■"> >■•<* 'MARY NLM QD5fil7Db fl SURGEON GENERAL'S OFFICE LIBRARY Section ________.................... Form 113c No. ~*.!7-/~.r...L-„.. W.D..S.Q.O. VERNWENT TRINTINO OFTICI ~^9- Z > THE SCIENCE AND ART OF OBSTETRICS. BY THEOPHILUS PARVIN, M.D., LL.D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, AND ONE OF THE OBSTETRICIANS TO THE PHILADELPHIA HOSPITAL. SECOND EDITION REVISED AND ENLARGED. ILLUSTRATED WITH TWO HUNDRED AND THIRTY-NINE WOOD-CUTS AND A COLORED PL A TE. PHILADELPHIA: LEA BROTHERS & CO. V Entered according to the Act of Congress, in the year 1890, by LEA BROTHERS & CO., in the office of the Librarian of Congress. All rights reserved. DORNAN, PRINTER. TO J. M. DA COSTA, M.D..LL.D., NOT LESS ADMIRABLE A3 A TEACHER AND PRACTITIONER THAN AMIABLE AS A MAN, FAITHFUL AND GENEROUS AS A FRIEND, THIS VOLUME IS DEDICATED. \ PREFACE. For the kind reception given by the profession of this country and of Great Britain to the first edition the author is sincerely grateful. In preparing the second issue, he has endeavored to justify the confidence which has been reposed in him by making such additions and alterations as will cause the work to represent the subject in its present state of advancement. Although these changes have been accomplished without material increase in bulk, they have been done with sufficient thoroughness to entitle the volume to be regarded as a new book. The author has sought to be useful to medical students and to the profession— this desire has been his chief inspiration, and if time shall prove that he has in fair measure succeeded, that success will be his chief rewrard. For the preparation of the table of contents and of the index the author is indebted to Dr. A. A. Eshner. Philadelphia, September, 1890. THEOPHILUS PARVIN. CONTENTS. PAGE Introduction ... T7 PART I. ANATOMY AND PHYSIOLOGY OF THE FEMALE SEXLA L ORGANS. CHAPTER I. Anatomy of the Pelvis......... 21 CHAPTER II. The Female Sexual Organs........49 CHAPTER III. Puberty—Ovulation—Menstruation......98 PART II. PREGNANCY. CHAPTER I. Conception—Early Development of Impregnated Ovule—For- mation of Deciduous Membranes—Foetal Appendages . 115 CHAPTER II. The Embryo and Foetus—Development—Anatomy and Physi- ology OF THE FOZTUS.........144 CHAPTER III. Changes in the Maternal Organism—Plural Pregnancy . . 168 Vlll CONTENTS. CHAPTER IV. PAGE The Signs and Diagnosis of Pregnancy.....I9I CHAPTER V. The Diagnosis of Plural Pregnancy—Differential Diagnosis of Pregnancy—Diagnosis of Previous Pregnancy, of Period of Pregnancy, and of Death of Foztus—Duration of Preg- nancy— Date of Labor — Precocious Births — Prolonged Pregnancy—Missed Labor.......209 CHAPTER VI. The Management of Pregnancy.......224 CHAPTER VII. The Pathology of Pregnancy—Intercurrent Diseases and Traumatisms.......... 238 CHAPTER VIII. The Pathology of Pregnancy {Continued)—Diseases that are Exaggerations of Physiological Conditions of, or other- wise Dependent upon, Pregnancy ...... 252 CHAPTER IX. Eclampsia............266 CHAPTER X. Diseases of the Sexual Organs—Diseases of the Ovum . . 278 CHAPTER XI. Diseases of the Ovum—Death of the Fcetus—Abortion . . 300 CHAPTER XII. Ectopic Pregnancy—Pregnancy in a Rudimentary Horn of the Uterus—Ectopic Development of the Placenta, or Pla- centa Pr/Evia—Premature Detachment of the Normally Situated Placenta ......... 322 CONTENTS. IX PART III. LABOR. CHAPTER I. PAGE Causes of Labor—Precursory Symptoms —Physiological Phe- . nomena—Changes in the Form of the Head in Vertex Presentation—Caput Succedaneum.....355 CHAPTER II. The Mechanical Phenomena of Labor......376 CHAPTER III. The Conduct of Labor.........417 CHAPTER IV. The Conduct of Labor (Continued)—Occipito-posterior Positions —Face, Brow, and Pelvic Presentations—Twins . . . 446 CHAPTER V. The Pathology of Labor—Anomalies of Uterine and of Abdo- minal Force—Structural and Positional Uterine Anoma- lies—Anomalies of Adjacent Organs.....460 CHAPTER VI. Pathology of Labor {Continued)—Foetal Dystocia . . . 477 CHAPTER VII. Anomalies of the Pelvis.........497 CHAPTER VIII. Pathology of Labor (Continued)—Injuries of the Vulva and Perineum—Injuries of the Vagina—Tears of the Cervix— Ruptures of the T;terus ........526 X CONTENTS. PART IV. THE PUERPERAL STATE. CHAPTER I. PAGE The Physiology and the Management of the Puerperal State, and its Diagnosis—Care of the Newborn Child . 557 CHAPTER II. The Pathology of the Puerperal State—Accidental Diseases— Mental Disorders—Sudden Death.....5^4 CHAPTER III. Infectious Diseases—Mastitis—Tetanus......590 CHAPTER IV. The Pathology of the Puerperal State {Continued) Fever ......... PART V. OBSTETRIC OPERATIONS. CHAPTER I. Removal of Retained Placenta—The Induction of Abortion and of Premature Labor—Cephalic, Pelvic, and Podalic Version............621 CHAPTER II. The Forceps............638 CHAPTER III. The Forceps (Continued)—The Vectis......655 CHAPTER IV. Embryotomy............671 CHAPTER V. The Cesarean Operation and its Substitutes .... 680 —Puerperal • 594 LIST OF ILLUSTRATIONS. Plate—Evolution of the Placenta and of the Umbilical Cord (opposite page 134). FIG. I. 2. 3- 4- 5- 6. 7- 8. 9- 11. 12. 13- 14. 15- 16. 17. 18. 19. 20. 21. 22. 23. 24. 25- 26. 27. 28. 29. 3°- 31- 32. 33- 34- 35- 36. 37- 38- 39- 40. 41. 42. 43- 44. 45- Pelvis with Ligaments .... Left Innominate Bone .... Right Innominate Bone. External Surface Right Innominate Bone. Internal Surface Sacrum and Coccyx .... The Inlet, or Superior Strait . Antero-posterior Diameters of Inlet The Outlet as seen from below 10. Anterior Pelvic Wall and Lateral Planes Pelvic Obliquity..... Diagonal Conjugate .... Planes and Axes of the Inlet and the Outlet Inclination and Axis of the Pelvis Axis of the Childbirth Canal . Relations of Pelvic Planes and Axes due to Changes in Position of the Subject...... Male Pelvis...... Female Pelvis ..."... Pelvis of a Child..... The Pelvis with Soft Parts Uro-genital and Anal Regions in Woman Antero-posterior Section of the Aponeuroses of the Perineal Floor Angle Formed by Line of Escape with Line of Descent of Fcetal Head (Varnier)........ Vulva of the Virgin...... Situation and Relations of the Uterus Section of the Mucous Membrane of the Vagina . Arteries and Veins of Vagina and Uterus (Sappey) Bulbs of the Vagina...... Internal Genital Organs...... Transverse Section of a Nulliparous Uterus . Transverse Section of a Muciparous Uterus . External Muscular Layer of Posterior Wall of Uterus Internal Muscular Layer..... Middle Muscular Layer at the Fundus . Internal Surface of the Uterus .... Anterior Wall of Infantile Uterus .... Posterior Wall of Infantile Uterus .... Internal Surface of Posterior Wall of Uterus . Glands of the Body of the Uterus .... Vertical Section of the Mucous Membrane of the Virgin Epithelium with Vibratile Cilia .... Epithelium with Cup-shaped Cells .... The Ovarian, Uterine, and Vaginal Arteries (Hyrtl) The Nerves of the Uterus (Frankenhauser) Normal Situation of the Virgin Uterus when the Bladder is empty Xll LIST OF ILLUSTRATIONS. 46. Position of Uterus in a Woman who has borne a Child 47- Uterus with Adjacent Organs as seen from above 48. The Ovary and Oviduct..... 49. Bulb of Ovary....... 50. From an Ovarium of an Old Bitch 51. Section of Normal Fallopian Tube 52. Diagrammatic Outline of the Wolffian Bodies 53. Human Ovule, and Ovules of Rabbit, Pigeon, and Ascaris 54. Scheme of the Homology of the Internal Genital Organs of the Male and of the Female......... 55. Uterus Unicornis.......... 56. Uterus Bicomis Duplex........ 57. Double Vagina and Uterus........ 58. Bifid Uterus............ 59. Partitioned Uterus......... 60. Acinus of the Mammary Gland of an Adult Female during Lactation 61. Structure of the Breast......... 62. Ovary with Ripe Ovisac........ 63. Graafian Follicle of the Human Ovary..... 64. Human Ovary cut open..... 65. Human Ovary...... 66. Corpus Luteum of Pregnancy at the End of Fourth Month 67. Corpus Luteum of Pregnancy at Term..... 68. Section through Mucous Membrane of the Virgin Womb . 69. Spermatozoids.......... 70. Optical Section of a Rabbit's Ovum at Two Stages closely following Segmentation.......... 71. Diagram showing Hunter's Theory of the Deciduous Membranes 72. First Stage of Formation of Deciduas...... 73. Formation of Decidual Completed...... 74. Section through the Maternal Membranes in the Second Month of Pregnancy ........ 75. Diagram of the Rabbit's Ovum between seventy and ninety hours after Impregnation.......... 76. Diagrammatic Views of Blastodermic Vesicle of a Rabbit on the Seventh Day....... 77. Showing the Embryonic Area with Primitive Streak and Primitive Groove of the Ovum (Rabbit) at the Seventh Day . 78. Diagram of the Foetal Membranes of a Mammal 79, 80. Diagrams showing Development of Amnion . 81. Completion of the Amnion...... 82. Compound Villus of Chorion from a Three Months' Foetus 83. Foetal Surface of the Placenta..... 84. Maternal Surface of the Placenta..... 85. Section of a Portion of a Fully Formed Placenta with the Part of the Uterus to which it is attached........ 86. Vertical Section of Placenta showing relations of Maternal and Foetal Bloodvessels •-........ 87. Apparent Constriction of Bloodvessels of Cord, from absence of Whar ton's Jelly........... 88. Velamentous Insertion of the Cord...... 89. Scheme of a Human Embryo with the Visceral Arches still Persistent 90. Formation of Alimentary Canal....... 91, 92. Anterior and Posterior Fontanelles, Sagittal and Occipito-parietal and Occipito-frontal Sutures....... 93. Antero-posterior Diameters of Fcetal Head..... 94. Biparietal and Bitemporal Diameters of Fcetal Head . 95. Vertical Diameters......... 96. The Three Sub-occipital Diameters...... 97. Posture of the Foetus......... 98. Plan of the Foetal Circulation....... LIST OF ILLUSTRATIONS. Xlll FIG. 99- ioo. IOI. 102. IO3. I04. 105. I06. 107. 108. IO9. IIO. III. 112. "3- 114. 115. 116, 118. 119. 120. 121. 122. 123. 124. 125. 126. I27. 128. I29. 130. 131- 132. 133- 134- 135- 136. 137. 138. 139- 140. 141. 142. H3- 144. 145. 146. 147. 149. 150, Placentitis Position of the Gravid Uterus near Term, and some of the Relations of the Intestines.......... Cervix from a Woman Dying in the Eighth Month of Pregnancy Appearance of the Primary and Secondary Areola in Pregnancy The Hand Circumscribing the Fundus of the Uterus in Palpation A Method of Applying the Hands at the Beginning of Abdominal Palpation ......... Diagnosis of Pregnancy by Auscultation Retroflexion of the Gravid Uterus with Incarceration . Diagram of Partial Retroflexion (Oldham) Retroversion of Pregnant Uterus with Incarceration . Sacciform Dilatation of the Posterior Wall of the Uterus Placental Tissue Showing the First Stage of Interstitial (Hegar and Maier)....... Hydatidiform Degeneration of the Chorion . Knot in the Stage of Formation ..... Intermediate Form....... As it was found at Birth ...... Spontaneous Intra-uterine Amputation .... Placental Villi in Tubal Pregnancy .... 117. Diagrammatic Section of Fallopian Tube Representing the Two Directions of Rupture ...... Diagrammatic Representation of Interstitial Tubal Pregnancy at Time of Rupture........ Tubo-uterine, Interstitial, or Mural Gestation Uterus and Foetus in a Case of Abdominal Pregnancy Gestation in a Rudimentary Horn of Uterus Vaginal Tampon in Placenta Praevia .... Parturiometer........ The Bag of Waters....... Head of the Vulvar Opening..... Median Section of Pelvi-genital Canal (Farabeuf) Mode in which the Placenta is naturally expelled Palpation of Uterus, the Hands at its Sides . Ascertaining the Presence of the Foetal Head in Lower Part of Uterus Palpation when the Foetal Head is in the Pelvis . Left Occipito-anterior Position..... Place of Greatest Intensity of Fcetal Heart-sounds in Left Occipito anterior Position....... First Cranial Position....... Equal Resisting Forces acting through Levers of Unequal Length Illustrating the Different Lengths of the Frontal Arm and Occipital Arm of the Lever made by the Foetal Head..... External Rotation of Head in First Position Right Occipito-posterior Position..... Fronto-anterior Position in Presentation of Face . Attitude of the Head in Presentation of the Face Rotation forwards of the Chin..... Passage of the Head through the External Parts in Face Presentation Pelvic Presentation. Right Sacro-anterior Position Diagnosis of Pelvic Presentation by Palpation Pelvic Presentation....... Expulsion of the Breech...... Expulsion of the Shoulders...... Transverse Presentation. Dorso-anterior. Presentation of Right Shoulder......... Transverse Presentation. Dorso-posterior. Presentation of Right Shoulder........... Point of Maximum Intensity of Sounds of Fcetal Heart in Presenta tion of the Shoulder......... Showing Diagnosis of Shoulder Presentation by Palpation . XIV LIST OF ILLUSTRATIONS. [51. Spontaneous Expulsion, First Stage 52. Spontaneous Expulsion, Second Stage [53. Spontaneous Expulsion, Third Stage : 54. Examination in Labor with Index Finger of Right Hand, the Os Uteri just Opening 55. Examination in Labor with Two Fingers of the Left Hand, the Os Uteri more Dilated ......... 56. Head about to Pass the Vulvar Opening..... 57. Artificial Delivery of the Head in Pelvic Presentation . [58. Manual Extraction of the After-coming Head. Veit's Method . ! 59. Wigand-Martin Method (Winckel)..... [60. Position of Lower Limbs in Child Born with Presentation of Thighs [61. Breech Presentation, Application of the Blunt Hook . [62. Budin and Lefour's Method of Traction ..... 163. First Child presenting by the Vertex ; Second by the Pelvis [64. Illustrating Labor with Hypertrophic Elongation of the Cervix . [65. A Polypus occupying the Pelvic Cavity in Labor [66. An Enlarged Ovary blocking up the Pelvic Cavity in Labor [67. Cystocele complicating Labor....... [68. Dorsal Displacement of the Arm...... . [69. Dorsal Displacement of the Arm in Footling Presentation . 170. Evacuating Fluid in Hydrocephalus by Opening Spinal Canal . [71. Shows Head-locking, both Children presenting Head-first . 172. Shows Head-locking, first Child coming Feet-first; Impaction of Heads from Wedging in Brim........ [73. Hand Prolapsed by the Side of the Head..... 174. The Funis Prolapsed by the Side of the Head .... 175. Justo-major Pelvis. Normal Distance between the Iliac Crests. Justo minor Pelvis ......... . 176. Measuring the External Conjugate with Martin's Pelvimeter 177. Measuring the Diagonal Conjugate ...... [78. Marked Flexion of the Head entering a Generally-contracted Pelvis [79. Flat Rhachitic Pelvis......... [80. Pseudo-Osteomalacic Pelvis........ Si. Head passing through the Inlet in Flat Pelvis .... [82. Spondylolisthetic Pelvis, showing Dislocation into the Pelvic Brim of the Lumbar Vertebrae........ [83. Osteomalacic Pelvis, showing the Beak-like Shape of the Pubes . Robert's Pelvis......... [85. Lumbo-sacral Kyphosis ....... [86. Obliquely-distorted Pelvis, Naegele's Pelvis .... [87. A Coxalgic Obliquely-contracted Pelvis .... . Annular Laceration of the Cervix Uteri .... . Transverse or Semicircular Grinding Through of the Uterus [90. Shoulder Presentation. Threatened Rupture of the Stretched Lower Segment of the Uterus and Cervix 191. Arresting Hemorrhage by Compression of the Uterus in a Position of Anteflexion (Zweifel) [92, 193, 194. Three Degrees of Inversion [95. Inversion of Uterus 196. Tarnier's Apparatus for the Artificial Feeding of Premature or Feeble Infants........... [97. Barnes's Hydrostatic Dilators and Syringe..... ". Cephalic Version. Wright's Method...... [99. Braxton Hicks's Method of Combined Podalic Version, First Stage 200. Braxton Hicks's Method, Second Stage..... 201. Braxton Hicks's Method 202. Chamberlen's Forceps . 203. Palfyn's Forceps . 204. Hodge's Forceps . 205. Simpson's Forceps LIST OF ILLUSTRATIONS, XV FIG. 206. 207. 208. 209. 210. 211. 212. 213. 214. 215. 2l6. 217. 218. 219. 220. 221. 222 223. 22 1, 22C 226] 227. 228. 229. 230. 231. 2^2. 233- 234. 235. 236. 237- 238. 239- The Davis Forceps with Shoulders on Handles . Wallace's Forceps ...... Holt's Forceps....... Reamy's Forceps ....... Miller's Forceps . . Traction with the Common Forceps Traction with Tarnier's Forceps .... Smith's Method of Exerting Axis-traction . Pajot's Manoeuvre ...... Two Forms of Hubert's Forceps with Traction-arm at Right Angle to Handle....... Tarnier's Axis-traction Forceps McFerran's Forceps..... Breus's Axis-traction Forceps Stephenson's Device for Axis-traction . Knox's Forceps...... Forceps of Assalini . . . Introduction of the Left Blade of the Forceps Introduction of the Right Blade of the Forceps Protecting the Perineum in Delivery with the Common Forceps Protecting the Perineum in Delivery with Tarnier's Forceps Application of Forceps in Presentation of the Face Delivery by the Forceps in Presentation of the Face The Vectis .... Smellie's Scissors . Naegele's Perforator Blot's Perforator . Martin's Trephine Simpson's Basilyst Crotchet .... Simpson's Cranioclast . Braun's Cranioclast Tarnier's Basiotribe ; the parts united Application of Tarnier's Basiotribe Basiotripsy Accomplished 643 644 644 645 645 647 648 649 649 650 65. 652 652 652 653 656 659 659 661 662 666 667 670 673 673 673 673 674 675 675 675 677 678 678 ERRATA. Page 122, " 142, " 155. " 159, " 287, " 39i; " 456, " 476, 3d line from top, for " female " read " male." at foot of page, ist line of note 1, " Fig. 79 " should be " Fig. 87. ist and 2d lines from bottom, for "backward or forward" read "forward or backward." 10th line from top, for " former " read " latter." nth line from bottom, for " tumors " read " trauma." 8th line from top, for " right " read " left." 6th line from bottom, for " within outward " read "without inward.'' under figure 167, for " pregnancy'' read " labor.'' '• 480, paragraph included between 18th and 25th lines should precede 24th line from top of page 481. " 508, 13th line from top, " pelvic " should be " pelvis." " " 17th " " " " " " THE SCIENCE AND THE ART OF OBSTETRICS. INTRODUCTION. Obstetrics, the name given to one of the three fundamental divi- sions of medicine, is derived from the two words ob and stare, " to stand before," and strictly defined means the care of women during childbirth, but general use has extended the meaning of the term, so that it includes also the care of women in pregnancy, and in the puerperal state, or puerperality. The words midwifery, tocology, parturition, and accouchement have been, and still are more or less used as synonyms for obstetrics. The first term etymologically means, and for some centuries practi- cally meant, attendance by women upon women in labor. The name midwife,1 variously spelled, is first met with in the fourteenth century, while the coarse, contradictory compounds, man-midwife and man- midwifery, do not appear until some two or three hundred years later. Accoucher—from ac and coucher, a derivation that brings to mind the expression " put to bed," once not unfrequently used for attendance upon a case of labor—is the origin of the noun accouche- ment ; but although the last term has been adopted from the French into the English language, it has not by general use acquired full right of domicile. Tocology is a word rarely used by the profession; 1 I am indebted to Professor March, of Lafayette College, Easton, Penn., for the following note : Midwif does not appear in the Anglo-Saxon so far as yet explored; but in the earliest Old English vocabulary, the Promptorium Parvulorum, is mydwife, obstetrix (A. D. 1440). It is found earlier, in Piers Plowman, A. D. 1394; Myrc's Duties of a Parish Priest, A. D. 1400, spelt mydwyf and midwif. In Wycliffe's Bible, A. D. 1380, it is medewife, and in the later version of that Bible mydwiif; William de Shoreham's Poems, A. D. 1330, medewif. This is the earliest appearance I know of. I suppose it to be from mid and wif. The prefix mid is common. Mid-coyshta, a co- worker, is found in Anglo-Saxon ; in Dufch, mede-broeder, a companion ; German, mit-bruder ; D. mede-gemoct, G. mit-helfer, etc. The idea is that of the Spanish co-madre, co-mother, a midwife, and like the German bei-frau. It may be conjectured that as a doctor's word it was liable to fanciful learned spelling, and that the Latin medius led to its being spelt medewif occasionally, or that the Dutch form influenced it. At any rate, this bad spelling led to the theory that it was medewife, which has been favored by Trench and others. The theory working in the minds of the early writers may also have led to the spelling. It is, however, a comparatively rare spelling, and the derivation suggested by it improbable. 18 SCIENCE AND ART OF OBSTETRICS. and parturition, from the Latin partus, has been by some authors restricted to the phenomena of labor occurring in inferior animals. It has seemed to me that maieiitics is a better term, were it generally adopted, than any of those mentioned. It is more euphonious than obstetrics, and is equally classic in origin—//mfw, and fiauvrl^ a male obstetrician, and fiamr^p, a female obstetrician—and does not prejudice the sex of the attendant, as the word midwifery does. But the substitution of obstetrics by maieutics would be regarded as too great an innovation, and hence the former will be used in this treatise. Obstetric science means the classified knowledge of the laws of human reproduction ; obstetric art includes the rules drawn from those laws, or from intelligent experience, which are to be observed in individual cases of women in pregnancy, in labor, or in childbed. While obstetric art may claim an antiquity as great as either of the other departments of medicine, obstetric science is of recent origin. The tardy development of obstetric science is to be chiefly attributed to the fact that childbirth being regarded, justly, as a physiological function, and pathological conditions comparatively seldom occurring in its course, the practice of the obstetric art was almost exclusively in the hands of ignorant matrons; educated physicians were, if con- sulted at all, only called in case of serious difficulty. In the time of Hippocrates, dividing the umbilical cord seems to have been con- sidered the chief duty of the midwife ; she was called the omphaloto- mist. There could be but little progress with so narrow a conception of the office, and with the scant qualifications of those assuming it It is true that at one time in the history of Athens, if the story con- cerning Agnodice be accepted, men only were permitted to practise obstetrics, but this custom was altogether exceptional, and even in the most enlightened nations the rule, until comparatively recent years, was that women in labor were under the care of one of their own sex. So universal was the custom of employing midwives, and so strong the prejudice against men engaging in obstetric practice, that in 1522 Dr. Wertt, of Hamburg, having put on the dress of a woman, and thus disguised attended a case of labor, was burned alive for the offence; and, a little more than a century later, Dr. Percivall Willughby, an eminent English physician, assisted his daughter, who was a midwife, in a case of difficult labor, crawling into the darkened room of the parturient on his hands and knees without her knowledge. Chereau remarks that obstetrics was at first empirical, then super- stitious, then scholastic, that is to say the almost absolute slave of theories and discussions, and that it did not attain finally a scientific character until the sixteenth and seventeenth centuries. The obstetrician has a graver responsibility than has either the medical or surgical practitioner, for he has charge of two lives instead of one; while his efforts are directed to saving both, yet in some instances it may be that the one must be sacrificed for the salvation of the other, or saved at great risk to the other: hence may arise the most serious questions in casuistry. INTRODUCTION. 19 The importance of obstetric knowledge is further shown by the fact that very frequently the emergencies which occur in the practice of the art are sudden, and must be met promptly if successfully. They may give no time for consulting books, or a fellow practitioner, but immediate as is the peril must be the means to avert it. Further, should a fatal result occur, the public is apt to visit unjust reproach upon the obstetrician; it is slow to understand how that which is usually a physiological process may end in death, or in lasting disability. The obstetrician thus not only rests under greater responsibility than the physician or the surgeon, but is also liable to severer censure in case of failure or misfortune. In this work it is proposed to consider first, the female pelvis, and the anatomy and physiology of the female sexual organs; second, pregnancy, its physiology and conduct, its pathology and treatment; third, labor and its conduct, and then its pathology and treatment. The fourth division will include childbed, or puerperality, with refer- ence both to its physiology and management, and its pathology and treatment. While obstetric operations naturally belong chiefly, though not exclusively, to the treatment of the pathological condi- tions of labor, yet for convenience and for the clearer presentation of these operations, it is thought best that they should be considered in a separate division, which will, therefore, be the fifth, and the last. PART I. THE ANATOMY AND PHYSIOLOGY OF THE FEMALE SEXUAL ORGANS CHAPTER I. ANATOMY OF THE PELVIS. The pelvis is that part of the skeleton which is placed at the inferior portion of the body, and which, receiving the weight of the head and trunk, transmits it to the lower limbs. It has its name from a supposed resemblance in form to a basin once used by barbers, or from the fact that it serves as a temporary receptacle for certain secretions. Within or upon the pelvis the organs of repro- duction are placed; through its canal the foetus and its appendages pass; and the most serious difficulties in labor arise from its deformities. The study of the pelvis, therefore, is the first part of obstetrics; this knowledge is the very alphabet of obstetric science, and is the foundation of obstetric art. The anatomical pelvis is formed by the union of four bones, viz., the two ossa innominata, the sacrum, and the coccyx; the obstetric pelvis includes also the last lumbar vertebra. But while the static pelvis is thus constituted, the dynamic pelvis—the pelvis in the living subject and in labor—has in addition certain structures which make its floor, and prolong the birth-canal; it is necessary for the obstetrician1 to know two pelves, the one osseous, fixed, passive; the other soft, mobile, active. The former will be described first. The innominate bones form the anterior and lateral walls of the pelvis. Each os innominatum or unnamed bone resembles an elongated quadrangle narrowed in the middle, and twisted at the point of narrowing so that the two halves are in different planes. In early life the bone is composed of three separate bones, and as between them the ossific union is not complete until the subject is eighteen or twenty years old, anatomists are accustomed to describe it according to these divisions. In Fig. 2 a faint white line indicates the separation of the bone into three parts; viz., the upper and larger portion (1) is called the ilium, the lower portion (2) the ischium. and the anterior (3) the pubis, or pubic bone. The Ilium.—The external surface of this bone is called the dorsum. 1 Boissard : De la forme de 1'Excavation Pelvienne. Paris, 1884. 22 SCIENCE AND ART OF OBSTETRICS. It is convex in front, concave behind, and is marked by three lines, superior, middle, and inferior curved lines; to the surfaces intervening FlG. I. Fir,. Pelvis with Ligaments.—A. Last lumbar vertebra. B. Internal iliac fossa. C Anterior- superior spinous process. D. Anterior-inferior spinous process. E. Ilio-pectineal eminence. F. Spine of the pubis. G. Pubic symphysis. H. Great sacro-sciatic ligament. I. Less sacro- sciatic ligament. C. Great sciatic foramen. L. Ilio-lumbar ligament. N. Small sciatic foramen. O. Point of the coccyx. between these lines the glutei muscles are attached. The anterior two-thirds of the inner surface of the ilium are smooth and concave, and are called the fossa or venter, and in the living subject are oc- cupied by the iliacus internus mus- cle ; the posterior third presents first a semi-lunar surface for articu- lation with the sacrum, and behind this a roughened part for the at- tachment of ligaments. The upper margin of the bone is S-shaped,and is called the crest; this crest is quite thick, and is described as having an external lip, an internal lip, and a roughened interval, these different parts furnishing attach- ment to important muscles. The iliac crest ends in front by a promi- nence known as the anterior supe- rior spinous process, immediately below which there is a depres- sion, and then another prominence called the anterior-inferior spinous process. Similar projections with an intervening depression mark the posterior margin of the bone, and they are known as the Left Innominate Bone. ANATOMY OF THE PELVIS. 23 posterior-superior and the posterior-inferior spinous process; the word spine may very well replace spinous process in this connection. Immediately below the posterior-inferior spine the bone presents a deep notch, the sciatic notch. By means of two important liga- ments hereafter to be described the sciatic notch is converted into two foramina, the great and the less. Through the former the gluteal, sciatic, and pudic bloodvessels, the sciatic and pudic nerves, and the pyriformis muscle pass out; and through the latter the pudic vessels and nerves re-enter the pelvis, and the tendon of the obturator internus muscle passes out. The ilium unites externally and below with the ischium and the pubis to form.the acetabulum. Internally its union with the pubic bone is marked by an elevation important in obstetrics, the. ilio-pectineal eminence; this eminence is in the anterior portion of a line, the ilio-pectineal or the innomi- nate line, which marks the boundary between the true and false pelvis. The Ischium.—This bone is irregular in form and is composed of a body, a spinous process, a tuberosity, and an ascending ramus. The body is the largest part of the bone, and from it the spinous process, broad in its origin, then tapering, projects; this process gives attachment to the less sacro-sciatic ligament and to the coccy- geus muscle, while the great sacro-sciatic ligament is attached to the lowest part of the ischial tuberosity. The ramus of the ischium coming from the body of the bone is narrow, flat, ascends obliquely to meet and be fused with the descending ramus of the pubis, some irregular nodules marking their point of union. Ossa Pubis.—Each pubic bone is composed of a body and two rami or branches, the one known as the descending ramus, the other the horizontal, though the latter term is inappropriate, as the ramus has an oblique rather than a horizontal position. The body of the pubic bone is irregularly quadrilateral, and is obliquely directed from above below, and from within out; by its internal margin it articu- lates with the body of the os pubis of the other side ; beyond the pubic angle the superior margin of the body presents an elevation known as the pubic spine. The Sacrum.—This bone is single, symmetrical, and forms the greater part of the posterior wall of the pelvis. It is pyramidal in shape, narrowing from above down, from side to side, and from before back. It is directed from above below, and from behind for- ward obliquely, so that it forms by its articulation with the last lum- bar vertebra an obtuse angle named the sacro-vertebral angle. The anterior face of the sacrum is concave, and presents upon the median line five smooth surfaces separated by prominent lines which indi- cate the place of union of the originally separate vertebrae of which it is formed ; the first of these lines is most distinct, and in pelvic measurements upon the living may sometimes be mistaken for the sacro-vertebral angle. Four foramina are seen each side of the median line ; these are for the transmission of the anterior sacral nerves. On either side of the body of the first sacral vertebra may be seen the a/a, or wing, the upper surface of which furnishes part 24 SCIENCE AND ART OF OBSTETRICS. of the dividing line between the false and true pelvis. The posterior surface of the sacrum is convex, and presents in the median line an Fig. 3. Right Innominate Bone. External surface. Fig. 4. Right Innominate Bone. Internal surface.—1. Ala, or wing. 2. Acetabulum. 3. Crest of the ilium. 4. Anterior-superior spine. 5. Anterior-inferior spine. 6. Posterior-superior spine. 7. Posterior-inferior spine. 8. Sciatic notch. 10. Iliac fossa. 11. Rough surface for articulating with sacrum. 12. Innominate line. 13. Spinous process of ischium. 14. Ischial tuberosity. 15. Ischial ramus. 16. Horizontal ramus of pubis. 17. Articulating surface of pubic joint. 18. Descending ramus of pubis. 19. Spine of pubis. 20. Ischio-pubic foramen. irregular prominence known as the sacral crest. Above, the crest is bounded by an opening called the orifice of the sacral canal. Below, the crest bifurcates, and the sacral cornua are formed by the termination of each line. On each side of the sacral crest a depressed ANATOMY OF THE PELVIS. 25 surface is observed, and in it are the openings, the posterior sacral foramina, for the transmission of the posterior sacral nerves. Two parts compose the lateral borders—an upper and a lower; the former is large and rough, the auricular surface for articulation with the ilium, and behind this a more irregular surface for the attachment of ligaments; the latter is smooth, and gives attachment to the sciatic ligaments. The base of the sacrum, the superior surface of the first sacral vertebra, articulates with the last lumbar vertebra, and presents upon the median line a large, elliptic, concave, and horizontal facet. The summit or apex of the sacrum represented by the inferior surface of the fifth sacral vertebra presents a transverse elliptic surface for articulation with the base of the coccyx, while behind are the two sacral cornua already mentioned. The Coccyx.—The coccyx has its name from a fancied resemblance to the cuckoo's beak ; it is formed of five rudimentary vertebrae; and is triangular in shape, flattened from before back; it represents the caudal appendix in vertebrates. Its anterior surface is concave, its posterior convex; its borders give attachment to the sciatic ligaments; its base has an elliptic sur- face corresponding with that found on the apex of the sacrum with which it articulates, and two cornua which articulate with the sacral cornua; its apex, the fifth of the coccygeal vertebra, often a mere tubercle, completely fused with the fourth vertebra. In case of bony union between the coccyx and sa- crum it is possible difficulty in labor may result. Pelvic Joints.—Seven joints unite the bones forming the obstetric pelvis. Sacrum and Coccyx. They are three sacro-lumbar, two sacro- iliac, one sacro-coccygeal, and one pubic. Five of these joints are amphiarthrodial, Sacro-vertebral Joints.—The sacrum articulates with the last lower lumbar vertebra by the upper surface of the body of the first sacral vertebra, and by the two facets of the articular apophyses of this vertebra. Corresponding surfaces are presented by the under sur- face of the last lumbar vertebra; the union is similar to that existing between the other vertebrae. A remarkable peculiarity of the artic- ulation is that the inter-vertebral disk of fibro-cartilage is twice as thick in front as it is behind, and thus the sacro-vertebral angle is formed.1 The pelvic inclination does not depend entirely upon the angle, but in part upon the obliquity of the innominate bones to the sacrum. The union between the bodies of the vertebrae is amphi- arthrodial, but that between the apophyses is arthrodial. 1 Morris : Anatomy of the Joints. 26 SCIENCE AND ART OF OBSTETRICS. Sacro-iliac Joints.—According to Sappey, these joints are inter- mediate between mobile and semi-mobile joints, though classed by most authorities as amphiarthrodial. Most anatomists state that the auricular surface of the innominate bone, and the corresponding surface of the sacrum are covered with cartilage, the covering being much thicker upon the latter than upon the former; that which is upon the innominate is fibro-cartilage; that of the sacrum consists, first, of cartilage adhering to the bone; and, second, of fibro-cartilage. The existence of a synovial membrane, especially distinct in case of pregnancy, is taught by some authors. Gray, for example,1 states that in the early period of life, occasionally in the adult, and in the female during pregnancy, the intervening cartilages are in part smooth and lined by a delicate synovial membrane. Morris,2 however, holds that the cartilaginous mass uniting these bones is single, and not composed of two plates with a synovial space between them, stating that such may be the case sometimes, but that it is not constant, certainly not in the male, though more frequent in the female; if two plates are present, the joint is arthrodial. The joint is further secured by the following six ligaments: the ilio-lumbar, extending from the transverse process of the last lumbar vertebra to the crest of the ilium, is a firm band of fibrous tissue which not only greatly strengthens the joint, but helps to form the posterior wall of the false pelvis; the antero-superior, the antero-inferior, the postero- superior, the postero-inferior, and the inter-osseous ligament com- plete the direct means by which this joint is made one of the strongest in the body. But additional strength is given to it by the sacro-sciatic ligaments. The great sacro-sciatic ligament arising from the posterior part of the superior curved line of the dorsum of the ilium, from the postero-inferior ilio-sacral ligament, from the side of the sacrum and of the coccyx, is attached to the lower por- tion of the ischium and to its ramus ; this ligament is broad at first and then in its middle is narrowed, but again widens as it approaches its points of attachment. The less sacro-sciatic ligament is in front of the former, and is triangular in shape; it arises from the sides of the sacrum and the coccyx, and is at first confounded with the great ligament; afterward it becomes distinct from the former in making the lower boundary of the great sciatic foramen, and passes to its attachment to the spinous process of the ischium. When in labor the head has descended into the pelvic cavity, the expulsive force drives it against the lower portion of the sacrum, and hence results a strain upon the sacro-iliac joints tending to throw the lower part of the sacrum backward ; but nature guards against such dislocation by these strong fibrous bands which unite the sacrum and the ischium. The Sacro-coccygeal Joint.—This is composed of two articular surfaces, an interosseous fibro-cartilage, and four peripheral liga- ments. The retrocession of the coccyx thus secured adds materially to the antero-posterior diameter of the outlet. Sappey states that, 1 Anatomy. 2 Anatomy of the Joints. ANATOMY OF THE PELVIS. 27 prior to their consolidation, all the inter-coccygeal articulations are symphyses, and Lenoir that the backward movement referred to takes place between the first two bones of the coccyx, as between the first and the sacrum; exceptionally this motion is found to be between the second and the third, or between the third and fourth. Verneau1 says that he has frequently found even in young subjects complete synostosis of the sacrum and the coccyx, and describes the two as a single bone. The Pubic Joint.—Fibro-cartilage similar to that of the inter- vertebral disks is firmly fastened to the articulating surface of each pubic bone. The fibro-cartilage is soft in the middle, firm exter- nally ; it is much thicker in front than it is behind—thicker, too, in females than it is in males ; the presence of a synovial membrane is asserted by some, Allen, for example,2 stating that in the adult male its size is not greater than that of a split pea, but that it is larger in the adult female, and in the parturient may involve the entire thick- ness of the joint. Morris, however, only describes a fissure running through more or less of the antero-posterior as well as the vertical depth of the cartilage; it partially divides the cartilage into two plates, with a minute viscid pulp or a little fluid in the interspace; it is found in males as well as in females, but not constantly in either sex. Depaul and other French authorities generally deny the pres- ence of a synovial membrane in the pubic joint; this, too, is the teaching of most anatomists. Four ligaments add to the strength of the joint. These are the posterior, which is chiefly thickened periosteum ; the anterior, thicker and stronger than the preceding, is formed by several layers of fibres crossing each other obliquely, some of them continued into the inferior ligament; the superior consists of layers of yellowish fibres attached to the pubic crest on either side, and at the middle closely united with the interosseous cartilage; and, finally, the inferior or subpubic ligament. The last, also called ligamentum arcuatum, three-eighths of an inch in its vertical measurement, is composed of closely joined fibres, and fills up the angle made by the pubic rami, forming an arch, the pubic arch, a part of as great obstetric importance in the outlet, as the sacro-vertebral angle is in the inlet of the pelvis. Movements of the Pelvic Joints.—Of course there are in the three sacro-vertebral articulations movements similar to those of the ver- tebral joints elsewhere. There is also, as has been before men- tioned, an important movement in the sacro-coccygeal joint, or in one or more intercoccygeal joints, allowing retropulsion or pushing back of the coccyx, thus increasing the antero-posterior diameter of the pelvic outlet. But are there movements in the other pelvic joints by which pelvic diameters are notably increased? Dr. J. Matthews Duncan holds that in labor important movements occur in the sacro-iliac joints, movements which he describes as an eleva- tion and a depression of the pubic joint; or, if the sacrum be regarded as the moving bone, it has a nutatory motion upon an ' Le Bassin dans les Sexes et dans les Races. 2 Human Anatomy. 28 SCIENCE AND ART OF OBSTETRICS. imaginary transverse line passing through its second vertebra. Elevation of the pubic joint, or its equivalent forward movement of the superior part of the sacrum, lessens the antero-posterior diam- eter of the inlet, but increases the corresponding diameter of the outlet. On the other had, Mattei and Laborie assert an increase in the transverse diameter of the outlet by the wedge-like pressure of the fcetal head.1 But the form of the articular surfaces of the sacrum and the innominate bones is such—elevations upon the one fitting into depressions on the other, and the reverse—that any movement between these bones, whether it be described as rotation of the innominates upon the sacrum, or a movement of the base of the sacrum forward, while the lower portion of the bone moves backward, seems improbable, or impossible, in ordinary conditions. Moreover, the fixed position of the sacrum is further secured by its shape, and by the ligaments belonging to the sacro-iliat: joint, and also by the sacro-sciatic ligaments, and by the ilio-lumbar ligaments. " The shape of the sacrum, and the mode in which it articulates with the ossa innominata, render its position a secure and ordinarily an immovable one." 2 In so far as this movement of the sacrum, sup- posed usually to occur in all cases of labor, increases the coccypubic diameter, nature has provided a simpler method, which has been pointed out, and hence this is unnecessary. Uses of the Pelvic Joints.—Since, then, movements3 may be con- sidered as almost mil in the pelvic articulations, why is not this osseous girdle made of a single bone? The answer is that these joints have as their result the decomposition of forces, and thus prevent shocks and jars received by the lower limbs being trans- mitted directly to the vertebral column. Thus the uterus and the ovum as well as the prolongation of the spinal cord in the sacral canal are guarded from injury. These joints, especially the pubic,4 are swelled during pregnancy, permitting a slight separation, but such swelling is not for the increase of pelvic diameters, but for providing against injuries from falls or jars ; they serve a purpose similar to that of the cushioned buffers of railway cars. The Pelvis as a Whole.—Its External Surface. This is of no great obstetric importance; still a few points are worthy of attention. One feature of the pelvis is most striking—the great difference as to completeness between its anterior and its posterior portion. Behind, 1 Dr. Driver, in a paper read before the Massachusetts Medical Society, June, 1887. from a study of nearly 300 cases in his practice concluded that in a large percentage of women there was an increase of about one-third of an inch in the pelvic diameters from relaxation of the pelvic ligaments. 2 Morris. 3 Depaul. 4 Budin (Progres Xb'dical, 1875) examined more than eighty pregnant women to ascertain whether there were movements in the pubic joint. The method of examination was to intro- duce the index finger into the vagina, and apply the pulp of the finger directly against the inferior margin of the joint while the subject was standing, and then have her walk. At each step she took he found that the finger was pushed down by the descending pubic bone of one or of the other side ; that bone descends which corresponded with the limb moved ; the one corresponding with the limb that was fixed remained without change in position. His conclu- sions were, that in all pregnant women there was in the last months of pregnancy a certain mobility in the pubic joint; this mobility is greater as the pregnancy approaches its end ; almost absent in primiparse. it increases with the number of pregnancies. Even where there was very considerable mobility the subjects walked without difficulty. ANATOMY OF THE PELVIS. 29 the bony wall is complete from the beginning of the last lumbar vertebra to the tip of the coccyx; while in front the girdle presents a wide gap from the anterior margin of the iliac bones, above the pubic joint; the girdle is completed at the joint, but below another gap is formed, its boundaries being the divergent ischio-pubic rami. The ischio-pubic foramen1 is observed on either side; this foramen is closed by a membrane, and covering the membrane a muscle, known as the obturator externus in the living subject. The pos- terior surface, formed chiefly by the sacrum and coccyx, is triangular, the base of the triangle being superior. In the median line the sacral crest, formed by the fusion of the spinous processes of the sacral vertebrae, is found ; on either side of the iliac tuberosity, and intervening between these and the sacral crest, is a gutter, the two portions being occupied in the fresh subject by the sacro-lumbar muscles, while at the external side of each the posterior sacral foramina open. In general the rough, irregular surface of the pelvis posteriorly is in striking contrast with the corresponding internal surface. Internal Surface of the Pelvis.—Though the external surface of the pelvis is rough and irregular, and presents no lines for artificial divi- sion, the internal surface is smooth and symmetrical, and is plainly divisible into two parts, an upper and a lower, the dividing line being formed by the upper anterior margin of the sacrum and its alae, and the innominate, or ilio-pectineal line. The upper portion is known as the false, superior, or large pelvis, while the lower is the true, inferior, or small pelvis, or simply the pelvic cavity. The posterior wall of the upper, or false pelvis, is formed by the last lumbar ver- tebra and the ilio-lumbar ligaments ; its lateral walls are the iliac bones; in front the wall is absent, but in the living subject the gap is closed by the lower portion of the elastic abdominal wall, which, readily yielding, furnishes space for the uterus enlarging in preg- nancy. The convergence of the bony walls of the false pelvis—a con- vergence which, if continued, would cause them to meet at a point corresponding with the fourth sacral vertebra—has suggested the comparison of this part to a funnel which serves to direct the foetus into the pelvic cavity. The comparison is more striking when we remember that in the living subject the interval between the anterior margins of the iliac bones is closed by the lower part of the abdom- inal wall. Measuring from the highest point of the iliac crests to the plane of the inlet, the distance is a little more than three inches and a half, or nine centimetres and a half. The distance between the anterior-superior spines is about ten inches, or twenty-six centi- metres, and between the anterior-inferior spines a little more than nine inches, or twenty-four centimetres ; the widest interval between the iliac crests is eleven inches, or twenty-eight centimetres. These 1 Verneau remarks, op. cit., that <• foramen ovale" is incorrect, and ••obturator" mean- ingless. 3° SCIENCE AND ART OF OBSTETRICS. measurements vary somewhat in different subjects, but any notable deviations from those given of the distances between the iliac crests, and between the spinous processes, would be indicative of pelvic deformity. The Pelvic Inlet.—The entrance to the pelvic cavity is called the inlet, superior strait, brim, margin, or isthmus. The fitness of the term inlet is plain, whilst, it being " narrower than the upper pelvis, less in extent than the lower," there is a fitness also in the names strait and isthmus. Pelvic deformities most frequently affect the inlet, and therefore its study has special importance. Its form is irregular, and has been compared to an ellipse, to a circle, to a spherical triangle, to the heart of a playing card; it has been spoken of as oval, and as kidney-shaped. Its regularity of form is chiefly broken by the projection of the sacro-vertebral angle, commonly spoken of as the promontory, and thus a large, round notch is made, which is similar to the notch in the playing-card heart. The subjoined diagram represents the form of the inlet, and also the four diameters which are of obstetric importance. These diameters are one antero-posterior, one transverse, and two oblique. The oblique diameters connect what have been known as the four cardinal points of Capuron, viz., the right sacro-iliac symphysis with the left ilio-pectineal eminence, the left sacro-iliac symphysis with the right ilio-pectineal eminence. The first is known as the right,1 The Inlet, or Superior Strait. A P. Antero-posterior diameter. 4.3 to 4.5 inches, or 11-11^ centimetres. T S. Transverse. 5.3 " or 1314 R O. Right oblique. 4.7104.9 " or 12-12'/ L O. Left oblique. " •• •• « The circumference of the inlet is 15-8 inches, or 40 centimetres. the other as the left oblique diameter, the sacro-iliac symphysis determining the name. Further, it will be observed that the trans- verse diameter, which represents the widest measurement of the inlet, passes in front of the intersection of the oblique diameters 1 Some confusion arising from the fact that obstetric authors differ in the application of the terms right and left to these diameters, one designating that as right which another calls left and vice versa. While the selection is chiefly arbitrary, it seems more natural that the relation of right and left be made according to the sacro iliac joint concerned. ANATOMY OF THE PELVIS. 31 Antero-posterior Diameters of Inlet. S P. Sacro supra-pubic diameter. S P'. Sacro-sub-pubic " S P". Minimum " and this is characteristic1 of the normal female pelvis, indeed one of the means by which the female can be distinguished from the male pelvis. The antero posterior, sacro-pubic, or conjugate diameter extends from the sacro-vertebral angle to the pubic symphysis. The last is the shortest of the four, while the transverse is the longest; but the latter, as will be seen hereafter, is lessened by the encroachment of soft parts, so that each oblique diameter exceeds it, and hence the frequency of oblique positions of the foetal head as it enters the inlet. In addition to the antero-posterior diameter of the inlet which has been given, and which may be distin- guished as the sacro-supra-pubic, two other antero-posterior diameters are to be mentioned, called the sacro-sub-pubic, and the minimum useful or true conjugate ; the three diameters are represented in the subjoined diagram from Pinard. It will be observed that all these diameters start from a common point at the sacro-vertebral angle, but extend respectively to the superior margin of the pubic joint, to its inferior margin, and to its nearest point. In case of pelvic deformity involving the inlet, it is impor- tant to know what the minimum useful or true conjugate diameter is, and this is obtained by first ascertaining the sacro-sub-pubic diameter and deducting from this, if the pubic symphysis measures one inch and a half, four centimetres, or more, one-half to seven- tenths of an inch; but if the pubic symphysis is less than an inch and a half, the reduction must be one-half to three-tenths of an inch. The Pelvic Outlet.—While the boundaries of the inlet are formed of bone, and present a comparatively regular outline, those of the outlet are in part ligamentous, and are marked by projections of bone, the ischial tuberosities and the coccyx, and deep intervals, the most important of which is the pubic arch. Nevertheless, a somewhat rhomboidal form is attributed to the outlet. The sub- pubic ligament is its anterior boundary, its posterior the coccyx, while intervening on either side are the ischio-pubic ramus, the ischial tuberosity, and the lower surface of the sacro-sciatic liga- ments. The pubic arch is somewhat triangular, the base extending from one to the other ischial tuberosity, and its apex rounded by the sub-pubic ligament. As in the inlet, so in the outlet, four diameters are given, one 1 This statement, made by Verneau, I have verified in the measurements of some twenty male and female pelves. 32 SCIENCE AND ART OF OBSTETRICS. The Outlet as seen from below. — C. Under surface of the coccyx. A P. The antero-posterior, or coc- cy-pubic diameter. T E. Trans- verse. R O and L O. Right and left oblique diameters. antero-posterior, or coccy-pubic, one transverse, and two oblique. The first measures the distance from the tip of the coccyx to the sub-pubic ligament; the transverse that between the ischial tuber- osities ; while the oblique extend on either side from the middle of the un- der surface of the sciatic ligaments to the junction of the ischio-pubic rami. The oblique diameters may be slightly increased by yielding of the sciatic liga- ments, but this is unimportant. On the other hand, an important increase in the antero-posterior results from recession of the coccyx, so that it becomes the long- est diameter of the outlet, whereas it is the shortest of the inlet; the latter, since it is the shortest diameter of an ellipse, is correctly called the conjugate ; but to apply this term to the former, is plainly an error, or at least such application is purely arbitrary. Each of these diameters is about 4.3 inches, or 11 centimetres. The antero- posterior is increased by the recession of the coccyx, from one-half to one inch; the average increase is probably about three-fourths of an inch. The circumference of the outlet is 13.4 inches, or 34 centimetres. The Pelvic Cavity.—The pelvic cavity, the small or true pelvis, thus bounded by inlet and outlet, is somewhat cylindrical or barrel- shaped. Its walls measure one inch and a half in front, three inches and a half at the sides, and posteriorly four inches and a quarter, or, following the curve of the sacrum, about five inches and a half; the corresponding metric measurements are : 3.8, 8.9, 10.8, and 13.8 centimetres. Mr. Morris1 calls attention to an important fact in obstetrics, viz., that in no horizontal pelvic plane is the bony wall of the pelvis complete, for opposite the pubic symphysis is the movable coccyx, and thus at one point or at another of the cylinder there is always in some part of the plane either a joint motion or that permitted by elastic tissue. The protection from injurious pressure thus secured to the foetus and the maternal soft parts is obvious. The transverse measurements of the pelvic cavity lessen from above below, while the antero-posterior increase. The average diameters of the pelvic cavity are about four and three-quarters inches or twelve centimetres The antero-posterior diameter is measured from the middle of the posterior surface of the pubic joint to the middle of the line uniting the second and third sacral verte- bras; the transverse intersects and is perpendicular to the former • the oblique diameters connect the middle of each great sciatic fora- men with the middle of the ischio-pubic foramen of the opposite 1 Op. cit. ANATOMY OF THE PELVIS. 33 side. The points which the oblique diameters connect not being fixed, little importance is attached to the latter. It is plain that any oblong body, and the foetal head is such a body, which is longer than four inches and three-fourths cannot, having entered the pelvic cavity, pass out of it unless that part which entered first goes out first. This is illustrated in labor both in presentation of the vertex and in presentation of the face. Inclined Planes of the Pelvis,—The walls of the pelvic cavity, though presenting no natural lines of separation, have been arbi- trarily divided so as to represent certain inclined planes which were held to have an important influence in determining a part of the mechanism of labor. These divisions have varied with different obstetric teachers. The late Dr. Hodge, for example, after the Fig. 9. Fig. 10. Anterior Pelvic Wall and Lateral Planes. antero-posterior division of the pelvic cavity in the median line, had each half divided by a line beginning three-quarters of an inch in front of the sacroiliac joint and extending downward to the ex- tremity of the spine of the ischium; thus two anterior and two posterior inclined planes were formed, and an object impinging upon either of the former rotated into the pubic arch, while if impinging upon either of the latter it rotated into the hollow of the sacrum. Other authors make the line of division between anterior and pos- terior planes further forward. Still others, after dividing the pelvic walls into anterior, posterior, and two lateral walls, divide each of the latter—a lateral wall includes the part of the pelvis between the sacro-coccygeal surface and a line drawn from the ilio-pectineal emi- nence downward through the ischial tuberosity—into two inclined planes, the anterior and the posterior. Figs. 9 and 10 show the anterior wail of the pelvic cavity and the lateral inclined planes. It ought, however, to be said that few obstetric authorities now attach to these arbitrarily formed planes the importance which was once given them in explaining the mechanism of labor. Obliquity, Horizontal Planes, and Axes of the Pelvis.—The pelvis is not in the axis of the body, a fact which is at once evident when it is 3 34 SCIENCE AND ART OF OBSTETRICS. observed that the sacro-vertebral angle is nearly four inches higher than the superior margin of the pubic joint, but it is placed obliquely with regard to that axis, and hence the expression inclination or ob- liquity of the pelvis. This obliquity is caused, first, by the form of the articulating face of the upper sacral vertebra, which is so oblique as to make an acute angle with the anterior surface of the body of the bone; second, by the shape of the cartilage between the sacrum and the lumbar vertebra with which it articulates; and finally by the obliquity of the innominate bones in their articulation with the sacrum. The result of this obliquity is that the weight of the gravid uterus is borne chiefly by the anterior abdominal wall and the supe- rior border of the pubis. In order the better to show this obliquity of the pelvis it may be stated that the angle made by the antero- posterior diameter of the inlet and a line representing the axis of the body is from i30°to 1400, and that this diameter prolonged in front makes with a horizontal line an angle of 6o°. While, as taught by Naegele, the obliquity of the pelvis was represented by the angle made by the antero-posterior diameter of the inlet with a horizontal line—the subject standing—an angle which varied from 550 to 6o°, it is now held that this angle may vary greatly within even the lower of these limits, as the following passage from Kleinwachter1 explains: Naegele understood by it that angle which the conjugata vera makes with the horizon. (Fig. n.) Later researches showed, however, that, although this hypothesis is in general true, still the angle has no fixed size, but changes with various positions of the body. The most reliable angle (Fig. 12, B), indicating the pelvic obliquity, is, according to H. Mayer, that which a horizontal line makes with the so-called diagonal conjugate, the distance from the upper margin of the pubic joint to the middle of the anterior surface of the third sacral vertebra : this angle measures 300. The pelvic inclination, too much overrated in former times by Stein the elder and Naegele the elder, does not have any practical significance, for it may be changed by a corresponding change in the position of the parturient. Fig. 11. Fig. 12. Pelvic Obliquity. Diagonal Conjugate. It will be seen (Fig. 13) that the coccy-pubic diameter prolonged ;n front makes an angle with the horizontal line of u°, or 10° to 1 Grundriss der Geburts'iUlfe. ANATOMY OF THE PELVIS. 35 11°. But if the coccyx be pressed backward, as it is in labor, that diameter coincides with the horizontal line at first, and then forms an angle with, but below it. Planes and Axes of the Inlet and the Outlet.—H O. Horizontal line. V O. Vertical line. N. Umbilicus. A R. Axis of the outlet intersecting, at /, the axis of the inlet. A P. Sacro- pubic diameter. G K. Coccy-pubic diameter. The plane of the inlet is a surface supposed to touch all points of the circumference of the inlet; the antero-posterior diameter of the inlet is a line which measures that surface from before backward. The axis of the inlet is a perpendicular to the surface at its middle point, or, more simply, a perpendicular to the antero-posterior diam- eter at its middle. Similarly the plane of the outlet is a surface which theoretically touches all points in its circumference ; the axis of the outlet is a perpendicular erected at the middle of its antero-posterior diameter. As will be seen from Fig. 13 the axis of the inlet prolonged below meets the axis of the outlet, forming with it a very obtuse angle. In the illustration this angle measures 1240. Further, as shown in the diagram, the two antero-posterior diameters mentioned, if pro- longed in front of the pubic joint soon meet; but as these lines simply represent the middle of the surface of the inlet and that of the outlet, it follows that the planes of the inlet and outlet would in like manner meet. If the axis of the inlet be continued beyond the point where it meets that of the outlet, it would strike the coccyx— according to some the sacro-coccygeal articulation; extended above, it passes out at or a little below the umbilicus. It is therefore obvi- ous that the plane of the inlet is very oblique, while that of the outlet —the subject supposed to be standing—is nearly horizontal. Behind, the planes are separated by the length of the anterior surface of the sacrum and coccyx, while in front only the length of the pubic joint intervenes. It follows that the planes of the pelvic cavity cannot be parallel, but must Converge as they move from the posterior wall, meeting in front of the pubic joint, and are included between the plane of the inlet and that of the outlet. To ascertain the mathe- 36 SCIENCE AND ART OF OBSTETRICS. matical axis of the pelvic cavity, a series of planes may be imagined to extend from the intersection of the inlet and outlet planes to the anterior surface of the sacrum and coccyx. Take in the pelvic cavity the central point of each of these planes, and then a line connecting these central points is drawn; this line, which is curved, its concavity anterior, represents the action of the pelvis. Fig. 14. Fig. 15.' Inclination and Axis of the Pelvis. Rec- Axis of the Child-birth Canal. turn, a b. Plane of outlet of completed canal, e. Perpendicular to plane, or axis of expulsion. The pelvic axis is also known as the central line, and the line of direction. It may be further defined as a curved line passing through the centre of the pelvic cavity, equidistant from the sacrum and the pubic bone. While on theoretical grounds it is claimed that the foetus in its passage through the pelvic cavity follows this curved line, and that in the use of the forceps traction should be made according to this line, yet it is to be borne in mind that this 1 This illustration, originally given by Dubois, is inaccurate in two or three respects The antero-posterior diameter of the vulvar outlet is represented as inferior to the coccy-pubic diam eter, and the distance from the anus to the point of the coccyx is exaggerated, while that fro the former to the vulvar opening, by some known as the anterior perineum, is less than it m during the emergence of the child's head. IS ANATOMY OF THE PELVIS. 37 view applies to the static pelvis only, and it will be materially modi- fied by the study of the dynamic pelvis. Fig. 15, from Leishman, illustrates the generally accepted statement as to the axis of the birth canal, that is, of the pelvis and its prolongation by the addi- tion of soft parts yet to be described. While the relation between the pelvic planes and the pelvic axes is necessarily unchangeable, always remaining the same whatever the position of the body, the relation of these planes and axes to the body and to the horizontal line is necessarily changed by that position. For example, let the subject be standing. The axis of Fig. 16. d vr m a/ Relations of Pelvic Planes and Axes due to Changes in Position of the Subject.—A B. Hor- izontal line. ON. Antero-posterior diameter of outlet. FE. Axis of inlet. CD. Vertical line. H G. Change caused by leaning forward. JK. By bending backward. the body makes with a horizontal line an angle of 900. Now let the body incline forward, the angle is lessened, and the axis ap- proaches the axis of the inlet; now let the movement of the body be reversed, and the axis of the body is thrown further from that of the inlet. When the subject is standing, the plane of the outlet is nearly horizonal; but if she be lying on her back, the plane is almost vertical, and its axis is nearly a horizontal line ; and from this fact the practical rule has been drawn, that in delivery of the head through the outlet by the forceps the pulling should be in a horizontal line. Differences in the Pelvis as to the Individual, Sex, Age, and Race. Individual Differences.—As no two faces are exactly the same, so it is probable that no two pelves can be found which do not present some differences. Moreover, no pelvis is perfect in symmetry, form, and normal measurements. It has been said that, as the perfect statue exhibits the separate perfections of many individuals combined in the artist's representation, so the perfect pelvis of the obstet- rician represents a combination of the perfections derived from various pelves. Without any positive deformity, and without such change in form 38 SCIENCE AND ART OF OBSTETRICS. as to present serious hindrance to labor, pelves differ in size. There may also be differences in the thickness of the pelvic bones, in their relative smoothness or roughness, in the height of the pubic arch, in the size of the angle, in the breadth, length, and curvature of the sacrum, in the depth of the iliac fossa.', and in the distance between the iliac spines or iliac crests. As a rule, the development of the pelvis corresponds with that of the lower limbs. It does not follow that a tall woman has a small pelvis; its development may be in perfect relation to her stature; if her labor be protracted, while that of another, whose stature is much less, be brief, the occurrence is to be attributed, as Dubois has said, to the fact that in the latter the pelvic canal is shorter. Levret asserted that the circumference of the inlet was one-fourth the height of the individual. Finding the latter it was very easy to determine the former. But results have not proved the correctness of the assertion. Weber sought to establish an analogy between the head and the pelvis. As heads present various forms, but can be reduced to four chief ones—viz., oval, round, conical, and square—so the various forms of the pelvis may be reduced to the same types, and these types coincide in the individual—that is, the pelvis corresponds in form with the head. Not only so, but certain measurements of the head will represent pelvic measurements. Thus, the measure between the zygomatic arches represents that of the transverse diameter of the superior strait, while its antero-posterior diameter is found by taking the distance from the root of the nose to the chin. As observed by Depaul, this theory, if it were correct, would be of great service to the obstetrician: but, unfortunately, experience has not sustained it. Differences in the Sexes.—Verneau1 regards the sexual differences presented by the pelvis as much more positive than those of any other part of the skeleton, " although many of the differential characters commonly given are without value, such as the form of the ischio-pubic foramen, or are entirely false, such as the greater concavity of the sacrum in the female." Of course the pelvic bones, like the other bones of the skeleton, are in the male rougher, thicker, stronger, and less delicately curved than in the female. But there are many special characteristics which have been fully studied by Verneau. The most important of these will now be presented. The differences belong chiefly to the pelvic cavity, and are determined by the presence of the uterus. All the dimensions of the internal iliac fossa are less in the female, except the distance from the antero-superior iliac spine to the sacro- iliac joint. The fossa is more shallow in the female. In the male the iliac tuberosity is more developed, and projects further back. The pubic spines are further apart in the female. In woman all the diameters of the inlet are greater than in man. This difference is especially marked as to the transverse diameter. The inlet in the female pelvis is rounder, due partly to the increase in the transverse diameter, and to the fact that the diameter is placed further forward than in the male pelvis. The great sciatic notch is less open, and is deeper in man. In man, too, the points of the sciatic spine's are 1 Op. cit. ANATOMY OF THE PELVIS. 39 in some cases within the postero-inferior iliac spines, but in woman they are always without. The distance between the sciatic spines is greater in the female. The pubic arch is more open in woman, Male Pelvis. Flo t8. Female Pelvis. measurino- 750 ; in man only 580. In woman it is always rounded ; the ischio-pubic tubercle is turned more outward, and the ischio- pubic ramus is concave at its middle. In the female the coccyx and sacrum are not so high, and are more flattened. The ischio-pubic 40 SCIENCE AND ART OF OBSTETRICS. foramen is not oval in man, and triangular in woman;1 in woman it is relatively larger, and more oblique outward and below. The ischia are wider apart in woman, while all the vertical pelvic diameters are greater in man. Thus, while there are marked distinctions between the male and the female pelvis, so that ordinarily there is no possibility of con- founding the one with the other, yet in some instances2 the points of difference are so slight that it is very difficult to decide whether a pelvis is male or female. Differences depending upon Age.—The pelvis of the foetus at term is much less developed than is the upper portion of the body; delivery is therefore easier. The greater prominence of the abdo- men in infants arises from the imperfect development of the pelvis ; at birth the greatest portion of the rectum and the bladder are con- Fig. 1,9. Pelvis of a Child. tained almost entirely in the abdominal cavity, and do not assume their permanent position until about the period of puberty. At birth the false is more developed than the true pelvis ; the latter is straight and cylindrical. According to Wood,3 the parallelism of the lateral as well as of the anterior and posterior pelvic walls is sufficiently marked and general that it can be considered as a char- acteristic of the conformation of the infant pelvis, as is found to be the case with most of the lower animals, to which it imparts a square-sidedness. The antero-posterior diameter of the inlet is greater than the transverse diameter until the age of nine years, when it equals, then gradually exceeds it. The complete develop- ment of the pelvis, which is not accomplished before twenty years, is largely dependent upon the presence and activity of the internal sexual organs; if these are absent or undeveloped, the pelvis fails to assume the characteristics of the female sex. 1 The late Dr. John Neill. of Philadelphia, proved this fact more than thirty years aeo though most works upon anatomy and some upon obstetrics still repeat the erroneous state- ment that the foramen in oval in the male and triangular in the female. 2 Depaul. 3 Todd's Cyclopaedia of Anatomy and Physiology. ANATOMY OF THE PELVIS. 41 Differences dependent upon Race.—Some anthropologists have re- garded the pelvis as next in value to the skull in the indication of racial characteristics. Verneau suggests that it will one day be possible, by the comparison of pelves, to give, as by the comparison of crania, a classification of the human race. The relative proportions of the conjugate and transverse diame- ters of the pelvic inlet present remarkable variations in different races, though, according to Professor Turner,1 the form characteris- tic of the race is more fixed in the male than in the female pelvis, since in the latter there is, for sexual reasons, to a considerable extent, an approximation in form in different races. Nevertheless, the relation of these diameters has been chiefly studied in the female sex. In general, lessened transverse and increased conjugate diam- eters of the inlet seem characteristic of inferior races. Thus Gar- son,2 incorporating the measurements given by Verneau with those mode by himself, obtained an average conjugate of 106 millimetres in 49 European pelves, and a transverse of 134.5 ; while in 7 Aus- tralian pelves the average conjugate was 108.6, and the transverse 120. Verneau found that the pelvis of the Egyptian and that of the Laplander were each smaller than that of the French woman. In no people,3 however, has it been found that, where a sufficient number of pelves have been examined to make a just average, the conjugate exceeds the transverse diameter. Everywhere the form of the female pelvis indicates its part in labor when the foetus is perfectly developed. It is not improbable that a definite relation between the size and form of the fcetal head and those of the pelvis will be proved to exist in different races. With the progress of a race, with its greater intellectual and moral development, it is possible that there is a development pari passu of the pelvis. Broca has shown that the Parisian of to-day has a greater cerebral capacity than the Parisian of the twelfth century ; and that the skull of the latter had a greater capacity than the skull of the Greek of the Macedonian period, skulls of this period exhumed at Athens within a few years showing a decided inferiority. Now it is at least a probable conclusion that if the head has thus increased in size, the bony canal through which it is transmitted at birth has undergone a corresponding increase. Nevertheless, Spiegelberg4 has remarked that '' the opinion that the further north a race is living the larger the pelvis, and also the other assumption, that an in- crease in size of the pelvis occurs with the increase of civilization of a race, is not proved ; it would be more correct to state that favorable conditions of nutri- tion and activity are the basis of a well-formed pelvis." Ploss5 states that the habits and customs of a people and their mode of life undoubtedly have a certain influence in the formation of the prevalent pelvic type. The general nutrition, more particularly the supply of bone-forming material, is of importance. G. Fritsch found that a dwarfed, poorly developed pelvis bore a close relation to the general system of the Bushwomen and Hot- tentots. The pelves of the South African races present neither the typical male V nor female form, but rather a combination of the male and female pelvis, as a ' rule approaching the male form. This results to some degree from the unfavorable conditions in which these people live, the entire skeleton never attaining that per- fection found in a civilized people. It is asserted that the pelves of negresses 1 Tournal of Anatomy and Physiology, vol. xx., 1S85. 2 Ibid., vol. xvi., 1882. 3 Professor Turner. 4 Lehrbuch der Geburtshiilfe. 5 Das Weib in der Natur und Volkerkunde. 42 SCIENCE AND ART OF OBSTETRICS. born in America correspond more nearly to those of the European type, improve- ment of the general environment leading to better development of the entire osseous system. Soft Parts of the Pelvis.—Those structures which line the pelvis and those which chiefly make its inferior wall are called soft parts. On either side of the upper pelvis the iliacus and the psoas muscles are placed. The iliacus covers the entire iliac fossa; it arises from the anterior two-thirds of the iliac crest, from the anterior iliac spines and the space intervening, from the sacrum, from the sacro- iliac joint, and from the ilio-lumbar ligament, and is inserted into the external border of the tendon of the psoas. The psoas muscle has its origin from the sides of the bodies and the transverse pro- cesses of the four upper lumbar vertebrae, and from the last dorsal, descends to the base of the sacrum, fills up the depression on each side of the promontory, and thick, spindle-shaped passes along the innominate line, receives the fibres of the iliacus, then goes out of the pelvis between the ilio-pectineal eminence and the inferior iliac spine, to be inserted into the entire surface of the less trochanter. An aponeurosis called the iliac fascia covers the iliacus and the psoas muscles ; it divides into two layers, and thus furnishes a sheath for the iliac vessels and lymphatic ganglia. The external iliac artery and vein lie upon the internal border of the psoas. The lumbar plexus is placed in the substance of the muscle; its most important branch, the crural, after emerging from the muscle, lies between it and the iliac muscle, and then passes from the pelvis below Poupart's ligament. It has been suggested that the presence of these nerves in the psoas explains the violent lumbar pains which women suffer in labor, for the weight of the uterus then presses upon them.1 So, too, the pain felt at the inner part of the thighs, when the head of the foetus descends through the inlet, is explained by pres- sure on the obturator nerve at the base of the sacrum as it passes under the aponeurosis, this nerve furnishing branches to the ad- ductors. The psoas and the iliacus muscles acting from above flex and abduct the thighs; from below and on both sides they incline the lower portion of the spine and pelvis forward. The iliacus muscle serves as a cushion upon which the gravid uterus rests. The psoas lessens the obliquity of the iliac bone and makes the slope to the superior strait more uniform. The two psoas muscles and the vessels at their internal border lessen the inlet The diminution of the oblique diameters is only about one-eighth of an inch m each, but that of the transverse is three-fifths of an inch or I c of a centimetre. The diminution of the last diameter may be so great when the muscle is contracting as to prevent the entrance of the fcetal head. In the pelvic cavity the pubic joint and the median surface of the sacrum and of the coccyx have no muscular covering ; but on each side the obturator internus and the pyriformis muscle are found the 1 Depaul. ANATOMY OF THE PELVIS. 43 tendon of the former passing out of the pelvis through the less, the latter through the great sciatic foramen, notably contributing to the closure of these openings. The nerves of the sacral plexus lie in front of the pyriformis. The bladder is placed in the anterior part Fig. 20. The Pelvis with Soft Parts. (Bladder, nctum, uterus, and iis appendages having been re- moved.)—A. Aorta. B. Primary iliac of left side. C External iliac of left side. D. Internal iliac of left side. E. Inferior vena cava. F. Primary iliac vein of left side. G. External iliac vein of left side. H. Sacral insertion sacro-sciatic ligament. I. Sacro-vertebral angle. J. Quadratus lumborum. K K. Psoas muscles. L L. Iliac muscles. M M. External obturator muscles. N. Pubic arch. PP. Great trochanters. R R. Section of the muscles of the abdominal wall. of the pelvic cavity, behind the pubis, but its position varies in pro- portion to its fulness or emptiness. The rectum enters the pelvic cavity in front of the left sacro-iliac joint—thus slightly lessening the left oblique diameter of the inlet—passes obliquely to the middle of the anterior surface of the sacrum, and then descends in front of the sacrum and coccyx. The soft parts in the cavity make but slight 44 SCIENCE AND ART OF OBSTETRICS. change in its capacity. A full bladder or rectum may hinder the descent of the head in labor, and therefore the obstetrician is careful that each organ is emptied. The Pelvic Floor.—Skin, connective-tissue, muscles, and layers of strong fascia unite to form the pelvic floor which contributes to the support of pelvic and abdominal viscera, and which at the same time is so formed that it may be temporarily opened almost to the bounds of the bony outlet, to permit the passage of the mature foetus. This pelvic floor—diaphragm or inferior wall—is perforated by the urethra, vagina, and rectum ; but these are closed, the first two by the accurate apposition of their walls, and the last by the contraction of the anal sphincter, unless when in functional exercise. Fig. 21. Urogenital and Anal Regions in Woman.—i. Gluteus maximus. 2. Levator ani. 3. Su- perficial transverse perineal muscle. 4. Profound transverse perineal muscle. 5. Vaginal sphincter muscle. 6. External anal sphincter. 7. Fasciculi of vaginal sphincter passing to the perineal body. 9. Ischio-cavernosus muscle. 10. Clitoris. 11. Bulb of the vestibule. On examining the pelvic floor from within out we find, first, the superior pelvic aponeurosis, this aponeurosis being more or less covered, as all the pelvic organs are, by peritoneum. It is simply the united fascia of the pyriform, internal obturators, ischio-coccy- geal, and levator ani muscles; it is attached to the posterior part of the pubic joint, to the.upper part of the sciatic notch, and to the sacrum at the inlet, and it is continuous with the iliac fascia. Be- neath this aponeurosis are placed the levator ani and the two ischio- coccygeal muscles. The first has its origin, on either side, from the pubic ramus, the pelvic fascia, the ischial spine, and the less sciatic ligament; its fibres are inserted, first, at the base of the bladder, then in the vaginal walls, and in the coats of the rectum near the anus; the posterior fibres are inserted in a raphe extending from the tip of the coccyx to the anus. The broad muscular band thus ANATOMY OF THE PELVIS. 45 formed makes a diaphragm concave above, convex below, for the pelvic cavity. It raises the anal orifice, and dilates it in defecation. Budin, Progrcs Medical, states that in exceptional cases the muscular fibres of the levator ani in the female may undergo remarkable development, so that its contractions can be readily felt by the finger in the vagina; in some cases making a tightly constricting circle, in other cases an elevation of the posterior wall of the vagina, so that it is drawn toward the anterior wall. In either case certain results may follow, such as difficulty or impossibility of sexual intercourse, and delay in the escape of the foetus. Dickinson [American fournal of Obstetrics, September, 1889) contributes a well-illustrated study of the anatomy and action of the levator ani muscle. By introducing cylinders of modelling wax into the vagina and having the patient voluntarily contract the muscle by straining, he studied the contractions graphi- cally, with the following results : The distance from the vaginal orifice to the inner edge of the levator averages less than half an inch (1.2 cm.). The double band of the muscle is always sharply defined. The more the levator is stretched the closer the strong edges of the horizontal belly are brought together. The con- traction of the muscle crowds the penis against the cervix during coition; the vaginal outlet remains quiet, while the upper portion rises fifteen or twenty degrees toward the brim. A dynamometer test of the strength of the muscle gave an average of ten pounds, occasionally twenty-seven. It is especially strong in mus- cular and erotic women, in those with wide pelves, and in those suffering from painful lesions about the vulva and vagina. He adds two cases of laceration of the pelvic floor which illustrate the efficiency of the muscle in preventing rectocele, and has collected five cases of labor delayed by the spasmodic contraction of this muscle, to which he adds one from his own observation. The ischio-coccygeus is in the same plane as the levator ani, lying between it and the pyriform; it is triangular in shape, the base being attached to the border of the coccyx and of the lower part of the sacrum, and the apex to the ischial spine. The two ischio-coccygeal muscles hinder the backward movement of the coccyx. They, with the anal levators, make the deep muscular layer of the perineal floor, and beneath the plane they form the anal sphincter is placed. This muscle has the form of an ellipse, the long diameter being antero- posterior ; it arises by muscular fibres attached to the last bone of the coccyx and subjacent skin; these then form on each side of the anus a semicircular band, and, converging in front, are inserted in the perineal body. Beneath the sphincter is the skin. The part of the pelvic floor thus described is called the posterior perineal region ; it is triangular in form, the apex of the triangle being at the tip of the coccyx, and its base a line between the ischial tuberosities. The anterior perineal region is included between the line just mentioned and the pubic joint. The pelvic floor is here formed of skin, fasciae, and muscles. The latter are seven, viz., one vaginal sphincter, and two ischio-cavernosi, two transverse perineal, and two ischio-bulbous. The vaginal sphincter arises from the perineal body, surrounds the vaginal orifice, and is inserted upon the body of the clitoris and its suspensory ligament. The ischio- cavernosus has its origin on either side from the ischial tuberosity and from the ischio-pubic ramus, and is inserted by two tendinous expansions, one above and the other below the union of the crura of the clitoris. The transverse perineal muscles arise from the ischial tuberosities below the preceding, and are inserted in the perineal 4^ SCIENCE AND ART OF OBSTETRICS. body. The ischio-bulbous muscle passes from the ischium on each side to the corresponding bulb of the vagina. Three aponeurotic planes are found in the anterior perineal region—the deep, the middle, and the superficial. Between the last two the muscles just described are placed. Perineum.—This part of the pelvic floor is of especial interest to the obstetrician. It is bounded by the anus behind, by the ischial tuberosities on the sides, and by the vulval opening in front. These limits apply to its external surface only. It has also a vaginal and a rectal surface, so that a median section of the perineum would very closely resemble in form a spherical triangle. Fig. 22. Antero-posterior Section of the Aponeuroses of the Perineal Floor.—S. Sacrum. A P. Pelvic aponeurosis. B. Deep perineal aponeurosis. C. Middle perineal aponeurosis. D Super- fic.al perineal aponeurosis. E. Connective tissue layer which covers the lower surface of the levator an. behind the bis-ischiatic line, where it is fused with the posterior border of the deep perineal aponeurosis. F. Pubis. The distance from the anal to the vulval opening is about three centimetres or a little more than an inch, according to Spiegelberg. Foster found that ,n the parous this measurement was rather less b^n ? I 2'7 centimetres, but in the nulliparous somewhat more than an inch. The hypertrophy of pregnancy may increase this measurement to an inch and a half, or four centimetres. In labor the perineum may be so stretched by the presenting part as to mea- £Z r^heS,and auS f' °r f°Urteen centimetres It is generally held that h,s distens.bility depends " upon an irregularly Hmfted mass of elastic ttssue and muscular fasciculi, situated midway be- tween the posterior comrrussure of the vulva and the anus "known since the mvest.gations of Henle and Savage, as the perineal bod^! 1 American Journal of Obstetrics, 1880. ANATOMY OF THE PELVIS. 47 According to Savage,1 the greatly stretched perineal body is the final covering of the presenting part. In very fat women the peri- neum does not yield readily in labor, and hence the liability to its rupture; while in some' other patients it yields too readily, and its anterior margin is prolonged toward the pubic arch, while its cen- tral portion is so thinned that perforation may occur in it. Pubic, and Sacral Segment of the Pelvic Floor.—The pelvic floor, in its relations to labor, is divided by Hart2 into two parts, designated respectively the pubic and the sacral segment. The anterior vaginal wall is the posterior boundary of the former segment, and the poste- rior vaginal wall the anterior boundary of the latter segment. In labor the anterior segment is drawn up, while the sacral segment is forced down ; and thus, as two doors meeting at their free border are opened, the one by drawing it toward the passenger, the other by pushing it from him, so the pelvic floor is opened for the transmis- sion of the foetus. The vagina passes through the pelvic floor parallel to the conju- gate of the inlet. The Dynamic Pelvis.—From the parallelism of the vagina, as it passes through the pelvic floor, with the antero-posterior diameter of the inlet, it necessarily follows that if the presenting pole of the foetus enters the inlet in a line perpendicular to its plane, the emer- gence of that pole from the vagina will be in a line perpendicular to the prolonged previous line. Hence, according to the view of Bois- sard and some others, a curved line does not represent the line of direction taken by the presenting part in passing through the birth- canal, or the dynamic as distinguished from the osseous or static pelvis. Further, as has been shown by Fabbri and Pinard,3 a cast of the entire pelvis—that is of the bony pelvis with the membranous FiG. 23. canal formed at the expense of the soft parts, a membranous canal channelled in all the thickness of the perineal floor, which is greatly developed at the period of expulsion connected with the former- will make it evident that the completed pelvic cavity is not a curved 1 Anatomy of the Female Pelvic Organs. 2 Female Pelvic Anatomy. 3 Boissard: De la forme de 1'Excavation Pelvienne. Paris, 1884. 4^ SCIENCE AND ART OF OBSTETRICS. but chiefly a cylindrical canal. This cavity has its fundus at the coccyx, and the presenting part of the ftetus descends in a straight line to the fundus. The cavity, is there closed, but presents an opening upon the anterior wall, and the line of direction now be- comes one nearly perpendicular to that of descent. More recently Varnier, in a valuable monograph,1 has sought to es- tablish the position that the classic inferior strait of obstetricians does not, in its normal state, have any role in the mechanical phenomena which occur at its level in labor, and that there should be substi- tuted for this osteo-ligamentous strait an inferior muscular strait formed by the pubo-coccygeal fissure of the anal levator. The view of Varnier will be considered in describing the mechanism of labor; there is subjoined one of his illustrations for the purpose of showing that the head escapes from the dynamic pelvis in a line perpen- dicular to the line of descent of the static pelvis, the latter line of course being the axis of the pelvic inlet. Du Detroit Inferior Musculaire du Bassin Obstetrical. Paris, 1888. CHAPTER II. THE FEMALE SEXUAL ORGANS. The female sexual organs are divi those of lactation. The organs of the internal. The External Organs of Gener- ation.—These are included in the word pudendum or pudendum mu- liebre. Vulva1 is often used as a synonym, though this term does not, strictly speaking, include the mons veneris. Mons Veneris.—This is the upper part of the pudendum, and is bounded above by the hypogas- trium, by the groin on either side, and by the greater lips below. It measures three inches from side to side, and two inches from above down—j.6 by 5 cm. A very large number of hair follicles and seba- •ceous glands are found in the skin covering the mons. The growth of hair occurs at puberty, and hence the name for the bony part upon which the mons is placed. Beneath the skin there is a thick layer of connective and adipose tissue, which is traversed by fibres of elastic tissue passing in various directions. Some of these fibres are connected with the superficial abdominal fascia. Muscular fibres from the round ligament also enter this organ. labia Majora. — The greater lips, or alae,2 are two folds of skin passing from the median line and just below the mons veneris on ded into those of generation and generation are the external and Fig. 24. Vulva of the Virgin.—i. Greater lip of right side. 2. Fourchette. 3. Small lip. 4. Clitoris. 5. Urethral orifice. 6. Vestibule. 7. Orifice of the vagina. 8. Hymen. 9. Orifice of the vulvo-vaginal gland. 10. An- terior commissure of greater lips. 11. Anal orifice. 1 Vulva is from the word volvo, and was originally spelled volva ; it meant the womb, or covering of the unborn animal. Vulva has no connection with valva, though the latter is derived from the same root. 2 Winslow, in his Anatomy, says: " The ancients called the lateral parts of the cavity ales, which is a more proper name than that of labia commonly given them." 4. 50 SCIENCE AND ART OF OBSTETRICS. each side of the vulval entrance to meet in the middle and anterior part of the perineum. Their junction above is about half an inch, or one centimetre and a half above the clitoris, and is the anterior commissure. Their juncture below, or posterior commissure, is simply a fold of cutaneous tissue, marking the anterior margin of the perineum, and is called the fourchette. The depression between the fourchette and the hymen is called the navicular fossa. The external surfaces of the labia majora are convex, and somewhat darker than the adjacent skin. They have an abundant supply of hair- follicles and of sebaceous and sudoriparous glands. The growth of hair, which, like that of the mons veneris, occurs at puberty, is remarkable at the upper part, but lessens as the labia descend to the perineum. The internal surfaces of these organs are plane, some- what pink or rose-colored, and in children, in virgins, and in the fleshy are in direct contact; but in those who have borne many children, in the old, and in the emaciated, are separate, flabby, and relaxed, seeming like folds of dark and wrinkled skin, and expose the vulval entrance. The anterior borders are round and prominent, but become flattened and less distinct as they approach the posterior commissure. The posterior borders are attached to the ischio- pubic rami. Beneath the skin of the external surfaces and anterior borders of the labia there are found smooth muscular fibres forming that which Sappey has described as the dartos of the female, which is analogous to the dartos of the male. Each labium contains, according to Broca, a pyriform pouch, formed of elastic fibres, its large extremity being toward the posterior commissure, while its small end is directed to the inguinal canal. Sappey has described it as the elastic apparatus of the labia. The round ligament of the uterus, the analogue of the gubernaculum of Hunter, terminates in the labium majus. In some cases a prolongation of the peritoneum, forming the canal of Nuck, which is normally closed before birth, accompanies the ligament, and an accumulation of fluid in this canal may occur analogous to hydrocele of the cord, and frequently described as hydrocele of women. Connective and adipose tissue, bloodvessels, lymphatics, and nerves complete the structure of the labia. The superior commissure of the labia forms an arch over the clitoris, and partially covers and protects this organ. Labia Minora.—Two folds of skin are found at the inner surface of each labium majus, beginning about the middle of the base of each, greater lip, and are called the lesser lips, or nymphae. They extend above nearly to the clitoris, then each bifurcates; the lower divisions meet below the clitoris, but the upper, which are the larger, unite above this organ, forming the hood or praeputium clitoridis! The nymphae are rose-colored, and are without hair-bulbs, sudorip- arous glands, or muscular fibres. A layer of connective tissue, con- taining numerous elastic fibres and bloodvessels, unites the folds of skin of each nympha. The labia minora are remarkable for their sensitiveness and for their rich supply of sebaceous follicles. There are, according to Sappey, one hundred of these glands to every square centimetre of the external surface, and one hundred and twenty to one hundred and fifty to every square centimetre of the THE FEMALE SEXUAL ORGANS. 51 internal surface. While remarkably sensitive, and thus concerned in copulation, the nymphae are not erectile organs. In parturition they contribute to the enlargement of the vulvar orifice. The size of these organs is different at different ages. At birth they are quite prominent, because of the little development of the labia majora; at puberty the notable growth of the latter causes them to be hidden, though they also increase in size at that time, unfolding, according to the comparison of the Swedish botanist, Linnaeus, like the petals of a flower. They may be elongated by traction, and thus lengthened and hypertrophied, measuring some five inches, 12.6 centimetres, or more, form what has been called the apron of the Hottentots. If projecting beyond the labia majora they become brownish—in negresses, for example, they are then as dark as the skin. They were supposed to direct the flow of the urine, and hence received the name nymphae. Among some of the Orientals the nymphae are quite large, hindering the en- trance of the penis, and their partial excision was the circumcision of females. Cuvier states that in the sixteenth century missionaries in Abyssinia persuaded their converts to abandon the custom, but as girls could no longer find husbands the Pope authorized a return to it. The Clitoris)—Two crura, or branches—one attached to each ischio-pubic ramus—ascend, and converging meet in front of the pubic joint to form the body of the clitoris, this body consisting of two corpora cavernosa, analogous to the corpora cavernosa of the penis. It is fastened to the anterior and inferior part of the pubic joint by a suspensory ligament. Sappey asserts that from its con- nection with the pubic symphysis and with the nymphae change in its position or in its curvature is impossible. Its anterior portion, small and rounded, covered by the prepuce above and on each side, below by the inferior layers of the dividing nymphae, is improperly called the glans—it has no orifice, no glandular structure. The dimensions of the clitoris vary in different subjects, but according to de Sinety the average length is about three centimetres, or a little more than an inch. The mucous membrane2 of the clitoris, especi- ally that which covers the glans, is very rich in nervous papillae, containing corpuscles of Krause and Pacini. In the first three months of intra-uterine life the clitoris is rela- tively so large that a mistake in the sex of the product of abortion is liable to be made. So too, hypertrophy of this organ in children and in adults explains some of the cases of supposed hermaph- rodism. The clitoris is the analogue of the penis; it is an organ concerned in copulation, but to regard it as the chief or exclusive seat of sexual passion is an error.8 It has been asserted that the clitoris is hyper- 1 Three derivations of clitoris have been given: First, from kAeicj, to shut up, because con- cealed by the labia: second, from nXeiddu, to lock, the vulva being closed, and the clitoris sup- posed to point to the keyhole, and from Kkqrup, Doric, Klehop, one who invites, here the clitoris quce invitat ad coitum. 2 De Sinety. 3 The anatomist Colombus called this organ veneris amor et dulcedo. A recent obstetric author, Saboia, seems to adopt the same view, for he says that the clitoris is the chief organ of voluptuous feeling in the female. 5^ SCIENCE AND ART OF OBSTETRICS. trophied by masturbation; but this is no more true than that males have hypertrophy of the penis from the same cause.1 The Vestibule.—The nymphae, diverging as they descend from the clitoris, make the sides of a triangle, the base being the intervening margin of the vagina, and to the space thus included the name of vestibule is given: the triangle is equilateral, each side measuring about one inch, 2.5 centimetres. Just above the middle of the base of the triangle the orifice of the urethra, meatus urinarius, is found ; this orifice is circular, and often presents an irregular, elevated, and rather firm margin, so that it may be thus recognized by the finger gently pressing upon it; there may also often be felt at the lower margin of the orifice a projection known as the urethro-vaginal tubercle. Introduction of the Catheter.—A flexible rubber catheter is usually preferred when artificial evacuation of the bladder is necessary; the beak of the instrument and the forefinger having been oiled, the latter is introduced into the vagina and its palmar surface placed upon the lower part of the anterior vaginal wall in the median line; the catheter is now passed along the upper surface of the finger until it touches the margin of the vagina, and then a slight elevation of the point of the instrument brings it in the mouth of the urethra. Another method of introducing the catheter, though in some cases very objectionable because of the great sensitiveness of the clitoris, is to pass the finger from above, separating the nymphae,down the middle line of the vestibule about four-fifths of an inch, when the surface, hitherto smooth, becomes irregular, uneven, and the orifice of the urethra being recognized, the catheter is readily passed. When coition occurs in girls before the development of the sexual organs, it is not uncommon to find the urinary meatus hidden under the pubic arch, a partial inversion of the vulva having been pro- duced; and a similar displacement of the meatus is sometimes found in posterior displacement of the gravid uterus. On the other hand, a reverse displacement of the meatus may be observed after a severe labor, and consequent great swelling of the parts—the meatus is then further from the vaginal entrance, and lies somewhat obliquely with reference to the normal position of the plane of the vestibule: very rarely, however, is exposure necessary for catheterization. Hymen'; and Carunculce''' Myrtiformes—According to Budin,4 the 1 Winckel. 2 From 'vflfjV< a membrane. 3 Not given this name from their resemblance to myrtle berries, as commonly taught but from their resemblance to myrtle leaves, as observed by Winslow. ' * Budin's statement is upheld by Dr. Gustave Imbert in a monograph upon the development of the uterus and vagina. Dr. Imbert says, referring to the hymen: In view of its structure some admit that this membrane is formed by a fold of the mucous membrane of the vagina- others that it results from the vulval and vaginal mucous membrane being placed against each other. Properly speaking, the hymen is nothing but the anterior extremity of the vagina covered externally by the vulval mucous membrane ; this is proved not only by histological examination but by a dissection which shows the prolongation of the columns and ridges of the vaginal mucous membrane upon its internal face, and up to the orifice of the hymen. When the vagina is isolated from connected parts, it appears as a canal ending in front by a perforated hemi spherical part. Developpement de 1'Uterus et du Vagina, Paris, 1883. Dohrn states Zeitschrift fur Geburtshulfe und Gynakologie, 1885, that the development of the hymen is closely connected with the increase in the length of the vagina, and that in proportion to this increase an excess THE FEMALE SEXUAL ORGANS. 53 hymen as a distinct membrane does not exist; it is simply the lower end of the vagina, perforated like the extremity of the finger of a glove; or, it may be compared to the partially inverted and narrow fringed margin of a pantalette. But this view has not met general acceptance, and the following is probably the true explanation of the origin of the hymen:l About the nineteenth week of intra- uterine life, the first trace of the hymen appears as a slight projection on the posterior wall of the vagina, just above the point where the vagina unites with the uro-genital sinus. A smaller projection then appears upon the anterior vaginal wall, but somewhat higher. The two soon unite at the sides. Papillae are found upon the internal surface of the hymen, but its external surface is smooth, like the vestibule. It is composed of fibrillated stroma of connective tissue, has arteries and veins, and is rich in elastic fibres; muscular tissue is found in it, and the presence of nerves is proved by its exquisite sensitiveness in some cases. Winckel thinks its purpose is to prevent the entrance of amniotic fluid into the genital canal during labor-pains. In some cases the hymen presents a crescent form, and apparently occupies only the lower portion of the vaginal entrance; again, it may be a membrane with a single central opening, or with several small perforations like a colander, or, finally, it may completely close the vagina, rendering discharge of the menstrual fluid or entrance of the penis impossible. Rupture of the hymen usually occurs at the first sexual intercourse, but it may result from other causes, though it is impossible, as some have alleged, from any change of position of the lower limbs. If the vagina be large and greatly relaxed, the hymen may retain its integrity after repeated congress; occasionally it has been found an obstacle to childbirth, and its incision been necessary. Only a few drops of blood usually follow its rupture, but in some instances a severe hemorrhage has been thus caused. The myrtiform caruncles, or hymenal tubercles, as Dubois termed them, are small fleshy tubercles, two to five in number, found after complete rupture of the hymen, at the part of the vagina formerly occupied by its circumference. They are not seen, according to Schroder and Budin, until after labor, which converts the vagina and vulva into a common passage. They differ in size in different subjects, being so small in some as to be hardly visible, while in others they are relatively quite large. Vulvar Canal and Navicular Fossa.—The vulvar orifice is usually closed by approximation of the labia majora, but upon separating them a space is seen, shallow above at the vestibule, much deeper below at the posterior commissure, having somewhat the shape of a funnel, the smallest part being at the vaginal entrance; this is the vulvar canal. of tissue is produced which takes the form of a fold projecting over the vaginal entrance; as the posterior wall of the vagina exceeds in growth the anterior, the first beginning of the hymen is seen upon the former, and here it has a broader base, while the hymenal opening is nearer the anterior vaginal wall. 1 Winckel. 54 SCIENCE AND ART OF OBSTETRICS. So, too, upon separating the labia there is distinctly seen in the nullipara, not, however, so apparent in the parous, a depressed sur- face extending from the fourchette to the hymen, or to the myrti- form caruncles; this depression has been given, from a fancied resemblance to a boat, the name of navicular fossa. Vulvar Glands.—The glandular supply of the mons and of the greater and less lips has been stated ; the richness of the nymphae in sebaceous glands not only keeps these parts soft and pliable, but also guards them against injury from the contact of urinary and of utero-vaginal discharges. But in addition to the glands previously mentioned, there are other vulvar glands to be noticed. Huguier has described four groups of muciparous follicles—though dis- credited by Sappey—vestibular, urethral, latero-urethral, and latero- vaginal. Skene,1 in 1880, gave a description of two glands situated just within the meatus upon each side, near the floor of the urethra; these glands are from three-eighths to three-quarters of an inch in length. The vulvo-vaginal glands—also known as the glands of Bartholin, and of Duverney—are in the female the analogues of Cowper's glands in the male. They are situated at the sides and posterior part of the vaginal entrance, about two-fifths of an inch, or one cen- timetre above the anterior face of the hymen or of the hymenal tubercles, and just below the bulb on each side. They vary in size, in some cases as small as a pea, in others as large as a hazel-nut; their usual form is that of a flattened ovoid. They are composed of lobes, lubules, and acini; from the acini canaliculi pass, which, lessening in number and increasing in size in their further progress, finally open in a single efferent duct. A covering of fibrous and connective tissue, sending prolongations between the lobes and lobules, invests each gland. These glands are lined with a cup-shaped epithelium closely resembling that of the glands of the cervical canal, and hence the similarity of the secretion, which is a tenacious, usually colorless fluid, that lubricates the vulvar orifice, and thus facilitates coition. In some females the secretion is discharged in a jet, and this fact led to the long since rejected belief that woman as well as man furnished semen in coition, and the new being was the product of the united dis- charges. Bloodvessels, Lymphatics, and Nerves of the External Sexual Organs. —The arterial supply of these organs is by branches from the ex- ternal and internal pudics, and the epigastrics. The return of blood is chiefly through the external pudic veins. The lymphatic vessels communicate with the inguinal ganglia.2 The nerves are from the external pudic nerve, and from the genito-crural and abdominal branches of the lumbar plexus. 1 American Journal of Obstetrics. 2 " It ought not to be forgotten that the superficial lymphatics of the groin have a double communication with those of the iliac fossa by vessels which pass through the cribriform fascia to reach the deep lymphatics, and by the ganglion which generally occupies the orifice of the inguino-crural canal."—Siredey. THE FEMALE SEXUAL ORGANS. 55 I he Internal Organs of Generation.—The internal organs of gen- eration are the vagina, the uterus, the ovaries, and the oviducts. The Vagina}—The vagina is usually described as a musculo-mem- branous canal extending from the vulva to the uterus. From its continuity with the vulva it is an organ of copulation ; and from its connection with the uterus it is an excretory canal for uterine secre- tions and the monthly flow, and through it as part of the birth canal the foetus with its appendages passes. It is placed behind the urethra and the bladder, and in front of the rectum; it passes from the uterus obliquely from above downward, and from behind forward. It forms an obtuse angle with the uterus when the bladder is full, but if the latter be empty, a right angle. Its posterior wall is about four inches, or ten centimetres in length, while its anterior wall is a little more than three inches, or eight centimetres. But these are only approximate measurements, for the length of the vaginal canal varies in different subjects, and at different ages; it has been stated that in the negress this canal is longer than in the white woman; it is rela- tively longer in the newborn than in the adult,2 the proportion to the length of the body being in the former one to nine, while in the latter it is one to fifteen. When the organ is at rest the anterior rests upon the posterior wall, the two being in immediate contact, so that a section would represent a transverse slit, rather than a cavity. Nevertheless it is usual to refer to the vaginal diameters. The calibre of the vagina is least at the vulva, and gradually increases as the organ ascends to the uterus, so that were the vaginal walls held apart it would represent not a hollow cylinder, but a hollow truncated cone, the base of the cone being above; the mean antero-posterior and trans- verse measurements are in the nulliparous from rather more than an inch to an inch and a half, three to four centimetres ; in the parous two inches and a quarter to two inches and a half, or about six to seven centimetres. But in labor, the vagina is so greatly stretched that these diameters become nearly equal to those of the pelvis. The anterior wall of the vagina is in relation with the urethra the bas-fond of the bladder, and with the ureters. The connection be- tween the vagina and the urethra, especially at the inferior portion of the latter, is very intimate, and interchange of fibres takes place; that between the vagina and bladder is of looser connective tissue, in which numerous blood- and lymph-vessels are found. Pos- teriorly the vagina is in relation with the peritoneum3 nearly four- fifths of an inch, or somewhat less than two centimetres; the descent of the peritoneum from the posterior wall of the uterus to be reflected over the anterior wall of the rectum forming a pouch variously known as Douglas's, the recto-uterine cul-de-sac, and retro-uterine cul-de-sac. The subperitoneal tissue is here quite thin. 1 Vagina means a sheath. The old anatomists called the vagina the cervix, and the ostium uteri ; even Dionis and Mauriceau described it as the neck of the womb. 2 Huschke. 3 According to Bayer (Morphologie der Gebarmutter) the peritoneum may pass from the uterus at the same height upon the posterior as upon the anterior wall, and in such case of course the above statement would not be correct. 56 SCIENCE AND ART OF OBSTETRICS. Below the cul-de-sac the vagina is in relation with the rectum, but the connective tissue uniting the two above is quite loose, so that intra-peritoneal effusions may cause great descent of the peritoneal pouch. From the curving forward of the vagina below, and curv- ing backward of the rectum, these organs are there placed further apart, so that a section of the recto-vaginal wall, made antero-pos- teriorly, would have the form of a triangle, its base extending from the anus to the vulva, and its apex being immediately below the cul-de-sac. Laterally the vagina is in relation with the vaginal bulbs and sphincter, connective and fatty tissue, the anal levator, the lowest portion of the broad ligaments, and the pelvic aponeurosis. At its upper end the vagina is continuous with the uterus by means of muscular fibres common to the two organs, and by mucous membrane continuous from one to the other. This connec- tion is made at the junction of the lower with the middle third of the uterine neck, a little higher behind than in front, and the neck is thus divided in two parts, one intra-vaginal, and the other supra- vaginal ; the former is by some called the port 10 vaginalis or vaginal portion. In consequence of the vaginal walls arching over to unite with the uterus a dome or vault, sometimes called the vaginal fornix, is formed; this vault is divided into two lateral culs-de-sac, distin- guished as right and left, and one anterior and one posterior; the last is the deepest. The vaginal is continuous with the vulvar canal below : as the union between the two is made at the narrowest part of each, a strait is formed which is in some cases the cause of serious delay in childbirth. The anterior and posterior walls of the vagina pre- sent transverse elevations, those on the former being more promi- nect than those on the latter. These elevations, sometimes impro- perly called ruga} are more distinct at the entrance of the vagina, and gradually lessen until they disappear a little above the middle of the canal; those on the posterior wall in many cases ascend higher than those on the anterior wall. Labor temporarily effaces them, and after it, though gradually reforming, they are never as distinct as in the nulliparous. Two longitudinal elevations are formed at the junction of the transverse ridges in the median line, one on the anterior, the other on the posterior vaginal wall, that on the former being the more prominent, which are called the vaginal columns, and also the columna rugarum. Neither the columns nor the rugae are directly opposite, and thus a more complete apposition of the walls is secured. At the lowest portion of the anterior column, a projection is observed, tuberculum vagina ; this is important as a guide to the urethral opening, which is just above the tubercle. The walls of the vagina are from one-eighth to one-sixth of an inch, three to four millimetres, in thickness. They are composed 1 " These projections have been regarded as simply folds of the mucous membrane which are effaced in coition, and especially in labor. But they are not at all similar to folds Thev are prolongations, elevated above the walls of the canal .... and do not contribute t enlargement of the vaginal cavity, but to coition."—Sappey. THE FEMALE SEXUAL ORGANS. 57 of three coats or layers, the external fibrous, the middle muscular, which makes two-thirds of the thickness of the wall, and the inter- FiG. 25.1 Situation and Relations of the Uterus.—1. Body of the uterus. 2. Cavity. 3. Neck. 4. Cavity of the neck. 5. Intra vaginal part of the neck. 6. Vagina. 7. Vaginal orifice. 8. Bladder. 9. Urethra. 10. Vesico-vaginal wall. ir. Rectum. 12, 12. Rectal cavity. 13 Anus. 14. Recto vaginal wall. 15. Perineum. 16. Vesico-uterine cul-de-sac. 17. Utero- rectal cul-de-sac. 18. Pubic symphysis. 19. Small lip. 20. Great lip. nal mucous. The first is formed of connective tissue and elastic fibres; it contains large bloodvessel branches and nerve-tracts. It 1 In taking this plate from Sappey, some slight changes have been made so as to represent the vaginal walls nearer together. Nor does the illustration accurately represent the normal form and position of the uterus; these are correctly shown in in Figs. 41 and 42, from Schultze, the bladder being empty. There is a physiological anteflexion of the organ, not represented in the illustration ; moreover, according to Hart and Barbour, the anterior surface of the uterus rests upon the bladder, if the latter be full the uterus is retroposed. Van der Warker, as one of the conclusions of his study upon the Normal Position and Movements of the Unimpregnated Uterus, American Journal of Obstetrics, vol. xi., correctly states that the anatomical idea of coincidence between the uterine and the pelvic axes, main- tained with more or less relative exactness, is obsolete. 58 SCIENCE AND ART OF OBSTETRICS. is in relation externally with the organs which encircle the vagina, and internally with the middle coat. The arrangement of the mus- cular fibres composing the middle coat is given differently by differ- ent authors. According to Henle, the external layer is circular, and the internal longitudinal, while Luschka gives a reverse dispo- sition of these fibres, the longitudinal being external, the internal circular, and between the two oblique fibres are found. Tarnier describes the muscular fibres as inserted below in the ischio-pubic rami, and continued above with the middle of the three muscular layers of the uterus, some extend into the utero-sacral ligaments, and others cross each other in- all directions, leaving spaces occupied by venous enlargements. The mucous membrane is pale red ordinarily, but during men- struation, and especially in pregnancy, becomes violet-colored. Very numerous microscopic papillae supplied with bloodvessels are found in the lower part of the vagina, but are scanty in the upper part. While it is commonly stated that the vaginal mucous mem- brane is covered with pavement epithelium, according to v. Preu- schen the lowest layer shows cylindrical epithe- lium. By Sappey and most other anatomists T'"\ '""r'ft'- the presence of glands in the mucous mem- h-< sfi^©*'•'' brane of the vagina is denied, but the investi- •V© \ {$'&. gations of v. Preuschen, confirmed by those of Ruge, seem to prove their existence. They are not abundant, and are similar in form to the sebaceous follicles of the vulva; in the su- Section of the .Mucous r • i ..• r a j ... ... ,. . perficial portion of the sinuous ducts pavement Membrane of the Vagina; r . . ,. r , ". showing cylindrical cells. epithelium is present, but deeper, as in a sec- tion of the mucous membrane of the vagina, cylindrical epithelium is found, while in the remaining part of the gland both pavement and ciliated cylindrical epithelium occur. Jressels and Nerves of the Vagina.—The arterial supply is chiefly through the vaginal—derived from the anterior branch of the inter- nal iliac—and from branches from the uterine, inferior vesical, and internal pudic. The veins, which are many and large, empty into the venous plexuses, situated at the sides of the vagina. The lym- phatics of the lower fourth of the vagina, uniting with those of the vulva, communicate with the ganglia of the groin, while those of the remaining three-fourths enter the lateral pelvic ganglia. The nerves are derived from the hypogastric plexus. The Bulbs of the Vagina.—These are two erectile organs placed upon the anterior and lateral parts of the vagina; they are below and within the pubic rami, their internal concave surface embracing the vaginal orifice, their external convex surface being covered by the bulbo-cavernosus muscle. Above, the bulbs are united by veins and muscular fibres; the anterior borders have veins communicating with the veins of the nymphae and of the clitoris. A bulb has been compared by Kobelt to a leech gorged with blood. According to Savage, a single bulb when filled with blood is an inch and a half THE FEMALE SEXUAL ORGANS. 59 long, and half an inch thick; while the measurements given by Sappey, and by Tarnier and Chantreuil, and by Charpentier are: Fig. 27. Arteries and Veins of Vagina and Uterus (Savage).—B. Bladder cut at urachus and turned forward. R. Rectum. L. Round ligament. U. Uterus. O. Ovary. V. Vagina. S. Sacro- iliac articulation. K. Kidney. F. Fallopian tube. P. Pubic symphysis, a. Pyriformis mus- cles, b. Gluteal muscles, c. Ischio-coccygeus muscle, d. Internal obturator muscle, e. e. Psoas muscle, f. linea alba, g, g. Ureters, h. Obturator nerve, i. Internal inguinal ring. 1. Abdominal aorta. 2. Inferior mesenteric artery. 3, 3. Common iliac arteries. 4. External iliac artery. 5. Vena cava. 6. Renal veins. 7, 7. Common iliac veins. 8. External iliac vein. 9. Internal iliac artery. 10. Gluteal. 11. Ileo lumbar. 12 Sciatic. 13. Pudic. 14. Obturator. 15. Epigastric veins. 17. Uterine veins. 18. Vagino-vesical venous rete. 19. Spermatic veins. 20. Bulb of ovary. 21. Vein to round ligament. 22. Fallopian veins. 6o SCIENCE AND ART OF OBSTETRICS. length, one inch and one-tenth—thirty-five millimetres; breadth, half an inch—fifteen millimetres ; thickness, three- to four-tenths of an inch, or ten to twelve millimetres. Fig. 28. Bulbs of the Vagina.—A. Clitoris. B. Bulbs. C, D. Right and left halves of the vaginal constrictor. The Uterus.—Womb,1 matrix, from the Latin mater, Greek rfrrtp, fii/rpa, German, Mutter and Gebiirmutter. The Greek h>,t>,i>, the Latin mater, the Sanscrit matri, and German Mutter show a striking analogy with the word " mut," which, according to the famous Egyptologist, Professor Ebers, was used in ancient Egypt as the name of the womb. The uterus is the organ in which the impreg- nated ovule is developed, and by which the foetus and its append- ages are expelled from the mother's body when the development is complete; it is, therefore, the organ of gestation, and the organ of parturition. It is situated in the pelvic cavity with its fundus usually just below the plane of the inlet; it is behind the bladder and in front of the rectum, while at its sides are the broad ligaments which pass from it to be attached to the lateral walls of the pelvis. The uterus has been by some described as pear-shaped, and by others as resembling a gourd; that portion which lies above the reflection of the peritoneum over the posterior wall of the bladder presents somewhat the form of an inverted truncated cone, while that which is below is cylindrical. A slight depression or constriction upon its external surface, more distinct in the virgin than in the parous 1 The word womb was not at first employed to designate this organ of the female, but was used for the belly or abdomen. Thus in Wiclif s translation of the Bible, 1380, in the parable of the Prodigal Son, the translator states the fact that the prodigal would fain have filled his belly with the husks which the swine did eat, as he would have filled " his wombe," etc. In the same century Chaucer wrote his famous poems ; and in the Squire's Tale, Canterbury Tales, the fol- lowing passage is found : " He kissed her, and clipped her full oft, And on her womb he stroked her full soft," etc. The word "clipped" is embraced. These quotations show how far astray those lexicogra- phers are who have derived the word woman from womb-man. THE FEMALE SEXUAL ORGANS. 6l uterus—more distinct, too, anteriorly than posteriorly—known as the isthmus, marks the separation just mentioned ; all that part of the organ above the isthmus is called the body, or corpus, while that below is the neck, or cervix. If a line be drawn from the uterine end of one oviduct to that of the other, the portion of the body or Fig. 29. Internal Genital Organs.—C. Anterior part of the neck of the uterus. L. Broad ligament of left side. L'. Part of broad ligament of right side. M. Ligament of right ovary. O. Left ovary. O'. Right ovary. P. Pavilion of left oviduct. P'. Pavilion of right oviduct. R. Round ligament of left side. R'. Round ligament of right side. T. Left oviduct. T'. Right oviduct. U. Body of uterus seen from anterior face. V. Vagina opened from above below. V. Middle column of posterior vaginal wall. corpus above this line is known as the fundus. In infancy and in childhood the uterus is small, but it is remarkably developed at puberty ; it is atrophied after the menopause ; it is temporarily in- creased in size, one-half or more, during menstruation ; it is larger in the parous than in the nulliparous, larger, too, in the married than in the virgin. The virgin uterus is about two inches and a half, or seven centimetres in length, its greatest lateral measurement is about one inch and a half, or four centimetres, and its antero-poste- rior measurement is nearly one inch, or two and five-tenths centi- metres. Its weight in the nullipara is from eight to ten drachms, or thirty- 62 SCIENCE AND ART OF OBSTETRICS. two to forty-two grammes. The weight of the parous uterus is from one-fourth to one-third greater. The anterior face of the uterus is triangular, slightly convex; the posterior face, which is also triangular, is decidedly convex ; its superior border is convex from before back, nearly straight from side to side in the nulliparous, but convex in the parous uterus; the sides curve somewhat inward from above down, and are convex from before back. The angles of the uterus mark the union of the superior border with the lateral borders; they also correspond with the attachment of the oviducts. The lower end of the body of the uterus is continuous with the upper end of the neck, the isthmus marking the place at which one passes into the other. The relative proportions of the body and the neck differ in the child from those in the adult; so, too, this relation differs in the nulliparous and in the parous. In the child at birth, and for the first following years, the neck is three-fifths of the entire organ, but in the nulliparous only a little less than half; in the parous the body is three-fifths to two-thirds the entire uterus. The cervix in the virgin has nearly the form of a cylinder; it is, however, somewhat enlarged in the middle like a barrel, and flat- tened from before back so that the antero-posterior diameter is a little less than the transverse. It is commonly stated that the upper third of the anterior surface of the cervix is covered by peritoneum, while the middle third is attached to the bladder; the investigations of Bayer, however, show that the peritoneum is usually reflected from the anterior wall of the uterus at a point corresponding with the internal os uteri, and, therefore, this membrane does not cover any portion of the cervix anteriorly. The vaginal portion of the neck—its lower third—in the virgin is smooth ; as it descends it lessens in size, and is rounded at its lowest part; in the middle of this rounded part an opening, the os uteri, is found having usually the form of a short transverse slit, which becomes circular when mucus or blood is expelled; to the finger it feels like a simple depression. In the normal form of the virgin cervix any division of the tissue surrounding the mouth of the womb into an anterior and a posterior lip is purely arbitrary, in most cases nothing can be seen or felt but a uniform unbroken border; the distinction of anterior and posterior lip is almost invariably the result of a traumatism in labor, and the traumatism is usually physiological not pathological. In quite rare cases, however, labor may occur without any tears of the os, so that the latter retains its virgin character. So too, in some cases in which the fashionable operation for laceration of the cervix has been done, the skill of the operator may have perfectly restored the original form of the os. Hence an obstetrician, finding an os with the virgin form, in consequence of no tear' having occurred at childbirth, or because perfect restoration has been made by an operation, may erroneously conclude that the subject has never borne a child. The cervix in the parous is not conical as in the virgin, but often club-shaped, the mouth larger and fissures can be seen and felt, the most distinct usually being transverse; that upon THE FEMALE SEXUAL ORGANS. 63 the left side is more invariable and generally more distinct, and its greater depth and more uniform presence are explained by the greater frequency of left occipito-anterior positions. Childbearing also shortens the neck of the womb, and in a woman who has had many children the vaginal portion of the neck may be so lessened as scarcely to project in the vagina. The cavity of the uterus is divided into that of the body and that of the neck, the dividing line being a narrowed part corresponding internally with the isthmus externally ; this internal narrowed part is known as the os uteri internum, the internal mouth of the womb. The Cavity of the Body of the Uterus.—The cavity of the body of the uterus is triangular, the angles being at the entrance of the ovi- duct on each side, and at the internal os uteri. ■ The sides of this triangle are convex, the curve being toward the centre of the cavity in the nulliparous; the sides are straight, or even curved somewhat outward in the parous. The anterior, and posterior walls are in contact, or else separated by only a thin layer of mucus. The capacity of the uterine cavity in the nulliparous is from 2 to 3 cubic centimetres, or 32 to 49 minims; in the parous 3 to 5 cubic centi- metres, or 49 minims to 1 drachm, 21 minims. The Cavity of the Neck.—The cavity of the neck is fusiform ; but this character is less distinct in the parous than in the virgin. The Fig. 30. Fig. 31. Fig. 29. Transverse Section of a Nulliparous Uterus. Fig. 30. Transverse Section of a Multiparous Uterus.—A. Cavity of the neck and arbor vitae. C. Cavity of the body. O. Isthmus separating body and neck. £. Uterine tissue. anterior and posterior walls have each a longitudinal projection, the two projections not, however, directly opposite; from each of these as a central axis similar projections, plica palmatce, pass obliquely on either side : each axis with its branches forms an arbor vitce— arbor uteri vivificans was the name given it by the old anatomists. 64 SCIENCE AND ART OF OBSTETRICS. In addition to the median ridges or columns, there is one on each side at the junction of the anterior and posterior walls. The Structure of the Uterus.—The walls of the uterus are composed of an external serous, an internal mucous, and a middle muscular coat. The thickness of the uterine parietes varies at different parts from four-thirteenths to seven-thirteenths of an inch, eight to fifteen millimetres; the wall is thinnest at the entrance of the oviducts, thickest at the sides. The Peritoneal Coat.— All the uterus is covered with peritoneum except its borders, that part which is within the vagina, that is the vaginal portion, the part connected with the bladder, and that to which the vagina is attached. The union is so intimate upon the anterior and upon the posterior face of the uterus, that even a small part of the serous cannot be removed without taking away also a thin layer of muscular tissue. The peritoneum is reflected from the Internal Muscular Layer.—a. Section of uterine wall. b. Triangular bundle, c. Fibres returning to the tubes. e, e. Transverse fibres, v. Vagina. uterus in front over the bladder, and in this reflection the vesico- uterine cul-de-sac is formed ; its reflection posteriorly over the rec- tum forms the retro-uterine cul-de-sac, the lowest portion of the peritoneal cavity ; laterally the anterior and posterior layers of the peritoneum which include the uterus meet to form the broad liga- ments. In some cases the posterior peritoneal reflection begins upon that part of the posterior surface of the cervix which corresponds with the internal os ; in most, however, the peritoneum descends so as to be in relation for a short distance with the upper posterior vaginal wall, and then is reflected over the rectum. External Muscular Layer of Posterior Wall of Uterus. THE FEMALE SEXUAL ORGANS. 65 The Muscular Coat.—This is the most important of the three, and makes almost the entire thickness of the uterine wall; the uterus is in fact a hollow muscle. The muscular tissue of the non-preg- nant uterus is firm, resisting, has a grayish, or reddish-gray color, and when cut creaks like firm fibrous tissue. But this organ in pregnancy shows marked changes in its muscular substance. The tissue is now softened, very vascular and red; in consequence of both hypertrophy and hyperplasia its muscular character has be- come quite distinct. Most authors describe the muscular wall of the uterus as com- posed of three layers, one external, a middle, and an internal. The usual description will be briefly given first, and then some results of recent studies of this wall will be presented. The external layer is formed by alternate planes of transverse and longitudinal fibres. On the posterior wall transverse bundles are found beginning at each side at the level of the isthmus; running across toward the median line, they then turn abruptly to become longitudinal; fresh accessions to the latter come from the inflection of other fibres from either side in the ascent from the isthmus toward the fundus. The median portion of the bundles of longitudinal fibres pass over the fundus, but the fasciculi cross each other, those from the left passing to the right, and similarly the right passing to the left, to descend upon the anterior wall; the lateral bundles pass off to the broad ligaments and to the oviducts. The deep or internal layer is chiefly formed of orbicular fasciculi, having the openings of the tubes as centres, and arranged in con- centric circles. At the level of the isthmus more or less complete rings are found, making a sphincter. There also enter into the for- mation of this coat two triangular fasciculi, one on the anterior, the other on the posterior wall; the base of each triangle is at the fundus, and its apex at the isthmus; these fasciculi begin in trans- verse fibres below, and end in transverse fibres above, so that the general course of the twice-inflected fasciculi is represented by the letter Z; but the course of the fasciculi upon the anterior wall is the reverse of that of those upon the posterior wall, that is, it would be represented by an inverted Z. The middle layer, found only in the body of the uterus, is as thick as the two others united. Tarnier gives the following description : It is composed of bands of variable size which cross each other in every direction; some are transverse, others oblique, some longitu- dinal; large apertures, traversed by veins and sinuses, separate these bands from each other, or separate the fibres of the same band. Muscular fasciculi are curved around the uterine veins (the arciform fibres of William Hunter, 1772; fibres in anse of Calza, 1807), and each curve crossed by another forms with it a complete ring which encircles the vein. A series of these rings makes a canal for the vein. Large rings, similar in their formation to the preceding, encircle several veins at a time, and each of the latter in the chief ring also has its own ring. Most frequently the curved fasciculus 5 66 SCIENCE AND ART OF OBSTETRICS. forms only one-half or two-thirds of the circle, which another fas- ciculus completes by crossing the first, with which it is intimately united. Each venous vessel is thus surrounded by contractile annular fibres, and passes in a true contractile canal in all its course through the middle layer. The muscular tissue of the neck is derived solely from the exter- nal and from the internal layers. Its superficial muscular plane is formed exclusively of transverse fibres, the fasciculi crossing each other at the median line according to Schwartz; but Tarnier and others describe them as passing somewhat obliquely. Muscular Fig. 34. Middle Muscular Layer at the Fundus —a, a. Superficial layer dissected back. b. Branches belonging to the inner layer, t, t. Tubes. fibres pass from the neck to the vagina, to the utero-sacral, and to the utero-vesical ligaments. Immediately beneath the mucous mem- brane of the cervical canal, fibres of muscular tissue are found. The projections of the arbor vitce are formed by muscular fasciculi, whose fibres separate on each side in making the superposed arches. Bayer, from a very careful microscopic study of the muscular structure of the non-gravid uterus, has been led to the following conclusions : 1. The internal longitudinal fibres of the oviducts form the largest part of the submucous muscular layer of the uterus, while their external longitudinal layers form a part of the external layer. The circular fibres of the oviducts assist in the formation of the middle muscular layer of the uterus. 2. The greater portion of the muscular tissue of the lower pole of the uterus and of the cervix is developed from the retractors? The lowest and thickest part of the posterior wall of the corpus, a thinner and higher zone on the anterior wall, the whole of the lateral wall of the cervix, as well as the anterior lip, and the portion of the cervix immediately above it, may be traced to this origin. 3. The remaining portion of the uterine fibres is derived from the radiating fibres of the round ligament, and, indeed, the chief mass of the posterior wall of the body from the retractors ; and the muscle bundles surrounding both angles of the womb in diverse layers are derived from the ovarian ligament • on the other hand, the external layer of the anterior wall and the lower part of the cervix and the entire supra-vaginal part leads back to the round ligament The middle layer of the body is formed by both ligaments in common. 1 Morphologie der Gebarmutter. Freund's Gyniikologische Klinik. Strassbu 2 See description of the utero-sacral ligaments. THE FEMALE SEXUAL ORGANS. 67 It will thus be seen that a general division of the muscular mass of the womb into three or more layers is not feasible, since the arrangement of the muscular layers is diverse in different parts of the uterus. Its construction can only be understood by examining the several portions of the uterus separately. 1. The fundus is composed of— {a) A superficial layer, the median longitudinal fibres of which pass from in front back, while the lateral fibres are arranged in whorls around the insertions of the oviducts; these whorls pass from left to right around the right tube, from right to left around the left tube, compared with the direction in which the hands of a watch move ; a hood-like covering is thus formed, probably arising from the external longitudinal layer of the oviduct, and of the round ligament. (b) Of the deepest, or submucous layer, arranged in the same manner as the above, and derived from the internal longitudinal fibres of the oviduct. (c) Of a middle layer, which is derived from the round and from the ovarian ligaments, a broad band, anteriorly and posteriorly, on both sides of the median line, passing in a sagittal direction. This is interlaced with transverse bands from the circular fibres of the oviducts. Fibres from the ovarian ligament, in connection with the latter, surround the horns of the uterus in spirals and obliquely placed circulars. 2. The posterior wall is formed by the circular fibres of the oviduct, by diagonal lamellae from the ovarian ligament, which pass inward from above, and, finally, by the eccentric rings coming from the retractors, which penetrate all the layers. In this description the most superficial and the deepest longitudinal fibres originating from the oviducts, and which unite to form anteriorly and posteriorly a triangular muscle, are omitted. 3. The middle part of the anterior wall may be divided into an external longitudinal layer, which arises from the muscular fibres of the round ligament, united with the longitudinal fibres from the oviduct; a middle layer formed by the union of circular fibres from the oviduct with the anterior rings of the retractors, and an internal longitudinal layer formed by the crossing anteriorly of the inner longitudinal fibres of the oviducts. 4. In the lower part of the body, the greater part of the walls is formed by muscular bands from the round ligament. 5. In the internal and external portion of the cervix longitudinal fibres, which are the continuation of the corresponding layers of the corpus, anteriorly and posteriorly pass in the median line. Beside this, the posterior wall of the cervix essentially consists of eccentric rings of the retractors, the interlacing fibres of which form other parts, and finally, externally of fasciculi from the ovarian ligaments, which after passing longitudinally are inflected. In the anterior wall of the cervix only muscular lamellae, running diagonally toward the mucous membrane, and covering each other like the tiles of a roof, can be recognized ; the fibres of the retractors 68 SCIENCE AND ART OF OBSTETRICS. are found more especially in the lower third, forming a compact muscular mass from interlacing with the radiating fibres from the round ligament. Bayer remarks that if these manifold convolutions of the muscular fibres make the picture of the uterus a very complicated one, the vessels which pass in every direction and render the preparation of the muscular layers exceedingly difficult, render it still more com- plex. The most vascular portions are the posterior and lateral walls of the corpus and the entire posterior wall and the anterior lip of the cervix. Fig. 35 represents the internal surface of the uterus exposed by an incision through the middle of the anterior wall. The uterine portion of each oviduct is seen, sur- FlG- 35- rounded by a system of circular fibres which pass anteriorly and posteriorly into a median strip of longitudinal fibres. The lower portions of the sides are covered with horizontally arranged circular segments which project sharply above the level of the surface, and turn slightly upward as they approach the median line above mentioned. Careful examina- tion shows that the posterior longi- tudinal fibres pass outward, and the lateral fibres, after passing toward the horn of the uterus above the opening Internal Surface of the Uterus; as of the Oviduct. Curve around it and shown after incision in the median line pass into it at the lower margin. The of the anterior wall. anterior median line of fibres, how- ever, arches under the orifice of the oviduct, and these fibres disappear in the posterior and upper margin. The middle or central fasciculi pass directly over the fundus, in vertical arches, to the posterior wall. The circular systems around the orifices of the oviducts, therefore, appear to be composed of two spiral systems which wind around from the interior of the oviduct toward the anterior and posterior walls of the corpus. These fibres describe only a semicircle about the orifice of the oviducts, and it is by the union of the two systems that complete circles are formed. Fig. 36 represents an anterior view of the infantile uterus. Trans- verse fasciculi, issuing from the round ligament, and others from the broad ligament extend over the anterior surface of the uterus nearly as low as the peritoneal attachment. They cross in the median line, from which their longitudinal fibres pass over the fundus and also into the vesico-uterine folds. Frequently this median cross- ing presents the appearance of a raphe, which is continued without interruption in the direction of the external layer of the fundus. Fig. 37 shows a very distinct raphe on the posterior wall of the same uterus. This is constantly present in the undeveloped uterus From the point of union of the retractors, which are inserted under THE FEMALE SEXUAL ORGANS. 69 the internal os, a sharp, prominent ridge passes upward in the direction of the median line, and gives off transverse branches on each side. At the level of the insertion of the ovarian ligaments this ridge divides into two branches which pass horizontally and Fig. 36. Fig. 37. Anterior Wall of Infantile Uterus. Posterior Wall of Infantile Uterus. Fig. 38. ® then turn downward toward the ligament. These lines taken together may be represented by the capital T. The uterus here represented shows an anomaly in this, that the retractors were at different levels, the right being shorter and placed higher up. Fig. 38 represents the internal surface of the posterior wall of the same uterus ; the mucous membrane has been scraped off. The cavity of the body is low and broad, and suggests the mode of development. A small isthmus, marked above by the projection of the wall, is continuous with the body, and furnishes the com- munication with the wider cavity of the cervix; the characteristic radiations of the arbor vitae are seen in the cervical canal. The trunk of the arbor vitae is toward the left side on the posterior wall, but upon the anterior wall toward the right side, and by this arrangement there is more accurate fitting together as of two dentated parts; a trans- verse section of the cervix presents the well-known S-form. Several arch- shaped fasciculi pass from the upper angles toward the median line, their course corresponding with similar muscular fibres lying beneath them. The Mucous Membrane of the Uterus.—The mucous membrane of the body differs from that of the neck, and will be first described. It is a pale pink in life, but becomes a grayish color after death, and Internal Surface of Posterior Wall of Uterus, after Removal of Mucous Membrane.—A. Transverse section of cervix. 70 SCIENCE AND ART OF OBSTETRICS. is moist from its abundant glandular secretion. It has a thickness of 0.039 to 0.078 inch, two to four millimetres, in the virgin uterus, 0.23 to 0.31 of an inch, six to eight millimetres, in the parous uterus ; it is thinner in the vicinity of the entrance of the oviducts than elsewhere. It becomes greatly swelled during menstruation, so that its thick- ness is two or three times greater. Its free surface is smooth, and upon it the mouths of the uterine glands open ; these glands are so numerous that their openings occupy nearly one-third of the entire surface. Fig. 39. Fig. 40. tfy- •"-'i. -— w -g Glands of the Body of the Uterus.—a a, free mucous surface of the uterus, with mouths of glands opening in it. d d, glands. The adherent surface of the mucous membrane is so intimately attached to the muscular tissue that it is impossible to separate them; there is, according to Cadiat, an actual reciprocal penetration.1 A single layer of cylindrical ciliated epithelium is found upon the free surface; the movements of the cilia are from the mouth of the uterus toward the oviducts. Beneath this there is found amorphous matter containing a large number of fibro-plastic bodies. Utricular Glands.—These glands are cylindrical and flexuous. Engelmann states that they are often bifurcated at their lower third, but according to de Sinety they are rarely bifurcated, and Sappey describes them as generally single, sometimes bifid or trifid. They are lined with ciliated epithelium, and secrete a transparent, alkaline, fluent mucus. Mucous Membrane of the Neck.—This is whiter, thinner, and of firmer consistence than is that of the body. Cylindrical epi- thelium with vibratile cilia is found in the upper two-thirds, but in the lower third pavement epithelium. The borders of the elevations caused by the arbor vitce are lined by ciliated epithelium. But in passing from the free borders to the sides of the eleva- tions referred to, the ciliated is replaced by cup-shaped epithelium which becomes more and more developed as it penetrates more profoundly into the numerous glands situated at the fundus of a mucous fold.2 The "lands Vertical Section of the Mu- cous Membrane of the Virgin. — IV. Uterus, magnified forty diameters. S. Mucous mem- brane. D. Uterine glands. M. Muscular stratum Schwartz. 2 De Sinety. THE FEMALE SEXUAL ORGANS. 71 which are so abundant in the cervix that Spiegelberg calls it a great gland apparatus, are not tubular, like those of the corpus, but race- mose. The glands of the cervix secrete a thick, viscid alkaline, gelatin-like mucus; it forms the gelatinous plug that in pregnancy is frequently found filling the cervical canal. No glands are found at the level of the external mouth of the womb. Obstruction of the excretory duct of one of the cervical glands gives rise to retention by the accumulation of secretion ; and such cysts are known as ovula Nabothi, because of Naboth's error in regarding them as human eggs. Fi"- 4i- Fig. 42. Epithelium with Vibratile Cilia. (350 di- Epithelium with Cup shaped Cells. (350 ameters.)—a. Nucleus, b. Nucleolus, c. Body diameters.)—a. Nucleus, b. Nucleolus. of the cell. v. Vibratile cilia. c. Body of the cell forming a cavity. Beneath the epithelium there are fibrous1 laminae which are con- tinuous with those interposed between the muscular fasciculi, and hence the intimate union between the mucous membrane and the subjacent tissue. Bloodvessels of the Uterus.—The four chief trunks supplying blood to the uterus are the two uterine and the two ovarian arteries. The two latter, which correspond to the spermatic in the male, not only carry blood to the uterus but also to the ovaries and to the ovi- ducts. In addition to the arteries mentioned, a branch from the epigastric, on each side, passes through the round ligament to the uterus. On account of the number and volume of the arterial cur- rents supplying the uterus, this organ has been compared to the brain. The uterine arteries are given off by the internal iliacs, while the ovarian proceed directly from the aorta just below the renal. The uterine artery, pursuing a remarkably flexuous course, enters the base of the broad ligament, and at the middle of the cer- vix gives off two branches, one of which passes in front of, the other behind the cervix, to unite with corresponding branches derived from the other uterine artery, thus making a complete anastomosis, and at the same time forming an arterial ring which encircles this portion of the uterus. The chief trunk ascends, and at the level of the fundus gives off a large number of branches,2 which enter beneath the peritoneum into the muscular tissue to pass to the mucous layer becoming capillaries in the muscles, and forming a fine network around the glandular culs-de-sac. The uterine artery anastomoses with the ovarian, forming a large arch. The ovarian is chiefly dis- tributed to the fundus and the upper part of the body of the uterus. Both the uterine and the ovarian arteries are remarkable for their serpentine course or corkscrew form. 1 Schwartz. 2 Ibid. 72 SCIENCE AND ART OF OBSTETRICS. Uterine veins, which anastomose with each other, collect the blood from mucous and muscular capillaries. They are generally large, but in pregnancy so increased in size that they are called Fig. 43. The Ovarian, Uterine, and Vaginal Arteries (Hyrtl).--a. Ovarian artery, a' and b' Branches to tube. b. Branch to round ligament, c. Uterine artery, c'. Branches to ovary. g. Vaginal artery, h. Azygos artery of vagina. sinuses; their walls are firmly fastened to the muscular framework of the uterus by strong connective tissue, and thus " thousands of living ligatures " are provided for the arrest of hemorrhage after 16526� THE FEMALE SEXUAL ORGANS. 73 detachment of the placenta ; the construction of the middle muscular coat of the uterus, with the relation of the veins which traverse it, seems to have been especially designed for. this purpose. Emerg- ing from the uterus at its sides, the veins freely anastomose so that a large plexus is formed on each side, inclosed in the folds of the broad ligament, known as the utero-ovarian plexus ; this plexus is dilated in menstruation and in all other cases of uterine congestion. Four veins, two uterine and two ovarian, carry the blood from these plexuses; the uterine empty into the internal iliac veins, the left ovarian into the left renal, and the right ovarian directly into the vena cava. Veins also pass through the round ligaments, and empty into the epigastrics or into the external iliacs. The erectility of the uterus is claimed to result from the disposi- tion of its arteries and veins. Rouget showed that when its veins were injected it became erect, swollen, its size greater, and its cavity increased by the separation of its walls. This erection is by some supposed to occur during coition, and to facilitate the entrance of spermatozoids into the uterine cavity The Lymphatics of the Uterus.—These have been divided into three sets or systems, viz., a subserous, a muscular, and a mucous. The last has no vessels, but is composed of numerous and large lymph spaces, so that the mucous membrane has been called an enormous lymph gland; these spaces freely communicate with each other; they are formed by trabecular lined with endothelium, and encircle the vessels and glandular culs-de-sac; they communicate with the lymphatic vessels of the muscular wall. The lymphatic system of the muscular coat is arranged in three planes, internal, middle, and external. The first is composed of cyl- indrical vessels running transversely, placed between the muscular fasciculi, and uniting the submucous lymph set with the middle muscular plane. The second plane is composed of vessels provided with valves, and which are tortuous; these convey the lymph to the vessels of the broad ligaments. The third, or superficial muscular plane, consists of vessels placed longitudinally between the muscular fasciculi; they furnish communication between the large trunks of the middle layer and the subperitoneal lymphatics. The subperi- toneal lymphatics are found upon the anterior and upon the poste- rior face of the uterus, and at its sides. Those of the neck form a large subperitoneal plexus, and then unite in vessels which commu- nicate with the lateral and sacral ganglia. According to Champion- niere, a ganglion is found on each side of the uterus at the isthmus, and this fact is regarded as of importance in connection with the development of certain puerperal diseases. The subperitoneal lymphatics of the body of the uterus are large vessels provided with valves; those at the sides directly enter the lymphatic vessels of the broad ligaments, and those upon the anterior and posterior face indirectly through the vessels of the middle muscular plane. The Nerves of the Uterus.—The plexus uterinus magnus, formed by branches from the superior mesenteric plexus, and from the ovarian ganglia, which receive large branches on both sides from 74 SCIENCE AND ART OF OBSTETRICS. the fourth sympathetic ganglion, is situated at the bifurcation of the abdominal aorta. An inch and a half, 3 79 centimetres, below the bifurcation, directly at the promontory, this plexus divides into two branches which pass right and left about the rectum, and go to the upper part of the vagina and the uterus; these two branches are the Fig. 44. The Nerves of the Uterus (Frankenhiiuser).—A. Plexus uterinus magnus. B. Plexus hypogastricus. i. Sacrum. 2. Rectum. 3. Bladder. 4. Uterus. 5. Ovary. 6. Fimbriated extremity of tube. hypogastric plexuses. They receive numerous filaments from the fifth lumbar ganglion, and from the first, second, and third sacral ganglia of the sympathetic. When they have reached the side of the rectum, the hypogastric nerves divide into two unequal branches. The smaller of these remains at the inner side of the pelvic vessels, and is distributed to the posterior and lateral parts of the uterus. THE FEMALE SEXUAL ORGANS. 75 The larger branch goes under the vessels, and passes partly to the large cervical ganglion, and in part unites with the sacral nerves. The cervical ganglion in pregnancy is nearly two inches long, 5 centimetres, and an inch and a half broad, 3.79 centimetres ; it is situated at the side of the posterior vaginal vault, and is formed from both hypogastric plexuses, from the first three sacral ganglia, and from the second, third, and fourth sacral nerves. It supplies the entire uterus, and especially the cervix, with nerves. The mode of termination of the nerve fibres in the mucous mem- brane is unknown ; in the muscular tissue this termination is, accord- ing to Frankenhiiuser, in the nuclei of the muscle cells. No ganglia are found in the intramuscular nerve plexuses of the uterus, and in this regard there is a remarkable contrast between these plexuses and those of the stomach and intestines, which are very rich in ganglia. Physiological experiment has proved the presence of vaso-dilating and vaso-constricting nerves in the uterus. Klein- wiichter remarks that a knowledge of the nerve distribution does not explain the way by which uterine contractions are produced. Spiegelberg has stated that while a motor-centre for the uterus is found in the medulla oblongata, this centre is not the only one which controls the action of the uterus, and at most is a reflex one, and that there are independent centres for uterine contractions in the lumbar spinal cord; but he also stated that there are facts which show that the uterus is, to a certain extent, independent of the spinal centres. Dembo1 observes there is not a point in the cerebro-spinal system where a centre presiding over uterine contractions was not supposed to be found. According to some, the centre was in the cerebellum ; according to others, in the bulb ; and still others have found it in both ; some place it in the lumbar region of the spinal cord, others at the tenth dorsal vertebra, and others make all points of the spinal cord capable of causing uterine contractions. Some have placed the centre in the great sympathetic, though differing as to the part. Finally, some hold that the uterus has its own independent centres. Among recent investigations are those made by the author just quoted, and his conclu- sion is that most probably the centres governing uterine contractions are situated beneath the peritoneum, above the anterior wall of the vagina; he has found there numerous ganglionic groups of different sizes, some of them with a hundred cells or more. Position of the Uterus and Means by which the Organ is sustained. —The general place in the pelvic cavity which the uterus occupies, and the relations of the latter to the bladder and the rectum have been mentioned on page 60. The situation of the uterus is not a fixed one, but there is a great normal mobility provided for, so that the organ may change its position according to certain physiologi- cal functions, and according to the condition of the neighboring organs. Thus during respiration there are alternate descent and ascent of the uterus ; the position varies as to the state of the rec- tum and of the bladder; it is not the same when the subject is standing or lying down; it varies in the nulliparous and parous, and when at rest, or in the exercise of its physiological functions. The most remarkable change of position from a physiological cause is that which occurs in pregnancy, when from having been a pelvic, Annales de Gynecologic, Fev. 1883. 76 SCIENCE AND ART OF OBSTETKICS. the uterus becomes almost entirely an abdominal organ ; yet after pregnancy is over, and involution completed, it occupies nearly its original position. Figs. 45 and 46, from Schultze, show the position of the uterus in the virgin, and in the childbearing woman, when the bladder is empty. In most instances the uterus is not quite exactly in the transverse diameter of the pelvis, but a slight rotation occurs by which the left side is thrown toward the front, and the right backward. This rotation, which becomes very marked in most women during preg- nancy, is simply the expression of an embryonic condition that will be referred to hereafter. Fig. 45. Fig. 46. Normal Situation of the Virgin Uterus Position of Uterus in a Woman who when the Bladder is empty. has borne a Child. Fig. 47, from Ramsbotham, shows the position and relations of the uterus as seen from above. The uterus is kept in its normal position by its connection with the vagina, with the bladder, and with the pelvic fascia, and by certain ligaments which will now be described. The Uterine Ligaments.—These are six in number, three belonging to each half of the uterus as made by the antero-posterior division. They are known as the round, the broad, and the utero-sacral, and each is formed by a fold of peritoneum including between the two sides muscular and connective tissue, vessels, and nerves. THE FEMALE SEXUAL ORGANS. 77 The Round Ligaments.—The round ligaments are two cords cov- ered by peritoneum, passing from the uterus at a point a little below the origin of the oviducts, and at the junction of the anterior face with the lateral border of the uterus, to the inguinal canal, where their peritoneal investment ceases, and they somewhat change their form ; each ligament is continued through the inguinal canal, and ends by an expansion of its fibres in the upper part of the labia majus. The ligament has not only unstriped, but also striped muscular fibres; the latter originate from the lower part of the inguinal canal and from the pubic spine, and are continued toward the uterus, but end at the level of the pelvic inlet. The round ligament has a notable amount of connective and elastic tissue, and contains an artery, which, originating from the epigastric, passes on Fig. 47. Uterus with Adjacent Organs as seen from above.— a. Mons veneris, b. Bladder, c. Fundus of the uterus, d. The rectum. e,e. The oviducts. g,g. The ovaries, h, h. Posterior processes of broad ligaments. i,i. Round ligaments, k. Caecum with its appendages. /. Small intestine. m. Body of one of the lumbar vertebrae. toward the uterus, and anastomoses with the uterine artery, thus making a connection between the general circulation and that of the uterus. Up to the eighth month of fcetal life the peritoneum is continued into the inguinal canal, making the canal of Nuck, when 78 SCIENCE AND ART OF OBSTETRICS. it is usually closed; should it remain open, an effusion into this peritoneal prolongation may occur, and the disease is known as hydrocele of the female. In the non-pregnant condition the round ligaments play an important part in preventing retroversion or retroflexion of the uterus. During pregnancy they are notably increased in size, but unequally, and it has recently been stated1 that by examining them through the abdominal wall, and apprecia- ting their development, a correct prognosis can be given as to the activity of the labor-pains, for that development is a guide to the muscular development of the uterus. During labor the contraction of the round ligament draws the upper part of the uterus forward, securing economy of force by the direction given it during uterine contractions. The Broad Ligaments.—These extend from the sides of the uterus to the sacro-iliac joints. They are separated from each other by the intervening uterus, but the anterior layer of the one side is con- tinuous with that of the other, passing over the anterior face of the uterus ; in like manner the posterior layers are continuous. Thus the pelvic cavity by means of these ligaments and the uterus is divided transversely into two unequal parts, the anterior being known as the vesical, the posterior as the rectal. The superior border of the broad ligament presents three peritoneal folds, known as wings—an anterior, a middle, and a posterior wing; the first includes the round ligament, the second the oviduct, and the third the ovarian ligament, which is attached to the inferior border of the ovary. At the sides of the pelvis the peritoneal layers of the broad ligament separate, being continuous with that lining the pelvis ; below, a separation also occurs, the posterior fold to be reflected over the rectum, the anterior over the bladder. At the internal border of the ligament, the two peritoneal folds separate to receive the uterus. Large veins and lymphatics pass from the uterus at this border. The broad ligaments contain between the peritoneal folds connective tissue, vessels and nerves, and muscular fibres; the adherence of the serous membrane to the muscular tissue of the uterus is so intimate that the former cannot be separated without at the same time removing part of the muscular layer. The broad ligaments, beside assisting in the suspension of the uterus, prevent its lateral deviation, and aid in restoring it to its normal position after partial retroversion caused by a distended bladder. During pregnancy the peritoneal folds separate so com- pletely to accommodate the enlarging uterus, that at the end of gestation the broad ligaments have almost completely disappeared. The Parovarium, or Body of Rosenmuller.—If that portion of the recently removed broad ligament including the oviduct and the ovary, be held up to the light, there will be seen a series of fine tubes passing to the hilum of the ovary, and each terminating in a cul-de-sac; above these, tubules communicate with a canal perpen- 1 Homburger: Gynakologische Klinik herausgegeben von Dr. Wilhelm Alexander Freund Erster Band. 1885. THE FEMALE SEXUAL ORGANS. 79 dicular to them and parallel to the oviduct The number of tubes is said to be from fifteen to eighteen, but Doran1 mentions finding in one specimen twenty-four. The body thus described is called the parovarium, or body of Rosenmuller; it is the vestige of an embryonic structure known as the body of Wolff. The efferent duct continues patent in some of the domestic animals, and is called the canal of Gartner. The two urethral ducts, described by Skene, have been by some thought to be the inferior portion of the efferent ducts of the parovarium. The Utero-sacral Ligaments.—These are two semi-lunar folds pass- ing from the uterus posteriorly just above the union of the vagina, and attached to the third and fourth sacral vertebrae immediately within the lower part of the sacro-iliac joint. They form by their superior lateral borders a narrowed passage, or mouth of Douglas's cul-de-sac, or the retro-uterine peritoneal pouch, and in some cases, where the retroverted uterus has sunk into this pouch, may hinder its restoration. These ligaments contain muscular tissue, and are hypertrophied in pregnancy. According to Luschka, a part of the muscular fibres of each side unite behind the cervix, making a half ring, and the muscle formed by this union is called the muscle of Luschka, or with reference to the function assigned it by him, the retractor of the uterus. Schultze regards it as the elevator rather than the retractor of the uterus, while the general action of the folds is that of a suspensory ligament of the uterus. The utero-sacral ligaments are elongated in pregnancy. Vesico- uterine ligaments are also described by some ; however, little im- portance is attached to them as means for keeping the uterus in normal position. The Ovaries.—These organs, of equal importance with the testicles of the male for reproduction, were called by Galen testes muliebres. They are sometimes classed as glandular organs, their supposed function being to secrete ovules; but as the ovule has to a certain degree its existence before the ovary, the latter serves as a place of deposit, of preservation and completion for the primordial ovules, and does not secrete, but contributes to the evolution of these essential anatomical elements of the organ, and for which it is made. Number, Position, and Attachments of the Ovaries.—The ovaries in the human female, as in almost all vertebrates, are two ; in birds,2 however, but a single ovary, usually the left, is found, the other having atrophied, this atrophy beginning about the seventh day of incubation. These organs are in the pelvic cavity, one on each side of the uterus; their long diameter3 is not transverse, as is usually represented, but parallel to the lateral pelvic walls, and almost at the level of the plane of the inlet; their lateral attachment to the pelvis is higher than their attachment to the uterus ; their superior border is at the plane of the inlet, and below the internal border of the psoas and iliac muscles. According to Schultze, the contraction of the belly of the combined psoas and iliacus muscles is the best 1 Tumors of the Ovaries, etc. 2 Duval. 3 Schultze. 8o SCIENCE AND ART OF OBSTETRICS. guide for the external hand in bimanual palpation of the ovaries ; and Charcot states that the ovarian pain of the hysterical cor- responds most frequently with the point of intersection of two lines, the one drawn between the superior anterior iliac spines, and the other marking the prolonged lateral boundary of the epigas- trium. The ovaries are placed in the posterior wing of the broad liga- ments ; they are behind the oviducts, and in front of the rectum, being usually separated from the latter by coils of intestine. By their relation with the broad ligaments they are attached externally to the pelvic walls. Other attachments are by the utero-ovarian, the tubo-ovarian, and the posterior round ligaments. The utero- ovarian ligament, by some called the ovarian ligament, is a cord composed of smooth muscular fibres; these fibres may be followed into the posterior wall of the uterus, and traced down as far as the Fig. 48. The Ovary and Oviduct. (The latter opened longitudinally.)—1, 1. Ovary. 2. Part of the uterus. 3. Ovarian ligament. 4, 4. Oviduct, its walls opened by a longitudinal incision to show the longitudinal folds of its lining membrane. 5, 5 Pavilion from internal surface. 6, 6. Fimbria attached to the ovary, or tubo-ovarian ligament. 7, 7. Longitudinal folds. 8. Internal end of the oviduct. internal os ; it passes from the superior angle of the uterus on each side, to the internal end of the ovary. This ligament is about one inch and a quarter, 3.16 centimetres, in length. That portion of the broad ligament not occupied by the oviduct connects the ovary with the pelvic brim, and is known as the infundibulo-pelvic ligament. The ovary is thus suspended by and between this ligament and the ovarian; but the pelvic attachment is higher than the uterine, and hence the long diameter of the ovary is not horizontal, but parallel to the lateral pelvic wall, according to the statement of Schultze. On the other hand, he asserts that the long axis of the ovary is nearly vertical, a view which is confirmed by Hart and Barbour. The tubo- ovarian ligament is formed by the attachment of one of the fringed processes of the pavilion of the oviduct to the external end of the ovary. It is probable that the superior surface of this ligament bears an important part in the transfer of the ovule from the ovary THE FEMALE SEXUAL ORGANS. 8l to the oviduct. The middle fibres of the posterior round or lumbar ligament pass to the ovary. This ligament, according to Rouget, is formed of a lamella of smooth muscular fibres which originate from the sub-peritoneal fascia, passing from behind forward to be distributed, the internal upon the body of the uterus, the external to the pavilion, and the middle to the hilum of the ovary. The ovary has considerable mobility, and hence the possibility of both physiological and pathological changes of position, the most remarkable of the former being that which occurs in pregnancy, for the ovaries ascend with the uterus into the abdominal cavity, and afterward descend with it into the pelvis. Form, Size, and Aspect of the Ovaries.—The ovary is usually an ovoid, somewhat flattened antero-posteriorly; its superior border is convex, and its inferior plane; its ends, or extremities, give attach- ment to the ligaments already mentioned. Except these attachments, and that of the inferior border to the peritoneum, the organ is free. The size of the ovaries varies in individuals at different ages, and as to the condition of ovulation; it is greater during menstruation and during pregnancy than at other times; the right ovary is usually somewhat larger than the left. The average dimensions of the organ are, in length 1.4 inches, 38 millimetres, in vertical measure- ment 0.7 of an inch, 18 millimetres, and antero-posteriorly half an inch, or 15 millimetres. The weight of the ovary is from 90 to 120 grains, or 6 to 8 grammes. Doran1 states that the average weight of the normal ovary is at least IOO grains; its long axis is a little over two inches, its short axis one inch, its thickness quite half an inch. The surface of the ovary is white and smooth at the beginning of menstrual life ; it becomes uneven and irregular from the cicatrices of ruptured ovisacs, these being more numerous as age advances, and the color changes to a yellowish-brown. The Hilum and Bulb of the Ovary.—Between the two layers of peritoneum which are attached to the inferior border of the ovary, Fig. 49, Bulb of Ovary. the ovarian vessels and nerves pass. The arteries, eight or ten in number, derived from the anastomosing arch of the uterine and 1 Handbook of Gynecological Operations. Blakiston, Son & Co., Philadelphia, 1887. 6 82 SCIENCE AND ART OF OBSTETRICS. ovarian, have a helicine form before entering the hilum of the ovary ; upon this layer of arterial vessels there is placed, in front and behind, a much thicker layer of venous vessels ; an injected specimen shows a large mass of bloodvessels, chiefly venous, which com- municate with the pampini- Fig. 50. form plexus and with the ute- rine plexus. This is the bulb or spongy body of the ovary ; it should not be confounded with the bulbous portion of the ovary, which will here- after be described. Structure of the Ovary.—It was once generally held that the ovary was covered by peritoneum, and had a tunica albuginea, but neither state- ment is now regarded as true. The researches of Waldeyer have shown that the perito- neum ceases at the inferior border of the organ, and that all the rest of its surface is covered with a simple layer of flattened cylindrical epithe- lium ; this covering presents a dull-white appearance, which is in striking contrast with the bright, almost shining, appearance of the peritoneum; at the inferior border of the ovary there can be seen a finely notched line, marking the place where the latter ceases and the former begins. The supposed tunica albuginea has been proved to be, instead of a mere covering, the essen- tial part of the organ. A vertical section of the ovary shows that it is composed of two very different substances. The superficial, or cortical portion, is white, firm, and apparently homogeneous; the internal, or medullary portion is reddish, spongy, and not homogeneous; it constitutes seven- eighths of the organ. The ovisacs are found only in the superficial layer, and it is therefore called by Sappey the glandular or ovige- nous portion; while the central part, the great mass of the organ, From an Ovarium of an Old Bitch. High Power.—a. Germinal epithelium, b. Ovarian tubes. c. Younger follicles, d. Older follicles, e. Pro- ligerous disk, with egg. /. Epithelium of second egg in the same follicle, g. Tunica fibrosa folliculi. h. Tunica propria folliculi. /. Epithelium of the follicle (membrana granulosa). /. Vessels, m. Ceil tubes of the parovarium in long section, y. Tubi- form depression of the germinal epithelium into the ovarian tissue. (Strieker.) THE FEMALE SEXUAL ORGANS. 83 is called the bulbous portion; by some it is also called the medul- lary portion. The peripheral, or ovigenous layer is the essential part of the ovary; it is composed of an external layer of epithelium, representing the germinative epithelium of the pleuro-peritoneal cavity of embry- onic life; of a fibrous framework, the fibres crossing each other, the superficial portion more dense than that beneath it, yet no line of separation between the two ; in the meshes of this tissue the ovisacs are found. Only fifteen or twenty ovisacs can be discovered by the unaided eye, but the microscope reveals an almost infinite number. Sappey's investigations have authorized him to state that in each ovary of a girl eighteen or twenty years of age there are more than three hundred thousand, making some seven hundred thou- sand for the two ; in one instance, that of a girl four years old, the number was one million, one hundred and fifty thousand. Nature is prodigal in supplying means for the continuance of the race. The bulbous portion is composed of vessels, nerves, muscular and con- nective-tissue fibres; it furnishes nutritive material to the ovisacs and ovules, and also a surface upon which the ovisacs may be distributed, so as to facilitate their growth and rupture, and the reception of the escaping ovules by the oviduct. Vessels and Nerves of the Ovary.—The arterial supply of the organ, as well as the helicine course of the arteries before entering the hilum, has been mentioned. These vessels after penetrating the ovary still preserve the helicine form; they are distributed to the bulbous portion, and fine ramifications pass to the ovigenous layer, but scarcely reach the most external part; vessels, however, pass to the walls of ovisacs that have attained notable development. The veins are remarkable for their size, varicose appearance, and numerous anastomoses; after contributing to the formation of the bulb to the ovary, the blood passes from the bulb on either side into the ovarian veins. The nerves are from the ovarian plexus. Their final distribution is not known; Duval suggests that the)' are especially designed for the vessels and the unstriped muscular tissue of the bulbous portion ; Luschka has seen an axis-cylinder enter the wall of an ovisac. Large lymphatic vessels emerge at the hilum, and pass to the lumbar ganglia. It has been shown that the tissue about an ovisac is rich in lymph-supply, so that de Sinety remarks that the follicle is plunged into a closed lymph sac, a con- dition which appears very favorable for nutrition. The Ovisacs.—These were discovered by de Graaf, in 1672, and are frequently called the Graafian vesicles, or follicles ; but a desig- nation which points to their most important office, containers of ova, and therefore ovisacs, seems more appropriate. An ovisac consists of a capsule, and within the capsule the mera- brana granulosa, the liquid of the ovisac, and the ovum. The capsule is described by some as composed of two layers, an external called the tunica fibrosa, and an internal called the tunica propria. But as it is impossible to separate the supposed external one from the surrounding ovarian tissue, "from which it does not differ except 84 SCIENCE AND ART OF OBSTETRICS. from its fibres being looser, and the greater predominance of cell elements," most authorities consider the capsule as having but a single wall. This is a thin, transparent, vascular membrane, com- posed, according to Robin, of fibrous laminae pressed against each other, transparent amorphous matter with fine granulations, and large polyhedric cells with rounded angles, which are not found elsewhere, except in the uterine mucous membrane developed by pregnancy. The liquid of the ovisac, liquor folliculi, is clear, viscid, alkaline, and contains oil globules and granulations. Upon the inner surface of the capsule a layer of round nucleated cells is found, constituting the membrana granulosa. An accumula- tion of these cells occurs at some part of the ovisac, forming the discus proligerus, and in this mass the ovum is found. The discus proligerus is not usually at the most projecting part of the ovisac, but at its lowest. The ovum, or ovule, discovered in 1827, is spherical, and about j-^ of an inch in diameter. It is composed of three parts, an investing membrane, the vitelline membrane, a granular liquid, known as the vitellus, a transparent vesicle, the germinal vesicle, and, finally, the germinal spot. The germinal vesicle, or nucleus of the ovule, is y^- of an inch in diameter, and the germinal spot, or nucleolus, is -g-oVo~ °f an mcn m diameter. The Oviducts)—These are canals or tubes, placed one on each side of the uterus, through which the spermatozoids pass to or near to the ovaries, and by which the ovule is transmitted to the uterus. In relation to the ovaries, they are its excretory ducts. They are in the upper border of the middle fold of the broad ligaments. An oviduct is between four and five inches, ten to twelve centimetres, long; its diameter increases from the uterus to the ovary; this is, •according to Sappey, near the uterus, 0.15 of an inch, or four milli- metres ; at its middle portion, 0.19 to 0.22 of an inch, or five to six millimetres; and at the abdominal opening, 0.27 to 0.31 of an inch, or seven to eight millimetres. At the abdominal end there is an expanded portion, having a diameter of about seven-tenths to eight- tenths of an inch, 18 to 20 millimetres, called the pavilion or ampulla. The external surface of the pavilion is covered by perito- neum continuous with that of the body of the oviduct; its internal surface is concave, and lined with ciliated mucous membrane; its margin, where continuous with that lining the oviduct, meets serous tissue, is not uniform and regular, but divided by numerous fissures, so that it presents a fringed appearance, and the projections thus formed are called fimbriae. Some of the fimbriae are rounded at their free end, others elongated and irregular; one of them is without free extremity, but is attached to the ovary, making the tubo-ovarian ligament; and hence the pavilion necessarily follows the ovary in 1 Commonly called Fallopian tubes. Fallopius, a famous anatomist of the sixteenth century the successor of Vesalius in the University of Padua, describing the oviduct compared it to tuba, a trumpet, not a tube or canal; and his name has been given to the organ. But the ovi- ducts were described long before the time of Vesalius by Erophilus and then by Rufus of Ephesus. It seems, therefore^ that it would be better to have the names of these organs deter- mined by their most important function, that of excretory ducts for the ovaries, than to perpet- uate one which is doubly misleading. ' 11" THE FEMALE SEXUAL ORGANS. 85 its physiological or pathological changes of position; the tubo- ovarian ligament presents upon its upper surface a groove or canal leading directly to the oviduct. The number and delicacy of the fimbriae can be well seen by taking a fresh specimen of the oviduct, and gently moving the abdominal end to and fro in clear water. From the opening into the oviduct a number of folds, continuous with similar formations in the body of the organ, radiate to the cir- cumference of the pavilion. An accessory pavilion is found, according to Sappey, once in sixty subjects; once in sixteen according to Richard. In some in- stances two have been observed, and once three. They have the same form as the normal one, and communicate with the oviduct; it is possible that the ovule may enter one of these from the ovi- duct, and thence pass into the abdominal cavity. The internal or uterine orifice of the oviduct is only one twenty-sixth of an inch, or one millimetre in diameter. The oviduct is formed of three coats, an external peritoneal, a middle muscular, and an internal mucous. The peritoneal coat extends from the uterus over the entire length of the organ, but of course fails at the lower portion corresponding with the interval between the folds of the broad ligament. The muscular coat consists of a layer of longitudinal fibres, and beneath it one of circular fibres ; both of these are continued into the mus- cular walls of the uterus. The mucous membrane is thrown in folds which are closely applied to each other, so that there may result a capillary attraction, similar to that observed when two pieces of glass are pressed together, and then partly immersed in water. The mucous membrane is lined with ciliated epi- thelium, the movement of the cilia being from the ovary to the uterus; this condition is supposed to be a fac- tor in the transmission of the ovule to the uterus. J. Bland Sutton1 has recently shown that the mucous membrane of the ovi- ducts is glandular; these glands are formed by infoldings of the surface epithelium, and hence are very simple in character. In oviparous vertebrates the glands of the oviduct secrete a viscid albumen for the investment of the ovum. Sutton adds, " So far as the human ovum is concerned there is little room to doubt that the viscid albuminous material secreted by the glands of the Fallopian tube serves as a pabulum for the embryo in its early stages, absorption taking place by means of the chorionic villi, which, standing upon the zona pellucida, are immersed in a highly nutritive bath furnished by these glands." Fig. 51. Section of Normal Fallopian Tube (after Bland Sutton). 1 London Obstetrical Society's Transactions, vol. xxx. London, 1889. 86 SCIENCE AND ART OF OBSTETRICS. The oviducts have the same source of blood and nerve supply as the ovaries. The lymphatics unite with those of the uterus and of the ovary. Development a?id some of the Anomalies of the Female Generative Organs.—While naturally belonging to the subject of Embryology, it is thought suitable to give in connection with the anatomy of the female organs of generation a brief sketch of their development, and present some of the anomalies of obstetric interest and im- portance that may occur in that development. Development of the External Organs of Generation.—The formation of these organs begins in the fourth week of embryonic life. At that time1 there is at the posterior extremity of the body a simple opening, representing the orifice common to the intestine and the allantois, the future bladder, into which the Wolffian canals will also empty, and which is the orifice of the cloaca—the inferior por- tion of the intestine after the development of the allantois being called the cloaca. Before this single opening is divided into two, anal and uro-genital, there appears in front of the orifice an eleva- tion, called the genital swelling or tubercle; then two lateral folds, the genital folds. At the end of the second month this swelling is greater, and there is seen at its lower part a cleft or fissure, extend- ing to the opening of the cloaca, the genital furrow. About the middle of the third month the cloacal opening is divided so as to form two orifices ; the most generally received explanation of this division is that it occurs by the formation of two lateral folds from the cloaca, and at the same time a projection from the point of union of the rectum and allantois descends; the lateral folds and the cen- tral process unite so as to form a complete wall, the inferior border of which becomes the perineum, and the wall divides the cloaca into two cavities, rectal and uro-genital. The labia majora are developed from the lateral genital folds, and the labia minora from the borders of the genital fissure, while the clitoris is formed from the genital tubercle, or the upper part of the genital swelling. Into the uro-genital sinus the bladder developed from the allantois and the seminal ducts empty, and hence its name. This sinus is shortened by the descent of the vagina, and in the fourth month of embryonic life the urethra and vagina are distinct canals. Development of the Internal Organs of Generation.—The internal genital, as well as the urinary apparatus, is developed from two transitory embryonic structures known as the Wolffian bodies. From the fact that these bodies temporarily exercise the function of the kidneys, they are known as primitive kidneys, false kidneys, primordial kidneys, and kidneys of Oken. Their structure is analo- gous to that of the kidneys: they are composed of an excretory duct, which occupies a longitudinal position, and of fine tubes which are transverse and empty into this duct; these canaliculi are enlarged at their closed end, and in this enlargement a vascular glomerulus 1 Koliiker. THE FEMALE SEXUAL ORGANS. 87 is found. The duct appears prior to the gland, according to the general law1 in the formation of all glandular organs, that the excretory canal is first formed. In the second month of embryonic life the Wolffian body appears as an oblong mass situated on the side of the verte- bral column, and extending from the chest to the pelvis. These bodies soon become atrophied, leaving as their chief vestige on each side the organ of Rosenmiiller, or the parovarium which has been described in connection with the description of the broad ligaments. Before this atrophy occurs, there is a notable thickening of epithelium, called by Waldeyer germinative epithelium, composed of long cylindrical cells upon the inner and upon the outer surface of the Wolffian body; the former is the origin of Muller's duct, the latter of the ovary and the ovules. The formation of Muller's duct takes place, according to Waldeyer, by the appearance of a longitudinal fold of the germinative epithelium which is sunk in the con- nective tissue of the external lateral part of the Wolffian body; this fold is covered over and thus converted into a tube. It remains open externally, and that portion becomes the pavilion. The occurrence of sec- ondary pavilions, to be referred to in the description of the oviduct, is readily explained, according to Duval, by supposing that the canal of Muller is not completely closed in all its extent at the period of embryonic life when the two borders of the gutter, which give origin to it, are turned toward each other, in order to transform the gutter into a canal. Muller's ducts unite in a part of their course to form the uterus and the vagina; the limit to this union is the insertion of the round ligament, which is the analogue of the guber- naculum testis in the male, and has the same relations with the inguinal canal. All of the duct below the round ligament unites with the corresponding portion of the duct on the other side, thus making at first a double uterus and vagina; but absorption of the intervening wall occurs, and each organ is single. The left duct is usually further in front than the right, and the two are united in this oblique position; the presence of the intestine upon the left side is thought to explain the fact that the left duct is placed further to the front than the right. The fusion of the two ducts is complete in the embryo of two months. The point at which this union begins (From Allen Thomson.) Diagram- matic Outline of the Wolffian Bodies, and their relation to the ducts of Muller and the reproductive glands. —ot. Seat of origin of ovary or testes. W. Wolffian body. w. Wolffian duct. m. Duct of Muller. gc. Gen- ital cord. ug. Urogenital sinus, i. Rectum, cl. Cloaca. Imbert, op cit. 88 SCIENCE AND ART OF OBSTETRICS. is unsettled. Kolliker believes that it is at the middle of Muller's canals, while others hold that it takes place from below upward. All that portion of the duct above the insertion of the round ligament becomes the oviduct. The prominence on the internal face of the Wolffian body is composed of a mass of embryonic connective tissue covered by well-developed germinative epithelium ; it is the first rudiment of the genital gland, and is found alike in the embryo which is to be a male, as well as in that which is to be a female; in the female the ovaries and ovules are derived from the epithelial covering, while the outgrowth itself is de'stined to furnish the vas- FlG. 53. Human Ovule, and Ovules of Rabbit, Pigeon, and Ascaris.—A. Primordial egg (human) from a foetus at the eighth month. B. Primordial follicle from a rabbit; C. from a pigeon. D. A somewhat older follicle from the same animal, exhibiting the commencement of the formation of the secondary yolk. E. Caecal extremity of the ovary of the ascaris nigrovenosa. F. An egg of this animal. G. An egg from the follicle of a rabbit, 2 mm. in diameter; a. epithelium of the ovum; b. radially striated zona pellucida; c. germinal vesicle; d. germinal spot; e. yolk. High power. cular stroma of the ovary. The next change that is observed is the appearance of cells, which are round, have a well-developed nucleus and distinct nucleolus: these are the primordial ovules or primitive ova. At the deep part of the genital eminence, and in close contact with it, sections show that the tubes of the upper portion of the Wolffian body are narrower and have a clearer epithelium than those of the lower portion; the superior is known as the sexual or genital portion, the inferior as the urinary. If the genital promi- THE FEMALE SEXUAL ORGANS. 89 FIG. 54' M nence is to be developed into a testicle the germinative epithelium and the primordial ovules rapidly disappear; but if it is to be an ovary, the former becomes more developed, and the ovules increase in number. The primordial ovules, in consequence of the growth of other cells, especially of those of the mesoblast, which furnishes the frame- work of the ovary, pass from their super- ficial position into the subjacent layer; in this change of place they carry with them ordinary epithelial cells, and thus each ovule is furnished with an envelope which is lined with epithelium, and so the ovisac or Graafian vesicle is formed. According to Pfluger, however, the changes are as follows : the proliferat- ing germ epithelium sends prolonga- tions into the forming mass of the ovary —inversions of the external covering— and thus tubes full of cells, and which become separated from the surface, re- sult. Constrictions occur in these tubes and the portion between the two con- stricted parts, each bead in the strand, represents a Graafian vesicle, the inver- sions of the external covering, at first tubular, then becoming glandular cords. Dr. Foulis, from his investigations as to the development and structure of the ovary, denies the presence of tubular structures, and therefore the formation of Graafian vesicles as given by Pfluger. His statement is this: All1 the ova are derived from the germ epithelial cells. In the development of the ovary small and large groups of the germ epithelial cells become grad- ually embedded in the ever-advancing stroma. Germ epithelial cells do not grow downwards into the substance of the ovary. The ovarian stroma constantly grows outwards, surrounding and embedding certain of the germ epithelial cells. As these latter increase in size, and as the stroma thickens around them, the whole ovary becomes enlarged. Pfluger's tubes in the kitten's ovary have no existence as such, but are appearances produced by long groups of embedded germ epithelial cells, many of which groups are not completely cut off from the germ epithelial layer by the young ovarian stroma. Such growths of germ epithelial cells, in various forms, are met with in all ovaries, but have no importance whatever as tubular structures. No real tubular structures from which Graafian follicles are formed exist in the mammalian ovary at any stage of its development. Scheme of the Homology of the Internal Genital Organs of the Male (A. right side), and of the Female (B. left side).— O. Ovary. T. Testicle. W. Canal of Wolff; in the female it atrophies; in the male it forms the deferent canal. The genital part (1) of the Wolffian body is represented in the male by the epididymis, in the female by the body of Rosenmiiller. The urinary portion (2) forms in the male the paradidymis, in the female the par- ovarium ; it also forms in the male the vas aberrans (x). M. Canal of Muller; it disappears in the male. Its free extremity, which forms in the female the pavilion (P), forms in the male the hydatid of Morgagni {h). Its inferior extremity forms in the female the uterus and the va- gina (O), and in the male the pros- tatic utricle (P). 1 Transactions of the Edinburgh Obstetrical Society, vol. v., 1879. 90 SCIENCE AND ART OF OBSTETRICS. In reference to the general development of the internal generative organs, there is in embryonic life a certain period of sexual indiffer- ence, a period when the substratum for the evolution of a male or a female is alike, and nature gives no indication of her purpose as to which shall be produced. In this connection the homolo- gies between the male and female internal generative organs are of interest; these homologies are well shown in the subjoined illustra- tion from Duval. Anomalies of development of the external sexual organs may be the cause of sterility, but chiefly interest the obstetrician in regard to the determination of sex in some cases of miscarriage, or, in other instances, in which labor occurs after the foetus is viable. At three months the clitoris is as long as the penis, and indeed from the relatively greater size of the former compared with other organs of the vulva in the early months of intra-uterine life, mistakes as to the sex may arise if a thorough examination be not made. At birth, too, if there be congenital hypertrophy of the clitoris, similar error may occur, and a female be thought a male infant. The diffi culty1 is increased if not only the clitoris but also the labia majora be hypertrophied, for with the hypertrophy of the latter organs they may be united higher than normal, and may contain, as has been observed in some cases, the sexual glands. These anomalies may not only lead to mistakes as to the sex in some cases, but in others to the assertion of hermaphroditism. These errors were much more frequent in ancient than in modern times, and led to the sacrifice of many new-born, for the supposed union of the sexes in an individual was regarded as so monstrous that the Athenians threw into the Uterus Unicornis.—LH. Left horn. LI. Left tube. Lo. Left ovary. L Lr. Left round ligament. RH. Right horn. RT. Right tube. Ro. Right ovary. R Lr. Right round ligament. (From Schroder.) sea, the Romans into the Tiber, all infants who were thought her- maphrodites. In most cases of alleged hermaphroditism the con- dition is apparent, not real, and arises when the external generative organs of one sex very closely resemble those of the other • it is 1 Winckel. THE FEMALE SEXUAL ORGANS. 91 called female hermaphroditism when this condition is observed in the female. Anomalies of the uterus and vagina are in most cases plainly caused by arrests of development. Thus in case of duplicity of the vagina, the process of development was arrested after the union of Fig. 56. V a Uterus Bicornis Duplex.—a. Double entrance to vagina, b. Meatus urinarius. c. Clitoris, d. Urethra, e, e. Double vagina, ff. External orifices of uterus, g, g. Double cervix. h, h. Bodies and horns of uterus, i, i. Ovaries, k, k. Tubes. /,/. Round ligaments. m,m. Broad ligaments. (From Kussmaul, after Eisenmann.) that portion of Muller's ducts from which this organ originates, but before absorption of the intervening wall.1 If the vagina be double, usually the same condition is present in the uterus. In some cases 1 A novel explanation of duplicity of the uterus and vagina was published in an American medical journal a year or two since; " There was a superabundance of formative material directed to these parts, and in consequence of the richness of the vitalizing substance, the con- sequence was the formation of double organs.'' 92 SCIENCE AND ART OF OBSTETRICS. one of Muller's ducts atrophies, but the other is developed, and a one-horned uterus results. Miiller's ducts may unite below the insertion of the round ligaments, and the uterus then has two horns. Fir.. 57. Double Vagina and Uterus. In some cases the fundus of the uterus is not developed, but the surface is depressed, and the organ is said to be heart-shaped, or cordiform. The dividing wall in the two parts of Muller's ducts Fig. 58. Bifid Uterus. may be complete, or the lower part absorbed ; in the one case the condition is described as uterus septus, or bipartitus, and in the other as semiseptus, or semipartitus. None of these anomalies pre- vent pregnancy—even plural pregnancy has been observed in the one-horned uterus, each child being perfectly developed ; a foetus may occupy each half of a double uterus, and normal labor occur at different times, showing that the conceptions were not cotempo- raneous. Pregnancy in one horn of a uterus, especially if there be but a single horn, very closely simulates an extra-uterine pregnancy, and doubtless has in many cases been mistaken for it. Illustrations of some of these anomalies are presented in Fio-s. 55-59- THE FEMALE SEXUAL ORGANS. Fig. 59. f Partitioned Uterus. The MammcB.—During the first period of life external to the mother, the young of the class of animals known as mammiferae are nourished by the secretion from certain glands of the mother which are called mammae, while in intra-uterine life they were nourished by her blood. The word mamma is from the Greek fid/n/na. It is remarkable that in many different languages almost the same word is applied to an organ so essential for the growth and develop- ment of the infant, and that this word is usually the one first spoken by the child. The mammae are usually two in the human female ; they are situated one on each side of the chest1 anteriorly, between two layers of the superficial fasciae upon the pectoralis major, 'corresponding with the space from the third to the seventh rib, and separated from each other by the space over the sternum. They are rudimentary in the male, and are also rudimentary in the female until she ap- proaches puberty, when they notably increase in size, but only attain their complete development under the stimulus of pregnancy fol- lowed by lactation. The probable suggestion has been made that when females through a few successive generations fail to nurse their offspring, these glands become permanently lessened in size. In many, if not in most cases, the mammae are of unequal size; though authorities differ as to which, the right or the left, is larger, it is probable that the right breast is the larger in the majority of 1 Plutarch, De Amore Prolis, thus explains the position of the mammse in women : Itaque quidem animalibus ventrem ubera desinunt, mulieri superne ad pectus nascuntur, utin promptu sit osculari, amplectique et fovere infantem : nimirum quiapariendi et alendi finis est non neces- sitas, sed amor. 94 SCIENCE AND ART OF OBSTETRICS. cases. A curious observation is attributed by Ploss1 to the Israelite physicians of the Talmud: The daughters of the wealthy class have the right breast better developed than the left, because of the gar- ment worn over the right shoulder : while the daughters of the poor have the left breast the larger in consequence of using the left arm in drawing water, and in carrying their younger brothers and sisters. The mamma; are usually somewhat hemispherical in form ; but they may be pyriform or conical, and are then by some regarded as indicating a more abundant secretion of milk. The volume of the breasts is not in direct relation with the vital power and force of the individual, nor do these organs if large necessarily indicate abund- ant supply of milk; in some women of delicate organization the breasts may be quite large, or again the great size in an individual case may not be from increase of the glandular tissue, but from an abundant deposit of fat. For convenience of description the breast, in regard to its surface, has been divided into three zones. One of these zones, the periphe- ral, is very much the largest, and presents a smooth, white surface, beneath which the veins may be seen ; if the female has given birth to a child, it is not uncommon to find the skin marked by stries, linece albicantes, similar to those found upon the abdominal wall. The second or middle zone is composed of the areola. The color of the areola is in striking contrast with that of the peripheral portion ; it is a pale rose in virgins, but becomes dark in pregnancy in brunettes, while it changes only slightly in blondes, or in those having red hair: the pigmentation occurring in pregnancy never entirely dis- appears. The areola is one to two inches, or 2.5 to 5 centimetres, in diameter. The skin of the areola contains many sebaceous glands, but in addition to these there are from twelve to twenty papular or tubercle-like projections, sometimes called the glands or tubercles of Montgomery, though it would be more appropriate to give them the name of tubercles of Morgagni, for they were well de- scribed by him more than a century before the great Irish obstetri- cian wrote, in-regard to the nature of which different views are held. Milk may be discharged or pressed out of them during lactation, a fact which, according to Sappey, results from a communicating galactophorous duct, arising from a supplemental lobule of the mam- mary gland, but they are essentially sebaceous glands. De Sinety2 and Duval, however, assert that they communicate with isolated miniature mammary glands ; and according to Depaul, they are rudi- mentary nipples. Whether sebaceous glands or nipples, they are greatly enlarged in pregnancy, thus making one of the most dis- tinctive mammary signs of pregnancy. Beneath the skin of the areola concentric circles of muscular tissue are found ; these circles, 1 Op. cit. 2 De Sinety, op. cit., states there are found upon the region of the areola, besides the sudor- parous glands, three other kinds of glands : simple sebaceous follicles, sebaceous glands divided into several lobes, and finally, isolated true mammiry glands, producing colostrum and milk under the same influences as the chief gland. The nature of these accessory mammary glands has been well established by Duval. THE FEMALE SEXUAL ORGANS. 95 widening as the periphery of the subareolar surface is approached, there cease ; contrary to that observed in the peripheral portion of the breast there is no layer of fat beneath the skin. The third or central zone is that occupied by the nipple. This rises from the centre of the areola, at a point corresponding with the fourth intercostal space ; it is conical or cylindrical, rounded at the summit, and measures nearly half an inch, or twelve to thirteen millimetres, in height, and nearly a third less in thickness. In some subjects, however, the nipple is retracted, so that its upper surface is level with, or beneath the surrounding areola, presenting in the latter case a depression similar to the umbilicus. The surface of the nipple has nearly the color of the areola, and presents a somewhat rough appearance from the numerous thick-set papilla? beneath, and in these papillae, according to de Sinety, corpuscles of Meissner are found. It has no hair follicles, but is abundantly supplied with sebaceous glands; generally a pair of these glands is found at the mouth of each of the fifteen to twenty galactophorous ducts which open at the summit of the nipple; the only part of the nipple in which these glands fail is at its junction with the areola, a matter of some practical importance with reference to the occurrence of fissures at this point during lactation. The nipple is provided with both transverse and longitudinal muscular fibres; contraction of the former causes thelothism,1 or projection of the nipple, from drjly, nipple, and o>f)eu, to push, while retraction of the nipple results from predominance of the action of the longitudinal fibres. Beneath the skin of the peripheral portion a layer of connective and of fatty tissue is found; it becomes thicker at the external circumference of the organ; the skin is supplied with sudoriparous and sebaceous glands and hair follicles. The mam- mary gland is racemose, and is composed of fifteen to twenty lobes, these being separated from each other by fibrous and fatty tissue; the gland mass is thicker at the centre than at the circumference. Each lobe is formed of a num- ber of lobules, and each lobule, in turn, of culs- de-sac, or acini. The structure1 of an acinus from within out is as follows: First, a single layer of cubic cells; second, an incomplete sub-epithelial endothelium; third, the mem- brana propria; fourth, connective tissue abound- ing in cellular elements ; and fifth, a fibrous tissue rich in elastic fibres and very poor in cells. A small duct passes from each acinus to unite with similar ducts from other acini, and by this union of ducts the larger duct of a lobule is formed; the ducts of the lobules of each lobe in their turn unite to form the excretory canal of that lobe, or the galactophorous or milk-duct. The ducts thus formed, Fig. 60. Acinus of the Mammary Gland of an Adult Female during Lactation.—a. Ep- ithelial cells, b. Nucleus. c. Nucleolus, d. Globules of milk. e. Fibres of con- nective tissue. /. Cells of connective tissue. Magni- fied 300 diameters. *( From de Sinety ) 1 Duval. 96 SCIENCE AND ART OF OBSTETRICS. Fig. 61. and equal in number to the entire number of lobes, convey the milk to the upper surface of the nipple ; at the level of the areola the ducts undergo a fusiform dilatation ; this dilated part is known as the lactiferous sinus. It is quite exceptional for the milk-ducts to anastomose with each other. The milk-ducts are lined with cylindrical epithelium ; the ducts of the acini, near the latter, have the same lining as that of the glandular structure, and, like them, secrete milk. The blood supply of the breasts is by the internal and external mammary and intercostal arteries ; the blood is returned through the internal mammary and the axillary veins. The lymphatic vessels are very numerous, and, as described by Sappey, form two planes. The first pre- sents a very delicate network beneath the areola and the nipple ; the second is deep- seated, and is peri-lobular; the vessels do not penetrate into the lobules, but there are numerous lymph spaces in the con- nective tissue surrounding these. All the trunks from the deep layer of lym- phatics are directed toward the areola, and they form a plexus remarkable for the size of the vessels ; from this plexus two, in some cases three, trunks pass to the axillary ganglia. The lymphatics of the skin communicate with the sub-areolar plexus. The nerves come from the fourth, fifth, and sixth intercostals, from the thoracic branches of the brachial plexus, and from the sub-clavicular branches of the cervical plexus. According to Winkler, the vaso-motor nerves come espe- cially from the brachial plexus. Development and Anomalies of the Mammce.—" The first indication of the mammary gland is seen about the third month of intra- uterine life, consisting of an in-growth of cells of the rete mucosum, surrounded by the fibrous tissue of the skin. At about the fifth or sixth month the rudimentary ducts of the lobules are apparent, springing from the central collection of cells."1 At birth the lobes are distinct, and the milk-ducts open at the nipple. A painful swelling of the breasts is sometimes observed in the newborn, male and female; it lasts four or five days, and there can be pressed from the nipple a few drops of colorless viscid liquid, and finally milk.2 Polymastia is much more frequent than amastia? The superfluous breasts are generally found in the axillae, or below the normal ones, but they may be on the thighs, on the back, or in the groins; more rarely they are in the median line, but when here, unlike' those Structure of the Breast. 1 Shakespeare and Simes : Cornil and Ranvier's Pathological Histology. 2 Bouchut: Traite Pratique des Maladies des Nouveau-Nes. 3 William Sneddon, M.D.: Numerical Anomalies of the Breast. THE FEMALE SEXUAL ORGANS. 97 placed in other abnormal positions, they do not secrete. There may be but one of these supernumerary organs, more frequently there are two, and a case has been reported in which there were five. Absence of the nipple is very rare, imperforation less so, and im- perfect developent not at all uncommon. Hypertrophy of the nipple has sometimes been seen ; in one instance this organ was as large as a pigeon's egg. Sometimes the increase of the nipple is in its length only; but even then it may be impossible for the infant to nurse. Imperfect development of the mammary glands is not infre- quent, and examples of primiparae, especially of those American- born, who cannot supply sufficient milk for their infants, are frequently seen. Many of these primiparae whose secretion of milk is so scanty, may after subsequent pregnancies have an abundant supply—a tardy development of the glands occurring. CHAPTER III. PUBERTY—OVULATION—MENSTRUATION. Puberty is that epoch in human life when the individual first becomes capable of reproduction. It occurs about two years earlier in the female than in the male, and the physical and psychical changes characterizing its advent are more marked in the former than in the latter. The girl's pelvis enlarges and her breasts notably increase in size as she enters this period of life ; the one change in- dicates preparation for childbirth, the other provision for the nour- ishment of the newborn. The external genitals are developed, and hair grows upon the mons veneris and upon the labia majora; the circumference of the neck is greater, and the voice changes ; the body is fuller and more gracefully rounded; sharp, irregular and angular outlines are replaced by symmetrical curves, and new beauty of form and of general expression is manifested—it is the spring- time of female life, the bud unfolding into the flower. The girl passing into womanhood puts away childish things, turning from frivolous amusements, from the toys and plays, or from rude sports in which she has found pleasure ; she enters a new life, has new thoughts, desires, and emotions. Hitherto she has been living solely in and for the present; but now the future with its lights and shadows, its hopes and fears, makes a large part of her life. She is more sensitive and reserved, and manifests a modest dignity, giving and expecting respect; her individuality becomes more manifest, her sense of duty stronger, and her ambition greater. This remarkable transformation is the expression of important changes in the internal generative organs, especially in the ovaries, for if the latter be absent or undeveloped, the distinctive sexual characteristics fail. During infancy and childhood the ovaries slumbered; nature's forces were busy building1 up the individual, and it is only when this end has been in good degree attained pro- vision is made for the continuance of the race. The ovaries now awaken from their silent, inactive state, notably increase in size, and enter upon the discharge of their special function : they determine the sexual character, and for thirty years or more exercise a domi- nant influence upon the female organism; commonly designated as uterine appendages, in a true physiology the uterus ought to be regarded as their appendage. The function of the ovaries is the maturing and rupture of ovisacs, with the consequent escape of ovules which are thus offered for impregnation; this orocess is known as ovulation, and as it occurs independently of sexual con- gress, it is called spontaneous ovulation. Until recent years phys- iologists have generally held that ovulation usually occurs at regular 1 Spiegelberg. PUBERTY— OVULATION—MENSTRUATION. 99 periods, but many now maintain that this is not true, and that the ripening and rupture of ovisacs go on independently of definite times; in a word, that ovulation is not periodical. During her reproductive life the human female has, unless pregnant or nursing, once a month a discharge of blood from the uterus, usually lasting from two to six days. This discharge is frequently called the menses, or months, and during it the subject is said to menstruate, each term pointing to the periodicity of the occurrence But, as will be explained hereafter, menstruation is not such a simple pro- cess, and the external flow is the mere sign of more important changes occurring in the ovaries and uterus, especially in the latter. While reproduction is possible at the beginning of puberty, science and experience alike condemn such early exercise of this important power. As in the male, premature exercise of the sexual organs is, to use the words of Hufeland, the surest means of inocu- lating old age, so early maternity brings increased morbidity and mortality to the female, while her offspring will be less well de- veloped, have less vital power, greater liability to disease and to early death than they would have had that maternity been delayed ; the general law of both animal and vegetable world is that early reproduction gives an inferior product. Woman's form is not, as a rule, well developed before she is twenty years old; her pelvis, which has been called the laboratory of generation, has not its per- fect shape until then ; hence an earlier maternity is not advisable. Moreover, she lacks the mental and moral growth necessary for the grave responsibilities of motherhood. Modern physiology and large experience confirm the judgment of Plato, the wisest of Greeks, in his rule that "A woman may bear children to the State at twenty years of age."1 The physician, whose duty is not only to heal the sick, but also to prevent disease and to improve the race, and hence who must be a teacher of men and women, should teach sound doctrine in regard to the injurious re- sults of precocious marriage. Mothers especially ought to be taught, though some have learned the lesson by their own sad experience, that puberty and nubility are not equivalent terms, but stand for periods of life usually separated by some years ; the one indicates capability, the Ovary with Ripe Ovisac. otherfitness for reproduction. Ovulation.—A brief statement of the process by which the ovule is liberated from the ovisac, and its following migration into the uterine cavity, will now be given. The ovigenous layer at birth i The Republic. 100 SCIENCE AND ART OF OBSTETRICS. forms almost the entire ovary, but soon after the bulbous portion begins to increase in size, while the former remains without notable change in bulk until the approach of puberty. As this period draws near several of the ovisacs grow rapidly; one of them becomes prominent by its great development; it may be as large as a cherry, and forms quite a projection from the surface of the ovary, as seen in Fig. 62. The growth of the ovisac causes increased flow of blood to the ovary; the emergent veins of the bulb having larger and thinner walls than the arteries bringing blood to it, are compressed by the contraction of the muscular tissue they traverse, and hence an in- crease of vascular tension in the entire organ, including not only the bulb, but also the ovisac. The contents of the sac augment, and its walls are more distended; the increased fluid in the ovisac is by some attributed to the breaking down of part of the cells of the membrana granulosa, or to a secretion of fluid by them ; according to some an intra-vesicular hemorrhage occurs, in many cases the blood forms a clot, and the effused blood is one source of the dis- tention. Rupture of the ovisac at last takes place, caused chiefly by distention, but also by fatty degeneration of the wall of the ovisac at its peripheric pole. An assisting cause, according to some, is muscular contraction of the ovary which has been depressed at that part where the ovisac was growing, and which under the stimulus of increase of blood, tends to efface that depression, thus lifting the ovisac out of its bed. Rouget believes that another factor in causing rupture is the action of the contractile coat of the ovisac. When the sac bursts the ovule surrounded by the proligerous disk escapes, and is received by the oviduct. With the development of the ovisac, there is a notable increase in the size of the ovary; this temporary increase affects chiefly the vertical and antero-posterior measure- ments, but only slightly the longitudinal measurement of the organ. Various explanations have been given of the transfer of the ovule to the oviduct. According to Rouget, the real, the only possible mechanism, is that which depends upon the fact that the uterus, the ovaries, and the oviducts are formed of a common muscular mem- brane, and by the contraction of muscular fasciculi the pavilion is applied to the ovary so as to receive the ovule. In some of the inferior animals the ovary and oviduct are inclosed in a common capsule, and thus escape of the ovule into the abdominal cavity is effectually prevented. In the bitch this inclosing capsule has a narrow slit, but in the bear and otter, and in some other animals it is entire. This formation is attributed by Rouget to an accident of evolution which has become permanent. Some have attributed the transfer of the ovule to the oviduct to the contraction of the elastic wall of the ovisac. A less improbable explanation is that which rests upon the presence, as first pointed out by Henle, of a gutter or canal upon the upper surface of the tubo-ovarian iigament through which the ovule passes into the oviduct, its progress being caused by the movements of the cilia of PUBERTY — OVULATION--MENSTRUATION. IOI the epithelium belonging to this structure. It has also been asserted that the transfer is effected indirectly by the movements of the cilia of the pavilion, causing a constant current to the oviducts of the fluid moistening the peritoneum ; the presence of this current has been proved by the fact that coloring matter introduced into the peritoneal cavity of animals, is afterward found in the oviducts and in the uterus. Cases of what is called the external migration of the ovule—that is, entrance of the ovule into the oviduct of the left side, for example, when it was discharged from the right ovary, are thus explained; the vibratile current of the oviduct receiving the ovule is stronger than that of the one nearest which it is when the ovisac bursts. After the ovule has entered the oviduct its further passage to the uterus is secured by the movements of the cilia and by peristaltic contractions of the oviduct. The experiments of Bruzzi1 upon rabbits have conclusively proved that external migration of ovules occurs; thus, for example, he endeavored, but failed, to cause extra-uterine pregnancy by remov- ing the ovary on one side, and ligating the oviduct of the other ovary, but copulation was followed by normal pregnancy, thus prov- ing that the ovules coming from the remaining ovary had passed through the pervious duct of the opposite side. The ovisac—its size lessened by the escape of the ovule and its surrounding granular matter, and of serous fluid, and the rent through which these passed closing—undergoes certain changes, which result in its obliteration, the most notable of these being the formation of the corpus luteum or yellow body. As observed by Raciborski, the term " yellow," as applied to these bodies, is incor- rect ; for while true of them as found in the ovary of the human female, yet in many of the inferior animals they do not have this color; thus, in the cow they are deep orange, in sows a whitish- gray, etc. Hence he proposed as a substitute for corpus luteum the word metoarion, from fiera, after, and bapiov, the ovule, and some have adopted it; but corpus luteum, with its plural corpora lutea, is in such general use by obstetric authors that it will be retained. The formation of the corpus luteum is due chiefly to hypertrophy of the membrana propria, or reticulata, of the ovisac; the yellow color re- sults from refracting granulations2 more or less colored, either free or contained in cells; lymph cells are also found; the endothelial lining, or membrana granulosa, does not participate in the formation of the corpus luteum. Raciborski asserts that an intra-vesicular hemorrhage occurs prior to the bursting of the ovisac, while Dal- ton's investigations have led him to conclude that the hemorrhage is simultaneous with or immediately after the rupture; still others regard the hemorrhage as not constant, but accidental and occa- sional, and should it occur the process of the formation of the cor- pus luteum is hindered rather than assisted. Benckhiser,3 from his studies of the corpus luteum in swine, concluded that a coagulum 1 Annales de Gynecologie, Janvier, 1885. 2 De Sinety. 3 Archiv fiir Gynakologie, 1884. 102 SCIENCE AND ART OF OBSTETRICS. was an inconstant and unnecessary condition for the formation of this body. I have examined very many corpora lutea in swine and in sheep, and have never yet found a blood-clot in the ruptured ovisac. In consequence of the limited space offered, the membrana propria from its hypertrophy is thrown into folds like the cerebral convolu- tions; these folds project toward the cavity of the ovisac, and crowded to each other from opposite sides, meet and then unite, thus obliterating that cavity. The hypertrophy does not begin until after the ovisac has burst, and hence cannot be a cause of that event. Fig. 64. Fig. 65. Graafian Follicle of the Human Ovary; Human Ovary cut open; showing a corpus recently ruptured during menstruation, and luteum divided longitudinally. filled with coagulated blood; longitudinal section.—a. Tissue of the ovary, containing unruptured ovisacs. b. Vesicular membrane of the ruptured follicle. c. Point of rupture. The growth of the corpus luteum reaches its maximum in thirty days, according to Dalton, in ten according to Coste, and is followed by atrophy, so that at the end of eight or nine weeks there remains of the entire mass a mere lamina of fibrous tissue, situated just beneath a pit or depression on the sur- face of the ovary, marking the place where the ovisac burst; according to Robin, there may also be found, in some cases, fat glo- bules, or free fat, and amorphous, or crys- talline coloring matter. During the regres- sion of the corpora lutea the color becomes much lighter, white, instead of yellow, so that they are sometimes called corpora albicantes. True and False Corpora Lutea.—Should Human Ovary; showing a corpus luteum, nine weeks after menstruation. From a girl dead the ovule be impregnated, the corpus luteum of tubercular meningitis. reaches a larger size and continues longer. Hence a distinction has been made between the corpus luteum of menstruation and that of pregnaney, the one being called false, the other true. But such terms are misleading, PUBERTY--OVULATION--MENSTRUATION. IO3 for these bodies, though, as before said, differing in size and dura- tion, are essentially the same. The history of the corpus luteum of menstruation has been given. The corpus luteum of pregnancy grows for thirty or forty days after conception ; it then remains stationary until the end of the fourth month, when it begins to les- sen, so that at the end of nine months it has only two-thirds its greatest size, and in a month after delivery is reduced to a small, indurated mass. In some cases, however, the growth of the corpus luteum of pregnancy may continue longer than has been indicated, while in others the regression may be more rapid; there is no abso- lute, only a general rule applicable to either. Fig. 66. Fig. 67. Corpus Luteum of Pregnancy at the End of Fourth Corpus Luteum of Pregnancy at Month. From a woman dead by poison. Term. From a woman dead in de- livery from rupture of the uterus. Menstruation.—This is a temporary and intermittent function of the female organism, and has as its most obvious phenomenon a dis- charge of blood from the genital canal The function is temporary, for it does not begin until puberty, and it ceases in almost all cases when the reproductive period of life ends. It is intermittent, usually recurring at regular periods each month, but also presents longer intervals of absence, as during pregnancy and lactation. The study of menstruation includes that of its general and local phenomena, the character, duration, and quantity of the discharge, and its periodicity; the time of life when it begins, and that when it ceases; and the theories which have been proposed explaining its occurrence, especially in its connection with ovulation. The general phenomena of menstruation are chiefly those con- nected with innervation and circulation. The reflex sensibility is increased; occasional chilliness and flashes of heat, neuralgic pains in various parts of the body may occur, and either light or grave manifestations of hysteria; some females during menstruation are drowsy, and few are disposed to exercise the usual activity of daily life, but rather seek rest, if not seclusion ; sensitiveness to moral or to physical impressions is greater. There is in many cases conges- 104 SCIENCE AND ART OF OBSTETRICS. Fig. 68. tion or irritation of various parts or organs of the body; the breasts may be swollen and painful; there may be sensations of fulness and throbbing pain in the head; the face is flushed in many cases, a dark circle is about the eyes, and an eruption may occur upon the skin ; some are attacked with diarrhoea, many with irritability of the bladder; the thyroid gland is larger, and some have a mild tonsillitis. The local phenomena are those connected with the generative organs. The external organs are swollen, and have increased sensibility ; there are a feeling of fulness, of weight, and of " bearing- down " in the pelvis, backache, pain or increased sensibility referred to the iliac fossae, and some fulness or me- teorism of the lower part of the abdo- men. Few women, at least among the civilized, when menstruating, are en- tirely exempt from physical discom- fort, so that the expression, "being unwell," used for this function by many, is something more than a mere euphemism. Very important changes occur in the internal sexual organs. Increased determination of blood to these causes congestion, and in some a temporary hypertrophy. This transitory hyper- trophy is especially manifested in the ovaries and in the uterus. The latter organ is increased in size one-fourth, one-third, or even more; its muscular fibres present a reddish appearance, and they are swelled and less firm. The mucous membrane, in conse- quence of excessive hyperaemia, is greatly swelled, and thrown into folds, " recalling by its anfractuosities and projections the aspect of the cerebral convolutions;" the orifices of the glands are more distinct, and pour out an abundant secretion, which is the prelude to the sanguineous dis- charge. The vaginal cervix is swelled and softer, and presents a deeper hue than in the menstrual interval; the os is somewhat open. The mucous membrane of the vagina presents a dark red, in some cases a violet color; it is swelled, and there is a slight elevation in its temperature. The phenomena of congestion and increased secretory activity are followed by hemorrhage. Section through Mucous Membrane of the Virgin Womb.—61. Mucous mem- brane. D. Uterine glands with funnel- shaped stria. M. Muscular stratum. 40 x. (After Engelmann.) PUBERTY—OVULATION--MENSTRUATION. 105 The hemorrhage results from the hyperaemia being so great that, according to some, rupture of the capillaries of the mucous mem- brane of the cavity of the body occurs. Menstruation, in its con- gestion and discharge of blood, has been called a diminutive of pregnancy, while Baudelocque called it a periodical abortion. The capillary tension immediately preceding the rupture of these vessels is explained by contraction of the muscular fasciculi inclosing the vessels of supply and return, this contraction affecting the veins more than the arteries, in consequence of the thin walls of the former, and by contraction of the muscular rings surrounding the large uterine veins. While rupture of the capillaries is chiefly due to their great distention, fatty degeneration with detachment of the superficial epithelial cells is held by some to facilitate this rupture. This statement is according to Dr. Engelmann's researches. Williams asserts1 that the entire mucous membrane is cast off, thus leaving the muscular surface bare, and that a new mucous membrane is produced therefrom; the physiological objection to this theory is apparent and seems insuperable. Leopold states that fatty degeneration instead of preceding, and in any degree causing the menstrual hemorrhage, occurs during its progress. Fritsch2 remarks that recently strong arguments have been adduced against these views, and that it is a mistake to attribute the hemorrhage to fatty degeneration, for in case of completely intact mucous membrane diapedesis occurs, the blood transuding from the vessels. We therefore return to the old theory which considered the hemorrhage as a result of the greatly swelled and distended vessels. Perhaps the arrangement of the vessels in the mucous membrane is important, for, according to Leopold, more vessels pass to than come from it. Haller, Hunter, and many other illustrious physiologists and physicians regarded the menstrual flow as a secretion. Among American medical teachers, both the late Dr. Dewees and Dr. Hodge earnestly upheld this view. On the other hand, the late Dr. Charles D. Meigs3 treated this opinion with unsparing ridicule, ex- claiming : " I leave it to the student, therefore, to settle with his own judgment the question how can blood-disks be the subjects of secretory action ? Can solids be secreted ? Could not a woman as well secrete a watch or a diamond ring as one single blood-disk ?'' No one now maintains the doctrine that the menstrual discharge is a secretion, but all consider it a hemorrhage, though different explanations are given of its occurrence. Character, Duration, and Quantity of the Menstrual Flow.—At the beginning of the monthly flow the discharge is chiefly serous or mucous, slightly tinged with blood; but as it continues the number of red globules increases until it is almost pure blood, having the color of that which escapes from a vein, though Dewees described the color as resembling that of mixed arterial and venous blood. The color, however, varies; thus, it may be very light, and the fluid almost watery in the chlorotic, and excessively dark if there be great venous congestion. The odor of the menstrual fluid has been compared to that of the marigold; it is due, in most cases, to long retention of the fluid in the uterus, or in the vagina, or else to the admixture of secretions from the genital glands. The fluid contains, in addition to red globules, white cells, globules of mucus, and 1 Obstetrical Journal of Great Britain and Ireland, 1875. 2 Krankheiten der Frauen. 3 Obstetrics: The Science and Art. 106 SCIENCE AND ART OF OBSTETRICS. epithelial cells from the uterus and from the vagina, the last increas- ing at the end of the discharge. It is alkaline, and usually does not coagulate; the non-coagulation is generally attributed to the intimate mixture of the secretion of the uterine glands with it, but Delore says that the blood flows so slowly from the uterus that it is in part defibrinated; however, the discharge of clots is frequently observed if the flow be profuse, and in some cases without this condition being present. The quantity of the discharge was asserted by Hippocrates to be eighteen ounces, but the usual estimate is four to six ounces, or about 128 to 192 grammes. According to Tarnier, if the flow amounts to 500 grammes, or between thirteen and fourteen ounces, there is menorrhagia. Sims suggested that by the number of napkins needed in twenty-four hours, the quantity could be determined; in a normal menstruation only three or four napkins being required in that time. Many have regarded climate as an important factor in determining the duration of the menstrual flow; among recent authorities, for example, both Playfair1 and Harris2 refer to this flow as being more profuse in warm climates; cold climates, on the other hand, have been thought to lessen the flow. This belief is erroneous, and, according to Raciborski,3 is especially founded upon the old theory of menstruation which regarded it as resulting from plethora. He quotes the statistics of Faye, of Christiania, and of Peixoto, of Rio Janeiro, showing that the menstrual epochs and the quantity of the flow in these climates present the same variations which are met in central Europe. Saint Vel, whose observations were made in Martinique, regarded climate as without influence, but attributed the menor- rhagia from which European women might suffer as owing to the anaemia resulting from malarial infection, and thus they were pre- disposed to the increased flow. The observations of Hewan upon menstruation in women upon the coast of Old Calabar, showed that the flow lasted from three to four days; and those of RochebruneJ in regard to this function in the Woloff negresses, that it lasted only three days and was slight. F. Weber5 has shown that at St. Petersburg the early or later beginning of menstruation has but a subordinate influence in the amount of the discharge; but he attributes an important role to the bodily constitution and the color of the hair. He rejects the opinion that menstruation is more profuse in brunettes than in other women, since it is very often abundant in blondes, and especially in women with red hair. A generous diet increases the flow, while it is lessened by scanty and unsuitable food. Excessive sexual intercourse may cause the flow to be greater, and so, too, a profound mental impression— though in most cases this arrests it—may for the time have such an effect. Idiosyncrasy in many cases has an important influence, and, 1 System of Midwifery. a Traite de la Menstruation. 5 St. Petersburger med. Wochenschrift, 1883. - Notes to Playfair's Midwifery. 1 Revue d'Anthropologie, 1881. PUBERTY—OVULATION—MENSTRUATION. 107 as so earnestly asserted by the late Dr. Hodge, every woman is a law unto herself as to the quantity of the monthly discharge, so that a physiological amount in one maybe pathological in another. The best criterion of a normal flow is the effect upon the general health; if that be not injuriously influenced the flow is neither too great nor too small. Hippocrates declared that the menstrual blood was as pure as that of a victim. Nevertheless this just opinion has not been held by primitive people; among them the menstruating woman was unclean,1 and even one of the most learned of ancient Romans, Pliny,2 has attributed to the monthly discharge such serious results that his statements are amusing from their absurdity. Recurrence and Duration of the Flow.—The intervals between menstruations are not the same for all women, and seldom, in rare cases only, the same for the individual; variations of a day or more are frequently observed, the flow either delaying or anticipating, in most women. The terms menses, catamenia, "monthlies," Monats- fluss, etc., point to the monthly recurrence of this function ; so, too, the word moons, used by the Chinese for this flow, has similar sig- nificance; it also points to the old belief of this function being subject to lunar influence. Goodman's statistics show that from the middle of one menstruation to the middle of the next is a fraction under twenty-eight days, or nearly one lunar month.3 On the other hand, according to Dubois and Courty, the typical interval is a solar month ; this is also the statement of Stoltz. Deviations from this interval may be observed; thus, one woman may menstruate every three weeks, or even more frequently, while another may have the flow only once in six or eight weeks. The duration of the discharge varies; usually it is from three to six days; it is probable that, as stated by Hippocrates, a larger pro- portion of women have the flow three than any other number of days. In some the discharge lasts but one or two days, while in others it continues eight or ten. In this, too, we are reminded that every woman is a law unto herself. 1 The Mosaic regulations as to menstruation are well known. It is stated by Raciborski and others that these were founded upon a wise hygiene, since the investigations of Diday, of Lyons, have proved that a chronic urethritis in the male may be caused by coitus during menstruation ; moreover it is probable that the menstrual fluid would have peculiarly irritating properties in the climate of Egypt. Even during some of the earlier Christian centuries women were con- sidered unclean while menstruating, and not allowed to partake of the " communion.'' Ploss observes (op. cit.), after referring to the general belief of the uncleanness of a menstruating woman, and the regulations to which she was then subjected: "We find such rigid rules, in which hygiene and religion unite, especially in the Indo-German race, in the Indian, as well as the Semitic, Jewish, and Arabian." 2 He asserted that at the approach of a menstruating woman must was made sour, seeds touched by her became sterile, garden plants are from like causes parched, and grafts wither; the fruit falls from trees beneath which she sits, her glance dims the brightness of mirrors, blunts the edge of steel, and removes the polish from ivory; dogs licking the discharge are seized with madness, and their bite is venomous and fatal. There may be appended to this terrible invective the statement that one of the fables as to the death of Lucretius is, that his jealous wife compelled him to drink menstrual blood, and mad- ness with death followed. Paracelsus asserted that the devil made of this discharge spiders, fleas, caterpillars, and all other insects that infest the air or earth. 3 Transactions of the American Gynecological Society, vol. ii. 108 SCIENCE AND ART OF OBSTETRICS. Causes Influencing the First Menstruation. Climate.—In temperate climates girls usually begin to menstruate when from thirteen to fourteen years old; in warm climates the function occurs earlier, in cold later. Raciborski1 states that a year's difference in puberty corresponds to a difference of eight or nine, sometimes of only four, degrees of latitude. His tables, including 25,952 observations, show that there is a difference of three years, ten months, and thirteen days between the time of the first menstruation of girls living in Central Asia and that of those living in Lapland. Krieger2 gives as the two extremes, eighteen years in Swedish Lapland, and ten years each in Egypt and in Sierra Leone. Race.—The daughters of English residents in India do not men- struate as early as Hindoo girls. " Negresses born under the burn- ing sky of Africa or of South America menstruate early, and those born in Europe are equally precocious."3 The Jewish race, which so strikingly keeps its individuality in all ages and places, and among all peoples, shows in regard to the first occurrence of menstruation but little differences of time, no matter what differences of latitude are compared. Residence.—Girls living in cities usually menstruate earlier than those living in the country. The country girl has a simpler diet, breathes a purer air; she has regular and abundant time for sleep, and is much less exposed to special causes of nervous excitement which are so prevalent in cities. Theatres, dances, novel-reading, frequent association with the male sex in schools or in society, too constant or improper musical culture, too rich and stimulating food, witnessing, if not at times participating in fashionable life, are among the factors which hasten female puberty in cities. It has been stated by physiologists that girls working in factories or elsewhere, constantly associated with males, have in many cases precocious menstruation. On the other hand, there are many girls in our large cities whose puberty is delayed. These are found among the very poor. They have insufficient food, are poorly clothed and housed, denied fresh air and sufficient rest, and compelled to toil beyond their strength ; their growth is checked, their bodies stunted, and hence failure in the vital power needed for sexual development. Heredity.—This influence, independent of race, is observed in some cases. Thus a mother menstruates early or late, and the peculiarity is transmitted to her female descendants. The Genital Sense.—The genital sense has been defined by Raci- borski as the greater or less vigor shown in the development of ovisacs ; it varies greatly in individuals, and has an important influ- ence in determining the time of the first menstruation. In some cases it proves superior to the influence of climate, and hence there may be precocious menstruation in cold, and delayed menstruation in warm climates. It is often hereditary. Precocious menstruation is to be attributed to the great power of the genital sense. Some 1 Op. cit. 2 Die Menstruation. 3 Depaul. PUBERTY--OVULATION--MENSTRUATION. IO9 years ago I reported1 a case in which menstruation began at three years and a half, and continued regularly. Ploss has collected forty- five instances of precocious menstruation, the oldest of the subjects being in her eighth year. But in some of these girls there was disease of the ovaries, in others hydrocephalus, and in still others rickets; nevertheless, the majority were healthy. In some in- stances of precocious menstruation precocious maternity was ob- served. Raciborski has given the name of emmenic monstrosities to infants or children who menstruated. Apathy of the genital sense is manifested by delayed menstrua- tion2 in persons whose health is good. This delay may extend to four or five years, or even a longer time, beyond the period when menstruation usually begins; in some cases menstruation did not occur until after one or more pregnancies, but of course the proba- bility of conception prior to the establishment of this function is very small. The Menopause.—The menopause, from p.yv, month, and -avoig, ces- sation, is the end of the menstrual life. It is influenced by various causes, such as social condition, climate, and race; and hence pre- sents as great differences in time as does the beginning of menstru- ation. The menopause occurs somewhat sooner in the poor than in the rich, probably earlier in cold than in warm climates, and also in the black races than in the white. Some cease to menstruate in the third decade, while in others the function is continued into the sixth ; thus Courty mentions the case of a woman who still men- struated regularly at sixty-five years. Charpentier states that in a woman under his observation menstruation ceased at forty-eight, but, after being absent for twelve years, returned, and continued for two years, the recurrence and quantity being normal. The following remarkable case was recorded by the most eminent of American physicians, Dr. Rush :3 " I met with one woman, a na- tive of Herefordshire, in England, who is now in the one-hundredth year of her age, who had a child at sixty, menstruated till eighty, and frequently suckled two of her children, though born in succes- sion to each other, at the same time. She had passed the greatest part of her life over a washtub." Gibbon4 states that Asima, the mother of Abdallah, when she was ninety years of age, upon hearing that her son was dead, had her menses return. Elsev/here it is stated that the flow was fatal in five days. Such hemorrhage and at so advanced an age would not be regarded by a physician as menstruation. If the puberty be early, the menopause will be late, while on the other hand delayed puberty indicates early cessation of the monthly 1 Cincinnati Journal of Medicine, 1866. 2 According to Villaret, Joan of Arc was "exempt from the tribute which women pay the moon ; " and he suggests that this exemption was due to her high destiny. She was only twenty years old when executed, so that admitting the fact of her amenorrhcea, it is possible she had simply delay in the establishment of menstruation. 3 Medical Inquiries and Observations, 1793, Philadelphia. * Decline and Fall of the Roman Empire. I 10 SCIENCE AND ART OF OBSTETRICS. flow. According to Petrequin's statistics,1 one-eighth of women cease to menstruate when between thirty-five and forty years of age, one- fourth from forty to forty-five, one-half from forty-five to fifty, and one-eighth from fifty to fifty-five. The obstetrician should remember that as girls have conceived before menstruating, so conception has occurred months and even years after the menopause. Theories of Menstruation. Connection between Menstruation and Ovulation.—Probably the earliest theory of menstruation is the chemical, or that which holds that certain materials which would otherwise be injurious to the organism are eliminated by the dis- charge. This view was to some degree expressed by pronouncing a woman unclean during the flow; even to-day, as remarked by Fritsch, the expression monatliche Reinigung, monthly cleansing, is retained. In recent years the doctrine has to a slight degree found a scientific basis in this, that the quantity of carbon burned by man increases up to thirty years, while in the female who menstruates it remains the same, and hence, according to Aran, menstruation serves to eliminate a certain amount of carbon from her organism. Dr. H. Newell Martin2 suggests that there maybe some truth in a modification of the purification theory, saying : " One important function of the mucous secretion of the alimentary canal appears to be that the mucus entangles and carries on with it to the rectum indigestible and other possibly harmful solid particles, as microbes. The uterus not merely cleanses itself by secretion and expulsion of mucus, which might sweep and cleanse its lining membrane, but discharges during menstruation all the superficial parts of that mem- brane. We know that lying-in women are especially liable to be infected by pathogenic bacterial organisms ; and in the earlier stages of its evolution, when the egg is still segmenting and the decidua reflexa forming, it may well be that the young embryo might be easily infected by extraneous organisms. This view gives us one logical meaning for menstruation. It gives us a reason for that entire casting off of the surface layers of the mucous lining of the womb which occurs each month. Menstruation breaks down and discharges all the old mucous membrane, and gets rid of bacteria which may have entered through the os and found a suitable nidus for development. Hence, in a modified form, the purification doc- trine is still tenable as giving a physiological reason for menstrua- tion." This ingenious hypothesis is open to two objections. All ob- servers do not teach the breaking down and discharge of " the old mucous membrane" as a phenomenon of menstruation, and accord- ing to some of the best it does not occur; the presence of pathogenic microbes, or microbes of any sort, in the healthy uterine cavity has not been proved, but disproved. The theory that the flow results from plethora is one of the oldest 1 American System of Obstetrics, vol. i. 2 Quoted by Tarni PUBERTY — OVULATION--MENSTRUATION. I II and most generally adopted. As the woman had to nourish the unborn babe she was supposed to be endowed with superior blood- making power. But if she did not conceive, a superfluous quantity of blood was made, and nature brought the entire amount in her body to the normal level by periodical hemorrhages from the womb. Some made the function peculiar to civilized women. Thus Roussel asserted that in the primitive or savage state women were exempt from menstruation; hard work and simple fare prevented them from being plethoric, and hence no hemorrhage occurred, as it was not needed ; but it was necessary in the case of civilized women, because they had less exercise and more abundant and better food. Auber also denied that menstruation occurred in savage women, and asserted that it happened in the civilized because of failure to gratify the reproductive instinct, and thus became a habit.1 Some recent writers, too, have sought to establish the pathological char- acter of menstruation ; in other words, menstruation is a disease which impregnation would prevent. For the moment admitting that Auber's theory is correct, that is, menstruation occurs from failure to satisfy the reproductive instinct, it has been suggested that a girl might be impregnated prior to menstruation, and then as soon as possible after her delivery let her be again impregnated, and thus through her entire reproductive life. At the end of that life she would have given birth to thirty or forty children, and if her example were to be generally followed, society would demand a new proclama- tion of Malthusianism. It is hardly necessary to state that menstru- ation occurs in savage women, and there is not the slightest proba- bility that at any period in the history of the race in any land women ever lived who, as a rule, became mothers without being subject to menstruation. It has been suggested that the menstrual hemorrhage is for the purpose of relieving a local plethora, that of the sexual organs, especially of the uterus, hypertrophy of its mucous mem- brane with consequent formation of a deciduous membrane being thus prevented. Dr. John Goodman has advanced the theory that menstruation is dependent upon a law of monthly periodicity. This law is the re- sultant and exponent of recurring cycles of physiological acts; these monthly cycles are supposed to depend upon the ganglionic nervous system. But, as remarked by de Sinety, to attribute the flow to the nervous system explains nothing. Passing from these theories, which have little more than mere historical interest, we turn to that which is founded upon ovulation, and which, though different explanations of the relations between the two phenomena may be held, meets with general professional acceptance. The view that has hitherto been commonly received, 1 Dr. Gill Wylie, of New York, has recently given (American System of Gynecology) a quasi-endorsement to the civilization theory of menstruation : "Although the generative organs are essential to reproduction, they are not essential to the individual, and are not necessarily used, Therefore, menstruation may be intended to take the place of the free exercise of the function of these organs, and thus compensate for the restraint and disuse so much and so necessarily practised by civilized races.'' 112 SCIENCE AND ART OF OBSTETRICS. and is still held by many, is that ovulation is periodical, the growth and rupture of an ovisac corresponding with each menstruation. As the ovisac grows it presses upon ovarian nerves, and by reflex irritation causes congestion of the internal generative organs, espe- cially of the uterus: the uterine hyperaemia results in hemorrhage from its mucous surface. Here the question arises as to whether this hemorrhage is facilitated by desquamation of the superficial epithelium, resulting from fatty degeneration, complete casting-off of the mucous membrane being rejected. According to some this superficial desquamation does not occur until the close of menstrua- tion, and therefore has nothing to do with the hemorrhage. Again, excellent authorities state that they have failed to find the proof of elimination of the superficial portion of the mucous membrane in menstruation. De Sinety, in examining the discharge during the monthly flow, could not discover the least fragment of mucous mem- brane or of epithelium ; so, too; in women dying while menstruating, he found the uterine mucous membrane entire in all its extent. Winckel1 says : " Since Ruge and Moericke have found that during menstruation the ciliated epithelium of the uterine mucous mem- brane remains intact, an observation which we have repeatedly con- firmed, the earlier view that during menstruation a fatty degeneration of the superficial layers was a cause of menstruation is incorrect." Admitting these statements, the necessary conclusion is, that the hemorrhage in menstruation occurs without destruction of any part of the uterine mucous membrane, and that the blood escapes from the superficial vessels, not by their rupture, but by diapedesis and through an intact mucous membrane. The periodicity of menstruation can be most readily explained by attributing it to the ripening of an ovisac, for this, like other pro- cesses of growth, would naturally be supposed to require a certain time. Again, this interpretation of the connection between ovula- tion and menstruation corresponds with what we know of ovulation and "rut" or "heat" in animals, which is the analogue of men- struation. Nature's legislation is general rather than special, and it is not probable she would make one law relating to reproduction for animals in general, and then a special law for human beings. But without pressing this point, let us see the proofs that are adduced to show that ovulation is not periodical. The results of Leopold's investigations are thus given by Foektistow :2 Fully developed follicles, those already ruptured, and fresh corpora lutea may be found at any time during the inter-menstrual period. These may not be present during menstruation. Hence ovulation occurs without menstruation, and menstruation may occur without simul- taneous rupture of the follicles. Ovulation, therefore, is independ- ent of menstruation, and is not periodical. Nevertheless, while Leo- pold denies the dependence of menstruation upon periodical ovula- tion, he does make it depend upon the ovaries, and he regards its 1 Lehrbuch der Frauenkrankheiten, 1886. 2 Archiv fiir Gynakologie, Band xxvii. PUBERTY — OVULATION--MENSTRUATION. I I 3 periodicity as placing it in the category of rhythmical manifestations, e.g., the pulse, respiration, or ejaculation of semen. The uterine hyperaemia results as a reflex from the ovaries caused, not by the ripening of an ovisac, but by the continued growth of several. Foektistow, in answer to the question why does not men- struation occur more frequently, gives these reasons: Comparatively slight ovarian irritation is not sufficient to cause a reflex so soon. The essential, too, of the menstrual process, is that anaemia follows hyperaemia, and irritability ceases. Equilibrium is restored, and to cause another reflex another sum of irritations is necessary, and these cannot occur at once. The changes in the uterine epithelium which began with the hyperaemia, pass away with the following anaemia, and the epithelium returns to its normal condition, a pro- cess which continues through more than one-half of the inter-men- strual period. Another theory of menstruation which is founded upon ovulation is that of Lowenthal.1 According to him, the ovule reaches the uterus before impregnation ; if it be impregnated, menstruation does not occur, but if it is not impregnated, it excites a uterine conges- tion which ends in hemorrhage. Winckel2 observes the Achilles heel of this bold hypothesis is that the death of the ovule can cause active congestion of the uterus. Further, this hypothesis is a revival of an old one; that is, menstruation results from the failure of im- pregnation, and is entitled to no more credence in its new than it was in its old form. Auvard3 holds that the menstrual function is composed essen- tially of two phenomena, ovulation and genital hemorrhage; these two phenomena are independent of each other, but dependent upon the same cause, this cause being unknown, and resulting from the constitution of the organism: in a physiological state they are associated, and on the contrary frequently dissociated in a patho- logical condition. He asserts further, that a genital flow simulating the discharge is not menstruation if ovulation is absent, any more than is ovulation without hemorrhage. It may be, as stated by de Sinety, that any positive theory of menstruation is, with our present knowledge, premature; neverthe- less it must be admitted that this function is connected with the ovaries, for if these organs are congenitally absent, or if they are undeveloped, menstruation does not occur. So, too, after double ovariotomy menstruation ceases. The exceptions to this rule cannot be admitted until a careful post-mortem examination has proved that no fragment of ovarian tissue has been left behind in the lower portion of the pedicle, as has happened in some cases. Women have borne children after both ovaries were believed to have been removed. Olshausen performed, as he thought, ovariotomy, but 1 Archiv fur Gynakologie, 1885. 