress should be loose and easy. Garters and tight corsets should be discarded. When the projection of the abdomen removes 116 PREGNANCY. the folds of the dress from the lower limbs, flannel drawers reaching to the waist should be worn as a protection. Gentle exercise, not pushed to the verge of fatigue, should be en- couraged. Walks and drives in the fresh air are the best means of fostering sleep and maintaining the appetite and general assimilative processes. Violent exercise, on the other hand, is liable to produce miscarriage. It is stated that the predisposition to miscarriage is greatest at the third and seventh month. Throughout pregnancy special care should be observed at the recurrence of the menstrual epochs. Long railway journeys at such times are a frequent cause of trouble. Marital relations, though not absolutely to be prohibited, should be of infrequent occurrence. Excesses in the newly married are a common source of abortion. The skin should be kept in good condition by frequent bathing, as by its eliminative action it is capable of relieving the kidneys of a por- tion of the work thrown upon them. The increased vaginal secretion renders it important for the woman to frequently wash the external genitals. The vaginal douche is a source of comfort to many women, but the quantity injected should not exceed a pint of water, and should be introduced slowly, with every precaution in the way of allowing an immediate reflux to take place. The increased irritability often observable in pregnant women calls for the greatest forbearance and gentleness on the part of those who are brought into close contact with them. Their unreasonableness is not to be cured by either impatience or stern treatment. It is the product of nervous derangement, and is to be regarded as due rather to physical than to moral fault. The Disorders of Pregnancy. — Among women reared amid the refinements of civilization the entire period of pregnancy is very fre- quently attended with a great deal of discomfort. The attempt to relieve the disorders of pregnancy seriatim, it should be stated in a general way, is a vain undertaking, and is a good method to beget hys- teria by fixing the female's attention upon minor ailments. The best medicine, in a large proportion of cases, is to devise amusements and occupations calculated to produce a forgetfulness of self. When, however, the disorders of pregnancy advance beyond the stage of dis- comfort to that of actual suffering or danger, every effort should be put forth for their relief or mitigation. The Blood-Changes of Pregnancy.—The most important changes consist in the loss of red corpuscles and albumen. The former, as the oxygen-carriers to the tissues, are illy spared from the economy. When they have undergone destruction to any material extent, the cell-elements, whose vitality is intimately associated with the power to take oxygen from the blood, suffer from inanition, and the starved cells waste or fill with fatty molecules. These changes are of neces- THE MANAGEMENT OF PREGNANCY. 117 sity followed by loss of weight, muscular prostration, impaired func- tional activity of the secretory organs, and increased nerve irritability. As a consequence, the appetite fails, the digestion is weakened, neural- gic pains develop, and even moderate muscular exertion is attended with effort and followed by a sense of fatigue ; vertigo, loss of memory, and, in severe cases, chorea, hysteria, and insanity, may result from the deranged condition of the nerve-centers ; attacks of syncope, palpita- tions, and precordial oppression point to feeble heart-action ; the arte- rial tension is lowered and venous hyperaemia results ; and, finally, the stagnant blood, deprived of its albumen, in place of inviting endos- motic currents, transudes through the walls of the vessels, giving rise to oedema and dropsical effusions. Gusserow* (1871) called attention to the fact that the anaemia of pregnancy might progress to such an extreme as to produce a fatal termination. The treatment of anaemia is largely prophylactic. Light, air, moderate exercise, good food, regulation of the bowels, cheerful society, and an occasional respite from household and family cares, will always be the main checks to its extreme development. Iron, though of little avail in repairing losses which have already taken place, is of the ut- most value in limiting the progress of the malady. Iron reduced by hydrogen, in three-grain doses, either alone or combined with a fiftieth of a grain of arsenic, has rendered me most service in this affection. It should, however, be continued without intermission for weeks at a time in order to obtain the full advantage of its beneficent action. The liquid forms of iron, so useful at other times, I have rarely found tolerated for a lengthened period in the pregnant state. In weakened states of the stomach, when the latter revolts at beefsteak and mutton, easily assimilated albuminoid articles, such as milk, soft-boiled eggs, and scraped raw or underdone meat, should be administered in small but frequently repeated portions. Where the marasmus is extreme, and the rectum tolerant, the stomach may be relieved of a part of its duty by the use of nutritive enemata prepared in accordance with the now familiar prescription of Leube. In the pernicious form of anaemia, Gusserow tried transfusion, but without success. He recommended, therefore, the resort to premature labor. In a case which occurred to me in hospital practice, before my attention was drawn to Gusserow's essay, I employed the latter method after consultation with my col- leagues. The patient made a slow but apparently sure progress tow- ard recovery, until, at the end of a month, she managed, in the tem- porary absence of the ward nurse, to get out of bed and make a hearty meal of corned-beef and cabbage. Vomiting set in, followed by collapse, which proved fatal in a few hours. This pernicious form of anaemia, though not confined to multiparae, develops most * Gusserow, "Ueber hochgradigste Anaemie Schwangerer," "Arch. f. Gynaek.," Bd. ii, p. 218. 118 PREGNANCY. frequently in women who have borne many children in rapid suc- cession. A not unusual result of hydraemia consists in a swelling of the lower extremities, beginning at the ankles, and thence extending up- ward and invading often the labia, the vagina, and the lower segment of the uterus. When not associated with kidney complications, this oedema is rarely dangerous, though often the source of extreme dis- comfort. In some cases of oedema of the vulva, the labia may attain to the size of a man's head, and become nearly diaphanous from the serous infiltration. When the distention is extreme, gangrene may threaten and make it necessary to resort to puncture. In lying-in hospitals this should be done with every antiseptic precaution. With free drainage established, the swelling rapidly subsides. In a half- dozen cases which I have thus far treated in this manner, premature labor has followed in the course of two or three days, a coincidence of such frequent occurrence as to make it necessary to employ puncture with circumspection. (Edema of the lower extremities seldom disappears entirely before confinement, though relief is sometimes experienced in the last month, when the fundus of the uterus falls forward. Slight degrees, such as swelling limited to the feet, making it necessary for the woman to go around in old shoes or her husband's slippers, do not require treat- ment. Where, however, the skin of the limbs becomes tense and painful, warm cloths should be applied, diaphoresis if possible should be induced, tonics should be administered, and the patient be kept in a recumbent position, or with the extremities raised a V Amerieaine. Hydragogue cathartics, by still further impoverishing the blood, tend to aggravate the difficulty. Varicose Veins.—Varicose veins occur with greater frequency in multiparae than in primiparae. So long as the large veins are not involved, they possess slight significance. The saphena is always first affected, then the lateral branches upon the inner surface of the leg and thigh, especially just above the knee,* and less commonly the veins of the vulva. Dilatation of the haemorrhoidal veins is a very frequent occurrence. The treatment of varicose veins is limited to the adoption of meas- ures to prevent their increase, and to provide against the dangers of rupture. The first indication is best fulfilled by regulation of the bowels and the wearing of elastic stockings. The injection of one to two grains of ergotine in solution has been recommended, and is re- ported not to awaken uterine contractions. As the danger of rupture is not speculative (Spiegelberg t reports two cases of fatal hemorrhage * Spiegelberg, loc. cit., p. 250. f Ibid., p. 250. For a complete discussion of the subject, vide " Des varices chez la femme enceinte," "These d'Agr^gation," par le Dr. P. Budin. THE MANAGEMENT OF PREGNANCY. 119 from this cause), the patient should always be provided with a com- press and bandage, which she should be taught to apply herself in case of a sudden emergency before professional aid can be obtained. Nausea and Vomiting.—There are few known therapeutical agents which have not at one time or another been essayed as remedies for the nausea and vomiting of pregnancy. Some of them have even en- joyed for a time high repute as specifics, but the sobering effect of experience has invariably served to dispel illusive hopes, the most suc- cessful of them proving uncertain, and of benefit to only a limited class of patients. It is usually, therefore, the part of prudence to do nothing for the minor degrees of the affection, such as the ordinary morning-sickness, or even for continuous nausea, so long as the inges- tion of food and the general nutrition of the patient are undisturbed. For these cases Seyfert's advice to let the wife go home on a visit to her mother, implying the value of changed surroundings, furnishes a serviceable hint in the way of practice. When, however, the distress- ing symptoms continue after the first three months, and perceptibly tend to exhaust the vital powers, every resource should be tried in turn, in the hope that some one of the many in repute may prove of service as a means of warding off impending disaster. At the outset of any systematic plan of treatment for pregnancy- vomiting, it is essential that the physician should inspire his patient with confidence in his ultimate success. Care should be taken to reg- ulate the bowels, as constipation invariably aggravates existing gastric disturbance. If, in the early months, the uterus is found retroverted or retroflexed, it should be replaced in the knee-chest position, and the recurrence of the displacement should be prevented by a suitable pessary. A speculum examination should be made of the cervix, and, should it be found eroded, the raw surface should be brushed at inter- vals of from two to three days with a ten-per-cent. solution of nitrate of silver. In quite a number of cases a mitigation of the distress is obtained by applying the faradaic current to the pit of the stomach ; in others, the ice-bag applied to the cervical vertebrae affords a con- siderable measure of relief. The inhalation of oxygen has likewise been tried by Pinard with success. To many, ice-cold effervescent drinks are grateful. Dr. Fordyce Barker recommends carbonic-acid water containing a drachm of bromide of potassium to the siphon. Dry champagne is of assistance to a comparatively small class, but more often I have found it revolting to a squeamish stomach. Of medicinal agents, subnitrate of bismuth and the oxalate of cerium possess the widest application. Usually I order ten grains of the former, com- bined with five to ten grains of the latter, to be taken ten minutes be- fore eating. In cases of gastric catarrh, my favorite is the tincture of nux vomica given in ten-drop doses before meals. Drop-doses of Fowler's solution at meal-time are said to exert considerable influence 120 PREGNANCY. in allaying stomach irritability. A twelfth of a grain of morphia given hypodermically or by the mouth will frequently aid the retention of food by the stomach, but may lead to the formation of the opium- habit. Simmons, of Yokohama, recommends the injection of thirty grains of chloral per rectum morning and evening, a practice of which Eichardson advises further trial.* After eating, digestion may be promoted by ten grains of pepsin, given alone or with either the dilute muriatic acid or Horsford's acid phosphate, t If the foregoing measures prove of no avail, the patient should be made to take small quantities of easily digested food, such as milk and lime-water, Valentine's beef-juice, or the pulp scraped from raw or underdone beef, at hourly intervals, while rest in bed is main- tained for the purpose of avoiding the slightest unnecessary waste of tissue. When the vomiting is literally uncontrollable, a rare event in cases where tho physician commands the full cooperation of his patient, and death from starvation threatens, there remains as an ultimate resource the artificial induction of abortion, or premature labor. Before, however, proceeding to this last extreme, it is proper to remember that, in many cases, the vomiting stops spontaneously after the termination of the third month, or, when more persistent, after the sixth month of pregnancy; and that furthermore, where practicable, it should be the rule to postpone measures for emptying the uterus until after the child has become viable. Now, where it is necessary to maintain the strength of the patient for two or three weeks only in the hope of obtaining a living child, or a natural sub- sidence of the disorder, rectal alimentation is capable often of ren- dering excellent service. J Milk, eggs, and defibrinated blood * may be used for this purpose, though I have found nothing so effective as the beef and pancreas preparation of Leube. || Dr. Henry F. Campbell * Richardson, " Hydrate of Chloral in Obstetric Practice," " Trans, of the Am. Gynsec. Soc," vol. i, p. 247. f Dr. E. Copeman recommends dilatation of the os externum and cervical canal with the index-finger. The latter should be passed to the first joint, but not up to the os in- ternum. This method, which bears Dr. Copeman's name, is regarded by its author as infallible. It has likewise received the enthusiastic indorsement of Dr. Marion Sims. —(" Arch, of Med.," vol. iii.) X Dr. Btjsey, in an article published in the "Am. Jour, of the Med. Sci. " (1879, pp. 112-117), recommends stomach-rest, nutritive enemata, and the rectal administration of bromide of potassium. * To prevent decomposition, Dr. A. II. Smith advises the addition of a grain and a half of chloral to each nuidounce of the blood. || Leube's formula consists of five to ten ounces of finely-chopped beef to which should be added one third its weight of finely-minced pancreas (pig or ox). The mixture should be treated in a mortar with five ounces of lukewarm water, and reduced to a thick soup (Foster's " Clinical Medicine," p. 24). Not more than four to six ounces should be given at a time, nor more frequently than once in four hours. TnE MANAGEMENT OF PREGNANCY. 121 relates a case where a patient of his was nourished for fifty-two days by rectal alimentation alone.* Such cases, however, are very rare, owing, in my experience at least, to the fact that in time the rectum becomes intolerant of the presence of the injected materials. As the induction of abortion, or premature labor, always subjects the operator to criticism, and as its performance is by no means unattended with risk to life, it is advisable to share the responsibility with an experi- enced professional colleague. Heart-burn.—Heart-burn becomes distressing in the later months of pregnancy. It can rarely be cured before delivery, but may, in most cases, be palliated by carbonate of magnesia, or half-teaspoonful doses of aromatic spirits of ammonia. Insalivation.—Excessive flow of saliva to the extent of two to three quarts in the course of the day has been observed. For this dis- order small doses of atropia, the twelfth of a grain of pilocarpine, and the fluid extract of viburnum prunifolium have been severally recom- mended. Pruritus.—Pruritus, without any visible affection of the skin, sometimes occasions in pregnant women an unendurable degree of suffering. When general, a temporary relief may be obtained by plac- ing the patient in a prolonged soda-bath, and subsequently rubbing the entire surface with vaseline. Very commonly the itching is con- fined to the distended abdominal walls. In such cases, cloths wet with camphor-liniments, with the addition of chloroform (lin. saponis comp., | v ; chloroformi, § j), or a solution of carbolic acid ( 3 j ad Oj) applied to the itching surface will usually allay the irritation for the time. In pruritus of the vulva, in addition to local external applica- tions, great pains should be taken to cleanse the vagina with solutions of borax or carbolic acid. A half-pint slowly injected into the vagina may be employed twice daily, without risk of provoking labor. If the itching results from an acrid discharge proceeding from an ulcer- ated cervix, the application of nitrate of silver and the introduction at night of a cotton plug soaked in a solution of tannin in glycerine (ac. tannic, 3 j ; glycerinae, § j) will usually afford relief. Face-ache.—Neuralgia of the fifth nerve is a common affection in pregnant women. It can often be quieted by the external application of aconite, chloroform, or camphor liniment. Should these or kindred remedies fail, it is best to resort at once to the hypodermic injection of morphia. The recurrence of pain, as the effects of the morphia pass away, can in most cases be prevented by giving to the patient once in four hours from three to five drop doses of the fluid extract of gelsemium, suspending its administration so soon as the slightest in- dication of ptosis is produced. Croton-chloral, in from two- to five- * H. F. Campbell, " Rectal Alimentation in Pregnancy," " Trans, of the Am. Gyn. Soc," vol. iii, p. 273. 123 LABOR. grain doses hourly, has likewise proved effective. Bartholow advises not to push the remedy beyond fifteen grains. Lindner ("Arch. f. Gynaek.," Bd. xvi, p. 312) recommends ten grains at a dose given at bedtime. Cephalalgia.—Headache should be treated according to the cause. Constipation should be removed, and iron should be given when the headache is dependent upon anaemia. If of malarial origin, I have never hesitated to give quinine in large doses, and have never yet ob- served its acting as an oxytocic. AVhen purely of reflex origin, the guarana-powder, the diffusible stimulants, and the entire range of nerve sedatives are indicated. Unfortunately, there are no fixed rules by which, in a given case, the appropriate remedy can be invariably selected. Insomnia.—Troublesome sleeplessness may toward the end of preg- nancy reduce a woman to an unfavorable condition for encountering the perils of childbirth. The main reliance should be placed, where possible, upon moderate exercise, upon bromide of potassium, chloral, camphor and hyoscyamus, and codeine. The ordinary forms of opium should be placed under the ban, on account of the fatal facility with which the opium-habit is acquired. Even in ordering the less ob- jectionable hypnotics, care should be taken against their continued employment. With proper caution, however, their occasional admin- istration for the purpose of breaking a morbid habit is to be com- mended. LABOR CHAPTER VII. THE PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. Causes of labor.—Uterine contractions.—Action of labor-pains upon the uterine walls.— Contraction of ligaments.—Action of abdominal muscles.—Action of vagina.—The pain of labor.—General influence of labor-pains upon the organism.—Precursory symptoms of labor.—First, second, and third stages of labor.—Duration.—Action of the expellent forces. Under the term labor are comprised all the physiological and me- chanical processes by means of which the extrusion of the ovum from the maternal organs of generation is effected. As the term implies exertion, its application is restricted to the parturient efforts of vi- viparous animals. The duration of pregnancy varies widely in the PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. 123 different classes of the animal kingdom. The occurrence of normal labor is coincident with the maturity of the foetus. This, in man, is found to correspond very nearly to the interval between ten menstrual periods. Causes of Labor. Speculation as to the proximate causes of labor have so far proved profitless. The following particulars comprise the extent of our knowledge of the conditions which prepare the way during pregnancy for the final expulsive efforts : 1. During the first three months the growth of the uterus is more rapid than that of the ovum, which is freely movable within the uter- ine cavity, except at its placental attachment. In the fourth month the reflexa becomes so far adherent to the chorion that it can only be separated by the exertion of some slight degree of force, and the am- nion is in contact with the chorion. After the fourth month the chorion and amnion are agglutinated together, though even at the ter- mination of pregnancy they may with care be separated from one another. After the fifth month the agglutination of the decidua vera and reflexa takes place. In the second half of pregnancy the rapid development of the ovum causes a corresponding expansion of the uterine cavity, the uterine walls becoming thinned, so that by the end of gestation they do not exceed upon the average two to three lines in thickness. The vast extension of the uterine surface is not, however, simply a consequence of over-stretching, a fact shown by the circum- stance that the uterus toward the close of gestation is increased nearly twenty-fold in weight, and by the histories of extra-uterine fetations, in which, up to a certain limit, the uterus enlarges progressively, in spite of the non-presence of the ovum. The augmented weight of the uterus is the result of the increase in length and width of the indi- vidual muscular fiber-cells, the extreme vascular development, and the abundant formation of connective tissue. Up to the sixth and a half month there has further been observed a genesis of new fiber- cells, especially upon the inner uterine surface. According to Ranvier, the smooth muscular fibers become striated as the end of gestation is reached.* The precise manner in which the distention of the uterus is accom- plished has as yet not been demonstrated. A priori only two possibil- ities are apparently admissible, viz., either the individual structure elements are stretched after the manner of elastic bands, or a rear- rangement of the muscular elements takes place in such wise that a certain proportion of the fiber-cells, instead of lying, as in the begin- ning of pregnancy, parallel to one another, gradually, with the ad- vance of gestation, are displaced, so that the ends only are in juxta- position. It is probable, though not proved, that toward the close * Vide Tarnier et Chantreuil, " Traits de Part des accouchements," p. 203. 124 LABOR. the thinning 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 muscular organ, from the extreme tension to which its fibers are ultimately subjected. Countenance to the affirmative side is afforded by the tendency to premature labor in hydramnion and multiple pregnancies, in which a high degree of tension is reached at a period considerably antedating the complete development of the foetus. 2. There is a perceptible increase of irritability in the uterus from the very beginning of gestation. Indeed, the facility with which con- tractions may be produced by manipulating the organ through the abdominal Avails has been put forward by Braxton Hicks as one of the distinguishing signs of pregnancy. This irritability is especially marked at the recurrence of the menstrual epochs, and becomes a more and more prominent feature in the latter months, when spontaneous painless contractions are ordinary incidents of the normal condition. 3. The researches of Friedlander, Kundrat, Engelmann, and Leo- pold have demonstrated that the decidua vera of pregnancy is dis- tinguishable into an outer, dense, membranous stratum, composed of large cells resembling pavement epithelia, probably metamorphosed cylindrical cells, and an—in appearance — underlying mesh-work, formed from the walls of the enlarged decidual glands. It is in this spongy layer that the separation of the decidua takes place, the Fig. 72.—The mucous membrane of the uterus. A, amnion; R, reflexa ; D, decidua vera; D, R, glandular spaces of the lower stratum ; M, muscular structure of uterus. (Engel- mann. ) fundi of the glands persisting, even after the expulsion of the ovum. By many, a fatty degeneration of the cells of the decidua has been observed toward the end of pregnancy, but Leopold, Dohrn, and Langhans have shown that this is not of constant occurrence.* The * LEoroLD, "Studien iiber die Schleimhaut," etc., "Arch. f. Gynaek.," Bd. xi, p. 49. PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. 125 trabeculae which inclose the spaces of the net-work diminish in size with the advance of pregnancy. Thus, while they measure at the fourth month about ^ of an inch in thickness, they become gradu- ally reduced in the subsequent months to ^fa^ of an inch, a change which materially facilitates the peeling off of the decidual surface.* 4. From the fifth month onward, large-sized cells make their appearance in the serotina, especially in the neighborhood of thin- walled vessels. The largest of these so-called giant-cells contain some- times as many as forty nuclei. Though a physiological 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 coagulation of the blood, and to the formation of young connective tissue, by means of which a portion of the venous sinuses becomes obliterated before labor begins. The subtraction of these vessels from the circulation tends to increase the amount of the venous blood in the intervillous spaces of the placenta. 5. It is proper to recall here the fact that the nerve-filaments of the uterus are derived in principal measure from the sympathetic system. The large cervical ganglion, which in pregnancy measures about two inches in length by one and a half inch in breadth, receives, however, in addition to the sympathetic fibers, 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 patients, with paralysis of the lower ex- tremities, 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 J 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 hand, Schlesinger * has shown that the sympathetic is not the only motor nerve, as reflex 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. * Engelmann, " The Mucous Membrane of the Uterus," p. 45. \ Op. cit., pp. 492, et seq. X Tarnier et Chantreuil, "Traite" de l'art des accouchements," p. 229. * Ober und Schlesinger, Strieker's " Wiener med. Jahrbuch," 1872. 126 LABOR. Reflex movements of the uterus may be provoked by stimulating the central end of any of the spinal nerves, a fact which serves to ex- plain the consensus long recognized as existing between the breasts and the organs of generation. When the spinal cord is divided below the medulla oblongata, this phenomenon 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 acts 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 move- ments. Finally, Kehrer f has shown that, when a cornu is removed from the uterus during labor, rhythmic contractions of the mus- cular fibers will continue from a half-hour to an hour after separa- tion, provided only the tissues be kept moist and at a suitable tem- perature. The following theory of the causes of labor is offered, not because of its completeness, but merely as a means of grouping the foregoing facts together in the order of their relative importance. The advance of pregnancy is associated with increase in the irritability of the uterus, a property most pronounced at the recurrence of the menstrual epochs. By thinning of the partitions between the glandular structures the way is prepared, as the time for labor approaches, for the easy separa- tion of the dense inner stratum of the decidua. The ready response of the uterus to stimuli reflected from the peripheral extremities of the spinal nerves, to direct local irritation, and to the presence of blood surcharged with carbonic acid in the uterine vessels, explains the fre- quency of painless contractions for days, or even weeks, in 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 circulatory disturbances in the cerebral centers sometimes effected by vivid emotions. Frequently repeated uterine contractions, without partial separation of the decidua, are hardly comprehensible after the decidua vera and reflexa are brought into close contact with one another. Such a physiological separation would, of necessity, when of sufficient extent, by converting the ovum into a foreign body, furnish an active cause for the advent of labor, in the same way that labor is prematurely excited by a similar separation when artificially induced. Thus, by the time the development of the foetus is com- pleted, all things are in train for its expulsion. When other causes do not early operate as determining forces, the increase of uterine * Vide Schlesinger, Strieker's " Wiener med. Jahrbuch," 1873. \ Kehrer, " Beitrage zur vcrgleichende und experimentellen Geburtskunde," 2tes Heft, p. 48. PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. 127 irritability at the recurrence of the menstrual epochs probably ac- counts for the ordinary coincidence of labor with the tenth cata- menial date. Physiological Phenomena of Labor. The Uterine Contractions.—The uterine contractions are entirely independent of volition. As in other organs composed of smooth muscular fibers, each contraction at the beginning is slow and weak • gradually it reaches the point of greatest intensity ; the acme con- tinues for a brief period, and then, finally, is followed by complete relaxation. Each complete excursion is termed a labor-pain. Peri- staltic movements have been observed in animals with two-horned uteri. A similar action, proceeding from the fundus to the cervix, has been sometimes assumed for the human subject. The peristaltic wave, however, if, indeed, it exists, extends so rapidly that it is best to consider the uterus as a hollow muscle, which contracts simulta- neously in all its parts. As labor advances, an increase in the length and the force of the contractions is developed. The stronger the pains, the shorter the interval between them. The average normal duration of a labor-pain is about one minute. The Action of Labor-Pains upon the Uterine Walls.—During the intervals between the pains, it is well known that the uterus possesses an ovoid shape, and is flattened antero-posteriorly by the pressure of Fig. 73.—Transverse section, dotted line Fig. 74.—Longitudinal section, dotted representing shape of uterus during line representing elevation of fun- a pain. (Lahs.) dus during a pain. (Lahs.) the abdominal walls. During the pains, however, the uterus, as it closes upon the fluid contents of the ovum, assumes a more nearly globular outline. As a consequence, the transverse diameter is dimin- ished, and the antero-posterior increased in corresponding proportion. By this change, the uterus, which had previously rested by its poste- 128 LABOR. rior surface upon the spinal column, rises upward so that its fundus produces a bulging of the anterior abdominal walls. Inasmuch as the lower uterine segment progressively diminishes in thickness toward the cervix, its walls offer less resistance to the pressure of the ovum, and thus are stretched downward during each pain. While, in contractions of the uterus, the lower segment is thinned, the diminished bulk of the contracted organ leads to an increase in the thickness of the walls of the body and fundus. * The Contractions of the Uterine Ligaments.—Structurally the mus- cular fibers of the round and broad ligaments are in direct continuity with the external muscular layer of the uterus. As would be anticipated, they contract simultaneously with that organ. In contracting, they fix the uterus at the pelvic brim, while the round ligaments serve additionally to incline the fundus forward. The Action of the Abdominal Mus- cles.—The contraction of the abdomi- nal walls is a powerful auxiliary to the expulsive action of the uterus. At the beginning of labor, the contrac- tions are voluntary, but, as labor ad- vances, they become more and more reflex in character, until, in many women, the disposition to press dur- ing each pain assumes the form of an uncontrollable impulse. The mechanism by which these auxiliary forces are called into play is as follows *. As, toward the acme of the pain, the fundus uteri is elevated and lifts up the abdominal walls, the woman takes a deep inspiration, the glottis closes, and the diaphragm contracts. The latter pushes the intestines downward, and thus aids in raising the uterus to a position nearly perpendicular to the pelvic brim. All the expiratory muscles then enter into active contraction. Meantime, the laboring woman secures fixation of the trunk by find- ing points of support for the upper and lower extremities. By these means the capacity of the abdominal cavity is greatly diminished, and the uterus is compressed not only by the adjacent muscular cover- ings, but by the entire mass of inclosed viscera. The effect is twofold : 1. There results an augmentation of the intra-uterine pressure. 2. A portion of the contents of the large vessels of the trunk is forced to the extremities. To this cause is attributable the flushed, congested appearance of the face during labor-pains. As the intra- * For most of the following deductions the writer is indebted to Dr. Lahs's ingenious work, entitled " Die Theorie der Geburt." ""cT Fig. 75.—Diagram representing the changes in the thickness of the uterine walls during labor. (Lahs.) PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. abdominal pressure is not brought to bear upon the organs within the pelvic cavity, hyperaemia of the vagina and the contiguous tissues follows. As a consequence, the channel through which the head has to pass, as labor advances, becomes infiltrated with serum, and offers less resistance to the presenting part. At the same time the glandu- lar structures are excited to increased action, and the lining mucous membrane becomes lubricated by the secretion which is freely poured out. The Influence of the Vagina in Parturition.—As the head advances through the cervix, the vagina at first opposes an obstacle to its fur- ther progress. After, however, the largest circumference of the child has passed through the genital canal, the contractions of the vagina aid somewhat in the expulsion of the after-coming extremities and of the placenta. The Pains of Labor.—The painful sensations, which are the accom- paniment of the uterine contractions, begin in the lower uterine seg- ment. They are at first especially felt over the sacrum, whence they radiate to the rectum and the bladder, across the abdomen, and down the thighs. In the beginning of labor, the sensations are dull, and of a bearing-down character. As labor advances, however, the pains increase in acuteness, and in many persons reach an unendurable de- gree of severity. They are mainly induced through the compression of the uterine nerves by the contractions of the muscular fibers. The severity of the pains is consequently proportioned to the resistance to be overcome. At first, as has been stated, confined to the lower segment of the uterus, the pains subsequently invade the body and the fundus. The sufferings of the female increase with the mechani- cal distention of the cervix, especially with that of the external orifice, and finally reach the point of supreme agony as the head passes through the vagina and vulva, which are abundantly supplied with sensitive spinal nerves. Though no labor is absolutely painless, where the first stage is slow and the resistance of the soft parts slight, the suffering may become comparatively insignificant. Influence of the Pains upon the Organism.—During each pain the arterial pressure is increased ; the frequency of the pulse rises until the acme is reached, when it slowly declines to the normal point; the respirations are slowed during the pains, owing to the contraction of the abdominal walls, but are more rapid in the pauses as a consequence of the general muscular exertion ; the temperature rises progressively during labor, but, as a rule, within narrow limits; and the urinary excretion, in consequence of the increased arterial pressure, is aug- mented.* * Naegele, "Lchrbuch der Geb.," p. 163. 9 130 LABOR. The Clinical Course of Labor. Precursory Symptoms.—About the thirty-ninth week of pregnancy it is usual for the entire uterus to sink somewhat downward into the pelvis, while the fundus falls forward. This change of position is followed by considerable relief to the respiration, and to previously existing gastric disturbances. At the same time there is experienced an increased difficulty in locomotion ; the oedema of the lower extremi- ties is aggravated ; the intra-pelvic pressure causes a frequent desire to urinate, and predisposes to the development of haemorrhoids, espe- cially where, as is the rule in primiparae, the head likewise descends deep into the pelvic cavity. Indeed, in primiparae the changes of position are more pronounced than in women who have passed through repeated pregnancies. As gestation draws to a close, a copious glairy secretion is poured out from the cervix, the vagina relaxes, the labia majora become swollen, and the vulva gapes open. For a variable period preceding the advent of labor, painless contractions occur at irregular intervals. These so-called dohres presagientes are the ordinary prelude to labor in multiparae, though they are often inappreciable in primi- parae. They very commonly begin in the evening hours and continue till toward the middle of the night. Very often they are associated with a dragging sensation between the sacrum and symphysis, and a feeling of tension in the abdominal region. Sometimes they expand the os internum to a considerable extent, but never in such a way that any portion of the cervical canal contributes to the enlargement of the uterine cavity. Actual labor has been divided, as a matter of clinical convenience, into three stages, as follows : First stage, or stage of dilatation of the cervical canal. Second stage, generally termed the stage of expulsion, comprising the period from the dilatation of the cervix to the expulsion of the child. Third stage, or stage of the placental delivery. 1. The First Stage—Dilatation of the Cervix.—The advent of true labor is characterized by painful contractions, which render the patient restless, and dispose her either to bend forward with clinched hands, or to seek some firm support for the sacrum to ease her sufferings. Usually, in the beginning of labor, women prefer the sitting posture, which enables them to press with the forearm against the sacrum dur- ing the pains. The pain of labor begins with the dilatation of the internal os. In true labor the dilatation progresses gradually. As the os internum opens, the contractions cause the membranes to descend and press upon the cervical canal. With the advance of labor, the pains increase in intensity and frequency. During their persistence the external os is put upon the stretch, so that the border becomes thin PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. 131 and sharply defined.* As the pain subsides, the os relaxes and the * membranes retreat. Each new pain increases the dilatation, and forces the membranes somewhat deeper. The softening, the relaxation, and the hypersecretion of the soft parts become more and more decided. As the borders of the os yield to pressure, lacerations form, which tinge the mucous discharges with blood. When the dilatation has reached a certain limit (usually by the time the diameter of the exter- nal os is three to three and a half inches), the protruding membranes remain tense in the intervals between the pains, and are then ready for rupture. After rupture, which usually occurs spontaneously, the water Fio. 7G.—Section through a frozen corpse. Stage of expulsion. (Braune.) 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. After a short pause the head descends into the cervix, the walls of which are stretched to the pelvic borders, and * In multipara? this resistance of the external os may be entirely lacking. 132 LABOR. finally become so far dilated that cervix and vagina form one continu- ous canal. In case the presenting part does not thoroughly tampon the lower segment of the uterus, a more or less complete escape of the entire amniotic fluid may follow the rupture of the membranes. As a rule, the tear in the membranes takes place in the most dependent point of the convex portion which constitutes the bag of waters in the cer- vical canal. Sometimes, however, the rupture takes place above the cervix, where there can be a gradual escape of fluid in spite of the persistence of the bag of waters. If the membranes rupture before the dilatation of the cervix is Fig. 77.—The uterus and parturient canal. Fcetus removed. (Braune.) complete, the head descends and acts as a dilating wedge. In rare cases the rupture of the membranes, if left to nature, does not occur, and the ovum may descend in its integrity to the vulva. In such in- stances the membranes sometimes rupture in the neighborhood of the PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. 133 child's neck, and the head is born covered with the so-called "caul," i. e., with the detached portion of the membranes, which old nurses regard as significant of good luck. In still rarer cases, where the foetus is small and the amount of amniotic fluid limited, the entire ovum may be expelled without rupture of its coverings. 2. The Stage of Expulsion.—After the short pause which follows the rupture of the membranes, the pains become stronger and more frequent, and are now powerfully reenforced by the involuntary con- tractions of the abdominal muscles, which, though previously not entirely inactive, have played only a subordinate part. With each pain the head now makes perceptible progress, retreating, however, as the pains decline. After the head has passed the pelvic outlet, and is covered only by the soft parts, the perinaeum bulges outward, the labia gape, and a portion of the head makes its appearance at the vulva. As within the pelvic canal, with each pain the head advances, and puts the perinaeum upon the stretch, receding somewhat in turn as the pains subside. The pressure upon the rectum leads to the evacuation of fecal contents. Finally, the thinning of the perinaeum reaches a point at which the sutures can be readily felt through its structure; the re- cession of the head ceases ; the anus assumes an oval shape ; the orifice of the vulva looks forward and upward ; the urethra is pushed against the symphysis pubis; while, as the circumference of the head in the neighborhood of the parietal bosses engages in the vulva, the labia and fraenulum form a thin circular band, through which, dur- ing a pain or the contraction of the abdominal walls, the head makes its way, usually leaving behind moderate lacerations of the fraenu- lum or anterior portion of the perinaeum. The same, or the succeed- ing pain, leads then to the expulsion of the trunk. The birth of the child is followed by the outpouring of the amniotic fluid, which, as a rule, escapes colored with blood from the site of the wholly or par- tially detached placenta. 3. The Placental Period.—The placental period embraces the time from the birth of the child to the delivery of the placenta and mem- branes. After the birth of the child, the recession of the blood from the brain, which follows the diminution of the intra-abdominal pressure, often produces a sense of faintness, and sometimes temporary syncope. The rapid evacuation of the uterus is at times, too, succeeded by a chill, which, however, does not betoken the onset of fever, but is the result of vaso-motor disturbance, and the loss, through the expulsion of the child, of a source of heat-supply. Most Avomen, however, experience a restful feeling of comfort and repose. This sense of quietude lasts anywhere from a few minutes to a quarter of an hour, when the con- tractions return, which detach the placenta, and force it into the vagi- na. The separation of the placenta takes place in the meshy, lamel- 134 LABOR. lated layer which is formed in the serotina by the thinned, elongated walls of the gland-tubules, the dense cell-layer which forms the ma- ternal portion remaining adherent to the placenta. As the maternal vessels are necessarily torn across, some haemorrhage follows the de- tachment. The haemorrhage is, however, speedily arrested by the con- tractions of the uterus, which both compress the vessels and furnish the conditions favorable to the formation of fibrinous clots in their distal extremities. When the mechanism of expulsion is left to nature, the placenta descends by its edge into the vagina, while premature trac- tions upon the cord cause it to present by its fetal surface at the cer- vical orifice. When once in the vagina, the expulsion is completed by the action of the abdominal muscles, sustained by the retraction of the muscles which form the floor of the pelvis. According to Gassner,* after confinement the female experiences, as a consequence of the expulsion of the ovum, of the exhalations from the lungs and skin, from the discharge of excrements, and from haemorrhage, a loss of weight equivalent to one ninth of that of the entire body. Duration of Labor.—Spiegelberg found, in 506 labors, the average for primiparae was 17 hours, for multiparae 12 hours. In primiparae past the thirtieth year Hecker found the average 21*1 hours, while Ahlfeld in 82 women over thirty-two years of age obtained an average of 27*6 hours, f In ordinary normal labor the second stage lasts about two hours in primiparae, and about half as long in multiparae, though in the latter the resistance is frequently so slight that a few pains suffice to com- plete the delivery. According to Kleinwachter,J the time at which labor-pains begin occurs most frequently between ten and twelve o'clock in the evening. Spiegelberg * states that the maximum frequency of births takes place between twelve and three o'clock in the morning. The Action of the Expellent Forces. Having considered separately the action of the uterus, the uterine appendages, and the abdominal muscles during labor, there remains for us to combine these factors together, and to show in what manner they contribute to the end of all parturient effort, viz., the expulsion of the ovum. In the first place, the contractions of the uterus are intermittent. * Gassner, " Ueber d. Yeranderungen des Korpergcwichtes b. Schwang., Gebar. und Wochner," "Monatsschr. f. Geburtsk.," xix, p. 18. f Spiegelberg, "Lehrbuch," pp. 134, 135. X Kleinwachter, "Die Zeit der Geburtsbeginnes," "Ztschr. f. Geburtsh.," Bd. i, p. 230. # SriEGELBERG, " Lehrbuch," etc., p. 135. PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. When they lose their rhythmical quality, and become continuous, they cease to belong to the domain of physiology. It is only during the act of contraction that work is performed. Whenever the alternating relaxation ceases, and the uterus passes into a condition of tonic con- traction, no work is accomplished, and the pains are ineffective. The uterus is a hollow muscle, which, during a pain, closes down upon its contents. If all parts of the uterine walls were of equal thick- ness, the contractions would be entirely expended upon the periphery of the ovum, and, as the contents of the latter are practically incom- pressible, the effort would be resultless. If, however, the walls were so constructed that the thickness varied in different regions, the periph- eral compression exerted during a pain would be followed by a bulg- ing at the points of least resistance, provided the thinned tissues pos- sessed the property of elasticity. Now, the unequal development of the uterine walls and the elasticity of the uterine tissue-elements are both anatomical facts. Thus, the fundus and the lower uterine segment are materially thinner than the intermediate portion. Indeed, the latter is often two to three times as thick as the lower segment.* As a result, therefore, of these conditions concentric pressure of the fluid contents of the ovum is followed by an increase in the longitudinal diameter of the uterus. While the convexity of the fundus is un- questionably increased during a pain, the effect of the latter is chiefly manifested in the distention of the lower segment. Various causes combine to produce this result. Near the cervix the tissues are not alone thinner, but the fibers run for the most part in a more nearly longitudinal direction, and therefore offer a weaker resistance than that afforded by the close interlacement of both circular and longitu- dinal fibers which prevails in the fundal and upper uterine zones. Then, too, as was pointed out by Lahs,f the lower segment sustains, * In 1876 Bandl (" Ueber das Verhalten des Uterus und Cervix in der Schwanger- schaft und wiihrend der Geburt") called attention to the thinned condition of the lower uterine segment, extending from what had previously been regarded as the os internum from four to six inches upward, and terminating abruptly in a muscular ridge upon the inner surface. This ridge, under the name of the ring of Bandl, has been the subject of warm discussion. Bandl regards it as the true os internum, and the thinned lower seg- ment as the upper portion of the cervical canal which has been opened by the growth of the ovum. What is usually regarded as the anatomical cervix, he insists, is simply the lower persistent portion of the original canal. This revival in a new form of the old Roederer doctrine has been bitterly attacked, and as hotly defended. The discussion turns chiefly upon the true limit of the cervical mucous membrane, but upon this point the observations of anatomists are at wide variance. For recent publications in favor of Bandl's views, vide Kustner, "Arch. f. Gynaek.," Bd. xii II. 3 ; Marchand und Bandl, ibid., Bd. xv, II. 2. In favor of the preservation of the cervix during pregnancy, vide Muller, ibid., Bd. xiii, H. 1; Langhans und Muller, Bd. xiv II. 2; Sanger, II. 3; Thiede, "Ztschr. f. Geburtsh. und Gynaek.," Bd. iv, H. 2; McDonald, " Obstet. Jour, of Gr. Brit, and Ire.," July, 1S77. •f- Lahs-, "Die Theorie der Geburt," p. 116. 136 LABOR. in the ordinary positions assumed by the female, the entire weight of the superimposed ovum with its fluid and solid contents; and, finally, the pressure, transmitted from the abdominal muscles, takes a direc- tion from above downward. So far, for the sake of simplicity, we have regarded the uterus as a closed sac, possessing walls of unequal thickness. In reality the lower segment terminates in an opening, the canal of the cervix, which, though at the beginning of labor of small size, and offering consider- able resistance to the pressure of the ovum, is capable of sufficient dis- tention to permit the exit of the foetus. The dilatation of the cervix is partly mechanical, and partly the effect of certain organic changes which have already received cursory mention. The mechanical dilatation is the result of—1. The pressure of the ovum upon the lower uterine segment, which forces open the os in- ternum, and unfolds the cervix from above downward. 2. The retraction of the uterus, an important property, which requires brief description. While each contraction of the uterus is followed by relaxation, and a period of repose, a gradual change is continually going on in the length and arrangement of the muscular fibers. In the thinned lower segment the fibers are stretched, and separated from one another. In the upper portion, on the contrary, they shorten, and change their posi- tion in such a way that those which previously had only their extremities in contact assume a more nearly parallel arrange- ment. The walls, therefore, in the upper zones, thicken and shorten, especially in the lon- gitudinal direction. The limit between the thinned lower seg- ment and the upper thickened zones is marked by a distinct ridge termed the ring of Bandl. It is to the changes in the ute- rus which take place above the ring of Bandl that the term re- traction is applicable. As the retraction is progressive, it leads to a gradual withdrawal upward of the uterine walls, in consequence of Fig. 78.—Longitudinal section through walls cf uterus in eighth month of pregnancy (Bandl). a, ring of Bandl; b, os internum ; d, os exter- num. PHYSIOLOGY OF LABOR AND ITS CLINICAL PHENOMENA. which the lower segment is not only put upon the stretch during the pains, but, toward the end of the period of dilatation, is subjected to a greater or less degree of permanent tension. Then, too, as the rino- of Bandl moves upward, the longitudinal fibers of the lower segment^ by reason of their insertion in part at least into the vaginal portion, exert a direct influence in dilating the cervical canal. 3. AVhen the abdominal muscles contract, the uterus is pressed downward into the pelvic cavity. The descent is, however, limited by the attachment of the uterine ligaments, and the adjacent organs. But the resistance afforded by the uterine attachments exercises a pe- ripheral traction upon the cervix, and thus tends to draw its walls asunder. The normal dilatation of the cervix is, however, by no means a matter of pure mechanical distention. If the canal which forms the communication between the vagina and the uterus were simply an elas- tic tube, it would of necessity retract down upon the neck of the foetus after the passage of the head, and thus a new distention would be required to permit the passage of the shoulders. Indeed, the condi- tions of an elastic tube are not unfrequently realized in versions, where an attempt is made to extract the foetus through an im- perfectly dilated os ; in which case, after the disengagement of the shoulders, the cervix is apt to close upon the neck, and arrest the delivery of the after-coming head. That this complication does not happen as a rule is due to the fact that in natural labors the me- chanical expansion is associated with certain organic changes which render the cervix soft and distensible, and at the same time diminish its retractility. The basis of the organic changes consists in the serous infiltration of the lymphatic interspaces, which separates the tissue- elements, and deprives them of the resistance afforded by the force of cohesion. The main factor in the production of the softening of the cervix is an active hyperaemia, which the cervix shares during preg- nancy with all the pelvic organs, and which during labor is greatly enhanced by the diminished pressure to which the parts below the pelvic brim are subjected. We have already noticed how, during the acme of a pain, the contents of the uterine vessels are forced into the vessels of the intra-pelvic viscera. In normal head presentations the organic changes are in a special degree furthered by the formation of what is known as the bag of waters. As the head descends into the lower uterine segment, the contraction of the muscular fibers around its largest circumference separates a layer of fluid from the contents of the uterine cavity. At first this layer becomes tense only during a pain. With the descent of the head the tension increases, and the "bag of waters" is formed. As the abdominal pressure is not operative below the pelvic line, and as the intra-uterine pressure is arrested in a measure by the child's 138 LABOR. head, in that portion of the uterus which lies below the circle of cephalic compression, hyperaemia, serous infiltration, and softening fol- low as necessary corollaries of the anatomical conditions. The value of the bag of waters in dilating the cervix is due, therefore, not only to the hydrostatic pressure it exerts, but to the manner in which it favors the development of the organic processes described. Thus far we have considered the expellent forces as acting upon the ovum as a whole. Many authorities accept in addition a direct pressure of the fundus upon the breech of the child, which is transmit- ted through the spinal column to the cephalic pole. A little reflec- tion, however, will show, as Lahs * has pointed out, that so long as the ovum contains any measurable quantity of fluid, or at least more than enough to fill the fetal interspaces, the immediate contact of the breech with the fundus is hardly possible. To be sure, Ahlfeld f de- termined, by direct measurements, that there was an actual increase of about one and a half inch in the distance between the two poles of the child in head-presentations during the height of a pain. Schroe- der J attributes this extension to the lateral compression of the foetus, which results from the diminution of the transverse diameter of the uterus during contraction ; but it is evident that lateral pressure would equally produce an elevation of the fluid contents of the ovum, and thus, as the fundus assumes a spherical shape, prevent the impinge- ment of the breech. Moreover, it is not easy to see how, so long as the foetus is surrounded by a fluid medium, any effective propulsive force can be transmitted through a flexible column like the spine. It is certain that, in the intervals of the pains, manual pressure upon the breech through the fundus simply bends the fetal body, and deflects it from the vertical direction. Even if during a pain the lessening of the uterus in the transverse diameter hinders this movement to some extent, the increase antero-posteriorly would still leave ample space for lateral incurvation. The descent of the ovum is followed necessarily by increased ten- sion of the bag of waters. Under a pressure, estimated by Duncan * as varying, according to the resistance of the membranes, between four | and thirty-seven and a half pounds, rupture occurs. The cervix then usually closes, but remains dilatable ; i. e., it yields readily to pressure, and offers no resistance to the advancing head. The pressure exerted by the united action of the uterine and ab- dominal walls requisite to accomplish delivery, according to the esti- * Lahs, "Studien zur Geburtskunde," "Arch. f. Gynaek.," Bd. iii, p. 195. f Ahlfeld, " Arch. f. Gynaek.," Bd. ii, p. 367. X Schroeder, "Lehrbuch der Geburtshulfe," 6te Aufl., p. 156. * Duncan, " Researches in Obstetrics." || Ribemont, " Recherches experimentales sur la resistance, etc., des membranes de l'ceuf humain," p. 35, places the minimum resistance at fifteen and three fourths pounds. MECHANISM OF LABOR. 139 mates of Schatz,* based upon manometric observations, varies between seventeen and fifty-five pounds, f Although the methods by which both the results of Schatz and Duncan have been obtained possess defects, which the authors themselves make no attempts to conceal, they are quoted as furnishing approximations to the truth. CHAPTER VIII. MECHANISM OF LABOR. Anatomical factors.— Anatomy of pelvis.— Sacrum.— Coccyx.— Ossa innominata.— The ilia.—The pubes.—The ischia.—Articulations of the pelvis.—Sacro-iliac articu- lations.—Symphysis pubis.—The pelvic ligaments.—Obturator membrane.—Sacro- sciatic ligaments.—Inclination of the pelvis.—The pelvis as a whole.—The pelvic planes.—Plane of the brim.—Plane of the outlet.—Planes of the cavity.—Ischial planes.—Pelvic axis.—Differences between male and female pelvis.—Differences be- tween the infantile and adult pelvis.—The soft parts of the pelvis.—The perineal floor.—The head of the foetus at term.—Sutures and fontanelles.—The diameters of the fetal head.—The articulation of the head with the spinal column. The mechanism of labor comprehends the movements of adjust- ment, by means of which the foetus accommodates itself to the dimen- sions of the bony pelvis and to the variations in the direction of the parturient canal. Its study is, therefore, properly prefaced by the enumeration of a series of anatomical details relating to the pelvic ring and the soft tissues which form the floor of the pelvic basin, and to the structure, the diameters, and the reductibility of the fetal head. The Anatomy of the Pelvis. The following description includes only such points as are of direct obstetrical interest: The bony pelvis is formed by the union of the sacrum and coccyx and the two ossa innominata. The Sacrum.—The sacrum is a curved quadrilateral bone, inserted like a wedge between the ossa innominata. Like a wedge, it is broad above and tapers toward its lower extremity. It is composed of a central vertebral portion, and two outer masses termed the alae or wings. The central portion, as its name implies, is really a continuation of the spinal column. In early childhood it consists of five distinct ver- tebrae with well-defined joint-surfaces and intermediate cartilaginous disks ; but, with the completion of the growth, the whole becomes con- solidated into a single piece by the inter-articular deposition of bone. * Vide Schroeder, "Lehrbuch," 6te Aufl., p. 158. f Polaillon, "Recherches sur la physiologie de l'uterus gravide," p. 38, estimates the minimum pressure at twenty-three pounds. 140 LABOR. The bony union is confined chiefly to the outer circumference, and is marked by ridges termed the linea transversa. The base of the sacrum articulates with the last lumbar vertebra, with which it forms a projecting angle. It possesses a convex anterior surface, termed the promontory, which juts forward and encroaches upon the pelvic space. From the sides of the central piece there extend two triangular portions of bone, termed the alae or wings. Under normal conditions they are symmetrical. They are developed upon each side from three independent nuclei, which make their appearance near the bodies of the three upper vertebrae. They are supposed to have the morphological significance of ribs. In the course of this growth they fuse together, except at the points of junction of the bodies of the vertebrae, where they have between them open spaces or foramina, for the passage of the spinal nerves. The sacrum in the female is about four and a half inches wide, and from four to four and a half inches long, when measured from the pro- montory to the lower extremity. The sacrum possesses two curves : PROMONTORY- ARTICULAR SURFACE Fig. 79.—Sacrum and coccyx (anterior surface). one, less marked, from side to side, and the other extending from above downward. The depth of the latter is greatest just below the upper border of the third vertebra, where it measures a little over an inch. Upon the posterior surface we notice a canal, continuous with the spinal canal, which runs the entire length of the sacrum, but is incom- pletely closed at the fifth vertebra, giving rise to a slit-like opening, termed the hiatus sacralis. In the middle line the spinous processes coalesce into a vertical crest for the attachment of the erector spinae muscle. The posterior lateral masses are formed by the fusion of the transverse processes, and their consolidation with the anterior struct- ures. Xext to the vertebrae, however, spaces are left between the MECHANISM OF LABOR. 141 processes for the passage of the posterior sacral nerves. Opposite the three upper vertebrae, the outer border is known as the tuberosity of the sacrum. It possesses a roughened surface, to which are attached the sacro-iliac ligaments. The upper portion of the side of the sacrum is furnished with an ear-shaped articulating sur- face termed the superficies auricularis. The Coccyx.—The coccyx is composed of four rudimentary vertebrae, which progressively dimin- ish in size from above downward. It possesses as a whole, therefore, a triangular shape. It is at- tached to the extremity of the sacrum by a hinge- joint, and is pushed backward during defecation, and in childbirth as the head passes the pelvic outlet. It is only when anchylosed that the coccyx assumes obstetrical importance. The Ossa Innominata.—Each os innominatum may be roughly compared to a figure eight, of, which the upper and larger portion slants upward, outward, and back- ward, while the lower smaller division inclines downward and inward. Up to the age of puberty it consists really of three bones, which are connected at the acetabulum by cartilage of a Y-shape. These three bones are termed respectively the ilium, the ischium, and the pubes, names which are subsequently retained for convenience of description, in spite of the fact that in adult life the separate parts become solidly united, by the deposition of bone-tissue, into a single continuous piece. Fig.: —Section of sacrum and coccyx. Fig. 81.—Os innominatum, before consolidation. 1, ilium ; 2, ischium ; 3, pubes The iliac portion has an external surface marked by a number of roughened lines, to which are attached the three gluteal muscles. The inner surface is excavated and forms the so-called iliac fossa, which 142 LABOR. contains the internal iliac muscle. The fossa is bounded below by the linea arcuata interna, a convex ridge which contributes to form the brim of the pelvis. The upper border or crest of the ilium possesses an S-shaped curve, the anterior extremities of which are directed in- ward. The crest of the ilium terminates, front and rear, in bony prominences, termed respectively the anterior and posterior superior spinous processes. Beneath the upper spines, and separated from them by curved indentations, are two lower, less sharply defined projections, termed the anterior and posterior inferior spinous processes. Behind the iliac fossa is situated an ear-shaped articular surface, the super- ficies auricularis, which corresponds to the surface of similar name described upon the sides of the sacrum. ANT. SUP SPINOUS PROCESS. LESSER SCIATIC NOTCH TUBEROSITY OF ISCHIUM. X* OBDURATOR FORAMEN. Fig. 82.—Outer surface of os innominatum. The pubic portion consists of the body and two rami. The body presents upon its inner border an oval surface, which articulates with the pubic bone upon the opposite side. The superior border is fur- nished with a rough crest, terminating in the projecting spine. The upper, or, as it is usually designated, the horizontal ramus, possesses a ridge, the pecten pubis, extending from the spine and becoming con- tinuous with the linea arcuata of the ilium. The linea terminalis or boundary-line of the pelvic brim, is generally known as the ilio-pec- tineal line, from its sources of origin. Near the junction of the ilium MECHANISM OF LABOR. 143 and os pubis is situated a slight elevation, the ilio-pectineal eminence, which, however, according to Luschka,* belongs entirely to the pubic bone. The descending ramus helps to bound the obturator foramen, and to form the pubic arch. The ischium completes the lower portion of the os innominatum. It consists of two rami, which, with the rami of the pubic bones, include the obturator foramen. It contributes about two fifths to the formation of the acetabulum ; from this the descend- ing ramus drops vertically downward, and thence curves forward, and forms the ascending ramus, which unites with the descending ramus of the pubes. At the point where the descending ramus hooks forward there is a thickened projection, termed the tuberosity of the ischium, upon which the body rests in the sitting posture. Upon the posterior border of the descending ramus there is a sharp spine, projecting inward, which plays an important part in the mechanism of labor. Between the posterior inferior spinous process and the spine of the ischium there is a deep incurvation, termed the great sciatic notch ; while a smaller incurvation, between the spine and the tuberosity, is known as the small sciatic notch. The Pelvic Articulations.—The articulations of the ossa innominata with the sacrum are usually termed the sacro-iliac synchondroses. The anterior articulation of the innominate bones with one another is known as the symphysis pubis. * Luschka, "Die Anatomie des menschlichcn Bcckens," p. 86. 144 LABOR. The term "synchondrosis," as applied to the sacro-iliac articulation, is really a misnomer. Luschka has shown that, in place of an inter- vening plate of cartilage, section demonstrates the existence of a true Fig. 84.—Section through the left sacro-iliac articulation (natural size). (Luschka.) synovial membrane, limiting a narrow but well-defined joint-cavity. The middle third of the iliac surface is convex, and fits into a corre- sponding concave depression on the sacral end. There is likewise a Fig. 85.—Section of symphysis. (Luschka.) "bite" or ledge in front, formed by the ilium, which aids in prevent- ing the sacrum from slipping forward into the pelvic cavity. The office of maintaining the sacrum in position devolves chiefly MECHANISM OF LABOR. 145 upon the ligaments distributed front and rear, and particularly upon the very numerous and closely interwoven bundles extending from the tuberosities of the sacrum to the roughened portions, or tuberosities, of the ilia, which project posteriorly beyond the articulation. The symphysis pubis is likewise supplied with a small cavity, only the posterior portion of which possesses a synovial membrane. The fibro-cartilage between the articulating surfaces of the bones is thicker in front than behind. The anterior ligaments are more developed than the posterior ones, and allow no movements of importance to take place in the non-pregnant condition. The Pelvic Ligaments.—In addition to the ligaments which have already been noticed as contributing to the solidity of the joints, the ANTERIOR SACRO-ILIAC LIGAMENT. iJ/SACRO SCIATIC LIGAMENT. Fig. 86.—Front view of pelvis, with ligaments. (Quain.) following help to close in the pelvis. Across the obturator foramen is stretched a fibrous septum, complete except where a small opening is left for the passage of the nerve and vessels. The great sacro-sciatic ligament extends partly from the lower bor- der of the sacro-iliac articulation, and partly from the lower border of the sacrum and coccyx to the tuberosity of the ischium. The small sacro-sciatic ligament lies in front of the preceding, and extends from the side of the sacrum and coccyx to the spinous process of the ischium. These two ligaments close the large and small sacro-sciatic notches, and convert them into two foramina, which bear the same name. vis inc. The Inclination of the Pelvis.—The plane of the brim of the pel... was formerly supposed to run nearly parallel to the horizon, whence 10 146 LABOR. the term "horizontal ramus," applied to the upper branch of the pubes. As a fact, however, in the upright position, the inclination of Fig. 87.—Transverse section through pelvis, to show the sacro-sciatic ligaments. (Tarnier et Chantreuil.) the brim to the horizon varies from 45° to 100°. According to Meyer, the center of gravity, instead of passing directly through the median line of the acetabula, is situated somewhat posteriorly, so that a tilting Fig. 88.—Section showing the inclination of the pelvis according to Naegele. (Tarnier et Chantreuil.) MECHANISM OF LABOR. 147 of the pelvis backward is only prevented by the strong ilio-femoral ligaments (Fig. 86). Whatever, therefore, serves to relax the ligaments in question diminishes the angle of inclination, while positions that increase the natural tension cause the pelvis to assume a nearly vertical attitude. Experimentally Meyer found that the pelvic inclination was diminished to the greatest extent when the thighs were moderately separated and rotated slightly inward, while its increase was due to four conditions : closing the knees, stretching the legs widely apart, exter- nal rotation, and exaggerated internal rotation. Naegele endeavored to ascertain the normal inclination upon the living subject, by deter- mining the distance between the extremity of the coccyx and an hori- zontal line drawn from the lower border of the symphysis, and then placing the bony pelvis in a position conforming to the measurement thus obtained. He found in this way the mean inclination was nearly 60°, a result explained by the fact that the method of measurement rendered a separation of the knees, and consequently an increase of tension of the ilio-femoral ligaments, a matter of necessity.* Movements at the Pelvic Articulations. At the symphysis pubis during gestation the fibers which compose its fibro-cartilage become infiltrated with serum, and the ligaments elongate, so that at term the distance between the articular surfaces of the pubic bones is increased twofold. Budin has shown that if the patient, when the finger is introduced into the vagina, and pressed upward against the lower border of the symphysis, be made to walk, an elevation of the ramus upon the side of the extremity in motion can be distinctly recognized. In the rule, this mobility is most marked in women who have borne a number of children, f Zaglass first pointed out that, in spite of the close union at the sacro-iliac articulation, a certain degree of mobility between the sacrum and iliac bones existed. Thus, in defecation, when the body is thrown forward, the promontory is tilted toward the symphysis, and the in- ferior extremity of the sacrum is thrown backward, thereby enlarging the outlet of the pelvis. Matthews Duncan describes similar move- ments, only exaggerated in extent, during pregnancy, and points out how they practically contribute to facilitate labor. Thus, at the be- ginning of labor, as the head enters the brim, the woman naturally Chooses to sit up, to walk about, or, if in bed, to recline with the lower extremities extended, positions which favor the rotation back- ward of the upper portion of the sacrum, and the consequent increase of the antero-posterior diameter at the superior strait. As the head, however, descends to the floor of the pelvis, the patient instinctively * Schroeder, " Lehrbuch der Geburtshulfe," 6te Aufl., note, p. 7; Naegele, 8te Aufl., p. 31. + Tarnier et Chantreuil, " Traite de l'art des accouchements," p. 239. 148 LABOR. Fig. 89.—Diagram movements of sacrum showing oscillatory (Duncan.) draws up her knees, throws the body forward, and during a pain contracts the abdominal muscles. In this way she succeeds in tilting up the pubes, in pressing the promontory forward, and in rotating the point of the sacrum backward, so as to perceptibly increase the con- jugate diameter at the pelvic outlet. The Pelvis as a Whole.—The pelvis is divided by the linea termi- nalis into an upper and lower por- tion. The upper, or, as it is usually termed, the large pelvis, is composed of the lumbar vertebrae and the up- per surfaces of the wings of the sa- crum behind, the spreading portions of the ilia upon the sides, while the anterior segment is closed in by the muscles of the abdominal parietes. In shape, the bony part of the large pelvis has been compared to the rim of a barber's basin. Obstetrically the iliac fossae are of interest, inasmuch as they furnish shelves upon which the head of the foetus in multiparae commonly rests during the latter part of pregnancy. The inclination of the ilia to the horizon, the shape of the crests, and the distance be- tween them, together with the distance between the two anterior superior spinous pro- cesses, are important points for study, because they fur- nish data upon which valu- able inferences are based in cases of pelvic deformity, relative to the shape and dimensions of the pelvic canal. It will be remembered that the crests of the ilia possess an S-shaped curve. Normally, the widest distances between the crests measure ten inches ; the distance between the anterior superior spinous processes measures nine inches. * The slope of the inner surfaces of the ilia is such that an extension of the lines drawn from the crest to the linea termi- nalis would meet in the neighborhood of the fourth sacral vertebra. * As no two pelves possess precisely the same dimensions, pelvic measurements arc given somewhat differently by authors. They are obtained cither by taking the mean of a large number of pelves (a method which furnishes fractions difficult to remember, but Fig. 90.—Anterior half of the pelvis. MECHANISM OF LABOR. 149 The inferior or small pelvis comprises the portion below the linea terminalis. It is formed by the sacrum, the coccyx, the lower por- tion of the ilia, the ischia and pubes, the obturator membrane, and the sacro-sciatic ligaments. Together the foregoing inclose a basin- like cavity, which, though open below in the skeleton, is closed in by soft parts in the living subject. The posterior wall, formed by the sacrum and coccyx, measures five inches in a direct line from the promontory to the apex ; the anterior wall at the symphysis pubis mea- sures one and three quarters inch; the lateral walls, from the linea ter- minalis to the tuberosities of the ischia, measure three and three quar- ters inches. The posterior wall is curved ; the symphysis pubis slopes downward and inward, so as to run nearly parallel with the two upper sacral vertebrae ; the rami of the pubes approach one another at an angle of 95° to 100° and unite beneath the symphysis in the form of an arch, the arcus pubis ; the side- walls are solid in front where they are constituted by the ischia, while behind the great sciatic notch is closed only by FlG. 91._Posterioi. half of the pclvia. soft structures and the sacro- sciatic ligaments. The transverse diameter, owing to the incline of the side-walls, narrows toward the outlet. The Planes and Axes of the Pelvis.—The eccentric forms of the pelvic bones render it extremely difficult to convey a clear impression of the nature of the pelvic inclosure. As a means to this end it is customary to study a series of planes drawn at different levels through the pelvic walls, which serve to show the changes in the shape and dimensions of the bony canal at selected points of observation. By a plane is meant simply a mathematical surface, without reference to depth or thickness. The upper and lower openings are both somewhat contracted, and hence are termed respectively the superior and inferior straits, while the space between is denominated the cavity of the pelvis. The first plane requiring our attention is that of the superior strait or brim. It is bounded by the linea terminalis, and has an elliptical contour, with a depression posteriorly, produced by the projection of the promontory of the sacrum. offering no special advantages in the way of accuracy), or by selecting as the normal stand- ard either a whole number, or, where fractions are necessary, the nearest half or quarter approximating to the mean average. The latter plan recommends itself in practice equally on the score of utility and convenience. 150 LABOR. The dimensions of each plane are determined by measuring the antero-posterior, the transverse, and the two oblique diameters. DISTANCE BETWEEN THE CRESTS I01N. ISTANCE BETWEEN ANT.SUP.SP PR0C.9IN. SACR0-C0TYL0I0-. OBLIQUE DIAMETER 5 IN. conjugate 4 '/+in. Fig. 92. The antero-posterior, or, as it is generally termed, the conjugate diameter, extends from the upper border of the symphysis pubis to the promontory. Its length is four and a quarter inches. About two fifths of an inch below the upper border of the symphysis is situated the obstetrical, as distinguished from the anatomical, conjugate. The length of the former, owing to the thickening of the pubic bones, is reduced to four inches. The transverse, sometimes termed the bis-iliac, diameter is the widest distance between the ilia. It measures five and a quarter inches. The oblique diameters extend from the ilio-pectineal eminences to the opposite sacro-iliac articulations. The distance between the points mentioned is five inches. The right oblique diameter is the one directed to the right acetabulum, and the left to the left acetabulum. The axis of the superior strait is represented by a line drawn perpendicular to the center of the plane. The extension of this line falls below upon the extremity of the coccyx, and above strikes the abdomen near the umbil- of the brim is very nearly Fig. 93. The circumference icus {vide Fig. 94) sixteen inches. The inferior strait proper, or outlet of the pelvis, is bounded by the sub-pubic ligament, the pubic rami, the rami and tuberosities of the ischia, the sciatic ligaments, and the coccyx. Owing to the pro- MECHANISM OF LABOR. 151 jection of the ischia, the surface of the pelvic outlet is rendered con- vex, or, perhaps, is better described by supposing it to be composed of two obtuse-angled triangles with apices at the symphysis and coccyx, and with a common base formed by a line drawn through the ischia. ' The antero-posterior diameter extends from the lower border of the symphysis to the extremity of the coccyx. It measures three and three quarters inches, though, when the coccyx is pushed backward, the distance may be extended to four and a half inches. The transverse diameter, between the inner borders of the tuberos- ities, measures four and a quarter inches. COCCYX \--\ PUSHED BACK OBSTETRICAL CONJUGATE. HORIZON. PLANEOF OUTLET ion of the pel Chantreuil.) Fig. 94.—Section showing the inclination of the pelvis according to Naegele. (Tarnier el ;reuil.) Owing to the elasticity of the sciatic ligaments, the oblique diam- eters are not regarded as of obstetrical importance. The axis of the inferior strait, when the coccyx is not disturbed, strikes the promontory. When the coccyx is pushed backward, a per- pendicular line drawn from the center impinges upon the lower bor- der of the first sacral vertebra. The circumference of the inferior strait measures thirteen and a half inches. The pelvic cavity or canal possesses an irregular,„cylindrical shape, constricted somewhat above at the superior strait, and narrowing rap- idly at the pelvic outlet. Below the brim, the dimensions are in- creased considerably by the concavity of the sacrum. Thus, a plane passing through the lower portion of the symphysis pubis, and across 15:2 LABOR. the upper margins of the acetabula, to the junction of the second and third sacral vertebra?, gains three quarters of an inch in the conjugate, while the transverse diameter is barely one fourth of an inch less than the transverse diameter of the brim. The narrowing at the outlet is most marked in a plane drawn so as to intersect the spines of the ischia and the extremity of the sacrum. At the level indicated, the distance between the spines (transverse diameter) is but four inches, and the antero-posterior diameter four and a half inches. The sciatic spines divide the pelvic cavity into two unequal sec- tions. In the larger, anterior section, the lateral walls slope toward the symphysis and arch of the pubes, while posteriorly the walls slope in the direction of the sacrum and coccyx. The declivities in front of the spines are termed the anterior inclined planes of the pelvis, over which rotation of the occiput takes place in the mechanism of normal labor. Behind the spines the lateral slopes are known as the posterior inclined planes. Meeting together in the median line of the sacrum, they constitute a sort of vault, into which the face is turned after rotation is completed. The general direction of the pelvic cavity is best shown by a line represent- ing the axis of the bony channel. It should, however, be stated in advance that the so-called pelvic axis of obstetri- cal writers is not to be construed as the Fig. 95.—Axis represented upon a median line of a cylinder in a strict vertical section through a plaster , , • ,, • , n t cast of the pelvic cavity. (Hodge.) mathematical sense, but is really intended to indicate very nearly the course which a round body like the fetal head would naturally pursue in its course through the parturient canal. In practice it is convenient to follow the suggestion of Hodge, and draw a plane from the supra- pubic ligament backward to the sacrum, and parallel to the plane of the superior strait. This second parallel would intersect the middle portion of the second sacral vertebra. Inasmuch as the pubic walls run nearly parallel to the upper portion of the sacrum, the axis of the cavity included between the two planes may be regarded as continu- ous with the axis of the brim. Below the second plane, owing to the curvature of the sacrum, the axis describes a nearly circular course with intersecting planes radiating from the lower border of the sym- physis as a center. Further on it will be shown that the axial curve is continued beyond the bony canal by the distended tissues which form the floor of the pelvic basin. Differences between the Male and Female Pelvis.—In the male the bones of the pelvis are thick and solid ; the brim is triangular in MECHANISM OF LABOR. 153 shape ; the promontory projecting ; the cavity deep, and sloping in- ward like a funnel; the sacrum long, narrow, and moderately curved ; and the arch of the pubes is formed at an angle of from 75° to 80°.' In the female, on the contrary, the bones are lighter and more delicate in contour, therein corresponding to the inferior muscular develop- ment of the sex ; the brim, owing to the less marked jutting inward of the promontory, has an elliptical outline ; the diameters, both antero-posterior and transverse, are increased ; the pelvic inclination is more pronounced; the sacrum is wider and more concave ; the tuberosities of the ischia are wider apart; the angle of the arch of the pubes measures from 90° to 100° ; and the entire depth of the pelvis is diminished. As a result of the increased transverse diameter in the female, the trochanters are at a greater relative distance from one another, and are directed somewhat obliquely to the front. This peculiarity brings the knees in close proximity, and accounts for the characteristic feminine gait. The configuration of the female pelvis, though unfavorable to rapid locomotion, is, in a special degree, adapted to render possible the birth of the child. A female pelvis approximating in type to that of the male gives rise to a variety of dystocia of a very formi- dable character. Differences between the Infan- tile and Adult Pelvis.—In the in- fantile pelvis the promontory occu- pies a relatively higher position above the upper border of the sym- physis ; the last lumbar and two upper sacral vertebrae possess a moderate convexity—i. e., the promontory does not project for- ward, as in the adult; the sacrum, after running a straight course, be- gins to curve forward first at the fourth vertebra ; the alae are slight- ly developed; the inclination of the ilia more nearly approaches the perpendicular ; the S-shaped curve of the crests is barely indicated, _ „„ „ 4. . t. , _ . . „ •" ' Fig. 96.—Vertical section of a female mfan- there being but slight difference tile pelvis. (Fehiing.) in the distances between the crests and anterior superior spines ; the conjugate diameter in proportion to the transverse is increased ; the side-walls converge toward the outlet; 154 LABOR. the pubic arch is formed at an acute angle ; and the distance between the spines of the ischia is greater than the transverse diameter of the outlet. Distinctions pertaining to sex are but slightly accentuated. In the female, the sacrum, owing to the smaller size of the vertebrae, is narrower than in the male ; the side-walls are higher; the symphysis lower ; the iliac incline approaches more nearly a vertical line; the pubic arch is less acute ; and the transverse diameter is increased. The most important agent in effecting the changes which char- acterize the adult pelvis is unquestionably the weight of the trunk. Owing to the wedge-shape of the sacrum, and the shelf-like ledge which projects from the lower surface of the iliac articulation, no dis- placement can take place in the direction of the long axis of the au- Figs. 97, 98.—Diagrammatic representations of sections through the infantile and adult pelves. (Schroeder.) ricular surfaces. But, when we bear in mind the inclination of the pelvis, it is obvious that pressure from above must act upon the sa- crum likewise in a downward, forward, and inward direction. Now, if the sacrum were, as it is sometimes represented, the key-stone of the pelvic arch, its position would be fixed between the ilia. We owe to Duncan,* however, the demonstration that this view is incorrect, and that in reality the sacral articulation slopes backward and inward in the direction of the median line. The fact that the sacrum does not under pressure drop from the arch is due to the strong sacro-iliac ligaments, which hold it in position as part of the bony ring. The ligaments do not, however, prevent the sacrum from sinking forward to a limited extent into the pelvic cavity, as is shown in the projection backward at maturity of the tuberosities of the ilia, whereas in the infantile pelvis the dorsal surface of the sacrum is level with the pos- terior superior spinous processes. * Duncan, " Researches in Obstetrics." MECHANISM OF LABOR. 155 As the line of gravity of the trunk falls in front of the sacrum, the weight from above presses the promontory forward and inward toward the symphysis pubis. At the same time the rotation backward of the sacral apex is restrained by the sciatic ligaments. The natural effect of these two simultaneously operative forces, acting at a period when ossification is still incomplete, is to increase the sacral curve, and consequently to shorten the distance between the upper and lower ends of the base. As a result, the height of the promontory is dimin- ished, the pelvic brim and outlet become constricted, and the dimen- sions of the pelvic cavity are increased. The upper portion of the sacrum, in rotating forward, drags upon the posterior ligamentous at- tachments of the ilia. This traction would, were it not for their union at the symphyses, and the pressure of the heads of the thigh-bones, cause the ossa innominata to revolve around the sacral articular sur- faces, like doors upon their hinges. As a result of the antagonistic action of the symphysis and the sacro-iliac ligaments, however, the ossa innominata bend at the point of least resistance in front of the sacrum, and in this way an increase takes place in the transverse at the expense of the antero-posterior diameter. The sexual differences are attributable to differences in the char- acter of the pelvic contents and the external sexual organs, to differ- ences in muscular development, and to certain distinctive peculiarities of growth. Thus, in the female eunuchs of India, described by Roberts,* there were absence of vagina and complete atrophy of cellular tissue in the genital organs ; at the same time the pelvis approximated to the male type, and, in place of the pubic arch, the rami of the pubes and ischia appeared as though they were in contact at the site usually occupied by the vagina. In fetal life, the female sacrum, owing to the smaller size of the vertebrae, is narrower than in the male. Subsequently the more rapid growth of the alae becomes the cause of the increased width which characterizes the sacrum of the female at maturity. The larger cir- cumference of the brim in the female is due partly to this difference in the width of the sacrum and partly to the greater length of the linea innominata. The Soft Parts of the Pelvis.—Prefatory to the history of the im- pregnated ovum, we have already considered the more important pel- vic viscera concerned in generation and parturition. In studying the mechanism of labor, it is, however, necessary in addition to recall— 1. The soft tissues which encroach upon the pelvic space ; 2. The structures which close in the openings of the pelvis, and convert it into a basin-like cavity. 1. The diameters of the brim are diminished somewhat by the ilio-psoae muscles. The iliac muscles proper occupy the entire surface * Vide Tilt, " Uterine and Ovarian Inflammation," p. 63. 156 LABOR. of the internal iliac fossae. The fibers converge below, and, passing beneath Poupart's ligament, become united to the borders of the psoas muscle. The pelvic portion affords a soft cushion for the support of Fig. 99.—Pelvis covered with the soft parts, with removal of bladder, uterus, and rectum. the gravid uterus. The great psoas muscles fill out the spaces upon the sides of the promontory. They take their origin from the lateral surfaces of the bodies and transverse processes of the four upper lum- bar and the last dorsal vertebrae. They cross the pelvis parallel to the linea innominata, which, however, they slightly overlap. They taper below, and, passing beneath the femoral arch, terminate in a tendon, which is inserted into the small trochanter. These two muscles flex the thighs upon the abdomen. The iliac muscle likewise acts as an abductor, and the psoas serves to flex the pelvis upon the spinal col- umn. The ilio-psoae muscles diminish the transverse diameter nearly a half-inch, so that the latter becomes very nearly equal in length to the oblique diameters. When the limbs are extended and the muscles MECHANISM OF LABOR. 157 are rendered tense, the influence they exert in lessening the pelvic space is somewhat greater than when they are relaxed by flexino- the legs upon the thighs. The large arteries and veins at the pelvic brim do not undergo com- pression during labor under normal conditions. When, however, con- siderable disproportion exists between the pelvis and the child's 'head, the effects of pressure are sometimes manifested in the swelling of all the soft tissues within the pelvic cavity—a swelling which, in turn, enhances the difficulties of delivery. 2. The open spaces of the pelvis, which are closed in by soft parts, are the great sciatic notches, the obturator foramina, and the pelvic outlet. SACRUM. PYRAMIDAIIS.M Fig. 100.—Section of pelvis, showing the pyramidal muscles. (Tarnier et Chantreuil.) The closure of the sacro-sciatic notches is effected by the pyramidal muscles. The pyramidal muscle has a triangular shape. Its base presents a series of digitations which are inserted upon the lateral portions of the anterior surface of the sacrum, along the outer borders of the four lower sacral foramina and the upper portion of the sacro- sciatic ligament. It then crosses the large sciatic foramen, and, passing outward, terminates in a tendon, which is inserted into the large trochanter. The obturator foramen is covered by the internal obturator mus- cle. The latter is attached to the quadrilateral surface which corre- sponds to the cotyloid cavity, to the circumference of the foramen, and to the inner surface of the obturator membrane. Its fibers converge to form a tendon, which passes through the lesser sciatic foramen, and thence is directed downward and backward to the digital cavity of the great trochanter. 158 LABOR. Owing to their tenuity, neither the pyramidal nor the obturator muscles appreciably affect the dimensions of the pelvic cavity. LESSER / SACRO-SCIATIC LI 3 PUBIS, INTERNAL OBTURATOR LARGE SAG RC-SCIATIC LIG. Fig. 101.—Section of pelvis, showing the internal obturator muscle. (Tarnier et Chantreuil.) The outlet of the pelvis is closed by a succession of layers, which together constitute the perineal or pelvic floor. These layers, passing from without inward, consist respectively of the external cutaneous tissue, the muscular layers with their associated aponeuroses, the sub- peritoneal cellular tissue, and the peritonaeum. COCCYGEUS. LEVATOR AMI SECTION OF RECTUM-fe SECTIOH OFVAGINA SECTION OF BLADDER; \!f—OBTURATOR Fig. 102.—Muscles of the perineal floor, as seen from the abdominal cavity The pyramidal muscle has been removed. The most important structure which enters into the formation of the perineal floor is the levator-ani muscle. This muscle is composed MECHANISM OF LABOR. 159 of two symmetrical halves, attached in front to the inner surface of the body and horizontal rami of the pubes, and laterally to the tendinous arch of the pelvic fascia which stretches from the inner border of the pubes to the spines of the ischia. Its fibers slope anteriorly down- ward and inward to the sides of the bladder, between and to the sides of the bladder and rectum, and posteriorly are inserted into a tendinous raphe, extending from the extremity of the coccyx to the rectum. Its rectal insertions become confounded with the upper fibers of the external sphincter ; those of the vagina are situated beneath the bulbs of the vestibule and the constrictor cunni. The ischio-coccygeus is a small triangular muscle, by many included in the description of the levator ani. It is situated between the latter and the pyramidal mus- cle, and in front of the small sciatic ligament. Its base is attached to Fig. 103.—Antero-posterior section of the perineal floor. (Tarnier et Chantreuil.) the sides of the coccyx and lower extremity of the sacrum ; the inser- tion of the apex is at the spine of the ischium.* The upper surface of the levator-ani and coccygeal muscles is con- cave. The muscles themselves are flattened, and of nearly membra- nous thinness. Alone they are capable of affording but feeble support to the superimposed viscera. They are, however, above closely at- tached to the strong tissues of the internal pelvic fascia, which pos- sess the qualities of elasticity and toughness. The internal pelvic fascia is attached to the upper border of the superior strait where it meets the fascia which lines the iliac fossae, * The coccygeus muscle is strongly developed in caudate animals, and enables them to move the tail laterally. 160 LABOR. and the transverse fascia of the abdominal walls. It covers the py- ramidal and the upper half of the obturator muscles. In front it de- scends from the symphysis to the neck of the bladder, and forms the pubo-vesical ligament. From the linea terminalis to the arcus ten- dineus the fascia upon the side-walls is firmly attached to the perios- teum. The tendinous arch marks the line at which the fascia leaves the pelvic walls to form the inner lining of the levator and coccygeal muscles. The upper surface of the internal pelvic fascia is covered by the peritonaeum, with which it is connected by loose connective tissue. The fascial coverings beneath the levator-ani muscle are divided into a posterior and anterior portion by a line drawn between the two ischia. The posterior portion consists of a single layer. It starts from the sacro-sciatic ligaments and the tuberosities of the ischia ; thence it mounts upward over the inner surfaces of the ischia and the obtura- tor internus muscle to the tendinous arch, which it contributes to form, and from the tendinous arch is reflected at an acute angle over the inferior surface of the levator-ani muscle. The space thus limited between the side-walls of the pelvis and the levator ani is termed the ischio-rectal excavation. The anterior portion, or perineal fascia proper, fills the space be- tween the bis-ischiatic line and the arch of the pubes. It is composed of three layers, as follows : 1. The deep perineal fascia, which covers the lower surface of the levator ani; 2. The median perineal fascia, sep- arated from the former by a narrow interval, and inclosing the pudic vessels and nerves; 3. The superficial perineal fascia which forms, with the median layer, a shallow compartment in which are lodged the superficial muscles of the perinaeum, the bulbs of the vagina, the vulvo-vaginal glands, and the rami of the clitoris. Each one of these organs, except the latter, is, moreover, enveloped in a special sheath, derived from prolongations of the upper surface of the apo- neurosis. The superficial perineal muscles are of slight obstetrical importance. They are the constrictor vaginae, the ischio-cavernosi, and the trans- versi perinaei. The constrictor vaginae consists of two small lateral muscles, situ- ated upon the outer sides of the vestibular bulbs, and surrounding the vulvar orifice. Posteriorly the extremities of the main muscle start from the perineal fascia at a point nearly midway between the sphinc- ter ani and the ischia, while a small bundle only is connected with the sphincter ani itself.* Above, the convergent ends separate into a superficial and deep portion. The superficial portions terminate in a tendon which unites them together above the dorsal vein of the clito- * Luschka, " Anatomie des menschlichen Beckons," p. 399. MECHANISM OF LABOR. 161 ris ; the deep portions pass between the upper ends of the bulbs and the clitoris, and are likewise united by an aponeurosis. The action of the muscle consists chiefly in compressing the veins Fig. 104.—Muscles of the perinaeum. (Henle.) crossed by its tendon, and in thus enhancing the turgidity of the erectile apparatus. It is in no sense a sphincter muscle, though, by pressing the turgid bulbs inward, it may narrow the vestibule of the vagina. The ischio-cavernosi muscles form a sort of fibro-muscular sheath about the crura of the clitoris. They are united together above by an aponeurosis which crosses the posterior extremity of the body of the clitoris. During sexual excitement these muscles are capable not only of compressing the crura, thereby forcing the blood toward the body of the clitoris, but, through the pressure exerted by the aponeurosis upon the dorsal vein, they help to retard the return of the blood from the turgescent organ. The transversi perinaei muscles are small, triangular, flattened muscles which pass from the inner sides of the ischia, underneath the constrictor muscle, to the sides of the vagina and rectum. When the 11 162 LABOR. perinaeum is lacerated, these muscles tend to produce gaping of the wound, and to interfere with union by first intention. A mere enumeration, such as has been given, of the thin, flat, mus- cular and aponeurotic structures of the pelvic floor affords, however, a very incomplete idea of the true anatomy of the lower portion of the parturient canal. Both as regards form and function, the role of the connective tissue which fills out all the available interstices between the different organs, the different muscular groups and the bony walls, is of the highest importance. It is to this tissue that the perineal body occupying the space between the vagina and rectum owes its ex- traordinary distensibility. In a sagittal section, the perineal body presents a triangular shape, with a convex vaginal and concave rectal surface.* Laterally it spreads out to the rami and the tuberosities of the ischia. In height it extends upward nearly one half the length of the vagina. Between the border of the anus and the inner commissure of the vulva, the external portion, which forms the base of the tri- angle, measures on the average an inch in length.f When the head of Fig. 105.—The parturient canal. (Hodge.) the child, during labor, descends below the level of the bony walls, it bulges the perinaeum and stretches it from four to five inches in the antero-posterior direction. Both the length and degree of curvature of the pelvic canal are thereby increased, the soft parts posterior to * Thomas, "The Female Perinaeum," etc., "Am. Jour, of Obstet.," April, 1880. f Foster, F. P., " Anatomy of the Uterus and its Surroundings," " Am. Jour, of Obstet.," January, 1880. MECHANISM OF LABOR. 163 the vulva forming a gutter-like extension, the axis of which is con- tinuous with that of the pelvis. The Head of the F tions, many manoeuvres have been proposed for the conversion of the latter into normal presentations. The manipulations chiefly recom- mended consist of either pushing up the face, or drawing down the occiput, by the fingers passed through the cervical canal. Though occasionally successful, they have been discountenanced by most ob- stetric writers, because experience has shown the results to be by no means commensurate with the dangers incurred. Schatz f has, how- ever, suggested a rational plan for reducing the extended head by external manipulations only, which avoids the objections to the earlier methods. His manoeuvre consists in restoring the normal attitude of the body by flexing the trunk, and leaving the head to resume spon- taneously its proper position as it sinks into the pelvis. It is per- formed by seizing the shoulder and breast with the hand through the abdominal walls ; then lifting the chest upward and pressing it back- ward, at the same time steadying or raising the breech with the other hand applied near the fundus, so as to make the long axis of the child conform to that of the uterus, and, finally, pressing the breech directly downward. As the child is raised, the occiput is allowed to descend, * Walther, Winckel's "Berichte," Bd. iii, p. 315. \ Schatz, " Die Umwandlung von Gesichtslage," etc., " Arch. f. Gynaek.," Bd. v, p. 313. MECHANISM OF LABOR. 191 and then, as the body is bent forward, head-flexion is produced by the resistance of the side-walls of the pelvis. Schatz illustrates these movements by the accompanying diagrams. If, owing to its elevation, Figs. 123-125.—Diagrams showing Schatz's method of converting uce presentations into vertex presentations. the head tends to move to one side when backward pressure is made upon the chest, the place of the pelvic wall may be supplied by ex- ternal pressure exerted by an assistant. The time for attempting this manipulation is previous to the rupture of the membranes. The requisites for success are experience in mapping out the fetal out- lines by external palpation, and the absence of abdominal and uterine irritability. After rupture of the membranes, great care must be exercised in vaginal explorations, to avoid injuring the eyes, or exciting premature respiratory movements by allowing air to enter the mouth. If the chin remains persistently directed to the rear, rotation may sometimes be promoted by either pressing forward with two fingers upon the lower jaw, or by pushing the forehead backward and upward, to produce a deep descent of the chin. To be effective, either ma- nipulation should be executed during a pain. Hodge advocates the vectis, and others a blade of the forceps, as of use in correcting mento- posterior positions. As a rule, however, good pains and complete ex- tension are the conditions most likely to effect the forward movement of the chin. It is practically of importance to bear in mind that tardy rotation is characteristic of face presentations. The treatment, in cases where all measures prove ineffective to secure a favorable change of position, and dangers accrue from delay to either mother or child, belongs to the domain of operative midwifery. During head-expulsion caution must be used in supporting the perinaeum, in order not to injure the neck by too strong forward pressure against the anterior wall of the pelvis. 192 LABOR. It is safe to assure the bystanders that the distortion of the face after delivery will disappear spontaneously in the course of from twen- ty-four to forty-eight hours. Brow Presentations. In brow presentations the head occupies a position intermediate between flexion and extension. Of necessity every face presentation has become such after first passing through the frontal stage. A tem- porary dip of the large fontanelle in the earlier period of labor is by no means uncommon. With the advance of the head, however, the resistance encountered usually causes the complete descent of either the chin or the occiput. The causes of brow presentations are, in the main, the same as those given for presentations of the face, viz., ob- liquity of the uterus and foetus, enlargements of the neck and thorax, contracted pelvis, and excessive mobility of the foetus. The diagnosis is made by recognizing the apex of the forehead in the pelvic canal, with the orbits and the root of the nose upon one side, and the large fontanelle and parietal bones upon the other. At the brim the frontal suture is usually transverse, but becomes oblique in its progress toward the pelvic outlet. A small head may pass through a roomy pelvis, the brow present- ing, without injury to either mother or child. In the mechanism of delivery the forehead turns to the front and appears at the vulva, the upper maxilla resting against the symphysis, and the cranium lying in the hollow of the sacrum and upon the perinaeum. The exit is accom- plished by the cranial vault first sweeping forward over the perinaeum ; the upper jaw, the mouth, and the chin afterward making their appearance beneath the symphysis pubis. Sometimes, though usu- ally only when the forceps is used, the head may be delivered in the transverse diameter, in which case the superior maxilla finds a point of support against one ischio-pubic ramus, while the cranium rotates trans- versely through the vulva. When the face turns posteriorly, delivery of a living child is scarcely possible. The configuration of the head is very striking. The swelling of the integuments extends from the root of the nose to the upper angle Fig. 126. -Outline of head after delivery, the brow presenting. (Budin.) MECHANISM OF LABOR. 193 of the large fontanelle. The forehead is nearly perpendicular, while the parietal and occipital bones form a slope which inclines downward and backward. The mento-frontal and sub-occipito-frontal diameters are increased, while the distance between the chin and a point in the sagittal suture anterior to the occiput is diminished. These changes impart to the head a triangular shape. The peculiar formation is ex- plained by the compression of the occiput between the pelvis and the dorsal surface of the child, and the compensatory elongation which takes place in the direction of the forehead. The prognosis is less favorable than in vertex presentations, but is by no means so sinister as is popularly supposed. Many cases of original brow presentations become converted into face or vertex pres- Fig. 127.—Brow presentation, subsequently converted into that of the face.* (Maternity Hospital.) entations during the progress of labor; many are delivered spontane- ously or by the aid of the forceps. Craniotomy is rarely called for. Ahlfeld ("Die Entstehung Steiss- und Gesichtslagen") furnishes twenty- six cases in which the result to both mother and child is given. Fritsch (" Klinik der alltaglichen geburtshulflichen Operationen," p. 46) gives the histories of seven cases, and Bvdin (" Tete du Foetus," p. 53) the history of one case. In the thirty- four deliveries there were two maternal deaths; in one of the fatal cases coxalgic oblique pelvis existed as a complication. In the other the brow spontaneously changed into a face presentation. There were ten spontaneous deliveries, the brow presenting, with four dead children, but one died previous to labor. There were ten cases of spontaneous delivery in which the brow during delivery be- came converted into either a face or vertex presentation. Of these one child died.. * Recovery of both mother and child. 13 194 LABOR. Fourteen children were extracted with the forceps, nine with the brow present- ing, of which two were dead, one from prolapsed funis, and one which bad died before labor; five, after conversion into face or vertex presentations, with no deaths. Thus, of the thirty-four children, there were seven deaths, but of these four only could be attributed to the presentation. From the foregoing, it is evident that the duties of the accoucheur, in the presence of brow presentation, should be confined to efforts to direct the labor to a favorable termination by one of the paths indi- cated by Nature. At the brim, previous to engagement, the dip of the anterior fontanelle is often temporary, in many cases simply sig- nifying a narrowing in the upper conjugate. For this reason it is evident that version, so frequently recommended with a view to the substitution of diameters more conformable to those of the pelvis, is to be regarded as of questionable value. Early in labor it does not better the prognosis, while at an advanced stage, when self-correction is no longer probable, the difficulties of its execution exclude it from the list of practicable measures. Manual attempts to convert a brow presentation into one of the face or vertex possess more legitimate claims to favor. The method of Baudelocque consists in seizing the head with the entire hand introduced into the vagina, lifting it to the brim, and then drawing the occiput downward with the fingers until flexion becomes com- plete. The procedure was bitterly opposed by Chailly,* who urged against it, in addition to the frequency of failure, the dangers of uter- ine rupture, of prolapse of the cord, and the inconveniences arising from the early evacuation of the amniotic fluid. There is no question of successes by this measure, but the concurrent risks ought to limit its employment to cases of absolute necessity. Thus, it would be proper to make the attempt when brow presentations complicate delivery in justo-minor pelvis, or in persistent mento-posterior positions, as in these cases craniotomy is the only alternative. Complete anaesthesia facilitates reduction; while elevating the head, firm counter-pressure should be made at the fundus uteri, f Occasionally the conversion of the brow into a vertex or face pres- entation may be effected by pressure exerted during a pain upon re- spectively the occipital or frontal extremity of the head. In bringing down the vertex, the movement should be aided by external pressure made with the disengaged hand above the brim of the pelvis. When a face presentation is desired, the woman should be made to lie during labor upon the side to which the child's abdomen is directed, and upon the side to which the back is turned when the descent of the vertex is aimed at. * Chailly-Honore, " Traite pratique des accouchemcnts," p. 783. f Vide Parry, " On the Use of the Hand to correct Unfavorable Presentations," etc., "Am. Jour, of Obstet.," vol. viii, p. 138. MECHANISM of labor. 195 Schatz * recommends, with the view to the production of a face presentation, the introduction of two fingers into the child's mouth, and making traction on the superior maxilla. When the head shows a disposition to revert to its original position so soon as pressure or traction is suspended, the forceps should be applied, and traction made in such a manner after reposition as to hold the head in the direction sought for. In case the brow presentation is irreducible, the labor should be allowed to continue as long as compatible with the safety of the mother. Owing to its plasticity, the head often adapts itself in the most surprising manner to the unfavorable diameters of the pelvis, so that, even when spontaneous delivery fails to take place, the forceps be- comes available. In mento-posterior positions, efforts should be made with the fingers, or the vectis, to rotate the chin forward. In fixed mento-posterior positions, the use of the forceps is impossible, and the conversion of the brow into a face presentation does not lessen the mechanical difficulties of delivery. The only artifice by which the life of the child can be saved consists in bringing down^the occiput, and producing a vertex presentation. Failing in this manoeuvre, craniotomy becomes inevitable. In all cases of brow presentation, if the child is dead, craniotomy is indicated in the interest of the mother. Breech Presentations. In breech presentations the attitude of the child is primarily the same as in those of the vertex, though, owing to a variety of causes, such as voluntary or reflex movements and the action of gravity, especially after rupture of the membranes, the extremities may advance in front of the breech, and give rise secondarily to presentations of the foot or knee. Sometimes one extremity may become prolapsed, while the other is retained in its normal position ; again, it may happen that, after the rupture of the membranes, the feet, which had previously been in close proximity to the breech, are pushed upward, so that the limbs become extended parallel to the anterior surface of the child's body. None of these changes, how- ever, materially affect the mechanism of delivery. Pinard f found in 100,000 cases of confinement 3,301 presentations by the breech, or in the proportion of one to thirty, but, excluding^ premature births, the proportion was reduced to one in sixty-two. Causes.—The causes of breech presentations are to be sought for mainly in the absence of the conditions which ordinarily determine the presentations of the head, or which interfere with the fixation of the foetus. Thus, the production of breech presentations is favored * Schatz, "Die Umwandlung von Gesichtslage zu Hinterhauptslage," etc., "Arch. f. Gynaek.," Bd. v, p. 328. f Tarnier et Chantreuil, " Traite de l'art des ac," p. 454. 196 LABOR. by an excess of amniotic fluid, by lax uterine walls, and by contrac- tions of the pelvis. They are more common in multiparae than in primiparae. Of the 3,301 cases collected by Pinard, there were 1,347 primiparae and 1,954 multiparae, though the entire number was nearly equally divided between the two classes.* Finally, they occur with greatest frequency of all in twin pregnancies, and during the expul- sion of premature and dead children. Of 32,264 children from the statistics of Hegar and Spiegelberg, f 910 were the product of multiple pregnancies, and 659 were premature. Of the former, 227, or 25 per cent., and of the latter 148, or 22*4 per cent., were delivered by the breech, though we have seen that the ratio of breech presentations Fig. 128.—Presentation of the breech. Left dorso-anterior position. (Tarnier et Chantreuil.) to the entire number of births does not exceed the proportion of one to thirty. Diagnosis.—By external palpation the recognition of the head at the fundus uteri furnishes the chief diagnostic sign. Upon vaginal examination, the presenting part, as in face presentations, is usually high up, and reached with difficulty. The bag of membranes is apt to be of large size, owing to the imperfect closure of the lower uterine segment by the small breech, often descending through the canal, where the cervix is rigid, in the form of an elongated pouch. Through the membranes, upon pressing the fcetus downward during the inter- * Vide Tarnier et Chantreuil, p. 455. f SriEGELBERG, he. Cit., p. 1*71. MECHANISM OF LABOR. 197 val between the pains, the breech is felt as a soft, irregular body, and with care it is possible to recognize the coccyx, the sacrum, the ilia, and sometimes to feel tapping movements from the feet. After rupture, the nates, the cleft between the nates, in boys the scrotum, the anus, the feet when accessible, the coccyx, the sacrum, and the ilia, furnish the necessary data for an exact diagnosis. The pressure of the uterus upon the breech frequently occasions an evacuation of meconium. The latter is thick and consistent, thereby differing from the meconium passed in vertex cases by a dying foetus, which is ordinarily thin from admixture of amniotic fluid. When the nates are much swollen they may be confounded with the cheeks in a face presentation, an error, however, easy to avoid, if the examination be made with deliberation, and the principal points of difference between breech and face already given {vide "Face Presentations," p. 189) are borne in mind. The foot, as compared with the hand, is longer and narrower, the toes are shorter, of nearly equal length, and continuous in a straight line with the sole, the ankle-joint is less flexible than the wrist, and is distinguished by the malleoli and the pointed heel. As the outer bor- der of the foot is thin and rounded, while the inner edge is thick and hollowed, it becomes possible to recognize which of the feet is under examination. The knee is distinguished from the elbow by its larger size, by the patella, and by the spine of the tibia. The Mechanism of Breech Presentations.—The position in breech presentations is defined by the direction of the back. Thus, we have right and left dorsal positions. Usually the hips occupy one of the oblique diameters of the pelvis. According, therefore, as the back is turned anteriorly or posteriorly, we distinguish right and left dorso- anterior and dorso-posterior positions. The cervix dilates slowly, especially when the feet are in close proximity to the breech, and increase the bulk of the presenting part. The latter is pressed downward into the pelvis until the perineal floor is reached. Here, owing to the shortness of the pubic wall, the ante- rior hip is felt with great distinctness, while the cleft of the nates lies near the curved sacrum. These anatomical relations give rise to the impression of an exaggerated degree of lateral obliquity. At the peri- naeum the breech glides forward and rotates upon its long axis, so that the bis-iliac diameter nearly corresponds to the lower conjugate. In the movement of rotation, it is always the anterior-lying hip, irrespec- tive of the position of the trunk, which moves to the front. At the outlet one hip engages beneath the arch of the pubes, the other rests upon the coccyx and perinaeum, while the sacrum is directed toward the tuber ischii. As the shoulders enter the pelvis in an oblique diameter, the trunk of the child becomes somewhat twisted by the 198 LABOR. rotation of the breech. The anterior buttock makes its appearance at the vulva, while the posterior distends the perinaeum. As rotation is rarely complete, the forward trochanter usually finds its point of sup- port against the nearest ischio-pubic ramus. During the advance of the breech, the lumbar region undergoes a certain amount of lateral flexion, owing to the forward movement imparted to the posterior hip by the coccyx and elastic perinaeum. The degree of flexion is, how- ever, limited by the rigidity of the lumbar portion of the vertebral column. When the posterior trochanter reaches the commissure of the vulva, the perinaeum retracts, and in gliding backward directs the breech still farther to the front. Fiq. 129.—Illustration showing lateral inflexion of the trunk during delivery of the breech. After delivery, the breech rotates into the oblique diameter it had originally occupied, this external rotation bringing the transverse diameter of the hips into correspondence with that of the shoulders. The uterine contractions continuing, the abdomen and base of the thorax slowly make their appearance ; the thighs are then delivered, and the arms, folded upon the upper portion of the thorax, emerge from the vulva. The shoulders, which enter the pelvis in an oblique diameter, are delivered in the conjugate, the anterior shoulder resting beneath the pubic arch, while the posterior shoulder sweeps over the perinaeum. The head enters the pelvis in an oblique diameter, with the chin flexed upon the thorax. The expulsive efforts as the chin reaches the perinaeum are followed by the rotation of the occiput to the pubes, and MECHANISM OF LABOR. 199 of the face into the hollow of the sacrum. At the outlet the neck is supported by the arch of the pubes, the face rests upon the perinaeum, and the large fontanelle is felt at the coccyx. Under the influence of pressure from the abdomen, the brow sinks deeper and deeper, and is pushed by the soft parts of the pelvic floor still closer to the thorax. The occiput then revolves beneath the pubic arch, and the chin, the mouth, the nose, the brow, the large fontanelle, and finally the occiput, appear in succession at the commissure of the vulva. Irregularities in the Mechanism of Breech Presentations.—Though it is by no means rare for the breech to enter the pelvis with the sacrum turned to the sacro-iliac synchondrosis, the rotation, begun with the passage of the hips through the vulva, usually continues in the same direction until the back revolves to the front; or, after a first slight retrograde movement, the rotation forward takes place as the shoulders engage at the outlet. Still, cases do sometimes occur in which the back remains posterior during the whole period occupied by the expulsion of the trunk, and in which consequently the head enters the pelvis with the face directed to the pubes. Even here, however, it is very common for the occiput to eventually rotate forward, and for delivery to follow in the ordinary manner. Should, on the contrary, the occiput remain in the hollow of the sacrum, spontaneous delivery may occur in either of two ways : 1. When no tractions have been made upon the extremities, the head reaches the outlet with the chin well flexed, the neck resting upon the commissure of the vulva, and the brow braced against the arch of the pubes. The birth of the head is then accomplished, as the neck pushes back the perinaeum, by the successive descent of the face, the cranial vault, and the occiput. With a rigid perinaeum, or an immovable coccyx, the considerable degree of flexion which this movement necessitates may be rendered impossible. 2. If, during the transit of the head through the pelvis, extension occurs, the chin may be arrested at or above the symphysis pubis. In this position pressure from above pushes back the brow, so that the face looks upward, and the occiput is turned to the bottom of the pelvic excavation. During delivery the occiput glides over the perinaeum to the fourchette, and the small fontanelle, the cranial vault, and the face escape in succession through the vulva. It is only possi- ble for this method of delivery to take place spontaneously when either the head is small or the pelvis roomy, and the soft parts are devoid of rigidity. In artificial extraction of the head, it is proper to bear in mind and to imitate the natural order in expulsion. In presentations of the foot and knee, the breech, if of small size, may pass the vulva in an oblique or transverse diameter, rotation fol- lowing later during the passage of the trunk. Excessive rotation is not uncommon, both head and trunk some- times describing a half-circle. This occurrence is most frequently ob- 200 LABOR. served in cases where the posterior extremity presents, while the ante- rior buttock is caught above the pubic wall, the prolapsed limb then rotating, as a rule, to the front.* The Configuration of the Foetus in Breech Deliveries.—During the descent of the child through the genital canal, more or less swelling is developed upon that portion of the presenting part which is subjected to diminished pressure. This swelling varies, according to the du- ration of labor, from a slight oedema to a large, intensely discolored tumor. It is usually seated upon the anterior buttock, but often in- vades the genital organs, especially the scrotum, which at birth may present a bluish-black color, and be of double the usual size. The ex- tremities, when near the breech, may also show signs of discoloration. The head has usually a characteristic round shape. This is due, according to Spiegelberg,! to the pressure exerted by the genital canal upon the circumference of the head, while, at the same time, with the absence of pressure from above, there is produced an increase in the convexity of the cranial vault. Two cases reported by Hecker, J in which the length of the occiput was comparable to that found in face presentations, show, however, that the p original shape of the head counts for something in the appearances presented after delivery. Prognosis.—As regards the mother, the prognosis in uncomplicated cases does not differ materially Fio. 130.—Showing shape of head in breech presenta- ^rom tnat °f vertex Cases. tions. (Budin.) Where manual extraction becomes necessary, there is always, however, increased danger of lacerating—1. The cervix ; 2. The perinaeum. Lacerations of the cervix are apt to follow attempts to drag the after-coming head through an imperfectly dilated cervix. The prog- nosis is more favorable, therefore, in cases where the membranes do not rupture until after dilatation is completed. It is also better in pelvic presentations, where the bulk of the breech is increased by the addition of the extremities. In footling cases, when the membranes * Vide Kustner, "Die Steiss- und Fusslagen," p. 21. t Spiegelberg, he. cit., p. 176. X Hecker, " Arch. f. Gynaek.," Bd. xi, p. 348. MECHANISM OF LABOR. 201 rupture prematurely, the smaller size of the pelvis and its rapid de- scent through the cervix imperfectly prepare the way for the subse- quent passage of the head. A stricture is, therefore, liable to form about the neck of the child, and, as the spasm does not yield to force, the result of violent tractions is to sacrifice the integrity of the cervix, the extent of the laceration being proportioned to the power exerted. Lacerations of the perinaeum occur where with rigidity of the tis- sues it becomes necessary to introduce the hand to release the arms, or the interest of the child demands the speedy delivery of the head. The prognosis for the child is, on the other hand, extremely unfavor- able. According to the statistics of Dubois,* the mortality in full- term children is as one to eleven, while in vertex presentations the proportion is as one to fifty. The chief cause of this large death-rate is the pressure to which the cord is subjected between the child and the surface of the utero-vaginal canal, especially after the navel appears at the vulva. The pressure is exerted principally at the orifices of the uterus and the vagina, and is raised to the point of greatest danger after the head has become engaged in the pelvis. Other sources of peril arise from prolapse of the funis and the coiling of the latter around the body of the child, and from the complete escape of the amniotic fluid in premature rupture of the membranes. Treatment.—Early in labor, with the membranes intact, it is desir- able, in consideration of the unfavorable prognosis for the child, to try and perform cephalic version by external manipulations. In case of failure to bring down the head, pains should be taken to preserve the membranes until dilatation is completed. To this end unneces- sary examinations should be avoided, the patient should be placed upon her side and cautioned not to strain, and, when the membranes tend to form an elongated pouch, counter-pressure may be employed by means of a moderately distended Barnes's dilator introduced into the vagina. After rupture of the membranes it is best to remain passive. In the interest of the child, it is desirable that the expulsion of the trunk should take place slowly. Bringing down an extremity, as a prophylactic measure in order to secure a good handle in case of sub- sequent delay, is a questionable procedure. By this manoeuvre a path is opened for the descent of the cord, and the mechanism of delivery is disturbed. When the hips appear at the vulva, the attending physi-' cian should be ready to extract in case of emergency. The patient should, therefore, if lying upon the left side, be brought near the edge of the bed ; if upon the back, she should be placed across the bed with the hips well over the edge. She should be instructed to bear down during the pains. The lateral flexion of the lumbar portion of the trunk should be sustained by the hand applied to the perinaeum. The trunk, as it advances through the vulva, should be wrapped in a warm * Dubois, " Mem. de TAcad. Roy. de Med.," vol. iii, p. 450. 202 LABOR. cloth and raised upward. When the cord appears, it should be drawn gently downward in the direction of one of the recesses to the side of the promontory ; in case the cord passes between the thighs of the child, it should be released by slipping it over one hip. From this time on, the pulsations of the cord should be carefully watched, and, in case of failing strength, extraction should be resorted to. With one hand the physician now supports the body of the child, while with the other he should make sustained and gradually increas- ing pressure upon the fundus uteri. The patient should be exhorted to strain, and bring into play all the auxiliary muscles concerned in expulsion. During the passage of the arms, the lateral flexion of the body should be promoted by raising the hips and supporting the peri- naeum. After the engagement of the head, it is desirable, if possible, to commit to the hands of a skilled assistant the maintenance of the supra-pubic pressure. When the face reaches the coccyx, the physi- cian should raise the body of the child toward the abdomen of the mother. By this manoeuvre the occiput is pushed upward by the pubic wall, and the chin brought forward to the vulva. The delivery of the head is then speedily accomplished by pressing the forehead forward with two fingers applied to the perinaeum in front of the coc- cyx, or introduced into the rectum. By then keeping the head flexed, lacerations of the perinaeum are best avoided. When the occiput is turned posteriorly, the body should be raised if the chin is arrested at the symphysis, and depressed when flexion is complete. CHAPTER XI. CONDUCT OF NORMAL LABOR. Preliminary preparations.—Examination of the patient.—Management of the first stage. — Management of the second stage.—Preservation of the perineum.—Delivery of the shoulders.—Tying the cord.—Third or placental stage.—Care of patient after deliv- ery.— Treatment of perineal lacerations.—Ana?sthetics in midwifery. It is hardly an exaggeration to state that the greater proportion of the sins of midwifery practice are committed in the management of normal labors. It is equally easy to fall into errors of commission and errors of omission. It is as necessary to know when to abstain as when to interfere. It is an old but always good rule, not to meddle with the physiological performance of a function ; but the rule, when applied to obstetrics, presupposes a thorough familiarity with the physiological processes of childbirth, and the contingencies to which women in parturition are exposed. There is no sense in reposing a blind, unreasoning confidence in the powers of Nature. Indeed, legit- CONDUCT OF NORMAL LABOR. 203 imate grounds for interference are liable to arise in the simplest labors. The attitude of the medical attendant should be one of watch- ful expectancy. He should be ready, if needful, to assuage pain, to forestall dangers, and to limit the duration of suffering. Preliminary Preparations.—When summoned to a patient, the phy- sician should go armed to meet the sudden emergencies of obstetrical practice. His armamentarium should include a silver catheter, an English catheter of small size for use in asphyxia of the new-born child, a pair of forceps, needles and needle-holder, and silk or wire for sutures, a Davidson syringe, with long nozzle for uterine injections, and an hypodermic syringe. He should go provided with chloroform, Magendie's solution of morphia, ergot, the perchloride or persulphate of iron, and a small vial of sulphuric ether. At the house, ice, brandy, and hot and cold water, should be had in readiness. As it is not uncommon for women, especially among the poorer classes, to test the experience of young physicians by asking details relative to the arrangement of the bed upon which the confinement is to take place, it is trusted that a few words upon the subject will not be regarded as entirely superfluous. The bedstead should not be too low. If against the wall, it should be moved out, so as to allow easy access from both sides. The bedding should consist of a hair mattress or of a straw palliasse. Feather-beds are an abomination. Over that portion of the mattress upon which the woman expects to lie, a rubber cloth, or other impervious material, should be spread. Next to the water-proof, nurses usually lay a folded woolen comforter or blanket to absorb the fluid discharges. The whole is then Covered smoothly with a sheet, and a second sheet, folded in several thicknesses, is laid beneath the hips of the patient. All these preparations are designed to limit the soiling of the bedding to a cir- cumscribed space, and to facilitate the removal of the discharges after the termination of the delivery. Examination of the Patient.—The first duty which devolves upon the physician in the lying-in chamber is to examine his patient, and to inform the family if "all is right "—i. e., whether the head presents, and no unusual obstacle to delivery exists. It is a good plan to em- ploy external palpation in every case where no opposition is made, as, even where the diagnosis by ordinary vaginal exploration is clear and indisputable, no opportunity should be lost to perfect one's self in mapping out the foetus through the abdominal and uterine walls. The ability not only to recognize the presenting part, but the position of the entire foetus in the uterine cavity, is, in many cases of difficult labor, a possession of priceless value. During the manipulation of the abdomen, fetal movements should be carefully noted. If absent, aus- cultation should be practiced to ascertain whether the child is still alive. The internal examination should take cognizance of the condi- 204 LABOR. tion of the vulva and perinaeum, the state of the rectum and bladder, the length of the vagina, the degree of dilatation and softening of the cervix, the amount of cervical and vaginal secretion, the hardness of the child's head, and, if the membranes are not ruptured, the quantity of amniotic fluid. It is customary to begin the examination during an interval between the pains, but it is often convenient to continue the investigation during the pains, in order to judge of their efficacy and character. The history of the case should embrace the length of previous labors, the health during pregnancy, the number of times the woman has been pregnant, and whether in the present instance she has ad- vanced to full time. Inquiries should be made as to where the labor- pains commenced, as to their frequency and situation, and if the membranes have ruptured. After the examination of the patient is ended, the physician is ex- pected to express an opinion as to the probable duration of the labor. It is, however, necessary for the responses upon this point to be guarded and Delphic. In general terms, when the pelvis is normal, the head well flexed, the vagina short, and the cervix and perinaeum are dilatable, an easy and rapid labor is to be anticipated ; while, per contra, with a small pelvis, tardy flexion, a long vagina, and rigidity of the uterine and perineal orifices, a tedious period of waiting is to be assumed. Of course, too, labor is, as a rule, much longer in primi- parae than in women who have previously borne children. Moreover, with few exceptions, the result depends in a special degree upon the energy and persistence of the pains. The latter, however, represent always the uncertain element in the calculation. If the pains are good, therefore, the reservation should be made that, for a short labor, they must continue as at the beginning; while, if weak and powerless, it should be stated that better pains will be needed to bring the labor to a speedy conclusion. Management of the First Stage of Labor. The duties of the physician during the first stage of labor are, in normal cases, extremely simple. He should from time to time, say at hourly intervals, repeat the examination, with a view to inform him- self of the progress of dilatation. He should caution his patient to pass her urine frequently. In case of retention, he should draw the water with a catheter. When the head is low down, the urethra often follows its convexity. The introduction of the straight female cathe- ter may then be extremely difficult. Many recommend in such cases a silver male catheter to which a suitable curve has been given. I use by preference the English flexible catheter, which is passed easily, pro- vided the end is guided by the index-finger, through the anterior vagi- nal wall, to the point of contact between the head and the symphysis CONDUCT OF NORMAL LABOR. 205 pubis. A flattening of the tube by pressure to an extent causing obliteration is not likely to take place unless the catheter be small or has become over-pliable from long use. If, at the time of examination, the rectum is found clogged with faeces, an enema should be ordered. A disposition on the part of the patient to bear down during the first stage of labor should be dis- couraged, as wasting her strength without possessing any counter- balancing utility. The patient should be encouraged not to take to bed at the outset of labor. In the upright or sitting posture, gravity aids the fixation of the head and promotes dilatation. As the end of the first stage approaches, however, the woman should undress and lie down, as the pains, after rupture, as a rule, follow one another with rapidity, and make locomotion difficult. To avoid soiling, the night-dress should be drawn well up under the arms. Tidy nurses pin a folded sheet around the hips of their patients to arrest the soaking of fluids upward. Rupture of the membranes is, as a rule, a spontaneous act. Yet often enough something may be done in the way of shortening labor, by puncturing the membranes so soon as cervical dilatation is com- plete. They have then fulfilled their physiological mission, and their persistence simply retards the advance of the child's head. Artificial rupture is easily effected by means of a straightened hairpin, passed in the groove between the index and middle fingers of the examining hand to the amniotic pouch. The puncture should be made during a pain, at a time when the membranes are tense and separated from the scalp by a deep layer of fluid. Management of the Second Stage of Labor. The management of the second stage of labor calls for considerable tact on the part of the medical attendant. It is incumbent upon him to make frequent examinations, to determine the degree of rapidity with which the descent of the head takes place. So long as the ad- vance is regular, he should abstain from interference. Should the pains slacken, however, he should not allow the duration of the second stage to exceed the physiological limits. It is not easy to define ex- actly what is implied in the expression "physiological limits." As a rule, a very rapid second stage is not physiological, as it endangers the integrity of the vagina and perinaeum, and predisposes to post-partum haemorrhage. Still, now and then labor is ended by a single pain after rupture of the membranes, without detriment to the mother. Of course, such cases are extremely uncommon in primiparae. They re- quire an unusually distensible condition of the soft parts, and an ex- traordinary degree of resiliency in the uterus. On the other hand, pressure of the head, after its descent into the pelvic cavity, leads, if too long continued, to pathological changes in the tissues of the canal 206 LABOR. and of the outlet. It is usual, therefore, unless the head is small or the pelvis roomy, to use the resources of art to terminate labor when the head remains stationary at the perineal floor after two hours of effort. It is desirable, therefore, when the pains are weak and ineffec- tive, to utilize all the simple adjuvants which experience has shown to possess real efficacy in increasing the activity of labor. Changes of posture increase the power of the pains temporarily. When head-flexion is incomplete, it has been recommended to place the patient upon the side toward which the occiput is turned. Others, again, claim that the descent of the occiput is best effected by plac- ing the mother upon the side toward which the chid's forehead is directed. In point of fact, either posture frequently leads to the desired result, simply because the change from the dorsal to the lateral position is apt to be followed by a temporary addition to the uterine force.* In many women, owing to defective innervation, or to insufficient development of the muscular structures of the uterus, it is of great moment that the expulsion of the child be aided by the voluntary pressure of the abdominal walls. To be sure, in most cases, the reflex impulse to bear down is imperative ; but in others, where the impulse is feeble or held in abeyance by the dread of the patient lest she in- crease her sufferings, it becomes the duty of the physician, in tardy labors, to see to it that all the auxiliary forces are brought into play. To this end he should instruct his patient to fix her pelvis, either by pressing her feet against the foot-board of the bed, or by drawing up her knees and resting them against an assistant, who assumes the posi- tion best adapted to furnish the requisite support. Then the nurse, or other suitable person, should grasp the woman's hands, so as to enable her to fix her thorax and to bring all the expiratory muscles into full exercise. Often, when the agony is intense, the patient can be induced to strain with her pains, if her sufferings are first dulled by small doses of chloroform. When the head is on the peri- naeam, the physician may further expulsion by rubbing the abdomen to excite pains, and by pressing upon the breech through the fun- dus. During the second stage the patient's posture should be left in general to her own volition. The physician should accustom himself to conduct labor with equal facility, no matter whether the woman lies upon her side or upon her back. The left lateral position, affected by English accoucheurs, is very convenient at the time of delivery, especially when there is occasion to support the perinaeum, and where, owing to the flatness of the nates, the vulva is scarcely raised in the dorsal posture above the level of the bedding. * Lahs, "Die Thcorie der Geburts.," Bonn, 1877, p. 237. CONDUCT OF NORMAL LABOR. 207 The Preservation of the Perineum. By far the most delicate task which the physician has to fulfill toward his patient in the expulsion stage consists in so regulating the exit of the child's head as best to avoid perineal lacerations. It is needless to state that such lacerations, unless of slight extent, entail upon women a variable degree of subsequent discomfort and suffering. When the perinaeum is examined with care after labor, a practice which should be invariable with a conscientious attendant, the frequent oc- currence of more or less extensive rupture of its tissues is a matter of easy confirmation. Statistics of their frequency are of little value, much depending upon individual skill in management. Olshausen * reports, as the result of the preventive measures adopted at the clinic in Halle, during a period of ten years, 21*1 per cent, of perineal in- juries in primiparae and 4*7 per cent, in multiparae. These percent- ages did not include slight tears confined to the fraenulum. He regards 15 per cent, as not too high an estimate for the absolutely unavoidable lacerations, due to defective distensibility of the perinaeum, and to the disproportionate size of the child's head. The aim of prophylactic measures should be to develop the elas- ticity of the soft parts to the fullest practicable extent, and to cause the head to pass through the distended orifice of the vulva by its smallest diameter. Preliminary softening of the perinaeum is best accomplished by the continuous but not too rapid descent of the presenting part. The relaxation, as a rule, begins earlier and is more complete in mul- tiparae than in primiparae. In a few cases the soft parts will already have ceased, by the end of the first stage of labor, to offer any effec- tive barrier to delivery. The distensibility of the soft parts may be fairly inferred from the presence of a copious discharge of glairy mucus. When rupture takes place, the vaginal mucous membrane is the first structure to give way. In the ordinary form, the perineal body tears from the commissure backward to the rectum. In rare cases, a central perforation may result, and the child be expelled through a rent situated between the vulva and the anus. When the head begins to make the perinaeum bulge, the physician should be on the> alert, and inform himself during each contraction of the strain to which the parts are subjected. At first it is only neces- sary to rest the hand lightly upon the perinaeum. Direct pressure is to be avoided, except when the perinaeum is stretched to a membranous thinness, and the danger of central perforation threatens. As the head begins to distend the vulva, the tension at the fraenulum should be carefully gauged by a finger introduced between the labia. Measures to avert rupture may be classified under three headings, viz.: * Olshausen, " Ucbcr Dammverlctzung und Dammschutz," Volkmann's " Samml. klin. Vortr.," No. 41, p. 360. 208 LABOR. 1. Those designed to check the exit of the head before the fullest expansion has been secured, and to prevent expulsion during the acme of a pain, when the borders of the orifice are most rigid. 2. Measures which impart an upward movement to the head, with a view of making all unoccupied space beneath the arch of the pubes available. 3. Measures which favor expulsion during the interval between the pains, or at least after the acme has subsided. In ordinary cases Hohl's method, recommended by Olshausen,* has rendered me excellent service. It consists in applying the support, not to the perinaeum, but to the presenting 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 commissure. The unconstrained position of the hand enables the operator to exercise effective pressure in the direction of the vagina, while the posterior fingers favor the rotation of the head under the pubic arch. The patient should at the same time be directed not to hold her breath during the pains, except when they are weak and powerless. Where the impulse to bear down is irresistible, chlo- roform should be given to annul the excessive reflex irritability. Under the most skillful management, laceration is liable to occur, unless the physician is able to control the action of the auxiliary ex- pulsive forces. So soon as the bi-parietal diameter passes the tense border of the vulva, the perinaeum retracts rapidly over the face, and the expulsion of the head is completed. It is during this period that laceration is most apt to occur. This danger is, however, greatly lessened if the head is made to issue through the orifice after the pain has subsided, and when the soft parts are in a relaxed and dilatable condition. To accomplish this, in many instances where the resistance to be over- come is slight, it is sufficient for the Avoman to hold her breath during an interval between the pains, and voluntarily call into play all the muscles of expiration. In the larger proportion of cases, however, these efforts are futile, because of the comparatively feeble motor-force brought into action. An excellent method of manual delivery Ave owe to Ritgen,f which consists in lifting the head upward and forward through the vulva, between the pains, by pressure made with the tips of the fingers upon the perinaeum behind the anus, close to the extremity of the coccyx. Of course, the method is only available after the head has descended sufficiently for the pressure to be exerted upon the frontal region. * Olshausen, he. cit., p. 366. f Olshausen, " Ueber Dammverletzung und Dammschutz," Volkmann's " Sammlm^ " No. 41, p. 369. CONDUCT OF NORMAL LABOR. 209 Rectal expression has lately found warm advocates in Olshausen* and Ahlfeld. f The manoeuvre consists in passing two fingers into the rectum toward the close of the second stage of labor, and hooking them into the mouth or under the chin of the child through the thin recto-vaginal septum. By pressing the face forward and upward, the normal rotation of the head beneath the pubic arch can be effected, and delivery can be accomplished between the pains at the will of the operator. When rupture is felt to be imminent, mock-modesty should be dis- carded, and the parts imperiled should be unhesitatingly exposed to view. If, owing to its excessive elasticity, the occiput, in place of being directed forward to the vulva by the perinaeum, distends the latter so that central perforation threatens, the hand should be applied in such a way as to give direct support to the stretched tissues and to guide the head upward to the outlet. If, on the other hand, the danger arises from defective elasticity, the physician, standing to the right of the patient, with his face toward the foot of the bed, should pass the left hand between her thighs and press the head upward and imvard, during each pain, with the thumb and two fingers, as previ- ously described. At the same time, the movement of extension, should it threaten danger to the parts, should be hindered by pressing back- ward upon the frontal region, through the perinaeum, with the disen- gaged hand. Dr. Goodell J recommends hooking two fingers into the anus, and drawing the perinaeum forward during a pain, to remove the strain from the thinned border of the vulva, and to promote the elasticity of the tissues. Fasbender* places the patient upon the left side; then, standing behind her, he seizes the head between the index and middle fingers of the right hand, applied to the occiput, and the thumb thrust as far into the rectum as possible. By this manoeuvre the head is held under complete control, the rectal wall hardly affecting the grip in any ap- preciable manner. During a pain the progression and extension of the head are readily prevented. During the interval between the pains, by pressure with the thumb through the rectum and the poste- rior portion of the perinaeum, the head can be pressed forward and out- Avard at the will of the operator. Between pains, I have been in the habit, in cases of rigidity, of alternately drawing the chin downward through the rectum until the head distends the perinaeum, and then allowing it to recede. It is as- * See Ahlfeld, " Das Dammschutz Verfahren nach Ritgen," "Arch. f. Gynaek.," vi, p. 279. f Loc cit. X Goodell, " Am. Jour, of the Med. Sci.," January, 1871. * Fasbender, " Ztschr. f. Geburtsh. und Gynaek.," Bd. ii, H. 1, p. 58. 14 210 LABOR. tonishing how often apparently the most obstinate resistance can be overcome by the simple repetition of this to-and-fro movement, the parts rapidly becoming soft and distensible. Of course, it should be discontinued the moment contraction begins, and care should be taken to effect delivery after uterine action has subsided. With judicious management the number of unavoidable lacerations can be restricted to a small proportion of cases. Still there are indi- vidual peculiarities Avhich will now and then render abortive the best prophylactic measures. In this category I have already alluded to a primitive lack of development of the maternal parts, to unusual size of the child's head, and to the excessive rigidity of the perinaeum in primiparae, especially after the thirtieth year. In addition, should be mentioned cases where the pubic arch is diminished by the approxi- mation of the pubic rami, or Avhere the tissues have been rendered friable from chronic oedema, from a varicose condition of the veins, from condylomata, from syphilitic sores, or from inflammatory infil- tration consequent upon undue prolongation of the second stage of labor. Lacerations are more frequent in occipito-posterior positions, and in the delivery of the after-coming head, where hasty extraction is demanded in the interest of the child. When, in the judgment of the physician, rupture of the perinaeum seems inevitable, he is justified in making lateral incisions through the vulva to relieve the strain upon the recto-vaginal septum. To this operation the term episiotomy is applied. By it not only is the danger of deep laceration through the sphincter ani prevented, but, owing to their eligible position, the wounds themselves are capable of closing spon- taneously ; whereas, when laceration follows the raphe, the retraction of the transversi perinaei muscles causes a gaping to take place which inter- feres Avith immediate union. As, however, every wounded surface is a source of danger in childbed, episiotomy should never be performed so long as hope exists of otherwise preserving the perinaeum. It is essentially the operation of young practitioners, the occasions for its employment diminishing in frequency with increasing experience. The chief resistance encountered by the head is not at the thin border of the vulva, but is furnished by a narrow ring situated half an inch above, and composed of the constrictor cunni, the transversi perinaei, and sometimes of the levator ani muscles. Incisions should be made during a pain, when the ring becomes tense and rigid, and is easily recognized with the finger. As it is not desirable that the head should be driven suddenly through the vulva during the act of operating, the time selected for performing episiotomy should be at the commence- ment or close of a contraction. The division of the rigid fibers may be accomplished by means of a blunt-pointed bistoury, or a pair of angular scissors. So far as practicable, the incisions should be con- fined to the vagina, and should not exceed three quarters of an inch CONDUCT OF NORMAL LABOR. 211 in length. In cases where the head is on the eve of expulsion, the bistoury may be introduced flat between it and the vagina, half an inch anterior to the commissure, and the section made from within outward Care, however, should be taken at the same time to avoid severing the external skm, by drawing it as far back as possible.* In central per- foration it is best to divide the band left attached to the vulva, as its preservation is of no advantage. The Delivery of the Shoulders.—After the expulsion of the head, mucus should be wiped from the mouth and nose, and cleared from the throat with the finger, should laryngeal rales indicate an embar- rassment of the respiration. If the cord is found coiled around the neck, it should be loosened by drawing upon the placental end until the shoulders can pass readily through the loop. Should this be found impossible, either because the cord is unusually short, or because it is wound several times around the body, a ligature should be applied, the cord should be cut between the ligature and the placenta, and de- livery should be hastened by manual efforts, f In the majority of cases the shoulders are expelled spontaneously. Still, it is a good plan to expedite the descent by pressure made with the left hand at the fundus of the uterus. Care must be taken lest the lower shoulder convert a slight tear in the perinaeum into an ex- tensive laceration. The right hand should therefore be applied to the perinaeum in such a Avay as to lift the shoulder upward, and at the same time furnish a bridge over which it can glide in its movement forward. Sometimes after the passage of the head a deep vaginal laceration co- exists with an intact condition of the external parts. The shoulder then tears through the skin, and a complete rupture ensues. Olshau- sen recommends, in cases where rupture is imminent, to turn the shoul- ders so that they clear the vulva in an oblique or transverse diameter. If, after birth of the head, the child does not breathe, and asphyxia threatens, the physician should rub the uterus with the hand through the abdominal wall, to excite a pain, during which he should urge the patient to press down, and thus aid expulsion. The most common hindrance to delivery consists in an arrest of the upper shoulder be- neath the pubes. Usually its release is readily effected by seizing the sides of the head with the two hands and drawing directly downward. It is rarely necessary to raise the head subsequently, or to hook the finger into the armpit to extract the posterior shoulder. Tying the Cord.—When the cord is torn across, as sometimes hap- pens in street-births, no haemorrhage takes place from the lacerated vessels. Of course, this occurrence deprives the physician of the * Olshausen, he. cit, pp. 372, 373. f Tarnier recommends dividing the cord, and then compressing the proximal end be- tween the thumb and the index-finger. The proximal end is distinguished by the spout- ing of the two umbilical arteries. 212 LABOR. power of choosing the point at which the division shall be made. As it is desirable, for the sake of convenience, to sever the cord about two inches from the navel, it is the custom in all civilized countries to cut it with scissors, and to prevent haemorrhage by the application of a ligature. Almost any material may be employed for the latter purpose, though nothing is so handy as the narrow flat bobbin Avhich most nurses keep in readiness. The ligature should be applied tightly, and the cut surface should subsequently be examined once or twice by the physician before leaving, to make sure that the arteries are suffi- ciently compressed to prevent oozing from taking place. The cord should be held in the hollow of the hand at the time of its division, to avoid the possibility of including accidentally any portion of the child between the blades of the scissors. Commonly two ligatures are applied, and the cord is severed between them, though the ques- tion of one or two ligatures is, except in twin pregnancies, of trifling importance. In practice it is very desirable that the physician should understand the physiological difference between the effects of the early and those of the late application of the ligature. The custom, as regards this point, has been by no means uniform. The ancients deferred the liga- ture until after the expulsion of the placenta. Mauriceau, Clement, and Deventer followed the same plan, but employed artificial expe- dients to complete the third stage of labor rapidly.* The common practice at the present day is to tie the cord immediately after the birth of the child. Still, there have not been wanting in recent times warning voices against precipitate action. Nagel advised wait- ing until the pulsation of the cord had ceased ; Braun f first describes the changes from the fetal to the post-natal circulation, and then says : ** This stupendous process should be taken into consideration in the treatment of every case of labor, and because of it the cord should never be severed or tied so long as pronounced pulsations can be felt near the navel." Stoltz J noticed that, "after the child has respired well, division of the cord is followed by an insignificant loss of blood, while, after immediate section, blood escapes in abundance." In 1875 Budin, at that time interne at the Maternite of Paris, undertook the folloAving experiments at the suggestion of Professor Tarnier : In one series, the cord was tied immediately after the birth of the child, and the blood which escaped from the placental extrem- ity was measured ; in the other, the quantity of blood Avas determined in cases where the cord was not tied until several minutes after de- livery. By a comparison of the results thus obtained, he found that * Budin, " A quel moment doit-on operer la ligature du cordon ombilical ? " " Publi- cations du ' Progres Medical'," 1876. \ Braun, "Lehrbuch der Geburtshulfe," p. 192. X Stoltz, art. " Accouchement naturel," " Nouvcau Dictionnaire," p. 283. CONDUCT OF NORMAL LABOR. 213 the average amount of placental blood was three ounces greater in the first than in the second series of experiments.* Welcker estimated the entire quantity of the blood in the infant at one nineteenth the weight of the body, which would amount, in a child of seven pounds, to six ounces. To tie the cord immediately after birth would there- fore be equivalent to robbing the child of three ounces of blood which would otherwise pass into its circulation. This startling result has in the main been abundantly confirmed by subsequent observers. Two years later (1877), Schiicking, extending Budin's experiments by weighing the child at birth, and then observing the changes that took place up to the time of the cessation of the placental circulation, found that the child gained from one to three ounces in weight by delay. It is certain that these amounts do not represent the entire increase, as a portion necessarily escapes observation in the interA'al that must elapse before the weight can be ascertained. There is a difference of opinion as to the mechanism by which the transfer of the blood from the placenta to the child takes place. Ac- cording to Budin, the principal factor in the accomplishment of the result is thoracic aspiration. With the first breath, the afflux of blood to the lungs develops a " negative pressure " in the vessels of the larger circulation, so that a suction force is exerted upon the placental blood, which continues until the equilibrium is restored. To tie the cord prematurely, therefore, is to cut off from the child a supply of blood for which the establishment of the pulmonary circulation had created a physiological need. Schiicking, f on the contrary, maintains that, after the first inspira- tion, thoracic expansion ceases to operate as an active force, and that the main agent which drives the blood from the placenta through the umbilical vein is the compression exerted by the retraction, and, at intervals, by the contractions of the uterus. The difference in the theoretical standpoint of these two observers is of practical importance, for, if the movement of blood to the child results from thoracic aspiration, the quantity which enters its circula- tion will not exceed its requirements ; while, if the movement is due to uterine compression, the question arises as to whether the forcible transfusion thus accomplished is compatible with the child's safety and welfare. The ultimate decision will depend partly upon experi- mental and partly upon clinical observations. Provisionally, the case stands as follows : The manometric observations of Ribemont \ show that the pressure in the umbilical arteries is uniformly greater than that * Budin, he. cit. f Schucking, " Zur Physiologie der Nachgeburtsperiode," " Berl. kiln. Woch.," Nos. 1 and 2, 1877. X Rieemont, " Recherches sur la tension du sang dans les vaisseaux du foetus et du nouveau-ne," "Arch, de Tocol.," October, 1879. 214 LABOR. in the umbilical vein ; during a series of deep inspirations and expi- rations, the blood in the umbilical vein is subject to marked oscilla- tions : after the pulsations of the cord have ceased, the uterine con- tractions alone are insufficient to propel the placental blood through the umbilical vein to the infant. Again, Budin (discussion upon Ribemont's paper), in a breech-delivery, compressed the cord at the vulva as far as possible from the navel; at birth, the vein Avas dis- tended with blood, but with the first inspiration it was instantly emptied. Thoracic aspiration does, therefore, exist as an operative force. On the other hand, Schiicking found that when the placenta was rapidly expelled by Crede's method, so as to remoA'e it from the influence of uterine retraction, the pressure in the vein Avas slightly lessened, and the total amount of blood transferred to the infant was greatly restricted. According to the clinical observations of Budin, Ribemont, and Schiicking, infants which have had the benefit of late ligation of the cord are red, vigorous, and active, whereas those in which the cord is tied early are apt to be pale and apathetic. Hofmeier,* Ribemont, Budin, and Zweifel f have shoAvn that the loss of weight which occurs in the first few days following confinement is less in amount and of shorter duration when the cord is not tied until after the pulsations have ceased. There appear to be no harmful results to the child, groAving out of the practice of late ligation. Porak, indeed, reports two cases of dark vomiting, tAvo of melaena, and two with sanguineous discharges from the vagina, which he is convinced were the result of the practice ; but the extensive trial to Avhich it has since been subjected in the principal lying-in institutions of the Continent have sufficiently demonstrated that it is exempt from danger. In late ligation, the amount of blood retained in the placenta and the increase in the weight of the child differ materially in different cases, J a difference which seems to indicate that, so long as the placen- tal circulation is left undisturbed, the amount of blood passing to the child will be measured by its needs. In a case of Illing's,*°on the other hand, after the placenta had been expressed from the uterus, its contents and that of the cord were forcibly squeezed into the circula- tion of the child, and death followed from over-distention of the heart. Porak and Georg Violet || claim that there is a special predisposition * "Der Zeitpunkt der Abnabelung," etc., "Ztschr. f. Geburtsh. u. Gynaek." iv, 1 p. 114. ' t Zweifel, " Centralbl. f. Gynaek.," No. 1. X See Wiener, " Ueber die Einfluss der Abnabelungszeit auf den Blut-ehalt der r^rf'" "ArCh- ^ Gynaek"" xiv> !- P- S4; also, Meyer, "Centralbl. f. Gynaek.," 1878'No*10- *"Inaug. Diss.," Kiel, 1877. || Georg \ iolet, » Ueber die Gelbsucht der Neugeborcnen und die Zeit der Abnabe- lung," Virchow's " Archiv," Lxxx, 2, p. 353. CONDUCT OF NORMAL LABOR. 215 to icterus in children when the cord is tied after the placental circula- tion has ceased. Violet attributes the discoloration, not to bile-pig- ment, but to a rapid disintegration of the excess of blood-corpuscles. Helot, he says, found, on the first day after the birth, a difference of nine hundred thousand corpuscles to the cubic millimetre betAveen cases of late and those of early ligation, while on the ninth day the difference fell to three hundred thousand. Others have failed to notice any characteristic icteric discoloration peculiar to late ligation. Neither Porak nor Violet attaches any pathological significance to the symptom. The outcome of the foregoing observations may fairly be stated as folloAvs : 1. The cord should not be tied until the child has breathed vigor- ously a few times. When there is no occasion for haste arising out of the condition of the mother, it is safer to wait until the pulsations of the cord have ceased altogether. 2. Late ligation is not dangerous to the child. From the excess of blood contained in the fetal portion of the placenta, the child receives into its system only the amount requisite to supply the needs created by the opening up of the pulmonary circulation. 3. Until further observations have been made, the practice of em- ploying uterine expression previous to tying the cord is questionable. 4. In children born pale and anaemic, suffering at birth from syn- cope, late ligation furnishes an invaluable means of restoring the equi- librium of the fetal circulation. Management of the Third or Placental Stage of Labor. The duties of the physician in the third stage are to guard against haemorrhage, to promote uterine contractions, and to further the ex- pulsion of the placenta. These objects are best fulfilled by manipula- tions through the abdominal walls. Tractions upon the cord should not be resorted to before the placenta begins its descent into the vagina. The method, at present in vogue, of expressing the placenta by seizing the uterus through the abdominal coverings, is associated indissolubly with the name of Crede, for, though the value of friction, of kneading, and compression, Avas appreciated, as their writings show, by Mauriceau, Robert Wallace Johnson, Joseph Clarke, Busch, Mayer, and others,* it remained for Crede to elevate placental expression to the rank of a recognized procedure of obstetric practice. Crede's method consists essentially in applying at first light and afterward stronger friction to the fundus of the uterus until an ener- getic contraction is obtained ; at its height the uterus is grasped so that the fundus rests in the palm of the hand, with the fingers to the * For historical references, vide Riol, "Delivrance par expression," G. Masson, 18S0; Munde, "Obstetric Palpation," p. 103. 216 LABOR. front. The exercise of circular compression forces the placenta from the uterus, or in case of failure the process may be repeated until the object is accomplished. It is true that the expulsion of the placenta will, as a rule, occur spontaneously. The unaided uterus is, how- ever, liable to relax, and become the source of haemorrhage ; or, where the delivery does not take place speedily, it may, on the other hand, close down, so as to imprison the placenta within its cavity. The great merit of Crede's method is, that by maintaining retraction it prevents haemorrhage, and by promoting speedy expulsion it guards against the dangers of retention.* When systematically practiced, the bug- bear known as adherent placenta is the rarest of accidents. The prac- tice is not difficult, and is devoid of danger. To be successful, how- ever, expression should be practiced only during a contraction, and the propulsiA'e force should be directed from the fundus downward in the axis of the uterus. Spiegelberg f lays great stress on exercising com- pression of the uterus from the moment the head emerges from the vulva, and not waiting until the delivery of the child is ended. By so doing, general contractions are maintained, and the detachment of the placenta promoted. The evidence of the expulsion of the placenta is furnished to the operator by his feeling the anterior and posterior uterine walls in con- tact with one another. By then pressing the uterus downward in the axis of the brim, it is often possible to drive the pla- centa into the vagina and through the vulva. There is no objection, however, at this stage, to expediting delivery by drawing upon the cord downward and backward, while at the same time the uterine pressure is maintained. The ex- traction of the placenta should take place slowly, to avoid tearing the membranes. As the placenta passes the vulva it should be made to revolve so as to twist the mem- branes into a cord, Avhich should be with- drawn with the utmost care. If the mem- branes are felt to give Avay at any point, the fingers should be introduced, if neces- sary, into the vagina to seize them above the site of the laceration, and the re- moval should be proceeded with by gen- tle manipulations. When the mechanism of placental delivery is not interfered with by premature tractions upon the cord, the placenta descends edgewise * Riol, he. cit., p. 34. f Spiegelberg, " Lchrbuch," p. 192. Fig. 131.—Showing the effect of premature tractions upon the (Schultze.) cord. CONDUCT OF NORMAL LABOR. 217 through the cervix, and its expulsion is effected with the loss of but a trifling amount of blood.* When extraction, on the contrary, is at- tempted previous to descent by pulling upon the cord, the central portion of the placenta is dragged into the cervix, while the bor- ders are inverted in such a way as to form a cup-like cavity. This disturbance of the normal mechanism not only increases the difficulty of dehVering the placenta, but causes the latter to exercise a suction force which increases the haemorrhage, and at times even is capable of partially inverting the lax uterine Avails. Now and then, Avhere the occlusion of the cervix is complete, it may be found impossible to effect delivery without first introducing two fingers, and hooking down the margin of the placenta, so as to alloAv air to pass above into the uter- ine cavity. Care of the Patient after Delivery. As the danger of haemorrhage does not , . -. " ., , -, ° . Fig. 132.—Showing normal posi- always end with placental expulsion, the tion of placenta. (Duncan.) physician should be ready to sacrifice, even in simple cases, at least a half-hour to close observation of the subse- quent behavior of the uterus. The weight of the hand laid above the symphysis pubis is usually sufficient to maintain a safe degree of re- traction. Should, however, the uterus become lax, and lose its out- line, the physician should grasp it in his hand and knead it firmly until a contraction is excited. In this way he not only guards against haemorrhage, but, by preventing the formation of clots, he diminishes in multiparae the severity of the after-pains. Most physicians seek additional security against haemorrhage by administering ergot, which, as is well knoAvn, favors tonic retraction of the uterus. To this there is no objection, provided the ergot be given subsequent to the expulsion of the placenta. When given, as is com- monly done, at the time of the passage of the child's head, it is liable to produce its effect prematurely, and thus to give rise to hour-glass contraction. The rarity of the accident is no argument in favor of the popularity of the practice, in the face of the serious complication to which it is capable of giving rise. When the physician judges it is safe to suspend the prophylactic pressure upon the uterus, he should see that all the soiled clothing be removed from beneath his patient, and that the nurse wash the genitalia gently but thoroughly. Nothing * Matthews Duncan, " Edinburgh Med. Jour.," April, 1871. 218 LABOR. does so much to cause speedy disappearance of the soreness of the ex- ternal parts as perfect cleanliness. In hospitals a vaginal douche of warm carbolized water should be combined with external ablutions. The perinaeum should then be carefully examined, and, if lacerations are discoArered, the physician should make himself acquainted with their extent and importance. The application of the binder after delivery is one of those points in practice about which men of large experience entertain a difference of opinion. In my student-days in the Hopital des Cliniques in Paris, the binder was dispensed with. A folded sheet was, however, laid across the abdomen, it having been found that a certain amount of pressure was necessary for the comfort of the patient. This plan compelled her to lie upon her back, and thus had the disadvantage of restricting freedom of movement. Careful observation has failed, however, to show me a single good reason why the binder should be discarded. When properly applied, it adds greatly to the woman's comfort, and enables her to turn at will upon her side. My own pref- erence is for a piece of unbleached muslin wide enough to reach below the hips. In adjusting the binder the physician should place himself to the right of the woman ; he should seize the near end between the thumb and tAVo fingers of the left hand, while with the right hand he draws the farther portion smoothly over it. The two ends should then be held with the left hand, and the pins, which should preferably be of large size, should be inserted with the right. The process should be- gin below, and be followed upward at intervals of about two inches. These details are given because the writer remembers his own embar- rassment arising from his inability to get information upon this trivial subject in the early days of his practice. Moreover, as many women are somewhat tenacious of having the binder first applied by the physi- cian, to know how to do it with address is not an indifferent accom- plishment. Many place a compress made of a folded toAvel aboATe the symphysis pubis. This addition usually serves no better purpose than to displace the uterus to one side. The toilet of the patient is finally completed by laying a warm folded napkin at the vulva to receive the lochial discharge. Treatment of Perineal and Cervical Lacerations.—It is needless, as we have already stated, to invade the domain of gynaecology to explain the serious after-results of neglected perineal and cervical lacerations. During childbed, open wounds in the course of the genital canal are a source of danger from septic infection, and, even when kept clean by frequent carbolized douches, retard the progress of recovery. The art of closing lacerations of significant extent by suture deserves, there- fore, to be acquired by every obstetric practitioner. Wliile in hospital practice the results as regards immediate union are widely variable, CONDUCT OF NORMAL LABOR. 219 and often, in consequence of atmospheric conditions, are negative, in properly conducted labors occurring in private practice, where the hygienic conditions are favorable, failure to obtain union is a rare exception. The details of the operative procedures will be given in connection with the pathology of labor. Anaesthetics in Midwifery. The value of anaesthetics in certain irregularities of the labor- pains, in eclampsia, and in most midwifery operations, is no longer a matter of discussion. The benefits from their employment in such cases are palpable and beyond dispute. As to the right, hoAvever, of a woman to have her sufferings assuaged in ordinary normal labor, there is by no means unanimity of opinion. To be sure, the old ob- jections raised in Sir James Simpson's day that labor-pain is a salutary manifestation of life-force, that anaesthesia gives rise to paralysis, to peritonitis, to puerperal mania, to haemorrhage, to pericardial adhe- sions, to indecencies of language and behavior, and that it contravenes the word of God, are now known to be unfounded or imaginary. Still, there is no doubt that the vast majority of medical men refrain from the use of anaesthetics in ordinary labor, either from vain apprehen- sions or because some incident in their practice has led them to sus- pect that, in spite of statistics, they are not devoid of objectionable or dangerous properties. In my own experience during the last sixteen years there have been comparatively few cases in Avhich I have not used chloroform or ether in some stage of labor. The result of my experience has been to make me a warm advocate of their wider em- ployment on the one hand, while proclaiming the necessity of caution in their use upon the other. It seems to me that the hesitancy mani- fested regarding their general adoption is due, in large measure, to the fact that few practitioners give themselves the trouble to master the necessary modus operandi, to study the limitations of their usefulness, or to learn the conditions of their safe administration. It should be steadfastly borne in mind that the giving of anaesthetics in labor is an art to be acquired—a very simple one, perhaps, but the practice of Avhich admits of neither ignorance nor carelessness. As in ordinary surgical practice, anaesthetics are contraindicated by organic affections of the heart and lungs. Except in the prolonged insensibility required for difficult obstet- rical operations, I think the preference should be accorded to chloro- form rather than to ether. The former possesses the advantage of being more agreeable, more manageable, and more rapid in its action. Anaesthesia, not narcosis, is the object aimed at, and the dulling of the sensibility is much more readily effected by chloroform than by ether. As a rule, chloroform should not be administered during the first 220 LABOR. stage of labor, partly because of its tendency, when given at too early a period, to weaken the contractions of the uterus, and partly because protracted anaesthesia has a tendency to impair the cardiac force. To this rule there are, however, numerous exceptions, to which Ave shall have occasion to revert in connection with the consideration of irregu- lar labor-pains. . If the pains in the second stage are of feeble intensity, it is best to withhold the anaesthetic ; if of normal strength, chloroform may be given, but at first only in small doses and during the continuance of a pain. The anaesthetic should not be pushed to the stage of complete unconsciousness until the head begins to emerge at the vulva. Chloroform can be conveniently given upon a folded handkerchief. The latter should be held near to, but not in contact with, the respir- atory passages. The best diluent for chloroform, as was long ago stated by Sir James Simpson, is atmospheric air. If the handkerchief be laid directly across the nose, instant suspension of respiration may result. A minor evil is the cutaneous irritation produced by placing the chloroform in direct contact with the lips and mouth. At the beginning of each pain the patient should be directed to take a number of deep inspirations. During the acme of the pain the expiratory efforts which are then called into play prevent the inhala- tion of any considerable amount of the anaesthetic. When the head presses upon the perinaeum, the handkerchief should be intrusted to the nurse, but the administration to the end should be directed and strictly supervised by the physician. When chloroform is first given, it is common for the pains to become weakened, but this suspensive influence upon the uterus is usually temporary. Exceptionally, hoAvever, the weakness of the pains may continue, and render it necessary to withhold the anaes- thetic. In still rarer cases the pains remain inefficient after the anaes- thesia has subsided. On this account it seems to me certain that those who use chloroform habitually will find themselves compelled to resort to the forceps with somewhat increased frequency. A tardy labor, due to uterine inertia, will likewise call for additional vigilance during the stage of placental expulsion, to forestall the occurrence of haemorrhage. The immunity enjoyed by women in childbirth against the acci- dents which sometimes occur from anaesthesia in surgical practice is not absolute, but dependent upon its cautious and intelligent adminis- tration. I once narrowly escaped losing a patient in the Bellevue Hospital, upon Avhom I designed to perform version, in consequence of my house-physician suddenly crowding a paper funnel containing a towel wet with chloroform over the respiratory passages. Chloroform should not be given in the third stage of labor. The relative safety of chloroform in parturition ceases with the birth of the child. After delivery it favors the relaxation of the uterus, and MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 221 predisposes to haemorrhage. Moreover, after the uterus has been emptied there is always an increase of blood in the large vessels of the abdomen, and a corresponding recession of blood from the head. Now, it is known that the quantity of chloroform which one day is per- fectly tolerated by an individual in health may prove fatal on the suc- ceeding day, in case of the intervention of any considerable loss of blood. Cerebral anaemia, from any cause, increases the risk of anaesthesia. In lengthy operations requiring prolonged anaesthesia, ether, as has already been intimated, should be preferred to chloroform. CHAPTER XII. MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. Frequency.