OBSTETRICS A TEXT-BOOK FOR THE USE OF STUDENTS AND PRACTITIONERS BY J. WHITRIDGE WILLIAMS PROFESSOR OF OBSTETRICS, JOHNS HOPKINS UN VERSITY; OBSTETRICIAN-IN-CHIEF TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE, MD. FIFTH ENLARGED AND REVISED EDITION WITH SEVENTEEN PLATES AND SIX HUNDRED AND NINETY ILLUSTRATIONS IN THE TEXT D. APPLETON AND COMPANY NEW YORK LONDON 1924 COPYRIGHT, 1903, 1904, 1907, 1909, 1910, 1912, 1917, 1923, BY D. APPLETON AND COMPANY Printed in the United States of America OBSTETRICS PLATE r. FROZEN SECTION THROUGH WOMAN DYING AT BEGINNING OF SECOND STAGE OF LABOR; BREECH PRESENTATION. TO WILLIAM H. WELCH PROFESSOR OF PATHOLOGY, JOHNS HOPKINS UNIVERSITY AND WILLIAM T. COUNCILMAN PROFESSOR OF PATHOLOGY, HARVARD UNIVERSITY AS AN EXPRESSION OF RESPECT AND AFFECTION PREFACE TO THE FIFTH EDITION In this edition I have attempted to set forth, as fully as is possible within the limits of a textbook, the data upon which the science of obstetrics is based, and at the same time so to treat the practical aspects of the subject as to make the book a useful and conservative guide for the practitioner at the bedside. That insistence upon conservatism is particularly necessary is shown by the statistical studies of Howard and Eiehel, which indicate that Avhile the puerperal death rate had slowly, but progressingly, fallen down to 1916, a definite rise had occurred during the following five years, with the result that childbirth was actually more dangerous in this country in 1921 than in 1916. Furthermore, their studies show that the death rate is greater in urban than in rural communities, and that while reasonably satisfactory results are obtained in the largest cities, in which a considerable proportion of deliveries are cared for in hospitals conducted by trained specialists, they are superior in country districts to those obtained in the medium-sized and small towns. As the reverse would naturally be expected, I am inclined to explain the apparent paradox by supposing that many practitioners in urban communities have been led astray by the teachings of those who regard labor as a pathological rather than a physiological process, with the result that interference upon insufficient indications is frequently under- taken by those who do not fully appreciate the risk involved. That such a supposition is not fanciful is indicated by the fact, that an inquiry by a committee of the Massachusetts State Medical Society into the puerperal death rate in that state during the year 1921 showed that, after puerperal infection, cesarean section constituted the most frequent causes of death. For these reasons, while the technic of the various operative pro- cedures is described in all necessary detail, I have taken pains in stating the indications for their employment to insist upon the greatest possible conservatism consistent with the welfare of the patient and her child. The book has been revised throughout, and every chapter has been subjected to such changes as were necessary to bring it into accord with the advances recorded up to date. The most radical changes have been made in the following sections: The development of the ovum and placentation; the employment of the X-ray in the diagnosis of pregnancy and of foetal syphilis; the technic and indications for podalic version; the indications for cesarean section; the toxemias of pregnancy; the prevention and treat- ment of postpartum hemorrhage, and the part played by syphilis in the causation of foetal death. VII VIII PREFACE TO THE FIFTH EDITION The value of the sections upon the development of the ovum and upon the technic of podalic version has been greatly enhanced by original drawings kindly made by Mr. Max Broedel; while I am under many obligations to my former associate, Everett D. Plass, for assistance in revising the chapter upon the toxemias of pregnancy, and to my various assistants and my secretary for valuable aid. The book accurately represents the practice followed in The Woman’s Clinic of the Johns Hopkins Hospital and University, tempered by due consideration of the views of others, and I hope that it will prove con- tinuingly useful to students and practitioners. J. Whitridge Williams Baltimore PREFACE TO THE FIRST EDITION In the following pages I have attempted to set forth, as briefly as seemed to be consistent with thoroughness, the scientific basis for and the practical application of the obstetrical art. Especial attention has been devoted to the normal and pathological anatomy of the generative tract. At the same time I have endeavored to present the more practical aspects of obstetrics in such a manner as to be of direct service to the obstetrician at the bedside. No pains have been spared in illustrating the work, although mere artistic effect has necessarily often been sacrificed to accuracy and practi- cal teaching qualities. With the exception of those relating to pure embryology, all illustrations representing microscopical sections have been drawn from my own specimens under my direct personal super- vision, and are accurate reproductions of the originals. The drawings and diagrams illustrating labor and its mechanism for the most part represent the woman on her back, thus affording a closer correspondence with the actual conditions encountered in practice. The representations of the various operative procedures have been redrawn from photographs taken from life. Although no attempt has been made to present a complete bibliog- raphy, I have endeavored to give at the end of each chapter such refer- ences to the early history, as well as to the most recent advances in each subject, as to enable the student to refer readily to the most important original sources. In order to insure accuracy, the individual articles have been consulted in every case. In conclusion, I desire to express my appreciation of the excellent work of Miss Katherine M. Montague and Mr. F. S. Lockwood in the preparation of the illustrations and to thank my various assistants and my stenographer for most valuable aid. I am under very many obliga- tions to my friend, Dr. Frank R. Smith, for the revision of the text and for many suggestions which have added materially to its clearness. IX CONTENTS SECTION I Anatomy CHAPTER PASH I. The Pelvis 1 Historical 1 General considerations 2 The pelvis from an obstetrical point of view ... 3 Planes and diameters of the pelvis 4 Pelvic inclination 8 The pelvic axis 10 Individual variations in fhe pelvis 12 Sexual differences in the adult pelvis 13 Bacial differences in pelves 16 Pelvis of the new-born child 17 Transformation of foetal into adult pelvis .... 19 II. The Female Organs op Generation 26 The external generative organs 26 The vagina 35 The uterus 38 The fallopian tubes 56 The ovaries 61 SECTION II Physiology and Development op tile Ovum III. Menstruation and Ovulation 85 Menstruation 85 Belation between menstruation and ovulation ... 89 Migration of ovum 93 Place of meeting of ov.um and spermatozoa ... 95 IY. Maturation, Fertilization, and Development op Ovum . 100 Maturation of ovum 100 Fertilization of ovum 103 Development of ovum 105 Implantation of human ovum Ill Formation of chorion and amnion 114 Structure of chorion 126 Structure of amnion 131 Decidua 132 Development of placenta 140 Placenta at full term 144 Afterbirth 147 Umbilical cord 149 Umbilical vesicle 151 xi xii CONTENTS CHAPTER PAGE V. The Foetus 157 Foetus in the various months of pregnancy .... 157 Weight of the new-born 162 Physiology of fcetus 166 SECTION III Physiology of Pregnancy VI. Changes in the Maternal Organism Kesulting from Pregnancy 183 Uterus 183 Tubes and ovaries 188 Vagina 189 Abdominal walls 190 Breasts 191 In rest of the body J 192 General metabolism 198 VII. Diagnosis of Pregnancy, etc 206 Positive signs of pregnancy 206 Probable signs of pregnancy 210 Presumptive signs of pregnancy 215 Synopsis of signs and symptoms of pregnancy . . . 218 Differential diagnosis of pregnancy 218 Spurious pregnancy 219 Duration of pregnancy 221 Estimation of date of confinement 223 VIII. Management of Normal Pregnancy 227 IX. Presentation and Position of Fcetus 234 Nomenclature 236 Beasons for the predominance of head presentations . 239 Diagnosis of presentation and position of fcetus . . 241 SECTION IV Physiology or Labor X. Physiology and Clinical Course or Labor .... 248 Cause of the onset of labor 248 Physiology of labor pains 253 Physical changes during uterine contractions . . . 255 Clinical course of labor 256 Duration of labor 262 XI. Forces Concerned in Labor 266 Cervix in latter part of pregnancy 266 Lower uterine segment 267 Changes in uterus during first stage of labor . . . 271 Changes in uterus during second stage of labor . . . 274 Forces concerned in labor 276 Changes in vagina and pelvic floor during labor . . 278 CONTENTS xiii CHAPTER PAGE XII. Mechanism of Labor in Vertex Presentations . . . 285 Left and right occipito-anterior presentations . . . 285 Eight and left occipitoposterior presentations . . . 298 Changes in shape of head 304 XIII. Mechanism of Labor in Face, Brow, and Breech Presenta- tions 307 Face presentations 307 Brow presentations 315 Breech presentations 318 XIV. Physiology and Management of Third Stage of Labor . 326 Mechanism of separation of placenta 327 Mode of extrusion of placenta 330 Clinical picture of third stage of labor .... 334 Management of third stage of labor 336 XV. Conduct of Normal Labor 341 Preparations for labor 341 Conduct of first stage of labor 345 Conduct of second stage of labor 351 Anesthesia 359 Conduct of third stage of labor 365 Eepair of lacerated perineum ' . 365 XVI. The Puerperium 372 Anatomical changes in the puerperium . . . . 372 Clinical aspect of the puerperium . . . . . . 376 Care of patient during puerperium 380 XVII. The Newly Born Child 388 Circulatory changes 388 Care of the umbilical cord 389 Care of eyes 391 Stools and urine 302 Icterus 393 Anatomy of breasts and lactation 393 Nursing 396 Care of breasts 398 Artificial feeding 400 XVIII. Multiple Pregnancy 402 Frequency 402 Etiology 402 Eelation of the placentae and membranes .... 406 Superfecundation and superfetation 409 Diagnosis 411 Course of labor 412 xiv CONTENTS SECTION V CHAPTER PAGE XIX. Induction of Abortion and Premature Labor . . . 417 Preparations for obstetrical operations . . . . 417 Induction of abortion 419 Induction of premature labor 424 Accouchement force 431 Vaginal cesarean section . . 434 XX. Forceps 439 History 440 Functions 444 Indications 444 Preparations for operation 447 Application of forceps 448 Low and mid forceps operations 455 Application of forceps in obliquely posterior presentations 459 Application of high forceps . 463 Axis traction forceps 463 Application of forceps in face presentations . . . 466 Application of forceps in breech presentations . . . 467 Prognosis 467 XXI. Extraction and Version 471 Extraction in breech presentations 471 Cephalic version 483 Podalic version 485 Combined podalic version 491 XXII. Cesarean Section, Symphyseotomy, and Pubiotomy . . 493 History 493 Indications 496 Operative technic 499 Prognosis 511 Symphyseotomy 517 Pubiotomy 518 XXIII. Destructive Operations 527 Craniotomy 527 Embryotomy 533 Evisceration 533 Decapitation 533 XXIV. Operative Procedures Which Do Xot Aim at Delivery . 537 Douche 537 Curettage 539 Tampon or pack 541 Manual removal of placenta 543 Obstetric Surgery CONTENTS XV SECTION VI Pathology of Pregnancy CHAPTER PAGE XXY. Accidental Complications of Pregnancy Due to Disease . 545 Acute infectious diseases 545 Chronic infectious diseases 549 Diseases of circulatory and respiratory systems . . . 554 Diseases of alimentary tract and liver 559 Diseases of kidneys and urinary tract 561 Diseases of the nervous system 565 Diseases of blood . . . 568 Diseases of skin 569 Surgical operations during pregnancy 571 XXVI. The Toxemias of Pregnancy 577 Pernicious .vomiting of pregnancy 578 Acute yellow atrophy of liver 587 Nephritic toxemia 590 Pre-eclamptic toxemia 593 Eclampsia 597 Presumable toxemias 628 XXVII. Complications Due to Diseases and Abnormalities of the Generative Tract 637 Diseases of vulva and vagina 637 Diseases of the cervix 638 Developmental abnormalities of uterus 639 Displacements of uterus 642 Hypertrophic elongation of the cervix 648 Acute edema of the cervix 649 Hernia 649 Diseases of decidua 650 XXVIII. Diseases and Abnormalities of Ovum 656 Diseases of chorion . 656 Chorio-epithelioma 662 Diseases of amnion 667 Abnormalities of placenta 673 Diseases of placenta 677 Abnormalities of umbilical cord 683 Disease of the foetus 686 XXIX. Abortion, Miscarriage, and Premature Labor . . . 701 XXX. Extra-uterine Pregnancy 719 xvi CONTENTS SECTION VII Pathology of Labor CHAPTER . PAGE XXXI. Dystocia Due to Anomalies of Expulsive Forces . . 754 Prolonged labor 754 Precipitate labor 761 Tetanic contraction of uterus 762 Dystocia due to contraction of Bandl’s ring . . . 762 Hour-glass contraction of uterus 763 Missed labor 764 XXXII. Dystocia Due to Abnormalities of Generative Tract . 766 Atresia of vulva . 766 Atresia of vagina 766 Stenosis and rigidity of cervix 768 Dystocia due to uterine displacements 769 Dystocia due to operations for the relief of retroflexion of the uterus 769 Dystocia due to tumors of generative tract and pelvis . 772 XXXIII. Contracted Pelvis 780 History 780 Frequency 781 Methods of diagnosis 783 Pelvimetry 784 Classification 798 XXXIY. Anomalies Due to Abnormal Malleability of Pelvic Bones 801 Flat, non-rhachitic pelvis 801 Rhachitic pelvis 804 Forms of rhachitic pelves 807 Diagnosis of rhachitic pelvis 813 Mode of production of the rhachitic deformities . . 814 Osteomalacic pelves 816 XXXY. Abnormal Pelves Resulting from Primary Anomalies of Development 823 Generally enlarged (justomajor) pelvis .... 823 Generally contracted (justominor) pelvis .... 823 Masculine pelvis 825 Infantile pelvis 826 Dwarf pelvis 826 Obliquely contracted or Naegele pelvis .... 829 Transversely contracted or Robert pelvis .... 833 Split pelvis 834 Imperfect development of the vertebral bodies of the sacrum 835 Assimilation pelvis 835 Funnel pelvis 838 CONTENTS xvii CHAPTER PAGE XXXVI. Course, Prognosis and Treatment of Pregnancy and Labor Complicated by the More Common Forms of Con- tracted Pelvis 847 Effect of contracted pelvis upon the course of pregnancy 847 The position of the uterus 847 Position and presentation of foetus 847 Size of foetus 848 Mechanism of labor in rhachitic pelves .... 848 Course of labor in contracted pelvis 853 Treatment of labor complicated by contracted pelvis . . 860 Treatment of labor complicated by osteomalacic pelves 870 XXXVII. Pelvic Anomalies Due to Disease of the Vertebral Column 874 Kyphotic pelvis 874 Kyp ho rhachitic pelvis 881 Scoliotic pelvis 881 Kyphoscoliotic pelvis 883 Kyphoscoliorhachitic pelvis 884 Spondylolisthetic pelvis 884 XXXVIII. Pelvic Anomalies Resulting from Abnormal Direction of the Force Exerted by the Femora .... 892 Coxalgic pelvis 892 Coxarthrolisthetic pelvis 896 Pelvic deformity due to bilateral lameness .... 896 Atypical deformities of pelvis 898 XXXIX. Dystocia Due to Abnormalities in Development or Pres- entation of Fcetus 900 Excessive development 900 Malformation of fcetus 902 Deformities of fcetus 903 Hydrocephalus 904 Enlargement of the body of fcetus 906 Transverse presentations 909 Compound presentations 917 XL. Hemorrhage 920 Premature separation of the normally implanted placenta 920 Placenta previa 927 Postpartum hemorrhage 938 Inversion of uterus 944 XLI. Injuries to Birth Canal 950 Injuries to vulval outlet 950 Injuries to vagina 950 Lesions of cervix 952 Rupture of uterus 955 Instrumental performation of uterus 962 Perforation of genital tract following necrosis . . . 963 xviii CONTENTS CHAPTER PAGE XLII. Prolapse of Umbilical Cord, etc 965 Asphyxia 967 Sudden death during or shortly after labor . . . . 972 SECTION VIII Pathology of the Puerperium XLIII. Puerperal Infection 977 XLIV. Diseases and Abnormalities of the Puerperium . . . 1022 Tetanus 1022 Thrombosis of vessels of lower extremities .... 1023 Gangrene of the extremities 1023 Diseases of urinary tract 1024 Hemorrhages during puerperium 1025 Diseases and abnormalities of uterus 1028 Delayed chloroform poisoning 1031 Obstetrical paralysis 1031 Abnormalities and diseases of breasts 1034 Puerperal psychoses 1040 Acute infectious diseases during puerperium . . . 1041 Index .............. 1047 LIST OF PLATES FACING PLATE PAGE I. Frozen section through woman dying at beginning of second stage of labor; breech presentation .... Frontispiece II. Showing several varieties of hymen 32 III. Section through endometrium on third day. of menstruation . 86 IV. Peters’ ovum 112 IV, A. Diagram illustrating changes in the fertilized ovum during the process of imbedding 114 IV, B. Diagram showing mature ovum and its changes after fertilization 114 V. Section through four months’ placenta, showing junction of chorion and decidua 142 VI. Terminal chorionic villus with injected vessels . . . . 144 VII. Corrosion preparation of mature placenta, to show foetal vessels 146 VIII. Foetal circulation 168 IX. Seven and a half months’ pregnant uterus from woman dying in first stage of labor 270 X. Palpation in left occipito-anterior presentation .... 288 XI. Palpation in right occipitoposterior presentation .... 300 XII. Palpation in right mento-anterior presentation .... 308 XIII. Palpation in left sacro-anterior presentation 318 XIV. Placental infarct formation 678 XV. Palpation in right acromiodorso-anterior presentation . . .910 XVI. Hemorrhagic changes in uterus associated with premature sepa- ration of placenta 924 XVII. Section through endometrium in streptococcic puerperal infection 990 xix OBSTETRICS SECTION I ANATOMY CHAPTER I THE PELVIS Historical.—As the mechanism of labor is essentially a process of accommodation between the foetus and the passage through which it must pass, it is apparent that obstetrics lacked a scientific foundation until the anatomy of the bony pelvis and of the soft parts connected with it was clearly understood. We are indebted to Andreas Yesalius (1543) for the first accurate description of the pelvis. Prior to the publication of his observations it had generally been believed that the birth of the child could not be effected until the pelvic cavity had become increased in size by the separation and gaping of the pelvic bones. Yesalius demonstrated the fallacy of this conception, and showed that the pelvis, for practical pur- poses, should be considered as an unyielding bony ring. His work was further elaborated by his successor at the University of Padua, Realdus Columbus, who also demonstrated that each innominate bone was originally composed of three separate portions: the ilium, ischium, and pubis, which fused together just before the age of puberty. Julius Caesar Arantius, Professor of Anatomy in Bologna (1559), also made important contributions to the subject, and was the first to recognize the existence of contracted pelvis. That the teachings of these three great anatomists did not exert so great an influence as might have been expected was largely due to the fact that no less an authority than Ambroise Pare still continued to adhere to the doctrine of the separation of the pubic bones during labor, and promulgated it in his obstetrical writings. Among obstetricians, Heinrich van Deventer was the first to make a thorough study of the anatomy of the pelvis. In his New Light for Mid-wives (1701) he dwelt upon it in detail, and also described the main varieties of contracted pelves. At that time he felt called upon to apolo- gize for taking up what was apparently so useless a consideration. 2 THE PELVIS Smellie was the first English authority to devote particular attention to the subject. In his work on midwifery, published in 1752, he gave an accurate description of the pelvis and its various measurements, and also introduced the method of determining the anteroposterior diameter which we still employ. A few years previously (1735), Johann Huwe had gone over somewhat the same ground, but his work did not receive anything like the consideration which was accorded to Smellie’s investi- gations. Almost simultaneously with Smellie, Levret, the great French obste- trician, published the results of his observations, and was one of the first to promulgate the conception of the axis and the planes of the pelvis. The value of his work, however, was considerably impaired by many . Fig. 1.—Normal Female Pelvis. X 14- inaccuracies. Among the Germans, Stein the younger was apparently the first to give a thoroughly accurate description of the pelvis, and since his time correct ideas upon the subject have gradually become popu- larized. Practically, therefore, an attempt to follow the further develop- ment of our knowledge concerning the pelvis would resolve itself into writing a history of obstetrics. To do this would go far beyond the scope of the present work; and let it here suffice to say that among the more modern authors Naegele, Luschka, Michaelis, Litzmann, and Breus and Kolisko in Germany, and Hodge in this country deserve particular mention. General Considerations.—In both sexes the pelvis forms the bony ring through which the body weight is transmitted to the lower extremi- ties, but in the female it assumes a peculiar form which adapts it to the purposes of childbearing. It is composed of four bones: the sacrum, the coccyx, and two in- nominate bones, the last two being united by strong articulations with the sacrum at the sacro-iliac synchondroses, and with one another at the symphysis pubis. The purely anatomical characteristics of the pelvis THE PELVIS FROM AN OBSTETRICAL POINT OF VIEW 3 are dealt with at length in the standard works on anatomy, so that we shall limit our considerations to the peculiarities of the female pelvis which are of importance in childbearing. The Pelvis from an Obstetrical Point of View.—The linea terminalis forms the boundary between the false and the true pelvis, the former lying above and the latter below it. The false pelvis is bounded pos- teriorly by the lumbar vertebrae and laterally by the iliac fossae,\while in front the boundary is formed by the lower portion of the anterior ab- dominal wall. It possesses no particular obstetrical significance, but serves to support the intestines in the non-pregnant woman, arid the enlarged uterus in the pregnant condition. It varies considerably in size in different individuals, according to the flare of the iliac bones; but ordinarily in dried specimens the distances between the anterior superior spines of the ilium and between the most widely separated portions of the iliac crests measure 23 and 26 centimeters, respectively. The true pelvis lies beneath the linea terminalis, and is the portion concerned in childbearing. It is bounded above by the promontory and alae of the sacrum, the linea terminalis, and the upper margins of the pubic bones, and below by the pelvic outlet. Its cavity, roughly speaking, may be compared to an obliquely truncated cylinder with its greatest height posteriorly, since its anterior wall at the symphysis pubis meas- ures 4.5 to 5 centimeters, and its posterior wall 10 centimeters. With the woman in the upright position, the upper portion of the pelvic canal is directed downward and backward, while in its lower course it curves and becomes directed downward and forward. The walls of the true pelvis are partly bony and partly ligamentous. Its posterior boundary is furnished by the anterior surface of the sacrum, its lateral limits are formed by the inner surface of the ischial bones and by the sacrosciatic notches and ligaments; while in front it is bounded by the obturator foramina, the pubic bones, and the ascending rami of the ischial bones. The only part of the lateral wall of the pelvis which is entirely bony is made up of the body of the ischium and part of the ilium, the inner surface of which, with the woman in the upright position, forms an in- clined plane which is directed from above downward and inward, and from behind forward. These surfaces were designated as the inclined planes of the pelvis by Hodge, who taught that they exercised consider- able influence in causing internal rotation of the head during labor. This view, however, has since been abandoned. If the planes of the ischial bones were extended downward they would meet somewhere about the region of the knee. Extending from the middle of the posterior margin of each ischium are the ischial spines, which are of no little obstetrical importance, inasmuch as a line drawn between them represents the shortest diameter of the pelvic cavity. Moreover, since they can be readily felt on vaginal examination, they serve as valuable landmarks in determining the extent to which the presenting part has descended into the pelvis. The sacrum forms the posterior wall of the pelvic cavity. Its upper anterior margin, corresponding to the body of the first sacral vertebra, 4 THE PELVIS and designated as the promontory, can be felt on vaginal examination, and offers a landmark which serves as the basis of internal pelvimetry. Normally, the sacrum presents a marked vertical and a less pronounced lateral concavity, which, in abnormal pelves, may undergo variations. A straight line drawn from the promontory to the tip of the sacrum usually measures 10 centimeters, whereas if the concavity be fol- lowed the distance aver- ages 12 centimeters. The sacrum was form- erly regarded as the "keystone” of the pelvic arch, but Matthews Duncan showed that this conception was er- roneous, and that it represents an inverted keystone, inasmuch as it is wider along its anterior than along its pos- terior surface, so that it would tend to slip downward and forward into the pelvic cavity un- der the influence of the body weight were it not held in posi- tion by the strong posterior iliosacral ligaments (Dig. 2). In the female the pubic arch presents a characteristic ap- pearance. The de- scending rami of the pubis unite at an angle of 90 to 100 degrees, and form a rounded opening through which the head can readily pass. Its margins are more delicate than in the male, and are considerably everted. Planes and Diameters of the Pelvis.—Owing to the peculiar shape of the pelvic cavity and the difficulty experienced in rendering clear the exact location of a body occupying it, for greater convenience in de- Fig. 2.—Drawing showing that the Sacrum is not the Keystone of the Arch. Modified from Dun- can. X y%- Fig. 3.—Sagittal Section through Normal Pelvis. X }/&• PLANES AND DIAMETERS OF THE PELVIS 5 scription it is customary to construct certain imaginary planes through it. Those most frequently employed are designated as (1) the superior strait; (2) the inferior strait; (3) the plane of greatest, and (4) the plane of least, pelvic dimensions (Figs. 3 and 5). The superior strait represents the upper boundary of the cavity, and is frequently spoken of as the pelvic inlet. It is somewhat oval in shape, with a depression on its posterior border corresponding to the promontory of the sacrum, and is sometimes described as blunt heart-shaped. It is bounded posteriorly by the promontory and alae of the sacrum; laterally by the linea terminalis; anteriorly by the horizontal rami of the pubic bones and the upper margin of the symphysis pubis. Strictly speaking, it is not a mathematical plane, since its lateral margins, as represented Fig. 4.—Nobmal Female Pelvis showing Diametebs op the Superior Stbait. X K by the linea terminalis, are at a lower level than its central portion between the promontory and symphysis. Four diameters are usually described as traversing the superior strait: the anteroposterior, the transverse, and two oblique diameters. The anteroposterior diameter extends from the middle of the promontory of the sacrum to the upper margin of the symphysis pubis, and is desig- nated as the conjugata vera or true conjugate. This term was first em- ployed by Roederer, who likened the superior strait to an ellipse, whose shorter diameter ran anteroposteriorly. Normally, the conjugata vera measures 11 centimeters, but it may become markedly shortened in ab- normal pelves. From a practical point of view it is the most important diameter, inasmuch as it is the point of departure for all attempts to estimate the size of the pelvis in actual practice. The transv'erse diameter is constructed at right angles to the conjugata vera, and repre- sents the greatest distance between the linea terminalis on either side; it usually intersects the conjugata vera at a point a short distance in front of the promontory. Normally it measures 13.5 centimeters. Each of the oblique diameters extends from one of the sacro-iliac synchon- 6 THE PELVIS droses to the iliopectineal eminence on the opposite side of the pelvis. They measure 152.75 centimeters, and are designated as right and left respectively, according as the starting-point is the right or left sacro- iliac synchondrosis. Instead of employing these terms, the Germans usually speak of the first and second oblique diameters, respectively. The Fig. 5.—Diagram showing Pelvic Planes. X ks- sacrocotyloid diameters are sometimes described; they extend from the middle of the promontory of the sacrum to the iliopectineal eminence on either side, and measure from 8.75 to 9 centimeters. Normally these two diameters are of equal length, but in certain forms of contracted pelvis they may present marked variations. Fig. 6.—Pelvic Outlet. X }4- The anteroposterior diameter of the superior strait, or conjugata vera, is also designated as the anatomical conjugate. This does not represent the shortest distance between the promontory of the sacrum and symphy- sis pubis, which is along a line drawn from the former to a point on the PLANES AND DIAMETERS OF THE PELVIS 7 inner surface of the symphysis a few millimeters below its upper margin. The latter is the shortest diameter through which the head must pass in descending into the superior strait, and was designated by Michaelis as the obstetrical conjugate. It is a few millimeters shorter than the Pubis Rectus - Symphysis -'Rectus Obturator foramen/ \ Obturator xMforamen Ilium Obturator internus Minim 'Sciatic S nerve Iliopsoas Iliopsoas^ 3yriformis Sciatic nervec Promontory Sacrum Fig. 7.—Superior Strait (Veit). Fig. 8.—Plane of Greatest Dimensions. anatomical or true conjugate, but for practical purposes the distinction is rarely made, and the obstetrician simply speaks of the conjugata vera. Unfortunately, in the living woman, the conjugata vera can not be measured directly with the examining finger, and various more or less Pubic ramus Pubic ramus Iliunu Obturator Internus vllium. Isehium/j Ischium Iliopsoas Iliopsoas tl 'Obturator internus Tip of Sacrum "Sacrum Fig. 9.—Plane of Least Dimensions (Veit) Fig. 10.—Veit’s Main Plane. complicated instruments have been devised for its determination, none of which gives perfectly satisfactory results. For clinical purposes, there- fore, we are content to estimate its length indirectly, by measuring the distance from the lower margin of the symphysis to the promontory of the sacrum, and subtracting from the result 1.5 to 2 centimeters, ac- cording to the height and inclination of the symphysis pubis. This 8 THE PELVIS diameter is the conjugata diagonalis or oblique conjugate, the impor- tance of which was first emphasized by Smellie. The outlet of the pelvis is designated the inferior strait. It is not a plane in a mathematical sense, but consists of two triangular planes whose bases would meet on a line drawn between the two ischial tuber- osities. It is bounded posteriorly by the tip of the coccyx, laterally by the greater sacrosciatic ligaments and the ischial tuberosities, and an- teriorly by the lower margin of the pubic arch (Fig. 6). For the pelvic outlet two diameters are described: the anteroposterior and the trans- verse. The former extends from the lower margin of the sjunphysis pubis to the tip of the coccyx, and the latter between the inner margins of the ischial tuberosities. With the coccyx in its usual position, the anteroposterior diameter measures 9.5 centimeters, which is increased to 11.5 centimeters during labor by the backward displacement of the tip of the coccyx. The transverse diameter measures 11 centimeters. The plane of greatest pelvic dimensions was first described by Levret, and, as its name implies, represents the roomiest portion of the pelvic cavity. It extends from the middle of the posterior surface of the sym- physis pubis to the junction of the second and third sacral vertebrae, and laterally passes through the ischial bones over the middle of the ace- tabulum. Its anteroposterior and transverse diameters measure 12.75 and 12.5 centimeters, respectively. Since its oblique diameters terminate in the obturator foramina and the sacrosciatic notches, their length is indeterminate. The plane of least pelvic dimensions extends through the lower mar- gin of the symphysis pubis, the tip of the sacrum, and the ischial spines. Its anteroposterior diameter measures 11.5 cm. Its transverse diameter extends between the ischial spines and measures 10.5 centimeters, being the shortest diameter in the normal pelvic cavity. In order to facilitate the study of the pelvic cavity, Hodge con- structed four parallel planes, the first of which is the superior strait; while the other three are parallel to it and pass through the lower margin of the symphysis pubis, the ischial spines, and the tip of the coccyx respectively. The second parallel practically corresponds to the plane of greatest pelvic dimensions, and is very closely related to that described by Veit as the main plane of the pelvis, which' extends from the lower margin of the symphysis pubis to the junction of the first and second sacral vertebrae. According to Veit this, from an obstetrical standpoint, is the largest plane of the pelvis, inasmuch as it is not encroached upon by the pelvic soft parts, but passes above the obturator and pyriformis and below the iliopsoas muscles. Most pelves present slight individual variations in size, and perfectly normal and symmetrical examples are rarely seen. The measurements which we have given are those of Schroeder, and are the averages obtained from the accurate mensuration of 50 normal pelves. Pelvic Inclination.—The normal position of the pelvis, with the woman in the erect posture, can be reproduced by holding the specimen in such a way that the incisions of the acetabula look directly downward. According to Meyer, the same result is obtained when the anterior- PELVIC INCLINATION 9 superior spines of the ilium and the pubic spines are placed in the same vertical plane. Under these conditions the promontory of the sacrum is 9.5 to 10 centimeters higher than the upper margin of the symphysis pubis. By the term pelvic inclination is understood the angle which the plane of the superior strait forms with the horizon (see Fig. 3). This conception was first introduced by J. J. Muller and Roederer, and the early statements concerning it were very conflicting. According to Meyer, the center of gravity of the body passes along an imaginary vertical plane just posterior to the acetabula, so that under the influence of the body weight the pelvis would tend to rotate backward, were it not held in position by the strong iliofemoral ligaments. It is therefore apparent that the pelvic inclination must vary according to the degree of tension of these structures; it will be diminished when they are relaxed, and vice versa. It is least marked when the legs are slightly rotated inward and spread a little apart, and greatly increased when the knees are pressed tightly together, or when the legs are widely spread apart or rotated strongly either inward or outward. With the woman in the up- right position the pelvic inclination is usually estimated at 45 to 50 degrees, but may vary from 40 to 100 degrees, according to the degree of tension exerted by the iliofemoral ligaments. In certain diseased con- ditions it may be obliterated, when the plane of the superior strait may become parallel to, or even form an obtuse angle with, the horizon. The first accurate wTork upon this subject was done by Naegele, who measured the distance from the floor to the lower margin of the sym- physis pubis and the tip of the sacrum respectively, and in this way esti- mated the inclination which the inferior strait formed with the horizon. He then placed a normal pelvis in a similar position and estimated the inclination of its superior strait, which was usually about 60 degrees. In view of the variations to which the pelvic inclination is subject, Meyer introduced a new conception concerning it, and showed that it was considerably influenced by the extent to which the sacrum rotated about its transverse axis. As this passes through the center of the body of the third sacral vertebra, it is apparent that this portion of the sacrum retains approximately the same position, no matter to what ex- tent its upper or lower portions may be displaced. Meyer, therefore, constructed a diameter extending from the upper margin of the symphy- sis to the middle of the third sacral vertebra, and designated it the normal conjugate. Its inclination he estimated at 30 degrees, and stated that it remains practically constant in all positions of the body. Except when markedly abnormal, the pelvic inclination posseses no practical obstetrical significance, and is of value only in the study of atypical pelves and in anthropology. Several complicated instruments have been invented for determining it. In 1900, Neumann and Ehrenfest pointed out that for practical purposes the degree of pelvic inclination corresponds to the inclination of the external conjugate, and devised a comparatively simple instrument for determining it. Since the lower margin of the sjunphysis occupies a lower level than the tip of the sacrum, the plane of the inferior strait is also inclined to 10 THE PELVIS the horizon, forming an acute angle, which is usually estimated at 10 degrees. Much more important, however, is the angle which is formed between the posterior surface of the symphysis pubis and the conj ugata vera; this is usually estimated at 90 to 100 degrees, but varies consid- erably according to the shape, height, and inclination of the former. This must always be taken into consideration in estimating the length of the con j ugata vera from that of the conjugata diagonalis, since it is evident that the amount to be subtracted from the latter will vary with the size of the angle in question. The Pelvic Axis.—Deventer in 1701 introduced the conception of a pelvic axis. Since then numerous methods for its construction have been described, the most usual being a line drawn through the centers of in- numerable planes extending from the symphysis to the sacrum, thus Fig. 11.—Diagram showing Pelvic Axis. X Is- giving a graceful curve (see Fig. 3). This was formerly believed to represent the course which the child pursued in its passage through the pelvis, but the work of Naegele, Hegar, Pinard, and others has shown that such is not the case, and that an axis so constructed possesses only an historical interest. At the end of pregnancy the axis of the superior strait, if extended directly upward, would pass through the abdominal wall at about the region of the umbilicus, while the axis of the inferior strait would im- pinge upon the promontory of the sacrum. As the pelvic canal is prac- tically cylindrical in shape down to the plane of greatest pelvic dimen- sions, it is apparent that the head must descend along the downward prolongation of the axis of the superior strait until it has nearly reached the level of the ischial spines, and only begins to curve forward in the region of the inferior strait. Therefore the obstetrical pelvic axis should be represented as straight in its upper and curved only in its lower portion (see Fig. 11), as was well understood by Ilodge, and strongly insisted upon by Sellheim. THE PELVIC JOINTS 11 The Pelvic Joints.—Anteriorly the pelvic bones are held together by the symphysis pubis, which consists of a mass of fibrocartilage, and by the superior and inferior pubic ligaments, the latter being frequently designated as the ligamentum arcuatum pul)is. Luschka demonstrated the presence of a synovial cavity in the fibrocartilage, and therefore classed the symphysis among the true joints (Fig. 12). Joessel, and Loeschke, on the other hand, deny its existence, and state that the fluid in the interior of the symphysis is simply a product of degeneration. Whether it be a true joint or not, in any case the symphysis admits of a certain amount of motility, which becomes more marked during preg- nancy, particularly in multiparous women. This fact was demonstrated by Budin, who showed that if the finger were inserted into the vagina of Superior Pubic Li£f. Post. Sacro-iliac Lig. k Articular cavity /Sacral fcanal 1-Fibro-cartilag'e A Li?' \ Arcuatum > Pubis Interosseous Lig". Articular cavity 'Ant. Sacro-iliac Lig. Fig. 12.—Frontal Section Symphysis Pubis (Spalteholz). X 1. Fig. 13.—Sacro-iliac Synchondrosis (Spalteholz). X 1. a pregnant woman, and she were made to walk, one could distinctly feel the ends of the pubic bones move up and down with each step. The articulations between the sacrum and innominate bones were formerly described as synchondroses, but Luschka conclusively demon- strated the presence of a synovial cavity within them, and therefore classed them among the true joints (Fig. 13). These articulations pos- sess a certain amount of motility, which plays a not unimportant part in practical obstetrics. Walcher, in 1889, redirected attention to the variation in size of different portions of the pelvic canal resulting from changes in the relation between the thighs and the pelvis, and stated that the diagonal conjugate varied about 1 centimeter in length, according as it was meas- ured with the woman in the usual obstetrical position, or with her buttocks resting on the edge of the table and her legs hanging down without any support. This has since been known as the Walcher or hanging position, and is utilized in dealing with contracted pelves; and occasionally the increase in the size of the conjugata vera brought about by it has proved sufficient to permit the engagement of the presenting part, which otherwise could not occur. Kiittner in 1898 showed in three 12 THE PELVIS cases that the conjugata vera was respectively 1.4, 0.9, and 1 centimeter longer when measured in the hanging than in the lithotomy position. Fig. 14 gives a graphic illustration of the changes in shape in one of the pelves, which he studied. Furthermore, rotation of the innominate bones upon the sacrum causes changes in the anteroposterior diameter of the inferior strait. In the Walcher position it is short- ened, whereas it is lengthened when the legs are sharply flexed over the body. In 1911, I showed that it could also be in- creased by from 1 to 2.5 centi- meters by placing the woman in an exaggerated Sims position. Methods of Comparing Pelves.—Inasmuch as the nor- mal pelvis usually presents slight individual variations in its form and dimensions, and as contracted pelves differ mark- edly from one another in shape, several devices have been em- ployed to enable us readily to compare their points of difference. The decimal method, suggested by Litzmann, is very satisfactory for most purposes. In it the various diameters are expressed in terms of the conjugata vera, which is reckoned as 100. Fig. 14.—Diagram showing Variation op Anteroposterior Diameter of Pelvis in Various Positions (Kiittner). X Vs- A, lithotomy; B, horizontal; C, Walcher’s position. Comparison op Variotjs Diameters of Normal Pelves by Litzmann’s Decimal Method. DIAMETERS. Anteroposterior. Transverse. Oblique. Superior strait 100 122.7 113 Plane of greatest pelvic dimension 115 113.6 Plane of least pelvic dimension 105.5 95.5 Inferior strait 105.5 100 Breisky introduced a graphic method for comparing pelves and con- structed three diagrams, representing a vertical mesial section of the pelvis, the plane of the superior strait, and a frontal view of the pelvis. The first is constructed upon Meyer’s normal conjugate, the second upon the distance between the sacro-iliac synchondroses, and the third upon the transverse diameter of the pelvic outlet (Figs. 15-17). Individual Variations in the Pelvis.—With the exception of the skull, no portion of the skeleton presents greater individual variations than the pelvis. This is due partly to the fact that it is developed from a consid- erable number of bones, and partly to the varying mechanical and devel- opmental influences to which it is subjected during the early years of life. Indeed, we may say that no two pelves are exactly alike, and that perfectly normal pelves are rarely seen; so that an accurate conception of the form and dimensions of what may be termed the normal type can SEXUAL DIFFERENCES IN THE ADULT PELVIS 13 be obtained only from averages based upon the examination of numerous approximately normal pelves. Owing to the greater employment of the right half of the body, the corresponding side of the pelvis is more developed than the left. Indi- vidual variations may be observed in the form, consistence, and general character of the pelvic bones, in the angles which the iliac fossae form with the walls of the pelvic basin, in the shape of the sacrum, and par- ticularly in that of the cavity itself. In view of the varying thickness of the pelvic bones, and especially of the degree of flaring of the ilia, ac- curate conclusions cannot be drawn from external pelvimetry alone. Fig. 15. Fig. 17. Fig. 16. Figs. 15-17.—Breisky’s Diagrams for Comparing Pelves. I., inclination of iliac bones; I. P., iliopectineal eminence; promontory of sacrum; S., upper margin of symphysis; S.1, lower margin of symphysis; S. I., sacro-iliac synchon- drosis; Sp., iliac spines; Ttransverse diameter, superior strait; T. tuber ischii; 3, bend in body of third sacral vertebra. Sexual Differences in the Adult Pelvis.—The pelvis presents marked sexual differences. Speaking generally, we may say that in the male the pelvis is heavier, higher, less graceful, and presents a more conical ap- pearance than in the female. In the former the muscular attachments are much more strongly marked, and the iliac bones are less flared than in the latter. The pubic arch is more angular in shape, and presents an aperture of 70 to 75 degrees, as compared to 90 to 100 degrees in the female. This difference is so marked that one usually speaks of the pubic angle in the male and the pubic arch in the female. In the male pelvis the superior strait is smaller and more triangular in outline, while the pelvic cavity is deeper and more conical in shape. These dif- ferences are readily noted in Figs. 18, 19, and 20, and may be especially emphasized by a comparison of the various measurements in the two sexes. Broadly speaking, the external measurements are practically alike in both sexes, though the distance between the anterior-superior spines of the ilium is somewhat less in the male; while all the diameters of the 14 THE PELVIS pelvic cavity are shorter, as is shown by the table on page 15. Indeed, the outlet of the male type of pelvis is contracted to such a degree as to render very difficult the passage of a living child under the pubic angle. Fig. 18.—Front View Female Pelvis. X Occasionally the female pelvis may approach the male type, and such funnel pelves may offer insuperable obstacles to the birth of the child, and necessitate radical operative procedures to effect delivery. Fig. 19.—Front View Male Pelvis. X Numerous not very satisfactory attempts have been made to explain the cause of the differences between the male and female pelvis. Accord- ing to Fehling and most subsequent investigators, sexual differences make their appearance as early as the fourth or fifth month of intra- SEXUAL DIFFERENCES IN THE ADULT PELVIS 15 uterine life, so that the sex can be ascertained long before term by ex- amination of the pelvis. Arthur Thompson has made the same state- ment, and my own investigations have led me to similar conclusions. On the other hand, Schroeder and other authorities attributed the charac- teristic shape of the female pelvis to the presence of the internal genitalia, and stated that the pelves of female eunuchs, as well as those of individuals in whom the uterus is congenitally absent, conform to the DIAMETERS. Pelvis. Anteroposterior. Transverse. Oblique. Superior strait: Male 10.5 12 5 12 cm Female 11 13.5 12.75 cm. Inferior strait: Male 9.5 8 cm. F emale 11.5 11 cm. Fig. 20.—Diagram showing Difference in Shape of Male [. . .] and Female [ ] Pelvis. 16 THE PELVIS male type. While the correctness of such statements cannot be doubted, it nevertheless seems probable that the greater part of the sexual dif- ferences must be due to inherent developmental and hereditary factors. Racial Differences in Pelves.—Considerable variations may be ob- served in the form of the pelvis in various races, and especially upon comparing those obtained from aboriginal and civilized peoples. But in spite of the researches of Weber, Stein, Yerneau, Topinard, Turner, and others, our knowledge of the subject is still fragmentary. Stein distin- guished four groups of pelves: 1. Blunt heart-shaped. 2. Elliptical, with the greatest diameter transverse. 3. Bound. 4. Elliptical, with the greatest diameter anteroposterior. Topinard attempted to classify pelves according to their “general index”—that is, the relation between their height and width, as repre- sented by the distance between the iliac crests. His careful measurements showed that the pelves becomes increasingly lower and broader the more civilized the race from which it is obtained. Turner based his classification upon the relation between the trans- verse and anteroposterior diameters of the superior strait, and divided pelves into three great groups: dolichopellic, in which the conjugata vera is greater than the transverse diameter; mesatipellic, in which the conjugata vera and transverse diameters are of equal length; and platy- pellic, in which the conjugata vera is shorter than the transverse diameter. He stated that the first variety had not been observed in women, though it is not infrequent in men; but the investigations of Scharlau show that Turner was in error, as it is frequently noted in the aboriginal women of Australia. The mesatipellic variety is observed in the women of the lower races, notably among the Bushmen, Hotten- tots, and the lower classes of negroes; while the platypellic forms are found in all the higher races. But even among civilized whites con- siderable racial differences are frequently noted, and it is generally stated that the pelves of the English and Holstein women are broader than those of other nationalities; while the Jewesses living in the vicinity of Dorpat have extremely small pelves. Gache states that the pelvis is usually normal in the Argentine Kepublic, while it is im- perfectly developed and frequently funnel-shaped in Mexico. While the study of the racial differences in the pelvis presents a marked anthropological interest, it is, as yet, of little practical obstetrical value, as no extended studies have been made concerning the form and size of the heads of children which are born through them. The careful work of my former assistant, T. F. Biggs, has shown that contracted pelves occur several times more frequently among black than white women in Baltimore, while operative delivery is more frequently re- quired among the latter. This is due to the fact that the negro children are somewhat smaller and have more compressible heads, and thus com- pensate for the smaller size of the pelvis. Acosta-Sison makes a similar statement concerning the Philippine women, and Kinoshita of Tokio informs me that in Japan both the pelvic and cephalic measurements PELVIS OF THE NEW-BORN CHILD 17 fall below the average observed in European and American white women. Pelvis of the New-born Child.—The pelvis of the child at birth is partly bony and partly cartilaginous. The innominate bone does not exist as such, its place being taken by the ilium, ischium, and pubis, which are united by a large Y-shaped cartilage, the three bones meeting in the acetabulum. The iliac crests and the acetabula, as well as the greater part of the ischiopubic rami, are entirely cartilaginous in structure. Figs. 21 and 22 clearly show the extent to which the infantile pelvis is ossified. The cartilaginous portions of the pelvis gradually give place to bone, but complete union in the neighborhood of the acetabulum does not occur until about the age of puberty, and occasionally even at a later period. Indeed, we may say that Fig. 22.—Section through Infantile Pel- vis Parallel to Superior Strait, showing Relative Proportion of Bone and Cartilage. XI. A., acetabulum; I., ilium; P., pubic bone; S., symphysis pubis; S. A., ala of sacrum: S. B., body of sacrum; V. A., vertebral arch. Fig. 21.—Sagittal Section showing Relative Proportion of Bone and Cartilage in the Pelvis of a Newli Born Child. X 1. the innominate bones do not become completely ossified and fully de- veloped until between the twentieth and twenty-fifth years. Each innominate bone is developed from 12 centers of ossification. Three of these are primary and give rise to the ilium, ischium, and pubis. According to Adair, they appear in the order named, and are all present by the nineteenth week of pregnancy. The remaining 9 centers—the so-called epiphyseal centers—are secondary, and do not develop until a considerably later period, some of them not until after the age of puberty. The sacrum at birth is likewise partly bony and partly cartilaginous. It is made up of 21 distinct bones, each of which is derived from a single center of ossification. The 21 centers are arranged as follows: 1 for each vertebral body (5); 3 for the alae on either side (6); and 2 for the 18 THE PELVIS arches of each vertebra (10). To these must be added the various epiphyseal centers which appear later. The cartilage gradually becomes ossified, and the various component parts of the sacrum fuse together. The alae are the first portions to become united, after which the vertebral bodies gradually become welded together, the fusion extending from below upward. According to Litzmann, the bodies of the sacral verte- brae are not entirely united until the seventh year, and complete ossifica- tion of the sacrum is not effected until the twenty-fifth year. Fig. 23 represents the disarticulated pelvis of a child three years old, and clearly shows the extent to which ossification has progressed at that age. The pelvis of the new-born child differs from that of the adult not only in being made up of a large number of bones, which are united by cartilage, but more particularly in its characteristic shape. This is clearly seen upon comparing Figs. 25 and 26, which represent vertical mesial sections through the trunk of a new-born child and of an adult woman. In the former the vertebral column is almost vertical, and its lumbar curvature practically absent. The promontory is very slightly marked, and is situated at a much higher level than in the adult. The sacrum is almost straight from above Fig. 23.—Disarticulated Pelvis of Three- year-old Girl. X I3. Fig. 24.—Sagittal Section through Pelvis of Five- year-old Girl. X 16- downward, but presents a more marked transverse concavity than in the adult. Its alae are only slightly developed, and as a consequence the pelvis is relatively narrower. The iliac fossae are almost vertical, and the horizontal rami of the pubis are far shorter than in the adult. The pubic arch is much more angular, while the pelvic inclination is de- cidedly greater. The superior strait is narrower and more angular in shape, the relation between the conjugata vera and the transverse di- ameter being 100 to 105, instead of 100 to 122.5, as in the adult. The cavity of the pelvis is relatively much smaller, and is distinctly funnel- shaped. The anteroposterior and transverse diameters of the pelvic out- let, when expressed in terms of the conjugata vera, are respectively 93 and 73, instead of 104.5 and 100 as in the adult. As we have already indicated, sexual differences make their appear- ance at a very early period. Folding showed that they could be detected as early as the fourth month, when he found that the first sacral vertebra was wedge-shaped in the female, instead of cuboidal as in the male. His TRANSFORMATION OF FCETAL INTO ADULT PELVIS 19 results have since been confirmed by a number of observers, among whom Balandin, Jurgens, and Arthur Thompson may be mentioned; my own work also corroborates their statements. To recapitulate, the pelvis of the female foetus or new-born child presents the following characteristics as compared with that of the male. The pelvic canal is less funnel-shaped, the pubic arch is wider, the sacro- sciatic notches are larger, and the lumbar region of the spinal column is more markedly curved. Transformation of Foetal into Adult Pelvis.-—The mechanism by which the pelvis of the foetus is converted into the adult form is of in- terest, not only from a scientific, but also from a practical, point of view, as it affords important information concerning the mode of production of certain varieties of deformed pelves. Fig. 25.—Sagittal Section through Body of Newly Born Child. Fig. 26.—Sagittal Section through Adult Woman (Kelly), reduced to the Same Size as Fig. 25 for Comparison. The earliest investigations upon this subject were made by De Frem- ery, and Denman, who were followed by Litzmann, Duncan, Fehling, Schroeder, Yeit, Yon Meyer, and others. At present it is generally be- lieved that in the evolution of the form of the pelvis two sets of factors—- development and inherent tendencies, and mechanical influences—are concerned. That the process is not entirely the result of the action of mechanical forces is manifested by the existence of sexual and racial differences in the adult pelvis, but especially by the presence of the former in the foetal pelvis, long before it has been subjected to the usual mechanical influences. On the other hand, the mechanical in- fluences which come- into play after birth are identical in both sexes, 20 THE PELVIS but despite this fact the sexual differences become still further accen- tuated as puberty is approached. The part played by developmental and hereditary influences was clearly demonstrated by Litzmann, who showed that the female sacrum was characterized by a marked increase in width as compared with that of the male. At birth, in both sexes, the body of the first sacral vertebrae is twice as broad as the alae (100 to 50), but in the adult the relation becomes 100 to 76 in the female, and 100 to 56 in the male, indicating a much more rapid growth of the alae in the former. Falk, in 1908, held that all the changes in the developing pelvis are due to similar causes, and that the influence of the various mechanical factors is merely ac- cessory. The effect exerted by mechanical influences has been particularly studied by Duncan, Meyer, Veit, and Schroeder, while Kehrer has in- sisted upon the part played by muscular action. According to Schroeder, three mechanical forces take part in bringing about the final shape of the pelvis—namely, the body weight, the upward and inward pressure exerted by the heads of the femora, and the cohesive force exerted at the symphysis pubis. So long as the child remains constantly in the recumbent position these forces are in abeyance, but as soon as it sits up or walks the body weight is transmitted through the vertebral column to the sacrum, and, as the center of gravity is anterior to its promontory, the force trans- mitted is resolved into two components, one of which is directed down- wards and the other forward. Accordingly, the two together tend to force the promontory of the sacrum downward and forward toward the symphysis pubis, a process which can only be accomplished by the sacrum rotating about its transverse axis, so that its tip tends to become dis- placed both upward and backward. This displacement, however, is resisted by the strong sacrosciatic ligaments, which therefore permit of only slight extension, with the result that the partly cartilaginous sacrum becomes bent upon itself just in front of its axis—i. e., about the middle of its third vertebra—so that its anterior surface becomes markedly concave from above downward, instead of flat as it was previously. At the same time the body weight forces the bodies of the sacral vertebrae forward, so that they project slightly beyond the alae, thereby diminishing the transverse concavity of the sacrum. As the anterior surface of the sacrum is wider than its posterior, the bone tends to sink down into the pelvic cavity under the influence of the body weight, and would prolapse completely into it were it not held in place by the strong posterior iliosacral ligaments, which suspend it, so to speak, from the posterior-superior spines of the ilium. Accordingly, as the sacrum is pushed downward into the pelvic cavity it exerts traction upon these ligaments, which in turn drag the posterior-superior spines inward toward the middle line, and consequently tend to rotate the anterior portions of the innominate bones outward. Excessive out- ward rotation is prevented, however, by the cohesive force exerted at the symphysis, but particularly by the upward and inward pressure ex- erted by the heads of the femora. Practically, then, the iliac bone TRANSFORMATION OF FCETAL INTO ADULT PELVIS 21 becomes converted into a two-armed lever, with the articular surface of the sacrum as a fulcrum; as a consequence, it bends at its point of least resistance, which is just anterior to the articulation, and thus gives the pelvis a greater transverse and a lesser anteroposterior diameter (Figs. 27, 28). At the same time it must be remembered that a considerable part of the transverse widening is more apparent than real, and is due to the relative shortening of the conjugata vera by the downward and forward displacement of the promontory of the sacrum. It is apparent that the forces just mentioned must act in identically the same manner in the two sexes, so that, while they may serve to explain many points in the transformation of the foetal into the adult pelvis, they fail to give a satisfactory explanation of its sexual differences, Figs. 27, 28.—Diagrammatic Representations of Sections through the Infantile and Adult Pelvis (Schroeder). Fig. 27. Fig. 28. and we are therefore compelled to agree with Falk, Fehling, Freund, Joessel, and Breus and Kolisko that the latter must owe their origin to certain congenital tendencies concerning whose nature we are as yet ignorant. Breus and Kolisko insist that too great stress has been laid upon the action of mechanical forces in the production of the ultimate shape of the pelvis, and hold that the relative flattening of the superior strait is due not so much to the downward and forward displacement of the base of the sacrum as to the unequal rate of growth before puberty of the sacrum and the several component parts of the innominate bones. In making this contention, they lay great stress upon the so-called terminal length of the latter, which includes not only the linea termi- nalis, but also its imaginary continuation, which extends from the ventral margin of the sacro-iliac articulation to the iliac crest just above the superior-posterior spine (Figs. 29, 30). In the normal adult pelvis, the terminal length measures from 19.5 to 21 centimeters, and is divided into three parts—the sacral, iliac, and pubic portions. The first extends from the posterior margin of the iliac crest to the ventral margin of the articular surface, the second from the latter to the line upon the linea terminalis which indicates the union of the iliac and pubic hones, and the 22 THE PELVIS third from that point to the anterior end of the pubic bone. These portions measure 6.5 to 7, 6 to 6.5, and 7 to 7.5 centimeters respectively, and therefore are of practically equal length. During the period of developments, the sacral portion grows from the cartilage covering the iliac crest, the iliac portion from the upper limb of the Y-shaped car- tilage of the acetabulum, and the pubic portion from the latter as well as from the symphyseal cartilage. Up to the seventh or eighth year the sacrum increases steadily in width, and then ceases to grow until just before puberty, when it rapidly attains its full development. During the former period the superior strait grows relatively more rapidly in its transverse diameter, and there- fore assumes a flattened shape. Normally, the iliac portion of the in- Fig. 29.—Showing Terminal Length AS SEEN FROM ABOVE. X Bj. Fig. 30.—Showing Terminal Length AS SEEN FROM BeLOW. X }/%• nominate bone increases steadily in length, until it has attained its full development just before puberty, while the sacral and pubic portions grow much more slowly. Accordingly, as a result of these variations, combined with the arrested growth of the sacrum, the anteroposterior diameter of the superior strait will at some time equal or exceed the transverse diameter in length, so that between the eighth and twelfth years the pelvic inlet will become round or even oval in shape, with its long diameter extending anteroposteriorly. This, however, is only a transient phenomenon, as shortly before puberty the sacrum suddenly begins to increase rapidly in width, and the pubic bones in length, so that the superior strait reassumes its typical flattened shape with the long diameter extending transversely. Breus and Kolisko, therefore, contend that these variations indicate that the changes in shape of the pelvis must be attributed to something more than mere mechanical influences, since the latter come into play in infancy and continue as long as the individual is able to sit up or walk. Were they the only factors concerned, the pelvis would necessarily con- TRANSFORMATION OF FCETAL INTO ADULT PELVIS 23 tinue to become more and more flattened, until it had attained its ulti- mate form, whereas the occurrence of a rounded superior strait between the eighth and twelfth year clearly indicates that some other factor must be concerned. As yet they have advanced no explanation for the variable rate of growth of the sacrum and the component parts of the innominate bone, but they nevertheless hold that its occurrence precludes the ac- ceptance of the mechanical theory to the exclusion of all others, while at the same time they admit that the latter may also play an important part in the development of the pelvis. The effect of the mechanical factors is particularly emphasized in the production of certain varieties of contracted pelvis, which have been studied by ATon Meyer and Schroeder. In rare instances, as in one recorded by Gurlt, none of the mechanical forces come into play, and then one has an opportunity of studying the development of the pelvis in their absence. In Gurlt’s case, autopsy upon a thirty-one-year-old hydrocephalic woman, who had been bedridden since infancy and had never sat or walked, showed that the pelvis had retained its foetal char- acteristics. The cohesive force exerted at the symphysis pubis cannot act by itself, as it is manifested only when the force exerted by the body weight causes a tendency toward gaping of the pubic bones. Likewise, the effect of the upward and inward force exerted by the femora cannot be observed by itself, as this force conies into play only when it has to react against that resulting from the body weight, Hor has the action of the body weight alone ever been observed, though theoretically it might be noted in an individual presenting a split pelvis (congenital lack of union at the sym- physis pubis) who had never walked. Its action, however, has been studied experimentally by Freund, who suspended a cadaver bv the iliac crests after cutting through the symphysis, and found that the innomi- nate bones gaped widely. The effect of the combined action of the body weight and the force exerted by the femora has been studied by Litzmann in cases of congeni- tal absence of the symphysis pubis. In such circumstances there is a marked transverse widening of the posterior portion of the pelvis, while the force exerted by the femora causes the anterior portions of the in- nominate bones to become almost parallel. The action of the body weight and the cohesive force exerted at the symphysis, without the upward and inward pressure exerted by the femora, can be studied in individuals whose lower extremities are absent, and occasionally in cases of congenital dislocation of the hips. Holst has described a case in which the lower extremities were congenitally absent, the pelvis being characterized by a marked increase in width and a marked decrease in its anteroposterior diameter. Owing to the ex- cessive pressure exerted upon the tubera ischii in the absence of the counteracting force exerted by the femora, the innominate bones are rotated in such a manner as to turn their crests inward and the tubera ischii outward, thus producing a marked transverse widening of the in- ferior strait. More or less similar changes may be observed in cases of congenital dislocation of the hip if the patients have never walked. 24 THE PELVIS The effect of the various mechanical influences is particularly empha- sized when they are exerted upon pelves whose bones are softened by dis- ease, as in rachitis and osteomalacia. Consideration of the changes so produced will be deferred until the study of the deformed pelves is taken up. Acosta-Sison. Pelvimetry and Cephalometry among Filipinos, Philippine J. Sci., 1914, x, 493-97. Adair. The ossification centers of the fetal pelvis. Am. J. Obst., 1918, lxxviii, 175-199. Arantius. Anatomic® observationes. Yenetiis, 1857, Cap. xxxix. Balandin. Klinische Vortrage, St. Petersburg, 1883, Heft 1. Breisky. Zeitschrift der Gesellsch. der Aerzte. Wien, 1865, i, 21. Breus and Kolisko. Die pathologische Beckenformen. Leipzig u. Wien, Bd. I, Theil 1, 1900; Theil 2, 1904. Columbus. De re anatomica Libri XY, Venetiis, 1559. De Fremery. De mutationibus figur® pelvis. D. I., Lugd. Batav., 1793. Denman. An Introduction to the Practice of Midwifery. London, 1787-1795. Deventer. Neues Hebammenlicht, etc. III. Aufl., Jena, 1728. Duncan. Researches in Obstetrics. Edinburgh, 1868. (On the Os Sacrum, 55-82.) (On the Development of the Female Pelvis, 95-113.) Falk. Die Entwickelung und Form des Beckens. Berlin, 1908. Fehling. Die Form des Beckens beim Fotus und Neugeborenen. Archiv f. Gyn., 1876, x, 1-80. Freund. Ueber das sogenannte kyphotische Becken, etc. Gynakologische Klinik, 1885, i, 1-113. Gache. Le Raehitisme en Amerique, etc. Annales de gyn. et d’obst., 1903, lx, 175-195. Gurlt. Ueber einige Missgestaltungen des weiblichen Beckens. Berlin, 1854. Hegar. Zur Geburtsmechanik. (Die Beckenaxe.) Archiv f. Gyn., 1870, i, 193- 223. Hodge. The Principles and Practice of Obstetrics. Philadelphia, 1860. Holst. Beschreibung des Beckens u. der Geburtstheile eines 40 Jahre alten weiblichen Amelus. Holst’s Beitrage, 1869, Heft 2, 145-148. Huwfl. Onderwys der vrouwen, etc. Haarlem, 1735. Joessel and Waldeyer. Lehrbuch der topographisch-chirurgischen Anatomic. Bonn, 1899. II Theil, Das Becken. JItrgens. Beitrage zur normalen und path. Anatomie des menschlichen Beckens. Virchow’s Festschrift, Berlin, 1891. Keiirer. Beitrage zur vergl. u. exper. Geburtshiilfe, 1869, Heft 3; und 1875, Heft 5. KiiTTNER. Experimentell-anat. Untersuehungen fiber die Veranderlichkeit des Beckenraumes Gebarender. Hegar’s Beitrage, 1898, i, 210-229. Levret. L’art des accouchements. Paris, 1751. Litzmann. Die Formen des Beckens. Berlin, 1861. Das gespaltene Becken. Archiv f. Gyn., 1872, iv, 266-284. Die Geburt bei engem Becken. Leipzig, 1884. Loeschke. Untersuehungen fiber Entstehung und Bedeutung der Spaltbildung u in der Symphyse. Archiv f. Gyn., 1912, xevi, 525-560. Luschka. Die Anatomie des menschlichen Beckons, Tfibingen, 1864. LITERATURE LITERATURE 25 Meyer. Statik und Mechanik des menschliehen Knochengeriistes. Leipzig, 1873. Michaelis. Das enge Becken. Leipzig, 1851. Muller, J. J. Diss. sist. casum rarissimum uteri in partu rupti. Basileae, 1745. Naegele. Das weibliche Becken, etc. Carlsruhe, 1825. Neumann u. Ehrenfest. Ueber die Bestimmung d. Beckenneigung an d. lebenden Frau. Monatsschr. f. Geb. u. Gyn., 1900, xi, 253-60. Biggs. A Comparative Study of White and Negro Pelves. Johns Hopkins Hospital Reports, 1904, xxi, 421-454. Roederer. De axi pelvis. Goettingae, 1751. Elmenta artis obstetriciae. Goettingae, 1766. Scharlau. Das Australier-Becken. Berlin, 1903. Schroeder. Lehrbuch der Geburtshiilfe. XIII. Aufl., 1899. Sellheim. Die Beziehungen des Genitalkanales und des Geburtsobjektes zur Geburtsmechanismus. Leipzig, 1906. Smellie. A Treatise on the Theory and Practice of Midwifery. London, 1752. Stein, D. J. Lehre der Geburtshiilfe. Elberfeld, 1825. Thompson. The Sexual Differences of the Foetal Pelvis. Journal of Anat. and Physiol., 1899, xxxiii, 359-381. Topinard. Des proportions generates du bassin chez l’homme, etc. Bull, de la Soc. d’Anthropologie, 1875, 504-521. Turner. The Index of the Pelvic Brim as a Basis of Classification. Journal of Anat. and Physiol., 1886, xx. Veit. Die Entstehung der Form des Beckens. Zeitschr. f. Geb. u. Gyn., 1883, ix, 347-372. Die Anatomie des Beckens. Stuttgart, 1887. Verneau. Le bassin dans les sexes et dans les races. Paris, 1875. Vesalius. De humani corporis fabrica libri septem. Basilae, 1543. Walcher. Die Conjugata eines engen Beckens ist keine konstante Grosse, etc. Centralbl. f. Gyn., 1889, 892-893. Weber. Die Lehre von Ur- und Racen-formen des Schadels und Beckens des Menschen. Diisseldorf, 1830. Williams. The Frequency of Contracted Pelves, etc. Obstetrics, 1899, i, Nos. 5, 6. The Funnel Pelvis. Am. J. Obst., 1911, lxiv, 106-24. CHAPTER II THE FEMALE ORGANS OF GENERATION For convenience in description and on account of their differences in function, the female organs of generation are divided into two groups—- the external and the internal—the vagina being usually classed with the former. The external organs, together with the vagina, serve more espe- cially for copulation, while the internal organs are directly concerned with the development and birth of the foetus. THE EXTERNAL GENERATIVE ORGANS The term pudendum is occasionally applied to the external organs of generation, although the more common designation is the vulva. This includes everything which is visible externally from the lower mar- gin of the pubis to the perineum—namely, the mons Veneris, the labia majora and minora, the clitoris, vestibule, hymen, urethral opening, and various glandular and vascular structures. Mons Veneris.—The mons Veneris is the name given to the fatty cushion which rests upon the anterior surface of the symphysis pubis. After puberty the skin over it is covered by a thicker or thinner growth of crinkly hair, which is sometimes described as the “escutcheonGen- erally speaking, the distribution of the pubic hairs differs considerably in the two sexes. In the female they occupy a triangular area whose base corresponds to the upper margin of the symphysis, while a few hairs extend down over the outer surface of the labia majora. In the male, on the other hand, the escutcheon is not so circumscribed, as the hairs com- posing it extend triangularly upward toward the umbilicus and down- ward over the inner surface of the thighs. These differences were de- scribed in detail by Floss, and at one time it was believed that they might 1)0 of value in determining the sex in doubtful cases. Schultze showed that such variations were not absolutely characteristic, and my own experience has convinced me that the female escutcheon not infrequently approaches the male type. Vulva.—In the restricted sense, the term vulva (from the Latin valva, a folding-door), or rima pudendi, is applied only to the structures lying beneath the mons Veneris. Its position varies according to the inclination of the pelvis, but it usually runs horizontally when the woman is in the erect position. It presents marked individual variations in appearance, but its most noteworthy differences are dependent upon the age of the person and whether or not she has borne children. 26 THE EXTERNAL GENERATIVE ORGANS 27 Labia Majora.—On either side of the vulva extends a rounded mass of tissue, the labium majus. The labia majora vary markedly in ap- pearance, according to the amount of fat beneath them. They are less prominent after childbearing, and in old age usually assume a shriveled appearance. Ordinarily they measure 7 to 8 centimeters in length, 2 to 3 centimeters in width, and 1 to 1.5 centimeters in thickness. They are somewhat lozenge-shaped, and become narrower at their lower extremi- ties. In children and virginal adults they usually lie in close apposition and completely conceal the underlying parts, whereas in multiparous women they often gape widely. Until recently it was usually stated that Fig. 31.—External Genitalia of Nul- liparous Woman, Labia in Contact. Fig. 32.—External Genitalia of Mul- tiparous Woman, Labia spread Apart. they were connected above and below by the anterior and posterior com- missures of the vulva, but Luschka has shown that they are directly con- tinuous with the mons Veneris above, and fade away into the perineum posteriorly. Each labium majus presents two surfaces, an outer and an inner. The outer surface corresponds in structure to the adjacent skin, and after the age of puberty is more or less thickly covered with hair. In women who have never borne children the inner surface is moist and resembles a mucous membrane in appearance; whereas in multiparae it becomes more skinlike, but is not covered with hair. It is richly sup- plied with sebaceous glands. Beneath the skin there is a layer of dense connective tissue, which is rich in elastic fibers and adipose tissue, but does not contain muscular elements. Beneath this layer, which cor- responds to the tunica dartos of the scrotum, is a tolerably dense mass of fat, to which the labium owes the greater part of its size. This fatty 28 THE FEMALE ORGANS OF GENERATION tissue is supplied with an abundant plexus of veins, which may rupture as the result of external violence or injury sustained during labor, and give rise to an extravasation of blood or hematoma. The labia majora are analogous to the scrotum in the male, and at their upper ends receive the termination of the round ligaments. Ex- ceptionally one or both of the inguinal canals, which in the female are designated as the canals of Nuck, may remain patent, so that in rare instances there results a hernial sac which usually contains intestine, but occasionally the tube or ovary, and possibly even the uterus. Labia Minora.—On spreading apart the labia majora two triangular structures are seen, which meet together at the uppermost portion of the vulva and more or less resemble a cockscomb in appearance. These are the labia minora or nymphae, so-called because they were supposed to direct the course of the urine. They vary markedly in size and shape, and in nulliparous women are usually hidden by the labia majora. In multiparae, on the other hand, they project beyond them. The labia minora consist of thin folds of tissue, which when pro- tected present a moist, reddish appearance, similar to that of a mucous membrane. They are, however, covered by stratified epithelium, into which project numerous papillae. They have no hairs upon them, but contain many sebaceous follicles and occasionally a few sweat glands. Their interior is made up of connective tissue, in which are many vessels and a few non-striated muscular fibers, so that they are classed among the erectile structures. They are extremely sensitive, and are abundantly supplied with the several varieties of terminal nerve-endings, as has been shown by the work of Krause, Carrard, and Webster. The labia minora converge anteriorly, each dividing toward its upper extremity into two lamellae. Of these the two lower fuse together and form the frenulum clitoridis, while the upper ones make the preputium. Posteriorly they either pass almost imperceptibly into the labia majora or approach the middle line as low ridges, which fuse together and form the frenulum labiorum or fourchet (Luschka, Cullingworth, and Nagel). According to Nagel, the labia minora are homologous with the skin upon the under surface of the penis. They frequently become con- siderably hypertrophied, either from unknown causes or as a result of masturbation. Among the Hottentots they assume immense proportions, and project from the vulva in the form of an apron some centimeters long. Among certain uncivilized races voluminous labia minora are considered to enhance the beauty of their possessors; and it is generally believed that artificial means are employed to bring about an increase in their size, but Marius Wilson considers that it is the result of natural causes. According to Ploss, the Nubians and many other races practice infibulation as part of their religious ceremonial. In this operation, which is performed just before the age of puberty, the edges of the labia are freshened with a knife, and then sutured together in such a manner as to leave an opening only large enough to permit the escape of the menstrual flow. In such circumstances a second operation is necessary before marriage can be consummated. THE EXTERNAL GENERATIVE ORGANS 29 Clitoris.—The clitoris is situated at the most anterior portion of the vulva, and projects through the branched extremities of the labia minora, which form its prepuce and frenulum. It is the analogue of the penis in the male, from which it differs in not possessing a corpus spongiosum, and in not being perforated by the urethra. It consists of a glans, a corpus, and two crura. The crura are long, narrow structures which arise from the inferior surface of each ischiopubic ramus and fuse to- gether, just below the middle of the pubic arch, to form the body of the clitoris. The clitoris is usually a very rudimentary organ and rarely exceeds 2 centimeters in length, even when in a state of erection. It is sharply bent on itself, owing to traction exerted upon it by the labia minora, whose anterior extremities, as has already been said, furnish the prepuce and frenu- lum. As a result, its free end looks down- ward and inward toward the vaginal opening. At the end of the body is the glans, which rarely exceeds a small pea in size. It is covered by squamous epi- thelium, is richly supplied with nerve- endings, and is ex- t r e m e 1 y sensitive. The entire clitoris is very erectile, and its vessels are connected with the vestibular bulbs by means of the pars intermedia. Fig. 33 gives a good idea of the relations of the clitoris, its crura, and the vestibular bulbs. We are indebted to Kobelt for most of our knowledge concerning this organ, and since the appearance of his monograph, in 1844, the clitoris has been regarded as the chief seat of voluptuous sensation. About the middle of the last century Baker Brown proposed its am- putation as a panacea for nearly all the ills to which women are subject, and for a short time the operation of clitoridectomy enjoyed a con- siderable vogue, but has since been completely abandoned. Among many of the aboriginal races the same operation had been performed from time immemorial as a religious rite,—“girl circumcision/’ Occasionally the clitoris may become considerably hypertrophied, so as to markedly resemble the penis, and not a few cases of so-called hermaphroditism are to be explained by this abnormality. Vestibule.—The vestibule is the almond-shaped area which is in- closed between the labia minora and extends from the clitoris to the Fig. 33.—Preparation showing Clitoris and Its Vascu- lar Supply. (Modified from Chrobak and Rosthorn.) 30 THE FEMALE ORGANS OF GENERATION fourchet. It is the remnant of the urogenital sinus of the embryo, and is perforated by four openings—the urethra, the vaginal opening, and the ducts of Bartholin’s glands. Considerable uncertainty exists as to its boundaries, for the reason that the French anatomists usually de- scribe it as a triangular area, bounded above by the labia minora and below by the vaginal opening. The posterior portion of the vestibule, between the fourchet and the vaginal opening, is called the fossa navicularis. This is rarely observed except in nulliparous women, as it usually becomes obliterated after childbirth. Vestibular Glands.—In connection with the vestibule, certain glandu- lar structures—the glandulae vestibulares majores and minores- are usually described. The former are designated as Bartholin s glands, or the glands of Duverney, who first described them in the cow. They are two small compound racemose glands, varying from a pea to a small bean in size, and are situated beneath the vestibule, on either side of the vaginal opening. They lie under the constrictor muscle of the vagina, and in a few instances are found to be partially covered by the vestibular bulbs. Their ducts, from 1.5 to 2 centimeters long, open upon the sides of the vestibule just outside the lateral margin of the vaginal orifice. In caliber they are usually small, and the lumen will admit only a bristle. Under the influence of sexual excitement the glands secrete a small amount of yellowish material. The ducts fre- quently harbor gonococci, Avhich may gain access to the gland and cause it to suppurate, so that the entire labium becomes distended by a collec- tion of pus. The glandulae vestibulares minores are a number of small mucous glands which open upon the upper portion of the vestibule. Their ori- fices are occasionally several millimeters in diameter, and in such cases they are designated as lacunae. Urethral Opening.—The mouth of the urethra, or urinary meatus, is situated in the middle line of the vestibule, 1 to 1.5 centimeters below the pubic arch and a short distance above the vaginal opening. It usually presents a puckered appearance, and its orifice appears as a vertical slit, which on distention is 4 or 5 millimeters in diameter. The para-urethral ducts open upon the vestibule on either side of the urethra, and occasionally upon its posterior wall, just inside its mouth. They are of small caliber, 0.5 millimeter in diameter, of varying length, and in this country are generally known as Skene’s ducts. They wore, how- ever, described by Malpighi in the seventeenth century. Considerable discussion has arisen as to their origin, and certain observers, notably Kocks, believe that they represent the lower extremities of the wolffian ducts. Most authorities, however, do not share this view, and believe that they are simply exaggerated lacunae. Vestibular Bulbs.—Lying beneath the mucous membrane of the vesti- bule, on either side, are the vestibular bulbs. These are almond-shaped, erectile bodies, 3 to 4 centimeters long, 1 to 2 centimeters.wide, and 0.5 to 1 centimeter thick. They lie in close apposition to the ischiopubic rami, and are partially covered by the ischiocavernosus and constrictor vaginae muscles. Their lower ends usually terminate about the middle TEE EXTERNAL GENERATIVE ORGANS 31 of the vaginal opening, while their anterior extremities extend upward toward the clitoris, where they are united by the pars intermedia through which the blood from them reaches that organ. They were first de- scribed by Kobelt, and their vascular connections have been exhaustively studied by Gussenbauer. Embryologically they correspond to the corpus spongiosum of the penis. During parturition they are usually pushed up beneath the pubic arch, but, as their posterior ends partially encircle the vagina, they are liable to be injured to a greater or less extent, and their rupture may give rise to a hematoma of the vulva, or to profuse external hemorrhage if the tissues covering them are torn through. Vaginal Opening and Hymen.—The vaginal opening occupies the lower portion of the vestibule and varies considerably in size and shape in different individuals. In virgins it is entirely hid- den from view by the overlapping labia minora, and, when exposed by folding them back, appears almost completely closed by a membranous structure known as the hymen. The hymen presents marked differ- ences in shape and consistence. In the new-born child it is a redundant structure which projects considerably beyond the surrounding parts, while in adult virgins it is a membrane of varying thickness which closes the vaginal opening more or less completely, and presents an aperture which varies in size from a pin’s point to a caliber which will readily admit the tip of one or even two fingers. The hymeneal opening is usually crescentic or circular in shape—hymen semilunaris or annularis. In rare instances it may assume other forms, which have been studied more par- ticularly by Dohrn and Budin ; the most important varieties being the cribriform, septate, and denticulate or fimbriated hymen. In very rare instances the membrane may be imperforate and lead to the retention of the menstrual discharges. Dohrn devoted particular attention to the fimbriated variety, and stated that it might be mistaken by an inex- perienced observer for a ruptured hymen, so that this type possesses some little medicolegal interest. According to the embryological researches of Nagel, which have been confirmed by Gellhorn, the hymen represents the lowest portion of the vagina. In early embryos this is composed of a solid mass of epithelial cells, and after proliferating rapidly for a time those most centrally situated begin to degenerate so that a lumen is produced, except at the lower extremity of the mass, where the cells persist and give rise to the hymen. The hymen, therefore, is a fold of tissue presenting a structure Fig. 34.—Longitudinal Section showing Transition from the Cylindrical Epithelium of the Uterus to the Cuboidal Epithelium of the Vagina. From a 10-centimeter embryo (Nagel). U., uterus; V., vagina. 32 THE FEMALE ORGANS OF GENERATION similar to that of the vagina—namely, a connective-tissue core with nu- merous elastic fibers, is covered on either side by a layer of stratified epithelium, in which are numerous papillae containing vessels and occa- sionally nerve-endings. Taussig, on the other hand, holds that the hymen does not represent the lowermost portion of the vagina, but is derived from a definite projection into it some distance above its open- ing into the uro-genital sinus. The hymen may vary markedly in consistence in different individuals. According to Dohrn, many types are observed—from a delicate structure resembling a spider’s web to a fleshy, ligamentous, or even cartilaginous membrane, which in rare instances has even been described as “bony.” In the matter of elasticity, again, wide variations are met with, some hymens being so delicate that they rupture upon the slightest touch, while others still remain unbroken even after considerable distention. As a general rule the hymen ruptures at the first coitus, tearing at several points, usually in its pos- terior portion. The edges of the tears soon cicatrize, and the hymen becomes perma- nently divided into two or three portions, which are separated by narrow slits ex- tending down to its base (Plate II). The extent to which rupture occurs varies with the structure of the hymen and the degree to which it is distended, being most marked when it is delicately formed. Although it is generally believed by the laity that its rupture is associated with hemorrhage, this is by no means always the case, though in rare instances such a profuse loss of blood may occur as to re- quire surgical intervention. This idea is probably based upon the biblical statement that loss of virginity is always associated with loss of blood. Nor is it unreasonable to suppose that considerable bleeding usually occurred among the Hebrews of the biblical period, inasmuch as the girls frequently married before the age of puberty, so that marked disproportion must often have existed between the size of the male and female organs. On the other hand, it must be remembered that where Western civilization prevails full sexual development has usually been attained before marriage. In rare instances the membrane may be very resistant and surgical interference be required before coitus can be accomplished. Occasionally, instead of giving way in the middle, the hymen may be torn loose from its base in the attempt at coitus, while in other cases the penis may dilate the urethral canal instead of entering the vagina. Neugebauer has Fig. 35.—Sagittal Section through the Lower Portion of the Vagina of a 14-Centimeter Embryo (Nagel). U., urethra; H., hymen; Vag., vagina. PLATE TI Infantile. Annular. Semilunar. lmperiorate. Cribriform. Septate. Vertical. Normal injury at coitus. Carunculae myrtiformes. SHOWING SEVERAL VARIETIES OF HYMEN. THE EXTERNAL GENERATIVE ORGANS 33 collected an interesting series of injuries occurring during coitus, many of which were due to the presence of a very resistant hymen. The changes in the hymen following coitus are often of medicolegal interest, as the physician is occasionally called upon to testify as to the virginity of an individual. Unfortunately, however, it is not always pos- sible to arrive at a decisive conclusion as to this point. In occasional instances the hymen may he destroyed in early childhood, either as the result of masturbation or as a consequence of attempting to get rid of seatworms. Among certain Eastern races, again, it is ruptured in early childhood for purposes of cleanliness. On the other hand, the hymen may not be torn, despite repeated, coitus; whereas, in other instances, the denticulate or fimbriated type may be mistaken for one which has been ruptured. Haberda, wdien Professor of Legal Medicine in Vienna, stated that he wras able to make a positive diagnosis of loss of virginity in only about 50 per cent of the medicelogal cases wdiich he had examined. He believed that in many in- stances it is impossible to de- termine whether coitus has taken place or not, unless the individual is seen im- mediately after the attempt, before the torn surfaces have had an opportunity to unite. Achenbach, in 1890, collected 25, and Kanony, some years later, 43 instances of preg- nancy occurring in women with unruptured hymens. Some years ago I saw a pa- tient in w'hom conception had occurred through a hymen wdiich presented only a pin-point opening, and more recently one in wdiich an elastic hymen had become invaginated sufficiently to admit the penis, but did not rupture until it yielded to the advancing head at labor. The changes produced by childbirth are much more marked than those following coitus, and, as a rule, are readily recognized. As the result of the distention incident to the birth of the child, the hymen undergoes pressure necrosis in various places, and after the puerperium the remnants are represented by a number of cicatrized nodules of varying size—the carunculae myrtiformes (Plate II). Their significance was first emphasized by Schroeder. Practically speaking, they are in- fallible signs of previous childbearing, though occasionally they may follow great distention and long-continued pressure incident to the Fig. 36.—Almost Unrtjpttjred Hymen after Childbirth (Budin). 34 THE FEMALE ORGANS OF GENERATION removal of large tumors through the vagina. In rare instances the injuries resulting from childbirth are extremely slight, and very ex- ceptionally are entirely lacking. Such cases have been reported by Hyerneaux, Tolberg, Hyrtl, and Budin. Fig. 36 shows the external organs of one of Budin’s patients who had given birth to a full-term child. LITERATURE Aciienbach. 25 Falle von Schwangerschaft und Gcburt bei undurchbohrteni Hymen. D. I., Marburg, 1890. Budin. Recherches sur 1’hymen et 1’orifice vaginale. Le Progres Medical, aout, 1879. Description d ’un cas dans lequel 1 ’accouchement n ’a determine, chez une primi- pare, que de legeres fissures de 1’orifice hymenal. Femmes en couches et Nouveau-nes. Paris, 1897, 1-4. Carrard. Beitrag zur Anatomie und Pathologie der klcinen Labien. Zeitschr. f. Geb. u. Gyn., 1884, x, 62-93. Cullingworth. A Note on the Anatomy of the Hymen and on that of the Posterior Commissure of the Vulva. Journal of Anat. and Physiol., 1893, xxvii, April. Doiirn. Die Bildungsfehler des Hymens. Zeitschr. f. Geb. u. Gyn., 1885, xi, 1-19. Gellhorn. Anatomy, Pathology, and Development of the Hymen. Trans. Am. Gyn. Soc., 1904, xxix, 405-440. Gussenbauer.. Ueber das Gefasssystem der aiisseren weiblichen Genitalien. Sitz- ungsbericht der k. k. Akad. der Wissenschaften, Wien, 1869, lx. Haberda. Ueber den anat. Beweis der erfolgten Defloration. Monatssehr. f. Geb. u. Gyn., 1900, xi, 69-88. Kanony. De la frequence de cas de persistance de 1’hymen et de leur importance en medicine legale. These de Montpellier, 1899. Kobelt. Die mannliche und weibliche Wollustorgane. Freiburg, 1844. Kocks. Ueber die Gartner’schen Gange beim Weibe. Archiv f. Gyn., 1882, xx, 487-492. Krause. Die Nervenendigung innerhalb der terminalen Korperchen. Archiv f. mikr. Anat., 1881, xix. Nagel. Die weiblichen Geschlechtsorgane. Bardeleben’s Handbuch der Anat- omie, 1896. Ueber die Entwickelung des Uterus und der Vagina beim Menschen. Archiv f. mikr. Anat., Bd. XXXVII. Neugebauer. Ein Beitrag zur Lehre von den Verletzungen der weiblichen Sexualorgane sub coitu. Mit Kasuistik von 157 Beobachtungen. Monatssehr. f. Geb. u. Gyn., 1899, ix, 221. Ploss. Das Weib in der Natur und Volkerkunde. IV. Aufl., Leipzig, 1895, Bd. I. Schroeder. The Condition of the Hymen and its Remains after Cohabitation, Child-bearing, etc. Trans. Edinburgh Obst. Soc., 1878. Schultze. Zur forensischen Diagnose des Geschlechts. Jen. Zeitschr. f. Mcdizin und Naturwissensch., 1868, iv. Skene. The Anatomy and Pathology of Two Important Glands of the Female Urethra. Amer. J. Obst., 1880, xiii, 265-270. Taussig. The Development of the Hymen. Am. J. Obst. and Gyn., 1921, ii, 471-478. Webster. The Nerve-Endings in the Labia Minora and Clitoris. Edinburgh Med. Journal, 1891. Wilson. The Nymphae. South African Med. Congress, 1910. THE VAGINA 35 THE VAGINA The vagina is a musculomembranous tube which extends from the vulva to the uterus, and is interposed between the bladder and the rec- tum. It serves three important functions; it represents the excretory- duct of the uterus, through which its secretion and the menstrual flow escape; it is the female organ of copulation; and, finally, it forms part of the birth canal at labor. Its course runs almost entirely within the pelvic floor, and it is therefore practically outside of the pelvic cavity. The vaginal canal presents a somewhat S-shaped curvature. The com- mon statement that its course corresponds in direction to that of the pelvic axis is incorrect, since its lower third is parallel to the plane of the superior strait, while its upper portion presents a concavity cor- responding to the curve of the rectum. Anteriorly, the vagina is in contact with the bladder and urethra, from which it is separated by the vesicovaginal septum. Posteriorly, between its lower portion and the rectum, we have the perineum and rectovaginal septum; in its median portion it lies in close apposition with the rectum, while its upper portion is separated from it by Douglas’s culdesac. In view of these relations, Schauta, for purposes of descrip- tion, has divided its anterior wall into two parts—urethral and vesical—and its pos- terior wall into three—perineal, rectal, and peritoneal respectively. The urethral por- tion of the vagina is firmly united to the urethra and vesicovaginal septum, from which it can be separated only with some difficulty; whereas the vesical portion is loosely attached to the bladder and can be readily detached from it. Normally the anterior and posterior walls of the vagina lie in contact, a slight space intervening between their lateral margins. When not distended, the canal presents an H- shaped appearance on transverse section, as was first pointed out by Henle. The vagina is capable of marked distention, as is manifested at childbirth or when one attempts to pack it with gauze. The vagina and uterus meet at an acute angle, with its opening looking forward. The upper end of the vagina ends as a blind vault into which the lower portion of the cervix uteri projects. The vaginal vault, or, as it is usually designated, the fornix, for convenience of description, is sub- divided into the anterior, posterior, and two lateral fornices. As the vagina is attached higher up upon the posterior than unou the anterior Fig. 37.—H-shaped Lumen of Vagina (Henle). 36 THE FEMALE ORGANS OF GENERATION wall of the cervix, the posterior fornix is considerably deeper than the anterior. The vagina presents considerable individual variations in length. Since it is united to the uterus at an acute angle, its anterior is always shorter than its posterior wall—6 to 8, and 7 to 10 centimeters respec- tively. The vagina is relatively longer in the new-born child than in the adult, and according to Luschka forms about 1/9 of the body length in the former as compared with 1/15 in the latter (Figs. 25 and 26). Projecting from the middle line of both the anterior and posterior walls is a prominent longitudinal ridge—the anterior and posterior vaginal columns, the latter not infrequently being divided into two parts by a longitudinal furrow'. In women who have not borne children numerous transverse ridges or rugae extend outward from and almost at right angles to the vaginal columns, gradually fading away as they approach the lateral w'alls. They give to the surface a corrugated appearance, which is more marked in the early years of life, and grad- ually becomes obliterated after repeated childbirth, so that in old mul- tiparae the vaginal walls are often perfectly smooth. Fig. 38.—Vaginal Mucosa. X 90. ep., epithelium; p., papilla; c.t., connective tissue. The vaginal wall itself is composed of three layers—the mucous, the muscular, and the connective-tissue layers. The mucosa is composed of numerous layers of stratified epithelium, and closely resembles the skin in structure; hut, as its surface is not exposed to the air, the horny layer is absent. The lowest layer of epithelium is distinctly columnar in appearance, while the cells immediately above it are polygonal in shape, and gradually become more and more flattened as the free surface is approached. Beneath the epithelium is the submucosa, a thin layer of connective tissue, which is tolerably rich in blood vessels. Offshoots from it extend up into the epithelium and form papillae,, just as in the skin, and scattered here and there through the submucosa are small lymphoid nodules. The mucosa is very loosely attached to the underlying connective tissue, as is manifested by the ease with which it can be peeled off at operations. According to Nagel, Gebhard, Pretti, and Waldeyer, the vaginal THE VAGINA 37 mucosa is absolutely devoid of glands, nor have I, in any of the large number of specimens examined, ever encountered them. Hennig, Preuschen, and Cullen, on the other hand, affirm that they are some- times present. It is true that in rare instances Veit and Davidsohn found a few structures which the latter considered represented aberrant cervical glands, but I do not believe that typical glands lined by cuboidal or cylindrical epithelium can be considered as normal constitu- ents of the vagina. In women who have borne children one occasionally finds imbedded in the connective tissue masses of stratified epithelium, which may present a central cavity, and sometimes give rise to cystic formation. These, however, are not glands, but simply represent tags of ftmcosa which were buried during the repair of vaginal tears following labor. In other cases, cysts lined by ciliated epithelium, and lying out- side of the mucosa, should be considered as derived from remnants of the wolffian ducts. The muscular layer is not very sharply marked, and is usually de- scribed as being composed of two layers of non-striated muscle—an outer, longitudinal, and an inner, circular layer. At the lower extremity of the vagina, Luschka described a thin band of voluntary muscle, the constrictor or sphincter vagince. This can always be found in perineal dissections, but for practical purposes the levator ani muscle is the real closer of the vagina. Outside of the muscular layer is a layer of connective tissue which serves to connect the vagina with the surrounding parts. It is quite rich in elastic fibers, and contains an abundant venous plexus. In the non-pregnant condition the vagina is kept moist by a small amount of secretion from the uterus; but in pregnancy a well-marked vaginal secretion is present, which, according to Ddderlein and most subsequent observers, normally consists of a dry, thick, white, curdlike material composed of cast-off epithelium and many bacteria, and pre- sents a markedly acid reaction. A great deal of work has been done upon the bacterial flora of the vaginal secretion in pregnancy, and all ob- servers agree that bacillary forms predominate, though cocci are not infrequently seen. For practical purposes it may be assumed that the ordinary pyogenic organisms are not present in the vaginal secretion of healthy pregnant women. The subject will be considered in detail in the chapter on Puerperal Infection. The vagina possesses an abundant vascular supply, its upper third being supplied by the cervicovaginal branches of the uterine arteries, its middle third by the inferior vesical arteries, and its lower third by the median hemorrhoidal and internal pudic arteries. Immediately sur- rounding the vagina is an abundant venous plexus, the vessels from which follow the course of the arteries and eventually empty into the hypogastric veins. The distribution of lymphatics has been very accurately studied by Poirier, who found that the lymphatics from the lower third of the vagina empty into the inguinal lymph glands, those from its middle third into the hypogastric, and those from its upper third into the iliac glands. 38 THE FEMALE ORGANS OF GENERATION The vagina is formed by the fusion of the terminal ends of the miil- lerian ducts, which, according to Nagel, reach the urogenital sinus in embryos 2.5 to 3 centimeters long. As has already been said, when con- sidering the development of the hymen, the vagina is originally solid, and is made up of a mass of polygonal epithelial cells, its lumen resulting from their degeneration, which commences at about the third month of gestation (Fig. 34). LITERATURE Cullen. Vaginal Cysts. Tians. Am. Gyn. Soc., 1904, xxix, 459-483. Davidsoiin. Zur Kenhtniss der Scheidendriisen, etc. Archiv f. Gyn., 1900, lxi, 418-433. Dodeklein. Das Scheidensekret. Leipzig, 1892. Gebhard. Path. Anatomie der weiblichen Sexualorgane. Leipzig, 1899, 494. Henle. Eingeweidelehre des Menschen. Braunschweig, 1873. Luschka. Die Anatomie des menschlichen Beckcns. Tubingen, 1861. Nagel. Die weiblichen Geschlechtsorgane. (Bardeleben’s Handbuch der Ana- tomie.) Jena, 1896. Poirier. Lymphatiques des organes genitaux de la femme. Paris, 1890. Pretti. Beitrag zur histologischen Veranderungen der Scheide. Zeitschr. f. Geb. u. Gyn., 1898, xxxviii, 250-269. Schauta. Lehrbucli der gesammten Gynakologie. Leipzig u. Wien, 1896, 51. Veit. Cysten der Scheide. Handbuch der Gyn., 1897, i, 341. Von Preuschen. Virchow’s Archiv, Ixx. Waldeyer und Joessel. Lehrbuch der topographisch-chirurg. Anatomie, II. Theil, 819. Bonn, 1899. THE UTERUS The uterus is a muscular structure, partially covered by peritoneum, and presents a cavity lined by mucous membrane. It is the organ of menstruation, and during pregnancy serves for the reception, retention, and nutrition of the ovum, which it expels at the time of labor by its contractions. The non-pregnant uterus is situated in the pelvic cavity between the bladder and rectum, its inferior extremity projecting into the vagina. Almost its entire posterior wall is covered by peritoneum, the lower portion of which forms the anterior boundary of Douglas’s culdesac, only the upper portion of the anterior wall is so covered, its lower por- tion being united to the posterior wall of the bladder by a tolerably thick layer of connective tissue. Roughly speaking, the uterus resembles a flattened pear in appear- ance, and consists of two unequal parts: an upper triangular portion— the corpus—and a lower, cylindrical, or fusiform portion—the cervix. The anterior surface of the corpus is almost flat, while its posterior surface is markedly convex. In view of the fact that the former, which looks downward and forward, rests upon the bladder, while the latter is in contact with the intestines. His has suggested that the surfaces be described as vesical and intestinal, instead of anterior and posterior respectively. The fallopian tubes come ofl from the cornua of the uterus—i. e., at the junction of the superior and lateral margins on either side—the convex upper margin between their points of insertion THE UTERUS 39 is called fundus uteri. The lateral margins extend from the insertion ot the fallopian tubes on either side to the pelvic floor. They are not cov- ered by peritoneum, but receive the attachments of the broad ligaments. Fig. 39.—Anterior Aspect of Uterus. X 1. Fig. 40.—Posterior Aspect of Uterus X 1. The uterus presents marked variations in size and shape, according to the age of the individual, and whether or not she has borne children- The infantile organ varies from 2.5 to 3 centimeters in length; that of adult virgins measures from 5.5 to 8, 3.5 to 4, and 2 to 2.5 centimeters in its greatest ver- tical, transverse, and anteroposterior diameters respectively, as compared with 9 to 9.5, 5.5 to 6, and 3 to 3.5 centimeters in multiparous women. Virginal and parous uteri also differ considerably in weight, the former ranging from 40 to 50, and the latter from 60 to 70 grams. The relation between the length of the corpus and that of the cervix likewise varies widely. In the young child the former is only half as long as the cervix; in young virgins the two are of equal length, or the corpus may be slightly longer. In multiparous women, on the other hand, the relation is reversed, and the cervix represents only a little more than one third of the total length of the organ. On sagittal section it is seen that the great bulk of the uterus is made up of muscular tissue, and that the anterior and posterior walls of its body lie almost in contact, the cavity be- tween them appearing as a mere slit, while that of the cervix is fusiform in shape with a small opening above and below-—the internal and the external os. Veit and Aschoff have pointed out that the lowermost portion of the Fig. 41.—Lateral Aspect of Uterus, showing Supravaginal and In- FRAVAGINAL PORTIONS of Cervix and Ar- rangement of Perito- neal Covering. X 1. 40 THE FEMALE ORGANS OF GENERATION uterine cavity is very constricted—the isthmus uteri—whose upper end is sometimes confused with the internal os. On frontal section the cavity of the body of the uterus presents a triangular appearance, while that of the cervix retains its fusiform shape. After child-bearing the triangular ap- pearance becomes less pronounced, as its margins become concave instead of con- vex, as in the virginal condition. Cervix Uteri.—The cervix is the por- tion of the uterus which lies below the internal os. On the anterior surface of the uterus its upper boundary is indicated by the point at which the peritoneum is reflected on to the bladder. It is divided, by the attachment of the vagina, into two parts: the supra- vaginal and infravaginal portions of the cervix. The former is covered on its posterior surface by peritoneum, while its lateral and anterior Fig. 42.—Showing Junction of Vagina and Cervix (Skene). Fig. 43. Uterus and Appendages of Young Child. X Fig. 44.—Uterus and Appendages of Fourteen-year-old Girl. X %. surfaces are in contact with the connective tissue of the broad ligaments and bladder. The infravaginal por- tion of the cervix, which is usually designated as the portio vaginalis, pro- jects into the vaginal fornix, and at its tip pre- sents a small transverse opening, the external os, bounded in front and be- hind by the so-called an- terior and posterior lips of the cervix. Owing to the fact that the posterior fornix is deeper than the anterior, the posterior lip appears longer than the anterior. The external os may vary greatly in appearance. In the virgin it is a small, oval opening resembling a tench’s mouth, whence the name, Fig. 45.—Uterus and Appendages of Twenty-year- old Multipara. X %■ THE UTERUS 41 os tincae. On vaginal examination it gives a sensation similar to that obtained on feeling the cartilage at the end of one’s nose. After child- birth the orifice becomes converted into a transverse slit, and when the cervix has been deeply torn during labor it may present an irregular nodular or stellate appearance. These changes are very characteristic, and enable one to assert with tolerable accuracy whether a woman has borne children or not (Figs. 46 and 47). The cervix is composed of connective tissue in which are many nonstriated muscle fibers and a certain amount of elastic tissue, a large part of its distensibility being due to the presence of the latter. The cervical canal, as has already been said, is fusiform in shape, and presents a longitudinal ridge upon its anterior and posterior surfaces, from which numerous others run oif transversely, giving the membrane a corrugated appearance—the arbor vitae uterina or plicae palmatae. In the adult the arbor vitae is limited to the cervical canal; but in childhood it ex- tends throughout the entire cavity of the uterus, from which it begins to disappear as puberty is approached. In time, after repeated childbirth, it gradu- ally becomes obliterated even in the cervical canal, whose walls become almost smooth (see Figs. 43 to 45). The mucosa of the cervical canal, embryologically speaking, is a direct continuation of the lining of the uterine cavity, but has become differentiated from it and possesses a characteristic appearance, so that sections through the canal present a honeycomblike structure (Fig. 48). The mucosa is com- posed of a single layer of very high and narrow colum- nar epithelium, which rests upon a thin basement mem- brane. The oval nuclei are situated near the base of the columnar cells, the upper portions of which present a clear, more or less transparent appear- ance due to the presence of mucus. It is usually stated that these cells are abundantly supplied with cilia. The cervical glands extend down from the surface of the mucosa Fig. 46.—Virginal Exter- nal Os. Fig. 47.—Parous Exter- nal Os. Fic. 48.—Cross-section through Cervical Canal. X 6. 42 THE FEMALE ORGANS OF GENERATION into the stroma. They are of the branching, racemose variety, and are merely reduplications of the surface epithelium, being lined by epi- thelium of the same character. Friedlander was the first to dem- onstrate that it was made up of true “beaker” or mucous cells, which furnish the thick, tenacious secretion of the cervical canal. There is no submucosa in the cervix, the mucosa resting directly upon the underlying tissue. The mucosa of the vaginal portion of the cervix is directly continuous with that of the vagina, and, like it, consists of many layers of stratified epithelium. Normally, there are no glands beneath it, but occasionally those from the cervical canal may extend down almost to its surface, and, if their ducts are occluded, may become converted into retention cysts, which shimmer through it and appear as rounded protuberances the size of small peas. These are the so-called nabothian follicles or ovula Nabothi. Normally, the stratified epi- thelium of the vaginal portion and the cylindrical epithelium of the cervical canal meet abruptly at the external os. This, how- ever, is the case only in early life, as in older persons the strati- fied epithelium gradually extends up the cervical canal until its lower third, and occasionally its lower half, is covered by it. This change is more especially marked in multiparous women, in whom the lips of the cervix are not infrequently markedly everted; and occasionally, in cases of this character, almost the entire cervical canal may be lined by stratified epithelium. In rare instances the junction of the two varieties of epithelium may be upon the vaginal portion, outside the external os. This condition was first described by Fischel, who designated it as congenital ectropion, and stated that he had observed it in 10 out of 28 uteri of young persons which he had examined. Still more rarely, the entire vaginal portion may be covered by cylindrical epithelium, which may extend down over the vaginal walls. This anomaly was first described by Huge in a case of imperforate hymen, associated with hematolcolpos, in which the entire Fig. 49.—Cervical Gland. X 90. THE UTERUS 43 vagina and the inner surface of the hymen were covered by a single layer of columnar, ciliated epithelium. Corpus Uteri.—The wall of the uterine body is made up of three layers: serous, muscular, and mucous. The serous layer is foymed by the peritoneum covering the uterus, to which it is firmly adherent except at the margins, where it is deflected to the broad ligaments. Endometrium.—The innermost or mucous layer, which servos as a lining for the uterine cavity, is commonly known as the endometrium. It is a thin, pinkish, velvety membrane, which on close examination is seen to he perforated by large numbers of minute openings—the mouths of the uterine glands. On account of the constant changes to which it is subject during the sexual life of woman, the endometrium varies markedly in thick- ness, and may measure anywhere from 0.5 to 3 or 5 millimeters without being necessarily abnormal. It consists of a surface epithelium, glands, and inter- glandular tissue, in which are found numerous blood vessels and lymphatic spaces. As the endometrium does not pos- sess a submucosa, it is attached directly to the underlying muscular layer in such a manner that its outer boundary presents irregularities in outline corre- sponding with the interstices between the muscle bundles. This arrangement is of considerable importance in connection with +he of curet- tage ; for, as Diivelius and Werth first showed, it is the portions included between the muscle bundles +1 L the endometrium is regenerated after that procedure. The surface epithelium of the uterine mucosa is composed of a single layer of high columnar ciliated cells, which are closely packed together. The oval nuclei are situated in the lower portions of the cells, but not so near their bases as in the cervix. Beneath the epithelium is a thin basement membrane with narrow, spindle-shaped nuclei. The existence of cilia was first demonstrated by Nylander in the sow, but they have since been found in all mammals. The researches of Meyer show that the time of their first appearance is variable, as they may be present at birth, but sometimes do not appear until much later. Hoehne and Mandl state that they are not present upon all cells, but that the ciliated cells occur in discrete patches, while the secretory activity appears to be limited to non-ciliated cells. The cilia persist throughout the entire period of sexual activity, and, according to Par- viainen, disappear eight or ten years after the menopause. Up to 1893 it was generally taught that the current produced by them was directed from below upward—namely, from the cervix toward Fig. 50.—Reconstruction of Uter- ■ s, Showing Shape of Its Cav- ity and Cervical Canal. X 1. 44 THE FEMALE ORGANS OF GENERATION the fundus; but Ilofmeier conclusively demonstrated that it is in the opposite direction, and his researches have since been generally confirmed. It may therefore be considered as a definitely established fact that the ciliary current in both the tubes and the uterus is in the same direction, and extends downward from the fimbriated end of the tubes to the ex- ternal os. In very exceptional instances the uterine cavity may be lined by stratified epithelium, as in the cases reported by Zeller and F. Fried- lander. Such a condition readily explains the possible occurrence of flat-celled carcinoma of the body of the uterus. Projecting down from the surface of the endometrium are large numbers of small tubular glands—the uterine glands. These must be Fig. 51 - Formal Resting Endometrium. X 16. regarded as invaginations of the surface epithelium and, Til the resting state, resemble the fingers of a glove, though occasionally they branch slightly at their deeper extremities. They extend through the entire thickness of the endometrium to the muscular layer, which they occa- sionally penetrate for a short distance. They present the same histo- logical structure as the surface epithelium, and are lined by a single layer of high, columnar, ciliated epithelium, which rests upon a thin basement membrane. They secrete small quantities of a thin, alkaline secretion, which serves to keep the uterine cavity moist. Following the appearance in 1908 of the monograph of Hitschmann and Adler, much work has been done upon the anatomy of the endo- metrium, which was well reviewed by E. Schroeder in 1915. The con- sensus of opinion now is that it is undergoing constant change during ...each menstrual cvcle. and that four nhases may be observed every 28 THE UTERUS 45 days: menstruation, regeneration, period of rest and of premenstrual swelling. These changes will be considered in detail in the chapter upon menstruation, and here it will suffice to say during the resting period the membrane is quite thin and contains only a few tubular glands; while it increases rapidly in thickness during the period of premenstrual swelling, and then contains many convoluted or cork-screwlike glands. In the child the uterine glands are mere shallow depressions, which, according to Kundrat and Engelman, do not appear until the third year; but the researches of Meyer, which are confirmed by my own studies, show that they are frequently present at birth. At the meno- pause the entire endometrium undergoes atrophic changes; its epithelium becomes flatter, its glands gradually disappear, and its interglandular tissue takes on a more fibrous appearance (see Fig. 53). The portion of the endometrium lying between the surface epithelium and the underlying muscle, which is not occupied by glands, is filled by an interglandular tissue or stroma of an embryonic type. In the resting stage, under the microscope (Figs. 51 and 54), it is seen to be made up of closely packed oval and spindle-shaped nuclei, around which there is very little protoplasm. When the tissues are spread apart by edema it is readily seen that the cells present a stellate appearance, with branch- ing protoplasmic processes which anastomose one with another. The cells are more closely packed around the glands and blood vessels than elsewhere Cl. the other hand, during the premenstrual stage they become larger and more vesicular in character, and closely resemble decidual cells. Occasionally larger or smaller collections of round cells may be seen between them, though it is uncertain whether or not these are to be regarded as lymphoid nodules. The exact nature of the interglandular tissue has given rise to a great deal of discussion, concerning which the authorities are not yet fully agreed. Minot looked upon it as a form of embryonic tissue, while Nagel saw in it a resemblance to lymphoid tissue, and Arthur W. Johnstone held that it was of an adenoid type. On the other hand, Leopold, Championniere, Poirier, and others consider that it represents a lymphatic surface. According to Leopold, the “uterine mucosa should be considered as a spread-out lymph gland (Lymphdriisenflache), which does not contain true lymph vessels, but consists of spaces lined by en- Fig. 52.—Endometrium of Newly Born Child. X 150. 46 THE FEMALE ORGANS OF GENERATION dothelium.” There is a certain amount of evidence in support of all of these views, but I agree with Minot in considering it as merely an embryonic type of connective tissue. When preparations from the endometrium are treated by appropriate methods, an abundant reticulum can be demonstrated throughout its entire extent, which forms the scaffolding upon which it is constructed. The endometrium contains many blood vessels. The arteries pursue a spiral course and break up into a capillary network just beneath the surface epithelium, from which the blood is returned by a few com- paratively large vessels. Musculature of the Uterus.—The major part of the uterus is made up of bundles of non-striated muscle, which are united by a greater or lesser mucosa | muscle Fig. 53.—Senile Endometrium. X 16. amount of connective tissue, in which are found many elastic fibers (Pick and Anspach). On section the non-pregnant uterine wall presents a thick, feltlike structure, in which definite layers cannot be distinguished. A great deal of work has been done upon the arrangement of the musculature both of the pregnant and non-pregnant uterus. Tarnier and Kibemont-Dessaignes were unable to make out definite layers of muscle bundles in the non-pregnant organ, while Bayer, Kreitzer, Yeit, and others distinguished several, but did not agree as to their arrange- ment. All admit, however, that the'greater part of the uterine wall is made up of a mass of muscle which is perforated in all directions by blood vessels, and in which it. is impossible to make out any definite arrangement of the bundles—stratum vasculare. Eoesger studied the question from a developmental point of view, and demonstrated that the muscle fibers are developed along the course of the blood vessels, but failed to distinguish any definite arrangement. Simi- lar studies by Werth and Grusdew show that the musculature of the foetal and infantile uterus presents a very simple arrangement, which becomes THE UTERUS 47 much more complicated as puberty is approached. During gestation, on the other hand, the uterus undergoes marked hypertrophy, when it becomes possible to distinguish certain distinct layers which will be considered in the chapter on the changes incident to pregnancy. Under the name of the myometrial endocrine gland, Ancel and Bouin in 1911 described peculiar collections of cells which appear between the muscular cells of the rabbit’s uterus about the middle of pregnancy. They held that they were of connective tissue origin and probably pos- sessed a definite internal secretory function. Fraenkel was able to confirm their observations, but could not find similar structures in the human uterus. He was inclined to believe that they represented wan- Fig. 54.—Uterine Gland and Stroma. X 420. dering foetal cells, and was doubtful as to their secretory activity. Accordingly, the question must he regarded as sub judice until further investigations are available. Ligaments of the Uterus—Extending from either half of the uterus are three ligamentous structures—the broad, round, and uterosacral ligaments (ligamenta lata, teretia, and uterosacralia). The broad ligaments, or ligamenta lata, are two winglike structures which extend from the lateral margins of the uterus to the pelvic walls, and serve to divide the pelvic cavity into an anterior and a posterior compartment. Each broad ligament consists of a fold of peritoneum inclosing various structures within it, and presents four margins for examination—a superior, lateral, inferior, and median. The superior margin, for its inner two thirds, is occupied by the fallopian tube, while its outer third, extending from the fimbriated end of the tube to the pelvic wall, is known as the infundibulopelvic ligament—the sus- pensory ligament of the ovary (Henle)—and serves to transmit the ovarian vessels. The portion of the broad ligament beneath the fallopian THE FEMALE ORGANS OF GENERATION 48 tube is called the mesosalpinx, and consists of two layers of peritoneum which are united by a small amount of loose connective tissue, in which is embedded the parovarium or organ of Rosenmiiller (see Fig. 45). The parovarium consists of a number of narrow vertical tubules, lined with ciliated epithelium, which connect by their upper ends with a longitudinal duct, which extends just below the tube to the lateral margin of the uterus, in whose muscular wall it ends blindly at about the region of the internal os. This canal is the remnant of the wolffian duct, and in the female is designated as Gartner’s duct. The parovarium corresponds to the epididymis and is usually considered as the remains of the wolffian body. Waldeyer in 1870, however, showed that it repre- sents only the cranial portion of the latter, and designated it as the epoophoron, and suggested the term paroophoron for its caudal portion. The latter is the analogue of the organ of Giraldes, and according to the exhaustive work of Rielander is situated near the free end of the broad ligament between the terminal branches of the ovarian artery just before they enter the ovary. The paroophoron consists of a small num- ber of slightly convoluted tubules, lined by non-ciliated epithelium. The organ tends to disappear with advanc- ing years; and is of interest only from the fact that it occasionally gives rise to tumor formations. At the lateral margin of the broad ligament, its peritoneal covering is reflected upon the side of the pelvis. The inferior margin, which is quite thick, is continuous with the connective tissue of the pelvic floor. Through it pass the uterine vessels. Its lower portion—the cardinal ligament of Kocks, the ligamentum transversale colli of Mackenrodt, or the retinaculum uteri of Martin—is composed of dense connective tissue which is firmly united to the supravaginal portion of the cervix. The median margin is connected with the lateral margin of the uterus, and incloses the uterine vessels; through it certain muscular and con- nective-tissue bands extend from the uterus into the broad ligament. A vertical section through the uterine end of the broad ligament is triangular in shape, with the apex directed upward, while its base is broad and contains the uterine vessels; it is widely connected with the connective tissue of the pelvic floor, which is designated as the parame- trium. A vertical section through the middle portion of the broad liga- ment shows that its upper part is made up mainly of three branches in which the tube, ovary, and round ligament are situated, while its lower portion is not so thick as in the previous section. For further par- ticulars concerning the pelvic connective tissue the student is referred to the careful studies of Jung and Martin. Fig. 55.—Section through Uterine End of Broad Ligament, X %. THE UTERUS 49 The round ligaments, or ligamenta teretia, extend on either side from the anterior and lateral portions of the uterus, just below the insertion of the tubes. Each lies in a fold of the broad ligament and runs in an upward and outward direction to the inguinal canal, through which it passes, to terminate finally in the upper portion of the labium majus. The round ligament varies from 3 to 5 millimeters in diameter; it is composed of non-striated muscle, which is directly continuous with that of the uterine wall, and a certain amount of connective tissue. In the non-pregnant condition it appears as a lax cord, hut in pregnancy it undergoes considerable hypertrophy and seems to act as a stay for the uterus. It can be palpated during pregnancy, and by its varying position aids one in diagnosing the location of the placenta. The uterosacral ligaments—retractors uteri (Luschka)—are two structures which extend from the posterior and upper portion of the cervix, encircle the rectum, and are inserted into the fascia covering the second and third sacral vertebrae. They are likewise composed of connective tissue and muscle, and are covered by peritoneum. They form the lateral boundaries of Douglas’s culdesac, and are believed to play a part in retaining the uterus in its normal position by exerting traction upon the cervix. Position of the Uterus.—After many years of discussion, anatomists and gynecologists have agreed that the normal position of the uterus is one of slight anteflexion, and that the non-pregnant organ lies much deeper in the pelvic cavity than is usually realized. With the woman standing upright, it occupies an almost horizontal position and is somewhat bent upon its vesical surface, the fundus resting upon the bladder, while the cervix is directed backward toward the tip of the sacrum, with the external os about on the level of the ischial spines (see Fig. 26). The position of the organ varies markedly according to the degree of distention of the bladder and rectum, but when these are empty the uterus always tends to resume its normal position. The causes which bring about its anteflexed position have not as yet been definitely determined. Normally, as long as it is in situ, the organ is anteflexed, but when removed from the body it immediately straightens out. Schauta would attribute the anteflexion to the action exerted by the vessels when filled with blood, but his explanation does not appear altogether satisfactory. According to Nagel and most em- bryologists, the anteflexion exists from the earliest stages of develop- ment, and is to be accounted for by the fact that the entire body is developed along a curved line. The uterine ligaments were formerly supposed to play an important part in maintaining the uterus in its characteristic position. We have already indicated the functions of the round and uterosacral ligaments. The upper portion of the broad ligament appears to have no influence upon the position of the uterus, since Mackenrodt has demonstrated that it can be cut through without causing any change in position, which occurs only when its deeper portion—the ligamentum transversale colli—is divided. 50 THE FEMALE ORGANS OF GENERATION Blood Vessels of the Uterus.—The vascular supply of the uterus is derived from two sources: principally from the uterine, and to a lesser extent from the ovarian, arteries. The uterine artery is the main branch Fig. 56.—Blood Supply of Uterus (Kelly) of the hypogastric, which, after descending for a short distance, enters the base of the broad ligament, crosses the ureter, and makes its way to the side of the uterus. Just before reaching the supravaginal portion of THE UTERUS 51 the cervix, it divides into a larger and a smaller branch, the latter—the cervicovaginal artery—supplying the lower portion of the cervix and the upper portion of the vagina. The main branch turns abruptly up- ward and extends as a very convoluted vessel along the margin of the uterus, giving off a branch of considerable size to the upper portion of the cervix, and numerous smaller ones, which penetrate the body of the uterus. Just before reaching the tube it divides into three terminal branches—the fundal, tubal, and ovarian—the last of which anastomoses with the terminal branch of the ovarian artery; the second, making its way through the mesosalpinx, supplies the tube, while the fundal branch is distributed to the upper portion of the uterus. The ovarian or internal spermatic artery is a branch of the aorta and enters the broad ligament through the infundibulopelvic ligaynent. On reaching the hilum of the ovary it breaks up into a number of small branches which enter the organ, while its main stem traverses the entire length of the broad ligament and makes its way to the upper portion Fig. 57.—Radiograph of Thin Cross-section or Uterus Showing Arterial System (Sampson). of the margin of the uterus, where it anastomoses with the ovarian branch of the uterine artery. For further particulars concerning the vascular supply the student is referred to the comprehensive monographs of Freund, Farabeuf, and Kownatski. It is generally stated that there is very little communication between the vessels on the two sides of the uterus, but the experiments of Clark have demonstrated that such is not the case. This observer found that when the uterine artery on one side was injected the fluid escaped from the opposite uterine artery before it began to flow from the veins, thus indicating the presence of numerous arterial anastomoses in the sub- stance of the uterus. Figure 57 affords additional evidence of this fact, and shows how the radial branches of the arcuate arteries extend from the outer portion of the uterine wall to supply the endometrium. The veins of the uterus are very abundant and pursue a course the reverse of that of the arteries. When the uterus is contracted their lumina are collapsed, but when the musculature is relaxed the greater part of the uterine wall appears to be composed of venous sinuses as 52 THE FEMALE ORGANS OF GENERATION was pointed out by Sampson. The arcuate veins unite to form the uterine vein on either side, which then empties into the hypogastric vein, which makes its way into the internal iliac. The blood from the ovary and upper part of the broad ligament is collected by a number of veins, which form a large plexus within the broad ligament—the pam- piniform plexus—the ves- sels from which terminate in the ovarian vein. The right ovarian vein empties into the vena cava, while the left empties into the renal vein. Lymphatics. — The careful work of Leopold, Poirier, Bruhns, and others has given us a fairly defi- nite idea of the lymphatic system of the uterus. The endometrium is abundantly supplied with lymph spaces, but possesses no true lymphatic vessels. Immediately beneath it in the muscularis a few lymphatics may be found, which become better defined as the peritoneum is approached, and form an abundant lymphatic plexus just beneath it, especially on the posterior wall of the uterus. The lymphatics from the various portions of the uterus are connected with several sets of glands—those of the cervix terminating in the hypo- gastric glands, which are situated in the spaces between the external iliac and hypogastric arteries. The lymphatics from the body of the uterus are distributed to two groups of glands, one set of vessels making their way to the hypogastric glands, while another set, after joining certain lymphatics from the ovarian region, terminate in the lumbar glands, which are situated in front of the aorta at about the level of the lower portion of the kidneys (see Fig. 59). Innervation.—The nerve supply of the uterus is derived partly from the cerebrospinal, but principally from the sympathetic nervous system. The former is represented on either side by the pelvic nerve—nervus erigens—which consists of a few fibers derived from the fourth and fifth sacral nerves and loses itself in the plexus of Frankenhauser. The greater portion of the nerve supply, however, is derived from the sympathetic system, and consists of the hypogastric and Frankenhauser plexuses. Although first described in the eighteenth century by Walter and Haller, they were particularly studied by Lee and Frankenhauser, as well as by numerous later investigators, and particularly Dahl in 1916. The hypogastric plexus arises from the forking of the aortic plexus just below the promontory of the sacrum, and after descending into the pelvis loses itself in the Frankenhauser plexus on either side. The latter consists of a network of nerves along either margin of the uterus, and extends downward to the upper part of the vagina. It contains Fig. 58.—Radiograph of Thin Cross-section of Uterus Showing Venous System (Sampson). THE UTERUS 53 numerous ganglia of varying size, but particularly a large ganglionic plate situated a short distance from either side of the cervix. In an excellent gross anatomical study, Latarjet and Rochet state that the plexus is usually described as lying on either side of the cervix and in close proximity to it, whereas, in reality it lies posterior to it, and occupies the base of either uterosacral ligament. Fig. 59.—Lymphatics of Uterus (Kelly). Branches from these plexuses supply the uterus, bladder and upper part of the vagina, and are made up of both medullated and non- medullated fibers. Some of them terminate by free endings between the muscle fibers, while others make their way toward the free surface of the endometrium. According to Dahl no ganglionic cells are present in the walls of the uterus or tubes. Both the hypogastric plexus and the pelvic nerve contain motor and a few sensory fibers, whose functions are in great part antagonistic; the former causing muscular contraction and vasoconstriction, while the latter inhibits contraction and leads to vaso-dilatation. As the Franken- 54 THE FEMALE ORGANS OF GENERATION hauser plexus is derived from both sources it is apparent that it must partake of the properties of both types of nerves. Development of the Uterus.—It is universally admitted by embry- ologists that both the tubes and the uterus are derived from the miillerian ducts. According to His, the first signs of their development can be noted in embryos having a body length of from 7 to 7.5 millimeters, when a thickening may be noticed in the ccelomic epithelium on the outer Fig. 60.—Nerve Supply of Pelvic Organs (Dahl). A, plexus aorticus; B, plexus hypogastricus; C, Frankenhauser plexus; D, plexus pudendus et sacralis; E, nervus erigens; F, ganglion. margin of each wolffian body. These gradually become converted into two epithelial ducts, which converge and eventually meet together in the middle line, terminating in the urogenital sinus. The miillerian ducts reach the urogenital sinus in embryos having a body length of 2.5 to 3.5 centimeters. Their upper ends form the fallopian tubes, while their lower portions fuse together to form the uterus and vagina. The fusion of the miillerian ducts is usually com- pleted at about the third month, though the point at which the process is to occur is indicated at a much earlier period by the position of the round ligaments. LITERATURE 55 LITERATURE Ancel et Bouin. Sur 1’existence d’une glande myometriale endocrine, etc. Coniptes rendus de 1’assoc, des anatomistes, Paris, 1911. Bayer. Zur physiol, und path. Morphologie der Gebarmutter. Freund’s Gynako- logische Klinik, 1885, 369-662. Bruhns. Ueber die Lymphgefasse der weiblichen Genitalien. Archiv f. Anat. u. Physiol., Anat. Abtheil., 1898, 57. Championniere. Les lymphatiques uterines. Paris, 1875. Clark. The Causes and Significance of Uterine Haemorrhage in Cases of Myoma Uteri. Johns Hopkins Hospital Bulletin, 1899, 11-20. Dahl. Die Innervation der weiblichen Genitalien. Zeitschr. f. Geb. u. Gyn., 1916, lxxviii, 539-601. Duvelius. Zur Kenntniss der Uterusschleimhaut. Zeitschr. f. Geb. u. Gyn., 1884, x, 175-187. Engelman. The Mucous Membrane of the Uterus. Amer. Jour. Obst., 1875, viii, 30-86. Farabeuf. Les vaisseaux sanguins des organes genito-urinaires. Paris, 1905. Fischel. Beitrage zur Morphologie der Portio vaginalis uteri. Archiv f. Gyn., 1880, xvi, 192-202. Fraenkel. Untersuchungen fiber die sogenannte “glande endocrine myometriale.” Archiv f. Gyn., 1913, xcix, 225-230. Frankenhauser. Die Nerven der Gebarmutter. Jena, 1867. Freidlander, C. Phys. anat. Untersuchungen fiber den Uterus. Leipzig, 1870. Freidlander, F. Abnorme Epithelbildung im kindlichen Uterus. Zeitschr. f. Geb. u. Gyn., 1898, xxxviii, 8-16. Herlizka. Quoted by Joessel-Waldeyer, Das Becken. Bonn, 1899, 764. His. Die anatomische Nomenclatur. Leipzig, 1895. Hitschmann und Adler. Der Bau der Uterusschleimhaut des geschlechtsreifen Weibes, etc. Monatsschr. f. Geb. u. Gyn., 1908, xxviii, 1-81. Hoehne. Flimmerung im Gebiete des weibl. Genitalapparates. Zentralb. f. Gyn., 1908, 121-125. Hofmeier. Zur Kenntniss der normalen Uterusschleimhaut. Zentralbl. f. Gyn., 1893, 764-766. Johnstone. The Function and Pathology of the Reticular Tissue. Amer. Gyn. and Obst. Jour.,1896, ix, 166-187. Jung. Die Anatomie und Physiologie des Beckenbindegewebes. Martin’s Krank- heiten des Beckenbindegewebes, 1906, 1-49. Kocks. Die normale und path. Lage des Uterus, etc. Bonn, 1880. Kownatski. Die Yenen d. weibl. Beckens. Wiesbaden, 1907. Kreitzer. Anatomische Untersuchungen fiber die Muskulatur der nicht schwan- geren Gebarmutter. Petersburg, med. Zeitschrift, 1871, 113. Latarjet et Rochet. Le plexus hypogastrique chez la femme. Gyn. et Obst., 1922, vi, 225-243. Lee. On the Ganglia and Other Nervous Structures of the Uterus. London, 1842. Leopold. Die Lymphgefasse des normalen, nicht schwangeren, Uterus. Archiv f. Gyn., 1874, vi, 1-55. Studien fiber die Uterusschleimhaut. Berlin, 1878. Lusciika. Die Anatomie des Beckens. Karlsruhe, 1873. Mackenrodt. Ueber die Ursachen der normalen und path. Lagen des Uterus. Archiv f. Gyn., 1895, xlviii, 393-421. Mandl. Ueber die Riehtung der Flimmerbewegung im menschlichen Uterus. Zentralbl. f. Gyn., 1898, 322-328. 56 THE FEMALE ORGANS OF GENERATION Ueber das Epithel im geschlechtsreifen Uterus. Zentralbl. f. Gyn., 1908, 425- 429. Martin. Der Haftapparat der weibl. Genitalien. Berlin, 1911. Meyer. Ueber die fotale Uterussckleimhaut. Zeitschr. f. Geb. u. Gyn., 1898, xxxviii, 234-249. Minot. Human Embryology, 1892, 3. Nagel. Die weiblichen Geschlechtsorgane (Bardeleben’s Handbueh der Anatomie), Jena, 1896, 87-90. Parviainen. Zur Kenntniss der senilen Veranderungen der Gebarmutter. Berlin, 1897. Pick. Ueber das elastische Gewebe in der normalen und path, veriinderten Gebarmutter. Yolkmann’s Sammlung klin. Vortrage, N. F., 1900, Nr. 283. Poirier. Lymphatiques des organes genitaux de la femme. Paris, 1890. Ribemont-Dessaignes. Precis d’obstetrique. Paris, 1894, 30. Rielander. Das Paroophoron. Marburg, 1905. Roesger. Zur fcitalen Entwickelung des menschlichen Uterus. Festschrift zum 50-jahrigen Jubilaum der Gesell. f. Geb. u. Gyn. in Berlin, 1894, 9-52. Rosenmuller. Qusedam de ovariis embryorum et foetuum humanorum. Lipsias, 1802. Huge. Zur Erosionsfrage. Zeitschr. f. Geb. u. Gyn., 1882, vii, 231-233. Sampson. The Escape of Foreign Material from the Uterine Cavity into the Uterine Veins. Am. Jour. Obst., 1918, lxxviii. Schauta. Lehrbuch der gesammten Gynakologie. Wien, 1896, 5-14. Schroeder. Anat. Studien zur normalen und path. Physiologie des Menstrua- tionszyklus. Archiv f. Gyn., 1915, civ, 27-102. Tarnier. Traite de l’art des accouchements. Paris, 1888, T. I., 106. Veit. Uterusmuskulatur. Muller’s Handbueh der Geburtshiilfe, 1888, i, 122-129. Werth. Untersuchungen iiber die Regeneration der Schleimhaut nach Ausschabung der Uteruskorperhohle. Archiv f. Gyn., 1895, xlix, 369, 370. Zur Lehre von den Blutgefassen der normalen und kranken Gebarmutter. Jena, 1904. Werth und Grusdew. Untersuchungen iiber die Entwickelung und Morphologie der menschlichen Uterusmuskulatur. Archiv f. Gyn., 1898, lv, 325-413. Zeller. Plattenepithel im Uterus. Zeitschr. f. Geb. u. Gyn., 1885, xi, 56-88. THE FALLOPIAN TUBES The fallopian or uterine tubes are more or less convoluted muscular canals which extend from the uterine cornua to the ovaries. They are covered by peritoneum and possess a lumen lined by mucous membrane. They represent the excretory ducts of the ovaries, as it is through them that the ova gain access to the uterine cavity. They are more or less cylindrical in shape, and vary from 8 to 14 centimeters in length. For convenience in description, each tube may be divided into several parts—the uterine portion, isthmus, ampulla, and infundibulum. The uterine portion is included within the muscular wall of the uterus, and extends from the cornu to the upper angle of the uterine cavity. Its lumen is so small that it will admit only the finest probe. The isthmus is the narrow portion of the tube immediately adjoining the uterus, and gradually passes into the wider lateral portion or ampulla. The in- fundibulum, or fimbriated extremity, is the funnel-shaped opening of THE FALLOPIAN TUBES 57 the lateral end of the tube, the margins of which present a dentate ap- pearance (see Figs. 43 to 45, and Fig. 65). The tube varies considerably in thickness, the narrowest portion of the isthmus measuring from 2 to 3 millimeters, and the widest portion of the ampulla from 5 to 8 millimeters in diameter. With the exception of its uterine portion, the tube, throughout its entire length, is included within the upper margin of the broad ligament; it is completely surrounded by peritoneum except at its lower portion, corresponding to the mesosalpinx. The fimbriated extremity opens freely into the abdominal cavity, and one of its fimbriae—the fimbria Fig. 61.—Tubal Mucosa. X 280. ovaried—which is considerably longer than the others, forms a shallow gutter which extends almost or quite to the ovary. Generally speaking, the musculature of the tube is arranged in two layers—an inner, circular, and an outer, longitudinal layer. In its uterine portion a third layer, lying between the circular layer and the mucosa, and composed of longitudinal fibers, may be distinguished. In the lateral portion of the tube the two primary layers become less marked, and in the neighborhood of the fimbriated extremity are replaced by an interlacing network of muscle fibers. The writer was the first to call attention to the presence of the inner longitudinal layer in the uterine portion of the tube, and his observations have been generally confirmed. The lumen of the tube is lined with a mucous membrane whose epithelium is composed of a single layer of high, columnar cells, which rest upon a thin basement membrane (Fig. 61). According to Schaffer, only a portion of the cells are ciliated. These are arranged in discrete 58 THE FEMALE ORGANS OF GENERATION patches, while the non-ciliated cells are supposed to be secretory. Grosser, on the other hand, contends that the great majority are ciliated. There is no submucosa, the epithelium being separated from the under- lying muscle by a layer of connective tissue of varying thickness. Fig. 62. Fig. 63 Fig. 64. Figs. 62-64.—Sections through Uterine, Isthmic, and Ampullar Portions of Tube. X 15. THE FALLOPIAN TUBES 59 The mucosa is arranged in longitudinal folds which become more complicated as the fimbriated end is approached. Consequently, the appearance of the lumen varies according to the portion of the tube examined. In cross sections through the uterine portion four simple folds are seen, which together make a figure resembling a Maltese cross. In the isthmic portion a more complicated appearance can be noted; while in the ampulla the lumen is almost completely occupied by the arborescent mucosa, which upon careful examination is seen to be made up of four very complicated treelike folds (Fig. 65). The statements of Hennig and Bland-Sutton that the tube possesses glands have since been found to be erroneous, inasmuch as the structures, which they considered as such, are merely depressions between folds of the mucosa. This was conclusively demonstrated by Frommel, who showed that the glandular appearance disappeared upon distending the Fig. 65.—Longitudinal Folds of Tubal Mucosa (after Sappey). when the greater part of its lumen became perfectly smooth, with four arborescent folds of mucosa arising from its sides. It is interesting to note that Nature sometimes performs a similar experiment in cases of hydrosalpinx. The current produced by the cilia of the tube is directed from the fimbriated extremity toward the uterus, as was first demonstrated by the experiments of Pinner, Jani, and Lode, who showed that minute foreign bodies introduced into the abdominal cavity of animals eventually ap- peared in the vagina, after making their way down the lumen of the tubes and the cavity of the uterus* Contrary to the teaching of many that peristaltic muscular contraction is the main factor concerned in the downward passage of the ovum, Grosser contends that the ciliary current plays the principal part. The tubes are richly supplied with elastic tissue, blood vessels and lymphatics, and the latter sometimes become so dilated as to fill up almost entirely certain folds of the mucosa. Occasionally, as Eichard first pointed out, the tube may possess a second fimbriated extremity, which is known as an accessory ostium (Fig. 66). Again, small tubelike structures, with miniature fimbriated ex- tremities, frequently project from the exterior of the tube. As a rule, 60 THE FEMALE ORGANS OF GENERATION these are mere culdesac, but occasionally one is met with possessing a lumen which communicates with that of the main tube. In several instances of extra-uterine pregnancy has followed the arrest of the fer- tilized ovum in such a structure. Similar formations are frequently observed upon the anterior surface of the mesosalpinx, but have no connection with the tube. They have been studied more particularly by Kossmann, who designated them as accessory tubes. They are probably derived from aberrant portions of the ccelomic epithelium. In very exceptional instances there may be two tubes on one side, Bab having reported two cases of his own, together with five others collected from the literature. Diverticula may occasionally extend from the lumen of the tube for a variable distance into its muscular wall, and reach almost to its Fig. 66.—Tube with Accessory Ostium. peritoneal covering. Such structures were first described by Landau and Kheinstein and myself. The suggestion that they might play a part in the production of tubal pregnancy would seem plausible, inasmuch as a fertilized ovum, which might chance to make its way into such a diverticulum, would be arrested at its tip and there develop, if suitable conditions existed. In rare instances the main canal of the tube may branch, and two or even three lumina may be seen in sections. After extending for a cer- tain distance, more or less parallel to the main lumen, they usually rejoin it. It should always be borne in mind that such appearances are usually due to the fact that two or more twists or bends of the tube have been included in one section; although in several instances, by the use of the serial method, I have been able to demonstrate that more than one lumen really existed. In the new-born child the tubes are. markedly convoluted, and pre- sent a cork-screwlike appearance, as shown in Fig. 43. This gradually disappears with age, hut occasionally the foetal condition persists and may play a not unimportant part in the production of sterility and tubal disease, as was first pointed out by Freund and Schober. THE OVARIES 61 LITERATURE Bab. Ueber duplicitas tubse Fallopii. Areliiv f. Gyn., 1906, Ixxviii, 391-401. Ballantyne and Williams. The Histology and Pathology of the Fallopian Tubes. British Medical Journal, January 17 and 24, 1891. Freund. Ueber die Indicationen zur operativen Behandlung der erkrankten Tuben. Volkmann’s Sammlung klin. Vortrage, 1888, Nr. 323. Frommel. Beitrage zur Histologie der Eileiter. Verh. der deutschen Gesell. f. Gyn., 1886, 95. Grosser. Ovulation und Implantation und die Funktion der Tube beim Menschen. Archiv f. Gyn., 1919, cx, 297-327. Hennig. Ueber die Blindgiinge der Eileiter. Archiv f. Gyn., 1878, xiii, 156. Jani. Ueber das Vorkommen von Tube,rkelbacillen im gesunden Genitalapparat bei Lungenschwindsucht, etc. Virchow’s Archiv, ciii, 522. Kossmann. Ueber accessorische Tuben und Tubenostien. Zeitschr. f. Geb. u. Gyn., 1894, xxix, 253-268. Landau und Rheinstein. Beitrage zur path. Anatomie der Tuben. Archiv f. Gyn., 1891, xxxix, 273-290. Lode. Exp. Beitrage zur Lehre von der Wanderung des Eies vom Ovarium zur Tube. Archiv f. Gyn., 1894, xlv, 295-324. Mandl. Ueber den feineren Ban der Eileiter, etc. Monatsschr. f. Geb. u. Gyn., 1897, v. Erganzungs Heft, 130-140. Pick. Ein neuer Typus de3 voluminosen paroophoralen Adenomyoms. Archiv f. Gyn., 1897, liv, 117-206. Pinner. Ueber den Eintritt des Eies aus dem Ovarium in die Tube, etc. Archiv f. Anat. u. Phys., Physiol. Abth., 1880, 241. Richard. Pavilions multiplies. Gaz. Med. de Paris, No. 26, 1851. Schaffer. Ueber Bau u. Funktion d. Eileiterepithels. Monatschr. f. Geb. u. Gyn., 1908, xxviii, 526-542. Schober. Ueber Erkrankungen gewundener Tuben. D. I., Strassburg, 1889. Sutton. Glands of the Fallopian Tube and Their Function. Trans. London Obst, Soe., 1888, xxx, 207-213. Williams. Contributions to the Normal and Pathological Histology of the Fal- lopian Tubes. Amer. Jour. Med. Sciences, October, 1891. THE OVARIES General Anatomy.—The ovaries are two flattened, more or less almond-shaped organs, whose chief functions are the development and extrusion of ova, and the elaboration of an internal secretion. They may vary considerably in size, and during the child-bearing period measure from 2.5 to 5 centimeters in length, 1.5 to 3 centimeters in breadth, and 0.6 to 1.5 centimeters in thickness (see Fig. 45). After the menopause they diminish markedly in size, and in old women are often scarcely larger than peas. Normally, the ovaries are situated in the upper part of the pelvic cavity, one surface of each ovary resting in a slight depression in the upper portion of the inner surface of the obturator muscle—the fossa ovarica of Waldeyer. With the woman standing, the long axes of the ovaries occupy' an almost vertical position, which becomes horizontal 62 THE FEMALE ORGANS OF GENERATION when she is on her hack. Their situation, however, is subject to marked variations, and it is rare to find both ovaries at exactly the same level. Each ovary presents for examination two surfaces, two margins, and two poles. The surface which is in contact with the ovarian fossa is called the lateral, and the one directed toward the uterus is known as the median surface. The margin which is attached to the mesovarium is more or less straight, and is designated as the hilum, while the free margin is convex and is directed backward and inward toward the rectum. The extremities of the ovary are termed the upper and lower, or tubal and uterine poles respectively. The ovary is attached to the broad ligament by the mesovarium, which forms the posterior leaf of that struc- ture. The ovarian ligament extends from the lateral and posterior portion of the uterus, just beneath the tubal insertion, to the uterine or lower pole of the ovary. It is usually several cen- timeters long and 3 to 4 millimeters in diameter. It is covered by peritoneum, and is made up of muscle and connec- tive-tissue fibers, which are continuous with those of the uterus. The in- fundibulopelvic or suspensory ligament of the ovary extends from its upper or tubal pole to the pelvic wall. It rep- resents the portion of the upper margin of the broad ligament which is not occupied by the tube, and through it the ovarian vessels gain access to the broad ligament. For the most part the ovary pro- jects freely into the abdominal cavity, and is not covered by peritoneum ex- cept near its hilum, where a narrow band may be observed which is continuous with the peritoneum covering the mesosalpinx. It follows, therefore, that over its lower portion only can be noted the glistening appearance characteristic of peritoneum, while the greater part of its surface is of a dull white color and looks moist. This distinction was discovered by Farre, but its importance was first emphasized by Waldeyer (Fig. 72), who showed that the ovary above the peritoneal line was covered by cuboidal epi- thelium. In many of the lower animals, as in the rat, the ovary does not project freely into the abdominal cavity, but is inclosed in a peritoneal sac, into which opens the fimbriated end of the tube. In the cow, dog, and cat there is more or less free communication between the former and the peritoneal cavity. Fig. 67. — Cross - section Adult Ovary. X 4. THE OVARIES 63 The exterior of the ovary varies in appearance according to the age of the individual. In young women the organ presents a smooth, dull white surface, through which glisten a number of small, clear vesicles—- the graafian follicles. As the woman grows older it takes on a more corrugated appearance, which in the aged may become so marked as to be suggestive of the convolutions of the brain. The general structure of the ovary can best be studied in cross- sections, when the organ is seen to be made up of two portions: the cortex and medulla, or zona parenchymatosa and zona vasculosa. The cortex or outer layer varies in thickness according to the age of the individual, becoming thinner with advancing years. In this layer the ova and graafian follicles are situated. It is composed of spindle-shaped connective-tissue cells, through which are scattered primordial and graafian follicles in various stages of development, which become less numerous as the woman grows older. The most external portion of the cortex presents a dull whitish appearance, and is designated as the albuginea, though it is not analogous with the similarly named structure in the testicle; on its surface is a single layer of cuboidal epithelium— the ovarian epithelium of Waldeyer. The medulla or central portion of the ovary is composed of loose con- nective tissue, which is continuous with that of the mesovarium. It contains large numbers of blood vessels, both arteries and veins; and, according to His, Kollicker, and Rouget, a considerable number of non- striated muscle-fibers, whose presence caused the last-named observer to class it among the erectile tissues. The arrangement of the blood vessels has been studied exhaustively by Clark, to whose admirable mono- graph we would refer those interested in the subject. In the neighborhood of the hilum one occasionally observes short ducts or tubes, which are lined by a single layer of columnar epithelium. Their significance is not clear, and it is difficult to determine whether they represent remnants of the rete ovarii or of the wolffian bodies. In the human foetus collections of epithelial cells are frequently observed in the neighborhood of the hilum, which are arranged in masses or strands sharply marked off from the surrounding stroma. These are the medullary cords of Kollicker, who believed that they represented portions of the wolffian body which had become included within the ovary. The investigations -of Coert, Winiwarter, and other authorities have shown, however, that these cells represent the remains of the first proliferation of the germinal epithelium, and are analogous to the semi- niferous tubules of the testicle. In early embryos the lower extremities of the medullary cords develop lumina which eventually communicate with the tubules of the epoophoron (rete ovarii) (Fig. 71). In the female this is only a transient phenomenon, and usually disappears before birth; but in the male it persists and affords a satisfactory ex- planation for the employment of the wolffian ducts as the efferent channels for the testicles. On the other hand, the medullary cords are persistent and characteristic structures in many of the lower animals. Moreover, in many of the lower animals the medulla of the ovary is occupied to a variable extent by masses of characteristic epithelioid 64 THE FEMALE ORGANS OF GENERATION cells, somewhat resembling those making up the corpus luteum. Limon in 1901 called attention to their existence, and his findings were con- firmed by Bouin, Aime, and others. The origin of the cells is not clear, but, as they are supposed to take part in the formation of the internal secretion, they are sometimes designated as the interstitial gland of .the ovary. Strictly speaking, no such gland exists in women, and great confusion wTould have been avoided had many writers, who had no con- ception of the histological structure of the ovary, not allowed their imagination to run riot; as has happened in the case of Lipschiitz, in whose monograph it is described as the "puberty gland,” and every occur- rence in the sexual life of women, except fertilization, is attributed to it. The researches of L. Fraenkel, Schaeffer and Meyer confirm this view. On the other hand, Wallart, Aschner and Seitz have applied the term to the hypertrophic theca cells which develop about the periphery of follicles which are undergoing atresia, and Aschner has shown that such "interstitial glands” are not present in the nonpregnant adult woman, but are well marked before puberty and during pregnancy. They believe that these transient structures give rise to an internal ovarian secretion, and when present play an important part in the economy of the individual. The nerves of the ovary are derived in great part from the sympa- thetic plexus which accompanies the ovarian vessels—the so-called ovarian plexus, wdiile a few are derived from the plexus surrounding the ovarian branch of the uterine artery. Their finer anatomy, after they enter the ovary, has been studied by numerous investigators, among whom may be mentioned Yon Herff, Abel and Mcllroy, and Wallart. The consensus of these researches is that the ovary is very richly supplied with non-medullated nerve-fibers, which for the most part accompany the blood vessels, and are merely vascular nerves; whereas others form wreaths around normal and atretic follicles and give off many minute branches, which have been traced up to, but not through, the mem- brana granulosa. Elizabeth Winterhalter has described a collection of ganglionic cells in the medulla of the ovary which she designates as the ovarian ganglion; while Dahl is equally positive in denying their presence. Accessory Ovaries.—Waldeyer, in 1870, directed attention to the oc- casional presence of accessory bodies which are sometimes found on the broad ligament in the neighborhood of the main ovary. These structures are usually small, although in rare instances they may attain a consider- able size. Occasionally they result from faulty development, but more frequently are to be attributed to inflammatory changes occurring during foetal life, as a consequence of which small portions of the ovary have been cut off from the body of the organ. The subject has been con- sidered in detail by Engstrom, Thumin, Seitz, and Chiari, and cases have been described in which there was found a typical third ovary con- nected with the uterus by a separate tube. Transplantation of Ovaries.—Experimental studies undertaken by Grigorieff, Knauer, Marshall, and others have shown that the ovaries of animals and women may be excised from their original position and THE OVARIES 65 transplanted to other portions of the body, or even into other animals of the same species, and that in their new situation they can establish vascular connections and continue their functional activity. Pregnancy has repeatedly followed such operations in animals. For full literature upon the subject up to 1922 the reader is referred to the article of l1'. II. Martin, in which it is stated that the results in women have been disappointing, and that while satisfactory results sometimes follow auto- transplantation, there is little evidence in favor of homotransplantation and none in support of hetero-transplantation. Internal Secretion.—From the time that Brown-Sequard published his studies upon the internal secretion of the testicles, it has been more or less generally believed that the ovaries likewise elaborate a somewhat analogous product, which plays an important part in the female economy. Indeed, the work of Knauer, Mandl, Burger, and others indicate that this secretion is directly concerned in maintaining the integrity of the other generative organs; inas- much as they have shown that atrophy of the uterus and vagina rapidly fol- lows the removal of the ovaries, whereas this does not occur when they are removed from their normal position and transplanted to other portions of the body. They therefore conclude that in such cases the absence of atrophy must be attributed to the action of the internal secretion of the transplanted ovaries, since all nerve connections were severed at the time of operation. Frankel in 1903, and again in 1910, as the result of ingenious experi- ments and clinical work, stated that the internal secretion is elaborated in the corpus luteum. Notwithstanding considerable initial opposition, his views have obtained wide acceptance, and it is now generally believed that the structure has important secretory functions. Clinical observa- tion also lends support to such a view, as in various conditions, which are supposed to be associated with deficient ovarian secretion, more striking therapeutic results follow the administration of tablets com- posed entirely of corpus luteum substance than when the desiccated tissue of the entire ovary is employed. Reference has already been made to the so-called “interstitial gland,” and if the theca, which are Fig. 68.—Section through Wolffian Body and Beginning Ovary and Mullerian Duct (Wal- deyer). X 160. A.W., abdominal wall; C.E., germinal epithelium; M.D., beginning miillerian duct; 0., beginning ovary; P.O., primordial ova; W.B., wolffian body. 66 THE FEMALE ORGANS OF GENERATION so designated, elaborate an internal secretion it must be closely related to that product by the corpus luteum. Development of the Ovary.—An accurate idea of the structure of the ovary can be gained only through the study of its development. To Waldeyer we are indebted for much of our knowledge concerning the subject, though important preliminary work had been done by Aral- entin and Pfliiger. In 1870 Waldeyer published his monograph upon the Ovary and Ovum (Eierstoch und Ei) and, although subsequent investigation has invalidated many of his conclusions, it must be regarded as the founda- tion of our knowledge of the subject. His work, which was based in great part upon the embryology of the chicken, showed that by the fourth day of development the coelomic epithelium covering the inner surface of the wolffian body is differentiated from the surrounding tissue, its cells becoming larger and more cuboidal in shape, and some of them assuming a considerable size. Within a short time the epithelium proliferates to such an extent as to form a distinct elevation, which in- dicates the situation of the future ovary (Fig. 68). This epithelium Waldeyer designated as germinal epi- thelium and the large, clear cells found within it as primordial ova. As the pro- liferation continues, a mass of cells is formed consisting of large primordial ova and smaller epithelial cells. By the upward growth of the connective tissue and blood vessels from the wolffian body, the epithelial masses become divided into smaller portions, the so-called egg-nests or Pfiiiger’s tubes, which in turn become broken up into smaller and smaller masses, until eventually isolated primordial ova are found, which are surrounded by a single layer of more or less flattened epithelium. These represent the primordial follicles. Thirty-one years later, however, Waldeyer stated that the process was not so simple, and the work of Nagel, Wendeler, Winiwarter, Skrobansky, and Mcllroy clearly shows that in the higher animals, at least, the process of development is quite different. In either sex, the first trace of the sexual glands is found in a thickening of the epi- thelium on the inner surface of the wolffian body. These primitive sex cells rapidly proliferate and give rise to a distinct elevation, made up of closely packed undifferentiated epithelial cells, which are covered by a single layer of cuboidal cells arranged perpendicularly to the surface of the mass. The latter correspond to the future ovarian epithelium and take no part in the formation of ova and follicles (Fig. 69). The cells of the primitive sex gland proliferate rapidly and invade the underlying stroma of the wolffian body, so that a cortical and medul- Fig. 69.—Sex Giand of Pig Embryo, 1.2 cm. long (Skrobansky). THE OVARIES 67 lary portion can be distinguished at an early period. The epithelial cells soon become broken up into irregular masses by the upgrowth of connective tissue and have little or no connection with the surface epithelium. The most deeply lying cells do not become differentiated, but extend downwards as solid cords—the medullary cords. These terminate in a series of epithelial tubes—the so-called rete ovarii, which in turn communicate with the wolffian body tubules. In the female this is a transient condition, which dis- appears early in foetal life, but in the Fig. 70.—Cortex of Pig Embryo, showing Ger- mnal Epithelium, Pfluger’s Tubes with Oocytes in Various Stages of Development 'Skrobansky). Fig. 71.—Diagram showing Forma- tion of Ovary (Winiwarter). 1, germinal epithelium; 2, germ tube; 3, medullary cord; 4, rete ovarii; 5, epoophoron male it is permanent and affords a ready explanation for the utilization of the wolffian ducts as the efferent channels of the testicles (Fig. 71). The more superficial cells become arranged in irregularly shaped masses, continue to proliferate, and soon show signs of differentiation. Many become large cells with prominent clear nuclei, whose chromatin takes on a different arrangement, while others retain their original appearance. The former are the oogonia, from which the ova are to be developed, while the latter give rise to the follicular epithelium. 68 THE FEMALE ORGANS OF GENERATION After a certain period the oogonia cease proliferating, when the resulting cells become larger, and their chromatin undergoes a series of complicated changes, which eventually lead to the formation of the reticulated nucleus of the primordial ovum or oocyte of the first order (Fig. 70). By the continued growth of connective tissue the masses of oocytes and undifferentiated epithelial cells become still further broken up, so that eventually each oocyte is surrounded by a single layer of flattened cells, thus giving rise to a primordial follicle. That there is no essential difference between the differentiated and undifferentiated cells is shown by the fact that the cells of the medullary cord, which are of the latter variety, may develop into typical oocytes; Fig. 72.—Ovary of New-born Girl. X 22. these, however, do not give rise to primordial follicles, but degenerate vn situ. It would thus appear that the primordial ova or oocytes do not develop from the surface epithelium, but rather from the undifferentiated cells of the primitive sexual glands. This process has been observed by all recent investigators in rabbits, pigs, and human beings. In the latter the formation of oocytes ceases before birth, but in some of the lower animals, especially in the bat, the process may continue throughout life. At birth the greater part of the ovary consists of the cortex, which is made up of closely packed primordial follicles, which are separated from one another by very thin bands of connective tissue, although occasionally small groups of follicles may be in direct contact (Figs. 72 and 73). At this period the surface of the ovary is covered by a single layer of cuboidal epithelium which shows no signs of proliferation. All authorities agree that the primordial ova are derived from the primary sex cells, but there is still considerable discussion as to the origin of the epithelium surrounding them. According to Waldeyer THE OVARIES 69 and most other observers, the follicular epithelium is derived from the cells of the germinal or sexual epithelium, which have not been con- verted into oocytes. Kollicker, on the other hand, believed that it originated from the epithelium of the wolffian bodies, and that the medullary cords in the adult ovary represented portions which had not been utilized in this way. Foulis, in 1878, stated that the so-called follicular epithelium was derived from the connective tissue of the ovary, and later studies by Wendeler and Clark would seen to confirm this view. Waldeyer’s teachings, however, have obtained almost universal ac- Fig. 73.—Cortex of Ovary at Birth showing Primordial Follicles. X 300, ceptance, and are placed beyond all reasonable doubt by the work ot Winiwarter and Mcllroy, so that it would seem advisable to dismiss Foulis’s theory as untenable. In rare instances the surface epithelium of the ovary may be ciliated, and now and again, as has been pointed out by Yon Yelits and myself, the follicular epithelium may likewise be found to possess cilia. These observations, in spite of their rarity, speak strongly against the con- nective-tissue origin of the follicular cells. Microscopic Structure of Ovary.—From the first stages of its develop- ment until after the menopause the ovary is undergoing constant change. According to Waldeyer, each ovary at birth contains at least 100,000 oocytes, the majority of which disappear' before the age of puberty; so that at that time only 30,000 to 40,000 remain, and these disappear during the following thirty years. That this is a moderate estimate is 70 THE FEMALE ORGANS OF GENERATION shown by the fact that Haggstrom was able to count 400,000 follicles in the ovaries of a twenty-two year old woman. As only one ovum is ordinarily east off each month, it is apparent that a few hundred ova would suffice for the purposes of reproduction. The mode by which the others disappear will be considered when we take up the study of the corpus luteum and follicular atresia. Before considering the evolution of the mature follicle, it may be well to mention certain historical points in connection with it. The graafian follicle was first described in 1672 by De Graaf, a physician of Delft, who not only observed the vesicles, but demonstrated the pres- ence of ova in the tubes of rabbits. The human ovum was first recog- nized by Yon Baer in 1827, its nucleus or germinal vesicle by Purkyne in 1830, and its nucleolus or germinal spot a few years later by Wagner. In 1891 Boveri pointed out that the nomenclature usually employed in connection with the specific cells of the ovary was faulty. He con- tended that the terms ovum and egg are synonymous, and should there- fore be restricted to cells which are ready for fertilization. As this is the case only after the completion of maturation and the casting off of the polar bodies, he suggested that other terms be employed prior to that period. Accordingly, he designated the cells during the stage of division as oogonia, from then until maturation begins as oocytes of the first order, after the formation of the first polar body as oocytes of the second order, and as ova only after the formation of the second polar body. In the young child the greater portion of the ovary is composed of the cortex, which is filled with large numbers of closely packed primor- dial follicles, those nearest the central portion of the ovary showing the most advanced stages of development. In young women the cortex still contains large numbers of primordial follicles separated by thicker bands of connective tissue, which is made up of cells with spindle- shaped or oval nuclei. Each primordial follicle consists of an oocyte and its surrounding single layer of flattened epithelium. The oocyte is a single large cell, more or less round in shape, with a clear protoplasm and a tolerably large nucleus occupying its central portion. The nucleus presents a marked reticulated network and at one point a well-defined nucleolus, as well as numerous accessory nucleoli, which are formed at the intersections of the nuclear thread-work. According to Nagel, the oocyte remains constant in size from birth until the beginning of the transformation of the primordial into the typical graafian follicle, no matter at what period of life this change may occur. These primordial ova, or oocytes of the first order, measure from 48 to 69 microns, and their nuclei from 29 to 32 microns in diam- eter. The oocyte is surrounded by a single layer of small, spindle- shaped epithelial cells, which are somewhat sharply differentiated from the still smaller spindle-shaped cells of the surrounding stroma (Fig. 74). Occasionally a primordial ovum may contain two nuclei or germinal vesicles, as has been shown by Nagel, Klein, von Franque, and others. Again, occasionally two and sometimes three distinct ova may be found THE OVARIES 71 in a single primordial follicle, and it is from such structures that multiple pregnancies were formerly supposed to develop. When, under the influence of factors with which we are as yet un- acquainted, the primordial follicle begins to develop, we notice in the first place that its epi- thelium becomes converted into a single layer of cuboidal cells (Fig. 74). Nuclear figures soon make their appearance, and the cells begin to proliferate rapidly, so that in a very short time the ovum be- comes surrounded by a number of layers of epi- thelial cells. Certain of these cells undergo degen- eration, and vacuolated areas are not infrequently observed between them. This process continues until a considerable por- tion of the follicle is filled with fluid, which is formed partly by the degeneration of the follicular cells and partly by transudation from surrounding vessels. Coincident with the development of the fluid, the so-called liquor foUiculi, the ovum becomes pushed to one side of the follicle, where it is surrounded by a mass of cells—the discus proligerus or Fig. 74.—Ovary of Young Woman, showing Pri- mordial Follicles on Left Side and Follicle JUST BEGINNING TO DEVELOP ON RlGHT. X 210. Fig. 75.—Developing Follicle. X 210. Fig. 76.—Developing Follicle. X 210. cumulus obphorus—while the rest of the epithelium is arranged in a number of layers around the interior of the follicle, and is known as the membrana granulosa (Fig. 77). While these changes are taking place, the ovum itself becomes larger, important changes take place in its nucleus preparatory to the formation of the first polar body, yolk granules, or deutoplasm, are deposited in its 72 THE FEMALE ORGANS OF GENERATION protoplasm, and a thin, transparent structure—the zona pellucida—ap- pears about its periphery. At the same time, the stroma immediately surrounding the growing follicle becomes vascular, and its cells show marked evidences of proliferation. The membrana granulosa is sep- arated from the stroma by a thin basement membrane consisting of a single layer of flattened, spindle-shaped, connective-tissue cells. Just between the basement membrane and the outermost layer of the mem- brana granulosa there not infrequently appears a thin, transparent layer, AK AV. v. • Fig. 77.—Follicle Approaching Maturity. X 210. D., discus proligerus; M.G., membrana granulosa; T.ex , tunica externa; T.int., tunica interna. which was first described by Grohe and Slavjansky. This, no less than the zona pellucida, is a species of exudate from the granulosa cells. Mature Graafian Follicle.—From birth until the cessation of sexual life, graafian follicles are constantly being developed. Before the age of puberty they are found only in the deeper portions of the cortex, and do not reach the surface of the ovary; later, however, they develop in the superficial portions of the cortex and make their way to the surface, where they appear as transparent vesicles, varying from a few to 10 or 12 millimeters in diameter. As the follicle approaches the surface of the ovary its walls become thinner and more abundantly supplied with vessels, except in its most prominent projecting portion, which appears THE OVARIES 73 almost bloodless and is designated as the stigma, the spot where rupture is to occur. The mature graafian follicle consists of a connective-tissue covering —the theca folliculi; an epithelial lining—the membrana granulosa; the ovum, and the liquor folliculi. The theca folliculi is readily divided into two layers: an outer, the tunica externa, and an inner, the tunica interna. The tunica externa consists of the ordinary ovarian stroma, which is arranged concentrically about the follicle, while the connective- tissue cells of the tunica interna have undergone marked change. Almost as soon as the primordial follicle shows signs of development, nuclear figures appear in the stroma immediately surrounding it, and a Fig. 78.—Section theougii Wall of Mature Follicle (Highly magnified). M.G., membrana granulosa; T.I., tunica interna; T.E., tunica externa. considerable multiplication of cells occurs. These become considerably larger than the surrounding connective-tissue cells, and as the follicle in- creases in size assume a granular appearance, which is due to the presence of a yellowish pigment. These cells are designated as lutein cells and, as will be seen later, play an important part in the formation of the corpus luteum, as well as in the process of follicular atresia. In most hardened specimens the coloring matter has been dissolved out, and the cells appear not unlike those of the suprarenal capsules (see T. I., Fig. 78). At the same time there is a marked increase in the vascularity of the theca, and numerous lymphatic spaces make their appearance. The epithelial lining of the follicle, or membrana granulosa, consists of a number of layers of small polygonal or cuboidal cells, with round, darkly staining nuclei, which are arranged in fewer layers the larger the follicle. At one point the memhrana granulosa is much thicker than elsewhere, and forms a more or less pyramidal mound in which 74 THE FEMALE ORGANS OF GENERATION the ovum is included. This is the discus proligerus or oophorus, and is usually situated at the portion of the follicle farthest removed from the surface of the ovary (see Fig. 77). The follicle is filled with a clear, albuminous fluid, the liquor folliculi, which is partly the product of the degenerated follicular epithelium and partly a transudate from sur- rounding vessels. As the follicle approaches its highest development, its epithelium undergoes fatty degeneration, as can he demonstrated -by appropriate technique. As the ovum approaches maturity, it becomes the largest cell in the body, and, according to Nagel, measures from 150 to 250 microns (1/5 Fig. 79.—Mature Human Ovum. X 480. Carnegie Laboratory. millimeter) in diameter, as compared with 48 to 69 microns in its primordial condition; while Jackson estimates that it weighs 0.000004 gram. If the nearly mature ovum be examined in the liquor folliculi or in normal salt solution, the following structures, may be distinguished in and about it: (a) a corona radiata; (b) a zona pellucida; (c) a perivi- telline space; (d) a small, clear zone of protoplasm; (e) a broad, finely granulated zone of protoplasm; (/) a central, deutoplasmic zone; and (g) the germinal vesicle with its germinal spot. The corona radiata consists of a number of layers of follicular epithe- lium which adhere to the ovum, and was so designated by Bischoff, by whom it was first described. Inside of the corona radiata comes a nar- row, transparent zone—the zona pellucida—which is a product of the THE OVARIES 75 granulosa cells, and does not belong to the ovum itself. Separating the ovum from the zona pellucida is a clear, narrow space, the perivitelline space, within which the ovum is freely movable, so that no matter what position it may assume its germinal vesicle will always point upward. Inside of the perivitelline space is the ovum proper, which differs from the primordial oocyte, not only by its increased size, but more especially by the presence of a yolk or deutoplasm, which fills the greater part of its interior. The deutoplasm occupies the central portion of the ovum, and is made up of large numbers of irregularly shaped, highly refractive gran- ules. As it develops it pushes the germinal vesicle to one side, so that the latter always assumes an eccentric position in the ovum. Outside of the deutoplasm comes a narrow zone of finely granular protoplasm, which owes its peculiar appearance to the presence of very small yolk-granules; external to this, again, is a still narrower zone of clear protoplasm. The nucleus or germinal vesicle presents a distinct reticular, nuclear network, the intersections of which appear as very darkly staining points. The nucleolus or germinal spot is much larger than in the primordial ovum, and according to Auerbach presents ameboid movements. An ovum presenting the above characteristics is generally described as mature, but is not capable of fertilization and further development until it has undergone certain changes, which are designated as matura- tion, and manifested by the formation and casting off of the polar bodies. Graafian follicles, as we have already pointed out, develop through- out childhood, and occasionally attain a considerable size; but they rarely rupture at this time on account of their position in the depths of the ovary and the intervention of a thick layer of cortex between them and the surface. In adults, on the other hand, the developing follicle makes its way to the surface, and when it has attained its highest development ruptures and extrudes its ovum into the peritoneal cavity or the tube, where it may be fertilized. Formerly it was believed that rupture of the follicle was brought about by the increased tension resulting from the rapid formation of the liquor follieuli. Clark, however, has shown that rupture of the follicle is a complex process, and is due primarily to circulatory changes. As the period of ovulation approaches, the ovary becomes engorged with blood and, the intra-ovarian tension being markedly increased, the grow- ing ovum is forced to the surface; at the same time the circulation in the most distended portion of the wall of the follicle is interfered with, whence results necrosis at the point designated as the stigma, which eventually gives way. Corpus Luteum.—The corpus luteum is a structure which is formed at the site of a ruptured follicle. When the mature follicle ruptures, the ovum, liquor follieuli, and a considerable portion of the degenerated membrana granulosa make their escape, and the walls of the empty follicle collapse. In a short time, however, its cavity becomes filled with blood, which is derived partly from the vessels at the point of rupture, but principally from those of the tunica interna of the theca. 76 THE FEMALE ORGANS OF GENERATION The corpus luteum, therefore, in its earliest stages is simply a rup- tured follicle filled with blood, outside of which is a narrow yellow ring formed by the so-called lutein cells. These, however, proliferate rap- idly and invade the blood-filled follicle, forming a festooned layer about its central blood clot (Fig. 80). This layer is yellowish in color, whence the term “corpus luteum/’ As the structure becomes older, the yellow ring becomes thicker and thicker, until at last it almost entirely fills the interior of the follicle, the central blood clot remaining being now quite small. At its period of greatest development, namely, about 14 days after rupture, the corpus luteum is always larger than the original follicle, Fig. 80.—Portion of Ovary, showing a Corpus Luteum of Pregnancy, with Cystic Center. X 4. B.C., blood clot; C.F., corpus fibrosum; F., graafian follicles; L.C., lutein cells. and occupies a considerable portion of the ovary, sometimes as much as one-third of the entire organ. Microscopic sections through a well-developed example show that its center is occupied by a compressed blood clot, immediately outside of which is a thin layer of newly formed connective tissue. The greater part of the structure, however, is occupied by the festooned yellow ring, which is made up of large, polygonal, epithelioid cells, with small, round, somewhat faintly staining nuclei. These are the lutein cells•, whose protoplasm has taken on a granular appearance due to the pres- ence of a peculiar yellow pigment which is soluble in chloroform, alcohol, and ether. According to Escher, the pigment is chemically identical with carotin—the coloring matter found in carrots. Corner, THE OVARIES 77 who has carefully studied the cytology of the lutein cell in the pig, reports that it is unusually complicated. The layer of lutein cells is traversed by numerous radiate, tolerably thick, connective-tissue par- titions, to which it owes its festooned appearance. They are richly supplied with blood vessels and lymphatics (Fig. 81). As the cavity of the follicle is encroached upon by the growing lutein cells, the blood clot becomes more and more compressed, and vascular loops extend into it and soon cause its organization. At the same time, the blood pigment is removed by leukocytes, which can be found in the surrounding tissue with their bodies filled with particles Fig. 81.—Section through Yellow Layer of Corpus Luteum, showing Lutein Cells of it. Occasionally hemorrhage does not take place into the ruptured follicle, and a corpus luteum is formed 'without a central blood clot. This is the exception in human beings, but the rule in many of the lower animals. After the cavity of the follicle has become obliterated by the in- growth of the lutein cells and connective tissue, degenerative changes soon make their appearance in the former, some of which undergo hyaline, and others fatty, degeneration. In young women, in whom the circulation is active, the degenerated lutein cells are rapidly absorbed, so that in a short time the corpus luteum becomes replaced by newly formed connective tissue which corresponds closely in appearance to the surrounding ovarian stroma. But in more advanced life, when the ovarian circulation has become impaired, absorption goes on less rapidly; and not infrequently the degeneration extends to the intervening con- nective tissue and blood vessels until the entire structure is converted into an almost homogeneous mass of hyaline in which only a few con- 78 THE FEMALE ORGANS OF GENERATION nective-tissue cells and degenerated blood vessels can be seen (Pig. 82). These structures—the so-called corpora fibrosa or albicantia—present on fresh section a dull white appearance, somewhat suggestive of old scar tissue. They are, however, gradually invaded by the surrounding Fig. 82.—Corpus Fibrosum. X 75. stroma, and become broken lip into smaller and smaller hyaline masses, which are eventually absorbed, the site of the original follicle being indicated only by an area of slightly thickened connective tissue. When the circulation is very defective, absorption takes place much more slowly, so that it is not uncommon to find the ovaries of women near the menopause almost filled by corpora fib- rosa of varying size. Frequently the small hyaline bodies result- ing from the breaking up of these structures assume peculiar and bizarre forms, and very often present a curved and twisted ap- pearance suggestive of a degenerated artery (Fig. 83). Similar structures are sometimes left after the obliteration of non-ruptured follicles. Practically all authorities are agreed as to the life-history of the corpus luteum, and the only point which still remains unsettled deals with the origin of the lutein cells. The earlier observers considered that the changes were analogous to the organization of a blood clot which Fig. 83.—Later Stage of Corpus Fibrosum. X 75. THE OVARIES 79 was followed by the formation of cicatricial tissue, but at present this view possesses only an historical interest. Many investigators believe that the lutein cells are of connective- tissue origin and represent the cells of the theca interna. This view was first advanced by von Baer, and has been confirmed by the work of Kollicker, His, Beigel, Nagel, Clark, Waldeyer, Hegar, and many others. A number of more recent authors, on the other hand, following the example of Bischotf, consider that they originate from cells derived from the membrana granulosa. This explanation has been advocated more particularly by Sobotta, and has received additional support from the work of Marshall, Meyer, Huge, Miller and others. These in- vestigators claim that immediately following the rupture of the follicle, the cells of the membrana granulosa, instead of being exfoliated as was previously taught, rapidly proliferate, soon fill the cavity, and become the true lutein cells. While they do not deny that the cells of the tunica interna of the theca undergo pronounced changes, they contend that they play no part in the production of the corpus luteum, and designate them as theca lutein cells, as contrasted with the granulosa lutein cells. Corner, on the other hand, in the sow and Evans in the rat believe that both types of cells are involved; and, while those derived from the membrana granulosa are at first more numerous, those derived from the theca persist for a longer period. Up to a few years ago, I was convinced of the connective-tissue origin of the lutein cell, and even now I am not prepared to admit that I was entirely in error, but the proof adduced by Corner is so strong that I am prepared to concede that the lutein cell may have a double origin, and be derived from the proliferating membrana granulosa, as well as from the theca. Strong support in favor of the connective-tissue origin of the lutein cell is to be obtained from the changes observed in the great majority of follicles, which degenerate in situ without rupture. This process has been studied by a number of observers, notably Slavjansky, Schott- lander, Clark, Stevens, Seitz and others, and is designated as follicular atresia. In such circumstances, precisely the same proliferation of theca cells is observed as in the formation of the corpus luteum, except that hemorrhage is absent and that the process is less pronounced. After the follicle has attained a certain size, the ovum undergoes cytolysis*and with the entire membrana granulosa is separated from the wall of the follicle, and lies free in its cavity, undergoing degenerative changes and eventual absorption, while the cells of the theca are actively proliferating and are being converted into lutein-like cells. Eventually, the walls of the follicle collapse, the tissue composing it undergoes fatty and hyaline changes, so that later an irregularly twisted hyaline body results, which can not be distinguished from a similar structure derived from a corpus luteum, or even from a degenerated vessel. Moreover, the spontaneous involution of the large lutein cell cysto- mata, which frequently accompany hydatidiform moles, would seem to offer additional evidence in favor of the connective-tissue origin of the cells in question. Were they epithelial, such an outcome would be un- 80 THE FEMALE ORGANS OF GENERATION likely, as epithelial cysts generally tend toward enlargement rather than retrogression. One function of the corpora lutea is to bring about the obliteration of the spaces left by the ruptured follicles without the formation of cicatricial tissue; for if they healed by the latter process it is evident that in a very short time the entire ovary would be converted into a mass consisting of nothing but scar tissufe, the very nature of which would effectually prevent further ovulation. It has been estimated by Clark that if each follicle healed in this manner, and if ovulation could continue under such conditions, a fibroma would eventually be produced 3,000 times as large as the original ovary. Fraenkel, in 1903, advanced the theory that the chief function of the corpus luteum is to elaborate a secretion which regulates the blood supply of the uterus, and thus controls the process of menstruation, as well as the formation of the decidua and the implantation of the ovum. He elaborated his theory in 1910 by numerous additional experiments upon rabbits, and some upon women. In the latter he found that the next succeeding menstrual period failed to occur when the corpus luteum had been destroyed by means of a cautery, which might readily be done without danger during the course of a simple operation, such as sus- pension of the uterus. Fraenkel’s second contribution was very con- vincing, and, as has already been indicated, it is now generally believed that the structure should be regarded as a temporary gland of internal secretion. . It would lead too far afield to discuss the voluminous literature upon the subject, and it must suffice to state that certain investigators have even gone so far as to claim that they have succeeded in isolating from the corpus luteum substances which produce a specific effect when injected into animals. Thus, Seitz and Wintz state that they have isolated from early and late corpora lutea of the cow, respectively, two substances possessing different physiological properties. From the former they obtained lipamin, which they claim causes swelling of the endometrium, and from the latter luteolipoid which checks bleeding. It is usual to distinguish between true and false corpora lutea— namely, those following impregnation and menstruation respectively. This distinction is based entirely upon their relative size, and not upon any inherent anatomical difference, as they both present exactly the same structure, the larger size of the so-called true corpus luteum being simply due to the increased vascular supply incident to pregnancy. J. W. Miller stated in 1914 that the two varieties could be easily differentiated by histological and microchemical methods. He held that neutral fat could not be demonstrated in the corpus luteum of pregnancy until after delivery, but that areas of colloid and of calcification soon appear; while in the corpus luteum of menstruation fat is readily demonstrable, but colloid and calcification is absent. I have no experience with these criteria, but Corner has pointed out that in the sow fat is constantly present in the former. Not infrequently the corpus luteum of pregnancy contains in its center a small cyst filled with clear fluid, the walls of which are com- LITERATURE 81 posed of connective tissue, outside of which are the typical lutein cells. Such cysts are due to the liquefaction of the central blood clot (see Fig. 79). In rare instances the corpus luteum, instead of disappearing in the manner just described, may be the starting point of cystic formations, to which attention was first directed by Eokitansky, and with which every gynecologist is now familiar. The corpus luteum was first described by De Graaf as a conglomer- ate glandular body, and was considered by him and all earlier authori- ties as positive evidence of previous childbearing. Moreover, it was generally believed that the number of children which a woman had borne could readily be estimated by counting the number of corpora lutea in her ovaries. This view was held for many years, and was so firmly established, even at the end of the eighteenth century, that such eminent authorities as Abernethy, Sir Astley Cooper, and Denman had no hesi- tancy in swearing in a medicolegal case that a woman had been preg- nant because a corpus luteum was found in one ovary. Even after the more frequent performance of autopsies, and the closer attention directed to the condition of the ovaries had led to the abandonment of this view, it was for a time believed that the presence of corpora lutea indicated that the individual had indulged in sexual relations, or had at least been under marked sexual excitement. • Finally, as a result of the worfe of Bischoff, llaciborski, Negrier, and Pouchet (1840- 47), it was definitely established that a corpus luteum developed after each menstrual period in virginal as well as married women. For fuller information on this point the works of Montgomery and Dalton may be consulted. LITERATURE Abel and McIlroy. The Arrangement and Distribution of the Nerves in Certain Mammalian Ovaries. Proc. Roy. Soc. Med., 1913, vi, Obst. and Gyn. Sect., 240-247. Aim£:. Recherches sur les cellules interstitielles de 1 ’ovaire, etc. Arch, de Zoologie exp. et gen., 1907, 4me ser. vii, 95-113. Auerbach. Quoted by Nagel. Aschner. Die Blutdriisen-erkrankungen des Weibes. Wiesbaden, 1918. von Baer. De ovi mammalium et hominis genesi. Leipzig, 1827. Beigel. Zur Naturgeschichte des Corpus luteum. Archiv f. Gyn., 1878, xiii, 109- 122. Bischoff. Entwickelungsgeschichte der Saugethiere und des Menschen, 1842. Beweis der von der Begattung unabhiingigen periodischen Reifung und Los- losung der Eier als der ersten Bedingung ihrer Fortpflanzung, etc. Giessen, 1844. Bouin. Les deux glands a secretion interne de l’ovaire. Rev. med. de l’Est, 1902. Chiari. Ueber Ovarialverdoppelung. Centralbl. f. allg. Path. u. path. Anat., 1904, xv, 546-548. Clark. The Origin, Growth and Fate of the Corpus Luteum. Johns Hopkins Hospital Reports, 1898, vii, 181-220. The Origin, Development, and Regeneration of the Blood-vessels of the Ovary. 82 THE FEMALE ORGANS OF GENERATION Contributions to the Science of Medicine, by pupils of William H. Welch, 1900, 593-676. Corner. On the Orgin of the Corpus Luteum of the Sow from both Granulosa and Theca Interna. Am. J. Anat., 1919, xxvi, 117-183. Cyclic Changes in the Ovaries and Uterus of the Sow. Publication 276, Carnegie Institution, 1921, 117-146. Cornil. Note sur l’histologie des corps jaunes de la femme. Annales de gyn. et d’obst., 1899, lii, 373-381. Dahl. Die Innervation der weiblichen Genitalien. Zeitschr. f. Geb. u. Gyn., 1916, lxxviii, 536-601. Dalton. On the Corpus Luteum of Menstruation and Pregnancy. Philadelphia, 1851. Engstrom. Ueberzahlige Ovarien. Mittheil. der gyn. Klinik des Prof. Eng- strom, 1897, i, 55. Evans. The Rhythm of Gonadal Function with Special Reference to the Relations between Uterus and Ovary. Endocrinology and Metabolism, Barker, Hoskins and Mosenthal, 1922, ii, 573-599. Escher. Ueber den Farbstoff des Corpus luteum. Zeitschr. f. physiol. Chemie, 1913, Ixxxiii, 198. Farre. Uterus and Its Appendages. Todd’s Cyclopaedia of Anatomy and Physiology, 1858, Parts XLIX and L. Foulis. The Development of the Ova, etc., with Special Reference to the Origin and Development of the Follicular Epithelial Cells. Jour, of Anat. and Physiol., xiii. Frankel. Die Funktion des Corpus luteum. Archiv f. Gyn., 1903, lxviii, 438- 545. Ueber die innere Sekretion des Ovariums. Zeitschr. f. Geb. u. Gyn., 1910, lxiv, 426-437. Neue Experimented. Funktion d. Corpus luteum. Archiv f. Gyn., 1910, xci, 705-761. VON Franquel Beschreibung einiger seltenen Eierstockspraparate. Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 326-346. de Graaf, Regnerus. De mulierum organis generationi inservientibus tractatus novus, etc. Lugd., 1672. Grigorieff. Schwangerschaft bei der Transplantation der Eierstocke. Centralbl. f. Gyn., 1897, 663. Grohe. Ueber den Bau und das Waehstum dcs menschlichen Eierstockes, etc. Virchow’s Archiv, 1863, xxvi. Haggstrom. Zalilenmassige Analyse der Ovarien eines 22 jahrigen gesunden Weibes. Zentralbl. f. Gyn., 1921, No. 49. von Herff. Ueber den feineren Verlauf der Nerven im Eierstocke des Men- schens. Zeitschr. f. Geb. u. Gyn., 1892, xxiv, 289-308. Hegar. Studien z. Histogenese des Corpus luteum. Archiv f. Gyn., 1910, xci, 530-545. His. Beobachtungen iiber den Bau dcs Saugethiere-Eierstockes. Archiv f. mikr. Anat., 1865, i. Klein. Ueber mehreiige Graaf’sche Follikel beim Menschen. Miinchener med. Abhandlungen, 1893, IV. Reihe, Heft 4. Knauer. Die Ovarientransplantation. Archiv f. Gyn., 1900, lx, 322-376. Kollicker. Entwickelungsgeschichte des Menschen und der hoheren Thiere. II. Aufl., Leipzig, 1879. Lipschutz. Die Pubertatsdriise und ihre Wirkungen. Bern, 1919. Limon. Etude histologique et histogenetique de la glande interstitielle de l’ovaire. Th&se de Nancy, 1901. LITERATURE 83 McIlroy. The Development of the Germ Cells in the Mammalian Ovary. Proc. Royal Soc. Edinburgh, 1910, xxxi, 151-178. Mandl und Burger. Die biologische Bedeutung der Eierstoeke. Wien, 1904. Marshall. On the Results of Heteroplastic Ovarian Transplantation. Quart. J. Exp. Physiol., 1908, i, 115-120. Physiology of Reproduction. London, 1910. Martin. Ovarian Transplantation. Surg. Gyn. & Obst., 1922, xxxv, 573-585. Meyer. Ueber Corpus luteum-Bildung beim Menschen. Archiv f. Gyn., 1911, xciii, 354-404. Ueber die Beziehung der Eizelle zum Follikelapparat, etc. Archiv f. Gyn., 1913, c, 1-19. Ein Mahnwort zum Kapitel “ Interstitielle Druse.” Zentralbl. f. Gyn., 1921, 593-601. Miller. Corpus Luteum, Menstruation u. Graviditat. Archiv f. Gyn., 1914, ci, 568-620. Montgomery. An Exposition of the Signs and Symptoms of Pregnancy. 2d ed., London, 1863, 419-489. Morris. A case of Heteroplastic Ovarian Grafting, Followed by Pregnancy and the Delivery of a Living Child. Medical Record, May 5, 1906. Nagel. Das menschliche Ei. Arch. f. mikr. Anat., xxxi. Die weiblichen Geschlechtso.rgane. Jena, 1896. NLgrier. Recherches anatomiques et physiologiques sur les ovaries dans l’espeee humaine. Paris, 1840. Pfluger. Ueber die Eierstoeke der Saugethiere und des Menschen. Leipzig, 1867. Pouchet. Theorie positive de 1’ovulation spontanee et de la fecondation, etc. Paris, 1847. Purkyne. Symbol® ad ovi avium historiam ante incubationem. Lipsi®, 1830. Raciborski. De la puberte et de l’age critique chez la femme, et de la ponte periodique chez les mammiferes. Paris, 1844. Rokitansky. Ueber Abnormitaten des Corpus luteum. Allg. Wiener med. Zeitung, 1859, iv, Nr. 34, 35. Rouget. Recherches sur les organes ereetiles de la femme, etc. Jour, de la physiol., 1858, i. Ruge. Ueber Ovulation, Corpus luteum u. Menstruation. Archiv f. Gyn., 1913, c, 20-48. Schaeffer. Vergleichend histologische Untersuchungen iiber die interstitielle Eierstocksdriise. Archiv f. Gyn., 1911, xciv, 491-541. Schottlander. Ueber den Graaf ’sehen Follikel, etc. Archiv f. mikr. Anat., xxxi, 219-294. Seitz. Ueberzahlige u. accessorische Ovarien. Volkmann’s Sammlung klin. Vor- trage, 1900, Nr. 286. Seitz. Primat der Eizelle etc. Archiv f. Gyn., 1922, exv, 1-14. Seitz u. Wintz. Ueber die Beziehungen des Corpus luteum zur Menstruation. Monatsschr. f. Geb.u. Gyn., 1919, xlix, 1-23. Skrobansky. Beitrage zur Kenntniss der Oogenese bei Saugetieren. Archiv f. mikr. Anat., 1903, Ixii, 697-768. Slavjansky. Zur normalen u. path. Histologie der Graaf’schen Blaschen des Menschen. Virchow’s Archiv, 1870, li. Sobotta. Ueber die Bildung des Corpus luteum bei der Maus. Archiv f. mikr. Anat., 1S97, xlvii. Entstehung des Corpus luteum der Siiugetiere. Ergebnisse der Anat. u. Ent- wickelungsgeschichte, 1901, xl. THE FEMALE ORGANS OF GENERATION 84 Stevens. The Fate of the Ovum and Graafian Follicle in Premenstrual Life. Jour. Obst. and Gyn. Brit. Empire, 1904, v. 1-12. Thumin. Ueberzahlige Eierstocke. Archiv f. Gyn., 1898, lvi, 342-354. Valentin. Handbuch der Entwickelungsgesehichte des Menschen. Berlin, 1835. VON Velits. Beitrage zur Histologie u. Genese der Flimmerpapillarkystomen des Eierstocks. Zeitschr. f. Geb. u. Gyn., 1889, xvii, 232-278. Waldeyer. Eierstock und Ei. Leipzig, 1870. Beitrage zur Kenntniss der Lage der weiblichen Beckenorgane. Bonn, 1892. Die Geschlechtszellen. Hertwig’s Handbuch der Entwickelungslehre, 1903, Bd. I, 86-476. Waldeyer und Joessel. Lehrbuch der topographisch-chirug. Anatomie, 1899, Theil II, 790-804. Wallart. Studien fiber die Nerven des Eierstocks, etc. Zeitschr. f. Geb. u. Gyn., 1915, Ixxvi, 321, 368. Wendeler. Entwickelungsgesehichte und Physiologie der Eierstocke. Martin’s Die Krankheiten des Eierstocks u. Nebeneierstocks, Leipzig, 1899, 16-105. Williams. Papillomatous Tumours of the Ovary. Johns Hopkins Hospital Reports, 1892, iii, 1-84. Winiwarter. Recharches sur l’ovogenese et 1’organogenese de l’ovaire des mam- miferes. Archives de biologie, 1901, xvii, 33-199. Winterhalter. Ein sympathisches Ganglion im menschlichen Ovarium. Archiv f. Gyn., 1896, li, 49-55. SECTION II PHYSIOLOGY AND DEVELOPMENT OF TI1E OVUM CHAPTER III MENSTRUATION AND OVULATION-MIGRATION OF THE OVUM AND PLACE OF MEETING OF OVA AND SPERMATOZOA Menstruation.-—By menstruation we understand one of the manifesta- tions of the cyclic process associated with ovulation, which is charac- terized by a discharge of blood from the genitalia, and which recurs at regular intervals, except during pregnancy and lactation, from the time of puberty until the menopause. Ordinarily it comes on every four weeks and lasts from three to five days, though there are marked in- dividual variations as to its frequency and duration. The age at which the menses are established varies in different coun- tries, being earlier in warm and later in cold climdtes. In the tem- perate zone the first menstruation does not usually occur before the fourteenth or fifteenth year. Not a few instances of a much earlier ap- pearance of the function, however, are to be found in the literature, and are usually associated with precocious sexual development. One of the most notable cases of this character is that of Anna Mummenthaler, who, according to Haller, menstruated regularly from her second year, and gave birth to a full-term child at the age of nine. Frequently a bloody vaginal discharge is observed in new-born in- fants, which ceases after a few days, no further discharge occurring until puberty. To describe these as instances of precocious menstrua- tion, however, would be incorrect; more particularly as Ilalban at- tributes the loss of blood, as well as the occurrence of milk in the breasts of infants, to the circulation of a hormone probably derived from the placenta. In this country the menopause usually occurs about the forty-fifth year. In rare instances, however, the menstrual flow may cease as early as the twenty-eighth or thirtieth year, while occasionally it con- tinues until well into the fifties, or even until a later period. Thus, Kennedy reported the case of a woman who gave birth to her twenty- second child when she was sixty-three years old, after which she still continued to menstruate. For various interesting historical and ethno- logical data concerning menstruation, the reader is referred to the monu- mental work of Ploss. The menstrual flow is derived from the uterine mucosa, and consists 85 86 MENSTRUATION AND OVULATION of blood mixed with mucus, which, in ordinary circumstances, does not coagulate. It contains fewer red cells and more lymphocytes than the circulating blood, and according to Schickele, and Stickel and Zondek the absence of coagulation is due to substances formed in the uterine tissues, as the fluid expressed from the uterus under high pressure in- hibits coagulation when added to normal blood. Moreover, Bell has shown that the menstrual discharge is rich in calcium, while at the same time its amount in the circulating blood is diminished. It also con- tains some toxic substance, whose nature is as yet unknown. Attention was directed to this fact by Schick in 3 920, who demonstrated that con- tact with a menstruating woman would cause flowers to wither promptly, whereas controls retained their freshness. In our pharmacological laboratory this observation has been confirmed by Macht, who has further demonstrated that the phenomenon is due to the presence of a toxic substance. He found that the legume, lupinus albus, would sprout luxuriantly when placed in a vessel of water, but that the addition of a few drops of menstrual blood would result in a striking inhibition of growth. Hoppe-Seiler states that the quantity of blood lost at each menstrual period is greatly overestimated and rarely exceeds 37 cubic centimeters; while according to Labille the amount varies between 20 and 65 cubic centimeters. The former arrived at his conclusion by soaking in water all the napkins used by the woman during a single period, and deter- mining the amount of hemoglobin in the solution, and the latter by determining the quantity of iron in the effused blood. Anatomical Changes in Menstruation.—Until recently, the statements concerning the extent of the changes occurring in the endometrium during menstruation were very contradictory. Sir John AVilliams believed that the entire mucosa was cast off at each menstrual period, while Moericke and numerous other observers stated that there was little or no de- struction of tissue. Between these extremes we find a number of authors stating that a greater or lesser portion undergoes disintegration. Gen- erally speaking, the older authorities held that the entire mucosa, or at least a considerable part of it, was cast off. In 1882, Moericke stated that menstruation was accompanied by little or no destruction of tissue, basing his statements upon the exami- nation of 45 specimens of the menstruating endometrium which he obtained by curettage. His views were soon confirmed by other observers, among wdiom may be mentioned He Sinety, Strassmann, Gebhard, and Findley; while Kahlden and Christ believed that the destruction was always considerable. These statements were made before the important contributions of Ilitschmann and Adler in 1908 had revolutionized our ideas concerning the structure of the endometrium. Prior to that time it wTas gen- erally considered to be a thin membrane of relatively stable structure, and that the changes at the time of menstruation consisted in a certain amount of thickening and hyperemia, followed by the escape of blood into the uterine cavity, partly by diapedesis and partly by the rupture of distended capillaries. PLATE III. SECTION THROUGH ENDOMETRIUM ON THIRD DAY OF MENSTRUATION. X 52. B., blood; B. G., gland filled with blood; Bp., surface epithelium; G., hypertrophied glands; <S'., stroma. ANATOMICAL CHANGES IN MENSTRUATION 87 The investigations of Hitschmann and Adler, which have in great part been substantiated by all subsequent observers, and particularly by R. Schroeder, show that the process is not so simple, but that the en- dometrium is undergoing constant change either in anticipation of or in recovery from the menstrual flow. This series of changes is desig- nated as the menstrual cycle, and consists of four phases: menstruation, regeneration, interval and premenstrual swelling. It is only in the last stages of the period of regeneration and the first part of the interval that the endometrium presents the histological structure which was ■formerly described as normal—namely, a thin mucous membrane with simple tubular glands. In the later part of the interval the endometrium begins to show distinct evidences of proliferation and soon passes into the state of premenstrual swelling, or the secretory phase. During this period, as the result of changes in both the stroma and glands, it be- comes several times thicker than before, and presents the histological Fig. 84—Normal Endometrium. Interval or resting stage. A, glands cut transverely B, glands cut obliquely. X 30. picture which was formerly considered characteristic of the so-called glandular endometritis. The stroma cells lose their oval shape and become round or polygonal in outline, and approach the decidual cell in appearance. At the same time the glands undergo marked hyperplasia, associated wfith an increase in the size of the lumina and the develop- ment of projections from their walls, thereby assuming a twisted and corkscrewlike appearance. The individual epithelial cells become some- what larger and develop a marked secretory activity, so that upon appropriate staining the lumina are found to be fdled by secreted ma- terial, which was absent in the earlier phases of the cycle. There is also a marked increase in vascularity, and distended capillaries appear in the superficial layers. After this phase has existed for a number of days, blood escapes into the superficial layers and makes its way into the uterine cavity, whence it escapes as the menstrual flow. Following the escape of blood, the endometrium becomes much thinner and regen- erative processes commence, even before the flow has ceased (Figs. 84 to 861. MENSTRUATION AND OVULATION 88 Schroeder believes that menstruation is always associated with con- siderable destruction of tissue, so that in many instances only the deepest layers of the mucosa, which are in contact with the muscular is, are retained. In my experience, however, such is not always the case, and Plate III, which represents the endometrium from a uterus removed on the third day of menstruation, shows very distinctly that but little destruction of tissue has occurred. It accordingly appears that in the period of premenstrual swelling the endometrium becomes transformed into a relatively thick membrane, which is indistinguishable from the decidua vera as seen in very early pregnancy. Indeed, the likeness is so striking that not a few investi- gators employ the same terms in describing it, and distinguish a super- ficial compact and a deeper spongy layer. Consequently it is assumed that the object of the premenstrual swelling is to prepare a suitable nidus for the reception and implan- tation of the fertilized ovum, and Fig. 85.—Normal Endometrium. Early Premenstrual Period. X 30. Fig. 86.—Normal Endometrium. Advanced Premenstrual Period. X 30. that menstruation sets in in case it fails to occur. For this reason, Evans and others suggest that it would be more appropriate to designate this part of the cycle as the pre-gravid rather than the premenstrual stage. Evidence in favor of such a view is afforded by the observation of RELATION BETWEEN MENSTRUATION AND OVULATION 89 Wegelin and Aschheim that large quantities of glycogen appear during the premenstrual period and practically disappear after the flow, in- dicating that it was stored to aid in the nutrition of the ovum, and disappears if implantation fails to occur. We are still profoundly ignorant of the ultimate cause of menstrua- tion, although, as will be indicated in the following section, many authors associate it with degenerative changes in the corpus luteum. The re- searches of Schickele, and of Frankl and Aschner, however, may give a clue as to the mechanism by which it is effected. The former has shown that a substance can be expressed from the uterine tissue which possess the property of lowering the blood pressure and of dilating capil- laries; while the latter investigators have demonstrated the development of a tryptic ferment during the premenstrual phase, and it is possible that both of these factors may be implicated in the production of the bleeding. Relation between Menstruation and Ovulation.—By ovulation we understand the rupture of a mature graafian follicle and the extrusion of the ovum. The relation between menstruation and ovulation has given rise to a great deal of controversy, and, while many interesting facts have been added to our information, it must be conceded that the subject is still far from being satisfactorily understood. On the other hand, numerous investigations upon certain of the lower animals prove beyond question that a cycle of changes is con- stantly occurring in both the ovaries and uterus, which correlate the structure of the uterine mucosa to the various phases of ovarian activity, so that the animal goes into oestrus just about when the mature follicle is ready to rupture, with the result that the fertilized ovum descends into a uterus already prepared for its reception and offering the most favorable conditions for its implantation. Such investigations have been made in the dog by Marshall and Hainan, in the sow by Corner, in Dasyurus by Hill and O’Donoghue, in the guinea pig by Stockard and Papanicolaou and in the rat by Long and Evans. While their results vary in minor details, they all agree in establishing a definite oestrus cycle in which the ovarian and uterine changes are wonderfully cor- related, and indicate that the corpus luteum plays a controlling part in bringing about the uterine reaction. For these reasons it seems per- missible to conclude that oestrus in the lower animals is not comparable with menstruation in women, but that it probably corresponds with the early days of the period of premenstrual or pregravid swelling of the endometrium. Furthermore, the researches of Stockard, and Evans and Long, in the guinea pig and rat, respectively, as well as the unpublished in- vestigations of Corner in the monkey, demonstrate that the cyclical changes are not limited to the ovaries and uterus, but involve the vagina as well; so that frequent examination of the vaginal secretion makes possible the recognition of a series of cyclical changes in its cellular content, which are so characteristic as to enable the trained observer to predict the conditions existing in the ovaries and uterus, and to confirm them upon killing the animal. 90 MENSTRUATION AND OVULATION Furthermore, the demonstration of hypertrophic changes in the mam- mary glands of many animals following ovulation, without the occurrence of pregnancy, and more particularly the changes in structure of the brood pouch in marsupials, which have been demonstrated by Hill and O’Donoghue, indicate that the process is more than local, and must be associated with the circulation of some hormonic substance. The fact that young girls can not usually conceive until after the appearances of the menses, and the extreme rarity of impregnation after their cessation, rendered it natural for the earlier observers to suppose that conception could not occur without menstruation, and that the men- strual flow' represented the female semen. This view, however, was soon abandoned, and the discharge came to be regarded as a process of purification. It was not until the doctrine of periodical ovulation had been estab- lished by the work of Gendrin, Negrier, Bischoff, Pouchet, and others that definite ideas could be formulated concerning the relation between ovulation and menstruation. From then on, however, it has generally been believed that menstruation was brought about by the ripening of the graafian follicle, and that the two processes occurred almost, if not quite, simultaneously. This doctrine culminated in 1865 with appearance of Pfliiger’s article, in which he stated that the menstrual flow resulted from a reflex stimulation, which owed its origin to the pressure exerted by the grow- ing follicle upon the nerves of the ovary. This theory obtained almost immediate acceptance, and for years was the predominant belief; upon it was based our method of calculating the expected date of confinement, the rule being to date the beginning of pregnancy from the last menstrual period. Piliiger’s theory, however, was somewhat shaken by the work of Leopold and his coworkers, whose careful studies of the condition of ovaries removed at operation proved conclusively that the two processes were not necessarily synchronous, and accordingly ovulation could not bo considered the unvarying cause of menstruation. Clinical experience also lent further probability to this view, since it has shown that ovulation and subsequent pregnancy may take place without menstrua- tion; as is demonstrated by the instances of conception occurring before the establishment of menstruation or after the menopause, as well as during lactation, when the menstrual flow is usually absent. More- over, cases are recorded in which pregnancies had followed in such rapid succession that menstruation did not occur for years. Sigismund, Lowenhardt, Lowenthal, and Aveling next advocated the theory that ovulation preceded menstruation, and that the latter was due to the failure of conception. Aveling designated the process as nidation and denidation, and considered that a menstrual decidua was formed each month for the reception of the fertilized ovum, and that if conception did not occur it degenerated and was cast off with the menstrual flow. The gist of these theories was tersely expressed by Powers in the dictum, “Women menstruate because they do not con- ceive.” RELATION BETWEEN MENSTRUATION AND OVULATION 91 This view was also adopted by His and most embryologists as true, for a certain number of cases at least. They found on examining ova which were nominally of the same age, as estimated from the last menstrual period, that some presented a stage of development several weeks in advance of the others. They held, therefore, that this differ- ence could be explained only by supposing that the former resulted from conception soon after the last menstrual period, and the latter from conception shortly before the first period missed. That ovulation and menstruation are not synchronous is also confirmed by the reproduc- tive history of the orthodox Jewesses, noted for their fertility. Accord- ing to the Mosaic law women are considered unclean during the entire menstrual period and the seven days following it, so that in them con- ception must occur after that time. This view also seems to receive support from my experience that practically three-fifths of the women who marry in the middle of an intermenstrual period, and who miss the succeeding flow, are delivered of children of normal size 280 days after the onset of the last period, or in less than nine calendar months after marriage. Somewhat similar conclusions were drawn by Siegel and others, who studied the conditions in German women who con- ceived after a visit from the husband who left the army on a short furlough, although striking exceptions were sometimes noted. Fraenkel stated that menstruation was due to the elaboration of an internal secretion by the corpus luteum, which he believed regulates the blood supply of the uterus. In 1910 he still further elaborated this view, and concluded that ovulation usually occurs 19 days after the first day of the last period; as he held that the corpus luteum result- ing from the rupture of that follicle attains its highst development during the following week, when, if conception does not occur, it under- goes rapid degeneration, and gives rise to menstruation. This belief has almost been converted into a certainty by the work of Halban, Meyer, Huge, and E. Schroeder, in which the cyclical changes of the endometrium were studied in association with the development of the corpus luteum. As a result, these investigators conclude that ovula- tion usually occurs in the later days of the second week following the beginning of the last period, and is immediately followed by the rapid development of the corpus luteum, which attains its highest perfection ten or twelve days later. If fertilization takes place, the corpus luteum persists practically unchanged for months, when its secretion plays an important part in the woman’s economy and probably regulates the implantation of the ovum. Whereas, if conception and implantation do not occur the corpus luteum promptly showrs degenerative changes, which in turn lead to the onset of the menstrual flow'. Or, to use Meyer’s terse expression—“without ovulation no formation of corpus luteum, and without the latter no menstruation.” From the evidence before us, we must conclude that ovulation usually occurs shortly before the middle of the intermenstrual period, and is followed tw'elve or fourteen days later by the menstrual flow. In other w'ords, menstruation is dependent upon the presence of the ovaries, and can not occur without ovulation. Moreover, it is probably in- 92 MENSTRUATION AND OVULATION augurated by the degeneration of the corpus luteum, which originated after the rupture of a follicle during the intermenstrual period directly preceding the flow. The figures just mentioned should not be regarded as absolute, as there is evidence that under certain conditions ovulation may occur at any time. Indeed, this has happened so frequently in the experience of Schickele that he is unable to regard it as a cyclic process. Notwithstanding such exceptions, the present view concerning the re- lations between ovulation and menstruation indicates that the optimum time for the occurrence of conception is about the middle of the inter- menstrual period, and not just before or just after the flow, as is gen- erally believed. In any event, the old teaching that menstruation and ovulation are synchronous must be abandoned. The results following various operations upon the genital tract show that menstruation is dependent upon the presence of the ovaries, but that ovulation may take place without the presence of the uterus; as it Fig. 87.—Diagram Illustrating Menstrual Cycle (Evans). is generally admitted that the complete removal of both ovaries, which necessarily stops ovulation, is always associated with cessation of the menses. On the other hand, the total removal of the uterus, while associated with abolition of the menstrual flow, exerts no effect upon ovulation, as is manifested by the regular occurrence of the so-called menstrual molimina. A number of observers have attempted to show that menstruation may occur independently of ovulation, basing their contention upon the occasional continuance of menstruation after the removal of the ovaries. This conclusion, however, is fallacious, as in such cases either the ovaries had not been completely removed, or an accessory ovary was present. The now well-established fact that a very small portion of ovary will suffice for ovulation has been demonstrated by the occurrence, in rare instances, of pregnancy after the supposed removal of both ovaries by competent operators, cases of which have been reported by Gordon, Meredith, and others. Mary Putnam Jacobi, in 1876, advanced the so-called menstrual- wave theory, which has been accepted by Stephenson, Webster, Ott, Van MIGRATION OF THE OVUM 93 de Velde, and others. According to this idea, the metabolic processes in women present a distinct rhythm, and gradually increase in intensity up to the time of the menstrual flow, when they suddenly drop and reach their lowest point; after this they gradually rise again to attain their maximum intensity just before the next menstrual period, thus indicating that the entire process is under some central control, and is de- pendent upon some general and as yet unknown cause. Ordinarily, the fallopian tubes take no part in the menstrual func- tion, and in none of my specimens were there any traces of a bloody fluid in them. Occasionally, however, the tubal mucosa may share in the process, as has been shown by Thompson, who reported a case in which a pyosalpinx had ruptured through the abdominal wall, leaving a fistulous opening. Through this fistulous opening a slight amount of bloody fluid exuded at each menstrual period. Jagerroos, on the contrary, stated that the involvement of the tubal mucosa occurs only in inflammatory conditions and is absent in normal tubes. The latter, however, show distinct cyclical changes both in the epithelium and connective tissue. Migration of the Ovum.—The mechanism by which the ovum gains access to the tube after escaping from the ruptured follicle is a ques- tion of extreme interest, and one which has given rise to a great deal of discussion. The process is readily understood in those animals in which the ovaries are completely inclosed in a peritoneal sac into which the tube opens; but in women, and in animals in which the ovary projects freely into the peritoneal cavity, the question presents greater difficulties and has not as yet received a thoroughly satisfactory solution. As we have already shown, the fimbriated extremity of the tube lies in the neighborhood of the ovary, but is not necessarily in direct contact with it, the only organic connection between the two structures being furnished by the fimbria ovarica, which is attached to the upper or tubal pole of the ovary. Numerous theories have been advanced to explain the manner in which the ovum enters the tube. Rouget believed that the latter became engorged with blood at the menstrual period, and that, as a result of its becoming erectile, the fimbriae applied themselves to the portion of the ovary in which the ripe follicle was situated—so that, after its rupture, the ovum was immediately taken up by the fimbriated extremity of the tube. This view, however, has been abandoned, as it is difficult to suppose that the tube could instinctively pick out the exact portion of the ovary to which it should apply itself. Kehrer believed that the ovum was ejected from the follicle at the time of rupture with sufficient force to be thrown directly into the fimbriated end of the tube. This, the so-called ejaculation, theory for a time enjoyed considerable vogue, but has likewise been abandoned. At present it is generally believed that the cilia upon the fimbriated end of the tube give rise to a current in the capillary layer of fluid which lies between the various pelvic organs, so that the ovum, on escaping from the follicle, is taken up by the current and wafted toward one or the other tube, whence it is carried to the uterus. The correctness 94 MENSTRUATION AND OVULATION of this view has been substantiated by the experimental work of Pin- ner, Jani, and Lode. The former injected cinnabar and the latter the ova of ascarides into the peritoneal cavity of animals, and found that they made their way to the pelvis, where they were taken up by the tubes, through which they were carried to the uterus, and eventually appeared in the vagina. It is more than likely, however, that a con- siderable proportion of the ova which escape from ruptured follicles fail to gain access to the tubes, and perish in the peritoneal cavity. In 1844 Bischolf directed attention to the fact that in animals pos- sessing bicornuate uteri one frequently finds that the corpora lutea are in one ovary, while the embryos are developed in the uterine horn on the opposite side. lie supposed in such cases that the fertilized ova had come from the ovary in which the corpora lutea were found, and had made their way into the cornu of the opposite side, instead of into the one corresponding to the ovary from which they came. This process he designated as migration of the ovum. The possibility of such an occurrence in women was first carefully studied by Kussmaul, who stated that it might be brought about in two ways: either by the ovum making a circuit through the pelvic cavity and thus gaining access to the opposite tube, or passing doAvn one tube, traversing the uterine cavity, and then making its way up the opposite tube. The former he designated as external, the latter as internal, migration of the ovum. External migration of the ovum is frequently observed, whereas there is grave doubt as to the possibility of the occurrence of internal migration in women. We are unable to ascertain how frequently external migration takes place in normal uterine pregnancies, though it is prob- ably much more common than is generally believed. Its occurrence has been repeatedly demonstrated in cases of bicornuate uteri, and those presenting a rudimentary horn; and frequently in normal uteri, when the fimbriated extremity of one tube is occluded, as in cases of hydro- salpinx or inflammatory lesions, while that of the other tube is patent. In such cases, when the corpus luteum is found on the side of the diseased tube, it is inferred that the ovum had gained access to the uterus through the normal or only slightly diseased tube of the opposite side. External migration of the ovum has been produced experimentally in animals by Leopold, who excised one ovary and the opposite tube, and found in a number of such cases that the animals became pregnant after the operation. A very convincing case has been reported by Kelly, who removed the diseased left ovary and right tube from a patient, leaving the normal right ovary and left tube behind. Fifteen months later she was delivered at term, and seventeen months subsequently the remaining tube was removed for a ruptured extra-uterine pregnancy. I have examined numerous specimens of extra-uterine pregnancy, which apparently offered incontrovertible evidence of external migration of the ovum, the corpus luteum being found in the ovary of one side and the pregnancy in the opposite tube. The phenomenon was beauti- fully exemplified in a specimen which Dr. H. C. Coe sent me for examination. In this case the right tube had twice been the seat of PLACE OF MEETING OF THE OVUM AND SPERMATOZOA 95 extra-uterine pregnancy. The first pregnancy, which dated from several years before, was situated in the isthmic portion of the tube, the foetus having become converted into a lithopedion which completely blocked the lumen. External to this, and occupying the lateral portion of the tube, was a freshly ruptured four months’ pregnancy. The corre- sponding ovary was small, atrophic, covered by adhesions; the opposite one contained the corpus luteum of pregnancy. Apparently in this case the ovum must have been fertilized, soon after leaving the left ovary, by a spermatozoon which had made its way up the left tube; after which it had been carried to the right tube and had passed down it until arrested by the lithopedion, when it underwent further develop- ment. While no satisfactory evidence in favor of the occurrence of internal migration has been adduced for women, Corner has demonstrated its possibility in sows, by showing that the number of embryos in the two horns of the uterus is not necessarily the same as the number of corpora lutea in the corresponding ovary. For example, if four embryos are found in either horn, while the right ovary contains two and the left six corpora lutea, he assumes that the right horn originally contained two and the left horn six embryos, but that as they grew larger two embryos were forced mechanically from the left to the right horn. Place of Meeting of the Ovum and Spermatozoa.—During coitus the semen is deposited in the vagina, and the question arises, How do the spermatozoa contained in it make their way into the uterus, and when and where do they come in contact with the ovum? The number of spermatozoa contained in a single ejaculation is mar- velous, and has been estimated by Lode at 226,257,900. Various ex- planations of the method by which they gain access to the uterine cavity have been advanced, the most widely known being the aspiration theory of Litzmann, Wernich, and Beck, and the mucus-plug theory of Kristeller. The first-mentioned observers held that the external mus- cles of the uterus contract forcibly during coitus and compress the uterine cavity, into which the spermatozoa are aspirated when relaxa- tion occurs. Kristeller believed that at the height of the orgasm the thick tenacious mucus, which is usually found in the cervix, is forced down for a short distance into the vagina, where it becomes covered with spermatozoa, after which it returns to its original position and carries them with it. It cannot be denied that spermatozoa may gain access to the uterine cavity in either of these ways in a certain number of cases; but in the majority of instances it is probable that they make their way thither by their own activity. Moreover, the observations of Low indi- cate that the mucous secretion of the uterus possesses a positive attrac- tion for them, as can be verified under the microscope. That this view is correct is demonstrated by the instances of pregnancy following im- perfect coitus, and particularly those which have been observed in women with unruptured hymens. Furthermore, it has been shown by Henle that spermatozoa can move at quite a rapid rate, being able to travel a distance of 1 centimeter in three minutes. MENSTRUATION AND OVULATION 96 It was formerly taught that impregnation normally occurred in the uterine cavity, and it was believed by Tait, Wyder, and other observers that conjugation was favored by the direction of the currents produced by the cilia of the uterus and the tubes, the former being directed from below upward, and the latter from above downward, so that the two met in the upper part of the uterine cavity. Thus, the ciliary current would favor the entrance of spermatozoa into the uterus, while rendering impossible their entry into the tubes, except in diseased con- ditions. But in view of the observations of Hofmeier, Mandl, and others, which show that the ciliary current is directed from above down- ward, in the uterus as well as in the tubes, it is apparent that this theory must be abandoned, and it must be admitted that the spermatozoa have to make headway against the current from the time they enter the internal os. Years ago, Bischoff showed that large numbers of spermatozoa could be found upon the surface of the ovaries of animals within a few hours after copulation, and the occurrence of ovarian pregnancy demonstrates that the same may occur in women. From our knowledge of the sexual history of animals and women, it is universally admitted that sperma- tozoa promptly gain access to the tubes and that fertilization usually occurs at their lateral ends. Consequently, practically every pregnancy is primarily tubal, so that the question to be solved is how the fer- tilized egg gains access to the uterus. It is generally assumed that it is carried down by the ciliary current; but when it is realized how relatively large the egg is in comparison to the free space between the folds of the tubal mucosa, it may well be that muscular peristalsis also plays a part. In any event, the process is slow, being estimated by most authors at seven, and by Grosser at ten days. Until 1914, it was generally assumed that in married women, who copulate at ordinary intervals, living spermatozoa could always be found in the tubes, into which they had made their way by their own motility. In other words, the tube might be regarded as a species of receptaculum seminis, in which living spermatozoa were always present and waiting for the ovum. The studies of Hoehne and Behne, however, disturbed this belief, as their experimental work indicated that spermatozoa live a much shorter time in the generative tract than wTas formerly believed, and perish after a stay of one and a quarter hours in the vagina, and two or three days in the uterus or tubes. If they are correct, coitus must occur within a few days of the time of ovulation if fertilization is to be effected, or else it must he assumed that unfertilized ova can live for days, which appears improbable. Niirnberger, on the other hand, be- lieves in the correctness of the older views, as he claims to have kept human spermatozoa alive in test tubes for seven or eight days, and was able to demonstrate motile spermatozoa in normal fallopian tubes, which had been removed thirteen or fourteen days after the last coitus. Such observations bear out the experience of Birch-Hirschfeld and Diihrssen, and are in accord with the well known fact that in the bat spermatozoa retain their activity for months. In view of such conflicting opinions, LITERATURE 97 the question must be regarded as sub judice, until further work is avail- able. LITEEATUBE Aschheim. Ueber den Glykogengehalt der Uterusschleimhaut. Zentralbl. f. Gyn., 1915, 65-70. Aveling. Obst. Jour, of Great Britain and Ireland, July, 1874, 209. Beck. How Do the Spermatozoa Enter the Uterus? Amer. Jour. Obst., 1875, vii, 353-391. Bell. Menstruation and Its Eelation to Calcium Metabolism. Proc. Eoyal Soc. Med., July, 1908. Birch-Hirsch,feld. Quoted by Zweifel, Lehrbuch der Geburtshiilfe, II. Aufl., 1889, 20. Bischoee. Die Entwickelung des Kaninchen-Eies. 1842. Christ. Das Verhalten der Uterusschleimhaut wahrend der Menstruation. D. I., Giessen, 1892. Coe. Internal Migration of the Ovum. Trans. Amer. Gyn. Soc., 1893, xviii, 262-278. Corner. Cyclic Changes in the Ovaries and Uterus of the Sow, etc., 1921, Carnegie Inst. Publ. No. 276. Internal Migration of the Ovum. Bull. Johns Hopkins Hosp., 1921, xxxii, 78-83. Duiirssen. Lebendige Spermatozoen in der Tube. Zentralbl. f. Gyn., 1893, 593. Evans. The Bhythm of Gonadal Function with Special Eeference to the Eelations between Uterus and Ovary. Barker’s Endocrinology and Metabolism, 1922, II, 573-599. Findley. Anatomy of the Menstruating Uterus. Amer. Jour. Obst., 1902, xlv, 509-512. Fraenkel. Die Function des Corpus luteum. Archiv f. Gyn., 1903, Ixviii, 438- 545. Neue Experimente z. Funktion d. Corpus luteum. Archiv f. Gyn., 1910, xcl, 705-761. Frankl u. Aschner. Zur quantitativen Bestimmung des tryptischen Fermentes in d. Uterusmucosa. Gyn. Bundschau, 1911, 647-654. Gebhard. Die Menstruation. Veit’s Handbuch der Gyn., 1898, iii, 1-94. Gendrin. Traite philosophique de medecine pratique. Paris, 1839. Gordon. Two Pregnancies Following the Eemoval of Both Tubes and Ovaries. Trans. Amer. Gyn. Soc., 1896, xxi, 104-108. Grosser. Ovulation und Implantation und die Funktion der Tube beim Menschen. Archiv f. Gyn., 1919, cx. Halban. Schwangerschaftsreactionen der fcetalen Organen, etc. Zeitschr. f. Geb. u. Gyn., 1904, liii, 191-231. Halban u Kohler. Die Beziehungen zwischen Corpus luteum und Menstruation. Archiv f. Gyn., 1914, ciii, 575-589. Haller. Quoted by Ahlfeld, Lehrbuch, II. Aufl., 1898, 1. Henle. Lehrbuch der Anatomie. Hill and O ’Donoghue. The Eeproductive Cycle in the Marsupial Dasyurus Viver- rinus. Quart. Jour. Micros. Sci. N. S., 1914, lix, 133-174. His. Anatomie menschlicher Embryonen. 1880. Hitsciimann u. Adler. Der Bau d. Uterusschleimhaut. Monatschr. f. Geb. u. Gyn., 1908, xxvii, 1-81. Hoehne und Behne. Ueber die Lebensdauer homologer und heterologer Sperma- tozoen im weiblichen Genitalapparat. Zentralbl. f. Gyn., 1914, 5-20. Hofmeier. See literature on Anatomy of Uterus. 98 MENSTRUATION AND OVULATION Hoppe-Seiler. Ueber den Blutverlust bei der Menstruation. Zeitschr. f. physiol. Chemie, xlii, 545. Jacobi. The Question of Best for Women during Menstruation. Boyleston prize essay, New York, 1877. Jagerroos. Zur Kenntniss d. Veranderungen d. Eileiterschleimhaut wahrend d. Menstruation. Zeitschr. f. Geb. u. Gyn., 1912, lxxii, 28-40. Jani. See literature on Anatomy of Uterus. Kahlden. Ueber das Yerhalten der Uterusschleinihaut wahrend und nach der Menstruation. Hegar’s Festschrift, Beitrage zur Geb. u. Gyn., Stuttgart, 1889. Keiirer. Die Zusammenziehungen des weiblichen Genitalcanals. Beitrage zur vergleicli. u. exp. Geburtskundo, Heft 1, 1864. Kelly. Operative Gynecology. 1898 ii, 189. Kennedy. Edinburgh Medical Journal, 1882, xxvii, 1085. Kristeller. Berliner klin. Wochenschr., 1871, Nr. 27, 28. Kussmaul. Yon dem Mangel, der Yerkiiinmerung und Verdoppelung der Gebar- mutter und der Ueberwanderung des Eies. Wurzburg, 1859. Labille. Do la quantite du sang que les femmes perdent au cours des regies. Annalcs de gyn. et d’obst., 1917, xii, 535-544. Leopold. Studien iiber die Uterusschleinihaut. Berlin, 1878. Hie Ueberwanderung des Eies. Archiv f. Gyn., 1880, xvi, 22-44. Untersuehungen iiber Menstruation u. Ovulation. Archiv f. Gyn., 1885, xxi, 347-408. Leopold und Mironoff. Beitrag zur Lehre von der Menstruation u. Ovulation. Archiv f. Gyn., 1894, xlv, 506-538. Leopold und Ravano. Neuer Beitrag z. Lehre von d. Menstruation und Ovula- tion. Archiv f. Gyn., 1907, lxxxiii, 566-586. Lode. See literature on Anatomy of Uterus. Long and Evans. The Oestrous Cycle in the Rat. Berkeley, 1922. Lowenhardt. Die Berechnung und die Dauer der Schwangerschaft. Archiv f. Gyn., 1872, iii, 356-391. Lowenthal. Eine neue Deutung des Menstruationsprocess. Archiv f. Gyn., 1884, xxiv, 169-261. Macht. A phyto-pharmacological study of a menotoxin or menstrual toxin. Proc. of The Soc. for Exp. Biology and Medicine, 1923, xx, 265-266. Marshall. Physiology of Reproduction. London, 1910. Marshall and Halnan. On the Postoestrous Changes Occurring in the Generative Organs of the Nonpregnant Dog. Proc. Royal Soc. London, 1917, lxxxix, Ser. B, 546-659. Meredith. Pregnancy after the Removal of Both Ovaries for Dermoid Tumour. Brit. Med. J., 1904, i, 1360. Meyer. Ueber die Beziehung der Eizelle zum Follikelapparat, etc. Archiv f. Gyn., 1913, c, 1-19. Moericke. Die Uterusschleinihaut in verschiedenen Altersperioden und zur Zeit der Menstruation. Zeitschr. f. Geb. u. Gyn., 1882, vii, 84-137. Negrier. See literature on Anatomy of Ovaries. Nurnberger. Klin, und exp. Untersuehungen iiber die Lebensdauer der menschlichen Spcrmatozoen. Monatsschr. f. Geb. u. Gyn., 1920, liii, 87-101. Ott. Gesetz der Periodicitiit der physiologischen Functionen im weiblichen Or- ganismus. Vehr. des X. internat. med. Congresses, Berlin, 1891, Bd. Ill, Abt. viii, 33. Pfluger. Ueber die Bedeutung u. Ursaehe der Menstruation. Berlin, 1865. Pinner. See literature on Anatomy of Uterus.- Ploss. Das Weib in der Natur- und Volkerkunde, IV. Aufl., 1895, Bd. I, 266-334. LITERATURE 99 Pouciiet. See literature on Anatomy of Ovaries. Rouget. Recherches sur les organes ereetiles de la femme. Jour, de la Physiologie, 1858, i, 320. Ruge. Ueber Ovulation, Corpus luteum u. Menstruation. Archiv f. Gyn., 1913, c, 20-48. Schick. Das Menstruationsgift. Wiener med. Wochensehr., 1920, Nr. 19. Schickele. Wirksame Substanzen im Uterus u. Ovarium. Miinchener med. Wochensehr., 1911, No. 3. Schroeder. Der normale menstruelle Zyklus der Uterussehleimhaut. Berlin, 1913. Ueber die zeitlichen Beziehungen d. Ovulation und Menstruation. Archiv f. Gyn., 1914, ci, 1-35. Der Menstruationszyklus und seine Anomalien. Monatsschr. f. Geb. u. Gyn., 1920, liii, 207-251. Siegel. Gewollte und ungewollte Schwankungen der weiblichen Fruchtbarkeit. Berlin, 1917. Sigismund. Ideen iiber das Wesen der Menstruation. Berliner klin. Wochensehr., 1871, 824, 825. Stickel u. Zondek. Das Menstrualblut. Zeitschr. f. Geb. u. Gyn., 1920, lxxxiii, 1-26. Stockard and Papanicolaou. The Vaginal Closure Membrane in the Guinea Pig, with Further Consideration of the Oestrus rhythm. Biol. Bulletin, 1919, xxxvii, 222-245. Tait. See literature on Anatomy of Uterus. Thompson. Zur Frage der Tubenmenstruation. Zentralbl. f. Gyn., 1898, 1227. Van de Velde. Ovarialfunction. Wellenbewegung u. Menstrualfunction, Jena, 1905. Webster. The Biological Basis of Menstruation. Montreal Med. Journal, April, 1897. Wegelin. Der Glykogengehalt d. menschlichen Uterussehleimhaut. Centralb 1. f. allg. Path. u. path. Anat., 1911, xxii, 1-8. Wernicii. Ueber die Erectionsfahigkeit des unteren Uterusabschnittes, etc. Beitrage zur Geb. u. Gyn., Berlin, 1872, 297-307. Williams. The Normal Structures of the Uterine Mucosa, and Its Periodical Changes. Obst. Journal of Great Britain and Ireland, 1875. Wyder. See literature on Anatomy of Ovaries. CHAPTER IV MATURATION, FERTILIZATION AND DEVELOPMENT OF THE OVUM In the present work we shall not attempt to trace the development of the ovum through all its stages, but shall consider only those changes which are directly concerned in the formation of the foetal membranes and the placenta. For detailed information concerning the general development of the embryo the student is referred to the standard works upon embryology. Maturation of Ovum.—The ovum, as it occurs in the developing graafian follicle, is not adapted for fertilization and further development until it has undergone certain changes, more especially noticeable in its nucleus, which may be regarded as signs of maturation. This consists in the formation and extrusion of the polar bodies, which lead to the re- Fig. 88. Fig. 89. Fig. 90. Figs. 88-90.—Formation of Polar Body (Sobotta). X 500. n., nucleus; V., -vitelline membrane; Y., yolk granules; P., polar spindle; S., head of spermatozoon. duction in the number of chromosomes to one half of that characteristic of the somatic cells. The process has not as yet been proved for the human ovum, but it has been demonstrated in human spermatocytes. Arthur Thompson in 1922 described and figured the formation and casting off of what he considered as polar bodies by ova still within the human ovary, but his conclusions have not obtained general accep- tance. On the other hand, Theophilus Painter and others have con- clusively demonstrated that a reducing division occurs in human spermatocytes, Avhich results in the production of spermatids contain- ing only twenty-four instead of forty-eight chromosomes as in the spermatogonia and somatic cells. In view of these observations, as well as the fact that maturation of the ovum has been observed in all the the lower animals which have been studied, it must be assumed that it also occurs in man. The changes are supposed to begin just before the 100 MATURATION OF OVUM 101 rupture of the follicle, and to be completed while the ovum is in the upper portion of the tube. The process is most readily understood by the study of ova having but few large chromosomes. Accordingly, the egg of the ascaris megalocephala, which possesses four chromosomes, is well adapted for its demonstration. Sohotta has made an exhaustive study of the process in the mouse, and it is from his article that most of our statements are taken. When Fig. 91.—Diagram showing Normal Cell Division with Four Chromosomes. a, cell with four chromosomes; b, forma- tion of spindle; c, splitting of chromo- somes in spindle; d, separation of daugh- ter chromosomes; e, complete separa- tion into two cells, each with four chromo- somes. Fig. 92.—Diagram showing the Reduc- tion in the Number of Chromosomes in the Maturation of the Ovum. a-b-c, oocyte of first order in various stages of division; d, oocyte of second order; e, first polar body; /, mature ovum; fir, second polar body; h, cells derived from division of first polar body. the process of maturation is about to begin, the germinal vesicle ap- proaches the surface of the ovum, or oocyte of the first order, and appears to become smaller, while at the same time its membrane disappears. It gradually becomes less and less distinct, until finally its situation is indicated by a clear area surrounded by deutoplasm, which is traversed by many radiating lines. In a short time this becomes transformed into a typical caryocinetic or mitotic figure, which undergoes the usual changes and soon becomes spindle-shaped. The spindle, when it first 102 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM appears, is situated tangentially to the surface of the ovum, but later turns and becomes perpendicular to it. The chromatin of the spindle then becomes rearranged and a typical dyaster is formed (Figs. 88-90). Division rapidly ensues, and the new nucleus nearest the surface, with the portion of protoplasm surrounding it, is cut off from the bulk of the ovum and comes to lie between it and the vitelline membrane. In this way is formed the first polar body and the oocyte of the second order. As the process is a typical cell division, the nucleus of both the polar body and of the oocyte will contain the typical number of chromosomes. Almost immediately a new spindle appears in the oocyte, and division occurs without preliminary cleavage of the chromosomes, so that two cells are formed, each of which has only one half the number of chro- mosomes characteristic of the species. The smaller of these is cast off as the second polar body, while the remaining large cell is the mature ovum, whose nucleus is then designated as the female pronucleus. As the first polar body is formed by typical cell division, it must be regarded as homologous with the oocyte, from which it differs only by its smaller size; and it may divide again, giving rise to two cells. On the other hand, the second polar body is homologous with the mature ovum, and contains only one half the number of chromosomes char- acteristic of the body cells. Tinder abnormal conditions it may likewise become fertilized; in which event, according to the theories of Bonnet, Wilms, and Marchand, it may play a part in the production of a teratoma. It would therefore appear that in the process of maturation six cells may develop from the original oocyte of the first order: by the nonreducing division, the oocyte of the second order and the first polar body; while by the reducing division the oocyte gives rise to the mature ovum and the second polar body, and the first polar body to two cells homologous with the second polar body (Fig. 92). Maturation is essentially a means of reducing the number of chrom- osomes, though its exact significance is not clear. Following the theory of Weissman, it is generally believed that the object of the reduction is to make possible the introduction of paternal chromosomes into the ovum at the time of fertilization, without increas- ing the number of chromosomes char- acteristic of the species, as must in- evitably occur were some such mechan- ism not provided. In any event, the process must be regarded as a neces- sary preliminary to normal fertiliza- tion and further development of the ovum. As the researches of von Winiwarter and Painter show that in human beings the somatic cells, as well as the spermatogonia and spermatocytes of the first order, contain forty-eight chromosomes, it must follow that Fig. 93.—Human Spermatogonial Division, with 48 Chromosomes. (Painter). FERTILIZATION 103 the number is reduced to twenty-four in the spermatozoon, and inferen- tially in the mature ovum and second polar body. Fertilization.—By fertilization is understood the union of a sperma- tozoon and a mature ovum. Each spermatozoon must be regarded as a distinct cell, and consists of three portions—the head, which contains the nuclear material, the tail, and an intermediate portion. The head is somewhat tri- angular in shape and flattened from side to side. Interpolated between it and the long tail is a small cylindrical body, the intermediate portion (Pig. 94). The spermatozoa are endowed with marked motility, derived from the rapid vibration of their tails, and, according to Henle, can traverse a distance of 1 cen- timeter in three minutes. In spermatogenesis, changes are observed analo- gous to those occurring in the maturation of the ovum, and it has been clearly shown that each spermatocyte of the first order divides into two cells, each of which in turn gives rise to two others con- taining only one-half the number of chromosomes characteristic of the species (Fig. 95). These latter are the spermatids, which later become the sperma- tozoa. Each spermatozoon, therefore, must be re- garded as analogous with the mature ovum and the second polar body. Fig. 93, from Painter’s monograph, shows that the human spermatocyte contains forty-eight chromosomes, consequently each spermatozoon must contain twenty-four. As has already been pointed out, the spermatozoon and ovum usually come together in the lateral portion of the tube, although in rare in- stances the meeting may take place on the surface of the ovary or even in the graafian follicle, as is demonstrated by the occurrence of ovarian pregnancy. In the lower animals in which the process of fertilization has been studied, the ovum is found in the lateral end of the tube, surrounded by a considerable number of spermatozoa, as many as 60 having been counted about a single ovum. These rapidly penetrate the vitelline mem- brane, but it appears that normally only one of them makes its way into the ovum, and that after its entry the superficial portion of the latter becomes impervious to other spermatozoa. After the head has entered the ovum the tail rapidly disappears, and in a short time nothing is left of the original spermatozoon but a small spindle-shaped mass, the male pronucleus (Fig. 90). This rap- idly makes its way to the center of the ovum, where it meets and fuses with the female pronucleus to form the segmentation nucleus. As the male and female pronuclei each contain one half the number of chromosomes characteristic of the species, their union restores the normal number (Fig. 96). Thus, in ascaris, two of the chromosomes of the segmentation nucleus are of paternal and two of maternal origin, while in man twenty-four come from each cell. Moreover, as the Fig. 94. — Human Spermatozoa. h, head; c, interme- diate portion; t, tail. 104 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM chromosomes of both the mature ovum and the spermatozoon are the direct descendants of those concerned in the fertilization of the parent organisms, it is apparent that the process does not consists merely in the union of so many paternal and maternal chromosomes, hut has a much broader significance, in that it brings together nuclear substances derived from the ancestors of both parents, and thus affords a basis Fig. 95—Diagram showing the Reduc- tion in the Number of Chromosomes in Spermatogenesis in a Species with Four Chromosomes in Somatic Cells. a-b-c-, spermatocyte of first order in various stages of division; d, sperma- tocytes of second order; e, spermatids with two chromosomes each. Fig. 96.—Diagram showing Fertiliza- tion and Segmentation of the Ovum. a, fertilization; 1, male pronucleus; 2, female pronucleus; b-c, formation of spindle with chromosomes derived from both ovum and spermatozoon; d-e, cell division showing perpetuation of pa- ternal and maternal chromosomes in body cells. for a comprehensible theory of heredity. Consequently, in the case of man, in which the fertilized ovum contains forty-eight chromosomes, it is apparent that an almost endless number of combinations are possible. Ordinarily segmentation does not begin until after fertilization, but it is well known that in many insects it is not dependent upon the fusion of the male and female elements, as normal individuals may develop from unfertilized ova—parthenogenesis. Moreover, it has been GENERAL DEVELOPMENT OF OVUM 105 repeatedly shown that segmentation may be inaugurated in various animals without the presence of spermatozoa by subjecting the mature ovum to the action of various chemical agents, such as weak solutions of acids or alkalis—artificial parthenogenesis. In such cases develop- ment appears to progress normally up to a certain point, but at present there is no evidence available to indicate that thoroughly formed animals will result. It is now generally admitted that in such circumstances the egg casts off two polar bodies, as usual, so that the cells resulting from its segmentation will possess only one half as many chromosomes as when fertilization occurs. Accordingly, it would appear that the process of fertilization may be resolved into two parts: the fusion of the male and female chromosomes, and the inauguration of segmentation. In the higher animals it would seem that the two functions are inseparable, while experiments upon artificial parthenogenesis in some of the lower species indicate that the latter may occur independently of the former. In view of such facts, Loeb in 1909 stated that the spermatozoon may be regarded as an activator, which serves to stimulate nuclein synthesis. For a time it was believed that the centrosome—the structure which Figs. 97-99.—Changes in the Segmentation Nucleus (Sobotta). X 500, Fig. 97. Fig. 98. Fig. 99. P., polar body; s.n., segmentation nucleus. apparently presides over the act of cell division—disappeared from the ovum during the last phases of maturation, and accordingly the mature ova could not begin to segment until the lacking structure had been restored by means of the male pronucleus. This, however, cannot be accepted as a universal rule, particularly in view of the fact that such a possibility is lacking in artificial parthenogenesis. General Development of Ovum.