2 Op. cit. 3 Travaux d'Obstetrique, tome premier, Paris, 1889. This hypothesis fails in adding to knowledge. It is no more satisfactory than Avicenna's explanation of the cause of labor coming on: " At the end of nine months labor occurs by the grace of God," or that of one of Moliere's characters in regard to the action of opium : opium causes sleep by its sleep-pro- ducing properties. 114 SCIENCE AND ART OF OBSTETRICS. the result being fatal he found at the autopsy that neither ovary had been removed. Further, even if both ovaries have been completely removed, possibly there may remain a supernumerary ovary, a con- dition that Beigel's and Winckel's examinations1 prove to be far less rare than has been thought. Until in those cases of alleged perfectly normal menstruation2 post-mortem examinations prove the entire absence of all ovarian tissue, either a fragment of an organ that has been removed or a supernumerary ovary, the doctrine that men- struation depends upon ovarian action will remain. So, too, it is in the highest degree probable that there is an intimate connection between ovulation and menstruation. At the same time it must be admitted that the two may be distinct, the one occurring without the other, though they are usually associated. Thus there may be occasional monthly hemorrhages without ovulation, or the latter may occur without the former. Ovulation may begin before the first monthly flow, and impregnation take place; during lactation it may occur without menstruation, and it may happen, too, after the meno- pause ; thus there is an explanation of the comparatively frequent instances of impregnation of women while nursing; and of rarer cases in which this event has occurred after menstrual life has ceased. Further, there is reason, from what has been observed in the rabbit, for believing that coition may cause rupture of an ovisac and hence ovulation occur independently of menstruation. 1 Beigel found in 500 sections supernumerary ovaries 23 times. Winckel from his own examinations concluded they were present in 3.6 per cent. 2 Foektistow. PART II. PREGNANCY. CHAPTER I. CONCEPTION--EARLY DEVELOPMENT OF AN IMPREGNATED OVULE-- FORMATION OF DECIDUOUS MEMBRANES—FCETAL APPENDAGES. Conception, from concipio, means in metaphysics a grasping into one, and in physiology the uniting of two living elements, one male, the other female, from which a new being is evolved. Fecundation, impregnation, and by some incarnation are also used as synonymas. A woman who has conceived is pregnant; pregnancy begins with conception and ends with labor. The pregnancy is single or sim- ple if only one ovule has been fecundated, but plural if two or more have been. It is normal when the uterine cavity contains the fecun- dated ovule or ovules, and abnormal, ectopic, extra-uterine should it or they be external to that cavity. But whether the pregnancy be single or plural, whether normal or abnormal, its beginning is the same. Human conception was a subject of great interest to students of nature whether physicians or philosophers, in ancient times j1 numerous, and many of them very curious, hypotheses were pro- posed in explaining it, and indeed it is only in comparatively a recent period that, guided by the discoveries of the microscope, the initial step in reproduction has been placed upon a scientific basis. Aristotle compared the menstrual blood to a block of marble, while the seminal fluid was the sculptor, and the foetus the statue. Galen, who from his dissections had some knowledge of the ovries, and gave them, as has been previously stated, the name testes mulie- bres, held that they furnished a secretion which in the womb com- bined with the seminal secretion of the male to form the new being. For many centuries these two opinions alternately prevailed, now one, and again the other, receiving the more general acceptance. But they were alike rejected by the recognition of Harvey's apho- rism, omne vivum ex ovo. This illustrious physician maintained that reproduction in all animals was by a female element analogous to 1 " Drelincourt, an author of the last century, brought together as many as two hundred and sixty-two groundless hypotheses concerning generation from the writings of his predecessors ; and nothing is more certain, quaintly remarks Blumenbach, than that Drelincourt's own theory formed the two-hundred and sixty-third." (Allen Thomson.) n6 SCIENCE AND ART OF OBSTETRICS. the egg of the hen. But in explaining the way in which develop- ment of the egg was effected, he accepted the hypothesis of a semi- nal aura; fecundation occurred in like manner to the action of a magnet upon iron—contact with the former caused the latter to have magnetic virtue; again, he illustrated physical by mental concep- tion—the uterus conceives the foetus, as the brain ideas that are formed in it. Confirmation of Harvey's views as to the essential element in human generation was for a time given by de Graaf's discovery of the ovisacs, which were believed to be human eggs, and at first were known as ova Graafiana. But about 1677, Ludwig Hamm, of Dantzic, examining with a microscope the discharge occurring in the nocturnal emission of a patient suffering with gonorrhoea, dis- covered living spermatozoids. He made known the fact to the great microscopist, Leeuwenhoek, who also saw them ; the latter soon after found them in the seminal discharges of healthy men, of the dog, of the cat, and of the rabbit. Leeuwenhoek concluded from his observations that man was not produced—ex ovis imaginariis, sed ex animalculis vivis seu vermiculis in semine virili contends. He asserted : Sperma humanum parvulis puerulis esse plenum. The supposed ani- malculae received the name of spermatozoa, the plural of spermato- zoon, but as these terms indicate that the objects are independent existences, a view now held by only few, it is better that they should be replaced by spermatozoid and spermatozoids. Leeuwenhoek believed that the spermatozoids had sexual char- acter, and some observers went so far as to describe their sexual organs. Of course the Harveian theory of reproduction was for the time rejected ; and this process was simply the development of one of these homunculi in the uterus, the female merely furnishing a nidus for that development.1 But the progress of science has vin- dicated the truth of Harvey's theory as to the origin of the human being, and of all animal life ; it, however, gives no support to the hypothesis of a seminal aura which acting upon the ovum causes its development. We now know that there must be an actual combina- tion of the male and the female element in order that fecundation can occur. The Seminal Fluid.—The semen, when ejaculated, presents an appearance somewhat like that of thin, recently boiled starch ; it is alkaline and mucilaginous, and has an odor which is called sperma- tic, and has been compared to that of hemp flowers or of horn filings. The odor, according to Robin, does not belong either to the sper- matic or to any other of the secretions that combine with it during the ejaculation, but is developed by the mixture. Its specific gravity is somewhat greater than that of water; it is not coagulated by acetic acid or by heat, and does not contain albumin; but the substance found in it which has been by some given this name, is 1 The argument used in " The Furies " for the acquittal of Orestes for the murder of his mother would have been still stronger had the Greek poet known this view—for then indeed, as asserted in the successful defence of the matricide, the mother was only the nurse, and the father the true parent; and mythology tells us that Minerva had no mother, only a father. CONCEPTION. 117 spermatine; after it has become dry it presents upon the stiffened linen where it has been deposited yellowish-gray stains; the quan- tity discharged at a single ejaculation varies from fifteen grains to two drachms, one to eight grammes. Chemical analysis shows the presence of ninety per cent, of water, six of extractive matters, three of lime phosphates and muriates, and one of soda. In the sperm of the bull, Kolliker found 820 parts of water, 151 parts represented by spermatozoids, 26 by salts, and 21 by fat containing lecithine. In the sperm of some men there may be an excess of spermatozoids with a deficiency of water—all fish and no water, as Pajot has said —and sterility be the consequence. With the microscope there are seen cylindrical cells, pavement epithelium, leucocytes, fine granular matter, crystals of lime phosphate, and the essential element, the fertilizing agents, spermatozoids. Spermatozoids.—The form and size of spermatozoids vary in dif- ferent animals, but there is no relation between the size of the spermatozoid and that of the animal from which it comes; thus the spermatozoid of the elephant is no larger than that of man, while that of the rat is five times as large. Waldeyer1 states that the diversity of size and form of spermatozoids is astonishing, and that he does not know a single instance in which the spermatozoids of different animals are entirely similar, and he believes that their form may be advantageously used to determine their species. The spermatozoid is composed of a head, of a tail, and of an intermediate segment, the last being thus designated by some, but by others called the body. The entire length of the human sperma- tozoid is not more than ^\-§ to -g-^-g- of an inch, or one-twentieth to one-twenty- Fig. 69. fifth of a millimetre. The head is pyri- form, or ovoidal, the larger end being attached to the body or intermediate segment, while the smaller end is free. The head is about one-twentieth the V, length of the tail, and is quite or nearly twice as long as it is broad. The body, intermediate segment, or beginning of the tail, is only ToiHhro to to Ircnnr of an inch, or one-th/ee hundredth to one-four hundredth of a millimetre; it is oval and Spermatozoids. flattened, giving it somewhat the shape of an almond. The tail, or caudal filament, is thick at its origin, then gradually diminishes until its extremity is so fine as not to be visible even with the best magnifying glasses. One of the most striking characteristics of spermatozoids is the power of executing quick and rapid movements; these movements are especially rapid immediately after ejaculation ; a spermatozoid moves a distance equal to its own length in one second, and it was stated by the late Dr. Marion Sims, that spermatozoids pass from the hymen to the 1 Arch. f. mikrosk. Anat., August, 1888. n8 SCIENCE AND ART OF OBSTETRICS. neck of the womb in three hours. Lott states that spermatozoids in a minute move 3.6 mm., and Winckel adds that at this rate they might easily pass into the oviducts in a few minutes. The head is the part which always advances first; the movements have been compared to that of an eel swimming in water; the tail may be curved in a circle, but very quickly becomes straight again, and its simple undulatory movements, which cause progression of the sper- matozoid, are resumed; in its progress over the field of the micro- scope, it may sometimes be seen abruptly to push out of its way epithelial cells or crystals ten times its size.1 The movements grad- ually lessen, then there is no progression, but mere oscillations are seen, and finally all motion ceases; but by warming the slide, if it has become cold, or by adding a little warm water, slightly alkaline, if the liquid has become thick, they are resumed. In avoiding these two causes of death to the spermatozoids when the seminal fluid is placed between two glass slides, the movements may last for twelve, twenty-four, or even thirty hours. Spermatozoids have been found alive in men who were executed seventy, and even eighty-two hours after death; in the bull six days after it was killed ; in the oviducts of bitches and rabbits seven to eight days; in the cow six days after copulation; in the human female they were found endowed with active movements in the cervical canal, by Hausmann, seven days and a half, and by Percy eight days after coition. In the female bat they retain their fecun- dating power for many months, and in the queen bee for more than three years. The spermatozoids of a frog may be frozen four times in succession without killing them. They will live for seventy days when placed in the abdominal cavity of another frog. (Montegazza.) Acid solutions kill spermatozoids very quickly, and, on the other hand, weak alkaline solutions quicken or awaken their movements; cold water arrests their movements, and corrosive sublimate, one part to ten thousand of water, is destructive to spermatozoids, while they seem insusceptible to the action of poisons of organic origin.2 The normal secretion of the uterus, as well as the menstrual dis- charge, is favorable to their movements. In the examination of spermatozoids, a magnifying power of three hundred diameters is sufficient, but in medico-legal investigations one of five hundred is necessary. In temperate climates boys of twelve years may have a discharge simulating the seminal fluid, but it is unusual for spermatozoids to be found in these discharges before they are fifteen or sixteen years old.3 The reproductive power begins somewhat earlier in woman than in man, but it lasts much longer in the latter; Liegeois, from his investigations, concluded that about one-half of men between sixty and eighty years of age were capable of fecundation.4 1 Robin. 2 Duval. 3 In the light of the statement above made as to the time spermatozoids are first found, the story of Cato being a father at eight years, as well as that said to have been told by St. Jerome, of a boy ten years old, who, sleeping with his nurse, impiegnated her, is to be rejected. 4 The illustrious Corvisart was sceptical as to the prolonged power of propagation, for when the First Napoleon asked him if a man at sixty could be a father, he replied, " Sometimes." "And at seventy?'' then asked the emperor. "Always, sire.'' CONCEPTION. II9 Men who are addicted to sexual excess may have seminal dis- charges without any spermatozoids being present; so, too, sperma- tozoids may be^ absent in the case of some men who are in good health; thus Pajot found this condition in six of eighteen husbands whose marriages were sterile, and the late S. W. Gross stated, as an approximate estimate, that in one case in six of sterility the husband is at fault. As has been previously said, the animalcular character once given to spermatozoids is now generally denied. The arguments against this view are: they have neither organs of digestion nor of repro- duction ; they are anatomical unities which have their genesis from embryonic male cells or spermatoblasts, but they do not produce such cells; they indicate a finality, not a progress; they are regarded as similar to ciliated epithelium. In order that fecundation shall occur there must be an actual union between the male element and the female—between the spermatozoid and the ovule. In some animals external fecundation occurs, the eggs being fertilized after they have been expelled from the female; or, as in the frog and crab, while they are being dis- charged. But in human beings, as in most animals, fecundation is internal. The place of union, between the spermatozoid and the ovule, was supposed to be the uterine cavity, and this opinion is maintained by some eminent authorities, among whom may be mentioned Mayrhofer, Wyder, and Lawson Tait. But this opinion is generally rejected, because it does not explain the occurrence of ectopic pregnancy, and because the spermatozoids are found in the inferior animals to have entered the oviducts and advanced to the pavilions. Moreover, it is known that in some animals the ovule in its progress through the oviduct receives a covering of albumin1 which is impenetrable by spermatozoids, and also that, unimpreg- nated, it is affected during this progress by degenerative changes which render impregnation impossible. It is therefore now generally held that fecundation takes place in the oviduct, probably near or in the pavilion. Ascension of the Spermatozoids.—Four causes have been invoked to explain the passing of spermatozoids, deposited in vast numbers at the end of coition in the posterior vaginal cul-de-sac, from this point into the external portion of the oviduct, supposing this to be the usual seat of fecundation. Three of these, that of capillary force, of aspiration, or intraction by the uterus, and of the movements of the cilia, make these bodies merely passive—they do not ascend, but are transferred or translated. But it seems probable that the sperma- tozoids would not have been endowed with such force and rapidity of movement unless for the accomplishment of an important purpose, and therefore we recognize the inherent power of motion on their part as the chief, usually the only, cause of their being in the oviducts. Intraction on the part of the uterus is impossible in 1 This argument is strengthened by Bland Sutton's discovery of glands in the oviduct, these glands secreting albumin, according to his view. See page 51. 120 SCIENCE AND ART OF OBSTETRICS. certain structural diseases of the cervix, and is powerless when the seminal discharge has been from necessity or from precaution made upon the external sexual organs, and yet in each condition impreg- nation has been known to occur. Ciliated action would assist the spermatozoids once in the uterus to ascend to the oviducts, but the action of the cilia of the latter would oppose their further progress. It may be that Nature, rich in resources, does not limit herself to a single cause in securing this important step in the continuance of the race, but, while having a chief one, at times has this assisted by others. In all cases some time intervenes between coition and conception, between insemination and impregnation; this interval possibly is some hours, and it may be, as illustrated by the fecundation of the hen's egg twelve days before it is laid, several days. Hence the assertion made by some women, and accepted by a few obstet- ricians, that a peculiarly pleasurable sensation attends fruitful intercourse, is to be rejected. The intercourse may be with cruel violence, or the woman may be paralyzed by fear, or submit with indifference, or even with loathing and disgust; she may be in pro- found sleep, drugged, or anaesthetized; or, finally, artificial introduc- tion of the seminal fluid into the uterine cavity may be done, yet in all these instances fecundation may result. In such cases pleasure was impossible, and in some both mental and physical suffering was present. The role of woman in copulation is passive; the prob- ability is her pleasure cannot promote nor her pain prevent con- ception. The Combination of Male and Female Elements.—It has been held that the spermatozoids after reaching the ovule were dissolved, then by osmosis penetrated its walls molecule by molecule, and the development of the ovule resulted; it was vivified by a sort of spermatic bath, and the richer the bath was in dissolved spermato- zoids, the more certain would be impregnation. Another equally improbable explanation was that several spermatozoids entered the ovule, the greater the number entering the more certain the fecunda- tion, and then were disintegrated, and were mingled with the yelk. But the more recent studies of fecundation in some of the inferior animals render it in the highest degree1 probable, and it is quite rational too, that in all cases only one spermatozoid is concerned in normal impregnation. Certain changes occur in the ovule independently of impregna- tion. The germinal vesicle moves toward the periphery of the ovule, and from the vesicle there is formed a cell, which first pre- sents as a bud-like process projecting from the surface of the ovule, then the part nearest the free surface of the ovule becomes con- stricted, and separation follows; this process is repeated once, or oftener, and the bodies thus originating from the germinal vesicle, and ejected from the ovule, are called polar cells or globules. The forma- 1 Van Beneden, in only six cases of many thousands of impregnation of the e°-g of the studied by him, found that two spermatozoids entered the ovule. CONCEPTION. 121 tion of the polar cells1 may occur while the ovule is still in the ovary, but more frequently afterward ; they may precede or follow impreg- nation. These statements have been drawn from observation of the ova of some of the inferior animals; as remarked by Balfour, it is very possible, not to say probable, that such changes are universal in the animal kingdom, but the present state of our knowledge does not justify us in saying so. It is generally held that the germinal vesicle is not entirely cast out in the form of polar globules, but a portion remaining in the ovule forms the female pronucleus, which combines with the male pronucleus. The latter is believed to be formed by the head alone of the spermatozoid. The entrance of the male element into the female is provided for in some fish by a minute opening, called a micropyle, in the covering of the ovule; this opening is so small that only one spermatozoid can enter at a time. But the ova of the mammiferae show no such investment. Duval remarks that it is now proved that a great number of ovules at the time fecundation oc- curs are simply encircled by a pellucid zone—that is to say, a layer more dense, and having a special appearance, but which in a normal state is always fluid and permeable. Fol, of Geneva, states that putting in contact with an ovule liquids containing vibrions, the latter passed through this pellucid layer, and were found in the yelk; still more, then, this zone is permeable by the spermatozoid. The vitelline membrane is a secondary formation, and is not found upon the unfecundated egg; but after the first spermatozoid has penetrated the vitellus, the ovule is rapidly encysted by condensation of its peripheral layer, a kind of catalytic phenomenon the nature of which is not clear. It is thus seen that Nature provides for the entrance of one spermatozoid, but closes the door to a second, and if by mischance the latter enter, the result will be a double monster. The part of the spermatozoid which enters the vitellus increases in size and is the male pronucleus. The male moves toward the female pronucleus, which occupies the centre of the ovule ; the latter in some cases has beert observed to lose its spherical form and become crescent-shaped, so as to receive in its concavity the male pronucleus. After the fusion of the two pronuclei there is but a single nucleus, in which are initiated all the changes which result in the formation of a new being. Balfour describes the act of impreg- nation as the fusion of the ovum and the spermatozoid, and the 1 The apparently useless formation of polar globules has been given different explanations. One is that these globules are ejected from the ovule in order to secure space for the segmenta- tion of the vitellus. Another is that they testify to a descent from ancestral forms having a lower organization, in which the discharge of the globules plays an important part, as in the parthenogenesis of bees, etc. Balfour suggests as one of the reasons for the ovule having this function the prevention of parthenogenesis. It is the final act of the ovule ; unaided it can do nothing more. "There is but little doubt that the ovum is potentially capable of developing by itself into a fresh individual, and therefore, unless the absence of sexual differentiation were very injurious to the vigor of the progeny, parthenogenesis would certainly be a very constant occurrence; and on the analogy of the arrangement in plants to prevent self-fertilization, we might expect to find some contrivance both in animals and in plants to prevent the ovum developing by itself without fertilization. If my view about the polar cells is correct, the forma- tion of these bodies functions as such a contrivance.'' (Balfour: Comparative Embryology.) Thus parthenogenesis is prevented, and cross-fertilization made possible. 122 SCIENCE AND ART OF OBSTETRICS. most important feature in the act appears to be the fusion of a male and of a female nucleus. This is brought in still greater prominence by the fact that the female pronucleus is the metamorphosed head of the spermatozoid, which contains part of the nucleus of the primitive spermatic cell, and the female pronucleus is the product of a primordial ovum. The spermatic cells originate in primordial cells, which cannot be distinguished from primordial ova, and thus the impregnated ovule results from the fusion of morphologically similar parts in the two sexes. Time of Conception.—This cannot be certainly known, but the time when coition is most likely to be followed by impregnation is well known by the public as well as by physicians. The "conception curve " given by Foektistow1 shows that conception is most liable to occur from coition in the first seven days following menstruation; the first day after the flow ceases has the highest percentage, and from this time the latter gradually declines. Hensen's conclusions are in accordance. But while conception is very improbable during a certain portion of the menstrual interval, it cannot be affirmed that it is impossible at any time. Fate of the Spermatozoids not concerned in Impregnation.—As has been previously stated, it is almost certain that in human beings, as has been proved to be the fact in some of the inferior animals, only one spermatozoid is concerned in impregnation, and the question naturally arises what becomes of the multitude who have no part in this process, a number much greater than Penelope's suitors during the long absence of Ulysses. Is it not possible that they may permanently modify the organism or the undeveloped ovules so that the product of a future pregnancy, though by another father, may be affected?2 The heredity of influence is that observed in the chil- dren born by a widow who remarries, these children resembling morally and physically the first husband. Occasional instances of such heredity occur, and it is claimed that in reproduction in the inferior animals the first sire may materially modify the offspring of subsequent sires. Admitting the fact, possibly the factors in such modification may be the original spermatozoids that did not con- tribute to the first conception. But the question eludes investiga- tion. Production of Sex.—The essential causes of the differences of sex are not known. By Sadler and Hofacker the following conclusions were drawn as to the influence of age : If the husband be younger than the wife, there are as many boys as girls ; if both are of the same age, there are 1029 boys to 1000 girls; if the husband is older, 1057 boys to 1000 girls. These laws are not to be accepted as con- 1 Op. cit. 2 This is by some called infection of the mother. Doleris regards it as without positive proofs. He also quotes Colin as saying : If the male can indeed, in fecundating the female, exercise an action upon the eggs contained in the ovary, and which contribute to subsequent gestations, this influence is very difficult to conceive. Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, tome xxxiv. Modification of the ova was the view of the illustrious Haller, while fcetal inoculation of the mother was upheld by the late Professor Alexander Harvey, of the University of Aberdeen, in his little volume, Foetus in Utero, London, 1886. CONCEPTION. 123 elusive. The normal proportion between female and male births is 100 to 105 or 106. But in the case of illegitimate births, the pro- portion is reversed, at least for the children first born ; that is to say, in such births females are more numerous than males. The pro- portion of male children to females is slightly greater in the country than in the city. The chances of the young wife having at her first pregnancy a boy are at their maximum, while those of the matron near the close of her reproductive life are at their minimum. Swedish statistics prove that in the nobility, the age of the husband being greater than that of the wife, there are only 98.3 male to 100 female births ; this reverses one of the rules given by Sadler, accord- ing to which there ought to be a great preponderance of male births. Bertillon states that the influence of the ages of the parents upon the proportion of the sexes, if it exists, may be neutralized by the inherent qualities appertaining to the parents. The law of Thury that the incompletely developed ovule produces a female, and the completely developed one a male, has not been verified in the human race. It is claimed with apparent reason by Fiirst and others that each sex tends to produce the opposite; each one at the time of greatest sexual vigor is least apt to continue his or her own sex, most apt to produce the opposite.1 The probability is that we will never know Nature's secret in determining sex, and that " the production of the sexes at will" will always remain a dream if not a foolish delusion. Time of Year most Favorable to Conception.—In the subjoined table comprising the births in Philadelphia each month during five years, it is seen that the greatest number of births occurred first in August, second in January, third in December. Hence the three months in which the greatest number of conceptions took place were, in order, November, April, and March. The smallest number of births was in April, and therefore the fewest conceptions occur in July. 1880 1881 1882 1883 1884 Totals. January • • 1709 1647 1762 1839 1936 8893 . . 1638 1515 1671 1803 1832 8459 ■ - 1594 i5°4 1628 1768 1856 835o . . 1405 1386 1538 1572 1577 7478 . . i486 1437 1435 1506 1706 7570 . . i486 1403 1435 1682 1868 7874 July..... . . 1588 1601 1641 1945 1878 8653 1815 1554 1767 1874 1958 8968 I532 1883 1849 1937 8830 . . 1682 1502 1754 1833 1915 8686 1488 1784 1748 1779 8420 • • 1735 1585 1800 1818 1918 8856 Totals . . • • 19.388 18,154 20,098 21,237 22,160 101,037 The following is an abstract of statements made by Ploss2 in regard to the influ- ence of the seasons upon conception. The fact that there is an increase in the number of conceptions at certain times of the year, does not indicate that there is a greater ability on the part of the female to conceive at these times, or any change in the physiological condition of the female sexual organs. The influence of the seasons upon the male is also to be taken into consideration. Villerme found 1 Arch. f. Gynakol., 1886. 2 Op. cit. 124 SCIENCE AND ART OF OBSTETRICS. that the maximum of conceptions in Europe occurs in May and June, and he attributed it to the influence of spring. In order to justify this opinion he extended his observations to those parts of the world where, while the seasons follow in the same order, they occur at different times, e. g., Buenos Ayres, and found the re- sults the same. The times when marriages are most, and those when they are least frequent, have no apparent influence upon the number of conceptions according to the season of the year. On the other hand, the periods of compara- tive rest, of hard labor, and scarcity of food have a marked influence. The num- ber of conceptions is lowered by the harvesting season, scarcity of food, and by strict observance of religious fasts, as Lent. " Those conditions which strengthen us, increase our fertility, and those which weaken or depress us, or especially such as undermine the health, lessen it, though fertility is by no means governed by health alone." Wappenhaus's conclusions from his studies of the birth-rate in Sardinia, Bel- gium, the Netherlands, Saxony, Sweden, and Chili, are as follows : The maximum of conceptions occurs in May and June. The cause is the vivifying influence of spring, aided by the habits and customs of the church in all Catholic countries. There is a gradual decrease to the minimum, which is in September and October. The cause is in the increased heat of summer, and in the epidemic diseases result- ing therefrom, aided by the hard work of harvest. In Sweden this maximum is in January. The cause is found in social customs and in the religion. The dis- sipations incident to the period of Carnival, and the strict observance of Lent, lessen the maximum in Catholic countries. In Italy the maximum differs in the north and in the south. In the latter it is in April, but in the former in July. Illegitimate conceptions are more under the influence of physical conditions, e. jr., the seasons, than are legitimate conceptions. In western Europe the greatest number of illegitimate offspring are conceived in spring and summer, the fewest in fall and winter ; the difference is much less marked in the conceptions occur- ring in the married. In Russia the greatest number of conceptions occur in April and in January. Changes in the Fecundated Ovule.—The first of these changes is segmentation, or cleavage, the sphere dividing into two spheres. The process of division occurs in the nucleus first, and is followed by that of the vitelline mass surrounding the two newly formed nuclei, so that each new sphere has a part of the original nucleus. These spheres again similarly divide, thus the two become four, which also divide and eight are formed ; subdivision after subdivi- sion occurs until the entire vitelline mass has been converted into a number of minute spheres which from their supposed resemblance to a mulberry have been called the muriform body. These spheres are unequal in size, and fulfil different purposes in the process of organization. The larger and more transparent are called epiblastic from i-i, upon, and (Haarbq, germ ; the smaller hypo- blastic, from ,Vo, under, and /3/a 3i 3- Cavity of Amnion. 4, 4. Digestive Canal. S, 5. Pedicle of the Umbilical Vesicle. 6. Umbilical Vesicle. 7, 7. Allantoid Vesicle 8. Pedicle of the Allantois. 9, 9, 9. Chorial Villi beginning to atrophy. 10, 10. Villi in relation with the utero-placental decidua, which hypertrophy. \To face page 134 FCETAL APPENDAGES. 135 solid, and this is known as the primitive chorion. The permanent chorion is formed by the junction of the allantoid and subzonal membranes, followed about the fourth week by bloodvessels which begin to penetrate into the chorial villi, and these now hollowed out become sheaths for the vessels; an artery enters each villus, and supplies vessels to all its branches or bud-like offshoots ; capillaries connect with veins and the latter unite in a single trunk which returns the blood to the umbilical veins. At first all the chorial villi, thus made vascular, hypertrophy, but this lasts only until the third month when those villi in relation with the decidua of the ovum, the decidua reflexa, atrophy, while those connected with the serotine decidua, or the placental decidua, become larger and more branched; the portion of the chorion to which the former belong is sometimes spoken of as the chorion leve or the smooth chorion, while the latter is called the chorion frondosum or leafy chorion. The chorion is thicker than the amnion, but is weaker ; it is composed of two layers, one chiefly of connective tissue becoming fibrous in character at the end of pregnancy, and the other of pavement epithelium. Doubtless the chorial villi even before they become vascular are concerned in the nutrition of the embryo, but the chief use of the chorion is in the formation of the placenta. Fig. 83. In the accompanying Plate, exhibiting the evolution of the pla- centa and of the umbilical cord, the atrophy of the larger number of the chorial villi, and the hypertrophy of others, those which contribute to the formation of the placenta, are well shown. I $6 SCIENCE AND ART OF OBSTETRICS. The Placenta.—This is also called the afterbirth. The name pla- centa, from -?MXovc, a flat cake, was first used to designate this organ as found in the human female, by Realdus Colombos. In many of the inferior animals its form is very different from that signified by this name. The placenta is a fleshy, flattened mass, usually oval, but sometimes round or reniform. Its diameter is six to eight inches, fifteen to twenty centimetres ; it is thickest at the insertion of the cord, varying from a little more than one-third to more than an inch, one to three centimetres, and thinnest at the margin, where its thickness is about one-fifth of an inch, five or six millimetres; it weighs at the end of pregnancy about eighteen ounces, or five hundred grammes. Nevertheless there is great variation in the weight of the placenta; it may be only one-half that given, or may be twice as much ; usually the weight is in direct proportion to that of the child.1 It presents two faces or surfaces, one internal or Fig. 84. Maternal Surface of the Placenta. fcetal, and the other external, or maternal. The external, or uterine, surface of the placenta is dark-red, somewhat convex, rough and 1 This statement has recently been controverted by Mackness, Edinburgh Obstetrical So- ciety's Transactions, vol. xiv.; and certainly the statistics adduced by him, as well as the results obtained in the Dresden Lying-in Hospital which he quotes, do render the statement above made at least doubtful. Nevertheless, general professional experience has hitherto upheld the belief that if the child be large, the placenta is also large. FCETAL APPENDAGES 137 uneven. It presents irregular fissures, incompletely dividing the organ into lobes ; these fissures are partially bridged over and lined by a whitish membrane, the remains of the placental decidua, or the serotine decidua. The internal, or foetal, surface of the placenta is smooth, slightly concave, and covered by the combined chorion and amnion, which thus form its superficial layer; the attachment of the cord, and the larger division of its placental vessels are plainly seen. A large vein, called the circular or marginal sinus, is found at the border of the placenta. In some cases the placenta, instead of being a single mass, is composed of two parts, and is designated as placenta duplex; if composed of three parts, placenta tripartita, and if of many separated lobes, placenta multiloba; if in addition to the usual placental mass there should be one or more distinct and separate lobes, such additional placentae are called subsidiary placentas, or placenta succenturiatce. Situation of the Placenta.—The placenta is generally in the upper part of the uterus, upon the posterior or upon the anterior wall, in the vicinity of the opening of one of the oviducts. Attachment directly to the fundus—once regarded as frequent, if not the rule—is as rare as is that to the lower part of the uterus.1 But, as remarked by Levret, " there is not a single part of the interior of the womb where the placenta may not take root." When the attachment is in the lower uterine segment the placenta is called praevia. After the delivery of the placenta the obstetrician can, by noticing the place of rupture of the membranes, judge, approximately at least, the place which the organ occupied in the womb. It is not until in the third month of pregnancy that the placenta begins to be distinct, and it is not until the end of the month that its formation is completed. Part of this organ is of maternal, and part of fcetal origin, but these parts become so intimately united that they can only be separated in an early stage of its development. The placenta increases in weight until about the seventh month, when a regressive metamorphosis begins. The large villi of the chorion frondosum penetrate into the tissue of the decidua of the serotina; they do not enter the uterine glands, but into crypts formed by the hypertrophied uterine mucous membrane; the villi, at first compara- tively simple in form, not only greatly increase in size, but in num- ber; they become complex, presenting many branches and offshoots. Goodsir has compared a placental tuft to a tree, consisting of a trunk with its primary and secondary branches Meantime the villi of the chorion not in relation with the membrana serotina atrophy, and thus the chorion leve results. The villi of the chorion frondo- sum are formed of connective tissue, and also, as stated by Goodsir and confirmed by subsequent observers, receive an epithelial cover- ing from the hypertrophied serotine membrane. Each villus then is composed of connective tissue, of an epithelial covering, and of 1 Carmichael (Dublin Journal of Medical Science, 1839) having concluded, from his own examinations, that the usual site of the placenta was the lower part of the posterior uterine wall, caused so much controversy by the statement that he pleasantly remarked if he had an- ticipated such a result he would have left the placenta at the fundus. I38 SCIENCE AND ART OF OBSTETRICS. an artery and vein and connecting capillaries; this arrangement of the bloodvessels secures a closed vascular system. The placenta is composed of the hypertrophied villi of the chorion and of the serotine decidua, which grow into each other, mutually inter-pene- trating, so that a single mass is formed. Fig. 85. Section of a Portion of a Fully Formed Placenta with the part of the Uterus to which it is attached.—a. Umbilical cord. b,b. Section of uterus, showing the venous sinuses. 0,0. Branches of the umbilical vessels, d, d. Curling arteries of the uterus. After the interlocking of the chorial villi with the serotine mem- brane, blood-spaces or sinuses are found in the maternal portion of the placenta. This results according to some from great dilatation of the maternal capillaries, but according to others from disappear- ance of the walls of the capillaries, caused by the pressure of the growing chorial villi. Into these spaces,1 these blood-lakes, mater- nal arteries2 enter, and from them veins issue. The terminal villi of the chorion float freely in the blood-sinuses, and thus the maternal is brought into such close relation with the foetal blood that inter- change of gases and nutritive materials can readily occur. Uses of the Placenta.—The placenta is the organ of nutrition and of respiration for the foetus. It was once held that there was a direct communication between the bloodvessels of the mother and the foetus through the placenta, and thus the nutrition of the foetus was explained. This view is disproved by the following facts: The maternal and the fetal circulation are not isochronous; prior to the 1 Braxton Hicks (London Obstetrical Society's Transactions, vol. xiv.) denies the existence of placental sinuses, stating that from dissections early and late in pregnancy, there is no evi- dence of a sinus system. 2 Delore (Annates de Gynecologie, 1874) contends that the entrance of maternal blood into the placenta is chiefly by the placental coronary, or circular sinus, which was first described by Meckel, and which sometimes has a diameter as large as the little finger. FCETAL APPENDAGES. 139 extension of the allantoid vessels to the periphery of the ovum the embryo had a circulation; if the feel us die in labor when the mother perishes from hemorrhage, it dies from asphyxia, not from anaemia. If the placenta be delivered with the foetus, the circulation may con- tinue several minutes, and there is no discharge of blood from the Fig. 86. Vertical Section of Placenta showing relations of Maternal and Fcetal Bloodvessels. a, a. Chorion, b, b. Decidua. c, c, c, c. Orifices of uterine sinuses. uterine surface of the placenta: if hemorrhage from the umbilical cord occur during labor, it does not affect the mother; the foetal blood differs from the maternal blood in the form of the globules and in its composition. It is generally held that the interchange of gases and of nutritive elements between the maternal and the foetal blood depends upon osmosis.1 According to Marchal, the endosmotic 1 Ercolani taught that the foetal portion, of the placenta is vascular, or absorbent, and the maternal is glandular, or secretory. According to his theory the uterine juices, or milk, secreted r by the epithelium of the latter, is absorbed in the chorial villi, as chyle is absorbed by the intes- tinal villi. Balfour has given a qualified and partial support to this view, saying: " The walls of the crypts into which the villi are fitted also become highly vascular, and a nutritive fluid passes from the maternal vessels of the placenta to the fcetal vessels by a process of diffusion ; while there is probably also a secretion by the epithelial lining of the walls of the crypts, which becomes absorbed by the vessels of the foetal villi." Goodsir stated that the function of the placenta is not only that of a lung, but also of an intestinal tube, and that the internal cells of the villi absorb the matter secreted by the external cells. Kormann (Lehrbuch der Geburtshiilfe, 1884) states that the nutritive material which the foetus finds prepared in the placenta is the so- called uterine milk. According to Hoffman (Berlin. Zeitschr. f. Geb. und Gyn., 1882), the pur- pose of the decidua in man as well as in animals is to furnish the necessary nourishment of the young. The decidua is a milk-secreting organ; this milk, which is secreted into the spaces which are gradually formed, and in which the placenta villi are placed, here is mixed with the simultaneously extravasated blood of the mother, and thus the fcetal nourishment is formed which is absorbed by the placental villi. Landois (Manual of Human Physiology) states: "Between the villi of the placenta there is a clear fluid which contains numerous small albu- minous globules, and this fluid, which is abundant in the cow, is spoken of as the uterine milk. It seems to be formed by the breaking up of the decidual cells. It has been supposed to be nutritive in function." Stirling adds, that the maternal placenta, therefore, seems to be a secre- tory structure, while the fcetal part has an absorbing function. The uterine milk has been ana- lyzed by Gamgee, who found that it contained fatty, albuminous and saline constituents, while sugar and casein were absent. I4O SCIENCE AND ART OF OBSTETRICS processes by which nutritive juices pass from the mother to the foetus are facilitated by the greater blood-pressure in the vessels of the former than in those of the latter. Experiments show that substances in solution may pass from the maternal to the fetal blood. Among such substances are potassic iodide, salicylic acid, chloroform, chlorides, and turpentine. Many years ago Magendie detected the odor of camphor in the blood of the foetus fifteen min- utes after a solution of this substance had been injected into the maternal blood. Recent experiments, among others those of Dr. Pyle,1 prove that some undissolved substances and bacteria may thus pass from the mother to the foetus. Several other observers both before and since Dr. Pyle's experiments, have arrived at the same results. That the placenta is the organ of respiration for the foetus is shown by the fact that the blood going to the placenta is dark, and that re- turning from it light; and that the only substitute for placental is pulmonary respiration. If the umbilical circulation be arrested the foetus dies, and an autopsy proves the death was from asphyxia. In the placenta the foetus exchanges carbonic acid for oxygen, just as a fish through its gills receives oxygen from the water in which it swims. Bernard has shown that the placenta has a glycogenic function in the earlier months of fcetal life, prior to the formation of the liver. Foster suggests that the placental glycogen is of use, not for the foetus, but for the nutrition and growth of the placental structures. The Umbilical Cord.—The funis umbilicatus, or umbilical cord, receives its name from its twisted character. It is a cord essentially composed of bloodvessels, connecting the foetus and the placenta. The pedicle of the allantoid, originally a constricted portion con- necting the two portions of the allantoid, one within the embryo, the other external to it, is the beginning of the umbilical cord. At first, this pedicle or stalk had two veins as well as two arteries; one of the .veins, however, atrophies, so that the cord has one vein and two arteries. Hyrtl found in 6 per cent, of cases only one umbilical artery. Its formation begins at the end of the fourth week. At the middle of pregnancy its length is 5 to 8 inches, 13 to 21 centi- metres, and its thickness about one-third of an inch ; at the end of pregnancy its average length is about 20 inches, 50 centimetres, and its usual thickness that of a man's little finger. But the thickness may be much greater, equalling that of the thumb, or even exceeding it; if thus increased in size, it is commonly called a " fat cord," while if its diameter is notably lessened, it is called a " lean cord." The length of the cord may be reduced to two inches, or increased to five or six times the average previously given. Its surface is smooth and shining from its amniotic investment; it presents a twisted or spiral aspect; the number of spirals varies; in one case Meckel saw ninety-five. The spirals in the majority of cases turn Philadelphia Mi.-dical Times, June and July, 1884. FCETAL APPENDAGES. I4I to the left, and thus Auvard1 combining the results obtained by Neugabauer, Hecker, and Tarnier with his own found that there was sinistrotorsion in 533, dextrotorsion in 190, torsion in opposite di- rections in 4, and entire absence of torsion in 17, the total number being 744. The movements of the foetus which produce torsion of the cord begin very early, for when the embryo was only one inch long the cord was somewhat twisted ; according to Preyer, torsion of the cord uniformly commences in the eighth week. In most instances the vein is central, and the arteries turn round it; but in others, all three of the vessels are parallel, and turn round a fictitious axis. The amnial sheath not only incloses the vein and arteries, but also a greater or less quantity of a gelatinous substance called Wharton's jelly. An unusual quantity of this material causes the cord to be very thick, and when it is tied after birth there is great Fig. 87. Apparent Constriction of Bloodvessels of Cord, from Absence of Wharton's Jelly. liability to subsequent hemorrhage unless the tying be done very carefully so that complete constriction of the bloodvessels is secured. Wharton's jelly is a gelatinous-like connective tissue, consisting of branched corpuscles, lymphoid cells, some connective-tissue fibres, and elastic fibres. Accumulations of the jelly at particular parts of the cord, making decided prominences, cause what have been called false knots. But the absence of the jelly at a part of the cord does not prove that any of the vessels are impervious, or even that their 1 Op. cit. 142 SCIENCE AND ART OF OBSTETRICS. capacity is lessened.1 The vein has a thinner wall than the arteries ; the diameter of its canal is greater than that of either artery, and increases as the vessel approaches the foetus; from the inner surface of the vein crescent-shaped folds project, occluding two-thirds of the canal. The arteries widen in the course of the cord from the fetus to the placenta, and have projecting broad folds. The vessels have well-developed muscular walls, and hence are very contractile. Fig. 88. Velamentous Insertion of the Cord. According to Kleinwachter, the cord has lymphatics, and Ruyl claims that he discovered nutritive capillaries in it. Winckel remarks that Valentine, Schott, and Kolliker described nerves and lymphatics in the cord, but these were not found by Virchow. The strength of the umbilical cord varies, and in some cases very slight traction causes its rupture. Duncan and Turnbull have from experiments2 concluded that the average weight required to 1 The illustration, Fig. 79, represents the appearance of the foetal end of the umbilical cord in a large, seven months' stillborn foetus. The foetus was brought to me as showing intra-uterine death from obstruction of the umbilical vessels; injections, however, proved that they were not only pervious, but of normal calibre. Dr. James Young (Transactions of the Edinburgh Obstetrical Society, Edinburgh. 1870) has reported a similar case, a dead foetus at seven months being expelled; the umbilical cord was " greatly constricted near the abdomen;'' but the just test of constriction involving the bloodvessels was not made. 2 London Obstetrical Society's Transactions, vol. xxiii. FCETAL APPENDAGES. 143 break the cord is eight and one-quarter pounds; the weakest is torn by five and one-half pounds, and. the strongest fifteen pounds. Pfannkuch has shown that a varicose cord has little more than half the strength of one with its vessels normal. True knots are sometimes found in the cord. They have been attributed to the violent movements of the foetus, favored by excess of liquor amnii, and to similar movements of the mother; it is alto- gether exceptional for knots, however numerous, to interrupt the circulation. The attachment of the cord to the placenta is usually at some point between the centre and the margin; the central insertion, though by some authorities claimed to be the rule, Naegele correctly stated is relatively rare; Levret made a similar statement. In some cases the cord is attached to the margin of the placenta, insertio marginalis, and the placenta is called battledore placenta; in one variety of marginal insertion the cord is attached first to the membranes, and the vessels subdivide before entering the substance of the placenta,1 insertio velamentosa (see Fig. 88). Velamentous insertion occurs in nearly one percent, of cases. Auvard states that the insertion may be twenty centimetres from the placental margin. In some cases the vessels divide into branches before reaching the placenta, but in others they continue undivided to it. The dangers from this anomaly in labor are pressure upon the vessels, causing asphyxia of the child, or rupture when the membranes rupture, causing hemorrhage. The insertion of the cord,2 observed by Crede in 443 cases, was in 109 central, in 164 excentric, in 152 near the margin of the placenta, in 8 at the margin, and in 10 velamentous. 1 Lugol, Journ. de Med. du Bordeaux, June, 1889, has reported a case of single pregnancy, the insertion of the cord velamentosa, the placenta being double—the two parts, which were nearly equal, were three to four centimetres apart. 2 Lehrbuch der Geburtshiilfe. CHAPTER II. THE EMBRYO AND FOETUS—DEVELOPMENT—ANATOMY AND PHYSIOLOGY OF THE FOETUS. The term foetus, a Latin word for the young of mammifene while in the womb, is very commonly used as a synonym for embryo, the etymological signification of which has been stated. By many, however, the product of conception in the human female is called an embryo up to three months, and after that it is known as a foetus. This distinction between the two words is plainly arbitrary, and as far as the term embryo is concerned, is disregarded in such words as embryotomy and embryulcia. Nevertheless, as the history of the first three months differs very materially from that of the subsequent six of intra-uterine life, since by the end of three months the placenta is completed, and the new being has assumed the human form, and subsequent changes are of growth and development rather than of the beginning of organs belonging to the organism, and essential for its existence or for its perpetuation, it is well to retain the arbitrary distinction between the words embryo and foetus. Naegele said that the obstetrician was more concerned with expe- dition than with fabrication—that is, with labor rather than with embryology ; nevertheless, some study should be given to the latter; While, of course, embryology belongs to physiology, and is there fully presented, yet a general knowledge of the evolution of the new being from the fecundated ovule, "■ the dim speck of entity," belongs to obstetrics. Such knowledge is practically useful in that it enables the obstetrician to recognize how far development has progressed in a case of miscarriage; in some cases to ascertain the cause of miscarriage, whether the miscarriage be embryonic or fcetal, and also to explain the occurrence of certain deformities or so-called malformations, which are in most cases arrests of formation, failures of development. This knowledge, too, is of value in studying the physiology of the foetus. In the following summary sketch of em- bryonic and foetal development no attempt will be made to include all details and make a complete picture, but chiefly to present prac- tical matters of interest and importance to the obstetrician. First Month.—Recalling the statements made on page 127, as to the formation of the blastodermic vesicle, its separation into two portions, one embryonic, the other non-embryonic, and the appear- ance in the former of the medullary groove, with a fold or plate on each side, Iambics dorsales, the two subsequently uniting so that the groove is converted into a cylindrical canal—the medullary canal— it is seen that in the very beginning of organization the nervous system is placed first. The heart, at first a tubular cavity, is seen THE EMBRYO AND FOETUS. H5 by the end of the second week,1 when the embryo is only one- eighteenth of an inch, two millimetres, long; by the middle of the third week it has taken an S form ; and at the end of the fourth the different cavities are present, and the pericardium is formed. Accord- ing to Preyer,2 it cannot be doubted that the heart commences to beat by the beginning of the third week. The visceral clefts, four in number, and arches are apparent by the twentieth day ; the' former are fissures found on each side of the cervical region, while the arches are thickenings of the lateral walls between the clefts. Fig. 89. Scheme of a Human Embryo with the Visceral Arches still Persistent.—A. Amnion. V. Fore-brain. M. Mid-brain. H. Hind-brain. N. After-brain. U. Primitive vertebrae, a. Eye. p. Nasal pits. 61. Frontal process, y. Internal nasal process, n. External nasal pro- cess, r. Superior maxillary process of the first visceral arch. 1, 2, 3, and 4. The four visceral arches, with the visceral clefts between them. 0. Auditory vesicle, h. Heart, with e, primitive aorta which divides into five aortic branches, f. Descending aorta. 0 m. Omphalo mesenteric artery, b. The omphalo-mesenteric arteries on the umbilical vesicle, c. Omphalo-mesenteric vein. L. Liver with arriving and departing veins. D. Intestine. *. Inferior cava. T. Coccyx. all. Allantois, with Z, one umbilical artery ; and x, an umbilical vein. The extremities appear at the sides of the body as short unjointed stumps or projections in the third or fourth week. At the end of the fourth week the vertebral bodies and the nerve centres are quite dis- tinct, the thorax and abdomen make a single cavity, the diaphragm 1 Aristotle stated that the heart could sometimes be seen in the bird's egg as early as the third day, no bigger than a point; it is compared to a bloody spot, and its beating is mentioned : from his description the punctum saliens of later writers is derived. The heart is the first of organs not in formation, but in function, and in this sense is indeed primutn vivens, though not in all cases ultimum moriens. Modern observers know that the heart in the chick is at the end of the first day " a small, bright-red, contracting point." Its development in mammals is much later. 2 Op. cit. IO I46 SCIENCE AND ART OF OBSTETRICS. not yet having been formed, and the heart is in the upper part of this cavity. The ovum is about the size of a pigeon's egg. The embryo is a grayish curved mass, the cephalic end is much larger than the caudal, and so great is the curvature that the two approach ; the length of the embryo is about half an inch, or thirteen millimetres. The primitive intestine is a straight tube, proceeding from the head to the tail, and closed at each end. It was at first a gutter, and had free communication with the vitelline sac, but the gutter is covered over, and is converted into a cylindrical canal, and the vitelline duct, inserted at that point which at a later period corresponds to the lower part of the ileum, is obliterated. In some cases the duct remains pervious a short distance from the intestine,1 making a blind tube, the so-called "true intestinal diverticulum;" in very rare cases the duct may remain open to the umbilicus, forming a congenital fistula of the ileum, or it may give rise to cystic formations. Fig. g~>. Formation of Alimentary Canal.—a b. Commencement of amnion, c c. Intestine. /. Al- lantois. g. Umbilical vesicle, x. Dotted line showing the place of the formation of the oesophagus. Kolliker divides the primitive intestine into three segments—the buccal, middle, and terminal. From the buccal, or initial segment, all the buccal cavity as far as the glosso-palatine arches is derived; the terminal portion furnishes the lower portion of the cloaca, while all the rest of the intestinal canal and a notable part of the uro- genital system are derived from the middle segment. About the fourth week a depression upon the external tegument occurs at a point corresponding with the lower end of the terminal segment, with absorption of intervening tissue, and the anus is formed. A similar depression of the tegument occurs at a point corresponding with the position to be occupied by the mouth, and an opening is made which communicates with the buccal portion of the intestine; the mouth at first represents the space comprised between the first visceral arch and the most anterior part of the base of the cranium. 1 Landois. THE EMBRYO AND FCETUS. 147 Second Month.—During this month the visceral clefts completely close except the first, which becomes the external auditory meatus, the cavity of the tympanum, and the Eustachian tube. " Should any of the other clefts remain open, a condition that is sometimes hereditary in some families, a cervical fistula results, and it may be formed either from without or within." Branchiogenic tumors and cysts depend upon the branchial arches, according to Volkmann. The first visceral or branchial arch divides into two branches called the superior and the inferior maxillary process; the two inferior maxillary processes, one from each side, grow toward each other, meet, and unite, making the lower margin of the mouth. So, too, the superior maxillary processes grow toward each other, but there intervenes the frontal process {S, Fig. 89), which unites with each of the others, and thus the upper boundary of the mouth is made, and the oral separated from the nasal opening. The separa- tion between the nose and mouth within is made by the superior maxillary processes ; from these the upper jaw, the nasal, and the intermaxillary process are produced; at the ninth week the hard palate is closed; upon it rests the septum of the nose, descending vertically from the frontal process. Different varieties of harelip result from arrest of descent of the frontal process, or from its failure to unite upon one, or upon both sides, with the superior maxillary processes. It not unseldom happens that if an infant be born with harelip the mother attributes the deformity to her having seen while she was pregnant some one, adult or child, similarly affected. But if she saw such an object subsequent to the second month of preg- nancy, it is impossible that the foetus could have been affected through her mind, for the deformity already existed. Cleft palate arises from the failure of those portions of the superior maxillary processes concerned in the formation of the roof of the mouth to meet and unite. As is seen, the formation of the face chiefly results from the development of the first or maxillary arches. The second arch, hyoid, gives rise to the stapes, the pyramidal eminences, with the stapedius muscle, the styloid process of the temporal bone, the stylo-hyoid ligament, the smaller cornu of the hyoid bone, and the glosso-palatine arch. The third arch, thyro- hyoid, forms the greater cornu and body of the hyoid bone and the pharyngo-palatine arch. The fourth arch gives rise to the thyroid cartilage. In the second month the eyes appear first as two black points, one on each side of the head; the eyelids are not seen until the latter part of the month or the beginning of the next. The external ear appears as a slight projection at the seventh week. The devel- opment of the viscera causes the body to be less curved. The VVolffian bodies are notably lessened in size, but meantime the kid- neys and supra-renal capsules are formed. The fingers and toes appear, but they are webbed. The formation of the external sexual organs begins, as previously stated, in the sixth week, but they pre- sent the same appearance in each sex; the testicles or the ovaries I48 SCIENCE AND ART OF OBSTETRICS. appear about the seventh week. At the end of the second month the ovum is about the size of a hen's egg, the embryo measures from one inch to one inch and a half, twenty-five and a half to thirty- seven millimetres in length, and weighs about one drachm, four grammes; the umbilical cord measures a little more than one inch, twenty-five and a half millimetres. Third Month.—The fingers and toes have lost their webbed char- acter, and the nails begin to be developed, appearing as fine mem- branes. The eyes are nearer, the ear well formed, the walls of the body are thicker, and lose their transparency. The sex can be distinguished by the absence or presence of the uterus and vagina; the umbilical cord, inserted a little above the pubes, reaches a length of 2.7 inches, seven centimetres, and begins to take a spiral form. In the twelfth week the ovum is the size of a goose's egg, the embryo is from 2.7 to 3.5 inches, seven to nine centimetres long, and weighs five drachms, twenty grammes. At about three months points of ossification are found in all parts of the vertebral column. Ossific formation begins in the cervical vertebrae, then in the dorsal, finally in the lumbar, and in all the vertebrae it begins in the bodies before it does in the arches. Hence, spina bifida, which is a hernia of the spinal membranes through a cleft in their bony canal, is rarely anterior, and it is much more frequently lumbar than dorsal or cervical. Fourth Month.—The foetus is between six and seven inches, seven- teen centimetres long, and weighs nearly four ounces, three ounces and three-quarters, one hundred and twenty grammes; the umbilicus is above the lowest fourth of the linea alba, and the cord is seven and one-half inches, nineteen centimetres long. The development of the female external sexual organs has been given on page 86; that of the male is the same up to a certain stage, but in the first half of the fourth month, in the male, the genital fissure closes, and the genital folds are united together to form the scrotum ; the gen- ital tubercle, which in the female forms the clitoris, becomes in the male the penis, and in the third month shows the formation of the glans. A very distinct raphe upon the penis and scrotum indicates the place of union of the two sides of the genital fissure. The prepuce is formed in the sixth month. The prostate, beginning in the third month, as a thickening at the point where the urethra and genital cord meet, can be plainly seen in the fourth month. If the sides of the genital fissure fail to unite, the condition is known as hypospadias. A slight down-like growth of hair, lanugo, appears on the body, and a few hairs upon the head; meconium is found in the intestine, and feeble movements of the limbs occur. A foetus born at four months may live some hours ; no respiratory movement is made, but the pulsation of the heart and that of the umbilical cord are present; Cazeaux observed an instance where life continued four hours. Fifth Month.—At five months the foetus is about ten inches, 25 to 27 centimetres, long, and weighs eight to nine ounces; the average THE EMBRYO AND FCETUS. 149 is 273 grammes; the umbilical cord is about twelve inches, or 31 cen- timetres long. Hair on the head and lanugo distinct; vernix caseosa present. During the month, usually about its middle, the mother, in most cases, first becomes conscious of fcetal movements, and the sounds of the foetal heart can be heard by auscultation; movements of the foetus are felt somewhat earlier by the multigravida than by the primigravida. If the foetus be born at five months, it breathes, cries faintly, and lives longer than when born at four months, but dies in a few hours. Sixth Month.—The foetus is 12^ inches, 31 centimetres, in length, and weighs a little more than one pound, 634 grammes. Its form has become rounded by the increase of fat, lanugo covers the body and the members also, except the palms of the hands and the soles of the feet; the growth of hair upon the head is plain, and the eye- brows can be faintly seen, while the secretion from the sebaceous glands furnishes a more abundant vernix caseosa. A foetus born at the end of six months may live from one to fifteen days. Its death occurs not only because the digestive apparatus is incompletely de- veloped, and because the reduction of temperature is great and rapid, but because the rudimentary condition of the lungs renders respiration almost impossible,1 for, according to Cornil, at this period of intrauterine life air cannot distend the final pulmonary ramifica- tions because of their anatomical structure. Seventh Month.—At the end of the month the foetus is 13-15 inches, 33-36 centimetres, long, and weighs between 3 and 4 pounds, 1200 grammes. The eyelids are open, the testicles begin to descend in the seventh month, and are near the scrotum. The nails are almost completely formed, the insertion of the cord is about one inch and a half, four centimetres, below the middle of the length of the body. The child is said to be viable at the end of the month, but its viability is only relative to that of earlier birth; the majority of children born at this period die. On the other hand, there are instances in which children born before the end of seven months have lived. Tarnier states that by means of the couveuse and gavage several accoucheurs have succeeded in recent years in saving infants whose intra-uterine life was only six months, or six months and some days. A popular,2 founded upon a professional, belief prevailed for many centuries, to the effect that a child born at seven months was more likely to live than one born at eight months. Possibly this belief is not yet quite extinct. It is, how- ever, somewhat astonishing to find the late Dr. John W. Francis, Professor of Obstetrics in the University of New York, in his preface to the American edi- tion of " Denman" (1821), using the following language : " The singular circum- stance that a child of seven months' gestation has greater chance of living than one of eight was noticed by him," i. e. Hippocrates. Now, this notion, which was 1 Pinard. 2 As illustrative of this belief the following passage from the Memoirs of Madame Guyon is quoted. She was born in 1642, and was the founder of that peculiar form of religious belief and conduct known as Quietism : '• I was born before due time, for my mother, having received a terrible fright, was delivered of me at the eighth month, at which time they say it is almost impossible for a baby to live.'' 150 SCIENCE AND ART OF OBSTETRICS. held for more than two thousand years, had its origin in the infancy of obstetric science, and arose from ignorance of the essential cause of labor. It was believed that the foetus up to seven months had its head in the upper part of the womb, but at that time the increased weight of the head caused it to fall into the lower part of the uterine cavity ; the head of a boy, from its having greater size, turn- ing downward somewhat earlier than that of a girl. But as soon as the foetus had its head at the mouth of the womb, it made an effort to get out, and, if a very strong child, succeeded. If it failed, the effort was repeated at eight months, and in case it then succeeded the foetus, having been weakened by its previous unsuccessful attempt, had less chance of living than if birth had taken place at seven months. Eighth Month.—At the end of the eighth month the length of the fcetus is about 16 inches, a little more than 40 centimetres, and its weight is about 5 pounds, or nearly 2 kilogrammes. The insertion of the cord is about the middle of the length of the body ; only one of the testicles, usually the left, is in the scrotum ; during the month the body increases less in length than in breadth. Ninth Month.—The length of the foetus at term varies from about 19^ inches to a little more than 22 inches, 50-56 centimetres; its weight by many is placed as between six and seven pounds ; Lan- dois, however, makes it seven pounds, 8l{ kilos. The last statement corresponds more nearly with that resulting from statistics, includ- ing 500 male and 500 female children, taken from the obstetric re- cords of the Philadelphia Hospital.1 These statistics showed the average weight of female children to be seven pounds one ounce and a half, and that of male children to be seven pounds eight ounces. In only one of a thousand was the weight eleven pounds. Burns regarded the weight-proportion between the sexes in the newborn to be such that twelve males would weigh as much as thirteen females. The late Sir James Simpson has drawn attention to the fact that from the great size of the head of the male the fcetal mortality in childbirth was larger with male than with female chil- dren ; Bertillon's statistics prove that the foetal mortality in birth is in the proportion of 130 males to 100 females. If a child's weight at birth be decidedly under the average, the probability is that the labor is premature, or else the normal development of the child has been interfered with. So, too, if the weight be much above the average it is possible that in some cases the pregnancy has been protracted beyond the normal time.2 In one instance in my practice a child was born weighing only one pound and a half, the pregnancy ending a few days before the completion of the seventh month; the child lived, and is now a healthy boy of ten years.3 1 I am indebted to Dr. R. J. Phillips, one of the internes at the time, for preparing these statistics. A curious fact which I have observed in my hospital service is, that there is less dif- ference in weight between the sexes of the newborn in the black than in the white. While a sufficient number of observations have not been made to establish a law, there are a priori rea- sons for believing in its possibility. 2 Kormann, op. cit., believes that pregnancy may last at least two or three weeks beyond two hundred and eighty days, and that then the fcetus may be developed beyond the average so that its weight is 6000 grammes, and its length 30 centimetres. This subject will be referred to again in connection with the topic of prolonged pregnancy. 3 Gilbert (Zeitschrift fur Geburtshiilfe und Gynakologie, Band 16, Heft 1) reports the case of a female child, born in the twenty ninth week of gestation, weighing three and a half pounds; the child was twenty-two inches long when five and a half months old. Various incubators were tried, but daily warm baths were most successful. The child was taken into the open air THE EMBRYO AND FCETUS. 15 I Dr. R. P. Harris, in a note to " Playfair," states : " We have had children born in this city, Philadelphia, at maturity that weighed but one pound. The well- remembered ' Pincus ' baby weighed a pound and an ounce." In some instances children weighing twelve pounds and even more have been born. But it is remarkable that most of the cases of birth of unusually large children occur in private, not in hospital practice. Pinard, from an examination of the records of the Paris University, found but one in 20,000 that weighed 5300 grammes, a little more than twelve pounds. Nevertheless children have been born whose weight was very much greater than even this. For example, Dr. Adye, of Bentonville, Ind., in a recent letter to me states that in his practice a woman was delivered spontaneously and rapidly of a child weighing 16 pounds ; both mother and child did well. The most extra- ordinary case that has been communicated to me, however, was one occurring in the practice of Dr. Josiah Peltz, of this city. On the 29th of October, 1887, he delivered Mrs. S., at the end other fourth pregnancy, of a female child weighing 22 pounds. The child was stillborn, but the doctor believes that it could have been resuscitated had proper means been used; the means were not used because for some time his sole care was of the mother, who had dangerous uterine hemor- rhage. Dr. Peltz states that his patient is a woman of unusual size, ordinarily weighing 225 pounds, and that her pelvis is remarkably large. Harris, op. cit., says : " Probably the largest fcetus on record was that of Mrs. Captain Bates, the Nova Scotia giantess, a woman of 7 feet 9 inches in height, whose husband is also of gigantic build, reaching 7 feet 7 inches in height. This child, born in Ohio, was their second, and was lost in its birth, as no forceps of sufficient size to grasp the head could be procured. The foetus weighed twenty- eight and three-fourths pounds, and was thirty-nine inches in length. Their first infant weighed nineteen pounds." The Fcetus at Term.—There is no single criterion by which the maturity of the foetus can be known, but a strong probability, amounting to almost absolute certainty, is attained by combining certain characteristics. Thus the foetus should have the average weight and length that have been given ; the body should be plump, and more or less covered with the secretion from the sebaceous glands, this secretion being mixed with the detached lanugo and epithelial scales making the vernix caseosa, or cheesy varnish ; this covering is chiefly in the groins and axillae, at the flexures of the joints, and upon the back and chest. The nails of the fingers and toes are hard, those of the former projecting slightly beyond the tips of the fingers ; the cartilages of the ear and nose are resisting ; the cord is usually a little below the middle of the anterior portion of the body, in girls the insertion is said to be a little higher than in boys; the hair on the head is one to two inches, 2.6 to 5.2 centi- metres, long; the chjld cries vigorously, and makes active efforts at sucking an object placed between its lips. The Fcetal Head.—This is the part of the fcetus which is usually expelled first, and if it can pass through the birth-canal there is rarely difficulty or delay in the delivery of the body, and hence the knowledge of its form, size, and structure, and the changes in its from the moment of birth. For the first week a wet-nurse fed the infant; afterward the mother. From the seventeenth day it was fed breast-milk with a spoon. When eighteen weeks old cow's milk was given. In growth the greatest gain occurred at the time when birth would have normally occurred. The child suffered from frequent attacks of syncope until its fourth year; it had also spinal curvature (scoliosis 350) from rhachitis; this was afterward reduced by orthopaedic treat- ment (to 50). The milk teeth were complete at three and a half years. 152 SCIENCE AND ART OF OBSTETRICS. measurements and shape occurring in labor, is important for the obstetrician. The general shape of the foetal head is ovoidal, the larger end of the ovoid being posterior. It is composed of cranium and face ; the latter is of minor obstetric importance. The bones of the cranium of the fcetus differ from those of the adult's cranium in two important respects: they are to some degree flexible in con- sequence of incomplete ossification, and they are mobile, because instead of being united together by bone, their union is by fibrous tissue. Further, in the fcetal head mobility of the squamous por- tion of the occipital results, as pointed out by Budin,1 from its being united to the basilar portion by cartilage, which serves as a hinge, and the former is moved forward or backward according to the action of external force. Sutures and Fontanelles.—The membranous spaces between the bones of the head are called sutures and fontanelles. The sutures are straight or curved lines, and the fontanelles are at the junction or at the intersection of sutures; if at the former, the fontanelle is triangular, but if at the latter, quadrangular. The three most im- portant sutures are the sagittal, the fronto-parietal, and the occipito- parietal. The sagittal—from sagitta an arrow, meeting the bow- string at a right angle, passing directly over the bend of the bow, and thus intersecting the middle of the arc described by the fronto- parietal suture—is the longest, and extends from the root of the Fig. 92. Anterior and Posterioi Fontanelles, Sagittal and Occipito-parietal, and Occipito frontal Sutures. nose to the upper point or angle of the occipital bone; it is the dividing line between the two halves of the frontal bone, and be- tween the two parietal bones. The fronto-parietal, as its name indi- cates, is between the frontal and the parietal bones; it ends on either side at the squamous portion of the temporal bone. The occipito-parietal, usually called lambdoidal from its suggested re- FlG. 91. De la Tete du Fcetus au point de vue de l'Obstetrique. THE EMBRYO AND FCETUS. 153 semblance to the Greek1 letter lambda, 1, is between the occipital and parietal bones; it may be described as a bifurcation of the sagittal suture. The chief fontanelles are two, one anterior, the other posterior. The former, also called bregma, from fipt-xo to moisten, because of its being so yielding to the touch, is at the intersection of the two sutures, the sagittal and the fronto-parietal, and therefore quad- rangular. It is a large, membranous depressed surface, with unequal sides, the two anterior being longer than the two posterior; these features are so characteristic that its recognition in labor by the touching finger is usually quite easy. The posterior fontanelle is at the junction of the sagittal with the occipito-parietal suture, it is con- sequently triangular; it is quite small, and in labor cannot, as a rule, be recognized as a membranous space, for in consequence of the movement of the squamous portion of the occipital bone forward, the overriding parietal bones hide it from touch; but its position may be recognized by its corresponding with the point of apparent bifurcation of the sagittal suture, and by its being at the apex of a depressed triangle, two of the con- verging sides of the triangle being fig. 93. the posterior margin of each pa- rietal bone, and the intervening space occupied by the occipital bone. Lateral and supplementary fontanelles are also to be noticed. The chief of the former are at the junction of the occipito-parietal and temporal sutures, but they are con- cealed by soft parts. Supplemen- tary fontanelles are membranous spaces arising from failure of ossi- fication; they are sometimes found Anteroposterior Diameters of Foetal in the middle of a bone, sometimes Head. in the course of a suture; remem- bering these facts as to their position, one is not liable to confound them with either of the fontanelles that have been described, and which are such important guides in practical obstetrics. Diameters of the Fcetal Head.—These are lines drawn between certain points of the fcetal head. Following the example of Budin, these diameters may be classified according to their general direc- tion, as antero-posterior, transverse, and vertical. The antero-pos- terior are four, viz., the maximum, the occipito-mental, the occipito- frontal, and the suboccipito-bregmatic. The maximum diameter extends from the chin to a variable point, which is in almost every case situated in the sagittal suture between the two fontanelles. The occipito-mental diameter reaches from the point or angle of the occiput to the chin. The occipito-frontal is 1 Its resemblance is greater, as Bailly has said, to a capital V, whose angle corresponds to the end of the sagittal suture. 154 SCIENCE AND ART OF OBSTETRICS. between the angle of the occiput and the root of the nose, and the suboccipito-bregmatic is from the point of meeting of the occipital bone with the nucha to the middle of the anterior fontanelle, that is, where the sagittal and fronto-parietal sutures cross each other. The transverse diameters are three, viz., the biparietal, between the parietal protuberances, the bitemporal, between the origin of the fronto-parietal suture on each side, and the bimastoid, which extends between the mastoid apophyses. The vertical diameters are two, the fronto-mental, extending be- tween the highest point of the forehead and the chin, and the tra- chelo-bregmatic, from the.middle of the anterior fontanelle to the upper and anterior part of the neck in the immediate vicinity of the larynx. This diameter is also called the cervico-bregmatic and the laryngo-bregmatic. Biparietal and Bitemporal Diameters of Vertical Diameters. Fcetal Head. The illustration upon the next page, taken from Tarnier, shows the three diameters, suboccipito-bregmatic, suboccipito-frontal, and suboccipito-nasal, as measured in an infant immediately after delivery. The fact of the second diameter being greater than either of the others, and hence the circumference of the child's head correspond- ing with it will be that which will be with the greatest difficulty forced through the vulvar ring, are apparent. The importance of this diameter in regard to expulsion of the head, that is, the greater danger to the perineum at the time its circumference passes, has been in recent years especially urged by Matthews Duncan and by Ribemont. But long before them Smellie and Burton had referred to the essential fact. The greatest circumference of the fcetal head is that corresponding with the maximum diameter, and the least that which is similarly related to the suboccipito-bregmatic. THE EMBRYO AND FCETUS. Fig. 96. 155 The Three Sub-occipital Diameters. In the following table of diameters and circumferences, the measurements given by Tarnier and Chantreuil are presented. Each metric measurement is followed by its equivalent in inches and hundredths, and this in turn by an approximative measurement, where it seemed most convenient for remembering, substituting vulgar for decimal fractions. Maximum diameter Occipito-mental Occipito-frontal Suboccipito-bregmatic Biparietal Bimastoid Fronto-mental Bitemporal Trachelo-bregmatic Great circumference Small circumference 13.S cm. 13- 9-5 9-5 7-5 95 37- 32-5 5.31 inches oxsxA 5-H 5% 4.72 4% 3-75 3K 3-75 3H 2.75 2% 315 3-15 3-75 3H 14-57 WA 12.80 I2# Upon comparing these diameters of the fcetal head with those of the maternal pelvis, it will be seen that only two of the former exceed the greatest of the latter; but in normal labor neither of the two is brought in relation with a pelvic diameter. Modification of Diameters of Fcetal Head in Labor.—Budin has shown that certain modifications in the diameters of the fcetal head are produced by the overriding of bones at the sutures, from the pressure upon the head in passing through the pelvis, and that by these changes the head is changed in shape, the change varying with the position. In general the alterations in the diameters are as follows: The occipito-mental and occipito-frontal diameters are lessened. The maximum diameter is increased. The suboccipito- bregmatic and the bitemporal are lessened. The biparietal is very slightly lessened; but the mastoid not changed. Movements of the Foetal Head.—The head may be bent backward or forward so as to come in contact with the body; the first is called 156 SCIENCE AND ART OF OBSTETRICS. to 9.5 The sacro- Fic. 97. complete flexion, and the second complete extension; this move- ment takes places chiefly in the articulations of the cervical ver- tebrae, the occipito-atlantoid articulation participating only very slightly. The last articulation, however, permits rotation of the head to the right or to the left through a quarter of a circle. Tarnier, in reply to the question whether the head can be made to rotate much more extensively without injury to the cord or to the ligaments, asserts that the fears expressed are purely theoretical, and that a movement of rotation so extensive that the face is turned directly backward may be made without producing any lesion. This topic will be referred to in another part of the work. Diameters of the Trunk.—The bis-acromial diameter from one acromion to the other is the longest trunk diameter. It is 4.7 inches, or 12 centimetres; it can be reduced one inch, or centimetres. The dorso-sternal is 3.7 inches, 9.5 centimetres. bis-trochanteric diameter is 3.5 inches, 9 centimetres. The pubic diameter is a little more than 2 inches, 5.5 centimetres; by the flexion of the thighs upon the abdomen and the legs upon the thighs this diameter is nearly doubled, but compression readily lessens it. All the trunk diameters lessen by compression more than do those of the head. Attitude of the Foetus in the Womb.—By this is meant the general form and direction of the trunk, and the position of the limbs with reference to it. We have seen that in the very dawn of development the first distinct form which the embryo had was that of a curve, the ends of that curve tending to approach ; and the curved form is kept through all intra- uterine life. As shown in the above diagram of the foetus contained in the uterine cavity, the back is bent forward, the chin inclined to the chest, the arms folded over the breast, the feet flexed, the legs flexed upon the thighs, and the thighs upon the abdomen; the foetus is thus folded upon itself, making an ovoid, its position being not unlike that of a chrysalis in the cocoon, or a chick in the shell. Harvey's explana- tion of the attitude of the foetus was this : " The truth is, that all animals, whilst they are at rest or asleep, fold up their limbs in such a way as to form an oval or globular figure; so, in like manner, embryos, passing as they do the greater part of their time in sleep, dispose their limbs in the position in which they are found, as being most natural and best adapted for their state of rest." Cazeaux regarded the attitude of the fcetus as representing " a con- strained position, which could not have been produced by the mere Posture of the Foetus. THE EMBRYO AND FCETUS. 157 pressure of the uterine walls upon the child, since the latter is in a cavity much larger than its whole volume; hence it must be referred to the individual itself." As has already been stated, the attitude of the fcetus is the per- petuation of that of the embryo, and the primitive form of the latter must be regarded as one of the factors in causing it. But others are also concerned—indeed, by some made the exclusive factors ; Pinard, for example, saying1 that the causes are material, extrinsic,' and belong to the pressure forces much more than to the individual —and these will be considered under the next topic. Presentation of the Fcetus.—By presentation is meant that part of the fcetus which is in relation with the pelvic inlet, and in labor first descends into the pelvic cavity; that part, in a word, which presents at the inlet and in the cavity. In about ninety-six per cent, of cases of labor at term the head presents; many obstetric authorities indeed regard this as the only normal presentation, as it is certainly the most favorable. Various explanations have been given of the fact. The Hippocratic theory held that the foetus was attached by liga- ments passing from the umbilicus to the fundus of the womb, its head being above; rupture of the ligaments occurred at seven months, and then the child immediately turned its head down and attempted to force its way out of the womb. Aristotle held with Hippocrates as to the original position of the child, but added gravity in explaining the turning downward of the head. Trentius, 1564, found in the form of the uterus the reason for the head usually being in its lower portion at labor. The illustrious Pare attributed the presentation to instinct. Dubois sustained this hypothesis, illustrating it by instinctive acts of the newborn seeking the nipple and sucking. Sir James Simpson held that reflex action was not the exclusive but the ancillary cause,"using the following language:2 "At and toward the full term of utero-gestation, the position of the fcetus with its head lowest is thus greatly maintained by the relative physical adaptation of the ovoid shape of the rolled-up mass of the fcetus to the ovoid shape of the cavity of the uterus. But this par- ticular adaptation and position of the foetus would be often lost if no other additional and vital means were in operation, as we see, indeed, often happen when the child dies. The other additional means, by whose influence this special position is still further rigor- ously and carefully sustained, consists of the restoring influence of reflex motions on the part of the fcetus itself." The gravitation theory proposed originally, as we have seen, by Aristotle, is advocated by some to-day as an assisting, by others as the chief cause, notwithstanding the experiments of Dubois, and the criticisms of Simpson, which appear conclusively to disprove it. One of the most curious of modern hypotheses, mentioned by Cohnstein3 in his paper upon Normal Presentation of the Fcetus, is that of Probsting. The 1 Dictionnaire Encyclopedique des Sciences Medicales. 2 Obstetric Works. 3 Archives Generales de Medecine, 1869 and 1870. 158 SCIENCE AND ART OF OBSTETRICS. head presents because of the efforts of nature to place the orifice of the respira- tory organs of the fcetus as near as possible to atmospheric air. Cohnstein denies that the cause of presentation of the head is in the movements of the fcetus, or in forces external to it, but asserts that it is in the fcetal circulation, for until seven months a larger amount is sent to the upper part of the body, but then the amount of blood is equalized. For Pinard one law governs the relations between the fetal and the maternal organism, and this law is absolutely the same as the law of accommodation of labor, so well formulated by Professor Pajot: When a solid body is contained in another, if the container is the seat of alternate movement and rest, if the surfaces are slippery and little angular, the content constantly tends to accommodate its form and dimensions to the form and capacity of the container. While this law explains the presentation of the head of the foetus better than the gravitation theory, or that of instinctive or reflex fcetal movements, it seems probable that it is not the sole cause of the attitude of the fcetus, but merely assists the action of the primi- tive cause. Studying Pajot's law, as it relates to presentation alone, we find in the painless contractions of the uterus in pregnancy, in the vary- ing abdominal pressure, and the changes of position of the mother, which have more or less action upon the fcetus, the conditions of movement and rest; the fcetus presents more of a rounded than of an angular surface, and after the secretion of the sebaceous glands begins, this surface is smooth, slippery, and thus, the amnial liquor assisting, the accommodation of the content to the container is effected. This accommodation fails in those months of preg- nancy when the uterus is very much larger than the foetus. Thus Veit's statistics show that in 247 deliveries between the first of the fifth and the sixth month, the head presented in 140, the pelvis in 95, and the trunk in 12. If the foetus be dead and macerated, one of the conditions of the law fails, the content is no longer a solid body, and statistics show that in very nearly one-half of the cases in which delivery takes place before six months, the pelvis presents. As pointed out by Sir James Simpson, presentation of the pelvis is common if the child be hydrocephalic; here it is evident that accommodation causes the presentation. In twin pregnancies accommodation is difficult, and Kleinwachter's statistics show pres- entation of the head in 69 per cent., of the pelvis in 25 per cent., and of the shoulder in 5 per cent. In polyhydramnios the fcetus is usually small, and thus ample space doubly secured interferes with accommodation, so that malpresentations are common. Pinard1 attaches great importance to the action of the abdominal wall in assisting in accommodation, its elasticity and the contrac- tion of its muscles prevent the uterus from departing from the median line, press it at all points, especially upon the sides. He attributes the greater frequency of malpresentations in multiparas, 1 Op. cit. THE EMBRYO AND FCETUS. 159 seven to one in primiparai, to the relaxation of the abdominal mus- cles caused by preceding pregnancies. So, also, he assigns to the same cause the frequent changes of position of the fcetus in preg- nancy, and the delay in the engagement of the presenting part in the latter weeks. Nevertheless, while admitting the force of these arguments, much must also be ascribed, as held by Charpentier, to the greater relaxation of the multiparous than of the primiparous womb, and its larger cavity as explaining, in part at least, these results. Pinard divides the causes into active and passive. The former are the forms of the uterus and of the fcetus in the different periods of pregnancy, the folding together of the foetal body and limbs, the gliding surface of the fcetus, and the amnial liquor. The active causes are the contractions of the uterus, the painless contractions of pregnancy, and the contractions and tonicity of the muscles of the abdominal wall. Winckel concludes that the position and attitude of the child are determined principally by the shape and activity of the uterus, aided by the shape and move- ments of the parts of the foetus, and that the predominance of cephalic presenta- tions results from the direction of uterine force, the greater size of the upper than of the lower segment of the uterus, the greater mobility of the child's head, and the shape of the uterus and child, the latter being better adapted to the former when the head presents. It must be obvious that the most important part of this explanation is that which rest upon Pajot's law, previously stated. Dr. D. T. Smith, of Louisville, Ky., some time since1 gave an original explana- tion of the cause of presentation of the head, and has recently repeated it :2 "Who- ever has practised diving in deep water has discovered that if he holds his arms in such a way as not to hinder his progress—folded at his back or breast, for in- stance, or pressed to his sides—and then kicks out with his feet, he will go directly to the bottom. Now the position of the child in the uterus, and the course of its development are such that it makes essentially similar movements. The flaccid state of the walls of the uterus allows them to yield when pressed against by the lower limbs, and in this way the fcetus gains the advantage that would accrue to it from swimming in a larger mass of water than that contained in the uterus. Adding to the influence of these movements the increasing conicity of the lower segment of the uterus that develops during the latter months of pregnancy, we can easily account for the greater preponderance of head presentations. In every position the mother takes, except that of lying on the side, the outlet of the uterus is lower than the fundus, and in all except the latter the movements the child spontaneously makes will tend to place its head downward." Foulis3 concludes from the study of sections through the pelvis and abdomen that the continual movements of the child's lower limbs in extension cause the head-downward position. The prevalence of the situation of the occiput and back on the mother's left side results from the proportionally large size of the liver in the pregnant woman, which fits over the uterus like a cap, affording firm resistance to the impact of the child's feet. Physiology of the Foetus.—The chief fcetal functions are nutrition, circulation, respiration, secretion, innervation, and motility. Nutrition.—It is supposed that the nutrition of the impregnated ovule is at first by the granular matter, the discus proligerus, which 1 American Practitioner and News, 1887. 2 American Journal of Obstetrics, 1890. 3 Edinburgh Medical Journal, September and October, 1888. i6o SCIENCE AND ART OF OBSTETRICS. surrounds it when it escapes from the ovisac. In some of the infe- rior animals the ovule, during its passage through the oviduct, receives a covering of albumin, and probably the same fact exists in the human ovule ; if so, this albuminous coat may nourish it. After entering the womb the primitive chorial villi absorb nutri- tive material from the uterus; the granular contents of the um- bilical vesicle probably nourish the embryo, but as the vesicle is atrophied at the end of the fifth week, this supply lasts but a short time. The question as to the amnial liquor contributing to the nourish- ment of the fcetus—that it is the sole or chief supply no one now holds—is still in dispute. According to Fehling, the human em- bryo has at the sixth week 97-54 per cent, of water; in the fourth month the quantity of water of the foetus is between 88 and 93 ; in the fifth, between 88 and 93; in the sixth, between 83 and 90; in the seventh, between 82 and 85 ; and in the mature fcetus born dead 74.1. Bischoff, however, found in the newborn only 66.4 per cent. of water. Preyer's statements as to the fcetus obtaining water from the amnial liquor by swallowing, and by absorption through the skin, have been given on p. 134. Further, while the percentage of albumin in the amnial liquor is very small, the absolute quantity the fcetus obtains may be very great by accumulation; this liquor con- tains salts, sodium and calcium phosphates, which are important for the development of the fcetus. Ahlfeld1 concludes from the examination of the meconium, that the foetus swallows considerable quantities of the amnial fluid. This is a physiological process ; he has found the amnial fluid albuminous in several cases, ranging from twenty to fifty per cent, albumin. His tests were nitric acid and heat. He concludes that the albumin of the amnial fluid is nutriment for the foetus, " and by an elastic bag applied over the mother's abdomen at the location of the child's back, he demonstrated movements of the child's thorax in the uterus, which he considered motions of deglutition. Mekus2 has met with an instance supporting the belief that the foetus swallows the liquor amnii, in the case of a child who could not retain fluid swallowed; it died of inanition and was poorly developed at birth. On examination, the oesophagus was impervious at its middle. It was noticeable that the liquor amnii was very abundant at birth. The case is virtually a ligation of the oesophagus in the living foetus ; result, a poorly developed and nourished foetus, no evidence ot liquor amnii in the digestive tract, and an abnormal abundance in utero. Undoubtedly, materials present in the amnial liquor have been found in the stomach and intestines of the fcetus, and thus it is proved this liquor may be swallowed, but it is not proved that this is the rule, and up to the present most have regarded it as the excep- tion. Moreover, monsters in which the mouth is absent are born well developed, and therefore the entrance of amnial liquor into the alimentary canal is not essential to nutrition. Further, as plea- santly remarked by Pinard, the same physiologists who assert the nutrition of the foetus by the amnial liquor, also hold that the fcetus 1 Zeitschrift fur Geburtshiilfe, Band 14, Heft 2. 2 Centralblatt fiir Gyn'akologie, No. 42, 1888. THE EMBRYO AND FCETUS. 161 passes urine into this liqnor, and it is singular if such a fluid con- tributes to its nourishment.1 The permanent and certainly the chief, if not the only nutritive supply of the fcetus is secured through the placenta—other means are only temporary or secondary; during the formation of this organ chorial villi, especially those which contribute to its structure, the chorion frondosum, supply nutritive material to the embryo. The growth of the new being is much slower before than after the development of the placenta, the fcetus increasing in weight during the last six weeks of pregnancy to an amount equal to that which it attained in the first five months. Foetal nutrition has been com- pared to that of a vegetable parasite which takes from the circula- tory vessels of the plant on which it is developed the materials necessary for its growth. Reference has previously been made to the fact that the solutions of various substances may pass from the maternal to the fcetal blood. The following are the conclusions of Preyer2 in regard to the recip- rocal relation of the maternal and foetal blood: i. Very many substances in solution, easily diffusible, can pass from the blood in the sinuses of the maternal portion of the placenta into the capillaries of the villi of the foetal portion of the same placenta. 2. That oxygen certainly passes from the haemoglobin of the blood globules of the mother in the placenta, to the haemoglobin of the blood globules of the fcetus in the capillaries of the villi, as long as there is a sufficient quantity. 3. That some substances in solution, as the sodi-indigosulphite and the potas- sic iodide, can be directly eliminated from the mother into the amnial liquor with- out entering the blood of the fcetus. 4. That soluble substances easily diffusible can pass abundantly from the blood of the capillaries of the villi into the blood of the sinuses of the maternal portion of the placenta. 5. That oxygen certainly passes from the haemoglobin of the blood globules of the foetus in the placenta to the haemoglobin of the blood globules of the mother, if the maternal blood contains but a minimum or no trace of oxygen. 6. That some substances which are soluble may pass from the amnial liquor, probably in small quantity, into the blood of the mother. 7. That formed elements cannot, unless extremely small, probably pass in abso- lutely intact placentas, and that even then the transmission does not take place uniformly, but only in certain conditions, sometimes dependent upon the organi- zation, as in sheep, sometimes in anomalous states, possibly increase of blood pressure, or by means of diapedesis of leucocytes. 8. That it has not been conclusively provedthat formed elements migrate from the blood of the fcetus into the maternal blood in the placenta, but such passage is possible. From what has been proved as to the action of atropine, the natu- ral conclusion is that soluble salts of opium will readily pass from 1 Preyer, op. cit., admits the fact, remarking: However paradoxical it may appear, the fcetus discharges urine into the amnion, and drinks it, with the other constituents of the amnial fluid, in quantity so much greater as the term of gestation approaches, like the embryo of the bird before hatching. Diihrsenn, Centralb. f. Gynakol., 1888, concludes from his investigations that in the latter part of the intra-uterine life the organs of the foetus function as in extra-uterine life; and that the urine of the fcetus from time to time is emptied into the amnial fluid. He believes the nutrition of the foetus is dependent solely upon the placenta, and that amnial liquor is produced by fcetal excretion. 2 Op. cit. II l62 SCIENCE AND ART OF OBSTETRICS. the maternal to the fcetal blood. Two milligrammes of atropine were given hypodermatically to a woman three hours before delivery; the child was born with dilated pupils which did not react to light. So, too, the belief is probable that a woman who is an opium-eater is liable to give birth to a child affected by morphine; it is possible, too, more remote injury may result. In one case where morphine was administered to a pregnant woman by hypodermatic injection, the fcetal pulse became less frequent and arrhythmic. It has been shown by Porak that when fifteen grains, one gramme, of quinine were given to a woman in labor, the urine in the child, born an hour and a half afterward, showed the presence of quinine. Runge gave to women during several of the last days of pregnancy half a gramme daily of muriate of quinine, and in almost all cases quinine was found in the fcetal urine. Now if, as is alleged by some observers, the child may suffer from intermittent fever while in the uterus, obviously there is every reason to believe that the disease may be cured by giving quinine to the mother. Occasional cases in which intra-uterine vaccination has succeeded, and the transmission of certain diseases believed to depend upon germs, such as syphilis, variola, rubeola, scarlatina, etc., from the mother to the foetus, testify to the passage of micrococci from the maternal to the fcetal blood. Circulation.—The circulation in intra-uterine life passes through two important phases, while a third is entered upon at the close of that life. The first is very brief, and depends upon the formation of the umbilical vesicle; it is called the vitelline circulation. The heart, still a straight, tubular cavity, gives off from each end two vessels; the two superior are the first aortic arches, and the inferior are the omphalo-mesenteric veins. By the heart's systole the blood entering the aortic arches passes first into the body of the embryo, then into the omphalo-mesenteric or vitelline arteries, which carry it to the vascular area of the vesicle ; from there it enters the venous sinus, situated at the periphery of that area. The omphalo-mesen- teric veins are formed by branches originating at the sinus, and empty the blood thus collected into the heart during its diastole. Second, or Placental Circulation.—The vitelline is superseded at the beginning of the third month by the placental circulation. The heart is developed into an organ of four cavities, and externally presents the form of the adult heart; internally there are important differences. The most important of these differences is that the septum between the auricles is imperfect; it has a large opening, described by Galen, but to which the name of Botal has been given; it is also called the foramen ovale. Furthermore, the Eustachian valve situated at the entrance of the inferior vena cava is remarkably developed, so that it turns the current of blood coming through the latter vessel into the auricle to the foramen ovale, and thus into the left auricle. Two important structures must also be mentioned before describing the circulation, the venous duct and the arterial duct, ductus venosus and ductus arteriosus; the former connects the THE EMBRYO AND FCETUS. * 163 umbilical vein with the inferior vena cava; the latter, the ductus arteriosus, which appears as if a continuation of the pulmonary Fig. 98. Intenal Ihac AC Plan of the Fcetal Circulation. artery, connects the artery with the aorta at a point of the arch just below the origin of the arteries of the head and upper limbs. 164 SCIENCE AND ART OF OBSTETRICS. The blood, purified and rendered fit for nutrition in the placenta, is brought to the fcetus by the umbilical vein, which enters at the umbilicus; the greater part of the blood passes at once by the ductus venosus into the ascending vena cava, where it mixes with the blood brought from the lower limbs, the pelvis and the kidneys ; a small part passes to the liver, and on the other hand blood from the hepatic veins empties into the cava. These various collections, chiefly of course that which comes from the placenta, make the common stream which is carried by the vena cava into the right auricle, but the stream is turned by the Eustachian valve through the right into the left auricle, from which it passes, as in post-uterine life, into the left ventricle. The heart now contracting, the blood it contains is sent from the left ventricle into the aorta, from the right into the pulmonary artery. The blood which passes into the aorta from the left ventricle passes chiefly to the head and upper limbs; that which enters the pulmonary artery being needed in only small amount by the inactive lungs, and these organs incapable of exer- cising their function the blood does not need them, therefore the greater part of it is carried by the ductus arteriosus into the aorta; as the ductus venosus transmitted a purified blood, so the ductus arteriosus conveys an impure blood. The aorta, after the ductus arteriosus has emptied its supply into it, contains blood from both the left and the right heart, and transmits this mixed blood to the organs situated below, to the lower limbs, and by the umbilical arteries to the placenta. The blood which was expelled from the right ventricle had been received from the descending vena cava through the right auricle, and it was therefore an impurer blood than that which was expelled simultaneously from the left ventricle; thus it is plain that the lower half of the body has a blood less rich in nutritive materials than the upper half, and hence the greater development of the latter than of the former, a development which is necessary for the exercise of certain functions in the period of life immediately following delivery. The organ which receives the. purest blood is the liver. At birth that which is often called the third circulation is estab- lished. With the first inspiration of the newborn, the blood flows in increased quantity to the lungs, and the stream which passed from the pulmonary artery to the aorta through the ductus arteriosus, now goes into the branches of the pulmonary artery, and the arterial duct is narrowed, and obliterated in two or three days. The blood coming from the lungs fills the left auricle, prevents that which enters the right auricle passing through the foramen ovale; this opening in the wall between the auricles, not being used, is closed, the closure not being completed until some weeks after birth. Respiration.—The placenta is the respiratory organ of the fcetus. As remarked by Spiegelberg, the mother's blood is for the fcetus the external world from which alike its respiration and nutrition needs are satisfied. The importance of a supply of oxygen for the foetus is rendered probable by the abundance of ha_'moglobin in its blood. According to the investigations of several, the blood of the mature THE EMBRYO AND FCETUS. I65 foetus is richer*in haemoglobin than is that of the mother. Hoesslin found, too, in fcetal blood which contained 13.72 per cent, of haemoglobin, there were 5.88 millions of blood corpuscles in a cubic millimetre of the blood, a very much larger number than woman's blood has. Preyer, from his own investigations, has concluded that the haemoglobin in the pregnant woman's blood is never greater, often very much less, than in that of the foetus. He also states that important changes of matter occur in the foetus, as shown by the formation of certain products which are not ob- tained from the mother's blood, secretions from its glands, or building up permanent structures; exercise of voluntary and of involuntary muscles; the fcetus, too, has a higher temperature than that of the mother's uterus; and all these things indicate the fact that oxygen is necessary for the fcetus. The only source of supply is the maternal blood. The proofs of foetal blood-changes in the placenta, analogous to those which occur in pulmonary respiration, are the difference of color in the blood coming from and going to the placenta; the fact that, if the placental circulation be temporarily interrupted, the blood in the umbilical vein becomes dark like that in the arteries, and, if the interruption be permanent, the fcetus dies asphyxiated, and the only substitute for placental is pulmonary res- piration; finally, spectroscopic examination has proved the presence of oxygen in the foetal blood. It has been held that the foetus requires but a small quantity of oxygen because the nutritive changes are so simple, and its activity so slight. But it should be remembered1 as to the latter point that the heart begins its action early, and that its pulsations are twice as frequent as in the adult; that foetal movements occur some time before the mother is conscious of them, and that very many take place after she has this consciousness without her recognition, for only those affecting that part of the uterus which is in relation with the anterior abdominal wall can be known by her. In answer to the statement that the nutritive changes are slight, Weiner,2 from his study of these changes in the fcetus, has concluded that there exists in the fcetus, especially in the last period of fcetal life, a certain number of organs which function as in the newborn. The kidneys act, and this quite early, in relation to certain known substances arti- ficially introduced into the foetus, exactly as the kidneys of the newborn, and very rapidly excrete these products. Absorption by the lymphatics and rapidity of the lymph currents are very energetic; the intestinal mucous membrane not only absorbs substances in solution, but also fat. These facts connected with that of the active secretion of the liver, of the skin, and of the glands of the in- testinal mucous membrane, as well as the relatively pronounced development of digestion in the stomach, and the fermentation properties already present in the extracts of the parotid and of the pancreas, permit us to admit with great prob- ability that the secretory and absorbent organs of the fcetus are capable of per- forming their functions, and very probably do perform them, as soon as their anatomical structure and degree of development permit. Secretion.—The formation of the sebaceous glands begins toward the end of the fourth month, and in the fifth month their secretion is manifested, and in the sixth month becomes quite abundant. The vernix caseosa, smegma embryonum, which covers so generally the surface of the embryo, is a whitish or yellowish, inodorous, adhesive Preyer, op. cit. 2 Archiv fur Gynakologie, 1884. l66 SCIENCE AND ART OF OBSTETRICS. matter composed of epidermic cells, sebaceous cells, and fat-globules. The epidermic scales make the greater part of the mass, the amount of fatty matter being relatively very small. Depaul, who did not disdain a belief in nature's intelligence, regarded the vernix caseosa as a wise provision to prevent osmosis from the fcetal vessels. The sudoriparous are developed somewhat later than the seba- ceous glands, and probably do not secrete during intra-uterine life, though one of the many theories of the origin of the liquor amnii was that it was formed by their secretion. That the serous membranes of the fcetus have their normal secre- . tion is shown by those cases in which children are born having this secretion in excess, as in cases of hydrocephalus, of hydrothorax, and of ascites. The remarkable vascularization of the liver in the fcetus is, according to Kolliker, proof of its great physiological importance: but he regards its role as an organ of secreting bile as subordinate to that of producing in the blood special chemical and morpholog- ical modifications. The secretion of bile begins in the third month; a bile-like material is found in the fifth month in the small intestine, later in the large intestine, the precursor of meconium. The first excrement of the newborn has been called since Aristotle ^jx^vlov, meconium, from its resemblance to the juice of the poppy. Its presence indicates not only secretion from the liver, but also the activity of the intestinal glands, and its descent into the lower por- tion of the large intestine peristaltic action of the intestinal canal. From the seventh to the ninth month of foetal life it presents almost the same characters as after birth ; it is homogeneous, viscid, feebly acid, without odor, with a greenish, sometimes almost black color; it is composed of bile and intestinal secretions with, in exceptional cases according to some, in all cases according to others, materials derived from the amnial liquor, such as seba- ceous secretion, epidermic scales, and fine hairs. Preyer states that Huber has described two kinds of meconium which are fre- quently found in the fcetal intestine, namely, the amniotic meconium, which has as its component the swallowed amniotic liquor, and which is yellow-brown, and the hepatic meconium, which contains bile, and is dark green. The latter is also characterized by the presence of yellow-green chiefly ovoidal bodies from 0.005 to 0.03 millimetre in diameter, which Huber has called meconium corpuscles. The forensic proof of meconium may be given by these corpuscles; they are gen- erally surrounded by mucus, insoluble in ether and in acetic acid, but soluble in potash solution. Discharge of the meconium prior to birth rarely occurs except as a pathological manifestation; it is often observed in children born asphyxiated. The kidneys are exercised during the last half of pregnancy; upon an autopsy made of a fcetus dying during preg- nancy, it is usual to find urine in the bladder, and it is not uncom- mon to see urine escape from the newborn just after delivery, while in some cases it is expelled during labor; hydronephrosis may occur in pregnancy from obstruction of the ureters. Although still in dispute, the probability seems to be that the fcetus from time to THE EMBRYO AND FCETUS. 167 time discharges urine into the amnial liquor, for, in addition to the presence of urea in this liquid, in cases of imperforate urethra the bladder is found enormously distended. Fcetal Movements. Innervation. Passive Ideation}—Fcetal move- ments are usually perceived by the mother some time in the fifth month. According to Preyer, the foetus moves its upper and lower limbs long before the beginning of the sixteenth week, probably before the twelfth week. Many of the movements of the fcetus are passive, caused by change in the mother's position, by varying abdominal pressure, by uterine contractions, and by external press- ure upon the uterus. Others result from changed conditions of the maternal blood, and they are termed irritative movements; many are reflex, and others impulsive. The life of the foetus is compared to that of a dreamless sleep after birth. But, as Bailly has said, it is probable that a vague and obscure will intervenes in the produc- tion of movements which the fcetus exercises after a change of position of the mother, and which appears to have as their object the recovery of a comfortable position of which the movement of the mother has deprived the fcetus. Nevertheless, this view is not supported by Preyer. The question as to the sensibility of the foetus to sense impres- sions is not one readily answered. As far as sight, hearing, and smell are concerned, no such impressions are possible. Preyer regards it as probable that the development of the sense of taste is the earliest. Kussmaul has shown in one child born at eight, in another at seven months, that impressions upon the gustatory nerves were very distinct, as proved by the different expressions of face and movements of its muscles, as well as those of the mouth, according as sugar or quinine was placed upon the tongue. Jacque- mier, Tyler Smith, and Tarnier have each tried the following experiment: The uterus of a pregnant rabbit being exposed, the foot of one of the young was seized with forceps through the thin, transparent uterine wall, and immediately the animal withdrew the member. But this movement on the part of the fcetal rabbit has been by many regarded as simply reflex, and not indicative of pain, though probably such interpretation is erroneous. The imperfect development of nerve ends is regarded as preventing the sensation of pain from external impressions upon the fcetus. Nevertheless, as stated by Tarnier, during intra-uterine life, especially at the end of pregnancy, innervation ought probably to be almost as complete as in the newborn. It is probable, too, as suggested by Harvey, there are periods of alternate rest and action in the life of the foetus. Doubtless the intra-uterine exercise of the voluntary muscles con- tributes to their development, if not to the general development of the foetus. 1 Dr. Mortimer Granville very ingeniously maintains " that passive ideation, or the reception of mental impressions, which are fixed as images in the mind, proceeds in titer0." The argu- ment is interesting even if the conclusion be rejected. Lancet, 1876, vol. ii. p. 851. CHAPTER III. CHANGES IN THE MATERNAL ORGANISM—PLURAL PREGNANCY. The changes in the impregnated ovule having been traced from their beginning in conception to their end in the completely devel- oped fcetus, there are now to be considered the modifications which pregnancy causes in the maternal organism ; in a word, to present the natural history of pregnancy in regard to the mother. The changes in the maternal organism caused by pregnancy may be divided into general and local. General Changes.—These chiefly involve the digestive apparatus and nutrition, the heart and the blood, respiration, the nervous sys- tem, the skin, and the urinary apparatus and secretion. Morning Sickness.—Gastric disturbance is an almost constant phenomenon manifested in the first months of pregnancy. From the fact that nausea and vomiting are more frequent in the early part of the day, or if occurring at other times are usually more severe then, the disorder is commonly known as morning sickness. In some cases it may be so slight as scarcely to constitute an indis- position, only a transient discomfort, but in others so severe as to be a grave disease. It may begin soon after the supposed time of con- ception, but more frequently at the first following menstrual suppres- sion ; in either case it usually abates or disappears some time in the fourth month. In most cases the desire for food is lessened, and in women whose nausea is great or constant, disgust may take the place of desire. In a very few cases pregnancy seems from the first to increase the appetite, digestion is good, and the subject is in better health than usual. In still others the appetite may be capricious, fickle as to kinds of food, or wishing for those articles which at other times are not cared for, or, finally, it may be perverted. The whimsical or perverted appetences of pregnant women, commonly known as " longings," are in some cases assumed, or imaginary, not real; a primigravida, for example, has read or heard stories of such " long- ings," and believing them natural to her condition, the step is but a short one to imagining she has them. In the word mother-marks there is perpetuated the once popular belief that if the desire or longing of the pregnant woman for some particular article of food is not gratified, the fcetus will be marked. Pliny used the word malacia to express the "longings" of pregnant women. A distinction has been made by some between malacia and pica, the former being used to signify that the appetite sought unaccustomed, but still nutritious, sub- stances for food, while in the other there was a complete perversion of the appetite, which sought materials, such as chalk or charcoal, that were entirely indigestible, or which were repulsive and disgusting, like feces. But this distinc- tion has not been generally held. CHANGES IN THE MATERNAL ORGANISM. 169 The word pica is the Latin for magpie, and was used, Gardien says {Trait'e, Complet d'Accouchmens), to signify the whimsicalities of pregnant women and of chlorotic girls, because there was thought to be an analogy between their appe- tites and the parti-colored plumage of the magpie, or its inconstancy as shown in hopping from one to another branch of the tree on which it is perched. Strange stories have been told of these " longings,'' as, for example, of a preg- nant woman who longed for salted herring, and ate fourteen hundred during her pregnancy ; or of another who longed for a bite of the baker's shoulder, and the kind husband, fearing he would lose his wife if the longing were not gratified, got the baker's consent, and she took two bites; and of another who longed so earnestly to eat her husband that she killed him, ate heartily of his body, and then pickled the rest for future consumption.1 In the latter part of pregnancy, before descent of the uterus has occurred, and while the fundus is pressing Upon the stomach, some women have a recurrence of gastric disorder, but this is slight and transient. Neither this manifestation nor that of the earlier months should be confounded with the graver form of the disorder, which may occur as a symptom of albuminuria and a forerunner of eclampsia. It is easy to understand, as observed by Stoltz, that the irregular- ity or depravation of the digestive functions in the early months of pregnancy must cause imperfect nutrition. " Hence the pregnant woman emaciates in the first month ; her appearance is bad—that is to say, her features are drawn, her eyes surrounded by dark circles, and her expression becomes more or less dull. She is sluggish, melancholy, drowsy. In a word, there is developed a condition more or less resembling chloro-anaemia." But the nausea generally ceasing with the beginning of the fourth month, at least before or by the middle of this month, fcetal movements being recognized by the mother, all uncertainty as to her condition is removed, the appetite is restored, digestion becomes better, her general condition is greatly improved, nutritive processes are quickened, and she gains in weight. This increase of weight is greatest in the last three months of pregnancy, being, according to the investigations of Hecker and Gassner, from one kilogramme and a half to two kilo- grammes and a half each month. A woman's weight is about one- thirteenth greater at the end than it was at the beginning of preg- nancy. " In the cases when the weight lessened in the eighth or ninth month, Gassner ascertained conditions unfavorable to nutrition; for example, the death of the fcetus, and its retention in the uterus. This phenomenon, observed in three instances, always had as its 1 In the following passage, from Bartholomew Fair, these "longings" are well satirized: " Oh, yes! Win; you may long to see, as well as taste, Win : how did the 'pothecary's wife, Win, that longed to see the Anatomy, Win ?—or the lady, Win, that desired to spit i' the great lawyer's mouth, after an eloquent pleading?" The universal and deep-rooted popular belief in the " longings " of the pregnant woman, and the necessity for their gratification, have no more striking illustration than is given in one of the Coventry Miracle Plays (Ancient Mysteries Described; Especially the English Miracle Plays, by William Hone, London, 1823). Mary and Joseph are passing along the road, when they come to a cherry-tree laden with ripe fruit; she " longs " for the cherries, which he refuses to get for her, when the tree miraculously bends its branches to her, and her wish is at once grat- ified. Hone states that a Christmas carol founded upon the play, and in which this incident is fully given, was in his day sung in London and many parts of England. There was not a thought of irreverence in play or in song. The event was regarded as natural and necessary. 170 SCIENCE AND ART OF OBSTETRICS. consequence a diminution of the weight of two to three kilogrammes in a period of eight to fifteen days."1 Changes in the Blood and Circulatory Apparatus.—The blood- changes resulting from the pregnant state relate to quantity and quality. There is a decided increase in the amount of blood, this increase beginning about the middle of pregnancy. When we consider the greater nutritive demands, especially for the fcetus and its appendages and for the uterus, and the larger area of the circulation, an increase in the quantity of the blood is obviously necessary. The qualitative changes of the blood concern its con- stituents, water, albumin, corpuscles, fibrin, and iron. The water increases from 791.1 to 1000, the normal amount in the non-preg- nant, to 801.6, or according to Regnault, to 8199 in the last month of pregnancy. The red globules, normally 125 or 127, lessen to 104.49.2 At the same time the white globules increase in number, but not to a degree compensating for the loss in the red. The albumin lessens from 70.5 to 66 I. The fibrin, normally 3 to 1000, lessens until the sixth month, then increases so that at the end of the last month it is 4.3. This remarkable increase in fibrin above the normal amount found in the non-pregnant state, rendering the blood more coagulable, Tarnier suggests may be of advantage in preventing hemorrhage after the delivery of the placenta. The iron in the blood is diminished; this obviously follows from the lessened number of red corpuscles. Hypertrophy of the heart, as a constant phenomenon of preg- nancy, was first made known by Larcher in 1857. This hypertrophy, like that of the uterus, disappears after the pregnancy has ended. By Blot the increase in the weight of the heart was stated to be about one-fifth. Letulle3 claims that physiological hypertrophy of the heart is not a constant fact, but that dilatation of the cavities always occurs. According to observers, the hypertrophy is almost exclusively of the left ventricle. The greater activity of the circulation is manifested by increased arterial tension. The veins, too, are fuller, and varicose enlarge- ments frequent. Respiration.—The base of the thorax is increased during preg- nancy, while its vertical and antero-posterior measurements are lessened ; but it seems doubtful if the former increase in the pulmo- nary capacity compensates for the loss resulting from the two other changes mentioned. The pregnant woman, when the uterus has risen so high as to interfere with the normal descent of the dia- phragm in inspiration, suffers from hurried breathing, or from dys- 1 Tarnier. 2 Doleris and Quinquad, N. Arch. d'Ob. et de Gyn., 1888, state that the hemoglobin nor- mal at the beginning of pregnancy diminishes from the first to the end so that it becomes only a little more than one-half. They also state this proposition as the result of their investigation : The blood of the mother compared with that of the foetus, is less rich in haemoglobin. Its oxidizing power is less. 3 Archives Generates de Modecine, 1881. CHANGES IN THE MATERNAL ORGANISM. 171 pnoea when making great bodily exertion, as in rapid walking or ascending steps.1 The quantity of carbonic acid eliminated by the lungs constantly increases as pregnancy advances. Urine and Urinary Apparatus.—The blood now being increased, as well as the arterial tension, the quantity of urine secreted is greater. But this increase of urine is almost exclusively of its watery portion ; with the exception of the chlorides, the solid con- stituents progressively lessen with the duration of the pregnancy. The lessened elements are phosphates, sulphates, urates, uric acid, creatin and creatinin; and the suggestion, which in part seems quite probable, has been made that the lessened elimination of these in the urine may result from their being used in foetal development. Kyestine, from the Greek ki^c, pregnancy, is, as described by Nauche in 1831, a white, grumous, soft pellicle found upon the urine of a pregnant woman about thirty-six hours after it has been passed; about the fifth day this pellicle breaks up, and falls to the bottom of the vessel. The late Dr Elisha Kent Kane, who became so famous as an Arctic explorer, in 1841 verified by observations at the Philadelphia Hospital the statements of Nauche and other foreign investigators as to the presence of kyestine in the urine of pregnant women, and as to its character. Subsequent investiga- tions, however, have proved that kyestine is not an organic sub- stance, but is chiefly composed of ammonio-magnesium phosphates, vibrions and monads; it may be found in the urine of the non- pregnant as well as in the urine of pregnant women, and also in that of the male. Renal congestion may result from compression, and albuminuria follow. According to Spiegelberg, it is not rare to find albumin in the urine, especially during the latter weeks of pregnancy, and he regarded it as usually depending upon a vesical catarrh. The re- sults of observations made in the Philadelphia Hospital lead me to believe that albumin is not found in the last month of pregnancy oftener than in one out of ten women. In a very small proportion, probably not more than 6 per cent., sugar is present in the urine in the last weeks of pregnancy. The close attachment of the bladder to the uterus produces changes of position of the former, corresponding with those of the latter organ; thus, in the earlier weeks of pregnancy, the bladder descends somewhat with the uterus, and its full expansion is pre- vented ; hence vesical irritability is one of the first symptoms of pregnancy. Observation shows that the majority of pregnant women suffer from some disturbance or disorder of the bladder, the liability being greater in primigravidae than in multigravidae. Changes in the Skin.—Pigment deposits may occur upon the face, the forehead, the mammae, the labia, and upon the abdominal walls. 1 This fact would seem conclusive as to lessened pulmonary capacity. Nevertheless the measurements made by Kiichenmeister, Fabius, Wintrich, and more recently by Vegas in Winckel's clinic, show that there is no change even in the latter months of pregnancy. 172 SCIENCE AND ART OF OBSTETRICS. Pigmentation of the mammae and nymphae will be described in another place. Irregular yellowish-brown patches upon the fore- head and the face, form what has been called the mask of preg- nancy. The intensity of the color1 varies in different subjects; the patches become less distinct after pregnancy, but do not disappear, and are renewed at each succeeding pregnancy. In most cases a pigment deposit is found in the median line of the abdominal wall; it is more marked in brunettes than in blondes, but is very indis- tinct in those having red hair. The pigment band is two or three fingers' breadth, and reaches from the mons veneris to the umbili- cus, in some cases to the xiphoid cartilage, and then there is a ring of discoloration about the umbilicus, the umbilical areola; the band is more distinct below than above. No satisfactory explanation of these discolorations has been given. Dr. Barnes2 has suggested that the pigmentation of pregnancy is dependent upon a functional modification of the supra-renal capsules, while Jeannin3 suggests the amenorrhcea of pregnancy as the cause. Localized4 eczema and seborrhcea, especially upon the face and head, are often seen. The anterior wall of the abdomen becomes thinner. The enlarged uterus causes it to project, the projection being much more marked when the woman is standing than when she is lying; thus, accord- ing to Schroder, the measurement at the end of the pregnancy, from the xiphoid cartilage to the pubic joint is, if she be standing, eighteen inches and a half, 47 centimetres, but if she be lying, it is a little less than sixteen inches, 40 centimetres. During the first three months of pregnancy the umbilical depres- sion is slightly increased, or unchanged; in the fifth month it has become less, and at seven months has disappeared ; in the last two months there is more or less umbilical protrusion. Striae, stricegravidarum, lineo? albicantes, or cicatrices of pregnancy, usually occur in the first pregnancy,and it is not uncommon for new ones to be observed in subsequent pregnancies. These striae are in most cases abdominal, but in some are found upon the hips and thighs, and then are not connected with the pregnant state, or they are upon the breasts; the last in most instances originate after labor. When recent they have a pinkish or bluish-red tint, but after labor they become white, or pearl-colored; generally their surface is de- pressed, but in some cases, as the result of serous effusion from compression of the epigastric vein, it is prominent. They are caused5 by partial or complete atrophy of the lymph spaces, partial atrophy of the skin, and longitudinal arrangement of the fibres of connective tissue. They are generally in four concentric zones, the 1 '• Bomare, in an article cited by Blumenbach, mentions a French peasant, whose abdomen became entirely black during each pregnancy; and Camper gives an account of a female of rank who began to be brown as soon as she was pregnant, and before the end was as black as a negress. After delivery the color gradually disappeared. Le Cat relates the case of a female who was similarly affected in the face only during three successive pregnancies; and Gardien has recorded another." (Laycock on The Nervous Diseases of Women.) 2 Transactions of the American Gynecological Society, vol. i. 3 Gazette Hebdom., 1868. * Spiegelberg. 5 See contribution by Dr. Busey, Transactions American Gynecological Society, vol. iv. CHANGES IN THE MATERNAL ORGANISM. 173 centre being an inch or more below the umbilicus. They do not usually become well marked until the seventh month, and in the primiparous are a sign of some value in the diagnosis of pregnancy; nevertheless they are absent in from six to ten per cent, of pregnant women. Montgomery1 mentions the case of a woman who had borne five children, nursing three of them, and yet there were no cicatrices. According to CrSde they are absent in 10 per cent, and according to Hecker in 6 per cent. Schultze has found them in 36 per cent, of women who have not borne children. Changes in the Nervous System.—Pregnancy increases nervous sensibility, and hence numerous reflex disturbances may occur. There may be occasional rigors, dizziness, flashes of heat, hysterical disorders, fainting, disturbances of special senses, especially of sight and hearing, and neuralgic affections, those of the teeth being very frequent. In regard to the mental state, the general rule is women become more sensitive, and in the majority, probably, despondent feelings prevail. Dr. Hodge has remarked that " gestation has a very happy influence upon the minds of a few women ; they feel well, their mental powers are active, their imagination excited so that they become more interested in reading, writing, or other intellectual pursuits than at any former period; they become more cheerful, and more interested in the ordinary affairs of life." Unfortunately this picture is of the few. A larger number have needless anxiety as to their safely passing through labor, and as to the life and health of their offspring. The majority, however, as the pregnancy goes on, become reconciled to their condition, and patiently wait its end, while some indeed look forward to becoming mothers with joyful expectation. Even in those women whose pregnancy is marked by despondency and anxiety, it is not unusual as it approaches its end to find the cloud lifting, and they are ready to meet their final trial patiently, bravely, and hopefully. Osteophytes—Hypertrophies of Various Organs.—Before describing the modifications of the sexual organs caused by pregnancy, brief reference will be made to some other changes. Osteophyte was the name given by Lobstein to a bony formation originating from the bone, or from the periosteum. Rokitanski, in 1838, found in post- mortem examinations that in more than one-half of pregnant women there were growths upon the internal table of the cranial bones, and external to the dura mater bone-like formations which he called osseous neoplasms or osteophytes. Similar deposits have been found upon the inner surfaces of the pelvic bones of women dying in childbed. Osteophytes have no effect upon the cerebral functions, nor do they belong exclusively to pregnancy, for they have been found in the tuberculous. In addition to hypertrophy of the heart, which has been referred to, and that of the uterus, which will be hereafter described, some other organs, among which are the spleen, the kidneys, the liver, and thyroid gland, increase in size in the preg- 1 Signs of Pregnancy. 174 SCIENCE AND ART OF OBSTETRICS. nant woman. The increase in the spleen is about one ounce and a quarter, 40 grammes. Since Democritus, swelling of the neck has been popularly regarded as one of the signs of conception, and Cazeaux has remarked that hypertrophy of the thyroid gland, inde- pendent of any local disease or of endemic influence, is not rare during pregnancy. If the thyroid be hypertrophied in a pregnancy, the hypertrophy lessens subsequently, but does not entirely dis- appear, and it increases with each succeeding pregnancy. It is probable that the kidneys become somewhat larger in the pregnant woman. Local Changes.—Under this head it is proposed to describe modi- fications which occur in the external and internal genital organs, and in the parts adjacent to them, in the pelvic joints, and in the mammary glands. Changes in the External Organs of Generation and of the Vagina.— It is not until about the fourth month of pregnancy that changes in the external genitals are noticeable. The secretion of the vulvar glands is increased; the great and the small lips are larger, more elastic, resisting, and darker, pigmentation often being quite decided upon the external labia; the veins and venous plexuses are fuller; in some cases varicosities are present; the vulvar orifice is more open. A greater supply of blood to the vagina causes distinct throbbing of the vaginal arteries—the vaginal pulse—which Osiander spoke of as one of the signs of pregnancy. From venous stasis the color of the vagina changes, becoming much darker, so that it is purple or of a violet hue, which is regarded by Jacquemin and Kluge as an almost certain sign of pregnancy; but its value is les- sened by the fact that a similar change of color has been observed in menstruation. The temperature of the vagina is slightly in- creased ; its mucous membrane is swelled; a more abundant secre- tion is present, and the papillae are larger and more distinct, so that the surface becomes rough. The muscular coat, especially in the upper half of the vagina, is hypertrophied. The vagina is lengthened by the ascent of the uterus, but shortened again when the uterus descends, and also then greatly expanded, admitting the entrance of the presenting part of the fcetus covered by the uterine walls. Changes in the Perineum.—The perineum is more freely supplied with blood, it is somewhat hypertrophied, and it is gradually pre- pared for the great distention to which it is subjected in labor. Tarnier states that in many experimental applications of the forceps in women who died in pregnancy, or soon after labor, and in others who died not having been pregnant, he found in the last the perineal floor quite resisting and very liable to rupture. Changes in the Pelvic Joints.—These joints are swelled and soft- ened, and some movement in the pubic joint can usually be detected, but the opinion that in either this, or in the sacro-iliac joints, there is sufficient movement to facilitate labor by increase of pelvic diameters is not generally held by obstetricians. An important movement, however, does occur in the sacro-coccygeal, or in an CHANGES IN THE MATERNAL ORGANISM. 175 inter-coccygeal joint, by which the antero-posterior diameter of the outlet is increased. Changes in the Uterus.—These are the most important of all the modifications in the maternal organism caused by pregnancy. They affect the structure, size, capacity, form, weight, position, relations, and functions of the uterus. Some of the modifications of the uterus may occur independently of the presence of the ovum in its cavity, for they are present in extra-uterine pregnancy, but they are then limited in degree and in duration. It will be convenient to consider first the changes which occur in the body, and then those in the neck of the uterus Modifications of the Uterine Walls.—A larger supply of blood to the uterus causes increased growth of its tissues. The muscular fibres become relatively colossal, increasing from seven to eleven times in length, and from two to five times in breadth ; " embryonic muscle cells, that have been stored up for the time of need," now grow into larger and contractile forms; both hypertrophy and hyperplasia occur. The serous coat is also developed in corre- spondence with the general growth of the organ, but its connection with the underlying muscular tissue is probably as intimate as in the non-pregnant condition. The very great hypertrophy of the mucous membrane has been stated, and the early history of the deciduous membranes traced. By the end of the third month of pregnancy the decidua of the ovum, ovular decidua, decidua reflexa, and the uterine decidua, decidua vera, are in contact. It has been taught by Breschet and Velpeau that in the space at first intervening between these two membranes, a fluid called hydro-perione was collected; but this view is not now accepted. In the course of the fourth month the two membranes become closely united, making a single membrane, which in turn is closely united with the chorion, the external cover- ing developed by the ovum, and thus the ovum has not only the closely united chorion and amnion, but also external to these the doubled decidua of maternal origin. The mucous membrane of the uterus in pregnancy ceases to be covered with ciliated, but has pave- ment epithelium. The decidua, formed by the conjoined ovular and uterine decidua, atrophies, grows thinner, and in preparation for being thrown off with the ovum gradually becomes detached from the uterus. But the muscular tissue is not left bare by this detachment. Some physiologists, among them Robin, asserted that a new mucous mem- brane begins forming behind the decidua at four months; Dr. Matthews Duncan's criticism upon this view is that it implies that at some time the muscular tissue was left bare, and that it produces upon its surface a mucous tissue heterologous to it. According to Friedlander, the decidua is at the end of pregnancy reduced to two layers, superficial and deep ; the latter is composed of glandular culs- de-sac and connective tissue, and the former of cells in fatty degen- eration, and this only is thrown off. Engelmann also states that I76 SCIENCE AND ART OF OBSTETRICS. only the superficial part of the decidua vera is discharged. Ercolani1 taught that the uterine decidua was a product of materials elaborated by the utricular glands, and that the ovum, arriving in the uterus already covered by this decidua, soon itself receives a similar invest- ment, this covering fixing it at a particular part of the uterus. The deciduous membranes were regarded by him as exudations, new formations. His views have not met professional acceptance. Modifications of Arteries and Veins of the Uterus.—The arteries of the uterus increase in length, in volume, and in number. Jacquemier has stated that their increase in length cannot be attributed to their becoming less flexuous, for they are more flexuous at the end of preg- nancy than they are in the absence of pregnancy. The ovarian arteries acquire a diameter of nearly one-sixth of an inch, four and a half millimetres, and the uterine arteries are still larger; the branch on each side connecting the uterine and the ovarian arteries is larger than the radial; its course is nearly parallel with the epigastric, and it has received from Glenard,2 who thought it the seat of the uterine souffle, the name of puerperal artery. Arteries upon entering the uterus suddenly enlarge; branches of the one side anastomose freely with each other and with those from the other side ; they are situ- ated nearer to the peritoneal than to the mucous coat, except in the vicinity of the placenta; those which pass to the mucous coat make numerous subdivisions, and end in an extensive capillary network. The venous system in the muscular coat is composed of a large number of sinuses or large canals which communicate with each other; some of the vessels are as large as the little finger. They are without valves, and in the middle muscular layer are reduced to a single coat, which, however, is closely adherent to the surrounding muscular fibres. They are more numerous in the vicinity of the placenta. The ovarian veins become almost equal in size to the external or internal iliac. Changes in the Size, Capacity, and Form of the Uterus.—Increase of the constituents of the uterus is associated with remarkable de- velopment of the organ in size and capacity. The uterus undergoes very great eccentric hypertrophy, so that at the end of pregnancy it measures, according to Spiegelberg, about twelve inches and three- quarters, 35 centimetres, in length, about nine inches and a half, 24 centimetres, in breadth, and antero-posteriorly nine inches, or 23 centimetres. The late Sir James Simpson gave the following measurements of the uterus: length twelve to fifteen inches, breadth nine to ten inches, the antero-posterior measurement six to eight inches. He further stated the surface of the unimpregnated uterus is five or six square inches, and its capacity one cubic inch; but at the end of pregnancy the surface of the organ is three hundred and fifty square inches, and its capacity four hundred cubic inches. Tarnier regards the last measurement as somewhat exaggerated; Krause states the capacity is increased 519. The weight of the 1 Utricular Glands of the Uterus. Translated from the Italian by Dr. H. D. Marcy. 1 This theory of the uterine souffle has been proved erroneous. CHANGES IN THE MATERNAL ORGANISM. 177 uterus is twenty to twenty-four times greater than in the virgin state. Spiegelberg attributed the greater size of the uterus partly to the organ being stretched by the ovum, claiming that the thickness of the walls, which increases during the first months, diminishes in the latter months so that it is less than before impregnation. Vel- peau and Depaul both held that pregnancy caused no great change in the thickness of the walls, a view sustained by Charpentier; the uterine walls are thinner at the inferior segment, thicker in the fundus and body, especially at that part where the placenta is attached, according to Naegele and Grenser. Tarnier holds that the thickness generally lessens toward the end of pregnancy, but is quite variable in different subjects, and is very unequal in different parts. It is impossible, therefore, to fix a uniform measure for the thickness of the walls of the pregnant uterus. The uterus has different forms in the successive periods of preg- nancy. During the first three months it becomes pyriform instead of triangular. After three months it gradually takes the form of a flat- tened spheroid, and it is only in the latter part of pregnancy that it becomes ovoidal, the smaller end of the ovoid being below. Never- theless, as remarked by Spiegelberg, the uterus is not to be regarded, especially in the latter months, as a rigid body with a constant form, for many deviations occur, the shape depending upon the woman's position,t the volume of the ovum, the situation of the fcetus, the tension of the organ, and also upon its primitive formation. Changes in the Position of the Uterus, and in the Consistence of the Uterine Walls.—Modifications in the weight and in the size of the uterus necessarily cause changes in its position. It is generally taught that in the first weeks of gestation the uterus is lower in the pelvis; and indeed a flattening of the hypogastrium caused by this descent is regarded as one of the earliest signs of pregnancy. Tarnier thinks this change far from constant; in a great number of women the fundus of the uterus from the first weeks of pregnancy passes the superior pubic margin, and the neck does not descend. However this may be, at three months the fundus is a finger's breadth or more above the pubes; at the end of the fourth month it is two inches or more, five to six centimetres, above; at five months 3.5 to 3.9 inches, nine to ten centimetres, above; the distance of the fundus above the pubes increases, becoming greatest in the first half of the ninth month, when it amounts to Sj6 to 9.4 inches, 22 to 24 centi- metres. In the last two weeks there is usually a marked descent, arising from the entrance of the foetal head, still, however, inclosed in the uterus, into the pelvic cavity. It should be remembered that in the multigravida previous relaxation of the abdominal wall per- mits the uterus to project further in front, and does not compel the fundus to ascend as high as does the tense abdominal wall of the primigravida. Further, in the latter the descent of the presenting part into the pelvic cavity occurs earlier. While the chief factor in producing this descent is the resistance of the abdominal wall to further encroachment of the growing uterus, yet another factor is the uterus itself, which in the primigravida is more rigid, and, 12 I78 SCIENCE AND ART OF OBSTETRICS. according to Martel,1 this rigidity maintains the axis of the fcetal ovoid in correspondence with the axis of the uterus, hence there is a tendency to force the lower part of the uterine ovoid into the pelvic cavity. The uterus after ascending into the abdominal cavity in very few cases occupies a median position, for its posterior convex wall is not adapted to the convexity of the spine, and the organ therefore turns to one or the other side—to the right side in the great majority of women. This obliquity of the uterus, probably having its cause in some condition of embryonic development, should be borne in mind in case gastro-hysterotomy is to be done. So, too, this normal latero-version may in labor retard the descent of the fcetal head, and require to be corrected by changing the position of the woman. But in addition to the usual right obliquity, there is also a partial rotation of the uterus by which the left side of the organ is thrown forward, and the right backward, a change very plainly dependent upon its embryonic development, as has been previously mentioned. This change of position causes the left side of the uterus to be more accessible in auscultation made for the purpose of hearing the uterine souffle. The consistence of the uterine wall is greatly changed. Instead of being rigid and resisting as in the unimpregnated uterus, it becomes yielding to localized pressure from within or from without; but it is also elastic, so that as soon as the pressure is removed there is complete restoration of form. As Pajot observes, this suppleness and special elasticity of the uterus are neither softness nor a flaccid condition ; it is always possible to distinguish the uterus from the abdominal walls, and, on the other hand, the suppleness and elastic- ity contribute to maintain the normal accommodation of the fcetus, and thus avoid unfavorable presentations and positions without interfering with its active movements. Relations of the Uterus at the End of Pregnancy.—The lower fourth of the anterior uterine wall is in relation with the posterior wall of the bladder, the remaining three-fourths is directly applied to the abdominal wall, but sometimes omentum or intestine may intervene. The fundus is in relation with the transverse colon, part of the stomach, with the anterior margin of the liver, the xiphoid cartilage, and the lower floating ribs. The ovaries and oviducts are close to the sides of the uterus at a point corresponding with the junction of the upper and middle third ; this change in their position shows the remarkable development of the fundus of the uterus. Further, the right side of the uterus is in relation with the internal and external iliac vessels, with the obturator nerves, the psoas and iliacus muscles, the caecum and the ascending colon; the left side has similar rela- tions to bloodvessels, nerves, and muscles, and with the descending colon, instead of with the caecum and ascending colon. The pos- terior wall is in relation with the rectum, the sacrum, the primitive iliacs, the sacro-vertebral angle, the omentum, the small intestines, De l'Accommodation en Obstetrique. CHANGES IN THE MATERNAL ORGANISM. 179 the aorta, the vena cava, the dorsal and lumbar vertebrae, and the pillars and the posterior part of the diaphragm. Properties of the Pregnant Uterus: Sensibility, Irritability, Contrac- tility, Retractility.—As Pajot has said, pregnancy does not create any new property. But the properties which the uterus already pos- sesses are increased; for example, the organ is more sensitive, and its nerves respond more readily to stimuli, or, in other words, its sensibility and irritability are greater. From its vast increase in size it is more exposed to the action of causes that affect these properties. _ The sensibility of the uterus varies in different subjects, and hence in some all active fcetal movements cause severe suffering,' while others experience only a momentary inconvenience from such movements. The suffering caused by fcetal movements is often different in different parts of the uterus, in one severe, in another slight; the frequent repetition of movements referred to one portion of the uterus will there cause, in some cases, increasing distress. So, too, the irritability of the uterus is not the same in all; trivial causes in one woman will, from the great irritability of the'uterus, excite contractions, and lead to abortion, while another is subjected to the greatest violence without interruption of pregnancy. Idio- syncrasy is supposed to explain cases of excessive sensibility, or of excessive irritability of the uterus; but in some instances at least the explanation is to be sought, not in a peculiar physiological, but in a positive pathological condition. Consequent upon irritability is contractility, contraction is the response to irritation; contractility is manifested by shortening of muscular fibre followed by lengthening. The physiological irri- tability of the uterus is manifested by the occurrence of contractions, which become more frequent as the pregnancy approaches its end; these contractions are painless, but as they gradually merge into the contractions of labor they become more frequent, and are accom- panied with suffering. Contractility is a property of all the mus- cular tissue of the uterus, but of course is greatest in those parts of the organ where this tissue is most developed. The painless con- tractions of pregnancy promote the circulation of the blood in the uterine sinuses, and also assist in fixing the foetal presentation. The manifestation of contractility in labor will be elsewhere con- sidered. Retractility of the uterus has been defined as a property of the muscular tissue, by virtue of which the uterine walls tend to approach. It opposes distention, and is the antagonist of the elas- ticity which permits for the moment stretching of a part of the uterine walls. While contractility is a force manifested intermit- tently, retractility is constant in its action and permanent. It restores the form of the uterus, temporarily lost by fcetal move- ments, or by changes of the mother's position ; it keeps the uterine walls closely applied to the ovum in pregnancy, and after the detach- ment of the placenta it closes bleeding vessels, while during the puerperal state it prevents distention of the uterine cavity by blood- clots, and is one of the most important agents in promoting uterine i8o SCIENCE AND ART OF OBSTETRICS. FlG. 99. Position of the Gravid Uterus near Term, and some of the Relations of the Intestines.— a. Gravid Uterus, d. Ascending colon, e. Kidney, ff. Small intestine, n. Transverse colon. i. Liver. /. Diaphragm. CHANGES IN THE MATERNAL ORGANISM. l8l involution. Contraction and retraction are two distinct modalities of muscular action ; neither is a condition, but each is a manifesta- tion of muscular force. Changes iu the Neck of the Womb.—Slight hypertrophy of the neck of the womb occurs in pregnancy; this part of the uterus is not as well supplied with blood as the body is, and is not subjected to the irritation from the growing ovum, at least until the latter weeks of pregnancy, and then the pressure of the ovum is chiefly at its upper portion, and hence its little increase in size. The position of the neck depends upon the position of the womb, and therefore, as the latter ascends into the abdominal cavity, the neck is drawn up and apparently shortened. Anterior inclination of the uterus causes the cervix, unless there be marked anteflexion, to point backward to the hollow of the sacrum ; lateral inclination directs the neck toward that side of the pelvis opposite to the side of the abdominal cavity in which the fundus is ; in primigravidae the os uteri is usually found at the end of pregnancy quite far posteriorly and to the left of the pelvic cavity. In primigravidae the virgin form of the neck is more distinct—that is, more plainly conical; but after a time, in consequence of the accumulation of the secretion of its glands in its canal, it is spindle-shaped. In the multigravidae it is cylindrical or expanded at its lower portion so as to be club- shaped. Softening of the Neck.—Early in pregnancy a change in the con- sistence of that part of the neck adjoining the external os begins, and is manifested by the superficial tissues yielding to pressure. This softening is at first simply a continuation of that caused by the last menstruation ; the softening advances regularly and slowly in the primigravida to the remaining portion of the vaginal cervix, so that, approximately, one-fourth is affected by it at four months, one- half at six, three-fourths at seven, and the remaining fourth at eight months. In the multigravida the process is more rapid, because the neck is shorter, and has been previously softened. The soften- ing always begins below, thence passing above. It is attributed to a greater abundance of plasma, to hypertrophy and proliferation of fibre-cells, and, in the latter part of pregnancy, to blood-stasis caused by the pressure of the fcetal head in the lower portion of the uterus. The sensation which the finger receives by pressing upon the soft- ened cervix, has been compared to that which is given by similar pressure upon a piece of velvet placed upon a hard substance, at first a ready yielding to the pressure, and then a firm resistance. Softening of the neck is in the early months of pregnancy a valu- able sign, which may assist in a probable diagnosis of the pregnant state. State of the Internal and of the External Os.—In primigravidae the external orifice of the womb remains closed until the end of preg- nancy. In rare instances the finger can enter it, but usually for only a short distance, and in some of these possibly the penetration has been, not by an open canal, but from making it permeable by pres- sure. In still rarer instances the cervical canal in primigravidae is l82 SCIENCE AND ART OF OBSTETRICS. permeable by the finger in the latter weeks of pregnancy, so that the foetal membranes and presenting part may be touched ; such cases are quite exceptional. In multigravidae the external os is not surrounded by a regular and smooth surface, but by a structure marked with irregular fissures; the cervical canal is open to a degree in direct relation with the period of pregnancy, the finger readily passing, for example, to the middle of the cervical canal at seven months; the cavity thus entered by the finger is funnel- shaped, or the neck of the womb may be represented as a hollow cone, with its base below. Shortening of the Neck of the Womb.—The question as to shorten- ing of the cervix became the subject of controversy nearly two centuries ago, and in quite recent years the contention has been greater than at any previous time. De Graaf, 1671, held that the cervix remained unchanged until the end of pregnancy, and the same view was maintained by Verhegen, 1710, and Weitprecht, 1750. Roederer, 1753, asserted that expansion of the cervical canal, con- tributing thus to the uterine cavity, advanced regularly from above downward during pregnancy, stating that this change could be noticed as early as toward the sixth month.1 Stoltz, 1826, stated that the cervix was unchanged until the last fifteen days of preg- nancy, and then the internal os opens, the cervical canal dilates from above downward, and the cervix is gradually effaced. Taylor, 1862, brought forward important observations to prove that the cervix did not shorten until the beginning of labor. In 1876 Bandl revived the teaching of Roederer, asserting that during the last ten weeks of pregnancy shortening of the cervix is in progress; the upper part of the cervical canal is dilated so as to form with the lower segment of the uterus the canal of Braun, or, as Tarnier calls it, the cervico- uterine canal. Bandl contended that the superior limit of the cervical canal, or the internal os uteri, could be demonstrated at the close of pregnancy or during labor to be at the level of the pelvic inlet. While some have thus held that the lower uterine segment was cervical in origin,2 others partly from the cervix and partly from the body of the uterus, the view now most generally accepted, is, as expressed by Barbour,3 "that no suffi- cient evidence has been produced that the lower segment, which resembles in its essential structure the rest of the uterus, is cervical in its origin ; and until new evidence is brought forward we see no reason to ascribe to it an origin different from the rest of the wall of the uterus." It would seem, however, that after effacement of the cervix at the end of preg- nancy and the beginning of labor, the cervical tissue must contribute to the lower portion of the completed uterine ovoid, which then presents a simple nearly circu- lar opening and no canal. 1 Although Kleinwachter refers impliedly to Roederer's views as indicating that the changes occurred in the last ten weeks of pregnancy, yet upon referring to Wrisberg's edition of Roe- derer's Elementa Artis Obstetriciae, 1766, the time is stated to be versus sextem mensem. 2 According to this view, Bandl's ring is the dilated internal os uteri, the upper limit of the inferior segment, and Miiller's ring is that which appears to be the internal os, the upper limit of the shortened cervical canal. 3 The Anatomy of Labor. Edinburgh, 1889. CHANGES IN THE MATERNAL ORGANISM. 183 In regard to the changes of the cervix in pregnancy, Spiegelberg observed, it is no longer doubtful that the opening of the internal os uteri and the entering of the apex of the ovum into the cervical canal, thus causing this canal to contribute to the uterine cavity, are possible phenomena, and in fact do occur. Their occurrence is thus explained: In primigravidae the lower portion of the uterus does not readily yield to the pressure of the growing ovum and to the uterine contractions, which become more frequent in the latter part of pregnancy, and hence the development of" the cervical canal is more frequent in them, but the external os remains closed, or nearly so, until the end of pregnancy On the other hand, in multi- gravidae the lower portion of the uterus is less resisting, yields readily to the growing ovum, and therefore the internal os remains closed, not being subjected to so much pressure either from the ovum or from uterine contractions, and the finger can in these cases be passed further and further up the cervical canal with the pro- gress of the pregnancy, the development of the canal being from below above. Fig. 100. Cervix of a Woman Dying in the Eighth Month of Pregnancy. (After Duncan.) Fig. 100 shows no shortening of the neck, but in the last two weeks of pregnancy, according to Stolz, Tarnier, and others, such shortening occurs in most cases; it is admitted, however, that this change may not occur until a few days, or even a few hours before labor begins. Taylor has more recently repeated his statement1 as to the non-shortening of the cervix in pregnancy, and sustained it by additional facts and arguments. 1 Transactions Medical Society of New York, 1888. 184 SCIENCE AND ART OF OBSTETRICS. The latest discussion of the operation is by Barbour,1 and his conclusion from a study of "'frozen sections" of women dying in pregnancy is that the cervical canal, lined by characteristic mucous membrane, remains of "pretty constant length." Shortening of the neck of the uterus is in part effected by the pressure of the growing ovum, and in part by the painless uterine contractions of pregnancy, which, toward its close, become more frequent. When the neck has thus disappeared, been effaced" by being taken up into the body of the womb, the uterine changes of pregnancy are completed, and labor is at hand. Changes in the Uterine Appendages.—The broad ligaments have their peritoneal layers separated by the growing uterus, and as the organ ascends they are carried up by it; they share in the hyper- trophy of the peritoneum covering the uterus. The ascension of the uterus compels a change in their direction, so that at the end of pregnancy they are vertical instead of horizontal. The round ligaments have their thickness increased fourfold; they become much longer, and at the termination of gestation extend from the vicinity of the umbilicus to the inguinal canal on each side; in consequence of the greater development of the posterior than of the anterior wall of the uterus, they are not directly upon the sides, but at the junction of the posterior four-fifths with the anterior fifth of the lateral borders of the uterus. The utero-sacral ligaments, the uterine retractors of Luschka, undergo remarkable development. The ovaries increase in size; according to Jacquemier, their size is doubled ; they follow the movements of the broad ligament, and take nearly a vertical position. Ovulation in most cases, at least, is suspended, but the corpus luteum undergoes the changes which have been described as occurring in pregnancy. The oviducts also hypertrophy; their epithelial lining loses its vibratile cilia. Robin has stated that the canal of the oviduct contains a yellowish-white viscous matter, holding in suspension epithelial nuclei a,nd fine fat granulations. Changes in the Breasts.—In some cases the mammary glands be- come larger at the beginning of pregnancy, but oftener this increase in size commences at the time corresponding with the first men- strual suppression following conception. This enlargement is ac- companied with greater sensibility, and occasional shooting pains are felt in them; the axillary ganglia may also be similarly affected. The superficial veins are larger and more distinct; if the increase in size of the breasts be very great, it is not unusual for striae similar to those occurring upon the abdominal wall to be found about the fifth or sixth month. In some cases the enlargement lessens after four or five months, but again is manifest toward the end of pregnancy. The latter part of the second or third month the nipple 1 Op. cit. 2 Charpentier, by a strange confusion of language, as it seems to me, refers to the effacement of the neck as a phenomenon of pregnancy, but diiatation of the neck as a phenomenon of labor. But how after it is effaced can it be dilated ? Dilatation of the os, but not of the neck, is a phenomenon of labor. CHANGES IN THE MATERNAL ORGANISM. 185 is firmer, harder, more prominent, and sensitive ; a milk-like fluid may possibly escape or be pressed from it. but this is not usually observed until in the last three months, and it may happen even in the absence of pregnancy. Changes in the areola are more important and characteristic. These changes are swelling, development of the mamillary tuber- cles, and darkening of the entire surface. The first of these phe- nomena can usually be seen the second month ; the swelling is not hard and tense, but puffy, giving to the finger the sensation of an Fio. ioi. Appearance of ihe Primary and Secondary Areola in Pregnancy. emphysematous enlarged tissue. About the same time the areola becomes darker, and the hue deepens until the end of pregnancy, when in brunettes it is a dark brown, in some almost black, while in blondes this change is much less pronounced, and in the red- haired scarcely noticeable. The papular elevations, often called the tubercles of Montgomery, situated upon the areola, and regarded by some as miniature mammary glands, become much more promi- nent, projecting from the sixteenth to the eighth of an inch. The primary areola, which has a radius of about an inch, three centime- tres, is surrounded at the fifth or sixth month by a secondary areola; this is lighter in color, and flecked with whitish spots, presenting an appearance somewhat resembling that of dust-covered, white 186 SCIENCE AND ART OF OBSTETRICS. blotting paper upon which drops of water have been sprinkled. The illustration found on the preceding page (Fig. 101), from Depaul, very well represents the appearance of the breast in the latter months of pregnancy. Plural Pregnancy.—When the uterus contains two or more futuses the pregnancy is plural. If there are two foetuses they.are twins; if three, triplets;1 if four, quadruplets; and if five, quintuplets, and the pregnancies receive corresponding names, double, triple, quad- ruple, and quintuple. There is no2 established case in which a woman gave birth to more than five children at one time. In order that plural pregnancy can occur, a single ovary must furnish the necessary ovules, or some may come from each ovary; or, in case of twins, one ovisac may contain two ovules, or one ovule two germs, or the germ may split into two germs. Frequency.—According to Kormann,3 double pregnancy is found once in 90 pregnancies; triple, once in 7900 ; and quadruple, once in 370,000, The frequency varies in different countries. Pliny stated that it was greatest in warm climates, but modern statistics do not sustain this theoretical opinion. Thus in France and in Belgium there are scarcely ten twin births in a thousand cases of labor, while in Denmark and in Sweden the proportion is between fourteen and fifteen, in Ireland between sixteen and seventeen to the thousand.4 It is thus evident that climate is not a factor in determining the frequency of plural pregnancies. A remarkable difference in the proportion5 of twin to single pregnancies is found in different Italian cities. While in Genoa there is 1 to 54, Milan I to 56, in Palermo the proportion is only 1 to 114. Between Genoa and Milan at one extreme and Palermo at the other, in regard to the relative frequency of twin pregnancies, are placed Padua, Trente, Turin, Bologna, and Naples. Causes.—In addition to climate, race, stature, and the great de- velopment" of the ovaries have been regarded as causes of pluri- parous pregnancies. But, whatever influence may be attributed to any of these, the chief causes are multiparity and heredity. The statistics of Duncan show that the number of pluriparous multiparas is about eight per cent, greater than that of pluriparous primiparae ; those of Puech show that multiparas have triplets eight times as often as do primiparae. Heredity seems to be a more potent cause. 1 Readers of Livy's History of Rome will recall the combat, in the war of the Romans and the Albans, between the brace of triplets, three representing each army, the Horatii and the Curiatii. 2 Nevertheless this statement as to five being the largest number of foetuses in the human female must be set aside, for last year the case of an Italian woman, who in the fifth month of pregnancy miscarried, expelling six foetuses, was reported, and the truthfulness of the report is generally conceded. See London Lancet, October 20, 1888. Soon after the publication of this case of sextuplets in Italy, some patriotic American Ananias published in a Western newspaper an account of a similar event having occurred in the interior of Texas, with a description of the six living children, stating also the names that had been given them. 3 Op. cit. * Berlin. Nice-Medical, December, 1888, in the study of the births ai Nice for twenty-seven years, in all 56,505, finds that the proportion of twin births was 1 in 75, of triplets 1 in 5575. 5 De l'Obstetrique en Italic Millet. PLURAL PREGNANCY. I87 Female twins often give birth to twins. A woman had twin preg- nancies three times, her daughter had two twin pregnancies, and her daughter in turn a twin pregnancy. Instances in which this manifes- tation of heredity was transmitted to the male are also recorded. Leroy states that four brothers, in whose family twin pregnancies in the parents of a collateral branch had been observed, procreated twins—three of them twice each, and the fourth four times. The cases just cited indicate that excessive fecundity, though usually belonging to the female, as a cause of plural pregnancy, may depend upon the male. Sue mentions the case of a man whose wife gave birth to triplets seven times in seven years, and then seducing his servant girl she gave birth to triplets. Nor is the case of the Russian peasant, Feodor Wassilief, to be omitted. It was quoted by Velpeau from Merriman -,1 this peasant was married twice, and his first wife had quadruplets four times, triplets three times, twins sixteen times, in all sixty- nine children ; his second wife had triplets twice, and twins six times, making her contribution only eighteen to the entire number of eighty-seven. Moreover, eighty-four of these children and the father, who was then seventy-five years old, were living at the time the English merchant, whose story Merriman publishes, visited Russia. In sixty-one cases of twin pregnancy, analyzed by Kleinwachter, the youngest mother was nineteen, the oldest forty-one years; in 67tVtt the pregnancies occurred in women between twenty-three and twenty-nine years of age, a fact which does not sustain Matthew Duncan's view that " pluriparity is an unnatural or abnormal con- dition connected with sterility by being observed in the sterile ages, or ages of weakness or imperfection of the reproductive power.2 Super-impregnation.—The question naturally suggests itself as to whether the ovules which are developed in plural pregnancy are fecundated simultaneously or at different times. In the case of many, of the pluriparous inferior animals fecundation is simulta- neous ; for example, the boar impregnates the sow at a single coition. So it may be in the human female, and possibly is in the majority of cases. But super-impregnation is, arbitrarily at least, divided into super-fecundation, and super-fcetation. By the former is meant the fecundation of one or more ovules after one has been fecundated, that is successive instead of simultaneous fecundation ; by super-fcetation3 is meant fecundation effected after the uterus is occupied by the product of conception. The latter requires the occurrence of ovulation several days, weeks, or even months after the ovule was liberated which was first impregnated. That super-fecundation may occur in the human female, as well as in some of the inferior animals, is certain. Thus a white woman has twins, one a mulatto, the other white; or of a black woman's twins, 1 Merriman apparently believed the story, for in quoting it from the Gentleman's Magazine, 1783, he also quotes the following: "The above relation, however astonishing, may be de- pended upon, as it came directly from an English merchant in St. Petersburgh to his relation in England, who added that the peasant was to be introduced to the Empress." 2 Sterility in Women. 3 In regard to super-foetation in animals, some curious and absurd statements are made by Herodotus : see Cary's translation, p. 216. i88 SCIENCE AND ART OF OBSTETRICS. one is black, the other a mulatto. The only rational explanation is that in each case, each child shows a different paternity. A mare may be covered by a stallion, and at an interval varying from a few hours to fifteen days is covered by an ass ; she has twins, one a horse, the other a mule. A bitch in heat is covered by different dogs, and in her litter the puppies may indicate different fathers. But when super-fecundation occurs in the human female, the fact is presupposed that the ovules impregnated are liberated from their ovisacs at the same menstrual period. Nature intended her to be uniparous, and once fecundation has occurred, ovulation1 usually is suspended, so that the probability of super-fcetation is at once op- posed by a physiological reason; in other words, there is no ovule to be impregnated. This is admitted as a law; nevertheless, as claimed by some, there may be exceptions. There is, however, an anatomical argument derived from the con- dition of the uterine cavity occupied by the developing ovum ; room for the spermatozoids to pass to the ovule, and then space for the entrance of the latter into the uterus present theoretical objections. It must, however, be admitted that prior to the union of the ovular and uterine decidua, which, as has been before stated, occurs some time in the fourth month, there is no invincible anatomical obstacle to a new impregnation occurring. Nevertheless, with the difficulty just mentioned, and with the physiological one arising from the sus- pension of ovulation during pregnancy, the improbability of the occurrence of super-fcetation is very great; the strongest argument against super-fcetation is given by Auvard in the fact that in five- sevenths of plural pregnancies there is but a single placenta. Auvard also states that super-fcetation is only possible in case of a double uterus, or of an ectopic gestation. The hypothesis of super-fcetation is proposed, first, to explain those cases in which there is simultaneous expulsion of the products of conception, one large, well-developed fcetus, and the other a small and feeble fcetus,2 or the second product may be still in the embryonic condition. But twins usually differ in size and vital power, and this difference may be so great that the feeble one dies soon after birth; it may depend upon the fact that one was better supplied with nourishment than the other and prospered to the detriment of its companion, or there may have been an inherent difference in the vitality of the ovules impregnated. Where one product was still embryonic, and the other well developed, the answer is the former died early in pregnancy, and remained without material change until the pregnancy ended. But, second, the hypothesis is thought to explain the cases in 1 Playfa'.r gives the occurrence of menstruation as a proof of ovulation. Before admitting such an argument, it must first be proved that menstruation does then occur; next it must be proved that ovulation and menstruation are always necessarily connected. A woman may menstruate after her ovaries have been removed; and, according to Playfair's argument, she necessarily ovulates. 2 In a litter of pigs it is not unusual to find one, generally the last born, smaller, feebler, and more poorly developed than any one of its brothers or sisters; it is commonly known as the runt; but farmers never adduce this fact as a proof of super-fcetation. PLURAL PREGNANCY. 189 which several days, weeks, or, as is alleged in some cases, months intervened between the birth of twins. In some of these instances the mother was found to have a double uterus ; one fcetus was con- tained in one-half, the other in the other half of the organ ; and under such circumstances possibly a considerable interval occurred between the impregnations. But most of the cases correspond to a premature labor or miscarriage with one foetus, while the other was retained until full term or somewhat beyond. Many of the facts adduced to prove super-fcetation belong to a past age, when such marvels were more readily accepted than to-day ; and as a rule they fail in the details and thoroughness of investiga- tion necessary to establish their truth. " Few authors to-day be- lieve in the reality of super-fcetation."1 Doleris suggests that super- fecundation—that is, the fecundation of several mature ovules ex- pelled from the ovisacs at the same period—may occur within fifteen days, or at most three weeks ; after about this time fecunda- tion seems impossible. Fcetal Appendages in Twin Pregnancies.—Where two ovules from different ovisacs are impregnated, each foetus has its own chorion and amnion, and originally the ovular decidua of each was distinct, but the portion intervening between the two sacs is absorbed, so that they have a common decidua. The placentae may be closely united, but there is no vascular connection ; there is entire independ- ence as to the circulation in each. If there be a single placenta with one chorion and two amnions, either there were two germs in one ovuie, or the germinal vesicle has furnished two germinal areas. The bloodvessels of the twins com- municate in the placenta. Either the twins are well developed, or the greater heart activity of one takes away the nourishment needed by the other, and the latter dies. The twins are of the same sex. Most rarely there are one placenta, one chorion, and one amnion. The amnion folds between the two may have been absorbed because of pressure; or the origin of the twins may have been from the division of a germ ; the twins are of the same sex. Sex, Size of Twins, Course of the Pregnancy.—In the great majority of cases twins are of the same sex, and males predominate over females. The united weights of twins at birth is usually greater than that of a single fcetus at the same period of development, but the weight of each is considerably below the mean ; generally one of the twins is larger and stronger than the other. One of the chil- dren may die early in the pregnancy, and either be expelled with its appendages, and pregnancy go on; or it may be retained, the liquor amnii be absorbed, while it undergoes the change called mum- mification, or be pressed against the uterine wall by the other foetus and its membranes, so that it is flattened, making a thin mass called foetus papyraceus. In other cases the condition previously mentioned as to the heart of one of the twins having greater power than that of the other may be present, and the latter fail in development, 1 Doleris. 190 SCIENCE AND ART OF OBSTETRICS. except as to the lower part of the body and lower limbs, and a monster known as acardia results, while the former is perfectly developed. Abortions, polyhydramnios, and monstrosities are more frequent in plural than in single pregnancies ; acephalous monsters are only found in the former. Premature labor frequently occurs in twin pregnancies, its usual cause being excessive distention of the uterus. Triple pregnancies rarely, and quadruple probably never, reach the normal term. CHAPTER IV. THE SIGNS AND DIAGNOSIS OF PREGNANCY. Pregnancy is revealed by certain signs, and its diagnosis is made by the recognition and application of these. It is essential that the obstetric student faithfully study and clearly understand these signs, and then, by giving to each its true value and combining all, he will reach a correct conclusion. Van Swieten said that the physician's reputation was never more imperilled than in deciding as to preg- nancy : " frauds everywhere, often everywhere snares prepared for the unwary." But not only may a mistake in diagnosis be very injurious to his reputation, it may ruin the reputation of one unjustly accused of being pregnant, or risk the health, or even the life of another affected by a disease simulating pregnancy; and this disease, thus neglected, may become incurable. That great mistakes have been made in the diagnosis of pregnancy—this condition asserted when it was absent, or denied when it was present—and that these mistakes have in some instances led to most deplorable conse- quences, is matter both of printed and oral history. Few practi- tioners of a dozen years' experience can truthfully say that no error in the diagnosis of pregnancy has ever been made by them. Pajot states that he could make quite a volume giving in detail the history of all the erroneous diagnoses in regard to pregnancy which have come under his own observation in an experience of thirty years; and these mistakes made, not by sages femmes, but by practitioners of more or less, some of them with very long, experience. Now, there must be some reason for such great and comparatively frequent mistakes, and a brief exposition of the chief of these reasons may help to avoid their consequent errors. Socrates said: "To attain to a knowledge of ourselves we must banish prejudice, passion, and sloth." These, too, must be banished when we study the practical diagnosis of pregnancy. We must investigate a case without pre- judice—that is, without prejudgment—whether the prejudice be from the opinions of others, or from the subject's previous history and her surroundings. That the judgment of another is in favor of or adverse to pregnancy must not rule our own; nor should our opinion be biassed by the social position, reputation, and circumstances of the party; for some women, around whom apparently every safeguard has been thrown, may sacrifice their virtue, while others, less pro- tected, preserve it in the midst of the strongest temptations. In this judicial inquiry the woman must be divested of all the accidents of life, of all her artificial surroundings, and simply considered as capable of reproduction. Her statements are to be received with great caution, for, on the one hand, a strong imagination will beget in her, if she ardently desires to be a mother, some of the signs of 192 SCIENCE AND ART OF OBSTETRICS. pregnancy; or, if she wishes to deceive, she may assert them, and. if she wishes to conceal, she may deny them—yea, many a woman in the agony of childbirth, or in the very article of death, has denied her pregnancy with the vain hope of protecting her good name from reproach, or, more frequently, for the purpose of saving her seducer from exposure. Ambition to give a prompt decision, or pride in opposing that of another, may lead to error. Rapidity is very far from proving cor- rectness of diagnosis; here, as Lord Bacon has said of another matter, our intellects need not wings but weights of lead to mod- erate their course. The man of greatest knowledge least exalts his attainments, and is the most cautious and deliberate in judgment, and has respect for the opinions of others. Sloth may hinder or prevent our thorough investigation. We may be satisfied with a few facts instead of seeking all that are available. We may give undue weight to one or more of these facts, undervaluing or neg- lecting others. In illustration some cases that have been under my own observation will be given : A young lady of high social posi- tion, and against whose purity there was no whisper or thought of scandal, is attacked with obstinate vomiting. There is a denial of menstrual derangement; the vomiting resists all remedies, and she dies, but while dying a fcetus of three months and a half is expelled. A woman having passed twenty years of married life childless, some months after the menopause becomes pregnant; the pregnancy is suspected by one attendant, and denied by another. A girl who has never menstruated, and who does not fully present the other signs of puberty, becomes pregnant by violence, and gives birth to a child when she is twelve years old. A woman has menstrual suppression, coincident abdominal enlargement, the mammary and many other signs of pregnancy; but a post mortem examination proves cystic disease of the ovary. A girl of twenty has never menstruated; her abdomen enlarges, her breasts are swelled and secrete; after a time severe uterine contractions occur, and a physi- cian of large experience called to her during this attack declares she is in labor ; the cause of the abdominal enlargement is accumulation of many months' menstrual secretion, and the uterine contractions simulating labor-pains are the efforts to overcome the resistance of an imperforate hymen. Time would fail to give all the published cases in which a pregnant uterus has been tapped, or even abdominal section made for its removal, because it was thought an ovarian tumor, and many a patient has been saved from such perils because of the postpone- ment of the operation until happily labor prevented its performance; the unpublished instances of such errors are much more numerous. Pajot1 states that he has seen a pregnancy of four months taken for an abscess, and the uterus opened by a bistoury, introduced into the vagina, by one of his old masters, the most learned and vene- rated. But it is not necessary to multiply instances of wrong diag- Travaux d'Obstetrique et de Gynecologic THE SIGNS AND DIAGNOSIS OF PREGNANCY. 193 noses leading to an assertion of pregnancy when it does not exist, or a denial of it where it is present. Tardieu1 has said that all signs of true pregnancy, except the bruit of the foetal heart, may be ob- served when there is no pregnancy, from the development of the abdomen and breasts up to movements and the efforts of labor. It is not wonderful, then, that mistakes have been made, and yet in most cases they are avoidable. Liability to error is caused by the pregnancy being abnormal, or by its complication with some pathological enlargement, for ex- ample, ascites, ovarian tumor, or uterine fibroid, but these topics will be considered elsewhere. Concluding the subject of diagnostic errors as to pregnancy, the practitioner who would avoid them must faith- fully interrogate all the changes, both organic and functional, in the maternal organism, and those which are caused by fcetal develop- ment; he must be patient, thorough, painstaking in his investiga- tion, not hasty, partial, and superficial; he must be willing to delay his decision in all doubtful cases, rather than run the risk of a happy guess, or trust an average of probabilities. Many other errors in diagnosis may never come to the light, but time is the certain and remorseless revealer of these ; alike the asserted pregnancy which, like the weaving of Penelope's web, never ends, and the denied pregnancy which in a few weeks or months a babe's first cry contra- dicts, are too often made known, to the disappointment if not disgrace of the hasty diagnostician. Classification of the Signs of Pregnancy.—These may be con- veniently divided into the subjective and the objective. The former include the information we can get from the person herself—all the answers she makes to our inquiries "as to the functional changes caused by pregnancy, and as to the various new sensations she experiences : she tells us what she knows, or believes she knows. By objective signs, we mean those discovered by our own senses, the special avenues of certain knowledge; we may, or we may not, believe what another tells us, but that which we see with our own eyes, hear with our own ears, and handle with our own hands, commands our credence. The subjective signs will be considered first. Menstruation is Absent.—The absence of menstruation is a sign of great value in the case of a woman hitherto regular, there being no pathological cause for the suppression, and no pathological result from it; the sign increases in value each month that it continues. But conception may occur during lactation, in the first nine or ten months of which menstruation is normally absent, or it may take place before any flow has been observed; as La Motte said, a woman may have fruit before flowers, and in such cases of course the sign is without value. Again, a monthly flow may occur once or oftener after conception, even continue during the entire pregnancy; and stranger still are those rare cases where this hemorrhage is alleged to have taken place in women only when pregnant. Naegele and 1 Sur les Grossesses Fausses et Simulees, l3 194 SCIENCE AND ART OF OBSTETRICS. Grenser,1 referring to menstruation in pregnancy, state that some- times the flow does not differ in type, quality, and quantity from ordinary menstruation. But the general law is that the pregnant woman does not menstruate, and the apparent exceptions to this law are very few. Nature, when building up the fcetus, has no excess of material to be periodically discharged, and the intimate union which is established early in pregnancy between the ovum and the uterine mucous membrane, prevents the latter being normally a source of hemorrhage, whether irregular or periodical. Further, ovulation is, as a rule, absent in pregnancy, and in like manner the associated or resulting hemorrhage ought to be absent. Hemorrhages from the uterus of a pregnant woman are pathological, not physiological, and generally threaten abortion or premature labor, and should be so considered, and so treated. Rarely will one be deceived, says Stoltz,2 who regards a woman menstruating regularly, with all the characters of menstruation, as not pregnant, while trusting the contrary opinion he is exposed to frequent errors. Nausea and Vomi/ing—Salivation.—Gastric disturbance is one of the most frequent symptoms of pregnancy, and in rare cases it begins about the time of conception. As illustrating the last state- ment, the following report of a case by the late Dr. Montgomery is of interest: " I attended a patient who was married on Monday, and began to be squeamish on Saturday; her delivery took place within nine months." If the nausea and vomiting be associated with men- strual suppression, if the disturbance occur at a regular time each day without any other pathological symptom, and if food is vomited soon after it is taken, and the appetite is unimpaired, this sign has great value. Copious secretion of saliva occurs in some cases, but it is not very frequent; it generally accompanies excessive nausea and vomiting, though it may also occur when these symptoms are absent or insignificant. The late Dr. Dewees attached great im- portance to spitting a white, frothy mucus—" cotton-spitting "—as a sign of pregnancy. Nervous Disorders.—Changes in the disposition, increased sensi- bility, despondency, etc., are of no value as signs of pregnancy, " for they are often just as great when a woman believes herself preg- nant," the event proving her mistake, as when she is pregnant. The different forms of neuralgia from which pregnant women some- times suffer may occur to the non-pregnant. Mammary Pains and Swellings.—Pains in the breasts and some enlargement of these organs, with possibly a slight secretion, will probably be observed by most women early in pregnancy, but all these symptoms may occur in girls and women who are not preg- nant. Many females have more or less mammary pain and swelling in connection with menstruation. Irritability of the Bladder—Leucorrhcea.—It is not uncommon for . women in the first part of gestation to have some irritability of the 1 Traite Pratique de l'Art des Accouchements. Translated by Aubenas. Paris, 1880. - Op. cit. THE SIGNS AND DIAGNOSIS OF PREGNANCY. I95 bladder, and increased mucous discharge from the sexual organs. While inquiry may be made concerning these symptoms, but little importance is to be attached to them alone, for there are so many other conditions in which they may be found. Quickening.—Certain sensations perceived by the mother were believed to mark the time when the fcetus was endued with life and soul, and the woman was then "quick with child;" this distinction was recognized alike by physicians and by courts. We now know that the child's life begins with the union of spermatozoid and ovule; then and there was the quickening power, then the true creation, and the young life in its dim dawn is as real and sacred as in its maturity. The phenomenon commonly called quickening usually occurs between the first and the middle of the fifth month, but in rare cases it is noticed earlier, in others later, and in still others it is absent during the entire pregnancy. Different opinions have been held as to its cause. By some it is attributed to the direct contact of the uterus with the abdominal wall. Tyler Smith believed the sensations due to the first peristaltic actions of the uterus, and regarded the date of quickening as mark- ing the time when the contractile tissue of this organ is so far developed as to admit of these contractions. The opinion gener- ally received is that it is caused by the movements of the fcetus that are first recognized by the mother; they are not felt until the uterus rests upon the abdominal wall, and they are felt through it, and not immediately in the wall of the uterus. Of course, fcetal movements are made much earlier, and they can be recognized by the stethoscope before the mother is conscious of them. The value of this sign of pregnancy is lessened not only by the fact previously mentioned, that pregnancy may be completed without the mother ever having been conscious of them, but by this, that, as Hamilton said, no woman ever yet fancied herself pregnant without persuad- ing herself she felt the movements of the child. Nay, more : a woman after repeated experience as to the sensation in question may, with the best faith in the world, assert she feels these move- ments, and yet not be pregnant. Dr. Blundell1 mentions a case under his own care of a woman who had given birth to twelve children, who believed herself again pregnant, declaring she felt the movements of the child as plainly as she had in any of her previous pregnancies, and yet she was not pregnant. The story of the supposed pregnancy of Queen Mary, of Eng- land, and that of Joanna Southcote, furnish illustrious instances of self-deception in regard to the sensation of fcetal movements. Objective Signs.—These are sought, not by inquiries, but by direct examination of the patient; they are not her statements, but facts and conditions directly recognized by our own senses. Inspection.—We observe the patient's countenance as to whether anxious, haggard, expressive of suspicion, or indifference; her face 1 Principles and Practice of Obstetricy. I96 SCIENCE AND ART OF OBSTETRICS. as to whether full and florid, or pale, thin, and emaciated, and as to the presence or absence of discolorations. When the patient is standing or walking it is well to notice the position of the shoul- ders, the dorsal curve, and the abdominal prominence. Examina- tion of the naked abdomen may show striae and pigmentation, and changes in the umbilicus, a deeper or effaced cavity, or umbilical pouting. The labia majora may be found swelled and firmer, and presenting greater or less discoloration, and the vaginal mucous membrane purplish. Nevertheless, visual examination of these parts is not necessary in most cases of supposed pregnancy. Exposure of one of the mammary glands is less trying to the sub- ject, and furnishes more important information. Is the breast larger and firmer than usual? Is the nipple more prominent and harder, and can a fluid be pressed from it ? The areola is to be closely observed as to whether swelled and darkened, and as to hypertro- phy of its tubercles; supposing the primary areola to have under- gone the characteristic changes of pregnancy, if the gestation has lasted five months, the secondary areola is beginning to appear. The urine may be examined as to the presence of kyestine, or as to the lessened quantity of its solid constituents; but such exami- nation is of scientific interest rather than of practical value. Joris- senne's " sign " may be tried, the pulse counted when the woman is standing, then sitting, and, finally, when lying.1 Touch.—The obstetric definition of touch is a digital or manual examination of the female internal and external generative organs and adjacent parts for diagnostic or therapeutic purposes. Touch may be vaginal, rectal, vesical, or abdominal. In the first three it is almost always digital, but in the last it is usually manual, and commonly called palpation; sometimes vaginal touch and abdomi- nal palpation are combined, and this is bi-manual, or abdomino- vaginal examination. Vaginal Touch.—This is usually made with the index-finger of the right or of the left hand, whichever may be the more conven- ient with reference to the position of the patient; while the right hand is generally used, there are, as Cazeaux has said, some dis- eases of women and some positions of the fcetus which compel the accoucheur to use the left hand, and therefore he should accustom himself to touching with either hand. Some practitioners prefer to join the medius to the index, thereby gaining, according to Stein, a little more than half an inch, 15 millimetres; a gain of an inch is impossible. But if two fingers are used the examination may be quite painful in a primigravida, and the sensation given the ex- 1 Jorissenne (Nouveau Signe de la Grossesse) states that in the first months of gestation, in the absence or uncertainty of other signs of the pregnant condition, an important one is fur- nished by the fact that the pulse does not correspond with the changes of position, but remains the same whether the person is erect, sitting, or lying down. Fry (American Journal of Obstetrics, 1884) has not found this sign of any value. More recently and from quite exten- sive observations, Louge (Le Pouls Puerperal Physiologique) found the sign only occasionally present, and then after the fifth month, when other signs of pregnancy generally make the diagnosis quite easy. Fry regards (op. cit.) a vaginal temperature 070 above that of the axilla as presumptive of pregnancy, if there is no fever or local disease. THE SIGNS AND DIAGNOSIS OF PREGNANCY. I97 aminer by two fingers is less clear than that from one; beside, the index can be more easily separated from the adjoining finger, and thus can explore a greater part of the pelvic capacity. Hubert, who happily characterizes the accoucheur's finger as clairvoyant} states that in some localities in Holland accoucheurs and sagesfemmes have for their sign a representation of a long finger surmounted by an eye. A similar device was placed by the late Dr. Valentine Mott upon the tickets of admission to his lectures in the University of New York. The practitioner must carefully notice if there is the slightest abrasion upon the finger used in touching, or upon the other fingers of the hand, and if there be he should cover the abraded part with collodion or other protective material; if he neglect this precaution he may, even from a patient in regard to whom he has not the slightest suspicion of such disease, be inoculated with the poison of syphilis; many a physician in the discharge of his obstetric duties has become the subject of syphilitic infection from not taking proper precautions in a vaginal examination. The hands should be washed in warm water, especially if they are cold, not only for the sake of cleanliness, but to increase the delicacy of touch. The finger should be covered with vaseline, oil, lard, or some simple ointment, or, better than any of these, fine soap, in order to facilitate its introduction, and make that introduction pain- less. The patient must be prepared by having the bowels and bladder recently emptied, and her clothing quite loose. The exam- ination may be made when she is standing or when she is lying. If made in the former position, her back should be against the wall or some high, firm body, and the physician faces her, either sitting upon a low stool or resting one knee upon the floor—the right knee if the left index finger is used—the other knee furnish- ing a support for the elbow of the hand which touches. In the erect position the pressure of the intestines, and the contraction of the abdominal muscles force the uterus somewhat lower; hence, in some women who are very fat, it is difficult to reach the os uteri if they are lying, and the examination may have to be made in the former position; so, too, this position is more favorable for vaginal ballottement. But in most cases the examination is made when the patient is lying. She should be on her back, lightly covered, the thighs and legs flexed; the bed should be of such firm material that her hips will not sink in it, or they should be raised by placing under them three or four thicknesses of blanket or a hair cushion. The physician now takes his seat or kneels by that side of the bed nearest which the patient is—if it be the right side his right hand is used in the examination—extends the thumb and index finger, flexes the others, and introduces the hand under the clothes of the bed and of the patient, touching the middle of the inner surface of the knee next him with the extended thumb, then by following a line parallel with, and equidistant from the thighs, his finger 1 Cours d'Accouchements, professe a l'Universitie Catholique de Louvain, 1878. 198 SCIENCE AND ART OF OBSTETRICS. readily finds the vulvar orifice, or this may be entered by first carry- ing the hand directly to the perineum, and then slightly raising the finger in the median line. Whichever plan of reaching the vulvar opening is followed, it is very much better, the examination is easier, and the movements of the finger more free, if the forearm, instead of crossing beneath the thigh, is introduced under the cloth- ing so far as to lie in a longitudinal direction. Some obstetricians advise passing the hand over the thigh of the patient, but this prac- tice does not so well secure her immobility and relaxation of the abdominal wall; the latter is an important point if one failing to reach the os uteri, for example, or other part of which exploration is desirable, wishes to press, with the free hand upon the abdomen, the uterus toward the pelvic cavity. Before the finger is passed into the vagina, the condition of the vulva may be learned, espe- cially as to swelling from cedema, varices, or inflammation; it may be necessary subsequently to examine with the eye in case he finds such conditions. When the finger is passed into the vagina, the state of this organ should be carefully noted, its size, temperature, secretion, sensibility, and form. Next, the examination of the pelvis and uterus is made. Of course, any considerable encroachment upon the pelvic diameters by a new growth, or by change in the bones, would be readily ascertained. Such pathological growths and deformities are rare exceptions, and the physician's constant and generally only concern is the condition of the uterus. His first effort is to find the os uteri, and this is not in all cases easy to do. Remembering the usual right antero-lateral position of the body of the uterus in pregnancy, the os would be directed backward to the sacral cavity, and to the left side; it may be impossible to reach it while the patient is lying upon her back, nevertheless a trial may be made, first having her hips still more elevated, and by pressing, with one hand upon the abdomen, the uterus backward and toward the median line; if this should fail, the woman is directed to turn upon the side opposite to that of the latero-version, the finger during this change of position being retained in the vagina, and generally the os uteri may then be felt. The changes in the cervix and os caused by pregnancy have previously been stated, and there- fore no further reference to them is necessary. Examination of the body of the uterus, as far as it can be reached by the finger in the vagina, assisted by pressure upon the abdomen, is made; if the organ has changed its form so that the finger passes somewhat abruptly from the nearly cylindrical cervix to a round, expanded body, and if its walls are elastic, depressible, and yielding, the probability is, the uterine enlargement is caused by pregnancy. This sign is one of the earliest that is available, and one which, if not deserving to be ranked among the certain signs, yet gives a high degree of probability.1 1 Before attempting the certain diagnosis of pregnancy in the first months, it may be well to recall the caution which Dr. Wm. Hunter manifested: " I cannot determine at four months; I am afraid of myself at five months; but when six or seven months are over, I urge an exami- nation.'' Of course this is extreme, for it is only in exceptional cases that a positive diagnosis cannot be made in the fifth month. THE SIGNS AND DIAGNOSIS OF PREGNANCY. I99 Ballottement.—In obstetrics this word means the sensation which the examiner experiences when he communicates a sudden move- ment to the whole, or to a part of the fcetus; re-percussion is some- times used as a synonym. It is the result of a momentary displace- ment of a solid body in a liquid: just as one by striking a lump of ice1 in a tumbler of water with the finger causes it to recede—and the experiment would be the same if the finger-tap were made through a membrane fastened over the tumbler—so an impulsion is made upon the fcetus or a part of it. If the entire fcetus be displaced, and the finger be retained at the point where this movement was produced, the return of the fcetus may also be recognized, and the sensation thus caused is known as the choc deretour. It is thus seen that there may be a single sensation experienced in ballottement, and this is the more frequent, or a double sensation. Ballottement is either abdominal or vaginal; the former will be considered hereafter. In vaginal ballottement the woman is either standing or lying. The physician should, in the former case, pass one or two fingers into the vagina, and in front of the cervix, until they rest upon the body of the womb at its junction with the for- mer ; the free hand is applied to the fundus of the uterus, and then a quick movement is made by the finger or fingers in the vagina, a sudden impulse thus communicated to the fcetus, dislodging it from its position, and causing it to float upward in the uterine cavity; the return of the fcetus may be felt in many cases, that is unless this return be very gradual, or in those cases in which only a part of the fcetus has been displaced. If the woman be lying, it is well for her to have the head and shoulders somewhat raised, so as to throw the uterus forward, and then the ballottement may be sought just as if she were erect; if she be quite horizontal the finger must be passed into the posterior, instead of into the anterior cul- de-sac. Ballottement is an almost positive proof of pregnancy; neverthe- less, Pajot found it present when the woman was not pregnant, but had a multilocular ovarian cyst. The absence of ballottement does not prove that a woman is not pregnant; for great size or small size of the foetus, plural pregnancy, polyhydramnios, placental or shoul- der presentation may prevent it. A ballottement caused by entire displacement of the fcetus, though recognizable at about five months, is best perceived in the sixth and seventh months, and that from a partial displacement later. But before the date when ballotte- ment is readily done, signs of pregnancy are available which are certain. Rectal and Vesical Touch, Hegar's Sign.—Rectal touch may be necessary in case of vulvar or of vaginal obstruction, in posterior displacements of the uterus, and in the diagnosis of tumors of the recto-vaginal wall, of effusions in Douglas's cul-de-sac, and of extra- uterine pregnancy. It is a method of examination very repulsive to the subject, and is rarely necessary. Vesical touch, or examination 1 Tarnier. 200 SCIENCE AND ART OF OBSTETRICS. through the bladder, the urethra having been previously dilated to admit the finger, is still more rarely required. The sign of pregnancy known as Hegar's, is softening and thinning of that part of the uterus immediately above the cervix. This con- dition may be ascertained by introducing the index finger of one hand into the rectum above the utero-sacral ligaments, while the corre- sponding thumb is pushed against the lowest part of the uterine body anteriorly, and with the other hand upon the abdomen the uterus is depressed. It is claimed that the tissues intervening between the thumb and finger may " in most cases, be compressed almost to the thinness of a visiting card," if the examination be made during the latter part of the second month ; diagnosis of pregnancy has thus been made at the seventh week. This sign is not mentioned in the last edition of Schroder's work upon Obstet- trics, 1888, and Winckel, 1889, briefly refers to it among the signs that only have a relative value, and which may be present in some diseases of the uterus. Jag- gard states, American System of Obstetrics, vol. i., that obscure and confused notions embraced under this sign have rendered invalid the conclusions of cer- tain American observers. Abdominal Touch, or Palpation.—This consists in the application of the hands to the abdomen for the diagnosis of pregnancy, and Fig. 102. The hand circumscribing the fundus of the uterus in palpation. its duration, to ascertain whether it be single or plural, the presen- tation and position of the fcetus, and for the correction of an unfavor- able presentation. The woman, her bowels and bladder having previously been evacuated, lies upon her back, with her limbs extended; the abdo- THE SIGNS AND DIAGNOSIS OF PREGNANCY. 201 men is exposed from the epigastrium to the mons veneris. The physician, having previously warmed his hands if they are cold, takes his position at that side of the bed nearest which she is lying—the left is the better—and places one of his hands upon the hypogastrium, keeping it pressed there flat and with moderate firmness for two or three minutes in order to accustom the abdominal muscles to this contact, and thus obviate their contraction. So, too, if the preg- nancy be well advanced uterine contraction may be excited by the hand ; during it all pressure should cease. The first object in palpa- tion is to learn the presence and the size of the uterus, and to do this let the left hand, if the physician is upon the patient's right side, be pressed with the fingers and thumb slightly flexed so as to correspond to the convex surface of the uterus upon the hypogastrium, and gradually carry the hand further up the abdominal wall, each movement of ascent marked, first, by relaxed, then increased pressure, and the pressure being stronger at the ulnar margin of the hand, so that when the Fn;. 103. fundus of the uterus is reached that part at once recognizes the failure of resistance, and dips deeper in the abdominal cavity. An- other method is by using both hands held almost vertically so that the fingers begin pressing upon the hypogastrium in the median line, then the hands are gradually separated, the space widened between them until the fingers meeting with no resistance may be passed down on each side of the uterus ; the sides of the uterus can now be followed up until the fundus is reached. We recognize the ute- rus by its form, by its position, and possibly by its being the seat of intermittent contractions; further in cases of doubt, while one hand 202 SCIENCE AND ART OF OBSTETRICS. circumscribes the supposed fundus, a finger of the other may be passed into the vagina, so as to touch the cervix, and the continuity of this with the mass felt through the abdominal wall can easily be ascertained. The distance of the fundus above the pubic symphy- sis, supposing the woman to be pregnant, enables an approximate determination of the time of the pregnancy. Intermittent contractions of the uterus ascertained by palpation have been especially studied by Dr. Braxton Hicks, and he states that this sign is available by the last of the third month.1 " If then the uterus be examined without friction or any pressure beyond that necessary for full contact of the hand continuously over a period of from five to twenty minutes, it will be noticed to become firm if relaxed at first, and more or less flaccid if it be firm at first. It is seldom that so long an interval occurs as that of twenty minutes; most frequently it occurs every five or ten minutes, sometimes even twice in five minutes. However, in some cases, I have found only one contraction in thirty minutes. The duration of each contrac- tion is generally not long; ordinarily it lasts from two to five minutes." Dr. Hicks has also stated,2 referring to this method of examina- tion : " If we find a tumor changing in density and hardness, we have an assurance that it is the uterus." But Tarnier has called attention to the fact that a distended bladder gives the same sen- sation of intermittent contractions, and the 'experience of others can give confirming proofs; so, too, according to Duncan, contrac- tions quite as distinct may be observed in case of a soft fibroid of the uterus, and with as much change of shape as a pregnant uterus : the first source of error would, of course, be readily avoided by the use of the catheter. At five months the walls of the uterus have become so elastic and depressible, and the fcetus is sufficiently developed to be recognized by palpation if the abdominal wall be not too thick; in this exam- ination some parts of the uterine globe are harder, more resisting than others which are elastic, and permit depression. As pregnancy advances an indistinct fluctuation may be found, and if the uterus is embraced by the hands at its sides, by pressing these alternately, the foetus, or parts of it, may be moved toward one and then toward the other. This is known as abdominal ballottement. Passive movement of the fcetus may also be made by pressing with a single hand upon some portion of the uterine globe where there is felt a special resistance, that resistance coming from part of the fcetus, and the pressure forcing it momentarily away. Spontaneous movements of the fcetus are almost certain to occur during abdominal palpation; when they are being made the hand should be kept immobile, but closely applied to the abdominal wall. These movements may be recognized as early as the last of the fifth or the first of the sixth month. They maybe general or partial; in 1 Transactions of the London Obstetrical Society, vol. xiii, 2 Transactions of the International Medical Congress, 1881. THE SIGNS AND DIAGNOSIS OF PREGNANCY. 203 the former case the entire body changes its position, and a general change in the form of the uterus temporarily occurs; the move- ment is gradual, gliding or rolling, and is slow. The partial movements are those of the head, or of the members; they are quick, local, as if of sudden taps or blows given at a particular part of the internal uterine wall, and causing that part for an instant to change its form. Active movements of the fcetus are most frequently observed in the morning after the woman's rest, at least they are then most pronounced. Of course, if the obstetrician recognizes such move- ments, he has not only positive proof of pregnancy, but also of the fcetus being alive. But the inability to perceive these movements, or their absence, is not a proof that the woman is not pregnant; for the feebleness of the child, or excess of liquor amnii, may cause this sign to be absent. Or, again, contractions of the abdominal muscles, or movements of the intestines, may be mistaken, and have been so mistaken by even celebrated observers, for movements of the foetus. He, therefore, will act most wisely who avoids possibility of error by repeating once or oftener this examination, and also confirms the results obtained by touch by those given by sight—that is, both feels and sees the movements of the foetus. It is, moreover, fortu- nate that he is not restricted in deciding as to pregnancy by a single sign, but can combine others with it. In many cases at the end of the sixth or the beginning of the seventh month different parts of the fcetus, as the head, breech, or limbs, may be recognized by abdominal palpation. Nevertheless a tense, resisting abdominal wall, or one that is very thick, may render this recognition impossible. The late Dr. Albert H. Smith,1 of Philadelphia, advised in certain cases the following method of "external bi-manual ballottement: " The woman is placed upon the edge of the bed with her clothing removed from the abdomen, and then rolled upon her side; so that the anterior abdominal wall projects over the edge of the bed ; then the rotation of her body is carried still further until the enlarged uterus becomes so dependent that it may be supported by the hand placed beneath it, while the other hand makes counter-pressure upon the opposite side of the uterine mass. Thus let the woman be upon her left side, the right side, therefore, being above, the exam- iner takes his seat with his face toward her head, his left side being toward the pendent abdominal mass, but about opposite the hips. The right hand is then passed far under the uterus as it projects over the bed, the palmar surface being in contact with the abdom- inal integument and the ulnar edge toward the iliac bone. The left hand is thus placed similarly upon the right side of the abdomen, making counter-pressure upon the opposite side of the uterine body so as to grasp it between the two palms. This gives a full command of the tumor, and enables the examiner to appreciate the shape and 1 " Manual Examination in the Diagnosis of Pregnancy." A paper read before the Phila- delphia County Medical Society. 204 SCIENCE AND ART OF OBSTETRICS. density of the mass, its fluctuating character, and the movement of a separate body within it, which can be operated upon by manipula- tion and re-percussion." Dr. Smith further stated that by this method he has been "able to diagnose a pregnancy of six months when the fcetal heart was entirely inaudible.*' In another part of this paper its author said that even at three months and a half it is sometimes possible, if the uterine wall be thin and soft, to feel the movements of the child by a finger pressing firmly upon the uterus posteriorly to the neck, while the other hand makes counter-pressure through the abdominal wall upon the anterior and the superior surface of the uterus; and further, " by a gentle thrust of the vaginal finger upward, to feel the receding and return of a body loosely floating in a liquid;" during this abdomino- vaginal manipulation the woman is lying upon her back. Obstetric Auscultation.—Laennec's treatise upon Mediate Ausculta- tion was published in 1816, and two years later Mayor, of Geneva, stated that upon applying the ear to the abdomen of a pregnant woman the pulsations of the foetal heart could be heard, and he thus made known one of the most important discoveries in obstetric science. Kergaradec, of Lausanne, ignorant of Mayor's priority in the discovery, announced the same fact in 1821. The discovery was an accident to each; neither was listening for what he heard; Mayor listened hoping to hear sounds caused by movements of the fcetus, and Kergaradec those occurring in the amnial liquor from these movements. Kergaradec, in addition to hearing the pulsations of the fcetal heart, heard a sound attributed by him to the circulation in the placenta, which he therefore called the placental souffle. As will be shown hereafter, his theory of the origin of this souffle was erroneous; the souffle is not connected with the placental circula- tion, and therefore the name given it was incorrect. In addition to the two sounds mentioned, other sounds are dis- covered by obstetric auscultation: those caused by fcetal move- ments, a cardiac souffle, attributed to the passage of blood through the foramen of Botal, and a funic souffle j1 but they are of minor interest, and the two sounds first discovered are of prime impor- tance and therefore only will be considered. Obstetric auscultation is usually abdominal, but it may be vaginal; Nauche, at .the suggestion of Maygrier, devised an instrument called the metroscope for auscultating through the vagina. The objections to vaginal auscultation are its difficulty, the unwillingness of patients to submit to it, and when the instrument is applied to the fundus of the vagina, or in the cavity of the uterine cervix, great irritation, causing abortion, may be produced. Nevertheless it has recently been revived by Verardini, of Bologna, who by this 1 The funic souffle, discovered by Kennedy in 1833, is a blowing sound synchronous with the foetal heart, and, according to Winckel, is heard in three-fourths of all cases. This observer also states that in 33 per cent, of all the cases in which it is heard the cord is abnormally short, or long, and that in 8 per cent, the children perish. The sound is, as a rule, heard over the child's back, and near the heart. THE SIGNS AND DIAGNOSIS OF PREGNANCY. 205 means has been quite successful in diagnosing early pregnancies. Abdominal auscultation should be mediate for these reasons : The direct application of the ear to the abdomen is indelicate; pressure upon a great extent of surface, causing bruits from muscular con- traction, is necessary; it demands a constrained position on the part of the observer, and it is not possible thus to auscultate some parts of the abdomen, and the want of cleanliness on the part of some patients may make it very objectionable to the examiner.1 A stetho- scope is less trying to the patient and to the doctor; it permits ex- amination of parts that cannot be reached by the unarmed ear, and the sounds heard through it are better defined, and their limit better determined. The stethoscope should not be less than six inches, about 15 centimetres, long. The woman should lie upon her back, with her limbs extended, or only slightly flexed. In the course of the examination it may sometimes be necessary for her to turn upon one or the other side, but the chief examination will be made with- out change of position. In some cases, from motives of delicacy, the abdomen may be kept covered, and a single thickness of thin unstarched material will not usually materially interfere with hearing the sounds sought; but, as Depaul remarked, in all cases of doubt or difficulty the abdomen must be naked. Uterine Souffle.—Upon applying the stethoscope to the abdomen of a woman some five or six months pregnant, or more—according to Spiegelberg it may be audible at four months—probably the first sound which will be heard is that which was originally called the placental souffle, and which some physicians of to-day still thus mis- call ; it is properly termed the uterine souffle. That the placenta has nothing to do with the production of the sound in question is proved by the fact that it may be heard two or three—in some cases five or six—days after labor. Since this souffle may be heard several days after labor, it is plain that when heard during pregnancy the place where most distinct gives no indication as to the site of placental attachment. Beside the placental theory of this sound, it has been attributed to an impoverished condition of the blood, to pressure of the gravid uterus upon the iliac arteries and upon the aorta, more recently by Glenard at first to the circulation in the epigastric, and then to that in the "puerperal" artery. The theory of its origin which is now most generally accepted is that of Dubois, somewhat modified by Depaul.2 The sound is heard most distinctly at the sides of the uterus where the blood-supply of the organ is received; the arteries upon entering the uterus imme- diately dilate, offering permanently a capacity which seems too great for the blood they have to receive. This disproportion, which does not naturally exist in other parts of the organ, may nevertheless be produced under the influence of different causes whose action is transient, and varying from one minute to another. Among these causes the most common are those which result from compressions 1 Nevertheless, if failure occur using the stethoscope, immediate auscultation may be employed. 2 Dictionnaire Encyclopedique des Sciences Medicales. 206 SCIENCE AND ART OF OBSTETRICS. caused by projections of different parts of the fcetal ovoid. Thus it happens in correspondence with these changes, there are changes in the uterine souffle, which may be heard distinctly one minute at a particular part of the uterus, and then instantly cease. The sound is single,1 without shock, is synchronous with the mother's pulse, and resembles the souffle of a varicose aneurism ; it varies in character, and in distinctness; it maybe sibilant, or humming, or sonorous; it has been compared to the sound made by saying in a low tone voo. It is best heard when the stethoscope is applied to the lower lateral parts of the uterus ; it is usually first recognized in the fifth month, but Depaul heard it in the tenth week, Spiegelberg from the eighth to the ninth, as did also Verardini. From the explanation that has been given of the cause of this sound, it can readily be understood that whenever the uterus has a notably increased supply of blood, the uterine souffle maybe heard; thus it has been found in some cases of large uterine fibroids. As a sign of pregnancy, therefore, it has little value ; taken in connection with others it adds strength, but must not be relied upon alone. Even if the pregnant state be known, this sound gives no informa- tion as to the condition of the fcetus, for its death makes no change in the souffle. Sounds of the Foetal Heart.—These sounds have been very gener- ally compared to the tic-tac of a watch put under a pillow upon which the ear is placed. The first sound is the more distinct, and corresponds with the pulsation in the umbilical arteries; the interval between the two sounds is less than that between the double pulsa- tions, or, as one may say, it is twice as long between a tac and a tic as it is between a tic and a tac, and this difference may be thus expressed, tic-tac—tic-tac. 'Depaul in several cases heard these sounds at three months and a half, and in one at the latter part of the third month.2 "At the end of the fourth month the cases in which auscultation is uselessly practised are much more rare, and they become so much more exceptional as women are nearer the term." In 906 pregnant women examined by Depaul, the sound of the fcetal heart failed to be heard but eight times, and some of these failures, he states, are to be attributed to another cause than the powerlessness of auscul- tation. In listening for these sounds the stethoscope should be applied up to four months to the fundus of the uterus, and in a line corre- sponding with the axis of the inlet. With the ascension of the uterus in the abdominal cavity, the instrument must usually be placed upon one or the other side, though sometimes the sounds are more distinct in the median line. During the last three months of preg- nancy the sounds are, in the great majority of cases, most distinctly heard at the middle of a line drawn from the umbilicus to the left 1 Winckel believes that the murmur is not only intermittent, but may be continuous; in the former case being arterial, and in the latter venous. 2 Depaul, op. cit. THE SIGNS AND DIAGNOSIS OF PREGNANCY. 207 Fig. 104. anterior superior spinous process; failing to hear them here, the physician should next listen at a corresponding point upon the right side; if the sounds cannot be heard at either of these points, the stethoscope should be applied above the umbilicus, upon one, then, if necessary, upon the other side of the median line. The follow- ing illustration, from Depaul's Clinique Obstetricale, shows these different points. The examiner first applies his stethoscope at D; if he fails to hear the sounds at this point, or hears them only indistinctly, he next listens at C; finally, he tries the points A and B, if no satisfactory result has been obtained by auscultating at D or C. The pulsations of the fcetal are much more frequent than those of the maternal heart, and vary from 120 to 160 a minute, the mean being 140; these pulsations vary in the same fcetus as to frequency, becoming slower or faster from one time to another. The distinctness with which they are heard will of course depend upon the size and development of the fcetus, and upon its position, upon the quantity of liquor amnii, and the thickness of the uterine and of the abdominal walls. The frequency of the pulsations is unin- fluenced by the mother's circulation, but it is by her temperature, increasing as that increases. Important movements of the foetus, whether spontaneous or resulting from external causes, are followed by an acceleration of the pulsations, while these become slower at the height of a uterine contraction. It has been held that there is a rela- tion between the frequency of the pulsa- tions and the sex of the fcetus—Frank- enhauser, and others—while Cumming maintained that this frequency depended upon the weight of the child. Danzats states that if the pulsations are more than 145 a minute, the probability is in favor of the child being a female; under 135, a male, and between these numbers a prediction cannot be made. Hennig and Ziegenspeck found the average frequency of the pulsation of the heart of the male fcetus 136, and that of the female 139; this difference is so small that, as Winckel remarks, it is seldom possible to predict the sex. Some observers do not confirm these statements. In this country Pro- fessor Frank C. Wilson, of Louisville, Ky., has for some years given much attention to the subject, and his conclusions are presented on the next page. Diagnosis of pregnancy by auscultation. 208 SCIENCE AND ART OF OBSTETRICS. Louisville, Ky., July 14, 1884. Prof. Th. Parvin. Dear Doctor: In reply to yours of 10th inst. I would say that with a rea- sonable degree of accuracy the sex may be predicated from the rapidity of the foetal heart sounds. These vary from no to 170 per minute, and 134 maybe taken as the dividing line, above which the sex will be female, and below which the sex will be male, the certainty increasing the further you recede from the di- viding point. The following rules I have found useful in determining the sex : From no to 125 the sex will be, almost certainly male. 125 to 130 130 to 134 134 to 138 138 to 143 143 to 170 probably male. doubtful with chances in favor of male. " " " " female. probably female. almost certainly female. Although failures occasionally occur, they are not numerous. Very sincerely yours, Frank C. Wilson. Certainly, in view of the statements of Dr. Wilson, who is one of the most careful, competent, and conscientious observers, the sub- ject is deserving of further investigation. Foetal Shock, Choc Foetal of Pajot.—Toward the end of the first half of pregnancy if the stethoscope be applied with only moderate pressure to the abdomen, the observer has from a movement of the foetus a double sensation of shock and of a very slight and sudden bruit. Pajot claims that this sign, thus addressing general and special sensibility, is more readily recognized at this time than are the bruits of the fcetal heart, and in many cases can be heard earlier than the latter. Auscultation is the most valuable of all means in the diagnosis of pregnancy. It cannot offend the delicacy of the modest, nor arouse the suspicion of a woman claiming to be pregnant when she knows she is not, or of another who seeks to conceal her pregnancy—the sounds of the fcetal heart can " neither be simulated nor dissimu- lated." Only one other sign equals it in value, and that is recogni- tion of the fcetus by vaginal or by abdominal touch. By ausculta- tion we learn not only the fact of pregnancy, but also that the foetus is living. Of course, auscultation gives only negative evidence if the foetus be dead. The examiner should by counting the mother's pulse guard against confounding the sounds caused by her circulation with those of the fcetus. He should auscultate in a quiet room, and if his examination gives only partially satisfactory or entirely negative results, and there be any probability of pregnancy, repeat the examination once or oftener subsequently, bewaring of a hasty affirmation, but even still more of denial of pregnancy. Time is a most important element in the diagnosis. CHAPTER V. THE DIAGNOSIS OF PLURAL PREGNANCY—DIFFERENTIAL DIAGNOSIS OF PREGNANCY—DIAGNOSIS OF PREVIOUS PREGNANCY, OF PERIOD OF PREGNANCY, AND OF DEATH OF FCETUS--DURATION OF PREGNANCY— DATE OF LABOR—PRECOCIOUS BIRTHS—PROLONGED PREGNANCY-- MISSED LABOR. Diagnosis of Twin Pregnancy.—In the great majority of cases this is not made until after the birth of the first child ; indeed, Capuron1 thought that certain proof could only then be had; in this, how- ever, he was mistaken, as will be hereafter shown. The signs of a plural pregnancy2 are conveniently divided into probable and certain. Among the former are extraordinary enlarge- ment of the abdomen, the size being greater than in correspondence with the period of pregnancy; unusual form of the abdominal promi- nence, the uterus being developed more in its transverse than in its vertical diameter; lateral is more marked than median projection, so that in some cases, as Mauriceau stated, there is a depression directly in the median line, and " an eminence on each side of the abdomen ;" fcetal movements observed at different parts of the abdo- men, these movements being more frequent and stronger than usual; and finally, the disorders of pregnancy are more decided than when only one foetus is present; there is also greater liability to premature labor. The venous circulation is seriously interfered with by the great development of the abdomen, and hence oedema of the lower limbs and of the abdominal walls. Depaul attached some importance to an cedematous swelling, triangular in form, having its base at the pubes, and its apex pointing toward the umbilicus, as indicative of a plural pregnancy. The certain signs of plural pregnancy are given by vaginal touch, abdominal palpation, and by auscultation. Vaginal touch may, after labor has begun, furnish the evidence of a twin pregnancy ; thus, it is possible there may be recognized, as was done by Depaul in two cases, a furrow dividing the protruding bag of waters into two parts, indicating the presence of two fcetal sacs; according to Charpentier, this sign was first made known by Duges and Madame Lachapelle. The cases are rare in which it is present. In consequence of the relatively less quantity of liquor amnii, and of the fact that the uterine cavity is so largely occupied by the foetuses, passive movements of these, or abdominal ballotte- 1 When almost eighty years of age, and after having been a teacher of obstetrics for nearly fifty years, he one day said to Pajot: "My friend, there is but one way by which you may certainly know a twin pregnancy. If you have seen one fcetus born, and find there is another in the uterus, you may be sure there are twins." 2 Mr. Rigby, at the age of eighty, was the father of four children at one birth. Gooch's Compendium. 14 2IO SCIENCE AND ART OF OBSTETRICS. ment, cannot be so well effected ; and, on the other hand, if the very great uterine enlargement be caused by polyhydramnios, the mobility of the foetuses is greater than is normally present. Again, there is, as expressed by Pinard, a permanent tension of the uterine wall in case of plural pregnancy. "This wall, instead of being easily depressed, is tense and resisting; it gives a sensation similar to that caused by pressing upon a rubber bag distended by air or by a liquid." Next the presence of fcetal members in different parts of the uterus may be sought, and then the two fcetal poles in the upper and two also in the lower portion of the uterus concludes the diagnosis of twin pregnancy by palpation. By this means Pinard discovered in thirty-two cases the presence of twins in the uterus. He also diagnosed triplets between the fifth and sixth month of pregnancy; he found three heads, one in the pelvic cavity, a second in the right iliac fossa, and a third above and near the median line. It is well not to entertain too great confidence in this method of diagnosis, and therefore not to be disappointed by at least occasional failures ; indeed, Depaul regarded it as only exceptionally possible, as the following passage indicates:' " Some practitioners in fact teach that one can distinguish through the abdomi- nal walls two foetuses. The necessary conditions for such a diagnosis are only very exceptionally presented, for in multiple pregnancy the uterine and abdomi- nal walls are usually tense, and can only with pain and difficulty be depressed by the hand of the examiner. Besides, it is much less easy than is generally thought to distinguish the different regions of the foetus through the abdominal and uterine walls, and when you wish to apply palpation to the diagnosis of pre- sentations of the shoulder and of the pelvic extremity, you will recognize how much the hips, by their roundness and resistance, offer through the walls which separate them from the hand, resemblance to the cephalic extremity." Kergaradec was thefirst to point out the possibility of recognizing a twin pregnancy by hearing the sounds of two fcetal hearts. Sub- sequently, however, others regarded the supposed placental bruit as giving this proof, for indeed, according to the original theory as to the origin of this sound, it would be heard at two different points corresponding with the situations of the two placentae. But this view, according to which the sound referred to resulted from the circulation in the utero-placental vessels, being, as has been pre- viously shown, an error, of course a correct diagnosis could not be founded upon it. We return, therefore, to the original suggestion of Kergaradec, and find that the " double pulsations of the fcetal heart, heard at two different points of the uterus, with a maximum of intensity and without isochronism, show the presence of two foetuses in the uterine cavity." In making this examination care should be taken to exclude any error which would arise from confounding the sounds of the mother's heart with those of a fcetal heart. In order that the diagnosis of twins can be correctly made by auscultation, the obstetrician must hear fcetal heart-sounds most clearly at differ- ent parts of the uterus, in neither case isochronous with the mother's pulse, nor isochronous with each other. The variation in frequency Lecons de Clinique Obstetricale. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 211 between the heart-sounds of two foetuses may be only six or eight, or it may be fifteen or sixteen, but there is always a notable differ- ence. It must be borne in mind that the comparative results must be, in each case, those obtained at the same examination, for the frequency of the sounds of the fcetal heart varies from one time to another Usually the maximum of intensity of the heart-sounds of one fcetus is found higher than that of the other, nor are the two maxima upon the same side of the median line. For example, referring to Fig. 103, one maximum might be heard at D, and the other at A or at C. The conclusion as to multiple pregnancy should not be drawn from a single examination, lest an error may arise from change of position of the fcetus, in case of single pregnancy, or from change in the frequency of its heart-sounds. Of course an error might occur in case there were more than two foetuses in the uterus, but the contingency of triplets even is so small that mistakes thence resulting will be very rare. In a case of triplets, H. F. Naegele, by auscultation during pregnancy, diagnosed twins ; when labor occurred, and after one of the children had been born, he, by the same means, discovered that there were still two foetuses in the uterus, and then mode the diagnosis of triplets. Even if the practitioner, after careful examination, is positive of a plural pregnancy, it is not wise in most cases to let the woman know his discovery, for to some the fact would be a source of fear and anxiety as to the labor, and to others, of care and worry as to the double burden which would be imposed upon them after the birth of the children. Of course, auscultation will be without value in the diagnosis of plural pregnancy if one of the foetuses be dead, but palpation might then be of use. It is better, however, especi- ally for the young practitioner, not to depend exclusively upon either mode of examination, but rather combine them, modifying the results obtained by one with those derived from the other. Differential Diagnosis of Pregnancy.—Certain pathological condi- tions may be mistaken for pregnancy, and the chief of these, with the means by which error as to their character may be avoided, will now be given. First. Affections which-Increase the Size of the Uterus. Physometra.—Gas may be formed in the uterus from decomposi- tion of retained secretions, or of fragments of an ovum. This gas may be retained if there be acquired atresia, or it may be discharged from time to time in case there be only stenosis. When stenosis and discharges of gas occurred, Gooch called the condition flatus of the uterus. Of course there is little danger of confounding a case of either form of the disorder with pregnancy. The uterus is but slowly and slightly increased in size; if it be large enough for per- cussion to be made, the tympanitic sound evoked points to the nature of the enlargement, and at the same time palpation and auscultation give negative results. Hydromctra.—A collection of watery fluid may take place in the uterus when the os is occluded. Usually the uterus is no larger than an orange and the increase of size is slow; it generally occurs 212 SCIENCE AND ART OF OBSTETRICS. in women who have passed the childbearing period, though Voisin met with it in a patient only forty years of age. Schroder has mentioned a case of its occurrence in a woman in consequence of cervical atresia caused by the application of the actual cautery for sarcoma. In hydrometra, too, the development of the uterine tumor is slower than in pregnancy, and the other usual signs of this con- dition are absent. Both physometra and hydrometra are rare. Hcematometra.—Accumulation of menstrual blood in the uterus has given rise to some most deplorable errors of diagnosis, errors that, however, can be readily avoided by a careful study of the history of the enlargement, followed by a suitable examination. Such an accumulation results from either congenital or acquired atresia of some part of the genital canal, and of course this atresia can be readily ascertained by a direct examination. The history of the enlargement is that it has lasted longer than pregnancy does, that it has taken place abruptly from time to time, increasing peri- odically instead of continuously; the periods of abrupt increase, as a rule attended with more or less severe suffering, usually occurred once in each month. Upon palpation the uterus is found tense and resisting, not yielding and elastic as it ordinarily is in pregnancy; no fcetal parts can be felt, and auscultation is negative. Uterine Fibroids.—The uterus is in most cases irregular in form, and is hard and resisting, instead of elastic and yielding. Instead of menstruation being absent, as is the fact in pregnancy, it is in most cases irregular and profuse; the mammary signs of pregnancy are as a rule absent, and the umbilicus does not show the changes which occur in the pregnant woman. The sympathetic disturbances of the early months of gestation have not been observed, and the growth has been much slower than the physiological development of the uterus; the cervix does not present the changes character- istic of pregnancy. The uterine souffle may be present, but the sounds of the foetal heart are absent. Increase in Size of Abdomen without Change in Size of Uterus— Ovarian Tumors.—Among the means that may be available in dis- tinguishing these growths from pregnancy are the presence of men- struation, and the enlargement having been first observed upon one or the other side instead of in the median line, and its development being slower than that of pregnancy. But amenorrhcea is found in quite a number of patients suffering with cystic ovarian disease either if they have become anaemic, or internal hemorrhage has occurred; as to the place of origin of the enlargement, unfortunately many patients observe badly or forget readily, so that this help often fails, and while usually the enlargement of pregnancy is more rapid than that of an ovarian tumor, exceptions to the rule may occur. The deterioration of health and the emaciation, especially notice- able in the face, will be marked if the tumor has attained great size. The fluctuation is usually distinct in cystic disease of the ovary, absent or very obscure in normal pregnancy; in polyhydramnios the DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 2Ij fluctuation is quite marked, but it is especially at the upper part of the abdomen, while in ovarian dropsy the fluctuation is usually more general. The results of touch and auscultation are negative, and the usual reflex disturbances of pregnancy are generally absent. Never- theless, there are some cases in which a positive diagnosis should not be given at once; delay and repeated examinations may be necessary rather than risk a mistake. Ascites.—It seems strange, nevertheless it is true, that the abdo- men enlarged by ascitic effusion has been mistaken for the enlarge- ment of pregnancy. The shape of the former is different from that of the latter, and fluctuation is always distinctly and everywhere present, whereas in pregnancy fluctuation is not distinct except in polyhydramnios, and then chiefly discovered in the upper part of the uterus. In ascites the uterus is unchanged in form, size, and position ; the menstrual function may be regularly exercised, and the reflex disturbances of pregnancy are absent. The disease usually has an obvious cause in some affection of the liver, kidneys, or heart. Palpation and auscultation give negative results as to preg- nancy. Accumulation of Fat in the Abdominal Wall, or in the Omentum.— Such an increase of size is more frequently observed in women from forty to fifty years of age than at any other time of life. The abdo- minal wall becomes not only prominent but pendent, and the woman has, as Dr. Bailie expressed it, a double chin in the belly. In such a subject it is generally easy, if she be lying down, for the physician, placing a hand on each side of the abdomen, to include between them the entire mass, and partially lift it up, thus determining its true character. There is entire absence of the signs of pregnancy furnished by auscultation and touch. Pseudocyesis, or False Pregnancy.—False, or nervous, pregnancy generally occurs in women who have married late in life, and who are anxious for offspring, or who wish to give proof of their still having the power of reproduction. They frequently present many of the subjective and some of the objective signs of pregnancy, the intense desire to be pregnant begetting many of the evidences of the condition. In some of these subjects abdominal enlargement may be observed ; menstruation may be absent, or scanty and irregular ; the breasts may increase in size and contain milk; the stomach may be irritable; and, finally, the woman is usually positive that she feels fcetal movements. The climax of the delusion of spurious preg- nancy may be spurious labor. The etiology of these cases is ob- scure. The women are honest in their belief, they do not desire to deceive others, but they are themselves deceived. Nor can this self- deception and the phenomena of false pregnancy and labor be accounted for by the action of the imagination, for similar phenom- ena have been observed in some of the inferior animals. Overbed bitches, which admit the dog without fecundation following, are never- theless observed to be sluggish about the time they should have whelped, and to bark as they do when their time is at hand, also to steal away the whelps from an- other bitch, to tend and lick them, and also to fight fiercely for them. Others have 214 SCIENCE AND ART OF OBSTETRICS. milk or colostrum, as it is called, in their teats, and are moreover subject to the diseases of those which have actuilly whelped. (Harvey On Conception.) Professor Haughton reported to the Djblin Obstetrical Society (February 7, 1880) an interesting case of phantom tumor observed in an ass that had been covered by a zebra ; the appearance of pregnancy deceived an expert. In the diagnosis of pseudo-cyesis the physician must give little or no weight to the subjective signs of pregnancy, or he will almost certainly be misled. Let him, therefore, if the alleged pregnancy be far enough advanced to make the objective signs available, trust to them, and in the contrary case wait until they ought to be plainly present in a case of true pregnancy. Usually these patients, as has been frequently observed, do not send for the physician until they have been, as they think, pregnant for several months, and then they do not ask for a diagnosis—that they have made for themselves —but for the relief of some temporary indisposition, or to attend them in their approaching labor. To undeceive such an one, proving that her hopes are false, is generally a thankless and difficult task ; it ought not to be attempted without first having conclusive evidence obtained by touch and auscultation. Pathological Conditions Rendering the Diagnosis Difficult.