— Origin.—Varieties.—Acardia.—Weight.—Unequal development.—Superfe- tation.—Diagnosis.—Labor.—Presentations.—Simultaneous entrance of both children into the pelvis.—Locking.—Prognosis.—Conduct of labor. The term multiple pregnancy is used when more than one germ are simultaneously developed. Twins, the most common form, occur in the proportion of one to between eighty and ninety births ; triplets in about the proportion of one to seven thousand ; quadruplets and quintuplets are of extreme rarity. No authentic example of over five children at a birth is on record. An instance of quintuplets I have once witnessed. In the Prussian statistics of Von Hemsbach and Veit, based upon thirteen million births, the number of twin pregnan- cies amounted to 150,000. Of these, in 50,000 both children were boys ; in 46,000 both were girls ; and in 54,000 the children consisted of a boy and a girl. Twins may develop either from two distinct ova, discharged from the same or from distinct Graafian follicles, or may both originate from a single ovum. If two Graafian follicles rupture, the ovaries will offer two corpora lutea. In some instances a corpus luteum has been found in each ovary ; in others, both are situated in the same ovary. \ In the case Avhere twins develop from two ova, each foetus is con- tained in its own chorion. If the ova are imbedded in the decidua at sufficiently distant points, the placentae will be separate, and each ovum will have its distinct reflexa. If near one another, the placentae are often united at their borders, each, however, maintaining its inde- pendent circulation. In some cases the two ova lie so close together that they are encircled by a common reflexa. When twins are developed from two centers of deA'elopment con- tained in the same ovum, the placenta, the chorion, and reflexa are, of course, common to both. In most instances, each foetus is contained 222 LABOR. in its own amnion. Occasionally, however, twins are furnished with but one amnion, a peculiarity which, in some cases at least, is not primary, but the result of an absorption of the party-wall between two originally distinct cavities.* Twins from the same ovum are ahvays of the same sex. Anasto- moses of greater or less extent exist between the placental vessels of the two embryos. The consequences of these communications are of the utmost importance, for, when extensive, the heart's action in one Fig. 133.—Author's case of acardia; the monstrosity weighed three pounds nine ounces; there were no traces of heart, lungs, pancreas, liver, spleen, or sternum. foetus counterbalances that of the other ; the stronger blood-current in the placenta pushes back the weaker one, at first impeding the circula- * Ahlfeld, " Beitrage zur Lehre von den Zwillingen," " Arch. f. Gynaek.," Bd. vii, p. 281. MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 223 tion of the less favored foetus, then arresting it, and finally causing it to reverse its direction. The heart atrophies, and an acardia is pro- duced, which is simply an appendage to the healthy foetus. The cir- culation in the acardia takes place as follows : Venous blood from the healthy foetus is conveyed by the umbilical arteries to the placenta ; the force of the fetal heart drives the stream through the communi- cating branches to the umbilical arteries of the less favored twin ; this force is, however, insufficient to carry the current to the upper parts of the body, which are, therefore, not developed. The favorable posi- tion of the lower extremities for receiving the blood from the umbili- cal vessels explains their continued though imperfect growth and de- velopment. The blood carried to the foetus by the umbilical arteries is returned by the umbilical vein. According to Ahlfeld,* a division may take place in the formative material contained within a single area germinativa. This diA'ision may be complete, and thus produce separate twins inclosed in the same amnion, which not only are of the same sex, but bear to one another through life the most striking similarity as regards appear- ance, physical peculiarities, and both mental and moral characteris- tics ; or it may be incomplete, and thus give rise to conjoined twins, or one of the numerous forms of double monsters.f In triplets it is common to find one child derived from an indepen- dent ovum, and two from a single ovum. In a case of quadruplets reported by P. Muller, J two ova were simple, while the third contained two embryos. The children in the single ova were of the female, while those in the double ovum Avere of the male sex. The aArerage weight of the individual children in multiple preg- nancies is less than that of children born single. This is partly due to the frequency with which the excessive distention of the uterus becomes the exciting cause of premature delivery, and partly to the obvious fact that the maternal organism is rarely capable of furnishing the nutritive material requisite for the complete growth of more than a single child. TAvins often exhibit at birth a remarkable disparity as regards both size and development, a disparity unquestionably due to local condi- tions. A striking example of this is shown in a case related by Schultze.* One child, at the time of delivery, was nearly if not quite * Ahlfeld, " Die Entstehung der Doppelbildung und der homologen Zwillinge," " Arch. f. Gynaek.," Bd. ix, p. 196. f Schultze, on the other hand, contends that the double monsters are derived from the fusion of two embryos developed upon the blastodermic vesicle at points close to one an- other. Schultze, " Ueber Zwillingsschwangerschaft," Volkmann's " Samm. klin. Vortr." No. 34. X P. Muller, " Eine Vicrling's Geburt," "Ztschr. f. Geburtsh. und Gynaek.," Bd. iii, p. 166. # Schultze, he. cit., p. 308. 224 LABOR. mature, while the other presented the appearances of a six weeks' foetus. As both ova were enveloped in the same reflexa, their develop- ment must have begun at nearly the same time. Sometimes one foetus dies, and yields to the more fortunate broth- er the space and the nutritive material which would otherwise have fallen to his share. In such a case the ovum and the contained fcetus may be compressed by the surviving twin, and be flattened against the uterine wall, giving rise to the so-called "foetus papyraceus"; or it may degenerate into a mole; or the aborted ovum may be expelled, while the living fcetus advances to the full term of gestation. Very rarely, where the twins are both living, but have undergone unequal development, the stronger child may be delivered first, while the other remains in the uterus, and is born after weeks of delay, dur- ing which, under more favorable conditions, it makes good the defi- ciencies due to its retarded evolution. The most remarkable cases of this kind occur in the uterus duplex. Professor Fordyce Barker re- lates an instance in his practice where, in a double uterus, a mature living male child was born on the 10th of July, 1855, and on the 22d of September following the mother gave birth to a full-term living girl. Histories like the foregoing are often adduced in support of the theory of what is known as superfetation, a theory which supposes that, after conception has once occurred, a second gestation may result from a subsequent coitus. That this is possible, if tAvo ova are de- tached during the same menstrual period, seems to be established by authentic accounts of negro women giving birth to twins, showing the evidences of a paternity derived in one from the black and in the other from the white race. That impregnation can take place at two periods distant from one another must be regarded as an inadmissible hypothesis, until physiologists shall succeed in demonstrating in a sin- gle instance, by the presence of corpora lutea of different ages, that ovulation ever occurs during pregnancy. Diagnosis.—The diagnosis of multiple pregnancy is rarely to be made out with absolute certainty. Unusual size of the uterus, with exaggeration of the symptoms which result from pressure, would nat- urally lead to inquiry on the part of the physician, as it is certain to excite apprehensions in the mind of the pregnant female. Size, hoAv- ever, furnishes but an uncertain criterion, as it may be equally due to the presence of a very large child, or to an excess of amniotic fluid. More trustworthy information is to be obtained from palpation and auscul- tation. Thus the recognition of a number of distinct fetal parts and the exclusion of hydramnion would render the diagnosis of twin preg- nancy probable. The outlining of two fetal heads at a distance from one another would make the diagnosis certain. When the fetal heart is heard at two remote points, and the sound is found to die away in the intervening space, it is justifiable to conclude that the sound at MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. each point has a separate origin. If the two heart-beats are counted at the same time by different observers, and are found not to corre- spond in frequency, a tAvin pregnancy is established beyond dispute. After the birth of the first child, the presence of the second is deter- mined by the size and consistence of the uterus, and the perception of fetal parts both through the abdominal Avails and the vagina. The recognition of triplets and quadruplets is, of course, attended with even greater difficulties than that of twins. Labor in Multiple Pregnancies.—We have already noticed the fre- quency of premature labor in multiple pregnancies. Of one hundred and ninety-two twin births reported by Reuss* from the Wiirzburg clinic, fifty-one did not complete the full term of gestation. In one of these abortion resulted from small-pox, in another from syphilis, in two cases premature labor was induced artificially, in the others labor occurred spontaneously—in one instance at the seventh month, in the others in the ninth and tenth months. Twin labors are usually easy. The first child is delivered as in simple labors, and, except in faulty presentations, is followed shortly by the second. The interval varied, in seventy-four of Reuss's cases which terminated spontaneously, from five minutes to one and a half hour. In seventy-nine per cent, the interval was less than an hour. As the stage of dilatation is completed at the time of the expulsion of the first tAvin, a protracted interval is occasioned purely by weakness and inefficiency of the pains. The placentae are usually expelled after the birth of the second child ; now and then the placenta of the first child precedes the birth of the second ; again, the second child may not be born until after the delivery of its placenta. When the placentae are united, a portion may be torn off and expelled with the first child, while the remainder is not thrown off until after the birth of the second, f The placental stage is, owing to the relaxed state of the uterine Avails, apt to be of longer duration than in simple labors, and calls for the exercise of special care to guard against the occurrence of haemorrhage. Presentations in Twin Labors.—Spiegelberg \ furnishes the follow- ing table, derived from 1,138 deliveries, of which 899 Avere taken from Kleinwachter and 203 from Reuss : Both heads presenting............... Head and breech presenting............ Both pelvic presentations............. Head and transverse presentations...... ...... 71 " 6-18 " Breech and transverse................ ...... 46 " 4*14 " Both transverse................. * Reuss, "Zur Lehre von den Zwillingen," "Arch. f. Gynaek.," Bd. iv, p. 123. ■\ Vide SriEGELBERG, " Lehrbuch der Gcburtshiilfe," Bd. i, p. 203. \ Ibid. 15 226 LABOR. Fig. 134.—Twin pregnancy, both beads presenting. (Tarnier et Chantreuil.) The transverse presentations are mostly secondary, consequent upon the roominess of the uterine cavity and the sudden escape of the amniotic fluid. Version is, of course, in such cases easily per- formed. The Simultaneous Entrance of Both Children into the Pelvis.—The consideration of the various complications to which this anomaly gives rise belongs properly to the domain of pathology. To avoid, however, needless repetitions, they may, for convenience' sake, be properly con- sidered in the present connection. When both children present at the brim previous to the rupture of the membranes, it usually happens that, with the escape of the amni- otic fluid, one of the tAvins descends into the pelvis, Avhile the second glides to one side. The result is identical, whether the tAvins are con- tained in a single or in separate sacs. If interference is called for because of delay, the amnion, or one amnion in case there are two, should be ruptured, and the nearest presenting part brought into the pelvis, while the other is, at the same time, pushed out of the Avay. MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 227 If head and breech present, the head should preferably be allowed to descend first. It may happen, hoAvever, that, after rupture, both children may descend into the pelvis so close to one another as to hinder each the other in its further progression. This locking of the twins, as it is termed, may take place in one of two ways, viz. : 1. In double vertex presentations, delivery may be impeded by the pressing of the second head into the neck of the more advanced foetus, or, after the birth of the first head, the second may enter the pelvis and arrest the advance of the thorax. Obviously this difficulty could only arise in a case where both heads were of unusually small size. The diagnosis has rarely been made previous to the birth of the first head. The treatment consists in the artificial extraction of one head after the other, and then delivering the body of the first child. Cra- niotomy is usually not necessary. The prognosis as regards the chil- dren is extremely unfavorable. Reimann * reports six cases in which Fig. 135.—Twin pregnancy, head and breech presenting. (Tarnier et Chantreuil.) * Reimann, " Am. Jour, of Obstet.," 1877, vol. i, p. 58. 228 LABOR. the fate of the children was known. Of the six first-born, one sur- vived ; of the six last-born, two survived. Reimann, in commenting on these figures, remarks, ** The child whose head first enters the pel- vis is in great danger, because, not only is its neck squeezed by the head of the second child, thereby producing cerebral hyperaemia, but its umbilical cord is exceedingly liable to be compressed by the body of the second child." 2. When one child presents by the breech, the other by the vertex, the former, because of its smaller size, is apt to descend first into the pelvis. No difficulty is then experienced until the neck is born. In case, however, meantime the head of the second child has entered the pelvis, further progress may be rendered impossible, a lock resulting either from the overlapping of the chins, or of the occipital portions of the two heads, or from the pressure of the face of one child into the neck beneath the occiput of the other. By lifting the body of the child, and introducing the half-hand into the vagina, the diagnosis is rendered easy. In a large, roomy pelvis, if the pains are good and the children small, spontaneous delivery may take place. In a number of cases of this kind which have been reported, the head of the second child was born first. In a few instances, it has been found possible to push up the second head. Operative measures consist in applying the forceps and extracting the second head, and afterward, if necessary, the first. In case of failure, craniotomy remains as an ultimate resort. The first child is rarely born living. Of twenty-six children, the fate of which was ascertained by Reimann, only three survived. The prognosis of the second child is more favorable. Of twenty-nine cases, Reimann reports nineteen survivals. Naturally, therefore, the perforation of the first head Avould be preferred, were the matter one purely of elec- tion, but the operation is very difficult, and does not remove the ob- stacle, for even the diminished head can not pass the one already occupying the pelvis.* In the cases so far reported, Avhere decapita- tion of the first child has been performed, the operation has not proved successful in saving the life of the second. The possibility of one twin sitting astride the other when trans- verse requires mention, because of the perplexity that may arise as to the diagnosis, unless the hand is introduced into the lower segment of the uterus to determine the exact relations of the twins to one another. Prognosis.—The prognosis, both as regards the children and the mother, is much more unfavorable than in simple labors. Statistics on this point are valueless, as much depends upon the conduct of the physician. As regards the children, the increased mortality results from prematurity, from unequal development, and from the frequency * Reimann, he. cit., p. 61. MULTIPLE PREGNANCIES AND THEIR MANAGEMENT. 229 of malpositions and malpresentations, requiring operative interference ; as regards the mother, the mortality and susceptibility to puerperal diseases are augmented by the excessive distention of the uterus, the extent of the placental wound, the feebleness in many cases of uterine retraction after delivery, and by the operations which grow out of the anomalies to which labor in multiple pregnancies is subjected. Conduct of Labor in Multiple Pregnancies.—The management of multiple pregnancies does not differ essentially from that of ordinary labor. After the birth of the first child, the placental end of the cord should in all cases be tied, on account of the frequency with which anastomoses are found between the vessels of the placentae. A period of repose should then be alloAved, to enable the uterus to retract down upon the remaining ovum. During the birth of the second child, every care should be taken to folloAV the uterus with the hand, and redoubled precautions should be obseiwed against the occurrence of haemorrhage, to which the woman is exposed both on account of the large size of the placental wound and the disposition to relaxation. Expression should be employed to force the placentae into the vagina. When both descend at once, if it is necessary to make tractions, both cords should be drawn upon, simultaneously or in alternation, to find which placenta is most easily removed. When the placenta follows the birth of the first child, it should be left untouched until the ad- vent of the second. Vigilance after delivery should be long observed. AVe have already noticed that the length of time between the ex- pulsion of twins situated in separate membranes rarely exceeds an hour. When, therefore, there is a longer delay in the delivery of the second child, measures should be employed to excite pains, and the membranes should be ruptured. In case of a premature child deliA'- ered Avith its OAvn placenta, cases of continued development, in utero, of the remaining child, would point to the policy of abstention. In instances where more than two children are contained in the uterus, the anomalies of position are more frequent, and the danger of haemor- rhage is still further enhanced.* * Spiegelberg, " Lchrbuch," pp. 206, 207. 230 THE PUERPERAL STATE. THE PUERPERAL STATE. CHAPTER XIII. THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. The puerperal state borders closely upon pathological conditions.—Post-partum chill.— Temperature.—The pulse.—General functions.—Retention of urine.—Loss of weight. —Involution.—Separation of the decidua.—Closure of the sinuses.—The cervix.— The vagina.—Position of uterus.—After-pains.—The lochia.—The secretion of milk.—Anatomical considerations.—Milk-fever.—Composition of milk.—Diagnosis of the puerperal state.—The new-born infant.—Changes in circulation.—The navel.— Tumor upon the presenting part.—Digestion.—Skin.—Icterus.—Loss of weight.— Management of puerperal state.—Sleep.—Passing urine.—Visits of physician.— Washing the vagina.—Diet.—Laxatives.—Nursing.—Duration of lying-in period.— Care of new-born infant.—Bath.—Cord.—Nursing.—Wet-nursc3.—Artificial feeding. The puerperal state occupies the border-land between health and disease. Though in a strict sense physiological, it offers a variety of conditions, as Schroeder* has pointed out, which, at other times, and under other circumstances, would be regarded as pathological. Thus, the exfoliation of the decidua, and the copious serous transudation, with the abundant formation of young cells which accompanies the development of the new mucous membrane, would elsewhere be re- garded as characteristic features of catarrhal inflammation. The acute degeneration of the uterus presents a phenomenon which, when re- peated in any other organ of the body, would proATe speedily fatal. The thrombus formation in the open placental vessels possesses no corresponding physiological analogue. Again, the torn vessels may lead to haemorrhage, while the traumata, which eAren in normal labor result from parturition, the ease with which deleterious materials are absorbed by the wide lymphatic interspaces, the serous infiltration of the pelvic tissues, the exaggerated size of the lymphatics and veins, create a predisposition to innumerable forms of disease. The nicety of the balance between normal and morbid conditions renders it pecul- iarly necessary for the practitioner to make himself familiar with the physiological limits of the phenomena of childbed. Post-partum Chill.—The exertion of labor is followed by a sense of comfort and repose. Often after the birth of the child, a chill sets in of greater or less intensity, but of short duration, and of no prog- nostic importance. It is to be accounted for by the disturbance of the equilibrium between the internal temperature and that of the external surface. Thus, toward the end of labor, and for a short period sub- sequent to delivery, the loss of heat is increased by the evaporation * Schroeder, " Handbuch der Gcburtshiilfe," 6te Aufl., p. 216. THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 231 from the lungs and skin, and the cessation of muscular effort. This cooling process is, however, speedily arrested by the contraction of the cutaneous arterioles. During the period which intervenes until the external and internal temperatures rise to relatively equal levels, the patient experiences chilly sensations, or a distinct, well-defined chill.* This phenomenon is more frequent in hyperaesthetic women and in those whose skins are bathed in profuse perspiration, especially where there has been some necessary exposure of the person during the ex- pulsion of the head or of the placenta. Under the influence of a warm, dry bed, the chill at once subsides. Temperature.—A rise of temperature follows the parturient act, averaging one and a half degree in primiparae, and one degree in mul- tiparae. This eleA-ation continues during the first six days, with, how- ever, morning remissions and slight evening exacerbations. It is most pronounced in the first twelve hours, especially when they coincide with the normal evening increment. In the following days the high- est point is usually reached at five in the afternoon, while the lowest temperature is found betAveen eleven and one in the early morning. A temperature of 100£° belongs within physiological limits. My oAvn temperature-tables confirm amply the opinion of Schroeder, that a rise above 100£° is by no means incompatible Avith a generally satisfac- tory condition of the patient. Schroeder attributes the increased heat production to the combustion of organic substances Avhich attends the involution of the uterus. To this are to be added, as provoking causes, the reaction of small wounds in the course of the genital canal, and the disturbances attendant upon the establishment of lactation, f The Pulse.—In contrast to the increase in the temperature, the pulse often exhibits a remarkable diminution in frequency, in perfectly normal cases ranging between sixty and seventy beats, but not unfre- quently dropping to a still lower level, and may even sink to less than forty pulsations in the minute. This slowing of the pulse is of favor- able prognostic import. It is known to be associated with diminished arterial tension, J and has been attributed to a variety of not very sat- isfactory reasons, such as the sudden removal of the utero-placental vessels from the circulation, entailing a less degree of labor upon the heart, repose in bed, and disturbed action of the pneumogastric nerves. It is usually most marked on the second or third day, and does not appear to be specially influenced by the establishment of lactation. General Functions.—During the first week the skin is active and moist; the patient is, therefore, sensitive to temperature changes, and * Fehling, " Klin. Beobachtungen fiber den Einfluss der todten Fruchte auf die Mut- ter," "Arch. f. Gynaek.," Bd. vii, p. 151. f Vide Schroeder, " Schwangerschaft, Geburt und Wochenbett," pp. 168-177; Spiegel- berg, "Lehrbuch," p. 210. X Metberg, "Ueber die Pulse der Wochnerinnen," "Arch. f. Gynaek.," Bd. xii, p. 114. 232 THE PUERPERAL STATE. is subject to profuse perspiration when warmly covered or during sleep. The appetite is lessened, the thirst is increased, the bowels are slug- gish, and the urine abundant. In spite of the light diet and repose in bed, the amount of urea eliminated is but slightly diminished. Sugar in the urine is obseiwed at the time of the establishment of lac- tation. It disappears soon afterward, to reappear, however, whenever the milk production is in excess of its consumption.* . The diabetes is, therefore, due to absorption, f Retention of Urine.—In the first day or two following confinement, retention of urine is a common occurrence. It results, according to Schroeder, from the increased capacity of the bladder following the re- moval of pressure from the gravid uterus. Many women, who suffer from retention Avhen reclining, are able to voluntarily urinate when raised to a sitting posture, probably because of the greater facility with Avhich, in the latter case, the pressure of the lax abdominal parietes can be exerted upon the bladder. Loss of Weight.—Owing to the rapid retrograde changes in the pelvic organs, the discharges from the genital passage, the increased secretions of the skin and kidneys, combined with limited ingestion of food, the loss of weight in the first Aveek amounts to from nine to ten pounds, or, roughly speaking, to about one tAvelfth the weight of the body. I Involution.—The processes by means of which the uterus returns to its non-puerperal condition are inaugurated at the commencement of labor. During the rapidly following contractions of the uterus the cell-elements are consumed, while, at the same time, the compression of the nutrient vessels cuts off fresh supplies from the oxidized pro- toplasm. The fatty degeneration of the muscular fibers continues after the expulsion of the ovum. The contractions which bear the name of after-pains point to the continuance of muscular cells capable for a time of functional performance. Gradually, hoAvever, the pro- teine substances are converted into fats, which undergo absorption. Whether the enormously enlarged cells of pregnancy ever entirely dis- appear is still an open question. In the fourth week young cells of neAv formation make their appearance upon the external layer of the uterus, from which eventually a new uterus is developed. Thus de- struction and reparation go hand in hand. In from six to eight weeks, the process described reaches its completion. The lochia then cease, and, in women Avho do not nurse, menstruation returns (Schroeder). Immediately after birth the uterus weighs upward of two pounds ; in two days the weight falls to a pound and a half ; the uterus is seven * Johannovskt, " Ueber den Zuckergehalt im Harne der Wochnerinncn," " Arch. f. Gynaek.," Bd. vii, p. 44S. t Spiegelberg, he. cit., p. 212. X Gassner, "Monatsschr. f. Geburtsk.," Bd. xix, p. 47. THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 233 to eight inches in length and about four and a half inches broad ; the walls are from an inch to an inch and a half in thickness ; at the end of a week the uterus Aveighs a pound, and is five to six and a half inches long ; at the end of tAVo weeks the Aveight is three fourths of a pound, the length fiATe inches, and the Avails hardly a half-inch in thickness. Of course the individual variations from these averages are very great.* In six Aveeks the process usually reaches the end, though the uterus remains ever after somewhat larger and more rounded than in nulli- parae (Spiegelberg). Reparation of the Decidua.—With the expulsion of the ovum the outer portion of the decidua vera for the most part adheres closely to the reflexa, wliile the meshy portion, with the fundi of the glands, remains attached to the uterus. The adherent portion consists of empty areolar spaces, of gland septa, of lymphatic spaces and blood-vessels, while only the fundal extremities are lined with glandular epithelium, f As, hoAvever, the line of demarkation rarely takes place throughout the entire decidua at any fixed level, fragments of the outer, more com- pact layer may frequently be found here and there clinging to the inner surface of the residual membrane. J The uterine cavity is covered and in part filled with at first a bloody and subsequently a muco-sanguinolent fluid containing blood and mu- cus corpuscles, and decidua-cells in various stages of degeneration. At the end of a week the mucous membrane measures at most from a half to three quarters of a lin'e in thickness ; the inner surface has become smoother, from the disintegration and exfoliation of adherent shreds ; the glands, owing to diminished size of the uterus, are pressed closer together, and assume a more nearly perpendicular direction ; the gland-epithelium extends upward along the gland-Avails to the surface of the membrane ; the interglandular spaces are filled with lymphoid cells, with blood-corpuscles, fat-granules, and epithelial cells, in a state of fatty degeneration. As the regenerative process goes on, fine capil- laries Avithout walls form in the interglandular substance, so that the latter presents the appearance of granulation-tissue. By the third week these A^essels of new formation stretch upward to the surface of the mucous membrane, and by the sixth week the development of the vas- cular netAvork is complete. In the second week the lymphoid cells begin to dissoh'e, and thus the glands are brought into near contact with one another. Spindle-shaped cells of young connective tissue are found betAveen the glands in the second week, and with continued connec- * Borner, " Ueber den puerperalcn Uterus " ; Sinclair, " Measurements of the Uterine Cavity," "Trans, of the Am. Gynaec. Soc," vol. iv, p. 231. f Leopold, " Studien fiber die Uterusschleimhaut," etc., " Arch. f. Gynaek.," Bd. xii, p. 180. X Kustner, "Die Losung der mutterlichen Eihiiute," "Arch. f. Gynaek.," Bd. xiii, p. 422. 234 THE PUERPERAL STATE. tive-tissue proliferation the flattened tubules are draAvn upward, and assume a perpendicular direction. The epithelial cells at the mouths of the glands, Avhich at first formed separate islets, approach one an- other as the glands assume their normal positions, and by actively multiplying spread from the circumference until they form a contin- uous lining to the wounded surface. As regards the principal features, the changes which take place at the placental site are the same as those described elseAvhere within the uterine cavity. Immediately after delivery, however, the surface pos- sesses an uneven aspect, with elevations where the septa of the serotina had penetrated between the placental cotyledons, and with intervening depressions. The mouths of the torn vessels are closed by thrombi, and large vessels are irregularly distributed beneath the attached resi- due of the mucous membrane. The process of regeneration at the placental site takes place somewhat more sloAvly than elsewhere within the uterus. Closure of the Sinuses.—By the eighth month of pregnancy, as has been mentioned, a portion of the sinuses beneath the placenta are oblit- erated by the emigration of giant-cells which cause coagulation of the blood circulating through them. After delivery, the blood stagnates in the intact vessels in such a way that at first the inner walls are covered with fibrine, while the center contains fresh red blood. The walls then thicken by proliferation of the endothelium, and lymph- and blood-corpuscles penetrate into the coagulated layer. Finally, the thrombus fills the entire vessel, spindle-shaped cells radiate from the endothelium, and with the development of young connective tissue a gradual shrinkage takes place, which, however, proceeds slowly, so that four to five months after birth the placental site is still distinguish- able.* According to Engelmann, pigmentary deposits in the tissue of the mucous membrane are almost conclusive evidence of recent deliv- ery, as after menstruation they are not found, probably on account of the superficial character of the haemorrhage. The Cervix.—The cervix speedily resumes after delivery its normal size. At first it has a soft and pulpy feel. The os internum (ring of Bandl) forms a resistant ring, which constitutes a well-defined boun- dary between the corpus and cervix uteri. This ring varies in size in different subjects, but is always sufficiently open to permit the intro- duction of two fingers. Beneath, the walls are throAvn into transverse and longitudinal folds. The os externum is usually torn, especially upon the sides, and the thickened labia roll outAvard. The length of * Leopold, " Studien fiber die Uterusschleimhaut," etc., " Arch. f. Gynaek.," Bd. xii p. 169; Engelmann, "The Mucous Membrane of the Uterus," "Am. Jour, of Obstet.," May, 1875 ; Spiegelberg, " Lehrbuch," p. 214; Schroeder, " Lehrbuch," p. 222 ; Kustner, "Die Losung der mfitterlichen Eihaute," etc., "Arch. f. Gynaek.," Bd. xiii, p. 422; Friedlander, " Arch, f. Gynaek.," Bd. ix, p. 22. THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 235 the canal measures two and three quarters inches, and upward. At the end of twelve hours the distinction between the cervix and vagi- na is clearly marked, and the os internum is so far closed that a cer- tain amount of force is requisite to pass two fingers into the uterine cavity. The contraction of the os internum renders the longitudinal folds more pronounced in the upper portion of the canal. From this time on, the involution of the cervix advances rapidly. At the end of twelve days the canal is shortened to an inch in length. As the longitudinal muscles contract, the plicae palmatae become distinct as transverse ridges. The longitudinal folds, with the exception of the anterior and posterior ridge which belong to the plicae palmatae, dis- appear with the retrograde changes which take place in the mucous membrane. The os externum long remains patulous, and permits the finger to pass to the os internum for a period varying between the sev- enth and fourteenth days. The anterior lip is thicker than the poste- rior, and is frequently the seat of erosions and granulations. The involution of the vaginal portion is not completed until after the ex- piration of five to six Aveeks.* The Vagina.—The vagina during the first feAv days is soft, smooth, and relaxed, and requires from three to four weeks to regain its nor- mal dimensions. The contraction and involution proceed more rap- idly at the introitus than above in the neighborhood of the fornix, though, owing to the presence of lacerations, it remains, with feAv exceptions, permanently wider than in women who have never borne children. Position of the Uterus.—Immediately after the expulsion of the placenta the contracted uterus is felt through the abdominal walls as a firm, solid body, of a flattened, pyriform shape. When both hips are on the same level, and both bladder and rectum are empty, the uterus is found in the median line with the fundus between the symphysis and the navel. At the same time the weight of the body and the laxity of the abdominal walls lead to a moderate degree of ante- flexion. Urine in the bladder and faeces in the rectum give rise to a certain amount of lateral displacement, and noAV and then to a torsion of the uterus upon its long axis. As in pregnancy, the fundus of the uterus is thus generally, though not always, directed to the right, and the left border looks to the front. The mean elevation of the fundus above the symphysis is about four and one third inches, the width of * the fundus is upward of four inches, and the length of the entire uterine cavity, as measured by the sound, is in the neighborhood of six inches. The dimensions of the uterus are somewhat less in primiparae * Lott, " Zur Anatomie und Physiologie der Cervix Uteri," pp. 87 et seq.; Borner, " Ueber den puerpcralen Uterus," p. 47, states that at the end of the second week the os internum permits the passage of the finger in about half the cases, but is closed in all by the end of the third week. 236 THE PUERPERAL STATE. than in multiparae. A full bladder pushes the fundus upward, and increases the longitudinal diameter of the organ. Borner has observed an increase from this cause amounting to three and a half inches. A diminution in the size of the uterus is apparent in most cases in the course of the first twenty-four hours. An actual increase is either pathological or due to the above-mentioned influence of the bladder. The diminution is most marked in the first twenty days, but after- ward progresses at a sIoav rate. About the tenth day the fundus sinks below the level of the symphysis pubis, and the posterior surface of the anteflected uterus occupies the plane of the brim.* After-Pains.—The reduction of the uterus in the first few days of the childbed period is in the main the result of contractions, termed after-pains, resembling those of labor both as regards the hardening of the uterine walls perceptible through the abdominal coverings, and the nature of the dolorous sensations which they evoke. The after- pains stretch over a period varying from one to four days. Their duration and intensity are in inverse proportion to the duration and activity of the preceding labor. On this account they are more pro- nounced in multiparae, Avhile they are often absent subsequent to a first delivery. They are intimately associated with the permanent re- traction of the uterus, and are therefore to be regarded as a normal and favorable phenomenon. They are especially prominent in cases of over-distention of the uterus, as, for instance, in cases of tAvin preg- nancies and hydramnios. Suckling the infant produces reflex contrac- tions of a somewhat intense character. The Lochia.—The discharges from the genital passage consequent upon delivery are termed the lochia. At first the latter are composed of pure blood Avith coagula of fibrine, but after a few hours the wound- ed surface of the uterus furnishes an abundant exudation of a serous, alkaline fluid, Avhich washes away in its descent the secretion from the cervix and the vaginal mucus. For the first tAvo or three days the lochia are of a red color {lochia rubra) from the commingling of blood, while upon the third, fourth, and sometimes upon the fifth day, as the sanguineous elements diminish, they present a pale-red color {lochia serosa). As constituents we find under the microscope cervical and vaginal epithelium, blood and mucus corpuscles, bits of decidua, and sometimes shreds of membranes and of the placenta. The organic con- stituents consist of albumen, mucine, the saponified fats, and a variety of saline matters. From the fifth to the seventh or eighth day the dis- charge continues thin, but the blood-corpuscles become less abundant, Avhile there is an increase in the pus-cells and fatty globules. In the * Borner, he. cit. ; Crede, " Beitriige zur Bestimmungder normalen Lage der gesunden Gebarmutter," "Arch. f. Gynaek.," Bd. i, 1870, p. 84; Pjfannkuch, "Ueber die Einfluss der Nachbar-Organe auf die Lage und Involution der puerperalen Uterus," "Arch f Gy- naek.," Bd. iii, 1872, p. 327. THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. second week the discharge becomes of a grayish-white or greenish-yel- low color {lochia alba sen lactea), and of a creamy consistence. It contains chiefly pus-corpuscles, young epithelial cells, spindle-shaped connective-tissue cells, fat-granules, free fat, and crystals of choles- terine. The reaction is neutral or acid. Gradually the discharge diminishes, becomes transparent, and finally assumes a normal appear- ance. After the fourth day the odor is recognizable, and the lochia are found to contain bacteria, indicative of decomposition. In the vaginal secretion the trichomonas vaginalis is likewise present. To- ward the end of the first week, and especially after leaving the bed, fresh blood often makes its appearance. * The quantity of the lochia varies with the peculiarities of the indi- vidual. It is, as a rule, greater in multiparae, in women who do not nurse their children, and in those of flabby fiber, who habitually men- struate abundantly. The mean quantity, according to Gassner, of the lochia cruenta or rubra (to fourth day) amounts to nearly two and a fourth pounds; of the lochia serosa (to sixth day) to rather more than nine ounces ; and of the lochia alba (to ninth day) to six and tAvo thirds ounces : so that the entire amount lost during the first eight days reached the total amount of nearly three and a quarter pounds. The Secretion of Milk. Anatomical Considerations.—The breasts, Avhich furnish the secre- tion of the milk, are two large glands of the compound racemose vari- ety. They are covered by a fine, supple skin and a layer of adipose tissue, Avhich increases in thickness toAvard the periphery of the organ. The mass of the glandular substance is composed of from fifteen to tAventy-four lobes, which in turn are subdivided into lobules made up of a greater or less number of acini, or culs-de-sac. Fine canaliculi start from the latter, and unite together to form the canals of the lobules. These again anastomose, to form a principal canal for each lobe, termed the lactiferous duct. The lactiferous ducts terminate at the nipple by small openings measuring only from one sixtieth to one fortieth of an inch. Each duct, as it passes downward, enlarges in the nipple to one twenty-fifth or one twelfth of an inch in diameter, and beneath the areola it presents an elongated dilatation, from one sixth to one third of an inch in diameter, called the sinus of the duct' (Flint). The spaces between the lobes are filled with adipose tissue, and the various elements Avhich constitute the mammary glands are united into a single mass by a dense connective tissue continuous with that of the subcutaneous layer. The acini, which are merely rudimen- tary in the non-pregnant state, are lined with a single layer of small polyhedral cells, assuming a more cylindrical character in the neighbor- * Vide Schroeder, "Lehrbuch," etc., 6te Aufl., p. 226 ; Spiegelberg, "Lehrbuch," p. 218. 238 TIIE PUERPERAL STATE. hood of the canalicular ducts. The main ducts are lined with low cylindrical cells, and contain in their walls non-striated muscular fibers, the contractions of which are the cause of the spurting of the milk in lactation. c Fio. 136.—Mammary gland, a, nipple, the central portion of which is retracted ; b, areola; c, c, c, c, c, lobules of the gland: 1, sinus, or dilated portion of one of the lactiferous ducts; 2, extremities of the lactiferous ducts. (Liegeois.) During pregnancy the breasts enlarge in consequence of the swelling and increase of the connective tissue, the accumulation of fat between the lobes, and the multiplication of the acini, A\rhich fill with fatty glob- ules resulting from the disintegration of the lining epithelial cells. The changes in the secretory apparatus give rise to irregularly dis- tributed nodular cords, which, however, at first are most distinct at the periphery, and thence advance toward the center of the organ. With continued development a lactescent fluid is produced, which either exudes spontaneously from the nipple or is discharged by press- ure. Milk-Fever.—About the third or fourth day of the childbed period, the turgescence of the breasts is suddenly increased, and they become full, tense, nodular, and sensitive to the touch. The axillary glands enlarge, and radiating pains are experienced in the arm and shoulder. The intensity of the mammary congestion varies in different individ- uals. It is more pronounced in women who postpone nursing their children until after the secretion of milk is fully established. In ex- THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 239 ceptional cases it may be absent altogether. Since the general intro- duction of the thermometer into practice, and the better understanding of the causes of febrile temperatures in the puerperal state, the exist- ence of a distinct milk-fever referable to functional disturbances in the breasts during the period in question has been found to be an en- tirely exceptional occurrence. The temperature tables, Avhich have been kept with great regularity for the past ten years in the Maternity Hospital of this city, prove that under normal conditions the tempera- tures of the third day do not rise above 100$°. With this sub-febrile increase there is, indeed, often conjoined considerable general dis- turbance, indicated by slight chilly sensations, headache, anorexia, and a quickened pulse, which, however, disappear in the course of twenty-four hours, with profuse perspiration, and an abundant secre- tion of milk. Most writers regard the higher temperatures which are sometimes found associated with extreme turgescence, tenderness, and reddening of the mammae, and which subside when the latter are partially unloaded, as dependent upon a non-suppurative form of parenchymatous inflammation. Composition of Milk.—Milk is composed of a fluid portion, and of formed constituents, the first derived from the blood, and the second, termed the milk-globules, from the epithelial contents of the acini. In the production of the milk-globules, the gland-cells actively multi- ply, and become filled with granular particles, which gradually coa- lesce to form drops of fat. Subsequently the nuclei and the contours of the cells disappear, so that the latter consist of mulberry-shaped aggregations of fat-drops held together by the remains of the cell-pro- toplasm. The epithelial elements thus metamorphosed are termed 240 THE PUERPERAL STATE. colostrum-corpuscles. They are found sparingly distributed in the crude, imperfectly formed secretion known as colostrum, which is fur- nished by the breasts of women avIio have been but recently confined. Finally, the fat-globules of large and small size separate from one an- other, and form an emulsion with the fluid transuded from the blood, a process aided, according to Kehrer, by the diffusion through the fluid of the residual protoplasm of the cells. * Colostrum is a watery, semi-opaque, mucilaginous fluid, containing yellowish streaks composed of fat-globules and fatty-degenerated cells Avhich hang together in stringy masses. It is distinguished from true milk not only in the physical characteristics mentioned, but in the greater proportion of sugar and inorganic salts it contains, and in the fact that it coagulates upon boiling. It possesses laxative qualities, which render it of use to the infant in aiding the removal of the me- conium. Perfectly formed milk contains from 2*5 per cent, to 7*6 per cent. butter in emulsion, and from 3*2 per cent, to six per cent, milk-sugar in solution. Both of these substances are directly manufactured by the gland-structures. It possesses likewise a proteine substance termed caseine, which fluctuates in quantity between one, three, and four per cent. Kehrer maintains that it is not held in the milk in solution, but is composed of particles derived from cell-protoplasm which are diffused through the fluid. The salts in the milk amount to 0*14 per cent, f The Diagnosis of the Puerperal State.—The diagnosis of recent de- livery is based upon the physiological conditions which, we have seen, characterize the puerperal state. Thus, the abdomen is flabby and wrinkled, with pigmented linea alba, and is traversed by white-and-red lines ; the breasts are full, tense, and nodular, and secrete milk or colostrum ; the areola about the nipple is discolored ; the uterus is enlarged, anteflexed, palpable through the abdominal wall, and is ex- cited to contract by pressure ; the vulva is swollen, the labia gape apart, the hymen is ragged, the perinaeum is distensible, and in recent cases lacerations, in older ones ulcers or granulating wounds, are found about the vaginal orifice ; in the smooth, lax vagina there is observable the absence of the columnae rugarum ; the cervix is soft, wide below and narrowing above, with the labia often torn and contused ; when the finger can be passed into the uterine cavity, thrombi may be felt at the placental site ; finally, the lochia are hardly likely to be con- founded with haemorrhages or discharges from non-puerperal causes. During the first tAvo weeks an approximative estimate may be made as to the date of confinement by bearing in mind that just after delivery colostrum is found in the breasts, the lochia are bloody, and the lacera- * Kehrer, " Zur Morphologie des Milch-Caseins," " Arch. f. Gynaek.," Bd. ii, p. 1. f Spiegelberg, he. cit., p. 221. THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 241 tions about the vulva present a fresh appearance ; that during the fol- lowing days the lochial secretion changes first to a serous and then to a purulent character ; that the uterus gradually diminishes in size, the fundus at the tenth day sinking below the upper border of the symphysis, while the os internum remains patulous to the tenth day, and is usually impassable for the finger after the twelfth day. The Neav-born Infant. With the first inspiration the thorax expands, and air fills the alveoli of the lungs ; at the same time the blood passes from the right side of the heart to the capillaries of the pulmonary organs, and is returned arterialized to the left side of the heart. As a consequence of the establishment of the pulmonary circulation, the ductus arteri- osus contracts, the foramen ovale closes, and the left ventricle under- goes eccentric hypertrophy. As a consequence of the diversion of a part of the blood-currents to the lungs, the pressure in the aorta sinks, and the circulation in that portion of the umbilical arteries which lies outside the navel ceases, Avhile thoracic aspiration empties the umbili- cal vein. The cord dries from the cut surface toward the navel, and drops off on the fourth or fifth day. The line of demarkation forms at the termination of a capillary network which extends upward upon the cord to a distance of from three to four lines from the skin. When the cord drops off, a wounded surface is left, which heals in a few days. The swelling upon the presenting part subsides mostly in twenty- four to forty-eight hours. The head sloAvly resumes its normal shape—a process completed, probably, in the course of two to three weeks. Soon after birth the meconium is discharged from the intestines, and in a feAv days the evacuations assume a feculent character. The production of pepsin in the stomach, and the secretion by the pancreas of a fluid capable of emulsifying fats and digesting albuminoid sub- stances, render the assimilation of milk practicable. The kidneys excrete an abundance of urine of a Ioav specific gravity. About the third day an exfoliation of the epithelium begins, which is maintained for a week, or even a longer period. During this time the hyperaemia of the skin is very marked, and imparts to it a red color, Avhich as it fades passes into a yellowish tint. The breasts in both sexes sAvell very commonly, become red and sensitive, and yield upon pressure a serous, milky fluid. Icterus of the neAV-born infant is a pretty common affection. Its occurrence is, however, largely influenced by local conditions. Thus, Porak placed the frequency at eighty per cent, among the chil- dren born in the Hopital Cochin in Paris ; Kehrer, in the vast mater- nities of Vienna, at sixty-eight per cent. ; Ebstein, in Prague, at forty- 16 242 THE PUERPERAL STATE. two per cent. ; while West declares it is a rare phenomenon at the Rotunda Hospital in Dublin. It develops usually upon the second or third day, and ends, as a rule, by the sixth to eighth day. Kehrer * has shown statistically that it occurs more frequently in boys, in pre- mature infants, in the children of primiparae, and as a consequence of malpresentations. It is likewise promoted by atelectasis, by intes- tinal affections, by depressing the temperature of the child, by insuf- ficient feeding, and, in a Avord, by all the various pathological condi- tions and unfavorable hygienic influences intensifying or giving an abnormal direction to the ordinary changes which take place in the blood (Ebstein). Its frequency in lying-in hospitals is probably con- nected with a septic infection, for which the wounded surface at the navel furnishes the point of entry. It does not appear to be dependent upon gastro-duodenal catarrh, upon a narrowing of the bile-duct, or upon retention of meconium. The faeces are stained with bile, while bile-pigment in the urine is of exceptional occurrence. On the other hand, in all the tissues of the body, and most abundantly in the kidneys, pigment-crystals and yellowish-red amorphous granules are found de- posited in greater or less quantities. These pigment-bodies are presum- ably not products of the liver, but result from the disintegration of blood-corpuscles, their accumulation in the organism depending either upon the rapidity of the processes of destruction, or upon obstructed elimination by the kidneys. An expectant treatment is the only ra- tional one. Laxatives are unnecessary, and perhaps harmful, f OAving to the discharge of meconium and urine, and the limited amount of sustenance at its disposal, the new-born infant experiences a loss of weight in the first two to three days, estimated at from seven to eight ounces. After the second or third, day the loss is gradually recovered, so that between the fifth and eighth day the weight at birth is reached. The loss of weight is greater in the children of primiparae than in those of multiparae, in artificially nourished in- fants, and where the immediate application of the ligature to the cord at birth has been resorted to. The Management of the Puerperal State. Sleep.—After every precaution has been taken against haemorrhage, after the patient has been Avashed carefully and placed upon clean, dry bedding, and after the baby has been bathed and dressed, it is very de- sirable that the mother should enjoy a few hours of refreshing sleep. To this end the room should be darkened, and absolute stillness en- forced. The crying of the baby, the affectionate salutation of friends, * Kehrer, " Studien fiber den Icterus Neonatorum," " Jahrbuch f. Paediatrik," Bd. ii, p. 71, 1871. f Ebstein, " Ueber die Gelbsucht bei neugeborenen Kindern," Volkmann's " Samml. klin. Vortr.,"No. 180. THE physiology and management OF CHILDBED. 243 or the tidying of the room by household Marthas, often becomes the starting-point of nervous restlessness, which is with difficulty over- come by the aid of the strongest soporifics. Should the mother feel faint and exhausted, she should be allowed a cup of hot tea or bouillon. In multiparae it is well to leave with the nurse some form of ano- dyne, to be administered in case sleep is interrupted bv the frequent recurrence and severity of the after-pains. Opiates, while they lull the pain, do not, after labor, arrest those physiological changes in the uterus with which the after-pains are associated. Passing Urine.—As the natural impulse to urinate after delivery is very feeble, even when the bladder is full, the nurse should be in- structed to solicit the patient to pass water in the course of eight or ten hours. The act of urination should be performed upon the back, which of course necessitates the use of the bed-pan. To be sure, there are a good many women who are able to pass water without difficulty in the sitting posture, who fail in the attempt when recumbent. Still, the risk of exciting haemorrhage by placing the patient upright, during the first four or five days after delivery, is always sufficient to control the action of the careful physician. The physician should make it a rule to visit his patient within tAveh'e hours from the time of confine- ment. He should then inquire, not only whether she has passed water, but ascertain the quantity voided. If the quantity has not exceeded three to four ounces, he should introduce the catheter and make sure that the bladder is completely emptied. In cases of reten- tion, the urine should be draAvn at least three times in the twenty-four hours. Before using the catheter, the external parts should be care- fully washed, to avoid conveying the lochia into the bladder, as the lochial discharge after the first day is liable to excite cystitis. In introducing the catheter beneath the bedclothes, the urethral orifice can readily be detected by first feeling for the tumefied urethra with the index-finger of the right hand through the anterior vaginal wall, and then following it in a forward direction until the meatus is reached. Visits of the Physician.—The physician should see his patient at least once daily during the first week following confinement. During the first four days it is my custom to make both a morning and even- ing visit, not only for the purpose of noting carefully the pulse and temperature, but to be sure that my patient is not made a victim to t the traditional prejudices and superstitions of the monthly nurse. ' If the physician will take the trouble to call occasionally upon his patient subsequent to the first Aveek, to insure the unretarded progress of puerperal convalescence, he will do much to circumscribe the field of gynaecological practice. General Directions.—Great pains should be taken to keep the air of the lying-in chamber fresh and pure. If the room is warm, the 244 THE PUERPERAL STATE. patient should be lightly covered, owing to the tendency during childbed to profuse perspirations. There is no foundation for the prevalent belief that it is dangerous to comb the hair of a puerperal Avoman. Nothing contributes so much to the removal of soreness, and the healing of wounds in the genital canal, as cleanliness. Every morning the external parts should be washed carefully, and at least twice daily the vagina should be syringed Avith some warm disinfect- ant lotion. My own favorites are, for the first three days, an infu- sion of camomile or a saturated solution of boracic acid. After the third day, Avhen decomposition of the lochia is apparent to the sense of smell, carbolic acid ( 3 j ad Oj) should receive the preference. Diet.—The diet should be selected Avith reference to the physio- logical requirements of the patient. Thus, during the first three days, when, as a rule, the patient is thirsty, and is indifferent to solid food, the diet should consist of gruel, milk, milk-toast, and tea, to which may be added clear soups and bouillon should more stimulating ali- ments be called for. It is equally desirable on the one hand to avoid exciting colics and catarrhal affections of the stomach by too early resorting to a substantial regimen, and on the other to remember that the speedy establishment of an abundant milk secretion is apt to be hindered by subjecting women to a process of semi-starvation. After the bowels have moved on the third or fourth day, the normal appetite usually returns. All easily digested articles of food, such as soft- boiled eggs, chicken-broth, small birds, steak, chops, and the like, according to the taste of the patient, should then be allowed. Cooked fruits are of service in overcoming the natural constipation of the puerperal period. The popular prejudice against fish and vegetables containing a large amount of nitrogenized substances seems to me well founded. Laxatives.—The canonical practice of administering a laxative on the third day is of unquestionable utility. Very feAv women escape from an accumulation of fecal matter during the last weeks of preg- nancy—an accumulation which is often enormous in quantity, and which creates a predisposition to puerperal affections. The remedies selected should, however, be adapted to the peculiarities of the indi- vidual. In some Avomen an ordinary injection of soap and olive-oil in water suffices to procure an adequate evacuation ; in others the ob- ject is fulfilled by the milder laxatives, such as the compound rhubarb pill, a claret-glass of Hunyadi-Janos water, or the compound licorice powder of the German pharmacopoeia ; while in obstinate cases a calo- mel purge, or some such combination as the post-partum pill of my friend Professor Barker,* will be found requisite. Castor-oil I give only * Ext. colocynth. comp., 3j ; ext. hyoscyami, gr. xv; pulv. aloes soc, gr. x; ext nuc. vom., gr. v ; podophyllin, ipecacuanha, aa, gr. j. M. Ft. pil. (argent.) No. xii. Of these, two usually act efficiently and without causing pain. THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 245 in cases of severe colic, either alone or combined with fifteen drops of laudanum. In haemorrhoids complicating puerperal convalescence, I can add my testimony to that already given by Professor Barker as to the specific curative effect of half-grain doses of aloes administered night and morning. Nursing.—Every healthy Avoman should nurse her child at least through the puerperal period. The advisability of continuing lacta- tion subsequent to the resumption of household duties must depend upon the question as to Avhether the mother is in a position to make the necessary sacrifices to the interests of the child. When the do- mestic and social demands upon her time and thoughts are numer- ous and pressing, lactation is apt to be imperfect, and the child will not thrive. Humanity, in such cases, requires that the child be sur- rendered to a wet-nurse. Nursing may be rendered impossible by a lack of milk, by flattened, misshapen nipples, and by the health of the mother. It should be prohibited in phthisis, in epilepsy, and in cases of syphilis contracted shortly before the birth of the child. The child should be applied to the breast after the mother has rested, and within the first twelve hours following the end of labor. Soon after birth the child seizes the nipple eagerly, and, though the quantity of nourishment obtained is small, it is infinitely better adapted to the child's needs than the catnip-teas and SAveet-oil Avhich monthly nurses employ as substitutes. The early application of the child to the breast benefits the mother by promoting the contractions and the involution of the uterus, and by lessening the painful disten- tion of the breasts which occurs at the time when the function of lac- tation is fully established. As the child sleeps for the most part during the first feAv days of existence, no rule can be laid doAvn with regard to the frequency Avith which it should be placed to the breast. Afterward it should be ac- customed to some regular routine. So long as the stomach is of small capacity and regurgitates a portion of its food, the interval should not exceed a couple of hours. From an early period, however, the child vshould be accustomed to sleep six hours at night, which gives an op- portunity for the mother to recuperate her strength. This discipline is of course not practicable where the child sleeps in the same bed with the mother. After six months the child should not nurse oftener than five or six times in the twenty-four hours. The breasts should be suckled in alternation. The nipples should be carefully washed both before and after nursing. The addition of boracic acid to the water prevents the development of fungi. The extreme sensitiA'eness of the nipples at the commencement of lactation can be greatly relieved by applying constantly to them a rag wet with the liquorplumbi subacetat., in the proportion of a teaspoonful to a tumbler of water. For a few days a metallic shield over the nipples, 246 THE PUERPERAL STATE. to prevent the rubbing of the night-dress or the bedclothes, is a source of comfort. Duration of Lying-in Period.—Most women expect permission to be given them to sit up upon the tenth day. There should, hoAvever, be no fixed rule about leaving the bed which does not take into account the individuality of the specific case. Not to leave the bed before the tenth day is a safe rule in normal puerperal convalescence ; but, where there are wounds to heal by granulation, a much longer period of time may be necessary. Garrigues* expresses his conviction that "the up- right and sitting postures ought to be carefully a Avoided until involution has proceeded so far that the uterus has receded from the anterior wall of the abdomen and returned to the pelvic cavity"—a rule which Avould allow one Avoman to sit up in a week, while another would be kept in bed two weeks, or even longer. The continuance of the lochia rubra should serve as a warning against a change to the upright posi- tion. The first attempt at getting up should be tentative. The re- sumption of household duties should be postponed until the patient can walk about without fatigue or backache. When the abdominal walls are greatly relaxed, a well-fitted bandage should be worn for Aveeks subsequent to delivery. The Care of the New-born Infant. As the new-born infant possesses feeble powers of resistance to cold, the first bath should be ninety-eight degrees, or nearly that of the body. The vernix caseosa should be softened by oil or fat-inunc- tion, and gentleness employed in its removal. The child should then be gently dried in soft, warm cloths, and carefully examined Avith reference to any possible defect of formation or development. The cord should be Avrapped in an oiled rag, and held in place upon the left side by a flannel bandage. After the cord has separated, the Avounded surface should be dressed with a carbolic salve until the dis- charge ceases, f The dressing of the child is the province of the nurse, and varies considerably in the different social ranks. Cleanliness and fresh air are essential to healthy development. To avoid sprue, the mouth of the child should be washed with cool water each time after nursing. Selecting a Wet-Nurse.—Should the mother be unable to nurse her child, a wet-nurse should be urgently recommended. In selecting the * Garrigues, "Rest after Delivery," "Am. Jour, of Obstet.," October, 1880, p. 861. f Dr. Goodell seizes the cord, after it has been cut as usual, between the thumb and forefinger of the left hnnd, near the navel, and then strips off the gelatine of Wharton with the thumb and forefinger of the right hand. The pressure at the navel is next temporarily suspended where the internal portions of the vessels collapse. The cord is thereupon subjected to a second stripping, tied in the usual manner, and left free without any dressing whatever. The result is, that it separates without any bad smell. (Vide Parry's note, Leishman's "Midwifery," third American edition, p. 608.) THE PHYSIOLOGY AND MANAGEMENT OF CHILDBED. 247 latter, an examination should be made with regard to her constitution and health. The physician should, by inspecting the throat, the legs, the glands of the neck, and, if possible, the genital organs, exclude the existence of a syphilitic or strumous taint. A nurse should be between twenty and thirty-five years of age, and should present all the appearances of good health. The gums should be red and firm ; the breasts should preferably possess a pyriform shape, and should be marbled with blue veins ; it is not necessary that they should be large, but they should be firm, elastic, and nodular from abundance of glan- dular structure ; the nipples should be Avell formed, prominent, and free from cracks and erosions ; the milk should flow easily, and not be too bluish in color. The age of the milk should bear some corre- spondence to that of the child to be suckled. Aside from the question of adaptability, it is obvious that, where a great discrepancy exists, the milk of the nurse is liable to fail before the time of weaning is reached. One of the best tests of a nurse's capacity is the appearance of her own child. If the latter is plump, with well-rounded limbs, and with a healthy skin and mucous membranes, the presumptions are in her favor, even if she does not present in her own person, as Jacobi sport- ively suggests, "a combination of Aphrodite, Athene, and Psyche." When a choice has once been made, a change should not be recom- mended without a fair trial. It is by no means uncommon for a nurse but recently separated from her child, placed among strangers, and introduced to a foreign mode of life, to temporarily suffer from a dimi- nution of the lacteal secretion, the milk returning in a brief period under the influence of kindness, habit, and a nourishing regimen. Moderate exercise is necessary for the maintenance of health. The nurse should be allowed to drink milk freely, but malt liquors should be prohibited, at least until toward the close of lactation. Artificial Feeding.—If it is impossible to procure the services of a wet-nurse, or if the aversion of the parents to wet-nurses as a class proves unconquerable, artificial alimentation must be tried. It is un- questionable that many babies thrive fairly when brought up on the bottle. For success, scrupulous cleanliness, punctuality, intelligence, and experience are requisite. The beautiful roundness of outline, the Men aise, and the easy dentition of infants at the breast are, however, rarely attainable by those who are brought up by hand. Bottle-fed infants are apt to be lean, to be subject to attacks of indigestion, and to suffer from nervous disturbances Avhen teething. If cow's milk is used as a substitute for human milk, the experiment is more likely to proAre a success in the country, where the milk can be obtained fresh morning and evening, than in the city where milk is, of necessity, at least tAvelve hours old at the time of delivery, and thirty-six hours old before a fresh supply can be obtained. My own experience inclines me to favor employing, where it is practicable, milk from one cow, 248 THE PUERPERAL STATE. especially if the cow is selected with reference to the child's individu- ality, precisely in the same manner as a wet-nurse would be selected. The fitness of the milk to the child is to be determined rather by experiment than by analysis. In a general way, hoAvever, it is well to remember that the milk of a very young cow is deficient in fat-glob- ules, while that of an old cow is apt to err on the side of excessive richness, and that either extreme is equally liable to tax the infantile organs of digestion. The difference in the digestibility of human and cow's milk is depen- dent upon a difference in the molecular arrangement of the caseine vari- eties they respectively contain. The acid of the stomach precipitates human caseine in the form of flocculent shreds, while that of the cow's milk is converted into firm, solid masses. Now, of the two forms it has been experimentally proved that the former is much more soluble in the gastric juice than the latter. With many physicians the favorite plan for neutralizing this objection consists in substituting cream for milk (diluted at first with three and afterward with two parts water [Bie- dert]), and thus to reduce the quantity of caseine to minimum pro- portions ; but this diet, by confining the child almost entirely to the hydrocarbons, to the exclusion of the proteine constituents, has never seemed to me in practice, even when well borne, to meet the full tissue requirements of a growing child. After many trials of this mixture, which found a warm advocate in the late Professor Childs, of this city, I have finally returned to milk of good standard quality, stirring it before using to distribute the fat-globules evenly between the dif- ferent layers, and adding to it water proportioned to the age of the child, beginning with eight tablespoonfuls of milk to eight of water, increasing the one and diminishing the other a tablespoonful at a time as rapidly as the digestive organs exhibit a toleration of the change. The water does not, of course, alter the chemical constitution of the caseine, but aids digestion by provoking an increased floAV of the gastric juice, and incidentally contributes to alleviate thirst (Jacobi). City milk should be boiled to prevent fermentation, an unnecessary practice when milk can be obtained fresh night and morning. Instead of plain water, Jacobi has pointed out the utility of using some sub- stance '* which by its physical consistence is able to hold the caseine- clots in suspension, thus protecting the stomach from irritation, while they are being prepared for dissolution." I have been in the habit of following out to this end his earlier suggestion to employ an indif- ferent substance, as gum-arabic or isinglass for very young children, and afterward a thin decoction of oatmeal or barley, according to the tendency of the child to constipation or diarrhoea. Condensed milk is popular with many physicians, because children with whom it agrees fatten upon it, and suffer but little from indiges- tion and loose passages. The large amount of sugar it contains un- ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 249 fits it, however, for prolonged use. I have seen a number of children, exclusively fed upon it, after passing through apparently a blooming infancy, develop symptoms of rickets at the end of their first year. I have, however, been in the habit of allowing its habitual use during the first three months of existence, and in the city during the hot months of summer. Whatever the preparation selected, it should be warmed, before it is given to the child, to blood-heat. A small quantity of salt, and a grain or two of bicarbonate of soda, or a tablespoonful of lime-water, should be added to the infant's food, the former to promote assimila- tion, and the latter to neutralize any free acid the milk may chance to contain. When artificially reared, many children do not gain flesh, in spite of apparently healthy digestion. I have often derived great benefit after the third month from the addition to each bottle of a tablespoonful of Lofflund's Liebig's food for infants. Presumably the various forms of malt extract now so popular in this country would serve the same purpose equally well. The bottle from which the child is fed should be scalded each time that it is used, and should then be filled with cold water to which a little soda has been added. The tube and mouth-piece should both be washed, cleaned with a brush, and allowed to soak in cold Avater, in the intervals of feeding. Unless every precaution is taken to prevent the development of fungi, a bottle-fed infant will never prosper. THE PATHOLOGY OF PREG^A^CY. CHAPTER XIV. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. Variola.—Rubeola.—Scarlatina.—Scarlatina puerperalis.—Cholera.—Typhus, typhoid, and relapsing fever.—Malarial fever.—Icterus.—Cardiac diseases.—Pneumonia.—Emphy- sema, chronic pleurisy, and empyema.—Phthisis.—Syphilis.—Chorea.—Surgical oper-' ations during pregnancy.—Double uterus.—Anteversion and anteflexion.—Retrover- sion.—Retroflexion.—Prolapse of uterus and vagina.—Hernias. The pathology of pregnancy includes the various morbid condi- tions which exercise an unfavorable influence upon pregnancy, whether of maternal or fetal origin. The maternal diseases comprehended under this title may consist of simple exaggerations of normal disturbances, a class which has, however, already received attention in connection with the chapter on 250 THE PATHOLOGY OF PREGNANCY. the management of pregnancy ; accidental complications which mate- rially influence the circulation or the integrity of the pelvic organs ; and, finally, diseases of the uterus and the uterine appendages which endanger the health of the ovum, or pave the way to its expulsion. The pathological processes which affect the ovum may be primary, or may result secondarily from maternal disturbances. The haemorrhages of the first half of pregnancy and the prema- ture expulsion of the ovum are ordinarily the result of fetal or mater- nal disease. Their consideration, therefore, forms a fitting conclusion to the subject-matter in hand. The management of the haemorrhages occurring in the second half of pregnancy requires a preliminary knoAvledge of the operative pro- cedures of midwifery. Its consideration will therefore be postponed until the principles governing the conduct of difficult labor have un- dergone discussion. Morbid states which exercise an unfavorable influence less during pregnancy than after the development of labor will, to avoid double mention, be considered in connection with the pathology of the latter process. Accidental Complications of Pregnancy. Variola attacks pregnant women more frequently than any other eruptive fever, and, although it manifests a preference for those in whom pregnancy is not far advanced, its type is severer and its prognosis graver when it affects women near their confinement. Variola is, unless of a mild form, a peculiarly dangerous complica- tion of pregnancy, greatly imperiling the life of both mother and foetus,* through its tendency to metrorrhagia and abortion. When the disease pursues its course without producing abortion, the child may present characteristic variolous cicatrices, or the latter may be absent. Occasionally the child remains unaffected by the disease until after birth, and may, sometimes, escape it altogether. During epidemics of variola, women may, without manifesting other symptoms of infection from the variolous poison, give birth to premature chil- dren, who remain unaffected with the disease. Children sometimes suffer from variola either before or soon after birth, while their mothers enjoy complete immunity from the disease, f The healthy child of a mother affected Avith variola, or of one vac- cinated during pregnancy, may be insusceptible to vaccinia for some time after birth. J * Meyer, " Ueber Pocken, beim weiblichen Geschlecht," Berlin. " Beitr. z. Geburtsh.," ii, 1873, p. 197. f Schroeder, " Lehrbuch d. Geburtsh.," p. 364. X Spiegelberg, " Geburtsh.," p. 259; Max Runge, " Die acute Infectionskrankheiten in atiologische Beziehung zur Schwangerschaftsunterbrechung," Volkmann's " Samml. klin. Vortr.," No. 174, p. 1370. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 251 It is advisable that all women, becoming pregnant during an epi- demic of variola, should be immediately vaccinated. Rubeola is an infrequent complication of pregnancy, but is serious on account of its tendency to become haemorrhagic and to produce metrorrhagia, fatal alike to mother and child. Pneumonitis is a very frequent and dangerous complication of puerperal rubeola. Scarlatina is a less frequent complication of pregnancy than vari- ola, attacks primiparae by preference, although not exclusiA^ely, and manifests a decided tendency to develop itself in the puerperal state, even Avhen infection has taken place in the earlier months of preg- nancy. Olshausen* Avas able to collect from all the medical literature at his disposal only seven cases of scarlatina occurring during preg- nancy, while the number of cases taking place in the puerperal state amounted to one hundred and thirty-four. In the majority of recorded cases infection is known to have been only possible at a time more or less remote from the confinement, and the tardy development of the disease is, therefore, most rationally referred to a prolonged period of incubation, extending in some in- stances over Aveeks or months. Assuming the correctness of this theory, we must infer that some unknown condition unfavorable to the development of the scarlatinous poison exists during pregnancy and is removed by parturition. The mortality of scarlatina, occurring in pregnancy and in the puerperal state, varies notably in different epidemics, although it is usually high.! Attacks occurring immediately after confinement are more fatal than those developed later. The stage of invasion may be entirely absent or may exist for one or two days before the appearance of the eruption. When present, it is characterized by intense febrile movement, emesis, and notable con- gestion of the face. Usually, however, the earliest announcement of the attack consists in the sudden development of the eruption on all parts of the body. The eruption soon assumes a characteristic livid color, which is usually retained until the fatal issue, should the latter occur within a week. The pharyngitis and tonsillitis are either very mild or entirely ab- sent. Diarrhoea is a frequent and dangerous complication. Aside from the above-mentioned peculiarities, puerperal scarlatina presents no important A^ariations from the clinical history of ordinary scarlet fever. The lochial discharge, the lacteal secretion, and the uterine involution are unaffected by the disease. * Olshausen, " Untersuch. lib. d. Complic. des Puerp. m. Scarlat. u. d. sogenannte S. puerperalis," " Arch. f. Gynaek.," ix, 1876, p. 169; Braxton Hicks, " Trans, of the Obstet. Soc. of London," vol. xvii. f Denham saw only one recovery in eight and Hicks only four recoveries in eighteen cases, while McClintock had but ten fatal results in thirty-four cases. 252 THE PATHOLOGY OF PREGNANCY. Antipyretic measures, particularly cool baths, are indicated in pro- portion to the intensity of the febrile movement. Cathartics are to be avoided, because of the inherent tendency to diarrhoea, alluded to above. Stimulants are to be fearlessly employed when asthenic symp- toms are developed. Scarlatina Puerperalis.—Some authors have applied the designation " scarlatina puerperalis " to an infectious disease Avhich, although re- sembling scarlatina, is still said to be identical with or closely related to puerperal fever. The theory advocated by them is based upon the fact that, in the cases upon which their deductions are founded, the angina was trivial in character; the attacks occurred, usually, within three days after confinement; infection Avith scarlatinous poison could not, in the majority of cases, be established ; the rate of mortality was very high, and peritonitis and cellulitis were often revealed on autopsy. Olshausen * concludes with apparent justice, after a careful review of the reasons for and against the introduction of this new disease into obstetric nosology, that the grounds for its establishment are insuffi- cient, and that the cases of so-called " scarlatina puerperalis " are noth- ing more than ordinary cases of scarlet fever, modified by the concomi- tant puerperal condition, but in no Avay akin to puerperal pyaemia or septicaemia. It is worthy of note that scarlatina and puerperal fever may, in rare instances, occur in combination without mutually affecting their respective signs and symptoms. Braxton Hicks f advo- cates the extreme theory that a puerperal woman, when infected with scarlatina, develops puerperal fever, and that persons other than lying- in women, contracting the disease through intercourse with the puer- peral patients, are attacked by scarlatina of the usual'form. Cholera.—The predisposition, on the part of pregnant and puer- peral women, to cholera Asiatica is not usually decided, but varies with different epidemics, and is more marked in cities than in the country. Women are most liable to an attack of cholera in the latter half of pregnancy, particularly in the seventh and eighth months, and the prognosis is gravest for cases occurring at * those periods. The prognosis is almost necessarily fatal in the case of children born before the ninth month. J The intensity of the disease is somewhat mitigated by the existence of the puerperal state. Slight attacks of cholera may take their natural course without prejudicial effects upon mother or foetus, but the disease frequently results in abortion or premature delivery, due, in part, to haemorrhagic metritis. The pathological uterine conditions observed in the cases recorded by Slavjansky # com- * R. Olshausen, he. cit. t Braxton Hicks, " Trans, of the Obstet. Soc. of London," 1871, pp. 44, 75. X Ueb. d. Einfluss d. C. auf Schw. u. Wochenbett," "Monatsschr! f. Geburtsh.," 1868, xxxii, p. 60. * Slavjansky, " Endonietrit. decidualis haem. bei Cholerakranken," " Arch f Gynaek " iv, 1872, p. 293. '' ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 253 prised roughening of the inner surface of the uterus by dark-violet shreds of the decidua vera, numerous extravasations permeating the mucous membrane, Avhich remained intact in some places and was ulcerated at others, besides the presence in the uterine cavity of coagu- lated blood, pus, and shreds of the uterine mucous membrane. The placenta foetalis presented granular degeneration and almost complete disintegration of the epithelium covering the villi. Both pathological processes above described conspire to induce the death of the fcetus, which then, in common with coagula and inflammatory products in the uterine cavity, acts as a foreign body and produces abortion. Schroeder * refers the death of the foetus to asphyxia pro- duced by changes in the maternal blood which interfere with the pla- cental respiratory function. The clinical history of cholera is not materially affected by coexisting pregnancy, except in so far as uterine symptoms are concerned. Eclampsia sometimes occurs, and irregular uterine pains may persist for several days without producing abortion, f Cholera does not specially predispose to puerperal diseases, nor does it afford protection against them. Lactation, whether commencing or already established, is not markedly affected by cholera, although the lochia are often almost suppressed. The treatment is conducted upon general principles. The artifi- cial induction of premature delivery has had many advocates on ac- count of its supposed tendency to ameliorate the prognosis, but has now fallen into disrepute, although judicious measures to hasten par- turition, already begun by Nature, are regarded as justifiable. Typhus, Typhoid, and Relapsing Fevers.—These fevers more fre- quently complicate the earlier than the later months of pregnancy, and affect the prognosis more seriously at the former epoch, owing to the greater tendency then existing to protracted post-partum haemorrhage. \ They may also, rarely, complicate the puerperal state. Typhus feArer manifests a less marked tendency to the induction of abortion or of premature deliA^ery than either typhoid or relapsing fever, probably because it is less frequently accompanied by metrorrha- gia.# It, however, occasionally produces these results, thereby essen- tially increasing the danger of a lethal termination. || Typhoid fever is frequently, and relapsing fever almost constantly, accompanied by abortion or by premature delivery induced by profuse uterine haemorrhages,^ and thus greatly endanger life. The clinical history and the treatment of the fevers in question are unaffected by * Schroeder, "Lehrb. d. Geburtsh.," 1872, p. 365. f Hennig, he. cit. X Wallichs, "Monatsschr. f. Geburtsk.," xxx, II. iv, 1867, p. 253; Spiegelberg " Handb. d. Geburtsh.," p. 260. # Zuelzer, "Monatsschr. f. Geburtsk.," xxxi, H. vi, 1868, p. 419. | Wallichs, op. cit., p. 261. A Zuelzer, op. cit., p. 424. 254 THE PATHOLOGY OF PREGNANCY. coexisting pregnancy except in so far as symptoms and indications having reference to the occurrence of metrorrhagia, abortion, or pre- mature delivery, are concerned. Malarial Fever.—Malarial fever is not a very frequent complication of pregnancy, perhaps because the latter secures a certain freedom from exposure to the malarial poison. Women who have previously experienced malarial fever, and Avho have been considered cured of the disease for several years, often suffer a relapse during subsequent preg- nancies.* Attacks occurring under these circumstances may be re- garded as acute exacerbations of a chronic malarial disease which has remained latent for a certain time. Malarial fever does not produce abortion except in rare instances, f e\Ten when the febrile phenomena persist up to the termination of pregnancy. Parturition suspends the periodic paroxysms, supposing them to have continued up to confine- ment, possibly owing to the loss of blood dependent on delivery. During the puerperal state, however, particularly in the second and third Aveeks, the pardxysms usually return or a latent malarial cachexia may manifest itself in the manner previously alluded to. \ The disease may be communicated to the foetus, as has been proved by the detec- tion of the characteristic pathological appearances induced by mala- rial poisoning in the spleen, and by the discovery of malarial pigment- granules in the blood and skin of children dying before or immediately after birth.* Hubbard || reported an interesting case of intra-uterine malarial fever of the tertian type, in which the fetal movements Avere entirely suspended during the maternal paroxysms, and returned during the intermissions. The woman was confined during an intermission. On the folloAving day the mother and child had a simultaneous paroxysm. Quinia Avas now administered, Avith the result of curing both mother and child—the latter obtaining the antiperiodic through the medium of the mother's milk. The usual course of malarial fever is altered by coexisting preg- nancy. Intermissions are usually wanting, and the fever becomes continued or remittent, the chills occurring irregularly.A Even those cases Avhich most nearly approximate the usual malarial course shoAV a tendency to anticipation or retardation of the paroxysms. The fever may assume a pernicious character, its tendency in this direction being accounted for by the nervous prostration and anaemia attendant upon the puerperal condition. Quinia best controls the febrile phenomena, * Robert Barnes, " Trans, of the Am. Gyn. Soc," 1876, p. 144. \ Max Runge, Volkmann's " Samml. klin. Vortr.," No. 174, p. 10 1376. X Spiegelberg, " Geburtsh.," p. 261. # Max Runge, he. cit. || Hubbard, "Edinburgh Med. Jour.," June, 1866. A Mendel, " Intermittens wahrend Schwangerschaft und Wochenbett," " Monatsschr f. Geburtsk.," Bd. xxxii, H. i, p. 10. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 255 but must be given in large doses, since the powers of digestion and of assimilation are seriously impaired by the puerperal state.* Icterus.—Icterus, although a phenomenon of rare occurrence dur- ing pregnancy, is interesting and important on account of its tendency to precede or to accompany the fatal pathological changes and symp- tomatic events connected Avith acute yellow atrophy of the liver. It is ordinarily assumed that this grave general disease is developed from a form of icterus which, Avhen complicating pregnancy, usually has etiological relations identical with those of simple obstructive or so-called hepatic jaundice, although the causative condition frequently eludes observation. The development in pregnancy of icterus termi- nating fatally is, also, sometimes due to the lesions of phosphorus- poisoning. Davidson f attributes the fatal influence of pregnancy upon the course of simple icterus to the three following causes : 1. The impairment of the renal excretory function, due to the passive congestion produced by uterine pressure upon the renal veins. This etiological factor operates by causing the retention in the blood of the reabsorbed biliary acids, which, according to the investigations of Traube and others, are of themselves capable, even when present in the blood in moderate quantity, of producing acute yellow atrophy. 2. The hydraemia of pregnancy, Avhich renders the system less capable of resistance to toxic agencies. 3. The impairment of cardiac activ- ity, due to the retention of the biliary acids, Avhich still further com- promises renal eliminative action. Icterus often produces abortion by. destroying the life of the foetus. The causative connection betAveen icterus and fetal death has been proved by the intense icterus of the dead foetus, by the detection of biliary acids in its blood, and by the exclusion of other causes. After abortion a previously benign icterus may speedily develop all the characteristic lesions and symptoms of acute yellow atrophy. \ Under these circumstances, the sudden advent of the fatal symptoms may be accounted for by the anaemia and hy- draemia induced by the haemorrhage accompanying parturition. As- suming the correctness of the aboA'e-mentioned deductions Avith refer- ence to the usual etiology of fatal icterus complicating pregnancy, we must admit the urgent indication in these cases for measures cal- culated to facilitate the elimination of the biliary acids from the blood by restoring the normal excretory function of the kidneys. An early resort to appropriate measures might, partially or entirely, prevent the, accumulation of the poison upon whose presence such baneful results are believed to depend. * Barker, in a paper termed "Puerperal Malarial Fever" ("Am. Jour, of Obstet," April, 1880), furnishes a most valuable addition to our knowledge of the symptoms and treatment of this disease. f Davidson, "Monatsschr. f. Geburtsk," Bd. xxx, H. vi, 1867, p. 465. X Schroeder, " Lehrbuch der Geburtsh.," p. 366. 256 THE PATHOLOGY OF PREGNANCY. Cardiac Diseases.—The various effects produced upon pregnancy by coexisting heart-disease depend entirely upon the seat and character of the cardiac affection. While the results of myocarditis are seri- ous, because of its interference with the development of cardiac hyper- trophy adequate for the compensation of existing valvular lesions, and acute endocarditis, occurring during pregnancy, shows a marked ten- dency to assume the fatal ulcerative form,* pericarditis has no percep- tible effect upon the normal course of utero-gestation.f Chronic en- docarditis often produces disastrous results, which may, in general terms, be accounted for by the fact that an amount of cardiac hyper- trophy completely compensatory for preexisting valvular lesions is no longer able to overcome the increased arterial and venous pressure prevailing during pregnancy, or to adapt itself to the sudden variations in vascular tension due to the parturient act. The augmented arterial pressure which calls for increased cardiac activity is referable, in part, to the newly developed utero-placental circulation. It is also attrib- uted by some authors to the actual pressure of the gravid uterus upon the aorta; while Spiegelberg J believes it to be measurably due to the plethora of pregnancy, and to the limitation of the intra-thoracic space by the encroachments of the diaphragm. An important source of varying and perturbed heart-action is, moreover, found during labor in the suddenly changing conditions of pressure produced by the alter- nating uterine contractions and relaxations with the corresponding violent respiratory efforts. Spiegelberg * refers the symptoms of aortic insufficiency or stenosis, which are usually most marked in the later months of pregnancy, solely to cardiac disturbances due to increased arterial tension, and the disappearance of these symptoms, after birth, to the restitution of the normal pressure. He considers the grave symptoms of mitral disease, often presenting themselves soon after confinement, as referable to ex- cessive distention of the right heart with blood forced into it from the contracted uterus. Fritsch || opposes this view, and attributes the morbid phenomena of mitral disease to the accumulation of blood in the abdominal vessels recently released from the pressure of the gravid uterus, and to the cardiac paralysis resulting from an insufficient blood-supply and consequent defective nutrition of the heart. The hydraemia of the puerperal state may contribute to the impair- ment of nutrition, and thus cooperate with the above causative agen- cies in the production of cardiac paralysis. * Lebert, " Beitr. zur Ca^uistik der Herz- und Gef asskrankheiten im Puerperium " "Arch. f. Gynaek.," Bd. hi, 1872, p. 39. t Porak, " De l'infl. recip. de la grossesse et des mal. de cceur," 1880, p. 92. X Spiegelberg, "Arch. f. Gynaek.," ii, 1871, p. 236. # Spiegelberg, " Ueber d. Comp. des Puerp. m. chron. Ilerzkr.," ibid., ii, 1871, p. 233. || Fritsch, " Die Gcfahren d. Mitralisfchler," ibid., viii, 1875, p. 381. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 257 The symptoms of aortic valvular disease are usually manifested during the latter half of pregnancy. They consist in palpitations, dyspnoea, and, in extreme cases, abortion or premature delivery. Should pregnancy proceed to a normal termination, the symptoms are aggravated by parturition, but disappear speedily after it. Mitral valvular lesions, if slight or completely compensated for, may not manifest their existence by any rational symptoms. If, however, the compensation be inadequate, the patient's life may be greatly and sometimes suddenly endangered by the occurrence, either before or after confinement, of extreme pulmonary congestion and oedema, ascites, albuminuria or metrorrhagia. The foetus may die in utero, as the result of metrorrhagia or of impaired nutrition due to defi- cient oxygenation of the maternal blood. Children whose mothers are the Arictims of cardiac disease are often imperfectly deA-eloped, and predisposed to untimely death. The prognosis is based upon the gen- eral condition of the patient. It is impaired by coexisting pulmonary lesions, tending to obstruct the circulation in the lungs, as well as by diseases of other vital organs. Mitral lesions are of more grave signifi- cance than those at the aortic orifice, and mitral stenosis is particularly dangerous. * Women with cardiac disease of any considerable gravity should be dissuaded from marriage. The indications for medicinal treatment are the same as for cardiac diseases uncomplicated by pregnancy. Chloroform should be administered with special caution, if at all, dur- ing parturition. The artificial induction of abortion or of premature deliA'ery may be justified by the occurrence of symptoms menacing the mother's life. Acute Lobar Pneumonia.— Pneumonia attacks women less fre- quently than men. Its rate of mortality is, however, much larger among the former. These facts should be remembered by investiga- tors of the reciprocal relations between pneumonia and pregnancy, in order that the influence excited by the former upon the latter be not exaggerated. Pneumonia is an infrequent complication of the pregnant state, but affects the course of the latter very prejudicially.f Although a pneumonia of large extent may terminate in complete recovery, without having endangered the life of mother or foetus, J it often produces abortion or premature delivery, the frequency of these results increasing in direct proportion to the duration of pregnancy. The type of the pulmonary inflammation is also more severe in the later stages of utero-gestation, and parturition exerts an unfavor- * Porak, op. cit., p. 113; Fritsch, op. cit., p. 383. f Fasbender, " Ueber P. als Schwangcrsch. Complicat.," etc., " Beitrag z. Geburtsh.," iii, 1874, Sitzgsber., p. 54. X Gusserow, " Pn. b. Schwangercn," "Monatsschr. f. Geburtsk.," xxxii, H. ii, 1868 p. 93. 17 258 THE PATHOLOGY OF PREGNANCY. able effect upon women in proportion as their pregnancy is far ad- vanced. * It was formerly believed that pneumonia, occurring during preg- nancy, owed its fatal character chiefly to the encroachments of the gravid uterus upon the intra-thoracic space, and to the consequent interference with the necessary compensatory increase of functional activity on the part of the healthy lung-tissue. Later investigations having not only shown the fallacy of this theory, f but even rendered probable an actual increase in the intra-thoracic space during preg- nancy^ the fatal character of intercurrent pneumonia is referred to coexisting hydraemia, and to the inability of the poorly nourished heart to restore the balance of a pulmonary circulation disturbed by the consolidation of lung-tissue and by the consequent impermeability of large capillary areas. Pulmonary oedema, resulting from progres- sive cardiac asthenia, directly induces the fatal issue. Parturition itself, whether naturally or artificially produced, greatly imperils the woman's life* by making exorbitant demands upon the already failing heart-poAver and by aggravating existing hydraemia. Abortion, when occurring under these circumstances, is referred to fetal death caused by deficient oxygenation of the maternal blood, by placental anaemia produced through an inadequate supply of blood to the left heart, and by the abnormally elevated maternal temperature. || From the fatal results of parturition in pneumonia we conclude that the induction of abortion or of premature delivery, in ordinary cases, is unjustifi- able.*1 Should labor, however, have already begun, its termination must be hastened by all available means. Our further treatment must consist in efforts at strengthening the heart's action. Brandy and car- bonate of ammonia, digitalis and quinia, deserve the most confidence for the fulfillment of these indications. WTernich recommends cautious venesection, for the relief of extreme dyspnoea or cyanosis, and pro- poses that the collapse to which bloodletting may lead be combated by transfusion.A Emphysema, Chronic Pleurisy, and Empyema.—These affections are dangerous complications of pregnancy, in that they produce cardiac dilatation, and prevent the heart from successfully adapting its activity to the varying conditions of vascular tension obtaining in parturition and the puerperal state. The induction of abortion or of premature delivery may be indicated by the existence of these diseases, provided the mother's strength has become so impaired as to incapacitate her for continued utero-gestation. * Wernich, " Beitriig. z. Geburtsh.," iii, 1S71, Sitzgsb., p. 56. f Gusserow, op. cit., p. S8. X Wernich, Berlin. "Beitriig. z. Geburtsh.," ii, 1873, p. 249. # Fasbender, op. cit., p. 55. || Spiegelberg, " Lohrb. d. Geburtsh.," p. 265. A Wernich, op. cit., p. 261. Q Schroeder, " Lchrb. d. Geburtsh.," p. 364. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 259 Phthisis.—It was formerly erroneously held that pregnancy afford- ed immunity against pulmonary phthisis. This view may have been based upon the clinical fact that the progress of preexistent phthisis is sometimes retarded by the supervention of pregnancy.* This re- sult is observed, according to Lebert,f in only a small proportion of cases. In the majority of instances pregnancy not only hastens the progress of actually existing phthisis, but precipitates its development. The latter result is of especially frequent occurrence in those heredi- tarily predisposed to the disease, or in such persons as may have re- covered from a previous attack. These effects of pregnancy upon the development and course of phthisis are most manifest between the ages of twenty and thirty years, although they are not infrequent be- tween the ages of thirty and forty. The advanced stages of phthisis prevent conception, but the same is not true of its earlier periods.' The puerperal state often favors the development of phthisis, particularly in those hereditarily predisposed to it, and usually hastens the fatal issue of the disease if it have already manifested itself. In very ex- ceptional instances, however, parturition and the post-partum state exert a favorable influence upon the course of phthisis. It often happens that women Avith inherited tendencies to phthisis may escape it during their first pregnancy, only to become its victims in a later one. J Although women with progressing phthisis may pass through the parturient and puerperal states in safety, they are greatly prostrated thereby, and rarely have sufficient milk to nurse their children. They, moreover, often experience abortion or premature delivery. The chil- dren of such women are usually puny and feeble. They are sloAvly and imperfectly developed and are predisposed to pulmonary disease. Prophylactic treatment affords the only encouraging prospects of suc- cess in the cases under consideration. Girls with suspected hereditary predisposition to phthisis should, accordingly, not marry, as they should not become mothers. If they do bear children, they must never nurse them. Syphilis.—When syphilis, which is a frequent complication of preg- nancy, is contracted at the beginning or during the course of the latter, it is characterized by intense initial and by unusually mild consecutive symptoms.* The duration of the incubation is, ordinarily, about two Aveeks, but may be protracted to six weeks. The initial lesions, which are more extensive than in Avomen who are not pregnant, may involve the vagina, cervix, labia, nates, and thighs. They embrace SAvelling, reddening and excoriation of the mucous membrane and skin, oedema, * Wernich, "Berlin. Beitrag. z. Geb.," ii, 1873, p. 251. f Lebert, " Ueber Tab.d. weiblich. Geschlechtsorgane," " Arch. f. Gynaek.," iv, 1872, p. 469. X SriEGELBERG, " Lehrb. d. Geburtsh.," p. 266. # Sigmund, "Ueber d. Verlauf d. S. bei Schwangerschaft," " Wien. med. Presse," xiv, 1873, No. 1. 260 THE PATHOLOGY OF PREGNANCY. eczema, follicular abscesses, and even necrosis of connective tissue. These intense inflammatory processes may be referred to increased nutrition of the parts, and to the mechanical results of friction between them. The secondary symptoms are of a mild type, consisting chiefly of general glandular induration, papules on and around the genitals, and scales on the palms and soles. Mewis * states that the occurrence of parturition has a favorable effect upon these lesions, usually result- ing in their disappearance. Erythema, pharyngitis, alopecia, iritis, and febrile movement are either absent or slightly marked. Pregnant women OAve the mildness of their secondary symptoms to amelioration of their general nutrition. Syphilis exerts a very prejudicial influence upon the product of conception. If either parent be affected with general syphilis at the time of the coition resulting in impregnation, syphilis is communicated to the fcetus. It is almost equally impos- sible for a foetus poisoned by the paternal reproductive element to infect a healthy mother. Provided the mother were untainted at the time of conception, syphilis contracted by her during pregnancy can not be communicated to the foetus. If the father be syphilitic, the infection of the ovum is accomplished by the diseased spermatozoids. If the mother be constitutionally tainted, the ovum is already poi- soned. Should both parents be the victims of general syphilis, each equally bequeaths the disease to the offspring, f The syphilitic poison, therefore, will not traverse the septa intervening betAveen the fetal and the maternal vascular systems. \ In rare exceptions to this general rule the mother contracts the disease by so-called choc en retour.* A progressive and continuous diminution in the intensity of fetal syphilis, directly proportionate to the length of time which has elapsed since the contraction of the disease by the parent who communicated it, is observed in cases unmodified by treatment. Parents whose syphilis is allowed to pursue its natural course retain the capability of transmitting the disease to their offspring for varying periods, the average length of which is ten years. Latency of the parental syphilis does not secure immunity of the fcetus from the disease, although it diminishes the probability of its transmission. Parents with tertiary syphilitic symptoms may or may not communicate the disease to their children, according as the poison Avhose original pres- ence produced the gummata is still retained in the system, or has been eliminated by nature or by mercurials. | In accordance with the varying intensity of the hereditary influence, the foetus may either perish in utero, its death resulting in abortion or premature delivery, * Mewis, "Syphilis congenita," "Ztschr. f. Geburtsh. u. Gynaek.," iv, 1879, 1, p. 62. t Kassowitz, "Die Vererbung d. Syphilis," Strieker's "Med. Jahrb.," p. 372.' X Kassowitz, he. cit., p. 425. * Frankel, "Ueber Placentarsyphilis," "Arch. f. Gynaek.," v, 1873, p. 44. || Kassowitz, op. cit., p. 451. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 261 may be born alive but destined to die early, or may manifest the dis- ease only at the expiration of periods varying from weeks to years. Conception occurring during the first years after the parents' infec- tion with syphilis almost invariably terminates in abortion or prema- ture delivery, the causes of which are either the vitiated nutritive processes of the foetus, the increased maternal temperature due to syphilitic fever, or syphilitic degeneration of the fetal placenta, con- sisting, according to MeAvis,* of inflammatory changes in the tunica intima of the blood-vessels. Similar pathological changes are said, by the same author, to occur in the intima of the umbilical vessels. The pathological conditions observed in syphilitic disease of the placenta are either granular degeneration of the placental villi, with obliteration of the blood-vessels, or the morbid changes designated by the names endometritis placentaris gummosa and endometritis decidualis.f (For a more detailed account of placental syphilis, vide chapter on placental diseases.) Every pregnant woman who, at the time of conception, is or has been affected with constitutional syphilis, should be promptly subjected to a thorough mercurial treatment, preferably by the method of in- unction. This is desirable, even when no present symptoms are de- tected, with reference to the prevention of the frequently disastrous influences of latent syphilis. If, however, the disease be contracted during the later months of pregnancy, the treatment may consist of palliative measures, until after parturition, since no harm will result from the maternal syphilis to the fetal life. Local primary or sec- ondary disease of the genitals should receive appropriate treatment, in order that the child be not infected during delivery. Chorea in Pregnancy.—Chorea, which is a rare complication of pregnancy, affects primiparae by preference, particularly those possess- ing an hereditary predisposition. Barnes \ was able to collect only fifty- six and Fehling * only twelve additional cases from the whole domain of obstetrical literature. Organic cerebral lesions are assumed by Spiegelberg || as estab- lished causes of the disease. In regard to other etiological agencies Avide diversities of opinion preAail. According to Goodell,A the choreic movements are of reflex nature, and are referable to im- paired nutrition of the central nervous system, incident to the hydrae- mia of pregnancy. The association of chorea and organic cardiac disease has been frequently observed, and the discovery, in certain cases, of fibrous vegetations upon the mitral and aortic Aralves accounts for the assumption, by some authors, of embolism as a cause of chorea. * Mewis, he. cit., p. 42. f Fsankel, op. cit., p. 52. X Barnes, "Trans, of the Obstet. Soc. of London," x, 1869, p. 147. * Fehling, "Arch. f. Gynaek.," vi, 1874, p. 137. || Spiegelberg, "Lehrb.," p. 255. A Goodell, "Am. Jour, of Obstet.," May, 1870, p. 149. 262 THE PATHOLOGY OF PREGNANCY. Barnes * discountenances this view, and calls attention to the probable causative agency of myelitis. Terror and other intense emotions may act as exciting causes of chorea. Choreic movements occurring in pregnancy do not differ from those attending the disease in the unimpregnated state. They are usually bilateral. In most cases the muscular contractions manifest themselves in the earlier months of pregnancy, and continue until delivery is accomplished. In rare instances they are arrested at the beginning of parturition. In still more exceptional cases the contrac- tions may either cease before delivery or persist during the post-partum state. Transitory albuminuria and diabetes mellitus are occasional unexplained complications of chorea gravidarum, and the phosphates and urates of the urine are present in abnormal abundance. Abortion and premature delivery, due to the repeated succussion of the uterus, are of very frequent occurrence. Chorea exerts a prejudicial influence upon the course of preg- nancy,! having interrupted it in about one half the recorded cases. Death of the mother resulted in seventeen of the fifty-six cases collected by Barnes. J The lethal termination was usually referable to the exhaustion consequent upon protracted muscular exertion, or to hemiplegia secondary to grave cerebral or spinal lesions. The life of the child is less frequently sacrificed, but it is itself often affected with chorea. The treatment consists in the administration of iron and quinine, and the lowering of the reflex excitability by the prolonged use of the bromide of potassium. During the attack, chloroform, chloral, and the subcutaneous injection of morphia have proved serviceable. When palliative remedies prove fruitless, in view of the perilous nature of the affection, artificial labor or eA'en abortion is indicated. Surgical Operations during Pregnancy.—Massot * concludes, from the observation of a considerable number of cases, that ordinary surgi- cal operations do not interfere with pregnancy unless they materially and permanently disturb the uterine circulation, or call into activity the uterine muscular force by reflex irritation. This will, most frequently, be the result of operations upon the external or inter- nal genital organs. Cohnstein | states, as the result of his researches, that, after operations and injuries, pregnancy reaches a normal termination in 54*5 per cent, of all cases. Interruption of preg- nancy was, in his cases, determined : {a) by the period of pregnancy * Barnes, he. cit., p. 179. f Goodell, "Am. Jour, of Obstet.," vol. viii, p. 168. X Barnes, " Trans, of the Obstet. Soc. of London," x, 1869. * Massot, " Ueber d. Einfluss traumat. Einwirk. auf d. Verlauf der Schwangerschaft," Schmidt's " Jahrb.," 1874, 164, p. 266. fl Cohnstein, " Ueber chirurg. Op. bei Schwangeren," Volkmann's " Samml. klin. Vortr.," No. 59, 1873, p. 493. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERES. 263 when the operation took place, occurring more frequently as the result of surgical measures resorted to in the third, fourth, and eighth months ; {b) upon the seat of the operation, resulting in two thirds of all cases, from operations upon the genito-urinary organs ; {c) upon the extent of the Avound, folloAving amputations, exarticulations, and ovariotomies with great relative frequency ; {d) upon the number of children, occurring in multiple pregnancy with uniform regularity. Age seemed to exert no causative influence. Abortion directly results, under these circumstances, from reflex irritation, or from fetal death referable to haemorrhage or to septic poisoning on the mother's part. The prognosis, so far as the mother is concerned, depends upon the time when delivery occurs. The mortality ordinarily attending de- livery, if at term, is insignificant; for abortions and premature de- liveries it amounts, according to Cohnstein, to thirty-three per cent. The most frequent causes of the mother's death are shock, peritoni- tis, septicaemia, haemorrhage, and oedema pulmonalis. In vieAV of the manifest danger from operations of any magnitude, it may be stated as a general laAV that surgical measures not absolutely indicated by the existence of pathological conditions liable to aggravation by delayed interference should be postponed until after confinement. Those morbid conditions, however, whose development is hastened by pregnancy, or whose existence offers mechanical obstacles to par- turition, must be early subjected to operative interference. This re- mark applies Avith special force to carcinomatous growths in any part of the body and to intra-pelvic tumors. The time of operation should not coincide with the menstrual epoch of pregnant women, as abortion is more likely to occur at that period.* For a similar reason it is recommended that the third, fourth, and eighth months should be avoided. Massot is of the opin- ion f that anaesthetics, when employed during operations on pregnant women, exert rather a favorable than a prejudicial effect upon fetal life by diminishing reflex irritation. Abnormal Conditions of the Uterus. Double Uterus.—Double uterus occurs under various forms. The uterus and cervix*may be double, the vagina remaining single. The double uterus may haA'e a single cervix opening into an undivided vagina. The uterus, although double, may have a single cervix open- ing into a double vagina, the septum beginning at the os internum ; or uterus, cervix, and vagina may be double throughout. All these forms permit of normal utero-gestation on either side or on both sides simultaneously, provided that each half of the genital canal be sufficiently developed. If, however, the dividing septum ex- * SriEGELBERG, " Lchrb. d. Geburtsh.," p. 268. f Massot, he. cit., p. 267. 264 THE PATHOLOGY OF PREGNANCY. tends quite to the vaginal entrance, simultaneous pregnancy in each horn is exceedingly rare.* If pregnancy occur in only one side of a double uterus, a decidua vera is developed in the other side, and expelled at the end of preg- nancy. Double uterus is less readily diagnosticated during pregnancy than after or before it, but is usually recognized with facility. A double vagina is not necessarily indicative of double uterus, but if tAvo vaginae are found, each containing a cervix, the presence of double uterus may be safely assumed. If a double cervix terminate in an un- divided vagina, the uterus may or may not be double. When preg- nancy exists in only one horn, the uterine development is manifestly unilateral, and the existence of an unimpregnated half may be deter- mined by combined manipulation or by the uterine sound. In these cases presenting a double uterus with a single cervix and vagina, the diagnosis rests chiefly upon unilateral uterine development and de- pression of the fundus and body corresponding to the septum. The form of a double uterus is most plainly manifest during the contrac- tions accompanying and succeeding parturition, f It is still undecided whether double uterus be a cause of abortion and of premature de- livery. Ordinarily, however, the symptoms and course of pregnancy are unaffected by this malformation. The complete functional inde- pendence of the two segments is demonstrated by the fact that in twin pregnancies parturition is frequently not simultaneously accom- plished by them. In the case of unilateral pregnancy, the ratio of head to breech presentations is, according to Schatz, as twenty-one to two. Tedious labor may result in cases of double uterus, from uterine atony, referable either to imperfect muscular deA'elopment of the preg- nant horn, to its deviation from the normal pelvic axis, or to obstruc- tion produced by the unimpregnated horn. Post-partum haemorrhage may result from uterine atony or from attachment of the placenta to the septum, Avhose imperfect development prevents its firm and thor- ough contraction. Anteversion and Anteflexion.—The normal anteversion of the un- impregnated uterus is exaggerated by the increased weight of the gravid uterine body, but this deviation is usually rectified by the gradual development and upward movement of the uterus. In excep- tional cases the anteversion persists after the fourth month, and pro- duces vesical tenesmus, dysuria, or incontinence. No evidences of uterine incarceration are, however, obseiwed, and the comparatiArely trivial symptoms are relieved by regulating defecation, replacing the fundus, causing the patient to assume the dorsal decubitus, or by ad- justing an appropriate pessary. * Schroeder, " Lehrb. d. Geburtsh.," p. 376. f Schatz, " Mitth. aus d. Leipz. Geb.-klinik u. Polyklinik," " Arch. f. Gynaek.," ii, 1S71, p. 297. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 265 In the later stages of utero-gestation, anteversion combined with anteflexion may again occur, and produce the deformity known as pendulous abdomen. It is, then, chiefly due to the inadequate sup- port afforded to the uterus by the abdominal parietes. The failure of their sustaining power is referable to their relaxation—which is most marked in multiparae—to separation of the recti muscles, or to the yielding of old cicatrices produced by operations or injuries. The dis- placement is also favored by lordosis of the lumbar vertebrae, and by contracted pelvis, which prevent the normal descent of the uterus. In extreme cases of pendulous abdomen, the uterus, having separated the recti, descends, covered by fascia and skin, almost or quite to the knees, and seriously interferes with locomotion. Its pressure also pro- duces oedema of the abdominal wall, vesical tenesmus, and pain in the distended cutaneous tissues. These symptoms are relieved by repo- sition of the uterus, and by the application of a suitable abdominal bandage. Retroversion.—Betroversion, a comparatively infrequent form of displacement in the unimpregnated uterus, usually rectifies itself dur- ing the earlier months of pregnancy. Should spontaneous restitution not occur, the fundus being detained below the promontory until after the third month, the cervix bends upon itself at an acute angle, and the retroversion is transformed into a retroflexion. Retroflexion.—Retroflexion occurs infrequently in women who have not borne children, but often renders sterile those who are thus affect- ed. It is one of the most common uterine displacements in women who have borne children, though it does not, in their case, ordinarily prevent conception. When conception occurs in a retroflexed uterus, the latter usually rises from the pelvis, and assumes a position of ante- version at the fourth month. In many cases, however, the displace- ment produces congestion of the uterine mucous membrane, metritis, and abortion. In still other cases the fundus does not ascend above the promontory at the usual time, and either the symptoms of retro- flexion Avith incarceration are slowly developed, or that form of retro- flexion known as partial retroflexion, or retroflexion in the second half of pregnancy, occurs. This consists in the division of the uterine cavity into an anterior and a posterior diverticulum or pouch. The anterior diverticulum is produced by the more rapid upward develop- ment of the anterior uterine wall, which is subjected to comparatively slight pressure and contains the larger part of the foetus. The pos- terior uterine wall enters predominantly into the formation of the posterior diverticulum, and usually contains the fetal head. This peculiar form of uterine displacement may be spontaneously rectified during pregnancy, or may persist until delivery, producing no impor- tant symptoms except vesical and rectal tenesmus, Avith dysuria and painful defecation. In the latter case it materially interferes with par- 266 THE PATHOLOGY OF PREGNANCY. turition, inasmuch as the cervix, which is displaced upward and for- ward behind the symphysis, is not situated in the pelvic axis, and the posterior diverticulum is forced by the uterine contractions against the perinaeum and posterior Araginal wall. Even at this stage Nature may restore the uterus to its normal position ; but, in default of spon- taneous restitution, it must be replaced by forcing up the posterior diverticulum with the hand introduced into the rectum, while the an- terior pouch is displaced downward by pressure upon the abdomen and by traction applied to the cervix ; or, Avhere version is practicable, by bringing down the breech, room may be made for the release of the imprisoned head. Retroflexion of the Gravid Uterus, with Incarceration.—Although this form of retroflexion is usually developed in the gradual manner aboA'e described, it may, in rare instances, be rapidly produced by sud- den abdominal compression or concussion. The symptoms, which are in either case essentially the same, differ chiefly in the varying rapidity of their development, and result from the pressure of the displaced uterus upon the intra-pelvic viscera and tissues. They embrace dysuria, eventuating sometimes in complete retention of urine from urethral compression, vesical tenesmus, incon- tinence of urine, painful defecation, constipation, or obstipation, vio- lent sacral and lumbar pains, Avhich radiate into the thighs, and in grave cases emesis, with all the other symptoms of ileus. Abortion, followed by spontaneous restitution and recovery, may occur even at this stage. Should incarceration, however, persist, violent metritis, parametritis, and peritonitis may lead to a fatal issue. In rare cases, gangrene of the uterus or vagina may be induced. A lethal termina- tion may also indirectly result from pathological processes in the blad- der occasioned by retained and decomposing urine. These morbid processes consist in cystitis, sometimes complicated by diphtheritic and gangrenous inflammation of the mucous membrane and of the deeper vesical tissues, which may lead to septicaemia or to rupture of the blad- der. Death may, moreover, result from passive renal congestion and uraemia. The diagnosis of uterine retroflexion Avith incarceration is based upon the foregoing clinical history; the fluctuating abdominal tumor, from which large quantities of urine may be obtained by the catheter or by puncture; the oedema of the vulva ; the presence in Douglas's cul-de-sac of a tumor presenting the characteristic consistence of uter- ine tissue; the position of the cervix and meatus urinarius behind the symphysis; and the distention of the perinaeum by the fundus uteri. The distinction between an incarcerated uterus and an extra-uterine pregnancy is sometimes difficult, necessitating a thorough bimanual examination, aided, in cases of abdominal tenderness, by the employ- ment of an anaesthetic. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 267 The replacement of the uterus, Avhich, of course, is the objective point of treatment, should in all cases be preceded by the evacuation of the bladder. This is usually accomplished without much trouble by means of a sharply curved male catheter, and by remembering that the urethra is ordinarily deflected somewhat to one side. Veit,* in an experience of from seventy to eighty cases, found catheterization always practicable. Where intelligent effort is attended by failure, puncture is allowable. To this end an aspirator needle, Avhich, how- ever, should not be of too small caliber, should be passed through the abdominal walls at a point about three inches above the symphysis. In practice this operation has thus far proved devoid of danger, though the possible risk from infiltration of urine should act as a check to its rash employment. The replacement of the uterus should be attempted with the patient anaesthetized, and in the Sims latero-prone position, f Pressure upon the fundus should be exerted by four fingers introduced into the va- gina or rectum. Barnes J recommends tilting the fundus to one side, so as to disengage it from the projection of the promontory. It may happen that the first attempt may be only partially successful, while a reneAval of the manipulation after twelve to twenty-four hours may lead to complete reduction (Veit). It is possible that, after empty- ing the bladder and rectum, spontaneous reposition may take place; but the expectant plan is hardly to be recommended, both because of its uncertainty and on account of the prolongation of the patient's suffering. In exceptional cases the replacement of the uterus may be prevent- ed by inflammatory adhesions, or by the secondary swelling of the dis- placed organ. The induction of abortion then becomes imperative, either by the ordinary methods or by puncture of the uterine walls. The introduction of a uterine sound or a flexible catheter is rarely practicable. In a case reported by P. Miiller,* where the retroversion was complete, with the fundus upon the perinaeum and the cervix looking directly upAvard, Muller resorted to the following ingenious expedient : He cut off the end of a male silver catheter, and then bent the extremity into a hook. Having succeeded in passing the lat- ter into the cervix, he introduced a piece of catgut through the tube between the membranes and the uterus. After tAveh'e hours, during which the catgut was left in situ, the foetus Avas expelled. If catheter- ization can not be accomplished by either of the foregoing methods, * Veit, " Ueber die Retroflexion der Gebarmutter in den spateren Schwangerschafts- monaten," Volkmann's "Samml. klin. Vortr.," No. 170, p. 1363. f If no anaesthetic is used, the knee-chest position may be tried in difficult replace- ment. X Barnes, " Obstetric Operations," third American edition, p. 276. # P. Muller, " Zur Therapie der Retrovcrsio Uteri gravidi," " Beitr. ziir Geburtsh.," Bd. iii, p. 67. 268 THE PATHOLOGY OF PREGNANCY. puncture of the uterus with a fine trocar, and Avith antiseptic precau- tions, has proved a tolerably safe procedure, and, by the withdrawal of a portion of the amniotic fluid, a certain means of provoking abortion. Prolapse of the Pregnant Uterus.—In rare instances the normal pregnant uterus becomes prolapsed during the early months, through mechanical violence, and its sudden displacement may lead to abortion through uterine congestion and haemorrhage. Ordinarily, however, procidentia uteri is only observed, during pregnancy, when it has antedated conception, and it is most frequent in multiparae. A slight prolapse disappears temporarily with the ascent of the uterus. A well-marked procidentia, however, as a result of which a part or the whole of the uterus has been extruded from the vagina, is often at- tended by symptoms of incarceration terminating in abortion. There is no recorded instance of procidentia in which pregnancy persisted until the time of normal delivery, in a uterus lying Avholly without the vagina. Procidentia uteri is simulated by hypertrophy, either of the supravaginal or of the infravaginal portion of the cervix. This pathological condition is unattended by grave results, unless it lead to rigidity of the os uteri, tedious delivery, and uterine inertia. If excessively developed, however, the portio vaginalis may be trans- formed into a pulpy, polyp-like mass, which, by its constant friction and irritation, produces abortion. It should not be mistaken for pro- lapse of the uterus, as efforts at reposition may produce irritation suffi- ciently severe to induce premature delivery. Amputation of the hyper- trophied cervix may be performed, during the third month, without disturbing the course of pregnancy, and is indicated, in aggraA'ated cases, because of the possible prejudicial influence of cervical hyper- trophy, unmodified by treatment, upon utero-gestation and parturition. When prolapse, even of slight extent, exists in a pregnant uterus, the normal ascent of the organ should be encouraged by the avoidance of exertion, and by careful regulation of defecation and micturition. In more pronounced cases the uterus must be replaced and sustained by a suitable tampon. Spiegelberg * advises the use of a cotton tampon, soaked in glycerine, and held in position by a perineal bandage, and reneAved at short intervals. Caution is necessary in the reduction of the uterus, lest the fundus be caught beneath the symphysis and the procidentia converted into a retroflexion. When incarceration has oc- curred, and the parts are much swollen, their volume may be reduced by scarification, after which reposition must be attempted. Should it fail, abortion should be induced before the incarceration has irrepa- rably compromised the vitality of the pelvic tissues. Prolapse of the Vagina.—A slight degree of vaginal prolapse occurs more frequently in pregnant women than does uterine prolapse. Cases of more complete prolapse of the vagina are, however, almost invari- * Spiegelberg, " Geburtshulfe," p. 278. ACCIDENTAL COMPLICATIONS.—ABNORMALITIES OF THE UTERUS. 269 ably attended with procidentia uteri. The anterior vaginal wall is usually alone involved in the prolapse, although the posterior wall may descend alone, or both Avails become simultaneously prolapsed. This displacement produces traction upon the bladder and rectum, resulting in irritation of these organs and of the vulva. During par- turition, moreover, the prolapsed vagina offers an impediment to delivery, and may, therefore, be subjected to an amount of pressure in- compatible with the maintenance of its vitality. The treatment con- sists in producing regular alvine evacuations, and in sustaining the vagina Avith cotton tampons and a perineal band, or with the latter alone. During labor, persistent efforts at reposition of the prolapsed vagina must be made between the pains. Should these attempts prove effectual, the vagina must be sustained in proper position, until the descent of the head has occurred. If reposition be impossible, the forceps must be resorted to in order to prevent the disastrous results of excessive pressure on the vaginal tissues, and traction must be so applied as to avoid injury of the anterior vaginal wall. Hernias of the Pregnant Uterus.—Although hernias of the unim- pregnated uterus are very rare, they still occur much more frequently than those of the gravid uterus. The most frequent forms under which they present themselves are the umbilical and the ventral. Femoral and inguinal uterine hernias, as well as hernias through the foramen ovale and the great sacro-sciatic foramen, also occur. The sac of a ventral hernia is often formed by the yielding and dilatation of extensive cicatrices in the abdominal wall, such as result from ovari- otomies and gastrotomies, or by the separation of the recti muscles. Femoral and inguinal uterine hernias are either congenital or are produced by ovarian or omental hernias, betAveen Avhich and the uterus adhesions exist. Pregnancy has been observed to occur most frequently in inguinal uterine hernias, next in umbilical, and least frequently in femoral hernias.* It has never been discovered in a uterus Avhich had escaped through the foramen ovale or the greater sacro-sciatic foramen. Pregnancy occurring in inguinal or femoral uterine hernias is uni- formly terminated by abortion or by premature delivery. The diag- nosis is readily made if due regard be paid to the absence of the uterus from its natural situation, to the shape and consistence of the hernial tumor, to the physical signs furnished by auscultation and percussion over it, and to the displacement of the vagina toward the site of the hernia. When the hernia is recognized at an early date, the uterus must, if possible, be restored to its normal position, and there retained by an appropriate truss. Should attempts at reposition be unsuccessful, artificial abortion should be induced, as it will otherAvise occur spon- taneously at a later date, and under less favorable conditions. When * SriEGELBEP.G, " Geburtsh ," p. 280. 270 THE PATHOLOGY OF PREGNANCY. the product of conception has already attained a large size, reposition and delivery, whether spontaneous or artificial, are rarely accomplished unless the constricting hernial ring be previously divided. Even the latter procedure may prove ineffectual, in which case hysterotomy is the last resort. CHAPTER XV. DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. Endometritis decidua: 1. Chronica; 2. Tuberosa; 3. Catarrhalis.—Anomalies of the pla- centa.—Anomalies of form ; of position; of development; of circulation.—Placen- titis.—Degenerations.—Syphilis.—Anomalies of the amnion and of the amniotic fluid.—Hydramnion.—Deficiency of amniotic fluid.—Anomalies of the umbilical cord; torsion ; knots; hernias ; coiling of the cord ; cysts ; stenoses of vessels; marginal implantations.—Ilydatidiform mole. Endometritis decidua.—The normal congestion of the uterine mu- cous membrane attendant upon conception, and resulting in the forma- tion of the decidua, may, under the irritating influence of various exciting causes, develop into endometritis. The inflammation may be either acute in character, as is often the case in cholera Asiatica and other infectious diseases,* or may pursue a chronic course, presenting itself in the three distinct forms about to be considered : I. Endometritis decidua chronica diffusa.—The causes of this form of endometritis are not usually readily discoA*erable. It is believed to be sometimes developed from an endometritis antedating conception. It is also referred to syphilitic infection,! to excessive physical exer- tion, J and to secondary inflammation resulting from the death of the foetus and its retention in the uterine cavity.* The anatomical changes characteristic of this form of endometritis consist essentially in thickening and induration of the decidua, due to a more or less diffuse development of new connective tissue, and to proliferation of the decidual cells. Cysts have been observed in the hypertrophied decidua by Hegar and Maier.|| KaschewaroAva dis- covered neAvly developed and hypertrophied involuntary muscular fibers in the substance of the decidual Extravasations into the hyper- trophied decidual tissue are of frequent occurrence. v The decidua vera or the decidua reflexa may be separately or jointly involved in * Slavjansky, "Arch. f. Gynaek.," iv, p. 285. + Frankel, " Arch. f. Gynaek.," v, 1873, p. 53. X Kaschewarowa, Virchow's "Arch.," 1868, vol. xliv, p. 113. * Schroeder, " Geburtsh.," sixth edition, p. 392. | Spiegelberg, "Geburtsh.," p. 301. A Kaschewarowa, he. cit., p. 111. 0 Eigenijrod und Hegar, "Monatsechr. f. Geburtsk.," vol. xxii, 1863, p. 161. DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. 271 these pathological processes, and may be affected throughout a part or the whole of their extent. When the hyperplasia of the mucous membrane is developed in the later months of utero-gestation, pursues a notably chronic course, is limited in extent, or does not involve the placental decidua, pregnancy may proceed to a normal termination. When, hoAvever, the endometritis appears early, assumes an acute or haemorrhagic type, is attended by partial separation of the decidua, or involves the placental decidua, it frequently induces abortion or pre- mature delivery, either by causing the death of the foetus through in- terference with its nutrition,* or by exciting reflex uterine contrac- tions. Parturition may, in either case, be protracted by the slow separation of the decidua, betAveen which and the deeper uterine tis- sues adhesions have been formed by the newly developed connective tissue and muscular fibers. If the placental decidua be involved in the morbid process, the placenta may be separated with difficulty, and its slow expulsion be attended by copious haemorrhages. II. Endometritis decidua tuberosa et polyposa— The etiology of this variety of decidual inflammation is involved in obscurity. Syph- ilis was regarded as a causatiATe agent by Virchow, Avho first described the degenerate changes under consideration,! and preexistent endo- metritis is also supposed to occupy a causative relation to them. Gus- serow X suggests that conception occurring soon after delivery may excite the recently formed vascular uterine mucous membrane to ab- normal proliferative processes. It is doubtful whether the latter are ever secondary to irritation produced by the death of the foetus.* In Ahlfeld's cases the inflammation Avas apparently idiopathic. The pathological processes peculiar to this variety of endometritis are usually observed in the decidua vera alone, and manifest a prefer- ence for those portions of the decidua corresponding to the anterior and posterior uterine surfaces. In some cases, characterized by absence of the decidua vera, the decidua reflexa is found involved in the mor- bid changes. The latter consist in marked thickening of the entire decidua referable to proliferation of the interstitial connectiAre tissue and to extensive hypertrophy of the decidual cells, Avhich are provided with nuclei of enormous size. Occasional free nuclei occur. || The uterine surface of the decidua is rough and covered with coagulated blood, while the entire mucous membrane is exceedingly Avascular. Upon that surface of the decidua which is directed toward the ovum are situated large excrescences or elevations, the preA'ailing shape of which is polypoid. They may, hoAvever, appear in the form of nod- * Klebs, " Monatsschr. f. Geburtsk.," 1S66, vol. xxvii, p. 402. f Ahlfeld, " Arch. f. Gynaek.," vol. x, 1876, p. 173. X Gusserow, " Monatsschr. f. Gynaek.," vol. xxvii, 1866, p. 323. # Schroeder, " Geburtsh.," sixth edition, p. 393. | Gusserow, he. cit., p. 322. 272 THE PATHOLOGY OF PREGNANCY. ules, of cones, or of boss-like projections provided with a broad, non- pedunculated base. Their height is from one quarter to one half an inch, and their surface is smooth, very vascular, and devoid of uterine follicles. The latter are, however, plainly visible on the mucous mem- brane intenrening between the polypoid outgrowths, but they are com- pressed 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 occasion- ally form bridge-like connections between neighboring polypi. The uterine follicles are, in some cases, filled with blood-clots. The epi- thelium 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 case their cells are granular and cloudy. The foetus is generally dead and partially disintegrated. This form of endometritis decidua is, consequently, usually accom- panied by abortion, which occurs predominantly at an early stage of pregnancy. III. Endometritis decidua catarrhalis.—Hydrorrhcea gravidarum.— This form of uterine inflammation is less intense than the two varie- ties just described, affects pluriparae more frequently than primiparae, and seems to stand in etiological relations Avith hydraemia. The pathological processes involved in the disease are vascularity, hyperae- mia, and hypertrophy of the interstitial connective tissue and of the glandular elements of the decidua. f The inflammation involves the decidua vera by preference, but may simultaneously affect the de- cidua reflexa. J The most striking symptomatic occurrence is due to the glandular hypertrophy, and consists in the escape from the uterine cavity of a thin, watery, muco-purulent or sero-sanguinolent liquid, Avhich resembles the amniotic fluid both in color and in odor. Pro- vided that free exit be afforded to the secretion, its discharge is effected gradually and in small quantities. Should, however, obstacles to its continuous evacuation be encountered, either in the usual adhesions between the decidua vera and reflexa or in impenetrability of the os internum, the secretion, having accumulated between the decidua and the chorion, forces a passage through the decidua reflexa and is dis- charged in considerable quantities. In some cases even a pound or more of the liquid is thus suddenly evacuated. J Small quantities of * Hegar, " Monatsschr. f. Geburtsk.," vol. xxii, 1863, pp. 300, 429. f Spiegelberg, " Geburtshulfe," p. 302. X Schroeder, " Geburtshulfe," p. 394. DISEASES OF THE DECIDUA—DISEASES OF THE OVUM. 273 the secretion are often observed as early as the third month. The more abundant discharges occur only in the later periods of pregnancy, and are often attended by slight uterine contractions, which may, in exceptional cases, become so severe as to induce abortion or premature delivery. The diagnosis involves differentiation between a discharge emanat- ing from the hypertrophied decidual glands and the ante-partum es- cape of a fluid which sometimes accumulates between the amnion and chorion. The latter discharge, the quantity of which may be so large as to simulate hydramnion, differs from that of hydrorrhoea gravida- rum in that it occurs only once.* The escape of the decidual secretion might be mistaken for that of the amniotic fluid, which may be easily distinguished by the fact that it immediately precedes delivery. The treatment should embrace analeptic and tonic measures as well as the careful avoidance of vaginal douches and of all local irritation tending to produce abortion. Should uterine contractions accompany the es- cape of the decidual fluid, appropriate anodyne treatment must be adopted. Relaxation of the Pelvic Symphyses. f—This condition, which consists in an excess of the ordinary physiological softening at the pelvic artic- ulations, may permit of such a degree of mobility between the pelvic bones as to effectually hinder locomotion. This is usually accompanied by pains in the ligaments of the joints affected, in the thighs, and in the lumbar region. Its existence is easily recognized. Thus, motion at the symphysis pubis becomes apparent if, with the patient in an up- right position, she be made to throw the weight of the body upon each leg in alternation, while the accoucheur holds the symphysis between the thumb and two fingers placed within the vagina. Motion in the sacro-iliac joint is perceived by seizing the crests of the ilium and get- ting the patient to move forward. In the recumbent posture, moAre- ments at either the pubic or sacro-iliac joints may be recognized by means of the vaginal touch, upon extending or flexing the femur. The great relief afforded to all the symptoms in such cases by means of a firm binder makes it most desirable that the possibility of its oc- currence should be always borne in mind where the patient walks with difficulty during the latter months of pregnancy, or subsequent to the childbed period. The first case I witnessed at the Bellevue Hospital was altogether a mystery to me, until the nature of the disability was pointed out by Professor Barker. The patient was in the last month of pregnancy, had been six weeks in bed, unable to move, though appar- ently otherAvise in perfect health. A rude bandage, constructed of canvas and made to lace in front, furnished a good support, and ena- * Spiegelberg, op. cit., p. 303. f Snelling, " On Relaxation of the Female Pelvic Symphyses," " American Journal of Obstetrics," February, 1870; Barker, "Puerperal Diseases," p. 192. 18 274 THE PATHOLOGY OF PREGNANCY. bled my patient to stand and move around without inconvenience. She had, at the end of gestation, a good confinement, and subsequently recovered without a trace of her previous difficulty. In childbed a towel-binder is capable of rendering good service. During pregnancy, or during the period of puerperal convalescence, where frequent changes of the bandage are not necessary, Martin's girdle, consisting of a solid metal ring surrounding the whole pelvis. has been strongly recommended. In a case I have recently had to treat, where the relaxation became manifest after delivery, I employed a pair of strong breeches, furnished me by Philip Schmidt, instrument-maker, of this city, Avhich were carefully fitted to the thighs and hips of the patient, and were made to buckle in front and lace behind. The appa- ratus proved to be light, comfortable, and answered every requirement. Anomalies of the Placenta. 1. Anomalies of Form.—The usually round or oval placenta may be of a horseshoe or other irregular shape. The superficies depends upon the extent to Avhich the villi form vascular connections with the decidua. In general terms it may be stated that the thickness of the placenta is in inverse proportion to its surface extension. Placentae succenturiatae, small accessory placental developments, are due to the persistence of isolated villous groups, which form vascular connec- tions with the decidua vera. Placentae spuriae consist of circum- scribed deA'elopments of villi, the decidua not participating in the growth. A placenta membranacea is a broad and thin vascular mem- brane produced by a diffuse proliferation of the villi over the entire ovum, forming vascular connections with the reflexa or, Avhere the latter is absent, with the vera. 2. Anomalies of Position. — The placenta may be attached over the os internum, thus constituting placenta praevia, OArer the orifice of the Fallopian tube, or, in connection with extra-uterine pregnancy, at various points in the abdominal cavity. 3. Anomalies of Development.—An hypertrophied placenta is ab- normally large in proportion to the size of the fcetus, occurs chiefly in connection with hydramnion, and consists of a genuine parenchy- matous hyperplasia. A small placenta is referable either to defective development, to premature involution, or to hyperplasia of its connec- tive tissue, with subsequent contraction.* 4. Anomalies of Circulation. —Haemorrhage into the placenta is sometimes produced by congestion of the utero-placental vessels, due to disturbances in the mother's vascular system, f The extravasation may, rarely, be intra-placental, may occur into the serotina, thus con- stituting utero-placental apoplexy, or may take place into the uterine * Whittaker, "Am. Jour, of Obstet.," August, 1870, p. 229. f " Nouv. Diet, de Med. et de Chirurg. Prat.," vol. xxviii, " Placenta," p. 63. DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. 275 sinuses. In the last case, thrombosis of the placental sinuses is said to have occurred.* Placental haematomata are the above-mentioned collections of coagulated blood in various stages of disintegration. The causes of the haemorrhage are, chiefly, morbid changes in the de- cidual vessels, often referable to placentitis. The extravasated blood usually experiences the ordinary retrogressive metamorphoses. It sometimes undergoes cystic, fatty, or calcareous degeneration. The pressure upon the villi produced by the haematomata impairs the nutrition of the foetus, and may cause the death of the latter. CEdema of the placenta, a morbid condition usually attributed to derangement of the fetal or umbilical circulation, is characterized by abnormal pallor, with increased size, friability, and succulence of the placenta, due to serous infiltration. The morbid anatomical changes consist essentially in cystic dilatation in and between the villi, ac- companied sometimes by extravasations. 5. Placentitis.—The subject of placental inflammation is still in- volved in obscurity. Many authors dispute its very existence, con- tending that the morbid changes hitherto referred to placentitis are simply due to retrogressive metamorphoses in extravasations, f Other writers affirm its existence, assign to it etiological relations with me- tritis and endometritis, J and describe its pathology under the fol- lowing heads: {a) Congestion; (b) Hepatization and induration ; (e) Suppuration.* According to the latter view, the inflammation originates in the cells of the serotina or in the adventitia of the fetal arteries, and results generally in the formation of new granulation tissue, either nodular or diffuse, which, by contractions, leads to com- pression or obliteration of placental vessels and to consequent fatty degeneration of the villi. Haemorrhages also occur upon the fetal placental surface, and fibrous adhesions, forming between the de- cidua and the uterine wall, may lead to the retention of the placenta after delivery. Should the inflammatory process be of recent date, the friability of the new granulation tissue may cause separation and retention within the uterus of small parts of the placenta. The haemorrhages sometimes attending placentitis may destroy the foetus and induce abortion. Suppuration, circumscribed or diffuse, is a rare result of placentitis. 6. Degenerations and New Formations.—{a) Fatty degeneration of the placenta, circumscribed or diffused, may result from retrograde changes in extravasations. When developed early in pregnancy, it is sometimes regarded as a premature completion of the fatty degenera- tion normally occurring at the end of pregnancy, and may be due to * Slavjanskt, "Arch. f. Gynaek.," v, 1873, p. 360. \ Whittaker, he. cit., p. 240. X Schroeder, " Geburtsh.," 6te Aufl., 1880. » " Nouv. Diet, de Med. et de Chir.," he. cit., p. 61. 276 THE PATHOLOGY OF PREGNANCY. syphilis or scrofula, {b) Amorphous calcareous deposits are frequent, and are almost invariably found on the uterine placental surface, in the decidua serotina. Thence the process may extend to the fetal portion of the placenta. When the calcareous change begins in the fetal tissues it is confined to these, and affects the small blood-vessels of the villi, beginning in their terminal ramifications and gradual- ly involving their trunks, (c) Pigment deposits, resulting usually from alterations in the haemoglobine of extravasations, are found in both healthy and diseased placentae within the blood-sinuses or villi. {d) Cysts are of frequent occurrence in the placenta. They are found near the center of its concave surface, and vary from a few lines to several inches in diameter. The cyst-wall is formed by the protruding surface of the amnion, which is covered with pavement-epithelium. The cysts contain a reddish, cloudy, thin fluid. Ahlfeld* regards the cysts as liquefied myxomatous formations. They may also develop from apoplectic foci, {e) Tumors. Circumscribed tumors, fibromatous or sarcomatous in nature,! are found on the fetal side of the placenta, beneath the amnion. They are produced either by fibroid transforma- tions in the villi, or by cell proliferation in the decidua. Myxoma of the placenta, consisting in hyperplasia of the villi, and myxoma fibro- sum placentae, characterized by the fibroid degeneration of the base- ment-tissue in isolated villi, are the chief remaining varieties of pla- cental neoplasms. 7. Syphilis of the Placenta.—Placental syphilis, which only exists, according to Frankel,J in connection with congenital or hereditary fetal syphilis, involves the maternal portion of the placenta, when the mother was infected either before or soon after conception, and pro- duces gummatous proliferation of the decidua, characterized by the de- velopment of large-celled connective tissue, with occasional accumula- tions of younger cells. When the infection is conveyed by the father to the foetus alone, or to both mother and fcetus, pathological changes occur as the result of a chronic inflammatory process, embracing proliferation of the cells and connective tissue in the villi, with subsequent obliteration of the vessels, often complicated by the marked proliferation and hardening of their epithelial covering. The affected villi become swollen, cloudy, and thickened, while their epithelium undergoes proliferation and cloudy swelling. The parenchyma of the villi is filled with lymph-cells, and the vessels are either compressed or obliterated. The blood-sinuses are gradually encroached upon by the villi, the foetus dies from lack of adequate nutrition, and the villi undergo fatty degeneration. Portions of the * Ahlfeld, " Arch. f. Gynaek.," vol. xi, p. 397. f Spiegelberg, op. cit., p. 345. X Frankel, "Arch. f. Gynaek.," v, 1873, p. 52. DISEASES OF THE DECIDUA—DISEASES OF THE OVUM. healthy placental tissue, which often intervene between the diseased parts, may be the seat of extravasations. Anomalies of the Amnion and of the Amniotic Fluid. I. Hydramnion.—Inasmuch as the amount of the liquor amnii varies considerably within normal limits, the term hydramnion should be restricted to those cases in Avhich the amount of fluid is so large as to produce morbid symptoms by its pressure upon the uterus, the ab- dominal and thoracic viscera, or the foetus. Etiology.—The causes of hydramnion embrace varied morbid con- ditions, affecting either the mother or the foetus. Multiparae are more predisposed to it than primiparae. It is a noteworthy fact that the foetuses are females in the large majority of the cases. Schroeder as- serts * that McClintock collected thirty-three cases, in only eight of Avhich the foetuses were males. The occasional causative connection between morbid maternal states and hydramnion is proved by the fact that the foetus is sometimes free from disease while the mother is affected with syphilis. The existence of lymph-channels between the amniotic cavity and the uterine mucous membrane furnishes further grounds for the assumption that maternal disease may induce hydram- nion. f In most cases, however, it results from morbid states of the foetus, and particularly from mechanical disturbances of the placental or umbilical circulation. Kustner J relates a case in which hydram- nion was produced by obstruction in the umbilical vein, resulting from hepatic disease. The pathological placental process, leading to obstructed umbilical circulation, consists often in hypertrophy, the villi of the chorion being thickened and oedematous. The decidual tis- sues are sometimes the seat of inflammatory proliferate changes. The result of these diseased conditions of the membranes is an abnormally large secretion of liquor amnii, with diversion of an undue share of the nutritive material destined for the foetus, and the consequent atro- phy or death of the latter. Symptoms and Signs.—The distention of the uterus, and the conse- quent abnormal expansion of the abdomen, produced by hydramnion, results in an impediment to locomotion, and produces discomfort or actual pain by traction upon the abdominal parietes. The diaphragm is forced upward, and, encroaching upon the thoracic space, compresses the lungs and displaces the heart, thus producing dyspnoea and car- diac palpitation. The urine may become scanty and albuminous from impeded renal circulation. Neuralgic pains and oedema of the labia and lower extremities are produced by compression of the pelvic nerves and vessels. Dyspeptic symptoms result from direct compression of * Schroeder, " Lehrbuch," 6te Aufl., 1880, p. 437. f Spiegelberg, " Lehrbuch," p. 439. X Kustner, "Arch. f. Gynaek.," Bd. x, 1876, p. 134. 278 THE PATHOLOGY OF PREGNANCY. the digestive organs or from reflex irritation of them. Ascites may be produced by obstruction of the portal circulation. Physical exam- ination reveals, in advanced cases, an immensely distended abdomen. The uterus, which can be easily mapped out by palpation and percus- sion, is tense, elastic, and obscurely fluctuating. The fetal cardiac sounds are faint or imperceptible. The foetus changes its position with unusual rapidity and facility. Combined manipulation shoAVS the lower segment of the uterus to be elastic and tense, while the foetus can not be readily felt by the finger placed in contact with the cervix. Pregnancy accompanied by hydramnion seldom reaches its normal termination, delivery being prematurely induced by death of the foetus, by separation of the placenta, or by over-distention of the uterus. The first stage of labor is abnormally prolonged, because of the comparatively feeble contractions of the expanded uterine walls. Labor may become precipitate in the second stage, owing to the sud- den escape of the amniotic fluid ; and uterine inertia, in the third stage, frequently results in post-partum haemorrhage. Involution is apt to be protracted and incomplete. Diagnosis.—Hydramnion may be mistaken for twin pregnancy, but is easily excluded by the rational symptoms, by the tenseness of the uterine walls, by the feebleness or absence of fetal heart-sounds, and by the difficulty experienced in perceiving the fetus on palpation. Prognosis.—The prognosis for the child is fatal in nearly thirty per cent, of the cases. For the mother it is favorable, although the risk of post-partum haemorrhage is considerable. Treatment.—The treatment embraces the application of an abdom- inal supporter and the injunction to refrain from active physical ex- ertion. Grave disturbances of the mother's heart indicate the induc- tion of premature delivery, which should, however, in the interest of the child, be delayed as long as is consistent with maternal safety. In parturition, the membranes should be punctured if the accumulated liquor amnii retard the dilatation of the cervix. Puncture must be performed in the interval of the pains, in order that the Avaters may escape gradually and leave the position of the child unchanged. After the expulsion of the placenta, the usual prophylactic measures against post-partum haemorrhage must be promptly adopted. II. Abnormally Small Amount of Amniotic Fluid.—The quantity of amniotic fluid may, even in some cases of advanced pregnancy, be so limited as to render the uterus unusually small and firm, and to limit the freedom of the fetal movements. Under these circum- stances, the movements are so plainly perceptible to the mother as to be the source of positive discomfort. An abnormally small quantity of liquor amnii is, however, only of importance in the earlier stages of fetal development. If the amnion be not then separated from the foetus by an adequate amount of fluid, DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. 279 abnormal amniotic foldings and adhesions between the amnion and the surface of the foetus may take place. The so-called foeto-amniotic bands * thus formed may, by mechani- cal compression, result in various fetal deformities, or in spontaneous, intra-uterine amputation. Anomalies of the Umbilical Cord. I. Torsion.—Torsion consists in such a rotation of the umbilical cord upon its longitudinal axis that its vessels are thereby rendered nearly or quite impermeable. It occurs most frequently in foetuses which have advanced beyond the middle period of normal utero-gesta- tion, particularly, according to Spiegelberg, f in those of the seventh month. It is, howeA^er, often met with in foetuses of an earlier age. Until a comparatively recent period, authors have unreservedly attrib- uted torsion to active movements on the part of the foetus, and re- garded it as the cause of the latter's death. Martin J has shown that this theory is untenable for the majority of cases, because the patho- logical conditions which result from fetal death induced by torsion, whether rapidly or slowly produced, are almost invariably absent. These morbid anatomical processes embrace rupture of the umbilical blood-vessels, and extravasations, for cases of sudden origin, and con- gestion, with oedema, for those more gradually developed. Martin, therefore, concluded that torsion was a post-mortem event, resulting from rotation of the fcetus produced by maternal moA-ements. Ruge * earnestly advocated the same vieAV, and suggested the various morbid changes due to syphilis, endometritis placentaris, and sub-placental haemorrhage as the cause of fetal death in cases which subsequently developed numerous torsions. Schauta || appears as a recent champion of the same theory, although he admits that loose torsions, incapable of producing actual stenosis of the umbilical vessels, may often occur during the life of the fcetus. He bases his belief in the post-mortem occurrence of torsion—1. Upon the large number of twists often pre- senting themselves, any one of which would have involved the death of the foetus. EA'en granting the original torsion to have been of ante- mortem origin, the others must then have occurred after death. 2. Upon the improbability of the formation of very numerous torsions in a healthy cord, inasmuch as its elasticity would lead to compensatory reverse rotation. 3. Upon the fact that even twenty-five artificially induced torsions resulted in rupture of the normal cord from excessive tension. Schauta regards the cysts found in connection with some * Fcrst, "Arch. f. Gynaek.," Bd. ii, 1871, p. 318. f Spiegelberg, " Lehrbuch," p. 350. X Martin, " Ztschr. f. Geburtsh. u. Gynaek.," Bd. ii, Heft 2, 1878, p. 346. * Ruge, ibid., Bd. iii, Heft 2, 1878, p. 417. ' || Schauta, " Arch. f. Gynaek.," Bd. xvii, Heft 1, 1881, p. 20. 280 THE PATHOLOGY OF PREGNANCY. torsions as insufficient proof of their ante-mortem occurrence. Tor- sions are more frequently present in the umbilical cords of male than in those of female foetuses, and are sometimes surprisingly numerous. Schauta reports a case in which he observed three hundred and eighty rotations of the cord on its longitudinal axis. It occurs by preference in multiparae, probably on account of the greater latitude afforded for fetal movements. Unusual length of the cord favors its occurrence, for a similar reason. The seat of the torsion is ordinarily in close proximity to the umbilicus. It occurs but rarely at the placental end or in the center of the cord. The umbilical vessels are usually nearly occluded at the seat of the torsion, but still permeable. Thrombi of varying consistency are often found in the vessels. Sero-sanguinolent fluid in the abdominal cavity of the foetus, oedema, and cystic degen- eration of the cord, are also pathological conditions frequently attend- ing torsion. II. Knots.—Knots in the umbilical cord, which occur once in tAvo hundred cases, may result from the passage of the fcetus through a twisted loop of the cord, whether the passage be effected during preg- nancy, by the spontaneous fetal movements, or at term, by the uter- ine expulsive efforts or by the manipulations of the accoucheur. Knots formed during parturition are loose and easily untied. They are un- attended by any diminution in the gelatine of Wharton. Those oc- curring during pregnancy are more close- ly and firmly draAvn, and more difficult to loosen, than the former variety. The cord is partly or completely denuded of the gelatine at the seat of the knot, and plainly shows the location of the latter, after its solution, by well-marked indentations. Knots in the cord, of either variety, are comparatively insig- nificant, although a tightly contracted Fig. 138.—Knot of umbilical cord. one- *n a tnin cord, may occasion grave (Leyman.) or even fatal disturbance of the umbili- cal circulation. III. Hernia.—Hernia of the umbilical cord consists in the escape from the abdomen, at the point of insertion of the cord, of some or all of the fetal abdominal viscera. It is due either to arrested embryonic development, which prevents the complete closure of the abdominal cavity, or to the failure of the fetal intestines, originally situated out- side the abdomen, to enter the same. Hernia of the cord may occur alone, in otherwise normally developed foetuses, but is usually accom- panied by other deformities, such as stricture of the rectum, imper- forate anus, or distortions of the lower limbs and of the genitals, pro- duced by traction of the displaced viscera upon adjoining parts. The DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. 281 contents of the hernial sac, which is composed of the amnion and of the peritonaeum, are usually convolutions of the intestine, or these with a portion of the liver, although the kidneys, stomach, and spleen are sometimes also extruded, leaving the fetal abdomen nearly empty. IV. Coiling of the Cord.—Windings of the umbilical cord around the foetus, occurring during pregnancy, vary in their results with the rapidity of their formation. When rapidly developed they may, in rare cases, lead to sudden interruption of the umbilical circulation, and to consequent death of the foetus. Should the coils be gradually formed and firm, the extremity embraced by the cord increases, by its own growth, the tightness of the constricting ligature. The latter slowly lessens the caliber of the vessels supplying the extremity con- cerned, and finally, occluding them, produces death of the limb. Ab- sorption of the soft and hard parts of the extremity may result from the cord's unyielding pressure, and the limb be thus completely severed from the trunk by so-called spontaneous amputation. In cer- tain cases the combined pressure of the cord and of the slowly grow- ing member may suffice to completely arrest the umbilical circulation, and thus produce the death of the foetus. Should the neck be encir- cled by the cord, death will soon ensue, attended, in some cases, by almost complete amputation of the head. Coilings of the cord around the fcetus occurring at birth are of little importance unless they be numerous. In that case they lead to a shortening of the cord, and produce anomalous positions, premature separation of the placenta, retarded second stage of labor, and even death of the fcetus from inter- ference with the umbilical circulation. V. Cysts.—Cysts of the umbilical cord, within the amniotic sheath, are either produced by liquefaction of mucoid tissue or by accumula- tion of serum betAveen the epithelial layers of the allantois. VI. Stenosis of Umbilical Vessels.—Partial occlusion of the um- bilical vein, at the placental insertion, produced by new connective tissue resulting from circumscribed periphlebitis, is sometimes ob- served, but is not sufficiently marked to impede the umbilical circula- tion. Stenosis of the umbilical arteries is occasionally produced by atheroma and subsequent thrombosis. Stenosis of the umbilical vein, and, more rarely, of the arteries, may also result from chronic phlebitis characterized pathologically by the groAvth in the intima of spindle- shaped and round cells which, later, develop into new connective tissue. This process, which is usually referred to hereditary syphilis,* may extend into the muscularis, and even invade the adventitia. The result of the stenosis of the uterine vessels is, of course, prejudicial to the foetus in direct proportion to its grade of development. VII. Calcareous Degeneration. — Calcareous deposits have been observed in the cords of syphilitic foetuses. * Mewis, "Ztschr. f. Geburtsh. u. Gynaek.," Bd. iv, Heft 1, 1879, p. 62. 282 THE PATHOLOGY OF PREGNANCY. VIII. Marginal Insertion of the Cord.—This anomaly is sometimes called the battledoor placenta, while the term insertio velamentosa is applied to cases Avhere the vessels of the cord pursue their course for some distance through the membranes before reaching the placenta. Fig. 139.—Insertio velamentosa. (Lobstein.) To comprehend their origin, it is necessary to recall the main physio- logical processes involved in the normal development of the placental organ. The vessels of the allantois are not invariably carried at the outset to the point in the periphery of the ovum which the placenta will ultimately occupy. The vessels at first penetrate all the villi in- discriminately, but, as the process of obliteration advances in those villi not destined to participate in the formation of the placenta, vas- cular connections are only preserved between the vessels of the newly DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. 283 formed cord and the villi attached to the serotina. As the amniotic sheath forms around the rudimentary cord, the foetus performs a movement of rotation in such a way that the umbilical vessels are made to pursue a direct course toAvard their placental insertion. If, OAving to adhesions between the rudimentary cord and either the chorion or the amnion, the formation of the sheath is incomplete, the vessels diverge, and are distributed to points more or less distant from the placenta (Schultze). Hydatidiform Mole. I. Morbid Anatomy.—Before the time of Cruveilhier, who is said to have first demonstrated the difference between true hydatids and the uterine hydatidiform mole, these morbid formations were regarded as identical. Since his researches, it has been considered established that the essential pathological process involved in the production of the hydatid mole consists in a proliferative degeneration of the chorionic villi. This degeneration of the villi embraces hypertrophy of their investing epithelium, of their connective-tissue cells, which may also undergo mucoid degeneration, and of their mucoid intercellular sub- stance. The accumulation of the mucoid tissue imparts to the villi the appearance of cysts with translucent, semi-fluid contents, varying in size from that of a millet-seed to that of a Avalnut, and forming, by their aggregation, growths which may attain the dimensions of a child's head, or in rare cases may reach such proportions as to distend the ute- rus to the size usual at the full term of pregnancy. Smaller collections are much more frequently encountered than those of these enormous proportions. The fluid of the cysts is albuminous and closely resem- bles the liquor amnii, but contains in the earlier stages a larger pro- portion of mucin than the latter. At a later period the mucin is less abundant, Avhile the albumen increases in quantity. The larger cysts are richer in water, but contain less mucin, than the smaller ones. Inasmuch as the degenerative process does not attack the entire villus, portions of normal tissue intervene between the cysts, and impart to the degenerated mass the appearance of grape-clusters—the cysts representing the individual berries, and the unaltered tissues their connecting stems. A certain number of cysts are, however, attached to a single, continuous pedicle, instead of possessing a separate stem connected Avith a common trunk, as is the case in the grape-cluster. If the mole be formed, as is usually the case, during the first month, while the villi are equally developed upon the entire periphery of the ovum, the degeneration will involve its whole surface. In this case the foetus, dying and becoming disintegrated, may undergo complete absorption, leaving the amniotic cavity empty. The vessels of the villi are, under such circumstances, completely obliterated, while nu- merous blood-coagula are found between the cysts. If, however, the 284 THE PATHOLOGY OF PREGNANCY. placenta be already formed at the beginning of the cystic degenera- tion, the villi having already become atrophied upon that part of the chorion not participating in the development of the placenta, the neoplasm is confined as a rule to the latter, although cysts, evident- ly owing their origin to villi which have not undergone atrophy, some- times occur upon the smooth sur- face of the chorion. Should the hydatidiform mole be of sufficient extent, under these circumstances, to destroy the fcetus, the more or less disintegrated remains of the latter are found in the amniotic cavity, which sometimes contains an excess of liquor amnii. If only a few of the placental lobes or single cotyledons be implicated, the growth of the fcetus may not be disturbed. A healthy fcetus is occasionally developed side by side with a hydatid mole.* The hyda- Fig. 140.—Hydatidiform mole. tidiform mole is usually contained within the decidua. In an inter- esting case reported by Volkmann, however, f the degenerated villi had invaded the uterine blood-sinuses, and by pressure led to so extensive an atrophy and absorption of the uterine walls as to leave only a thin, transparent septum between the mole and the perito- neal covering of the organ. The cavity formed by this process of erosion in the uterine parenchyma was larger than the uterine cav- ity proper, and presented numerous intersecting trabeculae resembling the columnae carneae of the cardiac ventricles. The destructive char- acter of the cystic degeneration is attributed in such cases to some unknown morbid condition of the uterine walls, probably the result of malnutrition. Schroeder \ refers to two similar cases, in one of which the cystic degeneration was attended by fatal peritonitis and the other by rupture of the uterus, and death from haemorrhage into the peri- toneal cavity. II. Etiology.—Primiparae are less frequently affected by the hydatid- iform mole than multiparae, although the actual number of pregnancies seems to exert a less marked predisposing influence than advancing age. The cystic degeneration usually occurs during the first month * Spiegelberg, " Lehrbuch," p. 332. f Volkmann, Virchow's "Archiv," Bd. xli, p. 528. X Schroeder, " Lehrbuch," p. 429. DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. 285 of utero-gestation. According to Underbill,* the latter part of the third month is the limit within which the disease can originate. That the exciting cause of the hydatidiform mole may be a morbid maternal condition is rendered probable by the repeated recurrence of the dis- ease in the same patient, by its coexistence with inflammatory decidual disease, or with extensive uterine fibroids, and by the presence, in the majority of cases, according to Underbill, f of a cancerous or syphilitic dyscrasia on the part of the mother. If the origin of the degeneration be maternal, as it probably is in most instances, the degeneration of the chorion antedates and produces the death of the foetus. On the other hand, the fact that the morbid growth may owe its inception to foetal disease seems demonstrated by those cases in which, as has been already stated, a healthy foetus may be developed in the same amniotic cavity with a hydatidiform mole. This view is further supported by those cases in which death of the foetus is attended by so insignificant an amount of chorionic disease as to render its active causative agency in the death of the foetus highly improbable. Spiegelberg \ is of the opinion that the hydatidiform mole does not result from death of the embryo, and that its cause is often to be sought in an abnormal deA^el- opment of the allantois. The establishment of the true pathological relations of the hydatidiform mole have led to the abandonment of the once prevalent opinion that the neoplasm might be developed independent of conception. The theory that a portion of retained placenta might become affected with the hydatidiform disease has also been refuted by accumulated clinical evidence. III. Symptomatology.—A leading sign of the hydatidiform mole consists in a failure of correspondence between the uterine enlarge- ment and the computed period of utero-gestation. The uterus is usually larger at any given stage of pregnancy than it naturally would be in the course of normal gestation, but may be decidedly smaller in those cases attended by early demise of the embryo. Lumbar and sacral pains are prominent and distressing in proportion to the rapid- ity of uterine development. The uterus imparts a peculiar doughy feeling to the palpating fingers, and in rare instances plainly percep- tible fluctuation. Individual parts of the foetus can not be distin- guished through the uterine walls. The lower segment of the uterus is remarkably tense. Ballottement yields negative results and fetal moATments are absent, although they may be closely simulated by uterine contractions. The fetal cardiac sounds are diminished in intensity or quite imperceptible. There is a discharge from the uterus, either constant or intermittent, consisting of disintegrated and unrupt- ured cysts, cystic fluid, and blood, which, although usually not exces- siAre, may be so much increased by uterine contractions, induced by * Underhill, "The Hydatidiform Mole," "Obstet. Gaz.," January, 1879, p. 16. f Underbill, he. cit., p. 5. X Spiegelberg, " Lchrbuch," p. 333. 286 THE PATHOLOGY OF PREGNANCY. over-distention, as to seriously impair the general strength, or even to induce death from exhaustion. Abortion is usually produced by the mole before the sixth month, but the expulsion of the neoplasm may be delayed until the normal period of parturition, or even until a later season. The haemorrhage and the characteristic discharge cease after the complete expulsion of the tumor, but retained portions of the same may give rise to protracted bleeding. It is often impossible to distinguish the local signs pro- duced by the expulsion of a large hydatidiform mass from those ob- served after normal delivery. Diagnosis.—In cases of limited cystic degeneration it is often impossible to diagnosticate hydatidiform mole. The symptoms upon Avhich, in well-marked cases, the diagnosis is to be based are rapid in- crease in the dimensions of the uterus, the presence of obscure fluctu- ation, the impossibility of obtaining the fetal heart-sounds, or of grasping any of the fetal members, negative result of ballottement, and uterine contractions, attended by the mucous or muco-sanguinolent discharge containing the characteristic cysts. Prognosis. — The prognosis of hydatidiform mole is determined chiefly by the frequency and the violence of the attending haemor- rhages. It is not extremel y unfavorable in the majority of cases. The existence of the peculiar form of cystic degeneration described as the interstitial, intra-parietal, or eroding variety Avould, however, naturally render the prognosis exceedingly grave. The fatality of this class of cases results from their tendency to produce a rup- ture of the uterus complicated by intra-peritoneal haemorrhage, peritonitis, or septicaemia. The life of the fcetus is almost inA'ariably sacrificed. Treatment.