—Soon after the appearance of the segmentation nucleus, caryocinetic changes take place within it and give rise to a typical nuclear spindle, which is soon converted into a dyaster, to be speedily followed by the division of the ovum into two cells (Figs. 97 to 99). Each of these in turn divides, giving rise to four cells, though Sobotta’s investigations on the mouse show that one of the original cells divides earlier than the other, so that we next have three cells. This process of cell division or segmentation goes on until the original ovum becomes converted into a mass of cells, which is desig- nated as the morula, or mulberry mass (Fig. 102). 106 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM Fluid soon appears in the interior of the mulberry mass and forces the cells to the periphery, thus giving rise to a vesicular structure con- sisting of a single layer of cells which surround a cavity filled with fluid—the segmentation cavity. The entire structure at this time is known as the blastodermic vesicle, which in the rabbit and many other Fig. 100. Fig. 101, Fig. 102. Figs. 100-102.—Formation of Mulberry Mass (Sobotta). X500. animals is still surrounded by the vitelline membrane (Fig. 103), whereas in the mouse the latter disappears before the formation of the mulberry mass. In a short time a collection of several layers of cells can be noted at one point on the inner surface of the blastodermic vesicle. This is known as the internal cell mass, wdrile the single layer of cells forming the wall of the vesicle is frequently spoken of as the primitive chorion (Fig. 103). When viewed by transmitted light the in- ternal cell mass appears darker than the rest of the surface of the blastodermic vesicle, and hence is called the macula embryonalis. Sections made through it at this point show that it is composed of several layers of cells, those nearest the exterior being ectodermal, and those nearest the segmentation cavity entodermal in character. The formation of a blastodermic vesicle has not as yet been observed in the human ovum, but, as it has been demonstrated in the ova of all species of animals which have been available for study, there is no doubt that it occurs in all mammals. These changes are supposed to take place while the ovum is making its way through the tubes, or just after it has become implanted upon the uterine mucosa. Since the studies of Graf Spee show that in the guinea pig the blastodermic vesicle is not Fig. 103.—Blastodermic Vesicle of Rabbit (v. Beneden). c., cavity of vesicle; ect., primitive ectoderm; i.c.m., internal cell mass; z.p., zona pellucida; e., al- buminous envelope. GENERAL DEVELOPMENT OF OVUM 107 formed until after the ovum has become imbedded in the decidua, it is probable that the same holds good for man. The transit through the fallopian tube is believed to occupy a period of from five to seven days, as has been verified in the guinea pig, and appears probable in human beings. Following the formation of the blastodermic vesicle and its internal cell mass, the further development of the ovum varies according to the intimacy of its attachment to the uterine wall. If it merely adheres to the surface of the decidua, as in the rabbit and dog, and there is an abundance of space in the uterine cavity, important changes con- nected with the development of the embryo and its enveloping mem- branes promptly occur upon the surface of the vesicle. On the other hand, if the ovum is very minute and buries itself in the depths of the uterine mucosa, these changes are lacking, and further development takes place in the interior of the vesicle—the so-called “inversion” of the germ layers, to which attention was particularly directed by Selenka in 1884. At first this was considered peculiar to certain rodents, but it is now known to occur in many other mammals, and in all probability in man. We shall accordingly briefly consider the changes occurring in the rabbit and dog, and then take up in more detail those observed in man. In the first mentioned ani- mals, the cells composing the in- ternal cell proliferate, and soon give rise to a round or oval area at one point on the surface of the blastodermic vesicle—the em- bryonic area, which at first consists of two layers of cells representing the ectoderm and en- toderm respectively. The embryonic area, when viewed by trans- mitted light, is first round, but later oval in shape, and presents a dark center and a light periphery, which are designated respectively as the area opaca and the area pellucida (Fig. 104). This differentiation is due to the fact that the cells composing the former are arranged in several layers, whereas in the latter only two can be made out. Fig. 104.—Embryonic Area, Dog (Bonnet). X 90. A.C., area opaca; A.P., area pellucida; M.S., mesodermic sickel; P.S., primitive streak. 108 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM The embryonic area soon becomes slightly elevated above the general surface of the blastodermic vesicle, and now forms what is known as the embryonic shield. A few hours later a darker zone appears at one end of the shield and soon exceeds it in size (Fig. 104, M.S.). This is the mesodermic area, which on section is seen to be made up of spindle- Fig. 105.—Section through Early Embryonic Area of Dog (Bonnet). X 180. Ec., ectoderm; Ent., entoderm. Fig. 106.—Embryonic Shield of Rabbit, showing Primitive Streak and Med- ullary Folds (Kollmann). X 28. Fig. 107.—Chicken Embryo with Five Segments (Kollmann). H.f., head fold; M.f, medullary folds; P., primitive streak; P.s., primitive seg- ments; P.z., parietal zone; S.z., seg- mental zone. shaped and triangular cells. This area rapidly increases in size, and soon forms a complete layer inside the blastodermic vesicle between the ectoderm and entoderm. A little later there appears in the middle of the embryonic area a (slight depression—the primitive streak—which is bounded on either side by a slight elevation—the primitive folds (Fig. 104, P.S.). Shortly afterward a second depression—the medullary groove—appears in front GENERAL DEVELOPMENT OF OVUM 109 of the primitive streak. It is bounded on either side by an elevated fold—the medullary ridges—which converge anteriorly to form the head- folds. The medullary groove is in the same line with the primitive Fig. 108.—Section through Embyronic Area of Dog showing Three Layers. (Bonnet). X ISO. Ed., ectoderm; Ent., entoderm; M., mesoderm; M.G., medullary groove. streak, but never unites with it; while the medullary folds diverge posteriorly and inclose the anterior end of the primitive streak (Fig. 106). As the ovum becomes older the medullary groove and folds, which result from proliferation of the ectoderm and later give rise to Fig. 109.—Section through Dog Embryo showing Greater Development of Meso- dern (Bonnet). X 180. Ed., ectoderm; Ent., entoderm; M., mesoderm; M.G., medullary groove. the central nervous system, rapidly increase in size; while the primi- tive streak remains stationary, so that in a short time it occupies only an insignificant portion of the embryonic area. While these changes are taking place on the surface of the embryonic Fig. 110.—Section through Dog Embryo showing Formation of Annion (Bonnet). X 100. C., celom; Ch., notochord; Ed., ectoderm; Ent., entoderm; M., mesoderm; Som., somatopleure; Spl., splanchnopleure. area, others of no less importance are going on in its depths, which result in the formation of the mesodermic structures. On either side of the medullary canal can be observed a slight thickening—the seg- mental layer, outside of which is a thinner layer—the parietal zone 110 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVU1V (Fig. 107). The segmental layer soon becomes divided up into a num- ber of more or less cuboidal masses of tissue on either side of the medullary groove, which are variously designated as protovertebrae, primary segments, or mesoblastic somites; from these the musculature Fig. 111.—Section through Dog Embryo showing Formation of Amnion, with Greater Development of Somatopleure (Bonnet). X 100. C., coelome; Ch., notochord; Ect., ectoderm; Ent., entoderm; Mmesoderm; Sum., somatopleure; Spl., splanchnopleure. of the dorsal portion of the body is developed. The parietal zone, which is also made up of mesoderm, soon becomes divided into two layers which inclose a cavity, the celom. The outer layer is covered by ectoderm, and is designated as the somatopleure, while the inner is lined by entoderm and is called the splanchnopleure. From a part of Fig. 112.—Diagram representing Longitudinal Section through Mammalian Embryo, showing Formation of Amnion. the former the anterior and lateral abdominal walls are developed, while in many animals its greater portion gives rise to the chorion and amnion. Thus far we have considered the growing ovum as seen from without; IMPLANTATION OF THE HUMAN OVUM 111 but the study of microscopical sections through it aids us still further in understanding its development. Fig. 105 represents a section through the embryonic area at an early period, and shows that the greater part of the blastodermic vesicle is composed of two layers of cells, the ecto- derm and the entoderm, while in the region of the embryonic area the former is arranged in several layers, whereas the latter consists of a single layer. Fig. 109 represents a section through the embryonic area of a dog at a little later stage, and shows three distinct layers—ectoderm, mesoderm, and entoderm. In Fig. 110 a still later period of develop- ment is shown; the medullary groove is well marked, and the mesoderm has become thickened to form the segmental layer, lateral to which is the parietal zone, which has already split, giving rise to the meso- dermic layer of the somatopleure and splanchnopleure. From the ectoderm are developed the central nervous system and the cutaneous structures; from the mesoderm are derived the muscular and circulatory portions of the body, the reproductive organs and the connective-tissue framework of the various other organs; while the entoderm gives rise to the digestive tract and the organs which are more or less intimately connected with it. In the chicken, rabbit, dog, and many other mammals the chorion and amnion are not formed until the embryo has assumed definite Fig. 113.—Guinea-pig’s Ovum Attached to Uterine Mucosa, Seventh Day (Spee). X 375. C., segmentation cavity; Ep., uterine epi- thelium; O., ovum; Z., zona pellucida. Fig. 114.—Ovum of Guinea-pig Bur- rowing through Uterine Mucosa, Seventh Day (Spee). X 375. C., capillary; D., decidua; Ep., uterine epi- thelium; O., ovum. proportions, and the parietal layer of the mesoderm has become well developed and, together with the ectoderm and entoderm, has been differentiated into the somatopleure and splanchnopleure (Figs. 110 and 111). Then folds of somatopleure arise at the head and tail ends and sides of the embryo and, gradually arching over it, meet together and fuse, thus inclosing its dorsal surface within two membranes. The outer of these, the chorion, is composed of an outer layer of ectoderm and an inner layer of mesoderm; while in the inner membrane, or amnion, the mesoderm is without and the ectoderm within, toward the embryo (Fig. 112). Implantation of the Human Ovum.—As has already been indicated, the human ovum has not as yet been observed during the process of 112 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM segmentation nor in the earliest stages of implantation. Arguing by analogy, Grosser supposes that it reaches the uterine cavity and be- comes implanted upon it lining membrane seven days after fertilization. At that time it is probably still in the morula stage and, as the cells composing it have become progressively smaller with each division, it is assumed that it scarcely exceeds the mature ovum in size-—namely, 0.2 millimeter or 1/125 inch in diameter (Figs. 1 to 3, Plate IV A). These, however, are mere suppositions, but, as the youngest ova with which we are acquainted are already deeply imbedded in the decidua, we are forced by analogy to believe that implantation is effected in Fig. 115.—Diagram of Teacher-Bryce Ovum. X 50. (T. H. Bryce, Del.) P.e., point of entrance; cyt., cyto-trophoblast; pi., plasmodi-trophoblast; n.z., necrotic zone of decidua; gl., gland; cap., capillary; pi., masses of vacuolated plasmodium invading capillaries. The cavity of the blastocyst is completely filled with meso- blast, and imbedded therein are two cavities, the larger one representing the amnio- embryonic vesicle, and the sjnalLer one the yolk sac. somewhat the same manner as in the guinea pig. Graf Spee has demon- strated that the ovum of that animal reaches the uterus during the seventh day after fertilization while still in the morula stage, when, owing to the viscidity of its exterior, it becomes attached to the free surface of the endometrium. As a result of a supposed digestive action, the epithelium directly beneath it is destroyed and the stroma liquefied, so that the ovum gradually sinks into the decidua and comes to lie well beneath its surface. Following this the margins of the opening coalesce, so that the ovum is eventually buried in the depths of the decidua, and has no communication with the uterine cavity (Figs. 113 to 115 and Figs. 4, 5 and 6, Plate IV A). PLATE l\r. Bl.S., blood spaces; Cap., capillary; Comp., compact layer of decidua; D. C., decidual cells; Emb., beginning embryo; Fib., mass of fibrin covering point of entry of ovum into decidua; Men., connective-tissue layer of chorion; Ref., decidua reflexa; Syn., syn- cytium; Tr., trophoblast; U. E., uterine epithelium. PETERS’S OVUM. X 50. IMPLANTATION OF THE HUMAN OVUM 113 Such a procedure does not imply so radical a destruction of tissue as one might suppose, and Spee states that it involves an area only the width of a few epithelial cells. Moreover, the digestive action is not entirely hypothetical, as Grafenburg has demonstrated that human foetal ectoderm contains a tryptic ferment, which is capable of digesting culture media in laboratory experiments. Formerly, it was believed that in women the ovum was implanted upon the free surface of the endometrium, which had become transformed into a decidua for its reception, and eventually became cut off from the uterine cavity by an encapsulating upgrowth of the adjacent tissue—- the decidua capsularis; but, as early as 1896, Iierff stated that it prob- ably become implanted by a mechanism similar to that observed in the guinea pig. Such views, however, were not seriously considered until three years later (1899), when Peters described a very early ovum in situ (Plates IV and IV B). As this was deeply imbedded in the decidua and was completely separated from the uterine cavity, it became apparent that the views previously held concerning implantation were erroneous, and Peters concluded that it could be explained only by some such mechanism as that described by Spee. Since that time a constantly in- creasing mass of evidence has accumulated in support of such a view, which is now universally accepted as correct. Up to the beginning of 1923 at least fifteen early ova in situ have been described, none of which exceed 5 millimeters in diameter, and which vary from the latter part of the second to the end of the third week in age. They were described by the following authors, and are mentioned as far as possible in order of their age: Miller, Bryce and Teacher, Linzenmeier, Peters, Fetzer, Moellendorf, Kiss, Schlangen- haufer and Verocay, Heine and Hofbauer, Leopold, Herzog, Jung, Merttens, Strahl-Beneke, and Spee. Several other early human ova have also been described, as well as many at a somewhat more advanced stage of development, which permit conclusions as to the mechanism of implantation; more particularly a second ovum described by Moellen- dorf, which is not included in the preceding list for the reason that it is distinctly abnormal. In each instance the ovum was imbedded in the superficial portion of the decidua and was separated from the uterine cavity by a definite, but thin, layer of tissue, and, when the entire uterus was available for study, appeared as a minute vesicular structure whose upper pole projected somewhat above the general surface. In not a few instances, a funnel-shaped defect apparently marked the point of ingress of the ovum, while in a certain number of specimens a mushroom-shaped mass of fibrin infiltrated with leukocytes covered it. The youngest of these ova was described by Miller in 1913 and was probably ten or elev en days old ; that of Bryce and Teacher was probably thirteen days old ; no data are available for calculating the age of Linzenmeier’s ovum, but it is clearly younger than that of Peters, which is estimated to be 17 or 18 days old. The remainder of the ova in the series are about the age of Peters’ ovum, but none are older than the end of the third week after fertilization. As has already been intimated, no direct evidence is available as MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 114 to what happens to the ovum between the time of fertilization and the stage represented by Miller’s specimen, ten or eleven days later. This ovum was deeply imbedded in the decidua, measured 0.83 millimeter in its greatest diameter and was in a relatively advanced stage of de- velopment. If we admit with Grosser that a period of at least seven days elapses between fertilization and implantation, it may be assumed that this ovum represents the extent of development which occurs during the three or four days immediately following implantation, and that what is needed is information concerning the intermediate stages. In order to supply this temporary deficiency, Mr. Broedel was kind enough to prepare Plates IV, A and B, in,which Fig. 1 represents the mature ovum pictured in Fig. 79, while Figs. 7-10 represent the ova of Miller, Linzenmeier, Bryce and Teacher, and Peters, respectively, each magnified 50 diameters. Figures 2 and 3 represent the ovum in the two- cell and morula stage, and Figs. 4-6 represent hypothetical ova in various stages of implantation preceding that observed by Miller. These latter figures are slightly modified from those prepared by Graf Spee, and may or may not correctly represent what actually occurs. However that may be, the plate gives a graphic idea of the phenomenal changes which occur in the 17 or 18 days elapsing between fertilization and the stage of development represented by Peters’ ovum, and shows beyond per- adventure that the human ovum early makes its way into the depths of the decidua, and does not remain upon its surface as was formerly sup- posed. Formation of the Chorion and Amnion.—In each of the early ova depicted in Plates IV, A and B, it is seen that the center of the ovum con- sists of very loosely meshed mesodermic tissue, containing as its basal portion a small mass of cells, as in Miller’s specimen, or two minute cavities, as in Figs. 8, 9 and 10, to which reference will soon be made. Outside of this comes a capsule of ectodermal tissue—the trophoblast, in which two types of cells can be distinguished. The first, immediately adjoining the mesodermic tissue, consists of a single layer of cells with sharply marked outlines; while the second, which also contains indi- vidual cells, is characterized by the presence of masses and bands of protoplasm containing nuclei, but not divided into individual cells. The trophoblastic capsule, which is the most characteristic feature of the ovum at this time, varies greatly in thickness in its several portions, is actively invading the surrounding maternal tissue and opening up its blood vessels and gland spaces. In Peters’ ovum the mesodermic tissue has in great part become consolidated into a thin layer immediately inside of the trophoblast, while from its periphery outgrowths extend into the latter and repre- sent the earliest stage in the formation of chorionic villi. At this period the trophoblast with its mesodermic lining constitutes the chorion, while the cavity included within it is designated as the extra-embryonic coelom or magma cavity. In Miller’s ovum the small collection of cells at the basal portion of the mesodermic core represents the embryonic mass, while in the ova of Linzenmeier and Peters two cavities surrounded by mesoderm are PLATE IV, A DIAGRAM ILLUSTRATING CHANGES IN THE FERTILIZED PLATE IV, B OVUM DUE TNG THE PEOCESS OF IMBEDDING FORMATION OF THE CHORION AND AMNION 115 present, and represent the amnion and the yolk sac. In the lining of the former, two types of cells may be distinguished—first, a single layer of flattened cells, which constitute the amniotic epithelium and second, several layers of large ectodermal cells, which constitute the embryonic plate or shield, which, however, at this time shows no sign of further differentiation. The yolk sac is surrounded by mesodermal tissue and is lined by a single layer of entodermal cells. In other words, these early ova already present the three primary germ layers—ectoderm, mesoderm and entoderm, and consist of a rela- tively highly developed chorion with its mesodermic and trophoblastic layers inclosing a large ccelomic cavity, and a relatively small flattened amniotic cavitjq one side of which is occupied by the embryonic shield, which as yet presents no sign of the future embryo. It is, therefore, apparent that in man the chorion and amnion do not develop in the same manner as in the chick, rabbit or dog, as in them there is no sign of the amnion until the embryo has taken on a distinct form, when it appears as folds of somatopleure which arch over the embryo and even- tually meet and fuse. Furthermore, the mesodermic tissue has attained a degree of development far out of proportion to that observed in those animals. Consequently, some other mechanism must be invoked to explain their formation in man. In many mammals, particularly when abundant room is not available in the uterine cavity for the expansion of the foetal membranes, the embryonic mass develops upon the interior, in- stead of upon the exterior, of the blastodermic vesicle, giving rise to the so-called inversion of the membranes—“entypie.” This process has been studied particularly by Spee and Duval in the guinea pig, by Sobotta in the mouse, and by Huber in the white rat, but probably does not occur in man, for the reason that in the animals mentioned only a small portion of the periphery of the ovum is composed of chorion, while its greater part is covered by entoderm homologous with that lining the yolk sac; whereas in man the chorion persists up to the time of birth as the outermost membrane of the product of conception, and the yolk sac is preserved as a closed vesicle until the termination of pregnancy. All authorities agree in assuming that following fertilization the hu- man ovum undergoes segmentation arid eventually becomes converted into a blastodermic vesicle, but here the analogy with what occurs in the chick, rabbit, or dog ceases; and the evidence available indicates that in man the embryonic mass or area develops upon the interior of the blastodermic vesicle, rather than upon its exterior, as in the animals in question. At the same time, the process differs materially from “entypie” as it occurs in many rodents. For these reasons, it appears conceivable that the changes which occur in the human ovum during the first few hours or days following implantation may resemble those which Van Fig. 116.—Blastodermic Vesicle of Bat (Van Beneden). X 275. C., cavity of vesicle; C.M., internal cell mass; E., enveloping layer. 116 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM Beneden has demonstrated in the bat. In that animal the internal cell mass forms a lenticular enlargement upon the inner surface of the blastodermic vesicle. By the degeneration of the cells in its center and by the accumulation of fluid a cavity appears, which constitutes the amnion, while the embryonic area is developed from the cells at its base (Figs. 116, 117 and 118). Indeed, the only serious argument against Fig. 117.—Blastodermic Vesicle of Bat (Van Beneden). X 200. C.M., cell mass; Ect., ectoderm; Ent., entoderm; F.<S., yolk sac. such a supposition consists in relative paucity of mesoderm, which is so conspicuous a feature in the earliest human ova. As the earliest stages of development have not been observed in monkeys, no clue can be derived from that source, but the early ova described by Selenka boar a striking similarity to human ova of the third and fourth weeks, and likewise indicate that in that species the Fig. 118.—Bat Ovum (Van Bcneden). X 200. Showing Amnion and Embryonic Area. Am., amnion; C., coelom; Ch., chorion; E.A., embryonic area; Ect., ectoderm; Ent., entoderm; Y.S., yolk sac. amnion and embryo do not originate as in the chick or the rabbit. Thus, Fig. 119, which represents a section through an early ovum of the gibbon, shows a well-developed chorion and ccelomic cavity, while the small embryo is suspended in the latter by a pedicle arising from the inner surface of the chorion. As has already been stated, the earliest human ovum with which we are acquainted was described by Miller in 19.13. It was accidentally FORMATION OF THE CHORION AND AMNION 117 discovered in material removed from the uterus by curettage for hemorrhage twenty days after the last menstrual period, and was esti- mated to be ten or eleven days old. It measured 0.83 mm. in its great- est diameter and consisted of a mesodermic core 0.44 mm. in diameter, surrounded by a thick trophoblastic capsule, which was actively invading the surrounding maternal tis- sue. Slightly basal to its center was a mass of ecto- dermal cells, measuring 0.095 by 0.072 millimeter, which Miller interpreted as the amnion and embryonic shield. No sign of a yolk sac was observed, and as only a single well preserved section was available for study it would perhaps be hazardous to attempt to draw sweeping conclusions from it, but at the same time the ovum appears to be normal and to represent the youngest one described up to this time. Whether the credit of being the second earliest hu- man ovum belongs to the specimen of Linzenmeier or that of Bryce and Teacher is a matter of doubt. The former is definitely smaller than the latter, but at the same time presents a slightly more advanced stage of development. It was very well preserved and occupies a place midway between the specimens of Miller and Peters; while there is some doubt as to whether that of Bryce and Teacher is entirely normal, and for that reason the former will be first described. Linzenmeier’s ovum was found in a uterus removed on account of hemorrhage from a woman who had been curetted one month previously. It was imbedded in the decidua and measured 1.04 X 0.9 millimeters (Plate IV A, Fig. 8). It consisted of a chorionic membrane with actively proliferating trophoblast and a few rudimentary villi. The coeclomic Fig. 119.—Section through Young Ovum of Hylobates, showing Formation of Amnion (Selemka). X 8. A., amnion; a., amniotic pedicle; B., blood vessel C., chorion; C.V., chorionic villi; D., decidua E., embryo; I., point of inversion of blastodermic vesicle; Int., intervillous space; F.S., yolk sac. 118 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM cavity was traversed by numerous mesodermic strands, and at its basal portion, broadly attached to the connective tissue of the chorion, were two cavities surrounded by mesoderm; a larger one corresponding to the amnion and a smaller one to the yolk sac. On one side of the amniotic cavity was an embryonic shield made up of several layers of ectoderm and measuring 0.21 X 0.15 millimeter, but showing no sign of a primi- tive groove. (Fig. 120.) Bryce and Teacher’s ovum was described in 1908; was found in a shred of decidual tissue expelled eleven days after a menstrual period should have begun; measured 1.95 X 0.95 millimeters, and was estimated to be 13 or 14 days old (Fig. 115 and Plate IV B, Fig. 9). It consisted of a vesicle tilled with mesodermic tissue, which contained two small cavi- ties, each lined by a single layer of cuboidal cells, which were interpreted as the amnion and yolk sac, respectively. The outer wall of the vesicle was composed of several layers of ectodermal cells, pre- senting all stages of cell division, while springing from its periphery were irregularly shaped, branch- ing and interlacing masses of vacuolated protoplasm, not divided into individual cells, and which extended to the margins of the im- plantation cavity, opening up maternal vessels, whose contents had escaped into the meshes of the proto- plasmic network. The trophoblastic capsule was unusually extensive, and in view of its extraordi- narily open structure is not considered normal by many authorities. The next earliest ovum was described by Peters in 1899, and is of especial interest for the reason that its description afforded the basis for our present ideas concerning the mode of implantation of the ovum and the development of the chorion and amnion in man. It was found in the uterus of a woman who committed suicide three days after missing her menstrual period, and was originally considered to be only three or four days old, although it is now generally recognized as being two weeks older. It measured 1.6 X 9.8 X 0.9 millimeters in its various di- Fig. 120.—Embryo from Linzenmeier’s Ovum at- tached to Chorionic Membrane, Highly Mag- nified, SHOWING AMNIOTIC CAVITY AND EMBRYONIC Area and Relatively Small Yolk Sac. A, chorionic ectoderm; B, amniotic cavity; C, em- bryonic area; D, yolk sac. FORMATION OF THE CHORION AND AMNION 119 ameters, and presented a well developed chorion with rudimentary villi inclosing a large coelomic cavity, a very small amnion, an embryonic area and a yolk sac. Plate IV represents a section through the portion of decidua in which it was imbedded, and shows that the chorion is made up of two layers—a thin inner layer of connective tissue, to whose basal por- tion the amnion and embryonic area are broadly attached, and which forms the lining of the coelomic cavity, and an outer layer composed of many layers of ectodermal cells. In Peters’ opinion, this tropho- blastic capsule represented the primitive ectoderm of the ovum. The majority of its cells possess well-marked, rounded or cuboidal bodies with vesicular nuclei. Scattered between them, especially when in contact with maternal blood, are masses of protoplasm which show no Fig. 121.—Portion of Peters’s Ovum, Highly Magnified, showing Early Stage in Development of Embryo. A, amnion, C, chorion; ect., ectoderm; ent., entoderm; mes., mesoderm; E.S., embryonic shield; Y.S., yolk sac; Sp., portion of ccelome. sign of division into individual cells, and contain irregularly shaped, darkly staining nuclei—syncytium. The trophoblast has deeply invaded the surrounding decidual tissue and has opened up numerous blood vessels, so that many large irregularly shaped spaces have developed, which contain maternal blood and represent the forerunners of the intervillous spaces of the fully formed placenta. From the connective tissue layer of the chorion, which is not yet vascularized, numerous small processes extend into the trophoblast and represent the earliest stages in the formation of chorionic villi. Fig. 121 is a highly magnified section through the amnion and embryonic area, and shows that the former is a mere flattened slit, and that the latter is made up of several layers of large ectodermal cells, which as yet show no signs of a primitive streak. In all early ova, which are approximately of the same age as Peters’ 120 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM Fig. 122.—Microscopic Section, showing Ovum Embedded in Decidua and Sur- rounded by Decidua Reflexa Probably 17 Days Old (Leopold). Fig. 123.—Section through early Human Ovum, showing Chorionic Vesicle, CONTAINING IN ITS INTERIOR THE CCELOMIC CAVITY AND THE MlNUTE EMBRYO, CONSISTING OF TWO CAVITIES UNITED BY MESODERM, THE LARGER BEING THE Yolk Sac and the Smaller the Amniotjc Cavity with the Embryonic Area. (Streeter) X 25. FORMATION OF THE CHORION AND AMNION 121 specimen, the amnion and embryonic area are broadly attached to the basal portion of the inner surface of the chorionic membrane, or, in Fig. 124.—Wax Reconstruction of Mol- lendorf’s Ovum, showing early Em- bryo Attached to Chorionic Mem- brane and Projecting into the Ccelomic Cavity. A., chorionic membrane; B., body stalk; C., embryo surrounded by mesoderm. Fig. 125.—Wax reconstruction of Mol- lendobf’s Ovum in Sagittal Section, showing Embryo attached to Chori- onic Membrane. X 100. A., chorionic ectoderm; B, chorionic meso- derm; C., roof of amnion; /)., amnio tic cavity; E., embryonic area; F., Ento- derm of yolk sac; G., mesodermal cover- ing of yolk sac. other words, as far away from the uterine cavity as possible, with the apparent purpose of having the embryo attached at a point where the future maternal blood supply will be assured. This, however, is a transient condition; for, as the embryo becomes larger, its area of attachment becomes relatively nar- rower, becoming converted into a sort of peduncle—the abdominal pedicle or body stalk, the fore- runner of the umbilical cord, by which the embryo hangs from the chorionic membrane into the coelomic cavity (Figs. 127 and 129). Moreover, while none of the early ova are entirely spherical, they tend to become lenticular in outline with increasing age, so that by the end of the fourth week the longitudinal diameter greatly exceeds the vertical, as seen by comparing Figs. 122 and 123. Likewise, there is a marked change in the relative size of the yolk sac. In very early ova it is smaller than the amnion and embryonic area, but within a short time, Fig. 126.—Wax reconstruction of Mol- lendorf’s Ovum, with past of Amnion BEMOVED, SHOWING EmBBYONIC AbEA with Pbimitive Stbeak. X 100. A., chorionic membrane with villi; B-C., amnion; D., embryonic area with primi- tive streak. 122 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM the relations become reversed, so that it becomes so large that the amnion and embryonic shield sit upon it as a mere protuberance (Figs. 128 and 130). This, however, is a transient phenomenon, as the in- crease in size soon ceases, while the embryo continues to grow, so that at the end of pregnancy the yolk sac constitutes only a minute fraction of the entire product of conception. It is, however, important to re- member that, aside from the chorion, the yolk sac is the most imposing constituent of the early ovum during the third and fourth weeks of development, which must indicate that at that time it fulfills some im- portant function. In the early ova thus far considered, the embryonic shield is merely Fig. 127.—Median view of wax reconstruction of Mateer Ovum, showing the Amniotic Cavity and its relations to Chorionic Membrane and Yolk Sac (Streeter) X 50. A., chorionic villi; B., chorionic membrane; C, Body-stalk with allantois; D., flattened amniotic cavity; E., embryonic area; F., yolk sac. a smooth plate of ectodermal cells, which are continuous at the margins with the flattened cells which line the interior of the amnion. The first change indicative of the formation of the embryo is the appearance of the primitive groove towards the latter part of the third week. This is well exemplified in Figs. 124 to 126, which represent reconstructions of Mollendorf’s ovum, and in Figs. 127 and 128 from Streeter’s ovum. The latter measured 9 X 8 X 3.5 millimeters and was obtained at opera- tion 11 days after the failure of menstruation to appear. Fig. 127 repre- sents a segment through the chorionic membrane, to which the embryo, consisting of the flattened amniotic cavity, the embryonic shield, and the relatively large yolk sac, is attached by the abdominal pedicle, which FORMATION OF THE CHORION AND AMNION 123 contains in its interior a tubule lined by entoderm, which represents all of the allantois that is formed in man. Fig. 128 represents a frontal view of the same ovum, showing the large yolk sac, with the embryonic plate resting upon it and outlined by the cut edges of the amnion. The primitive groove extends forward from the cut end of the abdominal pedicle or body stalk. These specimens once more empha- size the fact that in man the amnion cannot originate from folds of the somatopleure as in the chick. Another ovum from the third week, described by Graf Spee, serves Fig. 128.—Frontal view of Ovttm shown in Fig. 127, Shield-shaped Em- bryonic Area, with Primitive Groove, resting tjpon the relatively large Yolk Sac. The band-like structure bounding the Embryonic area REPRESENTS THE BASIS OF THE AmNION, WHOSE MAJOR PORTION HAS BEEN CUT AWAY. The STRUCTURE AT THE MORE POINTED EXTREMITY OF THE AMNION REPRE- SENTS THE SEVERED BODY-STALK, WITH THE ALLANTOIS IN ITS CENTRE (Streeter). X 50. to confirm the views just stated concerning the formation of the amnion. This ovum measured 6 X 4.5 millimeters, and possessed a chorion with well developed villi, a portion of which is shown in Fig. 129. Projecting from its interior by the abdominal pedicle is a small vesicular structure -—the beginning embryo. Fig. 130 represents a cross section through it, and shows clearly the relations of its various parts. The embryo is attached to the inner surface of the chorionic membrane by the abdominal pedicle, and its greater portion is occupied by the yolk sac, from one end of which a small process, lined by entoderm, which must be considered as a rudi- mentary allantois, extends into the pedicle, Occupying one side of the 124 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM pedicle is a small cavity lined by a single layer of epithelium, wdiich represents the amnion. On one side of this, again, is a mass of cells arranged in several layers—-the embryonic area, in which a primitive streak can be distinguished. Fig. 131 represents a highly magnified section through the same ovum, and shows that the three germ layers Fig. 129.—Spee’s Human Ovum, Embryonic Area. 0.4 Millimeter long. X 24. A., amnion; Bs., abdominal pedicle; C., chorion; c.e., chorionic epithelium; c.m., chorionic mesoderm; V., chorionic villi; Y., yolk sac. are well developed, each of which, with the exception of the entoderm, consists of several layers of cells. Figs. 132 and 133 represent an older ovum with an embryonic area 2 millimeters long, which was also described by Graf Spee. The embryo is attached to the inner surface of the chorion by the abdominal pedicle, and is made up in great part of the yolk sac. The embryonic area is oval in shape, and presents a definite medullary groove and primitive Fig. 130.—Section through Spee’s Ovum, shown in Preceding Figure. X 24. c., chorionic membrane; ect., ectoderm; mes., mesoderm; am., amnion; e., beginning embryo; bs., abdominal pedicle; all., allantois; y.s., yolk sac. streak. The two are not in the same plane, but the latter is bent almost at right angles to the former and occupies the inferior end of the em- bryonic area. Between the two is a small opening, the neurenteric canal, which serves to connect the ectoderm with the entoderm. Fig. 133 represents a section through the same ovum, and shows a well-developed chorion with typical villi, while the amnion is a small sac closely applied DEVELOPMENT AND ANATOMY OF THE PLACENTA 125 over the beginning embryo. A highly magnified cross section (Fig. 134) shows the three germ layers and a well-developed somatopleure and splanchnopleure. By the folding in of the former it is readily under- stood how the body walls are formed, and by that of the latter how the primitive gut becomes differentiated from the yolk sac. Development and Anatomy of the Placenta.—The placenta may he defined as the organ by which intimate union is effected between the mucosa of the maternal generative tract and the embryonic adnexae, particularly the chorion, for the purpose of facilitating the transfer Fig. 131.—Cross Section through Spee’s Ovum. Highly Magnified. E.A., embryonic area; P., primitive streak; ect., ectoderm; ent., entoderm; mes., meso- derm. of the nutrititre material from the mother to the foetus, and of exere- mentitious material in the reverse direction. In the various species of animals the placenta exhibits such pro- nounced differences in the mode of union between foetal and maternal tissues, in intimate structure, and in gross appearance, that it is safe to say that no other organ in the animal economy, which serves a singlo function, presents such marked variations. For example, the liver or kidney is practically identical in all mammalia, yet the placenta of swine pig differs so radically from that of the guinea pig that the casual observer would hesitate to conclude that he had to deal with the same organ, were it not obvious that it serves a simliar function in each 126 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM animal. For this reason, it is unsafe to apply to a given animal con- clusions which have been drawn from the study of the placenta of any other species, even though closely related. Consequently, in considering the development and anatomy of the human placenta, it is essential that our conclusions be based entirely upon the study of placentation in hu- man beings. Unfortunately, many of the stages necessary to its complete elucidation have not yet been ob- served, and, until they are available, it would seem advisable, before tak- ing up the study of the developing and of the mature placenta, to con- sider separately certain points con- cerning the anatomy of its compo- nent parts—chorion, amnion and decidua. A. Structure of the Chorion.— In its very earliest stages the chorion probably consists of the single layer of ectodermal cells forming the wall of the blastodermic vesicle (Fig. 4, 5 and 6, Plate IV A). Soon after the implantation of the ovum, however, as shown by the researches of Hubrecht, Huekelom, Peters and all subsequent investigators, the chorionic epithelium rapidly prolif- erates and invades the surrounding decidual tissue, forming the many- layered trophoblast. In its earliest stages the external surface of the chorion is probably smooth, but in a short time buds from its connective tissue lining make their way into the trophoblast and give rise to rudimentary villi (Plate IV). Fig. 137 represents a section through the periphery of a three or four weeks’ pregnancy. In the chorion can be distinguished two portions —the chorionic membrane, and the villi projecting from it. The mem- brane consists of two (h?ys layers—the inner of connective tissue, the outer of epithelium. The former is composed of spindle- and star- shaped cells embedded in a mucoid intercellular substance, and at this period does not contain blood vessels. The latter is arranged in two layers; an inner, adjoining the connective tissue, which is composed of cuboidal or roundish cells with clear protoplasm and lightly staining vesicular nuclei, and an outer layer made up of coarsely granular protoplasm, which shows no signs of division into cells, and through which are scattered irregularly shaped, darkly staining nuclei-syncytium. Each villus arises from the chorionic membrane as a single stem, which soon gives origin to numerous branches which assume an arbo- Tesccnt form, the complexity of which increases with advancing age. Fig. 132.—Human Embryo 2 Milli- meters Long (Graf Spee). X 30. Am., amnion; C., chorion; C.V., chorionic villi; Bs., Bauchstiel; Mg., medullary groove; Nc., neurenteric canal; P.s., primitive streak; Y.S., yolk sac. STRUCTURE OP THE CHORION 127 The villi consist of a connective-tissue stroma and an epithelial covering, each of which is continuous with the corresponding tissue of the chorionic membrane. Projecting here and there from the surface of the villi are epithelial Fig. 133.—Section through Human Ovum, shown in Fig. 130 (Spee). all., allantois; c.e., chorionic epithelium; c.m., chorionic mesoderm; Bs., abdominal pedicle; E., beginning embryo; ent., entoderm; n.c., neurenteric canal; p.s., primitive streak; V., chorionic villi; ves., vessels in wall of yolk sac. Fig. 134.—Section through Spee’s Ovum, shown in Fig. 130. Am., amnion; ect., ectoderm; mes., mesoderm; ent., entoderm; M., medullary groove. buds, consisting of syncytium, and which, when seen in cross or tangential section, resemble giant cells. These buds indicate prolifera- tion of the outer layer of the chorionic epithelium, and may represent the first stage in the development of new villous branches. Here and 128 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM there, in the spaces between the villi, larger or smaller masses of small, clear cells with vesicular nuclei are seen. They were formerly described Fig. 135.—Early Human Ovum (Leopold). Fig. 136.—Three Weeks’ Human Ovum (Leopold) as decidual islands, and were supposed to represent sections through decidual septa, which projected upward toward the chorionic membrane. In reality, however, they are masses of trophoblast which have not re- Fig. 137.—Section through Three Weeks’ Human Ovum, showing Chorion, Decidua, and Intervillous Spaces. B.V., maternal blood vessel; C.M., chorionic membrane; D., decidua; G., uterine gland; I.S., intervillous space; 6'., syncytium; 7'., trophoblast; V., villus. ceived a connective-tissue core, and thus have not been converted into villi. . , In early ova, the embryo is connected with the connective-tissue layer of the chorion by a mesodermic structure, which was first described by STRUCTURE OF THE CHORION 129 His as the abdominal pedicle or body stalk, and is the forerunner of the umbilical cord. Through this the umbilical vessels of the embryo eventually make their way to the chorionic membrane and there fuse with blood vessels which have originated in situ. In this way, the foetal circulation gains access to the villi, and makes possible the exchange of substances between the maternal and foetal blood. In early pregnancy the villi are pretty equally distributed over the periphery of the chorionic membrane, but later they become more abundant over the portion which is in contact with the decidua basalis, the site of the future placenta. This portion is designated as the chorion frondosum, while the remainder, which is in contact with the decidua capsularis, is termed the chorion laeve, since the villi covering it even- tually undergo complete degeneration. A certain number of villi extend from the chorionic membrane to the underlying decidua, attaching the ovum to it, and hence are designated as fastening villi. The majority, on the other hand, are arborescent structures, whose free endings do not reach the decidua. In early Fig. 138.—Chorionic Vil- lus, Third Week. X 225. Fig. 138A. — Chorionic Villus at Fourth Month. X 225. Fig. 138B.—C hobionic Villus at Teem. X 225. pregnancy the villi are short and plump and represent simply the main stems, but later they give off numerous branches and assume an arbo- rescent appearance. Thus, sections through a young chorion show only a few large villi, while those through an older one are filled with a multitude of smaller branches. This change in appearance may be compared to what takes place in a clump of trees, which at an early period consists of a number of almost isolated trunks, each of which later gives off innumerable branches and twigs. These differences have been particularly emphasized by De Loos, who has shown that with a little practice one can roughly estimate the age of the chorion by its appearance on section. The stroma of the villi also varies in appearance according to the age of the chorion. In the earlier stages the cells arc branching in shape, and are separated from one another by a large amount of mucoid intercellular substance; later on they become more spindle-shaped and more closely packed together, so that the stroma assumes a denser appearance (Fig. 138). Another type of cell also occurs in the stroma—the so-called plasma or Hofbauer cell. These are roundish cells with vesicular nuclei 130 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM and very granular or vacuolated protoplasm. In fresh specimens Warren H. Lewis has shown that their granules stain so characteristically with vital stains that he is inclined to classify them as plasmatocytes, but at the same time there is some evidence that they may represent Lang- hans’ cells which have wandered into the stroma. They are present in all stages of pregnancy, but are most abundant during the early months, and particularly when the foetus is defective. After the third week, but before there is any sign of the foetal heart, blood islands appear in the mesodermic tissue of the chorion, and vascular walls soon appear around them. These coalesce to form larger vessels, and soon lead to complete vascularization of the chorion and its villi. It is important to re- member that in man these vessels originate in situ, and are not derived from tKe allantois, as is often taught. The "villous vessels soon become very abundant, and in the later months of pregnancy almost displace the stroma. The arteries and veins extend to the tips of the villi, where they break up into capillaries, but there is no anastomosis between the vascular supply of the various villi, any more than between the branches of different trees in a forest. The epithelium covering the villi was mentioned by Dalrymple in 1842, but was first definitely described by Langhans many years later. The latter pointed out that it was made up of the two layers already described (Fig. 138). The inner he designated as the cell-layer (Zell- schicht), although it is now generally known by his name; while the outer layer is described as the syncytium. This latter term was in- troduced in 1893 by Kossmann and Merttens, although the characteris- tics of the tissue had been recognized years before by Kastschenko, who designated it as plasmodium. During the first half of pregnancy the two layers are readily dis- tinguished, but later Langhans’ layer becomes more and more indis- tinct, so that during the second half the villi are covered only by a single layer of syncytium. Figs. 138 to 138 B give a good idea of the successive changes in the stroma and epithelium at different ages. Care- ful examination of properly prepared specimens shows that the syncytial layer presents a vacuolated structure, and that its outer margin does not present a smooth surface, but is made up of a vertically arranged pseudopodialike protoplasmic process. These structures are too coarse to be considered as cilia, and are designated by Marchand, Bonnet, Hof- bauer, and others as bristlelike processes. The origin of the two layers of chorionic epithelium has given rise to a great deal of discussion, but it has been established by the work of Langhans, Kastschenko, Minot, Webster, Heukelom, His, Ruge, Peters, as well as by all recent investigators that they are both ectodermal in origin, and are derived from the original trophoblastic covering of the ovum. In 1893 Kossmann advanced the theory that the syncytium was derived from the epithelium of the uterus, while only Langhans’ layer represented the original ectoderm, which was apparently confirmed by Merttens. This work was very plausibly set forth and accompanied by numerous excellent illustrations, so that the conclusions of Kossmann STRUCTURE OF THE AMNION 131 and Merttens were soon adopted by many authorities. This view is now regarded as untenable, inasmuch as all recent investigators have shown that the ovum is surrounded by the many-layered trophoblast before the formation of the villi begins, and that the syncytium represents only a modification of it. Still more convincing evidence against its uterine origin is afforded by our present knowledge covering the mode of im- plantation of the ovum (Plate IY A and B). Consequently, it may be positively stated that the syncytial layer is not of maternal origin, and that such a view is a relic of old and discarded theories concerning the implantation of the ovum. The theory of Kossmann and Merttens is only one of a large number which have been advanced in explanation of the origin of the chorionic epithelium. Those who are interested in the subject are referred to the article of Waldeyer, who in 1890 was able to arrange in ten groups tho numerous theories which had been advanced up to that time. In 19lS de Kervily studied mitochondrial formation in the chorionic villi, and his article represents a storehouse of information concerning all points connected with the minute anatomy of the chorion. B. Structure of the Amnion.—In the very earliest stages of preg- nancy, as we have already shown (Fig. HO), the amnion is a minute vesicle; later it forms a small sac which covers only the dorsal surface of the embryo, and eventually becomes larger and completely surrounds it. At first the amnion occupies only a minute portion of the entire ovum; but as pregnancy advances it increases in size, until eventually it comes jn contact with the interior of the chorion and obliterates the extra-embryonic portion of the coelom. When the outer surface of the amnion has'supplied itself to the inner surface of the chorion, the two membranes become slightly adherent, but are never very intimately connected, for even at the end of pregnancy they can be readily separated from one another. From its earliest stages the amnion consists of two layers: an outer layer of mesoderm and an inner layer, made up of cuboidal or flattened, ectodermal cells. The mesodermic layer eventually becomes converted into mucoidlike tissue, which does not contain blood vessels; while the ectodermal portion is represented by a single layer of cuboidal epithelial cells, which by their origin are homologous with the cells making up the embryonic shield, and hence may be regarded as simply an extension of the skin of the embryo. This relationship is accentuated by the fact that in somewhat more than one-half of all placentae, at term, small, rounded placques may be observed upon the amnion, particularly in the neighborhood of the attachment of the umbilical cord. Upon microscopical examination they are found to be made up of stratified epithelium, which bears a close resemblance to that of the skin. They are designated as amnionic caruncles, and will be considered more fully in the chapter on the pathology of the ovum. Soon after its formation, a certain amount of clear fluid collects within the amniotic cavity—the amniotic fluid—which increases in quantity as pregnancy advances. The amount varies within wide limits, and according to Fehling averages about 600 cubic centimeters at the 132 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM end of pregnancy, although under abnormal conditions it may vary from a few cubic centimeters to many liters. Its specific gravity ranges from 1.002 to 1.028, and it contains a certain amount of albumin, urea, kreatin, and various salts. Its origin and function will be considered when we take up the physiology of the foetus. C. Decidua.—The decidua is the mucous membrane of the uterus which has undergone certain changes under the influence of the ovulation cycle, to fit it for the implantation and nutrition of the ovum. It is so named from the fact that it is cast off after labor. The conversion of the uterine mucosa into decidua occurs shortly after the fertilization of the ovum, though we are unable to state exactly when the process com- mences, inasmuch as the premenstrual swelling is accom- panied by marked changes in structure, which must be regarded as pregravid or predecidual in character; but more particularly because a fairly well-marked decidua was present in all of the early pregnancies which have thus far been described. After conception the hypertrophic premenstrual endometrium be- comes still thicker and eventually attains a thickness of from 5 to 10 millimeters, while its surface becomes indented by furrows of consider- able depth, which give the entire membrane a mamelonated appearance. Under the magnifying-glass numerous small openings can be distin- guished which are the mouths of the uterine glands. The decidual formation is limited to the body of the uterus, and does not extend below the internal os, though in rare instances, as in the cases reported by von Franque, von Weiss, Yolk, Lynch, and others, isolated decidual cells are found beneath the cervical epithelium. For purposes of description the decidua is usually divided into three portions: that lining the main cavity of the uterus being designated as the decidua vera; that beneath the ovum as the decidua basalts or serotina; while the portion which surrounds the ovum and shuts it off from the rest of the uterine cavity is known as the decidua capsularis or reflexa. The terms reflexa and serotina date from the time of William Hunter, who crave excellent drawings of the decidual membrane in his atlas. Fig. 139.—Uterus lined by Decidua, containing an Early Ovum (Leopold). X 1. DECIDUA 133 Unfortunately, the explanatory text, was prepared by John Hunter and Matthew Baillie, who considered that the decidua represented a fibrinous exudate from the lining membrane of the uterus, which formed a corn- Fig. 140. Figs. 140, 141.—Diagrams illustrating Hunterian Theory of Formation of Decidua Reflexa. Fig. 141. plete cast of its cavity and covered the tubal openings. They supposed, therefore, that when the ovum reached the uterine end of the tube its further passage was opposed by the decidua vera, which it was obliged to push before it as it entered the uterus, whence the term reflexa; and that, after the latter had been pushed forward, a new exudate was de- veloped behind the ovum, to which the term serotina was applied (Figs. 140 and 141). This conception was universally accepted until 1846, when Weber in Germany and Sharkey in England demonstrated that the decidua contained uterine glands, and consequently must be the altered endometrium. It having therefore become necessary to explain the formation of the reflexa in a different manner, it was assumed that the ovum, on reaching the uterus, found its entire cavity lined by decidua vera, to some point of which it became attached; and that immediately afterwards the vera began to proliferate and to form a wall around the ovum, until it had completely inclosed and surrounded it. Later investigation, in turn, showed that this view was not correct, as the ovum remains upon the surface for only a few hours, and then burrows into the depths of the decidua, as has already been described. Notwithstanding these new ideas, the terms reflexa and serotina are still employed, though in the new anatomical nomenclature they are more properly designated as the decidua capsularis and basalis respectively. 1 ig. 142. Fig. 143. Figs. 142, 143.—D i a - GRAMS ILLUSTRATING Old Theory of For- mation of Decidua Reflexa. 134 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM Decidua vera.—The microscopic structure of the decidua vera was first studied by Hegar and Maier, but it was not until the work of Friendlander, and Kundrat and Engelmann that its structure was defi- nitely understood. Friendlander in 1870 pointed out that the decidua vera was composed of two portions: a compact layer superimposed upon a spongy or glandular layer, the latter adjoining the muscular wall of the uterus, and forming the main thickness of the membrane. He showed that the compact layer was made up of large round, oval, or polygonal cells, with large, lightly staining, vesicular nuclei — the de- cidual cells, while the spongy layer was composed of dilated and hyper- plastic uterine glands. Further- more, he formed the incorrect opinion that sep- aration at the time of labor took place at the junction be- tween the two layers. The decidua vera increases markedly in thick- ness during the first three or four months of preg- nancy, so that at the end of that time it may attain a thickness of about 1 centimeter. Figs. 51 and 144 show very graphically the difference between the normal endometrium and the decidua vera from a uterus four months pregnant. After the fourth month, owing to the distention of the uterus, the vera gradually be- comes thinner, so that at term it is rarely more than 1 or 2 millimeters thick. Under the microscope the compact layer is seen to be made up of somewhat closely packed, large, oval, or polygonal cells, which are dis- compact spongy muscle Fig. 144.—Decidua Vera, Fourth Month. X 16. DECIDUA VERA 135 tinctly epithelioid in appearance, and possess round, vesicular nuclei, which stain but slightly with the ordinary reagents. When the tissue has been distended by hemorrhage or edema, it is seen that many of the decidual cells present a stellate appearance, and are provided with long protoplasmic outgrowths which anastomose with similar processes from neighboring cells. Particularly in the early months of pregnancy, one sees scattered between the typical decidual cells a considerable number of small round cells, whose bodies are almost entirely filled by the nucleus. Such cells were formerly considered as lymphoid in character, but Marchand and Rossi-Doria contend that they are forerunners of new decidual cells, basing their contention upon the fact that they frequently contain mitotic figures, and that all gradations may be ob- served between them. In the early months of pregnancy the ducts of Fig. 145.—Decidua Vera, Fourth Month. X 420. the uterine glands may be seen traversing the compact layer, hut they soon disappear, so that in the later months all trace of them is lost. The spongy layer is made up of the distended and hyperplastic glands of the endometrium, which are separated from one another by a minimal amount of stroma. In many instances the glandular hyperplasia is so marked that the spongy layer suggests an adenoma in appearance. At first the glands are lined by typical cylindrical uterine epithelium, which presents evidence of abundant secretory activity. The material secreted probably serves as a pabulum for the ovum pending the estab- lishment of the placental circulation. Later the epithelium gradually becomes cuboidal, or even flattened, in shape and, undergoing fatty de- generation, is cast off in great part into the lumina of the glands. A certain amount of epithelium, however, remains intact throughout preg- nancy, and from it the endometrium is regenerated after labor. Par- ticularly, toward the muscularis, the stroma between the dilated glands 136 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM undergoes hut little change, and closely resembles that of the non- pregnant uterus. Under the influence of pregnancy, the surface epithelium covering the decidua soon loses its cylindrical shape and becomes cuboidal or flattened, sometimes even resembling endothelium. Klein first directed attention to this changed condition, and subsequently all observers have held that it is a characteristic microscopic evidence of pregnancy. Fig. 145 represents a section through the compact layer of the decidua vera at the fourth month, while Fig. 146 shows a gland with its surrounding stroma from a non-pregnant endometrium, drawn under the same magnification. On comparing them, it is readily seen that the decidua differs from the latter by a marked increase in size of the stroma cells, and a decrease in size of the epithelial cells. Schick in Fig. 146.—Gland and Stroma from Non-pregnant Endometrium. X 420. 1905 pointed out that the decidua is particularly rich in lymphatic spaces, and holds that in properly prepared specimens they occupy at least as much space as the hypertrophied glands. As a result of the work of Hegar and Maier, Leopold, Minot, and others, it is now universally held that the decidual cells are derived from the stroma cells of the endometrium, which have undergone marked increase in size, but only slight increase in number. Ruge directed attention to the resemblance which they bear to sarcoma cells, and stated that “the decidual cell represents the physiological type of the sarcoma cell.” The connective-tissue origin of the decidual cell was established only after prolonged investigation, and, before it was definitely proved, vari- ous theories were advanced as to their origin: Ilennig believing that they were derived from leukocytes, Frommel and Overlach from the DECIDUA VERA 137 uterine epithelium, and Ercolani from the endothelium of the blood vessels. At the present time these views are of interest only from an historical standpoint. The connective tissue origin has been further confirmed by obser- vations made in certain specimens of early tubal pregnancy, in which decidual cells may be seen developing in the smaller folds of the mucosa of the opposite non-pregnant tube. In such circumstances, it is apparent that they are derived from the ordinary connective-tissue cells, and result from the hypertrophy of preexisting units rather than from their proliferation. Furthermore, Schmorl, Kinoshita, Hormann, and others have described, in women dying soon after childbirth, small nodules, varying from structures just visible to the naked eye to bodies 1 to 2 millimeters in diameter, just beneath the peritoneum, covering the posterior surface of the uterus, Douglas’s culdesac, the anterior surface of the rectum, and occasionally also over the ovaries. Schmorl considers that such nodules are always present at the end of pregnancy, and has demonstrated that they are made up of decidual tissue. Unterberger has succeeded in producing them experimentally by scraping the peri- toneum from the exterior of the uterus, thereby demonstrating that the cells composing them must be derived from connective tissue and not from the peritoneal epithelium. Outerbridge has described similar formations in the appendix, while Geipel has shown that they may be present in the omentum, and also that decidual cells frequently develop in the pelvic lymphatic glands from the tissue just outside of the vessels. I have also studied several specimens which showed an unusually wide distribution of decidual formation. In the most pronounced instance, the pregnant uterus was the seat of an adenomyoma, and typical de- cidual formation was noted in the interglandular tissue of the endome- triumlike areas far removed from the uterine cavity. Likewise, in cases of hydatidiform mole, distinct decidual formation was noted not only in the mucosa of the tubes, but also in the connective-tissue just beneath their peritoneal covering. Decidua capsularis.—Except for the first few hours after its entry into the uterus, the ovum is shut off from the rest of the uterine cavity by the decidua reflexa or capsularis, which forms a capsule of decidual tissue around it. Fig. 139 shows an early pregnancy in which the reflexa is quite apparent, and Fig. 147 a five or six weeks’ pregnancy in which it is well developed. During the early months of pregnancy the decidua capsularis does not entirely fill the uterine cavity, so that a space of varying size exists between it and the vera. This is well shown in Fig. 148, which repre- sents an eight weeks’ pregnant uterus. At the fourth month of preg- nancy, however, the growing ovum entirely fills the uterine cavity, so that the reflexa and vera are brought into intimate contact, and the part of the uterine cavity which had remained unoccupied up to this time becomes obliterated. In a short time the two structures fuse to- gether, when the capsularis gradually degenerates and disappears. This view was first advocated by Minot, and appears to be well founded, inas- much as sections through the wall of the full-term uterus outside of the 138 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM placental site show that the entire decidua is only 1 to 2 millimeters thick, and no indication of the decidua reflexa can be discovered (Fig. 153). The decidua capsularis usually attains its greatest thickness at about the second month. Sections through it at this time show that it is Fig. 147.—Five Weeks’ Pregnant Uterus. X 1 (Anatomical Museum, Johns Hop- kins University.) Embryo drawn relatively too large. D.R., decidua reflexa; D.S., decidua serotina; D.V., decidua vera; E., embryo; O.L., ovarian ligament; R.L., round ligament. made up of decidual cells and is covered on its exterior by a single layer of flattened epithelial cells; while internally it is in contact with the foetal villi, and at no time shows any trace of uterine epithelium. In its lowest portion, where it is connected with the vera, a few glands may be found, whose ducts, when present, are seen to open only upon the outer surface of the membrane. Until recently it was universally believed that the capsularis origi- DECIDUA BASALIS 139 nated from the proliferation of the vera, which grew lip around and gradually inclosed the ovum. More accurate knowledge concerning the mode of implantation of the ovum, however, shows that this is not the case, but that the capsularis is merely the portion of the decidua vera which covers the ovum (Plates IY and IY A and B). Decidua basalis.—The decidua basalis or serotina is the portion of the decidua which lies immediately beneath the ovum; from it the Fig. 148.—Sagittal Section of an Eight Weeks’ Pregnant Uterus Slightly to One Side of the Midline. X 1. (Specimen from the Department of Embryology of the Carnegie Institution.) Note the early placenta on right and thick decidua vera on left side. The embryo lies in the amniotic cavity, outside of which is the chorion and the decidua capsularis. The remnant of the uterine cavity lies between the decidua vera and capsularis. maternal portion of the placenta is developed. Broadly speaking, it presents the same general structure as the decidua vera, except that it has been invaded by foetal tissue, so that its superficial portions are composed of foetal ectoderm, as well as decidual cells. Friedlander and Leopold stated in their original monographs that giant cells appeared in the basalis about the middle of pregnancy. These, they thought, made their way into the vessels and gave rise to thrombosis. Their interpretation, however, is no longer accepted, and 140 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM it is now known that the so-called giant cells are not of decidual origin, hut represent portions of trophoblast, which have invaded the decidua. Fig. 149, representing a section through the decidua basalis in the last month of pregnancy, shows clearly that its superficial portions are composed of a mixture of both fcetal and maternal cells. In the decidua basalis large numbers of blood vessels are observed. The arteries pursue a spiral course, and usually penetrate the entire thickness of the membrane; while many of the veins become markedly Fig. 149.—Decidua Basalis, showing Mixture of Fcetal and Maternal Cells. X 75. G., gland; V., vessel; F.ec., foetal ectoderm. dilated and form large sinuses. In Fig. 149 two small vessels may be seen which, after pursuing their course through the superficial layer of the serotina, open into the intervillous spaces of the placenta. The consideration of the vascular connections between the foetus and the uterus, however, will he deferred until we take up the study of the placenta. D. Development of the Placenta. -The mode of implantation of the ovum has already been described, and it is generally believed that it usually occurs upon the upper portion of either the anterior or posterior DEVELOPMENT OF THE PLACENTA 141 wall of the uterus, and only exceptionally upon its lower portion. The ovum is very rarely implanted at the fundus or in the angles, since in these locations the decidual reaction is much less pronounced than else- where. After the ovum has burrowed into the depths of the decidua, the portion separating it from the uterine cavity is known as the capsularis, and that beneath it as the basalis. Almost immediately it becomes converted into a blastodermic vesicle, whose outer ectodermal covering, which is now designated as the trophoblast, at once begins to proliferate and invade the surrounding decidual tissue. As it does so, it breaks through the walls of maternal capillaries, from which the blood escapes and forms cavities, which are bounded partly by tropho- blast and partly by decidua (Plates IV and V). As the process goes on more vessels are opened up, so that in a short time the trophoblast presents a sievelike appearance due to the presence of large numbers of blood spaces filled with maternal blood. As a result, the trophoblastic cells become compressed into irregularly shaped masses of varying size, some of which extend from the surface of the ovum to the surrounding decidua, and afford the epithelial basis from which the villi are de- veloped. The maternal blood spaces established in this manner represent the earliest stages in the formation of the intervillous blood spaces of the future placenta, and are abundantly present in the early ova recently studied. Coincidentally with their formation, the trophoblastic masses are invaded by connective-tissue offshoots from the chorionic membrane, and are thus' converted into villi, whose epithelial covering becomes arranged in two layers: the inner consisting of Langhans’ cells and the outer of syncytium. As already indicated, a considerable number of the primary villi extend from the periphery of the chorionic membrane to the surrounding decidua, while the majority project freely into the blood spaces. The former are designated as fastening villi, and serve to attach the ovum to the decidua. Where they come in contact with the latter, the tropho- blast at their tips, which is now designated as chorionic epithelium, undergoes marked proliferation, and like the roots of a tree invades the decidual tissue still further, until the two structures become firmly united. The proliferated trophoblast may be observed in placentae in all stages of development, and is represented by what are usually known as the cell nodes or cell columns. During the first few weeks of pregnancy branching villi project from the entire periphery of the ovum, as is well seen in Figs. 135 and 130. They come in contact not only with the decidua basalis, but also with the capsularis, so that for a time intervillous blood spaces surround the entire ovum. As the chorionic villi are devoid of blood vessels for the first few weeks, the ovum must be nourished during that period by osmosis from the maternal fluids. As pregnancy advances, the blood supply of the decidua basalis be- comes more and more abundant, while that of the capsularis diminishes; as a consequence the villi in contact with the former are better nourished and grow more luxuriantly and take part in the formation of the 142 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM placenta. Over the rest of the periphery of the ovum the villi develop less rapidly, and eventually atrophy, so that the portion covered by them becomes known as the chorion laeve. As the ovum increases in size, the intervillous spaces in the chorion laeve become smaller and smaller, and by the fourth month, when the decidua rellexa has come in contact with the vera, they become obliterated, and the villi which project into them undergo degeneration, but do not completely dis- appear. For, even at term, sections through the uterine wall (Fig. 153) show that the chorion laeve consists of several layers of epithelial cells, which represent the chorionic epithelium, through which are scattered round or oblong hyaline bodies, in which a few spindle-shaped nuclei can be distinguished. These are the remains of the earlier villi. At the same time degenerative changes take place where the chorionic epithelium comes in contact with the decidual tissue, which result in the formation of a fibrinlike material which will be considered in detail a little later. On the other hand, the villi of the chorion frondosum increase in size and number, and the blood vessels which originated with- in them become connected with branches of the umbilical vessels of the embryo, so that after the first few weeks the foetal circulation extends to the tips of the smallest villi. The placenta is formed by the union of the chorion frondosum and the decidua basalis, and therefore is composed of both foetal and maternal tissues. It soon constitutes a distinct structure, although its site is indicated at a still earlier period by the point of attachment of the abdominal pedicle to the inner surface of the chorionic membrane. Ac- cording to Benoist, its weight exceeds that of the foetus for the first three and a half months of pregnancy. One can probably best understand the structure of the placenta by studying sections through it at various periods of pregnancy. One from the fourth month is reproduced in Plate shows that the organ is made up in great part of chorionic villi, whose stroma presents a some- what mucoid appearance, and contains spindle- and star-shaped con- nective-tissue cells, between which well-developed arteries, veins, and capillaries may be observed. At this stage the villous epithelium is arranged in two layers—Laugh a ns’ layer and the syncytium—and from the latter many buds protrude, which, when examined in cross or tangential section, appear as giant cells lying free in the intervillous spaces. In the upper part of the plate is the decidua basalis, with which some of the fastening villi are connected. At their ends can be noted a marked proliferation of ectodermal cells, which invade the underlying decidua, giving rise to the cell nodes or cell columns, and corresponding to the trophoblastic proliferation of the early days of pregnancy. The cell nodes are composed almost exclusively of Langhans’ cells, as the syncytium does not follow them down into the depths of the decidua. The space between the chorionic membrane and the decidua, as well as between the villi themselves, is designated as the placental space. These intervillous spaces are filled with maternal blood and their walls are lined by syncytium. Scattered through them are isolated giant cells— PLATE V. SECTION THROUGH FOUR MONTHS’ PLACENTA, SHOWING JUNCTION OF CHORION AND DECIDUA. X 56. C. F., canalized fibrin; C. N., cell nodes; D., decidua scrotina; D. decidual island; O. giant cell; I. S., intervillous space; P. .proliferating villous epithelium; V., chorionic villi. DEVELOPMENT OF THE PLACENTA 143 the so-called placental giant cells—whose origin has already been con- sidered. Here and there are seen a few large areas composed of cuboidal or polygonal cells with vesicular nuclei, which frequently present signs of degeneration. These are the so-called decidual islands, and were formerly supposed to represent sections through decidual septa, which projected upward from the surface of the decidua basalis toward the chorionic membrane. But, as has already been pointed out, this con- ception is erroneous; as most of them represent masses of trophoblast, into which the chorionic connective-tissue has not grown, and which therefore have not developed into typical villi. At the junction between the foetal and decidual tissue, areas are noted which stain deeply with eosin, and which, on closer examination, are seen to be made up of fibrinoid material, honeycombed in various direc- tions by small spaces—canalized fibrin. This results from the degen- eration of both foetal and the decidual cells, and is known as Nita- buch’s fibrin layer, from the author who first called attention to its presence in the decidua. Its existence has been confirmed, and its characteristics have been studied by Langhans, Kohr, and others. It would seem that degenerative changes of this type occur wherever foetal and maternal tissues come in contact, and the phenomenon suggests that the function of the decidua is not merely to afford a suitable structure for the implantation and nutrition of the ovum, but also to protect the maternal organism against invasion by foetal cells. More particularly, as experience teaches that whenever the decidual reaction is defective or lacking the growing villi invade the maternal tissue al- most like a malignant growth, and lead to disastrous consequences, as in extra-uterine pregnancy and certain cases of rupture of the uterus. Until comparatively recently the participation of foetal tissue in the decidua basalis was not recognized. Furthermore, Winckler and other observers considered that the cells covering the maternal surface of the chorionic membranes were decidual in origin, instead of being chorionic epithelium as is now believed. They held that decidual tissue extended from the margins of the decidua basalis over the whole of the maternal surface of the chorionic membrane, so that the entire intervillous space was included between decidual or maternal tissue. Winckler, accordingly, designated the superficial portion of the decidua as the basal, and the portion covering the chorionic membrane as the closing plate of the decidua. As it has already been shown that the tissue in question is composed of foetal ectoderm, the conception of decidual plates should be abandoned. At present it is universally admitted that the blood in the inter- villous spaces is exclusively maternal in origin, and at one point (Plate V) a maternal vessel is seen which, after reaching the surface of the decidua, opens directly into them. At the point marked “P” in Plate V, a villus is seen whose tip projects into the lumen of a uterine vein, and in many instances the ends of such villi grow for a considerable distance into vessels. Veit has pointed out that in such circumstances portions of villi may become broken off, and thus gain access to the general circulation. He designates the process as deportation, and 144 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM -Decidua upon it has constructed an extensive theory con- cerning many of the ab- normalities of preg- nancy, to which refer- ence will later be made. The foetal blood in the vessels of the chorionic villi at no time gains access to the maternal blood in the intervillous spaces, the two being separated from one another by the double layer of chor- ionic epithelium, a por- tion of the stroma of the villus, and the ves- sel walls. Structure of Pla- centa in Latter Half of Pregnancy and at Full Term.—Except in its increased size, the pla- centa in the second half of pregnancy differs but slightly from that of the fourth month. Micro- scopic sections at this period, however, show certain points of differ- ence. These are well illustrated in Fig. 150, which represents a sec- tion through a seven and a half months pla- centa and the adjacent decidua. Studying it from below upward, we see that it is composed of the following struc- tures : amnion, chori- onic membrane, villi, in- tervillous blood spaces, and decidua basalis. The amnion covers the inner or foetal sur- face of the placenta, and consists of a single —Chorionic villi and Intervillous spaces. —Chorionic membrane —Amnion. Fig. 150.—Section through Placenta at Eighth Month. X 15. PLATE VI. TERMINAL CHORIONIC VILLUS, WITH INJECTED VESSELS. STRUCTURE OF PLACENTA 145 layer of cuboidal epithelium, below which comes a layer of more or less fibrillar connective-tissue, containing no blood vessels. The chorionic membrane presents essentially the same structure as in the earlier months of pregnancy, differing only in the presence of a large amount of canal- ized fibrin immediately beneath its epithelium, as well as in the presence of larger vessels. The great bulk of the placenta is made up of chorionic villa, whose branches are much more abundant, but at the same time considerably smaller, than at the fourth month. Their stroma, which is made up of spindle-shaped cells, is denser, is occupied in great part by blood vessels, and differs markedly from the mucoid tissue of the earlier months. These changes have already been referred to, and are clearly shown in Fig. 138. The epithelium covering the villi has also undergone marked change; Langhans’ layer has disappeared and there remains only a thin layer of syncytium, which gives rise to fewer buds than previously. In many villi immediately under the epithelium, and occupying the former posi- tion of Langhans’ cells, a thicker or thinner layer of canalized fibrin may be observed. This was first described by Langhans, is of constant occurrence in the latter half of pregnancy, and is probably indicative of senility of the organ. At the same time, many of the arteries present all stages of an obliterating endarteritis, to which, in part, the forma- tion of the tissue in question should be attributed. The superficial portion of the decidua at this period is covered by canalized fibrin, which probably results from coagulation necrosis of the cell nodes and columns. In the deeper layers numerous giant cells are observed, which occasionally extend into the connective-tissue septa between the muscle fibers. They are of various shapes, and represent portions of trophoblast which have wandered down into the decidua. From the free surface of the decidua numerous elevations of vary- ing shape and size extend upward for a greater or less distance into the placenta—the so-called decidual septa. They are now known to rep- resent masses of trophoblast, which have not been converted into villi, and are composed of cuboidal or polygonal cells with round vesicular, deeply staining nuclei. Owing to the absence of blood vessels they are very prone to degenerative change and tend to become converted into canalized fibrin, or to lead to the formation of small cystic structures. The space between the chorionic membrane and the free surface of the decidua serotina is designated as the placental space; into this the chorionic villi dip, thereby subdividing it into myriads of irregularly shaped cavities which communicate freely with one another—the inter- villous spaces. These are lined throughout by syncytium, except where it has given place to canalized fibrin. The syncytium is thinner than in the earlier months, and under suitable magnification its protoplasm presents a vacuolated appearance, which, according to Marchand, is due to the glycogen normally contained in it having been dissolved out by the fluids used in hardening the tissue. The intervillous spaces are at no time lined by endothelial cells, and it is probable that what has been described as such in reality rep- resents thinned-out syncytium. Hence, it would appear that the inter- 146 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM villous spaces are lined entirely by foetal tissue, and that the maternal blood, which is circulating through them, lies outside of the body of the mother. The maternal blood gains access to the placental space by branches of the uterine arteries, which pursue a convoluted course through the decidua serotina and, after their walls have gradually become reduced to a single layer of endothelium, open upon the sides of the decidual septa. The blood escapes from the intervillous spaces through more or less funnel-shaped openings upon the surface of the decidua, which can be traced directly into large venous sinuses in its depths. Consequently, there must he a distinct circulation through the inter-communicating intervillous spaces, though it is necessarily more sluggish than elsewhere in the body. The nature of the intervillous spaces and the question as to whether they contain maternal blood have given rise to a great deal of discussion. Vater, Noortwyk, and William and John Hunter, in 1754, expressed an affirmative opinion; and the last two investigators conclusively demon- strated it by injection experiments. Similar results were obtained by E. IJ. Weber in 1842. But this work was gradually lost sight of, and all sorts of theories were evolved concerning their nature. Braxton Hicks, Ercolani, and others believed that they contained so-called uterine milk, which was secreted by the mucous membrane of the uterus. Such a statement is correct for the pig and cow, but is incorrect for woman, and clearly demonstrates the fallacy of drawing inferences from con- ditions observed in other species. Correct conceptions were finally established by the work of Farre, Turner, Waldeyer, Bumm, Leopold, and others, who showed conclusively that vessels of the mother could be traced into the intervillous spaces, which they supplied with maternal blood. This was especially well demonstrated by Waldeyer, who, in five pregnant cadavers, was able to inject the intervillous spaces from the maternal vessels. Furthermore, the study of early ova in situ has placed the question beyond all reasonable doubt. In view of these facts, then, the placenta must be regarded as a collection of maternal blood, included between the chorionic membrane and the decidua basal is, into which the villi dip and by which they are surrounded. Some idea of the complexity of its vascular arrangement may be gained from Plate VII, which represents a corrosion preparation of the foetal portion of a full-term placenta, which was injected through the umbilical arteries and veins with red and blue celloidin. Normally there is no communication between the foetal blood con- tained in the chorionic villi and the maternal blood in the intervillous spaces, and it would appear that the transmission of substances from one to the other is accomplished partly by osmosis and partly by the direct cellular activity of the chorionic epithelium, the process being analogous to that which takes place in the tubules of the kidney and other organs. The effete materials from the foetus are carried by the umbilical arteries to the capillaries of the terminal villi, whence they are transmitted to the maternal blood in the manner just described. At the same time the oxygen and the materials needed for the nutrition of the foetus are taken up from the former and carried by the umbilical PLATE VIE CORROSION PREPARATION OF MATURE PLACENTA, TO SHOW FCETAL VESSELS. X H- THE AFTER-BIRTH 147 vein to the foetus. Thus, in a general way, we may say that the placenta represents the lungs, stomach, and excretory organs of the unborn child. Since the time of C. Bernard glycogen has been observed in various portions of the placenta—decidua, villi, chorionic membranes and am- nion. The researches of Flesch, Todyo and others show that it is most abundant during the first two months of pregnancy, but that traces can be discovered even at term. The Afterbirth.—The placenta, as it is cast off from the uterus after the birth of the child, is a flattened, roundish, or oval organ—15 to 18 centimeters in diameter, and 2 to 3 centimeters in height at its thickest part—from the margins of which the membranes extend. Ordinarily its weight is about 1/6 of that of the foetus, so that when the latter is normally developed the placenta weighs from 500 to 600 grams. It presents for examination two surfaces and a margin—the surface which was in contact with the decidua basalis being designated as the maternal or outer, and that directed toward the cavity of the ovum as the foetal or inner surface. The former is covered by a thin layer of decidua and presents a ragged, torn appearance, being divided by de- pressions of varying depth into a number of irregularly shaped areas, the so-called cotyledons, which vary considerably in number, as many as twenty being sometimes observed. On careful examination of the decidual surface, numerous vessels may be seen which have been torn through when the placenta was separated. These were first observed by John Hunter, and Klein was able to count 51 arteries and 53 veins in a single specimen. The foetal or inner surface presents a glistening appearance, owing to the fact that it is covered by amnion, which, however, is only slightly adherent. When the latter is removed it leaves a coarsely granular surface, upon which the umbilical cord is usually inserted somewhat eccentrically, though it may be just at the center of the organ or near its margin. The various modes of insertion will be considered when we take up the abnormalities of the placenta. The vessels composing the umbilical cord spread out beneath the am- nion and rapidly divide, but the main branches remain upon the foetal surface of the placenta until its margin is reached. In many instances a large vein, which is known as the circular sinus, extends around a considerable portion of the periphery of the placenta, but only rarely completely encircles it. The foetal membranes extend from the margins of the placenta, and consist of the amnion, chorion, and a thin layer of decidua. The amnion, the innermost of the membranes, is a thin, transparent, glistening structure, which is rarely thicker than a sheet of writing paper. Its outer surface is closely applied to the chorion, from which, however, it can usually be separated without difficulty. The chorion is more opaque and thicker than the amnion, though it rarely exceeds 1 millimeter in thickness. It represents the chorion laeve of the early months, and under the microscope is seen to possess a, number of degenerated villi. Clinging to its outer surface are a few shreds of decidual tissue, which are all that is cast off immediately after the birth of the child. Fig. Fig. 151.—Maternal Surface of Mature Placenta, showing Cotyledons; Mem- branes turned Back. X Fig. 152.—Fcetal Surface of Mature Placenta. X/4 UMBILICAL CORD 149 153 represents a section through the fcetal membranes and the uterine wall outside of the placental site, and gives a good idea of their com- position. Umbilical Cord.—The umbilical cord, or funis, extends from the navel of the child to the foetal surface of the placenta. Its exterior presents a dull white, moist appearance, and through it shimmer the umbilical Fig. 153.—Fcetal Membranes and Uterine Wall. X 75. a., amnion; c.t., connective tissue of amnion and chorion; c.e., chorionic epithelium; c.f. canalized fibrin; d., decidua; g., gland; m., muscularis; v., vein; Vatrophic villus. vessels—two arteries and a vein. It varies from 1 to 2.5 centimeters in diameter, and averages about 55 centimeters in length; though in ex- treme cases it may vary from 0.5 to 198 centimeters. The average length of 1,000 cords, which were measured at the Johns Hopkins Hospital, was 55 centimeters, the shortest being less than 1 and the longest 100 centimeters. The cord frequently presents a twisted appearance, the coiling usually being from left to right. As the vessels are usually longer than the cord, they are frequently folded upon themselves, thus giving rise to nodulations upon the surface which are designated as false knots. 150 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM The cord is covered by a sheath of amnion which is closely adherent to it. Under the microscope, the covering epithelium usually consists of a single layer of flattened cells, although occasionally it is arranged in several layers resembling those of the skin. Except for the vessels, the interior of the cord is made up of a mu- coid connective - tissue —the so-called Whar- tonian jelly. On microscopic ex- amination of sections through any portion of the cord, one gen- erally finds near its center a small darkly staining area, which under higher magnifi- cation appears as a small duct lined by a single layer of cuboidal or flattened epithelial cells, and surrounded by a zone of relatively dense connective-tissue. This is the duct or stalk of the umbilical vesicle. On the other hand, in section's taken just beyond the um- bilicus of the foetus, one occasionally finds a second duct, which represents the remnant of the allantois, but this is never found at the maternal end of the cord. Formerly it was taught that the cord was derived from the allantois, but the re- searches of His have definitely shown that such is not the case in man. In the youngest human ova, in which the embryo consists merely of a minute amnion and yolk sac, it is connected with the inner surface of the chorionic mem- brane by a thick mass of mesodermic or connective-tissue, which His designated as the abdominal pedicle or body stalk, and which, after increasing in length and receiving a covering of amnion, becomes con- Fig. 154.—Epithelium of Umbilical Cord. X 110. Fig. 155.—Umbilical Cord, Fcetal End. X U.A., umbilical artery; U.S., remnant of umbilical stalk; U.V., umbilical vein. UMBILICAL VESICLE 151 verted into the umbilical cord. Furthermore, the allantois in man at no time develops into the imposing organ which it becomes in many animals, but always remains a rudimentary structure, being represented by an entodermal tubule at the foetal end of the abdominal pedicle, which occasionally persists in the foetal end of the cord at the end of pregnancy. Fig. 157 represents a section through the abdominal pedicle of one of the early embryos studied by His, and clearly shows its analogy with the embryonic area. The great bulk of the structure is made up of mesodermic tissue in which the umbilical vessels and the allantois are embedded; its dorsal surface is covered by a single layer of ectoderm, showing at its middle a slight depression which represents a continuation of the medullary groove, while arching over it is the amnion. In its further de- velopment the amnion, corres- ponding to the somatopleure, extends downward and inward, eventually inclosing a small portion of the' coelom in a way similar to that in which the abdominal walls are formed in the embryo itself (Fig. 158). In this cavity the stalk of the umbilical vesicle or yolk sac is included. Fig. 159 represents a thirty days’ embryo described by His, and gives a very good idea of the manner in which the stalk of the umbilical vesicle gradually becomes included within the cord. Umbilical Vesicle.—The yolk sac, or, as it becomes later, the umbilical vesicle, is a very prominent organ at the beginning of pregnancy, and is present in all early ova. In its earliest stages it represents the largest and most striking structure con- nected with the embryo, but as the latter develops, it becomes relatively smaller, and, as we have already shown, is taken up in great part to form the intestinal canal, so that after the formation of the abdominal walls it protrudes from the umbilicus into the ccelomie cavity as a rounded sac with a distinct stalk. As pregnancy advances the sac becomes smaller and its stalk longer. The structure persists throughout pregnancy, and can nearly always be found at full term, when it is represented by a flattened oval sac, 3 to Fig. 156. — Section through Umbilical Cord, showing Stalk of Umbilical Vesicle. X 110. Fig. 157.—Section through Abdominal Pedicle of 2.25- Millimeter Embryo (His). X 50. All., allantois; M.G., medullary groove; U.A., umbilical ar- tery; U.V., umbilical vein. 152 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM 5 millimeters in diameter, which usually lies on the foetal surface of the placenta, between the chorion and amnion, but occasionally in the mem- branes just beyond the placental margin. It is connected with the um- bilical cord by a fine pedicle—the stalk, which, as has been already indi- cated, may be seen in sections through the cord at term. Schultze in 18G1 was able to demonstrate the umbilical vesicle in 146 out of 150 mature placentae examined. Meyer has found that the vesicle may sometimes exceed the usual proportions, and measure as much as 10 to 15 millimeters in diameter. The intra-abdominal portion of the duct of the umbilical vesicle, which extends from the umbilicus to the intestine, usually atrophies and Fig. 158.—Section through Young Um- bilical Cord (Minot). A., artery; All., allantois; U.S., stalk of umbilical vesicle; V., vein. Fig. 159.—Stalk of Umbilical Vesicle BEING INCLUDED IN THE UMBILICAL Cord (His). disappears, but occasionally it remains patent, forming what is known as Mechel’s diverticulum, which may play an important pathological part in later life. m In animals whose ova possess a large amount of yolk, the umbilical vesicle is the main source of nutrition for the embryo; but in women its significance is not so clear, since the proportion of yolk is exceedingly small. In some of the lower animals it affords a means of vascularizing the chorion, while in still others it takes part in the formation of an accessory placenta, in addition to the main one which is vascularized from the allantois. It must, however, play an important part in the economy of the embryo, as it develops a considerable circulation, and, as Selenka has shown, forms numerous crypts from its entodermal lining. LITERATURE 153 LITERATURE Beneke u. Strahl. Ein junger mensehlicher Embryo. Wiesbaden, 1910. Benoist. Des rapports entre l’embryon et le placenta dans 1’avortement. These de Paris, 1906. Bonnet. Ueber Syncytien, Plasmodien und Symplasma in der Placenta. Monats- schr. f. Geb. u. Gyn., 1903, xviii, 1-51. Zur Aetiologie der Embryome. Monatsschr. f. Geb. u. Gyn., 1901, xiii, 149-176. Bryce and Teacher. Early Development and Imbedding of the Human Ovum. Glasgow, 1908. Bumm. Zur Kenntniss der Utero-placentar-gefasse. Archiv f. Gyn., 1890, xxxvii, 1-15. Ueber die Entwickelung des miitterliehen Blutkreislaufes in der menschl. Pla- centa. Archiv f. Gyn., 1893, xliii, 181-195. Dalrymple. Medico-ehir. Transactions, 1842, xv, 21 (quoted by Waldeyer). de Kervily. La villosite du placenta. Archives mens, de gyn. et d’obst. 1916, v, 93-149 and 296-349. Duval. Le placenta des rongeurs, Paris, 1892. Engelmann. The Mucous Membrane of the Uterus, etc. Amer. Jour. Obst., 1875, viii, 30-87. Ercolani. Della struttura anat. della caduca uterina, etc. Bologna, 1874. Farre. Uterus and Its Appendages. Todd’s Cyclopaedia of Anat. and Physiol., Parts XLIX and L. Eehling. Ueber die physiologische Bedeutung des Fruehtwassers. Archiv f. Gyn., 1879, xiv, 221-224. Fetzer. Ueber ein menschliches Ei. Anat. Anzeiger, 1910, XXXVII. Erg. II. 116-126. Flesch. Glykogen in der menschlichen Placenta. Monatsschr. f. Geb. u. Gyn., 1911, xxxiv, 21-34. von Franqu£. Cervix und unteres Uterinsegment. Stuttgart, 1897. Friedlander. Physiol, anat. Untersuchungen iiber den Uterus. Leipzig, 1870. Frommel. Verh. d. deutschen Gesellschaft f. Gyn., 1886, i, 306. Gebhard. Ueber das sogenannte Syncytioma malignum. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 480-518. Geipel. Zur Kenntniss des Vorkominens des decidualen Gewebes in den Becken- lymphdriisen. Archiv f. Gyn., 1916, cvi, 177-206. Grafenburg. Beitrage z. Physiologie d. Ei-einbettung. Zeitschr. f. Geb. u. Gyn., 1910, lxv, 1-35. Grosser. Vergleichende Anat. u. Entwickelungsgeschichte d. Eihaute u. d. Pla- centa. Wien u. Leipzig, 1909. Hegar. Beitrage zur Pathologie des Eies, etc. Monatsschr. f. Geburtskunde, 1863, xxi, Supplement Heft, 1-66. Heine u. Hofbauer. Beitrag z. friihesten Eientwickelung. Zeitschr. f. Geb. u. Gyn., 1911, Ixviii, 665-688. Hennig. Die weissen Blutkorperchen und die Deciduazcllen. Archiv f. Gyn., 1874, vi, 508-509. Herff. Beitrage zur Lehre von der Placenta und von den miitterliehen Eihiillen. Zeitschr. f. Geb. u. Gyn., 1896, xxxv, 268-297 and 325-372. Herzog. The Earliest Known Stages of Placentation, etc., in Man. Am. J. Anat., 1909, ix, 361-400 Heukelom. Ueber die menschliche Placentation. Arch. f. Anat. u. Physiol., Anat, Abth., 1898, 1-36. 154 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM Hicks. The Anatomy of the Human Placenta. Trans. London Obst. Soc., 1873, xiv, 149-189. His. Bauchstiel and Nabelstrang, Anatomie inenschlicher Embryonen, 1885, iii, 222-226. Die Umschleissung der menschl. Frucht wahrend der friihesten Zeiten der Scliwangerschaft. Arch. f. Anat. u. Physiol., Anat. Abth., 1897, 399-430. Hofbauer. Biologic d. mensehlichen Placenta. Wien, 1905. Hormann. Beitrag zur Kenntniss der decidualen Bildungen in den Ovarien. Archiv f. Gyn., 1906, lxxx, 297-305. Huber. The Development of the Albino Bat. Jour. Morphology, 1915, xxvi, No. 2. Hubeecht. The Placentation of Erinaceus Europseus, with remarks on the Phylogeny of the Placenta. Quart. Jour, of Microscop. Science, 1889, xxx. Die Bolle des embryonalen Trophoblasts bei der Placentation. Zentralbl. f. Gyn., 1897, 1206. Hunter, John. On the Structure of the Placenta, Observations on Certain Parts of the Animal Economy. London, 1786. Hunter, Wm. Anatomy of the Human Gravid Uterus. London, 1774. Jung. Beitrage z. friihesten Ei-einbettung beim mensehlichen Weib. Berlin, 1908. Kastchenko. Das menschliche Chorionepithel und dessen Bolle bei der Histo- genese der Placenta. Arch. f. Anat. u. Physiol., Anat. Abth., 1885. Kinosiiita. Ueber grosszellige decidua-ahnliche Wucherungen auf dem Peri- toneum. Monatsschr. f. Geb. u. Gyn., 1898, viii, 500-509. Kiss. Ein junges menschliches Ei. Zeitschr. f. Anat. u. Entwickelungsges. 1921, lxii, 519-535. Klein. Entwickelung und Biickbildung der Decidua. Zeitschr. f. Geb. u. Gyn., 1891, xii, 247-295. Kollmann. Lehrbuch der Entwickelungsgescliichte des Menschen. Jena, 1898. Kossmann. Zur Histologie der Chorionzotten des Menschen. Leuckhart’s Fest- schrift, 1892. Zur Histologie der Extrauterinschwangerscliaft, nebst Bemerkungen iiber ein sehr junges mit der Decidua gelostes Ei. Zeitschr. f. Geb. u. Gyn., 1893, xxxvii, 266-286. Kundrat u. Engelmann. Untersuchungen iiber die Uterusschleimhaut. Strieker’s med. Jahrb., 1873. Langhans. Untersuchungen iiber die menschliche Placenta. Archiv f. Anat. u. Entwickelungsgesch., Leipzig, 1877, 188-276. Ueber die Zellschicht des mensehlichen Chorions. Beitrage zur Anat. und Einbryologie (Henle’s Festgabe), Bonn, 1882. Leopold. Studien iiber die Uterusschleimhaut, etc. Berlin, 1878. Ueber den Ban der Placenta. Verh. d. deutschen Gesell. f. Gyn., 1890, iii, 257. Uterus u. Kind. Leipzig, 1897. Ueber ein sehr junges menschliches Ei in situ. Leipzig, 1906. Leopold, Marchesi, u. Bott. Zur Entwickelung und der Bau der mensehlichen Placenta. Arch. f. Gyn., 1899, lix, 516-544. Linzenmeier. Ein junges menschl. Ei in situ. Archiv f. Gyn., 1914, cii, 1-17. Lynch. Cervical Decidua. Surg. Gyn. and Obst., 1913, June, 694-701. Loeb. Die chemische Entwickelungs-erregung des tierischen Eies. Berlin, 1909. De Loos. Das Wachstum der mensehlichen Chorionzotten. D. I., Freiburg in B., 1897. Marchand. Ueber die sogennannten “decidualen’’ Geschwiilste. Monatsschr. f. Geb. u. Gyn., 1895, i, 419-513. Beitrage zur Kenntniss der Placentarbildung. Marburg, 1898. Beobachtungen an jungen mensehlichen Eier. Anat. Hefte, 1902, 147. LITERATURE Beitrage zur Kenntniss der normalen u. path. Histologie der Decidua. Arehiv f. Gyn., 1904, Ixxii, 155-167. Merttens. Beitrage zur normalen u. path. Anatomie der menschlichen Placenta. Zeitschr. f. Geb. u. Gyn., 1894, xxx, 1-97. Meyer. On the Structure of the Human Umbilical Vesicle. Amer. J. Anat., 1904, iii, 155-166. Miller. Das jiingste operativ erhaltene menschliche Ei. Berliner klin. Wochen- schr., 1913, 865-869. Minot. Uterus and Embryo. Jour, of Morphology, 1889, ii, No. 3. Moellendorf. Ueber einen jungen operativ gewonnenen menschlichen Keim. Zeitschr. f. Anat. u. Entwickelungsges., ditto, 1921, lxxi, 406-432. Ueber das jiingste bisher bekannte menschl. Abortivei. 1921, lxii, 352-405. Nitabuch. Beitrage zur Kenntniss der menschlichen Placenta. D. I., Bern, 1887. Noortwyk. Quoted from Waldeyer. Outerbridge. Decidual Eeaction in the Appendix. Jour. Am. Med. Assn., 1913, lxi, 1702-1704. Overlach. Die pseudomenst. Mucosa uteri. D. I., Miinchen, 1885. Painter. The Spermatogenesis of Man. J. Exp.'Zoology, 1923, xxxvii. Peters. Ueber die Einbettung des menschlichen Eies. Wien, 1899. Rohr. Die Beziehungen der miitterlichen Gefasse zu den intervillosen Raumen der reifen Placenta, speciell zur Thrombose derselben (“weisser Infarct”). D. I., Bern, 1889. Ruge. Ueber die menschliche Placenta. Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 550-588. Schick. Ueber die Lymphgefasse d. Uterusschleimhant wiihrend der Schwanger- schaft. Arehiv f. Gyn., 1905, lxxvii, 1-20. Schlagenhaufer und Verocay. Ein ungles menschliches Ei., Arehiv f. Gyn., 1916, ev, 151-16$. Schmorl. Ueber grosszellige (decidua-iihnliehe) Wucherungen auf dem Peri- toneum u. den Ovarien bei intrauteriner Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1897, v, 46. Schultze. Das Nabelaschen, ein constantes Gebikle in der Naehgeburt des aus- getragenen Kindes. Leipzig, 1861. Selenka. Keimblatter u. Primitivorgane der Maus. Studien liber Entwickelungs- geschichte der Thiere, 1883, H. 1. Die Blatterumkehrung im Ei der Nagethiere, ditto, 1884, H. 3; 1891, H. 5. Menschen-Affen, Wiesbaden, 1899, ii; 1900, iii, Lieferung. Blattuinkehr im Ei der Affen. Biol. Zentralbl., 1898, xviii, 552-557. Sharkey. English translation of Muller's Handbuch der Physiologie, according to Schroeder’s Lehrbuch, XIII. Aufl., 1899. Sobotta. Die Befruchtung und Furehung des Eies der Maus. Arehiv f. mikr. Anat., 1895, xlv, 15-93. Die Entwickelung des Eies der Maus. Arehiv f. mikr. Anat., 1903, lxi, 274-330; and 1911, lxxviii, 271-352. Spee. Beitrag z. Entwickelungsgeschichte der friiheren Stadien des Meerschwein- chens, etc. Arehiv f. Anat. u. Phys., Anat. Abth., 1883, 44-60. Neue Beobachtungen iiber sehr friihe Entwickelungsstufen des menschlichen Eies. Arehiv f. Anat. u. Phys., Anat., Abth., 1896, 1-30. Beobachtungen an einer menschl. Keimscheibe mit offener Medullarrinne, etc. Arehiv f. Anat. u. Phys., Anat. Abth., 1899, 159-176. Die Implantation des Meerschweinehensei in die Uteruswand. Zeitschr. f. Morphol. u. Anthropol., 1901, iii, 130-182. Demonstration eines junges Stadium der menschlichen Eieinbettung. Verh. d. deutschen Gesellsch. f. Gyn., 1906, xi, 421-422. 155 156 MATURATION, FERTILIZATION AND DEVELOPMENT OF OVUM Strahl. Die Embryonalhiillen der Sauger und die Placenta. Herttvig’s Hand- buch des Entwickelungslehre, 1906, Bd. I, Theil II, 235-368. Streeter. A Human Embryo of the Presomite Period. Contributions to Em- bryology, No. 43, Washington, 1922. Thompson. The Maturation of the Human Ovum. J. of Anat., 1919, liii, 172-208. Todyo. Ein junges menschl. Ei. Archiv f. Gyn., 1912, xcv, 425-460. Turner. Observations on the Structure of the Human Placenta. Jour. Anat. and Physiol., 1873, vii, 120; also 1877, xi. Unterberger. Exp. Untersuchungen iiber ektopische Decidua. Monatschr. f. Geb. u. Gyn., 1921, li, 116-122. Van Beneden. Recherches sur les premieres stades du developpement du murin., Anat. Anzeiger,, 1899, xvi, 305-334. Vater. Quoted from Waldeyer. Volk. Das Vorkommen on Decidua in der Cervix. Archiv f. Gyn., 1903, Ixix, 681-687. Waldeyer. Bernerkungen iiber den Bau der Menschen- und Atfen-placenta. Archiv f. mikr. Anat., 1890, xxxv, 1-52. Weber. Zusatze vom Bau und den Verrichtungen der Geschlechtsorgane. Abh. der kgl. sachsischen Akademie, 1846. Webster. The Changes in the Uterine Mucosa during Pregnancy and in the Attached Foetal Structures. Amer. Gyn. and Obst. Journal, 1897, x, 168-264 and 535-662. Human Placentation. Chicago, 1901. von Weiss. Zur Kasuistik der Placenta prsevia centralis. Centralbl. f. Gyn., 1897, 641-649. Williams. Decidual Formation throughout the Uterine Muscularis. Trans. Southern Surg. and Gyn. Assn., 1905, xvii, 119-132. Winckler. Textur, Structur und Zellleben in den Adnexen des menschlicheu Eies. Jena, 1870. CHAPTER V THE FCETUS The Foetus in the Various Months of Pregnancy.—It is important that the physician be able to tell approximately the age of embryos and prematurely born children, and we shall therefore give a short descrip- tion of the foetus at its various periods of development. The actual duration of pregnancy is not yet known, but ordinarily two hundred and eighty days, or ten lunar months, elapse between the commencement of the last menstrual fioAV and the onset of labor, though a considerable number of children are born shortly before or after the expiration of that period. The following details concerning the development of the unborn child are taken in great part from His, who distinguished three periods in its evolution. Thus, during the first tAvo weeks of pregnancy the product of conception is designated as the ovum; from the third to the fifth Aveek—the period during which the various organs are developed Fig. 160. Fig. 161. Fig. 162. Fig. 163. Fig. 164. Fig. 165. and a definite form is assumed—it is known as the embryo; after the fifth week it becomes the foetus. First Two Weeks.—The earliest human ova with which we are ac- quainted were enumerated in the preceding chapter. With the exception of the one described by Bryce and Teacher, these were vesicular struc- tures whose main feature was the chorion, to one side of whose in- terior was attached the future embryo, so small a body that its component parts could be distinguished only with the aid of the microscope. In each instance the embryonic area was covered by a well-developed amnion, and the great bulk of the embryo consisted of the yolk sac. Moellendorf’s ovum presented the earliest stages in the formation of the embryo itself—namely, the primitive streak. Figs. 160 to 165 represent early ova described by His. Third Week.—The embryonal period begins with the third week, in the latter part of which can be detected the beginning formation of the groove and canal, soon to be followed by the appearance of the head folds. At this stage of development the abdominal pedicle is seen coming off from the tail end of the embryo, and lying almost in the same axis with it. The embryo is concave on its dorsal surface, and is made up in great part of the yolk sac. Figs. 160-165.—Early Embryos described by His. 157 158 THE FCETUS A little later the formation of the double heart may be noted; while the cerebral and optic vesicle, soon appear, as well as the visceral arches and clefts. The yolk sac becomes more and more constricted, and is connected with the ventral surface of the embryo by a broad pedicle. At the very end of the third week (about the twenty-first day) the limbs make their appearance as small buds upon the surface of the embryo. Fourth Week.—This week is characterized by a great increase in the size of the embryo, which becomes markedly flexed upon its ventral sur- face, so that its head and tail ends come almost in contact. The rudi- ments of the eyes, ears, and nose now make their appearance, and the Fig. 166. Figs. 166-169.—Embryos from Fourth and Fifth Weeks (His). X 2. Fig. 167. Fig. 168. Fig. 169. umbilical vesicle becomes still more pedunculated. At the end of the first lunar month the embryo measures from 7.5 to 10 millimeters (0.3 to 0.4 inch) in length. Second Month.—In the first half of the second month the human embryo does not differ essentially in appearance from that of other mam- mals. It is still markedly bent on itself, and the visceral clefts and arches are the most prominent characteristics of its cephalic region, while the extremities are in a rudimentary condition. In the latter part of the month, owing to the development of the brain, the head becomes disproportionately large, and assumes a certain resemblance to that of a human being. At the same time the nose, mouth, and ears become relatively less prominent and the extremities more developed, so that it can be seen that each is made up of three portions. The external genitalia also make their appearance in the latter part of this month, and at its end the foetus has attained a length of 2.5 centimeters (1 inch). Third Month.—At the end of this month the entire product of con- ception is about as large as a goose’s egg, and the embryo measures from 7 to 9 centimeters in length. Centers of ossification have appeared in most of the bones; the fingers and toes become differentiated and are supplied with nails; the external genitalia are beginning to shoAv definite signs,of sex. A foetus born at this time may make spontaneous move- ments if still within the amniotic sac or if immersed in warm saline solution. Fourth Month.—By the end of the fourth month the foetus is from THE FCETUS IN THE VARIOUS MONTHS OF PREGNANCY 159 10 to 17 centimeters long, and weighs about 120 grams. Casual ex- amination of the external genital organs will now definitely reveal the sex. Fifth Month.—The foetus varies from 18 to 27 centimeters in length, and weighs about 280 grams. Its skin has become less transparent, a downy covering is seen over its entire body, while a certain amount of typical hair has made its appearance on the head. Sixth Month.—At the end of the sixth month the foetus varies from 28 to 34 centimeters in length, and weighs about 634 grams. The skin presents a markedly wrinkled appearance, and fat begins to be deposited beneath it; the head is still comparatively quite large. A foetus born at this period will attempt to breathe, but always perishes within a short time, Fig. 170. Figs. 170-172.—Embryos from Second Month (His.). X 2. Fig. 171. Fig. 172. Seventh Month.—The length during this month varies from 35 to 38 centimeters, and the foetus attains a weight of over 1,200 grams. The entire body is very thin, the skin is reddish and covered with vernix caseosa. The pupillary membrane has just disappeared from the eyes. A fmtus born at this period moves its limbs quite energetically and cries with a weak voice; but, as a rule, it cannot be raised, even with the most expert care, although a success is occasionally recorded. It is generally believed among the laity that a child born at the end of the seventh month has a better chance of living than when it comes into the world four weeks later. This idea is a remnant of the old Hippocratic doctrine and is altogether erroneous, as the more developed the child the greater are its chances for life. Eighth Month.—At the end of the eighth month the foetus has at- tained a length of 42.5 centimeters, and a weight of about 1,900 grams. The surface of the skin is still red and wrinkled and the child resembles an old man in appearance. Children born at this period may live if properly cared for, though their chances are not very promising. 160 THE FCETUS Ninth Month.—At the end of the ninth month the foetus is 46 cen- timeters long, and weighs about 2,500 grams. Owing to the deposition of subcutaneous fat, the body has become more rotund and the face has lost its previous wrinkled appearance. Children born during this month have a very good chance of life if properly cared for. Tenth Month.—Full term is reached at the ehd of this month. The fcetus is now fully developed, and presents the appearances which we shall consider in detail when the new-born child is described. The foetus grows relatively much faster in the early than in the later months of pregnancy. According to Jackson, the weight of the mature ovum is only 0.000004 gram, which increases to 0.04 gram by the end of the first month after fertilization—an increase of 9,999 times, or practically one million per cent. In the second and third months the rate of increase has become reduced to 74 and 11 times respectively, and gradually falls to 0.3 times in the last month. Even this comparatively slow rate is not maintained after birth, for if it were the child would weigh about 160 pounds by the time it was one year old. Owing to inequalities in the length of the legs, and the difficulty of maintaining them in extension during mensuration, the determination of the sitting height (crown-rump) is more accurate than that of the stand- ing height. According to Streeter, the average sitting height and weight of the foetus at the end of the various lunar months, as determined from 704 specimens, are as follows: LUNAR MONTH. SITTING HEIGHT. WEIGHT. 2nd 0.23 centimeter 1.1 grams 14.2 “ 3rd 6.1 centimeters 4th 11.6 < ( 108.0 “ 5th 16.4 ( ( 316.0 “ 6th 20.8 i i 630.0 “ 7th 24.7 l ( 1,045.0 “ 1,680.0 “ 2,478.0 “ 3,405.0 “ 8th 28.3 < i 32.1 ( ( 10th 36.2 i Such figures possess only an approximate value, and generally speak- ing the length affords a more accurate criterion of the age of a child than its weight. Haase has suggested that the length of the embryo in centi- meters may be roughly approximated daring the first five months by squaring the number of the month to which the pregnancy has advanced; in the second half of pregnancy, by multiplying the month by 5, as is shown in the following table: At the end of the first month 1 XI, 1 centimeter. “ “ “ second month 2X2, 4 centimeters. “ “ “ third month 3X3, 9 “ “ ‘ ‘ fourth month 4 X4, 16 “ “ “ fifth month 5X5, 25 “ “ “ sixth month 6X5, 30 “ “ “ seventh month 7X5, 35 “ “ “ eighth month 8X5, 40 “ “ “ ninth month 9X5, 45 “ “ “ tenth month 10X5, 50 THE FCETUS IN THE VARIOUS MONTHS OF PREGNANCY 161 The Child at Full Term.—The average child at full term is 50 centi- meters or 20 inches long (36 centimeters or 14 inches sitting height), and weighs 3,250 grams or 7)4 pounds. The skin is smooth and polished in appearance, and shows no lanugo, except occasionally about the shoulders. Over the entire surface is spread a whitish, greasy material, the vernix caseosa, which is a mixture of epithelial cells, lanugo hairs, and the secretion of the sebaceous glands. The head is usually covered by darkish hairs 2 to 3 centimeters' in length, and the cartilages of the nose and ears are well developed. The fingers and toes possess well- developed nails, which project beyond their tips. In male children the testicles are usually found within the scrotum; in girls the labia majora are well developed and are in contact with one another, and usually conceal the rest of the genitalia. The bones of the head are well ossified, and are in close contact at the various sutures. The eyes possess a uniformly slate color, so that it is impossible to predict their final tone. Blecard in 1828 described a center of ossification, 0.5 centimeter in diameter, in the lower epiphysis of the femur. He considered it a diag- nostic sign of maturity, but it is not infallible. Ballantyne and Browne found it of this size in only one-third of one hundred full term children. Adair and Scammon have likewise studied the ossification centers at birth by means of Bontgen rays and have found that the results are not constant, which is in accord with my observations. Ordinarily, the proximal epiphyseal center of the tibia and two centers in the tarsus are present at term, while all are lacking in the carpus. On the other hand, the first was lacking in 19 per cent, of their cases; in the tarsus, a third center, that of the cuboid, is sometimes added; while two centers were noted in the carpus of 15 per cent, of their infants. Such observa- tions invalidate the conclusions of Hahn, according to which absence of the proximal epiphyseal center of the tibia always indicates prematurity. My own experience is that while X-ray examination of the ossifica- tion centers gives important information, it cannot always be relied upon to determine whether the child is premature, mature or post-mature. For example, Ballantyne and Browne pointed out that a third tarsal center was never observed in the premature child, was present in 7 out of 22 full term children, and yet was lacking in many which were clearly postmature. Holzbach holds that the most valuable sign of maturity is to be found in the relation between the fronto-occipital circumference of the head and that of the shoulder, as in only 1 out of the 31 premature children which he examined did the latter equal the former in size. Xo one of these conditions affords indisputable proof of the maturity of a child, but when the majority of them are present the evidence be- comes fairly convincing. Negro babies at birth differ somewhat in appearance from white chil- dren, but not so markedly as one might expect. Their skin presents a dusky, bluish-red hue, but does not at all suggest the darker color which it will assume in the course of a few weeks. Where there is a consider- able admixture of white blood, the dusky hue may be entirely absent, and the only certain evidence of negro ancestry will be found in an in- 162 THE FCETXJS creased pigmentation about the external genitalia, and at the matrix of the nails. Weight of the New-born.—The average infant at birth weighs about 3,250 grams (7% pounds), bo)rs being usually 100 grams (3 ounces) heavier than girls. Marked variations are frequently observed, which are dependent upon the race and size of the parents, the number of chil- dren which the mother has borne, her mode of life, and her nutrition and general condition during the later months of pregnancy. In 707 full- term white children born at the Johns Hopkins Hospital, T. F. Riggs found that the average length was 49.64 centimeters, and the average weight 3,316.9 grams (7.32 pounds), the smallest child weighing 2,180 grams (4 pounds 12 ounces) and the largest 4,553 grams (10 pounds). Colored children weigh considerably less than white, a fact which, in large cities at least, is indicative of the physical degeneration which characterizes the race. Four hundred and seventy full-term colored children studied by Riggs averaged 48.75 centimeters in length and 3,104.8 grams in weight, a difference of 211 grams (7 ounces) in favor of the white race. Perfectly healthy full-term children may vary from 2,300 to 5,000 grams (5 to 11 pounds) in weight. They rarely exceed the latter figure, although one occasionally hears of children weighing 15, 16, and even 20 pounds at birth. The majority of such cases, however, must be regarded as apocryphal, and careful inquiry will usually show that the weight has been only roughly estimated by lifting the child in the hand, and was not based upon accurate determination. Winckel found only 5 children that weighed over 5,000 grams in 30,500 deliveries, and Starcke 16 in 34,000 deliveries in Leopold’s clinic. According to Ludwig, out of 15,166 children born in Chrobak’s clinic in Vienna, only 1 weighed 5,300 grams (11% pounds), and Varnier stated that in seven years, at the Baudelocque Clinic in Paris, there were only 6 children that ex- ceeded 5,000 grams at birth, the heaviest weighing 6,150 grams (13 pounds 9 ounces). Moreover, it is probable in many instances that the excessive weight of such children should be attributed to the fact that the pregnancy had persisted several weeks beyond the usual term—in other words, that they were post-mature. In some 25,000 children delivered under my supervision, the largest weighed 6,470 grams (1414 pounds), and measured 62.5 cm. in length. Dubois, in 1897, collected from the literature 28 cases in which the child weighed 5,600 grams (12 pounds) or more at birth, and stated that the heaviest children on record were reported by Ortega, Rachel and Neumer, and Beech, and weighed respectively 11,300, 11,250, and 10,750 grams. Ludwig, in 1896, reported that he had been obliged to perform cesarean section, after craniotomy and amputation of the extremities, in order to deliver a child weighing 7,700 grams (16 pounds 10 ounces). In spite of these exceptional cases, one should be extremely skeptical in accept- ing reports concerning phenomenally heavy children, unless convinced that the reporter is a truthful person and has weighed the child upon an accurate balance. On the other hand, healthy full-term children frequently weigh less WEIGHT OF THE NEW-BORN 163 than 3,250 grams, and sometimes as little as 2,300 grams (5 pounds) ; although, when the weight falls below 2,500 grams, the child should be considered as premature unless its length exceeds 45 cm. Any weight below this limit, in the case of an infant born at term, should always lead one to suspect some disease on the part of the mother or foetus, as nephritis or syphilis. Generally speaking, premature children weighing less than 1,500 grams and measuring less than 35 cm. in length have practically no chance of life, though in exceptional cases they may do well. Piering reports raising a premature child that weighed only 1,120 grams at birth, and mentions instances in which children weighing only 717, 719, and 750 grams respectively were successfully reared. Dr. H. A. Powell, of Cleveland, informed me that he had successfully raised an infant which weighed 750 grams at birth. The size of the foetus usually increases with the age of the mother up to the thirtieth year, if pregnancies have not followed in too rapid succession. The size is also dependent, to a considerable extent, upon that of the parents, especially the father; and in many instances the child’s head closely resembles that of the latter in shape. The social condition of the mother and the comforts by which she is surrounded also exert a marked influence upon the child’s weight, heavier children being more common in the upper walks of life. Thus, on look- ing over the records of my private cases, I found that healthy full-term children averaged 3,795 grams in weight, as compared with 3,316.9 and 3,104.8 grams for the white and colored children in hospital practice— a difference of 478 and 690 grams, respectively. Pinard and Bachimont, from a study of 4,445 cases observed in the Baudelocque Clinic, arrived at somewhat similar conclusions. They found that the children of women who had lived in the hospital for three months prior to confinement averaged 500 grams heavier than those of patients who had entered it just before or during labor. They consider that this difference is due to the better nourishment of the former class of patients, as well as to the avoidance of premature labor incident to hard work. T. F. Riggs made similar observations in my service at the Johns Hopkins Hospital, but found that there was a greater increase in weight in the colored than in the white children. He was inclined to attribute the difference to the fact that the hospital fare was no better than that which the white women received in their homes, but was superior to that to which the average colored woman is accustomed. It is generally believed that the comparatively difficult labors of the women of the upper classes are due to the enervating influences of civ- ilization and luxury, while the easy labors of negroes are considered as manifestations of a closer approach to Nature. Such conclusions are not justified by my experience, as the physical degeneration of colored women living in large cities is proven by the fact that in them the incidence of contracted pelvis is four or five times as great as in white women. Were this not counterbalanced by the lesser weight of the black children, and particularly by the smaller size and greater com- 164 THE FCETUS pressibility of their heads, labor would be a disastrous function, and would comparatively soon lead to a solution of the race problem. If the negro children were as large and had as hard heads as in the upper classes, I should be obliged to perform a cesarean section a week, instead of 15 or 20 each year, as at present. Accordingly, it appears permissible to attribute the more difficult labors in the upper classes to the larger size of their children, resulting from abundant nutrition and a life of ease, rather than to the enervating influences of civilization. Provided the pelvis is normal, it is unusual for children weighing less than 5,000 grams (11 pounds) to cause difficult labor simply from their size, since A7arnier has shown that the diameters of the head to not increase in the same ratio as the weight of the child. The Head of the Child.—From an obstetrical point of view the head of the child is its most important part, as the essential feature of labor Fig. 173.—Child’s Head at Term. X %. (American Text-Book.) is a process of adaptation between it and the various portions of the pelvic canal through which it passes. An accurate knowledge of its characteristics and size is therefore of capital importance. Only a comparatively small part of the head of the child at term is represented by the face, the rest being composed of the firm, hard skull, which is made up of two frontal, two parietal, two temporal bones, the upper portion of the occipital, and the wings of the sphenoid. These bony portions are not firmly united together, but are separated from one another by spaces filled with membrane—the sutures. Of these the most important are the frontal, between the two frontal bones; the sagittal, between the two parietal bones; the coronal, between the frontal and parietal bones; and the lambdoid suture, between the posterior margins of the parietal bones and the upper margin of the occipital bone. All of these sutures can be felt during labor; whereas the temporal suture, ■which is situated on either side between the inferior margin of the THE HEAD O'? THE CHILD 165 parietal and the upper margin of the temporal bones, is covered by soft parts and cannot be felt on the living child. Where several sutures meet together an irregular space is formed, which is closed by a membrane and designated as a fontanelle. Four such structures are usually distinguished: the greater and lesser, and the two temporal fontanelles. The greater or anterior fontanelle is a lozenge-shaped space situated at the junction of the sagittal and the coronal sutures. The lesser or posterior fontanelle is represented by a small triangular area at the intersection of the sagittal and lambdoid sutures. These are readily felt during labor, and their recogni- tion gives important informa- tion concerning the position and presentation of the child. The temporal or gasserian fon- Occiput Fie. 174.—Child’s Head at Term. X H- (American Text-Book.) Fig. 175.—Head at Term, showin- Small, Sagittal, and Large Fong TANELLES. X Yl- tanelles, which are situated at the junction of the lambdoid and temporal sutures, cannot be felt on vaginal examination. Arnold Lea directed attention to the occasional presence of what he designated as the sagittal fontanelle, which is a lozenge-shaped space found in the sagittal suture at a point about half-way between the greater and lesser fontanelles. He considers that it results from faulty ossification of the parietal bones, and states that it occurred in 4.4 per cent, of 500 fcetal skulls which he examined. I have met with it less frequently, and while I cannot adduce accurate statistics, I would esti- mate its incidence at about one per cent. In several instances its presence gave rise to a serious error in diagnosis. To aid us in forming definite ideas concerning the shape and size of the foetal head, it is customary to measure certain diameters and circum- ferences. The diameters most frequently used are: (1) the fronto- 166 THE FCETUS occipital, which follows a line extending from the root of the nose to the most prominent portion of the occipital bone; (2) the biparietal, which represents the greatest transverse diameter of the head, and ex- tends from one parietal boss to the other; (3) the bitemporal, which represents the greatest distance between the two temporal sutures; (4) the mento-occipital, from the chin to the most prominent portion of the occiput; and (5) the suboccipito-bregmatic, which follows a line drawn from the middle of the large fontanelle to the under surface of the occipital bone, just where it joins the neck. For convenience the vari- ous diameters are frequently designated by initials, which, with their several average measurements, are given in the following table: Initials. Average Length. Riggs’ Figures. Fronto-occipital F. 0. 11.75 cm. White. 11.71 cm. Black. 11.26 cm. Biparietal B. P. 9.25 “ 9.25 “ 9.05 “ Bitemporal B. T. 8 8 7.81 “ Mento-occipital M. 0. 13.5 “ 13.33 “ 13.31 “ Suboccipito-bregmatic S. 0. B. 9.5 “ 9.70 “ 9.29 “ The greatest circumference of the head, which corresponds to the plane of the fronto-occipital diameter, is 34.5 centimeters, while the least circumference, corresponding to the plane of the suboccipito-bregmatic diameter, is 32 centimeters. The figures just given are based upon the average measurements of a large number of heads just after birth, in- dividual variations being frequently encountered. As a rule, boys have somewhat larger heads than girls, and the children of multiparae than those of primiparae. As indicated in the table, Riggs’s figures show that all of the diameters are shorter in negro children; but such meas- urements give no idea of the greater softness and compressibility of their heads. According to Calkins the various measurements of the head bear a constant relation to the standing height of the child. Conse- quently, he states that measurements of the head, when plotted as ordi- nates against the standing height as abscissae, result in a straight line curve. This being the case, the relationship between any two dimensions can be expressed by the straight line empirical formula— y = a x ± b; x and y being body dimensions and a and b constants. A certain amount of motility exists at the sutures between the various bones composing the skull. This may vary within relatively wide limits in different individuals, so that heads which afford the same diameters on actual measurement frequently differ markedly in the obstacle which they offer to labor; as the bones of one may be soft, compressible, and readily displaced, while those of another are firmly and densely ossified and admit of but little motility, the former being readily molded to the pelvic canal, while the latter are incapable of reduction in size. Physiology of the Foetus.—Our knowledge concerning the physiology of the foetus has been markedly enriched during recent years; neverthe- less, when compared with that of the adult, it offers many points con- cerning which we are but slightly informed or profoundly ignorant. PHYSIOLOGY OF THE FCETUS 167 Nutrition of the Foetus.—Owing to the small amount of yolk con- tained in the human ovum, the growth of the foetus is almost entirely dependent upon the amount of nutritive material which it obtains from its mother. During the first few months of pregnancy, as Fehling first pointed out, the embryo consists almost entirely of water, and it is during this period that it grows most rapidly. In the later months of pregnancy, when more solids are being added, the increase in size becomes gradually slower. Fehling’s conclusions mere confirmed by Michel, who analyzed the foetus at various periods with the results noted in the following table, which indicates that, as the foetus increases in age, it contains relatively less water and a markedly increased quantity of albuminoid materials, salts, and fats. Water. Albuminoids. Salts. Fats. At 2\ months. . 93.82 per cent. 4.49 per cent. Trace. Trace. 3d to 4th month 89.95 7.05 1.729 per cent. . 0379 per cent. 7th month 84.75 10.04 “ 2.487 1.823 “ At term 69.16 13.96 3.373 11.75 For the first few days after the implantation of the ovum, its nutri- tion must be derived from the serum which accompanies the edematous condition of the decidua. Furthermore, the surrounding maternal tissue which has undergone necrosis as the result of the digestive action of the trophoblast, as well as the greatly augmented glandular secretion which characterizes this period, probably serves as a pabulum, to which is added the glycogen, which Driessen has shown accumulates in the glandular epithelium and the stroma of the endometrium during the period of premenstrual swelling. Within the next week intervillous spaces, which are filled with maternal blood, begin to develop between the trophoblast and decidua. As the chorionic villi at this period are devoid of vessels, the only way in which nutritive material, which has been taken up by the trophoblast from the maternal blood, can be transmitted to the embryo is by means of direct osmosis. In the third week of pregnancy the omphalomesenteric vessels make their appearance upon the surface of the umbilical vesicle, and whatever nutritive materials the latter may contain are conveyed to the embryo by them. During the fourth week branches of the umbilical vessels appear in the chorionic villi, and from that time on make possible the direct transmission of nutritive material from the maternal to the foetal blood. The Foetal Circulation.—Owing to the fact that the lungs do not function, and that the materials needed for the nutrition of the foetus are brought to it from the placenta by the umbilical vein, the foetal circulation differs materially from that of the adult (Plate VIII). The blood is purified and laden with nutritive material in the placenta, and is then carried to the foetus through the umbilical vein, which, after penerating the abdominal wall, divides into two branches. Of these the smaller unites with the portal vein, the blood from which circulates 168 THE FCETUS through the liver and then gains access to the inferior vena cava through the hepatic vein. The other larger branch, which is designated as the ductus venosus, empties directly into the vena cava. The contents of the vena cava above the hepatic vein, therefore, consist of a mixture of arterial blood from the placenta and venous blood returning from the lower extremities of the foetus. Thus far all investigators agree, but there is still considerable divergence of opinion as to the course the blood takes after leaving the vena cava. It is generally taught that upon entering the right auricle it is deflected by the intervention of the eustachian valve in such a manner as to pass through the foramen ovale into the left auricle, whence it passes into the left ventricle, which forces it into the aorta. On the other hand, the blood returning from the head and upper extremities by way of the superior vena cava is poured into the right auricle, and, crossing the current from the inferior vena cava, passes into the right ventricle, whence it is forced into the pulmonary arteries. But so long as the lungs do not function, only a small portion of this blood gains access to them, the greater part of it passing through the ductus arteriosus to the arch of the aorta, and being then carried to the rest of the body of the embryo. According to this view, the blood from the inferior and superior vena cava does not mix in the right auricle, but the two currents cross one another in such a way that the purer blood from the inferior cava passes directly to the left side of the heart through the foramen ovale, and is supplied in great part to the head and neck; while the less pure blood from the superior cava passes through the right auriculoventricular opening and is forced by the right ventricle into the pulmonary arteries and the ductus arteriosus. Pohlman (1909) states that this view is incorrect, as it is physically impossible for the two currents to cross one another without mixing. Accordingly, he believes that the two currents mix in the right auricle, while enough of the mixed blood passes into the left auricle through the foramen ovale to make up for the deficient return through the pulmonary veins. Ziegenspeck likewise believes that the blood in the two auricles is identical in composition, but that the result is accomplished in a different manner. In any event, the blood which has gained access to the aorta directly from the left, as well as from the right, ventricle through the ductus arteriosus is propelled down the aorta and given off to the various organs according to their needs; but the bulk of it enters the internal iliac and hypogastric arteries—the latter after passing the umbilicus being desig- nated as the umbilical arteries—and through them gains access to the placenta. From the foregoing description it is apparent that the blood circu- lating in the foetus is at no time strictly arterial or strictly venous, but that the content of the inferior vena cava is purer than that of the aorta. The distinctive features of the foetal circulation are connected with the ductus venosus and arteriosus, the foramen ovale, the hypogastric arteries, and the umbilical cord. After birth these structures undergo marked changes. As soon as the child is born and begins to breathe, the PLATE VIII. FCETAL CIRCULATION. PHYSIOLOGY OF THE FOETUS 169 pulmonary circulation becomes established. As a result, a much greater quantity of blood is pumped by the right ventricle into the pulmonary arteries, while a lessened amount passes through the ductus arteriosus. Moreover, as soon as the circulation in the cord is abolished, the umbilical vein becomes functionless, and a diminished quantity of blood is returned to the right auricle by the inferior vena cava. This change leads to a diminution in the tension in the right auricle, while that in the left side of the heart is increased, bringing about the closure of the valvelike fora- men ovale. As the circulation through the umbilical arteries ceases almost imme- diately after the pulmonary circulation is established, the function of the hypogastric arteries is in abeyance, and their distal ends rapidly un- dergo atrophy and obliteration, which is usually complete three or four days after birth. The ductus venosus and umbilical veins also become occluded during the first week, whereas the closure of the ductus ar- teriosus is more gradual, and frequently its opening does not become impervious until several weeks after birth. Permanent closure of the foramen ovale does not occur for some time, and not rarely months elapse before it is completed. Occasionally it remains patent, and circulatory disturbances of greater or less gravity result from its persistence. Transmission of Substances through the Placenta.—As was shown when considering the structure of the placenta, there is no direct com- munication between the vessels of the chorionic villi and the intervillous blood spaces. In the first half of pregnancy foetal and maternal blood are separated from one another by the syncytium, Langhans’ layer of cells, a thicker or thinner leaflet of the stroma of the villus, and the walls of the foetal capillaries, while in the second half Langhans’ layer gradually disappears. The independence of the two circulations is readily demonstrated during the first months of pregnancy by comparing the contents of the foetal vessels with that of the intervillous spaces. In the former large numbers of nucleated red corpuscles are found, which are never present in the latter. In order that substances may pass from the mother to the foetus, or in the reverse direction, it is necessary for them to traverse the layers of tissue which we have just mentioned. It would appear that gases and substances in solution pass by osmosis directly from the maternal to the foetal blood and vice versa, but that colloids and formed substances must undergo certain changes in the chorionic epithelium before they can be transmitted. The transmission of gaseous substances has been definitely demon- strated both by clinical observation and experimental work. Comparison of the blood in the umbilical vein and arteries, respectively, shows that the former is lighter in color, indicating that it is richer in oxygen than the latter. This fact has also been demonstrated experimentally by Zwei- fel, who showed that the blood in the umbilical vein, when examined by means of the spectroscope, contained oxyhemoglobin. Again, Cohnstein and Zuntz have demonstrated that the blood of the umbilical vein in the sheep is richer in oxygen and poorer in carbon dioxid than that contained in the umbilical arteries. Zweifel has also shown that chloroform admin- 170 THE FCETTJS istered to the mother is rapidly transmitted to the foetus, and Nicloux has made similar observations with ether. The increase in the size of the foetus affords conclusive evidence that nutritive and other materials must pass from the maternal to the foetal circulation, and this has been demonstrated experimentally for many substances in solution. The first work of this character we owe to Mayer, who in 1817 proved the passage of cyanid of potassium. Since then conclusive evidence has been adduced of the transmission of many inorganic and organic salts, alcohol and other compounds. Moreover, the demonstration by Kronig and Filth that the freezing points of both the maternal and foetal blood are identical, indicates that they both possess the same osmotic pressure, and consequently that osmosis can occur equally readily in either direction. Nicloux summarized our knowl- edge upon the subject up to 1909, and among other substances men- tioned iodid and bromid of potassium, phosphorus, the salts of mercury, copper, arsenic, and lead, carbolic acid, salicylate of sodium, quinin, morphia, atropin, and urea. Slemons and his associates—Morriss, Morse, Stander, Bogert and Curtis, have clearly shown that such excrementitious substances as urea, non-proteid nitrogen, ammonia, and uric acid are present in the same concentration in both the maternal and foetal blood and therefore must pass from one to the other by simple osmosis; while Plass, and Hunter and Campbell have made similar observations in the case of creatinine and creatin. On the other hand, Slemons and his associates have shown that the content in amino acids is higher in the foetal than in the ma- ternal blood, while the reverse holds good for glucose. They assume that both of these substances are transmitted by osmosis, but that the higher content in amino acids indicates that they are in some way “fixed’'' by the foetal blood. Furthermore, they hold that the higher glucose content of the maternal blood represents a mechanism, which insures a constant osmotic flow of this important substance to the less concentrated blood of the foetus. On the other hand, they hold that lipoids do not pass the placental filter, and that the fat required by the foetus is built up from glucose. They base this conclusion upon the fact that, while the fat content of the maternal blood is definitely increased during pregnancy, and always exceeds that of the foetal, no fixed ratio can be established between the two. Consequently, Slemons and Stander hold that the increased lipoid content of the maternal blood should be regarded as a preparation for lactation, but plays no part in the nutrition of the foetus in utero. Stander and Tyler have also pointed out that great caution should be exercised in drawing conclusions from analyses of the foetal and ma- ternal blood, unless the moisture content is determined at the same time, as variations in this respect may lead to such changes in concentration as to vitiate the deductions. Plass in this clinic has studied the relations of calcium and phosphoric acid, and found that the former is more abundant in the foetal than in the maternal blood, which is what one would expect when the need for calcium in the formation of the foetal skeleton is borne in mind. At PHYSIOLOGY OF THE FCETUS 171 the same time, study of the phosphoric acid relations may lead to erroneous conclusions unless all of the factors concerned are critically considered. His analyses showed that the total phosphorus content was much greater in the maternal blood; but, on the contrary, when its lipoid and inorganic and organic fractions wrere differentiated, totally different conclusions became inevitable, and it appeared that the lipoid phosphorus did not pass to the foetus at all, while the inorganic and organic fractions did, and were present in considerably larger quantities in the foetal blood. Upon summarizing these observations, it is apparent that the various excrementitious substances and glucose follow the laws of simple osmosis, that fat is not transmitted at all, and that the amino acids, calcium, and inorganic and organic phosphorus are more abundant on the foetal side, so that if they are transmitted by osmosis some mechanism must exist for their fixation in the foetal blood. Otherwise, it must be assumed that the chorionic epithelium must exert some selective activity, such as Cunningham has demonstrated in the cat, in which sodium ferro- cyanide readily passes into the foetal blood while iron ammonium citrate does not. It is now generally believed that the passage of formed substances does not occur, unless the material has first undergone marked changes under the influence of the chorionic epithelium, or when the placenta presents lesions. The work of Bonnet, Ilofbauer, and others clearly shows that in various animals such substances as iron, fat, and al- buminous substances, are taken up by the syncytium, and after under- going radical changes are eventually passed on to the foetal circulation. Our knowledge upon the subject was well summarized by Hofbauer in 1909, while Goldmann advanced it still further in 1912 during the course of his researches upon “vital staining.” The work of Wislocki and Shimidzu has clearly shown that colloidal dyestuffs are unable to pass the placental filter unless their particles are extraordinarily minute in size. Iron is taken up by the trophoblast in the form of hemoglobin derived from hemolyzed maternal blood, and by appropriate biochemical methods can be demonstrated in the epithelium and stroma of the villi on its way to the foetal \^essels. It has already been pointed out that in man fats probably do not pass through the placenta at all, but in certain animals it may be broken down in the outer portion of the syncytium into its constituents, which are later recombined just as in the intestines. This was shown conclusively by Hofbauer, who, after feeding pregnant animals with fat stained with Sudan red, found that characteristically stained fat in the inter- villous spaces, but only unstained fat was demonstrable in the syncytium and stroma of the villi. Albuminous substances are not absorbed as such, but are likewise broken down into simpler compounds, which are recombined after passing into the foetal blood. It is now believed that they are resolved into their constituent amino acids, but Hofbauer and others could only demonstrate the presence of albumoses. Accordingly, it appears that the passage of organic substances through 172 THE FCETUS the placenta is accomplished by processes analogous to those occurring in the intestines, and that the syncytium is not only able to change many substances, but also has definite powers of selection. Plausibility is lent to such a view by the discovery by Bergell and Falk, Liepmann, Lockhead, and others of the presence of proteolytic, lipolytic, glycolytic, and oxidiz- ing ferments in the chorionic villi, more particularly in the syncytium. Although Claude Bernard, as early as 1859, demonstrated the pres- ence of glycogen in the placenta, its significance has only recently been appreciated. The investigations of Driessen, Jaretsky, and others have shown that before each menstrual period it is deposited in considerable quantities in the endometrium apparently in anticipation of the nutrition of the ovum. Moreover, in the first half of pregnancy, large quantities of glycogen are found not only in the decidua but also in the syncytium, cell nodes, and trophoblastic islands of the placenta, so that these struc- tures in all probability store glycogen and give it up to the foetus when- ever sugar is needed. Great caution must be exercised in applying to man, or even to other animals, conclusions drawn from observations or experiments upon animals of another species, on account of the remarkable differences in the structure of the placenta in even closely related species. It should always be remembered that in the semi-placentae of swine, cattle and sheep there is no possibility of the transfer of materials from the ma- ternal to the foetal blood by means of osmosis, but that the nutrition of the foetus is effected by direct absorption by the chorionic epithelium of the so-called uterine milk—the secretion of the uterine glands; and that in the dog and cat the conditions are by no means analogous to those obtaining in man. For example, in the latter animals it is not Unusual to observe maternal erythrocytes in the process of digestion within the bodies of the high columnar, chorionic, epithelial cells, those nearest the surface presenting a normal appearance, while those at the basal portion of the cells have undergone almost complete dissolution. The work of Polano, Wegelius, and others has shown that many toxins and antitoxins are transmitted through the placenta—notably those of diphtheria, tetanus, colon and typhoid. Furthermore, "Wegelius has proved that such transmission is not mere filtration or osmosis, but is due to some selective action on the part of the syncytium; as, after in- ducing active or passive immunity in the mother, he was able to demon- strate in certain cases that the antibody titer was higher in the foetal than in the maternal serum. The question as to whether the placenta acts as an efficient filter against bacteria has given rise to a great deal of discussion, but at present the consensus of opinion is that such transmission occurs but rarely, and usually only in connection with some distinct lesion of the organ. The occurrence of intra-uterine smallpox was urged by John Hunter and many subsequent observers as proof in support of the affirmative view. Formerly it was not infrequent for mothers who suffered from smallpox during pregnancy to give birth to children bearing marks, of the disease, and one of the most celebrated cases of this character was that of Mauriceau. the well-known obstetrician of the seventeenth century, who PHYSIOLOGY OF THE FCETUS 173 was born pock-marked. The significance of this occurrence, however, is by no means clear, inasmuch as we are not as yet acquainted with the materies morbi concerned. Lubarsch has shown that the organisms of anthrax, pneumonia, typhoid fever, relapsing fever, and the various infections due to pyogenic organisms may be transmitted now and again, but regards such an oc- currence as exceptional. This is particularly well shown in tuberculosis, but out of the large number of tuberculous women who are delivered every year, Hauser in 1898 was able to collect only 18 who had given birth to children or placentae which gave evidence of the disease. Like- wise, in none of the placentae from tuberculous Avomen which I have examined have I been able to find lesions in the foetal portion, even when the decidua was affected by the disease. In typhoid fever, on the other hand, it would appear that the trans- mission of organisms occurs frequently. Speier, in 1897, found the specific bacilli in the organs of a foetus whose mother was suffering with typhoid fever, and F. W. Lynch, in 1902, reported a case of the same character from my service. Since then we have repeatedly made similar observations, and Hicks and French noted such a transmission in 10 out of 30 cases, so that it is now generally recognized as a fre- quent concomitant of the disease. In other affections it would appear that transmission never occurs from mother to foetus. Thus, in malaria there is no evidence that the specific parasites can pass from the maternal to the foetal blood. The transmission of materials from the foetus to the mother has also been experimentally demonstrated for animals. Thus Savory and Gus- seroAv showed, by injecting strychnin into embryos still within the uterus, that the mother died within a short time from strychnin poisoning. Similar results Avere also obtained by Preyer Avith hydrocyanic acid, and by Nicloux Avith alcohol. The Nature and Functions of the Amniotic Fluid.—In addition to the materials received from the placenta, it is generally believed that the foetus obtains a great part of the fluid necessary for its development from that contained in the amniotic sac. Spiegelberg, Ahlfeld, Zweifel, and others have demonstrated that considerable quantities of it are swallowed, inasmuch as they found lanugo hairs, epidermic cells, etc., in the stomach and intestines of the foetus. Ahlfeld believes that the amniotic fluid is SAvallowed in such large quantities that even the small amount of al- bumin AAdiich it contains aids in the nutrition of the foetus; but this point is very doubtful. Besides this function, the amniotic fluid plays an important part by surrounding the foetus with a medium of constant temperature, which serves to prevent loss of heat, Avhile at the same time affording a protection against sudden shocks from without. It also sub- serves an important function by preventing the formation of adhesions between the foetus and the Avails of the amniotic sac, which, when they occur, often give rise to serious deformities. According to Iloppe-Seyler, the amniotic fluid is clear, alkaline in reaction, having a specific gravity of 1.006 to 1.008, and consisting of 98.48 per cent, water, 0.19 per cent, albuminoid material, 0.556 per cent. 174 THE FCETUS soluble inorganic salts, 0.8 per cent, extractives, and 0.024 per cent, insoluble organic salts. Unfortunately it is impossible at this time to make positive state- ments concerning the origin of the amniotic fluid in women, and those interested in the subject will find our knowledge up to 1912 well sum- marized in the articles of Ahlfeld and Wagner. From time to time four main views have been advanced as to its origin: (1) foetal urine; (2) transudation from maternal blood; (3) secretion through the am- niotic epithelium, and (4) a mixed origin. The first view was advocated in the seventeenth century by Portal, and has had many adherents until recently. Practically all investigators agree that the foetal kidneys are capable of functioning in the later months of pregnancy, and undoubtedly do so under abnormal conditions, notably in certain cases of uniovular twin pregnancy. On the other hand, it is extremely doubtful whether they function at all under normal condi- tions, as it would appear improbable that the foetus would swallow its own urine. Moreover, the fact that the amniotic fluid is present in very early ova, even before the development of the embryonic area, as well as before the development of the foetal kidneys, clearly indicates that in early pregnancy at least some other origin must be sought. Furthermore, the occurrence of dropsical ova, in which all trace of the foetus has disappeared, while the amniotic sac is distended by fluid, forces us to a similar conclusion. Finally analysis of the am- niotic fluid shows that it contains very small quantities of urea, and indicates, if it is foetal urine, that it differs very markedly from that excreted during extra-uterine life. The question has also been approached experimentally, particularly by Schaller. This observer availed himself of the well-known fact that the administration of phloridzin gives rise to a transitory diabetes, which re- sults from the action of the drug upon the renal epithelium and not from changes produced in the blood. He showed that after the drug had been injected into the mother its presence could readily be demonstrated in the tissues of the foetus, while the amniotic fluid rarely contained traces of sugar, which should have been present in large quantity had the foetal kidneys functioned. Until very recently many authorities believed that the amniotic fluid was in great part a transudation from the maternal vessels. Probability is lent to such a view by the fact that an excessive quantity of amniotic fluid is present in certain dropsical conditions of the mother, but more particularly by the results following the injection of certain substances into the maternal circulation. When potassium iodid or sodium indigo sulphate is so injected the substance promptly appears in the amniotic fluid, but no trace can be demonstrated in the foetal kidneys. Further- more, glucose is frequently present in the amniotic fluid of women suf- fering from glycosuria, while it is uniformly absent in normal preg- nancy. On the other hand, the fact that Zangemeister and all subsequent investigators have found that the freezing point of the amniotic fluid is lower than that of the maternal serum clearly indicates that the former PHYSIOLOGY OF THE F(ETUS 175 cannot be derived from the latter by filtration. Furthermore, the bio- chemical investigations of Polano show that the amniotic fluid does not contain certain antibodies found in the maternal serum, which should be present were the former a mere transudate. Likewise, the amniotic fluid and maternal serum lack a staphylolysin which is present in the foetal urine. Consequently, he concluded, since the amniotic fluid was derived neither from the maternal serum nor from the foetal urine, that the only origin possible must be a direct secretory action on the part of the amniotic epithelium. Particularly in certain cases of hydramnios, histological examination by Polano, Bondi, Mandl, and others shows that certain changes occur in the amniotic epithelium which can only be interpreted as manifesta- tions of secretory activity. Likewise, the investigations of Goldmann and Evans upon “vital staining” point to a similar conclusion. Upon injecting pregnant animals with pyrrol-blue, these observers found that the internal organs and external surface of the mother took on a blue stain, while in the foetus the coloration was limited to the external surface and to the lining of the intestinal canal. At the same time the amniotic fluid was blue and the amniotic epithelium pigmented. They accord- ingly concluded that the pigment gained access to the amniotic fluid through the amniotic epithelium, and that the pigmentation of the foetus was due to the fact that it was bathed by and also swallowed the colored liquor amnii. That the latter could not represent foetal urine was demonstrated by the absence of pigment from the vesical and renal epithelium. Finally, dt should be borne in mind that a great part at least of the amniotic fluid may represent a transudation through the surface of the foetus or through the vessels of the cord; and, furthermore, as shown by the experiments of Wolff, that the foetal kidneys may function if those of the mother become insufficient. Wagner, however, has shown that in experimental animals mere renal insufficiency on the part of the mother is not sufficient to cause the foetal kidney to function, but that this occurs only after double nephrectomy, or at least after the removal of three-quarters of the kidney substance. Accordingly, from the evidence at present available, it would appear that under normal conditions the amniotic fluid is derived primarily from the maternal serum, which is profoundly modified during its pas- sage through the amniotic epithelium; but that under abnormal condi- tions other sources, more particularly the foetal urine, will have to be taken into consideration. Respiratory and Digestive Functions.—It would appear that the foetus in utero requires a relatively small quantity of oxygen to support life, so there is but little tissue waste. Again, the fact that it is sur- rounded by amniotic fluid makes it necessary for the foetus to produce but little warmth, as only a small amount of energy is expended during its restricted movements. Its need of oxygen, however, is demonstrated by the rapid occurrence of death, with symptoms of asphyxia, whenever the circulation of the umbilical cord is interfered with even for a short time. 176 THE FOETUS It has been demonstrated that the foetus actually produces warmth, as Wurster showed that its temperature exceeded that of the interior of the uterus by 0.5° C. or 0.9° F. Champion, in 1903, arrived at a similar conclusion, and put the difference at 1° F. Very little is known concerning the functions of the intestinal tract of the foetus, though it has been demonstrated that the stomach contains pepsin and rennin after the fifth month, their presence indicating a cer- tain amount of glandular activity. The large amount of blood which circulates through the liver \vould go to show that this organ serves some important purpose, and the formation of bile is conclusively demonstrated by the presence of biliary materials in the meconium. While the foetus remains in the uterus its movements are restricted within narrow limits, though such undoubtedly occur, being felt by the mother as “life” from the middle of pregnancy, and at a little later period by the physician when he places his hand upon the abdomen. Ahlfeld demonstrated, by the use of the sphygmograph, that the foetus makes very rapid superficial movements—at the rate of sixty to the minute—which he considered represented an abortive type of respiration; but his conclusions have not been generally accepted, and we are still in doubt as to the significance of his observations. Sex of the New-born Child.—Statistics show that more boys are born at full term than girls, the proportion, according to the figures given by Rauber, being 106 to 100. Ahlfeld has pointed out that this ratio is still further increased in elderly primiparae. Furthermore, it is well known that in abortions and premature labors the males still further outnumber the females. In 1,200 specimens of abortion in the Carnegie Laboratory of Embryology, Schultz found that the sex ratio was 110 to 100, and stated that Auerbach had estimated that it was 125 to 100 at the onset of pregnancy, thus indicating a specifically greater mortality in the case of males. For these reasons, Schultz suggested the advisability of dis- tinguishing between primary, secondary and tertiary sex ratios: the first representing the conditions immediately following conception, the second those at full term, and the third those at any specifically chosen period of later life. Until recently we were almost absolutely ignorant concerning the causation of sex, though it was generally believed that it did not become established until some time after fertilization. Recent investigations, on the other hand, clearly show that this is not the case, but that sex is determined in the germ cells, either primarily or immediately after their union, so that it has become immutable by the time segmentation of the ovum begins. In the first place, support is lent to such a view by observations upon twin pregnancy in human beings. It has long been known that these result either from the fertilization of one or of two ova, and that a posi- tive distinction can be made by the study of the foetal membranes. In the first case the children are always of the same sex, whereas in the latter the sex may or may not he the same. Furthermore, still more striking evidence is afforded by the armadillo. In this animal each litter consists of four young which are derived from a single ovum, as is shown SEX OF THE NEW-BORN CHILD 177 by the fact there is only one placenta, one chorion, and four amnions. All the young in each litter are always of the same sex. Such observations simply show that the sex had been determined before the beginning of segmentation, but give no information as to the mechanism of its determination, and leave us doubtful whether it had been predetermined in the ovum or in the spermatozoon, or was due to changes taking place at the time of fertilization. Morgan, and Doncaster have given excellent reviews of the subject, and have pointed out that all these eventualities are possible. The latter lays particular stress upon the influence of the egg, and points out that male and female eggs occur in many species, and have been demon- strated in phylloxera, hydatina and certain gall flies. In these animals the two types of eggs can be readily distinguished, and as they develop by parthogenesis there is no possibility of any influence being exerted by the spermatozoa. On the other hand, Morgan, Wilson, Stevens, Boveri, and others con- tend that in many species the determining factor must be attributed to the spermatozoon. These investigators have carefully studied the ar- rangement of the chromosomes in numerous insects, and in some species have discovered that they are differently arranged in the germ cells. Thus, in the oocytes, the chromosomes are always in pairs of similar ap- pearance, while in the spermatocytes three types may be observed. In the first type one of the chromosomes is without a mate; in the second, the chromosomes in one pair may vary in size, one being larger than its mate; while in the third, no difference can be detected. Accordingly, when reduction occurs in the formation of the spermatozoa, two varieties of spermatozoa will occur in each of the first two types, while in the third there will be no variation. In the first type one variety of spermatozoa will contain one less chromosome than the other; in the second both varieties will contain the typical number, but one will possess an aberrant, or small chromosome, while in the other all the chromosomes will be similar. According to Wilson’s theory, sex will depend upon which variety of spermatozoon effects fertilization: those with identical chromosomes giving rise to females, and those lacking a chromosome, or provided with a small one, giving rise to males. Whether the determina- tion is effected solely by the spermatozoon, or whether it merely brings to the ovum certain substances which set in motion tendencies which already existed, is not yet known. In the latter event, the determination of sex must eventually prove to be a function of the ovum. Reference has already been made to the investigations of Theophilus S. Painter upon spermatogenesis in man, which apparently show beyond peradventure that the spermatocytes of the first order contain 48 chromosomes, one of which is of the “x-y” variety (Figs. 176, a and b). Consequently, when the reduction division occurs, two types of sperma- tozoa will develop, each containing twenty-four chromosomes, but differ- ing from one another by the fact that one type contains an x chromosome and the other a y chromosome. As all of the chromosomes of the mature ovum are of one type, it is apparent that after fertilization we may have to deal with two types of zygotes—one containing 46 typical and 2 x 178 THE FCETUS chromosomes, while the other contains an x and a y chromosome, the first developing into a female and the second into a male. In other words, for practical purposes, spermatozoa containing the x chromosome may be regarded as female and those containing the y chromosome as male spermatozoa. As each spermatocyte, at the reduction division, gives rise to two spermatozoa—one of which is male and the other female—it would appear that male and female children should be produced in equal num- bers, and yet we know that the primary sex ratio is 100 females to 125 males, which diminishes to a secondary ratio of 100 to 106 at the time of labor. Why this is so, we are unable to state; but such a result might Fig. 1 76A. — Portion of Human First Spermatocyte Spindle showing the X- Y Sex Chromosomes among the Tetrades (Painter). Fig. 176B.—First Maturation Division showing Segregation of X and Y Chromosomes to Op- posite Poles oj the Human First Spermatocyte Spindle (Painter). be attributed to a selective mortality on the part of the female sperma- tozoa, whereby the probability of fertilization by spermatozoa containing the x chromosome would be reduced. Or, it might be supposed that such spermatozoa can fertilize the ovum only when it is relatively fresh, while those containing the y chromosome can fertilize it over a longer period. The latter supposition might afford an explanation for Siegel’s observation that coitus about the time the follicle ruptures usually re- sults in girls, while coitus just before or after the menstrual period usually results in boys. He assumes that in the first case the ovum is relatively fresh, while in the latter it is overripe when fertilized. His observations were made by studying the menstrual history of women who conceived following a short furlough of their husbands during the war. They are, hoAvever, too few in number to be conclusive, and quite likely are equally explicable by some other hypothesis. Whatever the correct explanation may be, there seems every ground for believing that in human beings sex is determined primarily by the type of spermatozoon by which fertilization is effected. LITERATURE 179 Further evidence in favor of such a view is afforded by the study of so-called sex-limited inheritance, in which abnormalities or diseases, such as color blindness or hemophilia are transmitted from a man to his grandsons through the intermediary of his daughters. It would, how- ever, lead too far afield to consider such problems, and those desiring further information are referred to special works on heredity. In 1897 Schenk startled the world by stating that sex could be deter- mined at will, as it was entirely dependent upon the condition of nutri- tion of the mother, and could therefore be influenced by appropriate dietetic treatment. The considerations just mentioned, however, show that his conclusions were visionary. Reference might also be made to the erroneous, but wide-spread, belief that boys develop from eggs coming from the right ovary and girls from the left. Rumley Dawson in a monograph which appeared in 1917 attempted to prove that the two ovaries ovulated alternately, so that it was possible to control the sex provided the woman had previously given birth to a child. To do so, it was only necessary to remember that, at the first ovulation following labor, the ovum would come from the ovary which had not functioned at the last conception. Accordingly, if the child were a boy, the next ovum would be from the left ovary, so that by making the necessary calculation coitus could be had when the right or left ovary was to function, according as a boy or girl was desired. That such teaching is erroneous is demonstrated by the fact that women from whom one ovary has been removed continue to have chil- dren of either sex, and Murray, from my own material, conclusively showed the fallacy of such a belief. Moreover, I have for years made it a practice to note at caesarean sections which ovary contains the corpus luteum, and have found that it is a matter of indifference whether it is situated on the right or left side so far as the sex of the child is con- cerned. For example, in 64 observations the corpus luteum was found 36 and 28 times in the right and left ovary respectively. In the first instance, there were 23 boys and 13 girls, while in the second there were 16 and 12 respectively, thereby conclusively demonstrating that children of either sex may develop from eggs coming from either ovary. LITERATURE Adair and Scammon. A Study of the Ossification Centers of the Wrist, Knee and Ankle Joint at Birth. Am. J. Obst. & Gyn., 1921, 35-60. Ahlfeld. Die Geburten alterer Erstgeschwangerten. Archiv f. Gyn., 1872, iv, 510-520. Ueber die Bedeutung des Fruchtwassers als Nahrungsmittel fur die Frucht- Beriehte u. Arbeiten, Leipzig, 1885, ii, 22. Atem-bewegungen des Fotus. Lehrbuch der Geb., 1898, II. Aufi., 57. Zwanzig Betrachtungen fiber die Herkunft des Fruchtwassers. Zeitsclir. f. Geb. u. Gyn., 1911, Ixix, 91-116. Ascoli. Passirt Eiweiss die placentare Scheidewand. Hoppe-Seiler’s Zeitschr., xxxvi, 526. 180 THE FOETUS Bachimont. De la puericulture intrauterine au corns de la grossesse gemellaire. These de Paris, 1898. Ballantyne and Browne. The Problem of Foetal Post-maturity and Prolongation of Pregnancy. J. Obst. and Gyn. Brit. Emp., 1922, xxix, 177-238. Bergell u. Falk. IJeber die Funktion d. Placenta. Miinchener med. Wochenschr., 1908, No. 43. BlLcard. Quoted by Schroeder, Lehrbuch der Geburtshiilfe, 1899, XIII., Aufl., 67. Bondi. Zur Histologie des Amionepithels. Zentralbl. f. Gyn., 1905, 1075-1076. Bonnet. Ueber Syncytien, Plasmodien u. Symplasma in der Placenta, etc. Monatsschr. f. Geb. u. Gyn., 1903, xxiii, 1-51. Boveri. Ueber das Verhalten d. Gesehlechtschromosomen bei Hermapliroditismus. Verh. d. phys.-med. Gesellsch. z. Wiirzburg, 1911, N. F., xli. Galkins. Morphometry of the Human Fetus. Am. J. Obst. and Gyn., 1922, iv, 109-130. Cohnstein und Zuntz. Untersucliungen iiber das Blut, den Kreislauf und die Athmung beim Saugethier-Fotus. Pfliiger’s Archiv, 1884, xxxiv, 173. Cunningham. Studies in Placental Permeability, II. Am. Jour. Physiol., 1922, lx, 448-460. Dawson. The Causation of Sex in Man. New York, 1917. Doncaster. The Determination of Sex. Cambridge and New York, 1914. Driessen. Ueber Glykogen in d. Placenta. Archiv f. Gyn., 1907, lxxxii, 278- 301. Glykogenproduction, eine physiologische Funktion der Uterusdrrisen. Zentralbl. f. Gyn., 1911, 1308-1313. Dubois. Les gros enfants. These de Paris, 1897. Fehling. Beitrage zur Physiologie des placentaren Stoffverkehrs. Archiv f. Gyn., 1877, xi, 523-557. Goldmann. Vitale Farbung. Tubingen, 1909. Die aussere und innere Sekietion im Lichte der “vitalen Farbung. ” Beitrage z. klin. Chirurgie, 1912, lxxviii, 1-108. Haase. Charite-Annalen, ii, 686. Hicks and French. Lancet, 1905, i, 1491, 1493. His. Anatomie menschlichen Embryonen. Leipzig, 1880-1885. Hofbauer. Grundziige einer Biologie der menschl. Plazenta. Wien, 1905. Die menschliche Placenta als Assimilations-organ. Volkmann’s Samml. klin. Vortrage, 1907, Nr. 454. Die biologische Bedeutung d. Placenta. Zeitsehr. f. Geb. u. Gyn., 1909, lxiv, 668-686. Holzbacii. Ueber den Wert der Merkmale zur Bestimmung der Reife der Neuge- borenen. Monatsschr. f. Geb. u. Gyn., 1906, xxiv, 429-445. Hoppe-Seiler. Physiologische Chemie. 1877, I. Theil, 609. Hunter and Campbell. Placental Transmission of Creatinine and Creatin. Jour. Biol. Chem., 1918, xxxiv, 5. Jackson. On the Prenatal Growth of the Human Body. Am. J. of Anat., 1909, ix, 119-169. Kronig und Futh. Vergleichende Untersucliungen iiber den osmotischen Druck im miitterlichen und kindlichen Blute. Monatsschr. f. Geb. u. Gyn., 1901, xiii, 39-54. Lea. The Sagittal Fontanelle in the Heads of Infants at Birth. Trans. London Obst. Soc., 1898, xl, 263-270. Liepmann. Zur Biologie der Placenta. Zeitsehr. f. Geb. u. Gyn., 1905, lvi, 232-243. Lubarscii. Uebertragung von Infektionskrankheiten von Ascendenten auf De- scendenten. Lubarsch-Ostertag, Ergebnisse der allg. Path. u. path. Anat., 1896, i, 427-455. LITERATURE 181 Ludwig. Sectio caesarea bei iibermassig entwickelter todtfauler Frucht. Zen- tralbl. f. Gyn., 1896, 64-65. Lynch. Placental Transmission, with Report of a Case during Typhoid Fever. Johns Hopkins Hospital Reports, 1902, x, 203-222. Mandl. Weitere Beitrage z. Kenntniss der sekretorische Tatigkeit des Amnion- epithels. Zeitschr. f. Geb. u. Gyn., 1906, lviii, 249-257. Mayek. Yersuche welche den Uebergang tropfbarer Fliissigkeiten von der Mutter • an und in den Foetus erweisen. Med. Chirurgische Zeitung, 1817, ii, 431. Michel. Sur la composition organique et minerale de foetus et du nouveau-ne. L’Obstetrique, 1900, v, 252-261. Morgan. Heredity and Sex. New York, 1913. Murray. The Relation of the Supplying Ovary to the Causation of Sex. Bull. Johns Hopkins Hospital, 1918, xxix, 275-281. Nicloux. Sur le passage des substances chimiques de la mere au foetus. L’Obstetrique, 1909, N. S. ii, 840-865. Painter. The Spermatogenesis of Man. Jour. Exp. Zoology, 1923, xxxvii, Piering. Ueber die Grenzen des Korpergewichtes Neugeborener. Monatsschr. f. Geb. u. Gyn., 1899, x, 303-311. Plass. The Various Phosphoric Acid Compounds in Maternal and Foetal Serum. Jour. Biol. Chem., 1923. Total Creatinine in Plasma, Whole Blood, and Corpuscles of Mother and Foetus, Bull. Johns Hopkins Hospital, 1917, xxviii, 297. Pinard. Note pour servir a 1 ’histoire de la puericulture pendant la grossesse. Annales de gyn. et. d’obst., 1898, 1, 81-89. Pohlman. The Course of the Blood through the Heart of the Foetal Mammal. Anat. Record, 1909, iii, 75-109. Polano. Exp. Beitrag zur Biologie der Schwangerschaft. Wurzburg, 1904. Ueber die sekretorische Tatigkeiten des amniotischen Epithels. Zentralbl. f. Gyn., 1805, 1203-1206. Preyer. Specielle Physiologie des Embryo. Leipzig, 1885. Rauber. Uer Ueberschuss an Knabengeburten u. seine biologische Bedeutung. Leipzig, 1900. Riggs. A Comparative Study of White and Negro Pelves, etc. Johns Hopkins Hospital Reports, 1904, xii, 42-54. Savory. Quoted by Preyer. Schaller. Ueber Phloridzin-diabetes Schwangerer, etc. Archiv f. Gyn., 1899, lvii, 548-565. Schenk. Einfluss auf das Geschlechtsverhaltniss, II. Aufb, Magdeburg, 1898. Schroeder. Physiologie des Fotus. Lehrbuch der Geb., 1899, XIII. Aufl., 75. Schultz. Sex Incidence in Abortions. Contributions to Embryology. Carnegie Institution, No. 56, 177-191. Schmidzu. On the Permeability to Dyestuffs of the Placenta, etc. Am. J. Physiol., 1922, lxii, 202. Siegel. Gewollte und ungewollte Schwankungen der weiblichen Fruchtbarkeit. Berlin, 1917. Slemons. The Nutrition of the Foetus. New Haven, 1919. Slemons and Stander. The Lipoids of the Maternal and Foetal Blood at the Conclusion of Labor. Bull. Johns Hopkins Hospital, 1922, xxxiv, 7-10. Speier. Zur Casuistik des placentaren Ueberganges der Typhusbacillen von der Mutter auf die Frucht. D. I., Breslau, 1897. Spiegelberg. Fruchtwasser. Monatsschr. f. Geburtskunde, 1861, xviii, 374- 400. Stander and Tyler. The Moisture and Ash of Maternal and Foetal Blood. Surg., Gyn. and Obst., 1920, xxxi, 276-281. 182 THE FCETUS Starcke. Ueber Geburten, bezw. Spatgeburten bei Riesenkinder, etc. Archiv f. Gyn., 1905, lxxiv, 569-619. Stevens. Studies in Spermatogenesis. Carnegie Inst. Publication, Oct., 1906, pp. 33-74. Streeter. Weight, Sitting Height, etc., and Menstrual Age of the Human Embryo. Publication 274 of the Carnegie Institution of Washington. Varnier. Les gros ceufs. L’Obstetrique journaliere, 1900, 185-191. Wagner. Beitrage z. Frage d. Herkunft des Fruchtwassers. Leipzig u. Wien, 1913. Wegelius. Antikorperiibertragung von Mutter auf Kind. Archiv f. Gyn., 1911, xciv, 265-300. Williams. A Critical Analysis of Twenty-one Years’ Experience with Caesarean Section. Bull. Johns Hopkins Hospital, 1921, xxxii, 173-184. Wilson. Studies on Chromosomes. J. Exp. Zoology, 1906, iii. Recent Researches on the Determination and Heredity of Sex. Science, 1909, 53-70. Winckel. Neue Untersuchungen iiber die Daue.r der menschlichen Schwanger- schaft. Volkmann’s Sammlung klin. Vortrage, N. F., Nr. 292, 293, 1901. Wislocki. The Fate of Solutions and Colloids Injected into the Mammalian Embryo. Bull. Johns Hopkins Hosp., 1921, xxxii, 93-97. Wolff. Fruchtwasser, Oppenheimer’s Handbuch d. Biochemie, 1910, iii, 709-741. Wurster. Beitrage zur Tocothermometrie. D. I., Zurich, 1870. Zaretsky. Le glycog&ne dans le placenta discoide. L’Obstetrique, 1911, N. S. iv. Ziegenspeck. Zur Foetalkreislauf. Gyn. Rundschau, 1910, iv, 75-109. Zweifel. Untersuchungen iiber das Meconium. Archiv f. Gyn., 1875, vii, 474- 490. Die Respiration des Fotus. Archiv f. Gyn., 1876, ix, 291-305. Der Uebergang von Chloroform und Salicylsaurc in die Placenta. Archiv f. Gyn., 1877, xii, 235-257. SECTION III PHYSIOLOGY OF. PREGNANCY CHAPTER YI CHANGES IN THE MATERNAL ORGANISM RESULTING FROM PREGNANCY It should be constantly borne in mind that pregnancy is not a mere local condition affecting the genitalia, but is a process associated with fundamental changes in the entire organism. Ordinarily, one fails to realize how radical these changes are, and to how great an extent the child-bearing woman differs from man. The contrast was strikingly illustrated by Sellheim when he estimated that a woman who has borne six children has produced by her generative function—including men- struation, but excluding the production of milk—an amount of tissue twice as great as her original weight. Every portion of the maternal organism reacts to a greater or lesser extent undef the influence of pregnancy. Formerly, these changes were attributed in great part to nervous impulses originating in the pregnant uterus, but more extended clinical observation and experimental work show that such is not the case, and indicate that such changes can be explained only by the supposition that they are in some way connected with the circulation in the blood of substances concerning whose nature we are as yet ignorant. UTERUS Naturally the most apparent changes are observed in the generative tract, and especially in the uterus, which undergoes a very great increase in size. Thus, it is converted from a small, almost solid organ, 6.5 centimeters long, into a thin-walled, muscular sac, capable of containing the foetus, placenta, and a large quantity of amniotic fluid, and at the end of pregnancy is about 32 centimeters long, 24 centimeters wide, and 22 centimeters deep. Krause estimated that its capacity is increased 519 times. A corresponding increase in weight is also observed, the uterus at full term weighing in the neighborhood of 1,000 grams (2 pounds), as compared with 30 grams (1 ounce) in the virginal condition. This enlargement is due principally to the hypertrophy of preexisting muscle cells, but partly also to the formation of new ones during the earlier months of pregnancy. The fully developed muscle fibers are from 183 184 CHANGES IN THE MATERNAL ORGANISM 2 to 7 times wider and from 7 to 11 times longer than those observed in the non-pregnant uterus, measuring 0.009 to 0.014 X 0-2 to 0.52 milli- meter in the former, as compared with 0.005 X 0.05 to 0.07 millimeter in the latter. According to the researches of Lusehka and Veit, the forma- tion of new muscular fibers is limited to the first three or four months of pregnancy. With the increase in the number and size of the muscle fibers is asso- ciated a marked development of elastic tissue. D’Erchia has shown that it forms a network about the various muscle bundles, which hypertrophies with advancing preg- nancy, and thus adds materially to the strength of the uterine walls. At the same time there is a great increase in the size of the blood vessels, espe- cially the veins, which, in the neighborhood of the placental site, be- come converted into large spaces, the so- called placental sin- uses. Marked hyper- trophy of the lympha- tic and nervous supply of the uterus also takes place, which is well illustrated by the in- crease in size of Frankenhauser’s cervical ganglion from 2 X 2.5 to 3.5 X 6 centimeters. During the first few months the hypertrophy of the uterus, in all probability, is brought about by the circulation of certain substances derived from the ovum or corpus luteum. That it is not directly due to the presence of the ovum in the uterine cavity is shown by the occurrence of precisely similar changes in extra-uterine pregnancy, when the ovum is implanted in the tube or ovary. After the third month, however, the increase in size is in great part mechanical, and is due directly to ther pressure exerted by the growing product of conception. During the first few months of pregnancy the uterine walls are con- siderably thicker than in the non-pregnant condition, but as gestation advances they gradually become thinner, so that at the end of the fifth month they are from 3 to 5 millimeters in thickness. This measurement is retained throughout the succeeding months, so that at term the walls of the body of the uterus are rarely above 5 millimeters thick, and oc- casionally they measure considerably less. Consequently the organ soon loses the firm, almost cartilaginous consistence which is characteristic of the non-pregnant condition, and becomes converted into a muscular sac having very thin, soft and readily compressible walls. This is well Fig. 177.— Muscle Fibers from Non-pregnant and Pregnant Uterus (Sappey). UTERUS 185 demonstrated by the ease with which the foetus can usually be palpated in the later months, and by the readiness with which the uterine walls yield to the movements of the foetal extremities. Furthermore, it is frequently possible at abdominal operations to observe shallow depres- sions upon the surface of the uterus, which have resulted from the pres- sure of the intestines upon it. The enlargement of the uterus is not symmetrical, but is most marked in the fundal region. This can readily be appreciated by observing the relative positions of the insertions of the tubes and ovarian ligaments, which in the early months of pregnancy are almost on a level with the Fig. 178.—External Muscular Layer of Pregnant Uterus (H lie). Fig. 179.—Internal Muscular Layer of Pregnant Uterus (Helie). fundus; whereas in the later months their attachments are found at points slightly above the middle of the organ. The position of the placenta also exerts a determining influence upon the extent of the hypertrophy, the portion of the uterus to which it is attached enlarging more rapidly than elsewhere, as is clearly shown by the position of the uterine ends of the round ligaments, which are close together when the placenta is inserted upon the posterior, and far apart when it is upon the anterior wall. Arrangement of the Muscle Fibers.—Ever since the time of Vesalius, considerable attention has been devoted to the arrangement of the muscle fibers in the pregnant uterus. Among the numerous investigators whose careful studies on this subject deserve special mention are William Hunter in England; Madame Boivin, Deville, and Helie in France; Roederer, Luschka. Henle, Holfmann, Bayer, and Hofmeier. According to Luschka and Henle, the musculature of the pregnant uterus is arranged in three strata: an external hoodlike layer, which 186 CHANGES IN THE MATERNAL ORGANISM arches over the fundus and extends into the various ligaments; and an internal layer, consisting of sphincterlike fibers around the orifices of the tubes and the internal os; while lying between the two is a dense network of muscle fibers perforated in all directions by blood vessels. The most important contributions, however, we owe to Helie, Bayer, and Ruge. In the preface to his monograph Helie states that he had devoted twelve years to his investigations, and Bayer has been an in- defatigable worker upon the subject since 1886. According to Helie, the uterine musculature consists of three main layers, each of which is made up of several subsidiary divisions. The external layer is composed of two longitudinal or ansiform portions, between which lies a transverse layer. The internal layer is composed of two triangular por- tions running along the inner surface of the an- terior posterior walls of the uterus respectively, and connected by an archiform layer at the fundus, an obicular por- tion around each tubal opening and an annular layer around the internal os. The main portion of the uterine wall is formed by the middle layer, which consists of an interlacing network of muscle fibers, between which extend the blood vessels. Each fiber comprising this layer has a double curve, so that the interlacement of any two gives approximately the form of the figure “8.” As a result of such an arrange- ment, it happens that when the fibers contract after delivery they con- strict the vessels and thus act as living ligatures. Ruge pointed out that many of the layers which had been described by previous observers do not exist as such in the pregnant uterus, the appearances having resulted from the manner in which the dissections had been made. He showed that the muscle fibers composing the uterine wall, especially in its lower portion, overlap one another and are arranged like shingles on a roof, one end of each fiber arising beneath the perito- neal covering of the uterus, and extending obliquely downward and in- ward, to be inserted into the decidua, thus giving rise to a large number of muscular lamellae. The various lamellae are connected with one another by short muscular processes, so that when the tissue is slightly spread apart it presents a sievelike appearance, which on closer examina- tion is seen to be due to the presence of innumerable rhomboidal spaces. Ruge attaches great importance to this arrangement of the muscle fibers, and believes that it explains very satisfactorily the mechanism of the uterine contractions, and the manner in which the feltlike structure of the puerperal uterus is brought about. Changes in Size and Shape of the Uterus.—As the uterus increases in size, it also undergoes important modifications in shape. For the first Fig. 180.—Median Muscular Later of Pregnant Uterus (Helie). UTERUS 187 few weeks its original pyriform outlines are retained, but the body and fundus soon assume a more globular form, which at the third or fourth month becomes almost spherical. After this period, however, the organ increases more rapidly in length than in width, and assumes an oval form, which persists until the end of pregnancy. The increase in the size of the uterus is limited almost entirely to its body, the cervix remaining practically unchanged until the onset of labor, so that throughout the course of pregnancy it appears as a mere Figs. 181a and 1816.—Same Full-term I-para in Vertical and Horizontal Position Fig. 181a. Fig. 1816. appendage to the enlarged body. Its most characteristic change consists in a marked softening, which is readily appreciated by the examining finger, and constitutes one of the physical signs of pregnancy. The slight increase in size which can be noted is due in great part to increased vascularity, and depends only to a small extent upon hypertrophy of its muscle fibers. As a result, the secretion of the cervical glands becomes more copious and the cervical canal becomes filled with a plug of mucus. The changes occurring in it in the latter part of pregnancy will be considered in detail when we take up the physiology of labor. As the body of the uterus becomes larger, the angle which it forms 188 CHANGES IN THE MATERNAL ORGANISM with the cervix becomes more acute—in other words, its physiological anteflexion is increased. By the fourth month the organ becomes too large to be contained in the pelvic cavity, and forms a tumor, the upper border of which reaches midway between the symphysis pubis and the umbilicus. As it becomes still larger, it comes in contact with the an- terior abdominal wall, displacing the intestines to the sides of the abdo- men, and gradually rises up until it almost impinges upon the liver. As the uterus leaves the pelvis for the abdominal cavity, considerable ten- sion is exerted upon the broad ligaments, which then become more or less unfolded at their median and lower portions and thus contribute to the mobility of the pelvic peritoneum, which is characteristic of pregnancy. The pregnant uterus possesses a considerable degree of mobility. Since its upper portion projects into and lies free in the abdominal cavity, and its lower portion is held in check by the cervical attachments, it readily changes its position. With the woman in a standing posture its longitudinal axis corresponds closely with that of the superior strait, the organ resting in great part upon the anterior abdominal wall; but, when lying on her back, the uterus falls backward and rests upon the vertebral column. Figs. 181, a and b, represent the same woman in the upright and horizontal positions respectively, and give a good idea of the changes in contour of the abdomen. As the uterus grows out of the pelvic cavity, it usually becomes slightly twisted to the right, so that its left margin is directed more anteriorly than the right. Occasionally the torsion may be in the oppo- site direction, statistics showing that it occurs to the right in 80 per cent, and to the left in 20 per cent, of the cases. The torsion is due in great part to the presence of the rectum, which occupies the left side of the pelvis; though occasionally the condition may represent merely an exaggeration of the original position of the non-pregnant uterus, which, as is well known, is not always perfectly symmetrical. TUBES AND OVARIES As has already been mentioned, the tubes and ovaries undergo marked changes in position with the advance of pregnancy, so that instead of extending outward almost at right angles from the cornua, their long axes become nearly parallel to the margins of the uterus. Occasionally, as the result of the upward traction exerted by the en- larging uterus, the ovaries become greatly elongated. More important, however, is their increase in vascularity, to which the large size of the corpus luteum of pregnancy is in great part due. It is generally be- lieved that ovulation ceases during pregnancy, so that new follicles do not ripen, and, accordingly, only the single large corpus luteum of pregnancy can be found in one of the ovaries. Seitz, Keller, Aschner, and others have shown that while typical ovulation does not occur, many follicles begin to grow and, after reaching a certain stage of develop- ment, undergo atretic changes, associated with a marked development VAGINA 189 of lutein cells in the theca folliculi. In many instances these cells occupy the greater part of the interior of the ovary, and present a characteristic and striking appearance, but disappear soon after delivery. In such circumstances, they are designated by many writers as the “in- terstitial gland”; and, after once seeing them, it is difficult to escape the conclusion that they must have some specific internal secretory func- tion. Fellner states that the lipoids derived from them cause uterine hypertrophy when injected into experimental animals. It is generally stated that the muscular fibers of the tubes undergo considerable hypertrophy under the influence of pregnancy, but I believe that Mandl is correct in stating that, if it occurs at all, it is very slight in extent. Occasionally, in uterine pregnancy, decidual cells may develop in the stroma of the tubal mucosa, but they never lead to the formation of a continuous membrane, as in the uterus. Such observa- tions are of extreme rarity, but I have made them in several instances. VAGINA Increased vascularity is the most marked change in the vagina, and to it are due the more copious secretion and the characteristic violet coloration of pregnancy. At the same time there is considerable hyper- trophy of the elements composing the vaginal walls, the latter not in- frequently increasing in length to such an extent that the lower portion of the anterior wall protrudes slightly through the vulval opening. The papillae of the vaginal mucosa also undergo considerable hypertrophy, whence results an increased roughness of the membrane, which some- times feels almost like a calf’s tongue. The vaginal secretion is considerably augmented, and normally is represented by a thick, white, crumbly substance, somewhat like cottage cheese, which possesses a distinctly acid reaction. Doderlein showed that it consists of epithelial cells and a large number of long, tolerably thin bacilli, but that under normal conditions it does not contain leukocytes or pathogenic microorganisms. Zweifel showed that the acid reaction is due to the presence of lactic acid, which he believes plays a marked part 'in preventing the growth of pathogenic bacteria. Grafen- burg has shown that the degree of acidity varies with the phase of the sexual cycle, the titer being lowest at the period of ovulation and high- est during pregnancy. Whether the cellular contents of the vaginal secretion undergo cyclical changes analogous to those observed by Long and Evans in the rat, and by other observers in various experimental animals, is not known, but the subject otfers an interesting field for research. The increased vascularity attending pregnancy is not confined to the genitalia, but extends to the various organs in their vicinity, and as a consequence there is a slight relaxation of the various pelvic joints, which is accompanied by an increase in their motility, as was con- clusively shown by Budin. 190 CHANGES IN THE MATERNAL ORGANISM ABDOMINAL WALLS With the enlargement of the uterus the skin covering the anterior abdominal walls and the adjoining portions of the thighs is subjected to considerable tension, which, according to Zeiler, results in the rupture of the elastic fibers of the reticular stratum of the cutis, and- the forma- tion of depressed areas which a re known as the stnne of pregnancy. In primiparae these present a pinkish or slightly bluish appearance, Fig. 182.—Abdomen of Primipara at Term, showing Striae. as is well illustrated in Fig. 182, whereas in multiparae two varieties are observed, some resembling those of primiparous women, while others present a glistening silvery appearance, the former resulting from the present condition, and the latter representing cicatrices from previous pregnancies. The formation of striae is not characteristic of pregnancy, as it is lacking, according to Taussig, in about 22 per cent, of the cases and is frequently observed in non-pregnant women and occasionally in men, in whom there has been a rapid increase in the size of the abdomen, either from the presence of a tumor or ascites, or the rapid development of fat. They occur less frequently in women of the upper classes, and can be prevented to some extent by massaging the abdomen with some oleagi- BREASTS 191 nous substance and by the use of a properly fitting corset or abdominal support. Not infrequently the abdominal walls are unable to withstand the tension to which they are subjected, and the recti muscles become sep- arated in the middle line, giving rise to a diastasis of greater or less extent. Where the process is exaggerated, a considerable portion of the anterior wall of the uterus is covered by nothing beyond a thin layer of tissue consisting only of skin, fascia, and peritoneum. In rare in- stances the separation is sufficiently extensive to admit of a hernial pro- trusion of the gravid uterus. BREASTS Under the influence of pregnancy marked changes occur in the breasts, and in the early weeks the woman not infrequently complains of a sense of tenseness and pricking in these regions. After the second month the breasts begin to increase in size and offer a somewhat nodular sensation on palpation, which is due to the hypertrophy of the mammary alveoli, and as they become still larger a delicate tracery of bluish veins appears just beneath the skin. Even more characteristic, however, are the changes occurring in the nipples and the tissues in their vicinity. The nipples themselves soon become considerably larger, more deeply pigmented, and more erectile, and after the first few months a thin, yellowish fluid—colostrum—may be expressed from fhem by gentle massage. At the same time the areola surrounding the nipple becomes considerably broader and much more deeply pigmented, the degree of pigmentation varying according to the complexion of the individual. In blondes the areolae and nipples assume a pinkish appearance, while in brunettes they become dark brown and occasionally almost black. Scat- tered through the areola are a number of small roundish elevations, the so-called glands of Montgomery, which result from the hypertrophy of the sebaceous glands. In a small number of cases similar structures make their appearance in a less deeply pigmented area outside of the periphery of the areola, and which is designated as the secondary areola. If the increase in the size of the breasts be very marked, the skin frequently presents striations similar to those observed in the abdomen. Formerly it was believed that direct nervous connection existed be- tween the uterus and the breasts, but the demonstration that lactation can be established after excluding the spinal nervous mechanism by severing all nerves supplying the breast, or even after transplanting the organ to other portions of the body, clearly indicates that some other factor must be invoked in explanation of the mammary changes in preg- nancy. Starling and Lane Claypon in 1906 stated that they were able to produce definite hypertrophy of the breasts of virginal rabbits by the injection of extracts obtained from the bodies of foetal rabbits, and attributed the result to certain specific hormones. Their conclusions were generally accepted until 1911, when Frank and Unger stated that they were unable to confirm them and attributed them to faulty observa- 192 CHANGES IN THE MATERNAL ORGANISM tion and technic. However that may be, there is no doubt that the mammary changes characteristic of pregnancy must be due to the action of specific substances circulating in the blood, as was demonstrated by the observations of Schauta and of Basch upon the Blazek sisters. In this instance, one of the pygopagous twins gave birth to a child, which could be suckled equally well by its own mother or by its nulliparous aunt. CHANGES IN THE REST OF THE BODY As has already been indicated, the changes resulting from pregnancy involve nearly every portion of the body, and in many cases the general condition of the patient differs markedly from what it was before con- ception. Many women suffer numerous inconveniences, while others enjoy better health than at any other time. Heart.—Owing to the upward pressure upon the diaphragm, the heart becomes displaced in such a way that its area of dullness undergoes a considerable increase in size. Basing his opinion upon this fact, Larcher in 1827 promulgated the doctrine that considerable cardiac hypertrophy was a constant concomitant of pregnancy. His views ob- tained rapid acceptance in France, but were received with skepticism in Germany. On the other hand, the researches of Dreysel indicate that hypertrophy does take place, as he found that the hearts of 76 pregnant and puerperal women weighed 8.8. per cent, more than those of non- pregnant individuals. The question, however, cannot be regarded as definitely settled, and offers an attractive field for future work. If the total quantity of blood is not increased during pregnancy, and even more so if it is, it would seem that the demands of the enlarging uterus and its contents could be satisfied only by a more rapid cir- culation of the blood. As the pulse rate is not materially in increased during pregnancy, it appears justifiable to conclude that such a result is accomplished by the heart expelling an increased amount of blood at each beat, which inevitably necessitates increased work, with coincident hypertrophy. The investigations of Slemons and Goldsborough in my service upon the blood pressure confirm such a view; as they were able by means of Erlanger’s sphygmomanometer to demonstrate a considerable increase in the pulse pressure, as well as in the “index” of the work of the heart. This was most marked in the later months of pregnancy and disap- peared during the puerperium; consequently, as fhe more extensive ob- servations of Jaschke in 1911 led to similar results, it seems reasonable to believe that the heart undergoes a certain amount of hypertrophy. Blood.—In former times it was generally believed that the changes incident to the placental circulation demanded an increase in the amount of maternal blood, and all the earlier writers stated that under the influ- ence of pregnancy an increased hydremia and a diminution in hemo- globin and red corpuscles took place, while at the same time an abnormal amount of fibrin could be noted. These observations were based upon antiquated methods of research, and it was not until 1886 that Fehling, CHANGES IN THE REST OF THE BODY 193 by the aid of modern appliances for examining the blood, came to the conclusion that it underwent little if any change. Since then a number of articles have appeared upon the subject, notably those of Wild, Zangemeister, Payer, and Dietrich. These investi- gations show that in the later months of pregnancy the amount of hemo- globin and of red corpuscles is normal, or even slightly increased, while there is a slight increase in the number of white cells. The leukocytosis is markedly accentuated at the time of labor, but falls rapidly in the puerperium unless infection supervenes. Observations made in my clinic in 1915 by Miller, Keith and Roun- tree upon the plasma and blood volume in pregnancy seem to show that there is a definite increase in both factors, which disappears during the puerperium. These conclusions were based upon the injection of known quantities of “vital red” into the circulation, and the colorimetric com- parison of the patients’ serum with standard preparations of serum colored with the same dye. More extended, but as yet unpublished, observations by Harris in our service during 1922 and 1923, reenforce such conclusions, and demonstrate that the volume of blood is definitely increased, while the cell and hemoglobin content is relatively, but not actually, diminished. Moreover, the demonstration by Dienst of a change in the relative proportions of the several protein constituents of the blood plasma during pregnancy points in the same direction. The specific gravity of the blood is somewhat lowered, and Zange- meister and Landsberg demonstrated a diminished freezing point and a decrease in its albuminous content; while Zangemeister and Payer noted a decrease in the alkalinity of the blood during pregnancy, but its exact significance' is not let clear. In all probability the blood also contains various substances which are not present at other times, but our information upon the subject is as yet very vague. In this connection it suffices to note that Grafenburg, Clowes and Goldsborough and Ecalle have demonstrated a definite in- crease in the antitryptic ferment content, and Chauffard, Laroche, Grigand, Huffmann, and Ecalle a striking increase in the cholesterin content, which has been confirmed by Slem,ons and Stander w*ho have shown that the lipoid content of the blood is greatly augmented during pregnancy, and are inclined to regard it as a preliminary provision for lactation. Furthermore, Heynemann and Ecalle state that there is a marked difference between the serum of pregnant and non-pregnant women, in that the former after heating will induce hemolysis of washed horses’ corpuscles in the presence of cobra poisoning, w’hereas the latter will not. It was formerly believed that the adrenalin content of the blood was increased during pregnancy, but Keu has demonstrated that such is not the case. He has, however, shown the presence of a pressor substance in the serum, but not in the plasma, which he believes is histamin, which has originated during the changes connected with the coagulation of the blood. Respiratory Tract.—According to Siegmund, Koblanck, and others, more or less characteristic changes may occur in the nasal mucosa. These consist in reddening and thickening of the so-called Fliess’ areas, 194 CHANGES IN THE MATERNAL ORGANISM and it is stated that at the time of labor the character of the uterine contractions may be altered by intranasal manipulations. It has long been known that pregnancy may exert a deleterious in- fluence upon the voice of singers, and Hofbauer has shown that it is associated with changes in the larynx which occur in three-quarters of all pregnant women. These consist in reddening and edema of the false vocal cords, as well as of the interarytenoid region. In addition to the usual histological manifestations of inflammation, decidua-like cells make their appearance in the submucosa. Owing to the upward displacement of the diaphragm in the later months of pregnancy, it would seem as though the capacity of the lungs would be decreased. Nevertheless, Dohrn has shown that such is not the case, since the diminished height of the pleural cavities is compensated for by an increase in width. Furthermore, the investigations of Zuntz and myself upon the respiratory exchange show that, while there is no great increase in the consumption of oxygen or in the output of carbon dioxid, there is nevertheless a great increase in the amount of air inspired. Digestive Tract.—In many instances the early months of pregnancy are complicated by minor disorders of digestion. Frequently these are not independent affections, but are to be regarded as a manifestation of a mild toxemia. At least one-half of all pregnant women suffer from constipation. In the later months of pregnancy this may be regarded as being partly due to the pressure of the enlarged uterus, and partly to the loss of tonicity of the abdominal walls resulting from their distention. During pregnancy the liver is in a state of unstable equilibrium, and is readily affected by various conditions, as is demonstrated by the lesions accompanying eclampsia, vomiting of pregnancy, and acute yellow atrophy of the liver, which will be discussed in detail in the chapter on the toxemias of pregnancy. Hofbauer considers that even in normal pregnancy the liver presents characteristic changes, so that one is justified in speaking of the “liver of pregnancy.” The changes consist in the appearance of fat in the cells occupying the central portion of the lobules, the disappearance of glyco- gen, and the dilatation of the biliary channels, the central veins, and the afferent capillaries. Opitz has cast grave doubt upon these state- ments, but should such changes occur as regular concomitants of preg- nancy, they would offer a satisfactory explanation for several of the alterations in metabolism which characterize the condition. Urinary Tract.—The kidneys are likewise under a considerably in- creased strain during pregnancy, and slight degrees of parenchymatous change are so common that they are assigned by the Germans to the “kidney of pregnancy.” Such conditions are usually connected with the various disturbances of metabolism associated with the toxemias of preg- nancy and will be considered under that heading, while various altera- tions in the constitution of the urine in normal pregnancy will be taken up in the section on general metabolism. The ureters are sometimes compressed by the growing uterus, and CHANGES IN THE REST OF THE BODY 195 under such conditions a mild infectious process, which otherwise might not give rise to symptoms, may eventuate in a pyelitis or pyelo- nephrosis. In the early months the bladder is more or less compressed by the growing uterus, and consequently increased frequency of micturition is often noted. As the uterus rises up into the abdominal cavity it carries with it the bladder, which then becomes an abdominal rather than a pelvic organ. Corresponding to the torsion of the uterus about its vertical axis, the bladder is pushed to the right side of the abdomen in possibly 90 per cent, of all pregnant women. Ductless Glands.—With the great increase in our knowledge con- cerning the functions and correlations of the endocrin glands it has gradually become recognized that all of them exert directly or indirectly a stimulating or retarding effect upon the sexual processes in women, which may become greatly exaggerated during pregnancy. Our still somewhat fragmentary knowledge upon the subject was well summarized by Blair Bell, and particularly by Seitz in his exhaustive report to the German Gynecological Congress in 1913, to which the reader is referred for detailed information. Lange in 1899 reported that he found the thyroid gland definitely hypertrophied in 108 out of 133 women during the last three months of pregnancy. As albuminuria was present in 18 of the women in whom no hypertrophy was noted, he naturally thought that there might be some direct relation between its absence and the urinary changes. With this in mind, he administered iodothyrin to a number of albuminuric pregnant women, and in some instances noted a rapid disappearance of the albumin. His views were promptly taken up by Nicholson and others, and made the basis for a theory concerning the origin of the toxemias of pregnancy. As will be indicated in the appropriate chapter, the theory rests upon very unstable foundations, and has in great part been abandoned. With the exception of von Graff, it is now generally believed that a moderate degree of hypertrophy of the thyroid is a usual concomitant of normal pregnancy, and may be recognized clinically in 65 to 90 per cent, of all cases. Its significance is not clear, but that the thyroid plays an important part in pregnancy was shown by the experiments of Halsted and Ukita. The former found that when the gland was partially re- moved from pregnant dogs, puppies were born whose thyroids were many times the normal size, thereby indicating that they had hyper- trophied in order to supplement the deficient maternal secretion. The latter states that the removal of the gland from pregnant rabbits led to a great prolongation of the duration of pregnancy, and to the birth of undersized and poorly developed offspring, whose thyroids were defi- nitely hypertrophied and showed definite signs of increased secretory activity. It is likewise generally admitted that the parathyroids undergo a considerable hypertrophy during pregnancy, and that their secretion is essential to its normal progress. To a great extent they act through the calcium metabolism. Insufficiency of the parathyroid secretion fre- 196 CHANGES IN THE MATERNAL ORGANISM quently manifests itself by the development of tetany in the mother, as will be described in the appropriate place. As the thymus gland ordinarily atrophies with the approach of puberty it would not appear to exert any influence upon pregnancy. Bompiani, however, has shown that in cases of abnormal persistence of the organ it undergoes diminution in size during pregnancy, to enlarge again after delivery. Theoretically, it is possible that the presence of a persistent thymus may have important effects upon the entire genera- tive process. Since Launois and Mulon, in 1904, directed attention to an hyper- trophy of the hypophysis during pregnancy, a great deal of work has been done upon the subject, and the investigations of Eisemann and Stumme, Cushing, Mayer, and others have definitely shown that the anterior lobe of the gland regularly undergoes great hypertrophy during pregnancy, and returns to the usual size after its completion. The hypertrophy, which may double the size of the lobe, is due in great part to a marked increase in the number and size of the “Hauptzellen.” Its significance is not yet clear, but it has been suggested that the hypo- physeal secretion may supplement a supposed deficiency in that derived from the ovaries. Wallis and Bose suggest that the well recognized intolerance of pregnant women for sugar, as well as the occasional occurrence of transient glycosuria may be attributed to excessive func- tioning of the hypertrophied organ. Furthermore, on account of the known relation existing between abnormalities of the hypophysis and the development of acromegaly, a similar origin has been suggested for the non-edematous thickening of the features, as well as of the extremi- ties, which is observed in so many pregnant women. The posterior or infundibular portion of the hypophysis does not hypertrophy during pregnancy, but, in addition to its effect upon the blood pressure, it possesses the power of markedly stimulating uterine contractions, as has been shown by Dale, Bell, and others. Whether it is normally concerned in the regulation of uterine contractions at the time of labor is not known, but from it has been isolated a substance which is closely related to imidazolylethylamin, which, as is well known, is one of the constituents of ergot. Extracts of the posterior lobe are now marketed under various names, such as pituitrin and hypophysin, and are extensively used in obstetrical practice to stimulate inefficient uterine contractions. It is also definitely known that the cortex of the suprarenal bodies undergo definite hypertrophy during pregnancy, which, according to Kolde, is most marked in the zona fasiculata. Aschner, who has con- sidered the question in detail, emphasizes the great increase in the lipoid content of the gland, and suggests that it may be the source of the greatly increased content of such substances in the blood of pregnant women. Skeleton and Teeth.—Bokitansky described the formation of irregu- larly shaped placques of porous, newly formed bone, or osteoid tissue, upon the internal surface of the cranial bones during pregnancy. These he designated as puerperal osteophytes, but neither he nor the subsequent CHANGES IN THE REST OF THE BODY 197 observers, who have confirmed his findings, are clear as to their signifi- cance. Dreyfuss states that their existence may be demonstrated by the use of the X-ray in every third pregnant woman, and is inclined to believe that their production is in some way associated with 1he activity of the pituitary body. Hanau considers that they are most pronounced when an excessive formation of osteoid tissue occurs in other parts of the body. This he is inclined to attribute to a slight grade of osteomalacia, which he and Gelpke regard as physiological in all pregnancies, and associated with the supply of calcium salts to the foetus. Dibbelt estimates that through- out the second half of pregnancy at least 0.17 gram of calcium oxid must be supplied to the foetus each day, while Bar, and Givens and Macy calculate that during the last two months the quantity must be increased to 0.64 or 0.70 gram per day. It is therefore evident, unless the pregnant woman assimilates an unusual amount of calcium from her food, that the foetus must he supplied from her own body, and this is usually effected by partial decalcification of the bones and teeth. For that reason the teeth are prone to decay rapidly, so that the expression “for every child a tooth” has become proverbial. As a pint of milk contains 0.5 gram of calcium, it is apparent that the ingestion of a quart each day will more than cover the need for calcium, and will likewise serve as an efficient prophylactic. Owing to the increased vascularity, the various pelvic joints become more succulent and permit greater mobility. Occasionally they become so relaxed that locomotion is seriously interfered with. The treatment of this abnormality will be considered in the chapter upon the pathology of pregnancy. Nervous System.—Various disturbances of the nervous system occur during pregnancy, but as they are distinctly abnormal they will be con- sidered later. On the other hand, mild degrees of disturbed mental equi- librium are so frequently observed as to be considered almost physio- logical. In this category may be placed the longings and cravings for unusual or abnormal articles of diet. Many women also experience pronounced changes in disposition, and not a few multiparous patients recognize the occurrence of pregnancy by their appearance. Again, in those of neuropathic tendencies the mental equilibrium may be over- thrown to a greater or less degree, the patient becoming excitable, mor- bid, or morose, and in rare instances developing a true psychosis. Skin.—Reference has already been made to the formation of striae and to the pigmentation of the nipple and areola. In other cases the linea alba becomes markedly pigmented. Occasionally irregularly shaped, yellowish patches of varying size appear on the face and neck, the condition being known as cloasma, which fortunately usually dis- appears after delivery. Very little is known concerning the nature of those conditions, but Wvchgel has demonstrated that the pigment de- posited in the papillary layer of the skin responds to the usual tests for iron. He considers that it is derived from the hemoglobin of the ma- ternal blood cells which have succumbed in the tight against the foetal tissues. 198 CHANGES IN THE MATERNAL ORGANISM General Metabolism.—Generally speaking, gestation is characterized by improved health. In some instances the improvement in nutrition is noted shortly after conception, but it may not become manifest for several months. For this reason it is frequently possible to distinguish two periods in pregnancy. The earlier is characterized by lassitude, mental depression, and some loss of weight, while the latter is conspicu- ous for an excellent condition of body and mind. Analogous conditions have been observed in pregnant dogs, rabbits, and guinea-pigs by Hagemann, Yer Eecke, Jageroos, Bar, and Murlin. Those interested in the subject are referred particularly to the monu- mental mentabolic studies of Bar, which clearly show that in animals catabolic processes are most prominent in the first half of pregnancy, as is indicated by the fact that more material is excreted than ingested, whereas the reverse obtains in the second half. During the latter period there is a marked tendency toward storage of the various food stuffs. As was shown by Bar in pregnant dogs, this storage, particularly of proteids, is more than sufficient for the needs of the foetuses and their appendages, so that in the healthy animal the second half of pregnancy may be regarded as a period of gain, and not as a sacrifice of the individul for the sake of the species. • Metabolic studies show that women in the weeks immediately pre- ceding delivery possess an unusual capacity for storing up the essential elements of their diet, and that their metabolism is analogous to that observed in animals in the corresponding period of pregnancy. In 1802 Gassner studied the changes in weight during the last three months, and found an average monthly increase of from 3% to 5!/2 pounds. The gain was proportional to the weight of the individual, and was relatively larger in multigravidae. Moreover, he considered that the absence of such a gain in weight was indicative of the death of the foetus in utero. Confirmatory results were obtained by Zangemeister in 1916, who found that a daily increase averaging 55 grams occurs during the last months of pregnancy. Moreover, he noted that the gain continues until three or four days before the onset of labor, after which a loss of 1,000 grams in weight occurs. Accordingly, if normal patients are weighed daily before breakfast, the imminence of labor may be pre- dicted whenever the usual gain is replaced by a loss in weight, On the other hand, he showed that an excessive gain in weight is abnormal, and in many instances enables one to detect the presence of occult edema, before visible swelling and pitting of the skin occur. The daily output of urine is subject to so many variations, being in- fluenced by climatic, dietetic, and individual peculiarities, that it is difficult to fix a normal standard. Ordinarily, it varies between 1,000 and 1,500 c. c., though smaller or larger amounts may be excreted without necessarily indicating a pathological condition. Of particular interest, though, is the ratio which the volume of the urine bears to the fluid in- take. In three normal pregnancies my former associate, J. M. Slemons, found that during the days immediately preceding delivery it represented from one-half to three-quarters of the fluid taken by the mouth, whereas CHANGES IN THE REST OF THE BODY 199 in a patient with dead twins it amounted to 93 per cent., which is ap- proximately the normal non-pregnant ratio. Proteid metabolism in the later months of pregnancy has been studied by Zacharjewsky, Schrader, Hahl, Hoffstrom, Hoogenhuyse, as well as in my clinic, and shows that considerable quantities of nitrogen are retained when the woman is allowed an adequate diet. The average daily nitrogeneous exchange in three women studied by Slemons is given in the accompanying table. Type Fluid Ingested. Quantity of Urine. Nitrogen in Food. Nitrogen in Urine. Nitrogen in Faeces. Nitrogen Balance. Primigravida.. . Multigravida... Twin Pregnancy 1,780 c. c. 1,890 c. c. 2,354 c. c. 1,306 C. C. 1,007 c. c. 1,135 c.c. 13.80 gms. 16.77 gms. 15.00 gms. 12.43 gms. 13.26 gms. 8.28 gms. 0.95 gm. 0.53 gm. 2.00 gms. +0.42 +2.98 +4.72 Such a storage of nitrogen as shown by these figures would indicate a considerable construction of proteid tissue, and corresponds to the growth of the foetus, placenta, uterus, and the maternal organism in general. As to the period of pregnancy at which the maternal organism first acquires the power of storing nitrogen, it is impossible to make definite statements. In one of my patients, studied by Karl M. Wilson, daily observations upon the nitrogen exchange from the tenth to the four- teenth week of pregnancy, revealed a considerable capacity for storing nitrogen, and even at that early period the total storage for the four weeks amounted to 59.99 grams. As it is evident that this amount was greatly in excess of the needs of the developing ovum, it must be assumed that the bulk of it was added to the general maternal organism, possibly as a reserve to be drawn upon later, when the needs of the embryo be- come greater. In a patient studied by Hoffstrom for the last twenty-four weeks of pregnancy, storage of nitrogen was observed throughout the entire period. This averaged 1.84 grams per day, so that the total amount stored amounted to 310 grams ; the most marked storage occurring from the twenty-ninth week onward, when the needs of the growing foetus were at a maximum. He estimated that 101 grams of this amount were needed for the development of the foetus, whereas the balance must have been added to the general maternal organism. He calculated that approximately 51 grams of this balance were utilized in the development of the uterus and breasts, leaving 158 grams to be added to the maternal nitrogen capital, although it was impossible to make a definite statement as to the exact manner in which it was stored. Furthermore, similar results were obtained in two patients studied in my clinic in 1915 by Wilson during the last nineteen and fifteen weeks of their respective pregnancies. Both were found to be storing nitrogen throughout the entire period, and in both the storage was far in excess of the actual needs of the developing foetus. As the first patient stored 419.38 grams, and the latter 336.21 grams of nitrogen, 200 CHANGES IN THE MATERNAL ORGANISM and as the total nitrogen of the child was 79.95 and 78.91 grams re- spectively, it is apparent that large amounts of nitrogen were added to the general maternal organism. It would therefore appear that in healthy women the ability to store nitrogen is acquired at a comparatively early period of pregnancy, and possibly at its very inception. Moreover, this capacity for storage increases as pregnancy advances and as the needs of the foetus become greater. As the amount stored is far in excess of the needs of the foetus, a considerable quantity of “reserve” nitrogen must be added to the maternal organism, which can be drawn upon, and possibly entirely exhausted, during labor and the puerperium. In patients suffering from gastrointestinal disturbances, which so frequently accompany early pregnancy, it is probable that storage of nitrogen does not begin until the symptoms have subsided; at it is frequently noted that such patients lose considerably in weight during the continuance of the attack. In general, however, it may be assumed that pregnancy is not necessarily a period of sacrifice on the part of the individual, but may actually be one of gain. It might be assumed that the nitrogenous content of the urine is increased during pregnancy on account of the fact that it contains the waste products of both the foetal and maternal metabolism. Such a belief, however, is erroneous, at least in the latter months of pregnancy, as the nitrogen storage to which we have just referred must necessarily be accompanied by a decrease in the urinary nitrogen. Along with the quantitative change in the elimination of nitrogen are associated certain qualitative variations. Thus, the urea content is rela- tively low, and represents only 80 to 85 per cent, of the total nitrogen, instead of 85 to 90 per cent, as in non-pregnant individuals. At the same time there occurs a slight rise in the percentage of ammonia, which is still further accentuated in twin pregnancy. Furthermore, there is usually an increase in the percentage of undetermined nitrogen, a part of which, according to Falk and Hesky, is accounted for by an increased elimination of amino acids and peptid nitrogen. In our experience, these increases are relative rather than absolute; for, while the per- centage is greater than in non-pregnant women, the lessened total nitrogen output will result in the elimination of but little more of these substances than in the non-pregnant condition. Zacharjewsky found that the uric acid excretion was practically normal. Chemical examination of the blood leads to similar conclusions, and, since the appearance of Folin’s contribution in 1917, it has been generally admitted that the non-protein nitrogen content of the blood is diminished rather than increased; while the content in urea is relatively decreased, as one would expect from the low urinary findings. In animal experiments of Hagemann, Jageroos, Harnack and Klein, and Bar, study of the mineral metabolism revealed changes analogous to those observed in the nitrogenous elimination, and indicated a reten- tion of various inorganic substances. The investigations of Schrader, Boni, Hoffstrom, Zangemeister, and others, in women show a similar retention, whose object is to supply the calcium, phosphorus, sulphur, chlorin, etc., essential to the upbuilding of the foetus. That the mechan- CHANGES IN THE REST OF THE BODY 201 ism is not always perfect has already been indicated in connection with the calcium metabolism, when it was stated, if sufficient quantities of calcium were not obtained from the food, that deficit would be made good by the decalcification of the bones and teeth of the mother. Fetzer showed in rabbits that the amount of iron contained in the foetal tissues varies with the amount in the mother’s food, but that when this falls below an irreducible minimum the quantity necessary for the well-being of the foetus is abstracted from the maternal tissues. Following the delivery of the child or its death in utero, the various constituents in- volved soon show a tendency to return to the usual non-pregnant relations. Acetonuria was formerly considered a sign of foetal death, but more recent work shows that it is of no clinical significance. Stolz observed it in more than one-third of a series of 97 normal pregnancies, and Jageroos demonstrated it in nearly every normal labor. On the other hand, the appearance of the other acetone bodies—diacetic or oxybutyric acid—is always of pathological significance. The respiratory exchange has been studied in women by means of the Zuntz apparatus by Magnus-Levy, Zuntz, and myself. These investiga- tions show a considerable increase in the total quantity of air inspired, but indicate that the consumption of oxygen and the elimination of carbon dioxid is but little greater than would be expected on account of the increased weight of the pregnant woman. Baer, on the other hand, who has studied the basal metabolism in 44 pregnant women, concludes that in late pregnancy the metabolic rate is 33 to 35 per cent, above normal, but falls rapidly after delivery, so that on the third day post- partum it is increased by only 15 per cent., and falls to normal within the following week. Carpenter and Murlin in 1911 reported the results of their investi- gations upon the total energy metabolism of pregnant women by means of a modified Atwater Calorimeter in the Carnegie Nutrition Laboratory in Boston. They found “that the energy metabolism expressed per kilogram and hour is but little larger (4 per cent.) than for a woman in complete sexual rest.” Furthermore, they stated, while the energy metabolism of the newly born child was two and a half or three times as great per kilogram of weight as that of the mother, that the total energy metabolism of both mother and child during the first days of puerperium was not greater than before labor. The more we learn concerning the metabolism of normal pregnancy, the more are we impressed with the fact that the maternal organism in the second half of gestation preserves the strictest economy in its meta- bolic processes. Its purpose, of course, is to facilitate the upbuilding of the foetus without too great strain upon the mother, but we are as yet entirely ignorant of the mechanism by which such changes are rendered possible. 202 CHANGES IN THE MATERNAL ORGANISM LITERATURE Asciiner. Die Blutdriisenerkrankungen des Weibes, 1918. Bar. Legons de pathologie obstetricale. Paris, 1907. Baer. Basal Metabolism in Pregnancy and Puerperium. Trans. Amer. Gyn. Soc., 1921, xlvi, 46-53. Basch. Ueber exp. Milcliauslosung, etc. Deutsche med. Wochenschr., 1910, xxxvi, 981. Bayer. Zur physiol, u. path. Morphologic der Gebarmutter. Freund’s gynakolo- gisehe Klinik, 1885, i, 369-662. Weitere Beitrage zur Lehrc voni unteren Uterinsegment. Beitrage zur Geb. u. Gyn., 1898, i, 167. Bell. The Pituitary Body. Brit. Med. J., 1909, Dec. 4. The Relation of the. Internal Secretions to the Female Characteristics, etc. Proc. Boy. Soc. Med., Gyn. and Obst. Sect., 1914, vii, 47-76. Boivin et Duges. Traite pratique des maladies de 1’uterus, etc., 2me ed., Bruxelles, 1834. Bompiani. De.r Einfluss des Saugens auf die Bestitutionsfahigkeit d. Thymus nach der Schwangerschaft. Zentralbt. f. allg. Path., 1915, xxv, Nr. 22. Budin. Des varices chez la femme enceinte. Paris, 1880. Carpenter and Murlin. Energy Metabolism of Mother and Child. Archives Int. Med., 1911, vii, 184-222. Chaupfard, Laroche et Grigaud. Evolution de la cholesterinemie au cours de l’etat gravidique. L’Obst., 1911, N. S. iv, 481-492. Clowes and Goldsborough. On the Antitryptic Reaction Exhibited in Preg- nancy. Proc. Soc. Exp. Biology and Med., 1913, x, 109. Cushing. Experimental Hypophysectomy. Bull. Johns Hopkins Hospital, May, 1910. Deville. Quoted in extenso by Cazeaux, Traite de l’art des accouchements, 3mo ed, 1850, 107-111. Dibbelt. Die Bedeutung d. Kalksalze fiir d. Schwangerschafts- und Stillperiode. Ziegler’s Beitrage, 1910, xlviii, 147-169. Dienst. Die Eiweissstoffe im Blutplasma unter normalen Verhiiltnissen in der Schwangerschaft, etc. Archiv f. Gyn., 1918, cix, 669-702. Dietrich. Studien iiber Blutveranderungen bei Schwangeren, etc. Archiv f. Gyn., 1911, xciv, 383-401. Doderlein. Das Scheidensekret, etc. Leipzig, 1892. Dohrn. Zur Kenntniss des Einllusses von Schwangerschaft, etc., auf die vitale Capacitat der Lungen. Monatsschr. f. Geburtskunde, 1866, xxviii, 457. Dreyfuss. Beitrage zur Frage der Osteophytenbildung in der Schwangerschaft. Archiv f. Gyn., 1922, cvx, 126-144. Dreysel. Ueber Herzhypertrophie bei Schwangeren und Wochnerinnen. D. I., Miinchen, 1891. Eisemann u. Stumme. Ueber die Schwangerschafts-veranderungen de.r Hypo- physe. Ziegler’s Beitrage, 1909, xlvi, 1-142. Falk u. IIesky. Ueber Ammoniak, Amino-siiuern u. Peptid-stickstoff in Harne. Zeitschr. f. klin. Med., 1910, lxxi, 261-276. Fehling. Ueber Blutbeschaffenheit und Fruchtwassermenge bei Schwangeren, etc. Archiv f. Gyn., 1886, xxviii, 453. Fellner. Uber die Tatigkeit des Ovarium in der Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1921, liv, 88-95. Fetzer. Studien iiber den Stoffhaushalt in der Graviditat. Zeitschr. f. Geb. u. Gyn., 1913, lxxiv, 542-578. LITERATURE 203 Folin. Recent Biochemical Investigations in Blood and Urine. Jour. Am. Med. Assoc., 1917, ii, 1209-1218. Frank and Unger. An Experimental Study of the Changes Which Produce Growth of the Mammary Gland. Archives Int. Med., 1911, vii, 812-838. Frankenhauser. Die Nerven der Gebarmutter. Jena, 1867. Gassner. Uebe,r die Veranderungen des Korpergewichtes bei Schwangeren. Mo- natsschr. f. Geburtskunde, 1862, xix, 1. Gelpke. Die Osteomalacie im Ergolzthale, Basel. 1891. Givens and Macy. The Ca and Mg content of the human fcetus. J. Biol. Chem., 1922, li, 34. Grafenberg. Die zyklischen Schwankungen des Sauretiters im Scheidensekret. Archiv f. Gyn., 1918, cviii, 628-656. Hagemann. Ueber Eiweissumsatz wahrend der Schwangerschaft. Archiv f. Anat. u. Physiol. Phys. Abtheil., 1890, lvi, 577. Hahl. Beitrag zur Kenntniss des Stoffwechsels wahrend der Schwangerschaft. Archiv f. Gyn., 1905, lxxv, 31-48. Halban. Schwangersreactionen der fotalen Organe, etc. Zeitschr. f. Geb. u. Gyn., 1904, liii, 191-231. Hanau. Ueber Knochenveranderungen in der Schwangerschaft, etc. Fortschritte d. Med., 1892, Nr. 7. H£:lie. Recherches sur la disposition des fibres niusculaires de 1’uterus developpes par la grossesse. Paris, 1864. Henle. Eingeweidelehre, II. Aufl., 476, 1873. Heynemann. Eine Reaction im Serum Schwangerer. Archiv f. Gyn., 1910, xc, 236-254. Hofbauer. Die Graviditats-veranderungen. Yolkmann’s Samml. klin. Vortrage, 1910, Nr. 586. Hoffmann. Morphologische Untersuchungen fiber die Muskulatur des Gebar- mutterkorpers. Zeitschr. f. Geb. u. Frauenkrankhelten, 1876, i, 448-473. Hoffstrom. Une experience sur les echanges nutritifs pendant la grossesse. L’Obstetrique, 1910, N. S. 1060-1071. Hofmeier. Das untere Uterinsegment in anat. u. physiol. Beziehung. Der schwan- gere und kreissende Uterus, Bonn, 1886, 21-74. Hoogenhuyse et Doeschate. Recherches sur les echanges organiques chez les femmes enceintes. Annales de gyn. et d’obst., 1911, N. S. vii, 17-33. Huffmann. Zur Bestimmung des Gesammtscholesterins im Blute, etc. Zentralbl. f. Gyn., 1915, 33-40. Hunter. The Anatomy of the Gravid Uterus, 1774. Jageroos. Studien fiber den Eiweiss-Phosphor- u. Salzumsatz wahrend der Gravidi- tat. Archiv f. Gyn., 1902, lxvii, 517. Ueber die Aceton-korper des Harnes, etc. Archiv f. Gyn., 1911, xciv, 656-663. Jaschke. Blutdruck und Herzarbeit in der Schwangerschaft, etc. Archiv f. Gyn., 1911, xciii, 809-832. Joessel und Waldeyer. Das Becken. Bonn, 1899, 781. Keller. Ueber Veranderungen am Follikelapparat des Ovariums wahrend der Schwangerschaft. Beitrage zur Geb. u. Gyn., 1913, xix, 13-38. Krause. Quoted by Spiegelberg-Wiener, Lehrbuch der Geburtshulfe, III. Aufl., 1891, 53. Landsberg. Untersuchungen fiber den Gehalt des Blutplasmas an Gesammtei- weiss. Archiv f. Gyn., 1910, xcii, 693-720. Lange. Die Beziehungen der Schilddrfise zur Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1899, xl, 36-72. Larcher. Quoted from Ribemont-Dessaignes and Lepage, Precis d’obstetrique. Paris, 1894. 204 CHANGES IN THE MATERNAL ORGANISM Launois et Mulon. Etude sur l’kypopliyse humaine a ia fin de la gestation. Annales de gyn. et d’obst. 2me Ser., 1904, i, 2-13. Long and Evans. The Oestrous Cycle in the Rat. Berkeley, 1922. Luschka. Die Anatomie des menschlichen Beckens. Tubingen, 1864, 365. Magnus-Levy. von Noordeu’s Handbuch der Pathologic des Stoffwechsels. 1906, 408. Mayer. Ueber die Beziehungen zwischen Keinidriisse u. Hypopliyse. Archiv f. Gyn., 1910, xc, 600-625. Miller, Keith & Rowntree. Plasma and Blood Volume in Pregnancy. J. Am. Med. Assn., 1915, lxv, 779-782. Murlin. Nitrogen Balance during Pregnancy. Amer. J. Physiol., 1910, xxvii, 177-205. Protein Metabolism of Normal Pregnancy. Surg. Gyn. & Obst., 1913, xvi, 43-53. Neu. Zur Kritik der Frage: “ Adreningehalt ” des Blutes innerhalb der Gesta- tionszeit. Archiv f. Gyn., 1917, cvii, 35-44. Nicholson. Puerperal Eclampsia Treated by Large Doses of Thyroid Extract. Jour. Obst. & Gyn. Brit Emp., 1904, v, 32-37. Opitz. Ueber Leberveranderungen in der Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1913, lxxii, 351-361. Payer. Das Blut der Schwangeren. Archiv f. Gyn., 1904, lxxi, 421-459. Roederer. leones uteri humani. Gottingen, 1759. Rokitansky. Das Osteophyt. Lehrbuch d. path. Anat., III. Aufl., 1856, ii, 100. Ruge. Ueber die Contraction des Uterus in anat. u. klin. Beziehung. Zeitschr. f. Geb.u. Gyn., 1880, v, 149-157. Schauta. Die Pygopagen-Sehwestern Blazek. Gyn. Rundschau, 1910, iv, 437- 445. Schrader. Einige abgrenzende Ergebnisse phys.-chemischen Untersuchungen fiber den Stoffwechsel wahrend der Schwangerschaft u. im Woehenbette. Archiv f. Gyn., 1900, lx, 534. Seitz. Die Follikelatresie wahrend der Schwangerschaft. Archiv f. Gyn., 1905, lxxvii, 203-356. Innere Sekretion u. Schwangerschaft. Leipzig, 1913. Sellheim. Die Geburt des Menschen. Deutsche Frauenheilkunde, 1913, i, 291. Siegmund. Head’s Felder u. weibl. Geschlechtsorgane. Zeitschr. f. Geb. u. Gyn., 1908, Ixii, 309-346. Slemons. Metabolism during Pregnancy, Labor, and the Puerperium. Johns Hopkins Hospital Reports, 1904, xiii, 111. Slemons and Goldsborough. The Obstetrical Significance of the Blood Pressures. Bull. Johns Hopkins Hospital, 1908. Slemons and Standee. The Lipoids of the Maternal and Fetal Blood at the Conclusion of Labor. Bull. Johns Hopkins Hospital, 1923, xxxiv, 7-10. Starling and Lane Claypon. Experimental Inquiry into the Factors Which Determine the Growth and Activity of the Mammary Gland. Proc. Roy. Society, 1905-06, 505-22. Stolz. Die Acetonurie in der Schwangerschaft, Geburt u. Woehenbette. Archiv f. Gyn., 1902, lxv, 531. Taussig. Factors in the Formation of Skin Striations During Pregnancy. Surg. Gyn. & Obst., 1913, 335-340. Ukita. Influence of Thyroidectomy on Gestation. Abstract J. Am. Med. Assoc., 1920, lxxiv, 213. Veit. Anatomie des schwangeren Uterus. Mfiller’s Handbuch der Geburtshfilfe, 1888, i, 193. LITERATURE 205 Ver Eecke. Les echanges materiels dans leurs rapports avec les phases de la vie sexuelle. Bruxelles, 1900. VON Graff. Schilddriise u. Genitale. Archiv f. Gyn., 1914, cii, 109-140. Wallace and Bose. Glycosuria in Pregnancy. Jour. Obst. & Gyn. Brit. Emp., 1922, xxix, 274-295. Wild. Untersuchungen iiber den Hamoglobingehalt und die Anzahl der rothen und weissen Blutkorperchen bei Sehwangeren und Woehnerinnen. Archiv f. Gyn., 1897, liii, 363-381. Wilson. Nitrogen Metabolism in Pregnancy. Bull. Johns Hopkins Hospital, 1916, xxvii, 121-129. Wychgel. Untersuchungen iiber das Pigment der Haut, etc. Zeitschr. f. Geb. u. Gyn., 1902, xlvii, 288-303. Zacharjewsky. Ueber den Stickstoffwechsel wahrend den letzten Tagen der Schwangerschaft, etc. Zeitschr. f. Biologie, 1894, xii, 368. Zangemeister. Die Beschaffenheit des Blutes in der Schwangerschaft und der Geburt. Zeitschr. f. Geb. u. Gyn., 1903, xlix, 92-103. Ueber die Auscheidung d. Chloride in d. Schwangerschaft. Archiv f. Gyn., 1908, lxxxiv, 825-836. Ueber das Korpergewicht Schwangerer. Zeitschr. f. Geb. u. Gyn., 1916, Ixviii, 325-365. Zeiler. Zur Pathogenese der Dehnungstreifen der Haut. Munchener med. Woch- enschr., 1905, iv, 1764-67. Zuntz. Respir. Stoffwechsel u. Athmung wahrend d. Graviditat. Archiv f. Gyn., 1910, xc, 452-470. Zweifel. Die Scheideneinhalt Schwangerer. Archiv f. Gyn., 1908, lxxxvi, 564- 601. CHAPTER VII DIAGNOSIS OF PREGNANCY—DURATION OF PREGNANCY ESTIMA- TION OF DATE OF CONFINEMENT Ordinarily, the diagnosis of pregnancy offers little or no difficulty, and the patient is usually aware of the true condition before she consults a physician. In a small minority of cases, however, the task is by no means easy, and despite every known method at our command we are occasionally unable to decide with absolute certainty. Mistakes in diagnosis are most frequently made in the first few months, while the uterus is still a pelvic organ; although it is by no means impossible to confound a pregnancy, even at full term, with a tumor of some other nature. Such errors are usually the result of hasty 01 imperfect examination, but a false conclusion may sometimes be arrived at, even after the most conscientious exploration of the patient. Some idea of the frequency of such mistakes may be realized when it •is stated fhat there is hardly a gynecologist of experience who has not opened the abdomen on one or more occasions, with the expectation of removing a tumor of the uterus or its appendages, and has been surprised to find himself in the presence of a normal pregnancy. It is often a matter of considerable importance that a diagnosis be made in the early months of pregnancy; but, unfortunately, it is just at this period that our diagnostic ability is most restricted, as the absolutely positive signs do not as a rule become available until the fifth month. Hence, it follows that in cases in which the existence of such a condition might a fleet the reputation or interests of the patient a positive expres- sion of opinion shoulu be deferred until the diagnosis is beyond all doubt. 'Ihe diagnosis is based upon the presence of certain symptoms and signs, the former are chiefly subjective and are appreciated by the patient ; while the latter are made out by the physician after a careful physical examination, in which the senses of sight, hearing, and touch, as well as certain laboratory procedures, are employed. The signs and symptoms are usually classified into three groups: the positive signs, which cannot usually be detected until after the fourth month; the probable signs, which can be appreciated at an earlier period; and the presumptive evidences, which are usually subjective in character, and may be experienced at varying periods. Positive Signs of Pregnancy.—These are four in number, and con- sist in (1) hearing and counting the foetal heartbeat, (2) ability to pal- pate the outlines of the foetus, (3) perception of its active and passive movements, and (4) reegonition of the foetal skeleton by means of the Roentgen ray; and when any one of them is obtained the diagnosis is established beyond all doubt. 206 POSITIVE SIGNS OF PREGNANCY 207 The Foetal Heart.—Whenever one can hear and count the pulsations of the foetal heart, the diagnosis of pregnancy is assured beyond per- adventure; unfortunately, this sign cannot usually be appreciated until the eighteenth or twentieth week, though Sarwey and Benoist claim that it may be possible as early as the twelfth or fourteenth week. The foetal heart was first heard by Mayor, of Geneva, in 1818, but was recognized independently by Lejumeau de Kegaradec in 1821, to whom we are indebted for our fundamental information upon the sub- ject; indeed, so complete was his monograph that subsequent investiga- tions have revealed but little with which he was not familiar. He made his discovery quite accidentally, while attempting to hear the sounds which he supposed would be made by the foetus splashing in the liquor amnii. On auscultating the abdomen of a pregnant woman through her clothing, including the corset, he heard a double sound, which varied in frequency from 143 to 148 beats to the minute, and closely resembled the ticking of a watch under a pillow. He concluded that it could be produced only by the foetal heart, as the pulse of the mother did not exceed 70. For further details concerning the history and earlier work upon the subject the reader is referred to the works of Kegaradec, Kennedy, Depaul, and Montgomery. The foetal heartbeat, after the eighteenth or twentieth week of preg- nancy, should be detected without difficulty. Ordinarily it varies in fre- quency from 120 to 140 beats to the minute, and is a double sound, closely resembling the tick of a watch under a pillow. In order to hear it the abdomen should be bared, or at most covered by a thin cloth. In the earlier months it is best detected by means of a stethoscope, but at a later period the direct application of the ear gives more satisfactory results. One should not be content with merely hearing the foetal heart, but should always attempt to count its rate and compare it with that of the maternal pulse. In the early months the heart should be sought just over the sym- physis pubis; but in the later months the situation at which it is best heard varies according to the position and presentation of the foetus, details concerning which will be given when we consider the methods of obstetrical examination. The rate of the foetal heart is subject to considerable variations, which afford us a fairly reliable means of judging as to the well-being of the child. As a general rule, its life should be considered in danger when the heartbeats fall below 100 or exceed 160. Following Franken- hauser’s publication in 1859, various writers have stated that there is a marked difference in the rapidity of the heartbeat in the two sexes, and that a rate of 124 or less indicates a boy, and 144 or more a girl. Subsequent investigation, however, has failed to confirm their conclu- sions, as a positive diagnosis can be made by this means in only about 50 per cent, of the cases. Indeed, there is no method by which the sex can be definitely determined before birth, except occasionally in breech presentations, when the genitalia can be differentiated by the examin- ing finger. In women possessing very thin abdominal and uterine walls the im- 208 DIAGNOSIS AND DURATION OF PREGNANCY pulse of the foetal heart may occasionally be appreciated by direct palpa- tion, especially when the child is lying in the right mento-iliac position. Such observations have been reported by Fischel, Duval, and others. Other Sounds Which May Be Heard on Auscultation.—In addition to hearing the foetal heart, auscultation of the abdomen in the later months of pregnancy often reveals other sounds, the most important of which are the funic souffle, the uterine or placental souffle, sounds due to movements of the foetus, the maternal pulse, and the gurgling of gas in the intestines of the mother. The funic souffle is a sharp, whistling sound, synchronous with the foetal pulse, which can be heard in about 15 per cent, of all cases. It is very inconstant in its appearance, as it may be recognized distinctly at one examination and be absent on succeeding occasions. It was first described by Evory Kennedy, who supposed that it was due to some interference with the circulation of the blood through the umbilical ar- teries, and subsequent investigations have served to confirm his conclu- sions. Its mode of production may occasionally be demonstrated in very thin women, in whom the umbilical cord may be palpated between the body of the child and the uterine wall, and on making pressure upon it with the stethosocope a distinct souffle can occasionally be elicited. This is not, however, a sign of very great importance, although, when heard, it is distinctly characteristic of pregnancy. The uterine souffle is a soft, blowing sound, synchronous with the maternal pulse, and is usually most distinctly heard upon auscultating the lower portion of the uterus. It is due to the passage of blood through the dilated uterine vessels. This sound was first described by Kegaradec, who considered that it was produced by the circulation of the blood through the placenta. He therefore designated it as the placental souffle, and believed that it was of value in determining the situation of that organ. Subsequent investigations, however, have shown that such is not the case, and that the sound originates as I have indicated. As stated by Hotter and others, it may occasionally be appreciated by the palpating finger. This sign is not characteristic of pregnancy, as it may be present in any condition in which the blood supply to the genitalia becomes markedly increased, and accordingly may be heard in non-pregnant women presenting tumors of the uterus or ovaries. Certain movements of the foetus may likewise be recognized on auscul- tation. According to Ahlfeld, it is impossible to hear the movements of the extremities, but he considers that the sounds which are usually so interpreted are produced by spasmodic contractions of the diaphragm, and are analogous to singultus. The maternal pulse can frequently be distinctly heard on auscul- tating the abdomen, and in some instances the pulsation of the aorta is so violent as to communicate a distinct throb to the ear. Occasionally, in neurotic women, the pulse may become so rapid during examination as to mask the foetal heart sounds. In addition to the sounds just mentioned, it is not unusual to hear certain others produced by the passage of gases or fluids through the intestines of the mother. POSITIVE SIGNS OF PREGNANCY 209 Mapping Out the Outlines of the Foetus.—In the second half of preg- nancy it is possible to distinguish the outlines of the foetus by palpation through the abdominal walls, and this becomes easier the nearer term is approached. When it is desired to map out the foetus the examination should be made in a methodical manner, following the rules which will be given later. A diagnosis of pregnancy should not be made from this sign alone, unless one is able to feel distinctly the various portions of the foetus and to distinguish its head, breech, back, and extremities. Subserous myo- mata occasionally simulate the head or small parts, or both, and may occasionally give rise to serious diagnostic errors. Movements of the Foetus.—The third positive sign of pregnancy is present whenever the physician is able to feel the spontaneous movements of the foetus. After the fifth month the active movements may be felt at intervals on placing the hand over the abdomen. These vary from a faint flutter in the early months to quite violent motions at a later period, which are sometimes visible as well. Occasionally, somewhat similar sensations may be produced by contractions of the intestines or the muscles of the abdominal wall, though these should not deceive an experienced observer. The passive movements, obtained by ballottement, consist in the re- bound of a foetal extremity when displaced from its position by the examining finger, whereby a sensation is afforded similar to that pro- duced when a sudden motion is given to a piece of ice in a glass of water, so that at first it sinks and then slowly comes back to the finger. This sign is available from the early part of the fourth month, and may be obtained through either the vagina or the abdominal walls. To obtain vaginal ballottement the patient should be on her back; the physician then introduces two fingers into the vagina and carries them up to the anterior fornix, to which he imparts a sudden motion with his finger-tips, afterwards retaining them in the same position. After a moment the extremity of the child, which occupies the lower segment of the uterus, usually the head, drops down upon them again. External ballottement can be obtained by imparting a sudden motion to the portion of the abdominal wall covering the uterus; in a few seconds the rebound of one of the extremities or of the head of the foetus can be felt. This sign, while not absolutely positive, is of very considerable value, as it can be simulated only by a pedunculated tumor swimming in ascitic fluid. The X-ray.—Whenever the outlines of the foetal skeleton can be distinguished by means of the Roentgen ray, the existence of pregnancy is assured. Unfortunately, like the other positive signs, this method of diagnosis is not available until the second half of pregnancy. By its means Bartholomew, Sale and Calloway were able to make a positive diagnosis in one-third of their patients at the fifth month, in one half at the sixth month, and almost constantly later. In my experience, the method has been of especial value in differentiating the pregnant uterus from abdominal tumors of other origin, particularly when the child is dead. 210 DIAGNOSIS AND DURATION OF PREGNANCY Peterson claims that the employment of the X-ray in association with artificial pneumoperitoneum permits a positive diagnosis as early as the sixth or eighth week. In this event, the decision is not based upon the recognition of foetal bones, but rather upon the detection of changes in the lower uterine segment. These changes consist in an enlargement of the isthmus of the uterus in its long axis, together with a lateral widening. I have had no experience with the method, but, in view of Peterson’s well known conservatism, I am prepared to accept his state- ments. Probable Signs of Pregnancy.—These consist in (1) enlargement of the abdomen; (2) changes in the shape, size and consistency of the uterus; (3) changes in the cervix; (4) the detection of intermittent con- tractions of the uterus; and (5) the positive outcome of Abderhalden’s serum reaction. Enlargement of the Abdomen.—From the third month onward the uterus can be felt through the abdominal wralls as a tumor, which gradu- ally increases in size up to the end of pregnancy. Generally speaking, any enlargement of the abdomen during the childbearing period should be regarded as prima facie evidence of the existence of pregnancy. Figs. 183, 184, 185, and 186 give a good idea of the changes in the shape of the abdomen at the various months. The abdominal enlargement is less pronounced in primiparae than in multiparae, for the reason that in the latter the abdominal wralls have lost a great part of their tonicity and are sometimes so flaccid that they afford little or no support to the uterus, which then sags forward and downward, giving rise to a pendulous abdomen. This difference is so apparent that it is not unusual for women in the latter part of a second pregnancy to suspect the existence of twins from the increased size of the uterus, as compared with that noted in the corresponding month of the previous pregnancy. It should also be borne in mind that the abdomen changes its shape materially according as the woman is in the upright or horizontal position, being much less prominent when she is lying down. (See Fig. 181, b.) Changes in Size, Shape, and Consistency of Uterus.—In the first three months these are the only physical signs available, and the existence of an enlarged uterus at any time during the childbearing period should be regarded as presumptive evidence of pregnancy, until such a possibility has been conclusively eliminated. During the first few weeks the increase in size is limited almost en- tirely to the anteroposterior diameter; but at a little later period the body of the uterus becomes almost globular in shape, and at the third month attains the size of an orange. During the first two months the pregnant uterus still continues to be entirely a pelvic organ, whereas during the third month it begins to rise above the symphysis. At the same time the angle between the hodv and cervix becomes accentuated •—in other words, the physiological anteflexion is increased. More characteristic than the changes in shape are those affecting its consistency. On bimanual examination the uterine body offers a doughy or elastic sensation, and in many instances becomes so soft as PROBABLE SIGNS OF PREGNANCY 211 to be hardly distinguishable. Dickinson has pointed out that these changes can be noted at a very early period. According to E. von Braun, it would appear that as early as the first week evidence of pregnancy is afforded by the appearance of a more or less longitudinal furrow upon either the anterior or posterior surface of the uterus. Its presence he attributes to changes in consistence and the alternation between contraction and relaxation of the portion of the organ in which the ovum is situated. Fig. 183. Fig. 184. Fig. 185. Fig. 186. Figs. 183-186.—Showing Relative Abdominal Enlargement at Third, Sixth, Ninth, and Tenth Month of Pregnancy. At about the sixth week another sign of very considerable value—the so-called Ilegar’s sign—becomes available. On careful examination with one hand upon the abdomen and two fingers of the other hand in the the firm, hard cervix is felt, and above it the elastic body of the uterus, while between the two the isthmus is felt as a soft compressible area. Occasionally the change in consistence in this location is so marked that no connection between the cervix and body appears to exist, so that inexperienced observers may mistake the cervix for a small uterus, and the softened body for a tumor of the tubes or ovaries. 