—In case of pregnancy occurring in a woman suffering from an abdominal enlargement, the former is liable to be overlooked, the pathological condition only being recognized. In some cases it is possible to remove the cause or condition hiding the pregnancy, and then the latter will be discovered. Thus, if ascites be present, after para- centesis the proofs of pregnancy may become evident. But the chief means to avoid error from these sources are repeated examina- tions and waiting until the signs of pregnancy become unequivocal. Pajot, in referring to these difficulties, remarks that there is one distinct characteristic of the gravid uterus by which it may be known from ascites, fibroids, haematometra, ovarian cysts, etc., that is, that it, in the last third of pregnancy, is the only abdominal tumor in which there is found a mobile solid body in a liquid. Diagnosis of Previous Pregnancy.—In some cases it is important to know whether a woman is pregnant for the first time, or whether she has been pregnant before, the pregnancy not ending in abortion. In the primigravida the.abdominal wall is smooth, tense, and resist- ing, and cannot be readily depressed; the uterus is more strictly confined to the vicinity of the median line, and especially does not incline anteriorly so much as it does in the multigravida. In the latter part of pregnancy the striae usually found upon the skin of the abdomen are not white or pearl-colored, but pink or purplish. The mammary glands are round, full, prominent, firm, not relaxed, flabby, and pendent. The vulvar orifice is small, closed, the posterior commissure complete, the hymen may be torn, but the carunculae myrtiformes are absent. The vagina is comparatively small, and the rugae are distinct, prominent, and in intimate contact by the close apposition of the anterior and posterior vaginal walls. The neck of the uterus is conical, its orifice, which is closed, presenting a uniform rim or border. DIAGNOSIS OF TIME OF PREGNANCY. 215 In the multigravida the skin of the abdominal wall is not smooth, but is relaxed, can be grasped in folds by the hand, and presents old white striae, though there may also be new striae present. " The uterus, which often gives a sensation of flaccidity, readily permits palpation through the thin and relaxed abdominal covering." The previous1 great stretching apart of the recti muscles, in some cases permits placing the entire hand in the intervening space. The breasts are less firm, somewhat pendent, and in many cases the skin is marked by old striae. The vulva is more or less open, and often has a bluish aspect from varices. ' As a rule, the posterior commis- sure has been torn, and the perineum may show cicatrices and loss of substance. The labia minora project beyond the labia majora, and in the orifice of the vagina the posterior vaginal wall may be found prolapsed. The only vestiges of the hymen are the carunculae myrtiformes. The vagina is large, its walls soft, relaxed, and form- ing broad folds. The vaginal portion of the cervix is cylindrical or club-shaped, and becomes soft more rapidly than in the primigravida. The os, which is open, presents an irregular border consequent upon tears in childbirth, and the distinction between the anterior and the posterior lip is well marked. In consequence2 of the greater mo- bility of the foetus, and hence the more frequent transverse position, the vaginal vault is often empty. The greater pendulousness of the abdomen causes the vaginal portion of the neck to be directed to the sacral cavity. But, as observed by Kleinwachter, all these signs have only a relative value. The striae upon the abdomen and the breasts, and the tears of the cervix may be wanting, the perineum be entire, and the hymen no more torn than may be seen in a woman who has had sexual intercourse without pregnancy, and yet the party may have been pregnant. The signs of a previous pregnancy are chiefly the results of mechanical force, produced by carrying and giving birth to a large fcetus. They may, therefore, be in part or entirely absent, provided the first labor was premature, and the fcetus too small to produce any injury from distention or tears. It should be also remembered that abdominal striae may be observed as conse- quences of great abdominal distention from ascites, or from ovarian cystic disease. "If several years elapse between two labors, the soft parts may be so nearly restored to their original condition, that it will be impossible to decide whether the person be a multipara or a primipara." Diagnosis of the Time of the Pregnancy.—In some cases it is of importance to determine how far the pregnancy has advanced. Independently of an estimate made of this time by counting from the supposed date of conception, an approximately correct conclusion may be obtained by an objective examination. This examination gives more satisfactory results in primigravidae than in multigravidae, because in the former the changes caused by pregnancy are more characteristic and typical.3 The chief means in making this diag- nosis are the changes in the neck of the womb, including, in multi- gravidae, the patency of the external os, and the progressive perme- 1 Kleinwachter. 2 Kleinwachter. 3 Schroder. 2l6 SCIENCE AND ART OF OBSTETRICS. ability of the cervical canal; the size of the uterus as learned by bimanual examination, and the distance of its fundus above the pubes as measured on the abdominal wall; the changes in the umbilicus, and the formation of the secondary mammary areola; the time when the uterine souffle and the fcetal heart-sounds become audible, and the measurement of the length of the fcetus. With the exception of the last, measuring the foetal length, all these have been considered. Ahlfeld's method of ascertaining the length of the fcetus is to put one knob of the calipers in the vagina, so that the head of the fcetus is touched necessarily through the thickness of the uterine wall, while the other is placed at the fundus of the uterus, as near as possible to the highest part of the breech, the abdominal and the uterine wall, of course, intervening. The length of the child is about twice this measurement. Knowing what its length usually is at successive months, a conclusion may be drawn from the length of the fcetus ascertained by this measurement, as to the time of the pregnancy. The objections to Ahlfeld's method1 are that we cannot know upon what parts of the fcetus the points of the calipers are placed, or the thickness of the soft parts lying between, or, what is still more important, the degree of curvature of the foetal spine; hence the method may be set down as worthless. Duration of Pregnancy.—Since pregnancy does not begin imme- diately after coition or insemination, but with the actual union of the spermatozoid and ovule, and as an uncertain time intervenes between insemination and conception, it is impossible for us to know its actual duration. We know in all cases when it ends, but in no case when it begins. In those rare instances in which pregnancy was known to have resulted from a single coition, the date of the coition does not correspond with the beginning of gestation. It is probable that in any case some hours, and in many several days intervened before the combination of the male and the female element occurred; Schroder states that the in- terval may be from one' to fifteen days. Further, we do not know whether the ovule that is fecundated2 is the one liberated at the menstrual period immediately preceding the sexual intercourse, or the one corresponding to the succeeding menstrual suppression, or one escaping from its ovisac in the menstrual interval. Hence a variation of a few or of several days in the time when pregnancy actually begins. While denied this certainty of knowledge, general observation agrees in making the period of gestation nine calendar or ten lunar months. Harvey said: " Unquestionably the ordinary term of utero-gestation is that kept in the womb of his mother by our Saviour Christ, of men the most perfect; counting, viz., from the festival of the Annunciation, in the month of March, to the day of 1 Kleinwachter. 2 " His found by careful examination of 16 embryos, that in 12 the stage of their develop- ment showed them to be the result of impregnation at the time of the first missing menstrual period, while the 4 others corresponded to the last preceding menses, and it only remains to prove, by a more extended series of observations which is of more frequent occurrence.*'— Winckel. DATE OF LABOR. 217 the blessed Nativity, which we celebrate in December. Prudent matrons, calculating after this rule, as long as they note the day of the month in which the catamenia usually appear, are rarely out of their reckoning, but after ten lunar months have elapsed, fall in labor, and reap the fruit of their womb the very day on which the catamenia would have appeared, had not impregnation taken place."1 Dr. Matthews Duncan speaks of Harvey's opinion here quoted, as " very correct," and also states that his remarks tally with the late Dr. Tyler Smith's ingenious views upon the question. When pregnancy resulted from a single coition, the average interval between insemination and labor was two hundred and seventy-five days. The average interval between the end of men- struation and labor is two hundred and seventy-eight days. Varia- tions from these averages will be considered subsequently. Predicting the Date of Confinement.—Tables for readily calculating the time of labor are usually found in " Physicians' Visiting Lists," and therefore it is unnecessary to insert any here. But, moreover, there are simple rules by which the calculation can be made, and therefore such tables and " periodoscopes" may well be omitted. One plan is to count the number of days between the beginning of the last menstruation and that of the one immediately preceding it, and multiply the number by ten ; labor comes on at what would have been the tenth menstrual period had not pregnancy occurred. A much simpler rule given by Tarnier is this: Count nine calendar months from the cessation of the flow, and add five days. Or we may add five days to the date when the flow stopped and count back three months. Thus, a woman ceased to menstruate on the fifteenth of February, now adding five to fifteen, we have the twentieth of the month, and then counting back from the twentieth of February three months, we find that the twentieth of November is the proba- ble day of labor. An objection to the plan of counting the duration of the preg- nancy from the duration of the menstrual cycle arises from the fact that in many women this is not a uniform period, often varying from one month to another, and it certainly is very different in dif- ferent individuals. According to such plan, the woman who men- struates every three weeks, ought to have her pregnancy end in two hundred and ten days, while another whose period may happen to be thirty-one days, would have her pregnancy protracted to three hundred and ten days. " Quickening" has been by some regarded as so uniformly occur- ring at four months and a half, that the time of the ending of pregnancy might be determined from the time when this was ob- served. But, as previously stated, this phenomenon is not so uni- form in its time of manifestation as to give accurate guidance. 1 Professor A. R. Simpson, in referring to Harvey's statement fixing the duration of preg- nancy as 275 days, remarks, " The dates are derived only from the teachers of the Roman Catholic Church, and when their true meaning is investigated, it is found that the 25th of March was held as Lady-day in Pagan Rome, in honor of Cybele, the mother of the Babylo- nian Messiah, long before the era of our Lord; while the 25th of December was kept among many Gentile people as the birthday of the Son of that ' Queen of Heaven.' " 218 SCIENCE AND ART OF OBSTETRICS. In some cases it may serve to correct an error that has been made in regard to the time at which the last menstruation occurred, and may assist in forming a probable conclusion as to the time when labor will occur. While it is usual to speak of predicting the day of confinement, it should be remembered that the prediction is only a probable one, and indeed that the day when labor occurs is most frequently one just before or just after this. Precocious Births.—La Motte has given the history of a woman who was delivered of a child seven months after marriage ; her hus- band suspected her chastity, but seven months after her convales- cence she was delivered again, greatly to the relief of the husband's mind ; her daughters married, and each of them was delivered at seven months. He also mentions another case in which marriage took place the day that the bride left the convent, and just seven months subsequently labor occurred ; after recovery she again be- came pregnant, and this pregnancy also lasted only seven months. Both children lived. One of these cases was quoted by Depaul, and he observed that while precocious births are generally admitted, the unanswerable facts proving them are very rare. The late Dr. Hodge taught that in many instances strong and healthy children are delivered before the usual time. The same belief was expressed by Spiegelberg. Nevertheless it cannot be reasonably asserted that a child born, for example, at seven months will present the development of one born at nine months.1 The former will be feeble, its weight and length will be less than normal, and the biparietal diameter measures the same number of centimetres as that of the months of pregnancy. Ronaldson2 has reported a case of "early viability," the child being born six calendar months and nine days after coition. The French law recognizes as legitimate a child born six months (180 days) after marriage ; but while this is a legal viability, yet it is quite exceptional for a child born before the completion of seven months to live, and even when born then, very great care is generally necessary to preserve its life. The nearer the time of birth approaches the normal the greater the probability of the child living. While not claiming that a child born at eight months will be as vigorous and as well developed as one born at full term ; it is not unreason- able to believe that in some cases the fcetus may develop somewhat more rapidly, its growth favored especially by abundant supply of nutriment, than in other cases, just as seeds may germinate more rapidly, or plants have their fruits and flowers earlier in one soil than in another; in other words there may be precocious births, but the boundary within which this may occur, though incapable of being defined, is probably a very narrow one. 1 It is somewhat remarkable that we have comprised within a few lines in the nineteenth book of the Iliad, not only a statement of the normal period of human pregnancv, nine months, but also an example of the successful induction of labor at less than seven calendar months, and of the prolongation of pregnancy beyond nine months in another subject. 2 Edinburgh Obstetrical Society's Transactions, vol. vi. PROLONGED PREGNANCY. 219 Prolonged Pregnancy.—Few questions in obstetrics have caused more controversy than as to whether the period of utero-gestation can be materially prolonged beyond two hundred and eighty days. It is still unsettled. As late as 1870, in a trial before the Court of Queen's Bench, upon the charge of seduction, very contradictory evidence as to the prolongation of the ordinary period of pregnancy was given by distinguished obstetricians. In the United States obstetric authorities have generally upheld the view that gestation may be prolonged. Dewees asserted that in each of four women under his observation, pregnancy lasted ten calendar months. Bed- ford stated that there is undoubted evidence that pregnancy occa- sionally extends beyond three hundred days. Dr. Hodge gave from his own practice a case in which he regarded it as certain that preg- nancy continued three hundred and two days. Warrington, appa- rently founding his opinion upon the evidence in the Gardner Peer- age case, says that some women have been pregnant ten calendar months (311 days). Meigs, after detailing Asdrubali's case, in which pregnancy was alleged to have continued thirteen months and twenty-two days, and expressing his belief in its truth, narrated the history of a pregnant woman under his own care, whose pregnancy lasted four hundred and twenty days. American physicians have reported in medical journals a few instances of protracted gestation. Among these is that of a case in which pregnancy was believed to have lasted three hundred and thirty days.1 Dr. L. A. Rodenstein has given four cases of prolonged pregnancy;2 he suggests as the probable limit to this increased duration, two months. Rossie has published3 a case in which pregnancy did not end until 317 days after coition. McTavish4 gives a case in which he believes pregnancy lasted 318 days, and Maur,5 one of 334 days. It has been in this country judicially decided that pregnancy may last 317 days. Thomson has recently reported a case in which pregnancy lasted three hundred and seventeen days from the last menstruation, or three hundred and one from the last coition.6 Some of the most eminent of foreign physicians have held that prolonged gestation may occur. Naegele, in his well-known work, asserts that there are undoubtedly cases in which the pregnancy has lasted 300 days and even longer. The late Dr. Churchill7 said : "Dr. Montgomery relates two cases in his work, one of which came under my observation ; in the first, the gestation continued 291 days, and in the second, forty-one weeks and two or three days at least." He adds to this statement, that the question being one chiefly of authority, positive evidence must infinitely outweigh mere negation. Spiegelberg8 has remarked that the variations in pregnancy lie 1 Boston Medical and Surgical Journal, May. 1859. 2 American Journal of Obstetrics, June, 1882. 3 American Journal of Obstetrics, Jan. 1886. 4 New York Medical Journal, April, 1889. 5 Ibid., May, 1889. 6 London Obstetrical Society's Transactions, vol. xxvii. 7 Theory and Practice of Midwifery. 8 Op. cit. 220 SCIENCE AND ART OK OBSTETRICS. chiefly between the 265th and the 280th days ; cases in which a fcetus has matured in a shorter time are rare, somewhat more fre- quent are those in which birth took place after 280 days. Indi- vidual conditions certainly have an influence upon the pregnancy, thus primiparous and legitimate pregnancies end earlier than their opposites. He also refers to the dependence of the duration of the pregnancy upon the menstrual cycle, as pointed out by Cederschojold and Berthold, and hence variations in individuals according to their menstrual periods ; there may be also variations in the same person in different pregnancies. Winckel, from his own study of cases in which pregnancy followed a single cohabitation, and from the ob- servations of others, reaches the following conclusion: The average duration of pregnancy is about 280 days ; it may vary, however,, from 240 to 320 days, and perhaps even exceed this latter limit, and such excess is by no means so rare as was formerly supposed, for in 6.8 per cent, the duration is over 300 days. So, too, Olshausen1 has recently stated that the duration of pregnancy should not be restricted to 300 days, but the limit should be advanced to 320 or 325 days. On the other hand, Stoltz takes the position that pregnancy can- not be prolonged more than fifteen days ; Depaul, referring to the French law making a child legitimate born 300 days after the departure or death of the husband, considered the limit very large; Kleinwachter denies prolonged pregnancy; Dr. Robert Barnes holds that a pregnancy lasting 300 days is highly improbable; and Tarnier states that it is impossible to admit an intra-uterine preg- nancy passing the highest limit of normal pregnancy unless some obstruction at the cervix prevents delivery. That labor may be delayed for a few weeks, is the belief of many obstetricians from their personal observations. Thus, in illustration, it is not uncommon for a woman, in most cases a primigravida, who passes the time at which her delivery, counting from her last men- struation, was expected, and then after a delay of two, three, or even four weeks falls in labor; the labor is tedious, a large head, its ossi- fication further advanced than is usually found at birth, is to be moulded; in some cases the forceps must be used, but whether the child be delivered spontaneously or artificially, it weighs consider- ably more than the average, and not unseldom is stillborn. Delore mentions an instance of a primigravida whose gestation lasted a month beyond the usual period ; Duncan, one of a multigravida in whom the pregnancy also lasted a month over time, the child weighed ten pounds and four ounces, and the placenta two pounds. Schroder quotes the case reported by Rigler, as " a very conclusive one" in proof of prolonged pregnancy. A woman four weeks after the expected term, gave.birth to a dead male infant, weighing ten pounds and a quarter, the hair and the nails were well developed, and the placenta weighed more than three pounds. Cases of this kind will be admitted by most as proving the prolongation of pregnancy. Such facts, belonging so generally to 1 Centralblatt f. Gyniikol . 1889. PROLONGED PREGNANCY. 221 personal experience, have more weight than an appeal to the uniformity of Nature's laws. The argument drawn from occasional instances of prolonged pregnancy in some of the inferior animals, also has weight in sustaining the view that this is not impossible in the human female. For example, the average duration of pregnancy in the cow is 282 days, but the time may be prolonged to 321 days. Reese, in his excellent manual,1 takes the ground that it is pos- sible for human pregnancy to be prolonged beyond the usually admitted normal period, but that the question how far beyond is more difficult to answer, though the greater the amount of the deviation, the stronger and more convincing should be the proofs. He further endorses the statement of Taylor to the effect that we must "be prepared to admit either that conception may in some cases be delayed for so long a period as five to seven weeks after intercourse, or that there may be a difference of from five to seven weeks in the duration of pregnancy." In regard to the question of a perfectly matured child being born prior to the normal period of pregnancy, he criticises the evidence given by the late Sir James Simpson in an English case, in which the legitimacy of a child was made to depend upon the period of the mother's gestation, 259 days, Sir James testifying that it was impos- sible for a child perfectly matured to be born three weeks before the usual term. I am indebted to James P. Baker, Esq., of Indianapolis, for the following presentation from a legal standpoint of the duration of pregnancy: The period of gestation is frequently a matter of judicial inquiry, particularly in bastardy proceedings, and in controversies among heirs, affecting legitimacy. Lord Coke, who was one of the great masters of the common law, in his work upon Littleton, written nearly three hundred years ago, held that nine months, or forty weeks, is the longest time allowed. Mr. Hargrave, in his edition of Coke upon Littleton, at page 123 b, carefully reviewed the law, and came to a different conclusion. In summing up, he said: " The precedents, therefore, so far from corroborating Lord Coke's limitation of the ultimwn tetnpus pariendi, do, upon the whole, rather tend to show that it hath, been the practice in our courts to consider forty weeks merely as the more usual time, and consequently not to decline exercising a discretion of allowing a longer space where the opinion of physicians, or the circumstances of the case have so required. In the course of our inquiries into the subject of this note we were curious to know the general sentiment of that eminent anatomist, Dr. Hunter, on three interesting questions. These were, What is the usual period of a woman's going with child ? What is the earliest time for a child's being born alive ? and What is the latest? " Dr. Hunter's answer was as follows : " 1. The usual period is nine calendar months ; but there is very commonly a difference of one, two, or three weeks. 2. A child may be born alive at any time from three months ; but we see none born with powers of coming to manhood, or of being reared, before seven calendar months, or near that time. At six months it cannot be. I have known a woman bear a living child, in a perfectly natural way, fourteen days later than nine calendar months, and I believe two women to have borne children alive in a natural way, above ten calendar months from the hour of conception." Mr. Hargrave's note has been frequently quoted by the courts up to the present Text-book of Medical Jurisprudence and Toxicology. 222 SCIENCE AND ART OF OBSTETRICS. time, and is still regarded as a sound exposition of the law. The question may arise, Which Dr. Hunter gave the above reply ? Hargrave lived in London, and wrote the preface to his edition of Coke in January, 1785. Dr. William Hunter died in 1783. Dr. John Hunter, his brother, died in 1793. The note was prob- ably written near the time of the completion of Mr. Hargrave's work. It is probable, therefore, from these facts, though not certain, that John Hunter was the author of the reply. But a certainty seems to be established by Mr. Hargrave referring to Dr. Hunter as " that eminent anatomist," a designation which applied more especially to John than to William Hunter, for the latter was more celebrated as an obstetrician. Judges, like doctors, are liable to differ, and the decisions of courts have not been entirely harmonious as to the period of gestation. In the case of O'Brian 7'. The State ex rel. Swift, 14th Ind. 469, the Supreme Court of Indiana say : " Those who have investigated the subject, know that in the course of nature, a child living and capable of surviving to the ordinary age of man, may be born in seven, and may not be born until the expiration often months from the cessa- tion of the catamenia indicating the time of its conception." The case of Duck v. The State ex rel. Dill, 17th Ind. 210, was a prosecution for bastardy. In such a case the question always is, " Is the defendant the father of the child ?" Any evidence tending to show that any other man is the father is admissible. The child was born on September the 18th, 1858. On the trial the defendant offered to prove that the relatrix had had sexual intercourse with another person in the first week of November, 1857. The evidence was rejected. The Supreme Court held that this evidence was rightly rejected, and said: " It is true, experience proves that the period of gestation is almost as variable in individual cases, though within narrow limits, as that of the length of human life, but the longest period we have ever known to be judicially allowed was 313 days. See the case of Commonwealth v. Hoover, 3d Clark, Pa. 514. In the case at bar the evidence might have covered a period of 322 days." A still longer time was judicially allowed, however, in the case of the United States v. Collins, tried in the U. S. District Court for the District of Columbia in 1809, and reported in Cranch's Circuit Court Reports, vol. 1, page 592. The case was an indictment for not supporting a bastard child. The mother was received as a witness. The attorney for the government objected to the cross-examination as to her connection with other men than the defendant. The Court overruled the objection, but limited the time of inquiry to a period of not more than twelve months nor .less than six months before the birth of the child. This is an extreme case. In Paul 7/. Padleford, 16 Gray (Mass.), 263, a bastardy prosecution, the Court refused to allow proof of acts of intercourse of the plaintiff with other persons than the defendant, at a time more than ten months and twelve days before the birth of the child. In Phillips v. AJilen, 2d Allen (Mass.), 453, the Court said: " The child was born in eight months after the marriage, and the fact that a child is born thus soon after the husband had first access to the wife does not prove beyond all reasonable doubt that the child is not his. There are ancient decisions that gestation somewhat more than nine months after the husband could have had access to the wife, does not disprove the legitimacy of the child. See Hargrave's note to Coke's Litt. 123 b, where these decisions are cited, and where in support of them the testimony of Dr. Hunter is introduced, expressing his opinion that gestation often varies from one to three weeks from nine calendar months, and that children are sometimes born in seven months from conception, and live and grow to manhood." In Eddy v. Gray, 4 Allen (Mass.), 435, which was a bastardy prosecution, the Court below had admitted testimony tending to show illicit intercourse by the complainant with other men than the defendant at a period of time more than ten months before the birth of the child. The Court said : " Such testimony, in the absence of proof that the period of gestation extended beyond the usual duration according to the common and natural course of life, which is recognized as well by legal as medical authorities, is inadmissible, and should have been excluded. See Co. Litt. 123 b, and note by Hargrave." In the recent case of Ronan v. Dugan, 126 Mass. p. 176, a prosecution in bas- tardy, the Supreme Court of Massachusetts say : MISSED LABOR. 223 " In cases of this kind, the admissibility of evidence of illicit intercourse of the complainant with any other man than the defendant, depends upon the relation to the time when the child was born. In Eddy v. Gray, 4 Allen, p. 435, where the intercourse offered to be proved occurred more than ten months before the birth the evidence was held to be inadmissible, without proof that the period of aestation was prolonged beyond the usual duration. We see no reason why the same rule should not be followed where the intercourse offered to be proved took place less than seven and a half months before the birth, in the absence of the proof that the birth was premature." In such a case the Tennessee Code limits the inquiry between the first of the tenth and the first of the sixth month next before the birth of the child. See Crawford v. The State, 7 Baxter, 41. Wharton, in his work on Evidence, at section 344, says: " The court will take judicial notice of the ordinary periods of gestation, so as to assume the non-legitimacy of children born ten months after intercourse, or when prior non-intercourse is proved five months after the act of intercourse." At section 1300 he says : " The time of conception is determined by the Roman practice by reckoning backward from the time of birth ; and the rule is that there must be not less than one hundred and eighty-two days and not more than ten months to establish legitimacy. German jurists have continued to maintain the minimum of one hundred and eighty-two days. In our own practice the question of legitimacy, when a child is born on either side of the usual limits of parturition, is deter- mined on the testimony of experts; though in cases beyond question, the court may determine what is notorious as a part of the ordinary laws of nature." After all, the light of the courts in this matter is reflected light. Physicians must determine the matter; and if the space between the minimum and maximum periods, hitherto allowed, is shown to be too long or too short, the courts will readily follow the truth as it is made manifest. Missed Labor.—This term, introduced by Dr. Oldham, is applied to those cases in which a fcetus dying after the period of viability has been reached, is retained in the uterus for weeks, or even months, beyond the time when pregnancy ordinarily ends. In these cases nature makes an effort at the normal time to expel the con- tents of its cavity, but the effort fails, and the pregnancy continues an indefinite period until those efforts are renewed successfully, or the contents are removed by artificial means. CHAPTER VI. THE MANAGEMENT OF PREGNANCY. Woman only escapes being sick twelve times a year by having an illness which lasts nine months, was the assertion of a once famous French litterateur. Though, of course, rejecting this statement and denying that gestation is a disease, we must admit that it has many discomforts, and in numerous instances causes great liability to pathological conditions, and in some these conditions are mani- fested. The remarkable changes that occur in the organism or in the organs of a pregnant woman may open the way for maladies which are manifested during or subsequent to the pregnancy. It is advisable therefore that all care, and even precautions, be taken to ward off threatened dangers, and to conduct the subject safely through her pregnancy, both in her own interest and in that of her offspring.1 The conduct of pregnancy includes hygienic and medical care. Hygiene of Pregnancy.—This relates to food, clothing, air, exer- cise, rest, sleep, bathing, care of the breasts, and to the mental con- dition. Food.—In many cases during the first months of pregnancy the disturbance of the stomach, and the less active life often consequent upon this disturbance, and in some the associated mental anxiety, lessens the desire for food. Nevertheless it is better that an effort at least be made to have regular meals, although the quantity of food taken may not be as much as usual. 1 That special care of the pregnant woman was in the early times regarded as important, is shown by the practices of many ancient people, and by the injunctions of old medical writers. The following, for example, are the directions given by Susru-fa, the earliest known medical writer of India, who lived at least fourteen hundred years before the Christian era. Many of these directions are wise, while the reason for others cannot be understood: '• The pregnant woman should avoid becoming weary, indulging in coition, sleeping in the daytime, watching at night, sorrow, climbing into a wagon, sitting upright, violent movements, phlebotomy, and long-continued exertion. Her longings must be satisfied in order that she may have a strong and long-lived child. From the first day she must be cheerfnl, pious and clean in clothing and person. She should not touch dirty or deformed objects, nor eat any dry or spoiled food. She must not go out, or remain in an empty house, or go to the holy altar, or in graveyards, or near trees; she must avoid getting angry, carrying loads, or talking too loud.'' Probably the first recorded example of the hygiene of pregnancy was given by Samson's mother when pregnant with the Jewish Hercules; she was to abstain from wine. There is reason for believing that drunkenness among the Jewish women was not uncommon at that time, or not long subsequently, as the interview between the priest Eli and Hannah, recorded in the first chapter of Samuel suggests. Furthermore, abstinence from intoxicating beverages in pregnancy is certainly a rule of prudence, while great indulgence in them, according to excellent professional authority, is very mischievous. For example, Dr. Kirk, Glasgow Medi- cal Journal, 1885, remarks : " For my part I am convinced that indulgence in alcohol beyond the most moderate extent is frequently in the last degree disastrous to a pregnant woman and her progeny." Dr. Norman Kerr, in the second edition of his work upon Inebriety, London, 1889, says in reference to the influence of alcoholism of the parents upon the child: " The mother probably is the more important factor of transmission. She exerts an influence, not only with the father THE MANAGEMENT OF PREGNANCY. 225 In some cases the morning sickness may be lessened, if not averted, by the patient having a light breakfast an hour or two be- fore rising.1 When this disorder disappears the appetite usually returns, and in some is greater than it was before pregnancy. The food should be both animal and vegetable, and especially include digestible fruits in their season ; for the latter will aid in preventing the constipation which so generally attends the pregnant condition. It occasionally happens that a woman when pregnant desires articles of food to which at other times she is indifferent; and these desires ought not to be refused, for they may express some need in her system for certain materials which are thus supplied; they are very different from the perversions of appetite which by some are imagined or assumed. It is important that the stomach be not overloaded at any time, especially in the evening. When the uterus encroaches most upon the stomach in the latter part of pregnancy, it is generally the case that only a small quantity of food can be taken at a time, and then the meals may be more frequent than usual. Alcoholic liquors ought not to be used, but the drink should be milk, water, or chocolate; those who are accustomed to coffee and tea will doubtless continue them, but these beverages should not be strong, nor taken in large quantities. Clothing.—This should be such as will not hinder the develop- ment of the abdomen and the breasts, and at the same time will protect from cold. The word enciente, meaning in Latin ungirdled or without girdle, commemorates the custom of Roman women, who, when they became pregnant, laid aside their girdle, the fascia mamillaris, and it suggests avoiding all compression of the body. Baudelocque mentions the case of a girl who sought to conceal her pregnancy by tight lacing, and thus caused a dangerous hemorrhage. The corsets should be quite loose; the garters, if tight, may cause oedema of the legs, or varicose veins. Insufficient or unseasonable clothing may lead to an acute affection of the respiratory organs attended with violent coughing, and the latter cause abortion; or sudden suppression of the perspiration occur from exposure to cold and result in albuminous nephritis. The high-heeled shoes so com- monly worn by ladies tend to increase the forward inclination of the body, and thus render more' difficult the position which a pregnant in the conception, but, in addition, during, the whole period of utero-gestation wields a special influence upon the unborn child." And again : " Considerable number of the children of female inebriates succumb to intra-uterine death. Of those who reach the period of birth, a goodly number have been so affected in the womb by the alcoholic cerebral and meningeal congestions, and other pathological states induced by alcohol, that they die from hydrocephalus or convulsions." 1 The late Professor Meigs stated: " Many of those examples that consist of nausea and vomiting during the early part of the day, but which cease after the meridian hour, may be set aside by the following method: Let a cup of coffee, with a toast, be brought to the bed- side at the earliest morning hour. The patient should be called from her sleep to take this preliminary breakfast without rising from bed. As soon as it is taken let her lie down to sleep again, if possible. It appears useless to offer a rationale of this method. I am very confi- dent, however, that, in a considerable number of persons, it will be found to put a sudden stop to the vomiting as well as to the nausea. Certainly many of my patients have been speedily, as well as permanently, cured by it, and that in very distressing instances of the nausea." 15 226 SCIENCE AND ART OF OBSTETRICS. woman must take to preserve the centre of gravity when standing or walking; they make her more liable to missteps, and thus danger of falling, thereby injuring herself or the fetus, and of jars that may cause partial detachment of the ovum. If, as is often the case in the multigravidae, the abdominal wall be greatly relaxed permitting decided anteversion of the uterus, a suitable bandage contributes very much to the patient's comfort, and by correcting the malposition of the womb assists in preventing an unfavorable presentation of the fcetus. Air.—Pure air is of especial importance for the pregnant woman, for she breathes for two, and is eliminating an increased quantity of toxic matter. A confined atmosphere has an injurious influence both upon her and upon the fcetus, and breathing air poisoned by carbonic acid may cause abortion. She should avoid all crowded halls, whether theatres, concert or ball-rooms, or churches; all poisons in the air, such as that of sewer gas or of infectious diseases, should be carefully guarded against; the room occupied in the day or in the night must be well ventilated; if possible, a part of each day ought to be spent in the open air. Exercise, Rest, Sleep.—If a woman in the first months of pregnancy suffers much from nausea and vomiting, she is little disposed to exercise; she is weak from the less amount of food taken or retained, and any movement may increase the gastric irritability. Again, toward the close of pregnancy her great size interferes with ready movement; both her condition and instinct ask for repose more than for active exertion;1 if we observe the conduct of preg- nant animals we find that as parturition draws near they are indis- posed to exertion, and spend much of their time lying down. But in woman during the intervening time daily exercise in the open air, carried to the point of slight fatigue, is one of the best means to increase her vitality and that of her offspring; her appetite is thus improved, her digestion made stronger, and refreshing sleep secured. The best exercise is given by walking, and without some special reason against it, that should be chosen rather than riding. All violent exercise, such as riding over rough roads, dancing, or lifting heavy weights, must be forbidden; so, too, prolonged exercise, causing great fatigue, and protracted journeys by land or sea, are to be avoided. Regular hours of rest are to be observed; from eight to ten of the twenty-four may be given to sleep. In women liable to abortion absolute rest is often necessary, especially at the time corresponding with a monthly period, to guard them against the danger; in some rare cases, rest in bed during almost the entire pregnancy has been required in order to avert this accident. While making these observations as to the importance of general rest, it is well to refer also to rest from sexual inter- course. Obstetric writers agree in forbidding coition when there is a liability to miscarriage, in advising it to be less frequent in other cases, and abstained from at times corresponding with 1 Stoltz. THE MANAGEMENT OF PREGNANCY. 227 monthly periods, especially the third and seventh, in one the danger of abortion, in the other that of premature labor being greatest. Among recent writers, Kleinwachter remarks that co- ition is to be restricted the first half of pregnancy, and uncondi- tionally forbidden the second half. In a recent work1 by Dr. Ben- jamin Ward Richardson, the direction is given that the bed of the pregnant woman should be occupied by herself exclusively. Dr. Richard2 says that if the human race were guided by the example of animals, and if it perfectly conformed to the advice of nature which most frequently inspires the pregnant woman with complete indiff- erence and even some aversion to marital caresses, coition during gestation would be entirely abandoned. Other writers have referred to the aversion which Richard mentions. Thus Roederer3 enumerated among the signs of pregnancy virifastidium. It is re- markable that among the signs of pregnancy given by Susru-fa, the dread of coition is mentioned. Stolz* states that women have told him that as soon as they were enceintes they had horreur du mari, some of them by this sign first knowing that they were pregnant. If the relation between husband and wife had no higher purpose than perpetu- ating the race, it is plain that sexual intercourse should cease when the vow of nature is being fulfilled ; such indulgence may cause abortion, and has been compared to ploughing the soil when the seed is germinating ; in many cases it is painful, excites or aggravates leucorrhcea, and may cause more or less reflex disorder. There is a moral side to this question. Many a wife must have less love and reverence for her husband when she, sick and suffering, or at least often wearied by the growing burden she bears, her mind a prey to anxious fears as to the issue of her pregnancy, is the victim of lust,5 a lust which has no excuse in her desires, no demand for the continuance of the race. Man does not learn that self-restraint which makes him purer and nobler, but nourishes a passion that becomes more dangerous by such exercise than it could by any voluntary conti- nence during his wife's pregnancy. Admitting that the state of society changes the instincts of nature, and that the indulgence condemned, in many cases, brings no immediate and obvious injurious physical results, it may well be questioned whether most obstetric writers have not, either tacitly or explicitly, granted a license which leads to more evil than good. Both Stoltz and Spiegelberg disapprove of sexual intercourse in pregnancy, but the former states that such disapproval is preaching in the wilderness, and the latter that it is preaching to the rocks. Nevertheless let the truth be spoken, whether men will hear or not, and let the right way be pointed out though a mul- titude may choose the wrong. 1 Preventive Medicine. 2 Histoire de la Generation. 3 Op. cit. 4 Op. cit 5 In Swift's terrible satire upon human beings, given in Gulliver's Voyage to the Houy- hnhnms, it is stated that " the she-yahoo admits the male while she is pregnant," and this is spoken of "as such a degree of infamous brutality as no other sensitive creature arrives at.'' For the following statements I am indebted to Ploss's work, Das Weib : In the majority of heathen nations sexual continence is observed during pregnancy. Among many the abstinence from coition has arisen from the belief that the pregnant woman is unclean. By the Medes and Persians cohabitation with a pregnant woman was severely punished. Among some people polygamy is based upon abstinence from coition in pregnancy. The old Hebrews and the Rabbis in the Talmud taught that coition during the first three months of pregnancy was very injurious to both the mother and child. Whoever cohabited on the ninetieth day did that which destroys human life, but the prudent Rabbi Abaja adds, " Since we cannot know this day with certainty, God preserves the simple from injury." The ancient Irans very severely punished cohabitation with the pregnant woman. The man received 2000 lashes, and was compelled to carry 1000 loads of heavy and 1000 of light wood to the fire. He must offer in sacrifice 1000 of the smaller domestic animals, and kill 1000 snakes, 1000 land lizards, 2000 water lizards, and 3000 ants, and lay 30 bridges over flowing water. 228 SCIENCE AND ART OF OBSTETRICS. Bathing.—The frequency and temperature of baths will depend upon a patient's previous habits; but usually once or twice a week is as often as a bath, cold or warm, is advisable:1 hot baths, whether of the feet or of the entire person, must be forbidden. The external genital organs should be bathed daily with cool water as a protection from erythema, and to cleanse from increased secretion which re- tained might cause irritation ; if leucorrhcea be troublesome there is is no objection to tepid vaginal injections of water, plain or medi- cated, e. g., with common salt, creolin, chlorate of potassium, or borax ; the fluid should be injected gently, used as a wash, not a douche. The late Dr. G. W. Lawrence, for many years a distinguished practitioner at Hot Springs, Arkansas, informed me that abortions have frequently been caused by the use of hot baths at this famous health resort. Tardieu,2 after referring to the universal use of baths under all forms by those practising abortion, observes that he does not know a single instance authorizing him to believe that abortion was its direct consequence. Care of the Breasts.—It has been previously stated that the clothing should be such that no compression of these organs, especially of the nipples, is permitted. If the nipple be small the woman should be taught to use her thumb and finger to draw it out, giving it suit- able form and size; this process begun some months before labor, and exercised for a few minutes each day, will often give very favor- able results. It is in the highest degree improbable that the action of the uterus could be thus excited, causing abortion or premature labor. In rare cases it may be advisable to use at first, but very gently, atmospheric pressure by means of a breast-pump, and also to wear a solid nipple-shield which protects the organ from pressure, and gives room for its development. Keeping the nipple too con- stantly, too warmly covered, renders the skin more delicate and sensitive, and therefore is to be avoided, while daily exposure to the air has, according to Delore, the beneficial effect of rendering the epidermic secretion more active. Cleanliness is important, for the secretions from the nipple and that from the gland, which occur during pregnancy in many cases, if allowed to collect, render the skin beneath very liable to become excoriated when nursing begins ; the nipples, therefore, are to be washed each day, generally with simple water, occasionally soap may be added. Bathing the nipples daily with alcoholic and astringent solutions is a common practice in pregnancy, it being believed that thereby excoriations and fissures of the nipples are prevented. But it is doubtful whether the theory is wise, or the practice justified by results. Such appli- cations effectually remove the secretion and probably lessen the activity of the sebaceous glands—thereby in some degree doing away with the protection nature gives to surfaces exposed to con- tact with liquids; and make the skin hard and stiff, which nature 1 Warm hip-baths during the last week of pregnancy are by some thought useful in facili- tating labor. 2 Etude Medico-legale sur l'Avortement. THE MANAGEMENT OF PREGNANCY. 229 meant to be soft and pliable. It would be better to use simply tincture of arnica, or bay rum, one part to three of water, if an alcoholic preparation is advisable; but in any case there should be applied to the nipple at night a small quantity of cocoa butter, Certainly the prophylaxis of acute disease of the nipple in nursing women, which so often leads to mammary inflammation, is better, more rationally sought by the simple means just mentioned, than by those in common use. Condition of the Mind.—Not only the pregnant woman's own health, but that of her child is in some degree dependent directly or indirectly upon her mental state. Her sensibility is increased, and therefore si.e should be carefully guarded against injurious impres- sions ; she should be saved all needless pain, all possible petty irri- tations, all sudden fright or shock. The exercise of a cheerful temper should be advised, as well as occupation of the mind in some useful work, in reading or study, and the society of agreeable friends, with occasional pleasant recreation. Maternal Impressions.—The question1 as to the fcetus being in- juriously affected, whether by arrest of development, malformation, or " marks," in consequence of impressions made upon the mother's mind, is one of great interest, and probably of no mean importance. These psychical conditions may be subjective or objective; that is, may originate in the patient's mind, or be made by an external cause: only in the latter case is it correct, so far as strict use of language is concerned, to speak of an impression. The belief in the former source is perpetuated in the term ncevus maternus, while almost countless illustrations of the alleged power of the latter may be found in professional literature. Dr. Barker has called attention to the fact that three of the most distinguished writers of fiction in modern times—Goethe, in his Elective Affinities; Sir Walter Scott, in the Fortunes of Nigel; and Dr. Holmes, in Elsie Venner—" have based incidents on this belief, in a way which they would not have done if they had supposed that these incidents would be rejected by their readers as improbable." It may be added to this statement, that in Redgaunllet,2 Scott, not so much by the inci- dent narrated as by the accompanying footnote, indicates his faith in this influence. Quatrefages said it has been long observed that children begotten 1 " Up to the beginning of the eighteenth century physicians adopted the opinion of Hip" pocrates, and the philosophers admitted with Empedocles, not only that strong emotions experienced by pregnant women could cause deformities of the fcetus, but also the desires or 'longings' of these women cause 'marks' of infants."—Bayard: Annales Medico-psychol- ogiques, tome troisieme. 2 Lilias, in conversation with her brother, Darsie, exclaims: "See, brother," she said, pulling her glove off, " these five blood-specks on my arm are a mark by which mysterious Nature has impressed on an unborn infant a record of its father's violent death and its mother's miseries.'' Sir Walter Scott adds the following footnote: " Several persons have brought down to these days the impressions which Nature had thus recorded when they were yet babes unborn. One lady of quality, whose father was long under sentence of death, previous to the rebellion, was marked on the back of the neck by the sign of a broad- axe. Another, whose kinsmen had been slain in battle, and died on the scaffold, to the number of seven, bore a child spattered on the right shoulder and down the arm with scarlet drops, as if of blood. Many other instances might be quoted." 230 SCIENCE AND ART OF OBSTETRICS. by a man when intoxicated often permanently present the charac- teristic signs of that state—obtuse senses, and almost entire absence of intellect. The remark of Diogenes to a stupid youth is well known: "Young man, your father was very drunk when your mother conceived you." If the temporary state of the progenitor has such an immediately powerful and permanent influence upon the germ, it is not probable that the evolution of that germ is unaf- fected by the mental condition of the mother. The belief in maternal impressions has that criterion which one of the great philosophers1 of the day regards as indicating some measure of truth—it is uni- versal and perennial. Though probably the majority of physicians are either very sceptical in regard to such influence or absolutely deny it, yet there is a large number of eminent names that can be cited as believers in it. Very interesting contributions to the subject have been made by Drs. Barker and Busey in the eleventh volume of the Transactions of the American Gynecological Society, and a valuable paper upon the question by Dr. Dabney will be found in the recently issued first volume of the Encyclopcedia of Diseases of Children. There is not space for even an imperfect discussion of the subject in this treatise, and I shall merely adduce a few of many illustrative cases that have been communicated to me, and which have never been published, suggesting to those who honestly doubt to consult the papers by Dr. Meadows,2 Drs. Barker and Busey, and by Dr. Dabney. Those who deny maternal impressions—of course, the expression is used to avoid a circumlocution—base a strong and unanswerable argument upon anatomical and physiological grounds. But let it be remembered, that when obstetric auscultation was made known, two of the most eminent of French obstetricians— Duges and Baudelocque—denied the possibility of hearing the fcetal heart through the amnial liquor, the uterine and the abdominal wall, and, so far as theoretical argument was concerned, proved their thesis. Those who believe in such impressions, acknowledge their ignorance of the way in which such impressions act; but if we ex- clude from belief all that we do not understand, our minds will be kept within very narrow limits.3 Case I.—Dr. H. Woodbury Coleman, of Trenton, N. J., has communicated to me the following history of a case under his own observation: " Mrs.----, of this city, twenty-three years old, and about two months pregnant, was one day rvery badly frightened by her son, two years old, nearly cutting off with a butcher- knife his left thumb, the member hanging apparently by but a shred. She was without any one to assist her, and dressed the injury as she best could. In two 1 Herbert Spencer: First Principles. Elsewhere, some two years ago, I quoted Lotze, one of the most eminent German philosophers of the century, as believing in the possibility of this influence. 2 Transactions of the London Obstetric Society, vol. vii. 3 In Coleridge's Table Talk, it is stated that Dr. Parr said to a person who asserted he would believe nothing which he could not understand: " Then, young man, your creed will be the shortest of any man's I know." In reference to this very question, a famous physiologist, Burdach, once said : " If we wish to deny a vital phenomenon, for the sole reason that it is impossible for us to say what are its material conditions, we must also assert that it is impossible for any quality to pass from the grandfather to the grandson, or that a child can inherit the traits, the stature, the constitution, the morbid predispositions, the talents and inclinations of the father." THE MANAGEMENT OF PREGNANCY. 23I hours I saw him, and she assisted me in that and subsequent dressing. Her mind constantly dwelt on the accident, and in due time she gave birth to a boy, who, to my great surprise, had his left thumb hanging to the hand by a thin pedicle of flesh." Case II.—I am indebted also to Dr. Coleman for the following case, occurring under the observation of Dr. Elias March, of Paterson, N. J. " In 1863 a married private in the army came home on furlough ; his left arm had been amputated near the shoulder-joint, a small stump remaining which had not yet healed, daily dressing being required, which was done by his wife. She became pregnant, and during the early part of her pregnancy her thoughts were constantly dwelling upon the condition of her husband. She was delivered at term of a child without any left arm, only a small fleshy mass attached to the shoulder-joint, resembling the amputated stump observed in her husband." Case III.—My friend, Dr. Edward P. Davis, Demonstrator of Obstetrics in Jefferson Medical College, narrates the following : "A multigravida, between two and three months pregnant, received by letter the news that an intimate friend had been injured by striking his head against the rear of a dray which presented three iron prongs or projections; these prongs caused three lacerated scalp wounds over the vertex. This pregnant woman did not see the injuries, but only had their description given her. Her child, a female, was born after a pregnancy of nearly 300 days, and is now living in good health and an adult. At birth, she was found to have upon the vertex three red, sensitive areas, exactly correspond- ing in location to the injury mentioned. These still remain, and upon them the hair has never grown." Case IV.—One of the students of Jefferson Medical College, a young gentle- man whom I believe perfectly reliable, showed me a varicose left popliteal vein; the right vein was quite normal—indeed, there were no varicose vessels to be found except the one mentioned. From his mother the following history was obtained. When she was four months pregnant, her ninth pregnancy, she was visited one day by a woman who told her how much she suffered from a swollen vein behind the left knee, and, without invitation, at once exposed it to her view. She was quite startled by the sight, and expressed her sympathy for the sufferer. When her child was born, a precisely similar condition of the vein behind his left knee was found, and, as I have said, has continued to the present. The four cases that have been narrated are more easily explained by the hypothesis of maternal impressions1 than in any other way. An ancient poet, uttering the limited knowledge of his age, de- clared that it was not known how the bones grew in the womb of her who was with child, though now an explanation is at hand, so possibly the clearer light of future science may make plain the mys- tery of the psychical action of the mother upon her unborn off- spring. But be this as it may, it is not wise to reject as resting upon old wives' fables an opinion avowed by such men as Rokitansky, Stoltz, Montgomery, Tyler Smith, and Meadows, and in this country by Fordyce Barker, Busey, Spitzka, and Dabney. Conception itself presents mysteries2 the solution of which will 1 " The singular influence thus exerted by the mind of the mother on the growth of the foetus, is not one ' for which,' as has been remarked of other modes of action of the mind upon the body, ' it is likely we shall ever be able to assign a reason, or which it would be any great hard- ship to be obliged to regard as an ultimate fact in physiology.'"—Dr. Alexander Harvey, op. cit. 2 " Is it not marvellous," says Montaigne, " that this drop of seed from which we are pro- duced should bear the impression not only of the bodily form, but even of the thoughts and inclinations of our fathers ? Where does this drop of water keep this infinite number of forms ? and how does it bear these likenesses through a progress so haphazard and so irregular that 232 SCIENCE AND ART OF OBSTETRICS. probably always elude the research of man, so that we may continue with Harvey to admire and marvel at this process.1 But in recog- nizing the fact that the fcetus may be affected through the mother's mind, we must beware of accepting most of the popular evidence given in its favor; for example, a child is born with a deformity which the mother attributes to her having seen a similar deformity while she was pregnant, but upon inquiry it is ascertained that she saw it after the stage of embryonic development in her own child had passed when its deformity resulted. Very many of the stories of the influence of maternal impressions are absurd,2 carrying with them their own contradiction, and are often suggested, or even fabricated after the birth of the child. In addition to the probable but occasional coarser proofs of the influence of maternal mental impressions upon the unborn child, as shown in monstrosities and in deformities, it is possible, nay prob- able, that very important effects are produced by the condition of the mother's mind in pregnancy which belongs to the psychical5 rather than to the physical nature, effects that are gradually made manifest in childhood, in youth, and in adult life. It not unfre- quently happens that children of the same mother differ very greatly in mental and in moral qualities, they differ in the power of acquiring knowledge, in objects of desire and pursuit, in aptitudes and accom- plishments. In some instances it is possible to trace a probable connection between these differences and, not only the condition of the mother's health during the several gestations and the sur- rounding circumstances, but also with the state of her mind during those periods. Here is opened a wide field not merely for specula- tion but for actual investigation. And the more the whole subject of human reproduction is studied with regard to the physical and mental health, and the happiness and usefulness of the offspring, the more grave and solemn the responsibility of paternity and of mater- nity will be proved. Enough is known, and enough has been said, to urge the importance of the pregnant woman living as far as pos- sible a calm, equable, and cheerful life, avoiding all intense emotion and all great excitement.* the great-grandson shall resemble the great-grandfather?'' Had Montaigne lived after the important discovery made by Ham, he would have substituted spermatozoid for " drop of seed,'' and declared the marvel vastly greater. 1 Bain has said: " The reproduction of each living being from one or two others through the medium of a small globule which contains in itself the future of a definite species, is the greatest marvel in the whole of the physical world ; it is the acme of organic complication." 2 Of course there have been, as there are many reported cases of-' maternal impressions" that only amuse by their absurdity. Burton, Anatomy of Melancholy, has mentioned several. Montaigne narrates the following: "There was presented to Charles the emperor and king of Bohemia, a girl from about Pisa, all over rough and covered with hair, whom her mother said to be so conceived by reason of a picture of St. John the Baptist, that hung within the curtains of her bed." 3 In a paper by Dr. Robert J. Lee, entitled " Maternal Impressions," published in the British Medical jfournal, 1875, the following remark is made: " It would, on reflection, appear to be most natural that maternal impression should be more frequently followed by some unnatural condition of the intellect of the child than by abnormalities of growth, and this point is worthy of particular attention." 4 Plato, in the Seventh Book of Laws, after speaking of the susceptibility of the newly born infant to impressions, remarks: '' Nay, more, if I were not afraid of appearing to be ridiculous, I would say that a woman during her year of pregnancy should of all women be most carefully tended, and kept from violert or excessive pleasures and pains; and at that time she should cultivate gentleness, and benevolence, and kindness.'' THE MANAGEMENT OF PREGNANCY. 233 The Medical Care.—Under this head it is proposed to consider briefly some of the most frequent, but usually minor, disorders of pregnancy and their treatment. Nausea and Vomiting.—The gastric irritability so generally mark- ing the early months of pregnancy is reflex. It is probably caused, in most cases, by the unaccustomed stretching of the uterine tissues, and ceases as those tissues become more relaxed and yielding. Diseased conditions of the cervix or displacement of the uterus may also be causes. The affection is usually more severe in the primi- gravida than in the multigravida, because in the former the uterine fibre yields less readily. If hygienic means fail, such as taking the morning meal in bed, iced drinks, lime-water and milk, etc., a change of scene and medical treatment may be required. Among these med- icines no one probably is more useful than tincture of nux vomica, given in doses of two to five drops three or four times a day, or oftener if necessary, especially when the smaller quantity is used. The oxa- late of cerium was highly recommended by the late Sir James Simp- son ; it may be given in five- or ten-grain doses. The tincture of aconite root, two drops three or four times a day, was very favor- ably regarded by both Dr. Meigs and Dr. Hodge. Chloral in solu- tion, either with or without bromide of potassium, may be injected into the rectum ; the dose is twenty grains. Water as hot as it can be taken, and given in teaspoonful doses—as advised by Mr. Keith for the relief of ether-vomiting after ovariotomy—will in some cases prove useful. Morphine, used either by the hypodermatic or the endermic method, is valuable; so, too, counter-irritation at the epi- gastrium. Among the great number of other means that have been recommended are water impregnated with carbonic acid, iced cham- pagne, creasote, hydrocyanic acid, bismuth, Fowler's solution, wine of ipecacuanha, belladonna, an ice-bag applied to the spine, ice or ether-spray to the epigastrium, inhalation of oxygen, and the elec- tric continuous current. Fraiport1 states that Weiss in 1884 was the first to employ the muriate of cocaine for the vomiting of pregnancy ; he advised teaspoonful doses every half hour of a solution containing 15 centigrammes to 150 grammes of water. Engelmann, of Creuznach, and Holtz used a 3-10 per cent, solution, giving 10-30 drops a day. It has been applied in solution and in ointment to the neck of the womb. Fraipont prefers the hypodermatic injection, a Pravaz's syringeful of a 4 per cent, solution being used. Antipyrine, too, is one of the recent remedies that is claimed to have some success. The valerianate of cerium has been tried as a substitute for the oxalate, being free from the impurities alleged to be usually found in the latter. Giinther, of Montreux, has been successful in five patients with electric treatment. He used the continuous current, beginning with a strength of two and a half or three milliamperes, and never increasing it to more than five ; each application was from seven to ten minutes ; the vomiting ceased in four days at most, but as some nausea remained, the treatment was continued for a few weeks. He applied the anode in the form of a sponge in a metal case covered with rubber, to the cer- vix ; the cathode, a plate four inches by five, was applied over the spine, between the eighth and twelfth dorsal vertebras. The very multiplicity of the means advised is a strong testimony to the uncertainty of the results obtained in the treatment of this disorder. 1 Revue Medico-chirurgicale des Malades des Femmes, August, 1889. 234 SCIENCE AND ART OF OBSTETRICS. In all cases obvious derangement of the secretions should be corrected, and constipation should be relieved. A strong desire for particular food or drink may be usually gratified ; one patient who rejected all food apparently the most appropriate, and could not retain even ice-water, lived for some days upon lager beer. The local treatment of the affection includes the application of belladonna to the neck of the womb (Cazeaux), nitrate of silver to the cervix when congested or inflamed (Bennet), correction of ute- rine displacements (Hewitt), leeching the cervix (Clay), digital dila- tation of the cervical canal (Copeman). Without adopting Graily Hewitt's theory of the etiology of the disorder, it is certain that in some instances the patients are cured by rectifying a malposition of the uterus. In rare cases it is advisable to give the stomach a few days' rest, nourishing the patient exclusively by rectal injections. Salivation.—This is a less frequent disorder than the preceding, but the two may be connected, and usually are when either is severe. Washing the mouth out frequently with a cold astringent solution has been commonly recommended, but is of doubtful value in a severe case. A sudden suppression of the excessive secretion may be followed by serious consequences. Baudelocque refers to a young woman who in her first pregnancy suffered greatly from sali- vation, but was refused any means for its relief; in her second preg- nancy the same symptom recurred, and means were successfully used to arrest it, but the day following she died of apoplexy. Schramm1 has reported a case of sialorrhcea in a pregnant woman cured by bromide of potassium, after the use of iodide of potassium, atropine, galvanization of the sympathetic, and hypodermatic injections of pilocarpine without any, or only temporary benefit. Constipation.—If this cannot be prevented by suitable diet, an injection of a pint of cool water may be used each morning. If medicines must be resorted to they should be mild laxatives, such as calcined magnesia, compound licorice powder, Seidlitz powder, Rochelle salts, the liquid citrate of magnesia ; a few prunes that have been stewed in an infusion of senna, eaten in the evening, will in some cases prove an efficient means of removing the constipa- tion ; so too one of the mild aperient waters, such as Hunyadi, may be used. All drastic purgatives should be avoided. If the consti- pation be associated with hemorrhoids Dr. Fordyce Barker2 advises a grain of aloes made into a pill with soap, hyoscyamus, and ipe- cacuanha and given night and morning. Cazin3 commends a pill containing one or two centigrammes of belladonna given daily, as advised by Bretonneau. Hemorrhoids.—In addition to the removal of constipation by the means just mentioned, half a pint of cold water should be injected into the rectum morning and evening, the injection being retained. When the piles protrude and are painful, they may be bathed with 1 Berlin, klin. Wochen., 1886. 2 Puerperal Diseases. 3 Archives de Tocologie, 1881. THE MANAGEMENT OF PREGNANCY. 235 warm water and laudanum, or the ointment of galls and opium may be applied. Dr. Bartholow1 speaks favorably of the following ointment, advised by Oesterlen, for hemorrhoids: Pulv. gallae, "Sj ; pulv. opii grs. x; ung. plumbi subacetat., !|)ij; ung. simplicis, oij. M. The protrusion should be reduced as soon as possible. CEdema of the Legs—Varices.—The former is in many cases a consequence of the latter. It usually disappears after lying down for a time, and is to be treated by position, by removing all constric- tion, as from garters, and by bathing with cool water. Varices, according to Budin, occur in twenty to thirty per cent, of pregnant women ; but in many cases the dilatation of veins must be very slight if there be so large a percentage ; my own observation leads me to believe that only from five to ten per cent, of women are thus affected in pregnancy. Varices of the lower limbs are treated by position and compression. Cazin2 advises the application first of an old linen bandage, and over this one of flannel extending from the toes to a point above the enlarged vessels. Some prefer an elastic stocking, but a flannel bandage is less expensive, and properly applied, more comfortable. It is to be remembered that too great compression has caused abortion. An accident to which the patient is liable, either from violent scratching, from a blow, or sometimes simply from the pressure of the column of blood in unsupported vessels, is a rupture of one of them permitting a hemorrhage rapidly fatal if the flow be not promptly arrested. The patient should be informed of this danger of rupture, and told, should this accident occur, to lie down at once and stop the flow by firmly pressing her finger upon the bleeding point. Pruritus of the Vulva.—Itching of the vulva is a symptom of various conditions, such as oedema, follicular inflammation, eczema, herpes, or prurigo, etc. It is not remarkable that the external generative organs, sharing in the increased supply of blood occurring in pregnancy, and in some cases the seat of passive congestion caused by the enlarged uterus, should be liable to some of the local affections mentioned, and which have as their most prominent symp- tom a more or less intense itching. The violent rubbing and scratching which the pruritus may cause of course aggravates the disease. The irritation sometimes extends to the vagina, but it usually occupies only the great and less lips. The vulvar inflamma- tion from which the pruritus results may be caused by a vaginal discharge. The suffering of some pregnant women from pruritus is often very great. Dewees has spoken of a woman under his charge thus afflicted, who was confined to her room during three months of her gestation, and whose only relief in her entire period was had by the nearly constant application of ice-water. He also described an aphthous eruption as present in some cases, and for this he advised a strong solution of borax; it may be used Materia Medica and Therapeutics. 2 Op. cit. 236 SCIENCE AND ART OF OBSTETRICS. for bathing the vulva, and also for injecting in the vagina, and frequently proves quite beneficial. Some patients find relief for the itching by applying to the vulva cloths wrung out of hot water. Dr. Tauszky recommends the application with a brush to the affected parts eight or ten times a day of the following solution, first suggested by Hufeland : Two drachms of powdered gum-Arabic, one of balsam of Peru, one and a half of oil of almonds, and one ounce of rose-water. Bulkley advises an ointment, made by rubbing together one drachm each of camphor and chloral, and then incorporating the mixture with eight ounces of ointment of rose-water. Doubtless cocaine in ointment or in solution would prove useful. Spiegelberg found the most reliable treatment the use of solution of corrosive sublimate, 1 to 3 times (1 : 100-200 parts of dilute alcohol), fol- lowed by the application of hot water and by chamomile hip-baths. Herpes Gestationis.—Bulkley has described this affection as begin- ning with clusters of vesicles upon the extremities, whence exten- sion to the trunk occurs. The disease does not disappear until after labor, and may recur in subsequent pregnancies ; the treatment does not differ from that usually required by herpes. General Pruritus.—This, like the last, is a comparatively rare affection. It is characterized by intense itching of the skin, without any eruptio'n being present to explain it. In a case narrated by Spiegelberg the pruritus began in the second month of pregnancy, and lasted until labor, being only partially relieved by Fowler's solution. Stoltz gives two cases. Probably arsenic or sulphur internally, and alkaline or mercurial lotions may effect slight miti- gation in some cases. The affection may be so serious, depriving the patient of rest, and causing such rapid deterioration of health and so great emaciation that the question of ending the pregnancy may be presented. Neuralgia.—This is more frequent in pregnancy than in the non- pregnant state, and may require the administration of tonics, espe- cially of quinine and iron, and the use of anaesthetics locally; in some instances the suffering requires morphine hypodermatically. Odontalgia is so common in pregnant women, and the pain may be so severe that extraction of an offending tooth is too often done, and hence the familiar adage, " for every child a tooth." Marshall states1 that softening of the dentine is not uncommon in pregnancy, and caries may result. He holds that long, tedious operations, like the restoration of form in decayed teeth with gold, are inadmissible during gestation. "All operations upon the teeth at such times should be as free from pain and fatigue as is possible, from the fact that in certain cases miscarriage might be the result." He advises as means preventive of caries a thorough and frequent use of the tooth-brush and floss silk at least three times a day, supplemented by tooth-powders and antacid mouth washes. 1 Journal of the American Medical Association, February 22, 1890. THE MANAGEMENT OF PREGNANCY. 237 Sleeplessness.—If this cannot be remedied by hygienic means— such as taking only a light supper, exercise in the open air, and a sponge-bath before retiring—and if caused by no obvious physical disorder which can be corrected, one of the alkaline bromides may first be tried alone, and should this fail chloral may be combined with it. Opium is in some cases necessary, but great care should be taken that it is not given so frequently the habit of using it is formed. The obstetrician should visit the pregnant woman from time to time, especially during the latter weeks of pregnancy, so that he may know her condition is favorable for her approaching trial. Once a week, during the last two or three months of gestation, the urine ought to be examined with reference to possible albuminuria; the examination should be made earlier if any symptoms, hereafter to be mentioned, indicate the probability of this disorder being present. Few women, if a proper explanation be given, will object to an external examination made in pregnancy for obstetric diagnosis. Certainly such examination is advisable in most cases ; and in some, if there is the least suspicion of an unfavorable presentation, must be insisted upon. Moreover, if the history of previous labors indi- cates any pelvic deformity, or there may be other reasons for sus- pecting such condition, the examination must be not only external but internal also. In lying-in institutions careful pelvic measurements are made in the case of a pregnant woman, and hence when serious deviations from the normal are discov- ered in time, appropriate means to avert danger to mother and child are taken. The pregnant woman in private practice, and her unborn child, are entitled to quite as great prophylactic care. I know that occasionally a mother perishes in labor, and her child too, because of the failure of the obstetric attendant to know in time the existence of a pelvic deformity. CHAPTER VII. THE PATHOLOGY OF PREGNANCY—INTERCURRENT DISEASES AND TRAUMATISMS. The pathology of pregnancy includes, first, those diseases or in- juries which may happen to the woman in gestation, and which affect her condition, or are affected by it, in other words, intercurrent mal- adies, and traumatisms; second, the diseases which are exaggerations of physiological conditions belonging to pregnancy, or otherwise dependent upon the pregnant state; third, affections of the sexual organs; fourth, diseases of the ovum. Intercurrent Diseases.—Pregnancy brings no exemption from acute or from chronic disease, and very often a reciprocally injurious influence is exerted by the condition and the disease. Acute febrile diseases are injurious to the foetus whenever the temperature reaches 1040 F., and remains at this abnormal height. The temperature of the fcetus being normally somewhat higher than that of the mother, it is supposed in these cases to be still greater than her abnormal temperature, and hence its danger. Nevertheless this statement as to the injurious effect of increased maternal tem- perature needs to be qualified, for, as the original conclusion rested upon experiments upon pregnant lower animals, so other experi- menters have found by similar investigations that if the heat be gradually raised, not only no harm is done to the fcetus by the tem- perature stated above, but that it can endure for a time a much higher one. The truth remains that if there be a sudden elevation of temperature, or a continued high temperature, injury is done the fcetus. In some of the acute infectious diseases hemorrhage from the internal surface of the uterus, a hemorrhagic endometritis, occurs which detaches the ovum, and is followed by abortion or by pre- mature labor. Finally, the infection may pass from the mother to the fcetus, endangering or destroying its life, and interrupting the pregnancy. Acute Infectious Diseases—Typhoid Fever.—Griesinger observed typhoid fever in five pregnant women; all aborted, and three died. In eighteen cases in the hospital at Basle, reported by Liebermeister, abortion or premature labor occurred in fifteen, and of these fifteen six died. Charpentier gives a table including 322 cases, collected from various authors; in 182 of the number abortion or premature labor occurred. He also states that when premature labor results, the child may be stillborn, or if born alive it is feeble, and death may occur, preceded by the symptoms of typhoid fever.1 1 Jaggard> American Journal of Obstetrics, 1889, thus states the causes of abortion, or pre- mature labor, in a pregnant woman suffering with typhoid fever: 1. Elevation of maternal THE PATHOLOGY OF PREGNANCY. 239 Murchison1 stated that, "according to Rokitansky and Niemeyer, pregnancy confers almost entire immunity from enteric fever; but the correctness of this opinion has been denied by Forget, Jenner, Griesinger, and others. I have met with many instances of pregnant females attacked by the disease." He regarded pregnancy as a less serious complication than is commonly supposed. The women generally miscarry, or have premature labor, but recovery takes place in the great majority. Savidan2 has collected 31 cases of typhoid fever in pregnancy, with five deaths. One of the fatal cases was complicated with the obstinate vomiting of pregnancy, and another with, probably, acute yellow atrophy of the liver. In typhus fever only about one-half abort, but the majority of these even recover. Murchison's statistics from 1862-70 include 107 pregnant women suffering from typhus under his care; 49 aborted, and nine of these died. In relapsing fever nearly all the pregnant women miscarry; the fcetus seems to be poisoned by the maternal blood. Cold baths3 and antipyrine have each been used in the treatment of typhoid fever in pregnant women, and without any injurious effect. Yellow Fever.—Millot4 notes the fact that when yellow fever ap- peared at Livourne, in 1804, the only time it has been seen in Italy, all pregnant women perished of black vomit. In general, yellow fever is one of the most dangerous of acute diseases in pregnancy. I am indebted to my friend, the late Dr. S. M. Bemiss,5 of New Orleans, for the following conclusions as to the relations of yellow fever and pregnancy: 1. Pregnancy is altogether indifferent as it regards liability to attacks of yellow fever after exposure. My observations on this point are sufficient to justify an opinion that pregnant women are neither more nor less liable to the disease than the non-gravid. 2. When pregnant women are attacked by yellow fever the danger of fatal results is so much increased, that one might almost say it is exceptional for recovery to occur. But this strong statement of danger ascribable to pregnancy is applicable to other severe epidemic visitations, and includes all cases treated in hospitals and in the various social conditions of private practice. In recalling the events which have occurred in the ordinary run of private practice in the best districts of this city, I can safely say that I have not lost over thirty-three per cent, of pregnant patients. This is something more than double the per- centage of mortality of the non-pregnant. We may therefore safely postulate the danger to the pregnant woman as being double that of the non-gravid. 3. The dangers attending pregnancy are to be ascribed to the great liability to abortion and death from hemorrhage. Perhaps liability to suppression of renal secretion and death from uraemia may also be greater. Embolism and thrombosis are quite common events in protracted cases of yellow fever, but I have no recollection of such accidents in any pregnant woman in my practice. temperature, causing death of the fcetus by insolation, or its premature expulsion by thermic irritation of the uterine musculature. 2. Hemorrhagic endometritis. 3. Depression of ma- ternal blood-pressure with asphyxiation of the child. 4. It has been proved that the bacillus of typhoid fever may pass into the blood of the foetus. 1 Continued Fevers. Third edition, 1886. 2 Paris Thesis, 1884. 3 Lyon Medical, 1887. * Op. cit. 5 Dr. Bemiss, as will be at once admitted by all who knew this excellent man and wise phy- sician, was eminently careful and conscientious in his investigations, and hence his conclusions may be readily accepted. 240 SCIENCE AND ART OF OBSTETRICS. 4. The pregnant woman, being attacked by yellow fever and recovering without miscarriage, immunity from future attacks is conferred upon the offspring con- tained in the womb during the attack. This is an extremely interesting proposi- tion. I regret that I have only three accurate observations which support it, but I believe that further investigations will confirm its truth. 5. The recently delivered woman is more liable to be attacked by yellow fever than one differently circumstanced, both being equally exposed. I cannot establish this proposition by any indisputable facts. It is a current belief among those who have observed much yellow fever, that traumatic conditions invite attacks of yellow fever. My own observations support this opinion, and more especially as it relates to the parturient woman. 6. The recently delivered woman being attacked by yellow fever, encounters an increased degree of danger nearly or quite equal to that of the pregnant woman. Intermittent Fever.—It is a mistake which some have made, to regard pregnancy as furnishing any immunity from malaria. The opposite opinion, that is, that the condition creates an increased liability to the occurrence of its manifestations, is more probable. Torti,1 Doublet,2 and Osiander' mentioned the occurrence of inter- mittent fever in pregnant women; Doublet spoke of it as quite frequent. Goth's statistics, quoted by Charpentier, show that forty-six of eight hundred and eighty-one pregnant women suffered from mala- rial attacks ; of the forty-six, five miscarried, fourteen had premature labor, and in only twenty-seven the pregnancy was uninterrupted. Bonfils4 has collected 140 cases, many of them unpublished. In very many premature labor occurred, but in very few abortion. He found that chronic malarial poisoning manifested its influence espe- cially by the death of the fcetus, and by its insufficient development. In regard to the last point, the weight of the fcetus was found to be 500 grammes under the normal, and its length ten centimetres less than the normal length. One of the curious5 facts asserted by different observers, is that the fcetus may suffer with intermittent attacks, occurring at the same time with those of the mother; in some instances the attacks have continued after birth, and in all the child had at birth an enlarged spleen. Goodell and Harris6 have " related cases in which the fcetus seemed to have been affected by the malarial poison, the mothers stating that they were aware of periodical convulsive movements of the children, their own system being apparently unaffected." In nine cases the fcetus was thought to be affected by malarial poisoning while in the uterus, according to Bonfils. The treatment of intermittent fever in pregnancy is the same, so 1 Therapeutice Specialis ad Febres Perniciosas. Venice, 1709. 2 Nouvelles Recherches de la Fievre Puerperale. Paris, 1791. 3 Beobachtungen Abhandlung und Nachrichten. Tubingen, 1787. * Paris Thesis, 1885. 5 In a recent paper by Dr. R. W. Felkin, Edinburgh Obstetrical Society's Transactions, vol. xiv., the author states that it has long been recognized tfiat a foetus in utero can suffer from a paroxysm of malarial fever, and ague-cake in the foetus is perfectly familiar to those who have practised in tropical countries. Dr. Felkin further adduces two cases to show that the mala- rial, as the syphilitic poison may be communicated from the father, the mother being entirely free from any malarial manifestations both before and after the conception of the child. 6 American Journal of Obstetrics, vol. ii. THE PATHOLOGY OF PREGNANCY. 241 far as the administration of antiperiodics is concerned, as if the patient were not pregnant. There need be no hesitation in giving quinine, for example, and giving it freely, unless some idiosyncrasy forbids its use. Dr. Henry F. Campbell1 refers to " the thousands of pregnant women who daily use the drug to prevent or break the force of paroxysms of fever," without its ever entering the mind of patient or of physician that it has any influence in interrupting pregnancy. If abortion or premature labor follow the use of quinine in malarial fever, the result is, as a rule, that of the disease, not of the medicine. Cholera.—Pregnancy neither exempts from nor predisposes to cholera. Kleinwachter states that this more frequently than any other epidemic disease attacks the pregnant woman, especially in the latter months. Abortion or premature labor is caused in about 60 per cent. According to some the fcetus, too, may have cholera. The death of the fcetus, if not due to the cause just mentioned, may be attributed to the cramps and spasmodic movements of the abdominal muscles of the mother, producing mechanical pressure ; to the absolute diet to which she is subjected ; to the loss of the serous portion of the blood, making it unfit for nutrition : some regard asphyxia as the chief, if not the sole cause of the death of the foetus; Kleinwachter conjoins with it the great loss of the water of the blood, and the lessened blood-pressure. The prognosis for the mother is also bad, but the pregnant condition furnishes no special therapeutic indications. In the statistics2 of Queirel, embracing 67 cases of cholera in pregnant women, 39 died, and 28 recovered. If abortion or prema- ture labor occurred, the mortality was about 66 per cent.; but if the pregnancy was not interrupted, the mortality was 50 per cent. Variola.—This is the most grave of acute infectious diseases which may attack the pregnant woman. According to Curschman,3 her condition causes a certain predisposition to the disease, and increases its malignancy. The danger to mother and fcetus is very slight in varioloid, but in variola, if confluent, abortion or premature labor usually occurs, and is followed by the death of the mother. If a pregnant woman has the disease, the rule is that her fcetus is also affected, and it may pass through all the stages of the disease in the uterus; in some instances it is born with the disease, while in others it is born apparently well, but is attacked soon after birth. In rare instances an apparently healthy mother gives birth to a child having variola ; Curschman explains such cases by the hy- pothesis that the mother had " variola sine exanthemate," and thus infected the child. When mother and fcetus are both affected, the disease begins earlier in the former, the latter not being attacked until the suppurative stage has begun in the mother. The disease may appear in the fcetus as early as the fourth month. In twin 1 Transactions of American Gynecological Society, vol. v. 2 Gaz. Hebdom. de Science Medicale de Bordeaux, 1887. :i Ziemssen's Encyclopaedia. 16 242 SCIENCE AND ART OF OBSTETRICS. pregnancy, one foetus may be born with the disease, while the other is entirely free from it. When the infection takes place early in pregnancy, the dead fcetus is usually expelled in three or four days, but it may remain for as many weeks. In some cases the disease is so severe that the woman dies very early without aborting or having premature labor. The further advanced a woman is in pregnancy, the greater the liability to the disease, and the greater its gravity. Vaccination of the pregnant woman, if she has not been recently vaccinated, ought to be done when there is the slightest danger of her being exposed to the poison of variola. Scarlatina.—This disease, several times observed in the puerperal, has been rarely seen in the pregnant woman. Of 141 cases collected by Oishausen, in only 7 did the disease show itself before labor. In 3 out of 16 cases1 observed by Boxall, the disease appeared in pregnant women. Nevertheless, it is probable, as suggested by Hervieux,2 after mentioning a case under his own care in which scarlatina occurred in a woman six months pregnant, and caused abortion, and a similar one observed by Dance, that a great number of other cases of the disease occurring in pregnancy have escaped being properly recorded, but from the fact that the disease caused abortion or premature delivery, have been regarded as belonging to the puerperal rather than to the pregnant state. The pregnant, as well as the puerperal condition, adds to the danger of the disease. In an epidemic of scarlatina which occurred in Vienna in 1801, abortion occurred in all pregnant women who were attacked, and the majority died. Bourgeois. One of Boxall's3 conclusions is the following : It seems possible that the poison of scarlet fever, like that of smallpox, may occasion- ally, at any rate, determine premature labor, and even before the symptoms of the disease have had time to develop. Another of his conclusions is, that if labor occurs during an attack of scarlatina, pains are apt to be feeble throughout, inertia sets in early, and there is a liability to post-partum hemorrhage. Thomas4 states that the mortality of scarlatina in adults is greatest in pregnant, in puerperal women, and in invalids. Rubeola.—The number of reported cases of measles in pregnancy is small. Gautier has collected a few,5 among which is one from Fabricius of Hildanus, having considerable interest. The patient of Fabricius was attacked by measles in the middle of the ninth month of pregnancy, and the fourth day of the disease gave birth to her child, which was covered with the eruption of measles. In a case under my own care, the patient being also in the ninth month of pregnancy, premature labor occurred the third day after the eruption appeared; the child was born apparently well, but in a few days had measles, and the disease proved fatal; the mother recov- ered. Gautier's conclusions are that the disease predisposes to 1 London Obstetrical Society's Transactions, vol. xxx., 1889. 2 Maladies Puerperales. 3 Op. cit. 4 Ziemssen's Cyclopaedia. 5 Annales de Gynecologie, 1879. THE PATHOLOGY OF PREGNANCY. 243 miscarriage by causing the death of the foetus, and that it is not without danger to the mother. Underbill's conclusions are not materially different,1 but he especially emphasizes the danger to the mother. Chronic Infectious Diseases—Phthisis.—The statistics2 of the late Dr. Austin Flint, as well as the investigations of Gaulard,3 show that a large per cent, of women become phthisical during pregnancy. The former has stated that in 11,5 per cent, of women under forty years of age who are affected by phthisis, the disease is developed during gestation, and in 13!^ per cent, soon after confinement. According to Gaulard, the puerperal state and lactation determine phthisis in at least three-fourths of the cases of the disease in women. The late Dr. George B. Wood4 taught that the occurrence of pregnancy undoubtedly, in many instances, arrests for a time the progress of the disease, and that lactation appears to exercise a favorable influence over it. He even held that the disease might be kept at bay for many years by childbearing and nursing, so that occasionally the predisposition appeared to be overcome. Dr. Flint's statistics show that in the majority of cases pregnancy does not show an unfavorable influence. Quite recently James5 has maintained that pregnancy has a favorable effect upon phthisis, but that labor and lactation are undoubtedly injurious. But, as Stoltz has said,6 it is not probable that an exhausting function which involves the entire economy will spare a diseased organ. In many cases the phthisical succumb some weeks or some days after prema- ture delivery. The cases are exceptional in which the health seems to be, or is temporarily, benefited by pregnancy. " The children born of phthisical mothers are usually feeble, often at first become scrofulous, and subsequently tuberculous."7 Syphilis.—Fournier regards pregnancy as a complication of syph- ilis:8 " It complicates it by adding to it its own peculiar anaemia, its debilitating influence, its disposition to neuroses, its disorders of nutrition, etc." Abortion or premature labor is a very common consequence of syphilis. Thus, out of 414 pregnant women at Lourcine, only 260 arrived at term. Abortion from syphilis is not produced alone in coincidence with cotemporary syphilitic mani- festations;9 it often, very often, occurs independent of all actual accident, as an isolated phenomenon, as the sole expression of the diathesis. The secondary stage of the disease is that which furnishes the greatest liability to abortion ; from the fourth month to the end of the second year is, according to Fournier, the time when syphilitic abortions most frequently occur. Thus, a woman who, being syphilitic, becomes pregnant, is more liable to abort than one who, being pregnant, becomes syphilitic. If the contagion is commu- 1 Obstetrical Journal of Great Britain and Ireland, 1880. 2 Phthisis. 3 Quoted by Charpentier. 1 Treatise on the Practice of Medicine. 5 Edinburgh Medical Journal, 1886. 6 Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, tome xvii. 7 Gaulard. 8 Lecons Cliniques sur la Syphilis, second edition, 1881. 9 Fournier. 244 SCIENCE AND ART OF OBSTETRICS. nicated at the time of the impregnation—that is, the fecundating is the infecting coition—there is great danger of abortion ; but if the poison is received after the fourth month the danger is slight, and almost nothing if the infection occurs toward the close of pregnancy. According to excellent authorities, the father may beget syphilitic offspring without the mother being affected. Again, it is held by some, Fournier among the number, that the disease may be trans- mitted by the fcetus to the mother. The antisyphilitic treatment is indicated in pregnancy if the father be syphilitic, even though the mother has had no manifestations of the disease, but still more if she has such manifestations. Sporadic Diseases—Pneumonia.—This is a much more frequent disease of the male than of the female, but in the latter has a one-third greater mortality. It is not frequent in pregnancy. Devilliers and Matton,1 however, regard the increase of fibrin in the blood as predisposing to it, but this could only be the case in the latter part of pregnancy. The disease is one of great gravity both for the mother and for the child. The high maternal tem- perature, want of proper oxygenation of the blood, and a less sup- ply of blood to the placenta explain the dangers to the foetus. A greater mass of blood in the pregnant woman to be purified, and much lessened space for its purification, indicate the danger of the disease to the mother, the lungs made hyperaemic in the effort of the right ventricle to overcome the difficulty, and possibly oedema resulting from the hyperaemia. Pregnancy is more liable to interruption the further it is advanced when the disease occurs. If abortion or premature labor occur, one-half the mothers die; but if the pregnancy continue, only one in between five and six dies. Martin2 confirms the statement of Ricau,3 derived from statistics, that a pneumonia before the one hundred and eightieth day is least dangerous for the mother and the fcetus. Ricau found that in 28 cases of pneumonia in pregnant women, 23 recovered, 6 with, 17 without miscarriage; of 15 others with pneumonia after the one hundred and eightieth day, only 8 re- covered, 5 with, 3 without miscarriage, while 7 died. Chatelain's statistics,4 quoted by Lepine, include 39 cases. In 10 abortion occurred, and in 9 premature labor was induced; of the 19, 10 died, and of the remaining 20, 10 also died, the entire mortality being nearly 50 per cent. Ricau states that when pneumonia occurs in the last three months of pregnancy, half the patients die, while death is the exception if the disease occur in the first six months. Some have advocated the induction of abortion or of premature labor in the treatment of grave cases of pneumonia. Upon theoret- ical grounds such treatment has been condemned. The evacuation of the uterus, as Kleinwachter has said, suddenly reduces the intra- abdominal pressure, but even if the diaphragm be immediately given 1 De la PuerperalitS, par le Dr. Raymond. - Zeitschrift fur Geburtshiilfe und Gynakologie, 1885. '■'■ Paris Thesis, 1874,. * Nouveau Dictionnaire de Medecine et de Chirurgie Piatiques, tome, xxviii. THE PATHOLOGY OF PREGNANCY. 245 greater range, which he doubts, with every inspiration there is a greater flow of blood to the numerous venous branches of the thorax, and also permanent increase of pressure in the pulmonary vessels, and an increased load of venous blood is thrown upon the pulmonary arteries when a considerable portion of the lung is unfit to decar- bonize the blood. Charpentier believes that the induction of labor ought not to be absolutely rejected, but reserved for special cases; but Spiegelberg absolutely rejects it in all cases.1 Pleurisy.—This disease usually terminates favorably, and does not disturb the pregnancy. But if bronchitis be associated with it, or if the pleurisy be double, abortion or premature labor may result. Nevertheless, in all cases pleurisy is a more serious disease in the pregnant than in the non-pregnant, because the effusion for the time lessens the pulmonary capacity, which is of course a greater evil to the former than to the latter. Thoracentesis has been done in pregnancy without any injurious effect upon it. Jaundice.—This disease may occur in pregnancy in either one of two forms, simple or malignant. The first, observed in the later months, is attributed by Frerichs2 to pressure of the enlarged uterus, or of the colon distended by fecal matter, upon the bile-duct. Bed- ford3 suggests that jaundice in pregnancy may sometimes be in part due to strong mental emotions. The second form of the disease, malignant jaundice, may occur much earlier than the simple form, and is dependent upon very serious structural change in the liver. Peter4 explains the jaundice of pregnancy as resulting from an exaggeration of the physiological hyperaemia of the liver. According to Tarnier, the liver of a woman dying in pregnancy or in childbed is enlarged, and there is fatty infiltra- tion between the cells. It is an organ for the elimination of ternary compounds, and its work is greatly increased in pregnancy. When the elimination is deficient, infiltration occurs. " But apart from the benign, there is a malignant jaundice of pregnant women. Some women having a benign jaundice up to a certain time, are suddenly attacked by accidents which rapidly end in death, and which characterize malignant jaundice. This jaundice is the poisoning of the organism by the accumulation in the blood of bile materials uneliminated by the diseased liver, a poisoning which I call cholemic typhisation." Acute yellow atrophy of the liver, which is present in malignant jaundice, is supposed to result from a constitutional affection. Buhl regards the hepatic disease as one of the evidences of impaired nutrition of the entire organism. Wunderlich considers the de- structive process in the liver to be caused by an acute pernicious constitutional affection. Duncan5 states that the disease is not seen oftener than once in 10,000. Its greater relative frequency in preg- nant women, and its progressing so rapidly, have been attributed to the fact that pregnancy predisposes to parenchymatous degenera- tion of the glandular organs, especially of the liver and of the kidneys. 1 " Fischl has compared the 21 cases collected by Gusserow in which premature labor was induced on account of pulmonary disease, with 21 others in which an expectant treatment was pursued ; of the former 15 women died, of the latter only 3."—Spiegelberg. 2 Clinical Treatise on Diseases of the Liver. 3 Obstetrics. 4 Clin. Medicale. ■> Clinical Lectures on Diseases of Women. 246 SCIENCE AND ART OF OBSTETRICS. The statistics of Frerichs show not only that females are more liable to the disease than males—in 31 cases, 22 were females—but also that pregnancy was a predisposing cause, one-half of those attacked being pregnant. Spaeth, finding only two cases in 33,000 pregnant women, concluded that the disease was extremely rare, But Ollivier1 has said in reply, that women suffering from jaundice in pregnancy would be received into general hospitals, and'not enter maternities, and that recent observations have shown that grave jaundice in pregnant women is not so rare as those statistics indicate. The disease has occurred as an epidemic, and is then peculiarly fatal. In nearly two-thirds of the cases abortion or premature labor occurs. Dr. J W. Underhill2 regards it "as doubtful whether a well- authenticated case of malignant jaundice occurring in gestation has recovered." On the other hand, Charpentier presents a table of 68 cases; 42 of these patients miscarried, and of these 30 died, and 12 recovered, while the remaining 26 were delivered at full term. Premonitory symptoms are observed in one-half the cases. They may precede the serious manifestations of the disease two or three weeks, but usually only three to five days ; they generally indicate acute catarrh of the stomach and bowels. The jaundice is slight, and, Duncan states, may be absent. Great nervous excitement, generally violent pain in the head, delirium, and convulsions are succeeded by prostration and stupor, and then a coma which ends in death. Abortion or premature labor usually precedes death; in some cases the disease is so rapidly fatal that the uterus does not discharge its contents. Treatment.—The mild form requires little or no medication. It may be advisable to give laxatives, and direct an occasional warm bath; in some cases diuretics to assist the eliminating action of the kidneys will be useful. In the grave form of the disease, Duncan suggests emptying the uterus as the only thing in the way of treat- ment. But Charpentier, in view of the disastrous results which have been seen to follow abortion, regards the induction of abortion, or even of premature labor, as out of the question. Cazeaux advises that the woman change her residence. But if already attacked, this change could do no good. Diseases of the Heart.—As has been previously stated, hypertro- phy of the heart is a normal phenomenon of pregnancy. But this hypertrophy involves especially, if not exclusively, the left ventricle, for, as stated by Peter, the resistances to be overcome are greater in the department of the aorta than in that of the pulmonary artery. Moreover the hypertrophy is usually transitory, disappearing after pregnancy. But it is possible, as has been suggested, that in some cases normal cardiac, like uterine involution, may be imperfect, and the persisting hypertrophy may increase with recurring pregnan- cies, especially if the recurrence be rapid. Now the tendency of 1 Archives Generales, 1873. 2 Transactions of the American Gynecological Society, vol. vi. THE PATHOLOGY OF PREGNANCY. 247 hypertrophy of the left heart is to change the diameter of the aortic, and that of the mitral orifice, and hence valvular insufficiency may result. It is probable that a pathological condition thus induced is excep- tional. The cardiac disease in most cases is rheumatic in origin, and antedated pregnancy, but the latter reveals the former, that is to say, a crippled heart may cause no serious disturbance in the non-pregnant condition, but when pregnancy occurs it is unequal to the increased work thrown upon it, and what Peter has first called cardiopathic accidents result.1 The pregnant woman's heart, it has been said, beats for two, as her lungs breathe for two. "There is consequently greater pressure in the vascular system of these organs, a necessary congestion, and this new anatomical condition resulting from the needs of haematosis for two gives a satisfactory explanation of the suffocations which some pregnant women ex- perience, and of the pulmonary hemorrhages which occur in others." Peter says that not only is the blood-distribution interfered with, but also the blood-making by the cardiac lesion, and hence the nutrition of the fcetus is doubly compromised, for it receives with greater difficulty a blood which is more imperfect. In fourteen cases reported by him, the form of lesion in almost all was mitral insufficiency with or without stenosis, and once only in the fourteen was there aortic insufficiency. The time when gravido-cardiac acci- dents begin, or become very intense, is from the third to the sixth month, generally in the fifth. According to MacDonald,2 serious symptoms do not usually appear until after the middle of pregnancy ; they are apt to be aggravated by exposure to cold or by exertion, and patients suffering from severe cardiac lesions almost always are delivered prematurely. While the statistics of observers confirm the statement of Peter as to the lesion being more frequently mitral than aortic, yet they do not make the proportion so great as his statistics did. Thus Berthiot3 gives only 22 out of 36 as mitral; Porak4 found 57 mitral, 22 complex, and 13 aortic. Gravido-cardiac accidents are rarely seen in first pregnancies, but their frequency and severity increase from the second in subsequent pregnancies. The danger from cardiac disease is greatest, probably, in labor;5 after labor the disorder is lessened. The greatest danger occurs when the cardiac lesions are complex. The lesions ranking next in point of peril are mitral; MacDonald and Porak regard mitral stenosis as presenting the greater, mitral insufficiency the less risk. Aortic insufficiency is extremely dangerous in the latter months of pregnancy and in labor, but provided the delivery is safely accomplished, the threatening symptoms disappear. The liability to abortion or to premature labor, and to hemorrhage, is 1 Maladies du Coeur, et de la Crosse de 1'Aorte, 1883. 2 Chronic Disease of the Heart in reference to Pregnancy and Parturition. t 3 Grossesse et Maladies du Coeur. 4 Quoted by Charpentier. 5 Murray estimates that in 22,000 labors, of 282 deaths independent of septic disease, 16 were from diseases of the heart. American Journal of Obstetrics, 1889. 248 SCIENCE AND ART OF OBSTETRICS. very great in the cardiopathic. The placenta is in some cases dis- eased. Hygiene and Treatment.—Peter states that a woman with disease of the heart had better not marry. If she is married, she ought not to be a mother. If she has once or twice become a mother with impunity, she ought not to have another pregnancy. If safely de- livered, she ought not to nurse her child. Medical Treatment.—In mitral stenosis the tincture of strophanthus has been especially commended by Edinburgh obstetricians.1 In general the treatment will be symptomatic during pregnancy, espe- cially regulating the various secretions, and directing easily digested food. Obstetric Treatment.—Berthiot advises auscultating the heart of a pregnant woman, so that if disease be discovered means may be taken to guard against its accidents. If serious accidents arise before the child is viable, it is justifiable to empty the uterus, and still more is this action right if the period of viability has been reached. Wessner states that in the Berne maternity 25 women suffering with cardiac disease passed through 95 parturitions, and only one died. Winckel, quoting these statistics, says they corre- spond with his experience, and rejects artificial interruption of preg- nancy in the treatment, because we cannot be sure of success, and because " this proceeding entails injurious physical excitement and local irritations, and particularly because it is not certain that the mother's suffering will be relieved by it." When labor occurs, either spontaneously or artificially, art should, as far as can be done with- out violence, replace uterine and voluntary effort in effecting de- livery. Hart,2 in the management of the third stage of labor in a patient suffering from mitral stenosis, rejects the use of ergot, and regards a free discharge of blood as favorable. If the circulation becomes embarrassed, push strophanthus and dry-cup over the heart: bleed the patient from the arm if the latter fail. Disease of the heart does not necessarily contra-indicate anaes- thesia in labor. Macdonald3 claims that chloroform is useful, in that it prevents bearing-down efforts. Vergely, quoted by Dutertre,4 states that cardiac diseases do not forbid the use of an anaesthetic in labor, and chloroform acts as a sedative to the heart in these affec- tions, and may be given prudently. Chorea—This affection, much more frequent in the female than in the male—the proportion, according to Simon, being three to one— is seldom seen in pregnancy. In 1868 Barnes5 could find but 56 cases of chorea as a complication of pregnancy. Fehling, in 1874, found 68 cases. Charpentier remarks that in 1600 deliveries at the Clinique there were but two cases of chorea, but recently he has seen a third, in which, however, the disease appeared after delivery. 1 Edinburgh Obstetrical Society's Transactions, vols. xiii. and xiv. 2 Edinburgh Obstetrical Society's Transactions, vol. xiii. s Op. cit. ' * De l'Emploi du Chloroforme dans les Accouchements Naturels, 1882. 5 London Obstetrical Society's Transactions, vol. x. THE PATHOLOGY OF PREGNANCY. 249 Winckel states that he has seen but one case. The liability to the disease is greater in first than in other pregnancies; the larger number of those affected are between twenty and twenty-five years of age. Chorea may occur in a first and not in a subsequent preg- nancy, or it may be manifested in several pregnancies. Previous attacks of the disease, as in childhood, create a liability to it. It usually begins in the first half of pregnancy and continues through the pregnancy ; in rare instances it continues in the puerperal state. Barnes considers the disease is chiefly dependent upon an altered condition of the blood, but states that in addition to this there is an antecedent condition, a predisposing cause, the nature of which is a matter of speculation. Spiegelberg regarded the cause of chorea, except in cases where a central lesion exists, and others of an hereditary character, as imperfectly understood : " Occasionally it is found in connection with disease of the heart and rheumatism, and possibly some of the central lesions may be connected with embolic processes consequent upon cardiac disease. In many cases no clearly defined cause can be found, and these may be considered reflex neuroses, which may be developed under the influence of pre- disposition, insufficient nutrition of nerve centres from impoverished blood, and the peripheral irritation from the sexual organs." Psychical causes—such as fear, sorrow, and anxiety—often have a marked influence in determining an outbreak of the disease, but Trousseau has recorded a case in which chorea ceased with the occurrence of pregnancy.1 Chorea may begin gradually or suddenly. In most cases the movements are bilateral, and in almost all they cease during sleep. The mortality of chorea in children is, accord- ing to See, 5.7 per cent., while according to the statistics of Wenzel, it is 27.3 per cent, in pregnant women. Spiegelberg found in 84 cases 23 deaths. Death occurs from the complications rather than from the disease itself. Chorea in many cases causes abortion or premature labor. Treatment.—The medical treatment includes tonics, the alkaline bromides, opium, hypodermatic morphine, and chloral. Wade2 nar- rates a case in which digital dilatation of the os uteri was successful in curing the patient, the pregnancy being uninterrupted. If the fetus be viable, and the usual means for the relief of the disease have been faithfully tried without benefit, the choreic movements are violent, and the patient's strength is failing, the induction of labor is generally considered by obstetricians advisable. But whether cases occur in which abortion is proper is still an unsettled question. Hysteria.—Notwithstanding the Father of Medicine advised mar- riage as the remedy for hysteria, the value of this treatment has not been confirmed by modern observation. In regard to the influence of pregnancy upon hysteria, no absolute rule can be given, but cer- tainly it does not cure it. In the earlier months the hysterical 1 Bulletin Gen. de Therap., 1846. 2 London Obstetrical Society's Transactions, vol. xxii. 25O SCIENCE AND ART OF OBSTETRICS. attacks are usually more frequent and severe, while in the later months the opposite is often seen. Raymond1 states that the hys- terical may pass through labor without suffering as a common fict which has been mentioned by a number of authors. Epilepsy.—In some cases of epilepsy the convulsive attacks during pregnancy are less frequent, but after the pregnancy ends they re- sume their former frequency ; in others no change is observed, while in still others the attacks are more severe. In one case under my own care the attacks were less severe and frequent during the preg- nancy, but after puerperal convalescence they resumed their former frequency and severity. Traumatism.—This includes injuries, whether accidental or inten- tional, received by the pregnant woman, and surgical operations per- formed upon her. The subject has been especially studied in recent years by Cohnstein,2 Gueniot,3 Verneuil,4 Mann,5 and Tiffany. It presents two aspects, the influence of traumatism upon the preg- nancy, and that of pregnancy upon the traumatism. In considering the first of these topics one cannot but be struck by the fact that pregnant women have endured very severe accidents or grave surgical operations without the pregnancy being interrupted. Thus fractures of the lower limbs, of the pelvis, and even of the vertebral column have occurred in pregnancy, and miscarriage was not produced. In one instance a woman seven months pregnant jumped from the third-story window to the pavement, breaking her legs and her arms, but labor did not ensue until the normal time. Amputation of limbs, disarticulation of joints, ovariotomy, herni- otomy, removal of a diseased breast, and amputation of the cancerous vaginal cervix have been done without affecting the course of the pregnancy. On the other hand, minor operations upon the rectum or the anus, upon the perineum or the vulva, and slight accidents, have been followed by abortion. Cohnstein states that penetrating wounds of the abdomen caused by falling on a fork, by injury from a scythe, or from the horn of a bull, even though the uterus be intact, usually arrest pregnancy. If the pregnancy was not interrupted, the wounds have healed readily; in that reported by Fricke cicatrization took place after sixteen days. Three cases of gunshot wounds of the pregnant uterus are given in the writer's contribution to the International Fjicyclopcedia of Surgery, these cases being reported by Richard, Staples, and Hays. The pregnancy was arrested in all; in one a living child was born, and all the mothers recovered. Gueniot's conclusions as to the influ- ence of traumatisms upon pregnancy are as follows : 1. The harmlessness of traumatism in pregnancy is not governed by any abso- lute law. 2. A traumatism, if the woman be without morbid predisposition, she, her ute- rus, and the ovum healthy, is generally without injurious effect upon the preg- nancy. 1 Op. cit. 2 Ueber Chirurg. Op. bei Schwang. 3 Annales de Gynecol., tome vi. 4 International Encyclopaedia of Surgery, vol. i. 5 Transactions of American Gynecological Society, 1883. THE PATHOLOGY OF PREGNANCY. 251 3. If gestation be complicated with a pathological condition, such as abnormal irritability of the uterus, disease, or great size of the ovum, albuminuria, etc., the traumatism, however slight, and whatever the part involved, most frequently causes premature expulsion of the ovum. 4. Great caution is advisable in performing surgical operations during preg- nancy. Gueniot further states that a surgical operation involving the genital zone is, except in urgent cases, contra-indicated by the state of gestation. Sir James Paget1 states that while, on one hand, it would be mere recklessness to operate on a pregnant woman with- out good cause, yet if good cause for operation exists she may be treated very successfully. Verneuil gives several important rules to guide the surgeon in deciding as to an operation during pregnancy ; he also strongly condemns operating during the puerperal state. In case of danger, he advises operating during pregnancy; and, under opposite circumstances, postponing interference until a period suffi- ciently remote, two to four months, from delivery. Among Mann's conclusions are the following : Operations on the vulva cause little danger to the mother or the child, while those on the bladder are not at all dangerous. Operations on the vagina are likely to cause severe hemorrhage, but are not otherwise dangerous, while those upon the rectum involving the anal sphincter are. Operations upon the perineum and upon the cervix may be done in the earlier months of pregnancy with a fair prospect of success. Notwithstanding the results derived from Mann's statistics, it is safer to postpone until after puerperal convalescence all operations, whether involving the sexual organs or not, unless there be an urgent necessity for operating, as, for example, in some cases of malignant disease or of ovarian tumors. Tiffany, from a consideration2 of the relations between pregnancy and operative surgery, presents ten conclusions, the first and last of which are the following : Pregnancy is a physiological condition, and does not contra-indicate a surgical operation. When a surgical operation upon a pregnant woman is under consideration, the functions of all the patient's organs must be carefully investigated and regulated. An operation then conducted antiseptically may be expected to result as though pregnancy were not present. Clinical Lectures and Essays. 2 Maryland Medical Journal, January, 1889. CHAPTER VIII. THE PATHOLOGY OF PREGNANCY {continued)—DISEASES THAT ARE EXAGGERATIONS OF PHYSIOLOGICAL CONDITIONS OF, OR OTHERWISE DEPENDENT UPON, PREGNANCY. Hyperemesis: obstinate, incoercible, uncontrollable, pernicious vomiting of pregnancy. The very common occurrence of some gastric disturbance in the earlier months of pregnancy has been mentioned, and also the hygienic and medical treatment of the less severe cases of the disorder given. We are now concerned with the exaggeration of this affection, an exaggeration which in some cases may be so great that not only the pregnancy but the life of the woman is imperilled. In about two-thirds of the cases of hyperemesis of pregnancy the disease begins before the end of the third month. In most patients there is at first a gradual passage of the ordinary nausea and vomit- ing into the severe form of the disorder, and the patient's stomach rejects the simplest food, liquid or solid, in a short time after it is taken. It may be you see her take even only ice-water, but with eagerness and relish, and you congratulate her upon retaining it, but her previous experience leads her to reply : " No ; it will come up as soon as it gets warm," and the event in a short time verifies the prediction. There may be copious secretion of saliva associated with the emesis, and the dribbling discharge annoys the patient night and day. Change of position, as from the back to the side, or the reverse, will often be the exciting cause of vomiting. The tongue becomes dry, the gums spongy and bleeding, the breath offensive, the thirst excessive, and the urine scanty and high-colored; the pulse is 90 to 100, or even more frequent. The inability to retain food, and the loss of rest, for even the night gives no inter- mission to, scarcely remission of, the vomiting, and the distressing nausea, result in a rapid emaciation and loss of strength ; the patient, necessarily confined to her bed, may faint upon attempting to stand, or even upon sitting up ; her face is sharp, haggard, sometimes of a dusky hue, or oftener remarkably pale; her eyes sunken, the skin frequently cold and clammy; prostrate, and almost utterly hopeless, she may be willing or eager, as relief from her prolonged and severe suffering, to welcome death, whose shadow seems to be resting upon her. In the above sketch, an endeavor has been made to represent the condition of a patient under my care a few years since. She was in her third pregnancy; the two previous ones—I was not then her physician—had been ended by artificial abortion, though the symp- toms, according to her own and her husband's statement, were not so grave as now presented. Her condition was so serious that an THE PATHOLOGY OF PREGNANCY. 253 able and estimable practitioner who saw her in consultation with me, thought that the induction of abortion furnished the only hope, and probably this had been delayed too long. Nevertheless the patient recovered. The vomiting gradually ceased in the sixth month, and at the end of the normal period she gave birth to a healthy, well-developed male child. But the result is not in all cases so fortunate. Diarrhoea may occur, and hence the emaciation and exhaustion are more rapid and extreme. The patient passes into the second stage of the disease in which the grave symptoms previously given become graver; fever is now apparent; in some there is acute pain in the head, in the epigastrium, or in one or the other hypochondrium ; "the emaci- ation is frightful, and attacks of syncope are frequent." The third stage succeeds. Vomiting usually ceases, but in some cases con- tinues, blood being mixed with the vomited matters; jaundice occurs; not alone the breath, but the body emits an unpleasant odor; the pulse is from 120 to 140, and is small and thread-like; mental disorder is shown in hallucinations and delirium, and coma closes the scene. The duration of the disease is in most cases from two to three months. Of the 118 cases collected by Gueniot, 46 died. In the third stage a fatal result is almost inevitable. The disease is, in some instances, complicated1 with pulmonary tuberculosis, intestinal catarrh, or round gastric ulcer. In some cases spontaneous abortion occurs, and if the patient be not too exhausted, convalescence fol- lows. The vomiting dependent upon the pregnancy should not be confounded with that which may be caused by albuminuria, cancer of the stomach, or tuberculous meningitis; these mistakes have been made. Causes.—The etiology of the vomiting of pregnancy, whether this vomiting be mild or severe, is obscure. Various theories have been proposed. That which has been generally received is, that the gastric disorder is sympathetic;2 that is, it is caused by sympathy between the uterus and stomach. We now substitute reflex for sympathetic, but thereby add nothing to our knowledge in explain- ing the phenomenon. The explanation most commonly received has been stated on page 233. Violent vomiting is also observed when the pregnant uterus is subject to severe internal pressure, or when the organ has become incarcerated in the pelvis. Hewitt has dwelt especially upon versions and flexions of the uterus as causes. Bennet asserts an important connection between inflammation of the neck of the womb and the vomiting of pregnancy; circumscribed inflammation of the body of the womb is a cause according to 1 Kormann. 1 The term sympathetic can be more appropriately applied to the nausea and vomiting of the husband as a consequence of his wife being pregnant, and thus suffering. Seeing another vomit, especially if there be a strong attachment for the one thus affected, and especially, too, if the vomiting be very frequent, may cause vomiting. Possibly, too, there is something to be attributed to unconscious imitation in marital vomiting. Certainly the few facts illustrating this disorder in the husband are not to be regarded as wonderful and mysterious, but admit of a very simple explanation. 254 SCIENCE AND ART OF OBSTETRICS. others; rigidity of the tissues of the cervix, or adhesion of the membranes at the internal os, are causes given by still others, While the influence of at least some of these will be admitted in individual cases, there are cases in which none of them are present. According to Lebert and Rosenthal, in some cases the nausea and vomiting are nervous, partial manifestations of a general nerve inan- ition ; and Barnes refers to the stomach as not the seat of the dis- ease,1 but " simply that of election for the discharge of superfluous nervous energy," but these are merely unproved hypotheses. Treatment.—This is dietetic, medical and surgical, and obstetric. When the vomiting is not very severe, a trial of various different articles of food may be made, as previously suggested, .with the hope that some one of them maybe acceptable to the stomach ; but if it be severe, it is better, as so strongly urged by Dr. Busey, not to allow the patient to take anything, not even a lump of ice, by the mouth, the stomach being given absolute rest. Rectal alimentation should be the chief trust. The late Dr. Austin Flint has recorded2 the case of a patient who lived sixteen months solely by this means. Dr. Henry F. Campbell thus successfully3 treated a lady for the vomiting of pregnancy, continuing the method for fifty-two days; so sanguine is he of its applicability and value that he states " under the careful and systematic application of rectal alimentation, artificial abortion for the relief of gravid nausea can be banished from prac- tice, even as a last resort." Dr. Busey advises enemata of beef-tea, bromide of potassium, tincture of opium, and brandy every four hours during the first twenty-four or forty-eight hours, and after- ward at longer intervals. At the end of forty-eight hours he begins nourishment by the stomach, using milk and lime-water. Animal broths, peptonized milk, the whites of eggs stirred in water, Leube's pancreatic meat emulsion, and defibrinated blood may also be used for injections into the rectum. Lusk4 advises that the quantity of a nutritious enema should not exceed four to six ounces, and should not be repeated more frequently than three or four times in the twenty-four hours. Unfortunately in some of the cases of grave vomiting there is already diarrhoea, and the rectum is intolerant of even so small a quantity as just advised ; or again, in other cases after these injections have been successfully used for several days, such rectal intolerance may result that this method of nourishment must be abandoned. Blundell suggested "injecting blood into the vessels in case of a high degree of weakness and irritability of the stomach and bowels.'' He referred, in sup- port of this proposed method, to an experiment he had made upon a dog, into whose jugular vein he injected every day, or every other day, for three weeks, several ounces of blood; the dog was allowed water only, and at the end of the time was in good condition. Medical and Surgical Treatment.—The chief medical and surgical means have been mentioned. In all cases of persistent and severe 1 Op. cit. 2 American Practitioner, 1878. 3 Transactions of the American Gynecological Society, vol. iii. « The Science and Art of Midwifery. THE PATHOLOGY OF PREGNANCY. 255 vomiting a vaginal examination should be made, and, where possi- ble, means at once used to correct any uterine displacement that may be present. Alkalies, antispasmodics, laxatives, or stimulants may find useful application. By some practitioners more reliance is placed upon opium, or morphine, than upon other agents. Matthews Duncan commends atropine ; Talma, of Utrecht, has recently recom- mended nitro-glycerin, one milligramme in the course of the day, given in three doses; Bailly succeeded in relieving an obstinate case of vomiting in pregnancy, by applying to the dorso lumbar region Chapman's rubber bag filled with ice-water, and a blister to the epigastrium. Quite recently Kohler has cured a case of obsti- nate hysterical vomiting, by pencilling the fauces with a ten per cent, solution of muriate of cocaine; the same method might be tried with a fair prospect of occasional success in cases of pregnancy vomiting. In the surgical treatment may be included the applica- tion of nitrate of silver to the cervix, dilatation of the cervical canal, ete. (See page 234.) Gueniot, in a recent paper upon the subject, after referring to " the three organs or apparatuses concerned," viz., the uterus, which is subjected to abnormal or morbid excitement, the nervous system, spinal and ganglionic, which from reflex power transmits the excite- ment, and the stomach, which is the agent and seat of chief symptoms, sums up the principles of treatment nearly as follows: 1. Remove the excitement of the uterus by remedying the pathological states causing it. 2. Diminish the activity or suppress the exaggeration of reflex transmission. 3. Combat the intolerance of the stomach. Obstetric Treatmetit.—As these patients generally recover, pro- vided the exhaustion be not too great, when the womb is emptied, the induction of abortion or of premature labor may be necessary. The proportion of recoveries after one or the other event is given by Gueniot as two-thirds; and among those who die, the death of some is to be attributed to delay in the operation. The induction of premature labor in a case of hyperemesis that persists in spite of the best treatment, and imperils life, need not cause the least hesitation on the part of the practitioner. But the question of abortion is a graver one; it is the certain sacrifice of one life, and, unless abso- lutely demanded for the saving of the mother's life, is murder. No man should take so serious a responsibility as causing abortion in a case of hyperemesis, unless endorsed in his action by a qualified, conscientious consultant. But at the same time he should re- member the words of Pajot: " The true, radical treatment of inco- ercible vomiting in pregnancy is emptying the uterus." 1 Relaxation of the Pelvic Joints.—Swelling and softening of the pubic and sacro-iliac joints occur normally in pregnancy; exaggera- tion of this condition allowing decided motion is a pathological condition. The pubic is more frequently affected than either of the sacro-iliac joints; the disorder usually occurs in the latter half of pregnancy, generally in the last two months, but Moreau has men- 1 Arch, de Tocol., Oct. 1889. 256 SCIENCE AND ART OF OBSTETRICS. tioned a case in which the condition began in the second month ; in this patient the relaxation continued for more than two years after delivery. Having once occurred, it may recur in successive preg- nancies. The late Professor Meigs stated that one of his patients, who had been confined twelve times, generally suffered for several weeks, in the latter part of each pregnancy, from relaxation of the pubic joint. On the other hand, one of my patients who in the latter part of her first pregnancy suffered from relaxation of the pubic and of the left sacro-iliac joints, and for nearly a year after delivery was not able to walk, passed through her second pregnancy without any manifestation of the disorder. Relaxation of the pelvic joints, first described by Hippocrates, begins gradually; there is a feeling of weakness or weariness, espe- cially after walking; this after a time is followed by pain upon ex- ertion, but, after rest, ceases. The pain may be distinctly referred to the joint affected, especially if that be the pubic, and pressure upon it by the finger shows increased sensibility. The patient will protest against exercise, unwisely advised under these circum- stances ; she will say it causes severe distress near the hips, that her steps are uncertain, and she feels as if there was something " giving way " in the pelvic bones. When she walks her steps are waddling. Barker1 states that the patient can stand with compara- tive ease, resting upon one leg or the other, but cannot balance herself upon both legs at once. Abnormal movement in the pubic joint can readily be detected by placing two fingers upon the pos- terior surface of the joint when the patient is standing, and then having her move the lower limbs alternately ; in some cases it may be recognized when the patient is lying in bed. Very frequently there are pain and numbness in the lower limbs. The joint may become very sensitive, so that the slightest movement in bed in- volving the pelvis is attended with severe suffering, and the unhappy patient is condemned to absolute repose. The relaxation having once begun increases until pregnancy ends. In some cases labor, either natural or artificial, may cause rupture, or, either in pregnancy or in the lying-in, inflammation of the joint may occur. Each of these events, however, is very rare. A guarded prognosis should be given, for while recovery is the rule, it is in some cases very slow, and in few rapid. Treatment.—Rest is of the first importance when this affection occurs in pregnancy. I am quite sure one of my patients was injured by persistent efforts to walk in the last weeks of pregnancy. A prolonged rest, too, is necessary after labor, and when the patient gets up the joints should be immobilized by a suitable apparatus. Barker states that in all cases he has seen, this immobilization has been effected by a little ingenuity in making and adapting a hip- binder of very strong, coarse cloth. Boyer recommended a girdle of leather. Snelling2 has suggested sole leather, properly moulded to the shape. Martin's girdle, according to Bailly, has in several Puerperal Diseases. 2 American Journal of Obstetrics, vol. ii. THE PATHOLOGY OF PREGNANCY. 257 instances immediately corrected abnormal mobility of the pelvic joints, and enabled the patient at once to stand and to walk. A plaster-of-Paris bandage would probably be equally efficient and more economical. Inflammation of the Pelvic Joints.—This has sometimes occurred in pregnancy, but oftener after labor; it may follow relaxation, or occur without it; the inflammation usually affects but a single joint. In very rare cases suppuration occurs; thus, Kiwisch evacuated half a pint of thick pus from the pubic joint. Hilton has narrated a case1 in which inflammation of the sacro-iliac joint followed labor; the inflammation ended in suppuration, but the pus was absorbed. Rupture of the Pelvic Joints.—This is a rare accident; it usually affects the pubic joint, but may also one or both sacro-iliac joints. It is impossible for it to occur in natural delivery, or in ordinary obstetric operations unless there be an anterior lesion. The treat- ment is rest and a firm hip bandage. Hydrcemia.—Increase in the water of the blood is a physiological phenomenon of pregnancy: excess in this increase is pathological, and is appropriately called hydremia. Stoltz2 describes the condi- tion as a serous cachexia, " a cachexia which does not differ from symptomatic dropsy, for example, that which results from organic disease of the heart, in its course and in its ordinary termination. Instead of being connected with a local organic malady, it is the consequence of a vicious composition of the blood, an exaggerated hydraemia." Cardiac disease may be present, and then the symp- toms are manifested earlier. There may be oedema of the lower limbs only, or it may become general, and there may be, in addition to serous effusion in the con- nective tissue, effusion also into the great serous cavities, especially in that of the abdomen, constituting ascites. The face is puffed, the limbs greatly swelled, the external genital organs much distended, clear, almost transparent, looking like sacs of water. The patient is incapable of exercise from the greatly swelled condition of the lower limbs, and moreover is readily exhausted by slight exertion; she suffers from palpitation of the heart and difficult breathing. In some cases the fcetus dies, and premature labor or miscarriage occurs. The urine is abundant, and contains no albumin, or only a trace of it; and therefore the condition is not to be confounded with the oedema which may occur in renal disease. In some cases the effusion into the connective tissue is so great that gangrenous patches may be formed upon the lower limbs or upon the external organs of generation. Treatment.—While we endeavor to improve the nutrition of the patient by suitable diet and the administration of tonics, especially of iron, and employ occasional derivation to the intestinal canal, or excite increased activity of the kidneys, the most immediately bene- ficial result is obtained by the use of hot baths. In using the hot 1 Pain and the Therapeutic Influence of Rest. - Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, tome vii. '7 238 SCIENCE AND ART OF OBSTETRICS. bath the temperature of the water should be 980 to iOO° F.; the patient remains in the bath for twenty minutes, and during this time drinks half a pint of hot water; immediately after coming out of the bath the skin is quickly and well dried, and she is wrapped in a warm blanket, and remains in a warm room, a copious perspira- tion lasting an hour or more is caused, and the relief is great and immediate. (Edema of the lower limbs is treated by rest in the recumbent position, or, when sitting up placing the limbs upon a chair; that of the vulva requires frequent cold bathing, possibly in some cases a compress and bandage; in either manifestation of the disease, punctures may be necessary to prevent gangrene. In ascites the effusion may be so great that it either must be removed, or the pregnancy ended; Cohnstein1 gives very decided preference to the former, and certainly this is the wiser choice. If there be serous effusion into the thorax so that there is great interference with respiration, thoracentesis should be done without hesitation, as this operation is well borne by pregnant women. Anczmia—Pernicious Ancemia—In the affection which has just been considered there is that which is designated as anaemia. But there may be such anaemia without the grave manifestations that have been described; for example, the oedema if present is only slight. In addition to the discomforts of the condition, it carries with it future dangers, especially that of post-partum hemorrhage. Hence the importance of improving the character of the blood by proper diet, by correcting any digestive disorder that may be pres- ent, and especially by giving an iron tonic ; the prophylactic treat- ment of some cases of hemorrhage after labor ought to begin in pregnancy. Pernicious anaemia is a much rarer and graver disease. In 1851 Dr. Barclay2 published the report of a case of anaemia, the disorder occurring in the puerperal state, and proving fatal the fifth month after delivery. Addison in 18553 described a grave form of anaemia, which he termed idiopathic. Lebert, in 1853, recorded cases of fatal puerperal chlorosis at Zurich, where subsequent observations were made by Gusserow and Biermer; he regarded them as exam- ples of essential anaemia. Biermer, in 1871,4 published an account of 15 cases of what he termed progressive pernicious anaemia; and Gusserow five cases of this disease in pregnant women. Coupland' collected 110 cases, 54 of the subjects being females, and in twenty of these the starting-point of the pernicious anaemia was pregnancy. Causes and Symptoms.—Malaria, insufficient or improper food, multiparity, obstinate vomiting, hemorrhage, violent emotion, men- tal shock, and diarrhoea are among the alleged causes in some cases. In other cases no explanation of the occurrence of the malady could be given. In the majority of cases the disease begins grad- ually. The face grows more and more pale, and presents a waxy appearance, in some cases it is slightly yellow, but it is not 1 Op. cit. 2 Medical Times, 1851. 1 Sydenham Society's edition of Addison's Works, p. 212. 4 Ziemssen's Cyclopaedia, vol. xvi. 5 Gulstonian Lectures, 1881. THE PATHOLOGY OF PREGNANCY. 259 emaciated, the patient retaining, for a time at least, her general plumpness of form, for as Addison remarked, there may be an actual increase in subcutaneous fat. After a time fever occurs, and then there may be some emaciation. The more prominent general symptoms are palpitation of the heart, fainting, headache, generally sleeplessness, but in some drowsiness; hemorrhages are not unusual, there may be epistaxis, or bleeding from swelled and spongy gums, the appearance being that of scorbutus ; cerebral hemorrhage has been occasionally observed, and cases of retinal hemorrhage have been frequent. Though Charpentier states the latter are rare, Quincke, quoted by Coupland,1 found such hemor- rhage in all but 7 of 31 cases; Sorensen2 found it in 10 cases out of 11 examined. The urine is abundant, contains no albumin, or only a trace, has a low specific gravity, and is light colored. Fever, called by Biermer anaemic fever, is a striking characteristic of the disease. The blood is marked by great deficiency in haemoglobin, and in case this constituent be lessened to about one-fifth the nor- mal quantity, the disease, according to Quinquaud,3 invariably has a fatal result. Not only is the quantity of the red corpuscles lowered, but here and there micrococci, moving about rapidly, are found in the blood.4 Treatment.—Good food and tonics are of first importance. Trans- fusion has been tried several times, but has rarely been beneficial; in one case the number of red globules was less forty-eight hours after than it was before the operation. Interruption of pregnancy, proposed by Gusserow, and approved by Charpentier, is condemned by Kleinwachter as hastening the usual fatal termination of the disease. In the autumn of 1856, and in the succeeding winter and spring, there occurred in Indianapolis, at that time my home, and its vicinity several cases of what physicians then termed puerperal anaemia, but which has since been described by Gusserow and others as pernicious anaemia; this conclusion, I think, will be drawn by any one who reads the appended description of the disease, and compares it with that previously given. Dr. Funkhouser,5 who treated several of these cases, read a paper before a local society, giving a narrative of them. Having myself seen two patients suffering with puerperal anaemia, and having heard the doctor's paper read, I hoped to have at least the leading facts contained in it to present in this work. But unfortunately he failed to find the paper, and in lieu of it sent me the following note : " Having been requested to furnish you with a paper upon puerperal anaemia, which I read before the Indianapolis Medical Society in 1857, and the paper having been mislaid, I will endeavor to give from memory the chief facts it con- tained. There were probably in the city about twenty cases in all of the disease, and all, or nearly all, proved fatal during gestation, in labor, or shortly after. It seemed to me that the disease manifested three forms, (1) purely anaemic, (2) scorbutic, and (3) cachectic. In all there was hemorrhage from some mucous surface, in the scorbutic from the gums. There was total anorexia ; the patients suffered from neuralgic pains, they were pallid, exsanguinous, in some cases had a jaundiced hue, and the skin had here and there purplish spots. Generally 1 Op. cit. 2 Archives Generales de Medecine, tome i., 1880. 3 Ibid., 1879. * Winckel. 5 The late Dr. Funkhouser was an esteemed practitioner of Indianapolis for nearly forty years; he graduated at Jefferson Medical College in 1847. He died July, 1886. 260 SCIENCE AND ART OF OBSTETRICS. there was irritability of the stomach, but the most striking feature was an utter aversion to food. Some of the patients had suffered with malarial fever, but in many there was no such history. In many cases premature labor occurred, and it was not uncommon for the fcetus to be dead both in such labor and in labor at term." I have merely to add to this note that the disease was chronic, having no cor- respondence in this respect with acute yellow atrophy of the liver, and that I can recall only two cases in which recovery occurred, and in each instance the recovery occupied several months. Varicose Veins.—The proportion of women who in pregnancy have varicose veins, as has been mentioned, Budin states to be twenty to thirty per cent., but Cazin1 makes the number one in twenty-one. The latter proportion, I think, from observations made at the Philadelphia Hospital, nearer correct. Varicose veins are found with almost relatively equal number in primigravidae and in multigravidae, though less distinct in the former; in the one they appear from the fourth to the fifth month, but in the others from the second to the third. The internal saphena is in most cases first affected, and in some it only is affected, but the external saphena is frequently secondarily involved. Varicose veins in the majority of cases are found only in the lower limbs, quite as often in the left as in the right; in some cases the disease exists also in the external genital organs, and in some affects them alone. Among the causes of varicose veins in pregnancy the following have been alleged: Gravitation, compression of intra-abdominal veins by the uterus, increase of blood, change in its character, and increased vascular tension. Cazin refers to the case of a cook, quoted by Chaussier, who always knew her*self to be pregnant by the development of varices in her lower limbs—this manifestation occurred in the second month ; by compressing them, she readily produced abortion. Cazin suggests from this incident that the en- larged veins act as a diverticulum for the blood plethora, which not thus provided for would affect the womb, and end the pregnancy. CEdema is liable to occur from varicose veins. It results from the internal pressure of the blood being greater than the external pressure upon the vessels. According to Hardy, pregnancy predis- poses to eczema, and this tendency is assisted by the patient's scratching the limb to relieve the itching with which a varicose part is often affected. The scratching may lead to the formation of a varicose ulcer, though this is not frequent, it having been observed but once in forty-seven cases of varicose veins in pregnancy. The treatment of the eczema, usually eczema simplex, and of varicose ulcer, are the same as in the non-pregnant condition. The most serious complication of varicose veins is rupture. If it be external, an open hemorrhage results, but if internal, and the skin unbroken, the effused blood forms a tumor commonly known as thrombus. A thrombus of the lower limbs is rare, but one of the external genital organs comparatively frequent; the latter may occur 1 Archives de Tocologie, 1880-1. THE PATHOLOGY OF PREGNANCY. 26l before, during, or after labor; the last form is most frequent. Bryant1 has reported a case in which a spontaneous, subcutaneous rupture of the internal saphena occurred in a pregnant woman, with the formation of a thrombus on the inner side of the thigh. Cazin met with a similar case, only the rupture was not spontaneous, but caused by violence. The treatment of thrombus is rest, with cold applications to the swelling. The effused blood is usually absorbed, but in occasional instances suppuration occurs. Rupture of a vari- cose vein with external hemorrhage has occurred from straining at stool, from lifting a heavy weight, standing for a long time, or a pro- longed walk, and by a fall or a blow, or from scratching a varicose ulcer. In some cases, however, the rupture has occurred without obvious cause, for example when the patient was in bed and asleep. If the opening be from a large vessel, and the bleeding be not promptly arrested, death comes very quickly. Several fatal cases have been reported. It should be remembered, in explanation of the rapidly mortal result that the blood comes not only from the distal, but also from the cardiac side of the opening in the vein. In some cases in which there was serious hemorrhage without death resulting, abortion or premature labor followed. A pregnant woman who has varicose veins ought to avoid all those causes which may lead to rupture, such as being costive, carrying heavy loads, standing long, etc. She should lie down a part of each day, and if the veins are very much enlarged, she may wear a flannel bandage when up. She should further be advised as to the best means for arresting the flow, i. e., immediate and firm pressure upon the bleeding point. The professional attendant called to a case of hemorrhage from the rupture of a varicose vein of one of the lower limbs, will in most cases succeed in permanently stopping the bleeding by the application of a compress and bandage. Should this treatment fail, a needle is passed into the skin on one side of, then beneath, the bleeding vessel, and finally through the skin on the other side; a figure-of-8 ligature is firmly applied to the projecting ends of the needle; Cazin suggests a serre- fine if the opening be small. Albuminuria.—Authorities differ very widely as to the frequency of albuminuria in pregnancy. Dumas, uniting the statistics of Blot, Hippolytte, Meyer, Abeille, Moricke, and Petit, makes the propor- tion of pregnant women whose urine contains albumin 1 to 5 or 6. Gillette,2 30 per cent.; Van Arsdale and Elliott, 1 in 56; Barker,3 4 per cent. "Out* of 200 cases in the Guy's Hospital Charity, in which the urine was tested about the time of labor, albumin was found in only four, and two of these appeared to be cases of chronic Bright's disease." In observations at the Philadelphia Hospital I have not found the urine albuminous in more than six per cent. Meyer5 found in 1124 pregnant women albuminuria in 61, that is, 5.4 per cent., and 22 of these had casts, 2 per cent. 1 Medical Times and Gazette, 1850. 3 Ibid. 5 Archives of Gynaecology, 1889. 2 American Journal of Obstetrics, vol. xi. 4 Galabin's Manual of Midwifery. 262 SCIENCE AND ART OF OBSTETRICS. Albuminuria occurs more frequently in primigravid;e than in mul- tigravidae ; according to Litzmann, it is the rule in twin pregnancies; it is more frequent in the late than in the early months of preg- nancy ; Petit found that in one-fifth of albuminuric mothers the weight of the child was above the average. Causes.—A woman who is suffering with chronic renal disease may become pregnant, and hence the albuminuria; the disease simply continues. Another may, in her pregnancy, be subjected to some of the causes of nephritis, such as exposure to cold, and albuminuria result. But these explanations only answer for a small number of those who have albuminuria in pregnancy. Other hypotheses are necessary. These are, that the renal disorder results from the increased work thrown upon the kidneys by the pregnant state, the greater intra-vascular tension, pressure upon the renal veins by the enlarged uterus, pressure upon the ureters from like causes, and, finally, reflex irritation, this irritation arising from the uterus, and affecting the renal circulation and secretion. A few words in explanation or in criticism of the chief of these opinions may be useful: Quinquaud states that the pregnant woman excretes a greater quantity of urea than the non-pregnant—30-38 grammes in the twenty-four hours for the former, and only 22-24 f°r the latter. Such increased excretory labor would, as observed by Riviere,1 necessarily cause excessive functional hyperaemia, and the greater vascular pressure may result in albuminuria. Barnes2 holds that the albu- minuria may be simply the indication of a physiological difficulty, and the escape of albumin by the kidney may be a natural means of relieving vascular tension ; "the important researches of Dr. Mahomed point to the conclusion that the ap- pearance of albumin in the urine is the direct consequence of high arterial ten- sion." These explanations materially differ, but they have this in common—each rests upon a physiological fact, and each admits the probable conclusion that albuminuria in pregnancy is not, as indeed clinical experience has abundantly proved, in the great majority of cases attended with serious results. It is now admitted that direct compression of the renal vessels3 by the gravid uterus is impossible, and indirect compression by increased intra-abdominal pres- sure, with resulting renal venous stasis and albuminuria, has replaced the former. This hypothesis may be true in a limited number of cases, but it fails to explain the early appearance of albuminuria in a pregnant woman sometimes observed, its occurrence in multigravidae, and its usual absence in cases of abdominal tumors such as those of the ovary, though they may be as large as, or larger than, the gravid uterus at term. Halbertsma, of Utrecht, attributes to obstruction of the ureters the origin of renal disorder, this obstruction arising from the enlarged uterus; these organs are stretched, distorted, flexed or directly compressed, and hence their permeability lost in a variable degree. The experiments of Ludwig are adduced to show the low secretory tension of the kidneys, and hence a slight obstruction in the course of a ureter would cause arrest of the flow, and accumulation of urine in the corresponding renal pelvis. In autopsies made by Leyden of women dead of eclampsia the lesions usually found in the kidneys were not those characteristic of venous stasis, but a simple fatty degeneration of the epithelium. Further, many autopsies have also shown deviation of the ureters, catarrh and distention. In answer to this hypothesis, it may be first said that if the cause were so com- mon, the effect ought to be correspondingly frequent; that is, albuminuria in pregnancy should be the rule instead of a comparatively rare affection. Again, 1 Pathogenie et Traitement de 1'Auto-intoxication Eclamptique. Paris, 1888. - Obstetric Medicine and Surgery. '■'' Graily Hewitt, London Obstetrical Society's Transactions, vol. xxvi., considers pressure of the gravid uterus upon the renal veins as an important cause of albuminuria. THE PATHOLOGY OF PREGNANCY. 263 Barbour1 states that " there is only one point, on the ischium, where the ureters may be compressed, and that the chances of their compression are small; we must look elsewhere, therefore, than to a mechanical cause for the explanation of albuminuria." Winckel rejects Halbertsma's hypothesis because, first, in many autopsies of women dying in pregnancy, he has found the ureters greatly dis- tended, yet these women had not manifested the slightest tendency to eclampsia. Moreover, the conclusion is based on the assumption, certainly fallacious in many cases, that the change in the kidneys or the diminished excretion of urine is the primary factor, and the rest of the symptoms only consequences, though there are authentic cases on record in which albuminuria was entirely absent, and besides it fails to recognize the possibility of the renal disease being the result ot antecedent poisoning. That condition of the kidney described by Flaischlen as the kidney of preg- nancy is an anaemia of the organ caused directly or indirectly by the gravid uterus. Changes occur in the epithelium of the glomeruli, albumin and casts with epithelial debris are finally found in the urine. ''In kidneys otherwise normal these phenomena usually appear about the middle, or oftener toward the end of pregnancy, and occur in two per cent, of all cases; they disappear after labor, and, as rule, do not lead to chronic affections."— Winckel. Symptoms and Course.—Swelling at first of the lower limbs, after- ward more general, from serous effusion in the connective-tissue, puffiness and paleness of the face, disorders of digestion,2 disturb- ance of vision, neuralgic pains, feebleness, indisposition, and in- ability to take exercise are symptoms which ought at once to direct the practitioner's attention to the condition of the urine, which should be tested for albumin. The importance of examining the urine from time to time during the latter part of pregnancy, espe- cially if the subject be a primigravida, ought to be impressed on the practitioner's mind. If albumin is found in the secretion, then an examination with the microscope should be made, so that it may be known if there be simply congestion of the kidney, or serious struc- tural change. Another reason for repeating the examinations of the urine is that the quantity of albumin is quite variable, not only from one day to another, but from morning to evening. The albu- min may entirely disappear for a time, and then reappear in much greater amount. In many cases, probably in most, if albumin is found in notable amount in the urine of a pregnant woman, it does not permanently disappear until after labor; then its final absence occurs in most within a short time, in others it may still be found months after delivery; thus in one of my patients, who had premature labor with twins, there was some albumin in the urine even at the end of six months, after which it disappeared. Considerable and continuing albumin in the urine of a pregnant woman may threaten abortion, or premature labor, eclampsia and post-partum hemorrhage. So far as eclampsia is concerned, it should be remembered that it may occur in a woman whose urine is not al- buminous, and that a very small number of albuminurics become 1 Op. cit. = Dr. W. L. Richardson, of Boston, has especially directed attention to the importance of nausea and vomiting returning in the latter months of pregnancy, as a symptom of nephritis. American Journal of Obstetrics, 1879. 264 SCIENCE AND ART OF OBSTETRICS. eclamptics, only 1 in 35, according to Auvard. This probably indi- cates too small a number. All cases of albuminuria in pregnancy do not require direct treat- ment, for, as pointed out by Auvard, the condition may result from fever, from cachexia, or from disease of the heart, and here the indi- cation is, if possible, to remove the cause, or moderate its action. But if the disorder results from renal disease or is gravidic, and especially if the quantity of albumin is considerable, active treat- ment must be at once instituted. The most important remedies are the hot bath, free catharsis, and the milk diet. The hot bath is em- ployed once in two or three days, by the method advised when referring to the oedema resulting from hydraemia. Winckel for twenty-two years has given to every pregnant woman who had any notable albuminuria, each morning, I to 3 pills of extract of aloes and extract of colocynth, each pill containing three-fourths of a grain of each of these medicines. The diet of milk has been espe- cially advocated by Tarnier. He directs the first day one litre, a little more than a quart of milk, and two meals the first day; the second day, two litres of milk, and one meal; the third day, three litres, and half a meal; the fourth day, four litres of milk, or as much milk as can be taken, but no other food, no other drink, and thus through the succeeding days. If the case be a grave one, and eclampsia be threatened, the absolute milk diet should be begun at once.1 Satisfactory results often, not always, follow the milk regimen. Moreover, many patients soon weary of it; they grow weak, milk disgusts them, and it is with the greatest difficulty they can be per- suaded to continue the treatment; at least they are unable to take the quantity of milk advised by Tarnier.2 While not going as far as Pajot, who says that the milk regimen has never prevented eclampsia except in a woman who would not have the disease, it must be confessed that it is not by any means successful in all cases. Routh has mentioned3 a case of eclampsia in a woman during labor, and after using chloroform without benefit, prolapse of the cord led him to place her in the knee-chest position, when the convulsions ceased, and did not return. This suc- cess suggests that it might be well to try the same position in treating the albu- minuria of pregnancy, letting the patient assume it several times a day ; and she should as much as possible avoid lying upon her back. Of course, the end ac- complished by the position is relief of renal congestion arising from pressure of the gravid uterus. Most authorities reject abortion, or the induction of premature labor in the treatment of albuminuria. Never induce labor, and 1 The value of the milk diet has been claimed by Riviere, op. cit., to depend especially upon the fact that this food leaves the least possible residue for intestinal putrefaction, such putre- faction of ordinary food leading to the formation of new toxic principles which, entering the blood, are important factors in the production of eclampsia. 2 Galabin, op. cit., in referring to the diet in albuminuria, says : " Great advantage has been found from a diet which gives the kidneys as little work as possible in excreting nitrogenous material. The indication is best fulfilled by a diet consisting of milk and starchy material, such as corn flour, sago, arrowroot, etc., alone. In chronic cases a little meat and bread may be given, but beef-tea and meat extracts should be avoided.'' This treatment may be tried in cases in which it is impossible to continue a diet exclusively of milk. 3 London Obstetrical Society's Transactions, vol. xxiv. THE PATHOLOGY OF PREGNANCY. 265 especially never abortion, for it is a practice more dangerous than eclampsia itself, is the teaching of Pajot. According to Tarnier, pregnant women suffering with albuminuria in almost all cases escape eclampsia when the milk treatment is early and faithfully pursued. Winckel rejects the interruption of pregnancy, whether by inducing abortion or premature labor, alike in albuminuria and in eclampsia. Auvard reserves such intervention for quite excep- tional cases in albuminuria, in which, notwithstanding appropriate treatment, the almost inevitable occurrence of eclampsia or the death of the patient is feared. In regard to the induction of premature labor, Thomas1 takes the position that in cases in which the urine, treated by nitric acid and heat, is almost completely coagulated—where there is excessive anasarca, the stomach, brain, and nervous system sympathize, and tendency to coma is denoted by constant desire to sleep—the con- dition calls for premature delivery. Barker2 believes that resort to this operation should be limited to those cases in which treatment has been thoroughly and perseveringly tried, without success, for the removal of symptoms of so grave a character, and there is a strong possibility that their continuance would result in the death of the patient.3 The induction of abortion or of premature labor in albuminuria, especially if there be albuminuric retinitis, will be further considered in another part of this volume. 1 New York Medical Journal, 1870. 2 American Journal of Obstetrics, vol. xi. 3 Partridge has probably gone further than anyone else, further indeed than most obstetri- cians would or should follow him in advocating the interruption of pregnancy in case of albuminuria. His words are, that " in all cases where there is a reasonable probability that chronic nephritis exists, no matter how slight the degree, pregnancy should be interrupted, just as early as gestation is known to exist." " I have induced labor in about forty per cent, of my cases of albuminuria of pregnancy.'' American Journal of Obstetrics, 1889. CHAPTER IX. ECLAMPSIA. Eclampsia—Puerperal Eclampsia—Puerperal Convulsions.—Eclamp- sia is an acute disease occurring in women in pregnancy, in labor, or in childbed, often sudden in its onset, rapid in its progress, char- acterized by convulsions, with loss of sensation and of conscious- ness, ending in coma. (Bailly.) The sudden onset is indicated by the word eclampsia, from kKldfinu, to shine out, to flash. The intimate connection in most cases between this disease and albuminuria suggests that its consideration should immediately follow that of the latter It belongs to the pathology of pregnancy rather than to that of labor, for though, according to most authori- ties, it is more frequent in the latter than in the former, it is more serious if it occurs in pregnancy. Possibly, too, as held by Bailly,1 it is really more frequent in pregnancy, for as labor generally results from eclampsia, many of the cases of the disease may have been reported as occurring in labor, and " statistics often fail in giving information as to whether labor had actually begun before the firs' convulsion." The disease is most frequent in the last months of pregnancy, though it has been observed as early as the first month. Considering eclampsia as it may occur in pregnancy, in labor, or in childbed, its frequency, according to Kleinwachter2 and Galabin,3 is one in 500 ; Kormann makes the proportion one in 600, while Cazeaux stated it one in 200. Lusk4 found one fatal case in about 700 deliveries; now it is not unreasonable to suppose that there were at least two cases that recovered from eclampsia to one that died. Again, in the five years, from 1880 to 1884 inclusive, there were, by the statistics of the Philadelphia Board of Health, 94 cases of eclampsia to 100,935 deliveries, or nearly I in about IOOO. Sup- posing, again, that there were at least two cases that recovered to one that died, the number of cases of eclampsia would be I to 333^. Corson5 met with 10 in 3036 cases of labor, that is, about I in 300. It is probable, therefore, that in this country at least the proportion is 1 to 250 or 300. Eclampsia is less frequent in childbed than in pregnancy or in labor. The attack usually occurs a few hours after delivery, but the interval may be several days, or even some weeks. Bailly saw a case twenty-nine days, Simpson four weeks, after 1 Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, tome xii. 2 Op. cit. a Op. cit. ■t " The total number of deaths from this cause reported to the Board pf Health in New York City, in the nine years from 1867 to 1875 inclusive, were 408. The estimated maximum num- ber of deliveries during that period was 284,000, or nearly 1 death to 700 confinements." The Science and Art of Midwifery. '■ New York Medical Journal, May, 1886. ECLAMPSIA. 267 labor. The disease is more frequent in primiparae1 than in multi- paras, and in plural than in single pregnancies. Premonitory Symptoms.—These occur in almost all cases. The most important are headache, disturbance of vision, and epigastric pain.2 The first is generally in the forehead, and in some upon one or upon the other side of the forehead; it is rarely in the occiput. Hamilton referred to frontal pain as especially characteristic. At first it is not continuous, but has irregular intermissions, or at least remissions; when it becomes constant the attack is at hand. It is the most frequently manifested premonitory symptom. It is not unusual, if this pain occur several days before the convulsive mani- festations, for slight mental disorder to be associated with it, gener- ally simply dulness of intellect, or apathy; the patient, too, may be either sleepless or drowsy. Disturbance of vision is observed in very many cases. This at first is usually indistinctness of sight, or inability to use the eyes for more than a few minutes at a time; the letters on the page which the patient is reading are blurred, or she cannot take the stitches in the work she is sewing in the right place; she wearies in the effort, and lays aside one or the other object. In rare cases more or less complete blindness may be pres- ent for hours, or even for days before the attack; in other instances amblyopia, hemiopia, or diplopia is manifested. Epigastric pain is the least frequent of the prodromata. If present, it may be so severe that the patient groans, or even cries out with the suffering: she leans forward to relax the abdominal muscles, and usually has, with the pain, oppression or difficulty in breathing.3 Other pre- monitory symptoms have been observed in some cases, such as vertigo, vomiting, somnolence, or insomnia, ringing in the ears, irritability of temper, and despondency. The Attack.—After a longer or shorter duration of some of the prodromata—their apparent absence in any case probably being from a failure of observation—the convulsive manifestations come abruptly. The patient lying in bed may have been talking to you one minute, the next she is silent, and you see her face in complete repose, her eyes fixed apparently upon some distant object, and her body motionless ; this is the brief calm which precedes the terrible storm. While you are looking, and possibly, if it is your first ex- perience, wondering why her speech has so suddenly ceased, the 1 In fifteen years, 1874 to 1889, 2655 women were delivered at the Philadelphia Hospital, and there were 9 cases of eclampsia, or 1 in 295. But the 9 were primiparae. I am indebted to Dr. J. L. Rothrock, one of the resident physicians at the hospital, for furnishing me with these statistics. 2 This was mentioned among the premonitory symptoms of eclampsia in the former edition. About a year since there appeared in one of the London medical journals several communica- tions upon this symptom, some writers apparently thinking it was a recent discovery, and others referred to the neglect to mention it in works upon obstetrics. Such criticism could only have been made by those whose obstetric reading was very limited or very careless. For example, Ramsbotham mentioned this symptom, and so did Jacquemier, 1846, and Chailly- Honore, 1842, and before these Denman. Ramsbotham's words are " severe cramps in the stomach." Velpeau, 1835, states, in referring to premonitory symptoms, " Denman and others have attached great importance to pain in the stomach." 3 Auvard gives as the principal prodromata disturbance of vision, epigastric pain, the con- sequence of dyspnoea, and dyspnoea the result of imperfect action of the lungs. 268 SCIENCE AND ART OF OBSTETRICS. storm begins with quick movements of the eyelids and of the nasal alae, then of all the muscles of the face. The eyelids rapidly open and close, the pupils are dilated and insensible to light, the eye- balls move in various directions, then are half hidden beneath the upper lids, the face turns slowly toward one and then to the other shoulder, the mouth is distorted, usually deviated to the left. The wave of convulsion extends to the muscles of the trunk and limbs, and a stage of tonic contraction occurs; the body is rigid and the back is arched as from opisthotonos; the lower and upper limbs are rigid and usually extended; the thumb is flexed upon the palm, and the fingers contracted over it. Bailly mentions a case in which at the beginning of numerous convulsive attacks the unhappy patient invariably raised the left arm over her face, almost in the position taken to ward off a threatened blow. The diaphragm and thoracic muscles are involved, and respiration is arrested; the livid pallor of the face is succeeded by a dusky red hue; the face is swelled and indicates asphyxia; the muscles at the base of the tongue cause this organ to protrude from the half-open mouth, and it is in many cases more or less severely bitten, and then blood mixed with saliva escapes from the mouth. The muscles of the larynx by their con- traction prevent the ready escape of air from the compressed chest, and it passes out with a hissing sound. In ten to twenty seconds clonic succeed the tonic convulsions ; these begin in the face, then affect the muscles of the body and limbs ; the jaws open and close violently and rapidly, the tongue may be again wounded; breathing is stertorous, irregular, and difficult; at each expiration frothy saliva flecked with blood may be thrown in spray over the clothing of the upper part of the body; jerking movements of the muscles of the body and limbs occur rapidly. The sudden transition from calm to storm is not more striking than the rapid' transformation of the face and expression ; the convulsions destroy every trace of beauty and intelligence that may have been present a few minutes before; the face is disfigured by " horrible grimaces," distorted, discolored, and while calling for pitiful and active sympathy, may be even hideous or repulsive. Whether the muscles of organic life are affected by convulsive movements or not, is a question in regard to which difference of opinion exists; if they are, the explanation of the passage of the feces or of urine, occurring in some cases, is obvious ; but if they are not, such evacuations are to be attributed to the convulsive action of the diaphragm and of the abdominal muscles. Braxton Hicks1 states that in one case of eclampsia, occurring in the sixth month of pregnancy, " when an attack of convulsions came on, the uterus became intensely firm, and so remained for the space of ten to fifteen minutes without any change, after which it slowly subsided into the ordinary condition of gentle contraction with relaxation." Similar phenomena were observed by him in another case. There is not an abrupt arrest of the disordered movements of the 1 Transactions of the London Obstetrical Society, vol. xxv. ECLAMPSIA. 269 clonic stage of eclampsia, but they first lessen in violence and fre- quency, then cease. Their duration is generally from one to two minutes, but it may be five minutes, and Tarnier once found it twenty minutes. According to Cazeaux, the pulse is full and strong at the beginning of the attack, but this is probably not the rule ; in either case it becomes weak, small, and almost imperceptible with the progress of the convulsive phenomena. During the attack the patient is insensible to the most powerful external excitants ; she can neither see, nor hear, nor feel. Coma or stupor follows the clonic convulsions, the duration of the coma being proportional to the severity of the attack. In most cases within half an hour after the convulsive movements have ceased, the patient wakens, at first into a sort of semi-consciousness ; she looks upon those surrounding her bed, and does not at once recog- nize them; when the recognition comes, she does not understand the anxiety which their countenances so often betray; her face has a sadly bewildered expression, the past, so far as the convulsions are concerned, is a perpetual blank, and the present a temporary cloud. In rare cases the patient's recovery immediately begins, and is rapid and perfect. But in the majority eclampsia is not limited to a single attack; other attacks generally follow, the intervals varying from a few minutes to several hours ; the attacks may be so rapid, the intervals so brief, that the patient passes directly from coma to convulsions without a moment of even partial conscious- ness intervening, The coma becomes more profound with the suc- cessive attacks. It is caused by cerebral congestion; the congestion results from the arrest of respiration, and" from the impeded return of blood from the brain arising from compression of the jugulars by convulsed muscles of the neck ; in addition to cerebral conges- tion, there may be serous effusion. The number of attacks may be only two or three, or ten to twenty, or there may be one hundred1 and even more. Charpentier refers to a case observed by Crettet, in which there were one hundred and sixty. The urine, which is usually scanty, in 84 per cent, contains albu- min ; in some cases it is smoke-colored, or red, from the presence of blood. The pulse varies in frequency from 100 to 140; even this last number may be exceeded. The temperature2 progressively in- creases during the continuance of the attacks ; it may reach 1040 F., or go even higher, and after death still greater elevation of tempera- ture is observed. 1 Pajot and Bailly have each had a patient in whom more than one hundred convulsive attacks occurred, yet both patients recovered. 2 Jean Robin (Paris Theses, 1883) remarks, in referring to the temperature in the diagnosis of eclampsia: " M. Bourneviile has shown that the temperature is progressively elevated in eclampsia and attains even after death the great degree of 1090 F." This would be a valuable sign as an element of diagnosis if met with in all cases, for nothing similar occurs in uraemia, where, on the contrary, the temperature is lowered. Unfortunately in a quite recent observa- tion, it completely failed. We see in fact that the temperature did not pass 99.5° F. (Thesis of Caix, Paris.) Winckel first called attention to elevation of temperature in eclampsia. But both in diag- nostic and prognostic value this sign is by no means constant. For example, in a case occur- ring last year under my care at the Philadelphia Hospital, and proving fatal, the temperature was usually less than 1010, only once reaching 1020 ; an hour after death it was 98.8°. 27O SCIENCE AND ART OF OBSTETRICS. Terminations—Maternal and Fcetal Mortality.—Eclampsia usually terminates within forty-eight hours, and the great majority of patients recover. Death may occur from asphyxia, during a pro- longed tonic convulsion, but this is rare; the majority of patients die during coma by a " slow asphyxia." Others die from conges- tion or cerebral hemorrhage. The eclamptic is more liable to post-partum hemorrhage and to puerperal accidents, and a number surviving the convulsions may perish in the puerperal state. " In the Guy's Charity, the mortality was 50 per cent, in cases which began before the onset of labor, 25 per cent, in those which began during labor, and only 8 per cent, in those which began after delivery, the total mortality being 25 per cent." (Galabin.) Auvard regards the mortality as 25 per cent., while Winckel states that with the improved methods of treatment of the last ten years, it is only 7 to 10 per cent. In the majority of those who do not die, recovery is complete, but in others disorder of intellect or of sense may con- tinue for a greater or less length of time; the eclampsia may end in puerperal mania or puerperal paralysis. The fcetal mortality is 50 to 70 per cent. Prognosis.—This is more favorable if the disease occurs after labor, than during, and especially before labor. It is rendered graver by the frequency and severity of the attacks, by the pro- foundness of the intervening coma, by the urine being scanty and containing much albumin, by great oedema, and by the temperature steadily increasing; it should be remembered, however, that in some cases eclampsia proves fatal though the temperature may vary little from the normal: Schroder regarded the pulse as furnishing the most important prognostic indication. As long as this remains hard and full, though moderately frequent, there is no immediate danger; but if it be frequent, small and easily compressed, the prog- nosis is almost absolutely bad. The prognosis is more unfavorable, if there be a complication, such as cardiac or pulmonary disease. Winckel states that the death of the child improves the prognosis in eclampsia occurring in pregnancy. In connection with the fact just stated it is of interest to refer to a paper1 by Barbour, the report of a case of diminution of albuminuria in pregnancy coinci- dent with the death of the fcetus. The author adduces three similar cases observed by Underhill, McLaren, and Spiegelberg. Pathological Anatomy.—Schroder, after observing that the autopsy offers little that is characteristic, states that there will usually be found cerebral anaemia, cedema, and flattening of the cerebral con- volutions, degrees of renal change varying from congestion to the most marked parenchymatous nephritis, and degeneration of the cardiac muscular tissue. But the brain may show great congestion, even apoplectic effusions. The lungs are generally affected—there may be congestion, apoplexy, oedema—and several observers have called attention to the condition of the liver. Stumpf, for example, Edinburgh Obstetrical Society's Transactions, vol. x. ECLAMPSIA. 271 has seen instances of acute yellow atrophy. Pilliet has reported1 a case of fatal eclampsia in which the post-mortem showed interstitial hepatic hemorrhage, and he quotes Jurgens as saying, " In all cases of eclampsia in which I have made autopsies, I have constantly found large hemorrhages of the liver which, in my opinion, have an important role in the pathology of the disease. They are seated in the peripheral zone, and make their way between the acini, and often destruction of the parenchyma is a consequence. The micro- scopic examination of the blood of the right heart constantly shows hepatic cells, fat and globules containing fat. In all cases of eclampsia there are fat emboli proceeding from the liver." All the theories of eclampsia may be reduced to three.2 The dis- ease is a neurosis, it results from renal disease, functional or organic, and it depends upon the blood. The last includes not only the old view that eclampsia was caused by cerebro-spinal congestion, but also the more recent one of toxaemia, and so toxaemia might be made to include the condition consequent upon renal failure; but this last hypothesis has rallied so large a number of supporters it is better that it should be considered by itself. Eclampsia is a Neurosis.—This theory was upheld by Mauriceau, and Sydenham called the disease hysteric apoplexy. But Tyler Smith, one of the ablest and most thoughtful of obstetric writers, was the eminent upholder of the theory. He declared that " the true puerperal convulsion can only occur when the central organ of this system, the spinal marrow, has been acted upon by an excited condition of an important class of incident nerves, namely, those passing from the uterine organs to the spinal centre, such excite- ment depending on pregnancy, labor, or the puerperal state." The answer to this is that eclampsia ought to be much more fre- quent in primigravidae in the early months of gestation when nervous irritability in consequence of the new condition is so great, it ought to be very much more frequent in epileptics and in hysteri- cal women, and the theory does not explain the outbreak of con- vulsions in the last three months of pregnancy, when there are no painful contractions of the uterus such as occur in labor, and when the system has accommodated itself to gestation; nor does it ex- plain convulsions occurring hours and even several days after the labor is over. The most recent3 contribution to the nervous origin of eclampsia has been made by Lantos, from material collected in the obstetric and gynecological clinic of Professor Kegmarszky at Budapesth. According to Lantos, albuminuria in the course of pregnancy and of labor, independently of all morbid changes in 1 Nouv. Arch. d'Obstet. et de Gyn., 1888. 2 Emile Blanc (Arch, de Tocol., 1889) presents investigations made by him, showing the pathogenic action of a microbe which he has found in the urine of the eclamptic. Delore first suggested that eclampsia was an infectious malady. The matter was studied by Doleris (1882-5), and he made experiments which sustained the microbian hypothesis; but, according to Blanc, in 1886 he seems to have abandoned this view, and endeavored to establish that a toxic, crys- talline substance in the blood was the cause of eclampsia. The infectious nature of eclampsia is not a probable theory, and it is quite possible that investigators are finding more microbes than can be utilized in pathology. 3 Archiv. f. Gyn., vol. xxiii. 272 SCIENCE AND ART OF OBSTETRICS. the kidneys, is not a rare phenomenon, and is even very frequent during labor. Eclampsia occurred once in 278 cases, the entire number of labors being 14,815, and 15 died—28.3 per cent. The mortality was greater after artificial delivery. He regards the disease as an acute peripheral epilepsy. The albuminuria and the eclampsia have a common origin; irritation of uterine nerves is reflected to the kidneys, and acts upon their vaso-constrictors, and thence albuminuria; or, upon the medulla, and convulsions result. It is well known that oftentimes in a case of eclampsia a convulsive seizure is coincident with a uterine contraction ; and so, too, such seizure has occurred from pressure upon the abdomen, or from vaginal examination, or from artificial dila- tation of the os uteri. Also, a few cases of eclampsia have been reported as occurring in puerperal women whose bladders were distended with urine, and catheterism cured the disease. Do not such facts prove the reflex origin of eclampsia ? Various agents may cause the explosion of a powder magazine—an electric spark not less than the blazing fire or the lighted match or the falling spark; but without the powder explosion would be impossible. Thus, in the eclamptic, when reflex irritation apparently is the cause of the convulsive seizure, there is a condition of unstable equilibrium resulting from prior cause, and that equilibrium is readily disturbed by an agent which, under ordinary circumstances, would be powerless. I am more explicit upon this point because, in the former edition of this work, I did give some credence to the reflex origin of eclampsia in certain cases, an opinion which larger study and experience lead me now to reject. Eclampsia is Caused by Disease of the Kidneys.—The renal theory finds strong support in the fact that albuminuria exists in the great majority of cases of eclampsia, and the convulsions received the name of uraemic upon the hypothesis that urea was the poison in the blood, as a consequence of renal failure, which excited them, and thus was their essential cause; the name is still retained,though none now believe in the etiology which it expresses. The relation of eclampsia to albuminuria is not constant, for the great majority of women who in pregnancy are albuminuric do not become eclamp- tic, and moreover, there is a considerable number of cases of puer- peral convulsions observed by reputable and competent men who found no albumin in the urine. It is entirely gratuitous for those who are wedded to the albuminuric theory to assert that the failure to discover albumin in such cases arises in consequence of the neglect or ignorance of the practitioner. I have seen a primipara the second day after her labor have five severe convulsions, yet the secretion of urine was abundant, and it presented only the slightest trace of albumin; these convul- sions, from which the patient recovered, could not justly be regarded as having any connection with albuminuria. That urea retained in the blood is not the cause of eclampsia is further disproved by the fact that in many cases, as stated by Winckel, there was no evidence of such retention in the most im- portant organs, especially in the liver and the muscles; on the con- trary, these contained less urea than normally, and in cases of eclampsia that recovered, the amount of nitrogen excreted in the urine was only equal to the minimum quantity excreted in a state of absolute hunger. Though urea is a poison, the quantity required to produce a lethal effect is very large. The pregnant woman nor- ECLAMPSIA. 273 mally eliminating, as has been previously stated, 30 to 35 grammes, in place of 22 to 24 grammes, at least ten days must elapse without elimination in order that intoxication can result. Finally, in uraemia the temperature does not rise, while, as a rule, in eclampsia it does. Eclampsia is dependent upon the Blood.—Here three explanations are offered; first, cerebro-spinal congestion ; second, hydraemia; and third, the blood in consequence of the failure of eliminating organs, especially of the kidneys, becomes poisoned—in a word, there is toxaemia. The first, so generally held half a century ago, with the universal advocacy of the lancet as the supreme remedy, is now so generally rejected that it need only be mentioned. The hydraemic hypothesis fails in support by clinical evidence, gives no useful guidance in therapeutics, and has been positively disproved by autopsies and by experiments upon animals. There remains, then, only the toxaemic theory for consideration. This is founded upon the fact that there are constantly developed in life-processes substances which must be eliminated, various organs being concerned in this process of elimination; if one or more of these organs fail in their function, and it is impossible for others to act vicariously, a toxaemia results; hence there is auto-intoxication. Riviere thus presents the foundation of the toxaemic theory of eclampsia : 1. The organism receives and makes without ceasing poisons, which the liver destroys in part, but which are chiefly eliminated by the cutaneous, pulmonary, intestinal, and renal emunctories. The value of these different emunctories is not the same ; the renal filter certainly enjoys the preponderating role. 2. These products of elimination are all toxic, as clearly proved by experi- ment ; but their toxicity constantly varies in the same individual according to the functional state of these different emunctories and according to diverse spe- cial conditions. 3. These poisons being multiple and of diverse origins, the intoxication pro- duced by their retention in the organism is and ought to be complex and may present several forms. 4. Eclampsia is one of the forms of this intoxication. It seems probable that failure in elimination by the skin, the lungs, and intestines cannot have the important part in the production of eclampsia that belongs to similar failure of the liver and kidneys, and possibly, as Auvard suggests, there is one renal and one hepatic eclampsia. In regard to the poison or poisons which retained in the system may cause eclampsia, we are ignorant. Winckel remarks that there are not only great differences in the degree of intoxica- tion, but probably also various poisons, or, at least, one poison aris- ing in different ways in the body of the pregnant woman, which may be the cause of the disease. In connection with this topic the observations1 of Stumpf should be mentioned. He, from original investigations, concluded that under abnormal processes of decom- position, a substance free from nitrogen, toxic in its action, perhaps acetone, or a body resembling it, reacting to the same tests, may be formed, which produces in its excretion an irritation of the kidneys that may finally cause nephritis, has a destructive effect upon the 1 Winckel. 18 274 SCIENCE AND ART OF OBSTETRICS. coloring matter of the blood, greatly alters the activity of the renal cells, causes sugar to appear in the urine and produces destruction of the parenchyma of the liver, advancing to acute yellow atrophy with the formation of tyrosin and leucin, and induces coma and convulsions from an irritation of the brain. Nevertheless he does not regard this view as applicable to all cases of eclampsia. In the etiology of eclampsia some place, but certainly not a very important one, ought to be given the greater nervous sensibility of the pregnant woman, for thus she becomes more susceptible to the action of causes acting upon the cerebro-spinal system. But still the disease should be regarded as essentially a toxaemia, the poisoning resulting from a failure of one or more eliminating organs to exercise perfectly their function. By the light of this theory, pos- sibly, we may see why in case of the death of the fcetus, if the eclamptic attacks occur in pregnancy, they cease, or if albuminuria has occurred it lessens or disappears. While the fcetus lived it was constantly throwing into the mother's blood materials which ought to be eliminated through her emunctories. But if the fcetus dies, this process no longer goes on, the mother has only to eliminate self- created poisons, and the organs concerned are adequate to this single work though they failed when the double burden was cast upon them. Influence of Eclampsia upon Pregnancy and upon Labor.—The con- tinuance of pregnancy in an eclamptic is quite exceptional, abortion or premature labor usually resulting from the disease. Even in cases in which neither occurs immediately, the fcetus usually dies, though it may not be expelled until several days afterward. The progress of the labor is usually quickened, not because of any in- creased force of uterine contractions occurring during the convul- sive phenomena, but because of the lessened resistance which accompanies the general relaxation occurring in the intervals be- tween the attacks. Diagnosis.—Premonitory symptoms usually herald the disease; in the majority of cases of eclampsia the physician can, if in previous attendance, give a probable prediction as to its coming. Hysterical convulsions will mislead only a careless observer, for the past history of the subject is different; the convulsive phenomena in eclampsia pursue a regular succession, there is order in disorder, but in hys- teria they are irregular, there seems almost a capriciousness in the movements, they may be grotesque, sometimes ludicrous, and the face presents a striking contrast with that of the eclamptic, horribly distorted by the rapid movements of clonic convulsions ; in eclampsia the convulsive movements end in coma; in hysteria they may cease with tears or laughter, or with a profuse secretion of urine. A cry heralds the onset of an epileptic attack; the history of the patient tells of previous attacks; the urine does not contain albumin; the coma is brief. If coma result from apoplexy there will be accom- panying paralysis, and the urine does not contain albumin. Treatment.—This is naturally divided into prophylactic, curative, and obstetric. So far as prophylactic treatment is concerned, there is little to be added to that advised in the treatment of albuminuria. ECLAMPSIA. 275 Prophylactic Treatment.—Especially let the value of the hot bath be empha- sized. While revising these pages I have had an illustration of the great utility of the bath in averting threatened eclampsia. A primipara, seen in consultation with Dr. Murray Cheston, was in the first stage of labor; there was almost com- plete arrest of renal action, and the patient was suffering with headache and nausea and vomiting : the scanty urine was albuminous and contained blood. She was immediately put in a hot bath, and very free perspiration with great relief to her symptoms followed; chloroform was administered during labor, which ended in a few hours with the birth of a living child. The kidneys soon resumed their function, and in a few days the albumin had almost entirely disap- peared. I believe that by the use of the hot bath as promptly beneficial effect can be had as the older practitioners had from bleeding. Free catharsis, not by salines, but by the extracts of aloes and colocynth, as previously advised, would be indi- cated. Next in importance is an absolute milk diet; milk is " a complete aliment, reconstituant, and usually digested more easily and quickly than any other," and besides, as Riviere suggests, does not leave a toxic residue in the intestines which may be absorbed, and from the blood pass to the kidneys. Curative Treatment.—During the attack the obstetrician should see that the clothing of the patient is loose, should forbid efforts, so often unwisely made, with the vain hope of restraining her move- ments, but at the same time care should be taken to prevent the possible accident of her falling from the bed; injury of the tongue must be guarded against, not by interposing cork, or rubber, or a spoon, or piece of wood between the jaws, but by stretching a soft napkin between them, from one side to the other of the mouth, so as to keep the tongue from protruding. As soon as possible, an active cathartic may be given, and also a stimulating enema. Bleeding was formerly regarded by most authorities as the essen- tial treatment of eclampsia, but in recent years it is absolutely rejected by some of the best obstetric teachers. But may there not be an error in the therapeutics of those who renounce this means, as there was on the part of those who accepted it in all cases ? Those who always bled in eclampsia were certainly wrong, but is it quite sure that those who never bleed are invariably right? It may be admitted that there are very few cases in which bleeding is advisable, but to say that there are none is, I think, going too far. It instantly removes a certain amount of toxic material from the blood, whereas elimination by different emunctories is gradual. It relieves renal congestion, which may be the immediate cause of the eclampsia, and cerebral congestion, which may be the consequence of the attack. Moreover, as pointed out by Peter, a dynamic effect, vascular contraction, results from bleeding. If there are not clinical facts proving the value of venesection in eclampsia, then the statistics adduced by Charpentier must be rejected. The teaching of Fordyce Barker upon this question, I think, may be accepted: " When the attack occurs before labor, if the pulse be strong and hard, with great fulness of the vascular system, and the appearance of the face indicates vascular congestion, bleed at once." It should be remembered, however, that whether venesection be employed before or during labor, copious depletion is not advisable, the results, according to Charpentier's statistics, being more favor- able if it be moderate. 276 SCIENCE AND ART OF OBSTETRICS. But more important than bleeding, and of general use, is chloral administered by the rectum. This remedy lessens arterial pressure and reflex excitability, and therefore meets indications clearly pre- sented by eclampsia. Thirty to forty grains, either with the yelk of an egg and six ounces of milk, or in a mucilaginous mixture, should be at once administered by rectal injection ; the remedy may be re- peated, if necessary, in two to three hours. Meanwhile the patient is to be kept completely at rest by chloroform anaesthesia, the remedy being used at the occurrence of uterine contractions, or at the slightest threatening of an eclamptic attack. These two agents, chloral by the rectum, though some practi- tioners use it by the mouth, and chloroform by inhalation, con- stitute by far the most important means in the treatment of eclampsia. Plant1 has reported a case of eclampsia occurring after delivery, in which he gave within twenty-four hours 250 grains, about 15 grammes, of chloral. In some cases even 20 grammes, or more than 300 grains, have been given within twenty-four hours. Of eight cases treated by Pinard2 at the Hopital Lariboisiere, in 1883, by chloral, only one died. The quantity of chloral administered in a single rectal injection was six to eight grammes. Morphine hypodermatically is very favorably regarded by many. Spiegelberg advised either chloral or morphine, but seemed to give his preference to the latter. Clark,3 of Oswego, has been a warm advocate of the treatment of eclampsia by morphine. He directs that the patient should at once have injected into the arm a grain and a half. " Should the paroxysm return at any time after two hours this dose should be repeated. And, if she be in labor, she should have another dose after eight hours any way." Smith,4 of Melbourne, is quite as ardent in his praises of this remedy as is Clark, though he does not use such heroic doses ; he states that no case of eclampsia has died in the Melbourne Hospital since em- ploying the morphine treatment. Veit5 advocates morphine in large doses, but he also uses hot baths; he lost only two of more than sixty patients thus treated. He gives hypodermatically one-fourth to one-third of a grain—it should not be combined with atropine ; the injection, but with a smaller quantity of morphine, is repeated in a few hours if the patient has another fit. Pilocarpin, nitro-glycerin, and nitrite of amyl are among the new drugs that have been used with varying success in the treat- ment of eclampsia. The first is forbidden by long continuance of the paroxysms and profound coma; it may be very dangerous and Winckel thinks should not be employed. Nitrite of amyl was first used6 upon the suggestion of Dr. Weir Mitchell, by the late Dr. W. F. Jenks, of Philadelphia; in the case in which it was employed the eclampsia began in labor and con- tinued afterward uninfluenced by ether inhalation; the effects of inhaling a few drops of nitrite of amyl were most remarkable, the eclamptic attacks being at once arrested; but the patient had severe uterine hemorrhage, which Dr. Jenks attributed to the action of the drug. Budin7 tried the remedy in a case of eclampsia in pregnancy, but without any effect. 1 Obstetric Gazette, Feb. 1882.1 3 American Journal of Obstetrics, 1880. *> Centralblatt fur Gynakologie, 1888. 7 Obstetrique et Gynecologic 2 Paris Thesis, by Chambert, 1883. * London Lancet, July 16, 1881. 6 Philadelphia Medical Times, Aug. 1872. ECLAMPSIA. 277 Fearn,1 Boyd,2 and Kenyon3 have reported cases of eclampsia successfully treated by veratrum viride. In one case Boyd gave twenty drops of the fluid extract every fifteen minutes, until one hundred and twenty drops had been taken ; at the time the last dose was administered the pulse had fallen from 144 to 130; in ten minutes the patient vomited, and the pulse fell to 54. Obstetric Treatment.—In nearly one-third of the cases of eclamp- sia, convulsions cease if the uterus be emptied; and therefore all obstetricians agree in facilitating labor if it comes on, as it does in the great majority of cases. Free the uterus from its contents as soon as this can be done without the least violence, was the teaching of Dubois, and this is a good rule for the practitioner. Artificial dila- tation of the os, and delivery by turning or by forceps, may be indi- cated in some cases. But of course whenever artificial means are used for hastening the labor, chloroform or chloral must also be employed to prevent reflex irritation. But if the eclampsia occur and no uterine action follow, while the convulsions do not yield to treatment, should uterine action be excited by the obstetrician ? Authorities differ. Pajot, for example, has condemned it as unreasonable, and more dangerous than eclampsia itself. The arguments against the practice are, chiefly, the convulsions may continue after delivery, or they may end before this can be effected; they may cease, and the pregnancy be com- pleted. Winckel says the induction of premature labor is to be considered obsolete, because it is irritating for the mother and dan- gerous for the child, and especially because the results of the dia- phoretic treatment are so good. I frankly avow my own belief is that, as a rule, the maxim of Gooch was a wise one, " Take care of the convulsions, and let the uterus take care of itself." If the eclamptic attack be severe, uterine contractions generally occur spontaneously. The irritation of a uterus unprepared for labor is liable to add to the severity of the convulsions. The force of these arguments must be admitted, but, on the other hand, there is being accumulated a number of cases in which artifi- cial means were used to empty the uterus, and the patient recovered. The induction of labor in cases of eclampsia, if the mother's life is in danger, if the disease resists the best directed treatment, has received the endorsement of some of the ablest American obstetri- cians, among whom may be mentioned Barker, Busey, and Lusk. But the practitioner who determines—and, as a rule, the determi- nation should be made only after a consultation with a competent confrere—upon this course, must be prepared for the possibility of his patient dying after, and in spite of, the induced labor, just as in some instances happens after a spontaneous labor in the eclamptic. If eclampsia begins or continues after labor, the chief therapeutic means are chloral, and chloroform' inhalation. Caution must be taken not to use these agents in too large quantities, and especial care not to anaesthetize the patient too profoundly, lest the artificial sleep end in the sleep of death. 1 American Journal of Obstetrics, 1871. 2 American Practitioner, 1878. 3 New York Medical Journal, 1879. CHAPTER X. DISEASES OF THE SEXUAL ORGANS—DISEASES OF THE OVUM. Vegetations of the Vulva.—Papillary hypertrophy may occur at various parts of the vulvar surface, giving rise to wart-like eleva- tions, in the pregnant woman. While probably in the majority of cases these growths have a specific origin, yet in some it is believed that they result from the irritation of parts rendered more vascular by pregnancy, like plants springing up luxuriantly from a moist soil. The proof of their non-specific character is given by the fact that as a rule they spontaneously disappear when the pregnancy is over. They may occupy the nymphae, the vestibule, the hood of the clitoris, the labia majora, the adjacent skin, the vaginal orifice, and in some cases extend into the vagina. Unless large, and so extensive that they obstruct the birth-canal, active treatment in pregnancy is not advisable, for excision might be attended with considerable hemorrhage, and followed by abortion or premature labor, or inflammation of lymphatics or veins. When removed they are very liable to return, and their probable sponta- neous disappearance after pregnancy is an additional reason for re- fraining active treatment. The surfaces affected must be kept apart as much as is possible, and disinfectant or astringent solutions applied; one of the best local applications is a solution of carbolic acid. Charpentier states that in two pregnant women these growths disappeared by isolating the affected parts, and applying compresses dipped in Labarraque's solution. Prolapse of the Vagina.—This is to be treated by astringent injec- tions, by having the bladder frequently emptied, especially if, as is frequently the fact, a cystocele is associated with the prolapse, and by wearing a suitable pessary; the elastic ring will in most cases be best; if a pessary cannot be worn, a large tampon of absorbent cotton dipped in a mixture of tannin and glycerin may be used; this tampon should be removed each night and a fresh one intro- duced in the morning. Leucorrhcea.—It is not uncommon for a pregnant woman to have a more or less abundant milk-like discharge from the vagina; it arises from a simple or catarrhal vaginitis, induced in part by the increased congestion of pregnancy. Another form of vaginitis may also occur; it was first described by Deville in 1844, and called by him granular vaginitis; he believed it peculiar to pregnancy, but it may occur in the non-pregnant, though more frequent in the former condition. It is characterized by the formation of a large number of hemispherical elevations about the size of a hemp-seed upon the vaginal surface, making it rough, by burning and itching, and by a rather profuse yellowish discharge which irritates the parts with DISEASES OF THE SEXUAL ORGANS. 279 which it comes in contact in passing out of the vagina. Other vaginal discharges may be caused by gonorrhoeal infection, or by cervical endometritis. Winckel described in 1871 a condition which he observed in three pregnant women, and which was characterized by the presence upon the vagina of a vast number of transparent cysts, fifteen or twenty being found upon a spot the size of a dollar, ^nd usually associated with hypersecretion; most of the cysts contained gas, and when punctured collapsed with a sound readily heard. He named the disease colpohyperplasia cystica.1 The treatment of the vaginal discharges of pregnancy will be, in the slighter cases of increased secretion, by tepid injections of solu- tions of astringents, as of alum, borax, salts of zinc, etc., or a mix- ture of creolin, usually half a teaspoonful to a pint of water; in severer cases, in addition to cleansing injections of a two per cent. solution of carbolic acid, of potassic chlorate, or of common salt, a cotton tampon inclosing half a teaspoonful of powdered alum and of subnitrate of bismuth, maybe passed to the upper part of the vagina, and left there for twelve or twenty-four hours, when, by means of a string which has been tied to it before its introduction, it is removed; the tampon may be repeated the following day. Instead of the dry tampon just advised, one of cotton dipped in a mixture of boric acid and glycerine, I to 10, may be used, or of tannin and glycerine. If the vaginitis be gonorrhoeal it will be advisable, beside the means that have been mentioned, to apply with a brush a solution of nitrate of silver to the exposed vaginal wall, or to use injections of a solution of corrosive sublimate; during labor the vagina must be well cleansed, a disinfectant solution being used, so if possible to prevent the contact of any infectious matter with the child's face, lest some of it might find its way to either conjunctivae, and a specific conjunctivitis result. Positional Disorders of the Uterus—Prolapse and Procidentia.—In prolapse of the uterus the organ is still within the vulvar orifice, but if it protrudes from that orifice there is procidentia. The uterus in the fourth month of pregnancy begins to ascend, and most cases of prolapse are thus spontaneously cured. But in the pregnant as in the non-pregnant condition the same causes—such as sudden pressure upon the abdomen, or a fall, or jumping from an elevated position—may, especially if the bladder be full, cause acute uterine prolapse. Most cases, however, of prolapse of the uterus in preg- nancy, are those in which the prolapse was present before the pregnancy, for even procidentia of the uterus does not prevent impregnation, as the organ may be spontaneously replaced when the subject lies down; and further, instances in which coition taking place through the dilated os impregnation has followed. Many cases of supposed prolapse of the uterus are really examples of hyper- trophic elongation of the cervix. Kleinschmidt2 has narrated a case 1 See Winckel's work on Diseases of Women for full description. 2 American Journal of Obstetrics, vol. xviii. 280 SCIENCE AND ART OF OBSTETRICS. of prolapse of the uterus in pregnancy, the organ protruding about an inch from the vulva if the patient was erect, when the pregnancy was only six weeks advanced; at six months and a half the protrusion still remained, even when the patient was recumbent, and a bandage was worn to support the organ. Kleinwachter states that in case of considerable prolapse and injudicious treatment, especially if reposition be neglected, the organ may become incarcerated, and the pregnancy thereby be arrested. He denies that it is possible in case of complete prolapse or procidentia for the pregnancy to be completed, because of the injuries to which the organ is exposed. Winckel believes that a complete prolapse of the gravid uterus may occur in the first half of pregnancy, but rejects the reported cases of this accident during labor. The treatment of prolapse of the uterus is reduction, the recum- bent position for the patient, and the wearing of a suitable pessary. In cases of difficult reduction, the patient may be anaesthetized, or a solution of cocaine applied previous to the manipulation. Should the pessary not retain the reduced uterus, a large vaginal tampon, of absorbent cotton or of prepared lamb's-wool, well covered with an ointment of creolin may be employed, and a bandage used to keep it in place. Of course the tampon is removed at night, and a fresh one introduced in the morning before the patient rises. Abor- tion is indicated if a prolapsed uterus becomes incarcerated. Anteflexion and Anteversion of the Uterus.—Anteflexion of the pregnant uterus is an exaggeration of the original condition, and therefore is by most regarded as normal, though very great impor- tance is attached to it by Graily Hewitt as a cause of vomiting; it very seldom reaches such a degree as to be pathological. The rule is that if the uterus be greatly anteflexed, sterility results, caused not so much by the displacement, but by conditions associated with it. An anteflexion, or an anteversion, in the earlier months may cause great irritability of the bladder and other inconveniences; but unless some pathological condition be associated with the positional disorder, it is not probable there will be any arrest of pregnancy; nor does it seem possible that the uterus can become incarcerated, and its fundus fixed behind the pubic joint. Anteversion of the uterus is physiological in multigravidae in the latter part of preg- nancy, for the relaxation of the abdominal wall permits the uterus to fall forward; if this relaxation be very great it may rest upon the thighs when the patient is sitting. The condition is some- times spoken of as hanging belly, or pendulous abdomen. Very great discomfort may result from this condition in pregnancy, and the entrance of the head of the fcetus into the pelvic cavity be hin- dered. In labor the uterine contractions work at much disadvantage from the malposition of the womb. The remedy is found in a firm, properly applied bandage. Posterior displacements of the uterus in pregnancy are graver conditions. A woman with a retroverted uterus rarely becomes pregnant; hence, if the uterus be found retroverted in pregnancy, it is probably an accident that has occurred after gestation has DISEASES OF THE SEXUAL ORGANS. 28l begun. On the other hand, a woman who has a retroflexed uterus may become pregnant more frequently than one whose uterus is in Fig. 105. Retroflexion of the Gravid Uterus with Incarceration.—A. Bladder. B. Internal orifice. C. External orifice. D. Urethra. E. Vagina. F. Rectum. Fig. io5. Diagram of Partial Retroflexion (Oldham). 282 SCIENCE AND ART OF OBSTETRICS. the normal position, for the deviation is very often the cause of abortion. In regard to the occurrence of retroversion of the preg- nant uterus, there has been much controversy as to whether the de- viation is sudden or gradual, and as to whether distention of the bladder is cause or consequence. It may be admitted that each form of displacement can take place—that is, in some cases it is gradual, in others sudden, and that distention of the bladder may occasionally be a cause, while in all cases it is one of the gravest consequences of the change of position. In the majority of cases of posterior displacement of the gravid uterus spontaneous cure occurs, the uterus gradually rising out of the pelvis. Further, in some cases of retroflexed uterus, as first suggested by Merriman, and as confirmed by the observations of Oldham1 and Stille,2 pregnancy may go on to term, or near it, though the uterus remains retroflexed. Oldham's case was one in which at term he found the head of the child occu- pying the fundus of the uterus, which was in the pelvic cavity, while the lower segment of the uterus was raised considerably above the pelvic brim. He suc- ceeded in delivering the woman of a dead child, by first introducing the finger into the child's anus, failing to reach the bend of the child's thigh, thus exerting traction, and he was enabled after considerable effort to draw the breech a little lower, and some elevation of the head followed; then pressure upon the lower part of the tumor, while external pressure was made, caused the fundus to ascend above the brim and into the abdominal cavity; the os uteri now being accessible, a foot was brought down, and the child delivered. In Stille's case a retroflexion at the fourth month of pregnancy caused retention of urine, but no interference with evacuations from the bowels. Replacement being impossible, daily cathe- terization of the bladder was done ; development of the uterus continued, the child's head remaining in the pelvic cavity, the body above. Labor came on seven weeks prematurely, and delivery was accomplished by podalic version. Further, nature may end the case by abortion ; this result is not unfrequent; but, none of the events which have been mentioned occurring, symptoms of incarceration supervene. The uterus con- fined to the sacral cavity, possibly by the adhesions of an old perito- nitis in some cases, continues its development; there result reten- tion of urine and obstruction of the rectum; uraemia and local or general peritonitis may occur; the bladder may rupture, or there may be either a simple or diphtheritic cystitis from retention of urine, and, as a consequence, detachment of the whole or of parts of the vesical mucous membrane. Valenta3 has reported a case in which retroflexion in the fifth month caused gangrene of the blad- der, perforation into the small intestine, and death of the patient. The diagnosis of retroflexion or of retroversion of the pregnant uterus will not usually present any great difficulty. First, the fact of pregnancy is to be established; next, the bladder is to be emptied, a flexible catheter being used for this purpose, and in case it is impossible to use a catheter, aspiration would be preferable to leaving the organ distended ; then digital examination by the vagina, 1 London Obstetrical Society's Transactions, vol. xi. 2 Memorabil., 1881. 3 See Kormann. DISEASES OF THE SEXUAL ORGANS. 283 and by the rectum; and, finally, bi-manual examination ought to remove all doubts as to the nature of the disorder. Fig. 107. Retroversion of Pregnant Uterus with Incarceration. Having discovered the displacement, the treatment will be, in the simple cases in which the uterus is mobile, digital or bi-manual re- placement of the organ, and the introduction of an Albert Smith or Hodge pessary. The patient ought to avoid any compression of the abdomen, constipation, straining at stool, and allowing any accu- mulation of urine in the bladder. She should each day occupy the knee-chest position for a short time, and when recumbent should avoid, as far as possible, being upon her back. At four months the pessary may be removed. In other cases, the uterus not being mobile, and if no evidences of inflammation are present, efforts at gradual reposition may be made as follows : Let the patient take the knee-chest position; then the practitioner may, by two fingers introduced into the vagina, press upon the posterior wall of the uterus, or the fingers may exert this pressure through the rectum; no violence should be used ; generally immediate reposition is not expected, but a slight gain being made from day to day, final suc- cess may be obtained after a week, or even longer time. Another method, either employed alone or assisting that which has been given, is to introduce into the vagina the broad blade of Sims's speculum, the broader the better, and with it not only draw back the perineum, but also press up in the posterior vaginal cul-de-sac, 284 SCIENCE AND ART OF OBSTETRICS. thus pushing the body of the uterus up, and at the same time drawing the neck backward ; the last may be assisted by seizing the cervix with a tenaculum, and drawing it toward the posterior vaginal wall. This entire method may be summarized in push and pull. Let the operator, however, always have as his motto, non vi sed arte. In manual replacement, care is to be taken to direct the fundus of the uterus toward one of the sacro-iliac joints, thus avoid- Fig. 108. Sacciform Dilatation of the Posterior Wall of the Uterus.—1. Os uteri. 2. Artificial.os. The distance between the two was about three inches and a half, 9 centimetres. The distance from the fundus of the uterus (6) to the os was 6.7 inches,or 17 centimetres, while that extend- ing from the same point (5) to the new opening was 9 inches, or 23 centimetres. The dis- tance from the os to the median point of the fundus was, following the curve of the anterior wall, 8.2 inches, 21 centimetres, but following the curve of the posterior wall, 18.1 inches, 46 centimetres. ing the sacral promontory. Another method which counts some successes is the use of continuous elastic pressure, by means of a rubber bag distended with air or water, introduced into the vagina or into the rectum. But neither organ is very tolerant of such an DISEASES OF THE SEXUAL ORGANS. 285 instrument; this is especially true as to the rectum; moreover, it does more harm than good when the pressure is made through the vagina if the fundus of the uterus be lower than the cervix, for then the pressure will be greater upon the latter than upon the former. I doubt, indeed, whether it is of any value, even if the uterus is simply transverse; the space furnished by the rectum below the retroverted uterus is so small that but slight force can be exerted through it. If an anaesthetic is used when efforts at reposition are made, of course the patient cannot be in the knee-chest position, but must lie upon her back or upon her side. If reduction be im- possible, and symptoms of incarceration occur, the only remedy is the induction of abortion. Sacciform Dilatation of the Posterior Wall of the Uterus.—A condition rarely observed, and which has been mistaken in some cases for retroversion of the pregnant uterus, was very fully described by Depaul1 in 1876. It has been called sac-like dilatation of the posterior wall of the uterus. The diagram p. 284, represents the post-mortem appearance of the uterus of a patient under the care of Depaul. It was impossible for him to find the os uteri, the patient being in labor, and he made an opening through what the autopsy proved to be the pos- terior wall of the uterus. The patient died undelivered. Hernia of the Uterus.—In rare instances the pregnant uterus has in part protruded at the abdominal ring, the disease being known as uterine exomphalos, or uterine umbilical hernia. In Murray's case2 more than two-thirds of the uterus thus protruded in the latter part of pregnancy ; reduction was readily accomplished, and a bandage prevented reproduction of the hernia. In Oliver's case,3 not seen until labor began, a cone-like mass—the base of the cone being at the umbilicus—was observed projecting from the abdomen. After the delivery of the child the tumor was still evident, and proved to be the upper portion of the uterus containing an enormously de- veloped placenta, the weight being eight pounds, as estimated* after its expulsion. Reduction of the hernia was readily effected. The woman had umbilical hernia in childhood. Examples of herniae in pregnancy resulting from dilatation of an abdominal cicatrix have been given by Boivin and others. More frequently, however, herniae at the linea alba have been observed; separation of the recti muscles occurring, the uterus projects in the interval. Prochownick, in a recent paper upon diastasis of the abdominal muscles in childbed,5 states that English women are less liable than German women to pen- dulous abdomen after confinement, because they remain longer in bed, and espe- cially because they wear well-fitting bandages after getting up. His consideration of the disorders that arise in the lying-in from diastasis of the recti muscles will be referred to elsewhere. 1 Archives de Tocologie. 2 London Obstetrical Society's Transactions, vol. i. 3 Western Journal of Medicine, 1867. * In a private communication Dr. Oliver states that he did not weigh the placenta, but he did the child, its weight being but four and a half pounds, and ihe placenta seemed to be nearly twice as heavy. The heaviest placenta mentioned in obstetric works, I believe, is that described by Stein, and referred to by Velpeau—the weight being six pounds. 5 Archiv ivir Gynakologie, 1886. 286 SCIENCE AND ART OF OBSTETRICS. The treatment of ventral hernia is the same as that of pendulous abdomen. Crural, and Inguinal Hernia.—Winckel1 remarks that in view of the possibility of the uterus entering into the various canals passing from the false and from the true pelvis, such terms as inguinal her- nia of the uterus, crural, obturator, ischiatic, etc., have been used, but as a matter of fact the uterus has been found only in the hernial sac of inguinal and crural herniae. Eisenhart2 states that hernia of the gravid uterus is nearly as rare as hernia of the non-gravid organ: the slight preponderance in number of the former is prob- ably due to the fact that pregnancy directs attention to a condition which would otherwise be unnoticed. In his historical references, he says that Nicolaus Pol, 1531, reported the first case; Caesarean section was done, the mother survived three days, the child lived to be one year and a half old. In April, 1610, Sennert operated on a case, the mother lived twenty-five days, and the child until nine years and a half old. Saxtorph's and Ledesma's cases are next given ; the latter occurred in 1840. Rektorzik reported a casein i860; the Caesarean operation was done, the mother died, but the child lived. Inguinal hernia is frequently associated with uterus bicornis or didelphys. In Winckel's case, reported by Eisenhart, the hernia occurred suddenly in the fourth month of pregnancy ; the right horn of the uterus was concerned. Scanzoni has reported a case of inguinal hernia in which two pregnancies occurred in one year ; one of the pregnancies ended by spontaneous, the other by artificial, abortion. Adams3 has collected 23 cases of hernia of the gravid uterus ; 9 of these were of inguinal hernia; in one spontaneous delivery occurred, in a second abortion was produced, in a third Porro's operation (Winckel's case), and in the rest the Caesarean operation ; four mothers died, two children lost, including the abortion. One crural, mother died, child saved. Four umbilical, no life lost. Eight ven- tral, all mothers recovered; craniotomy in one case, and in another the child was stillborn. In these herniae Winckel advises abortion. If the foetus be viable, the Caesarean section should be done at the end of gestation, and then, if the uterus can be restored to the abdominal cavity, this should be done, but if it cannot be, it must be removed. Structural Diseases of the Uterus.—Two only of these require con- sideration, fibroid tumors and malignant growths. Fibroids of the Uterus.—A relative sterility results from fibroid tumors of the uterus; thus while the average sterility of women is one in eight, that of those having these growths in one is three. In the great majority of women having uterine fibroids pregnancy is not interrupted ; if the tumors be situated at the fundus, it is thought abortion in the earlier months is very liable to occur; placenta praevia is very much more frequent in cases of fibroids. The tumors usually increase in size, and become softer during pregnancy, and after pregnancy may greatly lessen in bulk; but such changes are observed more especially in those that have a predominance of mus- cular tissue, myomata. The treatment of fibroid tumors in pregnancy is chiefly sympto- matic. Thus, if the tumor becomes incarcerated in the pelvic cavity, an effort should be made to push it up in the false pelvis ; if 1 Op. cit. 2 Archiv fiir Gyniikologie, 1885. '■' American Journal of Obstetrics, 1889. DISEASES OF THE SEXUAL ORGANS. 287 hemorrhage occurs, rest, cold drinks, opium, or finally the vaginal tampon may be employed. Schroder successfully removed a pe- dunculated, rapidly growing uterine subserous myoma in the third month of pregnancy by laparotomy; the pregnancy was not inter- rupted. A similar result attended the operation of Thornton, done a few months earlier than Schroder's, and those of Landau and Studsgaard; Pean's patient recovered from the operation, as did also Braun's, but each aborted; Barnes's and Hegar's patients died.1 So, too, supra-vaginal amputation of the uterus was successfully done by Kaltenbach. But partial amputation or supra-vaginal am-' putation, including Kaltenbach's case, was followed by death in four out of nine cases.2 If the tumor occupies the lower segment of the uterus, and be so large that the birth of a living child is impossible, even though premature labor be induced, the question of abortion may be presented, or either the Caesarean section or craniotomy will be necessary if the pregnancy is completed. If the tumor occupies the cervix, it may be possible in some cases to enucleate it during labor, and thus remove all obstruction to delivery. Malignant Disease of the Uterus.—If cancer or sarcoma occupy the fundus of the uterus, there is little probability of pregnancy oc- curring, and a certainty of abortion should it occur. Cancer of the neck does not present such hindrance to pregnancy, and the latter, provided the malady involves only the vaginal portion, most fre- quently continues to term. The disease is in almost all cases unfa- vorably affected by gestation. Should the cancer be limited to the vaginal cervix, and show any progress, amputation ought to be done at once. The operation has been performed in some cases without interruption of the pregnancy. Even when the affection is more extensive and gives rise to copious purulent and hemorrhagic dis- charges, an operation for partial removal of the cervix, taking away all the diseased tissue possible, is proper. The induction of abortion or of premature labor is not generally regarded with favor, never- theless, in some cases the alternatives are, when labor comes on spontaneously, the Caesarean operation or craniotomy. Disease of the Breasts.—Occasionally mastitis is seen in the latter part of pregnancy, the disease being in most cases probably trau- matic ; Schroder, however, speaks of its occurrence from tumors as exceptional. The treatment is not modified by the pregnant condi- tion, nor does the former have any disturbing influence upon the latter, unless very high fever occurs. Malignant disease of the mammary gland usually makes more rapid progress during preg- nancy ; hence the indication is plain as to removal of the diseased structure, without waiting until the pregnancy ends. According to Verneuil, adenomata of the breast are either not affected by, or diminish during pregnancy. Ovarian Tumors.—If an ovarian tumor be small, it usually causes no serious interference with pregnancy. But if the tumor be large 1 Du Traitement Chirurgical des Myomes Uterins. By Dr. A. Vautrin. Paris, 1886. 2 See Vautrin's statistics. 288 SCIENCE AND ART OF OBSTETRICS. the pregnancy in many cases ends in abortion, or in premature labor. Other accidents are inflammatory adhesions between the tumor and the fundus of the uterus, rupture of the cyst wall, twisting of the pedicle of the tumor, followed probably by hemorrhages into the cyst, and more or less extensive adhesions through which the tumor receives its nourishment. In some cases, in which the tumor is not large, it may become wedged in the pelvic cavity. The treatment of ovarian tumors, so long as they do not give the patient discomfort and threaten the pregnancy, is expectant. But ' when the tumor is fixed in the true pelvis, an effort should be made, with the patient occupying the knee-chest position, to push it out of the pelvic cavity. Large tumors are to be treated by abortion, tapping, or ovariotomy. The first is generally rejected, and the second is only applicable to a monocyst, or to a tumor which is composed chiefly of one cyst. The general professional sentiment is in favor of ovariotomy if the tumor be large; the results are usually good, and especially if the operation be done early in the pregnancy. The following facts and conclusions are found in a recent valuable monograph by Remy.1 In eleven cases of pregnancy complicated with ovarian tumor occu- pying the abdominal cavity, in which premature labor was induced, three mothers died, and of the eleven children only five lived. Puncture of the cyst, according to Heiberg's statistics, has a maternal mortality of 22.5 per cent., and a fcetal mor- tality of 37.5 per cent. Ovariotomy in pregnancy was first suggested by Mer- riman in 1817, and was first successfully done by Marion Sims; the operator, however, did not know before the operation was begun that the patient was preg- nant. The mortality for mothers from ovariotomy in pregnancy is, when the opera- tion is done in the first four months, 11.3 per cent., and for the fcetus 42.8 ; if the operation be done in the last five months the maternal mortality is 16.6 per cent., and the fcetal mortality 50 per cent. Expectation—of course it is presumed that the ovarian tumor is of considerable size—gives a maternal mortality of 39.2 per cent, and a fcetal mortality of 67 per cent. Mr. Tait2 has performed ovariotomy thirty times in pregnancy, and in no in- stance did abortion result. Diseases of the Ovum.—The ovum includes the deciduous mem- branes, the chorion and the amnion, the amnial liquor, the foetus, placenta and cord. The pathology of the ovum, therefore, embraces that of the several parts of which it is composed. The ovum may occupy an abnormal position, and hence a variety of pregnancy known as ectopic gestation. Again, instead of the entire ovum occupying an abnormal position, the placenta alone may be in such position, and thus ectopic development of it occur, constituting that form of disease described as placenta praevia, the most prominent symptom, in almost all cases, being a variety of hemorrhage which has been called unavoidable. The placenta, occupying its nor- mal position, may be prematurely detached in part or entirely, and another variety of hemorrhage, identical in source, but differing in etiology, called accide?ital hemorrhage, result. These conditions will 1 De la Grossesse compliquee de Kyste Ovarique. Paris, 1886. 2 The Causes and Treatment of Abortion, by Robert Reid Rentoul, M.D., 1889. DISEASES OF THE OVUM. 28g be considered under the head of the pathology of the ovum. As a consequence of maternal or of fcetal disease, or of trauma, the ovum may be expelled prior to the time when the fcetus is viable, and abortion, the gravest accident to the pregnancy, is to be studied. Decidual Endometritis.—Inflammation of the decidua is very fre- quent, and in many instances causes abortion. The decidua fur- nishes,1 as Martin Saint-Ange expresses it, an incubating chamber for the impregnated ovule, and if the former become diseased, injury to the latter is very likely to result. Decidual endometritis may be either acute or chronic. The former is caused by acute febrile dis- eases, is especially characterized by hemorrhage, and its usual con- sequence is miscarriage. Four varieties of chronic decidual endometritis have been de- scribed. 1. Diffuse decidual endometritis. This usually affects the parietal, or uterine decidua, decidua vera, rather than the decidua reflexa, the ovular decidua; it is characterized by the thickening of the decidua from proliferation of the decidual cells, and development of the connective tissue; subjacent muscular fibres may also be involved in the hyperplasia. 2. Polypoid decidual endometritis. Here, with chronic proliferation and thickening of the decidua vera, poly- poid growths appear; these are about three-fourths of an inch in height, and are broad-based and irregular in form. If polypoid endometritis occur early, the inflammatory process readily extends to the chorial villi, with resulting atrophy of the ovum, and abortion; upon the aborted ova the manifestations of diffuse and of polypoid decidual endometritis may be seen.'2 3. Cystic decidual endometritis. In this form of decidual endometritis the inflammation involves the glands of the mucous membrane; the intra-glandular connective tissue is increased, and the membrane is swelled; hence obstruction of the gland ducts, and retention of glandular secretion with the formation of cysts. In other words, they are retention cysts. 4. Ca- tarrhal decidual endometritis. The characteristic indication of this disease is the discharge from time to time of a watery fluid from the uterus, constituting what is generall}7 known as hydrorrhcea gravi- darum. The disease is more frequent in multigravidae than in pri- migravidae ; it may occur as early as the third month, but usually not until the late months of pregnancy. The fluid is albuminous, and generally yellowish, and at times may contain blood. The probability seems to be that its chief source at least is the uterine glands. At first it appears between the decidua vera and the decidua reflexa, but after these are united the transudation must be between the chorion and the reflexa; the occasional presence of blood in the discharge from the uterus is probably explained as resulting from the fluid, after passing by partial rupture of the decidua to the out- side of the ovum in its descent, causing detachment of a part of the decidua from the uterus. Many of the cases of supposed rupture of the membranes, days or weeks before labor, are really examples of 1 Iconographie Pathologique de l'CEuf Humain Feconde. 2 Archiv fiir Gyniikologie, 1885. Breus, Ueber cystose Degeneration der Decidua vera. '9 29O SCIENCE AND ART OF OBSTETRICS. hydrorrhoea, a discharge of false waters, not of the amnial liquor, occurring. Slight pains usually accompany the discharge, and in most cases it is repeated several times before pregnancy ends. Pre- mature labor very rarely follows hydrorrhoea, but its possible occur- rence indicates that the patient thus affected, especially if there be any uterine contractions, should remain lying down, and in some cases a rectal injection of twenty to thirty drops of laudanum will be advisable. The causes of decidual endometritis are not well known. In some cases the disease may arise from syphilis, or from great bodily effort, or from excessive work; in others, it was present prior to pregnancy, and in still others it follows the death of the fcetus. Jaggard has reported1 a case of obstinate vomiting caused by decidual endome- tritis. Atrophy of the Decidua.—This may affect the decidua vera, or the decidua serotina and reflexa. In hypoplasia the development of the decidua is imperfect. These anomalies of the vera are less im- portant as causes of abortion than if they affect the serotina and the reflexa. In general, diseases of the decidua do not furnish so much thera- peutic indication during pregnancy, as after its interruption they do for treatment of the endometrium in order to prevent a recurrence of the accidents in a new pregnancy. Diseases of the Placenta—Apoplexy of the Placenta.—Hemorrhages into the placental tissue rarely occur. If happening early in preg- nancy, they take place near the fcetal surface; but if late, near the maternal surface of the organ, according to Desormeaux and Dubois. Hemorrhage is very rarely seen at the fcetal surface, beneath the amnion. In some cases the hemorrhage is into the maternal sinuses. The extravasation may be single or multiple. The size of the apoplectic masses varies from that of a pea to that of a hazelnut or of a pigeon's egg. They at first appear as circumscribed, blood- red extravasates; afterward they lose their deep hue, and become grayish-red, or yellowish white, fibrin-like masses. Kleinwachter states that in most cases inflammation of the placenta is the cause of the hemorrhages. If the effusions are multiple or large, they may by pressure upon the adjacent chorial villi interfere with the nutrition of the fcetus. Placentitis.—According to Spiegelberg, we are indebted to Hegar and Maier for the first accurate knowledge of inflammation of the placenta. The disease may be diffuse or circumscribed, the latter form being rare. It is described as an interstitial endometritis, starting with an exudation of soft granular matter, and resulting in various forms of induration and degeneration. " The decidual tissue normally consists of elongated cells imbedded in a small quantity of amorphous intercellular substance. When inflammation begins there is an enormous development of fusiform cells with an increase of intercellular granular material. Then the cells become deformed, Journal of the American Medical Association, 1889. DISEASES OF THE OVUM. 29I distended with fine fat granules, and eventually the whole structure is converted into fibroid tissue." (Priestley.) Extravasations of blood take place upon the fcetal surface, and abnormal adhesions between the placenta and the uterine wall may, in some cases, result from the hypertrophied and sclerosed decidual tissue sending bands and fibres to it. Fig. 109. Placental Tissue showing Granular or Slightly Striated Matrix, with Elongated Decidual Cells, constituting the First Stage of Interstitial Placentitis. (Hegar and Maier.) It is doubtful whether suppuration ever occurs in inflammation of the placenta, or at least the cases are admitted to be very few: Robin1 has shown that the liquid contained in supposed abscesses of the placenta was really a fibrinous pseudo-pus very different from true pus. Priestley remarks2 that " the presence of purulent matter in the placenta in most of the reported cases is supported by imperfect evidence. There are only ten cases of abscess in the placenta recorded, and as no account is given of the microscopic examination of the supposed pus, the evidence is plainly unsatisfactory." And in the last edition of Schroder, 1888, it is stated that suppuration is extremely rare, and without careful microscopic examination statements are valueless. The cause of placentitis is probably an endometritis arising before and continuing in pregnancy, and therefore suitable treatment when the gestation ends, either prematurely or at term, is plainly indi- cated. Sclerosis, Atrophy, Phthisis, Hypertrophy and CEdema of the Placenta. —Sclerosis, as described by Neumann, is caused by hypertrophy of the villi which hence encroach upon the blood-sinuses until they are obliterated. But, according to Spiegelberg, it is uncertain whether this sclerosis originates from hypertrophy of the villi, or is a con- sequence of the so-called inflammatory interstitial connective tissue hypertrophy with atrophy of the villi; the change is probably due to syphilis. Atrophy of the placenta is the consequence of localized hemor- rhages, or of cellular hyperplasia. Under the term placental phthi- sis, originally applied by the late Sir James Y. Simpson, Priestley 1 Recherches sur l'apoplexie placentaire et les hematomes du placenta, par le Dr. Verdier. Paris, 1868. 2 The Pathology of Intrauterine Death, 1887. 292 SCIENCE AND ART OF OBSTETRICS. describes an affection which in its first stage consists of an exudation or deposit, thrown out among the villi; but as he states that it is probably due to some modification of a low inflammatory process, therefore it is to be regarded as simply a variety of placentitis. CEdema of the placenta is rarely found except in case of a dead and macerated fcetus ; exceptionally the child has been born alive. The organ is larger, heavier, and paler than normal, and from the tissues a bloody serum escapes ; there will frequently be found blood-extra- vasates ; the causes of the affection are unknown. Hypertrophy of the placenta is caused by hypertrophy of the decidua and its prolongations ; in rare cases there is an unusual de- velopment of this organ without pathological condition. Tumors of the Placenta, Pigment and Calcareous Deposits.—Both solid and cystic tumors of the placenta have occasionally been seen ; the latter are less rare than the former. Calcareous deposits are not uncommon ; they are more frequent upon the uterine surface ; in one instance more than 500 concretions were found, Chambord's case; in minor extent and not occupying the bloodvessels of the fcetal portion of the placenta, they are of no significance. Pigment de- posits usually arise from the extravasations of blood, and may be found in both healthy and diseased placentae. Fatty Degeneration of the Placenta.—Dr. Robert Barnes1 makes an important distinction between fatty degeneration and fatty metamor- phosis ; the former begins in living, while the latter is found in dead tissues. He describes fatty degeneration of the placenta as " gener- ally partial, invading one or more cotyledons, or part of them, forming in many cases diseased masses imbedded in comparatively healthy tissue, thus giving evidence that it originated during the life of the fcetus. In some instances we find, indeed, a living fetus with a placenta in part affected ; in others we find the disease more advanced and the fcetus dead, but with some healthy placenta the vessels still containing blood. To the naked eye the fatty placenta may exhibit masses of a pale yellowish color, more solid than the spongy, healthy tissues surrounding them, and easily friable." Among the consequences of fatty degeneration of the placenta is abortion. Dr. Barnes also states that this change may explain some cases of hemorrhage during gestation which are attributed to pla- centa praevia. Priestley says that the tendency of modern investi- gators is to regard fatty degeneration not as a primitive change, but a phase or stage of some other morbid condition which precedes it or is associated with it. Syphilitic Disease of the Placenta.—Many of the pathological condi- tions of the placenta, some of which have been mentioned, are the consequences of syphilis. Some authors dispute as to whether syphilitic disease of the placenta presents such distinctive characters that its recognition is certain. Those who probably have given most attention to the study of placental syphilis are Fninkel and 1 Dr. Barnes's first publication upon the subject was in the Medico-Chirurgical Transactions, 1853. In a review of the previous edition of this work. Transactions of the British Gyneco- logical Society, 1887, Dr. Barnes states that his first description of the disease was in 1851. DISEASES OF THE OVUM. 293 Zilles. The researches of the latter are much the more recent, and doubtless may be regarded as fairly giving present professional knowledge, and his conclusions1 are therefore presented. Macroscopic Examination of Placenta'from Syphilitic Mothers.—The placenta is of massive development and of great weight, in comparison with the imperfect development of the fcetus. In most instances the placenta is pale-red in general color, and yellowish-white in the diseased portions. Here and there the tissue is firmer, more resistant, compact, and more friable than the normal placenta. At various points " gummatous" nodules are found ; these are wedged-shaped, nodu- lated, fibrous formations, with bases in the decidua, and lessening in size in the foetal portion of the placenta. They vary in size from that of a pin-head to that of a walnut; some are even larger than the last. In some cases they are found occupying circumscribed portions of the entire thickness of the placenta. Upon section the " gummata" show that their structure is formed by concentric lamellae ; the external layers are firmer, and more like fibrous tissue, and have a grayish- yellow color, while in the centre there is a yellowish-red, or orange-yellow, cheese- like, soft or fluid material. Scattered through the peripheral zone are nodules of a cloudy orange-yellow color, cheesy in character, and about the size of a miliary tubercle. If complete degeneration of the central portion has occurred, an irregular cavity is found, its walls formed of fatty, granular debris, and covered with pus corpuscles. The decidua at the uterine surface is greatly thickened, cloudy, and presents yellowish-white spots. If the fcetus be affected, nodules, such as those previously described, are found under the amnion. The umbilical cord is firmer than normal, and upon section a notable crescent-shaped thickening of the ves- sels can be seen with the naked eye. There are also to be seen the characteristic nodules, about the size of a miliary tubercle, at some distance from the vessels in the tissue of the cord itself. Microscopical Appearances.—The decidua contains a large quantity of fibrin, in which are small, round, granular cells. These are found in the meshes of the fibrin, as well as in the fibrin itself; they are scattered, collected in masses, or at times in rows or strands. The cells are also found independently of the fibrin, and presenting the disposition which has been mentioned. In portions the well- known large decidua cells are entirely destroyed, so that nothing remains of nor- mal tissue, but instead there is a luxuriant granulation tissue. In some instances nodules the size of a miliary tubercle are present upon the decidua ; their struc- ture is the same as that of the pathological formations found in the organs of syphilitics, and called by Wagner syphilomata. In a fresh state these bodies have an orange-yellow material occupying the centre, which is relatively firm and dry. It proved to be composed of granular, cloudy, non-nucleated masses, with a peripheral zone, composed of compact, small granulation cells. These cells are round, oval, or angular, usually nucleated; some had two or three nuclei. As these are found only in the placentas of syphilitic women, they may be called syphiloma of the decidua. Sections of the "gummatous" nodules show that they are composed of fibrin, altered villi, and masses of small cells. The villi are united in a compact mass, and surrounded, too, by granular, reticulated fibrin ; they are destitute of vessels and of epithelial covering. Some of the inter-villous spaces are rich in small-celled elements ; others contain round cells and blood-corpuscles. The villi thus sur- rounded are club-shaped, and filled with small cells. In some parts of the pla- centa the villi show calcification. In the periphery of the nodules, as well as in other parts of the placenta, fat granules or fat corpuscles are frequently found. The chorion in cases where both maternal and fcetal syphilis existed, was gener- ally rich in fibrin and in small cells. Sections at the insertion of the umbilical cord showed that the disease extended directly from the chorion vessels to the umbilical vessels, or vice versa. The walls of the arteries and the veins of the chorion and of the cord are often greatly infiltrated. In some cases the infiltra- tion extended completely around the vessel, but in others only half around. 1 Studien iiber Erkrankungen der Placenta und der Nabelschnur bedingt durch Syphilis, von Rudolf Zilles. Tubingen, 1885. 294 SCIENCE AND ART OF OBSTETRICS. The most abundant proliferation, was, as a rule, in the intima, but in some instances in the media. When the former is affected, there are many white blood- corpuscles attached to the inner surface of the vessels. The following are the general conclusions which Zilles gives from his investi- gations : I. There is such a disease as placental syphilis, and in many cases it can be diagnosticated by the experienced eye from macroscopic appearances. 2. Placental syphilis is generally, but not always as stated by Fraenkel, asso- ciated with fcetal syphilis. The mother may be infected and the child healthy ; these are usually cases where she becomes infected during pregnancy. 3. The placenta may be affected throughout its entire thickness, or only either the maternal or fcetal portion, (a) When the mother is infected by the fecundat- ing coition, we find, with fcetal syphilis, the placenta more or less affected in all its parts; the cord, too, is usually diseased, {b) If the semen alone carry the syphilitic virus, and the mother is not infected, we have fcetal syphilis, and usually only in addition syphilis of the fcetal placenta and of the cord. But it may extend to the maternal placenta, and then the mother is infected, (c) In case the mother be infected a short time before conception, the disease not yet constitutional, and the impregnation by a healthy man, if antisyphilitic treatment be employed, a healthy child may be born. In such cases the maternal placenta alone is usually affected, (d) If the woman was infected long before concep- tion, usually the maternal placenta only is affected ; but the process may extend to the fcetal placenta, and to the fcetus. (e)' When the mother is impregnated by a healthy man and becomes infected during gestation, the maternal placenta is invariably affected, and usually there is immunity for the fcetus. The placenta cannot be free from disease if the mother be syphilitic, unless the infection occurred shortly before labor. 4. That a woman may be infected by the passage of a syphilitic fcetus through the birth-canal, and vice versa, has not been proved. 5. Experience teaches that during the first few years after syphilis has been acquired, and the disease not treated, the children usually die in the uterus, or are non-viable when born. Suitable mercurial treatment may subdue the hered- itary power of syphilis, or make it latent for a number of years; and this is true, no matter what the stage of the disease. If the disease remain in a latent con- dition in some of the organs, the effect of treatment may be that for a time healthy children are born, but later syphilitic children. Myxomatous Degeneration of the Placenta—Hydatidiform Degenera- tion of the Placenta—Vesicular Mole.—This is a disease of the chorial villi, but whether these are primarily or secondarily affected is not determined. If the disease begins before the formation of the placenta, the entire chorial surface will be involved; but if after this organ is formed it is limited to the placenta chiefly, and in some instances to a part of the placenta; or there may be but a single cotyledon, or only a small portion of the placenta affected. In the former case the embryo dies, but in the latter it may be perfectly developed, there remaining a sufficient portion of the placenta for its nutrition unaffected. In myxomatous degeneration the part affected is converted into a vast number of cyst-like formations, there may be five or six thou- sand; these vary in size, some being as large as an almond, others smaller than currants, and still others so small as to be scarcely visible to the unaided eye; their shape may be spherical, ovoidal, or pyriform ; they have been compared to a cluster of white grapes or currants; this comparison is correct as to their general appear- ance, but it fails, as pointed out by Barnes, in regard to the attach- DISEASES OF THE OVUM. 295 Fin. ment of the pedicle, or stem of an individual vesicle, for one vesicle gives origin to another, and the pedicle of the latter is connected with the former—" berry grows out of berry, and the stalks do not unite berries with principal stems, but berries with berries, and lastly with a central mother-cyst." In some cases the entire mass has been expelled inclosed in a sac, the decidua, and this had to be opened to see the peculiar formation. In the centre of the degenerated mass there is usually a cavity found ; but if the myxo- matous change began early, that is before the formation of the placenta, and all the chorial villi were affected the nutrition of the embryo has been so in- terfered with that death resulted, and the embryo has undergone solution ; a little fluid may be found in the cavity, and also the remains of a part of the umbili- cal cord. In some instances the amnial cavity has disappeared, but there is almost always found in such a case a soft, yellowish, granular, and spongy tissue occupying its space. The death of the embryo is by most regarded as the consequence, not the cause of the disease. When the disease occurs later, involving only a portion of the placenta, it may not be discovered until after the birth of a well-developed child, and the expulsion of the placenta, which upon examination shows the altered structure. The degenerated villi may penetrate by their growth into the uterine sinuses, and destroy the uterine tissue; of course such penetration renders detachment difficult, or perforation of the uterus may occur with resulting peritonitis. One of the accidents that has resulted from this disease is rupture of the uterus. The normal villi of the chorion, as shown by Virchow, have entering into them the same tissue as that which forms the so-called Wharton's jelly of the umbilical cord. Each villus has an external epithelial covering, but the framework, the body of the organ, is formed of mucous tissue. Hyperplasia of this tissue is the essential fact in myxomatous degeneration of the chorial villi. With the in- crease in volume of a villus the more it presents the appearance of mucous tissue. " The escape of fluid upon puncturing one of these enlarged villi does not prove that a cyst has been opened any more than squeezing a fluid from the cut end of an umbilical cord would show a similar fact." The pedicle of the apparent vesicle is identical with Wharton's jelly. The vessels of the villi are usually oblit- erated ; nevertheless, capillary vessels are sometimes found in the external layers, especially when a part only of the chorion is de- Hydatidiform Degeneration of the Chorion. 