—The treatment is restricted to measures calculated to control haemorrhage, and to promote the expulsion of the diseased mass. Most Avriters recommend non-interference so long as the ute- rus remains passive. When, however, contractions set in, the vagina should be tamponed, and ergot given in full and repeated doses, until the mole is expelled entire. The expectant plan is, however, not de- void of danger. In one case, where the patient suffered from labor- pains for several hours before I saw her, the loss of blood was exces- sive. I succeeded in removing, with the hand, through the patulous cervix, an enormous quantity of cysts, sufficient to fill a wooden pail. This was followed by good contraction of the uterus and arrest of the haemorrhage, but the patient died two hours later from shock and anaemia. Unless, therefore, the patient is so placed that professional assistance can be obtained at a moment's notice, the propriety of di- lating the cervix so soon as the diagnosis has been established may well be considered. Dilatation should be effected by the finger, or bv the dilators of Molesworth, of Barnes, or of Tarnier, rather than by DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. tents, because of the tendency of the latter to increase the dangers of septicaemia. After expulsion, or after the manual removal of the hydatidiform cysts, the uterus should be Avashed out with antiseptic fluids, or, in case of haemorrhage, its inner surface should be swabbed with the per- chloride of iron. The irrigation of the uterine cavity with water, to which only sufficient perchloride of iron has been added to give it a wine-color, has often a powerful styptic effect. Underbill recom- mends the continued employment of ergot after delivery, and, in cases of persistent haemorrhage, the occasional introduction of the laminaria tent, and, if necessary, the employment of Thomas's dull- wire curette. Retention, in Utero, of the Dead Fcetus. The causative conditions producing retention of the dead fcetus are not invariably identical. If the placenta remain adherent to the uterus after the demise of the fcetus, the continued vitality and unin- terrupted development of the placenta sufficiently explain the fetal retention. When, however, all connection between the placenta and the uterus has been severed, retention is probably referable to the diminished irritability of those reflex nervous centers Avhich control the expulsive uterine efforts. The duration of retention produced by adhesion of the placenta, in cases of single pregnancy, is protracted until such time as morbid placental processes impair the vitality of that organ and induce its separation. In multiple pregnancies, at- tended by death of one or more of the foetuses, the latter are usually expelled with the healthy foetus at term. They are, hoAvever, some- times expelled earlier, and, in rare instances, later than the normal foetus, and it may in general terms be stated that retention produced by placental adhesion very rarely exceeds the natural period of gesta- tion. Retention due to diminished irritability of the reflex centers may be indefinitely prolonged. Liebmann* is of the opinion that all cases of retention protracted beyond the normal term of pregnancy belong in this category. The pathological changes which the foetus undergoes when retained in the uterus after its death vary with the condition of the membranes : 1. If their integrity be preserved, the most important pathological fetal conditions resulting from the retention are mummification, maceration, fatty degeneration, and calcification, f 2. If the membranes be rupt- ured soon after the death of the foetus, or if their rupture be the cause of the termination of fetal life, that form of degeneration to be presently described as mummification may ensue ; calcareous degenera- tion may, as in the first instance, result in the formation of a lithopae- * Liebmann, "Bcitrag z. Geburtsh. u. Gynaek.," Bd. iii, 1874, pp. 59, 63. \ Eulenkampp, "Retent. asgestorbenen Fruchtc in Utero," Kiel, 1874, p. 22. 288 THE PATHOLOGY OF PREGNANCY. dion, or, in the event of the entrance of air into the uterine cavity, the fetal tissues may undergo putrefactive changes. If mummification has already occurred, putrefaction does not take place.* Mummification.—Mummification is most frequently observed in foe- tuses whose death has apparently been the gradual result of inanition from inadequate blood-supply, this insufficiency of the nutritive fluid being often referable to torsion or constriction of the umbilical cord. Mummification affects, by preference, foetuses dying during the middle stages of gestation. Liebmann f suggests that this fact may be con- nected with the augmented rapidity of endosmosis, due to the larger percentage of saline ingredients then present in the amniotic fluid, or to the fact that torsion and stenosis of the cord are most liable to occur at that period of pregnancy. Mummification occurs chiefly in connection Avith twin pregnancies, \ one foetus being fully developed while the other becomes mummified. In this case the presence of the dead foetus does not usually excite expulsory uterine efforts before the normal termination of pregnancy is reached, when both foetuses are simultaneously delivered. In certain rare instances the mummified foetus may be expelled either before or after the healthy one, but its delivery is unattended by haemorrhage or other unpleasant complica- tion. When mummification affects a single foetus, the retention is supposed to be due to abnormally intimate connection between the placenta and the uterus. Symptoms closely simulating those of abor- tion occur, but they subside before the product of conception is ex- pelled, and probably even before the rupture of the membranes. The fcetus then becomes mummified, wliile the vitality of the placenta is not impaired. Under these circumstances the retention is never pro- longed beyond the normal period of gestation, and is thus distinguished from those cases of retention owing their origin to so-called "missed labor." A mummified fcetus is flattened from compression. Its viscera are of soft consistency and of small dimensions. Its surface is shrunken. The peritoneal and pleural cavities contain a scanty and discolored fluid. The subcutaneous areolar tissue has disappeared, and the skin lies in direct contact with the muscles. The placenta, which is dry, yelloAvish, and tough, is the seat of fatty degeneration, and contains the residue of old extravasations. Maceration.—The placenta of a macerated foetus is anaemic, soft, and friable. The cord, in which the vessels are permeable, is cylin- drical, smooth, spongy, and inelastic. Its coils have disappeared. It is club-shaped at the fetal extremity, and its color is brownish-red. The amniotic fluid has a peculiarly repulsive, sweetish, and sickening * Spiegelberg, "Lehrb.," p. 367. f Liebmann, op. cit., p. 54. X McCall, " Transactions of Philadelphia Obstetrical Society," "American Journal of Obstetrics and Diseases of AVomen and Children," vol. viii, p. 551. DISEASES OF THE DECIDUA.—DISEASES OF THE OVUM. odor, unlike that of putrefaction. The fluid is rendered turbid and of a greenish-yellow color by the admixture with it of sero-sanguino- lent fluid, and of meconium. The membranes, which retain their normal consistence for a long time, finally become friable, swollen, and discolored. A foetus of only one to two months may be completely dis- solved by the process of maceration. If the foetus be more mature, its general form and the outline of its organs are preserved, but granular degeneration and disintegration of their anatomical elements are every- where present. The epidermis is first affected by the process of macer- ation. It is separated from the corium by the formation of vesicles, similar to those of pemphigus, which contain either a reddish, sero- sanguinolent, or a clear serous fluid. The corium is infiltrated with the same fluid, and presents the appearance of brownish-red macerated parchment. The subcutaneous areolar and adipose tissues are reddish and oedematous. The oedema is most apparent over the cranium, the abdomen, the feet, hands, and sternum. The entire body is flaccid, and assumes, under the influence of external pressure, curiously dis- torted shapes, being distended at some points, and depressed or flat- tened at others. The cranial sutures are separated, the joints are disarticulated, and the periosteum has become detached from the long bones. The vessels are filled with dark, grumous blood. The serous cavities are distended with bloody serum. The brain is transformed into a grayish-red pulp. All the viscera are infiltrated and friable, the uterus and lungs preserving their normal consistence longer than the other organs. Pigment masses and fat-crystals are deposited in many organs. Sometimes the accumulation of fat is so abundant that the term, fatty degeneration is applicable to the process of its deposition. No trustworthy inferences can be drawn from the appearance of macer- ated foetuses as to the cause of their decease, since the gross patho- logical conditions are identical under all circumstances.* Apparent variations are due to the respective periods of retention. The rapidity with Avhich the process of maceration occurs is variable, and its extent is, therefore, no criterion of the time at which the fetal demise took place. Seventy-five per cent, of macerated foetuses are expelled, according to Ruge,f before the thirty-first week, and transverse or breech-pres- entations occur in nearly one half of all the cases. The cases in Avhich the dead foetus is retained in utero after the ex- piration of the normal period of gestation differ in symptomatic events and pathological conditions from those already considered. In these cases the death of the fcetus may have occurred either in the earlier or in the very latest stages of pregnancy, and the retention may extend over months or years. The term missed labor is applied to those cases in which, the uter- ine expulsiA'e efforts having been ineffectually made at full term, with- * Ruge, " Zeit. f. Geb. u. Gyn.," Bd. i, Heft 1, 1877, p. 58. \ lbid-> P- ?°- 19 290 THE PATHOLOGY OF PREGNANCY. out other result than the escape of the waters, the uterine contractions finally subside, leaving the fcetus still in utero. The causes of missed labor usually cited are abnormal absence of uterine irritability, or of that residing in the reflex nervous centers, obstructed labor, and un- usually close adhesions of the placenta. The pathological processes presenting themselves in cases of long-continued retention and of missed labor vary with the entrance of air into, or exclusion of air from, the uterine cavity. If the atmosphere have free access to the uterus, the foetus under- goes putrefactive changes. The soft parts, having been liquefied, es- cape, leaving the osseous framework of the fcetus in utero. This may also be gradually and partially disintegrated, liquefied, and expelled, but its complete evacuation is not often effected by Nature's processes. If, however, the cervix be narrow or unyklding, the continuous press- ure of some projecting and pointed bone may penetrate its tissues and force an exit through the vagina, rectum, or anterior abdominal wall. A similar irritation and penetration may induce suppuratiA'e metritis, and, eventually, fatal peritonitis, or septicaemia. If the air be excluded from the uterus, in cases of retention indefi- nitely prolonged, the fcetus either becomes mummified, and, forming intimate connections with the uterus through the medium of inflam- matory products, remains in utero without giving rise to any symp- toms, or it may produce by constant irritation suppurative metritis, with abscess formation and the escape of pus externally. Access hav- ing been thus afforded to the air, putrefaction and its consequences will then ensue. In rare cases of prolonged retention, the fcetus becomes the seat of fatty and calcareous degeneration. In the latter case it is designated by the term lithopaedion. The retention of the dead foetus is comparatively devoid of danger. Even if decomposition or putrefaction of the foetus occurs, the prod- ucts of disintegration are usually eventually eliminated without a fatal result, by natural efforts or by the intervention of obstetrical art. Hein * recommends the colporynter and the internal administration of ergot as effective means for securing the expulsion of the fcetus. In place of the colporynter, a large Barnes dilator, introduced into the vagina and filled Avith fluid, may be employed. * Hein, "Beitr. zur Geburtshulfe," Bd. ii, p. 172. THE PREMATURE EXPULSION OF THE OVUM. 291 CHAPTER XVI. THE PREMATURE EXPULSION OF THE OVUM. Causes of abortion.—Disposition to abortion.—Immediate causes.—Symptoms.—Moles.— Incomplete abortions. — Diagnosis.—Prognosis.—Treatment.—Prophylaxis.—Arrest of threatened abortion.—Treatment of inevitable abortion.—Treatment of neglected abortion.—Removal of fibrinous polypi.—Treatment of miscarriage. When pregnancy is interrupted, during the first three months, by uterine contractions leading to the expulsion of the ovum, the term abortion is used ; in the fourth, fifth, sixth, and seventh months, i. e., from the formation of the placenta to the time the child becomes viable, it is proper to speak of the accident as immature delivery, or miscarriage ; and, finally, a confinement occurring from the twenty- eighth week, the earliest period of viability, to the thirty-eighth week, when the foetus possesses every indication of maturity, is distinguished as premature delivery. This purely artificial division is justified by practical differences in the symptomatology and treatment of the groups thus separately designated. Causes which lead to the Premature Interruption of Preg- nancy. The underlying causes of abortion, miscarriage, and premature delivery are the same. Causes of abortion are rarely of sudden occur- rence. Usually the way is prepared, either by changes taking place in the ovum, or by certain pathological conditions affecting the mother. In either of these ways a disposition to abortion is pro- duced. When once, as the result of morbid changes, the attach- ment of the ovum to the uterus has been rendered insecure, causes usually inoperative suffice to determine uterine contractions and the time at which the expulsion takes place. The Disposition to Abortion.—The disposition may be due prima- rily to any disease of the chorion, of which we have an example in syphilitic degeneration of the villi {vide p. 276). In most cases, hoAV- ever, death of the fcetus precedes and leads to disease of the chorion. The causes of abortion resolve themselves, therefore, in large measure, into the causes Avhich produce death of the fcetus. The death of the foetus may be due to direct violence, as kicks and blows upon the abdominal walls ; to diseases of the fetal appendages (cord, amnion, chorion, placenta); to diseases of the decidua, especially those which give rise to haemorrhage (before the complete formation of the placenta, the separation of the decidua from the uterus inter- feres with the nutritive supplies which go to the fcetus); to febrile 292 THE PATHOLOGY OF PREGNANCY. affections, in which death results either from the high temperature, from associated diseased conditions of the decidua, or, as in certain acute infectious diseases, to the direct transfer of the poison from the mother to the fcetus ; and, finally, to excessive anaemia. Anaemia de- A'eloped by pregnancy rarely affects the child. In acute anaemia from profuse haemorrhage, the child may die from asphyxia. In times of famine great numbers of women abort. The disposition to abort ob- served in corpulent women is probably due to the fact that the blood is insufficient in quantity and quality to supply the wants of the growing child. The death of the fcetus is followed by the expulsion of the ovum, not usually at once, but after a longer or shorter period of time. Be- fore the third month, in such cases of delay, the embryo, which con- sists of hardly more than a heap of cells, may become macerated, and absorption may take place after the death of the embryo. Except in cases of hydramnion, partial collapse of the ovum ensues. As soon as the foetus dies, the circulation which passes from the foetus to the cho- rion and placenta is suspended. The villi then become obliterated, and undergo fatty degeneration. The decidua is affected by the same process. With the diminution in the volume of the ovum, contrac- tions begin. The villi, loosened in their attachments to the decidua, are drawn out; and the decidual vessels, exposed and subjected to in- creased pressure, rupture, and haemorrhage results. The uterine con- tractions are awakened and exercise an expulsive force upon the ovum, which in its descent expands the cervix from above downward, and passes finally into the vagina. In the first three months the ovum is not infrequently expelled with membranes unruptured. From the end of the third month omvard such an occurrence is rare, though I have seen an instance Avhich happened in the sixth month. In the early months the expulsion of an intact ovum is associated with incon- siderable haemorrhage. When the membranes give way, the embryo and the fluid contents of the amnion escape first. With the removal of the compression exercised by the ovum upon the inner surface of the uterine walls, haemorrhage occurs, which continues, as a rule, until the complete expulsion or removal of the membranes and placenta. Aside from the death of the fcetus, with consecutive changes in the chorion and decidua, and diseases of the fetal appendages leading to death of the fcetus, the predisposition to abortion may be the result of primary defects or changes in the decidua alone. Of these changes we recognize : 1. Atrophy of the Uterine Mucous Membrane.—The insufficient development of the mucous membrane exercises an injurious influence upon the development of the ovum in cases only in Avhich the serotina and the reflexa are involved. An abnormally small and undeveloped serotinal surface may give rise to a small placenta, or the serotinal THE PREMATURE EXPULSION OF THE OVUM. 293 Fig. 141.—Ovum, with imperfectly developed decidua; outer surface of vera. (Duncan.) attachment may be of such limited extent that the mere weight of the ovum drags it doAvnward and converts it into a long, narrow pedicle. At other times, the reflexa may be but partially developed, or may fail altogether, and then the ovum, covered only by the chorion, hangs by a pediculated attachment to the serotina. In both these cases, the uterine contractions, in place of at once effecting the expulsion of the ovum, may force the ovum into the cervix, where it may remain for a time, nourished by the long pedicle, but arrested in its further descent by a con- tracted os externum. To these cases the term cervical preg- nancy has been applied. The cervix, according to the month of pregnancy, is more or less spherically distended, and the corpus uteri above contracts down to nearly normal dimen- sions. As the cause of this con- dition lies chiefly in rigidity of the os externum, it occurs most fre- quently in primiparae. Even with a patulous os, though rarely, a cer- vical pregnancy may be produced by the resistance and firmness of the pedicle attaching the ovum to the uterus.* 2. Hypertrophy of the Mucous Membrane.—Thickening of the mu- cous membrane is the result of endometritis, and may lead to abortion in either of the following ways : The several forms of endometritis {vide p. 270) may give rise to affections of the placenta, and thus prove fatal to the fcetus, or the thinned, dilated vessels of the diseased de- cidua may rupture, and produce sanguineous effusions betAveen the membranes. The frequency of abortion in displacements of the uterus is prin- cipally dependent upon associated endometritis. In anteflexion of the uterus, sterility is common, but endometritis and abortion are rare. In retroflexion, on the contrary, while there is slight obstacle to con- ception, the congestion of the uterine Avails and the altered conditions of the uterine mucous membrane render abortion a frequent occur- rence. Rigidity of the uterine walls, which interferes with their due ex- pansion, may lead to premature uterine contractions. In this way an imbedded fibroid or carcinoma may ultimately become sources of abor- tion. Expansion of the uterus may likewise be hindered by old peri- toneal adhesions or pelvic cellulitis. * AV. Schulein, " Ueber cervical Schwangerschaft," " Ztschr. f. Geburtsh. und Gy- naek.," Bd. iii, H. 2, p. 408. 294 THE PATHOLOGY OF PREGNANCY. Finally, there remains a class of women in Avhose cases it is impos- sible to detect either disease of the ovum or of the genital organs, yet in whom abortion occurs, dependent, so far as our present knowledge goes, upon certain personal conditions of nerve irritability. Physical and psychical sources of excitement, which Avould be of small moment in some women, in them suffice to interrupt pregnancy. Immediate Causes of Abortion.—Changes in the ovum, other than rupture and escape of the amniotic fluid, rarely lead at once and di- rectly to abortion. The proximate causes which induce contractions, and the throwing off of the ovum, reside for the most part in the ma- ternal system. They consist of : 1. Hyper amia of the Gravid Uterus.—When the predisposing causes have operated to weaken the attachments of the ovum to the decidua, anything which determines the blood-currents to the uterus is liable to produce extravasations of blood around the ovum, and awaken uter- ine contractions. Because of this fact we surround patients predis- posed to abort with every precaution during the periodic menstrual congestion that not even pregnancy altogether suspends. Fevers, in- flammatory affections of the genital organs, excesses in coitus, hot foot-baths, valvular heart-lesions, obstructions to the circulation of the lungs and liver, may each lead to rupture of the decidual vessels. More frequently rupture follows jars to the body from vomiting, cough- ing, and straining, from railroad-journeys, from violent exercise, from falls, and the like. The importance of separating the predisposing from the immediate causes of abortion is shown by the impunity with which often per- fectly healthy women, with no abnormal conditions of the generative organs, set all the usual restraints at defiance with the intent to inter- rupt an undesired pregnancy. M. Brillaud Laujardiere relates the case of a peasant Avho took his wife, while enceinte, behind him on horseback, and started off with her at full gallop Avith the vieAV of caus- ing her to miscarry. Having thus thoroughly shaken her, he dropped her suddenly to the ground without slackening his speed. This brutal manoeuvre he repeated twice Avithout the least success.* On the other hand, women, eager for offspring, after an abortion, sometimes lay undue stress upon slight imprudences, and make them the sources of morbid self-reproaches, Avhich it becomes one of the functions of the physician to allay. 2. Uterine Contractions, produced by Influences which act di- rectly through the Nerves.—-Of this Ave have examples in the contrac- tions awakened by frictions of the uterus through the abdominal walls, in the reflex contractions produced by stimuli applied to the breasts, and in those excited by strong mental emotions. Symptoms.—As the detachment and expulsion of the ovum can not * T. Gallard, " De l'avortcment au point de vue medico-legal," Paris, p. 24. THE PREMATURE EXPULSION OF THE OVUM. 295 possibly take place without rupture of the decidual or placental ves- sels, haemorrhage becomes the constant and necessary result of every abortion. In the first tAvo months the haemorrhage resembles that of a profuse menstruation. Pain is present, in part due to uterine con- gestion, in part to the expulsion of blood-clots through the imperfectly expanded cervix. The latter pains resemble those of obstructive dys- menorrhoea. These symptoms last from four to five days. As the ovum passes aAvay unnoticed, enveloped in the clots, or piecemeal with the decidua, women are apt to regard these early abortions as the normal recurrence of a retarded menstrual period. After the third month prodromal symptoms are rarely Avanting. Among these may be mentioned fullness and weight in the pelvis, sa- cral pains, frequent micturition, periodic labor-like pains, and a mu- cous or watery discharge. These, followed by haemorrhage, indicate a threatened abortion. The haemorrhage, if slight, may cease, and the pregnancy go on undisturbed. Usually, hoAvever, the haemorrhage increases in amount, or after a brief cessation recurs. Contractions set in, which become more and more pronounced, until finally the ovum is expelled. In a typical case of abortion, in which the ovum is thrown off entire, uterine retraction and haemorrhage unite to effect the progres- sive separation from beloAv upward of the decidua from the uterine walls. The ovum then, coAered by the reflexa and the detached de- cidua, is gradually pressed downward, and dilates first the os internum, next the cervix, and finally the os externum. The ovum passes into the vagina, covered by the decidua vera, or drags the inA-erted decidua after it. The emptied uterus then retracts down, and the haemorrhage ceases. The aborted ovum is surrounded with coagulated blood. In the first three months, when the death of the embryo has preceded by a little time the completion of the abortion, every vestige of the em- bryo may be found to have disappeared. Sometimes, in the third month, a small placenta with shrunken umbilical vessels may now and then be met with. When the extravasation of blood upon the uterine surface of the vera is considerable in amount, the vera is sometimes broken through, and the blood effused between the vera and reflexa. Extravasation may likeAvise take place between the reflexa and chorion, either in consequence of the rupture of the reflexa, or from a haemorrhage start- ing from the placenta, Avhich finds its way along the outer surface of the chorion, and dissects away the reflexa. The pressure upon the ovum, unless it has previously undergone collapse as a result of the death of the embryo, leads to rupture and escape of the amniotic fluid. The retained fetal and maternal membranes, with the intervening lay- ers of coagulated blood, form a mass termed a mole. When the blood coagula are fresh, the mass is termed the mola sanguinea (blood- 296 THE PATHOLOGY OF PREGNANCY. mole), and when of older date the mola carnosa (fleshy mole). The cavity, Avhich is lined by the amnion, has usually an irregular surface. It is very exceptional for extravasations to break through both chorion and amnion, and thus form clots in the amniotic cavity itself. Moles seldom exceed an orange in size, and usually are expelled between the third and fifth month. In cases where abnormal adhesions attach the vera and serotina to the walls of the uterus, retained portions of the maternal membranes may remain after the ovum is expelled. In another class, and this is the rule after the third month, the fetal members rupture, and the embryo escapes with the liquor amnii. While ordinarily the re- tained portions quickly follow the discharge of the ovum or embryo, it frequently happens that the uterus retracts upon its contents, the cervix closes, and a period of repose follows. There is then produced what is commonly knoAvn as an incomplete abortion. Incomplete Abortion.—The various contingencies arising from these cases of incomplete abortion are thus truthfully depicted by Spiegel- berg : * 1. Most frequently haemorrhage continues at intervals, spontaneous elimination gradually taking place as, through retrograde changes, por- tions of the retained membranes become successively loosened in their attachments to the uterus. 2. In exceptional cases the haemorrhage ceases for a time entirely. For days, Aveeks, and even months, the woman appears quite well. Then suddenly strong contractions, accompanied by profuse haemor- rhage, usher in the elimination of the fetal dependencies. In a case of my OAvn, three months elapsed from the occurrence of the first haemorrhage, which took place toAvard the end of the third month, and was quite insignificant in amount, before the abortion Avas com- pleted. Meantime, as there Avere progressive abdominal enlargement, supposed quickening, and milk in the breasts, the threatened abortion Avas believed to have been arrested. Total retention, with a long in- terval of repose, is thought to be due to complete adherence of the placenta, which continues to receive nutrient supplies from the uterus. Spiegelberg believes that a menstrual period is the usual time at Avhich the discharge of the retained membranes takes place. 3. Of more frequent occurrence than the foregoing is the putrid decomposition of the retained portions. It occurs chiefly in cases where there is more or less complete loss of organic connection between the placenta and the uterus. Decomposition in the non-adherent por- tions is produced by the introduction of air during the escape of the embryo, or through the subsequent passage of the finger into the ute- rus, or, where portions of the ovum hang down into the vagina, by absorption of septic matter from the vagina upward into the uterus. * Spiegelberg, "Lehrbuch der Geburtshulfe," Jahr 1877, p. 377. THE PREMATURE EXPULSION OF THE OVUM. 297 As a result of putrid decomposition, the Avoman is exposed to septicae- mia, and infection of thrombi at the placental site. Fatal results are, hoAvever, rare, as decomposition is usually a late occurrence, setting in, as a rule, only after protective granulations have formed upon the uterine mucous membrane, and after the complete closure of the uterine sinuses. Continuous fever, with intercurrent attacks of haem- orrhage, is, hoAvever, set up, but passes aAvay finally with the gradual discharge of the decomposed particles, while the threatening symp- toms subside. Still, now and then septic processes lead to an'unfavor- able termination. Local perimetritic inflammation is a common event. Fig. 142.—Uterus, with basis of a fibrinous polypus after an abortion. (Frankcl.) 4. Where there is a certain degree of relaxation with enlargement of the uterine cavity, the fibrine of the extravasated blood may become deposited about any uneven surface within the uterus, and give rise to a polypus-shaped body, suggestive in its mode of development of the 298 THE PATHOLOGY OF PREGNANCY. stalactite formations in calcareous caverns.* These so-called fibrinous polypi generally develop around the debris of an abortion, such as retained bits of decidua, placental remains, and portions of the fetal membranes. In some cases, likewise, thrombi projecting from the placental site become the base of a loose fibrinous attachment. Pla- cental polypi give rise ultimately to bearing-down pains, and inter- current haemorrhages. They may even decompose, and endanger life by septic absorption. The retrograde changes that take place in a uterus after an abor- tion correspond to those which occur in deliveries at full term. Where a suitable plan of treatment is not adopted, or where the importance of care in the after-management is not adequately appreciated, sub- involution is apt to follow. Of all sources of uterine disease, none takes precedence of a mismanaged abortion. Diagnosis.—The diagnosis is based upon the presence of pain, haemorrhage, dilatation of the cervix, and the descent of the ovum. When the ovum can be felt through the patulous os, the demonstration is of course complete. A soft polypus may, however, present a decep- tive resemblance to a small ovum. In all cases of pregnancy the exist- ence of haemorrhage alone, even Avhen disassociated from other symp- toms, renders the probabilities of abortion sufficiently great to call for the exercise of every precaution. It is not easy to recognize pregnancy in the early months, but in doubtful cases the cessation of the menses should be regarded as presumptive evidence of its existence. The diagnosis of these pathological changes in the ovum and de- ciduae which pave the Avay for abortion can not be made out with certainty from mere subjective symptoms. Such changes may be regarded as probable when the size of the uterus does not correspond to the supposed period of gestation. Thus, if the uterus at the fifth month Avas no larger than is usual at the third month, the death of the embryo with arrest in the development of the ovum would be naturally inferred. When the physician is summoned to a case of haemorrhage occur- ring during pregnancy, he should at once examine the clots, where they have been preserved, for traces of the ovum. The clots should be broken up under water, and a careful examination made for floating fringes of villi. The ovum, when expelled entire, is usually enveloped in layers of coagulated blood, so that without thorough search it would easily pass unnoticed. If the coagula have been thrown aAvay, and the physician finds upon his arrival the cervix closed, so that he can not pass his finger into the uterus to explore its cavity, it may be im- possible at once to determine whether the abortion has taken place wholly or in part, or whether the entire ovum still remains in utero. * FrAnkel, "Beitrag zur Lehre von fibrinoscn Polypen," " Arch. f. Gynaek. " Bd. ii, p. 76. THE PREMATURE EXPULSION OF THE OVUM. 299 The subsidence of all symptoms points, as a rule, to a complete emp- tying of the uterus, or to an arrest of the abortion, though in some cases it precedes mole-formation. A renewal of the haemorrhage and the absence of normal involution indicate the continuance of the ovum in the uterus, or an incomplete abortion. Prognosis.—The prognosis takes cognizance of course of the results to the mother only. In the first place, it may be laid down in the way of broad general statement that all cases of spontaneous abortion (i. e., excluding criminal cases), not complicated Avith other morbid condi- tions, are, under suitable medical guidance, devoid of danger. But, in the second place, it must be borne in mind that the statement is only true with the reservations that limit it, for in point of fact the actual number of deaths from abortion is by no means inconsiderable. Thus, the deaths from this cause reported to the Bureau of Vital Sta- tistics of NeAv York City, between the years 1867 and 1875, inclusive, were one hundred and ninety-seven,* a number which falls short in all probability of the truth, by reason of the many circumstances Avhich precisely in this condition tempt to concealment. The total number of deaths during the same period from metria Avas, according to the reports rendered, 1,947. Hegar f reckons one abortion to every eight to ten full-time deliAreries. If this proportion be correct, it would seem to show that the mortality from abortion is hardly second to that from puerperal fever itself. Death, as a consequence of criminal abortion, is especially frequent. M. Tardieu found that in one hundred and sixteen such cases, of which he was able to ascertain the termination, sixty women died. \ But even in spontaneous cases death may take place from haemorrhage, from sep- ticaemia, or from peritonitis. In many instances the fatal termination is fairly attributable to the ignorance, the imprudence, or the willful- ness of the patient. How far the dangers of abortion may be neutral- ized by proper medical assistance is best shown by the statistics of large hospitals. Thus, I gather from the reports issued by Dr. John- ston, during his seAren years mastership of the Rotunda Hospital, in Dublin, that in two hundred and thirty-four cases of abortion treated in that institution there Avas but one death, and that not from puer- peral trouble, but from mitral disease of the heart. Bellevue Hospital is the receptacle annually of a tolerably large number of women suffer- ing from incomplete abortions, many of whom enter the hospital in a very unpromising condition from either excessive haemorrhage or septic decomposition of the retained portions of the ovum. Yet, of the many * Lusk, " Nature, Origin, and Prevention of Puerperal Fever," " Transactions of the International Medical Congress," Philadelphia, p. 830. f Hegar, " Beitrage zur Pathologie des Eies," " Monatsschr. f. Geburtsk.," Bd. xxi (supplement), p. 34. t T. Gallard, "De Pavortcment au point de vue medico-legal," Paris, 1878, p. 45. 300 THE PATHOLOGY OF PREGNANCY. cases whose histories I find in the record-books of the hospital, all have ended in recovery. Treatment.—The treatment is divided into—1. Prophylaxis in cases of habitual abortion ; 2. Arrest of threatened abortion ; 3. Means adopted to avert the dangers of a progressing abortion. Prophylaxis.—Prophylaxis considers the cause Avhich underlies, in each case, the disposition to repeated abortion. One of the principal of these causes is syphilis in one or both parents. It is just in these cases that the triumph of the mercurial treatment has been most com- plete. The treatment should be addressed to the parent affected, or both parents should be subjected to the same treatment. Among local conditions amenable to treatment may be mentioned endometritis, displacements, and perimetritic inflammations. In re- troflexions and retroversions, the best results often follow the replace- ment of the uterus and the employment of a suitable pessary. No harm results from the use of pessaries during pregnancy. They should, however, be watched, on account of possible vaginal irritation. After the completion of the third month they should be removed, as the uterus then remains in place without artificial assistance. When back- ward displacement of the uterus folloAVS abortion, reposition aids nor- mal involution. In carcinoma and large fibroids, treatment is powerless. WThere, in such cases, sterility does not exist, happily for the mother, the associated morbid conditions of the uterine mucous membrane and the rigidity of the uterine walls lead commonly to the death of the ovum and premature uterine contractions. Where a small fibroid in the posterior uterine walls leads to sterility by the production of retro- flexion, a pessary may, after replacement, at times be used with benefit. One abortion sometimes folloAVS another in rapid succession in newly married Avomen. While the first abortion may have been due to some accidental cause, the sequence is often kept up by a morbid condition of the endometrium, generated by the shortness of the inter- val betAveen the pregnancies, Avhich does not allow the restoration of the membrane to a normal condition. In such cases, a six weeks' abstention from sexual intercourse may be usefully enjoined. In certain diseases of the placenta, in which the respiratory func- tion of the organ had suffered any marked diminution, Sir J. Y. Simpson believed he had succeeded in averting the death of the foetus by increasing the oxygen in the blood of the mother, through the ad- ministration of chlorate of potash.* Chlorate of potash may be given in doses of twenty grains, three times daily, for Aveeks at a time, with- out injury to the mother. Though it has not always rendered me the hoped-for service, the experience of other physicians, among whom I * Sir J. Y. Simpson, " Obstetric Memoirs," edited by Priestley and Storer, Edinburgh, 1865, vol. i, p. 460. THE PREMATURE EXPULSION OF THE OVUM. 301 may mention Dr. Fordyce Barker, appears favorable to its employ- ment. In the class of cases in which abortion results neither from disease of the ovum nor of the uterus, but seems dependent upon some pe- culiar condition of nerve-irritability, the patient should not only avoid every knoAvn means of awakening uterine contractions, but should exercise the utmost caution at the recurrence of the menstrual epochs. Especially at the terminations of the second and third months a Aveek's quiet in bed should be insisted upon. Dr. E. J. Jenks * recommends the viburnum prunifolium in cases Avhere the habit of aborting has been formed. He writes : "My mode of prescribing the viburnum is to have the patient take from a half-teaspoonful to a teaspoon ful of the fluid extract four times a day, beginning at least two days before the menstrual date, and continuing it not only during the usual period of the menstrual flow, but two days longer than that discharge continues when the woman is not pregnant." From the fourth month onward, the danger of the occurrence of abortion rapidly diminishes. The Arrest of a Threatened Abortion.—Arrest may be accomplished in cases in which the death of the ovum has not taken place, and where the haemorrhage arises from a slight detachment only of the decidua or placenta. In every case of threatened abortion occurring in the early months, a careful examination should be instituted to ascertain whether retro- flexion or retroversion exists. In the genu-pectoral position, replace- ment is easy. If the fundus is slowly raised by two fingers introduced into the vagina, so soon as the horizontal line is reached the uterus falls forward of its own weight. Replacement alone, in certain cases, suffices to relieve the congestion which furnishes the immediate cause of the abortion. Pain in the back during pregnancy should be regarded by women as a warning for them to temporarily abstain from their ordinary avo- cations. With ever so slight a haemorrhage, they should at once be made to lie down and keep perfectly still. Simple turning in bed may start up fresh bleeding. Restlessness and mental excitement should be allayed by opiates in full doses. Ice to the vulva, cold cloths to the abdomen, and the internal administration of haemostatics are not indi- cated. The fluid extract of viburnum prunifolium is recommended by Dr. Jenks, in teaspoonful-doses every two or three hours, as long as its use seems to be demanded, f The author's somewhat limited experience has appeared favorable to the claims put forth for the viburnum as a uterine sedative. Where the foregoing measures prove successful, it is a safe rule to keep the patient in bed for a week after the final disappearance of the threatening symptoms. * Jenks, "Viburnum Prunifolium," "Trans, of the Am. Gynaecol. Soc," vol. i, p. 130. ■*• Jenks, he. cit., p. 130. 302 THE PATHOLOGY OF PREGNANCY. In cases of ascertained death of the fcetus, and in those of inevi- table abortion, all measures calculated to retard the emptying of the uterus should be at once abandoned. In the first four months there are no unequivocal signs of the death of the fcetus. From the middle of pregnancy onward, death may be assumed if, after repeated examinations, the absence of the fetal heart- sounds and fetal movements is confirmed. The signs of inevitable abortion are profuse haemorrhage, clots dis- charged from the uterus, dilatation of the cervix from the descent of the ovum, and a patulous condition of the os externum. Other symptoms consist of persistent uterine contractions, escape of the amniotic fluid, and the presence of the embryo, or of portions of the ovum, in the discharged clots. How far the ordinary signs may, in given cases, prove delusive is shown by a remarkable one reported by Scanzoni, of a Avoman who was seized with profuse metrorrhagia in the third month of pregnancy. Great numbers of clots were discharged. As all hopes of saving the ovum were abandoned, ergot was used in large doses, a tampon was placed in the vagina for thirty-six hours, a sound was employed to explore the uterus, and finally, as the bleeding continued for three weeks, an intra-uterine injection of a weak solu- tion of perchloride of iron was resorted to. Eight weeks later the patient quickened, and presented the distinctive evidences of a preg- nancy advanced to the sixth month.* The Treatment of Inevitable Abortion. In the treatment of inevitable abortion it is proper to distinguish between cases of abortion proper and those of miscarriage. To avoid, however, needless repetitions, it is only points of distinctive difference to which at the close attention will be directed. The management of premature deliveries differs in no respect from that of confinement at term. In the first tAvo months little treatment besides rest in bed for a few days is ordinarily required. In the exceptional cases, the treat- ment does not differ from that in the haemorrhages of the non-preg- nant uterus. In the third month we distinguish—1. Cases in which the ovum is throAvn off entire ; 2. Cases in which the sac ruptures, and the embryo escapes with the discharged fluid. 1. When in the third month the ovum is thrown off Avithout rupture of the fetal membranes, the haemorrhage rarely assumes dan- gerous proportions. The uterine contractions press the ovum into the cervix, which dilates and, in primiparae, becomes somewhat elon- gated. As the OArum descends, the body of the partially emptied ute- rus retracts. The effused blood coagulates in thin layers between the * Scanzoni, "Lehrbuch der Geburtshulfe," Wien, 1867, p. 83. THE PREMATURE EXPULSION OF THE OVUM. 303 ovum and the uterine walls. The ovum forms a tampon, which fills the cervix and restrains the haemorrhage. No active treatment is, therefore, demanded. A vaginal douche consisting of a pint of tepid water may be used twice a day as a meas- ure of cleanliness. All attempts to disengage the ovum with the finger should be aA^oided, as endangering its integrity. The vaginal tampon is unnecessary. It should only be used as a safeguard, where patients live at a distance from medical assistance and can only be visited at long intervals. As it is never certain that the rupture of the ovum may not take place during the course of its expulsion, the tampon may in such cases be employed in anticipation of a possible increase of haemorrhage from sudden collapse of the membranes. In multiparae the ovum seldom remains long in the cervix. In primiparae, on the other hand, the tardy dilatation of the os externum may lead to a retention of the ovum in the cervix, lasting for days. As this condition is extremely painful, it is alloAvable to dilate the os exter- num with the index-finger, or even by incisions through the ring of circular fibers which furnish the cause of delay. Small portions of the decidua vera sometimes remain attached to the uterine walls after abortion. They commonly do no harm, but are discharged with the lochial secretion. 2. When the sac ruptures, and the liquor amnii escapes, the re- moval of the pressure exerted upon the uterine wall by the intact ovum is followed by profuse haemorrhage from the utero-placental vessels. The diagnosis of rupture may be made either from finding the embryo in the clots, or, in the case of a dilated cervical canal, by the direct examination of the uterine cavity. Although after rupture portions of the ovum may still be felt, we miss the smooth surface of the fluctuating amniotic sac. When the embryo can not be found, and the cervix is closed, profuse haemorrhage alone Avould render the occurrence of rupture extremely probable. The principles of treatment in these cases are very simple. The indications are, to check the haemorrhage and to empty the uterus. As to the best methods of attaining these results, opinions widely differ. When cases are treated with rest in bed, the internal administration of ergot, and cold cloths applied to the abdomen and vulva, the loss of blood is usually considerable, but the most of them terminate favor- ably. In some, however, the haemorrhage may prove so severe as even to threaten life. Now, it is in every way desirable, for the future wel- fare of the patient, to restrain the haemorrhage within the narrowest limits. The most effectual means of arresting the haemorrhage is to clean out the uterus. If, therefore, the physician at the time of his visit finds the cervix sufficiently dilated to allow him to introduce his 304 THE PATHOLOGY OF PREGNANCY. finger into the uterus, he should not hesitate at once to remove the retained portions of ovum. The operation does not require any con- siderable amount of technical skill, while the immediate results are in the highest degree satisfactory. The patient should be placed cross- wise in bed, with the hips draAvn well over the edge. The legs should be flexed and the thighs held, where assistants can be obtained, at right angles to the body, to secure the greatest degree of relaxation to the perinaeum and abdominal walls. The right index-finger should be then passed into the vagina and through the cervical canal, while the left hand, placed upon the abdomen, gradually presses the uterus down into the pelvic cavity so as to bring it within reach of the examining finger.* This portion of the act should be performed slowly, while every effort is made to divert the attention of the patient. Hasty manipulations invariably excite in the most willing of patients the full resistance of the abdominal walls. When the point of the finger reaches the os internum, it is sometimes necessary to pause for a minute or two, to await a sufficient degree of dilatation to alloAv the finger to pass beyond the insertion of the nail. When the right finger is used, it should be made to pass upward with its dorsal surface along the left side of the uterus to the opening of the Fallopian tube, thence across the fundus to the right side. As the tip of the finger passes down upon the right side, it presses the detached ovum before it toward the os internum. By the time the finger has thus made the circuit of the uterus, the ovum is pressed into the cervical canal, and thence passes easily into the vagina. With the left finger, the movement is exactly the reverse. The finger passes first, with its dorsal surface directed to the right side, from the right Fallopian tube across the fun- dus, and doAvnward along the left side of the uterus. The only resist- ance the finger meets is at the placental insertion, where a certain amount of manipulation is required to complete the detachment, f Where the uterus can not be pressed down within reach of the index-finger by force exerted above the symphysis pubis, it is permis- sible to introduce the hand into the vagina ; but, in such a case, the fingers are apt to become cramped, and all freedom of manipulation to be destroyed. A better means of overcoming the difficulty consists in the administration of an anaesthetic. In cases of extreme anaemia chloroform should be discarded as too dangerous. Ether, however, has often seemed to me, on the contrary, to possess a stimulating action, and its use to be followed by increase in the volume and force of the * Professor A. R. Simpson (" Transactions of the Elinburgh Obstetrical Society," vol. iv, p. 227) recommends drawing down the uterus by means of volsellum-forceps attached to the anterior lip of the cervix. I have once seen extreme haemorrhage follow this ma- noeuvre (seventh month of pregnancy), and now feel some hesitation about its employ- ment, at least in the later months. f Vide Huter, " Compendium der gcburtshiilnichen Operationcn," p. 22. THE PREMATURE EXPULSION OF THE OVUM. 305 pulse. The relaxation produced by the anaesthetic makes it easy to depress the uterus down to the pelvic floor, where it can be reached with comparative ease. After the removal of the ovum, the cavity of the uterus should be washed out with a stream of tepid carbolized water, in order to bring away any small detached portions of the ovum and decidua, In the manual extraction of the ovum, deliberation and perseverance are the main elements of success. If, when the patient is first seen by the physician, the cervix is not sufficiently dilated to allow the finger to pass without force, the vagi- nal tampon should be employed. The tampon restrains the haemor- rhage, stimulates the uterus to contraction, and alloAvs time for the employment of measures to rally a patient exhausted by profuse losses of blood. The material of which a tampon is made is a matter of in- difference, provided only it fills the vagina to its utmost capacity. In cases of urgent need, a soft towel, handkerchiefs, strips of cotton cloth, dampened cotton-wool, and the like, may be seized upon to meet a temporary emergency. The time-honored sponge, on account of its porosity, is least deserving of favor. When, however, the phy- sician proposes to leave his patient for a number of hours, the mere hasty filling of the vagina through the vulva will not suffice. On the contrary, the highest degree of safety can only be secured by the closest observance of the rules of art. The first essential of a good tampon is that it be carefully packed around the cervix uteri, and fill out the more dilatable upper portion of the vagina. This can be accomplished only by the aid of a specu- lum. The method I usually employ is one, the credit of which, so far as the general features are concerned, I believe belongs to Dr. Marion Sims. It consists in soaking cotton-Avool in carbolized water, and then, after pressing out any excess of fluid, in forming from the carbo- lized cotton a number of flattened disks of about the size of the trade- dollar. The patient is then placed in the latero-prone position, and the perinaeum retracted by a Sims's speculum. The dampened cotton disks are introduced by dressing-forceps, and, under the guidance of the eye", are packed first around the vaginal portion, then over the os, and thence the vagina is filled in from above doAvnward until the narrow portion above the vestibule is reached. No other plan of tamponing with which I am acquainted can compare in solidity and effectiveness with this. Its removal is accomplished by the detachment with two fingers of a portion at a time. This part of the procedure is moder- ately painful. Many methods have been suggested to overcome in the removal the necessity of introducing the finger into the vagina. A very ingenious one consists in attaching the cotton to a piece of twine so as to form a kite-tail, which can be withdrawn by simply making tractions upon the extremity of the string left hanging outside the vulva. Professor I. E. Taylor uses a roller-bandage. It is efficient, 20 306 THE PATHOLOGY OF PREGNANCY. and, like the kite-tail described, can be easily removed. Dr. F. P. Foster* advises the use of the lamp-wicking as a material for the tampon. Before the introduction of the tampon, the vagina should be thor- oughly washed out. No tampon should be alloAved to remain in the vagina much over twelve hours. Immediately after withdrawing the tampon, before proceeding to the examination of the uterus, the vagi- na should be cleansed by an injection of tepid carbolized water (gr. xxx ad Oj). Often, after removing the tampon, the ovum is found in the upper portion of the vagina or filling up the cervix. If this is not the case, and the cervix is not dilated, so that manual extraction may easily be performed, another tampon should be introduced. It is customary from the outset to sustain the action of the tampon by the administration of ergot, either in the form of the fluid extract (thirty drops every three to four hours), or of a solution of ergotin, given hypodermically (ergotin, gr. xij, glycerinae, 3 j- Ten minims twice in the tAventy-four hours. In women with abundant adipose tissue the injection should be made into the subcutaneous tissues of the lower abdomen. In others, the outer surface of the thigh should be selected). If the patient is collapsed from loss of blood after tamponing, opi- ates, tea, and alcoholic stimulants should be administered, the latter in small but frequently repeated quantities, until the cerebral anaemia is relieved and the capillary circulation restored. If, after the removal, the cervix is found not to be dilated, a third tampon may be introduced, and left in situ for another period of twelve hours. The employment of the tampon is not, hoAvever, to be recommended for a period much exceeding twenty-four hours. Its continued use is apt to irritate the vagina. In spite of carbolic acid, it acquires an offensive odor. It generates septic matters, which, in the long-run, creep upward through the cervix into the uterine cavity, and produce decomposition of the ovum. I prefer, therefore, in cases of undilated cervix, after twenty-four hours of vaginal tamponing, to resort to sponge-tents. The sponge-tent is most easily introduced when the patient is placed upon her left side, with the perinaeum drawn back by Sims's speculum, and the anterior lip of the cervix drawn down and steadied by a tenaculum (Sims's method). The tent may, however, in the absence of an assistant, be introduced, with the patient on her back, by the aid of a pair of strong dressing-forceps. The tent should be long enough to pass well up through the os internum. Within six to twelve hours the tent should be removed, and, after a preliminary vaginal douche, manual extraction be proceeded with in accordance with the rules already given. In manual delivery, it is desirable to remove the decidua as well as * Foster, " N. Y. Med. Jour.," June, 1880. THE PREMATURE EXPULSION OF THE OVUM. 307 the ovum. When the cervix is patent, this is easy, as the decidua is then detached from the uterine walls. When the cervix is unchanged, the detachment is usually incomplete. In such cases, it is advisa- ble, therefore, to try first the tampon before the sponge-tent, as the former stimulates the uterus to contract, and promotes the separa- tion of the decidua, even when it fails to secure the discharge of the ovum. Inside the uterine cavity, ovum-forceps should be used with great caution. I have discarded it altogether. In the first place, it is dangerous ; in the second place, it is unnecessary. When, however, the retained portions of the ovum have left for the most part the uterine cavity, and occupy the cervical canal, the delivery may at times be advantageously hastened by placing the patient upon her side, and, with the cervix well brought into A-iew by a Sims's spec- ulum, applying the ovum-forceps, under the guidance of the eye, within the cervix to the sides of the placenta (Skene). But great care requires to be exercised not to break away the fragile structures and leave material portions behind. Under like circumstances, Hoening * recommended a modification of Crede's method for expression of the placenta. With the patient lying upon the back, the operator, according to Hoening, should seek to compress the body of the uterus between the left hand, laid above the symphysis pubis, and two fingers of the right hand introduced into the vagina. The measure is only practicable when the ovum has, to a great extent, passed from the uterine cavity. As it is somewhat pain- ful, and requires for success lax abdominal parietes, it possesses a lim- ited range of applicability. Treatment of Neglected Abortion.—Where, following abortion, the uterus has once been completely evacuated, haemorrhage ceases. A slight lochial discharge persists for a few days during the period in which the uterine portion of the decidua vera completes its period of repair. If, therefore, a patient comes to us tAvo or three weeks after the supposed conclusion of an abortion, with the story of recurrent haemorrhages taking place, as a rule, whenever she leaves her bed and assumes the upright position, it may be assumed, with an approach to certainty, that portions of the ovum still remain within the uterus. Oftentimes a fetid discharge points to the fact that decomposition has been set up. The absorption of septic materials may, furthermore, become the source of chills, of fever, and of great uterine tenderness. In most cases, with rest in bed, the contents are discharged by sup- puration, and recovery ultimately takes place, but only after a slow, protracted convalescence, during which pelvic cellulitis and pelvic peritonitis occur as not uncommon complications. Haemorrhages, peritonitis, and septicaemia may, however, bring the case to a fatal * Hoening, Scanzoni's " Beitrage," Bd. vii, p. 213. 308 THE PATHOLOGY OF PREGNANCY. issue. The removal of the retained placenta and membranes is there- fore indicated, not only as a measure calculated to promote recovery, but to avert possible danger to life. With regard to the operation for removal, the rules already given are applicable. The following peculiarities should, however, be borne in mind. In case the retained portions are undecomposed, the cervix is usually found closed, and requires preliminary dilatation Avith the sponge-tent. When decomposition has once set in, the os internum will, as a rule, allow the finger to pass into the uterus.* When a decomposed ovum is removed by the finger, a chill and a septic fever, which rapidly disappear, hoAvever, are apt to follow in the course of a few hours. This chill and fever result from the slight traumatic injuries inflicted by the finger upon the uterine Avails, whereby the capillaries and lymphatics become opened up to the action of the sep- tic poisons. The fever ends in a short time, because the reservoir of supply is removed with the debris of the ovum. If the uterine cavity, after the operation, is carefully washed out with carbolized water, the septic fever is often averted. The beneficial results following the complete emptying of the uterus in these cases are so decided, that of late years I have not allowed myself to be deterred from proceeding actively, even when perimetritis and parametritis, in not too acute a form, already existed. In practice, multitudes of examples show that the products of inflammations situated in the pehis do not become absorbed so long as putrid materials are generated in the uterine cavity. The removal of a fibrinous polypus, owing to its smoothness and the small size of the pedicle, is often a Sisyphus's task. The separation can only be successfully accomplished Avhen the palmar surface of the index-finger presses from above upon the point of attachment. This necessitates a choice of hands. Thus, Ayhen the polypus is situated to the left, the right index-finger should be employed, and the left index-finger, when the polypus is situated to the right. After the detachment is complete, it is necessary to press the polypoid body firmly against the uterine walls, and proceed with its withdrawal slowly. If, as is sometimes the case, the polypus slips from under the finger, the latter should be again passed to the fundus of the uterus, and the attempt repeated. Small portions, not larger than a pea, can be washed out by the uterine douche. When the polypus is situated near the os internum, the latter will be found patulous, but, when it is well up within the body of the uterus, dilatation is a frequent prerequi- site to removal. For the removal of presumably small portions of retained ovum, especially in cases where, owing to inflammatory conditions, I have hesitated to make the circuit of the uterine cavity with my finger, * Huter, " Compendium der gebhulflichen Operationen," Leipsic, 1874, p. 32. EXTRA-UTERINE PREGNANCY. 309 I have succeeded admirably by employing a tolerably firm Thomas's wire curette.* The Treatment of Immature Deliveries.—Fourth to seventh month. —Distinctive of immature deliveries are : painful periodic contrac- tions, recognizable by the hand applied above the symphysis pubis, rupture of the membranes and discharge of the foetus, the complete formation of the placenta and umbilical cord ; while in abortion the uterine contractions are obscure, the placenta is rudimentary, and the ovum is frequently expelled entire. In the treatment of immature delivery, the tampon may usually be discarded. After rupture of the membranes and expulsion of the fcetus, the haemorrhage should be controlled by grasping the fundus of the uterus in the hand through the abdomen, and compressing the uterine walls firmly together. The passage of the foetus opens the uterus so as to allow, in the fourth and fifth months, the introduction of two fingers ; in the sixth and seventh months, that of the half-hand. In case compression of the uterus does not arrest the haemorrhage and expel the placenta, the cord should be carefully followed to its insertion, to determine the side upon which the implantation exists. If the placenta is implanted upon the right side, two or four fingers of the right hand, according to the degree of cervical dilatation, should be passed up along the left side of the uterus, across the fundus to the placental site. The de- tachment should be effected with the tips of the fingers, and the pla- centa pressed downward as the fingers descend along the right side of the uterus. The left hand should be employed in the reverse direc- tion, when the placenta is situated to the right. CHAPTER XVII. EXTRA-UTERINE PREGNANCY. Definition.—Tubal pregnancy.—Pregnancy in rudimentary cornu.—Interstitial pregnancy. —Tubo-abdominal and tubo-ovarian pregnancy.—Ovarian pregnancy.—Abdominal pregnancy.— Symptoms.— Terminations.— Diagnosis.—Treatment, in cases of early gestation.—Cases of advanced gestation (foetus living).—Cases of gestation pro- longed after the death of the foetus. After coitus, the spermatozoa make their way through the Fallo- pian tubes to the pelvic cavity. It is possible, therefore, for the ovum to become fecundated in any portion of the route from the ovary to * Skene, " Med. Record," 1875, p. 59; Munde, " Centralbl. f. Gynaek.," 1878, No. vi, p. 1. The patient should be placed in Sims's position, the perinaeum should be drawn back with Sims's speculum, the cervix hooked down and steadied with a tenaculum, while the curette is made to pass over all portions of the uterine surface. Attached bits of placenta are recognized by the resistance they offer. 310 THE PATHOLOGY OF PREGNANCY. the uterus. In exceptional cases, the ovum may, after fecundation, be arrested in its travels, and undergo development at some point outside of the uterus. To these fortunately rare cases the term extra-uterine pregnancy has been applied. The terms tubal, ovarian, and abdominal pregnancy designate different forms of extra-uterine development, and serve to express the site of the attachment from which the growth of the ovum be- gins. Tubal Pregnancy.—Tubal pregnancy is the most frequent of the three forms. The ovum may find lodgment in any part of the tube. The causes of this anomaly are to be sought for in catarrhal affections attended with loss of the ciliated epithelium, dilatation, and, in some cases, with the formation of hernial pouches, produced by the protru- sion of the mucous membrane through separated bundles of the mus- cular fibers ; or the ovum may be arrested by flexions and constrictions of the tube resulting from adhesions and old inflammatory bands. In a few instances a small polypus has been found filling up the caliber of the tube. Because of its connection Avith inflammatory processes, the occurrence of tubal pregnancy is often preceded by a long period of sterility. When the obliteration is only partial, the spermatozoa, owing to their small size, are not prevented from reaching the arrested ovum ; when complete, on the contrary, they can only gain access to the ovum by first passing through the patulous tube, and then migrat- ing across the rear of the uterus to the ovary or the open abdominal end of the tube upon the opposite side. In a considerable number of cases, the corpus luteum has been found upon the side opposite to the tube containing the fecundated ovum. With the present pre- vailing ATiews,* this phenomenon is only to be accounted for by the hypothesis of the migration of the ovum across the peritoneal surface of the pelvis or through the uterus from one tube to the other. As the ovum develops, the mucous membrane of the tube thickens after the manner of the decidua, and receives the club-shaped extrem- ities of the villi. Until the formation of the placenta, the detachment of the ovum is easy. Usually the two poles of the decidua-like cover- ing are closed, though sometimes the uterine end remains open, and in continuity with the mucous membrane of the tube and the decidua of the uterine cavity, f A decidua reflexa is in any event extremely * Mayrhofer, " Ueber die gclben Korper, und die Ueberwanderung des Eies," denies the whole doctrine of a distinct corpus luteum of pregnancy, and claims that corpora lutea are found at stated intervals, perhaps monthly, throughout the entire period of preg- nancy. Leopold, "Die Ueberwanderung der Eier," "Arch. f. Gynaek.," Bd. xvi, p. 24, however, found that after tying the right tube and after removing the entire left ovary in a couple of rabbits pregnancy still took place. + L. Bandl, Billroth's " Handbuch der Frauenkrankheiten," 5te Abschn., art. " Extra- uterinschwangerschaft," p. 44. EXTRA-UTERINE PREGNANCY. 311 rare. * The placenta is purely a fetal organ. The villi penetrate to the muscular structures of the tube, where they are occasionally surround- ed by large vessels. Nowhere, however, have they been observed to have broken through the walls of the maternal vessels, nor is there any evidence of maternal blood in the intervillous spaces, such as is belieA-ed to exist in cases of intra-uterine development, f With the beginning of pregnancy the muscular walls of the tube hypertrophy, but they subsequently are stretched thin by the growth Fig. 143.—Tubal pregnancy. (N. Sommer.) of the ovum. At an early period, usually within the first three months, rupture of the sac occurs at the point of least resistance, which corresponds in many cases to the site of the placenta. With rare exceptions death follows rupture, either immediately from acute internal haemorrhage, or secondarily from peritonitis. Rupture of the tube-walls may be associated with rupture of the ovum and escape of the foetus into the abdominal cavity, or the ovum may pass intact into the peritonaeum ; or, finally (and this is the more favorable termination), the ovum may remain in the tube, where it can serve as a tampon and diminish the extent of the haemorrhage. Recovery may occur in case of premature death of the embryo before rupture takes place ; or subsequent to rupture, by the forma- tion of false membranes around the embryo, or the entire ovum. Exceptionally tubal pregnancy may, OAving to an extraordinary thickening of the muscular walls, advance to full term. Spiegelberg refers to three instances of the kind—one reported by Saxtorph, one * Hennig found in one hundred and fifty reported cases a reflexa mentioned in but five ("Die Krankheiten der Eileitera und die Tubenschwangerschaft," p. 150). f Vide Conrad und Langhacs, "Tubenschwangerschaft," "Arch. f. Gynaek," Bd. ix, p. 358 ; also Leopold, " Tubenschwangerschaft," etc., ibid., Bd. x, p. 262. 312 THE PATHOLOGY OF PREGNANCY. by himself, and one by Fabbri.* Hof meier f likeAvise reports a case of probably the same character. J Rupture of the tube may occur in the portion not covered by the peritonaeum. Blood is then effused between the folds of the broad Fig. 144.—Pregnancy in rudimentary cornu. (Kiissmaul, observed by Heyfelder.) ligament, and into the cavity thus formed the ovum may escape. This form is known as extra-peritoneal pregnancy. Pregnancy in the Rudimentary Cornu of a One-horned Uterus — This anomaly so closely resembles the tubal form of pregnancy that the diagnostic distinction can rarely be established during life. Even after death the only certain guide is furnished by the situation of the round ligament, which in the rudimentary horn is found external to the sac, while in tubal pregnancy it lies betAveen the sac and the uterus. In tubal pregnancy, however, rupture takes place, as a rule, during the first three months, while the rupture of the cornu occurs * Spiegelberg, "Lehrbuch der Geburtshulfe," p. 312. f Hofmeier, "Ztschr. f. Geburtsh. und Gynaek.," Bd. v, p. 115. X Ernst Frankel ("Arch. f. Gynaek.," Bd. xiv, p. 205) collected twenty-six cases, occur- ring between 1875 and 1879, of pure tubal pregnancy, in which the diagnosis was con- firmed by subsequent post-mortem examination. Of these but seventeen terminated in rupture during the first three months. Of the remaining nine, two reached full term (Simpson's and Tinker's), one completed eight months of gestation (Cullingworth's), one six months (Dollinger's), one five months (Netzel's and Bliek's), and two four months (Frankel's .and Netzel's). EXTRA-UTERINE PREGNANCY. 313 somewhat later, usually between the third and sixth month. In one case, related by Turner,* pregnancy went on to full term ; the patient dying of phthisis six months after labor, the dead child was found in the left cornu. Rupture takes place at the apex of the cornu, where the tenuity of the walls is most pronounced. .Koeberle f mentions a case where the child died in the fifth month, and was converted into a lithopaedion. Interstitial Pregnancy.—The term interstitial pregnancy is applied to cases in which the ovum is developed in the uterine portion of the tube. The latter measures about seven lines in length by one line in diameter. At first the muscular walls hypertrophy and form around the ovum a sac which projects from the upper angle of the uterus. As, ordinarily, the growth of the muscular tissue does not keep pace Avith that of the ovum, rupture occurs at an early period, usually be- fore the fourth month. Rokitansky,J hoAvever, cites a case in which Fig. 145.—Interstitial pregnancy. (Hennig.) the thickened muscular walls resisted the pressure of the ovum to the end of gestation, the child having been removed by laparotomy in the tenth month. When the ovum develops in the outer end of the uterine portion, it * Turner, "Edinburgh Med. Jour.," May, 1866, p. 974. \ Kceberle, "Gaz. Hebd.," 1866, No. 34. X Vide Spiegelberg, "Lchrbuch der Geburtshulfe," p. 313. 314 THE PATHOLOGY OF PREGNANCY. may grow partly outward into the tube. This form is termed tubo- interstitial pregnancy. On the other hand, when near the inner ex- tremity, the ovum may dilate the ostium and pass into the uterine cavity, and be expelled after the manner of an ordinary abortion.* Another possible form of interstitial pregnancy is furnished by the occasional existence of a canal, open at its two extremities, and appar- ently a continuation or a bifurcation of the Fallopian tube. A case reported by Dr. Gilbert, in the " Boston Medical and Surgical Jour- nal " (March 3, 1877), where the head of the child could be felt just above the os internum, covered by a thin mucous membrane, and in which delivery was successfully accomplished by an incision through the partition, probably belonged to this variety. A similar case, in Fig. 146.—Bifurcation of tubal canal. (Hennig.) the practice of Dr. H. Lenox Hodge, is reported by Parry {op. cit., p. 266). In the post-mortem examinations the distinction between an inter- stitial pregnancy and one in a rudimentary cornu is not easy to make out, as in both the round ligament lies to the outer side of the tumor. The chief points of difference consist in the fact that in interstitial pregnancy the sac is separated from the uterus by a partition, Avhile in pregnancy in a rudimentary cornu the two halves of the uterus are united by a muscular band, which is situated, not at the upper angle, but near the os internum, f Tubo-Abdominal and Tubo-Ovarian Pregnancy.—When the ovum becomes lodged near the trumpet-shaped extremity of the Fallopian tube it grows outAvard into the abdominal cavity. Local peritonitis is then set up, and plastic exudation is thrown out, forming an envelope * In this category we should certainly place the case of Dr. Charles McBurney (" New York Med. Jour.," March, 1878, p. 273) and that of Dr. Cornelius AVilliams, in the December number of the same journal (p. 595), both of which were followed by the recov- ery of the mother. f Spiegelberg, "Lehrbuch der Geburtshulfe," p. 315. EXTRA-UTERINE PREGNANCY. 315 around the ovum, which is likewise bounded by the contiguous or- gans. In this way the ligamenta lata, the ovaries, the mesentery, the intestines, the bladder, and the uterus, may all contribute to the investment of the fetal membranes. In case of rupture in the tubal portion, inflammatory products may form, and limit the extent of the injury. At first, owing to its weight, the distended tube drops into the cul-de-sac of Douglas. In advanced pregnancy, the spleen, kidneys, and liver may become involved, and form part of the sac- walls around the ovum. Usually the placenta is developed in the pelvic cavity.* When the investment of the ovum is furnished by the tube and the ovary, the term tubo-ovarian pregnancy is employed. The course in either case does not materially differ from that of an abdominal pregnancy. Ovarian Pregnancy.—A number of well-observed cases are now on record \ where the fecundation and development of the ovum have taken place within the Graafian follicle, the walls of the latter and the ovarian stroma furnishing to the growing ovum, in whole or in part, a membranous envelope, like the wall of an ovarian cyst. Subsequent to fecundation the Graafian follicle may close, and the ovum continue extra-peritoneal, or the ovum may gradually make its way through the opening occasioned by the escape of the Graafian fluid, and thus come to lie eventually for the most part Avithin the peritoneal cavity. In either case, rupture of the sac takes place usually within three to four months, though, when the sac-walls are reenforced by adhesions to the peritoneal coverings of adjacent viscera, the full term of gestation may be reached. Abdominal Pregnancy.—The origin of abdominal pregnancies is unsettled. As no instances have been observed at an early period of development, it is not possible to say whether the fertilized ovum drops into the peritoneal cavity on escaping from the ovary or during its migration through the groove of the long ovarian fibria, or whether nearly all cases of abdominal pregnancy are not really secondary out- growths from the tubaland ovarian forms. Wherever the ovum comes in contact with the peritonaeum, a con- nective-tissue proliferation is set up, which surrounds it with a vas- cular sac. The latter often attains a degree of thickness which renders it comparable to the gravid uterus (Klob). The walls keep pace, as a rule, with the growth of the ovum, and, as they extend into the abdominal cavity, form adhesions to the intestines, the mesentery, and omentum. It is claimed that organic muscular fibers have been found * Vide Bandl, Billroth's " Handbuch der Frauenkrankheiten," 5te Abschn., p. 47. f Vide Spiegelberg, " Zur Casuistik der Ovarialschwangerschaft," " Arch, f. Gynaek.," Bd. xiii, p. 73; Landau, " Zur Lehre von der Eierstocksschwangerschaft," ibid., Bd. xvii, p. 436; Schroeder, " Lchrbuch," 4te Aufl., p. 385. 316 THE PATHOLOGY OF PREGNANCY. in the sac, especially near the uterine attachment. In this form the foetus most frequently reaches maturity. In rare cases the ovum develops free in the abdominal cavity, with- out the formation of pseudo-membranes, the fcetus being surrounded solely by the amnion and chorion. Still more remarkable are the so-called secondary abdominal preg- nancies, where rupture of the sac and the fetal membranes, Avhether primarily situated in the tubes, the ovary, or the abdominal cavity, takes place, and the foetus passes into the abdominal cavity. Usually the child dies at or soon after the time of rupture, but cases are re- ported by Walter, Patuna, and Bandl,* where it continued to develop Avithin the abdomen. The presence of the child excites an active pro- liferation of connective tissue, by means of which a secondary sac is formed. If the child dies, it may either become converted into a lithopaedion, or, through the vascular connective tissue by which it is surrounded, the soft structures of the body may preserve their integ- rity for years succeeding the fatal ending. There are, in addition to the varieties already mentioned, histories on record of the coexistence of extra-uterine and intra-uterine preg- nancies, the latter occurring at the same menstrual period as the for- mer, or subsequent to the death of the extra-uterine fcetus. f The Symptoms of Extra-uterine Pregnancy. The earlier symptoms of extra-uterine pregnancy do not materially differ from those of the intra-uterine form. Menstruation usually ceases, though not with the same regularity as in normal pregnancy. The recurrence of the monthly flow for one or two periods is not an uncommon incident. In some cases, too, a nearly continuous sero- sanguinolent discharge of moderate extent has been obserAred. Up to a certain point the hypertrophic changes of the uterus take place in the usual manner. The mucous membrane is converted into a de- cidua, and a mucous plug fills the cervix. In general terms, the length of the uterus is greater, the closer the contiguity of the ovum to the uterus. Thus, in interstitial pregnancies the length has been found to vary between four and seven inches, in tubal pregnancies the aver- age enlargement is less than in the interstitial, and in the abdominal less than in the tubal form. In a few cases of tubal pregnancy there has been no increase in the size of the uterus. The extra-uterine ovum may, in the course of its growth, drag the uterus upward, or push it downward, forward, or sideways, according to the site of its development. Characteristic symptoms of extra-uterine pregnancy do not occur until the ovum has reached a certain degree of growth, and in some cases not until rupture has taken place. Often preceding rupture, or, * Bandl, loc. cit., p. 63. •)- Ibid., p. 66. extra-uterine pregnancy. 317 in abdominal pregnancies, the death of the foetus, the patient suffers from paroxysmal pains in the sac, and uterine pains of a labor-like character. The latter are associated with a sero-sanguinolent dis- charge, and are followed by the expulsion of portions of the decidua. The symptoms of rupture are the usual ones of internal haemor- rhage, viz., yawning, languor, fainting, clammy perspiration, rapid pulse, intermittent vomiting, collapse, and acute anaemia. After the death of the ovum these symptoms may cease and not return again * whereas, if the ovum continues to grow, there may be repeated attacks of haemorrhage and local peritonitis, terminating finally in death or recovery. When the death of the ovum does not occur within the first three to four months, the pressure of the tumor usually gives rise to dysuria and constipation. Terminations,—In tubal and interstitial pregnancies the usual terminations are, as we have seen, rupture of the sac, haemorrhage, peritonitis, and death. It is Avell to bear in mind, however, that this is not the history of all, a pretty large percentage ending in recovery. Thus, a dead foetus may be retained for years Avithout furnishing the impulse to a fatal issue. When the foetus dies previous to rupture, the ovum may degenerate into a mole, or the fcetus may either undergo mummification, or be com-erted into a lithopaedion. In abdominal pregnancies, whether primary or secondary, the ovum or foetus usually excites a local peritonitis, attended with pain and fever, and followed by the production of pseudo-membranes, which exercise a conservative influence by shutting off the ovum from the peritoneal cavity. Indeed, in the exceptional instances where these inflammatory conditions do not develop, the moA-ements of the foetus within its own membranes may give rise to such intense suffering as to cause the woman to die from exhaustion (Schroeder). In ovarian and abdominal pregnancies the child may die prema- turely, or gestation may advance to full term. In the latter instances labor-pains set in, the decidua is expelled, and the child dies during the expulsive efforts. In the majority of cases the dead fcetus excites a suppurative inflammation in the sac by Avhich it is inclosed, and the patient dies either from general peritonitis or from profuse suppura- tion. In favorable cases, where the peritonitis remains local and the suppuration is tolerated, fistulous communications may form with one of the hollow viscera of the abdominal walls, through Avhich the con- tents of the sac may be eliminated. Most frequently the opening takes place into the large intestine ; quite often through the abdom- inal walls ; more rarely into the vagina and bladder. In any case, the process of elimination is slow, often lasting months and even years. When the bones and soft tissues have all been discharged, complete recovery may take place. In the larger proportion of cases, however, 318 THE PATHOLOGY OF PREGNANCY. if Nature is not assisted, the patient perishes from exhaustion and blood-poisoning before the elimination is ended (Schroeder). Sometimes the foregoing inflammatory changes do not occur as the result of the death of the foetus, in which case the fluid contents of the sac are reabsorbed, and the walls collapse and come in contact with the fetal cadaver. The skin of the latter, and at a later period the deep- seated soft tissues, undergo fatty degeneration, and form a greasy sub- stance, consisting of fat, lime-salts, cholesterin-crystals, and blood-pig- ment. Afterward the fluid portions are absorbed, so that nothing remains but the bones, lime lamellae, and incrustations upon the walls of the sac, or the fcetus may shrink up like a mummy, preserving its shape and organs to the minutest detail (Spiegelberg). A fcetus thus altered is termed a lithopaedion. It may remain imbedded in connec- tive tissue for years without injury to the mother. The lithopaedion of Leinzell Avas remoA'ed in 1720 from a woman ninety-four years of age, who had carried it for forty-six years. The presence of the lithopae- dion does not prevent pregnancy from taking place.* In some cases it may after years excite suppuration, a result which is fostered, according to Spiegelberg, by pregnancy and labor. Recovery may follow the artificial extraction of the foreign body, or death may result from inflammation and the discharge of pus. Diagnosis.—The diagnosis of extra-uterine fetation is based upon the existence of the signs of pregnancy, the exclusion of an ovum within the uterine cavity, and the presence of a tumor external to the uterus. In tubal pregnancy, the symptoms up to the time of rupture are often those of ordinary pregnancy. The existence of paroxysmal pains, radiating from one iliac fossa, should excite the suspicions of the physician and lead to a careful investigation. As these pains are ordinarily associated Avith flatulent distention of the colon, they are apt to be regarded as due to intestinal colic. Sero-sanguinolent discharges from the uterus, and afterward the expulsion of portions of the de- cidua, would, however, limit the diagnosis to a choice between mem- branous dysmenorrhoea and the condition in question, the decision depending upon the presence or absence of the menstrual, mammary, and uterine signs of pregnancy. An examination per vaginam, after the first five or six Aveeks, reveals the presence of a tumor to the side of the uterus. When situated low down, whether in the cul-de-sac of Douglas, or to the sides of the vagina, by conjoined palpation its ovoid shape, fluctuation in the sac, and, in the absence of peritoneal adhesions, a ballottement of the entire tumor, can be made out. Bal- lottement of the foetus may be detected by the end of the fourth month. Arterial pulsations in the vaginal walls beneath the tumor are of suspicious import. * Schroeder, op. cit., 6te Aufl., p. 421. EXTRA-UTERINE PREGNANCY. 319 Owing to the desirability of early recognizing an extra-uterine pregnancy, when the evidence in favor of its existence is very strong it is alloAvable to demonstrate the empty state of the uterus by a care- ful introduction of the sound, or, still more clearly, by introducing the finger after preliminary dilatation of the cervix. When the sac ruptures in the early weeks of pregnancy, the escape of blood into the peritoneal cavity may be moderate and run the course of ordinary haematocele. From the third to the fourth month, rupture gives rise to symptoms of extensive internal haemorrhage, and usually proves speedily fatal. With rare exceptions, Avhen extra-uterine pregnancy exceeds the fourth month without the occurrence of rupture, either an ovarian or abdominal pregnancy may be predicated. After the fourth month the ovum becomes of the size of the tAvo fists, and it is sometimes possible to make out the presence of fetal parts through the abdominal walls, provided the latter are not too thick. Of course, as pregnancy ad- vances, the heart-sounds and the contour of the foetus become more distinct. The difference between intra- and extra-uterine pregnancy may sometimes be established by frictions of the abdomen over the tumor with the hand, as the uterus alone contracts in response to the stimulus. If by the foregoing means the requisite certainty is not reached, bimanual examination should be made under anaesthesia. Sometimes the diagnosis can only be decided by the introduction of the sound or a finger into the uterus, the physician assuming the risk of premature labor, should he find his supposition of extra-uterine pregnancy an error. Treatment.—The treatment of extra-uterine fetation varies in ac- cordance with the stage of pregnancy and the condition of the foetus. For the sake of convenience, we distinguish—1. Cases of early gesta- tion ; 2. Cases of advanced gestation (fcetus living); 3. Cases of gestation prolonged after the death of the foetus. 1. Cases of Early Gestation. — The indication for treatment in the early months is plainly the adoption of measures to destroy the life of the foetus, and thus, by arresting the growth of the ovum, avert the danger of rupture and haemorrhage. Indeed, in this way we simply follow the plan marked out for us by Nature, spontaneous recovery commonly following the accidental death of the embryo. The methods which have heretofore been employed to destroy the ovum are puncture of the sac, injections of morphia solutions, elytrot- omy, and the faradaic current. Puncture of the Sac.—Puncture of the sac is usually easily effected by the introduction of an exploring trocar, through either the vagi- nal or rectal wall. The operation is to be recommended on the score of simplicity, but has not been attended with very brilliant results. 320 THE PATHOLOGY OF PREGNANCY. Recoveries after puncture have been recorded by Greenhalgh, Tanner, Stoltz, Jacobi, Koeberle, and E. Martin (two cases). Fatal issues from septicaemia and peritonitis followed puncture in the hands of Routh, J. Y. Simpson, A. Simpson, Martin, Braxton Hicks, Thomas (two cases), Conrad, Netzel, Hutchinson, John Scott, Gallard, and Depaul. Frankel * withdreAV nearly three fifths of an ounce of amni- otic fluid from the sac without interrupting the course of pregnancy. Injections of Solutions into the Sac, designed to destroy the Fatus. —This method was first suggested by Joulin. f He proposed injec- tions of sulphate of atropia (one fifth of a grain, dissolved in a few drops of water) into the sac by means of a long hypodermic syringe. His suggestion subsequently was successfully carried into effect in tAvo cases by Friedreich, J of Heidelberg. The needle of the syringe should be introduced into the sac through the abdominal or vaginal walls, a few drops of fluid should then be withdrawn, and its place supplied by the solution containing the poison selected. Friedreich employed by preference a fifth of a grain of morphia. The operation should be repeated every second day, until the diminished size of the ovum affords evidence that the result sought for has been accomplished. The operation seems to produce but slight inflammatory disturbance, and the maternal system has been found not to feel the influence of the narcotic. Elytrotomy.—Professor Gaillard Thomas reports a case Avhere he cut into the sac through the vagina by means of the incandescent knife attached to the electric-cautery apparatus. The patient nar- roAvly escaped with her life, but finally recovered. In the latest edi- tion of his work on diseases of women, Dr. Thomas recommenda Paquelin's cautery brought to a red heat. After cutting slowly through the sac, he advises removing the fcetus, but not the placenta, and then filling the sac with antiseptic cotton, which should be re- moved once in thirty-six hours. He offers the operation only, how- ever, in cases Avhere the severity of the symptoms demands immediate action. The Faradaic and Galvanic Currents.—The transmission of the faradaic current through the ovum has proved a safe and efficient method for destroying the life of the foetus during the first three months of its existence. The application consists in passing one pole into the rectum to the site of the ovum, and pressing the other upon a point in the abdominal wall situated two to three inches above Pou- * Frankel, " Zur Diagnostik und operative Behandlung der Tubenschwangerschaft, "Arch. f. Gynaek.," Bd. xiv, p. 197. f Joulin, " Traite complet des accouchements," p. 968. X Cohnstein, '' Beitrag zur Schwangerschaft ausserhalb der Gebarmutter," " Arch. f. Gynaek.," Bd. xiv, p. 355. Hennig reports likewise a case operated on by Kceberl^, where profuse haemorrhage occurred. It is not stated whether the patient recovered. (" Die Krankheiten der Eilciter und die Tubenschwangerschaft," p. 138.) EXTRA-UTERINE PREGNANCY. 321 part's ligament. The full force of the current of an ordinary one-cell battery should be employed for a period varying from five to ten min- utes. The treatment should be continued daily for one or two weeks, until the shrinkage of the tumor leaves no doubt as to the death of the foetus. The successful employment of the faradaic current in extra-uterine pregnancy we owe to Dr. J. G. Allen, who reported two cases of recovery through its instrumentality in 1872. His first case occurred in 1869, the second in 1871. Previously, in 1859, Burci had succeeded in shriveling up the ovum, in a case of tubal pregnancy, with the galvanic current transmitted through the tumor by means of two acupuncture-needles. In 1866 Dr. Braxton Hicks tried the faradaic current, but abandoned it after the second application. Dr. Allen was apparently in no haste to report his triumphs, but appears to have mentioned them incidentally in the course of a discussion before the Obstetrical Society of Philadelphia. So little pains did he take re- garding his discovery, that the subject was nearly forgotten, until a new success was reported by Drs. Lovering and Land is, of the Starling Medical College, in 1877. Since then, Landis has reported a second case of recovery, and one each has occurred in the practice of J. C. Reeve,* II. P. C. Wilson,f Harrison, and the writer. In three cases. treated, one by Dr. McBurney, J one by Dr. C. E. Billington, and one by Dr. Rockwell, the galvanic current, with one hundred and twenty interruptions to the minute, was employed with equally favorable results.# The treatment in my own case was begun at the end of the tenth Aveek, dating from the last menstruation. The tumor was at that time felt quite tow down upon the right side of the vagina, fluctuation Avas distinct, and by conjoined palpation ballottement of the entire ovum could be produced. The diagnosis was confirmed by Dr. Gail- lard Thomas, who saw the case with me in consultation. At his sug- gestion, I tried Allen's method, though skeptical as to any benefit to be derived from it. As no perceptible effect was produced by the first three seances, and as I believed rupture was imminent, I became ex- tremely anxious to make the vaginal incision at once. In a second consultation with Dr. Thomas, I was, however, persuaded to persevere, and was rewarded by finding, upon the tenth application, such dis- * Eeeve, " Trans, of the Amer. Gynsec. Soc," vol. iv, p. 313. Allen's case is referred to by Reeve. f Wilson, " Amer. Jour, of Obstet.," vol. xiii, p. 836. X McBurney, " Case of Tubo-Interstitial Pregnancy," " New York Med. Jour.," vol. xxvii, p. 273. * Verbal report of Dr. Rockwell at the County Society, in the discussion following the reading of a paper by the author on the " Treatment of Extra-Uterine Pregnancy." In the McBurney case two applications, in Billington's four, and in Rockwell's a single application, sufficed to destroy the embryo. 21 322 THE PATHOLOGY OF PREGNANCY. tinct evidences of suspended growth that I felt justified in leaving the case to Nature. The swelling has since nearly disappeared, and con- valescence has progressed without interruption. When the tube ruptures without previous warning, treatment should be directed to the arrest of internal haemorrhage and the re- moval of shock. An ice-bag applied to the abdomen meets the first indication, but it is to be employed with circumspection where great depression already exists. Compression of the aorta, or a sand-bag laid upon the abdomen over the site of the ovum, may prove of service. The patient should be cautioned to maintain the most perfect quiet; opiates should be administered, and stimulants should be given in small quantities, but at short intervals. The subsequent treatment should be that for peritonitis. Laparotomy.—As, under careful management, rupture of the tube most often proves fatal, Kiwisch recommended in such cases to make an incision four or five inches in length through the abdominal wall along the linea alba. In order to be sure that internal haemorrhage had really taken place, he advised, when the peritonaeum was reached, to first make a small puncture, and to introduce a pipette into the abdominal cavity. If the presence of blood was detected, the perito- naeum should then be laid open the length of the abdominal Avound, and, after first tying the bleeding vessels, the sac should be removed, and the peritonaeum carefully cleansed. Strange to say, intelligent as these instructions seem, no one, in these days of abdominal surgery, has so far had the hardihood to carry them into execution. The rea- sons for this backwardness are probably to be found in the uncertain- ties of the diagnosis, the risk of finding the sac hopelessly matted to the adjacent viscera, the dislike for operating upon a dying woman, and the fact that a considerable number of spontaneous recoveries occur, either from the mummification of the fcetus, or by the limita- tion of the sanguineous effusion and the production of a circumscribed haematocele. 2. Cases of Advanced Gestation {Fatus living). — During the progress of gestation, most patients suffer from transient though often severe attacks of peritoneal inflammation, from pains caused by the fetal movements, from irregular uterine haemorrhages, from inability to take food, and from the resulting emaciation and depression of the vital powers. The occurrence of labor is apt to excite peritonitis, and may be associated with separation of the placenta, haemorrhage into the sac, and disruption of the sac-walls. These manifold sources of danger have been advanced as grounds for early operative interference ; and assuredly laparotomy, furnishing, as it does, an opportunity to rescue the child from certain death, ought to enjoy the highest degree of favor, provided its performance does not at the same time increase the jeopardy in which the mother's life is placed. To de- EXTRA-UTERINE PREGNANCY. 323 cide this point, it is necessary to inquire as to the results thus far obtained from its employment. Parry reported twenty cases of so- called primary operations—i. e., operations performed during the life of the child—by means of which eight children and six mothers were saved. This, though not a particularly brilliant showing, was thought to furnish encouragement to continued trial, with the belief that ex- perience would so far lead to improvements in methods of operating and in the care of patients, as eventually to raise laparotomy for the removal of an extra-uterine foetus to the level of other forms of ab- dominal surgery. An examination of Parry's table does not, however, warrant his frequently quoted statement. Five of the reported mater- nal recoveries ought to be stricken out altogether.* For the sixth case, that of Hooper (No. 14), it is simply stated that " the cyst had burst into the bowel," and that the child was dead. Whether the death of the child long preceded the operation, it is impossible to determine. Litzmann f furnishes the results of nine additional operations, with only one recovery, viz., the now famous case of Jessup. Thus, in twenty-four cases of primary operation, only one mother certainly sur- vived. If we admit Hooper's case, the result will stand twenty-two deaths and two recoveries. If we accept Parry's statement as approxi- mately correct—that in 499 cases of extra-uterine pregnancy, includ- ing 174 cases of ruptured cyst, the mortality was 67*2 per cent.—it is evident that much remains to be done in the way of perfecting the primary operation before its admissibility, except under desperate con- ditions, can be recognized. In ten cases reported by Litzmann, only four children survived the third day. The unavoidable source of danger in the primary operation lies in the impossibility of removing the placenta, owing to the absence of any physiological contrivance to check haemorrhage from the maternal vessels. Even when the placenta is left in situ, fetal haemorrhages may occur during the process of its elimination. Again, in the pro- portion of one case to six, the placenta has been found in the line of the abdominal incision. * Vide Parry, " On Extra-Uterine Pregnancy," p. 229. Cases 5 and 6 are the same. They were found by Parry in different journals, in one case ascribed to Schreyer, who was the principal in the operation, and in another to Zwanck, who was present as an assistant. Litzmann, on seemingly good grounds, maintains that Schreyer simply performed Caesarean section upon a one-horned uterus. In De Coene's case (No. 9) of twin pregnancy, one of the children passed into the abdominal cavity through an opening in the uterus formed by the gaping of the line of union at the site of a previous Caesarean section. In Stutter's case (No. 10), the operation was performed in the forty-fifth week, six weeks after the death of the foetus. In Ramsbotham and Adams's case (No. 11), the foetus had been dead six months— operation in the fifteenth to the sixteenth month (Litzmann). f Litzmann, " Zur Feststellung der Indicationen fur die Gastrotomie bei Schwanger- schaft ausserhalb der Gebarmutter." 324 THE PATHOLOGY OF PREGNANCY. The extraction of a living child through an incision in the vaginal wall was reported by Dr. John King, of Georgia, in 1817. The mother made an easy recov- ery. Campbell reports nine cases, with the saving of five mothers and five chil- dren. Parry increased the number to fifteen, with six recoveries. No recent successes have been announced. Bandl,* in 1874, operated under what he re- garded as most favorable conditions, but the patient died at the beginning of the third day. The operation is only applicable to cases where the sac is low down in the pelvis, and the presenting part can be easily reached through the cul-de-sac of Douglas. 3. Cases of Gestation prolonged after the Death of the Fatus.— It is an accepted rule not to operate in advanced extra-uterine preg- nancy during the continuance of labor-pains, as the expulsive efforts at the same time diminish the chance of saving the life of the child, and increase the danger of the mother. Opiates should be adminis- tered and absolute rest enjoined, with the view of hindering the separa- tion of the placenta, an accident necessarily followed by haemorrhage, and possibly by rupture of the sac. After the death of the fcetus, the most favorable result consists in absorption of the amniotic fluid, continued shrinkage of the sac, and the conversion of the fcetus into a lithopaedion. More commonly, however, the fcetus undergoes maceration, and the amniotic fluid, soiled with meconium and serum, stained with dissolved coloring-matters of the blood, becomes turbid and of a dirty-red, reddish-brown, gray, or greenish-yellow color. The patient suffers from attacks of pain, due to peritoneal irritation, from loss of appetite, vomiting, and diar- rhoea, from fever with irregular chills, from emaciation, and general prostration. Owing probably to the contiguity of the intestines (Litzmann), septic germs are liable at any time to pass into the sac, and excite decomposition. When an incision is then made to remove the foetus, the latter is found in a putrid condition, and the amniotic fluid consists of a chocolate-brown, purulent menstruum of greater or less consistence. The nature of the changes that have taken place is evidenced by foul odors and the escape of stinking gases. It is ob- vious, therefore, that the presence of a dead foetus seriously compro- mises the safety of its possessor. To be sure, many cases have been re- corded where eventually suppurative processes have led to the forma- tion of fistulous openings communicating with the abdominal walls, the rectum, the vagina, and even the bladder, through which the fluid contents first escape from the sac, and afterward the piecemeal elimi- nation of the fcetus spontaneously takes place. As, under the circum- stances, the enlargement of the openings into the cyst, the removal of the contents, and the treatment of the cavity like an ordinary abscess, are attended with but moderate risk (three deaths in twenty-nine cases of abdominal fistula, according to Parry), it has been proposed to post- * Billroth, " Handbuch der Frauenkrankheiten," 5te Abschn., p. 87. EXTRA-UTERINE PREGNANCY. 325 pone surgical aid until Nature indicates the channel by which elimi- nation is to be effected. This proposition, however, ignores the de- plorable condition to which the suppurative process inevitably reduces the patient, and the incidental dangers to life. During the last decade, the success of secondary laparotomy, as distinguished from that performed during the life of the foetus on the one hand, and simple incisions designed to enlarge fistulous openings on the other, has been such as to warrant its being placed in the cate- gory of justifiable operative procedures. In thirty-three cases collected by Litzmann (twenty-four between 1870 and 1880), there were nine- teen recoveries. Of the two dangers inherent to the primary operation, viz., haemorrhage and septicaemia, the former is greatly lessened by the cessation of the fetal circulation and by the gradual thrombosis and obliteration of the maternal vessels, and the cutting off of the blood-supplies to the placenta. With the present perfection to which antiseptic measures have been carried, the risks from septicaemia are diminished though not entirely done away with. The time for the performance of laparotomy is of some impor- tance. All of Litzmann's patients which were operated upon during the first month subsequent to the decease of the foetus (seven in number) died, while, in twenty-six cases operated upon at periods varying from five weeks to a year after the decease of the fcetus, there were but seven deaths. The former mortality was partially due to the des- perate condition of the patients, which determined the early date of the operations, and in part to the occurrence of profuse haemorrhages from the patent mouths of the placental vessels. There are as yet no signs known by which the time at Avhich the obliteration of the placental vessels becomes complete can be ascertained. Schroeder re- moved the placenta three Aveeks after the cessation of fetal move- ments without loss of blood, while a patient of Depaul expired from placental haemorrhage from an operation performed four months after the foetus had perished. It is certainly evident that when the circum- stances admit of delay it is best to defer operative measures, and treat the patient symptomatically, as Litzmann suggests, with pure air, nourishing food, quinine, and gentle laxatives, until the obliteration of the maternal vessels has probably taken place. In case, however, of marked septic symptoms, the opening of the sac should not be delayed, as the subsequent use of antiseptics at least is calculated to restrain the pernicious influence of the decomposing contents upon the entire organism. The operation for laparotomy should be performed with antiseptic precautions. The incision should be made along the linea alba. In case the sac is not found adherent to the abdominal walls, it should be stitched to the cut borders of the abdominal wound previous to open- ing. The placenta should be left to come aAvay spontaneously, un- 326 OBSTETRIC SURGERY. less it occupies the site of the incision. The wound should be closed above and left open below for the passage of the cord, and the intro- duction of antiseptic injections. No rules can profitably be laid down as to the plans to be pursued in the enlargement of fistulous openings. Each case must be treated upon its own merits, and the surgical aid rendered must be adapted to the individual peculiarities which characterize it. OBSTETRIC SURGERY. CHAPTER XVIII. THE INDUCTION OF PREMATURE LABOR. Induction of premature labor.—Indications.—Contracted pelvis.—Habitual death of foetus. —Diseases which imperil the life of the mother.—Operation.—Catheterisatio uteri. —Intra-uterine injections.—Rupture of membranes.—Mechanical dilatation of cer- vix.—Vaginal douches.—Tampon.—Choice of methods.—Care of the child.—Artifi- cial abortion. The induction of premature labor is indicated in cases in which the continuance of pregnancy, or delivery at full term, is associated with risks to mother or child, or to both, which may be diminished by bringing pregnancy to a close at an early period after the fcetus is prepared for extra-uterine existence. The time at which the latter begins is usually placed at the twenty-ninth week. As, however, the preservation of the child at so early a date is an exceptional occurrence, and as a large proportion of those which by tender care are made to survive the first dangers of immaturity perish in infancy, commonly falling a prey to hydrocephalus or to intestinal derangements, the in- terests of the child call for the postponement of the operation as long as practicable. Where the choice lies with the physician, the provo- cation of labor is usually deferred until the thirty-third or thirty- fourth week. The principal indications are : 1. Moderate Degrees of Pelvic Contraction.—In flattened pelves measuring from tAvo and three fourths to three and one fourth inches, and in equally contracted pelves under three and one half inches, the passage of a full-term child is not impossible, though usually difficult and dangerous. By inducing premature labor, however, owing to the smaller size of the foetus, and especially to the increased compressibility of the fetal head, we are enabled to diminish the mechanical obstacles THE INDUCTION OF PREMATURE LABOR. 327 to delivery, and thus to improve the prognosis for both mother and child. To the mother the advantage from the operation is in all cases decided, while to the child not much is gained in the extreme degrees of contraction. The time at Avhich gestation should be interrupted depends upon the size of the pelvis and our estimate of the size of the fetal head. The distance from the lower border of the symphysis to the promon- tory should be accurately measured, and the side-walls of the pelvis carefully explored. Schroeder's measurements show that the bipari- etal diameter of the head is, between the twenty-eighth and thirty-sec- ond week, about three and one fourth inches ; between the thirty-second and thirty-sixth week, nearly three and a half inches ; and that after the thirty-sixth week the increase is insignificant.* One of the most important questions to be decided in reference to the induction of labor is the period to which gestation has advanced. But this, in the absence of well-defined signs, it is easy to miscalculate. Physicians have been misled by the large size of the uterus in twin pregnancies and hydramnion into provoking labor before extra-uter- ine existence was possible. Ahlfeld has shown that the long axis of the fcetus, when flexed in utero, is almost exactly one half its entire length in an extended position. He proposes measuring the former with a Baudelocque pelvimeter, by placing one extremity per vaginam upon the child's head, and the other upon a point in the abdominal walls over the fundus of the uterus at which the breech of the child is felt. Very nearly the same results were obtained by measuring from the upper border of the symphysis in place of passing the lower branch through the genital canal. The following arrangement, based upon his tables, places before us in a practical way the result of his investigations, so far as they apply to the questions involved in the induction of premature labor : f Axis of foetus. Length of foetus. Bi-parietal diameter. Duration of pregnancy. 10 inches. n 9 8 20 inches. 19 18 16 3^ inches. Si H 3 38-40 weeks. 35-37 31-34 29-30 * Schroeder, " Lehrbuch der Geburtshulfe," 4te Aufl., p. 235. It is to be remem- bered that the biparietal diameter is capable of a considerable degree of compression, and that it is usually the bitemporal rather than the biparietal diameter which has to pass the narrowest diameter of the pelvis. \ The arrangement is modified from one furnished by Stahl ("Geburtshiilfiiche Ope- rationslehre," p. 47). Owing to individual differences in the length of the foetus at the same period of gestation, a considerable source of error inheres to the Ahlfeld method of computation. It is, however, much less than those to which estimates based upon the size of the uterus are subject. 328 OBSTETRIC SURGERY. 2. Habitual Death of the Fatus.—It has been proposed that, when in successive pregnancies the foetus perishes in utero during the latter weeks of gestation, labor should be induced after the period of viability has been reached, but before the time at which, according to previous experience, the fatal ending was to be expected. This plan of treat- ment does not apply to cases where death is due to syphilis, as a better result is to be expected by subjecting both parents in advance to anti- syphilitic treatment. Little benefit, too, would be derived from pre- mature labor where the death is due to organic diseases of the foetus. But where death is the result of inanition, dependent upon maternal anaemia, fatty degeneration, faulty development of the placenta, or alterations of the umbilical cord, the operation is fully justifiable. With the difficulty, however, of making the diagnosis and fixing the time when labor should be induced, there have been but few cases in which the procedure has furnished favorable results. 3. Diseases which imperil the Life of the Mother.—In these cases the operation is primarily performed in the interests of the mother, and is indicated, therefore, even when the child is known to have per- ished. Sometimes, however, premature labor becomes a means of saving the life of the child, which shares the dangers that threaten the maternal existence. In this category belong especially chronic affections of the heart and of the respiratory organs ; enormous disten- tion of the abdomen from multiple pregnancy, hydramnion, tumors, and ascites, which occasion extreme dyspnoea ; pernicious anaemia ; un- controllable vomiting ; haemorrhages from placenta praevia; chorea; convulsions ; and nephritis, associated with excessive oedema. In each case, however, it is incumbent to carefully consider whether the special condition is rendered more threatening by the existence of pregnancy, and to weigh the question as to hoAv far, for the time being, the dan- gers are likely to be increased by the progress of labor. Stehberger has proposed extending this indication to cases where the preservation of the mother's life is hopeless, but in which prema- ture delivery affords a chance of saving the life of the child.* Operation. A great number of methods have been proposed with the view to provoke labor prematurely. Most of them, however, such as the ad- ministration of ergot, of quinine, or of jaborandi, the application of electricity to the uterus, the stimulation of the vagina with carbonic acid, frictions of the breasts, and the like, do not require anything more than cursory mention. The following procedures alone possess any special claims to favor : * Stehberger, " Lex regia und kunstliche Friihgeburt," " Arch, f. Gynaek.," Bd. i, p. 465. THE INDUCTION OF PREMATURE LABOR. 329 Catheterization of the Uterus.—This method consists in the in- troduction of a catheter, or, better still, an elastic bougie, between the membranes and the walls of the uterus, and leaving the instrument in situ until active labor sets in. In performing the operation it is a good plan to place the patient in a recumbent posture upon a hard table, with the hips brought near the edge, and the thighs well flexed upon the body. Two fingers in the vagina guide the point of the bougie into the cervix. The index-finger, passed to the os internum, then follows the instrument, and as it enters the uterus directs it to one side to prevent it from rupturing the membranes. In the case of primiparae, preliminary dilatation of the cervix may be secured, if necessary, by the use of a sponge-tent or of the vaginal douche. The bougie should be pushed slowly upward with the disengaged hand, and allowed to follow its own course, betAveen the membranes and the uterus. To prevent the instrument from slipping down, two inches of the extremity may be left outside the cervix to find support against the vaginal wall. A retentive tampon is rarely necessary. The method is tolerably certain. In favorable cases labor follows its employment in the course of a feAv hours. Sometimes, however, no action is set up during the first forty-eight hours, in which case it is well to resort to other additional measures. Outside of unwholesome hospitals, the use of the catheter or bougie to excite labor is not asso- ciated with any peculiar risks. The danger of detaching the placenta is not imminent, if the instrument be introduced slowly, as, owing to its elasticity, the bougie tends to make its way around the placental margin. In maternity hospitals, however, it may serve as a point of entry for miasmatic poisons, and thus be folloAved by local irritation and puerperal septic affections. Because of this danger the solid bougie is preferable to the hollow catheter. In all cases only a per- fectly clean and new instrument should be used. Injections between the Uterus and Ovum.—Cohen, of Hamburg, proposed in 1848 the separation of the membranes by injecting tar- water through a long-nozzled syringe made to penetrate about two inches within the uterine cavity. The nozzle was furnished with a rounded extremity, and with openings upon the side. He recom- mended that the injection should be continued until a distinct feeling of distention was experienced by the patient, which sometimes required the employment of nearly a quart of the fluid (720 grammes).* This plan has since been modified by the substitution of an elastic catheter for the metallic tube, and by the injection of a feAv ounces of simple Avarm water (98° Fahr.) in place of the aqua picea. In case of failure with a single injection, it has been recommended to repeat the pro- cedure. Professor Lazarewitch has demonstrated that the nearer the irritation is carried to the fundus the more certain and speedy the * Cohen, "Neue Ztschr. f. Geburtsk.," Bd. xxi, p. 116. 330 OBSTETRIC SURGERY. result. He therefore employs a syringe with a central opening, and passes it as near to the fundus as possible.* When efficiently performed, the method possesses the advantage of rapidly exciting uterine labor-pains. Kiinne reports fifteen cases in which he resorted to it with complete success. He cautions against using force in injecting, and recommends, as a means of avoiding the passage of air into veins, the withdrawal of the catheter, and its re- introduction, in case a haemorrhage should betoken that the placenta had been impinged upon. Others have employed the method many times with entire impunity. Still, cases of sudden death have occurred during its use, which have been referred to shock, to air getting into the uterine sinuses, and to rupture of the uterus. While, perhaps, the general results from uterine injections have not been less satisfac- tory than from the employment of other measures for inducing pre- mature labor, the suddenness of death in the fatal cases has had a deter- rent effect upon its extended employment. Rupture of the Membranes.—This is the oldest of all the methods now in use. It is best performed by means of a simple apparatus de- vised by the Freiherr Braun von Fernwald, consisting of a goose-quill sharpened like a pen and nicked upon its convex surface for the pas- sage of a uterine sound. Thus mounted, with its point guarded by the sound, it can be introduced, without risk to the maternal tissues, through the cervix to the ovum. Then, by simply pushing the quill upward, the point is made to clear the sound and effect the puncture of the membranes. The method is certain, though not always speedy in its action. It is open to the objections which hold good in all cases of premature discharge of the amniotic fluid. Hopkins recommended, as a mode to provide for the gradual escape of the liquor amnii, tap- ping the membranes Avith a sound at a distance from the os internum. Eokitansky has shown, from the statistics of Braun's clinic, that in hospital practice puncture of the membranes is the safest means of inducing premature labor, diminishing as it does the chances of infec- tion, which is the chief source of danger in all the measures where the irritation is applied directly to the inner surface of the uterus. Though in private practice I have never from choice selected this method, I have Avitnessed many cases in which the membranes have ruptured accidentally, and yet have failed to notice, either in the case of the mother or child, the serious consequences which theory would lead us to apprehend. It is not adapted for the higher degrees of pelvic contraction or for cases where speedy delivery is desirable. Mechanical Dilatation of the Cervix.—The dilatation of the cervix with sponge-tents or laminaria is rarely resorted to, except as prepara- tory to other measures. While the expansion of the tent softens the cervix and excites uterine contraction, the effect is quite frequently * Lazarewitch, "Trans, of the Obstet. Soc. of London," 1868. THE INDUCTION OF PREMATURE LABOR. 331 transient. To be sure, the action may be kept up by a succession of tents gradually increasing in size, but such a plan denudes the cervix of its epithelium, and is apt to lead to septic infection. The Barnes dilator is a most efficient aid in cases of induced labor. As, for the introduction of the smallest-sized bag, the cervix requires to be sufficiently expanded to permit the passage of at least two fingers, it is useful chiefly as an adjuvant to other plans of treatment. When labor has fairly begun, however, the fluid pressure of the dilator upon the cervix serves to strengthen the uterine action. When left in situ, the instrument insures the development of good pains. It should, however, be removed from time to time, if not forcibly expelled into the vagina, and carbolized injections should be employed to prevent infection. So soon as the physiological softening of the cervix which results from labor has been effected, rapid dilatation can be advanta- geously employed. When the cervix is rigid, the rubber-bag is only useful as a reflex exciter of pains. To be sure, the rigid cervix can be forcibly dilated to almost any extent by hydrostatic pressure, but, as a rule, it closes down to its original dimensions so soon as the pressure is removed. Tarnier has devised a bag which can be passed upward through the cervix and distended in the lower uterine segment. It serves to par- tially detach the membranes, and excites by its presence active uterine efforts. Its liability to rupture is the most serious objection to its employment. The Vaginal Douche. — The vaginal douche was introduced into practice by Kiwisch, in 1846. It consists in directing a stream of tepid water with considerable force directly against the cervix. The .stream may either be furnished by a Davidson's syringe, or a continu- ous current from a tube connecting with a vessel placed at an elevation above the patient may be used. The latter is the safer method. The large-sized fountain-syringe, made to hold a gallon of water, is a very convenient apparatus. The duration of each injection should be from ten to fifteen minutes. At the outset, three douches in the twenty-four hours suffice. Subsequently the frequency and duration should de- pend upon the degree of action excited and the urgency which exists for bringing labor to a close. Twelve are about the average number of injections required. In pressing cases they have been repeated as often as once in three to four hours. The temperature of the water employed should be about 106° Fahr. In using the douche the patient should be placed across the bed, and an India-rubber sheet should be so arranged under the hips as to convey into a vessel beneath the Avater as it escapes from the vulva. Every care should be taken to avoid the introduction of air into the vagina, and at the beginning of each douche precautions should be adopted to aid the escape of the fluid. The forcible pressure of 332 OBSTETRIC SURGERY. the stream has been known to drive air contained in the vagina into the cervix. The same accident has followed imperfection in the valves of the syringe. The douche acts by the warmth of the water, by stimulation of the lower uterine segment, and by dilatation of the vagina. After the douche has been continued for a time, the latter is sometimes dis- tended so as to be nearly in contact with the pelvic walls. The vaginal douche as a means of inducing labor has of late years fallen somewhat into disrepute. Its chief recommendation was the supposed harmlessness of the procedure—a precious quality, to which in reality it appears, however, to possess little claim. Numerous cases have been reported where death has followed the accidental introduc- tion of air, and sharp peritoneal symptoms, according to Kleinwach- ter,* have been known to result from the excessive distention of the vagina. The dangers referable to the latter cause increase with the repetitions of the douche. At present its employment is generally restricted to the preliminary dilatation of the os, or to the sustaining of the action of other measures. The Vaginal Tampon.—Braun introduced an India-rubber bag, furnished with a tube and a metal stopcock, Avhich, under the name of the colpeurynter, played a considerable role in obstetrical practice some dozen or more years ago. When filled with water in the vagina, it formed a painful and rather uncertain mode of inducing labor. It is now rarely employed except in haemorrhage and where it is desired to prevent premature rupture of the membranes. Care should be taken to only moderately distend the vagina, and not to continue the pressure for any lengthened period of time. Choice of Methods.—From the foregoing it will be seen that no one of the different proceedings mentioned is entirely free from objection. Aside, however, from infection, a danger more especially dreaded in maternity hospitals, and the avoidable accident of driving air into the veins, the most serious difficulties against which we have to contend arise from the tardy dilatation of the os and the prolongation of labor. Any of the methods are good if only they act speedily. It is advisable, therefore, in practice to follow the excellent advice of Dr. Barnes, and divide the induction of premature labor into tAvo stages, in the first of which provocative, and in the second of which accelera- tive, measures should be adopted. In the former category should be placed the dilatation of the cervix with sponge-tents, the vaginal douche, and the catheterization of the uterus ; in the latter, dilatation of the cervix with the rubber bags, rupture of the membranes, and, in case of delay, delivery with forceps or by version. The plan I have generally followed consists in beginning in the af- ternoon with the vaginal douche, and folloAving with the introduction * Kleinwachter, " Prager Viertcljahrschrift," 1872, Heft i, p. 56. THE INDUCTION OF PREMATURE LABOR. 333 of a solid bougie, to be left in the uterus overnight. In many cases labor is excited in the course of a few hours. In the morning, if the process is delayed, the vaginal douche is repeated. There are few cases in which, toAvard the end of the twenty-four hours, the cervix is not found softened and well lubricated with mucus. The dilators should then be employed, the operator taking his time, as permanent dilata- tion is the object sought after. If the membranes come down well, the dilator may be removed and the progress of the case left to Nat- ure. Often it is advisable to adopt the plan of Dr. Barnes, ruptur- ing the membranes when the cervix will admit three or four fingers, and then dilating Avith the large-sized bag until the uterus is opened fully for the passage of the child. Finally, according to the condi- tions present, the physician may either await the termination of the labor, or deliver by version or by lightly constructed forceps. Care of the Child.—Premature infants possess slight powers of re- sisting external agencies. They should immediately after birth be placed in warm cotton and kept near the fire. The customary baths should possess a temperature of about 100° Fahr., or very nearly the temperature of the amniotic fluid. The chances of raising premature infants are greatly enhanced by feeding them upon the mother's milk, which should be given by the spoon when the child is too feeble to take the breast. Before the thirty-second week the preservation of the infant's life depends almost entirely upon the unremitting watch- fulness and zeal of a devoted nurse or mother. In hospitals, where these conditions fail, success in raising very premature children is of rare occurrence. Artificial Abortion. Artificial abortion is justifiable whenever it offers the only hope of saving the life of the mother. The morality of this general proposi- tion is unquestioned. It is not, however, by any means easy to deter- mine in a specified case whether the requisite conditions which render the induction of abortion a duty really exist. The principal recognized causes for the operation which admit of little dispute are : 1. Incarceration of the prolapsed or retroflexed uterus when the dislocated organ can not be replaced. 2. Diseases of pregnancy Avhich immediately imperil life, and which have been vainly combated by all the resources at our disposal. Of these diseases the most prominent is uncontrollable vomiting. Exceptionally the indi- cation may arise in affections of the heart, lungs, and kidneys, where the symptoms are acute and peculiarly threatening. The justifiability of abortion is, however, by no means so clear when the danger to the mother first arises after labor has actually begun. This is specially the case in extreme degrees of pelvic con- traction, or where the presence of large tumors renders the parturient canal impassable, as in these cases, by means of the Caesarean section, 334 OBSTETRIC SURGERY. there is always a probability of saving the life of the child, with a fair prospect of preserving the existence of the mother. It is considered right, under such circumstances, after a dispassionate and colorless statement of the facts, to leave the decision to the mother and the friends more immediately interested. When the operation is per- formed for contracted pelvis, the following figures will show at how late a period it may be undertaken : Antero-posterior diameter of pelvis. Latest period for inducing abortion. 1£ inch. Beginning of sixth month. li inch. Beginning of fifth month. 1 inch. Four months and a half. With less than an inch the difficulties of inducing abortion increase to such a degree as to make the operation rarely advisable, or indeed even practicable.* The induction of abortion is accomplished by puncturing the mem- branes with a uterine sound, or by dilatation of the cervix with a sponge-tent. In the early months the sponge-tent possesses the ad- vantage of promoting the expulsion of the OArum entire. In the sixth and seventh months the same means are available that have been described in connection with the induction of premature labor. As to the choice of time when the operation should be performed, opinions differ. Some prefer the first two months, on account of the small size of the ovum, and the slight development of the fetal tufts at the decidua serotina. Others wait till the first three or four months have expired, as the diagnosis of pregnancy is then certain, the execu- tion of the operation easy, and the detachment and expulsion of the fetal appendages more complete. CHAPTER XIX. FORCEPS. History.—Varieties of forceps; short forceps, long forceps.—Action of forceps.—Indica- tions.—Preparations.—Forceps at outlet.—Operation; introduction; locking; trac- tions ; removal.—Forceps at brim ; operation.—Axis-traction forceps.—Forceps in occipito-posterior positions; in face presentations. History.—In 1647 Peter Chamberlen speaks, in a pamphlet written by himself, of a discovery made by his father, Paul Chamberlen, for saving the lives of infants during childbirth. The measure in the possession of the Chamberlens was, however, withheld from the pro- * De Soyre, " Dans quels cas este-il indiquS de provoquer l'avortement ? " Paris, 1875, p. 68. FORCEPS. 335 fession, and utilized purely as a means of gain. In the early part of the year 1670, Hugh Chamberlen, who enjoyed a great reputation as an accoucheur, went to Paris in the hopes of finding a purchaser for the family secret. Mauriceau, to test the value of Chamberlen's pre- tenses, suggested that the latter should attempt the delivery of a woman with extreme contraction of the pelvis, upon whom he had previously decided to perform the Caesarean section. Chamberlen de- clared that nothing could be easier, and at once, in a private room, set about the task. After three hours of vain effort he was obliged to acknowledge his defeat. The woman died ; the negotiations for sale were dropped ; and Chamberlen returned with his secret unrevealed to England. In 1672 Chamberlen published a translation of Mauriceau's work upon midAvifery, in the preface of which he states : " My father, brothers, and myself (though none else in Europe as I knoAv) have, by God's blessing and our own industry, attained to and long prac- ticed a Avay to deliver women in this case without any prejudice to them or their infants, though all others (being obliged, for want of such an expedient, to use the common way) do or must endanger, if not destroy, one or both with hooks." In 1688 Hugh Chamberlen went to Amsterdam and sold his secret to Roenhuysen for a large sum, who in turn disposed of it to Ruysch and others, and, as late as 1746, it was the rule of the Medico-pharmaceutical College, at Amsterdam, that no one should practice midwifery without first obtaining the se- cret measure, which was imparted by their examining body for a heavy money consideration. In 1753 Jacob de Vischer and Hugo van de Poll, who had acquired the secret from the daughter of a former pos- sessor, made it public property, but the instrument turned out to be the single-bladed vectis. Whatever doubts, however, this exposure may have cast upon the nature of the Chamberlen secret were set at rest, in 1815, by the discovery in a former residence of the family, in Woodham, in Essex, of a chest containing, besides letters and a variety of patterns of the vectis, a number of pairs of forceps, fenestrated, without a pelvic but with an excellent cephalic curve. Moreover, Chapman, in a short treatise upon midAvifery, published by him in 1733, stated that "the secret mentioned by Dr. Chamberlen was the use of forceps, now well known to the principal men of the profession both in town and country." And two years later, in a second edition of his work, he published an engraving of the instrument, which be- came known as Chapman's forceps, though it did not differ from the one used by the Chamberlens. Since Chapman's publication, the modifications made in the for- ceps by obstetric practitioners have been exceedingly numerous. In- deed, nearly every man widely engaged in midwifery practice finds it convenient to possess his own forceps. With few exceptions, however, the various patterns described by authors do not differ materially as 336 OBSTETRIC SURGERY. regards essential principles, but have each some peculiarity of con- struction which fits them to supplement a personal defect of the con- triver, or to meet some special indication. The forceps is by no means a perfect instrument. It is impossible to construct it in such a way as to cover every need. In consulting practice, it is convenient to possess a number of forceps for different emergencies. A good pair for general use is necessarily a compromise between conflicting aims, and requires, for successful use, experience and intelligence to correct its deficiencies. In selecting forceps it is well to bear the following points in mind : We have first to distinguish between the long and the short forceps. Short Forceps.—The original instrument of the Chamberlens fur- nishes the type of the short variety. By referring to Fig. 147, it will be seen that the Chamberlen forceps consisted of two levers, made to cross each other like a pair of scissors, with short handles, and blades diverging just beyond the point of articulation. The blades were fenestrated to lighten the instrument, and to enable them to seize the head with greater security. They were furnished with a cranial curve, as has been stated, but were straight when viewed in profile. Though somewhat rude in ap- pearance, they were capable of rendering good service when the head had once entered the pelvic cavity. Smellie, in place of the mortise lock of the Chamberlen forceps, which required to be se- cured by tape or cord, invented the easily ad- justed English lock, and covered the handles with wood and a durable coat of leather. The handles were five and a half inches in length, and the blades six inches. Short forceps, mod- ified someAvhat from the Smellie pattern, are used by some practitioners at the present day. It has been thought an advantage that they can be concealed in the pocket, and slipped over the child's head without the knowledge of the patient or of the assistants. Smellie laid great stress upon this point, and says, "As women are commonly frightened at the very name of an instrument, it is advisable to conceal them as much as possible until the character of Fig -Forceps of Cham- berlen. Fig. 148.- Forceps of Smel- lie. FORCEPS. 337 the operator is fully established." In these enlightened days, how- ever, secrecy is no longer advisable. Indeed, the forceps ought never to be used without such exposure of the vulva as will enable the opera- tor to exercise every precaution for the preservation of the perinaeum. Long Forceps.—Smellie tells us he found, in pelves with jutting-in of the sacrum, that he could not push the handles far enough back- ward to include between the blades the bulky part of the head, which lay above the pubes. He, therefore, to reme- dy this inconvenience, contrived a longer pair, curved on one side, and convex on the other. Thus, at an early period the necessity for long forceps was experi- enced. Smellie was deeply impressed, hoAv- ever, with the dangers of high forceps opera- tions, and sought to di- minish the risks inci- dental to them by mak- ing the handles short to free himself, as he said, from the temptation of using too great force. Levret, on the con- trary, contemporane- ously with Smellie, con- verted the forceps of Chapman into a power- ful tractor and compres- sor. He retained the iron handles, but rough- ened the surfaces, and made them slightly convex, to adapt them to the palms of the hand. The articulation was effected by means of a pivot and a mortise. The chief peculiarities, however, consisted in the weight and the length of the instrument and in the extent of the pelvic curve. So far from these features pnmng objectionable, they have been substantially retained in modern French instruments. The forceps of Smellie and Levret are the two type-forms from which are derived the great number of the models in vogue at the present day. 22 Fig. 149.—Levret's forceps. 338 OBSTETRIC SURGERY. The Naegele forceps, extensively used in Germany, in its main features resembles the instrument of Smellie. It is, however, two inches longer, and there is less dis- proportion between the length of the handles and the blades. The upper part of the handles is fur- nished with transverse shoulders, hollowed out for the index and middle fingers of the hand which exerts the traction force. The lock is that of Bruninghausen, and con- sists of a pivot, surmounted by a flat button, which fits into a notch upon the opposing blade. The Simpson forceps possesses a relatively short handle, with transverse shoulders, and indenta- tions for the fingers of the under hand. The English lock is im- proved by the addition of knees or projections to diminish its mobili- ty. The cephalic curve, in place of starting at the lock, is carried away two and three eighths inches by straight, parallel shanks, an arrangement which makes it possible to lock the instrument outside the vulva even when applied to the head at the brim, and which enables the operator to bring the head to the floor of the pelvis without placing the vulva upon the stretch. The pelvic curve does not exceed one inch and a half. I have been in the habit of recom- mending this forceps to my classes of medical students on account A B < Fig. 150.—Naegele's forceps. Fig. 151.—Simpson's forceps. of the ease with which it can be applied, its solidity, and the slight markings it leaves, under ordinary circumstances, upon the child's head. It is, however, defective in compressive power, when such action is necessary.* * The instrument makers of this city are accustomed to make for me an instrument exactly copied from a pair of forceps brought by me from Edinburgh in 1865. Many of FORCEPS. 339 The forceps of Hodge, of Wallace, and of White, are extensively used in this country. Like those of French make, they have metal handles, and a lock composed of a movable pivot, which slips into a notch at the moment of adjustment. They are, however, much lighter and of more graceful outline. The shanks are long and su- Fig. 152.—Hodge's forceps. perimposed. The blades are provided with Avide fenestrae, through which the parietal bosses are intended to project. I have tried each of these instruments, and, though I cling to Simpson's forceps from habit, have found them extremely serviceable. Finally, in choosing forceps, it is well to remember that, if there are none which are absolutely perfect, there are few Avhich are really poor. Objectionable features are very short handles and thin, springy blades, with sharp-cutting edges. A good pair of long forceps ren- ders the possession of short forceps a superfluous luxury. Action of the Forceps.—The forceps is primarily and essentially a tractor. When properly adjusted, it serves as a handle by means of which the head can be withdrawn from the parturient canal. Many excellent operators are in the habit of combining Avith direct traction a side-to-side swaying of the forceps-handles with a view of determin- ing the alternate descent of the lateral surfaces of the cranial vault. No doubt these so-called pendulum movements increase the extractive power of the forceps. The increase is, however, obtained at the expense of the maternal tissues. They should, therefore, be discountenanced. As to the efficiency of direct tractions, I am able to speak from ex- perience. At first insisted upon by the Vienna school, they have found warm adA'ocates in MattheAvs Duncan,* of London, and Albert Smith,! of Philadelphia. The crossing of the forceps at the lock renders it impossible to the forceps bearing Simpson's name in this country have only a faint resemblance to the original model. * Duncan, " Against the Pendulum Movement in working the Midwifery Forceps," " Trans, of the Obstet. Soc. of Edinburgh," vol. iv, p. 195. ■)• Smith, " The Pendulum Leverage of Obstetric Forceps," " Trans, of the Am. Gy- nsec. Soc," vol. iii, p. 235. 340 OBSTETRIC SURGERY. resort to traction without, at the same time, exercising compression upon the child's head. When the forceps is applied laterally over the parietal bones, moderate pressure is harmless to the child, and undoubtedly facilitates in some degree the act of delivery. When the head is high in the pelvis before rotation is completed, the lateral application is rarely possible. If the forceps is applied obliquely with one blade over the side of the broAV, and the other over the side of the occiput, bulging takes place in the opposite oblique diameter—a result which tends to retard rather than to aid extraction. Nevertheless, even at the brim some compressive force is necessary to seize the head solidly, and to avoid slipping of the blades. When the blades of the forceps are introduced Avithin the uterus, contractions are apt to be excited. This so-called dynamic influence, though an ancillary property of the instrument, is often of consider- able service in aiding delivery. Indications.—It would be an unprofitable undertaking to enumerate all the conditions which render forceps advisable. The indications for their use may be summed up in two general propositions. The forceps is applicable—1. In cases where the ordinary forces operative during labor are insufficient to overcome the obstacles to delivery ; 2. In cases where speedy delivery is demanded in the interest of either mother or child. Both these propositions are, however, subject to the limitation that, in the selection of the mode of delivery, choice should be made specially with reference to the maternal safety. Fortunately, in the great proportion of cases the interests of both mother and child are identical. Preparations for Forceps Deliveries.—When it has been decided to deliver by forceps, it is a good plan always to place the patient cross- wise in bed, Avith the head raised by a pillow, and with the hips well over the edge of the bed. To be sure, many prefer, in simple cases, to disturb the patient as little as possible, and pride themselves upon being able to slip in the forceps and deliver without the seeming of an opera- tive procedure. This trifling advantage is, however, more than coun- terbalanced by the increased risk of injuring the vulva and perinaeum, when the operator is compelled to assume a constrained or awkward position. In this country, as in France and Germany, it is customary to place the patient upon her back, whereas in England she is made to lie upon her left side. The difference is not material. In the descrip- tion to follow it will be assumed that the dorsal position is the only one likely to be selected. At the beginning it is well, in most cases, to bring the patient well under the influence of an anaesthetic. This I am accustomed to do before changing the patient's position. In easy cases the accoucheur FORCEPS. 341 can administer the anaesthetic before operating, and then leave the con- tinuance of the chloroform- or ether-giving to any intelligent bystander Avho acts under his supervision. In difficult cases, hoAvever, it is better to send for a skilled.assistant who is capable of taking entire charge of the anaesthesia, that the operator's attention may not be diverted from the work he has in hand. Before applying the forceps care should be taken to ascertain the position of the head, and to make sure that the membranes have freely ruptured. Forceps applied directly to the membranes might do harm by causing a premature detachment of the placenta. The position of the os and the degree of its dilatation should likewise be determined. In excessive anteversion the head sometimes bulges out the anterior wall of the cervix, and tfcins the cervical tissues to such an extent that the sutures, the fontanelle, and contour of the head, can be distinctly felt, as though the head had entered uncovered into the vagina * whereas, in fact, the undilated os is situated high up, and with care may be found looking backward in the direction of the sacrum. It is only necessary to indicate the possibility of such a source of error to insure the caution necessary for the avoidance of forceps applications to the cervix. As a preliminary to all obstetrical operations, both bladder and rectum should be emptied. The blades of the forceps should be dipped in warm water to remove the chill from the steel, and should be smeared with some oily substance to reduce to the minimum the friction produced by their passage into the utero-vaginal canal. Practically it is important to distinguish between forceps opera- tions at the brim and those conducted after the head has entered the cavity of the pelvis. The latter are simple, safe, and easy of accom- plishment, requiring only skill in the management of the perinaeum ; while the former belong in the category of capital operations, and call for a large degree of patience, experience, and obstetrical tact to bring to a successful issue. Forceps at the Pelvic Outlet.—The special indications for for- ceps when the head is low in the pelvis are so-called rigidity of the perinaeum, stenosis of the vaginal orifipe, and conditions demanding speedy delivery. The condition termed rigidity of the perinaeum is usually the sign of failing uterine action. So long as the labor-pains are good, the ex- [ ternal parts progressively soften and relax in preparation for the ad- vancing head. If after the head reaches the floor of the pelvis the pains lose their expulsive character, the perinaeum may be rigid simply because the ordinary physiological forces which induce softening are absent, or, in case softening has already begun, the perinaeum may become rigid from the sustained pressure to which it is subjected. In either contingency intermittent tractions made with forceps, in 342 OBSTETRIC SURGERY. imitation of the natural mechanism, is the speediest and safest method of overcoming the resistance of the soft parts. Stenosis of the vulva is sometimes the result of old cicatrices. Oftener it is found where there is faulty direction of the child's head, the vertex bulging the perinaeum in place of serving as a dilating wedge to the vulval orifice. The danger of central perforation of the perinaeum is best averted by applying forceps and bringing the occi- put well forAvard under the arch of the pubes. The commonest condi- tions demanding speedy delivery are convulsions, exhaustion, and fe- brile disturbances in the mother, and dangers threatening the life of the child. It is, however, of great importance to keep in mind the relation that the prolongation of the second stage of labor bears to these very dangers. So long as the head advances through the par- turient canal by regular progression, the vagina pours out an abundant secretion of mucus and relaxation takes place. If the advance of the head is arrested from the dying out of the pains, or from other causes, the continuous pressure exercised by the head upon the soft parts pro- duces venous stasis, oedema, disappearance of the secretion, and final- ly inflammatory infiltration. The genitals become therefore hot, dry, swollen, and friable, the intensity of the symptoms depending upon the more or less close adaptation of the head to the bony walls of the pelvic cavity. It is easy to understand that with these conditions the temperature rises and the pulse becomes frequent; if the urethra is compressed, retention of urine with convulsions may follow ; while, as after-results, we may have phlegmasiae extending to the pelvic cellular tissue and thence to the peritonaeum. Pressure too long continued can produce necrosis, and, as sloughing occurs, vesico- and recto- vaginal fistulae. At the same time there is reciprocal pressure exer- cised by the bony walls upon the child's head, and close retraction of the uterus upon the foetus. The first cause may lead to retarded heart- action and intra-cranial extravasations of blood; Avhile the second is a fruitful source of asphyxia, owing to the diminution of the maternal blood-currents Avhich circulate through the placenta. In vieAv of the foregoing, it will be seen that forceps is not alone indicated in the presence of perils fully deA'eloped, but is of still greater service as a prophylactic against the dangers of an unduly lengthened second stage. It is in vain to lay doAvn well-defined rules as to the precise time at which the forceps should be applied. Formerly it Avas advised to wait for the advent of a thin, reddish-brown discharge. As the latter simply consists of serum commingled Avith blood from overstrained capillaries, it furnishes a sign that delivery has been delayed too long. Some counsel applying forceps two hours after the completion of the first stage of labor, and proclaim longer waiting a useless barbarity. Clearly, however, it is not so much the length of the second stage of FORCEPS. 343 labor Avhich furnishes the indication for forceps, as the degree of the reciprocal pressure exercised between the head and the pelvis. A val- uable index to this pressure is furnished by the caput succedaneum. In the second stage, a scalp tumor of large circumference can only be produced by the circle of the bony pelvis. Such a tumor, increasing in size, without any evidence of progress in the delivery, is a signifi- cant evidence of pressure, and furnishes, therefore, the most reliable indication for forceps. Whether the ease with which forceps can be applied at the outlet and the safety which attends its employment justify its use as a Fig. 153.—Introduction of blades. means of saving the physician's time, or the patient from an addi- tional half-hour of suffering, are questions which are at least de- batable. I can only say that, with increasing experience, my own practice has groAvn more and more conservative, and my OAvn belief is that true wisdom requires us to abstain from even trivial oper- ations so long as Nature is able to do her work Avithout our assist- ance. 344 OBSTETRIC SURGERY. The operation consists of four acts, viz.: 1. Introduction of the blades ; 2. Locking ; 3. Tractions ; 4. Removal of the instrument. Introduction of Blades.—In introducing the forceps, each blade, if a long one with pronounced pelvic curve, should be seized like a pen near the lock, and should be held nearly vertically, with the ex- tremity in correspondence with the slit-like opening of the vulva. In the Simpson forceps, which possesses only a moderate pelvic curve, the handle should be lightly grasped in the half hand, and held at the outset nearly parallel to Poupart's ligament. Owing to the ar- rangement of the lock, the left blade should be passed first. The handle should accordingly be held in the right hand, Avhile two or three fingers of the left hand, inserted betAveen the head and the vagina, serve to guide and guard the point during its introduction. The passage of the blade should take place only during the intervals between the pains. It is customary to pass each blade at first oppo- site the sacro-iliac articulation, and then to change the direction as required, after the point has reached the linea terminalis. In introducing the forceps-blades, the two curves of the instrument should be borne in mind. By directing the handle toward the thigh of the mother which corresponds to the blade, the latter is made to glide over the convex surface of the child's head; by sinking the handle, the pelvic curve folloAVS the axis of the pelvis. The two move- ments should be made slowly, but simultaneously, and under the guid- ance of the inserted fingers. But slight force is necessary. The point Fig. 154.—Blade adjusted to the head at outlet. of the blade should impinge rather upon the fingers than upon the child's head. When the left blade is in place, the handle should be lowered and intrusted to an assistant. The right should be intro- FORCEPS. 345 duced on the right side, under the guidance of tAvo to three fingers of the right hand, in accordance with the same general rules. The cephalic curve of the forceps is intended to correspond to the lateral surfaces of the child's head. When the rotation of the occiput under the symphysis is complete, it is only necessary to sink the han- dles to make the blades assume the natural position over the parietal bosses. If the head is still in an oblique diameter, the forceps should be applied in the opposite oblique diameter. When, therefore, the oc- ciput is left anterior, the left blade should be alloAved to remain oppo- site the sacro-iliac articulation, while the right blade, by sinking and at the same time rotating the handle, is swept forward to the right ace- tabulum. If the head is right anterior, the left blade is at once swept forward toAvard the left acetabulum, while the right blade is allowed to remain opposite the sacro-iliac articulation. If the sagittal suture occupies the transverse diameter, the forceps should be applied in the oblique diameter of the same name as the side toward which the fore- head is turned. This is best accomplished by first applying the forceps in the usual Avay; then, leaving the occipital blade in the excavation to the side of the promontory, with the guiding fingers inserted into the vagina, direct the frontal blade forward toAvard the acetabulum. Dur- ing this manoeuvre the handle should be held loosely. The forceps will seize the head very nearly between the anterior frontal and the opposite posterior parietal protuberance. The direct application of the forceps to the sides of the head, Avith one blade beneath the sym- physis and the other opposite the promontory, is sometimes practica- ble, but is undeserving of commendation.* LocJcing.—When the occiput is rotated to the front, and the blades are applied to the sides of the head, locking is a very simple matter. The handles should be grasped in the full hand, with the thumbs directed upAvard. Coaptation is secured by slight movements of the blades as the operator sinks the handles dowmvard. When the head is transverse it is often, on the contrary, difficult to bring the separate parts of the lock in apposition. Under such circumstances no force should be used, but the blades should be with- drawn a little, and the attempt made to adjust the lock by gentle moA*ements in reintroducing them. After locking, a tentative traction should be made to ascertain Avhether the head is seized securely. In bringing the blades together, some caution should be observed lest the hair of the pubes, or the labia, become included. * The application of the forceps to the sides of the pelvis, without reference to the position of the child's head, has many warm advocates. That the head can be delivered in this way is beyond all question. These so-called direct applications I practiced exclu- sively for some years, and it was only gradually that I became convinced of the superi- ority of the methods the description of which has been given. 346 OBSTETRIC SURGERY. Tractions.—The instrument should be seized with the right or stronger hand, with the back of the hand turned upward. In forceps Fig. 155.—Method of making tractions. provided with transverse shoulders, the index-finger should be placed over one shoulder, and the remaining fingers over the other. The left hand, with the palm upward, seizes the handles from below and aids in extraction. When the handles are far apart, the index-finger of the left hand should be introduced into the vagina from time to time, to determine the position of the forceps-blades, and to estimate the amount of pressure upon the child's head during tractions. Steady tractions are preferable to pendulum or rotary ones. Trac- tions are most effective when made during a pain. This is specially the case when the rotation of the head is incomplete. However, in the absence of pains, it is often necessary to use the forceps as a substitute for, instead of a reenforcement of, the propulsive action of the uterus. Pressure through the abdominal Avails upon the uterus, made by a skilled assistant during tractions, is here, as in other obstetrical opera- tions, an adjuvant of great value. Tractions should not be too pro- FORCEPS. 347 longed. When not made in unison with the pains, they should not exceed one to two minutes in duration. The head should then be alloAved to recede. Haste in delivery exposes the patient to the dan- gers of laceration and post-partum haemorrhage. The alternate de- scent and recession of the head soften the external parts, and are the best means of overcoming rigidity. As the head advances, time should be given for the uterus to retract upon its contents, for, Avhen the pains are deficient, retraction after the sudden emptying of the uterus is apt to be imperfect or of short duration. Tractions should at first be made doAvmvard, until the head has descended below the symphysis pubis ; they should then be made in an horizontal direction until the occiput appears at the vulva. When in doubt about the direction, the handles should be held loosely during a pain, to serve as an index of the proper line of traction. If rotation has not previously taken place, it may be aided by the forceps, though rotation usually occurs spontaneously as the head descends. If the head Avas transverse, the forceps requires to be readjusted after rota- tion, either by removing it and then reapplying it, or by sinking the handle of the posterior blade and raising the handle of the anterior one. When the parietal bosses are in the act of passing through the vulva, tractions should no longer be made during the pains. The Fig. 156.—Position of operator when head is on perinaaum. 348 OBSTETRIC SURGERY. operator should stand to the right of the patient, and seize the handles in the left hand. During the intervals of a pain, by alternately sink- ing and raising the handles, the perinaeum and vulva can be gradually dilated. So soon as the convexity of the perinaeum is marked, and the parietal bosses press upon the commissure, it is better to sink the handles during a pain, so as to flex the head to its greatest extent, and cause the vertex to present. When the vulva is sufficiently dilated, it is only necessary to raise the handles toward the abdomen to complete the extrusion of the head, and finish the delivery. Removal.—Although not generally recommended, it is always my custom to remove the forceps so soon as the chin can be reached by the index-finger introduced into the rectum. The extrusion of the head, if it does not occur spontaneously, can then be easily effected, and the blades of the forceps, though of no great thickness, still add something to the distention of the vulva. The removal is accomplished by un- locking and reversing the direction the handles followed in their intro- duction. To avoid compressing the soft parts against the rami of the pubes, I am accustomed to place two fingers of the unemployed hand upon the upper border of the blade, and use them as a fulcrum around which the blade should be rotated. Forceps at the Brim.—The safe conduct of the head through the pelvic brim by means of the forceps is an achieA'ement which requires an accurate appreciation of the dangers to be avoided and the difficul- ties to be overcome. The forceps as a means of accelerating delivery is sometimes called for when the head is at the brim in cases of acci- dental haemorrhage, of placenta praevia, of eclampsia, of pelvic ob- struction, and in failure of uterine pains. So long, indeed, as the head is movable at the brim, and version is practicable, the latter operation furnishes the safer mode of deliArery. After the waters haA-e drained away, and retraction of the uterus ren- ders version impossible, a tentative application of the forceps may be made to test the adaptability of the head to the pelvic canal. Persist- ent attempts to drag the head into the pelvis by brute force, after moderate tractions have failed to effect an adA-ance, should be regarded as criminal, exposing as they do the maternal tissues unavailingly to injuries which are always serious, and which may prove fatal. When, however, the head has become fixed, Avhich does not occur until after the engagement of its largest circumference, the difficulties of forceps operations are greatly diminished. Still, dangers to the mother arise from the fact that the blades lnove to be passed into the lower segment of the uterus, where, oAving to the extreme vulnerability of the uterine tissues, lesions are only to be avoided by the patient carrying out of a multitude of precautionary measures ; to the child, from the rarity of the occasions which permit the blades to be applied to the sides of the head, to which the cephalic curve is alone adapted. FORCEPS. 349 Operation.—In introducing the forceps, the tips of the fingers of the guiding hand should be inserted between the child's head and the cervix. In this way we insure the entrance of the extremities of the blades into the uterus in place of into the cul-de-sac of the vagina. It is generally customary to apply the forceps to the sides of the pelvis, without reference to the position of the child's head. As a rule, under the conditions mentioned, the head will be found to have been seized obliquely—i. e., with the posterior blade over the parietal boss, and the anterior blade near the coronal suture. Thus applied, close approximation of the handles is impossible, and the tips are Fig. 157.—Forceps applied to head at brim. correspondingly separated from one another. Considerable compres- sion of the handles is necessary, therefore, to prevent the instrument from slipping, the degree of pressure depending naturally upon the extractiAre force requisite to advance the head. The adjustment of the lock often requires considerable patience, and sometimes the exercise of moderate force is necessary to bring the parts into juxta- position. Even when the instrument has been applied according to the strict rules of art, it will be found not infrequently that the upper border of the anterior and the loAver border of the posterior blade will project beyond the tissues of the scalp, and, unless managed with care, the exposed edges are liable during extraction to cut deeply into the soft structures of the parturient canal. 350 OBSTETRIC SURGERY. When the cervix is only partially dilated, the forceps should be em- ployed, not as an extractive instrument, but simply to bring the head into the cervical canal to act as a dilating Avedge, by means of Avhich the gradual and safe expansion of the os may be accomplished. If the head be made to descend and then allowed to re- cede at short intervals between the pains, in time the cervix will be found to soften and yield in the same manner as a rigid perinaeum ; whereas the resistance of an und dated cervix can only be overcome, when violent tractions are made, by the production of lacerations extending to, or even above, the vaginal junction. In seeking to effect dilatation of the cei*A*ix through the forceps, the utmost caution should, howeA'er, be observed. At short intervals the finger should be slipped into the vagina to note whether the tension of the cervix is raised during tractions to danger- ous proportions. Especial attention should be paid to the condition of the parts during a pain, as, when the uterus contracts, the os externum, Avhich previously was soft and dilatable, frequent- ly forms a sharp, resistant border. Dr. I. E. Taylor has devised a long, narrow- bladed pair of forceps, capable of introduction through a cervix measuring one and a half inch in diameter, which he has used with advantage in the manner above described at a very early stage of labor. In cases Avhere it is necessary to expedite de- livery, the resistance of the incompletely dilated os may be overcome by a number of incisions about one fourth of an inch in depth, made with a blunt-pointed bistoury passed between the cer- vix and the child's head. It is very rare, how- ever, that this otherAvise trivial operation is really called for. In drawing the head through the superior strait, the tractions should be made, as nearly as the perinaeum will permit, vertically down- ward. In doing this, however, care must be taken lest the pelvic curve be brought so far forward above the symphysis pubis as to subject the ma- ternal tissues to injurious pressure. On the other hand, it is nec- essary not to prematurely raise the handles of the forceps, as, in that case, the head is simply crowded forcibly against the anterior pel- Fig. 158.—Taylor's nar row-bladed* forceps. FORCEPS. 351 vie Avail. The best means of avoiding these two difficulties is to ex- ercise great patience, and be content Avith a very gradual advance of the head, as, by omitting anything like rude force, the risks arising from misdirected tractions are kept within the limits of safety. Many, indeed, seek to prevent the anterior pressure of the forceps, by placing the left hand upon the lock, and using it as a fulcrum around which rotation of the instrument is effected. As the right hand has then to be employed at the same time to make tractions and to raise the handles, the method requires both strength and expertness to be suc- cessful. In all high operations where the cervix is sufficiently dilated, I can not too strongly recommend the ingenious forceps of M. Tarnier, which, by its construction and action, obviates to a great extent the foregoing objections to the more familiar models. M. Tarnier's forceps possesses two original features : 1. The shanks, in place of running forward continuous Avith the pelvic curve, are bent backward, so that the handles, when placed horizontally, lie about three and a half inches above the plane of the posterior curve of the blades. This Tarnier curve makes it possible to bring the blades well forward in the sides of the pelvis without subjecting the soft parts above, or the perinaeum below, to pressure. A transverse screAv, cross- ing the handles beloAv the lock, approximates the blades to the sur- faces of the child's head. 2. Two movable traction-rods are attached to the lower cun'ature of the blades. These rods are curved to corre- spond to the lower border of the shanks, to which, when not in use, they are affixed by projecting pegs. When the instrument is adjusted, the outer ends of the traction-rods are detached and inserted into a socket-joint belonging to a strong steel bar with a downward curve, and furnished Avith a transverse handle which can be moved in any direction by means of a universal joint. Tractions are made by means of this transverse handle alone. As the head descends, the handles proper rise upAvard and serve as an index to sIioav the direction in which the force should be exerted. By simply raising the traction-rods in a line with the curved shanks, the blades of the forceps swing always in the transverse diameter, and the head follows as nearly as possible the axis of the pelvis. To one accustomed only to the familiar forceps, the facility with Avhich delivery can be accomplished by Tarnier's in- strument Avould seem hardly credible. Mr. Stohlmann has modified for me the original forceps of Tarnier by making the blades much lighter, modeling them somewhat after those of the well-known instrument of Wallace. This alteration makes their application, especially in contracted pelves, or through an imper- fectly dilated os, a much easier matter. In place, too, of the very clumsy socket-joint into which the traction-rods are inserted, he has substituted the key arrangement shoAvn in Fig. 159, by means of which 352 OBSTETRIC SURGERY. the handle can be adjusted or removed in a few seconds of time. These improvements do aAvay, to a great extent, with the unhandiness of the older model. Fig. 159.—Author's modification of Tarnier's forceps. As the solidity of the shanks prevents the blades from springing, the amount of pressure upon the head requisite to keep the instrument from slipping has been found in practice not to prove an element of danger to the child. When the head has been brought to the floor of the pelvis, unless the occiput has previously turned to the front, it is a good plan to re- move the forceps and Avait a little while to allow spontaneous rotation to take place. Indeed, it is a question whether axis-traction forceps should be employed at all at the inferior strait. Unless accurately applied to the lateral surfaces of the child's head, the backward curve, so useful at the brim, is apt to cut deeply into the posterior vaginal wall as soon as the converging soft parts embrace tightly the advancing head. Forceps in Occipito-posterior Positions.—So long as the occiput looks to the rear, it is the rule in midwifery practice to refrain from the use of forceps, which, of necessity, prevents forAvard rotation from taking place. An exception to this rule, hoAvever, arises in cases of a near danger to either mother or child demanding speedy delivery. As attempts to rotate the occiput around to the symphysis by instru- mental means are rarely successful, it is advisable under such circum- stances to apply the forceps directly to the sides of the child's head, and to imitate during delivery the mechanism of labor in occipito-pos- terior positions. If the sagittal suture occupies an oblique diameter, the forceps should be applied in the opposite oblique diameter. As the head descends, the occiput should be turned into the hollow of the sacrum. At first, tractions should be made directly downward until the forehead has passed under the pubic arch, and the anterior fonta- nelle makes its appearance at the vulva ; then, by raising the handles, the small fontanelle should be brought forward to the commissure, and, finally, as the vertex emerges from the vulva, the handles should be FORCEPS. 353 slowly depressed to aid the movement of extension by which the delivery of the face and chin beneath the pubic arch is accom- plished. Forceps in Face Presentations.—"When the face is deep in the pelvis and the chin has rotated to the front, forceps applications are easy and do not differ materially from those in vertex presentation, except that care should be taken to direct the blades far enough backward to se- curely seize the occipital extremity of the child's head. Tractions should be made in an horizontal direction until the chin has been brought Avell under the symphysis pubis, when the handles should be raised to lift the cranial vault over the perinaeum. In oblique mento- anterior positions, Spiegelberg advises introducing first the blade cor- responding to the chin (posterior blade), as, in adjusting the second blade and locking the forceps, spontaneous rotation usually takes place. In deep transverse positions, forceps operations should be deferred as long as possible, as tardy rotation of the chin to the front is a physi- ological peculiarity in face presentations. The forceps should be ap- plied in an oblique diameter, Avith the concavity of the blades directed to the side of the chin. Chin right, introduce the right blade pos- teriorly, and bring the left blade forward to the left tuberculum ilio- pubicum. An effort should then be made to rotate the chin to the front. If the attempt prove successful, the forceps should be un- locked, and the blades readjusted to the lateral surfaces of the head. Tractions when the face is transverse should not be attempted. The wide separation of the blades makes it necessary to compress the han- dles firmly to prevent slipping. When this is done, pressure upon the neck and thorax is unavoidable, so that extraction without sacrificing the life of the child is hardly possible. In high transverse positions, forceps should not be used, as rota- tion is not then permissible, and the blades, applied to the neck and thorax on the one side and upon the cranium on the other, can not, for the reasons just given, be safely employed in extraction. The choice in such cases, when speedy deliA^ery is called for, lies between version and craniotomy. In mento-posterior positions, the rotation of the chin to the front; by repeated applications of the forceps is inadmissible. In practice, such efforts do not succeed, while they are calculated to inflict injury upon both the mother and the child. Usually, if delivery becomes necessary because of danger to the mother, craniotomy should be re- sorted to. Smellie, Hicks,* and Braun, of Vienna, have, hoAvevTer. each reported a case of forceps delivery by drawing the chin down OA'er * Hicks, " On Two Cases of Face Presentations in the Mento-posterior Position," " Trans, of the Obstet. Soc. of London," vol. vii, p. 56. Hicks likewise reports the cases of Smellie and Braun. 23 354 OBSTETRIC SURGERY. the sacrum and perinaeum, when the occiput and calvarium glided underneath the pubes. In two cases, I. E. Taylor * extracted the chil- Fig. 160.—Taylor's method in mento-posterior positions of the face. dren with straight forceps after bilateral incision of the perinaeum. Unfortunately, both children were dead before the operation was un- dertaken. CHAPTER XX. EXTRACTION IN FOOT AND BREECH PRESENTATIONS. Extraction in pelvic presentations.—Attitude of the physician.—Prognosis.—Position.— Extraction of trunk.—Extraction by the feet; by the breech.—Management of the cord.—Liberation of the arms.—Exceptional cases.—Extraction of the head.—Smel- lie's method.—Veit's method.—Head at brim.—Prague method.—Forceps to the after- coming head. We have already seen, in studying the management of breech pres- entations, that the attitude of the physician during delivery, so long- as no immediate danger threatens either the mother or the child, should be one of watchful observation. As a rule, the results to the child are unquestionably more favorable when Nature does her work unaided. Should, however, there be any faltering in the natural * Taylor, " On the Spontaneous and Artificial Delivery of the Child in Face Presenta- tions," " N. Y. Med. Jour.," Nov., 1869. EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 355 forces, the physician should be in readiness to avert by prompt inter- ference the perils which, in pelvic presentations, are associated with delay. When an artificial breech-presentation has been produced by internal version, immediate extraction is usually advisable, as the act of version, when the entire hand has to be introduced into the uterus, is apt to compromise the safety of the child. Strong uterine contractions, a roomy pelvis, a dilated cervix, and a relaxed state of the vaginal outlet are conditions highly favorable to the success of the operation. Under such circumstances, artificial delivery can be performed Avith celerity and ease. But these condi- tions, however desirable, are not absolutely indispensable. Thus, ex- traction is rarely indicated if the pains are good ; it is often necessary to deliver before the cervix has reached the desirable degree of dilata- tion ; and it is possible to drag the head of the child through a moder- ately contracted pelvis without inflicting upon it any permanent in- jury. There is always danger, however, in the last tAvo cases, of not being able to extract the child rapidly enough to save it from asphyxia. The prognosis for the mother is generally favorable. Still, lacera- tions are apt to follow the forcible delivery of the head through the undilated cervix. Extraction is commonly performed with the patient on her back. In easy cases she may occupy the usual position in bed, while the phy- sician places himself at her side. If difficulty is anticipated, the pa- tient should be placed crosswise, Avith hips raised by a hard cushion, and brought over the edge of the bed ; or, better still, may be placed upon a table, as the operator is then enabled to draw downward in the direction of the superior strait without kneeling before her. It is de- sirable to have two assistants to hold the patient's knees. To one of these should likewise be assigned the duty of making firm pressure, during extraction, upon the fundus of the uterus. If anaesthesia is thought necessary, a third assistant will be required. The question of anaesthesia is not always easy to decide. Useful in unruly patients, and where the entire hand must be passed into the vagina, its occa- sional suspensive action upon the uterine pains and the loss of the cooperation Avhich intelligent patients are capable of affording are alloys to its beneficent action in stilling pain. My preference is to anaesthetize lightly at first, and then be guided by events as to whether the insensibility shall be subsequently made complete or the patient be allowed to return to partial consciousness. As in all obstetrical operations, care should be taken to insure the emptying of the bladder and rectum, and the operator should have in readiness, in case of need, forceps, a soft fillet, warm napkins, hot and cold water, and a small catheter, for use should the child be born in a state of partial asphyxia. 356 OBSTETRIC SURGERY. The operation is divisible into three acts : 1. Extraction of the trunk, as far as the shoulders ; 2. Extraction of the arms ; 3. Ex- traction of the head. First Act : Extraction of the Trunk to the Shoulders. The extraction of the trunk should take place slowly, with pauses betAveen the tractions, in imitation of the uterine expellent forces. Tractions are best made during the pains only, when the latter do not recur at too long intervals. It is desirable that the uterus be closely retracted upon the child during the entire period of its expulsion. Where this does not occur, the arms are liable to be brushed upward to the sides of the child's head, the chin to become extended, and the mechanism of the head-delivery to be disturbed. Haemorrhage, too, is more likely to folloAv hasty delivery than where the uterus has had time to pass slowly into a state of complete retraction. When, there- fore, it is necessary to extract during the intervals between the pains, firm pressure should be made upon the uterus through the abdominal walls, so as to maintain them in close contact Avith the fcetus. Steady tractions are preferable to pendulum movements. Tractions should be made downward and backward, in the direction of the superior strait, until the breech meets with the resistance of the floor of the pelvis. These general rules are applicable to every case of extraction. Special differences of procedure result from the presentation of one or both feet, and of the entire breech. Extraction by the Feet.—If a single extremity presents, the foot should be seized between the middle and index finger, with the thumb upon the sole. It is not necessary to go in search of the second foot, unless it crosses the first, or is reflected upward over the child's back. When the leg is drawn outside of the vulva, it should be wrapped in a warm napkin, and grasped by the entire hand. Always, in seizing a limb, the thumb should be directed upward and applied to the dorsal surface. The napkin serves partly to prevent the hand from slipping, partly to protect the surface from air, which at times is capable of exciting reflex respiratory movements. Tractions should be made downward, to avoid friction at the symphysis pubis. Until the pelvis is delivered, the child should be seized as near the maternal parts as possible. The hand, therefore, should be shifted upward as the limb is drawn out of the vulva. Whichever extremity is seized rotates for- ward under the symphysis pubis during extraction. So soon as the breech reaches the pelvic floor, traction should be made more in an upward direction, to facilitate the passage of the buttocks over the perinaeum. After the breech has cleared the vulva, the index-finger of the free hand should be carefully inserted into the fold of the pos- terior thigh, while the thumbs of both hands are placed upon the EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 357 sacrum. During the subsequent extraction of the trunk, the lower leg falls from the vagina without special assistance. Fig. 161.—Method of seizing both feet. If both extremities present, they should be seized so that the mid- dle finger is placed between the feet, while the index and ring fingers encircle the external malleoli. After they haAre passed sufficiently far outside the vulva, the left leg should be seized with the left hand, and the right foot with the right hand. During extraction the normal rotation of the child may be aided by dragging with somewhat greater force upon the limb, which should be turned to the front. Extraction by the Breech.—When the breech alone presents, it may be thought best to secure a foot, previous to the descent of the child into the pelvis, as a prophylactic measure, in case extraction should subsequently be found necessary. In this event, with both feet reflected upward, the hand should be passed over the anterior surface of the child to the knee of the front extremity ; the thumb should then be placed in the popliteal space, while four fingers grasp the leg, flex it upon the thigh, and draw it down into the vagina. 