212 DIAGNOSIS AND DURATION OF PREGNANCY The value of this sign, which was first described in 1884, by Reinl, one of Hegar’s assistants, is universally admitted, and I consider it the most valuable sign of early pregnancy. Its production probably depends upon the forcing of the p'art of the ovum occupying the lower uterine segment into the upper part of the body of the uterus, so that the empty and softened lower uterine segment can then be readily com- pressed between the fingers. Fig. 188 gives a good idea of the sensation to be obtained on bimanual examination; and Figs. 189 and 190 show the condition of the uterus which makes it possible. This sign is not, however, absolutely characteristic, as it may occasionally be elicited when the walls of the non-pregnant uterus are unduly soft. Macdonald in 1908 directed attention to a modification of Hegar’s sign, which he claims will make pos- sible the diagnosis of pregnancy during the course of the first month. It is based upon the exaggerated flexibility of the isth- mus of the uterus, and is manifested by the unusual case with which the fundus and cervix can be brought together on vaginal manipulation. Cervix.—Beginning with the second month of pregnancy, the cervix becomes considerably softened, and in primiparous women the os ex- ternum offers to the finger a sensation similar to that obtained by press- ing upon the more yielding lips instead of the harder cartilage of the nose, as at other times. Occasionally, however, the softening does not occur until much later in pregnancy, and in certain inflammatory con- < ditions, as well as in carcinoma, the cervix may remain firm and hard until the onset of labor. Intermittent Contractions of the Uterus.—From the first weeks on, at intervals of from three to ten minutes, the pregnant uterus under- goes painless contractions, which in the early months can be appreciated by bimanual examination, and later by the hand upon the abdomen, when the previously relaxed organ is felt to become firm and hard, remaining so for a few moments, and then returning to its original con- dition. Attention was first called to this phenomenon by Braxton Hicks, and the sign has since been known by his name. It is not, however, in- Fig. 187. — Pendulous Abdomen in a Multiparous Woman with Normal Pelvis. PROBABLE SIGNS OF PREGNANCY 213 fallible, as it is probable that similar contractions occur in the non- pregnant organ, as has been demonstrated by Keye in the pig and other animals. Moreover, similar contractions are sometimes observed in hem- atomctra, and occasionally in cases of soft myomata. Whenever one or several of these probable signs of pregnancy are detected the evidence becomes very strong. Nevertheless, if there is any possibility of wronging our patient we are not justified in making a posi- tive assertion, even though we may feel morally sure of our diagnosis, until the positive signs become available Fig. 188.—Method of Detecting Hegar’s Sign. Abderhalderi’s Reaction.—Abderhalden in 1912 described what he believed to be an absolute method for diagnosticating the existence of pregnancy by means of certain changes occurring in the blood serum of the patient. He reasoned that if foetal elements are constantly escap- ing into the maternal blood current, as is undoubtedly the case, some mechanism must be developed in order to render the foreign protein harmless. He assumed that this is accomplished hy the development of a ferment in the maternal blood which breaks down the foetal tissue into simpler substances; and, consequently, that the blood serum of preg- nant women should possess the power of breaking down placental tissue into its component amino acids. He then devised a method for demonstrating this reaction in vitro, extremely simple in conception, but very difficult in exact application. 214 DIAGNOSIS AND DURATION OF PREGNANCY It consists in placing in a small dialysing tube a definite quantity of especially prepared placental peptone and 1 or 1.5 cm. of the serum to be tested. The dialysing tube is then introduced into a small flask con- taining distilled water and placed in the thermostat for 16 hours. By the end of this time the specific ferment, if present, will have broken down at least a part of the placental peptone, when the resulting amino acids, together with a portion of the salts, will diffuse out into the distilled water, while the colloidal material remains within the tube. The presence of amino acids in the dialysate is then determined by means of the biuret test, or by means of a 1 per cent, solution of triketohydrindenhydrate (ninhydrin),. the latter giving a delicate purple color upon heating. Or, as was suggested by Abderhalden and Fodor in 1914, they can he detected by the estimation of the total nitrogen by the microkjeldahl method. Abderhalden also pointed out that more Fig. 189.—Ten Weeks’ Pregnant Uterus (Pinard). X Fig. 190.—Showing Mode of Produc- tion of Hegar’s Sign. accurate results could, be obtained by means of the polarimeter, which has the further advantage of obviating the use of dialysing tubes. This work aroused the greatest interest, was repeated in all parts of the world, and promptly gave rise to an immense literature, whose mere enumeration required 36 pages in the 4th edition of Abderhalden’s “Abwehrfermente,” which appeared two years after his initial publi- cation. Abderhalden states that the reaction becomes available in the earliest weeks and persists throughout the entire duration of pregnancy, to disappear in the first days of the puerperium. He considers that a posi- tive result affords indubitable evidence of the existence of pregnancy, and that unsatisfactory results are always attributable to imperfect technic. On the other hand, Williams and Pearce, Petri and others con- tend that the reaction is not specific, and may occur in non-pregnant women or even in men. Bar and Ecalle in 1919 found that the reaction was positive in all the pregnant women tested, but likewise obtained a similar result in 34 per cent, of patients in whom pregnancy did not exist. PRESUMPTIVE SIGNS OF PREGNANCY 215 Consequently they concluded that a positive result has no diagnostic significance, while a negative one excludes the possibility of pregnancy. Van Slyke in 1915 devised a quantitative method for determining the amount of amino acids which are liberated by the action of blood serum upon placental peptone. He experimented with serum obtained from men, non-pregnant and pregnant women; and as he found essen- tially the same quantities in each, he was forced to deny the presence of a specific ferment in the blood of pregnant women, and to conclude that the reaction is not characteristic of pregnancy. Whether these conclusions are correct or not, the method has been but little used since the World War, and a communication by Abder- halden in 1921 indicates that he has become somewhat skeptical as to its value, or, at least, as to its interpretation. It should, however, be regarded as an important contribution to medical investigation, as it has served to focus attention upon the important fact that foetal ele- ments are continually gaining access to the maternal circulation—a phenomenon which cannot be regarded as negligible. Presumptive Signs of Pregnancy.—The presumptive evidences of pregnancy are afforded in great part by subjective symptoms, which may be appreciated by the patient herself. These consist in (1) cessation of the menses, (2) changes in the breasts, (3) morning sickness, (4) quickening, (5) discoloration of the mucous membranes, (6) abnor- malities in pigmentation, (7) disturbances in urination, (8) mental and emotional changes, (9) diminished tolerance for sugar, and (10) changes in the blood serum. Cessation of the Menses.—Most important is the cessation of the menstrual flow. In women exposed to the possibility of pregnancy, and whose menses have previously been regular, a sudden cessation is a most characteristic sign; and from it alone the majority of married women do not hesitate to diagnosticate their condition. But in patients present- ing an irregular menstrual history this symptom does not possess the same diagnostic value, as we know that certain diseases may give rise to amenorrhea of many months’ duration, in the course of wdiich conception occasionally occurs. Furthermore, a single menstrual period may be missed by women who fear the possibility of pregnancy. On the other hand, false state- ments are often made, and a patient who has missed one or more periods may complain of profuse uterine hemorrhage, in the hope of misleading the physician and inducing him to curette the uterus. In not a few instances menstruation may appear once after the com- mencement of pregnancy, though the flow is usually less profuse than at other times. In many of these cases it is probable that conception has occurred shortly before the period. Only very rarely, however, does the menstrual flow appear more than once, and, although its regular recur- rence is theoretically possible until the decidua vera and capsularis fuse together at the fourth month, yet repeated bleeding should always arouse suspicion as to the existence of disease of the endometrium, carcinoma of the cervix, or some other pathological condition. One occasionally hears of women who menstruate regularly through- out pregnancy, but the majority of these accounts are apocryphal, or else the condition is associated with uterine disease. Changes in the Breasts.—In the chapter upon the Physiology of Pregnancy reference has already been made to the changes which occur in the breasts. Generally speaking, in primiparae these are quite char- acteristic, but are of less value in multiparae, since the breasts of the latter not infrequently contain a small amount of milk or colostrum for months, or even for years, following the last labor. Occasionally, changes in the breasts similar to those-produced by pregnancy may be observed in women suffering with ovarian or uterine tumors. Nor is the pos- sibility of their occurrence excluded in instances of spurious or imaginary pregnancy. Nausea and Vomiting.—The establishment of pregnancy is frequently manifested by disturbances of the digestive system, more particularly manifested by nausea and vomiting. This "morning sickness ” as the name implies, usually comes on in the earlier part of the day, and passes off in a few hours, although it occasionally persists longer or may occur at other times. It usually appears about the end of the first month, and disappears spontaneously six or eight weeks later, although some patients suffer from it for a longer period. Occasionally, similar symptoms result from nervousness or from the fear of an illegitimate pregnancy, as well as in certain cases of pseudo cyesis. It is generally believed that these symptoms are observed in most pregnant women, but, upon analyzing the records of my private patients, I found that slightly less than one half of them suffered from vomiting. In many it amounts to nothing more than an occasional sen- sation of nausea; others have considerable vomiting, while in rare in- stances the nausea and vomiting may be so persistent and constant as to interfere seriously with nutrition. It is then designated as pernicious vomiting, which will be considered in detail in Chapter NXVI. Quickening.—About the eighteenth or twentieth week the woman be- comes conscious of slight, fluttering movements in her abdomen, which gradually increase in intensity. These are usually due to movements of the foetus, and their first appearance is designated as “quickening” or the perception of life. Occasionally foetal movements may be perceived as early as the tenth week, while in rare instances they may not be ex- perienced at all. This sign offers only corroborative evidence of pregnancy, and is of no value unless confirmed by the hand of the physician, as in many nervous women similar sensations are experienced in its absence. Discoloration of the Mucous Membrane of Vagina and Vulva.—Un- der the influence of pregnancy the mucosa about the vaginal opening and the lower portion of the anterior vaginal wall frequently take on a dark bluish or purplish, congested appearance. Attention was first called to this condition by Jacquemier and Kluge, but particular stress was laid upon its significance by Ur. .Tames It. Chadwick, of Boston, so that in this country it is known as Chadwick3s sign. Tts presence sup- plies valuable presumptive evidence, but is not conclusive, as it may 216 DIAGNOSIS AND DURATION OF PREGNANCY PRESUMPTIVE SIGNS OF PREGNANCY 217 likewise be observed in any condition leading to intense congestion of the pelvic organs. Pigmentation of the Shin and Abdominal Striae.—1These manifesta- tions, which have already been referred to in the chapter upon the physiology of pregnancy, are usually observed in this condition, but are not absolutely characteristic of it, as they sometimes do not develop, and, on the other hand, may be associated with tumors of other origin. Urinary Disturbances.—In the early weeks of pregnancy the enlarg- ing uterus, by exerting pressure on the bladder, causes a desire for fre- quent micturition. This continues for the first few months, and gradually passes off as the uterus rises up into the abdomen, to reappear when the head descends into the pelvis a few weeks before term. Cravings—Mental and Emotional Changes.—Occasionally the appe- tite of the pregnant woman becomes very capricious, and she may evince an almost unconquerable desire for peculiar and sometimes revolting articles of food. I recall one patient who subsisted almost exclusively upon deviled crabs throughout the entire duration of pregnancy, and another who could retain nothing for the first few months except broiled lobster and Bass’s ale. Reference has already been made to the mental and emotional changes which sometimes characterize pregnancy, and occasionally we meet with women who diagnose their condition mainly from the occurrence of changes in their own temperament with which they have become familiar in previous pregnancies. Decreased Sugar Tolerance.—As the result of the demonstration by Xiirnberger and others that the renal threshold for sugar is definitely lowered during the first months of pregnancy, Welz and Van Nest have utilized the phenomenon as a diagnostic test for the existence of early pregnancy. For this purpose, the fasting patient is catheterized and a specimen of blood taken; 150 grams of glucose are then give by mouth, and 45 minutes later the urine is tested for sugar, and afterwards at half hourly intervals. As soon as a positive result is obtained, a second sample of blood is withdrawn and its sugar content is determined. The authors consider that decreased tolerance and the existence of pregnancy is demonstrated, whenever glycosuria is present, and the sugar content of the blood does not exceed 190 milligrams to 100 c.c.m. They state that the accuracy of the test was confirmed by the subsequent history in all but 2 out of 44 patients, but that it is less accurate after the third month. I have had but little experience with the method, but as I know of several instances in which it would have led to an erroneous conclusion, I fear that its advocates have taken too roseate a view of its applicability. Changes in the Blood Serum.—In the preceding chapter reference was made to changes in the antitryptic titer, and in the cholesterin content of the maternal serum which are said to characterize pregnancy. Fieux and Mauriac believe that in the early months it also contains an antibody whose presence can be revealed by the deviation of complement reaction, when young chorionic villi are used as antigen. The demon- stration of such changes, however, is too complicated for ordinary clinical 218 DIAGNOSIS AND DURATION OF PREGNANCY purposes. On the other hand, if the claims of Neumann and Hermann are substantiated, we may have at our disposal a valuable aid to diagnosis, which is attributable to an increase in the amount of lipoids present in the serum in the latter months of pregnancy. This reaction consists in adding a drop of distilled water to a filtered alcoholic extract prepared from one cubic centimeter of blood. The fluid becomes turbid if preg- nancy exist, while it remains clear and transparent in non-pregnant women. Linzenmeier claims that in early pregnancy diagnostic use can be made of the rapidity with which the corpuscles settle, as he found that they did so in two hours or less in pregnant women, instead of in six hours, as in the case with normal blood. Synopsis of Signs and Symptoms of Pregnancy.—For convenience of reference, we give a synopsis of the signs and symptoms of pregnancy, dividing them into three groups, according as they occur in the first three months, in the fourth and fifth months, or in the last five months of pregnancy. In the first period the symptoms are: (a) cessation of the menses, (&) changes in the breasts; (c) morning sickness; (d) urinary disturb- ances. The signs are: (1) enlargement and softening of the body of the uterus and increased anteflexion; (2) changes in the consistency of the body of the uterus; (3) Hegar’s sign; (4) Abderhalden’s reaction; (5) changes in the cervix; (6) Chadwick’s sign; (7) the abdomen is not prominent, the navel is depressed; (8) auscultation is negative. Second period. Symptoms: (a) menses still absent; (b) more marked changes in the breasts; (c) disappearance or subsidence of gastric and urinary disturbances; (d) quickening. Signs: (1) the fundus is felt several fingers above the symphysis at the forth month, and mid- way between the symphysis and umbilicus at the fifth month; (2) the cervix is soft; (3) ballottement is obtainable; (4) intermittent uterine contractions are recognizable; (5) at the very end of the period the foetal heart sounds can be distinguished; (6) Abderhalden’s reaction. Third period: Symptoms: (a) menses still absent; (&) changes in the breasts more marked; (c) in the last month frequent urination re- appears, often with neuralgic pains in the lower extremities. Signs: (1) progressive enlargement of the abdomen; (2) umbilicus smooth and later protruding; (3) the foetal heart can be heard; (4) the different parts of the child can be palpated; (5) foetal movements are perceptible; (6) positive X-ray findings; (7) Abderhal den’s reaction. In the first period the diagnosis is usually very probable, but never absolute; in the second, very rarely doubtful, and in the third absolute. Differential Diagnosis of Pregnancy.—The pregnant uterus is often mistaken for other tumors occupying the pelvic or abdominal cavities, and vice versa, though, as a rule, the former mistake is more frequently made. The early periods of pregnancy may be simulated by enlargement of the uterus due to interstitial or submucous myomata, sarcoma, hematometra, and conditions resulting from inflammatory disturbances. As a rule, the uterus in these circumstances is harder and firmer than in pregnancy, and does not present its characteristic elastic or boggy con- SPURIOUS PREGNANCY 219 sistency. Moreover, except in hematometra, such conditions are not at- tended by cessation of the menses. If, however, there is any possibility of a mistake, a delay of a few weeks will usually clear up the diagnosis. The pregnant uterus is occasionally mistaken for small ovarian or tubal tumors, though this error should rarely occur if the patient be carefully examined bimanually and the pelvic contents isolated, if neces- sary under an anesthetic. As the tumor becomes larger and rises up into the abdomen, other points become available for differential diagnosis, notably the positive signs of pregnancy and the intermittent contractions of Braxton Hicks. The diagnosis of pregnancy in a myomatous uterus often presents serious difficulties, and for a time may be impossible. But a short delay will show a more rapid increase in the size of the tumor than is con- sistent with the existence of an uncomplicated myoma, and variations in the consistency of its different parts should also serve to direct one’s attention to the pregnant condition. Occasionally, an ovarian cystoma may be complicated by pregnancy. In the early stages the diagnosis, as a rule, can be easily made, as careful bimanual examination should enable one to differentiate between the two tumors; but in the later months it may become extremely difficult and sometimes impossible, owing to the increased • distention of the abdomen. Furthermore, if the positive signs of pregnancy cannot be elicited, its existence is usually overlookod and a simple cystoma diagnosticated; whereas, if the heart sounds are heard and the X-ray findings positive, the cystoma may escape recognition and the excessive abdominal enlarge- ment be attributed to a hydramnios. In the early months hypertrophy of the supravaginal portion of the cervix may seriously increase the difficulties of diagnosis, as the enlarged cervix may be mistaken for the entire uterus, the soft and elastic body being either overlooked or regarded as a tumor of the uterine ap- pendages. Careful bimanual examination under anesthesia should do away with the possibility of this error. Irregular development of the pregnant uterus, associated with a sacculation of its anterior or posterior wall, may seriously complicate the diagnosis, especially if the foetus be dead; as even after the most careful examination the existence of pregnancy may remain unrecognized and the sacculation be mistaken for an ovarian cyst. This is especially apt to occur when the sacculation occupies the posterior wall, as in such cases the anterior wall may remain practically unchanged, and when, under anesthesia, one can feel the fundus with both tubes extending from it, it is a pardonable error to conclude that the fluctuant tumor lying posterior to it is an ovarian cyst. Spurious Pregnancy.—Imaginary pregnancy, or pseudocyesis, is a condition with which almost every practitioner, sooner or later, will meet. It is usually observed in patients nearing the menopause, or in younger women who intensely desire offspring. Such patients may present all the subjective symptoms of pregnancy, associated with a marked in- crease in the size of the abdomen, which is due either to an abnormal and rapid deposition of fat or to the existence of tympanites and 220 DIAGNOSIS AND DURATION OF PREGNANCY occasionally of ascites. When it occurs in the earlier years of life the menses do not, as a rule, disappear, but may present certain abnormalities which the patient considers are due to her supposed condition. In many instances the woman may imagine that she detects foetal movements, which are some- times so violent as to. make her fearful that they may be visible to onlookers. I recall a patient who imagined her- self in the last month of pregnancy, and who, while talking to me, exclaimed at the violence of the move- ments, but on examination I found that her uterus was normal in size, and that her enlarged abdomen was due to a rapidly increasing deposit of fat. The supposed foetal move- ments usually result from contractions of the intestines or the muscles of the abomi- nal wall, and occasionally are so marked as to deceive even physicians. Careful exami- nation of the patient usually enables one to arrive at a cor- rect diagnosis without great difficulty, as the small uterus can be demon- strated on bimanual examination, made, if necessary, under anesthesia. The greatest difficulty in these cases is to persuade the patient as to the correctness of the diagnosis. Bichebois has pointed out that insane women frequently suffer from the delusion that they are pregnant, and persist in such a belief for years. Distinction between First and Subsequent Pregnancies—Occasion- ally it is a matter of practical importance to decide whether a patient is pregnant for the first time or has previously borne children. Ordinarily childbearing leaves indelible traces behind it, which are readily appre- ciated; but very exceptionally such signs are lacking, as in a case reported by Budin (see Fig. 36). Again, in very rare instances, all the signs indicating a previous labor may follow the removal of a large tumor through the vagina. In a pregnant woman who has never borne children the abdomen is usually tense and firm, and the uterus is felt through it only with diffi- culty. The characteristic pinkish bluish striae and the distinctive changes in the breasts are readily observed. The labia majora are usu- ally in close apposition, the frenulum is intact, and the hymen torn in several places. The vagina is usually narrow and marked by well-de- veloped rugae. The cervix is softened, but does not usually admit the Fig. 191.—Abdominal Enlargement due to Fat, the Patient imagining herself to be in the Last Month of Pregnancy. DIAGNOSIS OF THE LIFE OR DEATH OF THE FCETUS 221 tip of the linger until the very end of pregnancy; and during the last four to six weeks of pregnancy the presenting part is found engaged in the superior strait, unless some disproportion exists. In multiparous women, on the other hand, the abdominal walls are usually lax, flabby, and frequently pendulous, and the. uterus is readily palpated through them. In addition to the pinkish striae due to the present condition, the silvery cicatrices of past pregnancies may also be noted. The breasts are usually not as firm as in the first pregnancy, and frequently present striae similar to those observed on the abdomen. The vulva is usually more or less gaping, the frenulum has disappeared, and the hymen is replaced by the carunculae myrtiformes. The external os, even in the early months of pregnancy, usually shows signs of lacera- tion, and at a little later period readily admits the tip of the finger, which can be carried up to the internal os. Furthermore, in the ma- jority of cases the presenting part does not engage in the superior strait until the onset of labor. Diagnosis of the Life or Death of the Foetus. —Generally speaking, the foetus should be considered to be alive unless definite evidence to the con- trary can be adduced. In the early months of pregnancy the diagnosis of foetal death offers considerable difficulty, and can be made only after repeated examinations have demonstrated that the uterus has remained stationary in size for a number of weeks. In the later months of pregnancy, the disappearance of foetal move- ments usually directs the attention of the patient to this possibility; moreover, she may suffer from ill-defined sensations, such as chilliness, languor, a sensation of weight in the abdomen, and perhaps a foul taste in the mouth. Careful investigation shows that the uterus does not cor- respond in size with the estimated duration of pregnancy, or even has become smaller than previously; while at the same time retrogressive changes have occurred in the breasts, which have become soft and flabby. The diagnosis cannot usually be made at a single examination, and is permissible only after repeated examinations, when in addition to the signs just mentioned one has failed to hear the foetal heart or perceive the movements of the child. Occasionally, a positive diagnosis can be made at once by palpating the macerated skull through the partially dilated cervix; in this event one feels that the bones of the head are loose and present a sensation as if they were contained in a flabby bag. Spalding claims that a positive diagnosis of foetal death can be made by the employment of the Roentgen ray. In such cases the plate will show overlapping of the bones of the'" skull at the several sutures, associated with distinct sign3 of shrinkage of the skull contents. I have as yet had no experience with the method, but I am prepared to believe that it may sometimes serve a useful purpose. Duration of Pregnancy.—As we have no means of ascertaining the exact date at which fertilization occurs, it is apparent that strictly accurate statements as to the duration of pregnancy cannot be made. Although conception may occur at any time, the researches of Fraenkel indicate that it is most usual somewhere about the middle of the inter- 222 DIAGNOSIS AND DURATION OF PREGNANCY menstrual period. Usually labor ensues about two hundred and eighty days (ten lunar months) after the first day of the last menstrual period, so that the actual duration of pregnancy is two hundred and seventy days, or less. This rule, however, is subject to many exceptions, as apparently well-developed children may he horn as early as the two hundred and fortieth and as late as'the three hundred and twentieth day after the last menstrual period. Every one practicing obstetrics occasionally meets with cases in which the patient believes that she has passed a month beyond term; or, in other words, that the pregnancy has lasted eleven lunar months. This belief, however, is usually erroneous, and in the majority of cases is due to some miscalculation. Exceptionally, however, pregnancy may last for an abnormally long period, and I recall a patient who on two occasions did not fall into labor until considerably over eleven months after the last period. In both instances the children weighed over 12 pounds, were 55 centimeters in length, and presented markedly increased thoracic measurements. Winckel, after carefully studying his material, states that about one-seventh of all children weighing 4,000 grams or more (9 pounds) have been carried for three hundred and two days or longer after con- ception, and that in very exceptional instances pregnancy may last as long as three hundred and thirty-six days. According to the German law, three hundred and two days after the last period constitutes the limit for legitimacy. Recently, this has given rise to considerable dis- cussion, and it appears that strict application of the law sometimes results in great injustice. Siegel states that this term is frequently exceeded and may be as long as three hundred and thirty-one days. Even when we know the date of the coitus from which the pregnancy has resulted, we are in no better position to estimate the actual length of pregnancy, inasmuch as Lowenhardt has pointed out that two women may have fruitful coitus on the same day, and yet the date of their de- liveries may vary markedly. Ahlfeld analyzed four hundred and twenty- five cases in which the date of coitus was supposed to be known, and found the average duration of pregnancy to be 269.91 days; but indi- vidual cases in the series varied from between two hundred and thirty- one to three hundred and twenty-nine days. Similar differences are reported by veterinarians, who usually date the beginning of pregnancy from a single coitus. Eor example, the average duration of pregnancy in the mare is three hundred and sixty- six days, but in a large series of cases individual variations between three hundred and seven and four hundred and twelve days were noted. In the cow the normal duration is placed at two hundred and eighty days, with extremes of two hundred and forty and three hundred and eleven days. Again, as Mme. Laurie has shown, the duration of preg- nancy also depends upon the extent to wdiich the patient can spare herself during the last three months of pregnancy. This observer found that it was twenty days longer in 1,550 women who lived comfortably in a hospital for several months prior to delivery than in the same number of women who entered at the onset of labor. Her figures, then, go to show ESTIMATION OF THE PROBABLE DATE OF CONFINEMENT 223 that hard work in poorly nourished women predisposes to the premature ending of pregnancy. In view of these facts we must conclude that the duration of preg- nancy varies within certain limits, which probably depend upon individ- ual peculiarities, and that it sometimes exceeds two hundred and eighty days from the last menstrual period. Generally speaking, however, pro- longation of pregnancy should not be assumed unless the child weighs at least 4,000 grams and the history indicates that eleven lunar months have elapsed since the last menstruation. As the post-mature child may give rise to serious dystocia by its mere size, it is the part of wisdom to regard with suspicion every patient whose menstrual history indicates that she has passed beyond the tenth lunar month, and to make weekly examinations in which particular attention is directed toward the size of the child and evidence of disproportion between its head and the pelvic inlet, and labor should be induced as soon as one is convinced that the normal proportions are exceeded. Estimation of the Probable Date of Confinement.—Unfortunately for the comfort of the patient, as wTell as of the physician, we possess no reliable means of es- timating the exact date, but are obliged to content ourselves with the method pro- posed by Naegele, which is' based upon the belief that labor occurs two hundred and eighty days from the beginning of the last menstrual pe- riod. The calcula- tion is readily made by adding seven days to the date at which the last menstrual period first appeared, and then counting back three months. For example, if the last period began on January 10th, we add seven days, mak- ing January 17, and count back three months, thus fixing upon October 17th as the probable date of confinement. In a small number of cases the patient will be confined on the precise day estimated, and in the great majority of cases within a few days of it; but occasionally a period of several weeks may elapse before labor Fig. 192.—Relative Height of the Fundus at the Various Weeks of Pregnancy. 224 DIAGNOSIS AND DURATION OF PREGNANCY occurs. Accordingly, the physician should hesitate to predict a definite day for the confinement, and should always allow a margin of two to three weeks in his calculations. I have made the interesting observation that in many young women who miss the first menstrual period after marriage, a fully developed child is born two hundred and eighty days from the beginning of the last menstrual period. As this is less than nine calendar months after the date of marriage, it would indicate that pregnancy does not always last as long as ten lunar months. Ldwenhardt believed that the duration of pregnancy was ten men- strual periods, and considered the labor as likely to occur when the tenth period following conception fell due, and Schatz has adduced consid- erable evidence along similar lines. Accordingly, in patients menstruat- ing at intervals of twenty-six or thirty days, for example, the duration of pregnancy would be two hundred and sixty or three hundred days respectively. In the long run, however, this method of calculation does not give more accurate results than that of Uaegele. Occasionally the patient believes that she can date her pregnancy from a single coitus, and prefers to estimate the approaching date of confinement from that rather than from the beginning of the last period. This method is subject to quite as great an error as if calculated from the latter date, as we have no means of ascertaining when ovulation takes place, nor how long the spermatozoa may remain in the genital tract before conception occurs. Frequent attempts have been made to estimate the date of confine- ment by adding twenty or twenty-one weeks to the date upon which the patient first perceived foetal movements. This method is founded on the belief that quickening is first experienced at the eighteenth or twentieth week of pregnancy. Unfortunately, this assumption is erroneous, as tho symptom is frequently first noticed at a much earlier period, and some- times not until considerably later. In not a few instances, especially in nursing women, conception may take place during a period of amenorrhea, and the patient is often sur- prised by the enlargement of her abdomen or by the perception of foetal movements; while occasionally the first intimation that she is pregnant is given by the fact that her milk, which has previously agreed very well with the infant, suddenly becomes indigestible. Under such circumstances, the usual methods of calculation are of no value, and we have to depend upon other means, which, unfortunately, are extremely unsatisfactory. In such cases our calculations are based upon the enlargement of the abdomen and the height to which the fundus of the uterus has risen. Generally speaking, with the patient on her back, we find that the fundus at the fourth month is several fingers’-breadths above the symphysis pubis; at the fifth month midway between it and the umbilicus; at the sixth month at the level of the umbilicus; at the seventh month three fingers’-breadths above the umbilicus; at the eight month an equal dis- tance above its position at the seventh month; at the ninth month just below the xiphoid; whereas in the last month, particularly in primi- parous women, it sinks downward and assumes almost the position it occupied at the eighth month. LITERATURE This method, however, gives only approximate results, as the position oi the umbilicus is subject to marked variations, while the distention of the uterus is dependent not only upon the size of the child, but also upon the quantity of amniotic fluid. According to Spiegelberg, the situation of the umbilicus varies from 13 to 28 centimeters above the symphysis, so that there may be a difference of 6 inches in its position. On this account it has been thought preferable by some authors to estimate the distance of the fundus from the symphysis pubis with a tape measure, the average results obtained by Spiegelberg being as follows: 22d to 28th week 24 to 24.5 centimeters. 28th week 26.7 ‘ ‘ 30th “ 28.4 . “ 32d “ 29.5 to 30 “ 34th “ 31 “ 36th “ 32 “ 38th “ 33.1 “ 40th “ 33.7 “ These measurements, likewise, are subject to considerable variations, as they are dependent not only upon the size of the foetus contained within the uterus, but also upon the degree of distention of the abdominal contents. Nevertheless, in cases in which we possess no other data, they occasionally afford us information of very considerable value. 225 LITERATURE Abderiialden. Die Serodiagnostik der Schwangerschaft. Deutsche med. Wochen- schr., 1912, Nr. 46. Abwehrfermente. IY. Aufl., Berlin, 1914. Weitere Studien iiber das Wesen der sogenannten Abderhaldenschen Reaktiou. Fermentforschung 1921, iv, 338-358. Ahlfeld. Beobachtungen iiber die Dauer der Schwangerschaft. Monatssclir. f. Geburtsk., 1869, xxxiv, 180-225. Die wahrnehmbaren kindlichen Bewegungen. Lehrbuch der Geburtshiilfe, II. Aufl., 1898, 56. Bar and Ecalle. De la utilization pour le diagnostic de la grossesse des recentes deeouvertes biologiques. Archives Mens, d’obst. et de gyn., 1919, viii, 372-400. Bartholomew, Sale and Calloway. Diagnosis of Pregnancy by the Roentgen Ray. Jour. Am. Med. Assoc., Ixxvi, 912-918. Benoist. Des rapports entre 1 ’embryon et le placenta dans 1 ’avortement. These de Paris, 1906. Bichebois. Contribution a 1’etude de l’idee de grossesse, trouble psychopathique. These de Nancy, 1903. von Braun. Ueber Friihdiagnose der Graviditat. Zentralbl. f. Gyn., 1899, xxiii, 488-489. Budin. • Femmes en couches et nouveau-nes. Paris, 1897, 1-4. Chabwick. Value of the Bluish Coloration of the Vaginal Entrance as a Sign of Pregnancy. Trans. Amer. Gyn. Soe., 1886, xi, 399. Depaul. Traite d’auscultation obstetricale. Paris, 1847. Dickinson. The Diagnosis of Pregnancy between the Second and Seventh Weeks by Bimanual Examination. Amer. Gyn. and Obst. Jour., 1892, ii, 544- 555. 226 DIAGNOSIS AND DURATION OF PREGNANCY Duval. Palpation of the Foetal Heart Impulse in Pregnancy. Johns Hopkins Hospital Bulletin, 1897, viii, p. 207. Fieux et Mauriac. De la possibility d’une toxemie villeuse et d’un sero diagnostic de la grossesse. Annales de gyn. et d’obst., 1910, N. S. vii, 65-75. Fischel. Ueber ein bisher nicht beobachtetes Phanomen bei Deflexionslagen. Prager med. Wochenschr., 1881, Nr. 12, 13; 1882, Nr. 28. Zur intrauterinen Tastbarkeit des fotalen Herzimpulses bei Deflexionslagen. Zentralbl. f. Gyn., ix, 1885, 769-771. Frankenhauser. Ueber die Herztone der Frucht und ihre Benutzung zur Diag- nose des Geschlechts derselben, etc. Monatsschr. f. Geburtskunde, 1859, xiv, 161-174. Hicks. On the Contraction of the Uterus throughout Pregnancy. Trans. London Obst. Soc., 1872, xiii, 216-231. Kegaradec. Memoire sur 1’auscultation appliquee a 1’etude de la grossesse. Paris, 1822. Kennedy. Observations on Obstetric Auscultation. New York, 1847. Keye. Periodic Variations in Spontaneous Contractions of Uterine Muscle, etc. Bull. Johns Hopkins Hospital, 1923, xxxiv, 60-63. Lauri£. De 1’influence du repos sur la duree de la grossesse. These de Paris, 1899. Linzenmeier. Eine neue Schwangerschaftsreaktion. Zentralbl. fiir Gyn., 1920, 816-820. Lowenhardt. Die Berechnung und die Dauer der Schwangerschaft. Archiv f. Gyn., 1872, iii, 456-491. Macdonald. The Diagnosis of Early Pregnancy. Am. J. Obst., 1908, lvii, 323-346. Mayor. Quoted in Bibliotheque universelle de Geneve, November, 1818, ix. Montgomery. An Exposition of the Signs and Symptoms of Pregnancy, 2d ed., London, 1863. Neumann u. Hermann. Biol. Studien iiber die weibliche Keimdriise. Wiener klin. Wochenschr., 1911, Nr. 12. Peterson. Value of Pneumo-peritoneal Roentgenography in Obstetrics and Gynecology. Jour. Am. Med. Assoc., 1922, lxxviii, 397-400. Petri. Neue Probleme des paraenteralen Eiweissabbaues in ihrer Beziehung zur Geburtshilfe und Gynakologie. Monatsschr. f. Geb. u. Gyn., 1915, xli, 309-336 and 388-435. Reinl. Ein neues sicheres diagnostisches Zeichen der Schwangerschaft in den ersten Monaten. Prager med. Wochenschr., 1884, Nr. 26. Rotter. Fiihlbares Uteringerausch. Archiv f. Gyn., 1873, v, 539-546. Sarwey. Zur Diagnostik in der ersten Halfte der Schwangerschaft. Zentralbl. f. Gyn., 1904, xxviii, 1156-1163. Sciiatz. Klin. Beitriige zur Physiologie der Schwangerschaft. Leipzig, 1910. Siegel. Beitrage zur menschlichen Schwangerscliaftsdauer. Zentralbl. f. Gyn., 1921, 984-995. Spalding. A Pathognomonic Sign of Intrauterine Death. Surg. Gyn. and Obst., 1922, xxxiv, 754-757. Spiegelberg. Lehrbuch der Geburtshiilfe, III. Aufl., 1891, 126, 127. Welz and Van Nest. Sugar Test in Pregnancy. Am. Jour. Obst. and Gyn., 1923, v, 33-36. Williams and Pearce. Abderhalden’s Biological Test for Pregnancy. Surg. Gyn. and Obst., 1913, xvi, 411-418. Winckel. Neue Untersuchungen iiber die Dauer der menschlichen Schwanger- schaft. Volkmann’s Samml. klin. Vortrage, 1901, Nr. 292-293. Van Slyke, Vinograd and Losee. The Abderhalden Reaction. J. Biol. Chcm., 1915, xxiii, 377-406. CHAPTER VIII THE MANAGEMENT OF NOEMAL PEEGNANGY From a biological point of view, pregnancy and labor represent the highest function of the female reproductive system, and a priori should be considered as a normal process. But when we recall the manifold changes which occur in the maternal organism, it is apparent that the borderline between health and disease is less distinctly marked during gestation than at other times, and derangements, so slight as to be of but little consequence under ordinary circumstances, may readily be the precursors of pathological conditions which may seriously threaten the life of the mother or the child, or both. It accordingly becomes necessary to keep pregnant patients under strict supervision, and to be constantly on the alert for the appearance of untoward symptoms. In private practice services of an obstetrician should be engaged early in pregnancy, so that upon him devolves the duty of advising the patient as to her mode of life during the months preceding labor. Any one who has a moderately extensive obstetrical practice can save himself no little trouble by having cards printed, which briefly outline what the patient is expected to do, and in which are enumerated the various abnormal symptoms which may occur and to which the physician’s attention should be immediately called. I reproduce below (page 231) the card which I give my patients, and in the chapter on the conduct of labor the one prepared for the nurse. Unless it be found upon inquiry that the patient has been leading an ill-ordered existence, very little change should be made in her mode of living, and she should be encouraged to go on much as usual, care being taken that she receives the proper amount of exercise, amusement, and diversion. It is the duty of the physician to gain the confidence of his patient and encourage her to come to him whenever anything occurs to worry her, instead of taking advice from her women friends. A woman in her first pregnancy generally stands in need of a certain amount of reassurance with regard to the dangers of parturition, and the knowledge that she is in the hands of a competent and careful physician will con- tribute largely to her peace of mind as well as to her physical well-being. One of the few creditable achievements of American obstetrics consists in the development of so-called “Prenatal Care.” The term has a wider application than the words imply, and may be defined as such super- vision and care of the pregnant, parturient and puerperal woman as will enable her to pass through the dangers of pregnancy and labor with the least possible risk, to give birth to a living child, and to be discharged in such condition that she may be able to suckle it and thus afford it 227 228 THE MANAGEMENT OF NORMAL PREGNANCY the greatest prospect of attaining maturity, as well as to fulfill her duties as mother and housewife with a minimal amount of invalidism. In hospital practice the first step in such a program consists in organ- izing the obstetrical dispensary and indoor service as a single unit. The patients should be taught to register early in pregnancy, and to return to the dispensary monthly until the seventh month and every two weeks thereafter, irrespective of whether they expect to be delivered in the hospital or in their own homes. At the first visit, in addition to a care- ful physical examination, a sample of blood should be obtained for the Wassermann test, and at each subsequent visit the urine should be examined, the blood pressure taken and any other abnormality should be detected, with a view to checking it in its incipiency or of admitting the patient to the hospital for its relief or cure, if necessary. On account of lack of intelligence and indolence many patients will fail to.follow the directions given unless they are supervised by prenatal nurses, and I know of no way in which money can be better expended than in providing for this type of care. Those interested in the subject will find in the 1915 Transactions of the American Association for Study and Prevention of Infant Mortality the report of a committee, of which I was Chairman, upon suitable methods of recording prenatal work. Exercise.—During normal pregnancy the woman should be encour- aged to take as much outdoor exercise as possible, though in individual cases it is often difficult to specify the exact amount—a safe rule being to instruct her to desist while still feeling that she could do more without tiring herself. Exercise should consist of walking, driving or motoring over good roads, but the ordinary sports should be interdicted, though in the early months sea bathing is beneficial. AVhen for various reasons outdoor exercise cannot be taken, massage in the hands of a skillful person is to be recommended. In the later months long journeys should not be undertaken unless absolutely necessary, and driving over rough roads should be avoided. When possible, the woman should lie down for an hour after the mid-day meal. Sleep is not essential, but the clothes should be loosened and the mind diverted from its usual channels. Among the poorer classes the patients should be cautioned against excessive work, especially during the later months, as over-exertion has been shown to play an important part in the production of pre- mature labor. Diet.—In normal pregnancy the diet should be abundant and nour- ishing, and ordinarily the patient should be allowed to continue her usual customs, but should be warned to abstain from very highly seasoned or indigestible articles of food. Accordingly, a, special diet is not indi- cated unless some complication, such as toxemia of pregnancy, super- venes, and the necessary directions will be given under the appropriate headings. In slight degrees of pelvic contraction, or in patients who have previously given birth to excessively heavy children, a restricted diet may be advisable during the last two or three months, as I have already stated that the larger size of the children in the well-to-do classes is SEXUAL INTERCOURSE 229 in great part attributable to the life of ease and the abundance of food enjoyed by the mothers. Prochownick pointed out that a diet poor in carbohydrates and fluids exerts considerable influence in lessening the weight of the child without otherwise affecting it, and these precaution- ary measures may obviate a difficult delivery. These conclusions stand in marked contrast to those usually held by the laity, who erroneously believe that abstention from proteid food is the essential point. On the other hand, too much should not be expected from such a regime, as experience teaches that it is practically impossible to reduce the weight of the child much below the usual limits. For example, it is well known that women in the last stages of tuberculosis frequently give birth to well developed, or even fat, children; while Hofmann states that during the so-called “hunger blockade” the undernourished German women bore children of normal size, but frequently they were unable to suckle them. Moreover, the work of Zuntz upon experimental animals demonstrates that during pregnancy a diet notoriously defective in one or more of its constituents has no effect upon the weight of the offspring, but that such undernourished animals are relatively sterile—a conclusion which is endorsed by Reynolds and Macomber. The Bowels.—During pregnancy the enlarged uterus sometimes inter- feres with the normal intestinal peristalsis, and gives rise to more or less marked constipation. Under such circumstances care should be taken that the bowels are moved daily, which is best accomplished by the ad- ministration of liquid petrolatum, phenolphthalein, cascara sagrada, or pills containing aloin, belladonna, and strychnin. The use of active cathartics is inadvisable, unless their employment be specially indicated in certain morbid conditions. In some instances, however, the judicious administration of an occasional dose of calomel is followed by beneficial results. Clothing.—The physician is frequently asked concerning the clothing which is best adapted to the pregnant state, and especially whether corsets should be worn or not. Generally speaking, the clothing should be loose and so arranged as to exert as little pressure upon the waist as possible; and in the later months of pregnancy, if the patient is ac- customed to the use of a corset, the ordinary type should be replaced by a loosely fitting corset-waist or by one of the specially designed “ma- ternity” corsets. In multiparous women, when the abdomen is markedly relaxed from previous childbearing, the wearing of an abdominal sup- port of elastic material or an ordinary Scultetus bandage adds materially to their comfort. When varicose veins of the extremities are present the legs should be bandaged or encased in elastic stockings, and when large varices exist about the vulva the patient should be cautioned con- cerning the possibility of their rupture. Sexual Intercourse.—In healthy persons sexual intercourse in mod- eration usually does not harm, as long as the abdominal enlargement is not too great to make it inconvenient for the patient. But where there is a tendency to abortion or premature labor it should be inter- dicted. It should also be forbidden in the last month of pregnancy, as I know of numerous instances in which severe puerperal infection has 230 THE MANAGEMENT OF NORMAL PREGNANCY followed coitus during that period; and, as the patients had not been examined internally but had had sexual intercourse just before the onset of labor, it seemed justifiable to attribute the streptococcic infection to that cause. The Breasts—In the last months of pregnancy attention should be devoted to the condition of the breasts, and more particularly to the nipples, as by appropriate preliminary treatment nursing may be ren- dered easier, and the occurrence of fissures and the consequent danger of mammary infection in great part prevented. For this purpose the patient, during the last two months, should anoint her nipples night and morning with lanolin or cocoa but- ter, which tends to render them more elastic. When the nipples are small it is advisable to attempt to lengthen them by making a few tractions upon them night and morning ; and where they are but slightly prominent good results sometimes follow the wearing of a wooden nipple shield (Fig. 193) for a few hours of each day, which is held in place by adhesive strips. 1 know of no means, however, by which retracted nipples can be made serviceable. Urine.—Owing to the frequency of the toxemias of pregnancy and the serious consequences which frequently result from them, the urine should be carefully examined at regular intervals: once a month for the first seven months, and twice a month, or preferably every week, during the last three months of pregnancy. It is advisable that the physician should not only arrange definite periods at which specimens are to be sent, but that he should himself make a note of these dates, so that, in case the patient becomes careless in the matter and neglects to carry out his directions, he can remind her. Of course it may be very plausibly argued that the patient incurs the main risk from such neglect; but the prevention of a single death from eclampsia will amply repay the conscientious physician for much self-imposed labor. In hospital practice, it is more convenient to procure an absolutely fresh specimen each time the patient returns to the prenatal clinic. The urine should be examined not only for the presence of albumin and sugar, but also microscopically. If more than a trace of albumin is detected, the amount should be determined daily by means of Esbach’s albuminometer, and whenever it exceeds one-half gram to the liter, or symptoms indicative of toxemia are present, the patient should at once be put to bed at home or sent into the hospital for observation and treatment. At each visit the blood pressure should be determined, and in young women a systolic pressure of 140 mm. or more should be regarded as a danger signal, even though albumin and casts be absent from the urine. Moreover, it is advisable to weigh the patient at each visit, as Zange- Fig. 193.—Wooden Nipple Shield. URINE 231 meister has shown that any excessive gain in weight may reveal the existence of “occult” edema, even before swelling of the face of ex- tremities becomes apparent, or before the skin pits on pressure. In addition to giving the patient the advice above mentioned, the physician should also impress upon her the importance of informing him at once in case any of the following symptoms be noted: a scanty flow of urine, persistent headache, disturbances of vision, swelling of the feet and face, any loss of blood no matter how slight, and persistent con- stipation. In the majority of cases these symptoms are of secondary importance, but occasionally they serve to warn us of the imminence of some serious affection which may be cured or alleviated by appropriate treatment. PRINTED DIRECTIONS EOR PRIVATE PATIENTS DURING PREGNANCY (a) Take as much outdoor exercise as possible, but guard against over-tiring yourself. (b) See that the bowels are moved daily. (c) On the first day of each month send me a 4-oz. bottle of freshly passed morning urine; and for the three months preceding the expected date of confinement send it on the first and fifteenth days of the month. Be sure to send your name with the specimen. About the same dates make an appointment to visit me at my office. (d) From the seventh month onward anoint the nipples night and morning with lanolin or cocoa butter in order to render them more resistant to the strain of suckling. (e) If you expect to be confined at home, buy my “Confinement Outfit” six weeks before the expected date. This includes everything needed by the nurse and myself, except baby’s clothes. At the same time provide two pieces of rubber sheeting, % X 1 yard, and 1X2 yards re- spectively; a bed pan, two small round agate basins, a 2-quart fountain syringe and 15 yards of gauze and two pieces of cotton batting for mak- ing bed pads, or 4 ready-made sanitary bed pads. (/) Go to the hospital as soon as labor pains commence, or, if you are to be confined at home, send for the nurse, and, unless some emergency arises, let her use her judgment in sending for me. (g) Notify me at once if any of the-following symptoms be observed at any time during pregnancy: 1. Scanty urine. 2. Persistent headache. 3. Disturbance of vision. 4. Swelling of feet or face. 5. Loss of blood. 6. Persistent constipation. 7. And also when you feel that anything is not as it should be. (h) I shall want to see you five or six weeks before you expect to be sick in order to ascertain your condition and to give you any desired advice. 232 THE MANAGEMENT OF NORMAL PREGNANCY Preliminary Examination.—In private practice it is not necessary to examine the pregnant woman vaginally in the early months of preg- nancy unless symptoms indicative of some abnormality occur, or unless the patient does not expect to be under one’s supervision throughout the entire duration of pregnancy. On the other hand, a careful and thorough examination is indispensable about six weeks before the ex- pected date of confinement, and to neglect in this respect can be at- tributed the deaths of untold numbers of women and children. At this time the general condition should be carefully noted, particular attention being also par'd to the measurements of the pelvis, as well as to the size, presentation and position of the child. Unless the physician fully appreciates the importance of this exam- ination, and has learned to look upon the making of it as a bounden duty, he may sometimes be deterred by feeling that it is repugnant to the patient, and that she may object to it or even refuse it. My experience, however, has always been that a few words of kindly explanation soon smooth away all such difficulties; and when, as happens fortunately in the vast majority of cases, after the examination we can reassure the woman as to the prospects of a simple and safe delivery, she will feel amply repaid for any inconvenience to which she may have been sub- jected. On the other hand, if any abnormality is present, it is essential for the physician to know of its existence in advance, and, even although he may not always deem it advisable to communicate his conclusions to the patient herself, he will do well to inform the husband or some other responsible member of her family of the existing condition. If, however, despite the exercise of the greatest tact on the part of the physician, and his insistence that such an examination is a necessity for her own sake, the patient persists in her refusal, the former has no al- ternative but to decline to have any further connection with the case. The first point in the preliminary obstetrical examination is careful pelvic mensuration, and Dohrn has well said that the physician who neglects pelvimetry is comparable to one who attempts to treat pul- monary diseases without the aid of auscultation and percussion. In the majority of instances the usual external measurements, including palpation of the pubic arch, are sufficient, for if these are approximately normal and the head is deeply engaged, it will be impossible to measure the length of the diagonal conjugate. On the other hand, no matter how normal the external measurements may be, the pelvis must be measured internally, and if necessary under anesthesia, whenever the head does not engage during the last month of a first pregnancy, or in any patient in whom the pelvic outlet is contracted, or who limps or presents signs of deformity of the spine or legs. Failure to observe this precaution may occasionally lead to most unpleasant surprises at the time of labor. If an abnormality be detected at this examination the physician is both forewarned and forearmed, and in extreme cases he will be prepared to interfere at the proper time with every prospect of a successful issue. After measuring the pelvis, the abdomen should be carefully ex- amined, the duration of pregnancy estimated, and the existence of any abnormality, as hydramnion or twins, noted; after which the size, position LITERATURE 233 and presentation of the child should he determined by external palpation, according to the rules which will be given later. An internal examina- tion should always be made; for, while it is usually not necessary for the determination of the presentation and position of the child, it may reveal the presence of some abnormality of the generative tract—such as an ovarian cyst or a myoma—which might give rise to disastrous results if unrecognized. Furthermore, it is essential when palpation gives uncertain or unsatisfactory results, or when the head is not engaged in primiparous women or when the patient presents a history of previous difficult labors. The physician who knows how to utilize all the re- sources of external palpation and manipulation will find that by these means he can usually not only recognize normal and abnormal presen- tations in advance, but can also convert breech, transverse, or face presentations into those of the vertex. When vaginal exploration is necessary at the preliminary examina- tion, if undertaken prior to the end of the ninth lunar month, rigorous hand disinfection is not necessary, and the physician may content him- self with the use of a nail-brush, soap, and hot water. In the last month of pregnancy, however, the use of a sterile rubber glove is imperative, for we have no means of knowing exactly when labor may supervene, and our neglect may occasionally give rise to puerperal infection. As will be pointed out in more detail later, one of the most important duties of the physician is to bear in mind the possibility of undue pro- longation of pregnancy which may result in the development of a child of excessive size. For this reason, whenever the patient does not fall in labor within a few days of the calculated date, she should be examined at weekly intervals, and, as soon as the impression is gained that the child has passed the usual limit in size, labor should be induced. The various abnormalities occurring in the course of pregnancy will be considered in a separate chapter. LITERATURE Dohrn. Ueber Beckenmessung. Volkmann’s Sammlung klin. Vortrage, Nr. 11. Hofmann. Ueber den Einfluss der Kriegskost auf die Geburtsmasse der Kriegs- neugeborenen. Archiv f. Gyn., 1919, cx, 451-478. Prochownick. Ein Yersuch zum Ersatze der kiinstlichen Eriihgeburt. Zentralbl. f. Gyn., 1889, xiii, 577-581. Reynolds and Macomber. Certain Dietary Factors in the Causation of Sterility. Am. J. Obst. and Gyn., 1921, ii, 379-394. Zangemeister. Ueber das Korpergewicht Schwangerer. Zeitschr. f. Geb. u. Gyn., 1916, lxxviii, 325-365. Zxjntz. Experimentelle Untersuchungen iiber den Einfluss der Ernahrung des Muttertieres auf die Frucht. Archiv f. Gyn., 1919, cx, 244-273. CHAPTER IX PRESENTATION AND POSITION OF THE FCETUS—METHODS OF DIAGNOSIS PRESENTATION AND POSITION OF FOETUS Irrespective of the relation which it may bear to the mother, the foetus in the later months of pregnancy assumes a characteristic posture, which is described as its attitude or habitus; and, as a general rule, it may be said to form an ovoid mass, which roughly corresponds with the shape of the uterine cavity. It is generally taught that the foetus is usually folded or bent upon itself in such a way that the back becomes markedly convex, the head is sharply flexed so that the chin is almost in contact with the breast, the thighs are flexed over the abdomen, the legs are bent at the knee-joints, and the arches of the feet rest upon the anterior surfaces of the legs. The arms are usually crossed over the thorax or are parallel to the sides, while the umbilical cord lies in the space between them and the lower extremities. Warnekros, on the other hand, contends that the normal habitus is much less constrained, and that the contrary view is due to the fact that our conclusions have been based upon the study of frozen or hardened specimens, in which the uterus is so retracted that it exerts an abnormal pressure upon its contents. In his wonderful X-ray atlas, he shows that before the onset of labor the head normally occupies a position midway between flexion and extension, the back is but slightly flexed, and the extremities are relatively freely movable—in other words, the foetus is in an uncon- strained position, analogous to that which it maintains outside of the uterus when at rest. The attitude is frequently modified by changes in the consistency of the abdominal and uterine walls, by the abundance or lack of liquor amnii, as well as by movements of the extremities. Occasionally the head may become deflected, when a totally different posture is assumed. The characteristic attitude results partly from the mode of growth of the foetus, and partly from a process of accommodation between it and the outlines of the uterine cavity. Presentation.—By this term is understood the relation which the long axis of the foetus bears to that of the mother, and we accordingly dis- tinguish between longitudinal and transverse presentations. Occasionally during pregnancy the foetal may cross the maternal axis at an angle, and thus give rise to oblique presentations; but, as these always become longi- tudinal or transverse during the course of labor, they need not be con- sidered. Longitudinal 'presentations are by far the most frequent occur- ring in over 99 per cent, of all cases. 234 PRESENTATION AND POSITION OF FCETUS 235 Considerable confusion has resulted from confounding the term pres- entation and presenting part. By the latter we understand the portion of the fcetus which engages at the superior strait, and is felt through the cervix on vaginal examination. Accordingly, in longitudinal pres- entations the presenting part may be either the head or the breech, and we speak of cephalic or breech presentations respectively. When the Fig. 194. Fig. 195. Fig. 196. Fig. 197. Figs. 194-197.—Showing Difference in Attitude of Fcetus in Vertex, Sinciput, Brow, and Face Presentations. foetus lies with its long axis transversely, the shoulder is the presenting part, and we speak of shoulder 'presentations. Longitudinal presentations are broadly classified as normal, and transverse as abnormal, inasmuch as with the former the child is usually delivered by the unaided efforts of Nature; whereas if the latter persist Fig. 198. Fig. 199. Fig. 200. Fig. 201. Figs. 198-201.—Showing Difference in Attitude of Fcetus in Frank Breech, Full Breech, Foot, and Knee Presentations. it cannot be born spontaneously, but always requires the aid of the ob- stetrician. These abnormal presentations will be considered in a separate chapter. Cephalic presentations are divided into several groups, according to' the relation which the head bears to the body of the child. Usually the PRESENTATION AND POSITION OF THE FCETUS 236 head is sharply flexed, so that the chin is in contact with the thorax. In these circumstances the vertex is the presenting part—vertex presen- tation. More rarely the neck may be sharply extended, so that the occiput and back come in contact and the face engages in the superior strait— face presentation. Again, the head may assume an intermediate posi- tion between these extremes, being partially flexed in some cases, when the large fontanel presents—sincipital presentation; or partially ex- tended in other cases, so that the brow becomes the presenting part— brow presentation. The last two are not usually classified as distinct varieties, as they are usually transient, and become converted into vertex or face presentations as labor progresses. When the child presents by its pelvic extremity, the thighs may be flexed and the legs extended over the anterior surface of the body— frank breech presentation; again, the thighs may be flexed on the abdo- men and the legs upon the thighs—breech presentation; or the feet may be the lowest part—foot or footling presentation. Occasionally one leg may retain the position which is typical of one of the above-mentioned presentations, while the other foot or knee may present—incomplete foot or knee presentation. As the mechanism of labor, however, is essentially the same in all modifications of pelvic presentations, the several varieties need not be considered separately. Position.—By this term we designate the relation of some arbitrarily chosen portion of the child to the right or left side of the mother. Ac- cordingly, with each presentation we have one or other of two positions—- right or left. With us and in France, the occiput, chin, and sacrum are the determining points in vertex, face, and breech presentations re- spectively; while in Germany the child’s back is the orienting portion. Variety.—Furthermore for the purpose of still more accurate orien- tation, we take into consideration the relationship of some given portion of the presenting part to the anterior, transverse, or posterior portion of the mother’s pelvis. Thus, as there are two positions, there will be in all six varieties for each presentation. But as the transverse varieties usu- ally represent only a phase in the mechanism of labor, and are not per- sistent, they need not be taken into account. Nomenclature.—Unfortunately, a universal nomenclature for desig- nating the various presentations and positions has not as yet been agreed upon, and the methods employed vary in different countries and even in different parts of the same country, though of late there has arisen a greater tendency toward uniformity. In the earlier works upon obstetrics, as in Eoesslin’s Eosengarten (1513), it was believed that the child might assume any imaginable posi- tion in utero, and the number of presentations and positions was limited only by the ingenuity of the writer. More accurate observation gradually did away with the fanciful forms, but even as late as 1775 Baudelocque distinguished 94 different presentations. Mme. La Chapelle (1821) ma- terially simplified the subject, and the classification which she suggested differs but little from that employed in France to-day, which has been best described by Farabeuf and Varnier. According to the French method, vertex, face, and breech presenta- PRESENTATION AND POSITION OF FCETUS 237 tions are designated as occipito-iliae (0. I.), mento-iliac (M. I.), and sacro-iliac (S. I.). At the International Medical Congress which met in Washington in 1887 an attempt was made to secure greater uniformity in nomenclature, when it was suggested that the denomination “iliac” be omitted and the various presentations designated as occipital, mental, and sacral respectively. The suggestion was quite generally accepted in America and Great Britain, and Bar in 1903 advocated its universal adoption. As the presenting part in any presentation may be either in the left or right position, we have left and right occipital, left and right mental, and left and right sacral presentations, which in an abbreviated form may be written L. 0. and II. 0., L. M. and R. M., L. S. and R. S. Again, as the presenting part in each of the two positions may be di- rected anteriorly, transversely, or posteriorly, we may have six varieties of each presentation. Thus, we have the classification given on the following page. In Germany considerable confusion exists, as the various authorities still’ employ different classifications. Thus Schroeder, Olshausen and Veit did not distinguish variety at all, and they designated the position according to the situation of the back of the child, speaking of first and second positions according as the back is directed to the left or right side of the mother respectively. Others employ a different nomenclature, and designate our L. 0. A., R. 0. A., R. 0. P., and L. 0. P. as first second, third, and fourth positions respectively. The exhaustive articles of Muller and Schatz deal fully with this subject. Our nomenclature presents many advantages over the German, as it is based upon the relation of the presenting part to the maternal pelvis, and enables one to describe with accuracy the situation of the former at any period of labor. Frequency of the Various Presentations and Positions.—According to the statistics collected by Schroeder, based upon several hundred thou- sand cases, the vertex presents in 95 per cent., the face in 0.6 per cent., and the breech in 3.11 per cent., transverse presentations occurring in only 0.56 per cent, of all cases. Markoe, in fifty-one thousand deliveries occurring in the New York Lying-in Hospital, noted 94.2, 0.48, *3.9, and 0.9 per cent., respectively, while in the first seventy-five hundred admis- sions to the obstetrical service of the Johns Hopkins Hospital the in- cidence of the several presentations was 94.6, 0.34, 3.9, and 0.96 per cent., respectively. These figures apply to the conditions observed at or near full term, but prior to the seventh month breech and transverse presen- tations occur more frequently. It is usually stated that about 70 per cent, of all vertex presentations occur in the left, and only 30 per cent, in the right position, and we have found 64 and 36 per cent., respectively. Schatz has shown that the former becomes more and the latter less frequent the nearer preg- nancy approaches term. Naegele first pointed out that the occiput was usually directed anteriorly in left, and posteriorly in right positions; so that it is usually found at one or other extremity of the right oblique diameter of the pelvis, owing to the fact that the left oblique di- 238 PRESENTATION AND POSITION OF THE FCETUS Position. Presentation. Variety. Abbreviation Vertex presentations Left. Occipital. Anterior. L.O.A. ‘ 1 Transverse. L.O.T. i ( < l Posterior. L.O.P. Right. i ( i ( Anterior. R.O.A. < ( Transverse. R.O.T. i i l ( Posterior. R.O.P. Fig. 203. Figs. 202, 203.—Showing Varieties of Vertex Presentations Fig. 202 Face presentations Left. Mental. Anterior. L.M.A. < i 1 < Transverse. L.M.T. i ( l ( Posterior. L.M.P. Right. i t Anterior. R.M.A < ( i ( Transverse. R.M.T i ( i i Posterior. R.M.P. Fig. 204. Fig. 205. Figs. 204, 205.—Showing Varieties of Face Presentations, Breech presentations Left. Sacral. Anterior. L.S.A. < < i i Transverse. L.S.T. ( ( i C Posterior. L.S.P. Right. i ( i ( Anterior. R.S.A. t l Transverse. R.S.T. i ( ( ( Posterior. R.S.P. Fig. 206. Fig. 207. Figs. 206, 207.—Showing Varieties of Breech Presentations PRESENTATION AND POSITION OF FCETUS 239 ameter is materially encroached upon at its posterior extremity by the rectum. Reasons for the Predominance of Head Presentations.—Hippocrates recognized the overwhelming frequency of head presentations at the end of pregnancy, but believed that the child presented by the breech up tq the seventh month, when it suddenly turned and presented by the head, the process being often expressed by the French term culbute. As a result of the more frequent examination of pregnant women, the error of the Hippocratic teachings was gradually demonstrated, so that from the time of Smellie and Baudelocque it was generally believed that head presentations predominated throughout all periods of preg- nancy, but became more frequent in the later months. For many years it was taught that the presentation remained constant throughout preg- nancy, and it was not until 1861 that Hecker and Schultze demonstrated that it was not unusual for changes of position to occur even in the later months. Now it is universally admitted that the presentation does not become definitely established until the presenting part enters the pelvic canal, although it becomse more and more stable the nearer full term is approached- The theories put forward to account for the prevalence of head pres- entations are divided into two groups, the one being based upon gravi- tation, the other supposing a process of accommodation between the foetus and the uterine cavity. The gravitation theory was especially advocated by Matthews Duncan and G. Yeit, both of whom showed that a foetus recently dead, when placed in a vessel containing a solution of salt having about the same specific gravity as itself (1.059-1.055), floated with its head and right side downward. This result they attributed to the greater specific gravity of the head, together with the presence of the liver on the right side. Yeit also showed that head presentations increase in frequency with the advance of pregnancy, but that breech presentations were noted much more frequently when the child was dead. This he attributed to the fact that the specific gravity of the head became diminished after death. Furthermore, it was pointed out that since the axis of the uterus, with the woman in the upright position, forms an angle of about 35 degrees with the horizon, the head would necessarily sink downward, and the convex back of the foetus would adapt itself to the concave anterior wall of the uterus; then, since the organ is usually so rotated about its long axis that its left margin is directed somewhat forward, the frequency of the left anterior presentations could be readily ex- plained. Schatz in 1904 showed that this tendency was increased undei: the influence of gravity. This he demonstrated by examining a series of women in the morning before arising, and again in the evening after they had been about all day, when he found that the anterior varieties of vertex presentations occurred more frequently in the evening. Warne- kros has still further emphasized, by means of X-ray photographs, the part played by gravity by showing that a vertex could be converted into a breech presentation by placing the woman in the Trendelenburg posture, thereby reversing the direction in which gravitation acts. 240 PRESENTATION AND POSITION OF THE FCETUS In 1900 doubt was cast upon the conclusions of Duncan and Veit by Schatz, who maintained that, although their results were correct when experimenting with a medium of the same specific gravity as the foetus, it does not necessarily follow that they hold good for the amniotic fluid, which, it must be remembered, possesses a specific gravity of be- tween 1.008 and 1.009, or considerably less than that of the foetus. Schatz suspended a recently dead foetus by the head and breech from the pans of a balance in a solution of salt of the same specific gravity as the amniotic fluid, and found that the breech had a greater tendency to sink down than the head; but, as the specific gravity of the fluid was gradu- ally increased, the breech slowly rose until the long axis of the child became horizontal, and, as a density of 1.050 was approached, the head sank down as in Duncan’s experiment. He therefore concluded that gravity alone does not account for the production of head presentations; for, if it were the most important factor concerned, breech presentations would predominate at the end of pregnancy. As this is not the case, some other influence must be invoked to explain the prevalence of the former. Seitz repeated this work, and upon determining the specific gravity of the head and body of the foetus, separately, found that the former was relatively lighter than the latter in the first eight months, but heavier in the last two months of pregnancy. Consequently, he concluded that gravity could account for the predominance of head presentation only in the latter period. Furthermore, as the specific gravity was identical whether the foetus were macerated or normal, and yet breech presentations were noted much more frequently in the former condition, he held that some other factor must be concerned. This is supplied by the theory of accommodation, advanced by Du- bois, Simpson, and Scanzoni, according to which cephalic presentations are brought about by a process of accommodation between the foetal ovoid and the interior of the uterine cavity, the shape of the latter being such that the foetus is most comfortable and fits it most accurately when presenting by the head. They held, therefore, that as soon as the foetus came to occupy any other position its cutaneous surface became irritated, whence resulted reflex movements of the extremities, giving rise in turn to uterine contractions, which tended to restore the head presentation. Pinard and Sellheim are enthusiastic advocates of this theory; and the latter has indicated that but little force is needed to bring about such movements, as for practical purposes, the weight of the foetus is almost negligible, being represented merely by the difference between its specific gravity and that of the amniotic fluid. The frequency of abnormal presentations in the early months of preg- nancy, and in all conditions in which the uterus is abnormally distended by an excess of amniotic fluid, tends to substantiate the accommodation theory; for in such cases the body of the child does not come in contact with the uterine walls, and accordingly the conditions necessary for the production of the reflex movements, which give rise to accommodation, are entirely lacking, and gravity alone comes into play. The subject was again taken up in 1915 by Barnum in this country and by Griffith in Great Britain, with the result that, while they were able DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 241 to confirm the observations of Schatz and Seitz, they held that they had failed to take into consideration all the factors concerned, and that their conclusions were therefore untenable. Both of the former investigators found in the last two months of pregnancy that the specific gravity of the head is greater than that of the body, but that, in the usual intra- uterine habitus, the center of gravity of the entire foetus lies slightly nearer the breech than the head, while the center of buoyancy, or the metacenter, is situated still nearer the breech. Consequently, as the latter must lie above the former in order for the foetus to float in an approximately vertical direction, the head must descend. Furthermore, as Griffith estimates that the effective weight of the foetus is only 150 or 200 grams, it may readily be admitted that while gravity is the main factor involved, the process of accommodation may play an important part in causing changes in the position of a body presenting so slight an effective weight. Notwithstanding the very considerable amount of research which has been done upon the subject, I do not believe that the final word has been spoken, and I would refer those interested to the articles of Barnum and Griffith, and to the monograph of Cohnstein published in 1868 for information concerning the various older theories. DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS The diagnostic methods at our disposal are fourfold: abdominal palpation, vaginal and rectal touch, combined examination, and auscul- tation, and in certain doubtful cases the X-ray. Obstetrical Palpation.—Under ordinary circumstances external or abdominal palpation is the most reliable and valuable, and I should unhesitatingly choose it were I restricted to the employment of a single method of examination. In trained hands it enables one to make a satisfactory diagnosis without danger of infection and with the least possible discomfort to the patient, and it is not going too far to say that its popularization forms one of the greatest advances in modern ob- stetrics. Accordingly it behooves the student to become thoroughly familiar with the proper technic, and to avail himself of every oppor- tunity to become proficient in the various manipulations. Although crude forms of abdominal palpation had no doubt been practiced from the earliest antiquity, just as they are still employed by many of the aboriginal peoples, its advantages were first pointed out by Roederer, Wigand, and Hohl, as late as the latter part of the eighteenth and the early part of the nineteenth century. Its practical importance, however, was not generally recognized until 1878, when Pinard published his work upon the subject, after which the method became popularized in France, but was not employed systematically elsewhere until Crede and Leopold had repeatedly urged its value. In order to obtain satisfactory results, the examination should be made systematically by following the four maneuvers suggested by Leo- pold. The patient should be on a hard bed or examining table, with 242 PRESENTATION AND POSITION OF THE FCETUS the abdomen bared, or at most covered with a thin chemise. During the first three maneuvers the examiner stands at the side of the bed which is most convenient to him, and faces the patient, but reverses his position and faces her feet for the last maneuver (see Plates XI to XIV). First Maneuver.—After outlining the contour of the uterus, and determining how nearly its fundus approaches the xiphoid cartilage, the fundus is gently palpated with the tips of the fingers of the two hands, and the foetal pole occupying it differentiated, the breech giving the sensation of a large, irregularly shaped, nodular body, and the head that of a hard, round object, which is freely movable and ballottable. Second Maneuver.—Having determined wdrich pole of the foetus lies at the fundus, the examiner places the palmar surface of his hands on either side of the abdomen and makes gentle but deep pressure. On one side he feels a hard resistant plane—the back—and on the other numer- ous nodulations—-the small parts. In women with thin abdominal walls the legs and arms can readily be differentiated, but in fat persons only irregular nodulations can be felt. In the latter case, or when a consid- erable quantity of amniotic fluid is present, the appreciation of the back can be facilitated by making deep pressure with one hand while palpat- ing with the other. After determining upon which side the back is situated, we next note whether it is directed anteriorly, transversely, or posteriorly, and thereby gain an exact idea of the orientation of the body. Third Maneuver.—The examiner grasps the lower portion of the abdomen, just above the symphysis pubis, between the thumb and fingers of one hand, and decides what is between them. If the presenting part be not engaged, a movable body will be felt, which is usually the head. The differentiation between it and the breech is made as at the fundus, the former being appreciated as a hard, round, ballottable body. If the presenting part be not engaged, this practically completes the examination, as we now know the situation of the head, breech, back, and extremities, and all that remains is to determine the attitude of the head. If careful palpation shows that the greatest cephalic prominence is on the same side as the small parts, we know that the head is flexed and that the vertex is the presenting part; but when the reverse is the case Ave know that the head is extended and that AA'e have a face presentation. On the other hand, if the presenting part is deeply engaged, this maneuver simply shows that the lower pole of the foetus is fixed in the pelvis, and the details concerning it are ascertained as follows: Fourth Maneuver.—The examiner faces the patient’s feet, and Avith the tips of the first three fingers of each hand makes deep pressure in the direction of the axis of the superior strait. If the head presents, he finds that one hand is arrested sooner than the other by a rounded body—the cephalic prominence; while the other hand descends deeper into the pelvis. In vertex presentations the prominence is on the same side as the small parts, and in face presentations on the same side as the back. Again, the degree of ease with Aldrich the prominence is felt indicates the extent to which descent has occurred. In many instances, Avhen the head has descended into the pelvis, the anterior shoulder of the child DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 243 can be readily differentiated by the third maneuver. In breech presen- tations the information obtained from this maneuver is not so definite as in head presentations. This method of examination is available throughout the later months of pregnancy, and in the intervals between the pains at the time of labor. By its use we can not only determine the presentation and position of the child, but also obtain important information as to the extent to which the presenting part has descended into the pelvis, and we know when the cephalic prominence can no longer be palpated from above that the head has descended so deeply that its most dependent part can be palpated through the pelvic floor. Moreover, when there is dis- proportion between the size of the head and the pelvis, its seriousness can be gauged by determining the extent to which the anterior portion of the head overrides the symphysis pubis. Likewise, with practice, it is possible to estimate roughly the size of the child, while in twin pregnancy the second foetus can be mapped out. During uterine contractions, on carefully palpating in the region of the internal abdominal ring, one can often distinguish a rounded cord on either side—the round ligaments—from which important information may be obtained. In the first place, the intensity of their contraction gives some idea of the manner in which the uterus is acting; and sec- ondly, by noting their course, as pointed out by Palm and Leopold, it is possible to diagnose the situation of the placenta in about 88 per cent, of all cases. When the round ligaments are found converging toward the fundus of the uterus, the placenta is usually situated upon the pos- terior wall, whereas it is upon the anterior wall when they are parallel or diverging. During labor, palpation also gives us valuable information concerning the lower uterine segment; when there exists some obstruction to the passage of the child, the contraction ring may be felt as a transverse or oblique ridge extending across the lower portion of the uterus. More- over, in normal cases, we can differentiate by palpation between the con- tracting body of the uterus and the passive lower uterine segment ; for during a pain the former presents a firm, hard sensation, while the latter appears elastic and almost fluctuant. Vaginal Examination.—During pregnancy the results arrived at by vaginal examination, concerning the presentation and position of the child, are necessarily somewhat inconclusive, for, as the cervix is still closed, one is obliged to palpate the presenting part through the lower uterine segment. During labor, on the other hand, after more or lesq complete dilatation of the cervix, important information may be obtained. In vertex presentations the position and variety are determined by the differentiation of the various sutures and fontanels; in face presen- tations, by the differentiation of the various portions of the face; and in breech presentations, by the palpation of the sacrum and ischial tuberosities. Under the most favorable circumstances the information to be de- rived from vaginal touch alone is not more accurate than that obtained by abdominal palpation, and in vertex presentations the fontanels are 244 PRESENTATION AND POSITION OF THE FfETUS frequently mistaken for one another; and occasionally face and breech presentations escape differentiation. Moreover, later in labor, after the formation of the caput succedaneum, detection of the various diagnostic points often becomes impossible. Fig. 208.—Diagram showing Method of Locating Sagittal Suture on Vaginal Examination. A much more serious objection, however, is the danger of puerperal infection, no matter how careful one's technic may be; for it is now generally admitted that absolute hand disinfection cannot be effected, Fig. 209.—Diagram showing Method of Differentiation between the Fontanels and, even granting that the use of sterile rubber gloves overcomes this difficulty, the gloved fingers may still carry up into the vagina pathogenic microorganisms from the margins of the vulva, and thus give rise to infection. DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 245 Accordingly, it is advisable to limit vaginal examination as much as possible, and in normal cases to do away with it altogether. For if the preliminary examination has shown that the patient has a normal pelvis, and presents no other abnormality, and we find by the fourth maneuver that the head is deeply engaged, all that we gain by vaginal examination is information as to the degree of dilatation of the cervix, and the condition of the membranes, and this can usually be ascertained equally well by rectal examination. Accordingly, vaginal examination becomes absolutely necessary only in the few cases in which palpation and rectal examination do not give satisfactory results, or in patients presenting some abnormality, or in whom the course of labor is unduly delayed. Personally, I conduct the great majority of my private cases in this manner, and ordinarily do not make a vaginal examination until about to discharge the patient. In attempting to determine the presentation and position by vaginal examination, it is advisable to pursue a definite routine, which is readily accomplished by three maneuvers. First Maneuver.—After appropriate preparation of the patient, two fingers of either the right or left gloved hand, as best suits the examiner, are introduced into the vagina and carried up to the presenting part. A few moments suffice to determine whether it is a vertex, face, or breech. Second Maneuver.—If the vertex be presenting, the fingers are ried up behind the symphysis pubis, and are then swept backward over the head toward the sacrum. During this movement they necessarily cross the sagittal suture. When it is felt, its course is outlined, and we know that the small fontanel must lie at one and the large fontanel at the other end of it. Third Maneuver.—We then attempt to determine the position of the two fontanels. For this purpose the fingers are passed to the anterior extremity of the sagittal suture, and the fontanel there encountered is carefully examined and identified; then, by a circular motion, the fingers are passed around the side of the head until the other fontanel is felt and differentiated. By this means the various sutures and fontanels are readily located, and the possibility of error is considerably lessened. In face and breech presentations it is still further minimized, as the various parts are more readily distinguished. Combined Examination.—By combined examination we understand the introduction of two fingers of one hand into the vagina, and the application of the other hand over the lower portion of the abdomen. This method is rarely employed except when the presenting part is not engaged, and the external hand is used to fix it so as to permit the in- ternal fingers to explore it satisfactorily. Auscultation.—By itself, auscultation does not give very important information as to the presentation and position of the child, but it some- times reenforces the results obtained by palpation. Ordinarily, the heart sounds are transmitted through the convex portion of the foetus, which lies in intimate contact with the uterine wall. Accordingly they are heard loudest through the back in vertex and breech, and through the 246 PRESENTATION AND POSITION OF THE FCETUS thorax in face presentations. The region of the abdomen in which the foetal heart is heard most plainly varies according to the presentation and the extent to which the presenting part has descended. In head presen- tations the point of maximum intensity is usually midway between the umbilicus and the anterior superior spine of the ilium, while in breech presentations it is usually about on a level with the umbilicus. Auscultation frequently gives us not a little supplementary aid in de- termining the position of the child. Thus, in oecipito-anterior presenta- tions the heart is usually best heard a short distance from the middle line; in the transverse varieties it is heard more laterally, and in the posterior varieties well back in the patient’s flank. Occasionally, how- ever, in obliquely posterior positions, the information gained from the location of the foetal heart is misleading, and may give rise to serious diagnostic errors; for if the flexion of the head be imperfect, the thorax may become convex, in which event the heart sounds may be trans- mitted through it and lead one to suppose that one has to deal with an obliquely anterior position. LITEEATUEE Bar. Rapport sur 1’unification de la nomenclature obstetricale. L’obstetrique, 1903, viii, 103-114. Barnum. The Effect of Gravitation on the Presentation and Position of the Foetus. J. Am. Med. Assn., 1915, lxiv, 498-502. Baudelocque. L’art des accouchements. Paris, 1789, 2me ed. Cohn stein. Die Aetiologie der normalen Kinderlagen. Monatsschr. f. Geburtsk., 1868, xxxi, 141-193. CrediS. Gesunde und kranke Wochnerinnen. Leipzig, 1886, 80-81. Cred£ und Leopold. Die geburtshiilfliche Untersuchung. Leipzig, 1892. Dubois. Memoire sur la cause des presentations de la tete. Mem. de l’Acad. de med., 1833, ii. Duncan. The Position of the Foetus. Researches in Obstetrics, Edinburgh, 1868, 14-37; also Edinburgh Med. and Surg. Jour., 1855. Farabeuf et Varnier. Introduction a 1’etude clinique et a la pratique des ac- couchements. Paris, 1904. Griffith. An Investigation of the Causes which Determine the Lie of the Foetus in Utero. Jour. Obst. and Gyn. Brit. Emp., 1915, xxvii, 105-123. Hecker. Klinik der Geburtshiilfe. Leipzig, 1861, i, 17. Statistisches aus der Gebiiranstalt Miinchen. Archiv f. Gyn., 1882, xx, 378-398. Hohl. Die geburtshiilfliche Exploration. Halle, 1834, ii, 144-166. International Medical Congress. Uniformity in Obstetrical Nomenclature. Amer. Jour. Obst., 1889, xx, 1084-1086. La Chapelle, Madame. Pratique des accouchements. Paris, 1821, i, 17-25. Leopold. Die Diagnose des Placentarsitzes in der Schwangerschaft und wahrend der Geburt. Arbeiten aus der Dresdener Frauenklinik, 1895, ii, 151-166. Leopold und Sporlin. Die Leitung der regelmassigen Geburten nur durch aussere Untersuchung. Archiv f. Gyn., 1894, xlv, 337-368. Markoe. Observations and Statistics on Sixty Thousand Labors, etc. Bull, of the Lying-in Hospital of the City of New York, 1909, vi, 101-115. Muller, A. Ueber die Ursachen der Ungleichheit und Unklarheit in der Benen- nung und Eintheilung der Kindeslagen. Monatsschr. f. Geb. u. Gyn., 1900. xii, 161-181; 266-291. LITERATURE 247 Naegele. Die Lehre vom Mechanismus der Beburt. Mainz, 1838, 10. Palm. Ueber die Diagnose des Placentarsitzes in der Schwangerschaft, etc. Zeit- schr. f. Geb. u. Gyn., 1893, xxv, 317-350. Pinard. L’accommodation fcetale. Traite du palper abdominal. Paris, 1878. Roederer. Elementa artis obstetriciae. Goettingse, 1766. Scanzoni. Lage und Haltung des Kindes in der Gebarmutter. Lehrbuch der Geb., II. AufL, Wien, 1853, 89-93. Schatz. Ueber den Schwerpunkt der Frucht. Zentralbl. f. Gyn., 1900, Nr. 40, 1033-36. Die Ursachen der Kindeslagen. Archiv f. Gyn., 1904, lxxxi, 541-651. Sciiroeder, Olshausen und Veit. Lehrbuch der Geburtshiilfe, XIII. Aufl., 1899. Schultze. Untersuchungen iiber den Wecksel der Lage und Stellung des Kindes in den letzten Wochen der Schwangerschaft. Leipzig, 1861. Seitz. Ueber den Einfluss der Schwerkraft auf die Entstehung der Schadellagen. Archiv f. Gyn., 1908, lxxxvi, 114-144. Sellheim. Exp. und vergleichend physiologische Untersuchungen iiber die Ent- wicklung der typischen Fruchtlage. Archiv f. Gyn., 1917, cvi, 1-57. Simpson. Attitude and Positions of the Foetus in utero. Monthly Journal of Med. Sciences, 1848-49, ix, 423; 639; 863. Smellie. A Treatise on the Theory and Practice of Midwifery. 8th ed., London, 1774. Veit, G. Die Lagenverhaltnisse bei Friih- und Zwillingsgeburten. Scanzoni 7s Beitrage, 1860, iv, 279-292. Warnekros. Schwerkraft und Kopflage. Archiv f. Gyn., 1919, cxi, 21-28. Schwangerschaft und Geburt im Roentgenbilde. Miinchen, 1921. Wigand. Die Geburt des Menschen. Berlin, 1820, ii, 99. SECTION IV PHYSIOLOGY OF LABOR CHAPTER X THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR By labor we understand the process which brings about the separation of the mature or nearly mature product of conception from the interior of the uterus, and its extrusion from the maternal organism, whether the birth occurs spontaneously or requires external aid. Cause of the Onset of Labor.—From time immemorial inquiring minds have sought an explanation for the fact that labor usually ensues about two hundred and eighty days after the appearance of the last menstrual period, but thus far no satisfactory universal cause has been discovered. The following are among the most important theories which have been advanced as to its causation: 1. The growing irritability of the uterus, associated with an increase in the frequency and strength of the intermittent contractions. 2. Increasing distention of the uterus. 3. Dilatation of the cervix by the presenting part. 4. Increasing distention of the lower uterine segment, with pressure upon the neighboring nervous structures. 5. Changes in the decidua—loosening, thinning, and thrombosis. 6. Excess of carbon dioxid or lack of oxygen in the placental blood, acting on nervous centers. 7. The circulation of foetal metabolic products acting upon similar centers. 8. Menstrual periodicity. 9. Anaphylactic action of foetal blood. 10. Heredity and habit. 11. Senility of the placenta. 12. Physical and emotional causes. 1. The increasing readiness with which the uterus reacts to stimula- tion during the later months of pregnancy affords abundant evidence of its growing irritability. The intermittent contractions, which occur at intervals throughout pregnancy, come on more frequently at this time, and occasionally with such intensity that it may be difficult, in the last few weeks before delivery, to distinguish between them and actual labor pains. 2. Since the time of Mauriceau it has been believed that the uterus, when distended up to a certain point, must begin to contract and attempt 248 CAUSE OF THE ONSET OF LABOR 249 to empty itself, just as happens in the ease of any other hollow viscus. This presumption is supported by the frequency with which premature labor occurs in hydramnion or twin pregnancies. On the other hand, extreme distention does not necessarily give rise to labor, as is shown by the cases of prolonged pregnancy which are associated with large children. 3. Galen supposed that labor resulted from gradual dilatation of the cervix, which was brought about by the pressure of the presenting part, and the view still has numerous adherents. That the condition of the cervix is not the sole factor is shown by the fact that occasionally con- siderable dilatation may exist for days or even weeks before the onset of labor. 4. Keilmann and Kniipffer advanced the theory that the onset of labor was the result of the gradual formation of the lower uterine segment, with consequent pressure upon the surrounding nervous ganglia. Their work was done upon the bat, and was quite convincing so far as that animal is concerned, but it is questionable whether identical factors are concerned in human beings. 5. Naegele, Simpson, Scanzoni, and others believed that the decidua in the later weeks of pregnancy underwent fatty degeneration, which resulted in the partial separation of the ovum and its practical conversion into a foreign body, which then gave rise to uterine contractions. More recent investigations, however, have shown that such changes do not occur normally. It is generally recognized that the septa, by which the glandular spaces of the spongy layer of the decidua are bounded, become progres- sively thinner in the later months of pregnancy, and some authorities assume that in the last few weeks they tend to rupture and thereby bring about more or less extensive separation of the ovum from the uterine wall. No conclusive evidence of such an occurrence has been adduced, and my experience, which is based upon the examination of a considerable number of uteri at or near term, indicates that as a rule the septa are not torn through until the third stage of labor. 6. Brown-Sequard in 1853 demonstrated that an excess of carbon dioxid in the blood led to energetic uterine contractions, and his state- ments have been confirmed by most subsequent investigators (Keiffer). Even if this be true, no one has as yet adduced evidence of a sudden increase in the amount of carbon dioxid in the blood sufficient to give rise to labor at the appointed time; although Leopold and others have con- tended that the carbon dioxid content of the placental blood is markedly increased as a result of progressive thrombosis of the decidual vessels. My own investigations, however, lead me to believe that such a con- tention is based upon uncertain foundations; for, while pronounced thrombosis may sometimes be demonstrated, it is lacking in most full- term uteri. On the othei hand, it occasionally develops early in preg- nancy without leading to its interruption. For these reasons, I believe that the last word has not yet been spoken concerning the striking vascular changes which occur in the decidua basalis. Moreover, recent work tends to invalidate Brown-Sequard’s conclusions. Blumreich holds that carbon dioxid has less effect upon the pregnant than upon the non- 250 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR pregnant uterus, while Kurdinowsky and Kehrer contend that it does not give rise to contractions at all. 7. Spiegelberg advanced the view that the onset of labor is due to foetal rather than maternal changes. He considered that the mature foetus needs materials for its sustenance other than those furnished by the placenta, and that as a result of insufficient nutrition certain excre- mentitious substances gain access to the maternal circulation, and in some way stimulate the uterus. The observations of Kurdinowsky upon the isolated uterus, of Kehrer upon the extirpated living uterus, of Kruieger and Offergeld upon the uterus separated from all connection with the central nervous system, of Sauerbruck and Heyde in symbiotic experiments, as well as various metabolic studies, tend to indicate that the ultimate cause of labor must be sought in some substance or substances circulating in the maternal blood. We are profoundly ignorant of the nature of this hypothetical substance, and do not know whether it is derived from the foetus, the ovaries, or the general organism of the mother, although certain evidence points toward the former. In the experimental observations of Kruieger and Offergeld, in which the uterus was cut off from all connection with the central nervous system, labor set in at the usual time and progressed normally. Accord- ingly, it must be admitted that the process is not necessarily dependent upon the stimulation of centers situated in the central nervous system, but must be attributed to the stimulation of the intra-uterine ganglia by substances brought to the uterus either by the circulating blood, or originating in the foetus itself. Furthermore, the experiments of Sauerbruck and Heyde, which I have been able to confirm to some extent, point to a similar conclusion. These investigators united rats to one another in such a manner that they continued to live in symbiosis, and, if both animals were pregnant, they found that the occurrence of labor in one set up a similar process in the other; whereas, if only one were pregnant, the onset of labor was associated with serious illness on the part of the non-pregnant animal. Such observations indicate that the cause of labor must be sought in the circulation of some substance in the blood, which is comparatively innocuous to pregnant but is poisonous to non-pregnant animals. They, however, reached no conclusion con- cerning its nature or origin. 8. Mende, Tyler-Smith, Lowenhardt, Beard, and others believe that there is an increased tendency toward uterine contractions at the periods at which the menstrual flow should appear if the patient were not pregnant, and that these reach their acme at about the date of the tenth menstrual period and give rise to labor. Observations of this character point toward the possibility of an ovarian hormone being the efficient cause. 9. Yon der Heide considers that the cause of labor should be sought in an anaphylactic reaction. He claims that in a certain proportion of cases labor will follow the intravenous injection of a few cubic centi- meters of fcetal serum. In normal pregnancy he holds that foetal sub- stances are constantly gaining access to the maternal circulation, and CAUSE OF THE ONSET OF LABOR 251 give rise to the formation of definite antibodies. As term approaches, he believes that excessive quantities of the foetal antigen enter the mother’s blood, and that in the reaction which ensues between it and the existing antibodies, substances are set free which give rise to labor. Rogny in 1912 confirmed Heide’s observations upon a number of pa- tients. In view of the collapse of the anaphylactic theory in connection with the production of eclampsia, and the fact that no further contributions have been made to the subject, it should be held sub judice. 10. Geyl and others are inclined to attribute the onset of labor at the usual time to the fact that Nature, after ages of experiment, has found the end of the tenth month to be the most suitable time. For when labor occurs at a much later period it is usually very difficult and results in dead children, while at an earlier period puny children are born which usually perish soon after birth. 11. Eden and I have pointed out that the frequent occurrence of infarct formation in the placenta at term must be regarded as evidence of its senility, and as analogous to the atrophy of the chorion laeve at an earlier period. Where these changes are marked the nutrition of the foetus must be interfered with, and it is possible that certain of its metabolic products may result in stimulation of the uterine centers. At most this explanation is of only limited application and cannot be in- voked for the great majority of cases in w'hich infarct formation is only slightly developed. 12. It is also a well-known fact that excessive physical exercise, sud- den jars or violence, as well as extreme mental emotion, such as grief and anger, may lead to the termination of pregnancy. While, then, there is no lack,of theories upon the subject, it is mani- fest that most of them are extremely unsatisfactory, and, with the ex- ception of the recent “biological” ones, none is of universal applica- tion. It is probable, therefore, that in the majority of cases a com- bination of a number of the above-mentioned causes are concerned in the causation of labor, and that only some slight additional stimulus is needed to set it in progress. On the other hand, it is possible that some law may be discovered in the future which will explain the rhythm of the various sexual functions in women—menstruation, as well as the onset of labor. Observations made in my clinic show that marked changes in metab- olism occur immediately before and at the time of labor, which in all probability stand in some causal relation to it. Thus, Slemons has shown that twenty-four hours or less before the onset of labor the output of nitrogen through the urine becomes considerably diminished, while at the same time a marked diuresis occurs, thus completely reversing the conditions which existed throughout the last months of pregnancy. Ac- cordingly, if the urinary analyses were made at sufficiently frequent intervals, it might be possible to predict the approaching onset of labor before the appearance of clinical symptoms. In order to determine the relation which these changes bear to the causation of labor, Slemons, at my suggestion, studied the metabolism 252 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR of two pregnant women in whom labor was induced by the introduction of a bougie, and found that the changes were absent, or at least less pronounced than when labor occurred spontaneously. We are not prepared to draw positive conclusions from these ob- servations, but, nevertheless, they seem to indicate that at least two factors may be concerned in the production of labor. One occurs in spontaneous labor, and is associated with the process which gives rise to the alteration in metabolism; while the second is a purely mechanical irritation, which is not accompanied by such changes. What the first factor is cannot be determined as yet, but it seems difficult to escape the inference that it is some substance which gains access to the circulation and profoundly alters the entire metabolism, and at the same time di- rectly or indirectly stimulates the uterus to contraction. Observations by Zangemeister, and Momm point to similar conclusions. They found if women are weighed daily during the last few months of pregnancy that they gain 55 or 60 grams each day until three or four days before the onset of labor, when they suddenly lose about 1,000 grams—or as much as they had gained during the preceding two or three weeks. This phenomenon occurs so constantly as to enable them to predict the onset of labor several days in advance. Moreover, observations which I have made upon the respiratory ex- change show that at the time of labor the output of carbon dioxid is less than one would expect in view of the increased muscular exertion incident to labor. Accordingly, as the latter must necessarily be accom- panied by an increased production of carbon dioxid, it must follow that that resulting from the general bodily activity is diminished, so that it may be assumed that labor is accompanied by profound changes which depress the general oxidative processes far below the usual limit. Nearly all of the theories to which reference has been made require the intervention of the central nervous system for the ultimate production of labor, and it is generally stated that there exists in the medulla a cen- ter for uterine contractions, which can be stimulated by anemia and the presence of various toxic substances. Dahl, however, denies the existence of such a center either in the brain or medulla, and states that if any exists, it must be situated in the lumbar column. Furthermore, his careful work apparently shows that no ganglionic cells are present in the uterus, but occur in large numbers in Frankenhauser’s plexus. In any event, the presence of a “uterine” center is not essential to the onset and completion of normal labor, as Franz, Kurdinowsky, and Kehrer have clearly shown that the intrinsic nerve supply of the uterus may suffice for its usual activities. Kurdi- nowsky has observed the completion of labor in isolated uteri, which were kept alive by the circulation of Locke’s fluid through their vessels; while Kehrer has shown that excised portions of the uterus of animals and women may live for hours in oxygenated Kinger’s fluid, and that their contractions may be graphically recorded by suitable appliances. In my clinic, Sun has made similar observations, and has shown that strips of muscle excised from the human uterus at any period of pregnancy and suspended in warm, oxygenated, Locke’s fluid, will continue to contract LABOR PAINS 253 rhythmically for hours. Such phenomena apparently correspond to the Braxton Hicks contractions of pregnancy, rather than to typical labor pains, but in any event they must be regarded as an essential function of the uterine muscle, and altogether independent of nervous control. As early as 1880, Rein showed that the transmission of impulses through the cord is not essential to the act of labor, while the more ex- tensive experiments of Kruieger and Offergeld prove that in animals section of the cord, and the separation of the uterus from all extrinsic nerve connections, has no further effect upon labor than to render it painless. Moreover, their observations, as well as those of Routh, Elkin and others, upon the course of labor in women who have sustained de- structive injuries of the lower part of the spinal cord show that labor may progress painlessly and normally, except that expulsive efforts on the part of the abdominal wall are lacking. Although Keiffer and others have shown that the uterus has a three- fold nervous supply, derived principally from the sympathetic system, partly from branches of the lumbar cord, and partly from its intrinsic nerves, and that contractions may follow the stimulation of any of them, the evidence at our disposal justifies the following conclusions: That the intrinsic nerves are the main factor concerned in the production of uterine contractions; that the central nervous system has principally a regulative function, makes possible the perception of pain, and con- trols the voluntary abdominal contractions; and that the sympathetic system regulates the vascular conditions. Labor Pains.—With the onset of labor, the painless intermittent con- tractions which have persisted throughout pregnancy are replaced by others of increasing intensity, giving rise to severe pain, and bringing about the dilatation of the cervix and the expulsion of the child and pla- centa. The uterine contractions, just as those of all other non-striated mus- cles, are independent of the will of the patient, and can neither be in- creased nor diminished in frequency by her volition. But at the same time they may be affected by the emotions, and any sudden excitement may either check them or cause them to become more violent. Thus, it is a matter of common observation that the entrance of the obstetrician may be followed by a temporary lull in the intensity and frequency of the pains. The contractions begin slowly, gradually reach an acme, and then gradually diminish in intensity,_ the active process being followed by a pause of some length. The tracings of Schatz and Polaillon show that the period of increase occupies the greater portion of the pain, and that its acme is of very short duration. In the lower animals which possess bicornuate uteri the contractions are distinctly peristaltic in character; and Schatz believes that such is also the case in human beings. It is im- portant to bear in mind that labor pains are effective only during the period of increase, and that the tightly contracted organ is worthless from a mechanical standpoint. These uterine contractions are nearly always accompanied by painful sensations, whence the term “labor pains,” although the amount of suf- 254 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR fering varies greatly in different individuals. The pain usually begins in the sacral region and then slowly passes to the abdomen and down the thighs. In the early stages of labor it is probably due to pressure upon the nerve-endings between the muscle fibers; but in the later stages it is augmented by the overstretching and dilatation of the soft parts, and becomes most marked when the head distends the vulva just before its birth. Usually the final pains are very severe, and - may be almost in- supportable, but occasionally the suffering is very slight, and, in rare instances, labor may be almost entirely painless, even though the patient be perfectly conscious. A number of such cases have been collected by Coliez and Wolff. At the onset of labor the pains come on at intervals of from fifteen to thirty minutes; as it advances they gradually become more frequent, and eventually occur every two or three minutes. Their average duration is about one minute—thirty to ninety seconds—though suffering is not experienced during the entire contraction, as the hand placed over the abdomen may feel the uterus becoming hard for several seconds before the patient perceives the slightest pain. Force Exerted by Labor Pains.—On this point there has been a good deal of misconception, and a tendency toward exaggeration appears in the writings of not a few authors. Thus Sterne, in Tristram Shandy, estimated that the force exerted at each pain during labor amounted to 470 pounds, while Professor Haughton put it at 577 pounds. Poppel, Duncan, Ribemont, and others have attempted to approximate it by de- termining the force necessary to cause the rupture of the membranes outside of the body. This, they found, varied markedly, and in 100 ex- periments Duncan placed the extremes at 4 and 37.58 pounds respec- tively, with an average of 16.73 pounds. Joulin and other observers have attempted to solve the problem by calculating the force exerted in forceps deliveries. Thus, on interpolat- ing a dynamometer between the operator and the handles of the instru- ment, it was found that the tractile force rarely exceeded 80, though in some cases it reached 100 pounds. A greater direct force than this can- not come into play, as it has been shown that one of 120 pounds is suffi- cient to tear the child’s head from its body. Schatz studied the subject by inserting into the uterus a rubber bag which was connected with a manometer. In this way he found that the intra-uterine pressure, in the intervals between the contractions, was represented by a column of mercury 20 millimeters high, 5 of which werd due to the tonicity of the uterine walls and 35 to its contents. During the pains, however, the mercury rose to a height of from 80 to 250 milli- meters, which corresponds to a force of to 2 7 pounds. He also showed that the force exerted by the uterus increases markedly when the foetus is partially expelled from it. A rough idea may also he gained by estimating the expenditure of energy necessary to restrain the head as it emerges from the vulva. This rarely exceeds 50 pounds, although the obstetrician frequently finds it impossible to hold it back at the acme of a pain. This inability is in great part due to the disadvantageous manner in which one’s energy PHYSICAL CHANGES DURING UTERINE CONTRACTIONS 255 is exerted, rather than to the actual force exerted by the uterine and abdominal contractions. Physical Changes during Uterine Contractions.—During contraction the uterus undergoes definite changes in shape. With the patient on her back, the organ in the flaccid state rests upon the vertebral column, and its transverse equals or exceeds its vertical diameter. But when it con- tracts the uterus leaves the vertebral column, becomes more erect, pushes the anterior abdominal wall forward, and its long axis comes into approximation with that of the superior strait. At the same time the vertical increases at the expense of the transverse diameter (Fig. 210). The dilatation of the cervix is usually brought about solely by the action of the uterine muscle, whereas during the expulsion of the child the muscles of the abdominal wall also come into play. During the sec- ond stage the patient braces her body against some fixed object, takes a deep inspiration, closes the glottis, and makes forcible straining move- Fig. 210.—Composite Picture, showing Shape of Abdomen before and during a Uterine Contraction, the Darker Outlines indicating Contraction. ments with the abdominal and respiratory muscles. By these means the intra-abdominal pressure is markedly increased, and is transmitted di- rectly to the uterus. At first these movements are voluntary, but as labor advances they pass beyond the control of the will, and may occur even with the patient under profound anesthesia. The abdominal muscles, therefore, play an important part in the ex- pulsion of the child, which in many instances makes no progress without their aid. The fact that spontaneous labors occasionally occur in women who are paralyzed from the waist down shows that their action is not indispensable in every case; but, on the other hand, the application of low forceps is frequently necessitated by the inability of the abdominal muscles to do their work, or to the unwillingness of the patient to bear the pain associated with their employment. The various ligamentary structures connected with the uterus also take part in the contractions. Of these the most important are the round ligaments, which in contracting tend to draw the fundus of the uterus 256 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR forward and to fix it in position. They can be readily palpated through the abdominal wall, and some idea of the intensity of the uterine con- tractions may be gained from their consistency. The part played by the vagina during labor is almost entirely passive, and it is only after the expulsion of the child that the contraction of the muscular elements in its walls comes into play. The general arterial tension is raised during the labor pains, as is in- dicated by the Rushed look of the patient, as well as by the more accu- rate observations of Yaquez, and of Slemons and Goldsborough in my clinic. The pulse becomes accelerated during, and slower in the intervals between, the pains. It is also stated that the temperature rises a fraction of a degree during each pain, though its detection requires the employ- ment of very accurate thermometers. Respiration becomes slower during the contractions, more rapid in the interval between them, and is totally abolished during the expulsive pains of the second stage of labor. My observations upon the respiratory exchange show that the consumption of oxygen and the output of carbon dioxid are increased during labor, but not to the extent one would suppose. As has already been stated, this probably indicates that the general oxidative processes of the body are reduced to a minimum at this time, and consequently that the actual work of labor is accomplished with comparatively less expenditure of energy than in the case of an equal amount of muscular exertion at other times. Clinical Course of Labor.—Before taking up the consideration of the forces concerned in the expulsion of the foetus and the mechanism by which it is accomplished, it is advisable for the student to follow as a spectator the course of parturition in a primiparous woman. Several weeks before the onset of labor the abdomen undergoes a marked change in shape, its lower portion becoming more pendulous, whereas in the neighborhood of the costal margin it looks decidedly flat- ter. This change is perceived by the woman herself, who feels that her waist has become lower; and occasionally it occurs so suddenly as to cause her to fear that something has given way inside the abdomen. Abdomi- nal palpation shows that the change is due to the fact that the fundus of the uterus has descended from the position which it occupied at the ninth month, and resumed that of the eighth, and that the head, Avhich was previously freely movable, has become fixed in the superior strait. These changes are most pronounced in primiparae, and frequently do not occur in multiparae until the onset of labor. After this the patient experiences considerable relief from the respira- tory disturbances from which she may have suffered; but at the same time locomotion may become more difficult, and she may suffer from severe cramplike pains in the lower extremities and a more frequent desire to urinate. During the last few weeks of pregnancy the vaginal secretion is in- creased in amount, the labia become more swollen and succulent, and in multiparae gape more or less widely, while the patient may experience a few transient pains for a number of days before confinement the so- called “dolores praesagientes.” CLINICAL COURSE OF LABOR 257 For purposes of description, labor is divided into three stages: The first, or period of dilatation, extends from the commencement of labor until the cervix is completely dilated. The second, or period of expulsion, extends from the complete dilatation of the cervix to the birth of the child; while the third stage, or placental period, lasts from the birth of the child to the extrusion of the placenta. First Stage.—About the end of the tenth lunar month the patient begins to experience cramplike pains in the lower portion of her abdo- men, which she sometimes mistakes for intestinal colic. At first these sensations recur only at long intervals, but soon are felt more frequently. They are most marked in the lumbar region and gradually extend toward Fig. 211.—Birth of Head, Scalp Appearing at Vulva. the abdomen and down the thighs. As the pains become more frequent they likewise increase in severity, and in the latter part of the first stage the patient may complain bitterly, and often seeks to ease herself by making pressure over the sacral region. The result of the pains in this stage of labor is to bring about the dilatation of the cervix, and, as it slowly yields to the pressure of the amniotic fluid contained within the membranes, slight lesions occur about its margins, which are manifested by a small admixture of blood with the vaginal discharge—the “show.” During this period the patient is perfectly comfortable between the pains, and for a time can attend to her ordinary avocations; but, as the pains become more severe, she assumes 258 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR a sitting or leaning posture, and frequently gives utterance to short, sharp, querulous cries. After the pains have continued for from twelve to fifteen hours, more or less, there is a sudden gush of clear fluid from the vagina, which usu- ally indicates that the cervix has become completely dilated, and that the membranes, having fulfilled their function as a hydrostatic wedge, have ruptured. The amount of fluid which escapes varies according to the situation of the point of rupture and the position of the presenting part. In vertex presentations, where the pelvis is normal, the cervix is tamponed, so to speak, by the rounded head, and only a small portion of liquor amnii escapes. On the other hand, if the head be not engaged, or Fig. 212.—Birth of Head, Vulva partially Distended. there be some disproportion between it and the presenting part., the entire amount of amniotic fluid may escape. But even in perfectly normal cases a small quantity gushes out with each pain. In a considerable proportion of cases the membranes rupture before complete dilatation of the cervix. In such circumstances further dilata- tion must be effected by pressure exerted by the presenting part, and, as it fills out the cervix less completely and accurately than the bag of waters, the process proceeds more slowly. These are instances of what are commonly known as dry labors. When the rupture occurs before the onset of labor, pains ordinarily set in within twenty-four hours, but exceptionally, several days or even a week or longer may elapse, so that in such cases one should be cautious in expressing an opinion as to when CLINICAL COURSE OF LABOR 259 labor will begin. Meyer-Ruegg in 1904 collected from the literature 15 cases in which several months elapsed between this occurrence and the completion of labor, though so long an interval is very unusual. Second Stage.—For a short time after rupture of the membranes there is a lull in the labor pains, after which they recur with increasing frequency and vigor, and compel the patient to take to her bed, where if left to herself she usually assumes a crouching or squatting posture. During this period the abdominal muscles are brought into play. At first the patient, with each uterine pain, may cause them to contract by an effort of her will. Later, however, this becomes involuntary, and she is usually unable to resist bearing down. At the onset of the pain she braces her feet against some solid object, takes a deep inspiration, and Fig. 213.—Birth of Head, Vulva completely Distended. brings her abdominal and respiratory muscles into active play, her efforts being accompanied by a characteristic grunting sound. At the same time her face becomes congested, and in the later stages of labor covered with sweat. As the pain passes off, the glottis is opened and respiration reestablished, the same phenomena being repeated as soon as another contraction comes on. It is during this period that the child passes through the pelvis. After expulsive pains have continued for about an hour the patient fre- quently experiences a desire to go to stool, which indicates that the head has descended deeply into the pelvic cavity and is pressing upon the rec- tum. In a short time the pelvic floor may be seen to bulge with each 260 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR pain, and a little later the scalp of the foetus may be detected through the slitlike vulval opening. With each subsequent pain the perineum bulges more and more, and the vulva becomes more and more dilated and distended by the head, being gradually converted into an ovoid, and at last into an almost circular, opening. With the subsidence of each con- traction, it becomes smaller and the head recedes from it, to advance again with the next pain. As labor progresses the perineum becomes still more distended and thinner, especially in its anterior portion; so that eventually its frenulum does not exceed a piece of paper in thickness, and looks as if it would rupture with each pain. At the same time the anus becomes markedly Fig. 214.—Birth of Head, showing Delivery by Extension. stretched and protuberant, and the anterior wall of the rectum protrudes through it. By this time the perineum has become converted into a deep gutter, 5 to 6 centimeters long, at the end of which is the vulval opening, which looks almost directly upward and is distended by the head of the child, whose occiput is firmly pressed against the symphysis pubis. The distention of the vulva is most marked at its perineal margin, and less so at its upper and lateral portions. The head advances a little with each pain and recedes in the intervals between them. This continues until the parietal bosses become engaged in the vulva, when further recession becoms impossible, and with the next two or three pains the head is rapidly expelled by a movement of extension, the base of the occiput rotating around the lower margin of CLINICAL COURSE OF LABOR 261 the symphysis pubis as a fulcrum, while the bregma, brow, and face suc- cessively pass over the fourchette. In the majority of primiparae the perineum is unable to withstand the strain to which it is subjected, and tears in its anterior portion, though usually only to a slight extent. Immediately after its birth the head falls backward, so that the face comes almost in contact with the anus. In a few moments the occiput turns toward the one or other thigh, and eventually the entire head assumes a transverse position. This is known as external rotation or res- titution, and indicates that the bisacromial diameter of the child has rotated into the anteroposterior diameter of the pelvic outlet. At this time the perineum is quite tightly retracted around the neck Fig. 215.—Birth of Head, Face falling Backward Toward Anus. of the infant, whose face in consequence may become markedly congested, so that the inexperienced obstetrician is often seized by an almost un- controllable desire to extract the child by traction upon the head. This, however, is usually unnecessary, for the next pain forces the anterior shoulder down under the symphysis pubis, where it becomes fixed; while the posterior shoulder emerges over the anterior margin of the perineum, after which the body of the child is rapidly expelled by a movement of lateral flexion, following a curve corresponding to the axis of the birth canal. Immediately after the extrusion of the child comes a gush of amniotic fluid, which represents the portion which did not escape when the mem- branes ruptured, and which may be more or less tinged with blood. 262 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR In primiparous women the second stage of labor usually lasts about two hours, but is much shorter in multiparous women, in whom two or three pains sometimes suffice for the completion of the period of expulsion. Third Stage— For a few minutes after the birth of the child there is a cessation of the uterine contractions, and the patient experiences a profound sense of relief. On glancing at the abdomen it is seen that the uterus has become much smaller and forms a firm, solid tumor whose upper margin lies well below the umbilicus. After a longer or shorter period the uterine contractions commence once more, and a few moments later the fundus of the uterus may be seen to rise up for several centi- meters, while a slight tumefaction appears immediately above the sym- physis pubis (see Figs. 309 and 310). This indicates that the placenta has become separated from the interior of the uterus and is now in the lower uterine segment or the upper portion of the vagina. From this position it is expelled by the action of the abdominal muscles, the time varying according to the efficiency of their contraction. . Occasionally the entire placental period may be terminated spontaneously within a few minutes after the birth of the child, but more frequently the placenta will remain in the lower uterine segment until forced from it by proper manipulation on the part of the obstetrician. During the third stage there is nearly always a moderate amount of bleeding, which in normal cases does not exceed 600 cubic centi- meters, and is usually much less—250 to 300 cubic centimeters being the most usual amount of blood lost. Frequently the patient may have a chill during this period, or immediately after its completion. This, although it may appear somewhat alarming, in itself has no significance, as it is merely a vasomotor phenomenon, and is not indicative of in- fection. Duration of Labor.—The duration of labor presents considerable in- dividual variations, and is usually about six hours longer in primiparae than in multiparae. Generally speaking, the average for the former is about eighteen hours, of which sixteen are occupied by the first, one and three-quarters to two by the second, and a quarter to a half hour by the third stage of labor; for the latter it is about twelve hours, eleven of which are occupied by the first, and one by the second stage. The slower course of labor in the former is due to the greater resistance offered by the soft parts. Occasionally labor may be extremely rapid, and even in primiparae the entire process is sometimes completed within a few hours; while, on the other hand, a duration of twenty-four to thirty-six hours or even longer is not unusual. Contrary to the general belief labor is exceptionally rapid and easy in very young primiparae. Harris, after analyzing the histories of 500 such cases in our service, reached the conclusion that, from a purely obstetrical point of view, sixteen years or less represents the optimum age for the birth of the first child—a view which is shared by Gache, and Bondy. On the other hand, labor is usually definitely prolonged in elderly primiparae—that is, after the thirtieth year. According to Ahlfeld, it exceeds the average by seven hours, though Yarnier states DURATION OF LABOR 263 that the difference is much less. At the same time the latter author points out that forceps are much more frequently required in old than in young primiparae, being applied in 25 per cent, and 1.6 per cent, of the cases respectively, thus indicating that labor would have lasted much longer had it not been terminated by operative means. It is generally stated that delivery occurs most frequently between the hours of 2 and 4 a.m. Observations by Lynch in my service, as well as the statistics of Knapp, which are based upon 39,000 cases, show that this is not correct, and that more children are born between 9 and 12 p.m. than in any other three hours of the day. Furthermore, if the Fig. 216.—Birth of Head, External Rotation. day be divided, according as delivery occurs in the twelve hours pre- ceding or following 6 p.m., respectively, it will be found that only 4 or 5 per cent, more children are born in the latter than in the former period. The general belief that most labors occur at night is due to the fact that the process usually lasts more than twelve hours, and accordingly either its beginning or end must necessarily fall between 6 p.m. and 6 a.m. 264 THE PHYSIOLOGY AND CLINICAL COURSE OF LABOR LITERATURE Ahlfeld. Die Geburten alterer Erstgeschwangerton. Archiv f. Gyn., 1872, iv, 510-520. Beard. The Span of Gestation and the Cause of Birth. Jena, 1897. Blumreich. Experimente zur Frage nach den Ursachen des Geburtseintritts. Archiv f. Gyn., 1904, lxxi, 135-179. Bondy. Die Geburt in den Entwickelungsjahren. Zeitschr. f. Geb. u. Gyn., 1911, lxix, 213-246. Brown-Sequard. Experimental Researches applied to Physiology and Pathology, 1853, 117. Coliez. Quelques considerations medico-legales sur les accouchements inconscients et sans douleur. These de Paris, 1899. Dahl. Die Innervation der weiblichen Genitalien. Zeitschr. f. Geb. u. Gyn., lxxviii, 539-601. Duncan. A Contribution to the Dynamics of Labour. Researches in Obstetrics, Edinburgh, 1868, 229-333. Eden. A Study of the Human Placenta. Jour. Path, and Bacteriology, 1897, iv, 265-282. Elkin. Spontaneous Labor in a Case of Decentralized Uterus. Jour. Am. Med. Assoc., 1922, 27-29. Franz. Studien zur Physiologie des Uterus. Zeitschr. f. Geb. u. Gyn., 1904, liii, 361-419. Gache. La grossesse et 1’accouchement chez les primipares de 13, 14, 15, et 16 ans. Annales de gyn. et d’obst., 1904, N. S., i, 723-736. Geyl. Ueber die Ursache des Geburtseintrittes. Archiv f. Gyn., 1881, xvii, 1-18. Harris. Pregnancy and Labor in Young Primiparae. Bull. Johns Hopkins Hos- pital, 1922, xxxiii, 12-16. Heide. Exp. biologische Untersuchungen iiber den Geburtseintritt. Miinchener med. Wochenschr., 1911, 1705-1709. Joulin. Memoire sur l’emploi de la force en obstetrique. Arch. gen. de med., 1867, i, 149 ; 313. Kehrer. Physiol, u. pharmakol. Untersuchungen an den iiberlebenden u. lebenden inneren Genitalien. Archiv f. Gyn., 1907, Ixxxi, 160-210. Keiffer. Recherches sur la physiologie de 1’uterus, Bruxelles, 1896. Keilmann. Zur Klarung der Cervixfrage. Zeitschr. f. Geb. u. Gyn., 1891, xxii, 106-178. Knapp. The Hour of Birth. Bull, of the New York Lying-in Hosp., Sept., 1909. Knupffer. Ueber die Ursache des Geburtseintrittes, etc. D. I., Dorpat, 1892. Kruieger und Offergeld. Der Vorgang von Zeugung, Schwangerschaft, Geburt u. Wochenbett an der ausgeschalteten Gebarmutter. Archiv f. Gyn., 1907, lxxxiii, 257-368. Kurdinowsky. Der Geburtsact am isolirten Uterus beobachtet. Archiv f. Gyn., 1904, Ixxiii, 425-437. Weitere Beitrage zur Pharmakologie des Uterus. Archiv f. Gyn., 1906, lxxviii, 539-578. Leopold. Studien iiber die Uterusschleimliaut, etc. Archiv f. Gyn., 1877, xi, 443- 500. Lowenhardt. Die Berechnung und die Dauer der Schwangerschaft. Archiv f. Gyn., 1872, iii, 356-391. Lynch. The Hour of Birth. Surg. Gyn. and Obst., 1907, v, 677-680. Mauriceau. Traite des maladies des femmes grosses, etc., 6me ed., 1721, 203. Mende. Handbuch der gerichtlichen Medicin, 1821, ii, 303. LITERATURE 265 Meyer-RueGG. Eihautberstung ohne Unterbrechung der Schwangerschaft. Zeit- sckr. f. Geb. u. Gyn., 1904, li, 419-468. Momm. Ein neues Zeichen fur den nachen bevorstehenden Geburtseintritt. Zen- tralbl. f. Gyn., 1920, 233-238. Naegele. Versuck eines Systems der Geburtskiilfe, 1812, 97. Polaillon. Reckerckes sur la pkysiologie de 1 ’uterus gravide. Paris, 1880. Poppel. Ueber die Resistenz der Eihaute. Monatsschr. f. Geburtsk., 1863, xxii, 1-15. Rein. Beitrag zur Lehre vcn der Innervation des Uterus. Pfliiger’s Archiv, 1880, xxiii, 68. Rogny. The Use of Fcetal Serum to Cause the Onset of Labor. Am. Jour, of Obst., 1912, lxvi, 1-22. Routh. Parturition during Paraplegia. Trans. London Obst. Soc., 1897, xxix, 191-200. Sauerbruck u. Heyde. Untersuchungen iiber die Ursachen des Geburtseintrittes. Miinchener med. Wochenschr., 1910, 2617-2619. Scanzoni. Ursache der Geburt. Lehrbuch der Geburtshiilfe, II. Aufl., 1853, 165-167. Schatz. Beitrage zur pkysiologischen Geburtskunde. Archiv f. Gyn., 1872, iii, 58-144. Ueber die Formen der Wehencurve und iiber die Peristaltik des menschliehen Uterus. Archiv f. Gyn., 1886, xxvii, 284-292. Ueber die Entwickelung der Kraft des Uterus im Yerlaufe der Geburt. Verh. d. deutschen Gesell. fiir Gyn., 1895, vi, 531-542. Slemons. Metabolism during Pregnancy, Labor and the Puerperium. Johns Hopkins Hospital Reports, 1904, xii, 111-144. Tyler-Smith. The Principles and Practice of Obstetrics. London, 1849. Vaquez. De la tension arterielle pendant la grossesse. Bull, de la d’obst. de Paris, 1906, ix, 30-33. Varnier. Combien de temps dure 1’accouchement. L’obstetrique journaliere, 1900, 174-181. Williams. The Frequency and Significance of Infarcts of the Placenta. Amer. Jour, of Obst., 1900, xli, No. 6. Wolff. Ueber schmerzlose Geburtsvvehen. Archiv f. Gyn., 1906, lxxvii, 402-418. Zangemeister. Ueber das Korpergewicht Schwangerer. Zeitschr. f. Geb. u. Gyn., 1916, lxxviii, 325-365. CHAPTER XI THE FORCES CONCERNED IN LABOR The Cervix in the Later Part of Pregnancy.—On vaginal examination in the later months of pregnancy, the cervix is found to be much softer and somewhat broader than in the non-pregnant condition. At the same time it usually gives the impression of being considerably shortened, espe- cially in its anterior portion. This condition led Mauriceau, Eoederer, and nearly all of the earlier authorities to believe that from the fifth month onward the upper portion of the cervix gradually became obliter- ated and contributed to the enlargement of the uterine cavity, that which was left at the end of pregnancy representing merely its inferior end. Stoltz, in 1826, stated that the shortening was only apparent, being brought about by a fusiform dilata- tion of the cervical canal which re- sulted in the approach of the internal to the external os. He believed that the cervix retained its integrity until about two weeks before the onset of labor, when the canal slowly became obliterated and came to form part of the uterine cavity. Matthews Duncan accepted these views, but pointed out that they had been anticipated by the anatomical work of Verhegen, De Graaf, and Weitbrecht (1710-1750). At the. same time he insisted upon certain modifications, holding that the cervical canal remained practically unchanged until the onset of labor. His statement soon received abundant confirmation from the observations of Holt, Muller, Lott, Taylor, Lusk, and many subsequent investigators. Muller pointed out that the apparent shortening of the cervix was due to the marked anteflexion of the uterus and the depression of the anterior fornix of the vagina by the presenting part, to which should be added the increased succulence of the entire genital tract. He also stated that the finger, at the end of pregnancy, could be introduced into the canal for a distance of 2.5 to 3 centimeters before it was arrested by the internal os. His conclusions were verified by further clinical ob- servation, so that it is now generally admitted that in the great majority of cases the canal remains practically unaltered until the onset of labor, and that it may even be slightly longer than in the non-pregnant condi- tion, thus indicating that the cervix shares somewhat in the general hvnertronhv of the uterus. Fig. 217. — Diagram Showing Condition of Cervix at the End of Pregnancy (Muller). 266 LOWER UTERINE SEGMENT 267 In recent years the results obtained by examination during life have received additional confirmation from the study of frozen sections made through the bodies of women dying late in pregnancy. Valu- able contributions along these lines have been made by Wal- deyer, Schroeder, Braune and Zweifel, Pinard and Varnier, Leopold, and others. Lower Uterine Segment.— For a short time after the ap- pearance of Muller’s work in 1868, the question concerning the behavior of the cervix was regarded as practically settled; but these hopes were shattered in 1872 by the studies of Braune upon frozen sections made through a woman who had died during the second stage of labor. His specimen showed distinctly that the in- terior of the uterus was divided into two parts by a projecting circular ridge, 10 to 11 centi- meters above the margins of the dilated external os, its situation being marked by a large vein, and by the deflec- tion of the peritoneum from the anterior surface of the uterus (Fig. 221). The por- tion above it possessed thick walls, while the remainder ap- peared.as a thin-walled, mus- cular tube through which the head had partially passed. Braune identified this ring or ridge with the internal os, and concluded that everything be- low it had been derived from the cervix; nor did he think it remarkable that the small canal which had existed up to the time of labor should have been converted into a structure of such dimensions. Bandl, in his work upon rupture of the uterus, which appeared in 1875, pointed out that when such an accident occurs the point of rupture Fig. 218.—Cervix at the End of Pregnancy (Waldeyer). X K- Fig. 219.—Cervix at the End of Pregnancy (Braune and Zweifel). X ]/2. Fig. 220.—Cervix at the End of Pregnancy, showing Preservation of Canal (Leopold). x 34 THE FORCES CONCERNED IN LABOR 268 is nearly always situated below Braune’s ring—namely, in the lower uterine segment. When he took up the subject the following year, he considered it inconceivable that the cervical canal, which was only 2.5 to 3.5 centimeters long at the end of pregnancy, could be converted in a few hours into the structure described by Braune. He therefore concluded that, if the upper boundary of the latter really represented the internal os, certain preparatory modifications must have taken place during the later part of pregnancy in order to make such a change possible. He believed that, during the last few weeks of pregnancy, the tissue forming the outer portion of the cervix had gradually shifted, so that it became incorporated into the musculature of the lower portion or the body of the uterus, while the cervical mucous membrane retained its original posi- Fig. 221.—Frozen through Woman Dying during Second Stage of Labor, showing Contraction Ring (Braune). tion. According to his view, then, the true internal os was situated not at the upper termination of the cervical mucosa, but much higher, and at a level corresponding to that of Braune’s ring. Although BandPs complicated explanation is no longer accepted, his name will always have a place in obstetrical literature. More particu- larly, are we indebted to him for our views concerning the clinical significance of the lower uterine segment, inasmuch as he was the first to distinguish clearly between the function of the upper contractile and active and of the lower passive segments of the uterus, as well as the rela- tion which they bear to the occurrence of rupture. The discussion started by Bandl has been responsible for an immense literature. Two main views have been advanced concerning the nature and origin of the passive segment of the uterus. According to the first, it is derived partly from the cervix, the internal os being supposed to be LOWER UTERINE SEGMENT 269 situated 3 or 4 centimeters above the external, while the rest of the struc- ture—the lower uterine segment—is formed by the lower portion of the body of the uterus. According to the second view, the entire structure, from the external os to Braune’s ring, is derived entirely from the cervix. The first view has received the indorsement of such authorities as Schroeder, Huge, von Franque, Barbour, Veit, and Zweifel, while the correctness of the second explanation is upheld by Bandl, Kiistner, Bayer, Grasel, and others. That the question is not settled is shown by the fact that Bumm and Blumreich, after studying a new frozen section in 1907, hold to the latter view; while Hans Schmidt, after a compre- hensive study of the question in 1922, unqualifiedly indorses the former. At first glance it might appear strange that the question has given rise to such divergence of opinion, as it would seem a very simple matter to demonstrate the struc- ture of the parts by microscopical examination. If the first view be correct, the inner surface of the portion which is supposed to be derived from the uterus should be lined by decidua, and the portion below it, corresponding to the cerv- ical canal, by the characteristic cervical mucosa. On the other hand, if the second explanation is to be accepted, the entire structure below Braune’s ring—the contraction or retraction ring, as it is vari- ously designated—should be lined by cervical epithelium. Unfortunately, the question is not so easily solved. In the first place, the formation of the structures in question is in great part a clinical phenomenon; and while the situation of the contraction ring can usually be definitely made out by the examining finger during labor, it is not so clearly marked after the removal of the uterus from the dead body. Again, many of the specimens which have been relied upon to settle the question were utilized for frozen sections before being subjected to microscopical examination, so that the finer histological details had be- come obliterated. In spite of these obstacles, however, the question has gradually approached a solution, and most investigators are inclined to believe that in general the first view is correct. Moreover, Aschoff in 1906, and again in 1908, stated that a great part of the confusion is due to the fact that those taking part in the discussion are not agreed as to what constitutes the cervix. He holds that in the non-pregnant uterus a narrow portion, the isthmus, usually separates the uterine cavity from the cervical canal, and is lined by typical uterine mucosa, and Schmidt points out that similar conditions obtain during Contraction ring. Internal oa. Internal ca. External oa. External oa. Fig. 222.—Diagram illustrating Main Views as to Nature of Lower Uter- ine Segment (American Text-Book). 270 THE FORCES CONCERNED IN LABOR the first months of pregnancy. It is therefore apparent that those who designate the upper opening of the isthmus as the internal os must claim that the lower uterine segment is derived from the cervix; while those who place the internal os at the junction between the isthmus and cervical canal are justified in holding that the passive portion of the uterus is derived both from its body and cervix. To obviate this difficulty, Aschoff proposes to designate the upper and lower openings of the isthmus, respectively, as the anatomical and histological internal os. If the contraction ring corresponds to the former, the lower uterine Fig. 223.—My Frozen Section, showing Condition of the Birth Canal in First Part of Second Stage of Labor. X 3^- C.R., contracting ring; o.e., external os. segment must be derived from the tissue lying between it and the his- tological internal os. In a symposium upon the subject before the Leipzig Obstetrical So- ciety in 1914, Veit, and Zweifel, while in general agreeing with Aschoff, held that the introduction of the term isthmus had tended rather to complicate than to clarify the question. They therefore proposed that, as the isthmus of the non-pregnant uterus becomes the lower uterine segment of the parturient organ, it should be given a single appellation at all times, and that the narrow passage interpolated between the uterine cavity and the cervical canal of the non-pregnant woman should also be designated as the lower uterine segment. Plate IX represents a vertical mesial through the uterus of a woman, seven months pregnant, who died at the Johns Hopkins Hospital PLATE IX. SEVEN AND A HALF MONTHS’ PREGNANT UTERUS FROM WOMAN DYING IN THE FIRST STAGE OF LABOR. X K- CHANGES IN THE UTERUS DURING THE FIRST STAGE OF LABOR 271 during premature labor. In this it is clearly seen that the external os is not dilated, but that the cervical canal has become obliterated and a dis- tinct lower uterine segment has been formed. Careful examination shows that the latter is lined with a typical cervical mucous membrane for a distance of 3.5 to 4 centi- meters from the margins of the external os, whereas above this point its lining is composed of decidua. Fig. 223 represents part of a frozen section through a pregnant cadaver, shown in Plate I, which was kindly placed at my disposal by Drs. J. Holmes Smith and L. E. Neale. The woman, who had a gen- erally contracted rachitic pelvis, died undelivered, with the child presenting by the breech and with the membranes protruding from the vulva. The cervical canal was obliterated and the external os fully di- lated, its margins being 1 millimeter thick. There was no trace of the internal os. Seven centimeters above the external os was a well-marked contraction ring. Unfortunately, the specimen was so macerated that the lining membrane of the cervical canal and lower uterine segment had disappeared. Micro- scopical examination revealed only a few cervical glands in the neighborhood of the external os. Hofmeier, in 1886, demonstrated that the struc- ture of the lower uterine segment is not homogeneous, and that the portion which corresponds to the cervix is composed of dense connective tissue rich in elastic fibers, while its upper part is made up of muscular lamellae which pursue an almost parallel course, whereas as soon as the contraction ring is reached the uterine musculature takes on its characteristic ap- pearance. Changes in the Uterus during the First Stage of Labor.—Passing from these more or less theoretical considerations to the condition of the uterus at the end of pregnancy, we find that the organ is made up of two parts; a large, thin-walled, muscular sac—the body—to the lower end of which the small cervix is attached. The wall of the former, including the de- cidua and foetal membranes, rarely exceeds 7 milli- meters in thickness. The cervix is softened and succulent. It usually presents a fusiform canal, 3 to 4 centimeters long, which is bounded at its upper and lower ends by the internal and ex- ternal os respectively; its walls rarely exceeding 1.5 centimeters in thickness. Occasionally, however, the resistance of the internal os has yielded, so that the upper part of the cervical canal has become con- tinuous with the uterine cavity. The condition of the external os varies in primiparous or multiparous women. In the former it barely admits the tip of the finger; while in the latter it is widely gaping, so that the Fig. 224.—Section through Lower Uterine Segment and Cervix, show- ing Rhomboidal Arrangement of Muscle Fibers in Former and Dense Structure in Latter (Hofmeier). P., peritoneal cover- ing of uterus; o.e., os externum; o.i., os internum. THE FORCES CONCERNED IN LABOR 272 index finger can be readily passed through the funnel-shaped cervical canaj up to the internal os. During labor, under the influence of the uterine contractions, the uterus becomes differentiated into two distinct portions, which are sepa- rated from one another by the contraction ring. The upper is the active contractile portion and becomes thicker as labor advances, while the Fig. 225. Fig. 226. Figs. 225, 226.—Diagrams of Birth Canal at End of Pregnancy and During Second Stage of Labor, Showing Formation of Birth Canal (Schroeder). lower, together with the cervical canal, plays a passive part, becoming converted into a thin-walled muscular tube for the transmission of the foetus (Fig. 226). On abdominal palpation, even before the rupture of the membranes, two zones can sometimes be differentiated during a con- traction, the upper one of which is firm and hard, while the lower affords a semi- fluctuant sensation. The former repre- sents the contractile portion of the uterus, the latter the dis- tended passive por- tion. With the onset of labor pains the fluid contents of the uterus are subjected to pres- sure, and the force exerted upon the liquor amnii is trans- mitted equally in all directions. As the lower uterine segment and the cervix will naturally constitute a point of least resistance, they are consequently subjected to an increased tension and distention. Again, since the cervix is perforated by its canal, the fluid pressure Fig. 227.—Dilatation of Cervix, Funnel-shaped Oblit- eration of Internal Os and Cervical Canal (Leo- pold). CHANGES IN THE UTERUS DURING THE FIRST STAGE OF LABOR 273 exerted by the bag of waters tends to cause its obliteration and final dila- tation, which is aided by the traction exerted upon its margins by the contracting fibers of the upper portion of the body of the uterus. When complete dilatation has been effected, the external os is about 10 centi- meters in diameter, and its margins lie 8 to 10 centimeters below the Fig. 228.—Dilatation of Cervix further advanced than in Fig. 227 (Leopold). X 1 contraction ring, while all trace of the internal os has disappeared. At the same time the bladder is gradually drawn up in front of the lower uterine segment until it becomes almost entirely an abdominal organ. The dilatation of the cervix should be regarded as consisting of two stages: first, obliteration of the canal; and, second, dilatation of the ex- Fig. 229.—Cervical Canal completely Obliterated, External Os Intact. X 1 ternal os. The obliteration occurs from above downward, the beginning being indicated by a funnel-shaped depression at the region of the in- ternal os, which gradually increases in extent and depth until the entire canal has disappeared, when the uterine cavity is separated from the vagina merely by the external os. This is clearly shown in Figs. 227, 228, THE FORCES CONCERNED IN LABOR 274 and 229, as well as in Figs. 230, 231, and 232, which represent recon- structions from the frozen sections of Schroeder, Winter and Saxinger. After the cervical canal has become obliterated, dilatation of the external os occurs. In many instances its margin becomes extremely thin, and when tense gives a sensation as if it might cut the examining finger. These changes are brought about almost entirely by the force ex- erted by the bag of waters, or, when that has ruptured prematurely, by the pressure exerted by the presenting part itself. The course of events differs considerably ac- cording as the woman is in her first or a subse- quent pregnancy. In the former case marked re- sistance is offered by the external os, and a consid- erable time must elapse before complete dilatation is accomplished; whereas in the latter, the os is gaping and very little force is required for its complete dilatation after the cervical canal has become obliterated. Fig. 230.—Dilatation of Cervix, Funnel-shaped Obliteration of Internal Os; Canal 2 Centi- meters Long (Schroeder). X Y- Fig. 231.—Dilatation of Cervix, all but Lower 10 Millimeters of Canal ob- literated; External Os Unchanged (Winter). X Vs. Fig. 232.—Dilatation of Cervix, all but Lower 3 Millimeters of Canal obliterated; External Os Unchanged (Saninger). X Changes in the Uterus during the Second Stage of Labor.—By the end of the first stage of labor the uterine contractions have resulted in the differentiation of the organ into two parts, which are separated from one another by the contraction ring. Above is the active, con- CHANGES IN THE UTERUS DURING THE SECOND STAGE OF LABOR 275 tractile portion, which becomes thicker as labor advances, and below the thin-walled, passive, lower uterine segment and cervix (Fig. 226). While these changes are being effected, there has been no descent on the part of the fcetus, and, as a rule, the position of the presenting part remains unchanged until after the cervix has become completely dilated. With the commencement of the second stage, however, descent begins, and under normal conditions continues slowly but steadily until delivery is accomplished. Naturally, the differentiation into stages is more or less arbitrary, so that it occasionally happens that the presenting part begins to descend during the latter part of the first stage, After it has brought about complete dila- tation of the cervix, the bag of waters has served its function, and rupture usually now occurs, which is manifested by a sudden rush of a variable quantity of a tolerably clear fluid from the vagina. On the other hand, the membranes may give way some time be- fore complete dilatation of the cervix has been brought about; while occasionally they may retain their integrity until the completion of labor, so that the foetus is born surrounded by them, the portion covering its head being designated as a caul. Attention has already been directed to the changes in shape which the uterus pre- sents during contraction. These may be noticed in the first, but more especially in the second, stage, when the organ increases considerably in length, and at the same time diminishes in its transverse and antero- posterior diameters with each contraction. The increase in length is due partly to the stretching of the lower uterine segment, and partly to a straighten- ing out of the foetus; but we are unable to make definite state- ments as to its extent, for at present we possess no means of ascer- taining how far the retraction of the upper portion of the uterus may serve to counterbalance the stretching of its lower segment. With the formation of the lower uterine segment, the upper portion of the uterus increases greatly in thickness, and, as labor proceeds, covers a progressively decreasing portion of the child. Thus, when the head is upon the perineum less than one-half of the foetus is in the upper seg- ment. In obstructed labors, in which definite disproportion exists be- tween the size of the presenting part and the pelvic canal, the lower uterine segment is subjected to excessive stretching, and consequently the contraction ring assumes a much higher level, when it can be palpated as a distinct transverse or oblique ridge a short distance below the umbilicus. In such circumstances, its recognition indicates that rupture of the uterus is imminent and will occur if the labor is not promptly ended. Fig. 233.—Diagram show- ing Action of Intra- uterine Pressure, Mem- branes not Ruptured. 276 THE FORCES CONCERNED IN LABOR Forces Concerned in Labor.—As long as the membranes are unrup- tured during the first stage and the uterus contains a normal quantity of amniotic fluid, as well as in the rare in- stances in which they remain intact, dur- ing the second stage, whatever force is exerted by the contracting uterus is trans- mitted to the liquor amnii, and by it to the foetus. In accordance with the laws of fluid pressure, therefore, it is applied with equal intensity to all portions of the child, and, were it not that the lower uterine seg- ment and cervix represent the point of least resistance in the uterus, all its effect would be wasted ; whereas, in the circumstances, it gives rise to the formation of the lower uterine segment and the dilatation of the cervix, but plays no part in causing the descent of the child. Attention was first directed to this point by Schatz and Lahs, and all subsequent authorities have accepted their conclusions. After rupture of the membranes, a greater or lesser portion of the amniotic fluid escapes from the uterus, but in vertex presentations the presenting part usually acts as a fairly efficient tampon and causes the retention of a quantity suffi- cient to fill out the interstices between the foetus and the uterine walls. Lahs believed the amount retained was usually sufficient to prevent actual contact with the surface of the foetus, and therefore held that extrusion of the latter was brought about by fluid pres- sure alone. He argued that in such cir- cumstances (Fig. 234) the entire surface of the foetus, except the portion projecting through the cervix, would be subjected to fluid pressure, which, as it is equal in all directions, would exert no effect upon the foetus, except in a line passing through the center of the portion not subjected to it, thus manifesting itself as a downward force bring- ing about descent. On the other hand, Lahs held that in all other presentations, as well as in vertex presentations after the amniotic fluid has al- most completely drained off, other factors come into play which he regarded as dis- tinctly pathological. In such cases the contracting uterus would come in direct contact with the surface of the foetus, and the force exerted by the Fig. 234.—Diagram showing Action of Intra-uterine Pressure after Rupture of the Membranes. Fig. 235.—Diagram showing Direct Pressure Exerted by Fundus after Complete Evacuation of Amniotic Fluid. FORCES CONCERNED IN LABOR 277 fundus would be directly transmitted to the presenting part by way of the vertebral column. Most recent writers have not hesitated to accept Lahs’s interpretation, but Olshausen in 1901 directed attentions to the fact that the latter force comes into play even in normal vertex presentations. The former pointed out that only four frozen sections, through women dying in the second stage of labor, were available for the study of the question—namely, two of Braune and those of Chiari and of Barbour—and that in three of them the fundus was in direct contact with the breech of the child. Warnekros made similar observations upon the living woman by means of the X-ray. Furthermore, Olshausen estimated that at least 300 cubic centimeters of amniotic fluid were required to fill out the interstices between the surface of the foetus and the uterine wall, and stated that fluid pressure could play no part in the expulsion of the foetus unless a greater quantity were present. Upon measuring the amount of amniotic fluid escaping when the child was born, Avhich practically represents the quantity remaining in the uterus after rupture of the membranes, he found that in 80 per cent, of the primiparae it did not exceed 300 cubic centimeters; while in 60 per cent, it was not over 200 cubic centimeters—an amount by no means sufficient to fill out the interstices, let alone to separate the breech from the fundus, which is essential for the proper action of fluid pres- sure. He therefore concluded that in such circumstances direct pres- sure must be exerted upon the breech, whence it is transmitted through the vertebral column to the head, and that this is rendered possible by a straightening out of the body of the child and its conversion into a comparatively rigid object, which is brought about by the diminution in the transverse and anteroposterior diameters of the uterus. The descent of the presenting part is also partly due to the straighten- ing out of the body of the child. According to Schroeder, its length from vertex to breech is increased by 5.5 centimeters as a result of this extension; while Olshausen considers that the increase is considerably greater, and may be as much as 13 centimeters. Part of this, it is true, is counterbalanced by the greater length of the uterus, but the remainder is an important factor in causing descent. In addition to these factors, the contractions of the abdominal mus- cles of the woman also play no mean part in effecting the extrusion of the child; indeed, according to Schroeder, they alone bring it about. Olshausen, while not denying their importance, does not consider that they are the sole factors concerned. It is apparent, however, that their action is usually essential, for when it is entirely absent, or only partially comes into play, labor is frequently so delayed that resort to forceps becomes necessary. When the head has descended through the pelvis and is resting on the pelvic floor, more than half of the entire length of the child lies beneath the contraction ring; moreover, as the upper portion of the uterus be- comes thicker and thicker, it necessarily exerts a diminished effect, so that, in the majority of cases, it becomes essential that the abdominal contractions should participate in the work. 278 THE FORCES CONCERNED IN LABOR Immediately after the birth of the child a marked change occurs in the position and size of the uterus, and on palpation it can be distin- guished as a firm, rounded body which does not reach to the umbilicus. At this time its contracted and retracted body is freely movable above the collapsed lower uterine segment and cervix, and can readily be dis- placed in any desired direction. Changes in the Vagina and Pelvic Floor during Labor.—The outlet of the pelvis is closed by a number of layers of tissue, which together con- stitute what is known as the pelvic floor. Beginning from within out- ward one meets successively with the peritoneum, the subperitoneal con- nective-tissue, the internal pelvic fascia, the levator ani and coccygeus muscles, the external pelvic and perineal fascia, and, included between the latter, the superficial muscles of the perineum, external to which are the subcutaneous tissue and the cutaneous covering of the perineal and vulval regions. Of these structures the most important are the levator ani muscle and the fascia covering its upper and lower surfaces, which for pratical purposes may be considered as constituting the pelvic floor. This muscle closes the lower end of the pelvic cavity as a diaphragm, and presents a concave upper and a convex lower surface. On either side it consists of a pubic and iliac portion; the former is a band 2 to 2.5 centimeters in width, which arises from the horizontal ramus of the pubis 3 to 4 centi- meters below its upper margin, and 1 to 1.5 centimeters from the sym- physis pubis. Its fibers pass backward and encircle the rectum, and possibly give off a few fibers which pass behind the vagina. The greater or iliac portion of the muscle arises on either side from the white line— the tendinous arch of the pelvic fascia—and from the ischial spine, at a distance of about 5 centimeters below the margin of the superior strait. Its fibers do not possess a uniform arrangement, but, according to the researches of Dickinson, the following portions can be distinguished: Passing from before backward, there is a narrow band which crosses the pubic portion and descends to the rectovaginal septum. The greater part of the muscle passes backward and unites with that from the other side of the rectum, while the posterior portions meet together in a tendi- nous rhaphe in front of the coccyx, the most posterior fibers being at- tached to the bone itself. The posterior and lateral portions of the pelvic floor, which are not filled out by the levator ani muscle, are occupied by the pyriformis and coccygeus muscles on either side. The levator ani muscle varies from 3 to 5 millimeters in thickness, though its margins, which encircle the rectum and vagina, are somewhat thicker. It undergoes considerable hypertrophy during pregnancy, and on vaginal examination its internal margin can be felt as a thick band extending backward from the pubis and encircling the vagina, about 2 centimeters above the hymen. On contraction it serves to draw both the rectum and vagina forward and upward in the direction of the symphysis pubis, and is to be regarded as the real closer of the vagina, since the constrictor cunni, one of the superficial muscles of the peritoneum, is too delicate in structure to have more than an accessory function. Although Farabeuf estimated that the levator ani upon contraction Fig. 236.—The Pelvic Floor seen from Above (Kelly). Fig. 237.—The Pelvic Floor seen from Below (Kelly). 280 THE FORCES CONCERNED IN LABOR exerted a force of from 12 to 15 kilograms, it is generally believed that it is not sufficiently strong to afford support to the pelvic contents were it not reinforced by the strong pelvic fascia. Paramore in 1910 expressed a contrary view, but the prevailing opinion was well summarized by Eduard Martin in 1911. The internal pelvic fascia, which forms the upper covering of the levator ani, is attached to the margin of the su- perior strait, where it is joined by the fascia lining the iliac fossae, as well as by the transverse fascia of the abdominal walls. It passes down over the pyriformis and the upper half of the obturator interims muscle, and is firmly attached to the periosteum covering the lateral wall of the pelvis, the white line indicating its point of deflection from the latter, whence it spreads out over the upper surface of the levator ani and coccygeus muscles. The inferior fascial covering of the pelvic diaphragm is divided into two parts at a line drawn between the ischial tuberosities. Its pos- terior portion consists of a single layer which, taking its origin from the sacrosciatic ligament and the ischial tuberosity, passes up over the inner surface of the ischial bones and the obturator internus muscles to the white line, in whose formation it takes part. From this tendinous structure it is reflected at an acute angle over upon the in- ferior surface of the levator ani, the space in- cluded between the latter and the lateral pelvic Avail being designated as the ischiorectal fossa. The structure filling out the triangular space between the pubic arch and a line joining the ischial tuberosities is known as the urogenital diaphragm, which, exclusive of skin and subcutaneous fat, consists principally of three layers of fascia: (1) The deep perineal fascia which covers the an- terior portion of the inferior surface of the levator ani muscle and is continuous with the fascia just described; (2) the middle perineal fascia which is separated from the former by a narrow space in which are situated the pudic vessels and nerves; (3) the superficial perineal fascia which, together with the layer just described, form a compartment in which lie the superficial perineal muscles, with the exception of the sphincter ani, the rami of the clitoris, the vestibular bulbs, and the vulvo- vaginal glands. The superficial perineal muscles consist of the constrictor cunni, the ischiocavernosus, and the transversus perinei muscles. These structures are delicately formed and possess no obstetrical significance, except the last-named muscles, Avhich are always torn through in perineal lacera- tions, when they serve in great part to bring about gaping of the wound. LAYERS OF THE PERINEAL FASCIA Fig. 238.—Diagram showing Arrangement of Pel- vic and Perineal Fascia (Tarnier). CHANGES IN THE VAGINA AND PELVIC FLOOR DURING LABOR 281 Studdiford holds that the perineal body, anterior and interior to the sphincter ani, contains numerous strands of non-striated muscle, which also play an important part in perineal tears. Urethra Clitoris Vagina M. Ischio-cavernosus \ Constrictor cunni Centrum tendineum Levator ani Sphincter ani Fig. 239.—Pelvic Floor distended by Presenting Part, showing Superficial Muscles of Perineum (Bumme). In the first stage of labor the bag of waters takes part in the dilata- tion and distention of the upper portion of the vagina, but after its Fig. 240.—Frozen Section showing Condition of Birth Canal in Last Month of Pregnancy (Braune and Zweifel). X XA.- 282 THE FORCES CONCERNED IN LABOR rupture the changes occurring in the pelvic floor are due entirely to the pressure exerted by the presenting part. As this descends, the anterior portion of the pelvic floor becomes forced against the inferior and pos- terior portions of the symphysis. On the other hand, the posterior portion undergoes marked changes, becoming pushed downward and forward, and subjected to great stretching, eventually being converted into a thin-walled, tubular structure—the perineal gutter. Fig. 239 gives a good idea of the changes occurring in the pelvic floor, and demon- strates the important part played by the levator ani and the altogether Fig. 241.—Fbozen Section, showing Condition of the Birth Canal in First Part of Second Stage of Labor (Braune). X insignificant function of the superficial perineal muscles. When the head distends the vulva, its opening looks upward and forward, and the course of the birth canal along the pelvic floor follows the curve indicated in Figs. 223 and 241. Webster has pointed out that the most marked change consists in the stretching of the fibers of the levator ani muscle and the thinning of the central portion of the perineum, which becomes transformed from a wedge-shaped mass of tissue 5 centimeters in thickness to a thin, almost transparent membranous structure 2 to 4 millimeters thick. At the same time it is pushed down about 2.5 centimeters from its original position. When the perineum is distended to the utmost, the anus becomes markedly dilated, and presents an opening which varies from 2 to 2.5 LITERATURE 283 centimeters in diameter, through which the anterior wall of the rectum is seen to bulge. LITEBATUBE Aschoff. Das untere Uterinsegment. Zeitschr. f. Geb. u. Gyn., 1906, lviii, 328- 332. Ueber die Berechtigung, etc., des Begriffes Isthmus uteri. Verh. d. deutschen path. Gesellsch., 1908, xii, 314-322. Bandl. Ueber Euptur der Gebarmutter. Wien, 1875. Ueber das Yerhalten des Uterus und Cervix, etc. Stuttgart, 1876. Bakbour. Atlas of the Anatomy of Labour Exhibited in Frozen Sections. 3d ed., Edinburgh, 1896. Is There a Lower Uterine Segment! J. Obst. and Gyn. British Empire, 1908, xiii, 237-248 and 315-327. Bayer. Zur physiol, und path. Morphologie der Gebarmutter, in Freund’s Gyn. Klinik. Stuttgart, 1885. Uterus und unteres Uterinsegment. Archiv f. Gyn., 1897, liv, 13-71. Braune. Die Lage des Uterus und Fotus am Ende der Schwangerschaft. Leipzig, 1872. Braune und Zweifel. Gefrierdurchschnitte durch den Korper einer Hoclischwang- eren. Leipzig, 1890. Bumm u. Blumreich. Gefrierdurchschnitt, etc. Wiesbaden, 1907. Chiari. Ueber die topographischen Verhaltnisse des Genitales einer intrapartum verstorbenen Primipara. Wien, 1885. Dickinson. Studies of the Levator Ani Muscle. Amer. Jour. Obst., 1889, xxii, 897-917. Duncan. On the Length of the Cervix Uteri in Advanced Pregnancy. Eesearches in Obstetrics, Edinburgh, 1868, 243-273. Farabeuf. Les vaisseaux sanguins des organes genito-urinaires. Paris, 1905, p. 32. von Cervix und unteres Uterinsegment. Stuttgart, 1897. Untersuchungen und Erorterungen zur Cervixfrage. Wiirzburg, 1899. Grasel. Beitrage zur Frage des sogenannten unteren Uterinsegmentes. Zeitschr. f. Geb. u. Gyn., 1911, lxix, 581-620. Hofmeier. Das untere Uterinsegment in anat. und klin. Beziehung. Schroeder’s Der schwangere und kreissende Uterus. Bonn, 1886, 21-74. Holst. Beitrage zur Geburtshiilfe u. Gynakologie, 1865, Heft I, 130-169. Kustner. Das untere Uterinsegment und die Decidua cervicalis. Jena, 1822. Lahs. Zur Mechanik der Geburt. Marburg, 1869; Berlin, 1872. Die Theorie der Geburt. Bonn, 1877. Langhans und Muller. Weiterer anat. Beitrag zur Frage vom Yerhalten der Cervix wahrend der Schwangerschaft. Archiv f. Gyn., 1879, xiv, 184-189. Leopold. Uterus und Kind. Leipzig, 1897. Lott. Zur Anatomie u. Physiologie der Cervix uteri. Erlangen, 1872. Lusk. The Science and Art of Midwifery, 1895, 82. Martin. Der Haftapparat der weibl. Genitalien. Berlin, 1911. Mauriceau. Traite des maladies des femmes grosses, etc. 6me 5d., 1721, t. i, 97. Muller. Untersuchungen iiber die Verkiirzung der Vaginalportion, etc. Scan- zoni’s Beitrage, 1868, v, 191-346. Olshausen. Beitrag zur Lehre vom Mechanismus der Geburt. Stuttgart, 1901. Paramore. The Pelvic Floor Aperture. Jour. Obst. and Gyn. Brit. Emp., 1910, xviii, 95121, 284 THE FORCES CONCERNED IN LABOR Pinard et Varnier. Etudes d’anatomie obstetricale normale et pathologique. Paris, 1892. Roederer. Elementa artis obstetricise. Gottingae, 1766, 26. Ruge. Unteres Uterinsegment u. cervikale Umanderung. Zeitschr. f. Geb. u. Gyn., 1906, Ivii, 294-313. Saxinger. Gefrierdurehschnitt einer Kreissender. Tubingen, 1888. Schatz. Der Geburtsmechanismus der Kopfendlagen. Leipzig, 1868. Beitrage zur physiologisehen Geburtskunde. 1871. Schmidt. Anat. Untersuchungen zur Frage des unteren Uterinsegmentes. Zeit- sehr. f. Geb. u. Gyn., 1922, lxxxv, 233-291. Schroeder. Der schwangere und kreissende Uterus. Bonn, 1886. Stoltz. Considerations sur quelques points relatif a l’art des aceouehements. These de Strasbourg, 1826. Studdiford. The Involuntary Muscle Fibres of the Pelvic Floor. Am. J. Obst., 1909, lx, 21-31. Taylor. On the Cervix Uteri. Amer. Med. Times, 1862, June 21. Varnier. Le col et le segment inferieur a la fin de la grossesse, etc. Paris, 1888, Veit. Unteres Uterinsegment und Cervixfrage. Verh. der deutschen Gesell. f. Gyn., 1899, viii, 430-449. Das untere Uterinsegment. Zentralbl. f. Gyn., 1914, 1369-1375. Waldeyer. Medianschnitt einer Ilochschwangeren bei Steisslage des Fotus. Bonn, 1886. Warnekros. Schwangerschaft und Geburt im Roentgenbilde, Miinchen, 1921. Webster. The Female Pelvic Floor. Researches in Female Pelvic Anatomy Edinburgh, 1892, 93-112. Winter. Zwei Medianschnitte durch Gebarende. Berlin, 1889. Zweifel. Zwei neue Gefrierschnitte Gebarender. Leipzig, 1893. Ueber das untere Uterinsegment. Zentralbl. f. Gyn., 1914, 1376-1382. CHAPTER XII MECHANISM OF LABOR IN VERTEX PRESENTATIONS Vertex presentations occur in from 95 to 97 per cent, of all cases— 94.6 per cent, in 7,000 consecutive cases in my service^—and in them, as was first pointed out by Naegele, the sagittal suture nearly always en- gages in the right oblique diameter of the pelvis. In other words, one usually has to deal with a left occipito-anterior or a right occipito-pos- terior presentation. That this is so, and that the first-mentioned pres- entation is the one most frequently observed, all the authorities are agreed; but that wide differences of opinion exist as to the relative frequency of the several other varieties is clearly shown by the following table: Dubois in 1,913 cases. Pinard in 500 cases. The author in 6,877 cases.! L. 0. A 71 per cent 52.6 per cent. 54.08 per cent. L. 0. P .63 11 9.14 R. 0. A 2.87 .2 25.09 R. 0. P 25.6 38.8 11.68 E. D. Plass, upon analyzing the incidence of the several varieties in 5,445 vertex presentations in my service, gives the following figures: L. 0. A., 47.8; L. 0. T., 12.9; and L. 0. P., 3.3 per cent. R. 0. A., 19.1; R. Q„ T., 8.9; and R. 0. P., 8.0 per cent. As many of our patients were not examined until late in labor, our figures do not adequately represent the initial incidence, as it is probable that a considerable proportion of the cases which are recorded as L. 0. T. or R. 0. T. originally entered the pelvis with the occiput obliquely pos- terior. That this inference is justified is shown by the fact that in 500 cases from my private practice the L. 0. P. and R. 0. P. varieties were noted more than twice as frequently as in his series. Statistics of German authorities are not available for comparison, as they usually only indicate whether the occiput is directed toward the left or right side of the mother, and do not distinguish between the several varieties. Thus, Zweifel, in 9,351 vertex presentations, found the occiput directed to the left in 71.1 and to the right in 28.9 per cent., as compared with 64 and 36 per cent., respectively, in our series. Mechanism in Left and Right Occipito-anterior Presentations.—We shall consider in the first place the mechanism of labor in the anterior varieties of vertex presentations—namely, the left and right occipito- anterior. 285 286 MECHANISM OF LABOR IN VERTEX PRESENTATION Diagnosis.—The mode of presentation of the foetus is most reliably determined by abdominal palpation, which can be utilized not only during pregnancy but also at the time of labor, provided it be practiced Fig. 242.—Diagram showing Child in L. O. A. Fig. 243.—Diagram showing Child in R. O. A. in the intervals between the pains. Its accuracy, however, is markedly impaired in patients with very fat abdominal walls, or in whom the uterus is unduly distended by an excessive amount of amniotic fluid, or Fig. 244.—Frozen Section through Woman at End of Pregnancy, Child in R. O. T (Zweifel). deformed by subperitoneal or intramural myomata, as the latter may occasionally be mistaken for portions of the child. For purposes of diagnosis we employ the four maneuvers already de- scribed, and with the foetus in the left occipito-anterior position obtain the following data: MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 287 First maneuver: Irregular breech at fundus. Second maneuver: Eesistant plane of back in the left and anterior portion of the abdomen, with the small parts on the right side. Third maneuver: If the head be not engaged, it is felt as a freely movable body over the superior strait; but if it be fixed, the anterior shoulder may be detected. Fourth maneuver: Negative if the head be not engaged; otherwise the cephalic prominence is felt on the right side (Plate XI). For the right occipito-anterior position the findings are as follows: First maneuver: Irregular breech at fundus. Second maneuver: Eesistant plane of back in the right and anterior portion of the abdomen, with the small parts on the left side. Third maneuver: As in L. O. A. Fourth maneuver: Cephalic prominence on the left side. Until the head has become engaged the information obtained by vaginal or rectal examination is relatively meager; and even after engage- ment satisfactory results cannot usually be obtained until the cervix has become sufficiently dilated to permit the differentiation of the various sutures and fontanelles. When this is possible and the child lies in the left anterior variety the sagittal suture will be found to occupy the right oblique diameter of the pelvis, with the small fontanelle in the neighbor- hood of the left iliopectineal eminence and the large fontanelle directed toward the right sacro-iliac synchondrosis. In the right anterior variety the sagittal suture occupies the left oblique diameter, the small fontanelle lying in the neighborhood of the right iliopectineal eminence, while the large fontanelle looks toward the left sacro-iliac synchondrosis. The diagnostic value of vaginal examination may be still further impaired when the presence of a marked caput succedaneum makes it impossible to feel the sutures and fontanelles. In the left anterior positions the foetal heart sounds are usually heard on the left side of the abdomen along a line joining the umbilicus and the left anterior-superior spine of the ilium; and in right positions at a corre- sponding point on the right side. Mechanism.—Owing to the irregular shape of the pelvic canal and the relatively large dimensions of the mature foetal head, it is apparent that any portion of the latter, chosen at random,, cannot necessarily pass through every plane of the former; hence, it follows that some process of adaptation or accommodation of suitable portions of the head to the various pelvic planes is necessary to insure the completion of childbirth. This is brought about by certain movements of the presenting part, which belong to what is termed the mechanism of labor. For purposes of instruction, one is obliged to describe the various movements as if they occurred separately and independently of one an- other ; whereas, in reality, the mechanism of labor consists of a combina- tion of movements, several of which are going on at the same time, as it is manifestly impossible for any one of them to occur unless the presenting part descends simultaneously. These movements are divided into two classes, according as they are essential to the completion of 288 MECHANISM OF LABOR IN VERTEX PRESENTATION labor, or as they merely facilitate its progress. To the first group belong the so-called cardinal movements—descent, internal rotation, and ex- tension; to the second the accessory movements—flexion and external rotation. As a preliminary to these movements, the uterine contractions bring about important modifications in the attitude or habitus of the foetus, which according to Sellheim, greatly facilitate the act of labor. These consist principally in a straightening out of the fcetus, so that its back loses its convexity, while the extremities and small parts are more closely applied against the body, with the result that the foetal avoid becomes transformed into a cylindrical body with the smallest pos- sible cross-section. Engagement.—The mechanism by which the presenting part enters Fig. 246.—Position of Fcetus after Engagement. Fig. 245.—Position of Fcetus befohe Engagement. the superior strait is designated as engagement. This is best studied in women Avho have borne one or more children, for the reason that some weeks before the onset of labor in primiparae the head normally descends so deeply into the pelvic canal that its most dependent portion lies just above a line joining the ischial spines; whereas in multiparous women this frequently does not occur until after the commencement of labor. In most multiparae at the end of pregnancy the head, which occupies a position midway between flexion and extension, is freely movable above the superior strait, or rests upon one or other iliac fossa. Accordingly, when the uterine contractions set in and force it toward the pelvic open- ing, the cephalic circumference which first engages is the one that passes PLATE X. First Maneuver. Second Maneuver. Third Maneuver. Fourth Maneuver. PALPATION IN LEFT OCCIPITO-ANTERIOR PRESENTATION. MECHANISM IN OCCIPITOANTERIOR PRESENTATIONS 289 through the extremities of the fronto-occipital diameter. This normally measures 11.5 centimeters; and, as the conjugata vera is only 11 centi- meters in length in the bony pelvis, and is encroached upon by various tissues in the living woman, it is apparent that a normal-sized head can- not engage with its sagittal suture directed anteroposteriorly. Accord- ingly, it must enter the superior strait either in the transverse or in one of its oblique diameters (12.75 centimeters). As has already been said, this usually occurs in the right oblique diameter, so that one end of the sagittal suture is directed toward the left iliopectineal eminence, and the other toward the right sacro-iliac synchondrosis. This is at- tributed to two factors. In the first place, the foetus, in the later months of pregnancy, tends to assume this position spontaneously; and secondly, the posterior end of the left oblique diameter is encroached upon by the rectum; so that, for practical purposes, it is shorter than the right. At first glance it may appear strange that the head does not engage in the transverse diameter of the pelvis, which measures 13.5 centimeters; but when one recalls the normal outlines of the superior strait (Figs. 247 Fig. 247. Fig. 248. Figs. 247, 248.—Diagrams showing why the Head does not Engage in the Trans- verse Diameter of the Superior Strait. and 248), it is seeti that this diameter extends only a few centimeters in front of the promontory of the sacrum, so that for practical purposes the available transverse diameter is one which bisects the conjugata vera, and is more than a centimeter shorter than the oblique diameter.. Prior to the middle of the eighteenth century little was known concerning the mechanism of labor, and it was generally thought that the head entered the pelvis with the sagittal suture directed antero- posteriorly. Fielding Ould in 1742 was the first to protest against such a view, and within the following thirty years the observations of Smellie, Saxtorph, and Solayres de Eenhac demonstrated that enlargement oc- curred in the manner just described. It is true that Sentex, McKerron, Muller, and Martins have revived the older teachings, and have reported cases in which the head engages with the small fontanelle either just behind the symphysis pubis or just in front of the promontory of the sacrum—occipitopubic or occipitosacral presentation; but, inasmuch as in these circumstances labor is extremely difficult, it is evident that such an occurrence must be considered as distinctly pathological. Naegele in 1838 held that engagement took place in such a way that the sagittal suture assumed an eccentric position, being nearer the 290 MECHANISM OF LABOR IN VERTEX PRESENTATION promontory of the sacrum than the symphysis, and that therefore the anterior parietal bone of the foetus was first felt on vaginal examination— Naegele’s obliquity. Varnier, on the other hand, from the study of the various frozen sections at his disposal, concluded that the reverse was the case, and that the head entered the pelvis with its sagittal suture nearer the symphysis pubis, so that the posterior parietal bone was first felt on examination. Neither of these views is quite correct when the pelvis is normal and the uterus not pendulous. The first presupposes that the axis of the uterus is to be found somewhat in front of that of the superior strait, and the second that it lies posterior to it. It would seem that Varnier overlooked the fact that the cadavers upon which his conclusions were based were frozen in the horizontal posi- tion, when the flaccid uterus would rest upon the vertebral column. In the living woman, however, such condi- tions do not obtain, as the uterus rises with each contraction, when its long axis cor- responds more or less closely with that of the superior strait. More- over, careful vaginal examination reveals the fact that the head usually engages in such a manner that its sagittal suture lies either in the middle of the pelvis or approaches the promontory of the sacrum but slightly, but not by any means to the extent that Naegele had supposed. On the other hand, the condition of affairs noted by Varnier obtains only when con- siderable disproportion exists between the size of the head and the pelvis. Descent.—The first requisite for the birth of the child is descent, whose extent varies materially according as the patient is a primipara or a multipara. In the former, when there is no disproportion between the size of the head and the pelvis, engagement is already so deep at the onset of labor that the most dependent part of the head is at, or only slightly above, the level of the ischial spines, so that descent does not begin until the second stage of labor sets in. In multiparae, on the other hand, descent begins with engagement, but is most pronounced during the second stage. It should, however, be remembered that in either event once having been inaugurated descent is inevitably associated with the various movements to which reference will be made. Descent is brought about by one or more of four forces: (1) Intra-uterine fluid Fig. 249.—Diagram illustrating Stnclitism (Ahlfeld). MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 291 pressure; (2) direct pressure of the fundus upon the breech; (3) con- traction of the abdominal muscles, and (4) extension and straightening of the child's body. The X-ray studies of Warnekros show that during the first stage of labor the back of the child is markedly convex, but becomes straightened out during the second stage. This he considers affords conclusive evi- dence that the expulsive force exerted by the uterus is transmitted through the vertebral column of the child; while Sellheim contends that this is not the case, and that only fluid pressure is involved, as he holds that even after rupture of the membranes sufficient fluid is retained within the uterus to make it possible. As the anterior surface of the sacrum and the posterior surface of Fig. 250.—Frozen Section, Second Stage of Labor, Child in R. O. A., Membranes Unruptured (Braune). Compare with Fig. 244. the symphysis measure 12 and 5 centimeters, respectively, it is apparent that, if all parts of a body passing through the pelvic cavity are to reach the inferior strait at the same time, the one lying posteriorly must de- scend much more rapidly than the anterior portion. This compensatory difference in the rate of descent of the portions of the presenting part occupying the anterior and posterior segments of the pelvis is known as synclitism, and is clearly illustrated in Fig. 249. Flexion.—As soon as the descending head meets with resistance, whether it be from the margins of the superior strait or the cervix, the walls of the pelvis or the pelvic floor, flexion results. In this movement the head rotates about its transverse axis in such a manner as to bring the chin into more intimate contact with the thorax, thereby substituting the suboccipitobregmatic for the fronto-occipital diameter. 292 MECHANISM OF LABOR IN VERTEX PRESENTATION This purely mechanical phenomenon, by which a diameter of 9.5 replaces one of 11.75 centimeters, is due to the manner in which the head is articulated with the vertebral column, whereby the former represents a two-armed lever, the short arm extending from the occipital condyles Fig. 251. Fig. 252. Figs. 251, 252.—Diagrams showing Effect of Flex- ion, Conversion of Occipitofrontal into Sub- OCCIPITOBREGMATIC DIAMETER. Fig. 253.—Diagram showing Head Lever (American Text-Book). to the occipital protuberance, and the long arm from the same point to the chin (Fig. 253). It is therefore apparent that when resistance is encountered the long arm of the lever, following the ordinary laws of mechanics, must ascend, while the short arm descends, and thus flexion is brought about. The point of the birth canal at which this movement occurs varies Fig. 254.—Diagram showing Anterior Rotation from L. O. A. Fig. 255.—Diagram showing Anterior Rotation from R. O. A. greatly. When there is no disproportion between the presenting part and the pelvic canal pronounced flexion does not occur until the resist- ance of the pelvic floor is encountered, but if descent begins before the external os is fully dilated, especially if its margins are resistant, flexion MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 293 may be completed before the head has left the uterus; while in generally contracted pelves the movement occurs in an exaggerated manner while engagement is being effected. Internal Rotation.-—By this is understood a turning of the head about its vertical axis in such a manner that the occiput gradually moves from the position which it originally occupied toward the symphysis pubis or the hollow of the sacrum;, as the case may be. Internal rotation is absolutely essential for the completion of labor, except when the child is abnormally small, and in the anterior varieties always occurs from left to right in left positions, and in the reverse direction in right position (Figs. 254 and 255). Indeed, no matter what the original position of the head may be, the occiput usually rotates to the front, although exceptionally, in occipitoposterior presentations, it may turn toward the hollow of the sacrum. It should be remembered that internal relation does not occur by itself, but is always associated with the descent of the presenting part. Various theories have been advanced in the attempt to explain the manner in which internal rotation is brought about, and a vast litera- ture has accumulated upon the subject, which was well reviewed by Paramore in 1909. Prior to the time of Ould and Smellie nothing was known concerning this movement, but afterwards it was believed that it was rendered necessary by the shape of the pelvic canal, it having been taught that the superior strait represented an ellipse whose long axis lay transversely, and the inferior strait one whose long axis was anteropos- terior ; so that for the head to descend it was necessary that its sagittal suture be directed transversely or obliquely to pass through the former, and anteroposteriorly to pass through the latter. A little consideration, however, will show that this is not the case, for, when the coccyx is displaced backward during labor, the in- ferior strait presents an almost circular opening, its transverse diameter being 11 and its an- teroposterior 11.5 centimeters. Yarnier was therefore justified in concluding that the shape of the pelvis alone does not explain the production of this move- ment. Moreover, when we recall the fact that it is the suboccipito-frontal circumference of the head which passes through the pelvic outlet, and that its greatest diameter measures only 10.5 centimeters (Fig. 256), it is evident that unless some other factor were concerned internal rotation would not be necessary. This factor is to be found in the structures of the pelvic floor, and particularly in the levator ani muscle, which, yielding before the impact of the head, nevertheless exerts sufficient force upon it to compel it to Fig. 256.—Diagram showing Suboccipito- BREGMATIC, SlTBOCCIPITOFRONTAL, AND OC- CIPITOFRONTAL Diameters. 294 MECHANISM OF LABOR IN VERTEX PRESENTATION adjust itself to its curvatures. Furthermore, the walls of the perineal gutter offer a concave inclined plane over which the rounded head readily glides in its downward course. This explanation, although fairly satisfactory when the occiput is originally directed obliquely anteriorly in the pelvis, would not neces-' sarily seem to apply with equal force to those cases in which it occupies an obliquely posterior position. But the following account of Dubois’s experiment clearly demonstrates that even in such circumstances the pelvic floor exerts a predominating influence in the production of this movement: “In a woman who had died a short time previously in child- bed the uterus, which had remained flaccid and of large size, was opened up as far as the cervical orifice and held by assistants in a suitable posi- tion above the superior strait. The foetus of the woman was then placed in the soft and dilated uterus in the right occipitoposterior posi- Fig. 257.—Frozen Section through Woman in Labor with Child Partly delivered showing Complete External Rotation of the Head and Imperfect Rotation of the Shoulders (Zweifel). tion. Several pupil-midwives, pushing the foetus from above, readily- caused it to enter the cavity of the pelvis. Much greater force was needed to make the head travel over the perineum and clear the vulva, and it was not without astonishment that we saw, in three successive attempts, that, when the head had traversed the external genital organs, the occiput had turned to the right anterior position, while the face was turned to the left and to the rear. In a wTord, rotation had taken place as in natural labor. We repeated the experiment a fourth time, but as the head cleared the vulva the occiput remained posterior. We then took a dead-born foetus of the previous night, but of much larger size than the preceding, and placed it in the same position as the first, and twice in succession witnessed the head clear the vulva after having executed the movement of rotation. Upon the third and following essays delivery was accomplished without the occurrence of rotation. Thus the movement only ceased after the perineum and vulva had lost the MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 295 resistance which had made it necessary, or at least had been the inciting cause of its accomplishment/’ From Solayres de Renhac (1771) to the present time, many authors, among whom may be mentioned Scanzoni, Hodge, and Reynolds, have sought to explain the production of rotation by calling attention to the shape of the pelvic canal, and pointing out that the inclination of its walls—the inclined planes of the pelvis—serves to direct the occiput anteriorly. By others it was thought that the projecting ischial spines also played a similar part by interposing an obstacle to posterior rotation. Schroeder believed that the movement was inaugurated by the body of the child rotating in such a way as to bring its back more to the front, and that the head followed it. He considered that this was brought about by an attempt on the part of the uterus to assume its normal flattened shape, as its contents were expelled. He did not believe that the shoul- ders were rotated into a directly transverse position, but considered that they remained somewhat behind the occiput—30 degrees, according to Schatz—and that the partial rotation of the body merely inaugurated that of the head, which was completed by the action of other accessory factors. Olshausen and Bumm argued in favor of this theory, but do not seem to have adduced ar.v. additional evidence in its support. Warnekros, on the contrary, states that his X-ray plates show that rotation of the body frequently precedes that of the head, but he is, nevertheless, inclined to believe that the pelvic floor plays the predominant part in bringing it about. Even if such views are accepted as partially correct, it must be admitted that they fail to solve the entire problem; as a flattening of the uterine cavity cannot be invoked in explanation of the rotation of the shoulders into the anteroposterior diameter following the expul- sion of the head. This must be regarded as a movement of internal rotation, just as well as that which the head had previously undergone, and must be brought about by identical causes; as it would seem im- probable that one factor would be concerned in the causation of one rotation, and a few minutes another factor would bring about the other. Furthermore, the frozen section of Zweifel through a woman, who had died just after the birth of the child’s head, shows that the shoulders had not yet rotated antero-posteriorly, and indicates that such a movement would be hampered, rather than facilitated, by a flattening of the uterus. In 1906 Sellheim made an important contribution to the subject, which was still further elaborated in 1913. He held that internal rota- tion, and indeed the entire mechanism of labor, is the inevitable conse- quence of definite physical laws, one of the most important of which is that whenever a cylindrical body of suitable size, which can be bent to a different extent in several locations, is forced through a curved cylindrical canal, it must necessarily rqtate until the portion which is most readily bent adapts itself to the curvature of the canal. By studying newly born children, he demonstrated that in vertex presentations such bending occurs most readily in the cervical region, and thus tends to bring about extension; while in face presentations it occurs in the opposite direction and brings about flexion. Accordingly, in the former rotation must take 296 MECHANISM OF LABOR IN VERTEX PRESENTATION place until the posterior portion of the neck adapts itself to the “knee” of the birth canal, while in the latter the anterior portion of the neck must become so adapted, thus causing the occiput or chin to rotate anteriorly, as the case may be. Fig. 258.—Diagram showing Delivery of Head in Vertex Presentation. By a series of ingenious experiments he has shown that rotation always occurs in accordance with this law, and that it makes no differ- ence whether the presenting part enters the pelvic canal in an obliquely Fig. 259.—Diagram showing Delivery of Head in Vertex Presentation. anterior or posterior position. Unfortunately, Sellheim’s explanation has only carried us one step further forward, and still leaves us in ignorance of the ultimate cause of the movement. Extension.—When, after internal rotation, the sharply flexed head MECHANISM IN OCCIPITOANTERIOR PRESENTATIONS 297 reaches the vulva, it undergoes another movement which is absolutely essential to its birth—namely, it becomes so extended that the base of the occiput comes in direct contact with the interior margin of the symphysis pubis. This movement is brought about by two factors. In the first place, as the vulval outlet looks upward and forward, extension must occur before the head can pass through it. For if the sharply flexed head, on reaching the pelvic floor, continued to be driven down- ward in the same direction as heretofore—-in the axis of the superior strait—it would impinge upon the end of the sacrum and the posterior portion of the perineum, and, if the vis a tergo were sufficiently strong, would eventually be forced through the perineal tissues. But when the head presses upon this structure, two forces come into play, the first acting downward, exerted by the uterus, and the second upward, supplied Fig. 260.—Diagram showing Delivery of Head in Vertex Presentation. by the resistant pelvic floor, the resultant force being one directed forward and somewhat upward in the direction of the vulval opening, thereby giving rise to extension. Joseph Jones in 1906 directed atten- tion to the fact that the movement of extension does not occur merely at the articulation between the occiput and atlas, but is preceded and inaugurated by an extension of the entire cervical region. He holds that such a movement brings about a marked change in the manner in which the force exerted by the uterus is transmitted to the occiput, and likens it to the interposition of the crank shaft between the end of the piston and the wheel of an engine. After the suboccipital region has come in contact with the inferior margin of the symphysis pubis, the head is no longer to be regarded as a two-armed, but simply as a one-armed lever, the occiput being the ful- crum with the arm extending from it to the chin, so that any force exerted upon the head must necessarily lead to farther extension. As this becomes marked, the vulval opening gradually dilates and the scalp 298 MECHANISM OF LABOR IN VERTEX PRESENTATION of the child becomes apparent through it. Now, if we mark the point which first appears, and carefully examine the child after its birth, we find in left occipito-anterior presentations that it was the upper and posterior margin of the right parietal bone that first came into view, while the reverse holds good in right occipito-anterior positions. With increasing distention of the perineum and vaginal opening, a larger and larger portion of the occiput gradually appears, and the head is born by further extension, the occiput, bregma, forehead, nose, mouth, and finally the chin successively passing over the anterior margin of the perineum. Immediately after its birth the head falls downward and the chin comes in contact with the region of the anus. External Rotation.—A few moments after its birth the head under- goes another movement, and, when the occiput has been originally directed toward the left, it rotates toward the left tuber ischii, and in the opposite direction when it has been originally toward the right. This Fig. 261.—Diagram showing child in L. O. P. Fig. 262.—Diagram showing Child in R. O. P. is known as external rotation or restitution, and is simply the index of a corresponding rotation of the body of the child, which serves to bring its bisacromial diameter into relation with the anteroposterior diameter of the pelvic outlet. This movement is brought about by essentially the same factors which produce the internal rotation of the head. Expulsion.—Almost immediately after the occurrence of external rotation, the anterior shoulder appears under the symphysis pubis, and in a short time the anterior portion of the perineum becomes distended by the posterior shoulder, which is first born, being rapidly followed by the other. Finally, the body of the child is quickly extruded along a curved line corresponding to the axis of the lower part of the birth canal—that is, with its upper side markedly concave and its lower convex. Mechanism in Right and Left Occipitoposterior Presentations.—In 5,488 cases of labor at the Johns Hopkins Hospital, in which the vertex presented, we observed 635 occipitoposterior presentations (11.3 per cent.), the proportion in which the occiput was directed to the right or left being about 5 to 2. The number of primary occipitoposterior posi- MECHANISM IN OCCIPITOPOSTERIOR PRESENTATIONS 299 tions was probably twice as great as is here indicated, but, owing to the fact that many of our patients were not examined until well advanced in the second stage of labor, it happened in many cases that anterior rotation had already occurred. Diagnosis.—Palpation in a right occipitoposterior presentation gives the following data: First maneuver: The fundus is occupied by the breech. Second maneuver: The resistant plane of the back is felt well back in the right flank, the small parts being on the left side and in front and much more readily palpable than in anterior presen- tations. Third maneuver: Negative if the head is engaged ; otherwise the movable head is detected above the superior strait. Fourth maneuver: Cephalic prominence on the left side (Plate XII). Whenever the back of the child is felt on the right side of the mother, the possibility of a right posterior position should always be borne in mind, as it occurs much more frequently than the right Fig. 263.—Diagram showing Anterior Rotation from L. O. P. Fig. 264.—Diagram showing Anterior Rotation from R. O. P. anterior variety. It should also be remembered, whenever the small parts are distinctly felt in the anterior portion of the abdomen, that one has in all probability to deal with a posterior position, more especially in the rare instances in which the occiput has rotated into the hollow of the sacrum. In the less frequent left posterior positions palpation gives similar results, except that the back is felt in the left flank, and the small parts and cephalic prominence are found on the right side of the abdomen. On vaginal or rectal touch in the right posterior position, the sagittal suture occupies the right oblique diameter, the small fontanelle is felt opposite the right sacro-iliac synchondrosis, the large fontanelle being directed toward the left iliopectineal eminence; while in the left position the reverse obtains. In many cases, particularly in the early part of labor, owing to imperfect flexion of the head, the large fontanelle lies at a lower level than in anterior positions, and is more readily felt 300 MECHANISM OF LABOR IN VERTEX PRESENTATION On auscultation the heart is heard in the right or left flank of the mother, according as one has to deal with a right or left position. But it should be remembered that in the right posterior position the heart sounds are sometimes transmitted through the thorax of the child, and are best heard either in the middle line or slightly to the left of it. This is due to a partial extension of the head and the altered relation of the body of the child, whereby the thorax comes in contact with the anterior uterine wall. Failure to realize this possibility sometimes results in serious diagnostic error. Mechanism.—In the great majority of occipitoposterior presentations the mechanism of labor is identical with that observed in the anterior varieties, except that the occiput has to rotate from the region of the sacro-iliac synchondrosis to the symphysis pubis, instead of from the ilio- Fig. 265.—Diagram showing Posterior Rotation from L. O. P. Fig. 266.—Diagram showing Posterior Rotation from R. O. P. pectineal eminence—through 135 degrees instead of 45 degrees (Figs. 263 and 264). In many instances internal rotation does not take place until the perineum begins to bulge, but occasionally it only occurs partially, or sometimes not at all, so that the occiput rotates only to a transverse or an obliquely anterior position, or remains obliquely posterior. In either event spontaneous labor is out of the question unless the child is very small. Even in favorable cases considerable time is usually re- quired for the completion of anterior rotation, so that there results a definite prolongation of labor. Varnier, upon comparing the histories in 400 cases of occiput posterior and in 660 cases of occiput anterior presentation, found that, in the former, labor averaged three hours and sixteen minutes to one hour and fifty minutes longer, according as the patient was a primiparous or multiparous woman; although in my ex- perience the prolongation is not so great. In a small percentage of cases, particularly in women with funnel pelves, the occiput, instead of rotating anteriorly, or retaining its original position, turns spontaneously toward the sacrum, so that it eventually occupies its concavity. According to West and Varnier this occurs PLATE XT. First Maneuver. Second Maneuver. PALPATION IN RIGHT OCCIPITO-POSTERIOR PRESENTATION. Third Maneuver. Fourth Maneuver. MECHANISM IN OCCIPITOPOSTERIOR PRESENTATIONS 301 in 2 or 3 per cent, of the cases, while we have noted it in a somewhat higher percentage of our obliquely posterior cases. In many instances it is difficult to explain why anterior rotation Fig. 267.—Usual Mechanism of Delivery of Head with Occiput in Hollow of Sacrum. fails to occur, but it may be stated as a general rule that it is much more likely to take place when the head is well flexed than when it is imperfectly flexed or partially extended. In the latter event the large Fia. 268.—Usual Mechanism of Delivery of Head with Occiput in Hollow of Sacrum. fontanelle occupies a lower level than the small, whence it would appear that it is usually the most dependent part of the head which rotates anteriorly. After the occiput has rotated into the hollow of the sacrum, the child 302 MECHANISM OF LABOR IN VERTEX PRESENTATION may be born in one of two ways. Ordinarily the head becomes markedly Hexed and lengthened in its mento-occipital diameter so that eventually the region just anterior to the large fontanelle impinges upon the lower margin of the symphysis pubis, after which the occiput is slowly pushed over the anterior margin of the perineum by a movement of flexion. Then by a movement of extension the occiput falls backward, and the brow, nose, mouth, and chin appear , successively under the symphysis. After the birth of the head, external rotation and expulsion of the body occur in the usual manner. According to Sentex, Winckel, Weiss, and Muller, the head is occa- sionally born by another mechanism, which comes into play in those cases in which partial extension persists. In such circumstances the brow appears at the vulva, and, while the root of the nose impinges upon the symphysis, by a movement of flexion the brow, bregma, and occiput successively pass over the perineum, until finally the face slips out from under the symphysis pubis. This mechanism approaches closely to that observed in brow presentations, and is much more difficult than the one just considered, and is more liable to lead to tears of the maternal soft parts, since it is evident that in the first instance the vulva is distended by the suboccipitofrontal circumference of the head, and in the second by the occipitofrontal, which measure 34 and 37 centimeters, respectively. It is generally believed that occipitoposterior offer a much more gloomy prognosis than occipito-anterior presentations. This is probably due to the fact that Mauriceau, Smellie, and all the early authorities taught that in such cases the occiput always rotated into the hollow of the sacrum, and that many later American writers, being led astray by their fears, have failed to realize what Nature can accomplish. It is true that Naegele showed that in the vast majority of cases the occiput rotated anteriorly, but in spite of his teachings, the older views still prevailed. Thus Capuron, in 1833, taught that spontaneous delivery could not take place; and Tarnier, while admitting the correctness of Naegele’s conclusions, nevertheless held that the prognosis was always serious, for, even when anterior rotation occurred, the duration of labor was markedly increased and the maternal and foetal mortality augmented. A comparatively large experience has led me to discount these gloomy views, and to regard the ■ occurrence of posterior presentations with equanimity, provided the pelvis and child are normal in size. Moreover, in view of our uniformly good results, I do not consider it advisable to attempt to convert them into other positions during the course of labor, except when the forceps is to be applied. It is true that labor is somewhat prolonged, and instrumental interference is required more frequently—in* 10 per cent, of the cases, according to Varnier, as compared with 3.6 per cent, in anterior presentations. In 635 of our cases, reported by Plass in 1916, in which delivery occurred spontane- ously or was aided by forceps, we had no maternal mortality attributable to the posterior position, and the foetal mortality was not appreciably increased over that occurring in obliquely anterior presentations. Even when the occiput rotates into the hollow of the sacrum, the prognosis is not bad, as in the majority of cases spontaneous delivery MECHANISM IN OCCIPITOPOSTERIOR PRESENTATIONS 303 occurs, being noted by Yamier in 30 out of 35 cases. No doubt in such cases there is an increased tendency toward perineal tears, which is particularly marked when the head is born by the less frequent mechan- ism. But to my mind the main cause of the dread in which posterior presentations are held is the fact that they frequently escape recognition, with the re- sult that the large number which rotate anteriorly and end spontaneously are over- looked, and only those cases are recognized in which the occiput remains obliquely pos- terior or rotates into the hollow of the sacrum. Furthermore, the latter are usually not diagnosticated until operative interference becomes necessary, and even then not until re- peated failure at forceps ex- traction leads to careful exami- nation and, the recognition that the instrument had been applied improperly—that is, as in occipito-anterior presenta- tions. When in occipitoposterior presentations the head has de- scended into the pelvis, it is my practice to leave the case to Nature as long as possible, and to interfere only when ab- solutely necessary. But when convinced that the best inter- ests of the mother and child will be subserved by prompt delivery, forceps should be ap- plied according to the direc- tions which will be given in the appropriate chapter. On the other hand, when the head is arrested at the superior strait in a posterior position, version should be resorted to as soon as one is convinced that spon- taneous advance will not occur, provided, of course, that the operation is feasible and is not contra-indicated by disproportion between the size of the head and the pelvis. Fig. 269. Fig. 270. Fig. 269-271.—Caput Succedaneum at Birth; its Disappearance Three and Ten Days Later. Fig. 271. 304 MECHANISM OF LABOR IN VERTEX PRESENTATION Changes in the Shape of the Head.—In vertex presentations the child’s head undergoes important and characteristic changes in shape, as the result of the pressure to which it is subjected during labor. In prolonged labors in which the membranes have ruptured before complete dilatation of the cervix, the portion of the head immediately over the os is relieved from the general pressure existing in the uterus, and, as a consequence, a serous exudate occurs under the scalp at this point, caus- ing a soft swelling, known as the caput succedaneum. Usually this attains a thickness of only a few millimeters, but in prolonged labors it may become very considerable and prevent the examining finger from distinguishing the various sutures and fontanelles. More usually the caput is formed when the head is in the lower portion of the birth canal, and frequently only after the resistance of a rigid vaginal outlet is encountered. It occurs upon the most dependent portion of the head, and therefore in left occipito-iliac positions is found over the upper and posterior extremity of the right parietal bone, and in right posi- tions over the corresponding area of the left parietal bone. Hence it follows that in many instances after labor we are enabled to diagnose the original presentation by the situation of the caput succedaneum. More important, however, are the plastic changes which the head undergoes. Owing to the fact that the various bones of the skull are not firmly united, movement may occur at the various sutures. Ordi- narily the margins of the occipital bone, and more rarely those of the frontal bone, are pushed under those of the parietal bones; and in many cases one parietal bone may overlap the other, the rule being that the one occupying the posterior position is overlapped by the anterior. These changes are of marked significance, especially in contrasted pelves, when the ability of the child’s head to be- come molded may make the difference between a spontaneous labor and a major obstetrical operation. As a result of pressure the head also undergoes a marked change in shape, which consists in a diminution of its suboccipitofrontal and occipitofrontal diameters. In other words, it becomes lengthened from chin to occiput and compressed in other directions. This is clearly shown in Fig. 272. In occipitoposterior presentations, when the occiput has rotated into the hollow of the sacrum, the frontal bone is markedly overlapped by the anterior margins of the parietal bones, which leads to a distinct depression of that part of the head, and gives some idea of the force with which the region of the large fontanelle has been pressed against the lower margin of the symphysis. Such pressure changes are of much more serious import than was formerly believed, and it is now known that they may play an important Fig. 272.—Diagram showing Config- uration of Head in Vertex Pres- entation (American Text-Book). LITERATURE 305 part in the production of fatal subdural hemorrhage. Holland, in his important work upon cranial stress during labor, has shown that they subject the tentorium cerebelli or the falx to excessive tension, which may result in actual lesions associated with hemorrhage, and which readily account for many foetal deaths which were formerly considered inexplicable. LITERATURE Bumm. Grundriss zum Studium der Geburtshiilfe. 1905, 206. Capuron. Memoire sur 1’impossibility de 1’accouchement naturel et la necessity du forceps dans les positions oecipito-posterieures. Bulletin de LAcad. de med., 1833, Nov. 2. Dubois. Quoted by Lusk. The Science and Art of Midwifery. New edition, 1895, 175. Hodge. The Principles and Practice of Obstetrics. Philadelphia, 1866, 159-160. Holland. Cranial Stress in the Foetus during Labor. Jour. Obst. and Gyn. Brit. Emp., 1922, xxix, 549-571. Jones. Some Causes of Delay in Labor, with Special Deference to the Function of the Cervical Spine of the Foetus. Jour. Obst. and Gyn. Brit. Emp., 1906, x, 407-435. Martin. Die Aetiologie des hohen Geradstandes. Zeitschr. f. Geb. u. Gyn., 1915, lxxvi, 763-787. Mauriceau. Traite des maladies des femmes grosses, etc. 6me ed., Paris, 1721. McKerron. Antero-posterior Position of the Head as a Cause of Difficult Labor. Trans. London Obst. Soc., 1900, xli, 142-150. MPller, A. Ueber Hinterhauptslagen und Scheitellagen. Monatsschr. f. Geb. u. Gyn., 1898, vii, 382-399, u. 534-550. Naegele. Die Lehre vom Mechanismus der Geburt. Mainz, 1838. Olshausen. Beitrag zur Lehre vom Mechanismus der Geburt. Stuttgart, 1901. Zur Lehre vom Geburtsmechanismus. Zentralbl. f. Gyn., 1906, 1113-1119. Ould. A Treatise of Midwifery. Dublin, 1742. Paramore. A Critical Inquiry into the Causes of Internal Rotation of the Foetal Head. Jour. Obst. and Gyn. Brit. Emp., Oct., 1909. Pinard. Traite du palper abdominal. 2me ed., Paris, 1889, 27 and 37-44. Plass. A Statistical Study of 635 Labors with the Occiput Posterior. Bull. Johns Hopkins Hospital, 1916, xxvii, 164-177. Reynolds'. Mechanism of Labor. Amer. Text-Book of Obstetrics, 1897, 384-492. Saxtorph. Theoria de diverso partu ob diversam capitis ad pelvim relationem mutuam. Havniae et Lipsiae, 1772. Gesammelte Schriften. Kopenhagen, 1803. Scanzoni. Lehrbuch der Geburtshiilfe, II. Aufl., Wien, 1853, 219. Schroeder. Lehrbuch der Geburtshiilfe, XIII. Aufl., 1899, 187-188. Sellheim. Die Beziehungen des Geburtskanales u. des Geburtsobjektes zur Geburtsmechanik. Leipzig, 1906. Die Geburt des Menschen. Deutsche Frauenheilkunde, 1913, Bd. I. Zur Auffassung von Warnekros iiber Geburtsmechanik. Monatsschr. f. Geb. u. Gyn., 1922, lviii, 237-249. Sentex. Etude statistique et clinique sur les positions oecipito-posterieures. Paris, 1872. Smellie. A Treatise on the Theory and Practice of Midwifery. Eighth edition, London, 1774. de Renhac. Dissertatio de partu viribus maternis absoluto. Paris, 1771. MECHANISM OF LABOR IN VERTEX PRESENTATION 306 Tarnier. De 1’accouchement dans les occipito-posterieures. Semaine med., Paris, 1889, ix, 1. Yarnier. De 1’attitude de la tete au detroit superieur et du mechanisme de son engagement. Annales d’obst. et de gyn., 1897, xlviii, 442-444. Accomodation de la tete fcetale au bassin maternal. Obstetrique journaliere, Paris, 1900, 131-149. Les occipito-posterieures. Obstetrique journaliere, 1900, 181-184. Warnekros. Schwangerschaft und Geburt im Eoentgenbilde. Miinchen, 1921. Weiss. Zur Behandlung der Vorderscheitellagen. Yolkmann’s Sammlung klin. Vortrage, N. F., 1892, Nr. 60. West. Cranial Presentations, etc. Glasgow, 1857. Winckel. Lehrbuch der Geburtshiilfe, II. Aufl., 1893, 147-150. Zweifel. Zwei neue Gefrierschnitte Gebarender. Leipzig, 1893. Erfahrungen an den letzten 10000 Geburten, etc. Archiv f. Gyn., 1914, ci, 643-699. CHAPTER XIII MECHANISM OF LABOR IN FACE, BROW, AND BREECH PRESENTATIONS Face Presentations.—In face presentations the head is sharply ex- tended, so that the occiput is in contact with the back, while the face looks downward. Markoe, and Pinard, upon analyzing 51,635 and 92,026 cases of labor, found that the incidence of such presentations was 0.48 and. 0.4 per cent., respectively—that is, 1 to every 207 or 250 labors. The face most frequently occupies the right oblique diameter of the pelvis, so that the chin is directed either toward the left iliopectineal Fig. 273.—Diagram showing Position of Child in L. M. A. Fig. 274.—Diagram showing Position of Child in R. M. A. eminence or the right sacro-iliac synchondrosis. Accordingly, the left mento-anterior and right mentoposterior are the varieties usually ob- served, and together they constituted 62.4 per cent, of Markoe’s 250 cases. It is generally stated that face presentations do not exist during pregnancy, but owe their origin to extension of the head at the superior strait at the onset of labor, although Mme. la Chapelle, Naegele, Spiegelberg, Kibemont-Dessaignes, Fieux, and others have described in- stances in which they were diagnosticated during pregnancy. These are designated as primary, in contradistinction to the much more frequent secondary face presentations. Diagnosis.—In the left mento-anterior variety palpation gives the following data: 307 308 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS First maneuver: Breech in fundus. Second maneuver: Back in the right and posterior portion of the abdomen, and distinctly felt only in its upper portion; small parts in left and anterior portion of the abdomen. Third maneuver: Marked cephalic prominence on right side. Fourth maneuver: Marked cephalic prominence on right side; fingers can be depressed deeply on left. The reverse holds good in the right posterior variety (Plate XII). The characteristic sign is that the cephalic prominence is palpable on the same side as the back, the latter being distinctly felt only in the neighborhood of the breech. On vaginal or rectal touch the face is found in the birth canal, and the variety of presentation is diagnosticated by the differentiation of the various features, the mouth and nose, malar bones, and orbital ridges being the distinctive points. In the left anterior variety the chin occu- pies the anterior and the brow the posterior extremity of the right oblique diameter of the pelvis, while in right posterior position the reverse obtains. The heart sounds are transmitted through the thorax; accordingly they are heard through the side of the abdomen which contains the small parts and generally below the umbilicus. The only other condition in which auscultation gives similar results is in brow presentations and in the rare cases of occipitoposterior presentations in which the head is partially extended. Causation.—The causes of face presentations are manifold, and, roughly speaking, are afforded by any factor tending to bring about extension or to prevent flexion of the head. Accordingly, they occur more frequently when the pelvis is contracted or the child very large. It is therefore an excellent practical rule to bear the latter possibility in mind whenever one meets with lack of engagement in a normal pelvis. Petit jean believes that the production of face presentation is favored by a low implantation of the placenta, which he has noted in two-thirds of the cases observed in Pinard’s clinic. To Matthews Duncan belongs the credit of having directed attention to the most frequent causative factor—namely, an oblique position of the uterus, which permits the child’s back to sag toward the side in which the vertex lies. He pointed out that in such circumstances the attitude of the foetus becomes distorted and abnormal, so that a slight obstacle to the descent of the posterior portion of the head will result in its extension. This occurs most frequently in right occipitoposterior presentations, as is shotvn by the fact that, while left occipito-anterior are many times more frequent than right occipitoposterior presentations, the same two varieties of face presentation occur with almost equal fre- quency. That multiparity would naturally favor the production of this condition is evident, since lax abdominal walls allow the uterus to assume an oblique position. Thus Pinard and Winckel state that 60 per cent, of their cases occurred in multiparous women. In exceptional instances, marked enlargement of the neck or thorax, coils of cord about the neck, or spastic contraction, or congenital shorten- PLATE XII. First Maneuver. Second Maneuver. Third Maneuver. Fourth Maneuver. PALPATION IN RIGHT MENTO-ANTERIOR PRESENTATION. FACE PRESENTATIONS 309 ing of the cervical muscles may cause extension (Morse). Again, it is well known that hemicephalic children usually present by the face, as the result of the faulty development of the cranial vault. Hecker pointed out that face presentations are occasionally due to an elongation of the occipital portion of the head—dolichocephalus. There is no doubt that most children that are born by the face have heads of this character, but the fact that they usually resume their normal shape a few days after labor shows beyond question that the deformity is the result, rather than the cause, of the presentation. Zweifel delivered by cesarean section a dolichocephalic child, which had presented by the breech, and held that the observation demonstrated the possibility of the existence of a primary dolichocephalus; but Fritsch and most ob- servers contend that the peculiar shape of the head resulted from pressure exerted upon it by the fundus of the uterus. On the other hand, Jellinghaus and Gessner have reported cases which they believe sup- Fig. 275.—Ttjmor of Neck . causing Face Presenta- tion. Fig. 276.—Dolichocephalic Head from Breech Presentation (Jellinghaus).. . port the original theory of Hecker; and, on the whole, it would seem probable that such a condition may occasionally bear a causal relation to face presentations. Mechanism.—As face are usually derived from vertex presentations, it is apparent that the former are but rarely observed in a fully developed state at the superior strait, where the brow generally engages, while the face descends only after further extension. The mechanism in these cases consists of the cardinal movements—; descent, internal rotation and flexion; and the accessory movements— extension and external rotation. Descent is brought about by the same factors as in vertex presentations, while extension results from the rela- tion which the body of the child hears to its head, the latter being con- verted as it were into a two-armed lever, the longer arm of which extends from the occipital condyles to the occiput; so that when resistance is encountered the latter is pushed upward, while the chin descends (Fig. 277). 310 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS Internal rotation has for its object the rotation of the face in such a manner as to bring the chin under the symphysis pubis, since otherwise natural delivery cannot be accomplished. Only in this way can the neck subtend the posterior surface of the symphysis pubis; whereas, if the chin rotates directly posteriorly, the relatively short neck cannot span the anterior surface of the sacrum, which measures 12 centimeters in length, so that the birth of the head is manifestly impossible unless the shoulders can enter the pelvis at the same time, which is out of the question except when the child is very small or premature (Fig. 278). Internal rotation is due to the same factors as in vertex presentations, and Sellheim holds that as bending in face pres- Fig. 277.—Diagram showing that in Face Presenta- tions the Occiput is the Long End of Head Lever. Fig. 278.—Diagram illustrating Impossibility of La- bor in Face Presentations when the Chin has rotated Directly Posterior. entations occurs most readily between the anterior surface of the neck and the chin that portion of the child must inevitably rotate to the front so as to accommodate itself to the “knee” of the birth canal. After anterior rotation the chin and mouth appear at the vulva; the under surface of the chin becomes stemmed against the symphysis, and the head is delivered by a movement of flexion, the nose, eyes, brow, bregma, and occiput appearing in succession over the anterior margin of the perineum (Figs. 280, 281, 282). After the birth of the head the occiput sags backward toward the anus, and in a few moments the chin, by a movement of external rotation, turns to the side toward which it was originally directed, after which the shoulders are born as in vertex presentations. In a small number of cases internal rotation, instead of occurring anteriorly, may take place toward the hollow of the sacrum, or, occa- sionally, as was pointed out by Hodge, the face may engage primarily in this manner. In such circumstances, for the reasons given above, the birth of a normal-sized child is usually impossible. Reed, in 1905, FACE PRESENTATIONS 311 has shown that such a view is somewhat too extreme, for, after reviewing 75 cases of persistent mentoposterior presentations reported in the litcra- Fig. 279.—Distention of Vulva in Face Presentation (modified from Ahlfeld). ture, he found that 17 had been delivered without change of presentation. This, however, should not be taken as indicating that such positions Fig. 280.—Diagram showing Delivery of Head in Face Presentation. are not very serious, as in the entire series 11.6 per cent, of the mothers and 40.6 per cent, of the children perished, in spite of attempts at de- livery by various methods. 312 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS In mental presentations the face becomes distorted owing to the effu- sion of serum beneath the skin, which when marked completely obliter- ates the features and may readily cause confusion with a breech presenta- tion. At the same time the skull undergoes considerable molding, which Fig. 281.—Diagram showing Delivery of Head in Face Presentation. is manifested by an increase in length of the mento-occipital diameter and a diminution in the vertical diameters of the head. Prognosis.—Until the latter part of the eighteenth century face pres- entations were considered extremely unfavorable, and most authorities Fig. 282.—Diagram showing Delivery of Head in Face Presentation. advised their conversion into some other variety. But about that time Deleurye, in France, and Zeller and Boer, in Austria, pointed out that most of them would end spontaneously if left alone. This doctrine was established by the last named author, who stated that he had observed FACE PRESENTATIONS 313 spontaneous labor in 79 out of 80 face presentations, and bad applied forceps in only a single instance. Deep tears of the perineum are of frequent occurrence, and are ofttimes erroneously attributed to excessive distention of the vulval out- let by the largest circumference of the head—the mento-oecipital. In reality, however, the trachelobregmatic is the circumference concerned, and as it is but little larger than the subocci- pitofrontal, which is concerned in vertex presentations, some other factor must be invoked to explain the greater in- cidence of perineal tears. This probably consists in the greater forward pro- trusion of the pelvic floor, as in face presentations the presenting part must descend very deeply before flexion of the neck under the symphysis can occur. Owing to the prolongation of labor the foetal mortality is markedly in- creased, being usually estimated at about 14 per cent. Markoe’s mortality was 21 per cent., while Weiss lost only 4 out of 78 children (5.1 per cent.). In dealing with face presentations it should always be borne in mind that internal rotation does not occur until the pelvic floor is well dis- tended by the advancing face; and frequently, when the chin is obliquely posterior, it may not take place until the obstetrician has almost aban- doned hope of its occurrence. Nor should it be forgotten that the face must occupy a lower level than the vertex before one can feel assured that the greatest circumference of the head has passed through the supe- rior strait. This can be readily ap- preciated from a study of Figs. 285 and 286, in which it is seen that the distance from the parietal boss to the vertex is only 3 centimeters, whereas a line drawn from the same point to the face will measure 7 centimeters. Treatment.—In the anterior vari- eties spontaneous delivery is the rule, and, even when the chin is obliquely posterior, anterior rotation usually occurs, although often not until a very late period. In view of the serious prognosis attending failure of the chin to rotate anteriorly and particularly when the face rotates into the hollow of the sacrum, an attempt should be made to substitute a vertex presentation. When the head is not deeply engaged, provided there exists no disproportion be- tween the size of the head and the pelvis and the amniotic fluid has Fig. 283.—Showing Distortion of Face after Delivery in Face Presentation. Fig. 284.—Diagram showing Config- uration of Head in Face Presen- tation (American Text-Book). 314 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS not long since drained away, this can sometimes be readily accomplished, either by pushing up the chin or by making traction upon the occiput. On the other hand, when the chin is directed anteriorly, attempts at conversion are not advisable, as they would merely substitute an occipitoposterior position, which is but slightly more favorable than the original face presentation, not to speak of the increased danger of infection attending the manipulation. In obliquely posterior face posi- tions, on the contrary, conversion is urgently indicated, and should be attempted as soon as the condition is recognized and the degree of dilatation of the cervix permits. If it cannot be readily effected, internal podalic version becomes the operation of choice. From time to time numerous methods of conversion have been sug- gested, the oldest and most effectual being the following, advocated by Fig. 285.—Diagram showing that when the vertex is on the Line joining the Ischial Spines, the greatest Diameter of the Head has Passed the Superior Strait. Fig. 286.—Diagram showing that when the Face is on the Level of the Ischial Spines, the Greatest Diam- eter of the Head is Still Above the Superior Strait. Baudelocque and revived by Thorn, Weiss, and others: Attempts are made to push up the chin by two fingers introduced into the vagina; if this does not succeed the patient is anesthetized, the whole hand intro- duced, and the head dislodged, after which the vertex is grasped and drawn down. At the same time the external hand of the operator or the assistant carries the back in the opposite direction, so as to facilitate flex- ion. Very excellent results have been obtained by this maneuver, and its adoption in suitable cases can be recommended. Schatz suggested the method of external manipulation, pictured in many text-books, by which the vertex is substituted for a presenting face. This, however, is rarely available, inasmuch as the presentation does not become well developed until after engagement has occurred. If the face be too deeply engaged in the pelvis to admit of the Baude- locque maneuver, the patient should be let alone and descent allowed to take place, in the hope that anterior rotation will occur when the face reaches the pelvic floor. If, however, this does not take place after a reasonable delay, and symptoms supervene which indicate the termina- tion of labor, manual rotation should be attempted, and if this cannot be BROW PRESENTATIONS 315 effected forceps should be applied in the manner to be described later, and an attempt made to rotate the chin to an anterior position; finally, if this fails, the only resource lies in pubiotomy or craniotomy, as cesarean section should not be considered on account of its high ma- ternal mortality when done so late in labor. When the chin is originally situated directly posteriorly, or has rotated into that position, internal podalic version should be performed as soon as the condition of the cervix will permit, provided the head is not too deeply engaged or the uterus so tightly contracted about the child as to contra-indicate it. On the other hand, if the face be so firmly engaged that it cannot be pushed up under anesthesia, craniotomy or pubiotomy must be resorted to as soon as the patient’s condition calls for de- livery. The former has been repeatedly practiced, and Morse has collected the few cases in which pubiotomy has been performed, including two successful operations done in my clinic. Brow Presentations.—In brow pres- entations the head occupies a position midway between flexion and extension; hence the portion situated between the orbital ridge and large fontanelle pre- sents at the superior strait. As nearly every child which is born by the face has gone through a preliminary stage of brow presentation, the latter must occur more frequently, later undergoing spontaneous conversion into either a face or a vertex presentation. On the other hand, persistent brow' presenta- tions are extremely rare, and are gen- erally stated to occur once in every 1,500 to 2,000 cases, though Weiss and Markoe observed one example in every 1,000 cases. The causes of this presentation, vdiich have been carefully studied by Ahlfeld, are practically identical vfith those giving rise to face presenta' tions, and depend upon any factor which interferes with flexion or promotes extension of the head. In twin pregnancies not infrequently one or both children may present in this manner, and Ahlfeld maintains that the anterior surfaces of the tvro foetuses coming in contact mutually disturb the normal flexed attitude, so that extension is facilitated. Usually the brow is directed toward one or other extremity of the right oblique diameter of the superior strait, and accordingly the left anterior and right posterior varieties are the ones most frequently encountered. Diagnosis.—The presentation can be recognized by palpation and vaginal touch, though the data obtainable from the former are less char- acteristic than in the more common presentations. The palpatory find- Fig. 287.—Diagram showing Di- rection of Pressure in Con- version of a Face into a Ver- tex Presentation by Thorn’s Maneuver. 316 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS ings are similar to those observed in face presentations, except that the cephalic prominence is less marked on the side of the back, while the resistance offered by the chin can be felt on the same side as the small parts. On vaginal or rectal touch the frontal and the anterior portion of the sagittal suture are encountered in one of the oblique diameters, at one end of which the large fontanelle or the portion of the skull just posterior to it may be felt; while at the other the orbital ridges, the root of the nose, and the eyes may be distinguished. It is not possible to palpate the mouth or chin, for when these are within reach we have to deal with a face presentation. Mechanism.—The mechanism of labor in brow presentations differs materially with the size of the foetus. Ahlfeld and most observers have stated that this is most frequently below the normal; whereas Weiss Fig. 288.—Diagram showing Position of Child in Left Anterior Brow Presentation. Fig. 289.—Diagram showing Position of Child in Right Posterior Brow Presentation. maintains that large children are the rule. In the former case the course of labor as a rule is quite easy, while in the latter it is usually very difficult. The cause of the difficulty is apparent when we consider that the circumference of the head which must engage at the superior strait is the mento-occipital, whose greatest diameter averages 13.5 centimeters in length, and that engagement is therefore impossible until after marked molding has taken place, by which the mento-occipital diameter has be- come diminished and the fronto-occipital increased in length. After molding and descent have occurred the brow usually rotates an- teriorly, and the forehead, orbital ridges, and root of the nose appear at the vulva. One of the superior maxillary bones then becomes stemmed against the inferior margin of the symphysis, and the rest of the head is born by a movement of extreme flexion, the brow, bregma, and occiput appearing in succession over the anterior margin of the perineum. After the birth of the occiput, the mouth and chin descend from behind the pubic arch by a movement of extension. In other words, we have a mechanism somewhat similar to that observed in the less frequent mode BROW PRESENTATIONS 317 of delivery in the case of posterior occiput presentations which have rotated into the hollow of the sacrum. In very rare instances, as re- ported by Bretz and Zimmermann, birth may occur without internal rotation, with the frontal suture extending transversely. Such a mechan- ism occurs so rarely that it should be regarded as an obstetrical curiosity. As has already been pointed out, a large child cannot enter the birth canal without considerable molding of the head. This adds materially to the length of labor and results in the birth of children with charac- teristically deformed heads. The caput is found over the forehead and extends from the orbital ridges to the large fontanelle, and in many cases is so marked as to render diagnosis by vaginal touch almost impossible. In these cases, as is shown in Fig. 290, the forehead is very prominent and square, the mento-occipital diameter being diminished and the fronto-occipital diameter increased in length. Prognosis.—In the transient varieties of brow presentation, the outlook depends upon the presenta- tion which ultimately results, and whether the face or vertex enters the birth canal; while in the per- sistent forms it is generally con- sidered to be bad, unless the foetus be small. It should always be re- membered that disproportion be- tween the size of the head and the pelvis is an important factor in the production of such presentations, and that with a pelvis and head of the same size the possibility of a spontaneous outcome is always much less in a. brow than in a vertex presentation. Rational methods of treatment, similar to those indicated in face presentations, and more particularly stricter attention to aseptic technic have led to a marked improvement in the prognosis of the persistent varieties. Thus, Markoe records a foetal mortality of 39 per cent., while Weiss, on the other hand, has reported 29 cases, without a death of foetus or mother. Treatment.—-If the brow be recognized at the superior strait, the treatment will vary according as the presentation promises to be transient or persistent. The former should be left alone, as it will undergo spon- taneous conversion into a vertex or face presentation, and the child will probably be born spontaneously. On the other hand, in persistent cases, particularly if the brow be obliquely posterior, attempts at conversion should be made as soon as the first stage of labor is completed. If they are not successful, version should be performed, if feasible, as recom- mended in face presentations. If the brow be deeply engaged, conversion should not be attempted unless one is able to push the presenting part up to the level of the superior strait, "when the treatment is identical with that outlined above. But if this cannot be accomplished, version Fig. 290.—Diagram showing Configu- ration of Head in Brow Presenta- tion (American Text-Book). 318 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIO: is also out of the question, and the case should be left to nature, and forceps applied when indicated by the condition of the mother or child, and followed by craniotomy if necessary. It should be remembered, however, that delivery in these circumstances is nearly always associated with considerable injury to the maternal soft parts, owing to the large circumference of the foetal head by which they are distended. Wallich has made an earnest plea for the performance of symphyseotomy in per- sistent brow presentations, and has reported 7 operation with no ma- ternal and only 2 foetal deaths. In my opinion late cesarean section is rarely indicated, because of its high maternal mortality, and, if under- taken, should be followed by supravaginal hysterectomy. On the other Fig. 291.—Diagram showing Position of Child in L. S. A. Fig. 292.—Diagram Showing Position of Child in R. S. A. hand, if section is done early in labor it should he on account of the pelvic indication, rather than because of the abnormal presentation. Breech Presentations.—As has already been pointed out, the relation between the lower extremities and buttocks of the child is not always the same in sacro-iliac presentations, and we therefore distinguish between frank breech, complete breech, foot and knee presentations. In all those varieties, however, the mechanism of labor is essentially the same, so that they need not be considered separately. Usually the breech engages in such a manner that the sacrum is di- rected to the left side of the mother, and accordingly the left sacro- anterior or posterior are the positions most frequently observed. In 100,000 cases of labor Pinard observed 3,301 breech presentations —about 3.30 per cent. These statistics include premature as well as full- term labors, but, if the latter alone are considered, the incidence would be somewhat less. Diagnosis.—On palpation, the first maneuver reveals a hard, round, readily ballottable body occupying the fundus of the uterus, and when the abdominal walls are very thin one can occasionally obtain a charac- teristic cracking sensation upon compressing the hones of the skull. By PLATE XIII. First Maneuver. Second Maneuver. Third Maneuver. Fourth Maneuver. PALPATION IN LEFT SACRO-ANTERIOR PRESENTATION. BREECH PRESENTATIONS 319 the second maneuver the back is found to occupy one side of the abdomen and the small parts the other, position and variety being determined by the location of the former. On the third maneuver, if engagement has not occurred, the irregular breech is freely movable above the superior strait; while, if it has already occurred, the fourth maneuver shows that the pelvis is filled by a soft mass which interferes with the penetra- tion of the fingers (Plate XIII). Kautsky has made the interesting observation that in breech presentations a distinct slowing in the foetal pulse rate can be elicited by compressing the head at the fundus between the fingers. In doubtful cases, the diagnosis may be established by means of the Fig. 293.—Frozen Section, Latter Part of Pregnancy, Child in L. S. T. (Waldeyr). X-ray, and in such circumstances it will usually be found that the head is less sharply flexed and that the arms occupy a much freer position than is generally taught. On vaginal or rectal examination the diagnosis of a frank breech presentation is made by recognizing its characteristic portions. Usually one can feel both tubera ischii, the sacrum with its spinous processes, and the anus, and when further descent has occurred the external genitalia may be distinguished. Especially where labor is prolonged, the buttocks may become markedly swollen, so that diiferentiation be- tween the face and breech may be rendered very difficult, as the anus may be mistaken for the mouth, and the ischial tuberosities for the malar bones. Care in examination, however, should prevent this error, for when the finger is introduced into the anus it experiences a muscular 320 MECHANISM OE LABOR IN FACE AND BREECH PRESENTATIONS resistance, whereas in the mouth the firmer, more unyielding jaws would be felt. Again, on removing the finger, it is sometimes found to be stained with meconium, which could never occur with a face presentation. The most accurate information, however, is obtained from the sacrum and its spinous processes, for when these are felt the diagnosis of posi- tion and variety is established. In complete breech presentations the feet may be felt alongside of the buttocks, and in footling presentations one or both feet may hang down into the vagina. In the latter case, one can readily determine which foot is encountered by bearing in mind the relation of the great toe. When the breech has descended deeper into the pelvic cavity, the genitalia may be felt, and if these are not deformed by an effusion of serum it is possible to determine the sex of the foetus. Only in such circumstances can we feel certain as to this point before delivery. Fig. 294.—Diagbam showing Direction of Internal Rotation in R. S. P. Position. The foetal heart sounds are heard through the back of the child, usu- ally at the level of the umbilicus or slightly above it. Etiology.—The causes of breech presentations are manifold. Ac- cording to the experiments of Schatz, the foetus, when suspended in liquor amnii, always sinks by its buttocks, so that, if gravity were the only factor concerned, breech presentations would be the most fre- quent of all. As a matter of fact, however, this is by no means the case. In the later months of pregnancy head presentations result from a process of accommodation between the foetal ovoid and the uterus; ac- cordingly, breech presentations are prone to occur when the process is interfered with. These factors do not so readily come into play in the earlier months, when breech presentations are much more common than at term. They are also frequently lacking in twin pregnancies and in cases of hydramnios, inasmuch as the increased distention of the uterus interferes with accommodation. According to Pinard’s statistics, 59 per cent, of all breech presentations occur in multiparae, in whom the BREECH PRESENTATIONS 321 flaccidity of the uterine and abdominal walls plays a part in their pro- duction. Their occurrence is also favored by the presence of any obstacle which opposes the engagement of the vertex, as contracted pelvis, excessive size of the normal head, or hydrocephalus. Mechanism.—Unless there be some disproportion between the size of the child and the pelvis, engagement and descent readily occur in one of the oblique diameters of the pelvis, the anterior hip being directed toward one iliopectineal eminence, and the posterior hip toward the opposite sacro-iliac synchondrosis. The former usually descends more rapidly than the latter, and, when it encounters the resistance of the pelvic floor, internal rotation usually occurs and brings the anterior hip to the pubic arch, the bitrochanteric diameter of the child coming into relation with Fig. 295.—Birth of Head in Breech Presentation. the anteroposterior diameter of the pelvic outlet. Rotation usually takes place from the iliopectineal eminence to the pubis through an arc of 45 degrees. If, however, the posterior extremity is prolapsed it always rotates to the symphysis pubis, rotation ordinarily occurring through an arc of 135 degrees, but occasionally it will take place in the opposite direction, the prolapsed hip rotating past the sacrum and through the opposite half of the pelvis, through an arc of 225 degrees. Sellheim explains the latter phenomenon by assuming that the retained leg acts as a splint to the corresponding side of the body, with the result that it can- not so readily undergo the lateral flexion necessary to delivery as the side which is not so splinted. After rotation, descent continues until the perineum is distended by the advancing breech, while the anterior hip appears at the vulva and is stemmed against the pubic arch. By a movement of lateral flexion of the body, the posterior hip is then forced over the anterior margin of the perineum, which retracts over the child, thus allowing its body to straighten out, when the anterior hip is born. The legs and feet 322 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS follow the breech and may be born spontaneously, although the aid of the obstetrician is sometimes required. After the birth of the breech a slight moveemnt of external rotation occurs, and the back usually turns somewhat to the front, as the result of the shoulders being brought into relation with one of the oblique diameters of the pelvis. They then descend rapidly and undergo internal rotation, the bisacromial diameter now corresponding with the anteroposterior diameter of the inferior strait. Immediately following the shoulders, the head, which is normally sharply flexed upon the thorax, enters the pelvis in one of the oblique diameters, and then rotates in such a manner as to bring the posterior portion of the neck under the symphysis pubis, after which the head is born in a position of flexion, the chin, mouth, nose, forehead, Fig. 296.—Birth of Head in Breech Presentation. bregma, and occiput appearing in succession over the perineum (Figs. 295 and 296). In a small number of cases rotation occurs in such a manner that the back of the child is directed toward the vertebral column, instead of toward the abdomen of the mother. In such circumstances the face appears under the symphysis pubis, the face, brow, and finally the occiput slipping down under it, as the head is born. It is of the utmost impor- tance to remember that if premature traction be employed the head may become extended, when its delivery can only be accomplished by the operation of extraction. Prognosis.