296 SCIENCE AND ART OF OBSTETRICS. generated, and the fcetus is viable. The contents of the enlarged villi consist of albumin, together with a relatively large quantity of mucin. The fluid is generally clear, but sometimes reddened by dissolved hematin. The disease is not frequent. Madame Boivin saw but one case in 20,375 deliveries. Diagnosis.—Depaul mentioned three important signs. 1. A more rapid development of the abdomen than occurs in normal pregnancy. In one of his patients the uterus was four fingers' breadth above the umbilicus at four months. 2. Attacks of uterine hemorrhage. This symptom has occurred as early as the forty-fifth day, and been delayed as late as the fourteenth month. Discharges of blood may, in some cases, alternate with watery discharges. 3. The expulsion of separate vesicles, or of branches of vesicles. Of course, this sign is conclusive. The pregnancy rarely goes to term ; yet, in the 32 cases collected by Boivin, in each of three it lasted until 9 months ; in three others to 10 months, while one was not delivered until 11 months, and another at 14 months. The danger to the mother is from the exhaustion caused by repeated hemorrhages, or a single sudden and large hemorrhage may prove immediately fatal. The fcetus in almost all cases dies. Yet there are instances in which a " hydatid " mass has been expelled, and the pregnancy continued to term, when a healthy child was born. Such cases were probably instances of a twin pregnancy in which the myxomatous degenera- tion affected one ovum, the one that was discharged, while the other remained healthy. Treatment.—No active treatment is indicated unless hemorrhage occurs. If this be slight, rest, cold drinks, and an opiate may be suf- ficient; but if it be severe, the tampon should be at once employed. Even should the fact of myxomatous degeneration be proved by the expulsion of hydatids, it does not follow that the uterus should be at once emptied.1 The dominant fact which guides the treatment is the hemorrhage. If this persists, if it is grave, and only temporarily restrained by the tampon, then dilate the os uteri, and remove the contents of the uterus with hands or instruments, and secure uterine hamiostasis by exciting uterine contraction mechanically, or by ergot, or by electricity; or, if these fail, use intra-uterine injections of hot water, or apply astringent solutions to the interior of the uterus. Anomalies of the Cord.—Some of these have already been men- tioned, such as length of cord, quantity of Wharton's jelly, and false knots. Coils.—One or more loops or " circulars " of the cord about the infant or one or more of its members occurs in many cases ; the most frequent are those in which the cord encircles the neck once or 1 All the world knows, remarked Depaul, that the celebrated Beclard was the result of a hydatidiform pregnancy. The possibility of a viable child being born, therefore, is the reason for abstaining from active interference in case of this disease, unless symptoms demand such interference. DISEASES OF THE OVUM. 297 oftener; in some cases an upper or lower limb may be caught in a coil. La Motte gives a case in which the cord passed around the neck, then over the chest like a scarf, and under the axilla, and again around the neck. Usually no injurious consequences follow, but in some instances, when the neck is encircled, the loop may be- come so tight that the circulation in the cord, or in the vessels of the neck, ma)' be interfered with, and the fcetus dies. " If the com- pression continues after death, the neck may be so thin that it is almost amputated." Amputation of one of the limbs may result from a tight coil of the cord around it, if continued for some time, even though the fcetus be living. Doleris1 has narrated a case in which the labor was protracted in consequence of the cord forming a double coil about the lower limbs of the fcetus at the ankles ; hence the cord was much shortened, and the fcetus, presenting by the vertex, was as it were suspended by the feet. This case illustrates one of the dangers that arises when the cord is coiled around the fcetus, relative shortness, which of course may cause the same difficulty in labor as absolute shortness does. It is possible, in some very rare cases, if the abdominal and the uterine walls are thin, to feel the pulsating cord when it encircles the body. Schatz2 claims that the diagnosis of the cord encircling the neck can be made during pregnancy by auscultation ; at first, mod- erate pressure with the stethoscope is made at the part corresponding with the depression of the neck, and the pulsations of the fcetal heart are normal in frequency; but when strong pressure is made their frequency is lessened to one-half. Knots.—In one out of two hundred infants there will be found at birth one or more knots in the umbilical cord. They result from the foetus passing through a loop of the cord, and according to most authorities may be formed in pregnancy, or during labor; Read,3 however, asserts that they cannot be formed, except by the passage of the child through the lower portion of the uterus, for a loop must fall to the vicinity of the os, it cannot remain in any other part of the uterus, and hence they can be formed only during labor; but this view is not generally accepted. Admitting the formation of knots in pregnancy, it is exceptional for the vessels to be so con- stricted as to interfere with the circulation of blood. Depaul has found in one instance five knots in the cord, quite near together, but the foetus was living and well nourished. On the other hand, Martin Saint-Ange has seen death of the fcetus result from a single knot, and many similar cases have been reported. Great length of the cord predisposes to this accident, and a relatively great size of the uterus facilitates its occurrence in pregnancy. The knot is sometimes double, as in a case observed by Dr. George H. Lyman, of Boston. Read gives the representations* of the successive stages in the 1 Archives de Tocologie, 1882. 2 Revue Medico-chirurgicale des Maladies des Femmes, 1885. :i American Journal of the Medical Sciences, October, 1861. * Charpentier in using these illustrations has substituted Leyman for Lyman. 298 SCIENCE AND ART OF OBSTETRICS. formation of the knot in Lyman's case. (See Figs. 111, 112, and 113.) Excessive Torsion.—Twisting of the cord upon its axis generally occurs, according to Spiegelberg, in the second half of pregnancy, especially in the seventh lunar month. He refers to torsions as " premortal," and "postmortal." The first are caused by the active movements of the fcetus, or by a severe fall received by the mother. Knot in the Stage of Formation. As it was found at Birth P. Placental end. Winckel suggests that the movements of one of the two foetuses contained in a single amnion may cause twisting of the cord of the other. The " postmortal " torsions are caused by the movements of the mother. Dancing is mentioned by Kormann as a cause of torsions of the cord. They occur more frequently in male than in female foetuses, the proportion being 13 to 9. Excessive move- ments of the fcetus, causing torsions of the cord, were attributed by Billi (quoted by Hecker) to disease of the brain. The facility of active and of passive movements, too, in the fcetus of the multi- gravida being greater than in the primigravida, these torsions are more frequent in the former. It is said that a division of the cord may be caused in a short, tense cord by twisting, it being thus separated from the fcetus, so that the latter is unattached in the uterine cavity. The torsions are most numerous in the vicinity of the umbilicus, and next at the attachment of the cord to the pla- DISEASES OF THE OVUM. 299 centa. Torsions of the cord may cause occlusion of its vessels, or only stenosis. Death of the fcetus follows occlusion or decided stenosis. In some instances fine thrombi are found in the vessels ; these indicate that the torsions occurred suddenly. Fritsch has observed that in some cases torsions occur in successive preg- nancies. I have seen a case in which there were forty-six twists in the cord; the fcetus had died in the seventh month, and was macerated. Narrowing of the vessels may occur independently of torsions. These stenoses are usually found in the vein near its placental end ; " they were first observed by Oedmanson and Winckel, and their anatomical description given by Birch- Hirschfeld.'' They have been described as sharply defined proliferations of the intima, partly of fusiform, partly of round cells, and forming a fibrillated tissue, as a granular matrix with oval and globular nuclei. Beginning in the intima, the adventitia becomes affected ultimately, and shows an accumulation of lymphoid elements. Birch-Hirschfeld found circumscribed stenoses involving the intima of the arteries in the vicinity of the navel and of the placenta; he regards them as resulting from syphilis, stating that the microscopical examination agrees in every particular with those changes which Heubner described as syphilis of the vessels of the brain. According to Spaeth, atheromatous changes may occur in the arteries. ' Stenosis may be the consequence of periphlebitis, according to Hyrtl. Cysts found in the cord are remnants of the urachus lined with epithe- lium. Martin-Saint-Ange1 narrates a case of a dead fcetus being expelled at seven months, the death caused by complete strangulation of the cord lying between the legs, which crossed each other and were firmly applied together by a convul- sive condition. 1 Op. cit. CHAPTER XI. DISEASES OF THE OVUM—DEATH OF THE Fc. 3 Probably the first historical reference to a person having supernumerary fingers and toes is in the Bible, 2 Samuel, chap, xxi., ver. 20. * Centralblatt f. Gynakol., 1889. 5 American System of Obstetrics, vol. i. 6 Arch, de Tocologie, 1889. 7 De la Pneumonie pendant la Grossesse, Annales de Gynecol., 1889. 3°4 SCIENCE AND ART OF OBSTETRICS. liver, spleen, supra-renals, pancreas and intestine, on its serous membranes and in its bones; they are most constant in the latter and in the spleen." In the spleen no pathological products have been found, but the organ is greatly enlarged. An osteo-chondritis is the special manifestation of syphilis, and is found in the tubular bones, the lowest end of the femur usually showing the most strik- ing changes. The disease "begins with an excessive proliferation of the cells at the margin of the epiphysis, which is rapidly followed by an irregular calcareous infiltration and sclerosis of the newly formed tissue." If the child is born living it is usually feeble, under sized, its skin presenting syphilitic eruptions, pemphigus and im- petigo, and there are buccal and genital mucous patches. Its cry is weak, and it suffers from obstinate coryza. Rhachitis.—Intra-uterine rickets produces similar deformities to those caused by the disease occurring after birth. Fractures of bones are not uncommon, and the limbs are not developed in pro- portion to the trunk, but are short. Spontaneous Amputations.—These may concern the upper or the lower limbs, more frequently, however, the latter ; they are caused either by amniotic bands or by the cord encircling the member that becomes mutilated, producing a constriction which prevents the part below the constricted place receiving any blood; if the bone be cartilaginous there is no improbability in the statement that complete section may occur, but in some cases at least of spon- taneous amputation the final separation of the member, after constriction of the soft parts, has resulted from a fracture. Cases of amputation cannot be confounded with those where there has been deficient develop- ment, for the amputated member has been expelled with the fcetus from the uterus. Generally those fetuses to whom this accident has happened are stillborn. Spontaneous and Accidental Fractures.—Chaussier saw one fcetus with 43 fractures in different parts of the skeleton, and another with 113. The late Dr. Hodgen, of St. Louis, reported the case of a child which at birth had 65 fractures; he attributed them to muscu- lar action during intra-uterine lifex Branfoot2 reports delivering a fcetus with the femurs and both bones of each leg fractured. Fractures may be caused by external violence to the mother. Pack- ard3 gives cases in which the broken bones were firmly united at birth, but others in which there was no union. Brinton has re- 1 St. Louis Medical and Surgical Journal, 1882. * British Medical Journal, 1888. '■'■ International Encyclopaedia of Surgery, vol. iv. Spontaneous Intra-uterine Amputation. DEATH OF THE FOETUS. 305 ported two cases of intra-uterine fracture, one of the tibia, the other of the clavicle, occurring from injuries received by the mothers.1 Luxations.—Dislocations of bones, more especially of the femurs, occurring in the fcetus are not absolutely rare, though their etiology is obscure. They are observed more frequently in females than in males. In some instances they may be the result of external vio- lence, but in most no such cause can be adduced, and therefore they are attributed to " anomalous development of articular cavities." Tumors.—In addition to the tumors caused by spina bifida, ompha- locele, meningocele, or encephalocele, various other tumors, fluid or solid, may be found upon different parts of the body. Some of these are pedunculated, others attached by a broad base; some are so large as to render parturition difficult or impossible without opera- tive means. Death of the Fcetus.—The fcetus having perished from disease or injury, whether affecting it directly or mediately, we have next to study the diagnosis, and the consequences of its death. Diagnosis of the Death of the Foetus.—The previous recognition of the fcetus being, alive facilitates the inquiry as to its being dead ; by the continued absence of those signs which gave conclusive proof of its life, we have a strong probability of its death; this absence must be ascertained by a most careful examination—indeed it is safer to repeat the examination once or oftener. The death may have occurred prior to the time that positive proofs of life were available, or they may not have been ascertained. We inquire as to whether any injurious influences, paternal, maternal, or directly acting upon the fcetus, the common result of which is death, have been present. Thus the father, or the mother may be affected with syphilis, the mother may have had an acute infectious disease, or received some severe injury. The absence of foetal movements which the mother had certainly recognized, the deterioration of her health, the breasts after having been, full, and possibly secreting milk, becoming flaccid, she is pale or sallow, has occasional chilly sensations, the abdominal wall somewhat relaxed, and she may complain of what seems a dull weight in the abdomen falling from one to the other side in correspondence with changes of position in bed. The temperature of the .uterus being greater than that of the vagina in pregnancy, will now show no such change; but this ex- amination will rarely be made. There is one sign constantly avail- able which, I believe, is a positive proof of the death of the fcetus, and that is, if, with the negative evidence furnished by auscultation and palpation there is found progressive diminution in the size of the abdomen, the woman not suffering from any disease explaining this change, we are justified in concluding that the child is dead. Last winter a multigravida whose pregnancy had lasted some seven months, came to the Jefferson Medical College Hospital, stating that she believed the child was dead. She was a Russian, and very little definite information could be got from her because of the difficulty of her understanding the questions addressed iier, or of others understanding the answers she made. I determined to rest the 1 Transactions of the American Surgical Association, vol. ii. 20 306 SCIENCE AND ART OF OBSTETRICS. diagnosis upon—all evidences of the child being alive furnished by repeated auscultation and palpation being negative—the progressive diminution in the abdominal circumference—diminution, whereas had the child been living there ought to be a constant increase. She was kept under observation three weeks, careful measurements being made from time to time by Dr. E. Graham. Finding this diminution, although not great, constant, I introduced, before the class during a clinic, a flexible bougie into the uterus, of course all antiseptic precautions being taken, and in twenty-seven hours she expelled a macerated fcutus of six months and a half; convalescence promptly followed. There may be conjoined with examination by measurement of the abdominal circumference, weighing the patient from week to week; if the child be dead she will probably lose in weight, whereas if it be alive there will be a constant gain. Consequences of the Death of the Foetus or Embryo.—These are remote or immediate. The only remote consequence is the expul- sion of the uterine contents, and this will be first considered, very briefly, however, because the subject must be presented elsewhere. This expulsion usually takes place within two weeks, and if delayed beyond that time the name given is missed abortion. This delay may be for a few weeks, or even for several months. In the case of one of twins dying during pregnancy it is not unusual for it to be re- tained until the normal end of pregnancy, and then it is expelled along with the living child. Such cases, improperly interpreted have furnished an argument for those who believe in superfcetation. So too in a single pregnancy, a three months' fcetus, for example, may be expelled at the end of nine months' gestation, and this ought to be borne in mind by the practitioner, lest a wife, her husband having been absent for some months before such expulsion, may suffer unjust suspicion or reproach. The Immediate Consequences of Death of the Product of Conception. —Certain changes follow this event; they are liquefaction, mummi- fication, maceration, and putrefaction. I. Liquefaction.—This may occur during the first two months at least, the embryo being dissolved so completely that no trace or only a trace of it is left. The amnial liquor becomes thick and opaque, sometimes having a milk-like appearance like an emulsion. Impor- tant changes meanwhile occur in the fcetal appendages. If myxoma- tous degeneration of the chorial villi has already begun, it continues. But more frequently the formation of what has been termed a fleshy mole1 follows. This is composed of the deciduous membranes, and the membranes of the ovum with a central cavity occupied as men- 1 Depaul has remarked that (Dictionnaire Encyclopedique des Sciences M6dicales, second series, vol. ix.) " nothing is yet more obscure to-day, than the etymology of the word mole. The most natural is that which derives it from the Latin word moles, which signifies mass." I think that Depaul is mistaken. It seems that both Hippocrates and Aristotle applied the word ISl'uAr), which originally meant a mill, to " a hard formation in a woman's womb.'' From this word the Romans had mola, also primarily meaning a mill; Pliny certainly applied mola to such an intra-uterine formation as has been mentioned. But both fivfai and mola mean secondarily the stone which was essential for grinding. Hippocrates undoubtedly had ob- served calcified fibroids discharged from the uterus, and it was quite natural that such a forma- tion should be called fibAT]. The application of the term to other solid masses expelled from the uterus would obviously follow. And, therefore, the derivation of the term mole from moles is unnecessary, for it seems properly to originate from the Greek fivki), the Latin mola. DEATH OF THE FCETUS. 307 tioned, of the placenta in process of formation, and of blood which is infiltrated between the chorial villi and between the membranes. The separation between the mass and the uterus being incomplete, the former is nourished, and growth of its elements continues, the clots are absorbed, or the fibrin, according to Scanzoni, becomes organized, the amnial cavity grows smaller, and finally a nearly solid mass results. The " fleshy mole" may be retained in the ute- rus for some weeks, giving rise meantime to occasional attacks of uterine " pains" and hemorrhage. 2. Mummification.—This has been compared to the change which a fruit undergoes when kept in alcohol. The soft tissues of the fce- tus become condensed, contracted, hardened, dried up, and thus it is lessened in size and presents a shrivelled appearance; its color becomes a dull gray or yellow, presenting a striking contrast with the normal color of the living fcetus. The amnial liquor finally disappears, leaving as a residue an earthy, grayish sediment "similar to the deposit left by a stream after an overflow of its banks." Mummification, of course, does not occur if the membranes have been ruptured, nor is it usually seen except in a fcetus of three to four months. 3. Maceration.—The macerated foetus is larger than corresponds with the period of intra-uterine life at which it perished ; it is swollen, its form changed, the abdominal cavity is often greatly distended ; its tissues are softened, the bones lose their firm attachment, and especially those of the cranium move freely upon pressure ; the skin presents numerous blebs, and the epidermis comes off in large flakes, showing the derm beneath of a dusky red ; the serous cavities con- tain blood-stained serum, and the blood escaped from its vessels contributes its coloring matter to dyeing the tissues. While the odor of the macerated fcetus is not pleasant, it cannot be called offensive like that which results from putrefaction. Ribemont-Dessaignes,1 after referring to the generally admitted view that the signs of external maceration—the formation of blebs and the detachment of the epidermis—are not manifested until the third day after the death of the fcetus, holds that these lesions may appear much earlier, a few hours after death, and even upon the living foetus, and adduces cases in illustration. 4. Putrefaction.—This occurs when the membranes have been ruptured, and thus air gets access; air with moisture and warmth furnishes the essential conditions for putrefactive changes. Putrefac- tion occurs very rapidly, and McClintock,2 referring to this fact, stated that he had seen the uterus become quite tympanitic from this cause after the accession of labor and before delivery. The abdo- men of the fcetus is distended by gas, the connective tissue emphy- sematous, crepitating upon touch, the entire body and members greatly swelled, so that serious difficulty in delivery may be pre- sented, and a horrible odor exhales from the fcetus. In some cases gas accumulates in the uterus, a condition known as physometra, 1 Annales de GynScologie, July, 1889. 2 Note to Sydenham Society's edition of Smellie's Midwifery. 308 SCIENCE AND ART OF OBSTETRICS. and the organ is greatly distended and tympanitic. Generally the effect of fcetal putrefaction upon the mother is more or less grave; she has chills, fever, diarrhoea, and death may result from the infec- tion of her system, unless the decomposing fcetus be promptly re- moved, and appropriate local antisepsis be employed. Abortion.—Abortion is the expulsion of the product of conception before the fcetus is viable. Miscarriage is commonly used as a synonym, though by some it is restricted to an abortion occurring after three months;1 the reason for this distinction is that the treat- ment of the accident varies at these different periods. But such distinction is purely arbitrary. Further, abortion has been divided into ovular, embryonic, and fcetal; the first is applied to an abor- tion in the first three weeks, the second to that which happens between the end of the three weeks and of the first three months, and fcetal is used to designate the accident from the end of three to that of six months. Classification.—Abortion has been divided into spontaneous, or natural, and accidental; by the former a miscarriage occurring from obscure or latent causes is designated, and by the latter one that has an obvious cause. But this distinction is in many cases impos- sible to be made. A better division is into spontaneous and artifi- cial. The latter class is divided into therapeutic and criminal; therapeutic abortion is that which is done by the physician in the interest of the mother's life or health, while criminal abortion is without this or any other justification. The term incomplete, or imperfect, is applied to abortions in which the entire ovum is not ex- pelled. Missed abortion has been previously defined. Frequency.—There are, and there can be, no data by which the absolute or relative frequency of abortion can be ascertained, for many cases occur without the subjects knowing it, and many other abortions are self-produced, or performed by professional abortion- ists, and, therefore, kept secret; in only exceptional instances when a fatal result follows do medical men or the public know of them. Whitehead's statistics2 show that 87 per cent, of women living in wedlock until after the menopause had aborted at some time in their married life. Priestley3 estimates the number of abortions as one to four labors. Even this proportion, though greater than given by most writers, is probably too small. The sterility of prostitutes as well as that of many newly married women may be attributed to early abortion. Time of Abortion.—The greater number of miscarriages occur in the first three months of pregnancy. There is an exception to this rule, however, given by those cases of criminal abortion which be- come subjects of judicial inquiry. Tardieu4 has shown by statistics collected by himself and others that criminal abortion is more fre- quent from the third to the sixth month than in the first two months. The explanation of this fact is, that up to three months a woman 1 Miscarriage in this restricted sense is also called parlus immaturus. - Abortion and sterility. '■> Op. cit. 4 Etude Mtdico-legale sur l'Avortern snt. ABORTION. 309 hopes there is simply a delay in the appearance of the flow, but when this hope fails she is ready to resort to active means to end a pregnancy which has now become almost certain; on the other hand, when six months have elapsed the life of the child has be- come so manifest that she shrinks from its destruction—fcetal move- ments make successful appeal to the mother's conscience, if not to her love also, for the salvation of the new life which dwells within her womb as its sanctuary. The great majority of spontaneous abortions occur at a time corresponding with a monthly flow; Boer- haave made the proportion nine out of ten. Causes of Abortion.— Very trifling causes may produce miscarriage in some women. La Motte has said that a misstep, raising the arms too high, a strong odor, as of musk, amber, or civet, a bad odor, as from a dead animal in the road, from a charcoal fire just kindled, or from a lamp or candle imperfectly extinguished, may end the pregnancy in some. On the other hand, the most active exercise, the severest injuries, grave surgical operations, the most cruel violence, or the use of enormous doses of irritant medicines reputed abortive, have not caused miscarriage in others. Instances of frequently recurring abortion are not uncommon ; one has been mentioned of a woman who miscarried twenty-four times at three months. These have been termed habitual abortion. But as remarked by Kleinwachter, habit is not to be regarded as a cause; it would be more rational, since habit did not begin the series, to attribute the abortion, in most cases, to the still acting original cause. Dr. Meigs ascribed so-called habitual abortions to excessive irritability of the uterus; others have held that they were caused by a want of nutritive material in the uterus for its complete development, the organ growing for a time, and then the growth ceases, and abortion follows. Neither hypothesis rests upon estab- lished facts, but each indicates the incorrectness of the view that habit is its cause. The causes of miscarriage do not, in all cases, act separately, but very frequently two or more are combined. Some simply predis- pose to the accident, while others are the efficient agents. In their further consideration, it is convenient to divide them into paternal, maternal, and those belonging to the ovum. Paternal Causes.—According to Deviliers, the procreative power being distinct from that of development, the evolution of the pro- duct of conception is almost entirely under the influence of the degree of vitality of the mother. Nevertheless, the father being syphilitic, the fcetus may be infected and perish, though the mother remains healthy. It is quite possible, too, that in addition to syph- ilis other diseased conditions of the father, such as alcoholism and phthisis, may result in a fcetal malady which is incompatible with the continuance of pregnancy. The injurious influence of lead-poi- soning acting through the mother upon the fcetus has been shown by Constantin Paul,1 Roque,2 and Rennert.3 But Lefour4 has also 1 Arch. Gen. de Medecine, i860. 2 Paris Thesis, 1873. :i Arch, fiir Gyn'akol., 1881. 4 Gaz. hebd. des Sci. Med. de Bordeaux, 1887. 3IO SCIENCE AND ART OF OBSTETRICS. shown that if the father be a worker in lead, the mother not being exposed to lead-poisoning, there is great liability to abortion. Maternal Causes.—These may be divided into external and inter- nal, or those coming from without and those acting from within. Among external causes are violent exercise, as running, dancing, jumping, riding on a bard trotting horse or over a rough road; lifting heavy weights, falls, blows1 upon the abdomen, compression of the body by clothing or by corsets, compression of a varicose limb, the use of the uterine sound, applications to the cervix, leech- ing the cervix or the vulva, and surgical operations, especially if involving the genital zone. Frequency of coition is not unseldom a cause of miscarriage. Whitehead2 has stated that there can be little doubt that a great number of cases of uterine disease, attended with vaginal discharge, and frequently resulting in abortion, may be attributed to intemperate sexual intercourse during pregnancy. Depaul held that two-thirds of the spontaneous abortions were caused by coition, while Miquel, of Tours, makes the proportion still greater, nine out of ten. Great altitudes are said to be a cause, and it is asserted that in certain mountainous countries pregnant women descend to the valleys to escape the accident. Hot climates are thought by some to cause it. This effect has also been attributed to hot baths. This opinion is confirmed by the statement of Kormann,3 that when used to excess they are apt to produce a miscarriage. Among internal causes are acute infectious diseases. Chronic infectious diseases differ in their influence upon pregnancy, phthisis comparatively seldom arresting it, while syphilis frequently does. Olshausen regards syphilis and retroflexion of the uterus as the most frequent causes of spontaneous abortion. Some of the sporadic diseases produce the same result, as has been previously mentioned ; so may lead-poisoning and albuminous nephritis.4 It is by some held that a pregnant woman working in a tobacco factory is thereby rendered liable to miscarriage. Abortion may result from violent sneezing, coughing, or vomiting; likewise from diarrhoea or dysen- tery. Adhesions of the uterus from former peritoneal inflamma- tion may prevent the development of the organ, and thus make an end to the pregnancy ; so, too, rigidity of its body, or relaxation of the cervix, are'regarded as causes. Abdominal tumors external to the uterus may occupy so much space that there is no room for the pregnant uterus, and hence its contractions resulting in expulsion 1 History gives us two noted instances of husbands causing abortion by kicking their wives. One of these was Cambyses, the son of Cyrus: he is referred to in " Ezra'' as Ahasuerus. He subjugated Egypt more than 500 years before the Christian era ; while living in that coun- try, according to Herodotus, he married his sister, and one day becoming enraged at her just rebuke of some of his many evil acts, kicked her, she being pregnant at the time, and death, preceded by miscarriage, resulted. In Fleury's Histoire Ecclesiastique, Paris, 1722, it is stated that one of the crimes of Xova- tus, an heresiarch of the Carthage church about the year 250 A.D., was kicking his pregnant wife, causing miscarriage. 2 Op. cit. s Op. cit. * The testimony of medical men who have investigated this subject differs, but I think the weight of authority is in favor of the statement made in the text. See article by Dr. Pradel, Journ. de Med. de Paris, Aug. 5, 1888. ABORTION. 3H of the ovum may be evoked. Positional and structural diseases of the uterus are causes. Among the former prolapse and posterior displacements are of especial significance; among the latter malig- nant diseases, particularly of the fundus, and polypi and fibroid tumors. Strong mental emotions as fear, sorrow, joy, or anger may produce it. Whitehead and Duncan, among others, have mentioned the fact that the last pregnancy in the childbearing period is quite liable to end in a miscarriage. Abortion from the Use of Medicines.—It sometimes happens that abortion is caused by the use of drugs, as, for example, active ca- thartics, or even laxatives, or emetics.1 It may be that in some cases the administration of quinine has been followed by miscarriage, and while in almost all instances the event is justly attributed to the disease for which the medicine is given, yet possibly the latter, in a few, was, from some peculiarity of constitution of the individual, the efficient agent. Nevertheless, neither this nor any other drug can be regarded as an abortifacient; there must be some tendency to miscarriage, some abnormal condition which renders those who thus suffer after taking any of these agents, liable to miscarry. I have known two pregnant married women take an infusion of May-apple in such large quantity as to produce violent catharsis and emesis with great prostration, yet in neither was the pregnancy interrupted. Causes belonging to the Ovum.—Velpeau, after examining the ova from two hundred abortions which occurred under three months, found one-half were diseased. The various diseases of the decidua that have been mentioned, and its premature atrophy, are frequent causes; also placental apoplexy, and the different degenerations of the placenta. Polyhydramnios in most instances causes the preg- nancy to be arrested, in consequence of the great distention of the womb resulting from the rapid and large accumulation of amnial liquor. The uterus, too, in many cases reacts prematurely in con- sequence of similar excessive distention in plural pregnancy. Ab- normal site of the placenta frequently leads to miscarriage. The fcetus may be affected by the same disease as the mother, or suffer independently of her, and its death result in abortion. Disease of the umbilical cord, or its compression, may have a like fatal effect upon it, and thus upon the pregnancy. Symptoms.—In some cases of abortion premonitory symptoms may be observed. These are alternate flushes of heat and chilli- ness, a feeling of languor or feebleness, lumbar pain, a sensation of pelvic weight, of fulness of the lower part of the abdomen, some irritability of the bladder, and possibly of the rectum also. The characteristic symptoms are hemorrhage and painful con- tractions ; contractions are, indeed, the efficient cause of abortion. In the first weeks it may be readily mistaken by the woman herself, especially if she has had other early miscarriages, and by the phy- 1 Drs. Mann and Sperry have each reported a case of abortion following the internal admin- istration of the potassium permanganate. Therapeutic Gazette, 1887. 312 SCIENCE AND ART OF OBSTETRICS. sician, for an attack of dysmenorrhcea. But the rule is, that in the latter pain precedes the flow of blood, whereas in the former the phenomena occur in the reverse order, or else they are associated. Some cases have early in their progress a gush of watery fluid slightly discolored with blood; this discharge does not necessarily indicate rupture of the ovum, and hence that miscarriage is inevitable, for it may occur from catarrhal endometritis. But no such discharge occurs either before or during menstruation. Usually the flow of blood is very much greater than that which occurs in menstruation. Further, it is possible some of the sympathetic disturbances arising from pregnancy may have appeared, and if so, this fact will assist in making a diagnosis. The final proof of the case being one of abor- tion, and not of difficult menstruation, would be finding the ovum in the discharge, possibly surrounded by a clot of blood. The ovum of an early abortion is generally entire, though the fact that the sac is ruptured is not a proof, as claimed by some, that the miscarriage has resulted from criminal means. In some cases, occurring from the first to the second month, blood may not only be effused between the decidua and the chorion, but also penetrate the chorion and then the amnion, more or less completely filling the amnial cavity. If the pregnancy has advanced to seven or eight weeks, or further, but still not reached three months, the symptoms of abortion are usually quite plain. The suffering, the regular recurrence of the pains, and the marked hemorrhage, scarcely leave room for doubt. It is a labor in miniature, at least so far as it relates to the expelling organ and to the expelled product,'but not in miniature in regard to the duration of the process and the attendant suffering. The ovum is in the majority of cases expelled entire if there has been no im- proper interference. The chorial villi are very distinct, and, as Pajot has said, the entire external surface of the ovum is placenta. The deciduous membranes are usually discharged afterward—at least a considerable portion of these does not pass off with the ovum. If the pregnancy has advanced to three months or beyond—that is, if the abortion be fcetal—the ovum is usually ruptured in the process, and the fcetus is expelled first, while its appendages wait a renewal of uterine activity for their discharge. In this respect the course is similar to that of labor. A delay of many hours, or even of several days, may occur in the expulsion of the fcetal append- ages; and during this retention the patient is liable to attacks of hemorrhage, or she may have a bloody and purulent offensive dis- charge. Secondary Cervical Pregnancy.—In some instances of early abortion, the ovum is expelled from the uterine, but remains in the cervical cavity, and, it has been asserted, is nourished through an elongated portion of the serotine membrane which thus forms a pedicle. The ovum continues to grow until the limit of the expansibility of the cervical canal is reached, that is, until about the third month. The possibility of this occurrence is greater in primigravidae. Montgomery1 has recently reported a case of cervical pregnancy. But, as cited by Thevenot, while 1 American Journal of Obstetrics, 1885. ABORTION. 313 primary cervical pregnancy may occur, though very rarely, the secondary form does not exist; those described as such should be regarded as cases of tem- porarily arrested abortion; growth of the ovum in the cervical cavity in such conditions, even if the pedicle of the serotine membrane were demonstrated, is very improbable. It happens in some cases that after severe pains, and more or less hemorrhage with dilatation, so that the finger can touch the ovum, even, too, with discharge of a fragment of decidua, as has been ob- served by Spiegelberg, Matthews Duncan, and others, the symptoms of miscarriage gradually cease, and the pregnancy is completed. More frequently, however, the cessation is temporary ; it may last some hours, or even days, and then uterine action is renewed, and the usual result follows. In those cases of threatened abortion in the early months in which the symptoms permanently cease, though there had been considerable hemorrhage, the discharge came from detachment of the ovum at its lower segment, not from detachment of the placenta; indeed such cases are usually seen before the pla- centa is completely formed. In the fourth month, and on to the seventh, the course of abor- tion is similar to that of premature, or of mature labor, the process being, however, longer than in labor, because the cervical changes which precede the latter must be effected, and because the uterine muscular structure is imperfectly developed. Hemorrhage is less to be feared as the seventh month is approached ; the uterine decidua is more readily cast off in late than in early abortions. Before the formation of the placenta the hemorrhage comes from the entire internal surface of the uterus, but after this has taken place only from the site of placental attachment. Very little discharge follows an abortion in the early months if it be complete; but if a portion of the ovum be retained, the hemorrhage may be great, and there is also in many cases a very offensive flow. Milk is usually secreted after miscarriage, in some instances even when that occurs quite early in pregnancy. Prognosis.—If the abortion be inevitable, of course the fcetus dies, or is already dead, and the practitioner is concerned with the inter- ests of the mother alone. The chief immediate dangers are hemor- rhage or septicaemia,1 which may be general, or be limited to a local pelvic inflammation. Tetanus has occasionally followed. Putrid decomposition of fragments left in the uterus, according to Klein- wachter, is less frequent than generally believed, because of the difficult entrance of air, and because manual intervention is less frequently resorted to than in birth at the normal time. The fatality following criminal abortion is very great. Hippoc- rates said that abortion was much more dangerous than labor, because the product of conception could not be destroyed except by violent means; but this remark is especially applicable to criminal abortions. Tardieu states that in 116 of this class, in which 1 In a paper upon Midwifery Among the Burmese, the author, Dr. Pedley, states that "puer- peral fever is recognized by Burmese midvvives, and seems to be more frequent after abortion." Transactions of the London Obstetrical Society, vol. xxix. 314 SCIENCE AND ART OF OBSTETRICS. the termination was certainly known, death occurred more or less promptly in 60. He refers to cases of sudden death which may be caused by embolism, by syncope either from excessive pain, or from the moral shock created by the consciousness of crime. Other causes which conduce to the fatality of criminal abortion are the secrecy with which the operation is done; usually the unhappy victim goes to the house of the abortionist, and he or she, for women are also engaged in the wicked work, endeavors to puncture or de- tach the membranes, possibly wounding the uterus in these efforts, in many instances " made by an ignorant or brutal hand, or one that trembles with conscious guilt." After the operation the subject walks or rides probably a long distance to her home, and there, in order to conceal all knowledge of her condition, engages in her usual avocation or work, until grave symptoms compel her to rest, and possibly to send for a physician. The remote dangers of abortion are chronic parenchymatous metritis, very often spoken of as sub-involution, and positional dis- order of the uterus; a portion of the placenta may remain, and be converted into a placental polypus, or hypertrophy of undetached decidua may occur, and either be the cause of uterine hemorrhage. These dangers may be prevented in most cases by proper care during and after abortion. Unfortunately too many women look upon miscarriage as a trivial matter, and do not take the rest after it that they ought. Treatment.—The treatment may be considered under three heads, prophylaxis, that required in threatened or commencing abortion, and that of inevitable abortion. Prophylactic Treatment.—This includes a recognition of the causes of miscarriage in individual cases, and their removal. It is not necessary to repeat the etiology of this accident, nor the treatment required in different cases. In habitually recurring abortion the probability is that syphilis, or uterine retroflexion, or an endometri- tis is the cause. The late Professor Henry Miller, of the University of Louisville, who was one of the first American physicians to teach and to practise the local treatment of uterine diseases, regarded inflammation of the lining membrane of the uterus as one of the most frequent causes of miscarriage, and urged the importance of properly treating the former in order to prevent the latter. When a woman who has previously aborted becomes pregnant, she should be advised to avoid all exercise at the time in the new pregnancy corresponding with that in the former when abortion occurred. So, too, rest at the times corresponding with " monthly periods " should be enjoined. Sexual intercourse ought to be forbidden. The late Sir James Y. Simpson advised the potassic chlorate, ten to twenty grains three times a day, as a preventive; he gave it for placental disease, and also as a means of arterializing the blood: it is impossible for it to produce the effect upon the blood suggested. Priestley states that many practitioners have tes- tified to its utility as well as to its harmlessness, and suggests that it may act suc- cessfully as an alkaline salt in preventing the formation of congestive and fibrinous deposits in the placenta. A preparation from the bark of the black haw ( Viburnum prunifolium) was recommended by Phares, in 1866, as useful in preventing mis- ABORTION. 315 carriage ; since then it has been occasionally endorsed for this purpose by others ; recently Wilson and Campbell1 have recommended it very highly, sustaining the claims previously made for this medicine, that it is a tonic and uterine seda- tive ; pills of two to four grains of the solid extract were given three or four times a day; Wood'2 states that we have no exact knowledge of the action of the remedy, and its value must be considered at present apocryphal. The dose of the fluid extract, the only preparation of viburnum which is officinal, is from half a teaspoonful to one or two teaspoonfuls, three times a day. In most cases if four months have passed without abortion occur- ring, that is, if a previous one were before this time, the probability is that pregnancy will not be disturbed, and the patient may grad- ally resume a moderately active life. Treatment of beginning Abortion.—Here the characteristic symp- toms, to wit, hemorrhage and uterine contractions, are present; under only three conditions is the abortion inevitable, the first is the death of the embryo or fcetus, the second, detachment of a large portion of the ovum, and the third, rupture of the ovum. But it is in excep- tional cases the physician can know at the beginning that any one of these conditions is present, and therefore his duty in all cases is to endeavor to arrest the miscarriage. The patient should at once lie down, her clothing being quite loose, the bed moderately hard, and she should be only lightly covered; her drinks should be cold— iced lemonade is very commonly given. Twenty drops of laudanum with half a teacup of warm water should be at once injected into the rectum, or an equivalent amount of opium in the form of a sup- pository may be used. The purpose sought to be accomplished by the opiate is to lessen the irritability and arrest the contractions of the uterus; it is claimed by some that the pregnant woman bears this remedy much better than when not pregnant. If the contrac- tions have not decidedly abated in one hour, the injection or sup- pository is repeated, and again if necessary at the end of the second hour, and still again at the end of the third hour. If the patient is very nervous and restless, twenty to thirty grains of chloral may be added to one of the opiate injections, and then the vehicle should be, not warm water, but the yelk of an egg and some warm milk. When opiates are given freely, it is quite possible that retention of urine will follow, and if this is the case the catheter should be used as needed, twice or thrice in the twenty-four hours ; the employment of the instrument is preferable to allowing the patient to sit up to urinate. The opium may be continued from day to day as long as there is any hope of arresting the abortion. Meantime, once in two days the bowels should be opened by a warm-water injection, or by a mild laxative. Supposing the pain and hemorrhage to cease, it is better for the patient to remain in bed for three or four days after this cessation; when she gets up she should only gradu- ally resume her usual habits of life, even then as an experiment, and prepared to return to bed at the first recurrence of the former symptoms. Unfortunately, in the majority of cases, the pains and hemorrhage do not cease, or having stopped they return, and the British Medical Journal, 1886. 3 U. S. Dispensatory, 1883. 316 SCIENCE AND ART OF OBSTETRICS. abortion is apparently inevitable, or the flow may be so great that its arrest is necessary without regard to the continuance of the pregnancy. Treatment of Inevitable Abortion.—Two indications are presented —stop the bleeding and empty the uterus. The application of cloths, wrung out of ice-water, to the vulva, to the lower part of the abdomen, and to the upper part of the thighs, has been recom- mended ; but apart from the uncertainty of this use of cold, such applications may chill the patient, and will make her uncomfortable, and may cause, if there be liability to either, an attack of bronchitis or of rheumatism. Vaginal injections of very hot water are to be preferred, both for haemostasis and exciting uterine action. If the os be sufficiently dilated to permit immediate and complete evacua- tion of the uterine cavity, this should be done. And to this end firm pressure is made with one hand through the abdominal wall upon the uterus, while in some cases two or more fingers are intro- duced into the uterine cavity to assist in the delivery of its contents, the greatest care being taken to avoid rupture of the ovum, if this be still entire. But in case the os is but little open, some advise dilatation, espe- cially by means of Barnes's dilators; Dr. Murphy, of Sunderland, for example, rejects the vaginal tampon, and uses them as a most efficient uterine tampon, not only arresting the hemorrhage, but making possible and hastening a complete delivery. The most valuable, the safest, and most certain means of arresting the hemorrhage generally available is the tampon. Of course the tampon can be best applied by using Sims's speculum, but this is not essential unless possibly when the hemorrhage is so great that the entire vagina must be tamponed. The following method may be satisfactorily employed in almost all cases: The vagina should be washed out with an antiseptic injection, and the bladder emptied; let the patient lie on her back with flexed legs and thighs ; the prac- titioner having provided a number of balls of absorbent cotton about the size of a hulled walnut, and some iodoform in powder, or a solu- tion of carbolic acid, now separates the labia with two fingers of one hand, then by means of an ordinary dressing forceps in the other hand, carries one and then another of the cotton balls up into the vaginal vault, firmly pressing them around the cervix; the balls first introduced should be covered with iodoform or dipped in the carbolized water. After filling the vaginal vault with the cotton, another layer of balls is firmly placed beneath the first, and still one or two beneath that, until at least the upper third of the vagina is completely filled, and the os uteri covered over. The use of an astringent solution, such as one of the salts of iron, is unnecessary, for by no possibility can one drop of the fluid come in contact with the bleeding surface, and needless irritation, even inflammation and sloughing of the vagina may occur if concentrated solution is em- ployed. Instead of balls of cotton, strips of iodoform or of creolin gauze may be used. I have in some instances made a vaginal tampon by taking a strip of absorbent cotton, 10 or 12 inches long, and about 2 inches broad; let one side of the strip ABORTION. 317 be covered with a 4 per cent, creolin ointment; then seizing one end of the cotton with forceps, while the vulvar orifice is kept open, it is carried up to the anterior portion of the vaginal vault, and from this as a starting point alternate folds made posteriorly and anteriorly until the upper part of the vagina is completely packed, a second and a third strip being used as necessary : the value of this method of using cotton as a tampon rests upon facility of application and of removal. In only rare cases will it be necessary to tampon the entire vagina, and secure the packing by a T-bandage. The tampon is a perfect safeguard against hemorrhage, but it must be of suitable material and properly applied; let no practitioner in this or any other case of uterine hemorrhage delude himself by trusting a tampon of sponge. The advantages of the tampon in abortion are, not only in the arrest of external hemorrhage, but its pressure evokes uterine contractions, and the small quantity of blood escaping from the detachment of the ovum is now shut up in the womb, and passes between the former and the uterine wall, completing the separation, and thus facilitating complete discharge. The tampon may be left in place twelve or twenty-four hours, perfect antisepsis having been observed in its application. Upon its removal the ovum will in many cases be found in the upper part of the vagina, or it may have entered the cervical canal, and so completely fill it that a repetition of the tampon is unnecessary ; in the latter case firm compression of the uterus may complete the expulsion of the ovum ; even before the descent into the canal, deliver}' by expression is sometimes suc- cessful. The general practice is to give ergot when there is much hem- orrhage; but if the cervical canal is undilated, it is claimed by some that the medicine contributes quite as much to the imprison- ment as to the expulsion of the ovum. This objection is completely removed if the tampon be used when ergot is administered. Ergot and the tampon are remedies that act admirably when associated in these cases. The practitioner in cases of miscarriage in the first three months should be especially careful not to rupture the ovum, for if the amnial sac be opened there is great danger of the abortion being incomplete. In case hemorrhage persists or returns, the abor- tion not yet having taken place, the tampon is to be repeated, and with the repetition ergot may also be used. While in the great majority of cases under this treatment the ovum is expelled entire, in some the embryo or the fcetus is dis- charged, but the appendages retained ; or the case may be one in which the abortion was begun by perforation or puncturing of the membranes. If the pregnancy has continued as long as four months, usually expression will cause the expulsion of the placenta and mem- branes ; if necessary this expulsion may be facilitated by digital or other dilatation of the os uteri. These cases as a rule do not pre- sent serious difficulties, though there may be delay and difficulty in completely emptying the womb. Cheron's method in case of retention of the placenta, the fcetus having been expelled, has much to commend it. It is thus1 described : The patient lies upon 1 Revue Medico-chirurgicale des Maladies des Femmes. Paris, 1889. 318 SCIENCE AND ART OF OBSTETRICS. her back, the legs flexed, and the thighs well drawn up to the abdomen. In this position the axis of the uterus is brought in correspondence with that of the vagina, thus one obstacle to the expulsion of the placenta is removed, and frequently this expulsion then takes place. If this should fail, the next step is to throw through a speculum upon the cervix a strong douche of hot water, which in most cases excites uterine contraction, and the placenta is expelled. But if the douche is not sufficient, and the os contracts, or immediate intervention is necessary, galvanism is employed. In this operation a flexible sound of tin or lead, connected with the negative pole of a battery, the current having an intensity of 15 to 20 milliamperes, is introduced into the uterus ; a large tin disc, perforated and covered with chamois skin, is placed upon the hypogastric region, at the level of the uterus, and con- nected with the positive pole; the continuous current is then passed with regular intermittences, the uterus contracts with increasing energy, and soon the placenta and membranes are expelled. But if a miscarriage occurs in the period from seven to ten weeks, and immediately after the expulsion of the embryo the cer- vical canal closes, what practice is to be pursued ? Some insist upon immediately emptying the uterus by means, if necessary, of in- struments, either forceps, curettes, or Simon's spoon. Certainly when miscarriage is incomplete, there is a possibility of serious dangers, but, on the other hand, hasty interference is not free from peril; the appendages are retained either because still at- tached to the uterus, or because of the obstacle presented by the narrowed cervix. If attachment prevents their discharge, they are a living part of the uterus, and tearing them away in itself is a traumatism, while rude efforts in this process may inflict additional traumatism, and as fragments are almost inevitably left behind, the detachment is incomplete; moreover, their presence in the uterus may for a time give rise to no symptoms.1 But, on the other hand, if partial or complete detachment has occurred there will be hemorrhage, or if retention is permitted for a day or two in addition to the hemorrhage, there may be an offensive discharge. Now the indications for active interference are unequivocal, and delay is perilous. In these cases gradual dilatation of the os may be effected by tupelo tents or a rapid dilatation by Hegar's hard- rubber dilators, and this is the preferable plan, the patient being anaesthetized if thought best. After the dilatation the uterine cavity is disinfected by washing it out with carbolized warm water, and one or two fingers made aseptic and dipped in an antiseptic solu- tion—one teaspoonful of creolin, for example, in a pint of water—are passed into the uterine cavity, while the other hand upon the hypo- gastrium fixes the uterus, and presses it down upon the internal fingers; or, as advised by Dr. Alexander R. Simpson, the uterus is drawn down to the mouth of the vulva by the vulsellum, and then one or two fingers introduced. In either case the membranes are 1 Charles says: We do not advise immediate efforts for the removal of the after-birth in abor- tions before four months, while after this period we recommend acting as soon as possible in the artificial delivery as after labor at term. The conditions are different. 1. The danger from retention is much less. 2. The introduction of the hand is impossible because of the narrowness of the cervical canal, and the smallness of the uterine cavity. 3. The dilatation of the orifice and the introduction of instruments designed to extract the placenta are dangerous, difficult, and painful; these instruments act blindly, contuse, lacerate the uterine walls, and rarely succeed in removing all the secundines, but almost always cause metritis. In a word, the danger from retention is much less than that of extraction.—Journal d'Accouchements, June, 1886. ABORTION. 3^9 detached by the fingers and brought down to the os; in some in- stances the finger and thumb may be used like a crab's claw, as Mauriceau expressed it, to seize them and draw them out. But if digital detachment fails to remove the remains of the ovum, I have found the following an excellent plan in an incom- plete abortion. The practitioner should have at hand a basin of warm carbolized water, Churchill's tincture of iodine, Emmet's curette forceps, a uterine tenaculum, one or more applicators, a uterine probe, absorbent cotton, and a bivalve speculum, Neuge- bauer's answers admirably. The patient now has her hips brought to the edge of the bed, and the thighs and legs strongly flexed; after the introduction of the speculum and exposure of the os, the tenaculum is inserted into the anterior lip from below and firmly held, so as to fix the womb, and also used to straighten any flexion that may be present; next the uterine probe is introduced to ascer- tain the size and direction of the uterine cavity, after which the blades of the curette forceps, first being dipped in the carbolized water, are passed into the uterus, then opened, the ends pushed on until touching the uterine wall, when they are firmly closed and withdrawn ; upon withdrawal they will be found to contain frag- ments of membranes which may be removed by opening them and moving them to and fro in the carbolized water; the process is repeated, and all parts of the uterine cavity, especially the vicini ty of the entrance of the oviducts, thoroughly explored, and membranes detached and removed. After completing the removal of mem- branes, or placental fragments, the uterine cavity is swabbed out with the iodine solution; iodine is both an excellent antiseptic and uterine haemostatic. Doubtless some one will think that the practice advised in incomplete abor- tion of the earlier weeks, when there is closure of the cervical canal after the ex- pulsion of the embryo or fcetus, and no symptoms demand interference, too con- servative. But I can fully adopt the words of that wise obstetrician, the late Dr. Churchill, " Longer experience has made me less fearful of leaving these cases to nature, and more unwilling to interfere hastily." The probability is, that they will end within a few days by the spontaneous expulsion of the uterine contents ; meantime the practitioner carefully watches the case, directs antiseptic vaginal injection twice a day, and is ready to meet any dangerous symptom and to assist nature's process ; his position is not that of simple expectation, but of armed ex- pectation, as a French obstetrician has expressed it. It is satisfactory to the writer to know that the conservative treatment—conserv- ative in opposition to the radical methods advocated by many authors in recent years—presented in the first edition of this work and now repeated, is in perfect correspondence with that of Winckel in his work upon obstetrics issued last year. This eminent and able practitioner, with an experience which is the fortune of few, uses the following language :* " I maintain that if, in an abortion or immature labor, fragments of fcetal membranes or placenta have remained behind, we are justified and obliged to proceed to operative interference only when there are severe hemorrhages from the uterus, or fever or sloughing occur. In the absence of these indications, I am strongly opposed to cleansing the uterus, either by hand or by instruments, because this method furnishes no guaranty against small frag- ments being left behind and against direct inoculation of sanious matter into existing lesions. If the placenta remain behind and the internal os be closed, or 1 Edgar's translation. 320 SCIENCE AND ART OF OBSTETRICS. permit at most the introduction of one finger, or even if an exudation can be de- tected in the neighborhood of the uterus, we must desist from any attempts at entering the uterus, but should administer ergot, irrigate the uterus daily through a Fritsch or Budin catheter with an antiseptic fluid, such as solutions of boracic acid, carbolic acid, or of potassic permanganate, or chlorine water, and as a rule we will find that in from two to ten days the placenta is completely and safely ex- pelled." The course in incomplete abortion1 advised by Tarnier and Budin is also con- servative. But it is just to place in opposition the methods pursued by other emi- nent practitioners. Duhrssen strongly advocates2 an active, in opposition to the expectant treatment of abortion. The chief grounds of this advocacy are: the danger is less, the mental anxiety of the patient is sooner relieved, her recovery is more rapid, and uterine involution takes place in a shorter time ; the rapid recovery is an important mat- ter especially for those women who are compelled to work. Whenever, therefore the abortion is inevitable, and the cervical canal is open, his advice is to empty the uterus at once. In abortions in the first three months the decidua vera not vet adhering to the decidua reflexa, is retained after the ovum is expelled ; there- fore in these cases the curette must be used, and it can be used so that the de- cidua is removed without any injury being done the muscular wall of the womb. A. E. Aust Lawrence advises3 in incomplete abortion dilatation of the cervix with an antiseptic sponge tent, first passing a bougie of 20 grains of iodoform into the uterus: after its removal washing out the vagina with a solution of carbolic acid, then with the finger passed iuto the uterus the remains of the ovum are removed—rarely is it necessary to employ a dull wire curette—and the final step is washing out the uterus with a carbolized solution. A few vears ago DoleYis devised the ecouvillon for removing fragments of the ovum left in the uterus. It resembles the instrument so commonly used for cleaning lamp chimneys. The cervical canal being sufficiently dilated, and the os exposed, the ecomnllon is dipped into an antiseptic solution, then passed into the uterus, and moved about in it so as to detach and entangle any fragments of membranes; it is then withdrawn, cleansed, dipped in the antiseptic solution, and reintroduced if necessary. The results, according to Doleris and others, more especially in France, who have followed this practice, are certainly very good. From a limited experience with this instrument, the writer believes that in some cases of incomplete abortion it will prove useful. Gueniot has given the following rules as to the time the practitioner should wait: Two days in abortions of the first two months ; twenty-four hours in those of the third or fourth month ; twelve hours for the fifth month, and six hours for the sixth. He thus makes a time-card for Nature, and denies her right to action if she does not meet the arbitrary requirement of the schedule ! In abortions of the later months the time given for delay is too long, for in almost all these cases the placenta and membranes can be removed by expression, and there is no necessity for introducing fingers or hand into the uterus. Those who are in haste to interfere immediately after the expulsion of foetus 01 embryo, may in some cases cause a new abortion, for it may have been a plural pregnancy, and the remaining ovum might be retained until the fcetus was per- fectly developed but for this interference. Pajot has pleasantly remarked, in referring to the treatment pursued by certain German authorities in incomplete abortion—that is, the use of the curette, or Simon's spoon, and subsequent appli- cations to the interior of the uterus of carbolic acid or perchloride of iron—that German wombs must be very complaisant in order to endure it. After-treatment.—The patient should remain in bed at least a week after a miscarriage, for many a woman becomes a permanent invalid from neglect of proper care at this time. Missed Abortion.—-Sinclair,4 in a paper upon this subject, classifies 1 Traite de l'Arte des Accouchements, tome deuxicme. - Cenlralblatt f. Gyniikol., 1887. :; Bristol Medico-Chirurgical Journal, March. 1888. 1 Journal of the British Gynecological Society, 1887. ABORTION. 321 cases of missed abortion as follows: (1) those in which expulsion occurs spontaneously before the end of pregnancy ; (2) those in which expulsion takes place at or about the full period of pregnancy ; and (3) those in which the ovum is retained beyond the full period of pregnancy. He shows from statistics that the accident is very rare in primigravidae ; he also calls attention to the fact that while in a large number of cases the expulsion of the ovum is apparently spontaneous, in others, a slight disturbance, in one instance a vaginal examination, determines the expulsion, remarking " It would seem as if there was a kind of equilibrium between the retentive and ex- pulsive forces, and that this equilibrium could be readily upset by any influence capable of slightly increasing the force of the uterine contractions." The indication in missed abortion is to empty the uterus. In some cases, as in one reported by Matthews Duncan, the introduction of a bougie will be sufficient to excite the uterine contractions ; in others it may be necessary to dilate the os uteri with tupelo, or with Hegar's dilators. In concluding the subject a single word upon criminal abortion. The temptations to this offence probably come to every physician. He will be appealed to by the unfortunate victim of man's passion and perfidy to save her and her family from disgrace, and his sym- pathies will unite with the teaching of some utilitarian theories of morals to stifle the voice of conscience; family friendship will be plead by the married woman already a mother, who does not wish to have any more children ; or finally, the baser motive of avarice will be invoked, and he may be promised a far more liberal sum than led Judas to be chief contributor to the crime of the ages. But he must turn a deaf ear to all these appeals. " Heart's blood weighs too heavily," and let him beware of violating both human and Divine law, no matter how great the temptation. CHAPTER XII. ECTOPIC PREGNANCY—PREGNANCY IN A RUDIMENTARY HORN OF THE UTERUS—ECTOPIC DEVELOPMENT OF THE PLACENTA, OR PLACENTA PREVIA—PREMATURE DETACHMENT OF THE NORMALLY SITUATED PLACENTA. The impregnated ovule should occupy in its development the cavity of the uterus. When it is external to that cavity, whether in the tube, ovary, or abdomen, or between the folds of the broad liga- ment, it is out of place, misplaced, and the pregnancy is best designated by the name proposed by Dr. Robert Barnes, ectopic. The term hitherto in common use, extra-uterine, cannot, accord- ing to Mr. Tait's just criticism, be applied to a case in which the developing ovum occupies that portion of the tube passing through the uterine wall, and commonly known as interstitial, or tubo- uterine pregnancy, and yet this is one of the most dangerous forms of misplaced gestation; hence the necessity for a word, including it with the other varieties. The subject has attracted very great interest in the last few years, and important contributions both to the pathology and the treatment of the disorder have been made. Nevertheless very much more remains to be known, notwithstanding the many articles upon the subject in the periodical press, or in monographs; dogmatic asser- tions have not been wanting, and contentions almost fiercely polemic in character; cases of alleged ectopic gestation have been reported in which such marvellous results have been attained by art, that there may be applied to them the words used by Winckel in regard to one of them, "rather more than improbable." Such cases do not bear an impartial criticism, and hinder professional advance by ministering to a mischievous credulity, or awakening a scarcely less evil scepticism. When dogmatic assertions have been by some accepted as truths, partisan zeal for a theory or a practice blinded the eyes to all contradicting facts, and many cases published which will not bear the interpretation given them by the reporters, much chaff must be cast to the wind in order that the grains of truth may be found. Classification.—Ectopic gestation may be divided into primary and secondary, the latter term being applied to those cases which in the beginning were tubal, for example, but rupture into the abdom- inal cavity occurred, the ovum remaining entire, the pregnancy continues, and it is called secondary abdominal pregnancy; or the rupture may have been in that part of the tube in relation with the broad ligament, and the folds of the latter being separated the ovum passes between them, and is there developed. The latter form is sometimes called simply by the term broad ligament, or intra- ECTOPIC PREGNANCY. 323 ligamentous; it is necessarily a secondary pregnancy in all cases. The primary ectopic pregnancies are four, viz., tubal, interstitial, ovarian, and according to most authorities, though Mr. Tait strenu- ously denies it, abdominal. The secondary are all the cases of "broad ligament" pregnancy, and at least most of those of abdomi- nal pregnancy. All these are intra-peritoneal except that in which the ovum is developed between the walls of the broad ligament, which of course is necessarily extra-peritoneal. Different sub-varie- ties have been described, such as tubo-ovarian, tubo-abdominal, etc., but such additions to the classification are of no practical value: nevertheless, the possible origin of some of those cases which have been called primary abdominal pregnancy, may have been in one of the varieties just mentioned. Frequency and Causes of Ectopic Gestation. — In the inaugural1 dissertation of Lorenz, the following statistics are given : 1 in 4— 500,000 pregnancies, von Loew; 1 in 3542, Arneth; 5 in 60,000, Bandl; in the Munich Frauenklinik, 5 in 3062. One in about 10,- 000 pregnancies is the statement made by Auvard, and nearly this proportion is suggested by some other authors. But the estimate is very much too small. Founding my opinion upon the number of deaths from the condition, as made known by judicial autopsies2 in less than six years in Philadelphia, and the number of abdominal sections done here, in some of which the diagnosis was made or believed probable before operating, while in others the discovery of the abnormal gestation was a surprise, and adding to the number thus obtained the probable number of women who died from ruptured gestation cyst, no autopsy having been made either out of regard for the feelings of the friends, or because the attending physician was satisfied with giving a certificate of death from internal hemorrhage or peritoneal inflammation, without any but hazy notions as to the origin of the one or of the other, and then add those cases in which the embryo early perished and the mother recovered after severe illness or possibly only minor trouble, I believe myself quite within the bounds of truth in asserting that there is one ectopic gestation in 500 cases of pregnancy. If the following statement made by Matthews Duncan is correct, the cases of ectopic gestation are still more numerous than has been suggested : " There3 are many cases in which the disease is never even suspected; the foetus dies, and is, so to speak, entombed." In regard to the frequency of the different varieties, nothing that even approximates a probable estimate can be given. This only can be said, that almost all the cases are tubal, and of course this variety is still greater if primary abdominal pregnancy be rejected. Mr. Tait a year since stated that of y6 cases of ectopic pregnancy 1 Munich, 1888. 2 Dr. Henry F. Formad, in August of last year, informed me that he, in his capacity as Coroner's physician, had made within less than six years 22 autopsies of women who suddenly died from rupture of an ectopic gestation. All these cases were tubal, and in all the fatal rup- ture occurred from the fourth to the eighth week of pregnancy; death happened in all cases, save one, within twelve hours, and in that it was delayed five days. 3 London Lancet, July 13, 1889. 324 SCIENCE AND ART OF OBSTETRICS. seen by him, the tube was the seat of the gestation in 75, and in 1 that portion of the tube passing through the uterus, that is, inter- stitial. Adding Mr. Tait's 76 cases to Dr. Formad's 22, we have 1 case of interstitial pregnancy in 98 of ectopic gestation, 97 of these being tubal. It is certain that even this gives a greater relative frequency for interstitial pregnancy, for of the many cases of ectopic gestation operated on in Philadelphia in the last four years,1 not one of that variety has been found. Interstitial pregnancies are more frequent in medical journals than they are in autopsies, or in abdominal sections. Careful and impartial study of reports of some of the unverified cases of interstitial pregnancy will convince any one that they were in all probability normal pregnancies, and meddlesome treat- ment caused abortion. It should be remembered that some of the best authorities regard the diagnosis of interstitial pregnancy impossible. Some two years since a former pupil and medical friend in a distant city wrote me of a double interstitial pregnancy occurring in one of his patients ; she was being treated by a gynecol- ogist for subinvolution of the womb, the sound having been more than once intro- duced, and applications to the endometrium having been made. Miscarriage of one embryo occurred, and within a few days, of the second. Both of the medical gentlemen who examined the patient prior to the abortions were confident that the uterine cavity was empty, and they alike believed, after these occurred, that there had been double interstitial pregnancy. Most authors regard stenoses or atresiae2 of the tubes as causes of ectopic gestation. Such partial or complete obstruction of an oviduct may result from perimetritic inflammation causing flexures and contractions. In three cases,3 Breslau's, Beck's, and Leopold's, a polypus at the uterine mouth of the tube proved an obstruction, causing ectopic gestation. Spiegelberg stated that the causes of tubal and abdominal pregnancy must lie in some obstruction which renders the passage of the ovum into and through the oviduct im- possible or difficult, or else they must be looked for in the so-called migration of the ovum. Migration of spermatozoids has also been suggested as a cause; one tube may be pervious, and the other obstructed, the spermatozoids passing through the former, an ovule of the opposite side may be impregnated, and enter its correspond- ing oviduct. Two cases of abdominal pregnancy had each a singular origin ; they were the cases of Lecluyse and Koeberle. In the former the ovum escaped from the uterus through an opening which remained after a Caesarean operation, done several years before, from the uterine into the abdominal cavity ; in the latter the uterus had been amputated two years previously for fibroid tumor, but a fistula was present in the cicatrix of the cervix, and spermatozoids passing through it into the peritoneal cavity, pregnancy followed. These cases are sometimes adduced to prove primary abdominal pregnancy, but a moment's study will prove that such conclusion does not necessarily follow from the facts. 1 Dr. Joseph Price within that period has in abdominal section found 30 cases of tubal, 3 of abdominal, and 1 of ovarian pregnancy. 2 One of the most remarkable explanations of an ectopic gestation is given in the Philadel- phia Medical Museum, vol. i., new series, 1811. Dr. W. B. Smith, of Jamestown, Va., describes the autopsy of a colored woman, in which he found double ovarian pregnancy, one ovary containing a foetus four inches, and the other one eight inches long. The tubes were diseased so that the ''male semen " could not have passed through either, and hence he suggests that impregnation resulted from the semen being taken up by the blood, and thus carried to the ovaries. '•'• Lorenz, op. cit. ECTOPIC PREGNANCY. 325 But the most important cause of ectopic gestation is a salpingitis causing destruction of the ciliated epithelium lining the tube. Mr. Tait asserts that " The cause, therefore, of ectopic gestation or tubal pregnancy will be any process or accident which has reduced the Fallopian tube, so far as concerns its internal lining surface, to the same condition as the uterus." All are agreed as to the impor- tance of the cause, but its action is differently explained. Accord- ing to most, the failure of ciliated movements in the tube prevents the transport of the ovum from the place of impregnation—the ex- ternal third of the tube, according to most physiologists—to the uterine cavity. On the other hand, Mr. Tait, holding that impreg- nation normally occurs in the uterus, believes that one of the func- tions of the tubal cilia is to prevent the entrance of spermatozoids, but in the absence of the former the latter enter, and fecundation occurs in the tube. It may be answered, first, that the changes found in the mucous membrane of the oviduct in a case of this variety of ectopic gestation, are the almost exact counterpart of the changes that take place in the mucous membrane of the uterus in normal pregnancy. Second, this view concedes too little to the active power of spermatozoids, the force and rapidity of movements on their part enabling them to overcome considerable obstacles, and it also concedes too little to the completely passive condition of the impregnated ovule, which possibly needs ciliated motion for its translation to the uterus. Third, the glandular formation found by Sutton in the lining membrane of the tubes, and secreting albumin, loses its significance if this albumin is not, as in certain inferior animals, nutritive material for the ovum, furnishing an investment for it. It might be added that the albuminous covering given the ovule, is in inferior animals regarded as impenetrable by spermatozoids, and that the unimpregnated ovule has been alleged to undergo degenerative changes which render it incapa- ble of being fecundated. Some of the cases of ectopic gestation occur in women without there having been any cause, either septic or specific, known which would result in a desquamative salpingitis. In conclusion, it is doubtful whether Mr. Tait's single cause of ectopic gestation can be exclusively accepted, and still more doubtful whether his theory of the action of that cause is tenable. It is generally agreed that multigravidae are more liable to the affection than primigravidae, and that it has often been observed in women who have had a long period of acquired sterility. Yet in a case upon which I operated successfully prior to rupture of the ges- tation cyst, the woman was quite young, had given birth to three children, and was nursing the last. In plural pregnancy, which according to the statistics of Parry and others is relatively very frequent, one ovum may be in the way of the other, the first enters the uterus, and the second is delayed in the tube. Browne1 has collected 24 cases of twin pregnancy, one fcetus being within, the other without the uterine cavity. A few Transactions of American Gynecological Society, vol. vi. 326 SCIENCE AND ART OF OBSTETRICS. instances are recorded of pregnancy in each tube. Dr. Joseph Price, of Philadelphia, successfully operated on a case of double tubal pregnancy, after the rupture of one of the tubes. Development of the Ovum in Tubal Gestation.—The ovum1 has the same deciduous membranes formed from the mucous membrane of the tube that in normal pregnancy are contributed by the lining membrane of the uterus. The muscular fibrillar of the tubes during the first two months hypertrophy, and then a retrogressive meta- morphosis begins, caused by a pressure-atrophy from the growing ovum. The chorial villi, forerunners of the fcetal portion of the placenta, enter the connective tissue; their penetration into the mus- cular tissue observed in one case by Leopold, was not found in the examinations made by Diihrssen. The following illustration is from Tait's lectures on "Ectopic Pregnancy." Fig. 115. Actual view of placental villi (c) encroaching upon and causing thinning of the muscular wall (a) of the Fallopian tube; (b) maternal blood sinuses. (Drawn by E. Teichelman from section made by Berry Hart.) May the ovum remain in the tube and fcetal development continue until the completion of the normal period of gestation? Spiegelberg claimed to have had this occur in a case under his charge, and added five similar ones. Dr. Eastman, of Indianapolis, in 1888 operated on such a case, saving both mother and child : he was positive that it was a true tubal gestation. Admitting these facts, the question must be answered in the affirmative; but at the same time such instances are quite exceptional, and the rule is that a tubal pregnancy ends in rupture within the first three months. In Zucker's2 case of tubal pregnancy rupture with fatal hemorrhage occurred when the gestation was only between two and three weeks. This rupture is generally 1 Lederer: Beitriige zur Anatomie der Tuberschwangerschaft. Berlin, 1888, and Berlin Thesis, by John von Glahn, 1888. * Centralblatt f. Gyniikol., 1888. ECTOPIC PREGNANCY. 327 into the peritoneal cavity, and very rarely between the layers of the broad ligament. In almost all cases the mother, unless saved by a surgical operation, perishes within a few hours. But if the rupture should occur in that portion of the tube not covered by peritoneum, the danger is much less, for the connective tissue uniting the two folds of peritoneum not yielding readily in some degree restrains the bleeding, which is the usual and immediate danger from rupture, and its meshes facilitate coagulation. In the great majority of cases the embryo dies, and an extra-peritoneal haematocele remains for a time; this may be gradually absorbed, or suppuration with the for- mation of an abscess occurs. But in exceptional • instances the Fig. 116. Diagrammatic Section of Fallopian Tube representing the Two Directions of Rupture—2. Into the peritoneal cavity; 3. Into the cavity of the broad ligament, a. Clot at point of rupture. b. Wall of the Fallopian tube. c. Cavity of the broad ligament, with (3) folds separated by haemic effusion, a. (From Tait.) development of the ovum continues, and there is an extra-peritoneal, broad ligament, or intra-ligamentous pregnancy. The course of this pregnancy will be described hereafter. Interstitial Pregnancy.—According to Mr. Tait, this variety of ectopic gestation is uniformly fatal by primary intra-peritoneal rupture before the fifth month. But such assertion ignores the case of Braxton Hicks,1 which in the sixth month of pregnancy ended by the discharge of the fcetus through the natural passage; the placenta was retained, and four days subsequently violent pain occurred, and the patient died in two hours in collapse. The post-mortem proved that there had been an interstitial pregnancy, and that while the fcetus escaped through a rupture into the uterus, » a subsequent rupture of the gestation cyst into the peritoneal cavity had occurred with fatal hemorrhage. It ignores the case of Maschka, in which a double rupture of an interstitial pregnancy Fig. 117. 1 London Obstetrical Society's Transactions, vol. ix. 328 SCIENCE AND ART OF OBSTETRICS. took place, the body of the fcetus being extracted through the uterus, while the head escaped into the abdominal cavity. Spiegel- berg has asserted that in rare cases the pregnancy may go to term, and there have been several cases reported in which the ovum was Fig. 118. Diagrammatic Representation of Interstitial Tubal Pregnancy at Time of Rupture. (From Tait.) Fig. 119. Tubo-uterine, Interstitial or Mural Gestation.—a. Cavity of uterus clothed with decidua. b. Broad ligament, c. Tubo-uterine sac which contained embryo, d, d. Thicker part of cyst- walls, e. Placenta. ECTOPIC PREGNANCY. 329 entirely expelled through the natural passage. While confessing to scepticism in regard to many of these reported cases, in some denial of the accuracy of the statements made by reputable and able observers might be unjust. That such an event is frequent is in the highest degree improbable, independently of the fact that intersti- tial is an exceedingly rare form of ectopic gestation, and that many of the cases should be credited by the reporters and by the profes- sion only illustrates the old adage that opinion travels the world without a passport. Ovarian Pregnancy.—Ovarian pregnancy results, according to some, from a spermatozoid penetrating the thin wall of the ovisac; this supposition is generally regarded as very improbable. The explanation commonly received is that the ovisac ruptures, but the ovule fails to escape, either because the rent is so small, or because it is remote from the former; the spermatozoid enters through the opening, and conception follows. The rent may now close, or re- main open; in the first case the ovisac furnishes the external cover- ing of the developing ovum ; in the second, while the placenta is attached within the ovisac, the ovum soon grows out of it through the rent that continued patent. Abdominal Pregnancy.—A primary abdominal pregnancy is denied by Mr. Tait on the ground that even if an impregnated ovule drop into the peritoneal cavity the digestive power of the peritoneum is so great that it would have no chance of development. Never- theless, if spermatozoids can live for months in the abdominal cavity of the frog, is it not possible that an ovum may defy perito- neal digestion, and its development take place in the peritoneal cavity? Moreover, what happens to the embryo of a ruptured ovum does not necessarily occur if the ovum be intact. Hart and Carter, however, whose researches will be referred to in connection with intra-ligamentous pregnancy, state that a purely intra-peritoneal variety of abdominal pregnancy is yet to be demonstrated. Vir- chow said at a meeting of the Medical Society of Berlin last Feb- ruary, that he could not believe with Olshausen that all extra- uterine pregnancies were tubal; that such an opinion was especially difficult to admit for large lithopsedions, and that he had seen one lasting twenty-six years which was completely outside an intact tube. Kleinwachter thus explains the occurrence of this very doubtful form of ectopic gestation, /. e., primary abdominal pregnancy. The reader cannot fail to observe that in the explanation hypotheses are more numerous than facts : 1. The ovisac may rupture at a point so far from the pavilion that the current caused by the movement of the cilia cannot carry the ovule into the oviduct. 2. A temporary abnormal position or movement of the abdominal organs may obstruct the passage of the ovum. 3. The end of the tube may be completely closed in consequence of former inflammation, and the ovule be impregnated by semen coming through the other tube. 4. The tubal orifice may be so narrow that while permitting spermatozoids to pass, the ovule enlarged by impregnation cannot pass. 5. The oviduct may have lost its cilia from disease, and the current fail so that the ovule is not carried to the oviduct. 6. Old exudations or pseudo- membranes may either obstruct the orifice of the tube, or be in the way of the ovule reaching the orifice. 7. Abdominal pregnancy may occur when both ovi- 330 SCIENCE AND ART OF OBSTETRICS. ducts are in normal condition. The ovule impregnated at one oviduct may pass out into the abdominal cavity, and then across to the other oviduct, but the latter will not admit it because meantime the ovum has become too large. Secondary abdominal pregnancy includes those cases in which " the fcetus, after lying primarily in the tube, the ovary or even in the uterus, continues after the rupture of such organ to grow in the abdominal cavity, and in which, while the ovum remains connected with its first sac, the latter is enlarged and strengthened by the ad- hesion of the abdominal viscera, and by the formation of pseudo- membranes." According to Mr. Tait, however, this pregnancy results from rupture of an intraligamentous pregnancy, the fcetus surviving this accident; and he quotes Mr. Jessop's case as one in which such rupture occured at seven or eight months, the fcetus continuing to live, as a unique instance of intra-peritoneal pregnancy. It is commonly stated that in abdominal pregnancy (Fig. 118) the developing ovum causes irritation of the adjacent parts, and a cyst is formed of pseudo-membranes. " In rare instances the cyst atrophies, or is not formed,and the ovum is free in the abdominal cavity; such cases have been seen by Lecluyse, Matecky, Schreyer, and others." If a sac is formed, it usually contains some muscular elements de- rived probably from the muscres of the subserous layer of the pelvis. The placenta has been found attached to the uterus, to the bladder, or to the ovary; "Sivard1 has seen it attached to the mesentery and Fig. i 20. Uterus and Fcetus in a Case of Abdominal Pregnancy. colon of the left side; Courtail to the omentum and stomach; Clarke to the kidneys and intestines; Tilt to a great part of the mesentery, mesocolon, portions of the small intestines, and to the two or three superior lumbar vertebrae ; Baldwin, Wilson and Koe- berle to the anterior abdominal wall in the line of incision made either at the post-mortem examination, or during an operation for gastrotomy." 1 Parry on Extra-uterine Pregnancy. ECTOPIC PREGNANCY. 331 Abdominal pregnancies, both intra-peritoneal and extra-peritoneal —the former being exceptional, the latter the rule—last longer than any other form. In many instances the fcetus develops during nine months, then dies, and it may be retained for many months, or even many years ; in one instance the pregnancy lasted fifty-four years ; a still longer retention is given below. The great danger of ectopic gestation, as has been pointed out, is hemorrhage, and if the patient does not die from this, subsequent peritoneal inflammation may lead to a fatal result. The death of the embryo or fcetus, which is a favorable event in all ectopic gestations, is followed by changes similar to those which occur after death in intra-uterine pregnancy ; but in addition to these changes the fcetus may be converted into adipocere, or into a lithopae- dion j1 the formation of a lithopaedion has been observed in pregnancy in a rudimentary uterine horn, the foetus dying at five months. The most widely known of the last is the lithopaedion of Leinzell, which was found in one of the tubes upon post-mortem of a woman ninety- two years old, who had carried it forty-six years. In August, 1883, Sappey presented to the Paris Academy of Sciences the membranes and fcetus which had been retained fifty-six years ; calcareous incrus- tations were limited to the wall of the cyst, but the fcetus was in a natural attitude, and the skin, superficial organs and those of the cavities, the muscles, and in fact all parts of the body, preserved their consistence, suppleness, and their normal color. Inflammation and suppuration may occur in the fcetal cyst, ending in the discharge of the fcetus by the abdominal walls, by the bladder, the vagina, or the rectum. According to Mattei, the first is the most frequent; according to Parry, the last. In one instance the cyst com- municated with the stomach ; it was reported by Darby ; " the cavity which contained the child had opened through the abdominal wall; when Dr. Darby enlarged the orifice and extracted the fcetus, imme- diately after the entire contents of the stomach emptied themselves into the cavity of cyst through a ragged, jagged opening, two inches in width." Intra-ligamentous Pregnancy.—The origin of this variety of ectopic gestation has been given, and its possible termination in a secondary abdominal pregnancy by rupture into the peritoneal cavity, should the foetus live, has been stated. While in a great majority of cases 1 Lithopaedion, literally a stone child, is the name given to the foetus when calcification has occurred. Barnes states that this change is limited to the membranes and sac, the shell thus formed preserving the fcetal structures but little changed. But this is only one of three forms. Kuchenmeister states (Archiv fiir Gynakol., 1881) that the fcetus falling into the abdominal cavity, in consequence of rupture of the cyst, is mummified, and by degrees covered by a cal- careous layer deposited immediately beneath the epidermis; this is a true lithopaedion, and it is the second form. The third form is when an incrustation involves both the membranes and the fcetus. Sarraute (Archives de Tocologie, March, 1885) in a contribution to the microscopic study of lithopasdions, states that most frequently all the cavities are found filled with calcareous salts, or salts derived from fat; the cartilages and bony cavities and the vertebrae are infil- trated with calcareons masses. " The oldest known case of lithopaedion is that reported by Sens, in 1582; it was carried twenty-eight years. This case inspired Rousset to make a curious poem, in which he presented the following questions: cur nascipotuerit ? cur per vigenti octo annoi in utero retentus non putruerit? cur in lapidem obduruerit?"—Maygrier. 332 SCIENCE AND ART OF OBSTETRICS. the embryo or fcetus perishes, the tube rupturing between the folds of the broad ligament, in a few pregnancy may continue for some weeks, the fcetus then dying and suppuration follow, or it may con- tinue until term. The changes that occur in the developing ovum in regard to the peritoneum are of great interest.and were first made known1 by the study of frozen sections by Hart and Carter ; these sections were of two specimens—the one a four and a half months' extra-uterine pregnancy, in situ in the bony pelvis ; the other an entire cadaver with advanced abdominal gestation. From the report of this examination the following passages are taken : "The consideration of these two sections shows, therefore, a special phase in the development of extra-uterine gestation. They demonstrate that a Fallopian tube pregnancy may develop between the layers of the broad ligament, and may continue this extra-peritoneal growth, stripping off the peritoneum from the ute- rus, bladder, and pelvic floor until it becomes in great degree surrounded by a peritoneal capsule derived from these organs. All this is done without any actual intra-peritoneal invasion. The placenta in the advanced gestation case is attached in front to the extra-peritoneal connective tissue, the veins there enlarging and acting like uterine veins." "In this special cadaver, therefore, the gestation began probably in the right Fallopian tube, developed into the layers of the broad ligament, and grew extra- peritoneally, lifting up the peritoneum on the right side of the middle line both anteriorly and posteriorly, and »lso stripping the posterior uterine wall and upper part of the anterior wall. " We have here what may be termed a slow displacement of the placenta. At first it lay in the Fallopian tube, but the growing ovum has slowly pushed it up (a process attended with blood extravasation) from pelvis to abdominal cavity, until at last its upper edge is about ten inches from its original site. Part of this is due to growth, of course." The authors suggest that this variety of pregnancy should be termed subperitoneo-abdominal. It has been thus demonstrated that one form of abdominal preg- nancy is not intra-peritoneal, but extra-peritoneal, and it is probable that this is the variety of most frequent occurrence. Diagnosis.—It is by careful study of physiological and pathologi- cal symptoms that the diagnosis of ectopic gestation is made. In the first place, the fact of probable pregnancy is to be established; it is not necessary to detail local changes in the sexual organs and the reflex phenomena indicative of this condition. Next, we en- deavor to learn that the uterus is not the seat of this pregnancy. This organ, though as a rule increased in size, is not so large as it would be at the supposed period of gestation. There is found adja- cent to it a growing, somewhat sensitive tumor, not solid, and with little mobility. Menstruation having been suppressed at one period, possibly two, there occurs a profuse and painful flow with the dis- charge of fragments of decidua, microscopic examination of which will be necessary to determine their character. Gusserow, in a case reported by Glahn, in order to assist in the diagnosis, used a curette for the removal of decidua from the uterus. Should the pregnancy continue until the sounds of the fcetal heart can be heard, aud bal- lottement is available—such prolongation of ectopic pregnancy, it 1 Transactions of the Edinburgh Obstetrical Society, vol. xii. ECTOPIC PREGNANCY. 333 must be remembered, is exceptional—the question is more readily answered. So, too, if the practitioner has sufficient evidence to justify dilating the cervical canal, and the use of finger and sound to explore the cavity of the uterus, the absence of intra-uterine preg- nancy can be conclusively proved, and therefore the ovum, provided the woman is pregnant, must be ectopic. The diagnosis of ectopic gestation in the first months has been a subject of no little controversy. Spiegelberg has said that a diagnosis is all but impossible during the first three or four months, and can only be arrived at in exceptional cases; and Bandl suggests that the practitioner will do well not to make an absolute diagnosis of extra-uterine pregnancy until he can appreciate the certain signs of fcetal life, active movements and the heart-sounds. On the other hand, it has been claimed that the early diagnosis of an ectopic is easier than of a normal pregnancy. The question is very fully discussed by Strahan, whose valuable monograph1 can be consulted by the practitioner with benefit. Winckel gives the following as probable symptoms which " in their entirety permit a cer- tain diagnosis, especially if their progressive increase is established by repeated observations: " i. The cessation of previously normal menses. 2. Hyperaemia and secretion of the breasts. 3. Hyperaemia and livid coloring of the vulva and vagina, which increases toward the portio vaginalis. 4. The strongly pulsating arteries in the vault of the vagina. 5. The softening, enlargement, and displacement of the uterus. 6. The clearly defined and growing tumor. 7. A vascular murmur or souffle above the symphysis, which is heard at rather an early period. Dr. Reeve in an article2 upon the subject, in which it is asserted that a diagnosis "can be made at an earlier period than in a normal pregnancy," refers to cases of its having been made as early as the eighth and fifth week, and gives the following classification and enumeration of symptoms : I. Suggestive.—a. The general and reflex symptoms of pregnancy, especially if the pregnancy had occurred after a considerable period of barrenness. b. Disordered menstruation, especially metrorrhagia coincident with symptoms of pregnancy ; gushes of blood accompanied with severe pelvic pains. c. Severe pain in the pelvis ; attacks of pelvic pain followed by tenderness in either iliac region, and other symptoms of pelvic inflammation. II. Presumptive.—a. The existence of a tumor: this tumor presenting the char- acteristics of a tense cyst, sensitive to touch, actively pulsating; steady and regu- lar growth of the tumor to be observed. b. The os uteri patulous, the uterus displaced and empty. III. Certain.—a. Paroxysms of violent and overwhelming pain in the pelvis, with general symptoms of collapse. b. Expulsion of the decidua. Dr. Baldy,3 in answer to Dr. Reeve's paper, maintains that in some cases of ectopic gestation in the early stage the diagnosis is easy and certain, that in a large proportion of cases symptoms are present justifying the diagnosis of such pregnancy, and yet it is not present, and, finally, that in certain others the symp- toms, until rupture occurs, are absent or of such a doubtful character as not to warrant the diagnosis; he gives cases observed by him in his own practice or in that of others, in which abdominal section was done, substantiating these state- ments. Diagnosis of Rupture.—The diagnosis of rupture of a tubal preg- nancy is made by learning of severe pain in the lower part of the 1 The Diagnosis and Treatment of Extra-uterine Pregnancy, 1889. 2 American Journal of the Medical Sciences, July, 1889. :; New York Medical Record, September 21, 1889. 33-4 SCIENCE AND ART OF OBSTETRICS. abdomen or pelvis, suddenly occurring, possibly when the patient was making some exertion, straining, stooping, lifting a weight, etc., and this is followed by faintness or fainting and collapse ; the skin is cold, the pulse feeble and frequent, and there is acute amemia. "The diagnosis of tubal pregnancy at the time of rupture maybe made with certainty seven times out of eight, and may be guessed at in the eighth instance. The symptoms are too serious to be lightly regarded at any time, and are practically coincident with those of pelvic hsematocele. If the rupture takes place into the broad ligament, they are the symptoms of extra-peritoneal hemato- cele. If the rupture takes place into the peritoneal cavity, they are the characteristic and most serious group which belong to intra- peritoneal haematocele." (Tait.) Treatment.—The treatment of ectopic gestation is naturally divided into that advisable before, and after, the rupture of the gestation cyst in the early part of pregnancy, that required in the later months, the fcetus living, and that which is necessary should the fcetus die before or at the completion of pregnancy. Admitting the diagnosis of an ectopic pregnancy, almost certainly tubal, before rupture, what course should be pursued ? Foeticide, or by abdominal section re- moval of the gestation cyst? The fceticidal means which have been used are evacuation of the amnial liquor, morphine injection, and electricity. The first is uncertain and dangerous, and is now without an advocate. Joulin in 18631 proposed injecting strychnine or atro- pine into the fetal cyst, and Friedrich in 18642 injected a solution of morphine in a tubal pregnancy. Since then the method has been employed by Koeberle, Rennert,3 Tarnier,4 and Winckel, the last having had seven cases. Winckel states that three out of twelve of the women died. He always injects 0.03 gramme, under the usual precautions, through the abdominal wall, at intervals of six to eight days; two or three injections generally suffice. He claims that this method of killing the fcetus may be practised successfully up to the end of the fourth and even during the fifth month ; it is very easy of performance and perfectly innocuous to the mother. Martin has objected to this treatment from the danger of wound- ing the intestine, and Veit from the danger of hemorrhage. The mortality attending it will prevent its general adoption, though recommended by so high an authority as Winckel. The Use of Electricity.—Depaul states Dubois first advised elec- tricity to kill the fcetus in normal pregnancy when grave accidents threatened the life of the mother. Bachetti, of Pisa, in 1857, suc- cessfully employed electricity in a tubal pregnancy of the third month; two long needles connected with an electro-magnetic machine were introduced into the cyst. In 1865 Braxton Hicks attempted to destroy the fcetus in an extra-uterine gestation of three months and a half by two applications of the galvanic current at an 1 Traite complet d'Accouchements. 2 Virchow's Archiv., 1864. 3 Arch. f. Gynakol., 1884-5. * Both in the original and in Dr. Edgar's translation of " Winckel," this name is given as Fournier—evidently a typographical error. ECTOPIC PREGNANCY. 335 interval of ten days, but failed. In 1869, J. G. Allen, of Philadel- phia, succeeded by faradization in arresting pregnancy. This treatment of ectopic gestation has been so frequently used by American practitioners, so little by others, that it is often called the American method. The galvanic current has been selected in some cases, and abroad—not in this country, I believe a single time— galvano-puncture, but general preference is given to the faradic current. An ordinary battery, with single cell, is employed; the negative pole is introduced in the vagina or in the rectum as near the tumor as it can be, while the positive pole, connected with a dampened sponge, is placed upon the abdomen. A current, not so strong as to cause the patient any great distress, is passed through the tumor for ten minutes; this is repeated each day until the tumor ceases to grow ; four or five applications probably will be necessary. Blackwood, of Philadelphia, who has had a large experience with this mode of destroying the life of the embryo or fcetus, prefers a strong current continued for an hour, but he is probably alone in this prefer- ence. The galvanic current has been advised by Rockwell, and has been successfully used in New York in several cases, though the method has differed, in some the interrupted and in others the con- tinuous being employed. Rockwell1 prefers the former, the strength being from 10 to 20 milliamperes. No impartial reader of the reports of cases by competent and reputable men, can doubt that some cases of ectopic gestation have by this means been conducted to a favorable termination ; that is to say the gestation was arrested, and the patient suffered no subse- quent or serious inconvenience. Brothers, of New York, an ardent advocate of the electric treat- ment of ectopic gestation, after the study of quite a large series of cases, some of them several years after treatment, has recently2 pre- sented the following conclusions: " 1. The risk of rupturing the sac of an extra-uterine pregnancy and causing death by internal hemorrhage, is slight. In but one case has this possibly oc- curred (Janvrin), but the reporter himself thought that the damage occurred prior to the employment of 'electricity. " 2. Suppuration of the dead fcetal mass has not occurred in any case in which electricity was employed before the third month. "3. Beyond the third, or possibly fourth month electricity should not be resorted to. "4. Electro-puncture is to be condemned in all cases. " 5. In cases of mistaken diagnosis no harm is done by the electric treatment. "6. Under galvanism or faradism early extra-uterine pregnancies can be checked in their growth, and caused to disappear entirely or to become shrivelled in their growth. These remaining masses have thus far caused no trouble." In considering the value of this treatment we must remember that, as Duncan * has said, " often, very often, and without any apparent cause, the fcetus dies early." It is probable electricity was applied in some instances in which the foetus was already dead. The fact stated in the first of the conclusions which have been quoted, renders it almost certain that some of the cases in the statistics were not pregnancies of any sort, for rupture of a tubal pregnancy, the ovum living, is so common an event that in such a large list some instances of its occur- 1 American System of Gynecology. 2 American Journal of Obstetrics, Feb. 1890. 336 SCIENCE AND ART OK OBSTETRICS. rence might reasonably be expected. Rockwell admits as one of the dangers of a strong current such rupture. Finally, three of the cases were interstitial preg- nancies, a condition which, according to excellent authority, cannot be determined without an abdominal section, or an autopsy. It is more probable that errors of diagnosis were made in these three cases, than that such an event, though not im- possible, as under electric treatment, the transfer of the ovum to the uterine cavity occurred whence it was expelled ; in one of the three, however, the expul- sion was delayed until pregnancy was completed. Yet throwing aside all doubtful cases, there remains a strong argument from actual experience in favor of the treatment of ectopic gestation, prior to the rupture of the fcetal cyst, by electricity ; after such rupture, as in Janvrin's case, electricity ought not to be used. The second conclusion is an important one, and seems to guard successfully against one of the dangers which may follow destruction1 of the life of the fcetus. It limits the use of electricity, it will be observed, to the first eight weeks of preg- nancy. Goodell would restrict the application of electricity to those cases refusing abdominal section, or when no one could be found capable of doing the operation. I think this is the most that ought now to be said in favor of the treatment by electricity. Treatment by Abdominal Section.—Tait remarks that " If I ever should make a diagnosis of tubal pregnancy before rupture I should advise its immediate removal by abdominal section." Strahan asserts that " the proper treatment of extra-uterine gestation in the pre-rup- ture stage, whenever diagnosed, or suspected with great probability rather, is instant abdominal incision and removal of the entire trouble." Werth2 believes that an ectopic pregnancy ought to be regarded as a malignant tumor demanding prompt removal; in an interstitial pregnancy a pedicle should be made of the lower-part of the uterus, and hysterectomy done. When one realizes by witnessing how suddenly in the midst of apparent health a gestation cyst may rupture, and how swiftly death follows in almost all cases not rescued by a surgical operation; when 1 Those who substitute death of the ovum for death of the foetus seem to assume a point in dispute, denying the possible growth of the placenta after fceticidal means have been success- fully used. That in some cases the placenta continues to grow does not rest alone upon Mr. Tait's assertion. The same statement is made by Hart and Barbour, Manual of Gynecology. Champneys and Thornton concede the fact, London Obstetrical Society's Transactions, vol. xxix. Bandl, in his well-known monograph on extra-uterine pregnancy, refers to the placenta developing for some time after the foetus is dead. Doleris, Nouv. Arch. d'Obstet. et de Gyn., 1888, says that when the fcetus dies in ectopic gestation " the placenta in these cases often con- tinues to vegetate, for habitually it does not atrophy until the term of gestation has been passed or attained.'' A case has just come to my knowledge, while revising this proof, showing that electricity is not a certain foeticide. An ectopic gestation was recently treated in Philadelphia by electricity, the galvanic and the faradic current being used alternately each day, for six days; the former was of 100 milliamperes, and the latter was as strong as the patient could bear. The treatment was harmless, for the ovum continued its growth. Abdominal section was then done, and an unruptured tubal pregnancy of three months or more was removed. Doubtless too much has been claimed for electricity, and even some of its earnest advocates abate their zeal and positiveness of utterance. One of them, well known for his honesty and ability, in 1887 stated that " it was safe to predict that electricity will yet become the only method of treatment in ectopic gestation prior to the rupture of the cyst, and that through this means :he dreadlul mortality from gestation of this nature will be reduced by fully three-quarters." He also stated that the method is applicable to every form of ectopic gestation prior to the middle or end of the fourth month, and prior to rupture of the cyst. In 1889 the same gentle- man said : " Electricity, then, under the third month, with absence of symptoms of rupture, 1 would advocate. At most it can do no harm, and it may do good." '-' Beitriige zur Anatomie und zur operativen Behandlung der Extrauterin-Schwangerschaft, Stuttgart, 1887. ECTOPIC PREGNANCY. 337 upon opening the abdomen he finds sometimes from a rent com- paratively small copious bleeding has occurred, he will hesitate to advise in an ectopic gestation the diagnosis of which is clear, any delay in its removal, even though the pregnancy may not have lasted a month. The vaginal1 operation, colpotomy, elytrotomy, is not to be com- mended in an early pregnancy, and is only exceptionally advisable in a late one. Treatment after Rupture.—Here the almost unanimous voice of the profession is in favor of immediately performing abdominal section, ligating the pedicle of the cyst, and then removing the latter; this is of course to be followed by thorough washing out the abdominal cavity with hot water, removing all clots, and if many adhesions have been broken up in order to detach the cyst, and oozing of blood continues, the introduction of a glass drainage-tube, which will sel- dom have to remain longer than forty-eight hours, even if it be kept so long. Extirpation of the gestation cyst here advised, and so often suc- cessfully done by Mr. Tait, and many others, was strongly urged many years ago by the late Dr. Stephen Rogers, of New York.2 If the rupture occurs into the broad ligament, the general practice is non-interference, but I doubt if this should be made an absolute rule. Treatment in the Second Half of Pregnancy.—If the gestation passes four months and the fcetus is living, the question of interference is presented. Hitherto the answer has been in the negative, an answer prompted by the hope that by waiting a living child might be re- moved. But as the risks the mother runs are better understood, and the successes of abdominal section increase, the answer of the future will be, even if it be not already of the present: Do not wait with the doubtful hope of saving mother and child, but end the gestation at once by abdominal section. If the normal period of pregnancy has been reached, abdominal section is done for saving the child's life, and there is also a reasonable probability of saving the life of the mother with certain improvements in the method of operating and subsequent treatment —certainly her chances of recovery are probably not lessened but rather improved by a properly performed operation. The treatment of the placenta has presented the most serious difficulty. Of course, if it can be removed with the foetal cyst it is a fortunate thing for patient and operator; it is rare, however, that perfect haemostasis can be secured, as in Eastman's case, or as in the cases of Martin and Breisky. Tait in two cases was able to remove the placenta, tying a large pedicle, the remains of the tube and broad ligament, which con- tained the chief blood-supply to the organ, and in each case the mother as well as the child was saved; But such cases are prob- ably exceptional. There may be no fcetal cyst, and then after the 1 A valuable paper on delivery by the vagina in extra-uterine gestation, by Herman, will be found in the xxixth vol. of the London Obstetrical Society's Transactions. 2 Transactions of the American Medical Association, vol. xviii. 33§ SCIENCE AND ART OF OBSTETRICS. removal of the fcetus, the cord is tied and divided, and its placental end is left hanging out of the abdominal wound, a drainage-tube being placed by its side. Tedious suppuration follows this method, and the woman may perish of septic infection more than a month after the operation, as in Champney's case, the disease occurring when convalescence seemed established. Tait proposes cutting off the cord near the placenta, closing the sac, and thus leaving the pla- centa to be absorbed. Should the fcetus be dead, perishing in the latter half of pregnancy or after false labor, which occurs in cases of ectopic gestation at the normal period of pregnancy, the chances of its conversion into a harmless lithopaedion are slight, and the probabilities of painful and prolonged suppuration with the passage of fcetal debris through the rectum, the vagina, the bladder, or the abdominal wall, imperilling the mother's life—in many instances she perishes—are so great that active interference is indicated. Therefore by abdominal section, rarely by elytrotomy, removal of the fcetus is advisable. Unless the indications are urgent, the operation is delayed until the pla- centa has probably undergone such changes that its removal maybe accomplished without serious hemorrhage. Fig. 121. Gestation in a Rudimentary Horn of Uterus.—A. Developed right horn. B. Rudimentary horn, with a rent through which the embryo had escaped, i. Right Fallopian tube. 2. Left Fallopian tube. 3. Left ovary. 4, 5. Right ovary and corpus luteum. 6. Round ligament. Pregnancy^ in a Rudimentary Horn of Uterus.—Winckel states that thirty-five cases of this form of pregnancy have been collected. The rule is that rupture is not delayed beyond five months. The symptoms of cornual pregnancy are those of tubal, and the treatment in no respect differs. 1 An interesting report of a case successfully operated upon by the late Dr. Angus Mac- Donald will be found in the tenth volume of the Edinburgh Obstetrical Society's Transactions. Dr. MacDonald with the report, has also given a good resume of the cases observed up to that time. PLACENTA PREVIA. 339 Ectopic Development of the Placenta—Vicious Insertion of the Pla- centa—Placenta Prcevia.—Benjamin Pugh, in his treatise upon Mid- wifery, 1754, remarked that " the placenta sometimes loosens before the membranes, which contain the waters, are broke, and by the child's turning itself, it is sometimes found to present at the mouth of the womb," etc. This was the explanation generally given by obstetricians of those cases in which the placenta was found at the mouth of the womb previous to the birth of the child. Neverthe- less, Paul Portal, in 1685, had spoken of firm adherences between the placenta and parts contiguous to the mouth of the womb; and Schlacher, in 1709, had given an anatomical demonstration of this condition upon the body of a woman dead from uterine hemorrhage. Rigby, whose admirable " Essay nl was published in the latter half of the eighteenth century, made a distinction which is still recog- nized, between accidental and unavoidable uterine hemorrhage, the former occurring when the placenta occupies its normal position, the latter when " it is fixed to that part of the womb which always dilates as labor advances." It will be observed by the words just quoted from Rigby that those authors who have attributed unavoid- able hemorrhage, occurring in pregnancy, to the abnormal situation of the placenta, have no authority from him for such use of the word unavoidable. Rigby's definition of placenta praevia is that which is in accordance with the most recent knowledge. For ex- ample, Spiegelberg has said that the placenta is praevia when a greater or less part of it is situated in that part of the lower seg- ment of the uterine body which must be stretched in labor. He further compares this part of the uterus to the segment of a hemi- sphere which during parturition must be converted into a cylindrical canal. Varieties.—These are central, partial, marginal, and lateral. In the first the centre of the placenta corresponds more or less nearly in situation with the internal os uteri. In the second variety the os uteri is also covered by the placenta* but the margins of the latter are not equidistant from it—on one or the other side of the os a placental margin is readily reached. In the marginal variety the os is not covered, but the placental edge projects to it, or possibly partially over it. In lateral placenta praevia the placenta reaches nearly to the os. " The frequency increases progressively from the first to the last." Frequency and Causes.— I in 573, Johnson and Sinclair; 1 in 575, Guy's Hospital Lying-in Charity, Galabin; 1 in 1000. Spiegelberg. In adding up the statistics given by Depaul, from Ramsbotham, Schwartz, Arneth, Klein, Collins, MacClintock, and Hardy, and from the Maternity at Wurzburg, and the Hopital des Cliniques de la Faculte de Paris, amounting in all to nearly 600,000, I find the pro- portion of cases of placenta praevia I to a little more than 1200. Winckel makes the proportion I in 1500. Central implantation 1 An Essay on the Uterine Hemorrhage which precedes the Delivery of the Full-grown Foetus, illustrated with cases. The fourth edition was issued in 1789. 340 SCIENCE AND ART OF OBSTETRICS. occurs in about one-fourth of the entire number of cases. It must be remembered that many cases of placenta praevia result in abor- tion, so that the relative frequency of the number of pregnancies with normal, and those with abnormal implantation of the placenta cannot be determined. Placenta praevia is at least six times more frequent in multipara' —though this statement, given on the authority of Miiller's statistics, Winckel doubts, and believes the proportion should be only I to 2 or 3, instead of 1 to 6—than in primiparae. It is more frequent in the poor than in the rich, either, as suggested by Spiegelberg, because of hard work in the early part of pregnancy, or more probably from subinvolution of the uterus. He quotes two remarkable cases from Ingleby, in which the oviducts entered the uterus near the internal os; one of these women had placenta praevia three, the other ten times. Plural pregnancy creates a liability to the ectopic develop- ment of the placenta, and also the previous occurrence of the acci- dent. Abnormal size of the uterine cavity, diseased condition of its lining membrane, and spasmodic contractions of the uterus, have been enumerated among the causes; and, very strangely, the stand- ing position in coitus, and epidemic influence. Robert Barnes1 remarked that the " ovum sought attachment to healthy endo- metrium ; if the upper part was diseased the ovum would be apt to stretch lower, that is, within the lower zone." This is in correspondence with the view of Hof- meier that the placenta, in placenta praevia, as a consequence most frequently of endometritis of the body of the uterus, develops within the decidua reflexa of the inferior pole of the ovum. Diagnosis of the Different Varieties.—If the os be penetrable the finger can touch only placental tissue in the central variety; in the partial, by carrying the finger far in, placental tissue is felt on one side, but on the other the membranes ; in the marginal variety, the border of the placenta and the membranes are each felt, provided dilatation of the os with effacement of the neck has not occurred, but if it has, the placenta has been carried up with the internal os, and unless the finger enters far in, only membranes are felt. In lateral placenta praevia the placenta is not felt unless the hand enters the uterus. Vaginal Ballottement.—This is impracticable, chiefly because the uterine wall being lined by placenta the fcetus is further removed from the fingers in the vagina, and it is impossible to communicate an impulsion to it by them. But in addition to this, vaginal bal- lottement is prevented in many cases by the fact that the presenta- tion is transverse. The frequency of transverse presentations is not caused by the presence of the placenta in the lower uterine segment; it occupies too little space to produce such an effect, but by the generally relaxed condition of the uterus, and from the fact that labor in many cases is premature. Depaul's statistics show that shoulder presentation occurred once in nine cases. This propor- tion is still greater according to the statistics of some other author- 1 Meeting of British Medical Association, 1889. PLACENTA PREVIA. 341 ities. Thus Charpentier found in 1148 cases of placenta praevia 66 per cent, head presentations, 24 per cent, transverse, 9 per cent, foot and breech. Lomer had 51 per cent, head presentations, 32 per cent, transverse, and 9 per cent, foot and breech presentations. The Placenta—-This frequently is thinner than usual, and is attached to a larger uterine surface. An explanation of the more extensive attachment of the placenta suggested by Galabin is, that the lower segment of the uterus being less adapted for supplying nourishment to the placenta, the placenta has become extended as a compensation. The attachment of the cord is oftenest at or near the margin; in some instances it is velamentous; the position of the cord favors its prolapse, a not unfrequent complication of labor in placenta praevia. Hemorrhage.—The dominant symptom of placenta praevia is uterine hemorrhage. This rarely occurs before the sixth month, and is most frequent from the eighth to the ninth month, and during labor. Depaul has stated that almost all the hemorrhages con- nected with placenta praevia occur in the last six weeks of preg- nancy. It is usually sudden, frequently without obvious cause, is external, and is intermittent, several days often intervening between attacks. The Source of the Hemorrhage.—When the placenta is partially detached there are two surfaces with torn vessels, one placental, the other uterine; from which does the bleeding come ? Somewhat and briefly from the placental, but its chief source is the uterine sur- face. The proofs which authorize this statement are, first, the hem- orrhage may continue after labor is over; second, it may continue during labor when the fcetus is dead; third, if a pregnant animal be opened so that the interior of the uterus is exposed, and the placenta be partially detached, the blood is seen to come from the uterine surface. The theory of the placental origin of the bleeding was held by the late Sir James Simpson. He said, in 1845 : " I be- live with Dr. Hamilton and others that the discharge issues princi- pally or entirely from the vascular openings which exist on that exposed placental surface." Acting upon this theory, he was led to uphold the practice of detaching the placenta in case it presented at the mouth of the womb, and became involved in a controversy with Robert Lee1 in regard to both his theory and practice, and in one with Radford, who claimed priority in this method for Kinder Wood and himself. Winckel states the causes of hemorrhage are rupture of the utero-placental vessels, laceration of a placental sinus, and detachment of the placenta by shocks or trauma, or by contrac- tions. The Causes of the Detachment of the Placenta.—Those who hold that hemorrhage prior to labor is accidental, at the same time state that the accident is much more liable to occur in ectopic develop- 1 This controversy was exceedingly bitter, especially on Dr. Lee's part. In one of his last —if not the last—contribution upon the subject, he denounced Professor Simpson's view as to the source of the hemorrhage as "a gross, unparalleled, and unretracted blunder." (Lancet, vol. ii., 1847.) 342 SCIENCE AND ART OF OBSTETRICS. ment of the placenta than when this organ occupies its normal posi- tion, and that, as taught by Rigby, unavoidable hemorrhage occurs only in childbirth. Others explain the detachment of the placenta by failure of correspondence between its development and that of the uterus. But while Jacquemier1 attributes to the uterus such rapid development that the placenta cannot follow it, Legroux upholds the opposite—that is, the placenta is extended too rapidly with reference to the lower uterine segment, According to one hypothesis the uterus grows away from the placenta, and according to the other the placenta grows away from the uterus. Barnes has maintained the latter view, and has recently stated,2 " that the first detachment of the placenta arose from an excess of growth of the placenta over that of the lower region of the uterus to which it was attached ; that the structure of the uterine region was ill-fitted to keep place with the placenta; hence loss of relation, the placenta shoots beyond its site, and hemorrhage results." But Bitot3 answers this theory by the statement that at the time in pregnancy when the hemorrhages usually occur, the development of the placenta has been completely accomplished. (Depaul.) Admitting it true, as claimed, especially by French authorities, that the development of the fundus is completed in the first seven or eight months, if the placenta were attached to it, or in its vicinity, the rapid growth of the placenta at the time alleged by Barnes would be in all cases a necessary cause of hemorrhage. Depaul has said* that " it may be stated that the hemorrhage consequent upon vicious insertion of the placenta results from this, that all the parts of the uterus are not developed in the same stage, and while the fundus and adjoining portions take at the beginning of pregnancy a considerable amplitude, during the first six months the lower segment of the uterus, on the contrary, is not notably developed but during the last three months. Moreover, the development of all these regions is not made in a uniform manner. I have had the opportunity of examining the uterus of women who have died in the last months of pregnancy, and I could see in the inferior portions that the increase was not everywhere the same. The anterior is generally developed much more than the posterior, and as I have said in a report which I presented to the Academy, if a perpendicular be let fall from the fundus, this line does-not pass through or near the cervix, but traverses the anterior wall at a variable distance from this opening." The author further states that the lateral parts have an unequal growth, one increasing more than the other, while it is impossible to fix precisely the part of the fundus which is enlarged most, and when this development is arrested; on the other hand, the inferior segment assuredly is enlarged later, and it may be said in general that this development begins from the sixth to the seventh month. Spiegelberg, how- ever, entirely rejected this view in explaining the hemorrhage. He maintained that the bleeding arises from uterine contractions, causing partial detachment of the placenta; when premature5 labor occurs, as it very frequently does in pla- centa praevia, it is not caused by the hemorrhage, but it causes the hemorrhage. No matter, however, the hypothesis accepted, it is obvious that the hemorrhage is unavoidable. 1 Placenta Praevia, by Auvard. 2 Obstetric Medicine and Surgery. 3 Contribution a l'Etude du Mecanisme et du Traitement de l'Hemorrhagie liee a l'lnsertion Vicieuse du Placenta. 4 Lecons de Clinique Obstetricale. 5 According to King's statistics (Transactions of the State Medical Society of Indiana), premature labor occurs in about one-half the cases. Lomer's statistics correspond in this respect. PLACENTA PRZEVIA. 343 Prognosis.—The prognosis varies with the character of the pla- cental insertion. Thus, in the tables given by Depaul in 25 cases of central insertion there were 14 deaths; in 31 in which the os was incompletely covered by the placenta, there were only 8 deaths; in 15 cases in which the placenta was near the os, there was no death. Danger is not over when delivery has occurred, for these patients are peculiarly liable to post-partum hemorrhage, and also to septi- caemia. The fcetal mortality rarely falls under 50 per cent., and in some statistics rises to 70, or even to 75 per cent. This topic will be further considered in connection with different methods of treat- ment. Treatment.—If loss of blood be slight, and especially if the foetus be not yet viable, the expectant plan is indicated.1 The patient should lie down, be lightly covered, use cold drinks, and. if much pain or restlessness be present, opium may be given. She ought to be directed not to take active exercise, to avoid as much as possible the. erect position, and all straining at stool. It would be well if there were some one at hand who was properly instructed in the application of the vaginal tampon, so that this may be at once used should grave hemorrhage occur. But if the fcetus is viable, and the hemorrhage is severe, the doctrine enunciated by Baudelocque nearly three-quarters of a cen- tury ago ought to direct the treatment.2 "The necessity of effecting delivery without having regard to the time of pregnancy, when the loss of blood is so abundant as to imperil the life of the mother and that of the child, has been recognized for more than two centuries." Admitting this principle, the question arises as to how the delivery is to be effected. The simplest, shortest, and safest way is to induce premature labor, or, as nature is in many cases endeavoring to do this, assist her efforts. This practice has been especially advocated byGreenhalgh and Thomas, while many others have been following it without calling it the induction of premature labor. By the use of Barnes's dilators the os is effectively plugged, and at the same time its rapid expansion secured, when if the presentation be favorable and the uterine contractions active, the membranes maybe ruptured, and the completion of labor left to nature. A strong argument in favor of the induction of premature labor is, statistics show, that the maternal and fcetal mortality are very much greater when labor occurs at term than when it is premature. Different Methods of Treatment of Placenta Prcevia.—Having stated the general principle which should govern the treatment of placenta praevia, and the way in which this may be accomplished, it is proper that other methods should be briefly mentioned. 1 This advice has been condemned by some critics, for the obstetric knowledge and ability of one of whom I entertain the greatest respect. I shall not quote, as I might, from Churchill, Depaul, and Spiegelberg in vindication, but simply introduce the words of Winckel as one of the most recent and highest authorities, who in referring to hemorrhage in pregnancy says: " Should the hemorrhage be moderate, it is sufficient for the patient to rest in bed." The ob- jection to at once arresting the pregnancy before the child is viable is obvious: such treatment utterly disregards its life, and I still believe should not be employed unless the interest of the mother imperatively demands it. 2 Traite des Accouchements. 344 SCIENCE AND ART OF OBSTETRICS. The Tampon.—French obstetric writers have given to Leroux, 1776, the chief credit for the use of the tampon; nevertheless this author mentions no instance of its application in placenta praevia. The honor of this application of the tampon undoubtedly belongs to Wigand; by means of it he attained a success in the treatment of placenta praevia quite equal, if not superior to, that of any other method. At the time he was led to make use of the tampon ac- couchement force was the general practice, a practice which involved serious dangers and great fatality. After many years' experience with the tampon, and having had a large obstetric practice, Wigand stated that he "had not lost a single child or mother," and that he had secured by the method a normal lying-in.1 Different methods of tamponing the vagina have been used. The rubber bags introduced flaccid in the vagina, and afterward dis- tended with air, are, in the opinion of most obstetricians, unreliable, for they cannot be perfectly adapted to the vaginal vault, and thus leave a space in which blood may collect. Other objections that have been made to the colpeurynter are that it is liable to tear, and that it may be the medium of infection. A tampon may be made of balls of absorbent cotton, each ball being about the size of a small walnut; fifty or sixty of these will generally be required—a hatful, according to Pajot. The bladder and rectum should be emptied, the vagina thoroughly cleansed by an antiseptic solution, and all clots removed ; the patient may lie upon her side or upon her back, the latter position is selected if Sims's speculum be used, but this instrument is not essential for perfect tamponing of the vagina. The obstetrician takes one of the cotton balls after it has been dipped in an antiseptic solution, or covered with an antiseptic ointment— that of iodoform is excellent—and by means of suitable dressing for- ceps carries it up to the vaginal vault; one after another is thus introduced until the vault is completely packed; the os is filled or covered with the cotton packing, and after this the rest of the vagina is completely filled, a large piece of cotton placed between the labia, and the whole secured by a napkin and a T-bandage. The dossils of cotton first introduced may each have a string attached to them to facilitate their removal. The use of astringent solutions into which the balls are dipped is unnecessary, and may be injurious by irritating the vagina; arrest of bleeding by pressure, not by coagu- lation, is the purpose accomplished by the vaginal tampon. Strips of iodoform or creolin gauze may be used for a tampon. 1 Die Geburt des Menschen, etc. The work was edited by Franz Carl Naegele, and pub- lished in 1820, three years after Wigand's death. Notwithstanding the success of his method which he had been pursuing for so many years, and his frequent publications concerning it, he stated that as far as he knew he had not " a single follower.'' Wigand must have begun the tampon treatment early in the present or possibly in the latter part of the last century. Nevertheless, a recent writer has stated that it was " about fifty years ago;'' but, as Wigand has been dead for nearly seventy years, of course this is a mistake. In the former edition I gave quite fully Wigand's method of treatment, partly as a matter of his- torical interest, vindicating his priority and also to show his remarkable success with the tam- pon Winckel in referring to my statements remarks : " Parvin is correct in saying that Wigand should be credited with having first applied the tampon in this manner in placenta praevia; and also in the statement that this had already been done toward the close of the last century.'' PLACENTA PREVIA. 345 The tampon has another important effect in the majority of cases : it excites the action of the uterus ; thus in 78 out of 128 cases given by Muller,1 strong uterine contractions followed its application. Fig. 122.2 Vaginal Tampon in Placenta Praevia —A. Deeply placed dossils to each of which a cord is attached. Superficial dossils without cord. C. Pledget of charpie or pad of cotton. D. T- bandage. Winckel states that he employs cotton tampons almost exclusively in labors complicated with placenta praevia, and they are applied so firmly that not a drop of blood flows from the vulva—a condition rarely attained by the colpeurynter even when filled to the utmost. In central placenta praevia and in lateral, tampon- ing should be continued until the os is almost completety dilated, so that either the presenting fcetal part may enter and plug it, or the compression of the placenta be obtained by introducing the hand and bringing down the breech into the os. This method of tamponing the vagina in placenta praevia has recently been vio- lently assailed and denounced as unscientific in principle, dangerous in practice, uncertain in controlling the hemorrhage and a prolific source of septicaemia. . . . If the hemorrhage in' placenta praevia springs from the wall of the uterus— whether a lower uterine segment has developed or not—we must endeavor in every case to compress the bleeding vessels by as direct a pressure as possible. This purpose is accomplished by the tampon in an indirect, not direct, and at the same time in a thoroughly scientific manner. The distention of the vagina by the tampons, and the irritation of the ganglia in the upper part of the anterior * This illustration is credited in Auvard's recent work to Bailly. In the French monograph upon placenta praevia from which it was taken, no name was mentioned, and therefore credit was not given in the previous edition of this work. 34^ SCIENCE AND ART OF OBSTETRICS. vaginal wall which they effect, cause an intense desire to bear down and an in- creased activity of the uterine contractions. We increase on the one hand the expulsive force of the uterus, and on the other hand its power of resistance, and last but not least, we also prepare the os by this dilatation of the vaginal vault, and render it more yielding in case any operation is called for. According to Lusk, the tampon should be removed in at least four hours, but Tarnier would let it remain twelve hours ; Depaul did not remove it for at least twelve or fifteen hours, or twenty-five to thirty hours at most; it is doubtful if any harm will result should a pro- perly applied antiseptic tampon be left for twenty-four hours. After its removal the vagina must be thoroughly cleansed with an anti- septic solution ; a new tampon is introduced if hemorrhage continues, and if immediate delivery is not practicable, unless the practitioner, following the method pursued by Pajot and Bailly, and which was that of Wigand, leaves the tampon in place to be expelled by the uterine and abdominal contractions which expel the fcetus; this plan was practised and warmly advocated for many years by the late Dr. Mears, of Indianapolis. Exclusive reliance upon the tam- pon in the treatment of placenta praevia is the practice of only a few practitioners ; the majority of those who use the tampon regarding it as simply a temporary means. Muller,1 after observing that it is neither a sovereign remedy, as its friends claim, nor to be entirely rejected, as its opponents desire, remarks that it is an important aid which should be used at the right time and then no longer than is necessary; apply it when the os is rigid and only slightly opened, if violent hemorrhage occurs, for immediate delivery is impossible; time is thus gained without danger, for even if it does not stop, it lessens the bleeding, and prepares the parts for labor. It has been objected to the tampon that it may convert an open into a concealed hemorrhage. The answer is, that in no case has such a result followed the use of a properly applied tampon. If during active labor the tampon is forced down by utero-abdominal contraction, and then when the contraction ceases there is recession of the uterus, leaving a space at the upper surface of the tampon in which blood may collect, the accident is prevented by the practi- tioner at once pressing the tampon back as soon as the bearing-down effort ceases ; or the same object may be accomplished by having the bandage which secures it made of elastic material which retracts after having been stretched during the uterine and abdominal con- traction. Bailly2 has stated, in considering the treatment of placenta praevia, that authors are unanimous upon this point. Whenever in pregnancy or in the first part of labor a hemorrhage, dangerous in amount or continuous, occurs, we ought to tampon. Madame Lachapelle's observations prove that sometimes she left the delivery in women she had tamponed to nature. Weil and Pajot, the latter preceding the former, taught that after having tamponed women suffering with hemorrhages from placenta praevia the delivery should be left to nature, this method giving the best results 1 Op. cit. 1 Gazette des Hop., 1873. PLACENTA PREVIA. 347 for the mothers. The tampon must be closely applied to the os during a uterine contraction, so that no space will be left for the accumulation of blood. Bailly makes the following conditions necessary for the use of the tampon: First, there must not be uterine inertia. Second, the tampon must be properly made and applied; the pieces of charpie should be covered with cerate, and a speculum should not be used in their introduction. Third, the presentation must be cranial or pelvic. According to the statistics given by Auvard, when the tampon was used the maternal mortality was 6 per cent, and the fcetal mor- tality 55 per cent. Ergot.—This is given by Auvard as the method of Paul Dubois. Statistics show that the results of this treatment are: maternal mortality 42 per cent., and fcetal mortality 77 per cent. If no ergot be given, the former is 24 per cent., and the latter 47 per cent. Auvard adds that these figures are eloquent. Ergot given in these conditions kills almost one-half of the mothers and more than one- third of the children. Complete Detachment of the Placenta.—This has already been re- ferred to as the method of Simpson. While the results as furnished by Simpson's statistics were very favorable in regard to maternal mortality, they showed an enormous fcetal mortality; it should be stated that the statistics of others are less favorable in regard to maternal mortality, and the method has now only a mere historical interest. Partial Detachment of the Placenta.—There are two varieties of this: Barnes's and Cohen's. The Method of Barnes.—This is founded upon the proposition that the "physiological arrest of flooding is neither permanent nor secure until the whole of that portion of the placenta which had adhered within the lower zone of the uterus is detached—that being the portion which is liable to be separated during the opening of the lower segment of the uterus to the extent necessary to give passage to the child."1 His directions as to detaching the portion of the placenta involved in this dilatation are as follows : " Pass one or two fingers as far as they will go through the os uteri, the hand being passed into the vagina, if necessary; feeling the placenta, insinuate the finger between it and the uterine wall; sweep the finger round in a circle, so as to separate the placenta as far as the finger can reach; if you feel the edge of the placenta where the membranes begin, tear open the membranes freely, especially if they have not been previously ruptured; ascertain, if you can, what is the presen- tation of the child before withdrawing your hand. Commonly, some amount of retraction of the cervix takes place after the operation, and of ten the hemorrhage ceases. You have gained time. You have given the patient the precious opportunity of rallying from the shock of a previous loss, and of gathering up strength for further proceedings." 1 Obstetric Operations. 34S SCIENCE AND ART OF OBSTETRICS. " If the cervix being now liberated, under the pressure of a firm binder, ergot, or stimulants, uterine action returns so as to drive down the head, it is pretty certain there will be no more hemor- rhage ; you may leave nature to expand the cervix and to complete the delivery, the labor, freed from the placental complication, has become natural." Murphy,1 pursuing the plan of partial detachment of the placenta, as advised by Barnes, and dilatation of the os by Barnes's dilators, in 23 cases saved ten children and all the mothers. His treatment will be more fully stated. Combined Turning.—In 1864 Braxton Hicks's well-known volume upon Combined External and Internal Version was published, and in it he advised the method which in recent years has been so success- fully used more especially by German practitioners, in the treatment of placenta praevia. Lomer2 thus describes it: "Turn by the bi- manual method as soon as possible, pull down the leg, tampon with it and with the breech of the child the ruptured vessels of the pla- centa. Do not extract the child then, let it come itself, or at least only assist its natural expulsion by gentle and rare tractions. Do away with the plug as much as possible ; it is a dangerous thing, for it favors infection, and valuable time is lost with its application. Do not wait in order to perform turning, till the cervix and the os are ' sufficiently dilated to allow the hand to pass.' Turn as soon as you can pass one or two fingers through the cervix. It is unnecessary to 'force your fingers through the cervix' for this. Introduce the whole hand into the vagina, pass one or two fingers through the cervix, rupture the membranes, and turn by Braxton Hicks's bi- manual method. Use chloroform freely in performing these man- ipulations. If the placenta is in your way, try to rupture the mem- branes at its margin; but if this is not feasible, do not lose time, perforate the placenta with your finger, get hold of a leg as soon as possible, and pull it down." Lomer3 states that putting the statis- tics derived from Hofmeier, Behm, and from his own practice, in the most unfavorable light, as including several cases treated by other methods before the bimanual method was employed, the maternal mortality was only 10 per cent. The fcetal mortality was 66 per cent.4 The following is a summary of the teaching of Braxton Hicks as recently given.5 We present it, only remarking that the first rule may be questioned. Is every case of pregnancy with placenta praevia to be at once ended, even though serious hemorrhage be absent, and the fcetus not yet viable ? 1. After diagnosis of placenta praevia is made, we proceed as early as possible to terminate pregnancy. 2. When once we have commenced to act we are to remain by our patient. 3. If the os be fully expanded and placenta marginal, we rupture the mem- branes and wait to see if the head is soon pushed by the pains into the os. 4. If there be any slowness or hesitation, then we_employ forceps or version. 1 Medical Press and Circular, 1885. 2 Op. cit. 3 American Journal of Obstetrics, vol. xvii. 4 Lomer, in a letter read at the last meeting of the British Medical Association, in the ob- stetric section, stated that he had now had 28 cases of placenta praevia treated by the Braxton Hicks method with only 1 death, and that in 190 cases occurring to German practitioners only 9 women were lost. 5 British Medical Journal, Nov. 30, 1889. PLACENTA PREVIA. 349 5. If the os be small and placenta more or less over it the placenta is to be carefully detached from round the os ; if no further bleeding occur we may elect to wait an hour or two. Should the os not expand, and if dilating bags are at hand, the os may be dilated. If it appear then forceps can be admitted easily, they may be used; but if not, version by combined external and internal method should be employed, and the os plugged by the leg or breech of the child; after this is done the case may be left to nature, with gentle assistance, as in footling and breech cases. 6. If the os be small, and if we have neither forceps nor dilating bags, then combined version should be resorted to, leaving the rest to nature, gently assisted. 7. If during any of the above manoeuvres sharp bleeding should come, it is best to turn by combined method in order to plug by breech. 8. When the fcetus is dead, or labor occurs before the end of the seventh month, combined external and internal version is the best method, no force following. In reference to the general subject of podalic version in placenta praevia, the following extract from Rigby is of interest:1 "From what has been said it appears, then, that the placenta is fixed to the os uteri much more frequently than has hitherto been supposed; that when it is so situated, nothing but turning the child will put a stop to the flooding." Murphy s Method.—This is fully presented in the author's words :2 "The practice which I follow, consists, not in a single method for stopping hemorrhage,but in several,and it is this: In the first place, in every one of my own patients, or in those that I am consulted about, when hemorrhage occurs after the seventh month, when it is clearly not from the cervix or os, and when there is presumptive evidence that it is from the placenta praevia, I advise premature labor to be introduced; or before that period of pregnancy when the hem- orrhage is severe, continuous, or frequently recurring. In cases that permit of a little delay from the symptoms not being very urgent, I appoint a time when I can give a few hours' continuous attendance —two hours is generally sufficient—as once you commence to induce labor I consider it necessary to remain with the patient until delivery is accomplished; and when the case does not require instant action one can fix his own time and can have what assistance he requires." " I find having an assistant a great advantage, and by thus arranging a definite time practitioners can secure the services of a specialist or fellow practitioner to help them and to share the responsibility. On examination, if the cervix will permit it, I intro- duce my finger, separate the placenta all around, and then put in a Barnes bag; and if not I gently and slowly insinuate my finger through the os, which I have always found easy of accomplishment, never having had recourse to the preliminary introduction of a tent, though in inducing labor for other causes I have frequently had to introduce tupelo tents. Having thus dilated the cervix with my finger, I separate the placenta freely around the internal os, and at once introduce a Barnes bag. I slowly fill it with water—and here 1 Op. cit. 3 Medical Press and Circular, 1885, p. 208. 350 SCIENCE AND ART OF OBSTETRICS. let me give a practical hint on the use of hydrostatic bags, which I do not remember to have seen mentioned in any of the text-books: When the bag is well through the cervix it is very difficult to say how full it is, and by continuing the injection it may very easily be burst, as once happened to myself, and has, I know, happened to many others; so, to avoid this, it is desirable to ascertain and re- member how many syringefuls each bag requires before being fully dilated, and then carefully to inject only that number. Having thus filled the bag, I wait patiently until the os is well dilated around it, and, before introducing another one, separate the placenta further should the hemorrhage continue, which it does not provided the placenta has been sufficiently separated at first. After the bag has been introduced for some time the pains come on fairly well, though as a rule they are not very strong. " I thus proceed until the os is fully dilated, when I give ergot freely, and decide what is the most suitable course to follow. If the placenta is lateral or marginal, and the pains fairly strong, I rupture the membranes and leave the case to nature; or, if the head is well into the pelvis, I may apply the forceps, but in the great majority of cases I perform version, preferably by the combined method, and deliver the child as quickly as is consistent with the safety of the mother." Murphy has now, 1889, had 38 cases with only 2 deaths; one of these was from septicaemia, and the second occurred in a woman who was dying when he was called to her. He believes that it should be a rule to induce premature labor in every case of placental presenta- tion if the pregnancy has advanced to seven months, and even before this when the bleedings are frequent and serious. Murphy's results, both as to maternal and foetal mortality, have been very good—much better in the latter regard than those secured by the Hicks' method. This sustains, too, the position taken in the begin- ning of the consideration of the treatment, viz., the " induction of premature labor in all cases of placenta praevia, when the hemor- rhage is serious." x Cohen's Method.1—Two fingers, the index and medius, are intro- duced into the os, and made to penetrate between the placenta and the uterine wall in that-direction offering least resistance, until the membranes are reached; the fingers are hooked over the border of the placenta, the membranes ruptured, and the corresponding semi- circle of placental attachment is broken, and the placental flap thus made is drawn toward the vagina so as to project from the mouth of the womb. Cohen reports three cases ; the mothers were saved, but the infants were lost. Rupture of the Membranes.—The method is generally known as that of Puzos. This obstetrician, in 1759, described his treatment of placenta praevia as consisting in dilatation of the os with his finger, 1 The writer advocated this treatment several years ago. American Practitioner, 1875, J87^- 2 Dr. Davis, of Wilkesbarre, Pa., without knowing Dr. Cohen's practice, was led to adopt a similar practice, and has been quite successful with it. ACCIDENTAL HEMORRHAGE. 351 » and then rupture of the membranes. According to Auvard, the results of the method of Puzos at the Clinique d'Accouchements and the Maternite were a maternal mortality of 13 per cent., and a fcetal mortality of 46 per cent. Rupture of the membranes is not in all cases followed by arrest of the hemorrhage. Thus in Muller's statistics it is shown that while bleeding ceased in six cases, in five others it continued or increased. There must be active uterine contractions to secure haemostasis; if these are not present, or do not follow the discharge of the amnial liquor, the patient's danger is increased by this treatment. The practitioner will act wisely who adapts his treatment to the conditions of the case; it may be necessary to use the tampon, temporarily at least, in one case, to use dilators in another, to per- form podalic version in a third, to apply forceps in a fourth, simply to rupture the membranes in a fifth, or to give ergot, or to combine two or more of the various methods, all these when so used being but means to one end—delivery. Hemorrhage occurring after delivery, a by no means rare sequel in cases of placental praevia, will be considered in the treatment of post-partum hemorrhage. Hemorrhage in the Normal Implantation of the Placenta.—Danger- ous hemorrhage may result in the latter part of pregnancy, or in labor, from premature detachment of the placenta when this organ occupies its normal situation in the uterus. The hemorrhage may be either open or concealed. The following history of a case of the former variety which occurred during my term of service at the Philadelphia Hospital has been furnished me by the resident physi- cian, Dr. John Chalmers Da Costa, under whose charge she was : J. L., thirty years of age, multigravida, when at the end of the seventh month of pregnancy, slipped and fell, the right iliac region striking a boiler. She im- mediately had severe pain, and blood flowed from the uterus to the amount of nearly a quart in a few minutes, then stopped. The finger readily entered the external and then the internal os. The pulse was rapid and very weak ; the ex- pression anxious ; body agitated with tremors and covered with cold sweat; pupils dilated ; heart's action weak, irregular, and beats intermittent; respiration shallow and hurried. Immediately upon being placed in bed she was given whiskey and aromatic spirits of ammonia: the head of the bed was lowered by raising the foot; the vagina was washed out with a hot solution of corrosive sublimate, and opium given freely. The hemorrhage did not return, and the pain gradually subsided in two days. The pregnancy went to term, when she was delivered of a healthy, well-developed child. This case illustrates the fact that a grave uterine hemorrhage does not necessarily arrest the pregnancy. Unfortunately, not being present after the labor, I did not have an opportunity of examining the placenta; I am confident careful examination would have found some lesion resulting from the fall which caused the hemorrhage. This case also shows one of the most frequent causes of the so-called accidental hemorrhage—direct violence. It may also occur from uterine contractions, or from acute diseases, as variola, scarlatina, typhoid fever, and acute yellow atrophy of the liver. Lifting a 352 SCIENCE AND ART OF OBSTETRICS. heavy weight, violent coughing, and straining at stool have been given as causes. Recently Winter1 has shown a connection between nephritis and premature detachment of the placenta in three cases. " None of the usual causes for premature detachment—cough, vomiting, straining at stool, etc.—were present; no history of injury or congestion of the uterus was obtainable. On the other hand, in each of my cases nephritis was present. In the first case it was probably due to preg- nancy, and associated with a hemorrhagic diathesis ; in the second the nephritis was chronic: the third was a case of typical nephritis of pregnancy, and left no doubt of the connection between nephritis and the premature detachment of the placenta." Concealed accidental hemorrhage is the much more serious form of the disorder. The subject has been especially studied by Goodell, who has collected 106 cases.2 He enumerates among the promi- nent symptoms an alarming state of collapse, pain, which in the majority of cases is referred to the site of the placenta, absence or extreme feebleness of the pains of labor, and a marked distention of the uterus. "Very often,3 before the lapse of many hours, a show of blood, ranging from an ooze to a gush, will clear up all obscurity; but this trustworthy symptom does not usually occur at the outset of the attack, but at a time when it may be too late to interfere." The mortality of the mothers in the cases collected by Goodell was nearly 51 per cent., and that of the children 94 per cent. Galabin states4 that out of 23,591 deliveries in the Guy's Hospital Lying-in Charity there were 31 cases of accidental hemorrhage, as compared with 41 of placenta praevia; 21 only were serious, and of these there were 5 deaths of mothers from hemorrhage, while the fcetal mortality was 66 per cent. In general the prognosis is worse both for the child and for the mother than in placenta praevia. Treatment.—In the less severe forms of open hemorrhage active interference is not indicated. The reader will find several cases of accidental hemorrhage recorded by Rigby5 in which immediate delivery was not attempted ; indeed he insisted upon the different treatment to be pursued in case of accidental hemorrhage from that required when the placenta was at the mouth of the womb, in the latter urging the importance of immediate delivery. The patient will lie with her head low, her body lightly covered, and stimulants be administered as required; the tampon is used if there is external hemorrhage. In grave internal hemorrhage, however, most obstet- ricians from Baudelocque on to the present, including such names as Goodell, Schroder, and Barnes, have taught that the membranes should be ruptured, and the uterus emptied. Nevertheless an oppo- 1 Zeitsch. f. Geb. u. Gyn., xi. p. 398. See abstract, American Journal of the Medical Sciences, Jan. 1886. Blot in his inaugural thesis, 1849, directed attention to the hemorrhage peculiarly liable to occur in albuminurics in the third stage of labor, finding that in 12 parturients who suffered from albuminuri, 12 of 41 parturients having albuminuria, this accident occurred. 2 American Journal of Obstetrics, vol. ii. 3 Goodell, op. cit. * Op. cit. 5 Op. cit. ACCIDENTAL HEMORRHAGE. 353 site opinion has been expressed by Spiegelberg and Winter. The former believed that the blood remaining in the uterine cavity caused a greater intra-uterine pressure, and thus the bleeding would be arrested, but if the uterus be emptied fresh hemorrhage may occur at once. Budin1 believes that expectation is the better course before labor so long as the woman's life does not seem to be com- promised. Nevertheless, if the labor has begun, or if the hemor- rhage is dangerous, the sooner delivery is effected, but without violence, the better. As deep calls unto deep, so one bleeding invites another, and the final and most faithful uterine haemostatic is uterine retraction ; but such retraction is impossible while the uterus is distended by the ovum and by effused blood, and hence the practice so generally advised. Rupture of the membranes is usually the first step to be taken ; it should be instantly followed by firm compression of the uterus. If the os be sufficiently dilated to admit of immediate delivery by podalic version, or by the forceps, one or the other method is indicated ; but if it be undilated, artificial dilatation is required, and if it yield readily ergot may be given. 1 Lecons de Clinique Obstetricale, 1889. 23 PART III. LABOR. CHAPTER I. CAUSES OF LABOR—PRECURSORY SYMPTOMS—PHYSIOLOGICAL PHENOM- ENA—CHANGES IN THE FORM OF THE HEAD IN VERTEX PRESENTATION —CAPUT SUCCEDANEUM. Labor is the physiological end of pregnancy, and may be defined as the process by which the fcetus and its appendages are separated from the mother; it is travail, bringing forth. Nature's design being the continuance of the race, the fcetus must have reached such development before its expulsion that it is viable, that is, capable of living external to the mother. If, therefore, the product of concep- tion be expelled before such capability, the process is not called labor but abortion or miscarriage. If labor take place in the eighth or ninth month it is called premature, because the fcetus has not attained its perfect development; if labor be delayed beyond nine months, it is called postponed, if the fcetus be alive, but missed labor if it be dead. When parturition is effected by the sole power of the maternal organism it is called natural; but if art aid or replace that power it is termed artificial labor. In order that a labor may be natural the fcetus must not exceed the normal sizet and the presen- tation must be favorable ; the birth-canal must be normal in size and form, and, finally, the forces, voluntary and involuntary of the mother, must be able to dilate the birth-canal, to mould the present- ing part, determine changes in its position so that shorter fcetal diameters are brought in relation with longer diameters of the mother's pelvis, the passenger thus accommodated to the passage, and all resistance overcome. Determining Causes of Labor.—For a long time it was believed that the fcetus escaped from the uterus by its own efforts, just as the chick leaves its shell, or the butterfly its cocoon. Harvey, for ex- ample, held that " the fcetus, with its head downward, attacks the portals of the womb, opens them by its own energies, and thus struggles into day." If the fcetus made its own way from the mother's womb, the question naturally arose as to the reason for its action, and various answers were given. The amni- otic liquor became acrid, and irritated the skin of the fcetus ; Drelincourt said that the intestine was filled with meconium, and hence a colic which disturbed the 356 SCIENCE AND ART OF OBSTETRICS. fcetus, and made it strive to get out, while others held that a distended bladder was the cause of this effort: the womb became too hot for it, or it needed to breathe, or sought different food ; Fabricius asserted that the weight of its head pressed open the mouth of the uterus. Some thought that obliteration of the utero- placental vessels caused the child to leave, others that the uterus having reached a certain distention, reacted and by its contraction incommoded the ftutus ; nar- rowing of the ductus arteriosus, of the ductus venosus, and of the foramen of Botal have also been suggested as the causes of the action of the foetus. Those who believed that the fcetus was an active agent in parturi- tion, asserted that the delivery of a dead child was more difficult than that of a living one. Admitting the assumption, Depaul has suggested three answers: First, the living fcetus by its movements may excite or increase uterine contractions. Second, in case the fcetus dies, some time may elapse between the death and the expul- sion, but the development of the uterus ceasing with the former its action in the latter may be less powerful than it is at the time of perfect development. Third, if the membranes have been ruptured the following fcetal decomposition may have a poisonous influence upon the muscular fibres of the uterus, weakening their action. Post-mortem births have been claimed as proof that the fetus could escape from the womb by its own efforts. But when these happen soon after death, they result from the persistence of uterine contractility while the resistance of soft parts is lost; occurring later, they are caused by the pressure of gases formed in the abdo- men external to the uterus. Fatty degeneration of the decidua by which the ovum is detached from the uterus and becomes a foreign body, is alleged by some to be the cause of labor. It is well known that artificial detachment of the ovum is one of the most certain methods of inducing labor. But the fatty degeneration which is supposed to excite natural labor is not a constant fact. The influence of the ovaries in exciting labor has been maintained. Tyler Smith believed he had established that ovarian excitement is the law of parturition in all forms of ovi-expulsion ; this excitement, this nisus, he alleged, is active at monthly periods through the pregnancy, becoming at the tenth so great as to cause labor. Prob- ably the majority of women are not conscious during their preg- nancy of periodical ovarian disturbance ; in the order of nature ovulation is then suspended, the ovaries for the time being having fulfilled their work now rest. Beside, the tenth period varies in dif- ferent women ; in one menstruating every thirty days it is three hun- dred days, while in another who has her flow every twenty days, it is only two hundred. Again, women may conceive who never menstruated, or in the physiological absence of the flow during lac- tation ; a nisus which fails to cause menstruation in the non-preg- nant state, has not enough power to start the machinery of childbirth. It is not probable that extirpation of the ovaries would prevent labor. Single ovariotomy has frequently been done during preg- nancy, and labor occurred at the normal time. Double ovariotomy has been done in a few cases during pregnancy, but this did not prevent the action of the uterus in the expulsion of the ovum. CAUSES OF LABOR. 357 But if the determining cause of labor be not found in the fcetus or in changes in the decidua or in the ovaries, may it not be in the uterus? It is held by some that when the muscular fibres of the uterus have attained their perfect development, expulsive contrac- tions result. But the contractile power of the uterus is manifested in premature labor and in abortion. Others teach that the uterus may be distended to a certain degree, and then reacts against the distention. But the thickness of the uterine walls is different in different subjects, and in the same subject varies in different preg- nancies, yet in each case the reaction occurs just when the fcetus has reached maturity. In plural pregnancy and also in polyhy- dramnios the uterine distention is greater than in single or in normal pregnancy. Brown-Sequard has shown that carbonic acid circulating in in- creased quantity in the blood of a pregnant animal, causes uterine contractions, and the occurrence of labor is therefore attributed to the accumulation of carbonic acid in the venous apparatus of the uterus. Dr. Robert Barnes1 has called attention to the fact that when the French army in Algeria kindled fires at the mouths of caves in which, among others, a number of pregnant women had taken refuge, almost all these women miscarried. But it is possible that mental emotion had as much to do with the accident as carbonic acid had. The carbonic acid hypothesis of the induction of labor fails, because it does not explain why the uterine muscular tissue did not act sooner, but was indifferent to the presence of carbonic acid until nine months ended, and then suddenly resented and began the process of labor. Dubois and Depaul upheld a theory first advanced by Power in 1819. According to it, the expulsion of the fcetus is similar to that of the feces or of the urine. Feces accumulate in the rectum, and after a time by pressure on the sphincter irritate it, until reflex action de- termines contractions which overcome its resistance, and the bowel is emptied. So, too, the renal secretion does not at first excite vesical contractions; but when the reservoir is more or less com- pletely filled, the fibres of the neck are stretched, causing irritation and dragging on the sphincter of the organ, and this sensation reacting upon the body, contraction is excited, and its contents dis- charged. In pregnancy, the upper part of the uterus is developed first; "little by little the lower segment takes part in the general development of the organ, and the ovum gradually occupies a larger space in this portion; thus at the ninth month that section of the uterus adjoining the internal orifice of the neck is developed in turn, and causes stretching of the circular fibres ; this purely mechan- ical irritation, by reflex influence, acts upon the upper part of the womb."2 r Transactions of the American Gynecological Society, vol. i. 2 Depaul, op. cit. Garimond, Nouv. Arch. d'Obstet. et de Gynecol., 1887, in a study of the determining cause of labor, referring to the analogy between the expulsive exertion action of the bladder and that of the uterus, observes that it is not irritation of the sphincter, but ex- cessive tension of the entire cavity of the bladder that causes this organ to contract, expelling its 35§ SCIENCE AND ART OF OBSTETRICS. But, as frankly acknowledged by Depaul, the theory of Power fails to explain the access of labor-pains in extra-uterine pregnancy. Some writers, plainly seeing the weakness of each of the various causes adduced as determining labor, have rested their explanation in a combination of them.1 It is better to refer the matter to a law of the organism, a law the cause of which we do not know, for, as truly said by Foster,2 we are utterly in the dark as to why the uterus, after remaining apparently perfectly quiescent, or with contractions so slight as to be with difficulty appreciated for months, is suddenly thrown into action, and within, it may be, a few hours gets rid of the burden it has borne with such tolerance for so long a time; indeed, none of the various hypotheses which have been put forward can be considered satisfactory. The Efficient Causes of Labor.—The chief agent in the expulsion of the fetus is the uterus itself. During the first part of labor the uterine contractions act unaided ; but when the os uteri is dilated so as to offer little or no resistance to the descent of the part of the fcetus which presents, they are reinforced by the action of the abdo- minal muscles. In exceptional cases, as in complete prolapse of the uterus, or when the patient is paraplegic, or profoundly narcotized, uterine contractions have alone effected delivery, but the labor under these cirumstances is longer. Precursors of Labor.—In some cases labor begins abruptly—the, patient, for example, being wakened in the night by frequent and strong uterine contractions. But in the majority a change in the form of the abdomen, increased secretion from the external organs of generation at first, and then from the glands of the neck of the uterus, swelling of the labia, and the hitherto painless contractions of pregnancy becoming more frequent and causing some discomfort, prepare the way and herald the coming of labor. The first of these phenomena is not constant; it results from the head of the fcetus covered by the inferior segment of the uterus and more or less of the expanded upper portion of the cervical canal entering the pelvic cavity, while the superior portion of the uterus inclines more in front and is lower. By this descent or settling down of the uterus—fall- ing of the abdomen it is sometimes called—the patient's waist is not so large, her breathing is less interfered with, she can take a fuller inspiration, and her stomach relieved from pressure, receives more food; on the other hand, the increased downward pressure may cause irritability of the bladder or of the rectum, difficulty in walk- ing and greater swelling of the lower limbs. This change in the form of the abdomen is marked in the primigravida, but may fail in the multigravida, for the uterus and the abdominal wall of the latter contents; and thus in regard to the uterus: tension of the uterine walls is the cause of uterine action beginning, and contractions occur, not in response to an elective sensibility seated in the body or neck, but this sensation belongs to the entire physiological organ. This is simply an old hypothesis in new clothes. 1 Their explanation has always seemed to me similar to the action of the physician who combined many medicines in his prescription, "so that the disease might take whichever it 'iked." 2 Text-book of Physiology'. STAGES OF LABOR. 359 having undergone development in one or more previous pregnan- cies, yield more readily, the uterus does not rise so high, and is more inclined forward earlier in pregnancy. In cases presenting this phenomenon1 its value as a sign of approaching labor is not great, for while it usually occurs from one to two weeks before, this interval may be only a day or two, or it may be a month. It is a favorable indication as to the labor, for it shows that the presenta- tion is normal and the pelvis roomy. Active hyperaemia and passive congestion, the latter resulting from pressure, cause more abundant secretion from the glands of the cervix. This discharge is viscid, yellowish, and in some cases toward the end of pregnancy contains striae of blood; when thus stained, its color being caused in the same manner as that of the sputa in pneumonia according to Velpeau, it is known in the lying- in room as a " show," and is then usually an indication of consid- erable advance in labor. It is caused, whether occurring at the end of .pregnancy, or in the beginning of labor, by partial detachment of the decidua near the mouth of the womb. The striae of blood observed at the close of the stage of dilatation of the os uteri, are caused by slight lacerations of the cervix. An abundant discharge from the cervical glands is a favorable indication as to the ready dilatation of the os uteri. The external organs of generation are swelled and moistened by their own and by the Vaginal secretions. The painless uterine con- tractions of pregnancy become more frequent, and begin to cause more or less discomfort. In the parous especially it is not unusual for these contractions to become decidedly painful some days before labor; they may come on at night disturbing the woman's rest, and making her believe labor is at hand, but disappear in the morning to be renewed the following night. When the cervix is effaced, and uterine contractions recur at regular intervals and cause dilata- tion of the os uteri, labor has begun. Stages of Labor.—Although labor is one process from the begin- ning to the end, yet it is usual to consider it as including three stages or periods. The first stage, the uterine period, begins with dilatation of the os uteri, and ends when that dilatation is completed so that the head, or the greater part of it, can pass through the os uteri, this being so expanded as to offer no resistance. The second stage of labor, the utero-abdominal period, then begins, and includes the expulsion of the child. The third stage, the placental period, embraces the detachment of the placenta, its expulsion from the uterus, and then from the vagina. While the boundary between 1 According to the investigations of Briihl, in primigravidas the greatest circumference of the fcetal head was found to have passed the brim at the end of pregnancy, in half the cases, but in multigravidae in one-fourth only. If the true conjugate is less than 10 centimetres, in only one-third. Prof. Muller, of Berne, directs in those cases in which the head has not thus passed the brim at the end of pregnancy, to grasp the fcetus through the abdominal wall and force the head as far as possible into the pelvic canal. But one who tries this experiment will find possibly that the head is very disobedient, and will not be pushed where desired—at least that has been my experience. 360 SCIENCE AND ART OF OBSTETRICS. the second and third stages is well marked, that between the second and the first is by no means so clear ; theoretically, the line is as stated, but in practice one rarely sees it so sharply and abruptly defined—the first oftener gradually passes into the second stage. Phenomena of Labor.—These are usually divided into Physiological and Mechanical. A third class has been added by some, and are called Plastic Phenomena; by these are meant the fetal form changes produced in labor, and dependent upon presentation and position; they are the deformations which the presenting part of the fetus undergoes in its transmission through the birth canal; they disappear a few days after birth. These in relation to vertex presentations will be mentioned at the close of the present chapter, and those of other presentations will be given in connection with the mechanical phenomena of labor. Physiological Phenomena.—First. Uterine Contractions.—As the con- tractions of the uterus are the chief power by which the fcetus and its appendages are expelled, their study is important. Characteristics of Utei'ine Contractions.—First. They are involun- tary. They are independent of the will; it can neither begin nor stop them. But though not subject to volition, they may be affected by mental impressions. Thus the presence of a person in the room of the parturient who is disagreeable to her, or for whom she has an antipathy, may interfere with their regular action and power, while they may be immediately arrested by the arrival of a stranger who takes the place of the expected family physician. Profound mental anxiety, grave apprehension of disaster, and deep sorrow may lessen the activity of uterine contractions. Second. These contractions are peristaltic. The most probable view, derived from observations of inferior.animals, is that the peri- staltic movements begin at the fundus of the uterus. Third. The contractions are intermittent. The periods of action and of rest are different in different stages of labor. The contrac- tions last about twenty seconds at the beginning of labor, and the intervals are twenty or thirty minutes ; toward the close of the second stage of labor the former may last a minute or more, while the latter only two or three minutes, sometimes less, but during it the intervals are about five minutes. In some cases the uterus after having manifested active contractions for a few hours, pauses in its work, and a rest of some hours may follow, after which its action is resumed with new vigor. Such a pause, therefore, neither the condition of the mother nor of the child indicating the demand for interference, should not be considered pathological. The ordinary intermittence in the succession of uterine contractions is important both for the mother and for the child ; the latter is saved by it from a continuous pressure which would cause asphyxia, and the former has her burden of suffering divided into many parts which can therefore be endured, while united they would be too heavy for human tolerance; and beside, such continuous and concentrated action would produce injurious pressure upon her tissues, and render rupture of the uterus almost inevitable. The intermittence of uterine PHYSIOLOGICAL PHENOMENA. 3* i action corresponds with that observed in the action of other organs, e.g., the heart, the lungs, the intestines, etc., and the noblest human organ, the brain, has a period of activity followed by one of repose; alternate work and rest seem to be the law of life. The contrac- tions do not begin and end abruptly, each gradually reaches its maximum and then declines—a climbing, and then a falling wave ; but in the latter part of labor this characteristic becomes much less marked. Fourth. The contractions of the uterus are associated with changes in its form and in its position. During a contraction the organ takes a cylindrical form ; its transverse-diameter is notably lessened, while both the longitudinal and the antero-posterior are slightly increased ; the shortening of the transverse diameter produces some extension of the fcetus, its curved form is lessened, and hence the slight in- crease in the longitudinal diameter of the uterus. The broad and round ligaments contracting simultaneously with the uterus have some effect in pressing it toward the pelvis; the round ligaments by their contraction also draw the organ forward, so that the fundus rests upon the abdominal wall. Fifth. The power of the contractions is in proportion to their frequency and the resistance; it increases with the progress of the labor, the duration of contractions being inversely proportionate to the intervals. The force and frequency of uterine contractions are not in all cases in relation with the general vigor of the subject; these contractions may be strong and frequent in feeble, delicate women, while weak, and the intervals long, in the robust. Sixth. The character of the contractions is related to the presenta- tion. Depaul has especially drawn attention to this fact, stating that the contractions are usually more regular and effective in presentation of the vertex. Uniform pressure upon the lower uterine segment and the dilating os seems necessary in order to evoke the regular and strong action of the body and fundus of the uterus ; this condition cannot be met by presentation of the face, of the breech, or of the shoulder, and hence the contractions present a manifest irregularity. The physiognomy of the labor will in most cases give a valuable indication as to the part of the fcetus which presents. It is not uncommon to find the contractions alternating in strength, a vigorous contraction being followed by a feeble contraction, and vice versa; they then come in couples. One of the characteristics of uterine contractions is that they are painful, but the subject of pain in labor will be considered in another connection. Force of Uterine Contraction.—Many endeavors have been made to ascertain the force exercised in labor. These have been by measur- ing the bulk and extent of the voluntary and involuntary muscles concerned in the function (Haughton); by determining the force necessary to rupture the fcetal membranes (Poppel and Duncan); by means of the tocodynamometer (Schatz); and by the tocograph (Poullet). Haughton's estimate was S77-7S pounds, which exceeds that quoted by Sterne in Tristram Shandy—" 470 pounds avoir- 362 SCIENCE AND ART OF OBSTETRICS. dupois acting upon the head of the child." Poullet's conclusion1 is that the maximum force of expulsion is about 50 pounds. Duncan states that in easy labor a force scarcely exceeding the weight of the child is necessary, while only a few difficult labors require for their whole work a force exceeding 50 pounds; and admitting the force asserted by Haughton, the child would be shot out of the vagina at the rate of 36 feet per second. Schatz's estimate is from 17 to 55 pounds. Ribemont has repeated the experiments of Duncan, and has found that with the membranes presenting a sur- face of 10 centimetres, the pressure necessary to rupture them was 10 kilo., 300 ; the maximum, 11 kilo., 179. Spiegelberg regarded all estimates as liable to errors—e.g., that derived from the resistance of the fcetal membranes in labor to this, that the water in front of the presenting head is not subjected to the same pressure as the other uterine contents, while the manometric method is liable to mistakes in measurement. It cannot, therefore, be claimed that we know the entire force, or that which is its chief element, the con- traction of the uterus as exerted in labor. Dr. Henry Leaman showed to the Philadelphia County Medical Society, January, 1885, an instrument of his invention, to which he gave the name of parturiometer. The following is his description of it: " It consists essentially of a metallic cylinder, in which is placed a spring ac- curately made to measure weight in pounds. The pressure impinges on a socket, and is conveyed to the spring by a plunger; at the other end of the cylinder is a self-registering indicator and scale. The socket is placed in contact with the Fig. 123. 1. Socket. 2. Plunger. 3. Cylinder with spring. 4. Scale and indicator. 5. Movable Band. 6. Short arm. 7. Long arm. 8. Screw. advancing part of the ovum, or fcetus, during an interval between pains. The effective movement of the mass is indicated on the scale during the uterine con- traction. The instrument is held in position by the band and arms, which are movable by means of a screw. The anterior, or short arm, rests between the 1 Poullet (Archives de Tocologie, 1880) refers to Tristram Shandy as an English author, and speaks of Professor Haughton as "one of his compatriots," a ludicrous mistake, into which more recently Delore and Lutaud (Traite Pratique de l'Art des Accouchements, Paris, 1883) have been led. PHYSIOLOGICAL PHENOMENA. 3^3 labia, against the arch of the pubes, the posterior on the coccyx. The socket can be placed inside of the cervix, in contact with the membranes ; or, if the mem- branes are broken, against the advancing part of the fcetus, before full dilatation of the cervix. It can be used at the superior strait with ease. In the various conditions in which it has been employed, its registration has corresponded with experience, and rendered observation more accurate. " The parturiometer indicates when it is proper to break the membranes ; when the cervix is fully dilated; when the application of instruments becomes neces- sary. By observing, in cases when the resistance is nil or at a minimum, and then again when it is at a maximum, the amount of force lost may thus be arrived at. Also, by close observation we may finally arrive at the separation of the true uterine force as distinct from anything else, and thus a more accurate knowledge of the physiological action of the uterus be obtained. This instrument promises to render the attendance of labor cases more exact and scientific."1 Dr. Leaman has been kind enough to furnish me with the following statement as to the practical application of his instrument: "Observations which have been made on the expulsive force of the uterus em- brace three stages in delivery, viz., the force required to overcome the resistance in succession of the cervix, the pelvis, and perineum. The parturiometer applied to the membranes within the cervix gives a marking of from one to three pounds. In one case the membranes ruptured while the gauge was applied, and the mark- ing on the scale was three pounds. In another case, where the pains were regular, good, and frequent, the os remained dilated to the size of one and a half inches in diameter during a period of nine hours without perceptible change. During this time the gauge was applied a number of times. The highest marking during contraction was one pound; frequently there was no perceptible indication by the instrument. Believing from these experiments that the uterine force was impeded by over-distention, I ruptured the membranes, and in one hour the child was born. The os being fully dilated, and not till then, does the fcetus impinge upon the pelvic walls. The first case in which I made use of this instrument was one where the first two children had been still-born, with the use of the forceps. The vertex was in the first position, and the head at the superior strait. The parturiometer was applied to the vertex, and the marking did not exceed at any time one and three-fourths pounds. These experiments, together with the previous history deter- mined the speedy use of the forceps, with a living child as the result. " In one case where the occiput was right posterior, the os being fully dilated, the gauge registered one and three-fourths pounds. At the expiration of three hours the gauge recorded the same as before, and there being no apparent ad- vance the child was delivered with forceps. In all cases where the pressure at this stage did not exceed two or two and a half pounds, the forceps has been found necessary. " During dilatation of the perineum the pressure may be as high as five pounds and over. These observations seem to point to the opinion that the uterine force is a definite quantity within a normal physiological range not yet determined. The pounds-pressure on the gauge is the difference between this definite quantity and the resistance. The resistance being great the gauge marks low, and vice versa.'' Winckel renarks that the apparatus of Leaman does not allow for the resistance of the soft parts; that is to say, the force with which the head advances is measured, but not that by means of which it is moved. Abdominal Contractions.—When the mouth of the womb is so dilated as to offer little or no resistance to the escape of the pre- senting part, the first stage of labor ends, and the second, or the utero-abdominal period, begins. The uterine contractions are now reinforced by voluntary contractions of the muscles of the abdomen. Preparing for one of these efforts, the patient bends forward, fixes 1 College and Clinical Record. 364 SCIENCE AND ART OF OBSTETRICS. her body by pressing the feet against a firm object, possibly grasps the bed or another's hands, takes a deep inspiration, pushing the diaphragm down, and the glottis is closed; the muscles are now firmly contracted, thus lessening the size of the cavity; the pressure from this contraction is exerted uniformly upon the contents; it is resisted above by the depressed diaphragm, and behind by the im- movable spine; it acts uniformly upon the uterus, forcing it down- ward, and is transmitted to its contents. This force not only assists that of the uterus, but also acts as a counter-force to uterine con- tractions, which, when violent, might, were this absent, cause rupture of the vagina at its uterine attachment. While, during the greater part of the second stage of labor, the action of the abdominal muscles is voluntary, it generally happens that toward its close, just when the fcetal head is about to be ex- pelled from the vulva, the patient cannot refrain effort, and the hitherto voluntary action becomes purely reflex. The Third Stage.—In ten to twenty or thirty minutes after the birth of the child uterine retraction, which detaches, and then uterine contractions, which expel the placenta into the vagina, occur; they may be assisted by voluntary contraction. So, too, these uterine and abdominal contractions, assisted in some slight degree by the elas- ticity and contractions of the vagina, may thrust the placenta with- out. This topic will be considered more fully hereafter. Pain.—Labor begins, continues, and ends with pain: "childbirth is the only necessarily and invariably painful function of the species." While in very rare cases delivery is without suffering, yet these are exceptional, for now, as of old, the law is, " in sorrow thou shalt bring forth children." But pain is relative; there is no measure of this phenomenon of vital sense which can be universally applied. One patient will be in restless agony in childbirth, vexing the air with her outcries, while another lies comparatively quiet, and suffers in silence, because sensation, power of endurance, and force of will so greatly differ. Nevertheless, pain is not so great in the parous as in the primipara; yet how often the former will declare that they suffer more in the present than in a previous labor, simply because of that beneficent law of the economy which leads human beings to forget painful sensations. The occurrence of pains during uterine action in labor is so constant that the name is generally, and in almost all languages, used as a synonym for uterine contractions. But the duration of a contraction and of a pain is not the same; while the former causes the latter, the contraction can be readily recognized by the obstetrician with his hand upon the patient's abdomen, or with his finger at the os uteri, before she complains of any suffering, and he likewise knows by the same means that it con- tinues after all complaint has ceased ; pain comes after contraction begins, and goes before it ends. Character of the Pains.—In the beginning of labor these are felt as a disagreeable pressure downward in the pelvis, later they are felt in the lumbar and sacral region, radiating thence to the pubes so that the patient is girdled with pain. At first they do not by PHYSIOLOGICAL PHENOMENA. 3^5 their frequency or their severity hinder a patient's being engaged in such occupations as reading, sewing, conversing, etc., only when one occurs she pauses for a minute or two, a slight change of ex- pression is noticed, a mere cloud passes over her face, she.bends her body forward during the brief suffering, and then resumes her conversation, reading, or work. The bending forward is instinc- tive, and is said to be an effort to withdraw the ovum from pressing directly upon the lower segment of the uterus, but it is probable that the movement is made in response to the anterior and down- ward positional change of the uterus, caused by the contraction of the broad and round ligaments, and to lessen the pressure upon the abdominal wall, just as more common abdominal pain leads to a similar movement. During the first stage of labor the pains are spoken of by the sufferer as " cutting," " grinding," etc., but by the obstetrician as dilating, or preparatory. As the frequency and intensity of the uterine contractions increase so do the pains increase in severity; the patient may become restless, irritable, despondent, and discour- aged, asserting that she suffers in vain, " the pains do no good," "the child will never be born," and she knows she will die. After a time, when the os has become fully dilated, and the birth canal is thus prepared for the descent of the child, expulsive, or " bearing- down," pains occur. The transition is not sudden but gradual, the call for voluntary effort is at first indistinct, and partly from this, and partly because the patient fears lest such effort may add to her suffering, the response begins in a hesitating, tentative way, and then gradually becomes equal to the demand. Hitherto the patient has been without power to assist the progress of labor—she has had only to endure, to suffer—but with the establishment of the second stage active duty devolves on her, and she usually becomes hopeful and resolute; no longer moaning and groaning, her lips are closed while voluntary abdominal pressure combines with uterine contraction to drive the fcetus down the birth canal, abrupt expira- tion occurs at the close of a pain, with a sudden and guttural outcry. The practitioner soon learns to know by a patient's cry whether she is in the first or second stage of labor. The Seat of Pain.—Madame Boivin, who knew from personal ex- perience the suffering of childbirth, thought the pain was almost entirely the result of stretching the os uteri. Depaul said that in the first stage of labor it was in the lateral and lower parts of the uterus, but afterward it arose from pressure of the fcetus upon the organs and tissues of the pelvic cavity. According to Spiegelberg, form-changes in the uterus and of separate muscular fasciculi in its walls, permitting pressure on nerves, are causes of suffering. The pressure upon the tissues surrounding the vulvar orifice made dur- ing its dilatation also causes severe pain. Dilatation of the Os Uteri.—At the beginning of labor the cervix has disappeared, only a slightly projecting border—more pro- nounced in multiparas—marking the boundary of the os uteri. This is the first barrier to the escape of the fcetus, and dilatation of the 366 SCIENCE AND ART OF OBSTETRICS. os, therefore, is the first part of labor. This dilatation is at once active and passive; the muscular fibres of the body and the fundus overcome the resistance of the circular fibres of the os, and the pressure of the ovum upon the os, made by the projecting mem- branes filled with amnial liquor—the bag of waters—mechanically dilates it. Further, this uniform pressure of the ovum upon the lower segment and mouth of the womb evokes regular and stronger contractions from the body and fundus ; and thus, in addition to its mechanical dilatation, assists labor. When the uterus contracts the cavity lessens, its walls tend to approach a common centre; but the ovum resists, and the resultant of the forces developed by the contracting muscular fasciculi is transmitted in the direction of least resistance, that is, to the os uteri, from which a part of the ovum, this part increasing with the progress of the labor, protrudes. As the os uteri expands, the cavity lessens ; and the former, by the contraction of the longitudinal fibres of the uterus tends to ascend, drawn up over the ovum or the presenting part. At the beginning of a contraction, the rim of the os uteri becomes thicker, irregular, as if " puckered," and the opening smaller, but with the progress of the uterine effort the border becomes thin, regular, uniform in thickness, and the opening expands ; with the advance of the labor the lessening of the os at the beginning of a contraction is not observed, but dilatation alone. In primiparae the border of the os uteri is at the beginning of labor very thin, scarcely thicker than parchment, is closely applied to the foetal head, and during a uterine contraction seems like a tense cord: but with the progress of the labor it becomes thicker and swelled, especially at the anterior part, and it is more dilatable; it never, however, becomes as thin as it was at first. The dilatation rapidly increases with the progress of the labor, nearly as much time being needed for the os to be expanded to the size of a silver dollar, as from this to reach complete expansion. The process is more rapid in the parous than in the primipara. At the beginning of labor the os is usually posterior, and to the left; but with its progress it comes nearer the centre; its form is at first circular, then oval, the large end of the oval being to the left, and somewhat behind. The posterior lip generally yields before the anterior, the uterine orifice being nearer to the sacrum than it is to the pubes; if the labor be prolonged, the anterior lip in most cases becomes cedematous. The Bag of Waters.—The ovum being equally pressed at all points except at the os uteri projects there, and that portion of the mem- branes containing amniotic liquor thus protruding, " making a her- nia through the more or less dilated os," is the bag of waters. The size and form of this protrusion are usually dependent upon the degree of dilatation, and upon the presentation. When the os is but slightly dilated, the bag of waters is small ; so, too, in vertex pre- sentation it is at first quite small, and has the form of a watch crys- tal, but as the dilatation approaches completion it increases, and is hemispherical. The bag is large in presentation of the face, of the PHYSIOLOGICAL PHENOMENA. 367 breech, or of the shoulder, because no one of these parts can be adapted to the cervico-uterine canal, but permits the amnial liquor to pass freely by it; the great size of the bag of waters rather than the form is an indication of an unfavorable presentation, especially when this is observed during the dilatation of the os uteri, and the presenting part of the fcetus does not readily descend. A double bag of waters is observed in some cases of twin pregnancy. Fig. 124. The Bag of Waters. The pouch is smooth and tense during uterine contractions, re- laxed and yielding in the intervals Tarnier's experiments have proved that the membranes are permeable by fluids, so that a moist condition of the vagina is not a proof of rupture of the sac. The bag of waters acts as a hydrostatic dilator of the os uteri, the best and the least painful one; and therefore care must be taken to guard against its premature rupture. In some cases rupture takes place before labor, or as the first indication that labor has begun, 368 SCIENCE AND ART OF OBSTETRICS. the patient being wakened from her sleep in the night by a gush of water ; this accident is more frequent in primigravidae than in mul- tigravidae, because in the former the uterine walls are more resisting, and yield less readily to distention. When the waters are evacuated before or at the beginning of uterine contractions, the labor is called a dry labor, and the first stage is generally quite tedious. A collection of fluid between the ovum and the uterus, or between the amnion and the chorion may take place, and its discharge simu- late that of the amnial liquor; when this occurs the flow is known as the " false waters,"1 and probably most of the cases in which it is thought that the ovum was ruptured sometime before labor are thus explained. This last statement, however, does not apply to all, for there are authentic cases in which the rupture took place some weeks before labor. Poullet, quoted by Tarnier, gives one instance of rup- ture six weeks, another nine weeks before labor, and then a living fcetus being born in each case. Matthews Duncan mentions an instance in which the pregnancy continued forty-five days after the first discharge of amnial fluid ; he also states that a medical friend, mistaking pregnancy for an ovarian dropsy, performed paracentesis, drawing off a large quantity of amnial liquor, when he desisted because feeling the fcetus strike against the canula, and yet the preg- nancy did not end for a month. If one is in doubt whether the fluid discharged in a given case be liquor amnii, and enough of it can be collected for examination, the presence or absence of seba- ceous matter promptly settles the question. In rare instances, less rare in premature than in mature labor, the ovum is expelled entire. Under these circumstances the membranes were known as a child's caul, which once was in demand by sailors as an amulet that would keep its possessor from drowning. For- merly when the child was born with a flap of membranes covering the head, the fact was regarded as a favorable augury. The bag of waters is usually spontaneously ruptured about the time the os uteri is fully dilated; in some cases, however, it may protrude from the vulvar orifice before being torn. As a rule, the rent is at the most dependent part of the pouch, and the water escapes suddenly and with noise, but it maybe above in the cervico- uterine canal, and the flow is gradual and silent, while the part of the membranes in front of the child's head being entire still forms a pouch. The quantity of fluid discharged depends upon the presen- tation ; thus if the vertex present, the head makes a ball-valve which, when pressed down during a uterine contraction entirely arrests the flow, and permits only a slight discharge in the interval; no other part of the foetal ovoid which may present can so well fill the cer- vico-uterine canal, but by its irregular form readily permits the escape of the amnial liquor. It is often observed in vertex presen- tations that when the head has descended so. that partial deflexion —a movement which some authors describe in the mechanism of ' These discharges are generally caused by catarrhal endometritis See p. 289. PHYSIOLOGICAL PHENOMENA. 369 labor as levelling—can take place, there is an increased flow of liquor amnii, because the neck does not completely fill the canal. It is very important for the obstetrician to know whether the membranes are ruptured. Generally there is no difficulty in deciding this question, but cases occasionally occur in which it is very great, and some deplorable mistakes have been made; thus the forceps has been applied to the fcetal head inclosed in the membranes, the distended bladder has been thought the bag of waters and incised, causing a vesico-vaginal fistula, and the fcetal scalp similarly mis- taken and treated in like manner, the incision being the starting point of a fatal erysipelas. A knowledge of the fact that such errors have been committed, and hence the possibility of their repetition, may prove a warning against the hurried and imperfect examination in which they originate. In doubtful cases the obstetrician should examine during a pain—of course taking care to avoid rupture of the pouch if it be present—for, however closely the membranes may be applied to the head when the uterus is at rest, there will then always be found some fluid interposed which causes their projection. In the interval between pains, the membranes are flaccid, and the finger can press them in wrinkles or folds which give a different sensation from that caused by directly touching the fcetal scalp. Finally, Charpentier advises carrying the finger as far as possible between the head of the fcetus and the cervix, thus opening a way by which, if the membranes have been ruptured, the liquor amnii will flow down into the palm of the hand. Muco-sanguineous Discharge.—A greater discharge from the ex- ternal genital organs and from the vagina is observed toward the close of pregnancy, but with the beginning of labor an increased secretion from the glands of the cervix occurs. The character of the latter, as well as the significance of the blood often found mixed with it, has already been stated; the discharge of any considerable amount of blood with it would indicate most probably either a serious rent of the cervix or a partial detachment of the placenta. Dilatation of the Vagina.—The upper part of the vagina was dilated by the descent of the lower portion of the uterus containing the fcetal head, and by the stretching of the margin of the os uteri, so that there is formed a complete utero-vaginal canal ample for the passage of the head; no resistance is presented until the inferior boundary of the vagina is reached; in primiparae the hymen is an obstacle which is removed by a series of rents. Budin has shown that the vaginal orifice may present a resistance lasting some hours, which has been commonly attributed to the perineum; in one case in which there was delay from this cause, he incised the vaginal orifice, and the labor ended rapidly without injury to the perineum or to the vulva. Dilatation of the Vulva.—The head now enters the vulvar canal, the perineum is behind, the labia at its sides, and the uterine con- tractions, whose force is increased with the partial emptying of the uterus, and the abdominal, which are stronger from reflex irritation caused by the head pressing on the perineum, drive the presenting 24 37° SCIENCE AND ART OF OBSTETRICS. part like a wedge, widely separating the vulvar walls. The peri- neum is greatly elongated, and so thinned that the bones of the fcetal head may be felt through it; it is converted into a gutter, ex- ternally from side to side, and from before backward ; its elastic tissue and muscles direct the head upward. Each pain pushes the head Fig. 125. Head at the Vulvar Opening.1 further, but it recedes in the interval between pains—the parts are stretched, and then relaxed; the anus is widely opened, and the anterior wall of the rectum exposed, making a part of the external covering of the foetal head ; the labia are separated by the head, more and more of this emerging at each contraction, which seems as if it were to be the last needed for its expulsion, until finally the parietal protuberances escape the rim of the vulva, and there is no more recession, for the bearing-down effort seems almost continuous, scarcely a pause for breath, until in a conquering agony and with the most intense suffering the head is born. A brief pause follows, and returning pains expel the body of the child; immediately fol- lowing it the remaining portion of the liquor amnii, frequently some blood from a partially detached placenta with it, is discharged. The condition of the soft pelvis, as Budin has termed it, during the passage of the head is represented in the following illustration from Varnier. 1 " In this figure, copied from Smellie, the child's head, a, is seen separating the labia ; the extension, thinning, and protrusion of the perineum, b, caused by the head's descent, and called by some the perineal tumor, are also well portrayed; d marks the point of the coccyx; c the anus dilated, so that the inner membrane of the rectum is to some extent exposed to the contact of the hand, when applied for the protection of the structures. This exposure is not injurious; no harm arises from it; and sometimes it is even greater than is represented here.'' Ramsbotham. PHYSIOLOGICAL PHENOMENA. Fig. 126. Median Section of Pelvi-genital Canal (Farabeuf).—The muscular fibres of the coccy- perineal levator. C. Ischio-coccygeal. R. Chief fasciculi at the point of the coccyx. R R. Fasciculi separated by elongation of the perineal line of insertion, b. Bladder, s. Pubic symphysis, cl. Clitoris, v. Constrictor of the vulva. /.Fourchette. a p. Anterior perineum. a. Anus opened, d d. Posterior perineum, r. Rectum flattened, c. Coccyx pushed back. Sacr. Point of sacrum. Expulsion of the Placenta.—The third stage of labor, the discharge of the placenta, usually follows within thirty minutes after the end of the second stage. The separation of the placenta from the uterus is caused, as taught by Jacquemier, by the retraction of the latter, and it is probable that this separation begins neither at the margin of the placenta, as some authorities assert, nor at the centre, as claimed by others, but is general, or at least, as stated by Ribemont-Dessaignes,1 almost simultaneous in all parts. After the placenta has been detached uterine contractions expel it into the vagina. Observers do not agree as to the part of the placenta which presents at the os uteri, some insisting that it is most frequently the margin, or some part in its vicinity, being folded upon its fcetal surface, while others find that the fcetal surface descends first, and that the membranes are inverted. In Fig. 126 the mode in which the placenta usually presents according to Matthews Duncan is given. Pinard found in 60 cases the placenta presented by its fcetal sur- face 51 times, by its uterine surface in 2 cases, and by its fcetal border only De la Delivrance par Tractions, et par Expression. Paris, 1883. 372 SCIENCE AND ART OF OBSTETRICS. 7 times. Ribemont-Dessaignes in 17 cases observed presentation of the fatal surface 12 times, of the border 4 times, and of the uterine surface once. This question must be determined by new observations ; it is Fig. 127. probable that the part which presents depends upon the part of the uterus to which the placenta was attached, and upon whether the membranes are separated before the uterine contractions which expel it begin. Some clots of blood are usually discharged with it; the uterine blood- vessels torn in its detachment are kept from bleeding chiefly by contraction of the middle muscular coat of the uterus, thus furnishing, according to the happy expression of Pinard, a thousand living ligatures for vessels that otherwise would pour out blood into the uterine cavity.1 Mode in which the Placenta is naturally ex- pelled. (Duncan.) in front, but another part in of False Pains.—It sometimes happens that women during the latter part of pregnancy have what are called " false labor pains." These have been attributed to rheumatism of the womb, to local uterine contractions, to contractions of the ab- dominal muscles, and to intestinal irritation. The last is probably the most frequent cause. False are distinguished from true pains by their not having been preceded by the premonitory symptoms of labor; by their situation, for they are not felt in the back, and from it extending the abdomen, sometimes in one, and again in it; by their being irregular in recurrence, not increasing in severity, and not causing any change in the os uteri. On the other hand, labor has begun when general contractions of the womb and progressive dilatation of its mouth occur. The Effects of Labor upon the Mother.—Parturition has an influence upon various functions of the maternal organism. The desire for food is lessened or lost; it is not unusual for nausea and vomiting to occur, especially toward the end of the first stage, and these are thought to facilitate dilatation of the mouth of the womb, a common belief being that sick labors are easy labors. But while this gastric disturbance is regarded as a good omen in the first stage, a very differ- ent character belongs to the vomiting which may occur in the second stage, with cessation of labor activity, and with exhaustion of the patient; the symptom is then dangerous, and immediate delivery is required. The pulse increases in frequency during a uterine con- traction, lessening at its close ; as this contraction drives much of the blood from the uterus into the general circulation, arterial ten- sion is greater. Increased arterial tension and nervous irritation cause a greater secretion of urine; at first this fluid has a less speci- fic gravity than normal, but afterward the quantity of salts is greater. A slight shivering is observed in some patients at the beginning of each contraction. The respirations, less frequent during a pain, are more frequent during an interval; the temperature of the body, as well as that of the uterus, is slightly increased. 1 In recent years, in addition to the papers referred to in the text, the subject of placental separation and expulsion has been studied by Fehling, Champneys, Berry Hart, Barbour, and otheis; but space does not permit of further reference to their contributions. PHYSIOLOGICAL PHENOMENA. 373 In the second stage the face is usually red and swelled, and it, and also the body and limbs, are bathed with perspiration. Patients in the absence of pains frequently are drowsy and disposed to sleep, this condition resulting in part from fatigue and in part from cere- bral congestion. In labor some women are irritable, restless, and lose all self-control; but the majority pass through the terrible ordeal with patience and resignation, if not always with hope. A woman loses in labor one-ninth of her weight; the amount of loss is some- what less in the primiparous than in the parous ; the loss is of course chiefly due to the removal of the ovum, but the increased quantity of urine secreted, the perspiration, and the blood discharged with the placenta, contribute to it. The Effects of Labor upon the Foetus.—Uterine contractions cause temporary modifications in the fcetal circulation j1 at the beginning of a contraction there is a slight acceleration in the pulsations of the foetal heart, then these become slower when the contraction is strong; and, finally, when the tension of the uterus lessens, the double pulsa- tions increase in order to resume their ordinary rhythm. The slowing of the fcetal heart during a contraction of the uterus is probably due to slight asphyxia from partial interruption of the pla- cental circulation ; it has also been attributed to greater intracar- diac pressure, and to compression of the head. Pressure upon the fcetus may cause evacuation of the bladder, or of the rectum ; dis- charge of the meconium is common in presentation of the breech. If the placental circulation be interrupted, and hence the fcetus threatened with asphyxia, instinctive efforts to respire by the lungs are made. When the child is still unborn, if air enter its respiratory organs, it may cry, and to this cry the name of vagitus intra-uteri- nus has been given. The fact has been attested by reputable obser- vers, but of course is exceedingly rare. Duration of Labor.—This varies with race, climate, place and man- ner of living, heredity, age, organization, physical conformation, and whether first or subsequent labor, and with the sex, presentation, and position of the child. Labor is said to be shorter in warm than in cold climates, in savage than in civilized races, in women in the country, accustomed to plain food, out-door exercise, and regular hours of rest, than in those leading opposite lives in the city. In primiparae labor is longer than in multiparas; it is longer also in face or breech than in vertex presentations, in occipito-posterior than in occipito-anterior positions, with male than with female children. In primiparae the usual period of labor is, according to Depaul, fifteen to twenty hours, but, according to Tarnier, twelve to fifteen hours; in multiparas six to eight hours. Hecker and Ahlfeld state that the average duration of labor in in primiparae, thirty years old and more, is twenty-one to twenty-seven hours; Dieterlen's study of labor in 2369 primiparae, the delivery being natural, shows that up to thirty-five years the duration varies but little, and is fifteen to 1 Depaul. 374 SCIENCE AND ART OF OBSTETRICS. sixteen hours, but that from thirty-five it rapidly increases, so that in primiparae above forty-one years it is thirty-three hours. The average of all labors is, according to Naegele, twelve to fifteen hours. The second stage of labor is generally one-third that of the first. The majority of labors begin between nine and twelve p. m. and end between nine p. m. and nine A. M. Plastic Phenomena of Labor in Vertex Presentations.—By these phe- nomena are meant, not only, as previously stated, the changes in the form of the cranium caused by labor, but also the production of the caput succedaneum. The head delivered in an occipito-anterior position presents a cylindrical form ; the occipito-frontal and occi- pito-mental diameters are lessened, but the maximum diameter is increased; the suboccipito-bregmatic, the bitemporal, and the bi- parietal diameters are lessened. According1 to Dohrn, there is an asymmetry of the two lateral halves of the cranium, marked by the prominence of one of the parietal bones, and by the flattening of the other, which is sometimes pushed farther in front, sometimes farther back than the one on the opposite side, so that the parietal protu- berances are not equidistant from the occipital protuberance. In occipito-sacral delivery the head has the appearance of being drawn out vertically from below above; the vertex makes a conical projection, so that the head has the form of a sugar-loaf. The forehead and the anterior part of the parietal bones are almost upon the same vertical plane; the occiput is flattened and pushed in front. Caput Succedaneum.—This is the name given to a tumor com- posed of a sero-sanguineous infiltration of the connective tissue, situated upon the presenting part of the fcetus. The swelling occurs upon that part which is not subjected to pressure. " In the course of labor,2 after the evacuation of the liquor amnii, the child is during pains subjected to strong pressure from the parturient forces, and equally strong counter-pressure from the resisting maternal passages. Every part of the child is subjected to these forces, except that adja- cent to the as yet undilated passage through which the child is being urged." The caput succedaneum does not fluctuate, pits on pressure, and is violet-colored. The longer and more difficult the labor, the larger this swelling. By some it has been improperly termed cephalha> matoma; Bouchut describes it under the name of supra-periosteal cephalhematoma, or pseudo-cephalhaematoma. The former is the name given to an effusion of blood between the periosteum and the bone: it is more frequently found upon the right than upon the left parietal bone, in some cases upon both, in others upon the occipital, upon the temporal, or upon the frontal. The affection rarely occurs. Bouchut3 describes it an indolent, distinctly circumscribed, soft, and fluctuating tumor, and attended by no discoloration of the skin; it may be as large as a pullet's egg. The severity or great length of the labor has no influence upon its production. There may be felt 1 Tarnier. 2 Duncan. 3 Op. cit. PHYSIOLOGICAL PHENOMENA. 375 in many cases a bony circle at its base separating it from adjacent parts. In left occipito-anterior position the caput succedaneum is upon the posterior and superior angle of the right parietal bone. In left occipito-posterior position, it occupies the superior and anterior angle of the right parietal bone. In right occipito-anterior position the caput succedaneum is at the posterior and superior angle of the left parietal; and in right occipito-posterior position, at the superior and anterior angle of the same bone. If in consequence of slight resistance the labor be very rapid, no caput succedaneum may be formed. After the head has descended to the pelvic floor, and anterior rotation occurred, if delivery be delayed a secondary caput, succeda- neum will be formed; but this will be always in the median line, and not limited to one of the parietal bones. CHAPTER II. THE MECHANICAL PHENOMENA OF LABOR. The mechanical phenomena of labor are the passive movements given the fcetus in its expulsion. These phenomena are included under the general term mechanism of labor. The efficient cause of labor is the force of uterine and of abdominal contractions; the final cause, that is, the design, is birth ; but the former in accomplishing this end must act by material and formal causes. Now, the material cause is the fcetus and the birth-canal, and the formal cause includes the adaptations of the former to the latter, adaptations by which its transmisssion is rendered possible. Certain diameters of the fcetal head are greater than any of the pelvic diameters, and hence if the former be brought in relation with the latter, the further movement of the fcetus is impossible. The birth-canal presents an axis of emergence almost perpendicular to the axis of entrance, and there- fore the fcetus going into that canal in one direction, must take another and very different direction in order to pass out. The long- est diameter of the pelvic inlet is an oblique diameter, while that of the outlet is antero-posterior; hence a diameter of the fcetal head, which requires the space given by the former for its transmission, will, when it descends to the outlet, need to be placed in relation with the latter in order that it can pass out. One word explains these various passive movements of the fcetus in birth, and that is accommodation; during the whole process of delivery there must be adaptations and correspondences between the passenger and the passage through which it is transmitted. It will be seen in the study of the mechanism of labor that there is a unity of character in all labors, no matter what the presentation or position of the fcetus; provided the labor be natural, occurring at term, and the fcetus be living, there is but one mechanism.1 Before studying the mechanical phenomena of parturition a few words must be said in regard to presentation and position. As has been before stated, presentation is that part of the fcetus which is in relation with the pelvic inlet—that which presents, offers to the examining finger at the mouth of the womb, or that part through which the pelvic axis passes—and our first inquiry is as to the number of presentations. Baudelocque described twenty-three, making for these ninety-four positions; but it is fortunate for medi- cal students that authorities do not follow him in this. Madame Lachapelle was the first to show that the fcetus presented by the cephalic, or the pelvic extremity, or by the trunk. But these pres- entations, which are apparently three, really include five. The fcetal 1 Pajot. THE MECHANICAL PHENOMENA OF LABOR. 377 ovoid usually corresponds with the uterine ovoid; that is, the fcetus occupies a longitudinal situation in the womb, and hence one or the other end of this ovoid, generally the head, is at the pelvic inlet. If the head be inclined forward with reference to the trunk, that is, flexion be present, and this is the case generally, the vertex— summit or top of the head—presents, and hence the presentation is cranial. On the other hand, if deflexion—bending back of the head, extension—has occurred, the face presents, and the presentation is called by this name or facial. The pelvis of the fcetus may be in the lower segment of the womb, and then the presentation is pelvic. This presentation is not changed by any change of position of the lower limbs; the pelvic wedge may be complete or decomposed—a knee or foot, both knees or both feet,1 may come first, but no matter what the changes of position of these parts, none of the mechanical phenomena of labor are needed to adapt them to the birth-canal, for they are small and the space offered by the maternal pelvis is relatively large; and on the other hand such changes, such mechan- ism, are required for the expulsion of the breech. Those parts, therefore, are included under pelvic presentation, which may be defined as embracing all that part of the fcetus below a horizontal line passing from one to the other iliac crest. The foetus lying transversely, or nearly so, may present some part of the body at the inlet; but the tendency in all cases is for one or the other shoulder to descend first, so that presentation of the body becomes that of the right, or that of the left shoulder. We thus have five presenta- tions, cranial, or vertex, facial, pelvic, right and left shoulder. The relations which the presenting part of the fcetus has to certain fixed points of the inlet give the position. For most obstetricians these points are the sacro-iliac joints and the ilio-pectineal eminences ; they are the terminations of the oblique diameters of the inlet. It follows, therefore, as some selected point of reference for each pres- entation is in relation with one of these four points of the mother's pelvis, sometimes called the cardinal points of Capuron, the posi- tion is determined, and that there are four positions. The latter part of this statement, however, only applies to the first three pres- entations ; each shoulder presentation has only two positions, but this will be explained hereafter. It is important that the student should have clearly fixed in his mind the essential difference between presentation and position, never confounding them, never using one as a synonym for the other. Presentation means an object, but position is a relation; the former 1 Those born with the feet first were called Agrippas. Roederer, Elementa Artis Obstet- ricice, observes: Quando foetus pedes primi ad orificium decidunt, partus agripparum oritur. In Pliny's Natural History, Book Seventh, the following passage is found : In pedes procedere nascentem, contra naturam est: quo argumento eos appellavere Agrippas, ut aegre partos. This explanation of the origin of the term has been accepted in the New Sydenham Society's Lexicon. But a more probable origin is given by Kraus, Kritisch-etymologisches medicin- isches Lexikon; agrippa is from aypior ijnror, feminine aypia imra, for the nomadic tribes being more familiar with parturition as it occurred in mares, gave this name to children born with the feet first. According to Schroder, there was a superstition that those born thus would be injurious to themselves and to society, and in confirmation of the belief the examples of Agrippa, Nero, Richard III , and Louis XV., were cited. 37§ SCIENCE AND ART OF OBSTETRICS. is part of the fcetus, the latter a temporary relation of that part to the mother's pelvis; position is an accident, the property of a pres- entation, belonging to it, while the reverse can never be true. Fur- ther, it is important not to confound position as belonging to pres- entation with position as belonging to the fcetus. The fcetus is said to be in a longitudinal or a transverse position in the uterine cavity; but this use of the word is very different from that in connection with presentation. The four positions belonging to each of the three presentations—cranial, facial, and pelvic—are generally desig- nated first, second, third, and fourth. Their relative frequency is not settled—at least all authorities do not agree—and, therefore, the fitness of the term is questionable; but as the mechanism of labor presents some slight differences according as the point of reference of the presenting part is in the right or left side of the mother's pelvis, and as to whether it is anterior or posterior, these positions will be distinguished as right and left anterior, and right and left posterior. In vertex or cranial presentation, for illustration, this Fig. 128. Palpation of Uterus, the hands at its sides. point of reference is the occiput, so that the four positions for this presentation are left occipito-anterior, left occipito-posterior, right occipito-anterior, and right occipito-posterior. Diagnosis.—The diagnosis of presentation and position is made by auscultation, abdominal palpation, and vaginal touch. The first two are most useful in pregnancy, the last in labor; the former cannot be made during uterine contraction, and the third, if then made, the membranes being unruptured, must be done with great care to avoid their rupture. Nevertheless, it is held that the prac- THE MECHANICAL PHENOMENA OF LABOR. 379 titioner who makes himself expert in obstetric palpation and auscul- tation, can reduce to a minimum vaginal examinations, thus lessening the liability to septic infection. Vertex Presentation—Diagnosis.—The vertex presents, according to Naegele, in 93 to 95 per cent., according to Spiegelberg in 97 per cent., of all cases; the causes of this great frequency have been stated. In making a diagnosis by external examination the prac- titioner should first ascertain that the fcetus is not placed trans- versely, but occupies a longitudinal situation in the womb—the foetal thus corresponding with the uterine ovoid. He learns this by ob- serving the general form of the abdomen, and by his being able in palpation to circumscribe with his hand the fundus of the uterus in its normal position. The next step is to find which end of the fcetal ovoid is in the lower segment of the uterus. In doing this the obstetrician places his hands extended and flat upon the lower part of the sides of the abdomen, pressing them somewhat downward at the ulnar border within the iliac fossae; then the hands still pressed Fig. 129. Ascertaining the Presence of the Fcetal Head in Lower Part of Uterus. downward and moved toward each other, will include the foetal head if it be in the lower part of the uterus, and if it has not entered the pelvic cavity. Instead of at first placing the hands upon the sides of the uterus, they may be in contact with each other directly in the median line of the uterine globe just above the pubes, then 38O SCIENCE AND ART OF OBSTETRICS. gradually separated, pressing the ulnar edge of each downward upon the abdominal wall in this movement until they pass deeper, when they reach the borders of the uterus, and the lower portion of this organ is then included between them. This manipulation, it should be observed, is of chief value in the diagnosis of pregnancy. A single hand may often be successfully used in abdominal palpation in order to determine that the fcetal head is in the lower part of the uterus. The distinguishing marks of the fcetal head in palpation are, its uniformity of shape, roundness, hardness, and mobility; if the head be in the pelvic cavity, the characteristic last stated fails. The fact that the presenting part is in the pelvic cavity in the latter part of pregnancy, or early in labor, is a strong proof that the presentation is neither the pelvis nor the face, but the vertex. Further, in this situation one hand can be carried deeper into the pelvis, while the hand on the other side of the pelvis meets with resistance (Fig. 130); the occiput therefore is upon the one side, the forehead upon the Fig. 130. Palpation when the Fcetal Head is in the Pelvis. other, and the former being more deeply situated allows the descent of the hand, while the latter prevents such penetration. Further, when the occiput is found the position of the back is known, for it THE MECHANICAL PHENOMENA OF LABOR. 381 must be upon the same side as the occiput. The practitioner may then verify his diagnosis by exploring the fundus of the uterus in which the pelvis of the fcetus will be felt. This part of the child is recognized as a large, firm, and somewhat round body, but it lacks the uniform shape, the solidity, and the mobility of the head; moreover, there will be found near it small movable bodies, parts of one or both lower limbs. The means by which a vertex is distinguished from a face presentation will be given when the latter is considered. Auscultation.—If the pulsations of the fcetal heart are heard most distinctly below the transverse line (see Fig. 104), the head is most probably in the lower part of the uterus, and when heard to the left of the median line, the occiput is in the left side of the mother's pelvis, but if upon the right, the occiput is in the right side Internal Examination.—The method of vaginal examination has been given on pages 196-98. Again, let the practitioner be cautioned against the danger of rupturing the membranes by pressure upon the bag during a uterine contraction ; he should, therefore, usually defer exploration of the presenting part until the contraction ceases. If the head has descended into the pelvic cavity, the finger touches a round, hard, projecting body, and the margin of the mouth of the womb. If the head be high up, only a small portion of the cranial vault is accessible to the finger, but a larger portion may be reached if the other hand is used to press firmly upon the hypogastrium so as to force the head further into the pelvis. When the os is dilated the bones may be plainly felt through the fcetal membranes, and during a contraction the wrinkling of the scalp, and the overriding of the bones. If labor has been in progress some time, a large soft mass, the caput succedaneum, may conceal the cranial bones : but by pressing firmly upon this mass, it is possible the finger may detect beneath it a bony surface, or else the finger should be passed within the os so as to touch parts above the swelling. Position.—Having ascertained that the presentation is cranial, the position is next to be ascertained. The occiput being the point of reference, in this presentation, the question is as to its relation to some one of the cardinal points of the inlet. If it is directed toward the left ilio-pectineal eminence, the position is left occipito- anterior ; if to the right, right occipito-anterior; if to the left sacro- iliac joint, left occipito-posterior, but if to the right, right occipito- posterior. The same means are available for the diagnosis of position, as for the diagnosis of presentation, viz., abdominal palpation, auscul- tation and vaginal touch. The application of these means will be considered with each of the four positions given, following the diagnosis with a description of the mechanism of labor. First. Left Occipito-anterior Position (Figs. 131, 132).—Ascertaining that the back of the child is upon the left side of the mother's abdo- men, we know that the occiput is anterior or posterior to the left side of the pelvis; and if the resistance given by the back lessens as 382 SCIENCE AND ART OF OBSTETRICS. the hand is carried farther to the left side, the occiput, of course, which is in the line of greatest resistance, points to the ilio-pectineal eminence—that is, the position is left occipito-anterior. Upon auscultation the maximum of intensity of the fcetal heart- sounds is found about the middle of a line passing from the left Left Occipito-anterior Position. ilio-pectineal eminence to the umbilicus; some, however, have the line start from the left anterior spinous process of the ilium. By vaginal touch the sagittal suture is usually felt crossing the pelvic area obliquely, though it may be transverse, and a little nearer the promontory than it is to the pubic joint. Having found the suture, the finger follows it either to the right or to the left until the anterior or posterior fontanelle is felt. The anterior fontanelle is upon the right side of the mother's pelvis, and necessarily the occiput is upon the opposite side. If the finger follows the course of the sagittal suture to the posterior fontanelle, the place rather than the presence of the latter is recognized by its being at the apex of a depressed triangle, two sides of which are made by the margins of the parietal bones overriding the occipital bone, these sides cor- responding with the bifurcation of the sagittal suture. The occiput is at, or near the left ilio-pectineal eminence. This position, left occipito-anterior, has been generally called the first, and it is the first in frequency, occurring in about seventy per cent. THE MECHANICAL PHENOMENA OF LABOR. Fig. 132. Place of Greatest Intensity of Fcetal Heart-sounds in Left Occipito-anterior Position. Fig. 133. First Cranial Position.—Occiput at the left ilio-pectineal eminence, forehead at the right sacro-iliac joint. 1 'Mechanism of Labor.—In studying this mechanism it is convenient to divide it into stages, or times ; but it is to be remembered that this division is arbitrary, for some of these stages may occur contempora- neously, or some may be absent, but in such cases the necessity for them does not exist, the factors causing them are absent. These different stages are, in presentation of the vertex, first, flexion; second, descent, also called engagement, or progression ; third, rota- tion ; fourth, extension ; fifth, external rotation of the head with in- ternal rotation of the body; and, sixth, delivery of the body. Each 3?4 SCIENCE AND ART OF OBSTETRICS. of these mechanical phenomena is to be studied as to its causes, its effects, and its diagnosis. Flexion.—This is bending the chin toward the chest so that it rests on it when flexion is complete ; it is essentially rotation of the head upon a transverse axis. In considering the causes of flexion the natural position of the head must be regarded as predisposing to this purely passive movement, for it is already somewhat flexed, and the flexion occurring in labor is simply an increase in this state. It has been taught by some that the articulation of the head with the ver- tebral column being nearer the occiput than it is to the forehead, the force passing through that column acts with greater power upon the occiput, causing it to descend while the forehead rises, and thus flexion is increased. But as long as the fcetus is inclosed in the membranes, direct pressure upon it does not occur; uterine con- tractions compress the ovum at all points equally, except at the lower segment of the uterus and the os uteri; these are dilated by the pressure, and the force is transmitted to the fcetus through the intervening liquor amnii. Even after the rupture of the membranes the fcetal head may so effectually plug the cervico-uterine canal that only a small quantity of amnial liquor escapes, and therefore direct pressure of the fundus of the uterus upon the upper portion of the Fig. 134. Fig. 135. Equal Resisting Forces acting through Levers of Unequal Length. fcetal ovoid fails. It therefore fol- lows that the direction of the uterine force cannot be determined by pressure of the fundus imme- diately upon the fcetus in the first stage of labor, or, indeed, subse- quently before the free discharge of the amnial liquor. The most generally received ex- planation of this phenomenon of Illustrating the Different Lengths of the Frontal Arm, F B, and the Occipital Arm, B O, of the Lever made by the Fcetal Head. THE MECHANICAL PHENOMENA OF LABOR. 385 labor is that it results from the unequal lengths of the two arms of a lever represented by the head, for that part of the head in front of the vertebral articulation presents a greater surface than that behind this articulation ; in other words, the anterior arm of the lever is longer than the posterior—that is, the distance from the occipital foramen to the forehead is greater than from the occipital foramen to the occiput. Hence, equal resistances applied to these two arms necessarily cause the anterior or longer arm to rise, the posterior or shorter to descend. In the subjoined diagram (Fig. 131), taken from Hubert, let the line F i represent the active force; N A and M B equal resistances; the short arm of the lever A B, that is B i, must descend, for the resistance, N A, is the more powerful, because acting through the long arm, A i. Fig. 132, taken from Ribemont, shows the much greater length of the anterior than of the posterior arm of the lever represented by the head ; F B is the frontal, and B O the occipital arm ; the sum of resistance-pressure to which the former is subjected must much exceed that which opposes the descent of the latter. Another principle in mechanics has been brought forward by Hubert as con- tributing to flexion. If a propulsive force be exercised centrally upon a mobile, and there be resisting forces not directly opposite each other, but at different levels, rotation of the mobile occurs ; thus, flexion of the head, which, as has been before stated, is simply rotation of the head upon a transverse axis, is frequently completed when the os uteri is almost entirely dilated so that the occiput has escaped, and the resistance of the os acts upon the forehead and the face, causing flexion. According to Lahs,1 the entire expulsive force of the uterus acts upon the fcetal head in a line perpendicular to the surface of what he terms ''the girdle of con- tact "—that is, the part of the birth-canal for the time resisting the advance of the head. " The head is a wedge, whose surfaces are found through the tangents made on those points of the head's surface directly in relation with the girdle of contact." That part of the head whose tangent makes the smaller angle with the perpendicular line of expulsion must descend first. This smaller angle is made at the occiput, and therefore this descends and flexion results. Whatever theory may be adopted of flexion, the movement itself is essentially one of accommodation, of adaptation of the fcetal head to its passage through the birth-canal. The head entered the inlet with the occiput at the left ilio-pectineal eminence, and the forehead at the right sacro-iliac joint, that is, the occipito-frontal diameter was in relation with the right oblique of the inlet, and the bi-parietal with the left oblique ; hence a circumference of the fcetal head whose diameter is the occipito-frontal is in relation with the circumference of the inlet. The long diameter is not perpendicular, but oblique to the plane of the inlet; beside this obliquity it was asserted by Naegele that the head entered inclined on the anterior parietal bone, so that the right parietal protuberance was somewhat lower than the left, and this inclination was known as Naegele's obliquity,2 but 1 Die Theorie der Geburt. 2 The obliquity of Solayres refers to the head entering the pelvic inlet in one of its oblique diameters, and Roederer's to the complete flexion of the head on the chest. 25 386 SCIENCE AND ART OF OBSTETRICS. most obstetricians reject it; at least its consideration may well be omitted in the study of the mechanism of normal labor. The effect of flexion is not only to bring the long diameter of the foetal head more or less completely in correspondence with the axis of the inlet, but to present a less circumference of the head to the circum- ference of the inlet, for as the chin comes to the sternum, not the occipito-frontal diameter, but a shorter one, the suboccipito-breg- matic, is in relation with the left oblique of the inlet. Remembering that flexion is a movement of accommodation, it occurs when and where such accommodation is necessary. It may, therefore, take place at the inlet, in the lower portion or at the mouth of the uterus, or at the perineal floor, or, finally, it may not occur because the small size of the fcetus, or the great size of the pelvis, the slight resistance of the os uteri, or of the pelvic floor renders it unnecessary. Flexion not only substitutes a less fcetal head plane, but, according to Pajot,1 prior to its occurrence there is a great loss of force from its transmission through a flexible, vacillating rod, to which he com- pares the foetus, the mobility existing especially at the articulation of the head with the trunk ; but when the head is firmly pressed upon the thorax it is found favorably disposed to participate in the impulsion impressed upon the general mass of the fcetus. Further, flexion facilitates moulding of the head so that it is adapted to the birth-canal. The diagnosis of flexion is made by the recognition of the relative position of the fontanelles ; at the beginning of labor they are almost upon the same plane, the anterior a little higher than the posterior; as flexion occurs, the former recedes with the ascent of the forehead, but the latter descends with the descent of the occiput, and when the anterior is very high, and consequently the posterior very low, flexion is complete, but if the two are equally accessible, it has not occurred. Descent.—The uterine, reinforced by abdominal, contractions now compel the head to descend into the pelvic cavity ; the axis of the uterus corresponding with that of the upper part of this cavity there is no loss of force, and hence if there be the proper relation between the fcetal head and the canal, the latter presenting only its usual resistance, and the driving force normal, there is no delay in the descent of the head. The head planes are parallel with the pelvic planes during the first part of the descent, and then in consequence of the greater resistance of the posterior than of the anterior pelvic wall, this synclitism—that is, the parallelism between the planes of the child's head and the transverse planes of the mother's pelvis— ceases, though Dr. Hodge and some other obstetricians held that it continued during the entire descent. A movement called levelling is described by some as occurring when the head has descended so that the occiput is at the lower margin of the ischio-pubic fora- men, and the bregma is at the second bone of the sacrum ; by this movement, essentially a lessening of flexion, the anterior fontanelle becomes more accessible, and the occipito-frontal diameter is in relation with the right oblique of the pelvic Dictionnaire Encyclopedique des Sciences Medicales. THE MECHANICAL PHENOMENA OF LABOR. 387 canal. This phenomenon is not constant, does not contribute when present to the progress of labor, and therefore may be dismissed from further consideration. The progress of the second stage of labor is ascertained by mea- suring with the finger the distance of the head from the vulvar opening. This measurement is most conveniently made by using the thumb as an index to the measuring rod, the finger. Two errors are to be guarded against: First, mistaking a caput succedaneum for advance of the head; and, second, the head may descend still inclosed in the uterus, whose lower segment maybe so thinned that without great care the examiner believes he directly touches the head, and may conclude that the labor is much further advanced than it really is. Rotation.—This is a movement by which the occiput turns in front, the entire trunk participating in the rotation. The expulsive power driving the head down, the occiput is forced to escape, but only anteriorly is there a gap in the pelvic wall, and to this gap the ischio-pubic ramus—bevelled, flaring—invites; the occiput descends with a pain, boring, feeling its way, receding in the interval between pains, until finally driven by a vigorous pain it passes the bony mar- gin at the latero-anterior part of the pelvis, and there is no subse- quent recession, but it sweeps forward toward the centre of the vul- var opening, and the sub-occipital region comes under the pubic symphysis. As observed by Dr. Ritchie,1 in some cases the head escapes all pivot movement in the pelvis, but comes down obliquely upon the perineum, and suddenly wheels round when it is on the point of escaping from the vulva, the rotation resulting from the shape of the perineum which, attached on either side, yields most in the median line, thus forming a gutter in which the head is best accommodated, lying not obliquely but antero-posteriorly. When rotation of the head occurs in the pelvic cavity, while the occiput comes in front, there is a reverse movement of the sinciput which turns into the sacral cavity. Obstetric authorities have devoted much attention to the study of the causes of rotation, and have greatly differed as to them. Bau- delocque referred this phenomenon to the inclined planes of the pelvis, the anterior determining rotation into the pubic arch, the posterior rotation into the sacral cavity. This view probably has had more adherents than any presented since ; some have modified it by changing the position of the arbitrary lines, separating the anterior from the posterior planes, but still essentially their teaching has been that of Baudelocque ; this was true especially of the teach- ing of Hodge. But the accepted explanation of the cause of rota- tion, while satisfactory so far as anterior positions of the occiput is concerned, failed as to posterior positions, for in these, too, as first proved by Naegele, the occiput in most cases rotates anteriorly. Perineal resistance, according to some, is the cause of anterior rota- tion ; but, as observed by Charpentier, this cannot be the sole cause, or the movement ought never to fail in primiparae, for in them the 1 Medical Times and Gazette, 1865. 388 SCIENCE AND ART OF OBSTETRICS. perineum is remarkably resistant. The unequal lengths of the two arms of the head lever is, according to others, the cause, for the occipital arm being the shorter the occiput moves in the direction of least resistance. The law of mechanics, which Hubert has applied to the explana- tion of flexion, has its application here also. When a mobile is subjected to resisting forces, which are not directly opposite, they tend to impress upon it a movement of rotation. While some assert that this explanation holds only for the rotation which occurs in anterior positions, it may be shown in the discussion of the mech- anism of labor in posterior positions that the anterior rotation which then occurs can also be thus explained. Pajot, rejecting all geome- tric explanations, finds the just idea of the causes of rotation in the immutable principle of mechanics which has been formulated in what is known as Pajot's law (see page 158): " The indispensable condi- tion for the execution of this law is that the power, the volume of the content, and the capacity of the container must be proportional." If the fcetus be too large, insurmountable obstacles are presented to its rotation ; if it be too small, there is no invitation to turn, and when the fcetus and the passage are in due proportion, turning may fail for want of sufficient expulsive force. The results of rotation are that the suboccipito-bregmatic diameter which corresponded with the right oblique of the mother's pelvis, is now in relation with the antero-posterior of the outlet, and the biparietal with the trans- verse, and the shoulders—as the body participated in the rotation —descend in the pelvis with the bisacromial diameter in relation with its transverse diameter. Rotation is known to have taken place by the position in which the occiput is found—that is, directly in front; in some cases the movement maybe recognized during its occurrence by a finger placed upon the occiput. Extension.—The third of the mechanical phenomena of labor is a movement of the head directly the reverse of the first; whereas the head then rotated forward on its transverse axis so that the chin came to rest on the sternum—it now rotates backward, and the chin recedes from the sternum, that is, deflexion or extension occurs. In this movement the nape of the neck presses the subpubic ligament, the shoulders are transverse, and close behind the pubic arch so that the occiput can advance no further in a direct line; meanwhile expulsive action continuing is met by the resistance of the peri- neum, and the resultant diagonal force is in the axis of the prolonged birth-canal; the expulsive force cannot act directly upon the occi- put, but only upon the long arm of the head lever, thus forcing the chin to descend; according to Pajot, the occipito-mental diameter represents a lever of the third order, the fulcrum being at the pubic arch, the resistance at the pelvic floor, and the power between the two, that is, at the occipital foramen. But extension or rotation backward of the fcetal head may also be explained as the result of a driving force met by two resisting forces acting upon the fcetal head at different planes, or two unequal forces, even if acting in the same plane. We have first the driving force of uterine and abdomi- THE MECHANICAL PHENOMENA OF LABOR. 389 nal contractions; the perineum resists, and there is also resistance at the pubic arch, but the former resistance being less than the latter rotation results—the head is rolled out of the vulvar opening, the bregma, the forehead, and the face appearing successively from behind the perineum, the occiput continuing to move in a curve over the pubic symphysis, the successive radii of this curve being the several suboccipital diameters.1 The longest of these diameters is the suboccipito-frontal, and the vulvar opening is of course in greatest danger of being torn during the passage of the head cir- cumference corresponding with this diameter. The progress of this stage of labor is known by the emergence of a greater part of the fcetal head at each expulsive effort, and its completion by the drop- ping down of the head in front of the anus, and by the retraction of the perineum. External Rotation of the Head with Internal Rotation of the Body.— In some cases just after the head drops down—face below, occiput above—there is a change of the head to an oblique position : this movement is called restitution, and it takes place when in internal rotation the body did not follow the head in this movement, but a twist in the neck occurred, and now the head is restored to its nor- mal position with reference to the trunk. Restitution is oftener seen in occipito-posterior than in occipito-anterior positions, but even in the former it is not frequent, for with perfect flexion the foetus is so compacted together that head and trunk make one mass, and move together. In most cases no such movement as restitution is recognized, but the head remains motionless after dropping down with the end of the fourth stage of labor, until a new expulsive effort occurs, and then it moves through the fourth of a circle so that the occiput points to the mother's left thigh, and the face to her right thigh. A simple law may be given in this connection— the occiput always points to that thigh corresponding to the side of the pelvis in which it was before the delivery of the head, and thus if the occiput was in the left side of the pelvis, no matter whether posterior or anterior, it will point to the left thigh. The external rotation of the head indicates the internal rotation of the shoulders; they descended into the pelvis, the bisacromial diameter in relation with the left oblique of the inlet; the body rotating with the head the bisacromial became transverse, but.as delivery in this position is impossible, body rotation, which is indicated by external rotation of the head, takes place so that the right shoulder is behind the pubic joint, and the left is in the sacral cavity. Expulsion of the Body.