358 OBSTETRIC SURGERY. This operation is facilitated by placing the patient upon the side to which the child's feet are turned. After, however, the breech has once fairly engaged in the pelvis, the execution of this manoeuvre is no longer easy. The attempt to bring down au extremity by the side of the breech in the pelvis is liable to cause fracture of the thigh. Then, too, the introduction of the hand is not always possible Avithout the exercise of an unjustifi- able degree of force. In such cases an attempt should be made to push the foetus doAvnward during the pains, by graduated pressure upon the fundus of the uterus. Should this measure prove insufficient, manual extraction should be attempted. To this end the index-finger of one hand should be inserted into the fold of the anterior thigh, and traction made directly dowmvard. By seizing the wrist of the hand which is hooked into the thigh with the disengaged hand, an increase of traction power can be exerted. Where the breech is low enough down, both index-fingers may be employed—the one in the anterior Fig. 162.—Method of seizing the breech. and the other in the posterior groin. Extraction is then effected by alternately raising and depressing the pelvic extremity. EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 359 Sometimes the resistance of the soft parts is such as to set all our best efforts in the way of manual extraction at defiance. Then a beg- garly array of alternatives present themselves to us. These are : 1. The blunt hook, which should be passed upward in the direction of the child's forward knee, and then turned and withdrawn so as to bring the curved extremity into the groin. The blunt hook furnishes a good hold, and may be used to materially further delivery. Some contusion is, however, inevitable from its employment. Great care must be exercised to see that the instrument is well placed. Should it slip forward upon the thigh during tractions, the thigh-bone is liable to be fractured. The risks to the child, from even its careful employ- ment, are so great that the blunt hook is rarely used excepting where the child is believed to have perished. 2. The fillet, formed of a silk handkerchief, a skein of worsted, a wide strip of linen, or of any soft material, which, when passed around the thigh, may be used to aid ex- traction. In placing the fillet, one end may be knotted, or rolled into a ball, and conveyed by the index and middle fingers around the anterior thigh, or an English elastic catheter, having been first guided around the groin, may be employed to draw the fillet into position. Before extracting, pains should be taken to see that the fillet is smoothly ad- justed, and fits Avell into the flexure of the thigh. To its use it has been objected that the fillet is apt to become twisted, and, when moist- ened with the vaginal secretions, forms an uneven band capable of cutting deeply into the tissues. While, however, these drawbacks should admonish us to caution, the testimony is abundant as to the serviceability and relative safety of the measure. 3. The obstetric for- ceps may be applied to the breech, in cases where the latter, rests upon the floor of the pelvis, and where the pains are insufficient to overcome the resistance of the perinaeum. The employment of forceps in breech cases has been generally decried from theoretical considerations. The experiences of Hiiter and Haake * have, however, been favorable. The latter limited the use of forceps to cases in which the breech was already in the pelvic outlet, and after complete rotation had taken place. The forceps was applied with one blade over the posterior thigh, and the other over the sacrum, with the extremity of the latter blade just above the crest of the ilium. Management of the Cord.—So soon as the cord has passed beyond the vulva, dragging upon the navel should be avoided by gently pulling the cord downward into one of the recesses to the sides of the prom- ontory until some resistance is experienced. Sometimes the cord is found passing between the child's legs and up over its back to the placenta. Then traction should be exerted upon the placental extrem- ity, and an attempt made to slip the loop over the posterior thigh. In * Hutkr, " Compendium der Operationen," Leipzig, p. 203 ; Haake, " Ueber den Gebrauch der Kopfzangen zur Extraction," " Arch. f. Gynaek.," Bd. xi, p. 558. 360 OBSTETRIC SURGERY. the rare cases of failure to obtain its release, and Avhere the cord is wound around the child's body, two ligatures should be applied, and the cord be divided between them, whereupon every effort should be put forth to complete the delivery as speedily as possible. Second Act : Liberation of the Arais. When the Arms are flexed upon the Thorax.—After providing for the safety of the cord, the pelvis of the child should be seized in the two hands with the thumbs upon the sacrum. Traction should be employed in a downward direction until the shoulder-blades make their appearance. Then no time should be lost in liberating the arms. If the latter are folded upon the chest, delivery is an easy matter. The palmar surface of the corresponding hand is passed over the belly of the child to the posterior arm (back to the right, right hand, and vice ver- sa), while the extremities, wrapped in a warm cloth, are drawn in the opposite direction. The forearm should be seized as near the wrist as possible, and be brought doAvn over the abdomen to the side of the child. When the Arms are extended.—Unless, however, great care has been exerted during extraction to keep the uterus by external press- ure closely in contact Avith the foetus, the friction of the parturient canal is apt to brush one or both arms upward to the sides of the child's head. In such cases the difficulties involved in liberating the arms are often very great. Here, too, OAving to the increased amount of space afforded by the curvature of the sacrum, an attempt should first be made to release the posterior arm. Release of the Posterior Arm.—This is best accomplished by draAv- ing the lower extremities strongly upward and to the side, thereby caus- ing the posterior shoulder to sink deeper in the pelvis and to furnish more room for the introduction of the hand ; then two fingers should be passed along the side of the child to the elbow-joint, which should be pushed across the face, and be brought down over the thorax. In case the foregoing manoeuvre can not be rapidly executed, the operating hand may be removed, and the extremities of the child may be drawn in the opposite direction, while the hand Avhich at first had. seized the feet or breech should pass upward over the abdominal sur- face to the posterior elboAV, and bend it, with tAvo fingers in the joint, toAvard the anterior pelvic Avail. Whether the hand be passed behind or in front of the child, it should be introduced slowly and without force during the intermission between the pains. Pressure should always be made at the joint, and never upon the humerus. A forgetfulness of the latter rule is apt to produce fracture. Release of the Anterior Arm.—As there is rarely space enough between the symphysis and the shoulder to alloAV the fingers to reach the elbow, it is customary after release of the posterior arm to rotate EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 361 the trunk so as to bring the anterior arm backward into the cavity of the sacrum. This is accomplished either by clasping the thorax in both hands and rotating while pushing the thorax imvard, or better still by seizing the liberated arm, and drawing it upward under the symphysis pubis. Indeed, the latter method has so far never failed me in readily securing the desired rotation. (If the back is turned to the left, the arm should be drawn upward along the left labium majus, and vice versa.) Exceptional Cases.—The shoulders, in place of rotating into the conjugate diameter, may enter transversely into the pelvis. If the back then be turned toward the symphysis, the hand should be passed over the abdominal surface in search of the arms. The space oppo- site the sacrum renders this movement one of easy execution. When the back is turned to the rear, so long as the arms are flexed, the hand should search for them under the symphysis pubis. If, hoAvever, they are extended upon the sides of the child's head, it is rarely possible to push the arms forward between the face and the symphysis pubis. An effort should be made, therefore, to bring one arm to the rear by rotating the thorax Avith the hands. Michaelis succeeded twice in similar cases without rotating the trunk, by pushing the elbow back- ward until it could be brought below the side-wall of the pelvis, and then drawing the forearm over the thorax. * I have repeatedly tested this movement in passing the cadaver of an infant through a bony pelvis, and find that it can be accomplished without producing fract- ure or dislocation. Of course, during the life of the child the result may be different. Sometimes, in rotating the shoulders, the anterior arm becomes displaced backward, so that the forearm is thrown across the neck of the child. When this accident is of recent occurrence, the release of the arm may be accomplished by pressing the thorax of the child back- ward into the genital passage, and rotating the body in the reA'erse direction from that which produced the difficulty. If, hoAvever, trac- tions haATe been made upon the child until the head has entered the pelvis, the arm may become so compressed between the neck and the symphysis pubis as to render its liberation a very difficult if not im- possible task. Then every resource should be quickly tested to turn the shoulder of the displaced arm to the rear, either by raising the released arm, or by rotating the thorax, or by drawing upon the elbow. In case of failure to obtain a speedy result, extraction may be attempted with- out releasing the arm. To be sure, fracture of the humerus is thereby rendered highly probable, but, if the bystanders are forewarned that the risk is incurred in the interest of the child, they are generally ready, where the life of the latter is preserved, to condone the injury. In setting a fractured arm, soft pads should be bandaged upon the * Michaelis, " Abhandlungcn," Kiel, 1833, p. 230. 362 OBSTETRIC SURGERY. anterior and posterior surface to hold the extremities in position. The posterior pad should run the entire length of the arm; the anterior pad need not extend below the elbow. The arm should then be band- aged to the thorax. In two or three weeks consolidation takes place.* In performing artificial rotation, it is well to bear the warning of Dr. Barnes in mind, viz., " That the atlas forms with the axis a rota- tory joint, so constructed that, if the movement of rotation of the head be carried beyond a quarter of a circle, the articulating surfaces part immediately, and the spinal cord is compressed or torn." f Pains should accordingly be taken to note, when a half-turn is given to the body, whether the head folloAVS the movements of the trunk. Third Act : Extraction of the Head. In the extraction of the head we have to distinguish—1. Cases in which the head has entered the pelvis, and has only to overcome the resistance of the perinaeum ; 2. Cases where the head is retained at the brim by pelvic contraction, stricture of the os uteri, extension of the chin, or insufficient expulsive action exerted by the uterus and the abdominal muscles. 1. Extraction of the head after it has entered the pelvis. Smellie's Method.—In the so-called Smellie's method the trunk of the child is wrapped in a warm napkin and placed astride the opera- tor's arm ; the hand is then passed into the vagina, and the index and middle fingers are placed upon the fossae caninae to the sides of the child's nose. By this means flexion of the head is induced. At the same time, upward pressure is made with the fingers of the other hand upon the occiput. Then by raising the trunk the face is rolled out over the perinaeum. This method possesses the advantage of avoiding the risks of injuring the child which are incident to the other proced- ures. It requires for its successful performance the completion of rotation, a small head, and a lax perinaeum. Combined Traction upon the Chin and Shoulders.—In case the fore- going plan is not followed by immediate success, the two fingers upon the fossae caninae should be introduced into the mouth, and, by press- ure upon the alveolar processes of the lower jaw, flexion should be accomplished. With the fingers of the other hand forked upon the shoulders traction should be made, and as the head descends the body should be raised by the joint movement of the tAvo arms, where- by the face sweeps over the perinaeum. By the combined method there is obtained the greatest amount of traction force in combination with the least degree of violence to the child. As the power is exerted chiefly upon the shoulders, the fingers in the mouth are not likely to fracture the jaw, but, by keeping the chin flexed and drawing gently * SrrEGELBERG, " Lehrbuch," etc., p. 809. f Barnes, " Obst. Operations," Am. ed., p. 210. EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 363 upon it, the danger of twisting the neck, in cases where the rotation of the face into the hollow of the sacrum is incomplete, is avoided.* Fig. 163.—Combined traction upon mouth and shoulders. (Chailly-Honore.) When the occiput is turned into the holloAV of the sacrum, and the forehead is pressed against the symphysis, the process just described should be reversed. As the fingers are forked OA'er the shoulders, the back of the child should rest upon the arm. With one or two fin- gers of the other hand the chin should be flexed. Tractions should be made downward, so that Avhile the neck rests upon the perinaeum the forehead rotates under the symphysis pubis. Ordinarily, when the head enters the pelvis in a transverse direc- tion, the occiput rotates to the symphysis pubis during extraction. Should the head, hoAvever, remain with its long diameter in the trans- verse diameter of the pelvis, a hand introduced into the vagina, with the back to the sacrum and the fingers over the child's face, may sometimes be successfully employed to rotate the latter into the sacral concavity. 2. Extraction with the Head at the Brim.—Schroeder, and a con- siderable portion of the modern German school, employ combined trac- tion upon the shoulder and chin for all emergencies alike, whether the head be high, or after its entrance into the pelvis. As, however, the life of the child depends upon the speedy extraction of the head, it is well to become familiar with the various procedures, as, by passing * The combined traction upon the chin and shoulders is in Germany known as the Smellie-A/eit modified method, the latter having warmly advocated the measure in 1863. Chailly, however, long before spoke of its adoption in France, and attributed its introduc- tion to Mine. La Chapelle. 364 OBSTETRIC SURGERY. rapidly from one to another, a successful result is often obtained, when failure might have followed ineffectual efforts in a single direction. The Prague Method owes its modern name to the advocacy of Kiwisch, Scanzoni, and Lange, all representatiA'es of the Prague school. It was, however, nearly a cen- tury earlier described by Pugh. It consists in seizing the feet Avith one hand, and directing the body of the child nearly vertically downward. The fingers of the other hand are hooked over the shoulders of the child, so that the tips rest upon the supra-clavicular region. Traction is exerted by both hands simultaneously. In the absence of pains, external pressure upon the head should be made by an assistant through the abdominal walls. Care should be taken to avoid twisting the neck, and to preserve the normal rela- tions between the head and the shoul- ders. After the head has passed the brim, and fairly entered the pelvis, the hand upon the neck should be em- ployed as a fulcrum, Avhile the extrem- ities are raised rapidly toward the ab- domen of the mother; the friction from the inner surface of the symphysis pushes the occiput upward, and forces the face to descend into the hollo av of the sacrum and to SAveep over the pe- rinaeum. When the chin is directed to the front, and at the same time is arrested at the symphysis pubis, if the occiput occupies the hollow of the sacrum, the body of the child should, during the tractions, be directed toward the abdomen of the mother, so as to cause the occiput to rotate over the perinaeum. Forceps to the After-coming Head.—The forceps to the after-coming head has been condemned by some and warmly approved by others. As, however, with its aid I have, in a number of instances, extracted children aliA'e in cases where the foregoing methods have failed me, it is now my custom to have the blades duly Avarmed and ready to hand before attempting manual extraction. The instrument is occasionally of use in overcoming the resistance of a rigid perinaeum in strongly- FlG. 164.—The method of extracting the trunk. EXTRACTION IN FOOT AND BREECH PRESENTATIONS. 365 built primiparae, but is chiefly indicated when both occiput and chin are arrested at the superior strait. With the chin anterior, the forceps Fig. 165.—The Prague method of extracting head. should be applied under the back of the child, and the handles raised so as to bring the occiput into the hollow of the sacrum. With the chin to the rear, the forceps should be applied under the abdomen, Fig. 166.—Chin arrested at symphysis. (Chailly-Honore\) 366 OBSTETRIC SURGERY. and be used to draw the face into the sacrum. Where the arrest of the head is due to stricture of the os externum or internum, the forceps will sometimes bring the head rapidly through the cervix, when trac- tion upon the feet only serves to drag the uterus to the vulva. In stricture of the cervix, however, great care must be exercised to aAoid laceration, as under no circumstances are extensive ruptures of the loAver uterine segment so apt to folloAV as in the forcible extraction of the after-coming head. The introduction of a large-sized catheter into the child's mouth and drawing back the perinaeum have been found useful as temporary means of introducing air into the child's lungs, where delay attends efforts at delivery. In extracting the after-coming head, the Tarnier forceps is par- ticularly to be recommended. CHAPTER XXI. VERSION Cephalic version.—External method.—Combined method.—Busch.—D'Outrepont.— Wright —Hohl.—Braxton Hicks.—Podalic version.—Bi-polar method.—Internal ver- sion.—Neglected version.—Use of the fillet. Version, or turning, is the term employed for the operations by means of which an artificial change is effected in the presentation of the child. It comprises the substitution of one pole of the foetus for the other, and the conversion of an oblique or shoulder presentation into one in which the long axis of the foetus corresponds to the verti- cal axis of the uterus. It is customary to designate specifically the character of the version by mentioning—1. The presentation to be changed. Thus, version is made from the head, the breech, or the shoulder, as the presenting part. 2. The presentation to be effected. The term cephalic version is used where the head is brought to the brim of the pelvis, and po- dalic version where the feet are seized and the extremities made the presenting part. 3. The method adopted by which version is accom- plished. The expression external version is applied to manipulations exclusively through the abdominal Avails ; internal version, to the in- troduction of the entire hand into the uterus ; and the combined method to cases in Avhich both hands, the one externally and the other Avith two to four fingers introduced through the os, cooperate together. Cephalic Version.—When it is simply required to rectify a faulty presentation (shoulder or transverse), without reference to modify- ing circumstances, cephalic version unquestionably deserves the pref- erence. In practice, however, this method requires the concurrence VERSION. 367 of so many favorable conditions that its employment is very limited. For instance, there must be no complications which call for rapid delivery. It would be unsuitable in prolapse of the cord and in cases of placenta praevia. There should be nothing to prevent the child's head from entering the brim of the pelvis. It should, there- fore, not be attempted in contracted pelves. A prolapsed arm, unless previously replaced, would render the operation impossible. The child should enjoy a considerable degree of mobility. An abundance of amniotic fluid contributes much, though it is not indispensable, to success, as, even after the rupture of the membranes, provided the uterine walls are sufficiently relaxed, the head may be brought into the pelvis. Before rupture, excessive sensitiveness to manipulations, and, after rupture, rigidity of the uterus stand in the way of success. The operation may be performed by either the external or the com- bined method. Of the external methods the best is that which is known as Wi- gand's (1807), which combines a suitable position of the mother, with manipulations through the abdominal walls. The mother is at first made to lie upon her back, with knees flexed, and with the abdomen exposed or covered by some light material. The physician stands by the side of the patient, looking in the direction of her face. He be- gins by laying his hands flat upon the surface of the abdomen, and seeks with the one the head and with the other the breech of the foetus. During the intervals of the pains, by gentle movements of the two hands working simultaneously, he strives to press up the breech and anterior surface of the child and to bring the head into the pelvic brim. Should the uterus harden, all friction movements of the hands should cease, and the efforts of the operator be confined to holding the foetus steady in the position previously produced. The movement may be aided by turning the woman upon the side toward which the head is directed. As the fundus of the uterus sinks to the side upon which the woman lies, it carries the breech of the child with it, while the change in the uterine axis tends to throw the ce- phalic end in the opposite direction. When the head is once brought to the brim of the pelvis it may be retained in situ, if the patient lies upon her side, by the hand of an assistant, or by a small, hard pillow pressed firmly against it. If the patient lies upon the back, two compresses may be laid along the sides of the uterus near the head, and a bandage applied to the abdomen to keep them in position. When the pains are regular and the cervix partially dilated, fixation of the head may be accomplished by ruptur- ing the membranes and allowing the waters to escape. Until the uterus retracts down upon the child, the head should be held at the brim either by the two hands through the abdominal walls, or by the thumb and four fingers of one hand applied directly to the head through the cervix. 368 OBSTETRIC SURGERY. The more important of the combined methods are those of Busch, D'Outrepont, Wright, Hohl, and Braxton Hicks. They have in com- mon the simultaneous employment of the external and internal hand. They differ, however, in detail. The methods of Busch and D'Outre- pont have now chiefly an historical interest. Busch introduced the hand corresponding to the child's head through the Aragina and cervix, while counter-pressure was made with the other hand upon the fundus Fig. 167.— D'Outrepont's method, modified by Scanzoni. uteri. The back of the hand is at first directed to the front. When, hoAvever, its widest portion has passed above the symphysis pubis, the back of the hand is turned to the concavity of the sacrum, and the fin- gers are pushed up with care between the membranes and the uterus to the head. The membranes are then ruptured, and during the escape of the waters the head is seized by the fingers and thumb and drawn into the pelvis, while the disengaged hand presses the breech toward the median line. Every pains should be taken to prevent, Avith the fingers, the prolapse of the cord, or of an arm,* during the escape of the water. D'Outrepont seized the presenting shoulder between the thumb and fingers of the hand corresponding to the breech, and, during the intervals between the pains, pushed the shoulder upward and in the direction of the breech until the head descended into the pelvis. During this manoeuvre, D'Outrepont simply used the external hand to support the uterus. Scanzoni recommended that it should be em- ployed externally to press the head toAvard the pelvic brim, f Wright's method differs from that of D'Outrepont, in that he em- ployed, to seize the shoulder, the hand corresponding to the head, and, Avhile he pushed the shoulder, without lifting, in the direction of the * Scanzoni, "Lchrbuch der Geburtshulfe," 1867, Bd. iii, p. 63. f Op. cit, p. 65. VERSION. 369 curve of the uterus, he applied the remaining hand to dislodge the breech and move it toward the center of the uterine cavity.* All the foregoing methods require for their successful performance a movable foetus and a dilated cervix, conditions which render podalic version safe and of easy execution. In practice, therefore, they have never enjoyed any considerable degree of popularity. Of far greater importance are the methods of Hohl and Braxton Hicks, which, pos- sessing the advantage of requiring the introduction of two fingers only into the uterus, can consequently be resorted to at an early stage of labor. Hohl, like Wright, employed for internal use the hand corre- sponding to the head. With two fingers in the cervix, he pushed the top of the shoulder in the direction of the breech, and pressed the head into the pelvis with the external hand. At the same time he in- trusted to an assistant the task of seizing the fundus of the uterus between the palms of the hands, and directing it to the side toward which the head was turned, f Braxton Hicks describes his method as follows: ** Introduce the left hand into the vagina as in podalic ver- sion ; place the right hand on the outside of the abdomen, in order to make out the position of the foetus and the direction of the head and feet. Should the shoulder, for instance, present, then push it, with one or two fingers on the top, in the direction of the feet. At the same time pressure by the outer hand should be exerted upon the cephalic end of the child. This will bring down the head close to the os ; then let the head be received upon the tips of the inside fingers. The head will play like a ball between the hands, and can be placed in almost any part at will. . . . It is as well, if the breech will not rise to the fundus readily after the head is fairly in the os, to withdraw the hand from the vagina and with it press up the breech from the exterior." J Lately, Hicks has proposed to employ the external hand to alternately press the head into the os and the breech to the fundus. His plan differs from that of Hohl, in that he operates with the patient upon the side, and uses the left hand with the patient upon the left side, and the right hand when she lies upon the right. He likewise dis- penses with an assistant.* Podalic Version. Podalic version is indicated in the following cases : 1. The transverse presentation, where cephalic version is contra- indicated, or attended with any considerable degree of difficulty. 2. In head presentations, Avhere there is reason to suppose that the * Wright, " Am. Jour, of Obstet.," vol. vi, part 1, 1873. f Hohl, "Lehrbuch der Geburtshulfe," 2te Auflage, 1862, p. 784. X Hicks, " Combined External and Internal Version," " Trans, of the Obstet. Soc. of. London," vol. v, p. 230. # Hicks, "Am. Jour, of Obstet.," July, 1879, p. 593. 2-1 370 OBSTETRIC SURGERY. result Avould be favorably influenced by bringing doAvn the feet. As illustrations of such conditions, we have faulty presentations of the head and face, prolapse of the cord and extremities, placenta praevia, and contracted pelvis. The various contingencies which call for ver- sion will' be more closely considered in connection with the special morbid conditions mentioned. The operation may be performed by combined external and inter- nal manipulations, or by the internal hand alone. The Bi-polar or Combined Method of Braxton Hicks.—In the bi- polar method of turning, the two hands operate simultaneously upon the extremities of the foetus. It may be carried out at will with the patient upon the side or upon the back. The latter position is the one Avhich finds most favor in this country. The patient should be placed transversely in the bed and the nates drawn to the edge. Two assistants are required to hold the legs, which should be flexed and ro- tated outward. As the beds in America are very low, where difficulty in operating is anticipated it is sometimes advisable to remove the patient after she has been anaesthetized to a table covered with a blan- ket or woolen comforter. Complete anaesthesia is useful as a means of facilitating the introduction of the internal hand, and maintaining a relaxed condition of the uterus. Care should be taken that both bladder and rectum are emptied. The hand selected for internal manipulations should be of the same name as the side to which the the extremities are turned—i. e., feet to the right, right hand ; feet to the left, left hand.* The fingers should be brought together in the form of a cone. The back of the hand and forearm should be Avell lubricated with oil or lard. In passing the hand into the vagina, the labia should be separated by the thumb and fingers of the disengaged hand. Entrance is effected by directing the fingers toAvard the sa- crum, and pressing backward upon the distensible perinaeum. In this stage of the procedure hasty action is out of place. Patience and gen- tleness are the prime requisites. Two or three fingers only need to be carried through the internal os. When the presenting part is reached, the external hand should be laid upon the abdomen, and pressure brought to bear upon the breech. The two hands should then move the extremities of the child in opposite directions. To quote Dr. Barnes, "The movements by which this is effected are a combination of con- tinuous pressure and gentle impulses or taps Avith the finger-tips on the head (or shoulder), and a series of half-sliding, half-pushing im- pulses with the palm of the hand outside." When the breech is Avell pressed doAvn to the iliac fossa, the membranes should be ruptured * In England the patient is delivered upon the left side, and the left hand is com- monly introduced into the vagina. In Germany, when the patient lies upon the right side, the left hand is employed inside; when upon the left side, the right hand. The choice of hands, it will be seen, is not a matter of considerable importance. VERSION. 371 during a pain, and a knee, which at this time is generally near the os internum, should be seized and hooked into the vagina with the fingers. As the breech is brought into the pelvis by tractions upon the leg, the outer hand should be employed to press up the head until the version is completed. The manipulations described are to be conducted during the inter- vals between the pains. Care should be taken not to hook down the cord with the knee. When the lower extremities are reflected upward upon the body so that a knee is not attainable, the breech may often be brought down by a finger inserted into the fold of the thigh, or by pressure upon some part of the pelvis. The combined method of version, which we owe in all its essential features to Braxton Hicks, is one of the most important contributions to obstetrical practice of the present century. It possesses the price- less advantages of enabling the physician to perform version early in labor, and to accomplish the operation without in any way imperiling the integrity of the uterus. The only prerequisites for success are : sufficient dilatation of the cervix to permit the passage of tAvo fingers, a certain degree of fetal mobility within the uterine cavity, and a precise knowledge of the fetal position. After rupture of the mem- branes and escape of the waters the operation becomes more difficult, but is even then not always impracticable. Internal Version.—In internal version the entire hand is introduced into the uterus. It is necessary, therefore, that the cervix should be so far dilated that the hand can be passed without violence through the cervical canal. Irregular uterine contractions require to be re- lieved by hypodermic injections of morphia, with or without the addi- tion of atropia, or by the induction of complete anaesthesia. As inter- nal version is not an indifferent operation, but may be followed by inflammations due either to injuries of the maternal tissues or to the introduction of infected air into the uterus, it should not be attempted until the impracticability of the combined method has been demon- strated. It is applicable chiefly to cases in which a certain degree of uterine retraction has followed upon the escape of the amniotic fluid.* The patient should be placed upon the back or side ; the bladder and rectum should be emptied ; and anaesthesia should be pushed until the action of the abdominal muscles is suspended. The exact position of the foetus should be carefully ascertained. The hand, well oiled upon its dorsal aspect, should be passed sloAvly, after the expira- * If the membranes are intact, and internal version is chosen in place of the bi-polar method, one of three plans is open in practice: 1. Boer recommended passing the hand between the membranes and uterus to the feet of the child, and then rupturing the mem- branes ; 2. Hiiter seized the feet of the child through the membranes, and turned without rupturing; 3. Levret ruptured the membranes at the os uteri, and introduced the hand during the outflow of the water. The third plan is the one most deserving of favor. 372 OBSTETRIC SURGERY. tion of a pain, with the fingers formed into a cone, through the vagina and cervix, opposite the sacro-iliac synchondrosis, upon the side of the child's feet. At the same time counter-pressure should be maintained over the fundus uteri, to prevent rupture of the vaginal attachments. If the uterus begins to contract, the fingers should be spread out, and the operator remain passive until the pain subsides. In head presentations, the hand employed should be always the one which corresponds to the side of the child's feet. In transverse presen- tations, when version is performed soon after the rupture of the mem- branes, before retraction of the uterus has taken place to any ex- tent, the choice of hands is of lit- tle consequence. This is especial- ly true in the dorso-anterior posi- tion. Thus, when the child lies with the head to the left, feet to the right, and belly to the rear, the right hand may be passed di- rectly across the belly to the ex- tremities of the child, or the left hand may be made to pass from the breech, along the surface of the thigh, to the nearest knee or leg. By the latter method the danger of mistaking an arm for the leg is avoided. Should, in any case, doubt upon this score arise, the characteristic differences be- tween the hand and foot should guide us to a correct diagnosis. Thus, the wrist enjoys greater mo- bility than the ankle, the fingers are longer than the toes, the palm is shorter than the sole, the posi- tion of the thumb is peculiar to the hand, and the pointed heel to the foot. Fig. 168.—Version in head presentations. (Chailly-Honore\) In the lateral position, the patient should be placed upon the side to which the child's breech is turned, with the buttocks near the edge of the bed. Here, obviously, the operator, standing in the rear of his patient, would use with the greatest facility the hand corresponding to the side upon which the woman lies (left side, right hand, and vice versa). In dorso-posterior positions, especially, the ad- vantages of such a selection are manifest. In easy versions, it is correct practice to bring down one foot or knee only. When one extremity is left reflected upon the abdomen, VERSION. 373 the larger size of the breech more fully distends the cervix, and thus prepares the way for the subsequent passage of the child's head. In difficult cases, or Avhen rapid delivery is to be effected, both feet should be seized. A single foot should be held at the ankle between the thumb and fingers. When practicable, the entire leg may be grasped with the closed hand. When it is sought to turn by both feet, the middle finger should be placed between them, while the ankles are held by the second and fourth fingers. Little importance should be attached to the question as to which extremity should be selected, so long as the version is uncomplicated. While in Germany preference is accorded to the seizure of the lower extremity, the superiority of turning by the more remote limb is gen- erally advocated in England. As in the bi-polar method, during the traction upon the foot, the Figs. 169,170.—Version in transverse presentations; direct method of seizing feet. (Braun.) external hand should aid version by pressure upward upon the head made through the abdominal walls with the disengaged hand. When, in transverse presentations, the membranes rupture, the lower arm not unfrequently becomes prolapsed into the vagina. As a rule, this complication does not embarrass version, though it may prove a hindrance to the introduction of the hand. It is a good plan, in arm-presentations, to slip a noose of tape about the wrist, which serA'es a twofold purpose, enabling us to draw the extremity up toward the symphysis, or back against the perinaeum, according as the hand is to be passed posteriorly or anteriorly, and to hold the arm to the side of the child's body during the performance of version, thus avoiding the 374 OBSTETRIC SURGERY. difficulties of arm delivery in the period of extraction. Dr. F. P. Foster, in a case where the mobility of the child Avas unimpeded, used the prolapsed arm as an aid to version in the folloAving ingenious manner : The child lay with the back to the front, the head upon the right iliac fossa, and the left arm presenting. With the right hand in the vagina, he seized the arm, and pushed gently upward in the direction of the humerus. In this way he succeeded in elevating the cephalic pole until Avith the index - finger alone in the cervix uteri he managed to reach the breech of the child. With the point of his finger he gently urged this along to the mother's right side, Fig. 171.—Method of reaching an extremity by first passing the hand around the breech. (Scanzoni.) and soon encountered the left foot, which he readily hooked down into the vagina.* When, after rupture of the membranes, aid is not promptly ren- dered, the shoulder becomes croAvded into the pelvic brim. If the pains are feeble the uterus may remain relaxed, so that hours after- ward version may be readily performed. If the pains are good, how- ever, as the waters escape the uterus retracts, until finally it becomes rigidly applied to the surface of the foetus. This condition is known to obstetricians as a neglected shoulder presentation. Version, under the circumstances, is embarrassed, partly by the difficulty of intro- ducing the hand into the uterus to seize the foot, and partly by the fact that when tractions are made upon an extremity, in place of the * Foster, " On Prolapse of the Arm in Transverse Presentations," " Amer. Jour. of Obstet.," vol. ix, p. 203. VERSION. 375 child turning in utero, both child and the closely applied uterus are apt to move together. In operating after the retraction of the uterus has become com- plete, the physician should seek to effect the utmost relaxation by pushing anaesthesia to complete insensibility. The hand should be introduced sloAvly and with the utmost gentleness. Precipitate action, or an attempt to overcome the uterine resistance by force, may cause fatal rupture. The external hand should make firm counter-pressure upon the fundus, to prevent the uterus from being torn from the vagina. The seizure of the loAver foot is usually alone practicable. Simpson, it is true, regarded the secret of success in such cases as depending upon making tractions Avith the upper limb, as tending to rotate the body of the child upon its long axis, and thus favoring the release of the presenting shoulder from its imprisonment. However rational all this sounds in theory, rotation within a rigidly contracted uterus is easier to represent by diagram than to carry out in practice. The result of seizing the upper leg is usually to cross it with its fellow, and to twist the child's body so as to injuriously compress the abdom- inal viscera. By making tractions upon the lower leg, the breech is brought by the shortest route to the uterine orifice. To be sure, by this manoeuvre the body of the child is bent laterally, but lateral flexion does the child no harm. In case of failure to effect version, a noose of tape may be placed upon the foot, and the hand returned to seek the other extremity. When the foot is within reach, the loop of the fillet, placed about the fingers, is easily conveyed upward to the ankle. When, however, the foot is high up in the vagina, where the movement of the fingers is im- peded, some form of instrument is needed to push the loop from the fingers over the foot. Unquestionably the most serviceable contriv- ance to this end is the repositor of Carl Braun, which consists of a gutta-percha rod, sixteen inches in length, with an aperture tAvo inches from the extremity, through which the loop of a doubled tape is threaded. When in use this loop is passed around the noose of the fillet, and is then reflected over the end of the rod. Thus secured, the fillet is conveyed to the position aimed at. Then by loosening the ends of the tape, Avhich during the upward movement are held to the sides of the rod by the operator's hand, and by shaking the rod, the instrument is easily detached, and can be Avithdrawn without difficulty. If the operator does not care to release the foot, because of the Fig. 172.—Braun's repositor. 376 OBSTETRIC SURGERY. difficulties he has encountered in getting possession of it, the fillet may be noosed around his arm, and thence be pushed upward OA'er the hand, to the seized extremity. A device, which in many instances has rendered me excellent service, has consisted of an ordina- ry catheter threaded with a doubled piece of twine, so that the loop projected from the eye of the in- strument. This loop, after inserting the stylet into the catheter, I have used in precisely the manner laid down for the employment of Braun's instrument. In case the second limb can not be reached, or where traction upon both extremities fails to bring the breech into the cervix, an attempt should be made to dislodge and elevate the presenting shoulder. This can sometimes be accomplished, in accordance with the suggestion of Professor Goodell, by bringing down the upper arm, and turning the child upon its long axis ; or, while the noosed foot is held out of the Avay by the at- as repositor. tached fillet, the hand corresponding to the child's head may be introduced into the vagina, and em- ployed to press the presenting part away from the cervix. The raising of the shoulder should be gradual, and should be performed with the utmost gentleness, as the danger of uterine rupture is pecu- liarly enhanced by the thinned, overstretched condition of the lower segment. Meantime a skilled assistant should support the uterus from without, and aid the descent of the breech by rightly directed pressure. Resolution to succeed, combined with patience in manipu- lation, usually overcomes the obstacles presented by the most difficult cases. In the few instances where failure follows all attempts to accom- plish version, or where rupture is imminent, or where the child is known to be dead, the obstacle to delivery may be overcome by decapitation, and the removal of the head and trunk separately. CRANIOTOMY AND EMBRYOTOMY. 377 CHAPTER XXII. CRANIOTOMY AND EMBRYOTOMY. Craniotomy.—Indications.—Operation.—Perforators.—Method of perforating.—Extrac- tion after perforation.—Forceps.—Cephalotribe.—Action of the cephalotribe.—Ob- jections.—Application of the cephalotribe.—Cranioclast.—Crotchet and blunt hook. —Cephalotomy.—Embryotomy.—Exenteration.—Decapitation. Craniotomy. Craniotomy includes all the various operations employed to reduce the dimensions of the child's head. Thus the term is applied —1. To the perforation of the skull, and the eA*acuation of the brain- contents ; and, 2. To the various procedures subsequently adopted to further minimize and extract the cranial walls. Indications for Perforation.—Perforation is resorted to, in cases of mechanical obstacles to delivery, to overcome the disproportion exist- ing between the child's head and the parturient canal. As the opera- tion is performed solely in the interests of the mother, it possesses a wider range of applicability when the child is dead than when still living. Perforation, in the dead child, is allowable in difficult labors so soon as temporizing becomes dangerous to the mother. The mere aesthetic advantage of removing by forceps an unmutilated child ought not, if attended by any risk, to be allowed to Aveigh with the physician against the welfare and safety of the parent. If the child is alive, the question of perforation is one of the most serious that falls to the lot of the conscientious physician. If the life of the mother is at stake, and the sacrifice of the child is necessary to her preservation, few would dispute at the present day the superiority of the mother's claim to existence. Still, it is not sentimentality to feel that it is an awful thing to destroy a living child before a clear conviction is reached that conservative measures, AA'hich hold out the hope of preserving both livTes, are of little or no avail. The proper position, however, of craniotomy, between the Caesarean section on the one hand and forceps and version upon the other, will be discussed in the section upon the treatment of contracted pelves. Operation.—When perforation has once been decided upon, there should be no delay in its execution. By delay, the very object of its performance, viz., the preservation of the life of the mother, is im- periled.* The patient should be placed in the usual obstetrical position, * Spiegelberg states that between the years 1870 and 1877, of thirty-three cases of perforation, three terminated fatally, while in the previous five years in which the opera- tion was performed, at a late period, of thirteen cases, seven ended in death.—("Hand- buch der Geburtshulfe," p. 833.) 378 OBSTETRIC SURGERY. with the knees flexed, and the hips draAvn over the edge of the bed. Chloroform is not requisite. It is useful, hoAvever, as a means of sav- ing the mother from painful after-memories. If the head is not fixed at the brim, it should be held firmly in position by the hands of an assistant, through the abdominal Avails, or the child should be turned, and perforation performed on the after-coming head. Complete dilatation of the cervix is not essential to the execution of the operation. If the object is simply to relieve the maternal soft parts from pressure, perforation may be performed at an early stage of labor. When, however, it is intended to folloAV perforation by immediate extraction, it is necessary to secure sufficient preliminary dilatation. In just this class of cases I have seen excellent results from the employment of Dr. I. E. Taylor's long, narroAV-bladed for- ceps, which can be passed through a cervix dilated to scarcely an inch and a half in diameter. They enable the operator to seize the head, and use it as a dilating wedge during and after a pain {vide p. 350). If the cervix hangs empty in the pelvis, and the head can not be moved from the brim, Barnes's dilators are often of great service. Unquestionably in many cases less violence is done to the mother, if simple perforation is resorted to, the brain evacuated, and the dila- tation of the cervix left to be accomplished by the pressure of the gradually collapsing head. This method, however, exposes the mother to the dangers of septic poisoning, as, unless the pains should be good and delivery rapid, decomposition of the foetus in utero speedily sets in after perforation. Instruments employed in Perforation.—Most of the perforating instruments in use in this country are patterned, Avith modifications, after the scissors of Smellie. Simpson's perforator is the one I have been in the habit of employing. As compression of the han- dles causes the separation of the perforating points, it can be easily managed with one hand. The projecting shoulders, just beneath the cutting portions, prevent the instrument from penetrating too far Fig. 174.—Scissors of Smellie. into the skull. The edges and points of the blades are rounded, so that they are not liable to injure the soft parts of the mother during the operation. The chief objection to the instrument arises out of these special measures of safety, as, owing to its bluntness, considerable CRANIOTOMY AND EMBRYOTOMY. 379 force has to be employed to penetrate the skull, which increases, of course, the risk of slipping. A better instrument is that of Monsieur Blot. It possesses a spear-point, which makes it effective as a per- forator. The blades, Avhen the instrument is shut, are superimposed, and are not capable of harming the maternal tissues. When the blades Fig. 176.—Blot's perforator. are separated, after perforation has been accomplished, they readily cut the bony structure of the skull. Hodge's craniotomy scissors can Fig. 177.—Hodge's craniotomy scissors. be used as a perforator, and afterward to cut away portions of bone. Dr. T. G. Thomas has devised a perforator with a gimlet-like extrem- ity, which is intended to bore its way into the skull. The opening is Fig. 178.—Thomas's perforator. 380 OBSTETRIC SURGERY. afterward enlarged by a knife which lies concealed and guarded in the body of the instrument until required for use. Mechanically consid- ered, Thomas's perforator is beyond reproach. It is, however, some- what more difficult to keep in order than those previously mentioned. The Germans employ for the most part a long trephining perfo- rator, which removes circular segments from the scalp and the skull. Fig. 179.—Trephine perforator. The trephine leaves behind no splintered portions of bones, and makes an opening which is not likely to close from overlapping ; but it can, on the other hand, be used only upon the cranial vault. Previous to practicing craniotomy, the bladder and rectum should be emptied. The operator introduces his middle and index fingers into the vagina, and presses them firmly against the most accessible por- tion of the child's head. Great care, at this stage, should be exercised to gain an exact idea of the situation and the extent of the dilatation of the cervix. The operator then seizes the handle of the perforator in the right hand, and passes the pointed extremity, under the guid- ance of the fingers of the left hand, to the region of the head at which it has been decided the perforation is to be made. If convenient, a suture or a fontanelle may be selected, in place of the bony table of the skull. The perforator should be pressed against the cranium with a boring movement until the cessation of resistance warns the operator that the bony incasement has been traversed. In cases where the skull is unusually thick or hard, this part of the operation may prove a matter of some difficulty. Care should be taken to hold the instru- ment at right angles to the point of perforation, as otherwise it is apt to glance from the rounded surface of the head. If the head, in place of being fixed in the pelvis, is situated high up, every precaution should be taken in the operation. The head should be pressed firmly against the brim through the abdomen by an assistant. The perforator should follow the axis of the superior strait. The point selected for perforation should be near the symphysis, as the instrument is then much less liable to slip than if carried back- ward toward the promontory. The fingers of the left hand should keep constant guard upon its direction. Oftentimes, by way of pro- tection, the operator introduces the entire half-hand into the vagina. After the perforator has penetrated the skull, the opening should be CRANIOTOMY AND EMBRYOTOMY. 381 enlarged by compressing the handles and separating the cutting blades ; then, allowing the latter to close, the instrument should be semi-rotated, and a second cut made at right angles to the first. Be- Fig. 180.—Operation for perforating the child's head. fore withdrawing the perforator, it should be moved about freely to break up the brain-mass. The rapidity and completeness of the col- lapse of the cranial walls are, in a measure, dependent upon the com- pleteness of the evacuation of the cranial contents. Care too should be taken to pass the perforator into the foramen magnum to break up the medulla oblongata, and thus to insure the death of the child before delivery. Sometimes it is adArantageous to wash out the brain- pulp by injecting a stream of water into the cranial cavity.* In face presentations care should be taken to pass the perforator through the frontal bones, or through an orbit. Where neither of * Von Weber has shown that no cephalotribe can fully decerebrate a perforated head, in general only the small part of the brain being evacuated. He has likewise demon- strated that a greater amount of compression can be accomplished in case of a fully than a partially decerebrated head. The head, therefore, that has been fully emptied can be more easily extracted than one that has only been partially deprived of its contents. 382 OBSTETRIC SURGERY. these points is, however, accessible, it is possible to make the open- ing through the roof of the mouth, behind the nasal fossae. The perforation of the after-coming head is ahvays a matter of considerable difficulty. The point of the perforator has to be inserted obliquely in place of at right angles to the skull, and therefore is more liable to glance. On theoretical grounds it has been recommended to insert the instrument either between the occiput and atlas, or through a lateral fontanelle. In practice, however, such niceties are rarely observed. The operator simply passes the four fingers of the left hand under the symphysis pubis, and, while the feet of the child are draAvn downward and backward by an assistant, the perforation is made at any point behind the ear at which the manipulation can be most easily effected. Chailly recommends hooking down the chin of the child, and perforating, as in face presentations, through the roof of the mouth.* The trephine-perforator requires to be pressed firmly and steadily against the parietal bone. Sometimes, when a large scalp-tumor exists, it is necessary to make a preliminary incision through the integuments. The trephine is not liable to slip, and is easily man- aged ; as it can not be used either upon the after-coming head or in face presentations, and as it is difficult to keep clean and in order, the less complicated lance-pointed instruments have, however, enjoyed the preference in all countries outside of Germany. Extraction of the Child after Perforation.—Formerly, after per- foration, a waiting policy was by many thought desirable. Osborne, indeed, recommended that at least thirty hours be allowed to elapse before delivery, in case craniotomy was performed upon a living child. The grounds for favoring a temporizing policy were found in the softening and relaxation of the sutures, and the ease Avith Avhich flat- tening takes place after putrefaction has once set in. At present, however, it is customary to extract so soon as the condition of the os renders it safe to resort to the necessary operative procedures. This change in practice results from altered vieAvs regarding the dangers due to mere protraction of labor, to fear of septic poisoning, and finally to improved methods now at our disposal for the termination of labor. Extraction may be performed by the forceps, the cepha- lotribe, the cranioclast, the crotchet, or the blunt hook. In some cases A-ersion may be employed with success. Each instrument, each method, has its limitations, and its range of applicability. Usually, in extreme disproportion, the operator finds it to his advantage to have * Cohnstein recommends cutting down upon the cervical and upper dorsal vertebra and then opening into the spinal canal by dividing the lamina?. Through the opening a silver catheter can be passed to the cranial cavity, and be used to break up the brain- mass, which should be washed out through the canal by injections of water.—(Vide " Ein neues Perforations Verfahren," "Arch. f. Gynaek.," Bd. vi, p. 505.) CRANIOTOMY AND EMBRYOTOMY. 383 at hand a complete equipment, and to resort at different stages of delivery to a succession of operative manoeuA'res. The acceptance of single measures and the wholesale condemnation of all others are cal- culated in difficult cases to lead to embarrassment and failure. A study, therefore, of the capacity of the various extractive instruments employed to deliver the perforated head is essential to the formation of correct judgment as regards practice. / Forceps.—The use of forceps as an extractive instrument, after per- foration, is recommended by Tarnier as folloAVS : " As the application of forceps has often succeeded in our hands, Ave do not hesitate to say that it is a good operation, applicable above all to cases in which the pelvic contraction is not considerable. The forceps possesses the ad- vantage of being in the hands of every physician ; it seizes the head firmly, and, by pressing the handles forcibly together, a sufficient evac- uation of the cerebral contents is effected to secure a marked flattening of the cranial walls. In making prudent tractions, one often succeeds in extracting the head without any harm to the mother; the danger begins only with too violent tractions." * These remarks apply, how- ever, to the powerful French forceps, Avhich is capable of exerting considerable compressive force. Hodge has found his forceps useful under similar conditions, f The short handles and the great width between the blades, in the English forceps, render it useless as a trac- tor when craniotomy has been performed. Cephalotribe.—On the 6th of June, 1829, Baudelocque, le neveu, read before the Institut Royal de France a memoir upon a new method of performing embryotomy. J He first pictured the dangers incident to all operations effected with pointed and sharp-edged instruments introduced within the uterus. From the statistics of the previous sixteen and a half years in the "Maternite," he showed that half the mothers thus operated upon died, and that the shortest of these opera- tions lasted three quarters of an hour. He then described an instru- ment he had invented, which he termed the cephalotribe, and repre- sented that with it he could crush in an instant the base and parietes of the fetal skull, forcing the brain from the orbits, the nostrils, and the mouth, the integuments at the same time remaining intact and forming a sort of sac, Avhich sufficed to prevent the edges of the fract- ured bones from inflicting injury upon the soft parts of the mother. The author furthermore expressed his conviction that the cephalotribe was destined to abolish and replace the perforator and the crotchet, and that it could be employed successfully in pelves measuring but two inches in the contracted diameter. This early instrument was tAvo feet long, and Aveighed over seven * Tarxier, " Diet, de Medecine et de Chirurgie," art. " Embryotomie," vol. xii, p. 657. f Hodge, "On Compression of the Fetal Head," "Am. Jour, of Obstet.,'' May, 1875. X A. Baudelocque, "Revue Med.," August, 1829, p. 321. 384 OBSTETRIC SURGERY. pounds. In shape it resembled the forceps. To the handles a crank was attached, destined to approximate the enormous blades to one another. The original cephalotribe has since been subjected to vari- ous modifications, with a view chiefly to the removal of its repulsive appearance. The observation of Chailly, in his " Traite pratique des accouchements," 1842, that perforation should always precede cepha- lotripsy, led specially to the construction of lighter and more conven- ient instruments. The dream of Baudelocque, that the cephalotribe was destined to abolish the perforator, has never been fulfilled. The models in use at the present day vary considerably in weight, the extent of the pelvic and cranial curves, and the character of the apparatus for producing compression. These different varieties are simply expressions of the defective Avorking of the instrument itself. The shape of the blades possesses the greatest importance practically. It is to be borne in mind that the cephalotribe is designed to act both as a crusher and as a tractor. Now, it so happens that whatsoever tends to make it available in the one direction is obtainable only by the sacrifice of some corresponding advantage in the other. Thus, it is evident that the greatest amount of crushing force is exercised Avhen the blades run nearly parallel to one another ; but, without a cranial curve, the blades, in place of being applied to the convexity of the child's head, open like scissors, and thus are liable to slip, if the in- strument is employed as a tractor. Again, as the blades are usually applied in the transverse or in an oblique diameter, it is necessary to rotate the cephalotribe to make the flattened head correspond to the flattened pelvic diameter. Rotation of the cephalotribe within the genital organs necessitates an instrument without pelvic curve; and yet, Avhere there is any considerable projection of the promontory, a straight instrument is apt to seize the head upon its posterior aspect only, and thus the head is often forced from the blades, Avhen com- pression is used, like a cherry-pit, to use Cazeaux's simile, from be- tween the fingers. Fig. 181.—Cephalotribe of Blot. Fig. 181 represents the French instrument of Blot, which is pro- vided with a good pelvic curve, but the blades are in close approxima- CRANIOTOMY AND EMBRYOTOMY. 385 tion to one another. In Scanzoni's cephalotribe, Fig. 182, the line of greatest difference betAveen the outer surfaces of the blades is nearly two inches. The inner surface of the blades is supplied with a longi- Fig. 182.—Cephalotribe of Scanzoni. tudinal ridge occupying the center, while the square extremities curve sharply inward like pincers. The instrument possesses a pelvic curve of tAvo and three quarters inches. When the Scanzoni cephalotribe is applied to the sides of the decerebrated head, the latter lengthens in the axis of the instrument, but Munde reports that he has witnessed the failure of the instrument to seize the head securely in the Wurz- burg clinic, in three cases out of four. Fig. 183 represents a cephalo- tribe made for me some years ago by Messrs. Tiemann & Co., which has met Avith considerable favor in NeAV York and its A'icinity. It has a cephalic curve of two inches and a quarter, measuring from the outer surfaces of the blades.* The pelvic curve is three inches and Fig. 183.—The author's cephalotribe. two lines in extent. These measurements are similar to those of the Prague instruments of Seyfert and Breisky. The blades are fenes- trated and grooved upon the inner surfaces. The advantages of an in- strument thus modeled are obvious. It is possible with its aid to seize the head when movable above the pelvic brim. As the points ap- proach each other closely after compression of the head is completed, * The advantages of making the blades parallel to one another are rather apparent than real; for, however effectively compression with such an instrument may be applied, the head acts as a wedge, producing a separation at the extremities proportioned to the absence of the cephalic curve. Breisky and Seyfert have insisted that it is better to transfer the greatest width between the blades from the extremities to the points at which they come into immediate contact with the child's head. 25 386 OBSTETRIC SURGERY. the instrument becomes a perfect tractor, holding the head as securely as an ordinary forceps. Its construction is, however, virtually the abandonment of two favorite but chimerical ideas regarding the ca- pacity and mode of action of the cephalotribe, viz., that it is capable of flattening the head so that the latter can be drawn through a pelvis measuring but two inches in the conjugate diameter, and that this can be accomplished by rotating the instrument, as we have men- tioned, so as to make the flattened head correspond to the shortened diameter of the pelvis. The actual result of compression by means of the cephalotribe was long a matter of dispute. Baudelocque, with his ponderous instrument, claimed to have been able to instantly crush the skull, including the base. Kilian* relates that in his first case of cephalotripsy he succeeded in breaking up the skull by a single application into fifty-four pieces. Von Weber, however, made a large number of experiments upon still-born children, employing for purposes of com- parison instruments of various patterns, and found that in no case did he suc- ceed in fracturing the bones of the skull. Even after the complete evacuation of the cerebral contents the bones would bend, but did not fracture. The result was different, however, in cases where the cephalotribe was employed in actual labor, where the head was subjected at the same time to pressure from the ute- rine and pelvic walls. Under such circumstances the bones certainly may break, if they do not invariably. Fractures he found, in fact, less common than simple incurvations. Where a fracture took place in one bone it rarely extended to contiguous ones, and, in general, contributed but little toward the actual reduc- tion of the head. Winckel t presented three heads to the Obstetrical Society of Berlin, upon which the cephalotribe had been used to facilitate delivery. Com- pression, in these cases, had been employed in several diameters, and each time the cracking sound elicited could have led one to suppose that the bones were being reduced to small pieces, yet subsequent examination showed that only a single bone, and that, usually, according to the position of the head, a parietal bone, was broken to any extent, while the opposite side, generally the basis cranii, was but slightly ruptured. Now, the greatest amount of compression effected by the cephalotribe does not exceed two to two and a quarter inches. The bizygomatic diameter, indeed, which measures three inches, is not, in or- dinary cephalotripsy, attacked at all.J It has always been objected to the cephalotribe that its application in the transverse diameter increases the length of the head in the antero-posterior diameter, or precisely where the pelvis is the narrowest, and thus adds to the difficulty of delivery. This is no doubt true when the head is fixed in the pelvis, a fact which should lead us to give the preference to other instruments for ex- traction after engagement has taken place. Above the brim, the cephalotribe seizes the head usually in an oblique diameter, so that the compensation takes place in the opposite oblique diameter. If the head is seized in the transverse diameter, it may easily be rotated into an oblique diameter. Sometimes the * Kilian, " Organ f. die gesammt. Medecin," Bd. ii, p. 279. f Winckel, "Kephalotripsie," "Monatsschr. f. Geburtsk.," Bd. xxi, p. 81. X Fritsch, " Der Kephalothryptor und Braun's Cranioclast," Volkmann's " Samml. klin. Vortr.," No. 127, p. 870. CRANIOTOMY AND EMBRYOTOMY. 387 compressed head rotates spontaneously, so that the cephalotribe comes to occupy the conjugate, a thing obviously possible only in moderate degrees of contrac- tion. Artificial rotation of the cephalotribe into the conjugate is dangerous and should under no circumstances be attempted. It must be borne in mind that the axis of the instrument is in a line between the upper border of one blade and the lower border of the other, and not in one drawn transversely between them. If spontaneous rotation occurs, the instrument should be removed, and the cranioclast employed as a tractor. Extraction with a powerful instrument like the cephalotribe can not be safely undertaken when the points of pressure from the blades are the soft tissues between the symphysis and promontory. Thus we find the cephalotribe useful in compressing the head before it becomes fixed at the brim. It is, moreover, advantageous as a tractor in moderate degrees of pelvic contraction. With two and three quarters inches in the conjugate, the limit for its safe employ- ment is, as a rule, reached. Of course it is understood that other factors than the pelvic diameters may influence the result. Thus, much depends upon the size of the child's head, the resiliency of the cranial bones, and the relations of the pelvic diameters to one another. It is not disputed that the cephalotribe is capable, if force is used, of accomplishing delivery through a smaller space than the one given, but the severe injuries to the maternal tissues which the instrument is apt to inflict, even when every caution is exercised, make its employ- ment dangerous in the higher degrees of pelvic deformity. In 1863 Pajot* published a paper in which he stated that, while in cases of distortion, in which the narrowing did not exceed two and a half inches, cepha- lotripsy was a favorable operation, requiring the exercise of no great amount of force, and but two or three applications of the instrument, below that point he regarded it as nearly as dangerous as the Caesarean section. In the belief that these results were due to rude attempts to drag an imperfectly reduced head through the contracted space, he proposed that in all cases below two and a half inches no tractions should be made, but, so soon as dilatation had proceeded far enough to permit, perforation should be performed, whereupon complete dilata- tion would occur more speedily, and cephalotripsy might be begun at an early period of labor—a point in itself of considerable importance. While applying the cephalotribe, one or two assistants should make counter-pressure over the pubes to steady the head. The blades should be introduced as high as possible by de- pressing the handles. After compressing the head, rotation, if it has not occurred spontaneously, should be cautiously attempted. The slightest obstacle should, however, be the signal for suspending rotation and withdrawing the instrument, when Nature usually brings about rotation with astonishing rapidity. The instrument should then be reapplied, and the compression repeated. The same process should be gone through with a third time, after which the Avoman should be placed in a convenient posture, and given bouillon to drink. Then, governed by the state of the pulse and the general appearance of the patient, the quiet or excitement manifested, the weak or energetic character of the pains, the cephalotribe should be applied two or three times every two, three, or four * Pajot, "De la c^phalotripsie r6pet£e sans tractions," Paris, 1863. 358 OBSTETRIC SURGERY. hours, leaving the expulsion of the foetus entirely to Nature. M. Pajot has never found more than four applications of this procedure necessary, while one or two have generally sufficed. After the passage of the head, one or two applications of the instrument are required, as a rule, to reduce the thorax. To be success- ful, however, it is requisite that the operation should be resorted to at an early period of labor, when, as a rule, not more than six to eighteen hours are needed for Nature to expel the uterine contents. Tractions should be employed only in those cases to which one is called at a late period, after the powers of Nature are exhausted. Objections to this plan of Pajot have been made as follows: That there is risk of rupture of the uterus from the prolongation of the labor; that the uterus is exposed to injury from the spicules at the point of perforation; that, owing to the great rapidity with which decomposition takes place after cephalotripsy, the bones of the skull are liable to become denuded of their cov- erings; and, finally, that after a given period the membranes become so far destroyed as no longer to protect the uterus from its decomposing contents. Pajot replies by adducing seven cases in which he employed his method. Five of the cases were successful, and two terminated fatally. The highest degree of deformity for which he operated was a case in which the contracted diam- eter was something less than an inch and a half. The patient died from ruptured uterus, due, according to M. Pajot, to attempts made previous to his arrival to perform cephalotripsy with a badly constructed instrument. The method of M. Pajot has never won the approbation of the profession, but, in the absence of the necessary instruments to execute other preferable manoeuvres, the success of its author recommends it for trial. The application of the cephalotribe does not differ from that of the forceps. W'here perforation has been performed, spiculae of bone should be carefully removed with the fingers. Confirmatory evidence as to the direction of the head may be obtained by exploring the cra- nial cavity with the finger, as, in this way, the exact position of the base and Arault may be determined. Great caution should be exer- cised during the introduction of the blades not to injure the vaginal or uterine tissues. It is not always easy to lock the instrument after the blades have been adjusted. The left blade is easily placed, but often the right blade is with difficulty brought forward to the cor- responding transverse or oblique diameter. Compression should be made slowly, and the opening made by the perforator should be care- fully guarded lest cutting portions of bone protrude. Extraction should take place under the guidance and protection of the fingers of the left hand. Sometimes the cephalotribe is used to compress and extract the after-coming head in cases of moderate pelvic contraction. Under such circumstances perforation is usually not a prerequisite. The cephalotribe seizes the head securely, and acts with great poAver upon the basis cranii. The increased diameters of the head accommodate themselves more readily, too, to the long diameters of the pelvis than in cranial presentations. When the head is retained in the uterus after it has become detached from the body, it should be held by an CRANIOTOMY AND EMBRYOTOMY. 389 assistant through the abdominal Avails, and steadied by a crotchet introduced into the foramen magnum, or fixed into an orbit, or in the loAver jaAv. The cephalotribe may then be applied to complete the extraction. Cranioclast.—It is necessary to distin- guish between tAvo instruments, each of Avhich bears the name of cranioclast. The original model was the device of Sir J. Y. Simpson, and Avas intended by him to replace the cephalotribe. It is substan- tially a poAverful pair of craniotomy-for- ceps. The larger blade, which is intended to be placed upon the outer surface of the head, is fenestrated and grooved. The smaller one, for introduction into the per- forated skull, is solid and supplied with ridges which fit into the grooves upon the opposite blade. The two blades artic- ulate by means of a button-lock. By a tAvisting movement, the cranioclast, when applied, can be employed to Avrench off the bones of the calvarium, different portions of the skull being seized successively with the A'iew of accomplishing that result. As the fractured bones are covered by the scalp, they are prevented from inflicting injury during the subsequent course of de- livery. But the cranioclast is not only of use in breaking up the cranial vault, it is likeAvise the most effective of all the in- struments employed for extraction of the perforated head. The principal defect of the Simpson Cranioclast is that it attempts to Combine Fig. 184.—Simpson's cranioclast. in the same instrument the functions of crusher and tractor. Now, as in the cephalotribe, the devices which make it the most effective instrument in the one direction weaken its utility in the other. Braun's modified cranioclast is intended to serve purely as a tractor. All idea of its undertaking to break up the skull is discarded. The work of compression and disarticulation is left to the counter-pressure of the pelvic walls, and to the employ- ment of craniotomy-forceps and the cephalotribe. The term crani- oclast is therefore a misnomer. Munde's proposed substitute of "cra- niotractor" is descriptive of its real action. Yet the modifications of Braun were as simple as they have proved appropriate. A pelvic 390 OBSTETRIC SURGERY. curve has been given to the blades ; the handles have been lengthened so that the lock, even when the instrument is introduced high up, is Fig. 185.—Braun's cranioclast. outside the vulva ; and, finally, an apparatus for compression has been added. The advantages of Braun's cranioclast over its rival, the cephalotribe, are as follows : it is of comparatively small size ; again, one branch lies inside the head, in a space not otherwise occupied ; the outer branch imbeds itself in the soft coverings of the head, Fig. 186.—Head of child after delivery with the cranioclast. (Simpson.) and thus is protected from doing harm. After a feAv tractions the cranioclast occupies the middle of the pelvis, where it can be so guarded by the hand that it need not even come into contact with the CRANIOTOMY AND EMBRYOTOMY. 391 vaginal walls ; as the head is drawn into the pelvis, the pressure is not concentrated at one or two points, but is diffused over the entire pelvic rim; the head is therefore able to mold itself to the shape of the pelvis. Subsequent to the use of Braun's cranioclast, extensive lacera- tions and injuries to the maternal organs are rarely found. The cra- nioclast takes firm hold of the head. It never slips during extraction. It is not apt to tear away when the cranium and scalp are seized together. The most secure grip is obtained Avhen the inner blade is passed to the base of the skull, while the outer one is applied to the face or over an ear. Should the portion grasped tear away, the read- justment of the instrument upon another part of the skull is easy. Thus, the inner blade can be turned, of course, in any direction with- out difficulty, while the outer blade is easily disengaged from the scalp- tissues and changed in its position by direct pressure from the fingers and slight leverage movements of the handle. The cranioclast may often advantageously be used as a tractor in cases where the head has been previously crushed and flattened by the cephalotribe, but, where extraction with the latter is rendered difficult by slipping, or by the inability of the operator to make the altered diameters of the head correspond to those of the contracted pelvic space, the immense superiority of the cranioclast consists in the capa- city to seize the head antero-posteriorly, and thus to bring its length- ened diameter into the transverse space of the pelvis. The cranioclast enables us to extend the limits of safe delivery far beyond what would be admissible with the cephalotribe, as with its aid it is possible, after the partial or complete removal of the flat bones of the skull, to tilt the chin downward, and draw the base by the edge through the conjugate. In this way craniotomy may be resorted to in pelves measuring less than two and three fourths inches antero-pos- teriorly. Indeed, Barnes claims that one inch and three fourths in the conjugate and three inches in the transverse diameter furnish sufficient space for a successful operation.* The proceeding to be pursued in these difficult cases is as follows : After perforation introduce a forceps-blade under the scalp, and detach the latter as far as possible from the cranial bones ; break up and wash out the entire brain-mass ; seize the parietal bones beneath the scalp with a good pair of craniotomy-forceps, f and break them away piece- meal by a twisting movement of the wrist. The withdrawal of the fractured bones is always a matter of delicacy. Unless the soft parts * Barnes, " Obstetric Operations," p. 402. For discussion of this point, see " Treat- ment of Contracted Pelves." \ Meigs's craniotomy-forceps has been largely used in America, and may be confi- dently recommended. There are two forms, one straight and the other curved. Dr. Tay- lor's modification consisted chiefly in increasing the length of the instrument, so as to render it more available in operations at the superior strait. 392 OBSTETRIC SURGERY. are carefully guarded by the hand, the maternal tissues are apt to be cut and lacerated by the sharp edges and splintered corners of the bones. Fig. 187.—Meigs's craniotomy-forceps (modified by Professor I. E. Taylor). Skene* has found it a great aid, in some cases, to use a large-sized Sims speculum to bring the head into view, and to go through the various steps of craniotomy with the guidance of the eye. The sug- gestion is an excellent one, but when the head is high up, as is the rule in difficult cases, I have not always found it practicable to expose in this way the presenting part. Honvitz f recommends, in difficult cases of the unexpanded cervix, to perforate through a large Fergusson speculum. After theremoA-al of the parietal bones, the fenestrated blade should be placed under the chin, or in the mouth, while the smaller one is introduced inside the perforation, and applied so that the fron- tal bones are included in the grasp of the instrument. The blades should then be screwed tightly together by means of the apparatus for compression, and the head turned so that its bizygomatic diameter is brought into the transverse diameter of the pelvis. As the distance between the orbital plates and the chin, including the instrument, does not exceed two inches, and the Avidth of the base is only about three inches, it is evident that, in skillful and experienced hands, this method is capable of almost indefinite extension. After delivery of the head, the extraction of the body may still cause difficulty. If, then, through an opening made with a perforator between the clavicle and shoulder-blade, the smaller blade be intro- * Skene, " Trans, of the Am. Gynaec. Soc," vol. ii. t Horwitz, "Uber ein Perforations Verfahren," "Ztschr. f. Geburtsh u Gynaek " Bd. iv, p. 1. ' ' "' CRANIOTOMY AND EMBRYOTOMY. 393 duced, and the outer blade bo applied on the back, so that the two include the spine, the cranioclast will seize the trunk firmly, and is capable of exerting great force as a tractor. Crotchet and Blunt Hook.— As tractors, neither of these instru- ments is much in vogue at the present day. It is well, however, to become familiar with their uses, as we are not always placed where we can have a complete armamentarium at our disposal. The crotchet is a steel hook, with a sharp-pointed extremity. The shaft is either straight or curved to adapt it better to the convexity of the head. In craniotomy the instrument is often useful in breaking up the brain. It may be inserted into an orbit when it is desired to bring the base of the skull end on into the pelvis. In default of either cranioclast or cephalotribe, it may be employed to extract the perfo- rated head. To this end it should be passed through the opening and its point inserted into one of the bones of the cranial vault. Tavo fin- gers of the left hand are then passed to the outer surface of the skull, to serve as a guard and to make pressure against the point fixed upon the inner surface. If much resistance is met with, the part is apt to tear away, and a new hold has to be taken. When portions of bone are broken away, they should be removed with the fingers, to prevent their doing harm. The process is often tedious, and, in unskillful hands, is not devoid of danger. When the bones of the vault yield under traction, a more effective grip may sometimes be obtained by fixing the crotchet at the foramen magnum or the sella turcica. Or, in place of introducing the instrument into the skull, it is sometimes inserted outside, behind the ear, into the mastoid process, or into the occiput, near the foramen magnum. The blunt hook, though not indispensa- Fig. 1S9.— Dr. Taylor's right-angled blunt hook. ble, is capable of rendering valuable service in deliA-ering the head after the performance of craniotomy. Dr. I. E. Taylor gives the preference to a right-angled instrument. The blunt hook can not, of course, be attached to flat surfaces of bone. It may be used, however, 394 OBSTETRIC SURGERY. to draAV down the chin, or it may be thrust into an orbit. Where perforation has been made upon the after-coming head, the blunt hook may be introduced through the opening and traction made directly upon the base of the skull. In difficult cases, delivery of the trunk is sometimes favored by tractions made by a blunt hook inserted under the posterior shoulder. Version.— Version, with extraction by the feet, with or without cephalotripsy, has been warmly commended by Bertin, Tarnier,* and Taylor, f while it has been condemned in harsh terms by others. Where it is practicable to perforate and turn early in labor, at a time when version is easy, the method has the advantage of bringing the longest diameter of the head into correspondence with the long diameter of the pelvis, and favoring the molding of the head to the shape of the canal it has to traverse. At the same time it avoids the dangers of contusing the soft parts incident to the use of the cephalotribe. Dr. Taylor recommends combining propulsion above the pubes Avith trac- tions made upon the extremities. Great ingenuity has been exerted to devise some good way to overcome the difficulty which grows out of the defectiveness of the preceding measures in act- ing directly upon the base of the skull. Cephalotomy,J or the removal of the head by segments, has been proposed as a substitute for perforation and cephalotripsy. Van Huevel's forceps-saw divides the head from crown to base into two halves. Tarnier's forceps-saw removes from the head a triangular segment, the apex of which is cut from the skull-base. Dr. Barnes* has suggested the application of Braxton Hicks's wire ecraseur to successive portions of the head. Hubert's transforateur is designed to bore through the sphenoid, and thus to destroy the resistance of the base. The sphenotribes of Valette, Huter, and the Lollines, are a combination of the cephalotribe and the transforateur. Notwithstanding the principle of cephalotomy is mechani- cally correct, the operation has never met with any general acceptance, partly owing to the high price and compli- cated structure of most of the instruments required for its performance, and perhaps in part to the fact that, in the higher degrees of pelvic deformity where their advantages over the more familiar methods would be theoretically most complete, the bulky nature of the forceps-saws and the sphenotribes interferes with their employment. The favorable reports made by their inventors, of the results they have personally obtained, render, however, a reference to the subject necessary. Fig. 190.—Segment re- moved by the Tar- nier forceps-saw, (P. Thomas.) * Tarnier, "Diet, de Medecine et de Chirurgie.," art. " Embryotomie," t. xii, p. 668. \ Taylor, " What is the Best Treatment in Contracted Pelves ? " " Trans, of the New York Acad, of Med.," 1875. X Tarnier, " Diet, de Medecine et de Chirurgie," art. " Embryotomie," p. 680. * Barnes, "Obstetric Operations," p. 411. CRANIOTOMY AND EMBRYOTOMY. 395 Embryotomy. In a literal sense, embryotomy includes all the graver operations designed to diminish the volume and resistance of the foetus. Custom has, however, restricted the term to those operations only which are performed upon the trunk of the child. It is used, therefore, as a rule, in contradistinction to craniotomy, and not in its generic sense. Indications for Embryotomy.—1. In extreme degrees of pelvic con- traction, where the size of the body obstructs delivery.* 2. In fetal malformations, with abdominal enlargement due to pathological con- ditions of the more important viscera, and in cases of extraordinarily developed children. 3. In neglected transverse presentations, in which version is impossible, or, at least, can not be performed without en- dangering greatly the life of the mother. Embryotomy includes two operative measures, viz., exenteration and decapitation. Exenteration.—By exenteration we mean the opening of one of the large cavities of the trunk, and the removal of the contained viscera. It is most commonly indicated in transATerse presentations, where de- capitation is not easy to perform, as in cases of extreme pelvic con- traction with the head high up above the pelvis. The opening may be made by means of a pair of curved scissors or the ordinary perforator. The same precautions against injury of the maternal tissues have to be observed as in craniotomy. In shoulder presentations an assistant should press the fundus of the uterus downward. The operator at the same time thrusts the perforator, or the scissors, betAveen the ribs, and then enlarges the opening by turning the instrument so as to make a second incision at right angles to the first. Next, splintered portions of bone should be carefully broken away with the fingers, until the opening becomes sufficiently extensive to permit the introduction of the half-hand. In tearing away the viscera, the fingers may, if neces- sary, be aided by the volsella-forceps. The abdominal cavity may be reached directly through the thorax by perforation of the dia- phragm, or a fresh opening may be made through the abdominal walls. After evisceration, the reduced bulk of the child renders it pos- sible to proceed directly to seize the feet and perform version. This method is, however, generally difficult, and endangers the distended cervix and lower uterine segment. If, therefore, the shoulder is high up, the breech, Avhich is easily reached, should be drawn down with * It has been said that, in cases which do not demand the Cassarean section, this indi- cation- is not likely to arise. In the extraction of the child's body, however, through a small justo-minor pelvis, which required for its completion upward of twenty-five min- utes, post-mortem examination showed more extensive disturbances from arrested pelvic circulation, due to compression from the child's body, than from the lesions arising out of the performance of craniotomy. 396 OBSTETRIC SURGERY. the fingers or the blunt hook, in imitation of the mode of delivery in spontaneous version. When, hoAvever, an arm presents, and the shoul- Fig. 191.—Braun's decapitating hook. der is crowded into the pelvis, the child may be drawn through doubled upon itself, as in spontaneous evolution. Decapitation.—Whenever, in neglected transverse presentations, the neck can be easily reached, decapitation furnishes the simplest and mildest plan for OA*ercoming the diffi- culties which prevent delivery. Decapitation may be effected in a num- ber of different Avays : 1. DraAV upon the prolapsed arm to bring the neck Avell down, and within reach. Pass the finger or a blunt hook around the neck, and then, carefully guarding the points, divide Avith a strong pair of scissors by a series of short move- ments the soft struct- ures and the vertebral column. 2. In many cases the division of the neck can be advanta- geously accomplished by Braun's decollator. This instrument is a modification of the blunt hook. The terminal Fig. 192.—Braun's method of decapitation. CRANIOTOMY AND EMBRYOTOMY. 397 portion is, however, bent at nearly an acute angle. It is likewise flattened from side to side, and ends in a button-shaped extremity. The handle is fixed at a right angle, and is capable of imparting to the instrument powerful leverage movements. In employing the de- collator, the index and middle fingers of the left hand should encir- cle the child's neck from behind, while the thumb is placed upon the anterior surface. The neck should then be firmly grasped and drawn doAvn into the pelvis as far as possible. The decollator should be passed up flat under the symphysis pubis along the thumb of the operator, until the button-end has advanced far enough to be turned to the rear over the neck. Finally, the instrument should be seized by the handle with the right hand, and rotated to and fro, Avhile tractions are simultaneously made in a downward direction. It is surprising how quickly, as a rule, the spinal column may be divided by this manoeuvre. After the separation of the vertebrae, care must be taken not to draAV down with too much force, lest the integuments and soft structures yield suddenly, and violence be done by the rapid with- drawal of the instrument. This accident may be avoided by using moderate tractions and dividing the last remnant of the tissues with a pair of scissors. The decapitating hook of Bamsbotham, which is curved, and has a cutting edge upon the concave part, is more difficult to apply, and is a less safe instrument in unskillful hands. Fig. 193.—Embryotome of P. Thomas. 3. Pajot originated an ingenious method of decapitation, which, in default of special instruments, is capable of rendering valuable service. It consists in passing a strong cord around the child's neck, and, by a 398 OBSTETRIC SURGERY. sawing movement, cutting through the parts. The vagina should be protected by a speculum from the friction produced by the to-and-fro movement of the string. The chief difficulty of the operation lies in getting the string around the neck. Pajot caused a groove to be made upon the concave surface of the blunt hook which forms a constant attachment to one of the handles of the ordinary French forceps. Through this groove he passes a string, to the end of which he fastens a round lead bullet; when the blunt hook is adjusted about the child's neck, the Aveight of the bullet draws the cord downward so that it can be reached by the hand of the operator. Dr. Kidd recommends attach- ing a string to an elastic ca- theter armed with a strong stylet; then, after impart- ing to the instrument the proper curve, it should be passed around the child's neck, and, as it is Avith- drawn, the string should be used to drag a strong cord or the chain ecraseur into place. Still more ingenious is the embryotome of Pierre Thomas, consisting of two blades modeled after a somewhat expensiA-e instru- ment devised by M. Tar- nier. The curved blade should be passed posterior- ly opposite the sacrum. The straight blade should be introduced in front direct- ly beneath the pubic bones. When adjusted, the extrem- ities of the blades are in apposition. Both blades contain a grooved canal. A piece of whale- bone armed with an ivory knob is then introduced into the canal of the straight blade, while a long, flexible piece of whalebone provided with an ivory ring is passed into the canal of the posterior curved blade. The descent of the posterior whalebone furnishes the evidence Fig. 194.—Embryotome adjusted around the neck of the child. CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 399 that the canals of the two blades are in apposition, and that the longer piece has entered the posterior canal. When the circuit is completed, a loop of cord is passed through an eyelet in the end of the Avhalebone, and serves as an attachment to a chain-saw, which, as it is drawn upward, leaves the grooA-e and encircles the child's neck. In decapi- tating the child by a to-and-fro movement, the soft parts are protected by the blades of the embryotome. CHAPTER XXIII. CESAREAN SECTION—OPERATIONS OF THOMAS AND PORRO. Caesarean section.—History.—Indications.—Operation.—After - treatment.—Prognosis.— Operation of Porro.—Operation of Thomas. The Cesarean Section. The term Casarean section is applied to cases in which the foetus is removed from the mother by an incision made through the abdomi- nal and uterine walls. Although the operation pretends to great antiquity, the earlier his- tories are probably of mythical origin. The supposed references in the Talmud are, according to Rodenstein, mistranslations of the text. The same authority suggests that even the lex regis, attrib- uted to Numa Pompilius, which makes it obligatory upon the physi- cian to remove the child by abdominal section in case the mother dies during pregnancy, was really added to the Roman law in the middle ages, with the intention of giving force to the decretals of the Church, which sought, through the Caesarean section upon the dead, to rescue the child for the rite of baptism before its life became extinct. Dur- ing the sixteenth century there seems no reason to doubt the authen- ticity of certain cases of laparotomy, performed during the life of the mother, for the removal of the foetus in extra-uterine pregnancies. In 1581 Francois Rousset * published the histories of fourteen successful Caesarean sections, six of which were said to have been performed upon the same individual. These cases were repeated from hearsay, and from accounts taken from letters written by friends. Their genuine- ness was challenged at the time of publication by the opponents of the operation, and they are now generally regarded as resting upon ques- tionable authority. The first operations mentioned after the publica- tion of Rousset's work are said to have proved fatal. The earliest well- authenticated record of Caesarean section comes to us from Germany. It was performed in Wittenberg, by Trautmann, in 1610. The patient * Rousset, " Traite nouvcau dc l'hystcrotomotokie, ou enfantement Cesarienne." 400 OBSTETRIC SURGERY. lived from the 21st of April to the 16th of May. Scarcely any doubt Avas entertained of her recovery, when she Avas suddenly seized with a fainting-fit and died, contrary to all expectation, in about half an hour. Indications for the Caesarean Section.—As the Caesarean section be- longs to the most hazardous operations of surgery, its performance is chiefly justifiable in cases in which craniotomy and the delivery of the child by the natural passages involve the life of the mother in still greater peril. It is indicated, therefore, in extreme degrees of pelvic contraction, in the case of solid tumors which encroach upon the pelvic space, and in advanced carcinomatous degeneration of the cervix. The Caesarean section is permissible if the mother is moribund, and the child is known to be alive, where rapid delivery by the natural passages is impossible. It may be undertaken at the mother's request if otherAvise delivery can not be accomplished without the sacrifice of the child. If in any case the decision is left to the physician, he should regard the welfare of the mother as of paramount importance. It has been said that if a woman, knowing herself to be incapable of bearing living children, exposes herself to the repetition of pregnancy, it becomes the duty of the physician to perform the Caesarean section in the interest of the child. The duty of the physician is, however, to his patient. He is not to constitute himself either judge or exe- cutioner. Operation.—The success of Caesarean section depends in large measure upon the control which the obstetric surgeon possesses over the conditions under which the operation is performed. The most suitable time to operate is after dilatation has begun, but previous to the rupture of the membranes : after dilatation, because it is desir- able to provide a free outlet for the uterine discharges subsequent to the operation, and because the retraction of the uterus after delivery, Avhich furnishes the most efficient means of controlling haemorrhage from the uterine wound, is best secured if the operation is performed at a time when the contractions are strong and frequent ; previous to rupture, because there is then greater probability of finding the child alive and the maternal tissues uninjured. Unless, too, the head or breech protrudes spontaneously through the incision made in the uterine wall, the delivery is much more readily performed while the membranes are intact than after the uterus has retracted firmly down upon the child's body. Michaelis reports a successful case operated upon by Schmitt, of Eylau, after eighty hours labor, and long after the escape of the waters, where the incision had to be extended over six inches in length before extraction could be accomplished.* The room where the operation is performed should be thoroughly aired and disinfected by the free use of the carbolic-acid spray, and the temperature raised to from 75° to 80° Fahr. A convenient oper- * Michaelis, " Abhandlungen aus dem Gebietc der Geburtshulfe," p. 162. CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 401 ating-table can be readily improvised by covering an ironing-table with blankets or ^n old-fashioned comforter. The head of the patient should be moderately elevated, the lower extremities slightly flexed, and the knees rotated outward. The abdominal tension in the com- plete horizontal position is apt to impede the circulation and respira- tion, and to facilitate intestinal hernia when the abdominal incision is made. Ether should be employed as an anaesthetic in preference to chloroform. All the details of antiseptic surgery should be carried out with painstaking exactitude. Five assistants are requisite, viz.: one to superintend the carbolic spray ; one to give ether ; one to steady the uterus and hold back the intestines ; one to take charge of the instruments ; and, finally, a nurse experienced in the methods for resuscitating partially asphyxi- ated children, to receive the infant. Convenient instruments to have in readiness are : a scalpel, a blunt- pointed bistoury, tAvo pairs of scissors, one straight, and the other bent at an angle, a large grooved director, artery-forceps, a half-dozen pair of Kceberle's compressing forceps, suture-needles, a long-handled needle-holder, sponge-holders, and plenty of clean, new sponges, which have been carefully soaked in a two-per-cent. solution of car- bolic acid. The instruments, with silver wire for sutures, should be kept immersed in a similar solution up to the time they are removed for actual use. If silk ligatures are employed, they should be first carbolized. A vessel with warm carbolized water should be conven- iently placed Avhere the operator from time to time can bathe his hands. For the dressing, subsequent to the operation, protective silk, antiseptic gauze, borated or thoroughly cleaned cotton, and a broad abdominal bandage, should be provided. The operation consists of four stages, viz. : 1. The incision through the abdominal wall; 2. The incision into the uterus and the extrac- tion of the foetus ; 3. The removal of the placenta, the arrest of haemorrhage, and the cleansing of the peritoneal cavity ; 4. The clos- ure and dressing of the abdominal wound. 1. After the operator has passed the catheter, and personally ascer- tained that the bladder has been emptied, he places himself to the right of his patient. The assistant stands upon the opposite side. The presence of loops of intestines in front of the uterus is then care- fully ascertained by percussion. If intestines are detected they should be pushed to the sides of the uterus out of harm's way. After first washing the abdomen Avith carbolized Avater, the assistant steadies the uterus in the median line, and produces a moderate degree of abdom- inal tension by means of the hands so placed that the ulnar edges press against the sides, and the thumbs encircle the fundus. The principal function of this assistant is to guard the field of operation from the protrusion forward of the intestines. The entire operation 26 402 OBSTETRIC SURGERY. should be conducted in an atmosphere of carbolized spray. The in- cision now universally adopted is made through the linea alba, and should extend from a point just below the navel to a distance two or three fingers in breadth above the symphysis pubis. In rachitic and undersized persons, the length of this incision may require subse- quently to be increased, in which case it should be extended upward to the left of the umbilicus. The section through the abdominal wall should be performed deliberately, and layer by layer. Bleeding from vessels should be arrested by compression or by ligature. When the peritonaeum is reached, it should be raised by the artery-forceps, a small opening should be made, and the incision then extended under the guidance of the index and middle fingers, or of a grooved direct- or, the entire length of the wound. 2. When the surface of the uterus is exposed to view, and an ex- amination has been instituted to make sure that neither omentum nor intestines present, the assistant redoubles his vigilance. Above and at the sides he should compress the uterus firmly, and push it some- what forward. He should keep the middle of the uterus carefully in the line of the abdominal incision, and be in readiness, after the opening is made in the walls, to quickly insert his index-fingers into the upper and lower angles of the Avound. The incision through the uterine walls should be made with a scalpel. The division of the muscular fibers should take place layer by layer. The operator should, however, work rapidly, as the haemorrhage, Avhich is often enormous, can only be controlled by the removal of the foetus. The site of the incision should be as nearly as possible in the body of the uterus. Both the fundus and the parts adjoining the os internum should, where it is possible, be avoided. The length of the incision required for the extraction of the child should be at least four and a half to five inches. To reduce the haemorrhage to the smallest limits, it is a good plan to begin with an incision of two inches, and Avork down at the loAver angle of the wound to the membranes, or, where the amniotic fluid has escaped, to the body of the child. Under the guidance of one or two fingers, the wound may then be lengthened upward by means of a blunt-pointed bistoury. Every care should be exercised to avoid puncturing the ovum, if at the time of operating it happens to be still intact. The moment the uterine incision is completed, the assistant should insert his index-fingers into the upper and lower angles of the Avound and lift the uterus into close contact with the abdominal wall (Winckel). As the uterus retracts during the delivery of the child, the assistant has to follow its movements doAvnward with great care, to avoid protrusion of the intestines. The membranes should be ruptured through the Avound, rather than through the vagina. It is more quickly effected, and time at this stage is precious. The escape of the amniotic fluid into the abdomen CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 403 can be avoided by a dexterous assistant.* If the head presents at the uterine opening, it should be seized and drawn out first. Sometimes the foetus is expelled spontaneously, as in natural labor, by the uterine contractions. Usually it is necessary to introduce the hand and seize one or both loAver extremities. The extraction of the child by the breech is performed in the usual way. The delivery should not be too rapid, but should be graduated so as to permit the assistant to ful- fill his duties in keeping back the intestines. If, owing to the retrac- tion of the uterus, the head becomes arrested, it is better to enlarge the incision upward with the bistoury than to tear the tissues, f Af- Fig. 195.—Method of extracting foetus. ter the removal of the child, the cord should be tied quickly, and the child handed to the nurse. The mother claims the entire attention of the physician. When the placenta is implanted upon the anterior wall of the uterus, it is liable to be cut down upon in making the Caesarean sec- tion. This accident occurs about once in three cases. J It occasions, for the time being, enormous haemorrhage. The bleeding begins with * The escape of a small quantity of amniotic fluid into the abdomen is of no great consequence, as it is for the most part bland and uninitating. f Owing to the presence of large veins in the neighborhood of the os internum, a tearing of the lower angle of the wound is apt to be followed by persistent haemorrhage. AVhen such an accident occurs, it is best to bring the wound together with fine sutures, as no reliance can be placed upon the contractile action of the cervical tissues. X Stoltz, " Dictionnairc de M6d. et de Chir.," t. vi, art. " Operation Cesarienne," p. 700. 404 OBSTETRIC SURGERY. the division of the outermost layer of muscular fibers. It is, however, necessary to complete the incision to the placenta, and then to detach the latter upon one side until the hand can pass into the uterine cavity. The extraction of the child furnishes the only effective means of controlling the haemorrhage. * In addition to the directions already giA'en for guarding against the escape of the intestines, it is sometimes useful for the assistants to press the uterus out of the abdominal opening. This method has the further advantage of preventing bleeding into the abdominal cavity during the extraction of the placenta and pending the retraction of the uterus. Of course, the assistant has at the same time to see that the cut surfaces of the abdomen are kept in close contact with the uterine walls. If from negligence, or from unavoidable causes, a pro- trusion of the intestines should take place, the assistant remains pas- sive, while their replacement becomes the charge of the operator. 3. In case, after the delivery of the child, the haemorrhage ceases, the uterus may be wrapped in a warm cloth, moistened with a weak so- lution of carbolic acid, and a short respite allowed before proceeding to the manual removal of the placenta, as its extrusion is often sponta- neously effected by the contractions of the uterus. After five to ten minutes have elapsed, or, in case the haemorrhage continues, immedi- ately after the extraction of the child, the uterus should be gently kneaded while tractions are made upon the cord. If needful it is allowable to introduce the fingers into the Avound to separate the pla- centa and membranes. Every pains should be taken to detach the membranes entire. After the complete removal of the ovum, the fingers should be introduced into the uterus to turn out clots and stimulate contractions. Finally, the uterine wound should be closed with sutures. If, owing to imperfect contraction, haemorrhage con- tinues after the uterus has been emptied, the suture is the safest haemo- static in our possession. Prolonged frictions of the fundus and the applications of ice are apt to increase the shock of the operation and to excite peritonitis. But even where, at the conclusion of the opera- tion, the uterus is well retracted, and the haemorrhage arrested, it is well to still use the suture as a prophylactic against secondary haemor- rhage. In many fatal cases the uterine wound has been found gaping, so that the lochia had escaped into the peritoneal cavity. The deep sutures should be inserted a half-inch from the cut borders, and at intervals of an inch from one another. Superficial sutures, designed * It is usual to caution against cutting through the placenta. Spiegelberg (" Hand- buch der Geburtshulfe," p. 858), who, in three of his cases, cut down upon the placenta found the direction to separate the latter with the hand a very difficult thing to follow. The fingers tore through the placenta without detaching it, so that in the end he was obliged to cut through the vascular organ to the membranes. Of course, the more rap- idly the operation is performed, the less the haemorrhage ensuing. CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 405 to approximate the peritoneal edges, should be introduced between the deep ones. Much ingenuity has been employed in devising a suture capable of being withdrawn a feAv days after the operation through the abdominal walls. As, however, experience in the extir- pation of ovarian tumors has shown that ligatures may be safely abandoned within the peritoneal cavity, preference is now given to the ordinary interrupted suture. The material used should be carbolized silk, as it cuts less than silver wire. Catgut has been found imprac- ticable, as the knots are apt to become loosened by the alternate con- traction and relaxation which normally take place in the uterus after confinement. After the sutures have been introduced, and the haemorrhage checked, the uterus should be returned to the abdominal cavity. Long sponge-holders, armed Avith sponges which have been soaked in Avarm carbolized fluid, should then be employed to cleanse the.vis- ceral and parietal surfaces of the peritonaeum, and to soak up any free fluid in the cul-de-sac of Douglas. 4. The abdominal wound may be closed by either silk or wire sutures. The sutures should be introduced an inch to an inch and a half apart. They should be inserted rather more than an inch from the border of the Avound, and should slope toward the inner surface, yet so as to in- clude upon each side a narrow strip of peritonaeum. Superficial sutures should be added to complete the adaptation of the wounded surfaces to one another. After carefully washing the abdomen, the wound is covered first by a layer four inches in breadth of protective silk, and afterward by six to eight layers of antiseptic gauze. The entire abdo- men should then be padded over with one or two layers of cotton- wool, and supported by a firm bandage of unbleached muslin. For three or four days the dressings do not usually require to be disturbed. When, howeAer, the antiseptic gauze shows evidence of soiling from the Avound-secretion, it should be replaced under carbolized spray. In case it should be thought desirable to insert a glass drainage-tube into the loAver angle of the abdominal wound, the antiseptic treatment may be carried out by adopting a device of Dr. Keith in ovariotomy. Dr. Keith makes a small incision in a piece of thin rubber sheeting, through which the drainage-tube is passed. After the latter is in- serted into the abdomen, a sponge soaked in carbolic fluid (1:20) is placed over the mouth of the tube. The rubber is then reflected over the sponge, which is thus kept from getting dry, while at the same time a carbolized Arapor at the mouth of the tube preserves the peritoneal caA'ity from the penetration of septic germs. Of course, every subsequent examination of the tube should be made under car- bolic spray. The writer is fully aware that it is not possible to realize in every case all the conditions and all the precautions contained in the fore- 406 OBSTETRIC SURGERY. going directions. Perhaps the majority of past operations haATe been performed after the Avoman has been days in labor, after the rupt- ure of the membranes and the retraction of the uterus, after the lower uterine segment has been subjected to prolonged pressure between the child's head and the pelvic brim, Avithout adequate assistance, Avithout antiseptic precautions, and Avith only the instruments of the physician's pocket-case. The uterine suture is rejected by many to-day, as indeed was the case with the abdominal suture in the early history of the op- eration. And yet it can hardly be hoped that the reproach which sur- rounds the Caesarean section will be removed until, in its performance, the rude methods of the veterinary art are replaced by the procedures of scientific surgery. In reading the histories of many of the bygone operations, we can not but agree with Mauriceau in thinking that, "if it is true that any women have escaped, it was the work of a miracle, or the express wish of God, who, if he wills it, is able to raise the dead, as he did Lazarus, . . . rather than by any effect of human prudence."* The After-Treatment.—The after-treatment is conducted upon the same principles as those followed in ovariotomy. The patient should be isolated, and perfect quiet maintained. A nurse should be in con- stant attendance. The circulation should be stimulated by the appli- cation of warmth to the surface of the body, especially to the extremi- ties. Pain should be subdued by opiate suppositories or subcutaneous injections of morphia. In vomiting, following the operation, only ice, or a teaspoonful of ice-water at intervals, should be allowed by the mouth. Until the stomach becomes quiet, nutrition should be main- tained by rectal alimentation. The diet during the first Aveek should consist of milk, beef-tea, and other fluid forms of food. The catheter should be passed every six hours, until the patient is able to void her water voluntarily without straining. The bowels should be kept con- fined for at least the first five days. Only in very exceptional cases should lactation be permitted. During the first three to four days, where antiseptics have been used, it is not necessary to disturb the dressings. The superficial sutures may be removed under spray on the fifth day, the deep sutures should be gradually removed between the seventh and tenth days. Peritonitis, septicaemia, and shock are to be treated according to the usual rules. Prognosis.—We have already alluded to the formidable character of the Caesarean operation. Michaelis f collected 258 authentic cases, of Avhich 54 per cent, ended in recovery. Kayser \ added 80 new cases to those reported by Michaelis, and reduced the recoveries to 38 per cent. Mayer* gathered 1,605 cases, with 54 per cent, recoveries. * Baudon, " L'anatomie abdominale," p. 12. f AIichaelis, " Abhandlungen aus dem Gebiete der Geburtshiilfc," 1833. X Kaiser, "De Eventu Sectionis Caesariae." * Mayer, notice by Bromcisl, " AVien. mod. Woch.," 1868, No. 67. CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 407 Pihan-Dufeilhay * collected 88 cases, published between 1845-'49, of which 57 per cent, ended in recovery. Finally, Dr. Harris has gath- ered with great industry the histories of 129 cases performed in North America, 57 of which, or over 44 per cent., ended in recovery. Under this shoAving it will be seen that fully one half of all the Caesarean operations end fatally. Large, however, as the mortality appears, the results are, I have no doubt, much more favorable than would be obtained from a similar number of craniotomies Avhich should include, as the statistics of the Caesarean section do, the work of many unskilled hands. But it has been objected to the statistics that they do not even approximately represent the truth. It is well knoAvn that many cases have never been included in the large collections. By some it has been assumed that the unpublished and omitted cases have all been fatal ones. Stoltz,f however, reports that he knew of five successful operations not contained in Kayser's statis- tics, though they had been published during the period embraced in his calculations. Harris collected 47 cases by correspondence with practitioners in various sections of the country. Of these, 14 ended in recovery and 33 in death. In Mayer's statistics, the recoveries from the operation«in America were placed at 33 per cent., while, as we have seen, Harris found them to have amounted to over 44 per cent. Thus it is by no means certain that statistics present the Caesarean operation in too favorable a light. The habitual indiffer- ence of the rural practitioner to the publication of his triumphs is one of his besetting sins. While admitting that the whole question is purely a matter of speculation, it is, at the same time, quite prob- able that a goodly number of successes as Avell as of failures lie buried, to use the Avords of Stoltz, in the note-books of modest physicians. If, however, Ave drop the numerical method altogether, and devote our- selves to a careful study of the cases upon which our statistics are built, Ave leave the mists of uncertainty, and are able to plant our- selves upon tolerably firm ground. Noav, the first pertinent fact that strikes us in examining the tabu- lated cases of Caesarean section is, that a very large proportion of the entire number have been derived from the reports of lying-in hospitals. Michaelis \ found that of 96 cases, the details of which were giATen with sufficient minuteness to leave no doubt concerning this point, 36, or rather more than a third of the entire number, were hospital patients. With astonishment, too, he noticed that 25 of the 36 died, and that only 11 recovered ; whereas, of the 60 cases in private practice, only 29 patients died while 31 recovered. This remarkable discrepancy in the result was such that Michaelis could not at first give it credence. * Pihan-Dufeilhay, " Arch. Gen. de Med.," 1861, t. ii. f Stoltz, " Lettre sur la provocation de l'avortement," " Gaz. Med.," 1853, p. 304. X Michaelis, loc. cit., p. 156. 408 OBSTETRIC SURGERY. When he found, hoAveATer, that there was no possible source of error in his figures, he sought to account for the mortality in hospitals on the ground that the latter were the receptacles of all the most unpromising and hopeless class of cases, while the private practitioner more often had to deal with Avomen in good health and Avith slight degrees of de- formity. Then he insinuates that the private physician does not usually care to stake his reputation upon an operation which probably will terminate fatally, but that, between weighing the case, and sum- moning counsel, and putting off action, the woman often dies undeliv- ered before a decision is reached. Kayser's results* were even worse than those of Michaelis, for in 67 hospital cases he found the mor- tality 79 per cent. Spaeth says that there has not been a single case in the lying-in hospital in Vienna during this century in which the mother has survived. Baudon, Avriting in 1873, says, "In Paris there has not been one successful case in eighty years, though in the present century the operation has been performed on perhaps as many as fifty women." This statement is often quoted as a crushing rejoinder to those who claim that the time has not yet come for sweeping the Cae- sarean section from the list of legitimate obstetrical operations. But, as we glance over the list of operators, and find .fourteen deaths ac- credited to Seutin, seventeen deaths to Paul Dubois, four deaths to Depaul, three deaths to Danyau, two deaths to Tarnier, and several to Moreau, we find in the ghastly record only fresh evidence that there is but little hope for the success of abdominal surgery, whatever the skill of the operator, when performed *in the putrid atmosphere of an infected hospital. On the other hand, the results of the Caesarean section in healthy rural localities are in striking contrast with those obtained in hospitals or even in large, overcrowded cities. Thus, Stoltz mentions that in the department of the Creuse the operation was performed six times be- tween the years 1843 and 1852, and in every case Avith success, f Hoe- becke operated sixteen times in the country, and, though his patients were poor, and so scattered that he was not able to visit them as fre- quently as was desirable, eleven of them recovered. Maslieurat-Lage- mard operated six times in the country; all of his patients recovered. J Prevost had three successes in four operations. Cottmann and Boaqui each had two successful cases. In Ohio, Harris reports six recoveries in eight operations; in Louisiana, fourteen recoveries in nineteen operations.* * Vide Baudon, "L'anatomie abdominale," p. 101. ■f Stoltz, op. cit., p. 689. X Baudon, " L'anatomie abdominale," p. 106. * Harris, "Caesarean Cases in Ohio," "Obstet. Gaz.," September, 1878, p. 99; " New Orleans Med. and Surg. Jour.," vol. v, 1878-79. In this article are related the successes quoted above of Prevost and Cottmann. Pilate in the article was accredited with two successes, but Harris subsequently assigned them to Boaqui. CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 409 Now, it does not seem logical, when such successes have been ob- tained in certain districts by certain operators, to place the Caesarean section under the ban, because other operators in other localities have failed altogether. No one reasoned, after the triumphs of Clay, Peas- lee, and Spencer Wells, that ovariotomy should be proscribed, because contemporaneously in France and Germany the extirpation of ovarian cysts had been almost constantly folloAved by death. Certainly the intelligent course to pursue always, in the face of conflicting results, is to sift out the reasons for failure on the one hand, and the conditions of success on the other. If Ave begin by asking why the Caesarean section has so often ended fatally, Ave have already found the answer for many cases in the fact that the patients Avere operated upon in the impure atmosphere of maternity hospitals. The frequency with Avhich gangrene of the uter- ine wound is mentioned in the post-mortem records bespeaks the prevalence and activity of septic germs. Ovarian patients placed in the midst of similar unAvholesome surroundings die almost certainly, in spite of the skill of the operator. Again, the accounts of the cases which have come down to us shed a deal of light upon the causes of the untoward results. I have before me the histories of one hundred and eight cases collected by Michaelis, and published by him in 1832. They all belong to the nineteenth century, and are of undoubted authenticity. Moreover, they are in- cluded in all the statistical tables Avhich have since been published. In the entire number, there were sixty-one deaths. In thirty-four of the fatal cases, the histories given are tolerably explicit. From these accounts, I gather the following suggestive particulars : Caesarean section performed upon a corpse. Case of ruptured uterus ; Caesarean section, the day folloAving the rupture. Bitgen's unsuccessful case of laparo-elytrotomy. As " the strength of his patient was failing fast," OAving to the haemorrhage from the vaginal Avound, and as "the contractions of the uterus had entirely ceased," the Caesa- rean section was performed to save the life of the child. In five cases Caesarean section was first tried after prolonged but vain attempts at delivery by the forceps and version. In another it was first resorted to after the failure of craniotomy. One operator extended his incision to the os uteri. Two cases were complicated with eclampsia, and one. with placenta praevia. In one case the operation was performed six days after the mem- branes had ruptured. The bladder had to be previously punctured. The foetus Avas putrid. To control haemorrhage, Kitgen in one instance tied nine arteries in the uterine wound. In one patient the operation was deferred until peritonitis had set in. 410 OBSTETRIC SURGERY. There were two cases of neglected shoulder presentation. In the one the operation was performed four days after the rupture of the membranes, and in the other thirty hours. In the latter the uterine tissues Avere found necrosed from pressure betAveen the promontory and the presenting part. In one case the operation Avas performed by violence, in spite of the protests and struggles of the patient. There were a number of Avomen upon whom the operation Avas repeated in a succession of pregnancies. Of these, tAvo died after the second operation, and three after the third. In one of the latter series the patient seemed to be doing well, until the twenty-seventh day, when she got out of bed, and sat by an open ivindow for an hour to watch the passing of a troop of soldiers. The wound gaped open, and death folloAved the same day. In one patient the first days of danger Avere past and the Avound promised to heal kindly, Avhen the brother, disappointed in the ex- pected succession to her property, beat the woman, Avhereupon the wound tore open, and fatal fever followed. In another case, all Avent Avell until the seventh day, when, de- lighted at the prospect of recovery, the patient jumped from bed, danced around, and swalloAved a pint of brandy. In two cases death resulted from the protrusion of the intestines from the abdominal wound subsequent to the operation. In one, this occurred on the third day. The physician, Avho operated with a razor and used no bandage or adhesive straps to support the abdomen, did not see his patient after the operation until the accident referred to had taken place. In the other, tAvo inches of the abdominal wound Avere intentionally left open, vomiting set in, and the boAvels were forced through the gap. The injurious effects of protracted labor upon othenvise perfect- ly natural deliveries are well known. In contracted pelves, in addi- tion to the exhaustion and nervxms depression Avhich follow in long labors, the pain, the loss of sleep, and the inability to take food, the outlook for the patient is still further darkened by the early and com- plete escape of the amniotic fluid, the consequent retraction of the uterus upon the foetus, the bruising of the maternal tissues from pressure of the child's head, and at times from perforation or even rupture of the uterus. A priori, therefore, one Avould expect that every hour's delay, after the Caesarean section had once been decided upon as necessary, would imperil the result. This deduction is fully justified by the facts. Thus Dufeilhay's statistics shoAved that, Avhen the Caesarean operation is performed before the woman becomes ex- hausted, eighty-one per cent, recover. Harris collected twenty-six cases of timely operation, Avhich ended in the saving of nineteen mothers, or upAvard of seventy-three per cent. If, hoav, we return to the fatal CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 411 cases reported by Michaelis, Ave find, in addition to those from the his- tories of which Ave have quoted, tAvo operations performed tAventy-four hours after the rupture of the membranes : two, forty-eight hours ; one, seventy-tAvo hours ; and one, ninety-six hours. Two operations were performed tAvo days from the beginning of labor ; two, five days ; and one, eight days. Thus Ave find that, in more than one half of Michaelis's reported fatal cases, the operation Avas performed upon the dead and the dying, or under circumstances which reduced'the chances of success to a slen- der possibility. How far the remaining cases are open to the same criticism it is impossible to say, OAving to the defectiveness of the his- tories. Now, Dr. Barnes says, with great truth, " Obviously, Ave can not recognize fatal cases of craniotomy in extreme deformity of the conju- gate diameter reduced to 2" or 1*75", unless the operation Avas begun under selected circumstances—that is, before exhaustion had set in— and conducted Avith due skill, and after the most approved methods." * But avc have an equal right to refuse to recognize fatal cases of Caesa- rean section in which the conditions and methods of the operation rendered success an improbable, if not an impossible issue. Porro's Operation and Laparo-Elytrotomy. While objection may be fairly taken to the disfavor with which the Caesarean section is commonly regarded among English-speaking races, it can not be denied that it is open to one strong objection, viz., that the results in the end depend upon the efficiency of the uterine contractions subsequent to the operation. When the operation is per- formed early in labor, after the pains are well established, but before the patient's strength is exhausted, and when the sutures have been introduced, art has done all that it can accomplish to prevent gaping of the uterine wound. But, eAren when these precautions haAre been scrupulously observed, imperfect retraction of the uterus or a cutting out of the sutures may leave an open communication betAveen the uter- ine and abdominal cavities. As the uterine section in itself is apt to excite a considerable degree of catarrhal endometritis, and as the admission of air into the uterus furnishes the condition for decom- position of the lochia, the patient is always exposed to the dangers arising from penetration of septic materials into the peritoneal sac. Porro's operation and laparo-elytrotomy have both been designed to avoid the risks incident to this cause. Porro's Operation, or Ovaro-Hystoreectomy.—The characteristic feature of the Porro operation consists in the removal, after the per- formance of the Caesarean section, of both uterus and ovaries.' As the result of experiments upon animals, its theoretical practicability * Barnes, " Obstetrical Operations," D. Appleton & Co., p. 418. 412 OBSTETRIC SURGERY. was demonstrated as early as 1769 by CaA*allini, and later, in 1823, by Blundell. G. Ph. Michaelis in 1809, after referring to the dan- ger from reaction following injury to any of the abdominal viscera, goes on to say : " That the danger specially depends upon this reac- tion, we see not only from the often greater associated disorders in other organs, but from the experience that, Avhen the uterus has been removed so that the reaction in other organs falls away, the danger appears to be much lessened. SeA'eral cases are knoAvn where the uterus has been excised by ignorant persons without the occurrence of violent disturbances [Zufalle]. ... It is a question, therefore, Avhether the Caesarean section would not be rendered less dangerous by connecting Avith it the extirpation of the uterus." The ablation of the uterus after Caesarean section was not, however, actually executed upon the living human female until 1868. This first operation was performed by Dr. Horatio B. Storer, of Boston, in the case of a pa- tient whose delivery was rendered impossible by the natural passages, owing to a large-sized fibro-cystic tumor blocking up the pelvic cav- ity. The haemorrhage Avhich followed the incision into the uterine cavity proving frightful, Dr. Storer ligatured the cervix, and, having applied the chain ecraseur, sloAvly removed the mass. Both the child and placenta were in a state of decomposition. The patient liA'ed sixty-eight hours. At the time of the occurrence the hardihood of the operator was the subject of a good deal of unfavorable com- ment. In 1874 Professor EdAvard Porro, of Pa via, having succeeded in preserving the lives of animals from which he had removed the gravid uterus, decided that, as soon as a chance offered, he would add to the Caesarean section as a completive measure the ablation of the uterus and its appendages. The sought-for opportunity presented itself on the 21st of May, 1876. The patient had a rachitic pelvis, with an antero-posterior diameter reduced to one inch and a half. The child was extracted living, and the mother surviA-ed. After the publication of Porro's report, the two Brauns and Spaeth, of Vienna, where the Caesarean section had been proArerbially fatal (no case saved in this century), resolved to give the new operation a trial. Spaeth led off with a success in June, 1877. Since then I learn, through a private communication from Dr. E. P. Harris, Avho has with untiring zeal made all questions connected Avith the Caesarean section his peculiar province, that the number of operations performed to the present time (June, 1881) has sAvollen to 71, of which 30 have ended in recovery, and 41 in death. These results, though they still leave much to be desired, are en- couraging Avhen we remember that they have for the most part been obtained in lying-in hospitals, where the unmodified Caesarean section has proved nearly uniformly fatal. As in all Caesarean operations, the CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 413 statistics contain a number of cases where the doom of the patient was decided in advance of the operation itself. In quite a number of cases, too, the unfortunate endings were apparently the consequence of errors of judgment on the part of the operator, against which it is to be anticipated that it will, in future, be possible in a measure to guard, as the methods of operating become more settled, and the indi- cations for the operation become more clearly defined. Operation.—The preparations and the details of the operation are the same as in Caesarean section, Avith the exception of those which have reference to the ablation of the uterus and the prevention of haemorrhage. Careful attention to the details of antiseptic surgery appears to be essential to a successful issue. In Porro's first case the abdominal incision was nearly five inches in length. After opening the uterus and removing the foetus, the placenta, and the membranes, Porro lifted the emptied organ from the abdomen, and placed the serre-naud of Cintrac around the lower segment, just above the os internum. The tissues were then constricted until all haemorrhage from the cut uterine surface was arrested. The uterus was then cut away Avith a bistoury, the stump Avas brought outside of the abdomi- nal Avound, and held in position by strapping the handle of the serre- naud to the patient's right thigh. Muller modified Porro's original method by enlarging the first incision upAvard sufficiently to enable an assistant to lift the uterus outside of the abdominal walls, and by applying compression above the cervix (either the wire ecraseur or the Esmarch bandage) before opening the womb and removing the child. This plan offers the obvious advantage of rendering the operation bloodless, and of making it easy to preArent the entrance of the am- niotic fluid into the abdominal cavity. Breisky, Litzmann, Muller, Tarnier, and Elliott Richardson, of Philadelphia, found no difficulty in thus draAving the uterus outside the abdominal cavity ; Spaeth, Wasseige, Tibone, Chiara, and Carl Braun, on the contrary, either encountered great difficulties in performing the manoeuvre, or were obliged to abandon it altogether. The modification is an important one, but is of limited applicability. The compressors which have so far been employed are the Cintrac serre-naud, the chain ecraseur with a Pean attachment rendering it possible, after detaching the chain from the handle, to maintain the constriction, and the various forms of Avire ecraseur. Compression should be made slowly, and should not be carried to the extent of cutting through the peritonaeum. Owing to the liability of Avire to break, great care should be taken in its selec- tion. In case of accident, a second instrument should be held in readi- ness. I am not aware that the clamp has thus far been tested. Yet it is hard to see Avhy a good clamp exercising concentric pressure, like that of T. G. Thomas, for instance, would not prove practically use- ful. 414 OBSTETRIC SURGERY. Levy,* gathering together the results of past operations, recom- mends, as most deserving of imitation, an abdominal incision six to seA'en inches in length ; the uterus to be raised where it can be accom- plished without violence ; the abdominal wound to be pressed together and covered Avith flannels or sponges wrung out in warm carbolized water, to absorb moisture and to prevent chilling of the intestines ; the constrictor then to be applied so as to include both ovaries, and the child to be extracted rapidly; or, in case the uterus can not be dis- lodged easily and brought through the abdominal Avound, after the size of the uterus has been reduced by rupture of the membranes per vaginam the assistant in charge should use the precautions already detailed in connection with the Caesarean section against allowing fluid to enter the abdominal cavity, and after the emptied uterus has been raised from the abdomen he should temporarily compress the vessels above the cervix Avith the fingers of both hands. When the constrictor has been adjusted and all haemorrhage arrested, the stump should be trimmed with scissors and mummified with the perchloride of iron. To prevent the ligature from slipping, and to sustain the pedicle, tAvo long steel pins should be passed through the cervix and allowed to rest upon the abdominal Avails. Elliott Richardson f em- ployed pins about five inches in length and of the size of a No. 8 bou- gie, French scale. Of these he passed one below and the other above the wire, and diagonally to the line of the abdominal Avound. He then tied "a, piece of stout silk cord previously soaked in carbolized oil (one part to eleven) around the cervix between the tAvo pins, and in the line of the temporary wire loop, which latter was removed as soon as the permanent ligature was applied, but before it Avas finally fast- ened. The silk ligature was wrapped twice around the cervix, and then tied." \ It should be here mentioned that on the second or third day the pulse becomes irregular and oscillates between one hundred and one hundred and forty pulsations without a corresponding rise in the tem- perature, a nervous disturbance attributed by Lucas-Championniere # to the dragging of the pedicle. The separation of the stump occurs from the twelfth to the fifteenth day. * Levy, " Ueber die Methode des Kaiserschnittes nach Porro," " Wiener Klinik," Heft xi und xii. f Elliott Richardson, " Caesarean Section, with Removal of Uterus and Ovaries, after the Porro-Mtiller Method," "Am. Jour, of the Med. Sci.," January, 1881. X All attempts to drop the pedicle into the peritoneal cavity have thus far proved fatal. In a remarkable case reported by Professor I. E. Taylor, the patient lived twenty- six days. On the seventeenth day phlegmasia dolens was developed, which was, how- ever, rapidly improving, when the woman, who was somewhat unruly, after sitting up in a rocking-chair against orders, was suddenly seized with dyspnoea, and died in a few hours from pulmonary embolism.—{Vide "Am. Jour, of the Med. Sci.," July, 18S0.) # Maygrier, " Etude de l'operation de Porro," Paris, 1880, p. 33. CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 415 The sterilization of the female as the result of amputating the uterus has been discussed from its moral aspect. FeAv persons in this country are likely, hoAvever, to be restrained in its performance by the extremely rare cases where the older operation has been success- fully carried out a number of times upon the same individual. The chief merit of the method of Porro lies in the fact that each step in the operation is capable of human control, and is capable, therefore, of human improvement. Thomas's Operation, or Laparo-Elytrotomy.—In Professor Thomas's operation, the dangers of opening into the peritonaeum and Avounding the uterus are avoided by incising the walls of the abdomen in the line of Poupart's ligament, lifting the peritonaeum, and dissecting doAvn to the vagina, dividing the vagina transversely, and then, having reached the cervix, extracting the child through the passage thus artificially created. The credit of defending the practicability of the extra-peritoneal delivery of the child above the pelvic brim belongs chronologically to Ritgen. It was the natural outcome of the teachings of Abernethy and Cooper, to whom we owe the ligation of the external iliac artery without opening the peritonaeum. The modus operandi was carefully thought out by Ritgen, and was put by him to the practical test Octo- ber 1, 1821. The incision through the vagina, which was made with a sharp bistoury in a longitudinal direction, was, however, followed by such profuse haemorrhage that the operation was discontinued, and the ordinary Caesarean section performed in its place. The patient died at the end of fifty-eight hours.* In 1823 Baudelocque the younger, unaAvare of the Avork of his pred- ecessor, advised an incision doAvn to the peritonaeum along the exter- nal edge of the rectus muscle, extending from the umbilicus to two inches above the pubes, separating the peritonaeum from the iliac fossa with the finger introduced into the loAver end of the Avound, incising the vagina to a length of four and a half inches, and then leaving the expulsion of the child to nature, or extracting it with the short for- ceps. In 1844 he published an essay reporting tAvo cases in which he had tried his plan, modified, however, by substituting the flank incision of Ritgen for that along the rectus muscle. Like Ritgen, Baudelocque did not complete his first operation, oAving to the extent of the vaginal haemorrhage. In his second case, he succeeded in delivering the child, which was, however, dead at the time of his undertaking the operation. Having accidentally pricked the external iliac artery, Baudelocque tied the common iliac, in order to arrest the haemorrhage thence resulting. The labor was likewise complicated by convulsions. Death took place * For the particulars of this and the succeeding cases, the writer is indebted to Dr. Henry J. Garrigues's model essay " On Gastro-Elytrotomy," " N. Y. Med. Jour.," October and November, 1878. 416 OBSTETRIC SURGERY. on the fourth day. The merit of first performing laparo-elytrotomy belongs, therefore, to Baudelocque. In 1837 Sir Charles Bell, in his "Institutes of Surgery," suggested practically the same plan of procedure as that subsequently advocated by Dr. Thomas. In 1870 Dr. Thomas, who was at the time unaAvare of the labors of his predecessors, read a memorable paper before the Medical Asso- ciation of Yonkers, giving an account of, first, laparo-elytrotomy per- formed tentatively upon the cadaver of a woman dying in the ninth month of pregnancy ; and, second, upon a living woman at the end of the seventh month of pregnancy, who had been suffering from pneu- monia for a week or ten days, and was at the time of his visit in ar- ticulo mortis. The operation Avas undertaken in the interest of the child, Avhich Avas extracted alive, and survived about an hour. In 1874 the operation was repeated by Dr. Skene. The patient had been forty-eight hours in labor, and unsuccessful attempts at delivering her by craniotomy had been resorted to. She was suffering at the time of the operation from exhaustion and shock, which gradually became more marked, and she died seven hours after. In 1875 and in 1877 Dr. Skene had the glory of successfully performing the operation under circumstances of great difficulty, with the result in each case of saving the lives of both mother and child. In 1877 Dr. Thomas had the good fortune to obtain a like triumph. In England the operation has been performed by Drs. Himes and Edes, both times in the interest of the child, the condition of the mothers being wellnigh hopeless. Both children were saved. In 1880 Dr. Walter R. Gillette * extracted by laparo-elytrotomy a putrid child, which he Avas obliged to perforate and extract with the cephalotribe, the forceps and version having been previously tried without success. The mother recoA*ered Avith scarcely an untoward symptom. The foregoing results present scarcely a parallel in obstetric sur- gery. They ought certainly to inspire the profession with a confidence at least equal to that enjoyed by the rival procedure of Porro. The question to be decided in the future is, as to how far laparo- elytrotomy is adapted to general usage. It is possible that the suc- cesses so far obtained have been largely due to the exceptional merits of the operators Avho have undertaken it. With the present experience it would seem as though it ought to receive the preference in all cases, where the dilatability of the cervix is such as to allow delivery by for- ceps or version, after the artificial passage has been formed, to be ac- complished Avith ease and celerity. The vaginal haemorrhage noted in the cases of Ritgen and Baude- locque can apparently be avoided by tearing the vagina transversely, * Gillette, " A Successful Case of Laparo-Elytrotomy," " Am. Jour, of Obstet.," Jan- uary, 18S0, p. 98. CESAREAN SECTION.—OPERATIONS OF THOMAS AND PORRO. 417 as recommended by Thomas, in place of incising it with a bistoury. In three of the cases vesico-vaginal fistulae were produced, but all healed spontaneously. The following description of the operation is borrowed from the excellent essay of Dr. Garrigues, which has already been quoted. It has received the sanction of Drs. Thomas, Skene, and Gil- lette, with the exception that, in discussion, all have agreed that it is desirable to insert a perforated drainage-tube through the abdominal wound into the vagina, and to keep the parts cleansed with antiseptic injections. Operation.—" The bowels having been emptied by an aperient and a copious enema, and the os having been fully dilated by Barnes's water-bags, if it is not so already, the patient is placed on her back, on a long, narrow table covered with a mattress or quilts, rubber or oil-cloth, and a sheet. The pelvis is well elevated on a hard cushion, the head and shoulders slightly raised by means of pillows, the legs stretched out. If, from some cause, it has been impossible to dilate the os fully by Barnes's dilators, it is now done by the fingers, or, if that is impossible too, it is dilated later through the abdominal wound. The patient is anaesthetized. Since disinfection can not be carried out strictly, and since its administration would give some additional trouble, it is scarcely necessary to operate under disinfectant spray. " The operator takes his place at the right side of the patient. Be- sides one who administers the anaesthetic, four assistants are needed ; one on either side of the operator, and tAvo in front of him. The first assistant, standing at the left of the patient's chest, lays his flat hands under the umbilicus and draws the uterus upward and toward the left, thereby putting the skin in the right iliac region on the stretch. Counter-extension may be made by the assistant placed at the right of the operator. A slightly curved incision is made through the skin from a point one inch and three quarters (4*5 centimetres) above and outside the spine of the pubes, parallel to and an inch above Pou- part's ligament, to a point an inch above the anterior superior spine of the ilium. This incision may also be made in the opposite direc- tion, from without inward. By a few touches with the edge of the knife the external oblique muscle is laid bare, and spouting branches of the superficial epigastric artery secured by holding-forceps. The abdominal muscles are cut to the same extent, layer by layer, the ex- ternal oblique, the internal oblique, and the transversalis, the first of which is aponeurotic. The transversalis fascia is very carefully hooked up with a fine tenaculum, and the knife carried horizontally, so as to make a small opening in it, avoiding the peritonaeum that lies be- neath it, separated from it by loose areolar tissue, and sometimes fat. A director is introduced through the opening and pushed between the fascia and the peritonaeum toward the inner and the outer angle of the wound, and the fascia is cut. The best instrument for this pur- 27 418 OBSTETRIC SURGERY. pose is Key's hernia director, the one which Spencer Wrells uses when incising the peritonaeum in ovariotomy. It is firm, a quarter of an inch (six millimetres) broad, slightly curved on the flat, well rounded at the end, and has on its concave side a groove that stops a quarter of an inch (six millimetres) from the point of the instrument. Next, the operator places the pulp of his fingers on the peritonaeum, separat- ing it from the transversalis and iliac fasciae, until he reaches the vaginal wall. The second assistant, placed at the left of the operator, holds the peritonaeum and intestines, applying a fine, warm napkin under his hands, in order to be sure not to let them slip. The first assistant draws the uterus vigorously upward and toward the left, in order to expose the deeper part of the vaginal wall on the right side. A female silver catheter is introduced into the bladder by the third assistant, placed at the left hip of the patient and held in the known direction of the boundary-line between the bladder and the vagina, below the ureter on the side on which the operation is being per- formed. A* blunt Avooden instrument, something like the obturator of a cylindrical speculum, only longer, is introduced into the vagina and applied above the linea ileo-pectinea, raising the vaginal wall as much as possible into the abdominal wound. An incision is made parallel to the ileo-pectineal line and the catheter felt in the bladder, as far below the uterus as possible, in order to avoid the ureter and Douglas's pouch, and incise where there are fewest vessels, cutting down on the obturator with Paquelin's thermo-cautery, the galvano- caustic knife, or simply cautery-irons (table-knives) only heated to red heat. The surrounding parts are protected by the application of wet compresses around the place to be cauterized. The incision made by the cautery is extended forward toward the symphysis and back- ward toward the promontory by placing the pulp of both index-fin- gers perpendicularly on the edges, and applying the force in different places in the direction of the os uteri and the ileo-pectineal line, so as to tear the vaginal wall as far forward as is deemed safe in regard to the bladder and the urethra, the locality of which organs is ascertained by feeling the catheter held by the assistant, and as far backward as the wound in the abdomen will allow. Now the catheter is withdrawn, the membranes ruptured if the liquor amnii has not escaped before, the uterus tilted as much as possible to the opposite side, and the os drawn with the forefinger into the iliac fossa. "The operator draws the child through the double wound either by simple extraction, or after turning, or by applying the forceps, accord- ing to the presentation and other particular circumstances. The pla- centa is expelled by compressing the uterus, and withdrawn through the wound. " If bleeding occurs, the operator tries to check it by applying liga- tures through the abdominal wound, holding-forceps, styptics, or can- AN0A1ALIES OF THE EXPELLENT FORCES. 419 teries, using a large wooden tubular speculum; or a Sims speculum may, perhaps, give easier access to the bleeding vessel than anything else. If it be impossible to check the haemorrhage, the vaginal wound must be firmly tamponed from below through the vulva and from the abdominal wound with cotton pledgets soaked in cold water and squeezed, and held in situ by broad straps of adhesive plaster round the abdomen, as after ovariotomy. Except in the last eventuality, the bladder is distended by injecting lukewarm milk in order to ascertain if this organ has been injured. If so, the fistula is immediately sewed with catgut, which need not be removed. The wound is cleaned by injecting a stream of lukewarm carbolized water (two per cent.), or a solution of thymol (two per thousand), from the vagina and from the abdominal wound. Next, the edges of the abdominal wound are brought together by interrupted sutures, and the lower part of the abdomen covered Avith borated or salicylated cotton, and surrounded by broad straps of adhesive plaster fastened to the hips, as in ovari- otomy. A pledget of cotton soaked in carbolized oil (1 to 10) is ap- plied at the entrance of the vagina." THE PATHOLOGY OF LABOE. CHAPTER XXIV. ANOMALIES OF THE EXPELLENT FORCES. Precipitate labors.—Tardy labors.—Irregular pains in the first stage of labor.—Treatment of protracted first stage.—Irregular pains in the second stage.—Treatment of pro- tracted second stage.—On the use of ergot in labor.—Irregular pains in the third stage; treatment.—Painful labors: from hysteria; from rheumatism; from intesti- nal irritation; from inflammatory changes. In physiological labor the expellent forces are adequate to over- come the resistance encountered. Labor becomes pathological—1. When the pains are defective ; 2. When the resistance offered by the soft parts or the bony pelvis exceeds the limits of safety to the mother or the child ; 3. When natural delivery is rendered difficult or impos- sible, owing to malformations or malpresentations of the foetus ; 4. In consequence of dangerous complications, such as haemorrhage, eclamp- sia, and prolapsed funis. From a clinical point of view the anomalies of the labor-pains are divisible into pains in excess, weak pains, pains attended by an extreme 420 THE PATHOLOGY OF LABOR. of physical suffering, and pains complicated by strictures. Physiologi- cally, however, these different forms are far from composing distinct conditions, isolated from one another. Thus, rigidity of the os is always intensely painful, and is usually dependent upon feeble action of the expellent forces. There is no standard of strength by Avhich the weak- ness or excess of pains can be measured. The terms are always rela- tive, and are used with reference to the obstacles to be overcome. In primiparae strong pains are requisite to induce softening and dilata- tion of the cervix. In multiparae pains may be intrinsically weak, and yet suffice to bring labor to a prosperous conclusion. Much confusion of mind is often occasioned by the double sense in which the term "labor-pains" is employed. Thus, it is frequently stated that the pains are good, when an examination reveals only a feeble measure of uterine contraction, the word "pains" representing nothing more than an acute degree of physical suffering. Clinically, pains are to be judged by the effects they produce. In practice it will be found con- venient to study the various forms of irregular uterine action in con- nection with the results of their influence upon the duration of labor. These results are—1. Precipitate labor ; 2. Tardy labor. Precipitate Labors.—It is customary to ascribe precipitate labors to an excess of the pains. The term excess is, however, only relate. There is no reason to believe that the uterus ever acts with such a degree of energy as per se to constitute a pathological condition. With a large, roomy pelvis, a soft, dilatable cervix, a distensible vagina and perinaeum, labor may be terminated by a feAv strong pains. Such rapid deliveries are not to be regarded with apprehension. As a rule, they are followed by firm retraction of the uterus, and the con- tinuance of good contractions acts as a safeguard against haemorrhage. The puerperal state usually pursues a favorable course. Aside from the inconvenience which sometimes results when, perchance, women are suddenly overtaken by labor-pains in the streets or in public places, an easy, rapid labor is to be regarded as one of the varieties of normal labor. Except the adoption of precautions against such untoward accidents, they call for no special treatment. When, however, the parturient act occurs in women who possess an undue reflex irritability, which impels them to an excessive use of the abdominal muscles, it is possible for serious mischief to ensue. Thus, if the patient happens to be seized when in the standing post- ure, the straining efforts may throw the child suddenly upon the floor; but even here the. consequences are less detrimental than would be naturally anticipated. The force of the fall is usually broken by the cord. Lacerations of the latter take place at a distance from the navel, and are not followed by haemorrhage. Post-partum haemor- rhage, prolapse, and inversion of the uterus are said to be possible occurrences, though of extreme infrequency. When all the expellent ANOMALIES OF THE EXPELLENT FORCES. 421 forces are called into play at an early period of labor, before the rigid- ity of the utero-vaginal canal has been overcome, the violent straining has been known to cause subcutaneous emphysema of the head and neck, to interfere with the utero-placental circulation, and even to produce fracture of the fetal skull. Excessive straining, before the soft parts have been properly prepared for the passage of the child, may likewise lead to lacerations of the cervix, vagina, and peri- naeum. The proper treatment for this condition is to lower the reflex irri- tability by hypodermic injections of morphia ; or, better still, by the production of complete anaesthesia, so as to suspend the action of the voluntary muscles. Tardy Labors.—For the proper understanding of labors protracted beyond the period of safety by irregular uterine contractions, it is necessary to bear in mind the principal features of normal delivery. These are, contractions of the uterus followed by relaxation and dis- tinct periods of repose ; stretching and thinning of the muscular fibers below the ring of Bandl, with retraction of the uterus above that point; softening and dilatation of the cervix; the fixation of the uterus in the axis of the pelvis; and the addition of the abdominal muscles to the expellent forces. • The first requisite of every normal labor is that the pains shall be good—i. e., shall possess a markedly expulsive character. We have seen that for the uterus to perform work the contractions should not be continuous, but distinctly rhythmical. For effective work, more- over, the excursions of the uterus during a contraction should possess a certain degree of amplitude, and the interval between the contrac- tions should be sufficient to allow the nervous system to recover from the shock of pain. Irregular Pains in the First Stage of Labor.—In the first stage of labor, pains are most frequently defective by reason of their short dura- tion. As a rule, short, cramp-like pains occasion acute suffering. When they recur with little or no interval between them, they are very exhausting to the patient. As the cervix in such cases is tense and rigid, it is to this condition that the delay is usually attributed. If, how- ever, the tissues of the cervix are healthy, the presentation is normal, and the pains preserve their expulsive character, rigidity of the cervix is never an obstacle to delivery. The activity of the organic changes which lead to softening and dilatation is closely related to the activ- ity of the uterine contractions. The exception to this rule in primi- parae is only apparent. To be sure, in them the firm, closely knitted tissues of the cervix yield more gradually to the dilating forces than in multiparae. Indeed, in multiparae Ave sometimes find the organic changes in the cervix induced by contractions which have hardly ex- cited the notice of the woman; but in primiparae, while good pains, 422 THE PATHOLOGY OF LABOR. under the reservations mentioned, certainly induce softening of the cervix, weak pains effect no changes in its tissues. The uterine contractions may be abnormal from the commence- ment of labor; more frequently the loss of their expulsive character is a secondary condition. In many primiparous women labor progresses in an auspicious manner for a time, inspiring hopes of a speedy ter- mination. Then the cervix, which had previously been dilating favor- ably, becomes rigid, the sufferings of the patient during each contrac- tion are enhanced, and further advance is arrested. This transforma- tion is not to be accounted for by a spasm of the circular fibers of the os, but is the result of secondary changes in the action of the uterus itself. The right understanding of the phenomenon in question ren- ders it necessary to recall the physiological fact that the uterus is endowed not only with contractility, but with retractile properties likewise. These are shown in a marked way by the manner in which the uterus closes upon its contents after the escape of the amniotic fluid ; so, too, by the manner in which the uterus follows down the foetus during the period of expulsion. Normally, the gradual closure of the uterus upon the ovum leads with a dilated os to the perma- nent formation of the bag of waters. Thus it will be seen that in normal labor retractility is a wholly beneficent possession of the uterus. WThen, however, from any cause the cervix dilates slow- ly, and the pains are strong and close together, as the uterus re- tracts upon the stationary ovum, the excursions made by the labor- pains shorten, which thus tend to assume the clonic form. The continuance of the same process leads finally to the close investment of the ovum by the uterus, when the only indication of contractility which remains is the increased hardening of the uterus at short in- tervals. These changes in the character of the contractions are marked by corresponding changes in the cervix, the condition of the latter affording an index of that of the entire uterus in much the same way that a furred tongue bespeaks a catarrhal condition of the stomach. These secondary changes in the pains are dependent upon a variety of conditions. The tardy dilatation of the cervix, which stands in a causal relation to them, may result from over-distention of the mem- branes with amniotic fluid, or from their firm adhesion to the walls of the uterus around the os internum—conditions which, in either case, interfere with the stretching of the lower segment, and thus lead to waste of uterine force by distributing it uniformly over the entire ovum. Again, where there is lack of parallelism between the axis of the uterus and that of the pelvic brim, the presenting part may, by bearing especially upon the anterior portion of the lower uterine seg- ment and of the cervix, exercise so little pressure upon the os that its sphincter long maintains its integrity. Finally, irregular contractions ANOMALIES OF THE EXPELLENT FORCES. 423 may be consequent upon faulty presentations, and upon any form of pelvic obstruction. A special and dangerous form of irregularity results when the mem- branes rupture prematurely, and the entire amount of amniotic fluid leaks away. This, to be sure, is a rare event, as the presenting part, as a rule, acts as a valve which closes the lower segment of the uterus, and prevents the amniotic fluid from escaping. When, however, ow- ing to the small size, the uneven shape, or the hindered descent of the presenting part, the accident in question takes place, as a combined result of muscular retractility and the pressure of the intestines dur- ing the pains, the uterus gradually conforms to the surface of the foetus. In this way the much-dreaded "dry labors" are produced. The consequences are far-reaching. The retraction of the muscular fibers about the child's neck in head presentations forms an impediment to natural delivery ; the disturbance of the utero-placental circulation endangers the life of the child ; the uterine walls applied to the convex surfaces of the child become anaemic, while the reentrant portions, subjected to negative pressure, become hyperaemic and oedematous, extravasations take place into the tissues, the walls are rendered fri- able, the contractions are associated with intense pain, and peritoneal irritability develops.* The prolonged retraction of the uterus may be followed in the end by the entire cessation of pains, and paralysis may ensue. Uterine retractility is not precisely the same force as that which causes the expulsion of a fluid from an over-distended elastic sac, for retractil- ity and contractility are in the uterus barely disassociated from one another. When the uterus ceases to contract, it forfeits, as a rule, its retractile properties likewise.! It sometimes follows, therefore, that, following prolonged tonic contraction, after the evacuation of the uterus, the walls of the latter collapse like those of a pricked bladder. The Treatment of a Protracted First Stage.—The treatment of a protracted first stage has for its object the mitigation of pain and the restoration of their expulsive quality to the uterine contractions. No plan of action should be decided upon without first carefully investi- gating the cause of delay. The suspensive influence of a full bladder or rectum is always to be borne in mind. In face, breech, and shoul- der presentations, and in contracted pelves, the slow dilatation of the cervix is the rule, and, with such exceptions as will be noted in their appropriate connections, do not call for interference. A faulty posi- tion of the uterus should, if possible, be rectified by suitable abdom- inal support. Adhesions of the membranes to the loAver uterine segment should be dissected up by the index-finger. In hydramnion, * Lahs, " Die Theorie der Geburt," pp. 285 et seq. \ Breisky, " Ueber die Behandlung der puerperalen Blutungen," Volkmann's " Samml. klin. Vortr.," No. 14, p. 92. 424 THE PATHOLOGY OF LABOR. rupture of the membranes, so as to allow the partial escape of the amniotic fluid, is sometimes serviceable. If the length of the labor is simply due to the insufficient uterine action, the conduct of the accoucheur will, in a measure, depend upon the frequency and severity of the pains and the endurance of the patient. If the pains occur at such intervals, and with such mildness that the patient is able to eat, to sleep, and to attend to ordinary household duties, the dilatory progress of labor should cause no appre- hension. In pathological conditions it is the element of pain which is most to be dreaded. Pain long continued is a powerful nerve-de- pressant. When combined with starvation and deprivation of sleep, it greatly impairs a woman's capacity to resist the perils of the puer- peral period. While, therefore, the indication for treatment is clear enough, it is not so easy in a given case to decide whether the remedy should be applied first to the relief of pain, or whether efforts should be directed at once to the acceleration of labor, so as most speedily to place the patient beyond the hazards of parturition. As a rule, how- ever, it may be stated that anodynes are appropriate in cases where the cervix is but slightly dilated, while accelerative measures naturally re- ceive the preference in those where the first stage of labor is already far advanced. The pain-stilling agents from which the selection should be made are the warm bath, chloroform, chloral by rectal injection, and mor- phia, either alone or combined with minute doses of atropia. In prac- tice it will usually be found convenient to begin with chloroform, and then to sustain its action by the hypodermic injection of morphia, suspending the chloroform so soon as the tranquillizing effect of the latter is developed. Opiates often accomplish wonders in one of two ways : when, owing to the prolongation 'of the labor and its attend- ant pain, the patient's nervous energies have become exhausted, the arrest of pain enables the woman to sleep, and, with the recuperation of power that comes upon awakening, good pains folloAV, which bring the labor to a happy termination. In other cases, after the employ- ment of the anodyne the parts apparently relax, and an acceleration of labor follows. In these cases the oxytocic effect is probably due to the quieting action exerted upon the spinal nerves. It has been surmised that the nerves of the uterus derived from the cerebro- spinal system possess inhibitory properties—a theory which, if true, readily explains how severe pain suspends uterine action, and how the quieting of pain would restore to the motor ner\~es their full energy. In a certain proportion of cases the effects of the anodyne or an- aesthetic are of but short duration. In from ten to thirty minutes the acute suffering returns, and the short truce is unattended with benefit. There is an erroneous opinion that, so long as the membranes are un- ruptured, this condition may be allowed to go on indefinitely. It is, ANOMALIES OF THE EXPELLENT FORCES. 425 however, of the greatest importance that the length of the period of non-interference should be governed by the strength of the patient. There is nothing that requires more judgment in midwifery practice than to decide when the time has arrived at which delay is fraught Avith more danger than active interference. For my own part, I be- lieve that many fair lives are needlessly squandered because of excessive timidity begotten of imperfect obstetric teachings. If pain-stilling agents do no good, or if the first stage is already far advanced, the physician should seek, by restoring to the pains their expulsive character, to hasten delivery. Of reputed service in cases of uterine insufficiency are the warm vaginal douche, the dilating bags of Barnes, the introduction of a bougie into the uterus, forceps, and the internal administration of quinine, ergot, viscum album, borax, cannabis Indica, cinnamon, or digitalis. The bougie is applicable only to cases where the membranes are intact, and where the pains are weak without being cramp-like in char- acter. In hospital practice it possesses the disadvantage that it can become the conveyer of infection to the uterine cavity. The vaginal douche possesses a wider range of utility. It is safe and tolerably effective, under favorable conditions. It promotes the organic changes in the cervix, stimulates the uterus to contract, and mechanically distends the vagina. Its action is, hoAvever, apt to be slow and somewhat uncertain. In a case of over-distention of the amnion, I once saw its employment followed immediately by complete tonic rigidity of the uterine muscular fibers. Of all the resources at our disposal, however, the water-bags of Dr. Barnes stand easily at the head. Passed within the cervix, and dis- tended so as to place the canal moderately upon the stretch, they not only serve to mechanically dilate the os, but are most efficient as reflex excitors of the labor-pains. If left in situ until expelled into the vagi- na by the bearing-down efforts they awaken, the cervix will be found to have lost its rigidity. If necessary, a larger dilating bag should then be employed in the same way. An attempt to dilate the cervix rapidly and with violence is neither safe nor profitable. To obtain permanent results it is essential to effect the organic changes in the tissues which render them physiologically dilatable. In cases of tonic rigidity of the uterus, the production of normal pains will sometimes be assisted by rupturing the membranes and raising the head, so as to allow a small portion of the amniotic fluid to escape, previous to resort- ing to the Barnes water-bags. When, after rupture of the membranes, a segment of the head presents at the os externum, the rubber bags are of less service. In such cases often we are able to accomplish speedy dilatation by simply asking the woman to hold her breath, and to reenforce the uterine 426 THE PATHOLOGY OF LABOR. pains by the action of the auxiliary muscles. If this plan fails, forceps should be applied, and the head be made to serve as the dilating body. To avoid lacerating the cervix, the tractions should be intermittent, and should be suspended during the acme of the pains. The rule given for the preservation of the perinaeum will be found most service- able in attempts to maintain the integrity of the cervix, viz., that the extraction is most safely accomplished during the period of greatest relaxation, and not at the moment of extreme tension.* Of the various internal remedies to stimulate uterine action, ergot should, in the first stage of labor, be unqualifiedly prohibited. In spite of numerous favorable experiences from its use, its tendency to intensify tonic contraction of the involuntary muscular fibers makes it always a perilous drug. The enthusiastic praises of quinine by Drs. Fordyce Barker and Albert H. Smith, of Philadelphia, warrant fur- ther trials of its efficacy. Dr. Smith says : "I do not hesitate to give it in every case, because, even where there is no decided inertia at the onset of labor, there may be failure of the powers of the mother from early exhaustion and fatigue, and we get the benefit of the quinia in diminishing this tendency and also in promoting the condensation of the uterine fiber after the delivery of the placenta, thus lessening the dangers of post-partum haemorrhage and the annoyances of the after- pains so commonly resulting from a slow condensation of the uterine muscle." f He recommends the bisulphate in a fifteen-grain dose, which he declares acts altogether beneficially as a stimulant to the normal uterus. The other agents mentioned as possessing direct or incidental ecbolic properties are now chiefly of historic interest. Irregular Pains in the Second Stage of Labor.—In many cases the pains maintain their normal quality until the completion of the first stage of labor, and the descent of the head to the floor of the pelvis. When in the second stage of labor the pains become inefficient and lose their expulsive character, the non-advance of the head is usually attributed to a rigid perinaeum. But it is a matter of every-day expe- rience that with really good pains and normal head mechanism the perinaeum speedily loses its rigidity. Of course, it is not denied that, in primiparae, the organic changes which effect the softening of the perinaeum need for their accomplishment relatiA'ely stronger pains than in multiparae. The faulty action of the expellent forces in the second stage is due either to exhausted nerve-power or to excessive uterine retraction. In the former case, labor becomes powerless from the feeble character of the pains ; in the latter, it results from the withdrawal upward of the uterine muscle, and the consequent les- * I have purposely avoided making mention of incisions through the vaginal portion of the cervix, as, in a large experience in difficult labors, I have never so far seen the occasion for their employment. f Albert H. Smith, " Retarded Dilatation of the Os Uteri in Labor," p. 27. ANOMALIES OF THE EXPELLENT FORCES. 427 sening of the intra-uterine pressure. These cases of retraction are worthy of special consideration. Thus, Hofmeier * found in a num- ber of instances, where the head rested on the pelvic floor, that the ring of Bandl, which was made out by palpation through the abdomi- nal walls, was situated at from five to seven inches above the symphy- sis pubis, so that the contractile portion of the uterus covered not more than one third of the foetus. Under such circumstances, while the patient suffers from intense pain, the contractions of the partially emptied uterus do not possess the force to overcome the resistance of a rigid perinaeum. Treatment.—In all cases of protracted second stage, before deciding upon the existence of uterine irregularity, both the bladder and the bowels should be emptied, and care should be taken to exclude the existence of obstruction from the bony pelvis. If the only resistance to be overcome is that furnished by the soft parts, weak pains should be reenforced by the action of the abdominal muscles. After rotation of the head is completed, a new vis a tergo may be supplied by press- ure applied to the breech through the abdominal walls after the method of Kristeller, or by the modified form of expression recom- mended by Bidder, f According to the latter, the physician should stand to the left of his patient, and grasp the breech of the foetus with the right hand ; he should then raise the breech and fix it in such a position that the pressure applied will be best transmitted through the spinal column to the cephalic end—a point to be determined by the fingers of the left hand, which should likewise control the movements of the head during the period of expulsion. The force, the frequency, and the length of the acts of expression should of course be decided by the judgment and experience of the operator. Where the movements of flexion and rotation have been imperfectly performed, little is to be expected from any of the forms of expression. The available remedies are then ergot and the forceps. Of these the advantages of safety and celerity are all on the side of the forceps. Many practitioners, howeA^er, who have observed that in practice ergot often acts likewise with speed and safety, accord to it a large measure of confidence. But along with these more fortunate experiences there is a shady aspect to be remembered. Wlien the tardy labor is due to tonic retraction, the use of ergot is calculated to aggravate the sources of delay. In other cases tonic retraction is the direct result of ergotic action, and, as a consequence of restricted utero-placental circulation, the life of the foetus is jeopardized. When, therefore, the drug is used, the heart-sounds of the fcetus should be carefully watched, and, * Hofmeier, " Ueber Contractionsverhaltnisse des kreissenden Uterus," " Ztschr. f. Geburtsh. u. Gynaek.," Bd. vi, p. 164. f E. Bidder, " Zur Beurtheilung der Kristeller'schen Expressionsmethode bei Kopf- lagen," "Ztschr. f. Geburtsh. u. Gynaek.," Bd. iii, p. 241. 428 THE PATHOLOGY OF LABOR. with the first signs of failing force, the forceps should be applied to rescue the child from the impending danger of asphyxia. Note on the Use of Ergot in PARTrjErnosr.—Secale cornutum, or ergot, the active principle of which is ergotin, according to Buchheim,* and ergotic acid, according to Zweifel,t is universally acknowledged to increase the frequency, length, and power of the uterine contractions during parturition, and to finally induce a tetanic condition of the uterine muscular fibers. Its action upon the unimpregnated uterus is the same in kind, but less marked in degree, and of less constant occurrence. The views of high authorities in regard to the manner in which these effects are produced present irreconcilable differences. Wernich J attributes the ecbolic properties of ergot to irritation of the uterine nervous cen- ters, induced by arterial anaemia of the spinal cord and of the uterine tissues. This anaemia is referred by him to loss of tone in and dilatation of the veins, whereby venous congestion, leading to secondary arterial anaemia, is produced.* Other observers assume a primary contraction of the capillaries, with a consequent increased arterial pressure, as the source of the anaemic irritation of the nerve- centers, while still others believe direct stimulation of the uterine muscular fibers, by the ergot, to be the cause of their exaggerated contractility.! Kohler refers the uterine contractions produced by ergot to increased irrita- bility of the peripheral nerves, in conjunction with anaemia of the spinal cord.A These conflicting views pertain chiefly to points of purely theoretical interest, and need cot prevent the obstetrician from obtaining a clear conception of his duty in the practical administration of ergot. The above-mentioned incontro- vertible facts concerning its operation suffice to guide the physician in the em- ployment of this useful drug, even if he be unable at present to definitively de- cide regarding the exact mechanism of its physiological action. Ergot should never be exhibited during the first stage of labor, because the tetanic uterine contractions, which it substitutes for the normal rhythmical ones, tend to prevent the further dilatation of the os uteri and to deprive the foetus of its blood-supply through the constriction of the uterine vessels. Should the membranes have ruptured before the termination of the first stage, the adminis- tration of ergot would endanger the life of the fcetus by causing undue pressure to be exerted upon the umbilical cord. "We should also abstain from the use of ergot during the second stage, unless it seem necessary as a prophylactic against post-partum haemorrhage. Even under these circumstances it should never be administered if there be the slightest mechanical obstacle to delivery, or if the fetal head be high up in the pelvic canal. Spiegelberg Q insists upon the neces- sity of carefully observing the fetal heart after the use of ergot, in order that instrumental delivery may, in case of threatened asphyxia, be promptly resorted to. Benicke records twenty-seven cases in which ergot was administered during the second stage on account of inertia uteri. Spontaneous delivery occurred in * Buchheim, Schmidt's " Jahrb.," vol. clxiv, p. 12. f Zweifel, " Ucb. d. Secale corn.," " Arch. f. exp. Pathol.," vol. iv, 18*75, p. 407. X "Wernich, "Einige Versuch. lib. d. Mutterk.," "Beitriig. z. Geburtsh.," vol. iii, 1874, p. 102. * AVeenich, op. cit., p. 07. || Benicke, "Ueb. Anwend. d. Mutterk. in d. Geburtsh.," "Ztschr. f. Geburtsh. u. Gynaek.," vol. iii, 1878, p. 174. A Kohler, Schmidt's "Jahrb.," vol. clxiv, p. 14. Q Spiegelberg, " Lehrb.," p. 414. ANOMALIES OF THE EXPELLENT FORCES. 429 only seven of these cases.