—So far as the life of the mother is concerned, the prog- nosis differs but slightly in breech and vertex presentations, except that with the former labor is slower, and in operative cases is more liable to be complicated by perineal tears, which sometimes extend through the sphincter ani muscle. The prognosis for the child, on the1 other hand, is considerably worse than in vertex presentations, the foetal mortality BREECH PRESENTATIONS 323 being generally estimated at 10 or 15 per cent. This figure applies to primiparous women, but a somewhat lower percentage obtains in multip- arous women. Porak states that 1 child in 9 succumbs in the former class of cases, as compared with 1 in 30 in the latter. The somber prognosis for the child is due to several factors. In the first place, after the breech is born as far as the umbilicus, the cord is exposed to a greater or lesser degree of compression between the head and the pelvic brim. It is usually stated that not more than eight minutes can elapse between the birth of the umbilicus and the delivery of the head, if the child is to be born alive. This is not quite correct, as a much longer time may elapse, provided the mouth has appeared at the vulva, thereby affording the possibility for the establishment of pul- monary respiration in case the circulation through the cord has been cut off. Occasionally foetal death is due to the premature separation of the placenta, for, if the delivery is not promptly effected after the head has passed into the lower part of the birth canal, the partially emptied uterus may retract to such an extent as to separate the placenta from its walls, and thus put a stop to the uteroplacental circulation. Holland, and Capon, in 1922, established the predominant cause of foetal death in breech presentations, by showing that the probability of the occurrence of tentorial tears and subsequent intracranial hemorrhage is twice as great as in head presentations. Furthermore, they have shown that when extraction is practiced, and especially when it is aided by supra- pubic pressure upon the head, the medulla may protrude through the foramen magnum and actually become herniated into the spinal canal. In primiparous women, where considerable resistance is offered by the pelvic soft parts, spontaneous delivery of the head is often unavoidably delayed and foetal death results, unless the child be extracted manually. Treatment.—In view of the serious foetal prognosis attending breech presentations, the obstetrician should aim to prevent their occurrence as far as possible, and whenever they are recognized in the later weeks of pregnancy an attempt should be made to substitute a vertex presentation by means of external version, unless there exists such disproportion between the size of the head and the pelvis as to make the occurrence of spontaneous delivery dubious. This is readily accomplished in multip- arae with lax abdominal walls, but is more difficult in primiparae. If the head can be forced into the pelvis after the substitution has been effected, the new position becomes permanent; but if this is not possible, the child will usually revert to its original position, notwithstanding the application of a properly fitting bandage. In the former case, the result is usually excellent, and affords striking proof of the value of routine ante-partum examination. External version may also be at- tempted in the first stage of labor, provided the breech has not descended deeply into the pelvis; but when it has once become fixed, all such efforts are unavailing. In most breech presentations spontaneous delivery occurs, and the at- titude of the obstetrician should be merely one of expectancy; neverthe- less, he should always hold himself in readiness to intervene at a mo- 324 MECHANISM OF LABOR IN FACE AND BREECH PRESENTATIONS ment’s notice. For this reason, as soon as the breech appears at the vulva, the patieni should be brought to the edge of the bed in order that not a moment may be lost in performing extraction should it become necessary. At the same time everything required for the resuscitation of the asphyxiated child should be ready for instant use. It is most im- portant to remember that the completion of labor is materially facilitated by the arms retaining their normal crossed position over the thorax, as well as by sharp flexion of the head. This is best attained by avoiding traction as far as possible and by moderate downward pressure upon the fundus as soon as the breech begins to emerge through the vulva, which should be maintained by the nurse or an assistant, so that the obstetrician can keep his hands clean for any emergency. Owing to the fact that the breech forms a less efficient dilating wedge than the head, care should be taken to prevent premature rupture of the membranes and the escape of the amniotic fluid. For this reason, as well as to facilitate dilatation of the outlet, Yignes states that Con- velaire for many years has introduced a rubber balloon into the vagina as soon as the external os has dilated to five centimeters in diameter. By so doing he has reduced the foetal mortality by more than one-half, and the incidence of perineal tears by 60 per cent. I have had no ex- perience with the method. Generally speaking, the frank breech forms a better dilating wedge than the complete breech, inasmuch as it allows a closer application to the margins of the partially dilated os. On the other hand, if interference becomes necessary, the complete breech offers more satis- factory conditions for immediate delivery, as a foot can readily be brought down and used as a tractor, so that the question arises whether it might not be better in the former class of cases to make it a rule to bring down one or both feet prophylactically. Usually this is not advisable, unless some abnormality exists on the part of the mother or child which renders it probable that prompt delivery may be called for. In such cases as soon as the cervix is practically fully dilated, the membranes should be ruptured and both feet brought down into the vagina so that extraction can be promptly effected when necessary. The technic of this manipulation, as well as the rules for extraction, will be considered in Chapter XXI. LITERATURE Ahlfeld. Die Entstehung von Stirn- und Gesichtslagen. Leipzig, 1873. BaUDELOCQUE. L’art des accouchements, 1789, t. ii, 36-40. Boer. Sieben Biicher iiber natiirliche Geburtshiilfe. Wien, 1834, 96. Bretz. Geburt bei Stirnlage mit querverlaufender Stirnnaht. Zentralbl. f. Gyn., 1922, 2065-2067. Capon. Intracranial traumata in the New-born. Jour. Obst. and Gyn. Brit. Emp., 1922, xxix, 572-590. Deletjrye. Traite des accouchements, etc. Paris, 1770. Duncan. On the Production of Presentation of the Face. Mechanism of Natural and Morbid Parturition, Edinburgh, 1875, 218-231. LITERATURE 325 Fieux. Une observation de presentation primitive de la face. Comptes rendus de la soc. d’obst., de gyn. et paed., 1900, ii, 225-231. Fritsch. Klinik der geburtshiilflichen Operationen. Halle, 1894, 142. Gessner. Zur Aetiologie der Gesichtslagen. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 302. Hecker. Ueber die Schadelform bei Gesichtslagen. Berlin, 1869. Hodge. The Principles and Practice of Obstetrics. Philadelphia, 1866, 331. Holland. Cranial Stress in the Fcetus During Labor, etc. Jour. Obst. and Gyn. Brit. Emp., 1922, xxix. Jellinghaus. Ueber fotale Schadelformen, etc. Archiv f. Gyn., 1896, li, 33-48. Kautsky. Eine neue Methode zur Sicherstellung von Zwllingssehwangerschaften, Beckenend- und Querlagen. Zentralbl. f. Gyn., 1921, 777-780. Lachapelle. Pratique des accouchements, 1821, t. i, 382. Markoe. Observations and Statistics on 60,000 Labors. Bull. Lying-in Hospital, New York, Dec., 1909. Morse. Pubiotomy in Posterior Face Presentations. Surg. Gyn. and Obst., 1912. Bilateral Congenital Caput Obstipum. Surg. Gyn. and Obst., 1915, xx. 74-77. Petitjean. Etude statistique concernant le cas de presentation de la face ayant lieu a la clinique Baudelocque. These de Paris, 1904. Pinard. Traite du palper abdominal, 2me ed., Paris, 1889, 32-50. Reed. Persistent Mento-posterior Positions. Am. Jour. Obst., 1905, li, 615-635. Ribemont-Dessaignes. Precis d’obstetrique, 1894, 425. Schatz. Die Umwandlung von Gesichtslagen zu Hinterhauptslagen durch allein- igen ausseren Handgriff. Archiv f. Gyn., 1873, v, 306-331. Ueber den Schwerpunkt der Frucht. Zentralbl. f. Gyn., 1900, xxiv, 1033-1036. Sellheim. Die Geburt des Menschens. Deutsche Frauenheilkunde, Bd. I, 1913. Die Physiologie der Geburt. Doederlein’s Handbueh der Geb., 1915, Bd. 1, 331- 444. Spiegelberg-Wiener. Lehrbuch der Geburtshiilfe, II. Aufl., 1891, 172. Thorn. Zur manuellen Umwandlung der Gesichtslagen in Hinterhauptslagen. Zeitschr. f. Geb. u. Gyn., 1886, xiii, 186-220. Die Stellung der manuellen Umwandlung in der Therapie der Gesichts- und Stirnlagen. Volkmann’s Sammlung klin. Vortrage, 1902, Nr. 339 Vignes. Presentation du siege. Le Progres Medical, 1919, 378-379. Wallich. De la symphyseotomie dans les presentations persistantes du front. Comptes rendus de la soc. d’obst., de gyn. et de psed., 1902, iv, 18-34. Weiss. Zur Behandlung der Gesichts- und Stirnlagen. Yolkmann’s Sammlung klin. Vortrage, N. F., Nr. 74. Winckel. Zur Lehre von den Gesichtslagen. Klinische Beobachtungen zur Pathologie der Geburt. Rostock, 1869, 59-65. Zeller. Bemerkungen iiber einige Gegenstande aus der praktischen Entbindungs- kunst. Wien, 1797. Zimmermann. Zur Mechanismus bei Stirnlage. Zeitschr. f. Geb. u. Gyn., 1921, lxxxiii, 725-735. Zweifel. Lehrbuch der Geburtshiilfe, III. Aufl., 177. CHAPTER XIY PHYSIOLOGY AND MANAGEMENT OF THE THIRD STAGE OF LABOR Situation of the Placenta in Utero.—The older authors believed that the placenta was usually implanted at or in the immediate neighborhood of the fundus. The researches of Schroeder, Pinard, Ahlfeld, Leopold, Holzapfel, and others, however, have shown that this is by no means the rule, hut that the most common situation is on the anterior or posterior wall of the uterus, occasionally on its lateral wall, and only in ex- Fig. 297.—Diagram showing Relation of Placenta to Uterine Wall in Latter Part of Pregnancy. X Vl- Fig, 298.—Diagram showing Relation of Placenta to Uterine Wall in Second Stage of Labor (modified from Schroeder). X 3^. ceptional instances upon the fundus. Fig. 297, which represents a vertical section through the uterus at term, shows the usual mode of attachment. As a rule, the lower margin of the placenta lies well above 326 MECHANISM OF SEPARATION OF THE PLACENTA 327 the internal os, because when it impinges upon or overlaps the latter we have to deal with a pathological condition-—placenta previa. Mechanism of Separation of the Placenta.—Under normal conditions the placenta remains fixed to the uterine wall until after the birth of the child, and becomes sepa- rated from it only during the third stage of labor. The uterine contractions bring about a slight de- crease in the area of placental attachment du- ring the second stage, and in its attempt at accommodation the pla- centa becomes thicker and its margins more rounded and prominent. It is pressed firmly against the uterine wall by the amniotic fluid, through which the intra- uterine pressure is trans- mitted; otherwise it is probable that premature separation would be the rule and not the excep- tion. As the child is being expelled from the uterus, its cavity becomes prog- ressively smaller to corre- spond to the decreasing bulk of its contents, so that when the birth is completed, the uterine cavity has become oblite- rated and the organ is represented by an almost solid mass of muscle, whose fundus lies several centimeters below the umbilicus. A vertical section through the uterus at this time (Fig. 299), shows that as the result of contraction and retraction its walls have become several centimeters thick and are closely applied to the placenta, which is still attached, but, owing to the diminution in its area of attachment, has become approximately twice as thick as at the onset of labor. As a result of the great decrease in the superficies of the rest of the interior of the uterus, the foetal membranes and the decidua vera are Fig. 299.—Vertical Section through Uterus Re- moved by Supravaginal Hysterectomy following Cesarean Section. X %■ (Note thickness of muscle walls, decrease in area of placental attach- ment, and increase in thickness of placenta.) 328 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR obliged to accommodate themselves to the changed conditions, and, as they are not contractile, they are thrown into innumerable small festoons Fig. 300.—Section through Wall of Pregnant Uterus Outside of Placental Site. X 66. (For comparison with Fig. 302.) A—amnion and chorion laeve; B—fibrin layer; C—decidua vera; D—muscularis. Note abundance of muscle spaces in this layer. or folds, so that the layer increases from a fraction of a millimeter to 3 or 4 millimeters in thickness. Figs. 300 and 301, which represent the lining membrane of the Fig. 301.—Section through Uterine Wall Outside of Placental Site During Third Stage, Showing Festooning of Membranes. X 25. Am., amnion; C.E., epithelium of chorion; Dec., decidua vera; Mus., muscularis. MECHANISM OF SEPARATION OF THE PLACENTA 329 uterus at the end of pregnancy and early in the third stage, respectively, give a good idea of the condition of affairs, and make it apparent that a very considerable proportion of the decidua vera has become included between the folds of the festooned amnion and chorion laeve. As the uterus continues to contract and retract, its muscular walls become thicker and thicker, and the area of the placental at- tachment smaller and smaller, so that even- tually a period is reached when the comparatively com- pact placenta can no longer follow this change, and is peeled off from the uterine wall and lies free in the cavity, whence it is expelled into the collapsed and flabby lower uterine seg- ment by further con- tractions. The sepa- ration takes place in the spongy layer of the decidua basalis, so that a portion is cast off with the placenta, while the balance remains at- tached to the muscu- laris (Fig. 303). The process of de- tachment is inaugu- rated by lesions of continuity in the decidua, and is ac- celerated by the ef- fusion of blood into the spaces thus formed. The amount of decidual tissue which is retained at the placental site is dependent upon the original thickness of the decidua basalis, and varies within wide limits, as is well shown by Figs. 304 and 305, which represent the conditions in two normal uteri, which were amputated at cesarean section just after the extrusion of the placenta. The membranes usually remain in situ until the separation of the Fig. 302.—Portion of Fig. 301 More Highly Magnified. X 66. Am., amnion; C.E., epithelium of chorion laeve; Dec., decidua vera, gland spaces; Mus., mus- cularis; V., vascular spaces in decidua. 330 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR placenta. is practically completed, and are then peeled off from the uterine wall partly by the further contraction and retraction of the muscularis, and partly by traction exerted by the separated placenta, which now lies in the flabby lower uterine segment or the upper portion of the vagina. At this time the body of the uterus has become converted into an almost solid mass of muscle, whose anterior and posterior walls each measure 4 to 5 centimeters in thickness and lie in such close apposition that the uterine cavity is practically entirely obliterated. Eeference to Fig. 302 makes it clear that the greater portion of the decidua vera has been included between the fes- tooned folds of the amnion and chorion laeve, and must be cast off when sepa- ration occurs. Consequently the portion which remains attached to the uterine Fig. 304.—Diagram of Placental Site Showing Retention of Minimal Amount of Decidua Basalis. A, decidua basalis, with blood spaces and glands; B, muscularis. wall is relatively thin, and, were it not for the great decrease in the size of the uterine cavity, it would represent only a fraction of the thickness noted during the last days of pregnancy. Mode of Extrusion of the Placenta.— As early as 1789 Baudelocque had de- scribed two ways in which the placenta could be extruded from the uterus. Thus, separation from the uterine wall could commence either at the center of the placenta or at a point in its circumfer- ence. “In the first case the middle of the placenta being pushed forward by an effusion of blood beneath it, the organ becomes inverted upon itself in such a manner that it presents by its foetal surface, which is covered by the membranes and vessels. . . . But Avhen the placenta becomes de- tached below, particularly if the loosening begins at a point in the neighborhood of the internal os, the mechanism is entirely different, for Fig. 303.—Diagram Showing Separation of Placenta, and Approximate Amount of Decidua Basalis Cast Off with it, and Retained in Utero. X 3. A, placenta; B, C, decidua basalis; D, muscularis. MODE OF EXTRUSION OF THE PLACENTA 331 the afterbirth becomes rolled upon itself in the form of a cylinder, whose long axis corresponds to that of the uterus, in such a manner that it presents its detached maternal surface to the examining finger, and its exit is always preceded by a small amount of fluid blood.” These ideas seem to have excited but little interest until 1865, when Schultze advanced the opinion that the placenta was usually expelled by the first method described by Baudelocque. This belief remained practically undisputed until 1871, when Matthews Duncan contended that the second was the more fre- quent and therefore the normal mechanism. The active discussion aroused by this controversy, although it led to no final settlement of the question, had the effect of directing more earnest attention to the physi- ology of this stage of labor. The two methods are now desig- nated by the names of Schultze and Duncan respectively. In the former separation begins first at the central portion of the placenta, between which and the uterine wall more or less blood is poured out, which gradually increases in amount until a retroplacental hematoma of con- siderable size is formed, which even- tually brings about the complete separation of the organ from its site of attachment, while the membranes still remain adherent. The placenta then presents at the internal os by its foetal surface and, passing through the opening in the mem- branes, drags them after it; it is then expelled from the vulva, its foetal or amniotic surface first, and the now inverted membranes follow- ing after. In this mechanism there is no escape of blood until after the extrusion of the placenta has taken place (Figs. 306 and 307). In Duncan’s method, on the other hand, the placenta, after its separa*. tion from the uterine wall, becomes folded upon itself and its lower mar- gin presents at the internal os. It then traverses the vagina and emerges from the vulva by one margin, the membranes being sometimes, but by Fig. 305.—Diagram of Placental Site showing Retention of Excessive amount of the Spongy Layer of the Decidua Basalis. A, decidua basalis; B, muscularis; B.V., blood vessel; Gld. glandular spaces. 332 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR no means always, inverted. When expulsion occurs in this manner, there is slight but continuous hemorrhage from the birth of the child until the placenta is delivered (Eig. 308). Fig. 306.—Diagram illustrating Extrusion of Placenta by Schultze’s Mechanism. With respect to the relative frequency with which these two mechan- isms occur there has been much discussion. In this country and in Eng- Fig. 307.—Diagram illustrating Later Stage in the Extrusion of the Placenta by Schulzte’s Mechanism. land Duncan’s views are commonly accepted, while in Germany the opin- ions are still very conflicting. Holzapfel, in an excellent monograph, has MODE OF EXTRUSION OF THE PLACENTA 333 given details and a full literature dealing with the status of the ques- tion up to 1899, and, concludes that the placenta nearly always presents at the internal os by Duncan’s, but leaves the uterus by Schultze’s mechanism. Certainty in this respect was attained by means of the interest- ing experiments of Weibel, and Warnekros, who immediately after the birth of the child cut the cord, and, through its vessels, in- jected the placenta with a substance which would cast a shadow under the X-ray. Roentgenograms made immediately thereafter showed three things—first, that in two-thirds of the cases separation occurred with the first or second postpartum contraction; second, that the placenta always passed through the contraction ring by its margin, and that the formation of a retroplacental hematoma played very little part in bring- Fig. 308.—Diagram illustrating Extrusion of Placenta by Duncan’s Mechanism. ing about its separation; and third, that the mechanisms described by Duncan and Sehultze developed only in the vagina and really applied only as the placenta emerged from the vaginal outlet. For this reason they contend that differentiation between the two methods is a matter of indifference, as the placenta always leaves the uterus in one way. While such a conclusion is doubtless correct, my experience is that the placenta usually escapes from the vulva by the Sehultze mechanism, and similar views are held by Freeman and Polak. The former in 2,GOO consecutive labors observed in the Rotunda Hospital, Dublin, noted Schultze’s mechanism in 82.5 per cent, of the cases, and believes that more frequent occurrence of Duncan’s mechanism is attributable to kneading the uterus during the early portion of the third stage. In other words, the evidence available indicates that the placenta usually escapes from the uterus by the mechanism of Duncan, and emerges from the vulva by that of Sehultze. 334 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR Clinical Picture of the Third Stage of Labor.—Immediately following the birth of the child the remainder of the amniotic fluid escapes, after which there is usually a slight flow of blood. The uterus can now be felt as a firm, hard mass, the fundus lying well below the umbilicus. For a short time the patient experiences no pain, but after a few minutes uter- ine contractions begin again and recur at regular intervals, until the placenta becomes separated and is expelled into the lower uterine seg- ment. At some time, varying between five and thirty minutes after the birth of the child, palpation shows that the fundus of the uterus has risen up to or above the umbilicus, or three to seven centimeters above its original position, while simultaneously a slight prominence has ap- peared immediately above the symphysis pubis (Figs. 309 and 310), At Fig. 309.—Abdomen immediately afteb Birth of Child. the same time the portion of umbilical cord protruding from the vulva has increased by 10 or .12 centimeters in length. These changes indicate that the placenta has become detached and has been extruded from the uterine cavity proper into the lower uterine segment, or even into the upper part of the vagina. The rising of the fundus is due to the fact that the lower uterine segment, which immediately after the birth of the child had collapsed upon itself, is now distended by the placenta, and mechanically lifts the tightly contracted body of the uterus to a higher level. Iii rare cases the placenta is born almost immediately after the child, in about one quarter of the cases it is delivered spontaneously fifteen to thirty minutes later, while occasionally hours may pass before it appears at the vulva. The possibility of wide divergence in this re- spect can readily be appreciated when we remember that the action of the uterus ceases after the placenta has been extruded from its cavity, CLINICAL PICTURE OF THE THIRD STAGE OF LABOR 335 so that its further descent depends upon the contractions of the abdomi- nal muscles, or upon the action of gravity. But owing to the great distention to which they have been subjected, the tonicity of the abdomi- nal muscles is frequently so impaired that they can no longer exert sufficient force to expel the afterbirth from the vagina, so that in many cases it will not be born for hours unless the patient assumes a sitting position or assistance is rendered by the physician. Ahlfeld has stated that spontaneous termination of the placental period occurred in only 13.6 per cent, of his cases, even when he waited for one and a half to two hours after the birth of the child. The average loss of blood during the third stage of labor is less than 500 cubic centimeters, a constant but slight flow occurring through- Fig. 310.—Abdomen of Same Patient, showing rising up of Fundus Following Extrusion of the Placenta into the Lower Uterine Segment out the entire period when the placenta is delivered by Duncan’s mechan- ism, and a sudden gush of blood immediately following its expulsion by Schultze’s mechanism. In 1,000 consecutive spontaneous labors I found that the average loss was 343 cubic centimeters, with extremes of 0 and 2,400 cubic centimeters. Indeed, even this average gives an exaggerated idea of what may be expected in the individual patient, for upon arrang- ing my patients in groups according to the number of hundred cubic centimeters of blood loss, it was found that groups 100 to 199 and 200 co 299 were much larger than any others. In other words, the amount of blood most commonly lost varies between one and three hundred cubic centimeters, or considerably less than the average. A loss exceed- ing 600 cubic centimeters should be considered abnormal, although post- partum hemorrhage rarely exposes the patient to serious danger unless it exceeds 1,500 cubic centimeters. Ahlfeld holds that the amount lost 336 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR increases with the size of the child and with that of the placenta. More- over, he contends that it is more profuse when the placental period is of short duration, and is least when it lasts for one and a half or two hours, but this is contrary to my experience. Management of the Third Stage of Labor.—Up to 1861 the manage- ment of the third stage of labor varied greatly, and delivery of the placenta was effected either by traction upon the cord or by passing the Fig. 311.—Expression of Placenta. hand into the vagina or uterus, as the case might he, and bringing it away. Both of these methods, but more particularly the latter, as will be explained later, are necessarily attended by grave dangers. In 1853 Crede described what he considered the ideal method of de- livering the placenta, which was somewhat as follows: Immediately after the exit of the child the obstetrician grasps the uterus with his hand and, after waiting from five to ten minutes, gently kneads it, thereby stimulating it to contract and to separate the placenta. The MANAGEMENT OF THE THIRD STAGE OF LABOR 337 hand is then applied to the abdomen in such a manner that the thumb rests upon the anterior and the fingers upon the posterior surface of the uterus, and as soon as a contraction occurs, firm and steady pressure should be made downward in the axis of the superior strait. The introduction and routine employment of Crede’s method, which aimed at hastening the separation of the placenta and then expressing it from the uterine cavity, undoubtedly marked a most important advance, inasmuch as, by doing away with the necessity for traction upon the cord and the frequent manual removal of the placenta, it has saved the lives of thousands of women. With certain modifications it is now generally employed throughout the world. As a matter of history, Jellett has noted that the method, while usually ascribed to Crede, had been prac- ticed for many years previously at the Rotunda Hospital in Dublin, and appears to have originated with John Harvie in 1767. In opposition to the expression of the placenta immediately after the birth of the child, Dohrn, Ahlfeld, and others have stated that a greater amount of blood is lost during the third stage, and that there is a greater tendency to postpartum hemorrhage, due to imperfect separation, than when the extrusion of the placenta is left to nature, or when expression is resorted to only after an interval of several hours. But, while it is recognized as incontrovertible that too early a resort to Crede’s method is harmful, inasmuch as it defeats the very purpose for which it is em- ployed and interferes with the physiological separation of the placenta, the arguments adduced in favor of waiting so long a time appear to be neither satisfactory nor rational. It is difficult to see what advantages are to be gained by delaying expression after the placenta has once be- come detached from its original site and lies in the lower uterine seg- ment, more particularly as Ahlfeld claims that spontaneous delivery will occur only in less than 14 per cent, of the patients at the end of two hours. Furthermore, there are certainly very obvious objections to any un- necessary prolongation of the third stage of labor. For the patient such a delay means additional discomfort, while the busy physician can ill afford the expenditure of valuable time, unless he be convinced that by such personal sacrifice he can better insure the well-being of his patient. In normal cases, therefore, attempts at expression should not be made until the placenta has been spontaneously expelled into the lower uterine segment or upper portion of the vagina, as is indicated by the rising up of the fundus; but as soon as this has taken place there is no reason why the process should not be hastened. In my own clinic the following pro- cedure has been adopted with satisfactory results: As soon as the child is born the hand is laid upon the abdomen, and if the uterus be felt as a firm, hard, globular mass it is left absolutely alone. On the other hand, if it appears to be soft and flaccid, it is gently kneaded until firm con- tractions are induced. The condition of the uterus is then carefully watched by applying the hand to it at intervals of five minutes, but kneading it only when necessary. In the majority of cases, after a lapse of ten or fifteen minutes, it is noticed that the fundus rises spontaneously several centimeters above the position which it had just occupied, and at 338 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR the same time remains firm and hard. This change indicates that the placenta has become separated from the uterine wall and is distending the lower uterine segment or the upper portion of the vagina. In doubt- ful cases important information may sometimes be obtained by holding the cord lightly between two fingers and making firm pressure upon the uterus with the other hand. If the placenta is still adherent, a distinct wave will be felt in the cord, which will be absent if separation has al- ready occurred. Attention was first directed to the significance of the rising of the fundus by Pinard, Schroeder, and Cohn, but its importance has not been generally recognized. The placenta is now expelled by grasping the uterus and making downward pressure in the axis of the superior strait, using the uterus merely as a piston to shove the placenta through the vagina. When the latter appears at the vulva it should be grasped by the hand and the membranes gently twisted into a cord, so as to prevent their being torn off from the margins of the placenta, after which they are slowly extracted. The modification here recommended, which we designate as “expres- sion from the vagina/’ leaves the separation of the placenta from the uterine wall absolutely to nature, and simply expresses it after it has been spontaneously expelled from the uterine cavity, and should not be confounded with the original Crede method, whose object is to hasten the separation of the organ and to express it from the uterine cavity. In most cases the placenta can be expressed from the vagina within half an hour after the birth of the child; but if the fundus does not rise up spontaneously by the end of that period, it is my practice to attempt to hasten separation by resort to the typical Crede method of expression. Frequently small portions of the membranes may be left behind in utero or in the vagina. If the ends be outside the vulva, they should be seized with an artery clamp and the remnants delivered by gentle traction; but otherwise it is advisable to leave them alone and to allow them to be cast off with the lochia, rather than to introduce the fingers into the vagina or uterus in the attempt to remove them. Immediately following the birth of the placenta the uterus should be again palpated; normally it will be found firmly contracted and retracted, and (if it remains so) there is no danger of hemorrhage. But, on the other hand, if it shows any tendency toward relaxation, it should be kneaded until it contracts, and the hand kept constantly upon it, so that beginning relaxation may be detected and combated. There is usually no danger of relaxation and consequent hemorrhage, provided no signs of it appear during the first hour after the extrusion of the placenta. Ac- cordingly, the condition of the uterus should be carefully watched during that period by the physician or nurse. But, even when this duty is dele- gated to the latter, the physician should remain at the house of the pa- tient for one hour, so as to be on hand in case an emergency should arise. In normal cases, there is no objection to administering one cubic centi- meter of pituitary extract hypodermatically, as a prophylactic measure, immediately after the extrusion of the placenta. While it is not neces- sary, the prompt and vigorous contractions which it induces add some- what to the peace of mind of the physician and can do no harm. On LITERATURE 339 the other hand, the drug should not be employed so long as the placenta remains in situ, for fear that it may give rise to an hour-glass con- traction of the uterus and thereby unnecessarily prolong the third stage of labor. Occasionally, the amount of blood lost immediately following the birth of the child may be so great as to render imperative the prompt delivery of the placenta, and under such circumstances Crede’s method of expression should be employed at once. Under all other conditions, however, we should watch for the rising up of the fundus before resorting to any form of expression. As soon as the placenta and membranes are born they should be care- fully inspected for the purpose of ascertaining whether they have been expelled entire, or whether portions have been left behind in the uterus. If they are perfectly intact, all is well; but if the maternal surface of the placenta shows defects which are not due to mere tears of its substance, but which appear to indicate that a considerable part has been left be- hind, the hand should be carefully redisinfected, a sterile rubber glove put on, and the retained portion removed manually, since if allowed to remain in the uterus it nearly always gives rise to hemorrhage. In rare cases spontaneous separation does not occur, and it may be found impossible at the end of half an hour to expel the placenta by means of Credos method. In such circumstances, unless the condition of the patient be serious, or there be free hemorrhage, the obstetrician should wait patiently and repeat his attempts at expression at intervals, and should not despair of eventual success until two hours have elapsed. In case of failure, it is probable that abnormal adhesions exist between the placenta and the uterine wall, but, in any case, manual removal of the organ must never be undertaken unless this course seems absolutely necessary, as it is a more serious procedure than most obstetrical opera- tions. In the former instance, the hand is introduced between the placenta and the uterine wall, and comes in direct contact with the freshly thrombosed vessels at the placental site, which afford a most excellent culture medium for bacteria; whereas in the latter the hands or instruments are introduced into the amniotic cavity, so that whatever microorganisms may have been carried up by them are likely to be cast off with the afterbirth. For particulars concerning the control of excessive hemorrhage or the technic of manual removal of the placenta, the reader is referred to the sections on hemorrhage and on obstetrical operations, respectively. LITEBATUBE Ahlfeld. Abwartende Methode Oder Crede’scher Handgriff? Leipzig, 1888. Ueber die ersten Vorgange bei der physiologischen Losung der Placenta. Zeitschr. f. Geb. u. Gyn., 1895, xxxiii, 418-442. Weitere Untersuchungen iiber die physiolog. Yorgange der Nachgeburtsperiode. Zeitschr. f. Geb. u. Gyn., 1897, xxxyi, 443-466. Die Blutung bei der Geburt, etc. Zeitschr. f. Geb. u. Gyn., 1904, li, 341-364. BaudelocQTJE. De la delivrance naturelle. L’art des aceouchements, 1789, t. i, 413-415. 340 PHYSIOLOGY AND MANAGEMENT OF THIRD STAGE OF LABOR Cohn. Zur Physiologic und Diatetik der Nachgeburtsperiode. Zeitschr. f. Geb. u. Gyn., 1886, xii, 381-417. Cred£. Ueber die zweckmassigste Methode der Entfernung der Nachgeburt. Mo- natsschr. f. Geburtskunde, 1861, xvii, 274-292. Ueber die zweckmassigste Methode der Entfernung der Nachgeburt. Archiv f. Gyn., 1881, xvii, 260-280. Dohrn. Zur Behandlung der Nachgeburtsperiode. Deutsche med. Wochenschr., 1880, vi, 545-547, Nr. 41. Die Behandlung des Nachgeburtszeitraumes. Jena, 1898. Duncan. The Expulsion of the Placenta. (Read to the Edinburgh Obstetrical Society, March 22, 1871.) Mechanism of Natural and Morbid Parturition. Edinburgh, 1875, 246-256. Freeman. The Third Stage of Labor. Am. Jour, of Obst., 1914, lxix, 302-309. Harvie. Practical Directions Showing a Method of Preserving the Perinamm in Child-birth and Delivering the Placenta without Violence. London, 1767. Holzapfel. Ueber die Losung und Ausstossung der Nachgeburt. Beitrage zur Geb. u. Gyn., 1899, ii, 413-481. Jellett. The Dublin Method of Effecting the Delivery of the Placenta. Dublin Jour. Med. Science, June, 1900, cix, 412-422. Leopold. Die Diagnose des Placentarsitzes in der Schwangerschaft und wiihrend der Geburt. Arbeiten aus dpr koniglichen Frauenklinik in Dresden, 1895, ii, 151-166. Pinard. Du palper pendant la delivrance normale. Traite du palper abdominal, 2me ed., Paris, 1884, 241-253. Pinard et Varnier. Etudes d’anatomie obstetricale normale et pathologique. Paris, 1892. Polar. A Study of the Management of the Placental Stage of Labor. Surg. Gyn. and Obst., 1915, xxi, 590-593. Schroeder. Beitrage zur Physiologie der Austreibungs- und Nachgeburtsperiode. Zeitschr. f. Geb. u. Gyn., 1885, xi, 421. Schroeder und Stratz. Zur Physiologie der Austreibungs- und Nachgeburts- periode. Der schwangere und kreissende Uterus. Berlin, 1886, 75-112. Sciiultze. Wandtafeln zur Schwangerschaft und Geburtskunde. Leipzig, 1865. Ueber den Mechanismus der spontanen Ausscheidung der Nachgeburt, etc. Deutsche med. Wochenschr., 1880, vi, 252. Warnekros. Die Nachgeburtsperiode im Rontgenbilde. Archiv f. Gyn., 1918, cix, 266-283. Weibel. Studien iiber die Nachgeburtsperiode auf Grund rontgenographischer Darstellung. Archiv f. Gyn., 1919, cxi, 413-507. Williams, J. W. A Histological Study of 50 Uteri Removed at Caesarean Section. Bull. Johns Hopkins Hospital. 1917, xxviii, 335-343. Tolerance of Freshly Delivered Women to Excessive Loss of Blood. Am. Jour. Johns Hopkins Hospital Bulletin, 1917, xxviii, 335-343. CHAPTER XV CONDUCT OF NORMAL LABOR The services of the obstetrician should be engaged as long as possible before the expected date of confinement, in order that the patient may have the advantages of medical supervision during at least the second half of pregnancy. The importance of a careful preliminary examination, not later than four to six weeks before term, has already been insisted upon. This should be carried out with the patient upon a suitable examining table or a firm bed, with sufficient clothing removed to give free access to all parts of the body. After making a thorough general physical examina- tion, the obstetrician should take careful measurements of the pelvis, de- termine the presentation and position of the child, and acquaint himself with any abnormality which may exist in the generative tract. At the time of this visit, if the patient is to be delivered at home, it is well to give her a list of such articles as may be needed at the time of labor and during the puerperium, and which she is expected to supply. The physician should also communicate with the nurse in order to make sure that she understands the preparations which fall to her share. Experience has taught me that the only way by which mistakes can be avoided is to use printed cards containing definite and concise in- structions for both the patient and nurse. Preparations for Labor on the Part of the Patient and Nurse.—If the patient is to be delivered at home, the room, to be used for the confinement, should be inspected in advance and suggestions made as to its arrangement. The obstetrician should also inquire as to the num- ber of wash-basins which are available; for with the increasing per- fection of plumbing the portable wash-basin is replaced by the permanent washstands, so that in the homes of the well-to-do it is sometimes difficult to find a sufficient number for disinfecting the hands and cleansing the patient. Four basins will be needed: three for the use of the physician and one for the nurse; and if so many are not already in the house, a sufficient number, made of plain agate-ware and measuring 10 inches across the top, should be procured. The patient should also be instructed to provide herself with a bed- pan, a 2-quart fountain syringe for rectal enemata, 15 yards of non- sterilized gauze and 2 pounds each of cotton batting and absorbent cotton for making bed-pads, or 6 prepared sanitary bed-pads and 2 pieces of rubber sheeting, one 1X2 yards and the other 1 X l1 for protecting the bed and bed covering. In addition to the above mentioned requisites the following articles should also be obtained from the drug store at 341 342 CONDUCT OF NORMAL LABOR least one month before the expected date of confinement, so that they may be in readiness in case labor should occur unexpectedly: 100 cubic centimeters Squibb’s chloro- form, 4 ounces boric acid, 2-ounce tube of green soap, 100 bichlorid tablets, 1-ounce tube of vaseline, 8 ounces alcohol, 4 drams ergotol, 1 nail-brush, 2 pounds absorbent cotton. If one has a large obstetrical practice it is advisable to have some reputable druggist arrange and keep in stock a box containing the above- mentioned articles, so that the patient can be told simply to buy an obstetrical outfit. Below is given the card which I prepared, while engaged in private practice, for the nurse, containing directions for the preparations before and at the time of labor, as well as for the care of the mother and baby afterward: DIRECTIONS FOR OBSTETRICAL NURSE (a) If the patient is to be delivered at home, see that she has pro- cured a “Confinement Outfit,” and the other articles called for in “Direc- tions for Patients,” which include everything yon or I shall need except baby clothes. (b) Prepare a sufficient number of sterile vulval pads. (c) A week before the expected date of confinement prepare seven packages, three containing six towels or diapers each; one containing leggings, two containing gauze sponges, and another containing cotton pledgets. Carefully sterilize and label them. AT TIME OF LABOR (a) If the patient is to be delivered in the hospital, take her there as soon as she is having regular pains at ten minute intervals. If, however, she is to be delivered at home, and pains begin between 8 a.m. and 11 P.M., notify me as soon as possible, so that I may know that labor has commenced and make my plans accordingly. But if labor begins after bed-time, do not notify me until morning, unless you think it necessary for me to see the patient at once. (b) At the commencement of labor prepare two large pitchers of boiled water. Keep one hot and allow the other to cool, covering each with a clean towel. (c) When labor has definitely set in, give the patient a warm bath and a soap-suds enema. (d) Make up the bed on the left side. (e) Procure a piece of oilcloth or an old rug to protect the floor. (/) Don’t give vaginal douches of any kind. PREPARATIONS BEFORE LABOR PREPARATIONS FOR LABOR 343 (g) Don’t examine patient vaginally under any circumstances. (h) To prepare the patient for vaginal examination place her upon a douche pan, and cut the pubic hairs. Then wash the genitalia thoroughly from above downward (toward the anus) with soap and warm water, using cotton pledgets instead of a wash cloth. Finally, bathe the vulva with a 1-1,000 bichlorid solution, and then cover it with a towel soaked in the same solution. (i) Before a vaginal examination, drape the patient with a clean sheet in order to minimize exposure, and when the birth of the child appears imminent, roll the nightgown up above the patient’s hips and pin it in position, then put on the obstetrical leggings. AFTER LABOR (a) As soon as labor is over, cleanse the genitalia with cotton pled- gets and water, and then bathe with bichlorid solution, after which apply a sterile vulval pad and place the patient upon a sterilized bed-pad. (b) Don’t use an abdominal binder, unless especially directed to do so. (c) Change vulval pads as often as necessary, washing the genitalia each time with a 1-4,000 bichlorid solution. (d) Take temperature and pulse four times a day (8, 12, 4, and 8), unless otherwise directed, and record upon chart. (e) Don’t catheterize unless the bladder is distended, and not until after the patient has failed to urinate in a sitting position. (/) Give 1 oz. of castor oil on the third morning after labor, and repeat in four hours if not effectual. (g) Bathe nipples with saturated boracic solution before and after each nursing. (h) Watch carefully for cracked nipples, and report them to me at once. (i) Diet: First twenty-four hours, milk, soup, tea, coffee or cocoa and buttered or soft toast. Second and third days, as above, with the addition of boiled or poached eggs, raw or stewed oysters, chicken breast, and wine jelly. Fourth and fifth days, as above, with the addition of sweetbreads, steak, chops, potatoes, rice, and fruit. Then gradually return to ordinary plain diet. CARE OF CHILD (a) Leave the baby alone until the mother is cared for, wrapping it in a woolen cloth and putting it in a safe place. (Not upon the mother’s bed or upon chairs.) (&) Wash the eyes with a boracic acid solution, unless otherwise di- rected. (c) Rub the child thoroughly with sweet oil or albolene, and then give it a lap bath with castile soap and warm water. (d) Dress the cord with boric acid powder and sterile cotton, or an alcohol dressing. 344 CONDUCT OF NORMAL LABOR (e) Wash the child daily in your lap, but do not give a full bath until the cord comes off. (/) Feeding: Until the milk appears, nurse three times a day, and don’t give any other food unless directed. After the milk appears, let the child suckle, except after its bath, every four hours by the clock, from 6 or 7 a. m. to 10 or 11 p. m. Time one feeding so that it will come directly after the bath, after which the child may be allowed to sleep as long as it will. Feed only once, or preferably not at all, between bedtime and 6 or 7 A. M. As soon as the milk appears, write out a schedule for nursing and adhere to it, awakening the child at each feeding time if necessary. (g) Weigh the child twice a week and record the result. Preparations on the Part of the Physician.—When the physician has promised to attend an obstetrical patient he should hold himself in readi- ness to respond promptly at any hour within two weeks of the expected date of confinement, and should instruct the patient as to the best method of communicating with him without delay. If he is obliged to leave town about that time, he should notify the patient and arrange for a competent substitute to take his place if necessary. He should also remember that the proper care of such cases requires a great deal of time, and frequently no small sacrifice of personal convenience, and if he is not willing to place himself at the disposal of his patients, as far as may be necessary, he should refuse to attend them. Undue haste is one of the most frequent causes of unsatisfactory results in this branch of medicine. The physician in private practice should provide himself with an obstetrical kit, which should be neatly packed in an appropriate box or valise and be kept ready for immediate use. It should contain not only the instruments which he may need, but also the various drugs required for hand disinfection, anesthesia, and the usual emergencies, as well as a supply of sterile towels and dressings, in case the patient has failed to provide herself wdth such materials, and for emergency cases. The obstetrical valise should contain a pelvimeter, nail-clippers and a nail-cleaner, chloroform, alcohol, bichlorid tablets, green soap, and nail-brush, sterile vaseline, ergotol or fluid extract of ergot, pituitrin, tablets of sodium chlorid for preparing normal salt solution, and a hypodermic syringe with the usual tablets. There should also be a chloroform inhaler, a suit of white clothes, and several sterilized roller bandages for packing the uterus. Glass tubes containing sterile catheters, catgut and silkworm-gut sutures, and bobbin for trying the cord are also needed, as well as a legholder, and a Kelly perineal pad for operative cases. The following instruments for repairing perineal and cervical lacera- tions should be ready for immediate use in a sterilized package: A pair of scissors, a needle-holder, four artery clamps, dissecting forceps, long dressing forceps, bullet forceps, a Simon speculum, and also an as- sortment of needles. The valise should also contain a tin box, 402 X 13 X 10 centimeters, provided with a lid and wooden handles. In this the various instruments can be packed when not in use, and at opera- CONDUCT OF THE FIRST STAGE OF LABOR 345 tions it serves as a boiler and as a receptacle for them after sterilization. A Tarnier axis-traction, or an ordinary Simpson forceps, should be carried, according as the physician has become accustomed to the one or other instrument, as well as a 3-quart fountain syringe with a glass nozzle for intra-uterine, and a hollow needle for subcutaneous injections of salt solution. The latter should be sterilized in advance and wrapped in a sterile towel, so as to be ready for immediate use. This list does not include the instruments required for the destructive operations, as they are not usually carried by the general practitioner. Fig. 312*—Obstetrical Bag. Everything mentioned in the above list may be packed into a box 21 X 8V2 X8 inches, or into a satchel measuring 20 X 10 inches at its base. Conduct of the First Stage of Labor.—As soon as the nature and se- verity of the pains indicate that labor has set in, the patient should receive a full bath and a rectal enema. When the physician arrives he should make a careful external examination, map out the presentation and position of the child, and listen to the fcetal heart. If the pelvis has already been found to be normal, and the vertex is firmly engaged, there is no necessity for making a vaginal examination, provided that the heart sounds are in good condition. Information concerning the degree of dilatation of the cervix can be obtained by rectal examination, as well as by the extent to which the head has descended into the pelvis, as shown by abdominal and perineal palpation. Again, the rupture of the membranes and the onset of bearing-down pains usually indicate the beginning of the second stage. If examination shows that labor is not 346 CONDUCT OF NORMAL LABOR well advanced, there is no necessity for the physician to remain with the patient, and he may leave to return again in a few hours. He should not, however, leave the house if the external os is fully dilated in a primiparous woman, or half dilated in a multipara, as in the latter the first stage is frequently very short, and the second occasionally terminates with a few expulsive pains. In general, if no abnormality is suspected, and the physician is well trained in the technic of abdominal palpation and rectal examination, vaginal examinations are unnecessary unless labor is unduly prolonged. They should be avoided for two reasons: to minimize the possibility of infection and to save the feelings of the patient as far as possible. Procedure in Hand Disinfection.—It is now generally admitted that it is impossible to render one’s hands absolutely sterile, no matter what method of disinfection may be employed. Even after the most rigorous directions have been scrupulously followed, there still remains a not inconsiderable danger of infection. With the view of still further minimizing these risks, the use of rub- ber gloves has been introduced. These can be rendered absolutely sterile by boiling, and, when drawn over the carefully disinfected hands, afford the greatest safety possible. Since, however, they are liable to tear oc- casionally, the necessity for disinfecting the hands before putting them on is apparent. But their employment, even in conjunction with all our other precautions, does not entirely do away with the possibility of intro- ducing pyogenic bacteria into the genital tract, since I have shown that they may be carried up from the vaginal outlet by the sterile gloved finger. In 1898 I demonstrated that pathogenic organisms are present upon the inner surfaces of the labia and the margins of the hymen in at least 60 per cent, of pregnant women, and that the mere introduction of a sterile glass speculum 2 centimeters in diameter, which is no larger than the two fingers employed for examination, carries microorganisms into the vagina in one-half of such cases. Moreover, inasmuch as the delicate structure of the parts renders their thorough disinfection out of the question, and as the examining fingers necessarily come in contact with them, it must be admitted that vaginal examinations during labor can never be entirely devoid of danger, and they should therefore be avoided so far as is consistent with the welfare of the patient. While these considerations should not deter us from making as many examina- tions as may be necessary in abnormal cases, it should always be borne in mind that the best results are obtained by the least possible employment of the vaginal touch, and the widest possible utilization of other methods of examination. If the hands of the physician have recently come in contact with in- fectious material at operation or autopsy, labor should be conducted by external manipulations alone, vaginal examinations being made only in the presence of some abnormality, and then only by the gloved hand. In all cases the hands should be disinfected as carefully as for a major surgical operation. Probably the best method for this purpose was introduced by Hr. Halsted, and described by Dr. Kelly in 1891, and consists of the following stens: CONDUCT OF THE FIRST STAGE OF LABOR 347 1. Cut the finger-nails to 1 millimeter in length. 2. Scrub the hands and forearms up to the elbows vigorously with nail-brush, green soap, and hot water, for five minutes or as much longer as may be necessary to render them macroscopically clean, paying par- ticular attention to the nails and palmar surface of the fingers. If run- ning water is not available, the water must be changed at least once. After changing it, remove dirt from beneath the finger-nails with nail- cleaner and renew the washing. 3. Einse the hands in fresh water and then soak them in a hot saturated solution of potassium permanganate until they take on a deep mahogany-brown color. 4. Dissolve this off in a hot saturated solution of oxalic acid. 5. Then soak the hands and forearms in a 1-1,000 bichlorid solution for three minutes by the clock. 6. Draw on the rubber gloves, which have previously been sterilized by boiling, and use no lubricant unless the entire hand is to be introduced into the vagina. The only objection which can be made to this method of hand disin- fection is the length of time which it requires and the roughness of the hands which sometimes follows it. The first objection cannot be over- come, as I do not believe that the hands can be thoroughly disinfected in less than ten minutes by any method. The second can be obviated to a great extent by anointing the hands with glycerin or some emollient after the examination has been made. Since 1917, however, I have discontinued the use of permanganate and oxalic acid, and, instead, soak the arms and forearms in 95 per cent, alcohol before immersing them in the bichlorid solution, and have had no reason to regret the change. For many years I have worn rubber gloves of medium thickness in all my obstetrical work, and cannot indorse their employment too strongly. Provided they have been properly boiled and drawn over the carefully disinfected hands with a suitable technic, they afford the patient absolute protection against infection by the physician’s hands; but, as has already been indicated, they offer no guarantee against infection by bacteria which' may be carried up from the external genitalia. I con- sider that it is better to draw on the gloves from a bichlorid solution, than to use the more convenient dry technic, for the reason that the fingers soon begin to sweat, with the result that bacteria which are in the deeper layers of the skin come to the surface, so that after a little while the tips of the glove fingers come to contain an emulsion of bacteria, desquamated epithelium and sweat. As long as the glove re- mains intact this is a matter of indifference, but should it be punctured by a needle or in any other way the emulsion is extruded into the wound. If the glove contains a small amount of bichlorid solution, the growth of the bacteria may be at least inhibited ; while if a dry glove has been used such inhibition is out of the question, and the possibility of infection would seem to be increased. The objection that the use of gloves interferes with the sense of touch is not valid, as I know from my own experience, as well as that 348 CONDUCT OF NORMAL LABOR of a large number of assistants, that it can be overcome by practice, so that .the most delicate procedures may be conducted just as satisfactorily as with the bare hand, with the one exception of rupturing the mem- branes. Consequently I urgently advise any one expecting to practice obstetrics to become accustomed to their use at the beginning of his career. An equally important prophylactic measure directed against infection consists in the greatest possible utilization of rectal examination with the index .finger. In nine cases out of ten it enables one to ascertain with accuracy the degree of dilatation of the cervix and the position of the presenting part in the pelvis. Furthermore, it has the additional ad- Fig. 313.—Showing Proper Method of Covering Patient with Sheet before Making a Rectal or Vaginal Examination vantage of not requiring disinfection on the part of the physician or the patient, as the non-sterilized glove is drawn directly over the un- washed hand, the glove being boiled and the hand washed after com- pletion of the examination. After many years’ experience, I have no hesitation in stating that in the conduct of labor vaginal examination should be made only after the findings on rectal exploration prove un- satisfactory. Preparation of Patient for Examination.—When directed by the physician, the nurse should prepare the patient for abdominal palpation and rectal examination. She should lie on the right or left side of the bed, according as the physician prefers to use his right or left hand. She should then be covered with a sheet, and the night gown rolled up as far as the costal margins. The sheet should be so arranged that by turning down its upper end the abdomen can be exposed for pal- pation, while its lower ends are so wrapped about the legs as to leave the external genitalia free with the least possible exposure of the patient. CONDUCT OF THE FIRST STAGE OF LABOR 349 If, after completing the rectal examination, it seems essential to examine by the vagina, the patient should be placed upon a douche pan and the pubic hairs cut short with scissors or shaved. Then the vulva and the inner surfaces of the thighs are thoroughly washed with soap and hot water, by means of a scrub-ball or cotton pledgets, par- ticular attention being paid to the regions about the anus and clitoris. After a thorough cleansing the parts should be rinsed with fresh water and then irrigated with two liters of 1-1,000 bichlorid solution poured from a small pitcher, after which they should be covered with a towel soaked in the same solution, which remains in place until the physician is ready to commence his examination. Finally, a sterile towel should Fig. 314.—Illustrating Spreading apart the Labia before Making a Vaginal Examination. be placed under the patient’s buttocks, so as to prevent the examining hand from coming in contact with the bed. Upon watching the routine cleansing of the external genitalia and observing that the soapy water almost unavoidably comes in contact with the vaginal opening, it occurred to us that the method employed might increase rather than minimize the possibility of infection. Upon my suggestion, Johnston and Siddall subjected the question to a clinical test by delivering a series of patients in our service, in which every alternate woman was prepared by the technic just described, while the others received no preparation except clipping the pubic hairs. Their observations, which were published in 1922, showed that the incidence of febrile puerperia was 16.3 and 12.4 per cent, in the two series, respectively, and indicated that if there was any difference it was slightly in favor of non-preparation. Although an additional series of obser- vations gave identical results, I am not yet prepared to advocate abandon- 350 CONDUCT OF NORMAL LABOR ing the time-honored method of preparing the genitalia, even though I am skeptical concerning its value. Method of Making a Vaginal Examination.—After the patient has been properly prepared, the thumb and forefinger of one hand distend the labia widely, so as to expose the vaginal opening and prevent the examining fingers from coming in contact with the inner surfaces of the labia and the margins of the hymen, while the index and second fingers of the other hand are introduced into the vagina. In making the examination a definite routine should be followed: 1. The fingers should be introduced along the anterior surface of the vaginal wall, and the shape and size of the pubic arch and the height of the sym- physis noted. 2. The cervix should then be examined in order to deter- mine whether its canal is obliterated, the degree to which the external os is dilated, and the character of its margins. Next we observe whether the membranes are intact or not, great care being taken to avoid ruptur- ing them if the patient is in the first stage of labor. 3. If the os be dilated, the presentation and position of the child should be made out, and the relation of the presenting part to the superior strait and to the line connecting the ischial spines determined. 4. After having decided these points the palmar surface of the fingers should be directed pos- teriorly, and the perineum palpated between the two fingers in the vagina and the thumb outside, with special reference to its consistency, thick- ness, and resistance. 5. The mobility of the coccyx should then be tested, after which the fingers should be passed upward over the anterior surface of the sacrum and its vertical and lateral curvature noted. If the pre- senting part is not low down, the three lower sacral vertebrae are readily palpable in normal women, whereas the first and second can be felt only in contracted pelves. 6. If the presenting part is not deeply engaged, and the diagonal conjugate has not been measured at the preliminary examination, its length should now be determined. After completing the examination, the physician is usually expected to express an opinion as to the probable course of events. If everything is normal, he should assure the patient that all is well, but he should guard against making any precise statement as to the probable duration of labor, and be content with saying that in the circumstances the average time is only a certain number of hours, and that her suffering will probably be ended within that period. The obstetrician who ven- tures to make more precise statements will speedily find that his predic- tions are often very faulty, even when the head is on the perineum. If some abnormality be present it is not always wise to inform the patient of the fact, but the physician should be careful to impart his knowledge to some responsible member of the family for his own protection. During the first, stage of labor the patient usually prefers to move about her room, and frequently is more comfortable when occupying a sitting position. During this period, therefore, she should not be com- pelled to take to her bed unless she feels so inclined, and when she does so she should be cautioned against attempting to hasten labor by volun- tarily bringing her abdominal muscles into play, for they have no effect CONDUCT OF THE SECOND STAGE OF LABOR 351 upon the dilatation of the cervix, and the effort will only serve to exhaust her strength. Conduct of the Second Stage of Labor.—The beginning of the second stage of labor is usually indicated by the rupture of the membranes and the onset of bearing-down pains, though these signs are not altogether characteristic, as rupture may occasionally occur at an early period, or the patient may attempt to hasten the course of labor by making pre- mature use of her abdominal muscles. On the other hand, the mem- branes sometimes remain intact until they protrude from the vulva. In still rarer cases they do not rupture at all, the child coming into the world surrounded by them, or, as it is popularly termed, being born with a caul. In the latter part of the first stage the pains generally become so severe that the patient instinctively seeks the recumbent position; but if she is still moving about the room or sitting up, she should go to bed immediately upon the rupture of the membranes and the beginning of bearing-down pains. Preparation of the Bed.—The bed should be prepared as soon as the oains become severe, since in the case of a multiparous woman the second stage of labor may be so short as to leave no time for such preparations. A high single iron bedstead is preferable, but in private practice one fre- quently has to be content with the ordinary double bed. Under such cir- cumstances one side of it should be prepared for the patient; whether the right or left depends upon which hand the physician expects to use for vaginal examination and the conduct of labor. A large piece of rubber sheeting, 1X2 yards, should be placed over the center of the mattress, covering its entire width, and over this a sheet is spread. A second piece of rubber sheeting, 1 X h/2 yards, is placed upon the side of the bed upon which the patient is to lie, in such a position that it will come directly under her buttocks. The entire bed is then covered by a draw-sheet; over this is placed a sterile bed-pad, upon which the buttocks rest. With this arrangement, the upper sheet and the smaller piece of rubber cloth can be removed at the completion of labor, leaving the mattress protected by the large piece of rubber sheeting and the under sheet. In ordinary deliveries I have abandoned the use of the rubber obstetrical pad, and have replaced it by sterile, absorbable bed-pads. The former is very difficult to keep clean, and owing to the irregularities of the surface of the bed frequently defeats the purpose for which it was devised, in that the fluid which collects in it escapes over the bed and under the patient. To avoid exposure, the legs should be encased in long leggings, which reach to the thighs and are pinned to the rolled-up nightgown. In winter these may be made of canton flannel and in summer of thin muslin. Examination of the Patient.—After the patient has been put to bed, the question arises whether or not a vaginal examination should be made, and this is determined by the condition of affairs in each case. If abdominal palpation shows that the head is deeply engaged, it should be omitted; but if the presenting part is not engaged, or any abnormality is present or suspected, an internal examination is absolutely necessary 352 CONDUCT OF NORMAL LABOR in order to ascertain whether the cord has prolapsed, or if everything is as it should be. If the patient has apparently been in the second stage of labor for some time without rupture of the membranes, a vaginal examination is advisable in order to determine the condition of the cervix; for, after it has become completely dilated, the membranes have served their purpose and retard, rather than hasten, the birth of the child, so that it may be advisable to rupture them artificially. Formerly this was usually readily accomplished by sawing through them with the finger-nail, or by pinching them between the two examining fingers, but this cannot be done when rubber gloves are worn, so that it becomes necessary to Fig. 315.—Palpating Head tiieotjgh Perineum. resort to instrumental means. For this purpose a sterilized bullet forceps is admirably suited, but if it is not available, a large safety pin, previ- ously sterilized by boiling, is a convenient substitute. The membranes should not be ruptured during the acme of a pain, particularly when the head is not engaged, as occasionally it happens that the rush of amniotic fluid may carry the cord along with it, and thus bring about its prolapse. The beginner should always be careful to differentiate between the distended membranes and a tense caput succedaneum. Ordinarily in the second stage of labor the necessary information can be obtained by rectal exploration, but when vaginal examination be- comes necessary the most rigid aseptic technic should be observed. When the head is deeply engaged in the pelvis, its descent can readily be traced by the increasing difficulty with which the cephalic prominence is felt on employment of the fourth maneuver. Moreover, when it can no CONDUCT OF THE SECOND STAGE OF LABOR 353 longer be felt from above, if the legs are widely separated and the tips of the fingers applied to the perineum, to the side of and in front of the anus, and pressed firmly inward and upward, the presenting part can be felt as a firm, rounded body. Generally speaking, this maneuver becomes available as soon as the head has passed below the level of the ischial spines. During the entire second stage auscultation should be practiced at frequent intervals, particularly when the head has reached the pelvic floor, for occasionally the cord is pressed upon tightly, and the child may become asphyxiated at this period and be lost, if not delivered promptly. Fig. 316.—Showing Patient Covered by Sterile Dressings and in Proper Position for Delivery. Delivery.—As soon as the head can be palpated through the perineum preparations should be made for delivery. A table should be placed in a convenient position at the side of the bed, and upon it a basin of boiled water and another of 1-1,000 bichlorid solution, as well as sterile cotton pledgets or gauze sponges, a certain number of sterile towels, and the material for tying the cord. The instruments needed for the repair of the perineum should also be within easy reach. The patient should then be placed in position upon the bed. In this country it is customary for her to lie upon her back with the legs drawn up, though in England and many places on the Continent the lateral position is preferred. I prefer the former, as it affords better facilities for the preservation of an aseptic technic. The night-gown should be 354 CONDUCT OF NORMAL LABOR rolled up beneath the patient's back, so that 'it may not be soiled, and the genitalia again washed with soap and water, and bathed with a bichlorid solution. After having drawn freshly boiled gloves over his carefully disin- fected hands, so that he may make an immediate vaginal examination if necessary, the physician should encase the patient’s legs in sterile leg- gings, and, while they are held up, a sterile sheet should be so placed as to extend from the patient’s buttocks to the foot of the bed. A sterile absorbent pad is then put under the buttocks, and sterile towels are placed over the abdomen and legs of the patient and pinned in position, so that everything with which the physician’s hands may come is cov- ered by sterile dressings, leaving only the vulva and perineum exposed. As the head passes down into the pelvis small particles of feces are frequently expelled, and as they appear at the anus they should be wiped away with a piece of cotton, after which the parts should be sponged off with fresh pledgets soaked in bichlorid solution. As soon as the head begins to distend the vulva, the patient’s suffer- ings become greatly increased, and are frequently excruciating. If anes- thesia has not already been induced, its use should be begun at this stage, partly to relieve the pain, and partly to aid in protecting the perineum. Directions concerning the choice of an anesthetic and its mode of ad- ministration will be given on page 359. Protection of the Perineum.—As soon as the perineum shows signs of bulging the physician should make preparations for its protection, placing himself in such a position as to be able effectually to check the progress of the head if necessary. Injuries to the perineum are of very frequent occurrence, and cannot always be avoided even under the most skillful treatment. The state- ments as to their frequency vary considerably, but all authorities agree that they occur much oftener in primiparous than in multiparous women. Thus, Schroeder observed them in 34.5 and 9 per cent, of his cases re- spectively, and Olshausen in 21.1 and 4.7 per cent. These figures would seem to be too conservative, as in my experience slight tears implicaiing the fourchette occur in about two-thirds of all primiparae, and in 10 per cent, of multiparae. Occasionally one meets with physicians who state that they have delivered several thousand women with one or two, or possibly without a single, perineal tear. Such statements, however, are always erroneous, and merely indicate that the physician has not inspected the parts after labor, and designates as torn only those cases in which the yagina and rectum have been converted into a cloaca, to the existence of which his attention would assuredly be called by the patient. In the greatest number of cases the fourchette alone suffers, but not uncommonly the tear extends through a greater or lesser portion of the perineal body and is usually associated with another extending some dis- tance up one or both vaginal sulci, while in rare cases the entire perineum is torn through and the rectum opened up. The first two varieties are frequently unavoidable, but the common occurrence of complete tears is an indication of negligence. CONDUCT OF THE SECOND STAGE OF LABOR 355 Generally speaking, the causes of rupture are fourfold: disproportion between the head and the vulva, too rapid expulsion, abnormalities in the mechanism of labor, or a narrow pubic arch. Where the head is unusu- ally large or the vulva excessively small, the mechanical conditions are such that birth cannot take place without a certain amount of laceration. In not a few cases the tearing is due not so much to absolute dispropor- tion between the head and the vulva as to the lack of elasticity of the perineum, which is particularly marked in elderly primiparae. Too rapid expulsion, however, is a much more frequent cause of rupture, and when the head is suddenly and forcibly extruded through the imperfectly distended vulva its mode of production is manifest. Various abnormalities in the mechanism of labor favor rupture of the perineum. The most frequent of these is imperfect extension of the head, so that the vulva is distended by the occipito-frontal, instead of the suboccipitobregmatic or suboccipitofrontal circumference. In a cer- tain number of cases the presenting part may be directed too far back- ward—in other words, extension does not occur—and under the influence of the uterine contractions the presenting part is forced directly down- ward upon the perineal body, instead of being guided upward and for- ward toward the vulval opening. A similar condition is observed in women having funnel-shaped pelves, in which the pubic arch is long and narrow, whereby the head is prevented from engaging directly under the symphysis pubis. Again, in rare instances, an abnormal inclination of the pelvis, by causing the vulval opening to look more upward than usual, may bring about a similar condition. In considering the mechan- ism of labor, we directed attention to the factors which predispose to perineal rupture, when the head is delivered in persistent occipitopos- terior positions, or when the child presents by the brow, face, or breech. Giffard, in 1733, was the first to direct attention to the advisability of attempting to prevent perineal tears, and very precise directions were given by John Harvie in 1767. Numerous devices have since been suggested having the same object in view, but their very multiplicity argues that they are not uniformly satisfactory. In most of the older methods pressure was applied directly to the perineum, or various at- tempts were made to relieve the tension to which it was subjected, so that the physician was said to support the perineum. An excellent resume of the early literature upon the subject will be found in Goodell’s scholarly article, published in 1871. In the method which has stood me in best stead, no attempt is made to support the perineum by pressure, but the obstetrician simply endeav- ors to favor extension of the head and prevent it from being suddenly extruded during the acme of a pain. For this purpose, when the vertex distends the vulva widely, it should be seized between the thumb and three fingers of one hand, and forcible pressure made against it during each pain, in such a manner as to bring the occiput, and later the nape of the neck, directly in contact with the inferior margin of the symphysis, and thus increase extension. Accordingly, as soon as the head appears at the vulva, the physician should be ready to restrain its progress. He should hold his hand in such a manner as to be able to bring it immedi- 356 CONDUCT OF NORMAL LABOR ately into action, for in many instances the resistance of the vulva is unexpectedly overcome, and a single pain may be sufficient to push the head suddenly through it with a resulting perineal tear. After the head is so far born that the vulva is distended by the parietal bosses, it may be advisable to attempt to express it by Bit gen’s method in an interval between the pains. For this purpose, the patient having been instructed to open her mouth and not to attempt to bear down, the anesthesia is deepened. At the same time two fingers are applied just behind the anus, and forward and upward pressure is made upon the brow through the Fig. 317.—Method of Holding back Head to Protect Perineum. perineum. I, however, only employ the method when spontaneous expulsion is delayed. The student is warned from attempting to protect the perineum by any method which aims at stripping it back over the presenting part, as such a procedure is useless, even if carried out successfully. The same may be said of the introduction of the finger into the anus, for the purpose of drawing the perineum up over the head, as suggested by Dr. Goodell. In fact, all such procedures are not only of questionable utility, so far as the protection of the perineum is concerned, but are dangerous in that they contaminate the hand and throw it out of func- tion in case an emergency should arise which calls for its prompt in- troduction into the genital tract. Formerly, it was customary to introduce one or two fingers into the CONDUCT OF THE SECOND STAGE OF LABOR 357 vagina as soon as the head reached the pelvic floor, so that it might not surprise the obstetrician by a sudden advance. Such a practice is extremely reprehensible, as it increases the possibility of contamination and infection. Many authorities, when rupture of the perineum seems imminent, ad- vise the performance of episiotomy. In this operation a strong pair of scissors is introduced between the head and the perineum, and an oblique incision made downward and backward on one or both sides between the anus and the tuber ischii. The operation is practiced in the belief that the vulval opening, if sufficiently enlarged by the incision, will not tear farther, or that in any case the laceration will occur in the continuation of the incisions, whose clean-cut edges will heal more readily than the irregular spontaneous tears. Personally, I see no ad- vantage in the procedure, as my experience is that ordinary perineal tears will heal almost uniformly if properly sutured and cared for. In an article entitled “Shall we Cut and Reconstruct the Perineum in every Primipara”?, Pomeroy, in 1918, advocated making a midline incision as soon as the perineum begins to bulge, with the idea that its accurate repair immediately after delivery would prevent the develop- ment of relaxation of the pelvic floor in the future. While this may be so, it would appear to be an inadvisable routine procedure for two reasons: first, that it converts every labor into an operative one, and second, that if ideally successful its renetition would be logically called for at each subsequent delivery. Coils of Cord about the Neck.—Immediately after the birth of the head, the finger should be passed to the neck of the child in order to ascertain whether it is encircled by one or more coils of the umbilical cord. This complication occurs in about every fourth case, and ordi- narily does no harm, but occasionally the vessels are pressed upon so tightly that asphyxiation results. If such a coil be felt, it should be drawn down between the fingers, and, if loose enough, slipped over the child’s head; but if it be too tightly applied to permit of this procedure, and the head appears congested and suffused, the cord should be seized and cut between two artery clamps, and the child immediately extracted. Delivery of the Shoulders.—In the majority of cases the shoulders appear at the vulva just after the occurrence of external rotation, and are born spontaneously. Occasionally, however, a delay occurs and im- mediate extraction may appear advisable. To accomplish this the occiput and chin should be seized by the two hands, and downward traction made until the anterior shoulder appears under the pubic arch; next, by an upward movement, the posterior shoulder should be delivered, after which the other shoulder will usually drop down from beneath the symphysis. The body almost always follows the shoulders without difficulty, but in case of prolonged delay its birth may be hastened by traction upon the head, but not by hooking the fingers in the axillae, since by the latter procedure the nerves of the arm may be injured and transient or permanent paralysis result. Indeed, even when the former method of ex- traction is employed, traction should be exerted only in the direction of 358 CONDUCT OF NORMAL LABOR the long axis of the child, for if it be made obliquely the neck will be bent upon the body, when excessive stretching of the brachial plexus on its convex side may occur, with subsequent paralysis. Tying the Cord.—Immediately after its birth the child usually makes an inspiratory movement and then begins to cry. In such circumstances it should be placed between the patient’s legs in such a manner as to leave the cord lax, and thus avoid traction upon it. If, however, the child does not begin to breathe immediately, the cord should be seized and cut between two artery clamps, and efforts at resuscitation commenced at once. Normally, the cord should not be ligated until it has ceased to pul- sate. In securing it, a ligature of sterilized bobbin should be applied 2 centimeters from the abdomen of the child and tightly tied; a second Fig. 318.—Traction to Bring about Descent of Anterior Shoulder. ligature is placed several centimeters above the first, and the cord cut between the two. Usually ligation of the maternal end merely serves to avoid soiling the bedclothes by blood escaping from it; but in single ovum twin pregnancies double ligation is essential, for there may be such extensive anastomoses in the placental circulation that the second child, while still in the uterus, may bleed to death from the maternal end of the cord of the first. The question as to the proper time for tying the cord has given rise to a great deal of discussion. Formerly it was the custom to ligate it immediately after the birth of the child; but Budin showed that 92 cubic centimeters more blood escaped from the maternal end of the cord after early than after late ligation, thus indicating that that amount was lost to the foetus by early ligation. Schiicking demonstrated the same fact by weighing the child just after birth and again after the cord had ceased to pulsate. Budin believed that this amount of blood was drawn into the circulatory system of the foetus by thoracic aspira- tion, while Schiicking held that it was driven into it as a result of the compression of the placenta by the contracting uterus. CONDUCT OF THE SECOND STAGE OF LABOR 359 I have always practiced late ligation of the cord and have seen no injurious effects following it, and therefore recommend its employment, unless some emergency arises which calls for earlier interference. After ligation of the cord, the child should be wrapped in a piece of flannel or blanket prepared for the purpose, and laid in a safe place until the placenta is born and the mother has been cleaned up and made comfortable. Anesthesia.—We are indebted to Sir James Y. Simpson for the introduction of anesthesia into obstetrical practice. He employed ether for this purpose in the year 1847, and replaced it by chloroform after he had discovered the anesthetic properties of the latter drug. Chan- ning of Boston introduced the prac- tice into America. Although it at first encountered great opposition from physicians, clergymen and lay- men, every one now agrees as to the marked Benefits derived from anes- thesia when operative procedures are to be undertaken, and, except for a few who still believe in fol- lowing literally the biblical in- junction—“in sorrow shalt thou bring forth”—all intelligent wo- men at present demand to be spared as far as possible from the suffering incident to the completion of normal labor. The most generally used anesthetics are ether and chloroform, and when obstetrical operations are to be performed it makes very little difference which is employed, as it is well-known that the dangers in- cident to chloroform are markedly reduced at the time of labor. It should, however, be remembered that this immunity is limited to the parturient woman, and does not exist during the puerperium, when chloroform is quite as dangerous as at other times. Exactly why this immunity should exist is a question which has not yet been definitely Fig. 319.—Delivery of Posterior Shoulder. 360 CONDUCT OF NORMAL LABOR settled, but it is nevertheless a fact which has been established beyond peradventure. Generally speaking, chloroform is preferable in normal labor, for by its use obstetrical anesthesia can be rapidly and safely produced. I be- lieve that it is practically devoid of danger when properly administered, and should be used whenever there is time for its administration, unless the patient has conscientious objections to its employment. The choice of the time for its administration, however, is of great importance, nor should it be used before the latter part of the second stage, when the head becomes palpable through the perineum. A few drops of chloroform should then be poured upon the inhaler, and with the beginning of a pain the patient should be instructed to breathe in the fumes vigorously; but as soon as the contraction has ceased the inhaler should be removed, to be used again when the patient makes a sign that she feels the first indication that another is beginning. This is known as obstetrical anesthesia or anesthesia a la reine, for the reason that Queen Victoria was the first crowned head to submit to its use, and is intended merely to diminish the sensation of pain and not to produce complete unconsciousness. When properly administered, the patient experiences marked relief after a few inhalations, but retains consciousness and is generally able to talk rationally. When the disten- tion of the vulva is at its maximum, obstetrical anesthesia is not sufficient to abolish the pain, and it is my practice at that time to render the patient completely unconscious by increasing the dose of the drug. By this procedure the woman is saved an immense amount of avoid- able suffering, and at the same time the danger of perineal lacera- tion is diminished. For, if the pain is minimized, and done away with entirely at the critical mompnt, the patient will lie still instead of tossing in bed, and there will not be the same danger of the head being sud- denly expelled at the acme of a contraction, while the physician is employing his energies in persuading the patient to keep quiet, or may even be forcing her legs apart so that he may be able to protect the perineum. The amount of chloroform required for this purpose rarely exceeds 2 or 3 drams. The administration of chloroform should not be resorted to in the first stage, except in the presence of exceptional indications. Leaving out of consideration its possible influence upon the efficiency of the uterine contractions, it is only natural that as soon as the patient has experienced the soothing effects of the drug she is extremely loath to do without it, and, once having begun, the physician may find himself forced to continue its administration, unless he possesses more fortitude than is generally the case. Against the employment of anesthetics in labor, it has been urged that they diminish the force of the uterine contractions. This state- ment is partially correct, for when administered for any great length of time they undoubtedly lead to a shortening of the contractions and to a prolongation of the interval between them, as was demonstrated by the experiments of Donhoff and Hensen. On the other hand, when exhibited only at the proper time and in no excessive amount, this CONDUCT OF THE SECOND STAGE OF LABOR 361 objection does not hold good, and in many instances small doses even appear to stimulate the uterine contractions, and, by diminishing the sensation of pain, enable the patient to bring her abdominal muscles into full play, which she previously may have been unwilling to do, and thus hasten the completion of labor. Again, it has been taught that anesthesia predisposes to relaxation of the uterus after the expulsion of the placenta, and thus increases the danger of postpartum hemorrhage. So far as my own experience goes, such sequelae are not likely to occur, provided the drug has been properly administered. At the same time it must be admitted that its prolonged administration does tend toward uterine inertia, and is not without a deleterious influence upon the child. In exceptional cases chloroform, while diminishing the pain, appears to excite the patient. Under such conditions its use should be discon- tinued unless complete anesthesia is necessary. It should never be used in the first stage of prolonged labors in the hope of hastening the dilata- tion of the cervix, as this object is better attained by the proper administration of chloral or morphia. Ordinarily the patient is allowed to come from under the influence of the anesthetic as soon as the child is born, as its exhibition is not necessary in the third stage of labor, except when the placenta is to be removed manually, or an extensive perineal laceration is to be repaired. Nitrous Oxid Gas Analgesia.—Although gas has occasionally been employed for the induction of anesthesia in obstetrical operations, more particularly in cesarean section upon patients whose general condition contra-indicates the use of the usual anesthetic agents, it was not until 1915 that Webster, Lynch and Davis directed especial attention to the feasibility of inducing obstetrical anesthesia by its means. These authors pointed out that by the aid of modern apparatus it is possible to induce the same type of analgesia with a mixture of nitrous oxid gas and oxygen, as with chloroform administered a la reine, and that if a few whiffs of gas are given with the onset of the contraction and are replaced by oxygen as it passes off, the patient soon loses all sensation of pain, but still retains consciousness. They likewise claim that this form of analgesia has the great advantage over that pro- duced by chloroform in that it stimulates rather than diminishes the frequency and intensity of the uterine contractions during the second stage, and thereby may actually shorten the duration of labor. Moreover, Lynch contends that its administration may be begun early in the first stage and be continued almost indefinitely without injury to the mother or child. Having extensively employed this form of anesthesia for years, I strongly advocate its use in normal labor in hospital practice, although full anesthesia must be induced as the head passes the vulva, which sometimes requires switching over to ether for a few minutes. Further- more, the administration of gas does not predispose to excessive post- partum bleeding, and apparently has no injurious effects upon either the mother or child. While Lynch may be correct in stating that gas anesthesia may be 362 CONDUCT OF NORMAL LABOR safely continued for many hours, I feel that its use should be limited to the second stage; but, in view of the fact that it stimulates rather than retards uterine activity, it may be commenced as soon as the cervix has become fully dilated, instead of waiting until the presenting part has reached the pelvic Jloor, as with chloroform or ether. Furthermore, I believe tha’t the method will necessarily be restricted to hospital use and to practice among the well-to-do; as the actual cost of the gas, the transportation of the more or less cumbrous apparatus, and the necessity of a trained assistant to manipulate it place it beyond the means of the ordinary patient in her own home with whom chloroform or ether will retain their pre-eminence. In my hospital service chloroform, or gas and oxygen is administered during the second stage in all normal labors, and if, in addition, 1/12 grain of heroin be administered hypodermatically as soon as the cervix has dilated to 3 or 4 centimeters in diameter, and the patient be kept in a semi-darkened room, from which all unnecessary noise is excluded, the suffering is reduced to a bearable minimum, and most of the ad- vantages attending “twilight sleep” are obtained without its dis- advantages. In my experience, heroin is greatly superior to morphia in its analgesic action, and it possesses the additional advantage that it does not decrease the intensity of the uterine contractions and has no deleterious effects upon the child. Scopolamin-morphin Anesthesia.—This method of combating the pain of labor was introduced in 1902 by Steinbiickel, who reported that the hypodermic injection of 0.0003 gram of scopolamin hydrobromate and 0.01 gram of morphia gave most satisfactory results and practically annulled the pains of labor, even permitting the application of forceps or the artificial dilatation of the cervix. In 1907 Gauss reported its administration in 1,000 cases in Kronig’s clinic in Freiburg, and stated that by a proper regulation of dosage 80 per cent, of the patients would pass into a semiconscious state, which he designated as “Twilight Sleep.” In this condition the patient appears to appreciate pain at the time, but has no recollection of it later. For this purpose he administers 0.0003 gram of scopolamin and 0.01 of morphia hypodermatically, and repeats the scopolamin, but not the morphia, once or several times later if necessary. The indication for its repetition is not afforded by the lapse of any specified length of time, but rather by the mental condition of the patient, who should be kept in a state of relative amnesia. This is determined by showing her some object, which she should promptly forget having seen, if sufficiently under the influence of the drug, but another dose should be administered if she possess any recollection of it thirty minutes later. A very considerable literature has accumulated upon the subject, which has been well summarized by Lequeux, Zweifel, Siegel, and by a committee of the London Obstetrical Society in 1918. Following a magazine campaign in 1914, great interest in the pro- cedure was aroused among the laity, and obstetricians all over the country were constrained to experiment with the method, and a large number of publications of varying value have been made concerning it. CONDUCT OF THE SECOND STAGE OF LABOR 363 My own expefience is that if 1/6 grain of morphia and 1/150 grain of scopolamin be administered when the cervical canal has been oblit- erated and the external os is just beginning to dilate, followed by a sec- ond dose of 1/300 grain scopolamin one-half or one hour later, the patient passes into a somnolent condition, with a flushed face, injected eyes, and an accelerated pulse rate, and sleeps quietly, and sometimes heavily, in the interval between the pains, but complains bitterly during their con- tinuance. Following the second dose of scopolamin, others are adminis- tered at intervals of from one and a half to three hours, according to the mental condition of the patient, but the morphia or narcophen is not repeated unless the labor is unusually prolonged. During this period the patient should be kept in a dimly lighted room, from which all noise is excluded, her ears should be plugged with cotton and her eyes shaded by colored glasses, while a competent attendant should remain continually in the room. The dosage indicated is not sufficient to control the pains during the latter part of the second stage, when chloroform or nitrous oxid gas should be administered. Following the completion of labor the patient is kept in a quiet, darkened room, and upon being questioned at the end of three or four hours, is usually surprised to learn that her baby has been born, and will state that she has no recol- lection of what had occurred after the second or third injection of scopolamin. If the drug is not administered until late in the first stage of labor, the results are always disappointing, and the child is usually deeply asphyxiated when born. The desired degree of amnesia is obtained in about three-quarters of the patients provided a suitable technic has been developed by those in charge; in the remainder the results are not satisfactory, as the patients remember everything that has happened up to the time the administration of chloroform or gas was begun. It should be added that behavior of the patient while under the influence of the drug affords no indication of the degree of amnesia; as many patients become violently excited and complain bitterly with every pain, and yet after labor claim that they have no recollection of what has occurred. On the contrary, others, who appeared to be profoundly under the influence of the drug, recall every incident and contend that the labor was most painful. The fact that we cannot promise a satisfactory subjective result to more than three patients out of four makes it apparent that the method is not ideal, and it is my belief that it will gradually fall into desuetude, or at least that its use will be restricted to a small group of neurotic patients, upon whom it is desirable to exert a psychic effect. In addi- tion to this relative defect, several serious objections are inherent to this form of anesthesia. In the first place, while some of its. enthusi- astic advocates claim that it slightly shortens the first stage of labor, all agree that it results in a definite prolongation of the second stage, necessitating more frequent instrumental interference, with its addi- tional danger of infection. In the second place it is attended by a definite, but slight, increase in the foetal mortality, estimated at between 1 and 2 per cent., which is apparently due to direct poisoning of the foetus. A large proportion of the children are born in an apneic con- 364 CONDUCT OF NORMAL LABOR dition; a smaller number are deeply asphyxiated, but can be resusci- tated without great difficulty; while occasionally the asphyxia is so deep that resuscitation is impossible. It has no effect upon the maternal mortality, nor apparently upon the incidence of postpartum hemor- rhage. From my experience, the method is not adapted to private practice for three reasons. First, that it can only be expected to give ideal results when it is carried out by a trained personnel, under suitable material conditions; secondly, that in a considerable proportion of cases it is attended by a degree of restlessness and excitement, which may require physical restraint, and which makes a very painful impression upon those interested in the patient. Finally, it makes such demands upon the time and nervous equation of the physician, as to put it beyond the reach of all but well-to-do patients; as the already under-paid obstetrician cannot be expected to devote twelve or fifteen hours of continuous service to a normal delivery, which ordinarily requires but a few hours of his time. Lumbar Anesthesia.—Following the rehabilitation by Bier of the sub- arachnoidal injection of cocain for the production of anesthesia of the lower portion of the body, and its popularization by the work of Tuffier, it was but natural that its efficiency should be tested upon the parturient woman. The first publication concerning its employment at the time of labor was made in August, 1900, by Kreis. Since then a number of observers have reported series of cases treated in this manner with cocain or some of its derivatives, and their work was well summarized by Muller in 1905. From their reports, as well as from personal observation, there is no doubt that most striking results are obtained in a certain pro- portion of cases. In favorable cases, the patient being in the second stage of labor, the injection into the lumbar portion of the vertebral canal of 10 to 15 minims of a 1 per cent, solution of novocain (1/10 to 1/6 grain) is fol- lowed within a few minutes by complete abolition of painful sensations. At the same time, the patient continues to make visible expulsive efforts with great regularity and ofttimes with increased frequency, so that, if the effects of the drug do not wear off too rapidly, the child may be expelled without pain and almost without the knowledge of the patient. Likewise, various operative procedures, such as manual dilatation of the cervix, version, or forceps, may be painlessly performed. I shall not enter into the details of its technic, as I advise strongly against its employment for the following reasons. In the first place, the results are not always uniform, a certain number of patients appear- ing to be refractory to the influence of the drug when administered in doses consistent with safety. Again, its effects are sometimes very transient and fade away just when most needed. More serious, how- ever, are the after-effects, the majority of patients suffering severely from headache and nausea, and frequently from an alarming, hut transient, elevation of temperature. The most serious objection, how- ever, is the fact that Hahn reported 8 deaths in 1,708 cases in whicl? REPAIR OF THE LACERATED PERINEUM 365 its use had been recorded in the literature. No doubt, in several in- stances the fatal issue could not be fairly attributed to the method, but in several others the autopsy showed lesions of the spinal or cerebral meninges which could be due only to infection. Hypnotism.—From time to time, various observers, among whom may be mentioned Leichstein, and Cocke, have reported instances in which labor was painlessly conducted under the influence of hypnotism. Latterly, its employment has been resumed, and in 1922 Schultze- Khonhof, Kirsten and others have reported a series of cases in which it was used with extraordinary success. Personally I have seen it employed successfully in a single instance, and consider that its field of usefulness is very limited, for the reason that the patient must be a susceptible subject, and one who has already been hypnotized on previous occasions. The Use of Ergot and Pituitary Extract.—In the past many authori- ties recommended the administration of a dram of fluid extract of ergot by mouth immediately after the expulsion of the placenta, as a prophy- lactic measure against postpartum hemorrhage, and at present many administer hypodermatically one cubic centimeter of pituitary extract for the same purpose. Ordinarily, both are unnecessary, and, while it has already been stated that the use of the latter is permissible, I strongly advise against the employment of the former. If, however, the uterus remains soft and flabby after massage, instead of forming a hard tumor beneath the umbilicus, the use of pituitary extract is imperative, and, if bleeding occurs, I follow it by the hypodermatic injection of 40 to 60 minims of ergotole, or some other reliable preparation of ergot, for the reason that one reenforces the other—as the action of pituitary extract is almost immediate, but only continues for a few minutes, while that of ergot is more tardy, but also much more persistent, so that the effect of the former is almost exhausted by the time that of the latter becomes manifest. This is the only time at which ergot should be employed in labor, as its administration before the completion of the third stage has led to untold harm. Formerly, even well-trained physicians used it in large quantities during the second stage to stimulate uterine contractions, but at the present time it is so employed only by ignorant midwives. The premature use of the drug readily leads to tetanic contractions of the uterus, which in the presence of any marked disproportion between the size of the child and pelvis are likely to bring about rupture of the uterus. Moreover, its administration in the third stage of labor, before the expulsion of the placenta, cannot be too strongly deprecated, as the resulting tetanic contraction tends rather to produce a further retention of the organ, so that its manual removal frequently becomes imperative. Conduct of the Third Stage of Labor.—This subject has already been considered in the preceding chapter. Repair of the Lacerated Perineum.—Strictly speaking, this subject should be deferred until the obstetrical operations are dealt with; but as perineal tears are of such frequent occurrence, and as they are best repaired in the interval between the birth of the child and the expulsion 366 CONDUCT OF NORMAL LABOR of the placenta, the proper method of procedure will be considered at this time. For convenience in description, perineal tears are divided into three groups, those of the first, second, and third degrees. To the first belong those which involve simply the fourchette and anterior margin of the perineum, giving rise to a small, triangular wounded surface which is rarely more than 1.5 centimeters deep. In the second the laceration extends through a greater or lesser por- tion of the perineal body, and frequently exposes the sphincter ani Fig. 320.—Superficial Perineal Tear. Fig. 321.—Deep Perineal Tear. muscle. Usually its course does not quite follow the median line, but extends obliquely downward and outward from the posterior margin of the vulva. The perineal tear is usually associated with lesions of the vagina, which extend up one or both sulci, so that a triangular portion of the vaginal mucosa, which represents the inferior extremity of the poste- rior column, may become separated from the rest of the canal. In the third degree, the tear extends completely through the perineal body and the sphincter ani muscle, and for a certain distance up the an- terior wall of the rectum, thus giving rise to a cloaca, into which both vagina and rectum open. These are designated as complete, in contra- distinction to those of the first and second degrees—the incomplete tears —in which the rectum is not involved. Incomplete tears are encountered very often in the practice of the most competent obstetricians, no matter what precautions may be taken to prevent them ; but the frequent oc- currence of the complete variety indicates that the method employed REPAIR OF THE LACERATED PERINEUM 367 for protecting the perineum has been at fault in spontaneous, or that the extraction has been too hasty in operative, deliveries. In tears of the first degree, the mucous membrane of the fourchette and the skin covering the upper portion of the perineum and the sub- cutaneous tissue are implicated; in those of the second degree the skin surface of the perineum, the vari- ous perineal muscles, particularly the constrictor vaginae and transversus perinei, are torn through, and the wide gaping wound is due in great part to the retraction of these mus- cles. When the tear extends up the vagina, the levator ani muscle may likewise be involved; while, in lacer- ations of the third degree, the sphincter ani muscle and the an- terior surface of the rectum are im- plicated in addition to the structures above named. In the rare cases in which the vulval outlet looks markedly upward, or in which the perineum is ex- tremely resistant and the mechanism of expulsion faulty, the laceration may begin in the central portion of the perineum, when the head appears in an opening which is surrounded on ail sides by skin. This is known as a central tear, and is of infre- quent occurrence. Ordinarily, as the head is forced down still farther, the tear extends toward the fourchette or toward the anus, or even in both directions, and thus gives rise to a deep incomplete, or to a com- plete, laceration as the case may be. In not a few cases, where the vaginal opening is very resistant, and when the head has remained a long time upon the pelvic floor, even although there may be no external wound or appreciable lesion of the vagina, there may nevertheless have occurred a submucous tear or sepa- ration of certain fibers of the levator ani muscle, which wull later give rise to a marked relaxation of the vaginal outlet. Frequently the condition, although unrecognized at the time, later gives rise to such aggravated symptoms as to call for operation years.after the birth of the child. Ho matter what the degree, the immediate closure of 'perineal lacer- ations by suture is urgently indicated. Even slight tears through the fourchette are better repaired than left alone. In more extensive tears immediate repair is always necessary, unless the condition of the patient Fig. 322.—Complete Perineal Tear. Fig. 323.—Needle for Repairing Perineal Tears. 368 CONDUCT OF NORMAL LABOR be so serious as to contra-indicate further operative procedures. For these operations, the patient should be brought to the edge of the bed and placed in the lithotomy position, and the sutures introduced while waiting for the expulsion of the placenta. If non-absorbable sutures are employed, they should not be tied until the completion of the third stage, as the distention of the vulva by the placenta may subject the repaired wound to undue strain. By introducing the sutures during this period time is saved, and the temptation to hasty expression of the placenta is diminished, since the physician has something to do while waiting for the fundus to rise up. The mode of repair differs according as the tear extends only through the perineal body or is complicated by lacerations of the vagina or rectum. In the first case, the wound should be closed by deep sutures of silkworm gut, or 40 day chromic catgut, which are introduced a centimeter from one margin and carried well down under its base, being then brought out through the skin surface on the opposite side. It is important that the sutures should be inserted at a considerable distance Fig. 324.—Needle Holdek. from the edges of the wound, for, owing to the edema which de- velops later, they are very prone to tear through unless this pre- caution be taken. They should be placed at intervals of about 1 centi- meter, and if accurate approximation is not secured superficial sutures should be placed between them. Large curved needles, which can make the entire sweep in a single movement, should be used, as they render much better service than small needles which require several bites. The sutures should be tied very loosely from below upward, and cut off short. When the perineal tear is complicated by laceration of the vagina, the edges of the latter should be brought together by chromicized catgut sutures, just as in Emmet’s relaxed outlet operation. These may be either interrupted or continuous, but in either event they should be laid deeply in order to insure coaptation of the torn structures of the pelvic floor, instead of merely bringing together the edges of the mucosa, after which the perineal wound should be repaired in the usual manner. In complete tears, attention should first be given to the wounded rectum and its ruptured mucosa united by buried catgut sutures. Then the ends of the sphincter ani should be isolated and firmly sutured by catgut or fine silk sutures, after which the vaginal and perineal tears should be dealt with in the manner indicated above. Whenever catgut sutures are employed in any but the most superficial tears, it is advis- able to place one or two deep silkworm gut sutures as a precautionary REPAIR OF THE LACERATED PERINEUM 369 measure, as even forty day chromic catgut sutures may be absorbed pre- maturely. The after-treatment of tears of all degrees is comparatively simple, and consists in keeping the wound clean and covered by sterile dressings. The wounded surface should be washed several times a day with plain water or a 1 to 4,000 bichlorid solution, as Plass in our service demon- strated that the elaborate technic formerly employed is unnecessary, and only adds to the discomfort of the patient. For this reason the use of antiseptic powders, such as iodoform or boric acid, is not indicated, as the wounds heal equally well without them. Nor is there any necessity Fig. 325.—Repair of Perineal Tear Extending up the Vagina. Fig. 326.—Same, Sutures Tied. for binding the legs together, unless the patient is very unruly. Catheter- ization should be dispensed with, except in cases of retention, as the flow of urine over the wound does no harm, provided it is followed by proper cleansing. Generally speaking, the external sutures should be removed on the tenth day. In tears of the first and second degrees the bowels should be moved daily, but in complete lacerations it is ad- visable to prevent an action for the first four or five days, after which a large high enema of sweet oil should be given, followed by one ounce of castor oil by the mouth. The results following these operations are usually very satisfactory, and primary union is the rule, provided the sutures have been introduced far enough from the margins of the wound and not tied too tightly. This is a point to which too much attention can hardly be paid, for too often there is a tendency to attempt to make a neat-looking operation CONDUCT OF NORMAL LABOR 370 by introducing the sutures close to the margins of the wound and tying them snugly. As a result, the majority of the stitches cut through and become useless. On the other hand, when less attention is paid to the first appearance of the wound, the sutures being introduced far from its margins and tied somewhat loosely, excellent results almost always follow. Unfortunately, operations for complete tears are by no means so satis- factory, and, as a general rule, not more than two-thirds of the cases heal by first intention. In the cases of complete or partial failure a sec- ondary operation is indicated before the patient is discharged from treat- ment. LITERATURE Bier. Versuche iiber Cocainisirung des Rfickenmarkes. Deutsche Zeitschr. f. Chirurgie, 1899, li, 361. Budin. A quel moment doit-on operer la ligature du cordon ombilical? Le Progres medical, 1875, decembre; 1876; janvier. (Obstetrique et Gynecologie, 1886, 1-35.) Channing. A Treatise on Etherization in Childbirth. Boston, 1848. Davis. Painless Childbirth, Eutocia and Nitrous Oxid Oxygen Analgesia. Chicago, 1916. Doniioff. Ueber die Einwirkung des Chloroforms auf den normalen Geburtsver- lauf, etc. Archiv f. Gyn., 1892, xlii, 305-328. Furbringer. Untersuchungen und Yorschriften iiber die Desinfection der Hande des Arztes, nebst Bemerkungen iiber den bakteriologischen Character des Nagelschmutzes. Wiesbaden, 1888. Gauss. Geburten im kiinstlichen Dammerschlaf. Archiv f. Gyn., 1906, Ixxviii. 579-631. Die Technik des Skopolamin-morphium Dammerschlafes in der Geburtshilfe. Zentralbl. f. Gyn., 1907, xxxi, 33-38. Gipfard. Cases in Midwifery. London, 1734, 396-398. Goodell. A Critical Inquiry into the Management of the Perinseum during Labor. Amer. Jour. Med. Sciences, 1871, lxi, 53-79. Hahn. Ueber subaraehnoideale Cocaininjectionen nach Bier. Centralbl. f. d. Grenzgebiete der Med. u. Chirurgie, 1901, iv, 304-317 und 340-354. Harvie. Practical Directions Showing a Method of Preserving the Perineum in Childbirth, etc. London, 1767. Hensen. Ueber den Einfluss des Morphiums und des .Ethers auf die Wehen- thatigkeit des Uterus. Archiv f. Gyn., 1898, Iv, 129-177. Johnston and Siddall. Is the Usual Method of Preparing Patients Beneficial or Necessary? Am. J. Obst. & Gyn., 1922, iv, 645-650. Kelly. Hand Disinfection. Amer. Jour. Obst., 1891, xxiv, 1414-1419. Kirstein. Ueber Hypnosegeburten und Hypnonarkosen. Zentralbl. f. Gyn., 1922, 943-850. Kreis. Ueber Medullarnarkose bei Gebarcndcn. Zentralbl. f. Gyn., 1900, xxiv, 724-729. Kronig. Versuche fiber Spiritusdesinfection der Hande. Zentralbl. f. Gyn., 1894, xiii, 1346-1353. Lequeux. La scopolamine en obstetrique. * L’obst., 1911, N. S. iv, 165-234. Lynch. Eutocia by Means of Nitrous Oxid and Oxygen Analgesia. Illinois Med, Jour., April, 1915. LITERATURE 371 Muller. Ueber Lumbalanasthesie in der Geburtsbiilfe u. Gynakologie. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 169-185. Olshausen. Ueber Dammverletzung und Dammschutz. Volkmann’s Sammlung klin. Vortrage, 1872, Nr. 44. Plass. Post-partum Care of the Perineum. Bull. Johns Hopkins IIosp., 1916, xxvii, 107-109. Pomeroy. Shall We Cut and Reconstruct the Perineum for Every Primipara? Am. Jour. Obst., 1918, Ixxviii, 211-220. Report of the Committee Appointed to Investigate the Effects of Scopolamine- morphine Narcosis. Trans. Roy. Soc. of Med. (Gyn. and Obst. section), 1918, xi, 1-44. Ritgen. Ueber ein Dammschutzverfahren. Monatsschr. f. Geburtsk., 1855, vi, 321-347. Siegel. Schmerzlose Entbindungen im Dammerschlaf, etc. Deutsche med. Wochen- schr., 1914, 1049-53. Sciiroeder. Lehrbuch der Geburtshiilfe, VII. Aufl., 681. Sciiucking. Zur Physiologie der Nacligeburtsperiode. Berliner klin. Wochen- schr., 1877, xiv, 5, 18. Schultz-Rhonhof. Der hypnotische Geburtsdammerschlaf. Zentralbl. f. Gyn., 1922, 843-850. Simpson. On the Employment of the Inhalation of Sulphuric Ether in the Practice of Midwifery. Monthly Jour, of Med. Sciences, 1847, vii, 728. Anaesthesia. Philadelphia, 1849, 248. Steinbuchel. Yorlaufige Mittheilung iiber die Anwendung Skopolamin-morphium- Injektionen in der Geburtshiilfe. Zentralbl. f. Gyn., 1902, xxvi, 1304-1306. Sehmerzverminderung in der Geburtshilfe, etc. Leipzig u. Wien, 1903. Tuffier. L ’anesthcsie medullaire en gynecologie. Revue de gyn. et de chir. abd., 1900, iv, 683-692. Webster. Nitrous Oxid Gas Analgesia. Jour. Am. Med. Assn., 1915, Ixiv, 812- 813. Williams. The Cause of the Conflicting Statements Concerning the Bacterial Contents of the Vaginal Secretion of the Pregnant Woman. Amer. Jour. Obst., 1898, xxxviii, 807-817. Zweifel. Ueber den Dammerschlaf, etc. Monatsschr. f. Geb. u. Gyn., 1912, xxxvi, Ergriinzungs Heft 258-301. CHAPTER XYI THE PUERPERIUM Strictly speaking, the term puerperium or puerperal state (from puer, a child; and parere, to bring forth) comprises the period elapsing between the onset of labor and the return of the generative tract to its normal condition; but in common parlance it is restricted to the five or six weeks following the completion of labor. Although the changes occurring during this period are considered as physiological, they border very closely upon the pathological, inasmuch as under no other circum- Fig. 327.—Frozen Section, Showing Uterus Immediately After Delivery (Webster) stances does such marked and rapid tissue metabolism occur without a departure from a condition of health. Anatomical Changes in the Puerperium.—Involution of the Uterus.— Immediately following the expulsion of the placenta, the contracted and retracted body of the uterus forms a hard muscular tumor, the apex of which lies about midway between the umbilicus and symphysis, usu- ally 12 centimeters (4% inches) above the latter. At autopsy, shortly after labor, it consists of an almost solid mass of tissue containing in its center a flattened cavity, whose anterior and posterior walls are in close apposition, each of which measure four to five centimeters in thickness. On section, the uterus presents a markedly anemic appear- ance as compared to the pregnant organ, which, according to Webster and Longridge, is due to compression of its vessels by the contracted 372 ANATOMICAL CHANGES IN THE PUERPERIUM 373 and retracted muscular fibers. At the same time a considerable portion of the tissue juices is expressed. During the next two days the uterus remains apparently stationary in size, after which it atrophies so rapidly that by the tenth day it has descended into the cavity of the true pelvis, and can no longer be felt above the symphysis. It regains its normal size by the end of five or six weeks. Some idea of the rapidity with which the process goes on may be gained by recalling the fact that the freshly delivered uterus weighs about 1,000 grams, one week later 500 grams, at the end of the second week 375 grams, and at the end of the puerperium only 40 to 60 grams. This rapid decrease in size is due to what is designated as involution, and is the most striking example of atrophy with which we are ac- quainted; in that the organ becomes reduced to one-twentieth or one- twenty-fifth of its original size within a few weeks, and, when compared with the changes occurring in acute yellow atrophy of the liver, may well be designated as “atrophia acutissima.” It was formerly believed that the muscle cells underwent fatty de- generation during involution, and that large numbers of them com- pletely disappeared. Sanger, however, was the first to show that only the excess of protoplasm is removed, and that the actual num- ber of individual cells is not materially diminished. In other words, they undergo marked atrophy, but are not destroyed. Sanger estimated that their average length in the full-term uterus was 208.7 microns, as compared with 24.4 microns five weeks after labor. It is now held that involution is effected by autolyic processes, by which the protein material of the uterine wall is in great part broken down into simpler components, which are then absorbed and eventually cast off through the urine. The evidence in favor of such a view is principally afforded by the study of the nitrogen content of the urine. For the twenty-four hours immediately following labor 7 to 9 grams of nitrogen are excreted, but some time during the second or third day an increase of 30 to 50 per cent, is noted. This excessive output continues for a number of days, but gradually returns to normal at about the times the uterus has disappeared into the pelvic cavity. That this phenomenon is not entirely attributable to the removal of other products of pregnancy was clearly shown by Slemons, who, in one of my patients, from whom the uterus had been removed at cesarean sec- tion, found that the characteristic increase in the nitrogen output was lacking, and that the deficit practically corresponded to the quantity of nitrogen found upon analyzing the uterus. As yet we know nothing of the ferments giving rise to the autolysis, but it is readily conceivable that their action is facilitated by the acute anemia of the “blood-tight” uterus. Morse, who has studied the metabo- lism of the puerperium, found that the creatinin content of the urine becomes markedly increased during the first few weeks and later re- turns to its normal level. He associates this with the process of in- volution, as he found that it was much less in two patients from whom the uterus had been removed by Porro’s cesarean section. He also con- firmed the statement of Murlin that considerable quantities of creatin 374 THE PUERPERIUM appear in the urine, but was unable to determine its source. At the same time, by comparing the metabolism in normal puerperal women with that occurring after the removal of the uterus, he was able to show that its excretion is in no way dependent upon the process of involution, and that it is likewise independent of the creatinin metabolism. As has been said before, the separation of the placenta and its mem- branes occurs in the outer portion of the spongy layer of the decidua, and accordingly a remnant of the latter remains in the uterus after their expulsion. It presents striking variations in thickness, an irregular, jagged appearance, and is markedly infiltrated with blood, especially at the placental site. As the result of hyaline and fatty degeneration, the greater portion of this tissue is cast off in the lochia, leaving behind only the fundi of the glands and a minimal amount of connective tissue, from which the new endometrium is regenerated The processes concerned in its regeneration have been carefully studied by Friedliinder, Kundrat and Engelmann, Leopold, Kronig, and particularly by Wormser. The latter has shown that, within two or three days after labor, the portion of decidua remaining in the uterus becomes differentiated into two layers—one adjoining the uterine cavity being necrotic, and the other adjoining the muscularis being well pre- served. The former is cast off in the lochia, while the latter, which contains the fundi of the glands, remains in situ and constitutes a matrix from which the new endometrium is regenerated, its epithelium resulting from the proliferation of the gland cells, and its stroma from the connective tissue between them. For the first ten days or two weeks degenerative processes predominate, but after that mitotic figures appear and regeneration is rapid, the new endometrium being fully formed by the end of the third week, except at the placental site, where the process is more gradual. Changes in the Uterine Vessels.—Immediately after the completion of the third stage of labor, the placental site is represented by an irregu- lar, nodular, elevated area of about the size of the palm of the hand, the elevations being due to the presence of thrombosed vessels. This area decreases rapidly in size, so that it measures 3 or 4 centimeters in diam- eter at the end of the second week, and only 1 to 2 centimeters at the completion of the puerperium, although it still remains elevated above the general surface of the interior of the uterus and is tinged with blood pigment. Its original position remains recognizable for quite a long period, and even six months after childbirth appears as a slightly ele- vated pigmented area. According to Ilinselmann, with whom I agree, the sinuses at the placental site do not undergo thrombosis during pregnancy, but the process becomes inaugurated during the latter portion of the second and particularly after the completion of the third stage of labor, al- though many sinuses never become thrombosed, but are simply com- pressed by the contracting uterine muscles. The thrombi become organ- ized by the proliferation of the intima of the vessels, and eventually are converted into typical connective tissue. As the pregnant uterus requires a much more abundant blood supply ANATOMICAL CHANGES IN THE PUERPERIUM 375 than the non-pregnant organ, it is apparent that after delivery the lumina of its arteries must undergo a corresponding diminution in caliber. Formerly it was thought that this was brought about by a compensatory endarteritis, which disappeared in subsequent pregnancies. Now, how- ever, the prevailing belief is that the larger vessels are completely obliterated by hyaline changes, and that new and smaller vessels develop in their stead. The absorption of the hyaline material is accomplished by processes similar to those observed in the ovaries, although the changes may persist for years, and under the microscope offer a ready means of differentiating between the uteri of women who have, and those who have not, borne children. For details, the student is referred to the articles of Pankow, Goodall, Biittner, and Schwartz. Changes in the Cervix, Vagina, and Vaginal Outlet.—Immediately after the completion of the third stage, the cervix is represented by a Fig. 328.—Frozen Section Just after Completion of Third Stage of Labor, Show- ing Collapse of Lower Uterine Segment and Cervix (Benckiser) C.R., contraction ring; O.E., external os; 0.7., internal os. soft, muscular tube, whose boundaries can be made out only with difficulty. The margins of the external os are soft and flabby, and are usually marked by depressions indicating the seat of lacerations. Its opening contracts slowly. For the first few days immediately following labor it readily admits two fingers, but by the end of the first week it has become so narrow as to render difficult the introduction of one finger. At the same time the lower uterine segment collapses, and wdiat remains of the contraction ring comes in contact with the upper portion of the cervical canal. As Webster has pointed out, there is no doubt that the structure which is usually taken for the internal os on digital examination really represents the lower margin of the contrac- tion ring (Fig. 328). The vagina requires some time to recover from the distention to which it has been subjected. In the first part of the puerperium it is 376 THE PUERPERIUM represented by a capacious, smooth-walled passage, which gradually diminishes in size, though it rarely returns to its virginal condition. The rugae begin to reappear about the third week. The vaginal outlet is also markedly distended, and in primiparae usually bears signs of more or less extensive laceration. The hymen, as such, has disappeared, and its place is taken hy a number of small tags of tissue, which, as the process of cicatrization goes on, become converted into the carunculae myrtiformes, which are characteristic of the vaginal opening of parous women. The labia majora and minora become flabby and atrophic, as compared with their condition before childbirth. Changes in the Peritoneum and Abdominal Wall.—While these changes are taking place in the uterus and vagina, the pelvic peritoneum and the structures of the broad ligaments are accommodating themselves to the changed conditions of affairs. For the first few days after labor the peritoneum covering the uterus is arranged in folds, which soon disappear. The broad and round ligaments are much more lax than in the non-pregnant condition, and require considerable time to recover from the stretching and loosening to which they have been subjected. As a result of prolonged distention due to the presence of the enlarged pregnant uterus, the abdominal walls remain soft and flabby for some time. Except for the presence of silvery striae, they gradually return to their normal condition if the abdominal muscles have retained their tonicity; but when this is much impaired they never regain their original consistency, but remain lax and flabby. In not a few instances, particularly in women who have borne a number of children in rapid succession, there may be a marked separation or diastasis of the recti muscles, so that a considerable portion of the abdominal contents is covered simply by peritoneum, thinned-out fascia, and skin. The changes occurring in the breasts are very characteristic, and will be considered in Chapter XVII. Clinical Aspects of the Fuerperium.—Postpartum Chill.—Quite fre- quently the patient may have a more or less violent rigor, coming on shortly after the completion of the third stage of labor. This is a nervous or vasomotor phenomenon, and is without prognostic signifi- cance. In this respect it stands in marked contrast to a chill occurring later in the puerperium, which nearly always indicates the onset of an acute infectious process. Temperature.—The temperature should remain practically normal during the puerperium; hence any considerable rise should always be regarded as abnormal, and considered as a sign of infection until con- vincing evidence to the contrary can be adduced. Occasionally the tem- perature may become slightly elevated toward the end or just after the completion of a difficult labor, but rarely goes above 100° F. (38° C.), usually falls to normal within twelve hours, and does not rise again. A higher temperature during labor usually indicates intrapartum in- fection, associated with bacterial invasion of the foetal membranes and the liquor amnii. Owing to the fact that slight rises of temperature occur frequently during the puerperium without apparent cause, it is customary to desig- CLINICAL ASPECTS OF THE PUERPERIUM 377 nate as normal all puerperia in which the temperature remains below 100.4° F. (38° C.), and as febrile all those in which that limit is reached or exceeded in two different days. It was formerly believed that the establishment of the lacteal secre- tion on the third or fourth day of the puerperium was naturally attended by a slight rise in temperature. Indeed, so prevalent was this idea that in pre-antiseptic times the so-called milk fever was regarded as a normal phenomenon. At present we no longer believe in the existence of such a pathological entity, and whenever the temperature exceeds the arbitrary normal limit at this time the conscientious obstetrician should fear the beginning of an infection, and begin to search for the errors of technic which may have led to it. Pulse.—During the puerperium the pulse is usually somewhat slower than at other times, averaging between 60 and 70. In nervous women, however, and in those who have had difficult labors or have suffered any considerable loss of blood, a more rapid rate than normal is not infre- quent. In a certain number of cases, a day or two after the birth of the child, the pulse becomes markedly slower, and sometimes falls to 50, 40, or even fewer beats to the minute. Fehling has reported a case in which the rate was only 36. Ordinarily this phenomenon becomes most marked on the second or third day, after which the pulse becomes quicker and attains its normal rate by the end of the first week or ten days. The slow pulse is usually regarded as a favorable prognostic sign, whereas a rapid heart action, unless it can be accounted for by hemorrhage or cardiac disease, should be looked upon with suspicion. This puerperal bradycardia is usually regarded as a characteristic phenomenon. Heil, however, in 1898, stated that he observed it in only 12 per cent, of his cases. He affirmed that if the pulse be carefully counted in the same patient for some days before, as well as after, labor, it will usually be found slightly quicker in the puerperium than during pregnancy. ArarnieFs investigations failed to confirm HeiFs conclusions, since they showed that the puerperal slow pulse occurred in 72 per cent, of the cases. In a series of patients in my service, reported by Lynch, in which the pulse rate was recorded during pregnancy, as well as during the puerperium, a slowing of ten or more beats per minute was noted in 20.5 per cent., and occurred more than twice as frequently in multiparous as in primiparous women. Numerous theories have been advanced from time to time in the attempt to explain its mode of production, but none of them is wholly satisfactory. It is not impossible that the solution is quite simple, and that the condition may depend upon two factors: the absolute rest of the patient in bed, together with the great diminution in work which the heart is called upon to perform after the elimination of the uteroplacental circulation. Kehrer attributed the slowing in great part to the lowering of the blood pressure following delivery; Schroeder, to the sudden dim- inution of the vascular area after the uteroplacental circulation is thrown out of function; Fritsch, to the horizontal position and rest in bed; Loh- lein, to stimulation of the vagus or other nervous influences; Olshausen, 378 THE PUERPERIUM to the absorption of various products set free in the blood during the involution of the uterus; and Novak and Jetter, to vagus stimulation. Changes in the Blood.—It is usually stated that there is a slight de- crease in the number of red corpuscles and the amount of hemoglobin, attributable to the loss of blood immediately following delivery. Obser- vations upon the blood volume made in our clinic by Harris, but not yet published, indicate that this statement is incorrect. He has found that the blood volume is increased during pregnancy, giving rise to a relative hydremia, which is associated with a lowered blood count and hemoglobin content. Immediately following labor, however, the blood volume undergoes an acute concentration, with the result that the cellular constituents, as well as the hemoglobin content, are increased, and after- wards slowly return to the normal non-pregnant proportions. Iiofbauer has directed attention to the occurrence of a marked leuko- cytosis occurring during and just after labor. He showed that the leukocytes gradually increase in number from the onset of labor and reach a maximum ten or twelve hours after its conclusion, at which time they are nearly twice as abundant as during pregnancy. Having at- tained their acme, they promptly fall to normal, rising again slightly on the third or fourth day, with the establishment of the lacteal secretion, after which they remain at the normal level. After-pains.—In primiparous women the uterus remains in a state of tonic contraction and retraction during the puerperium, unless it has been subjected to unusual distention, or blood clots or other foreign bodies have been retained in its cavity, as a consequence of which active contractions occur in the effort to expel them. In multiparous women, on the other hand, the uterus has lost part of its initial tonicity, so that persistent contraction and retraction cannot be maintained, and con- sequently it contracts and relaxes at intervals, the contractions giving rise to painful sensations, which are known as after-pains, and which occasionally are so severe as to require the administration of a sedative. In many patients these are particularly noticeable when the child is put to the breast, and may last for many days, but ordinarily they lose their intensity and become quite bearable after the twenty-four hours imme- diately following delivery. Lochia.—During the first part of the puerperium there occurs nor- mally a variable amount of vaginal discharge—the lochia. For the first few days after delivery it consists of blood-stained fluid—lochia rubra; after three or four days it becomes paler—lochia serosa; and after the tenth day, owing to a marked admixture with leukocytes, it assumes a whitish or yellowish-white color—lochia alba. It is alkaline in reaction, and has a peculiar fleshy odor, suggesting fresh blood. In normal cases its total quantity varies between 500 and 1,000 grams, being less profuse in women who suckle their children. Foul-smelling lochia indicate in- fection with putrefactive bacteria. In many instances the reddish color is preserved for a longer period, but when it persists for more than two weeks, it indicates the retention of small portions of the after-birth, or imperfect involution, which is frequently associated with retroflexion of the uterus. When examined under the microscope during the first few CLINICAL ASPECTS OF THE PUERPERIUM 379 days, the lochia consist of red blood corpuscles, leukocytes, fatty epithelial cells, and shreds of degenerated decidual tissue. Microorganisms can always be demonstrated in the vaginal lochia, but are not always present when the discharge is obtained from the uterine cavity. The investigations of Doderlein, Kronig, Little, and myself have shown that normally the latter does not contain bacteria during the first few days of the puerperium, but that they occur with increasing frequency as it advances. They are not, however, of the pyogenic varieties, except in cases of infection. Furthermore, Kronig has demonstrated that the normal vaginal lochia, although rich in harmless parasites, do not contain pyogenic organisms, with the exception of gonococci. lie also showed that the bacterial flora of the vagina undergoes a marked changed during the puerperium, when the bacilli, wThich predominated during pregnancy, are in great part replaced by cocci. This change is probably due to the altered reaction of the secretion, which is markedly acid before, and alkaline after, labor. General Functions.—The function of the skin is markedly accen- tuated, as is demonstrated by the profuse sweating which frequently characterizes this period. It is most marked at night, and it is not unusual for the patient to awake from a sound sleep to find her night- gown drenched with perspiration. It passes off spontaneously and does not require treatment. The appetite is usually diminished during the first few days after labor, and the patient experiences little desire for nutritious food. At the same time, owing to the marked diaphoresis and the quantity of fluid lost through the lochial discharge, thirst is considerably increased. The bowels are nearly always constipated during the first part of the puerperium. This is due partly to the fact that the patient eats but little solid food, but principally to the relaxation of the abdominal walls and their consequent inability to aid in evacuating the intestinal con- tents. Urine.—There is a marked increase in the urinary output during the puerperium. More important, however, are the changes in the composi- tion of the urine, to which reference was made on page 373, and which afford an index to the profound changes in metabolism which charac- terize this period. In the majority of cases the examination of urine, removed by cathe- terization immediately after the completion of labor, shows a slight amount of albumin and numerous hyaline casts, even though both may have been absent throughout pregnancy. In a series of patients studied in my service by Little, traces of albumin were noted in 89 per cent., and casts in 41 per cent. This is a transient phenomenon resulting from the systemic strain caused by labor, and usually disappears within twenty-four hours, though in a certain number of cases traces of albumin persisted for some days, but always disappeared by the end of the second week, unless the patients were suffering from toxemia or chronic ne- phritis. It should be remembered that such statements apply only to urine obtained by catherization, as voided specimens always contain albumin so long as the lochia persist. THE PUERPERIUM 380 Occasionally a small amount of sugar may be found in the urine during the first weeks of the puerperium. Careful investigation has shown that the reaction is due to the presence of lactose, or milk-sugar, which is supposed to be absorbed from the mammary glands, so that the condition has no connection with diabetes. Ney observed it in 77 per cent, of his cases, while McCann and Turner detected it in small quantities in every case which they examined. In my own clinic, the routine weekly urinary examination in 3,000 patients showed a much smaller incidence—4.G9 per cent. For a full discussion of the question the reader is referred to the section on glycosuria and diabetes in preg- nant women. Couvelaire, and Scholten have demonstrated that there is a marked increase in the amount of acetone in the urine immediately after labor, which disappears within the next three days. The last-named investi- gator noted it in 94 per cent, of his cases, and found that it was most abundant after difficult and prolonged labors. He attributes its produc- tion to the excessive breaking up of carbohydrates resulting from the increased muscular activity incident to parturition. There is a marked tendency toward retention of the urine during the first few days of the puerperium, and occasionally the distended bladder can be distinguished as a fluctuant tumor above the umbilicus. The retention may result from numerous causes, but is particularly apt to follow operative or difficult labors; and in such circumstances may be attributable to contusions or other slight lesions of the urethra. In other cases it is probably caused by the diminished intra-abdominal pressure, which allows a greater quantity of urine to accumulate in the bladder than under other conditions, as well as by the flaccidity of the abdominal walls and the consequent difficulty of bringing them into play during urination. In not a few cases it is due to the fact that possibly at any time the patient is unable to evacuate the bladder in the recumbent position. Loss of Weight.—In addition to the loss of 6 to 6% kilos, which results from the evacuation of the contents of the uterus, it is generally stated that there is a still further loss of body weight during the puer- perium, which, according to Gassner, amounts to 4,500 grams in the first week. Heil estimates it at 2,000, and Klemmer at only 900 grams. This apparent contradiction is due to the fact that Gassner\s results were obtained at a time when the diet was greatly restricted, but at present, when it is more liberal, the loss of weight is much less, and in many instances does not occur at all if sufficient food be taken. In normal cases it is nearly always regained by the end of the puerperium. Care of the Patient during the Puerperium.—Attention Immediately after Labor.—After carefully examining the placenta immediately after its expulsion, to make sure that it is intact, the physician should devote his attention to watching the condition of the uterus. At this time it should form a hard, round, resistant tumor, whose upper margin lies below the umbilicus. As long as it resembles a cricket-ball in consistence, there is no danger of postpartum hemorrhage, which becomes imminent if the uterus should grow soft and flabby. To guard against such an CARE OF THE PATIENT DURING THE PUERPERIUM 381 occurrence, the uterus should be gently palpated through the abdominal walls immediately after the conclusion of the third stage, and the ma- neuver repeated at frequent intervals. If it is found to be tightly con- tracted, all is well; but if any tendency toward relaxation is detected, the organ should be grasped through the abdominal walls and vigor- ously kneaded until it remains persistently contracted; at the same time pituitary extract or ergot should be administered hypodermically. Even in normal cases, the physician should not leave the patient immediately after the completion of labor, but should remain within call for at least one hour, so as to be available should any complication arise. If at the end of that period the uterine contractions are satis- factory, the patient can be safely left, but, if they are not, they should be stimulated by appropriate measures, and the behavior of the organ carefully watched until the physician feels assured that all danger of hemorrhage has passed. Occasionally, this may necessitate a wait of several hours. Toilet of the Vulva.—Immediately after the birth of the placenta, the soiled linen having been removed from beneath the patient, the buttocks and external genitalia are cleansed with hot water and soap and bathed with a 1-2,000 bichlorid solution. A sterile vulval pad, made of cotton wrapped in gauze, is then applied over the genitalia and held in place by a “T” bandage, being replaced by a clean one whenever necessary. The number of pads required in the twenty-four hours varies according to the amount of lochial discharge, and affords a fairly accurate means of estimating its quantity. Each time the pads are changed, and after each movement of the bowels, the genitalia should be cleansed with fresh cotton pledgets soaked in bichlorid solution, care being taken that the parts are washed from above downward, so as to avoid contamination from the rectum. The use of bichlorid solution is not essential, as comparative observations made in my service by E. If. Plass have shown that, even in the presence of perineal tears, equally good results may be obtained by the use of boiled water. The vulval pad not only absorbs the lochia and prevents contamina- tion of the vulva from without, but also makes it difficult for the patient to touch her genitalia, a practice very common among the uneducated classes, and one that occasionally gives rise to infection. Binder.—Many authorities recommend that a tightly fitting binder of unbleached muslin, reaching from the trochanters to above the umbilicus, be applied immediately after delivery, since they hold that it exerts a beneficial effect upon the involution of the uterus, makes the patient more comfortable, and tends to restore her figure to its original condition. Personally, I am not in favor of its routine employment dur- ing the first days of the puerperium, as I am convinced that it has no influence upon the involution of the uterus, nor upon the restoration of the figure. On the other hand, I feel that it may retard the latter by inhibiting the movements of the abdominal wall; as in my experience the tonicity of the abdominal wall is the main factor concerned, and when this is seriously impaired I know nothing that will bring about the desired result, although massage and systematic gymnastic exercises 382 THE PUERPERIUM during the last week the patient spends in bed may do something toward it. If, however, the abdomen is very fat or unusually flabby, a well- fitting bandage adds materially to the comfort of the patient, and should be applied. After-pains.—Since after-pains occur in primiparae only when the uterus has been subjected to undue distention, it is not usually necessary to provide for their relief after the birth of a first child. On the other hand, after the delivery of a multiparous patient, it is advisable to leave with the nurse several tablets of y± grain of morphin and 1/150 grain of atropin, with instructions to administer them by the mouth at intervals of four or six hours, if the pains be severe. Rest and Quiet.—As soon as the patient has been made comfortable, the room should be darkened and she should be encouraged to sleep. The relatives should be excluded, and the nurse should bathe and dress the baby in an adjoining apartment, if there is one at her disposal. The patient should be kept in bed for the first ten or twelve days, but should always be permitted to move freely and to sit up to make her toilet and to eat her meals. During this period, as a rule, only the immediate members of the family should be admitted to see her. Moreover, if these are numerous, strict instructions should be given the nurse as to the number of visitors each day. Diet.—Formerly it was the custom to restrict to a minimum the diet of the puerperal woman, and, as has already been said, this limitation goes far to explain the loss of weight which was frequently observed during the first few days. At present, however, a more liberal allowance is customary, and the patient is encouraged to take plenty of plain nour- ishing food. If not nauseated, she should be given a glass of milk or a cup of tea soon after labor. For the first few days the appetite is not vigorous, but small quantities of easily digested food may be taken at frequent intervals. I usually give the nurse the following directions: For the first twenty-four hours, water, milk, coffee, tea, or cocoa, boiled or poached eggs, and buttered or soft toast. On the second and third days the same, with the addition of simple soups, or bouillon, raw or stewed oysters, sweetbreads, chicken breast, and wine jelly. On the fourth and fifth days as above, with the addition of birds, steak, chops, baked pota- toes, and rice, after which the ordinary diet may be resumed. Temperature.—The temperature should be carefully watched during the first week of the puerperium, as fever is usually the first symptom of the onset of an infectious process. If the patient be in charge of a trained nurse, it should he taken four times daily—at 8 a. m., 12 M., 4 p. m., and 8 p. m., and recorded upon a suitable chart. The physician should be immediately notified it it rises above 100°. But when the nurse is ignorant the temperature should be taken by the physician him- self, morning and evening, for the first five days. This, of course, means that during that time he must visit the patient twice a day, once a day for the following two or three days, and afterward at less frequent intervals. But when the nurse is competent a single daily visit will suffice, unless untoward symptoms develop, as the physician can rely CARE OF THE PATIENT DURING THE PUERPERIUM 383 upon being notified promptly of any change. It is always better, how- ever, whenever possible, that the patient should be seen within the first twelve hours following delivery. Urination.—The patient should be encouraged to urinate within the first six hours. When she is unable to do so, the catheter should not be employed until the bladder forms a definite tumor above the sym- physis, and not even then until the patient has attempted to urinate in a sitting position; inasmuch as many women are unable to use a bed- pan. I consider the change in position much less dangerous than catheterization, as the latter, no matter how carefully performed, always carries with it some risk of infection and of a consequent cystitis, par- ticularly as the investigations of Alsberg have shown that the normal urethra always harbors colon bacilli. Moreover, in not a few cases, the procedure, when once commenced, must be continued for a number of days, a condition of affairs which, leaving out of account the danger of infection, becomes very onerous to the physician, unless he has a com- petent nurse in charge. When, however, catheterization becomes absolutely necessary, the genitalia having been first exposed and bathed with a bichlorid or boric solution, a freshly boiled glass catheter should be introduced by carefully disinfected fingers; or, better still, it should be grasped with a piece of freshly boiled cotton, so as to prevent its coming in contact with the fingers at all. At the present day, to catheterize a woman under a sheet or by the sense of touch is not justifiable. If repeated catheterization becomes necessary, 5-grain tablets of hexamethylenamin should be ad- ministered four times daily as a prophylactic measure against cystitis. Bowels.—In view of the sluggishness of the bowels in the puerperium, a mild cathartic should be administered on the morning of the third day, unless they have previously been evacuated spontaneously. For this purpose I generally employ an ounce of castor oil, or an ounce of Rochelle salts in a small quantity of water. After the preliminary cathartic, the bowels should be moved once daily. If a spontaneous action does not occur, the administration of the fluid extract of cascara at bedtime, in 20- to 60-minim doses, or 1 or 2 drams of the aromatic elixir, according to the susceptibility of the pa- tient, is indicated. Sometimes a pill containing aloin, belladonna, and strychnin, or 1 to 2 teaspoonfuls of compound licorice powder, prove more satisfactory. Care of the Nip-pies.—Details concerning the care of the nipples will be given in the next chapter, but the physician should be careful to im- press upon the nurse the necessity of observing aseptic precautions in dealing with them; and she should be directed to report immediately the appearance of fissures, as their proper treatment will usually prevent mammary infection and the consequent danger of mastitis. Time for Getting Up.—It is a time-honored custom to allow the puerperal woman to sit up on the tenth day. This rule, however, should not be slavishly followed, and every patient should be kept in bed until the fundus of the uterus has disappeared behind the symphysis pubis. This frequently occurs by the tenth day, occasionally a day or so earlier, 384 THE PUERPERIUM but very often not until some days later. Generally speaking, a two weeks’ rest in bed is not excessive. Kiistner advocated the practice of allowing the patient to get up on the third or fourth day after delivery, and stated that he had seen no ill consequences following it. His suggestion was promulgated before the German Gynecological Congress in 1899, and has found many fol- lowers, especially in Germany. No doubt it is feasible in most cases, but it has yet to be demonstrated whether it subserves the best interests of the patient. It is interesting to note that a similar suggestion was made by Charles White of Manchester as early as 1773, and 100 years later by Goodell of Philadelphia. It is also advisable to give strict directions as to the length of time the patient should remain out of bed. I have found it a convenient rule to direct that she should sit up for one hour on the first day, two hours on the second, and to increase the time by an hour each day until she is able to be up all the time. She should be kept in her room until the expiration of the third week, and allowed to move about on the floor on which she was confined during the fourth week. She should not be permitted to go downstairs until the expiration of this period, as it is a matter of experience that the average woman cannot be prevented from assuming the ordinary duties of her household after she has once gone downstairs. In hospital practice, normal ward patients are usually discharged by the end of the second week and immediately assume their household duties. Private patients, who live in the city in which the hospital is located, may be discharged at the same time, but they should be cautioned to spare themselves for the following two weeks, as in- dicated above. On the other hand, those who must travel any con- siderable distance to return to their homes, should remain in the hospital for a longer period. jReappearance of Menstruation.—If for any reason the woman does not suckle her child, the menstrual flow will probably return within eight weeks after labor. On the other hand, it is generally believed that the flow ordinarily does not appear as long as the child is suckled, or at least not until it is nearly a year old. My own experience has shown that such a belief is erroneous, and that a considerable proportion of women menstruate during lactation, and usually without ill effect upon the children. Moreover, Pinard stated that from 40 to 73 per cent, of all his patients menstruated within six months after the birth of the child, and that the function becomes reestablished later in multiparous than in primiparous women. Ehrenfest in 1915 arrived at somewhat similar conclusions, and stated that 51.3 per cent, of his patients menstruated within three months, and 71 per cent, within six months after delivery; while in 80 per cent, menstruation occurred before the cessation of lactation. Final Examination.—At the end of the third or the beginning of the fourth week the patient should he subjected to an internal examination, when the condition of the perineum, uterus, and appendages should be carefully investigated. In approximately one-third of all patients— Lynch states 41 per cent,—the uterus will he found displaced, when LITERATURE 385 its replacement and the introduction of a properly fitting pessary may lead to a prompt cure; whereas if the treatment be deferred until symptoms appear, the condition may not be relieved so readily. In other cases various abnormalities may be noted, which should be treated before the patient is discharged, and occasionally it may be necessary to warn her that operative procedures will be required in the future. If everything is perfectly normal, it is a great comfort to the patient to be assured of the fact; whereas if any abnormality is noted and the atten- tion of some responsible member of the family be directed to it, the physi- cian may save himself from censure if a subsequent examination be made by someone else. Even though everything was found in order at the latter part of the puerperium, it is a wise precaution to encourage the patient to return for reexamination six months or one year later. In this event, ab- normalities, which may have originated in the meantime, can be recog- nized and, if necessary, corrected, while the visit affords the physician an opportunity to observe the general effect of childbearing upon his patient, as well as to ascertain what influence it has exerted upon any complication from which the patient may have suffered during pregnancy or labor. For a number of years, I have insisted upon such a yearly return in the case of our ward patients, and I am convinced that the results obtained have amply repaid both the patients and the members of the staff for the time and trouble taken. LITERATURE Alsberg. Die Infektion der weiblichen Harnwege, etc. Archiv f. Gyn., 1910, xc, 255-302. Buttner. Die Gestationsveranderungen der Uteringefasse. Archiv f. Gyn., 1911, xciv, 1-21. Couvelaire. De l’acetonurie transitoire du travail de 1’accouchement. Annales de gyn. et d’obst., 1899, li, 353-367. Doderlein. Untersuchungen iiber das Yorkommen von Spaltpilzen in den Lochien des Uterus und der Vagina, etc. Archiv f. Gyn., 1887, xxxi, 412-447. Das Scheidensekret. Leipzig, 1892. Ehrenfest. The Reappearance of Menstruation After Childbirth. Am. Jour. Obst., 1915, lxxvii, 577-599. Friedlander. Physiol.-anat. Untersuchungen iiber den Uterus. Leipzig, 1870. Fritsch. Die puerperale Pulsverlangsamung. Archiv f. Gyn., 1875, viii, 383-390. Gassner. Ueber die Veranderungen des Korpergewichtes bei Schwangeren, Gebarenden u. Wochnerinnen. Monatsschr. f. Geburtskunde, 1862, xv, 1-68. Goodall. The Involution of the Puerperal Uterus. Studies from the Royal Victoria Hospital, 1910, ii, No. 3. Goodell. Obst. J. Great Brit, and Ireland, 1875, No. 16. Heil. Untersuchungen iiber die Korpergewichtsverhaltnisse normaler Wochner- innen. Archiv f. Gyn., 1896, li, 18-32. Giebt es eine physiologische Pulsverlangsamung im Wochenbette? Archiv f. Gyn., 1898, liv, 265-280. Hinseemann. Die angebliche, physiologische Sehwangerschaftsthrombose, etc. Zeitschr. f. Geb. u. Gyn., 1913, lxxiii, 146-222. Hofbauer. Zur Physiologie des Puerperiums. Monatsschr. f. Geb. u. Gyn., 1897, v, Frganzungsheft, 52-57. 386 THE PUERPERIUM Klemmer. Untersuchungen iiber den Stoffwechse] der Wochnerinnen und die zweekmassigste Diat derselben. Winckel’s Berichte und Arbeiten, 1876, ii, 155-186. Kronig. Bakteriologie des Genitalkanales der scliwangeren, kreissenden und puerperalen Trail. Leipzig, 1897, 54-64 und 196-201. Beitrag zum anat. Verhalten der Schleimhaut der Cervix und des Uterus wahrend der Schwangerschaft und im Friiwochenbett. Archiv f. Gyn., 1901, lxiii, 26-38. Kundrat und Engelmann. Untersuchungen iiber die Uterusschleimhaut. Strieker’s nied. Jalirb., 1873. Kustner. 1st einer gesunden Wbchnerin eine protrahirte Bettruhe denilieh? Yerh. der deutschen Gesellsch. f. Gyn., 1899, viii, 525-535. Leopold. Studien iiber die Uterusschleimhaut, etc. Archiv f. Gyn., 1878, xi and xii. Little. Bacteriology of the Puerperal Uterus. Am. Jour. Obst., 1905, lii, 815- 847. The Albuminuria of Pregnancy, etc. Am. Jour, of Obst., 1904, 1, 321-336. Lohlein. Ueber das Verhalten des Herzens bei Schwangeren und Wochnerinnen. Berliner Zeitschr. f. Geb. u. Frauenkr., 1876, i, 482-516. Longridge. Excretion of Creatinin in the Lying-in Woman. Jour. Obst. and Gyn. Brit. Emp., 1908, xiii, 420-429. The Blood-tight Uterus and Its Influence on Involution. Brit. Med. Jour., 1909, ii, 1459-1462. Lynch. The Bradycardia of the Puerperium. Surg. Gyn. and Obst., 1811, xii, 441-451. Retroversions of the Uterus following Delivery. Am. J. Obst. & Gyn., 1922, iv, 362-371. McCann and Turner. On the Occurrence of Sugar in the Urine during the Puerperal State. Trans. London Obst. Soc., 1892, xxxiv, 473-490. Moore. Creatinin and Creatin Output during the Puerperium. J. Am. Med. Assoc., 1915, lxv, 1613-1615. Murlin. Protein Metabolism of Normal Pregnancy. Surg. Gyn. & Obst., 1913, xvi, 43-53. Ney. Ueber das Vorkommen von Zucker im Harne der Scnwangeren, etc. Archiv f. Gyn., 1889, xxxv, 239-256. Novak u. Jetter. Beitrag zur Kenntniss der puerperalen Bradycardia. Monats- schr. f. Geb. u. Gyn., 1910, xxxii, 531-550. Olshausen. Ueber die Pulsverlangsamung im Wochenbette und ihre Ursache. Zentralbl. f. Gyn., 1881, v, 49-53. Pankow. Graviditats-sclerosen der Uterus- und Ovarialgefasse. Archiv f. Gyn., 1906, lxxx, 271-282. Pinard. La menstruation dans ses rapports avec ovulation, etc. Annales de gyn. et d’obst., 1909, N. S. vi, 721-733. Sanger. Die Riickbildung der Muscularis des puerperalen Uterus. Beitrage zur path. Anat. und klin. Med., von Wagner’s Schiilern, 1887, 134. Sciiolten. Ueber puerperale Acetonurie. Beitrage zur Geb. u. Gyn., 1900, iii, 439-451. Schroeder. Lehrbuch der Geburtshiilfe, XIII. Aufl., 1889, 268. Schwartz. The Pathology of Chronic Metritis and Chronic Subinvolution. Am. J. Obst., 1919, lxxix, 63-94. Slemons. Involution of the Uterus and Its Effect upon the Nitrogen Output of the Urine. Bull. Johns Hopkins Hosp., 1914, xxi, 195-200. Varnier. Du ralentissement du pouls pendant les suites des couches. Annales de gyn. et d’obst., 1899, li, 30-47. LITERATURE 387 Webster. The Anatomy of the Female Pelvis during the Puerperium. Researches in Female Pelvic Anatomy, Edinburgh, 1892, 1-55. White. A Treatise on the Management of Pregnant and Lying-in Women. Lon- don, 1776. Wormser. Die Regeneration der Uterusschleimhaut nach der Geburt. Archiv f. Gyn., 1903, lxix, 449-579, CHAPTER XVII THE NEWLY BORN CHILD In this chapter will be considered only those conditions which are of direct practical interest to the obstetrician, who is referred to the standard works upon pediatrics for information concerning the special physiology and pathology of the infant. Normally the newly born child begins to cry almost immediately after its exit from the vulva. This act indicates the establishment of respiration, which is accompanied by important modifications in the circulatory system. The mode of production of the first breath has given rise to much speculation. Among the many hypotheses that of Warnekros deserves consideration. In his X-ray studies of the process of labor, he noted an almost conical compression of the thorax during the second stage, and suggested that the expansion which must inevitably follow the delivery of the shoulders would afford a plausible explanation for the first inspiratory movement. Circulatory Changes.—As soon as the lungs begin to function, the blood which is brought by the inferior vena cava to the right auricle no longer passes through the foramen ovale, but makes its way directly through the right ventricle, whence it is carried to the lungs by means of the pulmonary arteries. Coincident with the establishment of the pulmonary circulation, there ensues a marked increase in the pressure in the left auricle. This in turn brings about the closure of the valve of the foramen ovale, which after a few months fuses with the periphery of the opening. At the same time the blood ceases to flow through the ductus Botalli into the aorta, and the canal itself gradually becomes obliterated. According to Strassmann, the primary cause for this change is to be found in the fact that the ductus traverses the wall of the aorta in an oblique direction, so that, as soon as the pressure in the aortic arch is increased, its wall acts as a valve and in this way occludes the distal end. The circulation through the umbilical arteries normally ceases in from 5 to 15 minutes after birth, pulsation disappearing first at the maternal end of the cord. This is brought about by the contraction of the thick muscular walls, which practically obliterate the lumina of the arteries. It is usually stated that after the establishment of the pulmo- nary circulation the general arterial pressure is diminished to such an extent that it is insufficient to force the blood through them. The investi- gations of Ahlefeld have shown that this is not the case, and would rather indicate that the contraction of the arteries is brought about by the stimulation resulting from the cooling of' the cord immediately after 388 CARE OF THE UMBILICAL CORD 389 birth. That this explanation is correct is demonstrated by the fact that the circulation can be reestablished by immersing the child in a warm bath. This point is of practical importance in view of the fact that occa- sionally, when the cord has not been ligated sufficiently tightly, secondary hemorrhage occurs from its foetal end after the child has been placed in a warm bed. To guard against such an occurrence the cord should be reinspected before the physician leaves the patient. The child passes urine almost immediately after birth, and fre- quently while in the act of being born. In a considerable number of cases a certain amount of meconium is also discharged. As a result of the cooling of the surface of the child on coming into the world, its temperature becomes reduced by a few degrees, which, however, are promptly regained after it has been bathed and placed in a warm bed. For the first few days of life the temperature is in very unstable equilib- rium, and a very slight cause may give rise to a considerable elevation. Care of the Umbilical Cord.—As has already been said, the umbilical cord should not be ligated until it has ceased to pulsate, unless there is some urgent reason to the contrary. Two ligatures of sterilized bobbin should be placed about it and tightly tied, one about 2 centimeters from the surface of the abdomen, and the other about the same distance beyond the first, the cord being then cut between them with a pair of sterile scissors. Owing to the absence of circulation, what is left of the cord under- goes mummification, and gradually a line of demarcation appears just beyond the skin surface of the abdomen, until in a few days the stump sloughs off, leaving behind a small, granulating wound, which, after healing, forms the umbilicus. This separation usually takes place within the first ten days after birth, but it is not unusual for it to require a longer time, and occasion- ally several weeks may elapse before it occurs. In the very rare in- stances in which the stump is still adherent at the end of the puerperium, it may become necessary to clip it off with a pair of scissors. Formerly the care of the cord was considered a very trivial matter, and the midwife, as a rule, would wrap it in a piece of greased or singed linen, after which little or no attention was paid to it. This practice, however, and the total neglect of aseptic precautions frequently resulted in an infection which was transmitted through the umbilical vessels, so that in times past large numbers of children perished from so-called “puerperal fever,” as well as from tetanus neonatorum. Even now, when the necessity for proper treatment is generally recognized, umbil- ical infections are not unknown. Attention was redirected to such conditions by Eross in 1891, who stated that a great part of the rises in temperature occurring in young infants is due to umbilical infections. Keller, after studying the vital statistics of Berlin for the years 1904 and 1905, concludes that at least 20 per cent, of all deaths during the first weeks of life are due to this cause. Usually these umbilical infections indicate gross lack of care, but 390 THE NEWLY BORN CHILD occasionally they occur in spite of every precaution. Thus, within one week four babies in my service died from general streptococcus per- itonitis, which could be traced to an infectious process in the umbilical vessels. This epidemic occurred at a time when especial interest was being taken in the care of the cord, and when not a single case of puer- peral infection had been in the ward for weeks, so that the only cause which could be discovered for it was an infected finger in the mother of one of the children. As the umbilical stump in these cases presented no outward sign of infection, the conditions would have escaped detec- tion had autopsy not been performed. Accordingly, it may be stated as a general rule that, whenever children die without any appreciable cause within two weeks after birth, such an infection should be suspected, and the examination of the intra-abdominal portion of the umbilical vessels will usually show that they are filled with purulent thrombi, in which pyogenic microorganisms can be demonstrated, and which have given rise either to a general infection or a peritonitis. In view, there- fore, of the not inconsiderable danger of infection from this source, strict aseptic precautions should be observed in caring for the cord. The reader is referred to Ploss’s work for interesting details concerning its treatment in various countries and by aboriginal peoples. After making the mother comfortable, the nurse should devote her attention to the child. After being anointed with vaseline or olive oil, it should be thoroughly washed with Castile soap and water, as experience has shown that the vernix caseosa is much more readily removed when some oleaginous substance is first employed. Or, it may be removed by means of cotton pledgets soaked in albolene, and the bath dispensed with. After the vernix caseosa has been removed, the stump of the cord should be thickly sprinkled with powdered boric acid and covered with a pad of sterile gauze, which should be held in place by narrow adhesive strips. If the child is doing wTell, this dressing need not be changed for some days unless it becomes moist or soiled. On removing it, the cord will usually be found to have become completely separated, otherwise a similar dressing should be reapplied. I have obtained satisfactory results with this method of treatment, although in some cases it appears to prolong unduly the separation of the cord. Since 1906, I have employed the alcohol dressings recommended by Budberg. For this pur- pose the umbilical stump is wrapped in a small strip of sterile gauze soaked in 95 per cent, alcohol, after the excess has been allowed to drain off. Such dressings must be changed daily. After the cord has sloughed off, the granulating umbilicus should be covered by a sterile dressing, and the child should not receive a full bath until it has completely healed. During this period it should be bathed in the lap of the nurse, care being taken not to contaminate the umbilical dressings. Dr. W. M. Dabney, while an assistant in my service, made compara- tive observations in the hope of determining the best method of dealing with the cord. He treated several series of cases, respectively, with the following dressings: boric acid, salicylic acid, a mixture of salicylic acid and starch, and a wrapping of silver foil. So far as he could see, it CARE OF THE EYES 391 made no difference which method was employed, provided the dressings were sterile. In still another series of cases he applied an occlusive dressing of liquid celloidin, but found that in such circumstances thq cord was kept unduly moist, and separation was perceptibly delayed. The question as to the proper method of treating the cord has given rise to a great deal of discussion. Dickinson in 1899 in a paper en- titled, Is the Sloughing Process at the Child’s Navel Consistent with Asepsis in Child-bed? answered the question in the negative, and in 1916 reaffirmed his belief. He recommended that the cord be completely excised where it joins the abdomen, its vessels ligated, and the wound closed by sutures. Possibly this may be the ideal method of treatment, but it is a question whether it is advisable in private practice, as it is probable that, should the child die within a few weeks after such a procedure, the physician would be severely criticized by members of the family who have become accustomed to the time-honored treatment. Martin recommended that the cord be ligated close to the abdomen and cut through with a pair of red-hot scissors. Porak and others advo- cate its compression by powerful forceps, as in angiotripsy, while Ziegler has devised an ingenious rubber clamp for the purpose. Ilachmanow, on the other hand, believes that all such precautions are useless, and reported that in 9,000 out of 10,000 consecutive children delivered under his care he had simply cut the cord, after it had ceased to pulsate, and in not a single instance did serious hemorrhage occur, notwithstanding the fact that no ligatures w'ere used. Such results, however, are con- trary to my experience, as I have repeatedly observed profuse hemor- rhage after the cord had been carefully ligated. Care of the Eyes.-—In view of the frequency with which the eyes of the newly born child become infected when passing through the birth canal of women suffering from gonorrhea, Crede in 1884 introduced the practice of instilling into each eye immediately after birth one drop of a 1-per-cent, solution of nitrate of silver, which was afterward washed out with salt solution. This procedure has led to a marked decrease in the frequency of gonorrheal ophthalmia and the cases of blindness result- ing from it, and should be followed as a matter of routine. Even in my private work I habitually employ Crede’s method, as the development of ophthalmia in several babies treated w ith boric acid solution taught me that gonorrhea may be present where least expected. The prophylactic value of silver nitrate was strikingly demonstrated by Haab, whose statistics showed that its employment in hospital prac- tice had reduced the frequency of ophthalmia neonatorum from 9 to 1 per cent., while the statistics from many hospitals show an incidence of only 1/5 to 1/10 of 1 per cent. If, however, the disease should appear in spite of the precautions taken, it should be promptly and vigorously treated, inasmuch as when neglected it almost invariably leads to cloud- ing of the cornea and often to complete blindness. Cohn estimated in 1876 that 30 per cent, of the patients in the blind asylums of Germany, Austria, Holland, and Switzerland owed their trouble to ophthalmia neonatorum. Twenty years later these figures had become reduced to 19 per cent.; while Crede-Horder in 1912 reported a further diminution 392 THE NEWLY BORN CHILD to 12.39 per cent. Dr. J. J. Carroll stated that 30 per cent, of the inmates of the Maryland School for the Blind in 1909 owed their blindness to the same cause, and that its incidence had increased rather than decreased during the previous twenty years. This means that our results are much worse than in Germany, and that the average prac- titioner and midwife have failed to appreciate the prophylactic value of Crede’s method, and makes pertinent the inquiry as to the advisability of legislation making the use of silver nitrate compulsory in all cases. In very rare instances the process may be thoroughly established at the time of birth—the so-called intra-uterine ophthalmia. In such cases the infection developed while the child was still in utero, and Stephen- son states that it may even occur without premature rupture of the membranes, having been noted in children born in a "caul.” Zweifel in 1900 advocated substituting a 1-per-cent, solution of silver acetate for the nitrate, and reports that, in a series of 5,222 children so treated, ophthalmia was observed in only 0.23 of 1 per cent. The employment of protargol, argyrol, sophol, and various other preparations of silver has been suggested, but experience has shown that they give no better results than silver nitrate. Care should be taken that only fresh solutions are employed, as they rapidly deteriorate on keeping, especially when exposed to the light. Stools and Urine.—For the first few days after birth the intestinal contents are represented by a brownish or brownish-green, soft material —the meconium. It is made up of cast-off epithelial cells from various portions of the intestinal tract, a few epidermal cells and lanugo hairs which have been swallowed with the amniotic fluid. Its peculiar color is due to the presence of bile pigments. During pregnancy and for a few hours after birth the intestinal contents are sterile, but bacteria soon gain access to them and are afterward present throughout life. After the third or fourth day, with the establishment of the mam- mary secretion, the meconium disappears, and its place is taken by feces, which are light yellow in color, homogenous in consistence, and possess a characteristic odor. For the first few days the stools are not formed, but after a short time they take on the characteristic cylindrical shape. The bowels, as a rule, move twice daily, but a single large dejec- tion is sufficient. The physician should make it a rule to inspect the stools at each visit, and instruct the nurse to save a napkin in anticipation of his arrival, as in this way important information may be gained concerning the digestion of the child. The child usually urinates almost immediately after birth, and con- tinues to do so at frequent intervals for the first few months of its life. The physician should impress upon mother and nurse the necessity of attempting to train the child to regular habits as to urination and defe- cation, and it is surprising how soon these may be formed if proper care is taken. For this purpose the napkins should be changed before each feeding, and after the first few weeks the child should be held over a small chamber at these times. It should also be encouraged to defecate at regular intervals. To accomplish this, it should be laid upon the bed ICTERUS 393 at the same hour each day with a napkin under its buttocks, and its ab- domen stroked along the course of the colon. Icterus.—Not infrequently on the third or fourth day after birth, the skin and conjunctivae of the child take on a yellowish hue, which may vary from a hardly visible discoloration to an intense jaundice. Kehrer concluded that icterus occurred in 75 per cent, of all children, and, although this estimate is certainly too high, there is no doubt that it is very common. According to Hofmeier, the condition is hematog- enous in origin, and is due to the breaking down of large numbers of red corpuscles soon after birth. Its mode of production has given rise to considerable discussion, which was well summarized by Linzen- meier and Lilienthal, in 1922, who believe that it is hepatogenous in origin, and is due to the fact that the liver has not fully assumed its postnatal functions. Ordinarily it possesses no clinical significance, and passes off in a few days without treatment. Initial Loss of Weight.—-Owing to the fact that the child receives little or no nutriment, and at the same time casts off considerable quantities of urine, feces, and sweat, it progressively loses weight for the first three or four days of its life, the total loss usually aggregating 250 grams (8 ounces). If the child is nourished properly, this is usually regained by the end of the tenth day, after which the weight should increase steadily at the rate of about 25 grams (6 drams) a day for the first few months, so that it becomes doubled by the time the child is five months of age. The initial loss is usually much greater when the child is excessively large, as well as in premature infants and those who re- ceive an insufficient supply of food. Anatomy of the Breasts and Lacta- tion. — Each breast is made up of from 15 to 24 lobes, which are arranged more or less radial- ly, and separated from one another by a varying amount of fat, to which the size and shape of the organ is in great part due. Each lobe consists of several lobules, which in turn are made up of large numbers of acini. These last are composed of a single layer of epithelium, beneath which is a small amount of connective tissue richly supplied with capillaries. Every lobule is provided with a small duct, which, meeting others, unites to form a single larger canal for each lobe. These so-called lactiferous ducts make their way to the nipple and open separately upon its surface, where they may be distinguished as minute isolated orifices. The acini represent the functioning portion of the breasts, and it is Fig. 329.—Lactating Breast (Zeiss, DD-4). 394 THE NEWLY BORN CHILD from their epithelium that the various constituents of the milk are formed. This fact was first demonstrated by Heidenhain. We have already referred to the changes occurring in the breasts during pregnancy, and their condition remains much the same for the first two days after labor. At this time they do not contain milk, but a small amount of colostrum can be expressed from the nipples. This is a thin, yellowish fluid, which owes its color to the presence of a pig- ment which is soluble in ether and, according to Kiihne, is analogous to the coloring matter contained in the cells of the corpus luteum. When examined under the microscope, colostrum is seen to consist of a fluid in which are suspended numerous round bodies, 0.001 to 0.025 millimeter in diameter—the so-called colostrum corpuscles— which represent cast-off' epithelial cells which have undergone fatty de- generation. The fluid portion is a transudate which consists in great part of serum albumin and coagulates on heating. Colostrum con- Fig. 330.—Human Colostrum (Zeiss, DD-4). Fig. 331.—Human Milk (Zeiss, DD-4) tains more proteid material and salts, but less fat, than normal milk; while its sugar content is about the same. It is generally stated that it possesses but slight nutritive properties and that its chief function is to act as a mild cathartic. Jaschke and Ludwig, on the contrary, hold that children receiving it in considerable quantities suffer a much slighter initial loss of weight than usual. They also believe that the serum albumin which it contains is taken up without change by the epithelium of the digestive tract. Lewis and Wells consider that its chief value consists in its englobulin content, which can pass directly into the blood and apparently carries with it certain protective antibodies in which the child is deficient. For this reason they hold that it is most desirable that every new-born infant should receive its full ration of colostrum, whereby its immunity to various infections is increased. Milk.—On the third or fourth day after labor and occasionally on the second, the breasts suddenly become larger, firmer, and more pain- ANATOMY OF THE BREASTS AND LACTATION 395 ful. This indicates the establishment of the lacteal secretion, and on pressure a small amount of bluish-white fluid—the milk—will exude from the nipples. Coincident with these changes, the patient experi- ences more or less lassitude, and may suffer from headache. At the same time she has throbbing pains in the breasts, which may extend into the axillae, and the pulse becomes slightly accelerated. There is rarely any elevation of temperature. It was formerly believed that the establishment of the milk flow was associated with marked constitutional disturbances, which were regarded as manifestations of the so-called milk fever. As has already been said this is very exceptional, and usually a rise of temperature at this time is indicative of infection. Mother’s milk is usually bluish-white in color, though it sometimes has a yellowish tinge. It is slightly alkaline in reaction, and has a specific gravity of from 1.028 to 1.034. Under the microscope it ap- pears as a clear fluid in which are suspended large numbers of small round bodies, 0.008 millimeter in diameter—the so-called milk cor- puscles. These consist of minute drops of fat surrounded by a mem- brane. Chemical examination shows that they are made up of the triglycerides of olein, palmatin, and stearin. The fluid portion of the milk is a transudate, and consists of protein material, milk sugar, salts, and water. Milk, therefore, represents an emulsion of fine fat droplets in a fluid medium. The protein material in milk serum consists of one-third casein and two-thirds lactalbumin, which are direct metabolic products of the mammary epithelium, and differ from serum albumin in that they do not coagulate on heating. The fat and lactose, or milk sugar, are also products of the epithelial cells. The milk serum contains a con- siderable amount of mineral matter, one-half of which, according to the investigations of Holt, consists of calcium phosphate and potassium carbonate, while the remainder is made up of sodium chlorid, potas- sium chlorid, potassium sulphate, magnesium carbonate, and minute quantities of several other salts, including iron. The average composition of milk is as follows: Proteids, 1 to 2 per cent.; fats, 3 to 4 per cent.; sugar, 6 to 7 per cent.; salts, 0.1 to 0.2 per cent., the rest being water. According to Holt, the average com- position of 17 twenty-four hour specimens of mature milk was as follows: Proteids, 1.15; fat, 3.26; sugar, 7.5, and ash, 0.206 per cent., respectively; while in the so-called transitional period—from the end of the first to the fourth week—the proteid and fat content is consid- erably greater—1.56 and 4.37 per cent., respectively. Milk also contains a not inconsiderable number of bacteria, which, according to the re- searches of Kostlin, are derived from the terminal ends of the lac- tiferous ducts and the surface of the nipples; it is questionable whether they are present in the deeper portions of the breast. Nutritious mother’s milk varies markedly in its composition, not only in different individuals, but also in the same individual at various times. It is not unusual to find that the milk of one woman, which agrees perfectly with her own child, will prove indigestible when given to the healthy child of another woman. The variation in the compo- 396 THE NEWLY BORN CHILD sition of the milk of the same woman at different times is dependent upon various factors, principally the diet, the amount of exercise, and the mental condition. The quantity of milk varies to a large extent with the amount of fluid ingested by the patient, and a diet rich in cow’s milk conduces to increased mammary activity. There are large numbers of preparations in the market which are known as galactagogues, and are vaunted as increasing the amount of milk; but whatever virtue they may possess is due in great part to the quantity of fluid taken with them. Exercise in the open air also in- creases the milk flow, and it is frequently observed that a woman who has but a small quantity, so long as she is confined to her room, will secrete an abundant supply as soon as she begins to take outdoor exercise. The quality of the milk is likewise dependent in great part upon the food and the amount of exercise taken by the mother. It is a matter of experience that a diet rich in proteids increases the ratio of the fats, while excessive exercise diminishes the amount of protein material. Marked alterations in the quality and quantity of protein frequently result from nervous and mental influences, and it is not unusual for some profound emotion to lead to almost complete sup- pression of the lacteal secretion, or to so change its quality as to render it temporarily unfit for the use of the infant. Certain drugs also exert a marked influence upon the milk flow, and it is well-known that the use of belladonna or atropin markedly diminishes it. Many sub- stances ingested by the mother may be transmitted through the milk, and thus exert their physiological influence upon the1 child. This is particularly true of the various cathartics and alcoholic liquors. It is generally believed that the occurrence of menstruation, or the onset of another pregnancy during lactation, exerts a very deleterious effect upon the quality of the milk, in some cases rendering it neces- sary to wean the child. When it is remembered how large a proportion of women menstruate while suckling, and how often the first indication of the occurrence of pregnancy in a nursing mother consists in the perception of foetal movements, it is apparent that the deleterious effect of such occurrences is greatly overestimated. Nursing.—The ideal food for the newly born child is the milk of its mother, and, unless lactation be contra-indicated by some physical defect, it is the physician’s duty to insist that every woman should at least attempt to suckle her child. In many instances where the supply of milk at first appears insufficient, it becomes increased in amount if suckling be persisted in. The act itself also exerts a beneficial influ- ence upon the involution of the uterus, as it is well-known that the repeated irritation of the nipples results in reflex stimulation of the uterus, and Temesvary has further proved by actual measurement that involution occurs more rapidly in nursing women. This fact should be urged upon those who are unwilling to nurse their children, and it fre- quently happens that, although they may have commenced it from selfish motives, they will continue it as long as is necessary. Unless it be otherwise arranged, the physician who conducts the NURSING 397 labor should hold himself responsible for the well-being of the child during the first few weeks of its life, and should not limit his attentions to the mother. He should accordingly give minute directions as to the way in which it should be fed, and see that they are accurately carried out. Frequency of Feeding.—As the nutritive properties of colostrum are very limited, the child should be put to the breast only three times a day until the milk flow becomes established, but after that time it should be fed at intervals of three or four hours. Definite hours should be set for each feeding, and, if necessary, the child should be awakened from a sound sleep at stated times to take its nourishment, for only by this means can its habits be made regular. I do not consider that a nurse has fulfilled her whole duty unless she leaves the patient with a child properly trained in the matter of taking its food. A definite hour should be arranged for the child’s bath, which should be taken as a starting-point in arranging the schedule for feeding. Ordinarily the most convenient time is between 9 and 10 a. m. If the former hour be chosen, the first feeding should be at 6 a. m., and the next immediately after the bath. After bath the baby should be allowed to sleep as long as it will, which will usually be several hours, after which it should be given nourishment at fixed intervals. By this arrangement it will receive six to seven feedings during the twenty- four hours, according as the three or four-hour schedule is followed. In any event, the last feeding should be timed for the usual bedtime of the parents, and only one feeding should be given during the night— that is, between 11 r. m. and 6 or 7 a. m.—and frequently the child can be trained to sleep the entire night without awakening. This, however, can only be accomplished by feeding it at regular intervals during the day, so as to insure that it receives the proper amount of nutriment in the twenty-four hours. Just before each feeding the napkin should be changed and the child encouraged to urinate, but as soon as it is taken from the breast it should be placed in bed and not disturbed. It should not be allowed to sleep at its mother’s breast, nor should it be rocked or fondled after feeding. If these regulations be persisted in, the child will usually go to sleep within a few minutes after being put to bed, and if it wakes before the next feeding is due it will remain quiet. The importance of following these directions cannot be overestimated, for it is only by rigid adherence to such details that the child can be given regular habits, and its care prevented from becoming a strain upon all con- cerned. After the fourth or fifth week, unless the child is placed upon a four-hour schedule, one of the breast feedings may be replaced by a bottle, even though the milk supply is adequate. By so doing the tedium of nursing is greatly reduced, and many a woman is willing to suckle a child which she would otherwise wean. When a mother is obliged to return home every few hours to nurse her child, it is apparent that her time is so broken in upon as to render it impossible 398 THE NEWLY BORN CHILD for her to obtain any real relaxation; whereas if a single bottle be inter- polated between any two feedings a long free space will be afforded. Duration of Feeding.—Definite rules cannot be given concerning the proper length of each feeding, as this point is dependent upon several factors-—the quantity of milk, the readiness with which it can be obtained from the breast, and the avidity with which the child nurses. Generally speaking, it is advisable to allow the child to remain at the breast for ten minutes at first, and to lengthen or decrease the time according to circumstances, three or four minutes being suf- ficient for some children, while fifteen or twenty minutes will be re- quired by others. There is so universal a tendency toward overfeeding that at first it is better to err in giving too little rather than too much milk. Crying is not always a symptom of hunger, but much more frequently indicates indigestion, resulting from an overloaded stomach. A child which is receiving the proper amount of nourishment should not spit up its food, should increase steadily in weight, and should have normal yellow homogeneous passages. The occurrence of regurgi- tation, or the presence of curds in the stools, is a sure sign that it is being nursed too long. On the other hand, loss of weight, associated with normal stools and the absence of regurgitation, indicates insuf- ficient feeding. The child should be weighed twice a week, upon a fairly accurate pair of scales, and its actions inspected daily by the physician. As has already been said, it should regain its birth weight by the end of the tenth day, and from then on it should gain regularly 25 grams a day, or, roughly speaking, 5 ounces a week. After the first few months the increase is more gradual, the average child doubling its weight at the fifth and trebling it at the fifteenth month. Care of the Breasts.—Before and after each feeding the nipples should be carefully washed with a boric acid solution, so as to avoid the possibility of bacteria being ground into them during suckling. In many cases, particularly if preliminary precautions have not been taken to prepare them, the nipples become very sore during the first few days of nursing, and little cracks or fissures appear upon them. These are extremely painful to the mother, and in some cases render the act of suckling agonizing. In addition to the suffering which they cause, they are also a source of considerable danger, as it is through them that bacteria gain access to the interior of the breast. The nurse should therefore be instructed to be on the lookout for them, and to notify the physician of their appearance, as prompt treatment will usually lead to their speedy cure. On the other hand, neglect of these premonitory signs is frequently followed by a mammary abscess, for the occurrence of which the physician and nurse are usually more or less justly blamed. The fact that large numbers of remedies are recommended for the cure of fissured nipples is abundant evidence that they are not always readily relieved. They are best treated by rest, and if the infant could be kept from the breast for twenty-four hours they would heal without further treatment. As this is out of the question, some other means CARE OF THE BREASTS 399 of securing rest must be adopted, and this is best attained by the use of a so-called English nipple shield, or one of the curved variety de- vised by Slemons. Many women claim that they are unable to use such a contrivance, but the difficulty is usually due to the fact that the holes in the rubber nipple are too small, and if -they are enlarged by passing a red-hot hairpin through them a quantity of milk sufficient for the child can usually be obtained without much difficulty. The application of compound tincture of benzoin to the fissures tends to hasten the healing, and in the intervals between the feedings the nipples should be covered by compresses soaked with boric acid solution. Particular attention should be devoted to the care of the shield, which should be boiled daily, and carefully washed after each feeding and kept in a vessel containing a saturated solution of boric acid. In rare cases the nipples may be so depressed below the surface of the breast as to render nursing out of the question. Here it is useless to attempt it, and steps should be promptly taken to arrest the mam- mary secretion. It was formerly taught that the child’s mouth should be scrupulously cleansed before each feeding by washing it out with a clean piece of linen dipped in boric acid solution, with the idea of diminishing the possibility of breast infection. Although it is known that bacteria are constantly present in the buccal cavity of infants, experience has shown that the practice is useless, as it has no effect upon the incidence of mammary infection, and has the disadvantage that it sometimes leads to infection of the child’s mouth. When the child dies, or if for any reason the physician feels that lactation is contra-indicated, steps should be taken to check lactation, or, as it is usually designated, “to dry up the breasts.” Formerly this was accomplished by a tedious and laborious process, which con- sisted in tightly bandaging the breasts, after having covered them with belladonna ointment. Within a few hours they became very engorged and painful, when the excess of milk was drawn off by means of a breast pump, after which the bandage was reapplied, and the process repeated as frequently as necessary, days or weeks often elapsing before the secretion was checked. The treatment was sometimes so painful that the patient complained that it was far worse than the labor itself. Some years ago, Dr. E. R. Lewis, of Westerly, R. I., told me that equally good results could be obtained in far less time merely by the administration of 20 grains of potassium acetate every four hours. My investigations, however, have shown that the drug is without effect, and that Nature will take care of the entire process, if not aggravated by improper treatment. Since 1905 my practice has been to leave the breasts absolutely alone. Within twenty-four hours after the last nursing, or on the third day, if the child has not been suckled, the breasts become en- gorged, and sometimes quite painful. But if they are not touched, the swelling soon subsides, and the pain disappears within a few hours, after which the breasts gradually become smaller, and contain less and less milk, so that the entire process is over by the end of the third day. 400 THE NEWLY BORN CHILD If the patient is nervous a placebo may be administered, or if the pain is severe a single hypodermic injection of morphia may be required, but further medication is not necessary. When the breasts are large and pendulous, they may be supported by a bandage, which, however, should not be sufficiently tight to exert pressure. It wxmld accordingly appear that the methods formerly in vogue, and particularly the use of the breast pump and massage, defeated the very purpose for which they were employed, and really serve to stimulate the secretion of milk and subject the patient to great discomfort. My experience with the method, both in hospital and private prac- tice, has been so satisfactory that I can strongly recommend its adop- tion. Those who are interested in details concerning it are referred to the article by my former assistant, Henry J. Storrs. Artificial Feeding.—When the supply of mother’s milk is defective, or when abnormalities of the nipples or constitutional diseases render nursing inadvisable, artificial feeding must be resorted to. Numerous so-called infant foods are advertised for this purpose, but most of them are very defective, so that for practical purposes cow’s milk in some form is the only available substitute for the mother’s milk. Unfortu- nately, however, it differs markedly from the latter in composition, and under the most favorable circumstances is only an imperfect substitute for it. It is usually slightly acid in reaction, and has a specific gravity of 1.029 to 1.033. Its average composition is: proteids, 4 per cent.; fats, 4 per cent.; sugar, 4.5 per cent., and salts, 0.7 per cent. It is apparent, therefore, that it contains less fat and sugar, and more pro- tein material and salts, than mother’s milk, and consequently cannot be used in its natural form, but must first be modified in some way. If the child is healthy, satisfactory results are frequently obtained by diluting cow’s milk with various proportions of water and adding sugar. Such preparations contain approximately the normal amount of proteid material and sugar, but are lacking in fat. In hot weather the mixture should be pasteurized, but in cool weather this procedure is unnecessary. The space at our disposal is too limited to permit consideration of the many and complicated problems connected with artificial feed- ing, and the reader is referred to the various treatises upon Pediatrics for extended information. There are, nevertheless, two points upon which I must insist—namely, the capacity of the stomach and the necessity for training the child to regular habits, no matter what method of feeding is employed. It should be remembered that the stomach of the newly born child is very small, and that one ounce will fill it to repletion. That amount of fluid, therefore, should not be exceeded for the first few days, after which it should be increased gradually. The instructions as to the frequency and manner of feeding, which have already been given, apply equally well whether the child is fed at the breast or from the bottle, and too great stress cannot be laid upon their rigid observance. LITERATURE 401 LITERATURE Ahlfeld. Lehrbuch der Geburtshiilfe, II. AufL, 1897, 179. Budberg. Die Behandlung des Nabelschnurrestes. Zentralbl. f. Gyn., 1898, 1288-1289. Carroll. Why Does Ophthalmia Neonatorum Continue to Cause so much Blind- ness? Maryland Med. Jour. Dec., 1909. Cohn. Ueber Verbreitung und Verhiitung der Augeneiterung der Neugeborenen. Berlin, 1896. Credb. Die Verhiitung der Augenentziindung bei Neugeborenen. Berlin, 1884. Crede-Horder. Hat die Blennorhoea neonatorum abgenommen? Zentralbl. f. Gyn., 1912, 1503-1506. Dickinson. Is a Sloughing Process at the Child’s Navel Consistent with Asepsis in Childbed? Amer. Jour. Obst., 1899, xl, 14-66. Immediate Complete Amputation of the Umbilical Cord. Trans. Am. Gyn. Soc., 1916, xli, 713-717. Eross. Beobachtungen an 1000 Neugeborenen iiber Nabelerkrankungen, etc. Archiv f. Gyn., 1891, xli, 409-449. Haab. Die Mikrokokken der Blennorrhoea neonatorum. Festschrift zu Horde,r, Wiesbaden, 1881. Hofmeier. Die Gelbsucht der Neugeborenen. Zeitschr. f. Geb. u. Gyn., 1882, viii, 287-353. Holt, Courtney and Fales. A Chemical Study of Woman’s Milk. Am. Jour. Dis. Child., 1915, Oct., 229. Jaschke and Ludwig. Zur Biologie des Colostrums. Zeitschr. f. Geb. u. Gyn., 1915, 188-201. Kehrer. Studien iiber den Icterus neonatorum. Jahrbuch fiir Padiatrik, 1871, ii, 71. Keller. Die Nabelinfektion, etc. Zeitschr. f. Geb. u. Gyn., 1906, lviii, 454-475. Kostlin. Beitrage zur Frage des Keimgehaltes der Frauenmilch. Archiv f. Gyn., 1897, liii, 201-277. Lewis and Wells. The Function of the Colostrum. J. Am. Med. Assoc., 1922, lxxviii, 863-865. Linzenmeier and Lilienthal. Zur Frage des Icterus neonatorum. Zentralbl, f. Gyn., 1922, 1873-1883. Martin. Die Versorgung des Nabels der Neugeborenen. Zeitschr. f. Geb. u. Gyn., 1900, xlii, 593-596. Ploss. Das Weib in der Natur- und Volker-kunde. IV. AufL, 1895, Bd. II, 182-198. Porak. De l’omphalotripsie. Annales de gyn. et d’obstet., 1900, liv, 112-113. Rachmanow. Methode der Nieht-unterbindung der Nabelschnur. Zentralbl. f, Gyn., 1914, 590-592. Stephenson. Ophthalmia Neonatorum. London, 1907. Storrs. Checking the Secretion of the Lactating Breast. Surg. Gyn. and Obst., 1909, ix, 401-405. Strassmann. Anat. u. Physiol. Untersuchungen iiber den Blutkreislauf bei Neugeborenen. Archiv f. Gyn., 1894, xlv, 393-445. Der Verschluss des Ductus arteriosus. Beitrage zur Geb. u. Gyn., 1902, vi, 98-117. Temesvary. The Connection between the Female Breasts and Genitalia. Jour. Obst. and Gyn. Brit. Emp., 1903, iii, 511-525. Warnekros. Schwangerschaft und Geburt im Roentgen-bilde. Miinchen, 1921. Zweifel. Die Verhiitung der Augeneiterung Neugeborenen. Zentralbl. f. Gyn., 1900, xxv, 1361-1380. CHAPTER XVIII MULTIPLE PEEGNANCY The uterus occasionally contains two or more embryos; thus, ac- cording to the number present, we have a twin, triplet, quadruplet, quintuplet, or sextuplet pregnancy. According to Badouin, only five credible instances of sextuplet preg- nancy have been recorded, and even several of them have been sub- jected to considerable criticism. On the whole, it may be said that reports of the birth of a greater number of children at a single labor are to be regarded as apocryphal, although many such are to be found in the older literature, the most remarkable being the Rhine legend, according to which the Countess Ilagenau was delivered of 365 em- bryos at a single labor-—manifestly an hydatidiform mole. Frequency.—Wappaeus found that more than one child was born in 1.17 per cent, of 20,000,000 cases of labor which he analyzed. The statistics of G. Veit, which were based upon 13,000,000 cases occurring in Prussia, showed that twins occurred once in 89, triplets once in 7,910, and quadruplets once in 371,125 labors. According to Mira- beau, triplets occur more frequently—once in 6,500 cases. De Blecourt and Nijhoff, in 1904, reported a case of quintuplets, and stated that they found in the literature what appeared to be authentic histories of 28 additional cases. It would appear that multiple pregnancy is more common in cold than in warm climates. This statement is borne out by the statistics of Bertillon and Mirabeau, the latter stating that they occur once in 41.8 labors in Russia, as compared with once in 113.6 labors in Spain. Gache found that they occur most frequently in Greece and least so in Peru, being noted once in 50 labors in the former, as compared to once in 170 in the latter country. According to Duncan, twin preg- nancy is noted most frequently in multiparae, especially between the twenty-fifth and twenty-ninth years. It has been estimated that in 63.1 per cent, of the cases only one, and in 36.9 per cent, both sexes are represented. Thus, in the 717,907 observations collected by Nichols, both children were males in 234,497, both females in 219,312, and of different sexes in 264,098 cases. Etiology.—Certain individuals appear to be predisposed toward mul- tiple pregnancy, since it is not unusual for the same woman to give birth to twins or triplets upon several occasions. Thus Puech, upon analyzing 1,262 cases of pregnancy, found that 48 of the mothers had given birth to twins twice, 3 thrice, and 1 upon 4 occasions. In some instances, multiple pregnancy has been known to occur in all 402 ETIOLOGY 403 the females of a family throughout several generations. Mirabeau has pointed out that an hereditary tendency toward triplet pregnancies was recorded in 13 out of the 75 cases collected by him. This was par- ticularly marked in one family, in which the birth of triplets, not to mention twins, had occurred one or more times in five successive gen- erations. Less frequently, however, this tendency appears to come through the father, and reference is frequently made to the somewhat apocryphal case of the Russian peasant, Wasilef, who is reported to have had 87 children by 2 wives, the first having had 4 quadruplet, 7 triplet, and 16 twin pregnancies; and the second 2 triplet and 6 twin pregnancies. Davenport, in 1920, sifted the evidence in this regard, which was based upon his geneological tables, and holds that the hereditary influence is exerted almost as frequently through the father as through the mother, particularly in the case of single ovum twins. This was especially evident in couples who had twins in a first marriage, and then married again. In this event the hereditary tendency appeared to be transmitted almost as frequently by the man as by the woman, as the incidence of twins in second marriages was many times greater than in the average family. Twin pregnancy may result either from the fertilization of two separate ova or of a single ovum, the first giving rise to double, or fra- ternal, and the second to single-ovum, or identical, twins. In the former case the ova may come from the same ovary, or one from each ovary; while in the latter only a single ovum is concerned. Fraternal twins may or may not be of the same sex, and do not necessarily resemble one another more than other children of the same parents; while identical twins are necessarily of the same sex, and, if they reach maturity, resemble one another closely. Approximately speaking, one out of every five sets of twins belongs in the latter category; as out of 1,159 instances of twin pregnancy analyzed by Ahlfeld, 979 were derived from two ova and 180 from one ovum; whereas, Prinzing in 1,887 cases found that the incidence of single ovum twins was 26.3 per cent. According to Hellin, Patellani, and Larger, multiple pregnancy should be regarded as a sign of atavistic reversion analogous to the litters of many domestic animals, and Hellin states that the ovaries of women who have had a number of multiple pregnancies contain an excessive quantity of ova. According to this view, which can apply only to double ovum twins, we have to deal with the maturation and fertilization of several ova at a single ovulation period. If heredity is concerned in such cases it can be manifested only by the transmission of abnormally actively functioning ovaries. Biologically, double ovum twins are not twins at all, but are simply due to the maturation and fertilization of two ova at a single ovulation Fig. 332.—Ovum with Dou- ble Germinal Vesicle. 404 MULTIPLE PREGNANCY period. Single ovum twins, on the contrary represent twins par ex- cellence, as is well expressed in Newman’s definition—“Strictly speak- ing, twinning is twaining or two-ing—the division of an individual into two equivalent and more or less completely separate individuals.” Their mode of production has given rise to a considerable literature, to which American investigators have made important contributions. Formerly, it was believed that single ovum twins were derived from the fertilization of an ovum which presented two germinal vesicles. The existence of such ova is indisputable. Franque, Klein, and others having reported undoubted examples of such a condition; while Fig. 332 rep- resents an ovum of this character found in one of my specimens. When, however, one considers that in order for such an ovum to develop into single ovum twins each of its nuclei must undergo typical maturation Fig. 333.—Placenta, Double-ovum Twins, Velamentous Insertion of Cord. and cast off polar bodies, and moreover each of the female pronuclei so resulting must be fertilized by a separate spermatozoon, it is apparent that the process is not so simple, as might appear at first sight. Further- more, the problem is not simplified by accepting the hypothesis of Bromann, and Delucca and Widakowich, that fertilization may be effected by the two heads of a double-headed spermatozoon, whose occurrence they suppose is not infrequent. For a time Bonnet’s theory, that one of the two single ovum twins might originate from the fertilization of the second polar body before it had escaped from the ovum, enjoyed a considerable vogue, but now it finds few supporters. Recent biological investigations have shown that single ovum twinning occurs frequently in many species of animals, and can be produced experimentally and at will in several varieties of ETIOLOGY 405 fish, and also that it is fundamentally associated with the production of monstrosities—the normal twins representing the complete and the monstrosities an imperfect form of the same process. Stockard has shown that retardation in the growth of the egg, at what he calls critical periods of development, is the essential factor concerned; and has demonstrated that it may be brought about either by exposing the egg to cold or by diminishing its supply of oxygen. When exposed to such retarding influences, just as it is about to undergo gastrulation, the egg may die, or its developmental rate may be arrested or slowed down for a time, with the result that when growth is resumed two gastrulae or two embryonic areas will develop instead of one. If these are far apart two separate individuals will be formed, whereas if the two areas are partially in contact double monsters presenting vary- ing degrees of fusion will result. Furthermore, Stockard has shown that he can alter at will the degree of duplicity by changing the time at which the retarding influences are brought into play. In other words, he has adduced experimental proof of the closest relationship between single ovum twins and double monsters, and in human beings one can readily follow all gradations between typical identical twins and the well-known Siamese twins on the one hand, and the double-bodied, double-headed or double-legged monsters downward to the monsters by inclusion, and finally to the teratomata, on the other. The most striking example of the development of multiple pregnancy from a single egg is afforded by the nine-banded armadillo. As is well known, this animal gives birth to four young at a time, which are al- ways of the same sex and all of which are inclosed within a common chorion. All details of the process have been exhaustively worked out by Newman and Patterson, and it would appear that the key to the process lies in the fact that the fertilized ovum lies quiescent in the uterine cavity for three weeks before placental attachments are formed, and the resulting retardation in growth during this period of quiescence causes a partial loss of polarity, so that when growth is resumed four embryonic areas result instead of one. That something of the same kind applies in human beings is indicated by the fact that Arey has demonstrated that twins occur many times more frequently in tubal than in uterine pregnancy, and he is inclined to attribute the difference to the difficulty attending the implantation of the ovum in the abnormal location, with consequent retardation of growth. Newman in his two monographs—The Biology of Twins, and the Physiology of Twinning—has considered in detail the problems con- cerned in human beings. He states that single ovum twins may be due to (1) fission of the blastoderm, (2) double gastrulation, or (3) fission of the bilateral halves of a single embryonic axis. In each in- stance some retarding factor must come into play, and he considers that any one of the following three possibilities may be concerned: (a) Under stimulation of the egg due to some defect in the develop- ment-stimulating mechanism of the sperm. 406 MULTIPLE PREGNANCY (b) Belated placentation due to a failure of the corpus luteum to stimulate the uterine mucosa, and (c) That twinning is an hereditary character dependent upon a recessive gene. While such explanations may not be entirely satisfactory, enough has been said to indicate that single ovum twinning is a well recognized biological phenomenon; does not represent an inherent attribute of the ovum, and is attributable to conditions which effect its rate of growth after fertilization. Accordingly, in human beings at least, its cause may sometimes be sought in environmental conditions with which we are as yet unacquainted. In Fig. 127 (page 124) is shown one of the earliest examples of human single ovum twinning. In this specimen, which was described by Streeter, the main embryo was a relatively large structure, while the twin was represented by a small amniotic vesicle and yolk sac imbedded in the connective tissue of the chorionic membrane, just adjoining the body stalk of the larger twin. Saniter states that in triplet pregnancy the children are usually derived from two ova—one from one, and two from the other—while in rare cases, one of which he has studied personally, all three children were derived from a single ovum. In the quintuplet pregnancy de- scribed by De Blecourt and Nijhoff, three of the children were con- nected with a single placenta, while each of the other two had separate placentae; thus indicating that only three ova had been fertilized, one giving rise to triplets, and the other two to single children. Relation of the Placentae and Membranes.—The development of one child in either horn of a bicornuate uterus, or of one twin in the uterus and the other in a fallopian tube, affords indubitable evidence of their origin from two ova; while in uterine twin pregnancy, the examination of the placenta and foetal membranes after labor usually enables one to determine the mode of origin of the twins. When they are derived from a single ovum, there is a single large placenta from which the two umbilical cords come off; but, when they are developed from two ova, there are usually two separate placentae, although, when these were originally inserted near one another, their contiguous margins may fuse together, thus giving rise to an apparently single large placenta, in which, however, there is no connection between the circulation of the two twins. In double-ovum twins, no matter whether the placentae are sep- arate or fused together, there are always two chorions and two amnions, each child being enveloped in its own membranes. Single-ovum twins, on the other hand, possess only a single chorion, but, as a rule, two amnions, for the reason that the former represents the wall of the original blastodermic vesicle, while the amnion is more directly con- nected with the embryo itself. In rare instances a single amnion is found. This condition, which was noted in 44 cases collected from the literature by Holzapfel, is not primary, but results from perforation of the partition wall between the two original amniotic cavities. This arrangement of the membranes was known to Yiardel in the RELATION OF THE PLACENTAE AND MEMBRANE 407 seventeenth century, who stated that when the children were of the same sex they were usually inclosed in a single amnion; whereas twins of different sexes were separated by a partition wall. He ex- pressed the belief that Providence took this means of guarding their morals in utero. Saniter has care- fully studied the relation of the foetal membranes in triplet pregnancy. In single-ovum twins there is al- ways a certain area of the placenta in which there is anastomosis be- tween the two vascular systems, which is never present in the fused placenta of double-ovum twins. This condi- tion, which has been exhaustively studied by Schatz, and well reviewed by Newman, occasionally leads to seri- ous consequences. Thus, if at an early period the heart of one embryo is considerably stronger than that of the other, a gradually increasing area of the communicating portion of the placenta is monopolized by the former, so that its heart increases rapidly in size, while that of the lat- ter receives less and less blood and eventually atrophies. Herein is to be found the explanation of the de- formity known as acardia. In such cases almost the entire placental cir- culation is utilized by the normal em- bryo, while the deformed twin re- ceives only enough blood to nourish its lower extremities; wdiile occasionally it is represented only by a shapeless mass of tissue—ucardius amorphus. In other instances a difference in the strength of the two hearts leads to the production of hydramnios in the larger ovum. In such cases it is believed that the stronger heart ap- propriates an ever-increasing share of the blood from the placenta and undergoes hypertrophy, which in turn is followed by a marked hypertrophy of the kidneys, which leads to in- creased urinary secretion and a consequent excess in the quantity of amniotic fluid. In the rare instances in which single-ovum twins are inclosed in a common amnion, their umbilical cords may become so twisted about Fig. 334.—Diagram Showing Rela- tion of Placenta and Mem- branes in Double- and Single- ovum Twin Pregnancy. a, double-ovum twins; b, double-ovum twins, double membranes, single pla- centa; c, single-ovum twins, one cho- rion, two amnions, and one placenta. MULTIPLE PREGNANCY 408 one another as to interfere with the circulation through them, and thus lead to death and an early termination of pregnancy. Sonntag, in 1905, collected 23 such cases from the litera- ture. Ordinarily in twin pregnancies, whether derived from one or two ova, each ovum occupies, roughly speaking, one-half of the uterus, the long axis being directed vertically. Occasionally, however, they run transversely, so that one foetal sac comes to lie above the other. In such circumstances, the pla- centa and membranes of the first child must be expelled from the uterus be- fore the second child can be born, un- less the latter can make its way past them. Unless the uterus is distended by an excessive amount of amniotic fluid, its is evident that its more voluminous contents must be subjected to greater pressure than in the case of single pregnancies. In this event the twins are brought into the closest contact and may be markedly molded. Figs. 338 -—a and 5, from Filth’s frozen section through the body of a primipara dying undelivered from eclampsia, give an excellent idea of what may happen, al- though it should be remembered that the conditions are probably exaggerated as the result of postmortem changes. Generally speaking, twins are smaller and weigh less than children resulting from single pregnancies, al- though their combined weight is usually greater than that of a single child. The smaller size may be con- sidered normal, but in some instances is partially to be explained by the fact that the excessive distention of the uterus tends to premature labor, so that the twins are often born several weeks before maturity. According to Ribe- mont-Dessaignes, this occurs in 83 per cent, of primiparae, and in 75 per cent, of multiparae. It is not unusual for twins to differ considerably in size and weight, especially when derived from a single ovum. Ahlfeld has reported three Fig. 335. Fig, 336. Fig. 337. Figs. 335-337.—Diagrams Showing Position of Twins in XJtero. SUPERFECUNDATION AND SUPERFETATION 409 cases in which the twins weighed, respectively, 2,320 and 1,120, 2,700 and 1,650, and 1,920 and 790 grams. In double-ovum twin pregnancy one child may die at an early period and be expelled from the uterus soon afterward, while the other may go on to full development. More frequently, however, the dead foetus is retained until the end of pregnancy, and, being compressed between the uterine wall and the membranes of the living child, becomes flattened out and partially mummified—foetus papyraceus or compressus (Pig. 339). Superfecundation and Superfetation. The consideration of the dif- ference in the weight of twins, and the possibility of one being aborted Fig. 338A.—Showing Moulding of Twins (Fiith). Fig. 338B.—Showing Moulding of Twins (Fiith). while the other develops until full term, leads up to the question of superfecundation and superfetation. By the former, we understand the fertilization of two ova within a short period of one another, but not at the same coitus; whereas in the latter several months may intervene. Superfecundation is a well-recognized occurrence in the lower animals, and undoubtedly occurs in human beings, although it is im- possible to determine its frequency. It is probable that in many cases the two ova are not fertilized at the same coitus, hut this can be demon- strated only under exceptional circumstances. It is interesting to note that Dr. John Archer, who was the first physican to receive a medical degree in America, related in 1810 that he had observed a white woman, who had had connection with a white and a colored man respectively within a short period, and was delivered of twins, one of which was 410 MULTIPLE PREGNANCY white and the other a mulatto. Some years ago in my clinic, the sixth pregnancy of a colored woman terminated in the birth of twins, one being macerated and the other perfectly healthy. Autopsy and the microscopic examination of the placenta of the first child gave indubitable evidence of syphilis, while the second child showed no signs of the disease. On questioning the patient, who presented no manifestations of syphilis, it was ascertained that she had had connection with her husband and with another man within a period of a few days, and that the latter was under treatment for syphilis at the time. From this it might be inferred that the normal child was engendered by the husband, and the syphilitic one by the lover, and the infer- ence is rendered more probable by the fact that the patient was delivered in the ser- vice twice before and thirteen times after this event, and none of the other children or placentae showed any sign of syphilis. The occurrence of superfetation has never yet been clearly demonstrated, though its theoretical possibility must be admitted, as long as the uterine cavity has not become obliterated by the fusion of the decidua vera and reflexa. As this occurs at the end of the third month of pregnancy, superfetation is out of the question after that time; but prior to that there is no theoretical objection to supposing that, if ovulation should occur, a second ovum might find its way into the uterine cavity and there be fertilized. Still more favorable conditions would be afforded by a uterus duplex. Many French authorities consider that such an event has been conclusively demonstrated, and many of the arguments which have been advanced in its favor are given by Tarnier. On the other hand, most English and German authors are skeptical, and, while admitting its theoretical possibility, believe that the majority of instances put under this category have been due either to the abortion of one twin or to marked inequality of development. Moreover, the fact that ovula- tion is usually in abeyance during pregnancy still further diminishes the probability of such an occurrence. The arguments against the occurrence of superfecundation were well reviewed by A. W. Meyer, in 1919. Cases occasionally occur which at first glance appear to bear out the possibility of superfetation, but, upon closer study, fail to do so. Thus, Fig. 339.—Foetus Papyracues (Ribemont-Dessaignes). DIAGNOSIS 411 a physician sent me a specimen which he thought afforded conclusive evidence in favor of such an occurrence. It consisted of two foetuses, which had been expelled spontaneously by a healthy multiparous woman, who thought herself four and one-half months pregnant. One foetus measured 18, and the other 4 centimeters in length. The former was perfectly fresh, while the latter showed signs of atrophy and had evi- dently been dead for some time, so that there was but little doubt that each had begun development at about the same period. Even had both foetuses been alive, the evidence would not have been unassailable, unless both placentae presented identical conditions upon examination; as it is conceivable that some lesion might have been present in the placenta corresponding to the smaller child, which would seriously interfere with its growth, without, however, causing its death. Diagnosis.—It sometimes happens that the first intimation which the physician has of the presence of twins is afforded by the unusually large size of the uterus after the expulsion of the first child. Despite this fact, however, it may be said that such surprises will rarely occur in the practice of those who take the trouble to make a thorough pre- liminary examination. Excessive size of the abdomen during pregnancy frequently causes one to suspect the presence of twins, though usually it will be found to be due to some other condition. Thus,- owing to the relaxation of the abdominal walls following the birth of the first child, women preg- nant for a second time often think that they will give birth to twins, although, as a matter of fact, their fears are generally without foundation. The diagnostic means at our disposal are palpation, auscultation, touch, and the X-ray. If a multiplicity of small parts is encountered on palpation, the possibility of a twin pregnancy should always be suspected. Positive evidence is afforded by the palpation of two heads, two breeches, and two backs; or at least of one back and four foetal poles. The detection of three foetal poles is not conclusive, for the reason that in rare instances a subperitoneal or intramural myoma may simulate the head of a child. Auscultation frequently gives most valuable information, and if one can distinguish two areas, considerably removed from one another, in which a foetal heart can be heard, twins should be suspected; but a positive diagnosis should not be made unless there is a difference of at least 10 beats per minute in the rate of the two hearts, the sounds being counted for at least a minute in each location. In rare instances vaginal touch may reveal important findings, as it is sometimes possible to distinguish a macerated head through the intact membranes, or a prolapsed and pulseless cord may be felt through the cervix, while auscultation gives positive evidence of the presence of a living child. Gauss, in 1910, pointed out that the presence of a second child in utero may materially alter the manner of descent of the first through the pelvis. Accordingly, he considers that the existence of a twin preg- 412 MULTIPLE PREGNANCY nancy is indicated whenever vaginal examination shows a head deep in the pelvis in an anterior parietal presentation—that is, with the sagittal suture lying transversely and well posterior to the midline. In doubtful cases, the use of the Itoentgen ray sometimes enables one to make a positive diagnosis by detecting the skeletons of two chil- dren in the plate. On the other hand, a negative finding does not preclude the possibility of twins, as, owing to the unfavorable conditions under which the pic- ture must be taken, the presence of the second child may not be recognized. The presence of more than two chil- dren can be predicted with certainty only under very exceptional and favorable cir- cumstances, although Eibemont - Dessaignes reports the diagnosis of triplets during preg- nancy, and its confir- mation at the time of labor. Course of Labor.— We have already re- ferred to the enormous size of the uterus re- sulting from the pres- ence of twins, which may be still further in- creased by hydramnios of one ovum. This may give rise to con- siderable discomfort, the patient suffering markedly from dysp- nea, pressure symp- toms, and edema. Occasionally the extreme stretching of the uterus may lead to an early dilatation of the cervix. Thus, in one instance, I found the cervical canal completely obliterated and the os externum dilated to 5 centimeters three weeks before the onset of labor. Reference has already been made to the frequency of premature expulsion in these cases; and when labor sets in, owing to the overdistention of the uterus, the pains usually occur at long intervals and are lacking in intensity, so that the birth of the first child is often prolonged. The cord of this child should be cut between double ligatures, as failure to ligate its ma- Fig. 340.—Diagram showing Collision between Heads of Twins. COURSE OF LABOR 413 ternal end may lead to the death of the second child from hemorrhage, if the twins are derived from a single ovum. Generally speaking, the membranes of the second child appear at the cervix immediately after the first is born and soon rupture. Its ex- pulsion usually follows the first within half an hour, 75 per cent, of the cases collected by Kleinwachter occurring within this period; while in the remainder a longer time elapsed—as much as twelve hours in 7 of his cases. If spontaneous delivery of the second child does not occur within a reasonable time, interference is indicated, and the practice formerly in vogue of waiting hours for its spontaneous expulsion cannot be reprehended too strongly. Changes in position of the second child frequently occur during and just after the birth of the first, so that at this time a renewed examination is necessary in order that any abnormality may be de- tected and the proper measures taken. The condition of the foetal heart should also be carefully watched, and delivery immediately effected if it becomes abnormal. As a rule the placenta of the first child remains in situ until the completion of labor, but in rare instances it may become partly or completely separated and give rise to hemorrhage. Under these cir- cumstances the second child should be delivered at once. In most cases both twins present by the vertex, though not very rarely one descends by the breech. In 1,849 cases analyzed by Leon- hardt, the following conditions were noted: First twin. Second twin. Per cent. Vertex, Vertex, 38.53 Vertex, Breech, 21.19 Breech, Vertex, 14.35 Breech, Breech, 10.76 Vertex, Transverse, 8.32 Breech, Transverse, 4.29 Transverse, Vertex, 0.87 Transverse, Breech, 0.77 Transverse, Transverse, 0.92 Total 100.00 Except for the delay incident to uterine inertia, delivery in twin pregnancy usually causes but little difficulty, provided an accurate diagnosis of the presentation of the children has been made. Con- sequently, it is difficult to understand why many physicians approach the matter with grave forebodings, and fear that they may have to deal with one of the complications, which are about to be mentioned, but which occur so rarely that they may not be encountered by ob- stetricians of large experience. Occasionally, when the children are small in size, their presenting parts may both attempt to enter the superior strait at the same time, and thus mutually interfere with one another. This complication is known as collision, and may occur when both children present by the vertex, or when one presents by the head and the other by the breech. In the first case, an attempt should be 414 MULTIPLE PREGNANCY made to push up the presenting part which is less distinctly engaged, and then to deliver the other child rapidly. If this is not possible, the whole hand should be introduced into the uterus and the condition of affairs carefully studied. Occasionally it will be found advisable to apply forceps to the uppermost child and attempt to drag it past the other. In rare instances craniotomy upon one child may be indicated. Now and again during extraction, when the first child presents by the breech and the second by the vertex, the two heads may become locked just above the superior strait, that of the second fitting into the neck of the first child and making its delivery impossible. Under such circumstances, if the head of the second child cannot be displaced, the first child should be decapitated, as it must inevitably perish during any attempt at extraction; after this the body should be brought away and the second child then delivered by forceps. In rare instances, the first child may present transversely and be straddled by the second in such a manner that the legs of the latter protrude from the cervix. Traction upon them will serve only to wedge the shoulder of the other child more firmly into the pelvis and give rise to insuperable difficulties. The proper treatment can only be deter- mined after careful examination un- der anesthesia, with the entire hand in the uterus, but when the condi- tion of affairs has been clearly visual- ized, a little mechanical ingenuity will readily enable one to determine whether version or decapitation is the operation of choice. Owing to previous overdisten- tion, the uterus sometimes fails to contract and retract satisfactorily during the third stage of labor, so that abnormalities in the placental perior are not infrequent. If there is any tendency toward an excessive loss of blood, the obstetrician should immediately express the placenta by Crede’s method, instead of waiting for the fundus to rise up. Occa- sionally the area of placental attachment may be so large that ab- normalities in its detachment may render necessary its manual removal. This operation, however, should not be resorted to unless urgently in- dicated. The danger of hemorrhage does not end with the expulsion of the placenta, as the uterus sometimes relaxes during the hour immediately following. Accordingly, the physician should remain with the patient for some time after the completion of labor and give his personal super- vision to the condition of the uterus, kneading it upon the first indi- Fig. 341.—Diagram illustrating Locked Twins (American Text- Book) . LITERATURE 415 cation of relaxation, and reenforcing it by the hypodermic adminis- tration of ergot. Neglect in this direction has sometimes led to the death of the patient from postpartum hemorrhage. LITERATURE Ahlfeld. Die Entstehung der Doppelibildungen und der homologen Zwillinge. Archiv f. Gyn., 1876, ix, 196-251. Lehrbuch der Geburtshiilfe, II. Aufl., 1898, 356-362. Archer. Observations Showing That a White Woman, by Intercourse with a White Man and a Negro, May Conceive Twins, One of Which Shall Be White and the Other a Mulatto. Medical Repository, 1810, 3d Hexade, 1, 319-323. Arey. The Cause of Tubal Pregnancy and Tubal Twinning. Am. J. Obst. & Gyn., 1923, v, 163-167. Badouin. La grossesse sextuple. Gazette med. de Paris, 1909, 157-159 and 205-207. Bertillon. Bulletin de la soc. d 7anthropologie de Paris, 1874, ix, 267-290. Davenport. Influence of the Male in the Production of Human Twins. Am. Naturalist, 1920, liv, 122-128. De BlIqcouet u. Nijhofp. Fiinflingsgeburten. Groningen, 1904. Deltjcca and Widakowich. Recherches sur l’origine des gestations gemellaires uni-ovularies. Annales de Gyn. et d’Obst., 1919, xiii, 722-732. Duncan. On Some Laws of the Production of Twins. Edinburgh Med. Jour., March, 1865. von Franque. Beschreibung einiger seltener Eierstockspraparate. Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 326-346. Futh. Medianer Gefrierschnitt durch den Rumph einer an Eklampsie gestorbenen. Erstgebarenden mit Zwillingen. Wiesbaden, 1918. Gache. La fecondit6 de la femme dans 66 pays. Buenos Aires, 1904. Gauss. Ein neues Zeichen fur die Diagnose der Zwillingsschwangerschaft. Zen- tralbl. f. Gyn., 1910, 1281-1296. Hellin. Die Ursache der Multiparitat der uniparen Tiere, etc. Miinchen, 1895. Holzapfel. Zur Pathologie der Eihaute. Beitrage z. Geb. u. Gyn., 1903, viii, 1-32. Klien. Ueber mehreiige Graaf’sche Follikel beim Menschen. Miinchener med. Abhandlungen, 1898, IV. Reihe, Heft 4. Kleinwachter. Die Lehre von den Zwillingen. Prag, 1871. Larger. Les stimates obstetricaux de la degenerescence. These de Paris, 1901. Leoniiardt. Ueber die Kindeslagen bei Zwillingsgeburten. D. I., Berlin, 1897. Meyer. The Occurrence of Superfetation. Jour. Am. Med. Assoc., 1919, lxxii, 767-774. Mirabeau. Ueber Drillingsgeburten. Miinchener med. Abhandlungen, 1894, IV. Reihe, Heft 5. Newman. The Biology of Twins. Chicago, 1917. The Physiology of Twinning. Chicago, 1922. Nichols. Sex Ratio of Twins. Memoirs Am. Anthropological Ass., 1907, I. Patellani. Die mehrfachen Schwangerschaften, etc. Zeitschr. f. Geb. u. Gyn., 1896, xxxv, 373-413. Paterson and Newman. The Development of the Nine-banded Armadillo, etc., Jour. Morphol., 1910, xxi. Prinzing. Die Haufigkeit der eineiigen Zwillinge. Zeitschr. f. Geb. u. Gyn., 1908, Ixi, 296-308. 416 Puech. Des grossesses multiples, etc. Paris, 1873. Bibemont-Dessaignes et Lepage. Precis d’Obstetrique, 1894, 864-897. (Gros- sesse gemellaire.) Saniter. Drillingsgeburten. Eineiige Drillinge. Zeitschr. f. Geb. u. Gyn., 1901, xlvi, 347-385. Schatz. Die Gefassverbindungen der Placentakreislaufe eineiiger Zwillinge, ihre Entwickelung und ihre Folgen. Archiv f. Gyn., 1882-1900, Bde. xix, xxiv, xxvii, xxix, xxx liii, Iv, lviii und lx. Sobotta. Eineiige Zwillinge und Doppelmissbildungen. Meyer u. Schwalbe, Studien der Pathologie der Entwickelung. 1914, I, H. 3, 394-427. Sonntag. Yerschlingung u. Knotenbildung der Nabelschniire. D. I., Leipzig, 1905. Stockard. An Experimental Study of Twins, Double Monsters and Single De- formities. Am. Jour. Anat., 1921, xxviii, 115-266. Streeter. Formation of Single Ovum Twins. Bull. Johns Hopkins Hosp., 1919, xxx, 235-238. Tarnier et Chantreuil. Des grossesses multiples. Traite de I’art des accouehe- ments, Paris, 1888, t. i. 543-563. Veit, G. Beitrage zur geburtshiilflichen Statistik. Monatsschr. f. Geburtsk., 1855, vi, 126-132. Viardel, Anmerkungen von der weibliehen Geburt. Frankfurt, 1676, 21. Wappaeus. Allg. Bevolkerungsstatistik. Leipzig, 1859. MULTIPLE PREGNANCY SECTION V OBSTETRIC SURGERY CHAPTER XIX INDUCTION OF ABORTION AND PREMATURE LABOR—ACCOUCHE- MENT forc£ Preparations for Obstetrical Operations.—Owing to the increased ma- nipulation within the generative tract incident to an obstetrical opera- tion, any lack of cleanliness entails even more risk than in the case of normal labor. Accordingly, the maintenance of a rigid aseptic technic is as absolutely imperative as in major surgical operations. Fig. 342.—Showing Patient at Edge of the Bed, with Legs Held in Position by Leg-holder. The hands of the operator and his assistants should be thoroughly washed and disinfected, as described in Chapter XV, and then encased in sterile rubber gloves. As already indicated, I consider the use of the latter essential even for the conduct of normal labor, and conse- quently no argument need be advanced as to their necessity at operations. 417 418 INDUCTION OF ABORTION AND PREMATURE LABOR A sufficient quantity of dressings, towels, gauze, and ligatures, care- fully sterilized beforehand, should be in readiness. All instruments should be rendered sterile by boiling immediately before the operation. As an emollient, vaseline, albolene, or liquid green soap, which has been sterilized by boiling in small jars, may be used. The pubic hairs should be shaved, and the external genitalia thor- oughly cleansed with green soap and hot water, rinsed off with sterile Fig. 343.—Showing Patient Covered with Sterile Dressings Preparatory to Operation. water, freely irrigated with 95 per cent, alcohol, followed by a 1 to 1,000 bichlorid solution, and finally covered with a towel soaked in the same, which should remain in place until the operation is begun. Dis- infection with tincture of iodin has not proven satisfactory in my hands, as in certain patients it leads to intense irritation, which may persist for some days. If the woman is uninfected, it is not necessary to attempt to disin- fect the vagina by means of antiseptic irrigations or other manipula- tions. But if the temperature is elevated, or if the patient has been INDUCTION OF ABORTION 419 subjected to repeated examinations or attempts at delivery, a vaginal douche of a 1 to 5,000 bichlorid solution may be given, although I do not employ it. Before the sterile dressings are put in place, the bladder should be emptied by means of a sterile rubber catheter. In the early months of pregnancy, a distended bladder interferes with bimanual manipula- tions, at labor it may affect the engagement of the presenting part, and after the birth of the child it may interfere with the proper conduct of the third stage of labor. Obstetrical operations, with the exception of podalic version, cesarean section and other laparotomies, are usually undertaken with the patient in the lithotomy position. In hospitals, a suitable operating table is always available; while in private practice, as the low beds nowin use are very' inconvenient, it is advisable to place the patient upon a narrow table: one that will answer the purpose quite satisfactorily is usually to be found in every kitchen, but, if a suitable table is not available, a satisfactory makeshift may be improvised by unscrewing the mirror from a bedroom bureau. Anesthesia is indispensable for all but the simplest procedures, and if it is to be prolonged, ether is safer than chloroform, on account of the late poisoning which sometimes follows the use of the latter drug. As soon as the patient is fully under its influence, her buttocks should he brought to the edge of the table, and her legs held in place by a leg-holder. The nightgown should be rolled up above the hips to avoid soiling, and, as soon as the external genitalia have been prepared, the legs should be encased in sterile leggings, and the abdomen and buttocks covered with sterile towels in such a manner as to leave only the genitalia exposed. To avoid the possibility of con- tamination from the rectum, it is advisable to cover the anus with a folded sterilized towel, which can he held in place by a strip of ad- hesive plaster passed over the buttocks, or better still by small clip forceps which attach it directly to the skin. Finally, a specially prepared sterile sheet should cover everything except the immediate field of operation. Induction of Abortion.—By this term is understood the artificial termination of pregnancy before the foetus has attained viability— namely, prior to the twenty-eighth week. The operation dates from the most remote antiquity, and more or less accurate directions for its performance are to be found in the earliest writings upon medicine. It was so extensively practiced in Rome that we find it repeatedly re- ferred to by Plautus, Juvenal, and other secular writers as a matter of every-day occurrence. With the spread of Christianity, however, it came to be considered as criminal, except when undertaken as a last resort in order to save the life of the mother; and we now draw a sharp distinction between criminal and therapeutic abortion. For historical details the reader is referred to the works of Levin and Brenning, Brouardel, and Kleinwachter. Indications.—Three groups of conditions may offer an indication for the operation. Thus we may think it our duty to induce a therapeutic abortion: (1) As a direct means of saving the life of the mother; 420 INDUCTION OF ABORTION AND PREMATURE LABOR (2) to do away with a condition which may threaten her life if gesta- tion continues; and (3) to avoid certain dangers which may supervene if pregnancy is allowed to progress to full term. Under no circumstances should an abortion be undertaken, unless a careful and thorough examination has demonstrated that the condition of the patient is really serious. Her statements are entitled to but little weight, and the decision to interfere should be based entirely upon objective symptoms and clinical findings. Moreover, it should never be done without consultation with a second physician, who assumes his share of the responsibility. This precaution, besides securing for the patient additional advice, will protect the physician from possible blackmailing on the part of unscrupulous persons. In the first group, the best-recognized indication for the operation is afforded by pernicious vomiting of 'pregnancy. In most instances this condition is neurotic in origin and can be cured by appropriate measures. More rarely, however, the vomiting is a manifestation of a profound toxemia, as W'ill be described in the chapter on the toxemias of pregnancy. If the latter diagnosis be established, the prompt induc- tion of abortion is urgently demanded, as we know by experience that it offers the only hope of saving the life of the patient. Prior to the recognition of the varying nature of this condition, there was a natural hesitancy on the part of the physician to interfere owing to the fact that in many cases the vomiting ceased spontaneously, or was relieved by treatment. For that reason, the operation was fre- quently postponed until the condition of the patient had become so serious that death was the inevitable consequence, whether abortion was induced or not. How that we know more about it, interference is rarely necessary in neurotic vomiting, but is imperative in the toxemic type. The induction of abortion is likewise urgently indicated when the uterine contents have become infected, a condition which frequently follows attempts at criminal abortion. Under such circumstances, if the foetus has not already succumbed it will almost certainly die, and the greatest chance of saving the woman’s life lies in promptly emptying the uterus and cleaning its cavity. Formerly it was believed that abortion should be induced for in- carceration of the retroflexed pregnant uterus, as well as in the rare cases of hernia of that organ, inasmuch as death may result if the patient be left to herself. At present, however, unless infection has supervened, better results are obtained in the former condition by per- forming laparotomy, freeing the uterus from adhesions and replacing it in a normal position, after which pregnancy may pursue an uninter- rupted course. In the* second group, preeclamptic toxemia or pronounced renal insuf- ficiency may necessitate the operation. But inasmuch as such condi- tions usually develop later in pregnancy, they will be considered when we take up the induction of premature labor. With the extension of renal surgery, it is not uncommon for pregnancy to supervene in women from whom one kidney has been removed. If the remaining organ is INDUCTION OF ABORTION 421 normal, pregnancy proceeds uneventfully, as is shown by the fact that Matthews was able to collect 265 labors occurring in 241 nephrectomized women with only two deaths. On the other hand, if the remaining kidney shows signs of chronic nephritis, pyelitis or calculus formation, prompt termination of pregnancy is essential if fatal damage is to be avoided. Diseases of the ovum, such as hydatidiform mole, occasionally afford an indication for the operation. No matter at what period of preg- nancy this condition is diagnosticated, the uterus should be emptied at once, as in such circumstances the foetus is either lacking or very imperfectly developed, and, if the diseased chorion be allowed to remain in the uterus, a chorio-epithelioma may develop. Uterine hemorrhage in the early months of pregnancy is generally a sign of threatening abortion, but, if after appropriate treatment the loss of blood continues for some time, and is not followed by spontaneous abortion, it is usually associated with some serious abnormality on the part of the ovum, and indicates that the uterus should be emptied artificially. The rare cases of missed abortion, in which the ovum is retained for months after the death of the embryo, demand that the uterus should be emptied as soon as a satisfactory diagnosis is established. The indications in the third group are principally afforded by pul- monary tuberculosis, and occasionally by other chronic diseases. For- merly, the induction of abortion at an early period was considered jus- tifiable when the pelvis was so contracted as to present an absolute in- dication for cesarean section; but at present, in view of the excellent results which attend the latter operation, this view is no longer held. The same applies to the presence of uterine myomata. If the symptoms are urgent, hysterectomy should be performed without regard to the existence of pregnancy; but if the tumor promises to act merely as a mechanical obstacle at the time of labor, pregnancy should be allowed to go on to term, and cesarean section then performed, followed by removal of the tumor or of the entire uterus, as seems most advisable. Ovarian tumors complicating pregnancy do not call for the induc- tion of abortion, but should be removed by laparotomy as soon as the diagnosis is made. This can frequently be done without causing inter- ruption of the pregnancy, when spontaneous delivery will occur at term. The induction of abortion is not indicated in malignant growths involving the uterus or adjacent organs. In carcinoma of the cervix, the treatment to be pursued differs according to circumstances. If the condition be operable, immediate hysterectomy is indicated with- out regard to the presence of pregnancy; but if the disease has pro- gressed too far to offer a prospect of permanent cure after operation, gestation should be allowed to continue in the interests of the child, which should be delivered at term by the procedure most appropriate to the particular case. Owing to the well-known fact that pulmonary tuberculosis usually progresses much more rapidly after child-birth, it is advisable that tuberculous women take every precaution to avoid the possibility of conception. If conception occurs, however, it is the duty of the physician 422 INDUCTION OF ABORTION AND PREMATURE LABOR to induce abortion at the earliest possible moment, in the hope that by ending the pregnancy, and placing the patient in proper surroundings afterward, the disease may be arrested. I feel very strongly that inter- ference is not only justified, but is almost imperative, in a first preg- nancy, or in patients in whom the existence of the disease is only dis- covered after the occurrence of conception. On the other hand, I feel equally strongly that a second abortion should not be done after the patient has been warned to avoid the possibility of becoming pregnant until after the disease has been either cured or arrested. Methods of Inducing Abortion.—The methods of inducing abortion vary according to the dur- ation of pregnancy. In the first few months the operation can frequently be completed at a single sit- ting, if necessary, whereas between this period and the seventh month the methods employed for the induction of premature labor are more appro- priate. In the first period, if the cervix is somewhat softened, it can usually be sufficiently dilated by means of Goodell’s instrument, followed by Hegar’s graduated dilators, to admit one finger. The entire hand, anointed with sterile vaseline, is then introduced into the vagina and the index finger carried up into the uterine cavity. While the other hand, placed upon the abdomen, forces the uterus downward, the finger within its cavity separates the placenta from its attachments, after which the product of conception is removed entire or is broken up into small pieces, which can be removed by means of an abortion or ovum forceps. Following this, the interior of the organ should again be explored to make sure that it is empty. To attempt to empty the uterus blindly by means of a curette and ovum forceps is an unwise procedure, inas- much as cases are occasionally reported in which such procedures have caused perforation. More fre- quently fragments of the placenta are left in the uterus, giving rise by their presence to serious hemorrhage and occasionally to infection. In other instances only a portion of the decidua is curetted away, while the ovum is left in situ and goes on to further development. Accord- ingly, one can never feel sure that the operation is complete, unless a finger has been introduced into the uterus and has carefully palpated its interior. Particularly in women pregnant for the first time, the cervix may be so resistant that rapid dilatation can be effected only at expense of deep laceration. In such circumstances, if haste is not imperative, a strip of sterile gauze may be tightly packed into the cervical canal and the vagina firmly tamponed with the same material. When the pack is removed at the end of twenty-four hours, the entire ovum will Fig. 344.—Gooddell’s Dilator. Fig. 345.—Ovum Forceps INDUCTION OF ABORTION 423 sometimes follow it; while in other cases the cervix will be sufficiently softened to permit its dilatation with a suitable instrument. The employment of a laminaria tent was formerly recommended by many authorities, and affords an efficient means of slow dilatation, but, as tents cannot be sterilized satisfactorily, their use adds greatly to the risk of infection. Abortion is sometimes induced by perforating the membranes with a sterile sound and allowing the liquor amnii to drain off. In addition to increasing the danger of infection, the desired result does not always follow, and it frequently becomes necessary to supplement it by one of the procedures just described, so that the maneuver is not to be recommended. On the other hand, when rapid dilatation is not feasible, and it is desired to complete the abortion at one sitting, the uterus may be readily and rapidly emptied after vaginal hysterotomy. In this opera- tion, the bladder is separated from the anterior wall of the cervix, and the latter incised with scissors up beyond the internal os. The finger can then be introduced into the uterine cavity and peel off and remove the ovum, after which the uterine and vaginal wounds are united by catgut sutures. The details of this operation, which I employ with increasing satisfaction and frequency each year, will be found under Vaginal Cesarean Section. In the case of women suffering from active tuberculosis, as well as from chronic nephritis, serious cardiac lesions and certain other con- ditions, the mere induction of abortion, and the injunction to avoid the possibility of future pregnancies, is not satisfactory; as a large pro- portion of such patients soon become pregnant again, when the pro- priety of repeated interference must be considered. For a number of years I have faced the problem more radically, as I hold that in patients suffering from an incurable disease it is justifiable to follow the abortion by a sterilizing operation, while in those suffering from a disease which offers a reasonable prospect of eventual cure the abortion should be followed by some procedure, which will insure sterility for as long a period as may be necessary, and yet leave a possibility for the occurrence of conception after the underlying disease has been cured. In either event, I effect abortion by performing a miniature cesarean section. In the first class of patients, I follow this by supravaginal hysterectomy with retention of the ovaries, provided they no longer desire to menstruate; while if they do, I close the uterine wound by means of interrupted sutures, and then excise the uterine ends of the tubes from the cornua, taking care to bring the peritoneal covering into the closest approximation. On the other hand, in the second class of patients, after closing the uterine incision, I effect temporary sterility by applying two ligatures to either tube at the junction between its proximal and middle thirds and cutting between them. After this the uterine end of the broad ligament is spread apart, the corresponding end of the tube buried within it, and the wound closed by fine sutures. This procedure, which I described in detail in 1921, is technically easy and effectively sterilizes the patient without the loss of any tissue. 424 INDUCTION OF ABORTION AND PREMATURE LABOR Later, should it be thought desirable to restore the possibility of con- ception, the abdomen can be reopened and the proximal ends of the tubes freed and united by fine sutures to the distal ends. I have not yet had occasion to resort to the second operation, and I imagine that it will be desired but rarely. At the same time, the knowledge that such a procedure is possible has a valuable psychological effect upon the patient, which is lacking when more radical means of sterilization have been employed. In the early months of pregnancy exposure to the action of the Rontgen ray sometimes leads to the death and subsequent extrusion of the foetus. Reifferscheid, however, states that the method is not ap- plicable to the induction of therapeutic abortion, as repeated exposures are required and even then the result is not assured. Moreover, it has the insuperable objection that it destroys the functioning portion of the ovaries and brings about a premature menopause, with all of its disadvantages. Prognosis.—The prognosis varies according to the indication for which the operation is undertaken, but, with the patient in fairly good condition, satisfactory results should always follow, provided a rigid aseptic technic is observed. In my hands vaginal hysterotomy has proved a much more satisfactory and less dangerous procedure than forced instrumental dilatation of a rigid cervix. Induction of Premature Labor.-—By this term we designate the arti- ficial termination of pregnancy after the child has reached the period of viability—that is, after the twenty-eighth week. The operation was performed by Guillemeau, Mauriceau, Justine Siegemundin, and others in isolated cases for hemorrhage, but, according to Denman, it was not generally advocated until 1756, when a conference of physicians was held in London to devise means for doing awray with the frightful mor- tality then followed cesarean section for contracted pelvis. Indications.