—Expulsive efforts continuing, the pubic Shoulder passes out first—it has the shorter distance to traverse, and it represents the occiput v/hich was delivered first—and the su- 1 This hitherto generally received explanation of the expulsion of the foetal head has recently been controverted by Berry Hart, who denying extension, claims that progression, or translation of the head occurs, occiput and sinciput constantly advancing. He attributes that which he calls the erroneous idea of extension to the fact that " the attendant, while the patient lay on her left side, watched the passage of the foetal head from behind, saw more of the anterior portion of the head appear, and accounted for it by extension." Hart's opinion will be referred to on a future page. 39° SCIENCE AND ART OF OBSTETRICS. perior part of the trunk pivots upon the arm just below the shoulder, while the sacral shoulder sweeps the sacral curve, and follows the course of the distended perineum, the perineal pressure and the Fig. 136. External Rotation of Head in First Position. direction of the canal causing incurvation of the body upon its lateral plane; the sacral shoulder is finally delivered, and the arm quickly follows, and then the pubic arm passes out, and the lateral curvature of the body is at an end. Just as the nape of the neck was fixed at the subpubic ligament in delivery of the head, so is the upper part of the pubic arm situated in delivery of the superior portion of the truuk ; delivery of the head was effected through extension, but that of the shoulders by flexion, the lateral incurvation of the body is simply the analogue of extension of the head. Authorities differ as to which shoulder is delivered first, and some end the con- troversy by asserting a simultaneous delivery. The illustration just presented, shows that the upper shoulder has passed the pubic arch, while the under one is still hidden by the perineum ; although Dr. Hodge, from whose work the diagram is taken, taught that they escaped at the same time, the statement is contradicted by it. Cazeaux held that in primiparae the delivery is as stated in the text, but not in the parous when the perineum has been torn. But this is a concession of the very point at issue, and we may say with Pajot that in the normal mechanism of labor the pubic shoulder is first delivered. The expulsion of the rest of the body rapidly follows that of the shoulders, the trunk making somewhat of a spiral movement; if the hips are very large there may be some delay, and the same mech- anism occurs as in the delivery of the shoulders. Right Occipito-anterior Position.—In this position, which is the rarest of the four, the occiput is in the inlet, at the right ilio-pecti- neal eminence, and the forehead at the left sacro-iliac joint, the child's back is in the right and anterior portion of the uterus, and the limbs in the left and posterior portion. By abdominal palpation the head is found in the lower segment of the uterus, and the back in the situation mentioned; the hand passes more deeply in the THE MECHANICAL PHENOMENA OF LABOR. 39I pelvis upon the right side than upon the left. Upon auscultation, the maximum of intensity of the fcetal heart sounds is found, according to Depaul, at the middle of a line passing from the right ilio-pectineal eminence to the umbilicus (see Fig. 104; this maximum is found at C), but according to Ribemont upon the median line, sometimes, indeed, a little to the left of it. Digital examination confirms the diagnosis of a vertex presentation, and the sagittal suture is found to be in the right oblique diameter of the inlet, the occiput at the right ilio-pectineal eminence, and the forehead at the left sacro-iliac joint. The mechanical phenomena are the same as those which have been described as taking place in a left occipito-anterior position. First, flexion occurs, a process of accommodation, an adaptation of the presenting part to the birth-canal, by substituting a smaller head circumference to the pelvic area, a lessening of the fcetal part which descends first. Descent follows, and then rotation; but the occiput, instead of rotating from left to right, now rotates from right to left into the pubic arch. Extension occurs next, for direct progression of the occiput is impossible, because it is held back by the shoulders lying transversely, but indirect advance occurs by the occiput tend- ing to approach the back, the chin departing from the chest, and the entire head is rolled out of the vulvar opening; the head thus rotates backward upon its transverse axis in deflexion, just as it rotated forward in flexion. After the birth of the head it rotates externally as the sign and the effect of internal rotation of the body, but the occiput now is directed to the mother's right thigh, the face to her left, which is the reverse of the situation of these parts of the head in a left occipital position. By the direction in which this external rotation occurs the student may correct or confirm the diagnosis of position made at the beginning of labor. Finally, delivery of the body takes place in the manner described for a left occipito-anterior position. Right Occipito-posterior Position.—This is next in frequency to the position first described; it is that position reversed, and hence the occipito-frontal and the biparietal diameters hold the same rela- tions to the two oblique diameters of the inlet that they did in left occipito-anterior position. The former of these fcetal diameters, which it will be remembered is the longer, avoids the left oblique of the inlet, which is practically the shorter of the two pelvic meas- urements, because of the presence of the rectum upon the left side. The occiput is at the right sacro-iliac joint, and the forehead at the left ilio-pectineal eminence; the back of the child is posterior and to the right, the limbs anterior and to the left side of the mother's abdomen. Palpation proves the presence of the head in the lower part of the uterus ; the hand can pass more deeply in the right side of the pelvis than in the left; in the latter it is arrested by the projecting fore- head at the ilio-pectineal eminence. The dorsal plane of the fcetus can be more readily recognized if the woman lies upon her left side. The maximum of intensity for the fcetal heart-sounds is in a line 392 SCIENCE AND ART OF OBSTETRICS. passing from the right sacro-iliac joint to the umbilicus. Digital examination shows that the anterior fotanelle is in front and to the left, the posterior fontanelle to the right and behind, while the sagittal suture is in the right oblique of the inlet. Right Occipito-posterior Position. The mechanical phenomena of labor are in almost all cases the same as have been described, and therefore need not be detailed. One of these, however, requires special study—that of internal rota- tion. In occipito-anterior positions the occiput rotated only through a little more than one-eighth of a circle in order to be placed in the pubic arch, but now it must rotate through three-eighths. More- over, it sometimes happens that the shoulders do not rotate at all, or only partially, and hence there results greater or less torsion of the neck, this torsion being proved by the movement of restitution immediately following the delivery of the head. It is natural to ask why the occiput when in this position, so near the sacral cavity, does not, as the forehead did, rotate, when in a somewhat similar location, into that cavity, instead of by a much longer course seek the pubic arch. Dr. Hodge's answer was that the promontory of the sacrum determines the whole head toward the anterior part of the pelvis, and that when the point of the occi- put strikes upon the spinous process of the ischium, rotation upon the right anterior inclined plane necessarily occurs, but if the point of the occiput strikes posteriorly to this process, rotation into the hollow of the sacrum follows. But the most satisfactory reply to the question as to the anterior rotation of the occiput, and the posterior rotation of the sinciput, is, as stated by Dr. Ritchie, that in both anterior and posterior posi- tions the former is lower than the latter when resistance begins ; in occipito-anterior positions that resistance from the pelvic floor begins when the occiput is level with the pubic arch, and the fore- head with the cavity of the sacrum, but in occipito-posterior posi- THE MECHANICAL PHENOMENA OF LABOR. 393 tions the resistance begins when the occiput is past the sacral cavity, and the forehead too high for the pubic arch. There are forces of resistance presented to a progressive mobile at different levels, and consequently they cause it to rotate, the most prominent or advanced part of that mobile moving in the line of least resist- ance. In the further consideration of this mechanical phenomenon we must bear in mind that unchangeable law which compels in all vertex deliveries, whether artificial or natural, the occiput to pass out first When the flexion is perfect, the head and neck make, with the upper part of the thorax, according to the comparison of Dubois, a stiff, inflexible rod. If the occiput rotates into the pubic arch, the neck more than measuring the length of the pubic joint the occiput can pass out, and extension of the head occur, and thus the rod becomes flexible, and the trunk does not enter the pelvic cavity until the head is being delivered. But the condition is very different in an occipito-posterior position; the neck is much shorter than the lateral wall of the pelvis with which it is in relation, and hence the greatest diameter of the rod, the dorso-frontal, must enter the pelvic inlet, so as to be in relation with its right oblique diame- ter. But the descending back, curved and projecting, cannot rest upon the promontory of the sacrum, and hence there is a force of resistance which tends to throw the presenting part from an oblique to a transverse position. This change is possible only when flexion is perfect—that is, when the chin is so firmly pressed upon the chest that the head and upper part of the trunk make a unit and thus a movement communicated to the trunk also causes the head to move. Meantime, on the other side of the pelvis the forehead is not adapted to the pubic arch, is resisted more by the anterior than by the lateral pelvic wall; thus the two resisting forces determine rotation of the head from an oblique to a transverse position, and then the rotation is continued until the position becomes right occipito-anterior, from which the occiput finally turns into the pubic arch. In rare cases—probably once in fifty, Stoltz; twice in fifty, Uvedale West—the occiput fails to rotate anteriorly, but turns to the sacral cavity, and the head is in an occipito-sacral instead of an occipito- pubic position. If this posterior rotation occurs, the head descends in the axis of the pelvis; but the occiput is not adapted to the con- cavity of the sacrum, nor the forehead to the pubic arch, so that both in front and behind space is lost. The straight, rigid rod can- not become flexible until the occiput has traversed the sacral cavity and the inner surface of the perineum, so as to pass out over its anterior margin; but this end is not possible until the trunk has also entered the pelvic cavity, for the longest diameter of the head is less tjian the distance from the inlet to the vulvar opening. When the occiput escapes, the nape of the neck pivots on the anterior margin of the perineum, the occiput passing backward—extension occurring in like manner to that observed in an occipito-anterior delivery—and the anterior fontanelle, the forehead, and the face are 394 SCIENCE AND ART OF OBSTETRICS. successively delivered, all the diameters being sub-occipital, just as in an occipito-anterior delivery. After the head is delivered it drops down, and then follow in order external rotation of the head with internal rotation of the body, and delivery of the body. It is plain that the labor is slower in an occipito-posterior delivery, not only from the great distance the occiput must pass before it can escape from the vulvar opening, but also from the difficulties in that passage; the suffering of the woman is greater, and there is more danger that the perineum will be torn. The child is born alive if it is not large and the pelvis is normal; but if the latter be small, or the former large, stillbirth is common. In very rare cases, if the fcetal head was small, conversion of a vertex into a face presentation has occurred at the inferior strait, extension taking place, so that the chin instead of being born last is born first, emerging at the pubic symphysis, and the delivery of the head takes place by flexion. It is unnecessary to give the diagnosis and describe the mechan- ism of labor in left occipito-posterior position, for they can be readily understood from the explanations already made, substituting left for right in the description of the diagnosis and the mechanism of right occipito-posterior position. In concluding this exposition of the mechanical phenomena of labor in vertex presentation, it must be remembered they all concur to one end, the expulsion of the child, and therefore if one or an- other is not needed for this end, it may be absent. In the main they are processes of adaptation, of accommodation of the fcetal head and body to the birth-canal, and are the results of a driving and of resisting forces, hence varying as these forces vary. In some cases the fcetal head may be so small, or the mother's pelvis so large, that any increase in the head flexion is not needed for descent, flexion being essentially a lessening of size by placing a smaller head plane in relation with a greater pelvic plane; or, again, internal rotation of the head may not occur, and the head be born in the same oblique position which it had upon entering the inlet. These and other variations in the mechanism of labor are not, as Pajot well says, violations of law, but occur because some of the factors which carry out the law may be absent, or others have more power. The phenomena as described always occur if the foetal head, the birth- canal, and the driving force are normal. If, in a given case, two of these phenomena are simultaneous, it does not follow that their individuality as to causes, results, and diagnosis is lost, and that they should be regarded as a single event._ Presentation of the Face.—In order that the face may present, the head must be extended instead of flexed, the occiput bearing the same relation to the back that the chin does to the sternum in vertex presentation. Frequency and Causes.—Authorities differ as to the frequency of presentation of the face; i in 324, Spiegelberg; 1 in 231, Churchill; THE MECHANICAL PHENOMENA OF LABOR. 395 I in 217, Lachapelle; 1 in 247, Pinard; 1 in 175, Depaul; 1 in 276, Galabin; 1 in 250 or 300 cases, Hodge. Winckel has stated that thirty-three different causes have been suggested. One of the most remarkable was that given by Osiander, viz., that the fcetus inherited a disposition from its parents to carry the head back. Hodge1 regarded as the best hypothesis that such presentation resulted from the spontaneous motions of the child, the head being fixed in this unusual posture by contractions of the uterus. Hecker regarded dolicocephalia as a cause. According to him, the greater projection of the occiput in the dolicocephalic increased the length of the posterior arm of the head lever, so that when uterine contractions occurred it ascended, while the frontal arm descended. The answer generally made by obstetricians to this explanation is that dolicocephalia is a consequence of the delivery in a face presentation, not the cause of such presentation, and that it disappears a few days after birth ; further, even if this condition be present, the increase in the length of the occipital is never so great as to make it longer than the frontal arm. Spiegelberg met with a case of face presentation in a fcetus having hydrothorax. Other instances are mentioned where tumors of the neck were the cause. But apart from these special causes, the general ones are uterine obliquity, pelvic narrowing, and unusual size of the child. The presentation occurs more frequently in multipara? than in primi- parae, the proportion being, according to Kleinwachter, I of the former to 2.23 of the latter. The presentation may be primary or secondary; the latter is much the more frequent. The duration of labor is in primiparae 34 hours, and in multiparas 15 hours. The ordinary fcetal mortality in vertex presentation is 5 per cent., but in face presentation 15 per cent.'2 Premature rupture of the bag of waters, prolapse of the umbilical cord, and tearing of the perineum, are among the accidents liable to occur in face presentations. 1 Dr. Meigs said "that dead and half-putrid children, in whose tissues there is scarcely any resiliency or resisting power left, are not so unapt to come face foremost as living children, in whom departure of the chin from the breast occasions such a great extension of the head as to be painful, whence the living child instinctively opposes the wrong tendency, by acting with all its strength to get the chin back, or the head flexed again.'' The statement by Dr. Meigs, and also that by Dr. Hodge, suggest a voluntary movement of the foetal head in the one case causing and in the other preventing presentation of the face, that is not unquestionable. Sir Thomas Browne, whose Religio Medici all doctors read, among his many other literary works wrote a supposed dialogue between twins in the uterus, which unfortunately has been lost. Imagining a conversation under such circumstances is of course a very wide step beyond, but is in the same direction as the voluntary movements that have been suggested. Those who have observed how utterly powerless the new-born are to move the head in any direction, and that it falls inert according to gravitation, will hardly admit that the foetus can, against the force of gravitation, raise the head a single inch from the chest, or that when it is removed from the chest by external causes that the fcetus, though "acting with all its strength," can replace it if the slightest force opposes. Winckel endorses this criticism of the opinion of Drs. Hodge and Meigs I have made. In Preyer's very interesting volume upon the "Soul of the Infant" the following statement is made upon the authority of Dremme, giving additional confirmation: In 150 children the head may be held in equilibrium if the infants are very vigorous toward the end of the third, or in the first half of the fourth mdnth : in infants of medium force this is not seen until the second half of the fourth month, and finally, in infants less vigorous, somewhat below the normal in nutrition, not until the fifth or the beginning of the sixth month. 2 Kormann, quoted by Kleinwachter. 396 SCIENCE AND ART OF OBSTETRICS. Mechanism.—As in presentation of the vertex the occiput was selected as the point of reference, so in presentation of the face the forehead, following the example of Depaul, will be chosen. Most obstetricians select the chin, naming the different positions of the presenting part mento-anterior and mento-posterior, right or left, according to the side of the pelvis in which the chin is placed. But let the student imagine a case of vertex presentation with the occiput at the left ilio-pectineal eminence, and then, while the fcetus is un- changed in its general position, let the head be extended instead of flexed, and it is seen that the forehead at once takes the position which the occiput occupied; and this position is the most frequent in presentation of the face. Further, in many cases, if not in the majority, presentation of the face is a deviated vertex presentation, and such deviation can be better understood with the nomenclature proposed. The various positions in presentation of the face will therefore be called right or left fronto-anterior and fronto-posterior. Diagnosis.—Pinard1 states that examination of the pelvis enables us to recognize the presence of a large tumor at, above, or below the inlet, according to the period of labor at which the examination is made. Moreover, this tumor appears to occupy but one side, and is wanting at the other. Let the hand be now at once placed upon the fundus of the uterus, or both may be first put upon the sides of the uterus until the fundus is reached, and then one of them applied to it, and we find, usually upon the same side at which the lower tumor was prominent, the pelvis, that may be recognized by its peculiar characters. In order to follow and appreciate the resisting plane, it is indispensable2 to depress slowly and deeply the abdomi- nal wall, for this surface seems to bury itself in the abdominal cavity, while the superficial parts are readily felt. This is caused by the bending of the fcetus upon its dorsal plane. In operating properly one of the lateral planes can be examined, and it is readily ascertained that the portion of the cephalic sphere most accessible is in relation with the back. Moreover, between the back and the head there is, especially early in the labor, a deep depression into which the fingers sometimes readily enter. According to Budin,3 one can, in some cases, recognize on the side opposite to the accessible tumor a clearly marked projection having the form of a horseshoe; it is formed by the inferior maxillary and the chin. Charpentier regards the diagnosis by palpation alone as exceed- ingly difficult, stating that special conditions must be present, re- laxation and thinness of the abdominal walls, and a non-irritable condition of the uterus, in order thereby to make such a diagnosis, but it can be made by combining auscultation with palpation. The fcetus occupies a higher position than in vertex presentation, so that the maximum of the intensity of the heart sounds is heard at, instead of below, the transverse line (Fig. 104); further, in conse- quence of the head being turned toward the back, the latter is removed from contact with the uterine wall, so that the sounds are Abdominal palpation. 2 Pinard, op. cit. 3 Op. cit. THE MECHANICAL PHENOMENA OF LABOR. 397 heard better through the anterior wall of the chest; hence while the back is felt, for example, on the left side of the uterus, the heart- sounds are heard most distinctly upon the right side. This want of harmony between the results obtained by palpation and by ausculta- tion leads to the diagnosis of a face presentation, for palpation would point to the conclusion that there was a vertex presentation, but auscultation, both by the fact that the sounds are heard higher up than in such a presentation, and on the opposite side to that upon which the back is found, justifies at least the suspicion that the face presents.1 After labor has begun, digital examination brings conclusive proof of the presentation. There will be found upon one side of the pelvis a round, hard part, divided in the median line by the beginning of the sagittal suture, and bounded by the fronto-parietal suture, and in the median line by the bregma; while upon the other side of the pelvis there is felt a smaller, softer, and irregular surface; this sur- face immediately next to the frontal bone offers two soft, round, small tumors, the globes of the eyes; there is a depressed surface between them, then from it there rises a projecting part which ends in two openings, the nares; below the nares and transverse to them is the mouth, into which the finger may be introduced, and in some cases this introduction is followed by efforts on the part of the infant to suck; below the mouth the chin is found, the direction in which it points being plainly indicated by the opening of the nares.2 If the labor has been in progress for some time, the membranes having been ruptured, the face becomes greatly swelled, and its form changed ; one feature, however, remains comparatively un- changed, the nose; by this the diagnosis of the presentation can usually be made, and when the nose is recognized, the position is known, for the former points in a direction opposite to the forehead. The mouth should not be confounded with the anus, for the projec- tion caused by the point of the coccyx is always readily found near the latter. Left Fronto-anterior Position.—This is the most frequent position. The back is found by palpation upon the left anterior side of the uterus; the fcetal heart-sounds are heard most distinctly upon the right side. Upon vaginal examination the nose is found pointing toward the right sacro-iliac joint, and hence the forehead must be at the left ilio-pectineal eminence. 1. The first of the mechanical phenomena of labor is increase of extension, the occiput turned against the back; complete extension in presentation of the face corresponds with complete flexion in presentation of the vertex. Its cause is the driving force met by the unequal resistance of the two arms of the face lever. In Fig. 1 Fischel states the heart's action may be felt in face or brow presentation, when the anterior part of chest lies in contact with the uterine wall, after rupture of membranes. 2 Winckel states that in the diagnosis of this presentation chief reliance should be made upon recognizing the mouth and tongue. 398 SCIENCE AND ART OF OBSTETRICS. Fig. 138. Fronto anterior Position in Presentation of Face. Fig. 139. Attitude of the Head in Presentation of the Face. THE MECHANICAL PHENOMENA OF LABOR. 399 139, A F, being the long arm, necessarily offers more resistance than A M, the short arm ; hence the chin descends, and the forehead ascends. Further, the head being already partially extended, pre- pares the way for complete extension. The result of perfect exten- sion is: There is a lessened area of the head circumference brought in relation with the pelvic area, for, prior to complete extension, that circumference corresponded with a diameter passing from the chin to the bregma, the mento-bregmatic diameter, while now the diameter whose circumference occupies the pelvic area is the fronto- mental. There is no loss of force, at least after the waters have been evacuated and direct pressure upon the breech permitted, for the fcetus is no longer " a vacillating rod " in consequence of the mobility at the cervical vertebrae, but compacted together by the occiput being fixed upon the back. Complete extension is recog- nized by the recession of the forehead, and by the advance of the chin toward the centre of the pelvic cavity. 2. Descent.—This does not need to be defined nor its cause ex- plained. 3. Rotation.—It is essential, in order that delivery can take place, in the ordinary relations of the size of the pelvis and that of the fcetus, that the chin rotate anteriorly; that must escape first before Fig. 140. Rotation forwards of the Chin. any flexion of the foetal rod is possible. The descent is at an end as soon as the length of the child's head has been measured upon the pelvic wall, for then the chest tends to enter the pelvis, but the latter cannot accommodate both head and trunk. The length of the pelvic lateral wall is three inches and a half, between nine and ten centimetres, while the anterior wall is only one inch and a half 400 SCIENCE AND ART OF OBSTETRICS. long, four centimetres, a distance readily measured by the neck. Ordinarily, therefore, it follows that rotation of the forehead into the sacral cavity, and of the chin into the pubic arch, occurs before the face reaches the pelvic floor. Dr. Hodge, however, with Velpeau and Chailly, held that in many instances " the chin will pass below die sacro-sciatic ligament, and will often distend the perineum to a great degree." He justified this opinion by the following con- siderations ; first, the length of the neck is to be measured, not from the hyoid bone, but from the chin to the chest. When the head is in a state of extension we would have at least three inches and a half, and if the neck be elongated, probably four inches from the chin to the sternum. Second, the neck can be elongated to a considerable degree in these cases of great extension. If these views were correct we would probably have delivery of the foetus in face presentation without anterior rotation of the chin, as a frequent occurrence. Admitting, too, the great elongation of the neck claimed by Dr. Hodge, which, however, is of the anterior portion, this does not obviate the difficulty arising from both the head and chest occupying the pelvic cavity at the same time. Passage of the Head through the External Parts in Face Presentation.—The head is becoming flexed and sweeping over the perineum. The reasons for posterior rotation of the forehead are that it offers a more extensive surface, and the frontal arm of the face-lever is the longer, and hence meets with greater resistance ; it finds more room, and can be better accommodated behind than in front. With the corresponding rotation of the chin into the pubic arch the mental end of the face-lever'is free; it no longer meets resistance from the bony wall of the pelvis, and the head is no longer pressed against the back, but can be delivered, thus giving room in the pelvic cavity for the descent of the body. THE MECHANICAL PHENOMENA OF LABOR. 4OI 4. Delivery of the Head by Flexion.—The chin escapes, and thus the occipito-mental diameter is free to rotate partially. The head is, as it were, rolled out of the vulvar opening, flexion occurring, the throat applied to the summit of the pubic arch, the chin ascending over the pubic joint until the occipital end of the occipito-mental diameter escapes over the perineum, when the head drops down toward the anus as it did after vertex delivery. Here again we have illustrated the fact that when one end of the long diameter of the fcetal head enters the pelvis, that end must pass out of it first. 5. External Rotation of the Head with Internal Rotation of the Shoulders.—The conditions are the same as in vertex delivery, and the causes of the rotations and the consequences are identical. The forehead, or the chin, always turns toward that thigh corresponding with the side of the pelvis which it occupied ; thus, if the forehead was in relation with the left side of the pelvis it turns toward the left thigh. 6. Delivery of the Body.—This is the same as in presentation of the vertex. Anomalies of Mechanism in Face Presentations.—In some cases there may be, in consequence of imperfect extension, presentation of the forehead. But this rarely persists, for either flexion occurs and the presentation becomes that of the vertex, or, and this is the more frequent, extension is completed and there is simply a face presenta- tion. Sometimes, however, the forehead remains the presenting part, and is delivered first. The anomalies of the third time, rota- tion of the chin in front, are the most important. Not only may this rotation fail, but posterior rotation by which the chin turns to the sacral cavity may occur. Apparently spontaneous expulsion is impossible. Velpeau thought that flexion of the head might then take place by which the vertex would be substituted for the face. But this is impossible after the head enters the pelvic cavity if the fcetus and pelvis are of usual size. Cazeaux suggested that the soft parts might be depressed at the great sciatic foramen, " a depression permitting the chin to escape from the bony canal," so that the long diameter of the fcetal head might turn, and presentation of the vertex be substituted for that of the face. Another explanation was proposed by Dubois from two cases observed by him. The chin was behind and to the right, descent to the inferior strait occurred, and after the chin passed below the great sciatic ligament it depressed the soft parts so that space was gained to permit flexion of the head at the expense of the elasticity of the pelvic floor, and labor ended with presentation of the vertex. Pajot remarks that in directly posterior positions, which are so rare that he has never seen one, that Chailly has suggested an analogous mechanism theoretically probable, permitting sponta- neous delivery. The chin having reached the point of the coccyx, depresses the pelvic floor so that rotation of the occipito-mental diameter can occur, and the occiput is disengaged under the pubic arch. But whatever opinion may be suggested as to the termination 26 402 SCIENCE AND ART OF OBSTETRICS. of the labor in mento-posterior positions,1 practice demonstrates that they very rarely persist, and, moreover, when rotation of the chin does not occur, difficulties ordinarily arise requiring the inter- vention of art. Plastic Changes.—The form of the head is dolicocephalic; the longitudinal diameters are increased, the vertical and transverse diminished. The face is greatly swelled and discolored; the eyelids likewise, and it is impossible for the infant to open them ; in some cases the lips are so greatly swollen that the infant cannot nurse ; very often subconjunctival hemorrhage is present.2 The caput succedaneum occupies the inferior part of the malar region and the side of the mouth in fronto-posterior positions; on the contrary it is situated upon the superior part of the malar region and even upon the eye in fronto-anterior positions. Mauriceau3 has given a very graphic description of the appearance of a child's face after birth with facial presentation. Right fronto-posterior position is the reverse of left fronto- anterior; and just as the former might be considered a deviation of the most frequent position of vertex presentation, extension taking the place of flexion so that instead of the occiput the forehead is at the left ilio-pectineal eminence, so, imagining first the next most frequent position of vertex presentation, right occipito-posterior, we may suppose a deviation to result from extension taking the place of flexion so that the forehead instead of the occiput is placed at the right sacro-iliac joint. The mechanism of labor is the same as has been described. I. Completion of extension. 2. Descent. 3. Ro- tation. As the chin is so much nearer the pubic arch in this posi- tion than in left fronto-anterior, this process occupies much less time. 4. Delivery of the head by flexion. 5. External rotation of the head with internal rotation of the shoulders. 6. Expulsion of the body. It is not necessary more than to mention the names of the two other positions of face presentation, right fronto-anterior and left fronto-posterior, for a description of the mechanism of 1 Pajot. 2 A remarkable case of fatal hemorrhage from the conjunctivae in an infant born with face presentation occurred, March, 1890, during my last term of service at the Philadelphia Hospital. Dr. Frank R. Keefer, maternity resident, had charge of the mother in her labor, and has given me a full report of the case, which I hope to publish with some comments at an early day. Suffice it now to say that the child was delivered spontaneously after a not unusually long labor; it seemed quite well, weighed eight pounds, and had only the usual appearance of a child born presenting the face. The bleeding began twelve hours after birth, the oozing was first from the conjunctiva of the right upper lid, and after a few hours from the palpebral con- junctiva of the left eye. In spite of various local means, some of which temporarily arrested the bleeding, the child perished of hemorrhage a little more than twelve hours after the first oozing appeared. 3 In Mauriceau's Diseases of Women with Child, etc., translated by Hugh Chamberlen, and published in 1727, the great French obstetrician tells of a child being born face first, that " came with the face so black and misshapen as soon as it was born, as usually in such cases, that it looked like a blackmoor. As soon as the mother saw it she told me that she always feared her child would be so monstrous, because when she was young with child she fixed her looks very much upon a blackamoor belonging to the Duke of Guise, who always kept several of them. Wherefore she wished that, or at least cared not though it died, rather than to behold a child so disfigured as it then appeared. But she soon changed her mind when I satisfied her that this blackness was only because it came faceling, and that assuredly in three or four days it would wear away.'' THE MECHANICAL PHENOMENA OF LABOR. 403 labor in these positions would be essentially a repetition, and is therefore unnecessary. Pelvic Presentations.—Presentations of the pelvis are next in fre- quency to those of the vertex, and occur once in twenty to thirty cases in single pregnancies, but more frequently in twin preg- nancies. Excluding cases of premature labor, pelvic presentations occur, according to Pinard, one in sixty-two. Fig. 142. Pelvic Presentation. Right Sacro anterior Position. Varieties and Causes.—Usually the upper and lower limbs occupy the same position with reference to the trunk that they do in vertex or in face presentations. In some cases, however, not only are the thighs flexed upon the abdomen, but the legs extended over the chest. The knees may descend first, though, according to Spiegel- berg, such presentation is never primitive, one or both feet may descend, but these various modifications do not affect the essential mechanism of labor. Whether knees, feet, thighs, or pelvis present, all are included under the general name of pelvic presentations. Multiparity, premature labor, polyhydramnios, plural pregnancy, the fcetus being dead, or of small size, or hydrocephalic, pelvic narrowing, uterine tumors, and placenta praevia are the chief causes of pelvic presentations. In regard to the last, it is probable that it is not the fact of the placenta being praevia which causes pelvic presentation, but they both result from a common cause, the condition of the uterus. Diagnosis.—Before labor the pelvic cavity will be found empty, and the lower portion of the fcetal ovoid is partly in one or the other iliac fossa usually, and partly over the inlet; there will be found ad- 404 SCIENCE AND ART OF OBSTETRICS. jacent to this portion, except when the legs are extended over the chest, small movable parts; the head is in the proper portion of the uterus, and in the majority of cases at the right side, though in the illustration it is represented in the left, and cephalic ballottement may be made. Upon auscultation the maximum of intensity of the heart sounds will be found above the horizontal line at Fig. 104. Fir,. 143. Diagnosis of Pelvic Presentation by Palpation. Early in the labor before the presenting part has descended into the pelvic cavity, and the fcetal sac is entire, it will be difficult or impossible to make a diagnosis by vaginal examination. The bag of waters is large, and is sometimes described as "pudding-shaped;" such size and shape, and difficulty in reaching the presenting part, render it probable the presentation is pelvic. After the rupture of the sac and the descent of the pelvis, there usually is no difficulty in making a diagnosis. The finger touches a round object, but it is softer, less uniform in shape than the head, and has neither sutures nor fontanelles, nor the feeling of the scalp, wrinkled and covered with hair. The separation between the buttocks, the coccyx, the sacral crest, the anus, and the sexual organs may be recognized; if the child be alive the anus contracting resists the effort to introduce the finger, and the latter upon withdrawal will be covered with me- conium. If the feet are pressed against the thighs, so that one of them may be touched by the finger, the diagnosis becomes easier THE MECHANICAL PHENOMENA OF LABOR. 405 If the coccyx be felt the position is at once known, for the point of the coccyx is always directed toward the anterior plane of the fcetus. If afoot only is accessible to touch.it is distinguished from the hand by being at a right angle to the leg, by its being thicker upon one side than upon the other, by the toes being placed in the same line, Fig. 144. Pelvic Presentation.—A, Place where sounds of foetal heart are heard most distinctly in left sacro-anterior position. by the impossibility of separating the great toe from the second, and bringing the former in opposition to the other toes, as the thumb can be separated from the index finger, and brought in oppo- sition to the fingers; the projection of the os calcis is also an im- portant mark by which the foot can be distinguished from the hand. Presentation of a knee is very rare. The knee is broader than the elbow, and the patella flat while the olecranon is pointed ; the thigh and the leg, between which the knee is felt, are thicker than the arm and the forearm. If there still be uncertainty in the diagnosis, the member may be extended, and then the foot will be recognized. When the leg is extended the toes point to the anterior plane of the fcetus; but if the leg be flexed upon the extended thigh the toes point to the posterior plane. Mechanism of Labor.—The positions are named according as the sacrum of the fcetus is anterior or posterior, in the left or right side of the mother's pelvis; thus we have four positions for pelvic presentations: i, left sacro-anterior, the sacrum being at the left ileo-pectineal eminence, the most frequent position; 2, right sacro- 406 SCIENCE AND ART OF OBSTETRICS. posterior, the sacrum being at the right sacro-iliac joint; 3, right sacro-anterior; and 4 right sacro-posterior. Here, too, there are six stages, times, or processes in the mechanism of labor, as have been given in presentation of the vertex, and in presentation of the face. 1. Compression of the Presenting Part.—Just as a scattered crowd is brought into a compact mass in order to go from a ferry-boat to the landing wharf, so the presenting part is compacted together, reduced to the smallest dimensions in order that it can be trans- mitted through the birth-canal. It is a process of lessening, of adaptation of the passenger to the passage. In presentation of the vertex this process was by completion of flexion, and in presenta- tion of the face by completion of extension; in all the changes there is a lessening of the presenting part, and the means by which the changes are effected are the same driving and resisting forces, and in all the purpose of the change is the same, the fcetal region is reduced to form and size corresponding with the canal through which it must pass. 2. Descent.—This needs no explanation. 3. Rotation of the an- terior hip into the pubic arch, so that the bis-trochanteric diameter is placed in relation with the antero-posterior diameter of the outlet; this rotation includes the trunk of the child. 4. Delivery of the body: The anterior hip is at the pubic arch, and the pos- terior at the other end of the coccypubic diameter. Fig. 145. Expulsion of the Breech. The pubic thigh remains fixed, forced against the subpubic liga- ment, and makes the pivotal point upon which, by partial curvature, the hips pass out; the posterior thigh sweeps along the perineal gutter, and the lower portion of the body is delivered, greatly latero- THE MECHANICAL PHENOMENA OF LABOR. 407 flexed. The anterior shoulder now descends into the pubic arch, is fixed there, while the posterior shoulder sweeps over the perineum and is delivered first, meantime the arms and forearms remaining closely applied to the chest. 5. Internal Rotation of the Head and External Rotation of the Trunk.—This movement is designed to bring the occiput behind the pubic joint, and the face into the sacral cavity. It is essentially the same as that which is observed in a vertex presentation, only it occurs last instead of first. Its purpose is to place the head in the most favorable position for expulsion, a sub-occipital being brought in relation with the longest diameter of the outlet. 6. Delivery of the Head.—The head is forced down, the chin closely applied to the chest, the nucha pivots against the pubic arch, while the chin is born first, then the face, forehead, bregma, and, finally, the occiput emerge, the diameters presented being, as in head-first deliveries, sub-occipital. Anomalies in the Mechanism.—The only one of importance is that which may occur in the fifth time, arising from the failure of the occiput to rotate behind the pubic joint, but it rotates into the sacral cavity; the back of the child, instead of being anterior, is Fig. 146. Expulsion of the Shoulders. now posterior. The mechanism is different according as flexion of the head remains or as extension occurs, the chin resting upon the chest in the one case, but departing from it in the other. In the former the nucha presses upon the anterior margin of the perineum, and the head is delivered by extension occurring, the chin, face, forehead, bregma, and occiput passing out in succession, the back 408 SCIENCE AND ART OF OBSTETRICS. of the child being turned toward the mother's back. But when the chin departs from the chest it is delayed above the pubic joint, ex- tension is completed so that the occipital end of the occipito-mental diameter passes out first, then the rest of the head, delivery occur- ring by flexion, the throat pivoting upon the pubic joint; the abdo- men of the child in the delivery comes toward the abdomen of the mother. Plastic Changes.—The caput succedaneum is usually found upon the anterior thigh, but the swelling may also involve the external genitals, which are often greatly discolored. The head is remark- able for its round appearance; this arises from the fact that it is pressed at all points except at the top. * Mechanism in the Different Positions.—First. Left Sacro-anterior: I. Compression. 2. Descent. 3. Rotation. It is unnecessary to give all the details. In this position the back is toward the mother's left side anteriorly, the sacrum at the left ilio-pectineal eminence, the bis-trochanteric diameter is in relation with the left oblique, and the sacro-pubic with the right oblique of the inlet. The anterior hip, here the left, rotates from the right into the pubic arch. 4. Delivery of the body: The left hip is fixed at the pubic arch,pressing against the sub-pubic ligament; the right hip,passing over the sacro-coccygeal concavity and the perineal floor, emerges at the anterior perineal margin, the body of the fcetus being curved upon its lateral plane. The shoulders descend—the bisacromial diameter has the same relation with the coccypubic diameter that the bis-trochanteric had—and the trunk is entirely born. 5. Internal Rotation of the Head and External Rotation of the Body.— The occiput turns from left to right behind the pubic joint, the chin firmly pressed upon the chest. 6. Delivery of the head: This occurs by extension, the chin passing out first, then the rest of the face, the forehead, the bregma, and the occiput—the back of the fcetus is di- rected toward the abdomen of the mother. Second. Right Sacro-posterior Position: In this position the sacrum is directed to the right sacro-iliac joint. The right hip is anterior. The only difference in the mechanism from that observed in left sacro-anterior position is that the right hip turns from the right side in front. The mechanism in each of the other positions can be readily understood from the descriptions that have been given. Presentation of the Shoulder.—Either the right or the left shoulder may present, and for each there are two positions, depending upon the relation of the back of the fcetus to the abdomen of the mother, and hence known as dorso-anterior and dorso-posterior. Presenta- tions of the right shoulder are somewhat more frequent than those of the left; dorso-anterior positions are at least twice as frequent as dorsoposterior. Pinard indeed states that he never met, during pregnancy, with shoulder presentations unless occupying a dorso- anterior position. Shoulder presentations occur once in about 125 labors, Pinard; 6 to 7 in 1000, Kleinwachter; 1 in 297 Galabin gives as the proportion found from the statistics of Guy's Hospital Lying- in Charity. THE MECHANICAL PHENOMENA OF LABOR. 4O9 Causes of Presentation of Shoulder. — Smallness of the fcetus, its being dead, premature labor, polyhydramnios, peculiar shape of the womb, plural pregnancy, relaxation of uterine and of abdominal Fig. 147. Transverse Presentation. Dorso-anterior. Presentation of Right Shoulder. walls, pelvic narrowing, and placenta praevia are given as causes. As to the last, the remark made in regard to pelvic presentations being similarly caused, is here also applicable. Diagnosis.—I. Before labor begins, according to Depaul, the maximum of intensity of the fcetal heart-sounds is at the level of Fig. 148, Transverse Position. Dorso-posterior. Presentation of Right Shoulder. the line dividing the uterus in two equal parts, and the line of decrease of this maximum is horizontal, not vertical. This is shown in the illustration, Fig. 149. By abdominal palpation the form of the uterus is found very dif- ferent from the usual shape, being increased transversely; but it is a mistake to suppose, as is represented in some drawings, that the fcetus will be found lying with its head in one, its hips in the other 410 SCIENCE AND ART OF OBSTETRICS. iliac fossa; for apart from any other reason, the distance between the fossae is much less than the length of the fcetal ovoid at or near term. The head is usually lower than the hips, for the shoulder, in Fig. 149. A, Point of Maximum of Intensity of Sounds of Foetal Heart in Presentation of the Shoulder. Fig. 150, Showing Diagnosis of Shoulder Presentation by Palpation. THE MECHANICAL PHENOMENA OF LABOR. 4II most cases, is in relation with the pelvic area. Then by palpation the head is felt in one iliac fossa while the breech is found in the opposite flank, and a resisting plane connects the two; cephalic ballottement is possible (Fig. 150). Vaginal examination is without value prior to labor. During labor auscultation remains the same. The head is pressed nearer the inlet, and can be felt more distinctly, but ballottement is now impossible. The pelvic extremity is brought nearer the fundus of the uterus, toward the median line, and the resisting plane which unites the two ends of the fcetal ovoid is also brought nearer the vertical line.1 Depaul has dwelt upon the "peculiar physiognomy " of labor in case of shoulder presentation. The uterus does not contract with the same regularity that it does in vertex presentation ; very fre- quently quite a long time passes in which the contractions come, are suspended, and then resume, without producing a marked effect; the os scarcely dilates, and sometimes twelve, twenty-four, forty- eight hours, or even more pass, without the part engaging in the inlet. The bag of waters is unusually large, and sometimes reaches down between the labia. If the presenting part cannot be reached by the two fingers, and auscultation and abdominal palpation have rendered it probable that the shoulder presents, it is better to intro- duce the hand into the vagina so that the diagnosis may be made certain. The shoulder is round, and presents a bony prominence, the acromion ; but the most characteristic feature is the axilla, with the ribs parallel to each other, like the bars of a gridiron, called by Pajot the intercostal gridiron. The cavity of the axilla formed by the arm and the wall of the chest represents an angle opening toward the hips, and its apex pointing toward the head; and hence when this is recognized the side occupied by the head is at once known. Next, the position of the breech is to be determined, whether ante- rior or posterior ; this is done by feeling the scapula or the clavicle, the former corresponding to the posterior, the latter to the anterior plane of the fcetus; in some cases the spinous processes of the ver- tebrae may be readily felt. If the elbow presents, it is recognized by being smaller than the knee, and the olecranon pointed while the patella is flat; if there be doubt, the forearm should be extended, and the hand will be readily recognized. The elbow, before the forearm is extended, points from the head. Should the hand descend, the means of distinguishing it from the foot mentioned in the diagnosis of pelvic presentation are to be used; there is usually no difficulty in making this diagnosis. But it does not necessarily follow that there is a shoulder presenta- tion because the hand descends, for this may happen in presenta- tion of the head, or of the breech, and therefore it is necessary by auscultation, by palpation, and by vaginal touch, to know that the prolapsed hand is not a complication of either of these presenta- tions. Supposing the hand to descend in a shoulder presentation, 1 Charpentier. 412 SCIENCE AND ART OF OBSTETRICS. it is important to know whether it is the right or left hand. Two very simple ways are presented ; by following either, the question is answered. Put yourself in its place, and shake hands. That is, let the obstetrician imagine one of his own hands occupying the same position, and he at once knows which hand. Or let him apply one of his own hands to the projecting hand, the right, for example; if palm corresponds with palm, and the thumbs are directly applied to each other, it is the right hand. The hand3 gives the shoulder; the back of the hand the situation of the head ; the direction of the thumb indicates the direction of the breech; when the breech is posterior, the thumb is directed above from the side of the pubic joint; if the breech is anterior, the thumb is directed below, toward the anus. Three modes of spontaneous delivery may occur in shoulder pre- sentation : I. As observed by Roederer, Kleinwachter, and others, the fcetus may be delivered doubled ; but this is only possible when it is small, very flexible, and compressible. 2. Spontaneous version by which the head or breech is substituted for the shoulder may occur; if the head take the place of the shoulder, the change is known as cephalic version, but if the breech, pelvic version. Spontaneous version has been attributed to the active movements of the fcetus, and to irregular uterine contrac- tions. It would seem more natural to explain the change as result- ing from the uterus taking, though tardily, its normal ovoidal form, and compelling the fcetal ovoid to occupy its corresponding posi- tion. 3. Spontaneous evolution is the term given to the delivery, when, the shoulder still presenting, a series of changes, or mechanical phenomena essentially the same as those that have been described in connection with delivery in other presentations take place. These are : 1. Compression, by which the presenting part is lessened and thus adapted to the canal through which it must pass. 2. Descent. This stage requires no description. 3. Rotation of the shoulder into the pubic arch. These three stages occupy considerable time, during which the fcetus in most cases dies. The shoulder is the smallest part of the fcetal wedge, and hence advances first, driven in the direction of least resistance. With the rotation of the shoulder the head moves anteriorly and is fixed above the pubic joint. 4. Delivery of the body. The anterior shoulder remaining fixed at the sub-pubic ligament, the posterior shoulder is forced down the sacro-perineal curve, the body being strongly latero-flexed. By referring to Figs. 151 and 152, it is seen that the right shoulder is anterior, and remains fixed, while the left or posterior shoulder is driven further down ; the latter finally passes out at the anterior 1 Charpentier. THE MECHANICAL PHENOMENA OF LABOR. 413 margin of the perineum and is followed by the chest, abdomen, and hips, and then the anterior shoulder is delivered, the head only re- maining in the pelvis. Fig. 151. Spontaneous Expulsion.—First Stage. Fig. 152. Spontaneous Expulsion.—Second Stage. 414 SCIENCE AND ART OF OBSTETRICS. 5. Internal rotation of the head and external rotation of the body. This is the same as that which occurs in pelvic deliveries. Fig. 153. Spontaneous Expulsion.—Third Stage. 6. Delivery of the head. This, too, is the same as in pelvic de- liveries. Caput Succedaneum.—This is situated upon the shoulder which has presented; when the arm prolapses, it also is swelled and dis- colored, and frequently is the seat of phlyctenular. Of course, shoulder presentations are not trusted to spontaneous delivery, but demand the intervention of art. Nevertheless, it was important to present nature's method of dealing with these abnormal presentations. The student will recognize the truth of the state- ment made at the beginning of this exposition of the mechanical phenomena of labor, that there is a unity in this mechanism, one general plan, one common end. That this may be made, if possible, still clearer, the following table, including the different presentations, with the associated mechanical phenomena of labor, is given: Vertex Presentation. 1. Flexion of the head. 2. Descent. 3. Rotation of head. 4. Delivery of head. 5. Internal rotation of body. 6. Expulsion of body. Face Presentation. Extension of the head. Descent. Rotation of head. Delivery of head. Internal rotation of body. Expulsion of body. Pelvic Presentation. Compression of pelvis. Descent. Rotation of pelvis. Delivery of body. Internal rotation of head. Expulsion of head. Shoulder Presentation. Compression of shoulder. Descent. Rotation of shoulder. Delivery of body. Internal rotation of head. Expulsion of head. Prognosis of Vertex, Face, and Breech Presentations.—Auvard states as the mortality for infants, when the vertex presents, 1 per cent., in THE MECHANICAL PHENOMENA OF LABOR. 415 facial presentation 5 per cent., and in pelvic 10 per cent. But this is too favorable. If the vertex present and the position is occipito- anterior the mortality, according to Winckel, is 2.5 per cent. But in an occipito-posterior position, with rotation posteriorly, more than 15 out of 100 perish. In presentation of the face 13 per cent, are born dead, and 7.5 per cent, asphyxiated. Pelvic presentations give a mortality of about 20 per cent. CHAPTER III. THE CONDUCT OF LABOR. Having considered the phenomena of labor, its conduct or man- agement is now to be presented. Giving birth to a child, though a physiological function, differs very materially from any other func- tion of the organism. These differences are duration, suffering, and traumatism. Intelligent art may in many instances shorten the first, and lessen the second and third. Even admitting that the savage woman1 safely brings forth alone, or with only an ignorant attend- ant, the civilized woman is in many instances very far from being in a physiological condition, and thus childbirth brings to her peculiar pains and perils; her higher development renders her more sus- ceptible to bodily suffering, and in many instances has been attained by the partial sacrifice of physical endurance and vital force. More- over, in cases of labor for a time advancing favorably, sudden acci- dents imperilling the life of mother or of child may arise, and pro- fessional knowledge and skill be needed to meet them ; while the common role of the obstetrician is " to observe, to control, to alle- viate, and to protect," emergencies may come which demand his promptest action and greatest ability, though it is only in a small minority of births, not more than five per cent., any other interfer- ence is required. It is, therefore, important, in her own interest and in that of her offspring, that woman should have in labor a qualified professional attendant. Two important questions, the one relating to antisepsis, the other to anaesthesia, may be considered at the beginning of this exposi- tion of the obstetrician's duties. Antisepsis.—With our present knowledge of the gravest diseases which affect the lying-in woman, it is very probable they are caused by microscopic germs ; hence it is important that woman in labor should as far as possible be protected from the presence of such germs, and their entrance through the necessary or accidental trau- matisms of labor be prevented.2 As part of the means for the attain- 1 The following statement is made by Dr. Engelmann in his very interesting volume, Labor among Primitive Peoples, p. 7; "Among primitive people, still natural in their habits and living under conditions which favor the healthy development of their physical organization, labor may be characterized as short and easy, accompanied by few accidents and followed by little or no prostration.'' If birth were as easy as that of.Wenonah in Longfellow's song of Hiawatha, obstetricians would never be needed : "There among the ferns and mosses, There among the prairie lilies, On the Muskoday, the meadow, In the moonlight and the starlight, Fair Nokomis bore a daughter.'' 2 The testimony given by lying-in hospitals in regard to the value of antiseptics in greatly lessening not only mortality but morbidity, is so large and clear that no intelligent and con- THE CONDUCT OF LABOR. 417 ment of this end, it is important that the lying-in room be well ventilated and free from disease germs, or from the poisonous influ- ence of sewer-gas. I have seen in consultation a case of puerperal septicaemia in a multipara who occupied a room in which three months before two of her children were ill with diphtheria; in another patient the lying-in room had a washstand communicating with a badly drained sewer; in a third the disease apparently had its origin in connection with scarlet fever, the husband, a physician, attending some malignant cases of the disease immediately before and after his wife's confinement, and spending most of his time in her room. Thorough disinfection of the room which the patient is to occupy should be made, if it has been previously occupied by one suffering with scarlet fever, with erysipelas, or diphtheria, or with any disease attended with suppuration, as uterine cancer in its advanced stages; it would be better, indeed, for her lying-in to be in another house or other room. The room, too, should be free from the effluvia of decaying animal matter. If there be any sewer communication in it, as, for example, from a permanent washstand, that communica- tion should be, for the time at least, cut off. The obstetrician must know that the nurse has not recently been in attendance upon any of the forms of disease that have been mentioned, and especially upon a case of puerperal septicaemia. The parturient ought to have a warm bath at the beginning of her labor, and after it the external genital organs washed with a two to three per cent, solution of carbolic acid, or, which I much prefer, a mixture of one to two per cent, of creolin in water. If the labor is protracted vaginal injections of one teaspoonful of creolin to a quart of water may be given, and a napkin sprinkled with a mixture of one teaspoonful to a pint of water, may be applied to the vulva, especially when the head of the child begins to distend its opening. In all women having a purulent vaginal discharge, a creolin injection ought to be used at the beginning of labor. When the labor is protracted, a similar solution may be used as a vaginal injection once or oftener. All metallic instruments that may be used should be first disinfected by being put in hot water, and after- ward in a two per cent, creolin mixture. No soiled clothes, or ves- sels containing evacuations from the patient's bladder or bowels should be allowed to remain in the room. The obstetrician washes his hands with warm water and soap, diligent use of the nail-brush being made during this thorough ablution; after this washing and scrubbing, he bathes them in a two per cent, creolin mixture; one of the advantages of such mix- ture is that it so lubricates the fingers that he will not need to apply to them before making a vaginal examination, an ointment or oil. scientious practitioner can deny that system or wisely ignore the use of such agents. The mortality has been reduced to one-half per cent, or less, and the statistics of Schuster, of Innspruck, show that of the women delivered there, 93.1 per cent, did not have any febrile temperature. Centr. f. Gynakol., 1888. 27 4l8 SCIENCE AND ART OF OBSTETRICS. The use of antiseptics after labor will be considered in connection with the management of the puerperal state. Ancesthesia.—Historical. Early in 1847 the illustrious Sir James Y. Simpson proved that inhalation of sulphuric ether could be safely and successfully used for the relief of pain in childbirth, and later in the year he established the same fact as to the inhalation of chloroform. Obstetric anaesthesia soon found a few in Great Britain and on the Continent to advocate and practise it. In the United States, Dr. N. C. Keep, of Boston, was the first American physician to administer an anaesthetic in labor. But Dr. Walter Channing was the most distinguished of American physicians advocating the practice; his treatise on Etherization in Childbirth was published in 1848. The late Professor Henry Miller, of the Uni- versity of Louisville, gave chloroform to a woman in labor, on the 13th of March, 1848; this was the first time chloroform was thus used west of the Allegheny Mountains. Dr. Miller remained faithful to anaesthesia in labor the rest of his honored life; he strongly advocated the practice, and with his well-known ability answered the arguments adduced against it. Channing and Miller are the two names that in this country shine with the most lustre in connection with the early advocacy of obstetric anaesthesia. On the other hand, three of the most eminent obstetric teachers, Meigs, Hodge, and Bedford, strongly opposed the use of anaesthetics in normal labor, and their influence was more powerful than that of its advocates. The controversy here was but the reflex of that which was occurring in Great Britain. Simpson asserted that it was only a question of time as to the general adoption of anaesthesia in par- turition. On the other hand, Dr. Ashwell, who, with Tyler Smith and Rams- botham, were the most prominent London obstetricians opposing the practice, declared that " unnecessary interference with the providentially arranged process of healthy labor is sure, sooner or later, to be followed by injurious or fatal re- sults," " that chloroform need only be extensively used to insure its entire aban- donment," and that it was "a duty to urge every plea against its further use." More than thirty-five years have passed since these words of Simpson and of Ashwell were uttered ; the prophets are dead, but the prophecy of neither has been fulfilled; chloroform has not been generally adopted, nor has it been entirely abandoned in obstetric practice. Doubtless the influence of Drs. Meigs, Hodge,1 and Bedford did much in this country to prevent the use of anaesthetics in labor. It is certain that the great majority2 of women in the United States endure the martyrdom of maternity with- out anaesthesia. On the other hand, it often happens that a brief surgical opera- tion, in many instances much less painful than childbirth, is not done until the subject is anaesthetized. Various objections have been made to anaesthetics in physiological labor. It is needless to mention the argument drawn from the Bible, which was so triumphantly answered by Sir James Simpson, nor the assertion that suffering in labor is necessary in order that the mother shall love her child—Nature seems to have made no corre- sponding provision to secure paternal love. Another objection, which also once had its day, was that an anaesthetic caused lascivi- ous dreams. Coming to more recent, and apparently more rea- sonable objections, we may consider those which have been ably presented by Depaul3 in summing up his arguments against obstet- ric anaesthesia : " I, it may kill the patient; 2, the anaesthetic sleep 1 And yet Dr. Hodge, while refusing the parturient the relief to be had from chloroform, indi catesthe severity of her suffering by saying that she is " agonized and semi-delirious.'' 2 For example, in the Summary of Obstetric Cases reported by members of the East District Medical Society, and compiled by Dr. Samuel W. Abbott, Boston Medical and Surgical Jour- nal, July 6, 1882, in only twelve per cent, were anaesthetics used; as showing the great prefer- ence by New England physicians for ether, it was used in 323, and chloroform in only 2 cases. :i Dictionnaire Encyclopedique des Sciences Medicales. THE CONDUCT OF LABOR. 419 deprives her of reason so that she cannot participate in the great act accomplished, and this participation is in almost all cases necessary; 3, the inconveniences and dangers are not compensated by the ad- vantage arising from the diminution or suppression of pain." In reply to these objections it may first be answered, as Dutertre1 has said, that there has not been a single case of death that can be certainly attributed to obstetric anaesthesia, notwithstanding the immense number of accouchements in which it has been employed. " Chloroform has been used in natural labor many hundreds of thousandsof times, yet but a single case of death is on record where it was administered by a competent medical man, and in this there is a lack of post-mortem confirmation. Three other cases have been given at second-hand and without particulars."2 Many causes con- tribute to the almost complete exemption from danger. These are the position of the patient being horizontal, the intermittence in the use of the anaesthetic, the gradual manner of administration, the anaesthesia not being profound, the influence of uterine contractions, the uterus alternately relaxing and contracting reinforces the action of the lungs and heart, and thus asphyxia and syncope are avoided, and finally, as urged by Dr. Campbell, of Paris, the anaesthetic causes cerebral anaemia, while labor-pains produce an opposite effect. In answer to Depaul's second objection, it may be stated that it is not such a degree of anaesthesia that the patient is unconscious and incapable of voluntary effort, not surgical but obstetric anaesthe- sia which is sought. If the first and second objections are satisfac- torily answered, the third is without force. That the labor is ren- dered slower when the anaesthetic is properly given, or the patient is more liable to post-partum hemorrhage, are as yet unproved assertions. In regard to the first, moderate anaesthesia does not lessen the force of either uterine or abdominal contractions, unless there be some idiosyncrasy, or if it does it brings a compensation by diminishing the resistance which those contractions must overcome. Admitting that the labor maybe rendered slower in some cases, the lessened suffering makes the trial not so severe and exhausting. Admitting, too, that there may be a liability to post-partum hemor- rhage, a proper management of the third stage of labor, and the timely use of ergot, are almost certain to avert the danger. In fur- ther considering the subject of the relief of pain in labor, it will be convenient to divide it into general and local anaesthesia. General Anaesthesia.—This is usually accomplished by inhalation of an anaesthetic vapor. Chloroform3 is preferred by most to ether because of its pleasanter odor, its prompter action, and the less quantity required. On the other hand, ether is the safer; its ad- ministration is much less liable to cause profound narcosis; by some it is held that relaxation of the uterus and post-partum hemorrhage are much rarer after its use than after that of chloroform. 1 Op. cit. 2 Handbook of the Medical Sciences, vol. i. Dr. J. C. Reeve. 3 Dr. Fordyce Barker informs me that he always uses chloroform, and that he uses it in all cases of labor. 420 SCIENCE AND ART OF OBSTETRICS. Dr. J. C. Reeve, in his contribution to the American System of Obstetrics, "(Jn the Use of Anaesthetics in Labor," denies that ether is a safer anaesthetic than chloroform, and after a careful study of accidents from chloroform in labor, makes the following statements : I. But one well-authenticated case of death is on record where the administra- tion was by a medical man, and in that case no autopsy was held. 2. Dangerous symptoms have occurred but a very few times, and then almost always from violation of the rules of proper administration. 3. The danger when chloroform is used only to the extent of mitigation or abolition of the suffering of childbirth is practically nil; when carried to the surgical degree for obstetric operations, the danger is far below what it is in surgery. 4. No proof can be furnished that the parturient woman enjoys a special immu- nity from the danger of anaesthetics, although facts seem to indicate that such exists. Her best safeguard lies in the care and watchfulness of the administrator. If chloroform be employed, it may be inhaled from a handker- chief or small napkin, upon which half a teaspoonful is poured at a time; the napkin or handkerchief is held close to, but not touching, the patient's nose. For the administration of ether an extempora- neous inhaler may be made by first making a cone of a stiff towel, then this cone is surrounded at the sides and covered upon the top by thick, firm paper; a sponge as large as the fist is pressed into the cavity of the cone, and saturated with ether, being careful that the quantity is not so great as to drip upon the patient's face when the instrument is used. The hollow base of the cone is now placed so as closely to encircle the patient's mouth and nose. The anaesthetic is not to be used except just before and during a "pain," the pur- pose being not to cause unconsciousness, but to lessen or remove suffering while intelligence and will remain in full exercise. Anaesthetic inhalation is more frequently used in the second than in the first stage of labor. It may, however, be especially needed in the latter; for example, in the case of a primipara if the "pains" are unusually severe, and the os dilates very slowly, the new expe- rience wearies, weakens, and disheartens her, and great nervous irritability ensues; but now blunt the sharp edge of her suffering by an anaesthetic, and a happy change will often result in her mental and physical condition. In general, the indication for anaesthesia is great suffering, no matter whether this occur in the first or in the second stage of labor. Dr. J. C. Reeve, of Dayton, Ohio, whose name is so well known in connection with the subject of anaesthesia, states1 that "the periods of labor to which it is best adapted are two: when distention is greatest of the os, and of the vulva. The kind of labor where it does best is that in which energy of contractions is great, and expulsive force is in excess of dilatation." In all cases the practitioner will be guided by the effect of the anaesthetic, withholding, lessening, or increasing, as may be indi- cated ; he will never carry the anaesthesia so far as to suspend con- sciousness, unless during the birth of the head, and after it is born the use of the anaesthetic should stop. The bromide of ethyl as an obstetric anaesthetic has been warmly advocated by Montgomery, of Philadelphia, and Winckel states that the mixture of oxygen Private communication. THE CONDUCT OF LABOR. 421 and nitrous oxide (O=2o, N02=8o), proposed by Paul Bert, and first used by Klikowitsch, St. Petersburg, can be strongly recommended. Rarely, however, will the obstetrician employ any other anaesthetic than chloroform or ether. Relief of Pain by other means.—The administration of morphine, especially hypodermatically, is in some cases resorted to for the relief of very great suffering in childbirth, but usually in those in which the pain is a manifestation of some pathological condition, and very rarely in physiological labor. On the other hand, chloral is frequently used in normal labor, a few obstetricians regarding it as the best means for relieving pain. Chloral, though discovered by Liebig in 1832, was not used in medicine until 1869, when Liebrich showed some of its therapeutic properties. In December of the same year, the late Sir James Simpson1 gave it to a woman in labor, and he stated that while relieving pain it did not retard or weaken uterine contractions. Further study of the action of chloral in childbirth was made by Lambert ;2 its use was advocated by Kidd,3 and its indications were presented first by Pelissier4 and afterward by Play fair ;5 an elaborate paper upon the uses of chloral was published by Kane.6 Dr. Playfair regards chloral as peculiarly adapted to the first stage of labor, especially suitable in those cases in which the suffering is great, the os rigid and dilating very slowly or not at all. In his opinion nothing answers so well in cases of a rigid, undilatable cervix. He advises fifteen grains of chloral every twenty minutes until three doses are given, this generally sufficing; the patient becomes quite drowsy, dozes between the pains, and wakes up as each contrac- tion begins; it may be necessary to give a fourth dose at a longer interval, say an hour after the third, but rarely more than a drachm is required in the whole labor. Kleinwachter prefers chloral to all other anaesthetics ; he gives it in a dose of one gramme, or fifteen grains, every half hour until the suffering is relieved ; it has no injurious effect upon the fcetus, deep narcosis is unnecessary, and the activity of the pains is unaltered. If it cannot be taken by the mouth, equally good effects follow its injection in the rectum. Antipyrine has been used by several for the relief of suffering in labor, and cases in which the remedy succeeded have been reported. But the observations7 of Pinzani led him to conclude that the medicine relieves the pain solely by less- ening the force of uterine contractions: he found, also, that infants of women who had antipyrine in labor, were liable to suffer with diarrhoea. So, too, some cases of hypnotism in labor have been reported ; but considering how few can be hypnotized, and that women in labor are brought under hypnotism with greater difficulty than at other times, considering, too, the imperfect and the uncertain relief afforded, there are sufficient grounds, even if there were no other, for absolutely rejecting all attempts of the kind. Local Anaesthesia.—Friedlander8 states that called to a woman in labor who was suffering from intolerable pain in the sacral region, he relieved her after various other means had been vainly tried by the application of a mixture of chloroform and ether, one part of the former and two of the latter. He repeated the experiment in a great many other cases and found equally beneficial results. 1 Medical Times and Gazette, 1870. 2 Edinburgh Obstetrical Society's Transactions, vol. ii. 3 London Lancet, January 21, 1871. 4 Des Indications de l'Hydrate de Chloral, 1873. 5 London Lancet, February 21, 1874. 6 American Journal of Obstetrics, 1881. 7 British Medical Journal, March, 1889. 8 Deutsche Klinik, 1874. 422 SCIENCE AND ART OF OBSTETRICS. Doleris1 was the first to apply a solution of muriate of cocaine to the cervix and to the vulvar region in labor. He used a four per cent, solution, pencilling the surfaces with it; the experiment was tried on nine women, and the result was satisfactory in six—that is, there was a notable alleviation of the suffering; the application was begun when the os was dilated to about the size of a two- franc piece. The three patients who had no relief from the cocaine had been in the clinique for several days, and consequently had had several injections of corrosive sublimate, and he supposed that the retention of some of this salt in the vaginal culs-de-sac prevented action. The anaesthetic applied to the vulvar region just before the delivery of the head caused a remarkable diminution of the atrocious perineal pains without the progress of the labor being modified. The testimony of many others who have tried this means of alleviating the pains of childbirth is conflicting; nevertheless the majority of observers have found that more or less mitigation of the suffering results from the local use of cocaine. But the application must be made frequently, and the exposure of the parts will be very disagreeable to the patient, and probably is not without danger. Special Directions.—Prompt attendance is important when called to a case of labor, for though in most instances the call comes earlier than necessary, yet occasionally the presence of the obstetri- cian may enable him easily to correct an unfavorable presentation, which later may prove difficult or impossible, or arrest a dangerous hemorrhage, or ward off an attack of eclampsia. The following articles should be carried by the accoucheur: A stethoscope, a flexible catheter, muriated tincture of iron, a prepara- tion of ergot, a solution of morphine, or tablets for preparing such solution for hypodermatic use, and syringe, sulphuric ether, two or three long needles with silk, silkworm-gut, or properly prepared catgut, to be used if the perineum is torn, a silver female catheter, and if the patient lives at considerable distance, an obstetric forceps.2 If the patient has not already been provided with a fountain syringe, with an antiseptic solution, and an anaesthetic—chloroform, or ether, or a solution of chloral—the obstetrician should carry these too; on the other hand, if the anaesthetic selected be ether, and she has a supply, it will be unnecessary to include it in the list first men- tioned. Upon arrival, it is better that he should not immediately enter the patient's room, even if previously knowing her; especially if a stranger, and taking the place of her expected attendant, his coming should be first announced, for an abrupt entrance may have an unfavorable effect upon her. Admitted to her room, it is rarely necessary for him to make an immediate examination, or even at once to inquire as to her present condition; for a time at least, it is better for him to get his information indirectly, by observing the character of her pains, their frequency, regularity, and the apparent suffering they cause. Let him so guard his words and acts that no offence be given to woman's modesty, which is at once her ornament and defence. Physical suffering hushes the cry of shame, and until this occurs many a woman will shrink from a vaginal examination, especially if abruptly proposed. The obstetrician should be a gen- 1 Doleris made his report to the Paris Societe de Biologie, January, 1885. 2 The conservatism of Blundell did not permit taking instruments. " Lead not yourselves into temptation ; if you put your instruments into your pocket, they are very apt to slip out of your pockets into the uterus." THE CONDUCT OF LABOR. 423 tleman, gentle in his ways and words, and yet firm in conduct; he among all men must have the suaviter in modo as well as the fortiter in re. Two questions are to be decided by the professional attendant when in the presence of a patient supposed to be in labor. First, is she pregnant? second, has labor begun? A woman is very rarely deceived as to the fact of her own pregnancy, but occasionally she may have a false instead of a true pregnancy, and the physician must have the possibility of such occurrence in his mind. Provided the professional attendant does not already know, inquiry is made as to the date of the last menstruation, and as to that of "quickening; " so the question may be asked as to the premonitory symptoms of labor; if she has been previously confined, the character of the labor or labors should be ascertained. Next, inquiry may be directed as to her present condition, how long she has been sick, whether the "pains" are regular in recurrence, whether increasing in frequency and severity, and where they are felt; whether she has other suffer- ing than that of labor, headache, for example, and whether there have been recent and free discharges from the bladder and rectum. Examination in Labor with Index Finger of Right Hand, the Os Uteri just Opening. The necessity for an examination, if she does not already know it, is explained to her, and as a rule her consent is readily given. The physician retires from the room while the nurse makes the necessary preparations by arranging the person and the clothing of the patient. Very commonly upon his return, the woman will be found lying upon the side with the hips near the edge of the bed, this position being taken as less offensive to modesty. Though a vaginal ex- 424 SCIENCE AND ART OF OBSTETRICS. amination can, in most cases, be made more satisfactorily if the woman be in the dorsal position, and this position is essential for abdominal palpation, an immediate change need not be required, but after examining while she is lying upon the side, she may be requested to turn upon the back, and the exploration continued and completed. After the examination, external as well as in- ternal, the methods and purposes of which have been fully explained, and the physician finding a normal presentation with favorable posi- tion, vigorous and regular action of the uterus, and good condition of the birth-canal, he should frankly tell the woman and her friends that " everything is right," according to the stereotyped expression, or make some equivalent statement. Fig. 155. Examination in Labor with Two Fingers of the Left Hand, the Os Uteri more Dilated. Possibly the patient, after being informed of the favorable condi- tion of affairs, asks how soon the labor will be over. The question is sure to come sooner or later, and to be anxiously and wearily re- peated if the labor be long. Let the obstetrician beware of a positive answer, especially if it be the first stage of labor, and if a primipara, for the remorseless clock may contradict his prediction at the sac- rifice of all her hopes, and of her confidence in him. Velpeau remarked : The accoucheur who, in order to make a show of vain wisdom, thinks himself capable of telling exactly when the labor will terminate, not only exposes his ignorance or his bad faith, but he compromises the honor of his art and the safety THE CONDUCT OF LABOR. 425 of his patient. Gooch, referring to parturition in a primipara, said, " I am never fool enough to state any time within which the labor will be over." It sometimes happens that the first stage is brief and the second protracted ; or, again, the first unusually long and the second very short, and hence any answer as to the duration of the labor, founded upon the presentation and position, the primiparity or the multi- parity of the patient, the condition of the soft parts, the proportion between the presenting part and the birth-canal, derived from ob- serving the rate of progress in a definite time, can only be a prob- ability and an approximation to the truth, and should be so stated. Here, as in the general relations of physician and patient, the laws of truth must be observed, not that in all cases the patient is to be informed of any great peril that threatens her, but, on the other hand, let no falsehood ever be told her. Lying to patients, though the motive may be a kind one, never brings any good in the long run, and he who does it leads himself into temptation to be un- truthful upon other occasions, even if he does not forfeit his claim to be believed in all matters, and loses his own self-respect and also that of those who know him. It is well to explain to her, if this is her first experience, the dif- ferent stages of labor, the value of voluntary effort in the second, and its inutility and injury in the first period. Better, too, that she1 should know what she has to endure, and the greatness of her suf- fering be acknowledged, rather than treat it as being slight; and never endeavor to cheat her with false hopes and promises that will not be fulfilled. We are dealing with a rational being, and intelligent faith, will, and conscience are a stronger support in the endurance of great suffering than blind hope and unfulfilled predictions. Preparation of the Bed, and of the Patient's Person.—These duties are generally attended to by an intelligent nurse ; but sometimes the nurse is not intelligent, or the patient may be too poor to employ one, or the labor ends before her coming, and in such emergencies the practitioner must direct or make the necessary preparation of the bed. The bedstead should not be close to the wall, but accessible at each side; a firm mattress is laid upon it, and over the mattress a piece of rubber sheeting, oilcloth, or tarred paper to protect it from the patient's discharges, for these absorbed by it would cause both discomfort and danger. Above the pro- tective material an old quilt or comforter, first folded lengthwise, and then transversely, is placed on that part of the bed where the patient's hips will rest, and above this a sheet similarly folded. Now let a sheet be spread in the usual manner upon the bed, then folded from below above so that the fold will come higher than the 1 The great poetess of the century, Mrs. Browning, who knew from her own experience what the suffering of childbirth was, has thus described it: " I appeal To all who bear babes ! In the hour When the vail of the body we feel Rent round us, while torments reveal The motherhood's advent in power." 426 SCIENCE AND ART OF OBSTETRICS. quilt and sheet which have been put in place; this sheet is thus arranged that it may be protected from being soiled during labor, and after that has ended, and all wet clothes have been removed, it can be drawn down under the hips and to the foot of the bed, thus securing, with the least disturbance of her person, a dry, clean, and warm sheet to lie upon. Instead of the method just given, it is very common to have the under sheet extend over the rubber cloth to the foot of the bed, then upon this there will be placed a draw-sheet, made by folding a sheet four times in its length, and put upon that part of the bed where the patient's hips rest, and secured by safety pins. Rubber cloth now is placed so as completely to cover and protect the draw-sheet; next there may be laid upon the rubber a folded blanket, or comforter, and finally a sheet also folded. After the labor is over every article down to the draw-sheet is removed, and that is changed from day to day when it becomes soiled. In some parts of the country it is customary to prepare a large muslin sac and half fill it with bran, which is placed under the hips of the parturient, and readily absorbs all fluids that are discharged ; it is removed after the labor. When the patient lies down, in the second stage of labor, her chemise and nightdress should be drawn up above the hips, and a twice folded sheet pinned around the latter; this is far preferable to the skirt which is often worn at such a time, for the latter is not so easily removed, and its removal almost inevitably causes some soiling of the lower limbs. A piece of old carpet or of oilcloth is spread on the floor at that side of the bed upon which the patient lies. Management of the First Stage of Labor.—During this stage, the presentation being normal, and the general condition good, the patient ought not to be in bed; sitting, walking, or standing is more favorable for the entrance of the head into the pelvic cavity than lying; moreover, if she is up now, the necessary confinement to the bed in the second stage of labor will be less irksome. She may be encouraged to engage in some light occupation or in cheerful conversation so that the time will not drag, and her mind will in some degree be diverted from her suffering. Few per- sons should be in the room, and those only who are agreeable companions to her, and who will abstain from exciting her fears by the manifestation of great anxiety, by gloomy looks and untimely forebodings, or by narrating the misfortunes of other women in labor or in childbed. Her sympathies and her antipathies ought to be consulted in regard to those who are with her, and the obstetrician who knows how wisely to observe and judiciously to act, can often regulate this matter to the great benefit of the patient. Condition of Bladder and Rectum.—If these organs have not been recently, and cannot be spontaneously, emptied, artificial means most be used. It very seldom happens that there is urinary reten- tion, but accumulation of feces is common; the best means for the relief of the latter will be an enema of water, or of soap and water. Food, Drink.—Usually there is very little desire for food during labor, but if it be protracted the patient should take nourishment in THE CONDUCT OF LABOR. 427 some form lest she become exhausted; she may have any simple food she desires, care being taken that the stomach is not over- loaded. The most grateful drink will be cold water, and that may be taken freely. On the other hand, hot teas, so often in the country urged in domestic practice upon the parturient by injudicious friends with the purpose of" making the pains stronger," as well as alcoholic stimulants, ought to be forbidden. Active Interference with the Process of Dilatation.—There is a no- tion1 on the part of some women that the doctor can and ought to render important assistance in the physiological processes of child- birth by mechanical or other means. Some doctors, too, advocate and pursue this practice. Gillette, for example, upholds digital dilatation of the os uteri, a practice which Baudelocque censured the sages-femmes of his day for doing, and a practice which Dr. Robert Barnes speaks of as " old and bad." Dr. Gillette's method is described by him as follows :2 "An anaesthetic is administered to the obstetrical degree, that is, just to the ex- tent of dulling the pains; then during uterine contraction introduce two fingers into the os and expand them; or by hooking the forefingers on to the cervix make firm pressure, occasionally sweeping the finger around the whole cervical orbit." He believes that by following this plan he saves hours of agony to women, and avoids most of the dangers incident to protracted and powerless labor. Braithwaite3 advises, in a prolonged first stage of labor, however, dilatation with one or two fingers of each hand placed back to back, at intervals of a few min- utes, stretching the fingers apart, one moving backward, the other forward. The danger of septic infection by these dilatations, as well as those of the vulva, and by all unnecessary examination and manipulations, has been strongly pre- sented by Spiegelberg in considering the prophylaxis of puerperal septicaemia. " Care must be taken that labor go on as simply as possible; manipulations in the genital passages are to be made only when absolutely necessary. . . . Noth- ing is more objectionable and more repulsive than the almost incessant exploring and manipulating in the vagina, the os uteri, and the vulva, which most midwives are in the habit of doing when the labor does not progress as rapidly as they desire. . . . The danger in this for the puerpera cannot be too strongly em- phasized.'' In conclusion, the student may be assured that digital dilatation of the os uteri, or of the os vulvae, is rarely necessary, in most cases does no good, and in some may do much harm. Among the other means resorted to for shortening the first stage of labor may be mentioned the administration of ipecacuanha in an emetic dose, a practice which was never common, and which is now becoming almost unknown, and the application of belladonna to the cervix, or, as advised by Horton,' the injection of a solution of atropine into its substance. I can say nothing in favor of any of these means from personal experience, but in normal labor they are unnecessary. It sometimes happens, especially in a primipara, when the suffer- 1 Some years ago I saw a woman who had a torn cervix and perineum, and she explained her condition as resulting from the fact that " the doctor opened '' her " up too much " when she gave birth to her child. 1 Transactions of the American Gynecological Society, vol. vii. 3 London Obstetrical Society's Transactions, vol. xxi. 4 American Journal of Obstetrics, 1878. 428 SCIENCE AND ART OF OBSTETRICS. ing is very great, if chloral or anaesthetic inhalation is not used, a hypodermatic of a solution of morphine has both a general and local favorable effect. Presence of the Physician.—It is not advisable for the physician to remain constantly in the room during the first stage of labor; an occasional absence gives the patient an opportunity to evacuate the bladder, to make changes in her clothing, or attend to other matters which might be prevented by his presence. Further, if he constantly stays in the room she may anticipate a speedier termina- tion of her labor than is possible, or she may think her condition serious; beside this, he may be appealed to by her or by her friends to render some supposed assistance, which may be very injudicious or even injurious. In many cases it is not necessary for him even to remain in the house, and he may. take the opportunity to visit other patients; but it should always be known where he can be found, if any emergency arise demanding his immediate presence. A physician may exhaust his strength by too constant attendance, and too assiduous attention during the first stage of labor, and by denying himself needed sleep, so that when some serious difficulty arises in the second or third stage, he may lack the clear head, the firm hand, and the physical endurance upon which the salvation of his patient or of her child rests. Management of the Second Stage of Labor.—The uterine contrac- tions are reinforced by voluntary efforts, and the first usually passes into the second stage of labor by a gradual transition. The patient now goes to bed, her clothing being arranged as has been men- tioned, but if a primipara, or if the labor be slow, it is not necessary for her to remain constantly lying down; occasional sitting up, or taking a few turns in the room, will give her some rest, and also may hasten delivery. At the beginning of this stage the bag of waters usually ruptures; if it does not then, or soon after, it is advisable to rupture it, and this may generally be done by pressing the finger firmly against it during a uterine contraction; if such pressure does not succeed, a few notches may be cut in the finger-nail, making a saw of it, which may then be thus used against the tense membranes. Immediately after the escape of the amnial liquor, a vaginal examination must be made, in order to confirm, in some instances possibly to correct, the diagnosis of presentation and position that has been made, or to make this diagnosis if it has hitherto been impossible, and to ascertain any change of position, or any increase in descent of the presenting part, which in a multipara may sometimes become very rapid immediately after the evacuation of the fluid; so, too, this examination is now necessary, in order to ascertain whether prolapse of the cord, or of one of the upper or lower limbs, has occurred. Position of the Patient.—It varies in different countries, but with us she usually lies upon the back, or upon the left side. Until the head rests upon the pelvic floor the most favorable position during a pain is one between sitting and lying, the feet pressed against a firm object, or the bent knees fixed by the pressure of the hands of THE CONDUCT OF LABOR. 429 one of the attendants, the upper portion of the trunk drawn forward by the patient grasping the hands of the nurse or a sheet or towel fastened to the lower part of the bed for this purpose, and the chin turned to the chest. A kneeling1 or squatting position is the most favorable for the expulsion of the child, but the child maybe injured, the perineum cannot be protected, the liability to hemorrhage is greater, and it is impossible to manage properly the third stage of labor, as well as difficult to put the patient in bed. When lying upon the left side the usual right obliquity of the uterus is corrected, and in this regard the uterine force acts more advantageously; the abdominal pressure, however, is less, and the general force is directed too much in the direction of the axis of the inlet—that is, toward the fundus of the pelvic cylinder—whereas the line of exit for the fcetus is nearly at a right angle to that of entrance. Many women prefer the side position because of the relief to pain in the back which firm pressure of the hand upon the sacrum gives; such pressure, of course, cannot be made when the patient lies on her back. Schroder has proved that rupture of the perineum is more frequent in women delivered upon the back than in those delivered upon the side, and therefore the latter position should be taken in all cases in which there is danger of such rupture, as soon as the head begins to press upon the pelvic floor. In this position too, visual examination of the perineum, should it be necessary, is possible. Condition of the Child.—Occasional inquiry may be made of the patient as to her being conscious of the movements of the child. But a more certain way of learning its condition, either in the first or second stage of labor, is by auscultation. The first indication2 of the suffering of the child is shown by a greater rapidity of the car- diac pulsations; then, if this state continues, to the acceleration which appears at first there succeeds a slowing, which becomes more and more decided as the fcetal life is more and more compromised. At the same time that these variations are observed and irregularities are produced, the intensity of the bruits lessens. Whenever, says Depaul, the cardiac pulsations fall below 100, and especially below 80, the condition is a very serious one, and if possible the accoucheur ought to intervene and end the labor. Condition of the Os Uteri.—As has been stated, the rule is that in the first stage of labor attempts to dilate the os uteri by the fingers should not be made; so, too, they are usually not required in the second stage. But as it sometimes happens that in the former the force of the uterine contractions is in part lost in consequence of the os being directed too far posteriorly and to the side, and it may be then advantageous to hook the fingers into the os during the absence of a pain, and draw it toward the centre of the pelvic cavity, keeping it in this position during a contraction, so in the second stage the anterior margin of the os may be found closely applied to the fcetal head while the posterior has receded, hence liberation of 1 Kleinwachter. 2 Depaul, op. cit. 430 • SCIENCE AND ART OF OBSTETRICS. the former is indicated. The part of the fetal head in front descends at each contraction, hooded by the anterior portion of the dilated cervix, and this portion thus compressed between the head of the fcetus and the pelvic wall is liable to become swelled and cedema- tous.. Therefore, by the advice of the most conservative obstetri- cians, this part may be pressed up, in the intervals of contractions, by one or two fingers, and thus held during a uterine effort; some- times the head immediately passes the obstruction, but in others it may be necessary once or oftener to repeat the proceeding. Let it be remembered that this manoeuvre, which is seldom necessary, must be done without violence. Cramps in the Lower Limbs.—Cramps affecting the thighs or legs sometimes cause great suffering; they occur in the second rather than in the first stage of labor, and are attributed to pressure and dragging upon certain nerves of the pelvis, branches of the sacral plexus, the sciatic, the obturator, etc. Rubbing the affected part with the hand, change of position, or the use of an anaesthetic will give relief. Food, Drink, etc. Preparation for Delivery.—Unless the second stage be unusually long the patient rarely desires or needs nourish- ment; a full stomach will hinder the needed voluntary effort during a uterine contraction ; if food is given, only a small quantity is advisable, and it should be simple and easily digested. Now, as then, cold water may be taken as desired. Frequently bathing the patient's hands and face with cool water will in most cases be both agreeable and refreshing. When the second stage approaches its end, hot and cold water, an alcoholic stimulant, scissors, and a string for tying the cord are to be at hand. Pressure of the head upon the rectum often causes a factitious desire to empty the bowels, and the patient insists upon getting up for this purpose; but she must be refused, for the child might be born while she was on the commode or in the water-closet. Care of the Perineum.—Usually the most important of the ob- stetrician's active duties in the second stage of labor is protection of the perineum from being torn during the delivery of the head and shoulders of the foetus, or, if a tear is inevitable, cause that to be as slight as possible. Matthews Duncan and Schroder have shown that in primiparae some tearing of the vaginal orifice is inevitable, and the rent may involve the perineum, only 39 per cent., according to the latter, escaping rupture of the fourchette. Not only injury of the posterior portion of the vulva, but also of its anterior may occur, and the rents in some cases cause serious hemorrhage. The perineum is especially liable to tear from the direction of the force which propels the child through the birth-canal; it is a resisting wall designed to direct the fcetus toward the opening in the anterior portion of the dynamic pelvis. When the perineum gives way, the rent generally occurs in the median line, for there the distention is greatest and the tissues are furthest from their points of attachment. THE CONDUCT OF LABOR. 431 Even if the perineum receives no injury immediately apparent, it may have been subjected to pressure for so long a time and been so greatly stretched that, though entire for some days after delivery, it finally gives way, and the condition is then similar to laceration. Hibberd1 has reported two cases of the kind, and Duncan2 pre- viously directed attention to the fact, but a case of such injury was first described by Dewees.3 Frequency of Ruptures of the Perineum.—Taking hospital statistics rather than any derived from private practice, it is probable that the perineum is torn more or less in 20 to 30 per cent, of primiparae, and in 5 to 10 per cent, of multiparas. Causes.—Without referring to special conditions of the parts creating a liability to the accident, or the form of the pelvis, or cer- tain presentations and positions, it may be in general stated that the great majority of perineal tears occur from too rapid deliveries, the child being expelled before there is sufficient dilatation of the vulvo- vaginal opening; the force is too great, and the time too short, so that soft parts are not stretched but ruptured. Prevention.—It follows from the statement just made that, to pre- vent a tear of the perineum, or.to make the tear as slight as possible if some injury be inevitable, the most important means are to hinder abrupt expulsion of the fcetus, and to promote gradual dilatation of the part it traverses. In attaining these objects one of the first things to be done is to have the patient lie upon her side, preferably the left side. The advantages of the lateral position are lessened voluntary effort, preventing the wide separation of the thighs, and in this position the condition of the perineum may be known, if necessary, by actual inspection. There must be no pressure against her knees, and any object against which her feet may push, should be removed; she should be directed to take frequent respirations, and to refrain from all bearing-down efforts; if such efforts cannot be thus prevented, chloroform may be given. A doubled pillow or a quilt made into a roll is placed between her knees. If the.dilata- tion of the vulvar opening be insufficient the head must be held back by direct pressure, and, when it is finally expelled, it should be guided during the expulsion in the axis of the opening. Hohl directed grasping the head, after the occiput has passed under the pubic joint, with the hand, the thumb above,- the fingers below reaching to the anterior margin of the perineum, and thus holding the head back during a pain. Others apply pressure to the head with one hand, while the other is used to support the perineum.* Supporting the perineum is, as Matthews Duncan has remarked, a practice upheld by the majority of obstetricians, both now and in past times. In many cases the condition of the perineum as to ready dilata- bility is such, the expulsive force acts so regularly and moderately, 1 American Practitioner, 1881. 2 Papers on the Female Perineum, 1879. :' System of Midwifery, eighth edition, p. 287, 1837. 4 In the former edition I gave various means for saving the perineum advised by different authorities, Siebold, Bernati, Ritgen, Smellie, Goodell, Reamy, Price and others, but omit them in this. 432 SCIENCE AND ART OF OBSTETRICS. and the relation of the object to be expelled is so adapted to the outlet of the birth-canal, that there is no danger of injury, and there- fore no effort should be made to support it; the obstetrician's only duty then is to receive in his hand the head of the child as it is ex- pelled. But in other cases the following plan may be followed : Sup- posing the patient to be lying upon her left side, and her hips quite near the edge of the bed, the practitioner places his right hand so that the concave palm receives the convexity formed by the bulging perineum ; the thumb is upon the right, and the four fingers upon the left labium majus, while the fold between the thumb and index finger corresponds with the anterior margin of the perineum. Moderate resistance is made to the force driving the head against the perineum, and at the same time the head is gently pressed toward the pubic symphysis; strong pressure is to be avoided, because if the perineum be very thin, such pressure at this thinned part may cause a central tear. No napkin should be interposed between the hand and the perineum ; the hand is not applied until perineal distention begins, and the application is only during a pain. The left hand is passed over the patient's upper thigh, and grasps the fcetal head in the manner directed by Hohl, holding it back when necessary, and at the proper time guiding its exit in the axis of the vulvar orifice. Fig. 156. Head about to Pass the Vulvar Opening. A clearer understanding of the mechanism of perineal tears, and of their prevention, will be had by examining the subjoined diagram taken from Varnier, and in connection with it the sub-occipital diameters as shown in Figure 96. In Figure 156 it will be seen that the parietal protuberances have just cleared, or are about clear- ing, the vulvar ring, and that the sub-occipito-bregmatic diameter lies directly antero-posteriorly. But in order that the head may be born a longer diameter and consequently a larger circumference must be in relation with the ring; this change, as has hitherto been THE CONDUCT OF LABOR. 433 generally taught, occurs by a partial rotation of the head, the beginning of deflexion, or as taught by Berry Hart—his views will be more fully presented in a moment—by a progression, and thus there is not even the least deflexion of the head, no pivot- ing of a fixed point of the nucha upon the pubic joint. But with- out reference to either view just given, the danger of perineal rupture comes with the rapid advance of the head before retrac- tion of the perineum can occur, for the perineum does not need to be elongated at this stage—elongation means delay or rupture, length is not required but breadth; its own elasticity determines retraction, and in the retraction diminished length gives increased breadth. By moderating abdominal and uterine action, and by retarding the abrupt exit of the head, letting the perineum withdraw from the head rather than the latter advance from the former, we best preserve it from injury. If this view be correct then many of the methods advised for protecting the perineum are useless, and some are most unnatural and mischievous, proceedings that thwart rather than assist nature's method. Give the perineum time to draw back when the greatest strain upon the vulvar opening comes, and it can be better protected than in any other way. Support of the perineum must be continued during the passage of the shoulders lest a new rent be made, or a slight one caused by the expulsion of the head be increased. Hart denies1 that the chin leaves the sternum while passing the perineum, and that during the anterior fixation of the occiput under the pubic arch, antero-pos- terior and increasing diameters of the fcetal head form the antero-posterior diame- ters of the girdle of resistance. His method of'' protecting the perineum from undue tear" is this : " All the attendant can do, apart from the familiar means of relaxing perineal spasm by chloroform and hot applications, is to prevent the sinciput being forced down in advance of, or faster than the occiput. He restrains the fcetal head from passing too rapidly. He thus has always to get the occiput to lead, and to get it fully born if possible. So far as I can judge the best way of doing this is as follows : With the patient lying, of course, upon her left side, the attendant places the thumb of his right hand, guarded by a napkin soaked in hot sublimate, in frorit of the anus and presses it gently there. The pressure is not in the direction of a line joining his thumb and the pubic arch, but nearly in that of the pelvic outlet. By this, descent of the sinciput is hindered, and that of the occiput favored. When the latter is beginning to pass under the pubic arch, the fingers of the same hand are placed between it and the apex of the arch, so that when the occiput has cleared the arch the fingers are passed toward the nape of the neck, and the head thus grasped in the hand, the thumb lying over the ' sagittal suture. This gives one complete command over the head which is now engaging in the diameters between the nape of the neck, and forehead and face, and allows the whole passage with as little tear as possible." Episiotomy.—If a serious tear of the perineum seems inevitable, many advise that an incision or incisions be made to prevent this 1 Edinburgh Obstetrical Society's Transactions, vol. xii. It must be conceded that extension is impossible while the perineal band is stretched over the frontal bone—that band must hold the chin upon the sternum ; but once the forehead clears the perineal margin, or, which amounts to the same thing, the perineum retracts over the forehead, extension can begin—very slight indeed at first, but increasing until the head completely emerges, its perfect delivery being fol- lowed by a dropping down of the head, a return of partial flexion, which would be impossible if there had not been some extension. 28 434 SCIENCE AND ART OF OBSTETRICS. accident. This practice, though generally credited to Michaelis, 1810, was recommended by Ould1 1742. Opinions differ as to the necessity for incisions, and also on the part of those who approve of the operation as to where they should be made. The late Dr. A. H. McClintock stated that he had so often seen the perineum escape laceration where this accident seemed inevitable, he was led to doubt the possibility of recog- nizing the cases in which incision is an absolute necessity. Playfair asserts that when a distended perineum ruptures, its structures are so thinned that the tear is always linear; and, as a matter of fact, the edges of the wound are always as clean and as closely in apposition as if the cut had been made with a knife. This statement maybe received with some doubt, even by those who have never ex- amined a recent tear of the perineum. The incisions usually recommended are lateral. Tarnier, however, states that they do not always prevent even quite extensive tears, and they may leave de- formity and a painful cicatrix, or the duct of one of the vulvo-vaginal glands may be divided, and a fistula result. He therefore advises an incision of the perineum, beginning at the raphe, and then not passing directly back, but turning obliquely to one side, so that if a laceration follow, it cannot involve the same sphincter. He cautions again episiotomy, unless it is quite indispensable, for he has some- times seen the incised parts covered with eschars, and become the medium of grave infectious accidents. Delore, in referring to the lateral incisions advised by Dubois, states that he accepts in extreme cases this slight operation, but in ordinary cases it is prefera- ble to have a median rent, which cicatrizes uniformly, than two lateral ones which result in deformed cicatrices. It may be stated that episiotomy will very seldom be plainly indicated, and in private practice will rarely be done. Dr. Broomall2 regards episiotomy as a safe and justifiable procedure, when the perineum is threatened, and where the danger of deep laceration is evident, as the proper and indispensable means to be used with the hope of meeting that danger. She advises a probe-pointed curved bistoury to be used; the blade is slipped between the fcetal head and the lateral margin of the vaginal orifice, and its cutting edge directed during a pain toward the tuber ischii; the incision is made at a point one-third the distance from the posterior commissure to the clitoris; the length of the incision never exceeded 1.5 centimetres. A similar incision is made, if necessary, at the opposite side; after the labor, the edges of the wounds are united by silk sutures. Dr. Manton3 strongly advocates epis- iotomy, claiming that it diminishes the frequency of perineal ruptures to a minimum. He also operates with a probe-pointed bistoury, and makes an incision from 1 to 3 centimetres long, first on one, and then, if necessary, on the other side; he thinks it better not to to include the external skin in the incision, although no harm is done should this be done. Delivery of the Shoulders.—Immediately after the head is expelled and rests in the hand of the accoucheur, a finger is passed to the neck of the child to find if the cord encircles it, an accident occurring once in five cases; if this be the case, the loop must be 1 " It sometimes happens, though the Labour has succeeded so well that the Head of the Child has made its Way through the Bones of the Pelvis, that it cannot however come forward, by reason of the Extraordinary Constriction of the external Orifice of the Vagina; so that the Head, after it has passed the Bones, thrusts the Flesh and Integuments before it, as if it were contained in a Purse ; in which Condition if it continues long, the Labour will become dangerous, by the Orifice of the Womb contracting about the Child's Neck ; wherefore it must be dilated if possible by the Fingers, and forced over the Child's Head ; if this cannot be accomplished. there must be an Incision made toward the Anus with a Pair of crooked Probe-Sizars; intro- ducing one Blade between the Head and Vagina, as far as shall be thought necessary for the present Purpose, and the Business is done at one Pinch, by which the whole Body will easily come forth."—A Treatise on Midwifery. By Fielding Ould, Man-Midwife. Dublin, 1742. Ould also advised stitching the wound if the incision be made so near the "-Rectum as to weaken its Contraction." 2 American Journal of Obstetrics, 1878. s Ibid, 1885. THE CONDUCT OF LABOR. 435 enlarged, and an attempt made to draw it over the head ; if this fails, the shoulders are to be delivered through the loop. In some cases the cord encircles the neck not only once but even three or four times, and the coils may be so tight that dividing the cord is necessary; if this be done, it is advisable, unless the fcetus is imme- diately delivered, to tie each end of the severed cord. Moderate pressure is made upon the patient's abdomen during the expulsion of the body, the hand so placed that it " follows down " the uterus as it descends with the discharge of its contents, in the abdominal cavity. The shoulders are usually delivered soon after the head, any delay can generally be remedied by moderate manual pressure or friction of the uterus through the abdominal wall; it may be advisable in some cases to turn the head of the foetus with the occiput toward the mother's left or right thigh, according as the position was left occipital, or right occipital, thus having the ex- ternal rotation of the head invite and correspond with the internal rotation of the shoulders; then let the head, still held in the hand, drop down so that slight traction is exercised upon the anterior shoulder, which may be thus liberated. After the anterior shoulder comes in the pubic arch, the head is to be carried up toward the mons veneris, slight traction being made, when the posterior shoulder will be delivered; the injunction is repeated, during the delivery care must be taken that the perineum escapes injury. Difficult Delivery of the Shoulders.—In some cases, however, the delivery of the shoulders cannot be thus accomplished ; the body is very large, and the fcetal circumference of the shoulders and chest much greater than usual, while the vis a tergo, the uterine and abdominal contraction may fail. The difficulty may be increased by the child's breathing, for thereby the circumference of the chest is increased. Danger comes to the child from compression of the chest, or of the cord, which may encircle the body, and death is inevitable unless speedy delivery can be effected. One of the ways which may be quickly tried, is to exert traction with the hands applied to the sides of the child's head. Even if we cannot com- plete the delivery of the shoulders in this way, we may advance it so far that a finger can be readily introduced into the axilla of the perineal shoulder, and then pull with this finger; or traction may be made with the fingers in each axilla. Jacquemier, who gave special study to this difficulty in labor, and found that in 26 cases, 20 of the children died,1 advised bringing down the arms, upon which trac- tion can be made, and beside, when they are disengaged the size of the chest is lessened. Although the practice is endorsed by Charpentier, he acknowledges that in one case he fractured the humerus ; if there be room for this manipula- tion, there is room, as Spiegelberg taught, for delivery by other methods, and it may be rejected. Hodge advised pushing the anterior shoulder in behind the pubic joint, then bringing the neck of the child in the pubic arch, so that its side presses against the subpubic ligament; by this means the posterior shoulder is brought to the margin of the perineum ; when such change has been effected, the head is carried backward, and the anterior shoulder again comes just outside the pubic arch, and delivery is usually easily effected. This plan was also advised by Spiegelberg. Occasionally it may be necessary to use a blunt hook, instead of the finger, to exert traction from the axilla ; one must be careful, however, not to act upon the humerus on account of risk of detachment of the epiphysis ; 1 I have met with this hindrance to delivery in three cases in which the child could not be extracted soon enough to prevent death. The method advised by Hodge and Spiegelberg I think the best. In some instances the delivery is impossible until the size of the chest is lessened. 436 SCIENCE AND ART OF OBSTETRICS. after either traction by finger or blunt hook, temporary paralysis of the arm mav occur. Of course the patient should be urged to " bear down," and uterine action stimulated by friction and assisted by external abdominal pressure. Delivery of the Rest of the Body.—After the delivery of the shoulders the remaining portion of the body is in general very promptly ex- pelled ; but if it is not, and immediate delivery is necessary, the hands should grasp the thorax, and with gentle traction the process is completed. It is very much better, however, in most cases, to trust the expulsion of the child to the uterus. Attention to the Child.—The child is laid upon the bed at the side, not so near that by any sudden movement it may roll off, and not so far from the mother that there is any dragging upon the cord ; it is placed where it can get air, and in a position in which it will not be bathed in the fluids that often make a pool about the mother's hips. It usually at once breathes freely and cries vigor- ously; if respiration be hindered by accumulation of mucus in its mouth, the secretion must be wiped away by the finger covered with a little soft muslin. In case respiratory efforts are feeble or absent, they generally may be quickened or excited by dashing one or two teaspoonfuls of cold water upon the chest, or friction of the chest may be made by the obstetrician with one of his hands upon which a small quantity of spirits of camphor has been poured. It was the custom of Mauriceau, Clement, La Motte, and Deventer, indeed, of the old1 obstetricians generally, not to tie the cord until the placenta was expelled ; Zweifel has revived this practice, and he uses but a single ligature. Most obstetricians, however, are in the habit of ligating the cord as soon as the child breathes freely. Some experiments, made by Budin2 in 1875, in immediate and late ligation of the cord, proved that when the latter plan was followed the infant received a large quantity of blood, the average was 92 grammes, and thus immediate ligation deprived the infant of this. In March, 1885, he stated that almost all contribu- tions to the subject, published in different countries, confirm the general conclu- sion which he had previously reached, viz., ligation and section of the cord should not be done until after complete cessation of the vascular pulsations of the cord. Not merely is the child by late ligation secured a notable amount of blood other- wise left in the placenta, but its subsequent condition is more favorable, it loses less weight in the first days following birth, and acquires weight more rapidly than a child in whose case immediate ligation was done. These were the con- clusions not only of Budin, but also of Ribemont, Schiicking, Zweifel, and of most who investigated the subject. The matter has been studied anew by Engel.* He observed that the pulsations in the cord continue for some minutes, or even for a quarter of an hour, after birth. He found that late ligation secured to infants born at term 70 grammes, but to premature infants 90 grammes. Engel failed to discover any relation between loss of weight in the first days after birth, but his statistics prove that late ligation secures increased vitality to the infants. Thus the mortality of premature infants when immediate ligation was done was 18.88 per cent., but with late ligation only 9.45 per cent. The causes of the increased quantity of blood entering the fcetus are thoracic aspiration and uterine pressure. In regard to waiting until all pulsation has ceased, one might, in some cases, 1 Denman, without reference to the expulsion of the placenta, stated that " the navel-string of a newborn infant ought not to be tied or divided, till the circulation in it has ceased spon- taneously.1' 2 Obstetrique et Gynecologie, Paris, 1886. » Centralblatt fur Gynakol., 1885. THE CONDUCT OF LABOR. 437 wait until all patience as well as pulsation had ceased; for example, La Motte1 mentions going to a woman who had been -delivered trois grosses heures before his arrival; the child was lying between the mother's thighs, the placenta unde- livered, and "the beating of the cord was of a marvellous force." It is not necessary nor advisable to make an absolute rule that pulsation must cease before tying; when the child cries vigorously, breathes freely and the pulsation lessens in force, one need not wait. Various material has been used for tying the cord. The late Dr. Bedford preferred tape, believing that if a round string was used the child was more liable to trismus. Dickson2 first advised the elastic ligature, and Tarnier uses it in addition to the ordinary one. A few strands of hemp thread answer the purpose very well; but my pref- erence is for the Chinese silk used in tying the pedicle in ovari- otomy, for it is strong, and a tight knot can be made without any danger of either cutting the cord or the obstetrician's fingers. Whatever is used, it ought not to be so thin as to risk cutting the cord, or cutting the physician's fingers when he is drawing the knot. The ligature is placed about three fingers' breadth from the umbil- icus; the string or tape is passed under the cord, the ends brought above and tied, gradually and firmly compressing the cord so as to force away at the place of constriction the gelatinous portion, with a surgeon's knot, and then a single knot. The cord should be tied again at a distance of two inches from the first ligature and toward the placenta. The reasons3 for the additional ligature are, first, cleanliness, and, second, it is very probable that a placenta when only partially emptied of blood is more easily detached by uterine retraction than one which is flaccid, and hence which can more readily follow the lessened size of the uterus and diminished sur- face of attachment without separation. In plural pregnancy the second ligature is required because of the possible vascular connec- tion between the circulation of the two foetuses in the placenta. After ligation the cord is divided between the two ligatures, care being taken to leave a large button-like projection at the fcetal por- tion especially, so that the ligature cannot slip off; blunt-ended scissors are best for making this section, and the obstetrician must be watchful lest a finger or some other part of the fcetus be included with the cord between the blades. After the section press a soft rag upon the cut surface to dry it, and then watch for a minute or two to see if there be any oozing of blood; if there be, another ligature must be immediately applied. The obstetrician now hands the child to the nurse, who has a small blanket or shawl, which has been warmed for its reception. In handing it to her he either places the right hand under the shoulders, the thumb and index finger supporting the head, and the left hand holding the ankles; or, as taught by Dr. Hodge, he em- 1 Observation ccxxx. 2 Proceedings of Edinburgh Obstetrical Society, January 14, 1874. 3 Auvard places the second ligature close to the vulva, so that by its advance the process of placental detachment and discharge can be noted: others seek the same end by applying a third ligature at the point mentioned. 438 SCIENCE AND ART OF OBSTETRICS. braces the thorax of the infant with the right hand extended so that the palm is over the sternum, the thumb under the right axilla, and the fingers under the left, and the head falls toward the sternum; this is a natural position for the child, the practitioner has a firm hold, and the left hand is left free for any required assistance. Trivial as these directions may seem to the student, yet in practice he will find that attention to the little things has much to do with the obstetrician's success. Washing the Child and Dressing the Cord.—Though washing the infant and dressing the cord are usually done by the nurse, yet occasionally one or both of these duties may devolve upon the doctor, and even if this be not the case, he ought to know how they are best done. There are needed for the washing, a soft sponge, a piece of old linen or cotton cloth, water at a temperature of 900 to 960 F., some oily substance, such as unsalted butter, lard, sweet oil, or vaseline—or, instead of any of these, the yelk of a fresh egg—and Castile or some one of the finer soaps, transparent glycerine soap is good. The oily matter, or the egg-yelk, is used for the purpose of facilitating the removal of the vernix caseosa, and the body of the child is first rubbed with one of these substances. The face is now- washed with warm water simply, no soap being used, lest some of the soapy water should get into the infant's eyes, causing pain, and possibly a conjunctival irritation which may result in inflamma- tion ; children of a larger growth will strenuously object to soap- water for washing their eyes, and let the infant be treated as kindly. After washing and drying the face, the body and limbs are washed with soap and water, and well dried; the washing of course must be done in a warm room, quickly, avoiding prolonged or unnecessary exposure of the child, and with gentleness, care being taken not to irritate the sensitive skin by rude rubbing, even though some portion of the vernix caseosa may remain, for it will dry up in a day or two, and be spontaneously detached, or can be removed at a subsequent washing. After drying the infant, powdered starch is dusted over the surface, especially at the flexures of the knees, thighs, and elbows, and in the axillae. If the mother has had a purulent vaginal discharge, even if there is any suspicion of her having had a specific vaginitis, the child's eyes having been first carefully washed with warm water, should have applied to them a drop or two of a 2-grain solution of nitrate of silver. The common method of dressing the cord is this : A square piece of old linen, a little more than twice the length of the attached cord, is slightly scorched, a hole cut in its centre, and mutton suet put upon its under surface; the cord is passed through the hole, then the linen folded first transversely, and afterward from side to side, over the cord so that the latter is completely wrapped. Iodoform or creolin gauze may be used for wrapping the cord, absorbent cotton or cotton wool is objectionable because the drying of the cord cannot, when thus covered, occur so readily. Goodell advised squeezing out Wharton's jelly from the cord, and this certainly THE CONDUCT OF LABOR. 439 seems to me best. When the duty of caring for the cord devolves upon the practitioner, he may pursue the following plan: Let him take a piece of soft cotton rag, place it upon the cord, and grasp the latter just below where it has been tied with the thumb and the fingers of the left hand ; now cut off the cord at the point of ligation, and then squeeze out all of Wharton's jelly upon the rag, and in a minute or two the cord is reduced to half its former size, and instead of being a solid cylinder, is a limp, ribbon-like body. A new ligature is now applied, and bleeding is impossible. A little iodoform or salicylic acid may be sprinkled upon the cord, and then it may be encircled with a few turns of a linen or muslin bandage, an inch to an inch and a half in width, which is fastened by a silk or hemp thread tied around it; no subsequent dressing is needed; the cord and bandage will fall off together in a few days. The advantages of this plan are the comfort of the child, absolute security from hemorrhage, and the lessened mass to be detached. Dressing the Child.—The "belly band," which is almost universally used, should not be tight, for the increase in pulmonary capacity in the newborn is chiefly due to descent of the diaphragm, and the bandage should be sufficiently loose to allow for this increase; a bandage that is loose immediately after birth, may often after a few hours cause injurious compression; it will be the duty of the ob- stetrician to see that no mistake is made in this matter. The fewer pins used in fastening the clothing of the infant the better, and as far as possible tapes should replace them. Apparent Death in the Newborn.—The infant may be born ap- parently dead; it utters no cry, makes no movements, there is no pulsation or only a feeble pulsation in the umbilical cord, and it may be impossible either by the ear or by the finger to detect any beating of the heart. Yet the child may not be really, only appar- ently dead, and its life is in the hand of the physician. Two forms of asphyxia may occur in the newborn, which from the appearance presented by the latter have been distinguished as pale and livid; the former has been termed an anaemic, and the latter an apoplectic condition. The first, which is the most serious form, is characterized by general pallor of the skin, the child is "pale as baby carved in stone; " but it is far from having anything like the rigidity of stone ; the lower jaw drops, and the mouth is open; the limbs are relaxed and limp, and the body is without firmness, taking such shape as may be impressed upon it by external causes. In the second the child's skin is a dusky red, sometimes purplish, the color being most marked upon the face and the upper part of the trunk; the lips are swelled and dark; the limbs are not flaccid, but may be even some- what rigid; the body as to its external portion seems to have an excess of blood; contrary to that which is observed in the first case, the cord is large and its vessels are full of blood. The causes of the first form of asphyxia have been divided by Depaul into general or constitutional, and accidental. Among the first is premature birth, or a want of sufficient nourishment from dis- ease of the placenta, for there are changes in this organ which pro- 440 SCIENCE AND ART OF OBSTETRICS. duce a sort of progressive inanition which does not kill, but the child is born thin, emaciated, and feeble. Among accidental causes are compression of the cord, or rupture, tearing of the placenta, or its premature detachment. The principal conditions which produce livid asphyxia are prolongation of labor after rupture of the mem- branes, and uterine contractions more or less continuous in char- acter, such as result from the untimely administration of ergot. Depaul regarded obstruction of the respiratory passages as a cause of each form of asphyxia; such obstruction is the result of efforts at inspiration where the life of the infant is endangered during labor, for then there are introduced, with a variable quantity of air, according as more or less has entered the uterus, into the trachea and bronchi blood, mucus, and amnial fluid usually mixed with meconium. Treatment.—In pale asphyxia the infant needs all the blood it can get, at least none must be taken from it; possibly uterine pressure may add some, though thoracic aspiration invites none ; for securing more blood, Depaul advised forcing it from the accessible portion of the cord toward the umbilicus. But without any great delay the cord should be tied, then the child plunged into a hot bath, and a little cold water poured from a height upon the epigastrium. Next the surface is quickly dried with warm flannels, and friction made over the chest and along the spine, and the soles of the feet rubbed; if contraction of the toes is made in response to the irritation of the feet, there is hope that resuscitation will be effected. Irritation of the fauces with a feather is sometimes successful in exciting respira- tion. But these means failing, and not more than ten minutes should be given to their trial, artificial respiration must be tried. As the methods are the same in the two forms of asphyxia, it will be better before describing them to state the special treatment required in the livid or apoplectic variety before resorting to it. The cord is to be divided, and two or three teaspoonfuls of blood allowed to flow before it is tied;' this treatment is rejected by Champneys, but it is endorsed by some of the best obstetric authorities, and in some cases is followed by prompt improvement in the child's condition, its livid hue lessening, and efforts at respiration occurring almost immediately after the loss of blood. Any collection of mucus or other matter in the fauces or air-passages, both in this and in pale asphyxia, should be removed. This can be done in the former by the finger covered with soft linen, the child being placed upon its back, and the head raised. Depaul was in the habit of using his laryngeal tube, aspiring with his mouth fluids which might be in the trachea. Champneys advises the following plan : If there is great accumulation of mucus in the air-passages, a No. 9 gum-elastic male catheter should be introduced into the trachea, so that the point is three and a half inches from the lips. This length will secure its passing through the glot- tis, but not so far as the bifurcation of the trachea. Press the thorax gently with one hand to prevent the entrance of air, and blow through the catheter. The open- Respiration in Stillbirth, American Journal of the Medical Sciences, April, 1886. THE CONDUCT OF LABOR. 441 ing being low down in the trachea, the air and mucus with it being unable to pass into the lungs on account of its compression by the hand, will rush up through the glottis, and the mucus will be blown into the pharynx. This can be repeated as often as necessary, the general tendency of fluids in the air-tubes being to ascend during respiration, whether natural or artificial, toward the mouth. This manoeuvre is more efficient and far pleasanter than the suction usually recom- mended ; it has answered well in practice.1 Different Methods of Performing Artificial Respiration. 1. Sylves- ter s Method.—Charpentier states that he has several times suc- ceeded in resuscitating stillborn infants in the following way : The infant is lying upon the back, wrapped in warm cloths, the head resting on a pillow and the arms placed upon the sides of the chest. Then raise the arms, bringing them quickly toward the child's head, after which replace them at the sides of the chest. These move- ments, several times alternately repeated, dilate the chest and thus facilitate the entrance of air. Although not so designated by Char- pentier, it is really that which is known as the method of Sylvester. 2. Mouth-to-mouth Insufflation.2—Here, after wiping the mouth of the infant, the obstetrician, first taking a fresh and large inspiration, applies his mouth to that of the child lying upon the back, and ex- piration is made with some force. It is not necessary to close the infant's nostrils, for these, as Champneys suggests, act as a safety valve, and besides air escaping through them may drive out obstruct- ing mucus; it is useless to press upon the cricoid cartilage, accord- ing to the same authority, with the hope of preventing air passing into the child's stomach. The escape of air is secured by pressure upon the child's chest and over the stomach, for some inevitably enters the latter organ. The method is not to be recommended, for there is some danger of causing emphysema. 3. Insufflation through a Tube passed into the Larynx.—The French are very partial to this method ; Depaul's tube, a modification of Chaussier's, is preferred by most. Depaul, who had devoted much study to the subject, advised ten to fifteen insufflations a minute ; the escape of air after each insufflation resulting from the elasticity of the lungs, and this spontaneous expiration being rendered more com- plete by suitable pressure with the hand or hands applied to the chest: thus the play of respiration is aided, and there is produced upon the muscles of the chest and upon the diaphragm an advanta- geous excitement. He observes in regard to the time that insuffla- tions are continued, that it varies with the case. " Two or three have been sufficient in some ; in other circumstances it was necessary to continue them for ten minutes, half an hour, an hour, or even two hours." 4. Schultze s Method.—The operator stands with his lower limbs somewhat widely apart, and his body slightly inclined forward, the arms and forearms extended. The infant is now held, its anterior 1 Op. cit. 2 In the Holy Bible, Second Book of Kings, fourth chapter, thirty-fourth and thirty-fifth verses, we have an instance of resuscitation from apparent death, or restoration from actual death by the prophet Elisha, in which the method seems chiefly to have been mouth-to-mouth insufflation. 442 SCIENCE AND ART OF OBSTETRICS. plane in front, by the index finger of each hand entering the axilla; from behind, the thumbs supporting the face laterally, and their ends resting upon the upper and anterior part of the thorax. This is the position of inspiration. After a moment the operator very quickly raises his arms until they pass the horizontal line and become ob- lique with reference to his body, and the child is made to revolve upon the index fingers as an axis, so that its head is now lowest, and its hips highest, its lower limbs falling upon the anterior aspect of the body which is directly before the operator's face ; the child's weight in this position rests upon the thumbs of the operator, which are placed upon the anterior face of the thorax. If this movement of partial revolution be made too rapidly, the child's back is bent too much in the dorsal vertebrae, whereas it is designed the bending shall occur in the lumbar vertebrae. While the head is in the de- pendent position the movement of expiration occurs, and any fluids that may have entered the air-passages flow out. The operator now lowers his arms, swinging the child back into the first position, when all pressure of the thumbs upon the chest is relaxed so that they may give no impediment to inspiration. These movements are repeated at suitable intervals. Attentions to the Mother.—Immediately after the birth of the child the mother is placed upon her back, if she was delivered lying upon her side, with but a single pillow, or only the bolster under her head. From the time of the birth the hand of the assistant, which was placed upon the uterus, following it down during the expulsion of the child, is kept there until replaced by that of the obstetrician. It must be borne in mind that the hand is applied, not flat, but with the fingers and thumb so flexed that a concave surface is formed corresponding with the convexity of the uterus, and that the purpose of this normal application is to assist uniform uterine retraction, thus securing early delivery of the placenta, and guarding against hem- orrhage. It is the custom of some practitioners to administer from a half to a teaspoonful of fluid extract of ergot immediately after the birth of the child, while others defer it until after the delivery of the placenta, and still others omit its use altogether in physiological conditions. Ergot given after the removal of the placenta probably cannot interfere in any way with normal processes; it certainly is one of the most important means in the prophylaxis of post-partum hemorrhage, and possibly it assists uterine involution. But unless there are plain indications, it is better to omit it. Placental Expulsion.—The delivery of the placenta is one of the most important of the accoucheur's duties. The patient is anxious until this final act in the drama ends; she cannot have the soiled clothes removed from her person and from the bed, nor parts that have been bruised bathed, nor secure that repose which her ex- hausted condition needs; a delay is sometimes the source of fear to her at least, according to the popular expression, that " the after- birth has grown fast to her side." Therefore it is unwise, so far as her immediate comfort is concerned, to do as practitioners in ancient times did, leave the delivery of the placenta to nature, pursuing a THE CONDUCT OF LABOR. 443 merely expectant treatment. The time of the practitioner also gives an argument against expectation. He cannot wait hours at the bed- side, as would be necessary in some cases for nature to expel the placenta, when a little manipulation on his part, simply assisting nature, will accomplish this delivery in a few minutes. The follow- ing table of IOO cases in which the delivery of the placenta was left to nature is given by Kabierske •} 24 times . . 30 minutes. 5 times 20 " . . 1 hour. 3 " 25 '' . . 2 hours. 2 " 11 " • • 3 " 1 " 9 " ■ • 4 " These figures are conclusive against trusting to purely spontaneous delivery of the placenta. The method more or less closely followed by most obstetricians is known as that of Crede, and briefly stated is this: Frictions, at first gentle and then more or less vigorous, of the fundus and of the body of the uterus are made through the ab- dominal wall. When a uterine contraction occurs, the obstetrician applies his hand to the organ, the palm upon the fundus, the four fingers upon the posterior, and the thumb upon the anterior wall, and exerts a moderate pressure, which is soon followed by the ex- pulsion of the placenta—it is thus expressed, squeezed out " as the seed from a ripe cherry compressed between the thumb and fingers." It is necessary in some cases to repeat this manipulation once or oftener before successful. Crede's method has not escaped criticism. Riol2 justly states that if practised with too much rapidity and energy, and immediately after the delivery of the fcetus, it may cause tearing the membranes. Certainly retention of fragments of unde- tached membranes may result from too great haste in the delivery of the placenta. It would be better in physiological cases not to hurry uterine action by friction, but simply to keep the hand applied to the uterus, as first directed, acting in the beginning as a sentinel to warn of danger and advise of condition, and then as an ally of uterine contractions, when they normally occur, a reinforcement to uterine power, not usurping its place, but simply assisting it. De- livery of the placenta by expression is certainly preferable to delivery by traction; it is nature's way to have the delivery occur by a vis a tergo, not by a vis afronte, and untimely pulling upon the cord may cause inversion of the uterus, or serious hemorrhage. But granting all this, haste and great force in expression are an evil; nature should be the guide, give the signal for action, and art be the fol- lower and servant. Pajot advises, after taking hold of the cord, at first to exercise a prolonged ten- sion during some minutes, and subsequently moderate tractions in the pelvic axis. Ribemont-Dessaignes3 claims that this tension is as rational in principle as it is fortunate in results. Pajot's method, instead of seeking to increase the size of the uterine orifice, seeks to reduce the volume of the placenta; and this reduction, . 5 hours. . t> " . 8 " . 12 " 1 Centralblatt fiir Gynakol., 1881. 2 Etude Critique et Clinique de la Deliverance par Expression. 3 De la Deliverance par Traction et par Expression, Paris, 1883. 444 SCIENCE AND ART OF OBSTETRICS. favored by the special structure of the organ, is easily obtained if the latter is permitted to mould itself little by little to the passage it must traverse—in a word, to accommodate itself. " No teaching as to the delivery of the placenta can be scientific which does not direct attention to the character of the preceding labor ; and as the character of labors varies, so must the management of the third stage. If the pains have been frequent and energetic, and the birth of the child rapid, the placenta may be de- livered very soon ; if the labor has been tedious and the delivery slow, or if the uterus has been exhausted by long continuous effort, time must be given for the recuperation of its contractile force and nervous energy."1 It is generally advised that in removing the placenta from the vagina, the former should be rotated so as to twist the membranes into a rope, as it is supposed there is then less danger of their tear- ing, and fragments being left behind. Such an accident is not likely to happen if they have been completely detached from the uterus, and the manoeuvre is hardly necessary, simple, gradual withdrawal being sufficient. When removed, the placenta and membranes are put in a vessel brought by the nurse, which should be turned upon its side, and put with its rim as near the vulva as possible, so that they can be slid in rather than lifted, thus avoiding, as far as pos- sible, soiling the clothes or the person of the patient. After this the obstetrician removes clots that may be in the bed, and puts them into the vessel, when it is taken away, but kept unemptied until he has an opportunity to examine the uterine surface of the placenta, and be sure that no fragments have been left in the uterine cavity. Before removing the hand which has been applied to the uterus through the abdominal wall, the size, position, and firmness of the uterine globe should be found to be normal. Application of the Bandage.—After the removal of soiled clothes the abdominal bandage maybe applied. The value of this has often been disputed, nevertheless most patients think themselves more comfortable with it, and desire it to be used; indeed, some are not satisfied unless their professional attendant applies it. Confirmation of the value of the abdominal bandage has recently been given by Prochownick.2 It should be worn not merely while lying in bed, but for some time after beginning to sit up. Usually a bandage made for the occasion is at hand; but if not, a bolster cover, as suggested by Leishman, or, better than it, a moderately coarse crash towel may be used. The bandage is rolled one-half its length, and the roll carried under the patient's back to the op- posite side, when it is unrolled, drawn so as to be smooth, and arranged to extend from the chest somewhat over the hips. It is then pinned as tightly as is comfortable, the pinning being begun, as taught by Warrington,3 above, though of course this is not very material. To prevent the bandage from slipping a layer of cotton wadding maybe placed upon the abdomen, if the weather be not so warm that this addition will cause discomfort. Some place a pad, formed of one or more folded napkins, upon the abdomen before the bandage is fastened, for the purpose of producing compression of the uterus; if small, it does neither good nor harm, but if thick it may 1 Reeve: Transactions of the Ohio State Medical Society, 1884. 2 Op. cit. 3 Obstetric Catechism. THE CONDUCT OF LABOR. 445 press the uterus out of place. A better plan of securing uterine compression, should this be thought necessary, is the following: Make three firm rolls rather thicker than the wrist, of as many towels ; then place one of them transversely just above the uterus, and the other two at its sides, and let the bandage be pinned firmly over them; thus the uterus is as it were included in a box, the lid of the box being the portion of the bandage in front of the abdomen. The nurse uses a warm vaginal injection of a three per cent. solution of carbolic acid, or I to 4000 of corrosive sublimate, or a teaspoonful of creolin to a quart of water, and cleanses the external sexual organs and adjacent parts with a similar antiseptic wash. If there be the slightest suspicion of any injury to vulva or peri- neum it is the duty of the obstetrician to make a careful inspection of the parts. As a rule, if there be any serious tear of the perineum, sutures must be at once introduced. Slight tears there or elsewhere maybe covered with an antiseptic powder as of iodoform. Then an antiseptic napkin or pad is applied to the vulva, the chemise and night dress drawn down, and the patient prepared for that rest which her exhausted state so much needs. Antiseptic Pads.—A very good antiseptic pad for the puerpera may be made by including in the ordinary obstetric napkin a thick layer of absorbent cotton which has been dipped in a two per cent, solution of creolin and dried; the napkin is then folded in the form of a cravat. At the Preston Retreat Dr. Joseph Price uses antiseptic pads thus prepared : A piece of thin, cheap cotton material, thor- oughly antisepticized, and twenty-four inches square, is first folded diagonally; next, upon one side of this a piece of waxed paper nine inches by three is placed', and upon the paper antiseptic jute, and finally a layer of antiseptic cotton. The muslin is now folded so that it is given somewhat of a boat-shape, the cotton being exposed; a few coarse stitches secure the form, and when the pad is ap- plied the uncovered cotton is directly upon the vulva. The pad weighs one ounce and a half, and costs about five cents; four or five will be needed in the first twenty-four hours: the pad after use is, of course, burned. Dr. Edward P. Davis has devised for use at the Philadelphia Hospital an anti- septic napkin, of which he gives the following description : It is composed as fol- lows : first the strip of picked oakum or jute three-quarters of an inch thick and 16 inches long, 5 inches wide. On each side of this, cheap cotton batting suffi- cient to cover and inclose the oakum. The whole is included in a piece of cheese-cloth 18 inches long, 12 or 13 wide. The edges of the cheese-cloth are brought together and secured loosely by cotton thread. The ends may be closed to advantage in the same manner. This napkin is dipped in bichloride of mercury one to two thousand, and dried. On an average, six or eight are required for the first three or four days after confinement, and subsequently four daily. When the material is bought in large quantities at wholesale and these napkins are made by hospital nurses, the material itself, exclusive of the labor and the bichloride of mercury used, costs one and one-quarter cents for each napkin. When a small quantity are made— less than a hundred—the napkins cost, also excluding labor and bichloride, about three cents each. When stained through, the pad is removed, rolled up in a bit of old paper, and burned. The practitioner remains with the patient for an hour after the labor has ended, and then, if she be comparatively free from suffer- ing, the uterus well contracted, and the pulse and flow normal, he need not hesitate to leave. The woman is now, in the strict sense of the term, & puerpera, and the puerperal state has succeeded that of labor. The phenomena and management of puerperality will be studied hereafter. CHAPTER IV. THE CONDUCT OF LABOR {continued)—OCCIPITO-POSTERIOR POSITIONS— FACE, BROW, AND PELVIC PRESENTATION—TWINS. The Management of Occipito-posterior Positions.—As has been stated, in almost all cases of right or of left occipito-posterior posi- tions, the occiput rotates in front, and the head is delivered as in an original occipito-anterior position. The labor is longer and the suf- fering greater. In exceptional cases, when by perversion of rota- tion the occiput turns into the sacral cavity, the delivery of the head causes increased danger to the perineum, and the long and difficult labor greatly endangers the life of the child. The tediousness of anterior and the possibility of posterior rota- tion have led many obstetricians to urge the importance of manual, or even of instrumental, means to effect or assist the former. Smellie was among the first to claim that such rotation could be effected by the hand or by an instrument. He stated, referring to the former means, that " turn- ing the forehead into the hollow of the sacrum might be assisted by introducing some fingers or the whole hand into the vagina during a pain, and moving it to the right position." Portal and Leroux advised pressing with the hand upon the abdominal wall so as to withdraw the face from the anterior pelvic wall. Velpeau taught that when the head had descended into the pelvic cavity, almost imme- diately after the escape of the waters, two or three fingers should be placed just before the sacrum, in order to push the occiput in front or behind the pubes, upon the side of the forehead, in order to press the latter backward. Meigs, referring to delay in labor from failure of anterior rotation, directed that two fingers should be placed upon the child's head, just behind the ledge formed by one of the parie- tal bones overriding the occipital, and.then drawing the vertex down, thus increas- ing flexion; he added, " If such gentle measures will not succeed we have the powerful resource of half the hand, which may be introduced into the vagina, and sometimes within the cervix, and which, taking the head in its palm and fingers, can place the vertex wherever it may be desirable to fix it." Hodge's view was that anterior rotation could generally be caused by pressing on the temple during a " pain'' and also in the interval; the pressure should be made upon the left temple in right occipito-posterior, upon the right temple in left occipito-posterior position. Mattei believed that he had often succeeded in effecting anterior rota- tion of the occiput by acting upon each pole of the fcetal ovoid, the fingers of the right hand being used to draw the occiput in front, while the left hand was ap- plied to the fundus of the uterus to cause a corresponding rotation of the trunk. Tarnier advises this plan : When the os is nearly or quite dilated introduce the index finger—the left one in right occipito-posterior position—and apply it to the cranial surface immediately behind the left ear of the fcetus, thus securing a good purchase; at the beginning of a uterine contraction the finger is pressed firmly, but without violence, at the same time bringing the head toward the pubes, then to the joint, and'finally to the opposite side, so that the occiput is directly in front. The first attempt often succeeds, but if, after being repeated two or three times, there is still failure, it is better to desist. Angus MacDonald1 held that in all persistent occipito-posterior positions we may safely assume we have some pelvic peculiarity or 1 Transactions of the Edinburgh Obstetrical Society, vol. iii. THE CONDUCT OF LABOR. 447 disproportionately large head to deal with, and, as a rule, all at- tempts at rectification of the position of the head will prove abor- tive, and are even dangerous if attempted by means of levers, for- ceps, etc. Not dissimilar was the teaching of Cazeaux ; he regarded all manoeuvres to effect anterior rotation as quite useless. So, too, Charpentier looks upon manual efforts as in vain, and when they appear to succeed, the rotation would occur without them. When we consider the prolongation of the labor in a permanent occipito-poste- rior position, and the greater suffering of the mother and peril to the child, and the necessity oftentimes, especially in primiparae, of using the forceps, the final results probably being a dead child and a torn perineum, it certainly seems as if an effort ought to be made to effect anterior rotation by the hand, unless the posi- tion has become occipito-sacral, for then intervention is vain. The essential rea- son for the failure of anterior rotation is that the occiput meets with too great, and the forehead with too little, resistance. We cannot lessen the former, except indirectly, but we can increase the latter. Direct pressure npon the forehead then seems the most rational means for making way for the descent and anterior rota- tion of the occiput; all manoeuvres to push or pull the occiput forward and to push the forehead back by the fingers on the temple probably are vain—they seem to mistake nature and they do not invite the normal mechanism of labor. It may be said that this proposed resistance given to the descent of the forehead is simply increasing flexion. Very well, and why does flexion occur in any stage except to facilitate the descent of the occipital end of the occipito-mental diame- ter ? Resist the descent of the forehead, letting the occiput alone, seems the most rational means of effecting anterior rotation. The Management of Face Presentations.—The older obstetricians advocated in presentations of the face either changing it into that of the vertex, or podalic version. Louise Bourgeois, 1710, remarked that when the chin advanced first in the passage delivery was im- possible, and the hand must be introduced to push back the chin upon the chest. Baudelocque advised the same method, and if it failed only podalic version or instrumental delivery remained. Smellie said that when the " face presents resting upon part of the pelvis, the head ought to be pushed up to the fundus of the uterus, the child turned and brought by the feet." He admitted, however, that in some instances spontaneous delivery occurred. Paul Portal, 1685, nearly a century before Smellie made the statement I have quoted, was contented with " anointing the woman's parts with but- ter in order to soften and relax them, thus making the escape of the infant easier:" he stated that the accoucheur should be careful not to produce any irritation with his finger, otherwise he will cause a thousand times more injury to the mother and to the child than the accouchement, which has no more mystery than a natural labor. It was not, however, until Lachapelle asserted that these labors terminated as easily as those with vertex presentation that the profes- sion generally abandoned interference, leaving the delivery to nature. Nevertheless the affirmation of the perfect safety of labor in presenta- tion of the face is somewhat an exaggeration, and the profession is not unanimous in regard to the uselessness of intervening. Hodge held that when the practitioner was called early, and recognized a face presentation, he should, after the os is dilated, and before the present- ing part has passed this opening, substitute the vertex, for under 448 SCIENCE AND ART OF OBSTETRICS. these circumstances, especially in multiparous women, the opera- tion can be easily and rapidly performed without much suffering to the mother. Partridge has also advocated this plan of treatment., stating the conditions favor- able to it, and the method, as follows : " An os nearly or quite dilated; a face not engaged in or at least capable of being lifted from the pelvic brim ; an un- ruptured bag of waters ; a capacious vagina. In the majority of labors a stage is reached when these conditions are present. Chloroform to relax the structures of the parturient canal, to quiet the movements of the patient, and to obviate pain caused by the introduction of the hand into the vagina, is of primary importance. The manipulation requires the presence of the fingers only in the uterus, and does not involve any laceration of the cervix. Passing the palms of the fingers over the occipital bone, and pressing them firmly against it, traction downward should be made. In our endeavors flexion of the head almost immediately commenced and quickly became complete. The other hand aided greatly by external manipulation."1 Schroder referring to conversion of a face into a vertex presentation, states that Thorn succeeded in 9 cases of 24 in accomplishing this change without difficulty, and further, that Thorn is correct in saying that a good result is not to be had by external and internal manipulation of the head alone, still less as Schatz pro- poses by external manipulation of the head and shoulder, but that the half or the whole of the hand should be used internally to turn the head, while the external hand is employed to press it toward the chest, and finally pushing the breech to the other side so as to change the position of the body. The performance of podalic version in presentation of the face is not practised by obstetricians of the present day. Indeed the attempt to substitute the vertex for the face is seldom tried, though the success of Partridge and of Thorn is encouraging. Galabin objects to the attempt to change a face into a vertex presentation on the ground that it may only partially succeed, as is very probable, and then the head is brought into the more un- favorable position of brow presentation. He further states that the statistics of the Guy's Lying-in Charity show that more than 99 per cent, of the cases terminated favorably, and therefore interfer- ence is generally quite unnecessary. Supposing no effort to have been made to substitute the vertex for the face, or the effort has failed, an essential part of the mechanism of labor is anterior rotation of the chin. Efforts to promote this are advised by some, and they certainly are important in case of great delay. When the face is in the pelvic cavity it has been advised to en- deavor at once to secure anterior rotation of the chin ; others recom- mend waiting, Chantreuil, for example, directed a delay of three hours before intervention. This is made by pressing with a finger upon the side of the head so as to determine turning the forehead to the sacral cavity, or hooking a finger over the chin so that it may be drawn toward the pubic arch. Failing in this the forceps may be necessary, and for this use the straight is better than the curved instrument. Dr. Penrose2 advises in delayed rotation pressing with the forceps blade, or with the hand upon the posterior cheek. 1 American Journal of Obstetrics, 1884. 2 American Supplement to Obstetric Journal, 1876. THE CONDUCT OF LABOR. 449 Dr. Parry1 has recorded a case in which having failed in attempts to flex the head, or to rotate the chin anteriorly, or to extract with the forceps, and craniotomy seemed the only alternative, he succeeded by his hand introduced into the pelvic cavity in pushing the head above the inlet, and then converting the presentation into that of the vertex; such success when labor is thus far advanced must be altogether exceptional. Probably the best way of promoting anterior rotation of the chin, should inter- vention be thought advisable, is to resist the descent of that part of the face which is opposite—that is, the forehead. It is the same method as was advised to secure anterior rotation of the occiput when it was posterior. In this case it may be said that the proposed resistance causes perfect extension, as in the former perfect flexion. But besides that it pushes back, hinders, and resists the descent of that part which ought to rotate in the sacral cavity, and opens the way for the rotation in an opposite direction, and the descent of the part which is opposite ; when forces are applied to a mobile body, such as the head of a child is, whether the cranial or facial portion is presented, rotation occurs in the direction of least resistance. Rotation is here, as always in the mechanism of labor, simply one of the important phenomena of accommodation. In the management of face presentations great care must be taken that digital examination be made with the necessary care and gentleness lest injury be done, especially to one of the eyes. It is better frankly to tell the patient that the labor will be pro- tracted, but at the same time she may be assured that it is almost certain to have a fortunate issue both for herself and for her child. Friends who are with her ought to be informed of the probably very great disfigurement of the child's face, the statement being also made that this is sure to disappear in a few days. Great danger comes to the child in the disengagement of the head, for during this the throat is pressed against the pubic arch, and if delay occurs it may be necessary actively to assist the delivery. Management of Brow Presentations.—As extension of the head gives presentation of the face, so partial extension results in pres- entation of the forehead or brow. Upon digital examination the apex of the forehead is found to be the lowest part of the head, the suture between the two halves of the frontal bone can readily be traced to the anterior fontanelle, and in the opposite direction the different parts of the face are found. Now it is almost certain that the presentation of the forehead will be only temporary; for either flexion occurs, and the vertex presents, or, and this is the more fre- quent.extension becomes complete, and the final presentation is the face. If the head be small, spontaneous delivery is possible without change of presentation. Kleinwachter takes the ground that when the head is in the pelvic cavity, an attempt to substitute the vertex for the face is not to be made, for even if successful the head, which has already been more or less moulded into the form necessary for delivery, must undergo a new configuration for delivery with a new presentation, and thus time is lost, to the danger of both mother and child. Hodge taught that a brow presentation should be con- verted into that of the vertex as soon as the os uteri is sufficiently dilated for the passage of the hand of the practitioner. Even when the head has passed the os he thought this could be done in many 1 American Journal of Obstetrics, 1875. 29 450 SCIENCE AND ART OF OBSTETRICS. cases. Possibly his advocacy of an early active interference arose from the fact that he did not recognize the almost unexceptionally spontaneous change of presentation, for he cautiously observes, " perhaps in the majority of cases" this change occurs. Hilde- brandt directs that in persisting brow presentation the woman should be placed upon her side across the bed, and the practitioner then apply two fingers of the right hand, at the beginning of a uterine contraction, upon the forehead and exert a pressure directed toward the occiput if a facial presentation is desired, or toward the face if descent of the occiput is preferred. Long advises the same method, but urges the importance of conversion into a vertex presentation. He adds: " If this is unsuccessful the whole hand should be intro- duced into the vagina, and the fingers passed up over the occiput, pushing the head up first if necessary, and then drawing downward upon the occiput, and with the thumb pushing up the brow as well as possible, so that the head should be completely flexed. Assist- ance can sometimes be had by external manipulation with the other hand, and sometimes by having the woman in the knee-chest posi- tion. Anaesthesia should always be induced in order to relax the parts and render the manipulation painless."1 Thorn's method, previously stated, may be employed in this as well as in presenta- tion of the face. The Management of Pelvic Presentations.—The practitioner should guard against an early rupture of the membranes, and even though the first stage of labor is protracted it is well to have the woman lying down most of the time. No effort should be made to hasten delivery during the expulsion of the lower half of the body; no traction upon the trunk is to be made, for it may cause not only departure of the chin from the chest, but also of the arms to the sides of the head or even behind it. If the patient be anaesthetized, great care must be taken that the anaesthesia is not to such a degree as to lessen either voluntary or involuntary expulsive power when that power is most needed in the expulsion of the upper part of the trunk and of the head. One hand protects the perineum during the expulsion of the breech, which is received by the other. As soon as so much of the body is born that the umbilical cord comes within reach, a loop should be drawn down to guard against stretching and pressure, and also to know by the pulsation the condition of the child ; if the cord be around one of the limbs it should be removed from this position; next it must be placed in such position that it will be least liable to pressure; that is, where there is the most room for it, and this will generally be upon one or the other side of the sacral promontory. If the arms have departed from the chest, an accident which is not likely to occur unless traction has been made upon the trunk, they are to be brought down, usually the sacral arm first, by passing two fingers up to the shoulder, and along the inner side of the humerus, if this be possible, to the bend of the elbow, and then by gentle pressure drawing the forearm over the breast, American Journal of Obstetrics, 1885. THE CONDUCT OF LABOR. 451 causing the dislocated member to be returned by a movement the reverse of that which displaced it. But if it is impossible to reach the elbow, the finger or fingers must be passed over the acromion, and pressure made directly upon the upper part of the humerus, and gradually carried further toward the elbow, until both are drawn down. Rotation of the face into the sacral cavity next occurs, the shoulders now being transverse with reference to the vulvar orifice ; it may be assisted by making external rotation of the shoulders. Delivery of the Head in Head-last Labor.—Although placing here much which would be properly presented in the chapter upon obstetric operations, it seems to me best now to consider the different manual means used in the delivery of the head when it comes last. I. Continued flexion of the head is sought by assisting uterine contraction with manual abdominal pressure, and by passing two fingers of one hand into the vagina which press upon the superior maxillary, while two fingers of the other hand push the occiput up. This method is illustrated in the subjoined figure. Fig. 157. Artificial Delivery of the Head in Pelvic Presentation. Smellie1 employed this method ; it will usually be successful. 2. That which is called the Prague method, though probably originating with Puzos, is traction upon the child by grasping the ankles with one hand, while the other is placed over the shoulders, three fingers on one side of the neck, the thumb and index finger upon the opposite side; the pull is at first downward and backward until the head has entered the pelvis, then upward and forward, the back of the child coming nearer the mother's abdomen as the head emerges from the vulva. 1 Smellie performed traction upon the lower jaw in these cases, and it was only when he " was afraid of overstraining it,'' that he changed the pressure of his fingers to the superior maxillary. 452 SCIENCE AND ART OF OBSTETRICS. 3. A better method is represented in the annexed illustration. It was employed by Mauriceau, but is commonly known as the Yeit- Smeilie method. It will be seen in the illustration two fingers of Manual Extraction of the After coming Head: combined traction upon mouth and shoulders. Veit's method. one hand are passed into the mouth to exert traction upon the lower jaw, while the fingers of the other hand pull upon the shoul- ders ; flexion is secured partly by the direct force exerted upon the inferior maxilla, and partly indirectly by the resistance furnished at the pubic joint to the descent of the occiput.1 The trunk must be lifted up as the head descends further into the vulvo-vaginal canal. 4. This, known as the Wigand - A. Martin method, is the best2 of all in a difficult delivery, and when it is important it shall be quickly effected. It is seen that two fingers of one hand are introduced into the child's mouth which pull upon the lower jaw, while the other hand is used to press through the abdominal wall upon the head: traction and expression are thus combined. While as a rule in head-last labor the face rotates into the sacral cavity, the reverse rotation may occur, and the occiput is found pos- teriorly, deflection may follow and the chin rest over the pubic joint. It is necessary in such condition that the occipital end of the occipito- mental pole pass out first, and therefore in the delivery of the child 1 Litzmann, Centralblatt f. Gyniikol., 1887, referring to the method commonly " known as the Veit-Smellie which ought to be called the Mauriceau-Levret,'' modifies it according to the suggestion of d'Outrepont thus: The nucha is seized between the index and ring finger, the medius is placed against the occiput behind the pubic joint, and is used to press it upward : later, when stronger traction upon the shoulders is to be made, the medius is replaced by the ring finger. 2 Eisenhart, assistant at the Munich Frauenklinik, has recently published a paper, Archiv f. Gyniikol., 1889, contrasting this with the Veit-Smellie method, and from comparing the results of the two in a large series of cases, arrives at this conclusion : The delivery of living children, and of children that continue living, is at least seven times greater when pressure is made upon the after-coming head by the Wigand-Martin-Winckel method than when the Mauriceau- Lachapelle (Veit-Smellie) method was employed. THE CONDUCT OF LABOR. 453 the body is carried upward and forward, abdomen of the infant toward the abdomen of the mother. Fig. 159. Wigand-Martin Method (Winckel). In any of these methods in which the fingers are introduced into the mouth great care must be taken lest injury is done with a nail to the delicate mucous membrane: I have seen one child bleed to death from injury thus inflicted, and while I know that the obstetrician usually comforts himself with the reflection that the child was "a bleeder," I am not sure that the explanation is always true; the hemorrhage may occur when there is not the slightest proof of any hereditary influence. As to the amount of force that may be safely exerted in traction upon the lower jaw, Matthews Duncan from his experiments states1 that fifty-six pounds may be applied, in some cases, by dragging the lower jaw without producing any easily discovered injury of parts. A serious source of delay in the delivery of the head arises in some cases from contraction of the os uteri around the neck of the child, causing a dangerous compression of the throat. Depaul, who has described the occurrence of this obstacle, advised the use of the fingers, introduced into the os to dilate it, and, if resistance con- tinues, incisions. Presentation of the Hips.—Delay in the delivery of the pelvis in the usual form of pelvic presentation may require, in the interest of the mother or of the child, manual assistance, and there is usually 1 London Obstetrical Society's Transactions, vol. xx. 454 SCIENCE AND ART OF OBSTETRICS. no difficulty in bringing down one foot, or both feet, so that traction can then be readily exerted. There is, however, an unusual form of presentation in which not only are the thighs flexed upon the abdo- men, but the legs extended upon the chest: it is described by French obstetricians as presentation des fesses, or as presentation du siege dScomplete, mode des fesses. The lower limbs in this position act as a splint to the body, and make it rigid and inflexible. The diagnosis of presentation by abominal palpation presents a peculiar difficulty from the vicinity of the feet to the head, for, as a rule, when a solid, round body is felt with small mobile parts near it, the con- clusion justly drawn is that the body is the hips, so that in a case of this variety of pelvic presentation the error of believing that the head is in the lower part of the uterine ovoid can be very readily committed. It may be, too, that the hips have entered the pelvic cavity before the labor begins, and hence new difficulty, and in- creased liability to error in diagnosis by abdominal palpation. These cases are the most unfavorable variety of pelvic presentation, and, as a rule, assistance is necessary. Lefour, in an interesting paper,1 refers to primitive cases of this anomalous position of the lower limbs as distinguished after birth by the fact that though the limbs be drawn down, immediately when they are free from constraint they return to the position they had in the uterus. Fig. 160 shows this peculiarity. Fig. 160. Position of Lower Limbs in Child born with presentation of Thighs. Treatment.—There will be presented not only the means neces- sary in this, but in other cases of difficult and delayed pelvic delivery. The forceps may be rejected as a most uncertain, and possibly unsafe means if there is really a serious delay in the delivery of the 1 Contribution a l'Etude des Presentations du Siege decomplete, mode des Fesses. THE CONDUCT OF LABOR. 455 hips. I do not believe this instrument can be safely used to over- come any great resistance under such circumstances. Fig. 161. Breech Presentation. Application of the blunt hook. 456 SCIENCE AND ART OF OBSTETRICS. The blunt hook usually applied over the anterior thigh is fre- quently used. Fig. 161. There is danger of fracturing the thigh ; Bitot has shown that the femur will be fractured by a force of four- teen to fifteen kilograms acting perpendicularly to the axis of the femur. By consulting Fig. 162, it will be seen that any traction Fig. 162. Budin and Lefour's Method of Traction. upon the anterior hip is not made directly, only indirectly, upon the part which ought to be first advanced, the posterior hip, and therefore there is loss of force. Nevertheless the blunt hook will often prove useful; that of Delore is to be preferred, and certainly a pull upon the posterior rather than upon the anterior hip would be the better, if the instrument could be safely applied. The fillet may be tried and the following plan, advised by Gala- bin, seems excellent. A soft, oiled handkerchief may be used for the fillet; a knot is tied in it at two opposite corners. By means of the forefinger the corner is to be passed from without inward over the flexure of the groin till the knot can be reached between the thighs and drawn down. In the same way the opposite end of the fillet is to be passed from within outward over the other thigh. The centre of the fillet is then slipped up over the buttocks till it sur- rounds the sacrum, and traction is made by the ends. In this way the pressure is distributed over both groins and the circumference of the pelvis. With such a fillet traction is not only exerted over a great extent THE CONDUCT OF LABOR. 457 of surface, and therefore less danger of injury, but the pull may be made approximately in the line of resistance. If the fillet be placed over either thigh, the danger of its slipping, and producing fracture of the femur, is not slight. Moreover, the application of the fillet when the hips are firmly pressed in the pelvic canal, possibly con- siderably swelled, is by no means easy, and may be impossible. Traction with the finger in the anterior groin may not be diffi- cult, but the force exerted is not great, and, as previously explained, works at a disadvantage; much of it is lost. If the hand is intro- duced posteriorly to carry a finger over the perineal hip, traction upon which will obviously be much more advantageous, very pro- bably the hips will be pushed up by the entering hand. Budin and Lefour advise passing one finger in the anus of the patient, and through the anterior wall of the rectum hooking it over the posterior groin, while the index finger of the other hand is passed over the anterior groin, and traction then exerted by the two fingers, as shown in the illustration. This method has succeeded. Finally, the method advised by Barnes is to be commended, and in general it may be stated that when the obstetrician in a pelvic presentation brings down a foot, he is, as Dr. Goodell has happily expressed it, commander of the situation, able if delay occurs effi- ciently to assist the delivery. Barnes1 decomposes the wedge by bringing down a foot, stating that he has on several occasions brought a live child into the world after forceps, hooks, and various other means had been tried in vain for many hours, by passing his hand into the uterus and bringing down a foot. His directions are as follows: " Place the patient on her left side; produce anaesthesia to the surgical degree; support the fundus of the uterus with your right hand on the abdomen; pass your left hand into the uterus, insinuating it gently past the breech at the brim, the palm being directed toward the child's abdomen, until you reach a foot—the anterior foot is the better to take; a finger is then hooked over the instep, and drawn down so as to flex the leg upon the thigh. Maintaining your hold upon the foot, you then draw it down out of the uterus, and thus break up the wedge." The Management of Labor in Twin Pregnancies.—Tarnier's statis- tics show that in more than two-thirds of pregnancies with twins labor is premature. The reason for this fact is the very great disten- tion of the uterus. The labor is usually longer in both the first and in the second stage. The causes are: the changes in the cervix, belonging to the last period of pregnancy, have not occurred in the majority of cases, and hence increased resistance is to be overcome, the great distention of the uterus lessens its contractile power, and the force distributed over so large a surface is less efficient. The statistics of Depaul and Tarnier, embracing 316 twin labors, show that in 131 cases each fcetus presented by the vertex ; 81 times the vertex of one fcetus and the pelvis of the other presented, and Obstetric Operations. 45§ SCIENCE AND ART OF OBSTETRICS. 47 times the pelvis, and then the vertex, while the remaining pre- sentations were of the vertex and of the shoulder, of the pelvis and of the shoulder, vertex and face, face and vertex, etc. Kleinwach- ter makes vertex presentations 69.58 per cent., pelvic presentations 25.25 per cent., and transverse, 5.17 per cent. Most frequently both foetuses are born with vertex presentation, 49.29 per cent., more sel- dom one vertex, the other pelvic, 34.49 per cent. Still more seldom does the birth of both occur with pelvic presentation, or of the first with pelvic, and the second with shoulder presentation, or both with the latter, 6.23, 6.11, 3.55, 0.33. FlG. 163. First Child presenting by the Vertex ; Second by the Pelvis.—B and A, points of maxima ol intensity of sounds of the fcetal heart. While usually the twins lie longitudinally in the uterus, placed beside each other, as represented in the illustration, in some cases they may be either one above, or one in front of the other. A full description of the last two anoma- lous positions of twins has been given by Budin.1 In more than one-half the cases the second child is born within twenty minutes after the first. In one of 212 cases given by Collins the interval was twenty hours : twelve hours and forty minutes in I out of 188 cases observed at the Paris Maternity ; Reuss gives an instance in which the interval was twenty-six hours. When the pre- sentation of the first child is favorable, the rule is no interference is advisable in the first stage of labor; after the os is dilated the mem- 1 Op. cit. THE CONDUCT OF LABOR. 459 branes may be ruptured, and the labor conducted as usual. After the child is born the practitioner, in most cases, knows for the first time that the pregnancy has been plural; he finds the uterus firm, nearly as large as it was before the birth of the child, and upon digital examination ascertains that there is a second one within the womb. In all cases a second ligature of the umbilical cord is im- perative, for while there probably is no vascular connection between the placentae, the possibility of its existence requires guarding against destroying the life of the second child by hemorrhage. All traction upon the cord to remove the placenta from the uterus is especially forbidden. If the mother desires to know if she is to have another child, a knowledge which in many cases is by no means pleasant, let the truth be frankly told; she may at the same time be assured that the labor will almost certainly be easy and brief, for not only has the birth-passage been fully dilated, but the second child is generally smaller than the first. If the presentation is normal, the sounds of the fcetal heart distinct, and the mother's condition favorable—none of the grave accidents of labor, such as eclampsia or hemorrhage present—it is better to wait until expulsive pains return, and not cause immediate delivery. Supposing that the labor is premature, the child expelled feeble or dead, and the placenta discharged, it is possible, as suggested by Depaul, that the second child may be carried to the full period of gestation, and therefore interference would be forbidden. But when the placenta remains in the uterus there is no ground for this hope, and the practitioner should not leave the patient until she is delivered. As soon as decided pains occur the membranes are to be ruptured, and contrac- tion of the uterus secured by manual abdominal pressure during and for a time after the expulsion of the child ; ergot may be given immediately after the delivery of the placenta. CHAPTER V. THE PATHOLOGY OF LABOR--ANOMALIES OF UTERINE AND OF ABDOMI- NAL FORCE—STRUCTURAL AND POSITIONAL UTERINE ANOMALIES- ANOMALIES OF ADJACENT ORGANS. The pathology of labor includes anomalies of the forces by which the fcetus and its appendages are expelled, positional and structural anomalies of the uterus, and anomalies of the adjacent oro-ans, anomalies of the fcetus—abnormal size, either from excess of devel- opment, or from pathological conditions and new-growths, abnor- mal or complex presentations, and in a pluriparous pregnancy the interference of one fcetus with the expulsion of the other—anoma- lies of the pelvis, and finally accidents which may occur in connec- tion with labor imperilling the life of the mother or of the child. I. Anomalies of the Forces concerned in Labor.—These anomalies relate chiefly to the uterine force. This force may be abnormal by excess, by deficiency, or by perversion ; it may also be abnormal by being attended with unusual suffering. A. Excess of Uterine Force.—In those cases in which the uterine contractions are strong and recur rapidly the labor has a speedy1 end without danger to mother or child, provided the latter present favorably, and the birth-canal offers no serious obstruction, and suitable precautions are taken. But in the absence of proper care delivery may surprise the woman while she is standing, or while2 she is upon a commode, or in the water-closet, and the child be injured, the cord torn, the uterus inverted, or relaxation follow the violent uterine action, and hemorrhage result. Again, if the os or the perineum does not yield readily, a tear in one or both may occur from excessive uterine action. Emphysema of the Neck, Face, and Chest.—-If voluntary efforts in labor are very great, especially in primiparae, it sometimes happens that rupture of some of the air vesicles occurs, and emphysema of the neck, face, and chest follows. Blundell3 has spoken of the condition as follows: " It is not frequently that a disruption of the larger air-tubes occurs in the progress of laborious parturition ; yet this accident is sometimes observed, the trachea or bronchi giving way. After much exertion, the neck and face swell; from the hurrying of the circula- tion, an erythematous flush of the integuments is produced, and at first glance the patient appears to labor under a sudden attack of erysipelas ; the nature of the swelling manifesting itself on making an examination by the usual crepitus perceived on compressing, and lightly shampooing the skin with the tips of the fingers. Should emphysema occur, delivery is desirable. To retain the breath and force down is likely to aggravate the disease, so that the emission of the 1 The old authors described it as partus prcecipitatus, precipitate birth. 2 If a woman is delivered standing it is rare that the child is seriously injured by falling on the floor, because the force of the fall is broken by the limbs of the mother and by the resist- ance of the cord, though the latter be ruptured from the sudden strain. 3 Principles and Practice of Obstetricy. THE PATHOLOGY OF LABOR. 461 voice may be recommended. After delivery, if I may judge from the single case brought under my notice, the aperture, seldom capacious, heals spontaneously, and without inflammation the air is absorbed." The swelling and the characteristic crepitation indicate very clearly the nature of the accident; Schroder states that the emphysema, if not very great, disap- pears spontaneously in five or six days. Of course the patient is not permitted to continue any voluntary effort, but the labor must be terminated by the sole force of uterine contractions, or by instrumental delivery.1 As has been previously stated, very active uterine contractions are not to be regarded as pathological in a normal condition of the birth-canal, and normal presentation and size of the fcetus, and there- fore require no active interference. The woman should be in bed, and lying upon one or the other side; she should be directed not to make any bearing-down efforts, but keep her mouth open, refrain from pressing against any object with her feet, or grasping one with her hands during a uterine contraction. But if the unyielding con- dition of any portion of the birth-canal renders tearing probable from the rapidity of the labor, free inhalation of chloroform must be used to moderate the uterine force. Care must be taken in the third stage of labor to see that the uterus undergoes its normal retraction. B. Deficiency of Uterine Force.—Here the uterine contractions fail in intensity, in duration, and in frequency; this condition results in "tedious labor." Feebleness of uterine contractions is much more frequently met with than the condition just described, and it may occur in any one of three stages of labor, though most frequent in the first. It varies in degree and continuance, and may end in an actual cessation of uterine activity, which is commonly known as inertia of the uterus. The immediate danger to the mother from weak uterine contractions is greatest in the third stage of labor—for then hemorrhage is the inevitable consequence. Delay in the first stage of labor if rupture of the membranes has not occurred is not attended with danger to the child, or immediate danger to the mother; indeed, in very many cases, she suffers no injury immediate or remote from this delay. But? if the amnial liquor has been dis- charged some risk comes to the fcetus, though probably this is not as great as some have thought, for complete emptying of the liquor is exceedingly- improbable; especially if there be a presentation of the vertex, there usually remains filling up the interstices in the fcetal ovoid a considerable quantity of the fluid, so that the cord is protected from injurious pressure. Most practitioners of even a few years' obstetric experience have met with cases in which spontane- ous rupture of the membranes occurred twenty-four hours, or even three or four days before labor began, which in most instances ended in the birth of a living child. Delay in the second stage of labor is serious for both mother and child, for supposing the head to have entered the pelvic cavity it may produce by continued 1 In the British Medical Journal, October 24,1885, a case of emphysema in labor is reported, in which the entrance of air into the connective tissue of the neck and upper part of the chest, is supposed to have occurred through a small denuded, surface about the middle of the right cheek in the cavity of the mouth—certainly a very singular hypothesis. 462 SCIENCE AND ART OF OBSTETRICS. pressure upon the mother's soft parts inflammation and sloughing with consequent rectal or vesical fistulas ; even if openings into ad- jacent cavities are not produced, the injury to tissues opens the door for septic infection ; the child suffers from prolonged pressure, and fatal asphyxia is the not uncommon consequence. The mother's life is endangered by the exhaustion which follows long-continued powerless labor. It sometimes happens that weak and inefficient pains are associ- ated with unusual suffering—the pains are very "painful pains." In some cases at the close of the first stage of labor, and immediately after the evacuation of the liquor amnii, a pause occurs in the labor; there is an absence of uterine contractions, or these are very feeble, and this condition may, though it is not common, last some time unless means are used to evoke the languishing, or the delayed uterine force. The patient, usually a multipara, is herself surprised that the pains have ceased; the practitioner upon making a vaginal examination finds the head still within the uterus, the cervix per- fectly relaxed, and its walls hanging in loose folds, and a perfectly normal condition of the remaining portion of the birth-canal; a few vigorous pains assisted by abdominal efforts, are apparently all that is needed to effect the expulsion of the child. Longer labor-pauses sometimes occur before the discharge of the amnial liquor; labor has come on, and some degree of dilatation of the os been accom- plished; then uterine action, which has been manifest for hours, gradually ceases, and the patient goes to sleep, often to the surprise, if not the disappointment, of attendants who expected that in a few hours the labor would be over; twenty-four hours may pass before the labor is resumed. Such cases are not to be regarded as patho- logical, the cessation of uterine contractions is very different from that observed when the uterus has for hours vainly struggled against some invincible obstacle, until its force is exhausted. The condition last mentioned is most frequent after the rupture of the membranes, and in the second stage of labor. Voluntary force may be feeble, the abdominal contractions failing to contribute their part to the progression of the fcetus. This fail- ure, in the majority of cases, occurs when uterine contractions are attended with much suffering; the patient refrains from making any effort lest she may add to that suffering. Again, voluntary effort may fail from the general weakness of the patient, or from her being profoundly narcotized. Causes of Weak Pains.—Failure of uterine force may arise from previous exhaustion, or from that caused by protracted labor; the uterus has grown weary in its work, and falls into a condition of inertia. It may be the result of deficient uterine innervation, or it may be caused by excessive uterine distention, as from polyhy- dramnios, or from the presence of more than one fcetus; the upper portion of the uterus being thus thinned it cannot triumph over the normal resistance of the os. A full bladder or a loaded rectum may hinder normal uterine action. Kleinwachter has drawn attention to the fact that failure of uterine contractions may result from an THE PATHOLOGY OF LABOR. 4^3 artificial cause, as, for example, if during the course of labor the forceps is applied and unsuccessful attempts at extraction are made, the labor-activity may be permanently interrupted. Mental influ- ences may, temporarily at least, cause the labor to lag, the uterine contractions becoming weak and inefficient. A woman depressed by fear or anxiety, or offended by the presence of some one to whom she has an antipathy, or wounded by the unkindness of some one the nearest to her, and to whom she ought to be the dearest in this her hour of sore trial, and possibly of great peril, may have weak uterine contractions thus caused. Prognosis.—This depends upon the stage of labor in which feeble pains occur; upon whether the membranes have been ruptured or are still entire; upon the causes of the condition; upon the general state of the mother, and upon that of the child. In the first stage of labor, the membranes being unruptured, as a rule the child does not suffer; but the prolongation of the first stage is in many cases not a matter of indifference as far as the mother is concerned, for she may be deprived of sleep, become discouraged by the delay, and exhausted by her fruitless suffering, which exceptionally continues for several days. Charpentier mentions a case in his practice in which dilatation was not accomplished, notwithstanding all means employed, until five days; the delivery was then made by the forceps. In Greek mythology a case in which labor lasted nine days is given.1 The gravity of the condition if it occurs in the second or in the third stage of labor has been sufficiently pointed out. Treatment.—Here we must carefully distinguish between physio- logical and pathological labor pauses, for in the former we abstain from active interference, while in the latter it may be imperative, and often must be prompt. Again, for their wise treatment a recognition of the causes of weak pains is essential, and also the period in labor of their occurrence, and the condition of mother and of child. If the contractions are attended with excessive suf- fering we have in chloral one of the best of agents for the relief of that suffering. If feeble uterine contractions occur in the first stage wearying and exhausting the patient while dilatation of the os almost, if not quite, fails, the membranes being unruptured, we may imitate nature's action in many cases, and create a temporary labor pause by the administration of morphine; after a sleep of a few hours it is not unusual for uterine action thus temporarily suspended, to return with normal vigor. The practitioner should know that the bladder and rectum are completely emptied. Where the want of uterine contractions arises from a want of innervation of the uterus, a 1 Latona, pregnant by Jupiter, and her labor at hand, was pursued by jealous Juno, and at last found secure retreat in the Island of Delos. Her labor lasted nine days and nine nights, when, seizing hold of a palm tree, she gave birth to Apollo, the god of medicine and of music. The position she took to end a protracted and difficult labor might be adduced as an argument in favor of delivery being effected while the woman is erect or leaning forward. It may also be mentioned that from the legend we learn that Artemis, the twin sister of Apollo, was born twenty-four hours after—an interval that, as has been previously stated, may sometimes occur in the birth of twins. 464 SCIENCE AND ART OF OBSTETRICS. change of position, especially from the recumbent to the erect, or walking for a time, may produce a favorable alteration. Similar action may be accomplished by a stimulating injection into the rectum, or by hot water vaginal injections; taking a moderate quantity of food, a cup of hot tea, or a glass of hot lemonade is in some cases followed by increase of uterine action. If the uterus fails to contract because of its excessive distention, rupture of the membranes is indicated when certain conditions are present, though the os is only partially dilated but dilatable. Even though there may not be obviously great uterine distention, partial evacuation of the amnial liquor is often followed by vigorous uterine contractions. Charpentier states that the following conditions must be present: 1. The cervix must have attained a certain degree of dilatation, and as far as possible it must not be rigid. 2. The presentation and position must be good—that is, the head must present, and the posi- tion must be anterior. Sometimes rupture of the membranes is more injurious than beneficial in posterior positions of the vertex. 3. The pelvis should be normal; in some cases, however, rupture of the membranes is of value in case of a narrow pelvis. 4. There must be no complication, such as prolapse of one of the members, or of the cord, etc. " Practised with these precautions and in these conditions, rupture of the membranes has rendered us great benefit. But we cannot too often repeat, one ought not to act too soon. Hasty intervention is in the majority of cases more dangerous than expectation." The introduction of Braun's colpeurynter into the vagina, or of a flexible bougie into the uterus, placing it between the ovum and the uterine wall, have been used for the purpose of exciting uterine action, and each has sometimes been successful. The use of the forceps in the first stage of labor after the rupture of the mem- branes, not for the purpose of extraction, but simply to bring the head down so as to press upon the os uteri during uterine contractions, and effect dilatation, has been advocated, in this country especially by the late Albert H. Smith,1 and by Professor Isaac E. Taylor.2 The former has given the following directions as to this use of the forceps : When the os uteri is sufficiently dilated to allow the intro- duction of the blades, they may be carefully applied, and during each uterine con- traction the head may be drawn down gently, and with as little compression as may be required to keep the blades in place. We have then nature's own dilator, supplemented by art simply for the increase of its powers, without any change in the method of action, no new plan of operation being introduced. The application of the forceps before the os is dilated can only in exceptional cases be advisable. Digital dilatation of the os uteri will prove in the majority of cases demanding intervention either in the interest of the mother or of the child, after spontaneous and premature rupture of the membranes, a better method than the use of the forceps, at least in the hands of the majority of practitioners. Dilata- tion by means of rubber bags may in some cases be substituted for that by the fingers. Artificial dilatation can, as a rule, be more readily effected if chloral be first given. In labor delayed by insufficient uterine contractions foetal expression has been proposed by Kristeller,3 and advocated especially by him and by Suchard,4 though Kleinwachter states that it accomplishes no more than friction of the fundus of the uterus. 1 Medical and Surgical Reporter, 1877. 1 Transactions of the American Gynecological Society, vol. iv. '■ Monat. f. Geburt., 1886. * De l'Expression Uterine appliquee au Foetus. THE PATHOLOGY OF LABOR. 465 The following are the directions given by Kristeller for the appli- cation of this method : The patient lies upon her back, near the side of the bed ; by percussion and palpation the limits of the uterus are defined, the neighboring organs are isolated, and the intestinal folds separated. If the uterus incline too far anteriorly or laterally, it is brought into the axis of the inlet. It is then embraced by the hands, their cubital border being directed toward the pelvis, and their palmar face applied to the sides and to the fundus of the uterus, the thumbs being upon the anterior face. The fingers are now directed as far as possible behind the uterus; this succeeds very easily in the case of a multipara whose abdomen is relaxed and yielding, and in a pluripara after the birth of one child. Next press gently the abdominal walls against the uterus thus embraced at the superior part; gradually increase the pressure ; after keeping up this pressure for a certain length of time, it should be gradually diminished. The pressure upon the fundus of the uterus should be directed from above below, while that upon the sides converges toward the axis of the organ. The duration of the compression will vary from five to eight minutes ; it may be repeated at intervals of from one- half a minute to three minutes during a period of ten, twenty, or forty minutes, according to the urgency of the case, the period of labor, and the sensibility of the patient. In the succession of intermittent compressions thus made, it is sometimes necessary to act upon the fundus, sometimes upon the upper and lateral portions of the uterus, never forgetting that when the os is but slightly opened, not readily dilatable, and its diameter not more than five centimetres, nearly two inches, the pressure should be less upon the fundus, more upon the sides of the uterus. On the other hand, when the os is more dilated and yield- ing, compressions of the fundus produce the best effects. In difficult cases a longer pause, from ten to fifteen minutes, should be made after ten or fifteen compressions. Toward the end of the labor the place of applying pressure should not be changed; it can scarcely be made except at the fundus of the uterus. Kristeller directs that, as a rule, if twenty to thirty compressions properly made produce no result, it is better to desist. Medicines may be administered for increasing uterine contrac- tions ; the chief of these are quinine and ergot. It is asserted by reputable observers that the former given in doses of ten to twenty grains has this effect. Wood1 attributes the result not so much to a specific action of the remedy upon the uterus as by its arousing the general nervous forces of the system. Kleinwachter explains the apparently beneficial effect of quinine as resulting from reduc- tion of abnormal temperature ; after the fever abates the pains fre- quently increase spontaneously, and succeed each other rapidly, but not in consequence of the quinine. The late Dr. Albert H. Smith stated2 that in forty-two women, to each of whom he gave fifteen grains of quinine after actual labor-pains had begun, he observed within fifteen minutes a decided increase in the frequency and vigor of the con- tractions, a rapid progress of the labor, and where there was no obstruction, a speedy termination. He claimed that quinine not only increased the activity of the normal uterine contractions, but that it promoted permanent tonic contrac- tion of the uterus after the expulsion of the placenta, that it lessened the lochial discharge in those who previously had it in excess, and that it also lessened after-pains in the majority of cases. Ergot has been more generally given since its acceptance by the profession than any other agent to increase uterine contractions. 1 Therapeutics, Materia Medica, and Toxicology. 2 Transactions of the College of Physicians of Philadelphia, 1875. 3° 466 SCIENCE AND ART OF OBSTETRICS. Wernich's investigations show that it lessens venous tension, and while the blood in the veins increases, that in the arteries dimin- ishes; anaemia of the uterus and its nerve-centres occurs, and hence the uterine contractions become more powerful and longer. Accord- ing to Wood's statement,1 if ergot be given in small doses during labor, the natural pains are simply intensified ; but if the dose be large enough to have a decided effect, their character is altered ; they become not only more severe, but much more prolonged than nor- mal, and finally the intervals of relaxation appear to be completely abolished and the intermittent efforts are changed into one violent, continuous strain. Ergot was introduced into American practice in 1807,2 and received the name of pulvis ad partum ; but as fatal re- sults at least to the child followed its use, Dr. Hosack suggested that it should be called pulvis ad mortem. Many reputable obstet- ricians to-day reject the use of ergot during labor, some indeed in- sisting that it should be banished from obstetric practice. It is believed that this is a mistake, and it is unjust to conclude that because there has been gross abuse in the administration of the agent—it has been given in unsuitable cases, at improper times, or in too great quantities—it should therefore not be used at all. The form in which it is most frequently given is that of fluid extract, each minim of which represents one grain of the powdered drug. A preparation called ergotine, though Squibb denies the right to this name, is also used ; each grain of ergotine is supposed to represent five minims of the fluid extract. The remedy is given by the mouth, and also used hypodermatically, in the latter case a watery solution of ergotine usually being preferred. Ergot is not to be given in the first stage of labor. Neverthe- less, the rule is as has been stated, and exceptions to it are very rare. Next, it should not be given unless the labor be so far ad- vanced, and the conditions of presentation and of the birth-canal are such that an early delivery may be reasonably expected should the uterine force be made normal. Probably the most important rule in regard to its administration, however, is that it must be given in such amount that the normal contractions of the uterus shall be increased; the use of large doses, so that the uterus is roused to continuous action, may be followed, and too often has been, by rupture of the uterus, of the vagina, or of the perineum, and by the death of the child from asphyxia. Ten drops of the fluid extract, or an equivalent quantity of the infusion, or of ergotine, once in fifteen minutes, is a suitable dose when the remedy is re- quired during labor; if given for uterine inertia after labor, the dose should not be less than a teaspoonful. Kleinwachter advises com- bining Wernich's ergotine with tincture of cinnamon, a teaspoonful of the latter at each dose, stating that it then acts more efficiently; it might be well, therefore, to give ten drops, for example, of the fluid extract with a teaspoonful of the tincture of cinnamon in two tablespoonfuls of water. He also recommends as useful in weak 1 Op. cit. 2 Medical Repository, 1807. THE PATHOLOGY OF LABOR. 467 uterine contractions occurring either before or after dilatation of the os uteri, a bath at a temperature of from 82.4 F. to 84.2 F. ; the woman remains in the bath for at least twenty or thirty minutes, and its temperature must be maintained by the addition of warm water from time to time. The same authority remarks that electricity, which has recently come into vogue again, is unreliable. On the other hand, the use of faradization has been strongly advocated by Dr. Baird, of Texas. He claims that the action of electricity is certain, and that it need never fail to produce uterine contractions. The following1 is the description given by Dr. Baird of his method: " The patient is placed in a dorsal position. I then attach one cord to the cop- per plate, and covering it well with a napkin wet with warm water, apply it to the sacro-lumbar region. The other cord I attach to the wrist electrode. I now set the machine in action and attach both cords to it, the one connected with the plate to the positive pole. Then slide it under the bed or couch, where it and the cords will remain out of the way of the necessary attendants. The wrist electrode I now attach to one of my wrists, first covering the wrist with a napkin wet with warm water, then close the circuit by applying the hand, well moistened with warm water, of that wrist to the abdominal wall. By this means I am able to determine the exact condition of the uterus, and to note correctly all the changes which may occur in its contour; I can also estimate the amount of increase which occurs in its contractions, and I am enabled to perform uterine manual pressure; if it is necessary to use both hands for this purpose it can be readily done, and each hand then conveys the current to or from the uterine walls.'' Dr. Baird directs beginning with mild currents, gradually increasing them to the desired strength. He makes the application with the hand " continuous until a sufficient amount of sedation is produced—from five to thirty minutes ; then I open the circuit by removing my hand during the interval between the pains, and close it again when the pain recurs." These are the ends presented by him for the use of electricity: " 1. To modify the pains of labor. 2. To favor a more rapid dilatation of the os. 3. To promote more vigorous uterine contractions. 4. To add tone and strength to all the muscles engaged, and 'increase their power of.doing work.' 5. To abridge the time occupied by the labor. 6. To prevent shock, exhaustion, and post-partum hemorrhage. 7. To insure contraction of the uterus in cases of instrumental delivery. 8. To act as an auxiliary in the induction of premature labor. 9. To arrest hemorrhage, and accelerate labor in cases of placenta praevia. 10. To prevent an undue expenditure of nervous force in all cases of debility from whatever cause, thus leaving the patient in a condition to secure a speedy and favorable convalescence." I have thus presented the extraordinary claims in behalf of electricity in ob- stetrical practice advanced by Dr. Baird, but other observers and longer experi- ence must test their value; most probably some at least of the indications he has given will be rejected. Dr. Mary Putnam Jacobi2 has reported a case of labor at seven months in which dangerous delay occurred from rigidity of the os. All the usual and approved means of relaxing the rigidity, including chloroform inhalation, had been used unsuccessfully, when she 1 American Journal of Obstetrics, 1885. 2 Ibid., Jan. 1886. 468 SCIENCE AND ART OF OBSTETRICS. resorted to faradic electricity ; a small electrode was applied to the os, the other held in the patient's hand, and the application was continued fifteen minutes. Immediately afterwards the introduction of the finger into the os, heretofore impossible, was readily done, and artificial dilatation followed by delivery with the forceps. If after the rupture of the membranes and complete dilatation of the os labor does not advance, instrumental delivery will in many cases be the best resort both in the interest of the mother and of the child. " When the head has remained two hours in the vagina without making any progress, we do not wait, but end the labor by the application of the forceps."1 This is done in the interest of the mother, though the child may not be suffering; in some cases the condition of the latter will not permit even this delay, and instru- mental delivery must be at once employed. Feeble and inefficient uterine contractions in the third stage of labor usually have as their consequence uterine hemorrhage, and under this head they will be considered. C. Perversion of Uterine Force may be manifested by continuous general or by partial uterine contraction ; the former is sometimes called tetanic, while the latter causes what is known as a stricture. Tetanic or continuous contraction of the uterus occurs oftener in old primiparae; it may be caused by ergot given at an unsuitable stage of labor, or in too large a quantity; by irritation of the os from fre- quent examinations or other interference with the progress of labor, or result from disproportion between the size of the fcetus and the pelvis, the uterus struggling to overcome great or invincible resist- ance. The condition is generally associated with severe suffering. Of course the so-called tetanic contraction of the uterus, if there be no hindrance to the birth, simply causes this to occur more rapidly; but if there be such hindrance, as from a malpresentation, or from pelvic deformity, rupture of the uterus is liable to occur. This condition, too, makes difficult or impossible the introduction of the hand into the uterus for rectifying an unfavorable presentation or position. It usually occurs after the rupture of the membranes, and hence may interfere with the utero-placental circulation, or produce direct pressure upon the cord, and in either case the child may perish from asphyxia. Chloroform given until deep anaesthesia is produced will be neces- sary in cases demanding an obstetric operation, e. g., podalic version in presentation of the shoulder. Friinkel advises a hypodermatic in- jection of morphine and of atropine to be given before the chloroform inhalation ; in five or ten minutes the uterus relaxes, and the intro- duction of the hand can be readily made. Charpentier directs chlo- ral by rectal injection if the spasmodic condition occurs in the first stage of labor, but if in the second, chloroform inhalation. Partial uterine contraction is usually an accident of the third stage of labor; in its most common form it is known as hour-glass con- traction. In the great majority at least of these cases the condition Charpentier. THE PATHOLOGY OF LABOR. 469 is not pathological; there is general contraction of the uterine body while the cervical canal remains relaxed, and the apparent stricture is, according to most, the normally contracted internal os, while the placenta remaining in the uterine cavity prevents the complete approximation of it's walls. Kleinwachter denies the existence of partial uterine contractions, or partial ute- rine spasms, but asserts that in consequence of the relations of the muscular fibres to each other, the uterus must contract as a whole. The so-called spasmodic contraction of the external os uteri is nothing more than a condition in which the upper part of the uterus has not manifested enough power to overcome resistance ; the os is only slightly dilated, and it presents sharp edges, but as soon as the con- tractions have become more vigorous it opens, and the so-called spasm ceases. Again, in the third stage of labor, the placenta may not be detached spontaneously, in consequence of adhesions, and the uterus takes the form of an hour-glass. The relaxed lower uterine segment represents a funnel, the narrowest portion of which is above. The upper portion of the uterus contracts around the remaining pla- centa, and immediately below the walls of the body meet, as nothing intervenes ; but the lower segment is found, as after every normal birth, in a condition of par- tial paralysis, that is, it is relaxed. The so-called stricture, therefore, is not a pathological phenomenon, but is the normal condition after the delivery of the child. While this is the most frequent form of stricture, and, as Kleinwachter states, is not a pathological condition, yet the recent investigations of Bayer1 seem to prove that from the anatomical construction of the uterus strictures may occur at various parts of the organ. Clinical observation, too, confirms this view, though the occurrence of such cases is exceedingly rare. Excessive pain in labor may be caused by very great distention of the uterus, by peritoneal inflammation, by malpresentation or great size of the fcetus, or it may arise from a general hyperaesthetic con- dition. It does not interfere with the action of the uterus, but it does prevent the assisting action of the abdominal muscles in the second stage of labor. In the treatment of excessive pain, of course, the cause must be ascertained, and, if possible, removed; but in many cases remedies must be given directly to remove the suffering; for this purpose we may use chloral or laudanum by rectal injection, or morphine hypo- dermatically, or anaesthetic inhalation. Anomalies of Form and of Position of the Uterus.—The arrest of pregnancy in a rudimentary horn of the uterus has been stated in connection with the subject of ectopic development of the ovum. But in the cases in which the pregnancy has occurred in the fully de- veloped horn, either of a uterus unicornis or bicornis, its course has been uninterrupted and the labor normal; nevertheless, in some instances of the latter malformation it is stated that the unimpreg- nated horn has interfered with the entrance of the foetus into the uterus, and that there is a greater liability to a transverse position of the foetus. Instances have occurred in which both horns were preg- nant, the labor taking place in each at or near the same time; in other cases there has been an abortion from one horn, while the pregnancy in the other was completed. Cruveilhier has mentioned a curious instance of double uterus with duplicity of the vagina also, the woman being pregnant; she was visited by one physician who 1 Op. cit. 4JO SCIENCE AND ART OF OBSTETRICS. asserted that she was not pregnant, and then by another who found her in labor; the difference of opinion arose from the fact that one practitioner made a digital examination through the vagina which communicated with the non-pregnant half of the womb, while the second making his through the other vagina, recognized the dilata- tion of the os and the presenting part of the foetus. Latero-positions of the uterus, though usually rectified by uterine and abdominal contractions bringing the uterine in correspondence with the pelvic axis, can easily be corrected if necessary by having the patient lie upon the side opposite to that of the displacement. Anteversion or anteflexion is remedied simply by the dorsal posi- tion, or by the abdominal bandage ; Dr. Barker1 states that in some cases of pendulous abdomen he has been obliged to place the pa- tient in the dorsal position, her head and shoulders being consider- ably lower than her hips. Prolapse of the uterus can only occur in case of a very large pel- vis ; very rarely the head passes out still inclosed in the lower ute- rine segment. Occlusion and Narrowing of the Os Uteri.—Conglutination of the external orifice is occasionally met with. The labor is tedious, the lower uterine segment greatly thinned, and upon digital examina- tion no os can be felt, but usually a slight pit or depression marks its place, though sometimes this may fail; the closure in most cases is simply from a thickened secretion, but may be consequent upon a superficial endometritis. During a contraction of the uterus pressure should be made with the point of the finger or with the uterine sound at the depressed place, or if this be absent, at that which is most thinned, and the os will open ; it may be widened simply by the finger, or, as in a case2 reported by the late Dr. Albert H. Smith, by means of a uterine dilator. In rare cases it happens that the union between the maternal and fcetal membranes in the immediate vicinity of the external orifice is so firm that the lower segment of the uterus cannot retract over the ovum. Should this be the case, detachment of the membranes or rupture of the amnial sac is indicated. Cicatricial closure of the os may have resulted from an inflamma- tion following a previous labor, or from the application of powerful caustics to the cervix. It is rarely complete, and if there be atresia, of course, it must have been developed subsequently to impregna- tion. In most cases, even of atresia, nature is able to triumph over the obstacle, but the dilatation may require one or two days; it is rarely necessary to resort to incisions. Under the different names of anatomical, simple, or mechanical rigidity of the os, a condition is met with, especially in old primi- parae, which causes great delay, and in rare cases presents an invin- cible obstacle to labor. The cervix has not been completely effaced, and the borders of the os are thick, resistant, hard, but not sensitive. 1 Transactions of the American Gynecological Society, vol. v. p. 274. 2 Medical and Surgical Reporter, 1877. THE PATHOLOGY OF LABOR. 471 In some instances the neck is hypertrophied, and in these it is not unusual to find after labor has continued for some time a thrombus involving the anterior or posterior lip. At first warm baths, warm vaginal douches, and a laudanum injection into the rectum may be tried, then artificial dilatation; Schroder advises incisions freely made by curved scissors or by a probe-pointed bistoury. Dr. Robert Barnes, from whom the subjoined illustration is taken, narrates a case in which the labor was impeded by an hypertrophied cervix : "A primipara, aged twenty-two, was in labor. The cervix protruded through the vulva about Fig. 164. Illustrating Labor with Hypertrophic Elongation of the Cervix. three inches, forming a mass equal to a man's wrist in circumference. After reducing the cervix in the vagina the head could be felt. The cervix had a hard, gristly feel. Free incisions in the os externum were made, so that the os externum was freely opened up to meet the natural expansion of the os internum. She was then delivered after an anxious labor of fifty-two hours." Neoplasms of the Uterus—{Fibroid Tumors and Cancer).—The in- jurious influence of uterine fibroids upon labor depends upon their 472 SCIENCE AND ART OF OBSTETRICS. size and their position. If the tumors are small, or subperitoneal, they may present no complication, and, indeed, may not be recog- nized in some cases until the labor is over. Tumors of the neck, when large, prevent the presenting part from entering the pelvis; interstitial tumors of the body may be the cause of rupture of the uterus, or of post-partum hemorrhage, especially if the placenta be attached to the part of the uterine wall which they occupy. The relative proportion of fibroids of the neck to those of the body is much greater in pregnant than in non-pregnant women. Thus, while there are twenty cases in which these tumors are situated in the body to one where such a growth occupies the neck of the uterus in the non-pregnant, the proportion is only five to one in the preg- nant, as ascertained by Chahbazian from the study of 310 cases of uterine fibroids complicating pregnancy.1 Chadwick* has reported ten cases of pregnancy and labor com- plicated with fibroids, with the following results : 1 miscarriage, 7 recoveries of mother and 7 living children, 2 deaths of mothers and 2 stillborn children. Fortunately in one-half of cervical fibroids observed in pregnancy or labor the tumors are pedunculated, 38 out of 76, according to Chahbazian's statistics. Another notable fact is that transverse and pelvic presentations are greatly increased, so that the two nearly equal the number of vertex presentations. In Chadwick's cases there were in 9 labors 7 head presentations and 2 transverse. In the treatment of fibrous tumors of the uterus complicating labor, Lefour advises at first to wait, letting Nature accomplish all she can, but this delay must be determined by the interest of the mother and child. Next, act upon the tumor by its removal, or by pushing it up from the pelvis. Extirpation of the tumor was first performed by Michellacci in 1791.3 The operation has been re- peatedly done since, and with almost unvarying success as far as the mother is concerned, but with a very large fcetal mortality. As in a large proportion of cases the tumor is cervical, and as in one-half of these it is pedunculated (see Fig. 165), its removal will, under such circumstances, usually be neither difficult nor dangerous. If the tumor has no pedicle it must be enucleated. But other tumors may occupy such a position that they cannot be removed, as, for example, a subperitoneal growth with a long pedicle that has dropped into the pelvis, or a tumor involving the neck and the lower part of the body of the uterus. Here an effort must be made to push it above the pelvic inlet. The patient is put in the knee-chest position, and the fingers or the entire hand introduced into the vagina and used to press the tumor out of the way ; of course pressure should be made only in the intervals between contractions. If it is impossible to either extirpate the growth, or to remove it from the pelvis, and space permit, the forceps or podalic version may be next tried. The results from the forceps are very much more favorable than those 1 Des Fibromes du Col de l'Uterus au point de vue de la Grossesse et de l'Accouchement. " Boston Medical and Surgical Journal, July 30, 1885. ■' See Chahbazian, op. cit. THE PATHOLOGY OF LABOR. 473 given by version, and therefore the former method of delivery is to be preferred. In 20 cases1 of applications of the forceps, 12 mothers and 8 children were saved, while in a like number of versions only 7 mothers and 3 children were saved. Embryotomy is the next Fig. 165. A Polypus occupying the Pelvic Cavity in Labor. resort; but while, of course, all the children'are lost, it gives a fearful mortality for the mothers, 66 per cent of them perishing. The Caesarean operation has been regarded as the final resort, and general statistics have shown it to be unusually fatal when per- formed on account of uterine fibroids. One reason for this peculiarly great mortality is, that its performance is generally delayed until the patient is so exhausted that her condition is well nigh-hopeless. Cancer of the uterus gives a very unfavorable prognosis ; Cohn- stein found that of 126 mothers only 54 survived, while 72 died during labor or in the puerperal period. If the disease partially affects only the lips of the uterus, labor may go on without special difficulties, and there may be no great hemorrhage. But if the entire cervix be affected, and especially if the disease has extended to the adjoining part of the body of the uterus, it is impossible for the dis- eased tissue to dilate, and the expulsion of the fcetus can only occur 1 Chahbazian, op. cit. 4/4 SCIENCE AND ART OF OBSTETRICS. after rupture of the unyielding ring, which causes such a serious hemorrhage that may be difficult or impossible to arrest. Incisions of the cervix thus degenerated are dangerous because of consequent hemorrhage, and, according to Kleinwachter, because they must be carried through the entire wall and thus injure the peritoneum; nevertheless, Charpentier advises them, and directs that they should be followed by the application of the forceps. Hermann1 states that " when labor has actually come on, expansion of the os uteri should be aided by making numerous small incisions in its circumference." He also says that when dilatation is in progress, if it is necessary to accelerate labor the forceps is preferable to version. When the disease, however, involves the entire cervix, the timely performance of the Caesarean operation is plainly indicated, both in the interest of the mother and of the child. Anomalies of Adjacent Organs.—Chief among these which may interfere with labor are tumors of the ovary, the danger or difficulty Fig. 166. An Enlarged Ovary blocking up the Pelvic. Cavity in Labor. depending upon their size, position, mobility and nature. Thus, an immobile, solid tumor in the pelvis is more serious than a fluid 1 London Obstetrical Society's Transactions, vol. xx. THE PATHOLOGY OF LABOR. 475 cystic tumor. Even if the tumor furnished no obstacle to the birth, there may be, as Kleinwachter states, twisting of the pedicle during labor, and this be followed by rupture of the cyst in childbed with fatal peritonitis. Dermoid cysts give a more unfavorable prognosis than those which are liquid, because they are fixed, and their con- tents solid, so that they as a rule cannot be pushed out of the way, nor their size lessened by puncture. Fibroid tumors of the ovary, especially if calcareous change has occurred, may cause great diffi- culty by descending into the pelvis in advance of the presenting part of the fcetus, and thus preventing its progress ; on account of their hardness it is very difficult when they have thus become fixed, to distinguish them from pelvic exostoses.1 Remy2 sums up the treatment of ovarian tumors interfering with labor as follows: Do not delay intervention too long; begin by puncturing the tumor, and if this fails, make an incision with proper precautions. As means of extraction the forceps is preferable to version, but each operation is dangerous in case of rupture or inflam- mation of the cyst. In case of failure craniotomy and the Caesarean operation remain; statistics in regard to the mother are more favor- able when craniotomy is done. If the abdomen is opened an effort should be made to remove the tumor, and not resort to section of the uterus until after this has failed. Rectocele and Cystocele.—Obstruction of the vagina from pro- jection of the rectum loaded with feces, or of the bladder filled with urine, can scarcely offer a serious hindrance to childbirth, especially if the obstetrician gives heed early in the labor to having each of these organs thoroughly evacuated. Ramsbotham, however, has stated that he has seen many instances of the bladder prolapsing before the head, and mentions two cases in which it was punctured, one practitioner mistaking it for a dropsical head, and the other for the bag of waters. Such errors can only result from culpable ignorance or carelessness. Dr. Busey3 is the author of a paper upon cystocolpocele complicating preg- nancy and labor: by cystocolpocele is meant prolapse of the bladder into the vaginal passage; and if the sac occupies the cavity of the pelvis, filling the hollow of the sacrum, pushing the os uteri beyond reach and occluding the vaginal passage, it is complete. One of the most marked results of this displace- ment of the bladder is lingering labor. The diagnosis is made by introducing the catheter into the bladder and evacuating it. This displacement of the bladder in relation to pregnancy and labor was very fully considered by Broadbent in 1863 in a paper read before the London Obstetrical Society. In referring to the diagnosis he states: " The prolapsed condition of the bladder is readily recog- nized on examination, especially when it contains urine in any considerable quantity. The cavity of the pelvis is found to be occupied by a bag of fluid easily distinguished from the fcetal membranes by the fact that it springs from the pubis, and does not permit the finger to pass between it and the symphysis. As this sac, the bladder, fills up the hollow of the sacrum, the os uteri cannot be reached till the urine is evacuated ; and if this is done by the catheter, the instru- ment can be felt -from the vagina and followed to every part of the bladder. When the bladder is perfectly empty the displacement may be overlooked, but 1 Kleinwachter, op. cit. 2 Op. cit. 3 Transactions of the American Gynecological Society, vol. xii. 476 SCIENCE AND ART OF OBSTETRICS. the finger, instead of circumscribing the lower segment of the uterus readily, meets anteriorly with the bladder, passing from the symphysis pubis to the uterus, and usually disposed in rugae; the introduction of the catheter at once makes the case clear." Fig. 167. Cystocele complicating Pregnancy. Whether known as cystocele, prolapse of the bladder, or cysto- colpocele, the obvious indication is to empty the organ and press it out of the way of the descent of the presenting part of the fcetus. Vesical calculi have in very rare cases obstructed the birth- passage. It will generally be easy to push a tumor thus formed up out of the pelvis; if not, an opening may be made into the bladder from the vagina, and the stone or stones removed, after which sutures are to be introduced as in the operation for vesico-vaginal fistula. Vaginal cicatrices, consequent in most cases upon inflammation following a preceding labor, may require to be divided by bistoury or scissors ; similar treatment maybe necessary in case of a resisting hymen opposing the descent of the head, though in.the majority of cases this is unnecessary. CHAPTER VI. THE PATHOLOGY OF LABOR {continued)—FCETAL DYSTOCIA. Fcetal dystocia includes dorsal displacement of the arm, excessive size of the fcetus without, or resulting from, pathological cause, dif- ficult labor in plural pregnancy, the delivery of monsters, and un- favorable and complex presentations. Dorsal Displacement of the Arm}—This has occurred in vertex as well as in pelvic presentations. In the former variety Sir James Fig. 168. Fig. 169. Dorsal Displacement of the Arm. Dorsal Displacement of the Arm in Footling Presentation. Simpson, who first described the displacement, advised bringing the arm down, thus making a complex presentation, that of the hand and head. Playfair thinks it better to perform podalic version, and has done it successfully after having failed to deliver with the forceps. 1 Illustrative cases of this anomaly will be found in Dr. Alexander R. Simpson's Contribu- tions to Obstetrics and Gynecology, and in a paper by Dr. Freeland Barbour, Edinburgh Obstetrical Society's Transactions, vol. xii. 478 SCIENCE AND ART OF OBSTETRICS. If the displacement occurs in head-last delivery, Barnes advises rotating the child in the opposite direction to that rotation which he believes caused the difficulty. " By rotating the child back in the contrary direction, so as to restore the original position, you may possibly liberate the arm. At any rate, you will render more easy the further proceeding that may be necessary. You carry the trunk well backward, so as to give room to pass your forefinger in between the symphysis pubis and the child's shoulder; and hooking on the elbow, draw this downward, and then forward. It may be useful, as a preliminary step, to gain room by first liberating the other arm."1 Barnes further states that if the arm cannot be liberated, craniotomy may be necessary. Great Size of the Foetus.—This may relate to the head only, or the body also. The diagnosis of great size of the fcetal head prior to birth is uncertain; abdominal palpation previous to labor, or during labor, and by touch finding the distance between the anterior and the posterior fontanelle to be greater than usual, are thought by some to furnish useful information. Could we know the sex of the child we might be assisted in the diagnosis of the size of the head. In multiparas advanced in age it is usual to find that the child if male has a very large head. In primiparae more than thirty years of age the children are larger than in young primiparae. Possibly the patient's previous labors have been protracted in consequence of the great cranial development with premature ossification of the bones of the head, and they all may have ended in the birth of dead children. In case of prolonged pregnancy, as a rule, the develop- ment of the fcetus, especially of the head, is greater than if the labor occur at the normal time. The subject of premature ossification of the fcetal head as a cause of dystocia has been presented by Blake. He takes the ground that it would be a very judicious rule of practice in any dystocia caused by a large and prematurely ossified fcetal cranium not to consider the question of forceps delivery. " We may resort to the perfo- rator with less than our usual repugnance to its use if we bear in mind the fact that quite a proportion of children born with closed or partially closed fontanelles and ossified sutures will, if not early cut off with symptoms of brain irritation and pressure, be epileptic and idiotic."2 Jacobi states that premature ossification of the sutures and fonta- nelles occurs particularly with the first child, and in the milk of young mothers the phosphates are predominant as compared with the milk of mothers later in life.3 The induction of premature labor is clearly indicated in the case of a pregnant woman whose previous pregnancies have ended in stillbirths from the great cranial development of the children. One of the most frequent causes for the application of the forceps is the necessary disproportion which exists between the head and the 1 Obstetric Operations. - American Journal of Obstetrics, vol. xii. ■■ Ibid., p. 358. THE PATHOLOGY OF LABOR. 479 normal pelvis; if the former be unusually large, turning is not advis- able, but in some instances craniotomy may be necessary. Jacquemier has said that after spontaneous or artificial delivery of the head it was thought by some that the shoulders became too large by development of the chest, and presented an obstacle to the escape of the fcetus so that it was impossible for the uterus alone or assisted by the usual artificial means to expel it, at least as promptly as required by its precarious situation thus suspended be- tween intra- and extra-uterine life. It is not, however, the great volume of the shoulders so much as that of the chest which causes the delay, conjoined with some degree of uterine inertia. When this difficulty is anticipated the practitioner must beware of deep anaesthesia, provided an anaesthetic be administered, during the delivery of the head, lest, even if uterine inertia be not thereby invited, the voluntary expulsive efforts of the patient may fail when they are most needed. Great Size of the Fcetus from Pathological Causes.—I. Hydrocepha- lus.—By this is meant abnormal accumulation of serous liquid in the cranial cavity. It is met with once in 3000 births. It has been attributed to syphilis, alcoholism, cretinism, and to marriages of consanguinity. The mothers were, in many instances, past forty years of age, and lived in bad hygienic conditions. Poullet1 states there are cases in which women have a predisposition of unknown nature to produce hydrocephalic offspring, and cites an illustration from Franck of one who had in successive pregnancies seven chil- dren with hydrocephalus, and another from Goelis of one who had six. He also directs attention to the investigations of Dareste, who, in the artificial production of monstrosities, has caused dropsy of the nervous centres in experiments upon the embryo of the hen. In hydrocephalus the cranial bones are usually much thinner than normal, and more flexible ; they are flattened, are much more widely separated, and the fontanelles larger, and in some cases the latter occupy a greater extent than the ossified parts. In many cases of hydrocephalic heads there is a supplementary fontanelle, known as the fontanelle of Gerdy, situated between the anterior and the pos- terior fontanelles. One of the characteristics of the hydrocephalic head is the marked triangular form of the face, the base of the triangle being at the fore- head, which is broad and prominent, and presents a distinct suture, and the sides of the triangle rapidly approach, meeting at the chin. The great development of the head interferes with the normal accommodation of the fcetus, and hence there is a much larger pro- portion of presentations of the pelvis.2 Poullet found in 106 cases 30 in which the pelvis and 8 in which the shoulder presented. So far there has been no example of face presentation in hydrocephalus. 1 De l'Hydrocephale Fcetale dans ses Rapports avec la Grossesse et 1'Accouchement. Paris, 1880. , . , c u 3 Griffith suggests that the hydrocephalic head is more frequently in the upper part of the uterus, because the fluid it contains has a less specific gravity than that of the amnial liquor. London Obstetiical Society's Transactions, vol. xxix. 48O SCIENCE AND ART OF OBSTETRICS. If the enlargement be not very great, spontaneous delivery occurs after a more or less difficult and tedious labor: " But in the largest number of published observations the efforts of nature were entirely powerless to effect the expulsion of the hydropic head, and after alternatives of contractions and inertia from exhaustion of the uterus, final inertia supervened, or uterine rupture occurred, the woman dying undelivered ; this, at least, is the course of sponta- neous labor without more or less able intervention, when the head was large."1 In some instances, however, delivery may occur by the fluid passing from the interior to the exterior of the cranium, or it may become infiltrated in the connective tissue of the neck, of the chest and of the abdomen, thus producing a general oedema. A still more singular lessening of the size of the hydrocephalic head may result from the fluid passing into the pleural or into the peri- toneal cavity, and then the labor spontaneously ends. In some instances rupture of the head occurs, more frequently in presenta- tion of the pelvis than of the head, and with the free evacuation of the fluid the obstruction to labor ends. If the slow labor de- mands the application of the forceps, the introduction of the blades and the locking are difficult, the handles are wide apart, and efforts at traction usually end in the blades slipping. It should be added, however, that if Tarnier's forceps is used, this accident is much less likely to occur. I have with it delivered a hydrocephalic head when a Hodge's instrument had been unsuccessfully tried. Prognosis.—This is most unfavorable for the child. The statistics of Chassainat2 show that in 60 cases of fcetal hydrocephalus 41 died before or during labor, and only 19 were born alive ; only 4 of the 19 lived for several years. Poullet regards this result as too favor- able, stating that he has been unable after diligent search to find a case in which hydrocephalus caused dystocia and the child lived. Diagnosis.—If there is not an excess of liquor amnii it may be possible to recognize the great disproportion between " the round and voluminous tumor made by the head, and the other tumor at the opposite extremity of the fcetal ovoid, and which may be distin- guished as the pelvis." Upon auscultation when the head is below, contrary to that which is usual in head-first labor, the sounds of the fcetal heart are heard most distinctly higher than the umbilicus. Combining digital examination, after labor has begun and the mem- branes have ruptured, with abdominal palpation, it has sometimes been possible to perceive distinct fluctuation between the touching finger and the palpating hand. By vaginal touch alone a large sur- face, less rounded than the normal fcetal head, is felt; it seems like the bag of waters at first, but a more careful examination proves that its walls are thicker and more resisting than those of the fcetal sac, and possibly the hair may be felt; during a uterine contraction instead of the scalp being wrinkled it remains smooth and tense; it may be difficult to recognize the fontanelles or sutures, for the mem- branous spaces intervening between the bones are wide, but it will 1 Poullet, op. cit. 2 Quoted by Poullet. THE PATHOLOGY OF LABOR. 481 be possible to touch one of the cranial bones which will usually be found thin and quite yielding, and it is more flat and has a greater mobility. A macerated head, when the death of the fcetus has occurred some time before, may give similar increase of mobility, but there is no increase in the size of the head ; the bones override during a uterine contraction, the sounds of the fcetal heart cannot be heard, and the mother has not recognized fcetal movements for some days. If the diagnosis is not clear using one or more fingers in the vaginal examination, the entire hand is to be employed. The diagnosis of hydrocephalus in head presentation is sometimes difficult, but the difficulty is still greater in presentation of the pel- vis ; in most cases of the latter it is not made until after the body is delivered, and then a delay arises from the difficulty or impossi- bility of the head entering the inlet During this unexpected delay it is not unusual for the child to die. Possibly if a finger be now introduced so as to feel the occipital bone it will be found thinner and less resisting than normal; by abdominal palpation it will be ascertained that the uterus is much larger than it should be after the delivery of the body of the fcetus; if there be difficulty in disen- gaging the arms the great distance to which the finger must be carried to effect this disengagement is a probable indication of a hydropic head. Prognosis.—Poullet's statistics, including 106 cases, show that 21 mothers died ; Spiegelberg found in 94 cases 24 deaths. In 74 cases collected by Keith there were 16 of rupture1 of the uterus. Compli- cations, such as polyhydramnios, placenta praevia, uterine inertia, rigidity of the cervix, etc., add to the gravity of the prognosis. Treatment.—There is but one thing essential, and that is, lessen the size of the head. Schroder and some others have advised punc- ture by a fine trocar with the forlorn hope that the child may sur- vive, although he stated in 1880 that he knew no instance in which such survival occurred. The advantage of perforation is that the finger can be introduced into the opening, then curved so as to exert slight traction, thus, in some cases, speedily effecting delivery. Some obstetricians have recommended delivery by podalic version immediately after the evacuation of the fluid, but if the uterus be retracted it may be ruptured during the operation, and most obstet- ricians prefer delivery by the head ; the extraction may be made with the forceps, if the instrument does not slip, or if it does, with the cephalotribe; Pajot2 suggests extraction by taking a rod of wood two inches and a half long, to the middle of which a cord is attached, it is passed into the cranial perforation, which should be made through a bone and not in one of the sutures or fontanelles, given a transverse direction, and then pulling on the cord. 1 The late Dr. John Neill, of Philadelphia, reported in the Medical Examiner, 1854-5, a case of very large spontaneous rupture of the uterus in a woman in her sixth labor, the child being hydrocephalic; he performed the Csesarean operation twelve hours after the accident, removed the child from the peritoneal cavity, and the woman recovered. 2 According to Poullet, this method was first suggested by Augier about the middle of the last century. 31 482 SCIENCE AND ART OF OBSTETRICS. Perforation is advisable, too, in most cases if the pelvis presents, though in some the delivery may be effected by traction upon the lower limbs conjoined with supra-pubic pressure ; this traction, how- ever, has, in a few cases, torn the body away from the head, leaving the latter in the uterus, and therefore the force thus exerted should never be so great as to run this risk. Perforation has been made through the palatine vault, at the occipital bone, behind the ear, or through a lateral fontanelle. The almost insuperable difficulty in reaching the head with an instrument led Van Huevel to suggest an easier method of evacuating the dropsical fluid, and it has in some cases been successfully employed. The spinal canal is opened as near the body of the mother as possible by a transverse incision two inches long; then a rubber sound with a firm mandarin is easily made to pass through the opening and up to the cranium ; upon the withdrawal of the mandarin the fluid readily escapes through the catheter, and the head lessened in size may be readily withdrawn by traction on the body or lower limbs. (Fig. 170.) Fig. 170. Evacuating Fluid in Hydrocephalus by Opening Spinal Canal. Sir James Simpson, in the case of a woman who had in her two pregnancies hydrocephalic children, the delivery of each being possible only by cranial per- foration, in her third pregnancy induced premature labor, and she gave birth to a living child. THE PATHOLOGY OF LABOR. 483 2. Encephalocele.—The tumor formed by an encephalocele may be hydropic, though it is not often that the enlargement from this cause is so great as to furnish an impediment to birth, but if it should the treatment is puncture. 3. Hydrothorax.—This is rarely a cause of dystocia; it is seldom found independently of ascites, when it is, the latter is usually the obstacle to expulsion of the child. 4. Ascites.—This is commonly complicated with inflammatory lesions of the peritoneum or multiple lesions of the viscera con- tained in the abdominal cavity.1 The quantity of ascitic fluid varies from ten or twelve ounces to several pints. The diagnosis is made during labor; after the expulsion of the head the body remains, and cannot be withdrawn by traction; if the hand is now introduced into the pelvis, and the abdomen of the child felt, the cause of the delay is recognized. The treatment is puncture with the trocar; in some cases the abdominal walls are so thinned that the perforation has been made by the finger. 5. Hydronephrosis, Retention of Urine in the Bladder.—Either of these may be the cause of dystocia, and each requires tapping before the fcetus can be born. 6. Diseases of Various Organs. — Rogers has reported2 a case of dystocia caused by fibro-cystic disease of the undescended testicles; excessive size of the liver, of the spleen, and of the pancreas, disten- tion with fluid of an imperforate uterus, or vagina, aneurism of the aorta, and exomphalos have been rare causes of dystocia. 7. New-growths and Foetal Inclusion.—Fibrous, cystic, and fibro- carcinomatous tumors may be so large as to require operative influ- ence. The same remark is applicable to the tumor formed by fcetal inclusion; this may be superficial or profound; in the former case it is usually situated in the neck, scrotum, perineum, etc., and in the latter most frequently in the abdominal cavity. Two explanations of the origin of such a formation have been given : Either two sep- arate germs have been successively fecundated, and one penetrates into the other—the theory of penetration, as it has been called—or an ovule containing two germs is fecundated, and one growing more rapidly incloses the other. It may be stated in general that when fluid collections, either in cysts or in normal cavities, cause dystocia, evacuation by puncture is indicated; solid tumors pro- ducing the same result may be lessened by knife or scissors. 8. Single Monsters—Acardia, Acephalia, Anencephalia, Hemicepha- lia.—An acardiac monster is described by Schroder as originating from anastomosis of the vascular systems of twins contained in the same chorion, consequently of the same sex, the blood-pressure being greater in one than in the other; in the latter the circulation be- comes too feeble, as a consequence the heart, the lungs, and a greater or less part of the trunk atrophy, and the monstrous fcetus is nourished at the expense of the one which is normally developed. The stasis thus produced in the umbilical vein which leaves it, may 1 Charpentier. American Journal of Obstetrics, vol. ii. 484 SCIENCE AND ART OF OBSTETRICS. have as its consequence considerable hypertrophy and an (edema- tous tumefaction of the subcutaneous connective tissue. He adds that the acephalous monster is born frequently by the feet half an hour or three to twelve hours after the well-developed child. The hypertrophy of the trunk may render extraction necessary, and if this hypertrophy is very great make it exceedingly difficult; Mayer in such a case had to lessen the size of the trunk by the perforator. In hemicephalia or anencephalia there may be a large collection of serum in the ventricles, so that there is hydrocephalus. Difficulty in labor may come from the great development of the shoulders, especially if the head presents, for that is so small, unless enlarged as just mentioned, the way is not opened for the descent of the trunk. Delivery by podalic version is indicated; if version cannot be done, the hand may be applied to the head, or the finger intro- duced into the mouth, or the blunt hook used to make traction ; if these means fail, the arms should be brought down. Double Monstrosities.—Such monstrosities are found four times more frequently in multiparae than in primiparae, thus corresponding with the relative frequency of labors in these two classes. In almost all cases the labor ends spontaneously, partly from the fact that fre- quently it is premature, and partly because the mother in the great majority of instances has previously given birth to one or more children. In regard to the different varieties, some conjoined twins are united either by the heads or at the pelves so that they already are in a straight line, or can be brought in such line, and therefore while the entire bulk is increased, the twins not being placed side by side or back to back, delivery presents no difficulty. But instead of this the twins maybe united at the thorax or abdomen, or at the sacrum and lower portion of the vertebral column, or there maybe a single trunk with separate heads, or two trunks with the heads united. Finally there maybe a polymelic monstrosity—one fcetus is perfect, but the other is formed of one or more members which are inserted in the former. The monstrosity last mentioned is usually delivered spontane- ously and without difficulty. In regard to the other varieties, the results are as a rule more favorable if the lower part or parts descend first, and therefore, should the diagnosis be made during labor, podalic version is usually indicated. So, too, podalic version has been successfully done after the spontaneous delivery of one of the heads of united twins, the feet of both twins brought down, and then the bodies, and the head that was unborn delivered. Of course, the mother's life is of the greater importance, and therefore the obstetrician will have in the case of a monstrosity less hesitation in resorting to mutilating operations upon it. The Cae- sarean operation is never indicated for the purpose of saving the life of single or double monstrosity. There are two instances of children born with three heads, and in one the child was born alive, and continued to live three days, sucking and crying with each of the three mouths. THE PATHOLOGY OF LABOR. 