* Ergot is not specially adapted to the arrest of haemorrhage accompanying abortion or premature delivery. In these cases, and in haemorrhage caused by retained shreds of the fetal envelopes, the appropriate treatment consists in the tampon and in subsequent complete evacuation of the uterine cavity. The only imperative exhibition of ergot is presented by the occurrence of post-partum haemorrhage resulting from uterine atony, t The un- yielding, tetanic uterine contractions which it produces act most beneficently by occluding the orifices of the bleeding vessels. Even under these circumstances it should, however, be withheld until after the expulsion of the placenta, lest the uniform uterine contractions lead to its prolonged retention or interfere with manual efforts for its extraction. Irregular Pains in the Third Stage of Labor.—The tardy expulsion of the placenta, due to atony of the uterus, is of rare occurrence when the Crede method of expression is uniformly practiced. As, in relaxed conditions of the uterus, blood pours from the patulous mouths of the torn utero-placental Aressels into the fundus, a free external discharge of blood follows of necessity whenever contractions are excited—a fact to be borne in mind by an unpracticed obstetrician, lest he mistake the simple conversion of an internal into an external haemorrhage for one produced by the manipulations which have been recommended. The whole subject of atony in the third stage is, however, so closely associated with the occurrence of post-partum haemorrhage that its specific consideration will be reserved for separate study in connec- tion with the haemorrhages which take place during and subsequent to labor. After the birth of the child, retraction of the uterus is Nature's safeguard against haemorrhage. As a result of the abuse of ergot, or, in other cases, from an abnormal adherence of the placenta, such an extreme degree of retraction may be reached before the completion of the third stage as to lead to the imprisonment of the placenta Arithin the uterine cavity. In these cases, complete retraction in the body of the uterus is prevented by the presence of the placental mass. Below the latter, Avhere no obstacle is opposed to the shortening of the mus- cular fibers, a constriction results. The stricture is most pronounced at the ring of Bandl. The loAver uterine segment and the cervix proper are usually in a sub-paralytic condition, and widen from above downward to the vaginal insertion. From the shape thus imparted to the uterus, this condition is generally known as an " hour-glass con- traction." When met with for the first time, it is apt to prove ex- tremely puzzling. In following the cord upward, its continuation through the stricture is sometimes overlooked. In several cases I have known the pulpy mucous membrane of the lower segment to be mistaken for an adherent placenta, and have been, in consequence, summoned to assist in its removal. * Benicke, op. cit., p. 178. f Schroeder, " Lehrb.," fifth edition, p. 471. 430 THE PATHOLOGY OF LABOR. Treatment.—By patient waiting, relaxation of the stricture usually takes place spontaneously. The result may be promoted by the hypo- dermic injection of morphia, combined with atropia. It is not, how- ever, altogether safe to leave the patient before the expulsion of the placenta has taken place ; for, exceptionally, the muscular fibers of the body of the uterus may relax prior to those of the lower segment, and thus haemorrhage may result. Injections of ice-cold water Avere recommended in such cases by Seyfert, as tending not only to restrain haemorrhage, but to promote regular expulsive uterine action. Forci- ble dilatation is rarely necessary, and should be reserved for haemor- rhages of an alarming character. In nearly all cases, however, it is practicable, even in extreme examples, to extract the placenta in a short time without force or violence. The plan I have followed of late years, with uniform success, consists in introducing the index and middle fingers, with the whole hand in the vagina, to the point of constriction. Then, by pressing the uterus downward, the fin- gers are brought in contact with the placental border. Now, it is only necessary to draw a single cotyledon into the canal to render the further extraction a matter of certainty. Under the pressure of the soft placental mass the stricture relaxes slowly. By combining expression with slight traction, the delivery is surely accomplished. The principal difficulty of the operation lies in the manipulations needful to bring the placenta at the outset to the point of strict- ure, but this difficulty can be pretty certainly overcome by patience and the determination to succeed. During the period of with- drawal, the operator should be content with a very slow progres- sion, proportioned to the yielding of the tissues; otherwise the pre- senting portion of the placenta tears away, when the labor expended is lost. Painful Labors.—In nearly all forms of abnormal uterine contrac- tions the pain of labor reaches a pathological degree of intensity. Especially we have had occasion to call attention to the intolerable suffering in cases of long-continued reciprocal pressure between the uterus and its contents. But acute suffering sometimes attends upon the preliminary stages of labor. During the latter days of pregnancy in primiparae, often for a few hours only preceding the advent of true labor-pains in multi- parae, contractions occur which normally scarcely attract the atten- tion of the patient. In rare instances, however, the suffering they occasion is extreme. In hysterical women these preliminary pains are often of an agonizing character, rendering it necessary to resort for their relief to such palliations as the warm bath, opium, and chloro- form. But, even where hysteria does not exist as a cause, the pains may be so severe, while the cervix has still its normal length, that the ANOMALIES OF THE EXPELLENT FORCES. 431 woman believes herself in labor, and, indeed, the contractions are as painful as in actual labor. There are no febrile symptoms indicative of inflammation either of the uterus or of its appendages. The pain is like that in muscular rheumatism. Though the term rheumatism of the uterus is often applied to this condition, its pathology is uncer- tain. It is very probable that practitioners confound together, under the foregoing title, a number of distinct affections, such as hysterical hyperaesthesia, intestinal irritability, and the early stages of inflamma- tion. Excluding these morbid conditions, there remains a class of cases practically important from the disappearance of the pain upon the induction of intense diaphoresis. Patients, who for days have been treated with hypodermic injections of morphia, with only moderate results, are often relieved as if by magic by placing them in a warm bath, and then covering them with blankets, giving in addition hot drinks and Dover's powder, until they become bathed in abundant perspiration. It is often difficult, toward the close of pregnancy, to distinguish between colic-pains due to fecal accumulation, or the presence of gases in the stomach and intestines, troubles to which pregnant women are especially disposed, and uterine contractions of a painful character. Indeed, in the former case the uterus becomes involved to some ex- tent, so that the cervix is felt during a cramp to simultaneously harden. Moreover, after labor has actually begun, it may become complicated by colic-pains, which exercise in turn a suspensive influ- ence upon parturition. But the colic-pains are themselves inter- mittent, and are, therefore, liable to be mistaken for those of labor. Thus it is possible to become involved in perplexities which time alone can solve. EA^en when we have made out the diagnosis of "false labor," and giA*e an opiate for the relief of the patient, it may happen that the first result of quieting the pain may be the accelera- tion of labor. When this does not occur, we should guard against the return of the trouble by clearing out the bowels by purgatives or enemata. In normal labors, the pulse becomes more rapid at the beginning of each pain, and continues to increase in frequency until the pain has reached its acme, after which a gradual declination follows. But sometimes labor is attended by marked febrile symptoms. There exist rapidity of the pulse between the pains and a continuous elevation of temperature. Now, if, at the same time, the uterine contractions are the source of extraordinary suffering, there is strong reason for sus- pecting that labor is complicated by inflammatory conditions of the organs concerned in parturition. Thus, a latent pelvi-peritonitis may be converted into the acute form by the several acts which comprise normal labor, or the prolonged tonic contraction of the uterus upon the foetus after the rupture of the membranes, especially in neglected 432 THE PATHOLOGY OF LABOR. shoulder presentations and in contracted pelves, may give rise to inflam- matory affections in the uterus itself. In either case the coexistence of intense pain with febrile symptoms should awaken serious appre- hensions. Especially ought we to be upon our guard against the treacherous lull in the symptoms that, as a rule, takes place when labor is at an end. After a day or two we may expect a chill and the return of the fever. In the early stages of metritic and perimetritic trouble, a ten-grain dose of calomel often exercises a beneficent action in arresting the disease. Where labor has so far advanced that the induction of artificial diarrhoea is rendered impracticable, opiates, though of inferior value, soothe the pain, and are our next most valu- able resource. CHAPTEE XXV. CONTRA CTED PEL VES. Varieties.—Frequency.—Diagnosis.—Pelvic measurements.—Forms of the contracted pel- vis.—Justo-minor pelves.—Flattened non-rachitic pelves.—Rachitic flattened pelves. —Generally contracted, flattened pelves.—Irregular forms.—Pseudo-osteomalacia. —Scoliosis.—Kyphosis.—Influence of contracted pelves during pregnancy and labor. —Influence upon the uterus.—Influence upon the presentation.—Influence upon the pains.—Influence upon the first stage of labor.—Influence upon the mechanism of labor.—Effects of pressure upon the maternal tissues.—Influence upon the fetal head.—Effects of pressure upon the integuments ; upon the cranium.—Prognosis. In contracted pelves sometimes a single diameter, sometimes all the principal diameters are reduced below the normal average. The relative proportion of the parts may be to a considerable extent pre- served, or the pelvis may have been distorted by special morbid condi- tions, giving rise to unequal development and changes of outline. These peculiarities embarrass all attempts at classification. Still, the study of the subject is greatly simplified by the fact that the dimin- ished space is, in the great proportion of cases, located chiefly at the brim. Aside from these, there remain a variety of irregular forms of rare occurrence, each requiring a separate description and plan of treatment. It is to those cases in which the narrowing is chiefly at the brim that the term "contracted pelves" is generally applied. The other forms are all specially designated by some qualifying adjective defin- ing their character. Contracted pelves proper are divided into— 1. The pelvis aequabiliter justo-minor, in which all the diameters, from the brim to the outlet, are diminished in very nearly equal measure. CONTRACTED PELVES. 433 2. The flattened pelvis, contracted specially in the conjugate diam- eter. In this form, the transverse diameter may be normal, or may be diminished. Thus, Ave distinguish— a. Simple flattened pelves (transverse diameter normal). b. Flattened, generally contracted pelves (narrowing in the trans- verse as well as the conjugate diameter). As it is rare to find two pelves possessing the same measurements, the question arises as to the degree of antero-posterior shortening which suffices to distinguish the contracted from the normal pelvis. It is often customary to consider the contracted pelvis simply as furnishing a mechanical obstacle to the passage of the child's head, but this is to overlook a great variety of very important modifications to which it gives rise during pregnancy and labor. These remoter in- fluences are often observable in cases where labor, if considered from the standpoint of length alone, would be regarded as normal. Michaelis* and Litzmann,f whose investigations furnish the basis of modern opinion regarding the contracted pelvis, place the limit at three and a half inches for the simple flattened pelvis, and at four inches for those likeAvise diminished in the transverse diameter. Yet even above these limits the action of the narrow pelvis is not rarely manifested in disturbance of the normal mechanism of labor. In Germany, Litzmann, Michaelis, Spiegelberg, and Schroeder J place the average frequency of contracted pelves at fourteen per cent., and in my own field of experience, in the Emergency and Maternity Hospitals of New York City, the inmates of which are, however, almost entirely of foreign birth, every variety and degree of pelvic deformity finds abundant illustration. In our natiA*e American women abnormal pelves are rare. I frequently hear from country physicians, who attend lectures at the Bellevue Hospital Medical College, that, in long years of practice, they have never met with a single instance. Yet it is im- possible to study the cases of vesico-vaginal fistulae reported by Dr. T. A. Emmet* without arriving at the conclusion that the existence of contracted pelves is frequently overlooked. Certainly the immu- nity of American women is by no means so absolute as to justify the neglect into which the study of pelvic deformity has so generally fallen. The Diagnosis of Contracted Pelvis.—The diagnosis of pelvic deformity is based upon direct examination. Certain facts in the previous history of the patient are often of substantial value in the way of confirmatory evidence, or by directing attention to the prob- able existence of deformity. * Michaelis, "Das enge Becken," Leipsic, 1865. f Litzmann, " Die Formen des Beckcns," Berlin, 1861. X SriEGELBERG, " Lchrbuch," 1878, Bd. ii, p. 426. * Emmet, " Vesico-Vaginal Fistula," AVilliam Wood, 1868. 28 434 THE PATHOLOGY OF LABOR. Previous History.—Inquiry should be instituted regarding the oc- currence of rickets in early childhood, and especially in this connection as to the period of the appearance of the teeth. Late dentition is an ordinary sign of imperfect bone formation. A cross baby, bottle-fed, or improperly nursed, suffering from repeated attacks of indigestion, from restlessness at night, and profuse perspirations, who cuts the first incisor teeth in the second year, has presumptively had rickets. A history of this nature, even in the absence of the grosser evidences of rickets, such as the square head, the pigeon-breast, the tumefied abdomen, small stature, spinal curvature, enlarged joints, and incur- vation of the long bones of the extremities, is to be regarded Avith sus- picion. Data of the kind mentioned are, however, often difficult to obtain, and it should be borne in mind that not every case of mild rachitis is followed by pelvic narrowing. Instruction may likewise be obtained from the history of previous labors. Though a protracted and difficult labor is by no means uncommon in well-formed primiparae, it should stimulate us, both during parturition and subsequent to delivery, to make a careful inves- tigation as to the capacity of the pelvis. A pendulous abdomen and faulty presentations and positions of the foetus occur with much greater frequency in the contracted that in normal pelves. Certain of the rarer deformities proceed from inflammations be- tween the sacro-iliac bones and at the ^^"^ e*~**--\ hip-joint, from inequalities in the /^ ^v length of the limbs, and from spinal / \ distortion when these difficulties oc- / \ cur in early childhood. | | Pelvic Measurements.—The ex- I I animation should be made with the \ J patient upon her back, placed prefer- \ / ably upon a hard table covered by ^^^ ^/ a folded blanket, or a woolen com- ^^^^B liF388*1^ forter. The head and shoulders Inlr**^^. should be moderately elevated, the (ft h ^%k knees should be flexed, and the pel- II » v*s brought as near to the edge of the |jl ffl table as possible. m Facility in the recognition of ab- tt inc u j i , i • i normal conditions can only be ac- Fig. 196.—Baudelocque's pelvimeter. . J quired by making it a habit to note the general features of the pelvis in every case of labor Avhich is com- mitted to our charge. By experience we acquire a tolerably distinct idea of the relative thickness of the bones, the inclination of the ilia to the horizon, the height and angle formed by the symphysis pubis, the size and character of the pubic arch, the length, breadth, and CONTRACTED PELVES. 435 curvature of the sacrum, the position of the promontory, and the dis- tance between the ischia. More exact information is derivable from direct measurements be- tween different prominent points in the pelvis. Various pelvimeters have been devised to facilitate the required measurements. Those for determining the distance between certain external points are alone of practical value. For this purpose the circle of Baudelocque is the one I have most constantly employed. It requires to be used with caution on account of the spring of the metallic arms. Schultze's instrument possesses the advantages of greater firmness and portability. The points selected for measurement should be bony prominences, easy of recognition, and not covered by soft parts. Thev should be such as Fig. 197.—Schultze's pelvimeter. to alloAv us to form at least approximative conclusions relative to the diameters of the small pelvis. Experience shows us that, judged by these rules, three measurements only are possessed of real importance, viz., the distances betAveen the anterior superior spinous processes, the distances between the crests of the ilia, and the external conjugate diameter. In measuring the distances between the anterior superior spinous processes, the accoucheur should stand by the side of his patient, and, holding the arms of the pelvimeter between the thumb and fingers, apply the points of the instrument to the spines external to the inser- tion of the sartorius muscles. The points should then be pushed backward a number of times along the outer edge of the crests of the ilia, until, after a few trials, the greatest distance between the crests has been determined. The average distances thus obtained are nearly ten and a quarter inches between the spinous processes, and eleven and a half inches between the crests of the ilia. A pelvis in which 436 THE PATHOLOGY OF LABOR. these measurements are equal, or in which the relations arc inverted (i. e., Avhere the distance between the spinous processes is greater than that between the crests of the ilia), is rachitic in character. In rachitic pelves of the second variety mentioned it is customary to select, in measuring the distance between the crests, points situated two and a half inches posterior to the spinous processes. Any considerable falling below the normal average in these two diameters would warrant the diagnosis of transverse shortening in the inner dimensions of the small peh'is. Deductions as to the degree of shortening should, however, be made with caution, as the relations between the diameters of the large and small pelves depend upon such variable factors as the thickness of the bones and integuments, and the height and inclination to the horizon of the ilia. In measuring the external conjugate diameter the patient is turned upon her side ; one extremity of the pelvimeter is then placed upon the fossa just beneath the spinous process of the last lumbar vertebra, while the anterior point is made to rest upon the middle of the upper border of the symphysis pubis. The length of the external conjugate, or, as it is sometimes termed from its author, the diameter of Baude- locque, is normally about eight inches. Baudelocque thought that by deducting three inches from the external conjugate in spare women, and three and a quarter inches in women of a fleshy habit, the conju- gata vera could be determined. Litzmann has, however, strikingly shown the fallacy of Baudelocque's deduction. In thirty cases, where he had an opportunity to compare the measurements of the external conjugate with the length of the internal conjugate as determined sub- sequently by post-mortem examination, he found the mean amount to be deducted was about three and a half inches. However, the amount in indiA'idual cases widely varied, owing to differences in the thickness of the bones and integuments, the maximum amounting to nearly five inches, while the minimum did not exceed tAvo and three fourths inches. But, Avhile the external conjugate does not enable us to estimate to a fraction the length of the antero-posterior diameter of the pelvic brim, it furnishes useful information as to theexistence in general of flattening. Thus, if the diameter of Baudelocque measures less than six and one fourth inches, it may be assumed that the pelvis is flattened. If the pelvis measures less than seven and a half inches, flattening may be assumed in half the cases. AboA'e seven and a half inches, antero-posterior shortening is very exceptional.* For internal measurements, the only practical pelvimeter is the hand of the accoucheur. To be sure, it can only determine with exac- titude the diagonal conjugate, i. e., the distance from the lower border of the symphysis pubis to the promontory; but from the diagonal * Litzmann, " Ueber die Erkenntniss des engen Beckens," Volkmann's " Samml, klin. Vortr.," No. 20, p. 148. CONTRACTED PELVES. 437 conjugate it is possible to calculate the conjugata vera with a closer degree of accuracy than is obtainable by means of any of the ingenious instruments designed to measure directly the diameters of the brim. To ascertain the diagonal conjugate, the index and middle fingers of the left hand should be introduced, well oiled, into the vagina. By pushing the posterior vaginal wall backAvard, the points of the fingers are made to reach the sacral vertebrae. Then, following the sacrum upward, the promontory is reached. To do this it is necessary to sink the elbow, and give to the fingers a nearly vertical direction. The resistance of a rigid perinaeum and the vaginal wall is best overcome by continued, steady, upward pressure. It is often possible by this method to reach the promontory in even normal pelves. During the examination the patient should be requested to raise up her hips. The promontory is recognized partly by its convex surface, and partly by the width of the cartilage which intervenes between it and the ad- joining lumbar vertebra. In practice there are two possible sources of error, viz.: an angle may form between the first and second sacral vertebrae where the union has been incomplete, producing a ''false promontory" beneath the true one ; or the upper surface of the first lumbar vertebra may project in such a way as to be mistaken for the promontory in cases where the latter, as sometimes happens, forms with the spinal column a very obtuse angle.* Such deviations are not without practical interest, as the prognosis is rendered less promis- Fig. 198.—Normal inclination Fig. 199.—Diminution of angle Fig. 200.—Increase of angle of the symphysis pubis. between symphysis and pel- between symphysis and (Spiegelberg.) vie brim. pelvic brim. ing when the head, in place of a single point of contact, has to over- come the resistance offered by the surface of an entire vertebra. The measure of the diagonal conjugate is taken by pressing the * Litzmann, " Ueber die Erkenntniss des engen Beckens," Volkmann's "Samml. klin. Vortr.," No. 20, pp. 152, 153. 438 THE PATHOLOGY OF LABOR. middle finger firmly against the most salient portion of the promon- tory, while the radial edge of the hand or index-finger is raised to the ligamentum arcuatum. The point of contact with the latter is then carefully marked with the nail of the index-finger of the right hand. It is desirable in withdrawing the fingers that they maintain, as nearly as may be, the position assumed at the time of measurement. Finally, with a small rule, the length from the mark of the nail to the tip of the finger is readily ascertained. In calculating the length of the conjugata vera from the measure thus gained, it is necessary to reconstruct the triangle formed by the two conjugates and the symphysis pubis. The diagonal conjugate is the largest of the three sides. The length of the conjugata vera de- pends on the height and inclination of the symphysis pubis, and the degree of elevation of the promontory above the symphysis, as may be readily seen by reference to the diagrams. The height of the symphysis pubis may be determined by the finger through the anterior vaginal wall. When the symphysis does not measure above one inch and a half, the subtraction of two thirds of an inch from the diagonal diameter will, under ordinary circum- stances, furnish very nearly the conjugate. When the symphysis ex- ceeds one inch and a half, three fourths of an inch should be de- ducted.* The inclination of the symphysis pubis to the plane of the brim and the height of the promontory above the upper border of the pubes can only be estimated. When any unusual deviations in either of these regards are found to exist, some special allowance would need to be made by way of compensation. It is just here that judgment and experience furnish the best safeguards against vital inaccura- cies. In thin persons, during the non-pregnant state, the promontory can sometimes be easily reached through the abdominal walls, and an estimate made of the conjugate by deducting, from the distance thus obtained between the promontory and the symphysis, the supposed thickness of the intervening tissues. The transverse diameters of the pelvic brim and cavity can be neither directly measured nor calculated Avith any degree of certainty from other measurements. There are certain other dimensions which Ave find useful to deter- mine in the rarer forms of distortion, and which will be mentioned in their proper connections. For the three forms of contracted pelvis which at present engage our attention, four measurements alone are of practical ATalue—viz., the distance between the anterior superior spi- nous processes ; the distance between the crests of the ilia ; the external conjugate ; and the conjugata diagonalis. * Spiegelberg, op. cit., p. 433. CONTRACTED PELVES. 439 The Three Principal Forms of Contracted Pelvis. The Pelvis jEquabiliter Justo-Minor, or Symmetrically Contracted Pelvis.— This, the rarest of the three forms, presents to the casual view the appearance of a normal pelvis, except that the diameters from the brim to the outlet are reduced in nearly equal measure. We dis- tinguish tAvo varieties of this pelvis : 1. In the commoner variety the woman may be of small, medium, or large stature, and her figure thick-set, or, on the contrary, graceful and slender. Nothing in either her size or carriage is indicative of any abnormal condition. The pelvic bones themselves, both in their structure and in their connec- tions with one another, are free from all traces of morbid action. They are simply below the standard size. The pelvis as a whole is of the feminine type. Litzmann has shoAvn, however, that in the justo- minor pelvis the relations of the different parts to one another are not, as a rule, absolutely the same as in the normal pelvis. Thus, there is diminished width of the sacrum, due in special degree to the small size of the alae; the rotation forward of the promontory and the curv- ing of the lower extremity of the sacrum are less pronounced ; the con- cavity of the sacrum in the transverse direction is increased ; the pos- terior sacral surface is nearly on a level with the posterior superior spinous processes in place of sinking forward between the ilia; the height of the anterior and lateral walls is proportionately lessened ; and, finally, there is often an increase in the angle which the symphysis pubis forms with the conjugate.* These peculiarities point to a premature arrest in the develop- ment of the bones, whereby the pelvis retains something of the infan- tile type. The causes of arrest are in most cases traceable to general disturbances of nutrition during early childhood, such as scrofula and chlorosis, to rickets, Avhich in place of leading to deformity exception- ally exerts its influence in the suspension of bone-growth, and in rare cases to the influence of hard labor and the carrying heavy weights before the completed development of the body. A few cases in which no morbid conditions can be elicited from the history of the patient may perhaps be referred to some original defect in the primitive ma- terial from which the bones were built up. Cases have been reported in which this anomaly appeared to be hereditary, f 2. In veritable dwarfs the diminutive size of the pelvis may simply correspond to the Lilliputian proportions of the entire skeleton. These so-called dwarf pelves—pelves nana—are of the regular feminine type, but the bones are slight, and united, as in the child, by cartilage. * Litzmann, " Die Formen des Beckens," Berlin, p. 40. \ Michaelis, " Das enge Becken," herausgegeben von Litzmann, p. 190; vide like- wise, Lohlein, " Zur Lehre vom Durchweg zu engen Becken," " Ztschr. f. Geburtsh. u. Frauenkr.," Bd. i, p. 53. 440 THE PATHOLOGY OF LABOR. They are extremely rare. In pelves of this variety the highest degree of contraction is observed.* Fig. 201 .—Specimens from the Wood Museum (Bellevue Hospital). Drawn on same scale No. 1. Normal pelvis. No. 2. Justo-minor pel vis. + Diagnosis.—In the justo-minor pelvis all the external diameters are diminished. At the same time, rickets is excluded by the normal relations existing between the spines and the crests of the ilia {vide p. 436). The diagonal conjugate is lessened. In estimating the conjugata vera it is necessary carefully to notice the height of the promontory, and the inclination of the anterior pelvic wall, as these are sometimes * There is a third form of justo-minor pelvis, which is the concomitant of undeveloped organs of generation. As it occurs only in sterile women, it possesses no obstetrical interest. t Primipara, aged twenty-three. In labor three days previous to my seeing her. Waters all escaped. Large scalp-tumor reaching nearly to vulva. Cervix rigid. Os one third dilated and pushed down by scalp-tumor. Forceps tried. Afterward perforation and craniotomy. Chin tilted and head brought through the pelvis by the fronto-mental diameter. Patient died on third day. Extensive marks of pressure in the bladder oppo- site pelvic rami. Small circular perforation of uterus opposite promontory. Conjugate diameter three inches. Transverse diameter of brim four and a half inches. Slight Nae- gele obliquity on left side. Patient was fifty-nine inches in height, and presented no signs of rickets. CONTRACTED PELVES. 441 exaggerated and call for an increase in the amount to be deducted.* By careful palpation of the two sides of the pelvis with the half-hand introduced into the vagina, the fact but not the degree of transverse shortening may be recognized. Still, in this way the existence of ex- treme contraction would be noticed. In ordinary cases, it is fortunately safe to base practice upon the length of the antero-posterior diameter. Flattened Pelvis.—-We have seen that the characteristic of this form is a shortened conjugate diameter. The transverse diameter remains at the same time normal, or may sink below the standard. A special distinction is likewise to be made betAveen the flattened pel- ves of non-rachitic and rachitic origin : 1. The flattened non-rachitic form is the most frequent variety of contracted pelvis. At a first glance, or previous to measurement, it often produces the impression of a normal, well-formed pelvis. It is occasioned by a sinking of the sacrum doAvnward and inward between the tAvo ilia. As this movement takes place without any forward rota- tion of the promontory, the antero-posterior shortening is not confined to the brim, but extends throughout the entire pelvic cavity. Extreme contraction is uncommon, the length of the conjugate rarely falling below three inches. The flattening is of necessity associated with a compensating increase in the transverse diameter. As, however, the flattened non-rachitic pelvis is usually from the outset of small size, the compensation hardly suffices to give to the transverse diameter more than the normal dimensions. Indeed, it is not infrequent to find a slight lessening in the transverse diameter associated with an- tero-posterior contraction. There is nothing definitely settled regarding the etiology of this deformity. It has been attributed to lifting and carrying heavy bur- dens before the age of puberty, to incompletely developed rickets, and to retarded development. During life it is not easy to distinguish between this form and that of the symmetrically contracted pelvis. In both the external signs of rickets are absent, the relations between the spines and crests of the ilia normal, and in both all the external diameters may be somewhat diminished. The stature of the individual furnishes no clew; for, though both forms occur rather more frequently in diminutive persons, there are numerous exceptions to the rule. The sinking of the sacrum between the ilia is not easy to recognize. In a well-marked example, however, the relatively greater shortening of the conjugata externa and the diagonal conjugate,! with the difficulty of palpating the inner * On the contrary, owing to the shortness of the symphysis pubis, as a rule, the aver- age amount to be deducted is rather less than in normal pelves. Lohlein ("Kunsthiilfe bei der allg. Beckenenge") found the average in eighteen cases was three fifths of an inch. \ In reckoning the true conjugate from the diagonal diameter, the same reduction needs to be made as in the normal pelvis, for, though the outward slant of the symphysis 442 THE PATHOLOGY OF LABOR. surface of the pelvic lateral walls, furnish the prominent points for guidance. Sometimes, when no bony union has formed between the first and second sacral vertebrae, a double promontory may be felt. 2. The rachitic form of flattened pelvis presents the following characteristics : The bones are of small size, but usually of normal texture. Some- times, however, they are thin, and even translucent, while in other instances they may be unusually compact and thickened. The ilia are flattened, and run in a near- ly horizontal direction. The anterior superior spinous processes flare outward, so that the distance between them differs little from that between the widest points of the crests. The promon- tory projects inward toward the symphysis pubis. The upper portion of the sacrum sinks inward between the Fig. 202.—Flattened rachitic pelvis. (Wood's Mu- ilia, and lies farther in front of the posterior superior spinous processes than in the normal pelvis. The upper portion, too, is directed nearly horizontally backward, while the extremity, usually at the fourth or fifth sacral vertebra, is bent sharply forward. The anterior sacral surface loses its transverse concavity, and becomes either flat from side to side, or convex from the bulging forward of the sa- cral vertebrae. The antero-posterior shortening of the brim is accom- panied by a compensating increase in the transverse diameter. As, however, the rachitic pelvis is originally undersized, the transverse diameter rarely exceeds normal dimensions. The horizontal rami of the pubes are flattened, and the acetabula are directed to the front. The cartilage of the symphysis pubis generally projects inward, the pectineal line is often unusually sharp, and at times terminates at the insertion of the psoas muscle in a projecting spine. Below, the ischia diverge from one another, and the arch of the pubes is Avidened. The result of these changes is to produce a shallow pelvis, with contraction at the brim, and widening at the outlet. The shape of the brim varies between a long ellipse and that of a heart or kidney, the different degrees of variation depending upon the extent of the displacement forward of the promontory. Externally, OAving to the horizontal position of the sacrum, a depression exists in the lumbar re- is increased, this is compensated for by the diminished height of the symphysis and low position of the promontory. (Litzmann, Volkmann's " Samml. klin. Vortr.," No. 20 p. 160. CONTRACTED PELVES. 443 gion, the sulcus between the nates is broad and superficial, and the anal orifice is exposed to view. To appreciate the rachitic pelvis, it is necessary to bear in mind the changes wrought by rickets in the bony structures. In the physiolog- ical growth of the pelvic bones, new cell-elements develop beneath the periosteum and adjacent to the cartilaginous borders upon the articular surfaces. These cell-elements promptly ossify, and thus provision is made for the increase of the bones in extent and thickness. Simulta- neously with the formation of the new bone, medullary spaces are pro- duced in the bony tissues by a process of absorption. Now, in rickets, while the new cell-elements are deposited in such numbers that the preparatory layer is often five to ten times the normal thickness, the process of ossification is suspended or imperfectly performed. Thus, the rachitic pelvis consists of a number of more or less firm, bony masses, covered with soft osteoid layers, with broad cartilaginous bor- ders at the articular surfaces. These changes combine to increase the pliability of the pelvis, and to retard its growth. The pelvic deformity resulting from rickets is mainly due to the weight of the superimposed body. The pressure from above which the trunk exerts pushes the promontory forward toward the median line. At the same time the upper portion of the sacrum rotates upon its transverse axis, so that its posterior aspect is nearly on a line with the horizon. The bodies of the vertebrae sink downward between the flex- ile wings, Avhereby the concavity of the sacrum from side to side is effaced. The pliant border of the iliac articulation yields somewhat, and, as it is drawn inward by the sinking of the sacrum, the traction of the strong sacro-iliac ligaments approximates the posterior superior spinous processes to one another. The traction of the sacro-tuberous and sacro-spinous ligaments aids in hooking forward the lower extrem- ity of the sacrum, though to this deformity the pressure exercised upon the end of the spinal column by the half-sitting, half-recumbent posture, affected by rachitic children, unquestionably contributes its part. If we regard the sacrum as a fulcrum, and each os innominatum as a lever, it is evident that the traction of the sacro-iliac ligaments, under the pressure upon the sacrum from the trunk, would produce a separa- tion of the innominate bones in front were it not for their firm union at the symphysis pubis. The result of these two counteracting forces is an increased incurvation of the bones at the point of weakest resist- ance, Avhich is situated near the auricular surfaces. In advanced rick- ets, Avhere the bones are plastic and willowy, the linea arcuata is often bent at an angle, so that the greatest transverse diameter divides the pelvic brim into a posterior and anterior half. To the latter belong the acetabula, to the former the two ilia. The outAA'ard direction of the anterior superior spinous processes is 444 THE PATHOLOGY OF LABOR. probably due in a measure to an arrest of development, as the S-shaped curve of the crests of the ilia does not normally develop until after the age at which rickets usually makes its appearance (Kehrer). The flat- tening of the ilia is partly due to the drag of the sacro-iliac ligaments, and partly to the action of the sartorii and gluteal muscles. The di- vergence of the ischia and the wide arch of the pubes are the product of the increased transverse diameter, and the attachments of the ro- tator and adductor muscles of the thigh.* The diagnosis of the rachitic form of flattened pelvis is easy, if the characteristic changes are kept in mind. The prominent features to which the attention needs to be directed are : the relations of the dis- tances between the cristae ilii and the anterior superior spinous proc- esses (diminished difference, or distance, between the anterior superior spinous processes may equal, or even exceed, that between the crests); diminished distance between the posterior superior spinous processes ; diminution of the external conjugate ; the form and direction of the sacrum; the shape of the arcus pubis, and the marked projection of the promontory. A false promontory at the second sacral vertebra is not uncommon. The deduction to be made from the conjugata diago- nals in estimating the conjugata vera averages the same as in the normal pelvis. However, it is in rachitic pelves that the widest varia- tions in this respect occur, making it specially necessary in each case to observe the height of the promontory and the length and direction of the symphysis pubis. Flattened Generally Contracted Pelves.—In this variety we distin- guish likewise a rachitic and non-rachitic form, the latter occurring rarely, the former with comparative frequency. The non-rachitic form is apparently the joint product of a small justo-minor pelvis and the forces which lead to a sinking of the sa- crum between the ilia. In these pelves a short symphysis and a low promontory contribute often to reduce greatly the difference between the diagonal and the true conjugate. During life it is difficult to dis- tinguish it from the justo-minor pelvis. The rachitic form is found usually in persons of small stature. It presents in a striking degree the marked peculiarities of the rachitic pelvis. The existence of transverse narrowing is recognized by the * While Litzmann (" Die Formen des Beckens ") and Schroeder (" Lehrbuch der Ge- burtshiilfc ") lay special stress upon the weight of the body as the main factor in produc- ing the deformities of rickets, Kehrer ("Zur Entwickelungs Geschichte der rachit. Beckens," "Arch. f. Gynaek.," Bd. v, 1872, p. 55) has shown that many of the changes characteristic of rickets occur in congenital cases—i. e., before the action of the weight of the trunk is brought into play. Kehrer refers the changes, therefore, in the main, to muscular action. Fehling (" Die Entstehung der rachit. Beckens," " Arch. f. Gynaek.," Bd. xi, p. 173) ascribes the deformities in rickets to disturbances of growth and per- sistence of the fetal type. Engel ("Wiener med. Wochenschrift," 1872, No. 40) sought to prove the deformities to be the result of partially arrested growth. CONTRACTED PELVES. 445 Fig. 203.—Small symmetrical rachitic pelvis. (Wood's Museum.) narroAvness of the hips, by the ease with which, in internal examina- tion, the side-walls can be felt with the palmar surface of the half- hand, and by the modifications it produces in the mechanism of labor. Irregular Rachitic Pelves.—For convenience' sake it seems desirable to attach to the description of the flattened form the influence of two additional forces, which, upon occa- sion, operate to still further modify the shape of the rachitic pelvis. These are lateral pressure of the heads of the thigh-bones at the acetabula and the various forms of spinal curva- ture which so commonly result from rickets. Pressure at the acetabula is rarely an operative force, because rickets usually is developed at the time of the first dentition—i. e., before the child has learned to walk—and it is not until after the disease has declined that the child attempts to use its lower extremities. In the exceptional cases in which the dis- ease occurs later, after the child has begun to walk, the lateral pressure may act in either one of two ways : 1. As a counteracting force to that exercised by the weight of the trunk, in which case the pelvis, provided the path- ological processes have only advanced to a limited extent, retains a symmetrical appear- ance, and resembles closely the justo-minor pelvis. The rachitic ori- gin is betrayed by the shape of the ilia and the signs of rickets in other parts of the body. At the outlet the antero-posterior di- ameter is increased, and the transverse diameter somewhat dimin- ished. * 2. In cases of excessive softening of the bones, either from the se- verity or the long duration of the disease, the acetabula are sometimes pushed inward, upward, and backward, and the symphysis pushed forward, so that the rami of the pubes meet at an acute angle, or run nearly parallel to one another. This lateral compression, in conjunc- tion Avith the rachitic projection of the promontory, gives to the pelvic brim a triangular or clover-leaf shape, closely resembling the distor- tion produced in osteomalacia. The term pseudo-osteomalacia given * Schroeher, " Schwangerschaft, Geburt. und Wochenbett," p. 77. Fig. 204.—Pseudo-osteomalacia. (Naegele.) 446 THE PATHOLOGY OF LABOR. by Michaelis * to this form is warranted by the existence of certain features peculiar to rickets, such as the small size of the ilia, the dis- tance between the anterior superior spinous processes, and the nature of the changes in other parts of the bony skeleton.f In curvatures of the spine the shape of the pelvis is affected, when a compensatory scoliosis or kyphosis includes the sacral extremity : 1. In scoliosis (lateral curvature), all the rachitic features are usu- ally strongly pronounced. The promontory is tilted to the side of the incurvation, and is pressed by the weight of the body toAvard the cor- responding acetabulum. The ilium, owing to the increased pressure at the acetabulum from the femur of the affected side, is pushed upward, backward, and inward. In extreme cases the approximation of the prom- ontory to the acetabulum may be such as to prevent the en- trance of the child's head. The contracted portion becomes, therefore, unavailable for ob- stetrical purposes;); {vide p. 488). 2. In kyphosis (posterior curvature) many of the charac- teristic features of the rachitic pelvis are reversed. As the upper portion of the sacrum is tilted backward, either the con- jugata vera is increased, or the previous rachitic antero-poste- rior narroAving is greatly diminished. In the movement of the sacrum upon its transverse axis the loAver extremity is thrown forward, and the conjugate of the outlet is thereby reduced. Kyphosis, occurring at the beginning of rickets, diminishes the distance between the tu- berosities of the ischia, but has little effect upon the inferior transverse diameter after the rachitic changes have once been accomplished. Influence of the Contracted Pelvis upon Pregnancy and Labor. The influence of the contracted pelvis is not confined simply to the embarrassment which the form and size of the pelvis afford to the * Michaelis, "Das enge Becken," p. 139. f The supervention of true osteomalacia upon rickets has been observed. (Vide Spiegelberg, " Lehrbuch der Geburtshulfe," p. 490.) X Litzmann, " Die Formen des Beckens," p. 70. Fig. 205.—Scoliosis. (Litzmann.) CONTRACTED PELVES. 447 passage of the child in parturition ; it extends to the production of a multitude of remoter effects, which are often regarded by the unin- formed as isolated phenomena. These effects, which include faulty positions and presentations of the foetus, unfavorable shape or position of the uterus, abnormal character of the pains, and the like, enter in turn, except where the mechanical difficulties are absolutely insur- mountable, as important elements in the determination of the prog- nosis. For our knowledge of this subject we are indebted almost wholly to the enlightened labors of the Kiel professors, Michaelis* and Litzmann. f Influence of the Contracted Pelvis upon the Uterus during Preg- nancy.—In the early months the only way in Avhich the contracted pelvis exerts an influence is in sometimes favoring the dislocation of the uterus backward. This action is liable to take place when, in the second or third month, the uterus has been unusually depressed in the pelvis, and the fundus has swung backward toAvard the sacrum as the uterine axis approximates to that of the pelvic outlet. Under such circumstances the jutting of the rachitic promontory is calcu- lated to mechanically interfere later with the ascent of the organ into the abdominal cavity, in which case the pressure of the inflated intes- tines upon the anterior aspect of the uterus pushes the fundus over the inclined surface of the sacrum, and retroversion is produced. As the gravid uterus enlarges, owing to the limited space within the pel- vis the version gradual passes into a flexion, Avhich, unless relieved, is followed by symptoms of incarceration. In the latter months of gestation, the uterus, as a rule, is lifted to a greater extent above the pelvis than occurs under normal conditions. This elevation is due to the growth of the child, which is prevented from sinking into the pelvis by the contracted conjugate. Sometimes the upAvard tendency of the uterus is overcome apparently by the resistance of the round ligaments, so that, while the head is retained at the brim, the lower segment hangs empty in the pelvis. At the same time the uterus possesses an unusual degree of mobility, in part due to the lack of fixation afforded by the descent of the foetus into the pelvis, and in part to the laxity of the abdominal walls and the round ligaments. These latter conditions belong, of course, rather to multiparae than to women for the first time pregnant. In close connection Avith these two events, viz., the elevation of the uterus and its mobility, it is not uncommon to observe the higher degrees of the so-called pendulous abdomen, caused by the anteflexion of the gravid uterus. To this deformity, furthermore, the small stat- ure of rachitic patients, the increased inclination of the pelvis, the anterior projection of the lumbar portion of the spine, and the stretched * Michaelis, " Das enge Becken," Leipsic. f Litzmann, Volkmann's " Samml. klin. Vortr.," No. 23. 448 THE PATHOLOGY OF LABOR. state of the abdominal walls, associated often with separation of the recti muscles at the linea alba, all contribute their part. Influence of the Contracted Pelvis upon the Presentation of the Foetus.—Faulty presentations occur in contracted pelves more than three times as frequently as in those of normal dimensions.* Thus, when, during the latter part of pregnancy, the narrow conjugate me- chanically prevents the head from sinking into the pelvic cavity, the head frequently glides sidewise or forAvard, to rest upon an iliac fossa, or upon the upper border of the symphysis pubis. In pendulous abdo- men the uterus, in place of being inclined, when the patient is in an upright position, at an angle of thirty-five degrees, becomes nearly horizontal, or may fall forward so that the fundus occupies a deeper position than the inferior segment of the uterus. The great mobility of the uterus admits likeAvise of extensive lateral movements. These combined causes account for the lack of stability in the foetus and the comparative frequency with Avhich shoulder and breech presenta- tions occur. When the head is fixed at the brim, the conversion of the vertex into a broAv or face presentation is often simply an exag- geration of the normal mechanism of labor in a flattened pelvis. If the head, in place of filling the lower segment of the uterus, is re- tained at the brim, the space left between the head and the uterine walls favors prolapse of the cord and extremities. In like manner, in breech presentations, when the breech is detained by the narroAv con- jugate, the feet are apt to descend first into the vagina. Owing to the progressive relaxation of the abdominal and uterine -vails with successive pregnancies, the frequency of these irregularities increases nearly in proportion to the number of previous births. Influence of the Contracted Pelvis upon the Labor-Pains.—When the degree of pelvic contraction permits the delivery of the foetus by the normal passages without resort to embryotomy, the favorable or unfavorable ending of the labor is in large measure dependent upon the character of the pains. Good pains are of vastly more consequence in narrow than in wide pelves. Violent pains, where the mechanical obstacles are insurmountable, either from the smallness of the pelvis, the faulty presentation of the foetus, the position of the child's head, or its size and hardness, endan- ger the integrity of the uterus. Indeed, unless the mechanical diffi- culties are diminished by rectification of faulty positions and presen- tations, or by embryotomy, or unless relief is afforded by the removal of the child by Caesarean section, there is reason to dread in such cases the occurrence of ruptured uterus, or, after retraction of the cervix, that the uterus may be torn from the vagina. * Spiegelberg found that, of 544 labors in narrow pelves, the head presentation oc- curred in eighty-three per cent., whereas the proportion is ninety-five per cent, in normal pelves. ("Lehrbuch der Geburtshiilfc," p. 448.) CONTRACTED PELVES. 449 Still more frequently weak pains are the cause of unfavorable ter- minations. Weak pains lead to lingering labors. Even in moderate degrees of contraction they fail to rectify unfavorable positions of the head, or to force the head by the brim into the pelvis. Under such circumstances neither the forceps nor version can be employed without serious risk, while, if a waiting policy is pursued, the amniotic fluid gradually escapes, and, as the uterus retracts down closely upon its contents, the fcetus perishes from the gradually increasing hindrances to the uterine and placental circulation. In prolonged labors good pains alternate at intervals with those of less force. There is no standard by which the quality of pains per se can be determined. The quality of the pains is to be estimated rather by the results which they accomplish. It may be stated as a general rule, to which, however, there are numerous exceptions, that the strength of the pains is proportioned to the strength of the resist- ance to be overcome. Strong pains are on the whole rather more com- mon in flattened pelves, and weak ones in pelves contracted in all their diameters, Avithout, however, the rule possessing any such constancy as to lead one to regard the form of the pelvis as alone possessing any decisive importance in the production of the result.* In the first instance, the character of labor-pains depends upon the innervation of the uterus and upon the thickness and integrity of its muscular structures. The resistance which the narrow pelvis offers to the expulsion of the child increases necessarily during the pains the tension and irritation of the uterine walls ; and these, corresponding to the degree of irritability and contractility of the organ, may pro- voke pains of unusual violence, which, in turn, terminate, Avhen the resistance is not seasonably overcome, in exhaustion; or the uterine activity may cease without any previous stage of increment; or, finally, the tension and injurious pressure of the uterus may lead to local circulatory disturbances, and to textural changes Avhich in them- selves weaken the strength of the contractions. Michaelis obserA'ed that the dangers to the mother and child grow, as a general rule—to which, however, there are numerous exceptions— in proportion to the number of confinements. The increased mortal- ity, especially of the children, he attributed to a peculiar relaxation of the uterus and its pelvic attachments, due to over-exertion in previous confinements, f But it must be borne in mind that there are other results of contracted pelves which directly contribute to the fatality of * Michaelis thought that the partial pressure of the promontory and symphysis ex- cited increased reflex action of the uterus in flattened pelves, whereas the complete press- ure of the head upon the brim in generally contracted pelves exercised a paralyzing influence (he. cit., p. 185). This theory has been called in question by both Spiegelberg (loc. cit., p. 452) and Litzmann. (Volkmann's " Samml. klin. Vortr.," No. 23, p. 177.) •j- Michaelis, loc cit., p. 152. 29 450 THE PATHOLOGY OF LABOR. multiparous labors. Thus, we have seen that pendulous abdomen and mobility of the uterus favor abnormal positions and presentations of the foetus, complications of the utmost prognostic importance ; and again, that the displacements of the gravid uterus occur with special frequency when the abdominal parietes have lost their supporting power from the over-distention of previous pregnancies. Moreover, Avhen the uterus is not fixed during labor, the expulsive action of the abdominal walls can not be called into play, and thus one of the most important auxiliary forces is lost. Further sources of danger lie in the increased size and hardness of the fetal head observed in later pregnancies, and in the residue of inflammatory troubles which so often proceed from the first difficult delivery. * Influence of the Contracted Pelvis upon the First Stage of Labor.— At the beginning of labor the head in contracted pelves is usually re- tained above the os internum, while the lower segment of the uterus hangs empty in the pelvic cavity. As, under these circumstances, space is left between the head and the uterine walls, the entire column of amniotic fluid acts directly during the pains upon the cervix uteri. The dilatation of the cervix takes place gradually, from above down- ward, as expansion follows upon the descent of the amniotic sac. The shape of the bag of waters depends upon the greater or less degree of resistance offered by the cervical walls. If the latter are soft and dis- tensible, the usual semi-globular contour is maintained. If the cervix offers any material resistance, the membranes, if sufficiently elastic, protrude through the external os in cylindrical form. If, finally, the chief opposing force to dilatation is situated at the os internum, a con- striction may take place at that point, while below the membranes assume a spheroid shape. As the result of these conditions an unim- peded, wave-like movement of the amniotic fluid breaks against the protruding membranes during the pains, the shock of which is apt to produce premature rupture, an event which is all the more inopportune, because in early rupture the circumstances all favor the complete dis- charge of the amniotic fluid. After the rupture of the membranes, as the head does not descend at once into the cervical portion, the os and cervix reclose, though they continue dilatable in proportion to the degree of distention pre- viously accomplished. Then, as under the influence of the pains the head passes into the pelvis, it gradually once more unfolds the cer- vical canal, and completes its dilatation. Should, however, the head meet with any considerable resistance, so that the pressure of the pel- vic brim gives rise to the formation of a scalp-tumor, the latter serves to dilate the cervical canal and the os externum. If the obstacle is such as to prevent the complete descent of the head, two results are possible : * Spiegelberg, "Lehrbuch der Geburtshulfe," p. 453. -J CONTRACTED PELVES. 451 1. If the pains continue strong, and no measures are adopted to remove the disproportion, the uterus is either retracted up over the head of the child as it remains above the brim, until the over- distended vagina gives way, in which case the laceration occurs in a transverse or oblique direction, and usually upon the posterior wall; or the lower segment of the uterus becomes compressed between the child's head and the walls of the pelvis, and a thinning and bruising of the imprisoned portion take place. As the uterus contracts, its muscular fibers drag upon the compressed and weakened tissues at the fixed points, which yield finally to the tractile force, and rupture ensues. 2. If the pains are weak or fail outright, the lower segment of the uterus remains undilated until either strong pains are excited, or the mechanical hindrance is so far removed by perforation of the head that the weakened pains suffice to overcome the obstacle. Influence of the Contracted Pelvis upon the Mechanism of Labor- When the pelvic contraction is not such as to render the entrance of the head impossible, the mechanism of labor depends not only upon the size and shape of the pelvic space, but upon the size, form, com- pressibility and position of the child's head. If a small, soft head has to pass through a pelvis contracted to only a moderate degree, the mechanism may not differ from that of a normal labor. In cases of relatively great disproportion, delivery is only practicable where the position of the head is favorable—i. e., corresponds in each case to the peculiar shape of the pelvis. If the conditions are favorable, and the pains are of normal strength, a segment of the head, after the period of dilatation has been completed, is pressed into the pelvis. The size of the segment depends upon the extent of the resistance offered, and thus, at an early stage, it furnishes us a notion as to the degree of dis- proportion existing. As labor progresses, the cranial bones change in shape and overlap one another, so that the head gradually becomes molded to the contour of the pelvic ring. When the largest circum- ference of the child's head has become fixed at the pelvic strait, as the contraction exists for the most part at the brim, the difficulties are usually overcome ; and, where the pains continue good, the remainder of the labor is accomplished in accordance with the ordinary mechan- ism. If the pains fail, or the contraction continues throughout the entire pelvic canal, artificial aid may be needed even after the brim has been passed. In the simple flattened pelvis the occipito-frontal diameter of the head engages in the transverse diameter of the brim. Even when the position is originally oblique, the intermittent contractions of the uterus communicate movements to the smooth surface of the head, which gradually bring its long diameter into correspondence with the long diameter of the flattened pelvis. The head enters the brim with 452 THE PATHOLOGY OF LABOR. its posterior surface tilted toward the shoulder, the anterior parietal bone presenting, and the sagittal suture running parallel with, and in more or less close proximity to, the promontory. This lateral obliqui- ty, or obliquity of Naegele as it is termed, is due simply to the fact that the narrowing of the antero-posterior diameter prevents both parietal bones from entering the pelvis upon the same plane. When the broad region between the parietal bosses meets with the resistance of the conjugate, the occipital portion of the head glides to one side, and the narrow bitemporal diameter engages in the contracted space. In this position, the occiput usually rests upon the linea terminalis. Owing to the resistance offered to the occiput, the forehead sinks into the pelvis, so that the large fontanelle occupies a deeper position than the posterior one. Before the head adapts itself, therefore, to the pelvic entrance, the anterior parietal surface rests upon the symphysis, wliile the posterior surface is impinged upon by the promontory near the large fontanelle. The latter is felt low down, near the median line. The small fonta- nelle, owing to the dip of the forehead, is occasionally out of reach. Upon the side of the pelvis to which the forehead is turned, the space is incompletely filled out. The adaptation of the* head to the pelvic brim is the result of two combined movements, which occur nearly simultaneously : 1. The symphysis pubis furnishes a pivot around which the head rotates in the direction of the fronto-occipital diameter. As the head is pressed into the pelvis from above, the posterior parietal bone is flattened by the projecting promontory. During the descent the dis- tance between the sagittal suture and the promontory gradually widens, and the former approaches the median line. 2. We have seen that the head entered the pelvis at first with a deep position of the anterior fontanelle. By the time, however, the bitem- poral diameter becomes fairly fixed in the conjugate, the anterior fon- tanelle moves upward and forward toward the side-wall of the pelvis, while the small fontanelle sinks downward, and occupies a position near the center of the cavity. This movement is not simply a crowd- ing of the entire head in the direction of the broAv, but is due to a rotation of the head upon an axis furnished by the conjugate diam- eter,* the symphysis and the promontory furnishing the pivotal points. By the time, in the rotation of the head upon its fronto-occipital diameter, the posterior boss reaches the level of the promontory, the largest circumference of the child's head has already engaged in the straitened brim, and the influence of the pelvic flattening upon the mechanism of labor ceases. Then, if the pains continue good, the flexed head reaches the floor of the pelvis, the occiput rotates to the front, and delivery is accomplished as under normal conditions. * Litzmann, Volkmann's " Samml. klin. Vortr.," No. 74, p. 557. CONTRACTED PELVES. 453 In the justo-minor pelvis, the mechanism of labor is nearly the reverse of that described in the flattened form. Thus, as a rule, both parietal bones engage in the pelvic brim at the same time—i. e., the obliquity of Naegele is either slightly marked, or absent altogether! Again, the head may enter the pelvis in any of its diameters. To be sure, the oblique diameter is the one it usually occupies. Still, Litz- mann reports two cases in which the sagittal suture corresponded to the conjugate diameter from the outset of the labor.* In the early stages, it is not uncommon for the head to oscillate at the brim for a time before fixation takes place. Characteristic of transverse narrowing is the flexed condition of the head from the moment it begins its descent into the pelvis. In- deed, the flexion at the brim equals in degree that which usually ob- tains only at the pelvic outlet. The small fontanelle occupies the middle point of the pelvic space, the neck rests upon the linea termi- nalis, the anterior portion of the head and brow are pressed against the opposite pelvic walls, the long diameter of the head (from chin to vertex) lies in the axis of the pelvis, and the face looks upward toward the fundus uteri. If the transverse narrowing continues toward the outlet, the extreme flexion is maintained after the brow has passed below the level of the promontory. In such cases it may even happen that the small fontanelle may make its appearance at the frenulum in place of turning under the arch of the pubes. Sometimes the head gets fairly impacted in the pelvis, and further advance is rendered im- possible. When the pelvis widens belowthe brim, the small fontanelle noticeably leaves little by little its central position. In the generally contracted, flattened pelvis, the mechanism of labor is influenced by both the antero-posterior and transverse short- ening. As in flattened pelves, the head usually occupies the transverse diameter, and the sagittal suture looks backward toward the promon- tory. Before the head becomes fixed, it often balances at the conju- gate, rocking to and fro, as the uterus falls from the one side to the other. For a time, therefore, the position of the fontanelles varies with that of the woman. If, however, the disproportion is not abso- lute, and the pains suffice finally to fix the head, the latter usually becomes strongly flexed, and the occiput descends first into the pelvis. When the head does not enter the contracted pelvis in an advan- tageous position, and the fault is not rectified either by the hand or the action of the labor-pains, delivery of the child without perforation often becomes impossible. The most dangerous of these faulty posi- tions are : 1. Cases in which the lateral obliquity of Naegele is exaggerated, so that the presenting part is formed by the anterior parietal bone. The more striking forms usually occur in pelves with an extremely * Litzmann, Volkmann's " Samml. klin. Vortr.," No. 74, p. 545. 454 THE PATHOLOGY OF LABOR. narrow conjugate and a high promontory. The former maintains the head high above the brim, while the latter imparts to the uterus a posterior concavity. As the uterine curve is followed by the axis of the foetus, the head is strongly bent toward the posterior shoulder. Sometimes in presentations of the anterior parietal bone the sagittal suture lies above the promontory, and an ear can be felt just behind the symphysis. 2. Cases in which the pelvic brim is covered by the posterior pari- etal bone. The sagittal suture is then directed to the front, some- times lying even above the superior border of the anterior pelvic wall. Near the promontory the squamous suture, and at times the ear, can be felt. This peculiarity is rare in other forms of contracted pelves, but occurs as often as once in five times (Litzmann) in flattened pel- ves with coincident shortening of the transverse diameter. 3. In cases of well-marked kidney-shaped pelves, the head may engage in one side of the pelvis only. The occiput then enters usually the side of the brim to which the back of the child is turned. 4. Brow and face presentations are simply exaggerations of the anterior dip of the head, which we have seen is the normal mode of descent during the early stage of labor in flattened pelves. Although not peculiar to contracted pelves, they should ahvays, when present, lead to careful measurements of the pelvic diameters. They increase the difficulties of delivery, not only because of the unfavorable rela- tions of the diameters of the head to those of the pelvis, but because the pelvic deformity interferes with the proper rotation of the chin and forehead forward under the arch of the pubes. In breech presentations, the delivery of the trunk takes place in accordance with the ordinary mechanism in the normal pelvis. The arms, however, are more liable to be reflected to the sides of the head. In flattened pelves the after-coming head enters the brim in the transverse diameter. The position of the chin, where the transverse space is ample, varies with the degree of conjugate shortening. Where the latter is only of moderate extent, the ordinary flexion of the head may not be interfered with. If, however, the disproportion between the head and pelvic diameters is considerable, partial extension takes place. In cases of extreme contraction the entire head may be retained at the brim. The chin is then usually turned forward so as to rest upon one of the pubic rami, while chin and occiput occupy nearly the same level. In breech deliveries, the mechanism of the head's passage through simple flattened pelves varies as the head engages in a state of flexion or extension. In the former case, while the anterior parietal bone moves downward over the symphysis, the transit-line marked by the promontory upon the posterior parietal bone runs from its anterior inferior angle, just in front of the ear, in an oblique direction upward CONTRACTED PELVES. 455 toward the parietal boss. When, however, the head enters the pelvis in a state of partial extension, a furrow is formed by the promontory, Avhich runs nearly parallel to the coronal suture. If, finally, the ex- tension is complete, and the occiput descends first into the pelvis, the marking of the promontory is found between the boss and the lambdoidal suture. In pelves contracted in the transverse diameter, extension of the chin, unless the contraction be slight, proves an insuperable obstacle to delivery. Flexion, however, is the rule, as the resistance which the occiput meets with from the walls of the pelvis tends to direct the chin toward the chest. The Effects produced in Contracted Pelvis by the Pressure of the Child upon the Soft Maternal Tissues.—The body of the child rarely, and only in cases of extreme prolongation of the expulsive period, leaves any traces upon the maternal soft parts. Injurious pressure proceeds almost exclusively from the child's head. As the intra-pel- vic organs sustain excessive pressure when of short continuance more easily than that which is moderate but prolonged, the most striking lesions are produced in head presentations. The after-coming head usually passes through the pelvis too rapidly to produce any pro- nounced effects. The pressure is, as a rule, most marked at the brim, where, as we have seen, the contraction is in the generality of cases greatest, and where the pelvic canal is most encroached upon by sharp projections. The pressure may be either diffused over the entire periphery of the brim, or it may be more localized at certain definite points. Diffused pressure occurs in justo-minor pelves, or where complete accommodation of the child's head to the form of the pelvis takes place. It gives rise to disturbed circulation in the hypogastric veins, and as a further consequence to transudation of serum, and capillary haemorrhages in the tissues of the cervix, the vaginal walls, and exter- nal organs of generation. Circumscribed pressure leads to crushing, thinning, and at times to the complete destruction of the tissues acted upon, the extent of the lesion depending upon the intensity and duration of the force exerted. Usually the destructive action proceeds, following the direction of the pressure from Avithin outward—i. e., the injuries are more consider- able, both in degree and extent, in the tissues next to the child's head than in the deeper ones contiguous to the pelvic border. Complete perforation of the tissues during labor is rare. Perforation is com- monly the result of necrosis, the sloughing of the compressed tissues taking place during the puerperal period. The pressure from the promontory is brought to bear always upon the cervix uteri.* The supra-vaginal portion is more commonly * Litzmann, Volkmann's "Samml. klin. Vortr.," No. 23, p. 186. 456 THE PATHOLOGY OF LABOR. affected than the vaginal portion. The consequent loss of substance is of a funnel shape, starting from the inner surface, and rarely pene- trating through the peritonaeum. The coverings of the promontory are not affected by pressure. Pressure from the upper border of the symphysis pubis usually affects the vaginal wall and the adjacent tissues of the bladder. Fis- tulae resulting are, therefore, much more commonly vesico-vaginal than utero-vesical. Here, too, the lesions are more extensive upon the inner surface of the utero-vaginal canal, and diminish as they extend outward. Thus, the destruction of tissue is greatest upon the cervical and vaginal walls, is less marked upon the posterior bladder- wall, while the anterior wall exhibits only faint traces of injury. Pressure from the lateral walls, and from the horizonal rami of the pubes, occurs most frequently in faulty positions of the child's head. Thus, in brow presentations, the intervening tissues are apt to become clamped between the occiput and the margin of the side-Avail. Again, when the sagittal suture is directed to the front, and the posterior parietal bone presents, a similar compression may take place between the anterior wall and the child's head. Sharp bony projections from the crests of the pubes are commonly covered by the tendinous attach- ments of the psoas minor muscles. In case of long-continued labor, however, the spinous outgrowths and sharp edges of the crests are liable to rub through their protective coverings, and secondarily the utero-vaginal tissues. Influence of the Pressure of the Pelvis upon the Integuments of the Child's Head.—One of the commonest results of the peripheral pressure of the brim upon the child's head is the production of the scalp-tumor. Its formation is usually associated with compression of the cranial bones. As the bones overlap, the integuments of the engaged portion of the head are thrown into folds. As, however, in consequence of the obstruction in the venous circulation, transudation of serum takes place into the subcutaneous cellular tissue, the folds subsequently dis- appear, and a swelling ensues. It will be seen that conditions favor- able to the production of the scalp-tumor are a soft, easily molded head, and such degree of transverse pelvic contraction as serves to render the circular pressure of the scalp complete. Owing to the lat- ter condition, the scalp-tumor is found more frequently and more de- veloped in justo-minor and generally contracted, flattened pelves than in simple flattened pelves with normal transverse dimensions. Usually the tumor does not form until after rupture of the membranes. At times, hoAvever, in justo-minor pelves the head may become so fixed at the brim during the first stage of labor that a diffused swelling of the scalp may follow while the membranes are still intact. A scalp- tumor at the brim is of favorable import. It shows that the pains are good. So long as the tumor continues to increase, if the presentation CONTRACTED PELVES. 457 is favorable, the accommodation of the head remains a possibility. The increase of the tumor serves, too, to fix the head at the brim, and favors the overlapping of the cranial bones. It likewise gives to the head the form of an elongated ellipse, a form most favorable to its passage through the contracted pelvic canal. Localized pressure-marks upon the child's head are derived, in the great majority of cases, from contact with the promontory. With less frequency they have their origin in pressure produced by the anterior and lateral pelvic walls and the inward projection, in rachitic pelves, of the cartilage at the symphysis pubis. They consist of round and oval spots and reddened lines, which disappear in the lighter cases usually in from twelve to tAventy-four hours. If the pressure has been long continued, it may give rise to ul- ceration, or even to complete destruction of the skin down to the periosteum. While not usually dangerous to the child, in exceptional cases they may be- come the starting-point of suppuration in the surrounding subcutaneous cellu- lar tissue, and thus lead to fatal pyaemia. They are found with greatest frequency upon the parietal bones, especially upon FlG- 206.—Pressure-mark upon skull. j.i - • -»*-•,,, (Dohrn.) the posterior one. More rarely they are situated upon the frontal, and in very rare instances, finally, upon the occipital and temporal bones. The situation and direction of the red lines depend chiefly upon the manner in which the head enters the pelvis. Thus, in simple flattened pelves, where moderate extension occurs in the normal mechanism of labor, the mark of the promon- tory runs along the posterior parietal bone, between the boss and the large fontanelle, either parallel to the coronal suture, or at first in the direction of the boss, and then later as flexion occurs forward toward the frontal bone (Dohrn). In cases where transverse shortening causes flexion of the head at the brim, the principal point of pressure lies near the parietal boss, and the line runs obliquely forward toward the outer angle of the eye, or toward the cheek, according to the extent of the flexion. Sometimes a red line, running across the forehead nearly parallel to the coronal suture, is produced by the pressure of the side-wall. Pressure upon the ophthalmic vein, when it occurs, leads to oedem- atous swelling and hyperaemia of the lid, and to increased secretion from the conjunctiva. Influence of the Pressure of the Pelvis upon the Cranial Bones — The so-called molding of the child's head, by which it is made to con- form to the size and shape of the pelvis, is chiefly effected by the dis- placements and alterations in the form of the cranial bones. Of the 458 THE PATHOLOGY OF LABOR. displacements, the most important consists in the overriding of the bones at the principal sutures. The most common site is along the sagittal suture. Usually the posterior parietal bone is flattened and depressed beneath its fellow. At the same time the curvature of the anterior or presenting parietal bone is increased. In transverse nar- rowing, the occipital bone is depressed along the lambdoidal suture. The position of the frontal bones at the coronal suture is subject to a variety of influences. As a rule, however, they are depressed beneath the parietal bones. Overlapping often does not extend the entire length of a suture, but may exist in one part, while in another the bones may occupy the same level. Sometimes a displacement takes place between the two lateral halves of the head in the direction of the occipito-frontal diameter. This movement is supposed to be due to the influence of the promontory, which pushes the posterior half forward Avhen the head is flexed, and backward in cases of partial extension. The compression to which the child's head is subjected, when pro- longed and excessive, is apt to produce disturbed cranial circulation. Bupture of the capillaries which pass from the surface of the brain to the arachnoid sac, and to the sinuses of the dura mater, may give rise to intra-cranial extravasations. The overriding at the sagittal suture, in extreme cases, may cause laceration of the sinus longitudinalis. Separation of the bones at the sagittal and coronal sutures sometimes takes place while the coverings of the skull remain intact.* In a small percentage of cases (7*3 per cent., Litzmann) furrow-like depressions occur. The usual site is along the line of the coronal suture, where they are formed by the promontory. In front a grooved line is sometimes found near the squamous suture, produced by the pressure of the anterior pelvic wall. Triangular depressions (the spoon-shaped depressions of Michaelis) situated upon the posterior parietal bone, between the boss and the large fontanelle, are of still rarer occurrence. They are found chiefly upon the heads of prema- ture children, where they are of sinister import. Actual fracture of the skull in head presentations is extremely infrequent, and is gener- ally due to the employment of the forceps. In breech presentations, lesions of the scalp, owing to the shortness of the time to Avhich the after-coming head is subject to the pressure of the contracted pelvis, are, in two thirds of the cases, absent alto- gether. When they are present they are comparatively trivial, con- sisting of slight swelling of the integuments, and now and then of a red mark left by the promontory. The cranial bones, on the con- trary, when rapidly dragged by the projecting promontory, are pecul- iarly liable to serious injury. Thus, in breech cases, depressions, fract- ures, and fissures of the parietal bones, are much more common than * Litzmann, Volkmann's "Samml. klin. Vortr.," No. 23, p. 191. CONTRACTED PELVES. 459 in head presentations. Forcible tractions upon the trunk sometimes lead too to a rupture of the squamous sutures, or even to separation of the condyles from the occipital bones.* Prognosis in Contracted Pelves.—The mortality to the mother is at least twice as great as in normal pelves. The causes of this increased death-rate are to be found in the concurrent action of a great variety of influences. Among the chief of these is the prolonged labor, an event Avhich under all circumstances, especially after the rupture of the membranes, tends to diminish the chances of recovery. This re- sult is due to the strain upon the nervous system from the protracted duration of the associated pain, to the depression of the vital powers growing out of the fasting and loss of sleep which labor entails, to the irritation and crushing of the soft parts, and, finally, to decomposition of the fluids retained within the uterine cavity in cases where access of air has taken place. In contracted pelves we have superadded to these general sources of disturbance the special injurious effects pro- duced by the pressure of the lower segment of the uterus, the vagina and the soft parts which cover the cavity of the small pelvis between the hard head of the child and the bony walls. As the results of pressure, we have seen that obstruction to the venous circulation, oedema, capillary haemorrhages, superficial lacerations of the mucous membrane, and at localized points necrosis and even complete separa- tion of the interposed tissue may take place. These further lead to metritis, endometritis, parametritis, and perimetritis, which are an- nounced at times during labor, but more commonly subsequent to confinement, by sharp elevations of temperature. When the destruc- tion of tissue reaches the peritonaeum, general peritonitis follows, as a rule. When the necrosed tissues become gangrenous from access of air, the septic poisons generated spread through the cellular tissue, and lead speedily to a fatal termination. Sometimes shock destroys the patient during the first day or two following labor, before local in- flammations have had time to develop. Further dangers to be appre- hended are rupture of the uterus and the pelvic articulations, fistulous communications with the bladder and the rectum, injuries to nerves of the ischiatic plexus, post-partum haemorrhage as a consequence of uterine exhaustion, and thrombus formation in the veins of the uter- ine parenchyma. Even the operative measures resorted to for the relief of the patients are often new sources of peril, and their employ- ment is to be regared simply as a lesser evil. For the child the action of the contracted pelvis is even more del- eterious, f The infant mortality, in cases not requiring sacrificial >* C. Ruge "Verletzung des Kindes durch Extraction bei Beckenlage," " Ztschr. f. Geburtsh.," Bd. i, p. 74. •j- Spiegelberg puts the mortality of the children at thirty-five per cent, (vide " Lehr- buch der Geburtshulfe," p. 464). 460 THE PATHOLOGY OF LABOR. operations, is explained by the long duration of the labor, and the prevalence of faulty presentations and positions. In the majority of instances death takes place from asphyxia promoted by the early rupt- ure of the membranes, the complete escape of the amniotic fluid, the prolapse of the cord, the disturbances in the utero-placental circula- tion resulting from the retraction of the uterus upon the surface of the child's body, and sometimes by the premature separation of the placenta. The prognosis for the child is especially unfavorable in premature labors. This arises not alone from the increased frequency of malpresentations, but from the diminished power of premature children to resist external pressure. Thus, death may take place from direct pressure upon the medulla oblongata through the thin bony coverings of the head, or extensive cerebro-spinal effusions of blood may result from the laceration of the delicate walls of the infra-cranial and intra-spinal vessels. I CIIAPTEE XXVI. TREATMENT OF CONTRACTED PELVES. Cases of extreme pelvic contraction, rendering delivery per vias naturales impossible.— Cases indicating craniotomy or premature labor.—Cases where extraction of a living child at term is possible.—Premature labor.—Version.—Forceps.—Expectant treat- ment. The resources at the disposition of the accoucheur, in cases of con- tracted pelvis requiring obstetrical aid, are the Caesarean section, the induction of premature labor, craniotomy, forceps, and version. But, before it is possible to form an opinion regarding the treatment best suited to an individual case, it is necessary to first obtain a clear and definite idea regarding the degree and character of the pelvic deform- ity. We have, then, to settle the following questions : Has pregnancy advanced to term ? If not, does the case call for the induction of abortion or premature labor ? If the end of utero-gestation has been reached, is it possible to deliver the child through the natural passages ? Is the child living or dead ? If the former, do the interests of the mother require the sacrifice of the child's life ? If the conditions are such as not to render it impossible for a living child to be born, in what way can we best subserA'e the interests of both mother and child ? The right choice of measures requires not only an accurate apprecia- tion of the advantages, limitations, and drawbacks which inhere to the measures themselves, but the extent to which the mechanical obsta- cles to delivery are heightened or modified by those remoter influences which we have seen are exerted upon the organic processes of labor by the pelvic contraction. TREATMENT OF CONTRACTED PELVES. 461 The greater the degree of pelvic narrowing, however, the more de- cided the influence of the pelvis becomes, and the more definite, there- fore, the treatment. For the sake of convenience it is customary to consider apart the following classes : * 1. Cases of such extreme pelvic contraction thai the attempt to de- liver the child through the natural passages is inadvisable. In these extreme degrees of pelvic deformity premature labor holds out no hope of saving the life of the child, and affords but a trifling advantage to the mother. If abortion is not produced in the early months, the only resource is the Caesarean section or laparo-elytrotomy. The precise limit at which the dangers from delivery through the pelvis rise to the level of or exceed those from the Caesarean section is not easy to deter- mine. It depends partly upon the size and ossification of the child's head, and largely upon the experience and dexterity of the operator. Michaelis, in the case of a dwarf scarcely three and a half feet high, extracted a small child through a pelvis measuring but one inch and a half in the conjugate diameter, f The operation lasted two and a half hours. At the end of two weeks the patient was able to resume her household duties. Dr. Osborn, in the celebrated case of Elizabeth Sherwood, extracted a child through a pelvis measur- ing, as he believed, but three quarters of an inch in its narrowest portion ! Barnes J extracted with perfect success a child through a conjugate which, he says, certainly did not exceed one inch and a half. It would be easy to go on and extend this list, to show that there is no degree of conjugate shortening that renders it utterly im- possible to extract a mutilated child. But the question which Ave should ask for our guidance is, not what can possibly be accomplished by the skill and ingenuity of the exceptionally experienced operator, who is capable of making Avhatever rules he likes to govern his own actions, but what is the point at which men in every-day practice need expect to find the dangers from craniotomy and the Caesarean section rise to nearly the same level. Dr. Parry collected seventy cases of cranioto- my in pelves measuring two and a half inches and under. Seven had to be terminated, finally, by Caesarean section. Of the seventy women forty-three surviA*ed, and twenty-seven died. The work was not done by tyros, but by celebrated obstetric surgeons. Thus, the best results of the ablest accoucheurs show a mortality from craniotomy, in the higher degrees of pelvic deformity, of nearly forty per cent. In the hands of an operator of limited experience, I believe the Caesarean section, when timely made, offers ordinarily to the mother a better chance of recov- * The limits are those of Litzmann. Vide " Ueber die Behandlung der engen Beck- en," Volkmann's " Samml. klin. Vortr.," No. 90. f Michaelis, " Abhandlungen aus dem Gebiete der Geburtshulfe," p. 151. The op- eration lasted two and a half hours. X Barnes, " Obstetric Operations," p. 406. 462 THE PATHOLOGY OF LABOR. ery. There are, of course, exceptions to the rule. Most pelves measur- ing less than two and a half inches in the conjugate belong to the category of generally contracted flattened pelves. Where, exception- ally, the transverse diameter is not materially diminished, the difficul- ties of craniotomy are greatly lessened, and, if at the same time the child's head be soft and compressible, a comparatively easy extraction may give rise to false ideas concerning the real dangers of delivery by the natural passages. These are due chiefly to the fact that the opera- tion has to be carried on within the uterine cavity, when, owing to the contracted brim, no descent of the head is possible. A long op- eration conducted within the uterine cavity is always fraught with evil. The dangers are not altogether mechanical. Even if serious lesions, such as perforations, rupture of the uterus, and lacerated wounds, are avoided, some contusion of the lower uterine segment is inevitable, air enters freely the uterine cavity, the patient exhibits very commonly the symptoms of profound shock, and the delivery is often followed by post-partum haemorrhage, due to uterine inertia. The means employed to check haemorrhage tend still further to depress the vital powers. In many cases the uterus remains large, and the labor is followed by ca- tarrhal endometritis. This ordinarily mild puerperal affection is apt, owing to the introduction of air and the presence of bits of necrosed tissue, to assume a septic form, and pave the way to a fatal termination. The contiguity of the peritonaeum likewise adds to the formidable character of all supra-pelvic operations. When the outlet of the pel- vis alone is contracted, and craniotomy can be performed upon the head after it has entered the vaginal canal, the dangers of extraction are much diminished. Cases of extreme degrees of the justo-minor pelvis are believed to be exces- sively rare. Certainly the whole number reported since Naegele's day may be easily counted on the fingers of the two hands. At full term the labor takes place, provided the general contraction is such as to retain the head at the brim, in one of two ways: 1. The uterus retracts up over the head of the child. If the head does not descend, the vagina is drawn upward and is exposed to injurious tension. Should nothing be done to relieve this condition, the thin vagina is liable to be rubbed through by the pressure it encounters at the brim, and especially at the symphy- sis pubis. Version would here be impossible, and the forceps would only enhance the risks. Perforation and decerebration would at once diminish the pressure. With little over three inches in the conjugate and four in the transverse diame- ter, the vault of the skull may be broken up with the cranioclast, the chin tilted downward, and the head brought edgewise through the pelvis. In this way, with moderate skill, it would be possible to extract a dead child. The operation of laparo-elytrotomy, however, seems so peculiarly fitted to these conditions, that it deserves a trial in the interest of both mother and child. 2. The membranes rupture early, the waters gradually escape, and, as the head does not descend, the uterus retracts down firmly upon the child. A scalp- TREATMENT OF CONTRACTED PELVES. 463 tumor forms, which fixes the head at the brim and pushes the cervix and lower segment of the uterus before it. Here it would be proper to await for a time the results of uterine action. As the transverse diameter can only be roughly estimated, the head may lengthen out and adapt itself to the pelvic canal. But the delay should not be too prolonged. If, in spite of the formation of the scalp- tumor, the bony head remains unmoved at the brim, it is a question whether it would not be the wiser plan to proceed at once to the Caesarean section. Naegele * reports the history of a dwarf whose pelvis measured but three inches and seven lines in the transverse and three inches in the conjugate. He delivered her with forceps of a five-and-a-half-pound child, but she died on the tenth day. Heim reports the history of a dwarf with three and a quarter inches conjugate, and four and three quarters inches transverse diameter. Delivery by perforation and forceps. Rupture of the three articulations.f Spiegelberg reports a case with nearly the same dimensions. Child presented by the breech. Extraction difficult. Perforation of after-coming head. Ceph- alotripsy. The patient died shortly after delivery.! I have reported a case where the conjugate was three and one sixth inches, and the transverse four and a half inches. Delivery by perforation, the cranioclast, and the crotchet. The patient died on the third day ("Trans, of the Am. Gynsec. Soc," vol. iv). Kor- mann relates a case nearly identical with my own, both as regards its diameters and the existence of a slight lateral obliquity. After over three days' labor the head adapted itself to the pelvis, and the child was extracted alive by forceps. The mother died of peritonitis.* Thus, of five women with generally contracted pelves, in which the conju- gate ranged from three to three and a quarter inches, all died as a consequence of delivery through the natural passages. In cases where the uterus is rigidly applied to the child, and the cervix is undilated, the propriety of laparo-elytrotomy is questionable. The operation is not always a very easy one, and it certainly can not afford to be handicapped by anything which would cause delay in the delivery after the vaginal rent has been made. There are, of course, in so rare a condition, scant statistics in favor of any special plan of treatment. Michaelis reports a case of Mantz's, that of a woman who had a pelvis measuring two inches antero-posteriorly, and three inches in the transverse diameter. Here the Caesarean section became a matter of neces- sity rather than one of election. Twice the operation was performed with suc- cess. A third time the result promised to be equally favorable, but the willful and insubordinate conduct of the patient, as late as the twenty-seventh day, led to her destruction. In spite of the fact that in generally contracted pelves craniotomy is nearly always practicable, and notwithstanding the bad repute of Cesarean section, a careful study of the ground convinces me that where there is a diminution of nearly an inch in all the diameters, Caesarean section, or, probably, in cases of complete dilatation of the cervix, laparo-elytrotomy, holds out the best chances of success. * Naegele, " Das schrag verengte Becken," p. 102. \ Lohlein, op. cit, p. 42. X Spiegelberg, " Lehrbuch der Geburtshulfe," p. 444, vide note. * Kormann, " Ueber ein allgemein verengtes, schrag verschobenes Becken," " Arch. f. Gynaek.," p. 472. 464 THE PATHOLOGY OF LABOR. 2. Cases in which the pelvic contraction is such as to prevent the birth of a full-term living child through the natural passages, but in which extraction through the pelvis furnishes the best chance of saving the life of the mother. The choice of measures in this class of cases lies between craniotomy and, where the condition of things is recognized early enough, the induction of premature labor. In gen- eral terms we are authorized to assume such a degree of disproportion in flattened pelves with the conjugate ranging between two and a half and three inches, while in justo-minor pelves craniotomy will be usually requisite at full term, even with a conjugate measuring three and a third inches. In, however, these less extreme degrees of de- formity, other elements than those of the size of the pelvic canal enter into the formation of an opinion regarding the proper procedure to be selected. I have myself, in one case, extracted a child weighing six and a half pounds by forceps, without much difficulty, through a gen- erally contracted flattened pelvis with a conjugate measuring barely two and three fourths inches. Labor had lasted three days previous to my seeing the patient, which Avas in consultation. The child's head presented a singular appearance, from the molding it had undergone, having been greatly flattened in its biparietal diameter and enor- mously elongated in the occipito-mental direction. The child died, however, shortly after birth. The mother recovered, though consid- erable sloughing of the vaginal walls followed the long continuance of the pressure which had preceded delivery. Grenser, in the Dresden Hospital Reports (1861-1863), gives three cases of children born alive where the pelvis measured two and three quarters inches. In one of these, where the labor lasted twenty-two hours, a living child was born weighing six and a half pounds. If, therefore, labor comes on at full term before craniotomy is pro- ceeded to, an attempt should be made to gauge the degree of dispro- portion between the head and the pelvic brim, for not only is it among the bare possibilities that a living child may be expelled through a pelvis measuring less than three inches, but it is to be borne in mind that in pelvic mensuration even the most expert may make errors of a quarter of an inch. In any case it is Avell to preserve the mem- branes as long as possible. Even craniotomy is more easily performed after complete dilatation of the os. After the waters escape, the lower uterine segment is subjected to injurious pressure between the hard skull and the pelvic rim, the damage done increasing of course with the duration of labor. By early perforation and evacuation of the brain-mass this danger is avoided. But craniotomy should not be performed so long as the hope exists of saving the life of the child. The attempt should be made, at least, before perforating, to form an estimate of the size of the child's head and its relations to the pelvic brim. An approximative result may be obtained by palpating the TREATMENT OF CONTRACTED PELVES. 465 head through the abdominal Avails above the pubes, and, so soon as the cervix is dilated and the head becomes pressed by the labor-pains firmly against the brim, by introducing the half-hand into the vagina to de- termine the extent of that portion of the cranial vault which has entered the pelvis. When we have ascertained the size of the segment beneath the pelvic border, and the special points of the head which occupy the several pelvic diameters, we are in a position to estimate the size of the portion above the brim, and the mechanical difficulties which remain before the engagement of the head can be accomplished. In shoulder presentations, Avhere, of course, version is necessary, extraction alone should be first tried, and only when it is found impos- sible to effect the delivery of the after-coming head by other means should perforation be resorted to. Schroeder claims to have extracted living children through pelves measuring but seven and a half centi- metres (three inches) in the conjugate.* The induction of premature labor in pelves having from two and three quarters to three inches conjugate diameter possesses the merit of diminished risk to the mother, and affords a chance of saving the life of the child. Below two and three quarters inches the advantages of premature labor may be fairly called in question. To be sure, Kiwisch placed the biparietal diameter of the child's head in the thirtieth Aveek at two and a half inches. Seyfert, however, fixed it at three inches, and later Schroeder obtained nearly three and a quarter inches (8*16 centimetres) as the average between the twenty-eighth and thirty- second week. In point of fact there is too little uniformity in the diameters of fetal heads belonging presumably to the same week of development to make average measurements of any practical utility. It Avill be seen, hoAvever, that, in the higher degrees of pelvic contrac- tion we are now contemplating, the biparietal diameter of the child's head rarely falls within the limits of the narrowed conjugate. Still, it is possible to deliver a living child through a pelvis estimated at two and three quarters inches as late as the thirty-fourth week,f as the head, owing to the pliability of the cranial bones in premature chil- dren, is capable of sustaining a considerable degree of lateral compres- sion. Naturally the infant mortality in these cases is very large. In addition to the ordinary increased risks attendant upon premature labor, intra-cranial extravasations of blood from rupture of the deli- cate cerebral vessels are extremely common. Litzmann found in nearly one fourth of his cases (8 : 34) spoon-shaped depressions of the skull. Though this lesion is often met with upon the heads of living children at full term, in the series of Litzmann four of the children were dead at birth, three showed feeble signs of vitality, and in one only, Avhich lived but fourteen hours, was it possible to excite the * Schroeher, " Lehrbuch der Geburtshulfe," p. 539. f Wiener, " Zur Frage der kiinstlichen Friihgeburt," " Arch. f. Gynaek., Bd. xiii, p. 99. 30 466 THE PATHOLOGY OF LABOR. respiratory process. Thus the outlook for the child is by no means hopeful; but, inasmuch as, under three inches, the only operations which come into competition with premature labor are the Caesarean section and craniotomy, a small saving of fetal life is a powerful plea in its justification. But a stronger argument in its favor is the fact that the induction of premature labor offers a milder procedure, which, within certain limits, inures to the benefit of the mother. Below tAvo and three fourths inches the chances of saving the child by premature labor are too slight to be weighed in the balance.* Moreover, unless the child's head happens to be exceptionally small and yielding, approximating the conditions to those which obtain in immature deliveries, craniotomy in the end has usually to be resorted to. Now, as premature labor offers no peculiar advantages in the per- formance of craniotomy, and, as it is attended with certain risks of its own, it is advisable, in very narrow pelves after the twenty-eighth Aveek, to await the normal end of gestation. As the dangers to both mother and child are increased by delay, Barnes has proposed combining version with premature labor, in pelves of less than three inches conjugate, as a means of accelerating delivery. Milne {vide note), by this method, extracted a living child through a two and a half inch pelvis. Budin has found by experi- mentation with artificial pelves that a much less amount of traction force is requisite to drag the head of a premature child through a flat- tened conjugate by the feet than by forceps in cephalic presentations. 3. Cases in ivhich the pelvic contraction does not exceed the limits within ivhich the delivery of a living child at term is at least possible. In this category belong the overwhelming majority of all instances of contracted pelvis. It embraces not only cases in Avhich the con- junction of every favorable condition is essential to delivery, but those moderate degrees of narrowing Avhich are chiefly recognizable through the influence they exert upon the mechanism of labor. It includes flattened pelves with a conjugate of three inches and upward, and justo-minor pelves with a conjugate of over three and a third inches. Below these figures the delivery of living children at full term is too exceptional an eA'ent to be taken into account in any attempt at classi- fication. The obstetrical resources for overcoming the mechanical obstacles afforded by moderate degrees of pelvic contraction are, the induction of premature labor, craniotomy, forceps, and version. Each one of * In support of this opinion, which is thoroughly confirmed by my own experience, we have especially the authority of Spiegelberg, Litzmann, and Dohrn. Milne (" Prema- ture Labor and Aversion," " Edinburgh Med. Jour.," vol. xix, p. 70*7) relates a case where he was successful in a pelvis measuring but two and a half inches. He state?, however, that the space in the other diameters of the brim was ample, which was certainly an ex- ceptional advantage, as nearly all pelves with the higher grades of deformity belong to the category of generally contracted rachitic pelves. TREATMENT OF CONTRACTED PELVES. 467 these measures has its strenuous partisans, who have expended much unprofitable zeal in comparative estimates of their respective values. It is a mistake to regard them as rival pretenders to favor. Indeed, the very conditions Avhich indicate one form of procedure often ex- clude the others from consideration. Good midwifery requires a just appreciation of all the auxiliaries at our disposition and a careful study of the circumstances Avhich render them severally appropriate. Premature Labor.—The indiscriminate induction of premature labor in every case of contracted pelvis is particularly to be deprecated. In the first volume of the "Archiv fur Gynaekologie" Spiegelberg presented the statistics of 1,224 cases of full-term labor in contracted pelvis, in which the maternal mortality was 6*6 per cent, and the in- fant mortality 28 per cent.; while in 271 cases of induced premature labor the maternal mortality was 18*8 per cent, and the infant mor- tality 66 per cent. This startling discrepancy is due to the fact that a very large proportion of labors in contracted pelves either terminate spontaneously, or require forceps only after uterine action has over- come the obstruction at the brim. If all these minor cases be omitted, a very different result is obtained. Thus, Litzmann found that in flat- tened pehres measuring from two and three fourths to three and one fourth inches in the conjugate, and in justo-minor pelves between three and one third and three and a half inches, the maternal mortal- ity after premature labor amounted to 7*4 per cent., while the loss of life in labors at full term was 18*7 per cent.* But, in cases of recov- ery, the advantages of premature delivery are by no means inconsider- able, as, owing to the diminished head-pressure, lesions of the genital canal are of rare occurrence, in striking contrast to the fistulae, lacera- tions, and cicatrices Avhich so often follow delivery at full term. The prognosis for the child, as shown by the statistics of premature labor in contracted pelves, is decidedly unfavorable. In the restricted class of cases we are at present considering Litzmann found that, though tAvice as many children were born alive as at full term, the actual number discharged alive from the hospital was about the same. He concluded, therefore, that, while the operation was decidedly indi- cated in the interests of the mother, it offered a dubious advantage to the child. It is, however, always injudicious to draw deductions from hospital statistics alone. Especially is this true of feeble children, born prematurely, whose ultimate chances depend in a peculiar degree upon the care Avith which they are tended. Dohrn, who objected to the statistics of Spiegelberg and Litzmann, on the ground that the units of which they Avere composed repre- sented, not parallel cases, but an endless variety of dissimilar condi- tions, proposed, as a fairer Avay of testing the value of induced prema- * Litzmann, " Ucbcr den AVerth der kiinstlich eingleiteten Friihgeburt bei Becken- enge," "Arch. f. Gynaek.," Bd. ii, p. 194. 468 THE PATHOLOGY OF LABOR. ture labor, to compare the results of the latter operation with those of full-term labors in the same patients. Viewed in this way, prema- ture labor in contracted pelves has been found to furnish unexpectedly favorable results. Thus, Dohrn reports nineteen cases, with forty-one children, at term, of which thirty-seven died. In twenty-five preg- nancies premature labor was induced, with fifteen living children.* Kiinne and Berthold report eight cases, with twenty-four children at term, of which eighteen died. In eighteen pregnancies premature labor was induced, with thirteen living children, f Still more extraor- dinary is the report of Milne. Six women gave birth at term to twehre children, of Avhich eleA'en were dead. In the succeeding thirty-eight pregnancies premature labor was induced, and thirty-five children were born living. J The ordinary time for bringing on labor is from the thirty-second to the thirty-fourth week. Most writers now agree that the operation should be restricted to pelves measuring less than three and a half inches in the conjugate, Avhereas aboAre that limit it is best to await the results of spontaneous uterine action. Labor at End of Gestation.—But the physician may first be sum- moned to a case of contracted pelvis after the end of gestation has been reached, or he may at an earlier period have decided against the induction of premature labor. At full term, supposing the head to present, the latter, at the be- ginning of labor, is preATented by the pelvic narrowing from entering the brim of the pelvis, and is usually freely movable. The conduct of the first stage of labor should be directed to preparing the Avay for the subsequent delivery of the child. To this end every pains should be taken to preAent rupture of the membranes until the cervical dilata- tion has become complete. The patient should be cautioned against restless movements in bed, and from bearing down during the pains. Examinations per vaginam should be made with great care, and should be avoided except where absolutely necessary. The largest-sized Barnes dilator, moderately distended with fluid, placed in the vagina to exert counter-pressure upon the cervix, is at times of use where the mem- branes have a tendency to protrude in the form of a narroAV cylinder. Attention should likewise be directed to faulty positions and pres- entations of the child's head. Should these be dependent upon a pendulous abdomen, the fundus of the uterus should be elevated, and the normal relations of the uterine axis maintained by a suitably ad- justed bandage. ExcessiA'e lateral obliquity should be corrected by * Dohrn, " Ueber kiinstliche Friihgeburt bei engen Becken," " Arch. f. Gynaek.," Bd. xii, p. 10. f Kunne, " Funfzehn Falle der kiinstlichen Friihgeburt"; Berthold, "Zur Statistik der kiinstlichen Friihgeburt," " Arch. f. Gynaek.," Bd. vi, Heft 2. X Milne, " Premature Labor and Version," " Edinburgh Med. Jour.," vol. xix. TREATMENT OF CONTRACTED PELVES. 469 placing the patient upon the opposite side. Should transverse nar- rowing require a deep descent of the occiput, this can be furthered by placing the woman upon the side to Avhich the occiput is directed. Where, on the other hand, it is desirable to promote the dip of the forehead, the patient should be made to lie upon the side to A\hich the child's face is turned. The reason of this is obvious, as, when the breech falls to a given side, the cephalic pole has a tendency to move in the opposite direction. The right use of position as a corrective force depends upon the degree of accuracy with which the character of the pelvic deformity is estimated, and upon a proper appreciation of the mechanism appropriate to the ascertained deformity. Where the sagittal suture looks forAvard toAvard the symphysis pubis, so that the posterior parietal bone becomes the presenting part, a firm compress above the pubes may be advantageously employed to press the head backward and approximate the sagittal suture to the median line. The pains, when weak and inefficient, should be strengthened by the warm vaginal douche ; Avhen the source of exaggerated suffering, they should be mitigated by morphia, by rectal injections of chloral, or by the administration of an anaesthetic. Should, by good fortune, the rupture of the membranes be post- poned until after the completion of cervical dilatation, one of two contingencies may follow : 1. The disproportion between the head and the pelvis may prove to be slight, so that a considerable segment of the cranial vault may be felt below the brim ; then, provided the head en- ters the pelvis in conformity with the mechanical laws dictated by the character of the pelvic deformity, the expulsion of the child may be left to the natural uterine forces. 2. No engagement may take place, the head continuing freely movable at the brim. Under such circum- stances the disproportion may be assumed to be considerable. The physician has, therefore, to ask himself whether he shall await the action of the pains, in the expectation that the head will gradually adapt itself to the pelvis, or whether he shall at once proceed to per- form version, and drag the child rapidly through the straitened diam- eters. The forceps, as a means of delivery before fixation of the head, should be discarded, not because it can not be employed with success, but because its use, eA*en in the most skillful hands, is extra-haz- ardous. The question of Avaiting, or proceeding at once to Arersion, is one that Avill ahvays be decided largely by the individual experiences of the accoucheur. It is, however, vain to deduce rules of practice from the conduct of those who haA'e enjoyed exceptional opportunities, and who usually have developed exceptional skill in some one special direc- tion. It is to be remembered that in contracted pelves, in case the pains prove inadequate to overcome the obstacles to delivery, the alter- 470 THE PATHOLOGY OF LABOR. natives in head presentations are forceps and perforation. But there are very few experienced operators who have not a more or less per- sonal predilection for either forceps or version, and this unconscious bias exercises, necessarily, to some extent, a determining influence upon their choice. It is well known that there is hardly any subject which has been the source of so much heated controversy as the one at pres- ent under discussion. For the profession at large, however, there is little to be gained from the spirit of partisanship. The general prac- titioner requires instruction not only in the special advantages pos- sessed by each measure, but needs to have presented to his attention parallel statements of the dangers and difficulties from which neither procedure is free. Version.—In considering the application of version to the treat- ment of contracted pelves, it is well to state in advance certain points which are rarely alluded to, probably because they are matters of tacit agreement betAveen the contending parties to whose disputes we main- ly owe our present knowledge in relation to the subject. The first of these points is, that the intent of the operation is to save the life of the child. In the case, therefore, of a dead child, or of one in Avhich the heart-sounds have notably begun to fail, version affords no advantage over perforation. For the same reason the condi- tions must be such as to hold out a reasonable hope of rapid delivery of the child's head, without the infliction of necessarily fatal lesions. Now, there does not appear to be any well-authenticated case of the extraction of a full-term living child after version through a flattened pelvis measuring less than two and three quarters inches in the conju- gate diameter. But even with three, or three and a quarter inches, the result will still depend upon the length of the transverse diameter. Thus, in extreme degrees of the justo-minor pelvis, with the reduction of nearly an inch in all the diameters, the difficulties of delivering the after-coming head, even with the aid of the perforator and the cephalo- tribe, are wellnigh insurmountable. Again, the contraction should be limited to the pelvic brim, for, where it is continuous, or progressively increases toward the outlet, the fate of the child is not even doubt- ful. The other point of importance is, that Avith three and a half inches and upward in the conjugate, no interference is, as a rule, called for. Since it has become the custom to measure pelves with accuracy, the profession has learned that these moderate degrees of deformity exer- cise their influence not so much in a mechanical way as in the modi- fying effects they produce upon labor. A large proportion of the cases terminate spontaneously. If the pains fail prematurely, the conditions are generally such as to make it an easy matter to deliver with forceps. Difficulties only arise where the head is unusually large and incom- pressible, or in faulty positions, such as the anterior dip of the head in TREATMENT OF CONTRACTED PELVES. 471 justo-minor pelves, and the presentation of the posterior parietal bone in the flattened varieties. Thus, version is indicated in contracted pelves only where the. child's heart beats Avith nearly unimpaired vigor, and in pelves meas- uring between two and three quarters and three and a half inches antero-posteriorly, with the contraction limited to the brim, and with sufficient amplitude in the transverse diameter. The advantages of version in contracted pelves grow out of the unquestioned fact that the after-coming head passes more readily the contracted brim than the normal head-first presentation. This supe- rior facility is attributable to the entry of the head by its smaller bimastoid diameter. At the same time, the fronto-occipital descends in the transverse diameter of the pelvis. The pressure of the conjugate is encoun- tered by the bitemporal diameter of the child's head, which measures a half-inch less than the biparietal. Tractions upon the trunk of the child bring to bear simulta- neously pressure upon the head from many points in the pelvic walls. As a result, bi- lateral flattening is effected, and a deep groove, usually near the coronal suture, is produced in many cases upon the posterior cranial surface by the pressure of the pro- jecting promontory. The bulk of the head is still further diminished by an overriding » ,i , , ,, ., , , , ,° JUG. 207.—.liase ol skull: MM, ot the bones at the sagittal suture, and, bimastoid diameter. where the transverse diameter is insufficient, by the crowding of the occipital beneath the parietal bones. A reduc- tion of the cranial contents is brought about by the retreat of a con- siderable portion of the cerebro-spinal fluid into the spinal canal. All these changes are induced rapidly, and are not dependent upon the activity and strength of the uterine pains. The method of performing version and extraction in contracted pelves is, with few modifications, the same as in pelves of normal size. In contracted peh'es great care requires to be taken lest the arms be- come reflected upward to the sides of the child's head, or crossed upon the neck. To avoid this difficulty it is desirable to introduce the hand over the abdomen of the child, and bring down the arms before the engagement of the shoulders. In extracting the head, tractions may be made upon the loAver extremities and shoulders according to the method of Kiwisch, or they may be made with one hand upon the shoulders, while two fingers of the other are inserted into the child's mouth. Provided by either of these methods the relation of the head to the shoulders is such that no twisting of the neck takes 472 THE PATHOLOGY OF LABOR. place, the amount of force that can be employed without producing fatal lesions is often something astounding. Thus, Bokitansky,* ex- perimenting with the bodies of still-born infants, found the utmost strength put forth by tAvo men upon the trunk was insufficient to cause rupture of the vertebral ligaments and separation of the artic- ulations. It is usual, however, to combine pressure from above, exercised by a skilled assistant upon the head through the abdomi- nal walls, Avith tractions from below. Schroeder states f that this practice is coeval with podalic version. It was known to Celsus and Fig. 208.—Method of employing supra-pubic pressure. Head in the pelvic cavitv (Munde\) J recommended by Ambroise Pare. It has found warm advocates in Pugh, Wigand, Martin, Kristeller, and in this country in Taylor and Goodell. Both the latter gentlemen have made valuable suggestions regarding the technical management of difficult cases, Avhich are well worthy of special mention. Dr. Taylor J at first draws the body di- rectly backward, while the head is forced by supra-pubic pressure downward and backward into the pelvis. So soon, hoAvever, as the head begins to advance, he raises the body of the child and directs pressure upon the head to be made doAvnward and forward in the axis of the outlet. In case of failure or delay, he has sometimes succeeded by intentionally directing the back of the child to the sacrum, and then causing the occiput to be pressed doAvnward and backward into * Rokitansky, " AVien. mcd. Presse," 1874, No. 45. f Schroeder, "Handbuch," 6te Aufl., p. 307. X Taylor, " What is the Best Treatment in Contracted Pelves ? " p. 23. TREATMENT OF CONTRACTED PELVES. 473 the nearest sacro-iliac space, with the face looking upward, while trac- tion is made in the axis of the outlet. Dr. Goodell,* after first draw- ing in the direction of the outlet, Avith the assistant pushing down- ward and backward, reverses the direction, and sweeps the child's body backAvard upon the coccyx, the neck likewise being forced downward and backAvard into the hollow of the sacrum Avith all one's poAver. Where the projection of the promontory is not very marked, he likewise recommends as sometimes of assistance a pump- handle movement, the range of oscillation extending from the axis of the outlet anteriorly to very firm pressure on the coccyx poste- riorly. It is obvious from the foregoing description that version and ex- traction in contracted pelves expose the child to perils of no insignifi- cant character. Among the lesions which have been observed as a result of the extreme traction force necessary to bring the head rapidly through the narrow brim are fracture of the clavicles, fracture of the humerus in difficult arm-deliveries, lacerations of the sterno-cleido- mastoid muscles, rupture through the substance of a vertebra, extrav- asations of blood into the cavities of the head and trunk, separation of the condyles from the occiput, and of the squamous portion of the temporal from the parietal bones, fractures and depressions of the skull, and rupture of the sinuses of the dura mater, f To be sure, many of these accidents are not inevitably fatal, but they do not by any means furnish the chief sources of danger. These result partly from the respiratory efforts which are always excited by delay in ex- tracting the after-coming head, and partly from the depressing influ- ence exercised upon the fetal heart by pressure brought to bear upon the base of the brain. J Having thus made out, Avith great care, a full bill of particulars, embracing all the acknoAvledged draAvbacks to the performance of ver- sion in narrow pelves, we have next to consider how far these associ- ated evils tend to invalidate the claim of version to be regarded as facile princeps among conservative measures of treatment. The fol- lowing records of the individual experience of competent operators will help us to solve this question. Kormann turned in nine cases of contracted pehTes. Seven children were born living, and two dead. All the mothers recovered.4* Lowenhardt turned in twenty cases of contracted pelves. SeA'enteen children were born alive, and three dead. Only children that outlived the first week were counted in the * Goodell, " Clinical Memoirs on Turning in Contracted Pelves," " Am. Jour, of Obstet.," vol. viii, p. 211. f C Ruge, " Verletzungen des Kindes durch Extraction bei Beckenlage," " Ztschr. f. Geburtsh.," Bd. i, p. 68. X Dohrn, "Ueber Pulslosigkeit des Kindes wahrend Extraction an den Fiissen," "Arch. f. Gynaek.," Bd. vi, p. 365. * Kokmann, " Arch, f. Gynaek.," Bd. vii, p. 13. 474 THE PATHOLOGY OF LABOR. successful cases. The mothers recovered.* Goodell reports eleven cases. Four children Avere alive at birth, and four were still; but, of the latter, one was extracted through a pelvis measuring only two and a half inches conjugate diameter, and in one the case was complicated by eclampsia. The mothers recovered. Now, not to go beyond these forty cases, we obtain, as the result of version, thirty-one living in- fants, without the sacrifice of a single mother. A number of the women in AA'hose previous labors craniotomy had been found neces- sary were delivered by version of living children. Lowenhardt placed in contrast his OAvn experience with the forceps in narrowed pelves presenting degrees of contraction corresponding to those in which he had resorted to version. In forty-five deliveries, sixteen children were born dead and five died shortly after birth. Of the mothers, three died, while tAventy-one suffered from puerperal affections of greater or less severity. Now, if the foregoing testimony represented the entire truth, there would be no good reason for discussing other plans of treatment. They, in fact, show only how far special training and experience will enable an operator to overcome difficulties by dexterity and address. In the first case reported by Dr. Goodell the child was still-born. In commenting upon the cause of death Dr. Goodell states frankly : " Much force Avas needed to extract the head, but it was not made as promptly and efficiently as I have since learned to make it."f Another side of the question has been presented by Borinski,J who, at the instigation of Professor Spiegelberg, collected the statistics of version in contracted pelves from the Breslau Clinic between the years 1865-1872. In all there were ninety-three cases. Thirty-four chil- dren were saved, and fifty-nine were born dead, or died soon after birth. Fifteen mothers lost their lives. This seemingly disastrous showing is capable, however, to a certain degree, of explanation. Thus, twenty of the fifty-nine children born still died before version was attempted. In nine of the cases the transverse as well as the conju- gate was materially diminished. Of the children deliA'ered through these flattened generally contracted pelves, only one, and that a very small one, Avas extracted alive. Still, there Avere fifty-eight cases of version in ordinary flattened pelves, with the result that just one half the children were born dead. In only three of the fifteen mothers who died was the fatal result apparently connected Avith the opera- tion. In the others, death was due to spontaneous rupture of the uterus, placenta praevia, and nephritis, version having been resorted * Lowenhardt, " Wendung und Extraction das dominirende Verfahren bei Beckcn- enge," "Arch. f. Gynaek," Bd. vii, p. 421. f Goodell, " Trans, of the Intcrnat. Med. Congr.," Philadelphia, 1876, p. 777. X Borinski, " Zur Lehre von der Wendung auf die Fusse bei engen Becken," " Arch. f. Gynaek.," Bd. iv, p. 226. TREATMENT OF CONTRACTED PELVES. 475 to because of these complications. A considerable allowance should be made, too, in the cases from the Breslau Clinic, for the fact that the greater part of them took place in the out-department of the hos- pital, when they Avere under the charge of mid wives, who rarely send for timely aid except in the presence of dangerous complications. In eighteen instances the operation was performed on account of pro- lapse of the cord, and in eighteen instances because of some maternal affection. Forceps.—In presenting this less favorable side of version in con- tracted pelves, it is Avell incidentally to place in juxtaposition the re- sults of the high forceps operation as given by Dr. Harold Williams, in a recent number of the "American Journal of Obstetrics" (Jan- uary, 1S79). Williams collected one hundred and nineteen cases, re- ported since 1858, Avhere the forceps was applied to the head above the brim. Of the mothers nearly forty per cent., and of the children over sixty per cent., perished. The mechanical objections to the use of forceps at the brim are obvious. When the head is molded to the contracted pelvis by the natural forces, the head passes the conjugate with its long diameter in the transA^erse diameter of the pelvis, with the two fontanelles on nearly the same level, and with the sagittal suture looking toward the sacrum. The posterior parietal bone ro- tates around the promontory, the latter producing a furrow which runs either along the coronal suture, or at first in front of the parietal boss, and later, as flexion occurs, forward toward the frontal bone. The bilateral compression of the head is compensated for in part by a lengthening in the fronto-occipital and partly in a vertical direc- tion. The forceps applied in the transverse or oblique diameter of the pelvis prevents the former compensation from taking place. It in- creases the Avidth of the head, and thus adds to the difficulty of pass- ing the conjugate. Often it disturbs further the normal head mechan- ism by causing premature flexion and rotation to take place. In each of these ways it augments the difficulties of delivery, and renders neces- sary the employment of an increased amount of traction force. With forceps applied directly to the sides of the child's head I have had no experience, but Dr. Goodell,* who has clearly pointed out the objec- tions to this method in contracted pelves, has shown that they inevi- tably produce flexion, and cause the large biparietal diameter to pass through the narrow conjugate. So long as the head does not engage at the brim, there is no rivalry between version and forceps. The latter should be placed under the ban as hardly less dangerous than the Caesarean section. Expectant Treatment.—Now, let us suppose that after rupture of * Goodell, " Labor in Narrow Pelves," " Trans, of the Internat. Med. Congr.," Phila- delphia, 1876, p. 788. 476 THE PATHOLOGY OF LABOR. the membranes it is decided to resort to neither forceps nor version, but to adopt an expectant course, until circumstances arise which shall render active interference necessary. It is certain that a very consid- erable portion of labors in contracted pelves terminate spontaneously. Winckel* reports twenty-three cases in the Dresden Maternity in 1873, and twelve cases in 1874-'75. Of the thirty-five cases, two mothers and three children died. Osterloh f reported one hundred and thirty- nine cases from the Leipsic Maternity, between the years 18G3-1872 inclusive. There were one hundred and five cases where the pelves measured from three to three and a half inches. Of one hundred and six children, seven died. Of the mothers four died. In thirty-four cases where the pelves measured over three and a half inches, two chil- dren died. All the mothers recoArered. There were, however, forty- two cases in all of puerperal disease terminating in recovery. Borinski reports from the Breslau Clinic tAvo hundred and thirty-three spon- taneous deliveries in contracted pelves, with one hundred and ninety- tAvo living children. There were ten maternal deaths, but four were from non-puerperal intercurrent affections. Thus, in three large ma- ternity hospitals there were in cases of contracted pelves four hundred and seven spontaneous deliveries, with the loss of fifty-three children, and, from puerperal diseases, of twelve mothers, the latter represent- ing very nearly the usual mortality in lying-in hospitals. Even in pelves measuring less than three inches, now and then, the spontaneous birth of a small living child takes place. If we examine these results, we find that under favorable circum- stances, in all but the extreme forms of pelvic contraction, Nature will do her own work with the least expense of infant life, and with a rela- tively small maternal mortality. On the other hand, the long-contin- ued pressure upon the parturient canal, incident to the molding and adaptation of the head to the narrow pelvis, yields a large contingent of inflammatory affections, which complicate the puerperal period and protract the convalescence. By favorable circumstances we mean a presentation and position of the child's head suited to the form of the pelvis, and a sufficient degree of uterine activity. Rectification of a faulty position of the head after the rupture of the membranes is always a matter difficult of accomplishment. In case, therefore, the brow presents, or the head engages with an excessive degree of lateral obliquity (sagittal suture looking forward toward the pubes, or back- ward toward the promontory), in place of wasting time in futile efforts at correcting the malposition, version should be promptly performed. In prolapse of the cord, Avhich occurs in about six per cent, of the cases, the indication would clearly be version rather than replacement. * Winckel, "Berichte und Studien," 1874-76. f Osterloh, " Einigc Beitrage zu den spontan verlaufenden Geburtcn bei engem Becken," " Arch. f. Gynaek.," Bd. iv, p. 520. TREATMENT OF CONTRACTED PELVES. 477 In eclampsia and face presentations most operators would preferably resort to version. Thus, we have finally the field of controversy betAveen version and other plans of treatment narrowed down to cases in which, after rupt- ure of the membranes, the head remains above the brim, but the con- ditions are such that Nature is capable of overcoming the mechanical difficulties of delivery providing that the labor-pains are sufficiently energetic. There is always an element of chance in this last condition, which, however, is an essential one. If the pains are weak and pow- erless, it may be possible, even hours after rupture of the membranes, Avhen the head has not become fixed, to still accomplish version. More frequently, hoAvever, as the head but incompletely fills the lower seg- ment of the uterus, the Avaters escape, the uterus retracts upon the foetus, the cervix becomes oedematous and tender, and after a time the temperature and pulse rise, betokening the presence of danger. Sometimes the retraction of the uterus ends in the withdrawal of the cervix over the child's head, and, in the failure of the latter to de- scend into the pelvis, the vagina is drawn upAvard, and subjected to a perilous degree of tension. It is easy to see that under such cir- cumstances the time for version is past, and craniotomy is called for. Because, therefore, Avhere labor is left in contracted pelves to the spon- taneous efforts of Nature, in a certain proportion of cases the insuf- ficiency of the labor-pains leads to the necessity of sacrificing the child, there will ahvays be operators Avho, confident in their own skill, will prefer to turn soon after rupture of the membranes, that they may keep in their hands the control of the delivery. The bulk of pro- fessional men will, on the contrary, so long as spontaneous delivery is probable, prefer to wait, even though by so doing they may eventu- ally find themselves obliged to fall back upon the perforator and the crotchet. When the birth of the child is left to the contractions of the uterus, reenforced by the expiratory muscles, the physician should assume the role of a watchful spectator. Safety to the mother and the child requires that the time of the passage of the head through the bony canal should not be too prolonged. So long as the head de- scends steadily, however slow the progress may be, in case no compli- cations demand speedy extraction, the physician should await the results of uterine activity. Should the pains grow weak and inef- ficient, they may be stimulated by the uterine douche, the introduction of the catheter into the uterus, and by small doses of ergot or the viscum album, provided the inertia is not the result of pathological changes in the uterine tissues. When the advance of the head ceases, either from failure of the pains or, as in justo-minor pelves, from the growing resistance of the pelvic outlet, the rule should be to relieve the soft parts of the mother 478 THE PATHOLOGY OF LABOR. as speedily as possible from the pressure of the child's head. Press- ure too long continued ends in oedematous swelling, softening of the tissues, arrest of circulation, and eventually in necrosis and gangrene. When the integrity of the lower segment of the uterus has been im- paired to any extent, perforation should be resorted to, and the child sacrificed to the interests of the mother. If, on the contrary, the changes are insignificant, and the mechanical difficulties not insuper- able, by the use of forceps it may be possible to save the life of both mother and child. But to avoid the first-named cruel alternative, the forceps should be applied so soon as the requisite conditions for its employment are reached. Of course, as the forceps is used solely to save fetal life, in case the feeble heart-action of the child giA*es warn- ing of impending asphyxia the interests of the mother are to be alone consulted. In estimating the mechanical difficulties to be overcome by the forceps, it is necessary to determine how far engagement has taken place. Litzmann * recommends that the physician ascertain by inter- nal examination, combined with external palpation, both the size of the segment of the cranium below the brim and how much of the head remains to undergo compression before it can enter the pelvis. In ordinary flattened pelves, Litzmann found that in three fourths of all the cases the pains alone sufficed to overcome the resistance of the brim. When the head had so far descended that the sagittal suture had passed from three to four fifths of an inch beloAV the promontory, and the boss of the anterior parietal bone could be felt Avith ease behind the symphysis pubis, extraction with the forceps was a task of no great difficulty, even if before its application flexion had not begun to take place. In generally contracted flattened pelves, it is desirable that the head should be transverse and well flexed, with the posterior parietal bone at least three fifths of an inch below the promontory. With the forehead and occiput resting upon the side-walls of the pelvis, the sagittal suture near the promontory, and an ear felt behind the symphysis pubis, the prospects of forceps operations are extremely dubious. In justo-minor pelves of moderate extent (conjugate three and a half inches), the failure of the pains, which forms the necessity for forceps, is rather the result of the paralyzing effect of the pressure of the bony canal upon the entire circumference of the cervix than of the absolute degree of pelvic contraction. The heads descends in a state of complete flexion, with the large fontanelle at the pelvic brim. If, as the head advances, the small fontanelle moves from the median line, and the large fontanelle becomes accessible to the finger, it is * Litzmann, " Ueber die Behandlung der Geburt bei engem Becken," Volkmann's " Samml. klin. ViJrtr.," pp. 715 ei seq. TREATMENT OF CONTRACTED PELVES. 479 likely that the pelvis widens toward the outlet. If the forceps serves only to bring the fontanelle doAvn still deeper, and to increase the declivity of the sagittal suture, the opposite condition obtains, which may frustrate the delivery.* In flattened pelves the forceps should be applied as nearly as pos- sible to the fronto-occipital diameter of the head, as the latter needs to descend into the transverse diameter of the pelvis. When applied obliquely it tends to cause premature rotation, Avhich increases the difficulties of extraction. In justo-minor pelves the direction of the blades is of less importance, as the head often descends spontaneously in an oblique diameter. Success in high forceps operations depends upon the degree of accuracy Avith Avhich the tractions are made in the axis of the pelvis. With the long-curved forceps, it is especially dif- ficult to fulfill this requirement at the superior strait. Even when the directions to draw vertically downward are faithfully carried out, a considerable portion of the force is expended in the pressure of the for- ceps upon the soft tissues lying between them and the anterior pelvic wall. In careless hands this pressure is capable of inflicting a great deal of injury, particularly where the blades of the forceps are passed within an imperfectly dilated cervix, and where they project somewhat beyond the child's head. Various devices have been invented to cor- rect this defective working of the instrument. Pajot recommends placing the left hand upon the lock to make pressure backward, while with the right hand tractions are made downward and somewhat for- ward. I have generally succeeded by exerting a small amount only of force at each traction, Avatching at the same time with great care the direction of the blades in the pelvis. This method is pretty safe, and in the end generally successful, but often requires a very considerable outlay of time and patience. A pair of straight forceps, as recom- mended Dr. I. E. Taylor, will often enable one to draAV more directly in the axis of the brim, and Avill succeed when the curved forceps have had to be abandoned. Of late I have been in the habit of using Tarnier forceps in high operations, and am able to give it my cordial approval. The blades always SAving in the tranverse diameter of the pelvis, while the traction force is exerted as nearly as possible upon the center of the child's head. A few trials will convince the most prejudiced opponent of the Tarnier forceps that it will at the supe- rior strait bring the head to the floor of the pelvis in much less time, and with a less expenditure of force, than can be accomplished by other methods. The dangers from the forceps in contracted pelves are due not so much to the pressure it makes directly upon the child's head and the pelvic walls as to the compensatory bulging of the head in its transverse diameter. AYhen the head is fixed at the brim and the for- * Litzmann, "Ueber die Bchandlung der Geburt bei engem Becken." 480 THE PATHOLOGY OF LABOR. ceps is applied to the forehead and occiput, it is evident that the only change of form that can take place is in a vertical direction. Safety in deliA'ery requires that there should be no sudden augmentation of the bilateral pressure, which Avould necessarily deepen the furrow made by the promontory upon the posterior-lying parietal bone, and imperil the integrity of the maternal tissues confined at the conjugate between the promontory and the pubes. Until, therefore, the head has passed the narroAv strait, tractions should be made with moderate force, and with short periods of intermittence. After the head has once descended to the floor of the pelvis the forceps should be remoAred, and the head be alloAved to rotate into the conjugate, then a forceps of any pattern may be adjusted to the sides of the head should further aid be required to complete deliArery. So far we have considered cases in which the cervix was suf- ficiently if not completely dilated before rupture of the membranes. If, as is very common, the membranes rupture prematurely, the diffi- culties and risks to both mother and child are greatly increased. With rapture come, as we have already seen, escape of the amniotic fluid, retraction of the uterus, and interference in the utero-placental cir- culation. With an undilated os externum the cervix is stretched by the head, and its thinned tissues are subjected to pressure from the symphysis and promontory. Delay leads to arrest of circulation and necrosis at the points of pressure, but here version and forceps are alike. impracticable. This leaves as the only alternatives perforation and the Caesarean section. Timely aid, therefore, in such cases should be extended before a dangerous condition is reached. My first prefer- ence just after rupture is the Barnes dilator, which not only serves to expand the cervix, but, when employed promptly, helps to prevent the escape of the amniotic fluid. Next to the Barnes dilator, and of special utility Avhen the waters have already escaped, I would place the long, narroAV-bladed forceps of Dr. Taylor for introduction through the undilated os. With it the head can be grasped, and, when made to descend and then allowed to recede in alternation, oftentimes the rounded cranial surface will efficiently act as a dilating body, and se- cure such a degree of expansion as will pave the way for the safe adoption of other methods of delivery. RARE FORMS OF TELVIC DISTORTION. 481 CHAPTER XXVII. RARE FORMS OF PEL VIC DISTORTION. The Naegele oblique pelvis: morbid anatomy, etiology, diagnosis, mechanism of labor in, prognosis, treatment.—The kyphotic pelvis: morbid anatomy, etiology, diagnosis, prognosis.—Scolio-rachitic pelvis: anatomical characters.—Robert's pelvis: anato- my, etiology, diagnosis, prognosis.—Spondylolisthetic pelvis: anatomical characters, diagnosis, prognosis.—Funnel-shaped pelvis.—Osteomalacia.—Pelvis narrowed by exostoses.—Divided symphysis. I. The Naegele Oblique Pelvis. This variety of deformed pelvis derives its name from the author who first systematically studied it and called attention to its impor- tance as a cause of obstructed labor. Morbid Anatomy.—The pathological characters peculiar to this ATa- riety of deformed pelvis are, according to the classical description of Naegele,* the folloAving : 1. Complete anchylosis of one sacro-iliac Fig. 209.—Naegele oblique pelvis. (From specimen in the Wood Museum.) synchondrosis, or osseous union between the sacrum and one os innomi- natum. 2. Destruction or defective development of the lateral half of the sacrum and smaller caliber of the anterior sacral foramina on the anchylosed side. 3. Diminished breadth of the os innominatum and of the sacro-sciatic notches on the same side. The articular facet of the ili- um, which corresponds to the sacral auricular surface, is less elongated than on the non-anchylosed side. 4. The sacrum is displaced toward the anchylosed side, and its anterior surface is turned in that direction. The pubic symphysis is pushed to the healthy side, and is, therefore, not directly opposite the promontory. 5. The internal surface of the os innominatum on the deformed side is flatter than the correspond- * Naegele, "Das schragverengtes Becken," Mainz, 1850, p. 7. 31 482 THE PATHOLOGY OF LABOR. ing sound bone, and the linea ilio-pectinea is but slightly curved. 6. The sound side of the pelvis is not of an entirely natural shape, as is shown by the fact that its ilio-pectineal line is straighter posteriorly, and more curved anteriorly, than in a normal pelvis. 7. The results of the deformities mentioned are : {a) That the pelvis is contracted in that oblique diameter meas- ured by a line passing from the acetabulum of the anchylosed side to the opposite sacro-iliac joint, while the other oblique diameter is not shortened, but even elongated in extreme cases, {b) That the dis- tances between the promontory and either acetabulum, and those be- tween the apex of the sacrum and the spine of either ischium, measured from the aflected side, are less than the corresponding distances on the other, (c) That the distances between the tuber ischii of the anchy- losed side and the posterior superior spinous process of the opposite ilium, and those between the spine of the last lumbar vertebra and the anterior superior spinous process of the diseased side, are shorter than the corresponding distances on the opposite side, {d) That the distance of the superior posterior iliac spine of the anchylosed side from the lower border of the symphysis pubis is greater than that between the symphysis and the opposite posterior superior spinous process, (e) That the Avails of the pelvic cavity converge below, and that the pubic arch is narrowed and approximated to the type of the male arch. (/) That the acetabulum of the flattened side is directed farther forward than is normal, while the opposite acetabulum looks almost directly outward. We may add that the anterior surfaces of the bodies of the lumbar ver- tebrae are directed toward the anchylosed side. The ilium is higher, steeper, flatter, and reaches farther backward on that side. The pubic arch looks toward the flattened side. The conjugata vera is somewhat elongated. The transverse diameter is shortened at the inlet, and its shortening progressiA'ely increases as the outlet is approached.* The os innominatum of the healthy side is somewhat displaced outward, and is more markedly curved, hence the venter of the corresponding ilium is directed more anteriorly than that of the anchylosed side, f The deformity is most apparent at the inlet, which is compared by Naegele to an oblique oval figure. The tuber ischii on the anchylosed side is higher, and directed more posteriorly and internally than nor- mal. This description will also apply to the ordinary oblique-ovate pelvis, except so far as the anchylosis, which is the distinguishing feature of the Naegele oblique, is concerned. Etiology.—The essential cause of oblique-ovate pelvis in general is continuous pressure directed against one of its lateral halves, the weight of the trunk falling predominantly or exclusively upon the lower extremity of the deformed side, and leading to displacement and * Schroeder, " Lehrb.," p. 596. ■(■ Litzmann, " Die Formen d. Beckens," Berlin, 1861, p. 69. RARE FORMS OF PELVIC DISTORTION. 483 distortion of the pelvic bones. The conditions producing this pre- dominant unilateral pressure are tabulated by Litzmann * as follows : 1. Lateral spinal curvature, usually of rachitic origin. 2. Impeded or entirely abrogated function of one lower extremity. In this case the deformity will affect that side the lower extremity of which is intact, f The impairment or loss of function may result—(a) from unilateral hip-disease; {b) from amputation of one lower extremity; (c) from an old dislocation of the femur upward and backward. 3. Unsym- metrical sacrum, produced by defective deA'elopment, or by atrophy of one sacral lateral mass—{a) as the result of a defect in the original formation; {b) as the result of abnormal coalescence of the sacrum and ilium in early life, whereby the growth of both was hindered ; (c) as the result of a loss of substance from caries. Spiegelberg % calls attention to Lambl's statement that primary asymmetry of the sa- crum may be due to coalescence of the sacral lateral masses and the transverse processes of the last lumbar vertebra, whereby the outward growth of the former is impeded. He also emphasizes * the fact that simple chronic arthritis of the sacro-iliac synchondrosis produces sa- cral asymmetry, without anchylosis, by inducing contraction and atro- phic sclerosis of the contiguous osseous tissue. The continued use of one shortened loAver extremity is another cause of excessive pressure upon the corresponding side of the pelvis. When this condition ob- tains, the deformity will be on the side of the shortening. The sacro- iliac synostosis, which has been alluded to as the distinguishing char- acteristic of the Naegele oblique, as contrasted with the other forms of the oblique-ovate pelvis, is sometimes the primary deformity, as will be seen from the foregoing etiological table. The coalescence of the joint- surfaces is never, however, congenital, because the articulation is fully formed before the appearance of the centers of ossification for the sa- cral lateral masses. Nor can the synostosis be referred to involvement of the joint-surfaces in the process of ossification, since this does not occur in any true joint. The disappearance of the joint-cavity must, therefore, be referable to an inflammatory process, resulting in adhe- sion of the opposed articular surfaces. The inflammation may be either of traumatic or of strumous origin. The results of unilateral pressure upon the pelvis will depend upon the amount of pressure exerted, the resistance of the bones, and the firmness of their connections. Diagnosis.—The attention of the obstetrician will be directed to the possibility of the existence of the oblique-ovate pelvis when the subject limps and presents an inequality in the height of the hips or evidences of antecedent gluteal abscesses. The diagnosis is assured by a physical examination, which shows, in the first place, the distance * Litzmann, op. cit., p. 68. f Gusserow, "Arch. f. Gynaek.," Bd. xi, 1877, p. 264. X Spiegelberg, " Lehrb.," p. 475. * Spiegelberg, " Arch. f. Gynaek.," ii, 1871, pp. 159 et seq. 484 THE PATHOLOGY OF LABOR. between the spinous process of the last lumbar vertebra and the pos- terior superior spinous process to be considerably less on the deformed than on the healthy side. The absence of this sign is, however, no proof of the non-existence of the deformity. The distorted ilium is higher than the other, and projects farther posteriorly than is normal. A vaginal examination reveals the straight course of the ilio-pectineal line on the side of the anchylosis, the deviation of the sub-pubic arch toward that side, a disparity in the distances between the ischiatic spines and the apex of the sacrum, and the deviation of the promon- tory. Naegele* suggested, for the completion of the diagnosis, the application of the following measurements, which are equal on both sides in the normal, but different in the oblique-ovate pelvis : 1. The distance of the tuber ischii of one side from the posterior superior iliac spine of the other ; on the deformed side it is shorter. 2. That from the anterior superior to the posterior superior spine of the other side ; shorter from the anterior spine of the deformed side. 3. That from the spine of the last lumbar vertebra to the anterior superior spinous process of the same side ; less on the contracted side. 4. That from the trochanter major to the opposite posterior superior spinous process ; shorter when measured from the affected side. 5. That from the under surface of the symphysis pubis to the posterior superior iliac spine; longer on the narrowed side. These measurements are only of avail in well-marked cases, and may lead to erroneous con- clusions if other diseases of the bones be simultaneously present. The vaginal examination affords, on the Avhole, the most accurate results. Mechanism of Labor.—The mechanism of the birth, in an oblique- ovate pelvis, is the following: If the promontory be retreating, the sagittal suture of the fetal cranium enters the inlet parallel to the longer oblique diameter. If, however, the promontory project con- siderably, and is closely approximated to the ilium of the affected side, no portion of the head can be admitted between them, f The cranium will then enter the pelvis most easily with the sagittal suture in the short oblique diameter, and will pass through the pelvic canal without rotation. If the pelvis be originally small and the deformity marked, the obstruction to labor may be complete. Should the pelvis, how- ever, be roomy and the promontory retreating, no considerable impedi- ment will be offered to parturition. Prognosis.—It is obvious that the prognosis, for both mother and child, is best when the pelvis was originally large, and far less favor- able under the reversed condition. In the latter case the mother very frequently succumbs and the child is only rescued by the Caesarean section. Litzmann's J statistics report the death of twenty-two out of * Naegele, op. cit., p. 174. \ Litzmann, " Monatsschr. f. Geburtsk.," xxiii, 1864, p. 268. X Ibid., p. 284. RARE FORMS OF PELVIC DISTORTION. 485 twenty-eight mothers, five of whom perished undelivered, and that of thirty-one children out of forty-one cases. These figures by no means, however, fairly represent the average result, since many cases of slight and moderate deformity escape detection. Treatment.—In a case of extreme obliquity at the Bellevue Hospi- tal, where the distance between the ischia barely exceeded two inches, I induced premature labor at presumably the twenty-ninth week. The child Avas turned and lived long enough after extraction to receive the rite of baptism. The mother made a speedy recovery. This case affords a striking contrast to those reported by Litzmann. Undoubt- edly, if the obliquity were always recognized at a sufficiently early period of pregnancy, the induction of premature labor would favorably change the prognosis. Very commonly, however, the condition passes unperceived until delay in labor leads to a more careful investigation. In such cases, if the head has entered the pelvic cavity, and the dimi- nution of the space between the ischia is not excessive, a careful at- tempt should be made with the forceps to test the adaptability of the presenting part to the contracted diameter. Violent tractions should, however, be avoided. Studley * has recently reported a case of coxal- gic oblique pelvis in which fracture of the pubic rami upon the right side resulted from forceps delivery. If the disproportion is such that moderate tractions are unavailing to advance the head, or if the child is already dead, perforation should be performed. Craniotomy at the inferior strait is much less dangerous than at the brim. If the head fail to enter the pelvis, we have to inquire whether the result be due to absolute deficiency of the pelvic space, or to the fact that the sagittal suture of the head corresponds to the shortened ob- lique diameter. In the first event the case becomes a good one for laparo-elytrotomy, while in the second version should be performed with a view to bringing the long cephalic diameter into correspond- ence with the opposite longer diameter of the pelvis. If extraction is then found to be impossible, perforation can still be performed upon the after-coming head. II. The Kyphotic Pelvis. Morbid Anatomy.—The characteristic deviations of a kyphotic pel- vis from the normal type are due to the unnatural direction in which the weight of the superimposed trunk is communicated to the base of the sacrum, as the result of an existing antero-posterior spinal cur- vature. If a dorsal kyphosis be entirely compensated by a lumbar lordosis, the former may entail no pelvic distortion. As a rule, the deformity is most marked with lumbar and sacral kyphoses, which admit of no compensatory lordosis, and least apparent with remote dor- sal kyphoses. The effect of the altered direction, in which the weight of * " Am. Jour, of Obstet.," 1879, p. 269. 486 THE PATHOLOGY OF LABOR. the trunk is transmitted to the sacrum, is to force the latter more deeply between the ossa innominata and to rotate its upper portion in a pos- terior direction. The displacement backward of the inferior extremity of the trunk causes the center of gravity to be thrown far behind the acetabula, and produces a consequent diminution in the obliquity of the pelvTis by ele- vating the anterior pelvic pa- rietes.* The change in the pelvic obliquity is antago- nized by the ilio-femoral liga- ments, and the result of these opposingforces f is asfollows : The sacrum is narrowed and elongated by the traction from behind and above, and its upper part is displaced backward. Its transverse con- cavity is increased and its longitudinal concavity dimin- ished. J The bodies of the sacral vertebrae are on a plane posterior to their transverse processes. The promontory Fig. 210.—Specimen of kyphotic pelvis. (Litzmann.) is high and is directed far backward. The upper ante- rior surface is sometimes convex while the concavity of the loAver part is preserved, and an S-like shape is thus imparted to the sacral curve. The higher anterior sacral foramina look upward. Owing to the ten- sion of the ilio-femoral ligaments, the anterior inferior spinous pro- cesses of the ilium are well developed. The linea ilio-pectinea are only slightly curved. The sub-pubic arch is narrowed. The spines and tuberosities of the ischia are abnormally approximated. Owing to the narrowness of the sacrum, the posterior superior iliac spines are in close proximity to each other, while the spines and crest of the ilium are more remote than in a normal pelvis. The venters of the ilia are expanded and directed to the front. The transverse diameter of the false pelvis is, therefore, increased, Avhile that of the true pelvis is diminished. The symphysis is prominent, the horizontal pubic rami meeting at an acute angle. At the inlet the oblique and the conjugate diameters are elongated and the transverse diameter cur- tailed. In the true pelvis the transverse diameters are considerably, * Lange,-" Arch. f. Gynaek.," Bd. i, 1870, p. 231. \ Spiegelberg, "Lehrbuch," p. 483. X Breslau, " Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 319. RARE FORMS OF PELVIC DISTORTION. 487 and the antero-posterior diameter slightly shortened. These diame- ters become still more contracted as the outlet is approached. * If a lumbo-sacral kyphosis be present, the sacrum is shortened and very narrow. If this kyphosis be situated very low down, it may be com- pensated for by a Ioav lumbar lordosis, which overhangs and materially contracts the pelvic inlet, f Etiology.—The cause of the spinal curvature resulting in kyphotic pelvis is usually caries of the vertebrae. \ Diagnosis.—The antecedent history and the discovery of kyphosis will render the existence of this form of pelvis probable. On more careful physical examination, the shape and position of the sacrum, the short inteiwal between the spines and the tuberosities of the is- chium and the posterior superior iliac spines, the wide separation of the anterior superior iliac spines, the narrow pubic arch and prominent symphysis, the flatness of the iliac venters, and the difficulty experi- enced in reaching the promontory, will establish the diagnosis. The differential diagnosis between a kyphotic pelvis and one deformed by osteomalacia, with Avhich it is sometimes confounded, will be readily made by reference to these distinctive features and to the fact that the transverse diameters of the false pelvis are elongated in a kyphotic pelvis, the reverse obtaining in osteomalacia. Prognosis.—The amount of obstruction offered to parturition will naturally depend upon the grade of the pelvic contraction. The prognosis for the mother is not exceedingly grave unless the outlet be extremely contracted. The prospects for the preservation of the child's life are unfavorable. In some instances there is said to be a certain amount of mobility in the pelvic joints, which enlarges the outlet and facilitates the parturient process. Treatment.—Dr. I. E. Taylor has recently reported a case of ex- treme pelvic kyphosis, where the distance between the ischia, measured by me with great care, did not exceed one inch and three fourths. In the patient's first pregnancy he delivered her by craniotomy. She was out of bed on the tenth day. At her second confinement, Dr. Taylor resorted to Porro's operation, with a view to saving the life of the child. The latter object was accomplished, and the Avoman lived twenty-one days, but died eventually of pulmonary embolism following phlegmasia. It is obvious that in this, as in all other forms of pelvic contraction, the treatment will be determined by the extent of the deformity. In the extreme grades, however, the comparatively favorable results of craniotomy, when performed after the head has entered the pelvic cavity, would, except for the interests of the child, give to that operation the preference over the Caesarean section. * Huter, "Ztschr. f. Geburtsh. u. Gynaek.," Bd. v, 1880, p. 22. f Fehling, "Arch. f. Gynaek.," Bd. iv, 1872, p. 2. X Neugebauer, " Monatsschr. f. Geburtsk.," Bd. xxii, 1863, p. 297. 488 THE PATHOLOGY OF LABOR. III. SCOLIO-RACHITIC PELVIS. ' A brief allusion must be made to the anatomical characteristics of a purely rachitic pelvis, in order to render the differences between it and a scolio-rachitic pelvis intelligible. The leading pathological features of the infantile rachitic pelvis consist in expansion of the sub- pubic arch, prominence and lowering of the promontory, widening and elongation of the sacrum, flatness of the venters of the ilia, between which there is an abnormally wide interval, and in an irregularly rounded, triangular, or kidney-shaped pelvic inlet.* These anatomical features are not altered by the supervention of a scoliosis, but the latter adds to the deformity al- ready existing its own patho- logical characters. The latter combine to produce a marked unilateral asymmetry of the pelvis, f The most ordinary form of scoliosis consists in a deviation of the dorsal vertebrae to the right and a compensa- ting lumbar curve to the left. The adult scolio-rachitic pel- vis presents many points of re- semblance to the infantile, its leading peculiarities being the following : J The entire pelvis is inclined toward the side of the lumbar curve, and rests chiefly upon the corresponding thigh. The cause of the pelvic asymmetry is to be sought in the increased weight thus thrown upon the contracted half of the pelvis and in the counter-pressure exerted upon its ar- ticular surface. The contracted half of the pelvis is higher and more inclined than its fellow. The sacrum has sunk deep between the ilia, and is narrower upon the side of the lumbar scoliosis. The sacral vertebral bodies are sometimes displaced forward, project- ing beyond the lateral masses. The promontory is displaced toward the contracted side, and the corresponding lateral mass is often narrowed. There is rarely anchylosis of the hip-joint. The ilium * Fehling, " Arch. f. Gynaek.," Bd. x, 1876, p. 1; Ibid., Bd. xi, 1877, p. 173. t Kehrer, "Arch. f. Gynaek.," Bd. v, 1873, p. 60. X Leopold, "Das skoliotisches und kyphotisch-rachitisches Becken," Leipsic 1879 p. 7. Fig. 211.—Specimen of scolic-rachitic pelvis. (Litzmann.) RARE FORMS OF PELVIC DISTORTION. 489 is erect, looks inward, and is narroAved antero-posteriorly. Its crest is higher than that of the opposite side. The symphysis is dis- placed toward the uncontracted half of the pelvis. The ilio-pectineal line makes a sharp curve inward near the sacro-iliac synchondrosis, and then pursues an undulatory course to the symphysis, being notably bent inward opposite the acetabulum. On the uncontracted side the corresponding line forms a large and rounded arch. The tuber ischii on the side of the lumbar scoliosis is turned outward. The oblique diameter of this side is greater, but the distance between the sacrum and the acetabulum {distantia sacro-cotyloidea) is much shorter than on the uncontracted side. The plane of the inlet is obliquely cordi- form, being contracted upon the side of the lumbar scoliosis and ex- panded on the other. Exactly the reverse conditions obtain at the pelvic outlet.* The conjugata vera is notably shortened by the pro- truding promontory. The antero-posterior diameter of the outlet, although contracted, still far surpasses the conjugata vera in length. Other and independent pathological conditions may aggravate the obstruction caused by the peculiar deformity in question. Thus, Hu- genberger describes a case of scolio-rachitic pelvis complicated by an extensive sacral hydrorachis. f The peculiar deformity of a scolio-rachitic pelvis obstructs de- livery by so narrowing the space between the acetabulum and the sacrum as to prevent any part of the fetal cranium from engaging in it. Botation is thus prevented, and the delivery must be accom- plished, if indeed it be possible, by the same mechanism obtaining in a justo-minor pelvis, the conjugata vera of which Avould be here rep- resented by the distantia sacro-cotyloidea, and the transverse diameter of which would correspond with the oblique diameter of the uncon- tracted side. IV. Bobert's Anchylosed and Transversely Contracted Pelvis. This very rare form of contracted pelvis was first described by Robert, in 1842. Its leading characteristics are bilateral sacro-iliac anchylosis, and absence or rudimentary development of the sacral lateral masses. The sacrum is consequently very narrow, and only slightly wider at its upper than at its loAver extremity. The longi- tudinal and transverse concavities of the bone are nearly or quite ob- literated. In some cases the normal transverse concavity is trans- formed into a convexity. The sacrum is deeply pressed between the ossa innominata. The posterior superior iliac spines are, consequent- ly, closely approximated, and the ilia project far above the base of the sacrum. The promontory encroaches considerably upon the supe- rior strait. The iliac venters are flattened and directed anteriorly. * Leopold, op. cit., p. 10. f Hugenberger, "Arch. f. Gynaek.," Bd. xiv, p. 1. 490 THE PATHOLOGY OF LABOR. The lineae ilio-pectineae are slightly or not at all curved, and abnor- mally approximated. The descending rami of the pubes unite at an acute angle. The ischiatic spines and tuberosities are in close prox- imity to each other and to the lateral margins of the sacrum. The dimensions of the pelvis are materially altered. The transverse diameter is not- ably diminished and grows short- er from above downAvard, so that at the outlet, in marked cases, it is represented by a mere crevice betAveen the ischia and the pubic Fig. 212.—Robert's pelvis. (Lambi.) bones. The form of the inlet is that of a long and narrow wedge with its apex directed anteriorly. The average diameter of the outlet is less than tAvo inches.* The antero-posterior diameter is either of normal length or but slightened shortened, since the projection of the promontory is compensated for by the absence of the normal outward curve of the lateral borders of the inlet. The pelvic canal is deeper than in a normal pelvis. In some cases there is asymmetry of the two lateral halves of the pelvis. Etiology.—The decisive agency in the production of the deformity under consideration is the narrowness of the sacrum, which is chiefly due to the diminished breadth of its lateral masses, but also in a cer- tain measure to the small transverse diameter of the bodies of the sacral vertebrae. Diversities of opinion prevail regarding the connec- tion between the narrowness of the sacrum and the sacro-iliac synos- tosis. Some authors consider deficient development of the centers of ossi- fication of the lateral masses as the primary event and the anchylosis as dependent upon this. Others regard the synostosis as the primary change which determines the atrophy of the lateral masses, f and vari- ously refer it to inflammatory processes or to arrested deA'elopment. J In some cases it would seem that the sacrum was originally of normal breadth, but was narrowed and united with the ilium by osteitis and arthritis.** The transverse convexity of the anterior sacral surface is explained by the fact that the bodies of the vertebrae are pressed for- ward by the weight of the superimposed trunk after the union of the sacral lateral masses with the ilia, and at a time when the connections * Spiegelberg, " Lehrbuch," p. 482. \ Litzmann, " Die Formen des Beckens," Berlin, 1861, p. 62. X Kehrer, " Monatsschr. f. Geburtsk.," Bd. xxxiv, 1869, p. 20. # Kleinwachter, "Arch. f. Gynaek.," Bd. i, p. 156. RARE FORMS OF PELVIC DISTORTION. 491 between the bodies and the lateral masses are still pliable and yield- ing. The close approximation of the ilia and their parallel course are referable to the narrowness of the sacrum and to increased lateral pressure upon the acetabula.* The combined action of these agencies produces the narrowness of the sub-pubic arch, the acutely angular junction of the descending pubic rami, the approximation of the iliac crests, and the straight course of the lineae ilio-pectineae. Diagnosis.—The diagnosis is partly based upon the abnormal ap- proximation of the posterior superior iliac spines, which almost cover the deeply seated spinous process of the last lumbar vertebra, and upon a similar approximation of the trochanters, of the tubera ischii, and of the iliac spines and crests. A vaginal examination then reveals the parallel course of the descending pubic rami and the striking diminu- tion of the transverse diameter. The differential diagnosis betAveen the Bobert and the kyphotic pelves is based upon the absence of a kyphosis in the former and upon the striking difference between the respective transverse diameters. Prognosis.—This is very bad for the mother, inasmuch as labor is completely obstructed by the deformity, and operative interference is always indicated. The Caesarean section offers the only hope of preserving the child's life. V. Spondylolisthetic Pelvis. This rare form of contracted pelvis Avas first described by Eokitan- sky in 1839. f Its principal pathological feature consists in separation of the last lumbar from the first sacral vertebra and in descent of the lumbar spine into the pelvis, where the inferior, or in an extreme case the posterior, surface of the body of the last lumbar rests upon the ante- rior surface of the first sacral verte- bra. The anterior surface of the last lumbar vertebra is directed dowmvard. The anterior surfaces of the fourth, third, and second lumbar A*ertebrae form an arch, the most prominent part of which, being nearest the sym- physis, replaces the normal promon- tory. The result of this displace- ment is a considerable diminution in the antero-posterior diameter of the FlG- 213.—Spondylolisthetic pelvis. pelvic inlet. The descent of the lum- bar portion of the spine, which is gradually accomplished, is attended by atrophy of the intervertebral cartilages, and frequently by osse- * Litzmann, op. cit., p. 65. f Schroeder, " Lehrbuch," p. 574. 492 THE PATHOLOGY OF LABOR. ous union between the bodies of the lumbar and sacral vertebrae. The weight of the superimposed trunk being now transmitted to the anterior surface of the sacrum, instead of to its base, the pel- vic center of graA'ity is displaced forward. This is compensated for by a diminution in the normal pelvic inclination, the anterior portion of the pelvis being tilted slightly upward. The pressure upon the anterior surface of the sacrum forces its base backward. The posterior superior iliac spines are thus widely separated, and the apex of the sacrum is thrown forward, encroaching upon the antero- posterior diameter of the outlet. In a case cited by Breslau,* the sacro-iliac synchondrosis possessed great mobility. The traction upon the ilio-femoral ligaments, which approximates the tubera ischii, and the lateral displacement of the ilia, due to re- cession of the sacrum, produce a shortening of the transverse pelvic diameter, which becomes more marked in proportion as the outlet is approached. Etiology.—The original cause of the deformity under considera- tion is separation of the articular processes of the last lumbar from those of the first sacral vertebra. This may be effected by a fracture of the transverse processes, as in a case reported by Breisky, f by caries of the transverse processes, due to traumatism, J by traction upon the articular ligaments sufficient to produce luxation, or by such an un- usual congenital separation of the sacral articular processes as will permit the corresponding lumbar processes to glide between them. The dislocation may occur immediately after birth, or after the fuller development of the trunk.* The luxation is not followed by paraly- sis, because the cauda equina is well protected by its fibrous invest- ments, and occupies so small a portion of the sacral vertebral canal that it readily adapts itself to the altered form of the latter without being subjected to injurious pressure. Diagnosis.—Breisky || calls attention to the peculiar figure of per- sons whose pelves are spondylolisthetic. The thorax and extremities are of normal shape, while the abdomen appears unusually short and is sunken between the prominent iliac crests. The pelvis is but slightly inclined, and the crests of the ilia are separated by a wide interval. The pelvic inclination is lessened, and the gluteal regions are abnormally steep. Olshausen A first announced the fact that the point of division of the abdominal aorta into the common iliac arteries is displaced downward by the descending lumbar vertebrae to such an * Breslau, "Monatsschr. f. Geburtsk.," Bd. xviii, 1861, p. 411. f Breisky, "Arch. f. Gynaek.," Bd. ix, 1876, p. 1. 1 Blasius, " Monatsschr. f. Geburtsk.," Bd. xxxi, 1868, p. 241; Euder, " Monatsschr. f. Geburtsk.," Bd. xxxiii, 1869, p. 247. * Olshausen, "Monatsschr. f. Geburtsk.," Bd. xxii, 1803, p. 301. | Breisky, he. cit., p. 9. A Olshausen, " Monatsschr. f. Geburtsk.," Bd. xxiii, p. 204. RARE FORMS OF PELVIC DISTORTION. 493 extent as to enable the palpating finger, introduced into Douglas's cul- de-sac, to detect pulsation in these vessels. The same author * insists upon the diagnostic value of the development at puberty of a lumbar lordosis, which is attended by violent sacral pains. Hartmann f was enabled to feel the point of the aorta's division on the upper border of the fourth lumbar vertebra, and Breslau \ felt a pulsating vessel in the same situation. The spondylolisthetic lordosis may be mistaken for the sacral deformity peculiar to a rachitic pelvis. Breisky * suggests that this error may be avoided by attention to the fact that in the rachitic pelvis the sacral lateral masses pass outward from the projecting prom- ontory, while in spondylolisthesis one can feel at the pelvic inlet only the rounded prominence of a single vertebral body without laterally expanding wings. The projecting angle made by the body of the last lumbar vertebra with the anterior surface of the sacrum is also easily accessible to palpation. Prognosis.—The prognosis in a case of spondylolisthetic pelvis is bad as contrasted with that in pelves contracted to an equal degree from other causes, because the deformity begins above and extends below the pelvic inlet, instead of being limited to a comparativelv short space. Moreover, the outlet is more contracted than in many varieties of deformed pelvis. The treatment consists either in the induction of abortion or, at term, in the performance of the Caesarean section. VI. Funnel-shaped Pelvis. This term has been applied to two varieties of deformed pelves, both of which are exceedingly rare. The inlet of the first variety is either normal or but slightly contracted in all its diameters, but its canal is gradually and progressively narrowed as the outlet is ap- proached. The contraction affects chiefly the transverse diameter ; but either this alone, the antero-posterior diameter alone, or both to- gether may be shortened*. The lateral pehric Avails converge consider- ably, particularly in the vicinity of the outlet. The descending rami of the pubic bones are closely approximated, so that the sub-pubic arch forms an acute angle. The spines and tuberosities of the ischia are in close apposition. | The sacrum is elongated and but slightly curved, its position resembling that of the sacrum in a kyphotic pelvis. It will be seen that these deformities produce a close resemblance to the typical male pelvis. Pelves of this variety are frequently some- what unsymmetrical. * Olshausen, "Monatsschr. f. Geburtsk.," Bd. xxii, 1863, p. 301. f Hartmann, " Monatsschr. f. Geburtsk.," Bd. xxv, 1865, p. 469 ; Bd. xxxi, 1868, p. 2S5. X Breslau, " Monatsschr. f. Geburtsk.," Bd. xviii, p. 411. * Breisky, he. cit., p. 9. || Poppel, "Monatsschr. f. Geburtsk.," Bd. xxviii, 1866, p. 224; Braun, "Arch. f. Gynaek.," Bd. iii, 1870, p. 154. 494 THE PATHOLOGY OF LABOR. The second variety of the funnel-shaped pelvis is so exceedingly rare as to require only a passing notice. In this instance the deform- ity is exactly the reA^erse of that just described, the inlet being very narrow in either one or in all of its diameters, while the outlet is of normal size or even abnormally Avide in one *or more directions.* Etiology.—The causes of this deformity are imperfectly under- stood. The former variety .is believed to be due to arrest of develop- ment in the sacral lateral masses and to other causes cooperating to alter the direction in which the weight of the trunk is normally transmitted to the sacrum. This view seems to be confirmed by Schroeder's observation that the funnel-shaped pelvis is of unusual frequency in a certain German province, where the children are car- ried upon the back in a position intermediate between the erect and the recumbent posture, f The weight of the body Avould in this case be transmitted to the sacrum from above and in front, as in the ky- photic pelvis, rather than from behind and above, as is the case in a natural position, and the pelvis would neither acquire its normal ante- rior curvature nor its posterior inclination. The same theory explains the failure of the sacrum to exert its usual wedge-like action in sepa- rating the ossa innominata, and accounts for the consequent approxi- mation of the tubera and spines of the opposite ischia. Diagnosis.—In cases of slight deformity the diagnosis is difficult. In well-marked cases the approximation of the ischial tuberosities, the slight divergence of the pubic rami, and the acute sub-pubic angle are readily appreciated. Arrest of the head after it has already descended into the true pelvis will often be the first circumstance serving to direct the attention to the possible existence of funnel- shaped pelvis. Pelvic mensuration, Avith particular reference to the distance between the spines of the ischia and to the width of the sa- crum, will establish the diagnosis. Prognosis.