—The indications for the operation are fourfold: to obviate the dangers attending delivery at term through a contracted pelvis; to save the life of the mother, when seriously threatened by some disease from which she may be suffering; to end a pregnancy com- plicated by some pathological condition of the ovum or to effect the delivery of the postmature child before it becomes sufficiently large to cause dystocia by its mere size. In contracted pelvis, premature labor is induced with the idea that the imperfectly developed child will be born more readily than at term. This view is undoubtedly correct, and if the welfare of the mother alone were concerned, the operation should be undertaken in all cases. We know that labor will be easier the earlier the operation is per- formed, but it must be remembered that the child will be less liable to survive, and, even if born alive, its chances of succumbing to compli- cations after its birth will be proportionately greater. Inasmuch, then, as the outlook for the child is better the later the operation is per- formed, the induction of premature labor should not be attempted before the thirty-fourth, and preferably not before the thirty-sixth, week of pregnancy. INDUCTION OF PREMATURE LABOR 425 The question as to the propriety of the operation has given rise to an extensive literature. At the International Medical Congress of 1890, it was one of the chief subjects under discussion, when Sanger was practically the only speaker who opposed its employment in moderate degrees of pelvic contraction. With increasing knowledge as to the course of labor in contracted pelves, together with the generally good results following classical cesarean section, and other radical obstetrical operations, a marked change in sentiment has occurred, and the induc- tion of labor has lost greatly in popularity. It is now generally recognized that from 70 to 80 per cent, of all labors complicated by contracted pelvis, including the cases of pro- nounced deformity which require radical interference, will end spon- taneously if treated expectantly. With this fact in mind, Pinard, Bar, Kronig, myself, and others hold that the induction of premature labor is no longer justified, and that in cases of moderate pelvic contraction equally good results for the mother, and far better results for the child, will be obtained by abstaining from the former operation, and sub- jecting to cesarean section at term all patients who present such dis- proportion between the size of the head and the pelvis as makes a spontaneous outcome unlikely. Following these principles, 829 patients presenting contracted pelvis of all grades were treated in my clinic up to July, 1910, and 74.76 per cent, were delivered spontaneously; 90.3 per cent, of the children left the clinic in good condition, and upon deducting the cases in which the child was dead at the time of admission of the mother, or died from such extraneous causes as syphilis, bronchopneumonia, etc., the net foetal mortality due to the pelvic contraction was 4. per cent. The principal difficulty connected with the induction of labor is to recognize the cases which will require it, and to choose the correct time for its performance. Unfortunately, we are unable to determine accu- rately the size of the child’s head, and more particularly its degree of compressibility and ossification. The methods of Muller, Ahlfeld, and others, to which reference will be made in the chapter upon the treat- ment of contracted pelves, do not lead to very accurate results, so that the operation is frequently performed unnecessarily. The results obtained are satisfactory so far as the mother is con- cerned, the maternal mortality being only 1.03 per cent, in 391 opera- tions reported by Ahlfeld, Bar, Leopold, and Pinard. On the other hand, the foetal mortality is relatively high, varying from 12 to 45 per cent. Kleinwachter, after an exhaustive study of the subject, concludes that 78.3 per cent, of the children are born alive, but that only 60.4 per cent, leave the hospital in good condition, which means an immediate net mortality of 39.6 per cent. Furthermore, when we consider that careful nursing and appropriate feeding are afterward necessary, it is apparent that no inconsiderable portion of the children dismissed from the hospital in good condition must inevitably perish within the first year, and it is hardly an exaggeration to state that scarcely one half of those bom alive survive that period. It would, therefore, appear that the ultimate results, so far as the children are concerned, are 426 INDUCTION OF ABORTION AND PREMATURE LABOR so poor as not to commend the operation to favorable consideration, and that equally good results would be obtained by treating all cases expectantly, and performing craniotomy whenever operative delivery be- came necessary. As such a course would be a reductio ad absurdum, it follows that the operation should be abandoned. In my entire ex- perience, I have employed it in only one case of contracted pelvis, and have no cause to regret my action. It must, however, be admitted that all authors do not share this view, as Norris, Herlf, and others contend that their results are fairly satisfactory. The most usual indication for the operation, however, is afforded by diseases which threaten the life of the mother, while at the same time there exists a probability of cure after the termination of gesta- tion. This is particularly true in those cases of preeclamptic toxemia or chronic nephritis complicating pregnancy, which show no tendency to subside in spite of appropriate treatment. Experience teaches that under such circumstances,, even if pregnancy be allowed to continue, premature labor frequently occurs spontaneously, when a large propor- tion of the children are born dead, or, if born alive, they are very imperfectly developed. Accordingly, if threatening symptoms supervene, labor should be induced at any period of pregnancy without too con- servative a regard for the life of the child; as the ideal method of treating eclampsia is to prevent its occurrence. Cardiac lesions occasionally demand the induction of premature labor, but this should be resorted to only in cases of broken compen- sation, which do not yield to appropriate treatment. In many instances, more radical intervention by means of cesarean section followed by supravaginal hysterectomy is preferable. From the time of D’Outrepont (1828), it has been recommended that the operation be undertaken in the interests of the child in the rare cases of tuberculosis in which the condition of the mother is so serious as to make it probable that she will not live until term. Spontaneous interruption of pregnancy frequently occurs during the course of the acute infectious diseases—influenza, pneumonia, typhoid fever, etc.—but, inasmuch as experience has shown that it materially increases the risks to the mother, the induction of premature labor is contra-indicated. In rare instances a general peripheral neuritis may so endanger the life of the mother as to call for interference. Lepage and Sainton (1901) reported a case of alcholic origin in which the induction of labor was followed by most happy results. The milder forms of chorea complicating pregnancy are usually amenable to treatment, but when the disease assumes a grave type it is attended with great danger, the maternal mortality, according to Fehling, being 36 per cent. Therefore, if the patient appears to be in serious danger, premature delivery should be brought about, as experience has shown that the emptying of the uterus is sometimes followed by pronounced improvement. In patients suffering from true diabetes, gestation sometimes exerts a very deleterious influence upon the course of the disease. Usually, INDUCTION OF PREMATURE LABOR 427 however, the diabetic patient improves during the latter part of preg- nancy, supposedly as a result of the activity of the foetal pancreas. In several of our patients, who have been followed for a number of years, sugar free intervals while upon a normal diet were observed only during the last months of pregnancy and early in the lactation period. For these reasons, the induction of premature labor is rarely indicated, and, when carried out, rarely does good. Moreover, it should be remembered that in the majority of cases the so-called diabetes of pregnancy is merely a lactosuria which is not likely to be attended by serious symptoms. According to Graefe and Winter, the occurrence of pregnancy in patients suffering from pernicious anemia or leukemia adds markedly to the gravity of the condition, so that in occasional cases the induction of premature labor may be indicated. In patients suffering from pyelitis, the pregnant uterus may so compress the ureter as to cause a damming back of the purulent dis- charge, and thus give rise to a pyelonephrosis. In such circumstances the induction of premature labor is indicated. Fortunately, however, such interference is rarely necessary, as with rest in bed and ap- propriate dietary and medicinal treatment the results are surprisingly good. Formerly the induction of premature labor was recommended when pregnancy is complicated by uterine or ovarian tumors, or by malig- nant disease of the uterus or rectum, which would offer an insuperable obstacle to the birth of a full-term child. At the present day, how- ever, such indications are not tenable. What has already been said in connection with the induction of abortion under similar conditions also holds good here. In hydramnios, when the abdomen is so distended as seriously to threaten the life of the patient, pregnancy should be terminated with- out too much regard for preservation of the child, as in many such cases it is so poorly developed as to have but little chance of living, even if born at full term. Whenever placenta previa is positively diagnosed, the termination of pregnancy is urgently indicated, as it is impossible to predict at what moment uterine contractions may come on and give rise to profuse or even fatal hemorrhage. In rare cases of habitual death of the foetus in the later months of pregnancy, when not due to syphilis or renal disease, the induction of premature labor has been recommended at a time slightly anterior to that at which foetal death has occurred in previous pregnancies, in the hope that a living child may be obtained. In such cases the operation may be undertaken if the parents are extremely anxious for a living child, although in no instance should a positive assurance of success be held out to them. One of the most important and defensible indications for the in- duction of labor is afforded by the so-called postmature child. Whenever during the last weeks of pregnancy palpation shows that the child ex- ceeds the usual limits of size, and particularly in multiparae who give 428 INDUCTION OF ABORTION AND PREMATURE LABOR a history of dystocia resulting from excessive bulk of the child, labor should be induced, as it appears irrational to allow conditions predis- posing to dystocia to develop without interference. The same holds good in cases of prolonged pregnancy, and the physician should make it a rule to examine each week every patient whose history indicates that the calculated duration of gestation has been exceeded. Ordinarily, the child will be found normal in size, but when its development appears to be excessive or evident disproportion exists, labor should be induced immediately. As such indications are in great part dependent upon one’s personal judgment, the greatest care should be exercised in arriving at a de- cision, and interference practiced only when clearly demanded by the physical findings. The induction of labor at a fixed date merely to suit the convenience of the patient or obstetrician cannot be repre- hended too strongly, and should the outcome in such a case be un- favorable, nothing could be said in its defense. Prognosis.—As far as the mother is concerned, the prognosis of the induction of premature labor is excellent, provided a rigorous aseptic technic is observed and the physical condition is not critical at the time of the operation. The prognosis for the child depends, of course, upon the degree of its development, as well as upon the pathological condition for which the operation is undertaken. Generally speaking, in the case of children born before the thirty-second week, the chances of surviving are very small, especially when nephritis or hydramnios affords the indication for interference. Methods of Inducing Premature Labor.—These may be medicinal or operative in character. The former are available only during the very last weeks of gestation, while the latter may be employed at any time after the child is viable. For this reason, the chief indications for attempting induction by medicinal means are afforded by the post- mature child or by prolongation of pregnancy, and in such circum- stances, it should always be employed before resorting to operative procedures. For years castor oil and quinine have been administered for this purpose, but the results have been so uncertain that when a positive outcome follows, one is usually in doubt whether to ascribe it to the treatment or to the coincident onset of spontaneous labor. Watson supplements the castor oil and quinine by the administration of pitu- itary extract, and has developed the following technic which he claims is very effective: 6 p. m. castor oil 1 ounce, 7 p. m. quine ten grains, 8 p. m. large soap-suds enema, 9 p. m. quinine ten grains, 12 p. m. quinine ten grains. If pains have not supervened by nine o’clock the next morning, one- half cubic centimeter of pituitary extract is administered hypodermic- INDUCTION OF PREMATURE LABOR 429 ally, and repeated each half hour until labor sets in, or until six doses have been administered. In my hands, this technic has had the desired result in approxi- mately seven out of ten, instead of nine out of ten cases, as Watson claims. No untoward effects have been observed, and, as it is distinctly more efficient than the administration of castor oil and quinine alone, it should be employed in preference to operative means whenever haste is not essential. The simplest operative method of inducing labor is that of Scheele, which consists in perforating the membranes with a sharp instrument and allowing the amniotic fluid to drain off. The results, however, are uncertain, so that the procedure is applicable onlv Fig. 346a.—Champetieh de Ribes’ Bal- loon, DISTENDED. X }/%. in a very limited number of cases, more especially in hydramnios, and in marginal placenta previa. In the method most usually employed—that of Krause—a bougie is introduced between the membranes and the uterine wall. In carrying out this procedure the patient is placed in the dorsal or Sims’s position, and the external genitalia carefully disinfected. The cervix is then brought into view by means of a speculum, and one or more sterilized bougies are passed through it and gently carried high up into the Fig. 3466.—Champetier de Ribes’ Bal- loon Ready for Introduction. uterine cavity, between the membranes and the uterine wall. I prefer the very thick-w’alled Wales’ bougies made by the Goodrich Company, which, while flexible, are sufficiently stiff to be introduced without the aid of a stylet. The only objection to Krause’s method is its uncertainty. In many cases the introduction of the bougie is followed within a few hours by uterine contractions, wThich lead to the expulsion of the foetus after a longer or shorter period. Occasionally, however, twenty-four hours may elapse without the appearance of pains. In the latter circumstances 430 INDUCTION OF ABORTION AND PREMATURE LABOR the bougies should be removed, and the pregnancy terminated in some other manner. But in general, when haste is not essential, this is the safest and best method of procedure. More rapid results are obtained by the use of inflatable rubber balloons, but the greater manipulation incident to their introduction somewhat increases the possibility of infection. Those of Champetier de Eibes are conical rubber bags with reenforced walls, from whose small end extends a thick rubber tube provided with a stopcock. They are made in several sizes, the largest having a capacity of 500 cubic centimeters. If the cervical canal is 1.5 centimeters in diameter, the bag can be passed without difficulty, but if smaller, it should be dilated up to that size by means of a suitable dilator. The bag, which has been sterilized by boiling, is tightly rolled into cylindrical form, seized with an appropriately shaped forceps, thickly smeared with sterile vase- line, introduced into the lower uterine segment, and then pumped full of sterile salt solution. Within a few hours it usually so irritates the uterus as to induce contractions, which soon lead to dilatation of the cervix and the expulsion of the bag, after which the child can be extracted or labor allowed to end spontaneously, according to the ex- igencies of the case. Where greater haste is necessary, the dilatation may be accelerated by attaching a weight to the end of the tube and allowing it to hang over the foot of the bed. This method gives very satisfactory results, though it is evident that the introduction of the large bag into the lower uterine segment must displace the presenting part, and occasionally give rise to malpresentations. Tanner's excitateur uterin—a thin-walled rubber bag 3 or 4 centi- meters in diameter—and Barnes’s fiddle-bags are based upon the same principle, but their smaller size renders them much less efficient irritants. When the cervix is but slightly dilated, certain authorities recom- mend the use of a sterile tampon. In such cases the end of a sterilized 4-inch roller gauze bandage is tightly packed into the cervical canal by means of a uterine dressing forceps, after which the vagina is firmly and tightly packed with the same material. The pack should be re- moved within twelve hours, and at the expiration of that period the cervix will often be found sufficiently dilated to permit of other maneu- vers. Generally speaking, I advise against its use, for, in addition to being uncertain in its action, even when introduced under the most rigid aseptic precautions, it is sometimes followed by infection. Numerous other methods for the induction of premature labor have been suggested from time to time, among which may be mentioned that of Cohen. This consists in the injection of 200 to 300 cubic centi- meters of aqua picis between the uterine wall and the membranes. Other writers have substituted various fluids. Thus, Pelzer suggested the use of 100 cubic centimeters of sterile glycerin, which promptly gives rise to uterine contractions. Its employment, however, is not to be recom- mended, as it is occasionally followed by serious symptoms of intoxi- cation, hemoglobinuria, albuminuria, elevation of temperature, cyanosis, and occasionally by death. Full details respecting the various other ACCOUCHEMENT FORCE 431 methods suggested for the induction of premature labor will be found in the monographs of Klein wachter, Fieux, and Williamson. Accouchement Force.—By this term is understood the forcible dilata- tion, or clean cut incision, of the intact or partially dilated cervix, followed by the immediate delivery of the child. In pre-antiseptic times the operation was so universally followed by infection that it naturally fell into deserved disrepute; but it has since been rehabilitated, and when properly performed under suitable conditions has been the means of saving many lives. An excellent resume of the history of the opera- tion will be found in the dissertation of Ruhemann. Generally speaking, if the cervix be firm and hard and the canal not obliterated, forcible dilatation is apt to be very difficult and attended with considerable risk to the mother, so that its resistance had better be overcome by a cutting operation. On the other hand, when the cervical canal is prac- tically obliterated and resistance is offered only by the partially dilated external os, rapid dilatation is readily performed, and is followed by very satisfactory results. As a general rule, it is more difficult in primiparous than in multiparous women. Indications.—In this country the most usual indication for ac- couchement force is threatened or actual eclampsia. Occasionally it becomes necessary in concealed or accidental hemorrhage, or in other conditions which threaten the life of the mother or child, such as acute edema of the lungs, broken cardiac compensation, or in exceptional cases of prolonged labor in which the life of the child is endangered. It should, however, not be employed in placenta previa. Manual Dilatation.—If labor has already begun, the cervical canal is obliterated, and the resistance is offered only by the external os, which is five or more centimeters in diameter, excellent results are obtained by the method of manual dilatation suggested by Philander A. Harris. But if labor has not set in, and the cervix is intact and hard and rigid, the operation is both difficult and dangerous; and if the attempt at dilatation be forcibly persisted in, it gives rise to deep tears through the cervix, and occasionally through the lower uterine segment as well, which may lead to the death of the patient from hemorrhage or infection. Generally speaking, if rapid delivery is urgently demanded under such conditions, it should be effected by vaginal hysterotomy, or by caesarean section. At the time of operation the patient should be profoundly anes- thetized and the most rigorous aseptic technic applied. After ironing out the vaginal opening and the pelvic floor by the thoroughly lubricated hand, the index finger is carried up the cervical canal and through the internal os, and followed as soon as possible by the second finger. When this has been accomplished, completion of the dilatation is usually comparatively easy. The dilating force is exerted by the back of the thumb, which is pushed past the index finger with much the same motion as is employed in snapping one’s fingers; then, as dilatation progresses, past two, three, and finally all four fingers. These maneu- vers are clearly shown in Fig. 347. When the internal os is already obliterated, complete dilatation of 432 INDUCTION OF ABORTION AND PREMATURE LABOR the cervix can be readily effected by Harris’s method within half an hour. I employed this method 83 times in the first 5,000 cases de- livered in the Johns Hopkins Hospital, and found it very effective, and am able to confirm all that Harris has claimed for it. It should, however, be remembered that it is not devoid of danger, for if em- ployed before the external os has dilated to a diameter of five centi- meters, it is always associated with laceration, whose extent cannot be controlled. Its use is especially contra-indicated in placenta previa on account of the increased liability to deep cervical tears, and even to rupture of the uterus. Furthermore, the operator should bear in mind that the liability to laceration is greater the more rapidly dilatation is effected, and he should therefore be careful to avoid undue haste. This caution is the more necessary, as there seems to be an irresistible tendency to over- estimate the time consumed in the process, and from my own experi- Fig. 347.—Diagrams Illustrating Manual Dilatation of Cervix (Harris). ence I know that what may seem to be a long time to the operator is often in reality only a few minutes. For this reason, it is always well to control the rapidity of dilatation by watching the clock, as in such circumstances one should judge of the excellence of an obstetrician by the deliberation, rather than by the rapidity, with which he operates. Edgar and Bonnaire have described bimanual methods of dilatation, which they claim give most satisfactory results. I have not employed them, and therefore cannot express a personal opinion as to their merits. On general principles it may be assumed that they are effective, but also afford somewhat greater opportunity for infection from the rectal contents, since both hands are used and therefore must come into more intimate contact with the anal region than in Harris’s method. What- ever method of manual dilatation is employed, one should always suspect that it has given rise to lacerations. Accordingly, after delivery has been effected, the cervix should be freely exposed by the aid of a ACCOUCHEMENT FORCE 433 posterior retractor and tenaculum forceps and any serious tear imme- diately repaired. If such a precautionary inspection is made as a matter of routine, one will be surprised at the frequency and extent of deep cervical tears, and will learn to hesitate to make use of manual dilatation unless it is urgently necessary. Dilatation by Means of Champetier de Ribes’ Balloon.-—Whenever haste is not a great consideration, this is the ideal method of accouche- ment force, and should be employed whenever possible. It is particu- larly indicated in cases of placenta previa, and will be referred to more fully under that head. The entire literature upon the subject was well reviewed by Burger in 1906. Instrumental Dilatation.—Various instruments have been devised to Fig. 348.—Vaginal Cesarean Section. Exposure of Cervix and Primary Incisions. effect the rapid and complete dilatation of the cervical canal, but to my mind none of them is satisfactory. Leopold, in 1902, introduced into Germany the use of Bossi’s power- ful dilator, which was first employed by its inventor in 1889. This consists of four heavy blades, arranged as compound levers and operated by a screw handle. Leopold was most enthusiastic concerning it, and his hearty indorsement led to its trial, in various modifications, in all parts of the world; but the final verdict is that it is a most dangerous instrument. I have had no experience with it; for, while there can be no doubt as to its dilating power, it seems to me that its sphere of usefulness 434 INDUCTION OF ABORTION AND PREMATURE LABOR is very limited. If the cervix is undilated and rigid, its employment is unjustifiable; whereas, on the other hand, when the resistance of the internal os has already been overcome, equally satisfactory results may be obtained by other methods. Moreover, if cervical tears cannot be entirely avoided in manual dilatation, in which’ the resistance of the cervix can be accurately gauged by the operating hand, they must occur far more frequently when the dilating force is applied more or less blindly by means of a powerful steel compound lever. It is interesting to note that a similar instrument was devised in 1892 by Dr. H. S. Lott, of Salem, H. C., quite independently of Bossi’s invention. Deep Cervical Incisions.—When rapid delivery is urgently indicated in cases in which the cervical canal is obliterated but the external os not dilated, Diihrssen recommended, in 1890, that multiple incisions be made through the vaginal portion of the cervix, which are united by sutures after the completion of labor. The technic of the opera- tion is comparatively simple, as the incisions are readily made by means of scissors; but it has not been generally adopted, as there is no means of preventing further tearing of the incisions as the child is extracted, so that deep cervical lacerations frequently result, which may give rise to profuse hemorrhage and prove most difficult to repair. Vaginal Cesarean Section.—This operation, which is better designated as vaginal hysterotomy, was first described by Diihrssen in 1896, but did not come into general use for some years later on account of the polemical manner in which its inventor urged its claims. In my opinion it affords a satisfactory method for rapidly termi- nating pregnancy prior to the last month whenever the cervix is un- dilated and rigid, and is far superior to brutal attempts at manual or instrumental dilatation. Unfortunately, it requires some surgical skill on the part of the operator, as well as specially devised specula, and the aid of several competent assistants, so that its use must be limited i'o hospital practice or to that of trained specialists. After the usual preparations for operation, a heavy traction suture is introduced through either side of the cervix. The latter is then drawn down as near as possible to the vulva, and a longitudinal in- cision made through the anterior vaginal wall from a little below the urethra to the external os (Fig. 348). The bladder is then separated from the anterior surface of the cervix and lower uterine segment by means of a finger covered by a piece of gauze. The first part of the separation is done by touch alone, but later a large retractor, with a blade measuring 5 X 12 centimeters, is introduced into the wound, after which the process is completed under the guidance of the eye, the bladder being drawn up behind the retractor, when the entire wall of the uterus, from the anterior lip of the cervix to the contraction ring, is freely exposed. The anterior wall of the cervix and lower uterine segment is then incised for a distance of about 10 centimeters by means of a pair of heavy scissors (Fig. 349), and, after removing 4he speculum, the hand is introduced into the uterus, ruptures the membranes, and turns the child. After its extraction and the expression of the placenta, the speculum is again introduced, and, by making the traction sutures VAGINAL CESAREAN SECTION 435 taut, the entire uterine wound is visible as a triangular opening. Its edges are then united from above downward by interrupted catgut sutures, which are introduced under the guidance of the eye, after which the vaginal incision is closed by a continuous catgut suture (Fig. 350). The anterior incision affords sufficient space for the extraction of the child up to the eighth month of pregnancy, but after that period a posterior incision is also necessary. In this event, the operation is begun by making a transverse incision in the posterior fornix at the cervical junction, and peeling oh the peritoneum from the posterior Fig. 349.—Vaginal Cesarean Section. Incision of Anterior Uterine Wall after Separation of Bladder. wall of the cervix and lower uterine segment, which is then incised for a distance of 5 centimeters, after which the anterior wall is treated as has been described. The necessity for the double incision is readily understood, when one recalls that the suboccipitobregmatie circumfer- ence of the fully developed head measures 32 centimeters, so that if only an anterior incision is made, it must measure 15 to 16 centimeters in length to permit the passage of the head without laceration of its upper end, which would necessitate opening the peritoneal cavity; whereas if the incisions are double, each requires to be only half so long. In the latter event, the posterior wound should be closed first. In competent hands vaginal hysterotomy permits the delivery of the child in a few minutes, no matter what the condition of the cervix, 436 INDUCTION OF ABORTION AND PREMATURE LABOR and the entire operation requires thirty minutes or less for its com- pletion. Its advantages over manual or instrumental dilatation are that it leaves a clear-cut wound, properly united by sutures, in place of an irregular, deep, cervical laceration, which may extend into the lower segment, and which frequently cannot be properly repaired. If the incisions are made in the median line, the amount of hemorrhage is surprisingly small, and, if a suitable large retractor is employed, every step of the operation is readily visible. I consider that the difficulties which are sometimes encountered in its performance are usually due to two factors: first, that the speculum Fig. 350.—Vaginal Cesarean Section. Laying of Sutures in Anterior Incision. Posterior Incision Already Sutured. employed is too small to give a suitable exposure of the field of opera- tion; that the incision is either too short or not in the mid-line of the uterus. In the latter event profuse hemorhage may occur, either as the result of laceration of the upper end of the incision during extraction of the head, or because the incision lies to one side of the mid-line. Diihrssen showed that there was a tendency to relaxation of the uterus after the operation, and advised that the cavity be packed with gauze as a prophylactic against such an accident. I believe that this is a wise precaution, and always introduce the pack before laying the sutures in the anterior wall. Diihrssen in 1909 stated that the technic of the operation could be simplified by introducing a medium-sized rubber balloon into the uterus, LITERATURE 437 which, after being filled tightly with sterile salt solution, is used as a tractor, the anterior wall of the cervix and lower uterine segment being incised over it until it slips out. A full account of the operation, together with a list of all the cases of vaginal hysterotomy reported up to 1905, will be found in Diihrs- sen’s article in WinckeFs “Handbuch der Geburtshiilfe.” My own favorable opinion is based upon a considerable number of operations; although I now employ it less frequently, for the reason that I treat patients suffering from eclampsia, wdiich w~as the most usual indication for its use, much more conservatively than formerly. Peterson advo- cates it enthusiastically, and Winter reported that the mortality was only a trifle over 1 per cent, in 446 cases which he collected from the literature in 1909. LITEEATUEE Aiilfeld. 118 Falle von Einleitung der kunstlichen Friihgeburt. Zentralbl. f. Gym, 1890, xiv, 529-534. Bar. Contribution a 1’etude des indications del’accouchement premature arti- ficiel, etc. L’obstetrique, 1899, iv, 471. Bonnaire. De 1’accouchement methodiquement rapide. Presse med., 1909, Nos. 66 and 67. Brouardel. L’avortement. Paris, 1901. Burger. Die Bedeutung der Hystereuryse in der Geburtshiilfe. Archiv f. Gyn., 1906, Ixxvii, 485-556. Champetier de Bibes. De 1’accouchement provoque. Annates de gyn. et d’obst., 1888, xxx, 401-438. Davis. Puerperal Pernicious Anaemia. Trans. Amer. Gyn. Soc., 1891, xviii, 173. Denman. An Introduction to the Practice of Midwifery. 7th ed., London, 1823, 318. D ’Outrepont. Beobachtungen u. Bemerkungen. Gemeinsame Zeitschr. d. Ge- burtsk., 1828, ii, 549. Duhrssen. Ueber den Werth der tiefen Cervix- und Scheiden-Damm Einschnitte in der Geburtshiilfe. Archiv f. Gyn., 1890, xxxvii, 27-66. Der vaginale Kaiserschnitt. Berlin, 1896. Vaginaler Kaiserschnitt. Winckel’s Handbuch der Geburtshiilfe, 1905. Die neue Geburtsliilfe und der praktische Arzt. Volkmann’s Samml. klin. Vor- trage, 1909, No. 549-550. Edgar. Advantages of the Bimanual Dilatation of the Pregnant and Parturient Uterus. Tfans. Am. Gyn. Soc., 1906, xxxi, 108-115. Feiiling. Ein Fall von Chorea gravidarum. Archiv f. Gyn., 1874, vi, 137-139. Fieux. Procedes de provocation et de la terminaison artificielle rapide de 1’ac- couchement. Annales d’obst. et de gyn., 1901, lv, 409-450. Graefe. Ueber den Zusammenhang der perniciosen Anaemie mit der Graviditat. D. I., Halle, 1880. Guillemeau. De l’heureux accouchement des femmes. Paris, 1594. Harris. A Method of Performing Eapid Dilatation of the Os Uteri, etc. Amer. Jour. Obst., 1894, xxix, 37-49. Kleinwachter. Die kiinstliche Unterbrechung der Schwangerschaft, III. Aufl., 1902. Krause. Die kiinstliche Friihgeburt. Breslau, 1855. Kronig. Wie weit soil das Eecht des Kindes auf Leben bei der Geburt gewahrt werden? Monatsschr, f, Geb. u. Gvn., 1906, xxiii, 363-329, INDUCTION OF ABORTION AND PREMATURE LABOR 438 Leopold (Buschbeck). Beitrag zur kiinstl. Friihgeburt wegen Beckenenge, Ar- beiten aus der konigl. Frauenklinik in Dresden, 1893, i, 93-123. Leopold (Schoedel). Erfahrungen iiber kiinstliche Friihgeburten, eingeleitet wegen Beckenenge. Archiv f. Gyn., 1901, lxiv, 151-164. Zur schnellen vollstandigen Erweiterung des Muttermundes mittels des Dila- torium von Bossi, etc. Zentralbl. f. Gyn., 1902, xxvi, 489-495. Lap age et Sainton. Accouchement provoque pour un cas de nevrite peripherique alcoholique. Comptes rendus de la soc. d’obst., de gyn. et de psed. de Paris, 1901, iii, 93-99. Levin und Brenning. Die Fruchtabtreibung durch Gifte. Berlin, 1899. Lott. Instrumental Dilatation of the Cervix in the Last Months of Pregnancy. Amer. Gyn., 1903, iii, 295-299. Matthews. Pregnancy after Nephrectomy. Jour. Am. Med. Assoc., 1921, lxxvii, 1634-1639. Mauriceau. Traite des maladies des femmes grosses, etc. 6me ed., 1721, 161. Pelzer. Ueber Einleitung der kiinstlichen Friihgeburt. Zentralbl. f. Gyn., 1892, xvi, 35-36. Peterson. Indications for and Technique of Vaginal Caesarean Section. Surg. Gyn. and Obst., 1909, viii. Pinard. De 1’accouchement provoque. Annales de gyn. et d’obst., 1891, xxxv, 1-16; 81-112. Indication de 1’operation Cesarienne consideree en rapport avec celle de la sym- physeotomie et de 1’accouchement premature artificiel. Annales de gyn. et d’obst., 1899, Iii, 81-117. Reiffersciieid. Die Rontgentherapie in der Gynakologie. Leipzig, 1911. Siegemundin. Die konigL preussische und Chur-Brandenb. Hof-Wehe-Mutter. Berlin, 1756, 216. Watson. Further Experience with Pituitary Extract in the Induction of Labor. Am. Jour. Obst. & Gyn., 1922, iv, 603-608. Williams. The Induction of Premature Labor and Accouchement Forc6 in the First 5,000 Labors of the Obstetrical Department of the Johns Hopkins Hos- pital. Trans. Am. Gyn. Soc., 1906, xxxi, 316-333. Pernicious Vomiting of Pregnancy. Trans. Am. Gyn. Soc., 1905, xxx, 229-299. The Problem of Effecting Sterilization in Association with various Obstetrical Procedures. Am. Jour. Obst. and Gyn., 1921, i, 783-793. Williamson. The Induction of Premature Labor. Jour. Obst. and Gyn. Brit. Emp., 1905, viii, 252-271. Winter. Die Indieationen zur kiinstlichen Unterbrechung der Schwangerschaft, 1918. CHAPTER XX FORCEPS The obstetrical forceps is an instrument designed for the extraction, under certain conditions, of the child when it presents by the head. It consists of two branches which cross one another, and are designated right and left, respectively, according to the side of the pelvis to which each corresponds. They are introduced separately into the genital canal and are articulated after being placed in position. Each branch is made up of four portions—the handle, blade, shank, and lock. The instruments vary considerably in size and shape, as will be seen when certain varieties of forceps are considered. The blades possess a double curvature — the cephalic and the pelvic —the former being adapted to the shape of the child’s head, the lat- ter to that of the birth canal. The blades are more or less elliptical in shape, tapering toward the shank, and are usually fenestrated so as to allow of a firm hold upon the head. Certain authorities, however, prefer solid blades in the belief that they can be made less bulky. The cephalic curves should be such as to permit the head to he grasped firmly, but without serious compression. The greatest distance between the two blades should not exceed 7.5 centimeters (3 inches), when they are articulated. The pelvic curve corresponds more or less to the axis of the birth canal, but varies considerably in different instruments. When the foreceps is placed up on a plane surface, the tips of the blades should be about 8.8 centimeters (3y2 inches) higher than the handles. The latter are connected with the blades by the shanks, which give the requisite length to the instrument. The two branches articulate at the lock, which varies widely in different instruments. The English type consists of a socket upon each branch, into which fits the shank of the other half of the instrument. This arrangement permits of ready articulation, but does not hold the blades firmly together. In the French lock a pivot is screwed into the shank of the left branch, while the right presents an opening which can Fig. 351.—Simpson’s Forceps, Cephalic Curve. Fig. 352.—Simpson’s Forceps, Pelvic Curve. 439 440 FORCEPS be adjusted to it, the screw being tightened after articulation. The German lock is a combination of the two, the shank of the left branch bearing a pivot with a broad, flat head, while the right is provided with a notch which corresponds to the pivot. When the instrument is properly articulated the handles should fall together in such a way as to be conveniently grasped by one hand of the operator. History.—Crude forceps were in use from an early period, several varieties having been described by Albucasis, who died in 1112; but, Fig. 353.—Lock of English Forceps, Fig. 354.—Lock of Frecnh Forceps. as their inner surfaces were provided with teeth intended to penetrate the head, it is evident that they were intended for use only upon dead children. The true obstetrical forceps was devised in the latter part of the sixteenth, or the beginning of the seventeenth century, by a member ol the Chamberlen family. The invention, however, was not made public at the time, but was preserved as a family secret through four gen- erations, and did not become gener- ally known until the early part of the eighteenth cen- tury. Prior to that time version had been the only method which per- mitted the artificial delivery of an un- mutilated child, and accordingly when that operation was out of the question and delivery became im- perative, it was accomplished by means of hooks and crotchets, which usually led to the destruction of the child. Thus, before the invention of forceps, the use of instruments was synonymous with the death of the child, and frequently of the mother also, and tended to bring obstetrics into disrepute. Fig. 355.—Chamberlen’s Forceps HISTORY 441 William Chamberlen, the founder of the family, was a French physi- cian, who fled from France as a Huguenot refugee and landed at Southampton in 1569. He died in 1596, leaving a large family. Two of his sons, both of whom were named Peter, and designated as the elder and younger, respectively, studied medicine and settled in London. They soon became successful practitioners, and devoted a large part of their attention to midwifery, in which they became very pro- ficient. They attempted to control the instruction of midwives, and in justification of their pretensions claimed that they could successfully deliver patients when all others had failed. The younger Peter died in 1626 and the elder in 1631. The latter left no male children, but the former was survived by several sons, one of whom, born in 1601, was likewise named Peter. To dis- tinguish him from his father and uncle, he is usually spoken of as Dr. Peter, as the other two did not possess that title. He was well educated, having studied at Cambridge, Heidelberg, and Padua, and on his return to London was elected a Fellow of the Royal College of Physicians. He was most successful in the practice of his profession, and counted among his clients many of the royal family and nobility. Like his father and uncle, he attempted to monopolize the control of the midwives, but his pretensions were set aside by the authorities. These attempts gave rise to a great deal of discussion, and many pamphlets were written as to the morality of women in labor being attended by men, which he answered in a pamphlet entitled “A Voice in Ramah, or the Cry of Women and Children as Echoed Forth in the Compassions of Peter Chamberlen.” He was a man of considerable ability, and united at the same time some of the virtues of a religious enthusiast with many of the devious qualities of a quack. He died at Woodham, Mortimer Hall, Essex, in 1683, the place remaining in the possession of his family until well into the succeeding century. For- merly he was considered the inventor of the forceps, but, as we now known, this view was incorrect. He left a very large family, and three of his sons—Hugh, Paul, and John—became physicians, and devoted special attention to the practice of midwifery. Of these Hugh (1630-1706) was the most important and influential. Like his father, he possessed considerable ability, and at the same time took a practical interest in politics. Some of his views not being in favor, he was forced to leave England, and while in Paris in 1673 attempted to sell the family secret to Mauriceau for 10,000 livres, claiming that by its means he could deliver in a very few minutes the most difficult cases. Mauriceau placed at his disposal a rhachitic dwarf whom he had been unable to deliver, and Chamberlen, after several hours of strenuous effort, was likewise obliged to acknowledge his in- abilty to do so. Notwithstanding his failure, however, he maintained friendly relations with Mauriceau, and on returning home translated the latter’s book into English. In his preface he refers to the forceps in the following words: “My father, brothers, and myself (though none else in Europe as I know) have by God’s blessing and our own industrv 442 FORCEPS attained to and long practiced a way to deliver women in this case without prejudice to them or their infants.” Some years later he went to Holland and sold his secret to Roon- huysen. Shortly afterward the Medico-Pharmaceutical College of Am- sterdam was given the sole privilege of licensing physicians to practice in Holland, to each of whom, under pledge of secrecy, was sold Cham- berlen’s invention for a large sum. This practice continued for a number of years, until Yischer and Van der Poll purchased and made public the secret, when it was found that the device consisted of one blade only of the forceps. Whether this was all that Chamberlen sold to Roon- huysen, or whether the Medico-Pharmaceutical College had swindled the purchasers, is not known. Hugh Chamberlen left a considerable family, and one of his sons ■—Hugh (1664-1728)—practiced medicine. He was a highly educated, respected, and philanthropic physician, and numbered among his clients members of the best families in Eng- land. He was an intimate friend of the Duke of Buck- ingham, and when he died the latter caused a statue to be erected in his honor in Westminster Abbey. During the later years of his life he allowed the family secret to leak out, and the instrument soon came into general use. Por more than one hundred years it was believed that the forceps was the invention of Dr. Peter Chamberlen, but in the year 1813 Mrs. Kembell, the housekeeper of a rich brewer who had purchased Dr. Peter Chamberlen’s country house, found in the garret a trunk containing numerous letters and instruments, among the latter being four pairs of forceps, together with several levers and fillets. As is evident from the drawings, the forceps were in different stages of development, one pair being hardly applicable to the living woman, while the others were useful instruments. Aveling, who has carefully investigated the matter, believes that the three pairs of available forceps were used respectively by the three Peters, and that in all probability the first was devised by the elder Peter, son of the original William. Probability is lent to this view by the fact that Dr. Peter, on one occasion, at least, spoke of the invention of his uncle. Sanger and Budin, who have also in-' vestigated the subject, incline to the same belief. The forceps came into general employment in England during the lifetime of Hugh Chamberlen, the younger. The instrument was used by Drinkwater, who died in 1728, and was well known to Chapman and Giffard. The former, writing in 1733, says: “The secret mentioned by Dr. Chamberlen was the use of the forceps, now well known by all the principal men of the profession, both in town and country.” In 1723 Palfyn, a physician of Ghent, exhibited before the Paris Academy of Medicine a forceps which he designated as mains de fer. It was crude in shape and did not articulate. In the discussion fol- lowing its presentation, De la Motte stated that it would be impossible Fig. 356.—Palfyn’s Forceps. HISTORY 443 to apply it to the living woman, and added that if by chance any one should happen to invent an instrument which could be so used, and kept it secret for his own profit, he deserved to be exposed upon a barren rock and have his vitals plucked out by vultures, little knowing that at the time he spoke such an instrument had been in the possession of the Chamberlen family for nearly one hundred years. The Chamberlen forceps was a short, straight instrument, which pos- sessed only a cephalic curve, and is perpetuated in the short or low forceps of to-day. It was used, with but little modification, until the middle of the eighteenth cen- tury, when Levret, in 1747, and Smellie, in 1751, quite inde- pendently of one another, added the pelvic curve and increased the length of the instrument. Levret’s forceps was longer and possessed a more decided pelvic curve than that of Smellie, and it is from these two instruments that the long forceps of the present day is descended—the long French forceps being the lineal descendant of the former, and that of Simpson of the latter. Fig. 357.—Smellie’s Short Forceps. Fig. 358.—Short Forceps. Fig. 359.—Long French Forceps (Levret). As soon as the forceps became public property it was subjected to various modifications, so that Mulder, in his atlas published in 1798, was able to give illustrations of nearly 100 varieties. Some idea of the desire to modify and im- prove the instrument may be gained by glancing at Wit- kowski’s Obstetrical Arsenal, in which are pictured several hundred forceps, which, after all, constitute only a small portion of those devised. Poullet’s interesting mono- graph contains an excellent historical sketch of the development of the instrument. But, considering all the work done, it is surprising how’ little advance was made over the instruments of Levret and Smellie, until Tarnier Fig. 360.—Smellie’s Long Forceps. 444 FORCEPS in 1877 clearly enunciated the principle of axis traction, which has since revolutionized our ideas upon the subject. Choice of Forceps.—Inasmuch as it would appear that in the past nearly every one interested in obstetrics has thought it necessary to attempt to modify the forceps, and to have an instrument bearing his own name, the young physician is likely to be embarrassed by the multitude from which he has to choose. Any properly shaped instru- ment will give satisfactory results, provided it be used intelligently, but for general purposes the ordinary Simpson forceps is probably the best, though, if one expects to do much obstetrical work, a Tarnier axis-traction forceps becomes essential. Personally I always employ the latter, using the traction rods or not, according to circumstances, as I believe it better to become thoroughly familiar with one instrument than to have several for use under different conditions. The forceps should be entirely of metal, so that it can be readily sterilized by boiling. Functions of the Forceps.—This subject has been considered in de- tail by Chassagny. The forceps may be used as a tractor, rotator, com- pressor, dilator, lever, or irritator. Its most important function is traction, exercised for the purpose of drawing the head through the genital tract. In not a few cases, how- ever, particularly in transverse and posterior occipital presentations, its employment as a rotator is attended by most happy results. It should never be used primarily as a compressor, though of course it is impos- sible to make traction without subjecting the head to a slight degree of compression; but when it is desired to bring about a diminution in its size other instruments are more appropriate. Particularly in the past, certain authors advocated applying the forceps through a partially obliterated cervix, and assisting dilatation by traction upon the head. Such a procedure, however, is unjustifiable, for, when delivery becomes necessary under such conditions, the cervix should be stretched manually, and forceps not applied until after dila- tation has been completed. In rare instances one blade of the forceps may be employed as a lever—the vectis, although at present use is very seldom made of this function. Before the use of anesthesia became general, great stress was laid on the so-called dynamic action of the forceps, by which is meant the irritation of the uterus which follows its introduction. But at present this function is of no significance. Indications for the Use of Forceps.—-Strictly speaking, the termina- tion of labor by forceps, provided it can be accomplished without too great danger, is indicated in any condition which threatens the life of the mother or child, and which offers a reasonable prospect of being relieved by delivery. On the part of the mother, such conditions are eclampsia, heart lesions attended by broken compensation, acute edema of the lungs, hemorrhage from premature separation of the placenta, intrapartum infection, or exhaustion. Whenever there is question of interference for the last-named condition, definite objective svmptoms should be present, the condition of the pulse being of especial impor- INDICATIONS FOR THE USE OF FORCEPS 445 tanee; whereas, on the other hand, but little weight should be attached to the statements of the patient. As regards the child, the operation may be called for by prolapse of the umbilical cord, premature separation of the placenta, undue pressure exerted upon the head, and especially by changes in the rhythm of its heart beat and the escape of meconium in vertex presentations. A fcetal pulse falling permanently below 100, or exceeding 160 to the minute, indicates that the child is in danger and may perish if not promptly delivered. In vertex presentations the discharge of amniotic fluid tinged with meconium usually indicates interference with the placental circulation and imperfect oxygenation, manifesting itself by paralysis of the sphincter ani. In breech presentations, on the other hand, the escape of meconium is without significance, being due merely to pressure exerted upon the child’s abdomen. In practice, however, the maternal indications for the use of forceps may be considerably extended, and in many instances the operation may be advisable in the case of women suffering from acute infectious dis- eases, heart lesions, and diseases of the respiratory tract, who must be saved as far as possible from the exhaustion incident to an unaided second stage of labor. Likewise, it is generally advisable to relieve the strain upon a cicatrix resulting from a previous cesarean section. One of the most frequent indications is afforded by faulty con- traction of the uterine or abdominal muscles, the forceps being utilized merely to reenforce the insufficient vis a tergo. Furthermore, in elderly primiparae, the amount of resistance offered by the perineum and the vaginal outlet may sometimes be so great as to oppose a serious obstacle to the passage of the child, even when the expulsive forces are normal. In the absence of disproportion, it is a good practical rule to apply forceps if advance does not occur after two hours of satisfactory second stage pains, but if the head is upon the perineum and no progress has been made for one hour in spite of good pains, it is usually not advisable to wait longer. At the same time it must be insisted upon that the operation should never be performed to save the physicians’ time, nor to quiet the importunities of the patient’s family, but only when distinctly indicated by the condition of the mother or child; so that, whatever the outcome may be, the conscience of the operator will be clear. De Lee takes a more radical position, as he believes that prolonged pressure of the foetal head against a more or less rigid perineum frequently results in serious injury to the cerebral tissues, and recommends the performance of what he designates as “the pro- phylactic forceps operation.” In this procedure, forceps are applied as soon as the head rests firmly upon the pelvic floor and has begun to part the pillars of the levator ani muscle; and is preceded by a deep lateral incision through the perineal and vaginal tissues, which extends into the levator ani if the' disproportion promises to be great. He considers that the procedure adds greatly to the safety of the child, relieves the patient from a considerable part of the strain incident to the second stage of labor, and leaves her genitalia in such condition 446 FORCEPS that the occurrence of outlet relaxation in the future is reduced to a minimum. In his skillful hands, these objects are no doubt accom- plished, but even he recommends restricting the operation to the trained specialist. For my part, I am confident that the results would be disastrous were his suggestion generally adopted. The following conditions must be fulfilled before forceps can be applied with safety: (1) The child must present correctly; (2) the cervix must be fully dilated or dilatable; (3) the membranes must be ruptured; (4) the head of the child must be neither too large nor too small; and (5) the pelvis must not be too contracted. The child should present by the vertex or face, and an accurate diagnosis be made as to the position and variety, forceps not being available when the chin is directly posterior. The forceps is not ap- plicable to shoulder presentations, nor is it intended to be applied to the breech. Generally speaking, it should not be employed in brow cases until after conversion into a vertex or face presentation has been brought about. The cervix must always be completely dilated before the application of forceps, offering a diameter of from 9 to 10 centimeters. Of course it is possible to apply the blades through a canal measuring only 4 or 5 centimeters, but in such circumstances the cervical ring offers marked resistance, and, if the head be dragged through it, deep tears may re- sult, which may also implicate the lower uterine segment. Accordingly, if prompt delivery becomes imperative when the cervix is only partially dilated, its complete dilatation should be effected manually before for- ceps are applied. On the other hand, if the head is only partially engaged, or is floating above the superior strait, delivery is best effected after podalic version provided the uterus is not too tightly contracted and serious disproportion does not exist. The membranes should always be ruptured before applying forceps, for, if they intervene, the grasp upon the head is not so firm, and, what is more important, traction upon them may occasionally bring about premature separation of the placenta. Before applying forceps, particularly when engagement has not yet occurred, the size of the head should be determined as accurately as possible, for if it be unduly large, as in an excessively developed or hydrocephalic child, it cannot pass the superior strait. On the other hand, if it be abnormally small, it cannot be properly grasped, since the blades will slip off when traction is made. Accordingly, the em- ployment of forceps is questionable when the foetus is small or mac- erated. Generally speaking, contracted pelvis presents an absolute contra- indication to the application of forceps; for, if the contraction be marked, it will be impossible to drag the head through the pelvis, and the employment of brute force may result in the death of the child and severe injuries to the mother. On the other hand, when the contraction is but slight, and especially when the head is firmly engaged in the upper part of the pelvic cavity, the tentative application of forceps may be justifiable. Under such circumstances a few tractions of mod- PREPARATIONS FOR OPERATIONS 447 erate intensity should he made; if the head follows they should be con- tinued, but if not the forceps should be removed and delivery effected in some other manner. Preparations for Operation.—When the application of forceps be- comes necessary, either in the interests of the mother or child, the physician should inform a responsible member of the family of his Fig. 361. Robb’s Leg-Holder. decision. It is not advisable to inform the patient until the prepara- tions for operation are completed. Whenever possible, the patient should be placed upon a table of suitable height, as ordinary beds are too low and too soft for con- venience. Anesthesia should always be employed, and whenever practic- able its administration should be intrusted to a competent assistant, rather than to the nurse or some member of the family, since in the latter case a large part of the obstetrician’s attention must of necessity be de- voted to watching the gen- eral condition, instead of being concentrated upon the operation. When anesthesia is complete, the patient’s but- tocks should be brought to the edge of the table, and her legs held in position by an appropriate leg- holder, which is particu- larly convenient in private practice, as it enables one to dispense with assistants for holding the legs. The patient is then prepared for operation, as is described on page 417. Except when the outlet is greatly relaxed, it is advisable to dilate it manually before beginning the operation; as by so doing, the liability to laceration is decreased, and less powerful traction is necessary. For this purpose, the hand is freely lubricated, and preliminary dila- tation is effected by making downward and lateral traction with two fingers. Then, the fingers, being arranged in the form of a cone, are Fig. 362.—Diagram showing Position of Head in Various Forceps Operations. 448 FORCEPS given a rotary motion and slowly introduced into the vagina, gradually dilating it until the closed fist can nass the vulval outlet with ease. > I regard this “ironing out” of the vaginal outlet and pel- vic floor as so essential that I hold that forceps should not he ap- plied until it has been effected. Application of For- ceps.—Forceps operations are designated as low, mid, high, and floating, according to the position of the head. When the presenting part rests up- on the perineum, or lies well below the line join- ing the ischial spines, we speak of low forceps; when it presents at or just above the ischial spines, mid for- ceps; when the head has partially descended into the pelvic canal, hut its greatest circumference has not passed the su- perior strait, high for- ceps; and when it is freely movable above the pelvic brim the operation is termed forceps up- on the floating head. The low forceps oper- ation usually offers hut little difficulty, except in certain funnel-shaped pelves, and may be un- dertaken upon compara- tively slight indications. The mid operation is more difficult, but not often excessively so. On the other hand, the high operation is always difficult, and should not he attempted unless imperatively de- Fig. 363.—Forceps Correctly Applied along occi- pitomental Diameter, Pelvic Curve towards Occiput. Fig. 364.—Forceps Correctly Applied along Occi- pitomental Diameter, Pelvic Curve towards Face. Fig. 365.—Forceps Applied to Face along Occipito- mental Diameter. APPLICATIONS OF FORCEPS 449 manded by the condition of the mother or child. Forceps upon the floating head is a most serious procedure, and is very rarely indicated. Fig. 366.—Forceps Applied Obliquely over Brow and Mastoid Region. Fig. 367.—Showing that when one Blade is Applied over Occiput and Other over the Face, Forceps cannot be Locked. Fig. 368.—Showing Extension of Head when One Blade is Applied over Brow and Other over Occiput, explaining Tendency of the Instrument to Slip Off. Generally speaking, the fact that the head is not engaged indicates gome disproportion between it and the superior strait, so that the 450 FORCEPS operation should not be thought of until accurate information as to the size of both is available. Moreover, in those eases in which there is no serious disproportion, delivery can usually be accom- plished more safely and rapidly by version. The forceps is so constructed that its cephalic curve is best adapted to the sides of the child’s head, the biparietal diameter cor- responding to the line of greatest distance between the blades. Consequently, the head is grasped in an ideal manner only when the long axis of the blades cor- responds to the occipitomental diameter, the fenestra including the parietal bosses and the tips lying over the cheeks, while the concave margins of the blades look toward either the occiput or the face. With such a grasp the forceps obtains a firm hold and cannot slip off, and traction can be made in the most advantageous manner. On the other hand, when the forceps is applied obliquely with one blade over the brow and the other over the opposite mastoid region, the grasp is less secure, and the head is exposed to injurious pressure. If one blade is accurately applied over the face and the other over the occiput, the instrument can- not be locked, while, if the blade over the face is slipped down so as to permit articulation, the grasp is very insecure and each traction tends to extend the head (see Figs. 367 and 368). For these reasons, then, the for- ceps should be applied, when pos- sible, directly to the sides of the head along its occipitomental or jugoparietal diameter. This is known as the cephalic, in contra- distinction to the pelvic application. . ■ : The former was recommended by Smellie and Baudelocque, but, as it is more difficult than the latter, it fell into disuse, and was not gen- Fig. 369.—Low Forceps; Introduction of Left Blade to Left Side of Pelvis. Fig. 370.—Low Forceps; Left Blade in Place. APPLICATIONS OF FORCEPS 451 erally practiced until Pinard, Farabeuf, and Yarnier dem- onstrated the inestimable ad- vantages which it possesses over the pelvic application. In the pelvic application, the left blade is applied to the left and the right blade to the right side of the mother's pelvis, no matter what the presentation, consequently the head is grasped satisfactorily only when the sagittal suture is directed anteroposteriorly. An accurate idea of the exact position of the head is essential to the cephalic ap- plication. With the head low down, this can usually be ob- tained by examining with two fingers; but when it is higher up an absolute diagnosis can be made only by locating the posterior ear, which necessi- tates the introduction of the entire hand into the vagina. This, of course, requires pro- found anesthesia, and is therefore practicable only just before introduc- ing the forceps. After locating the ear, the examining hand is not removed, but remains in place to serve as a guide for the introduction of the first blade, which should be applied over the posterior ear, no matter whether it be the right or left. This rule admits of exception in two instances only—namely, when the head is resting upon the perineum, when the sagittal suture usually extends antero- posteriorly, or when it is mov- able at the pelvic brim. Faulty diagnosis frequently results in an improper application of for- ceps, and is a leading factor in converting what should be a simple procedure into a serious and difficult operation. Fig. 371.—Low Forceps; Left Blade in Place, Introduction of Right Blade. Fig. 372.—Low Forceps; Instrument in Place and Articulated, FORCEPS 452 Forceps Delivery ivith the Head at the Vulva.—With the head in this low position, the obstacle to delivery is usually due to insufficient expulsive force or to abnormal resistance on the part of the perineum. In such circumstances the sagittal suture usual- ly occupies the antero- posterior diameter of the pelvic outlet, with the small fontanel directed toward either the sym- physis pubis or the con- cavity of the sacrum. In either event the forceps, if applied to the sides of the pelvis, will grasp the head in an ideal manner. Accordingly, the left blade is introduced to the left and the right blade to the right side of the pelvis, the mode of pro- cedure being somewhat as follows: Two fingers of the right hand are passed into the left and posterior portion of the vulva and carried up the vagina past the Fig. 373.—Low Forceps; Horizontal Traction. Fig. 375.—Low Forceps, Extreme Up- ward Traction. Fig. 374.—Low Forceps; Upward Trac- tion. margins of the external os. The handle of the left branch is then seized between the thumb and two fingers of the left hand—just as in holding a pen—and the tip of the blade is gently passed into the vagina along the palmar surface of the fingers of the right hand which APPLICATIONS OF FORCEPS 453 serve as a guide. As it is introduced, the handle is at first held almost vertically, but, as the blade adapts itself to the head, it is depressed, so that it eventually takes a horizontal position. The guiding fingers are then withdrawn, and the handle is left to itself or held by an Fig. 376.—Low Forceps; Occiput Directly Posterior; Horizontal Traction (Farabeuf and Varnier). assistant. In the same manner, two fingers of the left hand are then introduced into the right and posterior portion of the birth canal to serve as a guide for the right blade, which is held in the right hand Fig. 377.—Low Forceps; Occiput Directly Posterior; Upward Traction (Farabeuf and Varnier). and introduced into the vagina. The guiding fingers are now removed and all that remains to be done is to articulate the branches. Usually they lie in such a manner that they can be locked without difficulty; but when this cannot be done, first one and then the other blade should be 454 FORCEPS gently moved until the handles are brought into such a position as to be articulated with ease. When this has been accomplished, an examination is made to ascer- tain whether the blades have been correctly applied, or whether they inclose the lips of the cervix. In the latter case the forceps should be loosened and reapplied. When it is certain that the blades are satisfactorily placed, the handles are seized with one hand and gentle intermittent traction is made in a horizontal direction until the peri- neum begins to bulge. As soon as the vulva begins to be distended by the occiput, the handles are gradually elevated, and eventually come almost in contact with the abdomen of the patient as the parietal bosses emerge. During the latter maneuver, the four fingers should grasp Fig. 378.—Mid Forceps; Hand in Vagina Seeking Posterior Ear. Fig. 379.—Mid Forceps; Introduction of First Blade. the upper surface of the handles and shanks, while the thumb upon their lower surface exerts the necessary force. In delivering the head nature’s method should be simulated as closely as possible, and the minimum amount of force employed. Accordingly, traction should be made intermittently, the head being allowed to recede in the intervals, as in spontaneous labor. Except when urgently indi- cated, it should be extracted very slowly, so as to give time for proper stretching and dilatation of the perineum, which in primiparous women cannot be satisfactorily accomplished in less than from ten to fifteen minutes. When the vulva is well distended by the head and the brow can be felt through the perineum, the mode of completing delivery varies. I usually do so with the forceps in place, holding that in this way I have the greatest control over the advance of the head. Others, on the contrary, contend that the thickness of the blades adds to the distention of the vulva and thus increases its liability to laceration. For this APPLICATIONS OF FORCEPS 455 reason, they remove the forceps and complete delivery by Kitgen’s maneuver—slowly expressing the head by making upward pressure upon the brow through the posterior portion of the perineum. It is a matter of indifference which procedure is followed, but I prefer the former. Occasionally the forceps are removed too soon, and in this event Ititgerds maneuver proves a tedious and inelegant procedure. When the occiput lies directly posteriorly, traction should be made in a horizontal direction until the forehead or root of the nose engages under the symphysis, after which the handles should be slowly elevated, until the occiput slowly emerges over the anterior margin of the perineum, and then, by imparting a downward motion to the instrument, the forehead, nose, and chin will successively emerge from the vulva. This ex- traction is more difficult than when the occiput is anterior, and, owing to the greater distention of the vulva, perineal tears are more liable to occur. Low and Mid Forceps Operas tions.—When the head lies above the perineum, the sagittal suture usually occupies an oblique or transverse diameter of the birth canal. In such cases the forceps should always be applied to the sides of the head. This is best accomplished by introducing two or more fingers into the vagina sufficiently deeply to feel the pos- terior ear, over which, no matter whether it be the right or left, the first blade should be applied. In left occipito-anterior positions the entire right hand, introduced into the left posterior segment of the pelvis, should locate the posterior ear, and at the same time serve as a guide for the introduction of the left branch of the forceps, which is held in the left hand and applied over the posterior ear. The guide hand is then withdrawn, when the handle may be held by an assistant or left to itself, as the blade will usually retain its position without difficulty. Two fingers of the left hand are then introduced into the right and posterior segment of the birth canal, no attempt being made to reach the anterior ear, which lies in the neighborhood of the right iliopectineal eminence. The right branch of the forceps, held in the right hand, is then introduced along the left hand as a guide. After its introduction it still remains to apply it over the anterior ear of Fig. 380.—Mid Forceps; Introduction of Second Blade. 456 FORCEPS the child. This is accomplished b)r gently rotating it anteriorly until it comes to lie directly op- posite the blade which was first introduced. The two branches being now articu- ulated, one blade of the for- ceps occupies the posterior and the other the anterior ex- Figs. 381, 382.—Mid Forceps; Instrument Applied in L. O. A. Fig. 381. Fig. 382. tremity of the left diameter (see Figs. 381 and 382) In the right positions, the blades are introduced in a similar manner but in opposite directions, for in this case the right is the posterior ear, over which the first blade inserted must ac- cordingly be placed. It should, however, be remem- bered that after the blades have been applied to the sides of the head the left handle and shank will lie above the right, and con- sequently the forceps will not immediately articulate, but this difficulty can be Fig. 383. Fig. 384. Figs. 383, 384.—Mid Forceps; Instrument Applied in R. 0. T. readily overcome by rotating tbe former around the latter so as to bring the lock into proper position (Fig. 399). APPLICATIONS OF FORCEPS 457 If the occiput is in a transverse posi- tion, the forceps is introduced in a similar manner, the first blade being ap- plied over the pos- terior ear, and the second being rota- ted anteriorly until it comes to lie op- posite the first. In this case one blade lies in front of the sacrum and the other behind the symphysis (Figs. 383 and 384). Whatever the original position of the head may be, delivery is ef- fected by making traction obliquely downward until the occiput appears at the vulva, the rest of the operation being completed in the manner Fig. 385.—Mid Forceps; Rotation to R. O. A. Fig. 386.—Showing Manner of Making Traction in Mid Forceps Operation. 458 FORCEPS already described. When the occiput is obliquely anterior, it gradually rotates spontaneously to the symphysis pubis as traction is made. But when it is directed transversely, in order to bring it to the front, it is sometimes necessary to impart a rotary motion to the forceps while Fig. 387. Fig. 388. Figs. 387, 388.—Diagrams showing Rotation of Obliquely Posterior Occiput to Sacrum and Symphysis Pubis Respectively. making traction. The direction in which this is to be made varies, of course, according to the position of the occiput, rotation from the left side toward the middle line being necessary when the occiput is directed toward the left, and in the reverse direction when it is directed toward the right side of the pelvis (see Figs. 383, 385). In making traction, be- fore the head appears at the vulva, one or both hands may be employed according to the amount of force required. When the Simpson forceps are used, one hand grasps the handles of the instrument, while the fingers of the other are hooked over the Figs. 389, 390.—Showing Inversion of Forceps when Anterior Rotation from an R. O. P. Position is Completed. Fig. 389. Fig. 390. transverse projection at their upper ends. Care must be taken not to employ too much force. To avoid this error the operator should stand or sit with his arms flexed and the elbows held closely against the APPLICATIONS OF FORCEPS 459 thorax, as it is not permissible to make use of the body weight, and still less to brace the feet against the side of the bed (Fig. 386). Application of Forceps in Obliquely Posterior Positions.—Prompt delivery may become necessary when the small fontanel is directed toward one or other sacro-iliac synchondrosis—namely, in R. 0. P. and L. 0. P. presentation. When interference is required in either of these, the head usually lies at or below the level of the ischial spines, and is often imperfectly flexed. In many cases, when the hand is introduced to locate the posterior ear, the occiput will rotate spontaneously to a transverse position, and delivery by forceps is then accom- plished, as already described. If, however, rotation does not occur, the head should be seized, with four fingers over its posterior and the thumb over its anterior ear, and an attempt made to rotate the occiput to a transverse posi- tion. This can usually be accom- plished with ease, and occasionally even rotation to an anterior posi- tion can be brought about. The forceps is then applied as de- Figs. 391, 392.—Scanzoni’s Maneuver; First Application of Forceps. Fig. 391. Fig. 392. scribed above. In other cases, after manual rotation has been effected, the head slips back into its original position before the forceps can be applied. To obviate this difficulty, De Lee recommends seizing the scalp by means of a pair of bullet forceps and holding the head in the desired position until the blades are adjusted. In a small proportion of cases, however, manual rotation cannot be effected, and in such cases the forceps must be applied with the occiput still' directed obliquely posterior. In these circumstances, if the instru- ment be applied to the sides of the head, or even obliquely, and it is attempted to effect delivery by making traction in the usual manner, great difficulty is experienced and powerful traction usually fails to bring about the desired result. It is this experience which has given rise to the great dread in which these presentations are generally held, and it is a very good practical rule, whenever unexpected difficulty 460 FORCEPS is experienced in delivering what is apparently a simple anterior presentation, to think of the possibility of a mistake in diagnosis and to reexamine the patient. It will then gen- erally be found that a mistake has been made, and that the small fontanel lies in the neighborhood of one or other sacro-iliac synchondrosis. In order to effect delivery, the head must be rotated so as to bring its sagittal suture into coincidence with the an- teroposterior diameter of the Figs. 393, 394.—Scanzoni’s Maneuver; showing Rotation to Transverse Position. Fig. 393. Fig. 394. pelvic outlet. This can be accomplished by rotating the occiput by means of the forceps, either through an arc of 45 degrees to the hollow of the sacrum, or through one of 135 de- grees to the symphysis pubis (Figs. 387 and 388). The latter is more advantageous, for the reason that delivery in the directly posterior position is more difficult Figs. 395, 396.—Scanzoni’s Maneuver; showing Rotation to Anterior Position Forceps Inverted. Fig. 395. Fig. 396. and also more likely to give rise to deep perineal tears. APPLICATIONS OF FORCEPS 461 Unfortunately, when it is desired to rotate the occiput forward, the forceps, if applied to the sides of the head with the pelvic curvature directed upward, becomes inverted by the time rotation is completed, so that the pelvic curve then looks posteriorly, and an attempted de- livery with the instrument in this position is liable to cause serious injury to the maternal soft parts (Figs. 389 and 390). In order to avoid this, it is best to remove and reapply the instrument, as described below. If one wishes to avoid this double application, the head may be seized obliquely with one blade over the anterior brow and the other over the posterior mas- toid region; but this is not advisable, however, as the procedure is more difficult for the operator and far more dangerous for the child. The double applica- tion of forceps, which Fig. 397. Fig. 398. Figs. 397, 398.—Scanzoni’s Maneuver; Second Application of Forceps, was recommended by Scanzoni many years ago, has given such excellent results in my hands that I employ it to the exclusion of all other methods when the occiput cannot be rotated manually from its obliquely posterior position. It, however, is rarely necessary, and in my service is employed in only 1 or 2 per cent, of all obliquely posterior occipital presentations. As the right posterior variety is much the more frequent, I shall describe in detail the steps of the operation. In the first application the blades are applied to the sides of the head with the pelvic curve looking toward the face of the child, whereas in the second manipulation it looks toward the occiput. For the first application (Figs. 391 and 392) the right hand is passed into the left posterior segment of the genital tract, and the posterior (right) ear sought for. Over it the left blade is applied. This is held in position by an assistant, while the operator’s left hand is passed into the right side of the vagina controlling the introduction of the right blade, which is then rotated anteriorly until it comes to lie opposite the blade first introduced. The forceps is then locked, its blades now occupying the left and the sagittal suture the right oblique diameter of the pelvis. 462 FORCEPS Downward traction is then made, and at the same time a rotary motion is imparted to the forceps when the head slowly descends and rotates to a right transverse, and later on when it impinges upon the pelvic floor to an obliquely anterior position (see Figs. 393 to 396). The forceps having become inverted, must be taken off, and reapplied in the usual manner to the head, -which now occupies a right anterior position, when delivery is readily accomplished. Some difficulty may arise in bringing about proper articulation, since the handle of the left branch lying above the right cannot be locked, but this can be readily overcome by rotating the former around the latter so as to bring the lock into proper position (see Fig. 399). In left positions the blades are applied in a simi- lar manner, but in the reverse direction. By this method I have been able to de- liver many women -with ease after the usual methods had failed. Indeed, my experience has been so satisfactory that I have ceased to dread occipitoposterior pres- entations, and now regard them with equanimity feeling that delivery can be readily and safely ef- fected when necessary. Bill, of Cleveland, is an enthusiastic advocate of a similar procedure, except that he rotates the head before beginning to make traction. Kielland, of Christiania, in 1916 described a forceps with narrow, somewhat bayonet shaped blades, which he claims can readily be applied to the sides of the head, and surpasses all other models as a rotator. He introduces the anterior blade first with its cephalic curvature directed forward, and, after it has entered sufficiently far into the uterine cavity, he turns it through 180 degrees in order to adapt the cephalic curvature to the head. I have had no experience with it, but it has been ex- tensively employed in Germany with varying results—some considering it an ingenuous and useful invention, while others hold that it possesses no advantages over the usual types of forceps. The critique of Fink Fig. 390.—Scanzoni’s Manuever; Showing Difficulty in Articulating Blades in Second Application of Forceps. APPLICATIONS OF FORCEPS 463 affords an admirable resume of the literature upon the subject up to 1923. To avoid the necessity of constantly bearing in mind which is the left and which the right branch of the forceps, it is a good practical rule for a beginner, after having made an accurate diagnosis of the position of the head, to articulate the forceps and to hold them before the vulva of the patient. In this way he readily appreciates how they should be applied, and which blade is to go over the posterior ear. High Forceps.—As has already been said, the high are much more difficult that the mid or low forceps operations, and should not be undertaken unless urgent indications are present. If the head be well engaged, the forceps should be applied as in the mid or low operation, except that, owing to the more elevated position of the head, the blades must be introduced for a greater distance into the genital tract before being applied. On the other hand, if the entire head lies above the superior strait, or only a small segment of it is engaged, the use of forceps is usually contra-indicated, as failure of engagement generally indicates the exist- ence of disproportion between the head and the pelvis. If, however, the operation appears to be called for, and the sagittal suture lies transversely, as it usually does if the pelvis is contracted, the forceps should be applied obliquely, one blade over the mastoid and the other over the opposite brow. To my mind this is the only condition in which the interests of the mother and child are not best served by the cephalic application; but in these circumstances, the blades of the forceps, if applied to the sides of the head, will occupy the extremities of the conjugata vera, and still further increase the disproportion. More important still is the fact that the posterior blade bridges over the anterior concavity of the sacrum and thus prevents the head from entering the pelvic cavity, thereby defeating the very' purpose for which the operation would be undertaken (Fig. 400). Axis-traction Forceps.—With the ordinary long forceps, the high and occasionally even the mid operation is comparatively difficult, strong traction being necessary to effect delivery. This is due to the fact that, owing to the shape of the birth canal and of the forceps, it is impos- sible to exert traction directly in the axis of the superior strait. The latter, as we know, would, if continued downward, pass through the lower portion of the sacrum; but, owing to the presence of the perineum, the extremity of the sacrum and the coccyx, it is impossible to depress the handles of the forceps sufficiently to permit of traction in the desired direction. As a consequence, a very considerable part of the force exerted is wasted in dragging the head against the symphysis, instead of bring- ing it downward. Thus, Tarnier pointed out that a force of 40 pounds employed in a high forceps operation would be resolved into two forces— one of 30 pounds and the other of 26 pounds—the former being in the axis of the superior strait and serving to bring about descent, whereas the latter would be directed against the symphysis pubis and would not only be wasted, but would actually retard delivery. This defect in the forceps has long been recognized. Saxtorph, in 464 FORCEPS 1772, suggested that delivery could be greatly facilitated by attaching a lac to the eye of each blade and making traction upon these, as well as with the handles. He also showed that a similar result might be attained by making strong downward pressure with one hand in the neighborhood of the lock, while the other was used for traction. This maneuver is variously attributed to Osiander and Pajot, but was recom- mended by Saxtorph forty-four years before either was born (Fig. Fig. 400.—Diagram Showing Defect of Cephalic Application of Forceps When Head is at Superior Strait; Black Line Indicating Direction of Actual and Dotted Line that of Ideal Traction (Farabeuf and Varnier). Hermann, of Berne, in 1844, was the first to attempt to overcome the difficulty by devising an axis-traction forceps, his crude instrument being shown in Fig. 403. Hubert, of Louvain (1860), found that in certain cases, by turning the handles downward, he could make traction along the axis of the superior strait, his instrument giving ideal results when the sagittal suture was directed anteroposteriorly, but being useless in all other positions. Morales (1871) added a perineal curve to the forceps, but his invention possessed the same disadvantages as that of Hubert. None of these instruments were of much practical value, but they served to emphasize the faults of those in general use. Finally, in 1877, Tarnier solved the problem by attaching a rod to each blade-and connecting them with a traction bar. His original forceps possessed a definite perineal curve, and was very cumbersome. The importance of his invention was soon recognized, and obstetricians throughout the world promptly attempted to improve upon it; so that at present one or more modifications of axis-traction forceps, each desig- nated by the name of the modifier, are to be found in every large city. APPLICATIONS OF FORCEPS 465 The modification devised by Milne Murray enjoys great popularity in Great Britain, but to my mind it is inferior to the last Tarnier model. Tarnier himself, not considering his original forceps satisfactory, Fig. 401.—Tarnier’s Diagram; Showing Defects of Ordinary Forceps. A E C, line of actual traction ; A D B, line of desired traction; ASF, force wasted against symphysis pubis. continued to make changes and improvements, so that before his death he had devised an instrument which leaves little to be desired. It is practically a long French forceps without a perineal curve, provided Fig. 402.—Saxtorph Maneuver. with short, detachable traction-rods, one of which is inserted just beyond the eye of each blade. When not in use, these are held in place by a pin upon the under surface of the shank, from which they can be readily 466 FORCEPS freed, and attached by their free ends to a traction attachment which terminates in a handle-bar which can be grasped by one or both hands (see Figs. 407 and 408). With this device, traction can be made almost in the axis of the superior strait, and, owing to the pres- ence of numerous joints in the trac- tion attachment, the instrument can be used in any po- sition. The handles of the forceps mere- ly serve to indicate the direction in which traction should be made, the force being applied to the handle-bar, which is held hori- zontally no matter what the position of the blades may be, the traction- rods being kept about one centi- meter beneath the handles (Fig. 409). To my mind, this instrument is superior to all other axis-traction forceps, and with it excellent results can be obtained with a minimum expenditure of energy, and by its aid a delivery can occasionally be effected which would have been impossible with the ordinary instru- ments. One of its best points is the joint between the horizontal and vertical portions of the traction attachment, as a result of which the handle-bar can be held hori- zontally, even though the for- ceps is applied at the ends of the anteroposterior diameter of the pelvis. I use this instrument in all cases, without the traction-rods in low, and with them in mid and high forceps operations. Application of Forceps in Face Presentations.—In face presentations the application of forceps occasionally becomes necessary, but is usually successful only in the transverse and anterior varities, the blades being Fig. 403. Hermann’s Forceps, Fig. 404.—Hubert’s Forceps. Fig. 405.—Morales’ Forceps. Fig. 406.—Tarnier’s Original Axis-Traction Forceps, APPLICATIONS OF FORCEPS 467 applied to the sides of the head along the mento-occipital diameter, with the pelvic curvature directed toward the neck. Traction is made in a downward direction until the chin appears under the symphysis; then by an upward movement the face is slowly extracted through the vulva, the nose, eyes, brow, and occiput appearing in succession over the anterior margin of the perineum. Forceps should not be applied when the chin is directed toward the hollow of the sacrum, as delivery cannot be effected in that position. In exceptional cases, if version is out of the question, and conversion into a vertex presentation cannot be effected, an expert operator may Fig. 407.—Tarnier’s Forceps; Traction Rods in Place without Handle-bar. endeavor to rotate the chin to a transverse and later to an anterior position before resorting to pubiotomy or craniotomy, though such at- tempts are rarely successful. Application of Forceps in Breech Presentations.—Occasionally the application of forceps is recommended in frank breech presentations, the blades being applied over the trochanters. This is very rarely in- dicated, as delivery can usually be effected more satisfactorily by the methods to he mentioned in the following chapter. From the time of Smellie, many authors have recommended the extraction of the after-coming head in breech presen- tations by means of the forceps. In such cases the body of the child is carried up over the abdomen of the mother, and the blades are introduced under it and applied to the sides of the head. As a matter of fact, it is never necessary to resort to the forceps under such conditions, so its employment is not to be recommended, since the more expert one becomes in the use of Mauriceau’s method of extraction the less frequently will difficulty he experienced in delivering the after-coming head. Prognosis.—Low and mild forceps operations, when intelligently per- formed upon healthy women under proper aseptic precautions, should not he followed by maternal mortality, the operation being undertaken to save maternal or fcetal life. It is generally held that perineal tears occur more frequently in for- ceps than in spontaneous deliveries. This, however, should not he the case, provided that the head is extracted sufficiently slowly. ITnfortu- Fig. 408.—Tarnier’s Forceps. 468 FORCEPS nately, it would appear as though the average operator, as soon as the head appears at the vulva, is seized with an almost uncontrollable desire to effect its immediate delivery by brusque traction, instead of imitating nature and devoting from fifteen to twenty minutes to overcoming the resistance of the perineum and vulval outlet. Leopold has stated that the forceps is the bloodiest of all obstetrical operations, and this is undoubtedly true if the child is rapidly dragged through a partially dilated birth canal by brute force. On the other hand, if properly employed, it is a means of sparing instead of destroying the perineum, Fig. 409.—Diagram showing Traction with Tarnier’s Forceps. A B in proper and X Y in improper manner (Ribemont-Dessaignes). inasmuch as the exit of the head can be controlled quite as effectively by means of the forceps as by any other procedure. Attempts at delivery through an imperfectly dilated cervix are most dangerous, and frequently give rise to deep cervical tears, which may lead to the death of the patient from hemorrhage or infection. More- over, the application of forceps requires an accurate diagnosis as to the position and presentation of the child, and when this is lacking, and the forceps is incorrectly applied in certain occipitoposterior and brow presentations, delivery can be effected only by brute force, which can hardly fail to cause serious lesions for mother and child. Similar un- toward results often follow an attempt to drag the head forcibly through a markedly contracted superior strait or pelvic outlet. The foetal mortality depends upon the position of the head and the LITERATURE 469 general difficulty of the operation. It should be practically zero in low and mid operations, except when a funnel-shaped pelvis has been over- looked. In a comparatively large experience, I can recall very few children whose deaths could be directly attributed to such operations when properly performed. On the other hand, the high forceps opera- tion is attended by a serious foetal mortality, which becomes still greater when the head is not engaged. In such cases the head may be subjected to injurious pressure, which may lead to the rupture of intracranial vessels and the subsequent death of the child. In rare instances actual fracture of the skull may occur, and occasionally the upper part of the occipital bone may become separated from its base. Occasionally the child may be born with facial 'paralysis, or the con- dition may develop shortly after birth. This is usually noted when the head has been seized obliquely, and is due to the pressure exerted by the posterior blade of the forceps upon the neighborhood of the stylomas- toid foramen, through which the nerve leaves the skull. Not every facial paralysis, however, following delivery by forceps, should be attrib- uted to the operation, as such a condition is occasionally encountered after a spontaneous labor, and may be due to intracranial causes quite independent of the use of instruments. Full literature upon this subject up to 1901 will be found in Mace’s article. LITERATURE Aveling. The Chamberlens and the Midwifery Forceps. London, 1882. Baudelocque. De la maniere de se servir du forceps, etc. L’art des accoche- ments. Nouv. ed., Paris, 1789, t. ii, 300-343. Bill. Forceps Rotation of the Head in Persistent Occipito-posterior Positions. Am. Jour. Obs't., 1918, lxviii, 791-795. Budin. L’invention du forceps a double courbure. Progies medical, 1876, iv, 779. Les Chamberlens. Lequel d’entre eux imagina le forceps. Obstetrique et Gyne- cologic, 1886, 659-668. Chapman. An Essay on the Improvement of Midwifery, etc. London, 1733. Chassagny. Le forceps, etc. Paris, 1871. Fonctions du forceps. Paris, 1891. De Lee. The Treatment of Obstinate Occipito-posterior Positions. Jour. Am. Med. Assoc., 1920, lxxv, 145-147. The Prophylactic Forceps Operation. Am. J. Obst. and Gyn., 1920, i, 34-44. Farabeuf et Varnier. Introduction a 1’etude clinique et a la pratique des ac- couchements. Paris, 1891, 276-466. Fink. Zur Kritik der Kjellandzange. Zentralbl. f. Gyn., 1923, 668-684. Giffard. Cases in Midwifery. London, 1734. Hermann. Ueber eine neue Geburtszange. Berne, 1844. Hubert. Note sur l’equilibre du forceps et du levier. Memoires de l’acad. .royale de Belgique, 1860. Kielland. Ueber die Anlegung der Zange am nicht rotierten Kopf mit Besch- reibung eines neuen Zangemodelles, etc. Monatsschr. f. Geb. u. Gyn., 1916, xliii, 48-78. 470 FORCEPS Levret. Observations sur les causes et les accidents de plusieurs aceouclicments laborieux. Paris, 1747. Mac£. Des paralysies faciales spontanes du nouveau-ne. L’obstetrique, 1901, vi, 517-526. Milne Murray. The Axis Traction Forceps, etc. Edinburgh Med. Jour., 1891, xxxvii, 142-158, 228-239. Morales. Modification nouvelle du forceps. Jour, de med. de Bruxelles, 1871, lii, 110-134. Mulder. Historia literaria et critica forcipum et vectium obstetriciorum. Lugd. Bat., 1794. Palfyn. See Levret. Poullet. Des diverses especes du forceps. Paris, 1883. Sanger. Die Chamberlens. Archiv f. Gyn., 1887, xxxi, 119-144. Saxtorph. Theoria de diverso partu, etc. Havnise et Lipsias, 1772. Scanzoni. Lelirbuch der Geburtshiilfe, II. Aufi., 1853, 838-840. Smellie. A Treatise on the Theory and Practice of Midwifery. London, 1752. Tarnier. Description de deux nouvcaux forceps. Paris, 1877. Williams. A Criticism of Certain Tendencies in American Obstetrics. New York State Jour, of Med., November, 1922. Witkowski. L’arsenal obstetrical. Paris, Steinheil. CHAPTER XXI EXTRACTION AND VERSION EXTRACTION Extraction in Breech Presentations.—The delivery of the child by traction when the feet protrude from the vulva in breech presentations was probably the earliest obstetrical operation. From the time of Hippocrates, up to the beginning of the sixteenth century, head presentations alone were considered normal, and hence all the authorities, with the exception of Celsus, advised the conversion of breech into vertex presentations at any cost, even though it rendered necessary amputation of the limbs. After the resuscitation of podalic version by Ambroise Pare and Jacques Guillemeau, more rational views prevailed, so that in the seventeenth century we find Mauriceau advising the method of extraction which is in general use at the present time. As the technic of the operation varies according as one has to deal with a complete breech or a foot, or with a frank breech presentation, it will be necessary to consider the two conditions separately. In both the essential prerequisite for the successful performance of extraction lies in the complete dilatation of the cervix and the absence of any serious mechanical obstacle. It is true that in a certain number of cases extraction through an imperfectly dilated cervix is possible, but this is usually effected only at the cost of deep cervical tears. Moreover, the additional resistance offered to the passage of the head will generally lead to its extension, the arms at the same time becoming elevated over it, thereby so complicating and delaying delivery that the child is almost invariably lost. For these reasons, when prompt extraction is indicated in the interests of the mother, it should always be preceded by complete manual dilatation of the cervix. Indications for Extraction.—It has already been pointed out that the foetal mortality is considerably greater in breech than in vertex pres- entations, since in the former death from asphyxiation is almost inevi- table if the mouth of the child be not brought to the vulva within eight minutes after the appearance of the umbilicus. Complete delivery of the head is not essential, as all that is necessary, in case of delay, is to have the mouth in such a position as to permit the access of air with- out danger of aspiration of the vaginal contents. The untoward result may be due to one of several causes. Thus, the cord may be subjected 471 472 EXTRACTION AND VERSION to such pressure between the pelvic brim and the head, as to check com- pletely the circulation. Less frequently the rapid decrease in the size of the uterus, following the extrusion of the body of the child, results in premature separation of the placenta before the head is born, so that death occurs unless extraction is promptly effected. Consequently, in all breech presentations, preparations should be made for extraction as soon as the feet or buttocks appear at the vulva, so that the operation can be promptly resorted to if, after the appear- ance of the umbilicus, the extrusion of the rest of the body does not rapidly follow. In a certain number of cases, no matter what the loca- tion of the breech, extraction may be called for by some condition which threatens the life of the mother or child, just as in vertex pres- entations. It should, however, be realized that the passage of meconium is without significance, as it is simply the result of the compression to which the abdomen of the child is being subjected. Moreover, it should be remembered that extraction by the feet constitutes the usual method of completing delivery following internal podalic version. Consequently, as that operation has a wide field of usefulness, extraction is employed in association with it more frequently than for primary breech pres- entations—in which event the joint procedure is designated as version and extraction. Extraction by the Feet.—Before beginning the operation, the patient should be placed upon a suitable operating table, but if one is not available she should be brought to the edge of the bed and subjected to the usual preliminary preparations. Complete anesthesia is desirable, even when the body of the child has already been born and only the head remains to be extracted. As a rule, extraction is a simple operation when the breech has been born spontaneously; whereas it is less so when the feet are still within the uterus. In the latter case, after “ironing out” the vaginal opening and pelvic floor, the entire hand should be introduced into the vagina and both feet seized, the ankles be- ing grasped in such a manner that the second finger lies between them. The feet are then brought down into the vagina, and traction is made until they appear at the vulva. If, however, difficulty is experienced in seizing both feet, one should be brought down, and the hand immediately reintroduced in order to grasp and extract the other. As soon as the feet have been drawn through the vulva, they should be wrapped in a sterile towel so that a firmer grasp may be obtained, Fig. 410. — Breech Extraction, Traction upon the Feet. EXTRACTION 473 since the vernix caseosa renders them so slippery that they are difficult to hold. Traction is then made in a downward direction (Fig. 410), and as the legs emerge they are grasped higher up, first by the calves and later by the thighs. When the breech appears at the vulva, traction is made in an upward direction until it is delivered. The thumbs are then applied over the sacrum and the fingers over the hips, and traction is continued in the same manner until the costal margins, and later the scapulae, become visible. Figs. 411, 412 and 413). As the buttocks emerge the back of the child looks more or less upwards, but as further traction is made it tends to turn spontaneously toward the side of the mother toward which it was originally directed. If, however, this does not occur, a slight rotary movement should be added to the traction with the object of bringing the bisacromial diameter of the child in approximation with the anteroposterior di- ameter of the outlet. As soon as the operator begins to pull upon the thighs, an assistant should exert pressure upon the uterus in the axis of the su- perior strait, with the object of preserving the flexed atti- tude of the head and prevent- ing the arms from becoming extended above it. If, how- ever, there is no disproportion and the cervix is fully dilated, this precaution is in great part unnecessary. Besides serving these purposes, it also aids directly in the expulsion of the child. In my experience, the cardinal point in successful extraction is to continue downward traction until at least the lower halves of the scapulae are outside of the vulva, and to give no thought to the birth of the shoulders and arms until one of the axillae becomes visible. Failure to observe this rule frequently renders difficult what would other- wise be a simple procedure. As soon as one axilla becomes visible, the time has arrived for the delivery of the shoulders, and, so long as the arms maintain their normal flexed attitude, it makes little difference which shoulder is delivered first; as it sometimes happens, when it is planned to deliver one that the other is born spontaneously. As the result of early training, I usually deliver the posterior shoulder first, while Potter prefers the anterior one. For this purpose, the feet Fig. 411.—Breech Extraction: Traction upon the Thighs. 474 EXTRACTION AND VERSION are grasped in one hand and drawn upward over the groin of the mother corresponding to the ventral surface of the child; in this way leverage is exerted upon the posterior shoulder., which slips out over the perineal margin and is usually followed by the arm and hand. (Fig. 414 A). Then by depressing the body of the child the anterior shoulder emerges beneath the pubic arch, the arm and hand usually following it spon- taneously. (Fig. 415). When this has occurred, the back tends to rotate spontaneously in such a way that it becomes directed more or less upward, or, in case it fails to do so, it is brought about by rotating the body manually, and then all is ready for the delivery of the head. Unfortunately, however, the process is not always so simple and it sometimes becomes necessary to free and deliver the arms. This is much less frequently called for than in the past, and I attribute the change to following the admonition to continue traction without thought of the shoulders until an axilla becomes visible, instead of pro- ceeding to free the arms shortly after the costal margins emerge. Since there is more available space in the posterior and lateral segments of the pelvis than else- where, the posterior arm should be freed first. As the correspond- ing axilla is already visible, up- ward traction upon the feet is continued and two fingers of the other hand are passed along the humerus until the elbow is reached (Fig. 414 B) The fingers are now applied in such a way as to serve as a splint to the arm, which is swept downward over the thorax and delivered from the vulva. To effect the de- livery of the anterior arm, it is sometimes only necessary to de- press the body of the child, when it slips out spontaneously; in other cases it can be wiped down over the thorax using two fingers as a splint, while occasionally the body must be seized with the thumbs over the scapulae and rotated so as to bring the undelivered shoulder into the neighborhood of the nearest sacrosciatic noth. The legs are then carried upward, so as to bring the body to the opposite groin of the mother, and if the arm be not born spontaneously it is delivered in the same manner as the other. If the arms have become extended over the head, their delivery, Fig. 412.—Breech Extraction; Extrac- tion of Body, Thumbs over Sacrum. EXTRACTION 475 although more difficult, can usually be accomplished by the maneuvers just described. In doing this, particular care must be taken to carry the fingers up to the elbow and to use them as a splint, for, if they are merely hooked over the arm, the humerus or clavicle is exposed to great danger of fracture. Very exceptionally the arm is found around the back of the neck, when its delivery becomes still more difficult. If it cannot be freed in the manner just described, its extraction may be facilitated by rotating the child through half a circle in such a direction that the friction exerted by the birth canal will serve to draw it toward the face; but if this fails, it must be forcibly extracted by hooking a finger over it. In this event, fracture of the humerus or clavicle is, unfortunately, very Fig. 413.—Breech Extraction; Scapulae Visible. common, and its probability should be pointed out to some responsible member of the family. Such an accident, however, is %not very serious, as good union can always be secured by appropriate treatment. After the shoulders have been born, the head usually occupies an oblique diameter of the pelvis with the chin directed posteriorly, when its extraction is best effected by Mauriceau’s maneuver (Figs. 416 and 417). For this purpose, the index finger of one hand is introduced into the mouth of the child and applied over the superior maxilla, while the body rests upon the palm of the hand and the forearm, with the legs straddling the latter. Two fingers of the other hand are then hooked over the neck, and, grasping the shoulders, make downward traction until the occiput appears under the symphysis. The body of the child is how raised up toward the mother’s abdomen, and the mouth- 476 EXTRACTION AND VERSION nose, brow, and eventually the occiput successively emerge over the perineum. Traction should be exerted only by the fingers over the shoulders, and not by the finger in the mouth; since the latter may slip from the superior maxilla and come to rest upon the inferior maxilla and base of the tongue, as a consequence of which serious injury may be done to the child if energetic traction be employed. This maneuver was first practiced by Mauriceau in the seventeenth Fig. 414.—Breech Extraction; (A) Upward traction to Effect Delivery of Posterior Shoulders. (B) Freeing Posterior Arm. century, but for some reason fell into disfavor. Nearly a hundred years later Smellie described a similar procedure, but rarely made use of it, as he preferred the employment of forceps. In the meantime other devices came into use, until G. Veit, in 1863, directed attention to the inestimable advantages which Maurieeau’s method of extraction pos- sessed over all others. For this reason in Germany the procedure is fre- quently called after Veit, or, when greater accuracy is desired, is desig- EXTRACTION 477 nated as the Mauriceau-Smellie-Veit maneuver. Litzmann, however, correctly pointed out the impropriety of such a nomenclature, and insisted that only the name of the original inventor—Mauriceau—should be used in describing it. Numerous other methods of extraction have been devised, Winckel being able in 1888 to collect 21 different procedures from the literature, although none has proved as serviceable as that of Mauriceau. In the vast majority of cases the back of the child eventually rotates toward the front, no mat- ter what its original position; but when it does not take place spon- taneously the movement may be inaugurated by making stronger traction upon the leg, which would naturally rotate anteriorly. If this does not bring about the desired result, and the back re- mains posterior after the birth of the shoulders, extraction must be begun with the occiput posterior. As a rule, rotation can still be effected by means of the finger in the mouth, after which the head can be extracted by Mauriceau’s maneuver. When, however, this is not possible, de- livery must be attempted, with the head in its abnormal position, by the employment of a modified Prague maneuver, which is so called for the reason that its ad- vantages were strongly urged and practiced more particularly by Kiwisch of that city, although it had been described by Pugh a cen- tury earlier. The procedure is somewhat as follows: Two fingers of one hand grasp the shoulders from below, while the other hand draws the feet up over the abdomen of the mother. As a result the occiput is born first and the perineum is necessarily subjected to greater liability of rupture. Extraction of Frank Breech Presentations.—When indications for de- livery arise after the frank breech has descended deeply into the birth canal its extraction can usually be effected without difficulty by hooking the index finger of one hand into the anterior groin and making traction until the buttocks appear at the vulva, the index finger of the other Fig. 415.—Breech Extraction; Delivery of Anterior Shoulder by Downward Traction. Fig. 416.—Breech Extraction; Mauriceau’s Maneuver, Downward Traction. Fig. 417.—Breech Extraction; Mauriceau’s Maneuver, Upward Traction. Fig. 418.—Delivery of After-Coming Head, Reversed Prague Maneuver. Fig. 419.—Extraction of Frank Breech; Finger in Anterior Groin. 480 EXTRACTION AND VERSION hand being then inserted into the posterior groin in order to furnish additional aid. On the other hand, when the breech is high up, delivery is much more difficult. In such cases it is advisable to try to decompose the wedge and to bring down one or both feet, which can be readily accom- plished if the membranes have only recently ruptured, but becomes extremely difficult if a considerable time has elapsed after the escape of the liquor amnii, more particularly if the uterus has become tightly contracted over the child. In many cases the employment of the following maneuver suggested Fig. 420.—Extraction of Frank Breech; Fingers in Groins. by Pinard will aid materially in bringing down the foot: Two fingers are carried up along one leg to the knee and push it away from the middle line. This is usually followed by spontaneous flexion, and the foot of the child will be felt to impinge upon the back of the hand, when it can be readily seized and brought down (Fig. 421). In view of the fact that it is often very difficult to seize and bring down a foot late in the second stage of labor, Ahlfeld and others have suggested the propriety of rupturing the membranes as soon as the cervix is fully dilated, and bringing down a foot prophylactically, so that a convenient tractor may be available in case extraction becomes necessary. This can be readily accomplished, but is not advisable as a EXTRACTION 481 routine practice, since the frank breech forms a much better dilating wedge than the incomplete breech presentation. The procedure is jus- tifiable, however, when it appears probable that extraction may eventually be required, as in elderly primiparae, or in patients suffering from heart lesions. If the indication for delivery is urgent, and it is impossible to bring down a foot, the child must be extracted as it lies. For this purpose the index finger of one hand is hooked into the anterior groin, and strong downward trac- tion made, supple- mented, if necessary, by the use of the other hand, which grasps the wrist. This procedure is continued until the posterior buttock has reached the pelvic floor, when the index finger of the other hand is hooked into the posterior groin and traction then made with both hands. As soon as this becomes possible, delivery can usually be readily effected, but, unfor- tunately, in a consid- erable number of cases, it is extremely difficult to bring the breech low enough to secure this advantage. For this reason, when the frank breech is high up, its ex- traction should not be attempted unless imperatively demanded by the condition of the mother or child. As soon as the buttocks are born, first one leg and then the other is drawn out and extraction is accomplished as described above. As was said before, traction should be supplemented by pressure, upon the abdo- men from above. This precautionary measure should never be neglected, as delivery can frequently be accomplished by its aid when it would be impossible if traction by the fingers were alone relied upon. Indeed, it is not until one has attempted a difficult frank breech extraction that one learns how little force can be exerted by the fingers. Use of Forceps.—In view of the difficulty which sometimes attends the extraction of the frank breech when high up, Lusk, Budin, Reynolds, and other authorities have recommended the employment of forceps, the blades being applied obliquely, one over the sacrum and the other Fig. 421.—Pinakd’s Makuevee for Bringing Down a Foot in Frank Breech Presentation. 482 EXTRACTION AND VERSION over the thighs. Up to the present time I have had no experience with this procedure, having been able to effect delivery in all my cases by traction exerted with a finger in the groin. When this fails, the appli- cation of forceps is justifiable, although when the breech is high up it should not be attempted except under pressing indications. In all forms of breech presentation, the application of forceps to the after-coming head has been advocated. It was first practiced by Smellie, but is rarely utilized by obstetricians who have made themselves familiar with Mauriceau’s maneuver. When forceps are used, the body of the child is efevated toward the abdomen of the mother and the blades applied under it to the sides of the head. The Fillet.—In frank breech extractions, it is sometimes convenient to make use of the fillet. This may consist of several thicknesses of sterile gauze bandage which are passed over the anterior groin. The fillet is a very efficient tractor, but its application offers considerable difficulty. Unless the operator has at his disposal a specially constructed instrument, a fairly satisfactory carrier may be improvised from a rubber catheter, through which a piece of stout thread is passed, a loop being allowed to protrude from the eye. A stylet is then introduced and, an appropriate curve having been given to the catheter, the bent extremity is passed around the anterior groin until the fingers in the vagina can seize the loop, to which one end of the fillet is attached and then cautiously drawn up into place. Aside from the difficulty encountered in applying it, the disadvantage of the fillet is its liability to cut through the skin of the groin; but this can be avoided by employing several thicknesses of gauze and taking care that they do not become twisted into a cord. The older authors advocated making traction upon the groin by means of a metallic hook. This instrument should never be employed upon living children on account of its liability to cause fracture of the femur. On the other hand, when the child is dead, and such an accident is a matter of indifference, the hook affords a convenient means of making traction. In all forms of breech extraction the prognosis for the mother is good, although it is more serious in frank breech than in the other varieties. In the former the increased manipulation affords greater opportunity for infection; while the attempt to reach the posterior groin often gives rise to deep, and sometimes to complete, tears before the buttocks have reached the perineum. In extraction by the feet, on the other hand, provided the outlet has been “ironed out” as a, preliminary procedure, the liability to perineal tears is no greater, and is possibly less, than in head presentations. Moderate degrees of disproportion be- tween the size of the head and the pelvis scarcely influence the maternal prognosis, since the pressure of the head upon the soft parts lasts but a few seconds, instead of being prolonged for hours as in head presenta- tions. For the child, however, the outlook is not so favorable, and becomes more serious the higher the presenting part is situated at the beginning of the operation. In addition to the increased liability to tentorial tears CEPHALIC VERSION 483 and intracerebral hemorrhage, which Eardley Holland, Capon, and Crothers have shown are inherent to breech presentations, the foetal mortality is augmented by the greater probability of the occurrence of traumatism during extraction. As has already been said, fractures of the humerus and clavicle cannot always be avoided when freeing the arms, while fracture of the femur may occur in difficult frank breech extractions. Occasionally, hematomata of the sternocleidomastoid muscles develop after the operation, though they usually disappear spontaneously. More serious results, however, may follow separation of the epiphyses of the scapula, humerus or femur. Exceptionally, paralysis of the arm follows pressure upon the brachial plexus by the fingers in making traction, but more frequently it is due to over-stretching the neck while freeing the arms. When the child is forcibly extracted through a contracted pelvis, spoon-shaped depressions or actual fractures of the skull may result, which generally prove fatal, while occasionally even the neck may be broken when great force is employed. In general it may be said that in simple extractions the prognosis for the child is excellent, while in complicated ones it is dubious. VERSION Version, or turning, is an operation through which the presentation of the fcetus is artificially altered, one pole being substituted for the other, or an oblique or transverse being converted into a longitudinal presentation. According as the head or breech is made the presenting part, the operation is spoken of as cephalic or podalic version, respectively. It is also designated according to the method by which it is accomplished. Thus we speak of external version when the manipulations are made exclusively through the external abdominal wall; of internal version when the entire hand is introduced into the uterine cavity; and of combined version when one hand manipulates through the abdominal wall, while two or more fingers of the other are introduced through the cervix. Cephalic Version.—This operation was practiced from the most re- mote antiquity, and only gradually fell into disfavor after the introduc- tion of podalic version by Pare and his followers. After the discovery of Wigand (1807) that the position of the child could easily be altered by manipulations through the abdominal walls, external cephalic version came into more general use, and since the publications of Hubert and Pinard has become a well-recognized procedure in certain conditions. The object of the operation is to substitute a vertex for a less favor- able presentation. As it does not, however, afford a means for imme- diate delivery, its field of usefulness is comparatively limited, and its employment is still further restricted by various contra-indications. Indications.—If a breech or transverse presentation is diagnosed in the last weeks of pregnancy, its conversion into a vertex should be attempted by external maneuvers, provided there be no marked dispro- 484 EXTRACTION AND VERSION portion between the size of the child and the pelvis. Cephalic version is indicated by reason of the increased foetal mortality attending spon- taneous delivery in breech presentations; while if the child lies trans- versely a change of presentation is imperatively demanded, inasmuch as a natural labor is out of the question, and if appropriate measures are not adopted the lives of both mother and child will be lost. Unfortunately, after the accomplishment of external cephalic version, the child tends to return to its original position, unless the head at once becomes engaged. Consequently many authorities recommend that the child be held in place by a suitable abdominal bandage in the hope that it will favor engagement, but in my experience such attempts are useless. Moreover, the operation can be accomplished only under the following conditions: (1) The presenting part must not be deeply engaged; (2) the abdominal wall must be sufficiently thin to admit of accurate palpation; (3) the abdominal and uterine walls must not be too irritable; (4) the uterus must contain a sufficient quantity of liquor amnii to permit the easy movement of the child. Given these essentials, external cephalic version should always be attempted, since it is absolutely harm- less, and, if the new position is maintained, may do away with the necessity for serious operative procedures at the time of labor. In the early stages of labor, before the membranes have ruptured, the same indications hold good, and at this time may be extended to oblique presentations as well, though these usually right them- selves spontaneously as labor progresses. On the other hand, external cephalic ver- sion can be effected but rarely after the cervix has become fully dilated and the membranes have rup- tured. Serious pelvic contraction is a de- cided contra - indica- tion, since, although external version may be readily accom- plished, the procedure is useless, as more radical operative measures will be necessary before delivery can be effected. Methods.—Cephalic version may be brought about either by external manipulations alone, or by the combined method—with one hand on the abdomen and two or more fingers, or even the whole hand, in the uterus. During pregnancy the former is the only method applicable, and at the Fig. 422.—External Cephalic Version (Pinard). PODALIC VERSION 485 time of labor it should be employed whenever feasible. The technic has been carefully described by Pinard, and is somewhat as follows: The patient’s abdomen having been bared, the presentation and position of the child are carefully mapped out. The foetal poles are then seized with either hand, and the one which we wish to present is gently stroked toward the superior strait, while the other is moved in the opposite direction. After version has been completed, the child will tend to return to its original position unless engagement occurs; but at the time of labor the head may be pressed down into the superior strait and held firmly in position until it becomes fixed under the influence of the uterine contractions. At the time of labor, if external manipulations prove futile, cephalic version may be accomplished by the combined or bipolar method of Braxton Hicks as soon as the cervix is sufficiently dilated to admit of two fingers. It, however, is rarely employed, as in such circumstances, it is usually advisable to wait until the cervix is fully dilated, and then to rupture the membranes and do a podalic version followed by ex- traction. For carrying out the former procedure Hicks gave the follow- ing directions: “Introduce the left hand into the vagina as in podalic version. Place the right hand on the outside of the abdomen in order to make out the position of the foetus and the direction of the head and feet. Should the shoulder, for instance, present, then push it with one or two fingers on the top in the direction of the feet. At the same time pressure by the other hand should be exerted upon the cephalic end of the child This will bring the child close to the os. Then let the head be received upon the tips of the inside fingers. The head will then play like a ball between the hands, and can be placed at almost any part at will. . . . It is well, if the breech will not rise to the fundus readily and the head is fairly in the os, to withdraw the hand from the vagina and with it press up the breech from the exterior” (Fig. 426). While the credit for popularizing this procedure undoubtedly belongs to Hicks, it is in- teresting to note that it had been described by Marmaduke Wright, of Cincinnati, in 1854; ten years before the appearance of Hicks’s first publication, but had remained buried in an obscure publication. Busch, D’Outrepont, and others advocated attempting cephalic ver- sion after complete dilatation of the cervix, by introducing one hand into the uterus and seizing the head, while the other is employed for external manipulations. This, however, is no longer done, as in such circumstances it is preferable to perform internal version, which is no more dangerous, and at same time permits immediate delivery if necessary. Podalic Version.—By this is understood the turning of the child by seizing one or both feet, and drawing them through the cervix, the operation being usually followed by extraction. Podalic version was introduced and warmly advocated by Pare, and, until the invention of the forceps, afforded the only means of artificially delivering unmuti- lated children. It is interesting to note that Guillemeau, one of Pare’s students, was enabled b.v this means to save his master’s daughter from 486 EXTRACTION AND VERSION dying of hemorrhage due to placenta previa. The value of the operation was recognized and insisted upon by Louise Bourgeois, Mauriceau, and among many others by De la Motte, who employed it very frequently with most excellent results. Indications.—Podalic version is indicated in two great groups of cases —namely, in transverse or oblique presentations, and in head presenta- tions in which it is believed that delivery can be more safely and more rapidly accomplished after version. The necessity for version in transverse and oblique presentations is obvious. In abnormal head presentations, when the face, brow, or occiput Fig. 423.—Patient in Position for Internal Podalic Version. Inset Shows Hand in Uterus Grasping the Feet. is posterior and movable above the superior strait, delivery can frequently be more readily accomplished after version than by any other means. Podalic version is usually the operation of choice in prolapse of the ex- tremities or umbilical cord, and in many cases of placenta previa. More- over, when the child presents some deformity, delivery is sometimes very much facilitated after version. Generally speaking, the operation is indicated in all cases requiring prompt delivery when the head is floating at the superior strait or is but slightly engaged, provided there is no great disproportion between its size and that of the pelvis. In such circumstances it is usually a safer and more satisfactory procedure than the application of high forceps. PODALIC VERSION 487 One of its widest fields of usefulness is in accouchement force, after the cervix has been completely dilated by means of the hand or of the balloon, especially in preeclamptic toxemia and antepartum hemorrhage. In such circumstances, the presenting part having been displaced dur- ing the manipulations employed for dilating the cervix, version and extraction constitute the readiest and most conservative method of de- livery. The most favorable time for performing the operation is just after the cervix has become fully dilated, but before the membranes have ruptured. In this event, the amniotic fluid will be still in utero and the child readily movable in any direction. On the other hand, podalic version should never be attempted when the child is suffering from hydrocephalus, nor when the cervix is imperfectly dilated, except in certain cases of placenta previa, when the bipolar method of Braxton Hicks is employed. It sometimes happens that the patient is not seen until long after rupture of the membranes, and conditions may then be present which render the operation extremely difficult or even impossible. For example, the uterus may be tetanically contracted and so tightly applied to the body of the child as to render even the introduction of the hand extremely difficult. In other cases, the contraction ring may have risen to such an extent and the lower uterine segment be so stretched as to render the operation dangerous in the highest degree, as the attempt at version will probably lead to rupture of the uterus. Before Cesarean section had become a reasonably safe procedure, many authorities practiced so-called “prophylactic version” in the treat- ment of moderate degrees of pelvic dystocia. In this the membranes were ruptured as soon as the cervix was fully dilated and the child turned and extracted, with the idea that the head would withstand momentary compression better than continued pressure against the pelvic brim in a long second stage. The operation is no longer employed for two reasons: first, on account of its relatively poor results, and second, because it converted all cases into operative labors, and deprived nature of the chance of demonstrating what she could accomplish. Within recent years Potter of Buffalo has advanced the revolutionary doctrine that all labors not complicated by serious disproportion, should be ended by version and extraction, in the belief that by so doing the duration of labor is shortened, the patient is spared unnecessary suffer- ing, and the danger to the child is not increased. In his monograph which appeared in 1922, he stated that he had performed over four thousand versions, and during the two years ending August 31st, 1921, had delivered 2,253 patients in private practice, as follows: 1,858 by version, 180 by cesarean section, 64 by forceps, 31 spontaneously and 130 various. In other words, all but 31 patients were delivered by operative means, and these escaped only because their labors had ended spon- taneously before his arrival. As far as can be gathered from his writings, as soon as the cervix is partially dilated and offers but little resistance, Potter completes its dilatation manually, and without removing the hand from the uterus, ruptures the membranes and turns and extracts the child. 488 EXTRACTION AND VERSION If his claims are substantiated, he will have effectively revo- lutionized obstetrics and will have converted child-birth from a physiological and in great part spontaneous process into a routinely operative one. Furthermore, he will have done away with the necessity for any knowledge of the mechanism of labor and in great part with everything formerly taught concerning the practice of obstetrics. He may be right, but I doubt it. Of two things, however, I am sure: first, that he is an extraordinarily accomplished operator, and second that should his practice become generally adopted the mortality from child- birth will increase, and many more children will perish than at present. Unfortunately, in his monograph, he is more concerned with the technic of the operative procedure than with the ultimate results to his patients. He does, however, state that during the year 1920, 41 chil- dren were stillborn and 34 others died during the two weeks following delivery; a mortality of 6.13 per cent., which does not commend his practice, as in the first ten thousand deliveries in our service the foetal mortality was practically the same—namely 7 per cent. When, however, it is remembered that Potter’s clientele is composed of private patients, in whom syphilis and contracted pelvis occur comparatively rarely, while ours consists of public ward patients, more than one-half of whom are black and many of whom are admitted after hours or days of neglect and sometimes in a moribund condition, the contrast is not flattering. Furthermore, when it is recalled that the majority of our patients were delivered by a succession of young men learning the rudiments of their art, while Potter’s patients were delivered by probably the most dexterous obstetrical operator in the world, only one of two conclusions can be drawn: either that dexterity and training count for nothing, which is contrary to all experience, or that some inherent defect in Potter’s practice counterbalances such advantages. I am convinced that the latter is the case, as I know from my own experience that in routine version and extraction technical difficulties will occasionally be encountered, which will inevitably increase the foetal mortality. For these reasons I advise against any wide acceptance of Potter’s teaching; but at the same time, it must be admitted that it has rendered an important service by forcibly bringing to the attention of the American profession the merits of a valuable procedure, which was in a fair way of being forgotten; as well as to make several impor- tant contributions to its technic. Technic.—For the performance of internal podalic version the patient should be placed upon a suitable table and the usual preoperative prepara- tions made. She should not be placed in the usual obstetrical posture, but instead the legs should be spread widely apart and held by assistants at about the same level as the body (Fig. 423). Version should never be attempted without an accurate diagnosis as to the presentation and position of the child, nor as to the existence of disproportion between its size and that of the pelvis. Its performance will be greatly facilitated by the use of long rubber gloves reaching to the elbow, as recommended by Potter, and by an extensive preliminary “ironing out” of the vaginal outlet and pelvic floor. Version is easiest effected while the membranes PODALIC VERSION 489 are intact, and becomes increasingly difficult with every half-horn after their rupture. The operative technic varies somewhat, according as one has to do with a head or a transverse position. In the first instance the hand and arm must be introduced considerably further into the birth canal than in the latter, which is facilitated by free lubrication of the operat- ing hand and arm by albolene or green soap. It is usually taught that the choice of the hand to be employed depends upon the location of the small parts, and that if the back be directed to the left, the feet can be most conveniently seized with the left hand, and vice versa. Potter, however, has taught us, and I agree with him, that the left hand can be used equally satisfactorily no matter what the position of the feet may be. Accordingly, if the membranes are still intact, the left hand is passed through the cervix and carried up into the uterine cavity until it reaches the neighborhood of the feet. The membranes are then ruptured, and if possible both feet are seized as shown in the inset to Fig. 423, and downward traction is made. Ordinarily the child turns without diffi- culty, so that the feet are readily brought down into the vagina, and thence through the out- Fig. 424, a.—Version; Transverse Pres- entation, Back Anterior, Seizure of Lower Foot. Fig. 424, b.—Version; Transverse Pres- entation, Back Anterior, Seizure of Upper Foot. let. When the knees emerge, one knows that version has been effected, after which delivery is completed by extraction as already described. The seizure of both feet materially facilitates the operation, so that 490 EXTRACTION AND VERSION if at first only one can be seized it should be brought through the cervix, and the hand immediately reintroduced into the uterus in order to grasp and bring down the other. Indeed, it should be the rule not to attempt to complete the version until both feet are available. If the membranes have already ruptured and the head is engaged, version is always more difficult. In this case, after pushing the head out of the pelvic brim, the hand should be introduced past it, when the feet are seized and brought down as before. Of course, if the amniotic fluid has long since drained off, and the uterus is tightly applied over Fig. 425, a.—Version; Transverse Pres- entation, Back Posterior, Seizure of Upper Foot. Fig. 425, b.—Version; Transverse Pres- entation, Back Posterior, Seizure of Lower Foot, showing Arrest of Buttocks at the Pelvic Brim. the child, this may be difficult or impossible, and if persisted in after the lower uterine segment has become markedly stretched may result in rupture of the uterus. In transverse presentations, it is likewise desirable to bring down both feet, but, in case this cannot readily be accomplished, one foot will suffice. In this event, however, the choice of the foot is a matter of very considerable importance. When the back is directed anteriorly, the lower one should be seized, as by so doing the back of the child is kept directed toward the symphysis; whereas, if the upper foot be seized, the back may turn in the opposite direction. On the other hand, when the back looks posteriorly, the upper is the foot of choice, since traction upon it will cause the back to rotate to the front; while, if PODALIC VERSION 491 the lower foot be seized, although anterior rotation will usually occur, the upper buttock is liable to impinge upon the anterior portion of the pelvic brim, and great force may become necessary to effect its dislodgment (Figs. 424 and 425). Not a few cases of transverse presentation are complicated by the prolapse of an arm into the vagina. In such circumstances, a fillet should be applied around the wrist and held loosely by an assistant, while version is performed in the usual manner. In this way the arm is prevented from becoming extended over the head, and the necessity of freeing it during extraction is obviated. • Whatever may have been the original position of the child, firm pres- sure should be exerted upon the fundus of the uterus as soon as extraction is begun, in order to prevent extension of the head or arms, and at the same time to facilitate delivery. Combined Podalic Version. —In other instances, particu- larly in placenta previa, version may be attempted by the com- bined or bipolar method of Hicks, as soon as the cervix is sufficiently dilated to admit two fingers. With these the present- ing part is dislodged and pushed upward, while the external hand gradually brings the breech downward toward the external os. As soon as a foot can be felt it is seized by the two fingers and drawn through the cervix. For the time being this finishes the operation, as extrac- tion should not be thought of until the cervix is fully dilated, for it can be effected only at the cost of deep cervical tears (Fig. 426). Prognosis.—For the mother the prognosis following podalic version is excellent in properly selected cases, provided the patient be in good condition at the commencement of the operation. On the other hand, when attempted in the case of a tetanically contracted uterus, or when the lower uterine segment is overstretched, forcible attempts at version may lead to the rupture of the organ and death. The prognosis for the child is fairly good, and depends upon the nature of the indication and the difficulty experienced in extraction. On the other end, if the operation be undertaken through an imperfectly Fig. 426.—Bipolar Podalic Version (Bumm). 492 EXTRACTION AND VERSION dilated cervix, and the child’s head be arrested by the external os, the time required for its extraction is usually so great that death from asphyxiation is inevitable. Moreover, in cases of marked pelvic contrac- tion, the foetal mortality is very high. In many such cases forcible traction may enable one to deliver the child, but usually not until after the cord has been so long compressed as to have caused pronounced asphyxia and death, not to mention injuries to the head resulting from pressure. LITERATURE Ahleeld. Ueber Behandlung gedoppelten Steisslagen, etc. Archiv f. Gyn., 1873, v, 174-176. Bourgeois, Louise. Observations diverses, etc. Paris, 1609. Budin. Tarnier et Budin, Traite de Part des accouchements. 1901, t. iv, 296. Capon. Intracranial traumata in the New-born. Jour. Obst. and Gyn. Br. Emp., 1922, xxix, 572-590. Crothers. Injury to the Spinal Cord in Breech Extraction as an Important Case of Foetal Deaths, etc. Am. Jour. Med. Sci., 1923, clxv, 94. De la Motte. Traite complet des accouchements. Nouv. ed., Leiden, 1729. D’Outrepont. Abh. und Beitrage, Wurzburg, 1817, Theil I, 69. Guillemeau. De 1 ’hcureux accouchement des femmes. Paris, 1609. Hicks. On Combined External and Internal Version. London, 1864. Holland. Cranial Stress in the Foetus During Labor. Jour. Obst. and Gyn. Br. Emp., 1922, xxix, 551-571. Hubert. Quelques faits sur les presentations vicieuses du foetus et sur la possi- bility de les corriger par les manipulations exterieures. Annales de gyn. et de pad., 1843, aout. Kiwisch. Beitrage zur Geburtskunde. Wiirzburg, 1846, I. Abth., 69. Litzmann. Der Mauriceau-Levret’sche Handgriff. Archiv f. Gyn., 1887, xxxi, 102-118. Lusk. The Science and Art of Midwifery. New York, 1895, 338-391. Mauriceau. Le moyen d’aecoucher la femme, quand 1’enfant presente un ou deux pieds les premiers. Traite des maladies des femmes grosses, 6me ed., 1721, 280-285. Pare. Edition Malgaigne, 1840, t. ii, 623. Pinard. De la version par les manoeuvres externes. Traite du palper abdominal, Paris, 1889. Quoted by Farabeuf and Varnier, Introduction a 1’etude clinique des accouche- ments. Paris, 1891, 185-187. Potter. The Place of Version in Obstetrics. St. Louis, 1922. Pugh. A Treatise on Midwifery chiefly with Regard to Operation. London, 1754. Reynolds. The Value of Forceps in Complicated High Arrest of the Breech. Amer. Jour. Obst., 1892, xxvi, 586. Smellie. The First Class of Preternatural Labors, when the Feet, Breech, or Lower Parts of the Foetus Present. A Treatise on the Theory and Practice of Midwifery, eighth edition, 1774, 195-206. Veit, G. Ueber die beste Methode zur Extraction des nachfolgenden Kindes- kopfes. Greifswalder med. Beitrage, 1863, ii, Heft I. Wigand. Ueber Wendung durch aussere Handgriffe. Hamburger mod. Mag., 1807, i, 52. Winckel. Zur Beforderung der Geburt des nachfolgenden Kopfes. Verh. d. deutschen Gesellsch. f. Gyn., 1888, ii, 19-32. Wright. Difficult Labors and Their Treatment. Trans. Ohio State Med. Soc., 1854, 59-88. 102-118. CHAPTER XXII CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY CESAREAN SECTION In this operation the child is removed from the uterus through an incision in the abdominal and uterine walls. The origin of the term has given rise to a great deal of discussion. It has been generally asserted that Julius Caesar was brought into the world by this means and obtained his name from the manner in which he was delivered (a caeso matris utero). This explanation, however, can hardly be cor- rect, as his mother, Julia, lived many years after her son’s birth; and, besides, Julius was not the first of his name, since there is mention of a priest named Caesar who lived several generations before. The fol- lowing view, however, would appear to be more plausible. In the Roman law, as codified by Numa Pompilius, it was ordered that the operation should be performed upon women dying in the last few weeks of preg- nancy. This lex regia,, as it was called at first, under the emperors became converted into the lex caesarea, and the procedure itself became known as the cesarean operation. History.—The history of cesarean section may be said to extend over four periods, the first lasting from the earliest times to the beginning of the sixteenth century. During this period the operation was occa- sionally resorted to after the death of the mother, in the hope of saving the child, but it is improbable that it was practiced upon the living woman, although several authorities are inclined to believe that certain passages in the Talmud may be so interpreted. The fact that Dr. Felkin saw a cesarean section performed by the natives in Uganda renders it possible that it may have been employed upon the living woman at an early period by certain of the uncivilized races. The second period extends from the year 1500 to 1876, when Porro described his method of amputating the pregnant uterus. According to Casper Bauhin, the first cesarean section upon a living woman was performed in 1500, when Jacob Nufer, a castrator of pigs at Sigerhausen, Switzerland, operated successfully upon his own wife after she had been given up by the midwives and barbers in attendance. The fact, however, that the woman had five spontaneous labors later would go to show that this was not a true cesarean section, but probably the removal of an extra-uterine child from the abdominal cavity. Frangois Rousset, a contemporary of Pare, wrote a treatise upon the subject in 1581, in which he gave the histories of a number of cesarean sections collected from various sources. Several of them were apocryphal, 493 494 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY while others, in all probability, were operations for advanced extra- uterine pregnancy. His article, however, had the merit of directing attention to the operation and to the possibility of performing it upon the living woman. The first authentic cesarean section was probably done in 1610 by Trautmann, of Wittenberg. Following this, it was occasionally performed until it became temporarily eclipsed by sym- physeotomy in 1777, to be taken up again after the latter operation had fallen into disrepute. During this period, the uterus was simply incised and the child ex- tracted. The uterine walls were not sutured, the contraction and re- traction of the organ being relied upon to check hemorrhage. Most of the women perished from hemorrhage or infection. Sutures were first employed by Lebas (17-69), but did not come into general use until after the appearance of Sanger’s epoch-making article in 1882. Before the work of Porro and Sanger, the mortality following the operation was appalling. Meyer (1867) collected 1,605 cases from the literature with a mortality of 54 per cent.; while in 80 cases per- formed in the United States up to 1878, collected by Harris, 52.5 per cent, of the women died. According to Budin, not a single successful cesarean section was performed in Paris between the years 1787 and 1876. Such poor results were obtained by physicians that Harris in 1887 pointed out that the operation was more successful when performed by the patient herself, or when the abdomen wras ripped open by the horn of an infuriated bull. He collected 9 such cases from the literature with 5 recoveries, and stated, that out of 11 cesarean sections performed in the city of New York during the same period, only one patient re- covered. The third period began with the year 1876, when Porro advised amputating the body of the uterus and stitching the cervical stump into the lower angle of the abdominal wound in order to lessen the danger from hemorrhage and infection. This procedure, being followed by very satisfactory results, soon became quite popular, so that in 1890 Harris was able to collect 264 operations from the literature. Storer, of Boston, in 1868, amputated a pregnant myomatous uterus, with a fatal result, hut, inasmuch as he did not appear to recognize the im- portance of the innovation, the credit for proposing it undoubtedly be- longs to Porro. Sanger, in 1882, revolutionized the cesarean section by directing attention to the necessity for the employment of uterine sutures. As the uterus was not sacrificed in this operation, it was designated as the conservative, in contra-distinction to the Porro cesarean section. With the increasing perfection of surgical technic, more and more satisfactory results were obtained from the former operation, while the latter became less popular. After the technic for supravaginal amputation of the myomatous uterus had become perfected, similar methods were applied to the Porro operation, the cervical stump being covered by a flap of peritoneum and dropped into the abdominal cavity; while in a small number of cases,, particularly when the cervix was carcinomatous, the entire organ CESAREAN SECTION 495 was removed. The latter procedure, which was first attempted by Bischoff, has but a limited field of application. The fourth period began in 1907 when Frank of Cologne, who had become dissatisfied with the results following the classical conservative section, particularly in women who had been exposed to the possibility of infection prior to the operation, reported 13 cases upon which he had operated by a new method. In this procedure a transverse incision is made through the anterior abdominal wall several centimeters above the symphysis, and the peritoneum separated from the posterior surface of the bladder and the anterior surface of the lower uterine segment. After proper exposure, the latter is then incised transversely, the child is extracted by forceps, the placenta removed manually, and the wound closed. By this method the entire operation is done extraperitoneallv, and, according to its inventor, may be safely employed when conservative section would be contra-indicated. The procedure was enthusiastically taken up in Germany, where it was soon found that in many instances the separation of the peritoneum could not be readily effected, or that in so doing it was torn through, thereby depriving the operation of its chief supposed advantage. Con- sequently, Latzo, Sellheim and others proceeded to modify the operation, and to convert it into a suprasymphyseal transperitoneal cesarean sec- tion. For this purpose, after exposing the uterus by a transverse abdomi- nal incision, its peritoneal covering is incised from one round ligament to the other just above its reflexion over the bladder. The peritoneal flap is dissected up for a short distance, and is then tightly sutured to the margins of the parietal peritoneum. In this way the lower uterine segment is isolated from the general peritoneal cavity and the possibility of infection limited. After separating the bladder from the lower uterine segment, the latter is incised transversely, and after the child is ex- tracted, the wounds are closed. As more extended experience with each of these modifications was not altogether satisfactory, Doederlein resuscitated the operation of laparo-elytrotomy, which had been suggested by Philip Syng Physick and by Baudelocque in 1823, and rehabilitated by Gaillard Thomas in 1871, to be afterward abandoned in favor of the classical cesarean sec- tion. After reporting 32 such operations, he in turn abandoned the procedure, as he found that the wound healing was complicated, that drainage was always required and that the operation was not available for use in infected patients. Kronig was not satisfied with any of these modifications, and con- tended that their main advantage consisted not so much in avoiding the peritoneal cavity, as in opening the uterus through its thin lower seg- ment. To accomplish this, he cut through the vesical reflexion of the peritoneum, and separated it and the bladder from the lower uterine segment. The latter is then opened by a vertical median incision and the child extracted by forceps. After closing the uterine incision, it is then buried under the vesical peritoneum. A somewhat similar technic has been employed by Beck and DeLee with satisfactory results. Finally, the historical aspects of the question were carefully con- 496 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY sidered by Kiistner, in bis monograph which appeared in 1915. In it he also described his own modification of extraperitoneal section, based upon a personal experience of 112 operations. This modification will be considered in detail in the section upon operative technic, when its advantages and contra-indications will be discussed. Indications.—With the increasing perfection of surgical technic, and an erroneous idea of the safety of the operation, there seems to be a growing tendency to regard cesarean section as the simplest means of coping with most obstetrical difficulties. At the present time I consider that the operation is being abused, and that not a few patients are sacrificed to the furor operativus of obstetricians and general surgeons who are ignorant of the fundamental principles of the obstetric art. This being the case, the conscientious obstetrician should be particularly careful in the recognition of indications for cesarean section. The most frequent and important indication is afforded by pelves which are so contracted as to offer serious mechanical obstacle to labor. The pelvic indication may be either absolute or relative, the upper limits being a conjugata vera of 5 and 7.5 centimeters respectively. In the former, the contraction is so pronounced that the birth of a child of normal size cannot be effected by any other means; while in the latter, it is sufficiently marked to render spontaneous labor impossible, but per- mits delivery after craniotomy. In view of the excellent results which now follow cesarean section, and the fact that the spontaneous delivery of an ordinary full-term child is out of the question when the conjugata vera is less than 7.5 centi- meters, the upper limit for the absolute indication has been extended to that point, provided the child is alive, the patient is in ideal condi- tion and amid suitable surroundings for a major operation. Even when the pelvis falls within the so-called “border line” category —with an upper limit of 8.5 centimeters in flat and 9 centimeters in generally contracted pelves—the operation may likewise be indicated. In pelves of this character, however, the course of labor depends not merely upon the degree of pelvic contraction, but more particularly upon the size and consistency of the head and the character of the uterine contractions. Given two women with pelves and children of the same size, one may have a spontaneous and easy labor, while the other may require radical operative interference. In the latter event, the operation is undertaken primarily in the interests of the child, instead of resorting to high forceps, version, and craniotomy. Accordingly, in this class of cases, when examination at the end of pregnancy reveals the existence of serious disproportion between the size of the head and the pelvis, and particularly when the patient pre- sents a history of previous operative labors with dead children, classical conservative cesarean section should be performed at an appointed time before the onset of labor, or within a few hours thereafter, since the prognosis for the mother becomes more serious with every hour inter- ference is deferred. On the other hand, if not seen until late in labor, I believe that better results for the mother, and nearly as good results for the child, will be obtained by allowing the patient to go into the second CESAREAN SECTION 497 stage, and then resorting to pubiotomy or extraperitoneal cesarean sec- tion if engagement does not occur after several hours of strong pains, provided, of course, the patient is in good condition, and in the hands of a competent operator. By so doing nearly all the children and many more mothers will be saved than after a late conservative cesarean sec- tion. If, however, these conditions cannot be fulfilled, the patient should be allowed to continue in labor until a definite indication for its termi- nation arises, when craniotomy should be performed. Pelvic contraction involving the superior strait is not the only indi- cation for cesarean section, as in not a few cases abnormalities of the pelvic outlet likewise call for its performance. It is usually stated that a Msischial diameter of 7 centimeters or less affords a positive indica- tion, but it will be pointed out in the section upon funnel pelvis that this does not necessarily hold good. Such a measurement should, how- ever, be regarded as a danger signal, as it indicates so great a narrowing of the pubic arch that spontaneous labor cannot occur unless there be sufficient space between the bisischial diameter and the tip of the sacrum to permit the passage of the head. Accordingly, in such cases, the abso- lute necessity for interference will depend entirely upon the length of Klien’s posterior sagittal diameter of the inferior strait. Other pelvic deformities which occasionally necessitate the operation will be consid- ered in the chapters upon Contracted Pelves. Obstruction to labor, not due to pelvic contraction, occasionally affords an indication for the operation. Thus, myomata in the lower segment of the uterus, as well as ovarian and other tumors, may so block the pelvic canal as to render cesarean section imperative. The same may be said of certain cases of atresia following cicatricial contractions of the cervix or vagina. Carcinoma of the cervix occasionally results in the formation of such dense and rigid tissue that dilatation becomes impossible. In such cases cesarean section is demanded in the interests of both the child and mother, and should be supplemented by total hysterectomy, if the disease be not too far advanced. In rare instances malignant tumors of the rectum may so obstruct the pelvic canal as to render cesarean section imperative, and Xijhoff collected the literature upon the subject up to 1905. As a curiosity, it may be mentioned that Jaschke has reported a case in which the pelvic cavity was so obstructed by a megacolon that cesarean section was necessary. Halbertsma, in 1899, suggested cesarean section as the best method of delivery in certain cases of eclampsia complicated by an undilated and rigid cervix, and since then it has been extensively employed in all parts of the world. In the future, however, I imagine that it will be used much less frequently for two reasons. In the first place, consid- erable skepticism has developed concerning the curative effect of rapid delivery in eclampsia; while in the second place the symposium upon the treatment of eclampsia before the British Congress of Obstetrics and Gynecology held in 1922, and which was based upon the consideration of 2,005 cases, showed that only accouchement force gave worse results than cesarean section. 498 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY Dudley, in 1900, suggested the advisability of cesarean section in certain cases of placenta previa, and Kronig and others have adopted his views. While admitting that such a procedure may be justifiable in very rare instances, I agree with Holmes that it is usually unnecessary, and, if adopted in a large series of cases, would probably increase the mortality of the complication. Following the discovery that in premature separation of the normally implanted placenta the uterine musculature may be markedly disasso- ciated by hemorrhage, cesarean section appears to be the operation of choice in that condition whenever the cervix is not dilated. Further- more, as the organ sometimes fails to contract after it has been emptied, the operation in such circumstances should be completed by supravaginal hysterectomy. In certain cases of pregnancy complicated by uncompensated heart lesions, cesarean section often affords the most conservative method of effecting rapid delivery, and the uterus should be amputated upon its conclusion as the most satisfactory method for preventing the occur- rence of pregnancy in the future. Reynolds has advocated cesarean section in the absence of pelvic contraction, or of any other mechanical indication, in women who appear to be mentally or physically ill-equipped to bear the strain of childbear- ing. Other writers have recommended its performance as a means of overcoming dystocia due to face, brow or transverse presentations; while still others have taken the extreme ground that it may even be justifiable in breech or obliquely posterior occipital presentations. While it may be admitted that in peculiar circumstances such indications may occa- sionally hold good, I cannot but feel that their advocacy has done great harm, and has afforded poorly trained physicians justification for reck- less and unnecessary operating. As it is generally believed that the cicatrix following a cesarean sec- tion represents a locus minoris resistentiae and may rupture during a subsequent pregnancy, many writers have laid down the dictum—“once a cesarean, always a cesarean.” As will be pointed out in the appropriate place, I do not entirely agree with such teaching. Naturally such a uterus is less efficient than one which has never been incised, and to my mind that fact should be regarded as a potent argument against the use of cesarean section for non-pelvic indications, except in the most pressing conditions. Contra-indications.—Except in the presence of an absolute indication, cesarean section should never be performed when the child is dead or in serious danger. It is likewise contra-indicated when the mother is in- fected, in poor condition, or among surroundings which render an aseptic operation impracticable. In such circumstances, craniotomy is the operation of choice, and cesarean section should not be undertaken unless a living child is earnestly desired; and then only after the risks incident to it have been clearly explained to a responsible member of the family. Again, the classical operation is contra-indicated when the patient has been long in labor or subjected to repeated vaginal examina- tions by those whose technic is questionable, even though no signs of CESAREAN SECTION 499 infection are apparent at the time. If, however, the operation should be decided upon in the presence of such risks, the body of the uterus should be removed after delivery of the child. Operative Technic.— (a) Conservative Cesarean Section.—The opera- tion will give almost ideal results if performed at an appointed time, a day or so prior to the end of pregnancy, or within a few hours after the onset of labor; whereas the prognosis becomes progressively w'orse for every hour it is deferred. When the operation can be performed at a fixed time, the patient should be prepared exactly as for an ordinary abdominal operation. On the night before she should receive a full bath and the abdomen and pubic hairs should be shaved. The bowels should be evacuated by an appropriate cathartic, and an enema given a few hours before she is put upon the table. If the patient is not seen until labor has set in, similar preparations should be made, except that the bath and the admin- istration of a cathartic must, of course, be dispensed with. Just before the beginning of the operation, the bladder is catheterized and the abdomen disinfected by means of tincture of iodin and alcohol. The woman being in the dorsal position, the entire body, except the field of operation, is covered with sterile towels. In order to insure satisfactory contraction and retraction of the uterus, one c.c. of pituitrin should be administered hypodermically just after the abdominal incision is made. In addition to the operator, four assistants are needed, one to give the anesthetic, one to assist directly at the wound, and two to handle the instruments. With the exception of the anesthetist, all should wear rubber gloves, and suitable sterile gowns and masks. A competent person should be charged with the reception and care of the child and receive careful instructions as to the best method of resuscitating it if necessary. The following instruments are required: 1 scalpel, 1 long blunt-pointed scissors, 2 dissecting forceps, 12 short and 6 long artery clamps, abdominal retractors, a needle-holder and appropriate needles, as well as the usual sterile dressings, suture materials, and gauze sponges. An incision 15 centimeters long should be made in the linea alba, beginning just below the umbilicus. The abdominal walls are usually very thin and bleed little, rarely more than two or three clamps being required to check hemorrhage. The uterus is found directly beneath the incision. If deflected to one side, its long axis should be brought into correspondence with the abdominal incision, and gauze packs, moistened with sterile salt solution, inserted between it and the margins of the abdominal incision, so that the possibility of contaminating the peri- toneal cavity may be reduced to a minimum. If there is no likelihood of infection, the uterus should be opened in situ; otherwise the incision should be sufficiently enlarged upwards to permit delivery of the organ from the abdominal cavity, and in this contingency it should not be cut into until the edges of the wound have been clamped together above the cervix and covered with sterile towels. In either event the anterior surface of the uterus is opened longi- tudinally along its middle line. This is best accomplished by making 500 cesarean section, Symphyseotomy, and pubiotomy Fig. 427.—Conservative Cesarean Section. Diagram showing location and extent of the abdominal and uterine incision. Distended fsetal membranes visible through uterine incision. an incision a few centimeters long with a scalpel, and then rapidly enlarging it with the scissors to 15 centimeters. The membranes are then ruptured, the child is seized by one foot and extracted. Two clamps are applied to the cord, which is cut between them, and the child handed to an assistant. This takes but a short time, and it is rare for more than ninety seconds to elapse between the beginning of the operation CESAREAN SECTION 501 and the birth of the child. Many authorities recommend that an at- tempt be made to locate the position of the placenta beforehand, so that the incision may be made in such away as to avoid it. This, however, is not necessary. If the placenta lies under the incision, it should be rapidly cut through or pushed to one side and the child extracted. This is accompanied by a slight increase of hemorrhage, but as the bleeding is only momentary, it is without significance. Immediately after the delivery of the child, the uterus contracts down and hemorrhage practically ceases. The uterus should then be delivered through the Fig. 428.—Conservative Cesarean Section. Contracted Uterus Delivered through the Abdominal Wound and Packed off with Gauze Compresses. Placenta still in situ. X %• abdominal incision, and the peritoneal cavity posterior to it protected by gauze napkins. If the placenta and membranes have not become sepa- rated spontaneously,, they should be peeled off and removed with the hand, care being taken that no shreds of membranes are left behind. Disinfection of the uterine cavity is not necessary. Even when the opera- tion is undertaken before the onset of labor, it is not necessary to dilate the cervix artificially, as the canal is always sufficiently patulous to permit free drainage. To prevent hemorrhage, Litzmann recommended that an elastic ligature be applied about the cervix before opening the uterus. This is, however, an unnecessary precaution; nor is it devoid of danger, as the 502 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY prolonged compression predisposes to uterine atony and hemorrhage afterward. If, however, there is considerable loss of blood after the delivery of the child, the assistant should grasp the cervix firmly between his fingers and thus compress the uterine arteries. This effectually controls hemorrhage and is preferable to the employment of a rubber ligature. Fritsch, in 1897, proposed opening into the uterus through a trans- verse incision over the fundus, instead of by the usual method, holding Fig. 429.—Conservative Cesarean Section. Placenta has been delivered and deep sutures laid. The upper sketch shows the bite oi • the suture which avoids the decidua and the external layer of muscles. X %■ that, the course of blood vessels in that location being parallel to the incision, the hemorrhage would therefore be less. His proposal was at once tested by many operators. The results were excellent, but not better than those following the more usual incision. There would appear to be no advantage in adopting Fritsch’s sug- gestion, except perhaps in the small number of cases in which it is desired to sterilize the patient by excising the tubes. It is urged that the fundal wound is less likely to be followed by adhesions between the uterus and the anterior abdominal wall. This is no doubt correct, but at the same 503 CESAREAN SECTION time, should infection occur with the transverse incision, virulent mate- rial is more liable to gain access to the general peritoneal cavity; while, if it occurs with the longitudinal incision, the abscess has more chance of opening through the abdominal wound. Asa B. Davis has recommended that the abdominal incision be made entirely above the umbilicus, and that the uterus be incised high up corresponding to it. Notwithstanding his advocacy of the high incision, Fig. 430.—Conseevative Cesarean Section. The deep sutures have been tied and cut, and the superficial layer of muscle and periton- eum are being brought together by a continuous suture. The upper sketch gives further details. my results have been so satisfactory with the method just outlined that I see no reason for changing it. After any of these methods of incision the uterine wound is closed by deep and superficial formol or chromicized catgut sutures. The former are placed at intervals of about 1 centimeter. They are introduced by means of a large curved needle just beneath the thin superficial muscular layer, and extend through the entire thickness of the muscu- laris, avoiding the decidua. They are then tied and cut short, after which the superficial muscular layer and peritoneum are brought together 504 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY over them by a continuous suture. This is readily accomplished, and is preferable to the original procedure of Sanger, in which small flaps of peritoneum were formed by excising a thin layer of muscle from either side of the wound. Any blood which may have escaped into the pelvic cavity is then carefully sponged out, and the abdominal wound closed. This is best accomplished by suturing the peritoneum, muscles, fascia, and skin in separate layers. (b) Porro Cesarean Section.—Until after the delivery of the child, the operative steps are identical whether the uterus is to be retained or its body is to be amputated. If, however, the latter is to be done, it is unnecessary to remove the placenta. In the typical Porro operation, the technic is as follows: As soon as the child is delivered an elastic ligature is tightly tied around the upper portion of the cervix. The infundibulopelvic ligaments are then ligated and cut through, after which the uterus is amputated a short distance above the rubber ligature. To prevent the stump from slipping backward, a long knitting needle is passed through it and allowed to rest upon the abdominal walls. The stump is then sewed into the lower angle of the abdominal wound, the remainder being closed in the usual manner. Within a short time the stump and elastic ligature slough off, leaving a depressed wound which heals by granulation. This operation is readily performed, but is rarely employed at present, because of the complicated healing, and the in- drawn scar which results. At present, when it is desirable to remove the body of the uterus, practically the same technic is employed as in an ordinary supravaginal hysterectomy with retention of the ovaries, and is greatly facilitated by placing the patient in the Trendelenburg posture. After the uterus has been delivered from the abdominal cavity, the tubes, ovarian and round ligaments on either side are ligated a short distance from the uterus, clamped still nearer to it, and severed. With a single stroke of the scissors the broad ligament on either side is cut through down to its base. An elliptical incision is then made through the peritoneum on the anterior surface of the uterus, just above the bladder, and a peri- toneal flap rapidly peeled off by means of a piece of gauze applied around the end of the finger or the handle of a scalpel. The uterine arteries are then isolated, ligated, and severed, after which the body of the uterus is amputated. The cervical stump is brought together by the necessary number of catgut sutures, covered by the peritoneal flap, and is then dropped into the pelvic cavity. The openings in the broad ligaments are closed by continuous catgut sutures, the pelvic cavity is sponged out, and the abdominal wound closed (Figs. 431 and 432). The operation is readily performed, and can be completed in as short a time as a conservative cesarean section; for, owing to the laxness of the pelvic floor and the abdominal wTalls, the upper portion of the cervix can be brought through the incision and the entire operation completed upon the surface of the abdomen. (c) Total Hysterectomy.—Bischoff was the first to remove the entire uterus after cesarean section, and, \mder thoroughly aseptic conditions, the operation gives satisfactory results. The technic is identical with CESAREAN SECTION 505 that employed in supravaginal amputation of the uterus, except that after the ligation of the uterine arteries the vaginal vault is cut through and the entire uterus removed, after which the opening in the vagina is closed with catgut and the broad ligament wounds are sutured. Total Fig. 431.—Cesarean Section Followed by Supravaginal Hysterectomy, with Retention of Tubes and Ovaries. Placenta Still in Utero. 11 Clamp applied to round ligament; 2, clamp applied to proximal end of tube and broad ligament; 8, anterior peritoneal flap; 4. clamp applied to proximal end of uterine artery; 5, transverse incision through cervix. X 1. hysterectomy is rarely indicated except in cancer of the uterus, or in occasional cases of infection. In all forms of cesarean section, as well as in all other laparotomies, loose sponges should not be used after the peritoneal incision is made. From then on, only sponge holders should be employed, and care should be taken to see that they hold the sponges firmly. Furthermore, com- 506 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY presses or pads should be used only when they are sewed to a piece of tape to whose free end an artery clamp is attached. They should be counted at the beginning of the operation and before closing the peri- toneal wound. Failure to observe these precautions will sooner or later result in a sponge or pad being left within the abdominal cavity, which is not only an uncomfortable accident for the patient, but may lead to serious medicolegal complications for the operator, Fig. 432.—Cesabean Section Followed by Supravaginal Hysterectomy. Note the tubes and ovaries in situ; the method of suturing the cervical stump, and the broad ligament wound which will later be closed by a continuous suture. X 1. (d) Extraperito7ieal Cesarean Section.—In appropriate cases very satisfactory results may be obtained by Kiistner’s modification of this operation. Its technic is as follows: The patient, who should be well advanced in labor, is placed in the Trendelenburg posture and 150 c.cm. of salt solution are introduced into the bladder, if it is empty. A vertical incision is made through the abdominal wall at the outer margin of the CESAREAN SECTION 507 left rectus muscle, extending 12 centimeters upward from Poupart’s ligament. After cutting through the lower layer of fascia, and being careful to avoid opening the peritoneal cavity, the reflexion of the visceral Fig. 433.—Extraperitoneal Cesarean Section. Diagram Showing Direction of Skin Incision. The dotted line to its right indicates the outer margin of rectus muscle. peritoneum and the lateral aspect of the bladder become visible. By means of scissors and gauze sponges the left side of the bladder is dissected off from the anterior surface of the lower uterine segment, and drawn beyond the midline by a suitable retractor. The peritoneal reflexion is 508 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY then pushed upward as far as possible and the anterior surface of the lower uterine segment exposed by means of retractors. This is then incised in the midline, and the child extracted by forceps. As the lower uterine segment is never more than a few millimeters thick, care must be exercised in incising it in order not to injure the foetus. After the placenta has been removed, the uterine incision is closed in two layers by continuous catgut sutures, and the various structures of the abdominal wall are united in appropriate layers, after a small gauze Fig. 434.—Extraperitoneal Cesarean Section. Abdominal Muscles Separated by Blunt Dissection, and Underlying Structures Exposed. a, lower uterine segment; b, peritoneal reflexion; c, bladder partly freed and drawn toward midline of body. X %• drain has been inserted into the deepest part of the wound and brought out through the lower end of the incision (Figs. 433 to 436) . There is usually comparatively slight hemorrhage, and, if the dis- section is carefully done, the danger of wounding the bladder or of opening the peritoneal cavity is not great. During the separation of the bladder, the left ureter and uterine artery are frequently visible, and consequently are but little exposd to injury. I he employment of the Trendelenburg posture is almost imperative, as without it the difficulty of the operation is greatly increased. CESAREAN SECTION 509 Choice of Operation.—When the operation is to be performed at an appointed time, or upon patients who have not been exposed to the pos- sibility of infection, the classical cesarean section is the operation of choice; whereas, when the operation is undertaken later in labor, or upon women who have been examined by those whose technic is open to suspicion, better results will probably be obtained by the extraperitoneal method. I am not convinced of the advantages of the various modifica- Fig. 435.—Extraperitoneal Cesarean Section. Final Exposure and Incision of Lower Uterine Segment. Note thinness of uterine wall, with the foetal membranes protruding through the incision. X %. tions of the low cervical operation; and, as my experience with the classical operation has been so satisfactory, I have left to others the development of its technic. On the other hand, if the patient is already frankly infected, supravaginal hysterectomy should be done, as it alone offers a prospect of satisfactory results. When the uterus is the seat of tumor formation, as well as in those cases in which osteomalacia is the cause of the pel\ic deformity, or in which persistent hemorrhage result- ing fi om uterine atony complicates the conservative operation, supra- vaginal hysterectomy is also the operation of choice. 510 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY While I am not able to share the enthusiasm of Kiistner concerning extraperitoneal cesarean section, who in 1920 reported 183 operations with four deaths, I admit that it constitutes an important addition to our resources, in that it makes possible the performance of cesarean sec- tion in a certain number of cases in which pubiotomy was formerly the operation of choice. On the other hand, I do not believe that it should be regarded as a competitor with the classical conservative operation under appropriate conditions for the following reasons: First, that its technic is so difficult that it can be performed only by practiced operators; Fig. 436.—Extraperitoneal Cesarean Section. Suture of Uterine Incision After Delivery of Child and Placenta. X %. second, that it is associated with considerable risk of injury to the bladder; third, that it always requires drainage of the prevesical space, and is sometimes complicated by extensive suppuration of the pelvic connective tissue; and lastly, that the adhesions following it render a repetition of the operation impossible in subsequent labors. In doing a cesarean section, the question often arises as to the advisability of sterilizing the patient so as to avoid the possibility of future conception. This can be effected by supravaginal amputation of the uterus, by excising the tubes, or removing the ovaries, I consider that it is best effected by supravaginal amputation of the uterus, but with preservation of the tubes and ovaries, in order that CESAREAN SECTION 511 the inconveniences attending a premature menopause may be avoided. This belief is based upon the fact that the uterus is useless if further pregnancies are out of the question, but more particularly because supra- vaginal amputation is safer and can be done more rapidly than the conservative operation followed by excision of the tubes. Furthermore, the convalescence following the former operation is more satisfactory, the difference being quite as marked as that observed in the treatment of uterine myomata by supravaginal amputation or by myomectomy, respectively. It was formerly believed that sterilization could be effected by ligating the proximal end of either tube; but experience has shown that the ligatures eventually cut through or become absorbed, and that the lumen of the tube may subsequently become restored, and with it the possibility of future pregnancy. It was next suggested that the object might be accomplished by applying a double ligature to each tube and excising the portion between them; but the experiments of Fraenkel upon animals, and the experience of Zweifel, and Cripps and Williamson upon the living woman, have shown that even these measures do not insure against conception, since the ligatures may be absorbed and the cut ends of the tube become united. In order, therefore, to effect per- manent sterilization by an operation upon the tubes, their proximal ends must be buried between folds of the broad ligaments, or they must be excised from the uterine cornua by wedge-shaped incisions and the wounds closed by sutures. The former procedure is preferable, is readily effected, and I now employ it as the operation of choice, unless amputa- tion of the uterus is indicated for some other reason. Sterilization should not be attempted by the removal of the ovaries, for the reason that the retracting uterus may exert such tension upon the pedicles that the sutures may slip and fatal hemorrhage result, but more particularly because their internal secretion is necessary to the future well-being of the patient. The opinion of those authorities who consider that sterilization should form an integral part of every cesarean section is certainly open to ques- tion. If the patient is intelligent, the decision should be left to her and her family, but at the same time the undesirability of a one child mar- riage should be strongly urged; whereas with the ignorant it is incum- bent upon the physician to do what he thinks is best under the circum- stances. Personally, I am unwilling to sterilize any patient at the first operation, unless operative complications necessitate the removal of the uterus, or unless the patient comes from a district where proper operative help might not be available in a future pregnancy. On the other hand, if she is weak-minded or diseased and is liable to become a public charge, the operation is justifiable. In general, with pauper patients, it is my practice to effect sterilization at the third cesarean section. Prognosis.—When considering the history of cesarean section, refer- ence was made to the mortality attending it in former times. Since the rehabilitation of the conservative operation by Sanger in 1882, and the constant advance in aseptic technic, there has been a corresponding steady improvement in the results: Caruso collected from the literature 512 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY 135 operations performed between the years 1882 and 1888, with a mor- tality of 25.56 per cent. Since then the death rate has gradually fallen and many writers would have us believe that it is as low as one or two per cent. While this is correct for selected cases in the hands of experts, I imagine that it would be found to be in the neighborhood of ten per cent, if the actual results for the entire country could be ascertained. That the mortality is generally underestimated is shown by the report of the committee on material and infant welfare of the Massachusetts Medical Society. This committee, in an attempt to ascertain why the mortality from childbirth was greater in 1920 than ten years previously, analyzed the deaths occurring in Massachusetts during the year 1921. After making certain justifiable deductions, it found that 525 deaths had occurred—a ratio of 1 to every 182 labors—and that one-sixth of the entire number had followed cesarean section, one-half of these being due to infection. In other words, after frank puerperal septicemia, cesarean section constituted the second most common cause for death in childbirth in Massachusetts. One of the members of the Committee informed me that he was convinced that this excessive mortality was in great part due to the performance of the operation by surgeons who did not appreciate its dangers, and who operated upon patients at other than the optilnum time. Routh in 1911 reported a mortality of 9.7 per cent, in 1,058 classical sections performed by 100 British operators; while Eardley Holland reported one of 4 per cent, in a collective investigation based upon 4,197 operations performed in 37 British hospitals during the following ten years. On the other hand, individual operators may report large series of cases with little or no mortality. Thus, Zweifel recorded 76 cesarean sections with 1, and Leopold 70 operations, with no deaths. No matter how good the operator, or how perfect his technic, it would appear that the mortality, even in apparently uninfected women, will be low only when the operation is done at an appointed time before the onset of labor or within a few hours after the first pains, and that it will increase progressively with every additional hour of delay. Reynolds first appre- ciated this fact in 1907, and upon analyzing 289 cases, according as the operations were done before labor, or early or late in labor, found a mor- tality of 1.2, 3.8 and 12 per cent, respectively. Routh arrived at almost identical conclusions, and noted a death rate of 2.9 per cent, when the operation was performed before rupture of the membranes, 10.8 per cent, after their rupture, and 34.3 per cent, following repeated examination or previous attempts at delivery. The following table from Holland’s article based upon 1953 sections for contracted pelvis, shows that the results have scarcely changed during the succeeding ten years. Time of operation No. cases Mortality Before labor 1202 1.6 per cent. Earlv in labor 389 1.8 Late in labor 220 10.0 After induction of labor 35 14.0 After attempts at delivery by forceps, etc. 107 27.0 Total 1953 4.3 per cent. CESAREAN SECTION 513 My own experience, which is based upon 253 operations performed by myself or my assistants at the Johns Hopkins Hospital up to April 15, 1923, has been similar. Our material may be divided into two groups: the first 50, and the succeeding 203 operations, with a gross mortality of 12 and 2.45 per cent, respectively. In the first period the operation was performed at any time, and frequently after a prolonged test of the second stage; while in the second period it was done preferably at an appointed time before, or within a few hours after, the onset of labor, and the body of the uterus was amputated if the patient presented signs of infection or if attempts at delivery had been made. Of the 5 deaths occurring in the latter period, only two were due to infection, so that in the last 203 cases the mortality from that cause has been 1 per cent. The radical change in my point of view is well exemplified by articles which I wrote in 1901 and 1921 respectively. As the operative technic was the same, the element of time must be regarded as the essential factor of difference in the two series. That this is correct, was shown by the histological study of uteri, which were amputated at the conclusion of the section. Naturally, if the patient presented signs of intrapartum infection, bacteria were found in the lining of the uterus, but we were at first surprised at finding them as well in patients who had been operated upon late in labor without such signs. As our experience became greater, and as we found that the bacteria were limited to the cervical mucosa, to the decidua lining the lower part of the uterus, or had extended throughout the entire mem- brane, according to the length of time which had elapsed after rupture of the membranes, the idea of ascending infection developed. In such circumstances, the infection has every chance to extend in the incised and involuting organ; whereas, if the body of the uterus is amputated, the focus of infection is removed, and the convalescence is usually ideal. Accordingly, one can reckon upon a mortality of 1 or 2 per cent, when the operation is done early and one of 10 or more per cent, when it has been preceded by a long second stage. For these reasons, the classical operation is justifiable solely in the interests of the child in the one case, but not in the other. If, however, the patient is not seen until late in labor, and interference is demanded, the extraperitoneal operation or pubiotomy becomes the procedure of choice, unless one is willing to sacrifice the uterus. Finally, it should be remembered that when any type of cesarean section is performed by inexperienced operators upon patients in poor conditions and among unhygienic conditions the results will be disastrous. The mortality following the typical Porro operation likewise shows a corresponding improvement. Thus, the tabulation by Harris of 441 such operations performed between the years 1876 and 1891 showed a decrease from 60 per cent, at the beginning of the period to 22.8 per cent, at, its end. During the same period the mortality following supravaginal hyster- ectomy with retroperitoneal treatment of the stump was reduced from S5.7 per cent, to a few per cent. In 177 operations more recently reported 514 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY by Chrobak, Schauta, Leopold, and Braun the gross mortality was 10.3 per cent., which became reduced to 2.5 per cent, on deducting the cases which were infected prior to operation. In our service the results were still better, as only three deaths occurred in 70 operations, and none of them were due to infection, notwithstanding the fact that in many instances intrapartum infection afforded the indication for operating, and the presence of streptococci could be demonstrated in the amputated uterus. Our results were critically analyzed by Harris in 1922. This marvelous diminution in mortality is due to several factors. Primarily, of course, it must be attributed to the ever-increasing per- fection of aseptic technic. At the same time, careful examination of the patient and the evaluation of the degree of disproportion in contracted pelvis during the last weeks of pregnancy have contributed markedly to the improvement, as they make it possible to do the operation at an appointed time before the onset of labor, instead of only after the failure of other methods of delivery. It is too early to express a definite verdict concerning the mortality of the various recent modifications of cesarean section, but the fact that so many have been proposed makes it evident that the results are not universally satisfactory. Kiitner reports 4 deaths in 183 operations per- formed by his extraperitoneal operation, and states that one-half of the patients were in such condition that he would have hesitated to employ the classical operation. My own experience and the reports of other operators lead me to conclude that such results are exceptional, and cannot be expected in frankly infected patients, for whose benefit such operations were first proposed. Repeated Cesarean Section.—The performance of conservative ce- sarean section does not interfere with future conception, as is shown by the fact that even in pre-antiseptic times not a few instances were reported in which the same woman had repeatedly been subjected to the operation. Nor does it necessarily affect recovery at a subsequent opera- tion. I have done four successful cesarean sections upon the same patient, and Ahlfeld, Birnbaum and others have reported cases of women who underwent five sections. With the increased employment of the operation, repeated cesarean sections are frequently necessary, Gamble, in 1922, having reported 51 such cases from our service; while as early as 1906 Friihinsholz was able to collect 52 instances in which the opera- tion had been performed for a third time upon the same patient. The occurrence of pregnancy after a cesarean section is not devoid of danger, as the recent literature indicates that rupture occurs through site of the previous incision in from 1 to 4 per cent, of the sub- sequent gestations, and certain authors consider it so real a danger that they have laid down the dictum, “Once a cesarean, always a cesarean.” This is an exaggeration, and is in part based upon the belief that the uterine incision heals by the formation of scar-tissue—whence the term cicatrix—and that the newly found connective-tissue stretches and some times yields when the uterus becomes distended. That such a belief is erroneous is shown in three ways. First, inspection of the unopened uterus at the time of repeated sections usually shows no trace of the CESAREAN SECTION 515 former incision, or, if present, it appears as an almost invisible linear scar. Second, when the body of the uterus has been amputated, no scar Fig. 437.—Section through Site of Previous Cesarean Section, Showing Interlac- ing Muscle, and Absence of Scar Tissue. is visible after hardening, or at most a shallow vertical furrow is present upon the external and internal surfaces of the anterior uterine wall, 516 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY while between them no trace of scar tissue is apparent. Third, and most important, histological examination of the site of the incision, shows that the uterus, just as all other organs made up of non-striated muscle, heals by regeneration of the muscle fibers and not by scar tissue. Fig. 437, which represents a microscopic section through the site of the previous incision in a uterus removed at a second cesarean section, shows the furrows above referred to and demonstrates that the tissue between them is made up of muscle fibers which interlace in such a way as to give no evidence of ever having been injured. Even when the healing has been so imperfect that marked thinning has resulted, the tissue which remains is almost entirely muscular in character. Consequently, I believe when the incision has been properly sutured that the risk of subsequent rupture is minimal, provided infec- tion has not occurred. That rupture, nevertheless, sometimes occurs is shown by the fact that Brodhead was able to collect 20 such accidents in 1906, which were increased to 97 by Holland in 1920. I have per- sonally seen two cases, one of which occurred in a patient whose original section had been done in the service. The possible occurrence of rupture should always be considered in connection with the employment of cesarean section for other than pelvic indications, as thereafter the uterus must be considered as a “locus minoris resistentiae.” In such cases a normal spontaneous termination should be anticipated in subsequent labors, unless the puerperium had been febrile, but it is nevertheless advisable for the patient to be under observation in a hospital so that immediate laparotomy can be undertaken should rupture occur. It is also stated that the adhesions which frequently form between the uterus and the anterior uterine Avail, as Avell as Avith the omentum and occasionally with the intestines, sometimes exert a deleterious in- fluence in subsequent pregnancies. Aside, however,, from the discomfort incident to their stretching, no serious consequences follow; although at subsequent operations they may seriously complicate the operative tech- nic. In earlier days, the formation of dense adhesions Avas considered advantageous, as they were sometimes so extensive that subsequent sec- tions could be done without opening into the general peritoneal cavity. At present, hoAvever, they are no longer so considered, as it is necessary to get rid of them in order to secure ideal closure of the new incision. Vaginal cesarean section has already been considered in the chapter upon accouchement force. Postmortem Cesarean Section.—From the earliest times, AAdien a pa- tient died undelivered in the neighborhood of full term, cesarean section was sometimes performed immediately after the death, in the hope of saving the life of the child. The number of children rescued by the procedure, hoAvever, has always been very small. In view of this fact, and the abhorrence in which it is more or less justly held by the laity, I do not consider that it should be recommended, more satisfactory results being obtainable from accouchement force, especially as the cerAux just before or immediately after death is more readily dilatable than at other times. SYMPHYSEOTOMY 517 SYMPHYSEOTOMY By symphyseotomy is meant the division of the pubic joint in order to bring about an increase in the capacity of a contracted pelvis suffi- cient to permit the passage of a living child. J. R. Sigault first performed the operation in 1777, and thereby successfully delivered a certain Madame Suchot, of Paris, who had a rhachitic pelvis with a conjugata vera of 6.5 centimeters and had previously given birth to four dead children. The procedure created a great sensation, though when the patient was exhibited before the Faculty of Medicine two months later she walked with considerable difficulty, and had a urinary fistula from which she never recovered. The operation was taken up with great enthusiasm, and was per- formed upon 11 patients within the first year after Sigault’s report. Opposition to it, however, soon developed, Baudelocque denouncing it as a “murderous and unphilosophical procedure”; and the discussion as to its merits waxed so bitter that the Parisian physicians became divided into two groups, cesareans and symphyseans. As a result of poor technic and its employment in unsuitable cases, symphyseotomy soon fell into disrepute and was forgotten except in Italy, where it was performed sporadically until the year 1858. The operation was rehabilitated in 1866 by Morisani, of Naples, who obtained fairly satisfactory results by its means, being able to report 50 operations with 40 recoveries to the International Medical Congress in 1881. It was reintroduced into France by Spinelli in 1891, who im- pressed its merits so strongly upon Pinard that he took it up and has since been its most enthusiastic advocate, being able to report in 1900 that 100 symphyseotomies had been performed in his clinic. The ana- tomical aspects of symphyseotomy were carefully studied by Farabeuf, who accurately demonstrated its theoretical possibilities. Dr. Robert P. Harris played a prominent part in directing attention to the operation in this country by a paper entitled The Remarkable Results of Antiseptic Symphyseotomy, read at the 1892 meeting of the American Gynecolog- ical Society. Stimulated by this report, Jewett, a few months later, performed the first operation in America, and was soon followed by many others. Symphyseotomy was the main theme of discussion at the German Gynecological Congress in 1893, the International Medical Congress in 1897, and the Obstetrical Society of France in 1899, but in recent years it has practically been abandoned in favor of pubiotomy. As soon as the symphysis is cut through, the ends of the pubic bones gape from 3 to 6 centimeters. Owing to the structure of the sacro-iliac joints, the ossa innominata flare outward, while the tips of the pubic bones become depressed downward. As a result of these changes the capacity of the pelvic canal becomes considerably increased, particularly in its transverse and oblique, and less so in its anteroposterior, diameters. It is usually stated that the conjugata vera becomes 2 millimeters longer for each centimeter of separation at the symphysis. As the latter may amount to 6 or 6.5 centimeters without imperiling the integrity of the sacro-iliac joints, the increase would aggregate 12 or 13 millimeters. 518 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY According to Farabeuf this estimate is not strictly correct, as the increase varies with the size of the pelvis, being 13 millimeters when the true conjugate measures 6 centimeters, and 10 millimeters when it measures 9 centimeters. This, however, does not represent the actual enlargement of the superior strait from an obstetrical point of view; for, as Farabeuf has pointed out, one of the parietal bosses fits into the opening between the gaping pubic bones, thereby considerably increasing the space available for the passage of the head. Doderlein has calculated that when the pubic bones gape 6 to 7 centimeters the area of the superior strait is increased by one half. As the results following symphyseotomy by the open method event- ually proved disappointing, and as those following cesarean section were constantly improving, the operation again fell into desuetude and is Fig. 438.—Diagram Showing Effect of Symphyseotomy (Farabeuf). now rarely resorted to, except by a few operators who employ a sub- cutaneous technic, such as Zweifel, Frank, and Schwartz, the latter having reported 113 cases with only three maternal deaths. For these reasons the indications and technic of the operation will not be considered, more particularly as what will be said in the following section concerning pubiotomy will apply to subcutaneous symphyseotomy as well. PUBIOTOMY This operation, which is more properly designated as hebotomy or hebosteotomy (from to wcroOi/), consists in obtaining a tem- porary enlargement of the pelvis by severing the pubic bone to one side of the symphysis by means of a Gigli saw. History.—In 1893 Gigli stated that from a surgical point of view there were two serious fallacies in the operation of symphyseotomy. In the first place, the wound through the cartilage was very prone to in- fection, and healed but slowly, and, secondly, the incision in the mid- line deprived the urethra and bladder of their natural support, and thus exposed them to serious injury during the delivery of the child. To overcome these difficulties, he proposed that the incision be made through the pubic bone itself, as he held that the bone wound would heal more rapidly and be less liable to infection, while its lateral position would avoid interference with the attachments of the urethra and bladder, and thus reduce to a minimum the possibility of their injury. In order to sever the bone he invented the flexible wire saw, which is known by his name. Gigli did not perform the operation until April, 1902, but his sugges- tion was put into practice by Bonard, of Lugano, in 1897, who was followed by Calderini and Van der Velde in 1899 and 1901, respectively. Following the report of the latter, the operation was rapidly taken up and modified, so that three methods are now available. Technic.—Originally, the anterior surface of the bone was exposed by an oblique incision, beginning slightly above the inner margin of the pubic spine and extending to the middle of the outer part of the labium majus. Then by means of a pair of artery forceps the saAv was adjusted to the posterior surface of the bone, which was then severed. In 1904 Doderlein modified the operation and, and instead of a large open wound, made a small incision, just large enough to admit a finger, parallel to and somewhat above the pubic bone. After separating the periosteum, a curved instrument, somewhat like a large aneurism needle, was passed behind the bone and pushed through the labium majus. The saw was then fastened to the protection at the lower end of the instrument, 'and brought into position by withdrawing it. In 1906 Stoeckel and Kan- negiesser reported that their respective chiefs, Bumm and Leopold, had performed the operation extirely subcutaneously. For this purpose the instrument was thrust through the upper end of the labium majus, and, under the guidance of a finger in the vagina, carried up along the posterior surface of the pubic bone and brought out through the skin above its upper margin, between the pubic spine and the symphysis pubis, the saw being adjusted by withdrawing the instrument from above down- ward. Up to April, 1915, my assistants or myself have performed 43 consec- utive successful pubiotomies upon 40 patients, three women having been operated upon twice. As Doderlein’s method was employed in all but the first case, and has proved most satisfactory, I shall describe its technic in some detail. After emptying the bladder and rectum and shaving the lower abdo- men and pubic region, the patient is brought to the edge of the table, and prepared for operation in the usual manner. The legs are held by assistants. An incision extending 2y2 centimeters inward from the pubic spine is then made just above the upper margin of the public bone, and the tissues cut through down to it. After incising the periosteum, a finger is passed into the wound and separates the tissues from the pos- terior surface of the bone. Then a Doderlein needle is carried down along the posterior surface of the bone, and when its inferior PUBIOTOMY 519 520 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY margin is reached the handle of the needle is rotated in such a man- ner that its tip is felt through the upper and outer part of the labium majus. A small incision is made over the projection, through which the tip of the instrument is pushed. To it one end of the saw it attached, and is drawn into position as the instrument is withdrawn through the upper wound. The handles are then attached to the saw and a few movements suffice to sever the hone. Care should be taken that the bone is severed in the desired direction, and that the movements are continued until the saw moves freely beneath the skin. In many cases the ends of the bone gape for 2 or 3 centimeters as soon as the section is complete; but, if all the ligamentary structures have not been divided, this does not occur until traction is made upon the child. Upon withdrawing the saw, blood gushes freely from both wounds, but in all of my cases the hemorrhage was readily controlled by firm pressure with gauze sponges. As soon as it is checked, the child should be delivered by forceps or version, as is most convenient, as I can see no advantage in waiting for its spontaneous expulsion, as recommended by certain German writers. As traction is made, the ends of bone will gape more widely, but a separation of more than 5 or 6 centimeters should be avoided by having the assistants make firm pressure upon the thighs. While waiting for separation of the placenta, a small gauze drain should be brought through the opening in the labium majus, and the upper wound sutured. After labor the patient is cleaned up, a sterile dressing is applied over the upper wound, and a long strip of adhesive plaster six inches wide is then passed around the entire body so as to make firm and equal pres- sure over the trochanters. This is not at all essential, as many German operators do not attempt to immobilize the pelvis. The patient is then put to bed, and, for convenience in handling, placed upon a Bradford frame, upon which she begins to move freely on the second or third day. She is not catheterized unless necessary, and is kept in bed for fourteen days, but is allowed to sit up as soon as she desires. She is encouraged to try to walk on the second day after getting up. The power of locomotion soon returns, and all of my patients have felt able to leave the hospital before the end of the fourth week. Fig. 439.—Showing Incisions for Pubiotomy. PUBIOTOMY 521 I have had no experience with the purely subcutaneous operation, but Roemer states that it is followed by injuries to the bladder twice as frequently as when Doderlein’s technic is employed, so that it would seem that the possibility of injuring the bladder is somewhat lessened by separating the tissues posterior to the bone with the fingers. Healing of the bone wound usually occurs by fibrous union, which was noted after all of our operations. This, however, has no effect upon locomotion, as all of my patients, upon reexamination months or years later, stated that they were able to walk as well and work as hard as previously. Moreover, the occurrence of fibrous union should be regarded as a favorable outcome, for the reason that it sometimes leads to a definite enlargement of the pelvic diameters, which may be still further accentuated in a subsequent pregnancy by the softening and relaxation Fig. 440.—Showing Position of Patient and Gigli Saw. incident to the increased hyperemia attending that condition. In 1915 I reported that 20 of my pubiotomy patients had subsequently given birth to 30 children. Ten of them had 12 spontaneous labors at term; in the others operative interference was again necessary. It therefore appeared that there is an almost even chance of the pelvis becoming definitely enlarged as the result of pubiotomy, and careful pelvic men- suration showed the correctness of the supposition; as the conjugata vera was found to be lengthened in 6 and the transverse diameter of the outlet in 11 instances. In the former, the increase was but slight, and only in two cases did it amount to as much as 1 centimeter; whereas in the latter the increase was considerable, varying between 1 and 3 centimeters, and averaging 1.8 centimeters. These observations indicate that considerable permanent enlargement of the pelvis is not to be expected when the contraction involves the superior strait; whereas, it does occur in funnel pelves, when it is often sufficient to convert the con- 522 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY tracted outlet into a normal one, and thus permit subsequent spontaneous labors. Prognosis.—Maier, in 1907, and Schlafli, in 1909, collected 267 and 700 operations from the literature with a mortality of 5.6 and 4.82 per cent., respectively. I do not consider that their figures correctly repre- sent the real dangers of the operation, as Schlafli’s statistics are based upon the results of 142 operators, many of whom had little experience, and naturally could not be expected to obtain the best results. On the other hand, Ddderlein states that in 321 pubiotomies performed in 7 German clinics up to 1910, the mortality was 1.8 per cent., and my own experience has indicated that it should not be greater. Such results are comparable to those following early conservative cesarean section, and are far superior to those obtained when it is performed after a test of the second stage of labor. Usually the hemorrhage, which may be quite profuse, is venous in character, and is readily controlled by pressure; but occasionally aberrant branches of the internal pudic artery may be cut, when it may become necessary to lay the entire wound open to ligate the bleeding vessel. Very exceptionally, even this is not possible, and one of Rosthorn’s patients died from uncontrollable hemorrhage. Moreover, deep vaginal tears frequently occur during the extraction of the child, and require immediate repair; while less often the bladder or urethra is injured, either by being perforated by the sharp ends of the bone, or as the result of traction. If proper care is taken in dilating the birth canal with hand before beginning the operation, by making horizontal instead of upward traction when delivering the head, and by avoiding undue violence, the occurrence of such accidents can be mini- mized. In only one of my cases was the bladder injured; in a number the vagina was torn, but in each instance satisfactory healing resulted after primary repair. Strange to say, the perineum is but rarely torn. Convalescence in general is very satisfactory, and the patients com- plain of but little pain or discomfort. In nearly one half of the cases the puerperium is slightly febrile, but only one of my patients wras seriously ill. In many instances there is considerable edema about the vulva and occasionally hematomata of considerable size develop. Moreover, several writers believe that the operation considerably increases the liability to femoral phlebitis. Indications.—Pubiotomy is performed solely in the interests of the child, and is contra-indicated when it is dead or in poor condition, or when the conjugata vera measures 7 centimeters or less. Furthermore, even in pelves above this limit, it is never indicated as a primary opera- tion. For this reason, it should not be performed in patients presenting disproportion between the size of the head and the pelvis, who are seen before the onset of labor or within a few hours thereafter, as in them classical cesarean section is the operation of choice. On the other hand, if the patient is not seen until late in labor, pubiotomy will give better results. In my experience, the chief indication for the operation is presented by patients in whom the disproportion appears to be so slight that spon- PUBIOTOMY 523 taneous delivery is anticipated, but in whom the test of several hours of second stage pains demonstrates that the head cannot be forced through the superior strait. In such circumstances the mortality following classical cesarean section is in the neighborhood of 10 per cent., while that of pubiotomy is 1 per cent., and consequently, there should be no difficulty in determining which operation is indicated. If, however, the innocuousness of extraperitoneal cesarean section can be demonstrated under these conditions, the field of usefulness of pubiotomy will be still further restricted. Bill of Cleveland took an identical position in 1923, and holds that pubiotomy has this restricted, but definite, field of useful- ness. In view of the permanent widening of the pelvic outlet to which reference has already been made, I consider that the ideal indication for pubiotomy is afforded by pronounced grades of funnel pelvis; as in them the operation will not only permit the delivery of the child, but in all probability will lead to such permanent enlargement of the outlet that spontaneous labor will be possible in the future. On this account, pubi- otomy is preferable to elective cesarean section, except in really elderly primiparae, in whom no chances can be taken with the prospects of secur- ing a living child. I cannot, however, endorse the suggestion of Jellett, who proposes that pubiotomy be done in non-pregnant women as a prophylactic measure, in the expectation that it will radically cure the pelvic deformity. I hold that pubiotomy will still further narrow the field for the induc- tion of premature labor, and practically do away with the use of high forceps, version, or craniotomy in moderate degrees of contracted pelvis when the mother or child is in good condition. Pubiotomy may also be indicated in face presentations when the chin has rotated into the hollow of the sacrum. In certain cases of breech or transverse presentation associated with moderate degrees of pelvic contraction, laying the Gigli saw prophylac- tically before beginning extraction adds greatly to one’s equanimity, as it enables one to saw through the pubic bone as soon as serious resistance develops, and thus save the life of the child which otherwise would be lost. In such cases, pubiotomy is usually not necessary, but the knowl- edge that it can be resorted to immediately adds greatly to the operator’s feeling of security. I do not believe that pubiotomy should be undertaken when signs of infection are present, as the interests of the mother will be better served by craniotomy or cesarean section followed by the removal of the uterus. Likewise, I feel that the employment of pubiotomy should be limited to well-equipped hospitals or to the practice of experts, since several well-trained assistants are necessary to its proper performance, and, moreover, serious complications may occur at any time, which will seriously tax the resources of even a competent surgeon. 524 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOft LITEBATUBE Ahlfeld. Lehrbuch der Geburtshiilfe, II. Aufl., 1898, 547. Bak. De 1’operation cesarienne conservative, etc. L’obstetrique, 1899, iv, 193- 230. Le§ons de pathologie obstetricale. Paris, 1900. Baudelocque, A. Nouveau procede pour pratiquer 1’operation cesarienne. These de Paris, 1823. Baudelocque, J. L. De la section du pubis. L’art des accouchements, nouv. ed., 1789, ii, 461-561. Bauhin. iryfj'repoTo/jlotokloc. Pt. Rousseti, etc. Basil, 1588. Beck. The Two-flap Cesarean Section. Surg. Gyn. and Obst., 1921, xxxiii, 290-295. Bill. Should Pubiotomy Be Recognized as a Justifiable Operation in Obstetrics. Am. Jour. Obst. and Gyn., 1923, v, 258-261. Birnbaum. 5 Kaiserschnitte bei einer Person. Arehiv f. Gyn., 1885, xxv, 422. Bischoff. Die totale Exstirpation des schwangeren und carcinomatosen Uterus Correspondenzbl. f. Schweizer Aerzte, 1880, Nr. 6. Braun-Fernwald. Ueber den in den letzten 10 Jahren ausgefiihrten Sectiones Caesareae. Arehiv f. Gyn., 1899, lix, 320-404. Brodhead. Rupture of the Uterus Through the Caesarean Cicatrix. Am. Jour. Obst., 1908, lvii, 650-666. Budin. Tarnier et Budin, Traite de l’art des accouchements, 1901, iv, 495. Budin et Demelin. Symphyseotomie. Tarnier et Budin, Traite de l’art des accouchements, 1901, iv, 456-489. Caruso. Die neuesten Ergebnisse des conservativen Kaiserschnittes mit Uterus- naht. Arehiv f. Gyn., 1888, xxxiii, 211-269. Chrobak. Quoted by Braun-Fernwald. Davis. A. B. A Report of all Abdominal Cesarean Operations Performed in the Service of the Lying-in Hospital. Am. J. Obst., 1915, lxxi, 116-132. De Lee-Cornell. Low Cervical Cesarean Section. Jour. Am. Med. Assoc., 1922, lxxix, 109-112. Doderlein. Ueber alte u. neus beckenerweiternde Operationen. Arehiv. f. Gyn., 1904, lxxii, 275-293. Ueber extra-peritonealen Kaiserschnitt u. Hebosteotomie. Monatsschr. f. Geb. u. Gyn., 1911, xxxiii, 1-21. Farabeuf. Sur la symphyseotomie. Annales de gyn. et d’obst., 1894, xli, 407- 431. Felkin. Quoted by Ploss. Das Weib in der Natur- und Volkerkunde, IY. Aufl., 1895, ii, 297. Fraenkel, L. Experimente zur Herbeifiihrung der Unwegsamkeit der Eileiter. Arehiv f. Gyn., 1899, lviii, 374-410. Frank. Ueber den subkutanen Symphysenschnitt, etc. Monatsschr. f. Geb. u. Gyn., 1910, xxxii, 680-692. Fritsch. Ein neuer Schnitt bei der Sectio Caesarea. Zentralbl. f. Gyn, 1897, xxi, 561-565. Fruhinsholz. De 1’operation cesarienne repute chez la meme femme. Annales de gyn. et d’obst., 1906, iii, 135-147. Gigli. Taglio lateralizzato del pube, sua vantaggi, sua tecnica. Ann, di os. e gin., 1894, No. 10. Lateralschnitt des Beckens. Zentralbl. f. Gyn., 1904, xxviii, 281-299. Halbertsma. Eclampsia gravidarum eine neus Indikationsstellung fur die Sectio Caesarea. Zentralbl. f. Gyn., 1889, xiii, 901. LITERATURE 525 Harris. Remarks on the Caesarean Operation. Amer. Jour. Obst., 1879, xi, 620- 626. Cattle-horn Lacerations of the Abdomen and Uterus in Pregnant Women. Amer. Jour. Obst., 1887, xx, 673-685, and 1033. Results of the Porro Caesarean Operation in All Countries. British Med. Jour., 1890, i, 68. The Remarkable Results of Antiseptic Symphyseotomy. Trans. Amer. Gyn. Soc., 1892, xvii, 98-126. The Porro Caesarean Section Tested by a Trial of Sixteen Years, etc. N. Y. Jour, of Gyn. and Obst., 1893, iii, 273-283. Harris. A Study of the Results Obtained in 64 Cesarean Sections Terminated by Supravaginal Hysterectomy. Bull. Johns Hopkins Hosp., 1922, xxxiii, 318-321. Holland. The Results of a Collective Investigation into Caesarean Section Per- formed in Great Britain from the Year 1911 to 1920 Inclusive. Jour. Obst. and Gyn. Br. Emp., 1921, xxviii, 358-446. Rupture of the Cesarean Scar in Subsequent Pregnancy and Labor. Proc. Royal Med. Soc., 1920, xiv (Gyn. and Obst.), 22-124. Holzapfel. Kaisersehnitt bei Mastdarmkrebs. Beitrage zur Geb. u. Gyn., 1899, ii, 59-77. Jaschke. Megakolon als Geburtshinderniss. Zentralbl. f. Gyn., 1915, 747-750. Jellett. The Radical Cure of Pelvic Deformity. Surg. Gyn. and Obst., 1919, xxix, 117-125. Jewett. A Case of Symphyseotomy. Brooklyn Med. Jour., 1892, vi, 790-792. Kannegeisser. Beitrag zur Hebotomie auf Grund von 21 Falle. Archiv f. Gyn., 1906, lxxviii, 52-105. Kronig. Zur Behandlung der Placenta praevia. Beitrage z. Geb. u. Gyn., 1909, xiii, 477-479. Transperitonealer, cervicaler Kaisersehnitt. Kronig-Doederlein, Operative Gynakologie, III. Auf., 1912, 879-886. Kustner. Kommen wir mit dem tiefen transperitonealen Kaisersehnitt aus, etc. Monatsschr. f. Geb. u. Gyn., 1920, liii, 13-56. Latzo. Ueber den extra-peritonealen Kaisersehnitt. Zentralbl. f. Gyn., 1909, 275-283. Lebas. Jour de Med. et de Chirurgie, 1770, xxxiv (supplement). Leopold. Welche Stellung nimmt die klassiche Sectio csesarea, etc. Archiv f. Gyn., 1910, xci, 453-460. Litzmlann. Kaisersehnitt mit temporarer Ligatur des Cervix. Zentralbl. f. Gyn., 1879, iii, 289-295. Maier. Der gegenwartige Stand der Hebotomie. D. I., Tubingen, 1907. Morisani. De la symphyseotomie. Annales de gyn. et d’obst., 1881, xvi, 444-445. Neugebauer. Ueber die Rehabilitation der Schamfugentrennung, etc. Leipzig, 1893. Physick. See Dewees’ Compendious System of Midwifery. Phila., 1824, p. 580. Pinard. De la symphysetomie. Annales de gyn. et d’obst., 1892, xxxvii, 81-94. Indication de 1’operation cesarienne consideree en rapport avec celle de la sym- physeotomie, etc. Annales de gyn. et d’obst., 1899, Iii, 81-117. Porro. Della amputazione utero-ovarica, etc. Milan, 1876. Report of Committee on Maternal and Infant Welfare of the Massachusetts Medical Society. Boston Med. and Surg. Jour., 1923, clxxxviii, 288-290. Reynolds. Constitutional 111 Equipment of the Patient as a Factor in Determin- ing the Performance of Caesarean Section. J. Am. Med. Assn., 1907, xlix, 1329-1333. 526 CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY Reynolds. The Superiority of Primary over Secondary Caesarean Section. Trans. Am. Gyn. Soc., 1907, xxxii, 116-118. Rousset. Traite nouveau de 1’hysterotomotokie ou 1’enfantement cesarien. Paris, 1581. Routh. On Caesarean Section in the United Kingdom. J. Obst. and Gyn. Brit. Emp., 1911, xix, 1-233. Sanger. Der Kaiserschnitt bei Uterusmyomen, etc. Leipzig, 1882. Schlafli. 700 Hebosteotomien. Zeitschr. f. Geb. u. Gyn., 1909, lxiv, 85-135. Sellheim. Der extra-peritoneale Uterusschnitt. Zentralbl. f. Gyn., 1908, 133- 142. Sigault. Discours sur les avantages de la section symphyse dans les ac- couchemens, etc., Paris, 1779. Spinelli. Les resultats de la symphyseotomie, etc. Annales de gyn. et d ’obst., 1892, xxxvii, 2-15. Stoeckel. Symphyseotomie oder Pubiotomie. Zentralbl. f. Gyn., 1906, xxx, 78-84. Storer. Extirpation of the Puerperal Uterus by Abdominal Section. Jour. Gyn. Soc. of Boston, 1861, i, 223. Thomas. Gastro-elytrotomy: A Substitute for the Caesarean Section. Amer. Jour. Obst., 1871, iii, 125-139. Trautmann. See Siebold, Versuch einer Geschicht der Geburtshiilfe, 1845, ii, 108- 111. Van de Velde. Die Hebotomie. Zentralbl. f. Gyn., 1902, xxvi, 969-976. Williams. Pelvic Indications for the Performance of Caesarean Section. Trans. Amer. Gyn. Soc., 1901, xxvi, 260-276. Is Pubiotomy a Justifiable Operation? Am. J. Obst., 1910, lxi, No. 5. The Effect of Pubiotomy upon the Course of Subsequent Labors. Am. J. Obst., 1915, lxxii, 1-25. The Abuse of Caesarean Section. Surg. Gyn. and Obst., 1917, xxv, 194-201. A Critical Analysis of Twenty-one Years’ Experience with Caesarean Section. Johns Hopkins Hosp. Bulletin, 1921, xxxii, 173-184. Zweifel. Die subcutane Symphyseotomie. Zentralbl. f. Gyn., 1906, 737-742. CHAPTER XXIII DESTRUCTIVE OPERATIONS CRANIOTOMY Under this heading are included all operations which bring about a decrease in the size of the foetal head, with a view to rendering its delivery easier. Prior to the introduction of podalic version and forceps, artificial delivery could be effected only by means of craniotomy or embryotomy, one or other of which was resorted to in nearly every case of difficult labor. Accordingly, in former times, the perforator, sharp hook, and crotchet were the most important instruments in the obstetrician’s arma- mentarium. Increased dexterity in the employment of forceps and version, however, brought about a rapid change, and now, as the result of the great decrease in the mortality from cesarean section, many obstetricians hold that craniotomy upon the living child is not justifiable in any circumstances. Indications. —Craniotomy is positively contra-indicated when the conjugata vera measures less than 5.5 centimeters, since in such cases the extraction of the child, even after the skull has been crushed, is at- tended by a greater maternal mortality than cesarean section late in labor. On the other hand, in pelves above this limit, while craniotomy may be indicated whenever the delivery of a mutilated child is the most conservative procedure, so far as the safety of the mother is con- cerned, its employment should be restricted to the greatest possible extent. The indications for its performance vary markedly. When the child is dead craniotomy is always indicated, unless the disproportion between the head and the pelvis is so slight that delivery by forceps or version can be accomplished without detriment to the mother. Esthetic con- siderations should never deter the operator from resorting to it. On the other hand, if the child is alive, the operation is justifiable only in very exceptional cases; indeed, many authorities go so far as to hold that, in view of the satisfactory results obtained from pubiotomy and cesarean section, it should never be performed. This, however, must be looked upon as too radical a view; for, although it must ever be the duty of the obstetrician to do his best to save the life of both mother and child, it is nevertheless conceivable that conditions may arise under w'hich craniotomy upon the living child may not only be perfectly justifiable, hut even imperatively demanded. Generally speaking, craniotomy should not be performed upon the 527 528 DESTRUCTIVE OPERATIONS living child if the mother is in good condition, amid suitable sur- roundings, and in the hands of a competent operator. In such circum- stances, if the obstacle to labor be due to a contracted pelvis or a large child, cesarean section or, in certain cases, pubiotomy is preferable, inasmuch as the slightly increased risk to the mother is more than compensated for by the rescue of her offspring. On the other hand, if the woman is not seen until she has been in the second stage of labor for a considerable time, and is already infected, classical or extra- peritoneal cesarean section, as well as pubiotomy, is clearly contra-indi- cated. In such circumstances in primiparous women the child should be sacrificed in the interests of the mother, as the only safe alternative consists in cesarean section followed by hysterectomy, which inevitably entails complete abolition of the reproductive function. Again, if the child is in poor condition, as shown by a too rapid or too slow heart- beat, or by the passage of considerable quantities of meconium with a vertex presentation, its life is already in such peril that, against that of the mother, it is no longer entitled to serious consideration. Moreover, in country districts, where the physician is unable to summon sufficient assistance, and is without the necessary appliances for an aseptic operation, cesarean section or pubiotomy should not be under- taken, and craniotomy becomes the operation of choice. But even under these adverse conditions, the destructive operation should be deferred as long as possible, and should not be resorted to until delivery becomes imperative in the interests of the mother, and then only after the failure of tentative attempts at forceps delivery. If, however, the patient hould again become pregnant, she should be sent to a city where expert treat- ment can be obtained, as I consider that a physician who repeatedly performs craniotomy upon the same patient is little better than a pro- fessional abortionist. Hydrocephalus affords a positive indication for craniotomy, which should be performed as soon as the cervix is completely dilated. In many instances extraction will not be necessary, as the mere evacuation of the fluid may be followed by the spontaneous extrusion of the child. In this condition a destructive operation is the more readily undertaken, as even a successful cesarean section will only give us a child that is doomed to die shortly or remain an idiot. When insuperable obstacles are encountered during the extraction of the after-coming head, craniotomy is a justifiable procedure, since the child is already dead, or dies within a few minutes after the nature of the obstacle has been recognized, and before preparations can be made for its delivery by pubiotomy. Craniotomy should not be performed upon the mature child until the external os has become completely dilated, as the imperfectly opened canal may offer a serious obstacle to its extraction. Operative Technic.—The patient should be placed in the lithotomy position, and prepared as for other obstetrical operations. Craniotomy usually includes two steps: First, the perforation of the head and evacuation of its contents; and, secondly, the extraction of the mutilated child. CRANIOTOMY 529 Numerous instruments have been devised for perforating the head the most suitable of which are Smellie’s scissors or Blot’s perforator" Braun’s trepan would serve the purpose admirably, but is not to be recommended on account of the difficulty with which it is kept clean. If the head is engaged and firmly fixed, perforation is accomplished with but little difficulty. With two fingers the large or small fontanel, as may be most convenient, is located, and the perforator plunged Fig. 441.—Smei,lie’s Scissors. through it. The opening is then enlarged and the instrument briskly moved about within the skull so as to destroy the central ganglia, and to disintegrate the brain to such an extent that it can be washed out with a douche of sterile water. If, however, the head is movable above the superior strait, it must be firmly fixed by means of pressure exerted by an assistant through the abdominal walls. To avoid wounding the maternal soft parts, the Fig. 442.—Method of Perforating Head (American Text-Book) perforation should be made through the portion of the head lying in the neighborhood of the symphysis pubis; for, should the instrument slip from this position, it is less liable to inflict serious injury than if it were near the sacrum. In face presentations perforation should be effected through the frontal suture. To pierce the after-coming head, the body of the child should be depressed, and the instrument carried into the skull in the neighborhood of the temporal suture. If, as occasionally happens, this point cannot be reached, the body of the child should be carried up over the abdomen 530 DESTRUCTIVE OPERATIONS of the mother, and perforation effected through the mouth and base of the skull. When a hydrocephalic child presents by the breech, and the head is arrested at the pelvic brim, the fluid contents of the skull may be evacuated by cutting through the arch of one of the cervical Fig. 443.—Simpson-Braun Cranioclast. vertebrae, after which a metallic catheter is passed through the opening and carried along the vertebral canal into the skull. After the brain has been washed out, the collapsed head may be expelled by the uterine contractions alone, or may be extracted by means of the forceps or a finger introduced through the per- foration opening. But even in moderate degrees of pel- vic contraction it is usually advisable to make use of a special instrument for grasping and crushing the base of the skull. The cranioclast, invented by Simpson and modified by Carl Braun, serves the pur- pose most satisfactorily. Its solid blade is introduced through the .perforation until its free end impinges upon the base of the skull, wdiile the fenestrated blade is applied over the face or lower portion of the occiput. The vise at the end of the instrument is then tight- ened, and as a result not only is the base of the skull more or less compressed, but at the same time a firm hold is obtained for the extraction that is to follow. Although the vault of the cranium collapses after craniotomy and the washing out of its contents, the base of the skull still remains unchanged and, as the bimastoid diameter measures between 7 and 7.5 Fig. 444.—Head Crushed by Cranioclast (Simpson). CRANIOTOMY 531 cm., it is obvious that delivery cannot be effected through a pelvis presenting smaller measurements until the base of the skull has like- wise been crushed. For this purpose many instruments have been Fig. 445.—Tarnier’s Cephalotribe. devised, and formerly the cephalotribe, invented by Baudelocque the younger, was extensively employed. This is essentially a very heavy forceps, whose blades come closely together and forcibly compress the head, when the vise at the ends of the handles is tightened. The in- Fig. 446a,—Tarnier’s Basotribe, Disarticulated. strument has been subjected to many modifications, the best being those of Tarnier and Braxton Hicks. At the same time it labors under the disadvantage that it aims to accomplish two purposes—i. e., crushing and extracting the head; and, unfortunately, whenever it is so con- Fig. 146, b.—Tarnier’s Basotribe. structed as to be an efficient crusher it is a poor tractor, and vice versa. For these reasons the cephalotribe, as such, is but little used. Tarnier, in 1883, invented the basiotribe, a three-bladed instrument DESTRUCTIVE OPERATIONS 532 which combines in one the advantages of the perforator, cranioelast, and cephalotribe. One blade is spear-pointed, and after serving as a per- forator is forced into the base of the skull. The second blade is then introduced over the occiput and the third over the face of the child. All three are articulated, and the vise at the handles is screwed down, with the result that the base of the skull is frac- tured in many directions, and the head is compressed into an elongated and shapeless mass. This is a most efficient instrument, and has been particularly recommended by Pinard and Bar. Sir A. E. Simpson, of Edinburgh, devised an instrument known as the basilyst-tractor, which likewise consists of three blades. The tips of two of them come together and form a screwlike instrument. This first perforates the skull, and by a rotatory motion is then worked into the base, which is fractured in many directions by separating the two blades by pressure upon the handles. After this the third blade is introduced over the face or occiput and screwed tightly in place, thus converting the instrument into a typical cranioelast (Pigs. 448 and 449). The basilyst-tractor gives very satisfactory results, and according to its inventor will compress the base of the skull into a mass 3.5 centi- meters in diameter. When perforating a hydrocephalic child, it is important to remember that the brain is spread out over the interior of the skull as a layer of tissue which may be only a few millimeters thick. When this is perforated, the Fig. 447.—Effect of Basio tribe. Fig. 448.—Simpson’s Basilyst, Disarticulated. fluid filling the dilated ventricles of the brain escapes and the skull collapses, after which delivery is readily effected. Occasionally per- EMBRYOTOMY 533 foration does not result in the death of the child, which will cry after its birth. In order to guard against this most distressing occurrence, the obstetrician should not be content with merely perforating the skull at one point, but should carry the instrument back to the base of the brain and stir it around so as to destroy effectually the upper portion of the medulla. Pernice having reported the case of an infant who survived craniotomy and grew up an idiot. Prognosis.—In moderate degrees of pelvic contraction, craniotomy, if properly performed in uninfected women, is almost devoid of danger. On the other hand, when the conjugata vera measures 5.5 centimeters or less, the mortality becomes considerable. Moreover, it must be re- membered that if the operation be deferred until infection has occurred, and the patient has become profoundly exhausted, its mortality approxi- mates that of late cesarean section. EMBRYOTOMY In embryotomy the viscera are removed through an opening in the thorax or abdomen of the child, or the head is severed from the body. The former operation is known as evisceration, the latter as decapitation. At present evisceration is rarely employed, though it occasionally becomes necessary in order to effect the delivery of certain monstrosities, or children Fig. 449.—Simpson’s Basii.ist, Articulated. suffering from unusual enlargement of the thoracic or abdominal cavities resulting from tumor formation. It may likewise become necessary in rare cases of transverse presentation, when the thorax or abdomen of the child lies over the superior strait and the neck is not accessible. In such circumstances an opening is made by scissors through the thoracic or abdominal wall, as the case may be, sufficiently large to admit two fingers, with which the viscera are torn loose from their attachments and slowly extracted. Decapitation is much more frequently employed, and is indicated more particularly in neglected transverse presentations. As a rule, when seen early, such cases can be readily delivered by version and extraction; but when the condition has been overlooked, and assistance is not called for until one shoulder has become firmly impacted in the pelvic canal, the lower uterine segment may have become so stretched as to make an attempt at version practically synonymous with rupture of the uterus. Under such circumstances the child can be delivered only by decapita- tion or cesarean section. The former is the operation of choice in 534 DESTRUCTIVE OPERATIONS neglected cases, and should always be chosen if the child is dead. It can readily be accomplished by means of Braun’s blunt hook or of John Ramsbotham’s sickle knife, which is extensively used in Eng- land. Classical cesarean section is always associated with a high mortality in such circumstances, as the patient has usually been long in labor and is exposed to serious danger of infection. If, however, the child is in good con- dition, as indicated by strong foetal heart sounds, and the mother is earnestly desirous of offspring, cesarean section followed by supra- vaginal hysterectomy may be undertaken if the patient is a mul- tipara ; whereas it should not be considered in the case of a primiparous woman, since the loss of a child with somewhat dubious chances of life should be regarded as a lesser evil than permanent sterilization. Fortunately, in neglected shoulder presentations, decapitation is usually materially facilitated by the prolapse into the vagina of one arm. This having been seized and brought through the vulva, firm traction should be exerted upon it so as to put the neck on the stretch as much as possible. The index finger of one hand is then passed over the neck and used as a guide in applying Braun’s hook as accurately as pos- sible. When in position, the tip of the instrument is covered by the finger so as to avoid wounding the maternal soft parts. All being in readiness, strong traction is now made upon the handle of the instrument, which at the same time is rotated from side to side, somewhat as a key in a lock, by which the cervical vertebrae are disarticu- lated, and on continuation of the mo- tion the neck is readily severed from the body. If any resistance is offered by the skin, it may be cut with scis- sors. After decapitation the body is extracted by traction upon the arm ; or, if that be not available, by version. The head can frequently be expressed from the uterus by maneuvers similar to those employed for the delivery of the placenta, but if these prove unsuccessful a finger is inserted into the mouth of the child, after which, as a rule, extraction is readily effected by traction upon the Fig. 450.—Braun’s Blunt Hook. Fig. 451.—Decapitation with Braun’s Blunt Hook (American Text-Book). LITERATURE 535 lower jaw. If this is not effectual delivery can be accomplished by means of a cephalotribe or after perforation. Zweifel believes that decapitation can be rendered easier by the use of the trachelorhelcter, which consists essentially of a double Braun’s hook. So far as my own experience goes, I see no necessity for .the new instrument, as I have always been able to effect decapitation by means of Braun’s hook. Again, if the latter be not available, the Fig. 452. Fig. 453. Figs. 452, 453.—Showing Mode of Action of Blunt Hook (American Text-Book) operation may be performed by means of a pair of long curved scissors, similar to the embryotomy scissors of Hodge. Occasionally, in head presentations, the excessive size of the shoulders may prove a serious obstacle to labor. In such cases cleidotomy renders excellent service. In this operation a pair of long curved scissors are introduced under the guidance of the hand and cut through the clavicles on either side, after which the shoulder girdle collapses and delivery is readily effected. According to Ballantyne, cleidotomy was first pro- posed by Herbert 11. Spencer, instead of Yon Herff as is usually stated. LITERATURE Bar. Embryotomie eephalique. Paris, 1889. Baudelocque. Nouveau moyen pour delivrer les femmes contrefaites et en travail. Paris, 1829. Braun. Ueber das teehnische Yerfahren bei vernachlassigten Querlagen, etc. Wiener med. Wochnschr., 1861, Nr. 45. Pernice. Ueber einen giinstig verlaufenen Fall von Perforation, etc. Zentralbl. f. Gyn., 1900, xxiv, 918-921. Pinard. Le basiotribe Tarnier. Annales de gyn. et d’obst., 1884, xxii, 321-341 and 406-442. Du soi-disant foeticide therapeutique. Annales de gyn. et d’obst., 1900, liii, 1-18. DESTRUCTIVE OPERATIONS 536 Simpson, A. R. Delivery by Basilysis. Scottish Med. and Surg. Jour., 1900 (May). Simpson, J. Y. Cranioclast. Med. News and Gaz., 1860, vol. i. Tarnier. Le basiotribe. Acad, de med. de Paris, 1883, December 11. Annales de gyn. et d’obst., 1884, xxi, 74-77. Von Herff. Die Zertriimmerung des Schultergiirtels (Kleideotomie). Archiv f. Gyn., 1895, liii, 542-546. Zweifel. Ueber die Dekapitation, etc. Zentralbl. f. Gyn., 1895, xix, 521-539. CHAPTER XXIY OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY In this chapter will be considered a number of procedures usually designated as minor operations, which may become necessary during pregnancy, labor, or the puerperium. The Douche.-—AVe distinguish between vaginal and uterine douches, according as a considerable quantity of fluid is injected into the vaginal canal alone or directly into the uterine cavity. Vaginal Douche.—Following the introduction of antiseptic methods into obstetrics, the use of an antiseptic, prophylactic vaginal douche became a routine part of the conduct of labor, in the belief that by its means the countless pathogenic microorganisms supposed to exist in the vaginal secretion of pregnant women could be destroyed, or at least rendered innocuous, and the risk of auto-infection minimized. Experi- mental work, however, has shown that, with the exception of the gono- coccus, the vaginal secretion at the end of pregnancy rarely, if ever, harbors pyogenic bacteria, and that the prophylactic vaginal douche is unnecessary. Furthermore, clinical experience has demonstrated that it is not only useless but even directly harmful, as its routine employ- ment is followed by a greater incidence of febrile cases during the puerperium than when it is omitted. This question will be dealt with more fully in the chapter upon puerperal infection. At the present time the vaginal douche is employed only exceptionally during pregnancy and labor; as, for instance, when the pregnant woman presents a profuse vaginal discharge due to gonorrheal infection. In such cases four liters of a hot 1 to 10,000 bichlorid or permanganate solution may be injected into the vagina twice daily during the last few weeks of pregnancy, not so much in the hope of curing the disease as avoiding infection of the child’s eyes during labor. This is all that can reasonably be expected, inasmuch as the gonococci have usually invaded the glands of the cervical canal, where they are protected from the action of the antiseptic fluid. Formerly, the employment of a prophylactic vaginal douche was recommended if the patient had been subjected to repeated examinations during labor by persons who habitually neglect ordinary aseptic precau- tions, and particularly if signs of infection are present. Owing to the impossibility of thoroughly disinfecting the vagina by antiseptic solu- tions, the value of such a procedure is questionable; although a douche of several liters of hot sterile salt solution can do no harm. After the first week of the puerperium, the vaginal douche is fre- quently employed when the lochia present an offensive odor. It need 537 538 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY hardly be said, however, that it is of but little value as a disinfectant, but merely removes mechanically the secretion collected in the vagina, and thus adds materially to the comfort of the patient. Sterile salt solution, or a weak solution of carbolic acid, either alone or combined with boric acid and a little oil of peppermint, may be employed. Occasionally, when a puerperal infection has become localized, and has given rise to induration at the base of the broad ligament or in Douglas’s culdesac, the application of heat by means of abundant douches of hot boiled water or salt solution alleviates suffering, hastens the maturation of the abscess, and prepares the way for its prompt evacu- ation. Before giving a vaginal douche, the external genitalia should be carefully cleansed and the patient placed upon a douche pan as she lies in bed, or brought to the edge of the bed and placed in the obstet- rical position with a rubber pad beneath her. A fountain syringe, containing four quarts and provided with an appropriately shaped glass nozzle, previously sterilized by boiling, is employed, and the fluid allowed to run in under moderate gravity pressure. For the first days of the pu- erperium rigid asep- tic precautions should be observed in the use of the vaginal douche, and its administration should not be intrusted to the nurse, unless one is assured of her competency. Intra-uterine Douche.—The intra-uterine douche is not employed so long as the uterine cavity is occupied by the product of conception, but is frequently used immediately after labor and during the puerperium. Formerly it was customary to give an intra-uterine douche after all obstetrical operations. Such a procedure, however, is indicated only when the patient has exhibited signs of infection during labor; in these cases an intra-uterine douche of several liters of hot salt solution given after the completion of the third stage does no harm and occasionally may be productive of good. The most usual indication for its employment immediately after labor is afforded by postpartum hemorrhage due to atony of the uterus. In such cases the administration of a douche of 4 or 5 liters of hot sterile salt solution will usually lead to efficient and permanent con- traction, provided that no fragments of the placenta are retained in utero. The intra-uterine douche is also frequently employed during the puerperium, especially in the presence of infection. It has, however, been greatly abused; for, while it must be admitted that it may be useful in mechanically removing debris from the uterine cavity, it is nevertheless true that it may be directly harmful. For these reasons great care should be taken in the selection of the cases in which it is employed. Generally speaking, it is contra-indicated in all cases of streptococcic infection, inasmuch as the necessary manipulations may Fig. 454.—Glass Douche Tube. CURETTAGE 539 give rise to an extension of the process. On the other hand, when the symptoms are due to infection hy the so-called putrefactive organisms, associated with retention of the lochial discharge, the introduction into the uterus of several liters of hot salt solution is frequently followed by an immediate fall of temperature and a permanent improvement in the condition of the patient. If a single douche does not bring about the desired result, its repetition is generally useless. Sterile salt solution should be employed for intra-uterine douching, instead of the antiseptic solutions which were formerly recommended; since the latter, no matter how strong they may be made, can act only in a purely mechanical way, and cannot destroy the bacteria which have already invaded the endometrium. On the other hand, their use occasionally causes the death of the patient, and particularly when bichlorid of mercury was employed, the literature contained the records of many deaths from mercurial poisoning following the intra- uterine use of such solutions. Inasmuch as the administration of an intra-uterine douche must always be regarded as a serious matter, it should be given by the physi- cian himself and not delegated to the nurse, no matter how competent she may be; since the most rigid aseptic precautions are necessary, and failure in this regard may result in additional infection of the patient. As a preliminary, the vagina should be douched out. Two fingers having then been employed to locate the external os, the douch-tube is passed through it until it impinges upon the fundus of the uterus. Four or five liters of fluid are then slowly injected, care being taken to insure a free return flow. During the puerperium the cervical canal rapidly diminishes in caliber, and, owing to the marked anteflexion of the uterus which fre- quently occurs in this period, may become so bent as to offer a consid- erable obstacle to the introduction of the nozzle. To overcome this difficulty, traction should be made upon the anterior lip of the cervix by means of a pair of bullet forceps, when the cervical canal becomes straightened out. Occasionally, the contraction ring offers an obstacle, and the nozzle is arrested in the collapsed lower uterine segment. By making traction upon the cervix, and cautiously moving the extremity of the douche-tube, it can usually be passed into the uterine cavity without further difficulty. Curettage.—By this term is understood the removal of the lining membrane of the uterus by means of a curette. The operation may be indicated in three conditions: incomplete abortion, imperfect involution of the puerperal uterus, and certain cases of infection. When portions of the placenta and membranes are retained within the uterus after an incomplete abortion, many authorities recommend their removal by means of a dull curette. As a preliminary, the cervix, if not sufficiently pervious, must be dilated by a suitable instrument, preferably that of Goodell or Hegar (see Fig. 343). The blunt curette is then introduced into the uterus and gently scrapes off the retained structures. The employment of an instrument, however, is rarely advis- able, as it is far better to peel off the adherent placenta and membranes 540 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY with a finger, whose movements are controlled by the other hand, through the abdominal walls. After they are once loosened, the retained struc- tures can be readily removed by means of the finger or by an ovum or placental forceps. The former procedure necessitates the introduction of the entire hand into the vagina, and can only be accomplished under anesthesia. After the uterus has been emptied in such cases, the finger is again introduced and carefully palpates its cavity, in order to make sure that the offending structures have been entirely removed and thereby to avert all danger of subsequent hemorrhage. If the curette alone is used, considerable portions of placenta may be left behind, which may later give rise to bleeding and necessitate another operation. On numerous occasions I have seen patients in consultation in whom hem- orrhage had persisted after curettage, and on examination found that considerable portions of the placenta, or even the entire ovum, had been left in the uterus, the physician having removed only a part of the decidua at the previous operation. Moreover, curettage always carries with it the possibility of perforating the uterus, the walls in many cases being so soft and friable that the accident may occur despite the exercise of the utmost caution. Fortunately, the injury is generally attended Fig. 455.—Curette. by but little danger, although, if the uterine contents be infected, it may give rise to fatal peritonitis; again, in rare cases, a loop of gut may prolapse through the rent in the uterus and necessitate a major operation. Probably the most justifiable indication for curettage in obstetrical practice is the loss of blood after the first two weeks of the puerperium, resulting from imperfect involution of the uterus, which is sometimes associated with the retention of portions of the placenta or membranes. In such circumstances the operation gives excellent results, provided it be carried out in an aseptic manner. Formerly most authorities recommended curettage in puerperal in- fection, in the belief that by its means the focus of infection could be removed. The operation is undoubtedly beneficial in a certain number of cases, but should be instituted only in the presence of definite indi- cations, as its routine employment is frequently more dangerous than the original infection, and has led to the death of many hundreds of women. Generally speaking, it is contra-indicated when the infection is due to the streptococcus, as under such circumstances the lesions attending its use simply offer new areas for infection. On the other hand, it is often folloAved by excellent results when the so-called pu- trefactive organisms are producing the mischief, and particularly when the uterine cavity contains necrotic tissue or larger or smaller portions of degenerated placenta. Nevertheless, even in this class of cases it is generally better to employ the fingers in emptying the uterus. THE TAMPON OR PACK 541 The Tampon or Pack.—The vaginal tampon is occasionally indicated in the following conditions: inevitable abortion, certain cases of placenta previa, and to dilate the cervix in the early months of pregnancy. Profuse hemorrhage occurring in the early months of pregnancy usually indicates that abortion is inevitable. In such cases, if the cervical canal is not sufficiently dilated to admit the finger, and instrumental dilatation does not seem indicated, it is sometimes advisable to pack it and the vagina tightly with sterile gauze. When the packing is removed twelve or twenty-four hours later, the product of conception is frequently found lying free in the vaginal vault, and when this does not occur the cervical canal will usually be sufficiently dilated to permit the introduction of the finger, by means of which the uterus can be emptied. In placenta previa, when the hemorrhage is alarming and the cervical canal is not sufficiently dilated to admit a finger, certain authorities rec- ommend the application of a tight tampon to the cervical canal and vagina. I have never employed it in such circumstances, but it is claimed that it effectually controls hem- orrhage, and on removing the pack a few hours later the cervix will usu- ally be sufficiently dilated to admit two fingers, after which combined version by the Braxton Hicks method can be performed, or a Champetier de Ribes’s balloon intro- duced. In the early months of pregnancy a tightly applied pack offers an uncertain means of dilating the cervix in any condition which demands the evacuation of the uterine contents, and rapid instrumental dilata- tion appears undesirable. In such cases, however, I prefer to evacuate the uterine cavity in one sitting by means of vaginal hysterotomy. The best material for a vaginal tampon is gauze, which is most conveniently handled in the shape of roller-gauze bandages 4 inches Fig. 456.—Packing the Uterus for Postpartum Hemorrhage. 542 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY wide, which have previously been carefully sterilized. For the intro- duction of the pack, the patient should be brought to the edge of the bed and prepared as for an operation. A bivalve, or preferably a Simon speculum is then introduced into the vagina and the cervix brought into view by means of a bullet forceps. Then with a long dressing forceps the bandage is carried up and tightly packed into the cervical canal, and afterward into the fornix, so that eventually the entire vagina is completely filled with it. Intra-uterine Pack.—Diihrssen, in 1887, advocated packing the uter- ine cavity with iodoform gauze as a means of controlling hemorrhage. Whenever there is persistent loss of blood following the third stage of labor, which does not yield to the ordinary methods of treatment, this procedure offers a most efficient method of controlling it, as the pack not only exerts pressure upon the bleeding vessels, but mechanically stimulates the uterus to renewed contraction. Plain sterilized gauze is preferable to that impregnated with iodoform or other antiseptics. It is most conveniently prepared for use in the shape of strips 8 yards long, each folded four times upon itself so as to give a bandage-like arrangement four inches wide, with the free edge hemmed, and with a tape attached to one end to facilitate its withdrawal. Six such packs should be sterilized in a package and a number of packages always kept available for immediate use. Before resorting to this procedure, however, it is essential that the hand be introduced into the uterus in order to ascertain that the hemorrhage is not due to retention of portions of the placenta. If the uterus is empty, after the usual preparations for an operation have been carried out, one blade of a Simon speculum is introduced and the posterior vaginal wall retracted; the anterior lip of the cervix is then seized with a bullet forceps and drawn down as near as possible to the vulva, after which sterilized bandages are rapidly packed into the uterine cavity by means of a long dressing forceps, the upper part of the vagina being also tamponed (Fig. 456). R. W. Holmes in 1902 devised a tubular device for packing the uterus, which I have employed with great satisfaction. This consists of a tube approximately 30 cm. in length, with a bore 2 cm. in diameter, slightly curved so as to conform to the shape of the birth canal, and provided with an obturator and a pronged staff. With the obturator in place, the instrument is carried up into the uterus until its end impinges upon the fundus, the obturator is then removed, the gauze introduced into the free end of the tube and rapidly fed into the uterus by means of the pronged packer. This device makes unnecessary the use of a speculum and bullet forceps, has the advantage of reducing to a mini- jnum the possibility of contamination by contact with the external genitalia, and greatly increases the rapidity with which the pack can be applied. However it has been introduced, the pack should be allowed to remain in place not longer than twenty-four hours, on account of the danger of infection. Removal is readily effected by traction upon the tapes, and one should make certain that the number of packs removed corresponds to that introduced. MANUAL REMOVAL OF THE PLACENTA 543 Manual Removal of the Placenta.—When considering the treatment of the third stage of labor, it was pointed out that previous to the introduction of Crede’s method of expressing the placenta its manual removal was frequently resorted to. With increasing knowledge as to the proper conduct at this time, however, the operation became less and less frequently demanded, so that at present competent obstetricians consider that it is indicated only once in several hundred cases, and then only when abnormal adhesions exist between the placenta and the uterine wall, or when one has to do with a placenta membranacea or succenturiata. Manual removal is indicated whenever there is alarming hemorrhage Fig. 457.