485 Dystocia in Plural Deliveries.—Interference of one foetus with the delivery of the other is a rare complication of twin labors. Among predisposing causes Besson1 mentions the great size of the pelvis, the small size of the foetuses, and their occupying a single sac; and among the determining causes the use of ergot, untimely rupture of Shows Head-locking, both Children presenting Head-first. a fcetal sac, and other interferences with the natural course of labor. This interlocking of the foetuses may occur in every one of the dif- ferent varieties of presentations observed in labor with twins. Delay may be caused by both heads presenting at the inlet, but this must be very rare, for Besson gives only one example. More frequently when the heads are first, one descends into the pelvis slightly in advance of the other, then the latter is forced down so that usually the neck of the first child is pressed upon. In some cases the first head is delivered spontaneously or by forceps, and then it is impos- sible to effect delivery of the trunk, or the arrest in labor may come before this. The illustration, Fig. 171 (from Barnes), shows very well this form of interlocking. In case the first infant presents by the pelvis and the second by the head, the body of the former is delivered, and then the labor stops from the two heads entering the pelvis or coming to its inlet together. One form of this difficulty is presented in the accompany- ing illustration (also from Barnes). In some cases the head of the second child is fixed upon the thorax of the first. When the heads are locked together this may not be, as in the illustration, by the 1 Dystocie Specielle dans les Accouchements Multiples. 486 SCIENCE AND ART OF OBSTETRICS. chins, but by the occiputs, or by a chin and occiput, or simply by the sides of the heads. When the first child presents by the head, the second by the pelvis, the bag of waters of the former has descended so as to in- Fig. 172. Shows Head-locking, First Child coming Feet-first; Impaction of Heads from Wedging in Brim.—D, Apex of wedge. E C, Base of wedge which cannot enter brim. A B, Line of decapitation to decompose wedge and enable head of second child to pass. terfere with the transmission of the latter, and the labor been delayed until the obstetrician ruptured the obstacle. Besson quotes a case of this difficulty occurring in the practice of Mauriceau. When both foetuses present by the pelvis, difficulties may occur from the simultaneous descent of the feet; and in one case of this kind, reported by Armand, the midwife exerted such powerful pull- ing that she brought away the trunk of each child, leaving the heads in the uterus. Schultze delivered a woman pregnant with twins, four feet and one hand presenting, by drawing upon the feet of the child which was lowest. Cazeaux gives a case from Pleiss- THE PATHOLOGY OF LABOR. 487 man, which was probably the first example in which difficult labor from the interlocking of foetuses was treated by raising the woman's pelvis higher than her chest, a treatment which has within a few years been successfully resorted to by Galbraith1—the principle but not the plan used. '* Pleissman states that on one occasion he found the orifice plugged up by the parts that had become engaged, and which at first sight appeared to him to be a quantity of hands and feet. A more careful examination enabled him to dis- tinguish four inferior extremities, which were delivered as far as the ham and one arm." "At first," he says, " I was in great perplexity because I could find no way of introducing my hand into the womb for the purpose of distinguishing and seizing the two feet belonging to each child, and because all my efforts to make even one of these extremities go back again proved abortive ; besides which, in drawing on any two of them, I might confound them, and bring down the feet of two different fcetuses at the same time ; and lastly, even if I succeeded in seizing the feet belonging to the same child, I might, by drawing upon them, engage the other parts, and thus augment the difficulties. Being greatly embarrassed as to the proper course, and yet obliged to act, the employment of a measure suggested by Hippocrates, under different circumstances, happily suggested itself; it was to suspend the patient by her feet, hoping that the heads and bodies of the children would, by their weight, draw one or more of the extremities toward the fundus of the womb, which was still distended by the waters. The husband and brother- in-law of the woman passed their hands under her hams, and thus held her sus- pended, so that only the head and shoulders rested on the bolster. I intended, as soon as I mounted on the bed, to press back one or more of the free ex- tremities into the womb, but two had already returned from the mere position of the mother, and the other three followed by the aid of my fingers. Immediately afterward, I was enabled to introduce my hand into the uterus, and to withdraw successively therefrom three children by the feet." The first child may present by the head, and the second be trans- verse. Jacquemier has narrated the post-morten condition found in a woman pregnant with twins who died undelivered; the head of the first fcetus was in the pelvic cavity, but the neck of the second was below the shoulder of the first, and formed a half ring about its neck.2 The first child may present by the pelvis, and the second be transverse. Here the feet and trunk of the former may pass the latter, and then the head is arrested by the body which obstructs the inlet. The last variety given by Besson is that in which the first child is transverse and the second presents by the pelvis. An illustrative case is quoted from Bartscher in which the feet of the second child were in the vagina, but the hand introduced into the vagina proved that the first was presenting by the shoulder and the second was upon it a cheval, that is, a lower limb had descended upon each side of its body. The treatment of dystocia from interlocking of twins is directed first to saving the mother, next to saving both, and if this cannot be done, to saving one of the twins. The first effort of the ob- stetrician should be to unlock the head or other parts causing the obstruction. This may be done in some cases by combined external 1 American Practitioner, 1880, and American Journal of Obstetrics, 1880. Manuel des Accouchements, tome ii. p. 131. 488 SCIENCE AND ART OF OBSTETRICS. and internal manipulations. Since Galbraith's1 success, certainly the knee-chest position should be tried. He was called to a case of labor with twins, first child with pelvic presentation, and delivered except the head, which could not be extracted; the second child with vertex presentation. He had the patient take the knee-chest position while he supported the lifeless body of the partly delivered child. On introducing his hand he found the obstructing head quite movable, and readily pushed it out of the way; in a few minutes the head of the first child was brought down, and its de- livery effected. If unlocking is impossible—and it may be, in a case in which both heads present—the next step is to apply forceps to the head of the first child and endeavor to deliver it. Barnes advises to have an assistant during this effort apply his hand and push away the second head, but this supposes a very capacious pelvis and a mobile head. Tarnier advises, if delivery cannot be effected by the forceps and the state of the mother requires action, especially if the child be dead, craniotomy. Decapitation of the first child has been practised by several obstetricians. Reimann in his paper,2 " Simultaneous Entrance of Both Heads of Twins into the Pelvis," mentions, among the number who have performed decapitation under these circumstances, Meigs, and Besson repeats3 the statement. It may be a matter of no great consequence, but Meigs4 said expressly that he never saw a case of the kind, afterward stating that one of his " brethren " in Philadelphia did meet with the difficulty "a few years since," and decapitated the first child, when the second was easily delivered. Reimann lays down the rule that in all cases "the forceps should be applied without delay to the second head; every other measure is unsuitable and useless." This statement seems too absolute. Considering now those cases in which the first child presents by the pelvis and the second by the head (Fig. 172), Barnes states that the first child whose trunk is partly born encounters by far the greater danger, and having discovered that there is but a faint or no hope of saving it, attention should be turned to the best means of securing the second; the wedge may be decomposed by detaching the head of the first, or craniotomy be done. Decapitation of the first child, too, is advocated by Besson. Referring to the rule of most obstetricians to apply the forceps to the head of the second child, a rule which in this particular variety of locking of heads corresponds with that which Reimann lays down for all cases, he says that it is irrational. Either the first child is living or it is dead. If it is dead, why not decapitate in order to facilitate the passage of the second, and lessen the pressure which the head of the other child and the soft parts of the mother are undergoing? If it is living, which is very improbable after the trunk has escaped, is there any chance of saving it? Craniotomy upon the second infant is to be rejected because it destroys a life which might be saved by other means. Reimann admits decapitation of the first child if the forceps applied 1 Op. cit. 2 American Journal of Obstetrics, 1877. 3 Op. cit. * Op. cit., 3d edition, p. 500. THE PATHOLOGY OF LABOR. 489 to the second does not effect delivery, and if the latter shows dis- tinct signs of life. Now in 34 cases collected by Besson in which the first child presented by the pelvis and the second by the head, there were only 4 in which the former was born living, and therefore because the probabilities of saving the life of the first are so small, our efforts should be chiefly directed to saving that of the second child, and when the former presents an insuperable obstacle to the delivery of the latter, it should be got out of the way as soon as possible. Mal-presentation and Complex Presentation.—The child presents badly, that is, there is a mal-presentation, when some portion of it descends first which offers such disproportion to the pelvic canal that spontaneous delivery is impossible. The most frequent mal-presen- tations are those of the shoulder, that is, the child instead of being longitudinal in the uterus, and one or the other end of the fcetal ovoid being in the lower uterine segment, is in a position approxi- mating a transverse line, and hence some portion of the side of the ovoid is in relation with the pelvic inlet; but as, in the course of labor, one or the other shoulder ultimately takes this position at the inlet, the presentation is called by this name. In addition to shoul- der presentations there may be, when the head comes first, a latero- flexion of the head upon the trunk, and hence the side of the head or of the face for a time present. Should this inclined lateral posi- tion of the head occur, nature, in almost all cases, rectifies the error, and the position becomes normal. Dr. Hodge has narrated the case of a primipara, to whom he was called after she had been in labor five days, first under the care of a midwife, and then under that of physicians, and who had been given ergot freely ; he found the superior strait "completely occupied by the head of the child, but an accurate diagnosis could not be made, owing to bloody tumors and infiltrations in the presenting part. The blades of the forceps were carefully passed on the sides of the pelvis to the superior strait, and, without difficulty, a firm grasp was made upon the child's head, which, however, was found perfectly immovable. Craniotomy being now determined on, the head was punctured, the forceps, which had not been removed, were now; used as compressors, their handles being approximated by means of a strong fillet; the head yielded to this compression, and was grad- ually brought down and delivered externally. It was now found that it had been originally a presentation of the right side of the head, and that one blade of for- ceps was over the face, and the other over the occiput; so that the long diameter of the head had been, by means of the forceps, so diminished as to allow the transit of the head through the outlet of the pelvis, with the face toward one ischium and the occiput toward the opposite. The patient recovered without any special difficulty." The case just narrated illustrates some of the evil effects of ergot; for had it not been given, the mal-presentation would almost cer- tainly have been corrected by nature, and the labor probably termi- nated spontaneously with the birth of a living child. Nevertheless, in case the lateral inclination of the head persists, the indication is plain, as urged by Dr. Hodge, to rectify it by manual means; but in some cases, version or the forceps will be indicated, with a final resort, as in the instance given by Dr. Hodge, to craniotomy. 490 SCIENCE AND ART OF OBSTETRICS. The management of shoulder presentations will be considered in " Obstetric Operations." Complex or complicated presentations are those in which two or more unrelated parts of the fcetus—as, for example, the head and a foot or a hand—descend. It is convenient also to consider, in this connection, prolapse of the cord, that is, a presentation of the cord with presentation of some part of the fcetal ovoid, for the same causes which usually produce prolapse of members are also in gen- eral those of a similar accident to the cord. As an illustration of a complex presentation the following case from La Motte1 is of interest. On the 27th of October, 1711, he was called to the wife of a carpenter, at Montebourg, who had been in labor since the preceding day, and whose child occupied such a position that the sage-femme could not explain it. He found the woman very much exhausted, and, upon touching, he distinguished two hands, the head, a foot, and the cord, the last being cold and without pulsation. He introduced his hand, pushing the head away, and carried it to the fundus of the uterus, where he found the second foot, which he drew into the passage, in order to have the two feet together; as he drew the feet out the arm ascended, thus leaving the passage free, and in fifteen minutes the woman was delivered. Frequency and Causes of Prolapse of Members.—Depaul found in 16,613 labors, 163 where there was prolapse of the members alone or with the umbilical cord; the proportion is, then, 1 to 102. The upper limbs more frequently prolapse than the lower. In some cases a hand or the arm may descend by the side of the head ; in others a hand is on each side of the head, or a hand or arm descends with the pelvis. These complex presentations occur more frequently when the vertex or face, rather than the pelvis, presents. In some cases a foot has descended with the shoulder, but the descent of a hand or arm when the shoulder presents does not complicate the presentation any more than the descent of a foot complicates that of the pelvis, since in each case the prolapsed member belongs to the part with which it descends. Madame Lachapelle and all au- thors who have written upon the subject since, says Depaul, have admitted as predisposing or occasional causes the small size of the fcetus, the abundance of the amnial liquor, its rapid discharge, oblique presentation of the fcetus—when, for example, instead of being directed in the middle of the superior strait it is rather directed obliquely toward one of the sides of the circumference of the strait—and, finally, vices of conformation of the pelvis. Char- pentier gives in addition, rupture of the membranes when the woman is standing, and unskilful or untimely attempts to perform version. Diagnosis.—We have not only to recognize the fact that the pres- entation is complicated, but also the cause of the complication; in other words, know that a member has prolapsed, and what that member is. The diagnosis before rupture of the membranes is 1 Observation CCXCII. THE PATHOLOGY OF LABOR. 491 usually difficult, and may be impossible. Perhaps a member may be found near the head, and then the former may be pressed against the latter, so that an examination will determine whether it is a hand or foot. In case the head or other presenting part of the fcetus Fig. 173. Hand Prolapsed by the Side of the Head. is too high for this to be done, Depaul suggests pressing the mem- ber against the pelvic wall, and thus fixing it momentarily for ex- amination. Of course the probabilities are that a member found near the head is a hand. After the rupture of the membranes the diagnosis is generally easy. Sometimes1 it is a hand that is applied upon one of the sides of the head in front or behind, but almost always resting upon one of the parietal bones, and in others it descends lower than the head, and is then readily distinguished. The forearm may be upon the side of the head as if the child were resting on it. If the pelvis presents, of course we know that the prolapsed member must be a hand. In some cases this has de- scended into the vagina and even projects from the vulva; then there is no difficulty in recognizing what this member is, but there may be in deciding with what presentation it is associated, for it is 1 Depaul. 492 SCIENCE AND ART OF OBSTETRICS. not uncommon at once to conclude from the hand*being in this position that there is a shoulder presentation, but to avoid error the practitioner should always follow up the member until he reaches the presenting part. So, too, if a foot be found in the vagina the conclusion that the pelvis presents is not a necessary one, for the former may have descended by the side of some other presenting part. A foot seldom descends low in the vagina, and being larger delays the descent of the presenting part much more than a hand does. Treatment.—In very many cases when a hand or foot is at the side of the fetal head before the rupture of the waters it is, as it were, pushed up by the descending head, or at least the former is crowded out of the pelvic inlet by the entrance of the latter. Or again, if the prolapse be slight, and space be sufficient, the head comes down, bringing the prolapsed member with it. If descent of one or more members be ascertained before the rupture of the membranes, the patient should lie down, and other precautions be taken to preserve them entire until the os uteri is completely dilated. If the prolapsed member interferes with the entrance of the head into the pelvis, it should be replaced by the hand intro- duced into the vagina, after which it may be advisable to use forceps, or if the contractions are vigorous it is possible that the entrance of the head into the pelvis, when the obstruction is pushed aside, takes place readily, and its rapid descent will render artificial delivery unnecessary. So, too, in some cases, especially in one like La Motte's, podalic version is indicated. Should reduction of a pro- lapsed member or members fail while the patient is recumbent, an attempt may be made when she is in the knee-chest position. Presentation and Prolapse of the Umbilical Cord.—When the cord toward the end of pregnancy is in the vicinity of the os uteri, or descends at the beginning of labor, or only during the period of dilatation, between the presenting part and the membranes, there is said to be a presentation of the cord; the term prolapse is applied to the descent occurring after rupture of the membranes, the pro- lapse being complete if the cord protrudes from, but incomplete if remaining within, the vagina. Frequency and Causes.—Churchill's statistics show that prolapse of the cord occurred in British, French, and German practice once in 231^ cases. In the Dublin Lying-in Hospital, in 50,061 cases it happened 304 times, or 1 in 168. Charpentier gives the proportion of 1 in 227. Naegele, in explaining the accident, attributed great importance to the lower uterine segment not being completely occupied by the fcetal part; if this application be perfect the cord is retained in the womb by the same cause which prevents the flow of all the amnial liquor and only that which is between the head and membranes is discharged. The accident is nearly four times more frequent in multiparae than in primipara. Among other causes usually given are : excess of the amnial liquor, premature rupture of the sac, small- THE PATHOLOGY OF LABOR. 493 ness of the foetus, face, shoulder, and pelvic presentations,1 great length and weight of the cord, its marginal attachment, the placenta being situated in the lower portion of the uterus, oblique position of the uterus, pelvic deformity, and prolapse of one of the fcetal mem- bers. Fig. 174. The Funis Prolapsed by the Side of the Head. Diagnosis.—The recognition of the cord being by the side of the presenting part may be difficult in the early stage of dilatation when the membranes are entire ; if the cord can be readily touched during the interval of a uterine contraction, its characteristics may usually be determined; it has not the size, shape, or consistence of foot or hand, and beside, it is not suddenly withdrawn as a member often is when touched; possibly by pressing it against a resisting part pulsation may be recognized. After the rupture of the membranes, if the cord has escaped from the os uteri, diagnosis is easy, especially if the pulsations can be felt. The absence of pulsation in the cord does not necessarily indicate that the fcetus is dead, for it may be only temporary ; Charpentier delivered a living child 1 Massman, quoted by Winckel, estimated the frequency, in head presentations at 1 in 150; in breech presentations, 1 in 21, and in shoulder presentations, 1 in 12. 494 SCIENCE AND ART OF OBSTETRICS. by podalic version ten minutes after no beating in the cord could be felt. On the other hand, as observed by Naegele, very often the pressure need be for only a few minutes to kill the fcetus. It is better, in a doubtful case, to listen for the sounds of the fcetal heart. Prognosis.—The accident does not affect the mother, but is very dangerous to the child. Engelmann states that of 365 cases of pro- lapse 171 of the children, 47.7 per cent., were saved ; in foot pre- sentations 71 per cent, of the children were saved ; in pelvic, 40, and in vertex, 36.7. Hecker had a mortality of 43 per cent, in head pre- sentations, and in pelvic 17 per cent; including all cases the mor- tality was 37.6 per cent. The statistics of Scanzoni gave a mortality of 55 per cent., and those of Churchill 53 per cent. Treatment.—Formerly it was thought the chief danger to the child occurred from the cord becoming cold in case of complete prolapse—Velpeau, indeed, attributed the danger partly to this— and hence they were careful to restore it to the vagina, or to have it wrapped in warm cloths. Some have held that the arteries only were compressed, and hence the danger was from plethora, while others thought the compression affected the vein exclusively, and therefore the child was anaemic. But partial compression is rendered impossible by the arrangement1 of the vessels. It is easy to under- stand that compression of the umbilical cord in suppressing haema- tosis causes asphyxia in the same manner as during extra-uterine life; suffocation, strangulation, or pulmonary embolism determines death in suppressing respiration.1 Recognizing the cause of death, we endeavor to avert it by pre- venting pressure upon the cord. If presentation of the cord be recognized in the first stage of labor the woman should be lying down, and great care taken to preserve the bag of waters unruptured until this stage is completed. After the rupture of the membranes if the cord prolapses in front of the child's head, and thus the life of the fcetus be endangered by pressure upon it, the advice given by Smellie still remains the best. He said: " If the navel-string comes down by the child's head, and the pulsation is felt in the arteries, there is a necessity for turning without loss of time; for, unless the head advances first and the delivery is quick, the circulation in the vessels will be entirely ob- structed, and the child consequently perish. If the head is low in the pelvis, the forceps may be successfully used."2 McClintock, in a note upon this passage, has stated that of all modes of treatment recommended, the most successful, as regards the child, is turning. " Thus of sixty-four cases, in the practice of La Motte, Mauriceau, Lachapelle, Boivin, Giffard, and McClintock, when turning was re- sorted to solely on account of the funis presenting, fifty-two of the children were born alive." It happens in some cases that after the membranes have ruptured, and the cord prolapses so as to be subjected to pressure, the head is expelled so rapidly there is no necessity for applying forceps, the 1 Depaul. 2 Op cit. THE PATHOLOGY OF LABOR. 495 cord being compressed for so short a time that there is no risk to the child. Prior to the rupture of the membranes turning is not indicated if the cord presents, for we do not know that after the discharge of the amnial liquor it will certainly prolapse so as to probably suffer compression. Replacement of the Cord.—Neither turning nor the forceps being employed, we may endeavor to partially at least protect the cord from pressure by putting it in that part of the pelvis where the most room is found, and that will be opposite one or the other sacro-iliac joints according to the position of the head. But it is better in most cases to replace the cord, and this reposition may be manual, instrumental, or postural. Mauriceau directed that an effort should be made to carry the cord by the fingers of one hand behind the head, and keep it there until the latter had descended so as to pre- vent its prolapsing again; he added that a compress might be placed between the head and the uterus to sustain the cord after it was replaced. For Mauriceau's compress other obstetricians substi- tuted a sponge, and still others sought to put the cord around one of the fcetal members. Dr. William Harris, of Philadelphia, in a presentation of the breech, returned the cord over the knee, and the child was saved.1 Boer thought so unfavorably of manual reposi- tion, because of the fact that generally the cord prolapsed again and again after repeated replacement, that he compared it to the task of the Dana'ides.2 In consequence of the liability to prolapse again after manual re- placement, various repositors, that are designed not only to facilitate the replacemennt but also to prevent the recurrence of the accident, have been devised. A simple and long known method is to attach a piece of whalebone, or an elastic bougie or catheter, to a small bag or purse, into which the cord may be placed, and then be re- stored. As soon as the head descends, the whalebone or bougie may be safely withdrawn.3 A repositor may be improvised of an ordinary rubber catheter and stylet, with a piece of tape or string. A loop of the tape or string is passed into the eye of the catheter, and the stylet then introduced so that it holds the loop; the cord is fastened by the free ends of the tape, and by the catheter carried into the uterus as far as desirable, and the stylet withdrawn, Char- pentier speaks favorably of the following method used by him suc- cessfully in one case : "The cord is encircled by a loop of silk, and the ends tied so that the cord will be firmly held but not compressed; the ends are now firmly fastened around the end of an olive-shaped elastic or wax bougie; the cord is now carried within the uterus until the lower end of the bougie is at the os. The bougie is left in. the uterus, there is no tendency to recurrence of the prolapse, and 1 Hodge, op cit. 2 Depaul used the same apt comparison. Recently an able and distinguished writer deserts the Dana'ides and seeks Sisyphus. No one has yet called upon Hercules, or upon Briareus. 3 Hodge. 496 SCIENCE AND ART OF OBSTETRICS. the instrument excites uterine contractions, and thus hastens, which is always desirable, the termination of the labor." Nearly two hundred years ago a famous Holland obstetrician, Deventer, advised the position on the knees and elbows in the treatment of prolapse of the umbilical cord : " The advantages of this position have been shown in later years, especially by Ritgen, Kiestra, Thomas, and Theopold."1 Winckel states that lie has never used the knee-chest position, and has never failed to replace the cord. This position, if maintained for some time, is quite weari- some, and certainly causes the uterine force to act at a great disad- vantage. Deventer also advised a lateral position in the treatment of prolapse of the cord; and Galabin states that if the patient can- not be readily induced to adopt the knee-elbow position, the semi- prone position may be used from the first with almost as much advantage. Even when the pulsations in the cord are feeble and separated by long intervals, hope of saving the child should not be abandoned; the less near the end of pregnancy the longer the child survives interference with the circulation. But when no pulsation has been discovered for fifteen minutes, examinations being made in the intervals of contractions, it maybe concluded the fcetus is dead, and the delivery conducted without reference to its interests. 1 Schroder. CHAPTER VII. ANOMALIES OF THE PELVIS. Anomalies of the pelvis may be conveniently divided into those of position, of size, and of form. The first division includes two varieties. The pelvis has a nor- mal inclination or obliquity, and the deviations from this obliquity may be by excess or by defect; that is, the inclination may be in- creased or lessened. So, too, the second division includes two classes : I, that in which the pelvis undergoes uniform increase, pelvis aequabiliter justo- major; and 2, that in which similar decrease occurs, pelvis aequabi- liter justo-minor. The latter is described as a'pelvis uniformly con- tracted : in order that a pelvis may be called contracted the true conjugate must be lessened one centimetre and a quarter, but if there be a uniform lessening of all the diameters one centimetre, or about four-tenths of an inch, then general contraction is said to be present. The third division includes those characterized by change in the pelvic form: in the second class there are simply changes in size, the pelvis remaining symmetrical, but in this it becomes asymmet- rical—its form perverted, or the pelvis is said to be deformed, and, so far as the injurious results in relation to labor are concerned, vitiated. Such deviations from the normal may involve the vertical diameters with reference to the transverse, or the latter with regard to each other, and these constitute the chief ones to be considered. The last presents three classes: I, that in which the antero-poste- rior diameter is lessened; 2, the transverse diameter is lessened; and 3, the diminution is in the oblique diameter. These various pelvic anomalies will now be considered in the order that has been given. I. Anomalies of Position.—As already stated, deviations from the normal obliquity of the pelvis are two; this obliquity may be in- creased or lessened. Lobstein,1 in an unpublished memoir presented to the Society of Medicine of the Faculty of Paris, 1817, first directed the attention of obstetricians to the conse- quences of too great or too slight inclination of the pelvis. The anterior obliquity may be so exaggerated that the axis of the inlet is horizontal. Moreau narrates a case in which the plane of the inlet was vertical, and there was also associated with this vicious inclination of the pelvis narrowing from rickets, which com- pelled the Caesarean operation. Naegele has described the case of a married woman in whom the inferior strait was turned directly behind; the pubic sym- physis and the upper part of the sacrum were directed horizontally, and conse- quently the plane of the superior strait was vertical: the venereal act never took place but in a position opposite to the natural one. She became pregnant, but 1 Dictionnaire Encyclopedique des Sciences medicales, t. viii. 32 49°" SCIENCE AND ART OF OBSTETRICS. the pelvis being normal no difficulty occurred at labor; six other consecutive pregnancies occurred, and ended with the same facility as the first. By so-called posterior obliquity—a true obliquity in a backward direction of course is impossible—is generally understood a marked lessening of the normal obliquity, that may go to such extreme that the plane of the inlet becomes hori- zontal. This obliquity is usually associated with deformed pelvis, but it has been observed independently of such vitiation. In cases of posterior obliquity or pelvic retroversion "the vulva is directed much more in front than usual, and the pubic symphysis presents a direction more or less approaching the vertical. The superior half of the sacrum has become parallel to the axis of the trunk, and the lumbar region is more or less without its posterior concavity—a flat back. Finally, the point of the coccyx is always found in the vertical position either at the level or beneath the summit of the pubic arch, and the last false rib is generally nearer the iliac crest than in the normal state." In addition to these obliquities, Lenoir has given a description of lateral obliquity of the pelvis. According to Depaul, lateral ob- liquities are very frequently found in connection with rhachitic skel- etons, and even in cases of shortening, atrophy, or old luxations of the abdominal members. Naegele, in referring to inclination of the pelvis, makes the following remarks: " Even when this inclination is normal, it quite often happens in cephalic pre- sentation that the head presses upon the superior border of the pubic symphysis, and thus to some degree its entrance into the pelvic cavity is retarded. If in such cases the other conditions of the mechanism of labor are normal, this resistance is overcome soon by the efforts of nature, and delivery is accomplished without special difficulty. But if at the same time there is a more or less great dispropor- tion between the head and the basin, the resistance presented by the anterior wall of the latter exerts a very injurious influence. This influence is much worse still when at the same time the inclination of the pelvis is too great. If, as frequently happens, an inclination exceptionally great coincides with narrowing of the pelvis, obstetric operations may be rendered much more difficult. For this reason it appears necessary in all cases where the head of the fcetus strikes against the pubic symphysis at entering the pelvis to have the woman lie in such a way that the lumbar vertebrae may be strongly flexed ; that is to say, give her a half-sitting posture by raising the hips and the upper part of the trunk, or have her lie upon the side, her back bent forward, and the thighs strongly flexed upon the pelvis." It has been advised, if deficient pelvic inclination hinders labor, to have the lumbar region elevated while the coccyx is placed lower. 2. Anomalies of Size.—This division, which includes uniform increase and uniform lessening of the size of the pelvis, might also be distinguished as symmetrical anomalies in contradistinction to the third class, in which the anomalies are chiefly asymmetric. The subjoined diagrams, taken from Depaul, represent the justo- major and the justo-minor pelvis, while the line marked B is the measure of the distance between the iliac crests in a normal pelvis. a. The Justo-major Pelvis. In the pelvis marked A the distance between the antero-superior spinous processes was 28 centimetres, more than 11 inches, and that between the iliac crests 32 centimetres, more than 12 inches. The antero-posterior diameter of the inlet was 13 centimetres (5 inches), the transverse 16 centimetres (6.3 inches), and the oblique 15 centimetres (5.9 inches). The justo- major pelvis has been justly compared to the pelvis of a giantess found in a woman of ordinary size. ANOMALIES OF THE PELVIS. 499 Schroder taught that the generally enlarged pelvis did not dis- turb the course of labor, not causing this to be rapid, and, in short, that it should not be regarded as pathological unless the same con- ditions were present as might be observed in the case of a normal pelvis. On the other hand, most obstetricians believe that such a pelvis contributes to precipitate birth by the ampler bony canal through which the fcetus is transmitted. b. The Pelvis Justo-minor, or the Generally-contracted Pelvis. This pelvis, as has been before stated, is characterized by a uniform lessening of its diameters : it is one of the most important anomalies Fig. 175. A. Justo major Pelvis. B. Normal distance between the Iliac Crests. C. Justo-minor Pelvis. of the pelvis. At least three varieties of this pelvis have been de- scribed. In the first the pelvis has the form characteristic of the sex. but seems to have been arrested in its development; the bones are frailer and smaller, and, while it is usually found in women whose stature is under the normal, it may also sometimes belong to talj 500 SCIENCE AND ART OF OBSTETRICS. women who are with this exception perfectly developed. While in another variety to be mentioned there usually is a departure from the strict definition of the justo-minor pelvis—uniform lessening of the pelvic measurements—this corresponds quite accurately. The second variety, the dwarf's pelvis, presents the usual characteristics of the normal female pelvis, only it is under size ; there is a corre- spondence between the pelvis and the height, and the bones of the former correspond in their development as to size and firmness with those of the rest of the skeleton. The third variety is the mascu- line pelvis. This may have the external form of the female pelvis, but in some instances very strongly resembles the male. The bones are thick and strong; the sacrum is narrow ; the ilia are straighter than normal; and the ischia are nearer each other. The external measurements may vary but slightly from the normal, and the con- traction may not be uniform, but may concern the inlet, the cavity, or the outlet; in the latter case the pelvis becomes funnel-shaped. The equally-contracted pelvis is not frequently seen; of its three varieties the masculine basin is the least, the dwarf's the most rare. The causes of the justo-minor pelvis are generally obscure. In some instances the anomaly may result from rickets. This origin has been generally accepted. Zweifel states that he has seen one typical instance of generally equally' contracted pelvis which was caused by rickets, though this disease usually produces another abnormal form. Muller has mentioned the frequency of this pelvis in cretins and semicretins. Still, there remain the great majority of cases of this partial pelvic development which cannot be attributed to any constitutional disease either hereditary or acquired. Before giving the diagnosis of the generally-contracted pelvis, studying the mechanism of labor in such pelves, and the treatment of labor there occurring, it is necessary first to consider the means by which deformities of the pelvis are known—a subject the import- ance of which cannot be exaggerated. Kleinwachter observes, no error in diagnosis is so terribly avenged upon the mother and the child as one relating to contracted pelvis. It might be added that the vengeance falls, too, upon the obstetrician, for he can never escape self-reproach if, suitable opportunity having been his, he has failed to recognize the deformity in time to ward off at least some of its conse- quences, or possibly saving both mother and child by means appropriate to the emergency. A primigravida, for example, is in labor at the normal end of preg- nancy ; her form is apparently perfect, her health excellent, and there is not the least suspicion that the pelvis is abnormal. The first period of labor is somewhat longer than usual; the second is protracted until instrumental interference is de- manded in her interest, if not in that of the child. One or more consultants come, and the forceps is tried, first one pattern, and then another, but all in vain. Mean- time, serious inroads upon the patient's strength have been made, and disappoint- ment at the delay in delivery almost brings her to despair. The next step is a craniotomy, the attendants now fully convinced that it is impossible for a living child to pass through the narrowed inlet. But before craniotomy and extraction of the mutilated fcetus can be completed she dies. Examination of the pelvis after death proves that the antero-posterior diameter of the inlet is barely two inches and a half. A timely Caesarean operation would probably have saved both mother and child, or this being refused, the mother's salvation might have been secured if the embryotomy had not been deferred until she was exhausted. ANOMALIES OF THE PELVIS. 501 Diagnosis of Pelvic Anomalies.—This is made by the recognition and appreciation of signs which may be classified as probable and certain. The former are ascertained from the history of the patient, from her general appearance, carriage, walk, stature, etc., while the latter are sought by direct examination of the pelvis. In the history we learn as to sickness during infancy and childhood; as to the period when walking began ; whether there was any bodily de- formity observed at birth or any manifested since; whether any injury to the pelvic joints or dislocation of one of the femurs occur- red in early life or in adolescence; whether one hip is higher than the other, or either femur is ankylosed. The vertebral column is examined for deformity, whether apparent or latent; if it presents a deforming curvature, the period of its first manifestation is inquired, for such curvature, if appearing in infancy, was most probably caused by rickets; and this origin will be confirmed by finding the lower limbs notably curved. In this case the pelvis is in almost all cases deformed. But if the spinal curvature began during adolescence, the cause is not rickets and the pelvis may be normal. The wOman is lame, and the first manifestation and cause of that lameness should be ascertained.1 If the woman has previously been delivered, we inquire as to whether the labor was natural or artificial, whether the child was born living or dead, and in case of instrumental delivery what means were employed. If possible, too, ascertain further as to the cause of the difficulty in a previous labor or labors, for that may have been from an abnormal presentation or from excessive size of the child. It should also be remembered, on the other hand, that though the first labor may have been spontaneous, there might still be some narrowing of the pelvis, which would render subsequent ones dif- ficult from the increasing size of the children. Certain Signs. As before stated, the positive proofs of pelvic de- formities are obtained by measurements of the pelvis, or pelvimetry. These measurements are made by an instrument called a pelvimeter, by an ordinary tape-measure, and by the hand or fingers. The pel- vimeter most generally employed is that of Baudelocque or that of Martin : the latter instrument has the recommendation of being quite portable, and is represented in use in Fig. 176. In using the 1 Peu, La Pratique des Accouchemens, Paris, 1695, makes the following statement, which is interesting as one of the earlier obstetric references to deformed pelvis, and as also showing that this wise observer could not be beguiled by beauty, intellect, wealth, and social position into marrying a young lady who he believed from her lameness had a deformed pelvis: " I remember that at the time of the second Paris war, having recently settled, it was proposed to me to marry a beautiful young lady, rich, very spirituelle, and one whose father I greatly hon- ored ; but she was small and lame in one lower limb. The consequences of the lameness which I apprehended prevented me from making this alliance. One of our aspirants in surgery, braver than I, or perhaps more unfortunate, fell in love with her and married her. Unfortu- nately, she became pregnant. Shortly her abdomen touched the ground, and she fell from the slightest misstep. Her frequent falls compelled her to lie in bed. Her child died, and she also when about eight months pregnant.'' Further reference to lameness as indicating deformity is given by Dionis, Traite general des Accouchemens, 1718. He has remarked that " the lame who have one of the hip-bones higher than the other sometimes have great difficulty in labor, because the basin formed by these bones is not exactly round, and the infant is obliged to redouble its efforts in order to go through the passage." 502 SCIENCE AND ART OF OBSTETRICS. pelvimeter the woman should be lying upon her back, and the lower portion of the body exposed, or at least covered with only one thickness of very thin material. Before beginning to measure with the pelvimeter, the obstetrician applies his hands externally to the pelvis, ascertaining whether one hip is higher1 than the other, finds out whether there is decided narrowing of the hips, the thick- ness and size of the iliac bones, the depth of each iliac fossa, the breadth and curvature of the sacrum, and the height of the pubic joint. Next the external measurements are made : first, the distance between the anterior superior spinous processes of the iliac bones, one of the knobs of the pelvimeter touching the one process, and the other placed upon the process of the opposite side: this is usually 25 centimetres, or about ten inches; second, the greatest distance between the iliac crests at their external margin is similarly ascer- tained : this diameter is 28 centimetres, or 11 inches.2 The third measurement made is that between the great trochanters; this in case of a normal pelvis is 31 centimetres, or 12J inches. If these three diameters are normal, we know that there is no lateral narrow- ing of the pelvis. The fourth measurement is taken from the spinous process of the last lumbar vertebra to the middle of the anterior surface of the pubic joint. This diameter, known as the external conjugate or the diameter of Baudelocque, enables us to approximate the probable antero-posterior diameter of the pelvic inlet, or the true conjugate ; the former measures 20 centimetres (7.9 inches), and by deducting from it 8 centimetres' (3.1 inches), the latter is approximately ascertained : such deduction is supposed to correspond with the combined thickness of the pelvic walls ante- riorly and posteriorly. But the only absolutely certain fact which we reach by measuring this diameter is, that if the distance be notably diminished the true conjugate is less than normal.4 Litzmann asserts that sometimes the measurement of the distance between the posterior-superior iliac spines may be useful in the diagnosis of the form of the pelvis. The relation between this and the distance between the antero-superior iliac spines varies in the normal and in the uniformly contracted pelvis between 1 to 3 and to 3.3 ; in the flat rhachitic pelves, 1 to 3.5 ; in rhachitic flat and gen- erally-contracted pelves 1 to 3.9, and in the simply flat rhachitic pelves, 1 to 4.3. The diagonal diameters extend from the postero-superior iliac spines to the antero-superior spines, passing from the right to the left, and from the left to the right: if the pelvis be symmetrical they are equal, or the difference is very small. They are each about 22.5 centimetres, and if normal indicate that the correspond- ing diameters of the inlet are also normal. Lohlein's oblique ascending diameters are regarded by him as pointing out the 1 Want of symmetry in this respect is so common as to be the rule, and it is only a marked deviation that should awaken the suspicion of the examiner. s Litzmann, Die Geburt bei Engen Becken, states that in 200 women with a large pelvis, he found these measurements 27 and 29.5 centimetres. Winckel states them to be 26 and 28, while Zweifel gives the numbers in the text. :i Litzmann states, op. cit., that in 30 cases in which he had an opportunity of comparing the external conjugate measured upon the living with the true conjugate measured upon the cadaver or upon the dried pelvis, he found a mean difference of 9.5 centimetres, with a maxi- mum of 12.5 and minimum of 7 centimetres. * If the external conjugate measures less than 16 centimetres the pelvis is always narrowed antero-posteriorly ; if below 19 centimetres there is narrowing in one-half the cases, between 19 and 21.5 scarcely once in ten, and above 21.5 almost never. (Litzmann.) ANOMALIES OF THE PELVIS. 503 transverse diameter of the pelvic inlet, this being obtained by subtracting 2 centi- metres from one of them; they measure the distance between the subpubic liga- ment and the upper anterior margin of each ischio-pubic foramen. In the great majority of cases the obstetrician will be content with measuring the distances between the iliac crests and the antero-superior iliac spines, and the external conjugate, so far as external pelvimetry is concerned. Pershing, in a valuable paper1 published a little more than a year ago, after urging the import- ance of examining the pelvis of every pregnant woman, adds : " The examina- tion should consist in measurement of the external conjugate, and anterior and posterior iliac spines, and iliac crests. If these external measurements indicate a normal pelvis, the examination may end with them. But if contraction is sus- pected, the diagonal conjugate and oblique ascending diameter of Lohlein should also be taken." The circumference of the upper or false pelvis is learned by ap- plying the end of an ordinary tape-measure to the spinous process Fig. 176. Measuring the External Conjugate with Martin's Pelvimeter. of the last lumbar vertebra, and carrying the tape along the iliac crest of one side, and thence to the median line at the pubic joint; similarly, the other half is measured, the results added, and thus the entire circumference is ascertained. Evidently, if the one measure- ment is greater than the other, the pelvis is asymmetrical. The normal circumference of the false pelvis is 90 centimetres = 35.5 inches. ' Pelvic Measurements and their Importance in Obstetric Practice, American Journal of the Medical Sciences, February, 1889. 504 SCIENCE AND ART OF OBSTETRICS. Next, the diagonal conjugate—that is, the distance from the lower margin of the pubic joint to the promontory of the sacrum—is found usually by means of one or two fingers. In the following illustra- tion the index and medius of the left hand are extended, the thumb abducted, and the third and fourth fingers folded upon the palm ; the extended fingers are carried up and backward in the pelvic cavity until the promontory is touched; then, still keeping up this contact, the hand is brought upward until its lateral margin, just below the index finger, comes in contact with the subpubic ligament. Next, this last point is marked by the nail of the index finger of the Fig. 177. Measuring the Diagonal Conjugate. right hand; then the left hand is withdrawn, and the measurement made from this mark to the tip of the finger. Kleinwachter holds that the introduction of the index and medius at the same time ought not to be permitted, except perhaps in the case of a multi- gravida, because the stretching of the soft parts by two fingers will cause pain; but he adds that in very difficult cases the half or the whole hand may be used. There is difficulty in reaching the pro- montory if the pelvis is normal, but of course it is more accessible as true conjugate is lessened. If the basin be normal the true conjugate may be found by sub- ANOMALIES OF THE PELVIS. 505 tracting 15-16 millimetres (T5^ - T6¥ of an inch) from the diagonal conjugate. "It is evident that this subtraction will vary according to the angle which the true conjugate makes with the pubic sym- physis, and as to the height of the symphysis. It is increased with the obtuseness of the angle and with the elevation of the symphysis. Hence, with the various pelvic deformities the subtraction will vary. Though the height and thickness of the symphysis may be ascer- tained, but not the angle which it forms with the true conjugate, the latter can only be estimated, and hence slight errors may be made. Nevertheless, with proper skill the length of the true conjugate may be determined within a few millimetres, and the error is so slight that it may be regarded as of no importance." Measurements of the diameters of the pelvic outlet are of much less importance; nevertheless, they may be required in some cases. To obtain the antero-posterior diameter, the woman lies, for example, upon her left side, and the obstetrician with the thumb and index finger of the right hand—the former externally, the latter in the vagina—finds the sacro-coccygeal joint, and includes it between them. The end of the finger is fixed at that point, while the body of the finger is carried forward and upward until its lateral surface is brought against the subpubic ligament, and while held firmly in that position is marked by the nail of the index finger of the other hand, as in ascertaining the diagonal conjugate. Upon withdrawing the finger the distance from the mark to the tip is measured, and this will give the desired diameter. Breisky places one of the knobs of the pelvimeter externally at the sacro-coccygeal joint, while the other is put at the lower margin of the pubic joint; now subtract from the measure thus obtained 1 to 1.5 centimetres, and we then have the antero-posterior diameter. Breisky recommends for measuring the transverse diameter of the pelvic outlet Osiander's pelvimeter. The knobs are placed upon the ischial tuberosities, and from the measure thus obtained of the intervening distance between the tuberosities, 1-2 centimeters must be subtracted for the thickness of the soft parts. Franken- hauser's method is to place the thumbs, their nails being directly opposite, upon the most prominent surface of the inner margin of the ischial tuberosities, and then with Osiander's pelvimeter measure the distance between the nails. Barbour1 states that the transverse diameter of the outlet is best estimated by Chantreuil's method: "Place the patient in the genu-pectoral posture or in the lithotomy posture, though the former facilitates the measuring; pass the index fingers into the vagina, and turn them back to back so that the pulp of the finger rests on the inner surface of the ischial tuberosities ; an assistant lays the points of the calipers on the palmar surface of the fingers just outside the vulva, the dis- tance of which apart corresponds to the inside measurement between the tuberos- ities. This allows us to use the ordinary calipers." Diagnosis of the Justo-minor Pelvis.—The distances between the iliac anterior superior spinous processes and between the iliac crests are found less than normal in all cases, an exception being made for the masculine pelvis, for in it, in consequence of the increased thick- ness of the bones, these differences may be very slight or even absent. The pelvic circumference is lessened, as is also the true conjugate. Contraction at the outlet will be suggested by the ap- parent approximation of the ischial tuberosities and spines, and be confirmed by ascertaining that the antero-posterior and the trans- verse diameters are under the normal. 1 Spinal Deformity in Relation to Obstetrics. 506 SCIENCE AND ART OF OBSTETRICS. Fig. 178. Marked Flexion of the Head entering a Generally-contracted Pelvis. Labor and its Treatment in the Generally-contracted Pelvis}—Labor begins with the fcetal head at the pelvic inlet, for there is not, as there is in the majority of primigravida^2 having a normal pelvis, descent of the head into the pelvic cavity during the last weeks of pregnancy. The resistance of the less- ened inlet compels strong flexion of the head upon the chest, and thus, with the occiput below, the head enters, the bipa- rietal diameter corresponding with the con- jugate, and the suboccipito-bregmatic with the transverse; the sagittal suture is at first usually in the transverse diameter. The uniformity of the pelvic contraction shows itself by the strong resistance to any less- ening of flexion, there being such constant and great pressure upon the frontal arm of the head-lever. Zweifel, in describing the mechanism of labor in generally-contracted pelvis, says the sagittal suture may sometimes be in the transverse or in the oblique, or even in the antero-posterior, pelvic diameter, and hence the child's head be- comes elongated. This elongation, however, cannot be in the occipito-mental diameter, but rather in that described by Budin as the maximum diameter, for the squamous portion of the occipital bone is pushed under the parietal bones, this movement being per- mitted by the cartilaginous connection between it and the basilar portion. So, too, the equally strong compression to which the head is subjected on all sides compels overriding of the frontal by the parietal bones, while the posterior of the latter overrides the an- terior. The caput succedaneum is large and long, even in some cases protruding from the vulvar opening while the head is in the cavity. The duration of labor is about one-third longer than if the pelvis is normal. From the head remaining so long at the pelvic brim while strong uterine contractions are going on, there is danger of injury to some portions of the lower uterine segment, resulting in subse- quent inflammation, or actual perforation by long-continued attrition may result. So, too, exhaustion may come on to such degree that the life of the mother is imperilled, the uterus falling into a state of atony. The long continuance of the labor carries danger to the fcetus, and injury may also result from the strong compression of its head. 1 Litzmann in considering the question what should be understood by a contracted pelvis, states that for the simply flat pelvis, and perhaps also for the generally-contracted flat pelvis, shortening of the true conjugate to about 9.7 centimetres constitutes the boundary line between the contracted pelvis and the pelvis of normal size, while for the pelvis uniformly contracted the limit of the true conjugate is 10 centimetres. 2 Litzmann found partial entrance of the head in 8.1 per cent, at the end of pregnancy, and that in scarcely one-fourth of the cases after labor had begun, did descent of the head occur before rupture of the bag of waters. ANOMALIES OF THE PELVIS. 507 Delay in rupture of the membranes until the os is fully dilated, descent of the occiput rather than of any other part of the fcetus, moderate size of the fcetus, yielding character of the bones of the head, and on the part of the mother a slight degree of pelvic con- traction and vigorous uterine and voluntary action, have been cor- rectly stated to be propitious, the labor under these circumstances usually terminating favorably for both mother and child. On the other hand, early rupture of the membranes, great size of the child, unyielding nature of the cranial bones, and unfavor- able presentation—as, for example, of the pelvis (usually a knee or foot descends first because of the difficulty of the pelvis entering the inlet), of the brow, or a shoulder—make the prognosis unfavor- able. The mortality of children Litzmann states is 9.5, and that of mothers a little more than 6 per cent. The forceps1 is not applicable in general contraction of the pelvis until the head is completely moulded. So, too, podalic version is not indicated if the head presents, for extraction after turning can- not be effected soon enough to save the child's life; the head must be moulded to the passage in a few minutes—a process which Nature's forces require hours to accomplish. Further, if crani- otomy should finally become necessary, the difficulties of the opera- tion are increased because of the head coming last. Another objec- tion to delivery by podalic version is the danger of ascension of the arms in consequence of the pelvic contraction. In those cases in which the contraction is chiefly at the inlet the mechanism of labor after the head has entered the cavity is the same as in a nor- mal pelvis, and the treatment also corresponds. 3. Anomalies of the Pelvic Form or Asymmetrical Changes in the Pelvis.—Two divisions of this class are made, the first including changes in the depth of the pelvis : a. That in which the vertical diameters of the pelvis are increased, without a corresponding change in the horizontal. Such change in- creases the depth of the pelvis, but, alone, does not to an important degree modify the course of the labor ; the latter will be longer, and in some cases its protraction may require the use of the forceps. b. The second class embraces those pelves whose depth is less- ened. But this change is in almost all instances associated with what are commonly called pelvic deformities. If occurring inde- pendently, all the horizontal diameters being normal, other con- ditions being favorable, the duration of labor is shortened. The second division is much more important, and includes those changes which deform, render asymmetrical, or vitiate the pelvis. It embraces three varieties: 1, those characterized chiefly by shortening of the antero-posterior diameter; 2, a like change in the transverse ; and 3, the same in the oblique diameter. The following subdivisions are made of these three classes of pel- 1 Kleinwachter. t;o8 SCIENCE AND ART OF OBSTETRICS. vie deformities. These subdivisions are the same as those adopted by Zweifel. I. Pelves chief!}'contracted in the antero-posterior diameter : a. The flat pelvis ; b. The rhachitic flat pelvis ; c. The generally contracted flat pelvis; d. The spondylolisthetic pelvis ; e. The pelvis flattened by double luxation ; f. The lumbo-lordotic pelvis. The last originates in lordosis of the lumbar vertebras, which is com- pensated by a deeply situated kyphosis. In consequence of the lordosis the lumbar vertebrae may project over the pelvic entrance, causing the deformity known as pelvic obtecta, or roofed pelvis. In the osteomalacic pelvis, to be described in the next class, there is also considerable contraction in the antero-posterior diameter. II. Pelves chiefly contracted in the transverse diameter: a. The osteomalacic pelvic ; b. The ankylotic transversely contracted pelvis ; c. The kyphotic transversely contracted pelvis. In b and c the narrowing is only in the pelvic outlet. III. Pelves chiefly contracted in their oblique diameter: a. The ankylotic obliquely contracted pelvis; b. The coxalgic pelvis ; c. The scoliotic pelvis. Neoplasms originating in the pelvic walls constitute a final class of pelvic deformities. The Simple Flat Pelvis.—This pelvis may be found in women who present no other anomaly of form which would awaken the slightest suspicion of its presence. They are usually of normal stature and apparently of perfect development. There is no history of disease of the bones in infancy or childhood, or of injury to spine or pelvis or lower limbs in adolescence. How often has this anomaly led to the most deplorable results in childbirth! Even in Europe this pelvis is found a little more frequently than the rhachitic, while the American obstetrician will meet with it oftener than any other pel- vic anomaly, and thus forewarned ought to be forearmed. The cause of the deformity is not clear. The deformity con- sists essentially in an approximation of the sacral promontory to the anterior pelvic wall, and the sinking of the sacrum has been attributed to walking too early, to sitting too long at a time in infancy, and also simply to the weight of the body, when neither of the other causes can be justly adduced. Still another explana- tion of the etiology has been suggested—the carrying of heavy weights in childhood ; but the occurrence of the anomaly in women who were never subjected in childhood to severe toil renders neces- sary the explanation that has been given—viz., the simple weight of the body may cause the deformity. The descent of the sacrum is without any rotation upon its trans- verse axis, and the approximation of this bone to the pubic bones. and the shortening, involve only the antero-posterior diameter of ANOMALIES OF THE PELVIS. 5C9 the inlet, or if those of the cavity and outlet are lessened the dimi- nution is very slight. The descent causes strong tension upon the ilio-sacral ligaments, which would result in separation of the iliac bones if it were not for the resistance of the pubic joint; and the consequence is that the transverse diameter undergoes slight increase and the pubic joint is brought nearer the sacrum. Schroder states that in very rare cases a flattened pelvis is also narrowed in the transverse diameter of the outlet. In a practical point of view, this is a very important complication of the flattened pelvis. Sometimes the articulation of the first with the second sacral vertebra, which remains unossified, forms that which is called a double promontory; that is to say, the two vertebrae meet at an obtuse angle posteriorly, and the articulation makes in contracting a projection in the pelvic cavity.1 If a line be drawn from this pro- jection to the pubic symphysis, it is as short as, or even shorter than, the true conjugate itself, and, as this anomaly has an essential obstetric importance, it must be included in pelvic measurements. The diagnosis of the flat, non-rhachitic pelvis is readily made by measuring. The transverse measurements are normal or slightly increased; the circumference is normal or slightly decreased, but the two sides of the upper pelvis are symmetrical; the external conjugate is always diminished, and by this diminution, com- FlG- *79- bined with that of the diagonal conjugate, the true conjugate is found, which of course is less than normal, and in the great majority of cases at least 8 cen- timetres (3.1 inches). Rhachitic Flat Pelvis. — This deformity results from pressure upon the base of the sacrum chiefly, causing not only descent of the bone, but also a partial anterior rotation upon its trans- verse axis ; thus the promontory is brought nearer the pubic joint, and the true conjugate necessarily shortened. In a flat rhachitic pelvis in the Museum of Jefferson Medical College I find the following measurements of the pelvic inlet: Oblique di- ameter, 5 inches; transverse, 5 J inches ; and true conjugate, 3 inches. The measurements of the outlet are : anterior-posterior, 3f inches, and the transverse 4 inches. The depth of the pelvis at the pubic joint is \\ inch, at the sides 2f inches. 1 Schroder. Nevertheless, Zweifel remarks in reference to the name given this pelvis, that we use the expression simple, einfach, in contradistinction to rhachitic. By this term Michaelis first expressed the difference between the single and double promontory. Flat Rhachitic Pelvis (Miitter Museum, Col- lege of Physicians, Philadelphia). 5io SCIENCE AND ART OF OBSTETRICS. Rickets is a disease occurring in infancy or early childhood, chiefly character- ized by a disorder of nutrition and development of bony tissue, the disorder in- volving various deformities of the skeleton, swelling of the epiphyses, bending or fractures of the diaphyses, important changes in the shape of the pelvis, and frequently curvatures of the spine. While in almost all cases it is a disease of extra-uterine life, yet there have been instances in which it occurred in utero, probably the first recorded one being given by Glisson in 1650. It is a disease especially of poverty, and is found most frequently in the large cities of the Old World, where the poor abound and the children of the poor often so greatly suffer from want of sufficient food, fresh air and sunshine, and proper clothing. Arnott1 speaks of its being frequent in India, though he also states that, so far as his experience goes, osteomalacia is, relatively to rickets and also absolutely, more common in India than in Europe. The child suffering from rickets does not walk as early as healthy children, but is much of the time in a sitting posture; the pressure of the body's weight causes not only the changes in the position of the sacrum previously stated, but also, through the resisting tension of the ilio-sacral ligaments, drawing of the innomi- nate bones, so that they would separate if it were not for the resisting pubic joint; this separation being impossible, the bones yield, and hence the transverse diameter of the inlet is increased, "just as a long bone may be fractured in the shaft by a force applied at one end, the other end resisting." In consequence of the weight of the body resting upon the ischial tuberosities, and by the action of muscular traction, the former are more widely separated, and also the pubic rami, and the pubic arch is broadened. If the child walks during the disease, the pelvic deformity is greatly increased, there being superadded the changes caused by pressure upon the acetabula. " The parts adjacent to the acetabula are pressed into the basin by the resistance of the heads of the femurs, and thus the sacro-cotyloid diameters are lessened. In consequence of the approach of the ilio-pubic tubercles the ischial spines are pressed in the pelvis ; the approximation of" the former causes a beaked protru- sion of the pubic joint." In the highest degree of the deformity the lumen of the pelvis is almost closed, and with bending of the sacrum and iliac bones the pelvis may take a triangular form and is known as the pelvis triloba, or the pseudo-osteomalacic pelvis. Fig. 180. Pseudo-osteomalacic Pelvis (Mutter Museum, College of Physicians, Philadelphia). Turning from these graver deformities of the pelvis caused by rickets, we will now consider the diagnosis of the simply flat rhachitic pelvis. The history of rickets is learned, and many of its obvious consequences in other parts of the pelvis may be present. The dis- Transactions of the Edinburgh Obstetrical Society, vol. x. ANOMALIES OF THE PELVIS. 5H tance between the antero-superior iliac spines is equal to, possibly exceeds, that between the iliac crests; the external conjugate is always lessened; the true conjugate is shortened; in some instances the second sacral bone protrudes into the pelvic cavity, making what is called the false promontory, and this may be more promi- nent than the true, when, of course, it becomes one of the terminal points of the conjugata vera. The antero-posterior and transverse diameters of the outlet are unusually large in comparison with the contraction at the inlet. The Mechanism of Labor in the Simple Flat and in the Rachitic Flat Pelvis—In consequence of the narrowing of the pelvic inlet, the head of the fcetus not only does not enter the pelvic cavity, as is the rule in the last weeks of pregnancy in primigravidae, but it may be turned aside at the brim, and hence the proportion of trans- verse presentations is increased. Another factor1 in causing such malposition of the fcetus is found in multigravidae in the relaxed abdominal and uterine walls, which permit anterior displacement of the uterus, though a pendulous abdomen, as Litzmann observes, is especially frequent in pelvic contraction, and in these cases there is not simple anteversion, but anteflexion of the uterus. If the pelvis be below, its descent through the narrowed aperture does not occur, but the feet are prone to enter. Supposing the head to be at the inlet when labor begins, it, as a rule, takes a transverse position; that is, the sagittal suture instead of being oblique lies directly from one side toward the other of the pelvis. Resistance to the descent of the occiput compels a partial deflection, and the anterior and posterior fontanelles may be in the same pelvic plane; thus the transverse diameter of the foetal head is in the pelvic conjugate, and the occipito- frontal in the pelvic transverse. But in this accommodation the anterior parietal is somewhat in advance of the posterior, and therefore the sagittal suture ap- proaches the sacral promontory. (See Fig. 181.) The anterior parietal bone, pressed against the anterior pubic wall, accord- ing to the description of Kleinwachter, becomes the fixed pivotal point around which a partial revolution of the poste- rior parietal occurs in the descent until the promontory is cleared. But in order that this descent can occur, the transverse diameter of the head must be lessened; this lessening is in part accomplished by the lateral margin of the posterior parietal passing under the corresponding part of the anterior parietal. In some instances the revolution is reversed; Fig. 181 Head passing through the Inlet in -Flat Pelvis. \ Kleinwachter. 512 SCIENCE AND ART OF OBSTETRICS. that is, the posterior parietal is fixed at the promontory, while the anterior moves down; then the relations of the parietals are changed, in that the posterior overrides the anterior. Further diminution of the head transversely may be effected by indentation, deep depressions, or even fractures or fissures of the revolving pa- rietal. After the head has passed the inlet the subsequent mech- anism is the same as in normal labor, and often then the delivery is more rapid from the ampler space furnished by the cavity, and especially by the outlet in the pelvis flattened by rickets, as has been previously mentioned. Nevertheless, as stated by Litzmann, often the uterine contractions fail in force in consequence of exhaustion from the prolonged effort made in forcing the head through the inlet, so that the delivery must be completed by art. In exceptional cases the sagittal suture is placed so near the pubic or the sacral wall of the inlet that what is termed a parietal presentation results ; if this presentation is not rectified delivery is impossible without craniotomy. Descent of the frontal bone first may occur in great narrowing; then the two halves of the bone play a corresponding part to that of the parietals in relation to the pubic and the sacral wall of the pelvis. Whether the parietals or the frontal halves pass the strait first, the posterior bone has a distinct pressure- mark from its being so strongly forced against the promontory. In pelvic presentation one or both feet usually descend first; if the contraction is slight, the body passes through it without serious difficulty; then the head may pass also—of course it must be in a transverse position for this passage—flexion being continued; the posterior parietal bone suffers from pressure in descending the pro- montory. In more decided narrowing departure of the chin from the chest is observed. The mortality of mothers is more than 7 percent., and of children 50 to 60 per cent. The prognosis is more favorable in the case of female than of male children, and it is also more favorable if the woman be a multipara than if a primipara, provided the head pre- sents. In the management of the labor care should be taken to keep the membranes unruptured until the os is dilated, and hasty interven- tion while the head is being moulded to pass through the narrowed inlet must be avoided. If nature is unable to effect the passage of the head through the inlet, resort to the forceps is not indicated, but podalic version. In regard to the former means, Zweifel observes that the application of the forceps to the movable head is not impos- sible, but to seize it firmly is purely accidental; an application of the blades over the parietal bones is absolutely impossible; and even if the head were thus grasped, it could not be drawn through the con- jugate. Version comes only in those cases in which the forceps cannot be used ; and even then the question, as Schroder has framed it, is, Shall we turn, or wait? "Whenever we perform version in contracted pelves we decide in favor of this operation without know- ing, in case this is not done, how the head would enter the true pelvis and how it would pass through. This renders the question ANOMALIES OF THE PELVIS. 513 as a practical one so difficult, and will probably thus keep it for a long time, probably forever." The usual rule is to wait after rupture of the membranes and dilatation of the os, with the hope that the head may enter and pass the inlet; but if after a reasonable delay this does not occur, podalic version is to be employed. Generally-contracted Flat Pelvis.—In this variety there is a greater degree of descent of the sacral promontory than is found in the generally-contracted pelvis, and the deformity rarely occurs except as a consequence of rickets. Not only all the pelvic diameters are below the normal, but the true conjugate especially is shortened. Litzmann states the mortality of mothers with this pelvic defor- mity is between 8 and 9 per cent., and of children delivered dead or dying, there are 66 per cent. The Spondylolisthetic Pelvis (from 6v6vlog, vertebra ; and bMa^ri^, a slipping or gliding).—This deformity arises from a gliding or slipping forward of the last lum- bar vertebra, so that it no longer rests upon the upper surface of the first sacral vertebra completely, but only partially; or even, in an excessive degree of spondylolisthesis, the posterior wall of the body of the former vertebra may be fixed to the anterior wall of the body of the latter, a synostosis occurring. Sometimes, indeed, the lum- bar vertebral column glides down to the body of the second sacral vertebra. The lumbar vertebrae thus sinking, lordosis results, and the lower edge of the fourth lumbar vertebra, or the union between the third and fourth, or even that between the second and third, is opposite the pubic joint. This pelvis was first described by Rokitansky. The question as to the cause of the deformity has been much discussed. From the firmness of the transverse processes of the normal vertebrae, it would seem impossible for a dislocation of one of the bodies to occur; and the view generally held as to its origin in the majority of cases is that it results from a fracture of the vertebral arch anterior to the articulating processes—this fracture caused by a fall upon the sacrum—and hence dislocation, becomes possible. " If a person should thus fall with the body bent forward, the sacrum being fixed at the moment of the accident, the force will mainly act upon the body and arch of the last lumbar vertebra, and a fracture of the arch would very probably occur." Zweifel remarks that we cannot overlook the weak side of this, F. L. Neugebauer's theory, which is, that hitherto the traces of such a healed fracture have been found in only one case.1 Nevertheless, he also states that a traumatic, and hence extra-uterine, origin of spondylolisthesis must be admitted for the majority of cases. There may also be congenital spon- dylolisthesis, the origin of the disease, from the failure of coalescence of ossifica- tion-centres in the vertebral arches, thus permitting dislocation of the vertebral body. This deformity is rare; Kleinwachter, writing in 1882, states that only fourteen cases have been observed. The diagnosis is made by the increased distance between the posterior superior iliac spines; by the marked lordosis just above the sacrum; by the shortening of the abdomen, its contents sinking so much between the ilia; by the peculiar " rocking gait" of the 1 Winckel mentions two cases under his observation, in which the probability was that the deformity had its origin as Neugebauer has stated. 33 5'4 SCIENCE AND ART OF OBSTETRICS. Fig. 182. pregnant woman, by the absence of any history or present mani- festation of rhachitis or of osteomalacia; by an account of a fall such as would result in fracture of the arch of the fifth lumbar ver- tebra; but, above all, by internal examination, counting the bodies of the sacral vertebrae, and recognizing the projecting lumbar ver- tebra by finding the sacral vertebrae complete, and by the absence of the alae in this, which belong to the first sa- cral. In Olshausen's case the bifurcation of the aorta could be felt on the deeply-sunken lumbar vertebral column. The Caesarean operation is unavoidable in a severe spon- dylolisthesis. Slight degrees of the deformity are much more common than was at first supposed, and the pro- gnosis is, according to Zweifel, no more unfavorable than it is in the flat rhachitic pelvis. The Pelvis Flattened from Bi- lateral Dislocation of the Femoral Bones.—Whether the double dislo- cation be congenital or occur early in childhood, the heads of the femurs pressing above and posteriorly to the acetabula, "great traction is exerted upon the round and upon the ilio- femoral ligaments ; the muscles of rotation passing from the inner side of the pelvis to the femur, the obturators and gemelli are also made tense. Hence traction in a transverse line at the pelvic outlet and its partial eversion. By the tension of the ilio-femoral ligaments passing from the capsule to the anterior inferior spinous process, and in consequence of the place of support of the trunk, the heads of the femurs, being placed further back, the centre of gravity is thrown anterior to the plane of support; continual care is necessary to prevent falling forward, and this is exerted by the dorsal muscles drawing the body backward, the consequence of which is, the inclination of the pelvis is lessened, and there is a lumbar lordosis. Tension upon the pelvic ring causes increase in the transverse diameter of the inlet and flattening of the pelvis, with necessary shortening of the conjugate ; the latter diminution is also increased by sinking of the sacrum." Not only the conjugate is lessened, but usually the corresponding diameters of the cavity and of the outlet, though, according to Kleinwachter, this lessening becomes less at the outlet in consequence of the recession of the lower part of the sacrum, while, on the other hand, it may be that, resulting from tension upon the ligamentous connections between the ischial tuberosities and spines upon the lower portion of the sacrum, the latter is drawn forward, and then there necessarily follows lessening of the antero-posterior diameter of the outlet. The true conjugate rarely falls below nine centimetres, but in some it has been reduced to seven. The characteristics of this pelvis are, in addition to the less- ened conjugate, the increase of the transverse diameter, the fact of the double luxation, the greater breadth of the pubic arch, the lessened pelvic depth, and the flattening of the pelvic inlet. The diagnosis in the living subject is greatly Spondylolisthetic Pelvis, showing dislocation into the pelvic brim of the lumbar vertebrae. The " Prague pelvis.'' 4, fourth vertebra; 5, fifth lumbar vertebra (Kilian). ANOMALIES OF THE PELVIS. 515 facilitated by observing the duck-like gait. This pelvic anomaly, if we know the peculiar walk of those having such a basin, Zweifel states, can be diagnosed at a distance of two hundred steps. This variety of pelvic deformity is quite rare ; according to Kleinwachter, only nine of such pelves have hitherto been observed. The labor usually ends favorably both for mother and child ; after the head once passes the inlet the pro- gress is quite rapid. The Second Class includes Pelves chiefly Narrowed in the Trans- verse Diameter. [a) The Osteomalacic Pelvis.—Osteomalacia (from bmkov, bone, and fialaxk, soft—mollities ossium, softening of the bone) is a disease of which the essential cause is a diminution of the earthy salts of the bones, this diminution being such that these salts are two, three, or even five times less than normal, and of which the most marked results are changes in the forms of the bones in consequence of their great flexibility. It is not a disease belonging exclusively to adult life nor to the female nor to childbearing. Nevertheless, the statistics of Collineau indicate very clearly the frequent origin of the disease in consequence of changes of the organism caused by pregnancy. He found only 14 of 43 women suffering with osteo- malacia who had never been pregnant, and of the other 29, 14 who had had from four to ten pregnancies, 6 one to three, and 4 who had been pregnant but once. Thus it is seen these statistics prove that the majority of cases of the disease are connected with preg- nancy. It may appear during gestation or in the puerperium; once begun, the disease is aggravated by succeeding pregnancies, especi- ally if the intervals are short. Osteomalacic Pelvis, showing the beak-like shape of the pubes. It is impossible to satisfactorily explain the anomaly of nutrition which is essential to the disorder. " While true that the disease has never been observed in women comfortably situated in life, even the lack of good nourishment, mis- 516 SCIENCE AND ART OF OBSTETRICS. erable and damp dwellings, a diet exclusively of potatoes or of rice, cannot be regarded as the absolute cause of the disease, though the conditions just stated are undoubtedly predisposing causes. If deficient nourishment of the bones in the large majority is the sole cause, so that the bones, losing their earthy elements. are softened, then osteomalacia would be much more frequent. A fact that is inexplicable is, that the disease occurs usually only rarely and sporadically, but in some countries very frequently, so that it may be called endemic; thus it is found on the banks of the lower Rhine and in the adjacent valleys, in East Flanders, and on the plains of the Po." The fact of its frequently being seen in India has previously been stated. The changes in the spinal column and in the pelvis result from softening of the bones affected by pressure and by traction. The spinal column, corresponding to its normal curvatures, is pressed by the weight of the body, and hence follow kyphoses, kypho-scolioses, and lordoses. " The weight of the body causes by its pressure upon the sacrum pushing of the promontory downward and forward, and the sacrum draws anteriorly the posterior halves of the ilia, so that they are bent. The sacrum is narrowed, especially from lessened expansion of the alae, and it is also bent forward. The pressure from the femurs forces the acetabula and adjacent parts inward and upward, so that the pubic joint and horizontal rami are pressed forward, the rami becoming parallel and proximate, so that the ilio-pecti- neal eminences are adjacent." The illustration given shows the beak-like projec- tion of the pubic joint—pelvis rostrata. The pubic arch almost entirely disap- pears, and while the antero-posterior diameter of the inlet may be increased, the available space is seriously lessened. The pressure upon the acetabula always makes the outlet less than the inlet. In making the diagnosis of deformity of the pelvis from osteoma- lacia, the history is of great importance; for example, the period when the disease was first manifested—just following pregnancy; the severe pains felt—tearing and drawing, mistaken in some cases for violent rheumatism. The pa- FlG-184- tient's walk is characteristic, for in consequence of the approximation of the acetabula the femurs are brought near, and she is compelled at each step to turn on one foot while the other is thrown around and in front of it. Those affected with the disease are small, and as it progresses they grow smaller. The bistrochanteric diameter is lessened; the external conjugate is not lessened in all cases, but the promontory is always accessible, the narrowed pubic arch and the approximated horizontal pubic Robert's Pelvis. rami giving a beaked form to the anterior portion of the pelvis; and finally the diminished outlet will be more or less readily recognized. A general rule in regard to the conduct of labor in a case of osteomalacic pelvis is not to interfere too early, for the bones may prove so yielding under uterine contractions that the passage for the fcetus is opened, and thus Caesarean section or embryotomy be averted. Because of the yielding of the pelvic bones to the ANOMALIES OF THE PELVIS. 517 pressure of labor, the pelvis has sometimes been called the India- rubber pelvis. (b) The Ankylotic Transversely-contracted Pelvis.—The first pelvis of this kind was described by Robert in 1842. Its origin seems to be in an arrested or imperfect development of the sacrum, followed by ankylosis of the sacro-iliac joints. The alae of the sacrum are absent or only imperfectly developed; the sacrum is narrow, and has descended deeply between the ilia; the ischial tuberosities and spines approach. The antero-posterior diameters of the pelvis are normal or increased, while the transverse are much lessened; espe- cially is the transverse of the outlet reduced. Kleinwachter states that in the cases hitherto observed the transverse of the inlet varied from 7 to 10 centimetres (2.7 to 3.9 inches), and that of the outlet from 2.25 to 6 centimetres (0.8 to 2.7 inches). The diagnosis is made by the narrowed pubic arch, the parallel- ism of the horizontal pubic rami without any abrupt bending of these bones which is observed in the osteomalacic pelvis, and chiefly by the great narrowing of the sacrum. This is a very rare anomaly, only nine cases having been observed. In six of the nine the Caesarean operation was done. In two cases in which the trans- verse diameter of the inlet was 8 centimetres (3.1 inches), and that of the outlet 5.25 centimetres (2 inches), delivery was effected by cephalotripsy, and this is, therefore, regarded as the limit of its applicability. (c) The Kyphotic Transversely-contracted Pelvis.—Kyphosis (nv^uoig, applied by Hippocrates to a bowing or curving of the spine, so that one was humpbacked) means an abnormal convex curvature of the spine. The origin of the kyphotic pelvis is found in an abnormal posterior spinal cur- vature, for a compensating curvature lower down results from the former; and in order that the pelvis may be affected by the spinal anomaly, the latter must be situated in the lumbar vertebrae, or in these the sacral vertebrae must be affected, the one known as lumbo-dorsal, the other as lumbo-sacral, kyphosis. Further, the sacrum is pushed downward and backward : just as in a pelvic deformity previ- ously considered this bone is pressed downward and forward, lessening the con- jugate, a rotation of the bone upon its transverse axis forward, so that the sacral promontory is brought nearer the pubic joint, so now a corresponding rotation backward is claimed to occur. Barbour gives the following summary of the peculiarities of the kyphotic pelvis based upon his examination : "The iliac crests are drawn out from before back- ward; the arching of the crests is diminished and their sigmoid curve lessened. The anterior superior spines are thrown apart. The pelvis is funnel-shaped. The conjugate diameter is greatly increased, while the transverse is relatively, and sometimes absolutely, lessened. The linea terminalis is less arched at the sides. In the cavity the conjugate is increased, but to a less extent than at the brim. Sacrum narrowed transversely and elongated vertically ; its vertical curvature is diminished throughout, its transverse in the upper portion of the bone. At the outlet the conjugate is not usually altered. The transverse may be contracted, and that to an extreme degree. The pubic arch is narrowed." The most characteristic anatomical peculiarity of the kyphotic pelvis is an increase in the antero-posterior diameter of the brim. The contraction in the transverse diameter of the outlet, which is the feature of obstetric importance, is not so constant. Further, Barbour, in opposition to the teaching of Breisky, states as the result 5 18 SCIENCE AND ART OF OBSTETRICS. of the study of the preparations he has had that there is not, as a rule, a rotation of the sacrum upon a transverse axis, and that the contraction at the outlet is not related to the elongation at the brim. He further maintains that the contraction at the outlet implies a rotation of the innominate bones ; and this is shown by the fact that the approximation of the tuberosities is related to separation of the crests. Fig. 185. Lumbo-sacral Kyphosis (Mutter Museum, College of Physicians, Philadelphia). The most characteristic indication of the kyphotic pelvis is found in the pres- ence of a lumbar kyphosis, and next in the peculiar walk of the subject, the movement being as if carrying some heavy load before her and a constant effort to avoid falling. By pelvimetry we find the true conjugate increased ; the trans- verse measurements of the false pelvis are normal, but that between the posterior iliac spines is lessened. The distinction just given is the direct opposite of the conditions observed in the osteomalacic pelvis, with which this may be confounded, for in that the anterior transverse diameters of the false pelvis are lessened, while the distance between the posterior iliac spines is increased. The pubic arch is narrowed in the rhachitic and also in the osteomalacic pelvis, while no narrowing is present in this. Besides, the first two occur in persons whose history points to one or the other disease. In such pelves, too, the promontory is quite accessible. Of course the prognosis rests chiefly upon the degree of contrac- tion. It is of especial importance in this connection to know the transverse diameter of the outlet. Further, it is important to know if "the ischial tuberosities move upon being pressed apart. Korsch has demonstrated that even in the normal pelvis the transverse of the outlet can be thus slightly increased, this movement being ac- companied by a diminution in the conjugate."1 But before this observation both Mattei and Laborie had asserted that an increase Barbour, op. cit. ANOMALIES OF THE PELVIS. 519 in the transverse diameter of the outlet resulted from the wedge-like pressure of the foetal head. In consequence of the lessened abdominal capacity arising from a lumbar kyphosis, the uterus may be strongly anteverted, and hence difficulty in the head entering the inlet. But the most frequent fact as to the position of the child in the abdomen that has been observed is that the fcetal back is posterior—that is, toward the mother's spine —" probably in consequence of the pendulous abdomen generally present, the limitation of abdominal space, and the compensating lordosis of the upper portion of the spinal column, through which the anterior plane of the fcetus can be better adjusted to the anterior abdominal wall." This explains the frequency of occipito-posterior positions. According to Barbour, the shape of the pelvis favors posterior rotation of the occiput. He gives a table of 32 cases of kyphosis and 52 labors; there were 33 recoveries from these 52 labors, but of the 32 mothers, 19 ultimately died after labor. He thus finds in his collection of cases that there was a fcetal mortality of 52 per cent, and a maternal mor- tality of 36.5 per cent., according to the number of confinements, or 594 per cent., according to the number of cases of kyphosis. The extreme limit admitted by Barbour for the application of for- ceps is 3.25 inches, and if this diameter is less he advises crani- otomy. There were 7 cases of Caesarean section, 6 mothers dying; 9 cases ended spontaneously, and 7 mothers recovered. Zweifel regards the prognosis as more favorable in that than in other pelvic contractions, because the narrowing is at the outlet. But he adds that Caesarean section has been necessary, and as spontaneous rup- ture of the uterus has occurred, and even after the use of the forceps death rapidly followed, it is advisable in a given case to keep this possibility in mind. Rhachitic Kyphosis}—While the changes in the pelvis caused by rickets are in the main directly opposed to those caused by kyphosis, on the other hand, should kyphosis result from rickets, the pelvis may present a similar form to that observed if the kyphosis has a different etiology. The kyphosis, in order to change the form of the pelvis, must, as in the account of the kyphotic pelvis just given, con- cern the lumbar vertebrae. The diameters of the outlet are lessened, and the diminution is greatest in the antero-posterior. The Third Class includes Pelves chiefly Contracted in the Oblique Diameter. {a) The Ankylotic Obliquely-contracted Pelvis.—Dionis was credited by Naegele with having first alluded to the pelvis contracted in an oblique diameter. Certainly, this distinguished French accoucheur does refer to difficult labor caused by spinal deformities, and also to changes in the pelvis caused by rhachitis, but his reference to the pelvis now to be considered is by no means clear. The oblique-oval, or Naegele's basin, was first described by Naegele in 1839. It is distinguished by the fact that one sacro-iliac 1 Zweifel. 520 SCIENCE AND ART OF OBSTETRICS. synchrondrosis has been ossified, and as a consequence one-half of the basin becomes narrower. The part of the sacrum belonging to the ankylosed side is imper- fectly developed, and its union with the innominate bone is made by Fig. 186, Obliquely-distorted Pelvis, or Naegele's Pelvis. a narrow ledge of greatly condensed osseous tissue instead of by a broad articulating surface. There is slight scoliosis involving the lumbar vertebrae. In Kleinwaehter's case there was also rhachitis. The iliac bone of the affected side is raised and projects farther back than its fellow. The sciatic notch is lessened in consequence of the ischium being pressed upward and inward, and the ischial tuberosity and spine approach the sacrum. The absence or rudimentary condition of the sacral wing upon the affected side finds its most rational explanation in the absence of ossification nuclei, and therefore the deformity may have an intra- uterine origin: this was the view favored, though not exclusively adopted, by Naegele. But it is also held that the deformity may result from pathological conditions of the joint in infancy or child- hood ; in other words, inflammation lies at the beginning of the change. The theory of an inflammatory origin in some cases after birth does not exclude that possibly this inflammation may begin in intra-uterine life; if the inflammation occurs after birth, its cause may be simply pressure of the trunk, which will be greater upon that side corresponding with an imperfectly developed sacrum. It is impossible for disease of one of the sacral joints in adult life to cause the deformity. Thomas,1 in 1861, from a study of the 50 cases of oblique oval basin up to that time described, classified them as to their etiology as follows : Das Schriigverengte Becken, quoted by Naegele and Grenser. ANOMALIES OF THE PELVIS. 521 (a) Oblique pelves found in women who during their infancy, or in all cases before the ankylosis was recognized, had suffered from disease of the pelvic bones, 9 cases. (d) Oblique basins with fracture of the pubis on the same side as the ankylosis, 2 cases. [c) Oblique basins with traces of periostitis or exostoses of the hip-bones, 3 cases. (d) Oblique basins in which there was found, beside the ankylosis, a coxal arthritis of the same side or of the opposite side, 5 cases. (e) Oblique basins without any other trace of disease, of which, nevertheless, the history was too imperfectly known to permit the absolute statement that in the women to whom these pelves belonged there was nothing observed, especially in youth, indicating a morbid state of the pelvic bones, 27 cases. (/) Oblique basins without visible traces of disease of the pelvic bones in women whose history was sufficiently well known, so that it could be affirmed they had never suffered from any affection of the bones. Whatever or whenever the origin of the deformity, the latter pre- sents a most characteristic form which is well shown in the illustra- tion that has been given. The pelvic inlet is asymmetrical, and presents the form of an obliquely placed oval with a point projecting to the ankylosed side. The antero-posterior diameter is increased, but the transverse is lessened, and there is a continued lessening of this diameter through the cavity and to the outlet. Most of the cases of obliquely-contracted pelvis have been diag- nosed after death ; the entire number of cases observed is given as about fifty, but probably this is too small. Zweifel states that with a great difference between the two sides of the pelvis the diagnosis during life cannot be difficult. Should there be delay during labor in the entrance of the head into the pelvis, the possibility of this deformity will be suggested if we find it impossible to reach the sacral promontory. The limping gait of the subject may not be observed, but it is important to learn whether there is any history of inflammation of the joint in infancy or childhood, and whether any evidences of suppuration following such inflammation can be found in healed sinuses. Freund claimed that, an examination being made per rectum, the woman standing alternately on one and then on the other foot, some movement would be detected in an unaf- fected joint, while the ankylosed one would be immobile. Internal examination should be made with the half or with the whole hand, and thus the want of correspondence in the position of the ischial spines, the distortion of the promontory, and the dis- placement of the pubic joint will be learned. The most important external measurement in order to prove that the basin is asymmet- rical is the distance between the trochanter major of one side to the iliac crest of the other, and vice versa. Naegele directed the following measurements to be made : 1. From the posterior superior spine of one side to the anterior superior spine of the other side—from the right side behind to the left side in front—normally 21.22 centimetres. 2. From the trochanter major of one side to the posterior superior spine of the other—22.25 centimetres. 3. From the middle of the inferior margin of the pubic joint to the posterior superior spine of each side—17.25 centimetres. 522 SCIENCE AND ART OF OBSTETRICS. 4. From the ischial tuberosity of one side to the posterior superior spine of the other—17.5 centimetres. 5. From the spinous process of the last lumbar vertebra to the anterior superior spine of each side—18 centimetres. These oblique diameters, as Naegele termed them, must show a difference be- tween each two corresponding ones of more than one centimetre in order to make the diagnosis of obliquely-contracted pelvis. In this pelvis, if the ankylotic contraction be great, the passage of the child is necessarily made through that portion of pelvic space corresponding to the healthy side, for that which belongs to the ankylotic side is so contracted that no part of the fcetus can be admitted. The space, then, that is available is quite similar in form to that given by the justo-minor pelvis ; and if labor be possible the mechanism is the same, the occiput descending first, as has been described in the course of labor occurring in that pelvis. Presen- tation of the breech is very unfavorable, because of the great diffi- culty in, or impossibility of, the passage of the head. The prognosis as to the mother of course depends upon the de- gree of the deformity, the vigor of labor-forces, the size and degree of resistance to moulding of the fcetal head, and the size of the child : the maternal mortality given by Litzmann and Thomas is 80 per cent. But this high percentage is to be attributed to the fact that in most of the cases the deformity was not recognized soon enough for the use of appropriate therapeutic means, and in some instances, according to Kleinwachter, the means employed directly caused the death of the mother. Zweifel, too, regards Litzmann's statistics as being too unfavorable. He advises the forceps if the head enters the pelvis, but if this entrance be impossible the Caesa- rean operation, especially as in cases of such difficulty uterine rup- ture is liable to occur. (b) The Coxalgic Obliquely-contracted Pelvis.—This pelvis is simi- lar to that just described, but there is this remarkable difference in manifestation : While in the Naegele pelvis the arrest of devel- opment or the inflammation of the sacro-iliac joint affects the side of the basin in which it occurs, in this deformity the coxitis and subsequent ankylosis are upon the side of the pelvis which remains comparatively normal, and the healthy side becomes misshapen. The pelvis, represented in Fig. 187, was taken from a negress upon whom Dr R. G. Curtin performed Caesarean section, and it exhibits very clearly the fact of the pelvic deformity being manifest upon the healthy side, while that upon which the coxitis occurred is normal. The history of the usual development of this pelvis h that a child suffers from coxitis so severely that the corresponding lower limb—fos example, let the affection be upon the right side—becomes useless, and the weighr of the body rests upon the left femur. This pressure causes similar changes in form in the basin to those observed in the Naegele. The left acetabulum is pressed upward, and it comes more in front; the innominate line is bent in front at an acute angle, and the left ilium is higher and less inclined; the left half of the sacrum is narrowed, so that the entire bone loses its symmetrical form; the left ischial tuberosity and spine move backward and outward, and the pubic joint is placed opposite the right side. There are several modifications of the coxalgic oblique basin according to the period in adolescence when the disease of the joint began and as to the degree of use permitted by the diseased limb. Thus, the earlier in childhood the disease ANOMALIES.OF THE PELVIS. 523 occurs and the more the limb is used, the greater the deformity. On the other hand, if the coxitis is first manifested after complete development of the basin, the obliquity may be completely absent. Fig. 187. A Coxalgic Obliquely-contracted Pelvis (Mutter Museum, College of Physicians, Philadelphia). So, too, the obliquity may involve first one side, and then it may change to the other. Zweifel gives the following illustration: A child has coxitis of the right side, ending in firm ankylosis, the right lower limb being shortened. It neces- sarily limps, and the concussion in walking will be greater than on the left side, this jar being felt not only at the hip-joint, but also in the corresponding sacro- iliac synchondrosis; hence, ascension of the iliac bone. If now a chronic inflam- mation in the sacro-iliac joint is superadded, the corresponding sacral wing will be retarded in its growth ; hence the right half of the pelvis becomes smaller than the left half, the pubic symphysis is pushed to the left, and the oblique diameter of the pelvis from the left anteriorly to the right is shortened. Suddenly, how- ever, all this may be changed, so that by muscular traction a pelvis presenting an opposite contraction may be developed. For if the child ceases to use the right lower limb, the plane of support is exclusively given by the left femur. But it is not necessary to follow the changes that then result in the form of the pelvis, the diseased side furnishing comparatively a normal condition of the corresponding side of the pelvis, and the healthy side becomes in this regard abnormal. Paralysis of a lower limb or amputation of a leg is rarely fol- lowed by any great change in the form of the basin, because in the great majority of cases this has attained complete development be- fore either occurs. The coxalgic pelvis so gravely deformed as seriously to interfere with labor is rarely seen. The recognition of the deformity will be made, first, by having a history of coxitis in early life, and finding its effect in a useless abdominal member, and then by direct exami- nation of the pelvis. In slight cases of the deformity labor needs no assistance, while in the grave ones labor and its treatment are the same as advised in similar circumstances in the Naegele pelvis. 767 524 SCIENCE AND ART OF OBSTETRICS. (c) The Scoliotic Obliquely-contracted Pelvis.—This deformity arises from a scoliosis involving the lumbar vertebne, there being thus caused a greater pressure upon that half of the upper articulating surface of the sacrum corresponding with the side toward which the spinal curvature occurs. By the connection of the sacrum with the innominate bone this increased pressure is transmitted to the femur of that side. But the resistance of the latter causes leaning inward of the parts adjacent to the acetabulum, and hence that side of the pelvis becomes greatly lessened. A scoliosis of the vertebne toward the right diminishes and deforms the right half of the pelvis, while the left is similarly affected by a scoliosis with its curve directed to the left. Should the scoliosis be limited to the dorsal vertebrae, a compen- sating curve of the.lumbar vertebrae may prevent any influence upon the pelvic form. This deformity renders one side of the pelvic canal useless, so far as furnishing space for the transmission of the child. The mechan- ism of labor is that described as occurring in the justo-minor pelvis, and the assistance to be given by the obstetrician, provided the con- traction be not so great as to forbid the passage of a living child, is by forceps, remembering, however, that this instrument is not to be used until the head has been sufficiently moulded. Deformities of the Pelvis caused by Fractures or by Neoplasms of the Pelvic Bones. Fracture of the horizontal ramus of one of the pubic bones may result in serious deformity of the pelvis, because of the impossibility of keeping the broken ends of the bone in apposition during healing. Eugene de Saint-Moulin1 narrates the case of a girl sixteen years of age who, while working in a coal-mine, was injured by the falling of a large mass of coal upon the lower portion of her back : after several months she recovered so that she could walk, though with some difficulty, and there was slight spinal de- formity. Five years afterward she became pregnant, and the diam- ter of the superior strait being only three centimetres six millime- tres, the Caesarean operation was successfully done at the end of the pregnancy. Seven years after she was again pregnant, and at seven months rupture of the uterus occurred, the tear being in part of the uterine incision made in the previous operation, and the rup- ture ended fatally. The autopsy showed that, in addition to marked lumbar lordosis, the second sacral vertebra was crushed, so that the first was directly buried in the pelvic cavity, and there was a synos- tosis between its inferior border and the superior border of the third sacral vertebra. The spondylolisthesis had thus a very rare origin in this case. Various neoplasms—enchondroma, sarcoma, carcinoma, exosto- sis, fibroma—may, originating from any part of the internal surface of the pelvic bones, encroach so greatly upon the bony birth-canal that the Caesarean section is necessary. Deventer, who was the first obstetrician to give any clear expo- 1 Journal d'Accouchements, 1885. ANOMALIES OF THE PELVIS. 525 sition of pelvic deformities, regarded the position of the coccyx in certain cases as furnishing a serious obstacle to labor, and devoted several pages of his well-known work to the consideration of this topic, giving explicit directions as to the method of pushing the bone back and thus enlarging the pelvic outlet. Some other ob- stetricians since have also regarded sacro-coccygeal ankylosis as an obstacle to be obviated by the obstetrician. But probably the truth is that in case of this ankylosis the pressure of the child's head is quite sufficient to overcome the resistance, breaking the synostosis, and there is no necessity for obstetric interference. CHAPTER VIII. PATHOLOGY OF LABOR {continued)—INJURIES OF THE VULVA AND PERI- NEUM—INJURIES OF THE VAGINA--TEARS OF THE CERVIX—RUP- TURES OF THE UTERUS. Injuries of the Vulva and of the Perineum.—Tears involving the nymphae sometimes occur in natural as well as in instrumental labor; one of these organs may be divided longitudinally, or par- tially detached from its base. There may be a tear involving the inferior margin of the vestibule, and it may extend upward to the side of the clitoris, possibly involving the corpus cavernosum, or it may be prolonged inward by the side of the urethra. In some in- stances, especially if the corpus cavernosum be injured, the bleeding is great; indeed, cases of fatal hemorrhage from such injuries of the vestibule have been reported.1 If hemorrhage is observed fol- lowing the birth of the child's head, the body being undelivered, it must necessarily come from an injury of the vulva. Arrest of hemorrhage can generally be accomplished by com- pression, but it would be better, should a serious tear be found, to use catgut stitches ; so, too, such stitches may be used in tears of the nymphae for the purpose of preventing deformity of the part; moreover the more completely closed these wounds are the greater the protection of the patient from infection, for if an injury be ex- ternal or near the exterior, there is more danger of exposure to and absorption of poison than if it be high up in the vagina or of the uterus. In addition to the stitching, the injured parts may be freely dusted with iodoform; so, too, in cases in which sutures are not used, a similar application should be made. According to Olshausen, unavoidable tears of the perineum occur in at least 15 per cent, of primiparae. Winckel confirms this state- ment. The majority of obstetric authorities hold that, as a rule, a torn perineum should be stitched as soon as practicable after the injury, or at least that the operation be not delayed longer than sixteen hours. When performed immediately it arrests hemorrhage, which, in some cases, is considerable, but in all cases an early ope- ration lessens the danger of septic infection taking place through the raw surfaces; and though a rent that seems great at first be- comes comparatively small in the course of three days, yet sponta- neous restoration is not the rule, while restoration is, after perine- orraphy, and, therefore, this ought to be done unless there are some strong contra-indications. 1 Young, Transactions of the Edinburgh Obstetrical Society, vol. viii., gives two cases of tears of the vestibule followed by serious hemorrhage seen by him ; one of the patients died from the bleeding. THE PATHOLOGY OF LABOR. 527 The stitches can be introduced most conveniently with the patient lying upon her back, and her hips near the edge of the bed. A hot antiseptic vaginal injection is first used, the parts being thus thoroughly cleansed, and oozing of blood lessened; an antiseptic sponge is placed in the vagina to restrain uterine discharge. Sup- posing the rent to be incomplete, the obstetrician, after threading his needle, which may be curved or straight according to his pref- erence, with silkworm-gut—other material may be used, silk, wire, horsehair, if the first-mentioned be not at hand—introduces one or two fingers of the left hand into the rectum ; then with the right hand enters the point of the needle half an inch from the margin of the tear at the lowest part of the latter, on the one side, and car- ries it across buried beneath the tissues, unless the tear be complete, in all its course, until it emerges at a corresponding point upon the opposite side; in case the tear be complete, the needle will be en- tered into the tissues a little below the anal rent—so as to secure the torn fibres of the sphincter—and, carried across, appears in the median line, as does the following suture, and then passes out on the opposite side at a similar point to that in which it was intro- duced. After placing the first suture, the second and then the third are introduced—rarely will a larger number be necessary, in some cases only one is required. The sutures are then tied, or if of wire, twisted; perforated shot and perineal bars, I think, are an abomina- tion in all perineal operations, needlessly complicating the method, causing much suffering afterward, but especially are objectionable in puerperal injuries of the perineum, for thorough cleansing behind the bars or shot is impossible when the parts become swelled, and thus there are lurking-places for septic poison. Of course instru- ments, sutures, and the hands of the operator are properly antisep- ticized; the silkworm-gut is rendered more pliable by being first soaked for a few minutes in very hot water. In some cases it is necessary before stitching to cut away loose shreds of tissue. If the tear extends up the recto-vaginal wall internal stitching may be required before employing the external sutures, the material for the former being catgut, and a short curved needle being used for the stitching, which, as a rule, should be continuous. After-treatment.—By some it is held important to tie the knees together, to use the catheter at regular intervals, and to keep the bowels confined for a week or more. By no probable movement of the limbs can there be any strain upon the perineal tissues now sewed together—tissues that have undergone the very great stretch- ing in labor—and therefore the bandaging of the knees is unneces- sary; moreover the bandage increases the discomfort of the patient, helps to imprison the lochial discharge in the vagina, and is thus an injury. Hildebrandt objects to the use of the catheter because vesical catarrh is very liable to result, and thinks it better for the urine to be discharged spontaneously if possible. Once in twenty- four hours the vagina should be carefully washed out with a warm antiseptic injection. On the third day the bowels maybe moved by castor oil or by compound licorice powder, assisted by an enema of 528 SCIENCE AND ART OF OBSTETRICS. warm water or an infusion of flaxseed; subsequently evacuation should be had at least once in forty-eight hours. The diet need not vary from that usually given after labor. The common practice is to remove the sutures in from eight to ten days. Central Rupture of Perineum.—Central rupture of the perineum has occasionally occurred, and the head and then the body of the child has passed through this opening, the anterior and posterior portion of the perineum being uninjured; in other instances the rent has been caused by the foot or elbow of the child. Duncan1 asserts that the passage of the child through such a rent rarely hap- pens, that this is probably sometimes believed in after the event, but is not care- fully observed during the process. Reeve2 has reported a case of central rupture of the perineum without implication of the vulva occurring in a multipara. " The rent began on the right side, near the junction of the upper fourth with the lower three-fourths of the labium, followed the outer boundary of the labium down- wards, and crossed the perineum to the rectum; both the anal sphincters were divided, the laceration extending upwards quite an inch and a half. The part of the perineum remaining intact at the posterior commissure and along the lower part of the right labium was about the thickness of a man's thumb." Duncan" has called attention to the fact that central perineal rupture may involve only the skin, or the mucous membrane of the vagina, or both of these with their subja- cent tissues while there remains entire some tissue intervening between the skin and the vagina. Obstetricians agree that if the beginning of a central rupture is observed, the tissues between the tear and the vulvar orifice should be at once divided, thus preventing the extension of the rent into the rectum. But if the injury is not discovered until after delivery, and division of the anterior bridge is not advisable, the tear is to be stitched by interrupted sutures, preferably of silkworm-gut. Injuries of the Vagina.—It is proposed under this head to con- sider not only lacerations, but also contused and perforating wounds of the vagina received in labor. It is convenient to divide tears and other injuries of the vagina into those of the upper, of the middle, and of the lower part of the vagina. Vaginal tears are frequently associated with corresponding injuries of the uterus. Nevertheless, McClintock,4 from the statistics of the Rotunda Lying-in Hospital, found 35 of 108 which involved the vagina only, or merely the os uteri with it; it is thus seen that the cases of vaginal injury alone are nearly one-third of the entire number. Spontaneous tears of the vaginal vault are more frequently transverse than lon- gitudinal, while those in the middle portion of the vagina are generally longitu- tudinal. In some instances the vagina has been, by a circular rent, partially or even completely separated from the uterus. Johnson and Sinclair5 give the case of a patient in whom a fatal injury of this kind occurred: the woman was a mul- tipara, but delivery being impossible because of cicatrices in the lower part of the vagina, even after division of the cicatricial tissue was made with a bistoury, craniotomy was performed ; death occurred the next day. An instance of per- foration of the posterior cul-de sac by a vaginal douche, used to induce labor at 1 Transactions of the American Gynecological Society, vol. i. 2 Ibid., vol. iii. 3 Op. cit. * Dublin Journal of Medical Science, May, 1866. ■■ Midwifery. THE PATHOLOGY OF LABOR. 529 the eighth month of pregnancy because of pelvic deformity, is given by Budin J So, too, the vaginal vault has been torn by the badly-directed blade of forceps or cephalotribe. Both spontaneous and artificial rents of the upper posterior portion of the vagina are especially liable to occur in case there be a pendulous abdomen permitting anterior displacement of the uterus, for by this displacement the tissues are stretched and thinned. Hart2 has shown that the posterior vaginal wall is structurally weak at its upper half inch, while it is more elongated than the anterior wall in labor. Rupture is most common where the posterior vaginal wall is covered by peritoneum, and when it occurs is a tension tear like cervical rup- ture. Instances of injury to the vagina anteriorly and posteriorly have occurred from the use of the perforator : in one case3 the practitioner, wishing to open the child's head, made a rent in the bladder, permitting the introduction of three fingers, and in another case* the obstetrician, attempting the same operation, thrust his instrument through the tissues, and applied it to the sacral promontory,' mistaking it for the fcetal head. Rupture of the vaginal vault has been caused by forcible introduction of the hand into the uterus for the purpose of performing version.5 Prolapse of the intestine through the rent has been observed in several cases. Danyau6 in 1850 collected 17 cases of rupture of the vagina in which the fcetus passed into the abdominal cavity: 4 of these patients recovered. Others, too, have recovered though the injury permitted prolapse of the intestine. Moysant has reported a case in which a woman being in labor the forceps was vainly ap- plied, and then delivery by podalic version tried ; the trunk was extracted, but the head left behind; the woman died in a few hours, and at the post-mortem the fcetal head was found in the left side of the abdominal cavity, having entered through a rent which extended from the uterine junction to the vulva. Schroder refers to a peculiar case recently reported by Battlehner, of rupture of the anterior vaginal vault with prolapse of the bladder into the vagina. McClintock7 gives as the cause of spontaneous rupture of the vagina in the cases which he collected—1, diseases of the vagina; 2, disproportion between the size of the fcetal head and the maternal pelvis ; and 3, osseous irregularity upon the inner surface of the pelvis. While, according to the same authority, the re- coveries after uterine rupture are only \% per cent., they are after similar injury to the vagina 12 per cent. The symptoms that have been most frequently observed in rup- tures of the vagina are cessation of labor-pains, hemorrhage, reces- sion of the presenting part, which, however, is slight unless the foetus enters the abdominal cavity; prolapse of intestine or of omentum is a not infrequent complication. Shock, too, has been observed in many cases. Treatment.—The treatment is essentially that required in a similar injury to the uterus. Prompt delivery is indicated, and usually this will be made through the vagina; arrest of bleeding will be accomplished by hot-water injections, by sutures, and in only exceptional cases will a tampon, of iodoform or creolin gauze for example, be employed; a lateral rent or one involving the peri- toneum will usually require a drainage-tube. Rents of the Middle Portion of the Vagina.—These are generally superficial: they may be caused by careless use of the perforator or of the crochet, or the vagina may be torn by sharp fragments of bones of the fcetal head in extraction after craniotomy. Injury may 1 Des Lesions traumatiques chez la Femme dans les Accouchements artificiels. Par Pierre Budin. Paris, 1878. 2 Edinburgh Obstetrical Society's Transactions, vol. viii. 3 Provincial Medical Journal, 1843. * Budin, op. cit. 0 Spiegelberg, op. cit. 6 Bulletins de la Societe anatomique, 1857. 7 Archiv med. 34 53° SCIENCE AND ART OF OBSTETRICS. be done in the introduction of the blade of the forceps, this being forced instead of caused gently to " feel " its way to the desired point; so too a tear may be made in the extraction, especially in case the blades are not accurately applied to the sides of the child's head and kept in such close relation, for the fcetal head ought to be a protection to the vagina from injury by the borders or by the ends of the forceps blades. Deep tears of the middle portion of the vagina may occur if there be structural change in its tissue, whether from malignant disease or from cicatricial contraction. Contused wounds of the vagina most frequently result from prolonged im- paction of the head in the pelvic cavity—and as a consequence sub- sequent sloughing occurs—which if involving the anterior wall of the vagina may result in a vesico-vaginal fistula, or if the posterior, a recto-vaginal fistula. Treatment.—It rarely happens that bleeding from wounds of the middle portion of the vagina is considerable, and its treatment does not differ from that required in similar injury of the upper portion. The most important part of the treatment of the colpitis resulting from the injury will be the use of warm antiseptic injections—I part of corrosive sublimate to 5000 of water, for example, or a 2 per cent. creolin mixture—and following the injection by introducing an iodo- form suppository: if a contused wound involving the anterior wall be present, great care must be taken to prevent distention of the bladder; after sloughing of any part of the vaginal walls means must be used during the healing to prevent contractions, metal, glass, or hard-rubber dilators being introduced from time to time. As showing the greater liability to injuries of the vagina in birth in case the child be male, the fact stated by Spiegelberg is significant: that in 12 cases of vesico-vaginal fistula at his clinic and polyclinic, in the labors from which they resulted all the children were boys. Tears of the Loiver Portion of the Vagina.—Though these are in most cases associated with corresponding injuries to the perineum or vulva, yet some are not, and therefore should be considered sep- arately. So far as spontaneous injuries of this class are concerned, their most frequent cause is excessive stretching of the vagina; they are usually superficial and situated at or near the median line; in some cases, however, they may have a diagonal course, or two diagonal tears may be united with a median tear, having approxi- mately the form of a Y. Contused wounds resulting from prolonged pressure by the presenting part are also found here, and they may be followed by sloughing, which may end in rectal or in perineal perforation. Improper use of the forceps is to be credited with many injuries to the lower part of the vagina: these injuries may result from too rapid extraction, but probably their most frequent cause is turning the handles of the forceps too soon toward the abdomen of the mother, and thus the points of the blades are with- drawn from the child's head and brought directly against the pos- terior wall of the vagina, making more or less deep furrows in its tissues: a similar accident has occurred from the attempt to with- draw the blades just before the expulsion of the head, a violent pain THE PATHOLOGY OF LABOR. 531 suddenly expelling the head, while the obstetrician, busy with the manoeuvre mentioned, was powerless to prevent the rapid delivery. Dupuy1 mentions a case in which, the feet presenting, one of these escaped by the vulvar opening, while the other, pressing strongly upon the vagina posteriorly, was forced through the perineum. I have seen a somewhat similar case, only the foot inflicting the injury made a rent at the lower portion of the recto-vaginal wall and pro- truded through the anus, there being also a slight tear in the pos- terior perineum. Dr. Barker2 has published a case he was called to in which he found the perineum " enormously distended by the pressure of the head, and the left hand and forearm projecting through the anus." He did not attempt to restore the member, but delivered with the forceps. The patient's bowels were kept con- fined by opium for ten days, and complete cicatrization followed. Treatment.—Bleeding from uncomplicated lacerations of the lower part of the vagina is usually only slight, and therefore can only ex- ceptionally require means for its arrest. While, too, in most cases these tears are only superficial, and therefore require no treatment other than cleanliness and the use of antiseptic applications, in others their extent is such that not only to protect from septic infection and to secure their rapid healing, but also to guard against possibly permanent injury to the pelvic floor, sutures are plainly indicated. Properly prepared catgut is the best material for stitching the sur- faces together, and the continuous suture is employed. Thrombus or Hematoma of the Vulva or of the Vagina.—In addi- tion to the injuries that have been mentioned, there may be tearing of the vessels of the connective tissue of the vulva or of the vagina without external opening, and the effused blood forms a mass known as labial, or vulvar, or vaginal thrombus or haematoma. This is not a frequent accident. Deneux,3 in a practice of more than forty years, saw but three cases, and Dubois a like number in 14,000 deliveries. Winckel gives the proportion as I in 1600. It is at least relatively more frequent in primiparae than in multiparae. Varicose veins are not a predisposing cause; Perrot's statistics, including forty-three cases, show that this condition was present in only two; Barker states that in a very large proportion no such condition preceded the thrombus. Among the causes of haematoma mental emotion, violent vomiting, and cough- ing have been given. But laying aside this doubtful etiology, we may say with Hervieux that the determining cause of this affection in labor is the prolonged stay of the head in the pelvic cavity, the delay arising from narrow pelvis, from resist- ance of the perineum, from size of the fcetus, etc., and hence excessive efforts on the part of the patient to overcome the obstacle to delivery. Perrot has shown that there may be a gliding of the vaginal walls upon the peripheral tissues, so that a partial detachment occurs from tearing of portions of the connective tissue, and thus spaces are formed in which blood poured out by the ruptured vessels col- lects. Or it may be that the walls of vessels are thinned by the great pressure from the fcetus, and when that pressure ceases, a new wave of blood distending them, 1 Considerations relatives aux Dechirures du Vagin a la Suite de 1'Accouchement. Paris, 1822. 2 The Puerperal Diseases, p. 42. 3 Maladies Puerperales, Hervieux. 532 SCIENCE AND ART OF OBSTETRICS. they give way. According to some authorities the vessels that rupture are venous, but Winckel says there is no question that the wound of an artery, as well as of a vein, may give rise to a haematoma, even though the effusion is most commonly of venous origin. In 35 out of 43 cases given by Perrot the hemorrhage did not occur until after labor. Dewees1 has given an instance in which the tumor formed ten minutes after the birth of the first of twins, and was ruptured by the descent of the second child, the patient recovering. Madame Sasanoff, in connection with a case under her care in the Maternity of Kolonna, St. Petersburg, has re- ported five others2—that of Dr. Dewees not being included—as the only ones she could find published in which the haematoma formed in the interval between the birth of twins. Of these five, four were fatal. She believes the rule of practice ought to be that, when there exists the least appearance of the formation of a thrombus, the delivery should be hastened, and that in this point of view version and extraction of the second child should receive a large application, so much the more as the escape of the first child favorably affects the dilatation of the orifice, and facilitates the introduction of the forceps or the hand into the genital canal. If the delivery be delayed the haematoma rapidly increases in size, and rupture or incision may be necessary for the passage of the child, and such early rupture or incision makes the prognosis quite unfavorable. The tumor, varying in size from a hen's egg to a child's head, usually appears a short time after labor, but exceptionally seve- ral days may intervene. Schroder refers to a case reported by Hei- fer in which it was first seen on the twenty-first day; in such instances the exciting cause was violent bodily exertion. Haematoma of the vulva is more frequent than of the vagina. The labia majora are oftener affected than the labia minora. The effusion may extend to the connective tissue, making a vulvo-peri- neal thrombus : "The blood is generally extravasated into the sub- cutaneous cellular tissue in the perineum between the superficial and median fascia, in the vagina into the submucous tissue, or into the cellular tissue encompassing the vagina; yet there are cases (Cazeaux and Hugenberger) in which it has extended along the vagina up to the peritoneum cellular tissue, and posterior to the peritoneum up to the kidneys, anteriorly in front of the peritoneum up to the navel, and on the sides as far as the sacrum."3 The tumor is in the majority of cases unilateral; and its forma- tion is usually preceded by severe pain; the surface is smooth, discolored, livid or violet, and it presents to the touch more or less elasticity with or without fluctuation. If the hemorrhage be great the symptoms of acute anaemia are present, but death does not fol- low unless the haematoma ruptures, and then it may be very rapid. Recovery generally takes place. Thus Winckel found only six that were fatal in fifty; Barker met with two deaths, both from puerperal fever, in thirteen hospital cases, while of nine in consultation and in private practice, all recovered. The prognosis will be governed by the size of the thrombus, and by whether it occurs before or after delivery; the larger the tumor, of course, the greater the danger, and, on the other hand, the case is more favorable if the formation occurs after the labor than during it. The termination may be by resolution, and this may happen even if the tumor be as large as the fist, by suppuration, by rupture, or by gangrene. 1 Diseases of Females: Of Bloody Infiltration in the Labia Pudendi. 2 Annales de Gynecologie, December, 1884. 3 Winckel, op. cit. THE PATHOLOGY OF LABOR. 533 Treatment.—During the formation of a haematoma we endeavor to lessen the effusion of blood by the application of an ice-bag and by compression. If rupture occurs, an astringent tampon should be applied and pressure also used. If it form during labor, and pre- sents an obstacle to the delivery of the child, even by forceps, though such condition is quite exceptional, " incise at once, remove all the clots that have formed, and then deliver by the forceps," and afterward compresses of cotton batting saturated with the solution of persulphate of iron are to be used and pressure made, constitute the directions of Barker. After labor, incision may be rendered necessary by threatened gangrene ; but it is always better if this can be delayed for three or four days after the development of the hae- matoma, for, as observed by Schroder, the longer we can wait the less danger from consecutive hemorrhage ; nevertheless, Chaussier mentions a case in which the incision was not made for a week, yet hemorrhage occurred, and Baudelocque one in which the opening was not made until three weeks after the tumor was formed, and the following hemorrhage was so great as to require the tampon. Tears of the Cervix.—Lateral tears of the cervix almost invariably occur in a first labor, that upon the left side being usually deeper than the corresponding one upon the right. In some cases the tear extends to the vaginal vault, more rarely above it so that the con- nective tissue is involved, and still more rarely the injury may reach to the peritoneum. In the multipara some tearing also may occur, but usually the rents are not so deep, and less frequently lateral. The injuries referred to occur not only in spontaneous, but also in artificial labor, both manual and instrumental; the applica- tion of the forceps and extraction of the fcetus before complete dila- tation of the os has occurred, as well as rude and hurried dilatation of the os by the hand or rapidly drawing out the child after podalic version is very liable to cause this accident; when the placenta is praevia, severe and even fatal laceration of the cervix, the tear ex- tending upward to the body of the uterus and downward into the vagina, has been known to result from too rapid dilatation of the os and too hasty extraction of the child. Lacerations of the vaginal cervix are physiological in the great majority of cases, neither immediately nor remotely demanding pro- fessional interference ; so far as ulterior consequences are concerned, probably an exaggerated1 importance has been attached to these injuries of the cervix, more especially in this country, since Emmet has devised the operation known by his name, an operation very beneficial in suitable cases, but often done, as Emmet himself has pointed out, unnecessarily. In exceptional cases serious hemorrhage comes from the rent 1 Some years ago Dr. Holmes pleasantly remarked that Mr. Huxley had given bioplasm about all it could bear. I am quite sure that some practitioners have given a lacerated cervix a good deal more than it can bear. The assumption that healed and innocent physiological tears of the cervix must indicate a plastic operation by which the os and cervix of the woman who has borne a child shall be restored to their condition prior to childbirth, is an error from which originates a great deal of mere carpenter work of no profit whatever except to the operator. 534 SCIENCE AND ART OF OBSTETRICS. in the cervix, and immediate arrest of the bleeding is demanded. This may be accomplished by copious injections of hot water, by the pressure of properly applied iodoform gauze, but the surest means is the suture; for its application the cervix must be seized with suitable forceps, and drawn down to the vulva, when the stitches can be readily introduced with the injured part thus ex- posed ; silkworm-gut is the best material for stitches. Transverse tears of the cervix are comparatively rare. They usually involve only the anterior lip, and then result from its being forcibly held by the descend- ing head against the anterior wall of the pelvis. Schroder refers to the accident as more frequent in induration of the cervical tissue, and he also mentions a case of Martin's in which there was found a polypoid body formed by the partially detached lip of the uterus. Fig. li Annular Laceration of the Cervix. A few cases of what has been termed annular separation of the cervix have been recorded. This accident results from an unyielding cervix and strong uterine contractions. Barnes1 refers to a case reported by Gervis in which ring- form detachment was not complete. It was replaced without sutures, as the patient was very prostrate. She recovered, and the ring reunited. Duparcque2 mentions meeting with a case in which the entire anterior lip was detached, so that at first it seemed as if there were a double os uteri. Ruptures of the Uterus.—Rupture of the uterus is one of the grav- est accidents that can occur to the pregnant or parturient woman, for her child almost without exception perishes, and her own life is lost in the great majority of cases. Frequency of Rupture.—This is variously stated by different au- thors : Collins found . . . . i rupture in 482 labors. McClintock.....1 " 737 Bandl.......1 " 1183 Jolly.......1 " 3403 Ramsbotham . . . . 1 " 4429 Von Franque . . . . 1 " 3225 1 Obstetric Medicine and Surgery. A similar case will be found in the Transactions of the Philadelphia Pathological Society, vol. i., reported by Dr. Keller. Dr. Barton C. Hirst recently met with one in the Maternity of the University Hospital. 2 Histoire complete des Ruptures et des Dechirures de l'Uterus, etc. THE PATHOLOGY OF LABOR. 535 Winckel saw rupture of the uterus during five years in the Munich clinic in 6 cases out of 4000 labors. In some instances the rupture is what has been termed " silent," as will be explained hereafter, and the woman perishes of hemor- rhage, or of septic infection, and only by accident, if an autopsy is made, is the injury known ; in the absence of such autopsy death is attributed to one or the other cause mentioned, the true condi- tion being unknown. Hence it is probable the accident occurs oftener than statistics lead us to believe. Rupture in Pregnancy.—This may be spontaneous or result from external violence. The cicatrix remaining after the Caesarean ope- ration may give way, or the thinned wall of a rudimentary horn yield to the pressure of the growing ovum, or a blow upon the abdomen, or a fall, cause a tear in the normal uterus. Spontaneous rupture in pregnancy has followed dancing, vomit- ing, lifting a heavy weight, and great fatigue. Barnes, op. cit., gives illustrative cases. Rupture during Labor; its Causes.—In considering the etiology of this accident, it is convenient to refer first to the rarer cases of this Fig. 189. Transverse or Semi-circular Grinding Through of the Uterus. accident. Rupture may be consequent upon attrition, the uterine tissue, usually cervical, being forced against abnormal bony projec- tions from some portion of the pelvic inlet, exostoses of pelvic 53^ SCIENCE AND ART OF OBSTETRICS. bones; and thus usur, a wearing away of those tissues, results. Naegele states that Kilian has drawn especial attention to a deform- ity of the ilio-pectineal eminence in which this, instead of present- ing its normal oval shape, has a spine-like process; similar sharp projections may occupy other parts of the pelvis; to the basin thus deformed the name of Stachelbecken, pelvis spinosa, was given; and Kilian showed the injurious effect in labor resulting from this cause. Depaul has stated that four out of twenty-four deformed pelves in his collection have exaggerated developments of particu- lar parts, forming knife-like projections; according to his observa- tion, this deformity was most frequent at the pubic crest. The following remarkable case is quoted by Duparcque } A woman had been in labor twelve hours, the presentation being pelvic. The os uteri was not yet completely dilated when all the anterior part of the neck, from one side to the other, separated. Immediately the fcetus passed into the abdominal cavity, and it was extracted with great difficulty in less than two hours; it was dead. The mother died five hours after being delivered. The basin was found a little narrow; the point of the sacrum had passed through the posterior part of the uterus (was this the sacro-vertebral angle?); the internal and salient border of the pubis and of the iliac bones resembled somewhat the edge of a paper cutter, and had cut all the thickness of the uterus as if it had been divided by a ligature. Breus2 has published a case of injury done to the uterus by its tissues being worn through in consequence of the pressure of the head of the child forcing these tissues against the sharp promontory of a rha- chitic pelvis. Not only may pelvic deformity cause such attrition, but I believe that it may also result from an irregular bony surface of the fcetal body being forced against the uterine walls, hour after hour, by uterine contractions; such a surface is pre- sented by the jagged margin of the imperfect arches of a spina bifida after rup- ture of the sac has occurred. This belief depends upon my having several years ago, in a judicial investigation, a midwife having been arrested for malpractice, examined the fcetus and the ruptured uterus of the dead mother. The rupture involved the cervix and the lower third of the body of the womb upon the right side ; in the labor the pelvis presented with the sacrum to the right, and the most rational explanation of the accident was, to my mind, that which has been stated. In rare cases no cause can be assigned for the accident. Thus Winckel remarks that the cases of Alexander Simpson and of Hofmeier are very remarkable and difficult to explain. " In Simp- son's case the laceration extended from the fundus uteri to the os on the left side; in Hofmeier's the laceration was of the same length, but on the right side; both occurred in pluriparae and the pains were not very strong; the former showed an abnormal fatty condi- tion of the uterine'muscular structure, which was absent in the latter. The most remarkable case of spontaneous rupture of an otherwise normal uterus is, however, the one which Ingersley ob- served in a 32-year old VH-para in the eighth month of preg- 1 Op. cit. 2 Ueber perforirende Usur des Uterus, Wien. med. Blatter. THE PATHOLOGY OF LABOR. 537 nancy, in whom a rupture from the fundus to within one-half inch of the internal os occurred without any external violence; the child escaped into the peritoneal cavity and the woman died in two hours." Passing from these rare and exceptional cases, we have now to consider the causes of the accident as it most frequently occurs. So far as immediate causation is concerned, it may be stated that rup- ture of the uterus is spontaneous or from violence, and this violence may be done by the instrument or by the hand of the obstetrician. Duparcque in his well-known work gives as his first conclusion, that ruptures of the uterus in labor are caused by the contrac- tions of the organ. Trask, in his at the time of publication ex- haustive study1 of the accident, said: "Unless caused by direct violence, rupture must, in almost every case, be the result of the contraction of the uterine fibres, whether the uterus be healthy or diseased." Tyler Smith expressed the following opinion: "Un- doubtedly cases of rupture of the uterus do occur which are de- pendent upon inflammatory action, either during or before labor, or upon malignant diseases of the uterus; but such cases are rare compared with rupture from self-contraction of the uterus." Jolly stated that the true cause is more or less violent uterine contraction. But contractions of the uterus, though violent, could not rupture the uterus if normal conditions are present, and therefore behind this cause there must be others that predispose or otherwise contribute to the result, and to these our attention will now be directed. The accident occurs more frequently in multiparas2 than in primi- parae, the latter furnishing only 12 per cent, of the entire number. The influence of multiparity is explained by Charpentier as causing thinness of the wall of the uterus, and changes in its tissue with enfeebling of power. Kleinwachter and others, however, believe that healthy uteri rupture more frequently, for they only contract powerfully. Scanzoni suggests the greater frequency of shoulder presentations; to this may be added the greater size of the children. The accident is more frequent in the births of male than of female children—of 67 children, 48 were male, only 19 female. They are more frequent, according to Bandl, among the poor than among the rich. It is probable that the untimely administration of ergot, or using it in too large doses, must be considered the chief factor in causing rupture of the uterus in some cases. The late Dr. Hugh L. Hodge stated that he had never met with this or seen a case of rupture, with perhaps one exception, in which ergot had not been given. Dr. Meigs has referred to three, and Dr. Bedford to four cases in which it was believed that ergot was the cause. Similar instances are given by Marot, and it would be easy to increase the list to large proportions, especially if cases were collected from the practice of midwives in this country, who, usually attend- ' American Journal of the Medical Sciences, 1848 and 1856. 3 Playfair states, "Tyler Smith contended that ruptures are relatively as common in first as in subsequent pregnancies.'' Charpentier says that all authors, except Tyler Smith, admit the influence of multiparity. How these statements can be reconciled with the following language, let others decide : " It is an interesting and remarkable fact that ruptures of the uterus seldom happen to primiparous women." (Lectures on Parturition and the Principles and Practice of Obstetrics. By W. Tyler Smith. Lancet, vol. ii. p. 495.) 538 SCIENCE AND ART OF OBSTETRICS. ing cases of labor for low fees, too often endeavor to hurry the labor by giving ergot in the first stage. The injurious effect of ergot given with a free hand in the first stage of labor can be readily understood when we remember that for the occurrence of sponta- neous rupture of the uterus the chief immediate factors are active contraction in the effort to overcome great or insuperable resistance. The undilated or partially dilated os is a barrier to the passage of the fcetus; if time be given, the tissues being healthy, gradually yield and perfect dilatation results; but if the uterus is stimulated to excessive activity the resisting os prevents escape of the presenting part, and the force prematurely or unduly evoked is expended upon the thinned lower segment of the uterus, and rupture follows. In some cases of pathological change in the cervix, as from malig- nant disease, rupture follows the vain effort to overcome the resist- ance. It must be remembered that in labor the uterus consists of two portions, one active, the other passive; an upper portion which seeks to expel the child, and a lower portion which is stretched so as to permit that expulsion. Now if, for example, there be a shoulder presentation, expulsion is impossible. So, too, if there be excessive size of the child, as from hydrocephalus, the same element of dis- proportion between the passenger and the passage is present. Schuchard1 in 73 cases of uterine rupture found hydrocephalus in 13. Winckel describes the occurrence of spontaneous rupture as fol- lows : " Some obstruction—whether it be hardness or rigidity of the external os, or an unusual size of the head (by hydrocephalus), or a faulty attitude (face presenta- tion, prolapse of an arm)—prevents dilatation and retraction of the cervix over the presenting part, while it is continually forced by the body of the child under the contraction ring; hence the lower uterine segment becomes thinner and thinner, until, finally, its fibres separate, by reason of the renewed force of the pains, at the points which have been most tensely stretched and attenuated, the laceration perforating rapidly from within outward." Symptoms of Threatened Uterine Rupture.—The premonitory symp- toms are the tense condition of the round ligaments, the great thin- ning of the lower uterine segment, the ascension of Schroder's contraction-ring, so that from its normal position near the pelvic inlet it may now be only the breadth of two or three fingers below the umbilicus ; this ring can be recognized by palpation, and during a uterine contraction can in some cases be seen making a somewhat obliquely-lying furrow across the abdomen, while at the same time that portion of the uterus below this furrow "is prominent as if it were a distended bladder;" but the use of the catheter will prevent, in a case of doubt, such mistake. The finger in the vagina passes readily between the presenting part and the cervical wall, which is everywhere found extremely thin. The general condition of the patient also foretells the accident. She is restless, and suffers not only during uterine contractions, but also in the intervals; the abdomen is tender;- the suffering and the anxiety cause an excited and frequent pulse, and there is some eleva- 1 Ueber die Schweirigheit der Diagnose und die Haufigheit der Uterusruptur bei fotaler Hydrocephalic Berlin thesis, 1884. 2 Spiegelberg. THE PATHOLOGY OF LABOR. 539 tion of temperature ; her countenance expresses anxiety. Instances of this variety of rupture that do not present premonitory symptoms are quite exceptional. Fig. 190. contraction ring round ligament internal os external os -------contraction-ring round ligament ——internal os Shoulder Presentation.—Threatened Rupture of the Stretched Lower Segment of the Uterus and Cervix. (After Schroder.) Tears of the uterus caused by the application of the forceps when the os is not sufficiently dilated, or by the rude and rapid dilatation with the hand, or by the manual extraction of the child in case of partial expansion of the os, have been previously mentioned. It only remains to refer to this accident in case of threatened rupture in consequence of obstetric manipulations. The shoulder, for ex- ample, presents, and the vain labor has continued for hours; the obstetrician performs podalic version, and although accomplished with ease, it may be, as the last straw that breaks the camel's back so the introduction of fingers or hand, even done with the utmost gentleness, may cause tearing of the uterus. Before mentioning the symptoms of rupture of the uterus, a word may be said of those cases in which there are no indications of the accident. Hervieux1 narrates a case from the practice of Dubois in which he performed podalic version on account of narrowed inlet; the woman died the next day, no symptom of uterine rupture having been manifested, yet there was found at the post-mortem an irregular rent involving a part of the anterior wall of the vagina, the entire length of the neck in front, and a portion of the left side of the 1 Trait6 clinique et pratique des Maladies puerperales. 540 SCIENCE AND ART OF OBSTETRICS. uterus. He also refers to a case occurring in the Maternite in his service in which Tarnier by external means changed a pelvic into a vertex presentation ; the woman was delivered on the 9th and died on the 1 ith of November, and at the autopsy there was found a rent in the side of the neck a little more than two in- ches long, extending from the internal os to the union between the neck and the vagina. In a paper presented four years ago to the Philadelphia County Medical Society, I narrated a case of uterine tear which was not suspected during life, but, the woman dying of septicaemia, a post-mortem showed that there was a complete rent involving the left side of the cervix and the lower third of the body of the uterus. Since that time a medical gentleman of this city brought me the uterus of a woman who died in labor from hemorrhage, so reported too in the certificate to the Board of Health, and examination showed that the cause of the hemorrhage was a tear extending from the external os nearly as high as the contraction-ring. Hervieux remarks that in some cases the uterine tear is made silently—neither pain not complaint nor crisis, and if the patient dies, as is usually the case, one is astonished to find at the autopsy a rupture which had not been even suspected. Winckel, after referring to these cases, as given in the previous edition of this work, adds a similar one occurring under his observation. If we add to these silent tears, many of which remain unknown because autop- sies in private practice are not frequent, and a few in which death does not follow the accident—those cases which, though recognized by the practitioner, are not made known—it is probable, as has been previously stated, that the accident, though by no means frequent, is less rare than published statistics indicate. Position and Extent of Tears.—Usually the rupture involves the lower uterine segment and the cervix, but it may extend upward into the contraction-ring or downward into the vaginal wall. Usually, too, the peritoneum is torn, so that there is a direct commu- nication between the uterine and abdominal cavities ; exceptionally the peritoneum is not injured, and then the rupture is incomplete. The tears are rarely longitudinal, but they may be transverse or oblique; they may be lateral, anterior or posterior. A part of the fcetus usually enters the abdominal cavity, sometimes almost all or even the entire body ; and, on the other hand, a portion of intestine may prolapse through the rent. Symptoms of Rupture.—It may be that during a pain of unusual severity, or an obstetric manipulation, as the introduction of the hand for the purpose of version, the patient has sudden suffering of the greatest intensity, "totally different from the pain of uterine contraction." Trask says that she is conscious of something having given way within her—"she feels a tearing or rending sensation, and in some instances the noise accompanying the rupture is heard by those around her." The last statement is now generally denied; Depaul regarded it as purely theoretical. The patient's face becomes anxious and pale, the skin is covered with cold sweat, there are nausea and vomiting, the pulse is rapid, threadlike, and irregular, the respiration is hurried, difficult and sighing, the sight is obscured, and there is ringing in the ears. There is severe pain in the abdomen, and the latter notably changes its form if the foetus has entirely or partially entered its cavity, or if there be large hemorrhage in it. The uterine contractions cease in almost all cases. Upon vaginal examination generally some hemorrhage is discovered, the presenting part has receded, or is replaced by an- other presentation, and possibly the rent can be at once felt. In the THE PATHOLOGY OF LABOR. 54I 580 cases studied by Jolly the symptoms narrated were manifested as follows : Abrupt cessation of contractions was observed in 218 cases. Gradual " " " " 38 Change in the pulse '• " 179 Prostration " 151 External hemorrhage, slight in 33, '■ " " 148 Retrocession of presenting part " ''146 Abdominal pain " J33 Alteration of countenance " .. II5 Fcetal parts felt immediately under abdominal wall " « 77 Acute pain at the moment of rupture " '• 62 These are the signs almost always presented, but others which may occur should not be neglected. Thus a remarkable change in the form of the abdomen is observed—two tumors, one formed by the escaped fcetus and the other by the uterus, may be present. In some cases the movements of the fcetus that have been active sud- denly cease, and the sounds of its heart can no longer be heard. Hemorrhage may be external, internal or both; Charpentier directs attention to the fact that the blood may accumulate at a particular point, forming a' hypogastric tumor. Kiwisch, M'Clintock, Mont- gomery, Paully, Ross, Crighton, and Schatz have indicated as a pathognomonic phenomenon the occurrence of emphysema at the level of the hypogastric region, very rapidly sometimes, and which results from the penetration of air through the rent and its diffusion in the connective tissue. But the emphysema referred to can be present only in those cases in which the rent is incomplete. Spiegelberg has stated that the air either enters from without through the tear during intra-vaginal manipulations, or else results from putrefactive changes in the fcetus. This symptom is always a very unfavorable one, all cases in which its presence has been recorded having proved fatal. Trask made the diagnostic marks two : recession of the pre- senting part, and the ability to distinguish the limbs of the fcetus beneath the abdominal parietes. In regard to the cessation of the uterine contraction, Jolly found 37 in which this did not occur, or was only temporary, and in some, indeed, the contractions retained their normal force. Prognosis.—This is most unfavorable both for the mother and for the child—especially for the latter. In Jolly's 580 cases only 100 mothers were saved, and of 237 children in regard to which the results were stated, only 7.5 per cent, were born alive. The mother may die very suddenly from shock, as in a patient of Churchill,1 who lived but five minutes after the accident, or one of Bluff,2 who gave a scream of suffering agony, vomited, and died. Instead of sudden death from shock, there may be rapid death from hemorrhage ; or a fatal result may occur from strangulation of a coil of intestine in the rent; but the most frequent cause of a fatal termination is septi- caemia. In two cases reported by Winckel death was caused by air 1 Diseases of Women. 2 Siebold's Journal, 1835. 542 SCIENCE AND ART OF OBSTETRICS. embolism. The same author regards the prognosis as improved1 by the use of antiseptics. While Jolly gave the percentage of recoveries as 17, Spiegelberg thought 5 per cent., the result established by Hugenberger, as being near the truth. Zweifel after quoting Trask as deriving from his statistics that the mortality of expectant treatment was 78 per cent., after delivery by the vagina 68 per cent., and after laparotomy 24 per cent., says these statistics cannot be correct. The surprisingly small mortality when laparotomy was done is to be explained by the fact that cases operated upon which recovered are reported, while the others are passed over, and by the relative smallness of the figures. Treatment.—This comprises that advisable in threatened rupture and that required after the accident has occurred. In the former immediate delivery is demanded, and this must be effected without additional stretching of the cervix. Hence, embryotomy is prefer- able to version, for the introduction of the hand or fingers for the accomplishment of the latter is liable to immediately cause the accident in such conditions, no additional strain to the over- stretched tissues being possible without this injury following. If the child occupies a transverse position, embryotomy; if the head presents in a contracted pelvis, craniotomy; or if there be hydro- cephalus, perforation—constitute the treatment advised by Zweifel; and he adds that transverse position, narrow pelvis, and hydro- cephalus are almost the sole complications of labor, bringing the imminent danger of rupture of the uterus. After rupture of the uterus, too, delivery must be made as soon as possible. If the woman is greatly prostrated, stimulants—especially hypodermatics of sulphuric ether—are indicated, and other suitable means employed to bring about reaction. The modes by which delivery is to be effected will depend upon the position of the child, the presentation, and the special obstacle to labor which has been the chief cause of the injury. The child is either in the uterus or in the abdominal cavity, or partly in each. In the first case, supposing the head to present, the forceps or the cephalotribe is indicated: of course the head is first opened if the latter instrument is employed. If the head be not accessible, delivery by podalic version is indicated. In the third case, still, delivery through the natural passage is the rule if the part of the fcetus that has entered the abdomen can be easily brought into the uterine cavity and without increasing the rent. But if such restoration is impossible without this additional injury to the uterus, and in the second condition that has been stated, abdominal section is required. After delivery through the natural passage, a 2 per cent, solution of carbolic acid is used to thoroughly wash out the cavity, and a drainage-tube introduced. 1 Nevertheless this opinion meets with no support from the recently published statistics of Schaffer, " Uber die Behandlungder Ruptura Uteri mitkompleten Austrittdes Kindes," Munich med. Wochenschrift, 1889. He states that of 100 laparotomies for this accident, there were, before 1875, 48 cases with 31 recoveries—65.1 per cent.; antiseptic operations, 52 cases, 19 re- coveries—36.1 per cent. THE PATHOLOGY OF LABOR. 543 Frommel,1 pursuing this method, had in 1880 three successful cases, and the next year Hecker2 reported a success obtained in like man- ner. Schlemer3 in 1882 had a case of rupture in which a portion of intestine prolapsed through the rent, the fact of the rent and of the prolapse being ascertained after delivery with the forceps; the bowel was restored, a drainage-tube introduced, an injection of carbolized water employed ; the injection was repeated daily, and the woman recovered. Associated with drainage a compressive abdominal bandage is employed. The drainage-tube is of glass, and is T-shaped; injec- tions are, as a rule, not made through it into the abdominal cavity, but the nozzle of a syringe may from time to time be introduced into the tube, and fluid drawn out: the tube is removed in about a week. Zweifel, after stating that Schroder, Frommel, Grafe, Hecker, and Morsbach have had excellent results from this treatment, adds that he has also had in his clinic a case that was successful by means of peritoneal drainage. In a case of rupture4 reported by Rhinestadter the peritoneal cavity was washed out through the drainage-tube with a 1 per cent. carbolic acid solution, an antiseptic vaginal tampon introduced, and an ice-bladder applied to the abdomen over the rupture. The vaginal dressing was renewed the next day, the drainage-tube was removed four weeks after the delivery; the woman recovered. Fleischman5 has shown the greater mortality of ruptures of the anterior portion of the cervix than of the posterior, for of 18 cases of the former all died, while of 14 of the latter only 9 were fatal, and he suggests that in the former injury the abdomen should be opened, while in the latter drainage should be used. Douglas's cul-de-sac presents favorable conditions for drainage, while the vesico- uterine does not. In one case successfully treated by drainage the abdominal cavity was washed out with a one per cent, thymol solution, and a firm drainage- tube passed posteriorly into the cavity, and retained in position by a loose tam- pon of iodoform gauze. Piskacek6 claims that the most successful treatment for complete rupture is drainage by iodoform wicking, the results being 12 per cent, better than from lap- arotomy. Seven cases from Breisky's clinic are given, 5 of them treated by drainage as stated, and 4 recovered. Leopold7 emphasizes the importance of delivering the child so that the mother's life may be least endangered, and of having especially in view the control of hemorrhage by the promptest treatment. He attaches more value to laparotomy than the previous authority. Coe, in connection with a case of laparo-hysterectomy successfully done by him for rupture of the uterus,8 believes this the only method of treatment proper after prolonged and unsuccessful attempts at delivery: he gives a table including 13 cases by different operators, and the maternal mortality is a little more than 69 per cent. In case laparotomy is done, it should be followed by hysterectomy if the hemorrhage cannot be controlled by suturing the uterine wound, and a tampon of iodoform gauze. 1 " Zur Therapie der Uterusruptur,'' Centralblatt fur Gyniikol., 1880. 2 Ibid., 1881. 3 Ibid-, 1882. * Op. cit. 5 " Ein Beitrao- zur Casuistik der Collumdehnung und der Uterusruptur," Zeitschrift fur Heilkunde, 1885. 6 See abstract of Piskacek's paper in the American Journal of the Medical Sciences, Novem- ber, 1889. 7 Archiv. f. Gynakol., 1889. 8 New York Medical Record, 1889. 544 SCIENCE AND ART OF OBSTETRICS. Hemorrhage after the Birth of the Child.—Bleeding subsequent to the delivery of the child may arise from tears at the vaginal entrance, of the vaginal wall, or of the cervix, or it may be from the interior of the womb. The treatment of vulvar, vaginal, and cervical hemor- rhage has been presented, and there remains now only that variety having its origin in the uterus to be considered. This hemorrhage is from the placental site, and of course is im- possible as long as the placenta is completely attached, but may occur in case of partial detachment. It may occur when the pla- centa is partially expelled, lying in the vagina, for example, or after its complete expulsion, an hour or more after the completion of labor. The essential cause of hemorrhage is in deficient uterine contrac- tion. The reason for this failure may be previous excessive disten- tion, as from a plural pregnancy, or from polyhydramnios; or it may be too rapid a labor: the uterus suddenly emptied of the fetus does not contract as promptly as if the labor had been of normal length, and, on the other hand, a prolonged labor may exhaust the power of the uterus; the liability of albuminurics to post-partum hemorrhage has been previously stated, while haemophilia is too obvious a cause to be more than mentioned. In some cases of uterine fibroids retraction of the uterus is hin- dered, but bleeding will not result unless the site of the placenta has happened to correspond with the situation of one of the tumors. Hemorrhage after the birth of the child is not a frequent, and in almost all cases is a preventible accident; it generally indicates some sin of omission or of commission on the part of the obstetrician. Spiegelberg has said : " I certainly do not exaggerate, when I say that severe post-partum hemorrhage is almost without exception the fault of the attendant. The value of his services can be esti- mated by the frequency with which this accident occurs in the labors he conducts." Symptoms.—There is generally observed an unusual frequency of the pulse, but this increase is possibly only slight, nevertheless its occurrence should put the practitioner upon his guard even though he finds the uterus at the time nearly normal in size and in firmness. The patient probably complains of great thirst, and she is somewhat restless. But often without any premonitory symptoms the flow of blood can suddenly be manifest, trickling through or down by the side of the bed to the floor; the discharge may be so rapid and great that it is appropriately called flooding, a flood upon which the patient's life is swiftly borne away unless proper measures are promptly used ; now she is usually restless, and her arms rise and fall, thrown to this side and to that in a sort of aimless way and agony of despair, her respiration is sighing and she wants fresh air, and possibly she complains of the darkness of the room, exclaiming " I can't see !" while a death-like pallor is upon her face. You put your finger upon her pulse, it is frequent, thready, intermittent; your hand upon her abdomen, and the small hard uterine globe is no longer felt, but there is excessive abdominal distention, and it is THE PATHOLOGY OF LABOR. 545 often difficult or impossible to define the boundaries of the uterus— a relaxed sac filled with blood. Treatment.—If ever there is one time more than any other in the obstetrician's life when he needs to be calm and collected and to put forth prompt and intelligent action, it is when he is brought face to face with post-partum hemorrhage. If he participates in the anxiety and alarm of bystanders, he will hesitate and falter in the instant use of necessary means, and fear becomes panic, while the peril of the unfortunate patient is increased by every minute's delay and by her loss of faith in him ; but if, on the other hand, he is armed with that self-confidence which comes from knowledge, he inspires others with trust, and they render prompt and wise obedience to his direc- tions, and he, doing the right thing at the right time and in the right way, will generally have the unspeakable reward of saving a fellow- being from swift death. In addition to lowering the patient's head and the administration of stimulants and of hypodermatic injections of sulphuric ether, etc., applicable in other cases of bleeding with consequent exhaustion, we use direct means to arrest the bleeding. First of these is uterine compression. The usual method of doing this is to grasp the ute- rus through the abdomen with one hand, while the other is intro- duced into the uterine cavity in order that its presence may evoke uterine contraction. Possibly, too, the placenta* may still be in the uterus, either free or partially attached ; in the latter case the fin- gers are used, as the uterus lessen's in size, to detach it, and in either case to remove it from the uterus at the proper time. Probably the uterus is very sensitive when pressed by the abdominal hand, but this arises from its great distention, and as soon as the organ is emptied the excessive sensibility ceases ; possibly the uterus cannot be felt at first by this hand—it is so relaxed that it has lost its form —but then so much the more necessity for prompt action. Should this means fail in arresting the hemorrhage, compression of the uterus, placed in a position of anteflexion, may be employed : Zweifel says it ought to be possible to stop every atonic hemorrhage by energetic use of this treatment. In it pass two fingers into the posterior cul-de-sac, and press the cervix forward, while the other hand, upon the abdomen, is made to press upon the fundus posteri- orly, bringing it also forward, as shown in the accompanying illus- tration. Compression of the abdominal aorta may be made with the fingers of the left hand, the obstetrician being upon the patient's right side: the abdominal wall is depressed just above the uterus and a little to the left of the median line until the pulsations of the vessel are felt, and then slight pressure with the first three fingers will arrest the current. An assistant will be needed, for the fingers become too tired after twenty or thirty minutes to maintain efficient compression. Com- pression of the abdominal aorta was probably first advocated by Riidiger, a prac- tioner of Tubingen, in 1797. His method was with the hand introduced into the uterus, pressing through its posterior wall. Ulsamer in 1825 introduced the method of pressure through the abdominal wall, and it received the strong in- dorsement, from personal experience, of Siebold and of Baudelocque. Gros1 has 1 De la Compression de l'Aorte dans les Hemorrhages apres l'Accouchement. 35 546 SCIENCE AND ART OF OBSTETRICS. reported nine cases of puerperal hemorrhage in which it was successfully em- ployed. Zweifel holds—this objection has been made by Jacquemier and others —that it is impossible to cut off by this means all the blood-supply to the uterus, Fig. 191. Arresting Hemorrhage by Compression of the Uterus in a position of anteflexion (Zweifel.) because the spermatic arteries pass off from the aorta above the part compressed, and that the chief benefit is in preventing cerebral anaemia, in this respect being upon the same level as bandaging the limbs or what is known as auto-transfu- sion. Uterine contractility has been in some cases evoked by flapping the abdominal wall with a wet towel, by pouring cold water from a height upon the exposed abdomen, by the application of ice to it, by the introduction of pieces of ice into the vagina or into the uterus, or by the injection of cold water into each. In recent years, how- ever, the general preference has been for injecting into the uterus of hot, rather than of cold water, the former being more efficient than the latter in producing permanent contraction and stimulating rather than depressing. The water should have a temperature of not less than 105° Fahr., and the injection be made by an irrigator rather than by a pump. The application of vinegar to the interior of the uterus was probably first advised by Leroux1 in 1776. Since Observations sur les Pertes du Sang des Femmes en Couches. THE PATHOLOGY OF LABOR. 547 then many obstetricians have regarded this remedy as of very great value. Dr. Penrose,1 for example, states that he has been using it alone as his last resort, both in hospital and private practice, in many apparently desperate cases of post-partum hemorrhage, and invariably with successful results. His method is the following : " I pour a few tablespoonfuls into a vessel; dip into it some clean rag or a clean pocket-handkerchief. I then carry the saturated rag with my hand into the uterus, and squeeze it; the effect of the vinegar flowing over the sides' of the cavity of the uterus is magical. The relaxed and flabby uterine muscle instantly responds." Similar stimulating applications have been successfully made to the interior of the uterus —e.g., whiskey. Betz2 succeeded in arresting post-partum bleeding by introducing into the uterus a sponge upon which chloroform had been poured; and it has been claimed that this agent acts by a powerful excitement of the walls of the vessels either directly or through the vaso-motors, and that it is incomparably more energetic than vinegar similarly applied. A styptic solution of one of the iron salts has been employed with success. There are three ways in which such a solution is used—by injection, by swabbing, and by tamponing. Dr. Robert Barnes has been the especial advocate of the first. The following quotation3 gives the formula for the iron styptic employed by him and his method of using it: "Solid ferric chloride 5j, dissolved in 5x of water, or the liquor ferri perchloridi (Br. Ph.) Sjss, water Svijss. The rules in using it are: (i) be sure that the uterus is empty of placenta, blood, and clots ; (2) compress the body of the uterus by the hand during the injection ; (3) have two basins at hand, one containing hot water, the other the ferric solution; pump water well through the syringe—a good Higginson's will do—so as to expel air; then pass the uterine tube*into the uterus, and inject first hot water, so as to wash out the cavity and give a last opportunity for evoking diastaltic contraction; then shift the receiving end of the syringe into the ferric solution, and slowly, gently inject about seven or eight ounces, carefully keeping up steady pressure on the uterus throughout and afterward." Dr. Wynn Williams4 has advised applying the iron solution by means of a sponge to the interior of the uterus. He directs pouring some of the tincture of the perchloride of iron into a sponge, which is then passed into the hollow of the hand already in the uterus, clots from the latter having been removed, and then the walls of the uterus are thoroughly sponged over. Tamponing the uterine cavity with cotton that has been dipped in a solution of the chloride of iron is regarded by Zweifel as only a final resort when all other appropriate means have been vainly tried ; and he refers to one case, the only one in which he tried this heroic treatment, that recovered with very slight eleva- tion of temperature. He directs two or three tampons to be dipped in a solution of chloride of iron, and then pressed directly upon the placental site, while ex- ternal pressure is simultaneously made upon the uterus; if the bleeding still continues, the application is repeated until it stops. He prefers this treatment to 1 Transactions of the American Gynecological Society, vol. iii. 2 Revue Medico-chirurgicale des Malades des Femmes, 1886. s Obstetric Medicine and Surgery, vol. ii. p. 292 * London Obstetrical Society's Transactions, vol. xi. 1870. 54§ SCIENCE AND ART OF OBSTETRICS. injections of an iron solution, stating that he has seen one patient die after such injection, and another recover after the tampon. Atony of the uterus has been successfully treated by Duhrssen,1 by tamponing the uterine cavity with iodoform gauze, and this practice has been followed also with success by Auvard, Eckerlein, Born, and others. The gauze is prepared by dipping it in a 20 per cent, iodoform solution; also powdered iodoform is sprinkled on it. Three strips the width of the hand and three metres in length will be used; the cervix is seized with forceps, and drawn down to the vulva, then thus exposed to sight, or if not the finger is used as a guide ; one end of a strip of gauze is taken up by forceps thirty centimetres long, and carried into the uterine cavity: after placing one hand externally over the fundus, the end of the gauze is carried up to the fundus internally, next a fold of the gauze laid over the first, and thus suc- cessive layers, like the folds of a closed fan ; the second, and then the third strip is similarly applied, and the uterus is soon filled, and the organ contracts in con- sequence of the contact of a foreign body with its mucous membrane. The tampon does not cause suffering; at the end of twenty-four hours it is removed, and there is no trace of decomposition : next, the uterus is washed out with a solution of salicylic acid. Kortiim'- objects to iodoform gauze on the ground of danger of poisoning, and regards gauze that has been dipped in a 2 to 3 per cent, creolin mixture as in every respect preferable, and certainly those who have employed the latter will agree with him. Schroder especially directed attention to paralysis of the place of placental insertion as a cause of post-partum hemorrhage, a condition first pointed out by Engel in 1840; and he urged the importance of large doses of ergot, and, in the worst cases, injection of a solution of chloride of iron to arrest the bleeding. The use of electricity for the arrest of uterine hemorrhage, advised by Radford more than half a century ago, is not to be forgotten; this agent, if the physician is fortunate enough to have suitable apparatus at hand, will act promptly, and often most efficiently in evoking uterine contraction. There are delays, difficulties, and dangers in transfusion which render it unavailable in the great majority of cases of acute puerperal hemorrhage, at least in general practice, though some of these ob- stacles are not found in hospital practice. Very few practitioners have the suitable apparatus; a*nd, if they have it, from rare use it is usually not in working order. Nor is the necessity for transfusion so great when we know how prompt hypodermatics of sulphuric ether are in rallying a patient from the collapse caused by hemor- rhage, and how efficient the introduction of fluids through the natural channels is in reviving a flagging, faltering heart. Auto-infusion has upon theoretical grounds and from small ex- perience somewhat to recommend it. By bandaging the members so that the blood which they contain is pressed out, and thus con- tributes to sustaining vital functions, possibly at times imminent death may be averted. But, on the other hand, death may be thus invited, for fatal pulmonary embolism has followed its employment. Grenser,3 and some others advocate the subcutaneous injection of a solution of chloride of sodium. Munchmeyer* regards it as free from danger, thus differing from intra-venous injection, and states that it is not painful. The quantity re- quired will be one litre, the strength of the solution 6 to 1000; it must be steril- ized, and the apparatus required for its introduction are a glass funnel of medium size, a rubber tube, and a fine needle: the solution has the temperature of the body, and the parts of election into which it is introduced are the sub- clavicular and the inter-scapular regions. 1 Archives de Tocology, 1887. 3 Centralblatt f. Gy'ankol., 1889. 2 Centralblatt f. Gyniikol., 1887-89. 4 Archiv. f. Gyniikol., 1889. THE PATHOLOGY OF LABOR. 549 Secondary Hemorrhage.—The subject of hemorrhage in connection with labor cannot be dismissed without briefly referring to a form of this disorder occurring one or more days after delivery during the puerperal period, and which is commonly called secondary. The most frequent cause is the retention of fragments of placenta or of membranes; a placenta succenturiata has in some cases given rise to dangerous hemorrhage. Several cases have been reported in which the retention of a blood-clot has caused flooding. Ordinarily, the uterus is adequate to the expulson of clots that may form in its cavity, but sometimes, this expulsion failing, the clot increases in size; the lochial discharge is scanty and serous; the uterus, though notably increased in size, is firm and resistant; for a time the clot acts as a tampon pressing upon the placental site, and thus prevents hemorrhage. After some days the coagulum spontaneously breaks up, the protecting pressure is at once withdrawn from the open vessels at the placental site, and a hemorrhage which is perilous or may be instantly fatal at once follows. In some instances a uterine fibroid or polypus has been the cause of secondary puerperal hemor- rhage. Mental emotion has in several instances produced it. Lac- tation, sexual intercourse, too early assumption of the erect position or engaging in household duties, the influence of malarial poisoning, and certain displacements of the uterus have been mentioned as causes. Among very rare cases may be stated one reported by Hewitt, of fatal hemorrhage the sixth week after labor from trau- matic aneurism of the uterine artery, and one by Johnson2 and Sinclair, in which death occurred the fourth day following delivery from rupture of a uterine thrombus. In regard to the special treatment of secondary hemorrhage, the importance of removing any foreign body, as a fragment of the placenta or clot, from the uterus is to be borne in mind. In regard to the method of emptying the uterus of a mass of coagulated blood which distends the organ, the fingers, Pajot's curette, or a stream of carbolized water may be employed. During this removal external compression of the uterus is important in order to secure retraction of the organ and thus prevent hemorrhage. The cases are rare in which the uterus is not able to empty itself but certainly some occur in which direct means must be used for the purpose, and thereby possibly a fatal hemorrhage may be prevented ; thus Conta- min3 found, in 6 out of 56 cases of secondary hemorrhage, an intra- uterine coagulum the cause. Inversion of the Uterus.—Inversion of the uterus is the gravest possible displacement of this organ. Fortunately, it is not a fre- quent accident, statistics showing that it does not occur oftener than once in one hundred and forty thousand deliveries. An inverted uterus has been compared to the finger of a glove turned inside out, the disorder has been described as a hernia of the uterus through the os; Pare applied the term " perversion " to it—a word which 1 London Obstetrical Society's Transactions, vol. ix. 3 Etude sur les Hemorrhagies. 2 Practical Midwifery. 550 SCIENCE AND ART OF OBSTETRICS. Crosse in his well-known monograph1 used to designate the final degree of this displacecment: if the inversion be complete, the simplest statement of the condition is: The uterus is upside down and wrong side out. Denuce2 attributes the first recognition of inversion of the uterus to Hippocra- tes, who also directed a plan for its restoration; he quotes, too, a passage from Aretaeus, who not only described the accident, but also referred to traction upon the cord as one of the causes, this traction being made in an effort to remove an attached placenta: so, too, subsequent great lights of ancient medicine, as Sora- nus, Moschion, Galen, Paul of ^Egina, and others, have referred more or less distinctly to inversion of the uterus as an accident of childbirth. Two conditions of the uterus are necessary in order that it can become inverted—increase of the cavity, and relaxation, either general or local, of the walls. These conditions are presented by the uterus in pregnancy and in labor, but they may also occur if the uterus be distended from other cause than an ovum; as, for exam- ple, by a polypus. In 400 cases of this accident collected by Crosse, only 50 occurred independently of pregnancy: most of the 350 thus connected with gestation occurred at its conclusion, only a very few happening after abortion. In this article the inversion occurring in connection with child- birth, and its treatment will alone be considered. Fig. 192. Fig. 193. Fig. 194. 1 2 3 Three degrees of Inversion: i, depression; 2, introversion; 3, complete inversion (Crosse) . a, fundus of uterus ; bb, cavity of uteri receiving inverted fundus; c, vagina; dd, mouth of inverted portion. The uterus when inverted forms a cavity lined with serous mem- brane and opening into the abdomen ; according to the degree and the recency of the inversion this newly-formed cavity will contain part of the oviducts, of the round and of the broad ligaments, and in some instances the ovaries and loops of intestine. Three degrees of inversion are described. In the first the fundus is depressed, a cup-like cavity being formed which may be felt from the abdominal 1 " Essay upon Uterine Inversion," Transactions of the Provincial Medical and Surgical Association, London, 1844 and 1847. 2 Traite clinique de 1' Inversion uterine, Paris, 1883. THE PATHOLOGY OF LABOR. 551 wall ; in the second the fundus has descended to the internal os uteri, the entire body of the organ thus participating in the displace- ment ; in the third degree the fundus and the body have passed out of the os: in the last case the uterus may pass out of the vulva and be external, the vagina necessarily undergoing partial inversion, and then there is prolapse of the inverted uterus. Fig. 195. Inversion of Uterus, from specimen in Musee Dupuytren (after Crosse) ; a, vagina, b, in- verted fundus, incised at c to show its cavity ; d, point of inversion, with round ligaments, tubes, and ovarian ligaments drawn in; ee, ovaries; ff, fimbriated ends of tubes, gg, round liga- ments; h, cervix covered by peritoneum. Causes of Uterine Inversion.—Remembering that the first degree of this disorder consists in a depression of the uterine wall at its upper portion—a cupping of the fundus, as it is sometimes called— this depression may result from intra-uterine traction or from extra- uterine pressure. Either traction or pressure may be spontaneous or artificial; the resulting inversion may be complete or incomplete. Pulling upon the cord for the delivery of the placenta was, as has been previously stated, reeognized by Aretaeus as one of the causes of uterine inversion, and probably it is the most frequent cause. The scepticism as to this being common, manifested by one of the wisest of American gynecologists, Dr. Emmet, upon the ground that such delivery of the placenta is so common on the part of igno- rant midwives, and therefore the accident ought to be much more frequent, is not well founded. Certain conditions must be present in order that traction upon the cord may invert the uterus, and 552 SCIENCE AND ART OF OBSTETRICS. among these are a firm attachment of the placenta, the site of that attachment the fundus or its vicinity, and uterine relaxation; the usual absence of these conditions explains the rarity of the accident. One of the most remarkable cases of uterine inversion caused by pulling upon the cord has been recorded- by an American physician, Dr. Woodson, of Ken- tucky: A negress four months pregnant was taken with severe uterine pains in a bath; she succeeded in seizing the fcetus and dragged it out, inverting the uterus. Relative or absolute shortness of the cord has in several instances been followed in spontaneous delivery by inversion of the uterus : Baudelocque has given two examples. So also delivery with the forceps has in a similar condition of the cord caused the accident: illustrative cases are given by Levret and Bock- endal.2 The cord may be normal in length, but from the unusual position occu- pied by the woman during the expulsion of the child the uterus may be inverted by the weight of the child dragging upon or suspended by the cord. Daillez reported the following case : A girl eighteen years old, near her labor, was driven from home by her father; she took refuge in the house of a friend, and soon felt the pains of childbirth. An accoucheur called to see her thought that she was suffering with false pains, and went away; upon his return he found her dying, the uterus completely inverted and hanging between her thighs ; he learned that the unfortunate girl was delivered standing, her elbows resting upon the back of a chair; the child suddenly escaped and the cord was ruptured.. The traction upon the uterine wall may be made by the partially-detached placenta and clots of blood; thus, Kormann3 quotes a case from Dr. Camillo Fiirst in which the accident occurred from the weight of a mass of blood resulting from a partial separation of the placenta retained by adherent membranes. The inversion may be caused by extra-uterine pressure. This pressure may be manual or abdominal. The former may be made in improper efforts exercised to effect the delivery of the placenta by the so-called Crede's method. But abdominal pressure, there being no manual interference whatever, may cause the accident. Denuce quotes from Galen the following remarkable passage, showing that he recognized this cause of uterine inversion : " Under the influence of the power of expulsion, which is the opposite of the power of retention of which we have spoken, the mouth of the womb opens, and the entire fundus of this organ so far as possible approaches it, pushing the fcetus out. At the same time as the fundus of the uterus, the parts that surround it, the abdominal walls, which are the ex- ternal walls of the instrument of expulsion regarded in its whole, pushing by the action of all their forces, strongly clasp the fcetus and force all out. This part of the action, which is under the woman's control, resides not in the uterus but in the abdominal muscles, which come to her aid as they do in defecation and in urination. Also in some women, when this expulsive power is exerted immod- erately, the violent pains may drive out the uterus itself. The accident is en- tirely similar to that which occurs in a struggle or combat, when one of the con- testants, forcing the other backward, throws him upon the ground, at the same time falling on him. Thus the uterus, when it violently expels the fcetus, may itself be at the same time precipitated without, especially if the ligaments which fasten it in the basin are previously relaxed." Paralysis of the placental site or general atony of the uterus is a condition which permits inversion of the uterus by abdominal pressure. Supposing the portion of the uterus corresponding with the place of placental attachment to be paralyzed, there may follow, either with or without abdominal strain, dropping down of this part 1 American Journal of the Medical Sciences, i860. 2 See Denuce. 3 Op. cit. THE PATHOLOGY OF LABOR. 553 into the grasp of non-paralyzed but active muscular walls of the uterus; these, therefore, receiving the introcedent mass actively contracting, may make the inversion complete. John Hunter, in describing an inversion of the uterus caused by a poylpus, observed; " I conceive the contained or inverted part becomes an adventitious or extraneous body to the containing, and it continues its action to get rid of the inverted part, similar to an intussusception of the intestine." Barnes in referring to Hunter's description, states that it contains the germ of most subsequent theoretical explanations. The late Professor Isaac E. Taylor believed that sometimes inver- sion begins at the cervix, this part undergoing eversion as in prolap- sus, and this going on to complete inversion of the organ. Denuce considers this prolapse which Taylor refers to as connected with the precise moment of evolution of partial inversion where the uterine depression, forced by uterine or abdominal contractions, escapes the orifice of the neck and is gradually transferred into an incomplete inversion appreciable in the vagina and between the lips of the neck. Duncan1 recognizes four kinds of uterine inversion occurring after delivery: I, spontaneous passive uterine inversion; 2, artificial passive uterine inversion; 3, spontaneous active uterine inversion; and 4, artificial active uterine inversion. " The only uterine condi- tion essential to the production of all these kinds is paralysis or inertia or complete inaction. This is the condition of the whole organ at the time of production of the first two kinds. In the last two kinds it is accompanied by uterine activity, and, as these cannot coexist in the same part, the paralysis is partial and the activity partial. Action of the uterine wall cannot cause introcession of it. Activity of the whole of the uterus renders inversion impossible. Activity of a part of the uterus renders introcession of that part im- possible. There must therefore be paralysis of the whole or of a part before inversion can begin." Symptoms and Diagnosis.—Pain, shock, and hemorrhage are the chief symptoms of sudden and complete inversion of the uterus. The woman in many cases cries out with the suffering; she may de- clare, if the inversion occurs rapidly as a consequence of traction upon the cord, that her intestines are being torn away. The shock is partly the expression of this acute suffering, partly the sudden withdrawal from the abdomen of one of its largest organs ; and should serious hemorrhage occur, the loss of blood contributes to it. The face is pale, the expression anxious, the pulse frequent and feeble, the limbs cool, and there may be vomiting and also convul- sions. The hemorrhage may be slight, for if the placenta be entirely adherent to the uterus there can be no considerable bleeding ; if, however, it be completely or partially detached, the flow may be very profuse and prove fatal in a short time. But there may be little or no bleeding, yet the collapse be profound. " Symptoms of incarceration may, and frequently do, arise when coils of intestine 1 Researches in Obstetrics, Edinburgh, 1868. 554 SCIENCE AND ART OF OBSTETRICS. have entered the funnel formed by the inverted uterus and have be- come compressed."1 Abdominal examination shows the absence of the uterine globe, and a tumor occupying the vagina, or even chiefly projecting from the vulva, is found. This tumor may have the placenta still attached, and then an error in diagnosis is impossible. If the placenta has been cast off, the obstetrician possibly doubts whether the tumor found in the vagina or at the vulva be an inverted uterus or a poly- pus, retention of urine being a common consequence of inverted uterus, and a distended bladder may simulate the uterus; therefore, let him who has not witnessed the accident, but who first sees the condition hours or a day or two after its occurrence, begin by using a catheter. No confusion from this cause, and no error in diagno- sis thence derived; a bimanual examination, the impossibility of passing a uterine sound into the uterine cavity if the organ be inverted, and ascertaining that the point of a sound passed into the bladder may be felt in the median line by two fingers in the rectum too distinctly to suppose that the uterus intervenes, will leave no doubt in the mind of the careful examiner. I have been called to three cases of inversion of the uterus, and I have not in one of them found the organ the seat of intermittent contractions ; yet such con- tractions have been brought forward as one of the means by which the inverted uterus, can be distinguished from a uterine polypus. So, too, I utterly reject dependence upon the sensitiveness of an inverted uterus as a means of diagnosis ; many years ago, in a case of doubtful vaginal tumor, I held in my hand that which by other means was proved to be the inverted uterus, and, watching the face of the patient, made two or three punctures of the tumor with an exploring needle, and not the slightest shade of suffering passed over her countenance coincidently with a puncture. The two signs that have just been mentioned, though indorsed by high authorities, may possibly in some cases be valuable, but, as" a rule, I believe they will prove doubtful or even deceptive. In rare instances inversion of the uterus has occured some days after labor, It is most probable, however, that in such cases there was already an unrecognized partial inversion, beginning at or soon after delivery, which under the influence of contractions was con- verted into a complete condition. Prognosis.—Acute puerperal inversion of the uterus is a condition of immediate and great peril. Even though restoration of the organ be promptly accomplished, death may follow, as in a case reported by Breus.2 Crosse's statistics show that of 109 patients who died, a fatal result occured in 79 within a few years, in 8 at the end of a week, and in 6 after a month. If the unhappy victim has escaped death from shock or hemorrhage, sloughing of the uterus in conse- quence of constriction by the neck may bring a fatal issue early in the puerperal period. Spontaneous restoration of an inverted uterus, even months or years after the accident, has occurred in very Kormann. 2 Wien. med. Woch., 1882. THE PATHOLOGY OF LABOR. 555 rare instances, but the probability of this event is too slight to sus- tain a rational hope. Treatment.—Immediate restoration of the organ to its normal place is indicated, and the sooner after the accident the effort is made the greater the probability of success. Supposing the pla- centa to be still attached,1 it is first removed, and then the obstetri- cian grasps the uterus in his hand —antiseptics being used, and, if the patient's condition does not forbid, she is anaesthetized— presses the organ upward, being careful to avoid the sacral promon- tory, and at the same time with the other hand counter-pressure is made through the abdominal wall ; and possibly the fingers of this hand may be usefully employed in overcoming the resistance of the entrance to the uterine cavity now opening into the abdomen. The fingers of the hand which holds the uterus may be usefully employed in dilating the external ring-like cervix, while the palm presses the uterus against the internal resisting portion of it. It will be observed that in this manipulation the taxis is peripheral, and the effort is made to restore first that part of the uterus which came out last. Another mode of restoration is by pressure directly made upon the fundus: this pressure is usually made by the fingers of one hand brought together in the form of a cone : of course the finger-nails are short; the attempt is made to depress that portion of the uterus against which the fingers push, and thus begin the restoration. The taxis in this case is central, and the part of the uterus restored first is that which came out first. The third method is that first suggested and successfully employed by Noeggerath, and consists in pressure upon one side of the uterus at a point corresponding with the en- trance of an oviduct, indenting or depressing the surface there, and thus starting the restoration : this method has been called that of lateral taxis. After the restoration of the uterus by one or the other of these plans, the hand, of course being in the uterus at the completion of the reduction, is used to detach the placenta and to stimulate, the external hand assisting, the uterus to contract. Barnes says care should be taken to avert what has happened, reinversion, and for this purpose he directs passing along the palm of the hand a uterine tube connected with an injecting syringe and throwing up a pint of hot water, I io° Fahr. If the physician is not called to the patient until several hours after the accident, or if previous efforts have been made without success, should he at once attempt the reduction ? The answer depends upon the condition of the uterus: if it is not inflamed and very sensitive, and if it is relaxed, gentle efforts at restoration may 1 Obstetricians are not agreed as to whether the placenta should be removed, provided no separation has begun, before restoration of the inverted organ is attempted. The argument in favor of its removal first is that this can be much more readily accomplished before than after the reduction, and that reduction will be more readily effected without than with the placenta, and that a re-inversion is liable to occur in delaying the removal until after the restoration. The argument against it is that thereby hemorrhage is at once caused ; undoubtedly, too, we are less liable to injure the uterine walls by pressure with the cone-formed fingers or with the fist, when these walls are in part protected by the intervening placenta. 55^ SCIENCE AND ART OF OBSTETRICS. be made even though a day or two has passed. Atthill1 takes the ground that if an effort at reduction has not been made within twenty-four hours after labor, it is better to wait until after uterine involution has been completed before attempting restoration. The reason for this delay is that the uterine tissues during involution are more liable to be lacerated in the manipulation necessary for reduc- tion. 1 Diseases of Women, Dublin, 1880. PART IV. THE PUERPERAL STATE. CHAPTER I. THE PHYSIOLOGY AND THE MANAGEMENT OF THE PUERPERAL STATE, AND ITS DIAGNOSIS—CARE OF THE NEWBORN CHILD. Puerperality, or the puerperal state, follows labor, and con- tinues until the genital organs return to their condition prior to pregnancy, and is generally regarded as including a period of about six weeks. But here a qualification of fact and one of time should be stated. There is never an entire restoration of the genital organs, especially in the primipara, to their ante-pregnant condition, the changes caused by gestation and labor are not completely effaced; and, as will be seen in the study of uterine involution, some of the phenomena in this process last much longer than the period men- tioned. While pregnancy was marked by extraordinary hypertrophy, a reverse process especially characterizes puerperality; construction distinguishes one, demolition the other. There was a building up, and now there is a tearing down and removal of structure no longer needed. Moreover, in the early part of the puerperal state, a new function is called in exercise, that of the mammary glands ; these organs, designed to supply nourishment for the infant during the first eight or ten months of extra-uterine life, enter into action while the ovaries and the uterus rest; ovulation, gestation, and lactation are the three characteristic functions of the female organism, and they are exercised in succession. It is important to know the physiological phenomena of child- bed, so that deviations from them may be at once recognized, and, if possible, promptly arrested. The condition of a woman after delivery has been compared to that of a person who has undergone a grave surgical operation ; neither is laboring under disease, but each is more or less exhausted, and each has undergone a trauma- tism which opens the doors for the entrance of disease-germs, and both need intelligent and constant care to guard against danger, and to guide to perfect recovery. The woman who has just passed through childbirth usually enters into a period of calm rest. The stormy struggle, the severe physical suffering, and the anxiety are happily ended for most in 558 SCIENCE AND ART OF OBSTETRICS. quiet and peaceful joy. Generally the puerpera is disturbed by conversation, or by movement of her body; her replies to questions are usually in a low tone of voice and brief, and she desires above all things mental and physical rest. In some cases there is very great nervous prostration, presenting, as far as frequency of pulse and somewhat difficult respiration are concerned, the characteristics of post-partum hemorrhage, and the heart's action is very feeble, but an error of diagnosis is easily avoided by finding the uterus well contracted and the flow quite normal. Perfect rest, the administra- tion of a stimulant, or a hypodermatic of sulphuric ether with digitalis may be required. But these are quite exceptional cases. and much more frequently a chill occurs. In about one-third of parturients there is a chill during labor or soon after; the latter is the more frequent. This chill, which is oftener observed after a rapid labor, lasts from a few minutes to a quarter of an hour; it is not attended with any change in the pulse or in the temperature. The most probable explanation of this phenomenon is that the organism suddenly loses a mass to which it had been progressively accustomed, and this rapid depletion of the abdomen causes imme- diate cessation of compression of the viscera, the blood leaves the exterior to fill the space left in these organs. But, whatever the explanation, the chill is physiological, and portends no danger. After-pains.—A still more frequent cause disturbing the rest of the newly delivered woman, if she be a multipara, is the occurrence of painful contractions of the uterus. These are more severe after a rapid labor; indeed they may be absent if it has been slow, they only exceptionally occur in primiparae, and they are more frequent, too, if the uterus has been greatly distended. They generally begin a short time after the expulsion of the placenta, recur at intervals of five, ten, fifteen, or twenty minutes, and disappear after twenty-four hours; they are excited or increased by the application of the child to the breast; exceptionally they continue for two days, or even somewhat longer. When after-pains are very close together, and continue thus for some hours, the fact is cause for anxiety, as they may indicate the beginning of a metro-peritonitis, and the tempera- ture of the patient should be carefully watched. Expulsion of clots is usually caused by these painful contractions of the uterus, and when they are moderate in severity their occur- rence is favorable, for they show a uterine activity which is a safe- guard against hemorrhage. The diagnosis ought not to present any difficulty, for the hand placed upon the abdomen recognizes the contraction of the uterus. But there may be very severe attacks of "uterine colic" occurring within a few days after birth, in some cases even causing marked temporary elevation of temperature, which are purely nervous; just as there may be vesical or rectal tenesmus, so there may be a similar disorder of the uterus, and in each case the organ affected be quite empty. Prochownick has shown1 that in some cases of diastasis of the abdominal mus- cles the intestine may protrude through the opening and pain result, which may 1 Op. cit. , PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 559 be mistaken for after-pains, and probably is thus mistaken in many cases. A careful examination will recognize the cause of suffering. The Pulse.—During labor the pulse usually increases from 70 or 75 to 90 or 100; but a short time after delivery its frequency lessens, sinking below the normal in from eight to forty-eight hours; usually the pulse oscillates between 50 and 60, but, accord- ing to Blot, between 44 and 56; Olshausen makes it between 40 and 50, and in rare cases says it falls below 40; the lowest that I have observed was 46. The lessened frequency of the pulse was attributed by Marey to increased blood-pressure, but others assert that this is diminished ; by Olshausen to absorp- tion of fat from the uterus, but, as will be presently shown, fatty degeneration ol the uterine muscular tissue does not occur; to the position of the woman, and to complete mental and bodily rest. Winckel states that the experiments of G. V. Liebig make it very probable that there is a causal connection between the slow- ing of the pulse and the increase of the vital capacity of puerperal women. The slowing of the pulse is justly regarded as a favorable indica- tion, and the slower the more favorable. The duration of this con- dition is usually several days, and the period when it is greatest is from the fifth to the seventh day (Olshausen), but the recent investi- gations of Louage1 have led him to conclude that it is the morning of the seventh day. Buffet, as quoted by Kleinwachter, says the slow pulse lasts in multiparas from five to seven days, but in primi- parae only from three to four. The Temperature.—During labor there is generally some increase in the temperature, and this increase may continue for twelve hours or more after; it is a little greater in primiparae, and may amount to two or three degrees. But within twenty-four hours the tem- perature declines and remains stationary during seven or eight days, there being only the usual morning and evening variations. The following table gives the result of the average temperatures of twelve patients in whom puerperal convalescence occurred without disturbance ; the first temperature was taken twenty-four hours after delivery.2 Morning. Evening. First day .......98 4° 98.8° Second day .......98-4 98-8 Third dav .......98-2 98 8 Fourth day .......98-2 984 Fifth day .......98-2 98-9 Sixth day .......98-4 98-8 Seventh day.......9». 9°-4 Eighth day .......98-2 98.4 The highest temperature observed in. any one of these twelve women was 98^°, and this occurred on the fifth day. Transient elevation of temperature may arise from mental causes, from dis- orders of the digestion, or from getting up too soon. But, as 1 Le Pouls Puerperale Physiologique, par Pierre Louage. Paris, 1886. 2 I am indebted to Drs. Phillips and Randall, resident physicians in the Obstetric Depart- ment of the Philadelphia Hospital during one of my terms of service for the preparation of this table. 560 SCIENCE AND ART OF OBSTETRICS. ♦ Tarnier remarks, these momentary elevations do not generally involve an unfavorable prognosis ; it is not the same with those that are progressive and continued ; especially when the thermometer placed in the axilla ascends above 100.40, some complication ought to be feared. Respiration.—The pulmonary capacity, according to Dohrn's in- vestigation, increases in the majority of cases; the respirations are from 14 to 18 per minute. Modifications of Secretions.—A few hours after delivery the body is generally covered with perspiration ; this secretion is more marked during sleep, and continues for about a week. Naegele draws atten- tion to the fact that on the head the congestion of the skin results in exudation into the hair-follicles which very generally involves the loss of part of the hair. The quantity of urine secreted during the first twenty-four hours of childbed is increased, while its specific gravity is lessened during one or two days. The presence of sugar in the urine of women in the course of their lying-in and while nursing was first shown by Blot in, 1856. This condition probably should be termed lactosuria rather than glycosuria, for it results from the passage of unused lactose into the renal scretion in conse- quence of there being an excess of milk formed or of arrest of nursing; in other words, as stated by Spiegelberg, it is a resorption diabetes. Macdonald found sugar present in each of thirty-five lying-in women, and therefore regards it as present in all cases at some time in the puerperium. Neither Kleinwachter nor Spiegelberg refers to it as being invariably present. In examina- tions made daily of the urine of fifty women at the Philadelphia Hospital, begin- ning a few days before, and continued seven days after delivery, sugar was found in that of four women before, and of six after labor, one of the six also being one of the four. In this woman the sugar was constantly and abundantly present up to eight weeks after delivery; she had remarkably well developed mammary glands, and a very abundant secretion of milk. In her case the test for a good wet-nurse suggested by Blot, to wit, the quantity of sugar found in the urine, would have proved true, as far as the abundance of milk was concerned. Retention of Urine.—Inability to evacuate the bladder is not un- common, especially in primiparae, if the labor has been protracted. The causes of the urinary retention are the ample space given the bladder to resume its spherical form, while during the latter part of pregnancy it was flattened, the swelling of the urethra and the neck of the bladder from severe compression in labor, the loss of abdominal pressure, and the position which the patient occupies while attempting to urinate, that is, she is horizontal. If the bladder be distended with urine, the uterus is carried higher up in the ab- dominal cavity. Such distention, too, may cause secondary hemor- rhage. Condition of the Digestive Organs.—The appetite for the first two or three days is lessened, but in consequence of the activity of various secretions, especially of the kidneys and the sudoriparous glands, the thirst is great. Evacuation from the bowels is delayed, partly because of having been so thoroughly emptied in labor, and PHYSIOLOGY AND MANAGEMENT OF PUERPER1TJM. 561 partly because of the character of the food usually taken, and because of the woman being in such absolute rest. Psychical Condition.—The newly delivered woman is peculiarly nervous and sensitive, and disturbed by causes to which she would be ordinarily indifferent. Lochia}—This name is given to the flow from the genital organs in childbed. It contributes to uterine involution, and indicates that process. This flow is composed of red blood-corpuscles, shreds of uterine decidua, sometimes of fragments of the placenta or of the membranes, epithelial cells from the uterus and vagina, leucocytes, also pus-cells, granule-clusters, granules, pigment, free fat, mucus, clusters of zooglea, infusoria (trichomonas vaginalis), etc., the quantity of each varying with the period of the flow.2 The discharge is alkaline for the first eight or nine days, when it becomes neutral or acid. The flow is at first chiefly sanguineous, then sero-sangui- neous, serous, and finally purulent. The first two varieties are included under the term locliia rubra, which is bright-red at first, then at the close pale from the diminished number of red globules and the increase of leucocytes; it changes about the fifth or sixth day into the lochia serosa; about the seventh day the lochia has a cream-like consistence, and is yellowish in color. It receives the name of lochia alba, when the discharge is composed of pus-cells, epithelial cells in various stages of development, spindle-shaped connective-tissue cells, fat granules, free fat, and cholesterine crystals. The discharge becomes gradually less, loses its opacity, appearing like the uncooked white of an egg, and disappears in two to four weeks. Artemieff3 states that the lochia of healthy women consist of blood-corpuscles, pavement epithelium, mucous corpuscles, fatty degenerated cells, and cells which he designates locheiocytes. In the first few days after labor red blood-corpuscles predominate, which gradually diminish, while the locheiocytes become more nu- merous. With a mixture of pavement epithelia, mucous corpuscles, and fatty degenerated cells, the locheiocytes constitute the lochia alba. Locheiocytes are larger than pus-cells in the proportion of one to two-thirds. The lochia of healthy women contain neither pus-cells nor micro-organisms. The question as to the presence or absence of microbes in the lochial discharge of the healthy puerpera is an important one with reference to so-called auto-infec- tion. Winckel asserts that from the third day on, numerous and various forms of micro-organisms are present, viz.: staphylococci, monococci, diplococci, strep- tococci, and bacilli. But it is generally conceded by those who find microbes in the lochial discharge that these are not present in the uterus in a normal condi- tion of the patient, and that they are found only in the vagina, more especially near its entrance. According to Gassner, the quantity of red lochia, until the fourth day, is one kilogram, 2.2 pounds ; of the serous lochia until the sixth 1 Aox'ia, or Ao^e/a was one of the names given to Artemis or Diana, from her helping pre- sence at childbirth. From the adjective Ao^eZoc, belonging to childbirth, we have the words used by Hippocrates, Ta Uxm, and $ Ux^a, the discharge after delivery. It would seem, therefore, that lochia may be used in the singular or in the plural. 2 Kleinwachter. _ . 3 Zeitschrift f. Geburt. und Gyn'akol. See abstract, American Journal of the Medical sci- ences, March, 1890. 36 i.62 SCIENCE AND ART OF OBSTETRICS. day, 280 grammes, between 14 and 15 ounces, and of the white lochia until the ninth day, 205 grammes, nearly 7 ounces, so that the entire loss of weight from the lochial discharge is about three pounds and a quarter. It is not unusual for the lochia to be very much lessened, or for a few hours absent, during the establishment of the secretion of milk. The red flow is liable to return after having disappeared, or to persist beyond the usual time in women who get up too soon, and resume household duties; in some cases it preserves this character until all discharge ceases. Exceptionally, the flow stops much earlier than the usual time, but an early cessation is not to be regarded as pathological, unless other symptoms indicating such condition occur. Doleris has stated that in a patient living in the country, having a well-ventilated room, and being in other favor- able circumstances, the lochial discharge may be much less in quantity, and much shorter in duration than in a woman in the city, and in a crowded maternity. Most authorities state that those women who nurse their infants have a less flow than those who do not; this seems a reasonable statement, though some deny it. The odor of the discharge is sometimes spoken of as sui generis, or as the gravis odor puerperii. Siredey states that the intensity and character of the odor are in relation with the odor of the perspiration and other secretions of the individual; but, whatever the individual varieties, it ought never to be fetid, suggesting that of macerating anatomical specimens, or of putrefying organic matter. Changes in the Genital Organs — Involution of the Uterus. — A woman immediately after labor has more or less soreness of the external organs of generation. They are tender, and there is the feeling as if they had been bruised, as indeed they have; if a primi- para, there is more or less tearing of the vulvar orifice, such injury affecting the fourchette, sometimes the nymphae, less frequently the labia majora, and in some cases the anterior margin of the vulva. These various parts may become cedematous, but the swelling usually disappears in two or three days, and they gradually return in the main to their condition before pregnancy. The vagina gradually becomes shorter and narrower, but its columns and rugae never are as distinct as before labor; its muscular tissue is atrophied, while the superficial epithelium of its mucous covering is exfoliated; during the 'continuance of the lochial discharge there is a catarrhal vaginitis. The layers of the broad ligaments, separated by the growing uterus, re-unite, and the ovaries and oviducts take their usual position in the true pelvis. But the most remarkable change occurs in the uterus. This organ, which weighs soon after delivery 2.2 pounds, two days later only weighs 26J ounces. At the end of a week it weighs about 1 pound, and at the end of two weeks its weight is about 12\ ounces (Spiegelberg). In six or eight weeks it has returned to nearly its size before pregnancy. The process by which this change is PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 563 effected is called involution. The uterus was progressively evolved in the course of pregnancy to meet the requirements of the new being, and now that gestation has ended, there being no further use for such size and capacity, the organ is involved.1 As Kleinwachter remarks, uterine involution begins with the first labor-pains. He further states that the contraction of so large a muscle must go hand in hand with a change of matter increasing to a high degree, and although the production of heat is by the consumption of non-nitrogenous substances, yet long-continued and increased action leads to the destruction of the functionally active contents of muscle-cells. Beside, the formation of new pro- toplasm is interfered with by the compression of bloodvessels during uterine contractions, and the involution of the muscle is thus in part affected. In regard to the degree and the character of the changes that occur in the ulti- mate muscular tissue, authorities are not agreed. According to Spiegelberg the uterine muscular substance, pale at delivery, becomes yellowish from the sixth day, the color being due to a granulo-fatty degeneration of its fibres. But Robin has stated that the presence of minute drops of fat can be seen from the third month of pregnancy ; he adds that the diminution of volume of the muscle-fibres is made solely by atrophy which occurs after labor, and he insists that the fatty infiltration lessens as the muscular fibres atrophy. Heschl's view, adopted by most obstetric authorities, attributes very great importance in uterine involution to fatty degeneration. This degeneration begins about the fourth or sixth day in the form of minute fat drops, which by degrees extend so as to fill the fibre-cells, and soon effect their destruction. From the fourth week a new formation is evi- dent in the external muscular layers, appearing first as nucleated cells which soon become fibre-cells; destruction and regeneration march side by side, and towards the eighth week, the latter is complete. Mayor's2 investigations led him to con- clude that fatty degeneration of the muscular fibres was more marked than Robin thought, but still had not the importance attributed to it by Heschl. From the fact that it was at its maximum at the points where these elements most rapidly resume their primitive volume, he regarded the degeneration as only a momen- tary transformation of the protoplasm of the cells designed to favor absorption, and the disappearance of the materials which constitute the gravidic hyper- trophy. The doctrine that there is a complete regeneration of the uterus certainly seems improbable. Admitting the truth of Aristotle's statement that nature does noth- ing in vain, it seems utterly unnecessary to destroy the whole, in order to remove a part. Moreover, it is somewhat remarkable, that if there is such entire regen- eration, a new uterus in fact created, the organ in another pregnancy, and after another labor, behaves so differently from the primitive one; the new uterus is more readily distended, and preserves its typical form less completely; after labor, it fails to contract perfectly, and thus permits the accumulation of blood-clots, and consequent after-pains. Nature may go on constructing a new uterus a dozen times even, and the oftener she tries, the more the product of her work deviates from the original pattern. Sanger,3 from his studies of the regressive metamorphosis of the muscular tissue of the uterus, arrives at a result directly contrary to the statements of Heschl, and of Kolliker, the former asserting entire, and the latter partial, destruction of the muscular tissue. He has found that the muscular fibres during uterine mvolu- 1 Numerous experiments have been tried using ergot daily during the puerperal period, and the conclusion of most observers, not of all, is that involution of the uterus is thus hastened, but some have found that the secretion of milk was lessened. Involution is a physiological process, and ergot is a medicine—its administration presupposes a pathological condition ; the healthy puerpera does not need ergot ,,-,..,, * Siredey, Les Maladies Puerperales. 3 Centralblatt f. Gynakol., 1888. 564 SCIENCE AND ART OF OBSTETRICS. tion, lessen in length and thickness until restored to their primitive form and size. The fatty degeneration of the muscular parenchyma has simply the signification of nutritive phenomena. There is never found external to the muscular fibrillar fatty detritus; the combustion of fat molecules takes place in the interior of the cell, so that the lipaemia, to which Olshausen attributed the slowing of the pulse of the puerpera, does not exist. Dittrich, from a study of the involution of the uterus in pathological states of puerperal women, embracing 92 cases,1 has con- firmed the view of Sanger. The restoration of the mucous membrane proceeds at the same time as the involution of the uterus. Normally, the superficial layer of the mucous membrane, the decidua vera of Hunter, is detached and expelled with the placenta and membranes; but no small part of it may be retained, passing off by fatty degeneration with the lochia. The uterine glands retain their lining; these are brought closer together by the retraction of the uterus; from the glandular cul-de-sacs epithelium is formed, which extends toward the uterine cavity—these proliferations about the end of the third week, accord- ing to Leopold, reaching the surface, and at the end of the fifth week this investment is complete; that is to say, a new mucous membrane formed from that lining the glands, covers the uterine wall. Very important changes occur at the site of the placenta. In the eighth month some of the venous sinuses are closed by thrombi, and after the expulsion of the placenta, the remaining ones are closed in the same way; the thrombi degenerate and are gradually absorbed, but the process is not completed until four or five months after labor. Changes in the Bloodvessels.—It is generally thought that many of these vessels are so firmly compressed by the contraction of the uterus as to undergo fatty degeneration and absorption. The larger arteries are partially obliterated by proliferation of the connective tissue of the intima; the media is destroyed by fatty degeneration; new muscular elements take the place of the degenerated ones where the vessels are to remain ; other vessels are simply narrowed, and continue. According to Balin, the regressive metamorphosis begins later and lasts longer than the same process in the muscular structure of the uterus, occupying several months. Position and Form of the Uterus.—Immediately after delivery the uterus is a round, hard body reaching a little more than four inches, eleven centimetres, above the pubic symphysis, and very nearly the same distance from side to side. A few hours later, either from relaxation or from the bladder being filled, it reaches somewhat higher; subsequently a more or less continuous diminution goes on, so that by the tenth day the fundus is at the superior margin of the pubic joint; the daily decrease in the height of the fundus above the pubic symphysis being from two-fifths to four-fifths of an inch, or from one to two centimetres. During this time its position varies with the position of the patient, but it inclines toward one or the other side, and does not occupy the median line. The puerperal uterus is often anteflexed, and in some cases this anteflexion is so 1 Centralblatt f. Gyniikol., 1889. PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 565 great that an obstruction to the passsage of the lochia is caused, and the condition known as lochiometra results. Depaul gave the following as the approximate relative positions of the fundus of the uterus in the first days of the puerperal state. The first day it is a finger's breadth above the umbilicus ; the second day at the level of the umbilicus ; the third day a little below ; the fourth day but little variation from the preceding; the fifth and the sixth days two fingers' breadth below; the seventh, eighth, and ninth days three or four fingers' breadth above the pubic joint; the tenth, elev- enth, and twelfth days at the level of or a little below the pubis. The progress of uterine involution has been sought to be ascertained by some through measuring from the symphysis to the fundus, by others by means of an instrument similar to the pelvimeter, one branch of which is placed upon the abdominal wall at the fundus and the other in the vagina at the mouth of the uterus—Autefage ; and by others by means of the uterine sound—Sinclair, Char- pentier, and Milsom. Changes in the Neck of the Uterus.—Directly after birth the neck of the womb is relaxed and soft, and has been compared by Klein- wachter to the vulva; the canal admits three or four fingers readily, but slight resistance is offered by the internal os; the length of the cervix is about 2.7 inches, or 7 centimetres. At the tenth day the canal no longer admits even one finger, and by the twelfth the neck is only 3 centimetres, or a little more than an inch long, according to Lott. Loss of Weight in Labor and during Lying-in.—Gassner states that the body increases during the last three months of pregnancy about one-thirteenth of the entire weight; this increase is proportionally less in primiparae than in multiparae ; during labor a woman loses one-ninth of that she had at the end of pregnancy, this loss being chiefly due to the expulsion of the fcetus and its appendages, and the amnial liquor, but also to the blood lost in the discharge of the placenta, to fecal matter expelled, and to pulmonary and cutaneous excretions. During the first eight days of lying-in the woman loses1 one-eleventh, the loss resulting from the lochial discharge, the in- creased action of the kidneys and the skin, and the mammary secre- tion. The total loss of weight in labor and in the puerperal state amounts to about one-fifth that of the body. At the end of three or four weeks after labor the loss has ceased, and generally a gain begins. The Secretion of Milk.—During the latter part of pregnancy and immediately after labor a fluid called colostrum is found in the breasts, and often spontaneously exudes or can be pressed from the nipple ; to this fluid, as found in the cow immediately after calving, the name of biestings is given. An abundant secretion of colostrum in pregnancy indicates a large supply of milk. Colostrum differs in color, specific gravity, composition, and morphologically from milk. It is yellowish-white, is richer in fat and sugar than milk, and contains albumen instead of casein ; it has a larger supply of salts 1 " Kleinwachter, however, by means of better nourishment, arrived at a different result; he noted only about half the loss of weight reported by Gassner, and Klemmer, in my Dresden clinic, by means of meat diet, succeeded in obtaining not only less falling-off in weight, but in some cases the patient gained up to the tenth day." (Winckel.) 566 SCIENCE AND ART OF OBSTETRICS. than milk, and hence, according to most authorities, proves a laxa- tive to the newborn child, assisting in carrying off meconium ; but this excess in salts is not great, and it is more rational to attribute the laxative property of the fluid, as De Sinety does, to its richness in glandular elements, which produce indigestion. The following is Marchand's statement as to the composition of the two fluids: In 100 parts of each— Colostrum. Milk. Proteine elements ....... 17.20 1 00 Laciine........ '. 6.30 S!So ssr .........«° "o ^u(s...........25 .18 Water .......• . 71.63 81.12 The liquid portion of milk is simply a transudation from the blood, while the morphological constituents proceed from the gland cells. Colostrum corpuscles are remarkable for their size, contain fat granulations, and are probably detached glandular elements; either the cell-wall is broken down, and the contents set free, or as De Sinety holds, the cells have contractile movements, and by these the fatty particles are expelled. These minute fat granules unite together to form larger masses and of different sizes; their mixture with the transudation from the blood makes a fine emulsion, and this is milk. The casein of milk is probably formed from the albumen of the blood, and the sugar of milk from the glucose. Phenomena associated with the Establishment of the Secretion of Milk—The current of blood which has been flowing to the uterus for nine months now turns to the mammary glands, and on the second, or oftener on the third day, these organs enlarge and their sensibility increases; the skin covering them is smooth and tense, the nipples are less prominent, and very frequently some pain is felt in the axillary glands; in consequence of the swollen condition of the breasts the arms cannot be brought close to the sides of the chest. The general phenomena attending upon the beginning of the milk flow are restlessness, thirst, headache, occasional neuralgic pains, loss of appetite, and possibly slight increase in temperature and the frequency of the pulse. But that which the old authors called milk fever is not now admitted; in very rare exceptions de- cided fever, even preceded by a chill and lasting twenty-four hours, has been observed in cases in which no complication was present, but the almost universal rule is that there is no milk fever; as Lorain remarked, it is a vague tradition which does not rest upon classic observation. Siredey, collecting in one year 360 observations with reference to its existence or not, states as the result that he can affirm that in every case in which the temperature in the axilla ex- ceeded 100.40, he found the explanation of the febrile movement in- dependent of the lacteal secretion. Chantreuil's investigation led him to conclude that the morbid entity called milk fever, very rarely occurred; that in entirely normal cases the pulse did not rise above 76, and consequently there could be no question about fever, and that the temperature followed the variations of the pulse. In normal cases the tem- perature did not rise during the secretion of milk above 100.40, or 100.20, figures which have been adopted as expressing the mean temperature by all authors who have been occupied with the study of thermometry. PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 567 The secretion of milk continues from 8 to 12 months. The quantity increases until 6 or 7 months, and decreases from the 8th month The casein increases until the 2d month, and decreases from that to the 9th, and so also the butter; the sugar lessens the first month, then increases; the salts increase the first five months, and then diminish.1 If the woman does not nurse, the milk disap- pears in about a week. Menstruation is, as a rule, absent during lactation, but ovulation may occur, and it is not uncommon for women to conceive while nursing; should conception occur, the supply of milk lessens, and finally ceases. The Management of Childbed.—There will be considered under this head not merely the care of the mother, but also that of the child. Attentions to the Mother:—After the thorough cleansing of the external sexual organ by a warm antiseptic solution and a similar injection in the vagina, the necessary care of injuries,3 if any have occurred, and proper arranging of the bed and body clothing, the patient may have some nourishment if she desires, and should have if she needs it. Rest.—In the great majority of cases, a few hours' sleep will be the most important restorative, and, therefore, means that conduce to this end should be used. Generally a quiet room and moderately darkened will be all that is required ; but in some cases there are such restlessness and nervous excitement that an opiate must be given. So, too, if after-pains are so severe and frequent that she cannot sleep, and external applications, e. g., of cloths wrung out of hot whiskey, with compression of the uterus, fail to relieve, opium and camphor, or antipyrine, may be given; quinine in a dose often grains is used by some practitioners. The practice which old obstetricians had of preventing a woman's sleeping during the first hours following labor lest flooding might occur, had no just foundation either in reason or in experience. 1 Zuelzer, quoted by Kleinwachter. 3 In some parts of the world it appears that attentions to the father are of great importance : thus— Peschel, The Races of Men, pp. 24-5, refers to paternal lying-in as having been observed by inhabitants of the four quarters of the globe^in Borneo, for example, the father of the new- born child is for eight days allowed to eat nothing but rice, must take care not to expose him- self to the sun, and must give up bathing during four days; and states such coincidence of error can be explained in one or the other of only two ways—either all the varieties of our race once dwelt together in a narrow home when the error originated, or the mental faculties of all these families even in their strongest aberrations are the same. 3 The following statistics of one of the residents during'my term of service in 1889, are here introduced, having been omitted in their more appropriate connection. They show that injuries of the perineum in childbirth are more frequent than practitioners who never make examina- tions after labors assert. Philadelphia Hospital, March 12, 1889. Dear Dr. Parvin : I am very happy to send you the following report on the condition of the perineums in the last 100 primipaiae and last ico multiparae delivered in the maternity de- partment: Primiparae: Perineum intact 58 Multiparas: Perineum intact 84 Lacerated 41 Lacerated 16 Episiotomy 1 100 100 Very respectfully, F. W. Talley. 568 SCIENCE AND ART OF OBSTETRICS. Of course the room is free from visitors, and if the baby's cries disturb the mother it should be taken for a few hours into another room. She should lie the first few hours chiefly upon her back, and then occasionally upon either side, for it is better she should not be restricted to one position. The question as to absolute rest in bed for some days after labor is not a new one. Sydenham's wise observation taught him that of those who died after child- birth, the result in the great majority of cases was from getting up.too soon, and he said he did " not suffer a woman to get up before the tenth day." That saga- cious and successful obstetric practitioner, the late Dr. Churchill, stated that for one evil result from an error in diet, he had seen ten from assuming an upright position, or leaving the bed too soon. White,1 on the other hand, had the puer- pera sit up in bed a few hours after delivery, and the sooner she got out of bed the better; this was not to be deferred beyond the second or third day. Goodell has the patient sit up the day after labor, while her bed is making; this sitting up is repeated once or twice a day, until the fourth or fifth day, when she, if so disposed, gets up and dresses herself. SoloviefP confirms the practice of Goodell. Garrigues,3 in an excellent article upon the subject, remarks: "Combining the teachings of great obstetricians and the consideration of the anatomical and physiological conditions with my practical experience, I have come to the result that the patient ought to be left lying quietly in bed, alternately on her back and on her sides, until the uterus has contracted sufficiently to be hidden behind the symphysis, and until all raw surfaces in the obstetric canal are covered with granulations, or healed, and that during two months she ought to avoid any great exertion.'' While some nurses and doctors think that the sooner a woman after confinement is up and dressed, apparently well, the greater their credit, it must be admitted that very seriously inju- rious consequences of too early getting up may not be immediate but remote, such as uterine displacement or subinvolution, and that prolonged rest is a less evil than the former; better keep a woman in bed a week too long, than have her get up a day too soon. Again, every woman is a law unto herself; one may conva- lesce much more rapidly than another, and uterine involution be more rapid. The condition of the patient is a better criterion as to the propriety of getting up, than the number of days after labor; so, too, the effect produced by being up ought to be considered in de- ciding as to the propriety of permitting it to be continued, so that if, for example, the woman has a return of the red lochia, or if abdominal pain be caused, the indication is very plain for immediate return to bed. It is probably best for most women not to sit up out of bed until ten or twelve days have passed, and then only for a short time, though sitting up in bed while taking their meals may be permitted in most cases after the third day; it is better for the puerpera to remain in her room for at least three weeks. Food.—In regard to this question the most diverse opinions have been held. Dionis referred to the popular notion of his day that a woman has lost so much blood in labor, and so much too is lost by 1 Treatise on the Management of Pregnant and Lying-in Women. 2 Archives de Tocologie, Feb. 1881. 3 American Journal of Obstetrics, 1880. PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 569 the lochia, she ought to eat more abundantly than at any other time, in order to repair the loss, and condemned it, because the woman was in "a state of fever," and the fever was sure to come on the second or third day. Dewees would not allow any animal broth until after the fifth day, or any animal substance until after the fifteenth ; he gave for the first few days oatmeal gruel, tapioca, sago, mush and milk, rice and milk, tea, coffee, or very thin chocolate. In recent years, however, there has been a reaction against the absolute diet once insisted upon by obstetricians. But there is a just mean between famishing and feasting, between absolute and generous diet, which the practitioner will best follow. Those who have seen how well a patient, upon whom ovariotomy has been performed, gets on for the first few days with water, barley-water, and lime-water and milk, will hardly believe that the puerpera on the first day needs either chops for breakfast, or abundance of roast beef for dinner, but rather that she will convalesce more rapidly if liquid food is chiefly given. Indeed, her often temporarily enfeebled digestion and her little desire for solid food point very plainly to proper dietetic practice ; her thirst is usually much greater than her hunger. At this time the simpler articles of food, such as tea and toast, the lighter animal broths, milk toast, or soft-boiled eggs will be most acceptable; let her gradually resume her usual diet. On the other hand, there are women whose digestion is perfect, and whose appetite from the first craves more liberal nourishment, and there can be no objection to giving them, from the beginning, the more easily digested animal foods. Or again, there may be a patient so greatly exhausted that beef-tea, milk-punch, or eggnog must be given at frequent intervals. Therefore, no absolute rule as to the diet of the first days can be given; each case must be judged by itself, and the food directed according to the condition. Cold water will usually be found the most acceptable drink, and can be given at frequent intervals. If, however, the secretion of milk be too abundant, it can be diminished by lessening the quantity of fluids taken, and under these circumstances it is well to have the patient quench her thirst by pieces of ice rather than by copious draughts of water or of other fluid. The Condition of the Bladder.—The puerpera should be directed to empty the bladder twelve hours after delivery, for unless so advised she may be unconscious of the accumulation of urine, and it may continue until the organ is so greatly distended that spontaneous evacuation is impossible, even in case there be no obstruction of the urethra from swelling. If urine is not passed within eighteen hours, the catheter must be used, and its use repeated twice or thrice in twenty-four hours until the patient recovers the lost power; the instrument should be carefully disinfected before and after use, and the parts adjacent to the urethral orifice washed with an antiseptic solution before the instrument is introduced, for a cystitis may result from neglect of these precautions; in some instances the inflammation passes from the bladder to the kidney, and a pyelitis occurs. In order to run no risk of carrying from the 5/0 SCIENCE AND ART OF OBSTETRICS. external genitals septic matter into the bladder, it is advised by some to trust to sight and not to touch in catheterization ; but unless the nurse uses the instrument, this is not expedient. In some instances there is dribbling of urine from a very full bladder, and both the patient and nurse insist that the organ is completely emptied when in fact it contains a large amount of urine ; in all doubtful cases the practitioner should carefully palpate the abdomen, and if doubt remains remove it by introducing the catheter. The patient usually recovers the power of urinating at the time the bowels are first moved.1 Condition of the Bowels.—On the third or fourth day a free alvine evacuation is to be had either by a warm-water enema, by a dose of calcined magnesia, by Rochelle salts, a Seidlitz powder, liquid citrate of magnesia, one of the mineral waters, as Hunyadi Janos, or by castor oil, which remains notwithstanding all prejudices and re- proaches one of the safest and most certain laxatives for the puerperal woman. In case she does not nurse her infant a saline is preferred, as the watery operation to some extent lessens the deter- mination of blood to the mammary glands. After the first free evacuation the bowels should be moved every day,.or every other day. The Lochia—Care of the External Genitals— Vaginal Injections, etc. —Napkins or preferably antiseptic pads are usually applied to receive the lochial flow; if the former, it would be well to have them sprinkled with a warm antiseptic solution before application, or to replace them by absorbent cotton, also made aseptic, which after use may be burned. At least once a day the external genital organs are to be bathed with a warm antiseptic solution, e. g., 1-2 per cent, creolin mixture in water, and if there be the least offensive odor of the lochia a similar solution should be injected in thewagina twice or oftener in the twenty-four hours; but unless there be this indication vaginal injections are not indicated. Raw surfaces at the vaginal entrance or upon the external genitals are to be carefully and gently washed twice a day with the creolin mixture, and then they may be dusted either with iodoform or with one part of salicylic acid and ten of starch. Sponges should not be used in bathing, but absorbent cotton or perfectly clean cloths, the cotton or cloths being afterward burned. The temperature of the room should be from 6o° to 65 ° ; the room must be well ventilated, but the patient is to be protected from drafts of cold air; all soiled clothing, nap- kins, etc., and urinary or fecal evacuations must be promptly re- moved so as not to poison the air by their exhalations. While care is taken that the patient is not chilled, the active state of her skin making her peculiarly susceptible to any sudden reduction of tem- perature, she ought not to be so carefully and heavily covered with bed-clothing as to make her uncomfortable and increase the per- spiration. The room is generally kept moderately darkened, in the 1 Schatz.of Rostoch, advocates in ischuria which persists in lying-in women, dilatation of the urethra to an extent admitting the little finger—rarely, a second dilatation is necessary. PHYSIOLOGY AND MANAGEMENT OF PUERPER1UM. 571 interest of the mother to promote her rest, and in that of the child to prevent the supposed injurious effect of light upon its eyes. Changes in the clothing of the puerpera are made from day to day as cleanliness and comfort require ; it is important that all clothing, and especially garments that come in direct contact with the skin, be dry and warm, though few would direct the method to secure this end advised by Hubert.1 The exclusion of visitors during the first week materially assists in the convalescence of the patient. Lactation—Care of the Breasts.—Moralists and obstetricians agree in urging the importance of the mother nursing her infant2 As a rule, she thus best secures her own and its health, she obeys nature's law and design, promotes the closest mutual attachment, and has an important influence in fashioning the first mental and moral development of her offspring. The prevalence of wet-nursing has been said to be the proof of a people's decline. Maternal nursing was once held in such high honor by some of the Romans that it appears no greater praise could be inscribed upon a mother's tomb than that found, according to Hubert, upon the tombs of many women dying in Hadrian's time:3 Filios suospropriis uberibus educavit. Obstacles to the Mother s Nursing.—Nevertheless there may be circumstances or obstacles arise which will forbid the mother nursing. First. The child may be illegitimate, and the mother, to hide her shame or to save it from disgrace, must part with it. Nevertheless it is better to nurse it during the first few weeks. Second. The poor quality or scanty secretion of milk may discour- age the mother from nursing. But means may be used to increase the secretion and to improve the quality of the milk; and, at any rate, mixed nursing is better than a diet exclusively of artificial food—that is, let the child get all it can from the mother, then make up the deficiency by artificial food. Third. Vices of con- 1 Hubert says that the chemise should be worn a day by the mother or the sister, or placed during a night in the husband's bed, before she wears it. Upon the page containing this sug- gestion he narrates from Dionis the well-known story in regard to Clement using for the dau- phiness after her first labor the fleece of a black sheep, this fleece being placed just after its removal from the living animal upon the naked abdomen of the puerpera, and his not using it in her subsequent confinements. The butcher brought the fleece carefully folded in his apron to the bedside of the patient, but unfortunately had left the door open, and the fleeceless sheep, bleating and bloody, followed him, greatly to the consternation of the dauphiness and of the ladies present; this accident prevented the repetition of the custom. Clement's and Hubert's practice may be placed side by side. Another curious fact is related by Dionis which shows that a medical sect of the present day had at least an illustrious example in the belief that odors, as of flowers, have an unfavorable effect upon the sick. " It is claimed that odors have a very injurious influence at this time; and persons who are perfumed are not allowed to enter the room of princesses or of ladies of rank. In the case of the dauphiness, the usher had orders to examine the ladies who came, and to send away any who were perfumed or had flowers.'' Traite General des Accouchemens, 1718. 2 The late Mr. Darwin, in his Descent of Man, suggests the probability that during ''a for- mer prolonged period male mammals aided the females in nursing their offspring, and that afterward from some cause, as from a smaller number of young being produced, the males ceased giving this aid ; disuse of the organs during maturity would lead to their becoming inactive." 3 Nevertheless in the time of Caesar this custom was not general, since he reproached Roman women for carrying in their arms monkeys and dogs, while they confided their infants to mer- cenary wet nurses. La G6neration Humaine. By Wiktowski. 57- SCIENCE AND ART OF OBSTETRICS. formation of the nipple, or changes in the structure of the gland, the latter generally resulting from inflammation in a previous confinement, may render lactation difficult or impossible. Fourth. Diseases of the mother which are aggravated by nursing, or will injure the infant through the milk, forbid her nursing. Thus if the mother be exhausted by anaemia, or if she be suffering from phthisis, she ought not to nurse; indeed, a marked predisposition to the latter is a reason for not nursing, since the statistics of Flint show that in 13.5 per cent, of married women under forty years who are phthisical, the disease is developed during lactation. If syphilis be recent the mother should not nurse, for then the probability is the child is not infected; but otherwise, that is, if the mother was syphilitic when she conceived, or acquired the disease in the first half of pregnancy, she may. It is criminal to employ a wet-nurse for a syphilitic child. As far as the infant is concerned, it may have been born pre- maturely, and be so feeble it cannot nurse at first; or it may be so deformed—as, for example, by harelip—or it may have been so injured in natural or in artificial delivery that it is unable to do so. In some cases the disability is only temporary. If a woman is not to nurse let her have a less liberal diet until the secretion of milk disappears, and until then, too, a saline laxative may be given each day beginning with the third; the breasts are covered with a layer of cotton-batting, which is to be frequently changed as it becomes wet with the mammary secre- tion or with that of the sudoriparous glands; in this, as well as in other cases, the gland may be supported when greatly enlarged by a properly applied handkerchief, the ends of which are tied over the opposite shoulder. Various popular as well as professional remedies have been recommended to stop the secretion of milk; among the former may be mentioned a piece of flannel saturated with spirits of camphor applied to each breast, and among the latter, iodide of potassium internally and belladonna locally. Generally all local treatment, except that which comforts the patient, is unnecessary, as the secretion stops if the milk is not required, for the great law of political economy is as true here as in the department of manu- factures—if there is no demand there will be no supply—and pos- sibly some if not all the remedies advised to arrest the secretion have no more virtue than one which Mauriceau1 mentioned as being employed in his day. In case the mother is to nurse, the child is put to the breast eight or ten hours after labor. Some advise the first application to be made as soon after delivery as the woman has had the necessary attentions, while others would wait until the secretion of milk is established, alleging that an earlier application is vain in securing nourishment, that it wearies the mother, and renders 1 " I know some women who hold it for a very great secret, and most certain to drive the milk effectually back—and that is, to put on her husband's shirt yet warm, immediately after he had taken it off, and wear it until the milk be gone.'' (Op. cit.) Of course the value of the remedy is indicated in the last words, " wear it until the milk is gone.'' PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 573 her more liable to sore nipples. Immediate application is to be re- jected because the mother is so fatigued and needs rest, and a late one because of the difficulty of the child's nursing then, from the breast being so swelled that the nipple cannot be readily seized by it. While it is true that the infant gets little nourishment during the first twenty-four or forty-eight hours, yet it does get the colos- trum which nature seems to have designed as a suitable laxative; moreover, it is usually satisfied with it, and is saved from having its stomach filled with improper food. It is probable, too, that the early and frequent removal of the contents of the breasts not only secures a proper formation, or drawing out of the nipple, but also leads to a gradual secretion of the milk, and thus local and constitutional disturbance from this cause is prevented. Certainly, if we follow the rule observed by the young of inferior mammals, the child will be put to the breast within a few hours after birth. The breasts are carefully protected from cold by covering them with soft flannel or linen, which must be changed when it becomes moist. The infant, as a rule, should not be applied to each breast at one nursing, but to them alternately, thus giving the nipples as long a rest as possible between the times of nursing, until liability to in- flammation has passed. The infant must not be allowed to sleep with the nipple in its mouth, for then it sleeps and sucks alternately, and its digestive organs, kept in almost constant exercise, are liable to become disordered ; this practice is very fatiguing to the mother, and the nipple being kept constantly moist and heated, softening and desquamation of the epidermis follow, with consequent erosions and fissures of the nipple, and thus the doors are opened for the entrance of germs, causing, finally, inflammation of the breast. After each nursing the nipple should be washed and well dried, and twice a day a little cocoa butter may be applied to it; if it becomes sensitive, and especially if the slightest rawness or ex- excoriation appears, the surface may be pencilled once or twice a day with compound tincture of benzoin; if this treatment does not suffice there may be conjoined with .it lightly touching the tender surface with a twenty-grain solution of nitrate of silver, and the use of a nipple-shield—the best is Needham's; after the application of the tincture of benzoin the nipple is left exposed until the tincture dries, and especially there must be no lint or a rag placed upon the surface, which of course can be removed only with the greatest difficulty at the next nursing. These details may seem to some unnecessary, but " sore nipples " cause so much suffering, and may lead to such serious consequences to both mother and child, that their prevention is of great importance. During the first two or three days the infant, if comfortable, sleeps almost all the time, and once in five or six hours is as often as it needs to nurse ; with the perfect secretion of milk the intervals must be shortened to two or three hours, endeavoring, however, to have the child nursed only twice in the night, so as to secure the mother as long periods as possible of uninterrupted rest. The infant ought to get an ample supply from nursing fifteen to twenty minutes; if it 574 SCIENCE AND ART OF OBSTETRICS. continue nursing longer, there is almost certainly insufficient secre- tion of milk. If the milk be scanty it may in many cases be increased by giving the patient a liberal diet, especially by having her take animal broths, chocolate and milk freely; if the last can be drunk at the temperature it is furnished by nature, it is best; some women find that malt liquors increase the flow of milk when all other means have failed, and only under those circumstances may they be advised. Various grJactagogues have been recommended, such as the leaves of the castor-oil plant applied to the breast, and different vegetable infusions, as of anise and of fennel; faradization of the breasts has in some cases produced remarkably beneficial results. But these are not to be compared with suitable and sufficient food conjoined with regular rest and as entire freedom from care as possible, the use of moderate but not fatiguing exercise in the open air, and avoidance of anxiety; mental worry, bodily fatigue, and loss of sleep notably lessen the supply of milk. Galactorrhcea may occur when there is polygalactia or excessive secretion of milk, and also when the secretion is normal in amount. As usually seen in the puerpera it is the former variety of the dis- order, is only temporary, and generally yields to moderate com- pression of the mammae, a restricted diet and saline laxatives. De Sinety refers to cases in which the supply of milk is so abundant that several infants could be nursed, and weaning does not arrest the exuberance. Very great inconvenience results from this condition, for the breasts are painful and the con- stantly flowing milk requires several napkins a day for its absorption ; finally the subject may become exhausted by the discharge, a condition formerly called tabes lactea resulting. Marvellous stories have been reported, especially by Puzos,1 as to the abundance of the secretion of milk. Borelli stated that a nurse had so great a supply she not only suckled two infants, but sold a large quantity to an apothecary who from it made butter for the phthisical. Ridley, a physician, said of his wife that she nursed twins, several small puppies, and then had enough milk escape from her breasts in twenty-four hours to make a pound and a half of butter."2 Diagnosis of Recent Delivery.