—In the slighter grades of funnel-shaped peh-es, the prognosis is not grave. If the deformity be marked, however, the child's life must almost inATariably be sacrificed ; and gangrene of the maternal soft parts, with resulting cicatrices and fistulae, or even with caries of the pubic bones, may be the consequence of the excessive pressure to which these tissues are liable. In a case reported by Scharlau the lesions already mentioned Avere accompanied by perfora- tion of the fundus uteri from gangrene, and by rupture of the right sacro-iliac artery."]; The treatment consists in the induction of premature labor, or, at term, in a cautious attempt to deliver with forceps. Should moderate tractions fail to advance the head, perforation and extraction with the cranioclast should be resorted to. * Spiegelberg, " Lehrbuch," p. 472. f Schroeder, " Lehrbuch," p. 582. X Scharlau, " Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 1. RARE FORMS OF PELVIC DISTORTION. 495 VII. Pelves deformed by Osteomalacia. Osteomalacia is almost confined to females, and appears, ordina- rily, in the puerperal state. It usually attacks fully-developed bones, but may, rarely, affect them during their period of growth. It is gen- erally observed in multiparae, although primiparae are in exceptional cases its victims. Each succeeding pregnancy is usually attended by a progressive development of the disease, which may, however, become non-progressive, or even be completely and permanently arrested.* In a case of this kind the bone is restored to its normal histological state, although its deformity re- mains. Osteomalacia may involve the entire osseous system, or be con- fined to individual bones. In the latter case the long bones and the vertebrae are most frequently dis- eased.! In puerperal osteomalacia the pelvis and the vertebrae are pre- dominantly and often exclusively affected. The disease is regarded. as an osteomyelitis, which, begin- ning in the center of bones, advances toward their periphery. The essen- tial pathological process consists in the absorption of calcareous matter, through the Haversian canals, and in the substitution of hypertrophic medullary tissue for the softened osseous structures. J The natural result of the changes is great friability or pliability of the bones, ac- cording to the stage reached by the disease, and their consequent distortion by compression or traction. The bones are of very light weight. Their transverse section reveals a porous, diploe-like struct- ure. Their outer, hard lamella is exceedingly thin, or entirely ab- sent. The bones are of a Avax-like softness, being readily cut and molded.* The term rubber or elastic pelvis has been applied to those pelves Avhose bones have reached this stage of degeneration. In the most advanced cases the osseous tissue is represented merely by membranous sacs of periosteum inclosing medullary tissue and fat. Morbid Anatomy.—The osteomalacic pelvis presents the following pathological anatomical features : The sacral lateral masses are very * Winckel, "Monatsschr. f. Geburtsk.," Bd. xxiii, 1864, p. 321. t Litzmann, "Die Formen des Beckens," Berlin, 1861. X Schroeder, "Lchrbuch,'' p. 615. # Schieck, " Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 178. Fig. 214.—Osteomalacia. (Specimen from Wood's Museum.) 496 THE PATHOLOGY OF LABOR. narrow, and the entire bone, which is displaced downward between the ilia, is sharply curved. The promontory is, accordingly, deeply de- pressed and approximated to the symphysis as well as to the apex of the sacrum, which is itself displaced forward and curved upward. The promontory and the apex of the sacrum may, in marked cases, almost touch each other. The ilia are placed almost vertically. Their crests are elongated and sharply curved. The anterior superior spinous processes are approximated. The posterior superior spinous processes are in the same plane with the posterior surface of the last lumbar spinous process. The iliac fossa is divided, near its middle, by a vertical furrow which may be bifurcated at its lower end. A prominence corresponding to either acetabulum encroaches more or less upon the pelvic canal. In grave cases these prominences may even come in contact with the promontory.* The pubic bones are in close apposition, and the pelvic inlet is consequently pointed anteri- orly, while the symphysis is prominent and sharply angular. The ascending rami of the ischia and the descending rami of the pubes are approximated, and the sub-pubic arch is partly or completely abol- ished. The tuberosities of the ischia are approximated. The deform- ities described may be asymmetrical. The pelvic canal is greatly narrowed, the outlet usually suffering more distortion than the inlet. The pelvic inlet and canal are of triangular form, and assume, in the highest grades of the disease, the shape of the letter Y. The trans- verse diameter is always contracted, and its shortening is more marked as the outlet is approached. The approximation of the ischial tuber- osities and of the pubic bones, together with the anterior displace- ment of the apex of the sacrum, sometimes almost obliterates the outlet. Etiology.—The etiology of this pelvic deformity may be divided into—1. That of the original disease; and, 2. That of the result- ing distortions. 1. The causes of osteomalacia are obscure. Cold and damp dwellings, insufficient air and light, inadequate aliment, and exposure, are cited as exciting causes, f but it seems probable that these alone are insufficient etiological agencies unless some un- determined predisposing cause be already in operation. The disease is sometimes observed to assume an endemic form, particularly in countries where the above-mentioned exciting causes prevail, as, for instance, in the Bhine provinces and in some parts of Italy. In the United States it is only observed in isolated cases, usually in persons of foreign birth. 2. The immediate causes of the distortions are found {a) in the altered structure of the bones, and {b) in the various forces acting mechanically upon them, (a) The lime-salts, which impart stability to normal bones, are greatly diminished. Although it is not * Spiegelberg, " Lehrbuch," p. 488. f Hennig, "Arch. f. Gynaek.," Bd. v, 1873, p. 519 et seq. RARE FORMS OF PELVIC DISTORTION. 497 definitely known by what emunctories they are removed, it is probable that they are chiefly excreted by the kidneys. Gusserow states that the proportion of lime-salts in the milk of women suffering from osteo- malacia is abnormally large.* Pagenstecher opposes this view.\ {b) The distortions are chiefly produced, when once softening of the bones has occurred, by the muscular traction and by the pressure exerted upon the pelvic walls. This pressure will vary in direction and inten- sity with the different positions assumed by the patient. If the dorsal decubitus be long maintained, the sacrum is displaced forward and the ilia are folded upon themselves, so that a vertical furrow traverses the iliac fossae. In the erect position the sacrum is forced downward and forward, dragging with it the posterior parts of the ilia, and increas- ing the bend in the iliac fossa. The same effect is produced by the upward and backward pressure exerted upon the acetabula by the femoral heads. In the lateral position the ilia are forced inward, and the transverse pelvic diameter is thus diminished. In the sitting post- ure the apex of the sacrum and the tubera ischii are forced upward. The deviations referred to above result from excess of pressure in some given direction, or from unequal progress of the disease in the various bones. Diagnosis.—In the earlier stages, the history of violent pains in the pelvis and lower extremities will direct attention to the existence of osteomalacia, and careful mensuration will reveal beginning distortion. Pelvimetry is most satisfactorily performed during anaesthesia, which permits the introduction of the entire hand within the pelvis. If the disease be more advanced the diagnosis will be based upon the above- mentioned morbid anatomical features, chief among which are the prominent pointed symphysis, the parallel pubic rami, the approxima- tion of the tubera ischii, the accessibility of the promontory to palpa- tion, the curvature of the sacrum, and the folding of the ilia. Spie- gelberg insists on the value of the pliability of the pelvic bones as an aid to diagnosis. | The pliability, although slight during pregnancy, is more marked in labor. Its first sign is great sensitiveness to press- ure over the symphysis.* Its grade can be determined by the method recommended for pelvic measurements. Prognosis.—The prognosis for the mother is very bad. The ma- jority of patients succumb to the effects of pressure in labor, to the results of operative interference, or to the exhaustion attending the almost invariably progressive disease. Amelioration of the symptoms and signs sometimes occurs when conception does not recur. In very exceptional cases not only may the pathological process be arrested but the normal histological character of the bone restored, (a) Even * Gusserow, " Monatsschr. f. Geburtsk.," Bd. xx, 1862, p. 19. f Pagenstecher, " Monatsschr. f. Geburtsk., xix, 1862, p. 128. X Spiegelberg, " Lehrbuch," p. 489. # Winckel, " Monatsschr. f. Geburtsk.," Bd. xxiii, 1864, p. 81. 32 498 THE PATHOLOGY OF LABOR. in such cases, however, the pelvic deformity remains unaltered, and would sadly cloud the prognosis if conception should recur. The prognosis for the child is more favorable. In the beginning of the disease, and in cases of pliable pelvis, the child maybe born uninjured.* In more advanced cases a fair prospect of preserving its life is afforded by a resort to the Caesarean section. The treatment will depend upon the results of a careful exploration of the pelvic space. This should determine, first, whether it is possi- ble to extract a living child through the natural passages ; or, second, where that is out of the question, whether it is possible to deliver after craniotomy. In estimating the chances it will be necessary to take into consideration the pliability of the pelvis, it having been found possible in many cases of advanced softening to open up the pelvic canal with the hand and deliver by version. Lazzati and Casati, in Milan, found it was only necessary to perform Caesarean section twice in sixty-two cases. Litzmann in 1857 reported forty Caesarean sec- tions in eighty-five cases ; fifteen years later Hugenberger reported but four Caesarean sections in twenty-five cases (Spiegelberg). Pseudo-Osteomalacia.—It is possible for a rachitic pelvis, in which the rachitic changes are excessive, to present a shape similar to that in osteomalacia. This form is, however, distinguishable from the latter through the hardness of the bones, their smaller size, the greater distance be- tween the anterior superior spinous processes, and the traces of rickets in other parts of the skeleton. (P. 445.) VIII. Pelves deformed by Exosto- sis, or by Osseous Tumors. Fractures of the pelvic bones may be the source of pelvic deformity, either by producing permanent displacement of the bones, or by leading to such ex- tensive deposits of callus as to obstruct the parturient canal. Multiple exostoses of the pelvic bones are of comparatively frequent occurrence, and are usually attended by multiple exostoses of the entire os- seous framework, f The pelves in which they are found are, as a rule, either of the oblique-ovate or of the rachitic variety, and the *Kezmarszky, "Arch. f. Gynaek.," Bd. iv, 1872, p. 537; Fasbender and Pullen, " Monatsschr. f. Geburtsk.," Bd. xxxiii, 1869, p. 177 ; Breslau, Ibid., Bd. xx, 1862, p. 355; Schieck, Ibid., Bd. xxvii, 1866, p. 178; AVinckel, Ibid., Bd. xxiii, 1864, p. 81. f Leopold/'AtcIi. f.Gynaek.," Bd. iv., 1872, p. 336 ; Kormann, Ibid., Bd. vi., 1874, p. 472. Fig. 215.—Osseous tumors filling pelvic cavity. (Naegele.) RARE FORMS OF PELVIC DISTORTION. 499 combination of these deformities is naturally a serious one, since the maternal soft parts are liable to contusion and perforation at many points during parturition. The ilio-pectineal eminence is sometimes so unusually prominent and sharp as to offer an obstacle to parturition. The same is true of the pubic crest and spine. Osteofibromata, sarco- mata, enchondromata, and carcinomata connected with the pelvic bones constitute tumors of rare occurrence. They usually spring from the sacrum or from the symphysis,* and are of various dimen- sions. Some of them almost completely occlude the parturient canal, and may constitute formidable obstructions to delivery. In this connection may be mentioned, as of rare occurrence, anchy- losis of the coccyx, a condition which materially shortens the antero- posterior diameter of the outlet. IX. Absence of the Symphysis. In this variety of deformed pelvis the symphysis is congenitally absent, and is replaced either by strong fibrous bands extending be- tween the opposing surfaces of the pubic bones, or by the muscles and connective tissue of the perinaeum. It is, accordingly, designated by Litzmann the split pelvis, f Morbid Anatomy.—It is usually attended by ectopia vesicae and by hiatus of the abdominal wall in the linea alba. In rare cases an abdom- inal hiatus exists without a corresponding opening in the bladder. If the split be located immediately below the symphysis, the urethra is involved rather than the bladder, and is sometimes so defective that cystocele may occur through the abnormal opening in its anterior wall. J Both the external and internal organs of generation are imperfectly developed. If the anterior wall of the urethral canal be absent, the mu- cous membrane of the fundus vesicae is directly continuous with that of the vaginal orifice. In other cases the bladder is only separated from the vulva by a narrow bridge. The vulva and anus are often situated more anteriorly than normal, and the perinaeum is thus diminished in thickness. The clitoris is bifurcated or absent, the nymphae are imper- fectly developed, and the defective labia majora widely separated. The vagina may be imperforate or partially occluded by a transverse septum. The uterus may be double and the ovaries rudimentary.* In a case reported by Winkler, separation of the pubic bones had occurred at the symphysis, as the result of an accident in early life, and they were only connected by bands of fibrous tissue.| The sacrum of a split pelvis * Harris, "Am. Jour, of Obstet.," vol. iv., 1372, pp. 633, 645; Braun, "Monatsschr. f. Geburtsk.," Bd. xxi, 1863, p. 311. f Litzmann, " Die Formen des Beckens," Berlin, 1861. X Kleinwachter, " Monatsschr. f. Geburtsk.," Bd. xxxiv, 1869, pp. 81_<# seq. # Litzmann, "Arch. f. Gynaek.," Bd. iv, 1872, p. 272. U Winkler, "Arch. f. Gynaek.," Bd. i, 1870, p. 346. 500 THE PATHOLOGY OF LABOR. is displaced forward between the ilia, its vertical and transverse curva- ture diminished, and its length increased. The iliac fossae are widely separated. The entire pelvis is greatly flattened antero-posteriorly, and strongly resembles the rachitic pelvis. Etiology.—The cause of the existing deformity is found in the increased pressure to which the lateral pelvic walls are subjected ow- ing to the absence of the symphysis. The natural resistance to the separation of the lateral pelvic parietes, offered by the normal symphy- sis, being wanting, the weight of the superimposed trunk naturally forces them apart posteriorly, while the pressure of the femora bends them inward anteriorly. In some instances anchylosis of the sacro- iliac joints occurs, as a consequence of an arthritis resulting from the increased pressure thrown upon them by the lateral displacement of the ossa innominata.* In other cases sacro-iliac synostosis is not pres- ent, but the firmness of the pelvis is, nevertheless, such as to admit of unimpeded locomotion. CHAPTER XXVIII. ABNORMALITIES OF THE SEXUAL ORGANS. Atresia of the genital canal.—Vulvar atresia.—Vaginal atresia.—Cystocele.—Rectocele. —Retention of urine.—Impacted calculi.—Vaginal hernias.—Cystic degeneration of the vaginal wall.—Vaginismus.—Echinococci.—Uterine atresia.—Conglutinatio ori- ficii externi.—Cicatricial atresia.—Rigidity.—Thrombus of the cervix. — Symptoms of atresia.—Note on treatment.—Tumors.—Fibroids.—Cancer.—Ovarian tumors. Atresia of the Genital Canal. Obstruction of the Gen- erative Passages by Morbid Processes in Neighboring Tissues. I. Vulvar Atresia.—The term atresia, as here employed, implies either partial or complete obstruction of the genital canal. Atresia of the hymen, usually denominated imperforate hymen, is of more frequent occurrence than any other variety of vulvar steno- sis, f Unless unusually thick and rigid, however, the imperforate hy- men offers only a trifling obstruction to delivery. Its chief importance is owing to the fact that it leads, in the unimpregnated state, to reten- tion and accumulation of the menstrual fluid, which may occasion serious inflammatory, septic, or reflex nervous phenomena. Adhesions of the labia majora and minora constitute other forms of incomplete vulvar atresia. Their causes are often ulcerative processes resulting from injuries, or developed during the course of variola and other con- * Freund, " Arch. f. Gynaek.," Bd. iii, 1872, pp. 398, 406. f Jenks, " Atresia of the Generative Passages of Women," " Chicago Med. Jour, and Examiner," September, 1880, p. 4. ABNORMALITIES OF THE SEXUAL ORGANS. 501 stitutional diseases. Under these circumstances they may consist of unyielding cicatricial tissue, which either ruptures in labor, or, forcing the head backward, leads indirectly to the exertion of injurious press- ure upon the recto-vaginal septum or upon the perinaeum. If the atresia be congenital, and not the result of cicatricial changes, it will rarely constitute an impediment to parturition. When the entrance to the vagina is very narrow, without exhibiting any pathological con- dition, as is often the case with aged primiparae, it may be extensively lacerated in labor. A rigid perinaeum is also well known to constitute a serious impediment to the normal progress of parturition. CEdema of the vulva, usually attendant upon albuminuria, produces atresia, and the oedematous labia and perinaeum may become gangrenous from excessive pressure during labor. Vulvar haematoma, or thrombus, if formed, as it rarely is, before delivery, likewise obstructs the outlet of the parturient canal. A similar effect is produced by cancers and polypi of the vulva, which are, however, not often of sufficient size to occasion serious difficulty. II. Vaginal Atresia.—This variety of stenosis of the generative passages is either congenital or accidental, complete or incomplete. {a) The congenital form may be either incomplete, in which case the stenosis sometimes affects the entire length of the vagina, and sometimes forms a circumscribed ring-like stricture,* or it may be com- plete. In either case the atresia is due to arrested embryonic develop- ment, which, in the latter instance, must have originated at a very early period of fetal life. Congenital narrowing of the vagina independent of any morbid process or any arrest of development is often observed, but is of trifling consequence, being overcome by the hypertrophy and relaxation accompanying pregnancy, and by the natural expulsive forces. Absence of the vaginal canal does not necessarily imply ab- sence or imperfect development of the uterus, Fallopian tubes, or ovaries. {b) Accidental vaginal atresia may be either complete or partial, but is ordinarily of the latter form. Both varieties result from the cicatrization following superficial or deep ulceration produced by con- stitutional diseases or by local injury. The diseases during the course of which vaginal ulceration occurs are chiefly diphtheria, variola, ty- phoid fever, cholera Asiatica, and syphilis. The mechanical injuries productive of vaginal stenosis are mainly those incident to protracted labors, to the unskillful employment of instruments, or to the improper performance of obstetrical operations ; but caustic local applications, pessaries, excessive coition, or any local irritant of sufficient intensity to produce ulceration, may lead to the same result. In consequence of impaired vitality, ulceration and stenosis of the vagina may follow normal labors unattended by any injurious pressure. Complete acci- * Schroeder, " Lehrbuch," 6te Aufl., p. 491. 502 THE PATHOLOGY OF LABOR. dental vaginal atresias are produced, as a rule, by grave mechanical injuries, but may, according to Spiegelberg,* also follow the acute in- fectious diseases enumerated above, although the ulcerations attending the latter usually lead to only partial stenosis. Mention may properly be made, in this connection, of various mor- bid conditions involving tissues adjoining the vagina and resulting in diminution of its caliber. Simple prolapse of the anterior vaginal wall sometimes occurs,f and, assuming an cedematous condition owing to the obstruction of its circulation, decidedly constricts the parturient canal. Cystocele fre- quently accompanies the prolapse of the anterior vaginal wall. If the bladder be distended with urine, the cystocele presents a tense, fluctu- ating tumor of sufficient size to completely occlude the vagina. The subjective symptoms of this condition are intense pain with vesical tenesmus and dysuria. In some cases the cystocele is retracted by the longitudinal cervical contractions, or it may be forced still farther downward by the advancing foetus, producing obstructed labor and even rupture of the vesico-vaginal septum. Prolapse of the posterior vaginal wall with rectocele produces vaginal stenosis, especially if the rectum be filled with impacted faeces. This condition is easily recognized by the characteristic feeling of the fecal mass, which admits of indentation by the palpating finger. Betention of urine becomes oftentimes a grave complication of parturition, in that the distended bladder, by displacing the uterine axis, prevents the presenting part from engaging in the superior strait. The pressure it exerts upon the uterus also interferes with the efficient contraction of that organ. The diagnosis is based upon the presence of a tumor near the uterus, and often situated laterally from it, which disappears as the urine is withdrawn through a catheter. The intro- duction of the latter is often extremely difficult, owing to the com- pression of the urethra and the retraction of the meatus urinarius within the vagina. Vesical calculi, if of any considerable magnitude, seriously obstruct the caliber of the vagina by becoming impacted in the base of the bladder, the urethra, or a cystocele, between the foetus and the pelvic walls. Under these circumstances not only is the labor obstructed, but contusion and rupture of the soft parts, resulting in vesico-vaginal fistula, may ensue. Impacted calculi have sometimes been mistaken for exostoses, J but attention to the fact that they are immovable during the pains and movable in the intervals, together with the use of the vesical sound, will prevent this error. * Spiegelberg, " Lehrbuch," p. 505. f Benicke, "Ztschr. f. Geburtsh. u. Gynaek.," Bd. ii, Heft 2, 1878, p. 256. X Schroeder, " Lehrbuch," 6te Aufl., p. 500. ABNORMALITIES OF THE SEXUAL ORGANS. 503 Vaginal hernia consists of a sac formed by the protrusion of the vaginal wall, lined with the parietal peritonaeum and containing some of the abdominal or pelvic viscera. The organs usually present in the sac are coils of the small and large intestine, the middle portion of the rectum with its elongated meso-rectum, parts of the omentum, por- tions of the urinary bladder, and sometimes blood, with various prod- ucts of peritoneal inflammation. The location of the hernia is usually in the posterior vaginal wall, although it may insinuate itself between the uterus and the bladder, and, descending, produce hernia of the labia majora. Perineal hernias are formed by hernial sacs which pass behind the ligamentum latum and distend the perinaeum. The intestinal vaginal hernia is the most important variety, inasmuch as it may not only obstruct labor, but may itself become incarcerated or strangulated, thus leading to symptoms of the gravest import. The diagnosis, which can be rendered very probable by palpation per vaginam, is made certain by a rectal examination. Vaginal neoplasmata, the most important of which are carcinomata and fibromata, are rare sources of vaginal stenosis, as is likewise thrombus of the vagina. Slight obstruction to labor may result from a pathological condition of the vaginal mucous membrane described by Winckel,* under the title colpohyperplasia cystica, and consisting of the development in the mucous membrane of numerous small and closely aggregated flattened cysts. The cysts are believed to be pro- duced by the distention of glandular depressions in the mucous membrane with mucus, which, according to Zweifel, f eventually pro- duces trimethylamine gas by decomposition. Others consider the loca- tion of the gas to be in the interstices of the submucous connective tissue. X Vaginismus is rarely a cause of vaginal stenosis in labor, inas- much as it is itself a cause of sterility. It has, however, been found in certain instances to constitute so serious an obstacle to delivery as to necessitate operative interference. In double vagina the septum is sometimes a source of slight vaginal atresia. Intrapelvic echinococci constitute a rare cause of vaginal constric- tion. Wiener* collected seven cases of pelvic echinococci, most of which occupied the loose connective tissue between the vagina and rectum. The leading symptoms due to their presence during preg- nancy were deep-seated traction in the pelvis, severe pain, vesical tenesmus, dysuria, and constipation. Menstruation was undisturbed. The tumors were, with one exception, so large as to completely ob- struct the vaginal canal, rendering operative interference necessary. * Winckel, "Arch. f. Gynaek.," Bd. ii, 1871, pp. 383, 406. f Zweifel, " Arch, f. Gynaek.," Bd. ix, p. 39. X Ruge, " Arch. f. Gynaek.," Bd. ix, p. 465. * Wiener, "Arch. f. Gynaek., Bd. vi, p. 572. 504 THE PATHOLOGY OF LABOR. In one instance the contraction, from cicatrization of the hydatid cyst following puncture, was so extensive as to produce vaginal stenosis. Hydatids may be mistaken for exostoses of the bony pelvis, for haema- tocele, malignant intrapelvic tumors, pelvic abscesses, or cellulitis. Their differential diagnosis is based upon the presence in the pelvis of smooth, tense tumors not connected with the uterus, the gradual development of the tumors without constitutional symptoms of any gravity, the presence of similar tumors in other organs, particularly in the liver, the hydatid thrill, which is not often observed on account of the strong pressure to which the cysts are exposed, and, finally, upon the examination of the cystic fluid. III. Uterine Atresia.—Uterine atresias, which occur less frequently than those of any other portion of the genital passages,* may be con- genital or accidental, partial or complete. Complete atresias, observed in parturition, have become so during pregnancy, since conception would not otherwise have occurred. Conglutinatio orificii externi, or adhesion of the lips of the os externum, is occasioned by the superficial union of the opposing mucous surfaces through the medium of inspissated epithelium or of new connective tissue resulting from adhesive inflammation pro- duced by vaginitis or cervical endometritis. Schroeder f regards these atresias as always incomplete, and seeks their origin in the gradual induration of tissues immediately surrounding the os, resulting from old inflammatory processes. According to his views, this pathological condition consists of deficient expansibility and not of real contraction of the os externum. On examination no marked induration of the cervix is felt. The os externum is hardly perceptible to the touch and can often only be discovered by inspection. If the examination be made during the first stage of labor the internal os is found widely dilated, while the os externum remains persistently contracted and conveys a sensation to the palpating finger akin to that produced by a narrow and tense rubber band. If the finger or an appropriate in- strument be firmly pressed against the os during the pain, it slowly yields and is gradually retracted by the longitudinal cervical contrac- tions. In default of such simple interference the cervical tissues above the os externum become enormously distended, and may finally be ruptured. Zweifel % refers this peculiarly unequal dilatation of the cervical canal to an abnormal presentation of the fetal cranium and to a consequent local expansion of the anterior uterine wall. The os externum having been simultaneously forced backward into the hollow of the sacrum, the yielding anterior uterine wall then forms a diverticulum which contains the presenting fetal part, and no dilating force is exerted upon the external os. Benicke * was unable to dis- * Jenks, op. cit., p. 5. | Schroeder, li Lehrbuch," 6te Aufl., p. 487. X Zweifel, " Arch. f. Gynaek.," Bd. v, 1873, p. 149. * Benicke, op. cit., p. 252. ABNORMALITIES OF THE SEXUAL ORGANS. 505 cover, in his cases, the posterior deviation of the os which is assumed by Zweifel as the basis of -his hypothesis. Cicatricial atresia of the os externum is rarer than the adhesive stenosis just described. It is usually confined to the lips of the ex- ternal os, but may involve the cervical canal for a varying distance. Its most frequent causes are post-partum ulceration, inflammation, cauterization of the cervix, and mechanical irritation applied for the purpose of producing abortion. The diminution of the uterine dis- charges during pregnancy affords a favorable opportunity for the de- velopment of the stenosis under consideration. If cicatricial atresia exist, the os externum remains undilated in labor, the cervix becomes immensely distended, and may even rupture, unless the os be dilated by artificial means. The diagnosis rests upon the discovery, usually easily made, of the cicatrized os externum. Should the latter have retreated into the hollow of the sacrum, the diagnosis may only be accomplished with difficulty, or the expanded cervical tissues be "mis- taken for the fetal membranes. This error is avoided by the discoA^ery of the direct continuity of the vaginal wall and the supposed mem- branes, and by inspection through a proper speculum. Abnormal rigidity of the os externum is often encountered in mul- tiparae as the result of genuine cicatricial processes or of fibrous hy- pertrophy. This condition is especially observed in connection with prolapse of the uterus. A similar rigidity in aged primiparae is due to atrophic degenerative changes in the cervical tissues, or to hyper- trophy of the portio vaginalis.* Haemorrhages occurring into the hypertrophied cervical tissue are distinguished as cervical thrombi, and constitute obstacles to delivery. The retraction and dilatation of the cervix may, further, be obstructed by adhesions in the lower segment of the uterus between the decidua and the chorion. Acute elongation of the anterior lip of the os externum, in conse- quence of its incarceration betAveen the foetus and the bony pelvis, and of the resulting oedema of its tissues, is referred to by Hirte f as a rare but serious obstacle to delivery. Parturition is sometimes delayed by double uterus. The ob- struction may in this instance be produced by an hypertrophied unimpregnated horn of the uterus. J Again, the oblique position of the impregnated horn may produce abnormal presentations * or ma- terially interfere with the efficiency of the pains. The uterine atresias produced by carcinomata, fibromata, and ova- rian tumors are considered in another chapter. * Benicke, op. cit., p. 240. f Hirte, "Arch. f. Gynaek.," Bd. vii, 1875, p. 552. X Muller, "Arch. f. Gynaek.," Bd. v, 1873, p. 132. * Schatz, "Arch. f. Gynaek.," Bd. ii, 1871, p. 297. 506 THE PATHOLOGY OF LABOR. Symptoms of Atresias of the Genital Canal.—The principal symp- toms of atresia in the unimpregnated state relate to the partial or complete retention of the menstrual fluids. If the stenosis be com- plete the uterus is enlarged and fluctuating, while severe uterine pains attend each monthly period.* The Eallopian tubes are dilated. Some of the retained and decomposed menstrual fluid may be forced through the tubes into the peritoneal cavity, producing serious or fatal perito- nitis. The mere dilatation of the uterus may become so excessive as to produce peritonitis, f Septic poisoning is sometimes induced by absorption of putrescent materials from the uterine cavity. A symp- tom often serving to attract attention to the existence of abnormal vaginal contraction is inability to perform the sexual act. The most prominent symptom of atresia during parturition con- sists, in general terms, of mechanical obstruction to delivery, which is more or less serious in proportion to the degree of existing stenosis. The special symptomatology of the individual pathological conditions productive of atresia has been considered in connection with their respective anatomical characters. Note.—Atresias for the most part require to be treated each by itself, according to the principles of surgical art. In a paper by Professor I. E. Taylor, in the fourth volume of the " Transactions of the American Gynaecological Society," entitled " Atresia of the Vagina, Congenital or Accidental, in the Pregnant or Non-pregnant Female," the author relates a case of seemingly complete imperforation of the vagina complicating labor, where he succeeded, by scraping with the finger-nail during the pains, in passing the index-finger through the intervening membrane to the child's head, and eventually in securing an opening large enough for the birth to be accomplished. I had previously reported two similar cases, one in the " New York Medical Jonrnal," and one to the Obstetrical So- ciety.*, The first, where I was aided by Professor Fordyce Barker, occurred in Bellevue Hospital, and the second in private practice. In both, similar success followed a gradual dissection of the vaginal walls with the finger. In such cases usually a depression, or a thinned point in the tissues, indicates the direction to be followed. C. Braun states, however, that he has seen three cases where vesico-vaginal fistulae were produced by this tunneling process, an admonition to extreme caution in its performance.* For stenoses of the vagina, dilatation should be employed, either by means of compressed sponges, the tampon of slippery-elm (Skene), or the water-bag. When dilatation is already well ad- vanced, incisions may be used to aid in completing the process. Uterine Tumors complicating Pregnancy, Parturition, and the Puerperal State. I. Uterine Myomata.—1. In pregnancy. Because of the disposi- tion of uterine myomata to produce sterility, they naturally constitute comparatively infrequent complications of pregnancy. They are sub- * Dohrn, "Arch. f. Gynaek.," Bd. x, 1876, p. 544; I. E. Taylor, "Atresia of the Vagina," " Trans, of the Am. Gynaac. Soc," vol. ix, 1880, pp. 9, 12. f I. E. Taylor, he. cit., p. 16. X " Trans, of the New York Obstet. Soc," vol. i, p. 44. # Braun von Fernwald, " Lehrbuch der gesammt. Gynaek.," p. 273. ABNORMALITIES OF THE SEXUAL ORGANS. 507 divided, according to their location, into subperitoneal, interstitial, and submucous myomata. The presence of either variety diminishes the probability of conception, but none absolutely precludes the possi- bility of its occurrence. Subperitoneal myomata prevent conception and interrupt utero- gestation only when they attain large dimensions, and their preju- dicial influence is then usually referable to the uterine retroversions or retroflexions which they induce. Interstitial myomata are more likely than the preceding variety to occasion abortion or premature delivery, either by producing uterine flexions,* or by acting as the exciting cause of haemorrhages, which are more severe when the pla- centa is located over the site of the tumor. This statement applies particularly to post-partum haemorrhages, inasmuch as the muscular atrophy induced by the myoma prevents the ready and complete clo- sure of the uterine sinuses. Submucous myomata rarely permit of conception, which, in the event of its occurrence, is almost uniformly followed by abortion, due usually to metrorrhagia. \ In rare cases, however, pregnancy progress- es to its normal termination. Myomata ordinarily participate in the uterine hypertrophy of pregnancy, becoming at the same time softer and more succulent. J This change in consistence, which is referred to increased vascularity and to serous infiltration, is attended by dila- tation of the lymphatics, which may lead to the formation of cysts. The softened tumor readily undergoes changes of form under the in- fluence of increasing intrapelvic pressure and of uterine traction. It may become so flattened that it ceases to be recognizable as a tumor, but regains its earlier shape after delivery. The diagnosis of uterine myomata, particularly of the interstitial and submucous varieties, is often attended during pregnancy by diffi- culty, inasmuch as their symptoms and signs are obscured by those of pregnancy. On the other hand, the existence of myomata may pre- vent the recognition of pregnancy. Fibrous tumors may be mistaken for fetal organs or for intrauterine cystic tumors. The latter error would be particularly unfortunate if it should lead to puncture of the myoma and be followed by metrorrhagia. 2. In Parturition and the Puerperal State.—Uterine polypi act as impediments to delivery only when they are situated beside or in front of the advancing child, and are possessed of considerable size and con- sistence. If the tumor be small, movable, and yielding, it may occa- sion only trifling obstruction to parturition and may even be expelled by the advancing foetus, after rupture of its pedicle. Interstitial myomata, when corporeal, constitute impediments to * Ponfick, " Beitr. z. Geburtsh. u. Gynaek.," Bd. ii, 1873, p. 92. f Thomas, " Am. Jour, of Obstet.," vol. viii, p. 606. X Spiegelberg, "Arch. f. Gynaek," Bd. v, 1873, p. 110. 508 THE PATHOLOGY OF LABOR delivery only when located in the lower segments of the uterus. Even when thus situated, they often spontaneously recede from the pelvic cavity under the influence of the longitudinal uterine contractions. By exerting traction on the uterine parietes they aggravate the sever- ity of the pains, and, according to Spiegelberg,* sometimes produce rupture of the uterine wall, in which their growth has already deter- mined atrophic degeneration. By interfering with symmetrical uter- ine contraction, interstitial myomata render the pains irregular and inefficient, besides predisposing to ante- and particularly to post-par- tum haemorrhage. By altering the form of the uterine cavity and preventing the engagement of the head in the superior strait, this variety of myoma frequently produces abnormal positions and presenta- tions.! In a case of my own eclampsia resulted, apparently from the same set of causes as those which obtain in multiple pregnancy. They also predispose to the development of retroflexions in the puerperal state. When interstitial myomata are developed in the cervical tissues they almost invariably offer a mechanical impediment to delivery, and are rarely capable of being displaced above the superior strait. If, how- ever, they have become intra vaginal and their base be not too extensive, they are often readily amenable to appropriate surgical interference. In default of the latter, fatal compression may be exerted upon the fetal cranium, or the vesico-vaginal septum may be lacerated during labor. Subserous myomata are ordinarily developed in the posterior uter- ine wall. If connected with the body of the uterus and located above the retro-uterine reflexion of the peritonaeum, they may be spontane- ously extruded from the pelvic into the peritoneal cavity. They originate, however, most frequently in the cervical tissues, and, ex- tending downward, become retro-vaginal, more or less completely oc- cupy the pelvic cavity, and offer, provided their size be at all con- siderable, an insurmountable obstacle to parturition. This variety has been designated as the incarcerated uterine myoma. \ Treatment.—Interstitial corporeal myomata, as a rule, do not inter- fere with the expulsion of the child. Dr. A. Kessler has reported a case which I saw with him in consultation, where, after the expulsion of a four months' foetus, it was found impossible to reach the placenta. The latter occupied an inaccessible position near the right cornu, far out of reach of the fingers, while the convexity of the tumor was such as to interfere with the working of curettes. The patient subsequently died of septicaemia. Bemoval of the entire uterus would, perhaps, have saved her life. If myomata encroach upon or occupy the pelvic cavity, they should be raised above the brim by sustained vaginal and rectal pressure. * Spiegelberg, " Lehrbuch," p. 509. f Thomas, he. cit., p. 608. X Spiegelberg, " Arch. f. Gynaek.," Bd. v, 1873, p. 100. ABNORMALITIES OF THE SEXUAL ORGANS. 509 The most serious obstruction to the birth of the child is offered by cervical and subserous myomata situated behind the uterus, and nearly filling the peh'ic space. In such cases the only means of delivery may be by the Caesarean section. The unfavorable results of the opera- tion, however, when complicated by the presence of uterine myomata, are shown by Spiegelberg's report, where of twenty-nine mothers but four recovered. A successful case of Caesarean section, made neces- sary by two large myomatous tumors of the uterus, has recently been reported by Dr. Moses Baker,* of Stockwell, Indiana. Polypoid growths should be pushed back into the uterus, if possible, in cases where the pedicle is out of reach. Where, howeA'er, the tumor is shoved down in advance of the head, and the pedicle is accessible, it should be removed with the ecraseur or with scissors. Polypoid elongation of the anterior lip, where replacement is im- possible, and where the swelling obstructs labor, may call for the de- struction of the child, as excision is likely to be followed by dangerous haemorrhage. II. Carcinoma of the Cervix Uteri.—1. In Pregnancy. Uterine cancer, which is one of the gravest complications of pregnancy, is, if primary, almost without exception of cervical origin. Conception often occurs in the earlier stages of the disease, and, since it is only absolutely prevented by a carcinoma which completely occludes the cervical canal, it occasionally takes place even in the later stages of the neoplasm's growth. The existence of pregnancy usually hastens the development of the cancer, the more rapid growth of which is probably referable to the increased vascularity of the uterus and to the correspondingly augmented activity of its nutritive processes. In rare instances the occurrence of pregnancy seems to arrest the devel- opment of the local and general symptoms referable to the cancerous growth, f In the majority of cases the neoplasm does not interfere with the completion of normal utero-gestation, J although abortion or premature delivery is a frequent result of its development. These issues of pregnancy are most frequently determined by cancerous tu- mors whose progress has invaded the higher, supravaginal portions of the cervix, and is probably occasioned by the interference, on the part of the neoplasm, with the normal process of uterine growth and expansion. The traction exerted by the enlarging cer\ix upon the unyielding tissues of the tumor may also produce a solution of their continuity, and give rise to formidable haemorrhage. In very exceptional cases uterine carcinoma seems to protract the period of gestation far beyond its normal limits, in which case the foetus dies and undergoes the changes usual in retention. * "Am. Jour, of Obstet.," 1881, vol. xiv, p. 596. f Spiegelberg, " Lehrbuch," p. 295. X Benicke, "Arch. f. Gynaek.," Bd. x, 1876, p. 405. 510 THE PATHOLOGY OF LABOR. 2. In Parturition and the Puerperal State.—If the cancer be con- fined to the lower margin of the cervical canal, the expansion of the latter is not materially interfered with, and delivery may be safely and speedily accomplished. If, however, the morbid process has involved the entire portio vaginalis, or has even extended quite to the os inter- num, the inelastic tissue of the cancerous growth has replaced the expansile muscular fibers, and an opening of sufficient caliber for the passage of the foetus can only be produced by rupture and contusion of the degenerated and unyielding cervix. The immediate result of such a laceration is violent haemorrhage, which is, however, quite amenable to treatment. The consequence of the excessive pressure to which the cervix is subjected during labor is necrosis of the con- tused tissues, which is frequently followed by fatal septicaemia. The diagnosis is accomplished by the same means which are em- ployed in the detection of cervical cancer in the unimpregnated con- dition. The prognosis is doubtful for both mother and child. The latter is imperiled by its liability to premature expulsion, and by the me- chanical obstruction to its birth produced by the tumor. The moth- er's life is not only shortened by the rapidity of the cancerous growth usually induced by pregnancy, but is jeopardized by her increased lia- bility to abortion, post-partum haemorrhage, and puerperal fever. Treatment.—-During pregnancy, in cases where the disease is con- fined to the cervical portion, either amputation or excision should be performed. The time selected for operation is usually the fourth month. Abortion does not necessarily follow. In advanced stages, where the carcinomatous process has inA'aded the contiguous tissues, operative interference should be postponed until the end of gestation. Just in proportion as the outlook for the mother grows question- able, the interests of the child rise in importance. An extensive removal of diseased tissue during pregnancy exposes the mother to the immediate dangers of premature labor and subsequent septicaemia, while it is hardly possible to do the work so effectively as to procure a free outlet for the child. Upon the advent of labor, if the child be living, the Caesarean section certainly holds out the hope of saving one life, and probably does not greatly increase the peril to Avhich the other is exposed.* Dr. Fordyce Barker states that he has met with three cases of spontaneous delivery where the cervix was carcinoma- tous, in all of which the mother survived the childbed period. Such good fortune, however, is necessarily rare, and is only likely to result in patients whose tissues are but moderately affected. Frommel \ re- * Herman ("Trans, of the Obstet. Soc. of London," vol. xx, p. 191) reports twelve Caesarean operations, with four recoveries. + Frommel, "Zur operat. Therapie d. Cervix-Carcinoms in d. Complication mit Gra- vidity," "Ztschr. f. Geburtsh. und Gynaek.," Bd. v, p. 158. ABNORMALITIES OF THE SEXUAL ORGANS. 5H ports a case from the Berlin Clinic, where, the child being dead, Schroeder broke away with his hands large masses of the neoplasm, and thus provided a passage of sufficient size to permit the extraction of the child by version. The patient was discharged on the tenth day, but died a few days after. III. Ovarian Tumors.—1. In Pregnancy. Ovarian tumors, par- ticularly those of the cystic variety, are quite often encountered as complications of pregnancy. They usually antedate conception, but may make their appearance during pregnancy. Utero-gestation often favors their development by increasing the general vascularity of the pelvic viscera, although an arrest of growth and an actual retrogres- sive metamorphosis of the tumor seem to be the occasional effect of intercurrent conception.* This retrogressive process affects only cys- tic tumors, and may result from the uterine pressure, which facilitates the absorption of their contents. After delivery the cysts present on palpation a relaxed and flabby condition. The natural tension of the tumor is soon restored by the secretion of additional fluid, except in those rare cases in which the compression of the gravid uterus seems to initiate a permanent process of retrogression and absorption. Wernich f advanced the opinion that the assumption by benign ovarian tumors of a malignant character was determined by the occur- rence of pregnancy, and Spiegelberg \ regards this transition as posi- tively established. The ovarian tumors under consideration may be bilateral. If they be of moderate dimensions, they may not interfere with utero-gestation or delivery, except by a slight aggravation of the usual disturbances attendant upon pregnancy. An ovarian tumor is, however, liable to occasion abortion or premature delivery if it be con- fined by adhesions to the pelvic cavity, or be closely connected to the uterus. Under these circumstances abortion results from interference, on the part of the new growth, with the natural uterine expansion, or from the retroflexion which it induces. In rare instances a rotation of the cyst upon its axis, followed by strangulation of its pedicle, is observed. This deplorable accident leads to a lethal issue by shock, by gangrene of the cyst and consequent septicaemia, or by haemorrhage into the tumor and the peritoneal cavity, followed by peritonitis. The rationale of the morbid phenomena referable to tumors of larger size is entirely different. These tumors do not often occasion abortion or premature delivery, but gravely complicate the later periods of preg- nancy by means of the pressure which they, in common with the gravid uterus, exert upon the abdominal and thoracic viscera. Ascites and dyspnoea are the chief results of the augmented intra-abdominal ten- sion. 03dema of the lower extremities is often observed. The ova- * Schroeder, " Lehrbuch," p. 399. •f- Wernich, " Beitr. z. Geburtsh. u. Gyn.," Bd. ii, p. 143. X Spiegelberg, " Lehrbuch," p. 297. 512 THE PATHOLOGY OF LABOR. rian cyst sometimes ruptures and produces fatal collapse, peritonitis, or septicaemia. The escaped cystic fluid may, however, be absorbed, and pregnancy reach a natural termination. Diagnosis.—If the ovarian tumor be of small size, it may be com- pletely masked by the growing uterus, or may be mistaken for a por- tion of the latter. If, on the other hand, the surface of the tumor be irregular and nodular, the uterus may, at an early period of pregnancy, itself be regarded as a part of the cyst. Palpation and auscultation will, however, usually afford satisfactory diagnostic points of depart- ure. Moreover, the absence of the menses in patients with an ovarian tumor, and an unusually rapid increase in the dimensions of the abdo- men, should awaken the suspicion of combined pregnancy and ovarian tumor. 2. In Parturition and the Puerperal State.—The dangers result- ing in parturition and the puerperal state from 0Ararian tumors com- plicating pregnancy are twofold, and consist {a) in the obstruction to labor which they occasion and {b) in the results of the morbid pro- cesses determined in the neoplasms themselves by the excessive press- ure of the surrounding tissues. {a) If the ovarian tumor is confined within the true pelvis in such a way as to render its spontaneous or manual displacement im- possible, it may offer a most serious impediment to the expulsion of the foetus. Dermoid cysts manifest a more decided tendency to con- tract adhesions in the pelvis than other ovarian tumors, and afford on this account, as well as because of the greater consistence of their contents, a worse prognosis than any other variety.* Obstructed labor more frequently results from the presence of small than from that of large ovarian tumors, since the latter oftener escape into the abdomi- nal cavity during pregnancy, and are unable at any subsequent period to effect an entrance into the true pelvis. {b) Even if the obstacle offered to parturition by an ovarian tu- mor be trivial, the changes induced in its own substance by the par- turient act may be productive of very serious results. The pressure and traction exerted upon the pedicle of the cyst are often so severe as to produce its strangulation, followed by necrosis of the tumor, with consequent septic poisoning. Rupture of the sac, with its fatal consequences, may also occur, or such severe contusions of the tumor may be occasioned by excessive pressure as to result in gangrene of its entire mass. The development of the foetus is, as a rule, not inter- fered with by ovarian tumors. The latter manifest a tendency to very rapid development in the puerperal state, except in those rare cases characterized by permanent retrogressive metamorphosis and absorp- tion. Ovarian tumors are a dangerous complication of pregnancy. Play- * Schroeder, op. cit., p. 501. ABNORMALITIES OF THE FCETUS. 513 fair reports fifty-seven cases, with thirteen deaths. The treatment, where the tumor interferes with delivery, consists in reposition, or, failing after persevering effort, in puncture of the cyst. The cul-de- sac of the vagina affords generally the most conA'enient point for introducing the trocar. The time selected for tapping should be during the existence of a pain, when the cyst is rendered tense by pressure. OAving to the rapid increase in the size of the tumor which commonly results from pregnancy, and in consideration of the rela- tively favorable issue of ovariotomy performed upon pregnant women, the radical operation during pregnancy may possibly prove in the future the most advantageous form of treatment. CHAPTER XXIX. ABNORMALITIES OF THE FOETUS WHICH OFFER AN OBSTRUCTION TO DELIVERY. Premature ossification of the cranium.—Hydrocephalus.—Encephalocele.—Hydrothorax. —Ascites.—Other causes of abdominal distention.—Tumors of the trunk.—Mon- strosities.—Double monsters.—Acardiaci.—Anenccphalous monsters.—Abnormal po- sitions.—Spontaneous version.—Spontaneous evolution. I. Fetal Diseases wrHiCH obstruct the Expulsion of the Head. Premature Ossification of the Fetal Cranium.—This condition is characterized by the complete or nearly complete closure of the fonta- nelles. The head, therefore, loses its compressibility, and no longer undergoes those changes of form which constitute so important a part in the mechanical processes of deliA'ery. As the anomaly is apt to in- terfere with brain development in infancy, the late Dr. John E. Blake* advocated early perforation where the interests of the mother had to be consulted. As I have never met with this form of dystocia in a large number of instrumental deliveries, I can not but regard it as extremely uncommon. Hydrocephalus.—Congenital hydrocephalus of sufficiently marked development to constitute an impediment to parturition is compara- tively rare, occurring, according to the statistics of Madame La Cha- pelle,f only fifteen times in 43,545 deliveries. It consists usually in a serous effusion confined to the cerebral ventricles. The effusion may, hoAvever, according to Jaccoud and Hallopean,! be situated in the meshes of the pia mater, in the cerebral parenchyma, in the sub- arachnoid cavity, or between the arachnoid and the dura mater. * Blake, " Am. Jour, of Obstet.," vol. xii, 1879, p. 225. f SriEGELBERG, " Lehrbuch," p. 525. X " Nouv. diet, de med. et chir. prat.," vol. xiii, article " Encephale," p. 151. 33 514 THE PATHOLOGY OF LABOR. Etiology.—The etiological factors of the disease have not been ascertained, although Herrgott * assumes an invariable causative rela- tion between coexisting cretinism and hydrocephalus. Morbid Anatomy.—The accumulated serum compresses the cerebral parenchyma and produces dilatation of the cranial cavity, which may become excessive. The cranial bones become abnormally thin, being in some instances no thicker than parchment. Their continuity may be interrupted by apertures of varying size, through Avhich the con- tents of the cranium may protrude, constituting an encephalocele. The skull is of disproportionate magnitude as compared with the face. The head may attain the dimensions of that of an adult. The fore- head is prominent and bulging, the sutures are widely open, and the fontanelles of large diameter. The body of the fcetus is usually well developed, and of a size corresponding to the existing period of preg- nancy, although spina bifida and other malformations may coexist. Hydramnion frequently complicates hydrocephalus. Diagnosis.—Cystic tumors, spina bifida, encephalocele, and the skull of a macerated foetus, are most frequently mistaken for hydrocephalus. The differential diagnosis is based upon different signs, according to the position and presentation of the foetus. If the head present and be still above the superior strait, abdominal palpation may sometimes detect a large, rounded, and hard" tumor above the pubes, while aus- cultation discovers the maximum intensity of the fetal cardiac sounds above the umbilicus. The abdomen is unusually distended. If the head has descended someAvhat into the pelvic cavity, palpation per vag mamreveals a fluctuating sac, which becomes notably tense dur- ing the pains. In the interval between the uterine contractions, the broad fontanelles, the thin bones, and the wide sutures are readily felt. These signs may, howeA'er, fail if the cranial bones be thick and the sutures already ossified. In this case the disproportion betAveen the forehead and face, the bulging frontal bone, and the prominence of the superciliary ridges are important aids to a diagnosis. If the mem- branes be ruptured, the hairy scalp may be felt. The diagnosis is easier when the cranial cavity is not greatly distended. In case of a breech presentation, the diagnosis, which is then more difficult, must chiefly rest upon the detection, at the fundus, of a tumor larger than the normal fetal cranium. The previous occurrence of hydrocephalus in the same subject and feeble fetal movements may, in this instance, slightly facilitate the task of the diagnostician. Mechanism of Delivery.—The course of parturition is sometimes not materially impeded even by a largely developed hydrocephalic foe- tus. This may be due, if the bones be attenuated, to the ready mold- ing of the fetal cranium to the pelvis, or to rupture of the head and * Herrgott, "Des mal foetal, q. peuvent faire obstacle a l'accouch.," Paris, 1878, p. 13. ABNORMALITIES OF THE FCETUS. 515 escape of the serum,* which event occurs chiefly in breech presenta- tions. The presentation materially affects the course of delivery. If the head be forced with its greatest circumference against the superior strait, it adapts itself less readily to the pelvis than when it impinges laterally or obliquely on the pelvic entrance. The difficulties of deliv- ery are increased if the cranial bones be firm and thick, or the sutures ossified. Breech presentations are favorable to a speedy delivery, in that the head is subjected during its descent to more equable press- ure by the pelvic parietes, and therefore assumes a conical shape best adapted to insure its easy expulsion. Spontaneous delivery is, how- ever, rare. In the vast majority of cases operative interference becomes necessary. Prognosis.—The child's life is usually sacrificed if the anomaly be sufficiently marked to considerably protract parturition. Even if the child be born alive, it will probably succumb at an early period of ex- tra-uterine life. The prognosis with reference to the mother depends largely upon the time at which obstetrical aid is extended, and upon the nature of the remedial measures adopted. If the labor be too long protracted, vesico-vaginal fistula may result from pressure of the fetal head, or the mother may die from exhaustion or from rupture of the uterus. Rupture of the uterus is comparatively frequent, having oc- curred in sixteen out of seventy-four' cases of hydrocephalus collected by Thomas Keith. The laceration usually occurs in the vicinity of the cervix, but is often located at the fundus uteri. The treatment consists in puncturing the head with a fine trocar and allowing the fluid to escape. If practicable, the child should be subsequently turned and extracted by the feet. The forceps is useless, as it can not be made to take a firm hold. If version is found to be attended with difficulty, the opening should be enlarged, and the head extract- ed with the cranioclast. Congenital Encephalocele.—This abnormality of the fetal cranium consists in the accumulation beneath the scalp of cephalic fluid, with or without an investment of meningeal or of cerebral tissue. The sac containing the fluid is attached to the cranium by a pedicle of varying length and form. The aperture through which the fluid originally contained within the cranium finds exit may be produced by attenu- ation of the cranial bones attendant upon hydrocephalus, or may be due to arrested development. In some instances the encephalocele is found still communicating with the cranial cavity through its pedicle, but in others the latter is impervious. Encephaloceles vary in size from hardly perceptible sacs to tumors of larger circumference than the cranium itself. They may occupy any part of the periphery of the head, but are most frequent in the frontal and occipital regions, f The head may itself be hydrocephalic or normal. The cause of the * Schroeder, " Lehrbuch," p. 632. f Herrgott, op. cit, p. 121. 516 THE PATHOLOGY OF LABOR. anomaly in question is not definitely knoAvn, but is inferred to be of inflammatory nature. Encephaloceles rarely obstruct delivery, because, their most frequent seat being in the frontal or occipital region, they are expelled either before or after the head. Their presence seems to determine nutritive changes in the cranial bones, whereby the latter, being rendered softer and more yielding, are more readily expelled. The amount of obstruc- tion caused by the encephalocele will reach its maximum when the size is large, the pedicle short, and the seat lateral; but simple puncture usually suffices to evacuate the sac, and obviates further difficulty. The prognosis for both mother and child is far better than in cases of con- genital hydrocele. II. Abnormal Conditions of the Foetus which obstruct the Expulsion of the Trunk. Hydrothorax.—Hydrothorax, unattended by serous effusion into any other of the closed cavities of the body, is infrequent, and when present is rarely of sufficient extent to offer any impediment to deliv- ery. Spiegelberg encountered only one such case, and refers to but two others observed by Hohl.* Ascites.—Ascites, although more frequent than hydrothorax, ordi- narily constitutes an insignificant obstruction to parturition, on ac- count of the yielding character of the abdominal walls and the small amount of fluid usually present. It has, however, in some instances markedly retarded delivery, f Ascites and hydrothorax are more frequently associated than iso- lated, and present, when combined, no inconsiderable obstruction to delivery. Pericardial effusions of varying magnitude may exist simul- taneously with either or both these affections. \ The size of the fetal abdomen may be so much augmented by dis- tention or enlargement of its viscera as to obstruct labor. Among the causes of abdominal distention from this source may be cited : {a) Cystic degeneration of the kidneys ; * {b) dilatation of the uri- nary bladder ; || (c) dilatation of the ureters ;A {d) fibro-cystic degen- * Spiegelberg, "Lehrbuch," p. 528. f Martin, "Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 28. X Herrgott, op. cit, p. 155. * Cummins, "Dublin Jour, of Med. Sci.," May, 1873, p. 499; Voss, "Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 28; Kanzow, Ibid., Bd. xiii, 1859, p. 182; Wegscheider, Ibid., Bd. xxvii, 1866, p. 27. || Whittaker, "Am. Jour, of Obstet.," vol. iii, 1871, p. 389; Duncan, "Edinburgh Med. Jour.," August, 1870, p. 163; Hartmann, "Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 273 ; Rose, Ibid., Bd. xxv, 1865, p. 425 ; Olshausen, "Arch. f. Gynaek," Bd. ii, p. 280; Kristaller, "Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 165; Hecker, Ibid.} Bd. xviii, 1861, p. 373. A Ahlfeld, " Arch. f. Gynaek.," Bd. iv, p. 161. ABNORMALITIES OF THE FCETUS. 517 eration of a testicle still retained in the abdomen ; * {e) enlargement of the liver, due to degenerative processes; f (/) enlargement of the uterus, produced by secretions accumulated in its cavity, the cervix being impermeable ;\ {g) enlargement of the pancreas ; * {h) enlarge- ment of the spleen; || {i) one foetus included within another.A In this case one foetus is completely invested by the integument of the other, and is attached to the latter by a pedicle, which is usually inserted either in the sacro-coccygeal, perineal, or cervical regions. Q A case of extensive anasarca of the foetus, characterized by the peculiar gelati- nous nature of the fluid contained in the subcutaneous cellular tissue, is reported by Keiller to have produced dystocia.J Emphysema of the entire fetal trunk may result from putrefaction occurring in the tissues of a child retained for some time in utero after the escape of the am- niotic fluid. % The putrefactive processes owe their origin to the en- trance of air within the uterus. The gaseous products of decomposi- tion are developed in all the fetal tissues and in the cavities of its body. The skin is distended, translucent, and glistening. It crepi- tates on pressure, and gas escapes from incisions carried through the cuticle. The trunk and extremities are largely increased in volume, and their augmented size offers an obstacle to delivery which the uterine forces, probably already exhausted by prolonged expulsive efforts, can not overcome. In such cases the bulk of the child should be diminished by punctures of the skin to allow the gases to escape, and when the head presents it should be extracted with the cepha- lotribe. Tractions upon the extremities are liable to be followed by their separation from the trunk. Tumors developed in different parts of the fetal trunk may disturb parturition. The most frequent site for these tumors is the sacral and perineal regions, where they are developed between the sacrum, the coccyx, and the rectum. Their size varies from that of a small wal- nut to that of the fetal cranium at term, and it may even exceed these dimensions. The tumors may be either cystic, fatty, vascular, carti- laginous, osseous, or carcinomatous. So-called cysto-hygromata are also frequently obserA^ed in this situation. Similar neoplasms may be located in the axilla, upon the pectoral muscles, and in the anterior or posterior cervical regions. Spina bifida, when accompanied by the formation of a large hydrorachitic sac, constitutes another form of congenital fetal tumor, and is most frequently observed in the lumbo- sacral region. Ectopia of the abdominal viscera, hernias, hydatid cysts, * Rogers, " Am. Jour, of Obstet.," vol. ii, p. 626. f Schroeder, " Lehrbuch," p. 634. X Spiegelberg, " Lehrbuch," p. 528. * Martin, "Monatsschr. f. Geburtsk.," Bd. xxvii, 1866, p. 28. || Voss, op. cit., p. 26. A Spiegelberg, "Lehrbuch," p. 529. v Herrgott, op. cit, p. 266. J Schroeder, " Lehrbuch," p. 636. % Spiegelberg, " Lehrbuch," p. 524. 518 THE PATHOLOGY OF LABOR. and encysted neoplasms of the abdominal walls sometimes constitute tumors sufficiently extensiA'e to impede parturition. We may also cite anchylosis of the fetal joints, adhesions of the extremities to the trunk or to one another, and rigor mortis, as rare abnormalities which interfere with that pliability of the child requisite for its adaptation to the parturient canal, and finally, adhesion of the fcetus to the pla- centa or to the uterine parietes as causes of dystocia.* Diagnosis.—An accurate differential diagnosis between these varied morbid conditions can, as a rule, only be made after delivery. If enlargement of the trunk be present, the head or breech is born with- out difficulty, but, the progress of parturition being then completely arrested, an investigation easily reveals the existence of an abnormally large trunk. A hydrorachitic sac is liable to be mistaken in a breech presentation for the fetal membranes. Its consistence is, hoAvever, not altered by the occurrence of uterine contractions, and no fetal parts are felt beneath the membrane, which is found to be continuous with the fetal cutaneous surface. III. Monstrosities. Dystocia is more frequently produced by double monstrosities than by any other variety. These are divided by Veit f into three princi- pal classes, characterized, respectively, by—1. Incomplete double for- mation of the upper or of the lower extremities; 2. Two separate bod- ies united either by their upper or by their lower extremities; 3. Two separate bodies attached to each other either by their abdominal or by their dorsal surfaces. Diagnosis.—The differential diagnosis of the individual deformities is usually impossible in the,earlier stages of parturition. Even in the succeeding stages it is difficult, since separate twins may present essen- tially the same phenomena. The diagnostician will derive some assist- ance from the facts that certain Avomen seem predisposed to the devel- opment of double monsters, and that certain smaller and easily recog- nizable deformities of the extremities (as club-foot) are often merely complications of more important ones, and serve to indicate the exist- ence of the latter. The family history may furnish valuable assistance, inasmuch as the deformities under consi deration are sometimes heredi- tary. Double monsters are most frequently observed in multiparae, but this fact is referred by Veit J to the relative numerical preponder- ance of the former over primiparae. When parturition has progressed sufficiently to allow of introduction of the hand within the uterus, should the necessities of the case call for this measure, the diagnosis becomes clear. * Whittakeu, "Am. Jour, of Obstet.," vol. iii, 1871, p. 247. f Veit, Volkmann's " Samml. klin. Vortr.," Volkmann, 1879, Nos. 164, 165. X Veit, op. cit, p. 1318. ABNORMALITIES OF THE FCETUS. 519 Mechanism of Labor.—The natural forces suffice, according to the statistics of Playfair and Hohl,* for the delivery of double monsters in more than fifty per cent, of the cases. This fact may be attributed to the comparatively small dimensions of the foetus and to the frequent occurrence of abortion or of premature delivery in cases of this nat- ure. The course of parturition in a case of the first variety is simi- lar to that obtaining when the head of a single foetus is of unusually large dimensions. The second variety does not ordinarily seriously interfere with delivery, particularly if there be a breech presentation. In this case the bodies pass through the parturient canal simultane- ously, lying parallel to each other. One head then passes along the hollow of the sacrum and is first expelled, while the other is retained above the brim, its neck being bent into close apposition to the pubes until after the expulsion of its fellow. Should there, however, be a disparity between the lengths of the necks, both the heads may simul- taneously pass through the pelvic canal. When they reach the outlet, the head attached to the longer neck is expelled. The second head must then be expelled with the neck and shoulders of the former. Under these circumstances, interference on the part of the obstetrician is usually required. Head presentations are the most common ones in cases of the third variety, and the course of parturition is as follows : The head of one foetus is born, that of the other being detained above the pelvic brim. The trunk belonging to the first head then follows. Next comes the second trunk ; and, finally, the head belonging to the latter. Spontaneous delivery, when it occurs, is usually effected in this man- ner. Head presentations of the first variety, i. e., those in which a single trunk possesses two heads, usually pursue the course just de- scribed. Prognosis.—The prognosis for the child is very unfavorable, owing to its expulsion in an undeveloped condition and to the compression exerted upon it during labor. The prognosis for the mother is favor- able because of the usual small dimensions of the fcetus and of the freedom with which measures for the reduction of its volume are resorted to in view of its probable early demise. An acardiacus is a monster devoid of a heart. It is developed simultaneously with a normal foetus, and is usually born after the lat- ter. Its development, as already explained, f occurs in the following manner : The balance of circulation in the anastomosing vascular sys- tems of tAvins contained in a single chorion (and therefore of the same sex) becomes disturbed, and the pressure in one system so preponder- ates over that in the other that the circulation of the latter is reversed, and its heart, lungs, and body atrophy. It now receives its nutritive supplies from the normal foetus. As the result of congestion in its * Spiegelberg, " Lehrbuch," p. 531. f Chapter on "Multiple Pregnancy." 520 ABNORMALITIES OF THE FCETUS. umbilical vein, its connective tissue often undergoes hypertrophy and oedematous infiltration. The same cause may result in hydrocephalus or in the development of a monster presently to be described as an Fig. 216.—Author's case of acardia. anencephalus. The most common variety of acardiacus is known as the acephalus, or headless monster. The amorphus is an acardiacus without head or extremities. It is of rounded form, and its surface, though ordinarily smooth, may present faintly marked tubercles, which are regarded as rudimentary extremities. The interior of the amor- phus contains a rudimentary intestinal canal, cystic cavities, muscles, and vertebrae. The umbilical cord is attached indifferently to any part of the body. The rarest form of the acardiacus is the acormus, or trunkless monster. It consists of an imperfectly developed head ABNORMALITIES OF THE FCETUS. 521 with a rudimentary trunk. Its umbilical cord is attached to the cer- vical region. An anencephalus or hemicephalus is a monster with a well-developed trunk and a rudimentary body. The neck is short and the head rests directly upon the shoulders, which are so unusually broad as to consti- tute an impediment to delivery. The amount of amniotic fluid is ordinarily large. The face is turned upward and the eyes are prom- inent. The most common presentations for an anencephalus are the transverse and the breech. Sometimes the face or the exposed base of the skull presents. In such a case the diagnosis may be made by recognizing the sella turcica and other bony prominences of the base. Reflex actions may be produced by irritation of the medulla, as it rests exposed upon the basilar process of the occipital bone.* This deform- ity produces obstruction by permitting other extremities to enter the pelvic cavity simultaneously with the diminutiA'e head, and by the unusual breadth of its shoulders. The latter are more readily ex- pelled when the parturient canal has been previously dilated by the passage of the breech. Spontaneous Version. The term spontaneous version is applied to the process by Avhich either a transverse position is transformed through Nature's unaided efforts into a longitudinal one, or to that by which a normal position is either partially or completely reversed. Spontaneous version, which occurs during pregnancy as a very frequent physiological phenome- non, is observed Avith comparative infrequency during labor. It may be partial or complete, according as the presenting member is dis- placed laterally through either 90° or 180°, may occur before or after the rupture of the membranes, and may result in the transformation of a transverse position into either a head, a breech, or a footling pres- entation. According to the statistics of Hausemann,f cases of spon- taneous version after rupture of the membranes are nearly five times as frequent as those occurring before their rupture. The same author states that the head presented in eighty per cent, of the cases occur- ring before rupture of the membranes, and the breech in seventy-five per cent, of those taking place after the occurrence of that event. Spiegelberg J cites two cases from his own practice in which there was an escape of so-called " false waters," the real membranes remain- ing intact, and attributes the occurrence of spontaneous version in such instances to the change of uterine form rendered possible by the evacuation of the false waters. Etiology.—Among the conditions predisposing to spontaneous ver- * Herrgott, op. cit, p. 263. f Hausemann, " Monatsschr. f. Geburtsk.," Bd. xxiii, 1864, p. 366. X Spiegelberg, "Lehrbuch," p. 539. 522 THE PATHOLOGY OF LABOR. sion is the uterine atrophy incident to repeated deliveries. About two thirds of all the women in whom spontaneous version occurs are, accordingly, multiparae,* and their average age is thirty years. Spon- taneous version often recurs during several consecutive pregnancies of the same individual. It is more apt to occur during deliveries effected at term than in abortions or premature deliveries. A living foetus is more frequently the subject of spontaneous version than a dead one, and many authors attribute an important agency in the production of the altered position to the active movements of the child. The uterine contractions are necessarily weak in cases of spontaneous ver- sion occurring before the rupture of the membranes, as powerful pains would force the presenting part still farther into the dilated os and fix it immoA'ably in the pelvic brim. On the other hand, the contrac- tions of the uterus during a spontaneous version which takes place after the escape of the amniotic fluid must be strong, as will be ex- plained in our remarks on the mechanism of the process in question. An undilated cervix, powerful contractions of the uterine fibers, and a fully developed child are essential conditions for the occurrence of spontaneous version after rupture of the membranes. Some authors consider the presence of a certain amount of amniotic fluid indis- pensable to the occurrence of spontaneous version in those cases taking place after rupture of the membranes. It is also necessary in such instances that the shoulder or other presenting part be freely mov- able, not having yet been firmly fixed in the cervical or pelvic canal. Mechanism of Partial Version. 1. Before Rupture of the Membranes. —In this case the shoulder usually presents, the head being lower than the breech. The os is only partly dilated. The woman having assumed a position upon that side of her body toward which the head is directed, the breech tends to descend under the influence of gravitation, while the head is thus approximated to the cenrix. The contractions of the oblique and longitudinal uterine fibers now complete the version by exerting pressure upon the breech. When the uterus has once regained its natural shape, the normal position is retained by the foetus until the completion of parturition. In other instances, the breech being lower than the head, the same mechanism leads to a breech or to a footling presentation. 2. After Rupture of the Membranes.—In this variety of spontane- ous version the amniotic fluid has partially or entirely escaped, allow- ing the foetus to be tightly grasped by the uterine muscular walls, which, therefore, labor under a mechanical disadvantage. The os is only partially dilated. The pains force the presenting part into close contact with the os internum. Owing to the absence of an equally * Hausemann, he. cit, p. 212. ABNORMALITIES OF THE FCETUS. 523 distending bag of waters, the os does not dilate, and soon assumes a condition of tetanic spasm, during which it can be felt as an unyield- ing, cartilaginous ring. The contractions of the oblique and trans- verse fibers at the fundus uteri having now become more forcible, the fetal head or breech, as the case may be, is subjected to violent press- ure. Inasmuch, however, as the unyielding os prevents any progress downward, the presenting part is displaced laterally, and that part of the foetus which previously occupied the fundus is forced into the pelvic entrance. The uterus next regains its natural form, the os dilates, and delivery is accomplished. Mechanism of Complete Version. Cases of complete version, which are very rare, consist in the trans- formation of one normal longitudinal presentation into the diametrical- ly opposite one, the part originally presenting having rotated through 180°. The mechanism is essentially identical with that just described. Version of this variety is only likely to occur when the amount of liquor amnii is large and the child small, so that it is freely movable. Spontaneous version before the rupture of the membranes occupies only half the time required for its accomplishment after their rupture. Twenty-four or thirty hours are often necessary for the completion of the latter variety. Delivery, too, is, accomplished more speedily in cases of the former kind when version has once occurred. Prognosis.—The prognosis for both mother and child is good in spontaneous version before rupture of the membranes, but is graArer when the turning occurs after that event, contrasting unfavorably with manual version, OAving to the fact that injurious pressure is liable to be exerted upon the prolapsed cord. Spontaneous Evolution. Spontaneous evolution is the process by which a shoulder presenta- tion is transformed, within the true pelvis, into a combined breech and shoulder presentation, and spontaneous delivery is then effected. Since this may be accomplished in two different ways, there are two corresponding varieties of spontaneous evolution. The former was, according to Leishman,* first described by Douglas, of Dublin, as "spontaneous expulsion." Dr. Taylorf takes exception to Leish- man's statement, and affirms that the term spontaneous evolution Avas applied by Douglas to the mode of delivery in question. The lat- ter was described by Roderer as "birth with double body" {" evolu- tio conduplicato corpore"), and more thoroughly explained by Klein- wiichter. J * Leishman, "A System of Midwifery," Philadelphia, 1873, p. 337. f Tarnier et Chantreuil, " Traite de Tart des accouchements," Paris, 1880, p. 672. X Kleinwachter, "Arch. f. Gynaek.," Bd. ii, p. 111. 524 THE pathology of labor. Etiology.—Various conditions contribute to the facility with which this process is accomplished by Nature. The most important are poAverful pains, a roomy pelvis, and a small foetus. Of these condi- tions, the first only is essential; Grenser * has demonstrated that a contracted pelvis is not an insurmountable obstacle to spontaneous evolution provided the conjugate diameter be alone shortened. Nor is small size of the foetus essential to the occurrence of the process in question. Spiegelberg f states that it is often observed in cases where the foetuses are mature and well developed. Softness and compressi- bility of the child naturally favor the production of spontaneous evo- lution, as is demonstrated by its frequent occurrence when the product of conception has undergone maceration. Mechanism.—The mechanism of the former and more ordinary variety of spontaneous evolution is as folloAVS : The presenting shoulder is forced into the depths of the true pelvis by the violence of the uter- ine contractions, instead of being diverted laterally, as is the case in spontaneous version, and becomes firmly fixed beneath the symphysis, while the corresponding arm protrudes through the vulva. The body Fig. 217.—Birth with doubled body. (Chiara.) of the foetus is then so forcibly flexed that the breech and the head lie in close proximity to each other. The former is in contact with the sacro-iliac synchondrosis, while the latter is immovably held between the breech and the upper border of the symphysis. The neck and shoulder, Avhich rest against the lower border of the symphysis, now become the pivot upon which the foetus rotates. The trunk of the * Grenser, " Monatsschr. f. Geburtsk.," Bd. xxvii, 1S66, p. 445. f Spiegelberg, "Lehrbuch," p. 541. ABNORMALITIES OF THE FCETUS. 525 foetus is driAren beyond the shoulder, and the thorax, breech, and legs are born in the order named. The other shoulder then follows, and the head is finally expelled. The mechanism of the second variety of spontaneous eArolution, designated by Roderer " evolutio conduplicato corpore," which is much rarer than the former, dif- fers from it in some essential feat- ures. It is greatly facilitated by softness and compressibility of the child, and therefore occurs predominantly in cases of macer- ated foetus. It is rarely observed in other cases, unless the foetus be unusually small and its tissues greatly relaxed. The shoulder is in this in- stance forced dowmvard and im- prisoned beneath the symphysis pubis, as in the former variety, Avhile the arm protrudes from the vulva. The trunk having been enormously flexed, the head and thorax simultaneously enter the pelvic cavity, the former being deeply imbedded in the latter. The second arm and shoulder lie betAveen the breech and thorax on the one hand, and the head on the other. The presenting shoul- der having been expelled, the head and thorax are born together, and these are followed by the breech and the legs. Prognosis.—The prognosis in spontaneous evolution is good for the mother but very bad for the foetus, since only immature children are, as a rule, able to pass through the ordeal of delivery by this method alive. This remark applies Avith special force to children born by the variety of sponta- neous evolution knoAvn as "evolutio conduplicato corpore.'''' Dr. Tay- lor * recommends, when the perinaeum is distended by the doubled body of the child, to make lateral incisions to the extent of three to four inches at the vulva, and thus remove the obstacle to delivery afforded by the pelvic floor. * Taylor, " Am. Jour, of Obstet.," July, 1881, p. 532. Fig. 218.—Neglected shoulder presentation. Sec- tion through frozen corpse. (Kleinwachter.) 526 THE PATHOLOGY OF LABOR. CHAPTER XXX. ECLAMPSIA. Definition.—Clinical history.—Prognosis, pathology, and etiology.—Treatment. Eclampsia is the term applied to convulsions, tonic and clonic in character, the foundation of which is laid in processes connected with pregnancy, labor, and childbed {eclampsia gravidarum, parturien- tium, vel puerperarum). By this definition it is intended to exclude the convulsions due to hysteria, true epilepsy, and cerebral lesions, which occurrences in pregnancy are to be regarded simply as accidental complications. In eclampsia there is loss of consciousness during the attacks, with at first a disturbance of the intellectual faculties in the intervals, deepening in severe cases into coma. Before entering upon a discussion as to the probable nature of this affection, it is proper to present a summary of its clinical manifestations. Clinical History.—Eclampsia is fortunately a tolerably rare event. Its estimated frequency is in about the proportion of once in five hundred pregnancies. The total number of deaths from this cause reported to the Board of Health in New York City, in the nine years from 1867 to 1875 inclusive, was 408. The estimated maximum num- ber of deliveries during that period was 284,000, or nearly one death to seven hundred confinements. The entire number of deaths occur- ring in pregnant women from all causes during the same period Avas 3,342, making the proportion of those from eclampsia as one to eight. In the majority of cases, though not invariably, premonitory symp- toms announce the impending outbreak. Of these the most impor- ant are headache, often limited to one side, vertigo, loss of memory, gloomy forebodings, flashes of light before the eyes, contracted pupils, amblyopia, sometimes amaurosis, ringing in the ears, dyspepsia, nausea, vomiting, dyspnoea, oedema of the face, of the labia majora, and of the extremities, and, finally, and of first importance, the presence of albumen and of casts in the urine. The attacks resemble those of epilepsy, the cry only lacking. When they occur during labor, the first convulsion often is preceded by a short calm, in which the patient ceases to complain, closes her eyes, and seems to have sunk into a peaceful slumber. This deceitful truce, which should always excite the keen attention of the physician, is fol- lowed in a few minutes by convulsive movements of the orbicularis oris muscle, giving to the patient a smiling aspect. Suddenly the eye- lids open, the eyes become fixed, and the pupils contract. Then, in a few seconds, the eyelids open and shut rapidly, the eyes move from side to side or roll upward, while the pupils dilate and lose their sensitive- ness to light. Very rapidly the convulsive tAvitchings extend to the ECLAMPSIA. 527 other muscles of the face, the mouth opens and is drawn to one side, the head is moved from shoulder to shoulder, sometimes with light- ning-like alternations. Frequently, for the first two or three convul- sions, the movements of the extremities are limited to the pronation and supination of the forearm and to the closing of the fingers upon the thumb. Afterward the arms, crossed upon the thorax, pass from flexion to extension with great rapidity. The movements, as a rule, are more pronounced in the upper than in the lower extremities. Sometimes the latter are fixed with tetanic rigidity, while at others they are flexed at the knee and then drop of their own weight, now upon one side, now upon the other. As a consequence of the resulting disturbances in the circulation and respiration, the carotids pulsate Avith great distinctness, the super- ficial veins of the neck swell, the conjunctivae become injected, and the face is cyanosed ; the heart's action becomes intermittent, and the breathing irregular and stertorous. In the tonic conA'ulsions, which occur intercurrently with clonic ones, the head is inclined to one side, the mouth is drawn in the same direction, the jaws are closed, the eyes are fixed, opisthotonos or pleu- rosthotonos develops, the pulse becomes small and intermittent, the respiration is suspended, the body becomes covered with a cold, clam- my sweat, and often involuntary micturition or defecation takes place. The tetanic condition, after lasting from fifteen to thirty seconds, gradually diminishes in intensity. As the convulsions cease, the distortion of the face disappears, the cyanosis diminishes, the eyelids droop, the mouth opens, and frothy saliva, tinged with blood, escapes from the mouth and nostrils. Ster- torous respiration marks the beginning of sopor. At first the pa- tient, unless the attack has been of unusual severity, can be roused when spoken to. The depth of the sopor is proportioned to the vio- lence and frequency of the attacks. When the convulsions are repeat- ed, the patient in the intervals can no longer be made to respond to inquiries, but passes into a state of complete unconsciousness. The duration of a single attack rarely exceeds a minute, and in the major- ity of cases lasts from ten to thirty seconds. On account of the impli- cation of the respiratory muscles, attacks of long duration are scarcely compatible with continued existence (Spiegelberg). After a single seizure the sopor usually disappears in from one half to two hours, and seldom persists beyond a single day. The number of seizures in a single day may, however, be exceedingly numerous. Thus, seventy compulsions have been reported by Braun,* eighty-one by Brummerstedt,f and one hundred and sixty by Depaul. J * Braitn, " Lehrbuch der gesammt. Gynaekologie," p. 822. f Brummerstebt, "Bericht," etc., Rostock, 1866. X Vide Spiegelberg, he. cit, p. 556. 528 THE PATHOLOGY OF LABOR. With very rare exceptions—of which, however, I have neArer seen an example—the urine after the convulsions is found loaded with albumen, and contains an abundance of renal epithelium, often in a state of fatty degeneration, casts, and sometimes blood-corpuscles. In all cases of exceptional severity the urine is scant or absent altogether. Terminations.—In favorable cases, after the expulsion of the ovum the attacks cease or diminish in frequency and intensity, the pulse and respirations become quiet, and the coma passes gradually into gen- tle slumber. On awakening the patient complains of headache and of impaired memory, and possesses no recollection of the perils through which she has passed. Pains are felt in the muscles, and in the tongue when the latter has been injured to any considerable extent by the teeth. But even after consciousness returns the danger is still not ended. Eclampsia predisposes to post-partum haemorrhage and to puerperal inflammations ; or it may leave behind hemiplegia, amblyopia, an en- feebled mental condition, or psychical disturbances, especially mania, which, hoAvever, usually terminates spontaneously in the course of the first three days. In fatal cases death results from carbonic-acid poisoning, due to tetanus of the respiratory muscles or to exhaustion of the nervous system. Bailly relates the history of a patient who died of asphyxia, due to swelling of the tongue. Of anatomical lesions found in post-mortem examinations, the most constant are hyperaemia, fatty degeneration, and atrophy of the kid- neys. The latter is rare, and in many cases the renal changes are of moderate extent. In thirty-two examinations, Lohlein * found in eight dilatation of one or both ureters and of the pelves of the kidneys. The same author likewise has demonstrated the existence of enlargement of the heart (the comparisons were instituted with those of other preg- nant women), indicative of increased arterial tension. The brain- lesions were in most instances insignificant. Prognosis.—The prognosis is always serious. In Dohrn's collec- tion of 747 cases the death-rate reached 29 per cent.; in 104 cases col- lected by Hofmeier f in Schroeder's Clinic the mortality was 32*4 per cent. A better showing is made by Braun, J who was able to report from Vienna in ten years, from 1869 to 1878, 73 cases, with twenty deaths (26 per cent.), five from peritonitis, and fifteen from Bright's disease alone. The earlier the convulsions occur in labor, the more unfavorable the prognosis. This is well shown by the statistics of Lohlein. Thus, of eighty-three cases where the first convulsions occurred before or * Lohlein, "Bemerkungen zur Eklampsiefrage," "Ztschr. f. Geburtsh. und Gynaek " Bd. iv, Heft 1, p. 89. "' f Hofmeier, he. cit X Braun, " Lehrbuch der ges. Gynaek.," p. 833. ECLAMPSIA. 529 during the first stage of labor, 40*5 per cent, of the patients died. Of fifteen cases Avhere the first stage Avas completed, but one patient died. Eclamp.sia, Avhich develops first in childbed, usually pursues a favor- able course. Lohlein reports eight cases, with one death, which, how- ever, was the result of infection. The longer the labor the more difficult the delivery, the deeper the coma ; and, the greater the insufficiency of the kidneys, the more de- pressing is the outlook. It is A'ery rare for the convulsions to cease previous to the expulsion of the child. According to C. Braun, after delivery in thirty-seven per cent, the convulsions cease entirely, in thirty-one per cent, they become feebler, while in thirty-tAvo per cent, they continue for a time with undiminished severity. In childbed it is of favorable import when copious diuresis sets in, and is followed by the disappearance of the albumen and of the oedema. As regards the children of eclamptic women, it is estimated that fully one half are born dead, a result probably due to asphyxia from the accumulation of carbonic acid in the blood of the mother. As the results depend upon the number and duration of the attacks, it is evident that the danger is greatly lessened after the completion of the first stage of labor. Pathology and Etiology.—As in discussions upon eclampsia it is evident that the treatment advocated by physicians is governed almost exclusively by theoretical considerations, it becomes of the utmost im- portance to place before the student an exact statement of knoAvn facts, with an attempt to estimate at their true A'alue the deductions which various observers have drawn from them. Now, in the first place, in reA'iewing the foregoing history of the disease, avc are brought face to face with the very striking coinci- dence in the vast majority of cases between renal insufficiency and the convulsive seizures. This insufficiency may or may not be as- sociated with albuminuria, though the tAvo go pretty constantly to- gether. The honor of first drawing attention to the relations between albu- minuria and puerperal convulsions belongs to Dr. John C. AY. LeArer, who reported in "Guy's Hospital Reports," second series, 1842, four- teen cases, in ten of which the urine was examined. Albumen was found in greater or less quantity in nine cases; in the post-mortem made in the tenth case the death was discoA*ered to have been due to acute meningitis.* These obseiwations were followed by others from British physi- cians, among whom may be mentioned Simpson, Garrod, Cormack, and * Vide Tyson, "The Causal Lesions of Puerperal Convulsions," Philadelphia, 1879. To this excellent summary I desire to acknowledge my indebtedness for a deal of labor saved, as regards the search for references. 34 530 THE PATHOLOGY OF LABOR. Rees ; and in France treatises upon the subject were published by Cohen and Delpech, and by Devilliers and Regnault. In 1851 Frerichs pointed out clearly the close resemblance betAveen the convulsions occurring in pregnancy and the uraemic convulsions of Bright's disease. After revieAving the evidence with scientific pre- cision he concluded that "true eclampsia occurs only in pregnant women suffering with Bright's disease, and it bears to the latter the same causal relation as convulsions and coma in Bright's disease in general; it is the result, of the uraemic intoxication, Avith which also in its mode of manifestation it agrees." To this view Braun, in the same year, and AVieger, in 1854, brought effective support by the pub- lication of a great number of observations confirmatory, both in re- spect to the clinical features and the post-mortem appearances, of the uraemic origin of puerperal convulsions. In 1857 Braun published one of the most meritorious treatises upon midwifery to be found in any language. In this work the new doctrine was presented with so much skill and clearness that since then, in the minds of the great body of practitioners, the terms eclampsia and uraemia have come to be regarded as synonymous. Now, though the lapse of time has tended to modify in many respects the less essential features of the Frerichs-Braun thesis, and though many of the earlier claims have had to be discarded, the evidence which has accumulated from every medi- cal man's experience during the last quarter of a century has contrib- uted to place the central idea upon an impregnable basis. The differ- ences which separate writers on the subject at the present day are less differences of creed than of definition. But, in order to understand the present position of the question, it is necessary to review the objections which the uraemic theory has had to encounter. Among its earliest opponents was Seyfert, of Prague, who, occupying the vantage-ground as director of the maternity hos- pital of that place, second only in size to the great maternity at Vienna, furnished the clinical counter-experiences which have since proved the most effective weapons in the hands of those Avho have re- garded the new doctrine as specious and heretical. The facts which, he insisted, invalidated the claims of Frerichs and Braun Avere as f oIIoavs : * 1. That convulsions may occur without albuminuria. 2. That the albuminuria is in many cases the effect and not the cause of the convulsions. 3. That in many fatal cases the kidney-lesions were absent or wholly insignificant. 4 That convulsions are rare in chronic Bright's disease which had existed prior to pregnancy. * As I have copied this list from notes taken from the lectures of Seyfert, delivered in the summer session of 1865, I shall not consider it necessary to more than incidentally refer to the corroborative testimony since advanced in support of their validity. ECLAMPSIA. 531 5. That in true uraemia, such as necessarily is produced by the suppression of urine when, in uterine cancer, the ureters are invaded, convulsions do not occur. That, in the main, these propositions are correct, hardly admits of question. But, in drawing conclusions from these, unnecessary stress is laid upon the presence or absence of albumen in the urinary secre- tion. It is the renal insufficiency, it should be fixed in the mind, and not the albuminuria, which causes uraemia and convulsions. The mere absence of albumen from the urine does not even exclude the existence of Bright's disease. Braun is careful to note that in certain cases of fatal eclampsia, in spite of the absence of albuminuria, the post-mortem examination revealed amyloid degeneration of the kidneys and of the heart-structures; and, again, in others, of atrophy of both kidneys, where the dropsy, and the albumen, and casts, which had been present earlier in pregnancy, had entirely disappeared at the moment the con- vulsions occurred. Bailly has shown that not rarely albuminuria in pregnant women may disappear for several hours and then reappear once more, so that it is possible for an examination to be made during the short period when the urine ceases to be albuminous. On the other hand chronic nephritis does not necessarily imply insufficiency of the renal secretion. Seyfert reported over 70 cases where women suffering from Bright's disease became pregnant; only two of these had convulsions. Every observer has seen similar in- stances of immunity. Nephritis in pregnancy brings with it its own peculiar dangers. Of forty-six cases, chronic in character, reported by Hofmeier, only one third of the patients had eclampsia, but one half died. Including acute and chronic cases together, Braun esti- mates that only sixty in the hundred develop uraemic con\'ulsions. Hofmeier found, in five thousand births recorded upon the history- books of the Berlin Clinic, 137 cases of nephritis entered. Of these, 104 patients only were attacked with eclampsia. Professor Bamber- ger* reports from autopsies of the "allgemeinen Krankenhaus" in twelve years 2,430 cases of Bright's disease, of which 152 Avere found in puerperal and pregnant women, viz., 80 acute cases, 56 chronic cases, and 16 cases of atrophy ; puerperal eclampsia was recorded in 23 instances. Lohlein examined the records of thirty-two autopsies made upon eclamptic women, and found in eight, or in twenty-five per cent, of the entire number, that dilatation of one or both ureters coexisted with renal disturbances. He, therefore, pertinently inquires how far sim- ple mechanical obstruction of the ureters may explain the apparent deA'elopment of uraemic manifestations in certain cases without the warning furnished by albumen in the urine. * Bamberger, " Ueber Morbus Brightii und seine Bezichungen zu anderen Krank- heiten," Volkmann's "Samml. klin. Vortr.," No. 173, p. 1541. 532 THE PATHOLOGY OF LABOR. Finally, it is not claimed by even the most stalwart champions of the uraemic nature of eclampsia that the convulsions which occur dur- ing pregnancy and labor are invariably the result of the same cause. Thus, Tyson says, "There are no reasons why we should exclude from the causes of the convulsions in the puerperal state those Avhich op- erate to produce convulsions in the non-puerperal condition." So- called cases of eclampsia without albuminuria, i. e., withoat uraemia, are admitted by Braun and Spiegelberg, and referred by them to reflex stimulation of the vaso-motor and convulsive centers (Krampfcentren). They advocate, hoAvever, separating them off into a class by them- selves, under the title of acute epilepsy, or eclamptiform attacks, a distinction they believe warranted by their rarity and their benign behavior. The question of mere names, however, is of small impor- tance. The main point upon which it is necessary to insist is, that it is not reasonable, because in very exceptional cases uraemia is absent in convulsions, to deny to uraemia, in the overwhelming proportion of cases in which it is demonstrably present, its importance as the most distinctive factor. The objection drawn from the insignificance of the kidney changes, frequently observed in post-mortem examinations, loses most of its force when we remember that in a large proportion of cases the reten- tion of excrementitious materials is due to acute suppression. Thus, in the 104 cases of eclampsia reported by Hofmeier, the kidney symp- toms developed suddenly. This sudden suspension of the urinary secretion can only result, Spiegelberg* argues, from disturbances in the renal circulation. A rapidly deA^eloped affection of the vessels would leave no marked post-mortem traces, and would, in cases of recovery, disappear as quickly as it had come. Were the kidney troubles due principally, as was formerly supposed, to pressure of the gravid uterus upon the renal veins, the kidneys should, in post-mor- tem examinations, exhibit evidences of congestion, whereas usually they are, on the contrary, found to be pale and anaemic. Besides, in cases of pressure from ovarian and pelvic tumors it is usually the ureters and not the veins which are implicated. The precise nature of the circulatory changes is not, of course, definitely knoAvn. Spiegel- berg suggests that either the walls of the vessels are altered in such a manner as to interfere with the process of diffusion, or that a reflex contraction of the vessels due to a peripheral stimulus operates to cut off the blood-supplies to the kidneys. Frankenhaeuser, having demon- strated a direct connection by means of the sympathetic nerve betAveen the ganglia of the kidneys and the nerA'e-filaments of the uterus, had likeAvise suggested in effect that the albuminuria of pregnancy was due not to pressure but to the excitation of the uterine and renal nerve plexuses. * Spiegelberg, "Lehrbuch," p. 501. ECLAMPSIA. 533 The statement contained in the fifth proposition relates to a curi- ous fact, which has since received confirmation from the pathological investigations of Cornil and Ranvier. In a very large proportion of women who had died from uterine cancer the ureters were found oc- cluded, with attendant dilatation and in some cases with hydrone- phrosis. The histories of these patients showed that in not one in- stance had convulsions taken place. But, however remarkable the fact itself maybe, it is not pertinent to the question of eclampsia. Seyfert adduced it to prove that uraemia had nothing to do with convulsions, a question which it is hardly necessary to discuss at the present time. A very different interest attaches itself, however, to the inquiry as to the causes of the outbreak of convulsions. It is Avell known that not every case of nephritis, or even of kidney insufficiency, is followed by eclampsia, though convulsive attacks are much more common in the uraemia of pregnant than of non-pregnant women. Frerichs be- lieved he had found the secret in supposing a ferment to develop in the blood, which converted the urea into carbonate of ammonia. In 1870 Spiegelberg reported an examination of the blood of an eclamp- tic Avoman by the latest methods, and demonstrated the presence of ammonia in quantities sufficient to give color to the supposition of Frerichs ; but, subsequent investigations proving negative, he con- cluded that " ammoniaemia is to be regarded as one of the rarest causes of convulsions." An apparently much more scientific explanation was afforded by the now well-known Traube-Rosenstein theory, which maintained that eclampsia took place when, in persons rendered hydraemic by the loss of albumen, the aortic pressure was suddenly increased, the in- creased pressure giving rise successively to oedema of the brain, then to secondary compression of the vessels, and finally to acute anaemia. An anaemic condition of the hemispheres would, it was predicted, pro- duce coma, while convulsions would ensue if the condition extended to the motor centers. The plausibility of this hypothesis was increased by the widespread acceptance of the doctrine taught by Andral and Gavarret. that the blood of all pregnant women is hydraemic, and by the fact that the existence of increased blood-pressure during the pains seemed natural- ly to account for the frequency of convulsions in labor. For a num- ber of years after the announcement of the Traube-Rosenstein theory it received from me complete acceptance ; but my faith became after- ward weakened by failing to find at post-mortem examinations the anticipated brain-changes, viz., oedema, anaemia, and flattening of the convolutions. In nineteen examinations, Lohlein reported these alter- ations in but a single case. In his " Lehrbuch der Geburtshulfe" Spiegelberg sums up the objections in a somewhat contemptuous fash- ion. First he asks why, if the pathogenetic symptoms, as assumed, 534 THE PATHOLOGY OF LABOR. are inA'ariably present, eclampsia is of such rare occurrence, and in what way the theory in question affords any explanation of eclampsia in pregnancy and childbed ; then he denies that eclamptic women are for the most part hydraemic, that hydraemia and arterial pressure are capable of inducing cerebral anaemia, and that the clinical evidences afforded by the pulse and pupils are those produced by oedema. Angus Macdonald reported in 1878 that in the examination of the brain in eclamptic persons he found the meninges congested and the venous sinuses filled with blood, while at the same time there was marked anaemia in the deeper layers of the brain-structure. The ven- tricles, in place of being empty, as should have been the case accord- ing to the Traube-Rosenstein the Dry of oedematous swelling, were found filled with serum. In place of the doctrine of secondary com- pression, he expressed his belief that the anaemia resulted from arterial contraction due to irritation of the vaso-motor centers from excremen- titious principles retained in the circulation by the insufficiency of the kidneys. The disposition to ascribe convulsions to cerebral anaemia is based upon the experiments of Kussmaul and Tenner, who demonstrated that convulsive twitchings might be produced in animals by tying the carotids or by opening the large vessels of the neck and allowing them to bleed to death. It is, of course, anticipated that anaemia due to systole of the arterioles would be followed by the same results. The phenomena of convulsions are twofold, viz., loss of consciousness, and tonic and clonic contractions. Loss of consciousness is easily to be accounted for by anaemia of the hemispheres, precisely as in cases of ordinary syncope. Convulsions occur, however, when the brain is removed, if only the pons Varolii and the medulla oblongata are pre- served. Deiters has shown that the motor fibers of the extremities and the trunk have their first central terminations in the pons. Noth- nagel * has proved that a collection of ganglionic cells in the substance of the pons furnishes the motor center from which the convulsive im- petus takes its departure. According to Schroeder van der Kolk, the groups of gray matter for the cranial nerves are situated in the floor of the fourth ventricle and in the substance of the medulla oblongata. Any influence producing contractions of the arterioles through the vaso-motor nerves would necessarily produce both coma and convulsions. As, however, convulsions may take place without loss of consciousness, Nothnagel concludes that the same cause which acts indirectly through the vaso-motor nerves may simultaneously set in action the centers of muscular movements. The foregoing considerations justify the older division of convul- sions into two classes, viz., those due to centric causes, and those pro- * Nothnagel, " Ueber den epileptischen Anfall," Volkmann's " Samml. klin. Vortr.,1 No. 39, p. 313. ECLAMPSIA. 535 ceeding from peripheral irritation. In both cerebral anaemia plays an important part. In the overwhelming proportion of cases, uraemia is the fountain and origin of the evil, the term uramia signifying, of course, the action, not of a single constituent of the urine, but of all the excrementitious principles, combined Avith that of increased arte- rial tension. AYhether, in exceptional cases, carbonate of ammonia or cerebral oedema is present, is a matter of slight moment. The role played by peripheral irritation is not, however, to be overlooked. Without uraemia, though rarely, peripheral irritation can provoke eclampsia. In uraemic cases the greater proportion deA'elop during labor. In Lohlein's collection, a hundred and six in number, ninety- three of the patients Avere parturient. Spiegelberg has frequently seen convulsions awakened in the placental period by the mechanical irritation of the uterus during the employment of the Crede method of expression. Convulsions occur more commonly in primiparae than in multi- parae, especially in elderly primiparae, in twin pregnancies, and in women Avith contracted pelves. They may occur epidemically in con- sequence of atmospheric conditions, which probably interfere with the functions of the skin and thus indirectly increase the labor thrown upon the kidneys. Treatment.—The occasional examination of the urine of pregnant women is to be regarded as an indispensable precaution. Faint traces of albumen are not infrequently found in the urine of women with harmless catarrhal affections of the bladder. Persistent albuminuria calls for special prophylactic treatment; for, though convulsions are not to be regarded as the necessary consequence of nephritis, the pres- ence of renal disease immensely increases the danger of sudden acute suppression. Nephritis is, moreover, apt to be aggravated by the pregnant state, and Hofmeier has shown that in a considerable pro- portion of the cases which have their origin in pregnancy the kidney- lesions, contrary to the accepted belief, do not disappear spontaneously after parturition. Every precaution should be taken, therefore, to remove from albuminuric patients all sources of mental excitement, to ward off attacks of indigestion, and to defend them from colds. In oedema of the face, the extremities, and the labia majora, a strict milk- diet should be enjoined, and the tincture of the chloride of iron, in full doses, should be given at least four times a day, both for its diu- retic and for its haematinic properties, and bkewise to improve the tonus of the weakened vessels. If the milk-diet is badly supported by the patient, she should be instructed to drink freely of the natural alkaline waters possessing mildly diuretic properties, such as the ATichy, the Selters, the Buffalo lithia-water, the Poland water, and others of like action. To remove the transuded serum, the skin should be compelled to aid the kidneys, either by means of the Turkish bath 536 THE PATHOLOGY OF LABOR. or, where the latter is not available, by the wet-pack. Mild laxatives, such as the Friedrichshall, the Hunyadi, or the Saratoga waters, are useful in constipation of the bowels. If cerebral symptoms threaten the outbreak of convulsions, the nervous irritability should be held in check by rectal injections of chloral and the bromide of potassium (thirty grains each), and a hy- dragogue cathartic should be promptly administered. Free catharsis unloads the blood of urea, diminishes the arterial tension, and relaxes the arterioles. The immediate results are usually in the highest de- gree satisfactory. The pain in the head, the sensory disturbances, the stomach troubles disappear, and the patient becomes calm or sinks into a gentle sleep. Lohlein recommends placing the woman in the latero-prone position, in order to diminish as much as possible the pressure upon the ureters and upon the renal veins. So far writers are practically unanimous. AYhatever differences exist betAveen them relate not to principles, but to the means best adapted to accomplish the end in A'iew. When, however, in spite of palliative measures and hygienic precautions, the uraemic symptoms have steadily progressed until the central nervous system has become involved, the question comes up for decision whether to persevere in a plan of treatment designed merely to ward off impending danger, or Avhether to place the patient without delay in a position of relative safety by the induction of premature labor/ The weight of authority, it seems to me, is favorable to procrastination, the interruption of pregnancy being regarded as an extreme measure, justifiable only in cases of utmost peril. But premature labor, with the indications thus limited, is not likely to save many lives. My own convictions are clear that, so soon as grave cerebral symptoms develop, the period of folded hands has passed. The relief to be obtained from chloral and catharsis is, as a rule, of short duration, and we can not go on giv- ing chloral and cathartics to the end of gestation, nor are we sure that the first fortunate results can be reduplicated. Moreover, it is necessary to take cognizance of the well-being of the foetus, which is threatened by the continued circulation of urea in the maternal blood. The induction of premature labor by means of the bougie, aided, if needful, by the vaginal douche and the dilating bags of Barnes, is at- tended with but moderate risk if resorted to after the uraemic symptoms have been got fairly under control; if employed as a last resource, where other therapeutical measures have failed, its use is still justifi- able, though it then partakes rather of the nature of a forlorn hope. The indications for treatment during the outbreak are for the most part the same as laid down for uraemic symptoms unattended by con- vulsions, viz., to lower the arterial tension, to diminish to the fullest extent practicable the irritation of the vaso-motor and convulsive cen- ters, and to restore to the kidneys their normal functions. Spiegel- ECLAMPSIA. 537 berg claims that these three indications are most completely fulfilled by venesection. A dozen years ago, at a time when the prejudice against "spoliative measures" was still strong, Professor Fordyce Barker pleaded for the restoration of the lancet in the management of puer- peral convulsions, insisting upon the unmistakable clinical evidences favorable to its employment. In my student-days in Paris, at the Hopital des Cliniques, Avhere the ancient usage Avas in full favor, I well remember my first feelings of alarm at the vigor of the treatment in vogue ; but, after carefully watching the cases to the end, I Avas led to conclude that the claims of bleeding in eclampsia rested upon a sub- stantial foundation. The special adA'antage of venesection lies in the rapidity of its ac- tion ; incidentally it favors absorption and renders the patient more susceptible to the influence of other remedies. It forms, therefore, naturally the first step in the treatment of convulsions. The quantity of blood to be withdraAvn varies from eight to sixteen ounces, according to the vigor, and, to some extent, according to the size of the individual. In the May number of the " American Journal of Obstetrics," 1871, Dr. H. Fearn, of Brooklyn, contributed an article on " Veratrum Viride in Large Dose?, as a Substitute for Bloodletting in Puerperal Convulsions," in which he recom- mended the tincture of veratrum in doses varying from fifteen minims to a tea- spoonful, repeated every five or ten minutes until the pulse became soft, or vomiting set in. For several hours after the convulsions are arrested, he ad- vises the veratrum to be administered in smaller doses, in-order to keep the pulse below fifty to the minute. He claims that the large doses are devoid of danger so long as the convulsions continue. According to Kenyon,* who has recently contributed two cases successfully treated by veratrum, " the drug is quickly absorbed, and enters the circulation rapidly. It enters the vasa vasorum and through them impairs the sensibility of the vaso-motor nerves, the blood-vessels thus losing their tonicity and power of contraction "—all good arguments for its use in convulsions if its safety can be established. After bleeding, narcotics and anaesthetics should be resorted to, with a view of preventing the renewal of the convulsions. Chloroform and morphia have long been tested in practice, and have sustained their claims to professional favor. From one sixth to one fourth of a grain of morphia should be injected hypodermically, the same quantity to be repeated in an hour in case of the convulsions returning. Chlo- roform was formerly recommended in full anaesthetic doses, so as to completely paralyze the motor centers. As, however, experience has shown that complete and prolonged anaesthesia is in itself a source of danger, it is advisable, except in cases where labor is nearly at a close, to restrict the chloroform to the pains, and to the restlessness Avhich is often the preliminary of a fresh seizure. * Kenton, " Treatment of Convulsions with Veratrum Viride," " N. Y. Med. Jour.," October, 1879, p. 370. 538 THE PATHOLOGY OF LABOR. The discovery of chloral has added another invaluable agent to our list of available antispasmodics and anaesthetics. It is my present practice, after beginning with chloroform, to administer thirty grains, each, of chloral and bromide of potassium by the rectum, and to sus- pend the chloroform so soon as the sedative effects of the latter agents become developed. The frequency Avith which the chloral should be given depends upon the frequency and violence of the attacks. A single dose will sometimes exercise a restraining influence for hours, while in other cases in the course of an hour or two the dose will re- quire to be repeated. As a subsidiary measure, with a view to the ultimate relief of the kidneys, the loAver bowel should be cleared out with an enema, and a cathartic (a drop of croton-oil, or calomel and jalap in case the patient is able to swallow) should be given by mouth. As convulsions which occur after the adA'ent of labor have a ten- dency to recur so long as the labor continues, and in the larger projjor- tion of cases cease after the birth of the child, every obstetrical re- source compatible Avith the safety of the mother should be employed to hasten delivery. In the early part of the first stage, the pains, if slug- gish, should be stimulated by catheterization of the uterus. Braun advocates rupturing the membranes, as he claims that the escape of the amniotic fluid often diminishes the frequency and A'iolence of the convulsions. The water-bags of Dr. Barnes, if necessary, should be used to promote the dilatation of the cervix. Incisions through the border of the os externum and accouchement force are unnecessary. After the first stage is completed, if no mechanical disproportion exists betAveen the head and the pelvis, a careful attempt to extract the child with forceps should be made. Every precaution should be used to avoid injuring the soft parts. Obstetrical aid is only warrantable Avhere it can be employed without detriment to the mother. In in- strumental cases, with the head high in the pelvis, I haAre had every reason to feel satisfied with the Tarnier forceps, exchanging it, how- ever, for one of English pattern so soon as the head is brought to the floor of the pelvis. When convulsions occur during pregnancy, the question as to the advisability of at once provoking labor is by no means settled. The material upon which to form an opinion is limited, as in most cases labor-pains occur spontaneously (as a consequence of the convulsions). Where medical treatment alone is employed it is certain that, in the absence of labor-pains, a certain proportion recover, and pregnancy may go on to completion. On this account it is commonly advised not to introduce labor as a complication into a state of affairs already sufficiently dangerous and difficult to manage. So far as my OAvn ex- perience goes, however, the practice of waiting upon Nature has proved uniformly disastrous, Avhile the induction of labor has furnished me with a certain proportion of recoveries. Braun declares he has never POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 539 known but one patient to recover between the fourth and sixth months of pregnancy except where abortion had taken place. The question is one, however, concerning which there exists a reasonable degree of doubt, and which can not be settled by the hap-hazard experiences of individuals. In the treatment of convulsions during the childbed period the agents used should be opium, chloral, veratrum, or digitalis. Chloro- form and venesection should be employed with extreme caution, if, indeed, they are ever entitled to confidence at that time. CHAPTER XXXI. POST-PARTUM HAEMORRHAGE AND RETAINED PLACENTA. Normal agencies for checking haemorrhage.—Disturbances of contractility, of retractility, of thrombus formation.—Treatment.—Method of securing contraction and retrac- tion.—Treatment of cerebral anaemia.—Retained placenta. The haemorrhages which occur immediately after the birth of the child may have their origin in the uterus, the vagina, or the vuh*a. It is customary, however, to consider those which spring from lacera- tions in a chapter by themselves, and to apply the term post-partum to those haemorrhages only which arise from the placental site. Unlike other grave complications of childbirth, post-partum haem- orrhage is not an uncommon event. It may follow the simplest of labors, and, in case of an unprepared physician, it may carry his pa- tient in a feAv moments to the brink of death. It is impossible to conceive a tragedy more terrible than this. Occurring, as the accident does, suddenly, without warning, in the period of joy that follows the birth of a living child, the sudden shifting of the scene becomes ap- palling. If the mother dies at such a time, the luckless attendant Avho stands at her bedside, a nerveless spectator, need never expect forgive- ness ; nor can he shield himself behind the recorded ill-successes of others. Every competent accoucheur knows in his own heart that he has no right to shirk his personal responsibility in cases of fatal post- partum haemorrhage, or to meanly throw the blame upon Providence. The treatment of post-partum haemorrhage is one of the most sat- isfactory departments of obstetrical practice. In no other emergency is the saving of life so little dependent upon chance, and so much upon intelligent human intervention. Successful treatment is, however, less the result of a familiarity with the various procedures extolled by writers, than of a correct understanding of the mechanism by means of which the arrest of the haemorrhage is to be effected. Normal Agencies for checking Haemorrhage.—In normal cases the 540 THE PATHOLOGY OF LABOR. flow which folloAVS the detachment of the placenta is of brief duration. The torn arterial tAvigs retract spontaneously, the patulous mouths of the veins become plugged Avith fibrinous clots, while the so-called A*e- nous sinuses, which are simply channels lined with endothelium, Avith- out A'alves or walls, become bent, flattened, and obliterated under the compression exerted by the muscular structures of the uterus. The first requisite against haemorrhage is the maintenance of firm, uniform contraction of the uterus. The contractions, which persist with lessened force after the birth of the child, during their continu- ance alone suffice to prevent haemorrhage from the placental site. The two diagrams borrowed from Professor Breisky serve to illustrate the Fig. 219. mechanism by Avhich this is effected. In the transition from a to b, the uterus, which shortly before harbored the entire ovum, becomes reduced to a body not larger than the two fists. But the duration of the contractions is short, with an ever-increasing interval between them. If their cessation Avere followed by the return of the uterus from b to a, the blood Avould once more rush into the sinures, the mouths of the veins would open, the thrombi would be washed out by the pressure brought to bear upon them, and flooding would of neces- sity ensue. That this does not take place is owing to the same force which in labor keeps the uterus closed upon its contents during the descent of the foetus—viz., tonic retraction. The tonic retraction of the uterus is in part the consequence of shortening of the muscular fibers, and in part of their rearrangement, a thickening of the uterine walls resulting as the cell-elements, in place of standing end to end, assume a position more nearly parallel to one another. Retraction is a permanent acquisition of the uterus, and POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 541 alone suffices to prevent the occurrence of haemorrhage. The differ- ence between it and contraction is exhibited by the difference in the consistence of the post-partum uterus during and between the pains. The contracted uterus is hard and firm like a billiard-ball, Avhile the retracted organ is relatively soft and relaxed. The tAvo properties, though distinct, are not, however, independent of one another. When- ever the contractions are good, the retraction is well marked also. Whatever diminishes the contractile powers of the uterus is folloAved by a corresponding falling off as regards its retraction. In cases where the muscular structures of the uterus fulfill their normal functions, the formation of thrombi is of subordinate impor- tance as a means of arresting haemorrhage. Confined to the adherent portion of the decidua serotina, they impart an uneven surface to the placental site. Thrombi Avhich extend to the intermuscular Aeins are pathological. It is only when the uterus is flabby, and the muscular action is in default, that the thrombi exercise any marked influence in the control of haemorrhage, and even then they bear so close a relation- ship to puerperal thrombosis as to approach dangerously near to the confines of pathology. The causes of post-partum haemorrhage are to be sought for in dis- turbances of the mechanism by which haemorrhage is normally pre- A'ented. Disturbances of Contractility.—Contractions of the uterus may fail from lowering of the muscular irritability. Atony follows most fre- quently exhausting labor, artificial deliveries, rapid evacuation of the uterus, especially in multiparae, where the failure to contract has often the significance of a prolonged pause, excessive distention (hydram- nios, tAvins), profuse haemorrhages, collapse, nervous depression, and severe general ailments. Again, in other cases, the functional disturbance may proceed from some abnormal condition of the muscular fiber. Thus, the defects of contractility may spring from incomplete development, as in anoma- lies of formation, in textural changes due to some antecedent disease or puerperal condition, especially as to the result of many preATious confinements, or finally from inflammatory infiltrations having their source in the bruising of the lower uterine segment during labor. The contractions of the uterus may be mechanically interfered with over limited areas by retained portions of the placenta and of the membranes, by peritoneal adhesions, by tumors in the walls of the uterus or in the uterine appendages, or by a distended bladder or rectum. Disturbances of Retractility.—AYe haA*e already seen that the tonus of the muscular fibers is lowered, and that their rearrangement is incomplete, Avhenever the uterine contractions are in default. At the same time the retraction of the uterus may be directly hindered by 542 THE PATHOLOGY OF LABOR. mechanical causes, especially by those which, like the placenta, the membranes, or coagula of blood, when retained in the uterine cavity, prevent, in spite of continued contractions, a sufficient closure of the veins. Disturbances in Thrombus Formation.—The disturbances which interfere with the formation of thrombi occur for the most part in those cases in Avhich, owing to the defective action of the muscular structures, the blood-stream arrives at the mouths of the vessels with unchecked rapidity. As a consequence, coagulation does not take place, or the coagula are of soft consistence and offer but feeble resist- ance to any sudden increase of blood-pressure, or become mechanically detached by restless moA'ements on the part of the patient, or by strain- ing with the abdominal muscles. Outlying Causes of Post-partum Haemorrhage.—The remote causes of post-partum haemorrhage—i. e., those not immediately connected with the uterus—all act by indirectly interfering with either the con- tractility or the tonus of the muscular fiber, or with the thrombus for- mation. This they do by influences exerted either through the ner- vous system or through the circulation. Thus, the muscular irrita- bility may be impaired by general debility, by wasting diseases, from impoverishment of the blood due to suffering and muscular effort, from psychical impressions, and from the external influences of heat and vitiated air. The normal tonus of the uterine muscles may be over- come, and the formation of thrombi disturbed, by any condition of the circulatory system associated Avith increased pressure in the venous or arterial trunks. The pressure in the uterine veins may be augmented by the patient's getting up suddenly in bed, by acts such as coughing, laughing, sneezing, vomiting, and defecation, in which the abdominal muscles are called into play, and by all the conditions Avhich produce chronic congestion of the pelvic organs. Increase of arterial tension as a cause of haemorrhage is rare. Breisky mentions a case where, in a multipara without valvular heart-disease, the cause of the haemor- rhage was. apparently due to intense palpitation of the heart associated with the hard, incompressible pulse indicative of arterial fullness.* Treatment.—It is not necessary to dwell upon prophylactic meas- ures. As has been shoAvn in the survey of the causes of post-partum haemorrhage, they comprise everything that has been said concerning the proper management of labor. Methods of securing Uterine Contractions.—It is my own practice, and one I would urge upon others, to make provision in the simplest * The foregoing description is little more than a transcript of the principles enunci- ated in Breisky's clinical lecture, " Ueber die Behandlung der puerperalen Blutungen," (Volkmann's " Samml. klin. Vortr.," No. 14, 1871). I have found them of the utmost service to me in practice during the ten years past, and believe with Breisky that they furnish the key to successful prophylaxis and treatment. POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 543 of cases against the possible occurrence of haemorrhage. In the be- ginning of the second stage, I examine my Davidson syringe to make sure that the valves are in good working order. I then direct a small table to be set by the bedside of my patient, and place upon it.a bowl containing pieces of ice of about the size of a hen's-egg, brandy, sul- phuric ether, neutral perchloride of iron, carbolic acid, ergot, a solu- tion of morphia, and a hypodermic syringe filled with a fluid extract of ergot, using preferably a watery solution. Within easy reach I likewise have placed a pitcher of hot water, another of cold water, an empty basin containing the Davidson syringe, and a bed-pan. All this requires but a few moments' time, and it is of no mean advantage to feel, in case haemorrhage follows the birth of the child, that all the appliances for prompt action are in order and close at hand. If haemorrhage takes place, in spite of the fact that the uterus has been carefully guarded by external pressure during the period of de- livery, draAV the pillows from under the head of the patient, direct the nurse to open the windows, and inject the ergot in the hypodermic syringe into the outer surface of the thigh. Ergot by the mouth acts too slowly to proA'e of service in the face of a great emergency; be- sides, in many patients ergot by the mouth excites nausea, and is not absorbed by the stomach ; hypodermically its action is, as a rule, rapidly developed. Then introduce the hand into the uterus. If a full bladder interferes, draAV off the urine Avith a catheter. The introduction of the hand into the uterus I believe to be a matter of the utmost importance. AYhen combined with external pressure it stimulates the uterus to contract. The placenta, if ad- herent, should be detached with the tips of the fingers ; if loose Avithin the uterine caATity, it should be withdrawn slowly, taking care to re- move the membranes entire. Bits of placenta or strips of membrane should be carefully scraped from the uterus, remembering that this is most easily effected during the contraction of the organ. Even if the placenta and membranes are expelled apparently entire, it is still desirable to pass the hand into the uterus to clear out clots, and to make sure that no part of the ovum has been left behind. Once I lost a patient by neglecting this rule. The haemorrhage was checked by compression, and upon careful inspection of the placenta and mem- branes I convinced myself that everything had come away. The patient died on the eighth day, of septicaemia. The autopsy revealed the presence of a small placenta succenturiata, of the existence of Avhich, aside from the haemorrhage, there had not been the slightest indication. So soon as the uterus has been emptied of everything capable of preventing contraction and retraction from taking place, withdraw the hand into the vagina, and, with the index and middle fingers in the posterior cul-de-sac, press the cervix forward toward the body of 544 THE PATHOLOGY OF LABOR. the uterus. With the external hand grasp the uterus through the abdominal walls, compress it firmly, and push it dowmvard toward the pelvis and forward against the pubic bone. By this manoeuvre the cervix is closed, the uterine Avails are brought into contact with one another, and contractions are stimulated by the direct irritation Fig. 220.—Bimanual compression of uterus. (Breisky.) of the large cervical ganglion and by the kneading of the fundus. Breisky states that in many cases it is possible to combine compression of the aorta Avith the foregoing manipulation. If bimanual compression fails to speedily secure contractions, without removing the internal band pieces of ice may be slipped into the vagina, and thence pushed upward into the uterine cavity. AA'ith rare exceptions, the uterus responds at once to the stimulus of cold applied to its inner surface. Should it not do so, however, the bed- pan should be placed under the hips, and warm water of about 112° Fahr. should be injected into the uterus, care being taken to expel previously all air from the tube of the syringe. The injection should be made slowly and Avithout force, alloAving the fluid to escape pari passu Avith its introduction. Although, as a precaution, I still keep within easy access one of the per-salts of iron as an additional resource in case of urgent peril, since the introduction of hot-water injections as a reflex exciter of uterine contractions I have never found it necessary to resort to their use. This I consider fortunate, for, though there is abundant testi- mony as to the efficacy of the per-salts of iron in post-partum haemor- rhage, the arrest of the flow appears, in some cases at least, to have been achieved at too dear a price. Barnes refers the haemostatic effect of the iron—1. To its direct action in coagulating the blood in the mouths of the vessels ; 2. To its action as a powerful astringent POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 545 on the inner membrane of the uterus, whereby the surface becomes corrugated and the mouths of the vessels are constringed ; 3. To the fact that it often provokes some amount of contractile action of the muscular wall. Trask, in recommending the substitution of tincture of iodine for the solution of the perchloride of iron, maintains that it is the third mode of action that should be placed first in the order of importance. This corresponds with my own experience. In two cases where Monsel's solution Avas used the uterus contracted promptly, and the injection was followed by no disturbing effects. In the third the uterus remained large and flaccid, notwithstanding the haemorrhage was arrested. For two days the patient did well; on the third the lochia became excessively offensive, the respirations stertorous, and the pupils dilated ; general paralysis ensued, and death followed within twenty-four hours of the attack. Although no autopsy was made, it was clear to me at the time that the coagulation had followed the vessels to the substance of the uterus, and that the fatal result was due to the absorption of septic material by the large, soft thrombi, which, by their disintegration, became the means of conveying infection to the remoter portions of the organism. Barnes uses the perchloride of iron after preliminary removal of the clots, in the proportion of one of iron to three of water. Most German authorities recommend the iron in a much more diluted form, and using it in no fixed proportion, but simply to pour the iron, following Seyfert's prescription, into the Avater until the latter assumes a deep wine-color. Engelmann speaks enthusiastically of swabbing the uterus with perchloride of iron, operating in the following manner : " I bring the patient," he says, " in position for forceps, introduce a Cusco's specu- lum, and with wads of cotton, prepared by an assistant, which I seize by my long dressing-forceps, I seek to clear the cavity of the blood which has again accumulated. The assistant has also soaked a num- ber of cotton wads, as large as a walnut, in perchloride of iron, and pressed out the mass of fluid, so as to leave them well soaked but merely moist with iron ; they must be well saturated, but not drip- ping. So soon as I have cleaned the cavity as far as it is possible amid the constant flow of blood, I seize a wad of new cotton on my forceps, and mop the walls of the cavity thoroughly, removing as much as possible of the clotted blood as I withdraw the cotton. I rapidly take up one cotton wad after another, and swab the uterus until the haemorrhage ceases. . . . The iron acts as a stimulant as well as styptic, and the uterus speedily contracts." Wallace* praises vinegar as a certain and safe remedy for post-par- tum haemorrhage : "I pour a few tablespoonfuls into a vessel," he says, " dip into it some clean rag or a clean pocket-handkerchief. I then carry the saturated rag with my hand into the cavity of the ute- * " Trans. Am. Gynaecol. Soc.,*' vol. iii. 35 546 THE PATHOLOGY OF LABOR. rus, and squeeze it; the effect of the vinegar floAving over the sides of the cavity of the uterus and the vagina is magical. The relaxed and flabby uterine muscle instantly responds. The organ assumes what I will term its gizzard-like feel, shrinking dcwn upon and compressing the operating hand, and in the vast majority of cases the haemorrhage ceases instantly. Should one application fail to secure sufficient con- traction, the rag can be withdraAvn, and a second or even a third can be made, until the uterus shall contract sufficiently to stop the flow of blood." Probably the faradaic current is a most efficient agent in secur- ing contractions of the uterus, but, unlike vinegar and hot water, a battery is rarely on hand when needed. An olive-shaped bulb elec- trode should be introduced into the uterus, and the other pole, a flat disk, pressed upon the fundus ; or both poles may be applied directly over the uterus through the abdominal walls. I have in a number of instances seen Dr. I. E. Taylor succeed in instantaneously causing the uterus to contract by slapping the lower part of the abdomen smartly with a Avetted towel. Compression of the aorta through the abdominal walls is capa- ble of rendering temporary service. The method has been objected to on theoretical grounds : first, because the compression is brought to bear equally upon the vena cava as upon the aorta; and, second, be- cause the pressure does not cut off the blood which goes to the uterus through the aortic uterine arteries. As a clinical fact, hoAvever, it is indisputable that the pressure does, temporarily at least, check the haemorrhage, a result attributed by Frankenhaeuser to the simulta- neous stimulation of the aortic uterine plexus, as that portion of the sympathetic nerve is termed which overlies the large vessels of the trunk situated in the lumbar region. The application of ice to the abdomen, or allowing a stream of cold water to fall from a height upon the hypogastrium, howeA'er efficacious they may prove as means of arresting haemorrhage, are open to the grave objection that they add to already existing shock and to the prostration produced by the loss of blood. Methods of securing Uterine Retraction.—Uterine contractions afford only a temporary safeguard against haemorrhage. It is uterine retraction that prevents recurrence. At first the hand furnishes the most available means of exercising external compression. It likeAvise possesses the advantage of being an intelligent instrument, capable of conveying to the accoucheur instant warning of any tendency to relax- ation. But, even after retraction is secured, its maintenance should not be left to chance. Before leaving his patient, the physician should provide some means of subjecting the uterus to sustained and equable pressure. The usual method consists in surrounding the anteverted organ with folded napkins or rolled stockings, and then applying a POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 547 bandage tightly to the abdomen to keep them in position. Unless skillfully executed, this method accomplishes little more than to dis- locate the uterus laterally. I have been in the habit of using a round bag of rubber covered with brown muslin, which I partially fill with cold water, and apply over the uterus. The dry cold is of value as a means of exciting contraction, while the hydrostatic pressure is evenly distributed over the fundus of the uterus, and helps to fix it in the median line. A reliable compress may be improvised in any house- hold by partially filling a sack with moistened sand or common salt. Treatment of Cerebral Anaemia.—In consequence of excessive loss of blood, the surface of the body becomes blanched, cold, and bedewed with clammy perspiration ; a feeling of muscular prostration is experi- enced, with distress in the praecordial region ; the pulse becomes small and frequent, the respiration rapid, and air-hunger is developed as the result of the deficient amount of oxygen carried by the attenuated blood-stream to the tissues and the medulla oblongata. With these general symptoms are associated special ones due to disturbances of the nerve-centers, as restless movements from side to side, yawning, vomiting, perversions of the special senses, fainting, and convulsions. Now, it is to these latter symptoms, indicative of intense cerebral anaemia, and directly imperiling the life of the patient, that treatment requires to be addressed. The pillows should be withdraAvn from the head, the foot of the bed should be raised, hot bottles should be placed to the extremities, and warm cloths to the head ; if syncope occurs, the abdominal aorta should be compressed to reserve the entire blood- mass for the upper portion of the trunk and the brain ; cerebral con- gestion should be promoted by opiates (thirty drops of laudanum by the mouth, or ten minims of Magendie's solution hypodermically in- jected), and the flagging heart should be stimulated by hypodermic injections of sulphuric ether, brandy, or whisky. The syringe should be filled with the agent chosen, and the injection should be made deep into the subcutaneous cellular tissue on the outer part of the thigh. The effect upon the circulation is almost instantly manifested. Ex- cept in cases which have passed beyond all possibility of recoA'ery, the pulse reappears at the wrist, often, however, to fade away again in a few minutes. The stimulant injections in many cases require to be repeated a number of times before the circulation becomes reestab- lished. So long, however, as there is a perceptible response to the stimulus, the case is never to be regarded as hopeless. Dr. Gaspar Griswold has employed successfully in a number of cases, Avhere the heart had apparently beat for the last time, intra- venous injections of ammonia, using for the purpose a five-per-cent. solution (the officinal solution diluted with equal parts of water), and injecting with a hypodermic syringe from fifteen drops to a half- drachm into one of the superficial veins of the forearm. 548 THE PATHOLOGY OF LABOR. In the collapse resulting from excessive haemorrhage, the restora- tion of blood to the circulation by transfusion is theoretically the rational mode of treatment. In practice, however, the difficulties of the technique, the hesitation of bystanders to furnish the required blood, combined with the somewhat unsatisfactory results of transfu- sion, are all obstacles to its employment. For a long time I carried with me Aveling's very simple and ingenious transfusion apparatus. In the feAv cases Avhere I had intended to use it, however, the tubing was never in perfect order. The fact that in each instance I suc- ceeded eventually in rallying my patient by methods less open to ob- jection has led me at present to omit it from my list of instruments. Professor Gaillard Thomas recommends the substitution of the- intra- venous injection of milk for that of blood, and reports cases illustrat- ing its successful employment. The results of his experiments he sums up in the following propositions : 1. The injection of milk into the circulation in place of blood is a perfectly feasible, safe, and legitimate procedure, which enables us to avoid most of the difficulties and dangers of the latter operation. 2. In this procedure, none but milk removed from a healthy cow within a few minutes of the injection should be employed. Decom- posed milk is poisonous, and should no more be used than decomposed blood. 3. A glass funnel, with a rubber tube attached to it, ending in a very small cannula, is better, safer, and more attainable than a more elaborate apparatus, which is apt, in spite of all precautions, to admit air to the circulation. 4. The intra-venous injection of milk is infinitely easier than the transfusion of blood. Any one at all familiar with surgical operations may practice it without fear of great difficulty or of failure. 5. The injection of milk, like that of blood, is commonly followed by a chill, and rapid and marked rise of temperature ; then all sub- sides, and great improvement shows itself in the patient's condition. 6. I would not limit lacteal injections to cases prostrated by haem- orrhage, but would employ it in disorders which greatly depreciate the blood, as Asiatic cholera, pernicious anaemia, typhoid fever, etc., and as a substitute for diseased blood in certain affections Avhich im- mediately call for the free use of the lancet, as puerperal convulsions, etc. 7. Not more than eight ounces of milk should be injected at one operation. After the heart's action has once been established, the efforts of the physician should next be directed to the filling of the emptied vessels. Even when the injections of milk or blood have been resort- ed to, the quantity of fluid introduced into the circulation is too small to restore the arterial tension. But, with the restoration of the cardiac POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 549 pulsations, the absorption from the stomach is very active and rapid. To avoid vomiting, however, it is necessary that fluids administered by the mouth should be given in small quantities and at brief inter- vals. I usually begin with either hot strong tea, without milk, or with brandy-and-water (1 : 2), at first a teaspoonful at a time, repeat- ing the quantity every minute, then giving a tablespoonful of any warm liquid every five minutes, carefully testing the capacity of the stomach to dispose of its contents, withholding everything with the first premonition of nausea, until milk, broths, tea, gruel, and the like are found to be tolerated in ordinary quantities. Fluid nourishment should be continued hourly, with ice and water in the intervals, ac- cording to the thirst experienced, until the radial pulse is restored to its normal fullness. For the successful management of these cases it is necessary that the physician assume the entire charge. It is not possible to give directions to a nurse which may not at any moment require modification. In cases of excessive loss of blood a tourniquet to each femoral ar- tery, a roller bandage, or, better still, an Esmarch bandage applied the length of the lower extremities, may be temporarily employed with a view to saving the limited amount of blood in the circulation for the important organs of the trunk and for the nerve-centers. Where the pulse is extremely rapid, the subcutaneous injection of one fiftieth of a grain of digitalin is reported to act favorably by caus- ing contractions of the arterioles and of the uterus. Opiates should be administered from time to time during convales- cence, the frequency and quantity depending upon the intensity of the headache which acute anaemia induces. The Puerperal Haemorrhages.—Haemorrhages occurring after the first day following confinement are the result either of the separation of the thrombi from the placental site or of a congested condition of the endometrium. Before the consolidation of the thrombi is completed, the mouths of single vessels may be opened by any sudden increase of pressure in the uterine vessels. A relaxed state of the uterus, obstacles to retraction, fecal accumulations, and malpositions of the uterus predispose to the occurrence of haemorrhage. Common causes of late haemorrhages are sitting up or leaving the bed at too early a period, exertions in caring for the infant, and straining at stool. In the case of a small, thin woman, who flowed profusely in the second week, I found the uterus croAvded backward and downward to the pelvic floor by the compress, which had been too tightly bandaged upon the abdomen by the indis- creet zeal of the nurse. Where portions of the ovum have been alloAved to remain behind in the uterus, they may lead to the formation of fibrinous polypi, which, as in the non-puerperal uterus, may lead to a Arascular condi- 550 TEE PATHOLOGY OF LALOR. tion of the mucous membrane, and become the cause of protracted bleeding. The treatment of late haemorrhages consists in rest in the horizon- tal position, in carefully regulated diet, in emptying both bladder and rectum, in the correction of displacements, and in the use of hot vagi- nal injections. In excessive anteversion a compress above the pubes is indicated ; in retro-displacements, lifting the uterus into position, maintaining it in place by a suitable pessary, is often at once fol- lowed by relief. If other causes can be excluded, the uterine cavity should be explored, and retained bodies, if found present, should be removed. AVhen the cervix is patulous this can be accomplished by the finger; if the cervix is closed, or if inflammation be present, the wire-curette can be used, as after abortion, without preliminary dilata- tion. In curetting the uterus the operator should be mindful of the delicacy of the newly forming mucous membrane, and should feel carefully for the offending bodies. If intra-uterine injections are fur- ther needed to arrest bleeding, the preference should be accorded to the tincture of iodine. Retained Placenta. Retained placenta is so frequent a cause of hindered uterine re- traction that a few Avords concerning the etiology and treatment of the condition form an appropriate appendix to the discussion of post- partum haemorrhage. Cases of so-called placental retention are often simply the result of injudicious management. Thus, they may be caused by pulling in such a way upon the cord as to draw the center of the placenta into the cer- vix, so that, without alloAving air to pass by the placenta to the uterine cavity, extraction is rendered impossible ; or, when Crede's method is practiced, the operator may, by pressing the fundus forward against the pubes instead of downward in the axis of the pelvis, produce an acute anteflexion, with stenosis of the lower uterine canal. True retention may be due to the large size of the placenta or to pathological adhesions, either of the placenta itself or of the chorion. An adherent placenta is of rare occurrence, and can usually be traced to a bygone endometritis. Separation normally takes place in the areolar layer. If the glandular walls which constitute the septa of the areolae consist of tough intercellular substance, instead of soft tissue abundantly supplied with cells, the separation does not take place and the placenta remains adherent. The thick bands which have to be severed in removing the placenta are in general the straight trunks of the villi, which run from the chorion to the serotina, the separation taking place not in the decidual but in the fetal layer. In placentitis the bands consist of thickened decidual tissue extending between the cotyledons. In either case the serotina is left nearly or POST-PARTUM HEMORRHAGE AND RETAINED PLACENTA. 551 quite entire ; in some instances, owing to their firm attachment, whole lobules may be left behind. Adhesions of the chorion may be due to thickening of the septa in the areolar layer; to defective involution of the cell-layer of the de- cidua, thickened portions of which in consequence remain attached to the separated chorion ; to secondary adhesions from consolidated masses of fibrine, the remains of apoplectic effusions into the decidua; and, perhaps, to excessive development of villi upon portions of the smooth chorion, from which proceed thick bands which are firmly united to the decidua (Spiegelberg). Adhesions of the chorion interfere with the separation of the placenta only when situated high up or around the placental border. The Artificial Separation of the Placenta.—Whenever compression of the uterus proves unavailing to procure the expulsion of the pla- centa, the operator should seek to aid the delivery by the resources of art. To leave the placenta within the uterus not only exposes the patient to the risks of haemorrhage, but to the even greater danger of decomposition and of septic poisoning. A digital examination will indicate the proper course to be pursued. If the placenta be found covering the os, a finger should be introduced to bring down a placen- tal border. If no adhesions exist, moderate tractions upon the cord will then suffice to deliver the placenta. Spiegelberg recommends using the vaginal finger as a pulley to cause the tractions upon the placenta to be made in a vertical direction. If tractions upon the cord are insufficient, or if the cord begins to tear, the outer hand should make counter-pressure upon the fundus, while the fingers of the vaginal hand are passed upward into the uter- ine cavity. At first a point should be selected where the placenta is already partially detached, and the fingers should be employed to roll the placenta away from the uterine wall. If the attachment of the placenta is firm, the fingers should be extended with the back of the hand to the uterus, and the separation attempted by a side-to-side movement, as in cutting the leaves of a book. Contractions are here of great service, as they both facilitate the separation and serve to ren- der distinct the border-line between the placenta and the uterus. Hildebrandt advises following the cord upward and separating the placenta with the hand covered by the membranes, as a means of avoiding the dangers of infection and of injuring the internal uterine surface. Spiegelberg says that in his experience this method has succeeded only where the placental attachment was loose and the separation easy. Bands should be divided by pressing them between the thumb-nail and the index-finger. When the placenta is situated upon the anterior wall, the patient should be placed upon the side. When the placenta is everywhere adherent, a thickened border should be chosen as the 552 THE PATHOLOGY OF LABOR. point for commencing the detachment. In a very thin, diffused pla- centa, it has been proposed by Hohl to inject the vessels through the umbilical vein. The operation of separating the placenta should never be performed hurriedly. Every pains should be taken to avoid injuring the uterine surface, and as little placental tissue as possible should be left behind. When the detachment of the placenta is completed, it should be grasped from abo\*e, in the full hand, and its expulsion should be effected by external pressure. If portions of the membranes are torn away during delivery, they should be sought for and carefully re- moved. In every case of artificial placental delivery the cavity of the uterus should subsequently be thoroughly irrigated with warm carbolized water. CHAPTER XXXII. PLACENTA PREVIA.—ACCIDENTAL HAEMORRHAGE.—INVERSION OF THE UTERUS. Situation.—Varieties.—Frequency.—Causes of haemorrhage.—Clinical features.—Prog- nosis.—Diagnosis —Treatment.—Accidental haemorrhage.—Inversion of the uterus. Situation.—Normally the placenta, as we know, is situated at the fundus and upon the side-walls of the uterus. It is said to be pravia when it occupies that portion of the uterus which is subject to disten- tion during labor, or, in other words, to the spherical surface of the lower portion of the uterus. Its clinical importance is proportioned to the extent of the placental segment which overlaps the os internum. Hence it is customary to distinguish— Varieties.—1. Placenta pravia centralis, where, after the dilata- tion of the os internum has become complete, the placenta only can be felt. 2. Placenta pravia partialis, where, with dilated os, there is recognizable a portion of the membranes, as well as a segment of the placenta. 3. Placenta pravia lateralis, or marginalis, where the placental border stretches down to but not beyond the margin of the inner cer- vical ring. Observations which tend to prove the attachment of the placenta in part to the cervical mucous membrane are unquestionably errone- ous. This fact, first stubbornly insisted upon by Professor I. E. Tay- lor, has, at least among physiologists, passed beyond the realm of dispute. Kuhn,* who investigated the subject in conjunction with * Braun, " Lehrbuch der ges. Gynaek.," p. 555. PLACENTA PREVIA. 553 Carl Braun, found that in no case was the placental portion which occupied the cervical canal adherent to the canal-walls, but that in all post-mortem examinations the remains of the placenta praevia ma- terna ended by a sharp border-line at the os internum. An exact central implantation of the placenta is extremely rare, though its occurrence is not impossible. Usually in the so-called central form not more than one sixth to one fourth of the placental surface overlaps the os internum. The smaller segment is oftener found upon the left side (37 : 56, statistics of L. Miiller).* Owing to the deficient thickness of the decidua in the vicinity of the internal os, the placental villi grow with less profusion at that point, Avhile by way of compensation in more favored localities they attain to an excessive development. The placenta thus assumes a characteristic uneven appearance. If the atrophic conditions exist over a wide extent, the surface of the placenta is, as a rule, corre- spondingly increased. Another peculiarity not devoid of practical interest is the fre- quency Avith which the placenta is found adherent to the uterine walls. Of 142 cases, L. Muller showed that in 56 adhesions existed. The insertion of the cord into the placenta is usually eccentric, often mar- ginal, and sometimes velamentous. As a consequence, prolapsed funis is a common accompaniment of the anomaly. Fortunately, placenta praevia is of rare occurrence. Muller, by adding together the statistics of various investigators, found reported 813 instances in 876,432 births, or not quite one case in a thousand. Etiology.—The causes are unknoAvn. The proportion of multi- parae to primiparae is very large (6 : l).f Placenta praevia is most fre- quent in women who have borne children with great rapidity, and in pregnancies shortly following abortions, conditions which favor relax- ation of the uterine walls, dilatation of the cavity, and defective development of the decidua. Muller advances the theory that the descent of the ovum is effected by contractions of the uterus soon after conception. Such expulsive pains naturally lead to abortion. In certain cases, however, Avhere the reflexa is absent, we have seen that the ovum may be forced downward into the cervical canal, and lingering there may give rise to "cervical pregnancy." Placenta praevia Muller believes to be due to an abortion begun at an early period, but arrested at the lower uterine segment to which the villi attach themselves, and enable the rescued ovum to continue its devel- * Ludwig Muller, " Placenta Praevia," Stuttgart, 1877. Most of my statistics arc taken from this work. They include those of Trask (" Am. Jour, of the Med. Sci.," 1856, vol. viii) and of most of the later writers, up to date of publication. f'Muller collected from different reporters 1,574 cases—227 of primiparoa and 1,347 of multipara?. Jiidell reports the multiparae at 90 per cent. King (';Am. Jour, of Obstet. " October 1880, p. 751) reports 183 cases collected in the State of Indiana, in which the proportion was 20 primiparae to 163 multiparae. 554 THE PATHOLOGY OF LABOR. opment. Ingleby relates two curious cases where the orifices of the Fallopian tubes opened near the os internum, in one of Avhich placenta praevia occurred three times, and in the other ten times. Clinical Features.—The chief clinical importance of placenta prae- via results from the mode of its detachment during labor. In normal positions, the separation of the placenta is effected by virtue of the uterine contractions after the fcetus has for the most part been ex- pelled. In placenta praevia the separation is due to the stretching to which the lower uterine zone is subjected in its conversion from a half- sphere to a cylindrical canal to permit the passage of the child. The extent of unavoidable separation in ad- vance of delivery is consequently meas- ured by the dimensions of the child's head, the largest circumference of which is estimated as equivalent to a circle with a diameter of four and a half inches. According to Duncan, the plane at which spontaneous detach- ment ceases is reached at a distance of two and a half inches by folloAving the curve of the lower segment, and of one inch and a half if measured in the di- rection of the uterine axis. AVhereas, in normal labor, the contractions of the uterus which determine placental sepa- ration close at the same time the ori- fices of the torn vessels, the stretching of the loAver segment in placenta prae- via leaves the mouths of the sinuses Fig. 221.—Diagram showing the una- gaping, from which the blood pours voidable placental separation as a ° , . x consequence of cervical dilatation, until the stream is arrested either by art or by the supervention of syncope. As the haemorrhage in such cases is the natural sequence of cervical dilatation, its occurrence during labor Avas termed by Rigby "unavoid- able " in contradistinction to haemorrhages from detachment of the placenta Avhen situated near the fundus, where the separation is attrib- utable to "accidental" causes. The haemorrhages of placenta praevia are not, hoAveA'er, limited to the parturient period. Indeed, there is no time in pregnancy when they may not occur. AVhen we consider that every jar of the body affects the lower segment with more force than the fundus, and that the thinned walls of the utero-placental A'essels are subject to increased pressure in placental presentations, it becomes evident that a very slight occasion is sufficient to produce rupture and haemorrhage. Thus placenta praevia is a common cause of the pseudo-menstruation PLACENTA PREVIA. 555 of pregnancy; it creates a predisposition to abortion, and, later in gestation, to premature labor, the haemorrhages being due probably in the first instance to accidental causes and not to labor-pains. Not every case of haemorrhage is, however, followed by labor. Indeed, in many instances thrombi form in the open vessels, the bleeding be- comes arrested, and pregnancy goes on for a time undisturbed. The tables of Muller show that in complete placenta praevia the first haemorrhage occurs Avith the greatest frequency between the twenty- eighth and thirty-sixth Aveeks, while in the incomplete form it takes place most commonly after the thirty-second week. In placenta praevia lateralis, haemorrhages are sometimes absent up to the time of labor. Cases of pregnancy, and in part of labor, without haemorrhage have been observed where the death of the foetus has been followed by atrophic changes in the placenta. The recurrence of haemorrhage is oftentimes prevented by secondary shrinkage of the placenta, due to pressure from the effused blood or to thrombosis of the vessels which supply the implicated cotyledons. The haemorrhages of placenta praevia are usually sudden, without premonitory warnings, Avithout pain, often without any apparent occa- sion, sometimes occurring at the time of urination, sometimes during sleep. The quantity of blood lost in a single haemorrhage depends upon the extent of the placental separation. The first outpouring may lead to intense anaemia, and if repeated at a short interval may cause death. It is estimated that from one to three pounds of blood may be lost in a single attack, and from four to five pounds in the course of labor (Muller). As a rule, however, the haemorrhages of pregnan- cy are at first moderate in character, increasing in violence with each repetition. A very formidable variety is the so-called "stillicid- ium," where the blood issues drop by drop for days and even weeks in succession. The most violent haemorrhages occur generally in the earlier part of the first stage of labor. As a rule, the extent of the haemorrhage is proportioned to the area of the placental segment attached to the uterine surface subject to distention. The haemor- rhage generally ceases Avhen the separation of the cotyledons is com- pleted and, after the rupture of the membranes, the pressure of the presenting part is brought to bear upon the bleeding surface. Dur- ing the height of the pains, too, the haemorrhage is for the moment arrested (Spiegelberg).* The number of abnormal presentations in placenta praevia is very large. Thus, in Miiller's statistics, in 1,148 cases there were 272 trans- verse and 107 breech presentations. The frequency of the anomalies is partly attributable to the large proportion of premature labors, and * This view was first advanced by Fountain in the " Am. Jour, of the Med. Sci." It has since been advocated by Duncan, Jiidell, Frankel, Spiegelberg, and others. Muller and Kuhn, however, dispute it, as justified neither by theory nor by observation. 556 THE PATHOLOGY OF LABOR. partly to the width and lax condition of the lower segment, and the consequent Avant of stability in the fcetus. During the first stage of labor the pains are apt to be feeble and the dilatation tardy. The causes of inertia are to be found in the thinning of the muscular structures in the lower segment from the enormous development of the utero-placental vessels; in the attach- ment of the placenta OA-er the os, Avhich mechanically hinders dilata- tion ; and in the fact that the ovum does not press directly upon the sensitive nerves of the cervix. Secondary weakness often follows the continued losses of blood and the prolongation of the first stage. When the obstacle afforded by the placenta to dilatation has been overcome, and, consecutive to rupture of the membranes, the uterus retracts, in many cases the scene speedily changes, and, in place of ineffective contractions, normal and often powerful pains develop. As a rule, quite early in labor the cervix is found soft and dilat- able, but to this rule there are numerous exceptions. Strictures and rigidity Muller computes to exist in about twelve per cent, of the cases. AVhere the loss of blood in labor is continuous the woman grows restless and complains of headache and vertigo ; the respirations be- come short, interrupted, and sighing, and the pulse small, weak, and thready. Toward the close unconsciousness develops, the brow is be- dewed with cold, clammy perspiration, and finally convulsions usher in the fatal termination. Even after labor is over the danger is not ended. Post-partum haemorrhage may result from atony of the placental surface of the uterus, or, after good contractions have been apparently secured, sud- den relaxation may folloAV, and the blood pour out in a torrent, so that the patient becomes a corpse before assistance can be rendered. Again, in childbed the imperfect contraction of the uterus at times allows the lochia to form a stagnant pool at the fundus, Avhence an ichorous discharge Aoavs constantly downward over the thinned Avails and open mouths of the vessels at the placental wound. The feeble circulation predisposes to the formation of thrombi, Avhich, when poisoned and disintegrated, are conveyed into the general circulation and gi\*e rise to the dreaded symptoms of pyaemia. Muller found in tAvo hundred and seventy-three of his cases specific information given regarding the puerperal state. "Puerperal fever" was recorded of seventy-nine patients, with fifty-four deaths. Prognosis.—The prognosis of placenta praevia is necessarily ex- tremely unfavorable. As many as one mother in four dies during or shortly after delivery. Including deaths from puerperal processes, Muller estimates the total mortality at not less than from thirty-six to forty per cent. Nearly two out of three of the children are born dead. More than one half of those born living die within the first ten days. PLACENTA PREVIA. 557 In general terms it may be stated that the prognosis is the more seri- ous, the earlier the haemorrhages begin in pregnancy, the more pro- fuse the floAV, and the shorter the intervals between the attacks. Dur- ing labor favorable conditions are a vertex presentation, good pains, rapid dilatation, and an unbroken constitution. The maternal mor- tality is twice as great in placenta praevia centralis as in placenta prae- via lateralis. In the city, there is the special danger of infection ; in the country, of delay in obtaining medical assistance. Finally, it is impossible to analyze the statistics of placenta praevia without coming to the conclusion that the result depends in a large measure upon the personal qualities of the physician. A self-possessed man, cool, resolute, with clear ideas of the anatomical conditions to be dealt with, will, if summoned in season, apparently deprive even placenta praevia of a good share of its terrors. Diagnosis.—There are no signs by which placenta praevia can be recognized in the first half of pregnancy. It may occasion abortion, which is then characterized by the absence of pain, both previous to the haemorrhage and during the period of expulsion. As a rule, the ovum is expelled entire without rupture of the membranes. In the second half of pregnancy, a haemorrhage occurring suddenly, Avithout ostensible cause and without warning, should always be regarded with suspicion. Upon digital exploration in placenta praevia the vaginal fornix is found soft and boggy, and occasionally thicker upon the one side than upon the other, where the placental presentation is incom- plete ; ballottement is obscure ; the cervix is long, wide, and soft, and contains at times vessels which pulsate distinctly ; the cervical canal permits the passage of the finger to the os internum, which at first offers resistance, but yields to gentle force. The diagnosis is rendered positive only in cases where the lower surface of the placenta is actually felt through the cervix, its rough, spongy, granular texture sufficiently distinguishing it from clots and other possible sources of deception. Treatment.—The history of placenta praevia brings into prominence the central point to be kept steadily in view in practice, that there is no safety for the mother so long as pregnancy continues. In a very large proportion of cases, accidental haemorrhage occurring in the first half of pregnancy leads to abortion, the management of which does not differ from that of abortions which take place in normal attach- ments of the placenta. Of the one hundred and twenty-eight deaths from placenta praevia collected by Muller, not one occurred previous to the seventh month. In the latter half of pregnancy, haemorrhage likewise leads to premature expulsion of the ovum with such fre- quency that it is reckoned that only one third of all cases reach the end of gestation. Most authorities advise, in the presence of the haemorrhages of ad- 558 THE PATHOLOGY OF LABOR. vanced pregnancy, that the physician maintain an attitude of expect- ancy, postponing active interference, except in cases Avhere the loss of blood assumes alarming proportions, until the spontaneous advent of labor. This policy is recommended partly in the interest of the child, and partly because of the tendency in premature labor to rigid- ity of the cervix, a complication which always in placenta praevia en- hances the risks of delivery. The wisdom of delay is, however, open to serious question. The fatality of placenta praevia is due not so much to the impotence of obstetrical art as to the losses of blood which occur suddenly in the absence of professional assistance. The first haemorrhage, which serves as a warning as to the patient's condi- tion, is fortunately in most instances slight. With each recurrence, however, the flow becomes more profuse. If the haemorrhages begin before the child is Aiable, the chances of saving its life are in any event too small to offset for a moment the Avelfare of the mother. Haemorrhages occurring as early as the seventh month are, as a rule, the result of complete placental presentation. To trifle with such cases is the best way to maintain the present mournful statistics. After the thirty-second Aveek it is safe to say that the child's life is less imperiled by the induction of premature labor than by exposing it to the dangers of continued gestation. On theoretical grounds, therefore, the induction of premature labor is to be regarded as obligatory so soon as the diagnosis of placenta praevia is established, or at least with the occurrence of the first haemor- rhage. The practical results of this measure in the hands of its advo- cates* plead still more effectively in its behalf. Thus, Dr. Gaillard Thomas t reports eleven cases, with but two deaths, one resulting from post-partum haemorrhage coming on several hours after delivery, and one from puerperal fever. Hecker J lost three cases in forty, Hoff- mann two cases in thirty, and Spiegelberg four cases in seventy-four early deliveries.* In this connection I can not help quoting the fol- loAving impressive remarks of Dr. Barnes : "If the pregnancy have advanced beyond the seventh month it will, as a general rule, I think, be wise to proceed to delivery, for the next haemorrhage may be fatal; Ave can not tell the time or extent of its occurrence, and, when it occurs, all, perhaps, that we shall have the opportunity of doing will be to regret that we did not act when we had the chance." In the management of placenta praevia it is very desirable that the practitioner should have a perfectly clear idea of the nature of the task * Premature labor in profuse or continuous haemorrhage has received the indorse- ment in this country of Thomas, Taylor, Parvin, Pallen, and Taber Johnson. f " Trans, of the N. Y. Obstet. Soc," vol. i., p. 262. X Statistics taken from L. Muller's monograph. * These statistics do not, however, like those quoted from Thomas, include deaths in childbed. Thus, Spiegelberg's complete death-rate reached sixteen per cent. PLACENTA PREVIA. 559 he has to perform. The birth of the child can not take place without preliminary expansion of the cervix. The cervix can not expand with- out detachment of the placenta. The principal objective point of treatment, therefore, is the haemorrhage which occurs during the stage of dilatation. Plans for restricting the flow within narrow limits have been proposed Avithout number by masters of the obstetric art. The best plans are those which at the same time contribute to shorten labor. The choice must be determined by conditions Avhich neces- sarily vary in different cases. The physician has at the outset to par- ticularly inform himself as to whether labor has begun or remains to be inaugurated, as to whether the placenta praevia is complete or in- complete, as to Avhether the presentation is normal and the pains are good, as to whether the membranes have ruptured or are intact, and as to the length and dilatability of the cervix. If the cervix is long, narroAv, and rigid, and the membranes are entire, the vaginal tampon should be resorted to as a temporary expe- dient. The tampon strengthens the pains, and, by the compression it exerts, causes coagulation of the blood which escapes from the uter- ine vessels. Professor I. E. Taylor advises packing the vagina with a surgical bandage, leaving one end outside the vulva, by means of which it can be withdraAvn Avithout difficulty. Braun, after many years' ex- perience at Vienna with the colpeurynter, maintains the superiority of hydrostatic dilatation. I use dampened cotton, crowding it into the upper portion of the vagina Avith the aid of a Sims speculum. The choice does not appear to be material. Having once introduced the tampon, the physician should not leave his patient until the labor is ended. After at most four hours the tampon should be removed, and the cervix should be examined. So soon as the os will permit its introduction, either the dilator of Barnes or of Tarnier should be employed in place of the vaginal plug. A Barnes rubber bag, expanded sufficiently to render the border of the os externum tense, fulfills admirably the principal indications. It acts as an efficient tampon, it strengthens the pains, and it dilates the cervical canal. As the latter expands, a larger-sized dilator should be introduced. It is important, in order to prevent haemorrhage, to maintain the tension of the external orifice. On account of the soft- ening Avhich exists in the lower uterine segment as a result of placenta praevia, in a large proportion of cases the cervix can be stretched Avith the utmost facility. If no urgent symptoms call for immediate inter- ference, it is desirable to render the dilatation complete. It is not, hoAvever, ahvays necessary. Indeed, Barnes, Taylor, Spiegelberg, and Braun advise to proceed boldly with the delivery so soon as the os externum has expanded to the size of a half-dollar, as by that time the expansion of the os internum is very nearly completed, and as the soft cervical canal does not offer sufficient resistance to materially inter- 560 THE PATHOLOGY OF LABOR. fere with the extraction of the child. The distinguished success of the authorities mentioned in the field of practice under consideration lends great weight to their recommendations. It is, hoAvever, more than probable that exceptional training and experience count in their case for quite as much as the plans of procedure they individually favor. At any rate, in reviewing the statistics of Trask and Muller it becomes evident that rigidity of the cervix is not a rare event in pla- centa praevia, and that the accouchement force, performed with a rigid cervical canal, is perhaps, next to doing nothing, the most responsible cause of the mournful results they have placed on record. After the cervix has been duly prepared, the membranes should be ruptured, and a part of the amniotic fluid should be permitted to escape. Then, if the placenta possesses a lateral or a marginal attach- ment, if the pelvis is of normal size and the pains strong and regu- lar, and if the head present, or at least can be brought down and fixed at the pelvic brim by external manipulations, the further prog- ress of the case may be left to Nature. Haemorrhage will then be pre- vented by the pressure of the foetus in its descent through the utero- vaginal canal. At first the method of expression advocated by Kris- teller is capable of rendering important service by promoting the speedy engagement of the child's head. Ergot, too, cautiously admin- istered, is useful in strengthening the uterine contractions. Even if tonic contraction follow from its employment—an unlikely event in placenta praevia—the effect would be to close the sinuses and to fur- nish afresh barrier against haemorrhage. The forceps may be applied under the same circumstances, and with the same restrictions, as in other conditions. Where, however, the head is movable, the patient anaemic, and haemorrhage persistent, version, as furnishing the more rapid mode of delivery, would receive the preference. In cases of complete attachment of the placenta there should be no trifling with half-Avay measures. If the cervix is long and rigid, the vaginal tampon should be employed as a preliminary measure. AArhen the cervical tissues have become softened, and dilatation has begun, the tampon should be removed. At this stage Barnes recom- mends separating at once that portion of the placenta Avhich is attached above the inner orifice of the cervix. By so doing, "we remove an obstacle to the dilatation of the cervix, for the adherent placenta acts as an impediment." The operation is performed as folloAvs : " Pass one or two fingers, as far as they will go, through the os uteri, the hand being passed into the vagina if necessary; feeling the placenta, insinu- ate the finger between it and the uterine wall; sweep the finger around in a circle, so as to separate the placenta as far as the finger can reach. . . . Commonly some amount of retraction of the cervix takes place after this operation, and often the haemorrhage ceases." * Next * Barnes, " Obstetrical Operations," p. 503. The artificial separation of the placenta PLACENTA PREVIA. 