—Manual Removal of the Placenta. and the placenta cannot be expressed by Crede’s method, though such a condition is but rarely observed. On the other hand, if there is no hemorrhage, the operation should not be resorted to merely to hasten the completion of the third stage of labor. Generally speaking, in such cases, repeated attempts at expression by Crede’s maneuver should be persisted in for at least an hour, under anesthesia, if necessary, and manual removal resorted to only after prolonged effort has shown that more conservative methods are ineffectual. The procedure is attended by a greater danger of infection than any other obstetrical manipulation. In the ordinary operations, such as forceps and version, the hand, when introduced into the uterus, is within the amniotic cavity, and eonse- 544 OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY quently microorganisms which may have been introduced along with it are cast off when the after-birth is expelled; whereas, in manual re- moval of the placenta the hand is inserted between the foetal membranes and the uterine wall, and, in separating the placenta from its attach- ments, comes in direct contact with the thrombosed sinuses. The latter may be regarded as blood serum culture tubes awaiting inoculation, so that if pyogenic bacteria are introduced, abundant facilities for their further growth are offered. When the operation becomes necessary, the strictest attention should be given to every aseptic detail. The external genitalia should be most rigorously cleansed, the hands and forearms of the operator carefully redisinfected, and encased in freshly boiled rubber gloves. After grasp- ing the uterus through the abdominal wall with one hand, the other, lubricated with sterile vaseline, is introduced into the vagina and passed into the uterus, following the umbilical cord. As soon as the placenta is reached, its margin should be sought for, and the inner surface of the hand insinuated between its margin and the uterine wall. Then, with the back of the hand in contact with the latter, the placenta should be peeled off from its attachment by a motion similar to that employed in cutting the leaves of a book. After its complete separation, the placenta should be grasped in the entire hand, but not extracted imme- diately, the operator waiting until the uterus contracts down firmly over the hand, which should then gradually be withdrawn. Once again, the importance of a most rigid aseptic technic in carrying out this procedure must be emphasized. Naturally, when the obstetrician finds himself face to face with an alarming postpartum hemorrhage, his only thought is likely to be as to the most rapid method of checking it, without regard to details. But even in such cases, the hand should be at least encased in a freshly boiled rubber glove; for, if introduced into the uterus without proper precautions, the patient, although saved from death from hemorrhage, may succumb to infection a few days later. LITERATURE Holmes, R. W. A New Method of Tamponing the Uterus Post-Partum. Am. Jour. Obst., 1902, xlv, 245-250. SECTION VI PATHOLOGY OF PREGNANCY CHAPTER XXY ACCIDENTAL COMPLICATIONS OP PREGNANCY DUE TO DISEASE Pregnancy may be associated with certain diseases which result from the condition itself, or by others which are to be regarded as accidental complications. The latter may have existed before the inception of pregnancy, or may have been acquired during its course. As a rule, all diseases which subject the organism to a considerable strain are more serious when occurring in the pregnant woman. Thus, a lung which is partially destroyed or thrown out of function may suffice for the respiration of an ordinary individual, but be unable to respond to the added demands of pregnancy, particularly in the later months, when the enlarged uterus restricts the mobility of the dia- phragm. Similarly, many a woman is unaware of the existence of a cardiac lesion, or at least leads a very comfortable existence, until the increased demands upon the activity of the heart incident to pregnancy bring about broken compensation with its attendant symptoms. In general, it may be said that pregnancy exerts a deleterious influ- ence upon all chronic organic maladies, while its effect is usually less marked in acute infectious processes. The latter, however, frequently lead to premature delivery, and the additional physical strain attending the latter may render the course of the disease much less favorable. Pregnancy Complicated by Acute Infectious Diseases.—Smallpox.— Smallpox complicating pregnancy carries with it a more serious prognosis than at other times. Thus Yinay reported a mortality of 36 per cent, in 235 cases, as compared with 25 per cent, in the non-pregnant con- dition. The hemorrhagic form of the disease is particularly fatal in pregnant women, Mayer having recorded the loss of 13 consecutive cases. Moreover, smallpox exerts a deleterious influence upon the product of conception, although the incidence of abortion or premature labor varies with the severity of the disease, Queirel stating that it is almost universal in the hemorrhagic, and comparatively infrequent in the dis- crete, variety. This may be due to hemorrhagic changes in the decidua, or to the direct transmission of the disease to the foetus, with its subse- quent death and expulsion. The occurrence of intra-uterine smallpox is well authenticated, children being occasionally born in the eruptive stage of the disease or with distinct pock-marks; as in the case re' 545 546 ACCIDENTAL COMPLICATIONS DUE TO DISEASE ported by Puig y Roig, in which the mother presented no manifestations of the disease. Mauriceau is said to have been infected in this manner, and the condition was well known to John Hunter and Smellie. More- over, in double-ovum twin pregnancy it sometimes happens that one child is definitely pock-marked, while the other shows no signs of the disease. Bollinger first suggested the possibility of the transmission from mother to foetus of the protective influence of vaccinia, and stated that when the mothers are successfully vaccinated during pregnancy a certain number of the children fail to take when vaccinated soon after birth. Behm noted this insusceptibility once in 29 cases, and believed that it was due to the transmission of an immunizing substance through the placenta. Kolloch held similar views. On the other hand, most authori- ties are skeptical as to the possibility of such an occurrence, and con- sider that unsuccessful vaccination in young children indicates that they are refractory to its influence, or that the virus was of poor quality. In 46 cases reported by Wolff, Palm, and Gast there was not a single instance of successful intra-uterine transmission. Scarlet Fever.—It is generally believed that the pregnant woman possesses a certain immunity to scarlet fever. Braxton Hicks and others considered that this was demonstrated by the fact that the dis- ease occurs much less frequently during pregnancy than in the puer- perium. Olshausen, who also held this view, was able to collect from the literature only 7 cases of scarlet fever occurring in the former, as compared with 134 in the latter, period. It is quite possible, however, that many of the puerperal cases were not examples of true scarlet fever, confusion having arisen on account of the rash which sometimes occurs in puerperal infection. The correctness of this latter supposition is supported by the fact that many authors believe in the intercom- municability of the two diseases, a point that cannot be demonstrated until the materies morbi of scarlet fever has been discovered. When occurring in the early months of pregnancy, the disease fre- quently causes abortion. This accident is usually attributed to the high temperature of the mother, though in very rare instances it may be due to the direct transmission of the disease to the foetus, Ballantyne having recorded a case in which the child presented a characteristic rash at birth. This view, however, has never met with any general acceptation. Measles— Measles is not a frequent complication of pregnancy, but when it occurs is very prone to cause premature delivery, which was observed by Klotz in 9 out of 11 cases. According to Fellner, the prognosis is much more serious during the puerperium than during pregnancy. It is stated that intra-uterine transmission of the disease to the foetus is now and again noted, Lomer, Fiori, and others having reported cases in which the child presented a characteristic eruption at birth. Cholera.—Pregnant women do not appear to be attacked by cholera more frequently than others, although they succumb more readily to the disease. Schiitz states that the mortality among them in the Ham- burg epidemic of 1892 was 57 per cent. The disease exerts a very deleterious effect upon pregnancy, 54 per ACUTE INFECTIOUS DISEASES 547 cent, of the cases, according to Schlitz, ending in abortion or premature labor. This may be due to various causes. One-third of the women suffering from cholera have uterine hemorrhage, which, when occurring during pregnancy, must be associated with changes in the decidua, Slavjansky having described a peculiar form of hemorrhagic endometri- tis. Moreover, in nearly every instance, the disease causes uterine contractions, supposed to result from the circulation of toxins in the blood. Tizzoni and Cantani are the only investigators who have demon- strated the transmission of cholera bacilli to the human foetus; but Vitanzi’s experiments render it probable that such an occurrence is quite frequent in animals. Typhoid Fever.—Typhoid fever is a serious, and often a dangerous, complication of pregnancy. Moreover, it increases largely the foetal mortality, abortion or premature labor occurring in from 40 to 60 per cent, of the cases. Formerly it was held that the death of the foetus and its subsequent expulsion were due to the high temperature charac- terizing the disease; but it is now known that it is usually due to the direct transmission through the placenta of toxins or of the bacilli themselves. Since F. W. Lynch, in my clinic, demonstrated the bacilli in the organs of a foetus aborted by a woman suffering from typhoid fever, we have repeatedly made similar observations, so that it is gen- erally admitted that the foetus succumbs to a typhoid septicemia. The literature upon the subject was collected by Knapp in 1909. Pneumonia.—The maternal mortality is materially augmented when pneumonia occurs during pregnancy, since the disease frequently leads to premature labor or abortion. This result is generally attributed to imperfect oxygenation of the foetal blood, though it is frequently due to the direct transmission of bacteria to the foetus, in whose organs pneumococci have been demonstrated by Levy, Netter, Carbonelli, Lu- barsch, and others. Premature labor is a very untoward complication in such cases, as the exertion incident to it subjects the already weakened maternal organism to so great an additional strain that death fre- quently results. When pneumonia develops during the last days of pregnancy or early in the puerperium, it is not unusual for pneumococci to be trans- mitted by means of the blood stream to the uterus where they give rise to hematogenous puerperal infection. Johnston and Morgan de- scribed such a case occurring in our service, and collected the literature upon the subject up to 1922. Influenza.—Our experience during the panepidemic of 1918 shows that influenza constitutes an unusually serious complication of preg- nancy, more particularly when of the pneumonic type. J. W. Harris in a statistical study based upon 1350 cases, found that the gross maternal mortality was 27 per cent., which increased to 50 per cent, when pneumonia developed. The disease also has a most deleterious effect upon the pregnancy, which was interrupted in 26 per cent, of the uncomplicated cases, and in 52 per cent, of those accompanied by pneumonia. Moreover, when the disease ended fatally spontaneous 548 ACCIDENTAL COMPLICATIONS DUE TO DISEASE termination of pregnancy occurred in 62 per cent, of the cases before the death of the mother. In other words, the occurrence of abortion or premature labor adds to the gravity of the disease—a fact, which, in our judgment, effectively demonstrates the unjustifiability of terminating pregnancy artificially in the hope of improving the prognosis for the mother. On the other hand, in many of the mild cases, the disease runs a benign course, and has no effect upon the pregnancy, thereby partially confirming the opinion of Bar and Boulle that it is almost without influence upon the course of gestation. Erysipelas and Sepsis.—Erysipelas is a very serious disease at any time, but is particularly dangerous when occurring in pregnant women, in whom the possibility of a streptococcic puerperal infection is markedly increased. That this does not always occur is shown by the fact that I have delivered several women suffering from severe facial erysipelas without the occurrence of uterine infection. Occasionally, as noted by Lebedeff, the streptococci, the cause of the erysipelas, are transmitted from mother to child, but this is unusual. A general septicemia some- times follows a streptococcic angina, and in such cases streptococci can be found in the uterine lochia, as well as in the foetal blood. Furthermore, as a rule, any septic condition offers a worse prognosis in pregnancy than at other times. Kronig has reported several instances of transmission of the offending bacteria to the child, having demon- strated the transmission of colon bacilli from a parametritic abscess. He also made similar observations in an infectious process due to an anaerobic bacillus. Gonorrhea.—The occurrence of gonorrhea in the pregnant woman should never be lightly regarded. In not a few instances the organisms invade the decidua and give rise to inflammatory conditions which lead to abortion. Gonococci have been demonstrated in decidual endometri- tis by Neumann, Maslovsky, myself, and others. More important, however, are the consequences of gonorrheal infec- tion at the time of labor and during the puerperium, leaving out of consideration ophthalmia neonatorum, to which reference has already been made. After labor the gonococci, which have remained limited to the cervical canal during pregnancy, may gain access to the uterine cavity and give rise to febrile phenomena. The condition, although rarely fatal, is always serious, and will be considered in detail in the section on Puerperal Infection. In rare instances the gonococcus may produce a general infection, Dabney and Harris, and J. T. Smith having reported fatal cases of gonorrheal endocarditis observed in women de- livered at the Johns Hopkins Hospital. Tetanus.—Always a very dangerous disease, tetanus is fortunately a rare complication of pregnancy, nor does it appear to be more fatal than in non-pregnant women. Archambaud has reported a case which terminated favorably. Anthrax.—Anthrax, or malignant pustule, is rarely observed in human beings under any circumstances, but is almost always fatal. Rostowzen met with three deaths in pregnant women, and was able in CHRONIC INFECTIOUS DISEASES 549 each case to demonstrate anthrax bacilli in the tissues of the child. A similar observation was made by Paltauf. Ahlfeld and Marchand have reported a case in which a child, born of a mother suffering from anthrax, died a few days after birth from the same disease; but in this instance it was not clear whether they had to do with intra-uterine transmission or post-natal infection. In certain animals, on the other hand, the placental transmission of anthrax can frequently be demon- strated experimentally. The first observations of this character were made by Strauss and Chamberlent in 1882. Pregnancy Complicated by Chronic Infectious Diseases.—Tubercu- losis.—Formerly it was believed that pregnancy exerted a temporarily beneficial effect upon tuberculosis, the mother improving as long as she carried the child, though she frequently succumbed rapidly after its birth. At present, however, it is generally conceded that its effect is almost always harmful. Moreover, the strain incidental to labor and the extra drain upon the system, if the child is suckled, pull such patients down still further, so that the final result is usually hastened. On the other hand, the disease does not appear to predispose to premature interruption of pregnancy, and it is not unusual for tubercu- lous patients to give birth to splendidly developed children at full term. Occasionally tuberculosis may be transmitted from mother to child. Hauser (1898) collected from the literature 18 cases in which the trans- mission of tubercle bacilli was definitely demonstrated. Since then many additional cases of congenital tuberculosis have been recorded, and their significance particularly considered by Chome, and Whit- man and Greene. The latter have collected 38 cases with charac- teristic histological findings, as well as 21 cases in which bacilli could be demonstrated in the foetus and placenta, and three in the foetus only, but as no histological lesions were present it appears doubtful whether the latter can be classified as examples of congenital tuberculosis. In this condition the infection .usually occurs through the placenta by means of the blood current, as is proven by the fact that the most advanced lesions are usually situated in the liver. Following the description by Lehmann of the first cases of placental tuberculosis, the subject has been carefully studied by many investi- gators. Novak and Ranzel, collected 39 such cases in 1910, while Whitman and Greene increased the number to 47 in 1922. As the former investigators found tubercle bacilli in 7 out of 10 placentae from women in various stages of the disease, it is apparent that the condition occurs more frequently than is generally believed, and con- firms the opinion of Baumgarten and Maffucci that the incidence of congenital tuberculosis is generally underestimated. According to Lanz tubercular lesions of the placenta may occur in the following forms: (1) tubercles attached td the periphery of the chorionic villi, but pro- jecting in great part into the intervillous spaces; (2) tubercles in the stroma of the villi, which are due to bacilli which have penetrated the villous epithelium; (3) tubercular changes in the chorionic mem- brane, and (4) caseous tubercular deposits in the decidua basalis. Of these, (1) and (4) are the most frequent, while (2), which is the 550 ACCIDENTAL COMPLICATIONS DUE TO DISEASE lesion most concerned in the production of congenital tuberculosis, has only occasionally been observed. The possibility of germinal infection should also be borne in mind. Friedmann in experiments upon the rabbits and guinea pigs showed that tubercle bacilli may be carried to the ovum by means of the spermato- zoa; while Sitzenfrey has demonstrated in women dying from tubercu- losis the presence of bacilli in the interior of ova while still within the graafian follicle. It is, of course, questionable whether such infected ova would go on to development, hut should it occur, the supposition that the bacilli might lie dormant for some time would afford a plausible explanation for the cases in which the tuberculosis does not become manifest until some time after birth. When one considers, however, the large number of tuberculous wo- men who become pregnant, and the relatively small proportion of cases in which the transmission of the disease to the foetus has been demon- strated, it is apparent that the latter must be an exceptional occurrence. Evidence in favor of this view was supplied by one of my patients, who died from tuberculosis a short time after delivery and in whose lochia tubercle bacilli could be demonstrated during life. At autopsy the child showed no signs of the disease, nor did the lining membrane of the uterus present any tuberculous lesion. It would appear, therefore, that in the vast majority of cases the disease is not transmitted directly from the mother to the foetus, but that the latter is horn with lessened resistance to tuberculosis rather than with the disease itself. Hence it follows that such children should be brought up under the best hygienic surroundings and should not be suckled by their mothers. In view of the fact that the tuberculous process usually becomes exacerbated either during pregnancy or after childbirth, most authori- ties recommend that abortion be induced as a matter of routine in all tuberculous women, and many that they.be rendered sterile by operative means. This appears to be a somewhat too extreme point of view, but I feel very strongly that abortion should be induced in the first preg- nancy occurring after the onset of the disease, or whenever it makes its appearance during the early months of pregnancy, in order to give the patient every opportunity to place herself under such dietetic and cli- matic conditions as may offer every chance of curing or arresting the disease, rather than to run any risk of its exacerbation after labor. If the patient is intelligent, she and her husband should then be warned of the danger of future pregnancies until the process has become either arrested or cured, and the necessary contraceptive advice given. Should conception occur in spite of the warning, I hold that repeated abortion is indicated only in exceptional instances; as otherwise the obstetrician may find himself called upon to repeat the operation at frequent inter- vals. On the other hand, with unintelligent patients such advice is useless, and the propriety of sterilization by operative means should be considered. When the pregnancy is far advanced, I do not consider the induction of premature labor justifiable, as experience teaches that its effect upon the patient is quite as deleterious as labor at term, CHRONIC INFECTIOUS DISEASES 551 while the chances for the child are greatly diminished. Exceptionally, if the mother is so ill that it seems improbable that she will live until the end of pregnancy, the operation may be performed solely in the interest of the child. Malaria.—Despite the somewhat widespread opinion to the contrary, it would appear that the ordinary forms of malaria have but little influence upon the course of pregnancy, although Goth has reported that 19 out of 46 cases ended in premature labor, and Edmonds states that this accident is very common in Africa. Some years ago I studied 15 cases of malaria complicating preg- nancy, the diagnosis being assured by the demonstration of the charac- teristic plasmodium. None of these patients aborted, and in but two did pregnancy end prematurely, and then only a week or so before term. It is probable, however, that the pernicious forms of malaria may have a much more deleterious effect. There is a marked tendency toward recrudescence of the disease during pregnancy and the puerperium, just as is frequently observed after surgical operations. Quinin should be administered unhesitatingly to women suffering from malaria during pregnancy, as its oxytoxic properties are appar- ently in abeyance under such conditions, so that it can be used with impunity without fear of setting up uterine contractions. Syphilis.—Syphilis is one of the most important complications of pregnancy, as it is the most frequent single cause of foetal death. In 1915, I reported that it was responsible for 26.4 per cent, of the 705 foetal deaths occurring in 10,000 consecutive labors under my super- vision. These figures include all deaths occurring after the period of viability has been reached, as well as during the first two weeks fol- lowing labor. They do not, however, tell the whole story of the ravages of the disease, for many children who were discharged alive, either died soon afterwards or presented manifestations of hereditary syphilis later in life. Furthermore, syphilis was demonstrated as the etiological factor in 40 per cent, of our dead-born premature infants and in approxi- mately 80 per cent, of the macerated children, and consequently should be suspected whenever a perfectly satisfactory explanation for the oc- currence of premature labor cannot be adduced. On the other hand, it plays but a small part in the causation of early abortion. In 1920, I reported that a positive Wassermann reaction was present in 11.2 per cent, of 4547 consecutive women passing through our service, but that such findings were less frequent in the white than in the black patients —2.5 and 16.3 per cent, respectively. When infection occurs during pregnancy, owing to the vascularity of the parts, the initial sore may assume larger proportions than under ordinary circumstances. The secondary lesions, however, are often but slightly marked, and may be practically limited to the genitalia, where they appear as large, elevated areas which occasionally undergo ulcera- tive changes, and sometimes lead to the destruction of superficial por- tions of the vulva. In many patients, however, no history of a primary sore or of a rash can be elicited, and the first intimation of the existence of the disease is afforded by the birth of a premature or 552 ACCIDENTAL COMPLICATIONS DUE TO DISEASE macerated foetus, or by the demonstration of a positive Wassermann reaction. The influence of syphilis upon pregnancy differs materially, and three classes of cases are distinguished, according as infection has taken place: (1) before pregnancy; (2) at the time of conception, or (3) during pregnancy. The syphilitic child is often dead when it comes into the world; less frequently it is born alive with definite manifestations of the disease. Again, in a still smaller number of cases, it may be born without signs of the disease, which, however, make their appearance later; while occasionally, particularly when the infection had occurred some years previously, the child may never manifest any signs of the disease. Moreover, my investigations have shown that syphilis is the actual cause of death in many children, which were apparently normal at birth, but succumbed some weeks later to what is usually designated as inanition or marasmus. When inoculation with the specific poison has occurred before con- ception, and is not treated, the disease usually causes premature labor or the expulsion of a macerated foetus. Le Pileur obtained a striking illustration of the disastrous effects of syphilis from a study of the reproductive histories of 130 women before and after its inception, 3.8 per cent, of the children being born dead before, as compared with 78 per cent, after, infection. When the mother is suffering from the affection at the time of conception, the offspring is always syphilitic. The same applies when the infection and conception occur at the same time. On the other hand, when syphilis is contracted during pregnancy, its effect upon the foetus varies. If infection occurs within the first few months, the foetus, as a rule, likewise manifests signs of the disease, but when it occurs later the child may not become infected. Until recently it was generally believed that foetal syphilis was frequently the result of paternal infection, and that a man suffering from the tertiary form might engender a syphilitic child without in- fecting his wife. This belief was based upon the observation that an apparently healthy woman might give birth to a definitely syphilitic child, and be able to suckle it with impunity, whereas it Avould certainly infect another woman. Such an occurrence was well stated in the dictum known as Colie’s law, assuming spermatic infection and a transmission of immunity from foetus to mother. Conversely, it was also believed that a definitely syphilitic mother might occasionally give birth to a healthy child, which would possess a definite immunity against the disease. Such observations gave the basis for Profeta’s law. With the discovery of the Spirochaeta pallida by Schaudinn, and the utilization of the Wassermann reaction as a means of diagnosis, grave doubt has been cast upon the validity of these laws, which are now denied by the great majority of syphilographers. In order for paternal transmission to occur it is necessary to suppose that the syphilitic virus is transmitted to the ovum by means of the spermatozoon. As long as the virus was merely hypothetical this did not seem improbable; but when CHRONIC INFECTIOUS DISEASES 553 Bab pointed out that the spirochete is three times as long as the head of a spermatozoon, it appeared unlikely that the former could enter the ovum along with the latter, unless some sporelike intermediate form exists. Recent investigations concerning other varieties of spirochetes, of which mention was made by Strong in 1923, make it conceivable that this may be the case; as not a few investigators believe that a so-called granular stage represents an important phase in the life-cycle of certain spirochetes. Moreover, Sergent and Foley have shown that monkeys can be infected with recurrent fever by the injection of human blood which contains no visible spirochetes, and consequently hold that the virus of the disease may exist in the blood of man and of the louse in a very minute form. Whether similar observations will be made for the spiro- chaeta pallida remains to be seen. Furthermore, the fact that the appar- ently healthy mothers almost universally present a positive Wassermann reaction has led most investigators to conclude that the immunity is only apparent, and is due to the fact that such women are really suffering from a latent syphilis, which has not given rise to symptoms. It must be admitted that these arguments greatly impair the validity of Colies’s law, as its acceptance implies the existence of a granular form of the spirocheta, as well as the supposition that a positive maternal Wassermann may be due to “immunizing substances” derived from the syphilitic ovum. Nevertheless, I am not prepared to deny such possi- bilities, for the reason that Colles’s law seems to offer a plausible explana- tion for certain definite clinical manifestations, and also because I can- not rid myself of the idea that the constant casting off into the maternal circulation of minute portions of the paternally infected ovum—in the shape of fragments of chorionic villi—would seem to offer an almost ideal means of bringing about active immunity. Boas is the only syphilog- rapher who shares my views, and he states that the question is still sub judice. Moreover, both he and Fildes hold that syphilis on the part of the mother does not necessarily imply infection of the foetus, and have adduced a considerable mass of figures in support of their con- tention. Consideration of the syphilitic lesions of the child and the placenta will be taken up in the chapter upon Diseases of the Ovum. Whenever we obtain a history of syphilis in either parent, no matter whether infection has occurred prior to or after conception, the mother should at once be treated by salvarsan, followed by a course of specific treatment; as by its means not only may she be cured, but, in view of the fact that the arsenical and mercurial salts, as well as iodid of potas- sium, are readily transmitted through the placenta, the foetus is treated at the same time. In hospital services for ward patients, one of the most important func- tions of prenatal care is the recognition and treatment of the syphilitic pregnant woman. As the great majority of such give no history of infec- tion and present no visible manifestations of the disease, this can be accomplished only by routinely taking a sample of blood for a Wasser- 554 ACCIDENTAL COMPLICATIONS DUE TO DISEASE mann test at the first visit. From our own experience, it is safe to say that if efficient treatment is instituted by the fifth month of pregnancy congenital syphilis can be almost entirely eliminated. Furthermore, the pregnant woman is unusually susceptible to its influence, so that it fre- quently happens that an amount of treatment which would be useless in the case of a man, makes the difference between the birth of an infected or a normal child. The treatment, however, cannot be regarded as efficient, unless the Wassermann reaction has remained persistently negative for at least one year after the administration of the last course of salvarsan. Conse- quently, the birth of an apparently normal child should be followed by sufficient additional treatment to insure the complete cure of the mother. In practice of the better class, the routine Wassermann is probably not necessary, and for the present, at least, should be restricted to those pre- senting a history of previous premature labors, or the birth of macerated children. In view of the practical application of Colles’s law, the syphilitic child may be suckled with impunity by its own mother. If, however, she is unable to nourish it, it should never be given to a wet-nurse, but should be fed artificially. Diseases of the Circulatory and Respiratory Systems.—Valvular Le- sions of the Heart.—While the work of Stengel and Stanton, and most recent authors, tends to show that little if any hypertrophy of the heart occurs during pregnancy, the investigations of James Mackenzie indicate that there normally occurs a certain amount of derangement in the cardiac function. He bases his conclusions upon the fact that the fol- lowing conditions may frequently be noted: (1) limitation of the field of cardiac response; (2) changes in the rate and rhythm of the heart; (3) dilatation of the right side of the heart; (4) tendency to edema of the lungs; (5) tendency to overfilling of the veins of the legs, and (6) the occurrence of marked pulsation in the veins of the neck. As all of these conditions are more or less abnormal, and are likely to become greatly accentuated in pregnant women suffering from valvular lesions of the heart, there is good reason for considering such complications as serious. The gravity of valvular disease complicating pregnancy is generally over-estimated, and the mortality of 28 per cent, reported by Guerard, which led him to consider the complication as more serious than eclamp- sia or placenta previa, can be explained only by supposing that his material was made up almost entirely of cases in which compensation had long since failed, and did not include the mild and moderately severe cases which occur relatively frequently in large series of deliveries. The figures of Demelin, Yinay, Kellogg and Fellner indicate that the inci- dence of heart lesions complicating pregnancy varies between 1 and 2.5 per cent., and that only about 2 per cent, of the entire number end fatally. In about three-fourths of the cases the condition is so mild that the woman is not aware of her condition, while in the remainder decom- pensation may develop with more or less serious results. In a series of 94 cases Fellner observed the following lesions: CIRCULATORY AND RESPIRATORY DISEASES 555 Mitral insufficiency 37 Mitral stenosis 5 Combined mitral lesions 34 Aortic insufficiency 3 Aortic and mitral lesions 10 Uncertain lesions 5 Myocarditis 2 He also stated that only one-seventh of such cases showed cardiac mani- festations. Mackenzie holds that systolic murmurs without signs of heart failure are of little significance, and that, while mitral stenosis is more serious, its prognosis is variable. If the process is stationary, the size of the.heart normal, its rate regular and the response good, the prognosis is good; whereas, if associated with enlargement of the heart, poor response and fibrillation, it is very serious. From my own experience, I should say that apparently functional cardiac murmurs are frequently heard in pregnancy, while serious organic lesions occur once in several hundred cases, and are accompanied by dyspnea and edema during the latter part of pregnancy, and occasionally some degree of collapse is noted shortly after labor. On the other hand, one occasionally sees cases with broken compensation associated with such urgent symptoms that artificial interruption of pregnancy is clearly indicated. In several of my cases the symptoms were most alarming. One multiparous patient, suffering from uncompensated mitral disease, collapsed in the last month of pregnancy, with signs of acute dilatation of the heart and intense pulmonary edema. Death was averted by blood- letting and the induction of premature labor; while in others the con- dition was so alarming that cesarean section was performed. It is generally admitted that the most untoward symptoms are ob- served in mitral stenosis. Lusk regarded this lesion as sufficiently serious to warrant the induction of abortion as soon as the diagnosis is made. This, however, is too extreme a view, although it must be admitted that this lesion is more apt to give rise to serious disturbances than all others combined. Thus, Kautsky found that mitral stenosis, either alone or associated with insufficiency, was responsible for the entire mortality in his series of heart cases, and that the mortality was 28 per cent, when that lesion was present. On the other hand, French and Hicks, after studying the obstetrical records of 300 women treated in Guy’s Hospital for this condition, hold that it is no more serious than other lesions; and in support of their statement adduce the fact that 135 of their patients went through 608 labors without a break in compensation. Generally speaking, the prognosis is good so long as compensation is retained, whatever the lesion. To this, however, there are certain ex- ceptions, as Zweifel has recorded two cases in which collapse and death occurred in pregnant women who had previously been absolutely unaware of their condition. On the other hand, if compensation fails, and rest in bed and appropriate therapy do not bring about amelioration of the symptoms, the prognosis becomes ominous; for even if the patient be saved from immediate death by the induction of premature labor, or by cesarean section, serious complications are usually in store for her in the future. 556 ACCIDENTAL COMPLICATIONS DUE TO DISEASE Grave heart lesions complicating pregnancy are generally believed to predispose to premature labor, which was noted in 20.2 per cent, of Fellner’s cases, as compared with 5.5 per cent, in those of French and Hicks. This accident may result from uterine hemorrhage directly at- tributable to the cardiac condition, from the death of the foetus due to insufficient oxidation, or from changes in the placenta. In not a few cases there is more or less profuse hemorrhage immediately following delivery; or again, at the time of labor, owing to the elevation of arterial pressure incident to the uterine contractions, compensation may fail and the woman’s life may be in peril. Moreover, collapse may manifest itself immediately after the expulsion of the child, as a result of the marked fall in the arterial pressure which occurs at that time. If the lesion is fairly compensated the patient should be kept under close observation, rest being ordered and digitalis or some other heart tonic being employed as soon as symptoms appear. If this treatment fails to bring about the desired result, pregnancy should be promptly ended by the most conservative method available. If the patient is allowed to go on to term, owing to the psychical disturbances incident to labor, and the elevation of arterial pressure brought about by the abdominal and uterine contractions, it is advisable to make use of an anesthetic during tthe second stage. As soon as the cervix is completely dilated and the head well engaged in the pelvis, the termination of labor by forceps is indicated. Some authorities recommend that women suffering from heart lesions should be dissuaded from marriage, or, if married, from becoming preg- nant. This, however, appears to be an extreme view, and should only apply when the lesion is serious and the compensation faulty. Myocarditis.—Owing to the difficulty in making an exact diagnosis, myocarditis is rarely recognized during life. Nevertheless, it is a most serious complication of pregnancy, and is one of the frequent causes of sudden death during the second stage of labor and the first few hours of the puerperium. Occasionally cases of tachycardia are observed during pregnancy for which no explanation can be given. Thus, in a multiparous patient the pulse-rate varied between 120 and 140 during the last three months of each pregnancy, but returned to normal within a few days after delivery. As a thorough physical and urinary examination failed to reveal any abnormality, I was forced to make the unsatisfactory and provisional diagnosis of neurotic tachycardia. Endocarditis.—Acute endocarditis may appear during pregnancy, just as at other times. It should always be regarded as a serious matter, but particularly so at this time, as occasionally the bacteria giving rise to it may be transmitted to the foetus and cause its death, while in other cases small portions of the vegetations upon the valves may be broken off and give rise to apoplexy or embolism. Phlegmasia.—Thrombosis of the veins of the thigh, or phlegmasia, is a very rare complication of pregnancy. F. C. Goldsborough in 1904 reported a case observed in my service and collected the literature upon the subject. AYhile there is no evidence that it is due to infection, as is CIRCULATORY AND RESPIRATORY DISEASES 557 the case with puerperal phlebitis, it should be regarded as a serious con- dition, particularly in view of the fact that incautious manipulations may lead to the detachment of small particles of a thrombus, which may then give rise to embolism of the pulmonary arteries. The symptoms and treatment are dealt with in Chapters XLIII and XLIV. On the other hand, thrombosis of the superficial vessels of the leg is frequently observed in women suffering from varicose veins, and can usually be regarded with equanimity. Pulmonary Embolism.—Embolism of the pulmonary arteries is a much rarer complication of pregnancy than of the puerperium. Barnes reports one case which ended fatally within a few moments, while Sperling has reported a second which eventuated in recovery. The con- dition should always be borne in mind in cases of sudden death during pregnancy which cannot otherwise be explained. Emphysema.—When pregnancy occurs in women suffering from ad- vanced emphysema, the dyspnea may become so intense as to demand its artificial interruption. In a certain number of cases premature labor occurs spontaneously, the untimely uterine, contractions being at- tributed to insufficient aeration of the blood. Asthma.—The symptoms of asthma are sometimes markedly aggra- vated during pregnancy. In some patients the disease makes its appear- ance only during pregnancy or at the time of labor, disappearing spon- taneously after childbirth. If the usual methods of treatment fail, cure may sometimes be effected by placing the patient upon an absolute milk diet, although careful analysis of the urine may not indicate the exist- ence of a toxemia. If this is ineffectual, a radical change of air sometimes proves beneficial. Dyspnea.—Almost every woman in the last few weeks of pregnancy suffers more or less from shortness of breath resulting from interference with the motility of the diaphragm by the enlarged uterus. Dyspnea occurring in the earlier months of pregnancy is usually due to cardiac or renal disease, and demands a thorough physical examination. Occa- sionally it follows excessive distention of the uterus, as in hydramnios. Vances.—Owing to the pressure of the pregnant uterus upon the veins returning from the thighs, and the fact that they are but poorly supplied with valves, abnormalities in their circulation are frequently observed during pregnancy, and manifest themselves by the appearance of varicose veins. These may assume considerable proportions in the legs or about the vulva, and give rise to distressing symptoms. When situated in the latter location, their rupture may lead to fatal hemorrhage if medical aid is not available. When they occur in the legs, relief is often obtained by the use of neatly applied bandages or elastic stockings. Active treatment is useless in vulval varices, but the danger of their rup- ture should be borne in mind at the time of labor. Edema.—Edema is a very frequent complication of pregnancy. It may be general and involve any portion of the body, but is usually lim- ited to the lower extremities. Occasionally the vulva becomes intensely edematous. When limited to the extremities, the swelling was formerly attributed to pressure exerted by the enlarged uterus upon the veins 558 ACCIDENTAL COMPLICATIONS DUE TO DISEASE returning from the legs, but Zangemeister considers it due to increased permeability of the capillaries, which he holds is part of a process peculiar to pregnancy—hydrops gravidarum—which is often the forerunner of a true toxemia and manifests itself before the blood pressure becomes elevated or albuminuria appears. In not a few instances, the condition may be recognized by an excessive gain in weight days before manifest edema appears. On the other hand, if the condition be generalized, it is likely to be a manifestation of toxemia, though occasionally it may be due to other causes. The patient should be cautioned as to its significance, and whenever edema appears the urine should be carefully examined. If the kidneys Fig. 458.—Edema of Vulva. are found to be doing their work properly, the swelling is probably of mechanical origin and can be relieved only by restricting the movements of the patient, or even confining her to her bed. If the urinary findings indicate the existence of a toxemia, the condition is more serious, and should be treated as will be indicated in the following chapter. When the marked swelling about the vulva is a source of discomfort and annoyance, and is not relieved by medicinal treatment, relief may be given by puncturing the most dependent portions of the swollen labia and allowing the serum to drain off. This slight operation should always be done under the strictest aseptic precautions, and the labia after- ward covered with sterile dressings, inasmuch as infection can readily occur and may be followed by serious consequences. DISEASES OF ALIMENTARY TRACT AND THE LIVER 559 Diseases of the Alimentary Tract and the Liver.—Icterus.—Preg- nancy is comparatively seldom complicated by jaundice, which is usually due to catarrhal processes in the duodenum or to cholelithiasis. The catarrhal variety is generally without significance and undergoes spon- taneous cure. At the same time, it should be borne in mind that jaundice may represent the onset of acute yellow atrophy of the liver; while its association with pernicious vomiting, toxemia or eclampsia is indicative of profound lesions in the liver, and adds greatly to the seriousness of the prognosis; for this reason simple catarrhal icterus should not be diagnosticated, until a careful examination has excluded such possi- bilities. Epidemics of jaundice have been recorded in various portions of the world, in which the disease ran its usual course in men and non-pregnant women, but was disastrous in pregnancy, some of the women dying in coma and many more aborting or falling into labor prematurely. More- over, it would seem that pregnancy sometimes predisposes to the occur- rence of jaundice, as Van der Velden and others have recorded instances in which it occurred in successive pregnancies and was frequently asso- ciated with hemoglobinuria. It is generally believed that women suffering from jaundice at the time of labor have a tendency to hemorrhage, but this was not noted in the few cases which I have seen. Gall-stones.—The fact that cholelithiasis occurs more frequently in women than in men would suggest a possible association with the repro- ductive function. Acute attacks may occur during pregnancy or the puerperium, and Peterson in 1910 collected 25 operations performed in the former, and 10 in the latter period. It is always a serious com- plication, and operation, if urgently demanded, should be undertaken without regard to the existence of pregnancy. In less urgent cases it is, of course, advisable to postpone interference until after the child has become viable. Acute atrophy of the Liver.—This condition will be considered in the chapter on the Toxemias of Pregnancy. Indigestion.—Pregnant women frequently suffer from indigestion, and the symptoms arising from it are sometimes very distressing. Kehrer is inclined to attribute them, at least in part, to the decrease in the amount of gastric hydrochloric acid, which he considers usual in preg- nancy. Such cases should be treated without reference to the existence of pregnancy. In many instances marked relief follows the adminis- tration of a wine-glass of cream a half hour before each meal. Constipation.—Owing to distention by the growing uterus, the ab- dominal walls may become so impaired in tonicity that considerable difficulty is experienced in evacuating the bowels. Indeed, it may be said that the majority of pregnant women suffer from constipation. This condition should be carefully guarded against in order to avoid auto-intoxication and increased strain upon the kidneys. It is best overcome by appropriate diet, regularity in going to stool, and the occasional use of pills of aloin, belladonna, and strychnin, the fluid extract of cascara, or compound licorice powder. Mineral oil by itself 560 ACCIDENTAL COMPLICATIONS DUE TO DISEASE does not give satisfactory results, but when taken in combination with the milder laxatives, it enables one to decrease the dose of the latter. The stronger cathartics should be avoided on account of their tendency to cause abortion. Enteroptosis.—The neurasthenoid symptoms which so frequently accompany enteroptosis are often markedly ameliorated during preg- nancy, inasmuch as the steadily enlarging uterus may tend to restore the displaced viscera to their normal positions. The comfort of the patient can be added to appreciably by the use of rational clothing, and especially by the application of a properly adjusted abdominal supporter. The condition, however, is prone to recur after childbirth unless the patient takes on considerable flesh. According to Maillart the improve- ment is sometimes permanent, especially if the relaxation of the abdom- inal walls be counteracted by the use of a snugly fitting binder during the puerperium and a suitable abdominal supporter afterward. Salivation.—In exceptional instances the salivary secretion becomes markedly increased during pregnancy. As a rule, this is not a serious complication, but now and again the amount of saliva is so great as to cause the patient great annoyance, and sometimes even prevent her from sleeping. One of my own patients expectorated between 500 and 600 cubic centimeters of clear fluid every day for several weeks, while Lvoff has reported several cases in which the secretion in the twenty-four hours varied from 1,000 to 1,600 cubic centimeters. The condition is usually attributed to a reflex neurosis incident to pregnancy, but sometimes it is a manifestation of toxemia. In the first class of cases the treatment is very unsatisfactory, astringent mouth washes, and even comparatively large doses of atropin, being without effect. On the other hand, when the condition is a manifestation of toxemia, prompt amelioration may follow the use of a rigorous milk diet. It sometimes happens that the cloudy fluid which is supposed to be saliva, in reality represents regurgitated gastric secretion. My assistant, John G. Murray, Jr., had under his care a patient, apparently suffering from salivation, and who was daily excreting nearly a liter of fluid. Chemical examination in our laboratory revealed the surprising fact that the fluid presented an acid reaction, which was due to the presence of hydrochloric acid in the same proportion as in gastric juice. How fre- quent such an occurrence may be can only be determined by future in- vestigation. Gingivitis.—Exceptionally, the gums of pregnant women become in- flamed and spongy, and bleed upon the slightest touch. The condition is usually observed in run-down individuals, and is very refractory to treatment, although in many cases it disappears almost immediately after delivery. It is best met by the employment of astringent mouth washes, especially those containing tincture of myrrh, combined with general tonic treatment ard an abundant diet. Dental Caries.—Many women suffer during pregnancy from dental caries, which may be associated with more or less severe toothache. It is a popular belief that pregnancy predisposes to the condition, as is evidenced by the saying, “For every child a tooth.” It is probable that DISEASES OF THE KIDNEYS AND URINARY TRACI 561 the condition is somewhat allied to the minor degrees of osteomalacia which occur only during pregnancy. Such patients should be referred to a skillful dentist, and at the same time should drink considerable quan- tities of milk, and take calcium chloride. Diseases of the Kidneys and Urinary Tract.—Chronic Nephritis.— Pregnancy occurring in patients suffering from chronic nephritis is always a serious complication, and will be considered in the chapter on the Toxemias of Pregnancy. Glycosuria and Diabetes.—Blot, in 1856, stated that sugar could usually be found in the urine of lactating women; but after it had been demonstrated that the condition was a lactosuria, the belief gained ground that the existence of true diabetes was inconsistent with con- ception. This view was first combated in 1882 by Matthews Duncan, who was able to find in the literature 22 cases in wrhich pregnancy was complicated by diabetes, and he laid down the dictum, which received general acceptance, that such an association was extraordinarily serious. True diabetes is rarely noted in pregnant women, and may exist before the inception of pregnancy, or may occur during its course. The prognosis is generally believed to be ominous for mother and child. In the 66 cases which I collected, 27 per cent, of the mothers died at the time of labor or within two weeks afterward, while an additional 23 per cent, perished during the following two years. Moreover, about one- eighth of the pregnancies ended in abortion or premature labor, and one- third of the children going to term were born dead. Such statistics give too gloomy a picture, as they are based mostly upon severe cases, and do not take into account the milder ones, which are usually not reported. Joslin takes a similar view, and considers that many serious cases can be carried safely through pregnancy provided that modern anti-diabetic treatment is intelligently employed. Furthermore, in several of my patients, who had suffered from diabetes for years, the glycosuria dis- appeared spontaneously during the second half of pregnancy to reappear some weeks after delivery. In such cases it might plausibly be assumed that the pancreas of the foetus had temporarily compensated for a pan- creatic deficiency on the part of the mother. Leipmann has stated that diabetic women are particularly prone to infection at the time of labor, and that gangrenous processes may occur in the uterus, in the form of metritis dessicans, just as are sometimes noted in other portions of the body in non-pregnant individuals. It is interesting to note that 7 of the 26 cases collected by Graefe were complicated by hydramnios, and that in five of these sugar could be demonstrated in the liquor amnii. According to Bossa, Ludwig, and Offergeld, such an occurrence may be regarded as affording presumptive evidence that the amniotic fluid is a maternal transudate, since no trace of sugar could be detected in the foetal urine. On the other hand, too much emphasis cannot be laid upon the fact that the mere demonstration of sugar in the urine does not justify the diagnosis of diabetes with its serious prognosis. With the ordinary Fehl- ing test, I obtained a distinctive reaction for sugar in about 5 per cent, of all women in the last months of pregnancy. Ordinarily this is due 562 ACCIDENTAL COMPLICATIONS DUE TO DISEASE to lactosuria and is of no clinical significance, but occasionally a true glycosuria is present. This occurs about once in 100 or 150 cases, and the amount of glucose may vary from to 2 or 3 per cent, without materially complicating the prognosis, as the patients suffer no discomfort and are safely delivered at term, after which the sugar disappears. Moreover, I have seen the condition recur in succeeding pregnancies. If more accurate chemical methods be used, sugar can be detected much more frequently, and Commandeur and Porcher state that traces occur at some time in the course of every pregnancy. They found glucose or lactose in 20 and 80 per cent, of their cases, respectively, and occa- sionally both varieties together. Four theories have been advanced to explain the production of this variety of glycosuria. Payer and others have shown that pregnant women are less tolerant of sugar during pregnancy than at other times, as he was able to produce alimentary glycosuria in 80 per cent, of his patients by increasing the amount of sugar ingested. Commandeur and Porcher hold that the condition is due to the inability of the non-functioning breasts to convert glucose into lactose, as normally occurs during lacta- tion; while Hofbauer believes that it is dependent upon hepatic insuffi- ciency, which he considers is an exaggeration of the fatty changes at the periphery of the liver lobules, which he has described as a concomitant of normal pregnancy. Benthin, however, as the result of careful investi- gation of the sugar content of the blood, is very skeptical concerning the part played by hepatic insufficiency, and is inclined to believe that hyper- glycemia and glycosuria should be attributed to alterations in function of some of the ductless glands—the pituitary, according to Wallis and Bose. Novak, Porges and Strisower in 1913 advanced the view that in certain cases the glycosuria of pregnancy is due to increased permeability of the kidneys and not to any perversion in the carbohydrate metabolism. Kustner, and Wallis and Bose share this opinion, and the former holds that whenever glucose is present in the urine, while the blood sugar content is less than 200 milligrams, the condition must be considered as renal in origin. They, therefore, conclude that glycosuria of this char- acter is in no way related to diabetes, but represents a temporary phenom- enon incident to pregnancy, and Kustner considers that he has adduced experimental evidence that it is in some way associated with the ovarian function. Due to the frequent occurrence of lactosuria, the first essential, fol- lowing a positive reaction with Fehling’s solution, is to determine by the fermentation test or the polariscope whether lactose or glucose is present; if the former, no anxiety need be felt, as lactosuria is a perfectly physiological phenomenon. On the other hand, if glucose is present, the matter is not so simple, as it is often difficult to determine whether it is a manifestation of true diabetes or merely of an alimentary, renal, or recurrent glycosuria. The former should be diagnosticated if it is found that the condition existed prior to pregnancy, or if large amounts of glucose are demon- strable in the blood, but more particularly if the characteristic symptoms DISEASES OF THE KIDNEYS AND URINARY TRACT 563 of thirst, emaciation, and dyspnea are present. A probable diagnosis of alimentary glycosuria is permissible if the glycosuria disappears upon regulation of the diet; while renal glycosuria should be diagnosticated if examination of the blood demonstrates the absence of hyperglycemia. Occasionally, however, slight glycosuria persists, notwithstanding the most rigorous antidiabetic regime; in such cases the patient should be carefully watched and the urine examined daily, and the pregnancy promptly terminated upon the first appearance of untoward symptoms. Fortunately, this has never been necessary in my experience, as the patients usually go through pregnancy and labor without difficulty, and the glycosuria disappears during the first days of the puerperium. Hematuria.—The passage of bloody urine is rarely observed during pregnancy, therefore its occurrence should always lead one to suspect and search for a serious lesion of the urinary tract. Nevertheless, Chiaventone has described an idiopathic hematuria due to pregnancy, and has collected 18 similar cases from the literature. He considers that the hemorrhage is probably due to histological changes in the kidney which result from a toxemia. In the absence of a more serious lesion, the bloody urine may be due to the presence of varicose veins in the wall of the bladder. Pyelitis and Pyelonephrosis.—According to Vinay, attention was first called to this complication of pregnancy by Eeblaud in 1892. Opitz in 1905 collected 84 cases, and since then an immense literature has ac- cumulated upon the subject. The disease usually appears in the latter half of pregnancy, when the patient, who had previously been well, or had merely complained of slight vesical irritation, is suddenly seized with intense paroxysmal pains, usually in the right renal region. This is accompanied by a marked ele- vation of temperature and occasionally by chills, the temperature some- times running a hectic course. Urinary examination reveals the presence of pus cells and bacteria. If the process goes on to the development of a pyelonephrosis, palpation shows that the affected kidney is definitely enlarged. In this event, the pain may disappear and the kidney become suddenly smaller after the passage of a large amount of purulent urine, the symptoms reappearing as the kidney fills again. If this condition is neglected, the patient may succumb to a septic process. Pyelitis results from compression of the uretter at the brim of the pelvis by the pregnant uterus, with damming back of the urine, to which must be added an infectious process. The latter may be due to an exten- sion upward from the bladder, or to transmission of bacteria through the blood or lymph channels, or from the intestines. Bacillus coli is the usual infecting agent, but the streptococcus, gonococcus, or tubercle ba- cillus is sometimes concerned. Ordinarily pain in one lumbar region, the palpation of the enlarged and tender kidney and the characteristic urinary findings, as well as the occasional detection of the enlarged and sensitive ureter on vaginal examination, should make the diagnosis clear. Yet the condition is frequently mistaken for appendicitis and occasionally for typhoid fever or salpingitis. The treatment consists of rest in bed and an abundant but bland diet, together with large quantities of water and milk, and enough sodium 564 ACCIDENTAL COMPLICATIONS DUE TO DISEASE bicarbonate to convert the urinary reaction from acid to alkaline. For this purpose 30 grains, administered every four hours, is usually suffi- cient, but occasionally larger doses may be necessary. In my experience better results are obtained in this way than by the use of hexamethyle- namin, which was formerly extensively employed. Ordinarily improve- ment is rapid, but if it does not take place and the condition becomes alarming, premature labor should be induced without hesitation, as the emptying of the uterus removes the ureteral obstruction and allows of free drainage from the kidney into the bladder, the establishment of which, as a rule, is followed by complete recovery. Irrigation of the bladder, the ureters, or renal pelves is rarely necessary. Occasionally, in cases of pyelonephritis, the process may continue after emptying the uterus, and necessitate nephrotomy or even removal of the kidney. I see each year many patients with pyelitis, and the great majority recover spontaneously; occasionally the induction of premature labor is necessary. In two neglected cases death occurred from a general septic process, due in one instance to the streptococcus, in the other to the gonococcus. Floating Kidney.—The symptoms arising from a movable or floating kidney are usually considerably alleviated during pregnancy, as the en- larged uterus tends to retain the organ in its normal situation. In rare instances, however, the pedicle of the kidney may become twisted and give rise to intense pain, which may be mistaken for renal colic or appen- dicitis. Careful taxis will usually suffice for reduction, after which the symptoms at once disappear. Owing to the increased laxity of the abdominal wall following child- birth, the symptoms are apt to become aggravated when the patient gets about, unless she has taken on considerable flesh, so that sufficient fat has formed about the kidney to hold it in place. A snugly applied ban- dage should be worn through the puerperium. Dislocation of the Kidney.—Cragin has reported an instance in which a congenitally displaced kidney, occupying the pelvic cavity, led to symp- toms of incarceration, necessitating its removal. He collected five some- what similar cases, while Stephans collected the literature upon the sub- ject up to 1912. The condition usually escapes recognition until it gives rise to dystocia, but in one of our cases, in which the condition had been discovered at a previous laparotomy, the displaced organ was gradually pushed out of the pelvic cavity by the enlarging uterus, so that easy spontaneous labor occurred. Pregnancy After Removal of Kidney.—With the extension of renal surgery it is not uncommon to have to consider what may he the out- come in women who have become pregnant after the removal of one kid- ney on account of tuberculosis, pyelonephritis or other lesions. Bleynie in 1910 collected 35 such cases from the literature, while 11 years later Matthews studied 265 labors occurring in 241 nephrectomized women, and I see several such cases each year. Owing to the fact that the potential renal function is much in excess of the needs of the individual, such women do perfectly well provided the remaining kidney is normal. On the other hand, if it is the seat of chronic nephritis irreparable damage may result from the additional DISEASES OF THE NERVOUS SYSTEM 565 strain incident to pregnancy; while the development of a toxemia must be regarded as much more serious than in a patient with two kidneys. Accordingly, in the absence of symptoms, such patients should be care- fully watched, and each month accurate chemical and functional tests should be made in order to make sure that the single kidney is function- ing satisfactorily, which is fortunately the case in most instances, when spontaneous labor occurs at term. Of the 265 labors reported by Mat- thews 250 were spontaneous and only two of the patients died. On the other hand, if the patient is suffering from chronic nephritis, abortion should be induced as soon as the diagnosis is made, and followed by a sterilizing operation unless the patient is cooperative enough to make intelligent use of contraceptive means. Moreover, premature labor should be induced at the first sign of the development of a toxemia. Cystitis.—Pregnancy is occasionally complicated by cystitis, which is usually due to gonorrheal infection, though the colon bacillus may be the infective agent. In view of the possibility of an ascending pyelitis and a resulting pyelonephritis, the condition demands prompt treatment. Floating Spleen.—Occasionally an enlarged spleen occupying the lower abdomen may be mistaken for the pregnant uterus. If pregnancy supervenes, it is usually uninfluenced by the floating organ, which is gradually forced into its normal position as the uterus enlarges. Occa- sionally, however, pronounced peritonitic symptoms may appear as the result of torsion of its pedicle, when splenectomy will be indicated. The literature upon the subject up to 1907 has been well reviewed by Heil. Diseases of the Nervous System.—Paralysis.—Paralysis of central origin sometimes occurs during pregnancy, and is generally associated with toxemic or septic processes. Thus, in the toxemias of pregnancy and eclampsia, serious disturbances may follow edema of the brain or apoplexy. In infectious processes thrombosis may occur in the cerebral vessels, and occasionally emboli may cut off the circulation of large areas of the brain and lead to various paralyses and even to death. Paraplegia of spinal origin occasionally occurs, but, except in rare cases of toxemia, is not directly dependent upon the existence of preg- nancy. It does not appear that spinal paraplegias interfere with con- ception, as women suffering from them frequently become pregnant. In this event, as well as in women with advanced tabes dorsalis, the course of pregnancy is usually uncomplicated and the labor easy and compara- tively painless. Neuralgia.—Neuralgic pains are frequent concomitants of pregnancy. In rare instances they are very obstinate and resist all treatment, though they often disappear spontaneously after labor. During the later months of pregnancy the head of the child, after descending into the pelvis, may compress one or other sciatic nerve and give rise to severe pain along its course, which is sometimes accompanied by intense muscular spasm. Owing to its mode of origin, this form of sciatica is not amenable to treatment. Neuritis.—Whitfield, Eulenberg, and others have directed attention to an idiopathic neuritis which occurs during pregnancy. Many cases are associated with severe vomiting of pregnancy, and, as the toxemic 566 ACCIDENTAL COMPLICATIONS DUE TO DISEASE origin of the latter has become recognized, the neuritis is considered as a manifestation of the same process, and not as the result of pressure. It usually disappears spontaneously, but slowly, after childbirth. The affection may be limited to a single nerve, or may appear as a multiple neuritis. It is characterized by paralysis of the affected region associated with muscular atrophy and the presence of the characteristic reaction of degeneration. There is marked sensitiveness along the course of the affected nerves, which is frequently associated with shooting pains. Sen- sibility of the parts is markedly impaired, and the patients frequently suffer from parasthesiae. Occasionally the symptoms are so severe that the induction of abortion or premature labor may be justifiable. Chorea.—Pregnancy occasionally occurs in choreic individuals, while in rare instances the disease does not appear until after conception. In the first class of cases it is comparatively unimportant, while in the latter the choreic movements are sometimes so intense as to interfere with sleeping or the taking of food. In these cases of chorea gravis the patient becomes maniacal, and may abort spontaneously. The appear- ance of fever is of serious import, and at autopsy evidences of malignant endocarditis are present. Buist has collected 255 cases of chorea complicating pregnancy, with a mortality of 17.5 per cent. French and Hicks in 1906 reported 29 cases which had been observed in Guy’s Hospital in the previous thirty years, with a mortality of 10 per cent. Many of the cases did well upon the usual medicinal treatment. They are skeptical as to the value of the induction of premature labor, but lay great stress upon the serious prognostic import of the appearance of fever. The only case of the grave variety which I have seen died, in spite of the fact that she fell into premature labor spontaneously shortly after entering the hospital. Albrecht holds that the condition is usually toxemic in origin, and re- ports that cure promptly follows the intravenous injection of 20 c.c. of blood serum obtained from a normal pregnant woman. Epilepsy.—This disease appears to have no effect upon pregnancy, though at the time of labor it may be mistaken for eclampsia by inex- perienced observers. If the attacks are frequent, the patient should be put upon large doses of potassium bromid and treated just as at other times. As a rule, it is not advisable to allow the mother to nurse her child, as lactation sometimes appears to aggravate the disease, while serious injury might possibly be done to the child during an attack. Hysteria.—Hysteria is a not infrequent complication of pregnancy, but does not appear to exert a deleterious influence upon its course. Indeed, the physical condition often undergoes marked improvement at such times. Occasionally, however, the hysterical symptoms may become aggravated. Many authors have of late been inclined to attribute the nausea and vomiting of pregnancy to a neurosis, which, in my experi- ence, is the dominating factor in most cases, but it cannot be regarded as the sole cause of the condition. Tetany.—In rare instances tetany may occur during the course of pregnancy, Meinert, in 1898, being able to collect 20 cases from the DISEASES OF THE NERVOUS SYSTEM 567 literature. In some patients the disease appears only during pregnancy and is absent at other times. H. M. Thomas reported a case in which the condition had appeared in 6 successive pregnancies, and gave a full resume of the literature up to 1895. Formerly tetany was thought to be connected in some way with abnor- malities of the thyroid gland, as it sometimes occurred after the removal of that organ. Following the experimental work of Frommer, Adler and Thaler, which was well reviewed by Seitz in 1913, it has been shown to be due to the absence or imperfect secretion of the parathyroid bodies; as it has been demonstrated that portions of the parathyroids could be removed from white rats without effect, but that symptoms of tetany would appear whenever the animals became pregnant. Kehrer reports that excellent results follow the administration of calcium chlorid, just as in non-pregnant persons. Goiter.—We have already referred to the slight enlargement which the thyroid normally undergoes during pregnancy. Bignami has reported a case which, in his opinion, proved that pregnancy occasionally exerts a pathological influence upon this gland. During his patient’s first preg- nancy the thyroid underwent considerable hypertrophy, but returned to its normal size after delivery. The condition returned in the second pregnancy, the enlargement reaching such proportions that death resulted from suffocation. While moderate degrees of exophthalmic goiter occur relatively fre- quently in women, there is but little evidence that pregnancy plays any part in its production. On the other hand, the existence of pregnancy frequently leads to an exacerbation of the symptoms, which was noted in 60 per cent, of the 112 cases collected by Seitz, who recorded a fatal issue in 7 instances. Serious consequences are to be apprehended espe- cially when the condition is associated with a persistent thymus, and when death occurs it is usually due to circulatory conditions or to a general intoxication. The child is but little affected, although there is some evidence to indicate that the tendency toward spontaneous prema- ture labor is increased. Formerly, the induction of premature labor was recommended when- ever the symptoms became urgent, but with increasing surgical knowl- edge it has found a formidable competitor in immediate operation upon the thyroid. In several of my patients the tachycardia was considerably exag- gerated during the latter part of pregnancy, but became less marked after delivery. In none, however, were the symptoms sufficiently urgent to justify terminating the pregnancy. Apoplexy.—Apoplexy is rarely observed during pregnancy, though it is an occasional complication of eclampsia. When it occurs independ- ently of the latter disease, it is usually the result of emboli due to endo- carditis, or to phlebitis of the lower extremities. Disturbances of Vision.—Disturbances of vision are rarely observed during pregnancy, but inquiries should always be made and the patient cautioned concerning their diagnostic significance if they appear. Amaurosis or total blindness occurring at this time is generally due to 568 ACCIDENTAL COMPLICATIONS DUE TO DISEASE albuminuric retinitis, and the first indication of a serious renal affection is sometimes afforded by an ophthalmoscopic examination. Diseases of the Blood.—Pernicious Anemia.—According to Osier, this complication was first described by Channing in 1842. Since then a considerable literature has accumulated upon the subject, which is well reviewed in the articles of Petersen, and Esch. The disease occasionally appears during pregnancy, but most frequently not until after labor. It is characterized by marked pallor and anemia, which are associated with weakness and shortness of breath, the extremities also becoming edematous. Most recent writers tend to attribute it to a toxic condition associated with pregnancy, but no evidence has been adduced concerning its nature. A positive diagnosis is made by the microscopical examination of the blood, when the number of red blood cells is found to be markedly diminished. Many of the corpuscles are irregular in shape, while nucle- ated varieties are not infrequently observed. At the same time there is a relative increase in the amount of hemoglobin, though its total amount is considerably below normal. As a rule, the disease ends in death if not properly treated, and marked fatty degeneration of the various organs is found at autopsy. Fowler’s solution should be administered in in- creasing doses, beginning with 5 drops 3 times a day, and occasionally actual transfusion of blood is necessary. Leukemia.—Leukemia is a very rare complication of pregnancy, Herman and H. Schroeder being able to collect from the literature only 8 and 10 examples, respectively. In 4 cases the disease had existed before the onset of pregnancy, while in the remainder it appeared after its inception. It exerts no direct effect upon gestation, though the asso- ciation of the two conditions may seriously affect the mother. In several instances premature labor resulted, after which the symptoms underwent marked amelioration. The diagnosis is rendered probable by the existence of marked anemia associated wfith enlargement of the spleen, and is placed beyond doubt by a differential blood count. Examination of the foetal blood indicates that the characteristic leukocytes are not transmitted to the foetus. In view of the good results which sometimes follow spontaneous premature labor, pregnancy may be terminated artificially in serious cases. Lead Poisoning.—0. Paul studied the histories of 141 pregnancies occurring in women suffering from chronic lead poisoning, and found that 86 ended in abortion or premature labor. Moreover, a large num- ber of the children which were born alive perished at an early period, only 10 per cent, remaining alive at the tenth year. There is no doubt that the lead is transmitted through the placenta, as in a premature child examined by Lewin 16 per cent, of the total weight of the liver was due to it. Erongea states that lead poisoning not only leads to abortion or premature labor, but is a potent cause of sterility; as in the lead works of Sardinia 20 per cent, of the married women are sterile, and an addi- tional 23 per cent, have only one child. Experiments reported by Weller in 1915 indicate that the deleterious effect of lead poisoning may be traced to either parent. He found that DISEASES OF THE SKIN 569 sterility was common when normal female guinea pigs were mated with males suffering from chronic lead poisoning, and when pregnancy resulted the young were subnormal in weight and exhibited an increased mortality after birth. Likewise, when normal males were united with poisoned females, still births occurred very frequently, and the living offspring were undersized. In the light of his experiments, Weller be- lieves that lead exerts a direct unfavorable influence upon the germ cells and the early ova. Diseases of the Skin.—Impetigo Herpetiformis.—Hebra was the first to call attention to the serious nature of this disease, which occurs almost exclusively in pregnant or puerperal women, and is characterized by superficial pustules, which are arranged in groups or clusters with in- flammatory bases. New lesions appear on the borders of older and crusted confluent patches, while recovery takes place in their centers. The lesions occur on the trunk, thighs, and in the neighborhood of the genitalia, but rarely upon the face. They are accompanied by itching and constitutional symptoms, chills and high fever. The recorded mor- tality is about 75 per cent., Debreuihl having collected 24 cases with 18 deaths. The disease, as a rule, does not lead to abortion or premature labor, and many of the women affected with it died undelivered. Accord- ing to Scheuer, it is toxemic and not bacterial in origin. The treatment is purely palliative, but in view of the serious prognosis it may be advisable to adopt Mayer’s suggestion and inject into a vein small quan- tities of blood serum obtained from normal pregnant women. Herpes Gestationis.—This disease, more frequently known as derma- titis herpetiformis, is an inflammatory, superficially seated, multiform, herpetiform eruption, which is characterized by erythematous, vesicular, pustular, and bullous lesions. It occurs occasionally in pregnant women, and is accompanied by marked burning and itching. It pursues a chronic course, is often attended with fever, and sometimes may even end in death. Diihring believes that it is probably toxemic in origin, though similar lesions sometimes occur during the course of sepsis. In view of its de- pressing character, the patient should be placed upon tonic treatment, while the itching is best allayed by the use of ointments or lotions con- taining oil of cade, carbolic acid, or similar substances. Pruritus.—Itching may occasionally be a distressing complication. It may extend over the greater part of the body or be limited to the genitalia. General pruritus should be regarded as a neurosis, which is probably toxemic in origin. It often gives rise to intense suffering, the itching sometimes being so constant that the patient is unable to sleep. In some patients the loss of rest and the nervous strain attendant upon it exert a marked influence upon the general condition. Such cases are best controlled by the administration of sedatives and general tonic treat- ment. A rigid milk diet is sometimes followed by excellent results. When the condition is not amenable to treatment and the patient shows objective signs of exhaustion, the termination of pregnancy may be jus- tifiable. Genital pruritus—pruritus vulvae—may be due to several causes. 570 ACCIDENTAL COMPLICATIONS DUE TO DISEASE among which are irritating vaginal discharges, parasites or glycosuria. When due to the first-named cause, the condition is best treated by the administration of astringent vaginal douches and the maintenance of absolute cleanliness. At the same time the itching may be allayed by the employment of ointments containing cocain, menthol, or carbolic acid. Pruritus of diabetic origin is observed but rarely, but the possi- bility of its occurrence should always be borne in mind and the urine examined. If sugar is present, relief can be obtained only by placing the patient upon a suitable diet, while at the same time appropriate oint- ments should be employed. Occasionally intense itching about the anus may be due to the presence of seat-worms, which are best destroyed by the use of rectal enemata of infusion of quassia. If local measures prove ineffectual, a dose of 5 grains of santonin at night, followed by Kochelle salts the next morning, will often bring about the desired result. Abnormalities of Pigmentation.—During pregnancy abnormalities in pigmentation are frequently noted, which are particularly marked along the linea alba and about the breasts. In other cases unsightly, more or less symmetrical yellowish splotches—cloasma—appear upon the face. They are not amenable to treatment, but usually disappear promptly after childbirth. Hematoma of the Abdominal Walls.—Stoeckel has reported two cases: of hematoma of the abdominal walls occurring during pregnancy. In one case the tumor was situated in the sheath of the right rectus muscle just above the symphysis, while in the other it appeared as a large mass in the right hypogastric region, and was mistaken for the head of the child. The condition resulted from rupture of the inferior and superior epigastric artery respectively. Relaxation of the Pelvic Joints.—Owing to the great vascularity incident to pregnancy, the various pelvic joints always show a somewhat increased motility. Occasionally, however, the softening of the inter- articular cartilage at the symphysis pubis admits of such abnormal motion in the joint as to interfere seriously with the comfort of the patient, who suffers from intense dragging pains in the pelvis and lower abdomen; while at the same time the gait may be so profoundly altered as to suggest the existence of cerebral or spinal trouble. In such cases the application jf a tightly fitting bandage about the thighs is followed by marked improvement, though occasionally the symptoms are so pro- nounced that the patient is obliged to take to her bed. The condition usually disappears spontaneously during the course of the puerperium, but in exceptional instances it may persist and give rise to such great discomfort that it may become necessary to “wire” the joint. Similar relaxation may involve the sacro-iliac joints and cause great suffering. Particular attention has been directed to its frequency and significance by Goldthwait and Osgood. In many instances great relief may be afforded by applying adhesive strips, which extend outward from the posterior surface of the sacrum to the external portion of the thighs. Accidents during Pregnancy.—The pregnant woman is exposed to the same possibility of injury as at other times. Prognosis is not altered SURGICAL OPERATIONS DURING PREGNANCY 571 except that abortion or premature labor may often occur. Pregnancy itself may be complicated by accidents which are incident to that con- dition, the most important being rupture of an extra-uterine pregnancy, rupture of the uterus, and premature separation of the placenta—all very serious complications. Their mode of production and treatment will be considered in detail in the appropriate chapters. Surgical Operations during Pregnancy.—Formerly it was believed that the performance of surgical operations during pregnancy would almost inevitably bring about abortion or premature labor, even the extraction of a tooth being considered a serious procedure. At present, however, thanks to anesthesia and a perfected surgical technic, many operations can be performed at this time with but little additional risk. Accordingly, whenever a condition arises in the pregnant woman which imperatively demands surgical treatment, the necessary operation should be performed without hesitation. At the same time, if the indication is not pressing, it is advisable to defer interference until after delivery, so as not to subject the patient to an added strain. A review of the literature goes to show that amputations are not more dangerous than at other times. I removed one kidney on account of a rapidly growing hypernephroma at the end of the fourth month of pregnancy, and the patient was delivered spontaneously at term; and Schmidt in 1915 collected from the literature thirty-six cases in which nephrectomy was performed, and had no effect upon the course of pregnancy in twenty-eight instances. Furthermore, numerous cases are on record in which paranephritic or broad-ligament abscesses have been opened. Tumors of the generative tract can likewise be excised without great risk or markedly increasing the danger of premature labor. These conditions are considered in the chapter upon the Complication of Preg- nancy by Diseases and Abnormalities of the Generative Tract. Appendicitis.—Appendicitis probably occurs as frequently during pregnancy as at other times, but until recently it was usually overlooked. Renvall in 1908 recorded 25 personal cases, and collected 253 cases from the literature. It should be regarded as a very serious complication, as many women die if not operated upon, while the surgical procedures undertaken for its relief are frequently followed by premature labor. Pregnancy does not predispose to its occurrence, but in cases of chronic disease, in which the appendix has become adherent to the appendages or uterus, exacerbation may result from the traction exerted by the enlarging organ. Moreover, when the process has eventuated in abscess formation, the rapid decrease in the size of the uterus following delivery may readily bring about rupture of the abscess walls. The symptoms do not differ from those observed in non-pregnant women, but the condition is frequently not recognized, as the pains are often considered as being due to the pregnancy itself, while the disten- tion of the abdominal walls by the enlarged uterus makes difficult the appreciation of the rigidity and muscle-spasm, which are usually valu- able diagnostic aids. One should always consider the possibility of appendicitis when a 572 ACCIDENTAL COMPLICATIONS DUE TO DISEASE pregnant woman complains of pain in the right side of the abdomen, associated with an elevation of temperature and pulse, provided some more satisfactory explanation for the condition cannot be found. It should, however, be remembered that pyelitis or inflammatory conditions of the appendages may give rise to identical symptoms. At the time of labor and during the puerperium its recognition is still more difficult, and many women have died from perforative peritonitis with the diag- nosis of puerperal infection. Operation is indicated in all cases in the early months, as abortion is not likely to occur unless the uterus is subjected to much manipula- tion. Later in pregnancy the presence of the enlarged uterus renders it difficult to expose the parts satisfactorily, and may seriously interfere with proper drainage should it prove necessary. In view of this diffi- culty, it is suggested that the uterus be emptied by cesarean section before attacking the appendix. I, however, do not believe that this is always necessary, and am convinced that its general adoption will add to the gravity of the operation. In the latter months premature labor is frequently observed, particularly in cases of abscess formation. It may be due to one of several factors—manipulation of the uterus, fever, and, when an abscess has formed, to the direct transmission of bacteria from it to the foetus. Intestinal Obstruction.—This rare complication of pregnancy should be treated upon general surgical principles. I have seen two cases. In the first intussusception occurred at the site of a tubercular ulcer, and death followed resection of the gut; while in the second case obstruction was due to constriction by a peritoneal adhesion in a case of tubercular peritonitis. This was relieved by operation, and the patient was deliv- ered at term, but died some weeks later from miliary tuberculosis. LITERATURE Adler u. Thaler. Exp. und klin. Studien liber die Graviditats-tetanie. Zeitschr. f. Geb. u. Gyn., 1908, 194-223. Ahlfeld und Marchand. Ahlfeld’s Lehrbuch der Geburtshiilfe, II. Aufl., 1898, 239. Albrecht. Zur .ZEtiologie der Chorea gravidarum. Zeitsehr. f. Geb. u. Gyn., 1915, lxxvi, 677-684. Archambaud. Le tetanos pendant la grossesse. La Revue med., 1896, 413. Bab. Bakteriologie u. Biologie der kongenitalen Syphilis. Zeitschr. f. Geb. u. Gyn., 1907, lx, 161-211. Ballantyne and Milligan. A Case of Scarlet Fever in Pregnancy, with Infec- tion of the Foetus. Trans. Edinburgh Obst. Soc., 1893, xviii, 177. Bar et BoullE. Grippe et puerperalite. L’obstetrique, 1898, iii, 193-214. Barnes. On the Thrombosis and Embolia of Lying-in Women. Trans. Lond. Obst. Soc., 1863, iv, 30-53. Behm. Ueber intrauterine Vaccination. Zeitschr. f. Geb. u. Gyn., 1882, viii, 1-21. Benthin. Uebpr den Kohlehydratstoffweehsel in der Graviditat, etc. Monats- schr. f. Geb. u. Gyn., 1913, xxxvii, 305-321. Bignami. Tiroidismo e gravidanza. Ref. 1’obstetrique, 1896, i, 174. Bleynie. De l’avenir des femmes nephreetomisees qui deviennent enceintes. Thfese de Paris, 1910. LITERATURE 573 Blot. De la glycosurie physiologique chez les femmes en couches, etc. Comptes rendus de l’acad. des sciences, 1856, xliii, 676. Boas. Die Wassermann’sche Beaktion. Berlin, II. Aufl., 1914. Bollinger. Ueber Menschen- und Thierpocken. Volkmann’s Sammlung klin. Yortrage, 1877, Nr. 116. Buist. Chorea Gravidarum. Trans. Edinburgh Obst. Soc., 1892, January 12. Ciiiaventone. De l’hematurie de la grossesse. Annales de gyn. et d’obst., 1901, lvi, 196-219. Ciiome. Sur un cas de tuberculose congenitale. Arch. mens, d’obst. et de Gvn., 1918, vii, 294-305. Commandeur et Porcher. Becherches sur les sucres urinaires chez la femme enciente. Archives gen. de med., 1904, cxciv, 2241 and 2325. Cragin. Congenital Pelvic Kidney Obstructing the Parturient Canal. Amer. Jour. Obst., 1898, xxxviii, 36-41. Dabney and Harris. Beport of a Case of Gonorrhoeal Endocarditis in a Patient Dying in the Puerperium. Bulletin of the Johns Hopkins Hosp., 1901, xii. Debreuihl. Impetigo herpetiformis. Besnier, Brocq et Jacquet, La Pratique dermatologique, 1901, ii, 915-920. Demelin. Contribution a 1’etude des cardiopathies, etc. L’obstetrique, 1896, i, 41-57. Duncan. On Puerperal Diabetes. Trans. Lond. Obst. Soc., 1882, xxiv, 256-285. Edmonds. Malaria and Pregnancy. Brit. Med. Jour., 1899, April 29. Esch. Ueber Dauerheilungen und iiber die Aetiologie der perniciosaartigen Graviditatsanamie. Zentralbl. f. Gyn., 1921, 341-345. Eulenberg. Ueber puerperale Neuritis, etc. Deutsche med. Wochenschr., 1895, 118-121 and 140-146. Fellner. Herz u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1901, xiv, 370- 417 and 497-520. Fildes. The Prevalence of Congenital Syphilis Amongst the Newly-born of the East End of London. J. Obst. & Gyn. Brit. Emp., 1915, xxvii, 124-137. Fiori. Un caso di transmissione di morbillo della madre al feto. Frommel’s Jahresbericht, 1900, xiv, 722. Fournier. L’heredite syphilitique. Paris, 1891. French and Hicks. Chorea gravidarum. Practitioner, 1906, lxxvii, 178-194. Mitral Stenosis and Pregnancy. J. Obst. & Gyn. Brit. Emp., 1906, x, 201-246. Friedmann. Exp. Beitrage z. Frage kongenitaler Tuberkelbazilleniibertragung, etc. Yirehow’s Archiv, 1905, clxxxi, 150-179. Frommer. Exp. 'Versuche zur parathyreoidealen Insuffizienz in Bezug auf Ek- lampsie u. Tetanie. Monatsschr. f. Geb. u. Gyn., 1906, xxiv, 748-761. Frongea. Quoted by Fritsch, Fruchtabtreibung. Wien u. Leipzig, 1911, p. 58. Gast. Experimentelle Beitrage zur Lehre von der Impfung. Schmidt’s Jahr- biicher, 1879, clxxxviii, 201. Goldsborough. Thrombosis of the Internal Iliac Vein During Pregnancy. Bull. Johns Hopkins Hospital, 1904, xv, 193-195. Goldthwait and Osgood. A Consideration of the Pelvic Articulations from an Anatomical, Pathological and Clinical Standpoint. Boston Med. and Surg. Jour., 1905, cliii, 593-601. Goth. Ueber den Einfluss der Malariainfektion aut Schwangerschaft, etc. Zeitschr. f. Geb. u. Gyn., 1881, vi, 17-34. Graefe. Die Einwirkung des Diabetes mellitus, etc. Graefe’s Sammlung zwang- loser Abhandlungen, 1897, ii, Heft 5. Gu£;rard. Herzfehler u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1900, xii, 571-577. 574 ACCIDENTAL COMPLICATIONS DUE TO DISEASE Harris. Influenza Occurring in Pregnant Women. Jour. Am. Med. Assoc., 1919, lxxii, 978-980. Hauser. Zur Vererbung der Tuberkulose. Deutsches Archlv f. klin. Med., 1898, lxi, 221. Hebra. Ueber einzelne wahrend der Schwangerschaft zu beobachtende Hautkrank- heiten. Wiener med. Woehenschr., 1872, Nr. 48. Heil. Die Complication von Schwangerschaft, Geburt u. Wochenbett mit Wander- milz. Archiv f. Gyn., 1907, lxxxi, 120-128. Herman. Leukaemia and Pregnancy. Lancet, 1901, ii, October 12. Hicks. A Contribution to Our Knowledge of Puerperal Diseases, etc. Trans. London Obst. Soe., 1871, xii, 44-113. Hofbauer. Beitrage zur HStiologie u. Klinik der Graviditats-toxicosen. Zeitschr. f. Geb. u. Gyn., 1908, lxi, 200-274. Johnston and Morgan. Acute Lobar Pneumonia and Hematogenous Puerperal Infection. Bull. Johns Hopkins Hospital, 1922, xxxiii, 106-109. Joslin. Pregnancy and Diabetes Mellitus. Boston Med. & Surg. J., 1915, clxxiii, 841-849. Kautsky. (Schwangerschaft und Mitralstenose. Archiv f. Gyn., 1916, cvi, 121- 158. Kellogg. Chronic Valvular Heart Disease in Pregnancy and Labor. Boston Med. & !Su.rg. Jour., 1917, clxxvii, 398-410. Klotz. Beitrage zur Pathologie der Schwangerschaft. Archiv f. Gyn., 1887, xxix, 448-475. Knapp. Typhus u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1909, xxx, 43-58. Kolloch. The Protective Influence of Vaccination, etc. Amer. Jour. Obst., 1889, xxii, 1078. Kronig. Bakteriologie des Genitalkanales der schwangeren, kreissenden und puerperalen Frau, 1897, 180. Lanz. Ueber einen Fall von Tuberculose der Plazenta u. der Eihaute. Archiv f. Gyn., 1915, civ, 238-258. Lebedeff. Ueber die intrauterine Uebertragbarkeit des Erysipels. Zeitschr. f. Geb. u. Gyn., 1886, xii, 321-327. Lepileur. Quoted by Ribemont-Dessaignes et Lepage. Precis d’Obstetrique, 1894, 642. Levy. Ueber intrauterine Infection mit Pneumonia crouposa. Archiv f. exp. Pathologie, 1896, xxvi, 595. Lewin. Ueber die Wirkung des Bleis auf die Gebarmutter. Berliner klin. Woch- enschr., 1904, xii, 1074-1078. Liepmann. Diabetes mellitus und Metritis desiccans. Archiv f. Gyn., 1903, lxx, 426-444. Lomer. Ueber die Bedeutung des Icterus gravidarum, etc. Zeitschr. f. Geb. u. Gyn., 1886, xiii, 169-185. Masern in der Schwangerschaft. Zentralbl. f. Gyn., 1889, xiii, 826. Ludwig. Ein Beitrag zur Pathologie des Fruchtwassers. Zentralbl. f. Gyn., 1895, xix, 281-284. Lusk. Mitral Stenosis in Pregnancy. Medical News, 1893, lxii, December 1. Lvoff. Ptyalismus perniciosus gravidarum. Ref. Frommel’s Jahresbericht. Lynch. Placental Transmission, with Report of a Case during Typhoid Fever. Johns Hopkins Hospital Reports, 1902, x, 283-322. Mackenzie. The Maternal Heart in Pregnancy. Brit. Med. Jour., 1904, ii, 918- 923. Heart Disease and Pregnancy. London, 1921. LITERATURE 575 Maffucci. Richerche sperimentale intorno al passaggio (lei veneno tubercolare dai genitori alia prole. Rivista critica di clinica med., 1900, i, 221-229. Matthews. Pregnancy after Nephrectomy. Jour. Am. Med. Assoc., 1921, lxxvii, 1604. Maillart. Ueber den gunstigen Einfluss der Schwangerschaft auf die Enterop- tose. Zentralbl. f. Gyn, 1900, xxiv, 1342-1353. Maslovsky. Endometritis decidualis gonorrhoica. Monatsschr. f. Geb. u. Gyn., 1896, iv, 212-218. Mayer. Normales Schwangerschaft-serum als Heilmittel gegen Sehwangerschafts- dermatosen. Zentralbl. f. Gyn., 1911, 350-354. Netter. Transmission intrauterine de la pneuinonie, etc. Competes rendus de la soc. de biologie, 1889, Mai 15, 187-194. Neumann. Ueber puerperale Uterus-gonorrhoea. Monatsschr. f. Geb. u. Gyn., 1896, iv., 109-115. Novak, Porges und Strisower. Ueber eine bensondere Form von Glykosurie in Geb. u. Gyn., 1910, lxvii, 719-751. Novak, Porges and Strisower. Ueber eine besondere Form von Glykosurie in der Graviditat, etc. Yerh. der deutschen Gesellsch. fur Gyn., 1913, 230- 245. Offergeld. Ueber das Vorkommen von Kohlehydraten im Fruchtwasser bei Dia- betes der Mutter. Zeitschr. f. Geb. u. Gyn., 1906, Iviii, 189-229. Olshausen. Untersuchungen iiber die Complication des Puerperium mit Schar- lach. Archiv f. Gyn., 1876, ix, 169-195. Opitz. Die Pyelonephritis gravidarum et puerperarum. Zeitschr. f. Geb. u. Gyn., 1905, lv, 209-294. Osler. Puerperal Anaemia, etc. Boston Med. and Surg. Jour., 1888, xcix, 454- 455. Palm. Beitrag zur Vaccination schwangerer Wochnerinnen u. Neugeborener, Archiv f. Gyn., 1901, lxii, 348-365. Paltauf. Zur iEtiologie der Hadernkrankheit. Wien. klin. Wochenschr., 1888, i, Nr. 18. Paul. Considerations sur quelques maladies saturnines. These de Paris, 1861. Payer. Ueber den Einfluss des Zuckers auf den Stoffwechsel der Schwangeren, etc. Monatsschr. f. Geb. u. Gyn., 1899, xi, 784-806. Petersen. L’anemie d’un type ressemblant a l’anemie pernicieuse durant la grossesse. Arch. Mens, d’obst. et de Gyn., 1918, vii, 1-21. Peterson. Gall Stones During Pregnancy. Trans. Am. Gyn. Soc., 1910, xxxv, 4-120. Profeta. Sulla sifilde allattamento. La sperimentale, 1865. Puig y Roig. Cas de variole foetale sans variole maternelle. Obst. et Gyn., 1922, vi, 176-183. Queirel. Variole et grossesse. Annales de gyn. et d’obst., 1907, N. S., iv, 137-147. Renvall. Ueber Appendicitis wahrend Schwangerschaft u. Geburt. Mittheilungen aus Engstrom’s Klinik, 1908, vii, 181-300. Rossa. Traubenzucker im Harn und Fruchtwasser. Zentralbl. f. Gyn., 1896, xx, 656-662. Rostowzen. Ueber den Uebergang von Milzbrandbacillen beim Menschen von der Mutter auf die Frucht bei Pustula maligna. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 542-552. Scheuer. Zur Frage der der Impetigo herpetiformis. Archiv fur Der- matologie, 1910 ciii, 285-304. Schmidt. Nephrectomy During Pregnancy. Surg. Gyn. & Obst., 1915, xxi, 679. 576 ACCIDENTAL COMPLICATIONS DUE TO DISEASE Schroeder. Ueber wiederholte Schwangerschaft bei linealer Leukamie. Archiv f. Gyn., 1899, lvii, 26-35. Schutz. Ueber den Einfluss der Cholera auf Menstruation, Schwangerschaft, Geburt u. Wochenbett. Zentralbl. f. Gyn., 1894, xviii, 1138. Seitz. Die innere Sekretion und Schwangerschaft. Leipzig, 1913. Sitzenfrey. Die Lehre von den kongenitalen Tuberculose, etc. Berlin, 1909. Smith. Severe Puerperal Sepsis Due to Gonococcus Infection. Cleveland Med. J., 1911, x, 810-818. Sperling. Zur Kasuistik der Embolie der Lungenarterie wahrend der Schwanger- schaft, etc. Zeitschr. f. Geb. u. Gyn., 1893, xxvii, 439-465. Stengel and Stanton. The Heart and Circulation in Pregnancy and the Puer- perium. Univ. of Penn. Med. Bull., 1904, xvii, 202. Stephans. Die kongenitale Nierendystopie beim Weibe. Zeitschr. f. Gyn. Urologie, 1912, iii, 303. Strauss et Chamberlent. Comptes rendus de la soc. de biologie, 1882, novembre 11 et decembre 16. Strong. Beseareh in Some Aspects of Disease Associated with the Fields of Zoology, Entomology and Parasitology. Science, 1923, lvii, 513. Thomas. Tetany in Pregnancy. Johns Hopkins Hosp. Bull., 1895, vi, 85. Tizzoni et Cantani. Eecherches sur le cholera asiatique. Ziegler ’s Beitrage zur path. Anat. u. zur allg. Path., 1888, iii, 189-237. Vinay. Maladies valvulaires et grossesse. Archives de Tocologie, 1893, 805. Vinay et Cade. La pyelo-nephrite gravidique. L’obstetriqne, 1899, iv, 230-256. Yitanza. Sulla transmissibilita dell’ infezione colerica della madre al feto. Eiforma medica, 1890, Nos. 48 and 49. Van der Velden. Icterus gravidarum. Beitrage zur Geb. u. Gyn., 1904, viii, 448-464. Weller. The Blastophthoric Effect of Chronic Lead Poisoning. J. Med. Ee- search, 1915, xxxiii, 271-293. Wendt. Beitrag zur Lehre vom Icterus gravis in der Schwangerschaft. Archiv f. Gyn., 1898, lvi, 104-128. Whitfield. Puerperal Neuritis Due to Vomiting of Pregnancy. Lancet, 1889, i, 627-628. Whitman and Greene. A Case of Disseminated Miliary Tuberculosis in a Foetus, etc. Archives lnt. Med., 1922, xxix, 261-273. Williams. The Induction of Premature Labor for Other than the Usual Indica- tions. Maryland Med. Jour., 1896, xxiv. The Clinical Significance of Glycosuria in Pregnant Women. Am. J. Med. Sci., Jan., 1909. The Limitations and Possibilities of Prenatal Care. J. Am. Med. Assn., 1915, Ixiv, 95-101. The Value of the Wassermann Eeaction in Obstetrics Based Upon the Study of 4,547 Consecutive Cases. Bull. Johns Hopkins Hospital, 1920, xxxi, 335-342. The Influence of the Treatment of Syphilitic Pregnant Women upon the In- cidence of Congenital Syphilis. Bull. Johns Hopkins Hospital, 1922, xxxiii, 383-386. Wolff. Ueber Vererbung von Infectionskrankheiten. Virchow’s Archiv, cxii, 177. Zangemeister. Der Hydrops gravidarum, etc. Zeitschr. f. Geb. u. Gyn., 1919, lxxxi, 491-559. Zweifel, Ueber plotzliche Todesfalle von Schwangeren u. Woehnerinnen. Zen- tralbl. f. Gyn., 1897, xxi, 1-16. CHAPTER XXVI THE TOXEMIAS OF PEEGNANCY Fortunately, in the great majority of cases gestation pursues a physiological course and is not attended by untoward symptoms. At the same time, there is no other condition in which the border-line between health and disease is less sharply marked, since a very slight irregularity often suffices to convert a physiological and normal into a pathological and abnormal state. The general metabolism becomes profoundly modified during gesta- tion, as is shown by the fact that during its later months the pregnant woman stores up nitrogen and water to a far greater extent than at other times, so that it would appear that her internal “housekeeping” is conducted upon much more economical lines than formerly. Al- though it is generally held that the excretory functions are more liable to serious derangement, since they are called upon to care for the elimination of the waste products of the foetal, as well as of the maternal organism, no evidence is available in support of such a view. On the contrary, analysis of the urine shows that during the last weeks of pregnanacy the woman eliminates less nitrogen than at other times, and it has not been demonstrated that the so-called toxemic disturbances of pregnancy are primarily dependent upon overworked kidneys, unless those organs were insufficient when conception occurred. Doubtless, the metabolic changes which characterize normal preg- nancy and continue for some time after delivery, result from functional organic alterations with which we are as yet unfamiliar. Such changes are generally attributed to the action of a toxin supposed to he elaborated in the maternal or foetal organism, but as yet no such toxin has been identified, and many are even skeptical as to its existence. For this reason, it would seem more plausible to attribute them, as well as the metabolic changes associated with many of the abnormalities of preg- nancy, to functional alterations in certain of the endocrine glands, al- though it must be admitted that at present such views are hypothetical, and may be altogether unfounded. With increasing knowledge of some of the more usual modifications of normal metabolism, the necessity for the accurate control of all the factors concerned in such studies has become more fully appreciated, and as such control was palpably lacking in certain of the older in- vestigations concerning the toxemic conditions, it has become necessary to disregard the conclusions based upon them. Up to the present, even the most careful metabolic studies have done little toward revealing their 577 578 THE TOXEMIAS OF PREGNANCY underlying causes, and at best have only served to render untenable certain hypotheses which formerly enjoyed a considerable vogue. It should always be borne in mind that totally different pathologi- cal conditions may be accompanied by identical clinical manifestations, so that a proper classification cannot be based upon the occurrence of such symptoms as albuminuria, fever, coma, or convulsions, but must depend upon our ability to isolate certain specific poisonous principles, or to demonstrate distinctive pathological lesions. Unfortunately, the former is as yet out of the question, but the latter has already been accomplished along certain lines. We shall therefore consider separately the following groups of “toxemia of pregnancy”: (a) pernicious vomit- ing; (&) acute yellow atrophy of the liver; (c) nephritic toxemia; (d) pre-eclamptic toxemia; (e) eclampsia; (/) presumable toxemias. PERNICIOUS VOMITING OF PREGNANCY We have already referred to the ordinary type of nausea and vomiting, which is noted in the early weeks of gestation. This occurs in approxi- mately one half of all pregnant women, usually appearing at about the sixth week, and disappearing spontaneously six or eight weeks later. In such circumstances the patient suffers from nausea, or even vomits shortly after arising, whence the term “morning sickness.” In other cases the vomiting occurs at other times and at more frequent intervals, and occasionally lasts for a longer period, while exceptionally it con- tinues throughout the entire pregnancy. Ordinarily, such vomiting is attended by no more serious results than the actual discomfort connected with it, and many women consider it so natural an accompaniment of pregnancy that they do not complain of it. Others, however, soon demand relief from the physician, and the mere enumeration of some of the many remedies recommended affords con- clusive evidence that a specific cure has not yet been discovered. In some instances the first remedy administered is followed by immediate relief, while in other cases various drugs may be employed in succession without result. Relief sometimes follows the administration before each meal of a capsule consisting of 2 grains of pepsin and *4 grain nitrate of silver. Oxalate of cerium in 5-grain capsules, corpus luteum tablets, dilute tinc- ture cf iodin, dilute hydrocyanic acid, cocain, or bismuth are also recom- mended. In my hands, however, drugs are rarely required, except for the relief of constipation, and the condition can usually be cured, or at least greatly ameliorated, by suggestion, the adoption of more hygienic methods of living, and regulation of the diet. The physician should not make light of the condition, hut he should impress upon the patient that vomiting is not a necessary accompaniment of pregnancy, as is shown by the fact that less than one half of all pregnant women suffer from it, and furthermore that it can be controlled by exercise of the will, and the adoption of suitable hygienic and dietetic measures. He should then inquire carefully info her mode of life, and see that proper exercise, oc- PERNICIOUS VOMITING OF PREGNANCY 579 cupation, amusement, and rest are obtained. The diet should be carefully regulated. I lay great stress, particularly on account of its suggestive influence, upon the patient eating a hard dry biscuit, such as one uses with cheese, the moment she awakens and before raising her head from the pillow. Afterwards breakfast may be taken in bed, or not, according to her habit. The important point, however, is to arrange that food be taken at frequent intervals throughout the day, so that the patient gets six small meals instead of three larger ones. It is not sufficient to pre- scribe this in general terms, but precise directions should be given as to exactly what should be eaten at definitely appointed hours. If the patient be impressed with the necessity of following these minutiae im- plicitly, the condition will usually pass off within a few days and the employment of drugs will be unnecessary. Occasionally, the vomiting becomes more frequent and severe, so that in extreme cases no nutriment of any kind, not excepting water, can be retained. The condition is then known as pernicious vomiting, which, unlike the ordinary morning sickness, is a serious disease, and some- times leads to a fatal issue, no matter how treated. According to Pick, pernicious vomiting occurs about once in every thousand pregnant women, but as such statistics are based upon Euro- pean hospital work they give no clue as to its incidence in private prac- tice. Among the neurotic women of the upper classes in this country, I believe that it is encountered once in every several hundred pregnancies, but it appears to be less frequent in England and Germany. Etiology.—Since pernicious vomiting is always preceded by the so- called morning sickness, and as the latter occurs in approximately every other pregnant woman, it may be assumed that the cause of vomiting in general must be sought in some factor commonly present in normal pregnancy; and, consequently, that pernicious vomiting is due to an increase in the amount or in the potency of the same factor, or to de- creased resistance to its action on the part of the woman. Accordingly, its etiology cannot be solved until this “toxic substance” has been dis- covered, and until it has been ascertained why it becomes increased in quantity in certain circumstances. As, unfortunately, neither of these criteria have as yet been satisfied, it is evident that whatever may be said is largely hypothetical, and may be subject to revision at any time. In my monograph, which appeared in 1906, I stated that the evi- dence then available seemed to justify the differentiation of three types of serious vomiting, namely, reflex, neurotic and toxemic. I now believe that practically every case of vomiting rests upon a toxemic basis, and that variations in its course depend upon the severity of the toxemia underlying it. In occasional instances, the toxic influence is predomi- nant, when we have to deal with toxemic vomiting, par-excellence. For- tunately, however, in the great majority of cases this factor appears to act merely as a predisposing cause in neurotic women, and becomes negligible after the nervous condition has been overcome. These are the cases of neurotic vomiting, which make up the bulk of those we are called upon to treat. I have abandoned the conception of reflex 580 THE TOXEMIAS OF PREGNANCY vomiting, as increased experience has taught me that it should be regarded as a subdivision of the neurotic type. In general, it may be said that toxemic vomiting is a very serious affection, which frequently leads to death; while neurotic vomiting is readily amenable to treatment and can usually be cured by suggestive means. Matthews Duncan in 1879 pointed out that pernicious vomiting was sometimes associated with serious hepatic lesions, but this was not generally recognized until the work of Stone, Ewing, and myself showed that in many of the fatal cases characteristic lesions were present in the liver and kidneys. The former are identical with those occurring in acute yellow atrophy. Ill such cases there is profound necrosis of the cen- tral portion of the lobules, while the periphery remains intact, and in one of my specimens the destruction of tissue was so great that prac- tically nine-tenths of the organ was thrown out of function (Fig. 459). In other cases the necrosis is absent, but the entire liver has undergone marked fatty degeneration, so that upon staining fresh sections with Sudan red practically the entire specimen seems to be filled with fat. Winter, Hofbauer, Ileinrichsdorff, Schickele and others have described similar changes. The renal lesions are degenerative in character, and are practically limited to the convoluted tubules, whose epithelium in many cases is necrotic and whose lumina are filled with debris. As a rule, the renal changes occur only in the terminal stages of the disease. As the hepatic lesions are altogether different from those observed in eclampsia, in which the process begins in the periportal spaces and is primarily due to thrombosis, I hold that toxemic vomiting is an entirely distinct process, and that it has only three points in common with eclampsia, namely, that both occur in pregnant women, are manifesta- tions of disturbed metabolism and are accompanied by hepatic lesions. It should not, however, be believed that the essential process in either disease consists in the liver lesions, but rather in the underlying toxemia to which they are due. The researches of Opie upon zonal necroses of the liver lend still further support to the toxemic basis of vomiting, as he pointed out that central and mid zonal necroses are usually the result of systemic poisoning. Moreover, it is well known that other poisons which act upon the liver—chloroform, arsenic and phosphorus—likewise produce cell destruction in these areas, while the peripheral portion of the lobules is spared to the last. Additional evidence of the toxemic origin of the vomiting is occasionally afforded, in patients who ultimately recover, by the development of a polyneuritis, which is associated with char- acteristic disturbances in sensation, motility and nutrition of the affected parts. Such a complication was first described by Whitford, and Job in 1911 collected 16 such cases from the literature, while I have observed several. On the other hand, it has been argued bv several writers that the lesions just described may result from starvation alone, but the relatively small amount of anatomical material, from which conclusions could be drawn, fails to support such a contention. In my original article, I pointed out that in toxemic vomiting a high ammonia coefficient could be demonstrated in the urine, so that instead PERNICIOUS VOMITING OF PREGNANCY 581 of 3 or 4 per cent, of the total nitrogen being excreted in the form of ammonia, the figure might rise to 10, 20 or even 40 per cent. This I at first attributed to such perversion in the intermediary protein met- abolism, as a result of the hepatic changes, that incompletely oxidized substances were excreted in large quantities instead of urea, and I be- lieved that the existence of a high ammonia coefficient would enable us to differentiate between toxemic and neurotic vomiting. This, however, Fig. 459.—Liver from Vomiting of Pregnancy Showing Central Necrosis. X 50. F. L. C., liver cells showing fatty degeneration; L. C., unchanged liver cells; N., areas of necrosis; P. <S., portal space. was soon shown to be erroneous, as Longridge, Leathes, and others pointed out that the high ammonia coefficient was a manifestation of an acidosis, while Eand and I'nderhill considered it an accompaniment of inanition and in no way associated with a toxemic process. Finally, in 1921, Nash and Benedict clearly demonstrated that the urinary ammonia is produced in the kidneys as an essential part of the mechanism for neutralizing such acids as are brought to them for excretion, thereby demonstrating that a high ammonia coefficient gives no information as to what is occurring in the liver, and consequently cannot he utilized 582 THE TOXEMIAS OF PREGNANCY as an index of its metabolism. Were the vomiting woman suffering from an acidosis, one might assume that the determination of the carbon dioxide combining power of the blood plasma would be diminished and thus afford an index of the degree of acidosis, yet the observations of Losee and Van Slyke, Emge, and Killian indicate that it shows no change, even when the ammonia content of the urine is definitely in- creased. No explanation has yet been advanced for this seeming para- dox. The belief in the existence of neurotic vomiting cannot be based upon anatomical findings, as patients suffering from it rarely die, and then only as the result of inanition. Particular attention was directed to it by Kaltenbach, who stated in 1891 that the vomiting of pregnancy is usually a manifestation of a neurosis, somewhat allied to hysteria, and is readily amenable to suggestive treatment. Clinical observation affords abundant evidence in favor of such a view, as it is well known that many women, who are apparently on the verge of death from starvation, suddenly become better spontaneously following a threat to induce abortion. Moreover, prompt cure sometimes follows the mere administration of an anesthetic, or the employment of the most varied and unscientific means of treatment, such as the use of an electrical battery which does not function, or the application of leeches to various parts of the body, or of medicaments to the cervix. Furthermore, it may be safely assumed that the cures following dilatation of the cervix, as recommended by Copeman, are in reality due to suggestion. Although, as has already been intimated, all types of vomiting in pregnant women are primarily dependent upon a “toxic” basis, the chief argument in favor of neurotic vomiting is afforded by the sur- prising regularity with which cure can be effected when suggestive means are intelligently employed, as will be described under treatment, which would seem to indicate that, once the abnormal neurotic tendency has been overcome, the organism can readily cope with the underlying toxic factor—whatever it may be. I no longer consider reflex vomiting as a distinct type, although every one has occasionally observed serious vomiting in women with uterine displacements, ovarian tumors or some other lesion of the sexual organs, and has noted immediate relief follow- ing the replacement of the uterus, the removal of the tumor, or the correction of the abnormality. With more extended experience I have come to doubt the etiological connection, and now attribute to sugges- tion most of the cures following the correction or removal of the so- called reflex factor. Harding and Watson and their associates attribute the nausea and vomiting of pregnancy to a lack of glycogen in the liver with subsequent fatty degeneration of the organ. They recommend the administration of glucose and report very satisfactory results. Analysis of their case reports, however, has not convinced me of the accuracy of their claims, more particularly as I have obtained equally good results by suggestive treatment. Likewise, Titus and his coworkers have employed the rapidity with which the organism utilizes glucose administered intra- venously as a measure of the degree to which the store of glycogen in PERNICIOUS VOMITING OF PREGNANCY 583 the liver has been depleted. They consider that their work throws con- siderable light upon the etiology of vomiting by indicating that the damaged liver cannot store glycogen, and that the administration of glucose is an efficient means of curing the condition. Since 1916, J. C. Hirst in repeated communications has advocated the view that vomiting of pregnancy is dependent upon deficient corpus luteum secretion, and bases his belief upon the fact that at autopsy the corpus luteum may be in a cystic condition. He reports satisfactory cures following the intramuscular or intravenous administration daily, or every second day, of commercial solutions of corpus luteum extract, representing one-third or two-thirds of a grain of the dried gland, until vomiting ceases or the condition of the patient becomes so serious that more radical treatment is imperative. As he admits that the condition sometimes proves refractory to such treatment, and as we obtain equally good results without its use, I am inclined to attribute to suggestion whatever good it may accomplish. Symptoms.—Ordinarily, pernicious vomiting begins as the simple nausea and vomiting of pregnancy, which gradually becomes so severe that nothing can be retained by the stomach. Unfortunately, the mere severity of this symptom gives no clue as to whether one has to deal with the neurotic or toxemic type. In the former the vomiting may continue for weeks, the patient gradually becomes more and more ema- ciated, and eventually dies of starvation if suitable treatment be not instituted. Toxemic vomiting may occur in either an acute or chronic form. In the former the disease pursues a rapid course, and the patient, after a few days of ordinary vomiting, may begin to eject coffee-ground vom- itus, soon passes into a somnolent or comatose condition, and dies within a week or ten days without emaciation. In the latter, and more fre- quent, variety persistent vomiting may continue for weeks, the patient becoming markedly emaciated before the seriousness of the condition is appreciated. Later she begins to vomit coffee-ground-like material, which she rejects in large quantities and without apparent effort. At this time symptoms indicative of toxemia appear, the patient becoming torpid or violently excited and passes into a condition of coma, which is occasionally accompanied by convulsions. In some instances slight jaundice may develop, and, toward the terminal stage of the disease, the urine becomes greatly diminished in amount, and contains albumin, casts, and even blood. Formerly it was taught that in the later stages of the disease fever frequently occurred, and was associated with a rapid and thready pulse and pronounced albuminuria. This, however, has not been by expe- rience, as fever was absent in all of my fatal cases. The behavior of the pulse is not constant—in some cases it soon becomes rapid and thready, while in others it is scarcely accelerated. Several of my patients have recovered with a pulse well above 120, while in a fatal case it did not exceed 96. For these reasons, I cannot accept Pinard’s dictum that abortion should always be induced whenever the pulse rate continues higher than 100, 584 THE TOXEMIAS OF PREGNANCY Diagnosis.—The diagnosis of pernicious vomiting should be made whenever the vomiting is constant enough to interfere seriously with the nutrition of the patient. The differentiation between the toxemic and neurotic types is sometimes difficult, but, as the latter occurs much more Fig. 460.—Urinary Chart, Neurotic Vomiting. In this and the following charts each square cor- responds to 1 gram of total nitrogen and 1% of ammonia nitrogen. Total Nitrogen: Black, Ammonia: Red. Fig. 461.—Urinary Chakt, Tox- emic Vomiting, Recovery After Induced Abortion. Total Nitrogen: Black, Ammonia: Red. frequently, the presumption should be in its favor unless isolation and suggestive therapy have failed to bring about improvement. Acute toxemic vomiting is readily recognized, but from my experience it PERNICIOUS VOMITING OF PREGNANCY 585 is impossible by a single clinical examination to diagnosticate the chronic variety. Thus, it may happen that two women may appear to be equally ill when first seen and to present the same degree of in- anition, yet careful examination will show that one is suffering from neurotic and the other from toxemic vomiting, and the former will re- cover within a few days after suggestive treatment, while the latter may die even after abortion has been induced. For these reasons it is highly important that a differential diagnosis be made at the earliest possible moment. Accordingly, a thorough physical examination should be made, and if any serious abnormality of the generative tract be detected, it should at once be corrected on the assumption that it may reflexly aggravate the symptoms. If no lesion can be detected, the diagnosis lies between neurotic and chronic toxemic vomiting, with the probabilities in favor of the former. I formerly believed that an ammonia coefficient of 10 per cent, or higher, justified the latter diagnosis, but as has already been indicated this does not hold good; as we now know that a high ammonia coefficient may merely be indicative of an acidosis resulting from inani- tion in neurotic vomiting. Notwithstanding such limitations, the de- termination of the ammonia coefficient may be of great diagnostic value, but in a negative rather than a positive sense. For example, should it fall within the normal limits, we know that no serious perversion of metabolism can exist and that pronounced acidosis is absent. In such circumstances a diagnosis of neurotic vomiting is justified. On the other hand, if the ammonia coefficient is high, we have no means of telling whether it indicates a serious pervesion of metabolism or merely an inanition acidosis. In this event a diagnosis can be made only by observing the course of the disease and by its response to treatment. It is a safe working rule to assume that, if improvement does not follow five or six days treatment in a hospital, the condition is toxemic in origin, and to consider the propriety of emptying the uterus. Prognosis.—The prognosis is extremely satisfactory in neurotic vomiting, as cure can usually be effected within two or three days by suggestive treatment, provided the physician is sufficiently sure of him- self to be able to impress his belief upon the patient. On the other hand, the prognosis is always grave in the toxemic variety, as we have no means of determining to what extent the internal lesions have pro- gressed, or whether it is possible for them to undergo repair, even if the underlying cause of the toxemia be removed by terminating the preg- nancy. In any event, it should be remembered that a certain proportion of such cases will die no matter what may be done. Pernicious vomiting sometimes recurs, and many women suffer re- peatedly from the neurotic variety in succeeding pregnancies. Unfor- tunately this may also occur in the toxemic variety, though the mere recurrence of vomiting in a subsequent pregnancy does not necessarily indicate that one has to deal with the same type, as I have seen several patients who suffered from toxemic vomiting in the first pregnancy, and from the neurotic variety in the second (Fig. 462). 586 THE TOXEMIAS OF PREGNANCY Treatment.—Formerly the treatment of pernicious vomiting was very unsatisfactory. This was in great part due to the fact that in the neurotic variety cure sometimes occurred when the patient was almost in extremis, so that the physician usually deferred inducing abortion in the hope that such an outcome might occur in his case. Consequently, interference was usually postponed until the patient was so ill that death was inevitable, no matter what was done. The recognition, however, of the several types of vomiting just described affords valuable information as to the treatment to be pursued, and indicates that abortion is usually A. No. 2310 Sept. 14 - Oct. 2nd, 1905. B. No. 2519 March 9 - 19th, 1906. Fig. 462.—Chart Showing Ammonia Coefficient in Two Consecutive Pregnancies A, toxemic, and B, neurotic vomiting. unnecessary in neurotic, and is frequently deferred too long in toxemic vomiting. When abnormalities of the generative tract are discovered, they should be corrected: the displaced uterus should be replaced and held in position by a properly fitting pessary, or the ovarian tumor should be removed, as the case may be. In the neurotic variety the patient should be put to bed and kept from her family as far as possible. Preferably, she should be removed to a well regulated hospital and be under the charge of an intelligent nurse, as it is only in such circum- stances that the full effect of suggestive treatment can be promptly obtained. She should be assured by the physician that her condition is not serious, and will not require active interference. For a day or so no attempt should be made to administer nourishment by mouth, but large amounts of saline solution or several hundred cubic centimeters of 5 per cent, glucose solution should be administered by the Murphy drip method every few hours. After a few days’ rest, however, small quantities of fluid nourishment should be administered at frequent in- ACUTE YELLOW ATROPHY OF THE LIVER 587 tervals, and the patient assured that her condition will pass off within a short time. Ordinarily, if the physician is sure of himself and possesses the confidence of the patient, the desired result will usually follow; but in exceptional instances more radical treatment is necessary, and an absolute rest cure should be insisted upon. The existence of an acidosis suggests the advisability of alkaline therapy. If properly controlled by frequent determination of the carbon dioxide combining power of the plasma, this may do good; but, in the absence of such control, the dosage of sodium bicarbonate should be kept within very moderate limits—2 or 3 drams a day—for fear that an alkalosis may develop, which in itself may lead to a fatal termination. If improvement does not follow these simple means, the physician will do well to make a more urgent suggestive appeal to the patient, such as lavage after each attack of vomiting, or the subcutaneous injection of saline solution under the breasts, preferably with a dull needle. Other methods will readily suggest themselves to the experienced physician. In such cases the intravenous administration of 250 to 500 c.cm. of 10 to 20 per cent, glucose solution, repeated four times daily, offers a ready means of supplying a certain amount of nutrition. It has no specific effect, although Whipple and his associates have shown that degenerative changes in the liver are most rapidly regenerated in the presence of an abundant supply of carbohydrates. We have for years employed this method of treating neurotic vomit- ing with the greatest possible success, with the result that the induction of abortion has become necessary only once in several years, and then only when the vomiting was definitely toxemic in origin. I have been unable to confirm the claims of Fieux and others that cure frequently follows the injection of 10 or 20 c.c. of serum obtained from a normal pregnant woman, and I believe that when satisfactory results are obtained by such means they should be attributed to the suggestive effect of the procedure. In the toxemic variety, on the other hand, prompt induction of abor- tion is the treatment par excellence, and should be performed as soon as the diagnosis is made. On account of the possibility of chloroform still further damaging the liver, anesthesia should be induced by means of ether or nitrous oxid, and the uterus emptied by the most conservative method: vaginal hysterotomy if the cervix is rigid, or dilatation by means of GroodelFs or Hegar’s dilators if it be soft and patulous. Following the operation the patient should be given copious saline rectal enemata, and for a short time, at least, the administration of food should be regarded as a matter of secondary importance. ACUTE YELLOW ATROPHY OF THE LIVER Acute yellow atrophy of the liver (icterus gravis, typhoid icterus, etc.) is an acute and wide-spread antolytic necrosis of the liver cells, characterized clinically hy jaundice, reduction in the size of the liver, and toxic disturbances of cerebration, proceeding to a fatal issue. The 588 THE TOXEMIAS OF PREGNANCY disease has been observed in both sexes and at all ages, and is a rare but very serious complication of pregnancy. Kerkring in 1706 was the first to report a fatal case in a pregnant woman, but since then every one who has studied the disease has laid stress upon the association. Thus, Thierfelder found that 62 per cent, of the 143 cases which he collected from the literature had occurred in pregnant women, while Quincke placed the incidence at 60 per cent. It is ordinarily observed during the second half of pregnancy or early in the puerperium, although Beatty and Masson have described cases at the sixth and eighth weeks of gestation, respectively. Etiology.—Nothing definite can be said concerning its causation, although several conditions are known to predispose towards the pro- duction of the disease. Thus, certain poisons (chloroform, arsenic, mercury and phosphorus), and several diseases, such as syphilis, septicemia and chronic passive congestion and cirrhosis of the liver, are at times associated with lesions, which cannot be distinguished from those occurring in the idiopathic form. In the production of this latter, and larger group, it is generally assumed that a specific toxin circulating in the blood must be concerned. The majority of the cases occurring in pregnant women belong in this category, although not a few of the recorded cases were probably due to delayed chloroform poisoning. Pathology.—In acute yellow atrophy the liver rapidly diminishes in weight, which in a comparatively short time may be reduced to less than one half of the normal. Its capsule assumes a wrinkled appearance and the entire organ becomes softened. On section it varies from dark red to almost chrome yellow in color, and upon closer examination each lobule is seen to present a reddish center surrounded by a yellowish periphery. The histological findings vary according to the severity of the dis- ease. In mild cases the center of each lobule has undergone necrosis and the cells of the periphery present an almost normal appearance, while between the two is a thicker or thinner zone of cells presenting more or less advanced fatty degeneration. In other cases almost the entire parenchyma of each lobule is destroyed and is converted into a granular mass of necrotic debris, while about the periphery only an occasional well-preserved liver cell is seen; at the same time the interlobular spaces with their blood vessels and biliary canals are but little changed. The kidneys present signs of acute nephritis and the epithelial cells lining the convoluted tubules are in all stages of degeneration, and in extreme cases are entirely necrotic, while the lumina are filled with casts and debris. On the other hand, the glomeruli and the cells lining the collecting cubules are but little changed. Symptoms.—The symptoms are identical whether ihe disease occurs during pregnancy or the puerperium, and if convulsions appear it is usually mistaken for eclampsia. In acute cases the symptoms may come on so suddenly as to arouse a suspicion of poisoning, and in some in- stances the condition has been mistaken for phosphorus or some other form of poisoning. Thus it may happen that a woman, who previously was in apparently perfect health, may be seized with pains in the abdo- ACUTE YELLOW ATROPHY OF THE LIVER 589 men, intense headache, and possibly severe vomiting and purging. In a short time she becomes torpid or violently delirious and soon passes into a condition of coma, which may be disturbed by convulsions. In most cases the coma continues for a few hours or days until death super- venes, but recovery may occasionally occur. There is generally a cer- tain amount of jaundice, which may vary from a mere discoloration of the conjunctivae to pronounced general icterus. The vomited mat- ter is frequently blood-stained, and sometimes assimies a coffee-ground appearance. The urine is diminished in amount, very high-colored, and contains albumin, all varieties of casts, and frequently large quantities of blood. Fever is usually absent, or the temperature may he even subnormal until just before death when it may rise to a high point. The pulse and respiration tend to he rapid, and the blood pressure remains normal until renal insufficiency develops. Due to the concentration of the blood the red blood cells are slightly increased in number, and the leukocytes somewhat more so, while the hemoglobin content is di- minished. In delayed chloroform poisoning the symptoms are very similar, and death usually occurs within the week following the anes- thesia. Should the patient survive for a longer period, the chances for recovery are excellent. In other cases the course of the disease is less rapid, and in its early stages may simulate an ordinary pre-eclamptic toxemia. Slight jaundice, however, soon appears, and the patient gradually becomes more and more apathetic and torpid, and eventually passes into a condition of coma, which usually terminates in death. In this class of cases the diminution in the size of the liver may be traced by percussion, and in one of my patients the area of hepatic dullness became diminshed by more than one half in the course of a week. If the disease occurs during pregnancy, the foetus usually dies as a result of the toxemia, and is expelled from the uterus. In such cases, examination of the foetal organs may reveal extensive hepatic and renal lesions, and thus aid in estab- lishing the diagnosis before the death of the mother. When recovery ensues, the convalescence is tedious, not so much on account of the damage to the liver, which is quickly repaired, but as a result of the renal insufficiency. Chemical examination of the urine shows changes analogous with those already described in toxemic vomiting, and similar to those ob- served in acute phosphorous poisoning. The total nitrogen is usually increased, and its partition always presents marked changes, the urea being always diminished and the ammonia coefficient greatly elevated. Moreover, there is a marked increase in the amino-acids, and crystals of leucin and tyrosin may be demonstrated by appropriate procedures. Small quantities of acetone bodies are usually present. The blood chemistry has been studied in too few cases to permit any general conclusions. In a case studied by Stadie and Van Slyke, the urea nitrogen was within normal limits, but the amino-acid nitrogen was so increased as to exceed it, while the total non-protein nitrogen was not determined. The plasma bicarbonate was at first above normal, but gradually fell, reaching 49 volumes per cent, on the day of death. 590 THE TOXEMIAS OF PREGNANCY It would accordingly appear that a primary alkalosis had been replaced by an acidosis as the end approached. Examination of the liver showed that it contained three times the normal amount of amino-acids. Such variations in the amino-acid metabolism are satisfactorily explained by supposing that, as the result of cell destruction, the liver function had become so insufficient as to affect the normal mechanism for desaminiz- ing the amino-acids and for synthesizing urea. It is generally agreed that the increased amino-acid content of the blood results from autol- ysis of the liver cells, rather than from the absorption of the products of intestinal digestion. Diagnosis.—The diagnosis can usually be made from the clinical findings and history. Although the occurrence of convulsions may lead to a suspicion of eclampsia, the appearance of jaundice should always be suggestive, when chemical examination of the blood and urine should confirm the diagnosis. When occurring in early pregnancy the condition cannot be differentiated from toxemic vomiting, since the lesions, symp- toms and urinary changes are identical. The prognosis is always bad, the possibility of recovery depending upon the extent of the organic lesions; and as this cannot be determined during life, one should he most cautious in expressing a hope of recovery. Treatment.—If the condition occurs during pregnancy, the uterus should be emptied as rapidly as is consistent with the safety of the patient, and the various excretory organs stimulated, as will be described under eclampsia. During the puerperium the latter is the only treatment available. Since the work of Whipple and his collaborators, the intra- venous administration of glucose solutions has been recognized as most useful in protecting the liver from further damage and in stimulating its repair. For this purpose, 500 cubic centimeters of a 10 or 20 per cent, solution may be administered every four hours, and if precautions are taken to avoid the production of an alkalosis, sodium bicarbonate may be added to the solution. NEPHRITIC TOXEMIA This condition, as its name implies, is associated with primary lesions of the kidneys and is usually noted in women who were suffering from chronic nephritis prior to pregnancy, or in whom an acute process origi- nates during that period. It differs materially from pre-eclamptic tox- emia, although it frequently happens that final differentiation cannot be made until some months after delivery. It occurs relatively frequently, and the more closely toxemic patients are studied the more it appears that in the past many were diagnosticated as suffering from pre-eclamptic toxemia, when in reality the condition was nephritic in origin. In my experience, nephritic toxemia is the underlying factor in cer- tain women who repeatedly give birth to premature infants and present a history of being perfectly well up to a certain period of pregnancy, when edema and albuminuria suddenly develop. In such cases, the urinary symptoms may persist for some months after delivery, but eventually disappear, to reappear at about the same period in each sub- NEPHRITIC TOXEMIA 591 sequent pregnancy. This condition differs markedly from the pre- eclamptic toxemia, and is explicable by assuming that the individual has slightly defective kidneys, which are efficient under ordinary conditions, but break down under the strain of pregnancy. Etiology.—Many patients present a definite history of having suf- fered from chronic nephritis before the inception of pregnancy, while in others no such history can be elicited. In either event, it must be assumed that a toxic influence comes into play, exaggerating in the one case the existing renal disease, or bringing it about de novo in the other. No information is as yet available concerning its nature or origin, but probably the same factors are concerned as in the causation of eclampsia, so that the various theories which have been advanced will be discussed under that heading. Pathology.—Little can be said concerning the pathology of nephritic toxemia as accurate information is not available. It must be assumed that the kidneys present the lesions characteristic of chronic nephritis, to which have been added acute degenerative changes in the convoluted tubules. Necrotic changes in the liver are absent. In the more chronic forms extensive red and white infarcts usually develop in the placenta, and may throw out of function so great a part of it as to interfere with the nutrition of the child and lead to its death and premature expulsion. Indeed, it may be said that with the exception of syphilis chronic nephritis is the most common cause of premature intrauterine death. Symptoms.—The condition may appear at any period of pregnancy, but is most frequent in its later months. It is usually accompanied by lassitude, general malaise, headache, and marked edema, and frequently by the ocular symptoms associated with albuminuric retinitis. In other cases, however, the patient may complain of little except edema, and with the exception of high blood pressure and the urinary changes, which will be described below, may appear but slightly sick, yet nevertheless she may suddenly pass into a condition of coma which may be accom- panied by convulsions, and either die or slowly recover. Diagnosis.—When symptoms of renal insufficiency develop before the child is viable, they are almost invariably due to nephritic toxemia, and the earlier the manifestations appear, the more certainly is this true. After the seventh month, it is usually impossible to differentiate between nephritic and pre-eclamptic toxemia by the ordinary clinical means, so that the diagnosis may not be established until several months after delivery. In either event, the quantity of urine may be normal or in- creased, although in pre-eclamptic toxemia oliguria is the rule. Albumin and casts are usually present in both conditions, but tend to be more abundant in the latter. Functional kidney tests are of little value in differential diagnosis, although the excretion of phenolsulphonephthalein is more likely to be lower in nephritic cases. The blood pressure affords no information, for while it may be excessively high, it is occasionally relatively low in both conditions. Study of the blood chemistry occasionally offers valuable assistance. A high non-protein nitrogen reading speaks in favor of nephritic toxemia, particularly if one-half or more of it is made up of 592 THE TOXEMIAS OF PREGNANCY urea nitrogen. On the other hand, a low reading does not necessarily indicate its absence. With the exception of a history of preexisting chronic nephritis, I believe that the most valuable clinical means for differentiating between the two conditions consists in the ophthalmoscopic study of the eye grounds. J. K. Miller reported in 1915 that retinal hemorrhage and albuminuric retinitis were frequently present in nephritic toxemia, but were absent in all cases of pre-eclamptic toxemia or eclampsia which he had examined, and when amaurosis was noted in the latter condition that it was due to retinal edema or to deep-seated toxic processes. Fur- ther experience has only served to confirm these statements, but at the same time it should be remembered that such lesions occur only in a fraction of the cases of nephritic toxemia, so that a negative finding by no means precludes its existence. Furthermore, the albuminuric ret- initis may not appear until after the termination of pregnancy. If the patient is not seen until after the onset of convulsions the condition is usually mistaken for eclampsia, while in the less severe cases a diagnosis of pre-eclamptic toxemia is usually made. In many in- stances the diagnosis becomes clear within the few weeks immediately fol- lowing delivery, in others several months must elapse, while occasionally the true condition of affairs is not recognized for many months or until symptoms supervene in a succeeding pregnancy. Generally speaking, it may be said that the diagnosis of eclampsia, or pre-eclamptic toxemia may be considered assured if the blood pressure falls to normal and all trace of albumin and casts disappears from the urine by the end of the second or third week after delivery; while the possibility of nephritic toxemia should be considered when the urine still contains albumin and casts at the end of the month. In such cases the patient should be examined at monthly intervals and if traces of albumin and a few casts persist the diagnosis of nephritis should be made. Unfortunately, the matter is not always so simple, as occasionally patients are discharged in apparently excellent condition, with normal blood pressure and urine, and yet when examined six months or a year later, present definite signs of chronic nephritis. Still less frequently everything seems in order until a new pregnancy supervenes, and a few months after its onset the old train of symptoms reappears. In this type of case it must be assumed that the renal damage is of such low grade that it becomes manifest only during pregnancy. Prognosis.—Provided convulsions and coma do not appear, the prog- nosis in nephritic toxemia is good so far as the immediate life of the mother is concerned, but in view of the frequency of placental lesions the possibility of the premature birth of a dead child should always be considered. The ultimate maternal prognosis is bad, as the renal con- dition tends to become exaccerbated with each pregnancy and to give rise to serious symptoms at an earlier period in each successive gestation. Consequently, childbirth becomes fraught with serious danger to the mother and with progressively poorer chances for the child. Treatment.—In the case of a woman seen for the first time, the treat- ment is identical with that which will be laid down for pre-eclamptic PRE-ECLAMPTIC TOXEMIA 593 toxemia, while if convulsions or coma occur it is along the same general lines as for eclampsia. After the termination of pregnancy, however, the woman and her husband should be made acquainted with the prognosis and with the seriousness of repeated pregnancies. Such information as is necessary for the prevention of conception should be given, and should pregnancy occur in spite of the advice, and serious symptoms supervene, the uterus should be emptied by abdominal hysterotomy and steriliza- tion effected by an operation upon the tubes. PRE-ECLAMPTIC TOXEMIA This is the most frequent variety of toxemia of pregnancy, and for many years was considered as its sole representative. It occurs several times in every one hundred pregnancies, and is more frequent in primi- gravidae than in women who have borne several children. Fortunately, it is usually amenable to treatment, though if neglected, and occasionally notwithstanding the most rational prophylactic treatment, it may termi- nate in eclampsia. Symptoms.—Pre-eclamptic toxemia usually appears in the latter part of the second half of pregnancy, and occurs but rarely in its early months. It should be suspected whenever the patient complains of headache, lassitude, or edema, and presents a high blood pressure, but particularly if the urine is diminished in amount and contains albumin. The symptoms vary from slight malaise to those indicative of profound auto-intoxication. In the latter event the patient may complain of severe and persistent headache, violent epigastric pain, or visual disturbances which may vary from slightly impaired vision to complete amaurosis. In many eases the ophthalmoscope shows edema of the retina, but if it is absent, the derangement of vision must be attributed to degenerative changes in the higher nervous centers. Now and again the patient may suffer from hallucinations, and border on the verge of insanity. In rare instances the woman may pass into a somnolent condition, which grad- ually deepens into coma, usually followed by death; but more commonly typical eclampsia supervenes. Then the toxemia is pronounced, even though it does not eventuate in eclampsia, the child may suffer, and not a few cases terminate in the spontaneous expulsion of a dead pre- mature foetus. The development of edema is associated with a rapid increase in the body weight, and Zangemeister has called attention to the fact that an abnormally large weekly gain may serve to call attention to the onset of a toxemia, before edema or other signs appear. The total amount of urine may be greatly diminished, and some- times falls as low as 200 or 300 cubic centimeters in the twenty-four hours. It contains a variable quantity of albumin, casts of all varieties, and in severe cases blood cells. Chemical examination has so far given no information of value, but that may be due to the fact that as yet no acceptable metabolic studies have been made. Conclusions based upon the older analyses are valueless, as they were made on incomplete collec- tions and without regard to the intake of food. 594 THE TOXEMIAS OF PREGNANCY Likewise, the results of chemical analysis of the blood have as yet failed to throw any light upon either diagnosis or prognosis. The inves- tigations of my former associate, E. D. Plass, show that the total-protein nitrogen of the whole blood or of the plasma is usually within normal limits at the height of the toxemia, and while the urea nitrogen occa- sionally constitutes a much smaller fraction of it, he does not agree with Killian that this is pathognomonic of the hepatic types of toxemia. The uric acid frequently exceeds the normal level of 3.5 milligrams per hun- dred cubic centimeters, but Slemons and Bogert have found such great variations during normal pregnancy and labor that the significance of these changes is dubious. Furthermore, it should be remembered that the increases noted in these substances are not proportionate to the severity of the symptoms; since, as will be pointed out later, the nitro- genous blood constituents all tend to rise at a rapid rate during early convalescence, when they may reach values several times as high as during the acme of the disease. Several investigators have reported large rest- nitrogen fractions and have attempted to correlate such findings with the severity of the symptoms, but Plass found no evidence of such an increase. There is usually an increase in the plasma chloride and a decrease in the plasma protein, depending upon the extent of the general edema. The blood sugar values are usually with the normal range; ■while the serum calcium is low, probably because of the blood dilution. The alkaline reserve of the plasma is diminished, but except in rare cases, it does not fall below the normal minimum for pregnant women, thereby indicating the absence of acidosis. Diagnosis.—The clinical differentiation between the nephritic and pre-eclamptic types of toxemia is not always easy, and was considered in the preceding section. Fortunately, the difficulty in diagnosis is of more importance from a scientific than from a practical point of view, as the treatment to be employed is identical in both cases. As pointed out by Goldsborough, conclusions based upon the phenolsulphonephthalein kidney function test should be taken with reserve, since in normal preg- nant women, the output of the dye is sometimes extremely low; whereas in toxic patients it may be nearly normal. Complete disappearance of all signs and symptoms within two weeks after delivery generally means that the condition was pre-eclamptic in type and was not associated with permanent lesions in the kidneys. Prognosis.—The prognosis in pre-eclamptic toxemia is usually fair, but it is entirely dependent upon the amenability of the symptoms to treatment. If marked improvement does not occur, particularly if the blood pressure remains high and the urine contains large quantities of albumin, premature labor should be induced in the hope of preventing the onset of eclampsia. On the other hand, even in severe cases the urine assumes its normal character within a few days after spontaneous or induced labor, while the albuminous content drops to a fraction of a gram per liter, and usually entirely disappears before the expiration of the second week. If it persists after that period, it is probable that the patient is really suffering from nephritic toxemia. Chronic renal disease rarely results from pre-eclamptic toxemia, and it is my experience that PRE-ECLAMPTIC TOXEMIA 595 it is unusual for the latter to recur in succeeding pregnancies. This is not a universal rule, but it would appear that one attack confers a relative immunity upon the patient, just as in eclampsia. Accordingly, when toxemia occurs in repeated pregnancies it may be inferred that it is of the nephritic type and is dependent upon the existence of a chronic nephritis. Treatment.—In the chapter upon the Management of Pregnancy attention was directed to the necessity for the frequent and routine ex- amination of the urine for the purpose of recognizing this condition, and of preventing the development of eclampsia by suitable treatment. Even in normal cases these examinations should be made once in four weeks during the first six months, and every two weeks during the last three months of pregnancy. The patient should also be cautioned to notify the physician whenever she suffers from headache, disturbance of vision, or edema. Ordinarily the presence of a trace of ‘albumin may be regarded with indifference; but, if a considerable quantity is present, particularly if associated with casts, the condition should be regarded as serious, and the patient should be kept under close supervision. During this time twenty-four hour specimens of urine should be collected and note made of its total quantity, as well as of the amount of albumin present. More- over, the blood pressure should be frequently taken and attention paid to changes in the subjective. symptoms. The sudden appearance of amaurosis or of blurring of the vision and more particularly of pain in the epigastrium, should always be regarded with suspicion, as they are frequently precursors of eclampsia. The same may be said of a sudden increase in the blood pressure, which occasionally exceeds 200 milli- meters. The best indices of the patient’s condition are the blood pressure and quantity of albumin. Any rise in the blood pressure above the 130 mm., which cannot be explained by temporary disturbances, should lead to more careful observation of the patient. There is little occasion for alarm when the pressure is below 150 or 160, but higher readings indi- cate danger of serious toxic manifestations. By testing the urine with Esbach’s reagent in a specially constructed albuminometer (Fig. 463), the albumin content per liter, as well as the daily output, can be deter- mined with sufficient accuracy for clinical purposes. The total daily output probably gives more reliable information, if it is certain that all the urine has been saved, but the content expressed in grams of albumin per liter of urine is also of great prognostic value. It should, however, always be remembered that the latter reading may vary considerably with alterations in the output of urine, whereas the daily quantity remains remarkably constant. Generally speaking, it may be said that an excre- tion of more than one gram of albumin per liter or of a total of more than three grams in twenty-four hours is indicative of a serious condition. In mild cases the patient should be put to bed, or at least confined to her room and placed upon a restricted diet, meats and the coarser vegetables being interdicted; or, better still, for a while she should depend solely upon milk, which is an excellent food, as well as efficient 596 THE TOXEMIAS OF PREGNANCY diuretic. At least two, preferably three, quarts should be consumed in the twenty-four hours. To relieve the monotony, she may be allowed small quantities of lettuce salad, bread and butter, and occasionally a little herring roe as a relish. She should also be made to take large quantities of fluid in the shape of plain water, lithia water, or cream of tartar lemonade (1 dram to the pint). In most cases such treatment will be followed by a marked ameliora- tion of the symptoms, an increased urinary secretion, a decrease in the amount of albumin, a fall in blood pressure, and a prompt return to normal conditions. If the desired result is not promptly obtained, a brisk purge of Rochelle or Epsom salts should be given. Hot packs or sweat baths were formerly advocated, but are now little used, as it has been realized that they only cause the elimination of water, which in all prob- ability has*been stored in the tissues as a protective mechanism. If under treatment the symptoms dis- appear, the albumin becomes less and the blood pres- sure falls, the outlook may be considered excellent. On the other hand, if the albumin steadily increases in amount, while the subjective condition of the pa- tient remains unchanged or becomes more serious, the prognosis is ominous, and the onset of eclampsia can probably be avoided only by emptying the uterus, no matter what be the period of pregnancy. In my experience, the continued daily output of over 5 grams of albumin per liter, or a blood pressure which persists in the neighborhood of 200 millimeters, irrespective of other symptoms, justifies interference. Before the induction of labor is resorted to, vene- section should be employed. The removal of 500 to 1,000 cubic centimeters of blood frequently leads to a prompt amelioration of the symptoms, the blood pressure falling and the output of urine increasing, while the subjective symptoms are largely relieved. As a rule this effect is only transitory, but exceptionally it leads to permanent improvement, just as happens after the completion of labor, and the pregnancy con- tinues as if nothing had happened. Induction of labor is the last resort, and should be regarded as a confession that our therapeutic resources have failed. If haste is not essential, this is easiest effected by the introduction of a bougie, but if the indications are urgent the uterus should be emptied by vaginal hyster- otomy, unless the cervix be so soft, and its canal so obliterated, that manual dilatation by Harris’s method can be safely effected. Unfortunately, we are not yet acquainted with the actual toxic agent or agents concerned in the production of this particular variety of toxemia, and consequently the indications for interference are only rela- tive. Thus, it sometimes happens that the urinary findings and clinical synrptoms so improve under treatment that one is inclined to feel that Fig. 463.—Esbach’s Albtjminometer. ECLAMPSIA 597 all danger has passed, nevertheless eclampsia suddenly supervenes. On the other hand, one occasionally feels that the induction of labor is imperatively demanded, but after deferring it for some reason, the patient may unexpectedly make a satisfactory recovery without any un- toward manifestation. Such experiences indicate that our knowledge of the subject is far from complete; but at present all that is possible is to follow the directions just given, and to interfere whenever the urinary findings and clinical symptoms indicate that the condition is serious. By so doing, it is possible that premature labor may occasionally be induced unnecessarily; but, on the other hand, many more patients will be saved from the dangers of eclampsia, as the prompt recognition and conscientious treatment of pre-eclamptic toxemia constitutes our only available means of preventing that dreaded disease. Some authorities go so far as to hold that such prophylaxis is abso- lute, and that the occurrence of eclampsia indicates neglect on the part of the physician. No doubt this is usually the case, but the rule is not without exception; as upon several occasions I have seen eclampsia occur in women, whose urine had been negative only the day before the out- break of convulsions. ECLAMPSIA Eclampsia is an acute toxemia occurring in the pregnant, parturient, or puerperal women, and is usually accompanied by clonic and tonic convulsions, during which there is loss of consciousness followed by more or less prolonged coma, and frequently results in death. Generally, convulsions and eclampsia are considered as synonymous terms, but such a view is not correct, inasmuch as a number of well-authenticated cases of eclampsia without convulsions are recorded, and, moreover, other toxemic conditions occasionally occur in obstetrical practice which are likewise accompanied by convulsions or coma. Accordingly, the only absolute characteristic feature of the disease is the presence at autopsy of the hepatic lesions which will be described later. Frequency.—Statistical studies indicate that eclampsia occurs about once in every 500 labors, but it is almost impossible to determine its incidence with any degree of exactness, inasmuch as few practitioners see a sufficiently comprehensive series of cases in private practice to permit of trustworthy conclusions, while, on the other hand, hospital records by themselves give an exaggerated idea of its frequency, for the reason that many of the patients would have remained at home had they not had convulsions. The following table would indicate that eclampsia occurs in less than 1.0 per cent, of the women entering lying-in hospitals. Goldberg (Dresden, 1891) in 10,717 labors, 81 cases of eclampsia (0.75%) Cassamayor (Paris, 1892) “ 16,225 “ 99 “ “ (0.61%) Veit (Germany, 1906) “ 149,366 “ 905 “ “ (0.61%) Knapp (Prague, 1900) “ 7,636 “ 41 “ “ (0.53%) Newell (Boston, 1900) “ 6,700 “ 99 “ “ (1.48%) Reinburg (Paris, 1905) “ 26,511 “ 90 “ “ (0.34%) Lichtenstein (Leipzig, 1911) “ 14,836 “ 400 “ “ (2.68%) Williams (Baltimore, 1912) “ 11,000 “ 110 “ “ (1.0%) McPherson (New York) “ 120,000 “ 890 “ “ (0.75%) 598 THE TOXEMIAS OF PREGNANCY In other words, 2,715 cases occurred in 362,991 labors, an incidence of 0.75 per cent. These statistics include all cases of eclampsia, but when Lichtenstein differentiated between the total number of cases and those who were in the hospital at the onset of the disorder, he found that in the latter the incidence was only 1 to 600. Eclampsia varies markedly in frequency at different times, Cassa- mayor stating that in Tarnier’s clinic in Paris it was observed many times more frequently in some years than in others. In my experience it often happens that months elapse without the occurrence of a single case, when suddenly a number are observed in quick succession. Such observations have led various writers to discuss the probability of the disease being of infectious origin, but convincing evidence in favor of such a view has not been adduced. Harrar has shown graphically the monthly variations at the New York Lying-in Hospital during a period of ten years (Fig. 464), and considers that the increased incidence in early spring is due to the cold damp weather prevailing at that time. Furthermore, it is generally accepted as true that eclampsia occurs less commonly in warm climates, as well as among those whose diet is largely vegetable in char- acter. During the World War, a decided decrease in its incidence was noted in Central Europe, and many writers have attempted to explain the fact by invoking the change in dietary customs made necessary by the food blockade. Clinical History.—Eclampsia occurs almost exclusively in the second half of pregnancy and becomes more frequent the nearer term is ap- proached, while in about one-fifth of the cases the first convulsion does not appear until after the completion of labor. Zweifel has reported a case occurring as early as the third month, while a number of writers have reported cases occurring late in the puerperium. Generally speak- ing, however, reports of eclampsia appearing more than twenty-four hours after delivery should be regarded with skepticism, as careful investiga- tion will usually indicate that the convulsions are of some other origin. Primiparity, multiple pregnancy and hydramnios are important pre- disposing factors and it is generally admitted that two-thirds of all cases and upwards occur in primiparous women. Moreover, the disease is noted proportionately six times more frequently in twin than in single pregnancies, and four or five times more frequently when the pregnancy is complicated by hydramnios. Eclampsia may occur during the course of advanced extra-uterine pregnancy, and Maygrier observed a case in the false labor accompany- ing that condition. Falk, Sitzenfrey and others have reported cases occurring in association with hydatidiform mole, and I have observed a case of profound pre-eclamptic toxemia complicating the same ab- normality, and in the appropriate section an illustration will show the uterine cavity completely distended by the mole. The possibility of such an occurrence has been urged as evidence that the metabolism of the foetus plays no part in the etiology of eclampsia. An eclamptic convulsion sometimes occurs without warning, 'dike a bolt from a clear sky,” in women who were apparently in perfect health. In the vast majority of cases, however, the outbreak is preceded for a ECLAMPSIA 599 longer or shorter period by premonitory symptoms indicative of pre- eclamptic toxemia, which was lacking in only 15 per cent, of the 2,005 cases analyzed by Eden in 1922. The attack may come on at any time, sometimes while the patient is sleeping. If she is awake, the first sign of the impending convulsion is a fixed expression of the eyes, which soon begin to roll from side to side. The pupils are usually dilated, less often contracted. The convulsive movements appear first about the mouth, which begins to twitch and is drawn to one side, the entire face becoming distorted. They extend rapidly to the arms, the body, and, finally, to the legs. They are usually clonic in character, though some- times they take on a tonic form and the patient becomes rigid. The Fig. 464.—Graphic Chart Showing the Incidence of Eclampsia in the Various Months as Determined from the Records of the New York Lying-in Hospital (Harrar). (The line shows the number of cases per 100 deliveries). breathing is stertorous, the face congested and flushed, the patient foams at the mouth, and often bites her tongue. During the convulsion, which may last for a few seconds to two minutes, the woman is profoundly unconscious, and after the movements cease passes into a condition of coma which lasts for a longer or shorter period. More particularly when the disorder appears in the latter part of labor or during the puerperium, a single convulsion only may be ob- served. Oftener, however, the first is the forerunner of other convul- sions, which may vary in number from 1 or 2 in mild, to 10 or 20 or even 100 or more in severe cases, the intervals between them becoming shorter in inverse proportion to the number. In rare instances they follow one another so rapidly that the patient appears to be in a pro- longed, almost continuous, convulsion. The duration of the coma is very variable. When the convulsions 600 THE TOXEMIAS OF PREGNANCY are infrequent, the patient usually recovers consciousness after each attack, while in severe cases the coma persists from one convulsion to another, and death may result without any awakening from it. In rare instances a single convulsion may be followed by profound coma, from which the patient never emerges, though, as a rule, death does not occur until after a frequent repetition of the convulsive attacks. The immediate cause of death is usually edema of the lungs or apoplexy, though if the fatal issue is postponed for several days, it is usually attributable to aspiration pneumonia or puerperal infection. In most cases during the seizure the arterial pressure is markedly increased, and may reach well over 200 mm., while the pulse is full and bounding. In severe cases, however, it is weaker and more rapid, becom- ing more compressible and filiform with each succeeding convulsion. The temperature usually remains normal, but occasionally it rises to a very considerable height from the onset of the disease. An elevation to 104 or 105 degrees is not unusual, and in one of my fatal cases the temperature reached 109.5 degrees just before the end. This complica- tion is of very serious prognostic import; although, if the patient does not die, the temperature usually falls to normal within twenty-four hours after the cessation of the eclamptic seizure. As regards the cause of this elevation there is much discrepancy of opinion. Olshausen be- lieved that the poison which causes the eclampsia also stimulates the thermal centers, while Zweifel holds that the fever is of infectious origin. I incline to the former view, for the reason that in all cases, which I have investigated, bacteriological examination of the uterine lochia gave negative results. On the other hand, if the fever persists for any great length of time after the convulsions have ceased, it is practically always a manifestation of puerperal infection, as women suffering from the disease appear to be especially susceptible to bacterial invasion. While the convulsions are by far the most striking clinical manifesta- tions of eclampsia, and even give the disease its name, instances are occasionally met with in which they are absent, the patients dying in coma and presenting at autopsy the hepatic and renal lesions charac- teristic of the affection. Three such cases were reported by Schmorl in 1902. I have seen several, two of which were recorded by Slemons in 1907. Since then the condition has been more generally recognized, and was considered critically by Schmid in 1911, and by Schickele in 1917. In many instances the absence of convulsive attacks has led to an erroneous clinical diagnosis, the condition having been regarded as uremic coma, phosphorus poisoning, fulminating bacterial infection, Weil’s disease, or acute yellow atrophy of the liver. In fact, a correct diagnosis can usually be established only at autopsy. According as the disorder first appears before or during labor or in the first hours of the puerperium, it is designated as antepartum, intra- partum, or postpartum eclampsia. It is generally stated in the text- books that the last is the least common; but that the conclusions as to the relative incidence of the different varieties are by no means unani- mous is shown by the following table: ECLAMPSIA 601 Antepartum Intrapartum. Postpartum. Olshausen 40 % 46 % 14 % Knapp 24.5% 60.9% 14.6% Goldberg 26 % 57 % 17 % Reinburg 49.5% 29.5% 20 % Lichtenstein 21 % 61.5% 17.5% Williams 55 % 22 % 23 % Eden 61.5% 19.2% 19.3% McPherson 56 % 9.6% 34.3% It would appear from the statistics just cited that postpartum eclampsia constitutes about one-fifth of the entire number of cases, while the statements as to the incidence of the antepartum and intra- partum varieties are not so unanimous. Eden and I hold that the former occurs much more frequently—an opinion which was shared by Ols- hausen, who considered that the contrary statements are due to the fact that most writers have failed to remember that eclampsia usually supervenes before the estimated end of pregnancy and that uterine con- tractions often set in Avith the first convulsion, so that if the patient is not seen before the seizure it is often difficult to determine with which variety one has to deal. Antepartum eclampsia may terminate in several ways. As a rule, labor sets in and a premature child is horn spontaneously, or the uterus is emptied by operative procedures. Sometimes the patient dies unde- livered. Lichtenstein has directed particular attention to the fact that labor does not always supervene, but that the woman may recover from the attack and give birth to a dead or macerated foetus some time after- wards, or may even go on to term and bear a living child. In 1911 he collected from the literature 56 examples of the former and 64 of the latter eventuality, and has pointed out that, while the death of the child in the first instance may account for the cure of the disease, such an explanation will not hold in the second instance, and renders it very questionable whether the life or death of the child has anything to do with its causation. Olshausen and others have described as recurrent eclampsia cases in which the patients, after being perfectly well for a longer or shorter period, have a recurrence of the seizure, which may terminate in any one of the ways mentioned above. If the attack occurs during labor, the pains usually increase in fre- quency and severity, so that the child will he born somewhat sooner than usual, after which the convulsions generally cease. On the other hand, in severe cases, or when there is some impediment causing dystocia, the patient may die undelivered, unless operative measures are under- taken. In postpartum eclampsia the attack usually comes on soon after delivery, and recovery often occurs after a single convulsion. In other cases, however, the seizures follow one another in rapid succession, and frequently cause death. The general belief that cases of this variety are comparatively benign is denied by Olshausen and Lichtenstein, who noted a mortality of 25 and 27 per cent., respectively. A few instances have been reported in which convulsions did not ap- pear until several weeks after the birth of the child. It can be safely assumed, as was pointed out by Van de Velde, that such conditions 602 THE TOXEMIAS OF PREGNANCY were not eclamptic at all, but were due to hysteria, uremia, or other causes. Occasionally the onset is preceded by a distinct aura, but this is usually lacking. In rare instances the convulsion comes on without warning, but it is generally preceded for some days or even weeks by symptoms indicative of pre-eclamptic toxemia. As has been pointed out by Olshausen, severe epigastric pain, or a sensation as if the thorax were encircled by a tight girdle, is a frequent precursor of the seizure, and is a sign to which too much attention can hardly be paid. The convulsions are always followed by unconsciousness. Moreover, the patient may not only not remember the attack itself, but even have no recollection of occurrences which had taken place several hours pre- vious to it. This is a not altogether uncommon observation, and may sometimes have an important bearing from a medico-legal point of view. In a small proportion of cases eclampsia is followed by marked mental derangement, and it must not be forgotten that such psychoses constitute one of the well-recognized varieties of puerperal insanity; but whether it is a direct result of the disease or is due to a coincident infection has not yet been demonstrated. In rare instances, as the result of cerebral lesions incident to eclamp- sia, a hemianopsia may develop during the puerperium. A case of this character, occurring in one of my patients, was reported in detail by Woods at the 1902 meeting of the American Ophthalmological Society. More frequently disturbed vision during the latter part of pregnancy is due to edema of the retina, which usually disappears spontaneously. Occasionally, hemorrhagic retinitis is observed, but in other cases the visual disturbance is unattended by demonstrable changes in the retina or optic nerve, and is to be regarded as a manifestation of the general toxemia, complete recovery usually following within a few days after the termination of pregnancy. As was indicated in the section on nephritic toxemia, aluminuric retinitis is a complication of chronic nephritis, but not of pre-eclamptic toxemia or eclampsia. Accordingly, the outcome is dependent upon the further course of the underlying disease. In a small number of cases the patient becomes markedly jaundiced, either during or shortly after the convulsive seizure. This sign is of grave prognostic significance, indicates serious hepatic involvement, and should lead one to suspect the possible existence of acute yellow atrophy of the liver. At the same time, it is well to remember that the icterus may be due to causes not associated with the pregnant state. The urine during the eclamptic seizure usually gives evidence of a marked renal insufficiency. It is invariably diminished in amount and frequently almost entirely suppressed. On microscopical examination various types of casts are found in great abundance, although the hyaline and granular varieties predominate. Epithelial casts also occur, as well as isolated renal cells, while blood is nearly always present. Hemo- globinuria may also be observed. Albuminuria is almost constantly present, and frequently is so pro- nounced that it is necessary to dilute the urine to several times its bulk ECLAMPSIA 603 before an accurate determination can be made by means of the Esbach tube. In the majority of my cases this test showed the presence of at least 10 grams of albumin per liter (one per cent.) during the acute stage of the disease, while in many instances much larger quantities were noted—sometimes as high as 30 or 40 grams. The albuminous preci- pitate is composed of both serum albumin and serum globulin, and in one instance, in which the relative amounts of each were determined, the latter was found to be 34 per cent. Wallis states that in eclampsia the ration is 2 to 1, while in nephritis it is 6 to 1. This high percentage output of albumin is only temporary, although the total daily excretion may remain high for some days. This is in part due to the fact that as recovery occurs the oliguria becomes re- placed by a polyuria, so that the same quantity of albumin in the greatly increased bulk of urine leads to a marked lowering of the Esbach readings. Usually it falls to a fraction of one gram per liter within 36 or 48 hours after delivery, and completely disappears in the course of two or three weeks. This rapid decrease was carefully studied by Emerson in one of my patients, specimens being taken at the time of convulsions, and at four-hour intervals during convalescence. During the eclamptic attack the urine contained 1.23 per cent, of albumin by weight, as compared with 0.25 per cent, twelve hours later. Whether it is better to consider the percentage or the total daily output of albumin is not yet clear. In my experience the former seems of greater prog- nostic value, while, on the other hand, it might well be urged that a considerable total daily output gives a more accurate conception of the extent of depletion of the proteins of the plasma, which are apparently so essential. It is interesting to note that these high grades of al- buminuria do not necessarily indicate profound renal lesions, as in many of my cases, in which the urine also contained large quantities of casts, only a mild degenerative nephritis was found at autopsy. There are no very significant alterations in the known chemical con- stituents of the urine, which cannot be well accounted for by the changes in the metabolic condition of the patient. As a result of the oliguria the total nitrogen output is low, and, consequently, the urea nitrogen output is proportionately diminished, while the twenty-four hour out- put of uric acid, creatinine, etc. is within normal limits. Both the actual and relative output of ammonia is diminished during the attacks, but if recovery ensues, this is soon followed by a moderate rise, which persists for a variable period. These figures were not obtained in ob- servation which were above criticism, but their frequent repetition leads us to believe they are correct. In our experience such a rise should be regarded as favorable, as in several fatal cases the ammonia remained consistently low. Similar observations were made by Landsberg in 1913, but their significance is not clear, and definite statements cannot be made until metabolic studies are available, which are much more elaborate than any which have yet been recorded. The output of chlorides is unusually low during the attack, to be followed by a pro- nounced rise during the first days of convalescence, after which normal conditions become restored. 604 THE TOXEMIAS OF PREGNANCY During convalescence the urine promptly returns to a normal con- dition, but at the same time the increase in its quantity and nitrogenous content cannot be regarded as being entirely due to the elimination of materials, whose retention was supposed to have caused the disease. We now know that somewhat similar changes are observed after normal labor, when the high nitrogen content must be accounted for by the involution of the uterus and other puerperal changes. Although the albumin usually clears up rapidly, it frequently shows a slight increase when the patient is allowed a more liberal diet. Oh the other hand, its persistence for longer than a month indicates the existence of a chronic nephritis, which in most cases antedated the eclamptic attack, but occa- sionally appears to have resulted from it. Within the past few years a great amount of chemical work has been done upon the various constituents of the blood, in the hope that altera- tions in their concentration would throw light upon the nature of the toxemic process, but as yet little helpful information has been obtained, although such investigations have served to discredit certain theories formerly in vogue. At present it must be admitted that chemical study of the blood is of little assistance from either the diagnostic or prognostic point of view. While certain authors claim that a distortion in the ratio between the quantity of nitrogen contained in the urea and the total quantity of non-protein nitrogen enables them to differentiate between “renal” and “hepatic” eclampsia, our extended experience in- dicates that such changes are not pathognomonic. Occasionally at the time of the attack a slight retention of the various non-protein nitrog- enous constituents may be demonstrated; while in other cases they are present in normal amounts. In accordance with the usual findings in chronic nephritis, the uric acid tends to show an increase before there is any evidence of either urea or creatinine retention, but when it is demonstrated, it occurs in the order named. In general it may be said that such work has failed to furnish any evidence in favor of the view that eclampsia is in any way connected with the retention in the blood of the end- or by-products of metabolism. Furthermore, Plass has shown in this clinic that during the first few days following the subsidence of the eclamptic attack the non- protein constituents of the whole blood or plasma rapidly increase in amount, and then promptly return to normal. While the explanation for this phenomenon is not clear, it has been suggested that preceding the attack those materials had been pathologically stored in the body tissues, whence they were abstracted during convalescence. Evidence in favor of such a supposition is afforded by the fact that the increases are most striking in patients with marked edema. That such changes are not due to an increased concentration of the blood is shown by the fact that determination of the total plasma protein indicates that in- creased hydremia or hydroplasmia immediately follows any procedure which leads to clinical improvement on the part of the patient. The blood sugar is usually normal, although as was first demonstrated by Benthin, it may be somewhat increased during the convulsive period. There is no evidence of a carbohydrate insufficiency. The chlorides of ECLAMPSIA 605 the whole blood tend to be increased when the edema is considerable, which can probably be explained by the greater dilution of the blood in such cases. The carbon-dioxid combining power of the plasma is ordinarily diminished, thus indicating a considerable decrease in the bicarbonate content, although the readings obtained are usually not strikingly different from those obtained in normal pregnant women. It has been shown by Henderson and Morriss that in eclampsia the carbon- dioxid combining power of the corpuscles is increased; consequently, the values for whole blood may be normal, even though the ability of the plasma to hold carbon-dioxid is definitely reduced. During recovery the reserve alkali rapidly increases and frequently goes above normal at the end of a few days, only to drop abruptly to normal bounds. If the low bicarbonate content be regarded as an evidence of an acidosis, it is diffi- cult to reconcile it with the low ammonia coefficient of the urine, except upon the basis of a mild and fully compensated acidosis. The serum calcium is low during normal pregnancy probably as a result of the blood dilution, and no marked variations occur in eclampsia, except that in certain cases wuth pronounced edema, the values are some- what subnormal. In view of work now in progress upon the mineral constituents of the blood, it seems inadvisable to speculate concerning the significance of changes in any one element. Zangemeister has called attention to the fact that in many eclamptics there is an increased hydremia, and has used this observation as the basis for his attractive mechanical theory of the disease. The blood lipase is greatly increased (Whipple), whereas the catalase is within normal limits (Winternitz and Ainley). Pathology.—After Rayer and Lever had demonstrated the presence of albumin in the urine of women suffering from this disorder, it was generally believed that the fundamental pathological lesion in eclampsia was a nephritis, and for a long time the condition was considered to be identical with uremia. This view, however, was gradually abandoned when it was found that only a small proportion of the women suffering from chronic nephritis had eclampsia; and still further modifications became neces- sary after it had been shown that the urine does not necessarily contain albumin at the time of the eclamptic attack, Schroeder, Ingerslev, and Charpentier having collected respectively 62, 112, and 143 such cases from the literature. Its absence, however, does not necessarily disprove the renal origin of the disease, since Van de Yelde has reported two instances of eclampsia in which the kidneys were markedly diseased, notwithstanding the fact that albumin was not demonstrable. For the most part, autopsy will reveal the presence of renal changes, which may be very marked in some and only slight in other cases. The lesions are usually those of an acute nephritis with marked degeneration and necrosis of the epithelium of the convoluted tubules—the so-called nephrosis of recent writers. Ordinarily, this is the only lesion, though occasionally the acute changes may be engrafted upon a chronic process. Prutz found that the kidneys were involved in all but 7 out of 368 autopsies collected from the literature, in which the description wras 606 THE TOXEMIAS OF PREGNANCY sufficiently accurate to be of value. Acute or chronic nephritis was present in 46 and 11.6 per cent, of his cases respectively, while de- generative changes were observed more frequently. His conclusions are stated as follows: “Notwithstanding the frequency of renal lesions, we are not justified in considering them as the anatomical substratum of eclampsia, for in many instances they are too insignificant; accord- ingly, it must remain a question whether they are not purely secondary in the greater proportion of the cases.” This view is also indorsed by Lubarsch, Schmorl, Bar and many other observers. Bouffe de Saint Blaise, moreover, states that the kidneys are often perfectly normal, and that lesions when present should be considered as secondary. On the other hand, Pels Leusden, Winckler, and Knapp observed pronounced renal changes in all of their cases, and were inclined to consider them as the characteristic lesion of the disease. Occasionally very extensive renal changes are observed, and Jardine and Kennedy, Kolleston, Schiippel and others have reported instances in which the entire cortex of the kidney had undergone com- plete and symmetrical necrosis. Consequently, the evidence at hand indicates that degenerative renal changes, while almost constantly present, are not, as a rule, sufficiently marked to justify one in considering them as the characteristic lesion of eclampsia, which must therefore be sought in some other organ. Halbertsma, in 1876, pointed out that the ureters were often en- larged and dilated, and was inclined to attribute the production of the disease to this condition. Prutz noted a similar finding 37 times in his analysis of 500 autopsies, and Lichtenstein in 15 out of 50 autopsies. As this incidence is scarcely greater than is noted in normal preg- nancy, it is evident that the abnormality cannot stand in an etiological relation to eclampsia. Although Jurgens and Klebs in 1886 had pointed out the existence of a hemorrhagic hepatitis in certain cases of eclampsia, it remained for Pilliet, in 1888, to direct our attention to characteristic hemorrhagic lesions in the eclamptic liver. His work was abundantly confirmed by Schmorl in 1893, who stated that he had found in every case lesions of the liver which he held to be more characteristic than those observed in the kidneys. These consist of irregularly shaped, reddish or whitish areas scattered through the entire organ and originating near the smaller portal vessels. Ordinarily they are readily seen with the naked eye, and on section give the liver a mottled appearance. Under the micro- scope they are recognized as areas of necrosis, involving the periphery of the individual lobules and the portal spaces, in which blood cells may or may not be present. Schmorl attributed their formation to de- generative changes following thrombotic processes in the smaller portal vessels, and considered that their presence justified the diagnosis of eclampsia without further knowledge of the history of the case (Pig. 465). Flexner has shown that the earliest stages in the thrombotic process are due to the agglutination of red blood corpuscles. These findings were soon confirmed by all subsequent observers, and Schmorl, in 1902, observed them in 71 out 73 autopsies, while in the ECLAMPSIA 607 two negative cases there was a fresh thrombosis of the portal vein. I have been able to demonstrate similar lesions in all the eclamptic livers which I have examined, and consider that they are absolutely character- istic ; since, as far as we know at present, they do not occur in any other disease; and Opie, in his article upon zonal necroses of the liver, takes a similar view. Heinrichsdorff reviewed the subject very thoroughly in 1912, as did Goldzieher in 1919. While generally indorsing Schmorl’s Fig. 465.—Eclamptic Liver. X 50. B. D., bile duct; C. V., central vein; N, periportal necroses. teaching, both of them hold that snch lesions are not always present, but are pathognomonic when observed. Several observers have described the presence of hematomata of vary- ing size, just beneath the capsule of the liver, Prutz having recorded a fatal intraperitoneal hemorrhage from the rupture of such a structure. Varying statements have been made concerning the pathological find- ings in the brain—edema, hyperemia, anemia, thrombosis, and apoplexy being described as the main lesions. Prutz noted edema in 42 per cent., hyperemia in 35 per cent., and apoplexy in 13 per cent., while the brain THE TOXEMIAS OF PREGNANCY 608 was apparently normal in only 10 per cent, of his cases. Schmorl, in 58 out of 65 autopsies, in which the organ was examined, noted the presence of thrombi in the smaller cerebral vessels, and regarded them as the cause of the small areas of necrosis which are so often observed. In most cases of eclampsia the heart is more or less involved, and was perfectly normal in only 8 out of 102 autopsies analyzed by Poliak. According to Schmorl, the changes usually consist in degenerative proc- esses in the myocardium, which are generally regarded as being due to eclampsia, though at times they may he attributed to the use of chloro- form in its treatment. Following Schmorl and Winckler, all investigators have demonstrated in the pulmonary capillaries the presence of giant cells, which they have Fig. 466.—Placental Giant Cell and Chorionic Villus in Blood Vessel of Tube Wall Some Distance from Placental Site. X 80. identified with the so-called giant cells of the placenta—namely, masses of syncytium. Schmorl formerly believed that their presence explained the origin of the thrombotic processes observed in various organs. But at present they are regarded as having no significance, as they can al- ways be found in pregnant women dead of other diseases. In patients who have died several days after the cessation of the con- vulsions, in addition to the lesions just described, bronchopneumonia or the various evidences of puerperal infection are frequently noted. It is apparent, therefore, that the main lesions in eclampsia are found in the liver, kidneys, heart, and brain; but in view of the marked dis- crepancy in the statements of the various authors concerning their rela- tive frequency and importance, it would seem, with the exception of the lesions in the liver, that the anatomical changes are not constant or characteristic. Accordingly, it must be assumed that the essential feature in the morbid process is the circulation of some as yet unknown “toxic” ECLAMPSIA 609 substance in the blood, which gives rise to lesions of varying intensity in the several organs. Etiology.—So many hypotheses have been advanced concerning the etiology of eclampsia that Zweifel has aptly designated it as “the disease of theories.” Unfortunately, exact knowledge is still lacking. From the earliest periods it was considered as a disorder of the nervous system peculiar to pregnancy. This conception is no longer entertained, though there is no doubt that the nervous system is in a condition of less stable equilibrium during pregnancy than at other times. This has been conclusively demonstrated by Blumreich and Zuntz, who showed that convulsions could be produced by the application to the cerebral cortex of far smaller quantities of powdered creatinin in pregnant than in non-pregnant animals. Following the discovery by Lever in 1843 that the urine of eclamptic patients contained albumin, the process was identified with Bright's disease, which had been described a few years previously. From then onward, but more particularly after 1880, the etiology of eclampsia has been industriously studied, and every important contribution to medical thought has been applied to its solution. Up to the present, however, none of the explanations advanced has stood the test of criticism, and we are still ignorant of its actual cause. Nevertheless, this great expenditure of effort has not been wasted, since it has led to the elimina- tion of many theories, and has thus prepared the way for the eventual discovery of the ultimate cause of the disease. In order for any theory to be regarded as acceptable, it must explain satisfactorily certain pathological and clinical facts, of which the follow- ing may be mentioned: A. The genesis of the characteristic hepatic lesions. B. The predisposing influence of primiparity, multiple preg- nancy and hydramnios. C. That the disease is more common in north- ern countries than in the tropics. D. That its incidence increases as pregnancy approaches term. E. That marked edema is usually a favor- able sign, while its absence adds to the gravity of the prognosis. F. That true eclampsia rarely occurs, whereas chronic nephritis gives rise to increasingly serious trouble in each succeeding pregnancy. G-. That intrauterine death of the fcetus is usually followed by improvement, and H. That a milk diet, which is high in protein and mineral con- stituents, is as efficacious as one low in protein and free of salt. Some idea of the scope of the researches may be gained by consider- ing the following twelve headings: I. Uremia. II. Bacterial origin. III. Auto-intoxication. IV. Biological reactions. V. Entrance of foetal elements into the maternal circulation. VI. Action of foetal metabolic products. VII. Action of decomposition products of the placenta. VIII. Alterations of maternal metabolism. IX. Endocrine disturbances. 610 THE TOXEMIAS OF PREGNANCY X. Mammary toxemia. XI. Effect of dietary alterations. XII. Physicochemical changes. I. Uremia.—It has already been mentioned that following the ap- pearance of Lever’s article, eclampsia was identified with uremia, and that view was slowly abandoned only after it had been demonstrated that the lesions of eclampsia and of chronic nephritis had little in common. Consequently, it is now generally recognized that the two processes are quite distinct, but at the same time it must be remembered that clinical differentiation is sometimes difficult, and occasionally impossible. II. Bacterial Origin.—Delore and Rodet of Lyons, in 1884, sug- gested bacterial invasion as a possible etiological factor, but adduced no evidence in support of such a view. The first investigations were made by Doleis in 1885, and following him many observers reported that they had cultivated various bacteria from the urine, blood, and tissues of eclamptic women, but their findings were so contradictory as to be of little value. On the other hand, all later investigators working with modern technical methods have obtained negative results, so that it is generally agreed that eclampsia is not of bacterial origin. Stroganoff in 1923 suggested that the possibility of infectious origin should be constantly borne in mind, as it would best account for certain of the clinical peculiarities of the disease. As his statement is not based upon experimental work, it is scarcely entitled to consideration. According to Talbot and LaVake, the existence of focal infections in the tonsils, teeth and other organs, plays an important part in the production of the disease, and Bugbee holds that infections of the urinary tract do likewise. While many eclamptic women doubtless harbor such foci of infection, no satisfactory evidence has been adduced to indicate that they play any essential part in its etiology. III. Auto-intoxication.—The work of Bouchard upon auto-intoxi- cation, led Riviere to put forward the theory that eclampsia was an auto- intoxication resulting from the heaping up of some substance in the system during pregnancy, holding that its presence was indicated by an increase in the toxicity of the blood serum and by a decrease in that of the urine. This conception was placed upon an apparently secure foun- dation by the work of Chamberlent, Tarnier and their students, who showed that the urine of women suffering from eclampsia, or just about to be attacked by it, when injected into the circulation of animals was less toxic than normal nrine, while the toxicity of the blood serum was definitely increased. They concluded, therefore that some poisonous sub- stance, which should have been excreted by the kidneys, was accumulat- ing in the blood serum, thereby giving rise to the hepatic and renal lesions, which still further accentuated the condition. The earlier work along these lines was in great part confirmatory, but as it was gradually learned how complicated are the conditions at- tending such experiments, more and more doubt was cast upon such conclusions; so that it is now generally admitted that satisfactory evi- dence has not been adduced in support of the view that a “toxin” ECLAMPSIA 611 in the blood serum is the cause of the disease, more particularly as Obata in 1919 was unable to detect any increased toxicity in his animal experiments. IY. Biological Reactions.—Following SchmorFs suggestion that the characteristic hepatic lesions were possibly due to the entrance of placental cells into the maternal circulation, the problem was approached from the biological side, and the phenomena of agglutination and hemolysis, and later those of anaphylaxis, were studied in the hope that they might throw light upon the subject. (a) Agglutination and Hemolysis.—After Flexner had shown that the agglutination of red blood corpuscles was the immediate cause of the thrombosis which initiates the characteristic peri-portal necroses, and Pearce had demonstrated that similar thrombi could be produced ex- perimentally by the injection of hemagglutinative sera, numerous at- tempts were made to associate such phenomena with the etiology of eclampsia. Leith Murray believed that, while agglutination leads to necrosis, hemolysis merely results in degenerative changes, and that the existence of a special endothelial toxin—hemorrhagin—mut be invoked in order to explain the production of hemorrhagic lesions. Accordingly, he considered that the toxemias of pregnancy are attributable to the action of a triple toxin, and that the lesions and symptoms will vary according to which one of the three factors predominate. While in- genious and interesting, this theory has not been substantiated. Dienst in 1905 attempted to demonstrate that the agglutinative changes occurring in eclampsia were the result of the invasion of the maternal organism by foetal cells, having previously shown that the maternal serum would agglutinate the blood cells of the foetus. He at once realized that such a theory could not be maintained unless it were shown that foetal blood could gain access to the maternal circulation, and he thought that this could be demonstrated in eclamptic women. Notwithstanding his advocac}1-, Dienst soon abandoned this view in favor of his original one that the prime factor consists in an excess of fibrin ferment in the maternal blood. In 1922, McQuarrie studied the question of isoagglutination in 180 mothers and their newly born babies in our service. He found that at the time of birth the blood grouping was already established in a surprisingly large number of infants, and that the maternal serum agglutinated the red cells of the latter in 23 per cent, of his cases, whereas, the reverse reaction was demonstrable in less than 3 per cent. Moreover, he found that mild or severe toxemic symptoms occurred 16.5 times more frequently when the maternal and foetal bloods were in- compatible than when they belonged in the same isoagglutination groups. At the same time, he cautiously stated that the number of cases was too small to justify binding conclusions, and that the ultimate fate of his theory must be dependent upon the demonstration that foetal blood cells can gain access to the maternal circulation, which is still lacking. W. M. Allen continued similar observations in our service during 1923. His, as yet unpublished, wrork was based upon the study of 400 additional women and their children—of whom 350 were normal, 22 612 THE TOXEMIAS OF PREGNANCY were suffering from pre-eclamptic toxemia, while 28 had actual eclampsia. Contrary to McQuarrie, he found that the percentage of cases in which the maternal and foetal blood was incompatible was practically identical in each group—namely 20.8, 22.7, and 25 per cent, respectively. In other words, his investigations afford no basis for the belief that agglu- tinative reactions play any part in the production of eclampsia, and thus effectively dispose of a theory which was attractive from many points of view. Furthermore, the outcome of his study emphasizes once more the well-known danger of drawing conclusions from insuffi- cient data; as at first his findings apparently gave promise of confirm- ing McQuarrie’s conclusions, whereas, when the larger series was com- pleted, they conclusively disproved them. (b) Anaphylaxis.—Rosenau and Anderson in 1908 suggested that eclampsia might represent an anaphylactic reaction. This idea was still further elaborated by Thies and Lockeman, and by Grafenburg, who, after an extensive series of experiments, held that the mother was sensitized during pregnancy by small quantities of foetal protein, and would go into anaphylactic shock if a quantity of foetal blood were suddenly introduced into her circulation. They identified the con- dition with eclampsia, and claimed that the liver and kidneys presented characteristic lesions. On the other hand, the researches of Johnstone, Murray, E. Zweifel and others have led to negative results, so that it is probable that Rosenau’s findings must be attributed to the introduction of the products of placental autolysis. A somewhat similar theory has been advanced by Mayer, who at- tempts to ascribe the striking reduction in the incidence of eclampsia, which occurred in Central Europe during the war, to relative sexual abstinence. He assumes that following coitus certain elements of the sperm are normally absorbed through the vaginal or uterine mucosa and thus sensitize the woman. Consequently, he holds that the frequent repetition of coitus might lead to a pseudo-anaphylactic reaction, namely pre-eclamptic toxemia or eclampsia. As such opportunities were greatly diminished during the war, he suggests that the lower incidence of eclampsia might be attributed to it. Such an hypothesis seems fanciful, more particularly since the facts can be explained more rationally upon the basis of the dietary changes incident to the food blockade, as well as by the observation that women who have become pregnant after a single coitus are not immune to the eclampsia. Y. The Enteance of Fcetal Elements into the Mateenal Blood.—Veit, in 1902, promulgated an hypothesis along the lines of Ehrlich’s side chain theory, which for a time bid fair to solve the prob- lem. Notwithstanding its failure to do so, his work has served to direct attention to the “biological” aspects of the problem and has been the in- centive for a large amount of investigation. This theory was based upon the fact that at all periods of pregnancy varying amounts of foetal ecto- derm, and even fragments of chorionic villi, are constantly gaining access to the maternal circulation—the process being designated as “deporta- tion.” Veit contended that such elements acted as a poison—syncytio- toxin, which is normally rendered innocuous by a supposititious antibody ECLAMPSIA 613 —syncytiolysin, which develops in the maternal serum. If, however, for any reason, the former is present in quantities too great to be neutralized, or if the elaboration of the latter is interfered with, symptoms of poison- ing result and eclampsia eventually follows. He considered that the correctness of the theory was established when he found that the injection of an emulsion of human placenta into the peritoneal cavity of rabbits was followed by albuminuria and sometimes by death. In drawing his conclusions, however, he overlooked the fact that similar results would follow the introduction of any heterogeneous animal tissue, and also that nature performs a much more ideal experi- ment whenever the rupture of a tubal pregnancy leads to the extrusion of the ovum into the peritoneal cavity. The fact that eclampsia does not supervene under such conditions speaks strongly against the correct- ness of this view. Aseoli, on the other hand, held that the disease was due to an excessive production of syncytiolysin. VI. Fcetal Metabolic Products.—Fehling in 1899 and Dienst in 1902 advanced the theory that eclampsia is due to intoxication by prod- ucts of the fcetal metabolism. The advocates of this view lay great stress upon the fact that death of the foetus in utero is in many cases promptly followed by cessation of the convulsions and the recovery of the patient, but particularly upon the fact that the children of eclamptic mothers occasionally develop convulsions shortly after birth and present char- acteristic hepatic lesions at autopsy. Cases of this latter type were collected and critically considered in Dienst’s monograph. Observations of neither type, however, can be relied upon to sup- port the contention that eclampsia is foetal in origin, except in so far as it must be conceded that the development of the foetus is the essential function of pregnancy, and that its death must lead to radical changes in the entire process. On the other hand, the presence of lesions in the foetus is noted so rarely, that it would seem more rational to attribute them to the action of substances derived from the mother, which had passed through the placental filter, than to regard them as a manifes- tation of a primary foetal disturbance. Furthermore, the occurrence of so-called intercurrent eclampsia, in which the patient recovers from the convulsive seizure and later gives birth to a normal living child, speaks against such a view. The argument that the foetal origin of the disease is disproved by the occasional association of eclampsia with hvdatidiform mole does not appear convincing, as it is conceivable that the metabolic processes incident to the continued growth of the chorionic villi may not differ materially from those of the normal foetus. However this may be, little is said at present concerning the foetal origin of eclampsia, except by the exponents of the agglutination theory, and it has been intimated above that it need not be considered seriously. VII. Placental Decomposition Products.— (a) Placental Endo- toxins.—Following Veit’s theory numerous investigators, including Liep- mann, Freund, and Guggisberg, have attempted to prove that eclampsia is due to endotoxins produced by the normally situated syncytial cells. They found that the injection into experimental animals of emulsions 614 THE TOXEMIAS OF PREGNANCY or extracts of placental tissue were usually followed by rapid death and sometimes by convulsions, but at autopsy the lesions were not character- istic. Furthermore, Lichtenstein demonstrated that the results were in great part mechanical, and that large quantities of such preparations could be injected with impunity provided all suspended particles had been previously removed by filtration. As subsequent writers have con- firmed his observations, it may be stated that there is no evidence to indicate that eclampsia can be produced by normal placental tissue, provided suitable precautions have been taken in the preparation of the material used for experimentation. (b) Autolysis.—Upon repeating Rosenau’s work, Leith Murray, and Johnstone proved that his results were dependent upon the fact that he had autolyzed the placentae for several hours before utilizing them for injection into animals. Not only did they demonstrate that un- autolyzed placental tissue failed to give any reaction, but they were able to reproduce the toxic symptoms, which he described by the use of extracts prepared from autolyzed liver. How difficult it is to elimi- nate from experimental work the effects of autolysis is evident from the contention of Dryfuss that it may occur even while the placenta is still functioning in situ. The toxicity of the autolytic products of the placenta was utilized by Young as the basis of his theory concerning the origin of eclampsia. He emphasizes the association of toxemia with infarct formation, and holds that the clinical symptoms are due to autolytic products, which have originated intra vitam. In a communication prepared in collabora- tion with D. A. Miller in 1921, he states that the failure to detect placental infarction in many cases of fulminating eclampsia is due to the fact that the changes are ultramicroscopic, but yet are sufficient to flood the patient with toxic autolytic products. The association of red infarct formation with severe nephritic toxemia has long been known, but most observers have not described them in connection with eclampsia, although they are sometimes present in the placentae of apparently normal pregnant women. Furthermore, McNalley and Dieckmann, as well as Haffner, have studied large series of placentae and have failed to detect any relationship between infarct formation and toxemia. When the placentae were carefully examined in slabs of about one centimeter in thickness, they found smaller or large red infarcts in about one-third of all specimens, while toxemic symptoms were present in less than one-tenth of the patients, and even in these infarcts were not always noted. In general, I think it safe to say that infarcts, when present, should be regarded as secondary to the toxemic process, and not as its cause, as Young believes. (c) Lipoids.—The placenta has been analyzed by various investi- gators in the attempt to discover some substance which might produce toxic symptoms, but in general the results have not been encouraging. Considerable attention has been paid to its lipoid constituents, and various fatty substances have been isolated. For example, Freund and Mohr considered that they had solved the problem of hemolysis when they isolated oleic acid or sodium oleate, but it is now generally believed ECLAMPSIA 615 that these substances are merely derived from the fat normally present in the placenta. Leith Murray showed that eclamptic placentae contained larger amounts of soluble lipoids than normal organs, and held that such sub- stances possessed marked hemolytic properties. He failed, however, in isolating a specific compound. Furthermore, Schonfeld in 1921, claims to have isolated a strong convulsant poison from the alcohol-acetone- glycerine extract of normal placentae. He considers that it produces lesions similar to those occurring in eclampsia, but, from his description, this seems doubtful. Moreover, it is difficult to believe that any such substance is of etiological significance, since ordinary placental extracts do not produce either symptoms or lesions when injected into animals under suitable precautions. VIII. Alterations in Maternal Metabolism.—The first meta- bolic hypothesis was advanced by Spiegelberg, who in 1870 suggested that the circulation of ammonium carbonate in the blood was responsible for the seizures. Chemical examination having failed to substantiate the statement, it was soon abandoned. It is, however, of historical interest, as it represents the first of a long series of attempts to correlate the manifestations of the disease with disturbed metabolism. Some years later, Ludwig and Savor considered the offending product to be carbamic acid, which they held was formed because of the inability of the liver to complete the synthesis of urea. (a) General Metabolism.—Satisfactory metabolic studies have not as yet been made on account of the great difficulty in making total col- lections in eclamptic patients, but from numerous investigations it is evident that the nitrogenous metabolism is seriously disturbed. The earlier workers, who dealt entirely with the percentage composition of the urine, demonstrated that the urea accounted for an unusually small proportion of the total nitrogen—the so-called rapport azoturique, while the percentages for amino-acids, creatinine, uric acid, ammonia, and rest nitrogen were increased. As a result, the theories of suboxidation and imperfect desamidization were expounded and for a time were gen- erally accepted, but with increasing biochemical knowledge they have in great part yielded to other ideas. Zweifel attempted to find some imperfectly oxidized body in the urine, and succeeded in isolating considerable quantities of sarcolactic acid, which was also found in the cerebrospinal fluid by Futh and Lockemann. It is now generally agreed that its presence must be re- garded as the result rather than the cause of eclampsia. The idea of the existence of an acidosis has become quite firmly fixed, and while the hydrogen-ion concentration of the blood may be somewhat increased, it scarcely exceeds that occurring in normal pregnancy, and is clearly not an index of the severity of the attack. The lowered urea output was regarded as an indication that the liver was not properly fulfilling its function as the chief urea-forming organ of the body, and consequently it was assumed that poisonous in- completely oxidized substances must be circulating in the blood. In addition, it was believed that the liver was incapable of fulfilling its 616 THE TOXEMIAS OF PREGNANCY detoxifying function. All of these assumptions are probably incorrect, as animal experimentation has shown that much more extensive de- struction of liver tissue than is noted in eclampsia must occur before these functions become seriously impaired. Furthermore, Folin has demonstrated that the tissues in general are able to produce urea, and has emphasized the relationship between the total nitrogen of the food and the percentage composition of the urine, so that it is likely that the lowered urea output can be explained by the decrease in the total nitrogen excretion. The increased percentage output of the amino-acids has been utilized to support the theory that the liver is functioning imperfectly. Van Slyke and Losee, however, have demonstrated that the excretion of these substances is within normal limits, and they were also unable to detect any increase in their amount in the blood, although such increases occur in acute hepatic degeneration, as represented by acute yellow atrophy of the liver and chloroform poisoning. On the other hand, the increased percentage of undetermined, or rest, nitrogen has remained unexplained, notwithstanding repeated efforts to discover the presence of some unusual nitrogen-containing body. Pearce and Jackson have shown that in animals focal and diffuse necroses of the liver are asso- ciated with the presence of a high undetermined nitrogen fraction in the urine, and numerous observations indicate that a similar condition ob- tains in the blood of eclamptic patients, but, in view of the negative results following experimental injections, it seems unlikely that such substances possess a special toxic action. As has been indicated, the urea output, which is greatly diminished during the acute stages of the disease, increases rapidly after delivery and is excreted in several times the normal gmount. Sikes attributed this to an accumulation of precursors of urea in the system, while Slemons insists that it is due to involution of the uterus. Plass rightly holds that the excess, over the normal puerperal output, must be re- garded as proof that an actual retention had taken place in the tissues. According to Wells, changes in the sulphur metabolism also indicate that the body oxidations are not proceeding at the normal rate. This is evidenced by the fact that a greater amount than usual of sulphur is eliminated in unoxidized form, as compared with sulphur dioxid. Chloride retention has been emphasized by Zinsser, and Biittner, who have shown that the elimination of chlorides is decreased during the eclamptic attack, and suddenly increases as improvement occurs. According to Zangemeister, this is associated with an increased per- centage of plasma chlorides and with a hydroplasmia, which he regards as the essential change. (&) Blood Changes.—Chemical analysis indicates that the blood of eclamptic women differs somewhat from that of normal pregnancy. Ordinarily the alterations are quantitative rather than qualitative in character, which apparently indicates that they are of secondary impor- tance. As was indicated in the section upon pre-eclamptic toxemia, there is little or no retention of the non-protein nitrogenous constituents, as occurs so frequently in nephritic conditions. ECLAMPSIA 617 In view of the fact that a low blood calcium content is recognized as an important factor in bringing about increased nervous irritability —such as tetany, its behavior in normal pregnancy, and especially in eclampsia, has been studied. Kehrer and others have found that it falls below the usual limits in normal pregnancy, and is still further decreased in eclampsia. Plass in our service was able to confirm the first observation, but not the second, and considers the former a result of the hydroplasmia which characterizes normal pregnancy and some- times becomes exaggerated in toxemic patients presenting marked edema. Extensive investigations along these lines are now in progress in our laboratory, but are not yet ripe for discussion. It may be said that they indicate considerable perversion of the entire inorganic met- abolism, but the changes are probably secondary in character, and thus can scarcely be reckoned with as primary factors in the causation of eclampsia. (c) Ferments— Schmorl originally suggested that the extensive thrombosis accompanying the disease might be due to the action of fibrin ferment (thrombin). This view has been especially advocated by Dienst, who holds that an increase in fibrin ferment, together with a higher fibrinogen and an abnormally low antithrombin content of the plasma, can account for all the observed phenomena. He believes that unusually large amounts of thrombin are produced in the placenta from leukocytes, and, as the diseased liver can no longer produce the neces- sary antithrombin, intravascular coagulation results. In 1920 he at- tempted to align his theory with the newer work of Zangemeister and others on the changes in the capillaries, and has adduced evidence in support of his view. The increase in the amount of fibrin ferment is apparently capable of proof, but it is generally believed that it is not the primary cause of eclampsia. It has been suggested that steapsin or lipase may have some etio- logical significance, but the evidence at present available indicates that their increase is secondary to the liver necrosis. Whipple has definitely shown that the latter is definitely increased in experimentally produced liver necrosis, and that in eclampsia the degree of liver injury, as de- termined at autopsy, is closely paralleled by the increase in the blood lipase. (d) Physical Changes in the Blood.—Fiith and Kronig and other observers have directed attention to an increase in the viscosity of the blood of pregnant women, which becomes accentuated in eclampsia; while Abderhalden, Fahraens and others have shown that in freshly drawn eclamptic blood the red cells sediment more rapidly than usual. These phenomena have been variously interpreted, and it has been as- sumed that they may be concerned in the production of the initial throm- bosis in the parenchymatous organs. However this may be, it seems safe to regard such changes as secondary to some more fundamental alteration. IX. Endocrine Disturbances.—As soon as the importance of the glands of internal secretion was appreciated, it became evident that their functions are so altered during pregnancy that a new endocrine balance 618 THE TOXEMIAS OF PREGNANCY is probably established, and many attempts have been made to connect them with the various types of toxemia, but thus far nothing definite has been elicited. After it had been established that the thyroid gland undergoes physio- logical hypertrophy during pregnancy, Lange and others suggested that its absence might predispose to toxemia. Nicholson, Ward and others soon put the suggestion into practice and recommended the administra- tion of thyroid extract in the treatment of pre-eclamptic toxemia and eclampsia. Notwithstanding a considerable amount of work along such lines, the consensus of opinion is that abnormalities in the thyroid secretion play no part in the causation of eclampsia, and that its treat- ment by thyroid extract is useless. Yassale and Zangfrongini ascribed a similar function to the para- thyroid glands. It is now generally recognized that insufficient secretion on their part leads to the production of tetany, but not to eclampsia. Furthermore, at autopsy upon patients dying from the latter disease, no lesions can be discovered in the parathyroids. Consequently, Seitz must be correct in holding that they are in no way concerned in its production, and that treatment by means of parathyroid extract is irra- tional. Hofbauer, on the other hand, believes that the cause of eclampsia is associated with hyperfunction of the hypophysis and adrenals result- ing from deficient secretion on the part of the ovaries. He, consequently, recommends ovarian therapy with the idea that it may restore the normal endocrine balance, but careful perusal of his article leaves one skeptical as to its merits. X. Mammary Toxemia.—Sellheim in 1910 suggested the possibility that eclampsia might be due to toxins elaborated in the mammary glands, basing the suggestion upon the supposed similarity between the partu- rient paresis of cattle and human eclampsia, and he even amputated the breasts from a patient in whom eclampsia had proved refractory to other treatment. Two years later Healy and Kastle stated that the two diseases were identical, and that they could produce eclampsia experimentally by in- jecting into the peritoneal cavity of guinea pigs small quantities of colostrum obtained from cows suffering from parturient paresis. At autopsy they found renal and hepatic lesions, which they considered suggestive of those observed in eclampsia. I am not prepared to accept this belief, for the reason that examination of tissues, which these investigators kindly sent me, showed that the liver lesions were more closely allied to those occurring in acute yellow atrophy of the liver than to the periportal necroses which characterize eclampsia. In any event parturient paresis is an interesting disease, which de- serves more extended study. As is well known, it occurs in well-nourished cows shortly after labor, and formerly almost always ended in death; while now recovery almost universally follows the injection of air into the udders. It is characterized by paralysis, coma, convulsions, albu- minuria, the presence of casts, and by a pronounced change in the nitrogenous partition. Owing to the fact that it is now rarely followed ECLAMPSIA 619 by death, little is known concerning its pathology, with the exception of the statement of Delmer that it is associated with lesions of the liver and kidneys. XI. Dietary Alterations.—The startling reduction in the inci- dence of eclampsia in Central Europe during the World War, with return to the prewar frequency after its conclusion, has led to some interesting speculation concerning the origin of the disease. The articles of Huge, Warnekros, Gessner, Yaro, Buiz and others show that the reduction was most pronounced in the cities, and was minimal, or lacking, in the open country. They explained the difference by assuming that the effects of the food blockade were felt most in the cities, but were scarcely noticed in the country, where the farmers took care that the needs of their families were supplied before disposing of their surplus stock. As the lack was greatest in meats and fats, the diet was restricted so far as possible to food of vegetable origin; consequently, the relative disappearance of eclampsia was generally attributed to restriction in the use of the former, and various attempts were made to explain the results, and attention was directed to the conditions prevailing in tropical countries in which eclampsia occurs but rarely. Gessner, on the other hand, was inclined to discount the effect of the change in diet, and to attribute the change to increased physical labor and to the loss of body fat. In support of his contention, he pointed out that, while the food control was rigidly enforced during the year 1919, the incidence of eclampsia, nevertheless, returned to the prewar figure, and, as the only important change in conditions was the cessation of war work, he believed that the latter was implicated. Whatever the true explanation may be, this experience seems to indicate that hard physical labor and an approach to a vegetable diet can play a definite part in the prophylaxis of eclampsia, and raises the question as to why milk, the other great prophylactic, should have a similar effect. At first glance, this appears improbable, as the latter contains large amounts of animal protein and fat, so that the only point in common between a milk diet and the German war diet is the presence of a high inorganic salt content. Whether an abundant supply of inorganic material has any prophy- lactic effect, or whether an actual or relative mineral deficiency is associ- ated with the causation of eclampsia can only be decided in the future, but it is interesting to consider that one of the by-effects of the war has been to direct our attention to the mineral metabolism. XII. Physicochemical Changes.—For some time Zangemeister has believed that edema of the brain is the essential cause of eclampsia, and has thus resuscitated the Traube-Rosenstein theory which was so popular sixty years ago. In 1919 he advanced his hydrops gravidarum theory, according to which, under the influence of some substance connected with the pregnancy, the permeability of the capillary walls becomes increased, with the result that fluid escapes into the tissues, giving rise to edema and anasarca. To overcome the increased peripheral resistance the blood pressure is raised, albuminuria results from the edema of the secreting renal cells, and the headache and eye signs from swelling of 620 THE TOXEMIAS OF PREGNANCY the brain and retina—or as he tersely expressed it in 1921—“the long sought for cause is indirectly water.” In view of Plass’ results indi- cating a tissue retention of various crystalloid metabolic products, it seems probable that the water which escapes into the tissues must carry with it certain other constituents of the plasma. These are, however, two serious objections to Zangemeister’s theory: first, that it does not explain the production of the characteristic hepatic lesions, and second, that it takes no account of the cases of eclampsia without edema, which in my experience offer the most serious prognosis. Zangemeister’s theory is supported to some extent by the observa- tions made by means of the capillary microscope, whose clinical use was introduced by Weiss in 1916, and extended into obstetrics particu- larly by Hinselmann. In this way it is possible to observe the circulation through the capillaries at the base of the finger nails, and to note peculiarities in its behavior. Hinselmann in various articles has pointed out that in toxemia and eclampsia spasmodic contractions of the capil- laries are constantly recurring, which result in periods of complete cessation of the current and occasionally in actual reversal of direction. While such changes are probably secondary in character they are very suggestive, and Hussy has demonstrated in the eclamptic blood a vaso- constrictor substance, which he believes is responsible for such changes. In summing up the subject, it is apparent that the cause of eclampsia has not yet been discovered, but at the same time we have learned that many factors, which were formerly considered as satisfactorily explaining its production, need to be considered no longer. Furthermore, it must be admitted that the treatment of the disease must remain empirical and unscientific so long as we are ignorant of its primary cause. Diagnosis.—Except for the possibility of confusion with purely uremic conditions, the recognition of eclampsia usually offers no diffi- culty. It might be confounded with acute poisoning from strychnin, phosphorus, or nitrobenzol, as in a case reported by Schild. However, such instances are extremely rare, and careful inquiry into the history of the patient should prevent error. Generally speaking, one is much more likely to make the diagnosis of eclampsia too frequently than to overlook the disease, as epilepsy, acute yellow atrophy of the liver, and even hysteria may simulate it. Consequently they should be borne in mind whenever convulsions or coma appear during pregnancy, labor, or the puerperium, and must be excluded before a positive diagnosis is made. Occasionally it is impossible to make an accurate clinical diag- nosis, and in such cases only the finding of characteristic lesions at autopsy will enable one to be positive as to the nature of the affection. Prognosis.—The prognosis is always serious, eclampsia being one of the most dangerous conditions with which the obstetrician has to deal. Dublin, in 1918, having pointed out that it, with the other toxemias of pregnancy, was responsible for 26.4 per cent, of the total mortality from childbirth. The average mortality varies from 20 to 25 per cent., while that of the child approaches 50 per cent. In 2,005 cases of eclampsia occurring in Great Britain and analyzed by Eden, the mortality was 22.5 per cent., ranging from 10.3 per cent, in Dublin to 25.1 per cent, in the ECLAMPSIA 621 North of England. As will be stated below the adoption of more con- servative methods of treatment has led to a considerable improvement in prognosis, and Stroganoff in 1923 reported a mortality of only 1.7 per cent, in 230 personal cases, which, I fear will be approximated by few. The prognosis was formerly thought to be more gloomy when the seizures come on before or during parturition than after delivery, but with the adoption of more conservative methods of treatment the death rate in the former has become materially diminished, while in the latter it has remained stationary. Thus, in 115 cases occurring in our service during the ten years ending in 1922, the gross mortality was 14.7 per cent.—with percentages of 13 and 21.7 in the two groups, respectively. There is considerable discrepancy of opinion concerning the relative prognosis in primiparous and multiparous women. Thus, Goldberg and Lichtenstein state that the disorder is twice as dangerous in multiparae. Olshausen, on the other hand, believes that there is no difference in the two groups, and his contention is borne out by Eden’s figures, which show a mortality of 22.9 and 27.4 per cent., respectively. In all proba- bility the prognosis really depends much more upon the severity of the attack than upon the number of children that the woman has borne. In individual cases it is often difficult to predict the course of the disease, some patients dying in the first seizure, while others recover after more than 30, Jardine reporting a recovery after 200 convulsions. Seitz states that the prognosis becomes worse with each convulsion up to 20 or 30, but that a greater number does not necessarily add to the gravity of the case, the prognosis depending upon the rapidity with which they follow one another and the duration of the coma after each attack. Valuable prognostic data ase also afforded by the condition of the pulse and temperature. When the former is of fair quality between the attacks the outlook is usually good; whereas a weak, rapid, and thready pulse usually indicates a fatal issue, particularly if the tempera- ture is high. The persistence of a high arterial pressure is always of bad prognostic significance, even when the other symptoms seem to improve. Complete anuria and the inability to sweat in a hot pack are ominous symptoms. Apoplexy, paralysis, and edema of the lungs are serious complications and usually end in death. Eden distinguishes between mild and severe cases, and believes that he has to deal with the latter whenever any two of the following seven symptoms are present: 1, coma; 2, pulse rate above 120; 3, temperature 103 or higher; 4, blood pressure above 200; 5, more than ten fits; 6, sufficient albumin to become solid on boiling; and 7, and least important, the extent of edema. Of 706 cases, in which the data were sufficiently comprehensive to permit such differentiation, 56 per cent, were mild and 44 per cent, severe, with mortalities of 6.6 and 37.2 per cent., respec- tively. If the eclampsia comes on during pregnancy the prognosis is very favorably affected by the death of the foetus, the convulsions usually ceasing soon afterward. The presence of marked edema in general jus- 622 THE TOXEMIAS OF PREGNANCY tifies a more favorable prognosis than when there is no demonstrable swelling, w’hich suggests that the retention of fluid in the tissues should be regarded as a protective mechanism, and possibly serves to withdraw temporarily from the circulating blood certain substances which may do harm. If the patient recovers, it is unusual for eclampsia to occur in subse- quent pregnancies. The observations of Slemons, and Lepage clearly show that one attack confers a relative immunity for the future. In my experience, a woman who has had eclampsia is less disposed to the disease in future pregnancies, than one who has never had it. On the other hand, in patients suffering from chronic nephritis the recurrence of uremic convulsions is not uncommon. The foetal mortality must always be high since the disease frequently appears while the child is still premature, when its chances of living would be only moderate even were the mother not suffering from a serious disease. Moreover, except in the postpartum variety, the thera- peutic measures adopted in the interests of the mother still further prejudice its chances. For these reasons, a foetal death rate of approxi- mately 50 per cent, is not surprising, and in our hands but little more than one-third of the children left the hospital with their mothers. Treatment.— (a) Prophylactic.—As, in the vast majority of cases, eclampsia is preceded by premonitory symptoms, its prophylaxis is in many ways more important than its actual cure, and is identical with that recommended for pre-eclamptic toxemia (p. 595). Indeed, the chief aim in treating the latter condition is to prevent the possible outbreak of eclampsia. Hence the necessity of regular and frequent examinations of the urine, blood pressure determinations, and weighings, and the immediate institution of appropriate treatment and diet as soon as symptoms appear, which indicate that the eliminative processes are at fault. By the employment of these precautionary measures, and by promptly inducing premature labor in those cases which do not improve, or which become progressively worse under treatment, the frequency of eclampsia will be greatly diminished and many valuable lives saved. At present, however, despite all we can do, eclampsia will still occur, and sometimes even in patients who apparently have responded most satisfactorily to prophylactic treatment. We have become convinced that prophylactic treatment, while pro- ductive of untold good, is not invariably successful or always applicable; and that those who teach that eclampsia is always a' preventable af- fection, and that its occurrence indicates neglect on the part of the obstetrician, take too extreme a view and have been led astray by their enthusiasm. (b) Curative.—As has already been indicated, the curative treatment of eclampsia must remain empirical and unsatisfactory until its actual cause has been discovered. Consequently, although no unanimity exists among authorities as to the best course to pursue, it may be said that two diametrically different methods of treatment are advocated—radical and conservative. The proponents of the former insist that the essential feature is to empty the uterus by operative means as soon after the first ECLAMPSIA 623 convulsion as possible, while the advocates of the latter claim that this is not only unnecessary, but is actually harmful. The plea for radical treatment is based upon the notoriously poor results which followed purely medicinal treatment in the past, as well as upon the fact that improvement frequently follows the termination of pregnancy. The conservative school, on the other hand, argues that the results following radical treatment have not been satisfactory, but are definitely inferior to those obtained by Stroganoff (1899) by means of profound narcosis, and by Tweedie and his followers (1903) by eliminative means. Generally speaking, it may be said that during the first fifteen years of the past quarter century radical treatment was predominant, whereas during the last ten years conservative treatment has found more and more advocates. Personally, I have followed the same general tendency, and now practice a degree of conservatism, which I should have considered reprehensible earlier in my career. In considering the treatment, I shall outline in the first place what is now done in my service, then I shall consider how this practice differs from that employed in the past, and finally I shall attempt to explain why the changes have been instituted. The patient should be in a hospital if possible, as the facilities for treatment in a well-regulated service are greatly superior to those in even the most comfortable home. She should be placed in a quiet, darkened room and care should be taken that she is disturbed as little as possible. A competent nurse should be in attendance, who should not leave the patient alone until she has definitely come out of coma. Immediately after being put to bed, one-quarter grain of morphia is administered hypodermically, and the necessary examinations made. A second dose of morphia may be given when required, but not more than one half grain should be used during the first twenty-four hours. It comatose, the patient should be turned on one side and the foot of the bed elevated, so as to permit the ready escape of mucus and other fluid from the mouth. If it collects, in spite of this precaution, it should be swabbed out by the nurse. If a second convulsion occurs, venesection should be done, and the blood pressure noted every few minutes during its course. The blood should be allowed to flow until 1,000 cubic centimeters have been with- drawn, or until the blood pressure falls to 100 millimeters. Provided the blood pressure is properly controlled, the condition of the pulse offers no contra-indication. Indeed, it is sometimes observed that vene- section acts most beneficially when the pulse is weak and thready. In many instances, no further convulsions occur, and, if labor has already set in, the process goes on to a happy termination. If, however, labor has not supervened, it occasionally happens that following the venesection the eclampsia becomes arrested, the threatening symptoms disappear, and the pregnancy continues for several days or weeks, when the patient falls into labor spontaneously. Such an outcome represents the so-called intercurrent eclampsia of Lichtenstein, and was noted in 41 of his 255 cases of antepartum eclampsia. If the patient is conscious she should be encouraged to drink large 624 THE TOXEMIAS OF PREGNANCY quantities of water, but if unconscious nothing should be given by mouth for fear of producing aspiration pneumonia. If the patient cannot drink on account of coma or lack of desire, 500 cubic centimeters of five per cent, glucose solution should be given intravenously, and repeated in twelve hours. In either event, as soon as the patient regains conscious- ness, fluids should be forced, and she should be encouraged to drink three or four liters of milk or water for each of the first few days of the puerperium. If the case is progressing satisfactorily there should be no thought of emptying the uterus until the cervix has become fully dilated, when anesthesia should be induced by gas or ether, and delivery completed by forceps or version, as seems most expedient. If, however, the convulsions and coma continue, and the cervix has become dilated to five centimeters in diameter, dilatation may be com- pleted by Harris’s manual method, and the child delivered by podalic version. This, however, represents our nearest approach to accouchement force, as we have learned by disastrous experience that any attempt at forcible dilatation of the cervix is not to the advantage of the patient. Generally speaking, cesarean section should be undertaken only in the presence of such disproportion or other condition as would indicate its performance irrespective of the existence of eclampsia, and with the understanding that it is resorted to solely on that account, and not with the idea of curing the eclampsia. As will be shown below, all recent stastistics indicate that it adds to the gravity of the prognosis. Conse- quently, I hold that its employment is not justified in the treatment of eclampsia, although it is sometimes indicated as a prophylactic procedure in women suffering from fulminating pre-eclamptic toxemia, in whom it is feared that eclampsia will supervene before the induction of labor can be effected by the usual methods. In postpartum eclampsia the same treatment applies, except, that when venesection is done, the amount of blood lost during the third stage should be taken into consideration. In connection with treatment, several important points concerning the general care of the patient should be mentioned. For example, if she is very restless or excitable between the convulsions, a few whiffs of ether or gas should be given before undertaking any manipulation, such as a vaginal examination, the administration of a hypodermic in- jection, catheterization, etc. On the other hand, the administration of an anesthetic for the purpose of controlling or shortening a convulsive seizure, is probably useless; but if it is done, ether should be employed instead of chloroform, as the latter is supposed to increase the tendency toward hepatic necrosis. Moreover, during the attack it is very important that a folded towel, a piece of thick rubber tubing, or a clothes-pin should be placed between the teeth for the purpose of avoiding injury to the tongue. If the bowels have not moved recently, one or two drops of croton oil in a tea-spoonful of sweet oil or two ounces of Epsom salts may be given by mouth, or if the patient is unconscious the croton oil alone may be placed upon the back of the tongue, or the salts may be given by stomach tube after that organ has been washed out. Twenty years ago the treatment would have been quite different, as delivery would have been effected as soon as possible after the first ECLAMPSIA 625 convulsion, the method employed varying with the condition of the cervix. After delivery, the patient would have been placed in a hot pack, with the idea of eliminating some of the toxic material along with the sweat; every attempt would have been made to stimulate diuresis by giving copious salt solution infusions under the breasts; and finally if recovery did not promptly ensue a few hundred cubic centimeters of blood would have been withdrawn. In other words, we formerly effected delivery at almost any cost, placed great reliance upon the efficiency of sweating, administered salt solution subcutaneously, and employed vene- section as a last resort. Why have we changed ? In the first place, we have gradually learned that forced delivery was occasionally the direct cause of the death of the patient, while in other cases it did not seem rational to subject a seriously ill woman to a radical operative procedure, unless assured of its necessity. In the second place, the results obtained by Stroganoff’s method caused us to take stock of what we were doing. The hot pack was abandoned for the reason that chemical analysis of the sweat showed that it con- sisted practically only of water, and contained but an insignificant fraction of excrementitious material, and, furthermore, because we gradu- ally gained the impression that the edema served some protective purpose, as experience taught us that patients did better when it was present than in its absence. Subcutaneous salt infusions have been abandoned for two reasons: First, since we have learned that there is an actual retention of sodium chlorid in the body, it does not seem rational to add to it; and, second, that glucose solution acts just as efficiently as a diuretic, and possesses the additional advantage that it enables us to introduce into the patient a small amount of an easily assimilable foodstuff. Finally, we learned if venesection is to be efficacious that it should be in considerable amount, and occasionally it results in as com- plete disappearance of the symptoms as if delivery had been effected. Such changes were only gradually put into practice, and sometimes in a halting manner, but we gradually gained the impression that after adopting them the patients did better and the duration of the attacks was lessened. Consequently, we became more and more conservative, with the result that when we tabulated our results in 1922, we found that they had improved by one-third, as shown in the following table: Table Showing Results of Treatment by Radical and Conservative Methods at the Johns Hopkins Hospital. Radical Treatment, 1916-1911 Conservative Treatment, 1912-1922 Cases Deaths % Cases Deaths % Antepartum and intrapartum 85 21 24.7 92 12 13 Postpartum 25 4 16 23 5 21.7 Total no 25 22 115 17 14.8 626 THE TOXEMIAS OF PREGNANCY In other words, in antepartum and intrapartum eclampsia, conservative treatment has decreased the mortality almost by one-half—24.7 to 13 per cent., while in the postpartum variety, in which the question of rapid delivery does not arise, it has remained practically unchanged. That others have obtained similar results is shown by the figures of Engelmann and Lichtenstein. The former went through a similar change during the ten years ending 1916, and reported a mortality of 26, 13.6 and 6.7 per cent., according as he employed radical, transitional or conservative therapy respectively; while the latter, in the cases of ante- and intrapartum eclampsia treated between 1901 and 1911, and 1911 and 1921, reported a mortality of 16.7 and 9.4 per cent., re- spectively. Unfortunately, however, the matter of treatment is not so simple, as the Stroganoff and Dublin methods apparently give as good, and possibly better, results, and yet are based upon diametrically opposite principles. For this reason, each will be briefly outlined. Stroganoff lays great stress upon following his directions in the most minute de- tails, which are as follows: When first seen morphia % grain, After one hour, chloral hydrate 30 grains in 200-250 c.cm. of saline solution by rectum, or in 100 c.cm. of milk by mouth. After 3 hours, morphia 14 grain After 7 “ chloral hydrate grains 30 After 13 “ “ “ “20 After 21 “ “ “ “20, and later every eight hours. Chloroform is administered to control the convulsions, cardiac stimulants are employed, delivery is not effected until after the cervix has become fully dilated, and if more than three convulsions occur 400 cc. of blood is withdrawn. Stroganoff has collected 2,208 cases treated by this method in various clinics with a mortality of 9.8 per cent., and reports that in 230 patients whom he treated personally it was only 1.7 per cent. On the other hand, Fitzgibbon and Solomons report 204 cases treated by the Dublin method with a mortality of 10.3 per cent. —the lowest in the British Isles. In this method stress is laid upon starvation, stomach lavage, bowel lavage and the submammary infusion of sodium bicarbonate solution. Epsom salts are given after the gastric lavage, and large quantities of sodium bicarbonate solution are used for flushing the bowels. Morphia, chloral, chloroform and venesection are not employed, and delivery is effected only after the cervix has become completely dilated. Accordingly, it seems that Lichtenstein and ourselves obtain rela- tively good results with free venesection, Stroganoff possibly better re- sults with sedatives and scanty venesection, while the Dublin School obtains equally good results with eliminative treatment, without either sedatives or venesection. In the present state of our knowledge, it is ECLAMPSIA 627 impossible to state which of us is correct, or whether all of us are wrong, but one thing stands out clearly, and that is that the best results are obtained by conservative treatment, and not by those who lay stress upon the earliest possible delivery, without regard to the condition of the cervix. Four important facts emerge from Eden’s analysis of the British cases, as follows: 1, that the general mortality is unnecessarily high; 2, that the best results are obtained in Dublin; 3, that the mortality is relatively low in the mild cases and high in the severe cases of eclamp- sia, irrespective of the method of treatment; and, 4, that in both groups the highest mortality follows the employment of cesarean section and accouchement force. It is my conviction that, excepting accouchement force, cesarean section represents the most dangerous method of treating eclampsia, and that resort to this spectacular method of delivery, by those who do not appreciate its dangers, has led to the unnecessary death of many women, and the same may be said of vaginal hysterotomy or vaginal cesarean section. That I do not stand alone in this opinion is shown by the fact that Peterson and Eardley Holland found that the mortality of cesarean section for this indication was 25.8 per cent, in this country and 32 per cent, in Great Britain. Consequently, the sooner the obstetrician and surgeon recognizes the fact the better it will be for their patients. In conclusion, a few words will be said concerning a number of procedures whose employment is not recommended for the reason that they have been tested and found wanting, or else evidence concerning their value has not been adduced. Thyroid extract has been advocated by Nicholson, who advises that 70 to 80 grains be given daily during the attacks. It was used by Sturmer in a series of 41 cases with 5 deaths. Since other therapeutic measures were employed as well, it is impossible to judge of its efficiency. In the few instances in which it was used in my clinic favorable results were not obtained. The use of veratrum viride, which is highly praised by many American writers, has never appealed to me, and Sturmer’s statistics from the East India Medical Service, where it was used for twenty years, show a maternal mortality of 45 per cent. After reading the enthusiastic report of Mangiagalli, and of Cragin and Hull concerning its merits, I felt that I was perhaps wrong in rejecting it. Accordingly, in a series of cases I gave it to every other patient, while the alternate patient was treated in identically the same manner except for the veratrum. While the hypodermic administration of 5 to 10 minims of the fluid extract, repeated if necessary, undoubtedly leads to a marked slowing of the pulse, and occasionally to an almost alarming fall in blood pres- sure, the patients did neither better nor worse than those who did not receive it. For this reason I abandoned its use. Engelmann in 1911 reported good results in 14 cases of eclampsia by the intravenous injection of 0.2 to 0.3 gram of hirudin (leech extract) in a liter of Ringer’s solution. The remedy is employed with the idea that it will inhibit coagulation of the blood and thus prevent thrombosis. 628 THE TOXEMIAS OF PREGNANCY Engelmann recommends its employment particularly in severe cases of postpartum eclampsia, but admits that further experience will be neces- sary before its merits can be fully determined. The intravenous injection of serum from normal pregnant women has been recommended with the idea that it may furnish some antibody, which should be normally present, and thus neutralize the supposititious eclamptic toxin. With somewhat the same idea, Blair Bell has recom- mended the transfusion of blood from normal individuals, but proof of the efficiency of either suggestion has not yet been adduced. In 1904 Kronig employed lumbar puncture in eclampsia with bene- ficial results. He found the cerebrospinal fluid under a considerably increased tension, and noted apparent improvement following the with- drawal of from 20 to 10 degrees cubic centimeters. The procedure has been rather extensively employed, and Spillman, after recently reviewing the literature upon the subject, found that in 25 out of 68 cases it was followed by cessation of the convulsions. As this corresponds to a mortality of 62 per cent., it cannot be regarded as a hearty recommenda- tion. From what I have seen, it appears to be unnecessary in mild, and useless in severe cases. Renal decapsulation was performed in a case of eclampsia by Edebohls in 1902, although it had previously been suggested by Sippel. The former considered that it acted by relieving the intrarenal tension, and thereby favored the resumption of urinary section. The subject has been re- viewed by Chamberlent and Pousson, Pinard, and Sippel, who believe that it is of value in cases of total suppression following delivery, and may be employed as a last resort. In view of the marked liability of eclamptic women to infection, all operative procedures must be conducted in the most rigidly aseptic man- ner, particular care being taken to avoid the contamination of the vagina rand the hands of the operator by faecal material. PRESUMABLE TOXEMIAS Under this heading are included a number of conditions occurring during pregnancy and the puerperium, concerning whose nature and origin we are as yet ignorant, but which are most readily explained by supposing that they are dependent upon some variety of auto-intoxication. Certain psychoses clearly belong in this category. In some cases they are definitely associated with pre-eclamptic toxemia, and disappear as the underlying condition becomes ameliorated. I recall one patient who, during the later months of pregnancy, suffered from delusions of persecution. At such times large amounts of albumin were present in the urine, while the urea output was greatly diminished. Sweat baths were repeatedly followed by an immediate improvement in the condition of the urine, after which the mental condition became normal, the delusions reappearing, however, within a few days, to again disappear under the same treatment. Complete recovery followed delivery. PRESUMABLE TOXEMIAS 629 Again, some cases occur in which the most careful study of the urine fails to reveal the slightest evidence of toxemia, and yet the mental derangement promptly disappears upon the employment of milk diet, rest, and eliminative treatment. On the other hand, most of the psy- choses occurring during the puerperium are to be regarded as manifesta- tions of infection, and are directly due to the absorption of poisonous materials generated by infectious microorganisms. Many cases of peripheral neuritis should also be regarded as due to toxemia, and we have already referred to its frequent association with the vomiting of pregnancy. Lindemann, in a fatal case, clearly showed that the nerve lesions were associated with degenerative changes in both the liver and kidneys. On the other hand, as far as can be ascertained by clinical observation, such an association is absent in other cases, but even here it is permissible to believe that the underlying factor must be an auto-intoxication of some character. Likewise certain non-contagious skin diseases, such as impetigo and herpes gestationis, are susceptible of a similar explanation, and sometimes yield to a milk diet and proper eliminative measures after obstinately resisting the usual local and medicinal treatment. Excessive salivation, which sometimes occurs in pregnant women, is also probably due to a toxemia of some kind, as is particularly shown in the cases associated with vomiting of pregnancy. At the same time, intense salivation may occur without such an association, and may resist all remedial measures until the patient is placed in bed and put upon a rigorous milk diet. Dirmoser, Sondern, and others have insisted that auto-intoxication from the intestinal tract plays a prominent part in the production of many of the abnormalities of pregnancy; and the former holds that most cases of vomiting during pregnancy are due to it, and, therefore, considers that the presence of indican, indol, skatol, and ethereal sul- phates in the urine affords strong evidence in favor of such a view. Glaessner has shown that profound symptoms of auto-intoxication can be produced experimentally in dogs by reversing the direction of in- testinal peristalsis. In such cases marked changes are manifested in the urine, which consist particularly in a distortion of the relative pro- portions of its nitrogenous constituents. Occasionally women suffer from asthma in every pregnancy, but at no other time; and there is a certain amount of evidence available which points to its being due to an underlying toxemia. Thus, I have seen several patients in whom the condition was not relieved by medicinal treatment, yet it yielded readily to milk diet and eliminative measures; though at no time could changes be demonstrated in the urine in support of its toxemic origin. On the other hand, in one of my cases the con- dition was associated with pre-eclamptic toxemia, and disappeared only after the induction of premature labor. Occasionally conditions occur during the puerperium which can only be explained upon the assumption of an underlying toxemia. Thus, I have seen three women, whose urine was apparently perfectly normal, go through an uneventful pregnancy and labor, and on the second or third day of the puerperium pass into a comatose condition, which per- 630 THE TOXEMIAS OF PREGNANCY sisted for several days, but from which they slowly recovered. In each instance a careful chemical and microscopical examination of the urine was made, but failed to reveal any abnormality. In one of these patients there was slight jaundice, and the clinical symptoms were such that one was forced to consider the possibility of chloroform poisoning. As all of the patients recovered, it is naturally impossible to speak positively as to the nature of the condition, but, notwithstanding the negative results obtained by the study of the urine, it is difficult to explain its production by any other supposition than that of a pro- found toxemia. This being the case, it must be admitted that we occasionally have to deal with conditions which in all probability are toxemic in origin, but concerning whose nature we are as yet absolutely ignorant. LITERATURE Ascoli. Zur exp. Pathogenese der Eklampsie. Zentralbl. f. Gyn., 1902, xxvi, 1321- 1326. Bar. Est-il demontre que 1’eclampsie est une maladie microbienne? L’ob- stetrique, 1898, iii, 481-505. Les reins des Eelamptiques. L’obstetrique, 1903, viii, 193-215. Bar et Guyeisse. Lesions du foie et des reins chez les Eelamptiques et les foetus issus des femmes eelamptiques. L ’obstetrique, 1897, ii, 263. Beatty. A Case of Acute Yellow Atrophy of the Liver. Medical Record, 1895, xlviii, 274-275. Benthin. Kohlehydratstoffwechsel in der Graviditat. Monatsschr. f. Geb. u. Gyn., 1913, xxxvii, 305-321. Blumreich und Zuntz. Exp. und kritische Beitrage zur Pathogenese der Eklampsie. Archiv f. Gyn., 1902, Ixv, 736-785. Bouchard. Legons sur 1’auto-intoxication. Paris, 1887. Boufee de Saint Blaise. Lesions anat. que l’on trouve dans 1’Eclampsie. These de Paris, 1891. Foie et eclampsie puerperale. Annales de gyn. et d ’obst., 1891, xxxv, 48. Quelques cas d’acces eelamptiques sans albuminurie. Annales de gyn. et. obst., 1900, liv, 76-77. Buttner. Untersuchungen iiber die Nierenfunktion bei Schwangerschaftsniere und Eklampsie. Arch. f. Gyn., 1906, lxxix, 421-478. Cassamayor. Contribution a l’etude de 1’eclampsie puerperale d’apres une statis- tique de la Clinique de 1872-1892. These de Paris, 1892. Chamberlent. Toxicite de serum maternal et foetal dans un cas d’eclampsie puer- perale. Archives cliniques de Bordeaux, 1894, 271-284. Recherches exp. anat. path, sur les causes de la mort du foetus dans 1’eclampsie puerperale. Nouv. arch, d’obst. et de gyn., 1895, 175. Charpentier. Eclampsie sans albuminurie. Traite pratique des accouchements. Paris, 1883, i, 699. Copeman. A Novel Treatment of Obstinate Vomiting In Pregnancy. Brit. Med. Jour., 1875, i, 637-638. Cragin and Hull. The Treatment of Eclampsia. J. Am. Med. Assn., 1911, lvi, 5-11. Davis and Whipple. Liver Regeneration Following Chloroform Injury as In- fluenced by Various Diets. Arch. Int. Med., 1919, xxiii, 711. Delmer. Contribution a l’etude de 1’eclampsie vitulaire. These de Paris, 1904. LITERATURE 631 DfiLORE et Kodet. Memoire sur 1 ’etiologie bacterienne de 1’eclampsie. Resume dans Parch, de tocologie, 1884, ii, 921. Dienst. Kritische Studien iiber die Pathogenese der Eklampsie, Archiv f. Gyn., 1902, lxv, 369-464. Exp. Studien iiber die aetiologische Bedeutung des Fibrinferments u. Fibrinogen fiir d. Eklampsie. Archiv f. Gyn., 1912, xcvi, 43-170. Zur Eklampsiefrage. Zeitschr. f. Geb. u. Gyn., 1920, lxxxii, 102-135. Diemoser. Der Vomitus gravidarum perniciosus. Wien, 1901. Dublin. Mortality among Women from Causes Incidental to Child-bearing. Am. J. Obst., 1918, Ixxviii, 20-37. Duhrssen. Ueber Eklampsie, Thiel II. Archiv f. Gyn., 1893, xliii, 49-161. Duncan. Clinical Lecture on Hepatic Diseases in Gyn. and Obst. London Med. Times and Gazette, 1879, i, 57-59. Duncan and Harding. A Report on the Effect of High Carbohydrate Feeding on the Nausea and Vomiting of Pregnancy. Jour. Can. Med. Assoc., 1918, viii, 1057-1069. Edebohls. Surgical Treatment of Bright’s Disease. New York, 1904. Eden. A Commentary on the Reports Presented to the British Congress of Obstetrics and Gynecology, June 29, 1922. Jour. Obst. and Gyn. Brit. Emp., 1922, xxix, 386-401. Emge. Further Observations on Acidosis in Pregnancy (with special reference to the COo method of Van Slyke). Am. Jour. Obst., 1918, lxxvii, 813-821. Engelmann. Ueber die Behandlung der Eklampsie mittels intravenose Hirudin- injektionen. Zeitschr. f. Geb. u. Gyn., 1911, lxviii, 640-664. Hat die Einhaltung der mittleren Linie bei der Behandlung der Eklampsie noch Berechtigung? Zentralbl. f. Gyn., 1920, 1113-1128. Ewing. The Path. Anatomy and Pathogenesis of the Toxaemia of Pregnancy. Am. Jour. Obst., 1905, li, 145-155. The Pathogenesis of the Toxaemia of Pregnancy. Am. Jour. Med. Sci., 1910, cxxxix, 828-846. Ewing and Wolf. The Clinical Significance of the Urinary Nitrogen, etc. Am. Jour. Obst., 1907, lv, 289-336. Fahraens. The Suspension Stability of the Blood. Stockholm, 1921. Fehling. Die Pathogenese und Behandlung der Eklampsie im Lichte der heutigen Anschauungen. Volkmann’s Sammlung klin. Vortrage, N. F., 1899, Nr. 248. Fieux. Sero-therapie. Annales de gyn. et d’obst., 1912, ix, 718-725. Flexner. Thrombi Composed of Agglutinated Red Blood Corpuscles. Univ. of Pennsylvania Med. Bulletin, 1902, No. 9. Freund und Mohr. Pathogenese der Eklampsie. Berliner klin. Wochenschr., 1908, xlv, Nr. 40. Futh u. Lockemann. Ueber den Nachweis von Fleischmilchsaiire in der Zarebro- spinalfliissigkeit Eklamptischer. Zentralbl. f. Gyn., 1906, xxx, 41-43. Gessner. Die badische Eklampsie-statistik, etc. Zentralbl. f. Gyn., 1922, 1914- 1918. Glaessner. Experimentelles fiber die Obstipation. Wiener klin. Wochenschr., 1904, xvii, 1205-1206. Goldsborough and Ainley. The Renal Activity as Revealed by the Phenol-sul- phone-phthalein Test. Jour. Am. Med. Assn., 1910, lv, 24. Goldzieher. Allg. Pathologie und path. Anatomie der puerperalen Eklampsie. Lubarsch-Ostertag: Ergebnisse der Allg. Path. u. path. Anat., 1919, xix I Abt., 117-158. Grafenburg. Die anaphylaktische Beziehungen zwischen Mutter and Kind. Zeit- schr. f. Geb. u. Gyn., 1911, Ixix, 270-282. 