—Very important questions in medical jurispru- dence may arise in connection with childbirth. One of these relates to the evidence of recent delivery. If a primipara, the fragments of the torn hymen will be visible at the entrance of the vagina; the fraetiulum will almost invariably be found torn, and very probably more extensive injury to the perineum ; the ex- ternal genital organs are swelled, red, sensitive to the touch, and show various recent injuries ; there is a bloody discharge from the vagina, and this organ will have injuries involving its mucous membrane, its rugae are absent, and its calibre is so much increased that the hand can be introduced. In multiparae all these signs may be wanting except the discharge and the capaciousness of the vagina, and the absence of rugae, though there will be almost always swelling and redness of the external genitals. The uterus is a round, hard body, readily felt by abdominal palpation ; the abdominal wall has its central line of pig- mentation, and laterally the bluish cicatrices of pregnancy may be seen, while if the woman be a multipara, white cicatrices are also found. The breasts are swelled, the areola discolored, and colostrum or milk may be pressed out of the nipple. After seven or eight days external injuries of the genitals will be healed, but the lochial discharge remains, and the characteristic striae and the pigmenta- tion may be observed upon the abdomen and the breast; the uterus will be found 1 Traite des Accouchmens, Paris, 1759. 2 It would appear from these illustrations that it is possible for a wet-nurse, contrary to the opinion expressed in a recent poem, " Glenaveril," to be a table d'ht-le. PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 575 enlarged. Kormann states that after the third week the question of recent de- livery can hardly be answered with certainty. When the delivery was premature the difficulty increases with the length of time that should have elapsed before the completion of pregnancy', and if there are no external injuries the diagnosis will chiefly rest upon the lochial discharge and upon the increased size of the uterus. May the second stage of labor be so rapid in its progress or so sudden in its termination that a woman is taken by surprise, as it were, so that she cannot lie down upon the bed or on the floor, and the child, born while she is stand- ing, falls on the floor, receiving serious or fatal injury? Kleinwachter's an- swer is, that it may happen with a multipara whose soft parts are greatly relaxed and offer little resistance, the labor-pains very strong, the basin of normal width, or somewhat greater, and the fcetus of the usual size; for several cases of this accident in which there was no question of medical jurisprudence involved have occurred. He regards it, however, as hardly possible in the case of a primipara. Yet it may be conceived as not impossible that a primipara alone, or without any intelligent person being present, may be deceived by the factitious desire to empty the rectum when the child's head is very low down, causing her to leave the bed for the water-closet, and the child being born there perish for want of proper immediate attention. Again : May a woman give birth to her child while she is in bed, and she be in such condition that the child perishes for want of proper attention, smothered it may be by the bed-clothes, or in conse- quence of its face falling directly into a pool of liquid between the mother's thighs ? The answer generally made to this question is that such an event may happen in the case of a primipara, but not in that of a multipara. Yet it would be going too far to say that while exceedingly improbable in the case of the latter, it is necessarily impossible. Attentions to the Child.—The care of the infant immediately after birth incase it should be in a normal condition has been considered. But if labor be premature or from other cause the infant is very fee- ble, it may be necessary to postpone the washing and dressing, and simply wrap it in warm cotton and surround it by bottles of hot water, or use other means to secure for it a normal temperature; it is then too feeble to suck, and must be fed with milk from the mother's breast for some days. The results which have been attained in Paris by means of the couveuse and gavage in prematurely born infants are very remarkable. By these 30 per cent. of children born at six months have been saved, 63.6 per cent, of those born at seven, and 85.7 per cent, of those born at eight months. The couveuse, or incu- bator, will rarely be used outside of maternities ; its purpose being to secure for the infant a uniform temperature of 85°-95° F.,this end must be obtained in private practice by the means previously suggested. But gavage is available to the prac- titioner. The apparatus used by Tarnier is shown in the subjoined illustration. The practitioner can easily improvise a simpler apparatus ; all he needs is a small glass funnel to which a rubber tube is attached—the red rubber catheter is advised. The food being ready, preferably milk from the mother's breast, the infant is placed, with its head slightly raised, upon the knees of the nurse ; the free end of the tube is moistened, then passed to the base of the tongue, and the infant by the instinctive efforts at swallowing will carry it to the entrance of the oesophagus, when the nurse by gentle pressure pushes the end into the stomach ; the distance is about six inches from the part which enters the mouth to that which is in the stomach. The milk is now poured into the funnel, or receiver, and gravity quickly carries it through the tube into the stomach ; the tube must be quickly withdrawn after the funnel is empty, lest the child vomit. The quantity and the frequency of the feedings will depend upon the age and strength of the infant A very feeble infant, born some time before the end of pregnancy, must be fed every hour, and between two and three teaspoonsfuls of milk given at each meal. (This description has been condensed from Tarnier's directions.) 576 SCIENCE AND ART OF OBSTETRICS, Fig. 196. Tarnier's Apparatus for the Artificial Feeding of Premature or Feeble Infants (Gavage); Luer's model. Discharges from the Bladder and Bowels.—Some time in the first twelve hours the infant usually urinates. The urine during the first few days has a low specific gravity, and is quite pale. Apparent retention is generally non-secretion ; for when the infant takes little or no food the quantity of urine secreted is necessarily very small. If there be actual retention and no urethral obstruction, a warm bath, followed by the application of cloths wrung out of warm vinegar to the hypogastrium has been recommended; the use of the catheter is very rarely necessary. Meconium, so named from its resemblance to the juice of the poppy, is usually passed a few hours after birth; but if the anus be not imperforate a delay of a day or two in this evacuation need give no anxiety ; in case of longer delay a simple enema of warm water or of flaxseed tea may be used, or a little sweet oil given by the mouth. The third or fourth day the meconium usually disappears from the stools, and these gradually become a light canary-yellow. The Umbilical Cord.—In three-fourths of infants born at term the stump of the umbilical cord falls off within five days, but in prema- ture infants the time is longer. The raw surface left by its detach- ment does not cicatrize for eight or ten days ; it may be washed daily with carbolized water, and afterward a carbolized ointment PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 577 applied, or it may be dusted with calomel or with a simple absorbent powder. Umbilical Hemorrhage or Omphalorrhagia.—It has sometimes happened that a woman has given birth to her child while standing, and the infant falling to the floor the cord has been torn, or a simi- lar tearing has occurred in forceps delivery, the cord being abnor- mally short, and in either case more or less serious hemorrhage followed. But the most frequent variety of umbilical hemorrhage observed is that which may happen several days after the birth and subsequent to the detachment of the cord. In forty-one cases col- lected by Minot1 the average time was eight days; in four the hemorrhage began before the separation of the cord, in three imme- diately after, and in the others at periods varying from one to thir- teen. Grandidier, quoted by Marduel,2 states that in one case it did not begin until the fifty-third. In a large proportion of cases jaun- dice was present: in some the hemorrhage was evidently dependent upon a hemorrhagic diathesis. The prognosis is quite unfavorable, for a great majority die in a time varying from a few hours to some weeks. In the treatment it is useless to trust to astringents and compression. The only plan which holds out the hope of success is to pass a harelip pin or a needle through the skin of the umbili- cus upon one side, then beneath the bleeding surface, and have its point emerge from the skin on the opposite side, and a second pin is passed beneath and transverse to the first; a figure-of-8 ligature is made around the projecting parts of each pin, and the entire mass ligated. The pins are removed on the fifth day, but the ligatures are undisturbed and left to fall off with the ligated mass. Secretion of Milk.—The enlargement of the breasts in male as well as in female children, which with secretion of milk is sometimes observed a few days after birth, has been mentioned on page 96. This irritation almost always spontaneously disappears in two days; probably suppuration does not occur except in those cases in which the organ has been accidentally bruised, or if injudicious nurses have rudely squeezed it in efforts to force the fluid out. Changes in the Shape of the Head—Caput Succedaneum—Cephal- hematoma.—The alterations in the form of the cranium occurring in childbirth disappear in the course of a week, or a somewhat longer time, and nature is quite able to restore the original form without efforts on the part of the physician or the nurse to mould the head. The caput succedaneum, unless very large, usually disappears in a few days, and meantime if anything is done, it may be occasionally bathed with a solution of muriate of ammonium. It is only rarely that suppuration occurs, and then if the collection of pus be large it must be opened. In cephalhematoma absorption may occur in from ten to sixty days ; suppuration is an occasional consequence, and recovery may follow the discharge of the matter; but sometimes necrosis of the bone and even perforation with resulting hernia of the brain is observed. Bouchut suggests in case 1 American Journal of the Medical Sciences, 1852. 2 Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, vol. xxiv. 37 578 SCIENCE AND ART OF OBSTETRICS. of a large tumor which does not diminish in ten or twelve days under the application of a solution of muriate of ammonium, or of camphor, or of an alcoholic mixture, the evacuation of its contents by an aspirator. Winckel from the sixth to the eighth day incises the tumor, unless it is quite small, following the incision by pressure on the detached periosteum with salicylated cotton: cure occurs in a few days. If an abscess forms, it is opened, the cavity washed out with one-half per cent, creolin mixture, and the gentle compression with salicylated cotton, previously advised, employed. Changes in the Skin of the Newborn—Desquamation, Jaundice.— About the third day after birth desquamation of the epidermis begins, and usually ends within a week. About two-thirds of children have what has been called physio- logical jaundice, first appearing two to four days after birth, and continuing for a week or ten days. This is more marked in feeble infants, in those born prematurely, or who have been exposed to cold, as is the fact frequently in foundlings. Various explanations have been given of the affection, but none is satisfactory. Active treatment is not indicated, as spontaneous recovery occurs. The grave form of jaundice, often septic in its origin, or patho- logical jaundice, is generally, if not always, fatal. According to Hofmeier,1 every infant lives for a time upon its own organism on account of insufficient nourishment being provided immediately after birth; this is accompanied with degeneration or decomposition of albumin and red cor- puscles. Bile pigment is formed from the pigment of the latter. At the same time the activity of the intestinal canal causes a great increase in the amount of bile secreted, so that the quantity is larger than that excreted after a certain degree of intensity has been reached and icterus neonatorum results, or if the skin be not colored, bile may be found in the urine. Bouchut2 regards hepatitis, of which one of the manifestations is jaundice, as very common in the newborn, its causes being compression of the body, or con- tusion of the liver in labor, the impression of air upon the external surface, and umbilical phlebitis caused by ligating the cord, and extending to the hepatic veins. In eight or ten days the jaundice disappears. Winckel adopts Birch-Hirschfeld's opinion, that in consequence of swelling of Glisson's capsule, resulting from lessened pressure in the portal system following division of the cord, the bile-ducts are compressed, and therefore the jaundice. But in the malignant form of jaundice there are fever, swelling of the abdomen, and tenderness in the right hypochondrium with enlargement of the liver ; there may be nausea and vomiting, and in some cases epistaxis, purpura, or haemate- mesis. The respiration is difficult, hiccough frequent, and as M. Richard points ' out, when this state is prolonged or increases, a profound change of expression follows, the eyes are fixed, convulsions affecting the muscles of the face and of the limbs occur, the infant sinks into collapse, becomes cold and dies. Bathing—Sleeping—Nourishment.—An infant should have a bath once in twenty-four hours, in order to insure that perfect cleanliness upon which its health and comfort so greatly depend. It should not be accustomed to sleep in the nurse's arms, nor in the • mother's bed, but in a separate one. As previously stated, it ought to be applied to the mother's breast eight or ten hours after 1 Kormann. 2 Op. cit. PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 579 birth. It ought, as asserted by Kleinwachter, to be subjected to a definite order in sucking from the beginning. After the secretion of milk has become abundant, generally the third day, "the child may be put to the breast every two hours, for at that time the capacity of the stomach is not great; after four or five days, once in three hours, and at night there should be an interval of six or seven hours; later on, six applications in twenty four hours will suffice." The child, as a rule, loses weight during the first few days; the loss is from 150 to 200 grammes, and is to be attributed to dis- charge of urine and of meconium, and also to the scanty supply of nourishment; at the end of the first week the child weighs nearly or quite as much as it did at birth. The best proof of the good quality and of the sufficient quantity of the milk, whether of wet-nurse or of mother, is given by the thriving of the infant. If the child grows well, is plump and healthy, it must have good and abundant food; the old law, " by their fruits ye shall know them," is here quite applicable. Never- theless, other means may be mentioned. When the infant is at the breast it can be known that it is getting milk readily by the move- ments of the cheeks alternating with those of swallowing; the last is often accompanied by a sound which Hubert compares to that made in uttering the French word glou-glou. So, too, if the milk is abundant it is found in drops1 at the angles of the mouth or upon the adjacent part of the cheek, after the child has finished nursing. It sometimes happens that the mother has apparently a sufficient supply of milk, but its inferior quality is shown not only by the child's failing to thrive, but by disorders of digestion, attacks of colic, and the abnormal character of the stools. It may be that one, two, or three meals of artificial food each twenty- four hours will work a happy change in the infant's condition, and the mother, less worried and her rest less disturbed, and at the same time less frequently nursing the infant, secretes a better milk, and therefore she may continue to nurse, her deficient supply being thus supplemented. Weighing the child from time to time is an excellent test of the quantity and quality of the milk : the increase in weight ought to be about one ounce a day. Selection of a Wet-nurse.—The most desirable age for a wet-nurse is from twenty-two to thirty-five years. If a married woman it is better that she should be a multipara, for the milk is then not only more abundant, but she is less liable to suffer from disease of the nipple, or mammary inflammation, and, moreover, has acquired useful experience in the care of an infant. If unmarried, she ought to be a primipara, for, as suggested by Hubert, while the first fault might be excused, after the commission of a second there would be no guarantee that a third might not occur while she was nursing. 1 The most gifted poetess of the century, if not of all centuries, Elizabeth Barrett Browning, has alluded to this where she speaks of the babe "knowing all things by their blooms, not their roots," etc.: "And human love, by drops of sweet White nourishment still hanging round The little mouth so slumber-bound." 58O SCIENCE AND ART OF OBSTETRICS. Delore states that from the time of Ambrose Pare blonde women were con- sidered inferior nurses, and indicates that brunettes are generally preferred as habitually more vigorous. Dionis asserted that the best nurses were those of a sanguine temperament, and who have black, or brown chestnut hair. Bad nurses were those of a bilious or melancholic temperament, and who have blonde or red hair. She must be free from syphilis, tuberculosis, or exanthematous disease. There ought not to be a difference of more than two months between the birth of her own and that of the infant she nurses. The breasts should be of medium size, and the nipple free from excoriations, of such size that the infant can readily grasp it with its mouth, and the milk be easily drawn. As a rule, a woman who menstruates regularly ought not to be taken as a wet-nurse. Supposing everything favorable as to the supply of milk and the physical health, consideration should be given to her moral char- acter and disposition, for while it is true that the milk of the nurse1 can transmit no intellectual or moral qualities to the nursling, yet it is also true that with the development of the infant's intelligence it will receive in its plastic nature impressions more or less profound and permanent from one with whom it is so intimately and con- stantly associated as the nurse. Moreover, the question as to her disposition is an important one, since for the time being she is to some degree a member of the family; taking the child to her own home to nurse is quite exceptional.2 Further, it is generally ad- mitted that the milk may at once undergo important modifications in consequence of profound mental emotion. Devilliers remarks that it would be easy to adduce examples of nurses in whom violent passions, especially anger, changed the qualities of the milk so as to disturb the health of the infant, and even cause severe convul- sions. And he adds: "A thousand times better a woman somewhat stupid, of an impassive character and almost insensible to passions, than a nurse with intelligence more developed, but of a passionate and choleric character." Artificial Feeding.—In case the mother cannot nurse her infant, and it is impossible to obtain a suitable wet-nurse, artificial nourish- ment must be used. Condensed milk is a very convenient form of food, especially in cities and in hot weather, when it may be difficult 1 The belief that the milk which nourished the newborn had much to do with the formation of the character is an old one ; even to this day it is not uncommon to hear one speak of having sucked in with his mother's milk certain beliefs or principles, especially those of a re- ligious character; but the expression is used more as a figure of speech to indicate how com- pletely and thoroughly those beliefs or principles are interwoven with his spiritual nature, having been taught him in the very dawn of his intelligent existence, than that they came by the nour- ishment derived from the mother. The famous Cato, however, did believe that affection might be thus communicated, for, according to Plutarch's statement, he had his wife, whenever she nursed her son, also give her breast to the infants of her slaves, so that sucking the same milk they might have an affection for him. Cruelty of disposition was also thought to be derived from the first nourishment. Thus among all the bitter reproaches which the deserted Dido cast upon the escaping ^Eneas, one of the severest, as indicating his cruel nature, was that he had nursed the breasts of Hyrcanian tigresses. Gardien quotes the statement that if young lions are nourished by cow's milk they are gentle, and, on the other hand, that if puppies are brought up by wolves they are fierce. 2 This seems not to have been extraordinary among the Egyptians, as the story of Moses' infancy suggests. PHYSIOLOGY AND MANAGEMENT OF PUERPERITJM. 581 to obtain pure milk from the cow. Babies like it, and rapidly fatten taking it, and they are free from constipation. The liability to rhachitis in children living on it exclusively has been stated by Fleischmann, Lusk, Galabin, and Starr. Certainly I have observed in children having no other diet the first year in some cases curva- tures of the lower limbs, which seemed to me to be attributable in part to the great weight they had to bear, for, as before stated, the children thus fed are large, fat, heavy ; hence I must recall an opinion as to the general value of condensed milk as a food expressed in the previous edition of this work. I am now prepared to adopt the lan- guage of my friend, Dr. Louis Starr •} " Without going further into detail, it is never safe to bring up a child solely on condensed milk. For a temporary change of diet, and as a food during travelling or under circumstances in which sound cow's milk cannot be obtained, it may be resorted to with advantage." The milk of the cow is that which, as a rule, can be best used for the nourishment of the infant; it has been the practice to select the milk from one cow; Winckel, however, advises that of several mixed together. In order to remove all possible infectious matter the milk ought to be boiled before using it; recently there have been invented apparatuses for sterilizing milk; milk after being subjected to this process may be kept for several days without change, but space does not permit describing the means and methods by which sterilization of milk for the use of infants is accomplished: the great lessening of infant mortality in hospitals since the introduction of sterilized milk is convincing proof of the importance of having it thus prepared. But cow's milk is far from being the same as human milk, and to make it approximate the latter certain additions must be made : these are cream, sugar of milk, and water. Here I wish to present the formulae which Dr. Starr has given, merely premising that I have several times in practice tested their value: the formulae for the first seven months only will be introduced: " For the successful management of children, the practitioner must not only be familiar with the theory of feeding, but must be able to write out precise directions for the preparation of the food. To this end a schedule of the diet of an infant from birth upward, with a sketch of the modifications that have to be made most frequently, will serve as a useful guide. " Diet during the first week : Cream ....... f^iij. Sugar of milk......gr. xv. Whey.......f^ss. f3ij. Water.......f|ss. f^ij. For each portion ; to be given every two hours from 5 A. m. to i i p. m., and in some cases once or twice at night. " To make whey, add three teaspoonfuls of wine of pepsin to a quart of warm fresh milk, and stand near the fire for two hours, then remove the curd by straining through muslin. 1 Diseases of the Digestive Organs in Children. 582 SCIENCE AND ART OF OBSTETRICS. " Diet from the second to the fifth week : Milk........f=ss. Cream........f.^ij. Sugar of milk . • . . . . . gr. xv. Water........f 3j. For one portion ; to be given every two hours from 5 A. m. to i i p. m. " Diet from the fifth week to the end of the second month : Milk........f,|j,f3ij. Cream . . . . . . . . f 5 ss. Sugar of milk.......gr. xxx. Water........f 5J, f 3ij. For each portion ; to be given every two hours. " Diet during the third month : Milk........f Jijss. Cream ........ f^ss. Sugar of milk . . . . . . . 3j. Water........fjj. For each portion; to be given every two and a half hours. " Diet during the fourth and fifth months : Milk........f^iijss. Cream ........ f.^ss. Sugar of milk ....... 3j. Water........f3J. For each portion ; to be given every three hours. " Diet during the sixth month, six meals daily. Morning and mid-day bottles, each : Milk........fgivss. Cream ........ f^ss. Mellin's Food ....... Sj- Hot water . . . . . . . f Jjj. Dissolve the Mellin's Food in the hot water, and add, with stirring, to the pre- viously mixed milk and cream. " Other bottles, each : Milk........f^ivss. Cream........ f^ss. Sugar of milk...... . 3j. Water........f|j. " In the seventh month the Mellin's Food maybe increased to two teaspoonfuls, and given three times daily." Difficulty and Pain in Urinating.—It occasionally happens that male children have great pain before, and some difficulty in urina- tion ; upon examination it will be found that the trouble arises from stenosis of the orifice in the prepuce. Of course circumcision is a certain and permanent cure, but dilatation will also be successful, and it will generally be preferred; dilating may be done by drawing the prepuce over the closed blades of a suitable forceps inserted in its orifice, and then opening the blades until about one-half of the PHYSIOLOGY AND MANAGEMENT OF PUERPERIUM. 583 glans is exposed; cold water is applied for an hour, and the dilata- tion may, if necessary, be repeated after one or more days. Thrush} Sprue, Muguet.—These different names are applied to an affection of the mouth of the infant characterized by the appearance upon the tongue, and upon the inner surface of the cheeks, thence possibly extending to other or to all parts of the buccal mucous membrane, of small, white curd-like patches. The affection is much more frequent in the hand-fed than in the breast-fed, and is not so much a disease as indicative of a diseased condition of the mucous membrane and of the secretions, furnishing a suitable soil for the growth of the fungus, saccharomyces albicans, formerly called by Robin o'idium albicans. The occurrence of such a growth is usually an indication that proper care of the child's mouth has not been taken in regard to washing it, or that in artificial feeding either the food is not in proper condition, or the vessel, the tube and the nipple are not thoroughly cleansed. The best local application is borax; it may be used as a solution in water, twenty grains to the ounce, freely pencilled three or four times a day upon the patches, or, as advised by Winckel, a mixture in syrup may be used, of which half a teaspoonful is given 1 to 3 times a day, the child by the move- ments of its tongue making a better application of the remedy to the diseased places than can be done with a brush. 1 Thrush, probably from the same root as thrust, and sprue, spelled by some lexicographers sprew, from the same root as sprout. CHAPTER II. THE PATHOLOGY OF THE PUERPERAL STATE—ACCIDENTAL DISEASES— MENTAL DISORDERS—SUDDEN DEATH. Accidental Diseases occurring to the Puerperal Woman.—It must be remembered that diseases entirely independent of the puerperal state may occur in childbed, and therefore the practitioner must not hastily conclude that a decided and continued elevation of tempera- ture is indicative of some form of puerperal infection. Rheumatism, pneumonia, scarlatina, pleurisy, rubeola, and malarial fever are some of the diseases which have been observed in childbed; probably that of most frequency is malarial fever—the germs of the disease being present prior to delivery, and the susceptibility of the subject to their action being increased by the exhaustion of labor. Some of the diseases more or less seriously complicate puerperal conva- lescence, and may, for example, manifest an injurious influence by causing secondary hemorrhage from the uterus. But space does not permit more than this brief reference to these maladies, save that what has been designated as puerperal malarial fever must be more fully spoken of, especially because there is danger of the practitioner mistaking puerperal infection for it. Malarial fever rarely occurs in childbed unless the woman has had previous attacks of the disease. She has been exposed to malarial poison. The attacks are regularly and distinctly remittent, or intermittent. The malarial tongue, first described by Osborn,1 in 1851, and then in 1869,2 will be of value in making the diagnosis in many cases : " It will be noticed that the middle of the tongue is heavily coated with a dirty fur, which thins off toward the point, where the color of the papillae can be seen pressing through the attenuated coating ; whilst on the sides of the fur there are clean, smooth, depressed margins, having a bright-red color. The sides or edges of the tongue are flattened, pinkish, and traversed by sharp lines, creating the impression to the eye of the observer that the parts are crenated, striated, corru- gated, puckered, or crimpled—either term having a shade of appropriateness— but which, upon close inspection, will be found situated in the substance of the tongue, leaving the mucous membrane even and smooth to both sight and touch." The transverse lines are too numerous and near to each other to attribute them to pressure by the teeth. Finally, the promptness with which quinine arrests the febrile paroxysms confirms the diagnosis : cura ostendit morbum. In concluding this topic, it seems to me that in some cases of what British obstetricians have described under the name of Weid? 1 Western Journal of Medicine and Surgery, August, 1851. '2 Transactions of the American Medical Association, vol. xx. 3 Garrigues, in referring to the word " weed," states: " The dictionaries of the English Ian- PATHOLOGY OF THE PUERPERAL STATE. 585 by some incorrectly called Weed, the disorder was malarial fever : this opinion rests upon the description of the disease as some have given it, and upon its successful treatment by antiperiodics. Mental Disorders —Under the name puerperal insanity, or puer- peral psychoses, disorders of the mind occurring in pregnancy, the puerperal state, or in lactation have been included. Probably such disorders occur in 2 of 1000 labors. Approximately one-twelfth of all cases of insanity in women are puerperal.1 Insanity appearing in the puerperium is the most frequent, and in pregnancy the rarest. The causes chiefly are heredity, eclampsia, hysteria, chorea, renal disease, infectious puerperal maladies, epilepsy, anaemia, ex- haustion from hemorrhage or from lactation. It is stated that moral causes are more frequently observed in the higher, and physical causes in the lower classes of society. Melancholia, mania and monomania are the chief forms. Ripping, as quoted by Kehrer, gives the following statement as to combi- nations of mental disorders observed by him in a hospital for the insane. These combinations are presented in a decreasing fre- quency: 1. Primary melancholia, lasting weeks and months, then mania. 2. First melancholia, then monomania with ideas of perse- cution and of exaltation. 3. Mania with following confusional in- sanity. 4. First confusional insanity, then melancholia. Insanity during Pregnancy.—It is not uncommon for a pregnant woman, especially if it be her first experience, to be at times pro- foundly depressed, and to be apprehensive of the most grave results from her condition. So, too, some pregnant women may be so vexed, so tormented at the prospect of being mothers, that they insist they "will go crazy," threaten to commit suicide even, hoping that the physician may be induced to rid them of their hated bur- den. But in neither of the cases presented is there actual insanity. The insanity of pregnancy is usually that form known as melan- cholia. The earlier in the prgnancy the disease appears, the more favorable the prognosis. When mania is associated the condition is much more unfavorable: the severity of the attack is also unfavor- able. In some cases attempts at suicide may be made.2 In the guage I have examined do not contain the word in the sense of a disease." American System of Obstetrics, vol. ii. Ephemeral Fever, or Weid, has been described by different obstetric writers; for example, Burns, Ramsbotham, and Churchill. " Weid, a kind of fever to which women in childbed, or nurses, are subject. German weide, or weite, corresponds to French accable, as signifying that one is oppressed with disease." Jamieson's Etymological Dictionary of the Scottish Language. Edinburgh, 1818. In Ogilvie's dictionary the following definition is given: "A general name for any sudden illness from cold or relapse, usually accompanied by febrile symptoms, taken by females after confinement or during nursing.'' Ramsbotham remarks that Scott, in his " Bride of Lammermuir," makes one of the women speak of a child as having the " weid ;*' so that it seems to be applied to children as well as puerperal women. 1 In examining the last Report of the Pennsylvania Hospital for the Insane, 1890, I find that including those cases of insanity attributed to the puerperal state and to prolonged lacta- tion, puerperal insanity embraced 15 per cent, of insane women. 2 Thorburn, Lancet, June 29,1879, reports a case of suicidal mania in a woman four months pregnant; he induced abortion—" premature labor," he calls it—and the patient in a very short time was sane. It is doubtful whether the treatment would meet general professional endorse- ment—at least it is to be feared if abortion were commonly recognized as the remedy, there would be many cases of feigned insanity. 586 SCIENCE AND ART OF OBSTETRICS. treatment care must be given to remove all sources of disquiet and worry from the patient—in some instances a complete change of scene and circumstances is advisable, even placing her in a hospital for the insane ; attention must be given to nutrition, and to securing regular and sufficient rest. Insanity in the Puerperal State.—It sometimes happens during labor that under severe suffering, a woman has temporary delirium, and there may be momentary irresponsibility for words or acts; but when the labor is over, the cloud and the storm pass away, leaving the intellect perfectly clear: the condition is too transient to be called insanity, or to demand special treatment, save the mitigation of the suffering by appropriate means. Mania is the most frequent form of true puerperal insanity. Hallucinations1 of sight and hear- ing, suspicion, even fear or hatred, of those hitherto loved and trusted, indifference or absolute aversion to her child occur. The disease in almost all cases appears in the first week of the puerperium— "within ten to twelve days after confinement," according to Weber. Melancholia, on the other hand, is later in its appearance, and if recovery occurs it is after a much longer period than when this follows mania. The prognosis of the psychoses of childbed is, as stated by Spie- gelberg, more favorable than that of any other puerperal forms, both as regards the duration of illness and as regards complete mental and physical recovery. Restoration in the majority of cases takes place within six months. In the treatment the removal of all exciting conditions, attention to digestion, quiet of body and of mind, improvement of the blood, if that is impoverished, especially by the administration of iron, regular bathing, the securing of rest by chloral, opium, sulphonal— several commend hyoscyamine, and Lloyd2 speaks favorably of par- aldehyde in cases of even acute mania. Of course if the disease does not readily yield to treatment at home, the sooner the patient can be removed to an asylum the better. The Insanity of Lactation.—This may appear six or seven weeks, or several months after labor, or finally a few days after ceasing to nurse. It may be manifested under any one of the forms, mania, monomania, melancholia, or insanity with a double form, " circular insanity," all "accompanied with hallucinations and impulsive ideas, and homicidal or infanticidal tendencies." The prognosis is favorable, most cases recovering if the child be weaned. Marce saw 20 cured out of 26; but the cure may be slow, and may not occur for several months, or even for years (Charpen- tier). In case the disorder follows suspension of lactation, cure has been effected by its resumption. 1 The poet's picture will impress this more strongly: " I hear a voice you cannot hear, Which says I must not stay ; I see a hand you cannot see, Which beckons me away.'' 2 American System of Obstetrics, vol. ii. PATHOLOGY OF THE PUERPERAL STATE. 587 Sudden Death during or follozviug Labor.—Whether one believe with the Roman emperor, that the death which is most sudden is that most to be desired, or place it, as is done in the rubric familiar to all, at the climax of earthly calamities, such event is always startling and usually most painful to the witnesses. This pain is greatest, the misfortune almost without exception the gravest, if a mother dies in childbirth or soon after. Many causes conspire to make such an event peculiarly sad. The abrupt severing of new ties, the loss of life in giving life, and the sharp contrast between an infant living and a mother perishing just when the former so greatly neds the loving care of the latter, are among these causes. The obstetrician not infrequently suffers public reproach when such an event occurs in his practice, for people are slow to under- stand how that which is in the majority of cases a simple physio- logical process may have a fatal issue. Moreover, in some instances death can be averted if the practitioner, forewarned of its imminence, uses appropriate means; in others the prophecy of such event as possible, probable, or inevitable may protect his reputation; and in still other cases, if prophecy should fail—the event, casting no shadow before it, coming unexpectedly to him as to others—his ability to explain its cause is very important. It is therefore alike his duty and interest to know the usual causes of sudden death in childbed. Constant supply of oxygen to the organism and the regular dis- tribution of blood suitable for nutrition are the two essentials1 for the continuing of life—in other words, the lungs and the heart must perform their respective functions, and thus the tripod of Bichat is replaced by a biped, for the brainless fowl lives, though it instantly perishes if deprived of heart or lungs. In most cases of sudden death the heart, the ultimum moriens of Galen, first stops— or, in other words, death is caused by syncope, not by asphyxia. If death begins at the lungs, the fatal event is usually slow in pro- gress ; nevertheless, it may then in some instances be sudden, as from pulmonary embolism, just as, on the other hand, cardiac death does not always occur even rapidly. In still other cases, lungs and heart may both fail, the failure of neither being the exclusive cause of death. Death from Syncope.—The fact that syncope may be caused by a strong mental impression, as fear, anger, joy, or sorrow, is familiar to the profession as well as to the public. A reasonable supposition is that in such cases the impression upon the brain is first reflected to the bulb, then probably through the pneumogastric nerves the bulb itself arrests the action of the heart, and hence the sudden paleness, the cerebral anaemia, and the syncope.2 Wundt, adopting Kant's classification of emotions into sthenic and asthenic,3 says that the former kill by apoplexy, and the latter by cardiac par- alysis, or rather by the interruption of cardiac function which 1 Strauss: Nouveau Dictionnaire de Medecine et de Chirurgie pratiques, t. xxxiv. 2 Strauss, op. cit 3 Elements of Physiological Psychology. 588 SCIENCE AND ART OF OBSTETRICS. energetic and persistent excitement of the inhibitory nerves of the heart causes. The greater nervous susceptibility of woman than of man, and its notable increase during pregnancy, would explain the special liability she then has to be injuriously affected by a profound emotion, whether of pain or of pleasure. Chevallier has collected and narrated cases of sudden death occurring to puer- perae which he attributed to idiopathic asphyxia. But, as remarked by McClin- tock,1 "some very competent authorities look upon the mortal affection described by M. Chevallier as merely a form of syncope." Undoubtedly the later term is the correct one. It is remarkable that several of the cases adduced were those in which death followed a strong emotion—in other words, they were instances of fatal emotive syncope. One of these, for example, taken from Morgagni, was that of a multipara who after an easy labor was delivered of a girl, her husband and she both being desirous of a boy; the sex of the child was imprudently told her: she was affected with such deep sorrow that her pulse became weak and her skin cold, and in a few hours she died; the autopsy presented no satisfactory cause of the fatal result. Winckel2 refers to strong mental emotion, especially severe suffer- ing, as a cause of sudden death, and states that Baart de la Faille has collected 13 cases of post-partum collapse in which neither embolism nor the entrance of air was probable, but in which, how- ever, the entire complexus of symptoms had very great similarity to cardiac paralysis. Dr. Lusk3 lost a primipara two hours after delivery with forceps, aud he attributed the death to " nerve-exhaustion and shock." Dr. Fayette Dunlap,4 in the case of a patient dying a few hours after the termination of her labor, regarded exhaustion as the cause of the unhappy event. 1. Death may be Caused by Pulmonary Embolism.—A thrombosis having formed in uterine, pelvic, or femoral vein, an embolus is detached, and passing to the right heart is arrested in the pul- monary artery. The most frequent instances of this accident have been observed in patients suffering with phlegmasia alba dolens. The unhappy victim may have taken the erect or sitting position after having been recumbent for days or weeks, or made other slight exertion, and death come suddenly as if from a thunderbolt. The death may be caused by embolism just after labor as a con- sequence of artificial thrombosis in a uterine vessel. Herman and Brown have reported the following case: An intra-uterine injection of a solution of perchloride of iron was used for post-partum hemor- rhage, and the woman died, the death being attributed to an embolus from a thrombus in the uterine vein.5 2. Death may be Caused by the Entrance of Air into the Uterine Veins.—A patient of Olshausen6 was having, used while she was in labor, a uterine douche to hasten effacement of the cervix; she com- 1 Dublin Medical Press, 1852. 2 Lehrbuch der Geburtshiilfe. 3 Journal of the American Medical Association, 1884. * Ibid., 1887. 5 Obstetrical Journal of Great Britain and Ireland, January, 1880. 6 For these cases see Braun on " Sudden Death from the Entrance of Air into the Uterine Veins," Wien. med. Woch., 1883. PATHOLOGY OF THE PUERPERAL STATE. 589 plained of pain, raised herself up in bed, gave some deep inspirations, and died in a minute. At the autopsy, made eight hours after death, bubbles of air were found in the cardiac vessels, in the uterine veins, and in the inferior vena cava. In Litzmann's case four uterine douches were given with Mayer's pump to induce premature labor; suddenly the woman became livid, and died in a few seconds. The post- mortem, made sixteen hours after death, showed bubbles of air in the uterine veins and in the ovarian and renal plexuses. Gunz has reported the case of a girl twenty years of age who was found dead in her room, having between her limbs an irrigator, the canula being in the vagina. She was found to be three months and a half pregnant, and the death was shown to have resulted from the entrance of air into the veins, the canula having penetrated the cervical canal. Spontaneous entrance of air is illustrated by the following case : A secundipara, twenty-five years of age, was after an easy labor delivered of her child while lying upon her side ; she was then turned upon her back, gentle massage used, and the placenta was expelled. The face sud- denly became livid, the respiration labored, the pulse weak; after vomiting a little mucus and after slight convulsive movements she became collapsed, and died. At the autopsy the uterus was found as large as the head of a child, and ■ its walls relaxed. In compressing the posterior wall and the fundus of the uterus at the place where the placenta had been attached fine crepitation was heard: when the organ was thrown into water a great number of small bubbles of air escaped. The parts of the uterus near the cervix did not appear to contain air, nor did the veins of the broad ligament, the ovarian veins, or the vena cava. Another instance is the following: Cordwent has given1 the history of a primi- para, twenty-eight years old, who was delivered while standing of a living male child, which fell to the floor, dragging the placenta and membranes with it. A "gurgling" was heard by the attendants, and the woman died almost imme- diately. At the post-mortem air was found in the uterine wall at the fundus, in the coronary vein, and in the right heart. Winckel,2 in referring to the entrance of air into the uterine veins as a cause of sudden death, remarks that in an examination during labor, in the removal of the placenta from the vagina, in the introduction of the hand into the uterus for the purpose of removing the placenta, the introduction of air is almost inevitable, and that sometimes the contained air escapes with a quite audible sound. He also refers to the fact that if the os uteri be closed and decomposition of retained material occur in the cavity, gas may enter the circulation. Lauffs has collected3 43 cases of air entering the uterine veins. In 17 the accident was caused by injections into the birth-canal, 18 were spontaneous, and 8 resulted from the formation of gas in the uterus: 39 of the 43 were fatal, and the presence of air was proved by the autopsy in 31. 3. Death may Result from Some One of the Accidents of Labor.— These accidents have already been considered, and it is hardly nec- essary to remind the reader that hemorrhage, rupture or inversion of the uterus, or eclampsia, may cause sudden death. 4. Different Diseases may Cause Sudden Death.—Among these may be mentioned rupture of an aneurism, or of the heart having under- gone fatty degeneration, cerebral or pulmonary apoplexy, pulmonary emphysema, haemoptysis, rupture of the spleen, rupture of an hepatic abscess, and haematemesis. ' St. George's Hospital Reports, London, 1873. 2 Op. cit. 3 Ueber Eintritt von Luft in die Venen der Gebarmutter bei und nach der Geburt., Bonn, 1885. C H A P T K R III. INFECTIOUS DISEASES—MASTITIS—TETANUS. Infectious Diseases.—Under this head it is proposed to consider Tetanus, Mastitis, and Puerperal Fever. The most generally ac- cepted view is that these maladies are caused by microorganisms, and therefore the classification proposed. Puerperal Tetanus.—This is quite a rare disease,1 and therefore its consideration will be brief. It has been observed after abortion, as well as after labor at term. It has followed obstetric operations, such as tamponing the vagina, removal of placental fragments, version, and, as it has been observed after ovariotomy—in 1877 I collected2 13 cases, including one of my own—so it has followed the Caesarean operation, /'. e., gastro-hysterotomy, and the Porro operation, or gastro-hysterectomy. Nicolaier, 1885, and Rosen- bach, 1886, proved that the essential cause was a bacillus similar to Koch's bacillus of the septicaemia of mice; this bacillus is diffused through the soil, especially soil containing horse-dung. The disease is more frequent in tropical countries, thus Wallace saw3 in ten years at Calcutta 23 cases, and Pedley states4 that it is a comparatively common cause of death in childbed among the Bur- mese. But it is possible, if not probable, that the utter disregard for cleanliness, as mentioned in Pedley's article, has more to do with the prevalence of the disease in certain tropical countries, than the climate itself. The disease usually appears from the third to the eleventh day, but Kehrer refers to a case in which it did not appear until the second month after delivery. The manifestations and course of the disease are the same as in traumatic tetanus, and as in it, too, the mortality is very great, 80.4 per cent. The treatment of puerperal tetanus does not differ from that of traumatic, except that in the former the local use of antiseptics is essential, the most efficient of them probably being corrosive subli- mate. Mastitis, Mammitis.—Nearly 6 per cent, of lying-in women suffer from mastitis. The disease is rare before the sixth day, and usually occurs in the second or third week. The disease generally begins with a chill, and the patient complains of severe pain in the affected breast; at the seat of pain there will be found a hardened mass, and the skin over it is found red ; frequently there may be seen too, 1 Those who desire to especially study puerperal tetanus will consult the contributions of Simpson, Obstetric Works; Hervieux, Maladies Puerporales; Garrigues, American Journal of Obstetrics, 1882, and Lioyd, second volume American System of Obstetrics. 2 Transactions of American Gynecological Society, vol. ii. 3 See Kehrer's article, " Starrkrampf im Wochenbett,'' Muller's Geburtshiilfe. 1 Transactions of London Obstetrical Society, vol. xxix. INFECTIOUS DISEASES--MASTITIS--TETANUS. when the inflammation is superficial, red lines marking the course of inflamed lymphatics : fever is present. Three varieties of the affection are recognized: i. Inflammation of the superficial con- nective tissue. 2. Inflammation posterior to the gland, retro-mam- mary phlegmon. 3. Parenchymatous inflammation : the last is the most frequent, and the second rarest. In parenchymatous inflam- mation, it is, however, seldom the case that the disease is limited to the glandular structure, but the adjacent connective tissue is also usually involved. Olshausen states that if the fever continues for two days suppura- tion will generally occur, and this is manifested in eight or ten days. Disease of the nipple in the majority of cases precedes the mam- mary affection. There may be excoriations, ulcers, or fissures of the nipple; the last is described as a linear ulcer situated at the base or at the summit of the nipple. These affections give rise to great pain when the woman nurses, and if there be ulcers, whether linear or broad, hemorrhage is not uncommon, and the infant swallows blood with milk: if an infant, therefore, vomits blood, the physician, before deciding that there is haematemesis, should first ascertain whether the discharge has not the source just mentioned. The immediate suffering from disease of the nipples, and the remote probability of such disease resulting in mastitis, make it important that the former should be prevented, or if it occurs, be promptly cured. As long as the lesions described remain, oppor- tunity is given for the pus-producing micrococci to gain access, and even 8 to 14 days after the cure of the disease of the nipple, mastitis may occur, the germs having previously entered: this explains some cases of mammary abscess which have been attrib- uted to other causes. But independently of wounds of the nipple, or in their absence, micrococci may enter through the milk-ducts; bacteria have been found in the milk of the not yet diseased gland. Winckel states that all bacteria which are known as producers of pus have been found in mammary abscesses, the staphylococcus pyogenes aureus most frequently and constantly. Cohn found in parenchymatous, non-suppurating mastitis a peculiar streptococcus. The retention of milk in the breast is popularly, and. by many in the profession, regarded as a cause of mammary inflammation, and acting upon this opinion the importance of "emptying the breast to prevent its gathering" has been urged, and means for accom- plishing this not always the most gentle, have been diligently used, in some instances to the suffering if not to the serious detriment of the patient. Olshausen denies that milk-stasis causes inflammation ; bacteria in the milk may cause decomposition with the formation of lactic and butyric acids, so it is comprehensible that milk-stasis may be favorable to the multiplication of bacteria. Mastitis in rare instances occurs as one of the manifestations of a general septic infection. 592 SCIENCE AND ART OF OBSTETRICS. Treatment.— I. Prophylactic. The prevention of mammary in- flammation is to be sought chiefly in perfect cleanliness of the nipple, and in averting or promptly curing disease of this organ. Again let the practitioner be reminded of the proper care of the nipples during pregnancy, so that suitable form and condition of the skin may be secured them for easy and safe lactation; the use of a nipple shield if abrasions or excoriations result from nursing, and the application of a lead wash, of a solution of carbolic acid, or of the compound tincture of benzoin to the raw surface does not heal them, is advisable. In cases of ulceration or fissure, the nitrate of silver may be applied in substance. Complete rest for 24 to 48 hours of the affected nipple will often accomplish more toward healing a lesion than can any local application. 2. Curative. If mastitis occurs, the child should not be permitted to nurse from the affected breast, though it continues to use the other. The breast is supported by a suitable bandage. Winckel advises the application of compresses of lead-water day and night; a saline may be given, and the patient restrict the quantity of liquid taken. Dr. Bartholow recommends enveloping the breast in lint wet with a solution of atropine in rose-water, four gains to the ounce; he adds to the advice the caution that as systemic effects may be produced by such an application, the removal of it should the pupils dilate and mouth become dry. If an abscess forms it should be opened, all antiseptic cautions being used ; the opening is to be made early and should be free, and a drainage-tube introduced, except in case the collection of matter is simply subcutaneous. Dr. Hiram Corson strongly advocates1 treating mammary inflammation by applications of ice, stating that during twenty-seven years in which he has em- ployed it, he has failed in no instance to disperse the inflammation, if suppura- tion had not already occurred, and at the same time brought comfort to the patient. He states, " There is no better way to apply the ice than to put it into a bladder with just enough water to float it, or just to form a water cushion, that will fit the inflamed part nicely. It is not necessary to put two thicknesses of muslin between the bladder and the breast; it is not too cold without any, but a single thickness is useful to keep the bladder in place more readily." Dr. P. A. Harris advises2 treating mastitis by bandaging and rest. The plan he pursues is thus stated: " Having discovered the existence of an inflammatory movement in the breast, of any grade of severity, or at any stage of advancement, short of the formation of an abscess, I should at once interdict nursing, friction, pumping, the application of fomentations, in fact overy local measure excepting such as are calculated to secure complete test for the gland ; rest from passive mo- tion, rest from secretion, and rest from pain. All these conditions can, in a great degree, be immediately secured for the patient. Procure at once a roll of soft cotton-wool, cotton batting, a plain roller bandage at least twenty yards long, and two, or two and a quarter inches wide, also eighteen large safety pins." The breast is first covered with a layer of cotton-wool, and the bandage so applied as to lift up and compress the affected organ. The patient should be seen daily, and the bandage reapplied until the crisis has passed; this time varying from one to several days. Dr. H. Clay Whiteford, of Darlington, Md., has Written me very warmly praising from his own experience the use of fluid extract of poke-root, Phytolacca 1 American Journal of Obstetrics, 1881. 2 Ibid., 1885. INFECTIOUS DISEASES—MASTITIS--TETANUS. 593 decandra, both internally and externally, in the treatment of mastitis, confirming the strongest commendations of others. He gives twenty drops every three or four hours, and at the same time has it applied to the breast: it is rarely neces- sary to continue the treatment longer than twenty-four hours. Garrigues1 attaches great importance to milk-stasis in the etiology of the dis- ease and to uniform compression in its prophylaxis. This compression may be accomplished, as at first advised by him, by means of a broad strip of muslin passing from the back in front, where its ends are fastened, so that the chest is firmly and completely encircled ; shoulder straps are fastened to the bandage to prevent its slipping down. This bandage, as improved by Miss Murphy, the doctor states, is used in all cases in the Maternity Hospital, " from the time the breasts begin to fill until the patients are removed to the convalescent ward—that is, from the third or fourth day to the ninth." Sore nipples are treated by the application of tannic acid, the breasts are emptied by the baby or by the fingers of the nurse. The doctor states that " this treatment is so effective that we have no mammary abscesses at all." 1 American System of Obstetrics, vol. ii. 38 CHAPTER IV. THE PATHOLOGY OF THE PUERPERAL S'J.ATE {continued)— PUERPERAL FEVER. Puerperal fever is an acute disease occurring in childbed, in quite exceptional cases manifested in labor, produced by the entrance of a poison through a wound of the genitals ; the disease is contagious, and the creation of the poison in the person affected is impossible without the action of external agents—in other words, the disease is heterogenetic. The term puerperal fever dates from the beginning of the last century, and in recent years has met not a little criticism j1 but if we do not understand by the name that a specific fever is designated, the chief objections to its use fall, and the difficulty in finding a suitable substitute is an argument for retaining the term. Foremost among essentialists, at least in this country, must be placed Dr. Fordyce Barker, who has claimed—and it is to be supposed still claims, for no recantation of this faith has been published—that there is a fever peculiar to puerperal women, and, therefore, appropriately named puerperal fever, that the symptoms of this disease are essential, and not the consequence of any local lesions, and it is as much a distinct disease as typhus, typhoid, or relapsing fever, This faith once commonly admitted finds few adherents to-day, or at least they restrict essential puerperal fever within such narrow limits, that the faith becomes a rapidly vanishing quantity. Grandin remarks : " The future, we think, will testify to the truth of Barker's views in very exceptional instances ; that is to say, while septicaemia will be the disease in nine hundred and ninety-nine cases, in the thousandth the disease will be of zymotic origin." When an empire is con- tent with one-thousandth part of what was once its domain, it may be safely left to the harmless dream of possession and power. The difficulty in finding a better term than puerperal fever must be obvious. If substitute for fever septicaemia, we attribute the manifestations of disease to a blood-poisoning, whereas in many forms the blood may be poison-free, the in- fection having found its way into the organism through the lymphatics,'1 and possibly localized in some part of their course. If we put infection in place of septicaemia we give the former a double meaning, for, as has been previously stated, there are other infectious diseases in the puerperal state, and two of these have been considered, mammitis and tetanus; Hansen3 has recently shown a con- nection between psychic disorders and septic infection—42 out of 49 cases of puerperal mental disorder being attributed to infection—and we cannot restrict it to those forms of disease which are generally recognized as included under the 1 Pajot has said that the designation puerperal fever should be consigned to the museum of the antiques. Hervieux declares that there is no puerperal fever in the sense ordinarily attached to the word. " The admission of this seductive and convenient hypothesis is chao?, it is return to the infancy of the art, it is the negation of all diagnostic science, the obstacle to all progress in therapeutics in puerperal maladies." 2 Spiegelberg used the term lymphatic septicaemia, but the words are plainly contradictory. 3 Hansen makes this statement, Zeits. f. Geburt., und Gynakol., 1888: " With scarcely an exaggeration, if in the first puerperal week a psychosis appears as acute confusional insanity, with hallucinations, without any other acute infectious disease and without preceding eclampsia, puerperal infection is present, though there is no fever, or other physical symptom discover- able." PATHOLOGY OF THE PUERPERAL STATE. 595 term puerperal fever; therefore it seems necessary to retain this term, though admitting it is not certainly free from objections. On the other hand, as Cullingworth remarks in his timely address,1 the term puerperal fever has certain unmistakable advantages. " Everyone knows what is meant by it; it is comprehensive, and it involves no theory as to the nature of the disease." It would seem unnecessary at this day to state that puerperal fever is contagious. Nevertheless the truth is so important there is no danger of emphasizing it too strongly. Many a practitioner can remember when leading obstetric teachers in one of our great cities taught the opposite of this truth ; and every one who was instructed by these able teachers was fortunate if he did not wait to learn at the death-bed of a puerpera who had put her supreme trust in him, and perished from his ignorance, the utter falsity of the teaching. Dr. Oliver Wendell Holmes, in a paper entitled " Puerperal Fever as a Private Pestilence," published in 1843, and republished in 1855, probably did more than any other American physician to correct this erroneous teaching and to convince the American profession of the contagiousness of childbed fever.2 Many an American mother owes her life to the striking array of facts he so clearly presented in sustaining his thesis; the number saved would have been still greater if his essay had been presented to every medical graduate before engaging in practice. Among the rules Dr. Holmes suggested were the following : "I. A physician holding himself in readiness to attend cases of midwifery should never take any active part in the post-mortem examination of cases of puerperal fever. "2 If a physician is present at such autopsies, he should use thorough ablution, change every article of dress, and allow twenty-four hours or more to elapse before attending to any case of midwifery. It may be well to extend the same caution to cases of simple peritonitis. " 3. Similar precautions should be taken after the autopsy or surgical treatment of cases of erysipelas, if the physician is obliged to unite such offices with his obstetrical duties, which is in the highest degree inexpedient." But it is not alone from autopsies of women who died from puerperal fever or peritonitis, nor from the living who are suffering from the former disease or with erysipelas the contagion may be carried to the puerpera. In 1847 Semmelweis,3 1 A Plea for the more General Adoption of Antiseptics in Midwifery Practice. London, 1888. 2 In Dr. Holmes's essay when republished some additions were made, and in these, refer- ring to the criticisms made by a Philadelphia teacher of obstetrics, he thus speaks: " One unpalatable expression, I suppose the laws of construction oblige me to appropriate to myself as my reward for a certain amount of labor bestowed on the investigation of a very important question of evidence, and a statement of my own practical conclusions. I take no offence and attempt no retort. No man makes a quarrel with me over the counterpane that covers a mother with her newborn infant at her breast. There is no epithet in the vocabulary of slight and sarcasm that can reach my personal sensibilities in such a controversy. Only just so far as a disrespectful phrase may turn the student aside from the examination of the evidence, by discrediting or dishonoring the witness, does it call for any word of notice." 3 In a biographical sketch of Semmelweis by Dr. Herdegen, American Journal of Obstetrics, 1885, tne following incident is related : "A martyr to the new doctrine was found in Michaelis, the professor of obstetrics at the University of Kiel, and one of the first obstetricians of all time, whose work on the ' Contracted Pelvis' is now considered classical, all our modern views on the mechanism of labor being founded upon it. A near relation of his, whom he had attended in labor, died of puerperal fever. Convinced of the correctness of Sammelweis's idea, and cer- tain that it was he who brought her death instead of help, being at the time much occupied with autopsies on patients dead of puerperal fever, he laid himself on the railway track and was ciushed by the train. 596 SCIENCE AND ART OF OBSTETRICS. a native of Hungary, and assistant physician at one of the Vienna maternities, having charge of two cliniques, one devoted to the instruction of midwives, and the other to that of medical students, was struck with the great prevalence of puerperal fever in the latter, and its comparative absence in the former, and attributed it to the fact that the medical students were engaged in dissections and in post-mortem examinations and thence conveyed the poison from which the disease developed to women in labor or recently delivered. He required these students to use thorough disinfection before entering the obstetric wards, and the mortality of puerperal women, hitherto fifteen per cent., became less even than in those devoted to the instruction of midwives. He, too, thus became a saviour of women, and his name deserves to be held in perpetual honor by the medical profession. Another important fact in the etiology of puerperal fever was observed by the Vienna obstetrician. A pregnant woman suffering from advanced uterine cancer was in the ward. The precaution which had been for some time used, washing the hands in a solution of chloride of lime before making a digital examination, was neglected. The labor was prolonged for several days. As the case was very grave and rare, the students were eager to examine. Fourteen women who were delivered in the interval, and who consequently had been "touched" by the pupils, had puerperal fever and died. With the exception of these unfortunate women there were no others sick. Siredey mentions seeing two women die from septicaemia who were delivered in the house of a sage-femme who had living with her her mother, suffering from uterine cancer; the midwife gave her mother vaginal injections, and the other attentions her state required, at the same time continuing her obstetric work. The instances are many in which hospital surgeons or physicians in general practice, going from patients with suppurating wounds to women in confinement, have carried fatal infection. Charpentier mentions the following case, in which the poison was communi- cated several days after labor: The wife of a physician, the seventeenth day after labor, was convalescing, when her husband, who had just returned from visiting a patient with diffuse phlegmon of the thigh, had the unfortunate thought of examining her to learn whether the uterus had returned to its normal state. The following day she had a violent chill, followed by all the phenomena characteristic of a purulent affection, and died the thirty-third day after labor. Local disease of the practitioner has, in some instances, been the source of the poison. Siredey relates the history of a physician who, in consequence of a sup- purating adenoma of his neck, had introduced a rubber tube as a seton ; previous to this he had attended eight hundred cases of labor without an accident, and now three women whom he delivered within three weeks were attacked with puerperal fever. He continued obstetric practice until the suppuration ceased. But the most striking illustration was given by a Philadelphia physician several years ago, Dr. David Rutter. He had nearly seventy cases of puerperal fever occurring within less than twelve months, while no instance of the disease was observed in the patients of any other accoucheur practising in the same district. Harris1 states that Dr. Rutter had ozaena, which in time much disfigured him from its effect upon the contour of his nose. He was unfortunately inoculated upon his index finger from a patient, and neglected the pustule. He had ninety- five cases of puerperal septicaemia in four years and nine months, with eighteen deaths. Siredey, in referring to the etiology of the puerperal fever which so fre- quently occurred in this physician's practice that he was indeed "a walking pes- tilence," says that the explanation suggested by Harris was true, for Heiberg has discovered septic bacteria in the muco-pus of an analogous case. In lying-in hospitals the contagion may be communicated by using the sponges, basins, syringes, bed-clothing, beds, etc., that have been employed in infectious cases. It is commonly believed that the poison may come from defective drains and from decom- posing animal excreta; many cases have been adduced to show 1 Note to Playfair. PATHOLOGY OF THE PUERPERAL STATE. 597 that sewer gas is a cause of septic infection of the puerpera, among them being those1 of Underhill. Schroder has stated that the fluids, even non-purulent or ichorous, from phlegmon or erysipelas, diphtheria, and scarlatina, from parts of dead bodies, especially in case of death from septic disease, sanies from cancer, and putrefying products of abortion, experience has taught to be especially feared. Kucher, in his valuable work,2 states that: " Some authors, among others Atthill, assert that the poisons of some zymotic diseases, as scarlatina, typhus, typhoid fevers, etc., become so changed by the conditions of the puerperal state as to produce puerperal fever. This assertion has often been made, but it is not supported by any convincing observations. Neither have any cases of scarlatina, typhus, or typhoid fever produced by puerperal fever been observed."3 The second proposition contained in the definition which needs exposition, is that the disease is heterogenetic. Some authorities have not been satisfied with one puerperal fever, but insist upon several, each having a different etiology. In most cases, for exam- ple, nine out of ten, of the disease, careful examination soon traces it to an external cause, so that all will admit it to be heterogenetic. But again other cases occur for which no external cause is discov- ered, and, therefore, the hypothesis of self-infection or autogenesis is proposed. We do not thus reason as to other contagious dis- eases when we are unable, as we often are, to discover the source of the contagion. For example, in many cases of scarlet fever we cannot tell whence the disease came, but we never say it was gen- erated in the patient. The doctrine of autogenesis is a confession of ignorance, the creed of fatalism, the cry of despair. It is more ra- tional when we meet with cases of puerperal septicaemia whose ori- gin we do not know, but which have the same history as others the source of which we can trace to an external cause, and which have the same evolution and the same infecting power, to conclude that they too come from like sources, though the connecting thread is so fine that it eludes our vision, than to erect an altar to the un- known god of autogenesis, and imagine that we have explained the mystery. Self-infection means that the house sets itself on fire, and that the powder magazine is exploded without any mischievous spark. What security can the practitioner give his patient when the foe which brings swift death is created within her, and when she kills herself? This doctrine of the autogenesis of puerperal septi- caemia is, to my mind, the very pessimism of obstetric medicine. Why should the city guard its gates when the enemy can already be in the citadel and begin the battle there ? Two4 of the most re- cent authorities upon puerperal diseases have very positively given their opinion in regard to the question of autogenesis and hetero- genesis. Siredey says, " I do not believe in gravidic auto-infection, 1 Transactions of the Edinburgh Obstetrical Society, vol. xiii. 2 Puerperal Convalescence. 3 Kucher, op. cit. * More recently Auvard bears like testimony: "Puerperal septicaemia is undoubtedly a microbian malady, a hetero-intoxication, thus absolutely and essentially opposite to eclampsia, due to chemical agents produced by the organism and of which the insufficient elimination causes an auto-intoxication." 598 SCIENCE AND ART OF OBSTETRICS. and my opinion is that septic puerperal maladies are due to hetero- infection." Fritsch is still more positive : " To admit the existence of a spontaneous infection is to take a long step backward." Winckel regards self-infection as, according to his experience, quite exceptional, "but, like the belief in miasm, it relieves the con- science, and therefore will always retain a considerable number of adherents." The doctrine of many puerperal fevers has no abler supporter than Dr. Robert Barnes,1 and therefore his views are presented : "The puerperal fevers may be classified under the two great divisions of autogenetic and heterogenetic. a. The autogenetic fevers are: 1. The simple excretory puerperal fever, the result of endosepsis, or the arrest of the excretion of waste stuff of involution : it is especially prone to arise in damp cold weather. This form complicates all other fevers, even the septicaemic form. 2. The fever resulting from the absorption of foul stuff from the parturient canal, either from the unbroken mucous surface, or by the open mouths of vessels, or from trau- matic surfaces; this is autoseptic. This form is also likely to complicate other fevers. 3. This, the proper septicaemic puerperal fever, is revealed under the forms of metritis, peritonitis, pelvic cellulitis, thrombosis and general toxaemia. b. The heterogenetic fevers are due to a poison from without. These may be divided into (1) the cadaveric poison which wrought such havoc before the days of Semmelweis, the septic stuff from other puerperae, animal poisons of obscure origin ; and (2) the known zymotic poisons, as smallpox, scarlatina, typhoid, diphtheria, erysipelas." Here are at least five different forms of puerperal fever! How are they to be distinguished from each other ? The difficulty is increased by the fact that Dr. Barnes states, ''number 1'' complicates all other fevers, and again, that " number 2 " is likely to complicate other fevers. How indeed at the bedside know whether the disease is autogenetic, or heterogenetic ? Such divisions must seem to most arbitrary, and show analysis pushed to an extreme. They, in my opinion, lead to darkness and confusion rather than to light and order. In general it may be stated that the progress of knowledge tends to diminish rather than to increase the number of causes. Hence there is an argument of probability against the views that have been presented. It will be admitted that the lessened morbidity and mortality of puerperae during the last few years are due to the fact that antiseptics are so generally used in obstetric practice. But how could these have any effect in preventing fever caused by failure of excretion ? If there be any " foul stuff" to be absorbed by the parturient canal, that stuff has become foul because germs of decomposition have found access to it. Germicidal solutions used at the right time would probably have prevented the accident, and now furnish the best hope of curing its consequences. Dr. Barnes, in the same article from which I have quoted, speaks in no gentle terms of my belief in the exclusively autogenetic character of puerperal fever, as avowed in the first edition of this work, and the same avowal is now repeated; but I am quite willing to have our declarations of faith placed side by side, and leave the decision to an intelligent profession. Kehrer,2 who speaks of external, internal, and mixed infection—illustrating the latter by supposing that the obstetrician introduces an aseptic finger into the vagina containing infectious matter, and carries some of this into the aseptic uterus, also finds fault with my statement, asserting that while it is just and reasonable to criticise carefully all cases of self-infection so that assistants and pupils may not be careless, but be ever alert and watchful, it will not do to deny the possibility of such infection. In completing the picture of the fortress I have given, he observes that "hundreds of fortresses have fallen because the enemy crept in or traitors were in the camp. A faithful commander is he who not only keeps a watchful eye upon the besiegers, but also upon the besieged. Had we no enemies, no pathogenic microorganisms in the genital tract, the word self-infection might be 1 British Medical Journal, March 16, 1889. 2 Muller's Handbuch der Geburtshulfe. PATHOLOGY OF THE PUERPERAL STATE. 599 dropped, but as long as we are not safe from this internal enemy, it must be retained." It may be stated that those who believe in autogenesis, regard it as acting only exceptionally, the rule being that the disease under consideration is heterogenetic in origin. Further, faith in it is lessening. Thus Leopold has recently published1 the result following the delivery of 427 women without vaginal examinations having been made, or injections used; 98.7 per cent, recovered without any rise of temperature : hence he is led to doubt auto-infection. Auto-infection and spontaneous generation seem to me alike unproved and improbable hypotheses. The second of the following conclusions of Ernst's valuable contribution to the American System of Obstetrics, may be accepted as expressing the present con- clusion of scientific study of this question, while the other conclusions are also very important in the study of puerperal fever: 1. Puerperal fever is not a spe- cific process, but only one form, from a clinical point of view, of an infectious wound-disease. 2. These infectious wound-diseases are never endogenous, but always exogenous in origin. 3. They are produced in all cases by the action of living ferments, but this action may be either direct, destruction of tissue or mechanical obstruction, or indirect, by the production of leucomaines, with the resulting toxic effects of these animal alkaloids produced during life.. The microbes which are regarded as the efficient agents of puerperal infection are, in the pyaemic form, pus-cocci, streptococci and staphy- lococci, which enter through the genital wounds. In the septi- caemic form Kehrer states that the disease is most probably caused by germs similar to those found by Gaffky in the septicaemia of mice, or perhaps the short bacilli cultivated by Frsinkel from the splenic pulp and venous pus of puerperal septicaemia. The sapraemic form he attributes to the entrance into the blood of the product of the action of microorganisms, stating that the recent investigations of Kossorotow of germs of putrefaction show that these germs cause no manifestations of disease, but that such manifestations result from the products of the synthetical activity of the microbes by poisons soluble in water and in alcohol. These poisons break up into pyro- genic matters, and by the exclusion of air into ptomaines. Winckel states that the streptococcus pyogenes must be regarded "as the specific wound-infection germ in the majority of cases of puerperal fever." The staphylococcus pyogenes aureus has been found in the lochia of the puerpera having slight fever. The staphy- lococcus pyogenes albus is rarer and probably less pathogenic. Winckel further states that there are surely many pathogenic cocci in the sexual organs of the female still undiscovered, just as we do not have full knowledge of the different forms of putrefaction bacteria. Believing that without microorganisms infection is impossible, it must be admitted that there are other causes concerned. The subject herself is by the fact of childbirth placed in a condition of receptivity. Then the traumatisms of labor open places of entrance in the genital tracts for germs or germ-produced poison. There are individual differences, too, by which one is more liable than another to receive, or to resist after reception of the toxic agent. Hence differences in the occurrence, and, in part, of the manifestations of 1 Arch. f. Gynakol., 1889. 6oo SCIENCE AND ART OF OBSTETRICS. disease. Statistics show that primiparae, especially if old, are more liable to septic infection than multiparae, and the liability is slightly greater after the birth of male than of female children ; here we have the influence of protracted labor, depressing the patient, labor in which more frequent examinations are made, and possibly termi- nated artificially, and the traumatisms greater in character and number. These, it is obvious, are conditions favorable for infection. Hirsch shows1 very clearly, as generally known by the profession, the greater prevalence of the disease in cold than in warm weather; but he also states that the influence of cold is indirect, that it is reasonable to suppose that it is the change in the hygienic condi- tions of the lying-in hospitals brought about by the cold season which furnishes the real grounds for the rise of the sick-rate and the death-rate. But it may be claimed that the disease had its origin in retained clots, fragments of membranes or of placenta. If these could be kept aseptic, the disease would fail. They produce infection indi- rectly by furnishing material upon which germs act, and these germs thus given opportunity and nutriment, indefinite multiplication fol- lows, so that they by their entrance into the organism, or by the absorption of poisons which they produce, cause infection. It is not necessary to maintain differences in puerperal poisons to explain different manifestations of disease in those infected. That such variety of manifestation may occur from a common cause must be admitted. For example, a woman in a lying-in ward has a re- tained placenta, and fruitless and frequent efforts are made to remove it completely. She has puerperal fever, and three others also, no two cases being precisely alike. Yet they had a common origin —one fountain, but many streams. Scarlatina is caused by a known poison, yet the cases of the disease even in the same family may be very different—one child dangerously ill, possibly dying, while another is only slightly indisposed. And observation of the course of other infectious or contagious diseases would furnish similar illustrations. No theory of puerperal fever is satisfactory that does not recognize the personal element in the manifestation of the disease. But, further, it may be that the same germs, independently of differences of nutritive material, may differ in vital power, in rapidity of develop- ment and multiplication. This may in part, and in addition to the different condition of the recipients account for the different mani- festations of infection. Independently of all culture experiments and inoculations, and microscopic examination of uterine and vaginal discharges of sick women in childbed, and of fluids or solids of women dying of puerperal septicaemia, there are some reasons which make it very probable the infectious agent is living, a contagium animatum, rather than any chemical substance. These are the very minute2 quantity 1 Handbook of Geographical and Historical Pathology. 2 A lethal quantity of morphine, for example, cannot multiply itself so that from the one victim perishing from it the toxic effect goes on until countless others die. Nevertheless, it is PATHOLOGY OF THE PUERPERAL STATE. 6oi which infects, the rapidity of its action, and finally the protective power of germicidal solutions. It is only upon the hypothesis of a living poison with the great rapidity of production which low forms of life have, that we can readily explain the fact of dangerous illness being so soon developed. And again, if we cure by using injections of corrosive sublimate or of carbolic acid in solution, or other anti- septic, it seems more rational to conclude that the agent has de- stroyed living rather than rendered dead matter harmless. Moreover, the demonstrated dependence of many other diseases upon germs makes it probable that this also has a similar cause. General Considerations.—Puerperal fever is coeval with the race and co-extensive with the globe. Hippocrates has left on record excellent descriptions of cases of the disease, and it has been ob- served in all lands from Iceland to India: wherever and whenever women bring forth offspring it may be manifested. While it has been a disease of lying-in hospitals especially and of dense populations, it has also appeared in private practice and in thinly settled parts of the country. In recent years the general and faithful use of antiseptics has reversed the relative frequency of the disease in hospital and in private practice. The liability to infection belongs to every puerpera, but the fact of the infection is inde- pendent of her. The disease presents many forms. It may be mild or malignant, and in the latter case slow or swift in causing death. The first manifestations may be, though the first is quite exceptional, during labor, the following day, or not until a week or more after. One patient may have multiple chills, another only one, and in still another this cry of alarm fail, or be so slight as to be unnoticed unless special attention be directed to it. In some cases there is severe suffering, while in others it is trifling. The local manifesta- tions may be very limited in one patient, but in another " the fount of all the blood is touched corruptedly," and scarce a function or an organ—spleen, liver, kidney, heart, lung, brain, or other part of the organism—that may not be affected. The benign form of the disease usually does not begin before the third day, and generally a chill, not invariably, announces its advent; as a rule, if a chill occurs it is not repeated. Pain, diminished or suspended lacteal secretion, offensive lochia, and arrested uterine in- volution are characteristic of at least the severer cases of the benign form of puerperal fever, which usually is essentially a localized lymphangitis. In the grave form the initial chill is often earlier, is more con- stant, and is severer. The disease is rapid in its evolution, severe symptoms appear soon; it may present an inflammatory form throughout, or a typhoid condition soon follow it. But instead of having an abrupt and early beginning, puerperal fever of malig- nant character may not appear until five or six days, a week, or admitted that in some varieties of infectious disease the intoxication may result, not directly from the entrance of germs, but from the absorption of the products of their vital activity, be that poison called sepsin or ptomaine. 602 SCIENCE AND ART OF OBSTETRICS. more after delivery. Chill and fever come, but after a few hours the temperature declines, it may be, to the normal, with a copious perspiration ; there is no very great suffering ; the lochia may not be offensive ; nausea and vomiting do not occur; the abdomen is neither swelled nor peculiarly sensitive to pressure; and uterine in- volution may not be materially retarded. We comfort ourselves, possibly, at first with the false notion that it is simply a case of malarial disease, and that return of the chill will be set aside by quinine, but after a few hours, a day or two, the false hope is rudely destroyed by the recurrence of the paroxysms ; the recurrences con- tinue irregular in time and in intensity, and we are brought face to face with that form of puerperal fever which is known as infectious phlebitis, and of which there is great danger of a fatal issue. Special Forms.— Vulvo-vaginitis. Inflammation of the vulva is not uncommon after a protracted labor. Though the labia may be swelled, yet the parts that have undergone the greatest injury are situated at the lower portion of the vulva and at the corresponding part of the vaginal entrance. Parts that have been subj'ected to severe pressure about the third or fourth day present what are known as puerperal ulcers; these ulcers have raised margins, and are covered with a diphtheroid yellowish-gray membrane. Spiegelberg stated that the membrane, though commonly called diphtheritic, has nothing whatever to do with true diphtheria (Birch-Hirschfeld); it consists of fibrin and granular detritus, which has resulted from the disintegration of the superficial layer of the injured tissues and of pus-corpuscles; it is an accompani- ment of the regenerating process which is connected with the suppuration. Siredey and Winckel also deny that the membrane is diphtheritic. The parts adjacent are usually swelled, and may present an ery- sipelatous appearance. It is rare that puerperal ulcers of the vulva are found without the vagina at its lower portion, at least, being in- volved. The fever resulting from this inflammation is rarely pre- ceded by a chill, and unless deep or extensive injuries have been sustained, usually is not high nor protracted. Through communi- cating lymphatics there may be involvement of the inguinal glands. The treatment is chiefly, if not exclusively, local. The affected parts are frequently cleansed with a solution of carbolic acid, 2 to 3 per cent, or with a I to 2 per cent, mixture of creolin, and, after the washing, done 3 or 4 times a day, covered with iodoform. If the coating of the ulcers remains adherent it is generally recom- mended to apply the muriated tincture of iron once a day. A vaginitis, endocolpitis, will, in most instances, require no other treatment than a thorough washing out twice a day with creolin mixture or carbolic acid solution twice a day, each washing to be followed by the introduction of an iodoform suppository. In all cases of vulvar and vaginal inflammation an antiseptic pad is a safe- guard against new infection from without. Endometritis.—Changed character of the lochia, especially their having a very offensive odor, and fever characterize inflammation of the endometrium; it must, however, be remembered that these symptoms often are present, and the disease not limited to the in- PATHOLOGY OF THE PUERPERAL STATE. 603 terior of the uterus. The great essential of the treatment is thor- ough cleansing of the uterus by antiseptic injections, aided in some cases by the curette or curette forceps, but this treatment will be described hereafter. Uterine Lymphangitis.—This is the most frequent condition caus- ing mild puerperal fever. In the majority of cases it begins with a chill the second or third day, followed by increased temperature, the mercury marking possibly only 1010 or 1020. There is pain felt at one or both sides of the uterus, or if this be not spontaneous it may be caused by direct pressure at these points; the uterus is larger than it should be, and if movements are given to it by the fingers in the vagina pain is produced ; no tumor can be felt either by abdominal or by vaginal examination ; some nausea may be pres- ent, but there is not the vomiting that is such a prominent symp- tom in peritoneal inflammation ; instead of diarrhoea there is con- stipation, and the pulse is full and only moderately increased in frequency. After a few days the symptoms usually subside, and the patient begins to convalesce. But should she now get up, or even without this exciting cause, a relapse may occur, and possibly there will be developed peritoneal inflammation, or inflammation involv- ing the broad ligament or the iliac fossa. "In every lying-in woman who has fever lasting two or three days, accompanied by pain upon pressure on the sides and at the cornua of the uterus, uterine lymphangitis ought to be suspected, and absolute repose should be insisted upon until no pain is caused by palpation of the abdomen, and retraction of the uterus to its normal volume has occurred." Peritonitis.—Two forms of this disorder are to be described: first, that in which the inflammation is limited to the pelvic peritoneum ; and, second, that in which it is general. Pelvi-peritoneal inflammation may begin at the same time with uterine lymphangitis, or it may follow it; in the latter case there is often a second chill, indicating this extension of the disease. But whether with or without a chill, the most prominent symptom in the beginning of the affection is acute pain—the sharp, knife-like pain by which inflammation of serous membranes so generally reveals itself. This pain is spontaneous, compelling the patient not only to keep her body immobile, but also to avoid coughing or a deep inspiration, and there is great tenderness upon pressure at one or at each side of the uterus; the lower portion of the abdomen is swelled, and frequently there are nausea and vomiting. The tem- perature usually is from 1020 to 1040, but may be higher ; and the pulse is from 100 to 120. Upon digital examination after the in- flammation has been in progress a few days, a sensitive tumor closely attached to the uterus will be felt; it generally is more prominent in the posterior cul-de-sac, and extends on each side of the cervix like a crescent; or it may be situated on one or the other side of the uterus. In some cases it is as large as the fist, and then, if lateral, it can be recognized not only by vaginal touch, but also by abdominal palpation. Another characteristic of this inflam- 604 SCIENCE AND ART OF OBSTETRICS. matory tumor, so well described by Bernutz, is that it causes more or less displacement of the uterus; still further, if the tumor is situ- ated posteriorly to the uterus, it causes the disappearance of the corresponding vaginal cul-de-sac, the surface there presenting a convexity instead of a concavity; but if it be at one side of the uterus the corresponding cul-de-sac is broader and shallower, while that of the opposite side retains its normal depth, but is narrower. Displacements of the uterus and deformities of the upper portion of the vagina are marked features of pelvi-peritoneal inflammation. The tumor of pelvi-peritonitis is at first not distinct and hard, but soon acquires these characteristics. It interferes with the normal mobility of the uterus, and is sensitive to touch ; this sensibility is most marked at first, then gradually diminishing. The pain disap- pears in two or three weeks, and in the great majority of cases the tumor undergoes resolution. If suppuration occurs the inflamma- tion, with associated symptoms, does not abate, but, especially after the formation of matter, fever, chills, pain, and frequency of the pulse continue ; the purulent collection may open into the bladder, the vagina, or the rectum, or a general peritonitis may occur. Sire- dey regards this form of peritonitis—that is, when suppuration occurs—as, in favorable cases, lasting from four to six weeks, while in many others it lasts for months. General peritonitis, as a rule, begins soon after labor; it may be only a few hours intervening, but oftener twenty-four or forty-eight. In some cases it is the consequence of pelvi-peritonitis, and then the disease is not manifested until several days later. It generally begins with a chill, more or less violent, which is followed by fever, fre- quent pulse, the latter often being 120 or more. The pain is that so characteristic of peritoneal inflammation, and need not again be described. The lochial discharge in a great majority of cases is very offensive; and so are the evacuations from the bowels, if, as frequently happens, diarrhoea occurs. The patient lies in one posi- tion, her breathing frequent and shallow, in consequence of the great abdominal tenderness and distention; the latter may be so great, encroaching so much upon the thoracic capacity, that the patient dies of asphyxia. Another reason for the difficult respiration is found in the associated pleuritis, which not uncommonly occurs, very frequently insidious in its onset, and its symptoms masked by the violent peritoneal inflammation. Headache, mental disturbance, and sleeplessness are not uncommon. The disease is generally fatal, death occurring in the worst cases within the first two days, but usually not before the fourth or fifth day. Adeno-phlegmon.—ln this variety of lymphangitis the inflam- mation involves the lymphatic ganglia and the surrounding con- nective tissue. In almost all cases a chill is observed, and this is followed by fever and pain—a pain much less severe than that occurring when the peritoneum is inflamed. There is tenderness upon pressure at the painful part, which is situated upon one or the other side of the uterus, in some part of the course of the broad ligament, or in the vicinity of its pelvic attachment. The lochial PATHOLOGY OF THE PUERPERAL STATE. 605 discharge in most cases is offensive. The next manifestation of the disease is the appearance of a tumor at the seat of pain. This tumor may become so large as to fill the iliac fossa, if the lymphan- gitis occurs here; or, if the lymphatics of the broad ligament are affected, it will not only be manifested to abdominal but also to vaginal touch. Many authors have described this affection under the names of parametritis, pelvic cellulitis, or inflammation of the pelvic connective tissue. Some claim that the disease is found more frequently upon the left than upon the right side, regarding tears of the cervix to be one of its most frequent causes : these injuries occurring oftener and usually being greater upon the left than upon the right, therefore the inflammation is oftener upon the side corresponding. The prognosis is generally favorable in this form of the disease, as it is in all others in which the infection is localized. The tumor resulting from adeno-phlegmon of the broad ligament, or of the iliac fossa, may disappear by resolution or by suppuration. If suppuration occur, the pus may find its way directly to the ex- terior through the skin, but in other instances the abscess opens into the rectum, into the bladder, or into the vagina. Phlebitis.—There are two varieties of phlebitis—adhesive and infectious. A. Adhesive Phlebitis.—This form of the disease, or phlegmasia alba dolens, usually occurs from the fourth to the twelfth day after delivery, but there may be an interval of two or three, or even five or six weeks.1 " Considered successively as a milk-metastasis, a rheumatic affection, a neuritis, an inflammation," various theories have been advanced to explain this affection of women in childbed. The chief characteristics are pain and swelling of one of the lower limbs, this swelling being of a white color. One of the oldest theories in regard to the disease is that which attributed it to a de- posit of milk in the affected member, and which is perpetuated in the once professional but now only popular designation of milk-leg. The theory of inflammation of the connective tissue, and then that which made it depend upon inflammation of the veins, probably were next in order. The last was advocated by Davis in 1817, and is now generally accepted. Inflammation of the lymphatics has been maintained by some as the cause. By still others it is claimed that spontaneous coagulation of the blood occurs in the affected vessels: the hyperinotic condition of the blood is an admitted fact, and then there is assumed an inopexia, which is the final agent in producing a physiological thrombosis, and the lesions of the walls of the vessel are consecutive to its spontaneous obstruction. As has been already stated, it is now generally held that phlegmasia alba dolens of child- bed is caused by phlebitis—that phlebitis being an extension of the disease from the vessels of the uterus. Symptoms.—Pain and swelling are the most striking characteristics 1 Greslon has recently reported, Nouv. Arch. d'Obstetrique et de Gynecologie, a case of phlegmasia alba dolens coming on the twenty-seventh day after delivery. I met with a case primarily of infectious phlebitis in which this adhesive phlebitis did not appear until four weeks after labor: the patient recovered after a very long illness. 606 SCIENCE AND ART OF OBSTETRICS. of the affection. Pain precedes the swelling, and in many cases is felt for some hours in the lower part of the abdomen at the pelvic inlet; possibly a chill occurs before the pain. With or without the pelvic pain first occurring, pain is felt below Poupart's ligament, and soon extends down the thigh to the leg. The swelling follows, and may begin in the gluteal region, or upon the upper anterior face of the thigh, thence extending to the leg and foot; the rapidity of the extension is so great that in some cases the entire limb is involved within a few hours. The swelling is so uniform that the limb has a cylindrical shape, or resembles a truncated cone, the base of which is at the upper end of the thigh; it is so great that sometimes the limb seems double its natural size. In most cases it is limited to the member, but in some it involves the hypogastric region. The skin is white, tense, and shining. By palpation, which ought to be done very gently, the obstructed veins are felt as solid, irregular cords. The limb is sensitive to pressure where the inflamed vessels are felt, but after the first day or two no severe spontaneous pain, but chiefly discomfort, is experienced; the member becomes inert, useless, the patient being unable to move it. In almost all cases premonitory symptoms occur ; in some the disease may appear in the course of a more or less severe attack of septicaemia, while in others there have been occasional manifesta- tions of fever and abdominal pain, a sort of masked infection, and a threatening of more serious danger, or, at least, some deviation from normal convalescence. The occurrence of the disease without some prior evidence of a pathological condition of the uterus, or in its vicinity, is quite exceptional. Progress and Termination.—Fever with some pain continues for about two weeks, and then in the great majority of cases the swell- ing begins to subside, the subsidence taking place very much more slowly than the accession. In rare instances the other limb is affected. Resolution is the usual termination, but the limb is a long time in recovering its lost power and natural feeling, being, as has been said, like a wooden leg; even for months the foot and leg swell after exercise or standing. In some instances a permanent oedema is the result. Among the perils of the patient are breaking down of the clot with consequent general infection, or detachment of a portion of it with pulmonary embolism, and sudden or rapid death follows. Crural Phlegmon}—This is a rarer affection in the puerpera than the preceding. It is a phlegmon of the thigh with primary disease of the skin or the subcutaneous and intermuscular cellular tissue; for instance, in the course of parametritis, in which the vessel walls may take part, when at times even secondary thrombi form in them, but in which they are not always implicated. The treatment advised by Winckel is early, free, long and deep incisions through the diseased integument in order to relieve the swelling, and evacuate, as soon as possible, the pus which has been formed. The wounds are then irrigated with a solution of carbolic acid, drained, and treated with iodoform powder. 1 Winckel. PATHOLOGY OF THE PUERPERAL STATE. 607 B. Infectious phlebitis is characterized by an initial chill followed by high temperature; the pain is not great when pressure is made upon the abdomen, and may be absent; the abdominal tympanites is absent, and the lochial discharge is usually offensive. The tem- perature changes very rapidly, abruptly rising or falling; chills occur at irregular intervals, these being a few hours, a day,' or two or three days, and, as a rule, they are severer than those observed in lymphangitis; the fact that they are multiple instead of single, and their severity, will assist in making a diagnosis between the two affections. The great increase of temperature followed by a decline with more or less perspiration, and the recurrence of chills with new accessions of fever, led Osiander thus to speak of the dis- tinction between this form of puerperal septicaemia and intermittent fever: " This fever differs from the common cold or intermittent fever which attacks women in childbirth sometimes, or with which they oftentimes pass from preg- nancy into childbed—and which, according to the testimony of writers, Torti, for example, is always very dangerous, but which can generally be cured by the' use of the Peruvian bark—in this respect: at the time between the attacks a real abatement of the feverish pulse cannot be perceived, and the chill never occurs at a definite or regular time." While intermittence characterizes the disease in the beginning, after a time the fever becomes continuous. But the chief charac- teristic of infectious phlebitis is the general distribution of the poison through the economy so that there is not an organ or part which may not be involved; very frequently the lungs and pleurae are affected ; for example, out of seven fatal cases under my charge at the Philadelphia Hospital, two died of pneumonia, in a third pneumonia was a complication of other lesions, and in a fourth there was double pleurisy. Disease of the heart, and especially of the kidneys, of the liver, of the spleen, of the brain or of the men- inges, and less frequently of the organs of special sense, as the eye,1 may be among the consequences of infectious phlebitis. Further, it may manifest itself in infections of the joints, of the sheaths of tendons, of the connective tissue in various parts of the body, or of the muscles themselves, or of the bloodvessels, especially the veins. Siredey describes three forms of infectious phlebitis; the first is that which is most acute, forme foudroyante, rapidly fatal, killing as if by a thunderbolt; second, the typhoid form ; and third, the late or delayed form. The last may not occur until eight or fifteen days after labor; this is the least fatal, but the patient is many weeks in recovering, should recovery take place; in one case under my care the first manifestation of the disease was nine days after labor, and 1 " Inflammation of the eye is probably always the result of embolism, and it generally in. volves the entire globe, ending in its destruction. I have seen this accident in three patients, and in one both eyes were affected. Out of thirteen cases of panophthalmitis from embolism, published by Hosch, twelve died. According to Litten, retinal hemorrhages in septic fevers without endocarditis, occur partly as the only change in the eye, and partly in the course of severe purulent ophthalmia. He considers them as caused by embolism, and, in doubtful cases, thinks them of great diagnostic value." (Spiegelberg.) 6o8 SCIENCE AND ART OF OBSTETRICS. when it had been in progress about three weeks phlegmasia alba dolens appeared, which must be regarded, if manifested in the course of the disease, as auspicious, for it indicates a favorable con- dition of the blood, and thenceforth the probable limitation of the disease to the affected limb; more than three months elapsed from the beginning of the attack before the patient could be pronounced completely convalescent. It must be remembered that, while in most cases septic lymphan- gitis and phlebitis can be distinguished, in many others both forms of the infection are present, and thus a confused picture is presented, in one case, or at one time, the features of one or of the other affec- tion predominating. Further, in a disease which presents such protean forms as puer- peral septicaemia, it is impossible within the brief compass of a few pages even hastily to sketch them all, and to trace the various symptoms and lesions; nevertheless the recognition of the disease at the bedside is rarely difficult, and therefore it is unnecessary to consider its diagnosis under the head of a special topic. Prognosis.—The sooner the disease occurs after labor the more unfavorable the prognosis ; violent uncontrollable vomiting, very great abdominal distention, a notable quantity of albumin in the urine, severity of pain, especially if it should be followed by sudden cessation, are likewise to be held as unfavorable indications, and to these must be added great frequency of the pulse. The severity and the repetition of chills are causes of anxiety. Should pneu- monia occur, the result will probably be fatal. The temperature is less important in reference to the prognosis than the pulse; thus in one patient at the Philadelphia Hospital who died of pneumonia the seventh day, the temperature was only ioi° the day before death, while in another, whose death did not occur until the sixth week, the thermometer during the last ten days showed only once an elevation above ioo°, and most of the time it was little above 990, but at the same time the pulse was from 120 to 140, and once 144. After stating those symptoms which are unfavorable, or even which' may indicate certain death, it may in general be said that the opposite conditions give good ground for hope of recovery. But on the one hand, the practitioner should not be too confident even in apparently a slight lymphangitis, or in a limited pelvi- peritoneal inflammation that the patient is safe; most probably she is, but a great fire may be kindled by the smallest spark, and the trifling disorder may be but the forerunner of a rapidly mortal manifestation of septic infection. On the other hand, it is his duty not to lose hope even in apparently desperate cases, when the shadow of death seems to be resting upon the unhappy victim, for by the judicious use of therapeutic means he will in some, if not in many, cases have the supreme happiness of seeing recovery reward his efforts; more than once patients in the Philadelphia Hospital, whom others, as well as myself, thought must die, were saved. PATHOLOGY OF THE PUERPERAL STATE. 609 The Pathological Anatomy of Puerperal Infection.—Practically speaking, the infection occurs in one of two ways, either by direct absorption of infectious matter into the blood current through the uterine vessels at the time of labor, or through some focus in the pelvic organs in which bacteria multiply, and from which they spread through the lymphatics ; of these, the latter mode of infec- tion is much the more common. The first lesion, ordinarily per- ceptible, is that of lymphangitis of the vulva and vagina, which is accompanied in severe cases by puerperal ulcers ; these ulcers have the usual characteristics of superficial necrosis in tissues covered by mucous membranes ; they are covered with a yellowish-brown secre- tion, which is composed of the pus forming in the ulcers themselves, and also of the lochia, which pass over the ulcer if it be in the pos- terior wall of the birth canal. In diphtheritic infection of the puer- peral tract, ulcers are found which are covered by a grayish dirty yellow slough ; in exceptionally severe cases, extensive necrosis may occur, and ulcers of considerable size result; in such patients the slough separates in patches, and the denuded surface thus created is so great that extensive formation of connective-tissue results, forming a scar, the contraction of which produces stenosis of the birth canal. If the secretion of the puerperal ulcer be wiped away, its base will be found covered by granulations or by dark reddish tissue, which bleeds easily on contact. The site of puerperal ulcers is usually at that point commonly lacerated in all first labors, that is, at the posterior commissure. Occasionally a solitary ulcer is found upon a lacerated cervix, but usually in the vagina. In a recent case, in which a very severe infection occurred, the patient presented but one puerperal ulcer, and that was upon the cervix near its junction with the vagina. Lymphangitis of the external organs results in redness, swelling, and pain upon pressure in the labia and about the vulva. If laceration of the parts has occurred with considera- ble extravasation of blood, an haematocele in one of the labia may form and become, by subsequent iufection, an abscess. In cases in which infection does not occur, lacerations in the puer- peral tract glaze over in the first twenty-four hours after labor, have no secretion, and do not resemble the excavated and softened surfaces of true puerperal ulcers. Lymphangitis of the external organs, and of the vagina, spreads through the lymphatics to the glands of the groin situated externally, and bubo may result; proceeding internally, the infection attacks the endometrium, and especially the site of the placental attachment; the endometrium becomes darker in color than normal, and the decidua lining the recently emptied uterus is softened, swelled, and, upon microscopic examination, is found swarming with streptococci at the placental site; small clots and thrombi, visible to the unaided eye, may be observed, darker and softer than is usual ; upon microscopic ex- amination, the uterine sinuses, at the placental site, are found oc- cluded by thrombi, which contain abundant streptococci, and which show symptoms of softening in portions; the submucosa of the 39 6lO SCIENCE AND ART OF OBSTETRICS. uterus is softened and distended with lymph, pus, and micrococci ; the lips of a lacerated cervix become ulcerated, or more commonly share in the red and softened appearance of the entire uterus; the uterine muscle is softer than normal to the touch, and, upon micro- scopical examination, the inter-muscular spaces are found full of lymph, pus, and micrococci; the peritoneum, covering the uterus, is also attacked by streptococci, which fill its lymphatic channels, causing infection in its blood vessels, and in many cases the forma- tion of an exudate ; the mucous membrane lining the tubes, shares in the infection and their abdominal ends slightly swollen, dark red in color; the ovary itself is also larger, softer, and darker in appearance than normal; a catarrhal inflammation of the tube gen- erally accompanies septic endometritis, and pyosalpyinx is not un- common ; the connective tissue surrounding the uterus becomes also infected ; its lymphatic channels are engorged and occluded by bacteria, lymph, and pus, and an exudate is poured out from the ruptured capillaries into the connective tissue spaces, whose disinte- gration with the multiplication of bacteria frequently results in peri- metritic abscess. The broad ligaments share in the inflammatory process, becoming thickened, and there is often between their layers connective tissue inflammation, which results in abscess; as inflam- mation and exudation go on, the contraction of one of the broad ligaments frequently draws the uterus toward that side, fastening it down as the formation of scar tissue proceeds. The general peri- toneal surface is next invaded, and there is first a brilliant injection with swelling, and, subsequently, an exudate with the formation of pus. The pus may be encysted, and is then susceptible to surgical treatment by evacuation and disinfection ; should, however, a gen- eral infection of the peritoneum occur, its entire surface will be found reddened, thickened with exudate, adhering to the abdominal peritoneum surface, and, often, to that of the intestines, and frequent adhesions, between the peritoneum and intestines, and loops of the intestines which lie in contact, are observed. When the infection has travelled beyond the genital organs proper, it is not rare to find both peritonitis and suppuration present in the connective-tissue. In puerperal pyaemia emboli, originating from thromboses in the engorged veins of the broad ligaments, and in the uterine sinuses, are carried by the circulation to the lungs, liver, spleen, kidneys, and into the tissue in and about the joints. Infarction takes place with all the phenomena which follow it. Septic pneumonia, from pul- monary embolism; hepatic embolism, resulting in jaundice, both haematogenic and hepatogenic, are observed; the synovial membrane of an elbow or a knee-joint is frequently the seat of the growth, and multiplication of streptococci and symptoms of inflammatory rheumatism may deceive the inexperienced observer. Abscesses in the connective tissue, about the pelvic joints may occur, while in- flammation of tlie inferior maxillary joint, and abscess of the parotid gland, are also among the possibilities of puerperal infection ; brain abscess may be produced by an infected embolus, and meningitis follow the plugging of a cerebral sinus. Among the rare sequelae PATHOLOGY OF THE PUERPERAL STATE. 6ll of puerperal sepsis is inflammation of the retina, with destruction of the interior of the eye. The mucous membrane of the intestines is affected in constitutional puerperal infection, and symptoms of typhoid fever may be present; on examination, the lymphatic patches of the intestines are found enlarged, and the mucous mem- brane is turgid with blood. Rupture of the capillaries often hap- pens, followed by bloody stools. Observation, however, will show that the lymphatic patches, commonly enlarged and ulcerated in typhoid fever, may enlarge in puerperal sepsis, but rarely ulcerate. The pelves of the kidneys, and the vessels of the renal glomeruli, may become the seat of inflammation and multiple kidney abscess, and surgical kidney result; microscopic examination of the organs mentioned, as affected by puerperal emboli and thrombi, shows the usual phenomena of pyaemia. It occasionally happens that fatty degeneration of the vessels of the skin occurs, caused by minute embolisms following septic endocarditis, thus skin eruptions of an anomalous sort are sometimes met with, and prove exceedingly puzzling in diagnosis. As we have said, septic infection occurs less frequently by direct absorption of septic virus from the bloodvessels of the uterus; in such cases the path of infection cannot always be traced ; there is no inflammation of the vagina and external organs, the decidua may not present gross lesions to the eye, the uterus is not enlarged, and the diagnosis rests upon the clinical history of the case; its fatal termination, and the evidences which the patient's body present, of an infectious malady that has destroyed life by the destruction of the elements of the blood, and by poisoning the vital centres of the nervous system. The pathological appearances in the body of a patient dying of this form of puerperal sepsis may be a soft dark- reddish appearance of the endometrium, which, possibly, is grayish in color at the site where the placenta was attached, a disseminated enlargement of the pelvic and abdominal lymphatics, and lymphatic patches in the intestines, but without the formation of abscess or the occurrence of ulceration. Microscopic examination of the tis- sues may reveal the existence of manifold forms of bacteria, the organism producing pus not predominating. Evidences, however, of ptomaine poisoning are found in the lymphatics, especially of the intestines, where nature seems to have made an effort to eliminate the poison; in the heart muscle, which is in a state of cloudy swell- ing, approaching fatty degeneration, and in the nervous centres, where examination shows the depressing effects of a circulating poison; examination by a skilled surgical pathologist is sometimes necessary to distinguish between a case of general septic infection and typhoid fever, dying before extensive ulceration of the intestines has occurred, and especially in some cases of puerperal sepsis, in which bichloride of mercury is used as an antiseptic, and in which inflammation and ulceration of the large intestines may be present, doubtless owing in part to mercurial poisoning ; as a rule, the lym- phatics of the small intestines, although they enlarge during the effort to eliminate septic poison, yet do not ulcerate, as in typhoid 6l2 SCIENCE AND ART OF OBSTETRICS. fever. There is, usually, evidence of degenerative changes in the cardiac muscle. Ulcerative endocarditis is occasionally met with, oftener in those who have previously had valvular disease, and chiefly affecting the valves. Inflammatory infiltration is rapidly succeeded by ulceration ; consequent upon the ulceration infecting emboli enter the circulation and pass to the different viscera. An examination of the blood of patients, affected by the direct absorp- tion of septic virus, shows an extensive disintegration of the red corpuscles with free haematin circulating in the blood, and an un- usual number of leucocytes. Treatment of Puerperal Septicemia.—The most important part of this treatment is prophylactic, and the prophylaxis includes pre- cautions taken before, during, and after labor; it extends to the nurse, to the practitioner, and to the patient. As far as the practitioner is concerned, Spiegelberg has laid down the judicious rule that he should not have been attending patients with infectious diseases or have had anything to do with infectious products shortly before attending a labor. French, in a discussion1 of the question, How soon after exposure to sepsis may the accoucheur resume practice ? adopts as his conclusion the statement of Esmarch : " If you have thoroughly disinfected yourself, you can immediately enter upon obstetric practice. Time does not destroy septic dirt." The last statement, which also appears essentially in a previous part of the paper, may be controverted, for, as Fritsch has said, a mechanical disinfection can be made; " if during the days which follow an autopsy the hands are washed a dozen times a day it is certain that, at the end of two or three weeks, the superficial epidermic layers are detached and with them all matters attached to them, so that it is not possible for bacteria which adhered to the fingers from the autopsy to remain." While, in his interesting article, French has adduced instances in which he attended cases of labor shortly after his hands had been exposed to septic fluids without the women having puerperal septicaemia, of course resorting to careful disinfection of his hands, and while he quotes distinguished authorities in favor of his thesis, it would be safer not to accept his conclusion as final, but rather observe the wise precaution advised by Spiegelberg. Winckel, in considering the question of the tenacity of puerperal wound viruses in regard to the infected obstetrician for the time abstaining from practice, con- cludes as follows : "In controlled, strict disinfection, abstinence may be limited to three or four days. When this is not possible, it should last not less than eight days, according to the experience of Huntley, Swiecki, and the writer." Vaginal examinations during labor should be few and brief, and never made without disinfection of the hand preceding each one. Introduction of the fingers into the vagina after labor and during the puerperal state can very rarely be necessary and should only be done with strict antiseptic precautions, including not alone the disinfection of the fingers, but also an antiseptic injection before and after the examination. Practitioners who have never met with puerperal fever may underrate the value of antiseptic obstetrics, and neglect necessary precautions until startled from the fancied immunity their patients have by a fatal case of the disease. Nevertheless this value rests upon incontrovertible facts. In the face of these facts, he is an 1 Journal of the American Medical Association, July 4, 1885. PATHOLOGY OF THE PUERPERAL STATE. 613 unwise, if not an unfaithful, obstetrician who does not throw around the puerpera every possible protection against the entrance of septic germs through the gateways opened by the necessary traumatisms of labor.1 Should the lochia become offensive, though there is no fever, and the condition of the patient is otherwise quite satisfactory, the indi- cation for an antiseptic injection—carbolic acid solution 2 to 3 per cent., creolin 1 to 2 per cent, mixture, or corrosive sublimate 1 part to 5000 parts of water—is plain. The vagina must first be washed out, and if at the end of 8 to 12 hours the discharge is still offen- sive, a uterine injection is given. Various tubes or catheters for uterine irrigation have been devised—Bozeman's, Rein's, Budin's, Hewitt,2 and others; the first is the one preferred by Fritsch, and it is the only one which I have ever used: different modifications of more or less value have been made. In both vaginal and uterine introduction of fluid, irrigation rather than injection is preferable. Poisoning with corrosive sublimate solution has occurred so many times in obstetric practice, in some instances a fatal result ensuing, and as we cannot know in advance the susceptibility of the individ- ual to mercury, a solution for vaginal or uterine use ought not to exceed the strength that has been mentioned, 1 part to 5000 of water. The curative treatment is local and constitutional. The former will be first considered, as it is really the first in importance. When the puerperal woman has continuous fever, either with or without a preceding chill, and the elevation of temperature is not caused by inflammation of the nipple or of the breast, or pulmonary disease, or rheumatism, or malarial fever, the presumption is that she is suffering from puerperal infection ; this presumption becomes a certainty if she has pain and tenderness in the lower part of the abdomen, and uterine involution is arrested. It may be asserted by the nurse that the lochial discharge is not offensive, or that it has been arrested; but the practitioner ought to examine the soiled napkins himself, or if the flow be absent, ascertain by conjoined manual examination whether, in consequence of a uterine flexion, the discharge is not retained in the uterus—in a word, whether there is not lochiometra. Offensive lochia indicate at once copious vaginal and uterine irrigation, as described in the prophylaxis. In regard to uterine irrigations the following important remarks are made by Fritsch : "When uterine contractions excited by the injection, washing of the uterus in part and in part by the force of the jet, sometimes detach decomposed and putrefying debris of the caduca, the debris are not evacuated until the next injec- tion. In cases—and they are the most numerous—where the injection is followed by a favorable result, in this that the temperature falls, but is subsequently ele- vated, there should be no hesitation. We ought not to content ourselves with 1 The injunction of Ovid is especially applicable : " Withstand the beginnings : the remedy is applied too late, when the evil has grown strong through long delay." 2 Double Current Tubes for Vaginal and Uterine Injections in Obstetric Practice. Lancet, March 8, 1890. 614 SCIENCE AND ART OF OBSTETRICS. the first injection, but repeat the operation in order to secure a definite result. Very often the secretion increases, it is said, under the influence of the intra- uterine irrigations, and the treatment causes a more abundant production of pus and lochia. But one will observe at the same time that the uterus, swelled and softened, has become smaller. This fact is easily explained: the injections make the cervical canal more permeable to the secretions, and hence they escape more readily. The retraction of the uterus is still another indication of cure ; the uterine muscular tissue, which was relaxed, infiltrated, and inflamed, recovers its functions and better accomplishes its work of expulsion. The organic debris still adherent are detached, and the process of desquamation, which precedes regeneration of the mucous membrane, is accelerated. When the intra-uterine injections bring out nothing, and this is easy to ascertain, they are to be aban- doned, only vaginal injections being used. But should the uterus return to its enlarged and softened condition, it is necessary to resume the treatment of its internal surface." Continuous irrigation, tried first by Schucking, is not to be com- mended. In those unfortunate cases in which manual detachment of the placenta has been necessary, or has been thought to be required, and, as is usually the case, placental fragments are left behind, the occurrence of puerperal fever indicates not merely the use of intra- uterine injections, but if these fail, the removal of such placental fragments with fingers or forceps, or with the dull wire curette; some practitioners use Simon's spoon. The irrigating curette is well adapted for use in these cases. In one case of septicaemia, at the Philadelphia Hospital, which followed arti- ficial and incomplete removal of the placenta, there were persistence of the fever and an offensive flow, notwithstanding antiseptic intra-uterine injections given twice a day, until in the third week, when I dilated the cervix with Hegar's dilators, and found in the uterine cavity at least two ounces of very offensive purulent matter; after its evacuation, I removed with Emmet's curette forceps, with a polypus forceps, and with Recamier's curette a tablespoonful of partially decom- posed placental fragments: within twenty-four hours the convalescence of the patient began. Many practitioners are favorable to the use of vaginal or uterine suppositories of iodoform. Garrigues, for example, recommends a uterine suppository made according to the following formula : iodo- form, 5v; starch, 5ss; glycerine, f5ss; acacia, 5!- To be made into three suppositories the size and shape of the little finger. It will be convenient in presenting the general treatment to mention first the chief remedies that have been or may be employed. The use of purgatives in puerperal infection is seldom advisable. Nevertheless in the beginning of peritoneal inflammation, a free evacuation of the bowels by Epsom salts ma)' be beneficial, especi- ally as this treatment has been so successful in Mr. Tait's hands in cases of inflammation following abdominal section. Antipyretic Means.—The reduction of temperature may be effected by the cold bath, or by wrapping in a wet sheet. Spiegelberg warmly advocated the cold bath, stating that it was indicated by continuous high fever, by the irregular chills of phlebitic septicaemia, with slight remissions, and in all cases in which the general evil results of an elevated temperature are present. This treatment is also upheld by Fritsch. He states that the temperature of the water PATHOLOGY OF THE PUERPERAL STATE. 615 should be from 72.5 ° to 86°; if the patient has severe shivering the temperature maybe raised to 93°, then reduced to 72.50; she should remain in the bath for ten or fifteen minutes. If decided reduction of her temperature is not obtained, that of the bath is to be lessened; prolonged immersion does not produce as good effects as lowering the temperature of the bath. Lusk commends the use of the coil of metal or rubber tubing, through which, after its application to the person of the patient, cold water is passed. The application of a bladder, containing ice broken in small pieces, to the abdomen, is advocated both by Siredey and Fritsch among others. It is suitable in peritoneal inflammation, lessening pain and diminishing the area of inflamed tissue. Whether a bladder or rubber sac be used, a fold of flannel should be interposed between either and the skin. This remedy is useless or injurious after exudation has occurred. If neither cold baths, the wet sheet, nor the cold coil is used, frequent sponging the surface with cool water may be employed. Neverthe- less, the application of cold is not useful in all cases. The following observations by Dr. Barker1 are very important in this connection. This eminent authority, referring to refrigeration as a means of reducing fever in puerperal diseases, states that his experience with it has not been favorable : " Many years ago I tried it in several cases in Bellevue Hospital, but I soon gave it up. Cold will effectively and usefully reduce the temperature in active inflammations and in acute fevers ; but in adynamic diseases and in hectic fever this must be attended with a rapid waste of tissue more dangerous than the pyrexia. In three cases which I have seen with others—two a year ago and one this winter—where the coil had been kept assiduously over the abdomen, most of the time two or three days, the conditions in each were remarkably similar. The abdomen was blanched, colorless, and not sensitive to pressure ; the patients all avowed that the coil gave them great comfort, but the temperature was very high in all—in one 104.3°, and in the other two over 105°. The pulse was very rapid and feeble; the heart's action extremely weak, with pulmonary symptoms —such as short, rapid, and shallow respiration—which caused grave apprehension lest there might be latent centric pneumonia. After some discussion I induced my friends to remove the refrigerating coil, and in its place to cover the abdomen with flannel saturated with the oil of turpentine, for the purpose of stimulating vaso-motor action, restoring the capillary, and equallizing the general circulation. All were taking quinine in large doses. This was greatly diminished or wholly stopped, and digitalis and ammonia in full dose were substituted. In a few hours the change in each of these cases was most remarkable. The temperature was reduced from two to three degrees, the pulse was greatly lessened in frequency and increased in force, and all pulmonary symptoms, which had caused so much anxiety, had disappeared." It may be remarked in connection with the observations of Dr. Barker as to applications to the abdomen, that in case of much abdominal tenderness or tympanites, flannel cloths wrung out of very hot water, and sprinkled with oil of turpentine are among the best applications; they should be used every six hours, and there ought to be some reddening of the skin produced by each application; during the intervals light warm poultices of ground flaxseed, or three or four thicknesses of flannel saturated with warm water, may 1 Medical News, Feb. 16, 1884. 6l6 SCIENCE AND ART OF OBSTETRICS. be applied, and over either a covering of oiled silk placed to prevent wetting the patient's clothes. Medicines are administered internally for the reduction of the temperature; chief among these are quinine, antipyrine, antifebrin, and alcohol. Fritsch advises quinine, preferably the muriate, by rectal injection, the dose being fifteen grains. Whether given by the mouth or rectum the dose should not be less than ten or fifteen grains; on the other hand, doses of twenty or thirty grains add to the discomfort of the patient, and probably do less good than the smaller amount. It has been especially advised in the remit- tent form of the disease, given at the time when the temperature has fallen, in order to prevent or lessen the usually succeeding eleva- tion of temperature ; it much more frequently fails than accomplishes the desired result. Even if the temperature is reduced by medicines, the effect is, in most cases, quite transient; and in a disease in which we wish to keep the digestive powers as nearly normal as possible, so as to secure sufficient strength for the patient that she may be safely carried through an exhausting and protracted illness, it is best to avoid frequent and large doses of these or of other medicines. It must be remembered that while a high temperature brings danger, yet its reduction does not cure: the course of the disease is scarcely modified by the reduction. Alcohol is probably the most valuable of internal remedies.1 In considerable doses it lessens the temperature of the body, and this effect is more marked in pyrexia than in the normal state; Siredey speaks of it as at once tonic and antithermic; Spiegelberg has re- ferred to it as " successfully used for a long time by English physi- cians in acute febrile diseases; its antipyretic action has since then been established also experimentally, and in its practical application we have had successful results." Fritsch observes that alcoholic drinks should be given freely, and recalls the observation of Conrad that large doses of alcohol cause better sleep. Recently Runge has presented a large series of cases sustaining its use. Winckel re- gards it as rational and deserving a further trial. Nevertheless, all cases of septicaemia do not require this remedy; probably the ma- jority will get on as well without it, nor is it usually advisable to administer it at the beginning of the disease. In the hospital cases for which it was prescribed whiskey was used ; the quantity varied from eight to sixteen ounces in twenty-four hours, and it was given at regular intervals in conjunction with milk, or in the form of egg- nog. Richardson urges that when alcohol is given in disease, it should be given as alcohol, and not in the form of wine, brandy, rum, whiskey, or any other form of alcoholic drink. He observes that so many ounces of wine, brandy, or whis- key mean nothing at all that is reliable, but if alcohol be used the therapeutical action is reduced to a positive method. If the remedy be used in the latter method, there is less danger of creating a constitutional appetite.2 These argu- ments deserve consideration by physicians. When we see such a vast amount of disease, suffering, and crime caused by the use of alcoholic beverages, we must 1 Bartholovv, op. cit. 2 The Medical Profession and Alcohol. PATHOLOGY OF THE PUERPERAL STATE. 617 beware lest we contribute in the least to the terrible flood. Moreover, if we ad- minister alcohol as alcohol, and not in the form of whiskey, or other alcoholic drink, there is less probability of a nurse making a blunder in the quantity to be given, for more than once patients have been killed by such blunder, a far greater quantity than that directed by the physician being given. Opium.—This remedy is frequently indicated to relieve pain or restlessness, or to check frequent evacuations from the bowels. In 1848 Dr. Alonzo Clark first applied the opium treatment, which he had employed from 1841 to peritonitis from intestinal perforation, to puerperal peritonitis with success. The following is an extract from a letter written to me in 1876 by Dr. Clark } " Regarding the rules, I begin with two grains of opium, or its equivalent opiate, and in two hours give the same, or more, or less, according to the effects produced. Patients resist or yield to the narcotic effects of the drug very differ- ently. In some cases twenty-four grains of opium a day are all that is required; in a few, twelve or sixteen grains is sufficient. In most, two to four grains at a dose are needed; in a few, more than this. The aim is to get and maintain the symptoms of safe narcotism, or, as I sometimes term it, semi-narcotism, indicated by subsidence of the pain, contracted pupils, itching of nose and skin, a con- tinuous sleep, from which, however, the patient is easily aroused, reduced fre- quency of respiration, followed by reduced frequency of the pulse, and absolute quiet of the bowels. Regarding the respiration, the aim is to reduce its frequency to twelve in the minute, and in- the attempt to do this it is often found to fall as low as seven without danger, if the opium is then withheld for a few hours, till it rises to ten, when a smaller dose is given, to be increased or not afterward." Most practitioners do not use opium, even in the treatment of puerperal peri- tonitis, so freely, but administer it chiefly for the relief of pain; frequently a hypodermatic of morphine may be usefully given for this purpose. Nourishment.—It is essential that easily digestible food should be given the patient in sufficient quantities and at frequent intervals. Milk, animal broths, beef-tea, and egg beaten up with wine or brandy maybe used. Care should be taken not to weary the patient with the same kind of nourishment, but to change from one to another each time when food is given. Treatment of Special Conditions and Manifestations. Nausea and Vomiting.—Iced and effervescent drinks may be given—champagne may prove useful. A blister to the epigastrium, or ether-spray can first be tried; some cases are relieved by taking small quantities of hot water, as advised by Keith in the vomiting following ovari- otomy; if other means fail, the hypodermatic injection of morphine will generally succeed. Constipation.—In peritonitis an evacuation from the bowels may be had once in three days; this can generally be secured by an enema of warm water and soap or salt; but if not, a mild laxative is given. Great Pain and Abdominal Tenderness.—Turpentine stupes, fol- lowed by the application of cloths wrung out of hot water, will give some relief; the application of ice to the abdomen frequently pro- duces remarkable alleviation of pain; opium, however, or morphine must be employed in cases in which this suffering is severe. 1 Author's Address on Obstetrics, International Medical Congress of Philadelphia, 1876. 6l8 SCIENCE AND ART OF OBSTETRICS. Another remedy, once more frequently used than now, and which in many cases brings notable relief to pain, is a blister; the special object sought by this means was revulsion. Now, how- ever, the remedy is seldom employed early in the disease, but later, and in those cases in which it is desired to hasten the resolution of an inflammatory deposit, as in one of the broad ligaments. For the purpose just mentioned various forms of counter-irritation are re- sorted to ; for example, the application every few days of Churchill's tincture of iodine. Intestinal Tympanites.—This may sometimes be lessened by cold applications, or turpentine stupes to the abdomen, by a stimulating rectal injection, or by the introduction of a rectal tube ; but if the distention is so great as to imperil life, the practice first advised by Pare- may be employed, and capillary puncture of the intestine has been successfully performed by Depaul in a case of puerperal fever. Nevertheless, this treatment will be in most cases of only temporary benefit—in some no good has followed. Surgical Treatment.—Apart from opening pelvic abscesses that point externally, and which may have their origin and development outside the peritoneal cavity, and occasional instances in which puncture of a tympanitic intestine is done, there are cases of puer- peral infection probably more frequently occurring than the pro- fession yet realize, in which a surgical operation presents the best hope and the speediest method of cure. Schultze has performed supravaginal amputation of the uterus seven days after labor because of a retained placenta undergoing decomposition, the in- fection not having extended beyond the uterus: the patient recov- ered. More recently, Roosenburg1 extirpated by the vagina the uterus of a woman who miscarried at four months, the placenta being retained, it being impossible to remove it completely, and peritonitis being threatened: this patient also recovered. The cir- cumstances must be quite exceptional in which such operations are necessary. But there are cases in which a purulent collection is encysted within the pelvic peritoneum ; probably it had its origin in septic inflammation of one of the tubes, or possibly there may be a purulent collection limited to the tube. Indeed, one cannot, in the light of many of the cases of abdominal, section made for the removal of the uterine appendages, help believing that some of the conditions de- scribed as puerperal parametritis and perimetritis—pelvic cellulitis and pelvic peritonitis—were really tubal or ovarian inflammations and suppurations. There have been in Philadelphia in the last few years several cases of puerperal infection in which the abdomen was opened,2 and either the pus-containing tubes removed, or other intra-peri- toneal collection of matter found, and either extirpated or evacuated and drained, recovery following in all except those in which the 1 See abstract of case in the American Journal of the Medical Sciences, June, 1890. 2 Among those who have done these operations are Drs. Baldy, M. and J. Price, and Longaker. PATHOLOGY OF THE PUERPERAL STATE. 6ig operation had been too long delayed. Neither the character of the disorder, nor the results following abdominal section give encour- agement to the operation in case of general peritonitis; but it may be done with propriety and hope in cases of pelvic inflammation ending in suppuration. The Treatment of Phlegmasia Alba Dolens.—Active treatment o*f this manifestation of puerperal septicaemia should not be employed, and hence leeching, cupping, and blistering, which were once used, are to be rejected. In regard to the last, Siredey says he positively proscribes blisters because of the injurious action which they have upon the kidneys, and of the predisposition to gangrene of a member the circulation of which is profoundly disturbed. As the greatest peril to life in the affection arises from the detachment of a portion of the clot and consequent pulmonary embolism, the limb should be kept at perfect rest, and all friction of it avoided. Barker advises elevating the limb at an angle above the trunk by raising the lower part of the mattress, " not so much to favor the gravitation of fluids back toward the trunk, as to retard the gravitation of the blood toward the limb." Siredey, however, objects to the elevation of the member on the ground that it facilitates the detachment of clots, and he directs it to be kept in a horizontal position. Certainly the elevation does not add to the comfort of the patient, and it is better to follow Siredey's direction. The affected member should be pro- tected from the pressure of the bed-clothes, and wrapped in cotton batting, then covered with oil-silk. Where there is great pain in the limb, Barker advises a liniment composed of six ounces of the compound soap liniment, one ounce and a half of laudanum, and half an ounce each of tincture of aconite root and extract of bella- donna. Opium will be necessary in may cases to relieve pain and restlessness and to secure sleep. If there should be much fever, quinine in antipyretic doses is indicated. After all fever has ceased, and the pain and oedema have disap- peared, the patient may be changed from the bed to a lounge, then in a few days sit for a while in a chair, and after this she may stand or walk ; an immediate change from the horizontal to an erect posi- tion must be positively forbidden. When she begins to use the limb, a properly applied bandage adds very greatly to her comfort, and to some extent prevents the swelling which may for some months occur after exercise. PART V. OBSTETRIC OPERATIONS. CHAPTER I. REMOVAL OF RETAINED PLACENTA--THE INDUCTION OF ABORTION AND OF PREMATURE LABOR—CEPHALIC, PELVIC, AND PODALIC VERSION. Obstetric operations may be necessary in the interest of the mother, or of her child, or of both. In some operations she need not change her position in bed, only be lying upon her back; in others, the dorsal position is necessary, e.g., version by external manipulations. Some practitioners, even in operations requiring the introduction of the hand, or of instruments into the genital canal, prefer the lateral position, the patient lying near the edge of the bed, the trunk flexed, and the lower limbs drawn up. But in this country preference is generally given in such operations to the dorsal position, the woman lying across the bed, her hips close to its edge, the lower limbs flexed and held by an attendant, while the feet rest on two chairs. In some operations an anaesthetic is advisable, and in others it is absolutely necessary. No operation involving the introduction of fingers, of hand or instrument into the vagina, still more into the uterus, until the external parts, then the vagina, the hand and instru- ments are thoroughly disinfected ; under some circumstances the uterus itself must also be washed out with an antiseptic solution, and certainly such thorough disinfection of its cavity is imperative if the hand or instruments have entered it. Manual Removal of the Placenta.—If the placenta is not spon- taneously expelled within two or three hours after the birth of the child, and if by stimulating uterine contractions by manipulation through the abdominal wall, assisted by moderate traction on the cord, it is still retained, then its removal by the hand is indicated. In order to guide the hand that is to enter the uterus into the os, and also to the position of the placenta, the other hand pulls on the cord so that it is made moderately tense. The hand is passed in a cone-shape, the fingers and thumb brought together so that the cone is formed, into the vagina, thence into the uterus and the placenta found, and then, the other hand, no longer required to pull upon the cord, is placed upon the abdominal wall so that the uterus is grasped 622 SCIENCE AND ART OF OBSTETRICS. by it. The placenta is detached, partially detached, or completely adherent. In the first case the operator includes as much as he can of it in his half-folded hand, not instantly withdrawing placenta and hand, but rather invites by the irritation of the hand within and by friction and compression of the hand without, uterine contraction which tends to expel both hand and placenta. In the second case, that is, in partial detachment of the placenta, there is no hemorrhage if the womb be well contracted; but even if there be no bleeding, still more if there is, the placenta is to be completely detached, this separation being effected by continuing the separation from the part where it has begun ; in this manipulation, supposing the right hand to be in the uterus and the placenta to be situated upon the poste- rior wall of the uterus, the ulnar border of the hand is used with a sort of sawing motion, or like the continuous movements made in using a paper-cutter, the back of the hand being toward the uterine wall, and the external hand keeping the uterus in position, and assisting in defining the uterine wall so that the internal fingers do it no damage. If the placenta be situated upon the anterior wall, then the radial margin furnishes the edge of the paper-cutter; but if the attachment be to the fundus, the ends of the fingers must make the separation, being careful that they turn toward the soft placenta rather than toward the harder uterine wall, and thus harm to the latter is avoided. Of course all manipulations must cease during a uterine contraction. If the placenta be completely adherent, the method of removal does not differ, but is more difficult. It ought to be added that an adherent placenta is very rare; that is, patho- logical adhesion, in consequence possibly of endometritis, is very seldom in occurrence. Hildebrandt advised separation within the fcetal membranes, these being made to form a glove-like covering for the operating hand, on the ground that thus avoidance of injury to the uterine wall was secured, and also danger of septic infection avoided. Spiegelberg found the method successful only in case the attachment was not strong, and that the assistance derived from tactile sensations was greatly diminished by this method. Budin advises if the hand has entered the fcetal sac, to tear the membranes at the border of the placenta so as to begin the separation there; if this fails, then the placenta is penetrated near its centre, and the fingers introduced into the button-hole thus formed, and the separa- tion made with them, making a circle from this starting-point be- tween the placenta and uterus. In case hour-glass contraction is present, or a similar contraction at one of the uterine cornua holds the placenta imprisoned, it may be the stricture can be overcome by a hypodermatic of morphine and chloroform inhalation, then dilatation with one, two, three, four fingers, until finally the hand enters, or dilatation with Barnes's hydrostatic dilators may be suc- cessful. If these means fail, Budin's answer is antisepsis and patience. Certainly the condition of the woman is one of imminent peril; but by the use of antiseptic washes and suppositories we can materially lessen that peril, and, in many instances, the patient INDICATIONS FOR ABORTION. 623 waiting is followed by the spontaneous detachment and expulsion of the placenta. Induction of Abortion.—The arrest of pregnancy prior to the viability of the fcetus is much oftener done with criminal than for therapeutic purpose. Historical Notice.—Artificial abortion was frequent in ancient times, without regard to saving the mother's life. In the Republic of Plato its production is authorized in certain circumstances.1 Aristotle not only did not condemn the practice, but even " desired that it should be enforced by law, when population had exceeded certain assigned limits." Lecky2 remarks that the general opinion among the ancients seems to have been that the fcetus was but a part of the mother, and that she had the same right to destroy it as to cauterize a tumor upon her body. It seems to have resulted among the Romans not simply from licen- tiousness and poverty, *' but even from so slight a motive as vanity, which made mothers shrink from the disfigurement of childbirth." The practice was avowed and universal. Ploss3 refers to the prevalence of abortion both in civilized and savage nations, this prevalence being especially great among Orientals, because of the slight value attached to the life of the foetus. The maternal instinct, which acts as a check to the crime, is counterbalanced among the Mohammedans by the severe punishment inflicted upon a woman who has an illegitimate child. Christianity was the most influential factor in revolutionizing Roman sentiment, and to-day is the most powerful protection of the unborn babe. Lecky, after stating that the average Roman in the later days of Paganism thought artificial abortion only a venial crime, scarcely deserving censure, says, " The language of the Christians from the very beginning was very different. With unwavering consistency and with the strongest emphasis they denounced the practice, not simply as inhuman, but as definitely murder. In the penitential discipline of the Church abortion was placed in the same category as infanticide, and the stern sentences to which the guilty person was subject, imprinted on the minds of Christians, more deeply than any mere exhortations, a sense of the enormity of the crime." Fortunate is that people or that community in which this sentiment prevails, reinforcing civil law, and strengthening the teaching of medical science in regard to artificial abortion, when resorted to from any other motive than the salvation of the mother's life. Kleinwachter states that it appears from the writings of Aspasia, fragments of which have been received through ^tius, who lived in the fifth century, that the ancient Greeks resorted to abortion in narrow pelves. With the extension of Christianity, however, even this form of abortion disappeared, and was only pre- served among the Arabs, as we learn from Rhazes and Avicenna. Further refer- ence to this operation is not made. It reappeared in the middle of the seven- teenth century, when it was recommended by the famous German midwife, Justin Siegmundin, for placenta praevia; but it seems most probable, notwithstanding Kleinwachter's statement, that she adopted this practice from French obstetri- cians. It was employed first in England by W. Cooper in 1717, in order to avoid the great mortality of the Caesarean operation. It was recommended for the same reason by Scheel in Copenhagen, in 1799. ^ was warmly advocated by Mende in Germany, 1802, and by Fodere in France, 1835, and subsequently by Dubois and Cazeaux. Indications for Abortion.—These indications may depend upon some general disease of the mother, or upon some local disease or deformity, or upon disease of the ovum. 1. Whenever the mother is suffering from disease arising from the pregnancy or originating before it, or accidentally occurring during it, which imperils her life, and there is a reasonable proba- bility that she will recover if abortion occur, its induction is indicated. 1 Jewett's Translation, vol. iii. p. 343- ' History of Morals in Europe. » Op. cit. 624 SCIENCE AND ART OF OBSTETRICS. Among these diseases may be mentioned the uncontrollable vomit- ing of pregnancy, and, in some cases, chorea, hydraemia, and ne- phritis. Breisky includes pernicious anaemia among the diseases that indicate abortion ; but Kleinwachter denies this, asserting that a fatal termination is hastened by it. The question of producing abortion in case of serious retinal disease has been in recent.years presented more especially by American oculists. The view held by them is offered in the extract from Dr. Noyes's volume, which will be given in a moment; it will be observed that the author uses the words " premature labor," though abortion is plainly meant. If hopeless blindness is to be the con- sequence of the continuing of the pregnancy, though the mother may escape eclampsia and the child's life be saved, is abortion justifiable ? This is one of the most difficult questions in obstetric casuistry, and its decision must be left to the practitioner, and especially to the woman and her friends. Knowing instances of hopeless, helpless blindness thus originating, my opinion is that abortion may be justifiable to prevent this great evil, if the woman and her friends insist upon it. Xoyes says:1 " Loring published a casein 1882, in which, at his suggestion, premature labor was resorted to, to save sight in a woman who, at three succes- sive pregnancies, was the subject of atrophy of the optic nerves, or rather of low neuritis optica. This was successfully done during the third month and achieved the desired purpose. No albumin was found in the urine, yet the lesion was attributed to the kidneys. Howe, Pooley, and Moore have recorded cases wherein the retinal disease was clearly pronounced, and by removal of the fcetus sight was restored.....The grave significance of loss of sight as denot- ing advanced degeneration of the kidneys lends added importance to the situa- tion and must be considered as arguing in favor of interference. The uraemic state of the blood is dangerous to the life of the fcetus ; when it has already caused lesions in the optic nerve and retina of the mother, and with the prospect of con- vulsions and peril to the mother's life, resort to artificial labor may be abundantly justified. This point in the management of labor must in the future be regarded with more attention than it has received, and because there may be lesions of the nerve or retina without impaired sight, inspection with the ophthalmoscope is strongly recommended for the same prudential reasons which call for the exami- nation of the urine^ even though there are no urgent symptoms. Vision may also be impaired with little or no visible lesion. The following conclusion by Howe seems judicious : " The induction of labor is warrantable when the retinitis appears in the early stage of pregnancy, and persists in spite of proper treatment, but is not warrantable in the last weeks, in spite of the greater ease with which it is accomplished, unless the inflammation is unusually severe." Dujardin, in 1883, referring to Loring's proposition, fournal des Sciences Medicates de Lille, remarked : " This reasoning has no value in it in opposition to the principles of natural right as well as to those of theology. All that we can admit, with a certain number of moralists is that abortion is permitted in such desperate cases, in which without it the child and mother are consigned to cer- tain death, and, on the contrary, if it is done the mother is saved with hope of baptism for the infant." A very extraordinary indication for the induction of abortion is excessive hypertrophy of the mammae; such indication has been sustained by Porro.2 Dr. William Duncan3 has recently very briefly considered the question, Should pregnancy be terminated prematurely in cases of phthisis ? The induction of premature labor in cases of phthisis has been advocated in the interest of the child, by some eminent obstetricians, but never hitherto the destruction of the child for the benefit of the mother. Dr. Duncan illustrates by a case under his care the latter view, and upholds it by a strong argument; nevertheless, the question must be postponed for more light. 1 Text-book on Diseases of the Eye, 1890, 2 Arch, de Tocol., 1880. :i London Obstetrical Society, January 8, 1890. It seems to me unfortunate that the wcrd prematurely is used, as it is unnecessary and may be misleading. INDUCTION OF PREMATURE LABOR. 625 2. In case of such obstruction of the birth-canal, either from pelvic deformity or from neoplasms, that a living child cannot be born through the natural passage even if premature labor be induced, and especially if the obstruction be so great that delivery is impossible after embryotomy, the indication for abortion is by most regarded as clear. This much all must admit: that a plain statement of the facts should be made to the pregnant woman, and then let her take her choice between such operation and the removal of the fcetus at the expiration of pregnancy by the Caesarean section. There is no doubt as to what that decision will be in nine cases out often; and certainly, even if embryotomy be possible at the end of gestation, an early abortion will be less dangerous. 3. Certain uterine displacements render abortion necessary. These are retroversion or retroflexion with incarceration, and at least most cases of irreducible procidentia. 4. Diseases of the ovum may render it necessary. Detachment of the ovum may have occurred, and hemorrhage require that the pregnancy should be ended, or the same indication be presented by cystic degeneration of the chorion. Prognosis and Means.—The prognosis will depend upon the condi- tion of the patient and the cause rendering the operation necessary; it is generally favorable. Various means, too well known by pro- fessional abortionists, will interrupt the pregnancy. Medicines have been given internally, electricity used, and uterine injections or puncture of the membranes employed; the safest way will be dilatation of the cervical canal with tupelo or sea-tangle tents, or partial detachment of the membranes. Of course, whatever method is used, great care must be taken to avoid septic infection, and after the abortion the same rest and precautions are required as after labor. Induction of Premature Labor.—Labor is induced prematurely if the continuance of the pregnancy until term would cause serious danger to the mother or to the child; it seeks to save the life of each, not sacrificing that of one for the sake of the other. The operation was introduced into obstetric practice more than a century ago by British obstetricians, the most famous of them being Thomas Denman: it was sooner and more readily accepted in Germany than in France, and the former country has furnished the most important contributions to the study of the indications and methods for inducing labor. In 4104 deliveries at the Philadelphia Hospital occurring in the period from 1848 to April, 1890, there have been 22 cases of induced labor. The causes were deformed pelvis 9, placenta praevia 3, renal disease 3, eclampsia, polyhydram- nios meningitis insanity, "exhaustion," death of child, accidental hemorrhage, each 1 The means used were Barnes's and Molesworth's dilators, puncture of the mem branes, manual dilatation, and the flexible bougie or catheter. So far as results to the mothers are given (20 cases), 13 recovered, and 10 children born alive continued to live, at least none of the 10 died within twenty-four hours. At the Woman's Hospital, Philadelphia, in 1704 women delivered from 1878 40 626 SCIENCE AND ART OF OBSTETRICS. to June, 1890, there have been 7 cases of induced premature labor, the cause being in all pelvic contraction ; no maternal death ; 5 children were born alive, but 3 died within three days. The means by which labor was induced were hot vaginal douches and the faradic current. [I am indebted to Dr. Frank L. Sothrn for the statistics of the Philadelphia Hospital, and to Dr. Louise Wylie for those of the Woman's Hospital.] The chief indications for the operation may be included under three heads, pelvic contraction, dangerous diseases of the mother, and disease of the ovum. Pelvic Contraction.—In the justo-minor pelvis with a true conjugate of 9 centimetres, 3.5 inches, the induction of premature labor is indi- cated, according to Litzmann. So too, it is preferable to the Caesarean operation, Dohrn holds, in the moderately contracted pelvis if the true conjugate is 7 to 8 centimetres. Winckel teaches that in con- tracted pelves of 8 centimetres and above, we are only justifiable in inducing labor if previous children have died during or as a result of the labor, because they were especially well developed. The time for inducing labor will be decided by the degree of deformity. If the conjugata vera is 7 centimetres, labor is induced at the completion of seven months; if j\, at the middle of the eighth month ; and if 8, at its completion ; if 8J, at eight and a half months. Disease of the Mother.—This may be one existing prior to preg- nancy, and aggravated by it, or it may be directly connected with or consequent upon the gestation, or it may be an accidental malady. Peter takes the ground that if gravido-cardiac accidents are attended with great and immediate peril in the pregnant woman, the induction of premature labor is indicated. Dujardin-Beaumetz1 states that, " The most serious complications, and the greatest danger of death for the mother appear at seven and a half or eight months. In presence of this fact, is the physician warranted in inducing prema- ture labor ? Durosier replies in the affirmative, and a great many obstetricians say the same." Schroder has spoken of conditions which cause danger of suffoca- tion, thus especially diseases of the organs of respiration and circu- lation, and mechanical hindrance of respiration in consequence of distention of the abdomen as giving occasion for premature labor. Renal disease may be an indication. If this disease causes great oedema, scanty urinary secretion, and there are symptoms threaten- ing eclampsia, and when appropriate treatment, especially the hot- water bath, does not avert the dangerous indications, labor may be induced : but it ought not be resorted to simply on account of the " kidney of pregnancy." The obstinate vomiting of pregnancy is recognized as justifying the operation in some cases, and a similar statement may be made as to chorea.2 1 Op. cit., Diseases of the Heart, translated from the French by Dr. E. P. Hurd. Berlin. klin. Woch., 1870. 'l Berlin, klin. Wochen., 1870. MEANS OF INDUCING LABOR. 627 Premature labor has been induced, according to the statement of Pippingskold in eclampsia with meningitis, croupous laryngitis, mammary carcinoma, and hectic fever connected with pelvic abscess. It was advised by Ferrario in epilepsy, apoplexy, eclampsia, dropsy, pneumonia, and severe hemorrhage—in 1845—in- dications many of which are not now admitted. Denman1 while recognizing pelvic deformity as the chief cause for the induction of premature labor, also advised it in case of the death of the child near the end of pregnancy, to be done in subse- quent pregnancies, and related two instances in which he had suc- cessfully employed this practice. This indication has been recog- nized by several eminent obstetricians since, among whom may be mentioned Sir James Simpson, but in recent years less attention has been given to it, some even denying " habitual death of the fcetus," and Spiegelberg, excluding all cases in which the cause of fcetal death was organic disease, especially syphilis, from the operation, stated that a successful case must always be regarded as an excep- tion. Winckel takes a broader view, and would not deny the opera- tion even though the premature death is caused by hereditary syphilis. The following is an extract from a paper read before one of our State medical societies five years since: "I have induced labor twice, solely for my own and for the convenience of my patients." It is to be regretted that this statement met with no rebuke at the time it was made. When we consider that there is no certain method of inducing premature laber which secures immunity from infection, but increases, though in slight degree, the liability to such infection, the obstetrician is never justified in exposing a woman to this risk for his own or for her convenience. Barlow, in his Essays on Surgery and Midwifery, published in 1822, has as the motto of the essay upon inducing premature labor this line from Horace's Art of Poetry : " Nee Deus intersit, nisi dignus vindice nodus." This maxim might well be pondered by any one who should for a moment think of imitating the bad practice referred to. Prognosis.—According to Wyder's statistics, 5 per cent, of the mothers, and 50 per cent, of the children, die: Winckel states that of the children born at seven and a half to eight months, only 33 per cent, are actually kept alive.2 Means of Inducing Labor.—The question was a very simple one for the obstetricians of Denman's day; they recognized but one method, as indicated by his statement " No person qualified to decide on the propriety of this operation can be ignorant of the manner of performing it, whether it be done with a quill sharpened at the point, or any more formal instrument." He frankly stated that while in some instances labor happened in twelve hours after puncturing the membranes, in others it did not under twelve or fifteen days. 1 London Lancet, January 4, 1845. An Introduction to the Practice of Midwifery. 2 The results obtained by the employment of the couveuse and of gavage show a much lower foetal mortality than above stated. 628 SCIENCE AND ART OF OBSTETRICS. Winckel gives nineteen different methods, but it is not neces- sary even to name them. Krause's method is that generally preferred. It is the introduction of a flexible bougie between the ovum and the uterine wall; before this introduction the vagina must be well washed out with an antiseptic solution, the hand of the operator must be first made aseptic as well as the instrument; if labor does not come on within twenty-four hours a second bougie is introduced in a different direction, the first having been withdrawn: great gentleness must be observed in the introduction of the bougie lest the membranes be torn or the placenta be partially detached— it must be made to " feel " its way in. In some cases the uterus may be so anteflexed, or the cervical canal be so contracted that Fig. 197. Barnes's Hydrostatic Dilators and Syringe. the bougie cannot be introduced; then a tupelo tent maybe first used in narrowing of the cervix, and also in flexion—in the latter case it can only be passed at first as far as the bend, and great care must be taken not to do any violence by trying to push it further. In all these manipulations an antiseptic injection into the vagina must be made, not only before the introduction of bougie or tent, but also after its removal and the introduction of a new one. 7564 VERSION OR TURNING. 629 Other methods are by means of Tarnier's dilator, Barnes's rubber bags, tamponing the vagina, hot-water douche (Kiwisch's method), and electricity. The rubber bags of Barnes may be usefully em- ployed to accelerate labor, but not even the smallest to begin it. Sometimes two methods are combined, as the hot-water douching and electricity, the means employed, as has been stated, at the Woman's Hospital of Philadelphia. Stehberger proposed, and the proposition was endorsed by Spiegelberg and others, that if a pregnant woman is suffering with a disease which will prove fatal before the normal end of pregnancy, premature labor may be induced in order that the life of the child may be secured rather than expose it to the doubtful chance of being extracted alive by a Caesarean operation performed after the mother's death. But can the date of death be foretold with anything like cer- tainty ? And can the obstetrician ever be quite sure that the induction of prema- ture labor will not shorten the mother's days ? Of course if this operation is ever done, with such indication, the mother's wish, not merely her consent obtained, must be for it. In case premature labor is induced because of placenta praevia, the Krause method is to be rejected, for the bougie in its introduction immediately causes hemorrhage. Therefore dilatation with tupelo tent at first, then with Barnes's dilators, is to be preferred, or even the doubtful method of tamponing the vagina. Cheneviere1 has recently employed the following method: Small iodoform tampons are by means of a thick sound pressed into the cervical canal, and somewhat above the internal os, and the canal is also filled, the whole being retained by a large vaginal tampon. In the Krause method, a flexible catheter is not to be used, but always a bougie, for infection is more liable to occur with the former. The preference given by some practitioners to the Kiwisch method is that by it there is less danger of infection. Version, or Turning.—Version is an obstetric operation by which one end of the fcetal ovoid is substituted for the other, or either for presentation of a shoulder. If in this operation the head is made to take the place of the shoulder or pelvis, the version is called cephalic; but if the pelvis is made to replace either of the others, it is pelvic, and when at the same time, this being more frequently the case, the operator brings down one or both feet, the version is podalic; thus it is evident that podalic is really a variety of pelvic version. Turning the child in the uterus is one of the oldest obstetric operations, for it was known in the time of Hippocrates, whose comparison of the fcetus lying transversely to an olive similarly placed in a bottle is so well known ; but the great master committed a sad error in teaching that the foetus could not be de- livered unless the head came first, an error which though some centuries after- ward Celsus corrected, still ruled, sustained as it was by the great name of Galen —for who could dispute what Hippocrates and Galen taught ?—until soon after the invention of printing in the fifteenth century, and then the illustrious French surgeon, Pare, established for podalic version its legitimate place. Guillemeau, the friend and pupil of Pare, advised turning by the head or by the feet in case the placenta came first. The famous Louise Bourgeois,2 I'accoucheuse de Marie de M'edicis__she had married an assistant of Pare, who had lived in his house for t Revue Medicale de la Suisse Romande, 1889. 2 Hergott. 63O SCIENCE AND ART OF OBSTETRICS. twenty years—recommended podalic version in prolapse of the cord, and also in case of uterine hemorrhage during labor, saying that it was necessary to rupture the membranes as one forces an entrance into a burning house in order to save it, and then extract the child by the feet. Until the invention of the forceps, and the knowledge of this instrument became the property of the profession, podalic version occupied a most important place in obstetrics, and turning bv the head sank into comparative neglect, for prior to possessing this instrument the accoucheur was powerless to end the labor, though he had brought the head in a favorable position. Cephalic Version.—This variety of turning, as the oldest, will be first described. There are two general methods by which it is per- formed, each being bi-manual, but in one of them one hand is ex- ternal and the other internal, while in the other both hands are external. A. Version by Internal and External Manipulation.—The great majority of cephalic versions are performed in consequence of pre- sentation of the shoulder, and generally when the labor has been so long in progress that rectification of the presentation is impossible by external manipulation, and therefore the method of performing cephalic version by one hand internal and the other external must be that which is most frequently employed. There are several ways of turning by the head, and I shall first describe that of the late Dr. M. B. Wright, of Cincinnati, a method which has received scant acknowledgment even by American ob- stetricians, and yet it is, as those who have tried it will testify, one of the safest, simplest, and most certain. The following is Dr. Wright's1 description of this method as given in 1854: "Suppose the patient to have been placed upon her back, across the bed, and with her hips near the edge—the presentation to be the right shoulder, with the head in the left iliac fossa—the right hand to have been introduced into the vagina, and the arm, if pro- lapsed, having been placed as near as may be in its original position across the breast. We now apply our fingers upon the top of the shoulder, and our thumb in the opposite axilla, or on such part as will give us command of the chest, and enable us to apply a degree of lateral force. Our left hand is also applied to the abdomen of the patient, over the breech of the fcetus. Lateral pressure is made upon the shoulder in such a way as to give the body of the fcetus a curvilinear movement. At the same time, the left hand, applied as above, makes pressure so as to dislodge the breech, as it were, and move it toward the centre of the uterine cavity. The body is thus made to assume its original bent position, the points of contact with the uterus are loosened, and perhaps diminished, and the force of adhesion is in a good degree overcome. Without any direct action upon the head it gradually approaches the superior strait, falls into the opening, and will, in all probability, adjust itself as a favorable vertex presentation. If not, the head may be acted upon as in deviated positions of the vertex, or it maybe grasped, brought 1 Difficult Labors and their Treatment. By M. B. Wright, M.D., of Cincinnati. For which a gold medal was awarded by the Ohio State Medical Society, Cincinnati, 1854. CEPHALIC, PELVIC, AND PODALIC VERSION. 63I into the strait, and placed in correspondence with one of the oblique diameters." One point upon which Wright insisted as peculiar to his method was that he did not attempt to raise the shoulder, but regarded this manipulation, advised by some obstetricians, as really hindering instead of promoting cephalic version. He directed that the entire process be done in the intervals between uterine contractions, and that when a vertex presentation was secured the practitioner should be governed as to time and manner of delivery by the general rules applicable to such presenta- tion. Dr. Wright first employed his method successfully in three cases in the year 1850. I believe his last published contribution upon the subject was in 1876.1 In the twenty-six years intervening between the first application of his plan and this time he had fre- Cephalic Version. Wright's Method. quent opportunities of verifying its value, and often succeeded in cases in which the shoulder was so impacted that others had vainly attempted podalic version. He usually operated with the patient in the position described, but in some difficult cases had her take the knee-chest position. Three other methods of performing cephalic version by one hand internally and the other externally, will be given, two of them ante- dating by many years that of Wright, while the third was not pub- lished until some years after it. I. Busch ruptured the membranes, and immediately after passed his hand into the uterus over the 1 American Practitioner, January, 1876. 632 SCIENCE AND ART OF OBSTETRICS. occiput and to the nucha so as to exercise a gentle traction during the escape of the waters, and to fix the head in the pelvic inlet until uterine contractions occurred. Coincident with this internal manipu- lation the other hand was used to act upon the breech through the abdominal wall. 2. D'Outrepont with one hand introduced into the uterus lifted up the trunk of the fcetus, acting upon the presenting shoulder, and with the other through the abdominal wall pressed the head out of the iliac fossa, in which it was resting, and into the pelvic inlet. 3. Braxton Hicks1 thus describes his method of per- forming cephalic version :2 " Introduce left hand into the vagina as in podalic version, place the right hand on the outside of the ab- domen, in order to make out the position of the fcetus, 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 direc- tion of the feet. At the same time pressure by the outer hand should be exerted on 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 two hands, it will be under their command, and can be placed in almost any part at will. Let the head then be placed over the os, taking care to rectify any tendency to face presentation. It is as well, if the breech will not rise to the fundus readily after the hand is fairly in the os, to withdraw the hand from the vagina, and with it press up the breech from the exterior. The hand which is retain- ing gently the head from the outside should continue there for some little time, till the pains have insured the retention of the child in its new position by the adaptation of the uterine walls to its form." B. Version by External Manipulation, or External Bimanual* Version. —Hergott states that the merit of having created this method belongs entirely to Wigand. Wigand held that version by external manoeu- vres was indicated whenever at the beginning of labor the presenta- tion of the fcetus is abnormal; its purpose was to make a regular presentation ; that is, of one or the other end of the fcetal ovoid. When Froriep advised the application of the method in the latter part of pregnancy before labor had begun, Wigand replied that he had several times done it successfully. The time of operating should be at the beginning of labor or in the latter part of pregnancy, and the preparations are the same as those required for abdominal palpation in the diagnosis of preg- nancy. A careful diagnosis of the presentation and its variety is made by palpation and by auscultation, and, also, if labor has begun, 1 Hicks's first publication upon combined external and internal version was in the Lancet, July, i860. 2 London Obstetrical Society's Transactions, vol. v., for the year 1863. 3 It seems to me unfortunate that some obstetric writers substitute for this term bi-polar, for confusion may thence arise, and moreover the new designation is incorrect, for when in ceph- alic version by internal and external manipulation, the fingers or hand are applied to the shoulder, that is not one of the poles of the fcetal ovoid ; or, again, when, as in a part of Hicks's method, just described, the head is made to " play like a ball between the two hands," those hands are not at the poles of the ovoid. There is not a step in the entire process that can be correctly termed bipolar. CEPHALIC, PELVIC, AND PODALIC VERSION. 633 Fig. 199, by vaginal touch. Upon turning to Fig. 150 it will be observed that the right shoulder is presenting, or would if labor had begun; the back is anterior, and the head is in the left iliac fossa. The operator is upon the woman's right side, and his right hand is placed upon the foetal head, while the left is applied to the other end of the fcetal ovoid; the arrows indicate the direction in which the two ends of the fcetal ovoid are caused to move, the head descending to the pelvic inlet, the breech ascending to the uterine fundus; when, by the action of the hands in concert, the change in the position of the fcetus has been effected so that the head is at the inlet, Wi- gand's direction is fol- lowed, and she lies upon her left side, that is, upon the side toward which the head was displaced. If labor has begun, again fol- lowing the direction of Wigand, the membranes are ruptured so that the head will be retained in its normal position by ute- rine contractions ; if labor has not begun, the same object is sought by the application of a bandage; one has been devised by Pinard for this purpose. Pelvic andPodalic Version. —Pelvic version by exter- nal manoeuvres is indi- cated, according to Klein- wachter, whenever the pelvis lies nearer the inlet .1,111, T, Braxton Hicks's Method of Combined Podalic Ver- than the head does. It . . t ^ . f,, . ,,, ,,.,, • j 1 1 , sion, first stage.—One or two fingers of the left hand lift may be done during labor the head from the brim and push it toward the left iliac Or in pregnancy. 1 he fossa| while the right hand pushes the breech trans- manipulation is similar to versely toward the right side (Hicks). that which has just been described as employed in cephalic version. But as a vertex presen- tation can be secured in the condition just stated with little more trouble, and as this is so much more favorable, pelvic version will rarely be employed. Podalic Version by Braxton Hicks's Method.—This method will be presented in the author's words, and with his illustrations. The patient occupies the left lateral position. The os uteri is supposed to be dilated so that one or two fingers can enter, and the membranes unruptured, and the face toward the right side. f>34 SCIENCE AND ART OF OBSTETRICS. Fig. 200. " Having lubricated my left hand, I introduce it as far into the vagina as is necessary in order to reach a finger's length within the cervix—sometimes it requires the whole hand, sometimes three or four fingers will be sufficient in the vagina. Having clearly made out the head and its direction, whether to one side or the other of the os uteri, I place my right hand on the abdomen of the patient, toward the fundus; I then endeavor to make out the breech, which is seldom a difficult matter. The external hand then presses gently but firmly the breech to the right side; as it recedes, so the hand follows it by gentle palpation, or by a kind of gliding movement over the integuments, while at the same time the other hand pushes up the head in the opposite direction, so as to raise it above the brim (Fig. 199). " It may here be mentioned that when the head has descended a considerable distance into the pelvic cavity, or more than half way through the os uteri, it is scarcely possible to lift it above the brim, especially if the uterus be active. " When the breech has arrived at about the trans- verse diameter of the uterus, the head will have cleared the brim, and the shoulder will be opposite the os (Fig. 200). That is pushed on in like manner at the head, and after a little further depression of the breech from the outside, the knee touches the finger and can be hooked down by it (Fig. 201). It very frequently happens when the mem- branes are perfect, that as soon as the shoulder is felt, the breech and foot come to the os in a moment, in con- sequence of the tendency of the uterus to bring the long axis of the child coin- cident with that of its own. Should it, therefore, be dif- ficult to hook down the knee, depress the breech still more, and it will almost always be the case that the foot will be at hand. ,; It will sometimes render turning more easy if, as soon as the head is above the brim, we pass the outside hand beneath it, and push it up from the outside alternately with the depression of the Braxton Hicks's Method, second stage.—The left hand pushes the shoulder to the left, while the right hand pushes the breech to the right and downward (Hicks). CEPHALIC, PELVIC, AND PODALIC VERSION. 635 breech. All this can generally be performed in a much less time than I have taken to describe it, although in some it requires gentle, firm, and steady perseverance, with such a supply of patience as is always required in obstetric operations." Fig. 201. Braxton Hicks's Method.—The right hand forces the foetal limb down within reach of the left hand, so that the fingers may be hooked over the knee (Hicks). Podalic Version by Direct Method.—In order that the version may succeed, the os uteri must be sufficiently dilated that if necessary the entire hand can be introduced into the uterus, the presenting part, for example, the shoulder, not having descended so low or having become fixed that the hand cannot readily push it out of the way or pass by it, and the pelvis must be so wide that the fcetus, after turning, can readily pass through it. The patient is placed across the bed with her hips at its edge, and her feet resting upon two separate chairs, an assistant holding each knee. As a rule, an anaesthetic should be employed. The operator, after the hands and forearms have been thoroughly cleansed with soap and warm water, immerses the hand which is to enter the uterus in a 2 per cent, creolin mixture; the choice of the hand is. determined by observing that when placed between pronation and supination it corresponds with the anterior plane of the fcetus. He takes his position, either sitting or standing, between the thighs of the patient, and giving his hand a conical form, the thumb resting in the palm, the index finger toward the pubic arch, the little finger at the fourchette, passes it into the vagina immediately after a uterine contraction; after the hand has cleared the vaginal entrance it is turned so that the dorsal surface rests upon the posterior 636 SCIENCE AND ART OF OBSTETRICS. vaginal wall; the conical form necessary for introduction is no longer kept, and the hand is passed up to the mouth of the womb; in case the membranes have not been ruptured this should now be done, for the practice once advised by some obstetricians not to do this until the hand has ascended so far in the womb that a foot can be felt, presents no real advantages and exposes to some dangers both immediate and remote; of course the more completely the amnial liquor is retained the more readily version is accomplished —"it is like turning a body floating in a bucket of water"—but if the hand enters the amnial cavity immediately after the rupture it acts as a plug and prevents the escape of any considerable amount of fluid. The search for the feet or for a foot is facilitated by the action of the free hand externally pressing upon the uterus keeping it in one position, and especially by pushing toward the internal hand the pelvis of the child. In this search two methods have been proposed, the one known as the German, and the other as the French ; in the former the hand is passed directly to the anterior plane of the fcetus and then to the part where the feet and knees are; by the other plan the hand follows the lateral plane of the fcetus until the lower limb is found, and then a finger may be hooked behind the knee, and the latter thus drawn to the mouth of the womb when the leg is extended and the foot brought into the vagina. The objections made by Hergott to the German plan, which he admits is the more rapid, is that upon the anterior plane the four members, hands and feet, forearms and legs, arms and thighs, are situated very near each other, and some- times crossed, so that difficulties of distinction may be presented, and the accouch- eur is liable to bring down a hand instead of a foot. He also, states, however, that one is often compelled to do as he can, neglecting the rules which seem the best and safest. It is not material whether the traction be made first at the knee or directly upon the foot, nor is it important which foot or knee is secured; generally it is the one which is nearest the posterior wall of the uterus. In regard to the question of bringing down two or one limb, this may rest upon the facility of securing both, and upon the demand for instant delivery; usually it is better to bring down only one limb, for the other remaining flexed on the abdomen dilatation of the os must be greater before the pelvis passes, and hence there will be less delay in the delivery of the head, a delay which is so perilous to the life of the child; moreover, the limb which remains in position protects the umbilical cord from pressure. If two limbs are seized, the operator can only have a secure grasp by placing the index finger between them just above the ankles, while the other three fingers are placed around one, and the thumb around the other limb. When one limb is seized and brought into the vagina, a noose of thick muslin may be placed around it so as to have a secure hold by which traction can be exerted, and this traction be outside of the vagina, the latter being a point of essential importance when, as in some cases of transverse presentation, the head cannot be dislodged, either by external pressure or by pulling CEPHALIC, PELVIC, AND PODALIC VERSIOH. 637 upon the foot, and the hand must be introduced into the vagina to push it up. It must be remembered that the movement given to the pelvic end of the fcetal ovoid by pulling upon one or both feet is to be assisted by a corresponding movement impressed upon the cephalic end by the hand pressing on it through the abdominal wall. If podalic version be required in shoulder presentation, when the arm has prolapsed, it is not always necessary to begin by returning the arm, but a noose is placed upon the wrist so that it may be drawn down when the chest is delivered, preventing its ascen- sion by the side of the head; of course, when the prolapsed arm interferes with the introduction of the operator's hand, the former should be pushed up in the anterior portion of the vagina. Turning having been accomplished the delivery of the child may in most cases be left to uterine action, as in an original pelvic presentation. But if traction upon the limb or limbs be necessary, because of inefficiency of uterine action or the necessity of speedy delivery, it must be made simultaneously with the contraction of the uterus, and assisted by manual pressure upon the abdomen; in other words, the fcetal expression of Kristeller employed. The rules as to the delivery of the trunk and head, the care of the cord, and the treat- ment of ascension of the arm or arms have previously been given, and therefore require no further reference. CHAPTER II. THE FORCEPS. The forceps obstetricius, known, because of its great value, as sim- ply the forceps—asserted by Baudelocque to be the most useful of all surgical instruments—made possible the rule given by Hippo- crates, that in certain difficult labors the hands should be applied to the child's head, and delivery thus effected. The forceps gave arti- ficial hands which could be applied without injury to the fcetal head, and rendered practicable the accomplishment of that which the un- aided, unarmed human hands could not do. Yet how many centu- ries Medicine waited for the realization of this important idea, and how imperfect obstetric art, until the idea was made actual! The word forceps, plural forcipes, is not derived, as some obstetric authorities have stated, from fortiter and capiens, or capio, that is, seizing strongly, but from formus, warm, and capio, as the use of the word by Virgil and Ovid, in describing the work of the Cyclops, plainly proves, and as also shown by the employment by other writers of the term formucales, which Scaliger has said should be formucapes, as a synonym for forcipes} Whatever the derivation, all understand by the forceps an instrument which can, with safety to both mother and child, be applied to the head of the latter, sub- stituting a vis a fronte for a deficient or absent vis a tergo, and thus effecting delivery. History of the Invetition of the Forceps.—In the year 1569 William Chamber- len, who, it is believed, was a medical practitioner, his wife Genevieve, and their family were living in Paris; they were Huguenots, and, fleeing from religious persecution, took refuge in England. Peter Chamberlen, the son of William and Genevieve, born in Paris, was, at the time of the removal from France, probably about ten years old; he became celebrated in the profession, but his great dis- tinction came long after death, for he was the inventor of the obstetric forceps, a fact which the researches of Dr. Aveling have clearly established, for previous to these researches the most conflicting statements were made as to which of the Chamberlens—a family which through two or three generations was represented in the profession, and no less than three of whose representatives bore the same name—the honor belonged. The date of the invention is not known, but it probably was some time in the last of the sixteenth or the first of the seventeenth century. The following is a representation of what Aveling asserts is doubtless the first forceps constructed by Chamberlen. The branches cross, a characteristic of most obstetric forceps made to this day, and they are united by a screw. The Chamberlens had at least three other forceps, similarly made, but somewhat im- proved upon this model. The invention was kept carefully concealed in the family, and used exclusively for their benefit, instead of being made known to the profession. In 1670 Hugh Chamberlen, a descendant of the brother of the inventor, went to Paris, hoping to sell the forceps for " 10,000 'ecus," about six thousand dollars. After spending 1 See Dictionnaire Encyclopedique des Sciences Medicates, article Forceps, by Chereau. THE FORCEPS. 639 some six months, his negotiations came to an abrupt close by his failing to de- liver a woman who had such pelvic deformity that Mauriceau, then in the height of his fame as an obstetrician, declared could only be delivered by the Cesarean operation. The latter, who we may be sure would tell the worst in regard to the conduct of this would-be rival, states that Chamberlen asserted he could deliver the poor woman in half of a quarter of an hour, but that he tried for three hours without stopping except to take breath, uselessly exhausting his strength as well as his industry, and then abandoned his efforts when he saw that the patient was likely to die on his hands. The post-mortem examination of the woman, who lived twenty-four hours after Chamberlen's attempt, showed that the uterus had been greatly injured by the instrument. Fig. 202. Chamberlen's Forceps. In a few days Chamberlen returned to England. In 1693 he went to Amster- dam, and was more successful in his efforts to dispose of his secret than he had been in Paris, for the famous Roonhuysen became its purchaser. The latter associated with him Ruysch and Boelkman, and the firm, with their successors, seem to have carried on for several years a successful trade in the forceps; this traffic was greatly increased by the original purchasers having a law passed for- bidding any to practise obstetrics unless first examined by them, and then pur- chasing the secret. The baseness of those who thus trafficked in the forceps sank, as Kleinwachter says, still lower; for in some cases only part of the secret was sold, one blade of the forceps being given. Roonhuysen had a student named Van der Swam, who had been with him several years, and whom he had promised to teach the art of delivery, but had failed to make his promise good. One day this student had, by a fortunate accident, an opportunity to see the for- ceps without the knowledge of his preceptor. He made drawings of it, and let a friend have them; that friend communicated them to Peter Rathlaw, who, coming to Amsterdam to practise obstetrics, had been rejected by the Amsterdam examiners because he refused to buy the secret. Rathlaw made good use of the knowledge acquired after his rejection, for, actuated possibly by revenge, he published a description of the forceps in 1747. In 1716 Jean Paifyn, of Gand, who was a celebrated surgeon, presented to the Paris Academy an instrument devised by him, consisting of two parallel blades, which were to be applied, one on each side, to the fcetal head, and by which ex- traction was to be then made; they were known as the Palfynian hands, Manus Palfyniana. Different devices were used for fastening the hands together after their introduction—Heister, among others, attempted thus to make the instrument useful, but failed—nevertheless the instrument was not successful. Still it repre- sented an idea in the construction of the obstetric forceps which a hundred years after was made practical, and which an obstetrician of the present day, Chassaignay, has sought to realize, regarding it as of great importance that the branches of the instrument should be parallel instead of crossing. The celebrated obstetrician La Mott saw Palfyn's instrument at Paris, and declared that it was as impossible to use it successfully as it would be to pass a cable through the eye of a needle. In 1734 Mr. Alexander Butter, surgeon in Edinburgh, published an account "of a forceps used by Mr. Duse, who practised midwifery in Paris," stating that it was "scarce known in this country, though Mr. Chapman tells us it was long made use of by Dr. Chamberlen, who kept the form of it a secret, as Mr. 64O SCIENCE AND ART OF OBSTETRICS. Chapman also does." Nevertheless " Chapman, in 1733, published a description and plate of the instrument, which he had used from the year 172C1, stating it to be the instrument used by the Chamberlens, but without stating whence he had procured it." (Churchill.) It also appears that Drinkwater, of Brentford, "sur- geon and man-midwife," who began practice in 1668, and died in 1728, had similar forceps. From the time of the publication by Chapman, the Chamberlen forceps became the property of the profession. Fig. 203. Palfyn's Forceps. The conduct of the Chamberlens in keeping the forceps a family secret has met with general professional condemnation. Recently, however, some voices have been lifted up, if not in defence, at least in palliation of their conduct, Aveling, for example, saying that it is not fair to judge members of the profession who lived two hundred years ago by the code of ethics which medical men now ac- cept; and Poullet promptly adds that those who condemn the Chamberlens commit an anachronism. Right must have some firmer foundation than the shifting sands of public opinion ; " ought is an ethical atom,'' not merely in the fact that it is an ultimate defying analysis, but that it remains always the same; human standards of right and wrong may vary with knowledge, with conventionalities, and the prevailing sentiment of the times ; nevertheless, none nor all of these can make that right which is essentially wrong. The ethical rule which governed the conduct of the Chamberlens was not found in the teaching of Hippocrates, and no one for a moment can suppose that if Sydenham or Harvey had invented the forceps, and learned its great value for the saving of human life, and the relief of human suf- fering, either would have kept it secret, but rather would have hastened to pro- claim the instrument and its importance to the profession. The general verdict of the profession upon the conduct of the Chamberlens had better remain undisturbed. Varieties of Forceps.—Kleinwachter states that at the beginning of the present century every professor thought it important that he should devise a new forceps, which, of course, when made, received his name. This ambition has not been limited to obstetric teachers, nor is it yet extinct. The profession has thus had forceps almost innumerable—some long, some short, some with narrow blades for introduction in the only partially dilated os ; others with asymmet- rical blades for sacro-pubic application ; some of " gigantic volume," dangerous alike to the mother and the fcetus ; some physicians have invented what Delore has called microscopic, or pocket forceps— mere toys, or at least capable of meeting only the most trivial needs. Undoubtedly hundreds of obstetric forceps have been devised, but, in regard to each one of the majority of these hundreds, only a single instrument has been made, and that for the inventor. In some instances the new forceps which gave fame to the inventor THE FORCEPS. 64I never existed, probably, save in the form of a drawing,1 nevertheless, drawing and description have been published of " the author's in- strument." Velpeau wisely remarked that very many of the alleged improve- ments in the forceps have been made by young men, who have not yet learned that in all surgical operations much less depends upon the form of the instrument than upon the skill and ability of the man. The most important improvement in the Chamberlen instrument was that made by Levret, the addition of the pelvic curve; he pre- sented his " new curved forceps " to the Royal Academy of Surgery, Paris, in January, 1747. It was not until after 1751 that the great British obstetrician, Smellie, speaks of using the pelvic curve in his instrument. Pugh, a contemporary of Smellie, a practitioner at Chelmsford, England, published in 1754 the statement that he had invented the pelvic curve in 1740 But professional opinion cheer- fully concedes priority in the invention to Levret, because of priority of publication. Fig. 204. Hodge's Forceps. Obstetricians universally accept the advantages of the pelvic curve. Not so, however, with the next great improvement in the instrument, that of Tarnier (1877), by which traction is made in the axis of the birth canal, some regarding the axis-traction forceps— 1 The writer happens to know of a treatise on obstetrics in which the author gives a repre- sentation of his forceps, and yet the instrument never advanced beyond this primary condi- tion ; it exists only as a drawing. 41 642 SCIENCE AND ART OF OBSTETRICS. chief among them is Pajot—as no advance upon the old instru- ment. A few obstetricians, especially those of Lyons, have insisted upon the importance of the branches being, as in the forceps of Palfyn, parallel, instead of crossed. Description of the Forceps.—The short, straight forceps, which never was much used in this country, and which has fewer advo- cates abroad, in Great Britain or Ireland, than it had even twenty years ago, will not be considered in this description, the ordinary long forceps only being referred to. This consists of two halves, known as branches or arms, these branches being distinguished as right and left. A fundamental law governing their application gives rise to these names ; thus the left branch is held in the obste- trician's left hand, and introduced in the left side of the mother's pelvis, while the right branch is held in the right hand, and intro- duced into the right side of the pelvis—and this is the only un- changeable law in the application of the forceps. The instrument is made of steel, and the blade should have some elasticity, but not the least flexibility; the surface should be smooth and polished, so as to be readily and thoroughly Fig. 205. cleaned; the gutta-percha covered instruments ought to be rejected, for in spite of all care the covering will be broken, and the roughened surface thus left will be a most inviting lurking-place for septic poison. Each branch is divided into a handle, an articulating por- tion or joint and a blade. The handle must be shorter than the blade, lest too much power of com- pression be given the instrument. In many forceps the handle ends externally in a blunt hook, which, in rare emergencies, may be of value, but often proves an incon- venience, and can very well be omitted. The handles should be covered upon their external side with ivory or ebony, this being grooved or notched, so that they may be firmly grasped. In some instruments, Simpson's for exam- ple, each handle has near the lock a transverse projection, or shoul- der, so that two fingers can be Simpson's Forceps. placed over these when traction is made; a similar addition can be usefully made to the Davis forceps, and thus not only a convenient method for traction is secured, but avoidance of too great compres- sion of the head which might occur, at least with some forceps, when THE FORCEPS. 643 the handles are firmly grasped. In Bedford's forceps rings take the place of shoulders in Simpson's. The lock may be a fixed button or tenon upon one branch, which accurately fits into a mortise or depression in the other; or there may be a screw which, after lock- ing, can by a few turns be made to fasten the branches more firmly together; or that which is known as the English lock, as seen in the illustration of Simpson's instrument, the one branch notched just beyond the shoulder, and into this notch a narro.wed part of the other fits. Fig.206. The Davis Forceps with Shoulders on Handles. The blade is fenestrated, thus making it lighter and securing better adaptation to the fcetal head; the fenestra has somewhat the form of an elongated oval, and both the external and internal mar- gins of the blade are bevelled. Looking at the branches when locked, it will be seen that each blade presents above a concavity, below a convexity; this curve was called by Levret the new curve, but is generally known as the pelvic curve ; it adds greatly to the facility of applying the instrument when the head is in the pelvic cavity, or at the inlet, and to its efficiency. Another curve which all forceps have in common with that originally invented, is called the cephalic curve; each blade is concave internally, but convex externally; the blades thus fit closely upon the fcetal head, and at the same time occupy the least space. In no forceps is this curve better adapted to the sides of the fcetal head than in the Davis instrument. When the branches of the forceps are united the points of the blades should not touch, but be at least half an inch apart; the distance between the blades themselves varies in different in- struments; thus, it is three inches in Simpson's, two inches and a half in Hodge's, and two and a fourth in Davis's. It should be remembered that this measurement is made between the two oppo- site most distant points of the margins of the blades. Forceps vary in length, and even the same forceps varies as furnished by different makers. In illustration of the latter point, I have three of the so-called Davis forceps, procured from three different dealers; one of the instruments is less than eleven inches in length, while the second is thirteen, and the third is fourteen inches long; the first instrument, though procured from a leading New York house, is coarse, heavy, and does great injustice to one of the best of obstetric forceps, while the second is modelled in all essentials after the forceps used by the late Professor Meigs, weighs but ten ounces and a half, and is ade- quate to almost every case in which forceps delivery is advisable. The Hodge forceps is sixteen inches long, that of the late Dr. Wallace, fifteen inches; Braun's Simpson, fourteen inches; Elliot's, fifteen inches; Robertson's, thirteen inches and a half; Barnes's, fifteen inches; Pajot's forceps is forty-five centimetres, and Stoltz's forty-two, the same length as Levret's. 1^44 SCIENCE AND ART OF OBSTETRICS. The forceps represented (Fig. 208) is that of Dr. loseph Holt, of New Orleans, formerly Professor of Obstetrics in the New Orleans School of Medicine. This 'FlG. 207. Holt's Forceps. instrument is, I believe, used by many Southern practitioners. Its inventor pre- sents the following claims in its behalf: I^A' A minimum weight of metal compatible with full efficiency. Such a dis- THE FORCEPS. 645 tribution of the metal as shall insure resistance and compressing power where these are especially required, elasticity where required, and all in proportion. The pelvic curvature is in actual correspondence with the curve of Cams, whereby the instrument can be applied at the superior strait, or even above the brim, as easily as at the pelvic floor. On account of this curvature the head at the brim can be pushed downward and backward in the direct axis of the superior strait as surely as it may be drawn down with a Tarnier forceps, and that, too, with all the power of which a man is capable, certainly enough for the safety of maternal and foetal tissues. It can accomplish the work of the latter instrument without any of its complex machinery. Again, this curvature insures the points at no time pressing upon the sacrum. The bowls accurately adjust themselves to the child's head, securing uniform and general distribution of elastic pressure. The points, nearly parallel and flat, enable the blades to be passed, insinuating themselves Fig. 209. Reamy's Forceps. between impacted surfaces. There is no degree of impaction that will not permit the instrument to be applied without force, as abundantly proved in practice. Being on, the points compress gently but never injure ; this peculiar modification in the points was introduced many years ago by Dr. Warrington, of Phila- delphia." Fig. 209 is a representation of the forceps invented by Prof. T. A. Reamy, of the Medical College of Ohio. Miller's Forceps. Fig. 210 represents the forceps of Dr. DeLaskie Miller, formerly Professor of Obstetrics in Rush Medical College. This forceps is 14^" inches long, the width between the points of the blades }i of an inch, the blades are 6% inches long and 3 inches apart; the handles are folding, and thus the instrument made more portable. 646 SCIENCE AND ART OF OBSTETRICS. Powers of the Forceps.— 1. A dynamic action has been claimed for this instrument. It sometimes happens that even after the intro- duction of a single blade of the instrument languishing uterine con- tractions are quickened, or absent ones recalled, and so much importance was attached to this occasional occurrence that Kilian devised a galvanic forceps, hoping thus to increase the dynamic power of the instrument, but the experiment, of course, failed. The obstetrician, so far from seeing any quickening effect upon uterine and abdominal force resulting from the application of the forceps, may find this activity entirely ceasing, and hence no trust can be put in a dynamic action of the instrument. 2. The forceps may be used to compress the foetal head. Experi- ments have proved that the diameter compressed can be reduced a little more than one-third of an inch, and that compression carried beyond this is liable to cause fractures. Moreover, when the blades are applied, as they ought always to be, if possible, to the sides of the child's head, there is no gain in compressing any of the trans- verse diameters, as there is no hindrance arising from any of these being too great. Still more, if the biparietal diameter be lessened by compression, the suboccipito-bregmatic is increased,1 so that there is no absolute, or only slight, diminution of the head-circum- ference. Further, such compression hinders the moulding of the head, by which nature seeks to adapt it to the canal it must pass through ; it hinders, too, the movements of the head occurring in normal labor. That a particular forceps is a powerful compressor is not a commendation, but a condemnation. In traction more or less pressure is made upon the head; according to Delore's experiments, the pressure perpendicularly to the axis of the head is about one-half the traction, and hence there is a relation between the force of trac- tion and the degree of compression. Most obstetricians regard any compression beyond that which is required to prevent the instrument from slipping unnecessary, and it may be injurious. 3. The forceps as a lever. Notwithstanding arguments by some, especially by Dr. Mathews Duncan and by the late Dr. Albert H. Smith, against the pendulum, lateral, or oscillatory movements of the forceps, most obstetricians use them in certain conditions, and this practice is indorsed by Delore and Berne. The former states, as the result of his experiments made with the dynamometer, that by slight oscillatory movements great differences are obtained, which may vary from twenty-five to sixty-five kilogrammes, when strong tractions are used. In using the forceps as a lever, the fulcrum is on one and then on the other side of the birth-canal—or one of the hands of the operator may be placed externally upon one, then upon the other side of the vulvar margin, and thus be made the fulcrum, while the other grasps the handles—the power is at the handles, and the resistance the head, firmly held by the blades. As Spiegel- berg especially enjoins, traction should always be associated with 1 Recent investigations, which will be mentioned, seem to invalidate this statement; but they need fuller and direct confirmation before their general acceptance. THE FORCEPS. 647 this to-and-fro movement, a movement which should be gradual, not abrupt, and not great, and should only be regarded as a supple- ment to the former when that is insufficient to effect delivery; if traction be not made the head simply see-saws with the lateral movements, the fulcrum on each side not advancing, but constantly remaining the same, and thus no progress is made in delivery. 4. The forceps used to effect rotation. It not unseldom happens that in occipito-anterior positions the introduction of the posterior blade of the forceps causes the occiput to rotate in the pubic arch. In persistent occipito-posterior positions many obstetricians advocate at least the attempt to produce anterior rotation by the forceps. While in the pendulum movements the fulcrum passes down in a straight line, in the rotation movements it moves spirally. Spiegel- berg further states that a ring so tight upon the finger that it cannot be removed by pulling in a straight line, but can be by twisting movements, or partial rotations, is an imperfect illustration of the pendulum and rotation movements. He regards rotation move- ments as less efficient, and decidedly more dangerous than pendulum Fig. 211. Traction with the Common Forceps. movements, but says that they may be useful when the position of the head is not known, as indicating the right direction for traction, and that of least resistance. This doctrine should be accepted not without hesitation, and yet, coming from such eminent authority, not be rejected without just consideration. But in general the use of the 648 SCIENCE AND ART OF OBSTETRICS. forceps as a rotator is only exceptionally advisable, and frequently then the attempt is only an attempt—simply an experiment. 5. The forceps as a tractor. Having thus considered the doubtful or occasional powers of the forceps, or powers that are only excep- tionally required, we come finally to the essential power of the instrument, that of traction. The pulling power made by means of the forceps is to be considered in reference to the force exerted, the line of direction of the pull, and as to whether this traction should be intermittent or continuous. In easy labors the force exerted is probably, as stated by Mathews Duncan, little more than equivalent to the weight of the child; in difficult labors it is very much greater, possibly amounting to fifty pounds, and in forceps delivery it is in some cases very much greater Traction with Tarnier's Forceps. than even the latter. Delore makes the following statement as to the force that can be used with the forceps : A man without support, that is, not bracing himself, exerts a force equal to 88 pounds; with support, twice as much, or 176 pounds, the same as two men. but the two with support, 286 pounds. Tarnier states, and the state- ment is indorsed by Delore, that it is scarcely ever necessary to use a force exceeding 132 pounds ; more than this is dangerous. Accord- ing to Spiegelberg, the pulling should be done with the forearms, while the arms rest by the sides; there is usually no necessity for THE FORCEPS. 649 extending the arms, still less for bracing the body by placing the feet against the bed. It is universally agreed that the direction of the pull should cor- respond with the axis of the birth-canal. But what is that axis ? Fig. 213. Smith's Method of Exerting Axis Tracti Obstetricians for a time held that it was represented by the curve of Carus.and then a parabolic curve was substituted, as better showing Fig. 214. \ ,# v :-v Pajot's Manoeuvre. this axis ; but as the investigations, first of Fabbri, afterward of Sabatier, of Pinard, and more recently of Boissard, and of Varnier, ^5° SCIENCE AND ART OF OBSTETRICS. show, the obstetric pelvis—the dynamic as distinguished from the static pelvis—the soft parts being appended to the bony pelvis, and those which make the pelvic floor, thus forming the entire pelvis— presents a cavity which is not in any respect a curved canal, but approximates the form of a cylinder, having two walls, anterior and posterior, almost vertical, and at the fundus forming a plane nearly Fig. 215. Two Forms of Hubert's Forceps with Traction-arm at Right Angle to Handle. perpendicular to these two walls. This cylinder has its fundus at the coccyx, and an opening upon the anterior wall. Now, laying aside confusing curves, pelvic inclined planes, and speculative syn- clitisms, the head descends to the pelvic floor in a straight line, then turns at almost a right angle to make its exit at the vulva; in other words, the axis of the birth-canal is at first a line directed backward and downward, and then a line almost perpendicular to it. Hence, until the head reaches the pelvic floor, the fundus of the pelvic cylinder, the traction with the forceps must be downward and backward, and then upward and forward. When the head is high in the pelvic cavity, or is just entering the inlet, pulling downward THE FORCEPS. 65I and backward, that is, in the axis of the obstetric pelvis, is not an easy task ; and yet, if it be not done, there is a great loss of power. Now, to effect such traction, many obstetricians, since Osiander, have resorted to pressure downward at or beyond the forceps lock with one hand, while the other grasps the handles near their end, not so much for making traction as to resist the downward pressure of the other hand, and thus the handles become a lever rather than a means by which pulling is done. Pajot's method is the following: "We apply the left hand as near as possible to the vulva, the right hand near the end of the handles; then we use sometimes these two hands in order to make the forceps, at times a lever of the first order, sometimes of the third, sometimes a lever and a tractor at the same time, sometimes a direct tractor, according to the resistance and the height of the pelvis at which they are found." Other methods of securing axis-traction have been by certain changes of the forceps itself or by attaching to it, at or near the blades, traction-rods. Hubert (i860) had arms projecting from Fig. 216. the under surface of each handle of his forceps. Morales gave the handles of his instrument a peri- neal curve, so that in pulling on the lower portion the pull was, theoretically at least, in the axis of the pelvis. Hermann, in 1840, applied traction-rods to the for- ceps blades, but this invention seemed to attract no attention until after 1877, the year in which Tarnier first exhibited his own forceps with a similar device. Fig. 216 is an illustration of Tar- nier's instrument, not as origin- ally devised, but as subsequently modified. Many modifications of Tar- nier's instrument have been made, Simpson's and Lusk's, for ex- ample, are excellent; other axis- traction forceps have been de- vised, and among those worthy of note are the instrument of McFerran, of Philadelphia, and that of Breus. Though many distinguished obstetricians have hailed the forceps of Tarnier as marking a new era in obstetrics, and as being the only important change since Levret gave the forceps the pelvic curve, others, chief Tarnier's Axis-traction Forceps. 652 SCIENCE AND ART OF OBSTETRICS. among whom may be mentioned Pajot, prefer the old instrument, " the classic forceps." Tarnier's is a much more expensive instru- FlG. 217. McFerran's Forceps. Fig. 218. Fig. 219. Breus's Axis-traction Forceps. Stephenson's Device for Axis-traction. ment, and more complicated, and probably never will supersede the old forceps, while it presents great advantages in special cases, which, however, rarely occur to the general practitioner. Winckel regards Breus's forceps as preferable to all others be- THE FORCEPS. 653 cause of lightness of the instrument, and the facility of its applica- tion. Fig. 219 represents the forceps of Dr. Stephenson, Professor of Midwifery in the University of Aberdeen. It will be observed that axis-traction is sought by means of a rod inserted in front of the lock. This instrument was shown at the Glasgow meeting of the British Medical Association in li Fig. 220. Knox's Forceps. The above represents the axis-traction forceps of Dr. J. S. Knox, Professor of Obstetrics in Rush Medical College. Axis Traction by Poullet's Method.—Poullet,1 of Lyons, has devised a method of axis traction by means of linen tapes ; he applied the tapes to the forceps commonly used in France, and has published a full account of his method. We have applied his system of traction by tapes to both the Simpson and the Davis forceps, with satisfactory results. The Simpson forceps most'frequently used, we have fitted with a tape attachment as follows : The blade of the forceps is made in its cephalic extremity a little heavier than ordinary, the fenestra of the blade measures four and a half inches in length ; two and one-half inches from the cephalic end an aperture is made in each limb of the blade surrounding the fenestra one-quarter of an inch in length, one-eighth of an inch in width; this aperture is so bevelled as to present no sharp surface; through it is passed a piece of strong linen tape one-half inch'in width, inserted from within outward through one aperture, and then from without inward through the other; each piece of tape is one yard long, or eigh- teen inches after it has been doubled by passing through the forceps blade; the tapes are received in a traction bar consisting of a straight portion eight inches long curving downward a distance of four inches, and terminating in a rotary cross bar; just before the traction bar curves downward, it has upon the upper surface a cross piece, two and one-quarter inches long, which is detachable, and which carries at each end a screw for making fast the tapes; the end of the traction bar which is nearest the mother has a rim of metal through which the tapes pass to be caught by the binding screws ; the forceps is applied to the head in the usual manner, the tape being held along the blade by the obstetrician and the instrument being first introduced on the left side of the mother as is cus- tomary ; care is taken that the tape rests between the forceps blade and the head of the child; the tapes are then passed through the ring of the traction bar, passing below the locked forceps, and are made secure at the binding screws ; to prevent cutting the perineum and posterior wall of the vagina, Sims's speculum or any suitable depressor or guard may be used. It has been found by expe- rience that a special screw for holding the forceps firmly locked is not necessary, extraction is made with one hand, while with the other the forceps is grasped as usual and easily held and applied to the head; the pull upon the tapes is such as to tend to keeD the forceps tightly applied to the head instead of drawing the blades apart We are accustomed to carry the tape and traction bar with us, using the forceps without them when axis traction is not necessary. The fact 1 My assistant, Dr. E. P. Davis, has prepared this description. 654 SCIENCE AND ART OF OBSTETRICS. that this attachment can be fitted to any forceps with which the practitioner is familiar, its little cost compared with expensive axis-traction instruments, the ease with which it is cleaned and carried in the regular obstetric bag, have made the instrument a very convenient one in our hands. The general rule, as to traction with the forceps, is that it should be intermittent—a pull, and a pause—our art thus an imitation of nature, which in normal labor expels the child by intermittent, not by continuous contractions. Nevertheless, Pinard regards slowness of traction as more important than intermittence. CHAPTER III. the forceps {continued)—the vectis. Indications for the Use of the Forceps.—The forceps is alike the mother's and the child's instrument, and the indications for its use may be summed up as, whenever the life of either requires imme- diate delivery. Thus, on the part of the mother, convulsions, hem- orrhage, rupture of the uterus, excessive feebleness, threatened asphyxia from cardiac or pulmonary disease, arrest of the progress of the labor from perineal resistance; on the part of the fcetus, pro- lapse of the cord, complicated presentation, sudden death of the mother, feebleness of the cardiac pulsations, either associated with great slowness or frequency, showing interference with the utero- placental circulation, or compression of the cord, may be present, and demand instrumental delivery. May the obstetrician use the forceps solely for the purpose of shortening the mother's suffering? Spiegelberg admits this indication, but wisely adds that he who undertakes such " luxus-operation" must understand how to control his hands intellectually and mechanically; but this is not always the case, and the intended assistance is often the reverse. Conditions necessary for the Use of the Forceps.—I. The forceps is to be applied to the head of the child; the head may be first or last, the presentation may be cranial or facial, but the rule is to apply the forceps blades only to the head. The application of the forceps in pelvic presentation was probably first sug- gested by Levret, and in recent years Pajot has given this use of the instrument a qualified approval if the child be dead. But for several years some obstetri- cians have used the forceps in pelvic presentation when the child was living, and sometimes delivery has thus been safely accomplished, after the means usually resorted to in delayed pelvic deliveries had been vainly tried. Among those who have in recent years recommended pelvic application of the forceps may be mentioned Frari, Tarnier, Miles, Pinard, Beluzzi, and Lusk. Frari, of Pavia, in 1847, devised a forceps for this purpose, and so have Miles, of Cincin- nati, and Beluzzi, of Bologna, each constructed an instrument for a like purpose. While probably other modes of artificial delivery in pelvic presentation will be generally selected, yet the operator, if expert with the forceps, need not hesitate to use it, after the experience of Tarnier, Lusk, and others ; the best instrument, except, of course, some of those devised for the purpose, is Tarnier's, because of its unvarying compression. Nevertheless, the few trials which I have made of this application of the forceps have been unsatisfactory. 2. The mouth of the womb must be completely dilated, or so far dilated and so dilatable that the blades can be readily introduced and applied, and then extraction of the head made without injury to the lower segment of the uterus; if this rule be neglected there is danger of the forceps blades tearing the neck of the womb as they are introduced, or else, when traction is made, the lower 656 SCIENCE AND ART OF OBSTETRICS. uterine segment will be dragged down, or the tissues about the mouth of the womb be torn or seriously bruised. Dubois devised forceps with narrow blades for introduction into the partially dilated os, but, according to Tarnier, the results were bad. The late Dr. Taylor, of New York, also had narrow-bladed forceps for similar use. 3. The head must be of normal size and consistence. A small or macerated head readily slips out of the forceps blades, and these cannot be sufficiently approximated if the head be very large, as, for example, in hydrocephalus. The advocates of forceps with parallel instead of crossed branches claim as an advantage of such instrument, that it is peculiarly adapted to large heads, grasping these with such firmness, and yet without injury, that extraction can be more readily accomplished. We present one form of the forceps with parallel blades. Fig. 221. Forceps of Assalini. 4. The birth-canal must present no serious hindrance, either from pelvic deformity or from neoplasms, to the passage of the child. The hindrance most frequently arises from narrowing of the pelvic inlet, and the question as to whether podalic version or the applica- tion of the forceps be indicated, is one in regard to which eminent obstetric authorities differ. Barnes makes the limit in the pelvic narrowing as three inches and a fourth, which will admit of the useful application of the forceps, at the same time stating that a head slightly below the normal size, and less firmly ossified than usual, may be brought through a conjugate diameter of only three inches. Pinard holds that-if the pelvis measure less than eight centimetres, the infant being at term and presenting normal ossification of the bones of the head, the forceps is not to be applied but with the greatest prudence; traction should be made gently and slowly, for the cases of exceptional success reported by different authors have naturally caused excessive tractions which could not but mutilate the fcetus, and, further, kill both mother and child. 5. Spiegelberg makes the condition positive that the head has passed the inlet by its greatest periphery, while Pajot regards it as favorable for the application of the forceps. When obstetricians speak of the head being at the superior strait or inlet, they do not mean that it is just at its entrance, but that it has so far descended that the parietal protuberances are as low as the ilio-pectineal line. The application of the forceps when the head is movable above the inlet is rejected by most obstetric authorities, podalic version being THE FORCEPS. 657 preferred, unless, as stated by Charpentier, the uterus, in consequence of the flow of the amnial liquor, is strongly contracted upon the fcetus, rendering version impossible, and one then rightfully tries the application of the forceps. Those who are partial to Tarnier's axis- traction forceps regard it as peculiarly favorable for use when the head is high up, not having entered the pelvic inlet; Spiegelberg observes that such application when the head is high, or, perhaps, to the movable head, is not a matter of indifference for mother or for child, and must not be made to the extent that many claim. Hodge regarded " fixation of the head and its partial projection through the superior strait," as " essential prerequisites for the oper- ation of the forceps." Preparations for Using the Forceps.—There are but {ew women, suffering the agony of childbirth, who will not gladly accept means which will shorten the duration of that agony; but few, when their unborn child is in peril, who have not the maternal instinct so strong that they will cheerfully consent to the use of the forceps to avert that peril. It is unnecessary, as some obstetric authorities have recommended, to show the patient the instrument; if foolish and timorous, she will not be thereby reassured, but rather have her fear increased; while the wise and courageous are willing to trust their physician. Delore very well suggests that, if it happen that the obstetrician has not his forceps with him, it is better to send rather than to go for the instrument, lest the labor end in his absence. If the fcetal head be low, and only the resistance of the vulvo- vaginal outlet to be overcome, the patient may be brought to the foot of the bed, the lower limbs being flexed; but if the head be in the pelvic cavity, or at the inlet, she should be placed across the bed, her hips at its edge, and each foot resting on a chair, while each knee is held by an assistant. The bladder is evacuated by a catheter, if necessary, for the use of the forceps when this organ is full may cause most deplorable injury to the vesico-vaginal wall. The use of an anaesthetic is advisable in most cases ; however, this may usually be left to the decision of the patient, it being always remembered that the anaesthesia is obstetric, not surgical. The vagina is washed out with an antiseptic solution. The obstetrician has at hand hot water and other means that may be necessary if the child happen to be partially asphyxiated, and also his hypodermatic syringe, sulphuric ether, and a liquid preparation of ergot, in case the condition of the mother after delivery should require either of the latter two to be given. He auscultates the fcetal heart, and thus knows the condition of the child; he very carefully repeats digital vaginal examination, so that he may be fully assured as to the pre- senting part and its position; and if any doubt remains, let him introduce his hand into the vagina, when he can, by feeling the ear of the fcetus and observing the direction of its convex border, at once know both presentation and position. He will require at least two assistants, for example, the nurse and the husband of the patient; but more may be needed, " according to the difficulty of the operation, or the indocility of the patient." 42 658 SCIENCE AND ART OF OBSTETRICS. Operation.—This includes three acts: (1) the introduction of the blades of the forceps; (2) locking the branches; and (3) extraction. The instrument having been first made aseptic and warmed by dip- ping each branch into a warm solution of carbolic acid or creolin mixture, the obstetrician applies to the external surface of each blade carbolized cosmoline, vaseline, or oil, and similarly anoints the fingers of his right hand.1 As locking is effected when the right branch rests upon the left, the general rule is to introduce the left blade first— " left blade, held in the left hand, and always passed in the left side of the mother's pelvis "—and accordingly this is taken in the left hand, the thumb being placed upon the inner, the fingers upon the outer surface near the lock; the grasp should be firm, secure, but gentle. The obstetrician takes a convenient position, for example, either sitting or standing between the patient's knees, if she be lying across the bed; introduces two, or if the head be high up four, fingers of the right hand into the vagina, and if possible brings their tips in contact with the margin of the mouth of the womb, and thus the fingers are made a guide to the course of the forceps blade, and a guard to the ma- ternal parts, saving them from injury. The point of the blade is now made to enter the vulvar orifice, the handle pointing upward and to the right, the blade " sinks by its own weight into the perineo-sacral gutter," its convexity presses against the inner sur- face of the introduced fingers, its concavity adapts itself to the fcetal head; with the ascent of the blade, which should be assisted by gentle pressure with the left hand, and its concave surface kept in contact with the fcetal head by the fingers of the right hand, the handle moves downward and to the left, so that it becomes nearly horizontal, and in the median line. Here the question arises, should the forceps be applied simply transversely with reference to the mother's pelvis, or to the sides of the child's head ? Many British and German obstetricians hold to the former, while the general teaching of the French and American is in favor of the latter. Of course, when the head is low and internal rotation has occurred, the mode of application necessarily meets both requirements; but the difference of methods comes when the head is high. The arguments in favor of placing the blades upon the sides of the child's head are, that the sides are the only parts that are symmetrical—the only parts, if labor has been in progress for some time, that lie in the same plane, and to them only are the concavities of the blades accu- rately adapted. The last remark applies especially to the Davis forceps, and if one prefers applying the forceps transversely in the mother's pelvis, without reference to the position of the fcetal head, he will select an instrument having a wide interval between the blades, such as that of Simpson. Whichever method is adopted, the obstetrician bears in mind that the blade is to be introduced gently, not forcibly—gliding, feeling its way to the proper place; decided resistance to its progress proves that the direction is wrong, and therefore must be changed; 1 If the creolin mixture is used, ointment or oil may be dispensed with. THE FORCEPS. 659 the words arte non vi, which Blundell suggested should be engraved on one of the forceps blades, should not be forgotten in their intro- duction. Fig. 222. Introduction of the Left Blade of the Forceps. After the first blade is placed in position, its handle is g charge of an assistant, while the obstetrician introduces the wen in second Fig. 223. Introduction of the Right Blade of the Forceps. blade. The latter takes the right branch in his right hand—right blade, held in the right hand, and introduced into the right side of 66o SCIENCE AND ART OF OBSTETRICS. the mother's pelvis—and, using the fingers of the left hand in a similar manner and for the same purpose that those of the right were used when the first blade was introduced, the second is placed on the opposite side of the child's head. When the operation is completed, the right handle rests upon the left, and they are usually locked without difficulty. Such difficulty may occur either because one blade has been introduced farther than the other, or because the handles are not in the same plane. The difficulty in the first case is removed by pushing the one blade farther in, or slightly withdrawing the other. If the handles are found to be in different planes, each handle is grasped by a hand, and the operator gently rotates the blades in opposite directions ; if this fail to make the handles parallel, the second blade is removed and reintroduced, and if failure still follow, both blades must be taken out, and the effort made to introduce them so that the proper relation shall be secured. If, with some difficulty in locking, it is afterward found that the handles cannot be approximated, but stand widely apart, this may result from the head being irregularly grasped, or from its being of unusual size, or from the blades not having been passed far enough over the head. In the last case it often happens that, if the handles are thus left without effort to bring them together—the blades of course being correspondingly separated—a few vigorous uterine contractions will force the head farther down in the embrace of the blades, and the difficulty is ended. Irregular seizure of the head—as, for example, that in which an oblique occipito-frontal diameter instead of the biparietal lies in the transverse diameter of the blades—is necessary in some cases; the operator recognizes this condition, and makes no effort to force the handles together, re- membering the golden rule as to compression—let it only be suffi- cient to keep the instrument from slipping. The difficulty in approximating the handles is always great, even insuperable in case of a very large head, and it is possible that the instrument may slip after the most careful application, when this method of delivery may have to be abandoned. A mistake which I am sure is not infrequently made, is failure to introduce the blades far enough, and then, for example, they lie in the direction of the occipito-frontal instead of the occipito-mental diameter. Care must be taken in the locking that hair or folds of skin of the external genital organs are not caught in the lock. The readiness with which locking occurs, the approximation of the handles, the firmness and fixed state of the forceps, the instrument and the head making for the time being a unit, indicate that the blades are in the proper position. That these include nothing more than the head—no prolapsed cord, or projecting border of the uterus, and no vaginal fold—has been guarded against by the careful manner of their introduction; but if there be any possibility of such an acci- dent having occurred, the sole means of resolving the doubt is to " introduce one or two fingers to the level of the blades, as well in front as behind." THE FORCEPS. 66l The traction, as before stated, should, as a rule, be intermittent; full force must not be employed at first; it may not be necessary at all, but if required it should be reached gradually ; pulling with the forearms, or with one of them at first, the arms being by the side, is a practice that has been advised. Usually if the power be given the right direction, it need not be great; but in rare instances the ac- coucheur has to exert considerable force—it must be his own, unassisted by that of another. In some instances the operator may find an immediate forceps delivery carrying greater danger to the mother and to the child, or both, than will a delay until nature's forces have moulded the fcetal head, thus facilitating the transmission through the birth-canal, and therefore the effort at instrumental de- livery must be postponed until such moulding has occurred. Should the forceps be removed before the head is delivered ? Such removal has been strongly recommended in recent years by Freund, Goodell, Lusk, and others, and was the practice of Taylor, of New York, for many years before his death. It is the revival of an old practice. "Among the German authors, Boer, and after him Joerg, Carus, and others, have recommended removing the forceps as soon as the head is engaged in the vulva, if there is no indication for the immediate termination of the delivery." (Naegele and Gresner.) Madame Lachapelle strongly advocated this plan. The object sought by the removal is to prevent injury to the perineum by thus taking away the addition to the head circumference caused by the blades of the forceps. The objections that have been made to this practice are, that while the accoucheur is removing the instru- Fig. 224. Protecting the Perineum in Delivery with the Common Forceps. ment a violent contraction may suddenly expel the head, and he being otherwise occupied is powerless to give any protection to the perineum; or nature's forces, on the other hand, may be unequal to the expulsion, and a reapphcation of the forceps may be necessary. Moreover, we have in the forceps the best means of retarding the exit of the head until the vulvar orifice is sufficiently dilated, and at the same time of guiding it in its proper direction when that exit is made; the 662 SCIENCE AND ART OF OBSTETRICS. forceps may be so used that the perineum will suffer less injury than in natural labor. Having given this general consideration of the application of the forceps, there will now be presented the method in which the instru- ment is used in different presentations and positions. Fig. 225. Protecting the Perineum in Delivery with Tarnier's Forceps. Head-first Labor.—Cranial Presentation, and (1) Occipito-pubic Position. In this position the head was so small that it entered the inlet with its occipito-frontal diameter in relation with the antero- posterior of the former, instead of with one of the obliques or the transverse; or, and this is the more frequent case, anterior rotation, instead of direct descent, has placed the occiput at the subpubic ligament, or in the pubic arch. The blades of the forceps are necessarily placed in direct relation with the sides of the mother's pelvis, and upon the sides of the child's head. In a primipara the nearer the head is to the vulvar orifice, the more difficult the intro- duction of the guiding fingers, but this introduction need go no farther than the parietal protuberances, for if the rim of the os uteri has cleared these it has retracted as far as the child's neck; passing the blades deeply in is unnecessary, and may do serious injury. After locking, which is easily done, the traction should be somewhat downward at first, if the occiput has not come in front of the sub- pubic ligament; but if it has, or after it has been brought thus in front, the handles are gradually raised so as to assist deflection, the occipital end of the long head diameter being outside the pelvis, and the normal delivery of the head taking place by a rotation upon its transverse axis through the arc of a circle, suboccipital diameters measuring the distance from the lower margin of the pubic joint to THE FORCEPS. 663 the anterior margin of the perineum. Care must be taken to observe this normal mechanism in forceps delivery. If immediate ex- traction of the child is not imperative, let the head be held back until the parts are sufficiently dilated, and gradually lead it out, the nucha being made to hug the subpubic ligament. At the end of the extraction of the head, the handles of the forceps will be near to and almost parallel with the mother's anterior abdominal wall Only one hand is needed for the forceps, and the other should be used to note the condition of the perineum, and to protect it from being torn. (2) Occipito-sacral Position. After the application of the forceps, the pull must be upward and somewhat forward, increasing the head-flexion, until the occiput emerges over the anterior margin of the perineum, and then the head is delivered by extension, the nucha.pivoting upon the anterior border of the perineum. Some accoucheurs, among whom Charpentier may be mentioned, always attempt anterior rotation, and it is only when this attempt fails that delivery over the perineum is accepted. (3) Left Occipito-anterior Position. Supposing the head to be in the pelvic cavity, the left blade, which is introduced first, is passed to the left side, and posteriorly, so that it corresponds with the left sacro-iliac joint; very frequently the introduction of this blade determines anterior rotation of the occiput, and then the position is simply occipito-pubic, so that the introduction of the second blade is the same as has been described. But when this rotation does not occur, the right blade is " directed at first below, to the right and posteriorly, then brought by a very extensive spiral1 movement to the level of the right ilio-pectineal eminence." After the blades are applied and locked, traction with anterior rotation, and delivery of the head as in occipito-pubic position follows; no attempt at rota- tion, however, should be made until the head has reached the pelvic floor. Should the head be at the inlet, still the effort must be made to place the blades at the sides of the head. The simple rule given by Pinard applies in common to these, and to all oblique or diago- nal positions which the head may occupy in the pelvis : Place the two blades at the two extremities of the empty oblique diameter; by such diameter is meant that in which the transverse diameters of the head are, and especially the biparietal, because this diameter 1 This is known as the method of Madame Lachapelle, and has been described by her as follows : " If the branches are to be placed diagonally, that is, one behind on one side, the other in front upon the opposite side, it will suffice to pass directly the branch which ought to remain posteriorly over the sacro-sciatic ligament—nothing arrests it. The other can be easily managed, if I commence with it. Held in the hand as a pen, and leaning it across over the opposite groin, I insinuate the point of the blade in front of the sacro sciatic liga- ment, then as it enters farther I lower the handle, bringing it by degrees between the thighs, until it inclines strongly below. By this movement I have made the end of the blade describe a spiral which the fingers in the vagina direct and complete. This movement carries the blade at the same time in front and above. It is necessary to encircle the head by an oblique passage which represents a line extending from the sacro-iliac ligament to the horizontal ramus of the pubes, and traced on the interior of the basin. The movement is effected in the twinkling of an eye, without the least pain, without the least bruising." The spiral move- ment is not to be employed in cases in which the head has not entered the inlet. 664 SCIENCE AND ART OF OBSTETRICS. does not occupy all its extent, there being always a space left be- tween the former and the pelvis. Winckel teaches that even if the head is transverse in the pelvic inlet it is necessary to apply the blades of the forceps to the oblique diameter, and he regards it as a mistake to apply one blade over the brow and the other over the occiput, because the child is thus easily injured, and besides the antero-posterior diameter of the head is too large for the cephalic curve and the instrument easily slips off. Dr. Fry, of Washington, at the meeting of the American Medical Association, 1889, showed a forceps invented by him for application to the sides of the head when it was transverse with reference to the pelvis, that is in the antero-posterior diameter of the latter, and reported cases in which he had successfully used the instrument. Milne Murray1 from experiments made with the cephalotribe upon the heads of dead foetuses, concluded that the fcetal skull is compressible in an 'antero- posterior direction by the sliding of the occipital and frontal bones under the parietals; and that the compression is not accompanied by any appreciable in- crease of the transverse diameters. Thus in a minor degree of flat pelvis in which forceps delivery is indicated, the blades may be applied over the ends of the antero-posterior diameter. (4) Right Occipito-posterior Position. The introduction of the blades is done in the same way as in a left occipito-anterior posi- tion. The head is brought to the pelvic floor, then anterior rota- tion2 attempted, which, if successful, requires removal, and then reapplication of the forceps; but if the attempt should fail, the occiput must be delivered over the anterior margin of the perineum. (5 and 6) Left Occipito-posterior position, and right occipito-an- terior position. The only difference in the introduction of the blades is, that in many cases it is difficult to introduce the second, right or posterior, blade after the first or left blade has been placed in position; hence, if this difficulty occurs, the right blade is intro- 1 Edinburgh Obstetrical Transactions, vol. xiii. 2 It is claimed that in natural labor anterior rotation does not occur until the head has reached the pelvic floor. This statement is too absolute, for the rotation may occur before there is the least pressure upon that floor. But in artificial rotation, as made by the forceps, no effort should be made to this end until the floor is reached by the descending head. Trac- tion should be made simultaneously with the effort to produce rotation, and it is important too, that the forceps should be used to keep the head well flexed. Richardson, of Boston, very ingeniously applies the forceps with the anterior and posterior pelvic curves reversed, in order to effect rotation, removing the instrument as soon as the desired change has been accomplished, and then reapplying if necessary in the normal position of the blades. Barnes holds that instrumental rotation is only exceptionally useful, more rarely necessary, and is not free from danger. The chief objection that is made to such rotation is that if the head be moved through more than one-fourth of a circle, the body being firmly held by the contracted uterus, and therefore not able to make a corresponding movement, injury is necessarily done to the spinal cord. The experiments of Tarnier and Ribemont have proved that this opinion is erroneous, for they have demonstrated that the torsion of the neck is distributed upon all the extent of the cervical column, and the first six or seven dorsal vertebrae. Tarnier states that exaggerated rotation exposes the spinal cord to injury less than does the great flexion necessary to be produced in order to deliver the occiput posteriorly. Wasseige states (Des Operations Obstetricales) that Van Huevel advised applying the new curvature of the forceps behind toward the occiput; as the blades only enter the excavation, it is, strictly speaking, possible, but, according to Wasseige, very difficult to execute, and he rejects it. The method differs only from that of Richardson, in that after rotation is effected there is no removal and reapplication. THE FORCEPS. 665 duced first, but of course the handles must be crossed before they can be locked. The difficulty may be obviated by following the method of Stoltz. After introducing the right blade, raise the handle and pass the left blade beneath it, and then the handles occupy their relative normal position without having to cross them after the application of the blades. Application of the Forceps in Head-last Labors.—Manual delivery is to be preferred if possible. Winckel regards the forceps as indi- cated only in those cases in which the mouth cannot be reached, the occiput has rotated posteriorly, and the face remains stationary under the symphysis. Schroder rejected the forceps, believing that if manual traction could not succeed, it would be impossible with the instrument to extract a living child, and that it was dangerous for the mother. Budin regards the failure to deliver by manual means, which is quite exceptional, as in most cases due to contraction of the os uteri about the neck and head of the child, or to resistance of the pelvic floor, and that under such circumstances the forceps should be used. In the application of the instrument, the occiput being in front, the child's body is raised, its back toward the mother's abdomen, and the forceps blades applied to the sides of the child's head, and extraction made, the mental end of the occipito-mental diameter coming out first. But if the occiput is posterior, the child's body is raised up, its abdomen toward the mother's, the instrument applied as before, and now the occipital end of the occipito-mental diameter passes out first. Head Movable above the Inlet.