561 put in a Barnes dilator and rapidly expand the cervix. Meantime try and bring the breech down into the lower uterine segment by external palpation. Both Taylor and Braun have found external ver- sion easy, on account of the inert conditions of the uterine walls. When the cervix has been sufficiently stretched to admit of delivery, two fingers should be introduced, the placenta should be separated, the membranes ruptured, and an extremity should be seized without passing the entire hand into the uterus. Extraction should then fol- low, the pressure of the fcetus preventing any considerable amount of haemorrhage. Usually the right hand is chosen to seek the feet, as the placenta more frequently overlaps the left side. Many times, however, it will be necessary to change the direction of the fingers before the edge of the placenta is reached. If external version can not be effected, the operator should push the hand forward into the uterus to find an ex- tremity. The arm acts during the search as a temporary tampon. Haemorrhage, which follows the withdrawal of the arm, will be arrest- ed by the descent of the breech. The accidental rupture of the membranes before the cervix is pre- pared for artificial delivery is hardly likely to occur in cases of pla- centa praevia completa. In cases of marginal implantation, dilatation with water-bags should be employed in such a way as to compress the open sinuses from which bleeding takes place. After the birth of the child, the danger of post-partum haemor- rhage must be kept in mind. Every preparation should be made in anticipation of its occurrence. If bleeding persists after the fundus is felt to be firmly contracted, a speculum should be introduced, and the open sinuses of the lower segment should be swabbed with cotton soaked in some styptic form of iron, as recommended by Engelmann {vide "Post-partum Haemorrhage"). Ergot should be given for sev- eral days, as the danger of late haemorrhages is specially great follow- ing placenta praevia. The utmost cleanliness and the use of disinfectant vaginal douches must be insisted on during the childbed period, as the exposure of the placental wound to the lochia, which constantly flow over it, renders the patient especially liable to septic infection. Haemorrhage from Normally Implanted Placenta.—The placenta, eAren when implanted over the upper polar circle, the safe placental seat of Dr. Barnes, may become detached to a greater or less extent, during pregnancy or labor, and may then furnish a flow of blood that either remains internal and concealed or may find its way between the decidua vera and reflexa and thus escape into the vagina. is unquestionably of service where it can be accomplished without difficulty. Much time should not however, be lost in fruitless efforts, nor is it desirable to persist if the sepa- ration can not be accomplished smoothly. 36 562 THE PATHOLOGY OF LABOR. The haemorrhages from this variety of placental separation are termed "accidental," in contradistinction to the "unavoidable" form, which is the accompaniment of placenta praevia. The circumstances under which concealed haemorrhage takes place are given by Goodell* as follows : {a) When the placenta is centrally detached, and the blood accumulates in the cul-de-sac formed by the firm adhesion of its margins to the uterine wall, {b) When the pla- centa is so detached that the blood escapes into the uterine cavity behind the membranes near the fundus, (c) When membranes are ruptured near the detached placenta and the effused blood mingles with the liquor amnii. {d) When the presenting part of the foetus so accurately plugs up the maternal outlet that no existing haemor- rhage can escape externally. The causes of internal haemorrhage, Avhen such can be determined, are for the most part similar to those considered in connection with abortion. Thus, the circumstances leading to placental detachment Goodell found to be irregular uterine contractions, external violence, and undue exertion ; in seven the causes were purely emotional, and ten took place during sleep. It occurs more frequently in multiparae and in the latter months of pregnancy. The symptoms are an alarming state of collapse, pain often exces- sive, absence or extreme feebleness of the pains of labor, marked dis- tention of the uterus, sometimes a lateral bulging of the uterine walls, a show of blood, a serous discharge, and blood in the liquor amnii. The diagnosis in the concealed form may be extremely embarrass- ing. The pain is often that of flatulent colic. The accident likewise presents many features which resemble those of ruptured uterus, but rupture, by contrast, rarely occurs until after the escape of the waters, the presenting part then receding from the os, and the uterus dimin- ishing in size. The prognosis is very unfavorable. Goodell reports : " Out of one hundred and six tabulated cases, fifty-four mothers perished ; and out of one hundred and seven children six alone are known to have been saved." I have had a case since his paper, where, after labor, I re- moved at least a basinful of firm clots from the uterine cavity, and yet both mother and child survived. In cases of external haemorrhage the diagnosis is easy and the prognosis more favorable, the latter probably because the walls are less flaccid than in the concealed form. The treatment consists in the subcutaneous injections of ergot, in dilatation of the os with Barnes dilators, in rupture of the membranes, and in version. * GoonELL, "On Concealed Accidental Haemorrhage of the Gravid Uterus" ("Am. Jour, of Obstet.," August, 1869, p. 281). This paper serves as a mine from which most subsequent writers have drawn their data. PLACENTA PREVIA. 563 In my own case, to which I have referred, the Barnes dilator acted capitally, not only enabling me to expand the cervix, but exciting the uterus to contract vigorously. The serious symptoms set in after the membranes were ruptured, and compelled me to deliver with forceps. In another case I should certainly first dilate, and, after rupture of the membranes, should choose version and speedy extraction, and should avail myself of a skilled assistant, whose duty it should be to compress the uterine walls externally during the act of delivery. Inversio Uteri.—Inversion of the uterus is a rare occurrence, Braun states that, of one hundred and fifty thousand births in the clinics respectively under the charge of Spaeth and himself, not a sin- gle complete inversion has come to their notice. There was one case in one hundred and ninety thousand confinements at the Rotunda Hospital in Dublin. The production of inversion is favored by a large, relaxed uterus, the result of over-distention, of rapid delivery, or of haemorrhage. The immediate cause may be either pressure exerted from above or traction from below. The first may proceed from straining efforts, especially in a sitting or kneeling position, or from attempts at pla- cental expulsion before uterine contractions have been secured; the second may proceed from a short or coiled cord during expulsion, from tractions upon the cord after the child is born, or simply from the weight of the placenta. Hennig * concludes that the attachment of the placenta to the fundus, instead of a more lateral implantation, is an active cause of the accident. Inversion may be partial or complete. In the former the fundus presents a saucer- or cup-like depression ; in the latter the entire fundus descends into the vagina ; in extreme instances the cervix may be inverted to the vaginal attachment. Dr. I. E. Taylor maintains a mechanism for a certain number of cases, which consists in a rolling out of the cervix, Avith gradual implication of the body and fundus. The symptoms of inversion are shock and haemorrhage. The shock is evidenced by the small pulse, cold extremities, vomiting, and sunken features, and is due, in part at least, to the sudden diminution of the intra-abdominal pressure and consequent plethora of the abdominal veins ; the haemorrhage results from imperfect contraction, and is therefore proportioned to the extent of the uterine paresis. Spontaneous reduction of incomplete inversion is not uncommon. Cases of spontaneous reduction of the complete form have likewise been observed, referable, according to Spiegelberg,f to retraction of the ligaments acting upon the uterus Avhile in a relaxed condition. The diagnosis is not difficult. The inverted uterus can only be * Hennig, " Ueber die Ursachen der spontancn Inversio Uteri," " Arch, f. Gynaek.," Bd. vii, p. 491. f SriEGELBKRG, " Lehrbuch," etc., p. 597. 564 THE PATHOLOGY OF LABOR. mistaken for a fibrous polypus, but by careful external and bimanual palpation the demonstration of the absence of the uterine tumor above the symphysis would guard against this error. The prognosis depends .upon the promptitude of the operator in restoring the fundus to its normal position. Still, according to Crosse's* statistics, one third of the patients died either at once or within a month of the occurrence of the accident. Treatment consists in pressing the fundus upward with the fingers or with the closed fist. To avoid tearing the uterus from its vaginal attachments, care should be taken to employ counter-pressure with the disengaged hand upon the upper border of the funnel-shaped de- pression. If the placenta is detached to any great extent, its separa- tion should be completed before replacement; if adherent, no time should be lost, but placenta and fundus should be pushed back together. If the cervix is contracted about the inverted portion, an anaesthetic should be given, and taxis should be employed. I can speak from ex- perience in favor of Noeggerath's method, which consists in indenting the uterus in the neighborhood of a Fallopian tube, in place of acting directly upon the fundus. If the reinversion proves successful, the hand should be allowed to remain within the uterus, and external pressure should be employed until contraction is secured. The re- maining treatment does not differ from that for uterine atony, already considered in connection with post-partum haemorrhage. CHAPTER XXXIII. RUPTURES OF THE GENITAL CANAL. Rupture of the uterus.—Etiology.—Pathological anatomy.—Symptoms and diagnosis.— Treatment.—Prophylaxis.—Treatment after rupture.—Rupture limited to the peri- toneal covering of the uterus.—Perforation from pressure.—Lacerations of the vaginal portion.—Laceration of the vagina.—Laceration of the vulva.—Thrombus of the vulva and vagina.—Rupture of the pelvic articulations. The genital canal may be ruptured in any portion of its course. Thus, lacerations may take place through the perinaeum and posterior vaginal wall, in the vestibulum, in the fornix of the vagina, in the cervix, in the uterus, and in the pelvic articulations. Rupture of the Uterus.—Ruptures of the uterus, for the most part at least, start from the lower segment and thence extend upward toward the body and fundus, or downward toward the vagina. They are termed complete when the rent extends through to the abdominal * Crosse, " An Essay, Literary and Practical, on Inversio Uteri," " Trans, of the Provincial Med. and Surg. Assoc, 1847," p. 344. (Spiegelberg.) RUPTURES OF THE GENITAL CANAL. 565 cavity, and incomplete when confined to either the muscular layers or to the peritonaeum. Bandl reported 19 cases in 40,614 labors (1 :2,137), occurring in nine years in the Lying-in Hospital at Vienna. Jolly, in Paris, found 230 cases in 782,741 labors (1 :3,403), but he excluded from his list lacerations of the cervix. Harris, whose authority as a statistician is of the highest, estimates in the United States one case of ruptured uterus to four thousand births. I found 47 deaths from this cause recorded in NeAV York between 1867 and 1875 inclusive, or about one death in six thousand labors. But it is hardly probable that these figures represent anything like the actual mortality; for, whereas in 1875 eleATen deaths were returned, there were but four recorded in 1867, and none in the years 1871 and 1872. It is not likely, moreover, that the 47 cases include any other than spontaneous ruptures, as naturally very few physicians are honest enough to record, as such, ruptures due to violent obstetric manoeuvres. Hugenberger estimated the mortality from ruptured uterus at 95 per cent., C. Braun* at 89 per cent. Their statistics were made up from hospital records. Jolly reported in civil practice 100 saved in 580 cases, but this Harris f believes to be too favorable a showing, as the proportionate loss is much less in published than in unpub- lished cases. The treatment of this condition is, therefore, compara- tively ineffective ; a careful study of the circumstances which favor its production is, however, capable of at least furnishing the ground- work of a rational prophylaxis. Etiology.—Rupture of the uterus may take place spontaneously as the result of defective resistance offered by the uterine walls to the pressure of the ovum, or it may owe its origin to some external me- chanical force. Rupture of the fundus is a very rare exception. It is said to take place under special abnormal conditions, as in the one-horned uterus, in imbedded myomata, when cicatrices exist as the result of previous Caesarean section, and in retrograde changes of the uterine walls. It is the great merit of Bandl \ to have shown that nearly all rupt- ures begin in the lower segment, and are preceded by an abnormal thinning and distention of that portion of the uterus situated between the ring Avhich bears his name and the os externum. In normal labor it will be remembered that during a pain the fundus and body thicken, while the lower segment is stretched by the ovum. So long as no ob- stacle exists which hinders the progression of the ovum or the foetus, this process ends in the conversion of the uterus and vagina into one * Braun, " Lehrbuch der gesammt. Gynaek.," p. 699. f Harris, " If a Woman has ruptured her Uterus, what shall be done in order to save her Life ? " "Am. Jour, of Obstet.," October, 1880. X Bandl, " Ueber Ruptur der Gebarmutter," Wien, 1875. 566 THE PATHOLOGY OF LABOR. continuous canal. In such cases the ring of Bandl is found in the neighborhood of the pelvic brim. If, however, the descent of the foetus is prevented by any cause, the resistance of the ligaments which hold the uterus in position is overcome by the retraction of the fundus and body, and as a conse- quence the ring of Bandl is withdrawn upward, the loAver segment is thinned, while in extreme cases the thickened fundus simply covers the pelvic extremity of the child like an inverted bowl. Under these circumstances it is possible at times to de- tect by palpation the ring of Bandl a hand's-breadth above the pubes, or even in the neighborhood of the umbili- cus. The stretching of the tissues is most pronounced in the upper portion of the lower segment, diminishing below until the vaginal por- tion is reached, which, of course, is not subjected to tension. In another place we have noticed that it is an unde- cided question whether the tensile structures beneath the Fig. 222.—"Diagram showing dangerous thinning ot ring of Bandl belong prop- the lower segment, owing to the non-descent i i. xi - whpthpr of the head in contracted pelvis. (Bandl.) ei lJ l0 xne "^rus, Or wne ilier they are deri\red from the cervix, which has been partially opened by the growth of the ovum. ■Spiegelberg terms this portion the " obstetrical cervix," an expression which happily defines its function without attempting to account for its origin. Now, when, as the result of the birth of any considerable portion of the child into the obstetrical cervix, the tissues of the latter are stretched so as to form little more than a membranous covering, the conditions which threaten rupture are established. Thus, contractility is lost; with each recurring pain, the child, driven still farther from the uterine cavity, increases the pressure upon the already enormously distended cervix ; gradually the thinned tissues separate ; the present- ing part of the child is forced into the opening ; at the height of a pain complete perforation of the cervical substance takes place ; the peritonaeum is lifted up from the underlying tissue, and finally, in the majority of cases, is torn through, permitting the partial or complete RUPTURES OF THE GENITAL CANAL. 567 passage of the child into the peritoneal cavity. The emptied uterus then contracts, and the expulsive pains cease. The conditions which, according to Bandl, especially predispose to dangerous cervical tension are pelvic contraction, shoulder presentations, and hydrocephalus. Rupture is favored AvheneA'er the tension, as in lateral obliquity and anteflexion of the uterus, and in transATerse presentations, falls more upon one side of the lower segment than upon the other. There are very great individual differences in the distensibility of the cervical tissues. In women who have borne many children, rupt- Fig. 223.—Case of ruptured uterus (anterior surface), a, body of uterus; b, ring of Bandl; c, thrombus, shining through the peritonaeum. ure may occur before any great degree of stretching has been reached. In the case of which the post-mortem appearances are given in Fig. 223, spontaneous rupture occurred in the tenth pregnancy. Labor 568 THE PATHOLOGY OF LABOR. commenced at noon, and the membranes, which had begun to protrude through the vulva, broke near midnight. The pains then became slow and feeble. At about three o'clock in the morning sudden collapse occurred. On my arrival, thirty minutes later, I found the pulse scarcely perceptible, the breathing hurried, and the extremities cold. As the head was well down in the pelvis I applied forceps, and ex- tracted without effort a dead child weighing ten and a half pounds. Previous to the collapse the patient had felt comfortable. At the moment of its occurrence a distinct snapping sound was heard by the hospital physician, Dr. J. D. Griffith, who sat several yards distant from the bedside. The patient stated that she felt a sensation as though a warm fluid was pouring into the abdominal cavity. As the pelvis was ample and the presentation normal, and as there was no irregularity of the labor-pains, the rupture could only be accounted for by assuming a vulnerability of the uterine tissues, and probably a clamping of the anterior lip between the head and the pelvic wall. On the other hand, so great is the distensibility of the tissues in certain cases that the foetus may pass entire from the uterus into the cavity of the obstetrical cervix without laceration ensuing. Bandl found that of 546 cases of rupture but sixty-four were in pri- miparae. Their preponderance in multiparae is for the most part the result of the laxity of the round and lateral ligaments of the uterus, which offer accordingly but slight resistance to the recession of the ring of Bandl; of the stretched condition of the abdominal parietes, which permits obliquities and anteflexion to take place ; and of the separation of the recti muscles, which interferes with the use of the abdominal compress. Of course, the loss of vitality over limited areas, resulting from the compression to which the uterine walls are frequently subjected in deformed pelves, enhances the disposition to rupture. It is likewise obvious that the existence of extreme cervical distention should not be overlooked in cases where operations are rendered necessary. The old prejudice against all operations within the uterine cavity while the cervix is undilated is based in great measure upon the real danger of laceration which proceeds from the association in many cases of the foregoing condition with difficult labor. Pathological Anatomy.—Rupture may occur in any point of the obstetrical cervix. More commonly it takes place upon the side. Owing to the right lateral obliquity of the uterus, and the greater frequency in shoulder presentations of head-left positions, the left side is oftener affected than the right. The laceration may follow any direction. Longitudinal tears occur usually in shoulder presenta- tions, or where the head is of disproportionate size ; the circular rents are for the most part limited to generally contracted pelves. The combination of a transverse with a longitudinal tear, the two meeting RUPTURES OF THE GENITAL CANAL. 569 at a right angle, is not uncommon. When the uterine walls possess unusual distensibility, a laceration may take place in the peritonaeum while the muscular structures remain intact. Again, in some cases, owing to an excessive elasticity of the peritonaeum, the latter may not give way even when the child has partially escaped from the uterine cavity. These incomplete ruptures are only possible upon the sides of the uterus, at the site of the folds of the broad ligament. The peri- toneal wound is usually more extensive than the uterine. Some separation of the peritonaeum from the underlying structures is usually found in the neighborhood of the rupture. Its extent is dependent upon the degree of tension to which the membrane was subjected before laceration took place. At the body of the uterus the close connection between the peritonaeum and the external muscular layer renders a separation at that point an impossibility. In the case represented by Fig. 223 the peritonaeum was, on the other hand, dissected away anteriorly by effused blood as far as the umbilicus. Haematomata are the rule in incomplete ruptures; in complete ones they are also found in cases where the peritonaeum has been late in giving way—i. e., after a cavity of considerable size has been formed by its detachment. The borders of the laceration are ragged. The body of the uterus rises high up in the abdominal cavity, and is inclined to the side opposite to that at which the rupture has taken place. Symptoms and Diagnosis.—The occurrence of rupture may some- times be foreseen and guarded against by the early recognition of exces- sive cervical distention. The development of the latter is possible in any case of obstructed labor. Unless the abdominal walls are very thick, the boundary between the body of the uterus and the thinned lower segment, in the form of a transverse or an oblique furrow, may be made out by palpation through the abdominal walls. Upon the sides the round ligaments, eA'en between the pains, have the feel of tense cords. Usually the stretching of the cervix is associated with violent pain, with increased rapidity of pulse, and an anxious expres- sion of countenance. If rupture takes place, and a portion of the child is extruded, the uterus inclines to the opposite side, and often vomiting sets in. When the rupture takes place gradually, violent manifestations are excep- tional. The pains then continue, as a rule, and force the foetus into the abdominal cavity. In cases of sudden rupture the pains cease instantly, and symptoms of collapse make their appearance. Vomiting, prostration, the cool skin, the rapid pulse, the drawn features, all point to internal haemor- rhage and shock. Blood flows from the vagina, and the presenting part recedes from the pelvic brim. Certainty in diagnosis is reached when the uterus upon palpation 570 THE PATHOLOGY OF LABOR. is found to be empty, and the outlines of the child can be made out through the abdominal coverings. If rupture takes place after the presenting part has become fixed in the pelvis, internal exploration is often out of the question previous to the birth of the child. Usu- ally, however, the existence of the rent is easily made out by the examining hand. The passage of the child through the opening into the abdominal cavity is usual, but to this rule there are exceptions. I haA'e seen three cases, two complete and one incomplete, where the child remained within the uterus in spite of the existence of extensive laceration. The symptoms of incomplete rupture are, at the time of its occur- rence, of less severity than the foregoing. The pain and collapse, the cessation of uterine contractions, and the recession of the presenting part are usually absent. Often the rupture may haA'e existed for some time without appreciable phenomena pointing to its existence. The frequent pulse is the most constant sign. As incomplete ruptures have almost always a lateral situation, large vessels are apt to be in- jured, and the internal haemorrhage to be profuse. In very rare cases sub-peritoneal emphysema, due to the entrance of air or gases arising from putrefaction, may be recoguized by the hand or by the ear on the anterior surface or upon the sides of the uterus, and extending sometimes into the iliac regions. . Treatment—Prophylaxis.—In view of the serious prognosis in cases of .uterine rupture, the question of prophylaxis is one of peculiar interest and importance. The outcome of Bandl's demonstration regarding the etiology of the accident is to place in a clear light the responsibility of the physician for its occurrence. If it can not always be foreseen and prevented, there is no excuse for the accident when the development of the recognizable conditions which lead to it is overlooked, or where palpable warnings are neglected. In multiparae with contracted pelves, where, as a consequence of previous pregnancies, the ligaments are lax and the lower segment is soft and distensible, it is desirable, so soon as the child is viable, to induce premature labor, and thus to diminish the disproportion be- tween the head and the pelvis. If the conditions described by Bandl begin to develop during labor, lateral obliquities should be corrected, either by placing the patient upon the side to which the presenting part is turned, or by fixing the uterus with compresses and a bandage in the median line. If the recession of the body of ihe uterus continues, and the head is movable, version should be performed, provided always that it can be accomplished without violence. In the introduction of the hand every pains should be taken to correctly appreciate the additional strain to which the cervical tissues are subjected. When an extremity has been seized, and tractions are made, the contraction ring which RUPTURES OF THE GENITAL CANAL. 571 separates the body from the lower segment interferes alike with the descent of the breech and the ascent of the head into the fundus. If rude force is employed, the increased pressure that temporarily is ex- erted upon the side of the cervix which is bulged by the presenting part can easily give rise to rupture. To avoid any unnecessary strain during version, counter-pressure should be made over the fundus of the uterus by a trained assistant, while the operator controls the di- rection of the head by means of his free hand laid upon the abdominal wall. If the head is fixed in the pelvis, the forceps is usually available. If, however, the head is movable and version contraindicated, the for- ceps is not likely to help the child, and is nearly certain to injure the mother. In a f bav cases it is pos- sible to press the head into the pelvis by force exerted with the two hands from above the pubes. If craniotomy becomes neces- sary, Bandl advises seizing the head in the forceps before using the perforator, as even moderate pressure upward in the tense state of the cervix may lead to lacera- tion. In neglected shoulder presen- tations, pains should be taken to ascertain whether the child is liv- ing before performing version. This can at times be accomplished by passing the hand upward near the shoulder and feeling for pul- sations of the cord. In all ex- treme cases, the continued retrac- tion of the uterus, by limiting the placental area, is apt to produce fetal asphyxia. If the child is living, the conditions are usually such that version can still be performed, provided care be taken at the same time to press the head from without toward the uterine axis. Exces- sive distention of the cervix develops much more slowly in primiparae than in women who have had previous confinements. If the child is dead, or where version is impracticable, decapitation should be em- ployed to release the patient from further danger. Treatment after the Occurrence of Rupture.—If rupture is suspected to have taken place, the child should be deliA'ered without delay. The means of delivery should be selected with the view to enlarge the opening as little as possible. In vertex presentations, if the diagnosis Fig. 224.—Retraction in a case of shoulder presentation. (Bandl.) 572 THE PATHOLOGY OF LABOR. is clear, it is advisable to perforate and extract with the cranio- clast, as the child is rarely born alive where rupture has taken place. If the head has passed through the rent, if the os is dilated, and if the feet are felt near the pelvic brim, the withdraAval of the child by version is usually effected without difficulty. If, however, the cervix is rigid, or if so large a portion of the fcetus has passed into the peri- toneal cavity that its withdrawal is liable to increase the size of the laceration, it is doubtless better to incise the abdomen at the linea alba, and deliver through the artificial opening. Indeed, it is a ques- tion whether it is not wise to perform gastrotomy in all cases of com- plete rupture, even where delivery by the natural passages has been accomplished, provided the rent does not close with the contraction of the emptied uterus. It may be fairly stated that an extensive internal haemorrhage is necessarily followed by the death of the patient. As, however, complete rupture is almost inevitably followed by the intra- peritoneal effusion of blood, the patient's condition is thereby rendered extremely desperate. Gastrotomy in such cases enables the operator to cleanse the abdominal cavity, and, if necessary, to introduce sutures as a means of preventing further bleeding from the uterine wound. The results of gastrotomies performed for the removal of the child after its escape into the abdomen are extremely encouraging—Trask's statistics showing 76 per cent, of recoveries, those of Jolly 69 per cent., and the United States statistics, collected with indefatigable zeal by Harris, 53j^ per cent. In the autopsies I have witnessed upon women who have died from rupture after delivery by the nat- ural passages, it has always seemed to me that a timely gastrotomy, performed before peritonitis had set in, would have afforded a good chance of saving the patient's life. In cases where the rupture is incomplete, or where the uncertainty as to the extent of the lesion leads the physician to shrink from ab- dominal section, clots in the vicinity of the opening should be removed with the hand, firm contractions should be excited, and the uterus should be fixed in position by means of a bandage and pads of cotton, and dry cold, to restrain haemorrhage and prevent peritonitis, should be kept continuously applied to the abdomen. At the same time the usual remedies against shock and collapse should be administered, according to the necessities of the patient. As the uterine opening has a tendency to speedily close, and as death, when not due to shock or loss of blood, is most frequently the result of the septic decomposition of retained fluids, a priori drainage ought to prove an essential aid to treatment. Recent successes through its instrumentality have been reported by Frommel,* Mos- * Frommel, " Zur Aetiologie und Therapie der Uterusruptur," " Ztschr. f. Geburtsh. und Gynaek.," Bd. v, Heft 2. RUPTURES OF THE GENITAL CANAL. 573 bach, Graefe, and Felsenreich.* The plan recommended by the latter, based upon the experience of Gustav Braun's clinic, consists in tak- ing a large-sized piece of drainage tubing, and bending it in the mid- dle so as to leave the extremities of equal length. A large opening should then be made at the arch, which is to be introduced through the point of rupture, and the descending branches of the tube should be fastened together to prevent the formation of a bridge of tissue be- tween them during the process of healing. The upper end of the drainage apparatus should be passed from a half-inch to an inch be- yond the torn borders of the uterine wound, and the loAver ends stitched with silk to the posterior commissure. Over the vuhTa and the apparatus there should be placed antiseptic cotton, Avhich should be changed several times daily. After the first forty-eight hours, by which time it may be assumed that protective adhesions will have formed in the neighborhood, a regular irrigation of the wound with a two-per-cent. solution of carbolic acid should be carried out, with a view to prevent a septic poisoning from the decomposition of the pus and the lochia. Rupture limited to the Peritoneal Covering of the Uterus.—This very rare form requires but brief mention. In all, but ten cases have been reported. It occurs under apparently normal conditions, with- out premonitory symptoms. It is supposed to be due to deficient elasticity of the peritonaeum, and may take place during either preg- nancy or labor. Death in the known cases resulted from internal haemorrhage, from peritonitis, or from shock (Spiegelberg). Perforation from Pressure.—In studying the influence of the con- tracted pelvis, we have already had occasion to consider the origin of circumscribed losses of substance in the uterus due to the pressure of the pelvic walls. In the present connection it is only necessary to state that they are more frequently followed by recovery than the ruptures, in favorable cases exudation closing the opening, and the necrosed tissue passing away through the vagina. Lacerations of the Vaginal Portion of the Cervix.—Lacerations at the os externum of moderate extent are the nearly constant concomi- tant of physiological labor. The "show" of monthly nurses consists of mucus tinged with blood furnished from the slight tears which are produced during the passage of the head through the cervical orifice. At times, however, these lacerations may assume a pathological im- portance, reaching upward to the vaginal junction, or even, in extreme cases, stretching outward through the upper portion of the vagina. At the time of their occurrence, they give rise to no special symptoms. After the birth of the child, they may become the source of post-par- tum haemorrhage, or they may interfere with involution, and during * Felsenreich, " Beitrag zur Therapie der Uterusruptur," " Arch. f. Gynaek.," Bd. xvii, Heft 3. 574 THE PATHOLOGY OF LABOR. childbed expose the patient to the risks of infection. In after-life they furnish the foundation of a multitude of uterine disorders (Em- met). They occur most frequently in primiparae, especially elderly ones; in oedema of the cervix ; in cases where the anterior lip, pushed downward by the occiput, is caught between the head and the pubic walls, and thus is prevented from retracting simultaneously with the posterior lip ; and as a consequence of obstetrical operations. Severe lacerations extending above the vaginal junction are most frequently produced in pelvic deliveries, where the head is extracted by force through an imperfectly dilated os. Most commonly these lacerations follow a longitudinal direction. In rare cases, where there is extreme rigidity of the os externum, or where, after the escape of the amniotic fluid, the head distends the an- terior lip without pressing upon the os, a transverse rent may occur through which the child may pass. Sometimes a longitudinal tear may be combined with one running transversely, the lip then hanging by a pedicle to the uterus, or the entire lip may be torn off. Isolated cases of so-called annular laceration have been reported, where the transverse rent has extended through the whole vaginal portion, so that the lower segment has been detached in the form of a ring. In addition to the ordinary principles which should govern the management of every labor, Bandl lays great stress upon the pushing up of the confined anterior lip as an important prophylactic measure. Haemorrhage due to cervical laceration should be controlled by cold-water injections, by plugs of cotton steeped in the solution of the persulphate of iron and applied through the speculum directly to the bleeding point, or, still better, by closing the rent with silver sutures. The latter plan, which appears to have been first successfully tried by Professor Montrose A. Pallen,* has of late years come into general favor. In view of the bad light by which the operation has usually to be performed, the suggestion of Schroeder, to draw the cervix with the volsella forceps outside the vulva, while an assistant pushes the uterus down into the pelvis from above, is worthy of being borne in mind. With the wounded parts thus exposed, moreover, the repara- tive operation advocated presents scarcely appreciable difficulties to even the least surgical of attendants. If no haemorrhage occurs, cervical lacerations are rarely recognized except by physicians who take pains to invariably investigate the post-partum condition of every patient. As a rule, they heal rapidly during involution. Perfect cleanliness, maintained by the free use of carbolized washes, promotes the healing process, and is a safeguard against the inflammations of the contiguous connective tissue and peri- tonaeum which arise from infection. * Pallen, " Accidents of Parturition requiring Surgical Treatment," " Richmond and Louisville Med. Jour.," May, 1874. RUPTURES OF THE GENITAL CANAL. 575 Lacerations of the Vagina.—Vaginal lacerations vary in gravity according to their extent and position. In the upper part of the canal they are, as a rule, continuous with ruptures begun in the uterus or in the vaginal portion. In contracted pelves, where, owing to excessive retraction, the head fills the vagina without entering the pelvic brim, isolated lacerations of the vagina may follow the same general causes as those which give rise to rupture of the uterus. Per- haps the most common vaginal lesion is that produced by the un- guarded blades of the forceps when applied diagonally in place of directly to the sides of the child's head. In most cases these lacerations heal speedily without serious symp- toms, provided cleanliness be maintained from the first. Lacerations of the fornix only are of great importance on account of their proxim- ity to the peritonaeum, and because of the exposure of the parametri- um to septic absorption. The immediate closure, therefore, of these rents with silver sutures ought to be attempted. Owing to the laxity of the tissues, the difficulties of reaching the wound are not excessive, while the dangers to be forestalled are of a peculiarly threatening character. The origin and nature of fistulous communications with the blad- der and the rectum have already been considered in connection with the pathology of labor. Resulting for the most part from necrosis due to pressure, they are rarely the immediate sequelae of childbirth, the sloughing of the dead tissue taking place during the course of the puerperal period. The treatment in such cases belongs properly to the domain of gynaecology. The closure by suture is only available as a plan of treatment in cases where complete laceration through the tissues into the neighboring organs takes place during labor, as the consequence of rudely performed obstetrical operations. Lacerations at the Vaginal Orifice.—Owing to the small size of the vaginal orifice, tears through the mucous membrane and erosions of the vulva, and, in primiparae, the rupture of the frenulum, are to be accounted as the almost inevitable consequences of childbirth. They are the principal cause of the external soreness experienced after labor. In healthy localities they heal rapidly, and are of but trivial impor- tance. The healing process is, even in simple cases, promoted by the use of warm disinfectant douches. Of greater moment are deep peri- neal lacerations and those of the vestibulum. Lacerations of the Vestibulum.—Tears limited to the mucous mem- brane are usually found after labor at the sides of the clitoris. In exceptional cases these tears may involve the underlying erectile tissue (bulbs of the vestibule), and become the source of profuse or, when OA'erlooked, even of fatal haemorrhage. The blood, which may be either venous, arterial, or of mixed origin, spurts in jets, or oozes as from a soaked sponge. The recognition of the lesion is easy upon 576 THE PATHOLOGY OF LABOR. inspection. It should always be thought of as a possible cause of post- partum haemorrhage in every case where the flow continues after the contraction of the uterus. The bleeding may be temporarily arrested by the pressure of the finger until the expulsion of the placenta. Ligatures to the bleeding vessels, owing to the complexity of the structures, are of no avail. In slight cases a stream of cold Avater is a sufficient haemostatic. In others, the bleeding requires to be checked by one or two deep sutures introduced so as to bring the torn surfaces into apposition. If the bleeding appears to come from one or two points, the pinces hemosta- tiques are of service. Styptics and astringents are usually effective, but they possess the drawback of augmenting the pain and soreness. Lacerations of the Perinaeum.—In the chapter upon the " Manage- ment of Normal Labor," the nature, origin, and prevention of perineal lacerations have already been considered. The diagnosis is made by a careful inspection of the genital organs after delivery. The extent of the lesion is estimated by including the recto-vaginal septum between the thumb and index-finger. The treatment of perineal laceration consists either in keeping the woman in bed until the wounded surfaces cicatrize, or in bringing the parts into apposition by means of sutures, with the intent to secure primary union. The first plan is sufficient, if the wound be of slight extent. If, however, the rupture extends to the sphincter ani, and involves the entire perineal body, the vagina is left without support, rectocele or cystocele ensues, the uterus sinks downward and becomes displaced backward, and in the end prolapsus is apt to result. If the sphincter ani and the recto-vaginal wall are involved, inability to re- strain the bowels adds to the discomfort of the patient. This sequence of symptoms, so familiar to gynaecologists, forms an urgent plea for the resort to surgical means to repair the injury. Only a very credu- lous person really believes that he has Avitnessed union by first inten- tion in extensive ruptures, as the result of tying the knees together and enjoining rest upon the side. The action of the transversi-peri- naei muscles tends to draw the torn surfaces apart. Moreover, the necessity of separating the knees in passing urine, and to enable the nurse to cleanse the genitalia, makes it impossible to keep them in contact for any lengthened period. To the immediate operation there is no valid objection. It is not difficult, it is not extremely painful, and its performance, as a rule, diminishes the risks of infection and shortens the puerperal period. It is true that the object aimed at may not be attained. In private practice, however, failure is the exception. The argument that the operation is in itself a confession does not deserve discussion. For its performance the patient should lie upon her back, with her hips well over the edge of the bed. Two assistants to hold the knees RUPTURES OF THE GENITAL CANAL. 577 are of great convenience. In operations requiring the introduction of not more than three or four sutures, anaesthesia may be dispensed with. In lengthy operations, such as are necessitated by lacerations extending up the posterior vaginal wall, ether should be given in place of chloroform, and its administration should be intrusted to an -experi- enced person only. It can not be too often repeated that anaesthesia after labor calls for the exercise of extreme caution. The wound should be prepared by carefully washing away blood and clots with warm carbolized water, and by removing shreddy por- tions with scissors. For lacerations not extending through the sphinc- ter ani I use Peaslee's needle, Avhich is furnished with an eye at the point, and is set in a wooden handle. It possesses the advantage of strength, a quality of no mean importance in making the circuit of the redundant tissues with which we have to deal after labor. I use the silver suture, and after repeated trials have not been able to con- vince myself that it can be equally well replaced by silk. The first suture should be passed just in front of the anus. It should be entered and brought out about a half-inch from the rupt- ured borders. The others should follow at from, one third to one half inch intervals. Each suture should make the entire circuit of the wound. This can be readily accomplished by guiding the point of the needle through the residue of the perineal body with two fingers in the anus and with the thumb upon the vaginal surface. To secure a stronger hold for the last suture, the needle should be made to enter the vagina above the upper angle of the rent, and the wire should be made to traverse a portion of undenuded tissue before completing the circuit. In closing the Avound, great pains must be taken not to twist the sutures too tightly, as in that case they are apt either to cut out or to produce sloughing. Sometimes, in rents extending through the sphincter ani and the rectovaginal septum, the simple perineal sutures will effect a satisfac- tory union. Thus, in a patient at the Emergency Hospital, with a laceration extending nearly to the cervix, and whose condition pre- cluded a lengthy operation, I obtained an excellent result by passing a single wire above the angle of the wound, and twisting the ends out- side the perinaeum. As a rule, however, it is desirable to adjust the edges with great care, first closing the rent upon the rectal side, then bringing together the split in the mucous membrane upon the vaginal side with transA-erse sutures, and finally bringing the lower borders of the perinaeum together by a separate operation. This disposition is the so-called triangular suture of Simon.* It requires fine needles, a needle-holder, an adjuster, a Avire-twister, and, in fact, all the para- phernalia of the gynaecologist. The length of the operation renders * Vide Garrigtjes's excellent paper entitled " The Obstetric Treatment of the Peri- neum," "Am. Jour, of Obstet.," April, 1880. 37 578 THE PATHOLOGY OF LABOR. necessary an anaesthetic, which should be ether rather than chloro- form. The disgusting condition of a patient with laceration through the recto-vaginal septum, where the healing process has been the re- sult of granulation, justifies the attempt to secure immediate union. The requirements in the way of after-treatment are very simple. The urine should be drawn every four to six hours with a catheter, until the patient is able to pass her water spontaneously; the bowels should be kept open with salines ; and the knees should be tied loose- ly, to remind the woman of the desirability of keeping them in con- tact. A little opium may be given, if the pain experienced is consid- erable. Pain in childbed from any cause helps to depress the vitality. The perineal sutures should be left a week in situ. Many promising cases are spoiled by removing the sutures too early. The vaginal sutures may be allowed to remain until the external union is suffi- ciently solid to permit the introduction of the speculum. Cat-gut sutures for the rectum are to be preferred when they can be obtained, as they obviate the necessity of future removal. For the more superficial lacerations of the perinaeum the serres fines invented by Vidal de Cassis, and extensively used in Vienna, have been warmly advocated in this country by Professor M. D. Mann,* and by Garrigues. f My own experience with them has not been fort- unate, but the better results from their use in the hands of their sup- porters recommend them to trial. Thrombus of the Vagina and Vulva.—Haemorrhagic effusions into the external organs of generation occur with greatest frequency in the labia majora, more rarely in the labia minora, and occasionally be- tween the superficial and median fasciae of the perinaeum. These extravasations may form tumors beneath the subcutaneous or submu- cous tissues of the vulva or vagina, which vary in size from that of a hen's egg to that of a child's head. As a rule, the blood is poured out into the cellular tissue seated below the diaphragm of the pelvis. The extraA'asation may, however, stretch upward along the vagina to the cellular tissue of the uterus, then posteriorly beneath the perito- naeum to the kidneys, and around in front to the navel and laterally to the iliac fossae (Winckel). The source of the haemorrhage may be venous or arterial. The vessel from which the haemorrhage takes place is usually situated in the lower portion of the vagina * in less frequent cases, in the vulva. Symptoms.—The first sensation experienced at the time of the rupture is usually one of intense pain, proportioned to the size of the tumor and the rapidity of its formation, though in a case witnessed by Professor Barker J this symptom was absent. As the effusion con- * Mann, " The Immediate Treatment of Superficial Rupture of the Perinaeum," "Am. Jour, of Obstet.," November, 1874. f Garrigues, he. cit. X Barker, " Puerperal Diseases," p. 58. RUPTURES OF THE GENITAL CANAL. 579 tinues, swelling of the vulva, usually upon one side, results, and the skin becomes blue and nearly translucent. The patient complains of pain, and feels faint, while her lips and cheeks grow white. If the sac contains fluid blood, fluctuation is detected ; after coagula- tion the tumor has a soft, boggy feel. If the tension increases, the skin may yield, the blood and coagula escape, and, if no means be adopted to arrest the haemorrhage, the patient may die in a few min- utes from acute anaemia. If the thrombus be of small size and situated low down, the after- symptoms may be of slight importance. The fluid may be absorbed, the walls of the cavity unite, and the tumor disappear entirely. Tumors of larger size produce symptoms referable to pressure, such as back-ache, rectal obstruction, and ischuria. The vagina may be so narrowed as scarcely to permit the passage of the finger. Rupture, if not immediate, usually occurs spontaneously in the course of a few days, and is, as a rule, preceded by necrosis of a portion of the de- tached mucous membrane. The most frequent point of spontaneous rupture is at the junction of the larger and smaller labium. If the necrosed tissues become gangrenous, death from septicaemia may result. Winckel * sums up the various terminations of thrombus as follows : 1. Death from haemorrhage, with or without precedent rupture ; 2. Death from decomposition of the sac-contents, with consecutive sep- ticaemia or septico-pyaemia, most frequently after rupture or opening of the sac ; 3. Rupture and recovery ; 4. Rupture, with formation of fistulae ; 5. Absorption without rupture, followed by recovery. Diagnosis.—The diagnosis is simple. The rapid development and increase of the tumor, its bluish color, its elastic or fluctuating char- acter, the sharp pain, and the acute anaemia, occurring independently of uterine haemorrhage, sufficiently point to a sanguineous effusion into the subcutaneous cellular tissue. The extent of the tumor must be determined by rectal and vaginal exploration. It is only at the beginning that it will be found possible to ascertain the seat of the haemorrhage, whether in the vulva, vagina, or perinaeum. Sometimes, after rupture and the discharge of the clots, the bleeding vessel may be detected. Etiology.—The formation of the thrombous tumor, with rare excep- tions, takes place during or shortly after labor. If the vessel rupture in advance of the presenting part, the effusion may be immediate and furnish an obstacle to delivery, or the descent of the foetus may check the haemorrhage for a time, to break out afresh after the labor is ended. In rupture due to necrosis consequent upon pressure, the haemorrhage does not, of course, take place until sloughing occurs. Rupture may folloAV excessive straining, rapid dilatation of the genital canal, or direct injuries. A varicose condition of the veins does not, as would * Winckel, "Die Pathologie und Therapie des Wochenbett?," ?to *-fl«™ n. 132. 580 THE PATHOLOGY OF LABOR. naturally be inferred, especially predispose to the occurrence of the accident. Thus, it was present in but six of the fifty cases collected by Winckel. Prognosis.—The prognosis of vaginal thrombus is serious. Deneux reported twenty-two deaths in sixty cases, a mortality evidently ex- cessive ; Winckel reported six deaths in fifty cases; Barker reported two deaths in twenty-two cases; and Scanzoni one death in fifteen cases. But statistics like these are apt to give rise to a misleading im- pression. A thrombus per se is rarely a dangerous complication. It may, however, become so either because after rupture no means are adopted to limit the amount of haemorrhage, or because, in unhealthy localities, the tense membrane covering the tumor is liable to become gangrenous, and the vast vaginal wound furnishes at once a congenial soil for the multiplication of septic germs, and an absorbent surface by which the septic poison generated is afforded a ready entry into the adjacent cellular tissue. Thus, Barker reports nine cases in private practice, in all of which the patients recovered. Of thirteen cases in hospital practice, two patients died of puerperal feArer. The progno- sis is likewise less favorable in cases where there exists at the same time extensive separation of the peritonaeum. Treatment.—The conditions of successful treatmen t are, restriction of the haemorrhage and the prevention of septicaemia. Early recog- nition of the accident is very desirable. So soon as effusion is recognized the forceps should be applied, and the head should be extracted as speedily as is consistent with the preservation of the integrity of the maternal tissues. To quote from Professor Barker's excellent treatise : " The exciting cause of the ac- cident is the arrest of the circulation by the mechanical pressure of the presenting part of the foetus. The sooner the pressure is removed the sooner the danger will be over, and the less will be the injury to the parts." Moreover, as we have seen, the head in its descent acts as a tampon, by means of which the haemorrhage, Avhether external or in the submucous tissue, is temporarily held in check. If the tumor in advance of the head is so large that the delivery can not be accom- plished without impairing the vitality of the sac-walls, the danger should be averted by incising the thrombus and turning out the coagula. Haemorrhage after the birth of the child is apt to be very profuse, especially if the sac has been opened either by spontaneous rupture of its coverings or with the knife. So long as the sac-walls are intact, the pent-up blood exercises a considerable pressure upon the bleeding ves- sel. For this reason it is well to coA*er an opening, if one happens to have formed, with lint soaked in a solution of one of the per-salts of iron. The continuance of internal haemorrhage should then be checked by means of a water-bag (a large Barnes dilator will suffice) intro- RUPTURES OF THE GENITAL CANAL. 581 duced into the vagina and distended with ice-water. The hydrostatic pressure rarely requires to be maintained for longer than half a day, during Avhich time it should be repeatedly removed for a few moments to allow the vagina to bo cleansed by disinfectant injections. The urine should be drawn with a catheter during the first forty-eight hours, as every straining effort is to be carefully guarded against. A tampon of linen rags, or of cotton, is inadmissible on account of the tendency it possesses to excite rapid decomposition in the lochial dis- charges. Immediate opening of the thrombus, followed by emptying the sac, and filling the cavity with lint soaked in astringent solutions, are measures which should, on account of the suppuration likely to be thereby excited, be reserved for cases where milder procedures have proved ineffective. The ultimate opening of the sac, after the haemorrhage has once been arrested, is rarely to be avoided. Still cases are on record where tumors the size of a man's fist have disappeared by absorption. As this is the most favorable mode of termination, every effort should be made to secure such a result. To this end quiet should be enjoined, cold should be employed, and pain should be subdued by opiates. If, however, the tumor increases in size, the skin becomes greatly discol- ored, and vesicles form upon its surface, it is better to anticipate threatened gangrene or rupture by incision. If the circumstances per- mit of delay, it is better to wait three to four days to make sure of the stoppage of bleeding. The best point for laying open the tumor is upon the inner surface of the labium majus. The incision should be tAvo to three inches in length. In the subsequent treatment of the cavity, disinfection should be scrupulously practiced. Rupture of the Pelvic Articulations.*—Rupture of the pelvic artic- ulations may take place spontaneously where either inflammation or excessive relaxation of the joints exists at the time of labor. More commonly it is the result of difficult forceps operations performed in cases of contracted pelves. The risk of the occurrence of this accident is especially great when the forceps is applied to the head at the brim and forcible tractions are made in a direction anterior to the pelvic axis. The symphysis is the articulation which is principally exposed to this form of injury, though it is obvious that no increase in the capaci- ty of the pelvis consequent upon the separation of the symphysis is possible without simultaneous rupture of at least one of the sacro-iliac synchondroses. At the symphysis the rupture is apt to be complete, at the synchondroses the rupture is usually confined to the anterior surface. It may take place in the median line, or upon the side, be- * Ahlfeld, " Die Verletzungen der Beckengelenke wahrend d. Geburt und im Wo- chenbett," Schmidt's "Jahrbiicher," Bd. 169, 1S76, p. 185; Spiegelberg, "Lehrbuch," p. 636. 582 THE PATHOLOGY OF LABOR. tween the cartilage and the pubic bone. If the injury be slight, the synovial cavity of the symphysis may not be injured. At the synchon- droses, opening of the joint-cavity is inevitable. An excessive degree of the lesion is accompanied by laceration of the vagina, the bladder, and the intervening connective tissue. Occasionally the rupture of the joint is announced by a perceptible sound, by intense pain, and, as the result of the increase in the pelvic space, by rapid advance of the head. In the lighter forms, however, which make up the bulk of the cases witnessed, there are no distinc- tive symptoms at the time of the accident. The pathognomonic sec- ondary manifestations are outward rotation of the thighs, and local- ized pain increased by movement of the limbs, and relieved by fixation of the pelvis. Objective evidence of rupture at the symphysis is afforded by the movements produced at the articulation by alternate pressure upon the ends of the pubic bones, and by combined internal and external examination. If the rent extends to the vagina, the laceration may be detected by the touch. Separation of the sacro-iliac synchondroses is rendered probable if violent pain is excited by alter- nately pressing the anterior portions of the ilia together and then drawing them apart from one another. Bladder disturbances are rare ex- cept in cases where the separation at the symphysis is complete, or where the rupture is followed by inflammation and the formation of pus. The treatment consists in supporting the pelvis by means of a suit- able bandage, in keeping the patient upon her back, and in maintain- ing strict cleanliness. The bowels should for a time be kept confined. As regards the first indication, Spiegelberg says an ordinary towel properly folded and fastened at the pubes, with care taken to avoid pressure upon the crests of the ilia, will answer all the requirements. Rupture of the pelvic articulations, when not complicated by other lesions, or by puerperal infection, run for the most part a favorable course. During convalescence the patient should wear some form of permanent bandage, such as has been recommended in cases of relaxa- tion of the pelvic symphyses. CHAPTER XXXIV. PROLAPSE OF THE FUNIS, ETC. Prolapsed funis.—Asphyxia neonatorum.—Collapse and sudden death during labor and childbed from thrombosis, from embolism, and from entrance of air into the circu- lation.—On the extraction of the child in case of death of the mother in preg- nancy or labor.—Tympanites uteri. When the cord is felt within the membranes next to the present- ing part, a funis presentation is said to exist. After the membranes PROLAPSE OF THE FUNIS, ETC. 583 have ruptured, the cord descends into the vagina, in front of the pre- senting part, and is then said to be prolapsed. Generally the cord occupies one of the hollows upon the sides of the promontory; less frequently it descends opposite the lateral walls of the pelvis; the site in front of the promontory or behind the pubes is very exceptional. As regards the frequency of the accident, the experience of individ- uals varies widely. Churchill collected 98,512 cases of labor, in which it occurred 401 times, or in the proportion of one to 245*5 cases. Dr. Christisen, of Wyandotte, Michigan, met with it 23 times in 1,516 cases. Meachem met with it 10 times in 931 cases. Mr. Bland met with it, on the other hand, but once in 1,897 cases.* Prolapse of the cord occurs only in cases where the head does not completely occlude the lower uterine segment. It is favored by a long cord, by a deep placental site, by the insertio velamentosa, by oblique and breech presentations, by prolapse of the extremities, by hydram- nios, by multiple pregnancies, and, above all, by the contracted pelvis. On account of the more frequent concurrence of these conditions in multiparae, the accident is oftener found in them than in primiparae. The diagnosis of prolapsed funis is easy. If necessary, the loop can be drawn outside of the vagina. Previous to rupture it forms a smooth, round, compressible, mobile body, not to be confounded with any other floating object liable to be encountered within the ovum. When the pulsations of the umbilical vessels are distinctly felt, the child is de- monstrated to be alive. In the second stage, however, the pulsations may cease for a moment during a pain, to return again in the ensu- ing interval. As the heart sometimes continues to beat for a few minutes after the circulation in the cord has ended, it is proper to carefully auscultate before assuming death to haA*e taken place (Spie- gelberg). The prognosis, so far as regards the children, is extremely unfavor- able, more than one half dying during labor. This fatality is owing to the pressure to which the cord is subjected during the passage of the child through the pelvis. There are, however, a variety of cir- cumstances which substantially modify the extent of the danger. Thus, in transverse presentations the cord is scarcely or not at all exposed to pressure. In breech presentations the prognosis is good, owing to the soft consistence and small size of the pelvic extremity, and to the fact that, where the life of the child is in peril, the condi- tions are such as to permit of speedy extraction. The most serious cases are those where prolapse occurs as a compli- cation of head presentations. Engelmann found that the infant mor- tality in the latter was sixty-four per cent., while in footling presenta- * These statistics I have borrowed from an article on the " Presentation of the Funis," by Dr. J. G. Meachem, reprinted from " The Transactions of the State Medical Society of Wisconsin," 1880. 584 THE PATHOLOGY OF LABOR. tions it was but thirty-two per cent. Favorable conditions in head presentations are a large, roomy pelvis and preservation of the mem- branes until cervical dilatation is completed. Of unfavorable import are a deep placental site, a contracted pelvis, and early rupture of the membranes. Treatment.—From the foregoing it will be seen that the one indi- cation for treatment in this anomaly is to relieve the cord from press- ure. The conduct of the physician in each individual case will depend upon the presentation and the modifying circumstances. If the head presents, so long as the membranes remain intact, and the dilatation of the cervix is incomplete, an expectant attitude should be maintained. Premature rupture should be guarded against by placing the patient in the latero-prone position, by forbidding her to strain, and by supporting the membranes by means of a moderately distended Barnes dilator introduced into the vagina. It is not rare in this class of cases, as the head descends, for the cord to be with- drawn upward into a place of safety. The more complete the dilata- tion before rupture, the more rapid the subsequent delivery of the child, and the greater the chance, therefore, of preserving its life. If, however, upon auscultation, there are signs of failing heart-action, an attempt should be made to push the cord upward with the fingers through the membranes. In case of success, in order to prevent a relapse, the sac should be ruptured, and the head should be brought down so as to fill the cervical canal. After rupture of the membranes, if the cervix is well dilated, the pains are good, and the head enters quickly into the peh'ic cavity, the case may be left to nature. Spiegelberg mentions fiA'e cases, in his own practice, where the birth of the child took place so rapidly that no harm resulted from the descent of the cord. If the pains are feeble, and speedy progress is not made, the forceps should be applied. If, after dilatation of the cervix, the head remains high and mov- able above the brim, the forceps should not be employed. It is then dangerous to the mother, and offers but scant hope of proving of ser- vice to the child. The choice in such cases falls either upon repo- sition of the cord, or version. Reposition of the prolapsed cord, as the milder procedure, should be first attempted. The reposition is most easily accomplished in the knee-chest jiosition, as has been beautifully demonstrated by Gail- lard Thomas.* By the simple plan of reversing the direction of the uterine axis, all the conditions which had previously favored the descent of the cord are made to promote its return into the uterine cav- ity. Thus the intra-abdominal pressure is removed, the amniotic fluid is retained, the head is easily pushed to one side so as to permit the * Thomas, " Postural Treatment of Prolapsed Funis," " Trans, of the New York Acad, of Med.," 1858. PROLAPSE OF THE FUNIS, ETC. 5S5 introduction of the hand, and the cord tends to glide by its own weight over the declivity furnished by the anterior wall to the fundus. The loop should be seized in the hollow of the hand, and should be carefully sheltered from pressure. It should be shoved beyond the greatest circumference of the head, and, where possible, to the back of the child's neck. As in all cases Avhere the hand has to be passed through the cervix, the uterus should be sustained by pressure from without. With the advent of a pain all manipulations should cease, to be renewed, however, as relaxation follows. If the replacement proves successful, the hand should be withdrawn gradually, while the head becomes fixed in the lower segment. This latter result may fre- quently be expedited by judiciously directed external pressure. As a precaution against relapse, the patient should be placed in the latero- prone position, with the hips elevated by a pilloAv. The Postural Treatment of Prolapse of the Funis.—K. F. J. Birnbaum * finds that quite frequent mention has been made by authors of the advantages to be derived from posture in the treatment of cases of prolapsed funis. The works of Camper, published about the middle of the seventeenth century, and referred to by Kiestra, be had no means of obtaining access to. Deventer t considers the subject of prolapsed funis in extenso, takes up its different modifications, its effect upon parturition and the life of the child, and the treatment it demands. In cases where the cord was pressed against either ilium, he directed to place the woman upon the corresponding side, with raised pelvis, and with the hand (right band if on the left side, and vice versa) to lift the bead, replace the cord, then, as seemed advisable, either to bring the head into the pelvis, or to turn and extract by the feet. When the cord was pressed against the pubes or the sacrum, he advised that the midwife should place the woman upon her knees with her body thrown forward, and that, in this position, the accoucheur should raise the bead and return the cord; if the woman should be too weak for this, she should be placed upon the side with one limb drawn up under the body. John Mowbray I ad- vises that the woman, if strong enough, should be placed upon her knees and elbows in cases where the cord lies next the sacrum or the pubes. Henry Bracken, a pupil of Boerhaave,* proposed returning the funis in head presenta- tions, with the woman placed upon the knees, and afterward to bring the fetal head into the pelvis. Ludwig Wilhelm von Knoer || devoted a long chapter to funis presentations. He says : " Introduce the hand so soon as the membranes rupture, and, according to the position of the child, perform either podalic or cephalic version, placing the woman at the same time upon her knees to prevent the protrusion of the cord." George Daniel BoesselA recommends turning in cases of funis presentation, and, in cases of difficulty to perform version, with * "Monatsschr. f. Geburtsk.," October, 1867. f " Operationes chirurgicae novum lumen exhibentes obstetricantibus," Lugd. Bat., 1701. X " The Female Physician, containing all the Diseases incident to that Sex," Lon- don, 1724. # " Midwife's Companion ; or a Treatise of Midwifery," London, 1737. || " Frauen Zimmer Medicus," Leipsic, 1747. A "Grundlegung zur Hebammen Eunst," Flensburg and Leipsic, 1756. 586 THE PATHOLOGY OF LABOR. the woman placed upon the knees. In recent times, Van Eitgen has certainly been the most ardent partisan of postural methods of treatment. In his work entitled " Anzeigen der inechanischen Hiilfen bei Entbindungen," published in 1820, he recommends them in a great variety of circumstances, but not then for prolapsed funis; but in his "Lehr- und Handbuch der Geburtshulfe fur Hebam- men" (Mainz, 1838) he says: "When the funis presents, the midwife should instantly send for the accoucheur; meanwhile she should herself place the woman, if strong enough, upon her knees and elbows, and attempt the replace- ment of the cord; if the woman is too weak to admit of this, she should be placed upon her side, with elevated pelvis. That side should be chosen upon which the funis is not situated. If the manipulation is successful, the posture should be maintained to prevent a recurrence of the prolapse." He recommends the position upon the elbows and knees for cases of prolapsed funis and trans- verse presentations in breech or foot presentations, also where the head is mov- able above the brim, and where there is no attainable presenting part. He ad- vises returning the funis high up with the hand, and then to let it fall into the uterus, where it would no longer be subjected to pressure. After reposition place the woman upon her side, with raised pelvis. Sometimes the postural method suffices without any manipulations. Kiestra* advises the position upon the knees and elbows in cases where the cord is felt near the head previous to rupture of the membranes, to prevent the occurrence of prolapse. After the rupture of the membranes, he says, the same position should be employed to facilitate the return of the cord, and should be maintained until the head is fairly engaged in the pelvis. Where the position could not be endured long enough, he counseled placing the woman in a half-kneeling, half-recumbent posture, with the side supported by cushions. Theobold, in 1860, hit upon the same idea. He considered the most favorable condition for the return of the funis was to place the woman upon her head, but, in view of the difficulty attending the execution of this manoeuvre, compromised the matter by suggesting the position upon the elbows and knees. The advantages of the postural method in the treatment of pro- lapsed cord are beyond all question. It is, hoAvever, difficult to per- suade the woman to long maintain so constrained an attitude, and the cases are not rare where, in spite of gravity, the cord refuses to remain within the uterine cavity. Efforts at replacement should not, there- fore, be long continued. It is impossible to handle the cord for any lengthy period Avithout enfeebling the force of the fetal heart. So soon, therefore, as it becomes evident that nothing is to be gained by further persistence, the hand should be pushed up to the feet, and the safety of the child should be secured by speedy extraction. In cases of contracted pelvis the question of version must be decided with ref- erence to the interests of the mother, as a difficult breech delivery complicated by prolapsed funis offers but a sorry prospect of saving the life of the child. If the membranes rupture and the cord is prolapsed while the cer- vix is still narrow and rigid, an attempt should first be made to push * "Nederl. Weckbl.," April, 1855. PROLAPSE OF THE FUNIS, ETC. 587 back the cord with two fingers after placing the woman in the genu- pectoral position. As a rule, however, instrumental replacement will be necessary. I have been in the habit of employing for the purpose, as recommended by Dudan, a large English catheter, which possesses the advantage of forming one of the ordinary properties of the phy- sician. The method of using the instrument is as follows : A piece of tape should first be fastened loosely around the cord, the stylet should then be made to emerge at the eye of the catheter, and a loop of the tape should be placed in the angle it forms. By returning the stylet and pushing it forward to the extremity of the tube, the band is held firmly. After replacing the prolapsed cord, the catheter is read- ily detached by the withdrawal of the stylet. Braun von Fernwald, who is the author of the best of the repositors made expressly for the prolapsed cord, says that the catheter is almost the only instrument to which he now resorts. Instrumental replacement is apt to prove a veritable labor of Sisy- phus. As one loop is pushed up another comes down, or the entire mass is returned with infinite trouble to the uterus only at once to be projected into the vagina. Rober- ton has proposed a handy plan for such cases, which certainly merits a trial. It consists in first passing a piece of twine doubled through an elastic catheter, so that the loop makes its appearance at the eye. Through this loop, a loop of the cord should be drawn. The ends of the twine should then be knotted to prevent them from slipping ; the catheter should be armed with a stylet, and should be pushed up- ward into the uterus, carrying the COrd With it. After introducing Fig. 225.-Robertson's repositor. the catheter, the stylet should be withdrawn, and the instrument should be left behind to keep the cord from again prolapsing. In one case Dr. Ashford * succeeded in attaching the cord to a Gariel pessary. The latter was then carried into the uterus, and in- flated to prevent its expulsion. If neither the cord can be returned nor the child extracted, it is proper to try by Braxton Hicks's method to convert the head presenta- tion into one of the shoulder or, better still, of the breech, in order by so doino- to relieve the umbilical vessels from pressure. Of course, if * F. A. Ashford, "'Ballooning' the Prolapsed Umbilical Cord," "Am. Jour, of Ob- stet.," October, 1878, p. 745. 588 THE PATHOLOGY OF LABOR. the prolapsed funis is associated with pelvic contraction, the rule heretofore given to consult first the safety of the mother remains the guiding one in practice. In face presentations version is indicated, as, owing to the imper- fect manner in which the face closes the uterine orifice, replacement of the cord is not likely to prove successful. If the opening through which the cord makes its way into the vagina is produced by a pro- lapsed extremity, the latter, of course, should be pushed back after the cord has been returned. In footling cases the pressure on the cord does not begin until long after the extremities can be reached and utilized for extraction. In full breech cases, where the size of the presenting part might interfere with the funic circulation, where it is possible to return the cord with the hand it is equally practicable to bring down an extremity. In cross-births, before the shoulder becomes wedged in the pelvis the cord is in no danger. No treatment is there- fore necessary, except that indicated by the faulty presentation. Suspended Animation, or Asphyxia Neonatorum. Definition.—The term suspended animation is applied to such grades of congenital asphyxia in the living neAV-born child as are not incompatible with the continuance of its life.* A larger number of males than of females are born asphyxiated, and the children of primi- parae are more liable to this condition than those of multiparae. f Etiology.—A perfect comprehension of the etiology of suspended animation must be based upon thorough knowledge of the physiology of intra-uterine life and of the conditions necessary to its preservation. The foetus lives only by virtue of its connection with the placenta, in which all the nutritive elements necessary to its life are transmitted to its circulation from the maternal blood, which in turn receives and removes the products of retrograde metamorphosis occurring in the fetal tissues. The placenta performs for the foetus the functions assumed after birth by the digestive and respiratory organs. J The proper performance of these functions is indispensable to the life of the foetus, which is forfeited so soon as they are completely inter- rupted or imperiled by their partial abrogation—unless, indeed, the speedy accomplishment of delivery afford the extra-uterine respiratory and digestive functions an opportunity of compensating for the corre- sponding intra-uterine ones. Since the alimentary fluids contained in the blood-plasma can be longer dispensed with, without prejudicial results, than the oxygen, the cause of fetal death or of suspended ani- * Schultze, "Der Scheintod Neugeborenen," Jena, 1871, pp. 9, 101. t Poppel, "Monatsschr. f. Geburtsk.," Bd. xxv, 1865, Supplement. Heft, p. 57. X Zweifel, "Die Resp. des Fcetus," "Arch. f. Gynaek.," Bd. ix, 1876, p. 304; Feh- ling, "Arch. f. Gynaek.," Bd. ix, 1876, p. 318; Boehr, "Monatsschr. f. Geburtsk " Bd. xxii, 1863, p. 408. PROLAPSE OF THE FUNIS, ETC. 589 mation is chiefly asphyxia from deficient oxygenation.* The causes of the interruption in the diffusion of gases and of the consequent fetal asphyxia are of two varieties : 1. Those which interfere with pla- cental respiration by limiting or checking the maternal supply of oxy- gen, as in cases of death, of grave anaemia, of ante-partum haemor- rhage, or of pulmonary diseases on the part of the mother, whereby the amount of oxygen in her blood is diminished. 2. Those which interfere with or entirely prevent the absorption of oxygen by the fetal blood. Among the latter causes may be mentioned torsion and com- pression of the umbilical cord, partial or complete separation of the placenta, diminution of the fetal cardiac action by cerebral or thoracic compression, and arrest of the placental circulation.! In cases of nor- mal delivery the extra-uterine respiratory function assumes control so soon as the uterine contractions haATe sufficiently compressed the placenta to prevent proper oxygenation of the fetal blood. The in- adequately oxygenated products of disassimilation are here supposed to act as powerful stimulants to the medullary respiratory center, and to produce contractions of the respiratory muscles. J So long as the diffusion of gases is normally provided for by the placenta, no stimu- lus is conveyed to the medulla. When, however, this source of aera- tion for the fetal blood is removed, spontaneous respiration mast at once begin. Most authorities are of the opinion that this is the pre- ponderating cause of the first extra-uterine respiratory movements.* Chilling of the fetal skin by the atmosphere is held by Kristeller, || and regurgitation of the placental blood toward the fetal heart by Lahs,A to be other causes of the first spontaneous respirations. Re- spiratory movements are produced in the manner described, whether the interruption of fetal hsematosis occur after or before the expul- sion of the placenta from the uterine cavity, provided the respir- atory center and the muscles of respiration be sufficiently developed to respectively originate and react to nervous impulses. In each in- stance the thorax is dilated, the pulmonary capillaries are filled Avith blood by the right ventricle, and whatever surrounds the external air- passages is aspirated, if these be permeable, into the trachea and bron- chi. In the former case the surrounding medium is air, the fetal blood is duly aerated and the extra-uterine respiratory function secure- ly established. When respiration begins in the uterine cavity, how- eA'er, only a little air and that in exceptional instances § is inspired, while mucus, blood, liquor amnii, vernix caseosa, and meconium are * Schroeher, " Lehrbuch," p. 714. f Spiegelberg, " Lehrbuch," p. 663. X SCHROEnER, op. cit. * Schwartz, "Arch. f. Gynaek.," Bd. i, 1870, p. 362; Boehr, "Monatsschr. f. Ge. burtsk.," Bd. xxv, 1865, p. 336 ; Schultze, op. cit, p. 105. || Kristeller, " Monatsschr. f. Geburtsk.," Bd. xxv, 1S65, p. 327. A Lahs, " Arch. f. Gynaek.," Bd. iv, 1872, p. 312. Q Bartscher, " Monatsschr. f. Geburtsk.," Bd. ix, 1857, p. 294. 590 THE PATHOLOGY OF LABOR. aspirated in considerable quantities. Aeration of the fetal blood can not now be accomplished by either method of respiration. The poison- ous products of tissue disintegration accumulate. The irritability of the medullary centers diminishes. Respiratory movements become infrequent, and are finally arrested. The heart becomes paralyzed, and the foetus dies unless delivery be speedily accomplished. If, now, the child be extracted asphyxiated, but not dead, its condition is said to be that of suspended animation. Provided the interference with placental respiration be of a tempo- rary character, the disturbances of the fetal functions due to intra- uterine respiration may, according to Schultze,* be compensated for in the following manner : Inspirations occur, at first, as above de- scribed, from interruption of the placental circulation. Since, how- ever, the medullary respiratory center no longer receives an adequate supply of arterial blood, its irritability diminishes and respiratory movements cease. The aspiration of blood from the right ventricle into the pulmonary circulation is now arrested, and the placental ves- sels are refilled. Owing to paralysis of the pneumogastric nerves, from over-stimulation, the cardiac activity is restored, and, if the obstruc- tion to the placental circulation be transitory, the placenta will reas- sume its respiratory function. This hypothesis explains the fact that foetuses, Avhich are knoAvn from observation to have breathed in utero, are sometimes not born in a state of asphyxia. Suspended anima- tion may occur without antecedent intra-uterine respiration. This is the case when disturbance or arrest of the placental functions takes place in foetuses so immature that their medullary centers can not respond to the irritation of insufficiently oxygenated disassimilative products by originating the nervous impulse necessary for the produc- tion of respiratory movements. Another cause of suspended animation unattended by intra-uterine respiration is a very slow progress of the placental respiratory dis- turbance, and a consequent gradual diminution of the amount of oxy- gen in the fetal blood. The deficiency in oxygen is, at first, so slight as not to stimulate the medullary center, and when the deficiency be- comes more marked the irritability of the medulla has been so much depressed that it is no longer capable of originating a respiratory im- pulse. In this case the foetus dies or passes into a condition of sus- pended animation without having breathed at all.* Compression of the fetal brain due to a contracted pelvis, to intra-cranial haemorrhage, to the use of the forceps, t or to delivery in breech positions, may occa- sion death or suspended animation without exciting respiratory"move- ments. The rationale of such cases is as follows : Cerebral compres- sion reduces or even arrests the heart's action by irritating the pneu- * Schultze, op. cit, pp. 102 et seq. f Dohrn, "Arch. f. Gynaek.," Bd. vi, 1874, p. 365. PROLAPSE OF THE FUNIS, ETC. 591 mogastric nerve. The placental respiratory function is thus impaired, the fetal blood is consequently deprived of oxygen, and the irritability of the medulla so reduced that the latter can no longer originate re- spiratory movements.* If intra-cranial extravasations are located upon the convexity of the cerebrum they are comparatively innocuous, since the medulla is not compressed. Their most pernicious effect is natu- rally observed when they are situated at the base of the brain. It is doubtful, according to Schwartz,! whether intra-uterine respiration, without asphyxia, may eArer result from cerebral compression, as is maintained by Poppel. J Morbid Anatomy.—Schultze recognizes two stages of suspended animation, which correspond to the terms asphyxia livida and pallida, usually employed to designate these respective conditions.* The boundary-line between the two stages is marked by the loss, on the part of the muscles, of their tonic contractility. In the first stage the muscular tone is still preserved. Although there are no spontaneous muscular contractions, the extremities are not completely relaxed, nor does the head drop. Reflex movements are easily produced by surface irritation. The skin is dusky-red or cyanotic, the cutaneous vessels are turgid, the conjunctivae injected, and the eyeballs protruding. The cardiac and umbilical pulsations are slow but forcible. The umbilical vessels are fully distended. Respiratory movements usually occur only after a certain interval. They are at first feeble, superficial, and at- tended by facial contortions, but soon become more poAverful. The increased deficiency in oxygen, occasioned by delivery, often furnishes to the medulla, in this stage of suspended animation, a stimulus of sufficient intensity to cause spontaneous respiratory movements. The same result is attained by irritation of the surface. If resjriration does not ensue, from either cause, the child passes into the second stage of asphyxia. In the second stage of suspended animation, or asphyxia pallida, the children are exceedingly anaemic. The conjunctivae are without luster ; the surface is cold; the sphincters are relaxed ; the limbs, head, and lower jaw hang loosely down. Reflex movements do not occur. The cardiac beats are frequent and feeble. The umbilical pulse is almost or quite imperceptible. The umbilical vessels are empty. Either no spontaneous respiratory movements occur, or they are few, snapping, and produced by the diaphragm Avithout the par- ticipation of the facial, nasal, or maxillary muscles. The respirations are ineffectual, since a post-mortem examination reveals little or no air in the bronchi, which are usually filled with fluid matter, and since * Frankenhauser, "Monatsschr. f. Geburtsk.," Bd. xv, 1860, p. 368. f Schwartz, " Arch. f. Gynaek.," Bd. i, 1870, pp. 365, 377. X Poppel, op. cit, p. 57. * Schultze, op. cit, pp. 6, 130, 147. 592 THE PATHOLOGY OF LABOR. no rales are heard during the respiratory efforts. The medulla is so completely paralyzed that the stimulus of the increased deficiency in oxygen, attendant upon delivery, merely produces these futile respira- tory efforts. Should artificial means succeed in restoring the child, the first signs of its resuscitation will be refilling of the cutaneous capillaries and returning muscular tonicity. The morbid anatomical features of suspended animation vary according as that condition has or has not been attended by intra-uterine respiration. In the latter case the blood is dark and uncoagulated. The pulmonary vessels are widely distended. The lungs are enlarged, heavy, and of a dark-red color. Numerous pulmonary, subpleural, subpericardial, and suben- docardial ecchymoses are present. The pulmonary extravasations are more extensive than in cases of asphyxia accompanied by intra-uterine respiration, for the reason that, in the latter, the aspirated fluids offer a certain support to the distended capillaries. Pulmonary congestion and ecchymosis may be absent if the inspirations were ineffectual, in- frequent, and of short duration. The obstruction of the pulmonary circulation further produces venous congestion of the surface, of the abdominal organs, and of the encephalon, resulting in subconjunctival, meningeal, and cerebral haemorrhages. Ecchymoses may, also, be found beneath and upon the pericranium. Aside from the extrava- sated blood, no foreign matters are found in the bronchi. The absolute proof that the asphyxia of still-born children, or of those born in a moribund condition, was attended by intra-uterine respiration consists in the discovery, within the bronchi, of substances introduced by tho- racic aspiration. When the proof is lacking, inspiration may still ha\*e occurred, but the entrance of foreign bodies has been prevented through occlusion of the nose and mouth by portions of the membranes, or by close apposition to them of the maternal soft parts. The quan- tity of aspirated material will depend upon its character and the force of the inspirations. The tough cervical mucus penetrates only to the trachea and primary bronchi. The liquor amnii, containing meconium, vernix caseosa, and blood and downy hairs, may even reach the terminal bronchioles. If air had found an entrance into the uterine cavity, it is also present in the bronchi, and, exceptionally, in the stomach and duodenum. The dilatation of the Eustachian tubes, as a consequence of the first inspirations, permits, in some instances, according to Wendt,* the penetration of liquor amnii into the middle ear. The pulmonary ecchymoses are less numerous and extensive in asphyxia attended by intra-uterine respiration than in the other variety, for rea- sons above stated, but congestion and extravasations in the abdominal and cerebral organs are quite as constant and important. Diagnosis.—An important diagnostic symptom of beginning as- phyxia is diminished frequency of the fetal heart-beats, due to inhibi- * Spiegelberg, " Lehrbuch," p. 667. PROLAPSE OF THE FUNIS, ETC. 593 tion of the placental respiration. This has no significance if it be manifest only during the pains, since it is then a physiological occur- rence due to the mechanical compression of the fcetus or to expression of the placental blood into the fetal vessels. If it persist, hoAvever, during the interval between the pains, and be progressive, it is of seri- ous import, betokening either considerable compression, or irritation of the medulla by an excess of deoxygenated blood. The diminished frequency is sometimes succeeded by increased rapidity of the cardiac contractions, indicating paralysis of the pneumogastric, and, conse- quently, a more advanced stage of suspended animation.* This in- creased rapidity is, probably, invariably preceded by the diminished frequency of the heart's action already alluded to. The evacuation of meconium is also diagnostic of asphyxia, provided it be not merely the result of the mechanical compression exerted upon the child in breech presentations. The appearance of the meconium is, probably, due to the increased intestinal peristalsis attendant upon asphyxia, although, perhaps, in part occasioned by relaxation of the sphincters and com- pression of the abdomen by the contracting diaphragm. The dis- charge of meconium, accordingly, usually attends that form of sus- pended animation in which intra-uterine respiration has occurred, and is absent in those cases of gradually induced asphyxia unaccompanied by respiratory efforts. The differential diagnosis between these two varieties is completed, after delivery, by the detection of bronchial rdles, due to the aspiration of intra-uterine fluids, in all cases of intra- uterine respiration except those in which the external air-passages were occluded. The discharge of meconium is sometimes not indicative of any pathological condition. Schultze f detected intra-uterine respira- tion by abdominal auscultation, as well as by intra-uterine palpation, and numerous observers have heard the vagitus uterinus, or intra- uterine cry, which bears testimony to the entrance of air into the uterus, and to the occurrence of respiratory movements."); When de- livery has been partially accomplished, the diagnosis of asphyxia is easily made from the failing fetal pulse, the cyanosis, the forcible respiratory efforts, and the relaxation of the child's muscles. Prognosis.—The prognosis depends largely upon the grade of the asphyxia, although the cause of the latter is of still greater signifi- cance. Suspended animation which is not accompanied by intra- uterine respiration offers the best prospects for resuscitation. The chances are smaller if inspiration has occurred, and the worst prog- nosis is afforded by the occurrence of respiration when the nose and mouth are occluded, on account of the graver derangement of the * Huter, " Monatsschr. f. Geburstk.," Bd. xviii, 1862, Supplem. Heft, p. 48. ■f Schultze, op. cit, p. 127. % Kristeller, " Monatsschr. f. Geburtsk.," Bd. xxv, 1865, p. 321; Bartscher, Ibid., Bd. ix, 1857, p. 294; Mayer, Ibid., Bd. xxv, 1865, p. 341. 38 594 THE PATHOLOGY OF LABOR. fetal circulation, and the more abundant pulmonary extravasations. The presence of aspirated foreign substances clouds the prognosis by interfering with efforts at artificial respiration, and by acting as the exciting cause of atelectasis and of lobular pneumonia. The prognosis is also rendered grave by the occurrence of intra-cranial haemorrhages. The mortality of asphyxiated children in the first eight days after delivery is, according to Poppel's statistics,* seven times greater than that of children born unasphyxiated, and the mortality in the first week in direct proportion to the duration and gravity of the sus- pended animation. Treatment.—Three indications are to be fulfilled in the treatment of suspended animation : 1. The child must be speedily delivered, so that it may inspire pure atmospheric air ; 2. The aspirated substances which occlude the air-passages must be removed, in order that the air may reach the alveoli; 3. If the asphyxia be so profound that no spontaneous respirations occur, the required air must be supplied, the abrogated function of the medulla restored, and the cardiac activity awakened by artificial respiration. First Stage.—The first step in the resuscitation of still-born chil- dren consists in clearing away the mucus from the upper respiratory passages. This can pretty generally be effected with the little finger. In other cases it may be advisable to lay a toAvel over the child's lips and practice mouth-to-mouth insufflation. By this method little air enters the lungs, but it is of great service as a means of expelling mucus from the nasal passages. If abundant rales announce the pres- ence of fluids in the larynx, trachea, and bronchi, they should be removed by aspiration with a small elastic catheter (No. 6 or 8) passed through the glottis. I have made great use of the catheter for the purpose mentioned, and believe it has been the means of saving a good many lives. I haA*e never seen any harm from its cautious em- ployment. In introducing the tube, the point should be guided down- ward by the index-finger placed behind the epiglottis, at the upper posterior border of the larynx. Only a very clumsy manipulator could, as has been suggested, perforate Avith an elastic catheter the walls of the larynx or trachea. By means of catheterization we are able not only to clear away mucus which, inspired into the smaller bronchial tubes, would eventually lead to death from atelectasis, but we are ena- bled to transfer air directly from our own lungs into that of the child. Usually this is not necessary. The stimulus imparted to the laryn- geal mucous membrane often produces spontaneous respiration. As a rule, after the removal of the aspirated fluids respiration may be ex- cited by ordinary cutaneous stimuli, such as sprinkling the face Avith cold water, rubbing the back with flannel, pouring a little whisky or brandy from a height upon the epigastrium, flagellation of the nates, * Poppel, op. cit, p. 57. PROLAPSE OF THE FUNIS, ETC. 595 or alternately immersing the child in hot and cold water. The cord should not be ligated so long as its vessels continue to pulsate, in order that all available placental blood may pass into the fetal circulation. Should these measures prove unavailing, artificial respiration must be resorted to. If the child is feeble, and the beating of the heart is scarcely perceptible, it should be wrapped in warm clothes and the catheter should be introduced. The obstetrician, after expel- ling the reserve air from his lungs, should then take a deep inspiration, and slowly breathe through the tube into the lungs of the child. If the catheter has been properly introduced the thorax will now be ob- served to expand. To imitate expiration, slight pressure should be made upon the sternum, and, as the air escapes, it will be heard to make a blowing noise in its passage through the tube. By patience, if only at the outset the heart beat at all, the circulation will be found to become stronger, the child will lose its excessiA'e pallor or lividity, according to the stage of asphyxia, and, as the sensibility is restored, spontaneous respiratory efforts will be made. The danger of injuring the delicate pulmonary tissue, and of producing either interstitial or subpleural emphysema by insufflation, appears to me to be exaggerated. The catheter never exactly fills out the trachea. Any excess of air, therefore, will find its exit by the mouth, rather than through the tissues. If the child be strong and well developed, and the heart beat strongly, I can heartily endorse the following method recommend- ed by Schultze : After ligation and section of the cord, the child should be grasped in such a manner that the operator's thumbs shall rest, on either side, upon the anterior thoracic wall, while the index- finger occupies the axilla, and the remaining fingers are placed diago- nally across the back. The child is then allowed to hang at arm's length between the knees of the obstetrician, its face being turned to the front. In this position the pectoral muscles are made to draw the superior ribs upward, the abdominal muscles draw the inferior ribs downward, and the weight of the liver causes the descent of the dia- phragm. By these means the capacity of the chest is increased and inspiration is produced. The child is next swung upward, until the arms of the operator reach an almost horizontal position. The swing- ing motion is then arrested, flexion occurs in the child's lumbar spinal region, its head is directed downward, and its lower extremities fall slowly toward the obstetrician, until the whole weight of its body rests upon his thumbs. By this motion the chest and abdomen are power- fully compressed, the diaphragm is forced upward, and an efficient expiration results, and any retained adventitious matters are expelled from the air-passages. An inspiration is now produced by reversing the direction of the swing and returning the child to its former posi- tion of complete extension, by which manoeuvre the chest is caused to 596 THE PATHOLOGY OF LABOR. expand and the diaphragm to descend. This procedure is repeated eight or ten times, at intervals of a few seconds, after which the child is placed in a warm bath, in order that its surface be not too greatly refrigerated. Should signs of returning vitality be now manifested, alternate immersions in cold and hot water may again be employed. Should no spontaneous respirations occur, the swinging may be repeat- ed, alternating with baths, until breathing begins or the heart ceases to beat. If the child be feeble and the second stage of asphyxia immi- nent, the method of Marshall Hall is preferable, since it involves less exposure and less violent manipulations.* The respiratory motions of the thorax are produced by the weight of the body and the elasticity of the chest. The child is first placed upon its abdomen, and the expiration, resulting from the compression of the thorax by the body's weight, and accompanied by expulsion of any foreign bodies still re- maining in the air-passages, may be assisted by pressure with the hand. The child is next turned upon its side, and, as lateral compression is exerted, the thorax expands in virtue of the elasticity inherent in its walls, and inspiration occurs. The child is then made to assume its former position, and, after a few seconds, is turned upon its other side. These alternations of posture should be made at the rate of fifteen to the minute. When the process has been repeated a few times the warm bath should be employed to prevent undue refrigeration of the cuta- neous surface. The movements described should alternate with the baths until spontaneous respiration occurs or the case becomes hope- less. Faradization of the phrenic nerves is recommended by Pernice, f and often furnishes excellent results ; but, as a battery in good order is rarely on hand in a moment of emergency, the practice is of limited applicability. Second Stage.—In the second stage of asphyxia the treatment is essentially the same. After the removal of the foreign substances from the air-passages, artificial respiration is employed. Insufflation by means of a catheter and Marshall Hall's method are Avell adapted to such cases, since the child's vitality is at so low an ebb as-to render its tolerance of more active measures problematical. Another mode of resuscitation suitable for this stage consists in artificial respiration, performed as follows while the child is immersed in warm water : The child is placed in the dorsal decubitus, the back only being supported by the operator's hand. The arms, head, and legs are allowed to fall backward. In this position inspiration is effected. Expiration is then produced, after placing the child in a leAel position, by raising the lower extremity of the trunk and by manually compressing the thorax. In prematurely delivered asphyxiated children these meth- ods are inapplicable, since the thoracic walls are so yielding as not * Seydel, " Monatsschr. f. Geburtsk.," Bd. xxvi, 1865, p. 284. f Pernice, " Monatsschr. f. Geburtsk.," Bd. xx-iii, 1864, p. 317. PROLAPSE OF THE FUNIS, ETC. 597 to undergo the changes of form requisite to the success of the meth- ods described. In such cases insufflation, through the catheter, follow- ing aspiration, of the foreign bodies in the air-passages, is the only available treatment. If the efforts at resuscitation be successful, the child must for the first few days after its birth be kept particularly warm and be regularly nourished.* Collapse and Sudden Death during Labor and Childbed.—We have already had frequent occasion to mention collapse during or following labor as a sequence of haemorrhage, or of injuries to which the genital passages have been subjected. Syncope is not an uncommon result of exhaustion following prolonged labor, or even normal labor in women with exceptionally sensitive nervous organizations. Again, it may be caused by the cerebral anaemia produced by the recession of blood from the nerve-centers Avhen the intra-abdominal pressure is suddenly diminished by the rapid emptying of the uterus. Temporary syncope, if followed by complete restoration of the normal circulation, has no positive prognostic significance. Where, however, the pulse continues feeble and rapid, it should be, even in the absence of other grave symptoms, a subject of profound concern. The arteries then gradu- ally become empty, while the large venous trunks fill with blood, and the sluggish current predisposes to the formation of thrombi. Thrombi owe their importance to the disposition they possess to disintegrate and form emboli, which are swept along by the circula- tion until arrested by the diminished caliber of the peripheral vessels. A small clot forming in the left side of the heart may block up an artery in the brain or in either an upper or lower limb. The symp- toms of the lesion in the latter case are the absence of pulsation in the artery below the thrombus, with pain, coldness of the surface, paralysis of the nerves of motion and sensibility if the arterial obstruc- tion be sudden and complete, and in some cases gangrene of the ex- tremity affected, f Of much more common occurrence are venous thrombi. Indeed, it may be stated that thrombosis of the veins furnishes the most fre- quent cause of sudden death in labor and during the puerperal period. It may—though this is rare—occur spontaneously in the pulmonary artery or in the right cardiac cavity. As a rule, however, the clot- ting takes place in the femoral, the pelvic, or the uterine veins. Spiegelberg I states that the emboli which become detached during or shortly after labor proceed from clots formed at the site of the placen- * In what is known as Sylvester's method, the child is placed upon its back; then, by raising its arms above the head, the chest is expanded and inspiration is produced ; while to produce expiration, the arms are lowered, the hands of the child are crossed, and the elbows are pressed against the sides of the thorax. + Barker, " The Puerperal Diseases," p. 257. The enumeration of these symptoms is credited to Dr. Barnes. *f Spiegelberg, he. cit, p. 661. 598 THE PATHOLOGY OF LABOR. ta. Usually there is first haemorrhage from partial detachment of the placenta; then thrombus formation in the veins, the clots, in the ab- sence of uterine retraction, extending from the open mouths of the sinuses in the direction of the heart; and, finally, under a powerful contraction, such as follows oftentimes the rupture of the membranes or the expulsion of the foetus, the clot is set adrift from its moorings, and is washed upward through the vena cava to the right side of the heart, and thence to the branches of the pulmonary artery. The symptoms of stoppage in a large pulmonary vessel are intense dyspnoea, air-hunger (to use an expressive German term), fluttering heart-action, a feeble, rapid pulse, a cold skin, and striking pallor of the countenance. Death may follow in a few minutes, or, where the main trunk is free, the more violent symptoms may in the course of a half-hour subside, to return, however, with the slightest movement or without apparent cause, the patient dying in a few days from abnor- mal lowering of the temperature, from dyspnoea and cyanosis; or, after a succession of attacks, the thrombus may be absorbed, and, as I have once seen, complete recovery may take place. A second and rarer cause of sudden death in labor and childbed results from the entry of air into the uterine vessels. * The conditions for the occurrence of this accident are the access of air to the uterine cavity, and open communication with the veins. The passage of air may result from operations necessitating the introduction of the hand or of instruments into the uterus. It is favored by gaping of the vulva, and by any circumstance which diminishes the intra-abdominal pressure. Thus, it has been observed as a consequence of the knee- chest position, the latero-prone position, and even of the ordinary position upon the side. Aspiration of air may follow sudden removal of intra-abdominal pressure after violent expulsive efforts which have ended in rupture of the membranes or the precipitate birth of the child. Air contained in the vagina may be forced upward into the uterus by means of the vaginal douches, or, more frequently, air min- gled with water may be conveyed into the uterus by a syringe with imperfect valves. Air enters the circulation during pregnancy and labor through the sinuses which are opened by the separation of the placenta, in child- bed by the accidental detachment of the thrombi which form at the placental site. The symptoms of the entry of the air into the veins are those of asphyxia. The diagnosis during life is to some extent a matter of speculation, as there are no direct physical signs of the presence of air in the right side of the heart. Experimentally it has been proved that sudden death results either * For the literature of this subject, vide Kezmarszky, " Ueber Lufteintritt in die Blut- bahnen durch den puerperalen Uterus," " Arch, f. Gynaek., Bd. xiii, p. 200. PROLAPSE OF THE FUNIS, ETC. 599 when a volume of air in the right side of the heart interferes with the complete filling of its cavity, or when a column of air enters the pul- monary artery and obstructs the passage of blood to the lungs. Air passing into the veins at a distance from the heart enters the lungs finely subdivided, and forms emboli which adhere to the walls of small vessels, and produce symptoms of dyspnoea, which often are of tempo- rary duration. In obstetrical cases it is necessary, therefore, to assume either that a large volume of air has been forcibly driven into the veins or that a \-enous thrombus is simultaneously washed into the circulation, and combines with air emboli to produce the fatal result (Spiegelberg). The treatment of pulmonary embolism, whether due to air or to a disintegrated thrombus, is necessarily for the most part prophylactic. The proper precautions for avoiding the accidents described are suffi- ciently indicated in the preceding discussions as to their etiology. As the violence of the symptoms at the outset of the attack is often out of proportion to the real gravity of the lesion, warmth should be ap- plied to the surface, and eA-ery effort should be made to maintain the action of the heart. To this end, injections of ether into the skin and of ammonia into the veins are to be counted as most powerful adju- vants. If the storm subsides, the utmost quiet should be enjoined. Extraction of the Child in Case of Real or Apparent Death of the Mother during Pregnancy or Labor. Death of the mother during pregnancy or labor may be threatened, or may actually result, either suddenly or slowly, from various morbid conditions which have been previously considered. Although sudden death of the mother is more frequent at the time of delivery, in con- sequence of haemorrhage, exhaustion, eclampsia, or rupture of the ute- rus, it may occur at any time, particularly when due to pulmonary and cardiac affections, or to cerebral emboliam. It is our present object to consider the methods of treatment best adapted to the preservation of the child's life in those cases necessa- rily attended by death of the mother, and to the preservation of both mother and child whenever there is any probability of such a result. Our inquiry may, therefore, be limited to those cases in which the child is unquestionably living, and its viability undoubted. While the majority of recent authors upon this subject have recognized the pro- priety of adopting prompt measures for the immediate extraction of the child after the mother's decease, the same unanimity has not pre- vailed either in regard to the propriety of operative interference before the mother's death, or as to the most appropriate methods of opera- tion. Schroeder * is content with the statement that, in cases of ma- ternal demise during parturition, efforts should be made to extract * Schroeher, " Lehrbuch," p. 712. 600 the pathology of labor. the foetus per vids naturales by version or the forceps. In the event of failure to accomplish delivery by this method, he advises immediate resort to the Caesarean section. Spiegelberg * recommends the Caesa- rean section for all cases of maternal death, excepting those occurring in the second stage of labor, as the surest method of preserving fetal life. He makes no provision for those cases in which the mothers are apparently dead, although actually in a state of syncope or asphyxia, recommends the Caesarean section, even in cases of impending death of the mother, in the child's interest, and disparages efforts at extraction through the natural passages. Duer f concludes {a) that no operative procedure should be undertaken until there is absolute certainty of the mother's death ; {b) that, death of the mother being assured, the Caesarean section should be performed with dispatch if the fetal head be above the pelvic brim ; (c) that, if the head have engaged in the brim, the question of resort to the Caesarean section or to extraction per vias naturales becomes debatable. He condemns the practice, attributed by him to Rizzoli and Esterle, of resorting to forced deliv- ery when the mother's death is imminent. One of the most recent and comprehensiAre articles on the subject of artificial delivery per vias naturales is that of Thevenot,| who, referring its original introduction to Schenk and Rigaudeaux, and its development to Rizzoli, Heymann, and Depaul, ardently advocates its adoption, to the exclusion of the Caesarean section. This method he declares to be applicable {a) to those cases with normal pelvic confor- mation in which the mother is dead, the labor somewhat advanced, the os dilated or dilatable, and the head at the superior strait; {b) to cases in which labor was only commencing, or had not begun at the time of death; (c) to cases, frequently occurring, according to the author, of apparent death of the mother (her real condition being that of syn- cope), whether labor had or had not begun at the time of her apparent decease ; and {d) to cases of impending maternal death. Thevenot's arguments in favor of the method of treatment under consideration are, that the operation may be more promptly resorted to than the Caesarean section, the preparations for and hesitations about which frequently occasion fatal delays ; that it is of less vital importance that the death of the mother be positively ascertained than in cases of Caesarean section ; that it is a less repulsive proceeding; that the results are better than in the Caesarean section; that the method is not productive of medico-legal complications ; and that it affords a numerous class of parturient Avomen, who are only apparently dead, a * Spiegelberg, " Lehrbuch," p. 269. f Duer, " Am. Jour, of Obstet.," January, 1879, p. 10. X Thevenot, " De l'acc. artif. par les voies nat. substit. a l'operation cesar. post mor- tem,''' "Ann. de Gynec," tome x, October, 1878, p. 257 ; November, 1878, p. 339; De- cember, 1878, p. 412. PROLAPSE OF THE FUNIS, ETC. 601 far better chance of recovery than does the Caesarean section. Theve- not cites fifteen cases of accouchement force employed upon women at the point of death, in which thirteen infants were alive at birth, and six lived permanently. Five of the fifteen mothers, who were apparently moribund, recovered, and in three other cases the original diseases were retarded, and their most distressing symptoms temporarily relieved. Tympanites Uteri.—If air enters the uterine cavity previous to the birth of the child, the dangers are not confined to its passage into the venous circulation. Even when this latter accident does not occur, the patient's condition in a lingering labor is perilous in the extreme. The essential condition for the admission of air is rupture of the mem- branes. As a result in many though not in all cases, untimely respir- atory efforts are excited in the child. In very rare instances it is said that the cry of the child, vagitus uterinus, has been heard within the uterus. Death speedily follows premature respiration, and, under the combined influence of air, heat, and moisture, decomposition rapidly develops.* The gases generated by putrefaction are some- times of enormous volume, and the uterus furnishes a tympanitic resonance upon percussion. As a result of prolonged labor, of the dis- tention of the uterine walls, and of septic poisoning, the pains become feeble and the patient suffers from dyspnoea, owing to the pressure upon the diaphragm by the enlarged uterus and the colon, which like- wise is found distended, with gases. A stinking discharge, sometimes mingled with gas-bubbles, is always present. The prognosis depends upon the intensity of the process and the length of time allowed to elapse before operative measures are em- ployed to remove the source of danger. Of sixty-four women, accord- ing to Staude's report, thirty-two died, eighteen had severe puerperal affections, and only fourteen recovered without further complications. The indications for treatment are, to extract the child as soon as prac- ticable when air has once entered the uterine cavity, to Avash out the uterus with disinfectant fluids, to use all available means to secure continued retraction of the uterus, and to follow every antiseptic pre- caution during the puerperal period. * Staude found putrefactive changes developed in foetuses born from three to twen- ty-one hours after the access of air to the uterus. " Ueber den Eintritt von Luft in die Gebarmutter," " Ztschr. f. Geburtsh. und Gynaek.," Bd. iii, p. 204. 602 DISEASES OF CHILDBED. DISEASES OF CHILDBED. CHAPTER XXXV. PUERPERAL FEVER. Frequency.—Pathological anatomy.—Endocolpitis and endometritis.—Metritis and para- metritis.—Pelvic and diffused peritonitis.—Phlebitis and phlebo-thrombosis.—Nature of puerperal fever.—Clinical history.—Symptoms of endometritis and endocolpitis; of parametritis and perimetritis ; of general peritonitis; of septicaemia lymphatica; of septicaemia venosa ; of pure septicaemia. Frequency.—In a careful search through the records preserved by the Health Department of New York City, I found that from 1868 to 1875 inclusive the total number of deaths for the nine years was 248,533. Of these, 3,342 were from diseases complicating pregnancy, from the accidents of child-bearing, or from diseases of the puerperal state ; or, in other words, one in seventy-five (1: 75) of all the deaths occurring during that period was the result of the performance of what we are in the habit of regarding as a physiological function. The deaths from miscarriage, from shock, from prolonged labor, from instrumental delivery, from convulsions, from haemorrhage, from rupture of the uterus, and from extra-uterine pregnancy, and deaths from eruptive fevers, from phthisis, and from inflammatory non-puer- peral affections complicating childbirth, made a total of 1,395, or about 42 per cent, of the entire number. The remaining 1,947 cases, variously reported as puerperal fever, puerperal peritonitis, metro- peritonitis, phlebitis, phlegmasia dolens, pyaemia, and septicaemia, represent the very serious sacrifice of life resulting from inflamma- tory processes which have their starting-point in the generative appa- ratus. If we apply the general term, puerperal fever, to this class of cases, it will be seen that the malady is the cause of nearly TiT of all the deaths occurring in the city. The actual number of births for the nine years in question was roughly estimated at 284,000,* an estimate erring upon the side of liberality. The total number of deaths to the entire number of confinements was, then, at least in the proportion of one to eighty-five (1: 85), or, from puerperal fever alone, in the propor- * This estimate was based upon the assumption that the natural birth-rate is 33 to the 1,000, a proportion believed by the statisticians of the Board of Health to be approxi- matively correct, though probably somewhat in excess of the reality. P. Osterloh has recently stated that my statistics were computed in so arbitrary a manner as to render deductions from them valueless. In this, however, he is mistaken. The most conscien- tious care was taken in their preparation; wherever the possibility of error existed, the fact was distinctly indicated; and all calculations were made in such a way that whatever corrections might be required would strengthen the conclusions. PUERPERAL FEVER. 603 tion of one to one hundred and forty-six (1 :146). Now, if we add to these naked statistics the fact that the average number of confine- ments to each woman during the child-bearing period is from four to five, it will become apparent that the community has a right to demand of every practicing accoucheur a familiarity with what is definitely known concerning the nature and prevention of a scourge which, according to the statistics of the "Puerperal Fever Commis- sion,"* appointed by the Berlin Society of Obstetrics and Gynaecolo- gy, destroys nearly as many lives as either small-pox or cholera. But puerperal fever differs from either small-pox or cholera in that the latter presses largely upon the aged and the very young, while the for- mer gathers its victims exclusively from a selected class, viz., from women in adult life, the mothers of families Avhose loss, as a rule, is a public as well as a private calamity. Before proceeding to consider the nature of puerperal fever, it is desirable to first recall the anatomical lesions with which it is associ- ated. These, it will be found, are for the most part inflammatory processes having their starting-point in injuries of the genital passage produced by parturition. The Pathological Anatomy of Puerperal Fever.—The lesions con- nected with puerperal fever are so various that the student will find it convenient to classify them according as they are situated in the mucous membrane of the utero-vaginal canal, the parenchyma of the uterus, the pelvic cellular tissue, the peritonaeum, the lymphatics, or the veins. Not, indeed, that such an arrangement is strictly in accord- ance with clinical experience—as a rule, the inflammatory processes are rarely limited to a single tissue—but because the prognosis and treatment are determined in great measure by the tissue system which is predominantly affected. The significance of puerperal inflamma- tions, wherever seated, likewise depends upon whether they are local and circumscribed, or whether they present a spreading character. Personally I have found the following classification of Spiegel- berg f of great utility as a means of keeping in mind the principal points to which inquiry should be directed in estimating the signifi- cance of the febrile conditions of childbed : 1. Inflammation of the Genital Mucous Membrane.—Endocolpitis and endometritis. a. Superficial. b. Ulcerative (diphtheritic). 2. Inflammation of the Uterine Parenchyma, and of the Subserous and Pelvic Cellular Tissue. a. Exudation circumscribed. * " Ztschr. f. Geburtsh. und Gynaek.," Bd. iii, p. 1. + Spiegelberg, " Ueber das Wesen des Puerperalfiebers," Volkmann's " Samml. klin. Vortr.," No. 3. 604 DISEASES OF CHILDBED. b. Phlegmonous, diffused; with lymphangitis and pyaemia (lym- phatic form of peritonitis). 3. Inflammation of the Peritonaum covering the Uterus and its Appendages.—Pelvic peritonitis and diffused peritonitis. 4. Phlebitis Uterina and Para-uterina with formation of thrombi, embolism, and pyaemia. 5. Pure Septicamia.—Putrid absorption. Endocolpitis and Endometritis.—In the superficial, catarrhal form of inflammation the mucous membrane of the vagina is swollen and hyperaemic, the papillae are enlarged, and the discharge is profuse ; in the vaginal portion of the cervix the labia uterina are oedematous and covered with granulations which bleed at the slightest touch ; in the cavity of the body there are increased transudation of serum and abun- dant pus formation. The deep structures of the uterus are usually not affected. Sometimes the inflammation extends to the tubes—sal- pingitis—or, passing outward through the fimbriated extremities, it may spread over the adjacent peritonaeum. The small wounds at the vaginal orifice are at times converted into ulcers with tumefied borders. These so-called " puerperal ulcers " are covered with a greenish-yellow layer. They are associated usually with oedematous swelling of the labia. Under favorable sanitary con- ditions the deposit, which consists in the main of pus-cells, clears away and the surface heals by granulation. The ulcerative form of inflam- mation is very rare outside of crowded hospitals. Diphtheritic ulcers are situated with greatest frequency in the neighborhood of the posterior commissure, or around the vaginal orifice. In rarer instances they are found upon the anterior wall and in the fornix of the vagina, in the cervix, and upon the site of the placenta. The borders are red and jagged ; the base is covered with a yellowish-gray, shreddy membrane ; the secretion is purulent, alka- line, and fetid ; and the adjacent tissues are oedematous. From the vulva they may extend to the perinaeum, or pursue a serpiginous course down the thighs. In the uterus and about the cervix they vary as regards size, and are either of a rounded shape or form narrow bands. The intervening portions of tissue which haA^e not undergone destruc- tive changes swell and stand out in strong relief. Where the entire inner surface has become necrosed, it is often covered with a smeary, chocolate-brown mass which, Avhen washed away with a stream of water, leaves exposed either the deepest layer of the mucous mem- brane or the underlying muscular structures. The difference between the superficial ulcerations of the genital canal and the diphtheritic form involving destruction of the deeper tissues is due to the presence in the latter of minute organisms termed micrococci, the relations of which to puerperal infection will be con- sidered in a subsequent division. PUERPERAL FEVER. 605 Metritis and Parametritis.—In ulcerative endometritis, and even in the extreme catarrhal form, the parenchyma of the uterus likewise becomes involved. The changes which are designated under the term metritis consist in the first place of oedematous infiltration of the tis- sues. As a consequence, the organ contracts imperfectly, and becomes soft and flabby, so that sometimes, upon post-mortem examination, it bears the imprint of the intestines. In diphtheritic endometritis the gangrenous process may attack the muscular tissue, and give rise to losses of muscular substance, a condition known as necrotic endometritis, or putrescence of the uterus. Inflammatory changes are rarely lacking in the intermuscular con- nectiA'e tissue, which exhibits in places serous or gelatinous infiltration with afterward pus formation, and with here and there small abscesses. The sero-purulent infiltration of the connective tissue is specially marked beneath the peritoneal covering of the uterus either behind or along the sides at the attachment of the broad ligaments. In the same situations the lymphatics, which normally are barely perceptible to the naked eye, are sometimes enlarged to the size of a quill, and are char- acterized by varicose dilatations occurring singly or presenting a beaded arrangement. In the substance of the uterus the dilated ves- sels are liable to be mistaken for small abscesses. The pus-like sub- stance contained in the lymphatics is composed of pus-cells and of micrococci. From the cellular tissue surrounding the vagina, or that beneath the peritoneal covering of the uterus, the inflammation may spread by contiguity of tissue between the folds of the broad ligament, and thence pass upAvard to the iliac fossae. Usually the process is uni- lateral. After the inflammation has crossed the linea terminalis it may take a forward direction above the sheath of the ilio-psoas mus- cle to Poupart's ligament, or it may creep upward, folloAving the course, according to the side affected, of the ascending or descending colon to the region of the kidney. It is rare for inflammation of the cellular tissue to travel around the bladder to the front. In such cases it pur- sues its course between the walls of the bladder and the uterus, and along the round ligament to the inguinal canal. In a few cases the cellulitis mounts above Poupart's ligament, between the peritonaeum and the abdominal wall. The course of the inflammation is not simply fortuitous, but follows pre- arranged pathways in the connective tissue. Konig* and Schlesinger t have shown that, when air, water, or liquefied glue is forced into the cellular tissue between the broad ligaments, the injected mass has a tendency to invade the iliac fossae. In Schlesinger's experiments, if the cannula of the syringe was in- serted into the anterior layer of the broad ligament, the glue spread between the folds to the abdominal end of the Fallopian tube; thence following the track * Konig, "Arch, der Heilkunde," 3 Jahrg., 1862. \ Schlesinger, " Gynaekologische Studien," No. 1. 606 DISEASES OF CHILDBED. of the vessels, it passed to the linea terminalis ; and finally mounted upward along the colon, or swept forward to Poupart's ligament until the advance was stopped at the outer border of the round ligament. If the injection was made to the side of the cervix through the posterior layer at the junction of the cervix and the body, the posterior layer gradually bulged out, the peritonaeum was lifted from the side-wall of the pelvis, and the glue passed beyond the vessels to reach the iliac fossa. If the injection was made to the side of the cervix through the anterior layer, the glue passed between the bladder and the uterus, and forward along the round ligament to the inguinal canal, while another portion of the fluid passed between the layers of the broad ligament, and reached the peritoneal covering of the side-walls behind the round ligament. If the injection was made in the median line in a peritoneal fold of Douglas's cul-de-sac, the fluid traveled forward upon one side along the round ligament and thence to the posterior wall of the bladder. The term parametritis, introduced into use by Virchow, is, prop- erly speaking, limited to inflammation of the connective tissue im- mediately adjacent to the uterus, the older one of pelvic cellulitis furnishing a more comprehensive designation for cases where, as a consequence of a progressive advance from the point of departure in the genital canal, the remoter regions have likewise been invaded. Connective-tissue inflammation presents, as the first essential charac- teristic, an acute oedema, the fluid which fills the gaps and interspaces consisting of transuded serum rendered opaque by the presence of pus- cells, or possessing a gelatinous character. In the mild, uncomplicated cases the oedema disappears rapidly. Where the cell-collections are of moderate extent, the entire process may vanish without leaving a trace of its existence. If the cell-elements, on the other hand, are present in great abundance, they, as a rule, first undergo fatty degeneration, and, after the absorption of the fluid portion, form a hard tumor com- posed of a fine granular detritus, which, under favorable circumstances, likewise after a few weeks becomes absorbed. In rare cases abscess formation in the tumor results. In the parametritis resulting from septic infection, especially in cases complicated by diphtheritis, the tissues seem as if soaked with dirty serum, and contain scattered yellowish deposits, which soon pre- sent, even to the naked eye, the appearance of pus-collections. This sero-purulent oedema is always associated with lymphangitis, the lym- phatic vessels possessing varicose dilatations and beaded arrangements similar to those already described in the uterine tissue. The foregoing changes are most distinct in the firm connective tissue adjacent to the uterus and at the hilum of the ovary, while they are less clearly traced in the looser structure of the broad ligament (Spiegelberg). In favorable cases the inflammation is circumscribed, or at least is limited by the nearest lymphatic glands. In cases of intense infection it spreads rapidly, and justifies the title bestowed upon it by Virchow of parametritic malignant erysipelas. PUERPERAL FEVER. 607 Pelvic and Diffused Peritonitis.—Inflammation of the pelvic peri- tonaeum may result from severe attacks of catarrhal endometritis, the inflammatory process either traversing the uterine tissue or passing through the Fallopian tubes to the adjacent serous membrane; or it may proceed, secondarily, from the stretching and irritation occa- sioned by an associated parametritis. As a rule, pelvic peritonitis is not attended with much exudation. The latter is situated upon the folds of the peritonaeum limiting the cul-de-sac of Douglas, upon the ovaries, and upon the broad ligaments. In favorable cases it consists of fibrinous flakes and fluid pus. If the latter is abundant, it may become encysted by the formation of adhe- sions between the pelvic organs. General peritonitis may result from the extension of a pelvic peri- tonitis, or from the transport of poison through the lymphatics into the peritoneal sac. In the first case the entire peritonaeum is injected, and the contents of the abdominal cavity are loosely bound together by pseudo-membranes, composed of pus and coagulated fibrine. The intestines are at the same time distended and the diaphragm is pushed upward. In the so-called peritonitis lymphatica, the inflammatory symptoms are at the outset lacking. The abdominal cavity is found filled with a thin, stinking, greenish or brownish fluid, composed of serum and micrococci. The intestines are lax and oedematous, and the muscular structures are paralyzed, with resulting tympanitic dis- tention. The peritoneal covering of the intestines is devoid of luster, and covered with injected patches, or is stained of a dark-brown color. Death often ensues before the occurrence of exudation. Septic forms of pelvic inflammation are often associated with oo- phoritis, the dilated lymphatics either extending to the substance of the ovaries, where they may lead to the production of small abscesses, or, as a result of blood dissolution, the organs become soft, pulpy, and infiltrated with discolored serum, and present haemorrhagic spots dis- tributed over the surface. Phlebitis and Phlebo-Thrombosis.—The formation of thrombi in the uterine and pelvic veins is sufficiently common during the puer- peral period. The coagulation may result from compression or from enfeeblement of the circulation. A predisposition to its occurrence is created by relaxation of the uterine tissue. A normal thrombus is in itself harmless. In time it becomes organized, and the occluded ves- sel is converted into a connective-tissue cord, or a channel may form through it which permits the passage of the blood-stream. When, however, pus or septic matters obtain access to a thrombus, it under- goes rapid disintegration, and the particles get swept away into the circulation until arrested in the ramifications of the pulmonary artery. Wherever these poisoned emboli happen to lodge, inflammation is set up in the adjacent tissues, and abscesses result (pyaemia multiplex). 608 DISEASES OF CHILDBED. Sometimes countless collections of pus may form in the lungs. Less commonly abscesses are found in the liver or spleen, originating either from emboli which have already made the pulmonary circuit, or from thrombi in the pulmonary veins. Inflammation of the veins (phlebitis) sometimes occurs, when the vessels have to traverse tissues in or near the uterus infiltrated with purulent or septic materials. The endothelium then undergoes prolif- eration, and thrombosis is produced. Phlebitic thrombi do not neces- sarily break down, and may in that case act as a barrier to the progres- sion of septic germs into the circulation (Spiegelberg). As a rule, however, under the influence of inflammation and infection, they be- come converted into puriform masses. The thrombi grow by accretion in the direction of the heart. They may extend from the uterus through the internal spermatic, or through the hypogastric and common iliac veins, to the vena cava. Sometimes the thrombus may be traced back to the placental site. Septicaemia.—From these local conditions, sooner or later, secondary affections develop in distant organs. The general affection is, in great part at least, likewise of local origin. Sometimes, however, where the poison, which enters the system through the lymphatics and veins, is very active and abundant, death may follow from acute septicaemia before the changes in the sexual organs have had time to develop. The fatal result in these cases is probably due to paralysis of the heart. After death, post-mortem decomposition rapidly sets in, the blood is sticky, and swelling is found in the various parenchymatous organs. The secondary affections consist in the metastatic abscesses already noticed as produced by infected emboli, in circumscribed purulent collections due to the conveyance of septic materials into the blood- current through the lymphatics, in ulcerative endocarditis, in inflam- mations of the pleura, the pericardium, and the meninges, and in puru- lent inflammation of the joints. A study of the nature of puerperal fever will best show how inti- mately these seemingly distinct processes are linked together. The Nature of Puerperal Fever.—It has now passed beyond the domain of dispute that puerperal fever is an infectious disease, due, as a rule, to the septic inoculation of the wounds which result from the separation of the decidua and the passage of the child through the genital canal in the act of parturition. To maintain this definition it is, however, necessary to group by themselves cases of childbed-fever dependent upon causes which are operative in the non-puerperal condition, though the latter imparts to these causes oftentimes an exceptional activity and virulence. In this category are to be placed scarlatina, typhus, typhoid, and malarial fevers. It is to be borne in mind that the zymotic fevers may pro- voke in the puerperal woman the same inflammatory lesions that are PUERPERAL FEVER. 609 commonly associated with puerperal fever.* This is in accordance with the well-known surgical experience that a febrile paroxysm from any cause exerts an unfavorable influence upon a wounded surface. Olshausen \ has, however, shown that pelvic inflammations and peri- tonitis are somewhat rare in scarlatina complicating the puerperal state. Again, instances of puerperal inflammations and febrile conditions are sometimes observed in which the symptoms of blood-poisoning are apparently absent, or are present only to a subordinate extent, and as a late feature of the disease. As illustrations of this class may be mentioned : 1. Cases of catar- rhal endometritis due to errors of diet and exposure. Indeed, I have frequently, in hospital practice, been able to trace severe cases of cel- lulitis, pelvic peritonitis, and general peritonitis occurring in the win- ter season, to the patient getting out of bed dripping with perspiration, and clad only in a night-dress, and going thus barefooted over a cold, uncarpeted floor to the water-closet. 2. Cases of puerperal disorders proceeding from emotional causes, the nervous system furnishing the first impulse to the disturbed action. 3. Cases of excessive vulnera- bility in non-pregnant women; individuals are sometimes found so susceptible that a parametritis follows a simple application of the tinct- ure of iodine to the cervix. 4. Cases of pelvic peritonitis starting from old intra-peritoneal adhesions. 5. Cases of peritonitis and retro- peritoneal inflammations secondary to ulcerative processes in the cae- cum or the descending colon. This condition is apt to be marked during pregnancy, but starts into activity during childbed as a conse- quence of fecal accumulation or of excessive purgation. It is by no means easy to decide as to the position of local inflam- mations following lacerations of the cervix, and the bruising or crush- ing the soft parts in long or instrumental labors. Similar circum- scribed inflammations in other situations are attributed to ordinary reaction from traumatic injuries. It is not, for instance, customary to ascribe a phlegmon of the breast proceeding from a lesion of the nipple to septic infection. At the same time the marvelous absence of heat, pain, redness and swelling in wounds treated in strict accord- ance with the principles of Lister, the very slight reaction when the atmosphere is pure, and the severity of these symptoms in crowded hospitals, all tend to strengthen the belief that even the simplest in- flammations proceeding from wounds owe their origin in great part to septic germs. That, however, the infectious diseases of childbirth are of septic origin, there is now abundant evidence. The question of the identity of puerperal fever and septicaemia is largely one of definition. It is a * Hervietjx, "Traite clinique et pratique des maladies puerperales," pp. 1073 et seq. \ Olshausen, " Untersuchungen iiber die Complication des Puerperium mit Scharlach und die sogenannte," " Scarlatina puerperalis," " Arch. f. Gynaek.," Bd. ix, Heft 2. 39 610 DISEASES OF CHILDBED. matter of ordinary experience that the retention of a small bit of the membranes within the uterus will produce fetid lochia, and, as the result of infection, a febrile condition, which, as a rule, subsides with the expulsion of the offending body and the use of disinfectant washes. A Adrulent form of fever is not unfrequently occasioned by retained coagula or placental debris which have undergone decomposition. I was once sent for to see a puerperal patient, suffering from fever, on the fourth day following her confinement. On entering the room I found the stench intolerable ; turning down the sheets, I discovered that the patient was lying in a decomposing mass, and learned that her doctor had forbidden, after the birth of her child, the removal of the soiled linen and blankets. The patient died in the third week from pyaemia multiplex. Haussmann * reported a case of auto-infection in the rabbit, which terminated fatally. A portion of the membrane, retained in the left cornu, led to diphtheritic losses of substance in the lower portion of the vagina, to haemorrhagic enteritis, and to peritonitis. The same author produced death from septicaemia by injecting into the gravid uterus of the rabbit serum from the abdomen of a rabbit which had died from infection. The post-mortem examination showed the mus- cles filled with granules, and the peritonaeum injected, but no fibrino- purulent exudation. Injections into the uterus of pus from the ab- domen of a woman who had died from infectious puerperal disease pro- duced no effect upon rabbits two weeks gravid, while in the second half of pregnancy premature delivery and death occurred, in one case in one and a half, in another in two and a half days. In the animal which died in thirty-six hours there was commencing perimetritis and peri- tonitis, while in the one that died after the lapse of sixty hours the ab- domen was found to contain fibrine and pus. f D'Espine injected into the uterus of a rabbit, which had just produced her young, pus from the abdomen of a woman who had died from puerperal disease two days before. This was subsequently followed by other injections of fetid fluids during the four days following. On the twelfth day the animal died. The autopsy revealed peritonitis, most marked in the pelvic cavity, inflammatory alterations in the vagina, uterus, and tubes, small abscesses in the body of the uterus, softened clots in the veins of the broad ligaments, and infarctions of the liver. J Schiiller found that subcutaneous injections of septic material in female ani- mals, during pregnancy, produced a diphtheritic, ulcerative process on the uterine surface, which determined the separation of the placenta ; diphtheritic patches, likewise, were found in the cornua of the uterus.* * " Entstehung der iibertragbaren Krankheiten des Wochenbettes," " Beitr. zur Ge- burtsh. und Gynaek.," Bd. iii, Heft 3, p. 345. % lbid-, p. 394. f " Contribution a l'etude de la septicemic puerperale," Paris, 1873, p. 28. * " Experimented Beitrage zum Studium der scptischen Infection," " Dtsch. Zeit- schr. fur Chir.," Bd. vi, p. 141. PUERPERAL FEVER. 611 Thus we find that in the human subject, and in experiments made upon animals, septic poisons introduced into the system following or near delivery produce lesions similar to those found in puerperal fever. As a further coincidence, we notice that, as in puerperal fever, the lesions from direct septic poisoning have nothing char- acteristic about them, producing in one case pyaemia, in another par- tial peritonitis, in another general peritonitis, in another diphtheritis, while in others the lesions are comparatively trivial—these differ- ences being due to differences in conditions which are but imperfect- ly understood. Samuel, in speaking of immunities from and dispositions to septic poisoning, says : " The statistical frequency of septic puerperal dis- eases is due to the length of the parturient canal, to the fact that through this long passage there must pass all the pathological and physiological excretions, and to the soiling of these parts with fingers, instruments, and secretions which have become the bearers of sep- sis." * He found, on the other hand, that it was extremely difficult to produce a progressive ichorous condition by daily painting an open stump with a septic fluid, t though the same was readily obtained when an infinitesimal quantity of septic fluid was injected underneath a fascia. Until very recently the whole subject of septicaemia has been in a state of wellnigh hopeless confusion. From Gaspard and Panum, through a long list of experimenters, hardly any two have arrived at precisely similar results. Something like an approach to order has, howeA'er, been effected since it has begun to be understood that the effects produced by septic fluids vary with the quality of the poison and the method of experimentation, and that, to obtain identity in the result, there must be identity in all the conditions. Thus, Samuel has shoAvn that the same organic substance produces different effects at dif- ferent stages of decomposition ; again, that the enteritis which is com- monly quoted as characteristic of septic poisoning occurs, as a rule, in animals when the septic fluid is injected directly into the blood, and is rare when it finds its way into the circulation through the lymphat- ics, as is the case usually in clinical experiences. \ There is one ex- perimental point of extreme practical importance, too, in connection with puerperal septicaemia, viz., that, if the injection of a septic fluid be made directly into a vessel, toxic effects speedily follow, but are transitory, unless the amount of the fluid be large, or its virulence ex- ceptional, or the animal very young;# whereas very small amounts injected subcutaneously, by developing rapidly spreading phlegmonous * " Ueber die Wirkung des Faulniss process auf den lebenden Organismus," " Arch. f. exp. Pathol.," Bd. i, p. 343. f Loc cit, p. 339. X L°c- cii-, P- 349. * Traube und Gscheidlen, " Versiiche iiber Faulniss und den Widerstand des leben- den Organismus," " Schlcs. Gcs. f. vaterliindische Cultur," February 13, 1874. 612 DISEASES OF CHILDBED. inflammation, resembling malignant erysipelas in man, are capable, after a period of incubation, of producing fatal results ; or they may, if injected into a shut cavity or underneath a fascia, lead to the devel- opment of an inflammation of an ichorous character. In other words, the eliminating organs suffice, under ordinary conditions, to remove from the blood the same amount of septic fluid which Avould prove fatal if injected into the tissues.* To produce similar results, the in- jections into the blood need to be repeated at intervals. This expe- rience leads us to the conclusion that, in the tissues, septic poison possesses the capacity of self-multiplication, and that, in the local inflammation set up, a reservoir is formed from which poison is con- tinuously poured into the circulation. This capacity of self-multiplication, Avhich septic fluids possess, has recently been found to be coincident with the presence of certain or- ganic bodies, termed variously micrococci, microspores, or sometimes, less specifically, bacteria. All carefully made experiments serve to show that, if a septic fluid be deprived of these organic bodies by boil- ing or filtration, while it continues capable of producing inflamma- tion, the inflammation is usually of diminished intensity, and remains local in its character ; \ whereas the microspores, retained upon the filter, possess all the virulent properties of the original fluid. J This does not alone necessarily prove that the virus resides in the micro- spores, for it does not exclude the possibility that both the virus and the microspores remain upon the filter. So far, attempts at isolating the microspores and cultivating them separately, in vehicles composed of water holding in solution certain inorganic constituents necessary for their healthy nutrition, haA'e been only partially successful in proving them to be the sole source of infec- tion. Some experiments of Tiegel, Klebs, and Doleris * were attended with positive results, but Hitler arrived at different conclusions. He found that bacteria Avashed in pure water were innocuous. || But pure water had long before been proved by observers to be inimical to the well-being of the organisms in question. Schuller says that Hiller's experiments prove apparently that, while a putrid fluid may be in the highest degree poisonous, its component parts, viz., either the fluid or * In some instances, in which absorption from the tissues is very rapid, the effects of subcutaneous injections may be similar to those produced by injections made directly into the circulation, and the local lesion be insignificant. f In filtration through porous earthenware cylinders, the filtrate possesses no phlogo- genic properties. X Tiegel, " Corrcspondenzblatt f. Schweizer Aertze," 1871, p. 1275; Klebs, "Arch. f. exp. Pathol, und Pharmakol.," Bd. i, Heft 1, p. 35. * Klebs, " Beitrage zur Kenntniss der pathogenen Schistomycetin," " Arch. f. exp. Pathol, und Pharmakol.," Bd. iv, Heft 3, pp. 241 et seq.; Tiegel, he. cit. | " Exp. Beitrage zur Lehre von der organisirte Natur der Contagion und von der Faulniss," " Arch. f. klin. Chir.," Bd. xvii, Heft 4, pp. 669 et seq. Fig. 226.—Specimens of micrococci. A, specimens from pus and blood presenting simple points (monococci), double points (diplococci), and beaded forms. B, micrococci of largo size from patient dying of lymphangitis and peritonitis. B', the same seventy hours later. In both the foregoing the micro- cocci have been isolated, and have been cultivated in independent fluids. C, shrunken, misshapen appearance of the blood-corpuscles produced by micrococci. D, appearance of micrococci in the lochia. E, clot in a crural vein. The dark points are colonies of micrococci beneath the endothe- lium. (Dolens.) 614 DISEASES OF CHILDBED. the bacteria singly, are neither deadly nor poisonous.* The fact is, that all isolation experiments are subject to what seems an unavoidable source of error. As Davaine noted, early in his observations, the physiological action of bacteria is very dependent on the constitution of the medium in which they are developed, which is in entire har- mony with what is known of organisms much higher in the scale. "Many plants," says Burdon-Sanderson,f "containing active prin- ciples become inert when transplanted from an appropriate soil.'' Buchholtz, in a series of experiments designed to test the influence of antiseptics upon the vitality of bacteria, found not only a difference between those taken directly from the infusion and those cultivated in artificial fluids, but between bacteria derived from the same source and cultivated in modifications of the nutrient medium. J Under these circumstances, all evidence of a positive character is to be regarded as of more value than that which is purely negative. It is, however, from the constant presence of the round bacteria in infected wounds, and their distribution through the tissues, that the argument in favor of connecting septic symptoms with the bacteria has been mainly deduced. Here the ground is sufficiently solid, and, judged by ordinary laws of scientific evidence, the pathological im- portance of the microspores may be regarded as established. To be sure, we find them in tongue-scrapings of healthy individuals, but tongue-scrapings are poisonous if injected into the tissues. That they do not ordinarily prove so in the mouth is no more singular than that woorara can be swallowed with impunity. Tiegel has endeavored to show that the round bacteria are found normally in the internal organs of the body.# If his experiments should, in fact, stand the test of criticism, they would only show that a few bacteria may be found in health in the liver and in the pancreas, but never in anything like the same numbers or the same general distribution, nor with the same characteristic groupings, that have been proved for a number of infec- tious diseases. || It is stated that they are sometimes absent from the blood taken during life in septic diseases. As, however, their constant presence has been confirmed in the vessels and glomeruli of the kid- ney, it is fair to assume that they are filtered out by those organs when the conditions favorable to their development do not exist in the blood. Again, it is an open question, which awaits confirmation, whether it be not true, as Hueter claims, that the microspores do not disappear, but * " Exp. Beitrage zum Studium der septischen Infection," " Dtsch. Ztschr. f. Chir.," Bd. vi, p. 162. f Lectures on " The Relations of Bacteria to Disease," " Brit. Med. Jour.," March 27, 1875; see, also, Klebs, " Beitrage zur Kenntniss der pathogenen Schistomycetin," " Arch. f. exp. Pathol, und Pharmakol.," Bd. iii, p. 321. X '* Antiseptica und Bacterien," "Arch. f. exp. Pathol, und Pharmakol.," Bd. iv, Hefte 1 und 2. # " Arch. f. path. Anat. u. Physiol, u. f. klin. Med.," Bd. Ix, p. 453. || Klebs, " Arch. f. exp. Pathol, und Pharmakol.," Bd. iii, p. 319. PUERPERAL FEVER. 615 are taken up by the blood-globules, rendering the latter adhesive, and predisposing the blood to the stases characteristic of inflammation.* Zahn has shown that the inflammation in the mesentery of the frog, in the Cohnheim experiment, does not take place if the air is first fil- tered through diluted carbolic acid, f As to the exact manner in which these minute bodies exercise their pernicious influence, whether they operate mechanically, or whether they produce a virus in the process of nutritive activity, or whether, as is probable, both suppositions are correct, we may safely leave as questions to be decided by subsequent investigations. It is enough for us to note that the connection between sepsis and the round bac- teria is intimate and vital. Panum, who is often quoted as opposed to what is known as the bacteria theory, admits as probable that the microsporon septicum is inoculable, appears in the blood during life, multiplies in the tissues, and, in part by production of a special poison, perhaps, and in part by mechanically irritating the tissues, excites in- flammation, suppuration, and fever. J Bergmann, who once thought that he had found the secret of sepsis in a crystallizable substance derivable from putrid fluids, which he termed sepsin,* now squarely accepts the modern doctrine. Virchow has so far given in his adhe- sion to the new school as to say : " Especially in this connection are to be mentioned the diphtheritic process and the erysipelatous, espe- cially erysipelas malignum. The granular deposit in diphtheritically affected tissues, of which I formerly spoke, has more and more proved to be of a parasitic character. What we formerly regarded as simple, organic granules, as infiltration, or exudation, has since proved to be a dense aggregation of micro-organisms which penetrate into the tis- sues and cells to compass their destruction." || Even Billroth, who contends that what he terms a zymoid ferment is the first thing devel- oped in the line of causation, and that the bacteria are a sort of epi- phenomenon, concedes that the organisms, by their migrations, may become the carriers of the ATirus into the interstices of the tissues.A I mention the less willing witnesses to the importance of bacteria in dis- ease : I need not recapitulate the names of a host of active advocates of the germ theory. * " Allgemeine Chirurgie," Cap. xvii, " Der ficberhafte Process." So, too, Schiiller, he. cit, pp. 168 et seq. Birch-Hirschfeld likewise found bacteria in the white globules of pyemia, Schmidt's " Jahrbiicher," Bd. 166, No. 5, p. 187. f " Arbeiten an der Berner pathol. Institut.," 1871. X " Das putride Gift, die Bacterien, die putride Infection und Intoxication, und die Septicaemie," " Arch, f. path. Anat. u. Physiol, u. f. klin. Med.," Bd. Ix, p. 348. * I have not been able to obtain access to Bergmann's original paper, but make this statement on the authority of Hueter, " Allgemeine Chirurgie," p. 543. || "Die Fortschritte der Krieg's Heilkunde," Berlin, 1874. A " Untersuchungen iiber die Vegetaliensformen von Coccobacteria septica," Berlin, 1874, p. 200. 616 DISEASES OF CHILDBED. I have been thus explicit regarding the evidence concerning bacteria in septic diseases, because it places the question of the infectious group of puerperal fever-cases in the following position : Experiences oc- curring clinically, as well as those produced upon animals, teach us that certain lesions and symptoms, similar to those we are accustomed to regard as characteristic of puerperal fever, result from septic poison- ing. In a large class of cases, however, the connection between child- bed-fever and sepsis has been deduced rather from analogy than direct proof. For those who chose to regard such as due to a specific poison peculiar to the puerperal state, there was really no objection. If, how- ever, round bacteria are characteristic of septic poisoning, the ques- tion presents itself in a different light, and we haA'e to inquire whether, in the less obvious cases, bacteria are present in puerperal fever in the proportions and groupings that we find them in other diseases due to putrid infection. Now, it is precisely proof of this nature that has recently been abundantly rendered. Waldeyer,* Orth,f Heiberg,J and Von Eecklinghausen, found the tissues and lymphatics of the parametria filled with pus-like masses, which consisted, in addition to pus-cells, chiefly of bacteria. Bacteria swarmed in the fluid of the peritoneal cavity. In one case examined by Waldeyer, six hours after death, while the body Avas still warm, the peritoneal exudation was like an emulsion, and furnished an abundant deposit which consisted almost entirely of bacteria. Orth injected ten minims of peritoneal fluid from a woman dead of puerperal fever into the abdomen of a rabbit. As the animal was dying he broke up the medulla oblongata, and found in the peritoneal fluid enormous quan- tities of these organisms. In puerperal fever round bacteria have been likewise found, though in less quantities, in the lymphatics of the dia- phragm and in the fluids of the pleura, the pericardium, and the ventricles of the brain. In post-mortem examinations of fresh sub- jects, the serous fluids, withdrawn under proper precautions, do not contain round bacteria except in cases of septic infection.* Orth found in the purulent contents of the vessels of the funis, in children who died of sepsis, precisely the same formations as existed in the exuda- tions of the mother. The presence of these germs in puerperal fever serves not only to fix cases hitherto considered doubtful in the category of septic diseases, but it affords the best explanation of the protean phenomena of puer- peral fever itself. Steurer, formerly interne at the Bellevue Hospital, * " Ueber das Vorkommen von Bacterien bei der diphtheritischen Form des Puerpe- ral-fiebers," " Arch. f. Gynaak.," Bd. iii, p. 293. f " Untersuchungen viber Puerperal-fieber," " Arch. f. path. Anat. u. Physiol, u. f. klin. Med.," Bd. lviii, p. 437. X "Die puerperalen und pyaemischen Processe," Leipsic, 1873. # Klebs, " Beitrage zur Kenntniss der pathogenen Schistomycetin," " Arch. f. exp. Pathol, und Pharmakol.," Bd. iv, pp. 441 et seq. PUERPERAL FEVER. 617 where he witnessed the epidemic which prevailed in that institution in the year 1874, afterward made, under the guidance of Professor von Recklinghausen, a special investigation of the pathological changes in a similar epidemic which occurred in Strasbourg. From a Avritten communication received by me from Dr. Steurer, many of the follow- ing facts concerning the pathogeny of the disease have been derived. These facts, I may add, are fully supported by the investigations of others, and form a most valuable contribution to our knoAvledge of puerperal fever. Steurer's cases all presented diphtheritic patches about the vulva, or upon the mucous membrane of the vagina and uterus. These patches were always associated with a loss of substance, and were com- posed of disintegrated fibrine, white and red blood-corpuscles, and colo- nies of round bacteria in great abundance. From the patches, the bacteria could be traced betAveen the muscular fibers, and deep down into the canalicular spaces of the connective tissue, where their pres- ence gave rise to cellulitis. From the canalicular spaces they entered the lymphatics, with resulting lymphangitis. In many cases the lym- phatics could be traced along the broad ligaments to the ovaries (puer- peral oophoritis) and into the subperitoneal tissue of the lumbar region. By perforation of the walls of the lymphatics which directly underlie the peritonaeum, they made their way into the peritoneal cavity and excited pyaemic peritonitis, an affection which differs from traumatic peritonitis, and for which the claim has been set up that it is peculiar to puerperal fever. The wide stomata upon the abdominal surface of the diaphragm allowed the facile entrance of the organisms into its lymphatics. Waldeyer found in diaphragmitis the lymphatics of the diaphragm filled with bacteria. And thus following the lymphatic system, if we only admit that the round bacteria are the carriers of sepsis, a fact Avhich hardly admits of dispute, the frequency, in severe types of puerperal fever, of inflammations of the serous membranes— of the peritonaeum, the pleurae, the pericardium, and the joints—finds an easy explanation. We can understand, too, how it is not always altogether accident which determines in different cases the precise se- rous membranes which are affected. The ductus thoracicus is the principal channel through which the poison enters the blood. Bacteria are difficult to find in the blood during life. A feAv hours after death they swarm in that fluid. Pos- sibly the rapidity of the blood-currents during life does not favor the multiplication of bacteria. That they, however, enter the general cir- culation during life, is incontestable. Steurer Avrites, "As the kid- neys are the great filters of the human system, I never neglected to examine them, and almost invariably found the glomeruli and arterioli filled with micrococci (round bacteria)." This is in correspondence with what occurs in other septic diseases, and accounts for the albu- 618 DISEASES OF CHILDBED. minuria and interstitial nephritis which often supervene in the ad- vanced stages. We have seen already that, in consequence of septic poisoning, the white blood-globules have a tendency to adhere to the walls of the A*essels. This leads to stases in the capillaries, to conges- tion of the deep-seated organs, and to an increase of blood in the large Areins of the trunk. Finally, death takes place from apnoea, partly from the inability of the blood-corpuscles to carry oxygen to the tis- sues, and partly from paralysis of the respiratory nerve-centers.* Sometimes the bacteria pass directly into the veins, where they give rise to phlebitis. Professor von Recklinghausen recognizes three ways in which this may take place : 1. Through a thrombus (and here let me call to mind that it is very common in uterine phlebitis to find the uterus large, and the vessels at the placental site filled with soft thrombi) ; 2. Through direct perforation of the venous walls; 3. By being taken up by white corpuscles and by them conveyed into the vessels in the manner described by Cohnheim. When the bacteria enter directly into the circulation, they some- times, in passing through the heart, adhere to the endocardium and the valves, causing exudation, ulceration, and decomposition, and thus give rise to the so-called endocarditis ulcerosa puerperalis. f In the cases studied by Waldeyer and Steurer there were diphtheritic patches, serving as the starting-points of the puerperal processes. Whether these so-called diphtheritic patches are identical with those which appear in the throat, is an open question. Morphologically, they are so, but in hospitals epidemics of puerperal diphtheritis are not associ- ated with throat diphtheritis. To avoid misapprehension, let me distinctly state that diphtheritic patches are not necessary to the infectious form of puerperal fever. They indicate an unwholesome atmospheric condition, and are some- what rare outside of public institutions. Orth and Heiberg noticed the same general post-mortem changes in those cases in Avhich the patches were absent as in those in which they were present. My own obser- vations show that they are rarely developed in the early stages of a hospital epidemic of puerperal fever, nor are they to be found in all cases when such an epidemic is at its height. In some of the lying-in hospitals in Europe puerperal diphtheritis appears, hoAvever, to be endemic. The question as to the extent to which erysipelas and puerperal fever are cognate diseases is in a fair way to be solved by recent inves- tigation. Orth took the contents of a vesicle from an erysipelatous patient, which contained bacteria in great abundance, and employed * Vide Schuxler, " Exp. Beitrage zum Studium der septischen Infection," " Dtsche. Ztschr. f. Chir.," Bd. vi, Hefte 1 u. 2, pp. 149 et seq. f Heiberg (" Die puerperalen und pyaemischen Processe," Leipsic, 1873, pp. 22, 34) gives references to cases reported by AViege and Eberth. PUERPERAL FEVER. 619 the same for injections under the skin of rabbits. In this way he succeeded in producing in these animals a species of erysipelas malig- num. In the subcutaneous oedema and affected portions of the skin he found enormous masses of bacteria, so far exceeding in quantity the amount introduced as to prove an abundant new production.* Samuel produced similar results by the injection of ordinary putrid fluids containing round bacteria. An affection resembling simple erysipelas he obtained most frequently by the application of fluid to a wound torn open after the second or third day.f Lukowski found that erysipelas could be produced by fluid containing micrococci, even when putrefaction did not exist. The contents of erysipelatous A-esicles containing no micrococci excited no morbid manifestations. Where the erysipelatous process was fresh and progressing, micrococci were found in great abundance in the lymphatics and canalicular spaces. Where the process was retrogressive, there were no micrococci to be found, even in cases in which inflammation existed to an intense degree. J Virchow's testimony we have already given. Thus we find in surgical fever, in puerperal fever, in diphtheria, and in erysipelas, the presence of a common element which links them together, and which establishes the relationship which has long been recognized as existing between these various processes. Experiments, made by competent men with care and intelligence, serve continually to increase the probability that the bacteria are no chance products, but that they have a vital connection with the diseases designated. Whether these organisms are identical in the different infectious dis- eases in which they have been recognized, is another question. Billroth complains of the monotonous appearance of always the same forms.4* When we bear in mind, however, that our best instruments fail to enable us to distinguish the ovum which is to produce a mouse from one that will produce a tiger, though the ovum is at least one hundred times larger than the micrococcus, the argument loses something of its value. Whether identical or not, they all possess the common property of penetrating the tissues, under favorable conditions, of multiplying, and of producing, by their migrations, local inflamma- tions and general infection. I can not refrain, in conclusion, from quoting entire the following statement of Panum, which appears to reconcile certain differences in the definitions of the term septicaemia by different authors : " The putrid poison may, during life, enter the blood with or without bac- teria, especially from wounds, and occasion all the symptoms of septic poisoning, * " Untersuchungen tiber Erysipel," " Arch, fur exp. Pathol, und Pharmakol.," Bd. i, p. 81. + " Arch, fur exp. Pathol, und Pharmakol.," Bd. i, pp. 335 et seq. X " Untersuchungen liber Erysipel," " Arcliiv. f. path. Anat. u. Physiol, u. f. klin. Med " Bd. Ix p. 430. # " Untersuchungen iiber die Coccobacteria septica," p. 3. 620 DISEASES OF CHILDBED. whereas, however, the bacterium termo does not appear to occur in the blood during life. This simple putrid infection does not appear to be inoculable. Another, as it appears, distinct, specific, pathogenic fungus, the microsporon septicum of Klebs, developed especially in pus (and blood ?), perhaps under the predisposing influence of the putrid poison, when the air (as in overcrowded hospitals) contains the latter, or when it is transferred by inoculation, seems, on the other hand, during life to increase in the blood and tissues, and in part, per- haps, by production of a special poison, in part, perhaps, in a more mechanical way, by penetration, and, under circumstances, by its irritative action on the tissues, excites inflammation, purulence, and fever."* Clinical History.—As in other infectious diseases, there is, from the time of the entry of the poison into the system up to the outbreak of fever, a distinct period of incubation. The first febrile symptoms usually occur within three days of the birth of the child. An at- tack coming on a few hours after childbirth is indicative of infection during or previous to labor. The third day is the one upon which ordinarily the beginning of the fever is to be anticipated. After the fifth day an attack is rare, and at the end of a week patients may be regarded as having reached the point of safety. Apparent exceptions to this rule are probably referable to cases of mild parametritis, in which the initial fever and the pain were insufficient to attract atten- tion to the existence of local inflammation. The symptoms of puerperal fever vary Avith the character of the local affections and Avith the extent to which the general system participates in the disturbed action. The different groups of puer- peral processes possess the following pathognomonic symptoms, viz., increased temperature, enlargement of the spleen, disturbed involu- tion and sensitiveness of the uterus upon pressure (Braun). In most cases the fever is ushered in by chilly sensations, or by a well-defined chill. This symptom, however, does not possess much prognostic importance. A chill is significant of a sudden change betAveen the temperature of the skin and that of the surrounding medium. It may, therefore, be absent in pernicious forms of fever, provided only that the temperature changes are inaugurated slowly, Avhereas it may follow a trifling increase of the body-heat if, as some- times happens in sleep, the moist skin is exposed to cool currents of air. Repeated chills indicate phlebitis and pyaemia. In order to grasp the many symptoms of puerperal fever, it is neces- sary to keep separately in mind the clinical features of each of the local processes, although in fact the latter rarely occur singly, but to a greater or less extent in combination with others. The Symptoms of Endometritis and Endocolpitis.—The uncom- * " Das putride Gift," etc., " Archiv. f. path. Anat. u. Physiol, u. f. klin. Med.," Bd. Ix, p. 349. I have translated literally. The meaning of the sentences, in spite of the involved construction, is sufficiently clear. PUERPERAL FEVER. 621 plicated catarrhal inflammation of the uterus and vagina is the most frequent and the mildest of the diseases of childbed. In endome- tritis the uterus is large, flabby, and sensitive upon pressure ; the after- pains are often unusually severe, involution is retarded, and the lochia become fetid, remain sanguinolent for a longer period than usual, and at the outset may be temporarily suspended. Sometimes the large intestine is distended Avith flatus. In endocolpitis the vaginal discharge is thin and purulent, the patient experiences pain and burning in the acts of defecation and urination, and, where the wounds of the vulva and vagina assume an ulcerative character, there is often found at the same time inflammatory oedema of the labia. The fever in these cases is ushered in frequently but not always by chilly feelings, and the temperature reaches its height usually upon the evening of the third or fourth day, is remittent, almost intermit- tent in character, and rarely exceeds 102° to 103°. In mild forms the occurrence of the fever is often overlooked, or is referred to disturb- ance produced by the secretion of the milk. In severer attacks the febrile symptoms may continue from three to seven days. At the end of a week the swelling of the labia subsides, the discharge becomes thick, and ulcers, if present, begin to assume a healthy granulating appearance. In diphtheritic ulcerations, and in endometritis due to decomposing remains of the ovum, the local condition is often complicated by the invasion of the neighboring tissues. Parametritis and Perimetritis (Pelvic peritonitis).*—The symptoms of these two affections, as would be naturally expected from the prox- imity of the peritonaeum to the pelvic connective tissue, for the most part overlap. It must be very rare for one form to occur entirely in- dependent of the other. For this reason it will be found convenient to consider first the symptoms common to both morbid processes, and subsequently to direct attention to what are believed to be points of distinction between them. During the period of incubation there are usually no prodromic symptoms. Elevations of temperature in the course of the first twelve hours following labor are equally frequent under perfectly normal con- ditions. Suspicious symptoms are disturbed sleep, excessively painful after-pains, and a pulse of 80 to 90. The beginning of the fever occurs in ninety per cent, within the first four days of childbed ; most frequently upon the second or third day, and taking place upon the fourth day in scarcely twelve to fifteen per cent, of the cases. If five days have elapsed without fever, the * The following clinical history, together with the statistical details, is borrowed in great part from the description of Olshausen (" Ueber puerperale Parametritis und Peri- metritis " Volkmann's " Samml. klin. Vortr.," No. 28), the exactitude of which I have had abundant opportunity to verify. 622 DISEASES OF CHILDBED. period of danger, with very rare exceptions, may be regarded as hav- ing passed. At the outset the fever, especially in perimetritis, is ushered in by chilly sensations, or by an intense chill. The temperature rises rapid- ly, though the highest point is usually not reached before the second, and in rare cases not before the third, day. In most cases the heat in the axilla exceeds 103°, and may even mount up to 105°. The decline occurs gradually, the fever ending in seventy per cent, in the course of a week, in twenty per cent, in two weeks, and only in ten per cent. extending beyond that period. Protracted cases indicate abscess formation. The fever does not, however, always pursue a regular course. In place of progressively declining until the termination is reached, the high temperature of the second day may be attained upon one or more occasions. The morning remissions are at first slight, but become marked as the disease approaches its close. In cases of long duration the morning hours are often free from fever, a circumstance calculated to mislead a physician who sees his patient but once a day. A pulse of 80 to 90 beats, a disturbed sleep, lack of appetite, and sensitiveness to pressure upon the sides of the uterus are, hoAvever, symptoms which should serA'e as a warning of some disturbing cause, and should lead the physician to renew his visit in the latter part of the day. If, from a mistaken notion that the morbid process has come to an end, the patient is allowed prematurely to resume her household duties, the pains across the abdomen and along the hip and thigh return, and an examination reveals the existence of exudation in the pelvic cavity or upon an iliac fossa. Errors of this kind are most frequent in cases of parametritis associated with slight peritoneal inflammation, as the local pain is then insignificant, and the initial chill, happening on the third or fourth day, is apt to be ascribed to engorgement of the breasts. Relapses after the complete disappearance of febrile disturbance occur in fifteen to twenty per cent. They are usually shorter, but sometimes more obstinate, than the original attack. As a rare excep- tion may be mentioned cases with evening remissions and morning exacerbations. In circumscribed pelvic inflammations the pulse rarely exceeds 120 beats to the minute. A pulse of 140, of more than a half-day's duration, betokens severe septic complications, and is therefore of evil omen. In some cases the slow pulse observed after labor makes its influence felt in the first day or two of the fever, so that the curi- ous phenomenon may be witnessed of a temperature of 104° coin- ciding for a time with a pulse ranging between 50 and 70 beats to the minute. As regards other symptoms, headache and sleeplessness are rarely PUERPERAL FEVER. 