632 THE TOXEMIAS OF PREGNANCY Guggisberg. Exp. Untersuchungen iiber die Toxikologie der Placenta. Zeitschr. f. Geb. u. Gyn., 1910, Ixvii, 84-112. Haffner. Les soi-disant infarctus placentaires et leur relation avec 1 ’albuminurie de la grossesse. Gyn. et Obst., 1921, iii, 81-89. Halbertsma. Ueber die iEtiologie der Eklampsia puerperalis. Volkmann’s Sammlung klin. Vortrage, 1884, Nr. 212. Harding and Watson. Further Observations on the Use of Carbohydrates in the Nausea and Vomiting of Pregnancy. Lancet, 1922, ii. 649-654. Healy and Kastle. Parturient Paresis (Milk Fever) and Eclampsia. Jour, of Infectious Diseases, 1912, x, No. 2. Heinrichsdorff. Die anat. Veranderungen der Leber in der Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1912, lxx, 620-665. HIslouin. Contribution a 1’etude du diagnostic de 1’hepato-toxcmie gravidique. These de Paris, 1899. Hinselmann. Die Capillarstromung bei der Eklampsie. Archiv f. Gyn., 1923, cxvi, 443-505. Hirst. The Intravenous Use of Corpus Luteum Extract in Nausea of Pregnancy. Jour. Am. Med. Assn., 1921, lxxvi, 772-773. Hofbauer. Zur Klarung der Eklampsiefrage. Zentralbl. f. Gyn., 1921, 1797-1810. Graviditats-toxikosen. Zeitschr. f. Geb. u. Gyn., 1908, Ixi, 258-271. Holland. The Results of a Collective Investigation into Cassarean Sections Performed in Great Britain and Ireland from the Year 1911 to 1920 In- clusive. Jour. Obst. and Gyn. Brit. Emp., 1921, xxviii, 358-446. Ingerslev. Beitrag zur Albuminurie wahrend der Schwangerschaft, der Geburt und der Eklampsie. Zeitschr. f. Geb. u. Gyn., 1881, vi, 171-212. Jardine and Kennedy. Symmetrical Necrosis of the Cortex of the Kidney Asso- ciated with Puerperal Eclampsia. Trans. Edinburgh Obst. Soc., 1912-1913, xxxviii, 158-183. Job. Contributions a 1 ’etude de la myelite et des polynevrites au cours des vomis- sements toxiques d’origine gravidique. Annales de gyn. et d’obst., 1911, viii, 129-146. Johnstone. Exp. Study of the Anaphylactic Theory of the Toxaemia of Preg- nancy. J. Obst. and Gyn. Brit. Emp., 1911, xix, 253-260. Jurgens. Fettemboli und Metastasen von Leberzellen bei Eklampsie, etc. Berliner klin. Wochenschr., 1886, xxiii, 519. Kaltenbach. Ueber Hyperemesis gravidarum. Zeitschr. f. Geb. u. Gyn., 1891, xxi, 200-208. Keiirer. Untersuchungen iiber den Kalkgehalt des Blutes, besonders in Schwanger- schaft, Geburt und Wochenbett, und bei Nephritis und Eklampsie. Arch, f. Gyn., 1920, cxii, 487-523. Killian. Significant Chemical Changes in the Blood in the Toxemias of Preg- nancy. Appleton, 1922, p. 183. Klebs. Multipel Leberzellen-thrombose. Ziegler’s Beitriige, 1888, iii, 1-30. Knapp. Ueber puerperale Eklampsie und deren Behandlung. Berlin, 1900. Kollmann. Zur ZEtiologie und Therapie der Eklampsie. Zentialbl. f. Gyn., 1897, xxxi, 341-346. Kronig. Ueber Lumbarpunktion bei Eklampsie. Zentralbl. f. Gyn., 1904, xxviii, 1153-1156 and 1511-1512. Landsberg. Untersuchungen von Harn und Blut bei Eklamptischen. Zeitschr. f. Geb. u. Gyn., 1913, lxxiii, 234-265. Leathes. Acidosis in Pregnancy. Proc. Royal Soc. Med., 1908, March. LeMasson. Les icteres et les coliques hepatiques ehez les femmes en 6tat du puer- peralite. These de Paris, 1898. LITERATURE 633 Lever. Cases of Puerperal Convulsions, with Remarks. Guy’s Hospital Reports, 1843. Lichtenstein. Im Kampfe gegen die placentare Theorie der Eklampsieatiologie. Zentralbl. f. Gyn., 1909, xxxiii, 1313-1325. Zur Klinik, Therapie u. iEtiologie der Eklampsie. Archiv f. Gyn., 1911, xcv, 183-368. Weitere Erfahrungen mit der abwartenden Eklampsiebehandlung. Monatsschr. f. Geb. u. Gyn., 1913, xxxviii, 152-165. Zehn Jahre geburtshiilfiich abwartender Eklampsiebehandlung. Zentralbl. f. Gyn., 1922, 5-34. Liepmann. Zur .ZEtiologie u. Therapie der Eklampsie im Wochenbett. Zentralbl. f. Gyn., 1906, xxx, 693-698. Zur iEtiologie der Eklampsie. Miinchener med. Wochenschr., 1905, Nos. 15 and 51. Lindemann. Zur path. Anat. des unstillbaren Erbrechens der Schwangeren. Zen- tralbl. f. allg. Path. u. path. Anat., 1892, iii, 625-630. Longridge. The Relation of the Alterations in the Ammonia Coefficient to the Toxaemias of Pregnancy. J. Obst. and Gyn. Brit. Emp., 1907, xii, 48-65. Losee and Van Slyke. The Toxemias of Pregnancy. Am. J. Med. Sciences, 1917, cl iii, 94-100. Lubarscit. Die Puerperal-eklampsie. Ergebnisse der allg. Path, und path. Anat., 1896, i, 113-134. Ludwig und Savor. Experiinentelle Studien zur Pathogenese der Eklampsie. Mo- natsschr. f. Geb. u. Gyn., 1895, i, 447-473.111 Lwow. Hyperemesis gravidarum. Deutsche Medicinal-Zeitung, 1900, xxi, 1013- 1015. McNalley and Dieckmann. Hemorrhagic Lesions of the Placenta and Their Relation to White Infarct formation. Am. J. Obst. and Gyn., 1923, v, 55-66. McPherson. A Study of Eclampsia. J. Amer. Med. Assn., 1907, liii, 1362-1363. A Consideration of the Pregnancy Toxemia Known as Eclampsia. Am. J. Obst. and Gyn., 1922, iv, 50-60. McQuarrie. Isoagglutination in Newborn Infants and Their Mothers, etc. Bull. Hopkins Hospital, 1923, xxxiv, 51-59. Mangiagalli. Veratrum viride in eclampsia. British Med. Jour., 1908, Sept., 19. Mayer. Ueber die Beziehungen der Geburtshilfe u. Gynekologie zum Krieg und zu den Kriegsverhaltnissen. Med. Klinik, 1922, Nr. 24-26. Miller. The Relation of Albuminuric Retinitis to the Toxemias of Pregnancy. Am. J. Obst., 1915, lxxii, 253-269. Muller. Die Kapillaren der menschlichen Korperoberflache. Stuttgart, 1922. Murray. Nature of Eclampsia. J. Obst. and Gyn. British Emp., 1910, xviii, 225- 245. Nash and Benedict. The Ammonia Content of the Blood, and its Bearing on the Mechanism of Acid Neutralization in the Animal Organism. J. Biol. Chem., 1921, xlviii, 463-486. Nicholson. Case of Puerperal Eclampsia Treated by Large Doses of Thyroid Extract. J. Obst. and Gyn. Brit. Emp., 1904, v, 32-37. Obata. On the Nature of Eclampsia. Jour, of Immunology, 1919, iv, 111-139. Olshausen. Ueber Eklampsie. Volkmann’s Sammlung klin. Vortrage, N. F., 1891, Nr. 39. Opie. Zonal Necroses of the Liver. Jour. Medical Research, 1904, xii, 147-167. Pearce and Jackson. Experimental Liver Necrosis. Studies from the Bender Hygienic Laboratory, 1907, iv, 35-51. 634 THE TOXEMIAS OF PREGNANCY Pels Leusden. Beitrage zur path. Anatomie de.r Puerperal-eklampsie. Virchow’s Archiv, 1895, cxlii, 1-45. Pick. Ueber Hyperemesis gravidarum. Volkmann’s Sammlung klin. Vortrage, N. F., 1902, Nrs. 325-326. Pilliet et Letienne. Lesions du foie dans l’eclampsie avec ictere. Nouv. arch, d’obst. et de gyn., 1889, iv, 312-367. Pinakd. De la decapsulation renale dans l’eclampsie. Annales de gyn. et d’obst., 1906, 2me S., iii, 193. Des vomissements de la gestation. Annales de gyn. et d’obst., 1909, N. S. vi, 385-399. Plass. The Significance of the Non-coagulable Nitrogen Coefficient of the Blood Serum. Am. J. Obst., 1915, lxxi, 608-615. Variations in the Distribution of the Non-P.rotein Nitrogenous Constituents of Whole Blood and Plasma During Acute Retention and Elimination. Jour. Biological Chem., 1923, Ivi, 17-29. Prutz. Ueber das anat. Verhalten der Nieren bei der Puerperal-eklampsie. Zeitschr. f. Geb. u. Gyn., xxiii, 1892, 1-52. Ueber Eklampsie. Vereins-Beilage der deutsch. med. Wochenschr., 1897, 194. Quincke. Acute Leberatrophie. Nothnagel’s Specielle Path. p. Thr., 1899, xviii, 294-315. Rayer. Traite des maladies des reins. Paris, 1839. Reinburg. Les acces dits eclamptiques. These de Paris, 1905. Riviere. Pathogenie et traitement de l’eclampsie. Paris, 1889. Rolleston. Symmetrical Necrosis of the Cortex of the Kidney Associated with Suppression of Urine in Women Immediately after Delivery. Lancet, 1913, Oct. 26. Rosenau and Anderson. Further Studies upon Anaphylaxis. Hygienic Lab. Bull., 1908, No. 45, p. 55. Rosenstein. Ueber Eklampsie. Monatsschr. f. Geburtsk., 1864, xxiii, 413-430. Schickele. Die Schwangerschafts-toxemie. Archiv. f. Gyn., 1917, cvii, 209-250. Schuppel. Ein Fall von doppelseitiger totaler Nierenrinden Nekrose bei Eklamp- sie. Archiv f. Gyn., 1914, ciii, 243-271. Schild. Sechs Falle von Nitrobenzol-vergiftung. Berliner klin. Wochenschr., 1895, xxxii, 187-189. Schmid. Eklampsie ohne Krampfe. Zeitschr. f. Geb. u. Gyn., 1911, lxix, 143-164. Schmorl. Path. anat. Untersuchungen fiber Puerperal-eklampsie. Leipzig, 1893. Zur Lehre von der Eklampsie. Archiv f. Gyn., 1902, Ixv, 504-529. Schonfeld. Die Toxizitat der Plazentalipoide und ihre Rolle in der Etologie der Puerperaleklampsie. Deut. med. Wochenschr., 1921, xlvii, 270. Exp. Untersuchungen fiber die Toxizitat von Placentalipoiden, mit Bezug auf die Etiogenese der Puerperaleklampsie. Arch, ffir Gyn., 1922, cxv, 80-125. Seitz. Innere Sekretion und Schwangerschaft. Leipzig, 1913. Selliieim. Die mammare Theorie fiber die Entstehung der Eklampsiegiftes. Zen- tralbl. f. Gyn., 1910, 1609-1615. Sippel. Die Nephrotomie bei Anurie Eklamptischer. Zentralbl. f. Gyn., 1904, xviii, 1341. Sitzenfrey. Eklampsie im 6sten Schwangerschaftsmonat bei Blasenmole, etc. Zentralbl. f. Gyn., 1911, 343-346. Slemons. Eclampsia without Convulsions. Bull. Johns Hopkins Hospital, 1907, xviii, 448-455. Is Albuminuria Likely to Recur with Succeeding Pregnancies? Am. J. Obst., 1913, lxvii, 849-860. Slemons and Bogert. The Uric Acid Content of Maternal and Fetal Blood. J. Biol. Chem., 1917, xxxii, 63-69. LITERATURE 635 Solomans. The Results of the Treatment of Eclampsia by the Dublin Method. Jour. Obst. & Gyn., Brit. Emp., 1922, xxix, 416-425. Spiegelberg. Ein Beitrag zur Lehre von der Eklampsie. Ammonia im Blute. Archiv. f. Gyn., 1870, i, 383-391. Spillman. Lumbar Puncture in the Treatment of Eclampsia. Am. J. Obst. and Gyn., 1922, iv, 568-571. Stadie and Van Slyke. The Effect of Acute Yellow Atrophy on Metabolism and on the Composition of the Liver. Arch. Int. Med., 1920, xxv, 693-794. Stone. Toxaemia of Pregnancy. Amer. Gyn., 1903, iii, 518-550. Strauss. The Toxaemia of Pregnancy. Amer. Jour. Obst., 1905, lvii, 145, 164. Stroganoff. Ueber die Behandlung der Eklampsie. Zentralbl. f. Gyn., 1901, xxi, 1309-1312. My Improved Method of the Prophylactic Treatment of Eclampsia. J. Obst. and Gyn. Brit. Emp., 1923, xxx, 1-31. Sturmer. Forty-one Cases of Eclampsia Treated by Thyroid Extract. Trans. London Obst. Soc., 1904, xlvi, 126. Talbot. Focal Infection and Its Relation to Obstetrics. J. Am. Med. Assn., 1920, lxxiv, 874-878. Tarnier et Chamberlent. Note relative a la recherche de la toxicite du serum sanguin dans deux cas d’eclampsie. Comptes rendus de la soc. de biol., 1892, iv, 179-182. Thierfelder. Acute Atrophy of the Liver. Ziemssen’s Cyclopedia of the Prac- tice of Medicine. Amer. ed., 1880, ix, 242-305. Thies. Zur Aetiologie der Eklampsie. Archiv. f. Gyn., 1910, xcii, 513-536. Titus, Hoffmann and Givens. The Role of Carbohydrates in the Treatment of Toxemias of Early Pregnancy. J. Am. Med. Assoc., 1920, lxxiv, 777-783. Titus and Givens. Intravenous Injections of Glucose in Toxemia of Pregnancy. J. Am. Med. Assn., 1922, lxxviii, 92-98. Underhill and Rand. Peculiarities of Nitrogenous Metabolism in Pernicious Vomiting of Pregnancy. Archives of Int. Med., 1910, v, 61-91. Van der Velde. Eklampsie puerperalis tardiforma. Ref. FrommeUs Jahres- bericht, 1897, 752. Varo. Krieg und Eklampsie. Zentralbl. f. Gyn., 1920, 523-526. Vassale. Ref. Frommel’s Jahresbericht, 1905, xix, 404. Veit. Ueber Albuminurie in der Schwangerschaft. Berliner klin. Woehenschr., 1902, xxxix, 512-540, Nrs. 22 and 23. Die Verschleppung der Chorionzotten. Wiesbaden, 1905. Wallis. The Toxemia of Pregnancy with Special Reference to Certain Renal Function Tests in Diagnosis. Jour. Obst. and Gyn. Brit. Emp., 1921, xxviii, 3-22. Ward. The Relation of the Thyroid Gland and Thyroidism to the Toxemia of Pregnancy. Surg., Gyn. and Obst, 1909, ix, 617-633. Warnekros. Kriegskost und Eklampsie. Zentralbl. f. Gyn., 1916, 897-902. Weiss. Beobachtung u. mikrophotographische Darstellung der Haut-kapillaren am lebenden Menschen. Deutsches Archiv f. klin. Med., 1916, cxix, 1-138. Whipple. A Test for Hepatic Injury; Blood Lipase. Bull Johns Hopkins Hospital, 1913, xxiv, 357-362. Whipple and Sperry. Chloroform Poisoning, etc. Bull. Johns Hopkins Hospital, 1909, xx, 278-289. Williams. Pernicious Vomiting of Pregnancy. Bull. Johns Hopkins Hospital, 1906, xvii, 71-92. Toxsemic Vomiting of Pregnancy. Am. Jour. Med. Sci., 1906, cxxxii, 343-354. Further Contributions to Our Knowledge of the Pernicious Vomiting of Preg- nancy. J. Obst. and Gyn. Brit. Emp., 1912, xxii, 245-265. THE TOXEMIAS OF PREGNANCY 636 Winckel. Lehrbuch dor Geburtshiilfe, 1893, II. Aufl., 536-547. Winckler. Beitrag zur Lehre von der Eklampsie. Virchow’s Archiv, 1898, cliv, 187-233. Winter. Zur ZEtiologie der Hyperemesis gravidarum. Zentralbl. f. Gyn., 1907, 1497-1504. Young. ZEtiology of Eclampsia and Albuminuria. J. Obst. and Gyn. Brit. Emp., 1914, xxvi, 1-28. Young and Miller. The Etiology of Eclampsia and the Pre-eclamptic State. Brit. Med. Jr., 1921, (1) 486-490. Zanfrognini. Ref. Frommel’s Jahresbericht, 1905, xix, 804. Zangemeister. Dei Eklampsie eine Hirndruckfolge. Zeitschr. f. Geb. u. Gyn., 1917, lxxix, 124-174. Der Hydrops gravidarum, sein Verlauf und seine Beziehungen zur Nephropathie und Eklampsie. Zeitschr. f. Geb. u. Gyn., 1919, Ixxxi, 491-558. Zinsser. Ueber die Nierenfunktion Eklamptischer. Zeitschr. f. Geb. u. Gyn., 1912, Ixx, 201-221. Zweifel. Zur Aufklarung der Eklampsie. Archiv f. Gyn., 1904, lxxii, 1-97, and 1905, lxxvi, 536-585. Das Gift der Eklampsie u. ihre Consequenzen fiir die Behandlung. Miinchener med. Wochenschr., 1906, liii, 297-299. Ueber die Behandlung der Eklampsie. Monatsschr. f. Geb. u. Gyn., 1913, 1-22. Zweifel, E. Wirkt fotales Serum art-fremd auf das Muttertier, 1920. CHAPTER XXVII COMPLICATIONS DUE TO DISEASES AND ABNORMALITIES OP THE GENERATIVE TRACT DISEASES OF THE VULVA AND VAGINA Varices.—Varicose veins sometimes appear in the lower part of the vagina, but are more common around the vulva, where they may attain considerable proportions and give rise to a sensation of weight and dis- comfort. Treatment has practically no effect upon the local condition. In rare instances the varices may rupture during pregnancy, though this accident is more frequently observed at the time of labor, when profuse and sometimes fatal hemorrhage may result if appropriate surgical treat- ment is not available. Inflammation of Bartholin’s Glands.—Pyogenic microorganisms may gain acess to Bartholin’s glands and give rise to abscess formation. In this event the labium majus on the side affected becomes swollen and painful, and incloses a collection of pus. Most often the infection is gonorrheal in origin, though other bacteria are sometimes associated with the gonococcus. Aside from the pain and discomfort, this com- plication may be the starting-point of a puerperal infection. For these reasons, whenever a labial abscess develops during pregnancy it should be opened and drained; or, better still, the entire pus sac should be excised. Owing to the increased vascularity incident to the inflammatory process, as well as to pregnancy, enucleation is sometimes accompanied by considerable loss of blood, and is not always easy. Relaxation of the Vaginal Outlet.—Even in nulliparous women the congestion incident to pregnancy frequently causes the anterior or pos- terior vaginal wall to protrude through the vulva as a redundant mass; while in multiparous women, particularly when the outlet is torn or relaxed, a distinct cystocele or rectocele may result. This condition is generally associated with dragging pains in the back and lower abdomen, and may interfere with locomotion. It is not amenable to treatment during pregnancy, though the symptoms may be temporarily relieved by rest in bed. Vaginitis.—This complication has already been considered in Chap- ter XXV, under the heading of Gonorrhea. Colpohyperplasia Cystica.—This rare condition, first described by 'VVinckel, is characterized by the presence in the vaginal mucosa of numerous small cavities filled with clear fluid or gas and forming ele- vations upon its surface. Although not amenable to treatment during pregnancy, it usually disappears soon after childbirth. The researches 637 638 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT of Lindenthal render it probable that the lesion is sometimes due to infection with Bacillus aero genes capsulatus, and Jaeger has been able to produce it experimentally in animals. DISEASES OF THE CERVIX Cervical Endometritis.—Gonorrheal infection of the cervical canal is frequently observed during pregnancy, the most prominent symptom being a profuse and persistent leukorrhea. The treatment has already been considered. Carcinoma.—About once in 2,000 cases, according to Sarwey, but less frequently in this country, pregnancy is complicated by carcinoma of the cervix. It is most common in women between the thirtieth and fortieth years of life, two thirds of the cases collected by Sarwey having occurred within this decade, while the youngest patient was twenty-six years old. In the majority of instances the condition has existed before con- ception, but it may make its appearance during pregnancy. A bloody, foul-smelling vaginal discharge is suggestive of malignant disease, but unfortunately the early stages are often unaccompanied by symptoms, and may escape detection unless a vaginal examination is made for some other reason, when an indurated and excavated ulceration of the cervix is discovered. Pregnancy tends to bring about rapid growth and extension of a preexisting carcinoma. On the other hand, the malignant disease in- fluences pregnancy very unfavorably, abortion being noted in 30 to 40 per cent, of the cases. Furthermore, if the patient reaches full term the dangers of labor are greatly increased. In the first place, the presence of the ulcerating crater affords opportunity for the access of pyogenic bacteria to the uterine cavity; while the cervix may be so indurated by carcinomatous infiltration that dilatation becomes impos- sible and spontaneous rupture of the lower uterine segment becomes imminent, unless suitable operative measures are undertaken to prevent it. In other instances, the cervix may be lacerated and give rise to profuse hemorrhage. In 603 cases collected by Sarwey the mortality at the time of labor, or during the puerperium, was 43.3 per cent., 8 per cent, of the patients dying undelivered. The treatment of pregnancy complicated by carcinoma of the cervix differs according to the period at which the diagnosis is made and the extent to which the disease has progressed. If the condition has not extended beyond the cervix, immediate abdominal hysterectomy should be performed in the hope of effecting a permanent cure, without regard for the chances of the foetus. Sarwey has reported 26 vaginal operations without a death, during the first half of pregnancy; but during that period I consider that a radical abdominal operation is preferable. On the other hand, if the case is inoperable, gestation should be allowed to continue in the interests of the child, and cesarean section performed at term, if the condition of the cervix is such as to render spontaneous delivery improbable. DEVELOPMENTAL ABNORMALITIES OF THE UTERUS 639 The treatment of inoperable cases by means of radium raises another question. If it is thought advisable to employ it, the uterus must be emptied as a perliminary procedure, since the action of the radium will inevitably lead to the death of the child. In such circumstances cesarean section may be indicated even though the child is not viable. DEVELOPMENTAL ABNORMALITIES OF THE UTERUS Abnormalities in the development or fusion of one or both miillerian ducts may result in malformations, which sometimes possess an obstet- rical significance. Various degrees of mal- formation—from an almost total absence of the uterus on the one hand to its duplica- tion on the other (uterus didelphys)—are encountered. The accompanying diagrams (Figs. 467 to 473) give an idea of the nature of the more important varieties. Pregnancy may be associated with any one of these malformations provided an ovum be cast off from the ovaries and no serious obstacle be opposed to the upward passage of the spermatozoa and their subsequent union with it. Pregnancy in the Rudimentary Horn of a Double Uterus.—In this condition the course of pregnancy is exposed to serious modifications. Fig. 467.—Diagram of Uter- us Unicornis (Kehrer). Fig. 468. — Uterus Pseudodidelphys (Kehrer). Fig. 469. — Utebtjs Bicornis Duplex (Kehrer). Fig. 470. — Uterus Bicornis Septus (Kehrer). Fig. 471.—Uterus Bicornis Subseptus (Kehrer). We owe to Mauriceau the first description of a case of this character, but since his time many examples have been reported. In 78 per cent, of the 84 cases collected from the literature by Kehrer, in 1900, the proximal end of the rudimentary horn did not 640 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT communicate with the uterine cavity, so that in them pregnancy must have followed external migration of the spermatozoa or of the fertilized ovum. The development of pregnancy in a rudimentary horn is associated Fig. 472.—Uterus Bicornis Unicollis (Kehrer). Fig. 473.—Uterus Bicornis Unicollis with Rudimentary Horn (Kehrer). with the formation of a decidua in the non-pregnant horn, as well as by a marked increase in its size. Unless there is free communication between the two horns, which is but rarely the case, a pregnancy in this situation is a very serious occurrence, since normal delivery is im- possible. If the muscular tissue of the rudimentary horn is poorly Fig. 474.—Pregnancy in a Rudimentary Left Uterine Horn. External Migration of Ovum (Kelly). developed, as is usually the case, spontaneous rupture occurs within the first four months and leads to the death of the patient from intraperi- toneal hemorrhage. This result was noted in 87, 47.6, and 5.5 per cent, of the cases collected by Sanger, Kelirer, and Beckmann, respectively, in 1884, 1900, and 1911. The marked improvement is attributable to greater accuracy in diagnosis and more frequent recourse to operative DEVELOPMENTAL ABNORMALITIES OF THE UTERUS 641 interference. On the other hand, if the muscular tissue is abundant the pregnant horn may hypertrophy normally, and the pregnancy go on to term. If not removed by operative means, the foetus may be grad- ually eliminated by suppurative processes, or be converted into a litho- pedion. The existence of pregnancy in a rudimentary horn can occasionally be recognized during the early months, a positive diagnosis having been made in 20 per cent, of Kehrer’s cases. When a tumor corresponding in size to the duration of pregnancy can be detected alongside of what appears to be the slightly enlarged uterus, this condition should always be thought of. In differentiating it from a tubal pregnancy, it is important to remember that the round ligament is felt coming off from the distal side of the tumor instead of from its proximal or uterine portion, as in the latter condition. In the later months, a diagnosis is usually not made until false labor sets in at term. In other cases this does not occur and the child dies; but, in either event, no abnormality is suspected until one attempts to empty the uterus, when it is found that its cavity is empty and that the child lies in a sac to one side of it, which must represent either a pregnant tube or a rudimentary horn. A satisfactory differentiation can always be made by determining the location of the round ligament as described above. Treatment.—If the condition be diagnosticated, treatment consists in promptly opening the abdomen and amputating the pregnant horn. This operation was first performed by Sanger in 1881, and has since been repeated on many occasions with constantly improving results, Kehrer, and Wells having reported 44 cases up to 1900, and Beckmann a large series in 1911, with a mortality of 13.4 and 4.3 per cent., respec- tively. Too frequently, however, the first suggestion of the existence of the abnormality is afforded by the symptoms of intraperitoneal hemor- rhage, when the operation is undertaken in the expectation of find- .ing a ruptured extra-uterine pregnancy. Pregnancy in Uterus Unicornis.—Occasionally only one horn of the uterus is developed, the opposite tube and ovary being lacking or arising from the lower portion of the uterus. In such cases pregnancy usually pursues an uneventful course, and the abnormality is only accidentally recognized at the operating or autopsy table. Pregnancy in Uterus Bicornis.—When the two horns of the uterus are well developed, but no connection exsits between them, as in uterus didelphys, or when they are partly fused, as in the various varieties of uterus bicornis, pregnancy may occur in either horn. In the very rare instances in which a twin pregnancy is observed, the two products of conception may occupy the same horn, although now and again an embryo has been found in each. \\ hen pregnancy occurs in one horn of a bicornuate uterus, the other undergoes sympathetic hypertrophy and a distinct decidua is formed in its cavity. Ordinarily there is no interference with the course of pregnancy, and spontaneous labor may be looked for. Much more rarely the non-pregnant horn may block the pelvic cavity, and give rise to dystocia similar to that produced by tumors of other origin. In a 642 COMPLICATIONS DUE TO DISEASES OF GENERATIVE T RACT case observed in my clinic and reported by Bettman, the non-pregnant horn obstructed the pelvic cavity and gave rise to rupture of the uterus. Van der Yelde made a critical study of the subject in 1915, and has collected from the literature a series of cases requiring cesarean section or some other radical intervention. Miller in 1922 analyzed the clinical histories of 54 cases reported in the literature. That the abnormality does not interfere with the possibility of conception is shown by the fact that 31 of the 34 married women conceived and had 67 pregnancies. It does, however, predispose toward the occurrence of abortion and premature labor, as only 61 per cent, of the pregnancies went to term. When difficulty was encountered at the time of labor, it was usually due to mechanical interference by the enlarged non-pregnant horn. The diagnosis is usually not made, as in the majority of cases spon- taneous labor occurs at term; although Halban states that a pathog- nomonic sign is afforded by the palpation of the vesicorectal ligament, as a band extending upward from the bladder over the top of the uterus, and lying between the two round ligaments. Our own patient had given birth to 8 children without any suspicion of the existence of the deformity having arisen. Sometimes the existence of a double vagina or a double cervix puts one on the alert. The former may occur with a normal uterus, whereas the latter condition almost invariably indicates the existence of a double uterus. When there is only a single cervix, as in uterus bicornis unicollis, the condition always escapes observation, unless the patient is subjected to examination at an early period of pregnancy, and the depression noted between the two halves of the uterus gives a clue to the true state of affairs. DIVERTICULA FROM UTERINE CAVITY Freund and Schickele have reported instances in which the pregnancy developed in a diverticulum from the uterine cavity, so that the foetus lay in a sac surrounded by uterine muscle, and connected with the main uterine cavity only by a narrow passage. It is apparent that it would be difficult to recognize such a condition clinically, unless the fingers were introduced into the uterine cavity, and it is likewise clear that it may give rise to serious complications at the time of labor. DISPLACEMENTS OF THE UTERUS Anteflexion.—Exaggerated degrees of anteflexion are frequently ob- served in the early months of pregnancy, but are usually without sig- nificance. In the later months, particularly when the pelvis is markedly contracted or the abdominal walls are very lax, the uterus may fall forward, the sagging being occasionally so exaggerated that the fundus lies considerably below the lower margin of the symphysis pubis. Even in less marked instances of the so-called pendulous abdomen, the patient may complain of various annoyances, more especially of exhaustion on DISPLACEMENTS OF THE UTERUS 643 exertion and dragging pains in the back and lower abdomen. Ameli- oration of symptoms frequently follow's the wearing of a properly fitting abdominal supporter. Anteversion of the pregnant uterus is occasionally observed in pa- tients who have previously been subjected to operative procedures for the relief of symptoms incident to retroflexion of the uterus, particularly after vaginal fixation, less frequently after an improperly performed ventrosuspension, and now and again after shortening of the round ligaments. The condition is accompanied by marked discomfort during pregnancy, and at the time of labor may give rise to serious dystocia, which will be considered in Chapter XXXII. Retrodisplacement of the Pregnant Uterus.—Retroflexion and retro- version of the uterus are frequently observed in non-pregnant women, and usually cause more or less incon- venience, though occasionally the condition may exist for years without any ab- normal manifesta- tion. In women who have never borne children the abnormal position of the cervix is supposed to render difficult the access of spermatozoa to the uterine cavity, so that the possi- bility of concep- tion is consider- ably diminished. In parous women, on the other hand, this influence is less pronounced, but pregnancy, when it occurs, is prone to early interruption. The abortion is usually due to inflammatory or trophic changes in the endometrium, which are in great part dependent upon abnormalities in the circulation of the displaced uterus. In the vast majority of cases of pregnancy complicated by retro- displacements, the uterus was already out of place before conception; although the abnormality may arise during gestation, when it would seem that the enlarged and softened organ is unable to retain the position which it maintained without difficulty when it was of normal size and consistency. Pregnancy is more frequently complicated by retroflexion than by retroversion, though it is said that the latter tends to give rise to serious symptoms at an earlier period. In either case several eventualities are Fig. 475.—Sacculation of Retroflexed Pregnant Uterus (Oldham). 644 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT possible: the displacement may undergo spontaneous reduction without any interruption to pregnancy; abortion may occur; or, if neither takes place, the uterus may become incarcerated in the pelvic cavity and serious consequences follow. If the displaced uterus is not adherent, spontaneous reduction usually occurs during the third month. This is rendered possible by an eccentric hypertrophy, owing to which the anterior wall undergoes more rapid distention than the posterior, and emerging above the superior strait eventually draws up the rest of the organ. After the fundus has once passed the promontory of the sacrum there is no fear of a recurrence of the condition. Moreover, spontaneous reduction is not wholly out of the question, even when adhesions exist, since they often become stretched and occasionally disappear without any treatment. Ketroflexion offers better prospects than retroversion; indeed, as Diihrssen and Keitler have Fig. 476.—Incarceration of Retroflexed Pregnant Uterus (Swytzer). pointed out, when the latter condition is marked spontaneous restitution is almost impossible, for the reason that the cervix rises above the symphysis pubis, while the fundus is held back by the promontory of the sacrum. In rare instances, when the fundus is firmly adherent, pregnancy may remain uninterrupted for a long while. This prolongation is ren- dered possible by the hypertrophy occurring almost entirely in the ante- rior wall of the uterus, while the posterior wall fills out the pelvic cavity, and forms a sac in which one pole of the foetus is retained. This so-called sacculation of the uterus has been described in detail by Oldham, Diihrssen, and others. Owing to the abnormal position of the cervix and the fact that the presenting part lies far below it, serious difficulties are to be expected at the time of labor, which will be considered in Chapter XXXII. Abortion is common in pregnancies complicated by retrodisplace- DISPLACEMENTS OF THE UTERUS 645 ments. It usually occurs in the course of the third month, when the growing uterus pretty well fills the pelvic cavity and, becoming irritated by the pressure to which it is subjected, begins to contract, and thus brings about the expulsion of its contents. This termination is particu- larly likely to occur when the sacrum possesses an exaggerated vertical concavity, since the projecting promontory opposes a serious obstacle to spontaneous restitution. If pregnancy continues and the displacement is not reduced in the natural course of events, or as the result of manipulations on the part of the physician, the uterus will continue to increase in size until it completely fills the pelvic cavity and, being unable to free itself, becomes impacted, and we have what is known as incarceration. Untoward effects, due to pressure, come on sooner in retroversion than in retro- flexion, for the reason that in the former the cervix compresses the lower portion of the bladder at an earlier period. Incarceration is ac- companied by characteristic symptoms, the woman complaining of pain in the lower portion of the abdomen and back, and disturbances in the functions of the urethra, bladder, and rectum. As the pelvis becomes more and more filled by the growing uterus, the pressure upon the neck of the bladder and urethra becomes so pronounced as to cause retention of the urine with consequent over-distention. Reed, however, holds that the ischuria is not merely mechanical, but is due to compression of the pelvic ganglia by the body of the uterus, with resulting paralysis of the motor nerves of the bladder. But, whatever its cause, when the retention has reached a certain limit, the overstretched viscus squeezes out small amounts of urine at frequent intervals, but never empties itself—paradoxicial incontinence. If the condition is not soon relieved, the symptoms become more intense, cystitis develops, and the bladder walls become thick and edematous, the urine becomes bloody, and eventu- ally gangrene may result, necrotic portions of the lining membrane of the bladder being cast off and finally expelled through the urethra wdth severe cramplike pains. In other cases the weakened walls of the bladder are unable to withstand the distention and rupture occurs, followed by a fatal peritonitis. Occasionally, as the result of the pressure to which it is subjected, the nutrition of the uterus may so suffer that it offers little resistance to bacterial invasion, when it becomes densely adherent to the surround- ing parts, while now and again the organ may be forced down and out of the pelvic cavity and emerge through the vulva or anus. In some cases the rectum is compressed to such an extent that defecation becomes impossible and gangrene results. Ileus, however, is an exceed- ingly rare complication. Gottschalk. found that the following were the most frequent causes of death in 67 cases reported in the literature up to 1894: Peritonitis of vesical origin 17 Uremia 16 Rupture of the bladder 11 Septicemia of vesical origin 4 Gangrene of the bladder 3 646 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT The possibility of a retroflexed pregnant uterus should always be suspected when a woman in the early months of pregnancy complains for any length of time of frequent and painful micturition, especially if there is a history of antecedent uterine trouble. Incontinence of urine during the first half of pregnancy is a most suggestive sign, and always calls for a thorough vaginal examination. With the bimanual method, the soft body of the uterus will be found occupying the pelvic cavity, while the cervix is forced up against the symphysis or lies above it, according as one has to deal with a retroflexion or retroversion. It should be remembered that a pregnant tube lying behind the uterus may give somewhat similar signs, and this possibility should be borne in mind until careful examination has shown that the enlarged uterus does not lie in front of the soft mass. Treatment.—If the retroflexion is detected in the first three months of pregnancy, bimanual reposition of the uterus should be attempted, aided by traction upon the cervix by means of a tenaculum or bullet forceps. After reposition has been effected, a properly fitting Smith- Hodge pessary should be introduced. On the other hand, if these simple maneuvers fail, the patient should be left alone until well on into the third month, in the hope that spontaneous reduction may occur. If this has not taken place by that time, a more determined effort at replacement should be made, with the patient in the knee-chest position. If this proves unsuccessful, reduction can usually be effected by bimanual manipulations under anesthesia. When dense adhesions are present, various procedures have been recommended—the forcible attempt to break them up under anesthesia, attempts to loosen them by means of a succession of vaginal packs, the colpeurynter, or the “watch-spring” pessary, from the use of which Sinclair has reported excellent results. Generally speaking, these methods are not to be recommended, and, if the uterus cannot be replaced under anesthesia, laparotomy may be performed, the adhesions separated under the guidance of the eye, and the uterus placed in normal position. Such radical interference, however, is rarely necessary, but in several of my cases it was followed by satisfactory results. On the other hand, if the patient has not been seen until after symptoms of incarceration have supervened, prompt treatment is impera- tive. The bladder should be immediately emptied. This cannot always be accomplished with the ordinary female catheter on account of the elongation of the urethra and neck of the bladder resulting from the displacement (Fig. 478), so that in many cases a flexible rubber catheter must be employed. Its introduction may often he facilitated by making traction upon the cervix with a tenaculum. After the bladder has been emptied, attempts should he made to replace the uterus—under anes- thesia, if necessary. But if this cannot be effected, most authors advise emptying it immediately by dilating the cervical canal. I believe that better results will be obtained in such cases by laparotomy, or by a modi- fied hysterotomy, in which the posterior instead of the anterior, portion of DISPLACEMENTS OF THE UTERUS 647 the lower uterine segment and cervix is incised. On the other hand, if symptoms of infection or gangrene are present, laparotomy, as recom- mended by Lobenstein, should not be done, since the weakened and necrotic bladder may be injured, or dense adhesions may be encountered which have formed over the uterus, practically shutting it off from the abdominal cavity and rendering the freeing of it almost impossible. Under these circumstances the obstetrician should content himself with emptying the uterus per vaginam in the most conservative manner, and then rely upon palliative treatment. Lateral Displacement of the Pregnant Uterus. —Slight degrees of lat- eral displacement of the uterus during pregnancy are relatively frequent, but usually have no effect upon its course and do not give rise to symp- toms. It should, how- ever, be borne in mind that in the early months similar conditions are sometimes mistaken for tubal pregnancy. Prolapse of the Preg- nant Uterus.—Impregna- tion in a totally pro- lapsed uterus is very rare on account of the difficul- ties attending a success- ful coitus, but is com- paratively frequent if the prolapse is only partial. In such cases the cervix, and occasionally a por- tion of the corpus, may protrude to a great or lesser extent from the vulva during the early months, but as pregnancy progresses the body of the uterus gradually rises up in the pelvis, and draws the cervix up with it, so that as soon as it has passed beyond the superior strait, prolapse is no longer possible. On the other hand, if the uterus retains its abnormal position, symptoms of incarceration appear during the third or fourth month, and abortion is the inevitable result, there being no cases on record in which pregnancy has progressed to term with the uterus outside of the body. If there is a tendency towards prolapse during pregnancy, the uterus should be replaced and held in position by a suitable pessary. If, how- ever, the pelvic floor be too relaxed to permit its retention, the patient Fig. 477.—Prolapsed Pregnant Uterus (Wagner) COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT 648 should be kept in a recumbent position as far as possible until after the fourth month. When the cervix reaches to or slightly protrudes from the vulva, the greatest cleanliness is necessary, as instances of fatal infection have been reported as occurring even without any internal examination. If the uterus persistently lies outside of the vulva and cannot be re- placed, it should be emptied of its contents. When the vaginal outlet is markedly relaxed, the congested anterior or posterior vaginal walls sometimes prolapse during pregnancy, although the uterus may still retain its normal position. This con- dition may give rise to considerable dis- comfort and inter- fere with locomo- tion. It is not amenable to treat- ment until after de- livery. At the time of labor these struc- tures may be forced down in front of the presenting part and interfere with its descent. When this occurs they should be carefully cleansed and pushed back over it. In rare instances a hernial protrusion may occur through the vagina, the an- terior or posterior wall forming part of the sac. Such a vaginal enterocele may form a tumor of considerable size filled with intestines. Hirst has collected 27 instances from the literature. If the condition occurs during pregnancy, the protrusion should be replaced and the patient kept in the recumbent position. At the time of labor it may seriously interfere with the advance of the head. In such cases the mass should be pushed up if possible, and, when this cannot be done, it should be held out of the way as well as may be, and the head delivered past it. Hypertrophic Elongation of the Cervix.—An abnormally elongated cervix seriously interferes with the occurrence of conception, but, as a rule, does not complicate the course of pregnancy or labor. The canal usually becomes shorter and more dilatable as term is approached. In one of my patients the vaginal portion of the cervix in the early ?ig. 478.—Pregnancy in Horn of Utertts Contained in Inguinal Canal (Eisenhart). DISPLACEMENTS OF THE UTERUS 649 months was 5 centimeters in length and the external os protruded from the vulva, whereas later it had undergone marked softening and become reduced to normal dimensions, so that labor occurred spontaneously. Acute Edema of the Cervix.—In very rare instances the cervix, par- ticularly its anterior lip, may become acutely edematous during preg- nancy and attain such proportions as to protrude from the vulva. This condition is referable to an angioneurosis, and may disappear almost as suddenly as it developed. Jolly, in 1904, was able to collect 10 cases from tbe literature. Hernia.—Pregnancy occurring in women suffering from inguinal her- nia is not influenced by the condition, although, owing to the increased Fig. 479.—Hernia of Pregnant Uterus (Adams). intra-abdominal pressure, the previous defect may become aggravated. Generally speaking, the hernia should be treated palliatively by rest and the use of a truss, operative treatment being deferred until after delivery. Very exceptionally, the uterus may form part of the contents of an inguinal hernia, and, indeed, several cases are on record in which con- ception has occurred under such circumstances. Full literature upon the subject will be found in the articles of Adams and Eisenhart, the latter having reported a case in which one horn of a five months’ preg- nant bicornuate uterus occupied the right inguinal canal. Umbilical herniae are frequently noted during pregnancy, but are usually without effect upon the condition. During the early months the uterus is not in the neighborhood of the hernial opening, while later, when the fundus reaches its level, it is usually too large to gain access to it; but when the abdomen is markedly pendulous, such an occurrence is not beyond the range of possibility, and several such instances are on 650 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT record. Much more common are the cases in which the cicatrix of an abdominal incision yields to the increased intra-abdominal pressure in- cident to pregnancy, and along the linea alba is formed a hernial sac into which the pregnant uterus often makes its way, being then covered merely by a thin layer of skin, fascia, and peritoneum. A similar condition is occasionally observed in women suffering from extensive diastasis of the recti muscles. Fig. 479 represents a patient in whom a hernia of this kind occurred suddenly during labor. Ordinarily, such herniae have no effect upon pregnancy, although they may add markedly to the discomfort of the patient. Temporary relief is frequently obtained by holding the uterus in its normal position by a properly fitting bandage. At the time of labor, owing to the loss of muscular tone in the abdominal walls, the second stage is liable to be prolonged, and the employment of forceps is often called for. Such herniae should be repaired during the later weeks of the puerperium. DISEASES OF THE DECIDUA In non-pregnant women the endometrium is frequently the seat of lesions which are grouped together clinically under the general heading of endometritis. Histological examination shows, however, that the term is usually a misnomer, as the changes are generally trophic rather than inflammatory in character, and in many instances merely represent phases of the menstrual cycle. The most important varieties are classi- fied as follows: Hyperplastic endometritis—general hyperplasia, localized hyperplasia, polypoid growths. Glandular endometritis—glandular hyperplasia. Interstitial endometritis—general hypoplasia. Acute and subacute endometritis—inflammatory changes. These conditions are prototypes of more or less similar lesions oc- curring in the decidua, except, of course, that the latter are modified by the histological characteristics incident to pregnancy. In the vast majority of inflammatory cases, as was first pointed out by Veit, the decidual affection represents the extension of a lesion already existing prior to pregnancy, conception occurring in a uterus affected by infective endometritis. In rare cases, however, the condition may originate during pregnancy. It is generally believed that endometritis is almost necessarily asso- ciated with sterility, the abnormal secretion of the uterine glands inter- fering with impregnation, and, even if conception occurs, the diseased mucosa does not offer a favorable nidus for the implantation of the ovum. Generally speaking, this belief is justified only when the endometrium is the seat of an acute inflammatory process, and every physician can recall instances in which sterility has persisted until more or less normal conditions were restored. On the other hand, slight degrees of chronic DISEASES OF THE DECIDUA 651 endometritis, or of hyperplastic conditions, do not, as a rule, interfere with conception. Diffuse Thickening of the Decidua.—Ilegar, Kaltenbach, Kaschewa- rowa, and others have described a general hyperplasia of the decidua, in which the membrane, instead of becoming thinner, as is generally the case after the first few months, assumes unusual proportions. The condition frequently results in abortion, as a large part of the nutritive material intended for the foetus is diverted to nourishing the decidua. After abortion or labor, thickened decidua may cause abnormalities in the separation of the pla- centa. In other cases, the thickening is more or less localized—decidua poly- posa. In this affection, the characteristic feature consists in the projection of irregularly shaped knoblike masses from the inner surface of the decidua. Virchow first described this condition as decidua tuberosa or polyposa, and considered it to be syphilitic in origin, which, however, is not always the case. Ahlfeld states that it is frequently observed, and Nyulasy of Melbourne has noted more than 100 cases in his own practice. Bulius holds that it oc- curs but rarely, and I have never met with an instance. Glandular Hyperplasia of the Decidua (Endometritis Decidua Gland- ularis).—Occasionally marked hyperplasia of the glandular structures of the decidua is present, and is usually associated with persistence of the glandular ducts. This affection commonly manifests itself by a profuse secretion of clear fluid, which may dribble away as rapidly as it is produced, or be retained in the uterus to be suddenly discharged in large quantities at variable intervals—hydrorrhea gravidarum. The amount of fluid expelled varies considerably, though Ahlfeld has re- ported a case in which it exceeded 500 cubic centimeters on several occasions. This condition precludes the fusion of the decidua vera and reflexa, and therefore in the occasional instances in which it continues Fig. 480.—Decidua Polypsa (Bulius). 652 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT throughout pregnancy it must be assumed that these structures had failed to unite as usual. Since 1899 considerable discussion has arisen concerning the nature of hydrorrhea gravidarum. Stoeckel, Meyer-Ruegg, and other authorities believe that it does not result from changes in the decidua, but is due to premature rupture of the foetal membranes. The latter observer, in 1904, collected 15 cases from the literature in which a period varying from fifty to one hundred and twenty days had elapsed between the rupture of the membranes and the termination of preg- nancy. In such cases there occurs a constant trickling of amniotic fluid, and examina- tion of the placenta shows that the membranes have be- come retracted about the maternal end of the cord, so that their cavity is far too small to inclose the foetus. Van der Hoeven inclines to the older view, and bases his belief upon the analysis of specimens of the fluid expelled, which differs from the liquor amnii in having a lower specific gravity and in not containing albuminous materials or urinary constituents. In rare cases the openings of the uterine glands may become occluded, small cysts being formed which project from the surface of the decidua, giving it a nodulated appear- ance. The affection has been described by Hegar, and Breus as endomet- ritis cystica. Atrophic Endo- metritis Decidua.— Under this heading Hegar, Ahlfeld, and others have de- scribed a disease in which large por- tions of the decidua vera and serotina undergo atrophic changes similar to those which occur normally in the portions corresponding to the lateral margins of the uterus. They offer no suggestion as to its etiology, but consider that it interferes with the nutrition of the ovum and is a fre- quent cause of abortion. It should be remembered, however, that the etio- Fig. 481.—Endometritis Decidua Cystica (Breus). Fig. 482.—Decidual Endometritis. X 280. DISEASES OF THE DECIDUA 653 logical significance of such conditions must be limited to the weeks immediately following implantation; as it often happens in the later months of pregnancy that the decidua basalis may become reduced to a fraction of a millimeter in thickness without interfering with the attachment of the placenta or with the nutrition of the foetus. Acute Endometritis Decidua.—Acute inflammatory lesions of the decidua frequently follow attempts at criminal abortion, though now and again they may occur without such a history, cases having been reported by Donat, Emanuel and Witkowsky, and others. Reference has already been made to the lesions of the endometrium associated with gonorrhea and occasionally with acute infectious diseases. In many instances I have been able to demonstrate the presence of cocci or bacilli in sections, and occasionally in cultures. These observa- tions prove beyond doubt the bacterial origin of the lesions, but it is usually difficult to decide whether the inflammatory process preceded, or was merely coincident with, the abortion. In these cases the decidua vera and basalis are thickened and their external surface covered with a yellowish purulent exudate. Under the microscope the tissue is found to be infiltrated with leukocytes, and presents the typical picture of acute inflammation, with here and there areas of necrosis. Maslowsky, Neumann and others have been able to demonstrate the presence of gonococci in acute inflammation of the decidua; and it is probable that such conditions are quite common. The various forms of endometritis decidua complicating pregnancy are most important factors in the causation of spontaneous abortion, and the existence of some one of them should be suspected whenever the patient complains of a sensation of weight in the lower abdomen asso- ciated with a slightly blood-stained or dirty brownish discharge, particu- larly when there is a history of gonorrheal infection or of repeated abortions which were not associated with palpable lesions of the genera- tive tract. Furthermore, it is permissible to assume that the hypertrophic or atrophic abnormalities of the decidua may play a part in the pro- duction of placenta previa, by making it necessary for the organ to establish a wide area of attachment. Endometritis is not amenable to treatment during pregnancy. Should the patient present the slightest sign of its existence after abortion or childbirth, appropriate measures should be promptly instituted, since the condition frequently persists and may become seriously aggravated in a subsequent pregnancy. Metritis.—Unless it results from infection, metritis is a very rare complication of pregnancy, and when it exists was usually present before conception. It predisposes to abortion and is not amenable to treatment during pregnancy. Peri-uterine Inflammation.—when pregnancy occurs in women suf- fering from peri-uterine inflammation, considerable discomfort may re- sult from the stretching of old adhesions. Not uncommonly abortion results. Now and again the inflammatory changes undergo exacerbation during pregnancy, and may eventuate in abscess formation, which is accompanied by the usual symptoms of pelvic peritonitis. Very excep- 654 COMPLICATIONS DUE TO DISEASES OF GENERATIVE TRACT tionally rupture may occur and give rise to acute peritonitis, which can be successfully combated only by radical operative measures. Pregnancy Complicated by is occasionally com- plicated by the presence of ovarian or uterine tumors. Although, as a rule, they do not materially affect its course, they frequently give rise to serious dystocia at the time of labor, and will therefore be considered in detail in Chapter XXXII. LITERATURE Adams. Hernia of the Pregnant Uterus. Amer. Jour. Obst., 1889, xxii, 225-246. Ahlfeld. Ueber Endometritis decidualis tuberoso-polyposa. Archiv. f. Gyn., 1876, x, 168-176. Hydrorrhcea gravidarum. Endometritis atrophicans. Lehrbuch der Geb., II. Aufl., 1898, 253. Beckmann. Weiterer Beitrag zur Graviditat im rudimentaren Uterus-Horn. Zeit- schr. f. Geb. u. Gyn., 1911, lxviii, 600-639. Bettman. A Case of Labor in a Bicornuate Uterus. Bulletin Johns Hopkins Hosp., 1902, xii, 57. Breus. Ueber cystose Degeneration der Decidua vera. Archiv. f. Gyn., 1882, xix, 483-489. Bulius. Ueber Endometritis decidua polyposa et tuberosa. Miinchener med. Wochenschr., 1896, Nr. 28. Donat. Endometritis purulenta in der Schwangerschaft. Archiv. f. Gyn., 1884, xxiv, 481-486. Duhrssen. Aussackungen, etc., der schwangeren Gebarmutter. Archiv. f. Gyn., 1899, lvii, 70-223. Eisenhart. Fall von hernia inguinalis cornu dextri uteri gravidi. Archiv f. Gyn., 1885, xxvi, 439-459. Emanuel. Zur Lehre von der Endometritis in der Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1895, xxxi, 187-198. Emanuel und Witkowsky. Ueber Endometritis in der Graviditat. Zeitschr. f. Geb. u. Gyn., 1895, xxxii, 98-111. Gottsciialk. Zur Lehre von de,r Retroversio uteri gravidi. Archiv f. Gyn., 1894, xlvi, 358-383. Halban. Ein diagnostisches Zeichen fur Schwangerschaft in einem Uterus bicornis. Zentralbl. f. Gyn., 1904, 9-11. Hegar. Kysten-bildung in der Decidua. Monatsschr. f. Geburtsh., 1863, xxi, Supplement-Heft, 11. Die Driisen der Decidua und die Hydrorrhoea gravidarum. Monatsschr. f. Geburtsk., 1863, xxii, 429-451. Hegar and Maier. Beitrage zur Pathologie des Eies. Virchow’s Archiv, 1871, lii, 161-192. Hirst. Vaginal Enterocele in Pregnancy and Labor. Trans. Amer. Gyn. Soe., 1893, xviii, 351-357. Jaeger. Das Intestinalemphysem der Suiden, etc. Archiv. f. Tierheilkunke, 1906, xxxii, H. 425. Jolly. Ueber acutes GEdem der Portio vaginalis. Zeitschr. f. Geb. u. Gyn., 1904, lii, 396-401. Kaltenbach. Diffuse Hyperplasie der Decidua am Ende der Graviditat. Zeitschr. f. Geb. u. Gyn., 1878, ii, 225-231. LITERATURE 655 Kaschewarowa. Ueber die Endometritis decidualis chronica. Virchow’s Archiv, 1868, xliv, 103-113. Kehrer. Das Nebenhorn des doppelten Uterus. Heidelberg, 1900. Keitler. Ein Beitrag zur Betroflexion und Betroversion der schwangeren Gebar- mutter. Monatsschr. f. Geb. u. Gyn., 1901, xii, 285-305. Lindenthal. Aetiologie der Kolpohyperplasia cystica. Wiener med. Wochenschr., 1897, Nrs. 1-2. Lobenstine. Incarceration of the Pregnant Uterus. Amer. Jour. Obst., 1909, lx, 1003-1016. Maslowsky. See Chapter XXV. Mauriceau. Histoire d’une femme,etc. Traite des maladies des femmes grosses, 6me ed., 1721, T. I., 86-91. Meyer-Buegg. Eihautberstung ohne Unterbrechung der Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1904, li, 419-468. Miller. Clinical Aspects of Uterus Didelphys. Am. Jour. Obst. and Gyn., 1922, iv, 378-408. Neumann. See Chapter XXV. Nyulasy. Polypoid Endometritis. Jour. Obst. and Gyn. British Emp., 1909, xvi, 9-15. Oldham. Case of Betroflexion of the Gravid Uterus. Trans. London Obst. Soc., 1860, i, 317-322. Beed. The .ZEtiology of Ischuria in Betroflexion of the Gravid Uterus. Amer. Jour. Obst., 1904, xlix, 145-156. Betfferscheid. Beitrag.zur Lehre von der Hydrorrhoea uteri gravidi. Zentralbl. f. Gyn., 1901, xxv, 1143-1145. Sanger. Ueber Schwangerschaft im rudimentaren Nebenhorn bei Uterus duplex. Zentralbl. f. Gyn., 1883, vii, 324. Sarwey. Carcinom u. Schwangerschaft. Veit’s Handbucli der Gyn., 1899, iii, 2te Halfte, lste Abth., 489-532. Schickele. Die Schwangerschaft in einem Uterusdivertikel. Beitrage z. Geb. u. Gyn., 1904, viii, 267-293. Sinclair. A Contribution to the Diagnosis and Treatment of Betro-flexio-versio Uteri Gravidi. Trans. London Obst. Soc., 1900, xlii, 338-355. Stoeckel. Beitrag zur Lehre von der Hydrorrhoea uteri gravidi. Centralbl. f. Gyn., 1899, 1353-1361. Van der Hoeven. Hydrorrhoea gravidarum. Monatsschr. f. Geb. u. Gyn., 1899, x, 329-337. Van der Velde. Geburtsstorungen durch Entwicklungsfehler der Gebarmutter. Monatsschr. f. Geb. u. Gyn., 1915, xlii, 307-321. Veit. Ueber Endometritis decidua. Volkmann’s Sammlung klin. Vortrage, 1885, Nr. 254. Allgemeines iiber die Aetiologie der Endometritis in der Graviditat. Zeitschr. f. Geb. u. Gyn., 1895, xxxii, 111-116. Virchow. Endometritis decidua tuberosa. Die krankhaften Geschwiilste, 1864, ii, 478-481. Wells. The Clinical Significance of Developmental Duplications of the Uterus and Vagina. Amer. Jour. Obst., 1900, xli, 317-365. Winckel. Ueber die Cysten der Scheide, etc. Archiv. f. Gyn., 1871, ii, 383-413. CHAPTER XXVIII DISEASES AND ABNORMALITIES OF THE OVUM Any portion of the ovum—chorion, amnion, placenta, or foetus—may be the seat of disease, or may present abnormalities. In many instances the morbid process is limited to a single portion, while in others a large part, or even the ovum as a whole, may be implicated. Accordingly, we shall take up successively those lesions or abnormalities which are limited to the chorion, amnion, or placenta; next, those in which the entire ovum, and finally those in which the foetus alone is affected. DISEASES OF THE CHORION Hydatidiform Mole.—In this condition, also known as vesicular mole, cystic degeneration of the chorion, or myxoma chorii, the terminal ex- tremities of the chorionic villi are converted into transparent vesicles with clear, viscid contents. These vary in size from minute bodies a millimeter or less in diameter to cystic structures the size of hazel-nuts, and hang in clusters from the villous stems, to which they are connected by thin pedicles, giving to the external surface of the chorion a grape- like appearance. The formation usually involves the entire periphery of the membrane, but may be limited to portions of it. It is generally stated that the condition was first described by Schenck von Grafenberg in 1565, hut Kossmann has pointed out that Aetius, of Ami da, in the early part of the sixth centum, wrote intelligently about an hydatidiform mole, although he seemed to have no clear idea of its nature. Owing to its peculiar appearance and the fact that it frequently con- tained no tract of a foetus, the hydatidiform mole was a source of not a little speculation to the early writers upon medicine, and all sorts of theories were advanced concerning its origin. As the name implies, the condition was long considered to he analogous to the hydatid cysts ob- served in other parts of the body, Goeze, Percy, and others believing that the vesicles contained wormlike structures. De Graaf held that the vesicles were mature ova, while some authors thought that each repre- sented an early pregnancy. It is probable that many of the extraordi- nary cases of multiple gestation recorded in the early literature, such as that of the Countess Hagenau, who was believed to have given birth to 365 embryos at a single labor, were really instances of hydatidiform mole. The true nature of the affection was first recognized by Velpeau and 656 DISEASES OF THE CHORION 657 Madame Boivin in 1827, and since then it has been universally admitted to be a disease of the chorion. Numerous theories were advanced as to the nature of the lesion, until Virchow in 1853 stated that the process was essentially a myxomatous degeneration of the connective tissue of the chorionic villi, and designated it as myxoma chorii. This view ob- tained immediate acceptance and held its ground until 1895, when Mar- chand demonstrated that the essential feature of the affection was to Fig. 483.—Uterus Removed by Supravaginal Hysterectomy, Containing a Hyda- tidiform Mole. X b2- be found not so much in the stroma as in the epithelial covering of the villi. He showed that both the syncytium and Langhans’ layer of cells undergo profuse and irregular proliferation, penetrating Nitabuch’s fibrin layer and making their way into the depths of the decidua, and not infrequently into the uterine musculature as well. At the same time the blood vessels of the terminal villi disappear and the stroma degenerates, so that in advanced cases its cells become necrotic and their nuclei fail to take up the usual histological stains. Moreover, inasmuch 658 DISEASES AND ABNORMALITIES OF THE OVUM as the fluid contents of the vesicles fail to give the characteristic reaction for mucin, Marchand felt justified in attributing them to edema. This work obtained almost immediate acceptance, and was promptly confirmed by many investigators, among whom Neumann, Fraenkel, Pick, Ouvry, Larrier and Brindeau, and Essen-Moller may be men- tioned. Fig. 484 represents a section through one of my specimens, all of which abundantly confirm Marchand’s view. With the discovery that the so-called chorio-epithelioma resulted from a malignant proliferation of the epithelial elements of the chorion, and particularly that it was preceded in from one third to one half of Fig. 484.—Section of Hydatidiform Mole, Showing Proliferation of Syncytium and Langhans’ Cells. X 75. S., syncytium; V., normal chorionic villi; Z., Langhans’ cells. the recorded cases by the expulsion of an hydatidiform mole., great interest arose as to the relation which the latter bore to the production of the former. The similarity in the microscopic structure of the two pathological processes made it apparent that there must be a genetic relationship between them, and the question arose whether it existed in all cases. Neumann, in 1897, held that it was possible to differentiate between two forms of hydatidiform mole, one of which was and the other was not followed by the development of a chorio-epithelioma. He considered that in the former the proliferating epithelium invaded the stroma, Yv 111x0 1JLX bAlVL JLCt/UlAsA xv Y» Ci.»D iiiiiivCU uv ) vajl VlLKs V 111UO. JLXXC DISEASES OF THE CHORION 659 observations, however, have not been confirmed, although Pick, Findley, Larrier and Brindeau, and many subsequent writers believe that moles may occur in one of two forms—benign or malignant—but that the differences are biological rather than histological, so that it is impossible to predict the outcome of a given case by microscopical examination. Marchand, in his original article, stated that in many instances the ovaries were likewise the seat of cystic changes. Stoeckel, in 1902, showed that one or, more commonly, both ovaries may become converted into polycystic tumors, which sometimes attain a diameter of 10 or 15 centimeters. The individual cysts vary from a few millimeters to 5 or 6 centimeters in diameter, are filled with clear contents, and are lined by one or more layers of lutein cells. Since then it has become generally recognized that the lutein cell cystoma is a frequent, but not a universal, accompaniment of the condition. As lutein cystomata do not occur frequently, their association with hydatidiform mole has given rise to a great deal of discussion, certain writers holding that they stand in some etiological relation to the mole; others that they are secondary to it; while a third group, represented by Wallart and Seitz, considers that similar, but less pronounced, changes occur in normal pregnancy. While it is generally admitted that the theca cell proliferation described by the last mentioned writers is a normal concomitant of pregnancy, I do not believe that it is identical with the tumor under discussion. Moreover, the fact that only a small proportion of hydatidiform moles are associated with lutein cystomata, speaks against the latter being concerned in their etiology, but the demonstration by Fraenkel and Santi, and the confirmation by others, that lutein cystomata sometimes undergo spontaneous involution within a few months after the expulsion of the mole, indicates that there must be a genetic relationship between the two processes. In one of my patients, whose second pregnancy ended in the expulsion of a large mole, both ovaries were converted into polycystic lutein tumors, 15 centimeters in diameter. They were successfully removed after laparotomy, and constitute my sole experience with this type of tumor. Causation.—Positive statements cannot as yet be made concerning the etiology of hydatidiform mole. Virchow and Veit held that it was dependent upon endometritic changes. At the 1901 meeting of the German Gynecological Congress Aichel stated that he had been able to produce the condition experimentally in dogs by destroying the vessels going to the decidua, but, in view of the fundamental differences in structure of the zonal placenta in carnivora and of the discoidal placenta in man, the greatest caution should be exercised in making inferential deductions. On the other hand, Marchand and most recent writers consider the changes in the endometrium as secondary, and seek the initial factor in the ovum itself. Durante considers that the condition is due to endarteritis of the villous vessels. Plausibility is lent to the view that the primary process originates in the ovum by the fact that in rare instances of twin pregnancy one ovum may be perfectly normal, while the other presents the lesion in question. Mme. Boivin was ac- quainted with the fact, and cases have been reported by Birnbaum, 660 DISEASES AND ABNORMALITIES OF THE OVUM Falgowski, Lukens, and others. It is hardly probable, if changes in the endometrium were the primary cause, that the vesicular change would be limited to one ovum. Clinical History.—Hydatidiform mole is a rare disease, occurring, ac- cording to Madame Boivin, once in 20,000 pregnancies. On the other hand, the statistics of Williamson, and Sunde would indicate that it may be found about once in 2,400 or 3,000 cases; while in my experience it occurs even more frequently. It may occur at any period of reproductive life, but is particularly frequent in the third and fourth decades, having been noted between the twentieth and thirtieth years in 41 and 38 per cent, of the cases collected by Borland and Kehrer respectively. Sunde, on the other hand, on the basis of 122 personally investigated cases, holds that it occurs two and a half times more frequently after the fortieth year if the total number of pregnancies is considered. Fig. 485.—Hydatiform Mole. X 50. Invasion of blood vessel. D. V., dropsical villus; Syn., proliferating syncytium; U. W., uterine wall; V., vein. The statement of Meyer that the disease was present in over 100 out of 348 specimens of abortion, which he examined, should not be accepted without reservation. He referred to degenerative changes in the stroma of the villi, which are associated with foetal or embyronic death; while in hydatidiform mole one has to deal with an active hyperplasia of the chorionic epithelium. Doubtless he is correct, so far as he goes, but he was not dealing with true hydatidiform moles. The process usually comes on early in pregnancy, rarely making its appearance after the third month, and was present in one of my speci- mens 38 days after the last menstrual period. When it develops com- paratively late it does not implicate the entire chorion; but whenever a considerable portion of the membrane is involved, atrophic changes affecting the foetus are constantly found, and its development is ma- terially influenced even when the disease is relatively mild in character. In the former class of cases the embryo may not be formed at all, or it DISEASES OF THE CHORION 661 dies at an early period, and undergoes complete dissolution, all trace of it disappearing except the maternal end of the umbilical cord. As the chorionic villi are nourished by the maternal blood, the mole may continue to grow after the death of the embryo, and may attain consider- able proportions, though spontaneous expulsion is rarely delayed after the sixth month. The clinical history is very characteristic. The uterus enlarges much more rapidly than usual, so that its size does not correspond to the supposed duration of pregnancy. This was formerly considered a gen- eral rule, but the tabulations of Briggs and Essen-Moller show that in many instances the uterus is smaller than would be expected. After a longer or shorter period more or less profuse hemorrhage occurs, which persists until the mole is cast off spontaneously or removed by the physician. In a small number of cases, the hypertrophic villi invade the uterine wall, following the course of venous channels, and in extreme instances the entire muscularis may become disintegrated. This happens in what is known as the destructive mole, characteristic examples of which have been reported by Krieger, Yolkmann, Jarotsky, and Waldeyer. Now and again the growth reaches the peritoneal surface of the uterus and gives rise to perforation, followed by fatal intraperitoneal hemorrhage. This complication was observed by Wilton, Madame Boivin, Ouvry, and others. In rare instances, at varying periods after the expulsion of the mole, small purplish or reddish tumors may appear in the vagina or about the vulva. On microscopic examination, after excision, these are found to consist for the most part of blood, through which are scattered dropsical villi showing the characteristic epithelial changes. In a number of cases recorded, the uterus was normal, and complete excision of the nodule was followed by permanent recovery. The question has accordingly arisen whether such tumors represent metastases from a chorio-epitheli- oma or a malignant hydatidiform mole, or whether they are merely due to the accidental transportation of particles of a benign growth. Neu- mann and Schmidt take the former, while Pick and Schlagenhaufer incline to the latter view. The observations of Yeit, Poten, and myself, concerning the transportation of villi in normal pregnancy, lend a cer- tain probability to the latter theory, although the question must be settled by future investigations (see Fig. 485). Aside from the possibility of the development of a chorio-epitheli- oma, which occurred in 16 per cent, of the 210 cases analyzed by Findley, but only in 5 per cent, of the cases studied by Sunde, the hydatidiform mole is a serious affection, since Dorland noted an immediate mortality in 10 per cent, of the 100 instances which he collected from the litera- ture, death being due to hemorrhage at the time of operation in 3 per cent., to perforation of the uterus in 2 per cent., and to infection in 5 per cent, of the cases. Sunde has pointed out that the occurrence of hydatidiform mole has no effect upon subsequent fertility, although Essen-Moller has shown that it may recur in successive pregnancies, and has collected 18 illustrative cases from the literature. 662 DISEASES AND ABNORMALITIES OF THE OVUM As was indicated in the chapter upon the toxemias of pregnancy, the growth may in rare instances be associated with pre-eclamptic tox- emia, and Fig. 483 represents a mole within a uterus which had been removed because of this complication. Diagnosis.—Hydatidiform mole should always be suspected when hemorrhage occurs in a patient over thirty years of age whose uterus is considerably larger than it should be for the supposed duration of preg- nancy, though in not a few cases similar symptoms are noted in hydram- nios. A positive diagnosis may be made when one finds one or more vesicles in the uterine discharges, or when the finger introduced through the cervical canal is able to palpate the characteristic grapelike masses. Treatment.—Owing to its inherent danger, but especially to the pos- sible subsequent development of a chorio-epithelioma, the uterus should be emptied as soon as a positive diagnosis is made. By means of a gauze pack or a steel dilator, the cervix should be dilated sufficiently to admit two fingers, with which the growth is peeled off from the uterine wall and then removed. Care should be taken that the manipulations are made as gently as possible in order to avoid a possible perforation of the uterus, whose walls are likely to have been weakened by the invasion of the growth. After removal of the mole, the uterine cavity should once more be explored to make sure that it is thoroughly empty. In view of the danger inherent to this abnormality, Schumann has advised opening the uterus by abdominal hysterotomy, and removing it, or sewing it up after the removal of its contents, according to the con- ditions found. 1 consider his recommendation unduly radical, and feel sure that it will lead to the unnecessary sacrifice of many uteri. At the same time, I should not disapprove of routine hysterectomy whenever the condition develops in women at the end of the period of sexual activity. Every woman who has expelled a hydatidiform mole should be care- fully watched for the next year, and if hemorrhage makes its appearance the uterus should be curetted and the scrapings subjected to microscopic examination; and, if the lesions characteristic of chorio-epithelioma are found to be present, immediate hysterectomy is imperative, in the hope of avoiding metastases. On the other hand, as has already been pointed out, vaginal or vulval metastases may occur without any apparent in- volvement of the uterus. Under such circumstances, the metastases should be excised, but the uterus left in place, as the history of similar cases shows that the majority of the patients recover permanently. Chorio-epithelioma.—This term is applied to a very malignant variety of tumor which develops after full-term labor, abortion, or hydatidiform mole, and in rare instances even before the last is expelled from the uterus. The nature of the growth has given rise to a great deal of dis- cussion, and various appellations have been suggested for it, the most important being decidnoma malignum, sarcoma deciduocellulare, syn- cytioma malignum, and carcinoma syncytiale. The first case was described in 1892 by Sanger, who based his article upon the following case: A woman, twenty-three years of age, aborted in the eighth week and died seven months later. At autopsy four large, soft, reddish, spongy tumors were found in the uterine wall, with DISEASES OF THE CHORION 663 metastases exhibiting similar characteristics in the lungs, diaphragm, tenth rib, and right iliac fossa. Microscopic examination showed that the tumor was made up in great part of blood spaces bounded by large cells, which were considered decidual in origin. The metastases presented a similar appearance and had resulted from the transportation of tumor masses through the venous channels. As Sanger believed that the tumor was derived from decidual cells and was therefore of connective-tissue origin, he designated it decidual sarcoma or sarcoma uteri deciduocellu- lare. The appearance of his monograph in 1893, in which was collected all that was then known upon the subject, created profound interest, and was soon followed by the publication of many similar cases. In 1895 I published a monograph upon the subject, in which I reported a case and collected 24 others from the literature. My patient Fig. 486.—Chorio-epitiielioma, showing Alveolar Arrangement of Primary Tumor. X 60. was a colored woman, who, one week after a spontaneous full-term labor, noticed a small painful nodule upon the right labium majus. This resembled a hematoma in appearance, rapidly increased in size, and within two weeks became as large as a hen’s egg. Shortly afterward it underwent necrotic changes, which were accompanied by a profuse, foul- smelling discharge. The patient gradually grew worse, eventually de- veloped a cough and bloody expectoration, and died six months after delivery. The nature of the vulval tumor was not suspected during life, but at autopsy the lungs were found to be studded with large numbers of metastases of varying size, which resembled placental tissue in appear- ance. Similar growths were present in the kidneys, spleen, and ovary, while the primary uterine tumor was a small nodule about 1 centimeter in diameter. Microsepic examination showed that the uterine growth and the metastases were made up in great part of blood spaces, whose walls were 664 DISEASES AND ABNORMALITIES OF THE OVUM formed by large clear cells with, definite vesicular nuclei. At the margins of the primary growth, invading the adjacent musculature, were large masses of syncytium; the nature of the individual cells was not so clear, although I was inclined to consider them due to transverse and oblique sections through the syncytial strands. The same year Marchand wrote an important monograph upon the subject. lie identified the protoplasmic masses with the syncytium, and the individual cells with those of Langhans’ layer. At that time it was generally believed that the former was of maternal and the latter of foetal origin; accordingly he held that the tumor was epithelial in origin, and was composed partly of maternal and partly of foetal tissue. Hence it followed that such tumors could not correctly be described as deciduo- mata or decidual sarcomata. Three years later, after it had been demon- strated that both layers of the chorionic epithelium were foetal.in origin, he proposed the term chorio-epithelioma, Avhich has since been generally accepted. The monographs of Sanger and Marchand were the beginning of an extensive literature upon the subject, which has rapidly increased in volume. Thus, Teacher, and Briquel in 1903 were able to collect 188 and 254 cases respectively, and Frank in 190G analyzed 28 cases which had been reported in America; Avhile Yineberg was able to collect 533 cases, Avhich had been described in the literature up to 1917. Risel, working in Marchand’s laboratory, contends that chorio-epithe- lioma may occur in a typical and an atypical form. In the former the tumor cells present an appearance identical with that presented by the chorionic epithelium in early pregnancy, while in the latter the foetal cells merely infiltrate the uterine wall, Avithout necessarily giving rise to a true tumor formation. Both varieties are equally malignant and give rise to metastases. In other instances, the primary groAvth may originate outside of the uterus. Thus, Risel in 1914 was able to collect 22 cases in AAdiich it had originated in the tube, and Sunde and 1 have observed additional in- stances; while Fairbairn, Klotz, Risel, Seitz, and others have reported cases in which it developed in the ovary. In the latter instance one’s first tendency would be to associate the condition Avith an ovarian pregnancy or Avith a teratoma, but, Avhile such an origin cannot be de- nied, Risel believes that in most cases the ovarian tumor is derived from a primary uterine groAvth, AA’hich had long since disappeared. In still other cases, as reported by Schmorl, Hiibl, Findley, and others, there Avas no trace of a primary groAvth in the uterus, tubes, or ovaries, but the patient nevertheless died from metastases in various organs. At first it was attempted to explain such an occurrence by assuming that the primary groAvth had been limited to the placenta, particles of A\rhich became broken off and Avere carried into the circulation, giving rise to metastases, while the primary tumor itself Avas cast off with the after- birth. Later, however, as the frequency of the “deportation” of chorionic villi became more fully recognized, it Avas assumed that metastases might develop in any case in Avhich the chorionic epithelium possesses malig- nant properties. Potrm and Yassmer have reported a case in A\Tiieh DISEASES OF THE CHORION 665 vaginal metastases appeared while an hydatiform mole was still present in the uterus. The chorio-epithelioma rapidly gives rise to abundant metastases, particularly in the lungs, vagina, and brain. They develop along the course of venous channels, which is explained by the tendency of the foetal ectodermal cells to arrode, and eventually invade, the blood vessels with Avhich they come in contact. In the 52 cases collected by Dorland, metastases were observed in the lungs of <8.38 per cent., in the vagina of 54 per cent., and in the kidney, spleen, and ovary of 13.5 per cent., of the liver, broad ligament, and pelvis respectively 10.8 per cent., and in the brain 5.4 per cent. The vaginal metastases are of particular sig- Fig. 487.—Chorio-epitheolioma, showing Syncytial Masses invading a Venous Channel. nificance, and occasionally are the only manifestation of the condition. In some cases, as reported by Hormann and others, their excision may be followed by complete recovery. Ennge in 1903 pointed out that lutein cystomata were sometimes ob- served in the ovaries. Upon analyzing 63 cases of chorio-epithelioma in which the condition of the ovaries was described, he found such forma- tions in 24 instances; but, just as is the case in hydatid if orm mole, neither he nor subsequent investigators have been able to adduce a satis- factory explanation of their significance. In 1902 Wlassow and Schlagenhaufer made a contribution, which for a time threatened to overturn our ideas concerning the significance and mode of origin of chorio-epitheliomata. They described generalized 666 DISEASES AND ABNORMALITIES OF THE OVUM metastases following certain teratomata of the testicle, which were made up of syncytium, Langhans’ cells, and even of structures resembling chorionic villi. Their observations have been abundantly confirmed by Eisel, Teacher, Frank, and others; while Pick and others have reported similar conditions associated with ovarian teratomata. In such cases, Schlangenhaufer assumed that portions of foetal mem- branes had been included in the teratoma, and suddenly began to proliferate after lying dormant for years. Risel and all subsequent writers, on the other hand, hold that such an assumption is unnecessary, as they consider that the tumor may develop from undifferentiated foetal ectoderm contained in the teratoma. Clinical History.—Chorio-epithelioma may occur at any age during the childbearing period, but according to Sunde it is relatively most fre- quent after the fortieth year. Except in the rare cases associated with teratomata, it always follows a pregnancy, no matter whether the latter is situated in the uterus, tube or ovary, or terminates in full-term labor, abortion, or hydatidiform mole, the last association being noted in nearly 50 per cent, of the cases. The converse, however, does not hold good, as only 5 per cent, of the 122 moles studied by Sunde were followed by the tumor. Ordinarily there is no suspicion of the existence of the growth during pregnancy, or even during the first few weeks after delivery. In a small number of cases hemorrhage in the latter part of the puerperium may be the first indication of its existence, though this symptom is usually lacking. Occasionally a much longer period may elapse, and Krosing has collected 16 instances in which a period of latency, varying between 1 and 9 years, was noted; while Sunde observed it in 5 of his 34 cases. Ries has given a satisfactory explanation for such an ap- parently contradictory development, as he was able to demonstrate the presence of chorionic villi in the uterus of an elderly woman 18 years after the termination of her last pregnancy. In more than one half of the cases the first indication is the appearance of vaginal or vulval metastases some weeks or months after the puerperium, though in Poten and Vassmer’s case they appeared before the extrusion of the mole. The development of metastases in the lungs is usually associated with pul- monary symptoms, cough, and bloody expectoration. Occasionally, as reported by Hormann and others, the growth may perforate the uterine wall and give rise to fatal intraperitoneal hemorrhage. Unless removed by operative procedures, the tumor rapidly causes death, the majority of patients succumbing within the first year. Indeed, it may be said that, in general, this is the most rapidly fatal malignant growth with which we are acquainted, though occasionally cases are encountered in which permanent cure follows a simple curettage. Diagnosis.—If the existence of the growth is not indicated by the early occurrence of vaginal or vulval metastases, the diagnosis is not made until uterine hemorrhage, occurring at a varying period after the puerperium, necessitates curettage, when the microscopic examination of the scrapings reveals characteristic changes. The possibility of its development should be especially borne in mind DISEASES OF THE AMNION 667 whenever a woman has expelled a hydatidiform mole, in whom the sub- sequent appearance of hemorrhage, or of other more obscure symptoms, should be an imperative indication for curettage and the microscopic examination of the scrapings. Treatment.—If curettage reveals the existence of characteristic lesions in the uterus, immediate abdominal hysterectomy is imperative. On the other hand, when only vaginal metastases are present, the indi- cations for radical operation are not so clear, as we know that the excision of the vaginal tumors may be followed by complete recovery. If, however, the uterus is also involved, hysterectomy as well as excision of the metastases is indicated, though the chances for ultimate recovery are very slight. In such cases properly supervised radium treatment may be valuable. Diffuse Myxoma of the Chorion.—Breslau and Eberth have called attention to a rare affection of the chorionic membrane, in which its connective tissue layer undergoes myxomatous degeneration and becomes converted into a jellylike substance analogous to the whartonian jelly of the cord. This layer may attain a thickness of 4 to 5 millimeters, but does not appear to exert any special influence upon pregnancy. DISEASES OF THE AMNION Hydramnios.—By hydramnios is understood the presence of an exces- sive quantity of liquor amnii. Exactly when the proper limit is passed cannot he stated with accuracy, for the reason that the authorities do not agree as to the amount to be considered normal, Fehling placing it at 680 and Gassner at 1,877 cubic centimeters, though, generally speaking, a quantity greater than 2 liters may certainly be considered excessive. Minor degrees of hydramnios—2 to 3 liters—are common, hut the more marked grades are not frequent. In rare cases the uterus may contain an almost incredible amount of liquor amnii, Kustner having observed 15 liters, and Schneider 30 liters at the fifth and sixth months of pregnancy respectively. In most cases the increase in the amount of amniotic fluid is quite gradual, but exceptionally it takes place very suddenly, so that the uterus may become immensely distended within a few days—acute hydramnios. The fluid in hydramnios is usually identical in appearance and composition with that normally present in the amniotic cavity, although Prochownick states that the former occasionally contains a slightly increased amount of urea. Etiology.—As was said when the physiology of the foetus was dealt with, the amniotic fluid is normally derived from the fluids of the mother, which have been modified hy the secretory action of the amniotic epithelium; while the foetal kidneys take no part in its production, ex- cept under abnormal conditions. This being the case, it is manifestly impossible to give an explanation for its excessive production which will be universally applicable. Generally speaking, writers upon the subject state that the excess of 668 DISEASES AND ABNORMALITIES OF THE OVUM amniotie fluid may be derived from several sources—from the foetus, from the mother, from both foetus and mother, and in rare cases from the amnion itself. In a certain proportion of cases careful examination of the foetus after death reveals the presence of some abnormality which may possibly bear a causal relation to the disease. Thus, hydramnios is sometimes, though not always, noted when the foetus presents some abnormality or deformity, particularly hemicephalus or spina bifida. Under such cir- cumstances, it is believed that the superabundant fluid results from ex- cessive urinary secretion, which is brought about by the stimulation of cerebral or spinal centers which have been deprived of their usual cover- ings, just as happens in the piqure experiments of the physiologists. Hydramnios is also found associated with other deformities, such as harelip, the various varieties of club-foot, ectopia of the bladder, etc., as well as certain tumors of the kidneys. More frequently, however, the abnormality which is supposed to give rise to hydramnios is to be found in lesions which cause obstruction to the circulation either in the cord or within the foetus. In other in- stances the condition is attributed to renal changes or to abnormalities in the cutaneous functions. Sallinger has shown that an obstruction to the circulation in the um- bilical vain is accompanied by an exudation of fluid from the external surface of the umbilical cord and from the foetal surface of the placenta. This he attributed to the persistence of the so-called vasa propria of Jungbluth, which, springing from the foetal end of the cord, lie between the chorion and amnion and usually become obliterated in the second half of pregnancy. Analogous observations have been made by Levison. According to Franque, obliterative changes in coats of the arteries of the chorionic villi may lead to similar results. Leopold and Bar have shown that the obstruction may be due to stenosis or thrombosis of the umbilical vein, while Fehling has attributed it to torsion of the cord. More frequently the obstruction lies within the foetus. Thus Opitz observed cirrhotic changes in the liver in all of his cases. Others have attributed it to syphilitic changes, though in my experience lues is an unimportant factor, as hydramnios does not occur more frequently in syphilitic than in normal children. In a small number of cases the obstruction to circulation is due to cardiac abnormalities. Thus, Woerz found the right auricle almost entirely occluded by a rhabdomyoma. Bar observed tricuspid insufficiency and stenotic changes about the pul- monary arteries; Lebedeff, aortic stenosis, and Nieberding, a narrowing of the ductus Botalli. Many authorities believe that in a certain number of cases hydram- nios is due to an excessive urinary secretion resulting from renal or cardiac lesions on the part of the foetus. Opitz thought he had demon- strated that in hydramnios the liquor amnii contained a lvmphagogue substance, which is normally absent. He considered that its presence in the tissues of the foetus resulted in the extraction from the intervillous spaces of the placenta of a greater amount of fluid than usual. This necessitated increased exertion on the part of the heart, which eventually DISEASES OF THE AMNION 669 resulted in its hypertrophy. As a consequence a larger amount of fluid circulated through the kidneys, giving rise to an increased urinary secre- tion. It is generally believed that the etiological importance of increased renal activity is strikingly illustrated in hydramnios occurring in single- ovum twins. Wilson (1899) analyzed the histories of 51 cases of hydramnios occurring in multiple pregnancy—46 twins and 4 triplets. Twenty-two of the twins were uniovular in origin, and, when one con- siders that these are four times less frequent than double-ovum twins, it is apparent that something connected with the former must exert an appreciable influence in the excessive production of amniotic fluid. In such cases, as a rule, the twins differ materially in size, and the hydram- nios is limited to the amnion enclosing the larger one, while the other contains a normal or diminished amount of fluid. At autopsy the heart and kidneys of the foetus accompanied by hydramnios are found to be both relatively and actually larger than those of the smaller twin. Wilson attributed this difference to the presence in the single placenta of an area of circulation common to both twins, and believed that one, for some reason, received a larger amount of blood than the other, this excess giving rise to cardiac hypertrophy which still further accentuated the condition, and in turn was followed by renal hypertrophy with in- creased secretion. He considered that the primary cause for the differ- ence in the amount of fluid received by the two twins was to be found in abnormalities of the umbilical cord, by which the flow of blood to one child was rendered more difficult, as in the cases which he analyzed the affected twin always presented some abnormality of that structure— velamentous insertion, excessive length, or marked narrowing. The mode of production of hydramnios in such cases has been con- sidered in detail by Schatz, Werth, Straussmann, and Kiistner. The last- named authority believes that the cardiac hypertrophy comes about in the manner already mentioned, and leads to a still further increase in the amount of circulating fluid. Eventually the heart becomes unequal to its task and insufficiency results, which is followed by signs of obstruction, particularly in the liver, thereby completing a vicious circle. Scheib, on the other hand, considers that the fluid is a transudate through the umbilical vein, which is brought about by the congestion consequent upon failure of compensation. Some authors consider that the skin plays a not unimportant part in the excessive formation of liquor amnii. Budin in one case was inclined to attribute it to a large nevus, through which he believed excessive exudation occurred. Furthermore, Wilson and others consider that excessive cutaneous activity is ofttimes associated with cardiac hyper- trophy. In a small number of cases inflammatory conditions of the amnion itself are believed to play a part in the production of the condition, leading to increased exudation through that membrane. Occasionally diseases of the mother which are attended by circulatory disturbances, particularly cardiac and renal affections, or visceral syph- ilis, lead to edema of the placenta, with increased transudation into the 670 DISEASES AND ABNORMALITIES OF THE OVUM amniotic cavity. The demonstration by Wolff that nephrectomy in preg- nant rabbits was followed by increased renal activity on the part of the foetus, with consequent hydramnios, also indicates the possibility of a similar occurrence in pregnant women suffering from serious renal dis- ease. One or other of the conditions just mentioned may account for the excessive production of amniotic fluid in a considerable proportion of the cases; but at the same time they do not always afford a satisfactory explanation, inasmuch as in many instances careful search fails to reveal the presence of any condition which can be supposed to play a part in its production. Symptoms.—The symptoms accompanying hvdramnios arise from purely mechanical causes, and are due to the pressure exerted by the over-distended uterus upon adjacent organs. The effects are particularly marked in the respiratory functions, and, when the distention is ex- cessive, the patient may suffer from severe dyspnea and cyanosis, and in extreme cases be able to breathe only in an upright position. Edema often occurs, especially in the lower extremities and about the vulva. It is surpising what great degrees of abdominal distention can some- times be borne by the patient with comparatively little discomfort, al- though this is the case only when the accumulation of fluid has taken place gradually. On the other hand, in acute hydramnios, a much slighter degree of distention may lead to disturbances sufficiently serious to threaten the life of the patient. Diagnosis— In moderate degrees of hydramnios palpation and per- cussion enable one to feel confident that the fluctuant tumor is the dis- tended uterus, in which a readily ballottable foetus can be felt, although its heart sounds are heard with difficulty. The excessive enlargement of the abdomen due to multiple pregnancy occasionally renders the differentiation from hydramnios almost impos- sible ; particularly, as the latter is a frequent complication of the former condition. In such cases the hydramnios is usually detected, whereas the multiple pregnancy associated with it may pass unnoticed. On the other hand, in a multiple pregnancy not complicated by hydramnios, the diagnosis is comparatively easy, inasmuch as the large uterus is not fluctuant, while careful palpation will reveal the presence of several foetal poles and an unusual number of small parts. When the uterine distention is so excessive that the foetus cannot be felt, the diagnosis of hydramnios becomes even more difficult, and many cases are recorded in which the condition was mistaken for a large ovarian cystoma, with the result that an unnecessary laparotomy was performed. Inquiry as to the possibility of pregnancy and careful ex- amination will generally serve to prevent such an error. Excessive abdominal enlargement due to ascites can usually be differ- entiated by the characteristic changes in percussion. In rare instances pregnancy, complicated by a large ovarian cystoma, may be mistaken for hydramnios. In some cases the detection of two tumors—one corre- sponding to the uterus and the other to the cyst—will permit a correct diagnosis, but in others the condition may escape detection until after childbirth. DISEASES OF THE AMNION 671 Treatment.—Minor grades of hydramnios rarely require active treat- ment. On the other hand, when the abdomen is immensely distended and respiration is seriously hampered, the termination of pregnancy is urgently indicated no matter to what period it may have advanced. In such cases interference is the more justifiable, since experience teaches that premature labor frequently occurs spontaneously if the patient is left alone, and that the child is often so poorly developed or so deformed that its chances of living are minimal. When necessary, the symptoms can be promptly relieved by per- forating the membranes through the cervix, and labor pains set in after the amniotic fluid has drained off. In many instances the course of labor is greatly prolonged as a result of the loss of tonicity of the uterine musculature incident to excessive distention. In other cases it may be almost pre- cipitate, and in this event there is an increased risk of atonic hemorrhage during and just after the completion of the third stage. For this reason the uterus should be carefully watched, and appropriate treatment instituted at the slightest sign of danger. Oligohydramnios.—In rare instances j:he amount of amni- otic fluid may fall far below the normal limits, and occa- sionally be represented by only a few cubic centimeters of clear, viscid fluid. The etiology is even less well understood than that of hydramnios. Jaggard, in 1894, reported a case in which the foetus presented an imperforate urethra with absence of one and cystic degeneration of the other kidney, and he therefore concluded that the lack of amniotic fluid was the result of non-secretion of urine. He likewise collected several instances from the literature, in which the anomaly was associated with complete absence of both kidneys. When oligohydramnios occurs early in pregnancy it is attended by serious consequences to the foetus, as adhesions may be formed between its external surface and the amnion and give rise to serious deformities.. When occurring later, its effect upon the foetus, though less marked, is quite characteristic. Under such circumstances the latter is subjected to pressure from all sides and takes on a peculiar appearance, and many minor deformities, such as club-foot, are frequently observed (Fig. 488). In some cases of oligohydramnios the skin of the foetus is markedly thickened, and presents a dry, leathery appearance. Most authorities at- tribute this to the lack of amniotic fluid, hut Ahlfield is inclined to believe that it is the cause and not the result of the condition, since the Fig. 488.—Compression of Fcetus in Oligohydramnios (Ahlfeld). 672 DISEASES AND ABNORMALITIES OF THE OVUM skin lesion may be so marked as to interfere with the normal cutaneous functions and "thus do away with one of the sources of the liquor amnii. Amniotic Adhesions.—In oligohydramnios, and occasionally even when the liquor amnii is present in normal amounts, adhesions may form between the amnion and the surface of the foetus. According to Simonart, Chaussier in 1812 was the first to direct attention to this condition, and its consequences were further studied hy Montgomery, GL Braun, Kiistner, Ahl- feld, Chiari, and others. The effects of amniotic adhesions are variable and depend in great meas- ure upon their location. As a rule, when they develop early in pregnancy they give rise to serious deformities of the foetus. The following abnormalities have been directly traced to the con- dition : Eneephalocele or hemicephalus; fissure of the face, jaw, or lips; fissure of the thorax with ectopia cordis, and eventration with hernia of the umbilical cord. In other instances, amniotic bands may encircle an extremity of the foetus and so compress it as to lead to strangulation and subsequent spontaneous amputation. Fig. 490 represents intra-uterine amputation of the fingers, and Fig. 491 amputation of the arms, produced in this way. Braun has reported two cases in which the death of the foetus Fig. 489.— Encephalocele re- sulting from Amniotic Ad- hesions (Ahlfeld). Fig. 490.—Amputation of Fingers by Amniotic Adhesions (Kustner). Fig. 491.—Amputation of Arm by Amni otic Adhesions. was attributable to strangulation of the umbilical cord by such bands. Exceptionally amniotic adhesions may give rise to dystocia, and Bar- deleben and myself have seen instances in which firm adhesions extend- ABNORMALITIES OF THE PLACENTA 673 mg from the placenta to the child seriously interfered with its birth. Inflammation of the Amnion.—Occasionally inflammatory processes implicate the amnion. These are usually associated with similar changes in the chorion and decidua, and result from preexisting gonorrhoea, from attempts at criminal abortion or from the extension of an intrapartum infection. Cysts of the Amnion.—Now and again small cystic structures, lined by typical epithelium, may be formed in the amnion. They generally result from the fusion of amniotic folds with subsequent retention of fluid. Special attention has been devoted to this subject by Ahlfeld. The same observer has also described a dermoid cyst of the amnion, which does not, however, bear critical examination, inasmuch as the small particles found in it were probably mere concretions. Amniotic Caruncles.—Under this name have been described certain nodules which occur upon the foetal surface of the placenta, as well as upon the free amnion. Usually they appear in the neighborhood of the insertion of the cord as multiple, rounded or oval, opaque elevations, which vary from less than 1 to 5 or 6 millimeters in diameter. Under the microscope they are seen to be made up of typical stratified epithelium. The lowest layer is cuboidal in shape and is continuous with the amniotic epithelium, while the upper layers become more and more flattened, and stain less and less well as the surface is approached. Such structures were found by my assistant, Solon B. Dodds, in 60 per cent, of a large series of placentae. As yet we are ignorant of their significance, although in the ruminants, in which they are very abundant and attain considerable proportions, they contain large quantities of glycogen. ABNORMALITIES 0E THE PLACENTA Abnormalities in Size, Shape, and Weight.—The normal placenta is a flattened, roundish, or discoid organ, which averages from 15 to 20 centimeters in diameter, and from 1.5 to 3 centimeters in thickness. As compared with the foetus, it is relatively larger in the earlier than in the later months of pregnancy, and varies considerably in size at term, though, generally speak- ing, the thickness is in inverse proportion to its area. Now and again, when inserted in the neighborhood of the internal os, the placenta may take on a horseshoelike appearance, its two branches running partially around the orifice. In very rare instances, as reported by Taurin, it may be a broad annular organ which encircles the uterine cavity just as the zonal placenta in carnivorous animals. Fig. 492.—Placenta Fenestrata (Hyrtl). 674 DISEASES AND ABNORMALITIES OF THE OVUM The normal full-term placenta on an average weighs about one sixth as much as the child—i. e., somewhere in the neighborhood of 500 grams. Exceptionally it may be considerably heavier, Levy having reported a number of cases in which it exceeded 1,000 grams in weight. In dis- eased conditions, on the other hand, this proportion no longer holds good, and in syphilis the placenta may weigh one fourth, one third, or even one half as much as the foetus. In albu- minuria similar ratios obtain, which are due almost entirely to the im- perfect development of the foetus which charac- terizes such conditions. The largest placentae with which we are famil- iar are observed in cases of general dropsy of the foetus and placenta. In one of my cases of this character the foetus and placenta weighted 1,140 and 1,200 grams, respectively, and in another the placenta weighed over 2,000 grams. Cohen has reported a case in which the placenta weighed 2,900 grams. Multiple Placenta in Single Pregnancies.—Occasionally in a single pregnancy the placenta is divided into several parts, which may be abso- lutely distinct, or more or less closely united. Such abnormalities have been studied more particu- larly by Hyrtl and Ribemont - Dessaignes, the latter stating that they occur about once in 352 cases. In rare in- •stances the pla- centa may be ob- long in shape, with an aperture of varying size somewhere in the neighborhood of its center. To this abnormality Hyrtl applied the term placenta fenestrata. More frequently, the organ is more or less completely divided into two lobes. When the division is incomplete, and the vessels extend from one lobe to the other before uniting to form the umbilical cord, we speak of a placenta dimidiata or lipartita (see Fig. 493). According to Ahlfeld, this anomaly is noted Fig. 493.—Placenta Bipartita. Fig. 494.—Placenta Tripartita (Hyrtl). ABNORMALITIES OF THE PLACENTA 675 about once in 600 cases. Again, the two lobes may be quite separate, the vessels being • perfectly distinct and not uniting until just before entering the cord—placenta duplex. Occasionally the organ may be made up of three distinct lobes—placenta triplex; while in very rare in- stances it may consist of a number of small lobes, Hyrtl having described as many as seven—pla- centa septuplex. All of these condi- tions result from ab- normalities in the blood supply of the decidua. Generally speaking, the portion of the ovum which is to become con- verted into the chorion frondosum, and later into the foetal portion of the placenta, is that which is in contact with the most highly vascularized portion of the decidua. If the vascularization, instead of being practically limited to a single area, de- velops in several separate portions of the decidua, some such anom- aly is bound to occur. Kiistner believes that cer- tain cases of pla- centa bipartita or duplex owe their origin to extensive infarct formation by which the inter- vening tissue is destroyed; but such an explana- tion cannot be accepted when the several lobules are sepa- rated from one another by apparently normal membranes. Placenta Succenturiata.—An important, and not infrequent, anomaly is the so-called placenta succenturiata, in which one or more small ac- cessory lobules are developed in the membranes at some distance from the periphery of the main placenta. Ordinarily they are united to the Fig. 495.—Corrosion Preparation of Placenta Septuplex (Hyrtl). Fig. 496.—Placenta Duplex, with Two Succenturiate Lobules. X Yi- DISEASES AND ABNORMALITIES OF THE OVUM 676 latter by vascular connections. Occasionally, however, these are lacking, and as a result we have what are known as placentae spurge. The placenta succen- turiata is of considerable clinical importance, because the accessory lobules are sometimes retained in the uterus after the expulsion of the main placenta, and may give rise to serious hemorrhage. For this reason, one should always bear in mind the possibility of their existence, and, in examining the after-birth, the membranes should be in- spected, as well as the pla- centa. Should small, round- ish defects be present a short distance from the pla- cental margin, the retention of a succenturiate lobe should be suspected, and this becomes a certainty if ves- sels extend from the pla- centa to the margins of the tear. If, in such cases, even slight hemor- rhage occurs, the hand should be introduced into the uterus for the pur- pose of locating and removing the offending structure. Placenta Membranacea. — In rare instances the decidua re- flexa is so abund- antly supplied with blood that the chorion laeve in contact with it fails to under- go atrophy. In such c i r c u in- stances, the en- tire periphery of the ovum is cov- ered by function- ing villi, so that the placenta, instead of being a discoidal organ limited to the decidua serotina, is a thin membranous structure occupying the Fig. 497.—Placenta Membranacea (von Weiss). Fig. 498.—Placenta Marginata. X Yi- DISEASES OF THE PLACENTA 677 entire periphery of the chorion—placenta membranucea. This abnormal- ity does not interfere with the nutrition of the ovum, but occasionally gives rise to serious complications during the third stage of labor, since the thinned-out placenta does not readily separate from its area of attachment and causes profuse hemorrhage. This necessitates manual removal, which is sometimes very difficult. Placenta Marginata.—Placenta marginata will be considered later in the chapter when we come to speak of infarcts of the placenta. Placenta Circumvallata.—In exceptional instances, the foetal surface of the placenta may present a central depression surrounded by an ele- vated portion, the amnion extending from the edges of the former. This condition is designated as placenta circumvallata, and is due to a proliferation of the villi at the margin of the placenta after the definite attachment of the amnion has occurred. Placenta Previa.—Once in several hundred cases the placenta, instead of being inserted upon the anterior or posterior wall or the fundus of the uterus, is implanted upon the lower uterine segment in such a manner as more or less completely to overlap the internal os—placenta previa. As this condition is unavoidably associated with hemorrhage during the first stage of labor, and is a most serious complication, it will be dealt with in a separate chapter. DISEASES OF THE PLACENTA Infarct Formation.—The most frequent abnormality of the placenta consists in the development of certain degenerative changes, which have been variously designated as placentitis, schirrus, atrophy, hepatization, apoplexy, phthisis, necrosis, fatty and fibrofatty degeneration of the placenta, etc., hut which are most appropriately described as 'placental infarcts. These structures vary materially in size, shape, and appearance, and are best described under the folloAving headings: 1. Small, whitish, or yellowish fibrous formations occurring upon either the foetal or maternal surface of the placenta, and varying in size from areas hardly visible to the naked eye to those having a diameter of several centimeters. These rarely attain a thickness of more than a few millimeters, and are sharply differentiated from the surrounding placental tissue. 2. Wedge-shaped or irregularly round areas of varying size in the interior of the placenta. These are usually dull white in color, exhibit a striated, fibrous appearance, and present a striking contrast to the normal tissue surrounding them. 3. Less commonly, considerable portions of the placenta are involved in the process, and occasionally one or more cotyledons are converted Into a pale white, dense, more or less fibrous tissue. In other instances a large portion of the organ may be involved in the change, one half and sometimes nearly its entire substance being implicated. 4. A broad rim of opaque, whitish, or yellowish-white material may 678 DISEASES AND ABNORMALITIES OF THE OVUM extend for a varying distance around the margin of the foetal surface of the placenta, and occasionally forms a complete ring around it-—pla- centa marginata. These bands vary from a few millimeters to several centimeters in breadth. They lie beneath the amnion and rarely attain a thickness of more than a few millimeters, except at the extreme margin of the placenta, where it merges into the membranes. In a certain num- ber of cases the band, instead of being situated at the margin of the placenta, lies somewhere between it and the center of the organ, thus forming a broad zone more or less parallel to the periphery, but sep- arated from it by apparently normal placental tissue. To this condition the term margo placentae is sometimes applied. 5. Pinkish or brickdust-colored, irregularly shaped, more or less solid masses, sharply marked off from the surrounding tissue, may occupy a larger or smaller portion of the placenta. They are usually most prominent on the maternal surface, and frequently extend through its entire thickness; they are sometimes termed red infarcts. 6. Somewhat more frequently, roundish areas varying from bright red to almost black in color, and measuring from one to three centi- meters in diameter, are scattered through the substance of the placenta. They are composed almost entirely of blood, and are sharply differ- entiated from the surrounding tissue by a capsule which presents a whitish and fibrous appearance. When they occur in considerable num- bers, the entire placenta is studded with them, presents a nodular sur- face, and on section an appearance which Pinard has aptly described as placenta truffe. These structures are also designated as red infarcts, though many authors prefer to speak of apoplexy or hematoma of the placenta. They differ markedly in structure and appearance from the other form of so-called red infarcts, and probably have nothing in common with them. Frequency.—Minute white infarcts are present in every placenta, while I found similar areas, measuring 1 centimeter or more in diameter, in G3 per cent, of 500 consecutive placentae. If not present in excessive numbers, such infarcts possess no clinical significance, and according to the researches of Eden and myself are to be regarded as signs of senility of the organ. On the other hand, when they are of large size and abundant, they may mechanically throw out of function so great a portion of the placenta as seriously to interfere with the nutrition of the foetus, and sometimes cause its death. On the other hand, McNalley and Dieckman in carefully studying a series of 320 placentae, noted hemorrhagic lesions in 38 per cent., of which somewhat more than one-third corresponded to the structures de- scribed under heading 6. Mode of Formation.—According to Clemenz four main views have been advanced in explanation of the formation of the usual type of white infarct: 1, placentitis; 2, peri- and endarteritis of the villous vessels; 3, changes in the decidua; and 4, the obliteration of maternal vessels. He considers that view 1 possesses only an historical interest, that views 2 and 3 are untenable, while view 4 affords the only reasonable ex- PLATE XIY. PLACENTAL INFARCT FORMATION. X 00. Fig. 1.—Fully developed infarct. Fig. 2.—Chorionic villi, showing endarteritis and formation of canalized fibrin. B., blood in intervillous spaces; C. F., canalized fibrin; End., arteries showing obliterating en- darteritis. DISEASES OF THE PLACENTA 679 planation. On the other hand, the researches of Ackermann, Orth, Eden, Kermauner, and myself, indicate that the usual type of infarct formation is the result of obliterating endarteritis in the vessels of the chorionic villi, and is brought about in the following manner: As soon as the circulation through the arteries of the chorionic villi is interfered with by the endarteritic process, necrotic changes begin to appear at their periphery (Plate XIV, Eig. 2). Owing to the fact that the syncytium is nourished in part by the maternal blood, the changes occur first in the layer of tissue just beneath it, and manifest them- selves as coagulation necrosis of the tissue which has replaced Lang- hans’ layer of cells. As the process becomes more marked, this is gradually converted into the so-called canalized fibrin. A little later the syncytium undergoes a similar change, the fibrin then coming in direct contact with the maternal blood in the intervillous spaces. As a con- sequence, the blood immediately adjoining the necrotic tissue coagulates with eventual fibrin formation. When similar changes occur in several adjacent villi, the maternal blood lying between them undergoes coagulation, so that eventually a number of villi become fused together by fibrin. A little later the stroma cells of the implicated villi undergo coagulation necrosis, and finally the conversion into fibrin becomes so extensive that large areas are produced in which only the shadows of degenerated villi can he distinguished (Plate XIV, Fig. 1). Ultimately the outlines of the villi disappear, and the entire mass takes on a homogeneous fibrinous appearance, in which it is impossible to distinguish the component parts. For full particulars concerning the process, the reader is referred to my monograph upon the subject. Less frequently another type of white infarcts is observed, which, for ease in differentiation, I designate as atypical infarcts, and which differ from those just described by the relative absence of fibrin and of changes in the villous vessels. In this event the villi are closely packed together, and there is little or no development of fibrin between them. The syncytium remains intact for a long time, while the stroma soon presents a necrotic appearance; finally the syncytium becomes im- plicated and a fibrous mass results in wdiich the pale outlines of villi are long distinguishable. While I cannot express a definite opinion as to their mode of origin, it is possible that Young and Clemenz are correct in attributing such infarcts to the occlusion of maternal vessels supply- ing isolated areas of the placenta. Sfameni states that placenta marginata is noted in 15 or 20 per cent, of all after-births, and is inclined to attribute its origin to me- chanical factors. Red infarcts of the placenta are less frequently observed. The type described in section 6 is sometimes associated with albuminuria on the part of the mother, which was present in 33, 60, and 67 per cent, of the cases collected by Cagny, Eossier, and Martin respectively. Unlike white infarcts, they may possess considerable clinical significance and, when well marked, may he associated with imperfect development of the foetus, and sometimes cause its death; although McNalley and Dieck- 680 DISEASES AND ABNORMALITIES OF THE OVUM mann deny such an association. They attribute them to hemorrhage into the substance of the placenta resulting from interference with the maternal circulation, and believe that as they become organized' they are converted into structures indistinguishable from the ordinary white infarct. With the latter point I agree; but, if one holds that the inter- villous spaces are normally filled by circulating maternal blood, it is difficult to conceive how isolated hemorrhage can occur into them. The mode of production of these interesting formations is in urgent need of elucidation, but, until it is forthcoming, I must confess my ignorance, and can make only one positive statement concerning them, and that is that they are not, as a rule, observed in the placentae of eclamptic women, being noted only in a certain proportion of patients suffering from pro- nounced nephritic toxemia. Cysts of the Placenta. — Cystic structures are fre- quently observed upon the foetal sur- face and occasion- ally in the depths of the placenta. Small cysts a few millimeters in di- ameter were noted in 56 per cent, of the placentae studied by Ker- mauner. Larger ones, occasionally attaining the size of a lemon, are ob- served but rarely. In one of my specimens, five cysts varying from 3 to 5 cm. in diameter, projected from the foetal surface of the placenta. Such cysts are derived from the chorionic membrane, as is shown by the fact that the amnion can be readily stripped off from them. Their contents are usually clear and transparent, but are sometimes bloody or grumous in character. The walls, especially the portions adjacent to the intervillous spaces, are lined in great part by a dull whitish mem- brane, while occasionally a portion is occupied by a white infarct. On microscopic examination, the lining membrane is found to be made up of one or more layers of tolerably large epithelial cells with round vesicular nuclei, which frequently present various degrees of de- generation. Here and there, corresponding to the situation of a white infarct, the cells are absent and the wall consists of fibrin. The re- searches of Ehrendorfer, Peiser, De Jong, Yassmer, and Schickele have clearly shown that the cells in question correspond to those of Langhans’ Fio. 499.—Cyst of Placenta (Ehrendorfer). X DISEASES OF THE PLACENTA 681 layer, and that the cysts result from the degeneration of masses of trophoblastic tissue. The cysts occurring in the depths of the placenta rarely exceed 1 centimeter in diameter. They frequently occupy the center of an in- farct, are filled with grumous contents, and were mistaken by the older writers for abscesses. In other cases the contents are clear. Such struc- tures may be derived in one of two ways: either by the softening and breaking down of an infarct, the cyst-wall then consisting of fibrin; or more frequently from the degeneration of the trophoblastic cells which make up most of the so-called “decidual islands or septa.” In the latter case the walls are composed of cells identical with those observed in the cysts occurring upon the foetal surface of the placenta. So far as present experience goes, cystic formations, whether occur- ring upon the foetal surface or in the depths of the placenta, are of interest purely from a pathological point of view, and exert little or no influence upon the course of pregnancy or labor. Tumors of the Placenta.—John Clarke in 1798 described a solid tumor about the size of a man’s fist, which made up a large part of the placenta. In recent years a number of tumors, varying in size from that of a pea to that of a man’s fist, have been described. Dienst and Nebesky in 1903 and 1914, respectively, were able to collect 48 and 79 cases from the literature. According to Virchow, the most frequent variety of placental tumor is the myxoma fibrosum, which is composed in great part of fibrous tissue having abundant oval nuclei, with typical myxomatous areas scat- tered through it, but in my experience the so-called angio-chorioma is much more frequent. Until recently the placental tumors have been variously designated, and the 36 examples collected by Albert were classified as follows: Myxoma fibrosum 14 Fibroma 10 Angioma 9 Sarcoma 2 Hyperplasia of chorionic villi 1 The researches of Dienst, Pitha, and Kebesky, however, show that they are practically all of one type, and consist of masses of chorionic villa with immense hypertrophy and hyperplasia of the terminal vessels, so that they may be designated as chorio-angiomata. Dienst suggested that they be designated as chorioma angiomatosum, or fibrosum, accord- ing as dilated vessels or connective tissue predominate. In many in- stances the tumor is connected with the chorion by a small pedicle, in which an artery and vein can usually he distinguished,, and Pitha holds that the etiological factor is to be sought in interference with the circulation in these vessels. As the chorio-angiomata do not atfect the surrounding placental tis- sue, they do no harm unless they involve so considerable an area as to throw a large part of the placenta out of function. Albert, on the other hand, holds that they exert a deleterious influence upon the course of 682 DISEASES AND ABNORMALITIES OF THE OVUM pregnancy and labor. I have observed approximately twenty chorio- angiomata, and also had an opportunity to study another specimen, which Dr. Cary of Brooklyn was kind enough to send. In this instance, the stroma of the large tumor was so rich in cells that I was tempted to diagnosticate it as a sarcoma of the placenta, but I now feel that it differed from the relatively common angiochorioma only in the relative absence of blood vessels. Walz in 1906 described a number of multiple tumors in the placenta presenting a structure typical of myxosarcoma. These he considered were metastases from a similar tumor in the leg, which had originated during pregnancy. Senge a few years later described a carcinomatous growth in the placenta, which he regarded as a metastasis from a car- cinoma of the stomach. These observations are of great interest, in that they forcibly illustrate the connection of the intervillous spaces with the general maternal circulation. Inflammation of the Placenta.—Under the term 'placentitis many of the older .writers described changes which we now recognize as infarct formation. Moreover, as has already been said, small placental cysts filled with grumous contents were formerly thought to be abscesses. Hence it follows that most of the statements in the abundant early literature upon inflammatory lesions of the placenta must be received with the greatest caution. At the same time acute inflammation of the placenta is occasionally met with. It is not a primary condition, but is usually due to the extension of a similar process from the decidua, resulting from an exacerbation of a preexisting chronic gonorrhea, or from an acute infection due to the gonococcus or other pyogenic bacteria. Very exceptionally, abscess formation may be a manifestation of a gen- eral infection originating in any portion of the body. In cases of prolonged labor, as will be elaborated in Chapter XXXI, Slemons has shown as the result of intrapartum infection that pyogenic bacteria may invade the foetal surface of the placenta, and, after gaining access to the intervillous spaces, give rise to general infection of the foetus. Frequently, upon examining sections of placental tissue under the microscope, I have found the decidua serotina infiltrated with leukocytes and presenting the characteristic picture of an acute inflammation, while the adjacent intervillous spaces were crowded with leukocytes. Franque observed similar conditions, but is inclined to believe that in most in- stances the implication of the placenta is secondary to the death of the foetus. Tuberculosis of the Placenta.—Tubercle formation in the foetal por- tion of the placenta is extremely infrequent. For particulars the reader is referred to the chapters upon the Physiology of the Foetus and upon the Infectious Diseases Complicating Pregnancy. Calcification of the Placenta.—Small calcareous nodules, sometimes occurring in the form of flat plaques, are frequently observed upon the maternal surface of the placenta, and are occasionally so abundant as to give to the finger the same sensation as when feeling a piece of coarse sand-paper. Frankd showed that the chalky material was usually de- ABNORMALITIES OF THE UMBILICAL CORD 683 posited in the necrotic tissue surrounding the ends of the “fastening5” villi, as well as in the superficial layers of the decidua serotina. When the widely spread occurrence of degenerative changes in the placenta is remembered, it should be a matter of surprise, not that calci- fication is occasionally met with, but rather that it is not noted in almost every placenta, inasmuch as apparently ideal conditions for its forma- tion are constantly present in the later months of pregnancy. Abnormal Adherence of the Placenta.—In the vast majority of cases the term adherent placenta is a misnomer, since the interference with its expulsion is usually due to abnormalities in the uterine contractions rather than to abnormal adhesions between it and the uterine wall. In rare instances, on the other hand, the adhesions may be so firm and extensive that separation cannot be effected spontaneously, and even at autopsy is possible only by tearing either the placenta or the uterine wall. Neumann, Hense and Schweitzer have examined uteri in which this condition obtained. Microscopic examination showed that the decidua serotina was almost entirely absent, and that the chorionic villi had deeply invaded the uterine wall and penetrated between the individual muscle fibers. Schweitzer’s article is accompanied by excellent illustra- tions, and reviews the literature up to 1918. ABNORMALITIES 0E THE UMBILICAL CORD Variations in Insertion.—The umbilical cord is usually inserted ec- centrically upon the foetal surface of the placenta, somewhere between its center and peri- phery. A central insertion is less common, while in a still smaller num- ber of cases the junction has taken place near the mar- gin, giving rise to a condition known as battledore pla- centa. In a series of 2,000 placentae, which I studied in this regard, the in- sertion was eccen- tric in 73 per cent., central in 18 per cent., and marginal in 7 per cent. These variations possess no clinical significance. On the other hand, the so-called velamentous insertion of the cord— insertio velamentosa—is of considerable practical importance. In this Fig. 500.—Marginal Insertion of the Cord. Battledore Placenta. 684 DISEASES AND ABNORMALITIES OF THE OVUM condition the vessels of the cord separate some distance from the pla- cental margin and make their way to the latter in a fold of amnion (Fig. 500). This mode of insertion was noted in 0.84 per cent, of 15,891 placentae examined by Lefevre, and in 1.25 per cent, of our cases. Ac- cording to Mironoff it occurs nine times more frequently in twin than in single pregnancies, being noted in 5 and 0.57 per cent, of the cases respectively. Its mode of production has given rise to a great deal of speculation. So long as the old views were in vogue concerning the part played by the allantois and the amnion in the formation of the umbilical cord, Schultze’s explanation obtained almost universal acceptance. According to this, the anomaly was the result of abnormal adhesions between the umbilical vesicle and the chorionic membrane, whereby the amnion was prevented from applying itself in the usual manner to the cord. At pres- ent, however, this explanation is not regarded as satisfactory, as it is now recognized that the allantois plays an insignificant part in the for- mation of the cord in human beings. According to Franque, the abdominal pedicle ordinarily extends to the foetus from that portion of the chorion which is in contact with the most richly vascularized portion of the decidua—usually the decidua serotina—so that the cord becomes inserted upon the placenta. Occa- sionally, however, during the first few days of pregnancy, the area of greatest vascularization may be in the decidua reflexa, and in such cir- cumstances the abdominal pedicle takes its origin from that location. With the advance of pregnancy, however, the area of vascularization eventually shifts to the decidua basalis—the site of the future placenta —while the abdominal pedicle retains its original position, and from its maternal end the vessels extend to the placental margin. The correct- ness of this explanation was endorsed by Ottow in 1922. When the placenta is inserted low down in the uterus, the velamen- tous vessels may extend partially across the internal os—vam previa— and as dilatation progresses be pressed upon by the presenting part, the interference with the circulation causing asphyxia of the foetus. In rare cases such vessels are torn through when the membranes rupture, and the foetus bleeds to death. The full literature upon this subject up to 1898 has been collected by Peiser. Variations in Length of Cord.—Normally, the umbilical cord averages about 55 centimeters in length, though it may present marked variations—3.5 to 198 centimeters (Dyhrenfurth and Hyrtl). In rare instances it may be so short that the abdomen of the foetus is in contact with the placenta, but under such circumstances a congenital umbilical hernia is always present. According to Kaltenbach the cord must be of a certain length in order to permit of delivery of the child—that, is, it must be sufficiently long to reach from its placental insertion to the vulva, 35 centimeters when the placenta is inserted high up, and 20 centimeters when low down; while Gardiner places the limit at 32 centimeters. On the other hand, it sometimes happens that cords, which actually exceed the normal in length, may be so twisted about the child as to ABNORMALITIES OF THE UMBILICAL CORD 685 become practically too short. When a coil encircles the neck, Gardiner estimates that the cord must measure 76 or 101 centimeters in length in vertex and breech presentations, respectively, if it is not to exert trac- tion upon the placenta. Accordingly, one distinguishes between absolute and relative shortness of the cord. Either of these conditions may give rise to dystocia. Brickner, who has carefully studied the subject, states that delivery cannot occur under such circumstances unless one of the following accidents occur: separation of the placenta, inversion of the uterus, umbilical hernia of the foetus, or rupture of the cord, the last two being of infrequent occurrence. Rupture of the cord may result from absolute or accidental shortness, being due to the former in Dyhrenfurth’s, and to the latter in Ahlfeld’s case, in which the cord measured 44 centimeters in length, but was tightly twisted about the foetus. Ordinarily an excessively long cord exerts no deleterious influence, although it predisposes to the formation of loops during pregnancy and to prolapse at the time of labor. Knots of the Cord.—It is customary to distinguish between false and true knots, the former being due to developmental abnormalities in the cord, while the latter result from the active movements of the child. True knots occur very frequently, and occasionally are of the most complicated character. Ordinarily they are of no clinical importance, but occasionally they may be pulled so taut as to compress the vessels and lead to asphyxia of the foetus. Loops of the Cord.—The cord frequently becomes wrapped around portions of the foetus, and in every third or fourth case of labor the child’s neck will be found loosely encircled by one or more loops. In rare instances these may produce strangulation. Most of these accidents are not due to any drawing taut of the loop, but rather to the fact that it does not become looser in proportion as the neck of the child increases in size. In other cases loops of the cord may so tightly encircle the body or one of the extremities of the child as to give rise to deep depressions, which in extreme cases may eventuate in the strangulation or gangrene of the affected part. In single-ovum twins, in which the amniotic partition wall has already been broken through, it sometimes happens that the cord of one foetus may become wrapped around some portion of the other so tightly as to cause its death. A number of cases of this character have been collected by Hermann. Torsion of the Cord.—As the result of movements on the part of the foetus, the cord may become more or less twisted. Occasionally the torsion is so marked as to interfere seriously with the circulation. The most extreme degrees occur only after the death of the foetus, Schauta having reported a case in which 380 twists were noted. In rare instances separation of the cord is produced, though this is possible only after the death of the foetus in the early months of pregnancy. Inflammation of the Cord.—As long as the child is alive inflammatory conditions are rarely noted, but after its death the whartonian jelly may be found infiltrated with leukocytes. Particularly in syphilis, obliterative changes occur in the vessels, the lumina becoming almost completely oc- 686 DISEASES AND ABNORMALITIES OF THE OVUM eluded, with leukocytic infiltration of the spaces between the muscle fibers, as well as in the adventitia. While suggestive, such changes are not pathognomonic of syphilis. Varices of the Cord.—In rare instances varices of the cord may rup- ture as the result of undue pressure. Meier has reported a case in which the death of the foetus was attributable to such an accident. Tumors of the Cord.—Tumor formations implicating the cord are rarely seen. Hematomata occasionally result from the rupture of a varix with subsequent effusion of blood into the cord. In one instance I observed such a tumor, 5 centimeters in diameter, at the foetal end of the cord. Myxomata and myxosarcomata have also been described. Winckel has reported two cases of sarcoma of the cord, while Budin has described a typical dermoid. The cases of Meyer and Haendly were of peculiar interest. In both instances a typical teratoma, the size of a child’s head, containing derivatives of all three germ layers, originated from the cord ten centimeters beyond its foetal insertion. Cystic structures occasionally occur in the course of the cord, and are designated as true and false cysts respectively, according to their mode of origin. The former are always quite small and, according to Kleinwachter, may be derived from remnants of the umbilical stalk or of the allantois; while the latter may attain a considerable size and result from liquefaction of the whartonian jelly. Haas has collected the literature concerning the latter variety up to 1906. As a rule such cysts are only apparent, and result from the liquefaction of the myxomatous tissue of the cord. Edema of the Cord.—This condition is rarely noted by itself, but is frequently associated with edematous conditions of the foetus. It is very common in dead and macerated children. In one of my cases, in which the child was born alive at full term, the cord was 3 centimeters in diameter and resembled an eel in appearance. Microscopic examination showed that the condition was simply due to an increase in the amount of whartonian jelly. DISEASES OF THE FCETUS Foetal Syphilis.—Syphilis is the most frequent cause of foetal death in the later months of pregnancy, and is usually maternal in origin. The mother may be suffering from the disease at the time of conception, or may contract it during the course of pregnancy, but in either event transmission to the foetus occurs through the placenta. Contrary to the present trend of opinion, as was stated in Chapter XXY, I believe that in rare instances the disease may be paternal in origin, and is transmitted in some way by the spermatozoa. In such cases the mother will or will not contract the disease according as the father does or does not pre- sent infectious lesions at the time of coitus. Since these are usually absent, the mother escapes, while the foetus ordinarily becomes inoculated —Colles" law. Indubitable evidence of paternal transmission will be lacking until the existence of some “sporal” form of the spirocheta pal- DISEASES OF THE FCETUS 687 lida has been demonstrated, as has been done with the spirochete causing recurrent fever. It has long been known that a syphilitic infection exerts a most deleterious influence upon the product of conception. In 1915 I stated that it was the most important single factor concerned in the production of foetal death in hospital practice, and in 1920 I demonstrated that it was responsible for 34 per cent, of 302 consecutive foetal deaths in our service. Usually it leads to the untimely expulsion of a macerated pre- mature foetus. Less commonly the child is bom alive showing distinct manifestations of the disease, while in other cases they do not appear until a later period. It should, however, be remembered that no evi- dence has been adduced to show that syphilis plays any part in the production of abortion. It is of the greatest importance that the practitioner should become thoroughly familiar with the characteristic lesions of foetal and placental syphilis, as upon their recognition the future treatment of the patient often depends. This is a point especially worthy of emphasis, inasmuch as, in consequence of ignorance or design on the part of one or both parents, the first intimation that the physician may have of the existence of the disease is often afforded by the birth of a dead child, or the appearance of syphilitic stigmata in a living one; unless the Wassermann reaction is determined in all pregnant women—a procedure which is possible only in well regulated hospitals. Syphilis not only gives rise to characteristic lesions of the foetus, but also affects the placenta, so that frequently a diagnosis can be made from an examination of the latter organ. This fact is of special impor- tance in those cases in which the foetus is born alive, or when an autopsy is not permitted upon a dead child. The appearance of the syphilitic foetus varies materially according as it is born alive or dead. In either instance it is markedly undersized, and the subcutaneous fat is poorly developed or entirely lacking. In the living child the skin usually pre- sents a dry, drawn appearance, and has a peculiar grayish hue. It is very brittle, especially at the flexor surfaces of the joints, where abrasions readily occur and expose the underlying corium. The skin covering the soles of the feet and palms of the hands is often thickened and glistening, and suggests the condition observed in the hands of washerwomen. In other cases, characteristic pemphigoid vesicles are noted in the same locations. If intra-uterine death has occurred, the foetus rapidly undergoes maceration, the skin peeling off upon the slightest touch and exposing the underlying discolored corium. Although Grafenburg states that 80 per cent, of macerated children are syphilitic, maceration is by no means pathognomonic, since it occurs whenever a dead foetus is long retained in utero, no matter what the cause of death. The lesions in the internal organs consist essentially in interstitial changes in the lungs, liver, spleen, and pancreas, and osteochondritis in the long bones. It is generally stated that the lungs frequently contain gummatous nodules. These, however, were lacking in the specimens which I have 688 DISEASES AND ABNORMALITIES OF THE OVUM examined. Usually the lungs are enlarged, pale, and scarcely float when thrown into water. On microscopic examination the alveoli are found tilled with cast-off epithelial cells in all stages of fatty degeneration— catarrhal pneumonia, the pneumonia alba of Virchow. In other cases the lesion consists in an increase in the interstitial tissue associated with pronounced round-cell infiltration, by which the alveoli are compressed, but do not become quite impervious to air. These changes have been exhaustively studied by Heller. As the result of hypertrophic cirrhosis, the liver undergoes a marked increase in size, and, according to Huge, its weight may equal one tenth or even one eighth of that of the whole body, instead of one thirtieth, as usual. Under the microscope there is a marked increase in the con- nective tissue surrounding the individual lobules and acini, with here and there small areas of round-cell infiltration. Many authorities lay great stress upon the presence of so-called blood islands—dilated capil- laries containing red cells in all stages of development—but in my expe- rience the condition is not pathognomonic. The spleen likewise undergoes interstitial changes and increases markedly in size, so that it frequently weighs two or three times as much as usual, which, roughly speaking, is one three-hundredths of the body weight. The pancreas also presents interstitial changes, and is slightly larger than normal. Prior to the middle of pregnancy, Tissier and Girauld state that the Spirochasta pallida is rarely found, but after that period the foetus may be said to suffer from a spirochetal septicemia when the parasites may be demonstrated in large numbers in the various organs and blood. They are most abundant in the adrenals, where they are noted in 97.5 per cent, of all cases, according to Trinchese, and progressively less frequently in the following organs: lungs, pancreas, liver and internal genitalia. The recognition of the organic lesions requires some pathological experience, though if the liver and spleen of a macerated foetus are markedly increased in size and weight the diagnosis is practically as- sured. An equally characteristic sign, and one which is readily detected, is afforded by changes occurring at the junction of the epiphysis with the diaphysis in the long bones—Wegner’s bone disease. Normally the two are separated by a narrow, whitish, slightly curved line, 0.5 to 1 milli- meter in diameter—Guerin’s line—representing the zone of preliminary calcification, which constitutes the scaffolding upon which the new bone is developed. In syphilis, on the other hand, this becomes converted into an irregular, jagged, yellowish zone 2, 3, or more millimeters in thick- ness. In advanced cases this alteration is associated with considerable softening and the formation of a soft pultaceous material, which some- times leads to complete separation of the epiphysis (Figs. 501 and 502). Upon microscopical examination of the normal epiphysis, as shown in Fig. 503, the cartilage cells are found to be arranged in parallel col- umns at right angles to Guerin’s line, while below it is the typical bony structure of the diaphysis writh its marrow cavities. The line itself is DISEASES OF THE FCETUS 68? formed by a deposit of lime salts between the median ends of the rows of cartilage Cells, and is gradually invaded by the newly formed bone. In syphilis, as is illustrated in Fig. 504, the changes are due to an Fig. 501. Fig. 502. Figs. 501, 502.—Normal and Syphlitic Fcetal Epiphysis. X 2. osteochondritis, as the result of which there is no longer a sharply- marked zone of preliminary calcification between the cartilage and the growing bone; but areas of bone formation, calcification, and leukocytic and small-cell infiltration are found scattered irregularly through the lower portion of the epiphysis, giving an irregular appearance to this region. These changes, which have been carefully studied by Wegner, and K. Muller, are most readily recognizable at the lower end of the femur, and fairly well so at the lower ends of the tibia and radius. They are extremely characteristic, and their detection justifies one in making a positive diagnosis and plac- ing the mother under specific treatment. Alexander has shown that the osseous lesions are widely diffused, occurring at the epi- physes of all the long hones, as well as in the phalanges of the hands and feet. Since the demonstration by Shipley and Pearson that the changes can readily be recognized by means of the X-ray, we have utilized the procedure as an accessory means of diagnosis. Accordingly, we take X-ray pictures of all dead children as a matter of routine—partly for diagnostic purposes, but especially to permit com- parison between the X-ray and autopsy findings. Furthermore, they are Fig. 503.— Normal Fietal Epiphysis. X 60. 690 DISEASES AND ABNORMALITIES OF THE OVUM taken in the case of live children, whenever anything in the history sug- gests the possibility of the existence of syphilis. Three years’ experience has convinced me that the procedure consti- tutes a most valuable addition to our diagnostic equipment, and whenever lesions similar to those depicted in Fig. 505B are present that the diagnosis of syphilis is assured. Placental Syphilis.—Under the influence of syphilitic infection the platenta undergoes very characteristic changes. It becomes larger and paler in color, and often presents a dull, greasy appearance. It is always relatively, and frequently absolutely, increased in size, and, according to the researches of Schwab and Levy- Solal, which I have been able to confirm, instead of one sixth, it may represent as much as one fourth, or even a larger frac- tion, of the entire body weight of the foetus. Still more char- acteristic, however, are the changes in the chorionic villi, to which Frankel called attention in 1873. During the last 3 or 4 months of preg- nancy when syphi- litic placentae are teased out in salt solution, the villi are seen to have lost their characteristic arborescent appearance and to have become thicker and more club-shaped (Figs. 506 and 507). At the same time there is a marked decrease in the number of blood vessels, which in advanced cases have almost entirely disappeared. This results partly from endarteritic changes, but principally from a proliferation of the stroma cells, which lose their normal stellate appear- ance, becoming round or oval in shape, and closely packed together. The changes are still more characteristic when sections made from hardened specimens are studied. As will be seen on comparing Figs. 508 and 509, the individual villi are increased in size and almost devoid of blood vessels, while their stroma is made up of closely packed, round, or oval cells. This appearance is so characteristic as to enable one with a little practice to make a positive diagnosis. In my experience, which is based upon the histological examination of many thousand placentae, such lesions are always associated with the presence of typical organic changes in the foetus. On the other hand, it must be admitted that negative placental findings do not necessarily imply the absence of Fig. 504.—Syphilitic Fcetal Epiphysis. X 60. DISEASES OF THE FCETUS 691 syphilis in the child. Consequently, the diagnosis is assured if the find- ings are positive, while a negative result is of no diagnostic significance. The lesions just described afford a satisfactory explanation for the poor development of the foetus when born alive, and in association with the spirochetal septicemia and the organic involve- ment readily explain the frequency of a fatal issue. On the other hand, Mohn, and others be- lieve that the changes just described, while very suggestive, are not absolutely characteris- tic ; and hold that a positive diagnosis can- not be made unless the presence of the spiro- chetes can be demon- strated in the placenta. This has been attempted by many investigators, who have found that the spirochetes are so sparsely scattered through the organ that their recognition is most difficult, even when they are present in large numbers in the foetal organs. Trinchese states that they can always be found, if one is willing to study several hun- dred sections, but in my clinic Pauli and Em- mons were not so suc- cessful. In my experience the demonstration of a posi- tive maternal Wasser- mann by no means implies the existence of foetal syphilis, as in 169 women presenting a positive reaction, but not treated, who were studied in my report of 1920, only 48.5 per cent, had syphilitic children. Furthermore, a negative maternal Wassermann does not necessarily imply the absence of syphilis, and in the same report, it was stated that approximately every tenth syphilitic foetus was bom of a mother whose Wassermann was negative. Consequently, it is particularly in Fig. 505, A and B.—X-Rays of Leg of Normal and Syphlitic Foetus. X 3ds- A. Normal. B. Syphilitic. Note the broad bands, occupying the position of Guerin’s line. X %• 692 DISEASES AND ABNORMALITIES OF THE OVUM this type of case that the X-ray and the histological examination of the placenta give valuable information, more especially if an autopsy is not permitted. Observations of this character emphasize the impor- tance of not relying exclusively upon the outcome of the Wassermann reaction in the diagnosis of syphilis, and make it apparent that the utilization of this valuable diagnostic procedure cannot replace accurate clinical observation, as so many are inclined to believe. For many years, it was our practice to make a routine Wassermann test upon the blood of the foetus obtained from the umbilical cord, and positive results were obtained in about one per cent, of approximately 5,000 observations. Upon following such children during the first year Figs. 506, 507.—Normal and Syphilitic Chorionic Villi Teased Out in Sai.t Solu- tion, Slightly Magnified. Fig. 506. Fig. 507. of life, it was found that a considerable number, who presented a positive Wassermann at birth, subsequently showed a negative reaction and at no time developed clinical manifestations of syphilis; while, on the con- trary, in numerous other instances the original negative reaction sub- sequently became positive and was accompanied by signs of congenital disease. For these reasons, we have abandoned the practice, as the results obtained did not seem commensurate with the time or expense consumed. Fildes takes a similar view. Such a statement, however, should not be considered as in any way invalidating the usefulness of the routine maternal Wassermann, as it is only by its means, and the subsequent intensive treatment of the mothers presenting a positive reaction that we can expect to cope suc- cessfully with the problem of foetal and congenital syphilis. It is generally stated that distinct syphilitic lesions, varying from a marked thickening of the membrane to distinct gumma formation, are DISEASES OF THE FCETUS 693 frequently noted in the decidua. I be- lieve, however, that many of the condi- tions described as such have no con- nection with lues, but represent vari- o u s hyperplastic conditions. Zilles, and many of the earlier writers, described gummata occurring in the foetal portion of the placenta. I have never met with such lesions, and am of the opinion that careful histo- logical study will show that the struc- tures designated as such are merely infarcts in various stages of development or degen- eration. Bondi in 1903 directed attention to changes in the umbilical cord, which he considered very characteristic, and his findings have been confirmed by most subsequent writers. These oc- cur in the vessels, and consist in edema of their walls, and leukocy- tic infiltration of the spaces between the muscle fibers. Similar changes are noted in the adven- titia, while the in- tima is more or less thickened. Mohn stated that he was able to demonstrate the presence of spirochetes in 50 per cent, of his cases, but subsequent study has shown that he was in error. They are sometimes present in the foetal Fig. 508.—Normal Full-Term Placenta. X 50. Fig. 509.—Syphilitic Full-Term Placenta. X 50. 694 DISEASES AND ABNORMALITIES OF THE OVUM end, but only rarely in the rest of the cord. Trinchese in 100 cases found them in 18 instances in the former, but never in the latter location, and Emmons in my clinic had a similar experience. General Dropsy of the Foetus.—In this rare condition, which has been carefully studied by Ballantyne and Schumann, the foetus and placenta are markedly edematous. As the result of infiltration with serum the former may attain immense proportions and the latter be increased to three or four times its normal size. In a case under my observation the foetus, at the seventh month of pregnancy, weighed 1,140 and the placenta 1,200 grams. Cohn has described a placenta weighing 2,900 grams. Although a good deal has been written upon the subject, no satisfac- tory explanation of the anomaly has as yet been arrived at. Formerly it was supposed to result from edematous conditions of the mother, but the researches of Ballantyne have shown that this view does not always hold good, and that in the majority of the cases submitted to a thorough study lesions were noted in the organs of the foetus sufficient to explain the production of the condition. It is interesting to note that in several cases collected by Seifert it was attributed to foetal leukemia. The disease always leads to the death of the foetus, which in no instance survived its birth for more than a few hours. In the majority of cases on record labor was spontaneous, though occasionally the in- creased size of the foetus and the placenta may give rise to dystocia. Other Diseases of the Foetus.—In most text-books upon obstetrics numerous morbid conditions of the foetus are described under the head- ing Diseases of the Foetus. The majority of them, however, are of interest mainly from a pathological point of view, and have no obstetrical significance, except when they lead to an increase in the bulk of the foetus, which in turn may give rise to difficult labor. Accordingly, they will not be considered in this place, although certain of them will be referred to in the chapter upon Foetal Dystocia. LITERATURE Ackermann. Der weisse Infarct der Placenta. Archiv. f. path. Anat., 1884, xevi, 439-452. Zu,r. normalen u. path. Anat. der menschlichen Placenta. Virchow’s Festschrift, Berlin, 1891, 585-616. Ahleeld. Multiple Dermoidcysten des Amnion. Berichte u. Arbeiten, 1885, ii, 200-202. Die Verwachsungen des Amnion mit der Oberflache der Frucht. Berichte u. Arbeiten, 1887, iii, 158-165. Zerreissung der Nabelschnur eines reifen Kindes wahrend de,r Geburt. Zeitschr. f. Geb. u. Gyn., 1897, xxxvi, 467-472. Aiciiel. Ueber die Blasenmole, eine experimentelle Studie. Iiabilitationsschrift, Erlangen, 1901. Albert. Ueber Angiome der Placenta. Archiv f. Gyn., 1898, lvi, 144-159. Alexander. Die ostealen Veranderungen bei kongenitaler Syphilis. Leipzig, 1915. LITERATURE 695 BallaNTyNe. General Dropsy of the Fcetus. The Diseases of the Foetus, Edin- burgh, 1892, i, 102-164. Bar. Becherches pour servir a l’histoire de 1’hydramnios. These de Paris, 1881. Bardeleben. Geburt bei Amnionanomalien. Zeitschr. f. Geb. u. Gyn., 1905, lvi, 240-263. Birnbaum. Blasenmole bei eineni Zwillingsei. Monatsschr. f. Geb. u. Gyn., 1904, xix, 175-186. Boivin, Madame. Nouvelles recherches sur la nature, l’origine et le traitement de la mole vesiculaire. Paris, 1827. Bondi. Die syphilitischen Veranderungen der Nabelschnur. Archiv. f. Gyn., 1903, lxix, 223-246. Braun, G. Ligatur der Nabelschnur durch Amnionstrange. Zeitschr. d. Ges. f. Aertze zu Wien, 1854, ii, 192. Breslau und Eberth. Diffuses Myxom der Eihiiute. Virchow’s Archiv, 1867, xxxix, 191-192. Brickner. A New Symptom in the Diagnosis of Dystocia Due to a Short Umbili- cal Cord. Ainer. Jour. Obst., 1902, xlv, 512-521. Briggs. On the Belative Size of the Uterus in Cases of Hydatid Mole. Proc. Boy. Soc. Med., (Gyn. Sect.), 1912, v. 172-198. Briquel. Tumeurs du placenta et tumeurs placentaires. Paris, 1903. Budin. Note sur une tumeur du cordon ombilieal. Femmes en couches et nouveau- nes, 1897, 179-184. Cagny. Hemorhagies placentaires de l’albuminurie. - These de Paris, 1891. Cary. Beport of a Well Authenticated Case of Sarcoma of the Placenta. Am- J. Obst., 1914, lxix, 658-664. Chiari. The Belation of the Amnion to Human Malformations. Bull. Johns Hop- kins Hospital, 1911, xxii, 35-39. Clarke. Account of a Tumor found in the Substance of the Human Placenta. Philosophical Transactions, London, 1798. Clemenz. Kritische und historische Untersuchungen iiber die weissen Nekrosen der Placenta. Zeitschr. f. Geb. u. Gyn., 1922, lxxxiv, 758-770. Cohn. Ueber das Absterben des Fcetus bei Nephritis der Mutter. Zeitschr. f. Geb. u. Gyn., 1888, xiv, 596. Dienst. Ueber den Bau u. die Histogenese der Placentargeschwiilste. Zeitschr. f. Geb. u. Gyn., 1903, xlviii, 191-261. Dorland and Gerson. Cystic Disease of the Chorion. University Medical Maga- zine, May, 1896, 565-590. Durante. La mole hydatidiforme. Bull. Soc. d’obst. et de gynec. de Paris, 1907, x, 244-49. Dyhrenfurth. Inversio uteri bedingt durch zu kurzen Nabelstrang. Zentralbl. f. Gyn., 1885, ix, 801, 804. Eden. A Study of the Human Placenta. Jour. Path, and Bacteriology, 1897, v, 265-282. Ehrendorfer. Cysten und cystoide Bildungen der menschlichen Placenta. Wien, 1893. Emmons. The Diagnostic Value of the Search for Spirochaeta Pallida in the Umbilical Cord of the New-born. Boston Med. and Surg. Jour., 1910, clxii, 640-641. Essen-Moller. Studien iiber die Blasenmole. Wiesbaden, 1912. Fairbairn. Primary Chorio-Epithelioma of the Ovary. J. Obst. and Gyn. Brit. Emp., 1909, xvi, 1-8. Falgowski. Blasenmole bei Zwillungsschwangerschaft, etc. Monatsschr. f. Geb. u. Gyn., 1911, xxxii, 290-302. 696 DISEASES AND ABNORMALITIES OF THE OVUM Fehling. Ueber die physiologische Bedeutung des Fruchtwassers. Archiv f. Gyn., 1879, xiv, 221-244. Fildes. The Prevalence of Syphilis Amongst the Newly-born, etc. J. Obst. & Gyn. Brit. Emp., 1915, xxvii, 124-137. Findley. Hydatidiform Mole. Am. Jour. Med. Sci., 1903, cxxv, 486-519. Primary Chorio-epithelioma Malignum Outside of the Placental Site. Jour. Am. Med. Ass., 1904, xliii, 1351-1357. Fraenkel. Die Histologic der Blasenmole, etc. Archiv f. Gyn., 1895, xlix, 481- 507. Riickbildung von Ovarialtumoren nach Blasemole. Monatsschr. f. Geb. u. Gyn., 1910, xxxii, 180-185. Frank. Ohorion-epitheliomatous Proliferations in Teratomata. Jour. Am. Med. Ass., 1906, xlvi, 248, 343. Frankel. Ueber Verkalkungen der Placenta. Archiv f. Gyn., 1871, ii, 373-382. Ueber Placentarsyphilis. Archiv f. Gyn., 1873, v, 1-54. FranquB. Anat. und klin. Beobachtungen iiber Placentarerkrankungen. Zeitschr. f. Geb. u. Gyn., 1894, xxviii, 293-348. Ueber histologische Veranderungen in der Placenta rind ihre Beziehungen zum Tode der Frucht. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 277-298. Die Entstehung der velamentosen Insertion der Nabelschnur. Zeitschr. f. Geb. u. Gyn., 1900, xliii, 463-488. Gardiner. Labor Complicated by Short or Shortened Cord. Surg. Gyn. and Obst., 1922, xxxiv, 252-256. Gassner. Menge des Fruchtwassers. Monatsschr. f. Geburtsk., 1862, xix, 30-33. von Grafenberg. Observationes medical rariores. Frankfurt, 1565. Grafenberg. Der Einfluss von Syphilis auf die Nachkommenschaft. Archiv f. Gyn. 1908, Ixxxviii, 190-219. Haas. Beitrag zur Lehre von den Cysten der Nabelschnur. Beitrage zur Geb. u. Gyn., 1906, x, 483-507. Heller. Die Lungenerkrankungen bei angeborener Syphilis. Deutsches Archiv f. klin. Med., xliii, 159. Hense. Adharenz der Placenta. Zeitschr. f. Geb. u. Gyn., 1901, xlv, 272-279. Hermann. Ueber Verschlingungen der Nabelschniire bei Zwillingen. Archiv f. Gyn., 1891, xl, 253-260. Hormann. Ruptur eines Chorio-epithelioma mit schwerer intra-peritonealen Blu- tung. Beitrage zur Geb. u. Gyn., 1904, viii, 404-417. Zur Frage der Bosartigkeit und iiber Spontan-heilungen von Chorio-epitheliomen. Beitrage zur Geb. u. Gyn., 1904, viii, 418-447. Hubl. Ueber das Chorio-epitheliom in der Vagina bei sonst gesunden Genitalien. Wien. 1903. Hyrtl. Die Blutgefasse der menschlichen Nachgeburt. Wien, 1870. Jaggard. Note on Oligohydramnion. Amer. Jour. Obst., 1894, xxix, 432-446. Jarotsky und Waldeyer. Traubenmole in Verbindung mit dem Uterus, etc. Virchow’s Archiv, 1867, xli, 528-534. De Jong. Ueber das Entstehung von Cysten in der Placenta. Monatsschr. f. Geb. u. Gyn., 1900, xi, 1072-1092. Jungbluth. Zur Lehre vom Fruchtwasser. Archiv f. Gyn., 1872, iv, 554-557. Kaltenbach. Zu kurze Nabelschnur. Lehrbueh der Geb., 1893, 316. Kehrer. Ueber Traubenmolen. Archiv f. Gyn., 1894, xlv, 478-505. Kermauner. Zur Lehre von der Entwickelung der Cysten u. der Infarcte in der menschlichen Placenta. Zeitschr. f. Heilkunde, 1900, xxi, 1-36. Kleinwachter. Ein Beitrag zur Anatomie des Ductus omphalo-mesentericus. Archiv f. Gyn., 1876, x, 238-247. LITERATURE 697 Klotz. Ein Fall von primaren Chorioepitheliom des Ovariums. Beitrage zur Geb. u. Gyn., 1912, xvii, 369-373. Kossmann. Zur Geschichte der Traubenmole. Archiv f. Gyn., 1900, lxii, 153-169. Krieger. Fall von interstitiellen Molenbildung. Berliner Beitrage zur Geb. u. Gyn., 1872, i, 10-15. Krosing. Das Chorio-epitheliom mit langer Latenzzeit. Arcliiv f. Gyn., 1909, lxxxviii, 469-505. Kustner. Ueber eine noch nicht bekannte Entstehungsursache amputirender amniotischer Faden u. Strange. Zeitschr. f. Geb. u, Gyn., xx, 445-458. Larrier et Brindeau. Nature de la mole hydatidiforme. Bevue de Gyn., 1908, xii, 203-214. Lebedeff. Quelques donnees sur la fonction physiologique de 1’amnios. Annales de gyn. et d’obst., 1878, ix, 241-251. LefSvre. De 1’insertion velamenteuse du cordon. These de Paris, 1896. Levison. Fruchtwasser und Hydramnios. Archiv f. Gyn., 1876, ix, 517-519. Levy. Bapports existant entre le poids du foetus et celui du placenta. These de Paris, 1900. Levy-Solal. Contribution a 1’etude des rapports de la syphilis et de 1’hyper- trophic placentale. Gyn. et Obst., 1921, iv, 94-118. Lukens. Hydatidiform Mole Associated with Normal Ovum, etc. Proc. Boy. Soc. of Med., (Gyn. Sect.), 1914, vii, 113. McNalley and Dieckmann. Hemorrhagic Lesions of Placenta and Their Bela- tions to White Infarct Formation. Am. Jour. Obst. and Gyn., 1923, v, 55-56. Marchaxd. Ueber die sogenannten ‘ ‘ decidualen ” Geschwiilste, etc. Monatsschr. f. Geb. u. Gyn., 1895, i, 419-438; 513-560. Ueber den Bau der Blasenmole. Zeitschr. f. Geb. u. Gyn., 1895, xxxii, 405-472. Die Blasenmole. Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 206-216. Ueber das maligne Chorionepitheliom, nebst Mittheilung 2 neuen Falle. Zeitschr. f. Geb. u. Gyn., 1898, xxxix, 173-258. Martin. De 1 ’influence des alterations du placenta sur le developpement du foetus. These de Paris, 1896. Meyer. Teratom der Nabelschnur. Yerh. d. deutschen path. Gesellsch., 1914, 582-583. Hydatidiform degeneration. Am. J. Obst. 1918, lxxviii, 641-668. Mohn. Die Veranderungen an der Placenta, bei Syphilis u. ihre Beziehungen zur Spirochoeta pallida. Zeitsch. f. Geb. u. Gyn., 1907, lix, 263-312. Montgomery. On the Spontaneous Amputation of the Foetal Limbs in Utero. An Exposition of the Signs and Symptoms of Pregnancy. 2d ed. (reprinted), 1863, 625-695. Muller, B. Beitrag zur path. Anatomie der Syphilis hereditaria. Virchow’s Archiv, 1883, xcii, 523-556. Nebesky. Beitrag sur Kenntniss der Chorioangiome. Monatsschr. f. Geb. u. Gyn., 1914, xl, 42-52. Neumann. Beitrag zur Lehre von der Anwachsung der Placenta. Monatsschr. f. Geb. u. Gyn., 1896, iv, 307-318. Beitrag zur Kenntniss der Blasenmole, etc. Monatsschr. f. Geb. u. Gyn., 1897, vi, 17-36; 157-177. Nieberding. Zur Genese des Hydramnios. Archiv f. Gyn., 1882, xx, 310-316. Opitz. Beitrage zur Aetiologie des Hydramnios. Zentralbl. f. Gyn., 1898, 553- 560. Orth. Infarct der Placenta. Lehrbuch der spec. path. Anat., 1893, ii, 603-607. Ottow. Interpositio velamentosa funiculi umbilicalis, etc. Archiv f. Gyn., 1922, cxvi, 176-199. DISEASES AND ABNORMALITIES OF THE OVUM 698 Ouvry. £tude de la mole hydatidiforme. These de Paris, 1897. Pauli. Placental Syphilis, etc. Bull. Johns Hopkins Hospital, 1908, xix, 326-28. Peiser. Verblutungstod der Frucht in folge Ruptur eine.r Umbilicalarterie bei Insertio velamentosa. Monatsschr. f. Geb. u. Gyn., 1898, viii, 619-624. Beitrag zur Pathologie der Placenta. Monatsschr. f. Geb. u. Gyn., 1899, x, 613-626. Percy. Memoire sur' les hydatides uterines, etc. Jour, de med., chir. et pharm., Paris, 1811, p. 171. Pick, Yon der gut- und bos-artig metastasirenden Blasenmole. Berliner klin. Wochenschr., 1897, xxxiv, 1069-1073; 1097-1102. Pitha. Des tumeurs du placenta. Annales de gyn. et d ’obst., 1906, 2me Ser., iii, 232-239, 268-280, et 360-369. Poten. Die Verschleppung der Chorionzotten. Archiv f. Gyn., 1902, Ixvi, 590-617. Poten und Vassmer. Beginnendes Syncytiom mit Metastasen, beobachtet bei Blasenmolenschwangerschaft. Archiv f. Gyn., 1900, lxi, 205-276. Ribemont-Dessaignes. Des placentas multiples dans les grossesses simples. An- nales de gyn. et d’obst., 1887, xxvii, 15-52. Ries. Chorionic Villi in the Uterine Wall 18 Years After the Last Pregnancy. Am. J. Obst., 1913, lxvii, 433-443. Risel. Ueber das maligne Chorion-epitheliom, etc. Leipzig, 1903. Das Chorio-epitheliom. Ergebnisse der allg. Path, und path. Anat., 1907. Zur Frage d. sogenanten primaren Chorioepithelioms des Ovariums. Verh. d. deutschen path. Gesellsch., 1914, 384-432. Rossier. Klin. und. histolog. Untersuchungen iiber die Infarcte der Placenta. Archiv f. Gyn., 1888, xxxiii, 400-412. Ruge. Ueber den Foetus sanguinolentus. Zeitschr. f. Geb. u. Gyn., 1877, i, 57-119. Runge. Ueber die Veranderungen der Ovarien bei syncytialen Tumoren und Blasenmole, etc. Archiv f. Gyn., 1903, lxix, 33-70. Sallinger. Ueber Hydramnios, etc. D. I., Zurich, 1875. Sanger. Deciduoma malignum. Yerh. d. deutschen Gesellsch. f. Gyn., 1892, iv, 333. Sarcoma uteri deciduo-cellulare, etc. Archiv f. Gyn., 1893, xlix, 89-149. Santi. Zur Riickbildung der Luteinkystome nach Blasenmole. Zeitschr. f. Geb. u. Gyn., 1910, lxvii, 667-685. Schatz. Eine besondere Art von einseitiger Polyhydramnie, etc. Archiv f. Gyn., 1882, xix, 329-369. Schauta. Zur Lehre von der Torsion der Nabelschnur. Archiv f. Gyn., 1881, xvii, 19-23. Scheib. Organveranderungen der polyhydramniotischen eineiigen Zwillinge. Chiari’s Festschrift, 1909, 51-78. Schickele. Die Chorionektodermwucherungen der menschlichen Placenta. Beitrage zur Geb. u. Gyn., 1905, x, 63-114. Schlagenhaufer. Zwei Falle von Tumoren des Chorionepithels. "Weiner klin. Wochenschr., 1899, Nr. 18. Ueber das Vorkommen chorionepitheliom- und traubenmolen-artigen Wucherun- gen in Teratomen. Wiener klin. Wochenschr., 1902, Nos. 22 and 23. Schmidt. Ein neuer Fall von primaren Chorio-epitheliom der Scheide. Zentralbl. f. Gyn., 1901, xxv, 1350. Schmorl. Demonstration eines syncytialen Scheidentumors. Zentralbl. f. Gyn., 1897, xxi, 1217. Schultze. Die genetische Bedeutung der velamentalen Insertion des Nabel- stranges. Jenaische Zeitschr. f. Med. u. Naturwiss., 1867, iii, 198, LITERATURE 699 Ueber velementale u. placentale Insertion der Nabelschnur. Archiv f. Gyn., 1887, xxx, 47-56. Schumann. A Study of Hydrops Universalis Fetus. Trans. Am. Gyn. Soc., 1915, xl, 12-32. Observations upon the Pathology and Treatment of Hydatidiform Mole. Trans. Am. Gyn. Soc., 1922, xlvii, 193-201. Schwab. De la syphilis du placenta. These de Paris, 1896. Schweitzer. Das pathologische Tiefenwachstum der Plazenta, etc. Archiv f. Gyn. 1918, cix, 618-668. Seitz. Die Luteinzellenwucherung in atretischen Follikeln. Zentralbl. f. Gyn., 1905, xxix, 257-263. Ueber das primare Chorioepitheliom des Ovariums. Zeitschr. f. Geb. u. Gyn., 1915, lxxviii, 244-259. Senge. Secundare Carcinosis der Placenta bei primarem Magencarcinom. Beit, z. path. Anat. u. z. allg. Path., 1912, liii, H. 3. Sfameni. Die Placenta marginata. Berlin, 1908. Shipley and Pearson. X-ray Pictures of the Bones in the Diagnosis of Syphilis in the Fcetus and Young Infant. Bull. Johns Hopkins Hosp., 1921, xxxii, 75-78. Simonart. Note sur les amputations spontanees. Archives de medecine Beige, 1845, xviii, 112-119. Slemons. Placental Bacteremia. J. Am. Med. Assn., 1915, lxv, 1265-68. Stoeckel. Ueber die cystiche Degeneration der Ovarien bei Blasenmolen. Beitrage zur Geb. u. Gyn., Festschrifts dem Prof. Fritsch. Leipzig, 1902, 136-164. Strassmann. Oligo- und Polyhydramnie. WinckeUs Handbuch der Geb., 1904, i, 2 Halfte, 797-812. Sunde. Chorioepithelioma malignum. Acta Gyn. Scandinavica, 1921, i, 16-60. Teacher. On Chorionepithelioma, etc. Trans. London Obst. Soc., 1903, xiv, 256-302. Tissier et Girauld. Syphilis congenitale. Bull. Soc. d’obst. de Paris, 1908, No. 1. Trinciiese. Bakteriologische u. histologische Untersuchungen bei kongenitaler Lues. Miinchener med. Wochenschr., 1910, lvii, 570-574. Ueber den Zeitpunkt der luetischen Infektion des Foetus. Beitrage z. Geb. u. Gyn., 1913, xviii, 201-224. Vassmer. Zur iEtiologie der Placentarcysten. Archiv f. Gyn., 1902, Ixvi, 49-69. Veit. Ueber Deportation vom Chorionzotten. Zeitschr. f. Geb. u. Gyn., 1901, xliv, 466-504. Velpeau. Quoted by Virchow. Vineberg. Clinical Data on Chorioepithelioma, with End-results of Operative Treatment. Surg. Gyn. & Obst., 1919, xxviii, 123-137. Virchow. Myxom der Placenta. Die krankhaften Geschwiilste, 1863, i, 405-414. Myxoma fibrosum placentae. Die krankhaften Geschwiilste, 1863, i, 415. Volkmann. Ein Fall von interstitieller Molenbildung. Virchow’s Archiv, 1867, xli, 528-534. Wallart. Ueber die Ovarialveriinderungen bei Blasenmole, etc. Zeitschr. f, Geb. u. Gyn., 1904, liii, 36-75. Walz. Ueber Placentartumoren. Verh. d. deutschen path. Gesellschaft, 1907, x, 279-282. Wegner. Ueber hereditare Knochensyphilis bei jungen KinJern. Virchow’s Archiv, 1870, I, 305-323. Werth. Einseitiges Hydramnion mit Oligohydramnie der zweiten Trucht. Archiv f. Gyn., 1882, xx, 353-377. 700 DISEASES AND ABNORMALITIES OF THE OVUM Williams. Deciduoma malignum. Johns Hopkins Hosp. Reports, 1895, iy, No. 9. The Frequency and Significance of Infarcts of the Placenta. Amer. Jour. Obst., 1900, xli, 775-801. The Limitations and Possibilities of Prenatal Care. J. Am. Med. Assn., 1915, lxiv, 95-101. An Early Ovum in situ in the Act of Aborting. Am. J. Obst., 1919, lxxx, 269-283. The Significance of Syphilis in Prenatal Care and in the Causation of Foetal Death. Bull. Johns Hopkins Hosp., 1920, xxxi, 141-145. The Value of the Wassermann reaction in Obstetrics, Based upon the Study of 4,547 Consecutive Cases. Bull. Johns Hopkins Hosp., 1920, xxxi, 335-342. The Influence of the Treatment of Syphilitic Pregnant Women upon the Incidence of Congenital Syphilis. Bull. Johns Hopkins Hosp., 1922, xxxiii, 383-386. Williamson. The Pathology and Symptoms of Hydatidiform Degeneration of the Chorion. Trans. London Obst. Soc., 1900, xli, 303-338. Wilson. Hydramnion in Cases of Uhiovial or Homologous Twins. Trans. Lond. Obst. Soc., 1899, xli, 235-272. Wilton. Hydatids, terminating Fatally by Hajmorrhage. Lancet, 1840, i, 691- 693. Winckel. Teleangiektatisches Myxosarkom der Nabelschnur. Zentralbl. f. Gyn., 1894, xviii, 397. Wlassow. Ueber die Patho- und Histo-genese des sogenannten Sarcoma angio- plastique. Virchow’s Archiv, 1902, clxix, 220. Woerz. Ein Fall von Hydramnios. Zentralbl. f. Gyn., 1895, xix, 580-581. Wolff. Ueber exp. Erzeugung von Hydramnion. Archiv f. Gyn., 1904, lxxi, 224- 257. Fruchtwasser. Handbueh d. Bioehemie, 1910, iii, 709-741. Young. Aetiology of Eclampsia and Albuminuria. J. Obst. and Gyn. Brit. Emp., 1914, xxvi, 1-29. Zilles. Studien fiber Erkrankungen der Placenta bedingt durch Syphilis. Tu- bingen, 1885. CHAPTER XXIX ABORTION, MISCARRIAGE, AND PREMATURE LABOR Spontaneous expulsion of the ovum may occur at any period of preg- nancy, and is variously designated according to the degree of develop- ment which the product of conception has attained. Strictly speaking, one should distinguish between abortion, miscarriage, or premature labor, respectively, accordingly as the pregnancy terminates before the sixteenth week, between the sixteenth and twenty-eighth week, or at a later period. Prior to the sixteenth week, owing to the imperfect development of the placenta, the entire ovum often comes away intact. From that time on, however, the placenta forms a definite organ and the expulsion of an intact ovum is exceptional, the foetus, as a rule, being extruded first, and followed after a longer or shorter period by the placenta and mem- branes. After the twenty-eighth week the course of labor differs but little from that observed at full term, and the child, if properly cared for, may survive; its chances of so doing increasing in almost geo- metrical proportion with every additional week. As the term abortion is somewhat suggestive of a criminal procedure, it is rarely employed in popular parlance, all cases terminating prior to the period of viability being designated as miscarriages. Among medical men, on the other hand, the latter term is but little used, and it is customary to speak of all cases ending before the twenty-eighth week as abortions. Abortion: Frequency.—It is difficult to arrive at accurate conclusions concerning the frequency with which spontaneous abortion occurs. Ke- liable vital statistics are not yet available in America, and, inasmuch as only women who are more or less seriously ill following abortions enter hospitals for treatment, the statistics based upon their records would give too low' an estimate—in my service about 6 per cent, of all patients. On the other hand, sufficiently large series from private prac- tice are not available; though Malins found that 19.23 per cent, of the pregnancies of 2,000 patients ended in abortion. A conservative estimate would indicate that about every fifth or sixth pregnancy in private prac- tice ends in spontaneous abortion, and the percentage would be increased considerably were the very early cases taken into account, in which a pro- fuse loss of blood follows the retardation of the menstrual period for a few weeks. Taussig estimates that one abortion occurs to every 2.3 labors, and considers that considerably over one quarter are criminally induced. It is difficult to give accurate figures concerning the fre- quency of the latter, but it is generally admitted that the induction of criminal abortion is practiced with increasing frequency in all strata of 701 702 ABORTION, MISCARRIAGE, AND PREMATURE LABOR society. Following the World War the increase has become alarming, and Schottelius states that official figures indicate that in Hamburg dur- ing the year 1919, 52 per cent, as many abortions occurred as full term deliveries. Etiology.—In the early months of pregnancy spontaneous expulsion of the ovum is nearly always preceded by the death of the foetus. For this reason, the consideration of the etiology of early abortion prac- tically resolves itself into determining the cause of foetal death. In the later months, on the other hand, the foetus is frequently born alive, and other factors must be invoked to explain its expulsion. Foetal death may be due to abnormalities occurring in the ovum itself, to abnormali- ties of the generative tract, or to systemic disease on the part of the mother, and now and again of the father. (a) One of the most usual causes' for the death of the foetus is to be found in abnormalities of development, which are inconsistent with life. The investigations of Mall indicate that such conditions are present in one-third of all early abortions, and would have resulted in monstrosities had pregnancy continued. We are as yet completely ignorant concerning the causation of such abnormalities in human beings, but reasoning from the results obtained in experimental teratology, it would seem probable that two main sets of factors are concerned:—abnormalities in the earliest stages of segmentation of the ovum, and changes in its environment. Stockard and others have shown that temporary reduction in the supply of oxygen or radical changes in temperature may lead to the death of the ovum or to such retardation of growth as to lead to the production of monstrosities. At a somewhat later period foetal death may result from changes in the appendages of the ovum, such as excessive torsion of the cord, hydramnios or hydatiform mole. In the last-named affec- tion the nutritive material conveyed to the intervillous spaces by the maternal blood merely suffices to nourish the hypertrophic villi, little or none remaining to be transmitted to the child. Figure 510 is a diagrammatic reconstruction of an early ovum in the act of aborting. The specimen was discovered accidentally in a uterus removed 38 days after the onset of the last menstrual period. Although no symptoms of impending abortion were observed, it was clearly in- evitable, as one pole of the ovum was emerging through the ruptured decidua capsularis. The process must be regarded as conservative, as the ovum was hopelessly abnormal, no trace of an embryo being discover- able in the celomic cavity, while some of the villi nresented the changes characteristic of hydatiform mole. Still later in pregnancy, certain diseases and abnormalities of the placenta may lead to the same result. Thus, Merttens and Franque have described an obliterating endarteritis in the vessels of the chorionic villi, independent of syphilis, which interferes with the foetal circulation to such an extent as to be incompatible with life. In other cases, the abundant formation of red or white infarcts may throw so large a portion of the placenta out of function that the remainder is not sufficient to supply the needs of the foetus.. Furthermore, such abnormalities as pla- centa previa, low implantation of the placenta, or velamentous insertion ETIOLOGY 703 of the cord, as well as premature separation of the placenta, may like- wise bring about circulatory conditions inconsistent with foetal life. Syphilis is usually mentioned as one of the most frequent factors concerned in the production of abortion. In my experience, it plays but little part during the first half of pregnancy, but, on the other hand, it constitutes the most important single factor in the etiology of prema- ture labor. Support is lent to this view by the fact that no one as yet has been able to demonstrate the presence of spirochetes in the tissues of foetuses expelled by syphilitic mothers during the first half of pregnancy, but all observers agree that they can be found with increasing frequency in each successive month of the second half. Diseases of the maternal kidneys, heart, liver and lungs are rarely concerned in producing abortion, but, as will be indicated in a later sec- tion, they play a prominent part in the causation of premature labor. (b) As was pointed out in the chapter upon the Accidental Com- Fig. 510.—Diagram Showing an Ovum in the Act of Aborting, 38 Days from Onset of Last Menstrual Period. The Free Pole is Emerging through the Rup- tured Decidua Capsularis, while the Other Pole is Still in Connection with the Decidua. D. C., Decidua Capsularis. D. V., Decidua Vera. plications of Pregnancy, all acute infectious diseases have a tendency to bring about the death of the child and its subsequent expulsion from the uterus. The fatal result is usually due to the transmission of toxins, and occasionally of the specific microorganisms from the mother to the child. Poisoning with phosphorus, lead, illuminating gas, and other substances may lead to similar results. Foetal death is sometimes attributable to malnutrition on the part of the mother, although this is very exceptional. On the other hand, it is not unusual for women suffering from wasting diseases to give birth to fully developed children. (c) Generally speaking, abnormalities in the generative tract play a most important part in the etiology of abortion. Thus, developmental anomalies of the uterus, or imperfect development of the normally formed organ, may be responsible for conditions which are unfavorable for the implantation of the ovum and later for the development of the placental circulation. Chronic metritis is supposed to act in the same way. Dense adhesions about the tubes and ovaries, resulting from in- 704 ABORTION, MISCARRIAGE, AND PREMATURE LABOR flammatory processes, only rarely interfere with the expansion of the uterus sufficiently to give rise to abortion, since in most cases the bands of adhesions gradually stretch and become elongated. Displacements of the uterus, more particularly retroflexion and pro- lapse, are justly considered as very important factors in the causation of abortion. As a rule, the interruption of pregnancy is due less to the abnormal position of the uterus than to lesions of its lining membrane resulting from circulatory changes incident to it. In the rare cases of incarceration, however, the accident must be attributed to pressure ex- erted by the surrounding parts upon the abnormally placed organ. The most important condition of the generative tract leading to the production of abortion is afforded by diseases and abnormalities of the decidua. In the hypertrophic form of decidual endometritis—decidua polyposa—the bulk of the maternal blood brought to the uterus goes to nourish the hyperplastic decidua, while in the atrophic forms the con- ditions are unfavorable for the implantation of the ovum and the de- velopment of the placenta. More important still is the part played by chronic glandular hyperplasia and acute inflammation of the decidua. These lesions are frequently accompanied by hemorrhagic changes, and, excepting the ill-defined conditions which are responsible for defective development of the foetus, are the most frequent causes of abortion in the early months. Histological examination demonstrated the presence of acute or chronic decidual endometritis in 70 per cent, of my speci- mens, but in many instances it was impossible to determine whether it was the primary cause, or merely an accidental complication. The occur- rence of abortion associated with the presence of myomata in the walls of the uterus must be attributed less to the mechanical effect of the tumor itself than to changes in the decidua incident to it. (d) In a few cases the cause of abortion is to be sought for in reflex influences, which take their origin from lesions of the generative tract or from irritative conditions about the breasts. In very rare instances the accident is attributed to intense mental emotions—anger, fright, or grief. It is customary to distinguish between predisposing and exciting causes of abortion. The various factors to which allusion has just been made predispose to abortion, while the exciting cause is often of a mechanical nature, such as a slight fall, jar, or overexertion. The state- ments of the patient concerning the latter, however, must be received with caution, as in many cases they are merely incidental and have no connection with the actual cause. At the same time, it must be admitted that the apparently healthy uterus sometimes possesses an abnormal degree of irritability, and will react to stimuli which ordinarily would be without effect. In such women the slightest violence, such as coitus, a simple bimanual examination, a misstep, tripping over a carpet, or a ride over a rough road, may bring on an abortion; while in others the most violent exercise and the rudest manipulations may be borne with impunity. For example, every physician can recall cases in which a sound has been introduced into the pregnant uterus without ill effects, and it is well known that, in the later months, the repeated introduction of a ETIOLOGY 705 large bougie, or even of a Champetier de Kibes balloon, may fail to bring about satisfactory uterine contractions. (e) Formerly, syphilis was mentioned as the chief paternal cause of abortion. As has already been indicated, this disease plays little or no part in the interruption of pregnancy during its first half. On the other hand, evidence is accumulating that excessive and long continued use of alcohol, lead intoxication, and other forms of chronic poisoning may so affect the vitality of the spermatozoa that, although the process of fertilization may proceed normally, the product of conception is incapable of continued normal development. It is not unusual to meet with women who give a history of repeated abortion occurring at about the same time in a number of successive pregnancies. In many such cases careful examination will demonstrate the existence of an endometritis or a uterine displacement; and it is only after the cure of the underlying condition that subsequent preg- nancies can be expected to progress to full term. In other instances no such lesions exist, nor will the most extended clinical study give a clue to the cause, and consequently the treatment of such patients is empirical and altogether unscientific. At present there is a tendency to regard repeated abortion as a manifestation of abnormal function pf certain of the ductless glands, but as yet satisfactory evidence has not been adduced in support of such a view. ' y The experimental work of Keynolds and Macomber upon the effect of dietary factors in the causation of sterility, as well as the experience of animal breeders, suggests the possibility that the prolonged use of defective diet, while not interfering with fertility, may so affect that vitality of the germ cells that the product of conception, will be able to attain only a certain stage of development before succumbing. With this idea in mind, it might be well in suitable cases to make inquiries con- cerning the dietetic habits of the patient and her husband. After Bang, McFadyen, Theobald Smith and others had directed attention to the epidemic form of abortion which occurs in cattle, and had shown that it is due to one of several specific microorganisms—the bacillus abortus of Bang and the vibrio foetus of Smith—and that healthy animals can be infected by their inoculation into the generative tract, it was suggested that repeated abortions in women might be susceptible of a similar explanation. Such a view was soon abandoned for two reasons: First, that there is no similarity between the conditions in cows and women; for in the former the infection almost invariably leads to permanent sterility, to which is due the great economic loss associated with the disease; while in women the possibility of conception is in no w*ay affected, but each succeeding pregnancy ends in abortion at about the same period as its predecessor. In the second place, there is no evi- dence of the infectious nature of repeated abortions in women, nor of the transfer of the disease from one individual to another. Further- more, bacteriological examination has failed to reveal the presence of analogous microoorganisms, and while bacteria are frequently found in the uterus of such patients they are simply the well known pyogenic or putrefactive varieties. Complement-fixation tests carried out by Wil- 706 ABORTION, MISCARRIAGE, AND PREMATURE LABOR liams and Kolmer have likewise failed to show that the bacillus abortus plays any part in the causation of abortion in women. Those interested in further details concerning infectious abortion in cattle are referred to the several publications of Theobald Smith, and to W. L. Williams’ text-book upon veterinary obstetrics. Pathology.—In spontaneous abortion, the immediate cause of the expulsion of the ovum is to be found in hemorrhagic changes in the decidua. Concerning their mode of production we must confess a pro- found ignorance, except when endometritis is the underlying cause. These changes, which are most marked in the decidua basalis, are fol- lowed by degeneration of the affected tissues, as the result of which the attachment of the ovum becomes more or less loosened, and the product of conception comes to act as a foreign body, and in turn gives rise to uterine contractions, which, after a longer or shorter period, finally lead to it.j expulsion. Especially in the early months, the entire ovum may be expelled after a few premonitory symptoms, and frequently the entire decidual lining of the uterine cavity is cast off with it. In such cases a triangular sac comes away which represents the decidua vera, which contains in its interior the vesicular ovum, covered by the decidua capsularis. More frequently, however, the decidua vera remains in utero, while the ovum, surrounded by the decidua capsularis, is expelled. Occasionally the latter is torn through, and, together with the decidua vera and basalis, is retained in utero, while a shaggy, more or less spherical structure is cast off—the ovum sur- rounded by the chorionic villi. As pregnancy advances, the expulsion of the entire ovum is observed less frequently, so that after the fourth month it is the rule for the membranes to rupture and the foetus to be expelled by itself, to be followed spontaneously, or not, by the placenta and membranes. In many early abortions, the expelled ovum is a thin-walled cystic structure, filled with clear fluid and containing a minute degenerated embryo, or only a remnant of the umbilical cord. This condition rep- resents an early stage of hydramnios, and corresponds to the dropsical or blighted ovum of the early writers. In many instances, the process of abortion occurs very slowly, so that the blood poured out between the periphery of the ovum and the decidua has an opportunity to coagulate. Under such conditions, the ovum on its expulsion is surrounded by a capsule of clotted blood of varying thickness with degenerated chorionic villi scattered through it. In its interior is a small cavity filled with clear fluid and lined by a thin, glistening membrane (the amnion), from one point of which hangs the Fig. 511.—Early Abor- tion, Showing De- cidua Reflexa and Serotina with De- generate Embryo. X 1. ETIOLOGY 707 umbilical cord and the degenerated foetus. Such structures are classified as blood or carneous moles, according to their appearance. In the former the capsule of coagulated blood is red in color, while in the latter it pre- sents a paler appearance, the result of fibrin formation (Fig. 512). Now and then, the interior of such structures, instead of being lined by the smooth amnion, may present an irregular nodular appearance, which is due to the formation of hematomata of varying size beneath the amnion and chorionic membrane. This condition, to which Granville applied the term ovum tuberculosum, has been more par- ticularly studied by Breus who desig- nated it as tuberous subchorial hema- toma of the decidua (Fig. 513) ; while Berry Hart, and Taussig described the condition as hematoma mole, or tub- erous fleshy mole, respectively. Breus believed that the tuberous appearance was the result of hemorrhage into col- lapsed folds of the amnion, while Gottschalk, Walther, Hart, and others considered that the hemorrhage was the primary factor. Davidsohn and Taussig take the view that the disproportion between the size of the foetus and the ovum is the result of hydramnios, and after the death of the former the amniotic fluid is gradually absorbed, when the redundant amnion is thrown into folds, the blood being effused into their in- terior. In all uterine moles the foetus is either lacking or is relatively smaller in size than would naturally correspond with the menstrual history. This fact indicates that the process is of gradual formation, and that a con- siderable period has elapsed between the death of the foetus and the expulsion of the ovum. Not uncommonly, indeed, the foetus may undergo complete dissolution, or be represented merely by a stub of umbilical cord hanging from the interior of the ovum. In the former event, after resorption of the amniotic fluid, the ovum may be represented by a solid mass of varying size, composed of the collapsed amniotic cavity and of chorionic villi embedded in coagulated Flood. Dissolution of the dead foetus is possible only in the early weeks Of pregnancy, and cannot occur after it has attained any considerable pro- portions. In the latter class of cases the retained foetus may undergo maceration. In such circumstances, the bones of the skull collapse, the abdomen becomes distended with a blood-stained fluid, and the entire foetus takes on a dull reddish color due to staining with blood pigment. At the same time the skin softens and peels off at the slightest touch, leaving behind the bright-red corium. The internal organs degenerate, and become soft and friable, losing their capacity for taking up the usual Fig. 512.—Section through Blood Mole. X 1. 708 ABORTION, MISCARRIAGE, AND PREMATURE LABOR histological stains. In rarer instances the foetus becomes compressed and takes on a dry, parchmentlike appearance, known as mummification. Although this condition is rarely observed in ordinary abortion, it is noted with comparative frequency in twin pregnancies, when one foetus has died at an early period while the other has gone on to full development—foetus papyraceus. In very exceptional instances, the foetus may be retained in utero for a long period, until the deposition of lime salts upon it converts it into what is known as a lithopedion. This phenomenon, though ex- Fro. 513.—Tuberous Subchorial Hematoma (Breus). X 1. tremely rare in uterine pregnancy in human beings, is relatively common in the lower animals. In extra-uterine gestation, on the other hand, it is not of unusual occurrence. Clinical History.—The onset of abortion is usually preceded by cer- tain premonitory symptoms, the most important of which are hemor- rhage and pain in the back and lower abdomen. Loss of blood, no matter how slight, in the early months of pregnancy, should always be regarded with suspicion, for, if it be not a premonitory symptom of abortion, it usually indicates the existence of a decidual endometritis, or an abnormal implantation of the placenta. When due to the former, the discharge CLINICAL HISTORY 709 is usually not very profuse, and is of a dirty brown or brownish-red color, while when due to the latter it is apt to be more profuse and dis- tinctly bloody in character. The premonitory bleeding may persist for weeks, or be promptly followed by the expulsion of the ovum. Indeed, in some cases the latter event may occur so rapidly as to surprise the patient. When a patient in the first months of pregnancy begins to lose blood, and the flow is associated with pain in the lower abdomen and back, an abortion is threatened. It, however, does not become imminent unless the hemorrhage be profuse or the cervix considerably dilated; even in the latter event it is not impossible for the disturbance to subside, and for pregnancy to go on without interruption. On the other hand, rupture of the membranes and escape of the liquor amnii indicate that abortion is inevitable. When abortion becomes imminent, the hemorrhage is usually quite profuse, though as a rule not sufficient to endanger the life of the woman. At the same time she experiences severe cramplike pains in the abdomen due to the uterine contractions, which later become distinctly bearing-down in character. After the cervix has become sufficiently dilated, the detached ovum may be expelled intact from the uterus, and when not retained in the vagina comes away spontaneously. This is known as complete abortion. More frequently, on the other hand, after rupture of the membranes and the escape of the amniotic fluid, the foetus alone is expelled, while the placenta and membranes remain in the uterus—incomplete abortion. In such cases the hemorrhage usually persists until the retained struc- tures are extruded spontaneously or are removed artificially, though the pains usually cease with the expulsion of the foetus. After the uterus has rid itself of the product of conception, the hemorrhage and pain cease, and a process of involution begins, identical with that observed after full-term labor. In my experience spontaneous complete abortion occurs most frequently during the first three months of pregnancy. In 197 spontaneous abortions occurring in my service and analyzed by Titus, the relative incidence of the complete to the incomplete variety was in the ratio of one to five. Such figures, however, understate the frequency of complete abortions, as a large proportion of the patients entered the hospital only because of profuse and prolonged hemorrhage incident to the incomplete extrusion of the foetal membranes, so that I estimate that a ratio of one to three would be more in accordance with the actual facts. Treatment.—Prophylactic treatment is most important, although, as a rule, it is not available in women aborting for the first time. After the patient has recovered from the abortion, a careful local and general physical examination should be made, and, in case any abnormality is discovered, the necessary curative or precautionary measures should be instituted before renewed conception occurs. If the uterus is retro- flexed, the organ should be replaced and held in position by a properly fitting pessary. If the desired results are not obtained in this way, the uterus should be suspended by a suitable operation. If endometritis 710 ABORTION, MISCARRIAGE, AND PREMATURE LABOR be present, curettage should be done, and the patient warned against becoming pregnant until sufficient time has elapsed to allow the uterus to recover from the morbid condition. If past experience has shown that the uterus is irritable and that the patient is predisposed to abort upon the slightest provocation, coitus should be interdicted during pregnancy, and the patient be cautioned against over-exertion, particularly upon the days during which the menstrual period would ordinarily occur, and be encouraged to lead a careful, well-ordered existence. Occasionally, the only means of leading the process to a successful termination is by keeping the patient in bed throughout pregnancy. Treatment of Threatened Abortion.—Whenever symptoms of threat- ened abortion appear, the patient should be kept in a recumbent position in bed. If pains occur, a hypodermic injection of grain of morphin should be administered at once, to be followed by 1-grain rectal supposi- tories of extract of opium, repeated at intervals of four or six hours. Bet- ter results are sometimes obtained by combining the opium with the extract of hyoscyamus. The following suppository, administered every four or six hours, according to circumstances, often serves a useful purpose: Codiae sulphat gr. ss. Ext. hyoscyami gr. j. 01. theobromae q. s. In many instances the symptoms rapidly subside under such treat- ment, but the patient should be kept in bed for some days after their disappearance, in the hope of avoiding any repetition. Unless the loss of blood is excessive it is unwise to subject the patient to a thorough pelvic examination during the first few days for fear that the manipula- tion may convert a threatened into an inevitable abortion. On the other hand, exploration should not he too long deferred, as in many cases similar symptoms are associated with extra-uterine pregnancy, and the failure to recognize the tubal swelling may result in postponing operative interference until after rupture has taken place into the peritoneal cavity. In other cases, the pain yields to the administration of sedatives, but the hemorrhage persists, and we then have to decide how long we are justified in permitting the bloody uterine discharge to continue, and whether there is any probability that the pregnancy will progress normally. So long as the loss of blood does not exceed that usually observed at the menstrual period, the flow is not necessarily incompatible with the continuance of pregnancy, and may be permitted to go on for some time. In view of the part played by developmental abnormalities of the foetus in the production of abortion, it is apparent that in many in- stances its occurrence should not be regarded as a misfortune, but rather as a conservative effort on the part of Nature to rid the organism of a product of conception which cannot attain maturity. For this reason I am of the opinion that palliative treatment is frequently continued un- necessarily long. Consequently, if the symptoms do not disappear TREATMENT 711 within ten days or two weeks, the patient should he allowed to assume her usual avocations, in the hope that the threatened abortion will be- come inevitable. On the other hand, if the bleeding at any time be- comes so profuse that the patient begins to show signs of anemia, the uterus should be at once emptied by the methods to be described below. In occasional instances, notwithstanding appropriate treatment and rest in bed, slight hemorrhage may persist for weeks, and it then becomes necessary to ascertain whether there is any possibility of the pregnancy continuing. Unfortunately, this problem cannot be solved at once, but necessitates a delay of several weeks and repeated bimanual examinations. Thus, if at the end of two or three weeks one is convinced that the uterus has not increased in size, or has even become smaller, one is justified in concluding that the foetus has perished; while, on the other hand, an increase probably indicates that it is still alive, but does not necessarily mean that pregnancy will go on to a happy termination. As soon as we are convinced that the foetus is dead, the uterus should be emptied. In such cases nothing can be gained by delay, as abortion will inevitably occur sooner or later, whereas temporizing treatments entails a waste of time and sometimes exposes the patient to serious danger. Treatment of Inevitable Abortion.—When convinced that abortion is inevitable, particularly in those cases in which the hemorrhage is pro- fuse, the uterus should be emptied in the most conservative manner, the choice of procedure depending upon the consistency and the degree of dilatation of the cervix. If it be sufficiently patulous to admit a finger, the patient should be anesthetized, brought to the edge of the bed, and prepared for operation. After preliminary dilatation of the outlet, the carefully sterilized hand, anointed with sterile albolene or green soap solution, is introduced into the vagina, and one or preferably two fingers are carried up into the uterine cavity, and, under the guidance of the other hand applied over the abdomen, peel off the ovum from the uterine wall and slowly extract it. If this cannot be effected, the ovum should be broken up by the finger, and its fragments extracted by means of a placental or ovum forceps, under the guidance of a finger within the uterus. But if, as often happens, the cervix is not sufficiently dilated to per- mit the introduction of a finger, the cervical canal and vagina should be packed tightly with a narrow sterile gauze bandage, as described in Chapter XXIV. When removed at the end of twenty-four hours, the pack frequently brings with it the intact ovum; but, even if this does not occur, the cervix will generally be sufficiently dilated to permit the introduction of the finger, when the ovum can be removed as recom- mended above. Dilatation of the cervix by means of a laminaria tent is recommended by many authorities. While it effects that purpose very satisfactorily, I strongly deprecate its employment, as I know no way by which it may be rendered absolutely sterile. Except when the hemorrhage is so profuse as seriously to threaten the patient’s life, these methods of procedure are preferable to the rapid dilatation of the cervix with a Goodell or some similar dilator, followed 712 ABORTION, MISCARRIAGE, AND PREMATURE LABOR by the immediate removal of the ovum by means of a curette or polypus forceps. Moreover, if the cervix is resistant it is frequently impossible to dilate it sufficiently by such means to permit the introduction of the finger, the employment of which, in my opinion, is essential for the proper evacuation of the uterus and the careful exploration of its cavity after the removal of the ovum. No doubt the uterus can be satisfactorily evacuated in most cases by means of the curette and polypus forceps, but no instrument has ever been invented which will prove an efficient substitute for the carefully trained sense of touch when it becomes necessary to satisfy one’s self that no remnants of the ovum are still retained in the uterus. On several occasions I have seen patients profoundly exsanguinated from profuse hemorrhage following the supposed thorough removal of the product of conception by curettage, but, on introducing the finger into the uterus, I have found that it still contained the bulk of the ovum. Experiences of this kind have therefore led me to do away with the use of instruments except in very rare cases. Moreover, in addition to the fact that they fulfill their object only imperfectly, they are not devoid of danger. Every gynecologist is familiar with cases in which the softened uterus has been perforated by the curette, and knows of instances in which a loop of gut has prolapsed through the opening so made. With these experiences in mind, it has become more and more my practice to resort to vaginal hysterotomy whenever prompt evacuation of the uterus becomes necessary in the presence of a rigid cervix, the only contra-indication being the existence of infection. When the ovum has been expelled intact, as in complete abortion, there is no necessity for further interference; and, as a rule, if the decidua vera is not cast off, it is not advisable to attempt its removal, as it is usually expelled spontaneously within a few days. At the same time, the physician should always satisfy himself by careful inspection that the entire ovum has come away, and that portions of it are not retained. For this reason, those in attendance on the patient should be instructed to preserve anything that may be passed in the absence of the physician, and not to follow the almost universal tendency to dis- pose of it at once; as careful inspection by a trained observer is required to recognize the component parts of the expelled ovum. In incomplete abortion, on the other hand, the retained placenta and membranes should be removed manually by the methods already de- scribed, since as soon as the uterus is emptied it contracts and the danger of hemorrhage has passed. In such cases it may happen that the physician does not see the patient until some days after the ex- pulsion of the foetus, when he is summoned on account of the persistent loss of blood, and upon examination finds that the cervix has become retracted to such a degree that it will not admit the finger. In this event, it can readily be sufficiently dilated by means of a Goodell dilator to permit the introduction of a finger, after which the remnants of the ovum are removed. In many cases of criminally induced abortion, or in neglected cases, infection may occur. Symptoms may develop while the entire ovum is MISSED ABORTION 713 still in the uterus, during the course of an incomplete abortion, or after the completion of the entire process. The latter will be con- sidered in the chapter upon Puerperal Infection. The two former con- ditions are always serious, and are responsible for the greater part of the deaths following abortion. The infection, may be due to the ordinary pyogenic bacteria or to the various so-called putrefactive types, and in hospital practice it is advisable to take an intra-uterine culture before undertaking any manipulation. The prognosis is always serious when the former bacteria are concerned, but is favorable when they are absent. In either event, the uterus should be promptly emptied in the most con- servative manner, and afterward washed out with sterile salt solution. The complication of a rigid cervix is always a source of anxiety, for, if the ovum is still in utero, the existence of infection contra- indicates the employment of vaginal hysterotomy, and renders more serious the lacerations which are usually associated with instrumental dilatation. On the other hand, in cases of infected incomplete abor- tion the uterus can usually be emptied without difficulty. Fortunately, in the great majority of cases, the temperature promptly falls after evacuating the uterus, and the patient goes on to complete recovery. In my streptococcus cases, however, the mortality was high, and, in view of a similar experience, Winter in 1911 raised the question as to whether it would not be better to defer interference until the acute symptoms have subsided. That the question is still sub judice is shown by the fact that Halban, and Latzo ten years later, after an experience in thousands of cases hold diametrically opposing views, the former advocating and the latter deprecating active interference. In general, it may be said that it is safer to interfere when the infection is limited to the uterus; whereas, if it has spread beyond it, as is indicated by pain on palpation, it is wiser to wait until the acute symptoms have subsided. With the exception of infected cases, the prognosis following abor- tion is excellent, provided a rigid technic is scrupulously observed. I have never had a death in an uninfected patient, and Young and Williams in a series of 1,331 cases, with an operative incidence of 87 per cent., record a mortality of only 0.07 per cent. The treatment of repeated abortion is in general so unsatisfactory as to constitute one of the opprobia of obstetrics. Unless some definite cause can be discovered and corrected by appropriate treatment, prac- tically our only resource is to keep the patient in bed until the time of danger is well past. Blair Bell claims that he has obtained good results by the administration of corpus luteum extract, but in my experience it has not been efficient. Missed Abortion.—This term was applied by Oldham to the cases in which the foetus is retained in the uterine cavity for months or years after its death. The condition occurs frequenly in mares, cows, and sheep, but comparatively rarely in women. Seventy cases were collected from the literature by Graefe in 1896, and 105 by E. Fraenkel in 1903, though I am convinced from my own experience that such figures give a very inadequate idea of its incidence. 714 ABORTION, MISCARRIAGE, AND PREMATURE LABOR Retention may exist for a long period without giving rise to symp- toms, and such a possibility should always be borne in mind in the case of an abortion occurring in a woman who has been for some time sepa- rated from her husband, inasmuch as an error in this regard occasionally results in irreparable damage to her character. In other cases the patient may believe herself to be far advanced in pregnancy, and yet on exami- nation the size of the uterus will be found to correspond to that of a much less advanced period. More frequently, however, the patient may present signs of threatened abortion, but, after a varying period, the loss of blood and the pain disappear under appropriate treatment, so that there seems to be every prospect that the pregnancy will go to term. Some months later the physician will be consulted on account of the failure of the abdomen to enlarge, or because the breasts show regressive changes, when the uterus will be found to be smaller than it was at the time of the threatened abortion. In rare instances, when foetal death has occurred very early in pregnancy, the enlargement of the uterus may be so slight as to escape recognition, and the condition may be regarded as one of essential amenorrhea. This happened in one of my patients, in whom the true state of affairs was not recognized . until the small product of conception was expelled thirteen months after the last menstrual period. Not uncommonly the condition, after per- sisting for months without symptoms, may exert an appreciable effect upon the patient, who may suddenly begin to lose flesh, suffer from a foul taste in her mouth, perhaps present a slight elevation of tempera- ture, and occasionally symptoms of mental derangement. According to Veit and Graefe, the retention is to be attributed to a lack of irritability on the part of the uterus, which does not contract as usual under the stimulation exerted by the dead ovum acting as a foreign body. In quite a number of cases the foetus has been retained for more than one year, and in one instance for twenty-eight years. After expulsion the ovum frequently presents the characteristic struc- ture of a hematoma mole; in other cases there are no manifestations of hemorrhage, and one has to deal with a so-called “dropsical ovum.” In the case to which reference was made in the preceding paragraph, the ovum was represented by an almond-shaped mass, covered by decidual tissue, and containing in its interior closely packed chorionic villi with well-preserved epithelium, but without a trace of a foetus or amniotic cavity. Whenever the diagnosis is established beyond doubt, the cervix should be dilated or incised, and the uterus emptied of its contents. In several of my cases, the cervix was so firm, that vaginal hysterotomy seemed the most conservative method of overcoming its resistance. In very exceptional instances the entire product of conception may be absorbed without a sign of external discharge. Polano and L. Fraenkel have reported cases in which this occurred after the pregnancy had advanced as far as the fourth month, and Koebner has demonstrated its possibility by animal experiments. Premature Labor.—By this is understood the spontaneous termina- tion of pregnancy after the period of viability has been reached—twenty- PREMATURE LABOR 715 eighth week—but before the child has attained maturity. For statistical purposes it is customary to designate as premature children which weigh between 1,500 and 2,500 grams or measure between 35 and 45 cm. in length. The accident may be due to one of numerous factors, the most im- portant being syphilis and continuous overwork during the later months of pregnancy. Less frequently, abnormalities of the product of con- ception, the various toxemias and chronic Bright’s disease, lesions of the heart and lungs, as well as certain operations upon the generative tract, may be etiological factors. As is well known, marked degrees of hydram- nios are frequently associated with premature labor, which is usually attributed to the excessive distention of the uterus. Placenta previa also plays an important part, and it is generally recognized that the high foetal mortality associated with the condition is attributable to the fact that it frequently leads to the premature termination of pregnancy. Abnormalities in the development of the foetus, and more particularly the grosser forms of monstrosity, also lead to a similar result, but we are as yet unacquainted with the mechanism by which such conditions give rise to premature expulsive efforts. The various types of toxemia, particularly eclampsia and nephritic toxemia, frequently lead to pre- mature labor. In the former, it is well known that the onset of con- vulsions is soon followed by uterine contractions, so that it is frequently difficult to determine whether one has to deal with ante- or intrapartum eclampsia. Nephritic toxemia often leads to the premature expulsion of a poorly nourished child or one which is already dead. Such a result may be due to the underlying maternal toxemia or to infarct formation in the placenta, which is sometimes so extensive as to inter- fere seriously with its nutritive function. Many authors ascribe considerable etiological significance to valvular lesions of the heart, and believe that the death of the child and the premature uterine contractions are attributable to deficient oxygena- tion of the foetal and maternal blood. From my experience, however, the importance of such lesions, as well as those of the lungs, appears to be exaggerated. One of the most important causes of premature labor consists in certain operations which had been previously performed upon the cer- vix—the extensive repair of old lacerations and particularly high ampu- tation. Each year I see several patients who had previously had one or more normal labors, but who, following such an operation, are unable to carry subsequent pregnancies to term. In such patients, gestation proceeds uneventfully until the sixth or seventh month when premature labor sets in without apparent cause. In my experience prophylactic treatment is of no avail, as absolute rest in bed for months before the danger period fails to avert the accident, so that the woman seems doomed to repeated premature labor as long as the reproductive function persists. For this reason I consider that high amputation of the cervix is an extremely serious procedure from an obstetrical point of view, and consequently should be restricted to women who have already passed the menopause, except under the most pressing indications. 716 ABORTION, MISCARRIAGE, AND PREMATURE LABOR In the absence of any of the conditions enumerated, the birth of a living premature child may be regarded as an accidental occurrence, but the expulsion of a macerated child should arouse the strongest suspi- cion of syphilis, which should not be dismissed unless autopsy upon the child, microscopic examination of the placenta, and a Wassermann test upon the mother give negative results. Furthermore, a history of the repeated occurrence of premature labor should arouse a similar suspicion, and although it may be accounted for by chronic nephritis, operations upon the cervix, or even by unusual irritability of the uterus, it should lead to the most careful search for syphilis in both parents. In my experience the recognition and treatment of this disease is the most important matter in connection with the prophylaxis of prema- ture labor, and until this teaching has permeated the rank and file of the profession, large numbers of children will continue to be sacrificed unnecessarily. Some idea of the importance of syphilis may be gained from the fact that in a series of 334 premature labors, I found that it was the etiological factor in over 40 per cent., while toxemia, placenta previa and foetal deformity were concerned in 8, 6 and 3.3 per cent., respectively. Sentex, who studied 485 cases in Pinard’s clinic, arrived at similar conclusions and found the underlying cause to be syphilis in 42.7, albuminuria in 19.8, and abnormalities of the foetus in 11.1 per cent. The figures of Holland, based upon the careful study of 300 foetal deaths occurring in London at the time of labor, justify somewhat similar conclusions, and at the same time indicate what may be ac- complished by proper prenatal supervision and by intelligent care at the time of labor. The percentage incidence of the several causes of death was as follows: Complications of labor 51, syphilis 16, cause undetermined 11, toxemia 10, relative placental insufficiency 6, foetal deformity 5, and chronic renal disease 2 per cent. He holds that 52 per cent, of these deaths could have been prevented—20 per cent, by prenatal care alone, 12 per cent, by combined pre-intranatal care, and 20 per cent, by intranatal care alone. In other words, all of the deaths from syphilis and three-fifths of those from toxemia and complications of labor could have been avoided—an impressive arraignment of current obstetrical practice. The course of premature labor differs but little from that of labor at full term, except that occasionally the entire product of conception is expelled en masse. In other instances, the onset of the accident is marked by premature rupture of the membranes and the escape of the amniotic fluid. The treatment is identical with that of full-term labor, except that when the patient is seen at the beginning of uterine con- tractions the accident may occasionally be averted by the administration of a powerful sedative and absolute rest in bed. The important point, however, is to make every effort to ascertain the cause of the accident, so that suitable prophylactic measures may be employed to prevent its recurrence. LITER AT U11E 717 LITERATURE Breus. Das tuberose subchoriale Haematom der Decidua. Leipzig u. Wien, 1892. Davidsohn. Zur Lehre von der Mola haematomatosa. Archiv f. Gyn., 1902, lxv, 181-216. Frankel. Ueber Missed Labour und Missed Abortion. Volkmann’s Samml. klin. Vortrage, N. F., 1903, No. 351. Franqu£. Ueber histologische Veranderungen in der Placenta und ihre Bezie- hungen zum Tode der Frucht. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 277-298. Gottschalk. Zur Lehre von den Hamatommolen, etc. Archiv f. Gyn., 1899, xviii, 134-169. Graefe. Ueber Ketention des menschlichen Lies im Uterus nach deni Fruchttod. Festschrift zu Carl Huge, Berlin, 1896, 38-79. Granville. Graphic Illustrations of Abortion, etc. London, 1834. Halban. Zur Behandlung der Fehlgeburten. Zentralbl. f. Gyn., 1921, 439-446. Hart. On the Nature of the Tuberous Fleshy Mole. Jour. Obst. and Gyn. Brit. Emp., 1902, i, 479-481. Holland. Report on the Causation of Foetal Death. Reports on Public Health and Medical Subjects. No. 7 Ministry of Health. London, 1922. Koebner. Knochenresorption bei intrauterinem Eischwund. Archiv f. Gyn., 1910, xci, 109-142. Latzko. Die Behandlung des fieberhaften Abortus. Zentralbt. f. Gyn., 1921, 425-439. Malins. The Antenatal Waste of Life in Nature and Civilisation. Jour. Obst. and Gyn. Brit. Emp., 1903, iii, 307-319. Mall. A Study of the Causes Underlying the Origin of Human Monsters. Phila- delphia (Wistar Institute), 1908. On the Frequency of Localized Anomalies in Human Embryos and Infants at Birth. Am. J. Anat., 1917, xxii, 49-72. Merttens. Beitrage zur normalen und path. Anatomie der menschlichen Pla- centa. Zeitschr. f. Geb. u. Gyn., 1894, xxx, 1-97. Oldham. Missed Labour. Guy’s Hosp. Reports, 1847, 105-112. Reynolds and Macomber. Certain Dietary Factors in the Causation of Sterility in Rats. Am. Jour. Obst. & Gyn., 1921, ii, 379-394. Sciiottelius. Aborte und Geburtenziffer in Hamburg. Zentral. f. Gyn., 1921, 70-72. Sentex. Des causes de la mort du produit de la conception pendant la grossesse. These de Paris, 1901. Smith. The Etiological Relation of Spirilla (Vibrio Fetus) to Bovine Abortion. Jour. Exp. Med., 1919, xxx, 313-323. Stockard. Developmental Rate and Structural Expression; An Experimental Study of Twins, “Double Monsters” and “Single Deformities, etc.” Amer. Jour*. Anat., 1921, xxviii, 115-266. Taussig. Haematom Mole. Am. Jour. Obst., 1904, i. 456-472. Prevention and Treatment of Abortion, St. Louis, 1910. Titus. A Statistical Study of a Series of Abortions. Am. J. Obst., 1912, lxv, 960-980. Veit. Yorzeitige Unterbrechung der Schwangerschaft. Muller’s Handbuch der Geburtshiilfe, 1889, ii, 23-57. Walther, Ein Fall von tuberosem, subchorialem Hamatom der Decidua. Zen- tralbl. f. Gyn., 1892, xvi, 707-710. 718 ABORTION, MISCARRIAGE, AND PREMATURE LABOR Williams. The Limitations and Possibilities of Prenatal Care. J. Ain. Med. Assn., 1915, Ixiv, 95-101. An Early Ovum in Situ in the Act of Aborting. Trans. Am. Gyn. Soc., 1919, xliv, 91-101. Williams, W. L. Diseases of the Genital Organs of Animals. Ithaca, 1921, Williams and Kolmer. Complement-fixation in Abortions in Women. Am. J. Obst., 1917, lxxv, 193-203. Winter. Zur Prognose und Behandlung des septische Abortes. Zentralbl. f. Gym, 1911, 569-576. Young and Williams. 2000 Cases of Miscarriage at the Boston City Hospital, Boston. Med. and Surg. Jour., 1911, clxiv, 871-876. CHAPTER XXX EXTRA-UTERINE PREGNANCY In extra-uterine pregnancy the fertilized ovum is arrested at some point between the ovary and the uterus, and there undergoes more or less complete development. Ectopic gestation, which is sometimes used as a synonymous term, has a broader meaning, inasmuch as it includes not only the usual forms of extra-uterine pregnancy, but also those in which the ovum is implanted in the rudimentary horn of a bicornuate uterus, or in a crypt far removed from the uterine cavity in a uterus presenting adenomyomatous changes, as described by Doderlein and Herrgott. For a long time extra-uterine pregnancy was of interest chiefly from a pathological point of view, but since 1883, when Tait first operated upon a case of ruptured tubal pregnancy, the subject has attained a markedly practical interest, as is manifested by the immense literature of recent years. This history of its development is treated in detail in the monographs of Campbell, Hecker, Parry, Tait, Werth, and Webster. Prior to 1876, extra-uterine pregnancy was considered so rare an affection that Henning stated that even the directors of large obstetrical institutions might never encounter a case, and Parry was able to collect only 500 instances from the entire literature. It was only with the gradual development of abdominal surgery that its relative frequency became recognized and it is now generally admitted that operations for extra-uterine pregnancy constitute a small percentage of all gynecological laparotomies. Thus, there were fifty operations in the Gynecological department of the Johns Hopkins Hospital during the five years ending 1922; while Wynne states that in the 22,688 patients admitted previous to that period the incidence of extra-uterine pregnancy was 1.3 per cent. Schumann calculated that the condition was noted once in every 303 pregnancies occurring in Philadelphia during the year 1918. He arrived at this conclusion by obtaining statements from the various hospitals and operators as to the number of cases cared for, and compared the total thus obtained with the number of births recorded by the Health Department. Classification.—As the fertilized ovum may be arrested at any point on its way from the graafian follicle to the uterine cavity, it may undergo development in the ovary or in any portion of the tube, giving rise to ovarian or tubal pregnancy respectively. It is doubtful whether the ovum can become implanted upon the peritoneum and a primary abdom- inal pregnancy follow. Etiology.—According to Leopold, ovarian pregnancy results from the fertilization of the ovum before its escape from the graafian follicle. 719 720 EXTRA-UTERINE PREGNANCY Moreover, he believed, when several follicles mature at the same time, that a deeply lying one may rupture into a more superficial one with- out the escape of its ovum, in which event the latter may be fertilized by spermatozoa entering through the superficial follicle. Such an occur- rence would afford a satisfactory explanation for a pregnancy occupying the central portion of the ovary. Unfortunately, equally concise and definite statements cannot be made concerning the etiology of tubal pregnancy, although a number of explanations, of greater or less plausibility, have been advanced. Broadly speaking, these may be divided into three main groups: (1) Conditions which interfere mechanically with the downward passage of the ovum; (2) Inflammatory diseases of the tubes; (3) Physical and developmental abnormalities which favor decidual formation in the tubes. 1. Conditions which Interfere Mechanically ivith the Downward Passage of the Ovum.—{a) Fritze, in 1719, first directed attention to the fact that peritoneal adhesions, by compressing the lumen of the tube or by interfering with its peristalsis, might cause the arrest of the ovum. (b) Leopold, Breslau, Beck, Wyder, and others believed that polypi projecting into the lumen of the tube might occasionally interfere with the descent of the ovum. It is quite probable, however, that such struc- tures were not primary, but had appeared only after conception. (c) Some observers believe that myomata, or other tumors, situated in the wall of the tube or in adjacent organs, may so compress the tubal lumens as to interfere with the passage of the ovum. (d) Schroeder, in 1887, but more particularly Tait, a few years later, advanced the theory that the most frequent etiological factor was an endosalpingitis. This they supposed led to the destruction of the cilia and the consequent cessation of the downward current, thereby allowing spermatozoa to enter the tube. This view implied that fertilization normally occurred in the uterine cavity, and was based upon the supposition that the ciliary current was directed downward in the tubes and from below upward in the uterus, the entry of spermatozoa into the uterine cavity being thereby facili- tated, while their access to the tubes was rendered difficult. After Ilofmeier and Mandl had demonstrated the fallacy of these suppositions by showing that the current extended downward from the fimbriated extremity of the tube to the internal os, it became evident that the spermatozoa were obliged to contend against it from the time they entered the uterus. As it is now known that fertilization occurs normally in the tubes, the problem to be solved in every case of tubal pregnancy is not how the spermatozoa may have gained access to the tubes, but why the fertilized ovum failed to make its way to the uterus. Furthermore, the cilia may persist in spite of acute inflammation, and I have been able to demonstrate their presence in nearly every preg- nant tube which I have examined, while Zedel saw them in motion in several specimens which he examined in the fresh condition. (e) Abel, Kreisch, and others believe that the foetal convolutions of ETIOLOGY 721 the tube occasionally persist in later life, and hinder the downward passage of the fertilized ovum either by constricting the lumen or by interfering with peristalsis. (/) In 1891 Landau and Rheinstein, and I demonstrated the pres- ence of diverticula from the lumen of the tube, and suggested that a fertilized ovum entering such a structure would eventually be arrested at its blind end, where it might undergo further development (Fig. 514). Specimens, in which the foetal sac lay entirely outside of the lumen of the tube, being separated from it by a layer of tissue of varying thick- ness (see Fig. 520), apparently offered confirmatory evidence of such an occurrence. At that time definite information concerning the mode of implantation of the ovum was not available, and it was supposed that it became implanted upon the surface of the mucosa. When, however, Spec’s teaching that the ovum immediately burrowed into the depths Fig. 514.—Diverticulum from the Lumen of Tube. of the mucosa had become generally accepted, it became apparent that the presence of the product of conception in the wall of the tube did not necessarily prove that it had been implanted in a diverticulum. Consequently, while it must be admitted that such an occurrence is pos- sible, it is difficult to adduce conclusive evidence in its support, unless reconstructions are made from serial sections, as was done by Hoehne in 1917. Now and again, in serial sections through the tube, it is possible to demonstrate the presence of accessory lumina—long processes, which extend from the main lumen and, after continuing parallel to it for a considerable distance, rejoin it, or end blindly. In several instances, I have noted conditions wdiich seemed to indicate that the fertilized ovum had been arrested in such a structure. Sometimes accessory ostia, instead of communicating with the lumen of the tube, represent mere culsdesac. That the fertilized ovum may be arrested in such a structure and go on to further development was EXTRA-UTERINE PREGNANCY 722 conclusively demonstrated by Henrotin, Herzog, and Walthard (Fig. 515). (g) Diihrssen believed that in occasional instances the arrest of the ovum may be due to puerperal atrophy of the tube, whereby its normal peristalsis remains permanently impaired. Hoehne contends that gen- eral hypoplasia of the tube may have a similar effect. (h) In a considerable number of cases which I have examined, the corpus luteum was situated not in the ovary corresponding to the preg- nant tube, but in the opposite one, indicating that external migration had occurred, and that the fertilized ovum had made the transit of the pelvic cavity. Sippel believed that such a phenomenon may favor the production of extra-uterine pregnancy, since the fertilized ovum may attain such proportions during its migration as to interfere with its passage through the tube. II. Conditions Resulting from Inflammatory Conditions of the Tubes.—As has already been said, Schroeder and Tait emphasized the Fig. 515.—Pregnancy in Accessory Tubal Ostium (Henrotin and Herzog). A, small accessory ostium; B, opening of pregnant ostium; C, blind end of same; D, blood clot containing remnants of ovum. etiological importance of such conditions. This view is supported by the fact that many cases of tubal pregnancy have been preceded by pelvic inflammatory trouble, and that a history of gonorrheal salpingitis or of inflammatory disease of the appendages can be elicited in a considerable proportion of the cases. After it had been demonstrated that the arrest of the ovum was not due to the destruction of the cilia by the inflam- matory process, great difficulty was at first experienced in explaining the connection between the two conditions. In 1902, however, Opitz noted in many of his specimens that the tips of the folds of the mucosa had become fused together, so that the section presented the cribriform appearance characteristic of the so-called “follicular salpingitis.” As similar lesions were usually present in the non-pregnant tube, he held that they afforded a satisfactory explanation for the arrest of the ovum. He assumed that some of the canals inclosed between the adherent folds communicated freely with the main lumen of the tube, but ended blindly ETIOLOGY 723 at the other extremity, so that if a fertilized ovum were arrested in such a culdesac a tubal pregnancy might develop. This explanation was enthusiastically accepted by Werth and Iioehne, who considered it of almost universal application. I have frequently observed the same condition, and agree with Mall that it is a frequent etiological factor. III. Physical and Developmental Conditions which Favor Decidual Formation in the Tubes.—Webster believed that the explanation for the comparatively infrequent occurrence of tubal pregnancy was to be found in the fact that the decidual reaction, which he considered essential to the proper implantation of the fertilized ovum, is usually lacking. He held that the abnormality can come about only when the tubes are capable of this reaction, which he considered represents a reversion to an earlier type, and therefore should be regarded as a sign of degen- eracy. This view was indorsed by Pantellani, Mandl and Schmidt, Wormser, Moericke, and others, but the belief is based upon theoretical considerations rather than upon anatomical observation. From what has just been said, it is apparent that there is no lack of theories concerning the etiology of tubal pregnancy, and the question which we have to consider is which of them is correct, or whether any one is of universal application. Tainturier, and Mandl and Schmidt approached the problem experi- mentally by applying ligatures to various portions of the generative tract of rabbits shortly after copulation. When applied to one uterine cornu some distance below the tubal opening, ova developed distal to the ligature, as well as in the normal horn, and when both cornua were ligated no ova developed median to the ligatures. On the other hand, when the ligatures were applied to the uterine ends of the tubes, extra- uterine pregnancy did not develop, although dead ova could be demon- strated above the ligatures. In a series of control experiments, when only one tube was ligated, the same result was obtained on that side, while the other uterine horn contained normal embryos. These experiments show conclusively that in the rabbit, at least, some factor other than mere mechanical interference with the downward passage of the ovum is necessary to the production of tubal pregnancy, and this Mandl and Schmidt sought in a preliminary decidual reaction. The fact, however, that the decidual formation is never abundant in the pregnant tube, and is frequently altogether absent, would militate strongly against such a view. The only positive experimental work along these lines was reported by Nuck many years ago, but it is probably open to the objection that he did not distinguish carefully enough between the cornua and the tubes in the bicornuate uterus of the lower animals. The idea that tubal pregnancy is a sign of degeneration or reversion, while extremely interesting, and to a certain extent borne out by facts, cannot be accepted as a universal solution of the problem; for in many instances the condition occurs in well developed women who live amid the best surroundings. Moreover, its great rarity in the lower animals also speaks against such a view. Bland Sutton states that in his large 724 EXTRA-UTERINE PREGNANCY experience in the zoological gardens of London he has never met with tubal pregnancy in animals, and believes that all such cases recorded in the literature are due to confounding the uterine cornua with the tubes. This statement, however, is too radical, as Waldeyer has reported an undoubted case in an ape. In view of the considerations just adduced, it is apparent that the etiology of tubal pregnancy is not a simple matter, and that there is no universal cause for all cases. In many instances, the arrest of the ovum in a crypt resulting from follicular salpingitis, or in a diverticulum, affords a satisfactory explanation; while the fact that the condition Fig. 516.—Dr. E. K. Cullen’s Specimen of Ovarian Pregnancy. X 1. occurs much more frequently in urban than in rural districts speaks strongly in favor of its inflammatory origin, as the possibility of gonor- rheal infection is much greater in large cities than in the country. On the other hand, in a certain proportion of cases even the most careful clinical history and microscopical examination of the specimen will fail to reveal a tangible cause for the condition, which will still remain as great a problem to us as to our predecessors. Ovarian pregnancy was first described in the seventeenth century, by Mercerus and St. Meurice, and its possibility was generally conceded until 1835, when Velpeau stated that none of the cases which had been described up to that time afforded conclusive evidence of ovarian origin. Similar views were expressed by Mayer in 1847, and were indorsed by OVARIAN PREGNANCY 725 Pouchet, Allan Thompson, and others. This skepticism was probably justifiable, since most of the early cases collected by Campbell and Gurgui were simply dermoid cysts of the ovary. With the exception of Mayer, the possibility of ovarian pregnancy has always been admitted by the German writers, but was strenuously denied until 1901 by the English authorities, particularly by Tait, Web- ster, and Bland Sutton. Indeed, as far as I can ascertain, only 3 cases were reported in Eng- land during the nineteenth century, namely, 2 by Granville in 1834 and 1 by Oliver in 1896. In this country most writers have followed the English authorities, although Parry admitted its existence and not a few operators had reported doubtful cases; but it was not until 1902 that Thompson demonstrated a conclusive specimen. Up to 1878 there existed no definite criteria by which specimens could be judged, and many were described as examples of ovarian preg- nancy which had no claim to such a title. In that year, however, Spiegel- berg formulated certain criteria which he held must be fulfilled in order to justify such a diagnosis. He demanded (1) that the tube on the affected side be intact; (2) that the foetal sac occupy the position of the ovary; (3) that it be connected with the uterus by the ovarian ligament; and (4) that definite ovarian tissue be found in its wall. When judged by these criteria, the majority of cases which had been described up to his time were wanting, and subsequent investigation has shown that a number of cases which he considered conclusive are likewise open to very considerable doubt. At present the possibility of ovarian pregnancy is universally ad- mitted, and even so rigorous a critic as Webster has abandoned his skepticism, and has reported two authentic cases. I have carefully gone over the literature upon ovarian pregnancy, and have classified the cases reported up to January, 1906, as positive, highly probable, fairly probable, and doubtful, according to the extent to which Spiegelberg’s criteria were fulfilled. I was able to find 13 specimens belonging to the first category, which were thoroughly de- scribed, and so carefully studied microscopically that their ovarian origin was conclusively demonstrated; namely, the cases of Gottschalk, 1893; Ludwig, 1896; Kouwer and Tussenbroek, 1899; Croft, 1900; Anning and Littlewood, 1901; Robson, 1902; Franz, 1902; Thompson, 1902; Mendes de Leon and Holleman, 1902; Micholitsch (2 cases), 1903; Boesebeek, 1904; and Webster, 1904. The patients of Gottschalk and Ludwig had gone to term, but in none of the other 11 had the preg- nancy progressed beyond the fourth month. Since then many more positive cases have been described, so that Lockyear, when reporting two personal cases in 1917, was able to increase the number to forty-one. Meyer and Wynne have since reported an additional case and analyzed the literature up to 1919. It is interesting to note that in one third of the positive or highly probable cases, which I collected, the pregnancy had gone to full term, and in several instances had eventuated in the formation of lithopedia, which had been carried for years before being removed. This would 726 EXTRA-UTERINE PREGNANCY appear to indicate that the ovary can accommodate itself more readily than the tube to the growing pregnancy; but at the same time it should be remembered that rupture at an early period is the usual termination. It is also important to bear in mind that the pregnancy may be de- stroyed at any early period without rupture, and give rise to a tumor of varying size, consisting of a capsule of ovarian tissue inclosing a mass made up of blood and chorionic villi, which may or may not contain an amniotic cavity, as in the specimens of Mendes de Leon and Webster. Such observations render it probable that a certain proportion of ovarian hematomata may actually represent the remains of an early pregnancy, but such a diagnosis should not be considered unless microscopical exami- nation reveals the presence of chorionic villi. In ovarian pregnancy, the ovum itself and its mode of implantation Amnion. Partially separated placenta. Uterine cavity. Cervix. Fig. 517.—Interstitial Pregnancy (Bumm). do not differ eventually from that observed in the uterus, except that a definite decidual membrane is lacking, so that the foetal ectoderm invades the ovarian stroma directly. Tubal Pregnancy.—In this, by far the most frequent, variety of extra-uterine pregnancy, the ovum may develop in any one of the three portions of the tube, giving rise to interstitial, isthmic, or ampullar pregnancy respectively. In rare instances it may be implanted upon the fimbriated extremity, and occasionally even upon the fimbria ovarica. From these primary types certain secondary forms—tubo-abdominal, tubo-ovarian, and broad-ligament pregnancy—occasionally develop. According to Rosenthal, the interstitial is the rarest variety, having occurred in only 3 per cent, of the 1,324 cases of tubal pregnancy which he collected from the literature. Lequex was able to collect 75 cases TUBAL PREGNANCY 727 up to 1911, which were still further increased by Wynne in 1918. Of 146 personal cases analyzed by Hartmann and Bergeret, 119 were ampul- lar, 24 isthmic, and only 3 were interstitial. Most recent writers state that the ampullar variety is the commonest, and this has also been my experience. Anatomical Considerations.— (a) Mode of Implantation of the Ovum. —Formerly it was taught that the implantation of the ovum, whether in the uterus or tube, was dependent upon the formation of a well- developed decidua. The pioneer work of Graf Spee and Peters, however, has demonstrated that even in the uterus this is not necessary, as the ovum burrows down into the depths of an edematous endometrium, whose stroma cells have not yet assumed a characteristic decidual ap- pearance. This work, which has completely revolutionized our con- ception of the mode of implantation of the ovum in uterine pregnancy, applies equally well to the tube, although certain anatomical peculiarities of the latter usually necessitate a different outcome. The ovum may become arrested in any portion of the tube, and, according to Werth, may become implanted in either one of two ways. In the first, or columnar, variety, which is very rare, the ovum becomes attached to the tip or side of one of the folds of the mucosa; while in the second, or intercolumnar variety, implantation occurs at the periph- eral portion of the lumen in a depression between two folds. In either event, the ovum does not remain upon the surface, but at once burrows through the epithelium, and comes to lie in the tissue just beneath it. At that time its periphery is made up of a capsule of rapidly proliferating trophoblast, whose cells soon invade the surrounding tissues. The in- vasive and arrosive properties of these ectodermal cells bring about de- generation of the muscle and connective-tissue cells, which eventually become converted into fibrin. At the same time maternal blood vessels are opened up, and the blood is poured out into spaces of varying size lying entirely within the trophoblast, or between it and the adjacent tissue. Young considers that edema and necrosis occur before the ma- ternal tissue is reached by the foetal cells, and are probably due to the action of chemical substances secreted by the latter. In the usual, intercolumnar mode of implantation, owing to the absence of a submucosa and the lack of development of a decidual mem- brane in the tube, as soon as the ovum penetrates the epithelium it comes to lie in the muscular wall, and is separated from the lumen by a layer of tissue of varying thickness—the capsular membrane or pseudoreflexa (Fig. 520). On the other hand, in the rare columnar mode of implanta- tion, the ovum lies in the interior of a fold of mucosa, and except at its base is surrounded on all sides by tubal epithelium, so that it has but slight space for expansion. Every specimen of early tubal pregnancy, which I have studied in recent years, has served to strengthen my belief that implantation occurs in practically the same manner as in the uterus. That this view is correct is shown by the fact that it has been endorsed by all subsequent investigators, who are now too numerous to mention. The further development of the pregnancy depends in great part 728 EXTRA-UTERINE PREGNANCY upon the portion of the tube in which implantation has occurred. When in the ampulla, the growing ovum pushes forward the capsular membrane into the tubal lumen, and the latter may eventually become so compressed as to appear as a mere crescentic slit. If the course of the pregnancy be not interrupted, the capsular membrane may fuse with the neighboring mucosa, so that the lumen of the tube becomes obliterated in the im- mediate vicinity of the ovum. On the other hand, when implantation occurs in the isthmus, and particularly in the portion immediately adjoining the uterus, the small Fig 518.—Section Showing Attachment of Chorion to Tube Wall. X 90, Dec., decidual cells, L. C., Langhans’ cells, Syn., syncytium, V., villi. size of the lumen precludes the possibility of such expansion. As a consequence the ovum distends the tube wall peripherally, so that the lumen may eventually become completely separated from the underlying muscularis and be surrounded by foetal tissue and villi, with the result that intraperitoneal rupture frequently occurs before the patient is aware that she is pregnant. (b) Decidua.—Bland Sutton in 1891, and Fiith and Griffiths a few years later, pointed out that the decidual reaction in the tube was nothing like so extensive as was generally believed; while Kiihne, Aschoff, and Kreisch were skeptical of its existence, and contended that the cells, which had formerly been described as decidual, were really of foetal TUBAL PREGNANCY 729 origin. The first mentioned view has been confirmed, by subsequent observers, and at present no one claims that a continuous decidual mem- brane is formed. On the other hand, it is erroneous to contend that a decidual reaction is always lacking, as it is possible by careful study to distinguish decidual cells, and to differentiate clearly between them and foetal cells. The former are usually found in discrete patches in the tips of some of the folds of the mucosa in the neighborhood of the ovum. Furthermore, one can occasionally find decidual cells scattered between the foetal tissues Fig. 519.—Section Showing Formation of Decidual Cells in Non-pregnant Tube, Demonstrating that They Could not Be of Foctal Origin. m.m., tubal mucosa; muse., muscularis; d, decidua. at the placental site (Fig. 518), but I have never observed a decidual membrane analogous to the decidua vera or serotina in uterine pregnancy. That the authors who deny the existence of decidual cells in the tube take too extreme a view is shown by the fact that they have been repeatedly observed by Webster, Both, Couvelaire, Kermauner, Young, myself, and others. Moreover, the possibility of a decidual reaction is demonstrated by the fact that I have repeatedly observed characteristic decidual cells in the non-pregnant tube (Fig. 519). Observations of this character are beyond criticism, as in such cases it is impossible to EXTRA-UTERINE PREGNANCY 730 confuse decidual with foetal cells. Furthermore, Mandl, Lange, and I have noted an identical reaction in the tubes in certain cases of uterine pregnancy. The absence, or comparative scantiness, of the decidual reaction is of interest not only from a scientific point of view, but also has a distinctly practical bearing, as it would seem to offer a satisfactory explanation for the invasion and destruction of the tube wall by the foetal elements. In uterine pregnancy, such an invasion is noted only in the rare in- stances in which there is an imperfect development of the decidua, and it would therefore appear that one of the main purposes of its formation is to protect the maternal tissues against the invasive and corrosive action of the foetal cells. (c) Decidua Capsularis.—Since the time of Kokitansky, the question as to the existence of a decidua cap- sularis in tubal pregnancy has been repeatedly dis- cussed, one set of investigators claim- ing that it is usu- ally present and the other set holding that it is always absent. The inves- tigations of the past few years have served to reconcile these differences. In view of the general scantiness of the decidual re- action, it is evident that one could not reasonably expect the formation of a structure identical with the decidua capsularis pf uter- ine pregnancy. On the other hand, in all intact early tubal pregnancies, the ovum is sepa- rated from the lumen of the tube by a thicker or thinner layer of connec- tive and muscular tissue, which may contain a few isolated decidual cells (Fig. 520). As the pregnancy advances this membrane becomes invaded by foetal cells, undergoes fibrinous degeneration, and, if rupture does not occur, eventually fuses with the mucosa of the opposite side of the tube. As this structure is only superficially analogous to the decidua capsularis, it is better designated as the pseudocapsularis or capsular membrane. Fig. 520.—Early Tubal Pregnancy, Showing Ovum Em- bedded in Wall of Tube Outside of Lumen. X 6. b.c., blood clot; v., chorionic villi; refl., capsular membrane. TUBAL PREGNANCY 731 (d) Placenta.—As the early stages of the development of the placenta are identical in both tubal and uterine pregnancy, the different outcome in the former is dependent upon the absence or scanty development of a decidual reaction. As a consequence, the tissues of the tube wall in contact with the ovum offer but slight resistance to the invasive properties of the foetal elements, and soon undergo degenerative change. The chorionic villi and foetal cells invade this tissue, almost like a malignant growth, and at the same time open up maternal blood vessels. In many cases they penetrate directly through the peritoneal surface or through the capsular membrane, and give rise to intraperitoneal rupture or tubal abortion, as the case may be. In other instances, however, early rupture is due to the sudden opening up of a large vessel, when the weakened tube walls yield to the increased pressure. Werth has quaintly expressed the process by stating that the ovum, in making its bed, digs its own grave. The microscopic structure of the foetal portion of the placenta is identical with that observed in uterine pregnancy. Even more frequently than in that condition, masses of Langhans’ cells, syncytium, or even fragments of villi become broken off, and are carried by the veins to various portions of the body. This process of deportation can be shown in almost every specimen by cutting serial sections. Yeit has still further extended this conception by applying it to the growth into venous channels of chorionic villi, which still retain their connection with the placenta. He considers that it plays an important part in the production of rupture, as such a clogging of the venous channels may so raise the pressure in the intervillous spaces that the weakened tube walls neces- sarily give way. It is stated by Gubb and others that the placenta may continue to grow after the death of the foetus. I, however, agree with Berry Hart, that it is improbable, except in the rare cases of hydatidiform mole formation; although it must be admitted that in advanced tubal preg- nancy hemorrhage into the placenta may lead to a considerable increase in its size. (e) Structure of the Foetal Sac.—In tubal pregnancy there is a marked increase in the vascularity of the affected tube, the larger arteries and veins being much hypertrophied, while the smaller vessels, especially in the neighborhood of the placental site, are markedly engorged. Microscopical sections through the sac in the early months show a slight hypertrophy of the muscle cells, but no apparent increase in their number. Except at the placental site, the tube wall is considerably thickened, and its cells are spread apart by edema. At a still more advanced period, the muscular constituents of the gestation sac appear to diminish in number, so that at full term almost its entire thickness is made up of a connective tissue poor in cells, with only here and there a muscle fiber. This indicates that the muscularis of the tube does not possess the same tendency to hypertrophy as that of the uterus, though occasionally it is quite marked, Pinard having reported a case in which the foetal sac contracted so strongly that he mistook it for a pregnant uterus. EXTRA-UTERINE PREGNANCY 732 In moat cases the exterior of the tube gives evidence of peritonitic involvement, and a considerable portion of the thickness of the foetal sac is often due to peritoneal adhesions. In order for complete tubal abortion to occur, the fimbriated ex- tremity must remain patent, but in other cases its condition varies, being sometimes closed, sometimes open. As a rule, the lumen of the tube communicates directly with either end of the foetal sac. Less commonly, however, this communication is noted only at one end, while still more rarely the foetal sac is completely shut off from the main lumen. A satisfactory explanation of these differences has not yet been adduced. (/) Uterine Changes.—In the first three months the uterine under- goes considerable hypertrophy, and its endometrium becomes converted into a structure similar to the de- cidua vera observed in uterine preg- nancy, and differing from it only in a less marked development of the spongy layer and a greater abund- ance of blood spaces just beneath its free surface. Careful study of its histological structure was re- ported by Sampson in 1915. Soon after the death of the foetus, the decidua degenerates and usually comes away in small pieces, but occasionally it is cast off intact, rep- resenting a triangular cast of the uterine cavity. Its discharge is usually considered of marked diag- nostic significance; so much so that in doubtful cases many observers recommend curetting the uterus, and base their diagnosis upon the pres- ence or absence of decidual tissue. Terminations of Tubal Preg- nancy— According to Tait, the uni- versal fate of tubal pregnancy was rupture either into the peritoneal cavity, or between the folds of the broad ligament, occurring not later than the twelfth week. Wider experience has demonstrated the incorrect- ness of his teachings, as more than one-half of the cases terminate at an early period by abortion after rupture through the capsular membrane. Very exceptionally, the pregnancy may go on to full term without rup- ture, as I have observed in several instances. (a) Tubal Abortion (Intratubal, or Capsular Rupture).—After Werth, in 1887, had directed attention to the possibility of tubal abor- tion, it has gradually become established that this is the most frequent outcome of tubal pregnancy. The marked change of opinion which has taken place upon this point is readily appreciated by comparing the statements made by Schrenck and Werth, in 1892 and 1904, re- Fig. 521.“Uterine Decidua from a Case of Extra-uterine Pregnancy (Zweifel). TUBAL PREGNANCY 733 spectively. The former found only 6 cases of abortion in 610 cases of tubal pregnancy collected from the literature; whereas the latter stated that seven out of eight cases ended in that way as compared to one by rupture. The frequency of tubal abortion depends in great part upon the site of implantation of the ovum. In ampullar pregnancy, it is the general Fig. 522.—Early Tubal Pregnancy, with Abortion of Ovum into Lumen of Tube, X 6. b.c., blood clot; v., chorionic villi. rule, whereas intraperitoneal rupture is the usual outcome in isthmic pregnancy. This difference is due to the fact that in the former location the tubal lumen is sufficiently capacious to permit of a considerable degree of expansion of the foetal sac, whereas in the latter the lumen is so small that this is impossible; and as expansion can occur only toward the periphery, early rupture is the usual termination. Tubal abortion results from the perforation or rupture of the cap- sular membrane or pseudoreflexa by the growing chorionic villi, and 734 EXTRA-UTERINE PREGNANCY therefore does not differ essentially from intraperitoneal rupture, except in the fact that in one case the accompanying hemorrhage occurs into the lumen of the tube, whereas in the other it takes place into the peritoneal cavity. Accordingly, the term “tubal abortion” could be well replaced by that of intratubal rupture, as suggested by Berkeley and Bonney. The immediate consequence of the hemorrhage is the loosening of the connection between the ovum and the tube wall, the former hecomiug completely or partially separated from its site of implantation. In the former case, the entire ovum is extruded into the lumen of the tube, and is gradually forced by the effused blood toward the fimbriated end, through which it may be extruded into the peritoneal cavity, whereupon the hemorrhage usually ceases. In the latter event, on the other hand, the ovum remains in situ, and the hemorrhage continues. Accordingly, Fig. 523.