—In case the forceps is applied before the head has entered the inlet, an application which should be avoided if possible, an assistant holds the head by suitable pressure upon the lower portion of the mother's abdomen during the application of the blades. Almost invariably one blade passes over one frontal protuberance, the other over the side of the occiput obliquely opposite; thus, the first blade over the right side of the frontal bone, the second blade over the left side of the occipital bone. If the head cannot be brought into the inlet after a few vig- orous efforts, some other method of delivery must be resorted to. Head Separated from the Trunk.—It may happen, by "accident or by design," that the head has been detached from the trunk, and remains in the uterus after the latter is delivered. Removal by the forceps is " delicate and difficult," and should not be resorted to unless other means, such as the use of the hand and the assistance of uterine contractions, have failed. Either make the head fixed, by pressure through the abdominal wall or by seizing the head with a hand introduced into the uterus, and apply the forceps to the sides of the head. The Forceps in Face Presentation.—In presentations of the face the chin must rotate anteriorly if the labor ends naturally; the chin in this movement takes the place of the occiput in vertex presenta- tions. While anterior rotation is the rule in the latter, yet delivery is still possible by nature's unaided efforts, even should the occiput 666 SCIENCE AND ART OF OBSTETRICS. rotate posteriorly. Not so, however, as to the movement of the chin in a face presentation, for anterior rotation is essential for delivery. It should therefore be remembered that, in the applica- tion of the forceps, the instrument is valueless if such rotation can- not be effected. The difficulty and the danger of the forceps appli- cation to the head above the inlet lead obstetricians to prefer greatly conversion of a facial into a cranial presentation, or podalic version. But when descent into the pelvic cavity has occurred, and the chin Fig. 226. Application of Forceps in Presentation of the Face. is right or left anterior, either as a primitive position, or as resulting from rotation from a transverse or a posterior position, the applica- tion of the forceps and extraction are no more difficult than in similar positions of the occiput. The same rules are followed as to the introduction and articulation of the blades in the one case as in the other; but in facial presentations it is especially imperative that the blades be upon the sides of the child's head; departure from this rule, as, for example, applying one of the blades in the trachelo- bregmatic diameter, would give an insecure hold, and probably do irreparable mischief to the child's throat. After the application of the forceps in a mento-anterior position, extension and rotation of the chin into the pubic arch are the move- ments at first to be executed, and then the delivery of the head is accomplished by flexion; " care must be taken in this last step to THE FORCEPS. 667 prevent too long compression of the vessels of the neck against the pubic joint." fe In mento-posterior positions, either right or left, the mode of ap- plication of the forceps-blades does not differ from that employed in corresponding occipito-posterior positions, and therefore need not be repeated. In transverse positions, if the forceps be used the rule as to the application of the blades to the sides of the head is Delivery by the Forceps in Presentation of the Face. necessarily departed from, and an oblique application is made in which " one blade is placed upon the cheek and the base of the jaw, while the other is upon the temporo-occipital region of the opposite side." " One ought not to apply the forceps except in case of absolute necessity, in presentation of the face; for an accouchement which may end spontaneously and favorably is sometimes arrested when its march is disturbed by untimely attempts; the operator acting rashly, if he fails in his attempts, regrets too late the resources which would have been found in prudent expectation." (Tarnier.) The changing of a face into a vertex presentation by means of the forceps has been recommended. In this proposed method the chin is directed toward one of the great sciatic foramina, where, by pushing before it the soft parts, it was thouo-ht that sufficient room might be obtained for the rotation of the occipito-mental diameter, so that descent of the occipital, with ascent of the mental, end might be obtained. This could only succeed if the pelvis were large and the head small, so that any attempt to accomplish it is but a forlorn hope. Dr. Hodge thought that it might occasionally be practicable to deliver a living child, if the head were small and the perineum greatly relaxed, by applying the 668 SCIENCE AND ART OF OBSTETRICS. forceps, when the chin had rotated posteriorly, as accurately as possible in the direction of the occipito-frontal diameter, and drawing the head down, then causing the occipitomental diameter to revolve between the anterior margin of the perineum and the subpubic ligament. Some cases are on record in which a living child has been delivered in a direct mento-posterior position, either sponta- neously, or after the application of the forceps; but they are simply rare excep- tions to a general law, and the rule in such positions is craniotomy. Application of the Forceps in Presentation of the Pelvis.—If the child be dead the blades may be placed simply upon the sides of its pelvis, and firm compression made without reference to possible injury to the bones; but if it be living there ought to be interposed between the handles of the ordinary forceps, according to Pinard, something that will prevent their coming too close together, and thus avoiding injurious compression. Pinard directs the blades to be applied as far as possible, so that the pelvis may be seized by its bisiliac, or bistrochanteric diameter; nevertheless he states that he has seen Tarnier with his forceps seize the pelvis by the sacropubic diameter, the genital organs being in the fenestra of one of the blades, and extract an infant without causing any lesion. The blades ought not to pass the iliac crests, lest injury be done the abdomen. The ex- traction must be made slowly. Accidents and Dangers in the Use of Forceps.—The blades may slip, the liability to this accident being greater if the head is high; slipping usually occurs because the blades have been improperly applied, or because the pulling is in the wrong direction. Madame Lachapelle described two varieties of this accident, vertical and horizontal. The first may occur when the head is high, so that it recedes during the application of the blades, and hence is incom- pletely and thus insecurely grasped; or it may happen that the operator, misled by a large caput succedaneum, does not introduce the blades far enough ; the handles do not readily approximate, or their points embrace one of the transverse diameters of the head. So, too, the accident may happen from the head being so small, or having so little firmness that the forceps cannot hold it. Horizontal slipping occurs when the blades imperfectly seize the head, being too far to its anterior or to its posterior surface, and it is held only by the posterior or by the anterior pelvic curvature of the instrument; this condition may be recognized by the easy approximation of the handles. The consequences of the slipping, when vigorous traction is made, are the sudden escape of the instrument from the pelvis, with more or less injury to the mother's soft parts and to the child, and the operator may find himself prostrate on his back. The obstetrician guards against this accident by observing whether the part of the fcetal head nearest the lock is receding, the beginning of the blades becoming visible without the handles taking the usual direction, and the blades appearing empty, while the forceps is " getting longer." The moment any indication that the blades are slipping occurs, all traction should cease, the instrument be un- locked, and the blades passed farther in. It has sometimes happened that one of the blades is pulled THE FORCEPS. 669 straight, the head curve being quite lost. Elliot describes this as having occurred with him in using a Simpson forceps; and I know of a recent case in which this accident happened with a Hodge forceps, the delivery of the child being very readily effected after- ward by the use of McFerran's axis-traction forceps. It is probable that the accident occurs from a want of proper direction of the traction, or from too great effort to force a delivery before the head is sufficiently moulded. Injury to the Mother by Forceps.—Among the dangers of the for- ceps to the mother are prolapse of the uterus, or lacerations of the cervix; if great traction is made before the dilatation of the os, the lower uterine segment may be dragged down, torn, or seriously bruised; the vaginal vault may be penetrated by the forceps-blade, or the vagina may be torn elsewhere. Spiegelberg mentions an instance he knew, in which the anterior vaginal wall was torn from the fornix down to the lowest portion of the urethra. " Severe compression of organs contained in the pelvis may lead to inflam- mation ending in suppuration or gangrene, causing fistulae, abscesses, and partial paralyses ;" injuries of the external generative organs, and laceration of the perineum ; fractures of the pelvis, or separation of pelvic joints; finally, a rapid forceps delivery may, if suitable care be not taken, lead to post-partum hemorrhage. Injuries to the Child from the Forceps.—The minor ones are abra- sions, bruises or even cutting the scalp, the cutting sometimes reaching the subjacent bone. Depressions and even fissures of the bones may be produced. Injuries to the brain have been reported, immediately fatal results sometimes ensuing, while at other times remote evil has been ascribed to the instrument: Winkler and Ballaan1 attributed the idiocy of two subjects of whom they made autopsies, to cerebral atrophy caused by pressure of the forceps at birth. Dr. Horatio C. Wood has said:2 "The brain at birth is so soft, so liable to injury, that while I would not have the obstetrician entirely discard the use of the forceps, I think he should never take the instrument in his hand without bearing in mind the possibility of doing serious permanent injury to the nerve centres of the child." Charpentier states that he has seen, as a consequence of an application of the forceps by an inexperienced operator, one of the branches pushed with such violence that the blade penetrated the scalp near the occiput, passing as far as the root of the nose, detaching in its progress the skin from the cranium ; the child died at the end of forty-eight hours. I have observed a similar case; the operator had passed one blade on the outside of the scalp, but the other was applied beneath the scalp, when the difficulty in making it penetrate far enough led him to ask professional assistance; fortunately the child was dead. Intracranial effusion of blood may occur, oftener, as suggested by Spiegelberg, not from the direct compression of the forceps, but indirectly from drawing the head rapidly through a narrow birth- 1 Centralblatt f. Gyn'akol., 1889. . . 2 From remarks made in the discussion of author s paper upon Injuries to the Foetus During Labor, read before the Philadelphia County Medical Society. Medical and Surgical Reporter, 1887. 6/0 SCIENCE AND ART OF OBSTETRICS. canal. Paralysis of the facial nerve, usually on one side only, in rare cases on each side, may occur from direct pressure by the forceps-blade upon the nerve-trunk; the compression maybe of one of the branches only, and then the paralysis is only of the parts supplied by it. Generally this paralysis disappears in one or two weeks without treatment, but in some instances it lasts for years, and then may be regarded as incurable. While the obstetrician will neither resort to the forceps " from complaisance, nor reject it from cowardice," he must be quite sure that the interests of the mother, or of the child, or of both, demand the use of the instrument, and that the conditions are present ren- dering that use safe. The Vectis.—This instrument is supposed to be, like the forceps, the invention of Chamberlen. The instrument has been given Fig. 228. The Vectis. different forms, according as it was used chiefly or exclusively as a lever or as a tractor; thus Roonhuysen's instrument was a plate of steel, slightly curved, but the form preferred by the few obstetri- cians who use the instrument is that of a fenestrated, curved blade, with a straight handle; Spiegelberg has briefly referred to it as being one blade of the forceps, and therefore an unnecessary instru- ment. Lowder's instrument, of which an illustration is given, is probably the best. It has been used chiefly to increase flexion, and to assist rotation, but is rarely employed and by but few obstetri- cians at the present day. CHAPTER IV. EMBRYOTOMY. EMBRYOTomY includes all operations employed to lessen the size of the fcetus, facilitating or rendering possible its transmission through the birth-canal. These operations embrace, therefore, per- foration of the cranium and removal of its contents, cephalotripsy, cranioclasm, breaking up the base of the cranium—as by transfora- tion, the method of Hubert, or by the basiotribe of Tarnier, or by the basilyst of Simpson—and the division of the head into sections, or lamination, decollation, evisceration, and spondylotomy. Embryotomy is one of the most ancient of obstetric operations, directions for its performance having been given by Hippocrates. All obstetricians recognize it as not only a right, but also a duty in certain circumstances, to perform em- bryotomy upon the dead fcetus ; while some, and the number is steadily increas- ing, condemn its performance when the child is alive; some, indeed, have had so strong a repugnance to directly sacrificing the life of the child that they have done it indirectly, waiting until it died before resorting to the operation, thereby in no sense evading the responsibility for its death, and at the same time by delay adding to the perils of the mother. The principle of morals upon which most obstetricians rest the right to sacrifice the child for the sake of the mother is a very old one, and has met with general acceptance ; that principle, clearly enunciated by Cicero,1 for example, and sustained in general by moralists of all ages, is that if two lives are in such peril that both cannot be saved, but one will be by the sacrifice of the other, let that life which is of least value to the state, or to society, perish. It is unnecessary to show that the adult woman, with her various domestic and social duties, has a life of greater value than that of the unborn child; and, therefore, while the duty of the obstetrician is to save both when he can, if either is to be sacrificed let it be that of the latter—in other words, if in a given case embryotomy is a less risk to the mother than Caesarean section, the former should be selected. This is a rule of obstetric ethics which cannot be set aside. Fortunately the brilliant successes recently had by a few operators in Germany render it highly probable that embryotomy upon the living fcetus will soon be restricted to very narrow limits. Winckel admits craniotomy upon the living child, first, if its life is much en- dangered so that its chances of being saved are improbable, in order to protect the mother, as far as possible, from the dangers of a more difficult operation; and, second, if a relative indication for the Caesarean section exists, that is, if the child cannot be delivered through the pelvis as it is, and the mother firmly refuses the operation. " The percentage of maternal deaths in the hands of skilful operators is reckoned at o after perforation and as at least 8.4 per cent. after the Caesarean section. The former is entirely free from danger, and the latter especially in the hands of an inexperienced man, only can be designated as quite dangerous; therefore, perforation of the living child will be considered justifiable in many cases." Winckel also states that craniotomy must not be performed on a living child without the mother's consent. Auvard makes the mortality of embryotomy for the mothers 6 per cent., the 1 " Ouid si in una tabula sint due naufragi, hique sapientes, sibine utervis rapiat, an alter cedat alterP Cedat vero; sed ei, cuius magis intersit vel sua, vel reipubhcse causa, vivere. n„iH «i haer naria in utroque ? Nullum erit certamen, sed, quasi sorte aut micando victus, aSterUedaraltePr" (Cicerone Officiis, Book III., xxiii. Pereya's ed.) 672 SCIENCE AND ART OF OBSTETRICS. fcetal mortality of course is 100; that of hysterotomy, 25 per cent, maternal, and 8 per cent, foetal. From these statistics, differing as it will be observed from Winckel's, he draws the conclusion that hysterotomy has four times greater peril for the mother than embryotomy, and on the other hand that it saves twelve times more infants than embryotomy, which sacrifices all. " If the life of the child were as valuable as that of the mother there could be no hesitation in giving the preference to hysterotomy ; but the appreciations are different in this regard, and while the Caesareans say that the life of a perfectly developed infant is more precious than that of a woman unfit for procreation, the anti-Cesareans reply that the life of the newborn, surrounded by so many dangers, cannot be regarded as equal to that of a healthy woman." " If it were your wife or your child, what would you do?" The Caesareans are embarrassed, for if obedient to their principles, they will be considered bad husbands. On the other hand, the anti-Caesareans will seem to be bad fathers for they do not hesitate to sacrifice their child. In this question, which ought to be purely scientific, it is better that sentiment should not enter, or it becomes in- soluble. However, in accepting that the life of the mother has a greater value than that of the child awaiting birth, we may attempt to indicate the better choice between the operations, though confessing that it is arbitrary and admits of discussion." Cancer of the uterus, or of the vagina, suggests hysterotomy rather than em- bryotomy, is one of the statements of Auvard, which may be accepted. Again, if the pelvic contraction be such that a living child may be born were premature labor induced, and the pregnancy is at term, embryotomy is selected with the hope that a subsequent pregnancy may occur, and be prematurely terminated, is also an opinion expressed by Auvard. The more difficult cases for decision are those in which it is impossible, on account of the pelvic deformity, for a woman to give birth to a living child though premature labor be induced, and embry- otomy can be done with little risk to the woman's life. Here Auvard, Winckel, and, indeed, the majority of obstetricians, would leave the decision to the woman herself. I think most practitioners will coincide with the opinion of Naegele, in saying that if the indication is only relative and the mother, in sound mind and after mature reflection, positively refuses to submit to the Caesarean operation, it would be an unjustifiable cruelty to compel her to undergo it. Dr. Jaggard has given, in the American Journal of Obstetrics, the following as the expression of Carl Braun's views as to the relative indication for the Caesarean operation : Caesarean section on the living woman, for the preservation of the living foetus in pelvic deformity—in which the child, dead and diminished in volume, can be extracted through the pelvic canal, and the health of the mother can with prob- ability be preserved by the perforation of the child's head—is not permissible under the following conditions : a. When the paiturient woman, in full consciousness and without any direct coercion, declines Caesarean section. b. When the parturient woman is rendered unconscious by disease (eclampsia, meningitis, apoplexy, etc.), by medicines (chloroform, ether), by poisons, or intoxicating drinks. c. When the child's life has been imperilled by uterine contractions, attempts at version, or the forceps, or when the child is deformed or not viable. For a series of years not a single parturient woman in the Vienna Lying-in Hospital has determined to submit to Caesarean section upon the ground of the relative indication. Indications.—Those relating to the pelvis, or caused by cancer of the uterus or vagina have already been stated. The operation has also been done in hypertrophic elongation of the cervix and in cicatricial contraction of the vagina. Excessive size of the foetus, EMBRYOTOMY. 673 or a neglected shoulder presentation in which version is impossible or would be attended with imminent danger of rupture of the uterus are indications. It may be necessary in a brow, or parietal presen- tation, or in that of the face when anterior rotation is impossible. Craniotomy.— Most frequently reduction of the size of the fcetal head is necessary, and the first step is perforation. So, too, perfora- tion precedes the application of the cephalotribe, or its most recent modification the basiotribe, or of the cranioclast. Perforation.—Reduction of the size of the head, whether this conies first or last, is necessary. Supposing the head presents, the first step is perforation of the cranium. In order that this may be done readily and safely, the head must be held by an assistant, who presses upon it through the abdominal wall with his hand during perforation. Smellie's Scissors. Fig. 230. Naegele's Perforator. Fig. 231. Blot's Perforator. Fig. 232. Martin's Trephine. Carus was the first to apply forceps in order to secure this immobility, a oractice in which many have imitated him. The instrument selected for perfora- tion may be Smellie's scissors, or Naegele's perforator, or Blot s, or a trephine, MWtincke^°rsSLmtPh1at he always prefers scissors if a fontanelle or suture can be reached, but if it cannot be, and the cranial bones are very hard, he uses a trephine. 43 674 SCIENCE AND ART OF OBSTETRICS. Fritsch condemns all trephine perforators—those of Kiwisch-Leissnig and of Braun, among them—because of the difficulty in thoroughly cleaning them ; for in order that this can be properly done they must be returned to the instrument- maker each time after they are used. If the operator has Tarnier's basiotribe, he will need neither scissors nor trephine. Fig. 233. Simpson's Basilyst. The patient occupies the position advised for the application of the forceps ; anaesthesia is usually unnecessary. The operator, after the vagina has been washed out with an antiseptic solution, and the hands and instrument have been made aseptic, introduces two fingers of the left hand into the vagina and brings their tips in con- tact with the fcetal head; the scissors, or perforator, now held with the right hand, has the blades guided along the palmar surface of the fingers in the vagina until their points are brought in contact with the fcetal skull and placed perpendicularly to the bony surface. It is better to perforate bone than to enter through a suture or a fontanelle, for then the opening is more likely to remain patent instead of being closed by the approximation of the fcetal bones under compression. The next step is, while carefully guarding the instrument from slipping, by a boring movement to make its points penetrate through the bone; when this is accomplished the blades are caused to enter as far as the shoulders of the instrument, then opened so as to divide the bone, and after this closed, given a quarter rotation and again opened, so that an incision perpendicular to the first one is made. The next step is to thrust the scissors deeply in the cranial cavity, move the blades in different directions, so as thoroughly to break up the brain substance, including the medulla oblongata—if, by misfortune, it has been necessary to operate upon the living fcetus—for more than once after a craniotomy, when this precaution was not taken, the child has been born alive and even lived for some days in a horribly mutilated condition, greatly to the distress of the family, if not to the disgrace of the obstetrician. In case a trephine be used for perforation, the instrument must be introduced and brought to press firmly upon the bony part selected, and held in position with the fingers of the left hand, while the right hand is used to give slow rotary movements to the crown after the screw has penetrated the bone. After perforation the nozzle of a syringe is introduced into the artificial opening and a stream of warm carbolized or creolin water thrown in, so that the brain substance is washed out. The delivery may now occur spontaneously, or the fcetus may be extracted with the crotchet, or a cranioclast may be used, an instrument which, if carefully used, does not deserve the reproaches that have been cast upon it (Figs. 234, 235, and 236). EMBRYOTOMY. Fig. 234. Crotchet. Of course, if the practitioner has at hand a cranioclast or a cephalotribe delivery can generally be more promptly accomplished with either than with the crotchet; but with most practitioners the last is more available than the other instruments. In order to prevent the injury that may be done the mother's soft parts by the crotchet slipping a guarded instrument has been invented, but it will prove a most inefficient one for traction ; it is guarded alike from doing any good as well as any harm. The hook-like end of the instrument is introduced into the fcetal skull, a firm hold secured, and two fingers placed upon the outside of the head, directly opposite the point at which the instrument has caught, so as to pre- vent its slipping, or if it does, to guard the vagina from harm ; if slipping occur, another part of the fcetal head should be sought and a firmer hold secured. Care must be taken not to tear the fcetal scalp, for this protects the mother's parts from being injured by the otherwise exposed edges of bones or of their fragments. Cranioclasm.—In most cases the cranioclast is one of the most efficient instruments not only for breaking up the bones of the skull, but also for extraction. The cranioclast is the invention of the late Sir James Simpson. It is composed of two separate blades, fastened by a button joint, one for introduction within, the other to be placed without the skull; when applied and locked the concavity of the external blade fits upon a convexity of the internal one, a por- tion of the fcetal skull being firmly included between the two. The cranioclast as now made includes a transverse arm connecting the ends of the handles ; this arm has a screw, and a nut after its applica- tion causes the handles to be brought closer together and makes them immovable, so that a firmer and fixed grasp upon the fcetal head is secured. 6j6 SCIENCE AND ART OF OBSTETRICS. Ccphalotripsy.—The cephalotribe, devised by the younger Baudelocque (nephew of the great obstetrician) in 1829, consists of two strong forceps branches, in some instruments straight, but in others having the pelvic curvature of forceps; the blades are very narrow, so as to admit of their introduction into a contracted pelvis, and in most instruments solid, but in Bailly's and in some others fenes- trated—a single fenestra in each blade in some, but in others, as Tarnier's, three. The instrument is provided with a transverse bar made as a screw and applied to the ends of the handles. The blades are applied to the sides of the fcetal head, which is then compressed by means of the powerful screw at the handles. Per- foration ought always to precede the application of the cephalotribe, but it is unnecessary to wash out the cranial cavity, for the strong pressure to which the head is subjected will force out the contents. In most of cases in which the cephalotribe is necessary there is such narrowing of the inlet that the head is in a transverse direction, and the blades of the instrument seize it in the direction of the suboccipito-frontal diameter. But as it is important to break up the base of the cranium, Wasseige1 advises when one cannot seize the head by the biparietal diameter, to diagonalize it, as far as possible, before the application of the instru- ment—"that is, we bring the head anterior and then apply the instrument in the oblique pelvic diameters : these applications can be made where the pelvic nar- rowing is between 5.5 centimetres and 7.5 centimetres—that is, between 2.1 and 2.7 inches—while below the former oblique applications are impossible." After the crushing, which must be done slowly, one or two fingers should be introduced to ascertain that the part of the head which has been widened in op- position to that which is narrowed lies in the longest pelvic diameter, and that no spiculae of bone are exposed which will tear the mother's soft parts in the extrac- tion of the head, and if these are found, the fingers are kept in the vagina to protect it from injury during the operation. To bring the long diameter of the foetal head in correspondence with that of the pelvis, a quarter rotation of the instrument, still of course retaining the head in the grasp of the instrument, is made, and then traction exerted as in forceps delivery. In some instances before the latter can be effected, it is necessary to remove the cephalotribe, especially if the instrument slip, and apply it in another direction so as more completely to crush the skull. If extraction remains impossible after repeated crushings, some operators advise waiting a few hours until uterine contractions have so moulded the head that its transmission becomes possible. It may be added that the cephalotribe is an instrument which has largely been superseded by the cranioclast, and many obstetricians entirely reject it. Lamination.—This name is given to the process of dividing the head into two or more segments. The first method is that of Van Huevel; in 1842 he devised his forceps-saw, and successfully applied it in 1844. The fundamental idea is the section of the cranium by a saw acting from below above between the blades of a forceps, and dividing the head, more especially the base of the cranium, into two portions. Other varieties of the forceps-saw have since been invented. The expense of the instrument and its somewhat complicated character will prevent its general use in craniotomy. Barnes says that it is difficult or impossi- ble to apply when the conjugate is reduced to 2 inches, or even to 2.5; Wasseige, however, states that the instrument can be used when the conjugate is only 30 millimetres, 2.1 inches. Barnes, 1869, showed that section of the foetal head could be made with the wire ecraseur, and this simple method is to be preferred. Breaking the Base of the Facial Head.—Various instruments have been pro- posed for this purpose, but only three will be mentioned: the transforateur of Hubert, devised in i860 ; the basilyst of Simpson ; and the basiotribe of Tarnier. The first consists of a firm rod of steel, terminating at one end in a transverse handle, and at the other in a pear-shaped screw with a sharp stiletto-like point, and of a protecting branch which is attached to the rod; it is shaped like the forceps blade, and has a conical opening in its lower end to receive the point of the perforator. This point, covered with wax, or concealed by the finger of a rubber glove, when introduced, is made to penetrate the cranial vault, either through a bone, a suture, or a fontanelle, and then by movements of rotation the 1 Op. cit. EMBRYOTOMY. 677 opening is gradually enlarged until the entire pear-shaped portion enters; the next step is by free movements of the instrument to break up the cerebral tissue. After this the point is guided to the occipital foramen, and when this is found, the former should be directed toward the chin, and when at a distance of 4 or 5 centimetres, 1.5 to 1.9 inches, in front of the foramen the sella turcica is reached, which is then perforated by means of rotary movements, and the protecting branch is applied just opposite upon the fcetal head. The basilyst of Alexander R. Simpson, which Wasseige states is only a modification of the diatripteur of Didot, was presented to the Edinburgh Obstetrical Society, January, 1880, and an improvement of it January, 1883, when the inventor reported a case in which basilysis was successfully employed in dystocia from hypertrophic elongation of the cervix (Fig. 235). The instrument has also been successfully used directly to break the base of the skull in narrowing of the pelvis ; in one instance the transverse diameter of the base was reduced from three to two inches. Whether, as Simpson has said, basilysis is the operation of the future or not, he certainly has invented a simple and ingenious instrument for accomplishing it. Fig. 237. Tarnier's Basiotribe ; the parts united. The basiotribe1 of Tarnier was presented to the Paris Academy of Medicine, December, 1883. It combines an excellent perforator 1 It has since been usefully modified by Barr. 678 SCIENCE AND ART OF OBSTETRICS. of the cranial vault and a cranioclast; it does not break the base of the head, as do the instruments of Hubert and Simpson, by pene- trating it, but by crushing. Fig. 237 represents the several parts of which the basiotribe is composed, united. In operating the perforator is made to penetrate the cranial vault, after which the left or short blade of the instrument is introduced, and fastened by the catch, C, and then the right or long blade; the screw is then fastened to the ends of the handles, and turned until sufficient crushing is effected. Fig. 238. Fig. 239. Application of Tarnier's Basiotribe. //^ ,. '"> {3)jf^k Jm^s£^mML. K- Basiolripsy Accomplished. Perforation in Presentation of the Face.—This is more difficult than perforation in vertex presentation; it may be done through the pal- atine vault, through one of the orbits, or through the frontal bone, the last being preferred. Perforation in Head-last Labor.—An assistant holds the body of the child to one side, and the operator perforates the head at one of the posterior lateral fontanelles. Chailly advised that the opening be made through the palatine vault, condemning acting either upon the forehead or the occiput, because the point of the perforating EMBRYOTOMY. 679 scissors could not be directed perpendicularly, but must be placed obliquely to either bony surface, and hence were liable to slip, in- juring the mother. In concluding the subject of craniotomy it is to be remarked that the student should not think it a very simple and easy operation that can be quickly performed and delivery promptly effected. This is true in some cases only, but, in many, difficulties attend almost every step in the process, and the delivery may not be accomplished for hours. Therefore the operation is not to be undertaken unless the proof be clear that it furnishes the best chance for the mother, and on the other hand, not delayed until her powers are so exhausted that she is liable to perish before or after its accomplishment. Decollation, Derotomy, or Decapitation.—In case of shoulder pre- sentation, when turning is impossible from the condition of the uterus, or from the presenting part being wedged in the pelvis, it is necessary in most cases to divide the neck. This operation may be done with the scissors of Dubois, with the decapitation hook of Braun, or simply by means of a piece of strong twine1 thrown around the neck, used as a saw, to-and-fro movement given it, the maternal parts being protected from injury by the ends of the string being passed through a tubular speculum, and in two or three minutes the neck will be divided. If the scissors of Dubois is used, or the hook of Braun, the first step is to pull down the pre- senting shoulder by traction on the corresponding arm ; the next step is, with thumb and finger of the left hand to seize the neck so that the hook may be passed over it, or—using scissors—hold it until the division is made ; it may also be held by the ordinary blunt hook instead of by the fingers. If Braun's hook is used, after placing it over the neck, strong traction with partial movements of rotation is employed, and the neck is quickly severed. The body is then readily extracted in most cases by pulling upon one of the arms; the head is withdrawn by traction with two fingers in the mouth, or by the forceps—in some instances it may be necessary to lessen its size. Melotomy.—It may happen that an upper or lower limb is in the vagina, and so greatly swelled that manipulations upon the body of the child are impossible in consequence of the obstruction ; the child being dead, the member is amputated by Dubois's scissors. Spondylotomy.—This is the name given to division of the vertebral column at some other point than the neck. It may be done with the scissors of Dubois. Evisceration.—This is chiefly resorted to in those cases in which an impacted shoulder presentation prevents access to the neck. Again, the scissors of Dubois, or a similar instrument, will be the most useful in opening the chest; after the contents are in part re- moved, an effort is made to deliver the fcetus, of course doubled upon itself, by the crotchet, or the blunt hook. 1 This method of decollation has been repeatedly done in practice, more especially in France • I have been in the habit for some years of illustrating it before my class at Jefferson Medical College, using a full-grown foetus, and Budin's obstetric manikin. CHAPTER V. « THE CESAREAN OPERATION AND ITS SUBSTITUTES. By the Cesarean section or operation is meant opening the abdomen and the uterus, and the extraction of the fcetus through the incision. The name has no connection with Caesar, but is derived from the operation itself, co?so matris utero. The operation performed after death is a very ancient one, having been estab- lished by the Romans as a law centuries before the Christian era, its purpose being to secure citizens to the State. The Christian Church strongly enjoined the operation, even when the mother's death occurred quite early in pregnancy. The first known operation upon the living subject was by Jacob Nuffer,1 a sow-gelder, in 1500, the patient being his wife; she recovered, and afterward bore several living children. Kleinwachter states that the next operations were by Ddring, 1531, and by Donat in 1549, and that the first operation in Germany was by Trautmann, in Wittenberg, in the year 1610. Terms designating the Cesarean Operation and its Chief Substitutes. —The term laparotomy2 has been strangely perverted from its etymological and original meaning, and applied as part of a com- pound word to the Caesarean operation, to that of Porro, and to that known by the name of Thomas. It will be better, while protesting against this great perversion, to replace the various compounds of laparotomy by correct terms, and thus the Cesarean operation will be called gastro-hysterotomy; gastro-hysterectomy is the proper designation for Porro's operation, and gastro-elytrotomy, the name used by Baudelocque, is the appropriate one for the operation com- monly called laparo-elytrotomy. I am very glad to strengthen the criticism which I have here repeated as given in the first edition, with the following interesting communication from Dr. Robert P. Harris, not less able in collecting and analyzing obstetric statistics than he is in philological research. Why should abdominal surgery continue the inaccuracy into which it was led by Fiedler, of Wurtemberg, in a student's thesis in 1811, and still call a Caesarean operation, a "laparo-hysterotomy" and a Porro operation, a "laparo-hysterec- tomy," when it is well known that the Greek word ^airapn applies to the parts 1 The earliest history of this operation which I have had the opportunity of reading is given by Scultetus in his Armamentarium Chirurgicum, Frankfort, 1666. We have the picture of a woman at the end of her first pregnancy some days in labor without relief from nature's efforts, or from the assistance of " thirteen midwives and several lithotomists.'' The husband, despair- ing of help from these means, suggests others to his wife, and she consents. Next he procured a licence from the civil authority, and returning home first addresses the midwives, exhorting them to be brave, but advising the timid to retire, and as a consequence eleven withdrew, only two remaining to assist him; the lithotomists also remained. He places his wife upon the table, implores Divine help, and then incises the abdomen nonsecus ac alicuiporco. Almost immediately after the incision had been made a living child was extracted uninjured, and the woman made a rapid recovery. 2 Laparotomie (from Xaxapa, flank, and to/j.//, section ). Operation for lumbar hernia or for artificial anus, practised in the lumbar regions. Litre and Robin's Dictionary of Medicine Surgery, etc. THE CESAREAN OPERATION AND ITS SUBSTITUTES. 681 between the short ribs and the ilium. Fiedler witnessed a true laparotomy under Dr. Gottlieb Heinrich Ohle, on Oct. 17, 1810, the patient, a man of fifty, lying on his right side, and the incision to expose the colon being made vertically through the left flank. He took it upon himself to extend the lanaparo/ifj over the whole abdomen, and coin, without explanation or argument, the terms " laparo-hystero- tomie," "laparo-gastrotomie," and "laparo-enterotomie." Other medical students at later periods extended the terms in their theses, and writers of dictionaries did the same until, in 1844, Kraus, of Gottingen, had 26 laparos in his dictionary. If we reject gastrotomy as applied to the abdomen, and confine it to the stomach itself, we still have in Koilia (belly), a Greek root long in use in '' cceliac," " cce- lialgia," " cceliocele," " ccelio-paracentesis.'' Rufus, of Ephesus, wrote in the second century, A. D.: "The omphalos (navel) is a hollow, which occupies the middle of the koilia (abdomen), where we cut the veins which nourish the fcetus ; the middle part of the hollow is the akromphalon." He used koilia and gaster as synonyms for abdomen. These facts justify us in changing the laparos into ca'lios for correctness, and adopting ccelio-gastrotomy, ccelio-hysterotomy, puer- peral ccelio-hysterectomy (Porro operation), ccelio-hysterectomy, cceliotomy, ccelio- elytrotomy, ccelio-enterotomy, etc. Indications for Gastro-hysterotomy.—These are absolute and rela- tive. When there is such obstruction of the birth-canal, whether arising from uterine tumors or tumors of adjacent organs, or of the pelvis, or from conditions of the cervix or of the vagina, or from pelvic contraction, that even a mutilated fcetus cannot be delivered through the natural passage—the operation should be done. In regard to pelvic contraction as furnishing an absolute indica- tion for gastro-hysterotomy, we may accept the limits assigned by Winckel, and which have been quoted on a previous page, 2.6 inches conjugate in a generally contracted pelvis, and 2.1 inches in a flat pelvis. Yet embryotomy in pelves that approximate such narrowing will, in the hands of those who are not expert and pos- sessed of the necessary facilities for operating, often if not usually prove more difficult, and more tedious than abdomino-uterine sec- tion, or exsection. Nevertheless let these limits be recognized. The relative indication is given by those pelves through which a living child cannot be extracted at term, or by the induction of premature labor, or if the pregnancy has advanced beyond the time for the safe induction of labor. This question has been sufficiently considered under the head of embryotomy. Time of, Preparation of Patient for, and Mode of Operating.—If a choice of time can be made it is preferable to do the operation about the end of pregnancy, but before labor begins. The patient is given a bath the evening before, soap being used with the water, and the skin thoroughly cleansed. The bowels are moved freely in the morning of the day on which the operation is done, the vagina thoroughly cleansed by an antiseptic injection, and immediately before operating a catheter is introduced so that it is certain the bladder is empty. The sub-umbilical region is shaved, the part washed with soap and water, then with ether. The lower limbs are each wrapped with a blanket or shawl, and the chest properly pro- tected from cold. The operator has ready a bistoury, twelve haemo- static forceps, twelve sponges, scissors, needles, needle-holder, silk of two sizes, rubber tubing—for encircling the neck of the uterus, 682 SCIENCE AND ART OF OBSTETRICS. if he prefers this method of preventing hemorrhage—a funnel to which a rubber tube is attached, and to the lower end of the latter a metal or hard rubber canula, for washing out the abdominal cavity, iodoform, iodoform gauze, antiseptic cotton, flannel bandage for the abdomen, safety pins, two hypodermatic syringes, ether, brandy, solution of ergotin, or fluid extract of ergot, and Tait's or other constrictor, as in preparation for hysterectomy, should this prove necessary. He must have—also, wire, and two long, thick needles. There must be at hand hot and cold water, basins and towels. The operating table should be narrow; the operator is upon the patient's right side, and his chief assistant upon the left. The abdominal incision must be about six inches in length, and is made through layer after layer in the linea alba—there is no difficulty in finding this when the tissues are stretched as they are in pregnancy—haemostatic forceps being used as re- quired for bleeding vessels; as the peritoneum is approached, it is advisable for the operator and assistant to lift up the tissues to be cut, each with forceps, and the incision is made between the points of the two instruments. The abdominal cavity having been opened, the incision if not long enough is increased by scissors; then the uterus is brought out through the opening, and encircled below the ovaries and as close to the neck as possible by rubber tubing, and constricted or, instead of this method of guarding against hemorrhage, an assistant compresses with his fingers the lower lateral part of the uterus. If the uterus is opened outside the abdominal cavity, a few sutures are introduced at the upper part of the incision so as to close it partially, and thus prevent the escape of amnial fluid or blood into the peritoneal cavity. Next, the anterior uterine wall is incised in the median line—if the organ be in situ, an assistant presses it on either side of the abdominal wall so as to bring it close against the cut in the abdominal wall, and also corrects any obliquity which there may be. " We can dis- tinguish previously, by the distinctness with which the extremi- ties are made out, whether the placenta is attached in front or not" (Winckel). If it should be found in this position, we may change the place of incising the uterus. But if the discovery is not made until during the incision, there will be a startling gush of blood ; this is only for a moment, and the operator does not delay an instant. The incision of the uterus completed, an assist- ant—this is Winckel's advice—places the palmar surface of each index finger at the ends of the opening, thus lifting up the uterus, and preventing its rapid retraction. Next the operator ruptures the membranes, introduces one hand into the sac, and the other hand assisting externally, brings the child out of the uterus, usually drawing forth lower limbs and hips first, shoulders and head last; if the incision in the uterus is not large enough for the child to pass through, it must be lengthened; when the child cries and breathing is established, the cord is divided, and after this it is put in charge of an assistant. The placenta and membranes are delivered through the wound; if not spontaneously detached they THE CESAREAN OPERATION AND ITS SUBSTITUTES. 683 are manually separated from the uterine wall. The open condition of the cervical canal is next secured, and the uterine cavity is washed out with a I to 2 per cent, solution of carbolic acid. Next the sutures for the uterine incision are introduced, and here is the great merit of Sanger's improvement in the Caesarean operation, an im- provement which has given the operation in recent years a marvel- lous success, conjoining with deep, superficial sutures so as to give the best security against hemorrhage. The deep sutures are made down to, but do not include the uterine mucous membrane; there may be five or six of, or seven of these, and then probably twice as many superficial sutures : the material for the sutures is of antisep- tic silk. After the introduction of the stitches, the constriction of the uterus, whether by fingers or tubes, is discontinued. If hemor- rhage from the wound follows, additional stitches; if from relaxed womb, uterine injections of hot water, ergot hypodermatically, tamponing with iodoform gauze, and should these means fail, supra- vaginal amputation of the uterus, known as Porro's operation, may be required. But such hemorrhage is exceptional, and supposing it absent, the next step is " the toilet of the peritoneum," thorough washing out the abdominal cavity with water as hot as can be com- fortably borne; for this purpose nothing is better than the appara- tus previously mentioned. Following the thorough cleansing of the abdominal cavity is the uniting the abdominal incision with stitches, silk being generally used; these are chiefly deep, includ- ing the peritoneum, and after they are introduced and tied, superfi- cial ones are employed at parts where the skin gaps. Iodoform is sprinkled upon the line of incision, antiseptic gauze laid next to the abdomen, then cotton batting, and finally a firmly fitting flannel bandage applied. The after-treatment is that of abdominal section in general, and therefore need not be given here. Gastro-hysterectomy, Supra-vaginal Amputation of the Uterus, Porro s Operation.—Porro, of Milan, in 1876, having come to the conclusion that the great mortality of gastro-hysterotomy was due to leaving the injured uterus in the abdominal cavity, performed supra-vaginal amputation after the extraction of the child. The suc- cesses were superior to those obtained by the usual Caesarean ope- ration, but with the improvement in the method of doing the latter introduced by Sanger, the mortality of the two has been reversed so that the profession generally prefer gastro-hysterotomy to gastro- hysterectomy in most cases; nevertheless they all admit a limited field for the latter. Mr. Tait is one of the enthusiastic advocates of Porro's operation, declaring that it "will revolutionize the obstetric art, and in two years we shall hear no more of craniotomy and evisceration, for the new method will save more lives than these proceedings do, and it is far easier of performance." Mr. Tait had performed gastro-hysterotomy four times, a fatal result following in all, but in three supra-vaginal amputations of the uterus all the women recovered; since that time, I believe, he has had two other successful cases. Nevertheless the o-eneral verdict of the profession cannot be set aside by the experience and the opinion of one man, no matter how great his eminence and ability. 684 SCIENCE AND ART OF OBSTETRICS. Indications for the Operation.—Parish in his valuable1 contribution to the subject states that the operation should be done when, through unwarranted delay, or by reason of unwarranted attempts at delivery, the uterine tissues have been seriously injured, or when the child is putrid, or when the patient is greatly exhausted by in- cipient or established septicaemia, and when there is extensive fibroid or fibro-cystic degeneration of the uterine body. Among the indications given by Winckel are: pregnancy in a rudimentary horn, the ovary on that side to be also removed, in hernia uteri gravidi bicornis inguinalis, if it cannot be reduced, in very exten- sive adhesions of the vault of the vagina, and in echinococci of the uterine wall and of the pelvic connective tissue, which cannot be removed in any other way and which make the pelvic canal abso- lutely impassable, and in severe puerperal osteo-malacia. Schultze's removal of the uterus seven days after delivery has been mentioned, as well as the indication given by uterine hemorrhage after gastro- hysterotomy. Supra-vaginal amputation of the uterus is also indicated after abdominal section for ruptured uterus if the hemorrhage cannot be otherwise arrested. Method of Operating; Muller's Modification.—The preparation and the abdominal section are the same as for gastro-hysterotomy; so too, the incision of the uterus and the extraction of the child, as directed by Porro. Muller, however, modified the operation by having the abdominal incision so large as to permit eversion of the body of the uterus, and encircling the lower portion with a rubber tube, and then the uterus is rapidly opened and the child extracted. No matter which method is employed, the placenta and membranes are left in the uterus. After cleansing the abdomen the upper por- tion of the abdominal incision is closed with sutures. Next the uterus is amputated with scissors, knife, or by the thermo-cautery about three-fourths of an inch above the constricting rubber. If the external treatment of the pedicle is employed, and this is the general rule with operators, the stump is encircled with a wire con- nected with a constrictor, Cintrat's, Tait's, or other, the wire tight- ened, the rubber removed, and two long, thick needles passed through the stump; these transfixion needles hold the stump out- side the abdominal cavity after the incision is completely closed. The advantages in using wire is that in case hemorrhage occurs, as may happen from shrinking of the pedicle, a few turns of the screw tighten the wire so that the bleeding is promptly arrested. Mr. Tait refers to the operation as the easiest " in abdominal surgery, and every country practitioner ought always to be ready to perform it. No special instruments are required—nothing but a knife, a piece of rubber drainage-tube, two or three knitting needles, and a little perchloride of iron." The stump is brushed over with a solu- tion of the perchloride of iron. The transfixion needles are re- moved in ten to twelve days. In case the intraperitoneal treatment 1 First edition of this work. THE CESAREAN OPERATION AND ITS SUBSTITUTES. 685 of the stump is selected, the operator begins by carefully stitching the mucous membrane of the stump with silk sutures; next the muscular tissue is stitched over this, and finally the serous above it. If any bleeding occurs upon removing the rubber tube, additional stitches are taken, or the afferent vessels of the broad ligaments ligated. When all bleeding is stopped, the pedicle is dropped in the abdominal cavity. Harris states that the mortality of the Porro operation is double that of the Sanger. Gastro-elytrotomy.—This operation was first suggested by Jorg, in 1807, attempted by Ritgen, in 1821, advocated by Auguste Baude- locque in 1823, twenty years later attempted twice by him, the first attempt a failure, but in the second a dead child delivered and the mother perishing seventy hours afterward, done in Italy in 1857, the child saved but the mother dying, was again brought before the pro- fession by Thomas, in 1870. Whatever of fame and success the ope- ration had during the brief period of its limited acceptance is chiefly due to T. Gaillard Thomas. But, as Winckel states, the operation rested on false premises regarding the peritoneum. Its success too, is inferior even to the operation of Porro. Clarke1 gives the mater- nal mortality as 54 per cent., and the fcetal as 36 per cent. The special purpose of the operation was to avoid exposing the perito- neal cavity, and it accomplished this by making an opening into the vagina, beginning with an incision upon one side about an inch above Poupart's ligament; the tissues were divided to the peri- toneum, and this was separated until the lateral cul-de-sac of the vagina was reached, the wound was four and a half to five inches long ; a small incision was made into the vagina, and the opening enlarged by tearing, the os was dilated : and child and placenta were removed through the abdominovaginal wound. "The operation has no future." Winckel, in condemning it, hopes that his lines may hasten it once more to a silent burial, and that it may have no resurrection. Symphysiotomy.—This operation done first by De la Courrue in 1654, revived by Sigault in 1768, then abandoned, has in recent years been revived in Italy by Morisani. The American obstetri- cian will find no condition justifying its performance, and, therefore, it is dismissed with this brief reference. Post-mortem Delivery.—The Caesarean operation was originally done in case of women advanced in pregnancy dying undelivered. This was the civil law in Rome2 dating from the time of Numa Pompilius. But the fact that post-mortem delivery by an abdomino- uterine incision was recognized in ancient mythology—as is exhib- ited by the history of the birth of Bacchus, the god of wine, and 1 Contribution a letude de la laparo-elytrotomie, 1887. 2 In Plutarch's Lives it is stated that Scylla having died, his wife, " Valeria was afterward delivered of a daughter, named Posthuma ; for so the Romans call those who are born after the father's death.'' It might be justly implied from this that the removal from a dead mother of a living child was unknown among the Romans. 686 SCIENCE AND ART OF OBSTETRICS. that of .Esculapius, the god of medicine—renders it probable that the operation is still older. The Church, as Hubert remarks, merely reproduced the injunc- tion of the Roman law in the following decree of its Ritual : Si mater praegnans mortua sit, fructus quam primum caute extrahatur. Three questions arise in reference to post-mortem delivery, the first relating to the period in pregnancy in which death occurs that this should be done; the second as to the method, and the third as to how long after the mother's death the operation can be done and a living fcetus extracted. In regard to the first, Duer,1 in his elaborate paper, gives the rule that the foetus should be artificially removed in all " otherwise favorable cases which have attained to the neigh- borhood of the sixth month of pregnancy." As has already been indicated, the method of delivery after the mother's death, exclusively recognized in ancient times, and indeed that which has most generally been employed since, was the Caesarean section. Unfortunately, in some instances, in which this method has been resorted to the woman was not dead, and more than one operator has fled horror-stricken upon finding the manifestations of life when he thought his incisions were made upon a corpse. Thevenot2 has earnestly contended for delivery through the natural passage, as successfully accomplished by the Italian school, especially by Rizzoli, and asserts that the post-mortem Caesarean operation belongs to another age and ought to disap- pear from our practice. Depaul, in 1861, said, "I cannot too strongly insist with almost all those who have studied this sub- ject, upon the advantages which extraction of the infant by the natural passage gives. One ought not to hesitate in the application of a bistoury to the cervix and relieving resistance by multiple incisions. There can be thus obtained in a few seconds suffi- cient dilatation to perform version or to apply the forceps." There have been several successful deliveries effected in this way,3 but of course it is only applicable in normal conditions of the pelvis, and will be most successful when the death of the mother occurs during labor. The method is especially applicable in cases of apparent death, or when there is doubt in regard to the question as to whether life is actually extinct. If the Caesarean operation is employed, the same precautions should be used as if it were being done upon the living subject. In 1 American Journal of Obstetrics, volume xii. 2 De l'Accouchement artificiel par les voies naturelles substitue a l'operation Cesarienne post-mortem. Paris, 1878. 3 Dr. Barton C. Hirst has recently reported a case in which the post-mortem Caesarean operation was avoided by dilatation of the os while the woman was dying ; the dilatation was accomplished in a few minutes, and a living child extracted. Philadelphia Medical News, May 24, 1890. According to Auvard, this method of delivery, accouchement force pendant l'agonie, was directed by Costa in 1827. He states that unless there is an urgent indication, it is preferable not to trouble the final minutes of the dying by an intervention which can be as well done after life ceases. Nevertheless in Dr. Hirst's case there does not seem to have any disturbance of the patient by the intervention. Millot, De l'Obstetrique en Italie, 1882, gives 14 cases, the first in 1858, the last in 1870, of this method of delivery, 5 of the 14 women suffering from pulmonary phthisis. Only 3 of the 14 children were delivered alive. THE CESAREAN OPERATION AND ITS SUBSTITUTES. 687 Duer's table, including 55 cases, "the time that elapsed between the death of the mother and the removal of a living child was in 40 as follows: Between I and 5 minutes, including 'immediately,' and 'in a few minutes,' there were 21 cases; between 5 and 10 minutes, none; between 10 and 15 minutes, 13 cases; between 15 and 23 minutes, 2 cases; after one hour, 2 cases, and after 2 hours, 2 cases. In addition to the two cases of survival for two hours after the death of the mother, which Duer has given, Hubert mentions one in which the mother was instantly killed by being struck by a railway locomotive, both her legs being cut off and her head fractured, and yet two hours after the accident a living child was removed by the Caesarean operation. Nevertheless such prolonged continuance of life is altogether exceptional,and indeed in the great majority of cases in which the delivery is post-mortem, no matter how prompt that delivery, or what the method, the child will be dead. INDEX. ABDOMEN, appearance of the, in preg- nancy. 172 discoloration of the, in pregnancy, 172 increase in size of the, without increase in size of the uterus, diagnosis of, from pregnancy, 212 in plural pregnancy, 209 Abdominal contractions in labor, 363 palpation in pregnancy, 200 pregnancy, 329 secondary, 330 section in the treatment of ectopic preg- nancy, 336 tenderness in puerperal septicaemia, 617 touch in pregnancy, 200 Abortion, 308, 355 after-treatment of, 320 beginning, treatment of, 315 causes of, 309 classification of, 308 definition of, 308 frequency of, 308 from causes belonging to the ovum, 311 from the use of medicines, 311 historical notice of. 623 indications for, 623 incomplete, 317 induction of, 623 inevitable, treatment of, 316 missed, 320 of maternal origin, 310 of ovular origin, 311 of paternal origin, 309 prognosis of, 313, 625 symptoms of, 311 time of, 308 treatment of, 314 of beginning, 315 of inevitable, 316 prophylactic, 314 Acardia, 190, 483 Accidental hemorrhage, 288, 351 treatment of, 352 Accommodation, 376 Accouchement, 17 Accoucheur, 17 armamentarium of the, 422 Acephalia, 483 Acute infectious diseases during pregnancy, 238 yellow atrophy of the liver during preg- nancy, 245 treatment of, 246 Adeno-phlegmon in the puerperal state, 604 Adipocere, 331 After-pains, 558 Air during pregnancy, 226 Albuminuria in pregnancy, 261 causes of, 262 course of, 263 symptoms of, 263 treatment of, 264 Allantois, 131 Amastia, 96 Amenorrhoea of pregnancy, 193 Amnion, the, 132 anomalies of, 300 fluid of, 133 formation of, 130 Amniotitis, 300 Amputations, spontaneous intra-uterine, 304 Anaemia in pregnancy, 258 causes of, 258 symptoms of, 258 treatment of, 259 pernicious, in pregnancy, 258 Anaesthesia, 418 general, 419 local, 421 Anencephalia, 483 Ankylotic, the, obliquely contracted pelvis, the, transversely contracted pelvis, 517 Anomalies of form and of position of the uterus during labor, 469 of organs adjacent to the uterus during labor, 474 of the amnial liquor, 300 of the amnion, 300 of the forces concerned in labor, 460 of the mechanism of labor in face presen- tations, 401 in pelvic presentations, 407 of the pelvis {vide Pelvis, anomalies of the), 497 of the umbilical cord, 296 Anteflexion of the uterus in pregnancy, 280 Anteversion of the uterus in pregnancy, 280 Antipyretic treatment of puerperal septicaemia, 6T4 Antisepsis in labor, 416 Antiseptic pads, 445 Aorta, compression of the, in post-partum hemorrhage, 545 Apoplexy of the placenta, 290 Appendages, fcetal, 132 Apron, Hottentot, 51 Arbor uteri vivificans, 63 vitae uterina, 63, 70 Area germinativa, 129 Areola mammae, 94 of pregnancy, 185 secondary, 185 Armamentarium of the obstetrician, 422 690 INDEX. Arm, dorsal displacement of the, causing dys- tocia, 477 Arteries, ovarian, 71 uterine, 71 Articulations [vide Joints). Artificial feeding of infants, 580 respiration, different methods of perform- ing, 441 insufflation through a tube passed into the larynx, 441 mouth-to-mouth insufflation, 441 Schultze's method, 441 Sylvester's method, 441 Ascites, diagnosis of, from pregnancy, 213 fcetal, causing dystocia, 483 Asphyxia in the new-born, 439 Asymmetrical changes in the pelvis, 507 Atrophy of the decidua, 290 of the placenta, 291 Attitude of the foetus in the womb, 156 Auscultation in the diagnosis of pregnancy, 204 in multiple pregnancy, 210 Axes of the pelvis, 33 Axis-traction by Poullet's method, 653 BAG of waters, 366 Ballottement, 199 vaginal, in placenta praevia, 340 Bandage, application of the abdominal, after labor, 444 Barnes, treatment of placenta previa, 347 Bartholin, glands of, 54 Basiotripsy, 676 Bathing during pregnancy, 228 the new-born child, 438, 578 Battledore placenta, 143 Bed, preparation of the, for labor, 425 Biestings, 565 Bifid uterus, 92 Binder, application of the abdominal, 444 Bladder, calculi in the, obstructing labor, 476 condition of, in first stage of labor, 426 discharges from the, of the child, 576 in the puerperal state, 569 irritability of the, during pregnancy, 194 Blastodermic vesicle, 127 Bleeding in eclampsia, 275 Blood, changes in the, in pregnancy, 170 eclampsia as dependent upon the, 273 Bloodvessels, changes in the, of the uterus, in the puerperal state, 564 Body, delivery of the, 436 Bowels, condition of, in puerperal state, 570 discharges from the, of the child, 576 Breasts, anatomy of the, 93 anomalies of the, 96 care of the, during pregnancy, 228 during lactation, 571. changes in the, during pregnancy, 184, 194 during the puerperal state, 566 development of the, 96 disease of the, during pregnancy, 287 in the puerperal state, 590 enlargement of the, in the new-born child, 577 Breech presentation, 403 Broad ligaments, the, 78 Brow presentation, 449 Bulb of the ovary, 81 Bulbs of the vagina, 58 Busch, metliod of, for performing cephalic version. 631 C.ESAREAN operation, 680 indications for, <>3i mode of performing, 681 preparation of patient for, 681 time for doing, 681 Calcareous deposits in the placenta, 292 Calculi, vesical, obstructing labor, 476 Cancer of the uterus during labor, 473 Capuron, cardinal points of, 377 Caput succedaneum, 374 changes in the, after birth, 577 in shoulder presentation, 414 secondary, 375 Cardiac diseases during pregnancy, 246 Care of the breasts during pregnancy, 228 medical, of the pregnant woman, 233 Carunculae myrtiformes, 52 Catarrhal decidual endometritis, 289 Catheter, introduction of the, 52 Caul, 368 Causes of labor, 355, 358 Cavity, the, of the body of the uterus, 63 of the neck of the uterus, 63 pelvic, 32 Central rupture of the perineum, 528 Cephalic version, 630 Cephalhematoma, 374, 577 Cephalotripsy, 676 Cervix uteri, 62 cancer of the, in labor, 473 in pregnancy, 287 cavity of the, 63 changes in the, in pregnancy, 181 in the puerperal state, 565 intra-vaginal portion of the, 56 portio vaginalis of the, 56 lacerations of, in labor, 533 shortening of the, in pregnancy, 182 softening of the, in pregnancy, 181 supra-vaginal portion of the, 56 tears of the, in labor, 533 Child, condition of the, during the seeond stage of labor, 429 the new-born, apparent death of, 439 artificial feeding of, 580 attention to, 436, 575 bathing of, 578 caput succedaneum of, 374, 577 cephalhaematoma of, 374, 577 changes in shape of head of, 577 circulation of, 164 discharges from the bladder and bow- els of, 576 dressing, 439 the cord of, 438 injuries to, by the forceps, 669 jaundice of, 578 milk, secretion of, in, 577 muguet in, 583 nourishment of, 578 skin of, desquamation of the, 578 changes in the, 578 sleeping of, 578 sprue in, 583 thrush in, 583 umbilical cord of, 576 hemorrhage from the, 577 urination, difficulty and pain in, 582 washing, 438 wet-nurse for, selection of, 579 Childbed {vide Puerperal state), 557 et seq. Choc foetal of Pajot, 208 Cholera during pregnancy, 241 INDEX. 69I Chorea during pregnancy, 248 treatment of, 249 Chorion, the. 134 Chronic infectious diseases, pregnancy in, 243 Cicatrices of the vagina complicating labor, 476 Circulation at birth, 164 the fcetal, 162 the placental, 162 the vitelline, 162 Circulatory apparatus, changes in the, in preg- nancy, 170 Clitoris, anatomy of the, 51 length of the, 90 Cloaca, 86 Clothing during pregnancy, 225 Coccyx, anatomy of the, 25 Cohen, method of, in the treatment of placenta praevia, 350 Coiling of the umbilical cord, 296 Colostrum, 565 Columnae rugarum, 56 Combination, the, of male and female ele- ments, 120 Combined turning in placenta praevia, 348 Complex presentation of the foetus causing dystocia, 489 Conception, 115 time of, 122 time of year most favorable to, 123 Conduct, the, of labor, 416 et seq. Confinement,- prediction of the date of, 217 Constipation in pregnancy, 234 in puerperal septicemia, 617 Contracted pelvis as an indication for the in- duction of premature labor, 266 Contractility of uterus during pregnancy, 179 Contraction, uterine, force of, in labor, 361 Contractions, abdominal, in labor, 363 uterine, characteristics of, in labor, 360 nerve centre controlling, 75 Convulsions, puerperal {vide Eclampsia), 266 Cord, umbilical {vide Umbilical cord), 140. 576 Corpora albicantia, 102 Corpus luteum, 101 false, 102 true, 102 Course of twin pregnancy, 189 Couveuse, 575 Coxalgic, the, obliquely contracted pelvis, 522 Cramps in the lower limbs in the second stage of labor, 430 Cranial presentation, 379 Cranioclasm, 675 Craniotomy, 673 Cranium, fcetal, 151 Cred6, method of placental expression of, 443 Crural hernia of uterus during pregnancy, 286 phlegmon in the puerperal state, 606 Cystic decidual endometritis, 289 Cystocele complicating labor, 475 DEATH, apparent, in the new-born, 439 treatment of, 440 of the fcetus, 305 consequences of the, 306 diagnosis of the, 305 sudden, during or following labor, 587 from accidents of labor, 589 from different diseases, 589 from pulmonary embolism, 588 from syncope, 587 Death, sudden, from the entrance of air into the uterine veins, 588 Decapitation, 679 Decidua, atrophy of the, 290 formation of the, 125 reflexa, 125, 175 serotina, 125 syphiloma of the, 293 vera, 125, 175 Decidual endometritis, 289 catarrhal, 289 cystic, 289 diffuse, 289 polypoid, 289 Decollation, 679 Deficiency of uterine force during labor, 461 Deformities of the pelvis caused by fractures or by neoplasms of the pelvic bones, 524 Degeneration, fatty, of the placenta, 292 hydatidiform, of the placenta, 294 myxomatous, of the placenta, 294 Delivery, diagnosis of recent, 574 difficult, of the shoulders, 435 post-mortem, 685 preparation for, 430 of the body, 436 of the head, in head-last labors, 451 of the shoulders, 434 Derotomy, 679 Desquamation of skin in new-born, 578 Detachment of placenta, causes of, 341 complete, in the treatment of placenta praevia, 347 partial, in treatment of placenta prasvia, 347 Determining causes of labor, 355 Development of the embryo and foetus, 144 of the female generative organs, 86 external organs of generation, 86 internal organs of generation, 86 of the mammae, 96 Diagnosis, differential, of pregnancy, 212, 213 Diameters of the fcetal head. 153 of the maternal pelvis, 29, 30, 31, 32 Differences in the pelvis as to the individual, sex, age, and race, 37 Diffuse decidual endometritis, 289 Digestive organs, condition of the, in the puer- peral state, 560 Dilatation of the os uteri in labor, 365 active interference with, 427 of the vagina, 369 of the vulva, 369 sacciform, of the posterior wall of the uterus during pregnancy, 285 Directions, special, in labor, 422 Disease, malignant, of the uterus, in preg- nancy, 287 of the breasts during pregnancy, 287 of the mother as an indication for the in- duction of premature labor, 626 syphilitic, of the placenta, 292 Diseases, accidental, occurring to the puer- peral woman, 584 acute infectious, during pregnancy, 238 of the foetus, 303 chronic infectious, during pregnancy, 243 of the fcetus, 303 dependent upon pregnancy, 252 et seq. exaggerations of physiological conditions of pregnancy, 252 et seq. infectious, in the puerperal state, 590 intercurrent, in pregnancy, 238 692 INDEX. Diseases of the heart during pregnancy, 246 of the ovum, 283 et seq. of the placenta, 290 of sexual organs in pregnancy. 279 et seq. of various organs of the fcetus causing dystocia, 483 sporadic, during pregnancy, 244 structural, of the uterus in pregnancy. 286 Displacement of the fcetal arm, dorsal, causing dystocia, 476 Displacements of the uterus {vide Uterus). Double vagina and uterus, 92 Douglas, cul-de-sac of, 55 D'Outrepont, method of, for performing ceph- alic version, 632 Drink in the first stage of labor, 426 in the second stage of labor, 430 Dry labor, 368 Duration of labor, 373 of pregnancy, 216 Dynamic pelvis, 21, 47 Dystocia, foetal, 477 from advanced ossification of the head of the foetus, 478 from dorsal displacement of arm, 477 from double monstrosities, 484 from great size of the fcetus, 478 from great size of the fcetus from pathological causes, 479 ascites, 483 diseases of various organs, 483 encephalocele, 483 hydrocephalus, 479 hydronephrosis, 483 hydrothorax, 483 new growths and foetal in- clusion, 483 retention of urine, 483 single monsters, 483 from prolapse of members, 490 of the umbilical cord, 492 in complex presentation, 490 in mal-presentation, 489 in plural deliveries, 485 ECLAMPSIA, 266 as a neurosis, 271 as caused by disease of the kidneys, 272 as dependent upon the blood, 273 diagnosis of, 274 fcetal mortality in, 270 influence of, upon labor, 274 upon pregnancy, 274 maternal mortality in, 270 pathological anatomy of, 270 prognosis of, 270 symptoms of, premonitory, 267 terminations of, 270 treatment of, 274 curative, 275 obstetric, 277 prophylactic, 275 Ectopic development of the placenta {vide Placenta praevia), 339 gestation, 322 pregnancy, 322 causes of. 323 classification of, 322 diagnosis of, 332 frequency of, 323 treatment of, 334 Ectopic pregnancy, treatment of,after rupture, 337 by abdominal section, 336 electricity in the, 334 in the second half of pregnancy, 337 Effects of labor upon the fcetus, 373 upon the mother, 372 Efficient causes of labor, 358 Electricity in the treatment of ectopic preg- nancy. 334 in weak labor-pains, 467 Embryo, the, 130 and the fcetus, development of, 144 Embryology, 144 et seq. Embryonic area, 129 Embryotomy, 671 indications for, 672 Emesis, 168, 194, 233 {vide also Vomiting). Emphysema of the maternal neck, face, and chest in labor, 460 Encephalocele of foetus causing dystocia, 483 Endometritis in the puerperal state, 602 Epiblast, 124 Epilepsy during pregnancy, 250 Episiotomy during labor, 433 Ergot in labor, 465 in the treatment of placenta praevia, 347 Evisceration, 679 Evolution, spontaneous, in shoulder presenta- tions, 412 Excess of uterine force in labor, 460 Exercise during pregnancy, 226 Expression of placenta, Crede's method of, 443 Expulsion of the placenta, 371, 442 Extent of tears of the uterus during labor, 540 External bimanual version, 632 organs of generation. 49 care of, in puerperal state, 570 changes in the, during labor, 359 during menstruation, 104 during pregnancy, 174 development of the, 86 FACE presentation, 394 Fallopian tubes {vide Oviducts), 84 False pains in labor, 372 pregnancy, diagnosis of, 213 waters, 368 Fatty degeneration of the placenta, 292 Feeding, artificial, of infants, 580 Fever, puerperal, 594 Fibroid tumors, diagnosis from pregnancy, 212 of the uterus during labor, 471 during pregnancy, 286 Flat pelvis, generally contracted, 513 rhachitic, 509 simple, 508 Flattened pelvis, from bilateral dislocation of the femoral bones, 514 Floor, pelvic, 44 pubic and sacral segments of the, 47 Foetal appendages, 132 in twin pregnancy, 189 circulation, 162 dystocia, 477 head, the, 151 breaking the base of, 676 diameters of, 153 modifications of the, in labor, 155 fontanelles of, 152 movements of, 155 INDEX. 693 Fcetal head, premature ossification of, dystocia. 478 sutures of, 152 heart, sounds of the, 206 inclusion, causing dystocia, 483 innervation, 167 members, prolapse of, 490 movements, 167, 202 nutrition, 159 passive ideation, 167 respiration, 164 secretion, 165 shock, 208 trunk, diameters of the, 156 Foetus, the, 144 accidental fractures in, 304 acute infectious diseases of, 303 ascites of, causing dystocia, 483 at term, 151 attitude of, in the womb, 156 chronic infectious diseases of, 303 death of, 305 consequences of, 306 diagnosis of, 305 diameters of the head of, 153 of the trunk of, 156 diseases of various organs of, causing dys- tocia, 483 effects of labor upon, 373 encephalocele of, causing dystocia, 483 from pathological causes, 479 hydrocephalus of, causing dystocia, 479 hydronephrosis of, causing dystocia, 483 hydrothorax of, causing dystocia, 483 liquefaction of, 306 • luxations in, 305 maceration of, 307 mummification of, 307 new growths of, causing dystocia, 483 papyraceus, 189 pathology of, 302 physiology of, 159 position of, 375 presentation of, 157, 377 putrefaction of, 307 rhachitis in, 304 retention of urine in, causing dystocia, 483 size of, causing dystocia, 478 spontaneous amputations in, 304 fractures in, 304 tumors of, 305 Fontanelles of the foetal head, 152 Food during pregnancy, 224 in the first stage of labor, 426 in the puerperal state, 568 in the second stage of labor, 430 Force of uterine contraction in labor, 361 uterine, excess of, in labor, 460 deficiency of, during labor, 461 perversion of, during labor, 468 Forces concerned in labor, anomalies of, 460 Forceps, the, 638 accidents in the use of, 668 conditions necessary for the use of, 655 dangers in the use of, 668 description of, 642 history of the invention of, 638 in cranial presentation, 662 indications for the use of, 655 in facial presentations, 665 in head-first labor, 662 in head-last labor. 665 injuries to the child from, 669 Forceps, injury to the mother by, 669 in left occipito-anterior position, 663 in left occipito-posterior position, 664 in occipito-pubic position, 662 in occipito-sacral position, 663 in pelvic presentation, 668 in right occipito-anterior position, 664 in right occipito-posterior position, 664 operation of the application of, 658 powers of, 646 as compressors, 646 as levers, 646 as tractors, 648 dynamic action. 646 to effect rotation. 647 preparations for using, 657 to the head movable above the inlet, 665 to the head separated from the trunk, 665 varieties of, 640 Form of uterus, anomalies of, during labor, 469 in the puerperal state, 564 pelvic, anomalies of the, 507 Fractures, accidental, in the fcetus, 304 of pelvic bones, deformities of the pelvis caused by, 524 spontaneous, in the foetus, 304 Fronto-anterior position, 397, 402 -posterior position, 402 Funis {vide Umbilical cord), 140 GALACTORRHCEA, 574 Gastro-elytrotomy, 685 Gastro-hysterectomy {vide Porro's operation), 683 Gastro-hysterotomy {vide Caesarean operation). Gavage, 575 Generally contracted flat pelvis, 513 pelvis, labor and its treatment in, 506 Generation, the external organs of, 49 changes in, during labor, 359 during menstruation, 104 during pregnancy, 174 in the puerperal state, 562 development of, 86 the female organs of, 49 anomalies of, 86 development of, 86 the internal organs of, 55 Genital organs, changes in the, in the puerperal state, 562 sense, the, 108 Gestation, ectopic, 322 tubal, development of the ovum in, 326 Glands, mammary, 93 {vide also Breasts). utricular, 70 Graafian vesicles or follicles {vide Ovisacs), 83 Gravis odor puerperii, 562 HEMATOMA of the vulva or of the va- gina, during labor, 531 treatment of, 533 Hasmatometra, diagnosis from pregnancy, 212 Head movable above the pelvic inlet, applica- tion of the forceps to the, 665 of the new-born child, changes in the . shape of the, 577 separated from the trunk, application of the forceps to the, 665 -first labor, application of forceps in, 662 -last labor, application of forceps in, 665 delivery of the head in, 451 694 INDEX. Head-last labor, perforation in, 678 the fcetal (vide Foetal head), 151 Heart, diseases of the, during pregnancy, 24* hygiene and treatment of, 248 medical treatment of, 248 obstetrical treatment of, 248 -sounds, the foetal, 206 Hegar's sign of pregnancy, 199 Hemicephalia, 483 Hemorrhage, accidental, 288, 351 after the birth of the child, 544 symptoms of, 544 treatment of, 545 in normal implantation of placenta, 351 the treatment of, 352 in placenta praevia, 288, 341 the source of the, 341 secondary, after the birth of the child, 549 umbilical, 577 unavoidable, 288, 341 Hemorrhoids in pregnancy, 234 Hermaphroditism, 90 Hernia of the uterus during pregnancy, 285 crural, 286 inguinal, 286 Herpes gestationis, 236 Hicks, Braxton, method of, for performing cephalic version, 632 for podalic version, 633 in treatment of placenta praevia, 348 Hilum of the ovary, 81 Hips, presentation of the, 403 Hook, the, blunt, in pelvic presentation, 456 Horizontal planes of the pelvis, 33 Hottentot apron, 51 Hydatidiform degeneration of the placenta, 294 Hydraemia during pregnancy, 257 treatment of, 257 Hydrocephalus of foetus causing dystocia, 479 diagnosis of, 480 prognosis of. 480, 481 treatment of, 481 Hydrometra. diagnosis from pregnancy, 211 Hydronephrosis of foetus causing dystocia, 483 Hydrorrhoea gravidarum, 289 Hydrothorax, foetal, causing dystocia, 483 Hygiene of diseases of the heart, 248 of pregnancy, 224 Hymen, 52 Hyoid arch, 147 Hyperemesis in pregnancy, 252 causes of, 253 treatment of, 254 Hypertrophies of various organs during preg- nancy, 173 Hypertrophy of the placenta, 291 Hypoblast, 124 Hysteria in pregnancy, 249 j CTERUS in pregnancy, 245 1 Ilium, anatomy of the, 21 Ideation, passive, in the foetus, 167 Impregnation, 115 fate of spermatozoids not concerned in, 122 Impressions, maternal, during pregnancy, 229 Incarnation, 114 Inclination of the pelvis, 34 Inclined planes of the pelvis, 33 Incomplete abortion, 317 Induction of abortion, 623 indications for, 623 means of, 625 prognosis of, 625 of premature labor, 625 indications for, 626 means of, 627 prognosis of, 627 Inevitable abortion, treatment of, 316 Infant, the new-born {vide Child, the new- born). Infectious diseases, acute, complicating preg- nancy, 238 chronic, complicating pregnancy, 243 in the puerperal state, 590 Inflammation of the pelvic joints during preg- nancy, 257 Inguinal hernia of uterus during pregnancy,286 Injuries of the vagina during labor, 528 treatment of, 529 of vulva and perineum during labor, 526 treatment of, 527,528 Inlet, the pelvic 30 Innervation, fcetal, 167 Insanity during pregnancy, 585 in the puerperal state, 586 of lactation, 586 Insertio marginalis, 143 velamentosa, 143 Insomnia in pregnancy, 237 Inspection during pregnancy, 195 Intercurrent diseases ol pregnancy, 238 Intermittent fever during pregnancy, 240 Internal organs of generation, 55 changes in the, during menstrua- tion, 104 development of the, 86 Interstitial pregnancy, 327 Intestinal tympanites in puerperal septicaemia, 618 Intraligamentous pregnancy, 331 Insufflation, in the asphyxia of the new-born, mouth to mouth, 441 through a tube passed into the larynx, 441 Inversion of the uterus, 549 causes of, 551 diagnosis of, 553 prognosis of, 554 symptoms of, 553 treatment of, 555 Involution of the uterus, 562 Irritability of the bladder in pregnancy, 194 of the uterus during pregnancy, 179 Ischium, anatomy of the, 23 1 AUNDICE in the new-born child, 578 "J in pregnancy, 245 treatment of, 246 Joints, pelvic, 26 inflammation of the, during preg- nancy, 257 movements of the, 27 relaxation of, during pregnancy, 255 rupture of the, during pregnancy, 257 uses of the, 28 pubic, 27 sacro-coccygeal, 26 sacro-iliac, 26 sacro-vertebral, 25 Justo-major, the, pelvis, 498 Justo-minor, the, pelvis, 499 diagnosis of, 505 INDEX. 695 JXIDN EYS,eclampsia caused by disease of,272 * *■ Knots in the umbilical cord, 297 Kyestine in pregnancy, 171 Kyphosis, rhachitic. 519 Kyphotic transversely contracted pelvis, 517 LABIA majora, anatomy of the, 49 minora, anatomy of the, 50 Labor, 355 et seq. abdominal contractions in, 363 accommodation in, 376 anaesthesia in, 418 anomalies of form and of position of the uterus in, 469 of organs adjacent to uterus in, 474 of the forces concerned in, 460 antisepsis in, 416 apparent death of the child following, 439 treatment of, 440 application of the abdominal bandage after, 444 artificial, 355 ascites, foetal, complicating, 483 attentions to the child, after, 436 et seq. attentions to the mother after, 442 bag of waters in, 366 bandage, application of the abdominal, after, 444 cancer of the uterus in, 473 caput succedaneum in, 374 causes of, determining, 355 characteristics of uterine contractions in, 360 complex presentation during, 489 conduct, the, of, 416 et seq. cord, dressing the, after, 438 cramps in the lower limbs in, 430 cystocele complicating, 475 death, sudden, during or following, 587 deficiency of uterine force in, 461 causes of, 462 prognosis of, 463 treatment of, 463 definition of, 355 delivery of the body in, 436 of the shoulders in, 434 difficult, 435 determining causes of, 355' dilatation of the os uteri in, 365 of the vagina in, 369 of the vulva in, 369 diseases of various foetal organs compli- cating, 483 dorsal displacement of the arm complicat- ing, 477 double monstrosities complicating, 484 dressing the child after, 439 the cord after, 438 dry, 368 duration of, 373 effects of, upon the foetus, 373 upon the mother, 372 efficient causes of, 358 emphysema of the maternal neck, face, and chest in, 460 encephalocele, fcetal, complicating, 483 episiotomy in, 433 excess of uterine force in, 460 expulsion of the placenta in, 371, 442 false pains in, 372 waters in, 368 fibroids of the uterus in, 471 Labor, foetal dystocia complicating, 477 from mal-presentation, 489 from prolapse of members, 490 inclusion complicating, 483 force of uterine contraction in, 361 great size of foetus complicating, 478, 479 haematoma of the vulva or of the vagina complicating, 531 head-last, delivery of the head in, 451 hemorrhage from the uterus after, 544 hydrocephalus, foetal, complicating, 479 hydronephrosis, foetal, complicating, 483 hydrothorax, foetal, complicating, 483 in the generally contracted pelvis, 506 influence of eclampsia upon, 274 injuries of the vagina in, 528 of vulva and of perineum in, 526 inversion of the uterus in, 549 levelling in, 369 loss of weight in, 373, 565 mal-presentation complicating, 489 management of, in twin-pregnancies, 457 mechanism of, 376 in face presentations, 396 in left occipito-anterior position, 383 in pelvic presentations, 405 in right occipito-anterior position, 391 in shoulder presentations, 412 missed, 223 mother, attentions to the, after, 442 muco-sanguineous discharge in, 369 natural, 355 neoplasms of the uterus in, 471 new growths, fcetal, complicating, 483 obstruction of the vagina during, 475 occlusion and narrowing of the os uteri in, 470 pain in, 364 pains after, 558 character of the, in, 364 pathology of, 460 et seq. perineum, care of, in, 430 ruptures of the, in, 430 perversion of uterine force in, 468 phenomena of, 360 mechanical, 376 physiological, 360 plastic, in vertex presentation, 374 .plural delivery complicating, 485 postponed, 355 precursors of, 358 premature, 355, 625 preparation of the bed and of the patient's person for, 425 presence of the physician during, 428 presentation of the umbilical cord in, 492 prolapse of the umbilical cord in, 492 pulse during and after, 559 rectocele complicating, 475 relief of pain in, 421 rents of middle portion of vagina in, 529 retention of urine, fcetal, complicating, 483 rupture, central, of the perineum in, 528 ruptures of the uterus during, 535 seat of pain in, 365 secondary hemorrhage after, 549 single monsters complicating, 483 special directions in, 422 stage of, first, or uterine period, 363 bladder, condition of, in, 426 dilatation of the os uteri, active interference with, 427 food and drink in the, 426 696 INDEX. Labor, stage of, first, or uterine period, man- agement of the, 426 presence of the physician in, 428 rectum, condition of, in, 426 second, or utero-abdominal period, 363 child, attention to, in, 436 condition of, in, 429 cramps in lower limbs in, 430 delivery of the body in, 436 of the shoulders in, 434 difficult delivery of shoulders in, 435 drink in, 430 episiotomy in, 433 food in, 430 management of, 428 os uteri, condition of, in, 429 patient, position of, in, 428 perineum, care of, in, 430 preparation for delivery, 430 third, or placental period, 364, 442 stages of, 359 sudden death during or following, 587 tears of the cervix in, 533 of lower portion of vagina in, 530 temperature during and after, 559 thrombus of the vulva or of the vagina complicating, 531 treatment of, in the generally contracted pelvis, 506 uterine contractions in, 360 vaginal cicatrices complicating, 476 vesical calculi obstructing, 476 washing the child after, 438 weak pains in, 461 Lactation, 571 insanity of, 586 Laminae dorsales, 144 Lamination, 676 Laparotomy [vide Caesarean operation), 680 Leaman's parturiometer, 362 Leucorrhcea in pregnancy, 194, 278 Levelling, 369 Ligaments of the uterus, 76 broad, 78 round, 77 utero-sacral, 79 Ligation of the cord, 436 Linea albicantes, 94, 172 Liquefaction of the fcetus, 306 Liquor amnii, 133 anomalies of the, 300 origin of, 134 uses of, 134 Lithopaedion, 331 Liver, acute yellow atrophy of the, 245 Lochia, 561. 570 alba, 561 rubra, 561 serosa, 561 Longings in pregnancy, 168 Loss of weight in labor and during lying-in, 565 Luxations in the foetus, 305 Lymphangitis, uterine, in puerperal state, 603 MACERATION of the fcetus, 307 Maieutics, 18 Malarial fever during pregnancy, 240 Male and female elements, combination of, 120 Malignant disease of uterus in pregnancy, 287 Mal-presentation of the fcetus causing dys- tocia, 4S9 Mammie. anatomy of the {vide Breasts), 93 Mammary pains and swellings during preg- nancy, 194 Mammitis in the puerperal state, 590 Management of childbed, 567 of labor in twin pregnancies, 457 of pregnancy, 224 of the first stage of labor, 426 of the second stage of labor, 428 Mania during the puerperal state, 585 Manual removal of the placenta, 621 Marginal insertion of the umbilical cord, 143 Mastitis in the puerperal state, 590 treatment of, 592 Maternal causes of abortion, 310 impressions during pregnancv, 229 organism, changes in the, during preg- nancy, 168 Mechanism of labor, 376 in face presentations. 396 anomalies of the, 401 in left occipito-anterior position, 383 in pelvic presentations, 405 in right occipito-anterior position, 391 anomalies of the, 407 in shoulder presentations, 412 Meconium, 166, 576 Medical care of the pregnant woman, 233 treatment of diseases of the heart, 248 Medicines, abortion from the use of. 311 Melancholia in the puerperal state, 585 Melotomy, 679 Members of the foetus, prolapse of the, 490 Membrana reflexa, 125 serotina, 125 vera, 125 Membranes, rupture of the, in the treatment of placenta prawia, 350 Menopause, 109 Menses {vide Menstruation). Menstrual flow, character of the, 105 duration of the, 106. 107 quantity of the, 106 recurrence of the, 107 Menstruation, 103 absent during pregnancy, 193 and ovulation, connection between, no causes influencing first appearance of, 108 theories of, no Mental disorders during puerperal state, 585 Mesoblast, 129 Metoarion {vide Corpus luteum), 101 Midwife, midwifery, 17 Milk, secretion of, 565 in newborn children, 577 phenomena associated with the estab- lishment of the, 566 Mind, condition of the, during pregnancy, 229 Miscarriage {vide Abortion), 308, 355 Missed abortion. 320 during the puerperal state, 585 labor, 223 Modification of the uterine walls during preg- nancy, 175 Modifications of arteries and veins of the uterus during pregnancy, 176 of secretions in the puerperal state, 560 Mole, vesicular, 294 Monomania, 585 Mons veneris, 49 Monstrosities, double, 484 INDEX. 697 Monstrosities, single, 483 Montgomery, glands of, 94 changes in the, in pregnancy, 185 Morning sickness of pregnancy, 168 Morphine in eclampsia, 276 Mortality, foetal, in eclampsia, 270 maternal, in eclampsia, 270 Mother, attentions to the, after labor, 441 in the puerperal state, 567 disease of the, as an indication for the in- duction of premature labor, 626 effects of labor upon the, 372 injury to the, by the forceps, 669 Movements, fcetal, 167, 202 of the pelvic joints 27 Muco-sanguineous discharge in labor, 369 Mucous membrane of the neck of the uterus, 70 of the uterus, 69 of the vagina, 58 Muguet in infants, 583 Muller's modification of Porro's operation, 684 Mummification of the fcetus, 307 Murphy, method of, in the treatment of pla- centa praevia, 349 Muscles of the pelvic floor, 44 of the pelvis, 42 Myxomatous degeneration of the placenta, 294 diagnosis of, 296 treatment of, 296 |\1 ARROWING of os uteri during labor, 470 1 ^ Natural labor, 355 Nausea and vomiting of pregnancy, 168, 194, 233 of puerperal septicaemia, 617 Navicular fossa, 53 Neck of the uterus {vide Cervix uteri). Neoplasms of the pelvic bones, deformities of the pelvis caused by, 524 of the uterus during labor, 471 Nervous disorders during pregnancy, 194 system, changes in, during pregnancy, 173 Neuralgia in pregnancy, 236 New growths of the foetus causing dystocia, 483 Newly-born child {vide Child). Nipples, the, 95 care of, during pregnancy, 228 diseases of, 591 Nourishment in puerperal septicaemia, 617 of the newborn child, 578 Nurse, wet, selection of a, 579 Nursing, obstacles to the mother's, 571 Nutrition of the foetus, 159 Nymphae {vide Labia minora), 50 OBJECTIVE signs of pregnancy, 195 Obliquity, of the pelvis, 33 Obstacles to the mother's nursing, 571 Obstetric art, 18 auscultation, 204 operations. 621 et seq. science, 18 treatment of diseases of the heart, 248 Obstetrics, 17 Obstruction of vagina complicating labor, 475 Occipito-anterior position, 381, 390 Occipito-posterior position, 391, 446 Occipito-pubic position, 662 Occipito-sacral position, 663 Occlusion of the os uteri during labor, 470 CEdema of the legs in pregnancy, 235 of the placenta, 291 Omentum, accumulation of fat in the, diag- nosis of, from pregnancy, 213 Omphalorrhagia, 577 Operations, obstetric, 621 et seq. Opium in the treatment of puerperal septi- caemia, 617 Organs of generation, anomalies of the, 86 development of the, 86 the external, 49 the internal, 55 Os uteri, condition in second stage of labor, 429 dilatation of the, in labor, 365 internum, 63 narrowing of the, during labor, 470 occlusion of the, during labor, 470 state of the internal and of the ex- ternal, during pregnancy, 181 Ossa pubis, anatomy of the, 23 Osteomalacic, the, pelvis, 515 Osteophytes in pregnancy, 173 Outlet, the pelvic, 31 Ovarian pregnancy, 329 tumors during pregnancy, 287 diagnosis of, from pregnancy, 212 Ovaries, the, 79 aspect of, 81 at puberty, 98 attachments of, 79 bulbs of, 78 form of, 81 hilum of, 81 influence of, in exciting labor, 356 nerves of, 83 number of, 79 position of, 79 size of, 81 structure of, 82 vessels of, 83 Oviducts, the, 84 Ovisacs, the, 83 at puberty, 100 Ovulation, 99 connection between menstruation and, no Ovule, causes of abortion belonging to the, 311 changes in the, independently of impreg- nation, 120 development of the, in tubal gestation, 326 diseases of the, 288 fecundated, changes in the, 124 et seq. PADS, antiseptic, after labor, 445 Pain, great, in puerperal septicaemia, 617 Pain in labor, 364 relief of, 421 the seat of, 365 Pains, after-, 558 character of the, in labor, 364 false, in labor, 372 weak, causes of, 462 prognosis of, 463 treatment of, 463 Palpation, abdominal, in pregnancy, 200 Parovarium, 78 Partitioned uterus, 93 Parturiometer of Leaman, 362 Parturition, 17 Passive ideation in the foetus, 167 Paternal causes of abortion. 309 Pathological anatomy of eclampsia, 270 of puerperal infection, 609 698 INDEX. Pathological anatomy of the puerperal state, 584 et seq conditions rendering the diagnosis of pregnancy difficult. 214 Pathology of the fcetus, 302 et seq. of labor, 460 et seq. Patient, position of the, in the second stage of labor. 428 preparation of person of, for labor, 425 Pelvic cavity, 32 contraction as an indication for the induc- tion of premature labor, 626 floor, 44 segments of the. pubic and sacral, 47 form, anomalies of the, 507 inlet, 30 joints, 25 changes in the, during pregnancy, 174 inflammation of the, during preg- nancy, 257 movements of the, 27 relaxation of, during pregnancy, 255 rupture of the, during pregnancy, 257 uses of the, 28 outlet, 31 presentation, 403 {vide Presentation) version, 633 Pelvimeter of Baudelocque, 501 of Martin, 501, 503 Pelvimetry, external, 501, 502 internal, 504 Pelvis, anatomy of the, 21 anomalies of the, 497 certain signs of, 501 diagnosis of, 501 as a whole, 28 asymmetrical changes in the, 507 axes of the, 33 deformities of the, caused by fractures or by neoplasms, 524 differences in the, as to age, 40 as to individuals, 37 as to race, 41 as to sex, 38 dynamic, 21, 47 external surface of the, 28 false, 29 form of the, anomalies of the, 507 antero-posterior diameter contracted, 508 flat, the generally contracted, 513 the rhachitic, 509 mechanism of labor in, 5" the simple, 508 mechanism of labor in, 5" flattened from bilateral disease of the femoral bones, 514 oblique diameters contracted, 519 ankylotic, the, 519 coxalgic, the, 521 scoliotic, 524 spondylolisthetic, the", 513 transverse diameter contracted, 515 ankylotic, the, 517 kyphotic, the, 517 osteo malacic, the, 515 rhachitic kyphosis, 519 generally contracted, the, 499 {vide Pelvis justo-minor). horizontal planes of the, 33 inclined planes of the, 33 Pelvis, inclination of the, 34 internal surface of the, 29 justo-major, the, 498 justo-minor, the, 499 diagnosis of, 505 labor in, 506 treatment of, 506 obliquity of the, 33 obtecta, 508 position of the, anomalies of, 497 size of the, anomalies of, 498 soft parts of the, 42 static. 21 true, 29 Perforation, 673 in face presentation, 678 in head-last labor, 678 Perineal body, 46 Perineum, the, 46 care of, in second stage of labor, 430 central rupture of, 528 changes in the, during pregnancy, 174 frequency of ruptures of, 431 injuries of. during labor, 526 after-treatment of, 527 Period of gestation, 221 Peritonitis in the puerperal state, 603 Pernicious anaemia during pregnancy, 258 causes of, 258 symptoms of, 258 treatment of, 259 Perversion of uterine force in labor, 468 Phenomena associated with the establishment of the secretion of milk, 566 of labor, 360 mechanical, 376 physiological, 360 plastic, in vertical presentations, 374 Phlebitis in the puerperal state, 605 adhesive, 605 progress and termination of, 606 symptoms of, 605 infectious. 607 Phlegmasia alba dolens, treatment of, 619 Phthisis during pregnancy, 243 of the placenta, 291 Physometra, diagnosis of, from pregnancy, 211 Physiology of the foetus, 159 Pigment-deposits in the placenta, 292 Placenta, the, 136 apoplexy of, 290 atrophy of, 291 battledore, 143 calcareous deposits in, 292 detachment of, causes of the, 341 diseases of, 290 duplex, 137 ectopic development of, 339 expulsion of, 371 fatty degeneration of, 292 hydatidiforn degeneration of, 294 hypertrophy of, 291 manual removal of, 621 myxomatous degeneration of, 294 normal implantation of, hemorrhage in, 351 oedema of, 291 phthisis of, 291 pigment-deposits in, 292 praevia, 339 341, causes of, 339 of detachment of, 341 frequency of, 339 INDEX. 699 Placenta praevia, hemorrhage in, 341 source of the, 341 prognosis of. 343 treatment of, 343 Barnes, method of, in the, 347 Cohen, method of, in the, 350 combined turning in the, 348 Braxton Hicks's method of, 348 Davis, method of, in the, 350 detachment of the placenta, com- plete, 347 partial, 347 different methods of, 343 ergot in the, 347 Murphy, method of, in the, 349 Puzos, method of, in the, 350 rupture of membranes in, 350 Simpson, method of, in the, 347 tampon, in the, 344 vaginal ballottement in, 840 varieties of, 339 diagnosis of the, 340 with fibroids of the uterus, 286 sclerosis of, 291 situation of, 137 syphilitic disease of, 292 tripartita, 137 tumors of, 292 uses of, 138 vicious insertion of, 339 Placentae from syphilitic mothers, 293 succenturiatae, 137 Placental circulation, 162 expulsion, 442 souffle, 205 Placentitis, 290 Planes of the pelvis, horizontal, 33 inclined, 33 Pleurisy during pregnancy, 245 Plexus uterinus magnus, 73 Plicae palmatae, 63 Plural deliveries, dystocia in, 485 pregnancy, 186 Pneumonia during pregnancy, 244 Podalic version, 633 Polyhydramnios, 300 etiology of, 300 forms of, 301 treatment of, 302 Polymastia, 96 Polypoid decidual endometritis, 289 Porro, operation of, 683 indications for the, 684 method of performing the, 684 Muller's modification of the, 684 Position, definition of, 377 diagnosis 0^378,381 dorso-anterior, 408 dorso-posterior, 408 fronto-anterior, left, 397 mechanism of labor in, 397 delivery of the body, 401 descent, 399 extension, 397 flexion, 401 rotation, 399, 401 right, 402 fronto-posterior, left, 402 right, 402 occipito-anterior, left, 381 application of the forceps in, 663 mechanism of labor in, 383 Position, occipito-anterior, left, mechanism of, descent, 386 expulsion, 389 extension, 388 flexion. 384 restitution, 389 rotation, 387, 389 right, 390 application of the forceps in, 664 occipito-posterior. right, 391 management of, 446 occipito-pubic, application of the forceps in, 662 occipito-sacral, application of the forceps in, 663 of tears of the uterus during labor, 540 of the maternal pelvis, anomalies of, 497 of uterus, anomalies of, during labor, 469 in the puerperal state, 564 sacro-anterior, left, 408 right, 408 sacro-posterior, left, 408 right, 408 Positional disorders of the uterus during preg- nancy, 279 Posterior displacements of the uterus in preg- nancy, 280 Post-mortem delivery, 685 Post-partum hemorrhage, 544 Postponed labor, 355 Poullet, method of, of axis-traction, 653 Precocious births, 218 Precursors of labor, 358 Pregnancy, 115 abdominal, 329 abdominal touch or palpation in, 200 absence of menstruation during, 193 acute infectious diseases during, 238 acute yellow atrophy of liver during, 245 air during. 226 albuminuria during, 261 anaemia during, 258 anteflexion of the uterus during. 280 anteversion of the uterus during, 280 ascites, diagnosis of, from, 213 ballottement in, 199 bathing during, 228 care of the breasts during, 228 changes in abdominal walls during, 172 in the blood during, in the breasts during, 184 in capacity of uterus during, 176 in circulatory apparatus during, 170 in consistence of uterine walls during, 177 in the external organs of generation during, 174 in the form of the uterus during, 176 in the maternal organism during, 168 in the neck of the womb during, 181 in the nervous system during, 173 in the pelvic joints during, 174 in the perineum during, 174 in the position of uterus during, 177 in the size of the uterus during, 176 in the skin during, 171 in the uterine appendages during, 184 in the uterus during, 175 in the vagina during, 174 choc fcetal of Pajot in, 208 cholera during, 241 chorea during, 248 chronic infectious diseases during, 243 700 INDEX. Pregnancy, cicatrices of, 172 clothing during, 225 constipation during, 234 contractility of the uterus during, 179 crural hernia during, 286 decidual endometritis during, 289 development of the ovum in tubal, 326 diagnosis of, 191 differential diagnosis of, 211, 213 disease of the breasts during, 2H7 diseases of the heart during, 246 of the sexual organs during, 278 duration of, 216 ectopic, 322 eclampsia during, 266 epilepsy during, 250 exercise during, 226 false pains during, 372 false pregnancy, diagnosis of, from, 213 fibroids of the uterus during, 286 foetal appendages in twin, 189 foetal shock in, 208 food during, 224 haematometra, diagnosis of, from, 212 Hegar's sign of, 199 hemorrhoids during, 234 hernia of the uterus during, 285 herpes during, 236 hydrtemia during, 257 hydrometra, diagnosis of, from, 211 hygiene of, 224 hyperemesis of, 252 hypertrophies of various organs during, 173 hysteria during, 249 in a rudimentary horn of the uterus, 338 inflammation of pelvic joints during, 257 influence of eclampsia upon, 274 inguinal hernia during, 286 insanity during, 585 inspection in, 195 intercurrent diseases of, 238 intermittent fever during, 240 interstitial, 327 intraligamentous, 331 irritability of the bladder during, 194 of the uterus during, 179 jaundice during, 245 leucorrhoea during, 194, 278 malignant disease of uterus during, 287 mammary pains and swellings during, 194 management of, 224 et seq. maternal impressions during, 229 medical care during, 233 mind, condition of, during, 229 modification of arteries and veins of the uterus during, 176 modifications of uterine walls during 175 morning sickness during, 168 nausea of, 194, 233 nervous disorders during, 194 neuralgia during, 236 obstetric auscultation in, 204 oedema of the legs during, 235 ovarian tumors, diagnosis of, from, 212 osteophytes in, 173 ovarian, 329 tumors, diagnosis of, from, 212 during, 287 pathology of, 238 et seq. pernicious anaemia during, 258 phthisis during, 243 physometra, diagnosis of, from, 211 ignancy, pleurisy during, 24: plural, 186 causes of, 186 frequency of, 186 pneumonia during. 244 positional disorders of uterus during. 279 posterior displacement of the uterus dur- ing, 280 previous, diagnosis of, 214 procidentia of the uterus during, 279 prolapse of the uterus during, 279 of the vagina during, 278 prolonged, 219 properties of the uterus during, 179 pruritus during, 235, 236 pseudo-cyesis, diagnosis of, from, 213 quickening during, 195 rectal touch in, 199 relapsing fever during,.239 relations of the uterus at the end of, 178 relaxation of the pelvic joints during, 255 respiration during, 170 rest during, 226 retractility of the uterus during, 179 rubeola during. 242 rupture of the pelvic joints during, 257 of the uterus during, 535 sacciform dilatation of the posterior wall of the uterus during, 285 salivation during, 194, 234 scarlatina during, 242 secondary abdominal, 330 secondary cervical, 312 sensibility of the uterus during, 179 shortening of neck of womb during, 182 signs of, 191 classification of the, 193 objective, 195 subjective, 193 sleep during, 226 sleeplessness during, 237 softening of neck of womb during, 18-1 sounds of the foetal heart in, 206 sporadic disease during, 244 state of the external os during, 181 of the internal os during. 181 structural diseases of uterus during, 286 syphilis during. 243 time of, diagnosis of the, 215 touch in, 196 traumatism during, 250 twin, course of, 189 diagnosis of, 209 fcetal appendages in, 189 management of labor in, 457 typhoid fever during, 238 typhus fever during, 239 urinary apparatus during, 171 urine during, 171 uterine fibroids, diagnosis of, from, 212 uterine souffle in, 205 vaginal touch in, 196 varices during, 235 varicose veins during, 260 variola during, 241 vegetations of the vulva during, 278 vesical touch in, 199 vomiting of, 194, 233 yellow fever during, 239 Premature labor, 355, 625 induction of, 625 Preparation of bed and patient for labor, 425 Presentation, 157, 377 INDEX. 701 Presenation, brow, management of, 449 application of the forceps in, 665 complex, causing dystocia, 489 diagnosis of, 378 of the face, 394 causes of, 394 diagnosis of, 396 frequency of, 394 mechanism of labor in, 396 anomalies of the, 401 management of, 417 perforation in, 678 plastic changes in, 402 prognosis of, 414 mal-presentation causing dystocia, 489 pelvic, 403 application of the forceps in, 668 causes of, 403 diagnosis of, 403 management of, 450 mechanism of labor in, 405 anomalies in the, 407 compression, 406 delivery of the body, 406 of the head, 407 descent, 406 rotation, 406, 407 plastic changes in, 408 prognosis of, 414 varieties of, 403 of the elbow, 411 of the hand, 411 of the hips, 453 treatment of, 454 of the knee, 405 of the shoulder, 408 bag of waters in, 411 caput succedaneum in, 414 causes of. 409 diagnosis of, 409 auscultation, 409 internal examination, 411 palpation, 409 frequency of, 408 '' peculiar physiognomy " of labor in, 411 spontaneous delivery in, 412 evolution, 412 version, 412 of the umbilical cord, causes of, 492 diagnosis of, 493 frequency of, 492 prognosis of, 494 treatment of, 494 replacement, 495 vertex, 379 diagnosis of, 379 auscultation, 381 internal examination, 381 plastic phenomena of labor in, 374 prognosis of, 414 Previous pregnancy, diagnosis of, 214 Procidentia of uterus during pregnancy, 279 Prolapse of foetal members, causes of, 490 diagnosis of, 490 frequency of, 490 treatment of, 492 of the umbilical cord, 492 causes of, 492 diagnosis of, 493 frequency of, 492 prognosis of, 494 treatment of, 494 Prolapse of umbilical cord, treatment of, re- placement, 495 of the uterus during pregnancy, 279 of the vagina during pregnancy, 278 Prolonged pregnancy, 219 Pruritus during pregnancy, 235, 236 Pseudo-cyesis, diagnosis from pregnancy, 213 Psychical condition of the mother in the puer- peral state, 561 Puberty, 98 Pubic joint, anatomy of the, 27 Pubic segment of the pelvic floor, 47 Pubis, anatomy of the, 23 Pudendum, 49 Puerpura, 445 Puerperal convulsions {vide Eclampsia), 266 eclampsia {vide Eclampsia), 266 fever, 594 general considerations in regard to, 601 special forms of, 602 infection, pathological anatomy of, 609 Puerperal septicaemia, abdominal tenderness in, 617 antipyretic treatment of, 614 constipation in, treatment of, 617 intestinal tympanites in, treatment of, 618 nausea and vomiting of, treatment of, 617 nourishment in, 617 opium in the treatment of, 617 pain in, treatment of, 617 prognosis of, 608 surgical treatment of, 618 treatment of, 612 of special conditions and mani- festations of, 617 state, the, 557 et seq. adeno-phlegmon in, 604 after-pains in, 558 attentions to the mother in, 567 bladder, condition of the, in, 569 bowels, condition of the, in, 570 care of the breasts in, 571 of the external genitals, 570 changes in the bloodvessels of the uterus in, 564 in the genital organs in, 562 in the neck of the uterus in, 565 crural phlegmon in, 606 death in, 587, 589 digestive organs, condition of, in, 560 diseases, accidental, occurring in, 584 infectious, in, 590 endometritis in, 602 food of the mother in, 568 form of the uterus in, 564 genital organs in, changes in the, 562 insanity in, 586 involution of the uterus in, 562 lochia in, 561, 570 loss of weight in, 565 mammitis in, 590 management of, 567 mania in, 585 mastitis in, 590 melancholia in, 585 mental disorders in, 585 monomania in, 585 pads, antiseptic in, 445 pathology of, 584 702 INDEX. Puerperal state, phenomena associated with the establishment of secretion of milk in, 566 peritonitis in, 603 phlebitis in, 605 physiology of, 557 position of the uterus in, 564 psychical condition in, 561 pulse in, 559 respiration in, 560 rest of the mother in, 567 retention of urine in, 560 secretion of milk in, 565 secretions, modifications of, 560 sudden death in, 587 temperature in. 559 urine, retention of. in, 560 uterine lymphangitis in, 603 vaginal injections in, 570 vulvo-vaginitis in, 602 Puerperal tetanus, 590 Pulse in the puerperal state, 559 Putrefaction of the foetus, 307 Puzos, method of, in the treatment of placenta praevia, 350 QUICKENING, 195, 217 RECTAL touch in pregnancy, 199 Rectocele complicating labor, 475 Rectum, condition of, in first stage of labor, 426 Relapsing fever during pregnancy, 239 Relations of uterus at end of pregnancy, 178 Relaxation of the pelvic joints during preg- nancy, 255 treatment of, 256 Relief of pain in labor, 421 Removal, manual, of the placenta, 621 Rents of the middle portion of the vagina during labor, 529 treatment of, 530 Re-percussion {vide Ballottement), 199 Replacement of the presenting cord, 495 Reproduction, proper age for, 99 Respiration, artificial, in the asphyxia of the newborn, 441 insufflation from mouth to mouth, 441 through tube passed into larynx, 441 Schultze's method of, 441 Sylvester's method of, 441 fcetal, 164 in pregnancy, 170 in the puerperal state, 560 Rest during pregnancy, 02.6 in the puerperal state, 567 Retention of urine in the fcetus causing dys- tocia, 483 in the puerperal state, 560 Retractility of uterus during pregnancy, 179 Retroflexion of uterus during pregnancy, 281 Retroversion of the uterus in pregnancy, 280 Rhachitic flat pelvis, 509 mechanism of labor in, 511 kyphosis, 519 Rhachitis in the fcetus, 304 Rosenmiiller, the body of, 78 Round ligaments, the, yj Rubeola during pregnancy, 242 Rugae of the vagina, 56 Rupture in tubal gestation, 333 treatment following, 337 Rupture of the membranes, 368, 428 in treatment of placenta prasvia, 350 of the pelvic joints during pregnancy, 257 of the perineum, central, 528 Ruptures of the perineum, causes of, 431 frequency of, 431 prevention of, 431 of the uterus, 534 during labor, 535 causes of, 535 pregnancy, 535 causes of, 535 extent of, 540 frequency of, 534 position of, 540 prognosis of, 541 symptoms of, 540 of threatened, 538 treatment of, 542 SACRAL segment of the pelvic floor, 47 Sacro-anterior position, 408 Sacro-coccygeal joint, 26 Sacro-iliac joints, 25 Sacro-posterior position, 408 Sacro-vertebral joints, 25 Sacrum, anatomy of the, 23 Salivation in pregnancy, 194, 234 Scarlatina in pregnancy, 242 Schultze's method of artificial respiration in the newborn, 441 Sclerosis of the placenta, 291 Scoliotic, the, obliquely contracted pelvis, 524 Secondary abdominal pregnancy, 330 cervical pregnancy, 312 hemoirhage after labor, 549 Secretion, foetal, 165 of milk, 565 in newborn children, 577 phenomena associated with the establish- ment of the, 566 Secretions, modifications of, in the puerperal state, 560 Section, abdominal, in ectopic pregnancy, 336 Caesarean {vide Caesarean operation), 680 Segmentation of the ovule, 124 Seminal fluid, the, 116 Sensibility of the uterus during pregnancy, 179 Septicaemia, puerperal, treatment of, 612 Sex, production of, 122 Sexual organs, anatomy of the female, 49 external, bloodvessels, lymphatics, and nerves of the, 54 Shortening of the cervix in pregnancy, 182 Shoulder presentation, 408 Shoulders, delivery of the, 434 difficult delivery of the, 435 Sickness, morning, in pregnancy, 168 Signs, certain, of pelvic deformities, 501 of pregnancy, 191 et seq. objective, 195 subjective, 193 Simple flat pelvis, 508 the mechanism of labor in the, 511 Simpson, method of, in the treatment of pla- centa praevia, 347 Size, great, of the fcetus, causing dystocia, 478 of the maternal pelvis, anomalies of, 498 of twins, 189 Skin, changes in the, during pregnancy, 171 of the newborn, changes in the, 578 desquamation of the, 578 INDEX. 703 Sleep during pregnancy, 226 of the newborn child, 578 Sleeplessness in pregnancy, 237 Smegma embryonum, 165 Softening of the cervix in pregnancy, 181 Soft parts of the pelvis, 42 Souffle, placental, 205 uterine, 205 Sounds of the fcetal heart, 206 Source of the hemorrhage in placenta praevia, 34i Spermatozoids, 117 ascension of, 119 fate of, not concerned in impregnation, 122 Spondylolisthetic, the, pelvis, 513 Spondylotomy, 079 Spontaneous intra-uterine amputations, 304 delivery in shoulder presentations, 412 evolution in shoulder presentations, 412 intra-uterine fractures, 304 version, in shoulder presentations, 412 Sporadic diseases during pregnancy, 244 Sprue in infants, 583 Stages of labor {vide Labor), 359 State of the internal and of the external os during pregnancy, 181 Striae albicantes, 94 gravidarum, 172 Subjective signs of pregnancy, 193 Super-fecundation, 187 Super-fcetation, 187 Super-impregnation, 187 Supra-vaginal amputation of the uterus, 683 Sutures of the fcetal head, 152 Sylvester's method of artificial respiration in the newborn, 441 Symphysiotomy, 685 Syncope, during or following labor, death from, 587 Syphilis during pregnancy, 243 Syphilitic disease of the placenta, 292 Syphiloma of the decidua, 293 TAMPON in treatment of abortion, 316 in hydatidiform mole, 296 in the treatment of placenta praevia, 344 Tears of the cervix during labor, 533 of the lower portion of the vagina during labor, 530 treatment of, 531 of the uterus during labor, position and extent of, 540 Temperature, the, in the puerperal state, 559 Terminations of eclampsia, 270 Tetanus, puerperal, 590 Thrombus of vulva or vagina during labor, 531 treatment of, 533 Thrush in infants, 583 Thyro-hyoid arch, 147 Time of abortion, 308 of pregnancy, diagnosis of the, 215 Tocology, 17 Torsion, excessive, of the cord, 298 Touch, abdominal, 200 definition of, 196 rectal, 199 vaginal, 196 vesical, 199 Traumatism during pregnancy, 250 Trunk, fcetal diameters of the, 156 Tubal gestation, development of ovum in, 326 rupture in, 333 Tuberculum vaginae, 56 Tubes, Fallopian {vide Oviducts), 84 Tumors of the foetus, 305 of the os uteri during labor, 471 of the placenta, 292 Turning (vide Version), 629 combined, in the treatment of placenta praevia, 348 Twin-pregnancy, course of, 189 diagnosis of, 209 foetal appendages in, 189 the management of labor in, 457 Twins, sex of, 189 size of, 189 Typhoid fever during pregnancy, 238 Typhus fever during pregnancy, 239 UMBILICAL cord, the, 140, 576 anomalies of, 296 coiling of, 296 dressing, after labor, 438 excessive torsion of, 298 hemorrhage from, 577 knots in, 297 ligation of, 436 management of, in pelvic presenta- tions, 450 presentation of, 492 prolapse of, 492 causes of, 492 diagnosis of, 493 . frequency of, 492 prognosis of, 494 treatment of, 494 replacement of, in prolapse, 495 Unavoidable hemorrhage, 288, 341 Urinary apparatus during pregnancy, 171 Urination, difficulty and pain in children, 582 Urine during pregnancy, 171 retention of, in the bladder of fcetus, 483 in the puerperal state, 560 Uterine appendages, changes in the, during pregnancy, 184 contraction, force of, in labor, 361 contractions in labor, 360 characteristics of, 360 fibroids, diagnosis of, from pregnancy, 212 force during labor, deficiency of, 461 excess of, 460 perversion of, 468 glands, 70 ligaments, 76 lymphangitis in the puerperal state, 603 souffle, 205 Utero-sacral ligaments, 79 Uterus, anatomy of the, 60 anomalies of the, 91 of adjacent organs, during labor, 474 of form and position during labor, 469 anteversion and anteflexion of the, during pregnancy, 280 arteries and veins of the, modifications of the, during pregnancy, 176 bicornis duplex, 91 bifid, 92 bloodvessels of the, 71 cancer of the, during labor, 473 capacity of the, changes in, during preg- nancy, 176 cavity of the body of the, 63 cervix or neck of (vide Cervix uteri), 62 changes in the, during menstruation, 104 704 INDEX. Uterus, changes in pregnancy, 175 ct seq. contractility of the, during pregnancy, 179 dilatation, sacciform, of the posterior wall j of the, in pregnancy, 285 disease, malignant, during pregnancy, 287 diseases, structural, during; pregnancy, 287 fibroids of the, during labor, 471 during pregnancy, 286 form of, anomalies of, during labor, 469 of the, changes in the, during preg- nancy, 176 of the. in the puerperal state, 564 glands of the, 70 hernia of the gravid, 285 crural, 286 inguinal, 286 inversion of the, 549 involution of the, 562 irritability of the, in pregnancy, 179 ligaments of the, 76 lymphatics of the, 73 motor centre for the, 75 mucous membrane of the, 69 muscular coat of the, 65 et seq. neck of the (vide Cervix uteri), 62 neoplasms of the, obstructing labor, 471 nerves of the, 73 partitioned, 93 peritoneal coat of the, 64 position of the, 75 anomalies of, during labor, 469 in the puerperal state, 564 changes in the, during pregnancy, 177 positional disorders in pregnancy, 279 posterior displacements of the, in preg- nancy, 280 pregnancy in a rudimentary horn of, 338 pregnant, properties of the, 179 procidentia of the, during pregnancy, 279 prolapse of the, during pregnancy, 279 relations of, at end of pregnancy, 178 ; retractility of the, during labor, 179 retractors of the, 66 retroflexion of the gravid, 281 j retroversion of the gravid, 280 ruptures of the, 534 during labor, 535 in pregnancy, 534 sensibility of the, during pregnancy, 179 size of, changes in. during pregnancy, 176 diagnosis, differential, 211, 212 structure of the, 64 supra-vaginal amputation of the, 683 walls of the, changes in the consistency of the, during pregnancy, 177 modifications of the, during preg- nancy, 175 Utricular glands, 70 X/AGINA, anatomy of the, 55 * anomalies of the, 91 bulbs of the, 58 changes in the, during menstruation, 58 Vagina, changes in the, during pregnancy, 58, 174 dilatation of the, in labor, 369 haematoma of the, during labor, 531 injuries of the, during labor, 528 obstruction of the, during labor, 475 prolapse of the, in pregnancy, 278 rents of, 529, 530 thrombus of the, during labor, 531 vessels and nerves of the. 58 Vaginal cicatrices complicating labor, 470 ballottement in placenta praevia, 340 injections in the puerperal state, 570 touch, 196 Varices during pregnancy, 235 Varicose veins in pregnancy, 260 Variola during pregnancy, 241 Vectis, the, 670 Vegetations of vulva during pregnancy, 278 Vernix caseosa, 151, 165 removal of, 436 Version, 629 cephalic, 630 by internal and external manipula- tion, 630 by external manipulation, 632 by the method of Braxton Hicks, 632 of Busch, 631 of d'Outrepont, 632 of M. B. Wright, 630 pelvic, 633 podalic, 633 by the direct method, 635 by the method of Braxton Hicks, 633 Vertex presentation, 379 Vesical calculi complicating labor, 476 touch, 199 Vesicular mole, 294 Vestibule, 52 Vicious insertion of the placenta, 339 Vitelline circulation, 162 Vomiting in pregnancy, 168, 194, 233 Vulva, anatomy of the, 49 et seq. dilatation of the, in labor, 369 injuries of the, in labor, 526 after-treatment of, 527 pruritus of the, in pregnancy, 235 thrombus or haematoma of, in labor, 531 vegetations of the, during pregnancy, 278 Vulvar canal, 53 glands, 54 Vulvo-vaginitis in the puerperal state, 602 WATERS, the bag of, 366 false, 368 Wet-nurse, selection of a, 579 Wharton's jelly, 141 Wolffian bodies, 86 Wright, M. B., method of, for performing cephalic version, 630 Y ELLOW fever in pregnancy. 239 m LEAIBROTHERS S CO.'S |jj CLASSIFIED CATALOGUE OF g MEDICAL MD SURGICAL M- D-> Professor of Surgery in the Jefferson Medical College of Philadelphia. To which is added the second American from the latest English edition of Landmarks, Medical and Surgical, by Luther Holden, F. R. C. S. In one imperial octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of edition in black: Cloth, $6; leather, $7; half Russia, $7.50. Price of edition in colors (see below). Cloth, $7.25; leather, $8.25; half Russia, $8.75. This work covers a more extended range of subjects than is customary in the ordinary text-books, giving not only the details necessary for the student, but also the application to those details to the practice of medicine and surgery. It thus forms both a guide for the learner and an admirable work of reference for the active practitioner. The engravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference with descriptions at the foot. In this edition a new departure has been taken by the issue of the work with the arteries, veins and nerves distinguished by different colors. The engravings thus form a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recall- ing the details of the dissecting-room. Combining, as it does, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of great service to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. For the convenience of those who prefer not to pay the slight increase in cost necessi- tated by the use of colors, the volume is published also in black alone, and maintained in this style at the price of former editions, notwithstanding its largely increased size. Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, has been appended to the present edition as it was to the previous one. This work gives in a clear, condensed and systematic way all the information by which the practitioner can determine from the external surface of the body the position of internal parts. Thus complete, the work will furnish all the assistance that can be rendered by type and illustration in anatomical study. The most popular work on anatomy ever written. It is sufficient to say of it that this edition, thanks to its American editor, surpasses all other edi- tions.—Jour, of the Amer. Med. Ass'n, Dec. 31,1887. A work which for more than twenty years ha9 had the lead of all other text-books on anatomy throughout the civilized world comes to hand in such beauty of execution and accuracy of text and illustration as more than to make good the large promise of the prospectus. It would be in- deed difficult to name a feature wherein the pres- ent American edition of Gray could be mended or bettered, and it needs no prophet to see that the royal work is destined for many years to come to hold the first place among anatomical text- books. The work is published with black and colored plates. It is a marvel of book-making.— American Practitioner and News, Jan. 21,1888. Gray's Anatomy is the most magnificent work upon anatomy which has ever been published in the English or any other language.—Cincinnati Medical News, Nov. 1887. As the book now goes to the purchaser he is re- ceiving the best work on anatomy that is published in any language.— Virginia Med. Monthly, Dec. 1887. Gray's standard Anatomy has been and will be for years the text-book for students. The book needs only to be examined to be perfectly under- stood.—Medical Press of Western New York, Jan. Also for sale separate— HOLDEN, LUTHEB, F. B. C. S., Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Landmarks, Medical and Surgical. Second American from the latest revised English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in the Penn. Academy of Fine Arts. In one 12mo. volume of 148 pages. Cloth, $1.00 DUNGLISON, BOBLEY, M.D., Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- ogy Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- prudence and' Dentistry, Notices of Climate and of Mineral Waters, Formula? for Officinal, Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, and the French and other Synonymes, so as to constitute a French as well as an English Medical Lexicon. Edited by Richard J. Duxglison, M. D. In one very large and handsome royal octavo volume of 1139 pages. Cloth, $6.50; leather, raised bands, $7.50; very handsome half Russia, raised bands, $8. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references.—London Medical Gazette. 6 Lea Brothers & Co.'s Publications—Anatomy. ALLEN, HABBISOX, M. D., Professor of Physiology in the University of Pennsylvania, A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. With an Intro- ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to the Philadelphia Hospital. Comprising 813 double-columned quarto pages, witli 380 illustrations on 109 full page lithographic plates, many of which are in colors, and 241 engravings in the text. In six Sections, each in a portfolio. Section I. Histology. Section II. Bones and Joints. Section III. Muscles and Fascia. Section IV. Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, and General and Clinical Indexes. Price per Section, $3.50; also bound in one volume, cloth, $23.00; very handsome half Russia, raised bands and open back, $25.00. For sale by subscription only. Apply to the Publishers. It is to ne considered a study of applied anatomy j care, and are simply superb. There is as much In its widest sense—a systematic presentation of of practical application of anatomical points to such anatomical facts as can be applied to the : the every-day wants of the medical clinician as practice of medicine as well as of surgery. Our [ to those of the operating surgeon. In fact, few author is concise, accurate and practical in his general practitioners wilfread the work without a statements, and succeeds admirably in infusing ' feeling of surprised gratification that so many an interest into the study of what is generally con-. Doints, concerning which they may never have sidered a dry subject. The department of Histol- ! thought before are so well presented for their con- ogy is treated in a masterly manner, and the | sideration. It is a work which is destined to be ground is travelled over by one thoroughly famil- the best of its kind in any language.—Medical lar with it. The illustrations are made witn great | Record, Nov. 25,1882. CLABKE, W. B., F.B. C.S. & LOCK WOOD, C. B., F.B. C.S. Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 31. Messrs.Clarke and Lockwood have written a book | intimate association with students could have that can hardly be rivalled as a practical aid to the given. With such a guide as this, accompanied dissector. Their purpose, which is "how to de- ' By so attractive a commentary as Treves' Surgical scribe the best way to display the anatomical I Applied Anatomy (same series), no student could structure," has been fully attained. They excel in fail to be deeply and absorbingly interested in the a lucidity of demonstration and graphic terseness study of anatomy.—New Orleans Medical and Sur- of expression, which only a long training and gical Journal, April, 1884. TBEVES, FBEDEBICK, F. B. C. S., Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 31. He has produced a work which will command a I This number of the " Manuals for Students" is larger circle of readers than the class for which it most excellent, giving just such practical knowl- was written. This union of a thorough, practical edge as will be required for application in relieving acquaintance with these fundamental branches, the injuries to which the living body is liable. quickened by daily use as a teacher and practi- j The book is intended mainly for students, but it tioner, has enabled our author to prepare a work will also be of great use to practitioners. Theillus- which it would be a most difficult task to excel.— trations are well executed and fully elucidate the The American Practitioner, Feb. 1884. ] text.—Southern Practitioner, Feb. 1884. BELLAMY, EDWABD, F. B. C. S., Senior Assistant-Surgeon to the Charing-Cross Hospital, London. The Student's Guide to Surgical Anatomy: Being a Description of the most Important Surgical Regions of the Human Body, and intended as an Introduction to operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. WILSON, EBASMUS, F. B. S. A System of Human Anatomy, General and Special. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. Cloth, $4.00; leather, $5.00.________________________ CLELAND, JOHN, M. D., F. B. S., Professor of Anatomy and Physiology in Queen's College, Galway. A Directory for the Dissection of the Human Body. In one 12mo. volume of 178 pages. Cloth, $1.25. HARTSHORNES HANDBOOK OF ANATOMY HORNER'S SPECIAL ANATOMY AND HISTOL- AND PHYSIOLOGY. Second edition, revised, j OGY. Eighth edition, extensively revised and In one royal 12mo. volume of 310 pages, with 220 modified. In two octavo volumes of 1007 pages, woodcuts. Cloth, $1.75. I with 320 woodcuts. Cloth, $6.00. liEA .Brothers & Co. s Publications—Physics, Physiol., Anat. 7 DBAFEB, JOHN C, M. D., LL. D., Professor of Chemistry in the University of the City of New York. Medical Physics. A Text-book for Students and Practitioners of Medicine. In one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. FROM THE PREFACE. The fact that a knowledge of Physics is indispensable to a thorough understanding of Medicine has not been as fully realized in this country as in Europe, where the admirable works of Desplats and Gariel, of Robertson and of numerous German writers constitute a branch of educational literature to which we can show no parallel. A full appreciation of this the author trusts will be sufficient justification for placing in book form the sub- stance of his lectures on this department of science, delivered during many years at the University of the City of New York. Broadly speaking, this work aims to impart a knowledge of the relations existing between Physics and Medicine in their latest state of development, and to embody in the pursuit of this object whatever experience the author has gained during a long period of teaching this special branch of applied science. This elegant and useful work bears ample testi- mony to the learning and good judgment of the author. He has fitted his work admirably to the exigencies of the situation by presenting the reader with brief, clear and simple statements of Buch propositions as he is by necessity required to master. The subject matter is well arranged, liberally illustrated and carefully indexed. That it will take rank at once among the text-books is certain, and it is to be hoped that it will find a place upon the shelf of the practical physician, where, as a book of reference, it will be found useful and agreeable.—Louisville Medical News, SeptemDer 26, 1885. Certainly we have no text-book as full as the ex- cellent one he has prepared. It begins with a statement of the properties of matter and energy. After these the special departments of physics are explained, acoustics, optics, heat, electricity and magnetism, closing with a section on electro- biology. The applications of all these to physiology and medicine are kept constantly in view. The text is amply illustrated and the many difficult points of the subject are brought forward with re- markable clearness and ability.—Medical and Surg- ical Reporter, July 18,1885. That this work will greatly facilitate the study of medical physics is apparent upon even a mere cursory examination. It is marked by that scien- tific accuracy which always characterizes Dr. Draper's writings. Its peculiar value lies in the fact that it is written from the standpoint of the medical man. Hence much is omitted that ap- pears in a mere treatise on physical science, while much is inserted of peculiar value to the physi- cian.—Medical Record, August 22,1885. BOBEBTSON, J. McGBEGOB, M. A., M. B., Muirhead Demonstrator of Physiology, University of Glasgow. Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- tions. Limp cloth, $2.00. See Students' Series of Manuals, page 31. ments. It will be found of great value to the practitioner. It is a carefully prepared book of The title of this work sufficiently explains the nature of its contents. It is designed as a man- ual for the student of medicine, an auxiliary to his text-book in physiology, and it would be particu- larly useful as a guide to his laboratory experi- reference, concise and accurate, and as such we heartily recommend it.—Journal of the American Medical Association, Dec. 6.1884. DALTON, JOHN C, M. D., Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. Doctrines of the Circulation of the Blood. A History of Physiological Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 12mo. volume of 293 pages. Cloth, $2. Dr. Dalton's work is the fruit of the deep research | revolutionized the theories of teachers, than the of a cultured mind, and to the busy practitioner it discovery of the circulation of the blood. This cannot fail to be a source of instruction. It will ! explains the extraordinary interest it has to all inspire him with a feeling of gratitude and admir-j medical historians. The volume before us is one ation for those plodding workers of olden times, of three or four which have been written within a who laid the foundation of the magnificent temple of medical science as it now stands.—New Orleans Medical and Surgical Journal, Aug. 1885. In the progress of physiological study no fact wa9 of greater moment, none more completely few years by American physicians. It is in several respects the most complete. The volume, though small in size, is one of the most creditable con- tributions from an American pen to medical history that has appeared.—Med. <& Surg. Rep., Dec. 6,1884. BELL, F. JEFFBEY, M. A., Professor of Comparative Anatomy at King's College, London. Comparative Physiology and Anatomy. In one 12mo, volume of 561 pages, with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 31. The manual is preeminently a student's book- clear and simple in language and arrangement. It is well and abundantly illustrated, and is read- able and interesting. On the whole we consider it the best work in existence in the English language to place in the hands of the medical student.—Bristol Medico-Chirurgical Journal, Mar. 1886. ELLIS, GEOBGE VINEB, Emeritus Professor of Anatomy in University College, London. Demonstrations of Anatomy. Being a Guide to the Knowledge of the Human Body by Dissection. From the eighth and revised London edition. In one very handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25; leather, $5.25. BOBEBTS, JOHN B., A. M., M. D., Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. or Graduates in Medicine. The Compend of Anatomy. For use in the dissecting-room and in preparing for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 8 Lea Brothers & Co.'s Publications—Physiology, Chemistry. CHAFMAX, HENBY C, M. D., Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia. A Treatise on Human Physiology. In one handsome octavo volume of 925 pages, with 605 fine engravings. Cloth, $5.50; leather, $6.50. It represents very fully the existing state of farther, and the latter will find entertainment and physiology. Thepresent work has a special value instruction in an admirable book of reference.— to the student and practitioner as devoted more j North Carolina Medical Journal, Nov. 1887. to the practical application of well-known truths ! m, , . , , ,..,,.. - which the advance of science has given to the I Tj16 W01* certainly commends itself to bpth profession in this department, which may be con- i student and practitioner. \\ hat is most demanded Bideredthe foundation of rational medicine.—Buf- by.the progressive physician of to-day is an adap- falo Medical and Surgical Journal, Dec. 1887. I t*t.lon of, physiology to practical therapeutics, and Matters which have a practical bearing on the I this work is a decided improvement in this resi.eot practice of medicine are lucidly expressed; tech- ov.er °ther works lnutne market. It will certainly nical matters are given in minute detail; elabo- | take place among the most valuable text-books.— rate directions are stated for the guidance of stu- Mtdtcal Age, I\ov. 25,1887. dents in the laboratory. In every respect the It is the production of an author delighted with work fulfils its promise, whether as a complete his work, and able to inspire students with an en« treatise for the student or for the physician ; for thusiasm akin to his own.—American Practitioner the former it is so complete that he need look no | and News, Nov. 12,1887. DALTON, JOHN C., M. D., Professor of Physiology in the College of Physicians and Surgeons, New York, etc. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, $5.00; leather, $6.00. From the first appearance of the book it has I have never been in any doubt as to its sterling been a favorite, owing as well to the author's worth.—N. Y. Medical Journal, Oct. 1882. renown as an oral teacher as to the charm of Professor Dalton's well-known and deservedly- simplicity with which, as a writer, he always appreciated work has long passed the stage at which it could be reviewed in the ordinary sense. The work is eminently one for the medical prac- titioner, since it treats most fully of those branches of physiology which have a direct bearing on the diagnosis and treatment of disease. The work is one which we can highly recommend to all our readers.—Dublin Journal of Medical Science, Feb.'KJ. succeeds in investing even intricate subjects. It must be gratifying to him to observe the fre- quency with which his work, written for students and practitioners, is quoted by other writers on physiology. This fact attests its value, and, in great measure, its originality. It now needs no such seal of approbation, however, for the thou- sands who have studied it in its various editions FOSTEB, MICHAEL, mVd., F. B7S., Prelector in Physiology and Fellow of Trinity College, Cambridge, England. Text-Book of Physiology. New (fourth) and enlarged American from the fifth and revised English edition, with notes and additions. Preparing. A REVIEW OF THE FIFTH ENGLISH EDITION IS APPENDED. It is delightful to meet a book which deserves j tions, and his energies are not frittered away and only unqualified praise. Such a book is now before | degenerated on petty and trivial details. Review- us. It is in all respects an ideal text-book. With a ing this volume as a whole we are justified in say- complete, accurate and detailed knowledge of his ing that it is the only thoroughly good text-book subject, the author has succeeded in giving a ' of physiology in the English language, and that it thoroughly consecutive and philosophic account' is probably the best text-book in any language. of the science. A student's attention is kept j —Edinburgh Medical Journal, December 1889. throughout fixed on the great and salient ques- i FOWEB, HENBY, M. B., F. B. C. S., Examiner in Physiology, Royal College of Surgeons of England. Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- ume of 396 pp., with 47 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 31. SIMON, W., Flu D., M. D., Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland College of Pharmacy. Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates illustrating 56 of the most important chemical tests. Cloth, $3.25. In this book the author has endeavored to meet! feature is the introduction of a number of plates the wants of the student of medicine or pharmacy showing the various colors of the most important in regard to his chemical studies, and he has sue- chemical reactions of the metallic salts, of some ceeded in presenting his subject so clearly that no of the alkaloids, and of the urinary tests. In the one who really wishes to acquire a fair knowledge part treating of physiological chemistry the section of chemistry can fail to do so with the help of this on analysis of the urine will be found very practi- work. The largest section of the book is naturally cal, and well suited to the needs of the practitioner that devoted to the consideration of the carbon of medicine.—The Medical Record, May 25,1889. compounds, or organic chemistry. An excellent Wohler's Outlines of Organic Chemistry. Edited by Fitttg. Translated by Ika Ke.msen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. LEHMANN'S MANUAL OF CHEMICAL PHYS- IOLOGY. In one octavo volume of 327 pages, with 41 illustrations. Cloth, $2.25. CARPENTERS HUMAN PHYSIOLOGY. Edited by Heney Power. In one octavo volume. CARPENTER'S PRIZE ESSAY ON THE USE AND Abuse or Alcoholic Liquors in Health and Dis- ease. With explanations of scientific words. 8mall 12mo. 178 pages. Cloth, 60 cents. Lea Brothers & Co.'s Publications—Chemistry. 9 FBANKLAND,E.,D. C.L.,F.B.S.,&JAFP,F.B.,F.I. C., Professor of Chemistry in the Normal School of Science, London. Assist. Prof, of Chemistry in the Normal School of Science, London. Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. This work should supersede other works of its class in the medical colleges. It is certainly better adapted than any work upon chemistry,with which we are acquainted, to impart that clear and full knowledge of the science which students of med- icine should have. Physicians who feel that their chemical knowledge is behind the times, would do well to devote some of their leisure time to the study of this work. The descriptions and demon- strations are made so plain that there is no diffi- culty in understanding them.—Cincinnati Medical News, January, 1886. _____________ This excellent treatise will not fail to take its place as one of the very best on the subject of which it treats. We have been much pleased with the comprehensive and lucid manner in which the difficulties of chemical notation and nomenclature have been cleared up by the writers. It shows on every page that the problem of rendering the obscurities of this science easy of comprehension has long and successfully engaged the attention of the authors.—Medical and Surgical Reporter, October 31,1885. FOWNES, GEOBGE, Fh. D. A Manual of Elementary Chemistry; Theoretical and Practical. Em- bodying Watts' Physical Inorganic Chemistry. New American, from the twelfth English edition. In one large royal 12mo. volume of 1061 pages, with 168 illustrations on wood and a colored plate. Cloth, $2.75; leather, $3.25. Fownes' Chemistry has been a standard text- book upon chemistry for many years. Its merits are very fully known by chemists and physicians everywhere in this country and in England. As the science has advanced by the making of new discoveries, the work has been revised so as to keep it abreast of the times. It has steadily maintained its position as a text-book with medi- cal students. In this work are treated fully: Heat, Light and Electricity, includin g Magnetism. The influence exerted by these forces in chemical action upon health and disease, etc., is of the most important kind, and should be familiar to every medical practitioner. We can commend the work as one of the very best text-books upon chemistry extant.—Cincinnati Medical News, Oc- tober, 1885. Of all the works on chemistry intended for the use of medical students, Fownes' Chemistry is perhaps the most widely used. Its popularity is based upon its excellence. This last edition con- tains all of the material found in the previous. and it is also enriched by the addition of Watts' Physical and Inorganic Chemistry. All of the mat- ter is brought to the present standpoint of chemi- cal knowledge. We may safely predict for this work a continuance of the fame and favor it enjoys among medical students.—New Orleans Medical and Surgical Journal, March, 1886. ATTFIELD, JOHN, Fh. D., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. Chemistry, General, Medical and Pharmaceutical; Including the Chem- istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. A new American, from the twelfth English edition, specially revised by the Author for America. In one handsome royal 12mo. volume of 782 pages, with 88 illustrations. Cloth, $2.75; leather, $3.25. Just ready. again it is a good laboratory guide, and finally it contains such a mass of well-arranged information that it will always serve as a handy book of refer- ence. He does not allow any unutilizable knowl Attfield's Chemistry is the most popular book among students of medicine and phai macy. This popularity has a good, substantial basis. It rests upon real merits. Attfield's work combines in the happiest manner a clear exposition of the theory of chemistry with the practical application of this knowledge to the everyday dealings of the phy- sician and pharmacist. His discernment is shown not only in what he puts into his work, but also in what he leaves out. His book is precisely what the title claims for it. The admirable arrangement of the text enables a reader to get a good idea of chemistry without the aid of experiments, and edge to slip into his book; his long years of experience have produced a work which is both scientific and practical, and which shuts out everything in the nature of a superfluity, and therein lies the secret of its success. This last edition shows the marks of the latest progress made in chemistry and chemical teaching.—New Orleans Medical and Surgical Journal, Nov. 1889. BLOXAM, CHABLES L., Professor of Chemistry in King's College, London. Chemistry, Inorganic and Organic. New American from the fifth Lon- don edition, thoroughly revised and much improved. In one very handsome octavo volume of 727 pages, with 292 illustrations. Cloth, $2.00; leather, $3.00. Comment from us on this standard work is al- most superfluous. It differs widely in scope and aim from that of Attfield, and in its way is equally beyond criticism. It adopts the most direct meth- ods in stating the principles, hypotheses and facts of the science. Its language is so terse and lucid, and its arrangement of matter so logical m se- quence that the student never has' occasion to complain that chemistry is a hard study. Much attention is paid to experimental illustrations oi chemical principles and phenomena, and the mode of conducting these experiments. The book maintains the position it has always held as one of the best manuals of general chemistry In the Eng- lish language.—Detroit Lancet, Feb. 1884. We know of no treatise on chemistry which contains so much practical information in the same number of pages. The book can be readily adapted not only to the needs of those who desire a tolerably complete course of chemistry, but also to the needs of those who desire only a general knowledge of the subject. We take pleasure in recommending this work both as a satisfactory text-book, and as a useful book of reference.—.Bos- ton Medical and Surgical Journal, June 19,1884. GBEENE, WILLIAM H., M. D., Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. A Manual of Medical Chemistry. For the use of Students. Based upon Bow. man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. It is a concise manual of three hundred pages, I the recognition of compounds due to pathological • • ~ on excellent summary of the best methods conditions. The detection of poisons is treated 5fTaS£vring the liquids and solids of the body, both with sufficient fulness for the purpose of thestu- f &e estimation of their normal constituent and | dent or practitioner.—Boston Jl. of Chem. June,*80. 10 Lea Brothers & Co.'s Publications—Chemistry. BEMSEN, IBA, M. D., Fh. D., Professor of Chemistry in the Johns Hopkins University, Baltimore. Principles of Theoretical Chemistry, with special reference to the Constitu- tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- some royal 12mo. volume of 316 pages. Cloth, $2.00 This work of Dr. Remsen is the very text-book examination of college facilities as the text-book of needed, and the medical student who has it at ' chemical instruction.—St. Louis Muheal a7id Sur- his fingers' ends, so to speak, can, if he chooses, | giml Journal, January, 1888. make himself familiar with any branch of chem- , It is a healthful sign when we see a demand for Istry which he may desire to pursue. It would be j a third edition of such a book as this. This edi- difficult indeed to find a more lucid, full, and at , tion is larger than the last by about seventy-five the same time compact explication of the philos- ! pages, and much of it has been rewritten, thus ophy of chemistry, than the book before us, and i bringing it fully abreast of the latest investlga- we recommend it to the careful and impartial I tions.—N. Y. Medical Journal, Dec. 31,1887. CHABLES, T. CBANSTOUN, M. D., F. C. S., M. S., Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. The Elements of Physiological and Pathological Chemistry. A Handbook for Medical Students and Practitioners. Containing a general account of Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and Excretions of the Body in Health and in Disease. Together with the methods for pre- paring or separating their chief constituents, as also for their examination in detail, and an outline syllabus of a practical course of instruction for students. In one handsome octavo volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. Dr. Charles is fully impressed with the import- | nowadays. Dr. Charles has devoted much space to the elucidation of urinary mysteries. He does this with much detail, and yet in a practical and intelligible manner. In fact, the author has filled his book with many practical hints.—Medical Rec- ord, December 20, 1884. ance and practical "reach of his subject, and he has treated it in a competent and instructive man- ner. We cannot recommend a better book than the present. In fact, it fills a gap in medical text- books, and that is a thing which can rarely be said HOFFMANN, F., A.M^Ph.D., s9. ! the list of treatises on this most important subject. An especially attractive feature is an arrange- j —American Practitioner and News, Nov. 9th, 1889. ment by which the physiological and therapeutical j EDES, BOBEBT T., M. D., Jackson Professor of Clinical Medicine in Harvard University, Medical Department. A Text-Book of Therapeutics and Materia Medica. Intended for the Use of Students and Practitioners. Octavo, 544 pages. Cloth, $3.50; leather, $4.50. The present work seems destined to take a prom- l commend the book and congratulate the author inent place as a text-book on the subjects of which j on having produced so good a one.—N. Y. Medical it treats. It possesses all the essentials which we : Journal, Feb. 18,1888. expect in a book of its kind, such as conciseness, j Dr. Edes' book represents better than any older clearness, a judicious classification, and a reason- book the practical therapeutics of the present able degree of dogmatism. All the newest drugs day. The book is a thoroughly practical one. The of promise are treated of. The clinical index at classification of remedies has reference to their the end will be found very useful. We heartily | therapeutic action.—Pharmaceutical Era, Jan. 1888. BBUCE, J. MITCHELL^mTd.^F. B. C. P., Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. Materia Medica and Therapeutics. An Introduction to Rational Treatment. Fourth edition. 12mo., 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 31. GBIFFITH, BOBEBTEGLESFIELD, M. D. A Universal Formulary, containing the Methods of Preparing and Adminis- tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- ists. Third edition, thoroughly revised, with numerous additions^ by John M. Maisch, Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. In one octavo volume of 775 pages, with 38 illustrations Cloth, $4.50; leather, $5.50. Lea Brothers & Co.'s Publications—Pathol., Histol. 13 GBEEN, T. HENBY, M. D., Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School, London. Pathology and Morbid Anatomy. New (sixth) American from the seventh reyisedEnglish edition. Octavo, 539 pp./with 167 engravings. Cloth, $2.75. Just ready The Pathology and Morbid Anatomy of Dr. Green is too well known by members of the medi- cal profession to need any commendation. There is scarcely an intelligent physician anywhere who has not the work in his library, for it is almost an essential. In fact it is better adapted to the wants of general practitioners than any work of the kind with which we are acquainted. The works of German authors upon pathology, which have been translated into English, are too abstruse for the physician. Dr. Green's work precisely meets his wishes. The cuts exhibit the appearances of pathological structures just as they are seen through the microscope. The fact that it is so generally employed as a text-book by medical stu- dents is evidence that we have not spoken too much in its favor.—Cincinnati Medical News, Oct. 1889. PAYNE, JOSEPH F., M. D., F. B. C. P., Senior Assistant Physician and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. A Manual of General Pathology. Designed as an Introduction to the Prac- tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored plate. Cloth, $3.50. Knowing, as a teacher and examiner, the exact needs of medical students, the author has in the work before us prepared for their especial use what we do not hesitate to say is the best introduc- tion to general pathology that we have yet ex- amined. A departure which our author has taken is the greater attention paid to the causa- tion of disease, and more especially to the etiologi- cal factors in those diseases now with reasonable certainty ascribed to pathogenetic microbes. In this department he has been very full and explicit, not only in a descriptive manner, but in the tech- nique of investigation. The Appendix, giving methods of research, is alone worth the price of the book, several times over, to every student of i pathology.—St. Louis Med. and Surg. Jour., Jan.'89. SENN, NICHOLAS, M.D., Ph.D., Professor of Principles of Surgery and Surgical Pathology in Rush Medical College, Chicago. Surgical Bacteriology. In one handsome octavo of 259 pages, with 13 plates, of which 9 are colored. Cloth, $1.75. COATS, JOSEPH, M. D., F. F. P. S., Pathologist to the Glasgow Western Infirmary. A Treatise on Pathology. In one very handsome octavo volume of 829 pages, with 339 beautiful illustrations. Cloth, $5.50; leather, $6.50. Medical students as well as physicians, who I manner, the changes from a normal condition desire a work for study or reference, that treats | effected in structures by disease, and points out the subjects in the various departments in a very the characteristics of various morbid agencies thorough manner, but without prolixity, will cer- so that they can be easily recognized. But, nol tainly give this one the preference to any with limited to morbid anatomy, it explains fully how which we are acquainted. It sets forth the most the functions of organs are disturbed by abnormal recent discoveries, exhibits, in an interesting conditions.—Cincinnati Medical News, Oct. 1883. WOODHEAD, G. SIMS, M. D., F. B. C. P. E., Demonstrator of Pathology in the University of Edinburgh. Practical Pathology. A Manual for Students and Practitioners. In one beau- tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. It forms a real guide for the student and practi- tioner who is thoroughly in earnest in his en- deavor to see for himself and do for himself. To the laboratory student it will be a helpful com- panion, and all those who may wish to familiarize themselves with modern methods of examining morbid tissues are strongly urged to provide themselves with this manual. The numerous drawings are not fancied pictures, or merely schematic diagrams, but they represent faithfully the actual images seen under the microscope. The author merits all praise for having produced a valuable work.—Medical Record, May 31,1884. SCHAFEB, EDWABD A., F. B. S., Jodrell Professor of Physiology in University College, London. The Essentials of Histology. In one octavo volume of 246 pages, with 281 illustrations. Cloth, $2.25. This admirable work was greatly needed. It has been written with the object of supplying the student with directions for the microscopical examination of the tissues, which are given in a clear and understandable way. Although espe- cially adapted for laboratory work, at the same time it is intended to serve as an elementary text-book of histology, comprising all the essen- tial facts of the science.—The Physician and Sur- geon, July, 1887. KLEIN, E., M. D., F. B. S., Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosp., London. Elements of Histology. Fourth edition. In one 12mo. volume of 376 pages, with 194 illus. Limp cloth, $1.75. See Students' Series of Manuals, page 31 Considered with regard to its contents, it can only be looked on as a large and comprehensive volume. New and original illustrations have been added, with the help of which the structure of each tissue becomes clear to the reader. A copious index affords a ready reference to the histology ol every tissue and organ, and presents, at the same time, a complete glossary of the scientific terms.— Provincial Medical Journal, May 1,1889. PEPPEB, A. J., M. B., M. S., F. B. C. S., Surqeon and Lecturer at St. Mary's Hospital, London. Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 31. Its form is practical, its language is clear, and I in it nothing that is unnecessary. The list o f ♦v/i information set forth is well-arranged, well- subjects covers the whole range of surgery.—New i dexer its purpose, and give it a foremost place among the text-books of this generation.—The London Lancet, March 12, 1887. J No text-book on the principles and practice of medicine has ever met in this country with such HABTSHOBNE, HENBY, M. D., LL. D., Lately Professor of Hygiene in the University of Pennsylvania. Essentials of the Principles and Practice of Medicine. A Handbook f or Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75; half bound, $3.00. f - Within the compass ol 600 pages it treats of the history of medicine, general pathology, general 8 ymptomatology, and physical diagnosis (including laryngoscope, ophthalmoscope, etc.), general ther- apeutics, nosology, and special pathology and prac- tice. There is a wonderful amount of information containedin this work, and it is one of the best of its kind that we have seen.—Glasgow Medical Journal, Nov. 1882. An indispensable book. No work ever exhibited a better average of actual practical treatment than this one; and probably not one writer in our day had a better opportunity than Dr. Hartshorne for condensing all the views of eminent practitioners into a 12mo. The numerous illustrations will be very useful to students especially. These essen- tials, as the name suggests, are not intended to supersede the text-books of Flint and Bartholow, but they are the most valuable in affording the means to see at a glance the whole literature of any disease, and the most valuable treatment.—Chicago Medical Journal and Examiner, April, 1882. BEYNOLDS, J. BUSSELL, 31. D., Professor of the Principles and Practice of Medicine in University College, London. A System of Medicine. With notes and additions by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- tions. Price per volume, cloth, $5.00; sheep, $6.00; very handsome half Russia, raised bands, $6.50. Per set, cloth, $15; leather, $18. Sold only by subscription. Really too much praise can scarcely be given to of reference it is invaluable. It is up with the this noble book. It is a cyclopsedia_of medicine times. It is clear and concentrated in style, and its form is worthy of its famous publisher.— Louisville Medical Net written by some of the best men of Europe. It is fall of useful information, such as one finds fre- quent need of in one's daily work. As a book Jews, Jan. 31,1880. SI ILLE, ALFBED, M. D., LL. D., Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- ment. In one handsome. 12mo. volume of 163 pages, with a chart. Cloth, $1.25. WATSON, SIB THOMAS, M. D., Late Physician in Ordinary to the Queen. Lectures on the Principles and Practice of Physic. A new American from the fifth English edition. Edited, with additions, and 190 illustration*, by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In two large octavo volumes ol 1840 pages. Cloth, $9.00 ; leather, $11.00. LECTURES ON THE STUDY OF FEVER. By ! BRISTOWE'S PRACTICE OF MEDICINE. In A. Hudson, M. D., M. R. I. A. In one octavo . ?n*J3?Z°J£l™?\ ™ t^,,™ volume of 308 pages. Cloth, 82.50. LA4 R°CHE ON YELLOW FEVER, considered in . ^i.Tj.n.ior nv nmrnn t> r. ^ t lts Historical, Pathological, Etiological and A TREATISE ON FEVER. By Robeet D Lyons, , Therapeutical Relations In two largelnd r.and- K. C. C. Inone8vo. vol. of 364 pp. Cloth, $2.26. , 80me octavo volumes of 1468 pp. Cloth. $7.00. Lea Brothers & Co.'s Publications—System of Med. 15 For Sale by Subscription Only. A System of Practical Medicine. BY AMERICAN AUTHORS. Edited by WILLIAM PEPPER, M. D., LL. D., provost and professor of the theory and practice of medicine and of clinical medicine in the university of pennsylvania, Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in tha Hospital of the University of Pennsylvania. The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, $7. In this great work American medicine is for the first time reflected by its worthiest teachers, and presented in the full development of the practical utility which is its pre- eminent characteristic. The most able men—from the East and the West, from the- North and the South, from all the prominent centres of education, and from all the- hospitals which afford special opportunities for study and practice—have unitedj in- generous rivalry to bring together this vast aggregate of specialized experience. - ^4 The distinguished editor has so apportioned the work that to each author has been assigned the subject which he is peculiarly fitted to discuss, and in which his views will be accepted as the latest expression of scientific and practical knowledge. The practitioner will therefore find these volumes a complete, authoritative and unfailing work of reference, to which he may at all times turn with full certainty of finding what he needs in its most recent aspect, whether he seeks information on the general principles of medi- cine, or minute guidance in the treatment of special disease. So wide is the scope of the> work that, with the exception of midwifery and matters strictly surgical, it embraces the- whole domain of medicine, including the departments for which the physician is accustomed to rely on special treatises, such as diseases of women and children, of the genito-urinary organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology and otology. Moreover, authors have inserted the formulas which they have found most efficient in the treatment of the various affections. It may thus be truly regarded as a Complete Library of Practical Medicine, and the general practitioner possessing it may feel secure that he will require little else in the daily round of professional duties. In spite of every effort to condense the vast amount of practical information fur- nished, it has been impossible to present it in less than 5 large octavo volumes, containing about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary octavos. Illustrations are introduced wherever requisite to elucidate the text. A detailed prospectus will be sent to any address on application to the publishers These two volumes bring this admirable work to a close, and fully sustain the high standard reached by the earlier volumes; we have only therefore to echo the eulogium pronounced upon them. We would warmly congratulate the editor and his collaborators at the conclusion of their laborious task on the admirable manner in which. from first to last, they have performed their several duties. They have succeeded in producing a work which will long remain a standard work of reference, to which practitioners will look for fiidance, and authors will resort for facts. rom a literary point of view, the work is without any serious blemish, and in respect of production, it has the beautiful finish that Americans always give their works.—Edinburgh Medical Journal, Jan. 1887. * * The greatest distinctively American work on the practice of medicine, and, indeed, the super- lative adjective would not be inappropriate were even all other productions placed in comparison. An examination of the five volumes is sufficient to convince one of the magnitude of the enter- prise, and of the success which has attended its fulfilment.— The Medical Age, July 26, 1886. This huge volume forms a fitting close to the great system of medicine which in so short a time has won so high a place in medical literature, and has done such credit to the profession in this country. Among the twenty-three contributors are the names of the leading neurologists in America, and most of the work in the volume is of the highest order.—Boston Medical and Surgical Journal, July 21,1887. We consider it one of the grandest works on Practical Medicine in the English language. It is a work of which the profession of this country can *eel proud. Written exclusively by Amerk-ac physicians who are acquainted with all the varie- ties of climate in the United States, the character of the soil, the manners and customs of the peo- ple, etc., it is peculiarly adapted to the wanta of American practitioners of medicine, and it seems to us that every one of them would desire to have it. It has been truly called a " Complete Library of Practical Medicine," and the general practitioner will require little else in his round of professional duties.—Cincinnati Medical News, March, 1886. Each of the volumes is provided with a most copious index, and the work altogether promises to be one which will add much to the medical literature of the present century, and reflect great credit upon the scholarship and practical acumen of its authors.—The London Lancet, Oct. 3, 1885. The feeling of proud satisfaction with which the American profession sees this, its representative system of practical medicine issued to the medi- cal world, is fully justified by the character of the work. The entire caste of the system is in keep- ing with the best thoughts of the leaders and fol- lowers of our home school of medicine, and the combination of the scientific study of disease and the practical application of exact and experimen- tal knowledge to the treatment of human mal- adies, makes every one of us share in the pride that has welcomed Dr. Pepper's labors. Sheared of the prolixity that wearies the readers of the German school, the articles glean these same fields for all that is valuable. It is the outcome of American brains, and is marked throughout by much of the sturdy independence of thought and originality that is a national characteristic. Yet nowhere is there lack of study of the most advanced views of the day.—North Carolina Medi- cal Journal, Sept. 1886. 16 Lea Brothers & Co.'s Publications—Clinical Med., etc. FOTHEBGILL, J. 31., 31. D., Ed in., 31. B. C. P., Lond., Physician to the City of London Hospital for Diseases of the Chest. The Practitioner's Handbook of Treatment; Or, The Principles of Thera- peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75; leather, $4.75. To have a description of the normal physiologi- j This is a wonderful book. If there be such a cal processes of an organ and of the methods of thing as "medicine made easy," this is the work to treatment of its morbid conditions brought accomplish this result.— Va. Sled. Month., June,'87. together in a single chapter, and the relations It is an excellent, practical work on therapeutics, between the two clearly stated, cannot fail to prove well arranged and clearly expressed, useful to the a great convenience to many thoughtful but busy ; student and young practitioner, perhaps even to physicians. The practical value of the volume is the old.—Dublin Journal of Medical Science, March, greatly increased by the introduction of many 1888. prescriptions. That the profession appreciates i We do not know a more readable, practical and that the author has undertaken an important work useful work on the treatment of disease than the and has accomplished it is shown by the demand j one we have now before us.—Pacific Medical and f or this third edition.—N. Y. Med. Jour:, June 11,'87. i Surgical Journal, October, 1887. VAUGHAN, VICTOB C, PluD^3LD., Prof, of Phys. and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. and NOVY% FBEDEBICK G.9 31. D. Instructor in Hygitne and Phys. Chem. in the Univ. of Mich. Ptomaines and Leucomaines, or Putrefactive and Physiological Alkaloids. In one handsome 12mo. volume of 311 pages. Just ready. Cloth, $1.75. This book is what has been wanted for some ; observers and experimenters on micro-organisms, years by the medical profession. The subject of and to trace the relationship of cause and eifect ptomaines and leucomaines, so far as their disease- of the putrefactive alkaloids. We congratulate producing relations are concerned, has been under the authors upon the successful presentation ol special study scarcely more than a decade, but the current views on the subject in such manner within that period facts have been discovered as to make them easily comprehensible, while to upon which theories of permanent standing have the practitioner, after he has carefully read the been built, until now the practitioner is far be- book, it will serve, also, as a frequent reference hind the times if he does not appreciate the work, because of the technical information it gives. importance of ptomaines. This is the first attempt , Va. Medical Monthly, Sept. 1888. made to collect into book form the results of I FINLAYSON, JAMES, 31. D., Editor, Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. Clinical Manual for the Study of Medical Cases. With Chapters by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of the Female Organs; Dr. Kobertson on Insanity; Dr. Gemmell on Physical Diagnosis; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- taking, Family History and Symptoms of Disorder in the Various Systems. New edition. In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. The profession cannot but welcome the second edition of this very valuable work of Finlayson and his collaborators. The size of the book has been increased and the number of illustrations nearly doubled. The manner in which the subject is treated is a most practical one. Symptoms alone and their diagnostic indications form the basis of discussion. The text explains clearly and fully the methods of examinations and the con- clusions to be drawn from the physical signs.— The Medical News, April 23, 1887. treatise on medical diagnosis, in which every sign and symptom of disease is carefully analyzed, and their relative significance in the different affec- tions in which they occur pointed out. From their synthesis the student can accurately determine the disease with which he has to deal. The book has no competitor, nor is it likely to have as long as future editions maintain its present standard of excellence. The general practitioner will find many practical hints in its pages, while a careful study of the work will save him from many pitfalls We are pleased to see a second edition of this | in diagnosis.—Liverpool Medico-Chirurgical Jour- admirable book. It is essentially a practical i nal, January, 1887. FENWICK, SA3LUEL, M. D., Assistant Physician to the London Hospital. The Student's Guide to Medical Diagnosis. From the third revised and enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 87 illustrations on wood. Cloth, $2.25.- HABEBSHON, S. O., M. D., Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital, London. On the Diseases of the Abdomen; Comprising those of the Stomach, and other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second American from third enlarged and revised English edition. In one handsome octavo volume of 554 pages, with illustrations. Cloth, $3.50. This valuable treatise on diseases of the stomach j to the times, and making it a volume of interest to and abdomen will be found a cyclopaedia of infor- ' the practitioner in every field of medicine and mation, systematically arranged, on all diseases of surgery. Perverted nutrition is in some form the alimentary tract, from the mouth to the associated with all diseases we have to combat, rectum. A fair proportion of each chapter is [ and we need all the light that can be obtained on devoted to symptoms, pathology, and therapeutics, a subject so bread and general. Dr. Habershon's The present edition is fuller than former ones in i work is one that every practitioner should read many particulars, and has been thoroughly revised i and study for himself.—N. Y. Medical Journal, and amended by the author. Several new chap- April, 1879. ters have been added, bringing the work fully up _________ TANNEB, THOMAS HAWKES, M. D. A Manual of Clinical Medicine and Physical Diagnosis. Third American f rom the second London edition. Revised and enlarged by Tilbury Fox, M. D. In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. Lea Brothers & Co.'s Publications—Hygiene, Electr., Pract. 17 BABTHOLOW, BOBEBTS, A. M., M. D., LL. D., Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila. etc. Medical Electricity. A Practical Treatise on the Applications of Electricity to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 308 pages, with 110 illustrations. Cloth, $2.50. The fact that this work has reached its third edi- tion in six years, and that it has been kept fully abreast with the increasing use and knowledge of electrieity,demonstrates its claim to be considered a practical treatise of tried value to the profession. The matter added to the present edition embraces the most recent advances in electrical treatment. The illustrations are abundant and clear, and the work constitutes a full, clear and concise manual well adapted to the needs of both student and practitioner.— The Medical News, May 14, 1887. This "practical treatise on the applications of electricity to medicine and surgery" has grown to be so important a work that every practitioner should read it, especially when it is recalled what possibilities lie in the path of the further study of the therapeutics of electricity. Dr. Bartholow has here presented the profession with a concise work that, beginning with elementary descriptions and principles, gradually grows, page by page, into a magnificently practical treatise, describing opera- tions in detail, and giving records of successes that prove electricity to be marvellous as a curative agent in many forms of disease. The doctor can- not now do better than to possess himself of Dr. Bartholow's treatise, just as it is.— Virginia Medi- cal Monthly, June, 1887. YEO, I. BUBNEY, M. D., F. B. C. P., Professor of Clinical Therapeutics in King's College, London, and Physician to King's College Pood in Health and Disease. In one 12mo. volume of 590 pages. Cloth, $2. Just ready. See Series of Clinical Manuals, page 31. Dr. Yeo is fully master of his subject and he supplies in a compact form nearly all that the practitioner requires to know on the subject of diet. The work is divided into two parts—food in health and food in disease. Dr. Yeo has gathered together from all quarters an immense amount of useful information within a comparatively small compass, and he has arranged and digested his materials with skill for the use of the practitioner. We have seldom seen a book which more thor- oughly realizes the object for which it was written than this little work of Dr. Yeo.—British Medical Journal, Feb. 8,1890. BICHABDSON, B. W., M.D., LL. D., F.B.S., Fellow of the Royal College of Physicians, London. Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5 Dr. Richardson has succeeded in producing a work which is elevated in conception, comprehen- sive in scope, scientific in character, systematic in arrangement, and which is written in a clear, con cise and pleasant manner. He evinces the happy faculty of extracting the pith of what is known on the subject, and of presenting it in a most simple, intelligent and practical form. There is perhaps no similar work written for the general public thatcontains such acomplete,reliable and instruc- tive collection of data upon the diseases common to the race, their origins, causes, and the measures for their prevention. The descriptions of diseases are clear, chaste and scholarly ; the discussion of the question of disease is comprehensive, masterly and fully abreast with the latest and best knowl- edge on the subject, and the preventive measures advised are accurate, explicit and reliable.—The American Journal of the Medical Sciences, April, 1884. This is a book that will surely find a place on the table of every progressive physician. To the medi- cal profession, whose duty is quite as much to prevent as to cure disease, the book will be a boon. —Boston Medical and Surgical Journal, March 6,'84. The treatise contains a vast amount of solid, val- uable hygienic information.—Medical and Surgical Reporter, Feb. 23,1884. THE YEAB-BOOK OF TBEATMENT FOB 1890. A Comprehensive and Critical Review for Practitioners of Medi- cine. In one 12mo. volume of 329 pages. Cloth, $1.25. Just ready. #*# For special commutations with periodicals see page 2. In the present issue of the Year-Book of Treat- ment we find the usual clear, concise, complete and accurate epitome of the chief advances made in the treatment of disease during the year end ing Sept. 1st. The different subjects are arranged in sections under the heads of the principal sys- tems of the body. The serial medical literature of England, America and of the Continent has been laid under contribution, with the result that a large mass of information, valuable to the prac- titioner, is presented for his immediate reference. Brief notices of the most important new books on each subject add greatly to the value of the annual retrospect. Such a book, produced as it is in an elegant and convenient form and at a very low price, ought to be in the hands of every member of the profession.—The Practitioner, Feb. 1890. THE YE AB-BOOKS of TBEATMENT for 1886-87-89. Similar to above. 12mo., 320-341 pages. Limp cloth, $1.25 each. SCHBEIBEB, JOSEPH, M. D. A Manual of Treatment by Massage and Methodical Muscle Ex- ercise. Translated by Walter Mendelson, M. D., of New York. octavo volume of 274 pages, with 117 fine engravings. Cloth, $2.75. In one handsome STURGES' INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome 12mo. volume of 127 pages. Cloth, $1.25. DAVIS' CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES. By N. S. Davis, M. D. Edited by Fbank H. Davis, M. D. Second edition. 12mo. 287 pages. Cloth, $1-75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of 320 pages. Cloth, $2.50. PAVY'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment From the second London edition. In one octavo volume of 238 pages. Cloth, $2.00. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With additions by D. F. Condik, M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. CHAMBERS'MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand- some octavo volume of 302 pp. Cloth, $2.75. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 18 Lea Brothers & Co.'s Publications—Throat, Lungs, Heart. FLINT, AUSTIN, 31. D., LL. D., Professor of the Principles and Practice of Medicine m Bellevue Hospital Medical Collage, N. Y. A. Manual of Auscultation and Percussion; Of the Physical Diagnosis ol Diseases of the Lungs and Heart, and of Thoracic Aneurism. New (fifth) edition. Edited by James C. Wilson, M. D, Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volume of about 300 pages, with 14 illustrations. Preparing. A notice of the previous edition is appended. The original work done by Dr. Flint in the devel- passed through four editions attests its popularity. opment of the art of physical diagnosis will always There is a tendency among physical diagnosti- make this manual an authority on this subject. I cians to make altogether too many varieties of Among all the works issued on this topic during ! morbid chest sounds, and especially of rales. The the last few years, none exceeds this one in sim- I conciseness of Dr. Flint's Manual is one of its chief plicity and completeness. The fact that it has | advantages —Medical Record, June 16,1888. BY THE SAME AUTHOR. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis ; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, $4. Essays on Conservative Medicine and Kindred Topics. In one very hand- some royal 12mo. volume of 210 pages. Cloth, $1.38. BBOWNE, LENNOX, F. B. C. S., E., Senior Physician to the Central London Throat and Ear Hospital. A Practical Guide to Diseases of the Throat and Nose, including Associated Affections of the Ear. With 120 illustrations in color, and 235 en- gravings on wood. New (third) and enlarged edition. In one imperial octavo volume of 714 pages. Cloth, $6.f,0. Just ready. SEILEB, CABL, M. D., Lecturer on Laryngoscopy in the University of Pennsylvania. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo. volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. Few medical writers surpass this author in I of topics and methods. The book deserves a large ability to make his meaning perfectly clear in a sale, especially among general practitioners—Chi- few words, and in discrimination in selection, both | cago Medical Journal and Examiner, April, 1889. COHEN, J. SOLIS, 31. D., Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third edition, thoroughly revised and rewritten, with a large number of new illustrations. In one very handsome octavo volume. Preparing. GBOSS, S. D., M.D., LL.D., D.C.L. Oxon., LL.D. Cantab. A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. BBOADBENT, W. H., M. D., F. B. C. P., Physician to and Lecturer on Medicine at St. Mary's Hospital, London. The Pulse. In one 12mo. volume of 312 pages. Cloth, $1.75. Just ready. See Series of Clinical Manuals, page 31. FULLER ON DISEASES OF THE LUNGS AND I valence in various Countries. Second and revised AIR-PASSAGES. Their Pathology, Physical Di- ' edition. In one l2mo. vol., pp. 158. Cloth, $1.26. agnosia, Symptoms and Treatment. From the SMITH ON CONSUMPTION ; its Early and Reme- second and revised English edition. In one diable Stages. I vol. 8vo., pp. 253. Cloth, $2.26. octavo volume of 475 pages. Cloth, $3.50. I LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 WALSHE ON THE DISEASES OF THE HEART ! page*. Cloth,$3.00. AND GREAT VESSELS. Third American edi- WILLIAMS ON PULMONARY CONSUMPTION; tion. In 1 vol. Rvo., 416 pp. Cloth, $3.00. : its Nature, Varieties and Treatment. With an BLADE ON DIPHTHERIA; its Nature and Treat- analysis of one thousand cases to exemplify its ment, with an account of the History of its Pre- | duration. In one 8vo. vol. of 303 pp. Cloth, $2.60 Lea Brothers & Co.'s Publications—Nerv. and Ment. Dis., etc. 19 BOSS, JAMES, 31.D., F.B.C.P., LL.D., Senior Assistant Physician to the Manchester Royal Infirmary. A Handbook on Diseases of the Nervous System. In one octavo volume of 725 pages, with 184 illustrations. Cloth, $4.50; leather, $5.50. This admirable work is intended for students of | the department of medicine of which it treats. medicine and for such medical men as have no time Dr. Ross holds such a high scientific position that for lengthy treatises. In the present instance the | any writings which bear his name are naturally duty of arranging the vast store of material at the i expected to have the impress of a powertui intel- disposal of the author, and of abridging the de- ] lect. In every part this handbook merits the scription of the different aspects of nervous dis- | highest praise, and will no doubt be found oi the eases, has been performed with singular skill, and i greatest value to the student as well as to the prac- the result is a concise and philosophical guide to | titioner.—Edinburgh Medical Journal, Jan. 1887. MITCHELL, S. WEIB, M. D., Physician to Orthopasdic Hospital and the Infirmary for Dismses of the Nervous System, Phila. etc. Lectures on Diseases of the Nervous System; Especially in Women. Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. No work in our language develops or displays more features of that many-sided affection, hys- teria, or gives clearer directions for its differen- tiation, or sounder suggestions relative to its general management and treatment. The book is particularly valuable in that it represents in the main the author's own clinical studies, which have been so extensive and fruitful as to give his teachings the stamp of authority all over the realm of medicine. The work, although written by a specialist, has no exclusive character, and the general practitioner above all others will find its perusal profitable, since it deals with diseases which he frequently encounters and must essay to treat.—American Practitioner, August, 1885. HAMILTON, ALLAN McLANE, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, Blackwell's Island, N. Y. Nervous Diseases; Their Description and Treatment. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. When the first edition of this good book appeared we gave it our emphatic endorsement, and the Eresent edition enhances our appreciation of the ook and its author as a safe guide to students of clinical neurology. One of the best and most critical of English neurological journals, Brain, has characterized this book as the best of its kind in' any language, which is a handsome endorsement from an exalted source. The improvements in the new edition, and the additions to it, will justify its purchase even by those who possess the old.— Alienist and Neurologist, April, 1882. TUKE, DANIEL HACK, M. D., Joint Author of The Manual of Psychological Medicine, etc. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. New edition. Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3. method of interpretation. Guided by an enlight- ened deduction, the author has reclaimed for science a most interesting domain in psychology, previously abandoned to charlatans and empirics. This book, well conceived and well written, must commend itself to every thoughtful understand- ing.—New York Medical Journal, September 6,1884. It is impossible to peruse these interesting chap- ters without being convinced of the author's per- fect sincerity, impartiality, and thorough mental grasp. Dr. Tuke has exhibited the requisite amount of scientific address on all occasions, and the more intricate the phenomena the more firmly has he adhered to a physiological and rational CLOTJSTON, THOMAS S., M. D., F. B. C. P., L. B. C. S., Lecturer on Mental Diseases in the University of Edinburgh. Clinical Lectures on Mental Diseases. With an Appendix, containing an Abstract of the Statutes of the United States and of the Several States and Territories re- lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 pages, with eight lithographic plates, four of which are beautifully colored. Cloth, ' the general practitioner in guiding him to a diag- nosis and indicating the treatment, especially in many obscure and doubtful cases of mental dis- ease. To the American reader Dr. Folsom's Ap- pendix adds greatly to the value of the work, and will m <^e it a desirable addition to every library. —A merican Psychological Journal, July, 1884. The practitioner as well as the student will ac- cept the plain, practical teaching of the author as a forward step in the literature of insanity. It is refreshing to find a physician of Dr. Clouston's experience and high reputation giving the bed- side notes upon which his experience has been founded and his mature judgment established. Such clinical observations cannot but be useful to gfc^rDr. Folsom's Abstract may also be obtained separately in one octavo volume of 108 pages Cloth, $1.50.____________________________ SAVAGE, GEOBGE H.,- M. D., Lecturer on Mental Diseases at Guy's Hospital, London. Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 31. PLAYFAIB, W. S^M. D., F. B. C. P. The Systematic Treatment of Nerve Prostration and Hysteria. In one handsome small 12mo. volume of 97 pages. Cloth, $1.00. Blandford on Insanity and its Treatment: Lectures on the Treatment, Medical and Legal, of Insane Patients. In one very handsome octavo volume. Jones' Clinical Observations on Functional Nervous Disorders. Second American Edition. In one handsome octavo volume of 340 pages. Cloth, $3.25. 20 Lea Brothers & Co.'s Publications—Surgery. ASHHUBST, JOHN, Jr., 31. D., Barton Prof, of Surgery and Clin. Surgery in Univ. of Psnna., Surgeon to the Penna. Hosp., etc. The Principles and Practice of Surgery. New (fifth) edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 1144 pages, with 642 illustrations. Cloth, $6; leather, $7. Just ready. A complete and most excellent work on surgery. It is only necessary to examine it to see at once its excellence and real merit either as text-book for the student or a guide for the general practi- tioner. It fully considers in detail every surgical injury and disease to which the body is liable, and every advance in surgery worth noting is to be found in its proper place. It is unquestionably the best and most complete single volume on surgery, in the English language, and cannot but receive thatcontinued appreciation which its merits justly demand.—Southern Practitioner, Feb. 1890. This is one of the most popular and useful ol the many well-known treatises on general surgery. It furnishes in a concise manner a clear and comprehensive description of the modes of prac- tice now generally employed in the treatment of surgical affections, with a plain exposition of the Crinciples on which those modes of practice are ased. The entire work has been carefully revised and a number of new illustrations introduced" that greatly enhance the value of the book.— Cincinnati Lancet-Clinic, Dec. 14,1889. DBUITT, BOBEBT, M. B. C. S., etc. Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- ley Boyd, M.B., B. S., F. K. C.S. In one 8vo. volume of 965 pages, with 373 illustra- tions. Cloth, $4; leather, $5. It is essentially a new book, rewritten from be- ginning to end. The editor has brought his work up to the latest date, and nearly every subject on which the student and practitioner would desire to consult a surgical volume, has found its place Druitt's Surgery has been an exceedingly popu- lar work in the profession. It is stated that 50,000 copies have been sold in England, while in the United States, ever since its first issue, it has been used as a text-book to a very large extent. Dur- here. The volume closes with about twenty pages ! ing the late war in this country it was so highly of formula covering a broad range of practical appreciated that a copy was issued by the Govern- therapeutics. The student will find that the new ment to each surgeon. The present edition, while Druitt is to this generation what the old one was J it has the same features peculiar to the work at .to the former, and no higher praise need be first, embodies all recent discoveries in surgery, accorded to any volume.—North Carolina Medical I and is fully up to the times. Cincinnati Medical Journal, October, 1887. 1 News, September, 1887. GANT, FBEDEBICK JAMES, F. B. C. S., Senior Surgeon to the Royal Free Hospital. The Student's Surgery. A Multum in Parvo. In one square octavo volume of 848 pages, with 159 engravings. Cloth, $3.75. The claims of this volume to be a multum in parvo are certainly substantiated. The author covers the whole field of clinical and operative surgery in about eight hundred pages of very com- pactly "printed matter. For a student's manual it appears to us in every way excellent, containing almost everything necessary to equip the student with sound, matter-of-fact knowledge on surgical subjects. The volume is a condensation of the author's well-known larger works on surgery, notably his "Science and Practice of Surgery". Students requiring the essentials of surgery in a handy and condensed form, and those who cannot devote time to theoretical or speculative pathology will find this volume exceedingly ser- viceable.— The Physician and Surgeon, April, 1890 BOBEBTS, J. B., M. D., Professor of Anatomy and Surgery in the Philadelphia Polyclinic. Professor of the Principles and Practice of Surgery in the Woman's Medical College of Pennsylvania. The Principles and Practice of Modern Surgery. For the use of Students and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 850 pages, with about 425 illustrations. In press. In this volume, as its title indicates, the author has endeavored to give a thorough exposition of the best surgical practice of the present time. Not relying on his own large experience, he has consulted the latest literature of all kinds bearing on his spec- ialty, and has gleaned therefrom the opinions of the best authorities, and the methods of the most practical surgeons. The well-established facts of the science are clearly stated, but history, theories and untried innovations are rigidly excluded. The work is richly illustrated. In the selection of matter and in the consideration of the vast number of questions involved, the author has used his most critical judgment in the endeavor to render the work of the greatest practical advantage to both practitioners and students. GBOSS, S. D., M. D., LL. D., D. C. L. Oxon., LL. D. Cantab., Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. Strongly bound in leather, raised bands, $15. BALL, CHABLESB^M. Ch., DiibT, F. B. C. S., E.f Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. Diseases of the Rectum and Anus. In one 12mo. volume of 417 pages, with 54 engravings and 4 colored plates. Cloth, $2.25. Just ready. See Series of Clinical Manuals, page 31.___________________ GIBNEY, V. P., M.D., Surgeon to the Orthopcedic Hospital, New York, etc. Orthopaedic Surgery. For the use of Practitioners and Students. In one hand- some octavo volume, profusely illustrated. Preparing. Lea Brothers & Co.'s Publications—Surgery. 21 EBICHSEN, JOHN E., F. B. S., F. B. C. S., Professor of Surgery in University College, London, etc. The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Dis- eases and Operations. From the eighth and enlarged English edition. In two large and beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. Cloth, $9; leather, raised bands, $11. We have always regarded "The Science and Art of Surgery" as one of the best surgical text- books in the English language, and this eighth edition only confirms our previous opinion. We take great pleasure in cordially commending it to our readers.—The Medical News, April 11,1885. For many years this classic work has been made by preference of teachers the principal text-book on surgery for medical students, while through translations into the leading continental languages it may be said to guide the surgical teachings of the civilized world. No excellence of the former edition has been dropped and no discovery, device or improvement which has marked the progress of surgery during the last decade has been omitted. The illustrations are many and executed in the highest style of art. —Louisville Medical News, Feb. 14,1885. We cannot speak too highly of this excellent work. It represents the most advanced and settled views in regard to the science of surgery, and will ever be found a faithful guide and counsellor in practice.—Canada Lancet, May, 1885. It appears simultaneously in England, America, Spain and Italy, and is too well known as a safe guide and familiar friend to need further com- ment.— New York Medical Journal, March 28,1885. BBYANT, THOMAS, F. B. C. S., Surgeon and Lecturer on Surgery at Guy's Hospital, London. The Practice of Surgery. Fourth American from the fourth and revised Eng- lish edition. In one large and very handsome imperial octavo volume of 1040 pages with 727 illustrations. Cloth, $6.50; leather, $7.50. The fourth edition of this work is fully abreast nf the times. The author handles his subjects with that degree of judgment and skill which is attained by years of patient toil and varied ex- perience. The present edition is a thorough re- vision of those which preceded it, with much new matter added. His diction is so graceful and logical, and his explanations are so lucid, as to Elace the work among the highest order of text- ooks for the medical student. Almost every topic in surgery is presented in such a form as to enable the busy practitioner to review any subject in every-day practice in a short time. No time is lost with useless theories or superfluous verbiage. In short, the work is eminently clear, logical and practical.—Chicago Medical Journal and Examiner, April, 1886. This book is essentially what it purports to be, viz.: a manual for the practice of surgery. It is peculiarly well fitted for the studentor busy general practitioner.—The Medical News, August 15,1885. TBEVES, FBEDEBICK, F. B. C. S., Hunterian Professor at the Royal College of Surgeons of England. A Manual of Surgery. In Treatises by Various Authors. In three 12mo. volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See Students' Series of Manuals, page 31. We have here the opinions of thirty-three I the salient points and the beginnings of new sub- authors, in an encyclopaedic form for easy and ' ready reference. The three volumes embrace every variety of surgical affections likely to be met with, the paragraphs are short and pithy, and jects are always printed in extra-heavy type, so that a person may find whatever information he may be in need of at a moment's glance.—Cin- cinnati Lancet-Clinic, August 21,1886. MABSH, HOWABD, F. B. C. S., Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 31. BUTLIN, HENBY T., F. B. C. S., Assistant Surgeon to St. Bartholomew's Hospital, London. Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 31. The language of the text is clear and concise. The author has aimed to state facts rather than to express opinions, and has compressed within the compass of this small volume the pathology, etiol- ogy, etc., of diseases of the tongue that are incon- veniently scattered through general works on sur- gery and the practice of medicine. The physician and surgeon will appreciate its value as an aid and guide.—Physician and Surgeon, Sept. 1886. TBEVES, FBEDEBICK, F. B. C. S., Surgeon to and Lecturer on Surgery at the London Hospital. Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 illustrations. Limp cloth, blue edges, $2.00, A standard work on a subject that has not been so comprehensively treated by any contemporary English writer. Its completeness renders a full review difficult, since every chapter deserves mi- nute attention, and it is impossible to do thorough See Series of Clinical Manuals, page 31. justice to the author in a few paragraphs. Intes- tinal Obstruction is a work that will prove of equal value to the practitioner, the student, the pathologist, the physician and the operating sur- geon.—British Medical Journal, Jan. 31,1885. GOULD, A. PEABCE, M. S., M. B., F. B. C. S„ Assistant Surgeon to Middlesex Hospital. Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 Cloth, $2.00. See Students' Series of Manuals, page 31. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D. In one 8vo. vol. of 784 pp. with 316 illus. Cloth, 83.75. MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh edition. In one 8vo. vol. of 638 pages, with 340 illustrations. Cloth, $3.75. MILLER'S PRACTICE OF SURGERY. Fourth and revised American edition. In one large 8vo. vol. of 682 pp., with 364 illustrations. Cloth, $3.75. 22 Lea Brothers & Co.'s Publications—Surgery, Frac, l>isloc. S31ITII. STEPHEN, 31. D., Professor of Clinical Surgery in the University of the City of New York. The Principles and Practice of Operative Surgery. Now (second) and thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 1005 illustrations. Cloth, $1 00; leather, $5.00. This excellent and very valuable book is one of | tic surgery, and the latest instruments known for the most satisfactory works on modern operative operative work. Itcan be truly said that asahand- surgery ytt published. Its author and publisher i book for the student, acompanlon forthe surgeon, have spared no pains to make it as far as possible and even as a book of reference for the physician an ideal, and their efforts have given it a position not especially engaged in the practice or surgery, prominent among the recent works in this depart-j this volume will long hold a most conspicuous ment of surgery. The book is a compendium for I place, and seldom willits readers, no matter how the modern surgeon. The present, the only revised unusual the subject, consult its pages in vain. Its edition since 1879, presents many changes from j compact form, excellent print, numerous illustra- the original manual. The volume is much en tions, and especially its decidedly practical char- larged, and the text has been thoroughly revised, j acter, all combine to commend it.— Boston Medical so as to give the most improved methods in asep- | and Surgical Journal, May 10,1888. HOL3IES, TIMOTHY, 31. A^~ Surgeon and Lecturer on Surgery at St. George's Hospital, London. A Treatise on Surgery; Its Principles and Practice. New American from the fifth English edition, edited by T. Pickering Pick, F. R. C. S., Surgeon and Lecturer on Surgery at St. George's Hospital, London. In one octavo volume of 997 pages, wilh 428 illustrations. Cloth, $6; leather, $7. Just ready. To the younger members of the profession and for the general practitioner, teaching those things to others not acquainted with the book and its I that are necessary to be known for the successful merits, we take pleasure in recommending it as a I pro ecution of the physician's career, imparting surgery complete, thorough, well written, fully j nothing that in our present knowledge is consid- illustrated, modern, a work sufficiently volurni- ered unsafe, unscientific or inexpedient.—Pacific nous for the surgeon specialist, adequately concise | Medical Journal, July, 1889. HOLMES, TI3IOT1IY, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. A System of Surgery; Theoretical and Practical. IN TREATISES BY VARIOUS AUTHORS. American edition, thoroughly revised and re-edited by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. In three large imperial octavo volumes containing 3137 double-coiumned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per set, cloth, $18.00; leather, $21.00. Sold only by subscription. STIMSON, LEWIS A., BA^M.D^ Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Suraery in the Medical Farulty of Univ. of City of N. Y., Corresponding Member of the Societe de Chirurgie of Paris. A Manual of Operative Surgery. New (second) edition. In one very hand- Bome royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. There is always room for a good book, so that while many works on operative surgery must be considered"^ superfluous, that of Dr. Stimson has held its own. The author knows the difficult art of condensation. Thus the manual serves as a work of reference, and at the same time as a handy guide It teaches what it professes, the steps of operations. In this edition Dr. Stimson has sought to indicate the changes that have been effected in operative methods and procedures by the antiseptic system, and has added an account of many new operations and variations in the steps of older operations. We do not desire to extol this manual above many excellent standard British publications of the same class, still we be- lieve that it contains much that is worthy of imi- tation.—British Medical Journal, Jan. 22,1887. By the same Author. A Treatise on Fractures and Dislocations. In two handsome octavo vol- umes. Vol. I., Fractures, 5»2 pages, 360 beautiful illustrations. Vol. II., Disloca- tions, 540 pages, with 163 illustrations. Complete work, cloth, $5.50; leather, $7.50. Either volume separately, cloth, $3.00; leather, $4.00. The appearance of the second volume marks the of Dislocations as it is taught and practised by the completion of the author's original plan of prepar- most eminent surgeons of the present time. Con- ing a work which should present in the fullest taining the results of such extended researches it manner all that is known on the cognate subjects must for a long time be regarded as an authority of Fractures and Dislocations. The volume on on all subjects pertaining to dislocations. Every Fractures assumed at once the position of authority practitioner of surgery will feel it incumbent on on the subject, and its companion on Dislocations him to have it for constant reference.—Cincinnati will no doubt be similarly received. The closing Medical News, May, 1888. volume of Dr. Stimson's work exhibits the surgery | HAMILTON, FBANKH.,3L~D^,LLVd., Surgeon to Bellevue Hospital, New York. A Practical Treatise on Fractures and Dislocations. Seventh edition thoroughly revised and much improved. In one very handsome octavo volume of 998 pages, with 379 illustrations. Cloth, $5.50: leather, $6.50. This book is without a rival in any language. It' fully given. The book is so well known that it does is essentially a practical treatise, and it gathers within its covers almost everything valuable that has been written about fractures and dislocations. The principles and methods of treatment are very not require any lengthened review. We can only say that it is still unapproached as a treatise.— The Dublin Journal of Medical Science, Feb. 1886. PICK, T. PICKEBING, F. B. C. S., Surgeon to and Lecturer on Surgery at St. George's Hospital, London. Fractures and Dislocations. In one 12mo. volume of 530 pages, with 93 illustrations. Limp cloth, $2.00. See Series of Clinical Manuals, page 31. Lea Brothers & Co.'s Publications—Otol., Ophthal. 23 BVBNETT, CHABLES H., A. M., M. D., Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. Second edition. In one handsome octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00; leather, $5.00. We note with pleasure the appearance of a second carried out, and much new matter added. Dr. edition of this valuable work. When it first came Burnett's work must be regarded as a very valua- out it was accepted by the profession as one of ble contribution to aural surgery, not only on the standard works on modern aural surgery in account of its comprehensiveness, but because it the English language; and in his second edition contains the results of the careful personal observa- Dr. Burnett has fully maintained his reputation, tion and experience of this eminent aural surgeon. for the book is replete with valuable information —London Lancet, Feb. 21,1885. and suggestions. The revision has been carefully POLITZEB, ADAM, Imperial-Royal Prof, of Aural Therap. in the Univ. of Vienna. A Text-Book of the Ear and its Diseases. Translated, at the Author's re- quest, by James Patterson Cassells, M. D., M. R. C. S. In one handsome octavo vol- ume of 800 pages, with 257 original illustrations. Cloth, $5.50. The whole work can be recommended as a reli- I the practitioner in his treatment.—Boston Medical able guide to the student, and an efficient aid to | and Surgical Journal, June 7,1883. BEBBY, GEOBGE A., M. B., F. B. C. S„ Ed., Ophthalmic Surgeon, Edinburgh Royal Infirmary. Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. In one octavo volume of 683 pages, with 144 illustrations, 62 of which are beautifully colored. Cloth, $7.50. This newest candidate for favor among ophthal- mological students is designed to be purely clinical in character and the plan is well adhered to. We have been forcibly sti uck by the rare good taste in the selection of what is essential which per- vades the book. The author seems to have the uncommon faculty of viewing his subject as a whole and seizing the salient points and not con- fusing his reader—presumably a student and a novice—with a mass of details with no key to their unravelling. It is apparent that the literature of each subject has been gone over in a very thor- ough manner. The fact that he was writing a clinical treatise for beginners and not an encyclo- paedia has always been present with the author. The number and excellence of the colored illus- trations in the text deserve more than a passing notice.—Archives of Ophthalmology, Sept. 1889. JULEB, HENBY E., F. B. C. S., Senior Ass't Surgeon,Royal Westminster Ophthalmic Hosp.; late Clinical Ass't, Moorfields, London. A Handbook of Ophthalmic Science and Practice. Handsome 870. vol- ume of 460 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; leather, $5.50 It presents to the student concise descriptions '' and typical illustrations of all important eye affec- tions, placed in juxtaposition, so as to be grasped at a glance Beyond a doubt it is the best illus- trated handbook of ophthalmic science which has ever appeared. Then, what is still better, these illustrations are nearly all original. We have ex- amined this entire work with great care, and it represents the commonly accepted views of ad- vanced ophthalmologists. We can most heartily commend this book to all medical students, prac- titioners and specialists.—Detroit Lancet, Jan. '85. NETTLESHIP, EDWABD, F. B. C. S., Ophthalmic Surg, and Lect. on Ophth. Surg, at St. Thomas' Hospital, London. The Student's Guide to Diseases of the Eye. New (third) edition, thor- oughly revised With a chapter on the Detection of Color-Blindness, by William Thomson M D Professor of Ophthalmology in the Jefferson Medical College. In one 12mo. volume of 479 pages, with 164 illust., test-types and formulae. Cloth, $2. " in the chapter devoted to operations. A very important partof the work to general practitioners Is that embraced in the consideration of eye dis- The extent of the sale of this now accepted authority has conclusively shown that its claim tor favor was not an imaginary one. The introductory chapter on optical outlines is a wonderfully clear statement of the principles involved. The writer s decision of character has fully impressed his pro- duction, and this is nowhere more apparent than eases in relation to general diseases and condi- tions. The arrangement of the remedies employed into a formulary is adopted, and it contains much useful knowledge.—South. Practitioner, Dec. 1887. NOBBIS, WM. F., M. D., and OLIVEB, CHAS. A., M. D. Clin. Prof, of Ophthalmology in Univ. of Pa. A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, with illustrations. Preparing. CABTEB, B. BBUDENELLTfEBOST, W. ADAMS, F. B. C. S., t. Jtt. L. S., Ophthalmic Surgeon to and Lect. on Ophthal- mic Surgery at St. George's Hospital, London. Ass't Ophthalmic Surgeon and Joint Lect. on Oph. Sur., St. George's Hosp., London. ntMl**1mio Surererv. In one 12mo. volume of 559 pages, with 91 woodcuts, oolor^SSS^St, Sypl and dots and appendix of formula. Cloth, $2.25. See Series of Clinical Manuals, page 31. titttt t .50. It may be said to be the best book in print on the guage in its account of the different affections.— subject of which it treats.— The American Journal ' The Manchester Medical Chronicle, July, 188ft. of the Medical Sciences, Jan. 18m;. The value of this treatise as a guide book to the The peculiar value and finish of thebookare in physician in daily practice can hardly be over- a measure derived from its resolute maintenance estimated. That it is fully up to the level of our of a clinical and practical character. It is an un- ; present knowledge is a fact reflecting great credit rivalled exposition of everything which relates . upon Dr. Roberts, who has a wide reputation as a directly or indirectly to the diagnosis, prognosis ; busy practitioner.— The Medical Record, July 31, and treatment of urinary diseases, and possesses ■ 1886. a completeness not found elsewhere in our Ian- PUBDY, CHABLEtfwV, 31. D., Chicago. Bright's Disease and Allied Affections of the Kidneys. In one octavo volume of 288 pages, with illustrations. Cloth, $2. The object of this work is to "furnish a system- ; short space the theories, facts and treatments, and atic, practical and concise description of the I going more fully into their later developments. pathology and treatment of the chief organic On treatment the writer is particularly strong, diseases of the kidney associated with albuminu- steering clear of generalities, and seldom omit- ria, which shall represent the most recent ad- ' ting, what text-books usually do, the unimportant vances in our knowledge on these subjects ;" and items which are all important to the general prac- this definition of the object is a fair description of titioner.— The Manchester Medical Chronicle, Oct the book. The work is a useful one, giving in a 1886. MOBBIS, HENBY, M. B., F. B. C. S., Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 31. In this manual we have a distinct addition to I he took in hand. It is a full and trustworthy surgical literature, which gives information not | book of reference, both for students and prac- elsewhere to be met with in a single work. Such ! titioners in search of guidance. The illustrations a book was distinctly required, and Mr. Morris in the text and the chromo-lithographs are beau- has very diligently and ably performed the task tifully executed.— The London Lancet,Feb. 26,1886. LUCAS, CLEMENT,^. B., b7s^F. B. C. S., Senior Assistant Surgeon to Guy's Hospital, London. Diseases of the Urethra. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 4. THOMPSON, SIB HENBY^ Surgeon and Professor of Clinical Surgery to University College Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and Urinary Pistulae. trom the third English edition. In one octavo volume of 359 pages, with 47 cuts and 3 plates. Cloth, $3.50. THE AMEBICAN SYSTEM OF DENTISTBY. In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- taining 3160 pages, with 1863 illustrations and 9 full page plates. Per volume, cloth, $6 ; leather, $7; half Morocco, gilt top, $8. The complete work is now ready. For sale by subscription only. As an encyclopaedia of Dentistry it has no su- ' doubtless it is), to mark an epoch in the history oi fierior. It should form a part of every dentist's j dentistry. Dentists will be satisfied with it and lbrary, as the information it contains is of the | proud of it—they must. It is sure to be precisely Greatest value to all engaged in the practice of what the student needs to put him and keep him entistry.—American Jour. Dent. Sci., 8ept. 1886. 1 in the right track, while the Profession at large A grand system, big enough and good enough j will receive incalculable benefit from it.—Odonto- and handsome enough for » monument (which | graphic Journal, Jan. 1887. COLEMAN, A., L. B. C. P., F. B. CTs., Exam. L. D. S., Senior Dent. Surg, and Lect. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised and adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. It should be in the possession of every practi- j The author brings to his task a large experience tloner in this country. The part devoted to first! acquired under the most favorable circumstances. and second dentition and irregularities in the per- ! There have been added to the volume a hundred manent teeth is fully worth the price. In fact, pages by the American editor, embodying the price should not be considered in purchasing such ' views of the leading home teachers in dental sur- a work. If the money put into some of our so- • gery. The work, therefore, may be regarded as called standard text-books could be converted into strictly abreast of the times, and as a very high such publications as this, much good would result, authority on the subjects of which it treats.— —Southern Dental Journal, May, 1882. American Practitioner, July, 1882. BASHAM ON RENAL DISEASES: A Clinical I one 12mo. toL of 304 pages, with 21 Illustrations. Guide to their Diagnosis and Treatment In | Cloth, $2.00. Lea Brothers & Co.'s Publications—Venereal, Impotence. 25 GBOSS, SA3IUEL W., A. M., M. D., LL. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila. A Practical Treatise on Impotence, Sterility, and Allied Disorders of the Male Sexual Organs. New (4th) edition, thoroughly revised by F. E. Stuegis, M. D., Prof, of Diseases of the Genito-Urinary Organs and of Venereal Diseases, N. Y. Post Grad. Med. School. In one very handsome octavo volume of about 175 pages, with about 20 illustrations. Preparing. A few notices of the previous edition are appended. It must be gratifying to both author and pub- I This now classical work on the subject of impo- lishers that large first and second editions of this tence and sterility in the male needs no extended little work were so soon exhausted, while the fact ' review, for it is already well known to the pro- that it has been translated into Russian may indi- J fession. Dr. Gross has by his tireless labor done cate that it filled a void even in foreign literature, more towards clearing up the diagnosis and treat- His is a careful and physiological study of the ] mentof these obscure cases than any other Ameri- sexual act, so far as concerns the male, and all can physician. The fact that this book has rapidly his conclusions are scientifically reached. The book has a place by itself in our literature, and furnishes a farge fund of information concerning important matters that are too often passed over in silence.—The Medical Press, June, 1887. run through two large editions, and that the author is now forced to issue a third, is good and sufficient evidence of its excellence.—Atlanta Medical and Surgical Journal, April, 1888. TAYLOB, B. W., A. M., M. D., Surgeon to Charity Hospital, New York, Prof, of Venereal and Skin Diseases in the University of Vermont, Pres. of the Am. Dermatological Ass'n. The Pathology and Treatment of Venereal Diseases. Including the results of recent investigations upon the subject. Being the sixth edition of Bumstead and Taylor. Entirely rewritten by Dr. Taylor. Large 8vo. volume, about 900 pages, with about 150 engravings, as well as numerous chromo-lithographs. Preparing. A few notices of the previous edition are appended. It is a splendid record of honest labor, wide J known that it would be superfluous here to pass in research, just comparison, careful scrutiny and review its general or special points of excellence. original experience, which will always be held as a high credit to American medical literature. This is not only the best work in the English language upon the subjects of which it treats, but also one which has no equal in other tongues for its clear, comprehensive and practical handling of its themes.—Am. Jour, of the Med. Sciences, Jan, 1884. It is certainly the best single treatise on vene- real in our own, and probably the best in any lan- guage.—Boston Med. and Surg. Journal, April 3,1884. The character of this standard work is so well The verdict of the profession has been passed; it has been accepted as the most thorough and com- plete exposition of the pathology and treatment of venereal diseases in the language. Admirable as a model of clear description, an exponent of sound pathological doctrine, and a guide for rational and successful treatment, it is an ornament to the medi- cal literature of this country. The additions made to the present edition are eminently judicious,, from the standpoint of practical utility.—Journal of Cutaneous and Venereal Diseases, Jan. 1884. COBNIL, V., Professor to the Faculty of Medicine of Paris, and Physician to the Lour cine Hospital. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially revised by the Author, and translated with notes and additions by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in the Univ. of Pa., and J. William White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. perusal without the feeling that his grasp of the wide and important subject on which it treats is a stronger and surer one.—The London Practir The anatomy, the histology, the pathology and the clinical features of syphilis are represented in this work in their best, most practical and most instructive form, and no one will rise from its tioner, Jan. 1882. HUTCHINSON, JONATHAN, F. B. S., F. B. C. S., Consulting Surgeon to the London Hospital. Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. Cloth, $2.25. See Series of "Clinical Manuals, page 31. Those who have seen most of the disease and those who have felt the real difficulties of diagno- sis and treatment will most highly appreciate the facts and suggestions which abound in these pages. It is a worthy and valuable record, not only of Mr. Hutchinson's very large experience and power of observation, but of his patience and assiduity in taking notes of his cases and keep- ing them in a form available for such excellent use as he has put them to in this volume.—London Medical Record, Nov. 12, 1887. GBOSS, S. D., M. D., LL. D., D. C. L., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. ____________ CULLEBIEB, A., & BUMSTEAD, F. J., M.D., LL.D., Surgeon to the Hdpital du Midi. Late Professor of Venereal Diseases in the College of Physicians and Surgeons, New York. An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- stead M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life. Strongly bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. HTT T ON SYPHILIS AND LOCAL CONTAGIOUS ! FORMS OF LOCAL DISEASE AFFECTING mqoRDERS. In one 8vo vol. of 479 p. Cloth, $3.25. I PRINCIPALLY THE ORGANS OF GENERA- LEE'S LECTURES ON SYPHILIS AND SOME \ TION. In one 8vo. vol. of 246 pages. Cloth, 82.25. 26 Lea Brothers & Co.'s Publications—Venereal, Skiu. TAY LOB, BOBEBT W., A.M., M.D., Surgeon to Charity Hospital, New York, and to the Department of Venereal and Skin Diseases oj the New York Hospital. A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis. Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and comprising 58 beautifully-colored plates with 213 figures, and 431 pages of text with 85 engravings. Complete work just ready. Price per part, $2.50. Bound in one volume, half Russia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen plates sent on receipt of 10 cents. A full prospectus sent to any address on application. The completion of this monumental work is a I allotted to a notice of this kind, and while we Bubject of congratulation, not only to the author have nothing but praise for this admirable atlas, and publishers, but to the professional large ; J it must be said in justification that it is more than indeed it is to tne latter that it directly appeals a^ a wonderfully clear exposition of a confessedly difficult branch of medicine Good literature has joined hands with good art with highly satisfac- tory results for both There are altogether 213 warranted by the merits of the work itself.— The Medical News, Dec. 14,1889. It would be hard to use words which would per- spicuously enough convey to the reader the great va'ue of this Clinical Atlas. This Atlas is more figures, many of which are Ufa size, and represent ! complete even than an ordinary course of clinical the highest perfection of the chromo-litho- j lectures, for in no one college or hospital course graphic art, and scattered throughout the text are j is it at all probable that all or the diseases herein innumerable engraving-*. Quite a proportion of | represented would be seen. It. is also more ser- these illustrations are from the author's own | viceable to the majority of students than attend- collection, wnile on the other hand the best atlases of the world have bpen drawn upon for the mist typical and successful pictures of the many different types of venereal and skin dis ease. We think we may say without undue ance upon clinical lectures, for most of the students who sit on remote seats in the lecture hall cannot see the subject as well as the office studentcanexaminethe.se true to-life chromo-lith- ographs. Comparing the text to a lecturer, it is exaggeration that the reproductions, both in color i more satisfactory in exa -tness and fulness than and in black and white, are almost invariably | he would be likely to be in lecturing over a single successful. The text is practical, full of thera lease. Indeed, this Atlas is invaluable to the gen- peutical suggestions, and the clinical accounts of eral practitioner, for it enables the eye of the disease are clear and incisive. Dr. Taylor is, I physician to make diagnosis of a given case of happily, an eminent authority in both departments, skin manifestation by comparing the case with and we find as a consequence that the two divis ions of this work possess an equal scientific and literary merit. We have already passed the limits the picture in the At'as, where will be found also the text of diagnosis, pathology, and full sections on treaiment.—Virginia Medical Monthly, Dec, 1889. HYDE, J. NEVINS, A. M., M. D., Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. New (second) edition. In one handsome octavo volume of 676 pages, with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50. The second edition of his treatise is like his We can heartily commend it, not only as an admirable text-book for teacher and student, but in its clear and comprehensive rules f>r diagnosis, its sound and independent doctrines in pathology, and its minute and judicious directions for the treatment of disease, as a most satisfactory and complete practical guide for the physician.—Ameri- can Journal of the Medical Sciences, July, 1888. A useful glossary descriptive of terms is given. The descriptive portions of this work are plain and easily understood, and above all are very accurate. The therapeutical part is abundantly supplied with excellent recommendations. The picture part is well done. The value of the work to practitioners is great because of the excellence of the descriptions, the suggestiveness of the advice, and the correctness or the details and the principles of therapeutics impressed upon the reader.— Virginii Med. Monthly, May, 1888. clinical instruction, admirably arranged, attractive in diction, and strikingly practical throughout. The chapter on general symptomatology is a model in its way; no clearer description of the various primary and consecutive lesions of the skin is to be met with anywhere. Those on general diagno- sis and therapeutics are also worthy of careful study. Dr. Hyde has shown himself a compre- hensive reader of the latest literature, and has in- corporated into his book all the best of that which the past years have brought forth. The prescrip- tions and formula; are given in both common and metric systems. Text and illustrations are good. and colored plates of rare cases lend additional attractions. Altogether it is a work exactly fitted to the needs of a general practitioner, and no one will make a mistake in purchasing; it.—Medical Press of Western New Yorkt June, 1888. FOX, T., 31. D., F.B.C.P., and FOX, T.C., B.A., M.B.C.S., Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the University College Hospital, London. Westminster Hospital, London. An Epitome of Skin Diseases. With Formulae. For Students and Prac- titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume of 238 pages. Cloth, $1.25. The third edition of this convenient handbook calls for notice owing to the revision and expansion which it has undergone. The arrangement of skin diseases in alphabetical order, which is the method of classification adopted in this work, becomes a positive advantage to the student. The book is one which we can strongly recommend, not only to students but also to practitioners who require a compendious summary of the present state of dermatology.—British Medical Journal, July 2,1883. We cordially recommend Fox's Epitome to those augmented.— The Medical News, December, 1883. whose time is limited and who wish a handy WILSON, EBASMUS, F. B.sT The Student's Book of Cutaneous Medicine and Diseases of the Skin. In one handsome small octavo volume of 535 pages. Cloth, $3.50. manual to lie upon the table for instant reference. Its alphabetical arrangement is suited to this use, for all one has to know is the name of the disease, and here are its description and the appropriate treatment at hand and ready for instant applica- tion. The present edition has been very carefully revised and a number of new diseases are de- scribed, while most of the recent additions to dermal therapeutics find mention, and the formu- lary at the end of the book has been considerably HILLIER'S HANDBOOK OF SKIN DISEASES; for Students and Practitioners. Second Ameri- can edition. with plates. In one 12mo. volume of 353 pages, Cloth, $2.25. Lea Brothers & Co.'s Publications—Dis. of Women. 27 The American Systems of Gynecology and Obstetrics. Systems of Gynecology and Obstetrics, in Treatises by American Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics and Gynecology in the Medical Department of the University of Buffalo; and Obstet- rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- taining 3612 pages, 1092 engravings and 8 plates. Complete work just ready. Per vol- ume: Cloth, $5.0C; leather, $6.00; half Kussia, $7.00. For sale by subscription only, Address the Publishers. Full descriptive circular free on application. LIST OF CONTRIBUTORS. WILLIAM H. BAKER, M. D., ROBERT BATTEY, M. D., SAMUEL C BUSEY, M. D., JAMES C CAMERON, M. D., HENRY C. COE, A. M., M. D., EDWARD P. DAVIS, M. D., G E. De SCHWEINITZ, M. D., E. C. DUDLEY, A. B., M. D., B. McE. EMMET, M. D., GEORGE J. ENGELMANN, M. D., HENRY J. GARRIGUES, A. M., M. D., WILLIAM GOODELL, A. M., M. D., EGBERT H. GRANDIN, A. M., M. D., SAMUEL W. GROSS, M. D., ROBERT P. HARRIS, M. D., GEORGE T. HARRISON, M. D., BARTON C. HIRST, M. D. STEPHEN Y. HOWELL, M. D., A. REEVES JACKSON, A. M., M. D., W. W. JAGGARD, M. D., EDWARD W. JENKS, M. D., LL. D., HOWARD A. KELLY, M. D., This is volume two of The American System of Obstetrics, completing the wonderfully full series issued from the house of Lea Brothers & Co. dur- ing the past two years. Two magnificent volumes devoted to gynecology, and now two like volumes embracing everything pertaining to obs-tetrics. These volumes are the contributions of the most eminent gentlemen of this country in these de- partments of the profession. Each contributor presents a monograph upon his special topic, apparently without restriction in space, so that everything in the way of history, theory, methods, and results is presented to our fullest need. The work will long remain as a monument of great in- dustry and good judgment. As a work of general reference, it will be found remarkably full and in- structive in every direction of inquiry.—The Ob- stetric Gazette, September, 1889. There can be but little doubt that this work will find the same favor with the profession that has been accorded to the " System of Medicine by American Authors," and the "System of Gynecol- ogy byAmerican Authors." One is at a loss to know what to say of this volume, for fear that just and merited praise may be mistaken for flattery. The subjects of some of the papers are discussed in various works on obstetrics, though not to the full extent that is found in this volume. The papers of Drs. Engelmann, Martin, Hirst, Jaggard and Reeve are incomparably beyond anything that can be found in obstetrical woiks. Certainly the Edi- CHARLES CARROLL LEE, M. D., WILLIAM T. LUSK, M. D., LL. D., J. HENDRIE LLOYD, M. D., MATTHEW D. MANN, A. M., M. D., H. NEWELL MARTIN, F. R. S., M. D., D.So., M.A., RICHARD B. MAURY, M. D., C. D. PALMER, M. D., ROSWELL PARK,.M. D., THEOPHILUS PARVIN, M. D., LL. D., R. A. P. PENROSE, M. D., LL. D., THADDEUS A. REAMY, A. M., M. D., J. C. REEVE, M. D., A. D. ROCKWELL, A. M., M. D., ALEXANDER J. C. SKENE, M. D., J. LEWIS SMITH, M. D., STEPHEN SMITH, M. D., R. STANSBURY SUTTON, A.M., M. D., LL. D., T. GAILLARD THOMAS, M. D., LL. D., ELY VAN DE WARKER, M. D., W. GILL WYLIE, M. D. tor may be congratulated for having "made such a wise selection < f his contributors.—Journal of the American Medical Association, Stpt. 8, 1888. In our notice of the "System of Practical Medi- cine by American Authors," we made the follow- ing statement:—"It is a work of which the pro- fession in this country can feel proud. Written exclusively by American physicians who are ac- quainted with all the varieties of climate in the United States, the character of the soil, the man- ners and customs of the people, etc., it is pecul- iarly adapted to the wants of American practition- ers of medicine, and it seems to us that every one of them would desire to have it." Every word thus expressed in regard to the "American Sys- tem of Practical Medicine" is applicable to the "System of Gynecology by American Authors," which we desire now to bring to the attention of our readers. It, like the other, has been written exclusively by American physicians who are acquainted with all the characteristics of American people, who are well informed in regard to the peculiarities of American women, their manners, customs, modes of living, etc. As every practis- ing physician is called upon to treat diseases of females, and as they constitute a class to which the family physician must give attention, and cannot pass over to a specialist, we do not know of a work in any department of medicine that we should so strongly recommend medical men gen- erally purchasing.—Cincinnati Med. News, July,1887. THOMAS, T. GAILLABD, 31. D., LL. D., Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y. A Practical Treatise on the Diseases of "Women. Fifth edition, thoroughly revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5.00; leather, $6.00. That the previous editions of the treatise of Dr. Thomas were thought worthy of translation into German, French, Italian and Spanish, is enough to give it the stamp of genuine merit. At home it has made its way into the library of every obste- trician and gynaecologist as a safe guide to practice. No small number of additions have been made to the present edition to make it correspond to re- cent improvements in treatment.—Pacific Medical and Surgical Journal, Jan. 1881. EDIS, ABTHUB W., M. D., Lond., F.B. C.P., M.B. C.S., Assist Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. The Diseases 6f Women. Including their Pathology, Causation, Symptoms, Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00; leather, $4.00. are among the more common methods of treat- ment, and yet very little is said about them in many of the text-books. The book is one to be It is a pleasure to read a book so thoroughly good as this one. The special qualities which are conspicuous are thoroughness in covering the whole ground, clearness of description and con- ciseness of statement. Another marked feature of the book is the attention paid to the details of many minor surgical operations and procedures, as for instance, the use of tents, application of leeches and use of hot water injections. These warmly recommended especially to students and general practitioners, who need a concise but com- plete rlsuml of the whole subject. Specialists, too, will find many useful hints in its pages.—.Boston Med. and Surg. Journ., March 2,1882. 28 Lea Brothers & Co.'s Publications—Dis. of Women, Midwfy. EMMET, THOMAS ADDIS, M. D., LL. D., Surgeon to the Woman's Hospital, New York, etc. The Principles and Practice of Gynaecology; For the use of Students and Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6; very handsome half Russia, raised bands, $6.50. We are in doubt whether to congratulate the [ the privilege thus offered them of perusing the author more than the profession upon the appear ance of the third edition of this well-known work Embodying, as it does, the life-long experience of one who has conspicuously distinguished himself as a bold and successful operator, and who has devoted so much attention to the specialty, we \ nal, May 16,1885. feel sure the profession will not fail to appreciate views and practice of the author. His earnestness of purpose and conscientiousness are manifest. He gives not only his individual experience but endeavors to represent the actual state of gynae- cological science and art.—British Medical Jour- TAIT, LAWSON, F.B. C. S., Professor of Gynaecology in Queen's College, Birmingham; late President of the British Gyne- cological Society; Fellow American Gynecological Society. Diseases of Women and Abdominal Surgery. In two very handsome octavo volumes. Volume I., 554 pages, 62 engravings and 3 plates. Cloth, $3. Just ready. Volume II., preparing. The plan of the work does not indicate the regu- Much of the text is abundantly illustrated with lar system of a text book, and yet nearly every- cases, which add value in showing the results of thing of disease pertaining to the various organs I the suggested plans of treatment. We feel con- receives a fair consideration. The description of | fident that few gynecologists of the country will diseased conditions is exceedingly clear, and the fall to place the work in their libraries.— The treatment, medical or surgical, is very satisfactory. ' Obstetric Gazette, March, 1890. DAVENPOBT, F. H., 31. D., Assistant in Gynaecology in the Medical Department of Harvard University, Boston. Diseases of Women, a Manual of Non-Surgical Gynaecology. De- signed especially for the Use of Students and General Practitioners. In one handsome 12mo. volume of 317 pages, with 105 illustrations. Cloth, $1.50. Just ready. We agree with the many reviewers whose no- ' Everything is of the newest, freshest and most tices we have read in other journals congratulating practical, so much so that we nave recommended Dr. Davenport on the success which he has - attained. He has tried to write a book for the student and general practitioner which would tell them just what they ought to know without distracting their attention with a lot of compila- tions for which they could have no possible use. In this he has been eminently successful. There is not even a paragraph of useless matter. it to our class of gynecology students. What the author advises in the way of treatment has all been practically tested by himself, and each method receives only so much commendation as he has found that it deserves. We are sure that these good qualities will command for it a large sale.—Canada Medical Record, Dec. 1889. MAY, CHABLES H., 31. D., Late House Surgeon to Mount Sinai Hospital, New York. A Manual of theDiseases of Women. Being a concise and systematic expo- sition of the theory and practice of gynecology. New (2d) edition, edited by L. S. Bau, M. D., Attending Gynecologist at the Harlem Hospital, X. Y. In one 12mo. volume of 360 pages, with 31 illustrations. Cloth, $1.75. Just ready. This is a manual of gynecology in a very con- densed form, and the fact that a second edition has been called for indicates that it has met with a favorable reception. It is intended, the author tells us, to aid the student who after having care- fully perused larger works desires to review the subject, and he adds that it may be useful to the practitioner who wishes to refresh his memory rapidly but has not the time to consult larger works. We are much struck with the readiness and convenience with which one can refer to any .subject contained in this volume. Carefully com- piled indexes and ample illustrations also enrich the work. This manual will be found to fulfil its purposes very satisfactorily.— The Physician and Surgeon, June, 1890. DUNCAN, J. MATTHEWS, M.D., LL. D., F. B. S. E., etc. Clinical Lectures on the Diseases of Women; Delivered in Saint Bar- tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. They are in every way worthy of their author ; rule, adequately handled in the textrbooks; others indeed, we look upon them as among the most of them, while hearing upon topics that are usually valuable of his contributions. They are all upon treated of at length in such works, yet bear such a mattersof great interest to the general practitioner. ' stamp of individuality that they deserve to be Some of them deal with subjects that are not, as a ; widely read.—N. Y. Medical Journal, March, 1880. HODGE ON DISEASES PECULIAR TO WOMEN. Including Displacements of the Uterus. Second edition, revised and enlarged. In one beauti- fully printed octavo volume of 519 pages, with original illu-trations. Cloth, $4.60. RAMSBOTHAM'S PRINCIPLES AND PRAC- TICE OF OBSTETRIC MEDICI XE AND SURGERY. In reference to the Process of Parturition. A new and enlarged edition, thor- oughly revised by the Author. With additions by W. V.Keat..\, 37. „„ WEST'S LECTURES ON THE DISEASES OF WOMEN Third American from the third Lon- don edition. In one octavo volume of 543 pages. Cloth, $:i 75; leather, $4.75. Lea Brothers & Co.'s Publications—Midwifery. 29 PLAYFAIB, W. S., M. D., F. B. C. P., Professor of Obstetric Medicine in King's College, London, etc. A Treatise on the Science and Practice of Midwifery. New (fifth) American, from the seventh English edition. Edited, with additions, by Robert P. Har- ris, M. D. In one handsome octavo volume of 664 pages, with 207 engravings and 5 plates. Cloth, $4.00; leather, $5.00. Just ready. Playfair's Midwifery has for many years been a favorite authority both among obstetric teachers and general practitioners of the obstetric art. A work of this kind having reached a fifth American from the seventh English edition would seem scarcely to require any extended notice. Of previous American editions the matter has been largely rewritten or remodelled, besides many new short notes have been added. For either the student or the old practitioner this work meets all needs; it is full and yet condensed ; it is clear and well arranged.—Obstetric Gazette, Nov., 1889. Truly a wonderful book; an epitome of all ob- stetrical knowledge, full, clear and concise. In thirteen years it has reached seven editions. It is perhaps the most popular work of its kind ever presented to the profession. Beginning with the anatomy and physiology of the organs concerned, nothing is left unwritten that the practical ac- coucheur should know. It sepms that every conceivable physiological or pathological condi- tion from the moment of conception to the time of complete involution has had the author's patient attention. The plates and illustrations, carefully studied, will teach the science of mid- wifery. The reader of this book will have before him the very latest and best of obstetric practice, and also of all the coincident troubles connected therewith.—Southern Practitioner, Dec, 1889. KING, A. F. A., M. D., Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- sity, Washington, D. C, and in the University of Vermont, etc. A Manual of Obstetrics. New (fourth) edition. In one very handsome 12mo. volume of 432 pages, with 140 illustrations. Cloth, $2.50. Just ready! Dr. King, in the preface to the first edition of this manual, modestly states that "its purpose is ' mal, that Dr. King is at his best. Here his style to furnish a good groundwork to the student at the beginning of his obstetric studies." Its pur- pose is attained; it will furnish a good ground- work to the student who carefully reads it; and further, the busy practitioner should not scorn the volume because written for students, as it con- tains much valuable obstetric knowledge, some of which is not found in more elaborate text- books. The chapters on the anatomy of the female generative organs, menstruation, fecunda- tion, the signs of pregnancy, and the diseases of pregnancy, are all excellent and clear; but it is in the description of labor, both normal and abnor- is so concise, and the illustrations are so good, that the veriest tyro could not fail to receive a clear conception of labor, its complications and treat- ment. Of the 141 illustrations it may be safely said that they all illustrate, and that the engraver's work is excellent. The name of the publishers is a sufficient guarantee that the work is pre- sented in an attractive form, and from every standpoint we can most heartily recommend the book both to practitioner and student.— The Medi- cal News, Dec. 7,1889. BABNES, BOBEBT, M. D., and FANCOUBT, M. D., Phys. to the General Lying-in Hosp., Lond. Obstetric Phys. to St. Thomas' Hosp., Lond. A System of Obstetric Medicine and Surgery, Theoretical and Clin- ical. For the Student and the Practitioner. The Section on Embryology by Prof. Milnes Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5; leather, $6. The immediate purpose of the work is to furnish a handbook of obstetric medicine and surgery for the use of the student and practitioner. It is not an exaggeration to say of the book that it is the best treatise in the English language yet published, and this will not be a surprise to those who are acquainted with the work of the elder Barnes. Every practitioner who desires to have the best obstetrical opinions of the time in a readily accessible and condensed form, ought to own a copy of the book.—Journal of the American Medical Association, June 12,1886. ■ The Authors have made a text-book which is in every way quite worthy to take a place beside the best treatises of the period.—New York Medical Journal, July 2,1887. PABVIN, THEOPHILUS, M. D., LL. D., Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila. The Science and Art of Obstetrics. New (2d) edition. In one handsome 8vo. volume of about 700 pages, with about 225 engravings and a colored plate. Shortly. BABKEB, FOBDYCE, A. M., M. D., LL. D. Edin., Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, New York Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc. Obstetrical and Clinical Essays. 12mo., about 300 pages. Preparing. PABBY, JOHN S., M. D., Obstetrician to the Philadelphia Hospital, Vice-President of the ObsteL Society of Philadelphia. Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. WINCKEL, F. xi_ i . _ . +-nT,.1-K. A Complete Treatise on the Pathology and Treatment of Childbed, For Students and Practitioners. Translated, with the consent of the Author from the second German edition, by J. K. Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. ASHWELL'S PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Third American from the third and revised London edition. In one 8vo. vol., pp. 520. Cloth, $3.50. TANNER ON PREGNANCY. Octavo, 490 pages, colored plates, 16 cuts. Cloth, 84.25. CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WO- MEN. In one 8vo. vol. of 464 pages. Cloth, 82.50. MEIGS ON THE NATURE, SIGNS AND TREAT- MENT OF CHILDBED FEVER. In one 8vo. volume of 346 pages. Cloth, 82.00. 30 Lea Brothers & Co.'s Publications—IHidwfy., Dis. Cliildn. LEISH3FAN, WILLI A 31, 31. Z>„ Regius Professor of Midwifery in the University of Glasgow, etc A System of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. Third American edition, revised by the Author, with additions by John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50; leather, $5.50. The author is broad in his teachings, and dis- cusses briefly the comparative anatomy of the pel- vis and the mobility of the pelvic articulations. The second chapter is devoted especially to the study of the pelvis, while in the third the female organs of generation are introduced. The structure and development of the ovum are admirably described. Tiien follow chapters upon must prove admirably adapted. Complete in all its parts, essentially modern In its teachings, and with demonstrations noted for clearness and precision, it will gain in favor and be recognized as a work of standard merit. The work cannot fail to be popular and is cordially recommended.—N. O. Med. and Surg. Journ., March. 1880. It has been well and carefully written. Tha the various subjects embraced in the study of mid- i views of the author are broad and liberal, and in- wifery. The descriptions throughout the work are ; dicate a well-balanced judgment and matured plain and pleasing- It is sufficient to state that in j mind. We observe no spirit of dogmatism, but this, the last edition of this well-known work,every i the earnest teaching of the thoughtful observer recent advancement in this field has been Drought ] and lover of true science. Take the volume as a forward.—Physician and Surgeon, Jan. 1880. whole, and it has few equals.—Maryland Medical To the American student the work before us ! Journal, Feb. 1880. LAND IS, HENBY G., A. 3L~,~3I. D., Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O. The Management of Labor, and of the Lying-in Period. In one handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. The author has designed to place in the hands of the young practitioner a book in which he can find necessary information in an instant. As far as we can see, nothing is omitted. The advice is sound, and the prfceedures are safe and practical. Centralblatt fur Gynakologie, December 4, 1886. This is a book we can heartily recommend. the author goes much more practically into the details of the management of labor than most text-books, and is so readable throughout as to tempt any one who should happen to commence the book to read it through. The author pre- supposes a theoretical knowledge of obstetrics, and has consistently excluded from this little work everything that is not of practical use in the lying-in room. We think that if it is as widely read as it deserves, it will do much to improve obstetric practice in general.—New Orleans Medi- cal and Surgical Journal, Mar. 1886. SMITH, J. LEWIS, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. A Treatise on the Diseases of Infancy and Childhood. New (sixth) edition, thoroughly revised and rewritten. In one handsome octavo volume of 867 pages, with 40 illustrations. Cloth, $4.50; leather, $5.50. For years it has stood high in the confidence of the profession, and with the additions and alter- ations now made it may be said to be the best book in the language on the subject of which it treats. An examination of the text fully sus- tains the claims made in the preface, that "in preparing the sixth edition the author has revised the text to such an extent that a considerable part of the book may be considered new." If the young practitioner proposes to place in his library but one book on the diseases of children, we would unhesitatingly say, let that book be the one which is the subject of this notice.—The American Journal of the Medical Sciences, April, 1886. No better work on children's diseases could be placed in the hands of the student, containing, as It does, a very complete account of the symptoms and pathology of the diseases of early life, and possessing the further advantage, in which it stands alone amongst other works on its subject, of recommending treatment in accordance with the most recent therapeutical views.—British and Foreign Medico-Chirurgical Review. Those familiar with former editions of the work will readily recognize the painstaking with which this revision has been made. Many of the articles have been entirely rewritten. The whole work ia enriched with a research and reasoning which plainly show that the author has spared neither time nor labor in bringing it to its present ap- proach towards perfection. The extended table ol contents and the well-prepared index will enable the busy practitioner to reach readily and quickly for reference the various subjects treated or in the body of the work, and even those who are familiar with former editions will find the improvements in the present richly worth the cost of the work.— Atlanta Medical and Surgical Journal, Dec. 1886. Dr. Smith's work has justly become the standard all over the world as the book on children's dis- eases The whole book is admirable, both for the practitioner and the student. Dr. Smith writes from a large experience and a close observation of cases at the bedside. He is extremely prac- tical, and these facts make the work what it is— the best of all works on the diseases of children. — Virginia Medical Monthly, June, 1886. OWEN, EDMUND, M. B., F. B. C. S., Surgeon to the Children's Hospital, Great Ormond St., London. Surgical Diseases of Children. chromo-lithographic plates arid 85 woodcuts page 31. One is immediately struck on reading this book with its agreeable style and the evidence it every- where presents of the practical familiarity of its author with his subject. The book may be In one 12mo. volume of 525 pages, with 4 Cloth, $2. See Series of Clinical Manuals, honestly recommended to both students and practitioners. It is full of sound information, pleasantly given.—Annals of Surgery, May, 1886. WEST, CHABLES, M. D., Physician to the Hospital for Sick Children, London, etc , On Some Disorders of the Nervous System in Childhood. 12mo. volume of 127 pages. Cloth, $1.00. I n one small CONDIE'S PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, re- vised and augmented. In one octavo volume of 779 pages. Cloth, $5.26; leather, 86.25. Lea Brothers & Co.'s Publications—Med. Juris., Miscel. 31 TIDY, CHABLES MEYMOTT, M. B., F. C. S., Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- tavo volume of 529 pages. Cloth, $6.00; leather, $7.00. Volume I. Containing 664 imperial octavo pages, with two beautiful colored plates. Cloth, $6.00; leather, $7.00. The satisfaction expressed with the first portion tables of cases appended to each division of the of this work is in no wise lessened by a perusal of subject must have cost the author a prodigious the second volume. We find it characterized by amount of labor and research, but they constitute the same fulness of detail and clearness of ex- one of the most valuable features of the book, pression which we had occasion so highly to com- especially for reference in medico-legal trials.— mend in our former notice, and which render it so American Journal of the Medical Sciences, April, 1884. valuable to the medical jurist. The copious TAYLOB, ALFBED S., M. D., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. Poisons in Relation to Medical Jurisprudence and Medicine. Third American, from the third and revised English edition. In one large octavo volume of 788 pages. Cloth, $5.50; leather, $6.50. » ---------------------- By the Same Author. A Manual Of Medical Jurisprudence. Eighth American from the tenth Lon- don edition, thoroughly revised and rewritten. Edited by John J. Reese, M. D. In one large octavo volume. PEPPEB, AUGUSTUS J., M. S., M. B., F. B. C. S., Examiner in Forensic Medicine at the University of London. Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Students' Series of Manuals, below. STUDENTS' SEBIES OF MANUALS. A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, written by eminent Teachers or Examiners, and issued in pocket-size 12mo volumes of 300-540 pages, richly illustrated and at a low price. The following volumes are now ready: Treves' Manual of Sur- gery, by various writers, in ihree volumes, each, $2; Belt.'s Comparative Physio ogy and Anatomy, $2; Gould's Surgical Diagnosis. 82; Robehtson's Physiological Physics, $2; Brtjce's Materia Medica and Thera- peutics (4th edition), $1.50; Power's Human Physiology (2d edition), $1.50; Clarse and Lookwood's Dissectors' Manual, $1.50; Ralfe's Clinical Chemistry, $1.50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical Pathology, $2 ; and Klein's Elements of Histology (4th edition), $1.75. The following is in press : Pepper's Forensic Medicine. For separate notices see index on last page. SEBIES OF CLINICAL MANUALS. In arranging for this Series it has been the design of the publishers to provide the profession with a collection of authoritative monographs on important clinical subjects in a cheap and portable form. The volumes will contain about 550 pages and will be freely illustrated by chromo-lithographs and wood- cuts. The following volumes are now ready: Yeo on Food in Health and Disease, $2; Broadbent on the Pulse, $1.75; Carter* Frost's Ophthalmic Surgery, $2 25; Hutchinson on Syphilis, $2.25; Ball on the Rectum and Anus, $2.25; Marsh on the Joint's, $2; Owen on Surgical Diseases of Children, $2; Morris on Surgical Diseases of the Kidney, $2.25; Pick on Fractures and Dislocations, $2; Butlin on the Tongue, $.1.50; Treves on Intestinal Obstruction, $2; and Savage on Insanity and Allied Neuroses, $2. The following is in active preparation: Lucas on Diseases of the Urethra. For separate notices see index on last page.____________________________ LEA, HENBY C. Chapters from the Religious History of Spain.—Censorship of the Press.—Mystics and Illuminati— The Endemoniadas of Queretaro — El Santo Nino de la Guardia — Brianda de Bardaxi. In one 12mo. volume of about 500 pages. In press. In making researches for a History of the Spanish Inquisition the author has been % led to investigate various subjects deserving of treatment more elaborate than could be * accorded to them in a continuous narrative. These he has worked out in the present vol- ume in the hope that beside the intrinsic interest of the themes themselves, they may serve to explain some of the causes which reduced to impotence a nation that in the sixteenth century aspired to universal monarchy. By the same Author. Superstition and Force: Essays on The Wager of Law, The Wager of BattleT The Ordeal and Torture. Third revised and enlarged edition. In one handsome royal 12mo. volume of 552 pages. Cloth, $2.50. By the Same Author. Studies in Church History. The Rise of the Temporal Power-Ben- efit of Clergy—Excommunication. New edition. In one very handsome royal octavo volume of 605 pages. Cloth, $2.50. Allen's Anatomy ..... h American Journal of the Medical Sciences 3 I American SvBterus of Gynecology and Obstetrics 27 American System of Practical Medicine. .15 American system of Dentistry - . . 24 | Ashhurst's Surgery . . . . .20 Ashwell on Diseases of Women . . .29 Attfield's Chemistry .... 9 Ball on the Rectum and Anus . . . 20, 31 i Barker's Obstetrical and Clinical Essays, . 29 Barlow's Practice of Medicine . . . '17 Barnes' System ol Obstetric Medicine . . 29 Bartholow on Electricity .... 17 Basham on Renal Diseases . . . .24 Bell's ComparaUve Physiology and Anatomy . 7, 31 Bellamy's Surgical Anatomy . . 6 Berry on the Eye . . . .23 Billings' National Medical Dictionary . . 4 Blandford on Insanity . . . .19 Bloxam's Chemistry ..... 9 Bristowe's Practice of Medicine ... 14 Broadbent on the Pulse . . . . 18,31 Browne on the Throat, Nose and Ear . . 18 Brace's Materia Medica and Therapeutics . 12 Branton's Materia Medica and Therapeutics . 11 Bryant's Practice of Surgery . . . .21 Bumstead and Taylor on Venereal. See Taylor. 25 Burnett on the Ear . . . . .23 Butlin on the Tongue.....21,31 Carpenter on the use and Abuse of Alcohol Carpenter's Human Physiology Carter m:<>yyy/yyy -.. -,.'>v.y1 -. i vavv.V'.v:-/,* v v ■•:•..••> vvX'nw cvv v.*. /.v.v.wv.*/ • '.■ '.v.oyvyAk» NLM005817068