623 absent. Profuse sweating follows the first febrile attack, and fre- quently recurs during the course of the disease. Pain is present at the onset in the majority of cases, and is then usually most violent. The spontaneous pain, which is due to the affec- tion of the peritonaeum, subsides in great part in the course of one or two days, but the sides of the uterus remain sensitive to pressure. In the rare cases of pure parametritis, hoAvever, this symptom may be absent altogether. The pain, like that from the inflammation of serous membranes, is of a lancinating character. Sometimes it is associated only with the contractions of the uterus. After-pains occurring under unusual cir- cumstances, as in primiparae or after the third day, are to be regarded with suspicion. Vomiting occurs occasionally, but is comparatively rare unless the peritonitis becomes diffused and spreads to the region of the stomach. The appetite is lost, and only returns, as a rule, Avith the departure of the fever. The tongue is coated and moist, and constipation is common. In other cases there is diarrhoea Avith rumbling in the bow- els, but without pain or tenesmus. The urinary secretion is rarely interfered with, and when this is the case it indicates the extension of the inflammation to the peritonaeum, covering the bladder. Most cases of perimetritis and parametritis terminate in five or ten days, the feA*er and other symptoms gradually subsiding. When, as may happen in exceptional instances, the temperature falls suddenly from a high to one below the normal level, the body grows icy cold, the pulse becomes small and irregular, and symptoms of collapse de- velop. But in twelve to twenty-four hours the symptoms of collapse subside, and the disease reaches its end Avith a disappearance of the alarming manifestations. If the fever subsides within a Aveek, exudation is somewhat rare. Its continuance beyond that date should lead to a careful exploration of the pelvic organs. The exudation is usually demonstrable in the course of the second week or at the beginning of the third Aveek. It is recognized, according to its location, by external or by internal exam- ination, or, where the. deposit is considerable, by both methods. In most cases the deposit is extra-peritoneal, and is situated between the folds of the broad ligament, above and to the sides of the vaginal cul- de-sac. It has generally a rounded form, though with less convexity than fibrous and ovarian tumors. Sometimes, however, the tumor is flat below, like a board. It seldom exceeds in size that of a large apple. In fresh exudations the sensation produced is often that of a hard tumor surrounded by a softer layer, due to continued succulence of the soft parts. In a few weeks they may reach or exceed the hardness of a fibroid tumor. The older the tumor, unless suppuration sets in, the less sensitive it becomes. Often the exudation extends to the pel- 624 DISEASES OF CHILDBED. vie walls. The uterus, as a rule, is fixed, and in cases of large tu- mors becomes pushed toward the opposite side, while as a consequence of later shrinkage the fundus may be drawn permanently toAvard the affected side. The cul-de-sac of the vagina is rendered broader and flatter by the pressure of the deposit, or, Avhen the tumor is deep enough, the vagi- nal surface may be rendered convex. Behind the uterus the exuda- tion is as it were flattened antero-posteriorly, and in some cases it may be felt in the form of rigid bands betAveen the posterior ligaments which inclose the cul-de-sac of Douglas. The ante-uterine tumors have a spherical shape, and depress the vagina anteriorly. Tumors situated in the iliac fossa have a more or less convex form, and may be of such considerable size that the swelling may be recog- nized by the eye through the abdominal walls. As the exudation be- tween the broad ligaments may in these cases have been slight from the beginning, or may have subsequently disappeared by absorption, the iliac tumors have often apparently a spontaneous origin. Sometimes the uterus is surrounded by exudation, and the entire pelvis appears as though it were a mold filled with a solid mass. The fornix is then often pressed downward, and irregular rounded masses are to be felt through the vaginal walls. The recognition of parametritic tumors through the abdominal coverings is possible when they are situated above Poupart's ligament, in the upper portion of the broad ligaments, and in the iliac fossae. The pain and the functional disturbances in the pelvic organs de- pend upon the size and situation of these inflammatory deposits. Of the functional troubles may be mentioned frequent and painful mic- turition, obstinate constipation, and difficult defecation, contractures of the ilio-psoas muscles, when the exudation is seated beneath the sheath or between the muscle and the pelvic bones, disturbances of motility in the abductor muscles, paresis of the lower extremities, and radiating pains in the upper portion of the thigh, and in the renal and lumbar regions, produced by pressure upon the obturator, the crural, the cutaneous, and the sciatic nerves. So long as fever is present, the exudation rarely diminishes. If absorption takes place in one point, growth almost certainly follows in some other direction. When, however, the apyretic period is reached, the exudation, as a rule, disappears rapidly, so that often in the course of six weeks no trace of its existence remains. In a smaller number the solid mass may persist for months, or even years. After the fever has departed, the patient usually feels well. The sleep and appetite return, the night-sAveats disappear, the pulse often falls to 50 or 60 beats, and the temperature is in many cases for a time subnormal in character. Where the fe\'er persists for from five to six weeks, there is always PUERPERAL FEVER. 625 a suspicion of abscess formation. With the exception of afternoon fever and night-sAveats, the patient may feel very comfortable. Then the exudation becomes sensitive, the spontaneous pains recur, sleep is lost, and locomotion, defecation, and urination occasion acute suffer- ing. The fever becomes violent, chills announce the presence of pus, and finally, about the seventieth or eightieth day, perforation of the abscess takes place. The usual seat at which the pus is discharged is just above Poupart's ligament; next in frequency perforation takes place into the colon, and in rare instances into the bladder, the uterus, and vagina. Fortunately of very rare occurrence is the discharge of pus into the peritoneal cavity, which is naturally followed by acute peri- tonitis. Another likewise unfrequent but most dangerous accident is the septic infection of the abscess, an occurrence referred by Olshau- sen to the diffusion of intestinal gases through the walls of the tumor. In suppuration of parametritic exudations the pus commonly forms in small scattered collections, and rarely gives rise to large abscesses. Although parametritis and perimetritis are usually found associated together, there are always cases in which the one form of inflamma- tion so far predominates over the other as to justify an attempt to establish a clinical distinction between them. In the beginning of the attack, sharp pain, high fever, and tym- panitic distention of the lower abdomen are symptomatic of inflam- mation in the pelvic peritonaeum. Whether the cellular tissue is si- multaneously implicated can only be determined by a digital examina- tion after the abdominal sensitiveness has subsided. The absence of the objective signs of cellulitis would then contribute to prove that the case had been one in which the peritonaeum had been in the main affected. On the other hand, moderate fever, pain elicited only on pressure, and tympanitic distention confined to the colon, coinciding with exudation between the folds of the broad ligament, would be indicative of a nearly pure cellulitis. A palpable exudation is by no means the necessary product of peri- toneal inflammation. Indeed, in many cases, the distinctive symp- toms of the latter may be present for from four to eight days, and may then subside without leaving a trace of its existence at the pelvic brim. The demonstration of a fluid effusion by noting the change of level upon shifting the position of the patient is rarely possible, either be- cause the quantity is too small, or because it quickly becomes confined by pseudo-membranous adhesions between the intestines. Bandl * mentions as a sign of local peritonitis, sometimes notice- able, a number of resistant points or tumors near the pelvic brim, or above one of the iliac fossae, due to a matting together of the intes- tines or to their adhesion to the uterine appendages. They are distin- * Bandl, " Handbuch der Frauenkrankheiten," red. von Billroth, 5te Abschnitt, p. 129. 40 626 DISEASES OF CHILDBED. guished from solid tumors by their emitting a tympanitic sound upon percussion and by their changing position in consequence of an accu- mulation of urine in the bladder, or of faeces or gases in the bowels. Again, all tumors may be reckoned as intra-peritoneal which very rap- idly form behind or to the side of the uterus from inclosed exudation :- products, and which at the same time rise far above the level of the pelvic brim. If, however, they start from the cul-de-sac of Douglas, and do not much exceed the linea terminalis, or if they occupy an iliac fossa, it becomes very difficult to decide whether they are of intra- or extra-peritoneal origin. The peritoneal exudation, however, long remains soft and fluctuating. It arises, as a rule, behind the uterus, and does not exhibit a tendency to spread to the sides or the anterior or posterior pelvic walls. Still more difficult is it to decide as to the seat of exudations met with beneath the abdominal walls. When diffused and continuous with a pelvic deposit, the diagnosis is uncertain. It is only safe to assume the peritoneal origin of extravasations of a rounded form, of a fluctuating consistence, and when they are situated high up and are disconnected from exudation at the pelvic brim. An opening of the abscess through the navel would indicate a peritoneal source, while the discharge through the abdominal parietes would point to a seat in the connective tissue. After the perforation of an abscess the fever and pain subside, the wound, if external, either closes in the course of one or two weeks, or fistulae form which become the source of protracted suppuration. In psoas abscesses the exudation extends beneath the sheath of the muscle, or between the iliacus and the bone. In puerperal patients they proceed from an inflammation originating in the broad ligament. They are situated too deep to be easily palpated. The pains they oc- casion are referred rather to the hip or knee than to the abdomen. The contracture of the psoas muscle furnishes a diagnostic sign which distinguishes this form from the superficial abscesses of the iliac fossae. The pus eA-entually is discharged beneath Poupart's ligament, in the lower portion of the inguinal fossa, at some point upon the crest of the ilium, or exceptionally along the thigh. Often the discharge is maintained for months. General Peritonitis.—This form generally begins with the usual symptoms of pelvic inflammation, but the tenderness, which at first Avas limited to the side of the uterus, gradually spreads over the entire abdomen. The abdominal pain is of a tearing, lancinating, some- times colicky character. It is increased by the slightest bodily move- ment, by jarring of the bed, or even by the weight of the bedclothes. As a consequence of the peritoneal inflammation and of the accom- panying exudation, the muscular walls of the bowels become paralyzed, and tympanitic distention results from the accumulation of gases. In PUERPERAL FEVER. 627 the dependent portions of the peritoneal cavity it is often possible to demonstrate by percussion the presence of fluid exudation, though dis- tinct fluctuation is rarely to be made out. The size of the abdomen is due much more to the tympanites than to the amount of effusion. Sometimes the liver, with the diaphragm, is pushed by the swollen bowels to the level of the fourth or third rib, and exercises such a degree of compression upon the posterior portion of the lungs as to place the patient in danger of suffocation. The respirations are jerky and attended with a moaning sound. The loss of muscular poAver in the intestines permits the contents of the middle portion to pass unchecked toward the duodenum, and thence, upon accidental contractions of the abdomen, they may pass to the stomach and be ejected by vomiting. The first vomited mat- ter has a dark-green color, and that ejected afterward presents the color of intestinal matter. Constipation at the outset may be subsequently followed by colliquative diarrhoea. The fever begins, as a rule, though not always, with an intense chill, the temperature rises to 104°, and the pulse becomes small, hard, and resistant. Its frequency rapidly increases, varying from 120 to 160 beats to the minute. The skin is sometimes dry, sometimes drip- ping with perspiration. In fatal cases, as the end approaches, the temperature frequently falls, while the pulse becomes more rapid, the face assumes a pinched, anxious expression, sweat gathers upon the forehead, the extremities grow icy cold, and the patient dies in col- lapse. The duration of peritonitis averages not more than from four to six days. In cases of recovery the pulse improves, the vomiting ceases, and the tympanites disappears. The diffuse exudation then becomes con- Alerted into circumscribed tumors, which on palpation are felt on the side of the pelvis and extending upward to the level of the umbilicus. Upon internal examination the uterus is often found depressed by the weight of the fluid, which likewise may bulge the cul-de-sac of Doug- las into the pelvic cavity. Sometimes the exudation may become en- cysted above the pelvis, and leave the contents of the latter free. In still other cases the uterus may become attached high up to the ab- dominal walls, so that the vaginal portion disappears, and the os is reached with difficulty. The peritoneal exudation may, as in pelvic inflammations, become absorbed and disappear. When, however, it is surrounded by loops of intestines it is apt to undergo purulent and septic changes, and the abscesses may then become discolored and filled with stinking gases. The patient, whose previous improvement has been watched with de- light, now loses appetite, the pulse becomes frequent, the strength fails, and death may follow from septic fever or from rupture of abscess into the abdominal cavity. 628 DISEASES OF CHILDBED. In the pyaemic form—a still more deadly variety of peritonitis— the symptoms differ materially from those which have been recounted. As, however, it constitutes only a single one of the pathological changes connected with the poisoning of the blood through the lymphatic sys- tem, its consideration belongs properly to the study of septic infec- tion. Septicaemia Lymphatica.—The symptoms of blood-poisoning in the infectious diseases of childbed vary to a considerable extent according to the channel through which the septic germs enter the general cir- culation. In the murderous epidemics which prevail in lying-in hos- pitals the lymphatics are, as a rule, the vessels primarily invaded. It is to this form that belong the cases already described, where, Avith diphtheritic patches upon the utero-vaginal canal, and sero-purulent oedema of the parametrium, there are associated pyaemic peritonitis and deformation of the blood-corpuscles ; or where, following the migrations of the round bacteria, the serous cavities become succes- sively involved, septic vegetations gather upon the heart, and the glom- eruli of the kidneys become choked Avith micrococci. The lymphatic form of septicaemia develops soon after labor, and is always ushered in by a chill. The temperature rises to 104° or even higher, and the pulse is thin and frequent. The abdomen swells rapidly, without being especially painful. Indeed, painless distention of the intestines is one of the characteristics of an acute invasion of the lymphatics. Peri- toneal effusion is absent in cases which run a rapid course, and is dis- tinctly recognizable only in a peritonitis of long continuance. The effusion is not so much due to exudation as to a transudation of serum with which micrococci are commingled. At the same time the tongue is moist, but slightly coated, and at times quite clean. Sometimes there is diarrhoea due to catarrh or to a diphtheritic affection of the colon. When the bowels have been constipated, the administration of a purgative may provoke discharges Avhich it may be found difficult to arrest. The skin is bathed in perspiration. At the beginning and during the course of the disease, bleeding at the nose is of not infre- quent recurrence. Toward the end the pulse runs up to 140 to 160 beats, while in many cases the temperature falls. Immediately after death the heat of the body may for a short time exceed the highest point reached during life. The respirations are superficial and jerky. In many in- stances the face, the neck, and the fingers are blue from defective oxygenation of the blood. At the same time the skin becomes clammy and the extremities cold. The sensorium, in cases which run a rapid course, is usually affected at an early period. The patients appear somnolent, are restless in bed, have light delirium, and respond only when spoken to loudly. As a rule, they make but little complaint, and, were it not for the dyspnoea, PUERPERAL FEVER. 629 would have nothing to disturb their sense of comfort. Very few, even as death approaches, have any idea of the danger that threatens them. Now and then, in place of stupor, great restlessness, and even a maniacal condition, is developed. Albumen is usually found in the urine. Pleurisy, so frequently associated with lymphatic septicaemia, is frequently double, more rarely single, and begins, as a rule, with sharp pain in the side and an aggravation of the previous dyspnoea. Pericarditis is less frequent, and occurs usually without symptoms toward the close of life. The joint affections are characterized by redness and swelling, and by pain which is sometimes so great that touching the inflamed part suffices to arouse the patient from sopor. Sometimes fluctuation is felt, but death occurs before perforation and discharge of the pus. The most frequent ending is death, which follows in from two to twenty-one days, and, as a rule, between four and seven days. Re- covery is, however, possible. Septicaemia Venosa (phlebitis uterina, pyaemia metastatica).—The putrid infection of a thrombus at the placental site may take place within twenty-four to forty-eight hours after labor. Usually, how- ever, the approach is insidious, and the disease develops from an ap- parently insignificant endometritis or parametritis; or the patient, Avith the exception perhaps of a tired feeling, of slight chilly sensa- tions, and of profuse perspiration, may not have been conscious of any indisposition for days preceding the attack, or even until the first getting up from childbed. The initial chill in typical cases is char- acterized by its violence and duration. In some cases it may last for hours. It is accompanied and followed by high temperature, the febrile attack ending with profuse perspiration as in intermittent fever, with which it is apt to be confounded. The fall in temperature often assumes the form of a prolonged remission. In many cases the pulse rises and falls with the variations in the body-heat, while in others it remains permanently above the average. A frequent pulse is always a suspicious symptom in childbed, even where the other symptoms are apparently normal. Erratic chills announce the lodgment of emboli in distant organs. With the formation of metastatic abscesses in the lungs and other parenchymatous organs, the typical character of the disease changes. In place of chills occurring at irregular intervals, followed by remis- sions and periods of apparent improvement, the fever is continuous, the pulse becomes small and rapid, while sopor, slight delirium, a dry skin, a dry, broAvn, cracked tongue, and a moderately tympanitic ab- domen give the case the appearance of one of typhus fever. Peritonitis is present in hardly one third of the cases. The abdo- men is therefore flat and soft, and often is not sensitive upon pressure. 630 DISEASES OF CHILDBED. Icterus, due to disintegration of the blood-corpuscles, is an ominous symptom. Death usually occurs in the second or third Aveek. In the typhus- like cases, however, it may follow the first attack speedily. RecoA'ery is possible where the organs secondarily affected are not of too great importance. A combination of the lymphatic and venous forms of septicaemia is not uncommon in cases running a protracted course. Pure Septicaemia.—Under the title of pure septicamia should be placed cases in which the absorption of putrid materials into the blood gives rise to symptoms of intense blood-poisoning Avithout the development of local lesions. A common example of this form is met with in the fever which results from the presence in the uterus of decomposing coagula or portions of retained ovum, the fever subsid- ing with the removal of the disturbing cause. In like manner we sometimes meet with cases of intense septic poisoning followed by speedy death, in which the post-mortem examination reveals only changes in the blood and softening of the parenchymatous organs. The symptoms are often similar to those produced by the injection of putrid materials containing rod-like bacteria into the vessels of ani- mals. As the long bacteria do not possess the capacity of self-repro- duction in the blood, to produce fatal results the quantity of putrid fluid injected must be large or be frequently repeated. This form is said not to be inoculable. CHAPTER XXXVI. PUERPERAL FEVER.—( Continued.) Causes.—The atmosphere.—Relations to zymotic diseases.—Season of year.—Social state. —The prevention of puerperal fever.—The treatment of puerperal fever.—Vaginal and uterine injections; opium; leeches ; laxatives; quinine ; salicylate of sodium; veratrum viride; digitalis ; alcohol; cold.—Treatment of peritoneal effusions. Causes of Pueeperal Fever. The Atmosphere.—The effect of a poisoned state of the atmosphere is best observed in the so-called nosocomial malaria of hospitals. At Bellevue and at the Maternity Hospitals I have had frequent occasion to witness febrile outbreaks among the patients in the lying-in service, which were instantly arrested by closing the tainted ward and trans- ferring the inmates to a wholesome locality. As at these times the nurses, the bedding, and the utensils remain unchanged, it is fair to assume that the previous unhealthy condition was not due to the trans- fer of the poison from patient to patient by the attendants, but by something residing in the air of the vacated apartment. In the inquiry PUERPERAL fever. 631 as to the production of this condition, it can be assumed that it is not caused by aggregation alone. The medical Avards, always croAvded, have been in time of need safe receptacles for lying-in patients. It is cer- tainly not due to the presence of what are generally regarded as the or- dinary constituents of the atmosphere. We must, therefore, look for some additional element capable of unfavorably affecting the economy. When the disturbance produced by nosocomial malaria is not arrested by change of locality, and the golden moment is allowed to slip by, the secretions of the patient affected become inoculable. Under such circumstances the epidemic spreads rapidly, and assumes continuously a more and more severe type. If, during such an epidemic, the exter- nal genitals be carefully watched, diphtheritic patches may now and then be obsened. At first these patches may not be of any special clinical importance. It is possible that they may rapidly clear off, and thus come to be regarded as of little consequence. When, at length, the epidemic has assumed a pestilential form, these patches, which may make their appearance in isolated cases at any time in a hospital, are rarely absent. I have already dwelt upon the composi- tion of these patches, not because I believe that they are essential to puerperal fever, but because their presence tells the tale of what it is in the atmosphere which accomplishes the charnel-house work. Con- ditions haA'e been present in the air to favor the multiplication of bac- teria, and ha\*e fitted them to become the active producers of disease. Can we doubt this ? First, the epidemic is mild. If a patient, how- ever, dies, her tissues and secretions are filled with bacteria, as has been described. Then the epidemic becomes virulent, and the lesions of the generative apparatus, especially of the external organs, which are most exposed to the air, become covered with patches which are found to SAvarm with micrococci. I can not, under the conditions named, but consider it more in accordance with ordinary scientific reasoning to conclude that the micrococci played an important part in the production of puerperal fever, than that the puerperal fever pro- duced the micrococci. To be sure, bacteria or their spores are always present in the atmos- phere, and it may be fairly asked how patients are ever spared from their perverse industry. The answer is, that they are not always equally active for evil. Buchholz found that the same bacteria, developed in Cohn's fluid, offered more resistance to carbolic and salicylic acids than those cultivated in an analogous fluid which he had adopted. Distilled water renders the action of bacteria extremely feeble. In experiments upon animals, the results obtained with septic fluids de- pend in no ordinary degree upon the age of the fluid, the material from which it is formed, and the conditions under which it is gener- ated. Micrococci multiply in hospitals when organic materials favor- able to their growth are present in sufficient quantities. Robin and 632 DISEASES OF CHILDBED. others have demonstrated the existence of albuminoid matters in water condensed upon vessels containing freezing mixtures, and placed in overcroAvded wards of hospitals. When the results of croAvding become manifest, these albuminoid matters not only impart a peculiar fetid odor and putrefy with great rapidity, but rapidly impart putrefaction to normal blood and healthy muscle Avith which they are brought in contact.* Micrococci both cause putrefaction and serve as the car- riers of septic virus. Hueter found putrid blood a most favorable fluid for septic experiments. It was noticeable in Bellevue Hospital that febrile outbreaks always arose in, and were usually confined to, the ward in the hospital which, by a bad arrangement, was assigned to patients for the first four or five days following confinement—i. e., during the period of the lochia cruenta. As puerperal fever is rare after the fifth day, this at first sight would seem natural. But if a patient was transferred directly after confinement, during one of these unhealthy periods, to the ward containing the patients who had passed the first five days, but had not completed the ten days, she would escape the fever. It was always the same ward that required to be disinfected. In a communicating apartment all the confinements took place ; and at all times, therefore, the conditions were present for load- ing the atmosphere with the products of decomposing blood. In the summer months, as long as the .windows were open all the time, the patients enjoyed immunity from nosocomial malaria. In the autumn, so soon as it became necessary to close the windows partially on ac- count of the cool nights, it was not uncommon for the more trivial disturbances, such as so-called milk-fever, the hospital-pulse, and ca- tarrhal affections of the genitalia, to manifest themseh^es. Through the months of February, March, and April the mortality was usually greatest. During the winter months there was, as a rule, crowding of patients, insufficient ventilation, the saturation of the air with albu- minoid materials chiefly derived from blood, which, under the further- ing influence of the heat requisite to make the Avards comfortable, entered readily into decomposition. That the latter winter months should prove the most perilous, is in accordance not only with the theory of continuous accumulation, but Avith the experimental fact that weeks sometimes elapse before a decomposing substance acquires the highest degree of virulence. Apart from the nosocomial malaria of hospitals, there is reason to believe in the influence at times of certain general widespread atmos- pheric states which affect the entire community. In the year 1871 the mortality from childbed in New York was 399 ; in 1872, 503 ; in 1873, 431 ; in 1874, 439 ; and in 1875, 420. Now, the excess in the deaths for 1872 was due wholly to an increase in the cases of me- tria, those from ordinary accidents remaining nearly the same as in the * "Lecons sur les humeurs," Paris, 1867, p. 195. PUERPERAL FEVER. 633 preceding years. The disease certainly did not extend into the city from the hospitals serving as foci, for the mortality at Bellevue Hospital was hardly more than half the usual average. There was no especial mortality that year from either diphtheria, erysipelas, or scarlatina, but the aggregate mortality was the largest knoAvn in the history of the city. There are no positive data connecting the civil deaths from puerperal fever in 1872 with parasiticism, but the prevalence of epizootics, of epidemic catarrhal affections, of peculiarly fatal forms of pneumonia, and other diseases which are now attributed to the presence of minute organisms in the atmosphere, renders such a source highly probable. It is proper to say here that, though the argument is very strong in favor of regarding the genitalia of puerperal women as the exclusive point of entry of infectious materials into the system, it seems impos- sible at the present time to make all the facts coincide with such a theory. I have the records of a number of cases occurring during an epidemic of puerperal fever, in which patients were either attacked with fever previous to parturition, or in A^hose cases the unusual length of labor, the frequency of post-partum haemorrhage, and the imperfect contraction of the uterus immediately after confinement were signs of some abnormal influence exercised upon the economy at an early period of labor, previous to the existence of traumatism. That deleterious materials may find other channels for entering the system than a wounded surface, is evidenced by the cachectic condition not unfrequently produced in physicians by too assiduous attendance in dissecting-rooms and places in Avhich post-mortem examinations are conducted. One severe and rapidly fatal case of puerperal fever, which occurred in Belle\Tue Hospital, I find it impossible to attribute to any other cause than that the Avoman, for five months previous to her con- finement, served as a helper in a lying-in ward. The post-mortem examination disclosed no special local lesions, but her symptoms were those of intense septicaemia. It does not yet seem quite time to give up the idea that, under exceptional circumstances, the respiratory, and probably the digestive, tracts may allow the passage of materials of a septic character. Inoculation.— Another and frequent source of puerperal fever is by direct inoculation. Any material of a septic character, introduced into the genital passages of a woman during or after confinement, may produce a general infection of the system. But the point upon which I wish especially to dwell is that it is possible to trace epidemics of puerperal fever directly to carrying puerperal poison from patient to patient, through the medium of attendants. In such cases changes in wards and the most rigid sanitary precautions avail but little, as lon«- as the affected personnel is continued in charge. Unless this fact is fully recognized, all the cleverest devices in hospital construction 634 DISEASES OF CHILDBED. will fail to prevent the occurrence of disasters. In epidemics this source of danger is especially to be guarded against, as septic poison is increased in intensity by successive inoculations. Davaine * showed that when a number of animals were poisoned, the one from the other, while from ten to fifteen drops of putrid blood were required to pro- duce death in the first animal, one ten-trillionth part of a drop was sufficient in the twenty-fifth animal of the series, and in puerperal- fever epidemics a similar augmentation in the deadliness of the poisons generated by patients is observed. The nurses in hospitals and in private practice are usually the carriers of contagion. In studying the records of New York City for nine years, I find, hoAvever, that the occurrence of two deaths from puerperal disease, following one another so closely as to lead to the suspicion of inoculation, occurred to thirty physicians ; a sequence of three case occurred in the practice of three physicians ; one physician lost three cases, and afterward two, in succession ; one physician had once two deaths, once three deaths, and twice four deaths, following one another; finally, a physician reported once a loss of two cases near together, then of six patients in six months, and then of six patients in six weeks. Thus in the practice of more than twelve hundred physicians, in nine years, I find, excluding cases occurring in hospitals, that the experience of thirty-six only lends color to the idea that puerperal feATer is due to criminal neglect on the part of the medical profession. Undoubtedly in many of these cases, too, the responsibility is only apparent, as when a practi- tioner has, for example, had the misfortune to lose in one Aveek a woman from puerperal convulsions, and another in the following week from placental haemorrhage. Singularly enough, not one of the sequences mentioned occurred in the practice of a physician connected with a lying-in hospital. In face of the charge that the physicians holding obstetrical appointments in public institutions are active disseminators of puerperal fever through populous com- munities, I find that the total loss from all puerperal causes, oc- curring in the private practice of ten physicians intimately asso- ciated with such institutions, numbered, during the nine years, but twenty-one cases. Of these, thirteen were the result of or- dinary accidents, and only eight cases of metria proper, of which one was developed before the physician was called in attendance ; Avhereas a single physician, holding no hospital appointment, lost dur- ing the same time twenty-seven cases, of which twenty-one Avere cases of metria. I have been interested in endeavoring to ascertain how far ex- perience corresponds with Semelweiss's theory that puerperal fever OAves its origin to poisonous materials obtained from dissecting-rooms, * Report before the Academic de Medecine, September 17, 1872. PUERPERAL FEVER. 635 and introduced into the genital canal by the hands of physicians at- tending cases of labor. With this view I have made personal applica- tion to a number of gentlemen who have engaged in midwifery practice while performing the functions of demonstrators of anatomy in our medical schools. Dr. H. B. Sands, of the College of Physicians and Surgeons, reports that, in the five years during which he held the office of demonstrator, he attended about sixty cases of labor. All did well. He lost his first patient, from childbed, a short time after he had re- signed his position in the dissecting-room. Dr. J. W. Wright, the present Professor of Surgery in the Medical Department of the New York University, Avho held for one year the position of Demonstrator in the Woman's College, writes me that "during the year, I attended one hundred and four cases, including twenty-two forceps cases, two of craniotomy, tAvo of podalic version, and four of breech presentation. Of this number I lost two cases, one from phlegmasia dolens compli- cating uraemia, from both of which troubles the patient had suffered during her previous labor, and one from double pneumonia, the result of unusual exposure following confinement. Out of these one hun- dred and four cases, I can recall but three or four cases of metritis, and those of a mild character; I have never thought they had any special connection with my duties in the dissecting-room. I may add that for ten years I have attended a pretty large number of confine- ments each year, and that during the whole of this time I have been in the habit of making autopsies as occasion has offered, and of han- dling and examining pathological specimens both in and out of the dissecting-room, notwithstanding which, my death-record among this class of cases has been unusually low." Dr. Samuel B. Ward, formerly Demonstrator at the Woman's College, at present Professor of Surgery in the Medical School at Albany, writes : "While I was daily in the dissecting-room, during the winter sessions of the school from 1868 to 1872, I attended thirty-two confinements, of which I have notes. All of the patients recovered, nor did any of them suffer from any com- plication that could be traced to infection." It is familiarly known that, after Semelweiss had introduced the practice, among the physi- cians attending patients at the large lying-in hospital in Vienna, of washing the hands in a solution of chloride of lime, there Avas a great diminution in the mortality which prevailed, notwithstanding which Gr. Braun reports, however, that in 1857, in the month of July, in two hundred and forty-five deliveries there were seventeen deaths. The folloAving month Professor Klein gave orders to suspend the use of disinfectants. By chance, in August there Avere only six deaths out of two hundred and fifty confinements, and in September, of tAvo hundred and seventy-five patients, none died. From 1857 to 1860 the mortality Avas slight, though disinfectants were not used, while during the three following years, in spite of the systematic and persistent 636 DISEASES OF CHILDBED. employment of these agents, the death-rate once more assumed formi- dable proportions.* Of course, I do not wish to underrate the importance of Semel- weiss's labors. There is no question but that it is a perilous experiment to pass from the dissecting-room to a patient in labor, without em- ploying rigorous measures to disinfect the hands and all parts of the person brought into contact with the dead body. But it is well to call attention to the fact that puerperal fever is not due to any single, simple cause, nor can be effectually guarded against by a single pre- caution ; and again that cadaveric poison does not of necessity exist in every cadaver examined. Haussmann found that injections into the vagina of gravid rabbits, in the latter half of pregnancy, of serum from the corpse of a person who had not died of septicaemia, produced no fatal results, while rapid death resulted from injections, under the same conditions, of pus from the abdomen of a woman who had died from puerperal infectious disease, f Relations to Zymotic Diseases.—In investigating, some years ago, the nature, causes, and prevention of puerperal fever, \ I prepared, from the statistics of the Health Board of New York City, tables ex- tending over a period of nine years, to answer the inquiry as to whether there was any relation between the frequency of deaths from scarlatina, diphtheria, and erysipelas and those from metria. Previous to their publication I was anticipated in my deductions by a paper upon the same subject, by Dr. Matthews Duncan. * Neither Duncan nor myself found any such relation existing between the statistical frequency of puerperal fever and the zymotic diseases mentioned. There was, however, nothing in our inArestigations to invalidate any direct testi- mony which tends to show that, in individual cases, a real connection between puerperal fever and the zymotic diseases may exist. Indeed, it seems to me to be fairly established that a poison may be comreyed from patients suffering from either of the foregoing morbid processes, which may be absorbed by the puerperal woman, and may in her give rise to an infectious fever possessing an intense degree of virulence. The close relationship between erysipelas and puerperal fever is some- times shown by the occurrence, in the latter, of an erysipelatous inflammation, extending from puerperal vaginal ulcers over the cuta- neous surface of the thigh doAvn to the knee, and upward over the abdomen to the waist. That in these cases the internal process is similar in character is a fact which can hardly be called in question. * Braun, " Riickblicke auf die Gesundheits Verhiiltnisse unter den Wochnerinnen," u. s. w., pp. 32, 33. + Haussmann, " Untersuchungen und Versuche iiber die Entstehung der iibcrtragbaren Krankheiten des AVochenbettes," " Beitr. zur Geb. und Gynaek.," Bd. iii, Heft 3, p. 374. X " Trans, of the International Med. Congress," Philadelphia, 1876. * Duncan, " On the Alleged Occasional Epidemic Prevalence of Puerperal Pyaemia, or Puerperal Fever, and Erysipelas," " Edinburgh Med. Jour.," March, 1876, p. 774. PUERPERAL FEVER. 637 Season of the Year.—On another occasion I have shoAvn that, in New York City, the death-rate from puerperal fever is nearly twice as great during the six months from December to May, inclusive, as from June to November. The greatest mortality occurred in February and March, comprising rather more than one fourth the entire amount. The smallest number of deaths occurred in September and October, in which months but one thirteenth of the entire number took place. Social State.—That puerperal fever, in its harvest of death, does not spare the wealthy and well-to-do classes is too familiar a truth to be worthy of discussion. That, howe\Ter, the wealthy do enjoy special immunities as compared with the less-favored members of society I have shown by comparisons made between sections of the city which, though lying side by side, exhibit in a marked degree the two extremes of wealth and poverty. Thus, the mortality among the representatives of the lower social strata, in proportion to population, was from three to six times as great as that among the more fortunate classes. The Prevention of Puerperal Fever. Of the 3,342 deaths from puerperal causes in New York City from 1868 to 1875, inclusiA^e, 420 occurred in hospital, or one eighth of the entire number. Of the 1,947 cases of metria, about 300, or not quite one sixth, Avere contributed by the hospitals. After such a showing, the first impulse would be to cry out loudly for the suppression of the maternities. But a wiser policy suggests an inquiry as to whether the large mortality mentioned is an evil necessity. The following reports will show how much may be done, in the present state of our scientific knowledge, to so control the conditions which favor the generation of puerperal diseases in large hospitals as to make them safe asylums for the needy. Dr. Goodell* has stated that, at the Preston Retreat, in 756 cases of labor there have been but two deaths from septic disease. Winckel, f of the Lying-in Institution in Dresden, reported, in 1873, 18 deaths from metria, or 1*8 per cent., but, from the 10th of January to the 7th of July, in 570 births there was but one case of septic disease; in the year 1872 the death-rate exceeded 5 per cent. The reduction in mortality was no fortuitous circumstance, but was due to rigid meas- ures for the prevention of disease. Stadfeldt J reduced the mortality from puerperal fever in the Maternity Hospital of Copenhagen from 1 in 37, the proportion between the years 1865 and 1869, to 1 in 87 between the years 1870-'74. Dr. Johnston # reports, in the Rotunda * Goodell, " On the Means employed at the Preston Retreat for the Prevention and Treatment of Puerperal Diseases," p. 13. + Winckel, "Berichte und Studien," Leipsic, 1874, p. 183. X Stadfeldt, " Les maternites, leur organisation et administration," Copenhagen, 1876. * Johnston,'" Clinical Reports," from 1870 to 1876, inclusive. 638 DISEASES OF CHILDBED. Hospital of Dublin, during the seven years of his mastership, 7,860 births, with 169 deaths, of which 85, or 1 in 91, were from metria. Braun von Fernwald,* in sixteen years, reports 61,949 confinements in the vast Maternity Hospital of Vienna, with 825 deaths from puer- peral fever, or 1 *3 per cent. Spiegelberg f lost, in 901 confinements at Breslau, only five cases of puerperal fever. Beurmann J reports that in the Hopital Lariboisiere, under the administration of M. Siredey, the death-rate in 1877 was 1 in 145, and in 1878 1 in 199 confine- ments ; in the Hopital Cochin, under the charge of M. Polaillon, the total mortality, from 1873 to 1877, was 1 to 108*7. In 1877 there was but one death from puerperal causes in 807 confinements. When the maternity service was transferred, in 1872, from Bellevue Hospital to Blackwell's Island, it became necessary to make some pror vision for so-called street-cases—i. e., women taken suddenly in labor without homes, and representing the extremes of penury and Avant. At first they were received, in part, by the various private institutions of charity in New York City, but these, in 1877, decided to exclude them thenceforth, on the ground that their condition at the time of their reception was such as to endanger the lives of the inmates for whom the charities were especially provided. An old engine-house was then put in readiness by the city, and, under the name of the Emergency Hospital, was placed under the charge of Dr. Henry F. Walker and myself. The number of confinements in the Emergency has averaged 220 annually. The death-rate from all causes has been two per cent., which, though large, is not an unfa\'orable showing when we remember that the patients all belong to the homeless class, that all were taken in labor before their entrance, and that many of them were in a deplorable condition at the time of their admission. The hospital, too, receiA-es a considerable number of patients annually who are sent there only after protracted, and often severe, operative meas- ures have been fruitlessly attempted outside its walls. The building possesses, for maternity purposes, two fairly ventilated rooms. Excel- lent nurses are furnished by the New York Training School for Nurses. Mr. Osborn, a liberal private citizen, has had constructed in the rear, but detached from the main house, a small pavilion, modeled after that of Tarnier, for the reception of infectious cases. The Commis- sioners of Charities have promptly responded to every call made upon them to extend the facilities for the care of patients. Surely these results do not support the idea that it is better for a woman to be confined in a street-gutter than to enter the portals of a lying-in asylum. Dr. Goodell's experience shoAvs that a hospital for * Braun von Fernwald, " Lehrbuch der gesammtcn Gynaekologie," p. 885. f Spiegelberg, " Lehrbuch," p. 748. X Beurmann, " Recherches sur la mortalite des femmes en couches dans les hopitaux," Paris, 1879. PUERPERAL FEVER. 639 respectable married women may be so conducted that its inmates may enjoy absolutely a greater degree of safety than do women in their homes, surrounded by all the aids that wealth can command. Equally good results are not to be obtained in hospitals Avhich are open to un- fortunates of every class. But there is much misapprehension and confusion of ideas respecting the fate of these Avomen Avdien no chari- table provision is made for them. In Copenhagen the Maternity Hospital is closed for from six to eight weeks in the summer-time. During this period, unmarried parturient women receive pecuniary assistance from the hospital to enable them to obtain a place in which to be confined. Now, Stadfeldt reports a larger mortality among this class than among those delivered in the hospital. Yet they are con- fined at a favorable season of the year, without any communication with the furniture, the sage-femmes, or the physicians of the hospital. As they fortunately receive nothing but money, that can hardly be suspected of communicating contagion. What their fate would be in New York City, perhaps, may be judged from the following facts : Excluding cases confined in hospitals, nearly one thirtieth of all the deaths and one twenty-fourth of the cases of metria between 1867 and 1875 are reported by four practitioners. Ten practitioners out of tweh'e hundred signed the death certificates of one fifteenth of the women dying from puerperal causes, and one tenth of the cases of metria. But it is not to be supposed that these deaths were all the result of malpractice and incompetence. The true history of most of them probably was that the doctor was engaged to attend the case of confinement for a small fee, with the understanding that he should make no calls subsequently, unless specially summoned by the friends of the patient. The latter, left to ignorant care, or perhaps Avithout any assistance whatever, and exposed to all the pernicious influences bred by poverty, when illness supervened probably did not call the physician to her aid until the time for help had passed, so that in the end his professional functions were confined to procuring the requisite permit for burial. Humanity demands that charity should furnish places of refuge in which poor outcasts can receive assistance during the perils of child- bearing. If we must, then, have maternities, we should make them safe, and this can be in great measure accomplished by remembering the twofold source of danger arising from a poisoned atmosphere and direct inoculation. A hospital must be clean, spacious, and well ventilated, or its atmosphere will become charged with decomposing albuminoid substances, and produce nosocomial malaria. The most rigid sanitary precautions observed by the attendants will not prevent a badly ventilated ward from becoming unwholesome, unless unoccu- pied wards are kept to which patients can be transferred upon the first admonition of danger. Dr. Goodell states that at the Preston Retreat 640 DISEASES OF CHILDBED. the wards are used invariably in rotation. In connection with the Maternity at Copenhagen there are a number of small supplementary hospitals scattered through the city, which serve as safety-valves for the central institution. Artificial methods of ventilation render the task of keeping the wards wholesome comparatively easy. They do not need, however, to be complicated and expensive. The good re- pute of the Rotunda Hospital, it seems to me, is in large measure due to the natural ventilation afforded by open fireplaces. In the Vienna Clinic, according to C. Braun, the mortality between 1834 and 1862 averaged six per cent., and in 1842 the enormous total of 521 deaths to 3,067 confinements was reached. With the introduction in 1862 of what is known as Bohm's heating and ventilation system an im- mediate improvement was experienced. In the sixteen years from 1863 to 1878, inclusive, the total mortality has been 1*6 per cent., though in that time five thousand four hundred and sixty-four practitioners have received an obstetrical training in its wards. In commenting upon this change Braun says : " I have now from practical experience arrived at the knowledge of the fact that the rapid and thorough pre- ATention of putridity by adequate ventilation is to be regarded as a good preventive measure against puerperal fever ; that it is not the number of patients in a lying-in hospital, nor yet the number of pa- tients in a single room, but the deficient circulation of air, a fault Avhich may inhere to separate compartments in the smallest materni- ties, which is the important feature in the spread of puerperal fever; that puerperal Avomen are to be protected from childbed diseases not by isolated buildings and gardens, nor by walls, but by the permanent introduction of great quantities of pure, warm air." He then adds, what is in thorough accord with my own experience, "Before new institutions are built, greater attention than heretofore should be paid to the ventilation of the old structures, and, where this is found de- fective, a system should be substituted corresponding to the scientific requirements." In the year 1872 puerperal fever destroyed twenty-eight women of one hundred and fifty-six who were confined in the Bellevue Hospi- tal. The service was then broken up, and a great outcry arose against "tainted hospitals." Wooden pavilions were accordingly erected on Blackwell's Island for the reception of lying-in women. These build- ings were constructed upon what is known as the cottage plan. They were favorably situated in any airy location remote from the general hospital. They Avere, however, heated by large iron stoves, and no means of ventilating the wards was provided, except by lowering the windows. In less than three months from their occupancy an epi- demic of puerperal fever made it necessary to remove the service for a time to the Charity Hospital. The same result followed every sub- sequent attempt to utilize them for maternity purposes, until after PUERPERAL FEVER. 641 three years' trial it was found necessary to abandon them alto- gether. In private practice it is likewise important that the lying-in room should be provided with plenty of light and air. The physician should insist upon the value of ventilation as a means of contributing to the speedy recovery of childbed women. By hermetically sealing the windows, through false fears of his patient's taking cold, he exposes her to the risk of becoming poisoned with her own exhalations. But the early experiences of the Hopital Cochin and the Hopital Lariboisiere, costly, palace-like structures, with every appliance of art, prove that fresh air alone does not protect patients from the conse- quences of inoculation. The great improvement in the condition of maternity patients in recent years has been due to the application of Lister's principles to obstetric practice. Complete antisepsis in the surgical sense is, of course, impracticable. The conduct of labor under carbolic spray has been tried in Germany, but has not been found to add to the safety of the puerperal woman. Adequate antisepsis has, hoAvever, been proA^ed to result from the observance of a variety of precautions which have been the slow outcome of experience. These, in brief, in hospitals consist in protecting the patient from eArery known form of contamination, and in the prompt remoATal and isolation of every puerperal woman who manifests febrile symptoms. As regards details, the bedsteads should be of iron, and should be frequently scrubbed with a carbolic solution ; after each confinement the palliasse upon which the woman lay should be washed in boiling water, and the straw should be burned ; in place of the usual rubber covering to the bed, Tarnier recommends tarred paper, which is anti- septic, and costs so little that it need be used in but a single case ; all soiled linen should be instantly removed from the ward, either to be burned or disinfected by prolonged boiling; sponges should be ban- ished, as, when they have once been soaked with blood, not even car- bolic acid can make them safe ; nurses employed in the puerperal wards ought not to have access to cases of labor, as D'Espine * has shown that the lochia of even a healthy person on the third day will poison a rabbit; a patient attacked with fever should be immediately removed, and the nurse in attendance should go with her. Doleris f formulates the indications for effective prophylaxis as follows : 1. Prevent the introduction of germs (antisepsis before confinement). 2. Paralyze their action (antisepsis after confinement). 3. Shut up the doors—veins, lymphatics, and Fallopian tubes (em- ployment of means which promote uterine contraction). * D'Espine " Contributions a l'etude de la septicemic puerp^rale," p. 18. f Doleris, " La fievre puerp6ralc," 1880, p. 303. 41 642 DISEASES OF CHILDBED. The first duty of the physician is to refrain from attending a.case of labor when fresh from the presence of contagious diseases, or from contact with septic materials whether derived from the dissecting- room or the clinic. Skepticism regarding these sources of danger is sure in the long-run to be severely punished. In a doubtful case the least concession should consist in a full bath and a complete change of clothing. A special coat for confinement purposes, stained with blood and amniotic fluid, is liable to convey infection. In every case of labor, Avhether in hospital or private practice, the hands and forearms « should be freely bathed in a carbolic solution before making a vaginal examination. A nail-brush should form a part of the ordinary ob- stetric equipment. Frequent examinations during labor should be avoided. All instruments employed during or subsequent to confine- ment should be carefully disinfected. In prolonged labors, in cases of dystocia, and where the membranes have ruptured and the foetus is dead, it is a useful precaution after delivery to wash both uterus and vagina with warm, carbolized water. In hospitals the woman should be bathed before entering the lying-in ward, and the vagina should be disinfected with carbolic acid both before and immediately after labor. In the puerperal period the warm carbolized douche stimulates uterine retraction and promotes the rapid healing of wounds in the vaginal canal; in hospital practice it possesses the additional advan- tage of preventing the accumulation of putrid albuminoid matters in the air. In private practice the patient should employ a new syr- inge ; in hospitals every woman should be supplied with a glass tube to be attached to the irrigator. When not in use these tubes should be immersed in carbolic acid. The stream injected into the vagina should be continuous, like that furnished by the fountain syringe. With my hospital patients, in place of cloths to the vulva, I have been in the habit of using oakum. By soaking the latter in a solu- tion of carbolic acid, the vulva is surrounded by an antiseptic atmos- phere. Pedantic as these directions may seem, they are justified by experi- ence, and the carrying out of the details given easily becomes a matter of habit. That by such precautions puerperal fever is destined to be erased from the list of dangerous diseases attacking the woman in childbed is saying more than is warranted. Nevertheless, it is true that a physician ought never to lose the sense of personal responsibility for its occurrence. Indeed, puerperal fever ought to be regarded as a preventable disease, and an attack as the evidence that some source of danger has been overlooked,* though, owing to the imperfection of our knowledge, it may easily happen that, even Avith the keenest scru- tiny, the precise cause in an individual case may escape detection. PUERPERAL FEVER. 643 The Treatment of Puerperal Fever. When the septic germs characteristic of putrid infection have once entered the blood they are beyond the reach of the physician. Ex- cept, however, in cases of acute septicaemia, where the quantity of poison introduced at the outset is excessive, the patient rallies from the immediate shock, and, provided no fresh pyrogenic material finds its way into the system, recovery is to be anticipated. The indications for treatment are, therefore, to neutralize the puer- peral poison at the point of production, in order to prevent its causing further mischief, and to adopt measures calculated to enable the pa- tient to tolerate its presence, when once absorbed, until it is either eliminated or loses its harmful properties. Toward the fulfillment of the first indication it is to be recom- mended that, in every case of fever of puerperal origin, the vagina be cleansed with a two- to three-per-cent. solution of carbolic acid every four to six hours. The douche in itself is absolutely harmless. In most cases the infection starts from the wounds of the vagina and of the cervix. Then, too, the tendency of the secretions to stagnate in the vaginal cul-de-sac, bathing as they do the cervical portion, is a prolific source of septic trouble. In all but the mildest cases the vagi- nal orifice should be examined with reference to the existence of puer- peral ulcers. All necrotic patches should be touched with hydrochloric acid, with a ten-per-cent. solution of carbolic acid, or, what I person- ally prefer, a mixture composed of equal parts of the solution of the persulphate of iron and the compound tincture of iodine. The latter acts as a powerful antiseptic, while the former, by corrugating the tis- sues, closes the lymphatics and shuts up the portals through which the septic germs penetrate into the system. Intra-uterine injections should be resorted to with extreme circum- spection. Unless the infection, which is more rarely the case, pro- ceeds from the uterine cavity, they are unnecessary. In circumscribed inflammations, where the morbific poison loses its virulence at a short distance from the puerperal wound, they are often injurious. I make this statement as an umvilling witness, for the practice of local disn- fection is in accord with my inmost theoretical convictions. It cer- tainly seems rational to treat the uterus as one would any other pus- secreting cavity. The procedure is warmly advocated by Fritsch, Schulein, Richter, Langenbuch, and Schroeder, as a prophylactic against puerperal affections. C. Braun, however, with his vast oppor- tunities for judging obstetrical questions, writes, with reference to this : " We must protest against injections made by physicians into the uterine cavity. Such meddlesomeness is more likely to do harm than good." This corresponds with my own experience. Frequently, at the hospital, I have had occasion to witness cases where the patient's 644 DISEASES OF CHILDBED. condition was plainly aggravated by injections administered with un- tempered zeal by members of the house staff. Accidents, such as con- vulsions, shock, and carbolic-acid poisoning, have been reported by others. This caution is not, however, intended to discourage the employ- ment of intra-uterine antisepsis in cases where it is strictly indicated. Thus, it would be folly, in a fever due to the decomposition of placen- tal debris, of shreds of decidua, of strips of membrane, or of retained coagula, or in diphtheritis of the mucous membrane, to treat the gen- eral symptoms, and neglect the local cause of difficulty. In a specific case it may proAre difficult to decide as to the correct course to pursue. In general, however, it may be stated that it is proper to Avash out the entire length of the genital canal when fever folloAVS prolonged opera- tions conducted within the uterine cavity, or the birth of a dead foetus; and in cases of fever associated with a fetid discharge which persists in spite of the vaginal douche, with the presence of recog- nizable portions of the ovum or its dependencies in the lochia, with the repeated discharge of decomposed coagula, or with a large, flabby uterus. The operation of cleansing the uterus should be conducted with the most scrupulous care. The syringe employed should produce a con- tinuous and not an interrupted stream, and all air should be expelled from the pipe. The tube to be passed through the cervix should be of glass, of the size of the little finger, and bent somewhat to conform to the pelvic curA'e. A tAvo-per-cent. solution of carbolic acid should first be injected into the vagina, by way of precaution against convey- ing septic materials into the uterus. The introduction of the tube should be made with the guidance of two fingers passed through the external os. But slight force is requisite to reach the ring of Bandl. It is neither necessary nor desirable to push the tube to the fundus. The carbolized fluid injected should be tepid, and of the strength of tAvo to three drachms to the pint. It should be introduced very slowly, and pains should be taken to insure its unimpeded escape, which can usually be accomplished by pressing the anterior wall of the cervix forward by means of the glass tube. Langenbuch recommends secur- ing permanent drainage by leaving a bit of rubber tubing in the cer- vical canal, a plan concerning the merits of which I am not able to speak from experience. The tube is said to be well tolerated, and to possess the advantage of enabling subsequent injections to be per- formed without disturbing the patient. In many cases the results of intra-uterine treatment are very strik- ing. Often the temperature falls notably within an hour or two of the operation. This result is, however, rarely permanent. Usually the fever recurs, and the operation has to be repeated. The patient should be carefully watched, and with the first sign of returning dan- PUERPERAL FEVER. 645 ger the injection should be repeated. Two to three injections may thus be called for in twenty-four hours, and they may require to be continued for a week. Still by the means indicated a certain pretty large proportion of women, seemingly destined to destruction, in the end make favorable recoveries. Of the symptoms, the first in order which calls for treatment is usually the peritoneal pain. It is, as we have seen, commonly of a lancinating character, and is associated with hurried breathing and extreme frequency of the pulse. So soon as the pain is once fairly under control, the violence of the onset begins to abate. It should be met, therefore, by the hypodermic injection of from one sixth to one third grain of morphia in solution. The anodyne action should be maintained by doses administered by the mouth in quantities and at intervals suited to the severity of the case. The most important ob- ject to be secured is freedom from spontaneous pain. It is, moreover, good practice to push the opiate until pain elicited by pressure is like- wise controlled, provided it can be accomplished without producing narcosis. In susceptible patients, and in localized inflammations, the quantity required may not be very great, while in acute general peri- tonitis the tolerance of the drug exhibited by puerperal women is sometimes extraordinary. Thus, a patient of Professor Alonzo Clark took the equivalent of 934 grains of opium in four days ; a patient of Professor Fordyce Barker 13,969 drops of Magendie's solution in eleven days ; and one of my own, at the Maternity, the equivalent of over 1,700 grains of opium in seven days.* In this latter instance the pa- tient was to all appearance moribund when the treatment was begun. Thus, the features were pinched, the face was drawn, the pupils were dilated, the finger-tips were blue and cold, the respirations were rapid, and the pulse was scarcely perceptible. In this condition the large doses of opium did not produce narcosis, but were folloAved by restora- tion of the circulation, by normal breathing, and by the disappearance of the symptoms of shock. Any attempt to relax the treatment was at once succeeded by a recurrence of the alarming symptoms. At the expiration of the disease the opium was discontinued abruptly without detriment to the patient. In contrast to cases of acute peritonitis, an extreme susceptibility to opium is often observed in the pyaemic variety. Here opiates seem to me rarely to do good. They do not hinder the migrations of the round bacteria, there is rarely pain to relieve, and I have sometimes thought that their administration was simply the addition of a sec- ond poison to the one which already was overwhelming the nervous system. In pelvic peritonitis, in the course of forty-eight hours plastic exu- * The details of this case have been reported in the "Am. Jour, of Obst.," Oct., 1880, 864 by Dr. F. M. Welles, who conducted the administration of the opium. 646 DISEASES OF CHILDBED. dation is thrown out and the pain to a great extent subsides. From this time very moderate doses of opium, as a rule, are needed to make the patient comfortable. In France, leeches applied to the abdomen are much used as a means of relieving peritoneal sensitiveness. That they do this is be- yond question. Their disuse in this country is due probably more to popular prejudice than to their inefficacy. In the beginning of an attack a turpentine stupe to the abdomen is a source of comfort to many Avomen, while the sharp counter-irritation exercises possibly a faA'orable influence upon the course of the disease. At a later period I commonly employ flannels wrung out in water, and covered with oil-silk to prevent speedy evaporation. It is an old expe- rience that, in the beginning of a puerperal fever, the provocation of loose stools by purgatives is frequently followed by a fall in the tem- perature and a great improvement in the patient's condition. The result, however, is far from uniform, as in other cases these artificial diarrhoeas have a tendency to aggravate the peritoneal symptoms. Owing to this uncertainty in their action, purgative remedies should be administered with caution, not from any theory as to their elimina- tive powers, but because of the ascertained existence of fecal accumu- lation. In pelvic inflammations, castor-oil in two to three tablespoon- ful doses, or five to ten grains of calomel rubbed up with twenty grains of bicarbonate of sodium, as recommended by Professor Barker, may be given Avhen thus indicated. After the bowels have once been freed, however, the purgative should not be repeated. In cases of intense local inflammation, and in general peritonitis, enemata should alone be employed for the removal of constipation. Every increase of body-heat is associated with rapid tissue-waste, with enfeebled heart-action, and with exhaustion of the nerve-centers. Since the modern recognition of the deleterious effects of high tem- peratures per se, antipyretic remedies in place of the old-time cardiac sedatives have come to play the leading role in the treatment of fevers. Of internal antipyretic agents quinine enjoys a deservedly high re- pute. In the remitting forms of fever it may be administered in five- grain doses at intervals of four to six hours. Given thus in medium doses it moderates the fever, diminishes the SAveating, and in most patients lessens gastric and intestinal disturbances. In continued fevers it should, on the contrary, be given in a single dose large enough to procure a distinct remission. By making a break in the febrile symptoms, if only of a few hours' duration, a retardation of the de- structive processes is accomplished. At the first administration, twen- ty to thirty grains may be given. In favorable cases the temperature falls in the course of a few hours below 101°. When the high tem- perature is only temporarily held in check, at the end of twenty-four hours, if all symptoms of cinchonism have disappeared, the same dose PUERPERAL FEVER. 647 should be repeated. If the doses mentioned, given in the manner prescribed, produce no perceptible effect upon the fever, their continu- ance may be regarded as unnecessary. C. Braun and Richter speak favorably of the action of salicylate of sodium.* It possesses antipyretic properties, though in a less degree than quinine. It is, hoAvever, rapidly absorbed, circulates through all the parenchymatous organs, and finally is discharged unchanged in the urine. It is said by Binz, in small doses, to hinder the action of the disease—producing ferments, while it leaves untouched the normal ferments of the organism. It is of special service where quinine is not Avell tolerated, or when given fifteen to twenty grains at a time every four to six hours as an adjuvant to large single doses of quinine. The remedy should be continued until all traces of febrile disturbance haA'e disappeared. A more powerful remedy than salicylic acid, where quinine has failed, is the Warburg's tincture. Some patients find, however, that it is somewhat difficult to retain upon the stomach. Not many years ago, OAving to the encomiums of Professor Fordyce Barker, f the tincture of veratrum viride was in great favor in puer- peral feA'er as a means of reducing the excited pulse of inflammation. The plan recommended was to administer five drops hourly, in con- junction usually with morphia, until the pulse was brought down to 70 or 80 beats to the minute. If the pulse had once been reduced, then three, two, or one drop hourly would be found sufficient to control it. Vomiting and collapse from its use were no cause for alarm, as they were temporary symptoms, and were followed by a fall of the pulse to 30 or 40 a minute, which was rather of favorable prognostic signifi- cance. In the rapid pulse of exhaustion, however, veratrum should not be given. Since the introduction of the thermometer into prac- tice, the reduction of the pulse by veratrum has been found to be asso- ciated with a fall in the temperature of the body. Of late, however, veratrum has gone rather out of vogue, not because it is not a very effective agent, but because its administration is an art to be ac- quired, and can not safely be intrusted to an unskilled assistant. Then, too, in the last ten years, there has grown up a better acquaint- ance with less dangerous remedies. Braun recommends in severe cases, where quinine alone is without effect, to give in addition from twelve to twenty-four grains of digi- talis in infusion per diem until its specific action is produced. Unlike veratrum, digitalis effects a permanent slowing of the heart. By pro- longing the cardiac diastole and contracting the arterioles, it alloAvs the left ventricle to fill, restores the arterial tension, diminishes cor- * Richter "Ueber intrauterine Injectionen," etc., "Ztschr. fur Geburtsh. und Gy- naek.," Bd. ii, Heft 1, p. 146. f F. Barker, " The Puerperal Diseases," p. 347. 648 DISEASES OF CHILDBED. respondingly the intra-venous pressure, and promotes absorption. Its tendency to produce gastric disturbances and the distrust felt as to its safety have prevented its becoming popular in practice. Alcohol as an adjuvant to treatment is indicated in all cases, whether quinine, or salicylic acid, or veratrum be simultaneously em- ployed. It stimulates and sustains the heart, it retards tissue-waste, and is in itself an antipyretic of no mean value. Usually I give it in conjunction with quinine, one or two teaspoonfuls hourly of either whisky, rum, or brandy, in accordance with the recommendation of Breisky.* But many years before I had learned from my friend Pro- fessor Barker that the specific influence of veratrum was in many cases not obtained until the use of alcohol was combined with it. The antipyretic action of drugs is probably due for the most part to some direct influence they exert upon the oxygenation of the tis- sues. Of course, the less the fire the less the heat. It is well, how- ever, to support their internal administration by the external employ- ment of cold. Cold owes its effect in fevers partly to the abstraction of heat from the body-surface, and in a still more important degree to the impression which it produces upon the nervous system. In healthy persons the action of cold is to increase the consump- tion of oxygen and the production of carbonic acid. The additional heat thus generated renders it possible to sustain the vicissitudes of climate. In fevers the primary effect of cold is similar in character. Its main therapeutical action is derived from its secondary influence upon the nen-e-center which regulates the body-heat. If the cold employed be sufficiently intense or sufficiently prolonged, there fol- lows, not always immediately, but in the course of an hour or two, a marked lowering of the temperature, which can only be accounted for by assuming an indirect influence exerted through the sympathetic nerve and the medulla oblongata. This peculiarity renders the exter- nal application of cold a most valuable addition to the therapeutical resources available in feA'ers. In cases of moderate severity, frequently sponging the patient with cold water will be found to be a grateful practice. An ice-cap to the head, where the blood lies near the surface, will often affect the en- tire temperature of the body. From immemorial times it has been employed to control delirium and promote sleep. An ice-bag placed over the inguinal region is locally beneficial to deep-seated pelvic inflammations, and, according to C. Braun, is capable of effecting a rapid fall of temperature. Ice-cold drinks should be freely alloAved. Schroeder recommends a permanent stream of cold water in the uterine cavity by means of a large irrigator and a drainage-tube ; oth- ers advise cold rectal injections maintained for long periods with the aid of a tube with a double current. * Breisky, "Ueber Alcohol und Chinin-behandlung," Bern, 1875. PUERPERAL FEVER. 649 In fevers of great violence, the systematic application of cold by means of baths or the wet-pack is capable in some cases of rendering important service. The temperature of the bath should range from 70° to 80°. Its duration should not exceed ten minutes. The pa- tient should, when removed to the bed, be wrapped in a sheet with- out drying, and should be comfortably covered. In employing the wet-pack, tAvo beds should be placed side by side. The body and thighs of the patient should be wrapped in a sheet wrung out in cold water, and be allowed to remain in the pack from ten to twenty min- utes. As the sheet becomes heated the patient should be placed in a fresh one upon the second bed, and the transfers should be continued until the desired fall of temperature is effected. Braun claims that four packs are equivalent in action to one full bath. Both these methods are, however, open to the objection that they can not be carried out without considerable disturbance of the pa- tient, a point of no small importance in cases of peritonitis. Dr. G. B. Kibbie has invented a fever-cot which ob\-iates the ordinary diffi- culties of this mode of treatment. The cot is covered with " a strong, elastic cotton netting, manufactured for the purpose, through which water readily passes to the bottom below, which is of rubber cloth so adjusted as to convey it to a A^essel at the foot." Professor T. G. Thomas,* Avho has employed this apparatus extensively to reduce high temperatures after ovariotomies, explains as folloAVS the modus ope- randi : Upon this cot a folded blanket is laid, so as to protect the patient's body from cutting by the cords of the netting, and at one end is placed a pillow cov- ered with India-rubber cloth, and a folded sheet is laid across the middle of the cot about two thirds of its extent. Upon this the patient is now laid, her cloth- ing is lifted up to the armpits, and the body enveloped by the folded sheet, which extends from the axillae to a little below the trochanters. The legs are covered by flannel drawers and the feet by warm woolen stockings, and against the soles of the latter bottles of warm water are placed. Two blankets are then placed over her, and the application of water is made. Turning the blankets down below the pelvis, the physician now takes a large pitcher of water, at from 75° to 80°, and pours it gently over the sheet. This it saturates, and then, percolating the network, it is caught by the India-rubber apron beneath, and, running down the gutter formed by this, is received in a tub placed at its ex- tremity for that purpose. Water at higher or lower degrees of heat than this may be used. As a rule, it is better to begin with a high temperature, 85°, or even 90°, and gradually diminish it. The patient now lies in a thoroughly soaked sheet, with warm bottles to her feet and is covered up carefully with dry blankets. Neither the portion of the thorax above the shoulders nor the inferior extremities are wet at all. The water is applied only to the trunk. The first effect of the affusion is often to elevate the temperature, a fact noticed by Ourrie himself; but the next affusion, * Thomas " The Most Effectual Method of controlling the High Temperature occur- ring after Ovariotomy," " N. Y. Med. Jour.," August, 1S78. 650 DISEASES OF CHILDBED. practiced at the end of an hour, pretty surely brings it down. It is better to pour water at a moderate degree of coldness over the surface for ten or fifteen minutes, than to pour a colder fluid for a shorter time. The water slowly poured robs the body of heat more surely than when used in the other way. The water collected in the tub at the foot of the bed, having passed over the body, is usually 8° or 10° warmer than it was when poured from the pitcher. On one occasion Dr. Van Vorst, my assistant, tells me that it had gained 12°. At the end of every hour the result of the affusion is tested by the ther- mometer, and if the temperature has not fallen another affusion is practiced, and this is kept up until the temperature comes down to 100°, or even less. It must be appreciated that the patient lies constantly in a cold wet sheet; but this never becomes a fomentation, for the reason that, as soon as it abstracts from the body sufficient heat to do so, it is again wet with cold water and goes on still with its work of heat-abstraction. I have kept patients upon this cot enveloped in the wet sheet for two and three weeks, without discomfort to them and with the most marked control over the degree of animal heat. Ordinarily, after the temperature has come down to 99° or 100°, four or five hours will pass before affusion again becomes necessary. Since reading this account, I haA'e made a good many trials of the method upon puerperal women, and have not found that it agrees with all in an equal degree. In some instances the affusions haA'e been fol- loAved, in spite of hot bottles to the feet and the administration of stimulants, by such a degree of depression and impairment of cardiac force, as shown by the persistent coldness of the extremities, that it has been necessary to discontinue them. On the other hand, I can look back upon cases apparently so desperate that the condition of the patients was looked upon as hopeless, Avhere they proved the means of saving life as by a miracle. Of course, the difference depends upon whether the high temperature is the sole cause of the alarming symp- toms, or whether the latter are in part due to blood dissolution and secondary changes in the parenchymatous organs. It is hardly necessary to state that, in puerperal, as in other fevers, the patient's strength requires to be sustained, and the waste of tissue to be repaired, as far as possible, by the regulated administration of liquid food, as milk and beef-tea, in such quantities as can be borne by the stomach, and at one to two hours intervals. In the treatment of encysted peritoneal effusions, and in inflamma- tory exudations into the pelvic and adjacent cellular tissue, after the acute symptoms have subsided, the attention should be directed to the afternoon fever, and to promoting the assimilation of food. So soon as the sweating and fever are checked, the absorption of the plastic materials begins. The most important agents for accomplishing this object are quinine, in moderate doses, combined Avith some form of alcohol and with tepid sponging. Deep-seated pain in the iliac region is best relieved by a large blister upon the side, over the point where the tenderness is felt. Prolonged rest in bed should be enjoined. Even PUERPERAL FEVER. 651 after convalescence is well advanced, so long as the exudation remains unabsorbed, the resumption of household duties is pretty certain to be followed by a relapse or by the development of a chronic condition of a most intractable description. The sooner the patient's stomach can be got to digest and absorb beefsteak and iron, the more speedy will be her recovery. In pelvic exudations the hot vaginal douche, warm baths, and the application of flannels wrung out in water to the abdomen aid in diminishing the local pain and, perhaps, in causing a disappearance of the tumor. The action of mercurials or of iodide of potassium in melting aAvay plastic inflammatory materials is sometimes very strik- ing, but more frequently they either do no good, or else do harm by disturbing the digestion. If fever, chills, and sweating announce the presence of pus, the most careful exploration should be made to determine, if possible, the seat of suppuration. It is of great advantage to treat pelvic abscesses as abscesses are treated elseAvhere in the body. If the redness of the skin above Poupart's ligament indicates a tendency to point in that direction, an aspirator-needle should be introduced to make sure of the diagnosis. If the sac is near the surface, a free incision should be made, and the pus should be allowed to escape. In many cases I make these incisions three to four inches in length. The red- ness of the external skin makes it certain that the abscess has be- come adherent to the abdominal wall, and that the incision con- sequently Avill not communicate with the peritonaeum. After the abscess has been opened, it should be cleansed twice daily, and the cavity should be filled with oakum. If after a time the granula- tions become flabby, Peruvian balsam should be poured into the sac at each change of the dressing. I can recommend this plan as essen- tially a mild procedure. With a large opening for the discharge of pus, the fever and sweating disappear, the appetite returns, and the abscess fills rapidly by granulation. With a small incision, hectic is apt to persist, and the abscess to end in the formation of intermina- ble fistulae. If softening and bagginess, or distinct fluctuation, indicate that the pus can be reached through the vaginal cul-de-sac, the aspirator-needle should be inserted deeply at the suspected point, and, if a large amount of pus is detected, an incision should be made with a long-handled bistoury, using the needle as a director, and making the opening large enouo-h to permit the introduction of a self-retaining Nelaton catheter. The latter is easily passed by means of a uterine sound inserted into the eye at the extremity. Through the catheter, without disturbing the patient, the pus-cavity can be washed as frequently as required, and with drainage and cleanliness, cases of the longest standing may be expected to recover. 652 DISEASES OF CHILDBED. Dr. P. F. Munde * has reported a number of cases of chronic char- acter where the aspiration of pus has been followed by rapid absorp- tion of the intra-pelvic exudation. The presence of pus was suspected because of a boggy, doughy feeling in the exudation tumor. CHAPTER XXXVII. PUERPERAL INSANITY.—PHLEGMASIA ALBA DOLENS.—DISEASES OF THE BREASTS. The insanity of pregnancy, of childbed, of lactation.—Phlegmasia alba dolens.—Defective milk secretion.—Galactorrhoea.—Sore nipples.—Subcutaneous inflammation of the breast.—Submammary abscess.—Parenchymatous mastitis.—Galactocele. The Insanity of Pregnancy, Childbed, and Lactation. When we remember the marked perturbation of the nervous sys- tem, in even normal pregnancy, from reflex causes, from disorders of the digestion, and from depravation of the blood, it is not strange that the same conditions which give rise to moral perverseness, to the loss of memory, to hysteria, or to hypochondria, should likewise prepare the way for the outbreak of the more pronounced forms of mental derangement. In character the psychical disturbances of child-bearing women do not differ from those which develop under ordinary circumstances, but so active are the causes during the period in question that, of the insane who crowd the public asylums, in one eighth, according to Tuke, the malady is of puerperal origin. In many women there exists in advance an hereditary disposition to insanity, the eA'ents of pregnancy and childbed, which are commonly associated with the ultimate attack, acting simply as the sparks which fire the mine. During pregnancy the prevailing form of mental disturbance is melancholia, Avith sometimes a tendency to suicide. The prognosis is faA'orable when the disease develops in the early months and follows physiological depression and hypochondria; unfavorable in severe at- tacks occurring first in the latter half of pregnancy, or where preg- nancy intervenes in the case of insanity previously existing. As a rule, these patients can be best cared for in well-regulated pri\-ate insti- tutions, where they are not subjected to the good-intentioned expos- tulations of intimate friends. The pains of labor in excitable persons are said to give rise at times to a transitory delirium, but this certainly is of very rare occurrence * Munde, " Diagnosis and Treatment of Obscure Pelvic Abscess," etc., " Arch, of Med.," December, 18S0. PUERPERAL INSANITY. 653 in these days of anaesthetics. The indications for treatment are, of course, to relieve the pain, and to hasten the birth of the child. Mania may occur in any severe puerperal affection. It has been observed not only in the various forms of metritis, but even, accord- ing to Winckel, as a result of sore nipples and very painful inflam- mations of the breasts. The delirium in these cases rises and falls with the fluctuations in the underlying malady, and is thought to be dependent upon associated cerebral hyperaemia. The maniacal mani- festations may consist, when there is freedom from suffering, of agree- able hallucinations—the patient often singing or wearing on her face a rapt expression ; or, if the pain is great, she may on the other hand see forms which threaten her, so that in terror she cries for help, springs from bed, and strips off her clothes in the effort to escape the source of danger. The prognosis depends, of course, upon the gravity of the morbid condition of which the mania is only a symptom. The treatment, with the exception of dry cold to the head, is that of the main affection. Again, puerperal mania may proceed from an hereditary predispo- sition or from diseases antedating pregnancy, in either case the puer- peral state acting as the proximate but not as the fundamental cause of the outbreak. The attacks may be accompanied by erotomania, by nymphomania, by religious anxiety, or by the delire de persecution. It may be evoked by psychical impressions. It occurs at an early period of childbed, when the strength is wasted by pain, excitement, or fever. Finally, puerperal mania may be caused by exhausting losses of blood, by intense pain, by eclampsia, or by anything which occasions cerebral congestion. In this, the so-called idiopathic form of puerperal mania, the attack is generally preceded by sleeplessness, indistinctness of speech, by restless movements, and the refusal to take food. At the beginning of the attack the delirium is usually of a noisy charac- ter, the patients screaming, praying, or preaching in a declamatory fashion ; or they try to get out of bed and to escape from the room by the doors or windows. Sexual excitement is rare, the disposition to strip off the night-dress and expose the person proceeding not from an erotic impulse, but from a desire to escape from some fancied restraint. Attempts to control these patients by force are apt to excite them to renewed violence. This acute stage is followed by melancho- lia, characterized by weeping, praying, and fears concerning the com- mission of the unpardonable sin. As a result of the mental depression, suicidal tendencies develop in a considerable proportion of the cases. The period at which the outbreak first attracts notice occurs most fre- quently Avithin the first two weeks. The indications for treatment are to check profuse, exhausting dis- charges to support the patient's strength, and to insure perfect quiet. 654 DISEASES OF CHILDBED. With the first sign of trouble the child should be taken from the breast, liquid food should be given at frequent intervals, care should be taken to keep the bladder and the rectum empty, the room should be dark- ened, and its temperature should be regulated. The activity of the skin should be promoted by means of the sponge-bath. The sacrum should be watched and strapped with adhesiA'e plaster if bed-sores threaten. Furniture, pictures, or any articles which disturb the pa- tient should be remoA'ed from her sight. There is no condition in which trained nursing can do so much toward effecting recoA'ery. The nurse's duties are to administer food, to see that urination is regularly performed, to keep the patient covered, and to prevent her from doing harm to herself or others. Members of the household who can not resist the impulse to show the insane woman the folly of her delusions should be regarded as disqualified from entering the sick-room. Pas- toral visits are rarely beneficial. If the patient becomes violent, it is usually possible for the family physician to obtain obedience without the exercise of restraint or force. So important is the question of personal influence in the management of puerperal insanity that the success of home treatment is almost Avholly dependent upon the control which the physician has acquired over the morale of his patient previ- ous to the occurrence of her malady. Narcotics do not cure, but Avhen they produce a few hours sleep they certainly promote recoA'ery. There is hardly one in the entire list which has not, at some time, done me good senrice. My preference is for chloral and the bromide of potas- sium (aa gr. xxx) in solution, and administered by the rectum. To procure an effect from moderate doses it is, however, necessary that the narcotic be given, not during the period when the patient is most Aroluble and restless, but either after she has become quieted by judi- cious management or during a natural interval of calm. Cold to the head is often very effective in relieving headache and cerebral conges- tion. If the stage of exaltation passes into that of melancholia, the question of continued home-treatment becomes a serious one. The mother sometimes exhibits not only indifference, but eAren a positive dislike, to her child, which makes it a risky thing to leave them alone' together. Again, owing to the suicidal tendencies which often go Avith melancholia, it never is safe to alloAV the patient to pass out of observation, as is shown by the folloAving case : A young woman after her first confinement had an attack of mania for which she was sent to a private asylum. Shortly after, she was removed by her friends to her own home. There her sweetness and passiA'e resignation dis- armed suspicion. One day, however, she dropped her sewing, put on her hat, and, bidding her mother a pleasant good-by, Avalked quietly down to the river—a half-mile away—and composedly laid doAvn in the shallow stream near the bank, so that the water covered her face. From this position she was rescued by some men who were mowing in PHLEGMASIA ALBA DOLENS. 655 a field near by, and by them was carried insensible to her home. The next day she was returned to the asylum, where she soon made a good recovery. The insanity of lactation is either the result of cerebral anaemia or a relapse from a previous attack. It begins, as a rule, six to ten weeks after confinement. In most cases it assumes the form of melan- cholia. The prognosis is good if the disease is treated in season, by stopping lactation and by removing the debility upon which it depends. In general, the prognosis of puerperal mania is favorable, more than sixty per cent, of the cases ending in recovery. In private practice the number is probably much larger. During convalescence care should be taken to secure to the patient rest, sleep, nutritious food, and a daily evacuation of the bowels, and little by little she should be brought back once more to old habits and the responsibilities of exist- ence. Phlegmasia Alba Dolens. Phlegmasia alba dolens is the term applied to a swelling of one or both lower extremities, occurring usually between the tenth and twen- tieth day after confinement, and characterized by pain, tension of the skin, and a milk-like whiteness of the surface. Owing to its color and its supposed origin, it has received the popular name of milk-leg. Phlegmasia is an affection of the connective tissue, and is associated in most, but not in all, cases with thrombosis of the veins. The origin of the swelling is somewhat obscure. In a certain pro- portion of cases phlegmasia is obviously the extension of an inflamma- tory process from the genital organs to the perinaeum, the nates, and the upper portion of the thigh. If confined to the subcutaneous and intermusculai cellular tissue, the vessels may not become affected. When, however, the morbid changes folloAV the sheaths of the vessels, the Avails of both veins and lymphatics thicken, and in most cases secondary thrombus formation results. In other instances the thrombus formation is apparently the pri- mary lesion. It may occur spontaneously from slowing of the blood- current. A predisposition to thrombosis is created by varicose veins. The vessels usually involved are the crural and its branches, the tibial and peroneal veins. Again, the intra-venous coagula may start from the placental site, and, extending along the pampiniform plexus to the hypogastric vein, may thence occlude the crural to Poupart's ligament, or, passing upward by the spermatic veins, they may obstruct the vena cava. Sometimes the occlusion of one crural A'ein is succeeded by that of the other, phlegmasia in that case developing in both extremities. Thrombus formation may begin during pregnancy, and is then usually attended with pain at the seat of trouble, and with stiffness in the toes or the dorsum of the foot. As a rule, however, the disease is rare before the second week following labor. Often it is preceded by 656 DISEASES OF CHILDBED. gastric disturbances, as lack of appetite, a furred tongue, and consti- pation, by chilly sensations, and by a heavy feeling in the affected limb. A careful examination sometimes reveals the existence of in- flamed or thrombosed veins in the leg, in the popliteal space, or upon the inner surface of the upper portion of the thigh. If the affected veins are superficial, the redness and sAvelling may be obvious to the eye. The first characteristic symptom is the development in the limb of a dull, dragging pain, which is increased by motion, Tenderness to pressure is only experienced along the course of inflamed vessels. In primary thrombosis the swelling usually begins at the ankle, and spreads rapidly to the knee and upward to the inguinal region; in secondary thrombosis, extending from the uterine sinuses, and in the superficial form of phlegmasia, the swelling, on the contrary, travels commonly in the reverse direction, viz., from the inguinal fold to the ankle. The onset may or may not be announced by a chill. Fever often precedes and accompanies the attack. It is, however, in uncomplicated cases, of a mild type, and sinks to the normal point long before the swelling of the limb subsides. Severe chills and intense fever, with marked remissions, are symptomatic of metastatic pyaemia. Other com- plications may essentially modify the course of the disease. The pain, the tenderness, and the febrile disturbance are usually greatest in the phlegmonous form of swelling, which starts from the genital organs. The ordinary termination of phlegmasia is by absorption of the thrombus, with restoration of the circulation. As this takes place, the tension of the skin subsides, and the parts pit upon pressure, as in ordinary oedema. As the swelling and pain subside, the mobility of the limb becomes restored. The period of extreme tension lasts, as a rule, for from five to eight days. Recovery takes place slowly, the dis- persion of the tumor requiring from three to six weeks. A less common result consists in the permanent obliteration of the vessel by the conversion of the thrombus into a solid connective-tissue cord, in Avhich case the extremity may long continue heaAry and loco- motion be attended with difficulty. In rare instances the process may terminate in suppuration and abscess formation. The prognosis of a pus collection in the vicinity of a vessel, resulting from periphlebitis, is usually favorable, the symp- toms that it occasions disappearing Avhen the abscess is opened and the pus is allowed to escape. When the suppurative process is of a spreading character, undermining the skin and attacking the inter- muscular cellular tissue, the destructive changes may assume frightful proportions. Thus, in hospital practice, we sometimes witness cases where the muscles are dissected from one another and are bathed in DISEASES OF THE BREAST. 657 an ichorous fluid, with greenish particles of necrosed tissue adhering to them, death ensuing from intense septicaemia. Sometimes a thrombus becomes infected and undergoes puriform softening, with detachment of small particles, which, entering the cir- culation, give rise to infarctions and metastatic abscesses ; or a large fragment may be separated accidentally from a normal clot, and, pass- ing by the vena cava and the right side of the heart, may cause sudden death by plugging the pulmonary artery. The prognosis, from what has been said, is evidently dependent upon the origin of the phlegmasia and upon the nature of the com- plications. The principal indications for treatment are, opium to al- leviate pain, cathartics, if needed, to unload the bowels, quinine, iron, and good food to sustain the strength, and rest for the swollen ex- tremity. The latter should be raised somewhat higher than the body, and during the early stages of the swelling should be wrapped, as rec- ommended by Dr. F. Barker, in cotton-batting and oil-silk. The tender- ness should be mitigated by the application of soothing liniments. If vesicles form upon the surface they should be punctured and the fluid be allowed to escape. When the extremity begins to pit on pressure and the tenderness to subside, absorption should be promoted by gentle frictions with alcoholic lotions and by bandaging the entire limb evenly with a flannel roller. Until every trace of tenderness and thickening has disappeared from the veins, the patient should under no circumstances be allowed to leave her bed. The danger of death from sudden obstruction of the pulmonary artery is always present until the thrombus has disappeared or become firmly organized. For some time after recovery has taken place the limb will swell as the result of standing or of protracted exercise, a condition which, as a rule, is greatly benefited by the patient wearing a long elastic stock- ing. Diseases of the Breast. Defective Milk-Secretion.—A scanty milk-secretion due to lack of mammary development, to extreme youth, to polysarcia, or to the mature age of the mother, is not amenable to treatment. Temporary insufficiency, resulting from defective nutrition, may sometimes be remedied by a regulated nitrogenized diet, by the tincture of iron, an out-door life, and by the consumption of large quantities of fluid. A diet composed for the most part of milk is strongly to be recom- mended. If the baby is feeble, and sleeps or cries when put to the breast it is a good plan for the mother to borrow for a time a healthy infant with strong suction-powers to stimulate the glands to perform their functions. Cataplasms of castor-oil leaves or fennel-teas possess no claims to confidence. Galactorrhoea.—An abundance of milk is not pathological, the quantity quickly accommodating itself to the wants of the child. A 42 658 DISEASES OF CHILDBED. constant dribbling of milk from the nipple, or galactorrhaa, an affec- tion which may continue long after lactation has been suspended, acts, like any other profuse discharge, in exhausting the strength and in producing a wasting of the tissues. The treatment consists in inter- rupting lactation, in compression of the breasts, and in the employ- ment of such dietetic measures as are best calculated to repair the general health ; of special measures, saline laxatives and the internal administration of iodide of potassium are of most repute. Sore Nipples.—Under the term sore nipples are included a number of lesions which, in spite of their seeming triviality, possess consider- able importance, not only on account of the suffering they occasion, but because they furnish the starting-point of most cases of mammary abscess. A simple erythema, associated with great tenderness, is a common trouble at the beginning of lactation, to which, however, primiparae are more subject than multiparae. It is a good plan to anticipate this difficulty by instructing the patient to wash the nipples daily, during the last weeks of pregnancy, Avith some astringent or alcoholic solu- tion. In childbed, in addition to strict cleanliness, great benefit is derived from folding a linen rag around the nipple and keeping it con- stantly wetted with Goulard's extract, a teaspoonful to a tumbler of water, until the sensitiveness and redness have disappeared. Before applying the child to the breast, care should be taken to wash away the deposited carbonate of lead. In many women, owing to the maceration and loosening of the epithelium from the oozing of the colostrum, suckling of the child is followed by the formation of small vesicles, which eventually rupture and produce isolated erosions. Under faA'orable conditions, these ero- sions become covered with crusts beneath which the healing process takes place. If, however, the crusts are remoA'ed by suckling before a new layer of epithelium has had time to form, the simple excoriation may be converted into an ulceration with deep destruction of tissue. If the child be suffering from sprue, the transfer of the oidium albicans may impart to the wounds of the nipple an aphthous character. If the primary vesicles, in place of remaining isolated, coalesce, the nipple may become bared of its epithelium OA-er a considerable extent of its surface. The papillae then enlarge and giA'e a raspberry-like appear- ance to the exposed structure. Fissures of the nipples are excruciatingly painful, and are capable of exciting even a high degree of fever. They occur with greatest fre- quency in nipples which have been flattened by the pressure of corsets, or in which the natural fissures between the papillae are of unusual depth. Most commonly they are seated at the base of the organ. Either they may develop from the erosions just described, or the clefts upon the surface may become covered by crusts composed of dirt and DISEASES OF THE BREAST. 659 colostrum, which, when torn away by the nursing child, detach the delicate underlying epithelium. As regards the treatment, it is well to bear in mind that, with cleanliness and the removal of irritating matters from the wounded surface, the worst cases of sore nipples will get well in from twenty- four to forty-eight hours, provided lactation is suspended. The object of treatment, therefore, is, to cure the lesion without interfering with the nursing of the child. This is comparatively easy when but one nipple is affected, as the child need only be applied to the sound side. In that case, however, the excessive tension which results from the suspension of lactation should be relieved by stroking the breast from the base toward the apex Avith the hands, or by getting the nurse to draw the milk with her mouth, or by means of a breast-pump with a wide, trumpet-shaped extremity. The healing process can at the same time be promoted by lead-lotions, by a solution of tannin, or by some astringent ointments. My rule is to keep upon the nipple a rag wetted Avith the Goulard's extract, as described for erythema, during the patient's waking hours, substituting therefor a carbolized oint- ment during the hours of sleep, when the drying of a lotion would cause the rag to adhere to the raAv surface. If the child be troubled with sprue, special attention must be taken to cure its mouth, and the development of the oidium albicans upon the nipple should be prevented by frequent washings with solutions of boracic acid or of the sulphite of sodium. Cracks are much more rebellious to treatment than simple erosions. If of any extent, the nipple should be drawn to one side, so as to expose the fissure, which should be touched with the point of the mitigated stick of nitrate of silver. As the effect of the latter is intended to be local, it should be applied dry, the lymph furnished by the denuded surface affording the requisite moisture. I mention this trivial detail, as, in hospital practice, I have sometimes seen the entire nipple robbed of its epithelium, OAving to the mistake made by the house-physician of first dipping the pencil in water, and then allowing the strong solu- tion to diffuse itself over the sensitive surface. The compound tinct- ure of benzoin, strongly recommended by Professor F. Barker, makes a good stimulating application to cracks of the nipple. Though somewhat painful Avhen used for the first time, it is afterward easily tolerated. If both nipples are simultaneously affected, lactation can not, of course, be entirely interrupted without drying up the milk, but the intervals between the acts of nursing should be lengthened as much as the comfort of the mother will permit. If the milk will not come without tugging, the flow should be furthered, before applying the child by stroking the breasts. Of nipple-shields I am not able to speak with much enthusiasm. Many, if not most, infants resent the 660 DISEASES OF CHILDBED. ordinary rubber ones, and refuse to suck through them. A more acceptable form is one provided with a rubber tube and mouth-piece, such as commonly goes with nursing-bottles, but it is apt to drive away the milk if its use is long persisted in. Legroux recommends a bit of gold-beater's skin, fastened to the breast by means of collodion, and perforated with a needle over the portion which covers the open- ings of the lactiferous ducts. But, even without these aids, in time a cure can usually be effected by perseverance in the use of the remedies already mentioned. It is necessary to stop nursing altogether only when the nipples are hopelessly flat and misshapen, or when mastitis threatens. For eczema, lead, zinc, or white-precipitate ointment may be em- ployed. In obstinate cases a solution of corrosive sublimate (gr. v ad | j) is recommended by Hebra. Subcutaneous Inflammation of the Breasts.—The subcutaneous in- flammation may be confined to the areola, which then becomes red, swollen, and excessively sensitive. This form generally terminates in suppuration, and may form fistulous communications with the lactif- erous ducts. Sometimes the inflammation begins in the sebaceous follicles, giving rise to small boils around the nipple. In other cases inflammation may extend beyond the areola, and either give rise to localized abscesses, or, when due to the septic infec- tion of excoriated nipples, assume an erysipelatous character. The treatment of both these forms consists in the application of Avarm lead-lotions, and in the early evacuation of the pus. To avoid cutting into the milk-ducts, the incision should radiate from the nipple. Inflammation of the Submammary Connective Tissue.—This rare condition owes its origin, according to Billroth, in most, if not in all, cases to abscess formation in the deep-lying glandular structures, the pus perforating the fascia-like connective tissue at the base of the organ into the loose connective tissue situated between the gland and the pectoral muscle. The breast is in consequence lifted from the trunk, and can be moved to and fro as though it rested upon a water-bed. The skin is not reddened, but is sometimes markedly oedematous. The pain is deep-seated and dull; the fever is high and continuous; the axillary glands swell, and movements of the arm are hindered by the increase of the pain they occasion. Stoltz is said to have removed from such a sac twenty ounces of pus. So soon as the pus-formation is recognized, a free incision should be made at the lower portion of the gland, and the wound should be treated Avith the antiseptic precautions which Avill be given in connection with parenchymatous mastitis. Parenchymatous Mastitis.—Inflammation of the glandular struct- ures of the breast develops usually in the first four weeks after confine- ment. It is characterized by pain, high fever, and nodular enlarge- DISEASES OF THE BREAST. 661 ment of the affected lobules. The attack usually begins with a sharp chill. These symptoms are sometimes observed three to four days after the birth of the child, at the beginning of lactation, but then are usually temporary, the commencing mastitis terminating in sponta- neous resolution. Mastitis leading to abscess-formation belongs, for the most part, to a later period, occurring most frequently in the third i or fourth week, long after the first inflammatory symptoms have sub- sided. Puerperal mastitis is quite commonly believed to be due to emo- tional causes, to cold, to blows, or to "caking" from milk retention —all suppositions of extreme convenience as relieving the physician from responsibility for their occurrence. They certainly, however, play a subordinate role in the etiology of the affection, the lesions of the nipples furnishing, with perhaps rare exceptions, the starting-point from which the inflammation travels to the glands, either passing to the deep-seated tissues by the lymphatics, or following the track of the lactiferous ducts to the glandular acini. The exact anatomical structure of the resulting nodular masses is, for the most part, matter of conjecture. Only this much is known certainly, that they are composed in part of glandular structures and in part of the swollen interstitial tissue ; that the lactiferous ducts are either constricted or closed; that suppuration takes place both in the connective tissue and in the acini; and that the large abscess-cavities form from the coales- cence of small pus-collections. The walls of the abscess are, therefore, never smooth, but are uneven, with projecting portions of glandular tissue which has, as yet, not undergone disintegration. The milk- secretion is arrested in the affected lobules. If, as sometimes happens, a large duct is perforated, pus may be discharged with the milk, or, in case the abscess opens externally, a milk-fistula may be produced. When several foci of inflammation exist, they may suppurate in suc- cession, so that abscess after abscess may develop, and the morbid condition be protracted for weeks, and even months. If the abscesses break spontaneously, at a point unfavorable for the discharge of pus, fistulous passages are liable to be produced. In hospitals, as the result of long-continued suppuration and necrosis of tissue, entire lobes may undergo destruction, with subsequent cicatricial formation and ensu- ing deformity of the breast; or, with the access of unwholesome air to the abscess-cavities, the sloughing tissues may become gangrenous and death may follow from septicaemia. The first important point as regards the treatment of parenchyma- tous mastitis is to take the child from the breast. If this is done early in a very large number of cases the inflammation will disappear without advancing to suppuration. If lactation is continued, espe- cially when sore nipples persist as a complication, the chances of avoiding abscess-formation are extremely small. In cases of pain due 662 DISEASES OF CHILDBED. to excessiA'e fullness of the milk-ducts, partial relief should be given by means of mammary expression. For the pain, opium, for the fever, a full dose of quinine, should be administered. A saline cathartic acts as a derivative and diminishes the hyperaemia of the breasts. As the pain of the inflammation is augmented by the weight of the organ, the breast should be raised and supported by a suitable bandage. Much comfort is often afforded by the local application of belladonna, in the form either of an ointment, or of the liniment diluted with three or four parts of opodeldoc. Considerable relief is likewise ob- tained by laying a flannel wetted Avith a lead-and-opium wash over the breast, and placing on the outside some water-proof substance to prevent speedy evaporation. A large flaxseed-poultice lessens pain by reason of its heat, but should not be employed, at least so long as the hope of absorption has not been abandoned. So soon as there are evidences of pus, such as bogginess, oedema, or reddening of the skin, the abscess should be opened with antisep- tic precautions. If the inflamed acini are situated near the surface, fluctuation is early apparent. In deep-seated abscesses, the precise situation of the pus collections is not easy to determine. If the matter is doubtful, it is better to first insert an aspirator-needle into the breast, rather than to subject the woman to a painful operation, which, if misdirected, may require to be repeated. In Billroth's clinic * the following plan is adopted in opening ab- scesses of the breast: The surface should first be cleansed Avith soap and drenched with a solution of carbolic acid or of thymol. The incision should be a half-inch in length, and should radiate from the nipple. A drainage-tube should be instantly introduced, and the pus should be gently expressed, after Avhich the breast should once more be bathed with a disinfectant fluid. The entire breast should then be enveloped in antiseptic gauze coA'ered with water-proof material. Finally, after packing the periphery with oakum, especially beneath the breast and in the axilla, the dressing should be fastened with a bandage extending over the thorax from the neck to the umbilicus. In doing this, care should be taken to pack sufficient cotton beneath and around the sound breast to prevent its surface being pressed into contact with that of the thorax. If the abscess is large and sinuous, the dressing should be changed in twenty-four hours, and then should be left in place for from three to five days. By these means the organ is equably compressed, the pus is prevented from decomposing, and the discharge is promoted, all conditions which tend to produce a painless course and a rapid recovery. If, while the bandage is applied, the patient once more suffers from pain and fever, it should be removed, and any new abscess in the process of formation should be opened and treated in the same manner. * Billroth, "Handbuch der Frauenkrankheiten," zelmter Abschnitt, p. 23. DISEASES OF THE BREAST. 663 By the practice recommended, even in bad cases, the ugly scars and deformities of the breast, which sometimes folloAV the older poul- tice treatment, are avoided. In fresh cases the pus is never decomposed, and irrigation of the wound is unnecessary. In old cases, on the contrary, which have been treated by small incisions and without antiseptic precautions, the pus is often acid and possessed of irritating properties. For these neglected abscesses, Billroth recommends placing the patient under an anaesthetic, dilating the openings so as to permit the passage of the finger, and breaking down the thin partitions between the abscesses so as to convert them as far as possible into large com- municating cavities ; Avhile this process is going on, the tube of an irrigator should be passed by the side of the finger, and the cavity should be washed with a three-per-cent. solution of carbolic acid until at last the fluid comes away clear and unstained. A drainage-tube should then be introduced, and the breast treated in the antiseptic manner already described. It is hardly necessary to add that the recovery of the patient is always aided by good food and an abundance of fresh, pure air. Galactocele.—In very rare cases, owing to the obliteration or stop- page of one of the milk-ducts, the sinus may become distended with milk and form a cyst termed a galactocele. Usually it is of small size, but in the often-quoted case of Scarpa the breast attained such dimensions as to reach to the thigh. Upon puncturing the tumor with a trocar, ten pounds of milk were removed, which in all respects resembled human milk of normal quality. INDEX. Abdomen: appearance of, in pregnancy, 91, 98. pain in, during pregnancy, 91. size of, in pregnancy, 98. Striae upon, in pregnancy, 91. Abdominal muscles, action of, in labor, 128. Abdominal pregnancy, 310, 315. Abdominal tumors: diagnosis of, from pregnancy, 512. Abortion (vide labor, premature): anaesthesia in, 304. artificial, 333. indications for, 333. care of child, after, 333. causes, predisposing, of, 291. atrophy of uterine mucous membrane, 292. hypertrophy of uterine mucous mem- brane, 293. causes, immediate, of, 294. hyperaemia of gravid uterus, 294. uterine contractions, from nervous influ- ences, 294. definition of, 291. diagnosis of, 298. expulsion of placenta, in, 295, 296. incomplete, results of, 296. indications for, 326. diseases which imperil life of mother, 328. habitual death of foetus, 328. moderate pelvic contraction, 326. induction of, 326. membranes, retention of, in, 296. methods for producing, 332. mole, due to, 295. operations for induction of, 328. catheterization of uterus, 329. douche, vaginal, 331. injections between uterus and ovum, 329. mechanical dilatation of cervix, 330. rupture of membranes, 330. tampon, vaginal, 332. Abortion: ovum-forceps, use of, in, 307. polypi, fibrous, removal of, after, 308. prognosis in, 299. prophylaxis of, 300. retention of membranes in, 296. symptoms of, 294. tampon, vaginal, use of, in, 305. time for, 327. treatment of, 300. when inevitable, 302. when neglected, 307. treatment, prophylactic, 300. treatment of threatened, 301. Abscesses, in mastitis, 661. in phlegmasia alba dolens, 656. in puerperal fever, 625, 651. Acardia, in multiple pregnancy, 223, 519. Accidental haemorrhage, 554, 561. treatment of, 562. Accoucheur, armamentarium of, 203. jEquabiliter justo-minor pelvis, 432, 439. After-paps, 236. Air, collapse and death from entry of, into uterine vessels, 598. Air-passages, catheterization of, in asphyxia neonatorum, 594. Albuminuria, 531. in pregnancy, 95. in eclampsia, 528, 529, 531. treatment of, 535 et seq. Alcohol, use of, in puerperal fever, 648. Allantois, 49, 50. Amaurosis, in pregnancy, 95. Amblyopia, in pregnancy, 95. Amenorrhcea, 97. Ammonia, intravenous injection of, in cere- bral anaemia, 547. Amnion, 48. anomalies of, 277. causing inertia uteri, 422. dropsy of, 277. fluid of, 58. 666 INDEX. Amniotic fluid, anomalies of, 277. deficiency of, 278. Anaemia, 116. cerebral, causing eclampsia, 534. treatment of, 547. in labor and childbed, 597. pernicious, in pregnancy, 117. treatment of, 117. Anaesthetics: in abortion, 304. in eclampsia, 537. in irregular pains of first stage of labor, 424. in midwifery, 219. Anaesthesia, in pregnancy, 95. Anasarca, fetal, causing dystocia, 517. Anchylosis of fetal joints, causing dystocia, 518. Anodynes, in protracted first stage of labor, 424. Anorexia, in pregnancy, 117. Anteflexion, in pregnancy, 264. Anteversion, in pregnancy, 264. Antipyretic treatment of puerperal fever, Gi6. by quinia, 646. by salicylate of soda, 647. Antiseptic treatment of puerperal patients, 641. Anus: development of, 02. imperforate, 62. Aorta, compression of, in post-partum haem- orrhage, 546. Apron, Hottentot, 4. Arbor vitce uterina, 13. Arch, palatine, 63. Arches, visceral, 62. aortic, 67. Area, germinativa, 44, 59, 67. opaca, 45, 59. pellucida, 45, 59. vasculosa, 45, 67. Areola, mammce, 237. of pregnancy, 92, 94, 98. secondary, of Montgomery, 92. Armamentarium of accoucheur, 203. for breech presentations, 355. Arms: liberation of, in breech presentations, 360. liberation of, when extended, 360. liberation of, when flexed, 360. release of anterior, 360. release of posterior, 360. Arteria, uterina hypogastrica, 22. aortica, 23. Arteries: inferior vertebral, 67. omphalo-mesenteric, 67. superior vertebral, 67. vitelline, 67. Articulations: anchylosis of fetal, obstructing labor, 518. of fetal head with spinal column, 166. pelvic, 143. pelvic, mobility of, in labor, 273. sacro-iliac, 143. Artificial feeding of infants, 247. Artificial respiration, in asphyxia neonato- rum, 595. Schultze's method of, 595. Marshall Hall's method of, 59G. Ascites, fetal, obstructing labor, 516. Asphyxia neonatorum, 588. definition of, 588. diagnosis of, 592. etiology of, 588. morbid anatomy of, 591. prognosis of, 593. treatment of, 596. Asphyxia livida, 591. pallida, 591. Astringents, use of, hi post-partum haemor- rhage, 543. Atony, uterine, in third stage of labor, 429. Atresia of genital canal, 500. symptoms of, 506. treatment of, 506. Atresia, uterine, 504. from cervical thrombus, 505. from cicatrices, 505. from conglutinatio orificii externi, 504. from elongation of anterior lip, 505. from ovarian tumors, 511. from rigidity of os, 505. from tumors, 505. Atresia, vaginal, 501. accidental, 501. congenital, 501. from cystic degeneration of vaginal walls, 503. from cystocele, 502. from ecchinococci, 503. from neoplasmata, 503. from rectocele, 502. from retention of urine, 502. from vaginal hernia, 503. from vaginismus, 503. from vesical calculi, 502. Atresia, vulvar, 500. Atropia, use of, in protracted first staga of labor, 424. Atrophy, of uterine mucous membrane, caus- ing abortion, 292. Attitude of foetus, 78. Auscultation, as aid to diagnosis of pregnan- cy, 100. Axis: of superior pelvic strait, 150. of inferior pelvic strait, 151. INDEX. 667 Bacteria: Davaine's experiments with, 614. in puerperal fever, 612, 614, 631. Ballottement, 100. Bandage, application of abdominal, 218. Barnes's dilator: use of, in accidental haemorrhage, 562. use of, in breech presentations, 201. use of, in eclampsia, 538. use of, in placenta praevia, 559. use of, in prolapsed funis, 584. use of, in protracted first stage of labor, 425. use of, in vaginal thrombus, 580. use of, to induce premature delivery, 331 Bath: cold, in puerperal fever, 648. of new-born infant, 246. Binder, application of abdominal, 218. Bladder: calculus in, obstructing labor, 502. development of fetal, 66. dilatation of fetal, 516. distention of, obstructing labor, 502. Blastodermic vesicle, 44. membrane, 44. Blood, changes of, in pregnancy, 116. Blunt hook: use of, in craniotomy, 393. Bodies, Wolffian, 28. Bottle for artificial feeding of infants, 249. care of, 249. Bougies, use of, in protracted first stage of labor, 425. Bowel, paralysis of, in puerperal fever, 626. Breech presentations, 196. causes of, 196. configuration of foetus in, 200. diagnosis of, 196. irregularities in mechanism of, 199. mechanism of, 197. prognosis in, 200. rotation in, 198. treatment of, 201. Breasts: anatomy of, 237. changes in, during pregnancy, 91. diseases of, 657. abscesses of, 661. causes of mastitis, 661. galactocele, 663. galactorrhea, 657. inflammation of, 660. mastitis, parenchymatous, 660. nipples, sore, 658. nipples, fissured, 658. treatment of sore nipples, 659. treatment of mastitis, 660. in new-born child, 241. symptoms of, relating to pregnancy, 98. Bregma, 164. Brim, of pelvis, 149 (vide strait, superior). application of forceps at, 348, 349. extraction with head at, 363. Tarnier's forceps at, 351. Taylor's forceps at, 350. Bromides: use of, in eclampsia, 538. use of, in emesis of pregnancy, 119. use of, in insomnia, 122. use of, in puerperal insanity, 654. Brow presentations, 192. diagnosis of, 192. mechanism of, 192. prognosis in, 193. treatment of, 194. Bruit, uterine, in pregnancy, 101. Bulbus arteriosus, 66. Bulbi vestibuU vaginal, 4. pars intermedia of, 4. Caesarean section, 399. after-treatment of, 406. assistant's duties in, 401. checking haemorrhage in, 404. cleansing peritonaeum after, 405. closure of wound after, 405. dressing of wound after, 405. extraction of foetus after, 403. history of, 399. incision in the abdominal wall during, 401. incision into uterus during, 402. indications for, 400. instruments necessary for, 401. operation of, 400. preparations for, 400. prognosis of, 406. causes for bad, 409. in lying-in hospitals, 407, 409. in rural localities, 408. removal of placenta, in, 404. Calcareous degeneration: of foetus, 290. of cord, 281. Calculi: vesical, obstructing labor, 502. impacted, mistaken for exostoses, 502. Canal, genital, atresia of, 500. ruptures of, 564. Cancer, uterine, 509. Caput succedaneum : in face presentations, 188. in vertex presentations, 179. Cardiac diseases, complicating pregnancy 256. Carunculm myrtiformes : formation of, 7. 668 INDEX. Catheterization: uterine, to produce premature delivery, 329. of air-passages, inasphyxia neonatorum, 594. Cephalic version, 366. Cephalotomy, 394. Cephalotribe, 383. action of, 386. application of, 388. Blot's, 384. objections to, 386. Lusk's, 385. Scanzoni's, 385. Cephalotripsy, 386, 388. Cervix uteri, 12, 25. apparent shortening of, in pregnancy, 86. explanation of, 88. atresia of, 505. canal of, 13. cancer of, 509. erectility of, 25. in puerperal state, 234. mechanical dilatation of, to produce abor- tion, 330. mucous membrane of, 17. portio vaginalis of, 12. lacerations of, 573. stricture of, 505. Child (vide foetus) : asphyxia of, 588. -bed, insanity of, 652. breasts of new-born, 241. conditions influencing size of, 76. icterus of new-born, 241. milk prepared for, 248. weight of new-bora, 76. Chill, post-partum, 230. in puerperal fever, 622. Chloral: in eclampsia, 536, 538, 539. in emesis of pregnancy, 120. in insomnia of pregnancy, 122. in puerperal insanity, 654. Chloroform: effect of, on pains, 220. use of, in eclampsia, 537, 539. use of, in labor, 220. Cholera, complicating pregnancy, 252. Chorda dorsalis, 46, 61. Chorea, complicating pregnancy, 117, 261. treatment of, 262. Chorion: formation of, 44, 49. permanent, 51. villi of, 50, 52. Cicatrices: atresia, uterine, from, 505. of os, obstructing labor, 505. of vagina, obstructing labor, 501. I Circle of Baudelocque, 435. Circulation: disorders of, in pregnancy, 117, 118. fetal, 71. varicose veins due to disorders of, in preg- nancy, 118. Clefts, visceral, 62. Clitoris: anatomy of, 3. corpus of, 3. frenulum of, 4. glans of, 3. praeputium of, 4. Coccyx, anatomy of, 141. Coelum, 48. Coiling of cord, 281. Cold, use of, in puerperal fever, 648. Collapse, in labor and childbed, 597. etiology of, 597. Colpohyperplasia cystica : vaginal atresia from, 503. Columns, vaginal, 9. Conception, 40. Confinement, prediction of day of, 111. Congenital encephalocele, 515. Conglutinatio orijicii externi: atresia from, 504. Conjugate diameter of pelvis: measurement of diagonal, 437. measurement of external, 436. measurement of vera, 438. Constipation: in pregnancy, 92. in retroflexion, with incarceration, 266. Contracted pelvis, 432 (vide pelvis, con- tracted). diagnosis of, 433. frequency of, 432. varieties of, 432. Contraction: hour-glass, of uterus, 429. pelvic, resources of treatment in, 466. Convulsions, puerperal, 526 (vide eclamp- sia). Cord, umbilical (vide funis): calcareous degeneration of, 281. care of, in infants, 246. coiling of, 281. cysts of, 281.. formation of, 57. hernias of, 280. knots in, 280. management of, in breech presentations, 359. marginal insertion of, 282. prolapse of, 582. reposition of, 587. souffle in, 102. stenosis of vessels of, 281. INDEX. 669 Cord, umbilical: torsion of, 279. tying of, in labor, 211. Cordiform uterus, 32. Corpus luteum : anatomy of, 37. false, 38. formation of, 37. true, 38. Cramps in pregnancy, 92. Cranial presentations, 168 (vide presenta- tions, vertex). Cranioclast, 389. action of, 391. application of, 391. Braun's, 390. Simpson's, 389. Craniotomy: before version, 394. Blot's cephalotribe in, 384. Blot's perforator in, 379. Braun's cranioclast in, 396. contraindications for, 464. contrasted with version, 460. eraniotomy-forceps of Meigs in, 392. crotchet and blunt hook in, 393. definition of, 377. extraction of child after, 382. Hodge's craniotomy scissors in, 379. indications for perforation in, 377. instruments used in, 378, 383. Lusk's cephalotribe in, 385. operation of perforation in, 377, 381. Scanzoni's cephalotribe in, 385. Simpson's cranioclast in, 389. Simpson's perforator in, 379. Smellie's scissors in 379. Thomas's perforator in, 379. trephine perforator in, 380. Cranium, fetal, 76. premature ossification of, 513. Crotchet, 393. delivery of trunk with, 394. Cuneus, 2. Cyanosis neonatorum,- 72 (vide asphyxia neo- natorum). Cystocele: atresia, vaginal, from, 502. obstructing labor, 502. Cysts: of cord, 281. of ovary, differentiated from pregnancy, 104. of vaginal walls, 503. Deafness, in pregnancy, 95. Death: fetal, diagnosis of, 109. real or apparent, of mother in pregnancy or labor, 599. Death: delivery of child in, 599. sudden, in labor and childbed, 597. Decapitation, 396. Braun's decollator in, 396. in embryotomy, 395. methods of, 396, 397. Pajot's method of, 397. Decidua, 49, 51. reflexa, 52. separation of, 233. serotina, 52. vera*, 51. Decollator, Braun's, 396. use of, in decapitation, 397. Deformities, pelvic, 432 (vide pelvis, con- tracted). due to absence of symphysis, 499. due to exostosis, 498. due to fractures, 498. contracted pelvis, 432. flattened pelvis, 441. funnel-shaped pelvis, 493. generally contracted pelvis, 444. irregular forms of contracted pelvis, 445. kyphotic pelvis, 485. Naegele oblique pelvis, 481. osteomalacic pelvis, 495. pseudo-osteomalacic pelvis, 498. Robert's anchylosed and transversely con- tracted pelvis, 489. rachitic pelvis, 442. Scholio-rachitic pelvis, 488. Spondolisthetic pelvis, 491. Degeneration: calcareous, of cord, 281. calcareous of foetus, 290. fatty, of foetus, 289. hydatidiform, of placenta, 283. Delivery: care of patient after, 217. immature, definition of, 291. treatment of, 309. premature, definition of, 291. Development of female organs of genera- tion, 28. Diameters of pelvis, 150. bis-iliac, 150. conjugate, 150, 438. diagonal conjugate, 436. oblique, 150. transverse, 150. Diameters of fetal head, 164. Diet, in puerperal state, 244. Digestion: disorders of, in pregnancy, 94, 119, 121. of new-born infant, 241. Digital examination in labor, 203. Digitalis, use of, in puerperal fever, 647. 670 INDEX. Dilator, Barnes's: use of, in accidental haemorrhage, 562. use of, in breech presentations, 201. use of, in eclampsia, 538. use of, in placenta praevia, 559. use of, in prolapsed funis, 584. use of, in protracted first stage of labor, 425. use of, in vaginal thrombus, 580. use of, to induce premature delivery, 331. Diphtheritic patches: in puerperal fever, 617, 163. Discus proligerus, 35. ' Diseases, complicating pregnancy, 250 (vide pregnancy, diseases complicating). anomalies of cord, 279 et seq. cardiac diseases, 256. cholera, 252. chorea, 261. coiling of cord, 281. cysts of cord, 282. degenerations of cord, 281. emphysema, 258. empyema, 258. endometritis decidua, 270. hernias of cord, 280. hydatidiform mole, 283. icterus, 255. maceration of foetus, 288. malarial fever, 254. mummification of foetus, 288. phthisis pulmonalis, 259. pleurisy, 25S. pneumonia, acute lobar, 257. relapsing fever, 253. rubeola, 251. scarlatina, 251. small-pox, 'J51. syphilis, 259. typhoid fever, 253. typhus fever, 253. variola, 251. Displacements, of uterus, 264, 265 (vide rus, displacements of). Dolores presagientes, 130. Dorsal plates, 46, 59. Double uterus, 263. Douglas, cul-de-sac of, 7, 14. Douche, vaginal: in protracted first stage of labor, 425. to produce premature delivery, 331. to prevent puerperal fever, 642. Dropsy : complicating pregnancy, 117. of amnion, 277. Ducts: of Miiller, 28. AVolffian, 28. Ductus, arteriosus, 69. Ductus, venosus, 71. Dystocia, from fetal emphysema, 517. Dysuria, from retroflexion of gravid uterus, with incarceration, 266. Echinococci, vaginal atresia from, 503. Eclampsia, 526. clinical history of, 526. definition of, 526. etiology of, 529. pathology of, 529. prognosis in, 528. | terminations of, 528. treatment of. 535. use of bromides in, 538. use of chloral in, 536, 538, 539. use of chloroform in, 537, 539. Ecraseur, Hicks's wire, in cephalotomy, 394. Ectoderm, 44. Ectopia of abdominal organs obstructing la- bor, 517. I Electricity : in emesis of pregnancy, 119. in extra-uterine pregnancy, 320. in post-partum haemorrhage, 546. Elytrotomy in extra-uterine pregnancy, 320. Embolus: collapse and death from pulmonary, in la- bor and childbed, 598. symptoms, 598. treatment, 599. Embryo: anatomy of, 46. nourishment of, 48. Embryotome: of P. Thomas, 398. I Embryotomy, 377, 395. [ decapitation in, 396. exenteration in, 395. indications for, 395. Emesis: in incarceration of retroflexed uterus, 266. in pregnancy, 119. in puerperal fever, 623, 627. Emphysema: complicating pregnancy, 258. fetal, causing dystocia, 517. Empyema: complicating pregnancy, 2,r>s. Encephalocele, congenital, 515. Endocarditis ulcerosa puerperalis, 618. Endochorion, 51. Endometritis decidua, complicating preg- nancy, 270. Endometritis decidua catarrhalis, or hydror- rhea gravidarum, 272. Endometritis decidua chronica diffusa, 270. Endometritis decidua polyposa, 270. Endometritis decidua tuberosa, 270. INDEX. 671 Enema, in labor, 205. Entoderm, 44. Erectility: cervical, 25. ovarian (theoretical), 26. vaginal, 8. Ergot: contraindications for, in parturition, 428. indications for, in parturition, 429. physiological action of, 429. use of, after normal labor, 217. use of, in accidental haemorrhage, 562, use of, in parturition, 428. use of, in placenta praevia, 560, 561. use of, in post-partum haemorrhage, 543. use of, in protracted first stage of labor, 426. Erysipelas, bow related to puerperal fever, 618. Eustachian valve, 68. Evohitio conduplicato corpore, 525. prognosis, 525. Evolution, spontaneous, 523. etiology of, 524. mechanism of, 524. Examination of patient in labor: method of conducting, 106, 107, 203. Exanthemata in pregnancy, 251. Excavatio : recto-uterina, 14. vesico-uterina, 14. Exochorion, 51. Exostosis, pelvic deformity from, 498. Expression of placenta: by Crede's method, 215. in irregular pains of third stage of labor, 429. Extraction of foetus : by breech, in breech presentations, 357. by feet, in breech presentations, 356. in Caesarean section, 403. in foot and breech presentations, 354. in pelvic presentations, 354. in real or apparent death of mother in preg- nancy or labor, 599. relief of arms in, 360. Extraction of head, 362. Extraction of trunk to shoulders, 356. Extra-uterine pregnancy, 309 (vide preg- nancy, extra-uterine). abdominal, 310, 315. definition of, 310. diagnosis of, 318. interstitial, 313. ovarian, 310, 315. symptoms of, 316. terminations of, 317. tubal, 310. tubo-abdominal, 314. | Extra-uterine pregnancy: tubo-ovarian, 314. treatment of, 319. (a) in cases of early gestation, 319. (b) in cases of advanced gestation, 322. (c) in cases of gestation, after death of foetus, 324. Face, development of, 63. Face presentations, 184 (vide presentations, face). abnormal mechanism of, 186. causes of, 182. configuration of head in, 188. diagnosis of, 189. frequency of, 182. mechanism of, 184. prognosis in, 189. treatment of, 190. Fallopian tubes, 18. ampulla of, 19. anatomy of, 18. isthmus of, 19. ostium abdominale of, 19. Fatty degeneration of foetus, 289. Fecundation, 40. Feeding, artificial, of infants, 247. Fever: -cot, use of, in puerperal fever, 649. malarial, complicating pregnancy, 254. milk, 238. puerperal, 602 (vide puerperal fever). relapsing, 253 (in pregnancy). typhoid, 253 (in pregnancy). typhus, 253 (in pregnancy^. Fibroid tumors, differential diagnosis of, from pregnancy, 104. Fillet, use of, in version, 375. Flattened pelvis, 441. non-rachitic, 441. rachitic, 442. Flatulence in pregnancy, 115. Floor, pelvic or perineal, 158. Fluid, amniotic, 58. anomalies of, 277. deficiency of, 278. Fcetus: abdominal enlargement of, obstructing de- livery, 516. abnormalities of, obstructing labor, 513, abnormalities of, obstructing delivery of trunk, 516. ascites of, obstructing delivery, 516. at term, 75. attitude of, 78 et seq. causes of death of, 291. circulation of, 71. congenital hydrocephalus of, 513. cranium of, 76. 672 Foetus: degeneration, fatty, of, 289. degeneration of liver of, 517. development of, 59. diagnosis of death of, 109. diameters of bead of, 164. diseases of, obstructing delivery of its head, 513. encephalocele of, obstructing labor, 515. extraction of: by breech, 357. by feet, 356. in breech and foot presentations, 354. in craniotomy, 382. in pelvic presentations, 354. instruments for, 383. with head at brim, 362. fatty degeneration of, 289. habitual death of, as cause for inducing abortion, 328. head of, at term, 163. heart-sounds of, in pregnancy, 100. hydrocephalus of, obstructing labor, 513. hydrothorax of, obstructing labor, 510. in first month, 72. in second month, 73. in third month, 73. in fourth to eighth month, 74. in ninth to tenth month, 75. length of, at term, 75. liver of, fatty degeneration of, 517. maceration of, 288. monstrosities developed from, 518. movements of, in pregnancy, 99, 113. active and passive, 99. mummification of, 288. papyraceus, 224. position of, 178 et seq. release of arms of, 360. retention, in utero, of dead, 287. tumors of trunk of, obstructing labor, 517. weight of, at term, 76. Follicles,Graafian, 33 (vide Graafian follicles). Fontanelles, 77, 163. large, 77, 164. small, 77, 164. Foramen ovale, 68. valve of, 69. Forceps, 334. action of, 339. application of, 343. to after-coming head, 365. at the pelvic brim, 348. at the pelvic outlet, 341. Chamberlen's, 336. Chapman's, 336. contrasted with version and craniotomy, 460 et seq. craniotomy of Meigs, modified, 392. | Forceps: Hodge's, 339. history of, 335. indications for, 340. at pelvic outlet, 341. in contracted pelvis, 477. in craniotomy, 383. in face presentations, 353. in occipito-posterior positions, 352. in placenta praevia, 560. in vaginal thrombus, 580. introduction of blades of, 344. Levret's, 337. locking of, 345. long, 337. Lusk's modification of Tarnier's, 352. Naegele's, 338. ovum-, use of, in abortion, 307. removal of, 348 short, 336. Simpson's, 338. Tarnier's, 351. Tarnier's, modified by Lusk, 352. Taylor's, at brim, 350. Taylor's narrow-bladed, 350. traction on, direction of, 347. Wallace's, 339. White's, 339. Fornix, 8. Fossae, nasal, development of, 62. Fourchette, 4. Fractures, causing pelvic deformities, 498. Frenulum vulva, 4. Frenulum clitoridis, 4. Fundus of uterus, 12. Funic souffle, 102. Funis, 57 (vide cord, umbilical). anomalies of, 279. calcareous degeneration of, 281. care of, in infants, 246. coiling of, 281. cysts in, 281. diseases of, 281. formation of, 57. hernias of, 280. knots in, 280. management of, in breech presentation, 359. marginal insertion of, 282. prolapse of, 582. diagnosis of, 583. prognosis of, 583. treatment of, 584. reposition of, 587. by postural treatment, 585. souffle in, 102. stenosis of vessels of, 281. torsion of, 279. tying, in labor, 211. Funnel-shaped pelvis, 493. INDEX. 673 Galactocele, 663. Galactorrhoea, 657. Ganglion, cervical, 27. Gastrotomy (vide Caesarean section). in uterine rupture, 572. Gelatine, of AVharton, 57. Generation: anatomy of female organs of, 1. \ development of female organs of, 28. Genital canal: ruptures of, 564. uterine atresia of, 504. vaginal atresia of, 501. Germinative spot, 37. Germinative vesicle, 37. Germs, in puerperal fever, 616. , bacteria, 612, 614, 631. micrococci, 612, 631. Glandidce vestibulares: I majores, 6. minores, 5. Glands: mammary, anatomy and changes of, in pregnancy, 91, 237. [ sebaceous, of nymphae, 5. j uterine, 16. Glans clitoridis, 3. Graafian follicles, 33, 36. macula of, 37. number of, 37. stigma of, 37. theca folliculi of, 35. tunica fibrosa of, 35. tunica propria of, 35. Gravid uterus: anteflexion of, 264. anteversion of, 264. hernia of, 269. prolapse of, 268. retroflexion of, 265. with incarceration, 266. treatment of, 267. retroversion of, 265. Hare-lip: complicated, 63. double, 63. single, 63. Head, fetal: after-coming, forceps applied to, 365. at term, 163. configuration of, in vertex presentations, 178. descent and extension of, in face presenta- tions, 184. descent and flexion of, in labor, 169. diseases which obstruct delivery of, 513. entrance of, into pelvis, 168. extension of, in labor, 175. external rotation of, in labor, 176. Head, fetal: external rotation of, in face presentations, 186. flexion of, in face presentations, 186. molding of, in vertex presentations, 178. rotation of, in labor, 172. rotation of, in face presentations, 185. scalp-tumor on, 179. Headache in pregnancy, 122. Heart: development of, 66. diseases of, complicating pregnancy, 256. -sounds, fetal, in pregnancy, 100. Heart-burn, in pregnancy, 115, 121. Hemicephalus, 521. Haemorrhage: accidental, 554, 561. concealed, 562. external, 562. from cervical laceration, 574. from normally implanted placenta, 561. in Caesarean section, control of, 404. in placenta praevia, 554. internal, 562. post-partum, 539. causes of, 541, 542. disturbances of contractility as cause of, 541. disturbances of retractility as cause of, 541. disturbances of thrombus-formation caus- ing, 542. electricity, use of, in, 546. intra-uterine injections in, 544. methods of producing uterine retractions in, 546. methods of producing uterine contractions in, 542. normal agencies for checking, 539. outlying causes of, 542. transfusion of blood in, 548. transfusion of milk in, 548. treatment of, 542. treatment of cerebral anaemia in, 547 puerperal, 549. unavoidable, 554. Hernia: of cord, 280. of gravid uterus, 269. of vagina, atresia from, 503. Hiatus sacralis, 140. Hook : blunt, 393. Braun's decapitating, 396. Bambotham's decapitating, 397. Hour-glass contraction of uterus, 429. Hydatidiform mole: anatomy, morbid, of, 283. diagnosis of, 286. 43 674 INDEX. Hydatidiform mole: etiology of, 284. prognosis of, 286. symptoms of, 285. treatment of, 286. Hydramnion, 277. as cause of tardy labor, 422. diagnosis of, 278. etiology of, 277. prognosis of, 278. symptoms and signs of, 277. treatment of, 278. Hydrocephalus, 513. diagnosis of, 514. etiology of, 514. mechanism of labor in, 514. morbid anatomy of, 514. prognosis in, 515. Hydrorrhea gravidarum, 272. Hydrothorax: fetal, obstructing labor, 516. Hygiene of pregnancy, 115. Hymen: anatomy of, 6. annularis, 6. cribriformis, 6. fimbriatus, 6. imperforatus, 6. Hypertrophy: of uterine mucous membrane, causing abor- tion, 293. Hysteria: in pregnancy, 117. Hysterotomy, 399 (vide Caesarean section). Icterus: neonatorum, 241. in pregnancy, 255. Ileus: due to retroflexed gravid uterus, 266. Ilia, anatomy of, 141. Impregnation, 40 (cide fecundation). Incarceration of retroflexed gravid uterus, 266. treatment of, 267. Inertia uteri, 422, 429. causes of, 422. treatment of, 423. Infant, new-born, 241. artificial feeding of, 247. bath of, 246. care of, 246. care of cord of, 246. changes in circulation of, 241. digestion of, 241. icterus of, 241. loss of weight of, 242. navel of, 241. selecting wet-nurse for, 246. Infant, new-born: skin of, 241. tumor on presenting part of, 241. umbilicus of, 241. Infectious diseases: complicating pregnancy, 251. Injections: between uterus and ovum, to produce abortion, 329. intra-uterine, in post-partum haemorrhage, 544. intra-uterine, in puerperal fever, 043. vaginal, in protracted first stage of labor, 425. to produce abortion, 331. to prevent puerperal fever, 642. Insanity: in pregnancy, 117, 652. of lactation, 655. puerperal, 652. Insertion: marginal, of cord, 282. Insomnia, in pregnancy, 122. Insufflation: in asphyxia neonatorum, 595. Intestine: development of, 62, 65, 66. Inversio uteri, 563. Involution, uterine, 232. Iron: injection of, \npost-partum haemorrhage, 544. use of, in vaginal thrombus, 580. Ischia, anatomy of, 143. Jaundice: in new-born child, 241. in pregnancy, 255. Jaw, development of, 63. Joints: anchylosis of, fetal, obstructing labor, 518. mobility of pelvic, in labor, 273. pelvic, 143. sacro-iliac, 143. Kibbie's cot: use of, in puerperal fever, 649. Kidneys: cystic degeneration of fetal, 516. pathological changes of, in eclampsia, 531 et seq. Knots in umbilical cord, 280. Kyphotic pelvis, 446, 485. Labia majora, 2. commissures, anterior and posterior of, 3. oedema of, in pregnancy and parturition, 118, 130, 535. thrombosis of, 4. minora, 4. I sebaceous glands of, 5. INDEX. 675 Labor: action of abdominal muscles in, 12S. action of expellent forces in, 134. action of pains on uterine walls in, 127. action of vagina in, 129. anaesthetics in, 219. causes of, 123. chloroform in, 220. clinical course, 122, 130. contraction of uterine ligaments in, 128. duration of, 134. dry, 423. false, 431. mechanism of: abnormal, in vertex presentations, 177. in abnormal face presentations, 186. in breech presentations, 196. in brow presentations, 192. in face presentations, 184. in irregular breech presentations, 199. in normal presentations, 169. in occipito-posterior positions, 177. missed, 290. normal: anaesthetics in, 219. care of patient after, 217. chloroform in, 220. conduction of, 202. examination of patient in, 203. management of first stage of, 204. management of second stage of, 205. management of third stage of, 215. preliminary preparations for, 203. preservation of perinaeum in, 207. treatment of lacerations after, 218. tying cord in, 211. obstructed (vide obstructed labor). painful, 430. cessation of, after diaphoresis, 431. from hysteria, 430. from inflammation of or around genital organs, 431. from intestinal irritation, 431. from rheumatism, 431. pains of, 129. influence of, on organism, 129. pathological, 419. precipitate, 420. consequences of, 420. treatment of, 420. premature, 291, 467. care of child after, 333. catheterization of uterus to produce, 329. choice of methods to produce, 332. indications for, 326, 465. induction of, 326. injections between uterus and ovum to produce, 329. Labor: mechanical dilatation of cervix to pro- duce, 330. operations to produce, 328, rupture of membranes to produce, 330. tampon, vaginal, to produce, 332. vaginal douche to produce, 331. stage of: first, 130. second, or stage of expulsion, 133. third, or placental period, 133. symptoms, precursory, of, 130. tardy, 421. anodynes in, 424. Barnes's dilator in, 425. bougies in, 425. douche, vaginal, in, 425. ergot in, 426. expression of placenta in, 429. hour-glass contractions of uterus in, 429. irregular pains in first stage of, 421. irregular pains in second stage of, 426. irregular pains in third stage of, 429. quinia in, 426. treatment of, 421, 427, 429, 430. uterine ligaments: contraction of, in, 128. uterine contractions in, 127. Laceration: at vaginal orifice, 575. of cervix, treatment of, after labor, 218. of genital canal, 564. of perinaeum, 218, 576. of uterus, 564. of vagina, 575. of vestibulum, 575. Lactation, 237. fever of, 238. insanity of, 652. Laparotomy (vide gastrotomy): in extra-uterine pregnancy, 322. Laparo-elytrotomy, 415, 461. detail* of operation for, 417. history of, 415. Laxatives in puerperal fever, 646. Leeches: in puerperal fever, 646. Ligamenta lata, 14. Ligament, round, 15. Ligaments: broad, 14. pelvic, 145. recto-uterine, 15. vesico-uterine, 14. Ligamentum: ovarii, 20. teres, 15. Liquor amnii, 58. Lithopaedion, 287, 290. 676 INDEX. Liver: development of, 65. degeneration of fetal, 517. Lochia, 236. alba, 237. lactea, 237. rubra, 236. serosa, 236. Locking: of children in multiple pregnancies, 227. of forceps, 345. Locomotion: impeded in labor, 92, 130. Lungs, development of, 64. Lying-in period: duration of, 246. Lymphatics of uterus: inflammation of, in puerperal fever, 628. Maceration: of foetus, 288. Macula folliculi, 37. Malarial fever complicating pregnancy, 254. Malformations (vide monstrosities) : of child, 518. Mamma: anatomy of, 1)1, 237. changes of, in pregnancy, 91. diseases of, 657. secretion of milk in, 237. Mastitis, parenchymatous, 660. Mania (vide insanity): puerperal, 653. treatment of, 654. Marginal insertion of cord, 282. Meatus urethra, 5. Meconium, 75. Mechanism : abnormal, in vertex presentations, 177. of abnormal face presentations, 186. of breech presentations, 197. of breech presentations, irregularities in, 199. of brow presentations, 192. of face presentations, 184. of labor, 139. of normal labor, 169. of occipito-posterior positions, 177. Melancholia (vide insanity): in pregnancy, 652. treatment of, 654. Membrana granulosa, 36. Membrane, blastodermic, 44. Membranes: artificial rupture of, 205. ,: rupture of, to produce abortion, 330. spontaneous rupture of, 205. Menses: suppression of, in pregnancy, 96. Menstruation, 37 el seq. Mesoderm, 45. Metritis, as result of retroflexion of gravid uterus, 266. Micrococci: Davaine's experiments with, 614. in puerperal fever, 612, 631. Micropyle, of Keber, 42. Microspores, in puerperal fever, 612, 631. Microsporum septicum, 615. Migration of ovum, 39. Milk, 237. anatomical considerations relating to, 237. condensed, 248. composition of, 239. fever, 238. preparation of, for infants, 248. secretion of, 237. defective, 657. Milk-leg, 655 (vide phlegmasia alba dolens). Miscarriage (vide abortion), 291. time of greatest liability to, 116. treatment of, 309. Missed labor, 290. Mola: carnosa, 296. sanguinosa, 295. Mole, hydatidiform, 283. anatomy, morbid, of, 283. diagnosis, 286. due to abortion, 295. etiology, 284. prognosis, 2S6. symptoms, 285. treatment, 286. Mons Veneris, 2,15. Monstrosities, 518. acardiacus, 519. anencephalus, 521. diagnosis of, 518. hemicephalus, 521. mechanism of labor with, 519. prognosis in cases of, 519. Morbus coxarius : causing pelvic deformities, 483. Morning-sickness of pregnancy, 119. Morsus diaboli, 19. Morula, 44. Morphia (vide opium): in eclampsia, 537. in post-partum haemorrhage, 543. in protracted first stage of labor, 424. in puerperal fever, 645. Movements, fetal, in pregnancy, 99. active, 99. passive, 99. Muller's ducts, 28. Multiple pregnancies, 221. acardia in, 223. INDEX. 677 Multiple pregnancies: conduct of labor in, 229. development of children in, 224. diagnosis of, 224. entrance, simultaneous, of both children into pelvis, in, 226. fcetus papyraceus in, 224. frequency of, 221. labor in, 225. locking, of children, in, 227. management of, 221. origin of, 221. presentations in, 225. prognosis in, 228. varieties of, 221. weight of children in, 223. Mummification: of foetus, 288. Myomata, uterine, 506 (vide uterus, myomata of). Naegele oblique pelvis, 481. Nasal fossae: development of, 62. Nausea of pregnancy, 119. Navel: changes of, in pregnancy, 90,103. of new-born child, 241. Neoplasmata: placental, 275. uterine atresia from, 503. vaginal atresia from, 503. Nephelis vulgaris: fecundation of ova of, 42. Nerves of uterus, 27. Nervous system: diseases of, in pregnancy, 117, 121, 122. Neuralgia, in pregnancy, 92, 95, 121. New formations in placenta, 275. Newly-born child: asphyxia of, 588. breasts of, 241. icterus of, 241. milk prepared for, 248. size of, 76. weight of, 76. Nipples: changes in, during pregnancy, 91, fissured, 658. sore, 658. treatment of, 659, 660. Nurse: wet, selection of, 246. Nursing: in pregnancy, 245. Nyctalopia : in pregnancy, 95. Nymphae, 4 (vide labia minora). sebaceous glands of, 5. Obstructed labor, due to— abnormalities of foetus, 513 (vide foetus). anchylosis of fetal joints, 518. arm, extended, 360. ascites, fetal, 516. atresia, uterine, 504 (vide atresia). atresia, vaginal, 501. atresia, vulvar, 500. bladder, distended, 502. coiling of cord, 279. cystocele, 502. displacements, uterine, 264, 265. fatty growths, 289. faeces, impacted, 205. fibrous growths, 503. hernias, vaginal, 503. hydrocephalus, fetal, 513. hydrothorax, fetal, 516. hypertrophy of cervix, 505. hymen, persistent, 500. knots of cord, 280. locked twins, 227. morbid growths of genital canal, 503, 505. monstrosities, 518. multiple pregnancy, 225. ovarian tumors, 511. ossification of fontanelles, premature, 513. perinaeum, rigid, 501. spina bifida, 517. tumors, intrapelvic, 503, 505. Odontalgia, in pregnancy, 95. CEdema: cervical, in labor, 505. in eclampsia, 535. in labor, 130. in pregnancy, 92, 118, 535. vulvar, in labor, 130, 505. vulvar, in pregnancy, 118, 266. Omphalo-mesenteric artery, 67. Operation: for Caesarean section, 400. for embryotomy, 395, 396. for extraction of foetus in breech presen- tations, 356. for perforation in craniotomy, 377, 381. for producing abortion, 328. Porro's, 411. history of, 412. details of, 413. Thomas's, or laparo-elytrotomy, 415, 461. history of, 415. details of, 417. Opiates: in eclampsia, 537. in post-partum haemorrhage, 543. in protracted first stage of labor, 424. in puerperal fever, 645. 678 INDEX. Organs ot generation: anatomy of female, 1. abnormalities of, 500. changes in, during pregnancy, 82 et seq, development of, 23. Orifice, oral, development of, 62. Orifidum vaginas, 6. Os innominatum, anatomy of, 141. Osteomalacia: pelvic deformity from, 495. pseudo-, 498. Os, tincv, 12. internum, 13. Os uteri : changes of, in pregnancy, 86, 98. dilatation of, in labor, 131, 136. causes of, 136, 137. elongation of anterior lip of, in labor, 505. oedema of anterior lip of, in labor, 505. rigidity of, atresia from, 505. thrombus of, in labor, 505. Ovarian: pregnancy, 310, 315. tumors, diagnosis of, 512. tumors, obstructing labor, 511. Ovaries: anatomy of, 20. arteries of, 24. cortical substance of, 22. discharge of ovum from, 37. erectility, theoretical, of, 26. ligament of, 20. medullary substance of, 21. tumors of, in pregnancy and the puerperal state, 511, 512. diagnosis of, 512. tunica albuginea, of, 21. Ovaro-hystorectomy, 411. history of, 412. details of, 413. Ovulation, 37. Ovum: anatomy of, 36. changes in, subsequent to fecundation, 42. development of, 33. discharge of, from ovary, 37. discus proligerus of, 35. germinative spot of, 37, germinative vesicle of, 37. membrana granulosa of, 36. migration of, 39. premature expulsion of, 291. segmentation of, 43. vitelline membrane of, 30. vitellus of, 37. yolk of, 37. zona pellucida of, 37. Ovum-forceps: use of, in abortion, 307. I Oxytocics: | contraindications for, 428. indications for, 429. in accidental haemorrhage, 562. in parturition, 428. in placenta praevia, 560, 561, in post-partum haemorrhage, 543. in protracted first stage of labor, 426. Pains: after-, 236. anomalies of, 419. effect of chloroform on, 220. good, 421, 449. in abdominal walls, during pregnancy, 91. in puerperal fever, 623. irregular, in first stage, 421. irregular in second stage, 426. irregular in third stage, 429. premonitory, 130. strong, 420. weak, 420. Palate, cleft, 63. Palatine arch, 63. Palpitation of heart in pregnancy, 117. Pancreas: development of, 66. dilatation of fetal, 517. Paresis in pregnancy, 95. Parametritis, from retroflexed gravid uterus, 266. Parturition (vide labor). Pelvic measurement, 434. external, 434. internal, 436. instruments for, 435. of conjugata vera, 438. of diagonal conjugate, 437. of external conjugate, 436. of transverse diameter, 438. Pelvimeter, 435. circle of Baudelocque, 435. Schultze's, 435. the hand as, for internal measurements, 4"6. Pelvimetry: external, 434. internal, 436. instruments for, 435, Pelvis: wquabiliter jvft -minor, 432, 439. anatomy of, 139. articulations of, 143. as a whole, 148. contracted, 432. as indication for abortion, 326. diagnosis of, 433. from history, 434. from measurements, 436. effects in, of pressure on mother, 455. INDEX. 679 Pelvis: contracted, effects in, of pressure on child, 456, 457. forms of, three principal, 439. frequency of, 432. generally, 444. influence of, in pregnancy and labor, 446. on labor-pains, 448. on mechanism of labor, 451 et seq. on presentations of foetus, 448. on uterus in pregnancy, 447. irregularly: pseudo-osteomalacia, 445. kyphosis, 446. scoliosis, 446. prognosis in, 459. treatment in, 460. expectant, 475. forceps, 475. premature labor, 467. version, 470. when child may be delivered through natural passages alive, 466. when child can not be delivered through natural passages alive, 461. when craniotomy or abortion must be performed, 464. varieties of, 432. deformed, rare forms of, 481. deformed by— absence of symphysis, 499. exostosis, 498. fractures, 498. osteomalacia, 495. rachitis, 442. diameters of, 150. differences between— adult and infantile, 153. female and male, 152. flattened, 441. non-rachitic, 441. rachitic, 442. floor of, 158. funnel-shaped, 493. inclination of, 145. kyphotic, 485. ligaments of, 145. measurements of, 434. movements in joints of, 147. Naegele's oblique (vide oblique). nana, 439. osteomalacic, 495. anatomy, morbid, of, 495. diagnosis of, 497. etiology of, 496. prognosis, 497. treatment, 498. oblique, of Naegele, 481. anatomy, morbid, of, 481. Pelvis: diagnosis of, 483. etiology of, 482. mechanism of labor in, 484. prognosis in, 484. treatment in, 485. planes of, 149. pseudo-osteomalaeic, 498. relaxation of symphysis of, in pregnancy, 273. Robert's anchylosed and transversely con- tracted, 489. anatomy, morbid, 489. etiology, 490. prognosis, 491. soft parts of, 155. spondolisthetic, 491. anatomy, morbid, 491. etiology, 492. prognosis, 493. Perforation: extraction of child after, 382. indications for, 377. instruments for, 378 (vide perforators). operation, how performed, 377, 381. preparations for, 381. Perforator, 379. Blot's, 379. Hodge's cranial scissors, 379. Simpson's, 379. Smellie's scissors, 378. Thomas's, 379. trephine, 380. Perinaeum: dilatation of, in labor, 133. laceration of, in labor, 133. preservation of, in labor, 207. rigidity of, obstructing labor, 501. Peritonitis, as result of incarceration of retro- flexed gravid uterus, 266. Phantom tumors, differentiation of, from pregnancy, 105. Phlegmasia alba dolens, 655. etiology, 655. history, clinical, of, 656. origin of, 655. prognosis of, 657. treatment of, 657. Phthisis, complicating pregnancy, 259. Physician, visits of, during the puerperal state, 243. Placenta: anatomy of, 49, 52, anomalies of, 274. in circulation, 274. in development, 274. in form, 274. in position, 274, artificial separation of, 551. 680 INDEX. Placenta: development of, 53. degenerations of, 275. expression of, by Crede's method, 215. in tardy labor, 429. fetal, 54. inflammation of, 275. new growths in, 275. praevia, 552. diagnosis of, 557. etiology of, 553. frequency of, 553. haemorrhages in, 554. history, clinical, of, 554. prognosis of, 556, 558. situation of, 552. treatment of, 557. Barnes's dilator, 559. detachment of placenta, 560. ergot, 560. forceps, 500. tampon, 559. varieties of, 552. retained, 550. treatment of, 551. structure of, fully developed, 55. syphilis of, 276. tumors in, ^75. uterina, 54. villi of, 52. in cat, 54. in mare, 53. Placentitis, 275. Planes of pelvis, 149-151. Plates: abdominal, 47, 61. dorsal, 46, 59. lateral, 47, 61. vertebral, primitive, 61. Pleurisy, chronic, complicating pregnancy, 258. Plexus: hypogastric, 27. pampiniformis, 23. uterinus, 23. magnus, 27. Plicx : vesico-uterince, 14. recto-uterina,, 15. Plural pregnancy, 221 (vide pregnancy, mul- tiple). Pneumonia, acute lobar, complicating preg- nancy, 257. Podalic version, 369. Polypus, fibrinous, removal of, 308. Porro's operation, 411 (vide ovaro-hystorec- tomy). history of, 412. details of, 413. I Portio vaginalis of cervix, 12. Positions: I classification of, 168. forceps, use of, in occipito-posterior, 352. fetal, 81. Post-partum haemorrhage, 539 (vide haemor- rhage, post-partum). i Prague, method of extraction with head at the brim, 364. Prceputium clitoridis, 4. Precipitate labor, 420 (vide labor, precipi- tate). Pregnancy: acardia, in multiple. 223. accidental complications of, 250. auscultation in, 106. auscultatory signs of, 100. ballottement in, 100. bladder and rectum, functional disease of, in, 92. blood-changes of, 116. breasts in, 98. carbonic dioxide, increase of, in, 93. cardiac diseases in, 256. cephalalgia in, 122. changes in abdominal walls in, 90. in breasts in, 91. in cervix uteri in, 98. in entire organism in, 92. in navel in, 90. in nipple in, 91. in os uteri in, 98. in sexual apparatus and neighboring or- gans in, 82. in thyroid in, 93. in vagina in, 89. in vulva in, 89. cholera complicating, 252. chorea complicating, 261. complications of, accidental, 250. complicated by : anomalies of cord, 279. anomalies of placenta, ^74. calcareous degeneration of cord, 281. coiling of cord, 281. cysts in cord, 281. deficiency of amniotic fluid, 273. hernias of cord, 280. hydatidiform mole, 283. hydramnion, 277. knots in cord, 280. maceration of foetus, 288. missed labor, 290. mummification of foetus, 288. placentitis, 275. retention of dead foetus, 287. stenosis of umbilical vessels, 281. torsion of cord, 279. conduct of labor in multiple, 228. INDEX. 681 Pregnancy: diagnosis, differential, of, 104. diagnosis of dead foetus in, 109. diagnosis of multiple, 224. disorders of, 116. distinction between first and second, 101? duration of, 109. effects of, on nervous system, 95. emphysema complicating, 258. empyema complicating, 258. endometritis during, 270, 272. extra-uterine, 309. abdominal, 310, 315. definition of, 310. diagnosis of, 318. interstitial, 313. ovarian, 310, 315. puncture of sac in, 319. symptoms of, 316. terminations of, 317. tubal, 310. tubo-abdominal, 314. tubo-ovarian, 314. treatment, 319. of early cases, 319. of advanced cases, 322. face-ache in, 121. fetal heart-sounds in, 100. funic souffle in, 102. frequency of multiple, 221. heart-burn in, 121. hydraemic oedema in, 117, 118. hygiene of, 115. icterus complicating, 255. impaired digestion in, 94. increase in size of abdomen in, 98. insalivation in, 121. insanity in, 652. insomnia in, 122. inspection of abdomen in, 103. interrogation of patient in, 102. interruption, premature, of, 291. malarial fever in, 254. management of, 115. methods of physical examination in, 102 multiple, 221. acardia in, 223. conduct of labor in, 228. development, unequal, in, 223. diagnosis of, 224. foetus papyraceus in, 224. frequency of, 221. labor in, 225. locking of children in, 227. origin of, 221. presentations in, 225. prognosis in, 228. weight of children in, 223. varieties of, 221. Pregnancy: nausea and vomiting in, 97, 119. oedema in, 92, 118, 535. palpation of abdomen in, 103. pathology of, 249. pernicious anaemia complicating, 117. phthisis complicating, 259. pneumonia complicating, 257. pleurisy complicating, 258. prediction of end of, 111-113. pruritus in, 121. quickening in, 99. rectal touch in, 107. relapsing fever complicating, 253. relaxation of symphysis in, 273. rubeola complicating, 251. salivation in, 98. scarlatina complicating, 251. speculum, use of, in, 107. suppression of menses in, 96. surgical operations during, 262. sympathetic diseases in, 97. syphilis complicating, 259. typhoid fever complicating, 253. typhus fever complicating, 253. urine, increase of, in, 95. uterine bruit in, 100, 101. vaginal touch in, 100. varicose veins in, 118. variola complicating, 250. Premature labor, 291, 420 (vide labor, p. 675). Preparations for labor, 203. Presentations, 78, 167. breech, 196. armamentarium for, 355. causes of, 196. configuration of foetus in, 200. diagnosis of, 196. exceptional cases of, 361. extraction of head in, 362, 363. extraction in, 354. irregularities in mechanism of, 199. liberation of arms in, 360. management of cord in, 359. mechanism of, 197. operation of extraction in, 356, 357. prognosis in, 200. release of arms in, 360. treatment of, 201. brow, 192. prognosis in, 193. treatment of, 194. cause of predominating, first, 169. classification of, 168. face, 182. causes of, 182. forceps in, 353. configuration of bead in, 188. diagnosis of, 189. 682 INDEX. Presentations, face: frequency of, 182. mechanism of, 184, 186. prognosis in, 189. treatment of, 190. natural, 167. normal, 167. pelvic, extraction in, 354. shoulder, 167, 465. version in, 465. transverse, 167. unnatural, 167. vertex, 168. frequency of, 168. diagnosis of, 168. theories to account for preponderance of, 79. Prolapse: of gravid uterus, 268. of vagina in pregnancy, 268. Primitive trace, 46, 59. Process, frontal or intermaxillary, 62. Protosoma, 46. Pruritus in pregnancy, 95, 121. Psoas abscess in puerperal fever, 626. Pseudo-osteomalacic pelvis, 498. Pubes, anatomy of, 142. Pudendum, definition of, 1. Puerperal diseases, 602. Puerperal eclampsia, 526 (vide eclampsia). Puerperal fever, 602. abscesses in, 625. bacteria in, 612 et seq., 631. . causes of, 630, 633, 636, 637. classification of lesions of, 603. clinical history of, 620 et seq. symptoms of endocolpitis and of endome- tritis, 620. symptoms of general peritonitis, 626. symptoms of parametritis, 621. symptoms of perimetritis, 621. symptoms of septicaemia, 628-630. definition of, 602. diphtheritic patches in, 617, 631. endocarditis in, 618. endocolpitis in, 604, 620. endometritis in, 604, 620. erysipelas, how related to, 618. frequency of, 602, 640. inflammation: of genital mucous membrane in, 603, 604. of peritonaeum, uterine, 604, 607, 626. of subserous pelvic cellular tissue in, 603, 607. of uterine parenchyma in, 603, 605. lesions of, 603. metritis in, 605, 621. micrococci in, 612, 631. microspores in, 612, 631. Puerperal fever: nature of, 608. pathological anatomy of, 603. phlebitis in, 604, 607, 629. phlebo-thrombosis in, 607. prevention of, 637, 641. septicaemia in, 604, 608, 611, 619, 628, 630. treatment of, 643. by alcohol, 648. by antipyretics, 646. by cold, 648. by digitalis, 647. by douche, intra-uterine, 643. by douche, vaginal, 643. by laxatives, 646. by leeches, 646. by opium, 645. by poultices, 646. by quinia, 646. by salicylate of soda, 647. by veratrum viride, 647. treatment of peritoneal effusions, 650. virus of, 612. Puerperal state, 230. after-pains in, 235. cervix uteri in, 234. closure of sinuses in, 234. diagnosis of, 240. diet in, 244. general functions in, 231. involutio uteri in, 232. lochia in, 236. loss of weight in, 232. management of, 217, 242. milk-fever in, 238. nursing in, 245. passing urine in, 242. pulse in, 231. retention of urine in, 232. separation of decidua in, 233. secretion of milk in, 237. sleep in, 242. temperature in, 231. uterus, position of, in, 235. vagina in, 235. visits of physicians in, 243. washing of vagina in, 243. Pulse, in puerperal state, 231. Quickening, date of, 113. Quinine: as antiphlogistic, in puerperal fever, 646. Rachitis: deforming pelvis, 442, 445. Rcctocelc: atresia, vaginal, from, 502. Relapsing fever: complicating pregnancy, 253. Repercussion (vide ballottement). Repositor: Braun's, 375. Roberton's, 5S7. catheter, used as, 376. Respiration: artificial, in asphyxia, 595. Marshall Hall's method, 596. Schultze's method, 595. Restitution, in vertex presentations, 176 (vide external rotation). in face presentations, 186. Retained placenta, 550 (vide placenta, re- tained). Retention: in utero, of dead foetus, 287. of urine— in pregnancy, 502. in puerperal state, 232. Retroflexion of gravid uterus, 265. with incarceration, 266. treatment of, 267. Retroversion of gravid uterus, 265. Rickets: causing pelvic deformity, 442, 445 (vide rachitis). Rigid os: atresia from, 505. Rima pudendi, 2. Robert's anchylosed pelvis, 489. Rotation of foetus: in breech presentations, 193. in face presentations, 186. in vertex presentations, 176. Rubeola, complicating pregnancy, 251. Rupture: at orifice of vagina, 575. of genital canal, 564. , of pelvic articulations, 581, 582. of perinaeum, 576. of uterus, 564 (vide uterus, rupture of the). of vagina, 575. of vestibule, 575. Sac: injections into, in extra-uterine pregnancy, 320. puncture of, in extra-uterine pregnancy, 319. Sacro-iliac articulation, 143. Sacrum: anatomy of, 139. superficies auricularis of, 141. Salicylate of soda in puerperal fever, 647. Salivation in pregnancy, 121. Scarlatina: in pregnancy, 251. puerperalis, 252. Schirrus, of uterus: obstructing labor, 509 (vide atresia, uterine). ,j2L 683 Scholiotic pelvis, 446. Scbolio-rachitic pelvis, 488. Seasons, relation of, to puerperal fever, 637. Section,Caesarean, 399 (vide Caesarean section). Secretion: disorders of, in pregnancy, 121. Segmentation of ovum, 43. Semen, 41. Senses, special: affections of, in pregnancy, 95, 97. Septicaemia: in puerperal fever, 604, 608, 611, 620. symptoms of, 628 et seq. Septum : recto-vaginale, 7. urethro-vaginale, 7. Serous lochia, 236. Serres fines, in perineal laceration, 578. Shoulder presentations (vide transverse pres- entation). Shoulders, delivery of, 211. Sinus terminalis, 67. Sinuses, closure of, in puerperal state, 234. Sleep, in puerperal state, 242. Sleeplessness, in pregnancy, 122. Smegma prceputii, 5. Social state, relation of, to puerperal fever, 637. Souffle, funic, 102. Speculum, use of, in pregnancy, 107. Spermatozoa, 41. Sphincter vaginae, 9. Spina bifida, 61. as obstruction to labor, 517. Spinal column, articulation of fetal head with, 166. Spleen: enlargement of fetal, 517. Spondolistbetic pelvis, 491. Spontaneous evolution, 523 (vide evolution). Spontaneous version, 521 (vide version). Spot : embryonic, 46, 59. i germinative, of ovum, 37. Stage of labor: irregular pains in first, 419. irregular pains in second, 426. irregular pains in third, 429. management of first, 204. management of second, 205. delivery of shoulders in, 211. preservation of perinaeum in, 207, tying cord in, 211. management of third, 215. treatment of long first, 423. by anodynes and anaesthetics, 424. by Barnes's dilators, 425. by bougies, 425. by douche, vaginal, 425. 684 INDEX. State, the puerperal, 230. after-pains in, 236. cervix, the, in, 234. chill in, 230. closure of sinuses in, 234. diagnosis ot, 240. diet in, 244. general functions in, 231. involution in, 232. laxatives in, 244. lochia in, 236. loss of weight in, 232. management of, 212. milk-fever in, 238. nursing in, 245. passing urine in, 243. pulse in, 231. relations of, to pathological conditions, 230. retention of urine in, 232. scarlatina in, 252. secretion of milk in, 236. sleep in, 242. uterus, position of, in, 235. vagina in, 235. visits of physician in, 243. washing vagina in, 243. Stenosis : of umbilical vessels, 281. Stigma folliculi, 37. Stimulants: in cerebral anaemia, 547. Strait: axis of inferior pelvic, 151. axis of superior pelvic, 150. forceps at, 348. inferior pelvic, 150. superior pelvic, 149. Striae: abdominal, in pregnancy, 91. Styptics: in post-partum haemorrhage, 54. Superfecundation, 221 (vide pregnancy, mu tiplc). Superficies auricularis, 141. Surgery, obstetric, 326. Surgical operations: during pregnancy, 262. Suspended animation, 588 (vide asphyxia n; natorum). Sutures: coronal, 77,163. frontal, 77, 163. lambda, 77, 163. premature ossification of, 518 sagittal, 77, 163. Symphysis pubis: absence of, 499. anatomy of, 145, Symphysis pubis: relaxation of, in pregnancy, 273. rupture of, 581. Syncope: in childbed, 597. in labor, 597. in pregnancy, 95, 117. Tampon: in abortion, 305. in placenta praevia, 559. method of applying, 305. to produce premature delivery, 332. Tardy labors, 421 (vide labor, tardy). Temperature: in post-partum state, 231. Testicle: fibro-cystic degeneration of fetal, 517. Theca folliculi: of Graafian follicle, 35. Thrombus: causing collapse and death in labor and childbed, 597. in veins and lymphatics, during phlegma- sia, 655. of os, in labor, 505. of vagina, 57b (vide vagina, thrombus of). of vulva, 578 (vide vulva, thrombus of). Tenesmus, vesical, from retroflexed incarce- rated gravid uterus, 266. Torsion of cord, 279. Trace, primitive, 46, 59. Tractions on forceps, 346. direction of, 347. time for making, 346. Transforateur, Hubert's, in cephalotomy, 394. Transfusions, of blood and milk, in post-par- tum haemorrhage, 548. Transverse presentations, 167. Trunk: delivery of, with crotchet, 393. expulsion of, in labor, 177. I- Tubal pregnancy, 310. Tubes, Fallopian: ampulla of, 19. anatomy of, 18. isthmus of, 19. ostium abdominale of, 19. »- Tubus .- intestinalis, 62. medullaris, 47, 60. Tumors: abdominal, diagnosis of, from pregnancy, 512. fetal, causing dystocia, 517. osseous, deforming pelvis, 498. ovarian, 511 (vide ovary, tumor of). in parturition, 512. in pregnancy, 511. Tumors, ovarian : in puerperal state, 512. obstructing labor, 511. parametritic, in puerperal fever, 624, 625. phantom, differentiation of, from preg- nancy, 105. scalp, 179. uterine: complicating pregnancy, parturition and puerperal state, 506. producing atresia, 505. Tunica : albuginea, of ovum, 21. fibrosa, of Graafian follicle, 35. propria, of Graafian follicle, 35. Turning (vide version). Twins: locking of, obstructing labor, 227. Twin-pregnancy (vide pregnancy, multiple). Tympanites: in puerperal fever, 627, 628. uteri, 601. Typhoid fever, complicating pregnancy, 253. Typhus fever, complicating pregnancy, 253. Umbilical cord, 57 (vide funis). anomalies of, 279. calcareous degeneration of, 281. care of, in infants, 246. coiling of, 281. cysts in, 281. diseases of, 28. formation of, 57. hernias of, 280. knots in, 280. management of, in breech presentations, 359. marginal insertion of, 282. prolapse of, 582. reposition of, 587. souffle in, 102. stenosis of vessels of, 2S1. torsion of, 279. tying of, in labor, 211. Umbilical vesicle, 47. Umbilical vessels: stenosis of, 281. Umbilicus: changes of, in pregnancy, 90, 103. of new-born child, 241. Unavoidable haemorrhage, 554. Uraemia: in eclampsia, 529, 532. Ureter: development of fetal, 516. Urinary calculus: obstructing labor, 502. Urine: albumen in, during pregnancy, 95. during eclampsia, 528, 529, 531. ■-■*• 685 Urine: atresia from retention of, 502. increase of, in pregnancy, 95. passing, in puerperal state, 243. retention of, in pregnancy, 502. retention of, in puerperal state, 232. Uterine: bruit, in pregnancy, 101. glands, 16. inertia, 422. pain, in pregnancy, 130. tumors, obstructing labor, 505. Uterus: abnormalities of, 29. . abnormal conditions of, 263. anatomy of, 11. anteversion and anteflexion of, 264. atrophy of mucous membrane of, causing abortion, 292. bicornis, 32. body of, 12. bruit in, during pregnancy, 101. cancer of neck of, 509. treatment of, 510. catheterization of, to produce abortion, 329. cavity of body of, 12. cervix or neck of, 12. contractions of— effect of chloroform on, 220. cordiformis, 32. corpus of, 12. didelphys, 30. dilatation of fetal, 517. double, 263. duplex, 30. fundus of, 12. glands of, 16. gravid: anteversion and anteflexion of, 264. retroflexion of, 265. retroversion of, 265. with incarceration, 266, 2G7. hernia of, 269. hour-glass contraction of, 429. hyperaemia of gravid, 294. hypertrophy of mucous membrane of, 293. injections between, and ovum to produce abortion, 329. injections into, \nposl-partumhaemorrhage, 544. inversion of, 563. laceration of cervix of, 573. ligaments of, 14. lymphatics of, 27. myomata of, 506, 508. nerves of, 27. neck of, 12. perforation of, from pressure, 573. position of, in puerperal state, 235. 686 INDEX. Uterus: prolapse of, 268. rupture of, 564. clinical history of, 569. diagnosis of, 569. etiology of, 565. pathology of, 568. treatment of, 570 et seq. semi-partitus, 32. septus bilocularis, 32. tumors of, complicating pregnancy, 506. tympanites of, 601. unicornis, 30. veins of, 23. vessels of, and of its appendages, 22. Vagina: atresia of, 501. accidental, 501. congenital, 501. from cystic degeneration, 503. from cystocele, 502. from echinococci, 503. from neoplasmata, 503. from rectocele, 502. from retention of urine, 502. from vaginal hernia, 503. from vaginismus, 503. from vesical calculi, 502. anatomy of, 7. arteries of, 11. bulbs of vestibule of, 4. changes of, in pregnancy, 89. changes of, in puerperal state, 235. columns of, 9. crista of, 9. cystic degeneration of, 503. double, 263. douche in, 425. examination by, in pregnancy, 203. laceration of, 575. laceration of orifice of, 575. prolapse of, in pregnancy, 268. sphincter of, 9. structure of walls of, 8, tampon applied to— in abortion, 305. in post-partum haemorrhage, 559. to produce abortion, 332. thrombus of, 578. diagnosis of, 579. etiology of, 579. prognosis of, 580. symptoms of, 578. treatment of, 580. veins of, 11. walls of, their structure, 8. Vaginal douche, 425, 331, 642. Vaginal growths, atresia from, 503. Vaginismus: atresia from, 503. Vagitus uterinus, 601. Valve: Eustachian, 68. of foramen ovale, 69. Varicose veins in pregnancy, 118. Variola in pregnancy, 250. Veins: of uterus, 23. of vagina, 11. varicose, in pregnancy, 92, 118. Veratrum viride: in puerperal fever, 647. Vernix caseosa, 75. Version, 366. after craniotomy, 394. after complete retraction of uterus, 375. after rupture of membranes, 374. cephalic, 366. Braxton Hicks's method, 369. Busch's method, 368. combined methods, 368. D'Outrepont's method, 368. external method, 367. Hohl's method, 369. Wigand's method, 367. Wright's method, 368. | combined with abortion, 466. I external, 366. hand, employed in, 372. in contracted pelves, 47o, 477, 479. in head presentations, 372. in lateral positions, 372. in prolapse of funis, 584, 587. in rupture of uterus, 572. in transverse presentations, 373. use of catheter as repositor in, 376. use of fillet in, 375. use of repositor, Braun's, in, 375. internal, 371. I neglected, 375. podalic, 369. bipolar method, 369. combined method, 369. indications for, 369. spontaneous, 521. etiology, 521. mechanism of complete, 523. mechanism of partial, 522. prognosis in, 523. Vertex presentation, 168 (vide presentation, vertex). Vertebrae, primitive, 61. Vesicle: blastodermic, 44. germinative, of ovum, 37. umbilical, 47. I Vesicles, cerebral, 60. INDEX. 687 Vessels; collapse and death from entrance of air into uterine, 598. umbilical, stenosis of, 281. uterine, 22. Vestibulum, 4. bulbm of, 4. glanduloe of, 5, 6. laceration of, 575. Villi, chorial, 50, 52. Vinegar, in post-partum haemorrhage, 545. Virus, of puerperal fever, 612. Visceral arches, 62. aortic arches, 67. Visceral clefts, 62. Visits of physician, in puerperal state, 243. Vitelline artery, 67. Vitelline membrane of ovum, 36. Vitellus, or yolk, of ovum, 37. Vomiting: in incarcerated retroflexed gravid uterus 266. in pregnancy, 119. in puerperal fever, 623. induction of abortion for, 120. Vulva: atresia of, 500. changes of, in pregnancy, 89. Vulva: connivens, 2. frenulum of, 4. hians, 3. laceration of, 575. mucous glands of, 5. oedema of, in labor, 130, 535. in pregnancy, 118, 266. Vulvo-vaginal: follicles, 5, 6. glands, 5, 6. Weight: loss of, in puerperal state, 232. of foetus, at term, 76. of foetus, in multiple pregnancy, 223. Wet-nurse: selection of, 246. Wet-pack: use of, in puerperal fever, 649. Wharton's gelatine, 57. Wolffian bodies, 28. Yolk of ovum, 37. Zona pellucida of ovum, 37. Zymotic diseases: their relation to puerperal fever, 636. THE END. THE Science and Art of Midwifery. By WILLIAM THOMPSON LUSK, M. A., M. D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDBEN IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE ; OBSTETRIC SURGEON TO THE MATERNITY AND EMERGENCY HOS- PITALS ; AND GYNAECOLOGIST TO THE BELLEVUE HOSPITAL. This Avork furnishes to students and practitioners the most recent acquisitions in obstetric physiology and pathology, and full details as regards the obstetric procedure. The science and art of midAvifery Avill not be considered as two distinct, independent subjects, but the one as the logical deduction from the other. The sections devoted to operations and to the influences exerted by the contracted pelvis upon pregnancy, labor, and childbed, are based upon purely clinical experience, and are intended to furnish complete and safe guides to these difficult departments of midAvifery practice. COMPLETE IN ONE VOLUME OF 700 PAGES, 8vo. PROFUSELY ILLUSTRATED. XeAv York : D. APPLETON & CO., 1, 3, & 5 Bond Street. THE NEW YORK Medical Journal and Obstetrical Review. PUBLISHED MONTHLY. Edited by FRANK P. FOSTER, M. D., PHYSICIAN FOR DISEASES OF WOMEN TO THE OUT-PATIENT DEPARTMEENT OF THE NEW YORK HOSPITAL. Subscription, $4.00 per annum. - - - Single copy, The volumes begin January and July of each year. York : D- APPLETON & CO., 1, 3, & 5 Bond Street. NEW BOOKS AND NEW EDITH IN PREPARATION. A Treatise on Insanity. By William A. Hammond, M. D. This, the first systematic work by an American author on insanity, is intended to be a thorough exposition of the subject in all its etio- logical, symptomatological, pathological, and therapeutical relations. It will constitute a volume of about 500 pages, octavo, and will be illustrated with woodcuts and autotype representations of the various types of mental derangement. A Manual of Gynaecological Operations. With Illustrations. By James B. Hunter, M. D., Surgeon to the New York State Woman's Hospital, Fellow of the New York Obstetrical Society, etc., etc. A Dictionary of Medicine. Edited by Richard Quain, M. D., F. R. 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The work has received the honor of a French translation by Dr. Labadie-La^rave of Paris, and an Italian translation by Professor Diodato JBorrelli, of the Royal University is now going through the press at Naples. " Dr. Hammond's work has now been before the profession for many years, and its characteristics are very generally known. The present edition has a good many valuable additions, but has lost nothing of its previous individuality as a medical work. Dr. Hammond has the qualities of a successful author. He has extensive knowledge, though it is more varied than profound. His practical experience is large, his convictions are positive, and he can set them forth clearly and attractively. It is not surprising that his book has been a very popular one. And the present edition is, as modestly stated on the title-page, 'improved.' "—Medical Record. " Our space, and indeed the very nature of the work, forbids a detailed notice of the book. Suffice it to say that we are convinced, from a by no means superficial examina- tion of it, that there is no work on the subject better entitled to the wants of the general practitioner at least."—Michigan Medical News. " The author has a captivating style of writing, in the first place from the clearness of it, and, in the second, from the graphic manner of his illustrations with which every chapter abounds. His particular strength is in depiction. Hammond is undeniably an artist in his profession, and he touches up the most somber backgrounds with bits of enlivening color. Some chapters, like that on epilepsy, have almost the fascination of romance. But, as we have already said, the profession is thoroughly familiar with all the strong, and we might add the weak points of this book, so that anything like a criti- cal review of it is unnecessary."—Lancet and Clinic. " During the five years which have elapsed since the publication of the sixth edition of this standard work on diseases of the nervous system, investigations in this special department of pathology have been pushed with remarkable activity and vigor, both in this country and abroad. New and improved instruments are constantly coming into use, enabling the physician to interpret accurately symptoms which formerly were obscure, and consequently make his treatment more rational. Among those who have contributed largely to this rapid advancement, few are more widely known than Dr. Hammond, and we°feel assured that this new edition, which has been thoroughly revised and enlarged by the addition of much that is new, will receive a hearty welcome from the medical pro- fession on both sides of the Atlantic. 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