—Tubal Abortion, Ovum Being Extruded through Fimbriated Extremity (Kelly). X 1. we distinguish between complete and incomplete abortions, the latter occurring ten times more frequently than the former, according to Wormser. In a small number of cases the ovum may be observed in the act of abortion (Fig. 523). Thus, among my own specimens are several which show the foetus surrounded by its membranes, protruding from the dilated fimbriated extremity of the tube. When the hemorrhage is moderate in amount and the ovum remains in situ, it may become infiltrated with blood and become converted into a structure analogous to the blood or fleshy mole observed in uterine abortions (Fig. 524). The hemorrhage usually persists as long as the mole remains in the tube, and the blood slowly trickles from the fimbri- ated extremity into Douglas’ culdesac, where it becomes encapsulated, giving rise to an hematocele. If the fimbriated extremity is occluded, the tube may gradually become distended by blood—hematosalpinx. TUBAL PREGNANCY 735 After incomplete abortion, small particles of the chorion may remain attached to the tube wall and, becoming surrounded by fibrin, give rise to a placental polypus, just as is often noted after an incomplete uterine abortion. (b) Rupture into the Peritoneal Cavity.—Less than one half of the cases of tubal pregnancy end within the first twelve weeks by intra- peritoneal rupture, which usually oc- curs spontaneously, but occasionally is the result of violence. Generally speaking, when rupture occurs in the first few weeks, the pregnancy is situated in the isthmic portion of the tube, a short distance from the cornu of the uterus (Fig. 525). On the other hand, when the ovum is implanted in the interstitial por- tion of the tube, rupture usually does not occur until after the fourth month, and sometimes considerably later. This difference is due to the fact that the interstitial portion of the tube is surrounded by a thick layer of uterine musculature, which reacts promptly to the stimulation of pregnancy, and by its hypertrophy allows the ovum to attain a con- siderable size before rupture occurs. The prime factor in the causation of rupture is the intramural embedding of the ovum, and the consequent invasion of the tube wall by chorionic ectodermal elements, with consequent fibrinoid degeneration of the muscular layer. Its direct cause may be violence, such as vaginal examination, coitus, a fall, or even mere overexertion, though in the great majority of cases it occurs spontaneously. In the latter event, rupture is brought about either by direct perforation by the growing villi, or by the weakened tube wall yielding to a sudden in- crease of pressure in the inter- villous spaces, following the sud- den opening up of a large vessel or the clogging of venous chan- nels by chorionic villi. The evidence at present available seems to indicate that the latter is the more usual factor. If rupture occurs in this way in an otherwise normal tube, it is apparent that it will be likely to occur at a much earlier period if the ovum be arrested in a diverticulum from its lumen, as in such cir- cumstances it will have only a portion of the tube wall to penetrate, instead of its entire thickness. Fig. 524.—Section through Tubal, Mole. X 1. B.C., blood clot; Ov., ovum; T.W., tube wall; U.T., uterine end of tube. Fig. 525.—Isthmic Pregnancy, Rupture Ten Days after Last Menstrual Pe- riod. X 1. 736 EXTRA-UTERINE PREGNANCY Occasionally, when the fimbriated end of the tube is occluded, secondary rupture may occur after a primary abortion. In such cir- cumstances the weakened tube wall yields to the pressure of the blood, which has been poured into its lumen and can find no other means of escape. Kupture usually occurs in the neighborhood of the placental site, and either into the peritoneal cavity or between the folds of the broad ligament, depending upon the original site of the ovum. The termina- tions of the two conditions differ so markedly that it will be necessary to consider them separately. In intraperitoneal rupture, the entire ovum may be extruded from the tube, but if the rent be small, profuse hemorrhage may occur without its escape. In either event, the patient immediately shows signs of collapse. If death from hemorrhage does not follow, the effect of rupture varies according to the amount of damage sustained by the ovum. If expelled intact into the peritoneal cavity, the death of the Fig. 526.—Ruptured Ampullar Pregnancy. X 1. Am., amnion; O., ovary; P., placenta; Tuterine end of tube. foetus is inevitable; and unless the pregnancy has advanced beyond the third month, the product of conception will be rapidly absorbed, as was shown by Leopold’s experiments upon animals. It is still thought by many that in such circumstances the placenta may become attached to any portion of the peritoneal cavity, and there establish vascular connections, which will render further development possible. I do not believe that this can occur, as it is improbable that such connections could be established before the ovum had become irre- parably damaged, not to speak of the negative evidence afforded by Leopold’s experiments. On the other hand, if only the foetus escapes at the time of rupture, the effect upon the pregnancy will vary according to the extent of injury sustained by the placenta. If much damaged, death of the foetus and termination of the pregnancy is inevitable; but if the greater portion of the placenta still retains its attachment to the tube, further develop- ment is possible, and the foetus may go on to full term, giving rise to a secondary abdominal pregnancy. In such cases, the tube may close TUBAL PREGNANCY 737 down upon the placenta and form a sac, in which it remains during the rest of the pregnancy. Or, while a portion of the placenta remains attached to the tube wall, its growing periphery extends beyond it and establishes connections with the surrounding pelvic organs. Under such circumstances one may find the placenta attached partly to the uterus, pelvic floor, rectum, or even the intestines. I do not believe, however, that the placenta can become solely and directly attached to organs far removed from the pelvic cavity, such as the stomach and diaphragm, for instance; and when such connections are observed, I consider that one has to deal with a broad-ligament pregnancy, which had become adherent to the organ in question, and that the placenta will be found to be attached to the inner surface of the foetal sac adjacent to the adhesion. Fig. 527.—Broad-Ligament Pregnancy (Zweifel). When the foetus escapes from the tube, following rupture, it is nearly always surrounded by its membranes, and most authorities believe that further growth is impossible, unless it is surrounded by the amnion, though several cases have been reported in which a full-term foetus lay perfectly free in the peritoneal cavity, and all that was left of its membranes was found in the tubal sac. (c) Rupture into the Broad Ligament.—In a small number of cases, especially when the original insertion of the ovum was basiotropic, as Lichtenstein designates it, rupture may occur at the portion of the tube uncovered by peritoneum, so that the contents of the gestation sac are extruded into a space formed by the separation of the folds of the broad ligament. Generally speaking, this is the most favorable variety of rupture, and may terminate either by the death of the ovum and the formation of a broad-ligament hematoma, or by the further de- velonment of the pregnancy. 738 EXTRA-UTERINE PREGNANCY The outcome depends largely upon the degree of completeness with which the placenta has been separated. If it still remains attached to the interior of the tube, it generally becomes displaced upward as preg- nancy advances, and comes to lie above the foetus; but when it is situ- ated near the point of rupture it gradually extends down between the folds of the broad ligament, being implanted partly upon the interior of the tube and partly upon the pelvic connective tissue. In either event, the foetal sac lies entirely outside of the peritoneal cavity, and as it increases in size the peritoneum is gradually dissected up from the pelvic and abdominal walls. This condition is designated as extra- peritoneal or broad-ligament pregnancy, and was carefully studied by Dezeimeris in 1836. Occasionally, the broad-ligament sac may rupture at a later period, and the child be extruded into the peritoneal cavity, while the placenta retains its original position—secondary abdommal pregnancy. The importance of rupture into the broad ligament was particularly emphasized by Tait, who believed that it was only under such circum- stances that extra-uterine pregnancy could go on to full term. But since a certain number of cases of tubal pregnancy go on to term without rupture, it is evident that his statements were based upon imperfect information. The frequency of this mode of rupture has been consid- erably overestimated, as it was noted in only 4 out of 276 cases collected from the articles of Mandl and Schmidt, Kiistner, and Fehling. The so-called tubo-uterine pregnancy results from the gradual exten- sion into the uterine cavity of an ovum which was originally implanted in the interstitial portion of the tube. Tubo-abdominal pregnancy, on the other hand, is derived from a tubal pregnancy in which the ovum has been inserted in the neighborhood of the fimbriated extremity, and gradually extends into the peritoneal cavity. In such circumstances, the portion of the foetal sac projecting into the peritoneal cavity forms adhesions with the surrounding organs, which often seriously compli- cate its removal at operation. Neither of these conditions is common, nor do they deserve to be classified separately; in reality, they are merely pregnancies developing at unusual portions of the tubes. The term tubo-ovarian pregnancy is employed when the foetal sac is composed partly of tubal and partly of ovarian tissue. Such cases owe their origin to the development of an ovum in a tubo-ovarian cyst, or in a tube whose fimbriated extremity was adherent to the ovary at the time of fertilization. They are therefore primarily either tubal or ovarian in origin. Abdominal Pregnancy.—In the earlier literature it was generally stated that the ovum could be implanted upon any portion of the peri- toneum, giving rise to a primary abdominal pregnancy, and in Hecker’s statistics it was recorded twice as frequently as the tubal variety. Later, however, when the specimens were more carefully studied, it became apparent that the great majority of abdominal pregnancies were sec- ondary in character, having resulted from ruptured tubal pregnancy. Gradually doubt began to be cast upon the existence of primary abdominal pregnancy, so that at present most authors, while admitting ABDOMINAL PREGNANCY 739 its theoretical possibility, are extremely skeptical as to its actual oc- currence. Bland Sutton positively denies its occurrence in women, and contends that it is not observed in the lower animals. Hirst and Knipe, Walker, and Jacquin have, however, described specimens, which, while not entirely convincing, so nearly fulfill the requisite criteria that it became necessary to reckon with this variety of extra-uterine pregnancy from a practical point of view. Occasionally, as was shown by Zweifel, Martin, Voigt, Leopold, and Werth, the fertilized ovum may become implanted upon the fimbria ovarica. Such conditions may closely resemble primary abdominal preg- nancy, inasmuch as the surface upon which the ovum was primarily implanted is so small that the margins of the placenta soon extend beyond it and become attached to the surrounding organs, thus giving the impression that the peritoneum was the original site of implanta- tion. A careful microscopical examination, however, will usually enable one to differentiate between the two conditions. Fate of Extra-uterine Foetus.—In the rare instances in which an unruptured tubal pregnancy goes to term, the foetus usually presents some abnormality, which is often attributed to pressure. On the other hand, absorption is the universal fate of small embryos which are ex- truded into the peritoneal cavity, unless the placenta retains its attach- ment to the tube wall and still offers conditions suitable for the con- tinuance of the circulation. Moreover, the young foetus is frequently absorbed while still within the tube, as is shown by the fact that, upon opening early gestation sacs, it is sometimes represented by an amor- phous mass of tissue attached to the umbilical cord. At times the only indication of its previous existence is found in a small stub of cord hanging free in the amniotic cavity. Mall, who has directed particular attention to the condition of the foetus while still within the tube, believes that it is particularly prone to abnormal development. In 117 specimens he found only 16 normal embryos, and, as rupture is more likely to occur under such conditions, he has calculated that in all probability not more than one per cent, of all extra-uterine pregnancies will reach full term. Furthermore, when the foetus has attained a certain size before death it cannot be absorbed, and must undergo suppuration, mummification, calcification, or adi- pocere transformation. Pyogenic bacteria often gain access to a gesta- tion sac, which is adherent to the intestines, and give rise to suppuration of its contents. Eventually the abscess perforates at the point of least resistance, and if the patient does not die from septicemia, portions of the foetus may be extruded through the abdominal wall or into the intestines or bladder, according to the situation of the perforation. This outcome is particularly frequent in broad-ligament pregnancies, on ac- count of their proximity to the rectum. Mummification and lithopedion formation have already been referred to in the chapter on Abortion, and are dealt with fully in Kiichen- meister’s article. The latter is generally regarded as the most favorable of the possible eventualities in cases of advanced extra-uterine preg- nancy, as in many instances the calcified product of conception may be 740 EXTRA-UTERINE PREGNANCY carried for years as a benign foreign body, and do no harm unless it gives rise to dystocia in a subsequent pregnancy. In several instances a lithopedion has been known to remain in the abdomen for fifty years, and the literature contains numerous cases in which a period of twenty to thirty years elapsed before its removal at operation or autopsy. Much more rarely the foetus may become converted into a yellowish greasy mass to which the term adipocere is applied. The fatty material is supposed to be an ammoniacal soap, but a satisfactory explanation of its formation has not as yet been advanced. Diseases of Extra-uterine Ovum.—If an extra-uterine pregnancy goes on without interruption beyond the first few weeks, the ovum is exposed to all the diseases which may occur in the ordinary uterine form. Thus, Schauta, Wertheim, and Micholitsch have rescribed tubal ova which had become converted into hematoma moles. Ilydatidiform moles have been observed by Otto, Kecklinghausen, Wenzel, Sykow, and others; and hydramnios by Teuffel, Webster, and others. Meyer’s statement that he found hydatidiform mole formation in 48 out of 104 pathologic tubal pregnancies can not be accepted without question. In my opinion he has described as such the myxomatous degeneration of the stroma of the chorionic villi, which so often occurs in degenerating pregnancies, and failed to lay stress upon the proliferation of the chorionic ectoderm, which is the characteristic feature of hydatidiform mole. Ahlfeld and Marchand first described a case of chorio-epithelioma following tubal pregnancy, and Eisel, in 1905, was able to collect ten additional cases from the literature. It is interesting to note that Spiegelberg and Holst observed the occurrence of eclampsia during the false labor in cases of advanced extra-uterine pregnancy. Symptoms.—Unfortunately, the manifestations belonging to an unin- terrupted extra-uterine pregnancy are not characteristic, and the patient and her physician are frequently unaware of the existence of any ab- normality until death of the foetus, rupture, or tubal abortion occurs. Ordinarily the patient considers herself pregnant, presents the usual subjective symptoms, and possibly suffers from slight pains in one or other ovarian region, which she regards as the usual concomitants of her condition. In rare instances, indeed, she may have no idea that she is pregnant, and rupture may occur and perhaps prove fatal, even before she has missed a single menstrual period. Suppression of the menses is not associated so regularly with this condition as with normal pregnancy, being noted in only one-half of Brady’s cases. These statements, however, do not carry as much weight as would appear at first sight, for frequently the hemorrhage does not represent a genuine menstrual flow, but is due to the fact that the dilated vessels in the uterine decidua are not covered by a layer of foetal tissue. Moreover, the death of the extra-uterine foetus, if not accompanied by rupture or abortion, is usually associated with more or less uterine hemorrhage, which is frequently mistaken for the menstrual flow or for an early abortion, the latter belief being still further con- firmed by the discharge of decidua. In many cases the first manifestation of the abnormal pregnancy is SYMPTOMS 741 the sudden occurrence of intense, lancinating pain in one or other ovarian region, which is soon followed by faintness, the patient rapidly passing into a condition of collapse. This indicates the occurrence of rupture or abortion. In the former case the collapse deepens, the face becomes pallid, and the patient complains of intense pain in the lower abdomen. The temperature may be subnormal, and an examination of the blood shows a marked diminution in the number of red corpuscles and in the amount of hemoglobin. Death may occur within a few hours unless the hemorrhage is checked by operative means. On the other hand, in most cases of tubal abortion, the general condition is not so alarming, the patient rallies promptly, gradual recovery ensues, and a few days later vaginal examination frequently reveals the presence of a fluctuant mass which fills a greater or lesser portion of the pelvic cavity—pelvic hematocele. Formerly hematocele was considered as a distinct disease, and it was mainly owing to Veit’s observations that its connection with extra- uterine pregnancy was established. It is described as diffuse or solitary, according as the collection of blood occupies a considerable portion of the pelvic cavity or is confined to the neighborhood of the fimbriated end of the tube. The diffuse variety usually occurs when preexisting adhesions about the pelvic organs facilitate the coagulation of blood and aid in the formation of an organized membrane over it, thus shutting it off from the peritoneal cavity. According to Sanger, the solitary hematocele does not require the presence of adhesions for its formation, but results from the gradual trickling of blood from the fimbriated end of the tube, the outer portions gradually coagulating and becoming organized, thus forming a capsule which slowly expands as more blood escapes. Hematocele formation, for the most part, promises a very favorable termination, for if left alone the mass gradually undergoes absorption and complete recovery occurs. Thorn has reported 157 cases with two fatalities, and Fehling 91 cases without a single death. Occasionally, however, if the hemorrhage persists, the hematocele increases in size until it finally ruptures and its contents are poured out into the peri- toneal cavity. Such an accident is speedily followed by collapse. Again, bacteria sometimes make their way into the mass from the intestines and cause suppuration. If the patient survives the rupture of a tubal pregnancy, and the placenta has not been separated to too great an extent, a secondary abdominal pregnancy may result. In such circumstances the usual symptoms of pregnancy persist, except that the woman suffers more pain and feels the foetal movements more acutely than usual. The pain is due partly to stretching and possibly to contractions of the foetal sac, but principally to traction upon adhesions which have formed between it and the various abdominal organs. In a small number of cases in which the primary rupture has taken place between the folds of the broad ligament, secondary rupture into the peritoneal cavity may occur at a later period, and the patient may bleed to death, or a secondary abdominal pregnancy may result. In 742 EXTRA-UTERINE PREGNANCY the latter event, the foetus lies within the peritoneal cavity, while the placenta remains partly within the tube and partly between the folds of the broad ligament. If a secondary abdominal pregnancy, or, as now and again occurs, an unruptured tubal pregnancy, goes on to term, false labor sets in, asso- ciated with pains similar to those occurring in the early stages of normal labor. These are due to uterine contractions, since the foetal sac con- tains so few muscular fibers that it cannot contract, and of course cannot lead to the birth of an extra-uterine child. False labor may last for some hours or several days, and is soon followed by the death of the child, although in a small number of cases the foetal movements have been known to persist for a considerable time after the cessation of the pains. After the death of the foetus, the placental circulation gradually becomes abolished, the amniotic fluid is absorbed, and the foetal sac retracts, so that it occupies a much smaller space than formerly. The abdomen consequently becomes smaller, and its change in size is soon noticed by the patient. After its initial shrinking, the tumor may remain stationary in size for a number of years, the child becoming mummified or converted into a lithopedion; while in rare instances suppurative changes may lead to its gradual discharge, or to the death of the patient from peritonitis. Combined and Multiple Pregnancies.—Parry stated in his monograph that 22 out of the 500 cases of tubal pregnancy collected by him were complicated by a coexisting intra-uterine pregnancy. He designated the condition as combined pregnancy. The condition occurs quite frequently, and has been investigated by numerous writers. Strauss in 1898 was able to collect only 32 cases from the literature, while Weibel in 1905 had increased the number to 119, to which Neugebauer in 1913 added many more. In rare instances twin tubal pregnancy has been observed, both embryos being sometimes found in the same tube, while in other cases there is a foetus in each tube, both showing the same development. Hardouin in 1919 collected 36 examples of the former type. Arey has also considered the subject in detail, and makes the surprising statement that single ovum twins occur many times more commonly in tubal than in uterine pregnancy. He explains the phenomenon by supposing that in view of the difficulties experienced in becoming implanted the rate of growth of the ovum is so retarded that two embryonic areas develop instead of one. Sanger, Krusen, and Diamant have reported cases of triplet tubal pregnancy. Repeated Tubal Pregnancy.—Parry collected 8 cases in which tubal pregnancy had occurred a second time in the same patient, and stated that Primrose in 1594 was the first to describe such a condition. With the increased employment of abdominal surgery, the abnormality has been recognized quite frequently, the first series of cases was reported by Abel in 1893, while Pestalozza in 1901 collected 111 cases. In several instances only a few months had elapsed between the two pregnancies, while in others they were separated by an interval of several years! DIAGNOSIS 743 Sampson and Smith hold that recurrence occurs so frequently that one is justified in removing the uterus and the non-pregnant tube at the time of the first operation. Smith states that patients who have once had a tubal pregnancy are less fertile than normal, but are exposed to a greatly increased probability of a second ectopic gestation. Thus, within five years after the primary operation 80 pregnancies occurred in his 144 patients, in whom subsequent conception was theoretically possible, and of these 23 were repeated tubal pregnancies, and Hartmann and Bergeret noted an almost identical proposition. Effects of Extra-uterine Pregnancy upon Subsequent Childbearing.— The presence of the products of an old extra-uterine pregnancy occa- sionally gives rise to dystocia, and necessitates the performance of a major obstetrical operation. Thus, in the cases reported by Hugenberger, Schauta, and Sanger, cesarean section was performed; while Hennigsen, Dibot, and Brossi induced premature labor, and Stein and Cheston resorted to craniotomy under similar circumstances. As a rule, however, dystocia is not encountered, Funck-Brentano having collected 92 cases in which spontaneous labor occurred in patients still carrying the remains of a previous extra-uterine pregnancy. Diagnosis.—Unfortunately, the symptoms to which uninterrupted extra-uterine pregnancy gives rise are usually so slight that the woman does not consult a physician, and as a result the diagnosis is rarely made before rupture or abortion occurs. If, however, a patient, pre- senting the usual subjective and some of the objective symptoms of pregnancy, be examined, for any reason, and a unilateral tubal tumor be found, the diagnosis is fairly certain, especially if she has been sterile for a number of years or a long interval has elapsed since her last pregnancy. In such cases the uterus is somewhat enlarged and softened, while the tubal tumor is soft and doughy, and corresponds roughly in size to the supposed duration of pregnancy. The first positive diagnosis of unruptured tubal pregnancy was made by Veit in 1883, and in this country by Janvrin in 1886. As a matter of fact, however, it usually happens that when lapa- rotomy is performed for a supposed unruptured early tubal pregnancy, a tumor of some other origin is found. On the other hand, the unrup- tured pregnant tube may prolapse into Douglas’s culdesac and be mis- taken for the body of a retroflexed pregnant uterus, in which event an attempt at its reposition may lead to rupture and occasionally to death. Likewise, when the foetus has died before the occurrence of rupture or abortion, errors in diagnosis are common, and many cases are mis- taken for incomplete uterine abortions or for tubal tumors associated with uterine hemorrhage. For this reason, no attempt should ever be made to empty the uterus in a case of suspected incomplete abortion, unless the tubes and ovaries have been previously palpated. If a careful examination shows that a tumor is present on either side, the possibility of tubal pregnancy should be seriously considered. It is generally taught that the discharge of a distinct decidual cast from the uterus, without evidence of a foetus, is a characteristic sign of tubal pregnancy, especially if a tumor mass can be detected to one side EXTRA-UTERINE PREGNANCY 744 of the organ. But that such a structure now and again may be discharged without the existence of pregnancy of any kind was demonstrated by Griffiths and Dakin. Formerly, such stress was laid upon the presence of decidual tissue that in doubtful cases curettage was recommended for diagnostic purposes. My own experience has taught me that the presence of decidua in such circumstances usually affords strong pre- sumptive evidence, but that its absence is not equally convincing, for occasionally the decidua may have been cast off at an early period, and have been replaced by normal endometrium by the time the patient is examined. The diagnosis of tubal abortion or rupture, on the other hand, usually offers little difficulty, and should be made without hesitation whenever a patient who is believed to be pregnant has complained of pain in the lower part of the abdomen, and suddenly becomes faint, deathly pale, and sinks into a state of collapse. If the collapse becomes more profound and the temperature is subnormal, rupture has probably occurred. On the other hand, if rapid recovery ensues, the probabilities are that one has to deal with an abortion, and the subsequent formation of an herma- tocele settles the question. As has already been pointed out, rupture may occur at a very early period, even before the patient believes herself pregnant. In view of such a possibility, therefore, one should regard sudden collapse asso- ciated with symptoms of abdominal hemorrhage in a woman during the childbearing period as prima facie evidence of a ruptured tubal preg- nancy. By so doing, and operating promptly in suitable cases, a number of lives will be saved which otherwise would inevitably be lost. Very often the patient comes into the hands of the physician some time after she has recovered from the primary shock due to abortion or rupture. Under such circumstances vaginal examination will show a mass on one side of the uterus which is usually mistaken for pelvic inflammatory trouble. In such cases, Cullen has directed attention to the diagnostic value of a blrdsh discoloration of the skin about the umbilicus. Its presence may be regarded as positively indicating the existence of intraperitoneal hemorrhage, but its absence by no moans precludes such a possibility. In a small number of cases, a fluctuant tumor can be felt posterior and lateral to the uterus, and when ex- ploratory puncture through the vagina reveals the presence of a dark bloody fluid, the diagnosis of a pelvic hematocele or a broad-ligament hematoma is assured. That the diagnosis is not always easy is shown by the fact that in the first 303 operations for extra-uterine pregnancy in the gynecological department of the Johns ITopkins Hospital, which were reported by Wynne, the pre-operative diagnosis was verified in only 46 per cent. Brady reports that in the succeeding fifty cases the percentage had increased to 72; but when the facility of diagnosis in the cases of rupture is taken into consideration, it is evident that in all other types errors are frequently made. If the child has survived the rupture, the diagnosis of secondary abdominal pregnancy is rarely made until false labor supervenes, unless TREATMENT 745 the physician’s attention is particularly directed to the previous history of the case. If, however, a careful physical examination is made, the uterus will be found smaller than it should be for the duration of the pregnancy, and displaced by the foetal sac, which makes up the greater part of the abdominal enlargement. Moreover, the child can be palpated much more readily than usual, and its movements are often very painful to the mother. In doubtful cases the introduction of a sound into the uterus is permissible. The diagnosis of broad-ligament pregnancy can be made by finding the uterus pushed to one side by a tumor intimately connected with it, which at the same time depresses the vaginal vault, instead of being high up in the abdominal cavity. The diagnosis of combined intra-uterine and extra-uterine pregnancy is rarely made until after rupture of the extra-uterine pregnancy, or unless the persistence of symptoms following the expulsion of the uterine foetus, leads to a very careful examination. The condition has never been diagnosed in the later months of pregnancy, although in several instances the presence of twins was recognized. After extra-uterine pregnancy has passed full term, the diagnosis is usually easy, and is based upon the history of pregnancy followed by a false labor and a gradual decrease in the size of the abdomen. Exami- nation shows the uterus to be practically normal in size, and displaced to a varying extent by a large tumor more or less intimately connected with it, in which the outlines of the child can occasionally be distin- guished. To recapitulate, a positive diagnosis is occasionally made before rupture, but in the majority of cases the condition escapes recognition until symptoms of collapse point to the probability of rupture or abor- tion. In advanced cases careful examination will usually disclose the real condition of affairs, and when full term has been passed the history is so characteristic that mistakes should scarcely occur. Treatment.—As soon as an unruptured extra-uterine pregnancy is positively diagnosed, its immediate removal by laparotomy is urgently indicated, since rupture may occur at any time and the patient die from hemorrhage before operative aid can be obtained. The importance of immediate operation cannot be too strongly emphasized, and all methods of treatment which aim at destroying the foetus and thus terminating pregnancy without operation are unjustifiable. This applies not only to the use of electricity, but also to the injection of various poisonous substances into the gestation sac. Although Stephen Rogers, in 1867, suggested the propriety of per- forming laparotomy for the purpose of checking hemorrhage from a ruptured tubal pregnancy, Lawson Tait, in 1883, was the first to under- take such an operation. After he had demonstrated the ease with which it could be performed and the surprisingly good results obtained thereby, the procedure came into general use. Its beneficent results were clearly demonstrated by Schauta, who, after a careful study of the literature, in 1891, found that 123 cases operated upon and 121 cases treated without operation presented a mortality of 5.7 and 86.9 per cent, respectively, 746 EXTRA-UTERINE PREGNANCY and at present it is not unusual to operate upon a considerable series of cases without a fatality. For these reasons, whenever we see a possibly pregnant woman in a state of profound collapse, and presenting a deathly pallor of the face, subnormal temperature, and other symptoms of intra-abdominal hemor- rhage, immediate operation is demanded, unless, indeed, her condition is so desperate that death is imminent. The abdomen should be opened rapidly, under coeain anesthesia if necessary. In many cases blood spurts from the abdomen as soon as the peritoneum is incised, and completely obscures the field of operation. In these circumstances, the hand passed down alongside of the uterus seizes the tubal mass, which is then clamped on either side by long forceps. The hemorrhage having been controlled in this way, the blood clots are removed and the field of operation is cleaned up, after which the operator will be able to remove the mass and replace the clamps by ligatures, under the guidance of the eye, at comparative leisure. After the foetal sac has been taken away, it is not advisable to attempt to remove all the blood from the peritoneal cavity, as experience teaches that it can be absorbed in great part, and thus be utilized by the patient. Frequently the appendages on the opposite side may be the seat of chronic inflammatory lesions. Some discretion should be exercised as to their removal at this time, it being better to allow them. to remain than to prolong the operation if the patient is in a very bad condition. At the same time, it should be remembered that their retention will predispose to a repetition of the accident, and on this account Sampson and others recommend removing the uterus along with the tubes. In desperate cases it is advisable to attempt to revive the patient tempo- rarily by the direct transfusion of a small quantity of blood before beginning the operation, and to continue the transfusion after its com- pletion. In less serious cases the subcutaneous or intravenous infusion of sterile salt solution should be begun while the necessary preparations for the operation are being made. In certain cases of tubal abortion, Prochownick, Martin, and others advocate attempting to save the tube, if possible, by opening it and removing the product of conception, after which it is closed by sutures. Although, in view of the important etiological part played by follicular salpingitis, such a procedure must usually be regarded as ill judged conservatism. A freshly ruptured tubal pregnancy should not be attacked through the vagina, for the reason that the procedure is more difficult than a laparotomy, affords but a limited view of the field of operation, while there is always a possibility that it cannot be completed by the vaginal route. If the patient is not seen until the acute symptoms have subsided and the effused blood has become encapsulated as an hematocele, she should be put to bed and carefully watched, operative procedures being instituted only when the hematocele increases in size or symptoms indi- cative of suppuration appear. This condition, however, rarely presents TREATMENT 747 itself, and Thorn operated upon only 6 out of 157 such cases. When, however, the occasion demands it, excellent results are obtained by evacuating the hematocele through an incision in the vaginal fornix and packing the cavity with sterile gauze. Broad-ligament hematomata should be treated in a similar manner. In the later months the treatment of extra-uterine pregnancy differs according as the foetus is alive or dead. In very rare cases a living foetus may be inclosed in an unruptured tubal or ovarian sac, or lie between the layers of the unfolded broad ligament. More frequently, however, one has to deal with a secondary abdominal pregnancy, with the child lying in the peritoneal cavity and inclosed in a sac composed of the foetal membranes and newly formed adhesions, the placenta being within the tube or broadly implanted upon the floor of the pelvis. What- ever the anatomical conditions, the mother is constantly exposed to the possibility of sudden and acute hemorrhage so long as pregnancy con- tinues, and accordingly prompt laparotomy is the only conservative method of treatment. When the child has nearly attained the period of viability, certain authorities urge the propriety of deferring the operation for a few weeks in its interests. While such a course is inadvisable, it may be permissible in exceptional cases, provided the increased dangers of waiting are care- fully explained to the patient and her family and accepted by them. In a small number of cases the operation is comparatively easy and the foetal sac can be removed as readily as a large ovarian cyst. More frequently, however, the sac is densely adherent to surrounding organs, or the placental attachment is spread over a broad area, thereby markedly increasing the difficulty of the operation. Now and again, in broad-ligament pregnancies it will be found that the portion of the broad ligament immediately adjoining the uterus has not been spread apart by the growing ovum, and in such circumstances the entire sac may be removed without great difficulty by ligating the vessels at the pelvic brim and at the uterine cornu before attempting its enucleation. As a rule, however, the complete removal of the gestation sac is by no means easy, and can only be effected by removing the uterus as well. When, as occasionally happens, it is apparent that the operation cannot be completed without seriously endangering the life of the patient, the sac should be incised, the placenta being avoided, if possible, and the foetus extracted. The margins of the sac are then stitched to the abdom- inal incision, the umbilical cord is cut off short, and the cavity packed with sterile gauze, the placenta being left in situ and afterward allowed to come away piecemeal. This method necessarily entails a prolonged convalescence, but is safer than any attempt at removal of the placenta. Occasionally, however, partial separation of the placenta gives rise to such profuse hemorrhage that its removal must be effected at any cost in the hope of preventing immediate death. The results following laparotomy in advanced cases of extra-uterine pregnancy with a living child have improved greatly since the intro- duction of aseptic methods. This was clearly shown by Harris, who 748 EXTRA-UTERINE PREGNANCY collected 27 such cases in 1887, and 145 additional cases ten years later, with a mortality of 93 and 31 per cent, respectively. Nevertheless, the operation is still one of the most dangerous which we are called upon to perform. On the other hand, if the foetus is dead the conditions are much more favorable, as the dangers incident to bleeding from the placental site are markedly diminished. For this reason, the operation should be deferred for six or eight weeks after foetal death in order to permit the obliteration of the vessels supplying the placenta, and thus render possible its removal without hemorrhage. In such cases, however, should dangerous symptoms supervene, immediate interference is indicated. In any event, the operation should not be deferred too long, as there is always a possibility that the foetal sac may become infected from the intestinal tract, when a fatal peritonitis may result. Lusk, in 1886, made an earnest plea for prompt operation in such cases, and supported his contention by a long array of statistics. In a small number of cases of advanced extra-uterine pregnancy operation through the vagina has been recommended* This method of procedure, however, has a very limited field, and laparotomy is usually the operation of choice. LITERATURE Abel. Zur Anatomie der Eileiterscliwangerschaft nebst Bemerkungen zur Ent- wickelung der menschlichen Placenta. Archiv f. Gyn., 1891, xxxix, 393-436. Ueber wiederholte Tubengraviditat bei deselben Erau. Archiv f. Gyn., 1893, xlv, 55-89. Ahlfeld. Ein Fall von Sarcoma uteri deciduo-cellulare bei Tubenschwangerschaft. Monatsschr. f. Geb. u. Gyn., 1895, i, 209-213. Anning and Littlewood. A Case of Primary Ovarian Pregnancy, etc. Trans. London Obst. Soc., 1901, xliii; Lancet, 1901, i, 100. Arey. The Cause of Tubal Pregnancy and Tubal Twinning. Am. Jour. Obst. & Gyn., 1923, v, 163-167. Aschoff. Die Beziehungen der tubaren Placenta zum Tubenabort und zur Tuben- ruptur. Archiv f. Gyn., 1900, lx, 523-533. Neuere Arbeiten iiber die Anat. u. Aetiologie der Tubenschwangerschaften. Cen- tralbl f. allg. Path. u. path. Anat., 1901, Nr. 11, u. 12. Berkeley and Bonney. Tubal Gestation: a Pathological Study. Jour. Obst. and Gyn. Brit. Emp., 1905, vii, 77-96. von Both. Bechtsseitige Tuberschwangerschaft. Buptur im 5ten Monat. Ent- bindung des frei in der Bauchhohle lebenden Kindes durch Laparotomie im 8ten Monat. Monatsschr. f. Geb. u. Gyn., 1899, 782-794. Brady. A Clinical Study of Extrauterine Pregnancy. Bull. Johns Hopkins Hosp., 1923, xxxiv, 152-154. Breslau. Zur Aetiologie und path. Anatomie der Extrauterinschwangerschaft. Monatsschr. f. Geburtsk., 1863, xxi, Supplement Heft, 119-124. Brossi. Quoted by Sanger. Campbell. Abhandlung iiber die Schwangerschaft ausserhalb der Gebarmutter. Translated from the English, Karlsruhe and Freiburg, 1841. Cheston. Quoted by Funck-Brentano. Chiari. Betirage zur Lehre von der Graviditas tubaria. Zeitschr. f. Heilkunde, 1887, viii, 127-146. LITERATURE 749 Couvelaire. Note sur 1 ’anatom ie de la reflechie dans la grossesse tubaire. Comp- tes rendus soc. d’obst., de gyn. et de paed. de Paris, 1900, ii, 50-61. Quelques points de 1 ’anatomic des grossesses tubaires en evolution, etc. Eevue de gyn., 1902, vi, 51-84. Croft. An Anomalous Case of Ectopic Pregnancy, Probably Ovarian. Trans. London Obst. Soc., 1900, xlii, 316-323. Cullen. Bluish Discoloration of the Umbilicus as a Diagnostic Sign when Rup- tured Extrauterine Pregnancy Exists. Contributions to Medical and Biological Research. (Osier volume), 1919, I, 420-421. Dakin. Cast from the Uterus Having All the Characters of the Decidual Mem- brane Pound in Connection with Ectopic Gestation, etc. Trans. Lond. Obst. Soc., 1897, xxxviii, 385-388. Dezeimeris. Grossesses extra-uterines. Jour, des conn, med.-chir., Paris, Dec., 1836. Diamant. Ein Fall von Drillingsschwangerschaft in demselben Eileiter. Zen- tralbl. f. Gyn., 1914, 128-129. Dibot. Quoted by Sanger. Monatsschr. f. Geb. u. Gyn., 1895, i, 21-28. Doderlein u. Herrgott. A New Type of Ectopic Gestation. Pregnancy in an Adenomyoma Uteri. Surg. Gyn. and Obst., 1913, xvi, 14-19. Duhrssen. Ueber operative Behandlung, insbesondere die vaginale Coeliotomie bei Tubarschwangerschaft, etc., nebst Bemerkungen zur Aetiologie der Tubar- schwangerschaft und Beschreibung eines Tubenpolypen. Arehiv f. Gyn., 1897, liv, 207-323. Fehling. Die Bedeutung der Tubenruptur und des Tubaraborts fiir Verlauf, Prognose und Therapie der Tubarschwangerschaft. Zeitschr. f. Geb. u. Gyn., 1898, xxxviii, 67-100. Franz. Ueber Einbettung u. Wachstum des Eies in Eierstock. Beitrage zur Geb. u. Gyn., 1902, vi, 70-81. Freund. Beitrage zur Anatomie der ausgetragenen Extrauteringraviditat. Beitrage z. Geb. u. Gyn., 1903, vii, 104-137. Funck-Brentano. Des grossesses uterines survenant apres la grossesse extra- uterine. These de Paris, 1898. Futh. Ueber die Einbettung des Eies in der Tube. Arehiv f. Gyn., 1901, lxiii, 97-158. Ueber Ovarialschwangerschaft. Beitrage zur Geb. u. Gyn., 1902, vi, 314-331. Gottschalk. Ein Praparat von Ovarialschwangerschaft aus der 3-4. Woche der Graviditat. Zentralbl. f. Gyn., 1886, x, 727. Ein Lithokelyphopadion, das gleichzeitig als Fall von reiner Eierstocks- schwangerschaft sehr bemerkenswerth ist. Yerhandlungen der deutschen Ges. f. Gyn., 1893, 304-305. Griffiths. Note on the Importance of a Decidual Cast as Evidence of Extra- uterine Gestation. Trans. London Obst. Soc., 1894, xxxvi, 335-340. Gubb. The Placenta in Ectopic Gestation and Its Growth after the Death of the Foetus. Med. Press and Circular, 1894, lvii, 326. Gurgui. Die Ovarialschwangerschaft vom path. anat. Standpunkte. Stuttgart, 1880. Hardouin. Grossesses extrauterines gemellaires unitubaires. Archives mens, de gyn. et d’obst., 1919, viii, 331-341. Harris. Operation of Primary Laparotomy in Cases of Extra-uterine Pregnancy. Amer. Jour. Obst., 1887, xx, 1154-1167. Weitere Fortschritte der Entbindung ektopiseher lebensfahiger Friichte durch Koeliotomie. Monatsschr. f. Geb. u. Gyn., 1897, vi, 137-156. Hart. On the Alleged Growth of the Placenta in Extra-uterine Gestation After the Death of the Foetus. Amer. Jour, of Obst., 1892, xxv, 721-735. 750 EXTRA-UTERINE PREGNANCY Hartmann and Bergeret. 146 cas consecutifs de grossesse extrautarine. Annales de gyn. et d’obst., 1919, xiii, 321-345. Hecker. Beitrage zur Lehre von der Sehwangerschaft ausserhalb der Gebar- mutterhohle. Monatsschr. f. Geburtsk., 1859, xiii, 81-123. Heinsius. Ueber tubare Einbettung des menschliehen Eies. Monatsschr. f. Geb. u. Gyn., 1902, xv, 315-322. Hennigsen. Abdominalschwangerschaft bei einer Sechstgebarenden. Archiv f. Gyn., 1870, i, 335-340. Henning. Die Krankheiten der Eileiter und die Tubenschwangerschaft. Stutt- gart, 1876. Henrotin et Herzog. Anomalies du canal de Miiller comme cause des gros- sesses ectopiques. Bevue de gyn., 1898, 633-649. Hirst and Knipe. Primary Implantation of an Ovum on the Pelvic Peritoneum. Surg. Gyn. and Obst., 1908, vii, 156-159. Hoehne. Die Hypoplasie der Tuben in ihrer Beziehung zur Extrauteringraviditat. Zeitschr. f. Geb. u. Gyn., 1908, lxiii, 106-123. Die Aetiologie der Graviditas extraute.rina. Archiv f. Gyn., 1917, cvii, 73-108. Hofmeier. Zur Kenntniss dem normalen Uterusschleimhaut. Zentralbl. f. Gyn., 1893, xvii, 764-766. Hugenberger. Bericht aus dem Hebammen-Institut in Moskau. St. Petersburg, 1863, 122. Jacquin. La grossesse abdominale primitive. Obst. et Gyn., 1922, v, 492-512. Janvrin. A Case of Tubal Pregnancy of Unusual Interest. Trans. Amer. Gyn. Soc., 1886, xi, 471-484. Kermauner. Beitrage zur Anatomie der Tubenschwangerschaft. Berlin, 1904. Kouwer. Fall von Sehwangerschaft im Graaf ’schen Follikel. Zentralbl. f. Gyn., 1897, xxi, 1426. Kreisch. Beitrag zur Anatomie und Pathologie der Tubargraviditat. Monats- schr. f. Geb. u. Gyn., 1899, ix, 794-812. Kuchenmeister. Ueber Lithopadion. Archiv. f. Gyn., 1881, xvii, 153-359. Kuhne. Beitrag zur Anatomie der Tubenschwangerschaft. Marburg, 1899. Kustner. Ueber Extrauterinschwangerschaft. Yolkmann’s Sammlung klin. Vor- trage, N. F., 1899, Nr. 244-245. Landau und Rheinstein. Beitrage zur pathologisehen Anatomie der Tube. Archiv f. Gyn., 1891, xxxix, 273-290. Leopold. Zur Lehre von der Graviditas interstitialis. Archiv f. Gyn., 1878, xiii, 355-365. Ovarialschwangersehaft mit Lithopadionbildung von 35-jahriger Dauer. Archiv f. Gyn., 1882, xix, 210-218. Beitrage zur Graviditas extrauterina. Archiv f. Gyn., 1899, lviii, 525-565, and lix, 557-594. Lequeux. A propos de quelques cas de grossesse interstitielle. L ’obst., 1911, iv, 493-524. Lichtenstein. Basiotrope Placentation, etc. Zentralbl. f. Gyn., 1920, 657-673. Lockyear. Two Cases of Primary Ovarian Pregnancy, etc. Proc. Royal Soc. of Med., 1917, x, 158-182. Ludwig. Eierstocksschwangersehaft neben normaler uteriner Sehwangerschaft, etc. Wiener klin. Wochenschr., 1896, ix, 600-604. Lusk. The Desirability of the Early Performance of Laparotomy in Cases of Abdominal Pregnancy. British Med. Jour., 1886, ii, 1083-1090. Mall. The Cause of Tubal Pregnancy and the Fate of the Enclosed Ovum. Surg. Gyn. and Obst., 1915, xxi, 289-298. On the Fate of the Human Embryo in Tubal Pregnancy. Publication 221, Carnegie Institution, 1915, p. 104. LITERATURE 751 Mall and Cullen. An Ovarian Pregnancy Located in the Graafian Follicle. Surg. Gyn. and Obst., 1913, xvii, 698-703. Mandl. Ueber den feineren Bau der Eileiter wahrend und ausserhalb der Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1897, Y. Erganzungsheft, 130-139. Ueber die Richtung der Flimmerbewegung im nienschlichen Uterus. Zentralbl. f. Gyn., 1898, xxii, 323-328. Mandl und Schmidt. Beitrage zur Aetiologie und path. Anatomie der Eileiter- schwangerschaften. Archiv f. Gyn., 1898, lvi, 401-487. Martin. Zur Kenntniss der Tubarschwangerschaft. Monatsschr. f. Geb. u. Gyn., 1897, v, 1-7 and 244-246. Mayer. Kritik der Extrauterinschwangerschaft, etc. Giessen, 1845. Mendes de Leon et Holleman. Be la grossesse ovarienne. Revue de gyn., 1902, vi, 337-400. Meyer. Hydatiform degeneration in tubal pregnancy. Surg. Gyn. & Obst., 1919, xxviii, 293-302. Meyer and Wynne. Some Aspects of Ovarian Pregnancy. Bull. Johns Hopkins Hosp., 1919, xxx, 92-98. Mikolitsch. Ueber Ovarialgraviditat. Zeitschr. f. Geb. u. Gyn., 1903, xlix, 508- 522. Zur Aetiologie der Tubenschwangerschaft. Zeitschr. f. Geb. u. Gyn., 1903, xlix, 42-62. Moericke. Zur Aetiologie der Tubengraviditat. Sammlung zwangloser Abhand- lungen aus dem Gebiete der Frauenheilkunde u. Geb., 1900, Bd. iii, H. 4 u. 5. Neugebauer. Eine neue Se,rie von 73 Fallen isochroner heterotyper Zwillings- schwangerschaft. Gyn. Rundschau, 1913, vii, 809-831. Oliver. Ovarian Pregnancy. Lancet, 1896, ii, 241. Opitz. Ueber die Ursachen der Ansiedlung des Eies im Eileiter. Zeitschr. f. Geb. u. Gyn., 1902, xlviii, 1-39. Otto. Ueber Tubenschwangerschaft mit Beriicksichtigung eines Falles von Gravi- ditas tubaria molaris hydatidosa. D. I., Greifswald, 1871. Parry. Extra-uterine Pregnancy. London, 1876. Pestalozza. Sulla gravidanza tubariea recidivante. Annala di ost. e gin., 1901, No. 1. Peters. Ueber die Einbettung des menschlichen Eies. Wien, 1899. Pfannenstiel. Extrauterine Graviditat. Verh. d. deutschen Gesellschaft f. Gyn., 1903, x, 194-199. Pinard. Nouveaux documents pour servir a l’histoire de la grossesse extra- uterine. Annales de gyn. et d’obst., 1892, xxxviii, 1-11; 99-118; 181-188. Prochownick. Ein Beitrag zur Mekanik des Tubenaborts. Festschrift der Ges. f. Geb. u. Gyn. in Berlin, Wien, 1894, 266-295. Zur Mekanik des Tubenaborts. Archiv f. Gyn., 1895, xlix, 177-241. Risel. Zur Kenntniss des primaren Chorioepithelioms der Tube. Zeitschr. f. Geb. u. Gyn., 1905, lvi, 154-189. Robson. Primary Ovarian Gestation. Trans. London Obst. Soc., 1902, xliv, 215- 221. Rogers. Extra-uterine Fetation and Gestation, etc. Philadelphia, 1867. Rosenthal. Ein Fall intramuraler Schwangerschaft. Zentralbl. f. Gyn., 1896, xx, 1297-1305. Runge. Beitrag zur Aetiologie der Extrauteringraviditat. Archiv f. Gyn., 1903, lxx, 690-722. Beitrag zur Anatomie der Tubergraviditat. Archiv f. Gyn., 1904, lxvi, 652-674. Sampson. The Influence of Ectopic Pregnancy on the Uterus. Trans. Am. Gyn. Soc., 1913, xxxviii, 121-166. 752 EXTRA-UTERINE PREGNANCY Sanger. Ueber einen Fall von ektopiseher Drillingssehwangerschaft. Zentralbl. f. Gyn., 1893, xvii, 148. Ueber solitare Hamatocele und deren Organisation. Yerh. der deutschen Ges. f. Gyn., 1893, 281-302. Conception durch ein accessorisches Tubenostium. Kaiserschnitt bedingt durch friihere ektopische Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1895, i, 21-28. Schauta. Beitrage zur Kasuistik, Prognose und Therapie der extrauterinen Schwangerschaft. Prag, 1891. Tubarschwangerschaft mit Haematommole. Zentralbl. f. Gyn., 1903, xxvii, 1402-1403. Schumann. Extra-uterine Pregnancy. Appleton, 1921. Sippel. Ueber aussere Ueberwanderung des Eies. Zentralbl. f. Gyn., 1901, xxv, 289-296. Smith. Final Results in One Hunderd and Ninety-two Patients Operated upon for Ectopic Pregnancy. Surg. Gyn. and Obst., 1914, xviii, 684-695. Spiegelberg. Eine ausgetragene Tubenschwangerschaft. Archiv f. Gyn., 1870, i, 406-414. Zur Kasuistik der Ovarialschwangerschaft. Archiv f. Gyn., 1878, xiii, 73-79. Stein. Quoted by Funck-Brentano. Strauss. Tubargraviditat bei gleichzeitiger intrauteriner Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1900, xliv, 26-38. Sutton. The Purvis Oration on Abdominal Pregnancy in Women, Cats, Bogs, and Rabbits. Lancet, 1904, ii, 1625. Tainturier. Etiologie de la grossesse ectopique. These de Paris, 1895. Tait. Lectures on Ectopic Pregnancy and Pelvic Hsematoeele. Birmingham, 1888. Taylor. Extra-uterine Pregnancy. A Clinical and Operative Study. London, 1899, 205. Teuffel. Hydramnion bei Extrauterinschwangerschaft. Archiv f. Gyn., 1884, xxii, 57-64. Thompson. Ovarian Pregnancy, with Report of a Case. American Gynecology, 1902, i, 1-15. Thorn. Ueber Beckenhamatome. Volkmann’s Sammlung klin. Vortrage, N. F., Nr. 119 u. 120. Toth. Beitrage zur Frage der ektopischen Schwangerschaft. Archiv f. Gyn., 1896, li, 410-482. Tussenbroek. Un cas de grossesse ovarienne (Grossesse dans un follicule de Graaf). Annales de gyn. et d’obst., 1899, lii, 537-573. Veit. Die Eileiterschwangersehaft. Stuttgart, 1884. Ueber Deportation der Chorionzotten. Zeitschr. f. Geb. u. Gyn., 1901, 466-504. Die Verschleppung der Chorionzotten. Wiesbaden, 1905. Velpeau. Traite complet de l’art des aceouchements. Paris, 1835, t. i, 214. Voigt. Sehwangerschaft auf der Fimbria ovarica. Monatsschr. f. Geb. u. Gyn., 1898, viii, 222-232. Walker. Ein Fall von primarer Abdominalschwangerschaft. Archiv. f. Gyn., 1919, cxi, 342-369. Walthard. Ueber ein junges menschliches Ei, etc. Zeitschr. f. Geb. u. Gyn., 1911, lxix, 553-581. Webster. Ectopic Pregnancy. Edinburgh and London, 1895. Study of a Specimen of Ovarian Pregnancy. Am. Jour. Obst., 1904, i, 28-44. A Second Specimen of Ovarian Pregnancy. Trans. Am. Gyn. Soc., 1907, xxxii, 122. Weibel. Ueber gleichzeitige Extra- und Intrauteringraviditat. Monatsschr. f. Geb. u. Gyn., 1905, xxii, 739-771. LITERATURE 753 Wenzel. Blasenmole im Eileiter. Alte Erfahrungen im Lichte de,r neuen Zeit, Wiesbaden, 1893, 85-89. Werth. Beitrage zur Anatomic und zur operativen Behandlung der Extrauterin- sehwangerschaft. Stuttgart, 1887. Die Extrauterinschwangersehaft. Winckel’s Handbuch der Geburtshiilfe, 1904, ii, 2, 655-1018. Wertheim. Hsematommole bei Tubenschwange,rschaft. Zentralbl. f. Gyn., 1903, xxvii, 1403. Williams. Contribution to the Normal and Pathological Histology of the Fal- lopian Tubes. Amer. Jour. Med. Sciences, October, 1891. Wyder. Beitrage zur Lehre von der Extrauterinschwangersehaft und dem Orte des Zusammentreffens von Ovulum und Spermatozoen. Archiv f. Gyn., 1886,, xxviii, 325-407. Wynne. Ectopic Pregnancy. Bull. Johns Hopkins Hosp., 1919, xxx, 15-25. Interstitial Pregnancy. Bull. Johns Hopkins Hosp., 1918, xxix, 29-35. Young. The Anatomy of the Pregnant Tube. Edinburgh Med. Jour., 1909, N. S. iii, 118-150. Reproduction in the Human Female. Edinburgh and London, 1911. Zedel. Zur Anatomie der schwangeren Tube mit besonderer Beriicksichtigung des Baues der tubaren Placenta. Zeitschr. f. Geb. u. Gyn., 1893, xxvi, 78-143. Zweifel. Ueber Extrauteringraviditat und retrouterine Hamatome. Archiv f. Gyn., 1891, xli, 1-61. SECTION VII PATHOLOGY OF LABOR CHAPTER XXXI DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FOECES Dystocia or difficult labor may be due to various causes, and is most commonly encountered in the following groups of cases: (1) Those in which the expulsive forces are subnormal and are not sufficiently strong to overcome the natural resistance offered to the birth of the child by the bony canal and the maternal soft parts. (2) Those in which, although the expulsive forces may be of normal strength, abnormalities in the structure or character of the birth canal offer a serious me- chanical obstacle to the descent of the presenting part. (3) Those in which the foetus, on account of faulty presentation or excessive develop- ment, cannot be extruded by the vis a ter go. (4) Those cases in which accidental complications, such as eclampsia, hemorrhage, or rupture of the uterus, lead to various irregularities which interfere with the normal progress of labor. The expulsion of the foetus is brought about by the contractions of the uterus, reenforced during the second stage of labor by the action of the muscles of the abdominal wall. Either of these factors may be lacking in force or intensity, while occasionally they may be abnormally strong. Unfortunately, there is no absolute standard by which the character of the labor pains can be gauged. Thus, in an exceptional primiparous woman a rapid and happy termination of labor may follow a few rela- tively slight pains, -which in the majority of normal primiparae would prove quite inadequate to bring about the desired result. Clinically the efficiency of the uterine contractions may be measured by their effect upon the course and duration of labor, provided there is no serious mechanical obstacle to be overcome, so that, other things being equal, prolonged or precipitate labor occurs as a result of abnormalities in their frequency and intensity. Prolonged Labor.—Normally, in the early stages of labor, the uterine contractions recur at infrequent intervals, and gradually increase in frequency, intensity, and duration as its termination is approached. Moreover, a proper alternation between the contraction and relaxation of the uterus is a very important requisite for the successful accomplish- ment of delivery. Anomalies are often noted in the first stage of labor. In many 754 PROLONGED LABOR 755 instances the pains recur at long intervals and are so feeble in character that dilatation of the cervix is unduly prolonged, with the result that labor, instead of being terminated within the usual period, may drag on for days. If the membranes are unruptured and the patient is in good condition, the delay may be regarded with equanimity, since in the great majority of instances the pains eventually become stronger and more frequent, when the birth of the child is effected without interfer- ence. For this reason, in the absence of symptoms indicative of danger to the mother or child, mere prolongation of labor is not necessarily serious; as it may happen that in a labor lasting 48 hours or longer the patient may suffer less and have actually fewer uterine contractions than another woman in whom the process is completed within the usual period. In such cases, the obstetrician should not interfere hastily, but should encourage the patient to bear her suffering patiently by a plain statement of the facts of the case, and the assurance that a favor- able outcome may be expected, not only for her but also for the child. Again, labor sometimes begins in a perfectly typical manner and gives every promise of an ordinarily speedy termination, and yet after a certain lapse of time, wdthout any appreciable cause, the pains become less frequent and less intense, although giving rise to quite as much or even more suffering than previously. At the same time, the cervix, which was becoming obliterated and dilated in a satisfactory manner, ceases to make further progress, and labor apparently comes to a stand- still. The former condition is attributed to primary, and the latter to secondary, inertia uteri. In other instances, the contractions, although recurring at frequent intervals, are very painful and cramplike in character, but exert very little influence upon the dilatation of the cervix. As a result, oblitera- tion of its canal is brought about very slowly, and the external os undergoes but little change. As a rule, such conditions do not give rise to serious complications, since under appropriate treatment the pains usually assume a more normal character, after which the termination of labor is speedily accomplished. In all of these conditions the prolongation of labor is commonly attributed to the imperfect dilatation of the cervix, which is supposed to be due to an abnormal rigidity of its tissues. Ordinarily, however, the converse is true, and the tardy dilatation is the direct result of faulty uterine contractions. That this interpretation is correct is shown by the fact that the appearance of satisfactory contractions is promptly followed by rapid dilatation of the cervix and a happy termination of labor. On the other hand, however, especially in elderly primiparae, who have passed their thirtieth year, excessive rigidity of the cervix and its consequent tardy and imperfect dilatation may be the essential factor in the production of the dystocia, especially when a further complication has been introduced by the premature rupture of the membranes. This accident may occur before the onset of uterine contractions, and hours, and occasionally days, may elapse between the escape of the amniotic fluid and the onset of uterine contractions. Consequently, it is unwise in such cases to express a definite opinion as to when laboi 756 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES will set in, but one is usually safe in predicting that contractions will begin within 24 hours. In other cases the membranes may rupture early in labor, and before any great degree of cervical dilatation has occurred. In either event, we have to deal with what is designated as “dry labor,” which is usually unduly prolonged and very painful. The delay is due in great part to the absence of the hydrostatic action of the bag of waters, in consequence of which the changes in the cervix must be brought about almost entirely by the direct pressure of the presenting part, which acts as a dilating wedge of imperfect shape and consistency. According to Basset and Demelin this complication occurs in about every tenth labor, and is less serious in multiparae than in primiparae, on account of the decreased resistance of the cervix in the former. Premature rupture of the membranes not only leads to prolongation of labor, but also increases the probability of intrapartum infection even though vaginal examinations have not been made, as bacteria from the vulva may multiply in the capillary layer of fluid in the vagina and readily gain access to the open amniotic sac. Fortunately, such infections, which occur in about every fifth dry labor, are usually not serious, and all signs of them disappear within 24 hours after delivery, but occasionally they may lead to puerperal infection of the patient, and Warnekros has demonstrated that bacteria may be found in the maternal blood before the completion of delivery. Even when the mother escapes infection, the condition is not devoid of danger, as it has long been known that in such cases the child, which is born alive, may succumb a few days later. Hellendahl and others thought that it became infected by swallowing the contaminated amniotic fluid, but Slemons showed that in a certain proportion of cases the bacteria make their way through the amnion covering the foetal surface of the placenta, and, after invading the large vessels which lie just beneath it, gain access to the foetal circulation and give rise to general septicemia or to peritonitis. Slemons designated the process as placental bacteremia, and held that it plays a considerable part in the production of late foetal mortality. Not uncommonly obliteration of the cervical canal takes place with- out difficulty, while the external os alone appears to offer the obstacle to dilatation. In such ca ses its margins are often extremely thin and sharp, and during a contraction may not exceed a sheet of paper in thickness. On the other hand, especially when labor is unduly prolonged, they may become thick and edematous. In the absence of any mechanical obstacle, prolongation of the second stage of labor is rarely due to abnormalities in the uterine contractions, but rather to deficient action of the abdominal muscles. In primiparous women, especially, the tardy labor is often ascribed to the resistance offered by a rigid perineum and a small vaginal outlet, but in the ma- jority of cases this is only apparent, the delay being really due to an insufficient vis a tergo, or to the head, which was descending with the occiput obliquely posterior, undergoing only partial rotation and being arrested in the deep transverse position. PROLONGED LABOR 757 Etiology.—Uterine insufficiency is usually attributed to one of three causes: faulty development or diseased conditions of the uterine muscu- lature, anomalies in its innervation, or mechanical interference with its contraction. The first factor is the one most frequently concerned in the causation of tardy labor, and is especially likely to be associated with imperfect general development, being most frequently observed in patients possessing justominor pelves, but only very rarely in sufferers from rachitic deformities. It should, however, be remembered that faulty development of the uterine musculature is occasionally noted in apparently normal women, and is relatively common in large, thick set, and corpulent individuals. Sometimes the faulty action of the uterine muscle is attributable to a loss of tonicity incident to excessive distention, and is therefore met with in women who have passed through a number of pregnancies in rapid succession, or in whom the uterus has been subjected to acute distention, as in multiple pregnancy and hydramnios. Much less com- monly the defect is due to general weakness following exhausting diseases, but that this is rarely responsible is shown by the common observation that the pains are usually efficient even in patients suffering from advanced stages of tuberculosis. We are almost entirely ignorant concerning the nervous control of the uterine contractions, and consequently direct proof of the existence of abnormalities in the innervation of the uterine musculature cannot be adduced; nevertheless, clinical observation affords strong presumptive evidence in favor of this view, or at least indicates clearly that ex- traneous causes may interfere reflexly with the activity of the uterus. Thus, it is a matter of common experience that the entrance of the obstetrician into the lying-in chamber is frequently followed by a tem- porary cessation of the labor pains. Moreover, extreme nervousness, profound mental emotions, or excruciating pain may have a similar effect. In such cases, the severe pain is often due to the irregular action of the uterus, which in turn, by acting reflexly, interferes still further with its function, thus giving rise to a vicious circle. That reflex nervous influences are frequently responsible is shown by the fact that the administration of a sedative may be followed by a return of satis- factory contractions. That the action of the uterus is occasionally influenced by mechanical conditions is shown by the frequent association of unsatisfactory con- tractions with the presence of multiple myomata in the uterine wall. Much the same effect is exerted when the organ sags markedly forward in a pendulous abdomen. Old adhesions about the uterus and appen- dages and fresh inflammatory areas in the same location may act in a similar manner. In the second stage defective abdominal contractions may be due to a number of causes. The insufficiency may result from faulty develop- ment of the muscles themselves—more frequently it is due to a loss of muscular tone following excessive distention, so that it is much more common in multiparous than in primiparous women. In many instances the insufficiency is only apparent, and is due to the fact that for fear of 758 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES increased pain the patient is unwilling to bring her abdominal muscles into full play, and accordingly makes voluntary efforts to restrain them. For this reason the obstetrician is sometimes obliged to terminate labor by means of low forceps, although he feels sure that a few minutes’ effective use of the abdominal muscles would lead to spontaneous delivery. In many such cases the induction of anesthesia is attended by happy results, since it dulls the sensation of pain sufficiently to enable the patient to bring her abdominal muscles into action. Treatment of Prolonged Labor.—Active treatment is rarely demanded when the tardy labor is the result of infrequent pains of slight intensity, as they gradually become more severe and eventually bring about a spontaneous delivery. It is highly important that the physician should remember that the gravity of a case of labor is not measured by its duration alone, and that interference is not indicated unless objective signs of exhaustion or infection, or danger to the child, become manifest. Should the labor last for several days it is important that the moral courage of the patient be maintained, and that she should sleep well at night. Consequently, the administration of hypnotics, or even of morphin hypodermically, is indicated. On the other hand, when the pains follow one another in rapid succession without exerting any appreciable effect upon the dilatation of the cervix, but are inefficient and cramplike, excellent results often follow the administration of a hypodermic injection of morphin (grain 1/4), combined with the sulphate of atropin (grain 1-150) ; or of a rectal injection containing 30 grains of chloral hydrate in 4 ounces of warm milk, and repeated, if necessary, in one hour. When the dystocia is due to secondary uterine inertia the problem is more difficult; though, as a rule, if the patient can obtain several hours of sound sleep, more satisfactory pains will appear when she wakens. For this reason the use of a hypnotic is often indicated. In other cases, the administration of 15 grains of quinin sulphate, in solution or in freshly prepared capsules, or the same amount of the hydrochlorate hypodermically, is promptly followed by a marked increase in the fre- quency and efficiency of the uterine contractions. If, however, the uterus does not respond to that amount of the drug, its further administration may be regarded as useless. As I have had no experience with the intravenous administration of a solution of glucose, which has been enthusiastically recommended by Muller, I cannot express an opinion as to its value. Following the discovery by Dale that the administration of an ex- tract of the infundibular portion of the hypophysis stimulated the uterine contractions, Hofbauer, in 1911, advocated its employment in uterine inertia. Since then an immense literature has accumulated upon the subject, and numerous preparations have been put upon the market —such as pituitrin, pituitary liquid, hypophysin, pituglandol, etc.. Fol- lowing the contribution of Parisot and Spire, it has become established that the hypodermic administration of 1 cubic centimeter of any efficient preparation promptly results in a great increase in the force of the uterine contractions. Many writers have therefore recommended its use PROLONGED LABOR 759 ill the class of cases under discussion, but, as will be indicated below, I consider its administration highly reprehensible during the first stage of labor. Ergot was formerly used with a free hand in this condition, but at present is employed only by ignorant midwives. It is true that its administration may be followed by an increase in the intensity of the uterine contractions, but they soon lose their normal characteristics and become tetanic. As a result the uterus is liable to remain firmly con- tracted upon its contents, and, no longer alternating between contraction and relaxation, loses its expulsive power, so that the final action of the drug is to defeat the very purpose for which it was given. Moreover, if a mechanical obstacle exists, the use of ergot may lead to so pro- nounced an overstretching of the lower uterine segment that rupture occurs. Accordingly, it should never be employed for its oxytocic prop- erties, but should be used only as a means for controlling uterine hemorrhage after the expulsion of the placenta. As has already been pointed out, abnormalities in the contractions of the uterus are usually associated with imperfect dilatation of the cervix, and in elderly primiparae, and occasionally in younger women who have suffered from inflammatory conditions about the cervix, rigidity of the tissues can sometimes be invoked as its underlying cause. In these circumstances, as well as in many cases of dry labor, the administration of a sedative is followed by satisfactory results. The use of an anes- thetic, although it sometimes leads to satisfactory dilatation of the cervix, is generally inadvisable, inasmuch as the patient, having once experienced its soothing effect, refuses to dispense with it, so that the obstetrician will often be obliged to continue its employment, with the result that the uterine contractions become less frequent and efficient, and render operative interference necessary. Occasionally a hot full bath is attended by satisfactory results. Operative interference, however, should be undertaken only in the presence of objective symptoms, indicative of profound exhaustion or infection on the part of the mother, or of actual danger to the child. In my experience, there are few obstetrical conditions which require greater nicety of judgment as to the necessity for interference and choice of procedure; for, should the result be unsatisfactory, one is usually inclined to regret his decision and to wish that he had delayed inter- ference or had chosen some other procedure. Generally speaking, if there is no disproportion between the size of the child and the birth canal, and the cervical canal is obliterated, and resistance is offered only by an external os, presenting thin margins and a diameter of five or more centimeters, excellent results may be obtained by completing the dilatation by Harris’ manual method, and then effecting delivery by version or forceps according to the exigencies of the case. This procedure, however, should be resorted to only in the presence of some pressing indication, and should not be attempted merely for the sake of shortening the labor; for, even when practiced under the relatively favorable conditions just mentioned, it frequently results in extensive laceration of the cervix, which requires immediate repair. That such 760 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES a warning is necessary is shown by the fact that each year I see in consultation several women who die from hemorrhage or infection fol- lowing deep cervical tears, which have resulted from unnecessary or too hasty interference. If the cervical canal has not become obliterated, manual dilatation should not be considered, but a moderate sized Champetier de Kibes bag should be introduced into the uterus. This usually acts as an efficient irritant, and brings about satisfactory contractions with resulting dilatation in the course of a few hours. If, however, the indication for delivery is urgent, vaginal hysterotomy may be employed with ad- vantage, as recommended by Seitz. In all such conditions, every detail of aseptic technic should be scrupulously observed and no attempt made to deliver the child until all obstacle on the part of the cervix has been overcome. Cesarean section should not be thought of in such cases, as so much time has elapsed since the onset of labor that, while the opera- tion may save the life of the child, it will expose the patient to an unjustifiable risk. Tardy labor, due to the prolongation of the second stage, whether resulting from deficient uterine or abdominal action or from unusual resistance on the part of the perineum, is best treated by the application of forceps, except when the dystocia is attributable to disproportion between the size of the child and the pelvis. Following the discovery of the oxytocic properties of pituitary extract a great revolution has occurred in the treatment of this type of prolonged labor, and my experience has shown that the judicious administration of pituitrin will do away with the necessity for the application of low forceps in from one-third to one-half of the cases in which it was formerly employed. Notwithstanding this apparently enthusiastic state- ment, I consider that great caution should be exercised in the use of the drug, as its injudicious employment may place the life of both mother and child in jeopardy. Furthermore, I feel that the claims made by several manufacturing chemists concerning its harmlessness are incorrect and reprehensible, and are calculated to lead inexperienced practitioners into therapeutic excesses to the great detriment of their patients. As a result of my experience, I would state categorically that the use of pituitrin is absolutely contra-indicated in the presence of me- chanical disproportion or before the cervix has become fully dilated, and, furthermore, that in primiparae it is generally inadvisable until the presenting part has reached the pelvic floor. Its chief indications are twofold—First, in multiparae suffering from uterine inertia, in whom labor has come to a standstill with the cervix fully dilated and the head lying below the ischial spines; and, secondly, in primiparae, -when the head has become arrested at the vaginal outlet, and it seems that only a few strong expulsive efforts are needed for its extrusion. In many such cases, within three minutes after the hypodermic administration of one-half cubic centimeter of a reliable preparation, the uterine contractions undergo a veritable revolution, and the pains, which were previously sluggish and far apart, become strong, regular and PRECIPITATE LABOR 761 efficient, with the result that labor is promptly terminated. The action of pituitrin is relatively evanescent, and usually becomes exhausted within 15 or 20 minutes; consequently, if a result is not obtained within that period none can be expected, and delivery should be terminated by low forceps, instead of repeating the dose. Occasionally, however, even when the above conditions are fulfilled, the results are not so happy, and the uterus, instead of being stimu- lated to regular activity, passes into a condition of tetanic contraction. In several instances this became so alarming that I felt compelled to place the patients under the full anesthetic action of chloroform. If this can occur during the latter part of the second stage in an otherwise normal labor, it is apparent what may happen if the head is arrested at the superior strait as the result of a contracted pelvis or an abnormal presentation, or when the cervix is only partially dilated. That the danger of rupture of the uterus is not hypothetical, is shown by the fact that Mundell was able to collect a considerable number of cases which had been reported up to the end of 1915, and since then nearly every one responsible for the conduct of a large obstetrical service has been obliged to resort to laparotomy in order to prevent death from intra-abdominal hemorrhage following it. In other cases, the excessive uterine activity may so interfere with the placental circulation that the child succumbs to intra-uterine asphyxia. I have not as yet observed such an accident, but several of my friends have, and I regard it as so real a danger that, whenever pituitrin is administered to a primipara, preparations are made so that forceps can be applied immediately should the foetal heart sounds indicate danger, and in several instances I feel that the life of the child has been saved as the result of this precaution. To summarize, I consider that we have in pituitrin a potent drug, which, while useful in properly selected cases, may lead to disaster if injudiciously used. Furthermore, I believe that in its employment the history of ergot will be repeated, and that, instead of being used indis- criminately as at present, its employment will be eventually restricted to several sharply defined indications; first, in conjunction with ergot, to stimulate prompt contraction of the freshly delivered uterus before the more slowly acting ergot can exert its effect; second, to replace low for- ceps in certain multiparous women, in whom merely a slight increase in the vis a tergo is required; and, possibly third, to act as an adjuvant to castor oil and quinine in the induction of labor by Watson’s method. Indeed, for my part, I would willingly dispense with it altogether, except for the first indication, where it serves a useful, and at times an indis- pensable, purpose. Precipitate Labor.—In certain multiparous women, and very rarely in primiparae, precipitate labor may result from an abnormally slight degree of resistance offered by fhe soft parts, or from abnormally strong uterine and abdominal contractions, or very occasionally from the absence of painful sensations during labor. Generally speaking, precipitate labor is not attended by serious con- sequences, although the child is sometimes extruded so rapidly that the 762 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES patient is unable to secure proper attention. In such circumstances deep tears of the perineum are common. It sometimes happens that the woman is suddenly overtaken by intense labor pains and gives birth to the child before she can reach her bed. In such cases, the child may fall to the ground and sustain severe or even fatal injuries. Occasionally the cord is torn through and it is generally believed that the child may bleed to death before aid is obtainable. This, however, is unlikely, as experience shows that the jagged and irregular tear, which must result in such circumstances, would probably lead to coagulation of the blood and cessation of hemorrhage before a fatal issue ensued. If tempestuous pains come on while the patient is under the observa- tion of a physician, they should be controlled by the administration of chloroform, in order that the head may be held back and prevented from being born too brusquely. The effects of precipitate labor have been studied particularly by Winckel. Tetanic Contraction of the TJterus.—Occasionally in the first, and more frequently in the second stage of labor, the uterus may cease to relax at regular intervals, and pass into a condition of continued or tetanic contraction. This condition is usually encountered in prolonged labors, in which a mechanical obstacle is opposed to the passage of the child. In such cases the danger of rupture of the uterus becomes im- minent, although now and again this accident may occur when every- thing seems to be going on normally. So long as the tetanic condition persists, the extrusion of the contents of the uterus is out of the question; while at the same time the patient suffers intense pain, and the child is exposed to considerable danger, owing to interference with the placental circulation. If the condition is not due to an obstruction, it can be temporarily controlled by the administration of sedatives or an anesthetic, after which delivery should be effected as soon as practicable. Contraction of Bandl’s Ring.—Closely related to this form of dys- tocia is that which is sometimes attributed to a stricture resulting from tonic contraction of Bandl’s ring. Considerable attention has been di- rected to this complication within the last few years, and numerous cases have been described by Budin, Demelin, Cheron, Rossa, Dickinson, and others. The French observers believe that, while the portions of the uterus above and below it remain flaccid, BandFs ring can undergo isolated contraction, and thereby so strongly compress the neck or some other portion of the child as to interfere seriously with its delivery. Cheron has reported instances of transverse presentation in which this kind of stricture developed and confined the child to the upper portion of the uterus, at the same time offering an almost insuperable obstacle to the introduction of the hand for the performance of version. Formerly I agreed with Yeit who doubted the correctness of such observations, and held that in the cases described one had to deal with tetanic contraction of the entire active portion of the uterus. In this event, the lower uterine segment would be flabby, while the rest of the organ would be tightly contracted, there by losing its ability to expel its contents, .and at the same time making difficult the introduction CONTRACTION OF BANDL’S RING 763 of the hand or instruments into the uterus. Since 1919, however, I have met with several cases, which have convinced me that I was in error and that contraction of Bandl’s ring may give rise to serious dystocia. My first experience was with an elderly primipara, whose labor had proceeded normally until the head had reached the pelvic floor. As no further advance occurred, I applied forceps to the sides of the head anticipating an easy extraction, but was surprised to find that strong traction resulted in no advance. Upon removing the blades, I found that difficulty was due to the fact that the neck was encircled by a rigid muscular ring, which held back the shoulders and opposed con- siderable resistance to the passage of a single finger past it. Under deep anesthesia I finally overcame the resistance manually, turned, and eventually extracted a living child. Within two weeks I encountered a similar condition, and have since met with it in several other patients. In one of them, cesarean section was done and the body of the uterus amputated, as I was unable to dilate the ring manually and the child was in good condition. Strange to say, all trace of the obstruction dis- appeared as soon as the organ was incised, and no further difficulty was experienced in extracting the child. Furthermore, careful examination of the extirpated organ failed to afford any explanation for the pro- duction of the clinical phenomenon. Clifford White in 1913 reported three personal cases in detail before the obstetrical section of the Boyal Society of Medicine. From one patient he removed the unopened uterus, which on section showed the presence of a thick ring at the junction of its middle and lower third, which thus afforded indisputable evidence of the nature of the obstruc- tion. In addition he was able to collect from the literature 13 cases in which cesarean section had been employed to cope with a similar com- plication; while Gammeltoft in 1919 studied the question exhaustively upon the basis of 23 cases observed in the Copenhagen clinic. Greenhill in 1922 reported a remarkable case in which the condition developed during the birth of the child. In this instance the head was born spontaneously and no difficulty was experienced until strong trac- tion was required to effect delivery of the body. After birth the child was found to be normal, except for a deep circular constriction at the junction of the upper and middle thirds of the right thigh. Above it the dimensions were normal, while below it the leg was swollen to twice the size of its fellow. The swelling disappeared within a couple of days, and the writer held that the condition could be explained only by assuming the development of an isolated constricting band, which he located at the upper part of the cervical canal or at Bandl’s ring. Hour-glass Contraction.—As the result of the misuse of ergot, or of extensive adherence of the placenta, the uterus sometimes undergoes such an extreme degree of retraction during the third stage that the latter becomes imprisoned in its cavity. In such cases the greater part of the upper segment of the uterus is tightly contracted over the re- tained placenta, while its lower portion is felt by the examining finger as 764 DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES a tightly contracted ring below the placenta. The lower uterine seg- ment and the cervix, not having recovered from the distention to which they have been subjected, are flabby in character, and widen from above downward to the vaginal insertion. From the shape thus imparted to the uterus the condition is generally designated as an “hour-glass con- traction” Its occurrence usually necessitates the manual removal of the placenta, which can sometimes be accomplished only under anes- thesia. Missed Labor.—In very exceptional instances uterine contractions come on at or near term, and, after continuing for a variable time, disappear without leading to the birth of the child. The latter then dies, and may be retained in utero for months, undergoing mummifica- tion or putrefaction, according as the membranes have ruptured or not. This is known as missed labor. The term should not be applied to those cases in which a living child is born, as they are probably only examples of prolonged gestation. In the cases described by Menzies and Hennig the child had been retained for two hundred and eighty and two hundred and ten days respectively after full term. In the former instance it was removed at autopsy, and in the latter after incision through the cervix. Krevet has recorded a typical case, in which the foetus, which had been retained for sixty-two days, was expelled spontaneously in a partially mummified condition, while the placenta looked as if it had been preserved in a hardening fluid. Nothing is known as to the etiology of the condition, though in the cases reported by Labhardt it was associated with carcinoma of the cervix and myoma of the uterus respectively. Cuilla is inclined to asso- ciate the phenomena with excessive fatty degeneration of the uterine musculature. It may readily be confounded with the retention of the child after the false labor following full-term tubal gestation, or with pregnancy in a rudimentary horn of the uterus, though a careful exami- nation should preclude the possibility of such a mistake. Labor should be induced as soon as the diagnosis is made, and in one of my patients was readily accomplished by the introduction of a bougie two months after the death of the foetus. LITEEATURE Basset. Ueber die Bedeutung des friihzeitigen Blasensprunges fiir Geburt und Woehenbett. Zeitschr. f. Geb. u. Gyn., 1913, lxxiii, 566-581. Budin. De la dystocie causee par l’anneau de Bandl. L ’obstetrique, 1898, iii, 289-310. Cheron. Des difficultes de la version eausees par la retraction de l’anneau de Bandl. These de Paris, 1899. Cuilla. Ueber die fettige Degeneration der Gebarmutter in der Schwangerschaft. Zentralbl. f. Gyn., 1907, 1109-1117. Demelin. De la retraction uterine avant la rupture des membranes. L’obstet- rique, 1898, iii, 49-59. Dickinson. Caesarean Section for Impassable Contraption Bing. Surg. Gyn. and 0b.pt., 1910, x, 377-391, LITERATURE 765 Gammeltoft. Zu der dureh den Bandl ’sehen Ring verursaehten Dystokie. Archiv f. Gyn., 1919, cxi, 29-104. Greenhill. Dystocia Due to Constriction of One Thigh by the Cervix in a Cephalic Presentation. J. Am. Med. Assoc., 1922, lxxviii, 98-100. IIellendahl. Ueber die Bedeutung des infizierten Fruchtwassers fiir Mutter u. Kind. Beitrage zur Geb. u. Gyn., 1906, x, 320-374. Hennig. Ueber Lithopaedia intrauterina. Archiv f. Gyn., 1878, xiii, 292-299. Hofbauer. Hypopliysenextract als Wehenmittel. Zentralbl. f. Gyn., 1911, 137- 141. Krevet. Retention einer in der normalen Gebarmutter am richtigen Ende der Schwangerschaft abgestorbenen Frucht bis zum 344 Tage. Archiv f. Gyn., 1900, lxi, 435-444. Labhardt. Ein Fall von “Missed Labour” bei Carcinoma uteri. Beitrage zur Geb. u. Gyn., 1902, vi, 437-448. Muller. Klinische Beobachtungen iiber Traubenzucker als wehenfordendes Mittel. Zentralbl. f. Gyn., 1922, 140-145. Mundell. Pituitrin in Labor. Am. Jour. Obst., 1916, lxxiii, 306-314. Parisot et Spire. La medication hypophysaire en obstetrique. Annales de Gyn. et d’Obst., 1911, viii, 689-706. Rossa. Der Contractionsring in seinem Beziehungen zur Mechanik der Geburt. Monatsschr. f. Geb. u. Gyn., 1900, xii, 457-480. Seitz. Ueber Weichtheilschwierigkeiten, etc. Archiv f. Gyn., 1910, xc, 1-120. Slemons. Placental Bacteremia. J. Am. Med. Assn., 1915, lxv, 1265-1268. The Significance of Fever at the Time of Labor. Am. Jour. Obst., 1918, lxxviii, 321-328. Veit., Ueber die Dystocie durch den Contractionsring. Monatsschr. f. Geb. u. Gyn., 1900, xi, 493-501. Warnekros. Plazentare Bakteramie. Archiv. f. Gyn., 1913, c, 173-195. White. The Contraction Ring as a Cause of Dystocia. Lancet, 1913, i, 604-607. Winckel. Ueber die Bedeutung pracipitirter Geburten fiir die Aetiologie des Puerperalfiebers. Miinchen, 1884. CHAPTER XXXII DYSTOCIA DUE TO ABNORMALITIES OF THE GENERATIVE TRACT Vulva.—Complete atresia of the vulva or the lower portion of the vagina is usually congenital, and unless corrected by operative measures would oppose an insuperable obstacle to conception. Von Meer has reported an exceptional case in which the lower two-thirds of the vagina were lacking, while the upper third communicated with the bladder. Coitus was accomplished per urethram, through which a three months’ foetus was subsequently expelled. More frequently vulval atresia is incomplete, and is due to adhesions and cicatricial changes resulting from injury or inflammatory processes. The defect may offer a considerable obstacle to labor, but the resistance is usually overcome by the continued pressure exerted by the head, though frequently only at the expense of deep perineal tears. I have seen cases in which an almost imperforate hymen had re- mained intact until the time of labor, and only ruptured when distended by the child’s head. In rare instances, as was pointed out by Coester, a thick septate hymen may form a bridge of tissue opposing the advance of the presenting part, and may require to be cut through before delivery can be completed. Especially in elderly primiparae, the vulval outlet may he very small, rigid, and altogether lacking in elasticity, and causes dystocia and pre- disposes to extensive laceration. Again, as the result of pressure or renal lesions, the vulva may become so edematous that its orifice is almost occluded. In these circumstances the soft parts may he so brittle that they are peculiarly liable to laceration. Moreover, when excessive edema has persisted for some time, the tone of the tissues may be so lowered that they even become gangrenous as a result of the traumatism incident to labor. The formation of thrombi or hematomata about the vulva, although more common during the puerperium, occasionally occurs during the latter part of pregnancy or at the time of labor, and may give rise to slight dystocia. Inflammatory lesions about the vulva, as well as malignant new growths, may have a similar effect. Vagina.—Complete vaginal atresia is nearly always congenital in origin, and is an effectual bar to pregnancy. Incomplete forms, on the other hand, are sometimes manifestations of faulty development, hut more frequently result from accidental complications. Very occasionally the vagina is divided into two halves by a longi- tudinal septum extending from the vulva to the cervix; more often the structure is incomplete, being limited to either the upper or lower por- 766 VAGINA 767 tion of the canal. Such conditions are frequently associated witli abnor- malities in the development of the generative tract, and their detection should always lead to further careful examination, with a view to deter- mining whether partial or complete duplicity of the uterus exists. A complete longitudinal septum rarely gives rise to dystocia, as the half of the vagina through which the child descends gradually undergoes satisfactory dilatation. On the other hand, an incomplete septum occa- sionally interferes with the descent of the head, becoming stretched over it as a fleshy band of varying thickness. Such structures are usually torn through spontaneously, but occasionally are so resistant that they must be ligated and severed by the obstetrician. Occasionally the vagina may be obstructed by ringlike strictures or bands of congenital origin. These, however, rarely offer a serious ob- stacle to labor, as they usually yield before the oncoming head, though in extreme cases incision may be necessary. Sometimes the upper portion of the vagina is separated from the re- mainder of the canal by a diaphragmlike structure with a small central opening. Such a condition is occasionally mistaken by inexperienced observers for the vaginal fornix, and at the time of labor for the undi- lated external os. A careful examination, however, should reveal the presence of the opening, through which a finger can be passed, the cervix then being distinguished above it. After the external os is completely dilated, the head impinges upon the abnormal structure and causes it to bulge downward. If it does not yield, slight pressure upon its opening will usually lead to further dilatation; but if this is not effectual crucial incisions may be necessary in order to allow of delivery. Accidental atresia is always secondary in origin, and results from the formation of adhesions following injuries or inflammatory processes. It sometimes follows severe puerperal infections, during the course of which the entire lining of the vagina may have sloughed off, so that as healing occurs its lumen has become almost entirely obliterated. A similar result is sometimes noted after diphtheria, smallpox, cholera, and syphilis; while in rare instances, as in a case reported by Schenk, it may be "due to the action of corrosive fluids injected into the vagina in the hope of inducing abortion. That the most frequent cause of atresia is injury or inflammatory conditions following labor is shown by the fact that 209 of the 1,000 cases collected by Neugebauer presented such a history. The effects of such conditions vary greatly. In the majority of cases, owing to the softening of the tissues incident to pregnancy, the obstruc- tion is gradually overcome by the pressure exerted by the presenting part; less often manual or hydrostatic dilatation or incisions may become necessary. If, however, the structure is so resistant that spontaneous dilatation appears improbable, cesarean section should be performed at the onset of labor. Full literature concerning this complication is to be found in the articles of Ward and Brindeau. Among the rare causes of serious dystocia, vaginal neoplasms are worthy of mention, Giider, in 1893, having collected 60 cases from the literature. The obstruction was due to the presence of cystic structures, DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACT 768 fibromata, carcinomata, sarcomata, or hematomata, arising from the vaginal walls or the surrounding tissues. When the tumor is accessible it is best treated by excision, no matter what its origin. If this is not practicable, and the growth is cystic, tapping becomes the operation of choice. The presence of a solid tumor may occasionally afford an indi- cation for cesarean section. Sasonoff observed a case in which a vaginal hematoma developed so rapidly after the birth of one twin as to inter- fere seriously with the delivery of the second child. Exceptionally tetanic contraction of the levator ani muscle may seri- ously interfere with the descent of the head. In this condition, which is analogous to the vaginismus of non-pregnant women, a thick, ring- like structure completely encircles and markedly constricts the vagina several centimeters above the vulva. Hue, in 1906, collected a number of such cases. Ordinarily the condition yields under the influence of anesthesia, though in one of my patients the obstruction persisted in spite of pro- found anesthesia, and it was only after steady pressure had been exerted upon it for some minutes that it relaxed sufficiently to permit the passage of the hand folded in the shape of a cone. Cervix.—Inasmuch as complete atresia of the cervix is incompatible with conception, it must be assumed, whenever such a condition is met with in a pregnant woman, that conception had occurred before its formation, or that the atresia was only relative. A good illustration is afforded by the so-called conglutinatio orificii externi. In this condition the cervical canal undergoes complete ob- literation at the time of labor, while the os remains extremely small with very thin margins, the presenting part being separated from the vagina only by a thin layer of cervical tissue. Formerly, this appearance was attributed to the existence of adhesions between the lips of the external os, but Schroeder was probably right in stating that it is simply due to a very small and resistant opening. Ordinarily, complete dilatation promptly follows from pressure with a finger tip, although in rare instances manual dilatation or crucial incisions may become necessary. Cicatricial stenosis of the cervix frequently follows difficult labor associated with infection and considerable destruction of tissue. Less frequently it is due to syphilitic ulceration and induration, several in- stances of which have been reported by Le Bigot. Now and again it results from the employment of corrosive substances for the purpose of producing abortion; while occasionally it is a sequel to gynecological operations. Ordinarily, owing to the softening and succulence of the tissues inci- dent to pregnancy, the stenosis, whatever its cause, gradually yields to the natural forces; but in other cases dilatation has to be accomplished by manual methods or by the employment of rubber bags. In rare instances, however, the resistance may be too great to be so overcome, and in such cases cesarean section should be performed early in labor. In a number of my patients cesarean section was necessary on account of complete atresia of the external os. As several of them had previous spontaneous labors, and as no history of inflammatory trouble or of UTERINE DISPLACEMENTS 769 attempts at abortion could be elicited, the cause of the condition re- mained doubtful. In other cases, the atresia had followed high amputa- tion of the cervix, and in one of them no trace of an opening could be found in the organ removed after cesarean section, although it must have existed at the time of conception. Ahlstrom, in 1904, thoroughly reviewed the literature. Rigidity of Cervix.—Reference has already been made to the unyield- ing cervix of elderly primiparae. Occasionally still greater rigidity is encountered in patients who have suffered from inflammatory lesions, though such conditions rarely give rise to serious dystocia. On the other hand, in certain cases of hypertrophic elongation of the cervix, spontaneous dilatation does not occur, although, as a rule, one is sur- prised to see how completely the abnormality may be effaced during the course of pregnancy. Uterine Displacements.—Anteflexion.—Marked anteflexion of the uterus is usually associated with a pendulous abdomen. In primiparae the condition is usually indicative of disproportion between the size of the head and the pelvis; whereas in multiparae it is more often an accompaniment of the flaccidity of the abdominal walls incident to re- peated childbearing. In the latter class of cases the abnormal position of the uterus prevents the force of its contractions from being properly transmitted to the cervix, hence the dilatation of the latter is inter- fered with. Marked improvement in this respect usually follows the maintenance of the uterus in an approximately normal position by means of a properly fitting abdominal bandage. Retroflexion.—As was said in Chapter XXVII, retroflexion of the pregnant uterus is usually incompatible with advanced pregnancy, since, if spontaneous or artificial reposition does not occur, the patient either aborts or presents symptoms of incarceration before the end of the fourth month. In very exceptional instances, however, pregnancy may go on to term, in which event the fundus remains attached to the floor of the pelvis, while the anterior wall hypertrophies to such an extent as to afford room for the product of conception. In this condition, which is known as sacculation, the head of the child occupies the fundus, while the cervix is sharply bent and so drawn up that the external os lies above the upper margin of the symphysis pubis. At the time of labor the contractions tend to force the child through the most dependent portion of the uterus, while the cervix dilates only partially, so that spontaneous labor is out of the question, and rupture of the uterus may occur, as in a case reported by Campbell. For these reasons cesarean section will afford the most conservative method of delivery, and at the same time make possible the reposition of the organ. Dystocia Due to Operations for the Relief of Retroflexion of the Cterus.—Unfortunately, several of the operations which have been sug- gested for the relief of retroflexion of the non-pregnant uterus, while rectifying the condition, occasionally give rise to serious dystocia. Until recently it was generally believed that this could only follow ventro- or vaginal fixation of the uterus, but as the result of my own experience I have been reluctantly forced to admit that it may also exceptionally 770 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACT occur after suspension, even when performed by competent operators with the most approved technic. Thus, it may occasionally happen, as the result of infection or some other unknown condition, that the proposed suspension becomes converted into a fixation, and as a conse- quence the uterus becomes firmly attached to the anterior abdominal wall by a thick adhesion, which will neither break nor stretch during pregnancy. In this event, serious difficulty may arise at the time of labor in one of three ways: Most frequently, the adherent anterior wall of the uterus is unable to expand, so that the enlargement of the organ is effected solely at the expense of its posterior wall, while the hypertrophied an- terior wall is represented by a thick mass of muscle extending from the point of fixation to the cervix, and obstructing the superior strait. As the uterus expands, traction is made upon the cervix, which is gradually drawn upward from its normal position, until the external os is on a level with, or considerably above, the promontory of the sacrum, so that in extreme cases its posterior lip may be opposite the second or third lumbar vertebra. When labor sets in, dilatation of the cervix is effected very imperfectly, since the bag of waters and the presenting part, instead of impinging upon it, are forced down upon the thickened anterior uterine wall. Accordingly, the uterine contractions, no matter how strong they may' be, are unable to effect the completion of labor, and, unless suitable operative aid is forthcoming, rupture of the uterus will occur, as in the cases reported by Dickinson and others. Less frequently, as in the case reported by Lynch, the anterior wrall of the uterus does not hypertrophy, and in such cases the dystocia will be due entirely to the upward dislocation of the cervix. In other instances, as in the case which I reported in 1906, both walls hypertrophy, and, because of the limited space available between the area of fixation and the cervix, the anterior wall buckles and becomes folded upon itself, instead of forming a thick muscular pad in front of the cervix. In such circumstances, the lower part of the uterine cavity is divided by a-crescentic fold, with a sacculation in front of it, in which portions of the foetus may lie, and thus be inaccessible to the operating hand. Moreover, the dystocia is exaggerated by the upward displace- ment of the cervix, as well as by the fold itself interfering with the engagement of the presenting part, as is indicated in the illustration (Fig. 528). Andrews, in 1905, collected the histories of 395 cases of pregnancy occurring in women who had been subjected to ventral fixation or suspen- sion. In the 359 patients who went to full term, delivery was effected by cesarean section in 20, by forceps in 21 instances, and once by crani- otomy. This, however, does not exhaust the untoward effects of the operation, as the uterus ruptured in 3 other cases, and transverse pres- entations were noted in 10 instances. In 1906, I was able to increase still further the list of complications, and collected from the literature 36 cases of cesarean section, as well as 2 additional cases of craniotomy. Since that time many more cases have been reported, and the condition is now recognized as a definite factor in the production of dystocia. UTERINE DISPLACEMENTS 771 In view of such experiences, the question arises whether the perform- ance of suspensory operations of any kind is justifiable in women during the childbearing period. Formerly I held that, while ventrofixation was contra-indicated, suspension was practically devoid of danger; but, in view of what we nowT know, it must be admitted that the latter operation Fig. 528.—Dystocia Following Ventrosuspension. Sacculation of Anterior Uterine Wall. X 1/z- Ad., adhesion between uterus and anterior abdominal wall; A.W., abdominal wall; U.W., uterine wall; B., bladder; F, folded anterior uterine wall; P., placenta. may also give rise to serious dystocia. Accordingly, I feel that during the childbearing period fixation should not be done except when the tubes or ovaries are likewise removed, and that suspension should be practiced only when urgently indicated. For a time it was felt that Gilliam’s operation would not be followed by dystocia, but after my friend Dr. F. S. Newell, of Boston, had been obliged to resort to cesarean section after that operation, it is apparent that even it is not innocuous from an obstetrical point of view. The vaginofixation, suggested by Duhrssen and Mackenrodt, in which 772 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACT the fundus was firmly stitched to the anterior vaginal wall, has been followed by such serious dystocia that it has been practically abandoned during the childbearing period. Kiihl has collected 9 cases of cesarean section following this operation. After Esch had reported that similar complications might follow the Schauta-Wertheim interposition opera- tion for the cure of prolapse of the uterus, the operation was restricted to patients who had passed the menopause, or who had been sterilized by removal of the ovaries or excision of the tubes. Nevertheless, Weibel in 1916 reported that he had been obliged to perform cesarean section upon two patients in whom the latter precaution had been omitted. Prolapse.—Pregnancy cannot go on to full term when the uterus is completely prolapsed, hut it may do so in the incomplete variety. In such cases the fundus occupies its usual level, while the protrusion from the vulva is made possible by elongation of the hypertrophied cervix. As a rule, the latter becomes retracted as pregnancy advances, though in rare cases it may continue to protrude from the vulva and become so edematous and swollen as to give rise to serious dystocia. Under such circumstances multiple incisions may be necessary in order to effect delivery. Even though dystocia may not result, the condition greatly increases the danger of labor. One of my patients, who Avas delivered spontaneously at term, was suffering from intrapartum infec- tion Avhen admitted to the service and died a few days later from strepto- coccus infection. Although she had not been examined vaginallv, the fact that the external os protruded from the vulva afforded a rational explanation for the occurrence of infection. Dystocia Due to Tumors of the Generative Tract and Pelvis.—Car- cinoma of the Cervix.—The effect of this condition upon pregnancy and labor and its appropriate treatment has been considered in Chapter XXVII. Fibromyomata of the Uterus.—Myomata were observed by Schauta and Pinard in 54 and 84 out of 55,311 and 13,915 consecutive cases of labor respectively—0.1 and 0.6 per cent. It is a matter of general observation that Avomen suffering from this disease are relatively sterile. Thus, 75 per cent, of Schauta’s patients were over thirty years of age Avhen the first pregnancy occurred. The obstacle to conception is most marked when the tumor is of the submucous or interstitial variety. Moreover, when pregnancy oc- curs, owing to the hemorrhagic changes in the endometrium, which are frequently associated Avith the presence of submucous myomata, there is an increased tendency toward premature expulsion of the ovum. On the other hand, pregnancy is not without influence upon the tumors themselves, Avhich frequently increase rapidly in size, more as a result of edema than of actual hypertrophy. Furthermore, OAving to the pres- sure to A\diich they are subjected by the growing ovum, the softened tumors may undergo considerable changes in shape. Occasionally the pedicle of a subserous myoma may become twisted and gangrene and peritonitis may ensue. The diagnosis of the association of pregnancy and myomata is not always easy. Hemorrhage may occur at intervals as the result of TUMORS OF THE GENERATIVE TRACT AND PELVIS 773 changes in the endometrium, and be mistaken by the patient herself for the menstrual flow, so that the idea of pregnancy may not suggest itself for months or until on abortion occurs. On the other hand, a sudden increase in the rapidity of the growth of the uterine tumor should direct attention to the possibility of pregnancy, and the diagnosis becomes assured when careful palpation shows the presence of soft areas interspersed between the firmer myomatous nodules. Subperitoneal myomata occasionally escape observation, being mistaken for the small parts, or sometimes for the head of the foetus, so that a diagnosis of multiple pregnancy may be made. At the time of labor the effect exerted by the myomata depends en- tirely upon their size and situation. Generally speaking, subserous tumors are without great significance, except when their large size leads to pressure symptoms, or when a pedunculated tumor prolapses into the pelvic cavity. On the other hand, interstitial myomata, developed in the cervix or lower uterine segment, may so obstruct the pelvic cavity that normal delivery will be impossible. As a result of the uterine con- tractions, a submucous myoma may become partially separated from its bed and protrude from the cervix as a polypoid mass. In such cir- cumstances, since it effectively prevents the descent of the head, it must be removed by cutting through the pedicle. Even when the tumor does not interfere with the course of labor by its size and situation, it predisposes to the occurrence of abnormal presentations. Thus Olshausen, in tabulating the cases reported in the literature, found only 53 per cent, of vertex presentations, as compared with 24 and 19 per cent, of breech and transverse presentations, respec- tively. Schauta, however, noted abnormal presentations in only 8 per cent, of his personal cases. Moreover, the mere presence of the tumor may so interfere with the character of the uterine contractions as to cause dystocia, as well as to favor the occurrence of postpartum hemor- rhage. The latter is due partly to the fact that the myomatous nodules interfere with the normal contraction and retraction of the uterus, and partly because they may offer a mechanical obstacle to the separation and expulsion of the placenta. In the puerperium, myomata frequently undergo degenerative changes, and if they have been subjected to prolonged pressure may become gangrenous. On the other hand, in certain cases the effect of pregnancy is beneficent, as the tumors may undergo puerperal involu- tion, and thus become smaller or occasionally disappear entirely. In preantiseptic times the outlook in the case of labors complicated by the presence of myomatous tumors was most serious. Thus, the maternal and foetal mortality were respectively 25 and 79 per cent, in 307 cases collected from the literature by Lefour in 1880. At present, thanks to early diagnosis and prompt recourse to operative procedures in suitable cases, the prognosis is much more favorable. Pinard reported that labor was spontaneous in 54, and required operative aid in 30 of his cases, with the maternal mortality of only 3.6 per cent.; while Schauta stated that in only 4 per cent, of his cases was radical operative interference necessary. 774 DYSTOCIA DUE TO ABNORMLAITIES OF GENERATIVE TRACT In case of extreme distention, serious hemorrhage, or symptoms of impaction occurring before the child has attained the period of viability, laparotomy is indicated; but whether removal of the tumor can be best effected by excision, enucleation, supravaginal or total hysterectomy will vary according to circumstances and the predilections of the individual operator. Generally speaking, isolated subserous myomata are best treated by excision, and those of the interstitial variety by enucleation; whereas, if numerous tumors are present, supravaginal hysterectomy is indicated without reference to the existence of pregnancy. Myomectomy and enucleation are frequently followed by abortion or miscarriage, but do not necessarily destroy all chance of saving the life of the child. Notwithstanding this, however, my own inclination is toward supravaginal amputation, whenever operation is imperatively demanded, as being a less dangerous procedure as far as the mother is concerned. Landau in 21 personal operations reported a mortality of 4.8 per cent., as compared with 10.6 per cent, in 471 operations collected from the literature by Carstens. If serious symptoms do not supervene during pregnancy, operative interference should be deferred until the time of labor, or shortly before its expected onset, since the tumor may so change its shape or position as to render an operation unnecessary from an obstetrical point of view. Thus, in one of my patients, a tumor the size of a fist was found in the upper part of the cervix at the fifth month, and gave every indication of offering a serious obstacle to delivery. To my surprise, however, when she returned at the end of pregnancy for a cesarean section, the tumor had risen out of the pelvis, so that operation was not thought necessary, and a few days later an easy spontaneous delivery occurred. So fortunate an outcome, however, cannot always be expected, and in any event the patient should be examined thoroughly, and under anes- thesia if necessary, shortly before the expected date of confinement. If the tumor is found to be firmly impacted in the pelvis, cesarean section should be performed before labor sets in, followed by supravaginal am- putation or enucleation, according to the judgment of the operator. On the other hand, if there is apparently no danger of impaction, and spon- taneous delivery seems probable, the patient should be allowed to go into labor spontaneously. If, however, a mistake in prognosis has been made, and symptoms of obstruction occur, cesarean section should be promptly performed in preference to attempts at delivery by the more usual obstetrical procedures. It should be remembered that the completion of labor does not necessarily indicate that all danger is passed, since, as has previously been indicated, the tumor may undergo gangrenous changes during the puerperium. Consequently, the occurrence of fever and abdominal pain should direct one s attention'to such a possibility and make one consider the advisability of laparotomy. Ovarian Tumors.—The presence of an ovarian tumor is one of the most serious complications of pregnancy, as it markedly increases the probability of abortion and frequently offers an insuperable obstacle to TUMORS OF THE GENERATIVE TRACT AND PELVIS 775 delivery at the time of labor. Moreover, even after a spontaneous labor, its presence may give rise to disturbances during the puerperium. While any variety of ovarian tumor may complicate pregnancy and labor, dermoid cysts have been described comparatively frequently in this connection. Thus, in 107 cases collected by McKerron, in which the nature of the tumor was stated, there were 47 eystomata, 46 dermoid cysts, 9 malignant tumors, 5 fibromata, and 2 colloid cysts; while Spen- cer observed dermoid cysts in 12 of his 41 patients. Swan, in 1898, was able to collect 14 cases of solid ovarian tumor. Of the 321 pregnancies complicated by ovarian tumors which were collected by Remy, spontaneous abortion or premature labor occurred Fig. 529.—Dystocia Due to Ovarian Cyst (Bumm). in 17 per cent, of the cases. As has been indicated, tumors may also give rise to serious dystocia at the time of labor. Thus, McKerron, in 720 cases collected from the literature in which pregnancy had been allowed to run its course without interference, noted a maternal mortality of 21 per cent., while more than half of the children were lost. The majority of these cases, however, were reported prior to the general'employment of radical surgical methods, very few laparotomies having been per- formed, and interference for the most part being limited to puncture or incision of cysts through the vagina. Moreover, the danger to the patient does not end with the birth of the child, as in not a few cases peritonitis follows gangrene of the tumor resulting from excessive pressure, while in others torsion of the pedicle may lead to a fatal ter- mination. 776 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACT Again, the cyst may rupture and extrude its contents into the peri- toneal cavity during a spontaneous labor or as the result of operative interference. This event is a matter of indifference with the ordinary cystomata, but in the case of a dermoid cyst is frequently followed by fatal peritonitis. When the tumor occupies the pelvic cavity it may lead to rupture of the uterus, or, if that does not occur, the tumor may be forced into the vagina and occasionally even into the rectum. While spontaneous rupture may occur, it is sometimes surprising that it is not more frequent. Thus, in one of my patients a unilocular cyst, which was impacted in the pelvic cavity, led to rupture of the uterus instead of its own walls, although the latter did not exceed one millimeter in thickness. Unfortunately, the presence of an ovarian tumor complicating preg- nancy often remains entirely unsuspected, the condition having been recognized in only 18 of McKerron’s first series of cases. Nevertheless, careful antepartum examination of all pregnant women should certainly eliminate a large proportion of these errors. Moreover, failure of the presenting part to engage, when the pelvis is known to be normal, sug- gests an obstructing mass. On the other hand, if the tumor does not occupy the pelvic cavity, the diagnosis may be extremely difficult, as the abdominal enlargement may be attributed to the presence of twin preg- nancy or hydramnios, and the true condition is not recognized until after labor. If the ovarian tumor is detected prior to the last month of preg- nancy, it should be removed immediately by laparotomy, as it is gen- erally admitted that the operation is attended by but little danger. Thus, Heil, in 1904, collected from the literature 188 such operations, with a maternal mortality of 2.1 per cent. It has been objected that such a procedure increases the chances of premature delivery, which occurred in 19.47 per cent, of Heil’s cases, but in only half so many of Szymanowicz’s personal cases. It should, how- ever, be remembered that a similar accident may take place even if the patient is not interfered with, having been noted in 17 per cent, of Remy’s cases. This difference is so slight that the chances for the child are little, if at all, impaired by operation, while those of the mother are markedly improved. On the other hand, when the diagnosis is not made until late in pregnancy, it is usually advisable to postpone the operation until term, for the reason that the fresh abdominal cicatrix is not well adapted to the strain of parturition. Consequently, if the tumor is impacted in the pelvis, cesarean section should be done at an appointed time, and fol- lowed by the removal of the tumor. If, however, it is not impacted, some authorities prefer to allow the patient to go into spontaneous labor and to remove the tumor later in the puerperium. Bland Sutton, Spencer and others advise that the tumor alone be removed, and that the birth of the child be left to Nature, or at most be assisted by forceps. I, however, am of the opinion that the double operation is preferable, believing that a woman should not be subjected to the strain of labor immediately following an abdominal operation. TUMORS OF THE GENERATIVE TRACT AND PELVIS 777 Formerly it was advised to attempt the reposition of the mass under anesthesia. This practice, however, is not to be recommended, for the reason that the tumor is liable to give rise to trouble during the puer- perium. Moreover, since operative interference will be necessary sooner or later, it would seem far better to institute radical measures without delay. Puncture through the vagina, although strongly advocated at one time, must he considered as a dangerous and extremely reprehensible practice, inasmuch as we possess no means of preventing the tumor contents from contaminating the peritoneal cavity. Furthermore, the statistics collected by Jones in 1913, indicate that the procedure is attended by a greater mortality than purely expectant treatment. If spontaneous labor has occurred, the patient should be carefully watched during the puerperium for the appearance of untoward symp- toms. Should they arise, prompt operation is imperatively demanded. In any event, a woman suffering from an ovarian tumor should not be discharged from treatment until the tumor has been removed, or at least until the importance of operative procedures has been strongly urged upon her. Tumors of Other Origin.—Labor is occasionally obstructed by tumors of various origin, which encroach upon the cavity of the pelvis to such an extent as to render delivery difficult or even impossible. In Chapter XXXYIII reference will he made to dystocia due to tumors arising from the pelvic walls. In rare instances a normal sized or enlarged Jcidney or spleen may prolapse into the pelvic cavity and offer an obstacle to labor. Bland Sutton has added an additional case of displaced kidney complicating pregnancy to those collected by Cragin; and has also reported the removal of a prolapsed spleen in the second month of pregnancy, which would have given rise to serious dystocia at the time of labor had it re- mained in situ. Echinococcus cysts are occasionally implanted in the pelvic cavity. Franta, in 1902, collected 22 cases noted during pregnancy and dis- cussed their effect upon the course of labor. I n Chapter XXX reference was made to those .cases in which an old extra-uterine gestation sac so obstructed the pelvic canal as to interfere with the delivery of a subsequent intra-uterine pregnancy. Enterocele or hernia through the vaginal walls occasionally gives rise to dystocia, Ihough in the majority of cases the prolapsed intestine can be replaced and the obstacle temporarily overcome. Where this is not possible, cesarean section is indicated as a more conservative procedure than forcibly dragging the child over a large irreducible hernia. In occasional instances tumors of the lladder may likewise offer an impediment to the passage of the child, though it is rarely so serious as to demand operative interference. On the other hand, it has sometimes been necessary to remove a large calculus from the bladder before de- livery could be effected. In Neer’s case the stone was almost spherical in shape, and measured 2.75 inches in its greatest diameter. A large rectocele or cystocele, though occasionally offering slight 778 DYSTOCIA DUE TO ABNORMALITIES OF GENERATIVE TRACT obstacle to labor, can generally be replaced while delivery is being effected. Tumors arising from the lower part of the rectum or pelvic con- nective tissue may likewise give rise to serious dystocia; Pederson, in 1922, having collected a series of cases in which carcinoma of the rectum rendered cesarean section necessary. LITERATURE Aiilstrom. Zwei Kaiserschnitte wegen narbiger Yerengerung der weichen Ge- burtswege. Mitth. aus d. gyn. Klinik des Prof. Engstroms, 1904, vi, 289-304. Andrews. The Effect of Ventral Fixation of the Uterus upon Subsequent Preg- nancy and Labour. Jour. Obst. and Gyn. Brit. Emp., 1905, viii, 97-125. Bland Sutton. The Surgery of Pregnancy and Labour Complicated with Tu- mours. Lancet, 1901, i, 382-386; 452-456; 529-532. Brindeau. De l’atresie acquise du vagin au point de vue obstetricale. L’obstet- rique, 1901, vi, 97-122. Campbell. Rupture of an Incarcerated Retroverted Gravid Uterus. Jour. Obst. and Gyn. Brit. Emp., 1908, xiv, 402-404. Carstens. Fibroid Tumor Complicating Pregnancy. Am. Jour, Obst., 1909, lix, 447-462. Coester. Ueber Geburtshindernisse durch liymenale Balken, etc. D. I. Marburg, 1900. Cragin. Congenital Pelvic Kidney Obstructing the Parturient Canal. Amer. Jour. Obst., 1898, xxxviii, 36-41. Dickinson. Pregnancy Following Ventrofixation. Amer. Jour. Obst., 1901, xliv, 34-45. Esch. Ueber Schwangerschaft und Geburt nach Schauta-Wertheim Prolaps-opera- tion. Gyn. Rundschau, 1911, v, 335-338. Franta. Les kystes hydatiques du bassin et de 1 ’abdomen au point de vue de la dystocie. Annales de gyn. et d’obst., 1902, lvii, 165-197; 296-308. Guder. Ueber Geschwiilste der Vagina als Schwangerschafts- und Geburtskompli- kationen. D. I., Bern, 1889. Heil. Beitrag zur Ovariotomie in der Schwangerschaft. Miinchener med. Wochenschr., 1904, li, Nr. 3. Huf:. Quelques recherches sur 1’ampliation du diaphragme pelvien, etc. Paris, 1906. Jones. Ovarian Cysts in Relation to Childbearing. Surg. Gyn. and Obst., 1913, xvi, 63-73. Landau. Myom bei Schwangerschaft, Geburt und Wochenbett. Berlin u. Wien, 1910. Le Bigot. De 1’influence du chancre syphilitique du col de 1’uterus sur 1’ac- couchement. These de Paris, 1899. Lefour. Quoted by Olshausen. Lynch. Kaiserschnitt und schwere Geburtsstorung infolge Ventro-fixation und Suspension. Monatsschr. f. Geb. u. Gyn., 1904, xix, 521-538. McKerron. Pregnancy with Ovarian Tumour. London, 1906. VON Meer. Conception und Abort durch den Ausfiihrungsgang der Blase bei angeborener Defect der Vagina. Beitrage zur Geb. u. Gyn., 1900, iii, 409-424. Neer. Dystocia from Large Bladder Stone Impacted in the Pelvis. Jour. Am. Med. Assoc., 1919, lxxvii, 479-480. LITERATURE 779 Neugebauer. Zur Lehre von dem angeborenen und erworbenen Yerwaehsungen und Verengerungen der Scheide. Berlin, 1895. Oldham. Sacculation of the Uterus. A Case of Retroflexion of the Gravid Uterus. Trans. Lond. Obst. Soc., 1860, i, 317-322. Olshausen. Myom und Schwangerschaft. Veit’s Handbuch der Gyn., 1897, ii, 765-214. Pederson. Dystocia Caused by Diseases of the Rectum. Acta Gyn. Scandinavica, 1922, i, 445-458. Pinard. Fibromes et grossesse. Annales de gyn. et d’obst., 1901, lv, 165-167. Remy. De la grossesse compliquee de kyste ovarique. Paris, 1886. RtiHL. Kritische Bemerkungen iiber Geburtsstorungen nach Vaginalfixatio-uteri. Monatsschr. f. Geb. u. Gyn., 1901, xiv, 477-490. Sasonoff. fitude du thrombus de la vulve et du vagin. Annales de gyn. et d’obst., 1884, xxii, 447-467. Schauta. Myom und Geburt. Compte-rendu XVIe Congres internat. de medecine, vii, 8-32. Budapest, 1910. Schenk. Hochgradige frische Aetzstenose der Cervix und des Fornix in der Schwangerschaft. Zentralbl. f. Gyn., 1900, xxiv, 161-170. Schroeder. Conglutinatio orificii externi. Lehrbuch der Geburtsh., XIII, Aufl., 1899, 590-592. Spencer. Ovarian Tumors Complicating Pregnancy, Labor and the Puerperium. Surg. Gyn. and Obst., 1909, viii, 461-466. Swan, The Management of Solid Tumours of the Ovaries Complicating Preg- nancy, with Report of a Successful Case. Bull. Johns Hopkins Hosp., 1898, ix, 56-61. Szymanowicz. Kystes de l’ovaire et gestation. Gyn. et Obst., 1922, vi, 405-419. Ward. Atresia Vaginae Complicating Labour. Obstetrics, 1899, i, 623-625. Weibel. Ueber Schwangerschaft und Geburt nach Interpositio uteri vesico- vaginalis. Archiv f. Gyn., 1916, cv, 65-73. Williams. Dystocia Following Ventral Suspension and Fixation of the Uterus. Trans. Southern Surgical and Gyn. Association, 1906, xix. CHAPTER XXXIII CONTRACTED PELVIS We designate a pelvis as contracted when it is so shortened in one or more of its diameters as to affect materially the mechanism of labor, but without necessarily retarding the birth of the child. According to Litzmann, this is the case when the conjugata vera measures 9.5 centi- meters or less in flat, and 10 centimeters or less in generally contracted pelves. History.—Inasmuch as Yesalius was the first to describe the normal pelvis correctly, it is clear that the conception of abnormal forms could not have existed before his time. His pupil, J. C. Arantius (1530- 1589), gave the first anatomical description of such a pelvis, but his discovery exerted no appreciable effect upon the obstetrical art of the period, for the reason that Ambroise Pare still held to the old view of the separation of the pubic bones during labor, and promulgated it in his writings. During the next century knowledge of the subject advanced but slowly, and we find Mauriceau (1637-1709) stating that in his very large experience he had observed only two instances of contracted pelvis. In one of these Chamberlen was permitted to apply the forceps invented by his uncle, but failed to effect a delivery. We are indebted to Heinrich van Deventer for our first knowdedge of contracted pelves from an obstetrical standpoint. In his "New Light for Midwives,” which appeared in 1701, he described the generally con- tracted and the flat varieties, and discussed the influence which they exert upon labor. From that time on mention of the subject is to be found in all the text-books, De la Motte, Puzos, and Dionis being the obstetricians of the first half of the eighteenth century who devoted most attention to it. The last-named observer was the first to point out the causal relation which rhachitis bears to many cases of pelvic deformity. Important contributions to the subject were made by Smellie. In his treatise on "The Theory and Practice of Midwifery,” published in 1752, is to be found an excellent description of the normal pelvis, as well as of the more usual varieties of deformity to which it is subject. He also laid down practical rules for the estimation of the degree of con- traction, carefully described the mechanism of labor in such cases, and gave excellent pictures showing the influence exerted by the contracted pelvis upon the foetal head. Baudelocque (1746-1810) contributed largely toward the develop- ment of our knowledge of the subject, as he devoted particular atten- tion to the diagnosis of the condition in the living woman, and showed 780 FREQUENCY 781 that it could be detected by measuring the distances between certain external bony points of the pelvis by means of a pair of calipers. He was the first to describe the external conjugate, which is now generally known by his name, and taught that by deducting 3 inches from it the length of the conjugata vera could be readily and accurately estimated. At the same time G. W. Stein, in Germany, did good work upon somewhat similar lines and devised a pelvimeter for the direct mensura- tion of the conjugata vera. The real foundation, however, for our modern doctrine was laid by Michaelis and Litzmann. The former was Professor of Obstetrics in the University of Kiel from 1843 to 1850, and during that time carefully measured the pelvis in 1,000 consecutive cases of labor. He designated as contracted all pelves in which the conjugata vera measured 8.75 centimeters or less, and found 72 such cases in his series, a percentage of 7.2. After his death he was succeeded by Litzmann, who continued the work, and soon reported accurate measurements based upon a second series of 1,000 cases. He advanced the definition which is given at the beginning of the present chapter, and placed the upper limit at a con- jugata vera of 10 or 9.5 centimeters, according as the pelvis is generally contracted or flat, respectively. Judged by these criteria he found 14.9 per cent, of abnormal pelves, and estimated that had Michaelis employed the same standard his percentage would have been 13.1. Litzmann’s definition and criteria have been adopted throughout the world, and since the appearance of his work scientific obstetricians have devoted an increasing amount of attention to the subject. To mention all who have added materially to our knowledge would be equivalent to writing the history of obstetrics for the past fifty years; but Kaegele, Kilian, Schauta, and Breus and Kolisko may be cited as among the most important contributors. Frequency.—In this country and in England very few statistics are available upon which to base accurate statements as to the frequency of contracted pelves, but in Germany and France many of the large lying-in hospitals supply valuable data. The incidence varies consider- ably in different countries, and even in various parts of the same coun- try. Thus, as is shown hy the following table, it ranges from 8 to 24 per cent, in various German clinics. Goenner (Basel) observed 7.9 per cent, in 2,433 cases. Pfund (Munich) “ 9.5 “ “1,199 “ Fuchs (Erlangen) “ 11.43 “ “ 1,766 “ Kottgen (Bonn) “ 13.45 “ “2,000 “ Litzmann (Kiel) “ 14.9 “ “ 1,000 “ Muller (Berne) “ 16 “ “ 1,177 “ Weidenmuller (Marburg).... “ 18.7 “ “ 3,224 ‘ ‘ Baisch (Tubingen) “ 24 “ “3,375 “ Leopold (Dresden) “ 24.3 “ “2,415 “ The statistics from the Austrian Empire seem to indicate a lesser frequency than in Germany, as is shown by the following table: Ludwig and Savor (Vienna)., observed 3.84 per cent, in 50,621 cases. Pawlik (Prague) “ 7.8 “ “29,615 “ Burger (Vienna) “ 10.4 “ “ 49,397 “ 782 CONTRACTED PELVIS Statistics based upon large series of cases are not available for France. Commandeur, however, places the incidence at 15 to 20 per cent., and states that it is Pinard’s belief that it has been greatly lowered since the last years of the nineteenth century following the introduction of more rational methods of infant feeding. Fancourt Barnes, in 1897, reported that only 0.5 per cent, of con- tracted pelves were observed in 38,065 cases of labor in London. In view of the fact, however, that every year many cesarean sections are performed in that city for this indication, it would appear probable that his figures in no way represent the true condition. It has been a matter of general belief that contracted pelves are very rare in America, and Dewees stated in 1824 that he had observed only three cases in his large experience. Lusk held a similar opinion, and said that rhachitis is rarely, and osteomalacia never, observed among native American women. We owe to Reynolds the first statistical state- ment upon the subject. In 1890 he reported that he had observed 1.34 per cent, of contracted pelves in 2,227 women delivered in Boston. His figures, however, gave a false idea of the frequency of the condition; since he measured the pelvis only when operative interference was re- quired. Had he also taken into account the cases in which labor terminated spontaneously, he would, in all probability, have reported a frequency of 6.8 per cent. Flint, in 1897, observed 8.46 per cent, of contracted pelves in 10,233 consecutive patients delivered by the Society of the New York Lying-in Hospital. Since the opening of the lying-in department of the Johns Hopkins Hospital, it has been our rule to measure both externally and internally the pelvis of every pregnant woman coming into our hands. In 1899 I reported that we had met with 131 contracted pelves in the first 1,000 women delivered. In 1911 I analyzed the conditions obtaining in 6,052 patients who had been delivered at term-—3,491 white and 2,561 black. For the entire series, the incidence of the usual types of contracted pelvis was 18.5 per cent., but a pronounced difference wras noted in the two races: 7.7 per cent occurring in the white, as compared with 33.2 per cent, in the black women. Furthermore, in the last 2,215 patients of the series the dimensions of the inferior strait were also measured, and all pelves were designated as “funnel” in which the distance between the tubera ischii measured 8 centimeters or less. Judged by this cri- terion 6.1 per cent, of the patients presented outlet contractions, but, in contrast to the contractions involving the superior strait, no difference was noted between the two races—the exact incidence being 5.9 and 6.4 per cent, in the white and black women, respectively. Accordingly, in my service contraction of the pelvic inlet occurs nearly five times more frequently in black than in white women, while funnel pelves are equally frequent in the two races. In other words, every thirteenth white and every third colored woman in Baltimore has a typical contracted pelvis; while, in addition, every sixteenth woman in either race has a funnel pelvis. Hence, it is evident that METHODS OF DIAGNOSIS 783 no one can practice obstetrics without frequently encountering such conditions. As will be explained in detail later, the preponderance of the usual types of contracted pelvis in colored women is due to the prevalence of rickets, and to the general physical degeneration which seems to overtake members of that race who live long in large cities. That labor is not more disastrous to them is due to the fact that their children are smaller and have softer heads than white children, as was demonstrated by my former assistant, T. F. Riggs. That contracted pelves are not limited to civilized peoples is indi- cated by the observations of Emmons and Acosta-Sison. The former studied the pelves of 217 American Indian squaws and found that 29 per cent, were abnormal; while the latter has stated that in Filipino women the pelvic conditions are practically identical with those observed in the American negress. Methods of Diagnosis.—It is essential that the obstetrician be able to determine the existence and extent of the contraction before the onset of labor, in order that he may, as far as possible, decide in advance upon the proper treatment to be instituted in each case. With this in view, accurate pelvic mensuration should constitute an integral part of the preliminary examination of the pregnant woman, and, in the present state of our knowledge, a physician who practices obstetrics without pelvimetry must be regarded as no better than one who treats diseases of the heart and lungs without the aid of auscultation and percussion. At the preliminary examination, four to six weeks before the ex- pected time of confinement, the physician should neglect no means of obtaining all possible data bearing upon the case. Generally speaking, large, well-built women are likely to have normal, and undersized women contracted, pelves; but this rule by no means always holds good, and it is not unusual for examination to disclose some abnormality in the former and normal pelves in the latter. The gait of the patient should be carefully noted, since the existence of a limp or some peculiar way in which the feet are placed upon the floor may serve to direct attention to the possibility of a pelvic deformity. Marked abnormalities of the spinal column—kyphosis or lordosis—are also suggestive, and even slight degrees of spinal curvature should not be overlooked, as they are frequently of rhachitic origin. The more usual signs of rhachitis—deformities of the extremities, the characteris- tically shaped head, and the rhachitic rosary—should always be looked for. Likewise, inquiry should be made as to the age at which the patient first learned to walk, and if she is found to have been backward in this respect the possibility of a rhachitic pelvis should be borne in mind, even though the usual external manifestations of the disease may be lacking. If the patient has already borne children she should be questioned as to the course of previous labors, and the history of any serious difficulty should always suggest the possibility of an abnormal pelvis. On the other hand, a negative history is by no means so valuable, as it is a well- known fact that in moderate degrees of pelvic contraction the first labor 784 CONTRACTED PELVIS may be relatively easy, while each successive one becomes more difficult. In primiparous women a pendulous abdomen, 01 t e ai me o en& ment of the head in the last month of pregnancy, should always be regarded as evidence of the existence of a disproportion between the child’s head and the pelvis, until careful examination shows that such is not the case. - • Pelvimetry.—While the above-mentioned conditions are of value suggesting the possibility of pelvic deformity, accurate information as to its existence and extent can be obtained only by measuring the pelvis For this purpose external and internal pelvimetry are employed, according as the measurements are taken from the surface of the body or through the vagina. As has already been said, Baudelocque was the first to insist upon the impor- tance and value of the former, and invented the first pelvimeter, which consisted of a pair of calipers or compasses provided with a scale to indicate the extent to which they are opened. Innumerable instru- ments of this kind have since been devised, but, although most of them give satisfactory results, before buy- ing one it is always well to see that the blades are sufficiently curved to allow them to span the thighs of stout patients. Thus, Budin’s pelvi- meter (Fig. 530), which can readily be carried in the pocket, gives satis- factory results in the majority of cases; but it cannot be used to measure the external conjugate in stout women, owing to the slight curvature of its blades. I usually employ the instrument devised by E. Martin (Fig. 531). (a) External Pelvimetry.—The ordinary measurements are four in number: the distance between the anterior superior spines of the ilium, between the crests of the ilium, between the heads of the trochanters, and between the depression beneath the spinous process of the last lumbar vertebra and the anterior surface of the symphysis pubis. Normally these measure 26, 29, 32, and 21 centimeters respectively in the living woman. Naegele suggested certain other measurements, which, as a rule, are not employed unless one suspects the existence of an obliquely contracted pelvis. When the pelvis is to be measured externally, the patient should lie upon a bed or table with her abdomen and hips either bared or covered only by a thin chemise. The legs and upper portions of the body should not be exposed. In order to make the first three measurements, the physician should face the patient. He then grasps the tips of the pelvim- Fig. 530.—Bitdin’s Pelvimeter. Fig. 531.—Martin’s Pelvimeter. METHODS OF DIAGNOSIS 785 eter between the thumb and second finger of each hand, and, having located the outer edges of the anterior superior spines with the index fingers, presses the tips of the pelvimeter upon them as closely as pos- sible, the distance between them being indicated on the scale of the instrument. In measuring the dis- tance between the iliac crests, the most widely sepa- rated portions are located, and the tips of the pelvi- meter applied to their outer edges. In taking these measurements, it should he borne in mind that the iliac spines and crests present an outer and inner lip and an intermediate ridge, and that the distance between the outer lips is 1.5 to 2.5 centimeters greater than that between the inner lips. Fig. 532.—Method of Holding Pelvimeter. Fig. 533.—Measuring the Distance between the Anterior Superior Spines. 786 CONTRACTED PELVIS In determining the distance between the trochanters, the patients legs having been brought into close apposition, the examiner carefully palpates the upper portion of the thighs until the most prominent points of the trochanters are felt on either side. The tips of the pelvim- eter are then firmly pressed against them, so that they come into the closest possible contact with the bones, after which the measurement is read off on the scale. The external conjugate, or Baudelocque’s diameter, extends from the depression just beneath the spine of the last lumbar vertebra to the anterior and upper margin of the symphysis pubis. For this measure- ment, the woman should lie on her side with her back toward the physi- Fig. 534.—Measuring the External Conjugate. cian. As a rule the spine of the last lumbar vertebra is quite prominent, and is readily found by palpating and counting the spinous processes lorn above downward. Immediately beneath it is a slight depression, which forms the posterior extremity of the diameter to be measured. Into this one tip of the pelvimeter should be inserted and held firmly m place, while the other hand seeks the upper margin of the symphysis I ubis, and firmly applies the other tip of the pelvimeter to it. The dis- tance separating them is then read off on the scale. In stout women some difficulty may be experienced in locating the ertramty of this diameter, owing to the fact that the spinous p ss of the last lumbar vertebra cannot be identified. This difficulty can usual y be obviated in the following manner: The depressions mart mg the attachment of the fascia to the superior posterior spinel oTthe ■hum, Which are usually clearly visible, are' located, and the ba of 1m METHODS OF DIAGNOSIS 787 thumb applied over one and that of the second finger over the other. The index finger then seeks the spine of the last lumbar vertebra, which will usually lie about 2.5 centimeters above the line joining the thumb and second finger, or at the apex of a four-sided space—Michaelis’s rhom- boid—whose upper and lower margins are formed by the transverse and sacrospinalis and gluteus muscles respectively. The Value of External Pelvimetry.—Baudelocque, in describing the external conjugate, stated that by deducting 3 inches from it the length of the true conjugate could be accurately estimated. He based his opinion upon the fact that he had rarely ob- served a difference of more than 1 or 2 lines between the estimated and the actual conjugata vera in 30 odd cases which he had measured during life and at autopsy. Later experience, however, has shown that these conclusions were erroneous, and that the length of the external conjugate gives a very imperfect idea of that of the conjugata vera, since several modifying factors may exist. Thus, the amount to be de- ducted varies with the thickness of the sacrum and the symphysis pubis, and also depends, to a great extent, upon the elevation of the promon- tory of the sacrum and the length of the spinous process of the last lumbar vertebra. Unfortu- nately, these factors cannot be accurately esti- mated in the living woman, and Skutsch has shown that in 100 pelves examined by him the difference between the length of the external and of the true conjugate varied from 5.5 to 10 centimeters. Baisset arrived at similar conclu- sions after studying 120 dried pelves; and I have in my possession two specimens whose true conju- gates are of equal length, but whose external conjugates show a difference of 5 centimeters. Although the measurement of the external conjugate does not give accurate information concerning the length of the conjugata vera, it nevertheless enables us to draw certain important conclusions. Thus, generally speaking, w'hen the former measures between 20 and 21 centimeters, the conjugata vera will rarely be found to be shortened; when, however, it measures between 18 and 19 centimeters, the conjugata vera is shortened in about one-half of the cases; and when it is below 17 centimeters pelvic contraction is almost uniformly present. It was formerly believed that one could form a fairly accurate esti- mate of the length of the transverse diameter of the superior strait by making certain deductions from the distances between the anterior supe- rior spines and between the crests of the ilium. The incorrectness of this conclusion, however, was first demonstrated by Scheffer, who showed Fig. 535.—Michaelis’s Rhomboid (Stratz). 788 CONTRACTED PELVIS that the transverse diameter of the superior strait may be of the same length in two pelves, while at the same time the distances between the iliac crests vary by as much as 3.3 centimeters. This source of error depends in great part upon the angle which the iliac fossa forms with the rest of the innominate bone, and the extent to which its anterior portion is' flared out. The distance between the trochanters is the least valuable of all the external measurements, as its length depends, to a great extent, upon the angle which the neck of the femur forms with its shaft; and as a consequence its shortening, unless very marked, does not indicate a cor- responding decrease in the transverse diameters of the pelvic cavity. Goenner, in 1901, demonstrated that external pelvimetry alone gave a very erroneous idea concerning the existence of contracted pelvis. After measuring the external diameters in 100 cadavers, he compared them with those of the pelvic cavity when measured directly, and found that, whereas the former indicated that nearly all of the pelves were contracted, the latter proved that such was the case in only 22 instances. My own observations bear out his conclusions; as the use of the external measurements alone would indicate the presence of contracted pelvis in three-quarters of all colored women, as compared with only one-third as shown by internal pelvimetry. Nevertheless, despite many possible inaccuracies', the external meas- urements are of considerable value, in that they serve to indicate with tolerable certainty the type of pelvis with which one has to deal. Nor- mally the distance between the spines is 2.5 to 3 centimeters less than that between the crests; but in the rhachitic pelvis, owing to the flaring of the iliac spines, this proportion becomes deranged, and the two meas- urements approximate one another, the former frequently being equal to, and occasionally exceeding the latter. If, however, both measure- ments are considerably below the normal, but preserve their usual rela- tion to one another, and at the same time the external conjugate is also proportionately shortened, it is permissible to conclude that the entire pelvis measures below normal in all its diameters, or, in other words, is generally contracted. It is my rule to employ external pelvimetry at the preliminary exam- ination four to six weeks before the expected date of confinement. If the measurements are approximately normal, the patient being a prim- ipara and the child’s head deeply engaged in the pelvic cavity, internal mensuration is not practiced. But if the head is not engaged, internal pelvimetry should be resorted to, no matter how normal the external pelvic measurements may be. (6) Internal Pelvimetry.—In the majority of abnormal pelves the most marked deformity affects the anteroposterior diameter of the supe- rior strait, and as a consequence we are especially anxious to ascertain the length of the conjugata vera. Unfortunately, this cannot be meas- ured directly in the living woman, except by means of especially con- structed instruments, concerning whose accuracy there is no unanimity of opinion, and consequently in practice it is estimated after measuring the diagonal conjugate—the distance from the promontory of the sacrum METHODS OF DIAGNOSIS 789 to the lower margin of the symphysis pubis—and making a certain de- duction from it. This method was introduced by Smellie, and still fur- ther elaborated by Baudelocque. Measuring the Diagonal Conjugate.—For this purpose the patient should be placed upon an examining table with her knees drawn up. If this cannot be conveniently arranged, she should be brought to the edge of the bed and a firm pillow placed beneath her buttocks. Two fingers are introduced into the vagina, and, before measuring the diagonal conjugate, the motility of the coccyx is determined and the anterior surface of the sacrum is palpated. The first is ascertained by seizing Fig. 536.—Measuring the Diagonal Conjugate. the coccyx between the fingers in the vagina and the thumb externally and attempting to move it to and fro. The anterior surface of the sa- crum is then methodically palpated from below upward, and its vertical and lateral curvature noted. In normal pelves only the last three sacral vertebrae can be felt without pushing up the perineum, whereas in markedly contracted varieties the entire anterior surface of the sacrum is readily accessible. Ordinarily, in order to reach the promontory of the sacrum, the elbow must be depressed and the perineum forcibly pushed upward by the knuckles of the third and fourth fingers, while the index and second fingers are held firmly together and directed upward in the direction of the umbilicus. The promontory is felt by the tip of the second finger as a projecting bony margin at the base of the sacrum. With the finger 790 CONTRACTED PELVIS closely applied to its most prominent portion, the hand is elevated until the radial surface of the index finger is brought into close contact with the pubic arch. This point is then marked by the nail of the index finger of the other hand, after which the fingers are withdrawn from the vagina and the distance between the mark and the tip of the second finger is meas- ured (Figs. 536 and 537). This represents the diag- onal conjugate, from which the true conjugate is esti- mated by deducting 1.5 to 2 centimeters, according to the height and inclina- tion of the symphysis pubis. In this method the problem consists in esti- mating the length of one side of a triangle, the con- jugata vera; the other two —the diagonal conjugate and the height of the symphysis pubis—being known. Were we able to measure satisfactorily the angle formed between the symphysis and conjugata diagonalis, the exact length of the true Fig. 537.—Measuring the Length of Diagonal Conjugate upon the Fingers. Fig. 538. Figs. 538, 539. Diagrams Showing Variations in Length of Diagonal Conjugate Dependent upon the Height and Inclination of the Symphysis Pubis. Fig. 539. conjugate could readily be ascertained by the ordinary rules of trigo- nometry. Unfortunately, this cannot be done accurately in the living woman, but for practical purposes it suffices to estimate the length of the METHODS OF DIAGNOSIS 791 diagonal conjugate as just described, deducting 1.5 centimeters from it if the pubis is low and slightly inclined, and 2 centimeters if it is high and has a marked inclination. The rationale of this is clearly shown in Figs. 538 and 539. The length of the diagonal conjugate also varies according to the position of the promontory, being longer when it is elevated, and vice versa (Fig. 540). Van der Hoeven (1912) has pointed out the fallacies involved in indirect menstruation, and holds that they are so great as almost to destroy its usefulness. Since the time of G. W. Stein (1772), numerous instruments have been devised for the purpose of measuring the conjugata vera directly; but unfortunately majority of them, while theoretically correct, are practically useless on account of the difficulty of their application. De- scriptions and illustrations of many of them are to be found in Skutsch’s excellent monograph. Skutsch, in 1886, devised a pelvimeter by which the conju- gata vera could be indirectly, though accurately, measured (Fig. 542). Hirst more recently described a simple device for the same purpose. Both of these instruments give fairly satisfac- tory results when properly used, but their employment is usually so painful to the patient as to require the administration of an anesthetic. Since 1904 renewed interest has been manifested in the direct mensuration of the conjugata vera, and Bylicki, Gauss, Zange- meister, and others have devised instruments for the purpose. In the hands of their inventors such pelvimeters have proven satisfactory, but others have found that their employment gives no more accurate results than can be obtained by the old manual method. I have not been able to use the instruments of Gauss or Zangemeister in primiparous women, except under anesthesia; and, even when the vaginal outlet is so relaxed that they can be employed without undue pain, the results obtained have not seemed especially accurate, except when the degree of con- traction was very pronounced. Neumann and Ehrenfest, in 1900, described a complicated instru- ment—the pelvigraph—by means of which the contour of the anterior and posterior walls of the pelvis can be graphically outlined, whence the exact length of the various anteroposterior diameters can be readily ascer- tained. This instrument gives excellent results, but is too complicated for use outside of a special hospital. Measuring the Transverse Diameter of the Superior Strait.—This diameter cannot be measured directly in the living woman, and, as a Fig. 540.—Diagram Showing Effect of Position of Promontory of Sacrt m upon the Length of the Diagonal Conjugate. 792 CONTRACTED PELVIS Fig. 541.—Stein’s Pelvimeter. Fig. 542.—Measuring Conjugata Vera with Skutsch’s Pelvimeter. Fig. 543.—Hirst’s Pelvimeter. METHODS OF DIAGNOSIS 793 rule, for all practical purposes it is necessary only to palpate the linea terminalis with the examining fingers, and in this way roughly estimate the outlines of the superior strait. If, however, we wish to be more exact, its length can be ascertained approximately by the employment of Skutsch’s instrument (Fig. 544). Lohlein attempted to estimate the size of this diameter by adding a “constant” to what he designated as the ascending oblique diameter. This extends from the lower margin of the symphysis pubis to the ante- rior and upper margin of the sacrosciatic notch, and can he measured by the finger. As the investigations of Steinbrecher show that the size of the “constant” varies in the several varieties of deformed pelvis, it is apparent that only approximate results can be obtained by this means. Contractions of the Pel- vic Outlet.—As has already been indicated, contractions of the pelvic outlet occur in about 6 per cent, of all women, and probably repre- sent the most usual type of abnormality encountered in the American white woman, and, as they may give rise to serious dystocia, should receive more extended con- sideration than they are usu- ally accorded. The con- traction may he limited to either the transverse of the anteroposterior diameter, or may involve both, and be either symmetrical or irregular in character. Leaving out of considera- tion the cases associated with kyphotic, osteomalacic, obliquely contracted, and other rare varieties of abnormal pelves, it frequently happens that pronounced deformity of the outlet occurs in pelves with otherwise approximately normal measurements. Measuring the Diameters of the Pelvic Outlet.—In view of what has just been said, the determination of the space available between the tubera ischii should be made an integral part of the routine examination of the pelvis. An approximate idea may readily be obtained by Sell- heim’s method of palpating the pubic arch. For this purpose, the woman having been placed in the dorsal position with the hips protrud- ing beyond the edge of the examining table and the legs drawn up, the buttocks are seized by both hands in such a manner that each thumb outlines the course of the corresponding ischio-pubic ramus, while the web of the thumb comes in contact with the ischial tuberosity and the Fig. 544.—Measuring Transverse Diameter of Superior Strait with Skutsch’s Pelvimeter. 794 CONTRACTED PELVIS hollow of the hand grasps the buttock (Fig. 545). In this way the outlines of the pubic arch are very satisfactorily indicated by the posi- tion of the thumbs, so that with a little practice one can readily deter- mine whether it is normal, narrowed, or very contracted. If the pubic arch appears to be narrowed, the transverse diameter of the outlet should be measured, and, if it be 8 centimeters or less in length, still other measurements should be made. For the former pur- Fig. 545.—Palpation of Pubic Arch pose the regions about both tubera ischii are carefully palpated with the thumbs, and, when the points corresponding to the ends of the transverse diameter have been located, the thumbs are brought into such a position that their nails represent the prolongation of the inner surface of each ischial bone. An assistant then measures the distance between them by means of a Budin or other suitable pelvimeter (Fig. 546). If an assistant is not available, equally satisfactory results may be obtained by using the outlet pelvimeter which I have devised, in which the tips of the blades are attached to the thumbs by adjustable rings (Fig. 547). Since 1915, however, I have used almost exclusively the pelvimeter METHODS OF DIAGNOSIS 795 Fig. 546.—Measuring the Distance between the Tubera Ischii. devised by Thoms, which has the additional advantage that it makes possible the measurement of the anterior and posterior sagittal diameters Fig. 547.—Mensuration of Transverse Diameter of Outlet with Williams’ Pelvimeter. X x!%. of the outlet, as will be described in the section on funnel pelvis (Fig. 548). Direct measurement by means just described is to be preferred to CONTRACTED PELVIS 796 the method described by Schroeder, in which, after carefully palpating the tuberosities, the skin corresponding to their inner margins is marked by means of a dermatographic pencil, and the distance between the two marks is measured. In view of the elasticity of the skin, ho\\e\er, it must frequently happen that considerable distortion will occur as soon as the pressure of the fingers is removed. The anteroposterior diameter, between the lower margin of the symphysis and the tip of the sacrum, is readily measured by a modifiea- Fig. 548.—Showing Mensuration of Transverse Diameter of Outlet by Means of Thoms’ Pelvimeter. X Vj. tion of Breisky’s method. For this, the woman should be brought so far down upon the table that the lower part of the sacrum becomes readily accessible. Then its tip is located through the skin, one end of the pelvimeter is applied over it, and the other is applied to the lower margin of the symphysis pubis. A deduction of 1 centimeter from this measurement will give a tolerably accurate idea of the length of this diameter (Fig. 549). Unfortunately, however, this is of but slight practical value in the cases in which information is most particularly desired, for the reason that, when the transverse diameter is markedly shortened, the pubic arch becomes so narrow that it is not available for the passage of the head, so that in extreme cases only a small segment of the occiput can engage between the tubera ischii. Consequently the possibility of its birth will depend not upon the length of the anteroposterior diameter of the outlet, but rather upon the distance available between the line joining the tubera ischii and the tip of the sacrum. This diameter was described METHODS OF DIAGNOSIS 797 by Klien as the posterior saggital of the outlet, and should be measured whenever the transverse diameter measures 8 centimeters or less. This, however, will be considered in greater detail under the heading of Funnel Pelvis. Use of X-rays.—After the discovery of the Pontgen ray and the demonstration of the various uses to which it might be put, it was thought possible that it might also afford a valuable method of investi- gating the shape and size of the pelvis. Budin and Yarnier, in 1897, Fig. 549.—Diagram Showing Williams’ Modification of Breisky’s Method of Measuring Anteroposterior Diameter of Outlet. X V*. reported their experience with it, and showed that, while it often gave an excellent general idea of the shape, the ideas as to size obtained by it were erroneous. A comprehensive review of the literature upon the subject was given by Mullerheim in 1898. All ordinary radiograms of the pelvis give distorted ideas in regard to its dimensions, owing to the fact that, as the symphysis and promon- tory of the sacrum lie in different planes, one part of the superior strait is enlarged out of all proportion to the other, according as the picture is taken with the woman lying on her back or abdomen, as the case may be. Such defects make it impossible to attempt to utilize the radio graph for purposes of mensuration. Bouchacourt suggested that this 798 CONTRACTED PELVIS might be obviated by placing a rectangular metal frame about the woman’s hips, more or less corresponding to the plane of the superior strait, each side of the frame being marked by indentations 1 centimeter apart. When the picture was taken these would also be reproduced, and upon connecting the corresponding points upon the four sides of the picture a definite idea could be obtained as to the dimensions of the superior strait. This method has been employed by Fabre for years, and has given satisfactory results. The method described by Thoms in 1922 is useful and interesting, but suffers from the defect that it is not avail- able after the middle of pregnancy, when information is most desired by the obstetrician. Classification of Contracted Pelves.—For the first classification of ab- normal pelves we are indebted to Deventer, who distinguished three groups: too large, too small, and too flat pelves. Most recent attempts at classification have been based upon the shape of the pelvis, without taking into consideration the etiological factors which lead to its production. This method was adopted by Michaelis, and reached its greatest perfection in Litzmann’s hands. The former thoroughly realized its inherent defects and regretted that other methods of classification could not be employed. Kilian, Busch, and Siebold had previously recognized the necessity of taking into account the etiological factors which are concerned, but their knowledge was too meager to permit of such a course. It was not until 1889 that Schauta was able to suggest a fairly satis- factory etiological classification, which soon obtained general acceptance, although it was still far from ideal. Tarnier and Budin, in their treatise issued in 1898, followed somewhat similar lines. Breus and Kolisko do not consider that either is perfectly satisfactory, and have suggested a substitute for them. Owing to the fact that our knowledge of the fundamental factors underlying the production of many forms of abnormal pelves is still very meager, and occasionally entirely lacking, it is apparent that at the present time no etiological classification can be perfectly satisfactory, though from a practical point of view the one employed by Tarnier and Budin would seem to approach it. In the following chapters I shall employ a combination of the classification of the latter and that of Schauta, although I am well aware that it is far from ideal. LITERATURE Acosta-Sisson. Pelvimetry and Cephalometry among Filipinos. Philippine J. Sei., 1914, ix, 493-497. Arantius. See Chapter I. Baisch. Reformen in de,r Therapie des engen Becken. Leipzig, 1907. Baisset. Be la mensuration externe du bassin. These de Lyon, 1901. Barnes. Internat. Gyn. Congress, Geneva, 1896. Zentralbl. f. Gyn., 1896, xx, 1089. Baudelocque. L’art des accouchements. Nouvelle ed., 1789, t. i., 76-90. Bouchacourt. De la radiographie du bassin de la femme adulte. L ’obstetrique, 1900, v, 320-351. LITERATURE 799 Breisky. Beitrage zur geburtshiilflichen Beurtheilung der Verengerungen des Beckenausganges. Wiener med. Jahrb., 1870, xix. Breus und Kolisko. Die pathologischen Beckenformen. Wien, 1900, Theil I. Budin. Statistiques de la Maternite de Paris. L’obstetrique, 1896, iii, 134. Photographie par les rayons x d’un bassin de Naegele. L’obstetrique, 1897, ii, 499. Busch. Geburtskunde, Berlin, 1849. Bylicki. Ueber eine Methoden den geraden Beckeneingangsdurclimesser inittelst einer Skala von Winkelhebeln unmittelbar zu messen. Monatsschr. f. Geb. u. Gyn., 1904, xx, Erganzungsheft, 441-452. Commandeur. Viciatious pelviennes. In Bar, Brindeau et Chamberlent, La pratique de Part des accouchements. 1914, ii, 184-346. Deventer. Operationes chirurgicae novum lumen exhibentes obstetricanibus, 1701. Dewees. A Compendious System of Midwifery. Philadelphia, 1824. Dionis. Traite general des accouchements, etc. Paris, 1718. Emmons. A Study of the Variations in the Female Pelvis, etc. Biometrika, 1913, ix, 34-57. Fabre. Radiographie du bassin. Precis d’obstetrique, 1922, III Ed., 201-211. Flint. Deformed Pelves. Rep. of Soc. of the Lying-in Hosp., New York, 1897, 258-271. Fuchs. Statistik der in den letzten 10 Jahren in der Erlanger Universitats- Frauenklinik vorgekommenen engen Becken. D. I., Wurzburg, 1899. Gauss. Die unmittelbare Messung der Congugata obstetricia. Zentralbl. f. Gyn., 1906, 763-766. Goenner. Zur Statistik de3 engen Beckens. Zeitschr. f. Geb. u. Gyn., 1882, vii, 314. Ein hundert Messungen weiblicher Becken an der Leiche. Zeitschr. f. Geb. u. Gyn., 1901, xliv, 308-325. Hirst. American Text-Book of Obstetrics, 1897, 498-510. Kilian. Die Geburtslehre von Seiten der Wissenschaft und Kunst dargestellt. Frankfurt, 1840. Klien. Die geburtshiilfliche Bedeutung der Verengerungen des Beckenausgangs. Yolkmann’s Sammlung klin. Vortrage, N. F., 1896, Nr. 169. Knapp. Bericht iiber 105 Geburten bei engen Becken aus den Jahren 1881-’95. Archiv f. Gyn., 1886, xl, 489-586. Kottgen. Zur Statistik des engen Beckens. D. I., Bonn, 1895. Leopold (Franke). Enges Becken und spontane Geburt. Arbeiten aus d. konigl. Frauenklinik in Dresden, 1895, ii, 29-48. Litzmann. Die Formen des Beckens. Leipzig, 1861. Die Geburt bei engen Becken. Leipzig, 1884. Ludwig und Savor. Klin. Bericht iiber die Geburten bei engen Becken in dem Zeitraum, 1878-’92. Bericht aus der II. geb. gyn. Klinik in Wien, R. Chrobak, 1897, 120-394. Lusk. The Science and Art of Midwifery. Fourth ed., 1895. Mauriceau. Observations sur la grossesse et 1’accouchement des femmes. Nouv. ed., 1738. Michaelis. Das enge Becken. Leipzig, 1851. DE la Motte. Traite complet des accouchements naturels, etc. Nouv. ed., Leiden, 1729. Muller. Zur Frequenz und Aetiologie des allgemeinen verengten Beckens. Archiv f. Gyn., 1880, xvi, 155. Mullerheim. Verwerthung der Rontgen Strahlen in der Geburtshiilfe. Deutsche med. Wochenschr., 1898, xxiv, 619-621. 800 CONTRACTED PELVIS Naegele. Das weibliche Becken, etc. Carlsruhe, 18.59. Das schrag verengte Becken, etc. Mainz, 1839. Neumann und Ehrenfest. Eine neue Methode der inneren Beckenmessung an der lebenden Frau. Monatsschr. f. Geb. u. Gyn., 1900, xi, 237-253. ParE. See Chapter I. Pawlik. Internat. Gyn. Congress, Geneva, 1896. Zentralbl. f. Gyn., 1896, xx, 1090. Pfund. AcrztI. Intelligenzblatt, 1895, xxxii, 247. Pinard. Fonctionnement de la maison d ’accouchement Eaudelocque. For various years. Puzos. Traite des accouchements, etc. Paris, 1749. Reynolds. The Frequency of Contracted Pelves. Trans. Am. Gyn., Soc., 1890, xv, 367-377. Riggs. A Comparative Study of White and Negro Pelves, etc. Johns Hopkins Hospital Reports, 1904, xii, 421-454. Schauta. Die Beckenanomalien. Muller’s Handbuch der Geb., 1889, ii. Scheffer. Ueber das Verhaltniss des Abstandes der Spinae und Cristae ilium zu dem des Querdurchmesser des Beckeneinganges. Monatsschr. f. Geburtsk., 1868, xxxi, 299-309. Sellheim. Zur Lehre vom engen Becken. Beitriige zur Geb. u. Gyn., 1906, ix, 253-312. Siebold. Lehrbuch der Geburtshulfe, 1854. Skutsch. Die Beckenmessung. Jena, 1886. Die praktische Verwerthung der Beckenmessung. Deutsche med. Woch., 1891, Nr. 21. Smellie. Treatise on the Theory and Practice of Midwifery, with Collection of Cases. Eighth ed., London, 1774. Stein, G. W. Beschreibung des kleinen und einfachen Beckenmcsser, etc. Kleine Werke zur prak. Geburtsh., Marburg, 1798, 135. Steinbrecher. Die Schatzung der Transversa des Becken-eingangs nach Lohlein. Archiv f. Gyn., 1907, lxxxi, 433-450. Thoms. A Statistical Study of the Frequency of Funnel Pelves and the Descrip- tion of a New Outlet Pelvimeter. Am. J. Obst., 1915, lxxii, 121-132. Outlining the Superior Strait by Means of the X-ray. Am. Jour. Obst. & Gyn., 1922, iv, 257-263. Van der Hoeven. Der Wert einiger Beckenmasse. Monatsschr. f. Geb. u. Gyn., 1912, xxxv, 1-24. Varnier. Etude anat. et radiographique de la symphyse pubienne apres le sym- physeotomie. Comptes rendus de la soc. d’obst., de gyn. et de paed. de Paris, 1899, i, 209. Wiedenmuller. Zur Statistik des engen Beckens. D. I., Marburg, 1895. Williams. Pelvimetry for the General Practitioner. Medical News, March 21, 1891. Frequency of Contracted Pelves in Baltimore. Johns Hopkins Hosp. Bulletin, 1896, vii, 164. Frequency of Contracted Pelves in the First One Thousand Women Delivered in the Obstetrical Department of the Johns Hopkins Hospital. Obstetrics, 1899, i, Nos. 5 and 6. Frequency, and Practical Significance of Contractions of the Pelvic Outlet. Surg. Gyn. and Obst., 1909, viii, 619-638. The Funnel Pelvis. Am. J. Obst., 1911, lxiv, 106-124. Zangemeister. Beitrag zur Lehre vom engen Becken. Zentralbt. f. Gyn., 1922, 1395-1406. CHAPTER XXXIV ANOMALIES DUE TO ABNORMAL MALLEABILITY OF THE PELVIC BONES FLAT N0N-EHACHITIC PELVIS It is generally held that this is the most usual variety of pelvic de- formity occurring in white women, as it was noted in 43 per cent, of the contracted pelves described by Michaelis. Litzmann stated that its fre- quency, as compared with that of the rhachitic pelvis, was as 7 to 5. In my experience, however, the funnel and the generally contracted pelvis are the most usual abnormalities in white women, in whom the simple flat pelvis occupies the third place, but occurs extremely rarely in black women. The following table gives the relative incidence of the more common types of contracted pelvis in the two races, as observed at the Johns Hopkins Hospital in a series of 4,000 women delivered at full term— 2,459 white and 1,541 black—in whom the diameters of the pelvic out- let were also measured (Case 2,000—6,957) : WHITE VARIETY OF PELVIS Total No. Incidence Percentage of | Contracted Pelves BLACK VARIETY OF PELVIS Total No. Incidence Percentage of Contracted Pelves Funnel 125 5.1 37.87 *Generally contracted.. *348 22.9 56.40 *Generally contracted.. *130 5.3 39.39 Gen. cont. rhachitic... 155 10.0 25.12 Simple flat 52 2.1 15.75 Funnel 89 5.8 14.42 Gen. cont. rhachitic.. . 11 0.4 3.36 Flat rhachitic 15 1.0 2.43 Atypical 7 0.3 2.12 Simple flat 7 0.5 1.14 Flat rhachitic 5 0.2 1 51 Atypical 3 0.2 0.49 330 13 4 100 00 Total 617 40 4 100 00 * Including generally contracted funnel pelves. In this series of patients, the simple flat pelvis occurred in 2.1 per cent, of the white and in 0.5 per cent, of the black women; and, upon omitting the outlet contractions, it represented 25 and 1.3 per cent, respectively, of the abnormal pelves in the two races. Most German authors confirm the statements of Michaelis and Litz- mann as to its frequency. On the other hand, Ahlfeld dissents from this view, holding that many of the pelves which have been designated as simple flat are really of rhachitic origin, and Tarnier and Budin state 801 802 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC EONES that only one-sixteenth of the abnormal pelves with which they met could be attributed to other causes than rhachitis. This variety is frequently described as the pelvis plana Deventeri, or simple flat pelvis, although it is doubtful whether Deventer differen- tiated between it and the rhachitic form. It was accurately described by Betschler in 1832, but Michaelis and Litzmann were the first to insist upon its importance and frequent occurrence. The characteristic feature of the flat non-rhachitic pelvis consists in a shortening of all the anteroposterior diameters of the pelvic cavity, Fig. 550. Fig. 551. Figs. 550-552.—Flat Non-rhachitic Pelvis. Fig. 552. while the transverse measurements remain practically normal.1 This condition is due to the fact that the entire sacrum approaches more nearly than normal to the symphysis pubis. At the same time it under- 1 -*-^e illustrations in the chapters on Contracted Pelves have been prepared with great care. The half-tone illustrations are exactly one-third natural size, and were diawn from photographs which were taken with the pelves as nearly as possible in the same position—that is, with the tip of the coccyx and upper margin of the symphysis pubis on the same horizontal level. Accordingly, the illustrations can be accurately compared. The diagrams of the superior strait and the sagittal sections through the pelvic cavity are one-sixth natural size, and are accurate to within one millimeter. The former were made by means of the camera with the plane of the superior strait at right angles to the horizon. The latter were made from tracings of casts of the pelvic cavity obtained by means of dental wax, and reduced by the pantograph. FLAT NON-RHACHITIC PELVIS 803 goes a slight rotation about its transverse axis, as is shown by the fact that the contraction is always more marked in the superior than in the inferior strait. The degree of contraction is usually not very pronounced, and it is rare to find the conjugata vera measuring less than 8 centi- meters. In fact, whenever this limit is passed, the probability that one has to deal with a flat rhachitic pelvis should always be borne in mind. The sacrum does not present the characteristic features of rhachitis, and preserves its normal vertical and side to side concavity. Occa- sionally it may appear somewhat more delicately shaped than usual, and be narrower transversely. In such circumstances the transverse diameters of the pelvic cavity are also slightly decreased. In not a few pelves of this character the line of ossification between the first and second sacral vertebrae is more marked than usual, thus giving rise to a so-called second or accessory promontory. Etiology.—By many European authorities it is believed that the ap- proach of the sacrum to the symphysis results from the carrying of heavy burdens upon the back or head during early life, though such an explana- tion cannot apply in this country, where it is unusual for girls to carry heavy loads. In other cases the condition is attributed to the fact that the child was allowed to sit up at too early an age and for too long periods. Ahlfeld, Tarnier, and Breus and Kolisko think that a part in the production of the deformity is played by rhachitis, which, they hold, may be present in a larval form without giving rise to its usual and characteristic manifestations. The latter state that the shortening of the conjugata vera is not so much due to a rotation of the sacrum as to the shortening of the iliac portion of the terminal length of the innominate bone; and, as they believe that this is usually the result of rhachitis, they consider that it aids materially in determining the etiology of the condition. Fehling and Schliephake consider that this variety of pelvic anomaly is congenital in a certain number of instances, as they have shown that the pelves of newly born children may occasionally present a flattened appearance. In several cases studied by them the relation between the conjugata vera and the transverse diameter of the superior strait as was 100 to 145, 100 to 160, or 100 to 177, instead of 100 to 122, as is usually the case. In such circumstances the mechanical factors above alluded to could certainly not have come into play. Diagnosis.—The presence of a simple flat pelvis, as a rule, is readily detected. By external pelvimetry the distances between the spines and crests of the ilium, as well as between the trochanters, are found to be approximately normal, whereas Baudelocque’s diameter is definitely shortened. On internal examination the diagonal conjugate is found to be shortened, though never to an extreme degree. In general, if it falls below 8 centimeters the pelvis does not belong in this category. The entire anterior surface of the sacrum appears to be nearer the symphysis than usual, but presents its normal curvatures. There is no widening of the transverse diameter of the pelvic outlet, as in the rhachitic form. The average measurements in 26 of my cases were: spines, 25.7; crests, ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 804 27.8; trochanters, 30.5; Baudelocque’s diameter, 18; and diagonal con- jugate, 10.7 centimeters. RHACHITIC PELVIS In many parts of Europe one of the most prominent factors in the production of contracted pelves in an ab- normal softening of the bones in early life resulting from rhachitis. In this country the disease is observed comparatively rarely in white children, occasionally in colored children inhabiting country districts, and very frequently in those living in large cities. In not a few cases the disease undergoes spontaneous cure, so that no trace of its existence can be discovered in later life; while in many instances permanent skeletal deformities result which are principally localized in the pelvis. Again, it is also not unusual to meet with women who to all appearances are quite normally formed, but whose pelves upon examination present rhachitic deformities. Ehaehitic pelves were noted in 0.64 per cent, of the white and 11.03 per cent, of the black women in the tables given on page 801. Omitting outlet contractions, they constituted 8 and 32 per cent., respectively, of the abnormal pelves observed in the two races, thus showing that even in this country the disease is of marked importance from an obstetrical standpoint. Nature and Pathology of Rhachitis.— Before describing the various changes in the pelvis which may result from rhachitis, it will be well to consider briefly the nature and pathology of the disease. Unfortunately it is impossible to make clear-cut statements in this regard, more particularly as the work of Schmorl, of Recklinghausen, of Ogata, and of others tends to indicate that the difference between rhachitis and osteomalacia is nothing like so marked as was formerly believed. According to Kassowitz, Spillmann, and others, the for- mei is to he looked upon as an osteitis associated with an excessive forma- tion of osteoid tissue at the epiphyses and beneath the periosteum of the long hones, as well as in the flat bones of the skull and pelvis. The proliferation is accompanied by defective calcification of the newly Fig. 553.—Section through Normal Epiphysis of Child (Spillman). cn., normal cartilage; cs., carti- lage cells arranged in parallel rows; cc., area of preliminary calcification; em., medullary spaces; o., osteoblasts; lo., osseous lamellae; m., marrow. RHACHITIC PELVIS 805 formed tissue, Zweifel stating that only 18 to 24 per cent, of inorganic salts are present, as against 63 to 65 per cent, in normal bone. It is customary to distinguish three stages in the disease: conges- tion, softening, and progressive deformity or cure, as the case may be. In the tirst stage there is a great increase in vascularity, which is most marked at the union of the articular cartilages with the diaphyses of the long bones and also beneath the periosteum. In the former location the zone of preliminary calcification—Guerin’s line—is slightly thickened, and its lower portion adjacent to the newly formed spongy bone is perforated by numerous vascular loops. A similar condition may also be observed beneath the peri- osteum covering the long and the flat bones (Fig. 554). In the second stage, while Guerin’s line has become markedly thickened and very irregular, the vascular proliferation has advanced to a marked degree. Under the microscope the former is seen to be broken up in all directions by the rapidly growing vascular loops, which subdivide it into large num- bers of small irregularly shaped calcific areas. At the same time the formation of osseous tissue just beneath it proceeds in an irregular manner, calcification either failing to occur or taking place im- perfectly. In newly formed tissue, between the vascular loops and the narrow cavities, there is a considerable formation of osteoid tissue, with spindle- and star-shaped cells, which does not become ossified at all. To summarize these changes briefly, one may say that the growing end of the bone, instead of undergoing normal ossification, consists in great part of dilated capillaries which separate irregularly shaped masses of calcified cartilage from areas of connective tissue and imperfectly formed bone (Fig. 555). Similar changes take place under the perios- teum of the long and flat bones, so that the shaft of the bone soon becomes converted into a spongy tissue corresponding closely to that observed at the epiphysis. In the third period the process continues until death occurs; or, if recovery ensues—the usual outcome—there is a progressive decrease in vascularity, and the normal process of ossification is resumed, so that after a time the only trace of the disease is to be found in an atrophy of the bone, which is frequently associated with thickening and an in- creased porosity. It is therefore apparent that the bones become abnor- mally soft and yielding in the acute stages of the disease, so that if the Fig. 554.—Section through Epiphysis in Early Stages of Rhachitis (Spill- mann). ex., cartillage cells arranged in parallel rows; tee., area of preliminary calcifi- cation; c., capillary; tc., unossified con- nective tissue. 806 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES child uses its extremities at the time, more or less marked deformity must result, depending upon the mechanical influences which are liable to modify the evolution of the infantile pelvis. Breus and Kolisko insist that practically no growth occurs during the acute stage of the disease, and, consequently, if it persists for any length of time, it must inevitably lead to atrophic changes, so that after recovery the bones are smaller and somewhat lighter than normal, even though they show no characteristic signs of deformity. Forms of Rhachitic Pelves.—As has already been said, the rhachitic type is one of the most frequently observed varieties of contracted pelvis, Fig. 555.—Section through Epiphysis in Advanced Stages of Rhachitis (Spillmann). tcc., area of preliminary calcification; cc., calcified cartilage; c, capillaries; tc., connective tissue. and in extreme cases presents the most marked deformities with which we are familiar, with the exception of those resulting from osteomalacia. Fortunately, however, the degree of contraction is usually not so pro- nounced, 1 arnier having found that the conjugata vera measured less than 8.5 centimeters in only 14.4 per cent, of 1,020 rhachitic pelves. ith the exception of the cases which are complicated by abnormali- ties of the vertebral column, or by deformities giving rise to a marked difference in the length of the limbs, rhachitic pelves are usually classified as follows: 1. Flat rhachitic. 2. Generally contracted, flat rhachitic. 3. Generally and equally contracted rhachitic. 4. Pseudo-osteomalacic. RHACHITIC PELVIS 807 1. Flat Rhachitic Pelvis.—In this variety the greatest contraction occurs in the anteroposterior diameter of the superior strait, while the transverse diameter is normal, or even slightly increased in length. Generally speaking, the pelvic bones - are less dense in texture than usual, and frequently are delicate in form, though occasionally they may appear clumsy and swollen. Owing to the marked lordosis, wdiich frequently results from rhachitis, the pelvic inclination, as a rule, is considerably increased. Most important changes are to be noted in the sacrum, which Fig. 556. Fig. 557. Fig. 556-558.—Flat Rhachtic Pelvis Fig. 558. differs from the normal in that it is broader from side to side, thinner from behind forward, shorter from above downward, and less concave on its anterior surface. The longitudinal axis of the bone is so altered as to form a greater angle with the conjugata vera, and consequently the promontory lies at a lower level than usual, approaches the symphysis pubis, and encroaches markedly upon the area of the superior strait. Usually the entire sacrum is sharply bent upon itself in the neighbor- hood of its third vertebra, so that its vertical concavity becomes markedly accentuated. Occasionally this does not occur, and in such cases the 808 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES sacrum may be quite straight from base to tip. At the same time the bodies of the individual vertebrae extend out beyond the level of their alae, thereby diminishing the lateral concavity of the sacrum, and generally converting it into a pronounced convexity. In the latter event the spinous processes project less far than usual beyond the poste- rior surface, which tends to become concave. As the upper part of the sacrum becomes displaced downward and forward, its posterior surface recedes from the superior posterior spines of the ilium, which approach one another more closely than in the normal condition, so that the posterior limb of the S-shaped curva- ture of the iliac crests becomes accentuated. Occasionally the anterior surface of the sacrum may be convex in both directions, and, when directed more vertically than usual, it may happen that the greatest convexity will correspond to the region of the second and third sacral vertebrae. In this event the shortest diameter of the pelvis will be the anteroposterior of the plane of greatest pelvic dimensions, instead of the conjugata vera. Breus and Kolisko have Fig. 559.—Accentuation of Vertical Concavity of Sacrum in Rhachitis. Fig. 560.—Showing Obliteration of Vertical Concavity of Sacrum in Rhachitis. classified such pelves in a special group, and designate them as “middle flat.” In such cases the promontory of the sacrum is not displaced downward, and the condition is usually associated with assimilation. Occasionally the body of the first sacral vertebra is more markedly displaced forward than those below it, so that its lower margin projects beyond the general surface, and can be felt as a false, or double, prom- ontory. In such circumstances the distance between it and the sym- physis pubis may be shorter than the conjugata vera. The presence of a false promontory is usually indicative of the assimilation of an extra vertebra to the sacrum, and its significance will be discussed when assimilation pelves are considered. The iliac bones are smaller and frequently more delicately shaped than usual, the vertical height of the pelvis as well as the length of the iliac crests being diminished. The iliac fossae are more concave, and frequently present a pronounced, sharp depression just in front of the sacro-iliac joint. As a result the anterior margin of the bone extends more vertically than usual, as is shown by comparing the slant ol the line joining the acetabulum and the anterior superior spine of RHACHITIC PELVIS 809 the ilium. At the same time the anterior portion of the bone flares out at the expense of the crest, so that the distance between the anterior supe- rior spines approaches that between the crests, and occasionally even exceeds it. The diminution in the size of the iliac bone is best appreciated by studying the “terminal length” (Figs. 27 and 28). Normally, its three component parts are practically of the same length, but in rhachitis the pubic portion retains its normal dimensions, the sacral portion is slightly shorter than usual, while the iliac portion is greatly shortened, Fig. 561. Figs. 561-563.—Flat Rhachitic Pelvis, Showing Double Promontory Fig. 562. Fig. 563. and occasionally presents only a fraction of its normal length. Breus and Kolisko consider these changes almost pathognomonic of rhachitis. In many cases the iliac bones bend just in front of the sacro-iliac synchondrosis, so that the iliopectineal line, instead of following a gentle curve, forms a sharp angle at that point, thus adding materially to the flattening of the superior strait. At the same time the acetabula are displaced forward, and thus come to lie upon the anterior instead of upon the lateral portion of the pelvic ring. The pubic arch is relatively wider than normal, and the tubera ischii may he so everted that the transverse diameter of the outlet appears to be exaggerated, and occasionally measures more than in the normal 810 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES pelvis. In view of the upward and backward dislocation of the tip of the sacrum, the anteroposterior diameter of the outlet is also either relatively or absolutely increased in length. Consequently, in contrast with the flattened superior strait, the pelvic outlet appears wide and gaping, and in ex- treme cases may be nearly twice as roomy as the inlet (Fig. 564, A and B). These changes ex- ert a decided influ- ence upon the shape of the pelvic cavity, the effect being most marked in the supe- rior strait, which may become oval, ren- iform, or even heart- shaped in outline, according to the degree of displace- ment of the promon- tory of the sacrum. The conjugata vera is always shortened, while the transverse diameter seems to be enlarged, although this may be only rela- tive unless the pelvis be of large size. Owing to the ap- proach of the ante- rior and posterior walls of the pelvis, the oblique diameters of the superior strait are always shortened, as are also the sacro- cotyloid diameters. In occasional cases sharp exostoses may make their appearance upon the pubic crests, the iliopectineal eminences, or in front of the sacro-iliac synchondroses—pelvis spinosa. When such structures are not well covered by soft parts, they may lead to -injury of the uterus at the time of labor. 2, Generally Contracted, Flat Rhachitic Pelvis.—It is in this variety o pelvis that marked degrees of contraction are often encountered, e conjugata vera sometimes being reduced to 3 or 4 centimeters. This pelvis corresponds closely to the ordinary flat rhachitic type, except Fig. 564.—Generally Contracted Rhachitic Assimi- lation Pelvis. X A, anterior view; B, same pelvis seen from below showing relative widening of outlet. RHACHITIC PELVIS 811 that the shortening applies to all its diameters instead of being limited to the conjugata vera. Notwithstanding the fact that all of the diameters of the inferior strait fall below the normal limits, the outlet usually appears abnormally large when compared with the generally contracted inlet (Fig. 564). The various component parts of the pelvis show a relative decrease in size, particularly marked in the sacrum, which may present a con- siderable diminution in its transverse measurements. The small size of the pelvis in such cases may be due either to atrophic changes in Fig. 565. Fig. 566. Fig. 567. Figs. 565-567.—Generally Contracted, Flat Rhachitic Pelvis, the bones resulting from the rhachitis itself, or to the fact that a primarily small pelvis had become affected with the disease. 3. Generally Equally Contracted Rhachitic Pelvis.—This variety was first described by Michaelis, and according to most authors is observed but rarely. Muller, however, considers that not a few cases which were previously described as instances of simple, generally con- tracted (justominor) pelvis belong under this category, and my own experience, particularly in the negro race, confirms his observations. According to Litzmann, this type differs from the justominor pelvis in its ungainly and angular appearance, and in the marked prominence of the pubic crests. The superior strait appears to be equally shortened 812 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES in all its diameters instead of merely flattened, while the rest of the pelvis presents indisputable signs of a past rhachitis, wdiich is more particularly marked in the sacrum and in the eversion of the tubera ischii. 4. Pseudo-osteomalacic Rhachitic Pelvis.—1This variety is a mani- festation of the severest form of rhachitis, and is associated with the most marked degrees of contraction. As the name implies, the pelvis resembles one deformed by osteomalacia, the sacrum and lateral walls approaching one another so as to give rise to a very small, trefoil-like superior strait, the contraction also extending to other portions of the Fig. 568. Fig. 569. Fig. 570. Figs. 568-570.—Generally Equally Contracted Rhachitic Pelvis. pelvic cavity. Such pelves, however, are readily differentiated from the true osteomalacic type, since the sacrum and innominate bones present characteristic rhachitic deformities. This form of pelvis was first described by Smellie, who depicted it in his anatomical plates. More particular attention was directed to it by Stein, and especially by Naegele. It is not of frequent occurrence, though Fasbender in 1878 was able to collect 40 cases from the litera- ture, not a few of which occurred in young children. Diagnosis of Rhachitic Pelvis.—Important information as to the presence of rhachitis may be elicited by inspection of the patient, when characteristic deformities may be noted about the head, vertebral col- RHACHITIC PELVIS 813 umn, and lower extremities. In not a few cases the presence of thick- ened epiphyses at the costal margins—the so-called rhachitic rosary— may also serve to call attention to the existence of the disease. A decidedly pendulous abdomen in primiparous women is always suggestive of marked disproportion between the size of the head and the pelvis, and should suggest a search for rhachitic changes. The age at which the patient first learned to walk is also of consider- able importance, as it is well known that children suffering from rha- chitis are usually backward in this respect. Again, when the disease appears after the first year of life, the child usually ceases to walk dur- ing its acute stages, and has to learn again at a later period. Accurate information concerning the pelvia; however, can be obtained only by pelvim- etry. On exter- nal mensuration the distances be- tween the spines and crests of the ilium no longer show their normal relations, but the former approach, and not infre- quently exceed, the latter in length. Normally, there is a difference of 2.5 centimeters between the two, and whenever this becomes reduced to 1 centimeter or less rhachitis should be sus- pected. The distance between the trochanters will be normal or not according as one has to deal with the flat or the generally contracted type. Baudelocque’s diameter is always considerably shortened. At the same time Michaelis’ rhomboid loses its regular outlines, and in pronounced cases, owing to the sinking downward and forward of the sacrum, becomes converted into a triangular area. The pubic arch is usually widened, and the transverse diameter of the outlet is either relatively or absolutely increased in length. Still more definite information may be gained by internal pelvimetry and palpation of the pelvic cavity. The diagonal conjugate is always shortened. The anterior surface of the sacrum is more readily accessible to the examining fingers, and on careful palpation its upper portion is found to be flatter than usual, and in many cases it is convex from side to side owing to the protrusion of the vertebral bodies; at the same time its lower portion is sharply bent forward. In other words, the normal vertical concavity of the anterior surface of the sacrum becomes accentuated, while its lateral concavity becomes decreased, or is even con- verted into a convexity. The average measurements in ten rhachitic pelves in white women were: Spines, 25.4; crests, 25.7; trochanters, 29.3; Baudelocque, 17; and diagonal conjugate, 10.1 centimeters; while in 79 colored women Fig. 571.—Pseudo-osteomalacic Pelvis (Naegele). 814 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES the measurements averaged: Spines, 23.7; crests, 24.4; trochanters, 28.6; Baudelocque, 17.3; and diagonal conjugate, 10.6 centimeters. The difference in the measurements between the spines and crests in the two races is due to the lesser flaring of the iliac bones and to the generally smaller size of the pelvis in colored women. Thus, in two series of 707 and 470 normal pelves respectively, the spines and crests measured 25.5 and 28 centimeters in white, as compared with 24 and 26 centimeters in colored women. The flat rhachitic pelvis is diagnosticated when the transverse ex- ternal measurements show but slight diminution, whereas in the gen- erally contracted variety they measure considerably less than normal. In practice, the generally and equally contracted variety is usually confounded with the generally contracted rhachitic type, and a correct diagnosis is not made unless the dried pelvis becomes available; while the characteristic deformity of the pseudo-osteomalacic form will be recognized on internal examination, and the decision as to whether it Fig. 572.—Diagrams Showing Changes in Shape in Rhachitic and Osteomalacic Pelves (Schroeder). is due to rhachitis or osteomalacia will be determined by the history of the patient, as well as by the detection of definite rhachitic deformities. Mode of Production of the Rhachitic Deformities.—In Chapter I, we considered the part played by various mechanical factors in the trans- formation of the foetal into the adult pelvis. Prior to the work of Breus and Kolisko, it was generally believed that abnormalities and variations in their mode of action upon the softened pelvis also served to explain the production of most of the characteristic rhachitic deformi- ties. This doctrine was developed in great part by Litzmann and Schroeder, and obtained almost general acceptance. According to their theory, as the young child in the acute stages of rhachitis is unable to walk, and spends its time in a sitting or reclining position, the upward and inward force exerted by the femora is in abeyance. Consequently, the body weight and the cohesive force at the symphysis pubis are the only forces which come into play, and when the former is transmitted by the vertebral column to the sacrum it is resolved into two forces— one directed downward and the other forward. As a result, the sacrum rotates about its transverse axis, the promontory being pressed forward RHACHITIC PELVIS 815 and downward, while the remainder of the hone moves in the opposite direction and tends to assume a more or less horizontal position. The extreme upward dislocation of its lower end is resisted by the traction exerted upon it and the coccyx by the strong sacrosciatic ligaments, and consequently the softened bone becomes sharply flexed at its lower por- tion, whereby its vertical concavity is accentuated. At the same time, owing to the softened condition of the sacrum and the imperfect union between the bodies and alae of its vertebrae, the former are pushed out beyond the latter, thus converting its normal lateral concavity into a convexity. As the promontory is displaced forward and downward under the influence of the body weight, the posterior surface of the sacrum recedes from the superior posterior spines of the ilium, thus subjecting the strong iliosacral ligaments to marked tension. As a result, the posterior spines are drawn nearer to the middle line, while at the same time the anterior portions of the iliac bones flare out, thus accounting for the changed position of the anterior superior spines. This movement is resisted by the cohesive force exerted at the symphysis pubis, and as a consequence the softened bones bend just ill front of the sacro-iliac synchondrosis, so that the iliopectineal line on either side, instead of following a gentle curve, becomes sharply bent at that point. Coincident with these changes, the positions of the acetabula become altered, and eventually become situated upon the anterior, instead of upon the lateral, walls of the pelvis. As a result, when the child begins to walk the forces exerted by the femora also add to the flattening of the superior strait. On the other hand, owing to the previous non-use of the lower extremities, these last forces have not been called into play early enough to counteract the widening of the pelvic outlet as a result of prolonged sitting, and consequently the ischial tuberosities remain flared out. The same factors are concerned in the production of the generally contracted rhachitic pelvis, its small size being due either to atrophy incident to rhachitis, or to the effect of the disease upon a pelvis already abnormally small. The pseudo-osteomalacic form results when the rhachitic softening of the bones is very marked and the child persists in walking. In such circumstances not only do the characteristic changes in the sacrum and iliac crests develop, but at the same time the anterior wall of the pelvis is compressed and its lateral portions are pushed in toward the sacrum, the pelvic cavity becoming almost obliterated. The mechanical doctrine just outlined was early opposed by Fehling, Freund, Kehrer, and others. The former held that the characteristic form of the pelvis might result in utero, from the so-called foetal rhachi- tis, before the various mechanical factors can come into play. Such a view, however, is no longer tenable; for, following the researches of Porak, and Kaufmann, it is generally accepted that this disease has nothing in common with true rhachitis, but is a distinct entity, which has been variously designated as achondroplasia, or chondrodystrophia foetalis. ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 816 Freund has attempted to show that in view of the peculiar nature of the sacro-iliac joints the sacrum cannot rotate about its transverse axis. His argument, however, appears to have been based in great part upon conditions observed in adult life, and he seems to have lost sight of the fact that the articular surfaces in early life are almost entirely cartilaginous, and thus readily permit of motion in any direction. Kehrer believed that the action of certain groups of muscles plays a most important part in the production of abnormal pelves. No doubt this is true to a certain extent, but it is hardly probable that it is the only factor concerned. On the other hand, Breus and Kolisko claim that the mechanical views of Litzmann and Schroeder are in great part erroneous, as they hold that most rhachitic deformities can be explained without invoking the intervention of the various physical forces. They have shown that rhachitis not only gives rise to a general softening of the pelvic bones, but manifests itself more particularly in the imperfect development of the ilium and sacrum. Consequently, they contend that the flattening of the superior strait is in great part due to the imperfect growth of the iliac portion of the innominate bone, while the pubic and sacral portions are but little affected. Such an abnormality must inevitably lead to the shortening of the anteroposterior diameter, while, as the result of the normal development of the pubic portion; the transverse diameter will become relatively lengthened. Moreover, they hold that the displacement of the sacrum is not due to rotation about its transverse axis, but rather to the fact that the lack of development at the sacral end of the iliac portion of the innomi- nate bone interferes with the normal backward displacement of the sacro-iliac joint. At the same time they are willing to admit that the changes in the curvatures of the sacrum may be due to the action of purely mechanical factors. While the investigations of Breus and Kolisko have thrown great light upon the mode of production of rhachitic deformities of the pelvis, 1 do not believe that they should be accepted as the only explanation. Accordingly, it would seem that three factors are concerned in the genesis of these deformities: (1) abnormalities in the development of the rha- chitic bones; (2) the mechanical action of the various forces upon the softened bones; and (3) the traction or compression exerted by various muscles and ligaments. OSTEOMALACIC PELVES Inasmuch as osteomalacia gives rise to the most marked pelvic de- formities with which we are familiar, it was only natural that the atten- tion of obstetricians should have been directed to it at an early date. Cooper performed cesarean section for this condition in 1768, but for the main pioneer work we are indebted to Stein, Ivilian, and Litzmann. Nature and Clinical History of Osteomalacia.—Osteomalacia, halis- teresis, mollities ossium, or malacosteon disease is a general constitu- tional disorder, probably dependent upon some as yet unknown perver- OSTEOMALACIC PELVES 817 sion of the internal secretory organs, which manifests itself by neuritic changes, muscular atrophies, and particularly by characteristic changes in the bones, which become soft, yielding, and occasionally brittle, and consequently undergo marked changes in shape as the result of the action of the various mechanical forces to which they are subjected. The disease is one of adult life, and is very rarely met with in children. It occurs far more frequently in women than in men, espe- daily during pregnancy or the puerperium. Litzmann, in 1861, col- lected 131 cases from the literature, 85 of which were in pregnant or puerperal women, 35 in non-pregnant women, and 11 in men. Since that time the number of cases in women has markedly increased, whereas in 1900 Hahn was able to add only 31 additional instances in males. The disease may occur in any part of the world, but is especially fre- quent, and may even be said to be endemic, in certain localities, notably in the Rhine Valley, the Ergolz Valley in Switzerland, the Olona Valley and Calabria in Italy, and in the city of Vienna. It is very rarely observed in this country, England, or France, Dock having been able to collect only 10 cases in America up to 1896. Tarnier, in his large experience, encountered only 3 cases in Paris, and I have seen the came number in Baltimore. Unless we are prepared to accept the bacterial origin of the disease, as urged by Arcangeli and other Italian investigators, no satisfactory explanation for its endemic occurrence has been adduced, but it seems to be intimately connected with unsanitary surroundings and inferior food. This was strikingly illustrated by the experience of Winckel, Sr., in Gummersbach in Germany, and of Hoebecke in Sottegem in Holland. The former performed 13, and the latter 14 cesarean sections upon osteomalacic patients prior to 1840. Since that time improvement in the hygienic conditions of both villages, together with more healthy occupation for their inhabitants, has led to an almost total disappearance of the disease. On the other hand, it may suddenly become endemic in localities in which it was previously unknown, as was illustrated by Ogata’s experience in the province of Toyama in Japan. Likewise, a striking increase in its incidence was noted in A7ienna apparently as the result of the privations incidental to the World War, and Schlesinger states that it especially affected elderly men. Osteomalacia may affect any portion of the skeleton, but seems to select more particularly the pelvis, vertebrae, and ribs. The fresh bones are yellowish or yellowish-brown in appearance, and very soft and brittle. In advanced cases their consistence is that of leather or wax, so that they can readily be cut with a knife. In the later stages of the disease the spongy bones present a markedly areolated appearance on section, and in some instances are so rarefied that only the outer layers remain intact. At the same time they become much lighter, the specific gravity being frequently reduced by one half. Under the microscope the marrow spaces are found to be greatly enlarged, and there is a marked increase in vascularity. The most im- portant change, however, consists in the substitution of osteoid tissue in place of the true bone surrounding the haversian canals. 818 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES All of the earlier writers upon the subject considered that the changes in the bone resulted from decalcification, which was due to the presence of lactic or a related acid in the circulating blood. But, after the correctness of this view had been denied by Virchow in 1852, the writers upon the subject became divided into two camps: the one claiming that the essential feature of the disease is decalcification, and the other, a disturbance in the relation between resorption and apposition, by which osteoid instead of osseous tissue is formed. Formerly, it was thought that the bone lesions in rhachitis and osteomalacia could be readily differenti- ated, but Recklinghausen, who was formerly a pronounced dualist, stated in his monumental work that it was practically out of the question. Full details of this discussion are to be found in the writings of Gelpke, Winckel, Laufer, Dibbelt, Marquis, and Christofoletti. One of the most important contributions to the subject was made by Fehling in 1888, who advanced the theory that the disease was a tropho- neurosis of ovarian origin. He believed that characteristic changes could be made out in the ovaries, that these gave rise to reflex stimula- tion of the vasodilators supplying the bones, and that cure could be effected by removal of the ovaries. Although the various investigators, who have studied those organs histologically have been unable to demon- strate the existence of characteristic lesions, it seems highly probable that the disease is in some way associated with ovarian hyperfunction; otherwise it would be very difficult to comprehend the results which have followed castration, as Seitz reports that 87 per cent, of 328 patients were definitely cured by the operation. Benzel in 1919 analyzed the results obtained in the Strassburg clinic, and stated that while cure occasionally followed the administration of adrenalin or the use of X-rays the most brilliant results were obtained by castration. It is not yet known whether the disease results from a primary dis- turbance of the internal secretion of the ovaries, or whether the latter is a manifestation of hypofunction on the part of the adrenals. A cer- tain amount of evidence in favor of the latter view is afforded by the favorable results obtained by the administration of adrenalin, as recom- mended by Bossi. It appears that osteomalacic women can take with impunity quantities of the drug,- which would give rise to serious symp- toms under other conditions, and that its prolonged administration is followed by cure in about one quarter of the cases. Furthermore, Varaldo states that its use is followed by the appearance of definitely degenerative changes in the ovaries. More important, from a practical standpoint, is the clinical history of the affection. In its earliest stages it is characterized by peculiar muscular palsies, which more especially affect the iliopsoas, and which are often accompanied by contractures of the abductor muscles of the thigh and by increased patellar reflexes. A little later rheumatoid pains make their appearance in various portions of the body, and at the same time the pelvis, ribs, and vertebral column become very sensitive upon pressure. As the disease advances still further and the bones become softer, various deformities appear, which are particularly marked in the vertebral column and pelvis, OSTEOMALACIC PELVES 819 The history of osteomalacic patients is usually quite characteristic: The multiparous woman complains of muscular symptoms and rheuma- toid pains during pregnancy. The same symptoms recur with added intensity in the succeeding pregnancy, and labor becomes more difficult. Should pregnancy again occur, the rheumatoid pains become severe and locomotion is so interfered with that for the last months the patient is obliged to take to her bed, and craniotomy or cesarean section is usually necessary at the time of labor. Shortly after delivery the pains disap- pear, and when the patient is able to get about again she notices that Fig. 573. Fig. 574. Figs. 573-575.—Osteomalacic Pelvis, Fig. 575 she has become some inches shorter than previously, the diminution in stature being sometimes associated with kyphotic changes in the vertebral column. To sum up, a history of rheumatoid pains and difficult locomotion requiring rest in bed during pregnancy, associated with a decrease in height, is almost pathognomonic of osteomalacia. Changes in the Shape of the Pelvis.—The extent of the deformity resulting from osteomalacia depends entirely upon the degree of soften- ing which the various pelvic bones have undergone. According to Kehrer, in the early stages of the disease the pelvis is simply flattened as the ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES 820 result of the forcing downward and forward of the promontory of the sacrum. In the later stages of the disease, when the bones have become very soft, the pelvis takes on a characteristic compressed appearance. The body weight presses the promontory still further downward and for- ward, while the upward and inward forces exerted by the femora push the lateral walls of the pelvis inward, so that the superior strait assumes a trefoil appearance, and in extreme cases becomes almost entirely oblit- erated. At the same time the ischiopubic rami are approximated, and the pubic arch is converted into a narrow slit into which it is some- times impossible to insinuate the fingers. The pubic rami are pushed markedly forward, giving rise to a beaklike protuberance upon the ante- rior wall of the pelvis. Coincident with these changes, there is a marked diminution in the size of the pelvic cavity and of the inferior strait, though in not a few cases, owing to constant sitting upon the softened bones, the tubera ischii are relatively flared out. In advanced cases the Fig. 576.—Osteomalacic Pelvis, Inferior Strait. pelvis is very much deformed, and may present any one of an almost infinite variety of bizarre shapes. Diagnosis.—The diagnosis is readily made, as careful inquiry will usually elicit the characteristic clinical history of the disease; while examination of the pelvis will show that it is markedly compressed in all directions, and the pathognomonic changes in the pubic arch can hardly escape detection. Indeed, the only form of pelvis with which it might be confounded is the very rare transversely contracted Eobert pelvis, but the clinical history and the lack of anteroposterior shortening in the latter will usually enable one to differentiate between them. LITEBATUKE Ahlfeld. Die Diagnose des einfaeh platten Beckens an der Lebenden. Zeitschr. f. Geb. u. Gyn., 1895, xxxii, 356-367. Arcangeli. Aetiologie u. Pathogenese der Osteomalacie. Bef. Zentralbl. f. Gyn., 1910, 430-431. LITERATURE 821 Benzel. Die Behandlung der Osteomalaeie an der Strassburger Frauenklinik. Archiv f. Gyn., 1917, cvii, 268-282. Betschler. Annalen der klin. Anstalten. Breslau, 1832, i, 24-60, ii, 31. Bossi. Nebennieren und Osteomalakie. Zentralbt. f. Gyn., 1907, 172-173. Breus und Kolisko. Rachitis-becken. Die pathologischen Beckenformen. Leip- zig u. Wien, 1904, i, Theil 2, 435-636. Ciiristofoletti. Zur Pathogenese der Osteomalazie. Gyn. Rundschau, 1911, v, 113-144. Deventer. Neues Hebammenlicht, III. Aufl., Jena, 1728, 199. Dibbelt. Weitere Beitrage zur Pathologie der Rhachitis. Verh. der deutschen pathologischen Gesellschaft, 1910, xiv, 294-299. Dock. Osteomalacia, with a New Case. Amer. Jour. Med. Sciences, 1895, cix, 499-516. Fasbender. Ueber das pseudo- und das rachitisch-osteomalacische Becken. Zeit- schr. f. Geb. u. Gyn., 1878, ii, 332-345. Fehling. Die Entstehung der rachitischen Beckenform. Archiv f. Gyn., 1877, xi, 173-183. Ueber Kastration bei Osteomalaeie. Yerh. d. deutschen Gesellsch. f. Gyn., 1888, ii, 311-318. Freund. Ueber das sogenannte kyphotische Becken. Gyn. Klinik, 1885, 1-134. Gelpke. Die Osteomalaeie im Ergolzthale. Basel, 1891. Hahn. Ueber Osteomalaeie beim Manne. Zusammenfassendes Referat. Zentralbl. f. die Grenzgebiete der Med. u. Chir., 1900, iii. Kassowitz. Die normale Ossification und die Erkrankungen bei Rhachitis und hereditarer Syphilis. Wien, 1882. Kaufmans. Untersuchungen fiber die sogenannte fotale Rhachitis. Berlin, 1892. Kehrer. Zur Entwickelungsgeschicte des rhachitischen Beckens. Archiv f. Gyn., 1873, i, 55-99. Kilian. Beitrage zur einer genauen Kenntniss der allgemeinen Knoclienerweichung der Frauen. Bonn, 1829. Das halisteretische Becken. Bonn, 1857. Latzo. Beitrage zur Diagnose und Therapie der Osteomalaeie. Monatsschr. f. Geb. u. Gyn., 1897, vi, 571-608. Laufer. Zur Path. u. Therapie der Osteomalaeie des Weibes. Zenlralbl. f. die Grenzgebiete der Med. u. Chir., 1900, iii, Nr. 1. Litzmann. Die Formen des Beckens, nebst einem Anhange fiber Osteomalaeie. Berlin, 1861. Die Geburt bei engem Becken. Leipzig, 1884, 36. Marquis. Diagnostic et role de la decalcification gravidique. L ’obstetrique, 1910, v, 561-580. Michaelis. Das enge Becken. Leipzig, 1851. Muller. Zur Frequenz und Aetiologie des allgemein verengten Beckens. Archiv f. Gyn., 1880, xvi, 155-174. Naegele. Das schrag verengte Becken. Mainz, 1839. Ogata. Ueber das Wesen der Rhachitis und Osteomalaeie. Beitrage zur Geb. u. Gyn., 1911, xvii, 23-80. Porak. De 1’achondroplasie. Nouvelles archives d’obst. et de gyn., December, 1889. Recklinghausen. Rhachitis und Osteomalaeie. Jena, 1910. Schlesinger. Zur Kenntniss der gehauften osteomalakie-ahnlichen Zustande in Wien. Wiener klin. Wochenschr., 1919, Nr. 10. Schliephake. Ueber path. Beckenformen beim Fotus. Archiv f. Gyn., 1882, xx, 435-454. 822 ANOMALIES DUE TO MALLEABILITY OF THE PELVIC BONES Schmorl. Die path. Anatomie der rachitischen Knoehenerkrankung. Ergebnisse der inneren Medizin, 1909, iv. Seitz. Die Osteomalacie in ihren Beziehungen zur inneren Sekretion und zur Schwangerschaft. Innere Sekretion u. Schwangerschaft. Leipzig, 1913. Smellie. Anatomical Tables, etc. New edition, Edinburgh, 1787. Spillmann. Le Rachitisme. These de Nancy, 1900. Stein. Kleine Werke zur prakt. Geburtshiilfe, 1798, 283-340. Die Lehranstalt der Geburtshiilfe zu Bonn, Elberfeld, 1823, I. Heft. Tarnier et Budin. Traite de 1 ’art des accouchements, 1898, iii. Varaldo. Exp. Untersuchungen iiber Eierstocksveranderungen infolge wieder- holten Adrenalineinspritzungen. Zentralbl. f. Gyn., 1913, 1350-1353. Virchow. Archiv f. path. Anat. u. Physiol., 1852, iv. Winckel. Behandlung der Osteomalacie. Pentzoldt u. Stintzing. Handbuch der spec. Therapie, 1896, Bd. v, Abth. vii, 214-242. Zweieel. Aetiologie, Prophylaxis und Therapie der Rachitis. Leipzig, 1900. CHAPTER XXXV ABNORMAL PELVES RESULTING FROM PRIMARY ANOMALIES IN DEVELOPMENT Three separate groups of cases are differentiated according as the abnormalities are: (a) Generalized and symmetrical; (b) localized and asymmetrical; (c) localized and symmetrical. I. GENERALIZED AND SYMMETRICAL ANOMALIES IN DEVELOPMENT Abnormal development may manifest itself in an excess or in a lack of the general growth of the pelvis. In the former case we have to do with the generally enlarged or justomajor pelvis, and in the latter with one of several varieties—the generally contracted (justominor) pelvis, the infantile, the masculine, or the dwarf type. The Generally Enlarged (Justomajor) Pelvis.—This variety of pelvis is symmetrically enlarged in all its parts, and differs from the normal only by its increased size. It is usually observed in giantesses, and occa- sionally in women of normal stature; indeed, if the external measure- ments alone are taken as a criterion, it is of quite frequent occurrence in the latter. According to Schauta, the various diameters in this type rarely exceed the normal by more than 2 centimeters, though he refers to De la Tou- rette’s case, in which the anteroposterior and transverse diameters of the superior and inferior straits measured 14.9 and 17, and 14.9 and 14.9 centimeters, respectively. In not a few cases the greatest increase is in the anteroposterior diameter, while the others remain practically normal. Occasionally the enlargement may be limited to the superior strait, while the lower portions of the pelvic canal retain their usual proportions, thus producing a funnel-shaped pelvis. In rare instances excessive external transverse measurements may be due to the fact that the fossa join the main body of the iliac bones at a less obtuse angle than usual. This variety of pelvis has no effect upon the course of labor, except that its excessive size now and again obviates the necsesity for the usual mechanism, and consequently the head may be born so rapidly and suddenly that extensive perineal tears result. The Generally Contracted (Justominor) Pelvis.—This type was first described by Deventer as the pelvis nimis parva, while Stein later applied to it the designation justominor. All of its measurements are more or less proportionately shortened, so that at first glance the pelvis may 823 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 824 appear perfectly normal, the narrowing being discovered only after men- suration. As a rule, the generally contracted pelvis is lighter in texture, and its component parts are more delicately formed than usual. The sacrum is smaller, and the alae proportionately shorter than the bodies of its verte- brae. At the same time its vertical concavity is sometimes increased. On careful examination it is found that the decrease in size is not uni- Fig. 577. Fig. 578. Figs. 577-579.—Generally Contracted Pelvis. Fig. 579. form, as occasionally the conjugata vera is relatively shorter than the transverse diameter of the superior strait, while in every fifth or sixth specimen the inferior is relatively smaller than the superior strait, so I hat we have a type approaching the simple flat or funnel-shaped pelvis, respectively. Michaelis considered that the anteroposterior shortening in this class of pelves rarely exceeds 1.5 centimeters; and, although this appears lo Be too conservative a figure, it may he said that whenever the conjugata vera measures 8 centimeters rhachitic changes should be sus- pected. GENERALIZED AND SYMMETRICAL ANOMALIES 825 This pelvis is usually met with in small women, although one is occasionally surprised to find it in those of large stature. It is generally said to occur but rarely in Germany and France, although it was ob- served in 37 and 28 per cent, of the contracted pelves studied by Muller and Gonner respectively; and Eichelet states that it is much more com- mon in France than is generally believed. My own observations show that it is by no means unusual in Baltimore, as it was noted in 5.3 per cent, of our white, and in 22.9 per cent, of our black patients. Further- more, in white women it ranks just below the typical funnel pelvis in order of frequency; while in black women it represents the most usual type of contracted pelvis, comprising 33.4 and 53.7 per cent, of all pelvic abnormalities in the two races respectively. It is undoubtedly a sign of degeneration, and in the colored race is a manifestation of the im- perfect physical development incident to living in large cities. Muller considered that its frequency in Berne was probably due to the prevalence of cretinism in that locality, but the fact that Gonner observed it almost as frequently in Basel, where the latter disease occurs but rarely, militates against such a view. It is quite possible that not a few so- called justominor pelves are really of rhachitic origin, especially in negroes, and that in such cases the other more characteristic changes are lacking. The diagnosis is readily made. The existence of a generally con- tracted pelvis should always be suspected in small women, and espe- cially in poorly developed working women, although it should not be forgotten that it may occur in large and apparently well-formed indi- viduals. Accurate information can be obtained by means of pelvimetry. All of the external measurements are considerably and uniformly short- ened. Internal examination shows a shortened conjugate vera, with general smallness of the pelvic cavity, typical rhachitic changes being absent. The average measurements in 36 white women in my clinic presenting pelves of this character were: Spines, 23.25; crests, 25.7; trochanters, 26.3 ; Baudelocque, 17.9 ; and diagonal conjugate, 11.1 centi- meters, while in 167 colored women each measurement was a few milli- meters shorter. It is usually taught that a generally contracted pelvis with a con- jugata vera of a given length offers a greater obstacle to labor than a flat pelvis offering a similar measurement, and for practical purposes half a centimeter is usually added to the latter to reduce it to terms of the former. The Masculine Pelvis.—Michaelis directed attention to the fact that generally contracted pelves are occasionally encountered in which the bones are thicker and clumsier than usual and approach the male type. Pelves of this class occur much less frequently than is generally believed, as many which are so described are in reality typical funnel pelves. They have the same effect upon labor as the ordinary justominor variety, though in many instances the relatively great contraction of the inferior strait may add to the dystocia. Berry Hart pointed out in 1916 that the pelvis may occasionally pre- sent an “inversion” of male and female characteristics, so that either 826 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT its iliosacral or ischiopubic portion may conform to the male type, while the rest retains its typical feminine conformation. The former leads to abnormalities of the superior strait, while in the latter the ischiopubic rami become so approximated that a funnel pelvis results. The Infantile Pelvis.—In rare instances, as the result of disease, which has caused the individual to spend her entire life in bed without attempting to sit up or walk, the pelvis retains the characteristic in- fantile form to which reference was made in Chapter I. Ex- amples of this abnormality have been described by Naegele, Leisinger, Bittner, and Gurlt, but naturally it possesses no obstetrical significance. The Dwarf Pelvis.—Ac- cording to Breus and Kolisko, several varieties of dwarfs must be distinguished —- i. e., the chondrodystrophic, the ‘'true,” the cretin, the rhachitic, and the hypo- plastic dwarf. In the first-mentioned variety the deformity results from chondro- dystrophia foetalis (Kaufmann), achondroplasia (Parrot and Porak), or foetal rhachitis, as the disease has been variously designated. The affec- tion is not allied to rhachitis, but is an entirely independent disease which begins in utero, and whose etiology is as yet unknown; although many recent writers are inclined to attribute it to abnormalities in the func- tion of the endocrine glands, Wagner believing that it is associated with hyperfunction of the ovaries. It is characterized by changes in the epiphyseal cartilages, which interfere with the normal apposition of bone, with the result that the shafts of the long bones are imperfectly developed so that the individual presents a normally formed body, while the extremities are short and stumpy. In many instances the head is brachycephalic, with a prominent forehead and saddle nose. The mus- culature is often excessively developed, so that chondrodystrophic dwarfs may be unusually strong. Full details concerning the condition may be found in Rischbieth and Barrington’s monograph on dwarfism. It is sometimes hereditary, and in such cases the tendency is usually trans- mitted through the father. Persons presenting the abnormality are fre- quently exceptionally fertile, and thus contrast markedly with cretin dwarfs, in whom sterility is the rule. In the “true” dwarf there is a proportionate lack of general develop- ment, which is particularly characterized by the fact that the various epiphyses do not undergo ossification, but remain cartilaginous, until an advanced age. In the cretin dwarf the lack of development is general. The bony changes are allied to those observed in the true dwarf, but are less marked. The term rhachitic dwarf should not be applied to individuals whose short stature is due to skeletal deformities, but should be restricted to Fig. 580.—Chondrodystrophia Fcetalis. GENERALIZED AND SYMMETRICAL ANOMALIES 827 those who would fall far below the normal height even if one imagined the deformities straightened out. In the hypoplastic dwarf the changes are quantitative instead of qualitative, so that the individual differs from the normal only in her miniature appearance. Each of these varieties of dwarfs has a characteristically shaped pelvis, which is more or less generally contracted. The Chondrodystrophic Dwarf Pelvis.— Fig. 580 represents a chondrodystrophic in- fant, and Fig. 581 a chondrodystrophic dwarf, whose pelvis, described by Breus and Kolisko, is reproduced in Fig. 582. The woman was twenty-seven years old and 123 centimeters tall, and died after a cesarean sept ion. This variety of pelvis is characterized by an extreme anteroposterior flattening, so that on first glance one might believe that one had to deal with a rhachitic pelvis. On closer examination, however, it is seen that the flattening is due to the imperfect de- velopment of the portion of the iliac bone entering into the formation of the iliopec- tineal line, owing to which the sacral articu- lation is brought much nearer the pubic bone than usual. In 6 pelves of this character described by Breus and Kolisko the con- jugata vera varied from 4 to 7 centimeters, while the transverse diameter of the superior strait was but slightly shortened, varying from 11 to 12 centimeters. The True Dwarf Pelvis {Pelvis Nana). —This variety of pelvis is extremely rare, only 4 well-marked specimens being in existence—those described by Naegele and Boeckh, Schauta, Paltauf, and Breus and Kolisko, two of which were in females. The pelvis is generally contracted and tends toward the infantile type, but its most characteristic feature is the per- sistence of cartilage at all the epiphyses. Thus, in Boeckh’s pelvis, which belonged to a thirty-one-year-old woman, 108 centimeters tall, the Y-shaped cartilage at the acetabulum was clearly marked and the sacral vertebrae were not fused together (Fig. 584). The Cretin Dwarf Pelvis.—This is a generally contracted pelvis with poorly developed and imperfectly formed bones. Unlike that of the true dwarf, it does not present infantile characteristics, but shows signs of a steady though imperfect growth throughout early life. Unossified carti- lage may be present here and there in young subjects, but it disappears Fig. 581. — Chondrodystro- phic Dwarf (Breus and Kolisko). 828 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT with advancing age and is never found in all the epiphyses as in the true dwarf pelvis. Fig. 582. Fig. 583. Figs. 582, 583.—Chondrodystrophic Pelvis (Breus and Kolisko). The Rhachitic Dwarf Pelvis.—True rhachitic dwarfs are rare, and possess generally contracted, rhachitic pelves, which do not differ from those described in the previous chapter except by their small size. Figs. 584, 585.—True Dwarf Pelvis (Boeckh). Fig. 584. Fig. 585. 1 he Hypoplastic Dwarf Pelvis.—According to Breus and Kolisko this variety ot pelvis is observed in very small individuals, and is simply a LOCALIZED AND ASYMMETRICAL ANOMALIES 829 normal pelvis in miniature. It differs materially from that of the true dwarf in that it is completely ossified. II. LOCALIZED AND ASYMMETRICAL ANOMALIES IN DEVELOPMENT The Obliquely Contracted or Naegele Pelvis.—Naegele, in 1803, was the first to recognize the significance of this variety of pelvis, and in 1839 published a monograph upon the subject based upon the study of 35 specimens, one of which had been obtained from an Egyptian mummy. The Naegele pelvis presents the following characteristics: The sacral ala on one side is normal, while the other is either lacking or imper- fectly developed, and the corresponding sacral foramina are smaller. In the great majority of cases the sacrum and the innominate bone are firmly synostosed on the affected side. At the same time the latter is pushed upward and backward, as well as inward from the region of the acetabulum, so that its crest is at a higher level than that of its fellow. The iliopectineal line is less curved than normally, being almost straight when the deformity is marked, while upon the opposite side the curvature is accentuated, particularly in the anterior portion. Corresponding with the change in position of the innominate bone on the affected side, the ischial tuberosity and spine are displaced inward, upward, and back- ward, thereby approaching the outer margin of the sacrum and narrowing the sacrosciatic notch. The symphysis pubis is displaced toward the well side, while the pubic arch instead of looking directly forward is directed toward the abnormal side of the sacrum. The sacrum itself is displaced toward the ankylosed side, while its anterior surface is directed more or less obliquely toward it. As a result of these changes the pelvis becomes obliquely contracted, the superior strait being ovate in shape, with its small pole directed toward the abnormal sacro-iiiac joint and its large end toward the horizontal ramus of the pubis on the well side. Consequently, its oblique diameters are of unequal length, the shorter extending from the sacro- iliac synchondrosis of the well side to the iliopectineal eminence on the diseased side, while the conjugata vera is usually somewhat lengthened and is directed obliquely. The walls of the pelvis converge below, so that the contraction in- volves the entire pelvic cavity, but is relatively greater in the plane of least pelvic dimensions and in the inferior strait than at the superior strait. The acetabulum on the diseased side is directed more anteriorly, while that on the well side looks almost directly outward. The distances from the promontory of the sacrum to the acetabulum and from the tip of the sacrum to the ischial spine are markedly dimin- ished on the diseased side. At the same time the distance between the tuber ischii of the diseased side and the opposite posterior superior spine is less than that between the tuber ischii of the well and the correspond- ing spine of the diseased side. Moreover, the tip of the spinous process of the last lumbar vertebra is nearer the anterior superior spine of the S3Q ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT ilium on the diseased than on the well side, while the distance from the lower margin of the symphysis to the posterior superior spine is less upon the well side. Mode of Production.—The genesis of this variety of pelvic deformity has given rise to a great deal of discussion, some writers claiming that the defect in the sacrum is primary and the synostosis secondary; others, that the synostosis results primarily from changes which bring about more or less destruction of the sacral ala. The former view was advo- cated particularly by IInna, Hohl, Litzmann, Olshausen, and Schauta, and the latter by Betschler, E. Martin, Thomas, and others. It is now generally admitted that the first-mentioned view is correct, Hohl and others having shown that the entire sacral ala might be lacking Fig. 586. Fig. 587. Figs. 586, 587.—Antebior View of Obliquely Contracted Pelvis (Naegele) without a sign of synostosis. Moreover, Thomas and Kundrat, among other observers, have demonstrated that the ala of one or more sacral vertebrae may be absent or imperfectly developed while the others are normal. Accordingly, while synostosis usually occurs at the affected sacro-iliac synchondrosis, it is not a necessary characteristic of this variety of pelvis. The mechanism by which the deformity is produced is as follows: Owing to the asymmetry of the sacrum there is compensatory scoliosis of the lumbar portion of the vertebral column with its convexity on the diseased side. This causes the pelvis to assume an angle with the horizon, thereby bringing about a lowering of the acetabulum on the diseased side. As a consequence greater pressure is exerted by the femur on that side, which gradually brings about an upward, backward, and inward displacement of the corresponding innominate bone. Owing to the increased pressure, the synovial membrane at the sacro-iliac synch on- LOCALIZED AND ASYMMETRICAL ANOMALIES 831 drosis gradually undergoes pressure necrosis, and synostosis eventually results. Frequency.—Thomas, in 1861, was able to collect from the litera- ture a description of 50 pelves of this character. Since then additional cases have been described, but at present the entire number does not exceed 100. Diagnosis.-—Generally speaking, the condition is readily recognizable, provided that one’s attention is directed to its possible existence. Un- fortunately, since the customary external measurements give no clew to its presence, the diagnosis is usually not made until labor is far ad- vanced, when the evident dystocia forces one to look for the cause. The patients do not limp, and as a rule give no history suggestive of Fig. 588.—Posteriob View of Obliquely Contracted Pelvis (Naegele) trouble at the sacro-iliac joint. On the other hand, the existence of sco- liosis, a variation in the height of the hips, or a difference in the distance between the spine of the last lumbar vertebra and the posterior superior spine on either side should cause one to suspect its possibility, when a radiogram will settle the question. Naegele suggested five measurements which should be made in such cases: (1) From the tuber ischii of one side to the opposite posterior superior spine; (2) from the anterior superior spine of one side to the opposite posterior superior spine; (3) from the spine of the last lumbar vertebra to the anterior superior spine on either side; (4) from the trochanter to the opposite posterior superior spine; (5) from the lower margin of the symphysis pubis to the posterior superior spines on either side. Normally, these various measurements should be the same on both sides, but they differ considerably in obliquely contracted pelves. Owing to the difficulty of definitely locating their end points, the first, fourth, and fifth measurements are rarely employed; but the in- 832 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT formation obtained from the second and third is of very considerable value. A difference of more than 1 centimeter between these measure- ments on the two sides indicates an obliquely contracted pelvis, but is not sufficient to enable one to differentiate between the Naegele and the other varieties. On internal examination the conjugata vera is not shortened, but on measuring the diagonal conjugate it is found that the symphysis pubis, instead of being situated directly in front of the promontory, lies considerably to one side of it. On palpation it is found that the sacrum is asymmetrical, and that the lateral wall of the pelvis, as well as the ischial spine and tuberosity, approaches it much more closely on the diseased than on the opposite side, while the iliopectineal line is markedly flattened. At the same time the distance between the tubera ischii is greatly diminished. Effect upon Labor.—AVhen the deformity is at all pronounced, the side of the pelvis corresponding to the small end of the oval is so con- tracted as to be useless for the passage of the child, so that engagement, if it is to occur at all, must take place on the opposite side. In effect, the pelvic inlet becomes converted into one of the generally contracted type, and an idea of its available space is gained by measuring, not the conjugata vera, but the distance between the symphysis pubis and the sacro-iliac synchondrosis on the normal side. If engagement is possible, the labor will progress more favorably when the occiput is directed toward the iliopectineal eminence of the diseased than toward that of the well side, for the reason that in the first instance the biparietal diameter lies in the long oblique instead of in the short oblique diameter of the superior strait. Owing to the progressive increase of the contraction in the lower portion of the pelvis, still further difficulty is experienced when the head attempts to pass between the ischial spines and tuberosities, and the possibility of delivery depends upon the distance between these points. Prognosis.—If the deformity is at all pronounced the prognosis is bad, unless cesarean section be performed. Litzmann stated that in pre-antiseptic days 22 out of 28 mothers died in the first labor, and that only 6 labors ended spontaneously out of the 41 making up his entire series. Generally speaking, spontaneous labor is out of the question unless the short oblique diameter measures at least 8.5 centimeters. Below this limit cesarean section is the only rational method of treatment if the child is alive and the patient in good condition. Pinard in one case gained sufficient room for the delivery of the child by sawing through the horizontal iamus of the pubis and the ascending ramus of the ischium on the diseased side ischiopubiotomy. The operation was strongly condemned by Budin, and its performance is not to be recommended, for the reason that the ankylosis at one sacro-iliac joint may prevent suffi- cient expansion of the pelvis. LOCALIZED AND ASYMMETRICAL ANOMALIES 833 III. LOCALIZED AND SYMMETRICAL ANOMALIES IN DEVELOPMENT These may be of several characters: (a) Imperfect development of both sacral alae; (6) lack of union at the symphysis pubic; (c) lack of development of the vertebral bodies of the sacrum; (d) assimilation of the last lumbar vertebra with the sacrum, or of the first sacral vertebra with the lumbar column. Fig. 589. Fig. 590. Figs. 589-590.—Transvebsely Contracted Pelvis (Robert) The Transversely Contracted or Robert Pelvis.—Imperfect develop- ment of both sacral alae produces a pelvis which is markedly contracted transversely, and is sometimes described as the double Naegele 'pelvis. This variety is extremely rare, Tarnier stating that only 10 cases had been described up to 1898 (Fig. 589). In the pelvis described by Robert, both alae of the sacrum were lack- ing, and the innominate bones were firmly synostosed with the rudi- mentary sacrum. The anterior surface of the latter was convex in both directions. Owing to the imperfect development of the sacrum, the pelvis was markedly contracted transversely, and only slightly antero- posteriorly, the transverse and anteroposterior diameters of the superior and inferior straits measuring 7 and 9.7, and 5.1 and 10.6 centimeters, respectively. Just as in the Naegele pelvis, bony union between the sacrum and innominate bones is not an essential characteristic, and is occasionally lacking, sometimes on one, much more rarely on both sides. Where there is a difference in the development of the alae on the two sides it can readily be understood how an asymmetrically transversely contracted pelvis may result. The diagnosis is readily made, all of the transverse external measure- ments being markedly shortened while the external conjugate remains practically normal. Internal examination shows the conjugata vera to be ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 834 only slightly changed, while it is hardly possible for the close approach of the ischial spines and tuberosities to one another to escape recogni- tion. In all cases thus far reported the transverse narrowing of the pelvis was so great as absolutely to preclude the possibility of the birth of a living child, and accordingly cesarean section is the oidy rational method of treatment. o.w ' . ; . :- Split Pelvis.—In rare instances union between the pubic bones at the symphysis does not occur, and the anterior portions of the pelvis gape widely (Fig. 592). This condition is usually associated with ectopia of the bladder and imperfect development of the lower portion of the Figs. 591, 592.—-Split Pelvis (Kreus and Kolisko) Fig. 591. Fig. 592. anterior abdominal wall. As such abnormalities greatly diminish the probability of prolonged life, the condition is more common in young •children than in adults. We are indebted to Litzmann for the first accurate description of a pelvis of this character from an obstetrical point of view. In the split pelvis, owing to descent of the promontory of the sacrum and the absence of union at the symphysis, there is marked transverse widening of the posterior portion of the pelvis, while its anterior portions extend more or less parallel. External pelvimetry in such cases shows a marked flaring of the anterior superior spines of the ilium, farid were the defective condition of the pubis not clearly evident a rhachitic 'pelvis might be suspected. «■•**- The distance between the extremities of the pubic bones varies con- siderably, and occasionally is as great as 14 centimeters. This space is usually filled by a fibrinous band. Schickele, in 19()ly Reported a case LOCALIZED AND ASYMMETRICAL ANOMALIES 835 of labor in a pelvis of this character, and stated that 8 others were to be found in the literature. In only 2 of them was labor spontaneous, but in none was great difficulty experienced; consequently for practical pur- poses the pelvis may be considered as generally enlarged, the dystocia being due to abnormalities of mechanism resulting from the absence of a resistant anterior pelvic wall. Gemmel and Paterson in 1913 described a remarkable case, in which the entire generative tract, as well as the bladder, was doubled. In successive pregnancies conception occurred in either uterus and eventuated in spontaneous labor. Breus and Kolisko give an excellent description of several hitherto undescribed cases, and Fig. 593.—Contracted Pelvis Due to Absence of Bodies of Sacral Vertebrae (Litzmann). discuss fully the mechanical factors concerned in their production; while Miller has carefully reviewed the literature upon the subject up to 1918. Imperfect Development of the Vertebral Bodies of the Sacrum.— Litzmann has described a remarkable pelvis, in which almost the entire sacrum was lacking. This defect was associated with considerable trans- verse contraction, which increased as the inferior strait was approached, the transverse diameter of the superior strait measuring 10.5 centimeters, while the distance between the ischial spines and ischial tuberosities was 6.5 and 8.5 centimeters respectively (Fig. 594). Assimilation Pelvis.—Quite frequently the transverse processes of the last lumbar vertebra may he transformed into structures similar to the lateral masses of the sacral vertebrae, and fuse with them. In this event the former assumes the functions of the first sacral vertebra, the sacrum being now composed of 6 instead of 5 pieces. In other instances the first sacral vertebra may take on the characteristics of a lumbar ver- tebra and become assimilated to the lumbar column, so that there are 6 836 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT lumbar and only 4 sacral vertebrae. Occasionally the first coccygeal verte- bra may become assimilated with the sacrum, but this has no effect upon the character of the pelvis. Unless the entire vertebral column is available for study, it is fre- quently difficult to determine with which variety of assimilation one has to deal, as it is impossible to ascertain whether what corresponds to the Fig. 595. Fig. &96, Figs. 594 596.—High Assimilation Pelvis. first sacral vertebra is the twenty-fifth vertebra, as normal, or is the twenty-fourth or twenty-sixth vertebra, as the case may be. According to Rosenberg, in the development of the pelvis the first portion of the sacrum to enter into the formation of the sacro-iliac joint is the twenty- sixth vertebra, which normally corresponds to the second sacral, the twenty-fifth vertebra not becoming involved until later. Accordingly, a LOCALIZED AND ASYMMETRICAL ANOMALIES 837 sacrum with only four vertebrae may indicate the persistence of a foetal type, while the presence of six vertebrae shows that the normal process of articulation has been exaggerated. Assimilation is the most common of all pelvic abnormalities, and is noted in at least every fifth or sixth pelvis; indeed Paterson noted it in 38 per cent, of all pelves which he studied. In a series of 217 Indian squaw pelves, Emmons stated that its incidence wras 21.7 per cent. Un- less especially sought for, the condition is usually overlooked, so that it frequently happens that pelves which have been demonstrated for years by trained anatomists as typically normal present one or other Figs. 597, 598.—Transversely Contracted Assimilation Pelvis (Breus and Kolisko). Fig. 597. Fig. 598. type of this abnormality. Moreover, the condition may be associated with rhachitis or general imperfect development, in which event one has to deal with rhachitic or generally contracted assimilation pelves (Fig. 564). More commonly, however, such an association is lacking, but the mere existence of assimilation may, nevertheless, give rise to marked changes in the shape of the pelvis. When the last lumbar is assimilated with the first sacral vertebra— high assimilation—so that the sacrum consists of 6 pieces, important changes in the shape of the pelvis result, which depend in great part upon the manner in which the sacrum and innominate bones articulate, as well as upon the width of the former. In some cases the condition gives rise to a pelvis which is very high in its posterior portion, and whose superior strait is almost round, the walls of its inferior portion converging, thus producing a funnel-shaped pelvis (see Fig. 595). In other cases the condition gives rise to a pelvis with a somewhat trans- versely contracted superior strait (see Fig. 598), in which the conjugata vera is either relatively or absolutely longer than the transverse diame- 838 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT ter. Fabre and Bourret have carefully studied this type of pelvis from a clinical point of view, and state that it favors engagement of the head with the sagittal suture directly anteroposteriorly, instead of obliquely as usual; so that it should be regarded as an essential factor in the production of primary anterior or posterior occipital presentations. On the other hand, when the first sacral vertebra is assimilated with the lumbar column—low assimilation—a pelvis results which is very shallow in its posterior portion, but which offers no particular obstacle to labor (see Fig. 600). Occasionally the assimilated vertebra may undergo only a partial change, one side of it retaining the characteristics of a lumbar or sacral vertebra, as the case may he, while the other side undergoes consider- able modification. Under such circumstances asymmetrical pelves result, which are frequently obliquely contracted (see Fig. 601). Fig. 599.—Low Assimilation Pelvis (Breus and Kolisko). Funnel Pelvis.—Until recently, it was believed that the most char- acteristic examples of funnel-shaped pelvis are associated with lumbo- sacral kyphosis; and while contractions of the pelvic outlet are also noted in spondylolisthetic, osteomalacic, obliquely contracted, and other rare types of abnormal pelves, they occur so rarely that they are of scientific rather than practical importance, On the other hand, moderate degrees of outlet contraction are fre- quently noted under other conditions. Thus, in every fourth or fifth justominor pelvis the measurements of the inferior strait are diminished out, of proportion to the rest of the pelvis, and occasionally to such an extent as to give rise to outlet dystocia. In such cases the diag- nosis of general contraction should inevitably direct one’s attention to the possible existence of the abnormality, so that it is not likely to pass unnoticed. Unfortunately, more or less serious contraction of the outlet fre- quently occurs in pelves which appear to be perfectly normal, so far as the usual pelvic measurements are concerned. Such pelves I have designated as typical funnel, in contradistinction to the generally con- LOCALIZED AND ASYMMETRICAL ANOMALIES 839 tracted funnel variety to which reference has just been made. If outlet pelvimetry is not made an integral part of the preliminary obstetrical examination, the former usually passes unnoticed unless the contraction is so marked as to give rise to serious dystocia. In which event the physician may find himself in the embarrassing position of being obliged to resort to a radical operation in order to save the child, after having assured the patient that her pelvis was perfectly normal. Whenever the transverse diameter of the outlet measures 8 centimeters or less I designate the pelvis as funnel, and typical funnel pelves were noted in 6.1 per cent, of a series of 2,750 consecutive patients whom I Fig. 600.—Asymmetrical Assimilation Pelvis (Breus and Kolisko). examined up to April, 1911. In that series it was the most frequent abnormality observed in white women, making up 44 per cent, of the con- tracted pelves occurring in that race, and being almost as frequent as all of the other varieties combined. On the other hand, it constituted only 15 per cent, of the abnormal pelves in black women. Notwith- standing this marked difference in the relative ratio, its actual inci- dence in the two races was practically identical—5.87 and 6.43 per cent., respectively. Further investigation has confirmed these views; as Thoms, wdio studied a series of 4,000 women, who were delivered in my service up to the end of 1915 (cases 2,000-6,957), reported an incidence of 5.3 per cent.—4.96 in white and 5.76 in colored women, respectively. Furthermore, the fact that Emmons observed the abnormality in 9.2 per cent, of 217 Indian squaw pelves indicates that its incidence is much greater than is generally believed. The fact that the incidence of typical funnel pelves is practically the same in black and white women is of great importance in deter- 840 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT mining their mode of production; for, when it is remembered that in my material the usual types of contracted pelvis occur five times more frequently in the former than in the latter, it becomes evident that outlet contractions must be due to some factor other than rhachitis or imperfect general development, which play so conspicuous a part in the genesis of abnormal pelves in the colored race. Formerly it was believed that the condition was a manifestation of the existence of a masculine or an infantile type of pelvis, but my observations have Fig. 601.—Diagram Showing the Significance of Anterior and Posterior Sagittal Diam- eters. X Vs* Spontaneous labor through a transverse diameter of 5.5 cm. Fig. 002.—Diagram of Pelvic Outlet of Same Case, Illus- trating Possibility of Spon- taneous Labor Owing to Long Posterior Sagittal Diameter. X Vs- taught me that such is not the case, and T now believe that many outlet contractions, at least, are associated with high assimilation, namely, the presence of six vertebrae in the sacrum. This may so alter the relations at the sacro-iliac joints that the walls of the upper portion of the pelvic cavity converge, while the upper portion retains approximately its normal proportions. The correctness of such a view is demonstrated by the fact that I was able to palpate six sacral vertebrae in a number of my cases, and in many more to detect the existence of a false or second promontory. That definite proof could not be adduced in all cases is not surprising, as the sacial Aeitebiae can be counted accurately on vaginal or rectal palpation in only a comparatively small proportion of cases. Nevertheless, I feel that the demonstration of the existence of high assimilation in a small number of living women justifies the assumption that it really occurs much more frequently. Earlier in this chapter attention was directed to Berry Hart’s views on sexual inversion in the pelvis, when it was stated that he held that the existence of male characteristics in the ischiopubic portion, in asso- LOCALIZED AND ASYMMETRICAL ANOMALIES 841 ciation with female characteristics in the iliosacral portion, would give rise to a funnel pelvis. I am not prepared to express an opinion upon this point, and it must be left to future research to determine the cor- rectness of his views. In the great majority of funnel pelves the shortening is limited to the transverse diameter of the pelvic outlet. Ordinarily this is reduced to between 7 and 8 centimeters, but occasionally it is less, and in one of my patients it measured only 5.5 centimeters (Figs. 602 and 603). Exceptionally, the decrease in the distance between the tubera ischii may be associated with a shortening of the anteroposterior diameter of the outlet, which greatly increases the gravity of the condition, as will be indicated below. In still rarer instances, the contraction may be Fig. 603.—Diagram Showing the Significance of Anterior and Posterior Sagittal Diam- eters. X Vs. Cesarean section in spite of a transverse diam- eter of 6.5 cm. Fig. 604.—Diagram of Pelvic Out- let of Same Case, Illustrating Necessity for Cesarean Sec- tion. X 34- limited to the anteroposterior diameter and this is usually associated with flattening at the superior strait; although, of course, the most typical examples occur in the kyphotic and spondylolisthetic pelvis. Contractions of the latter type, however, are not classified as typical funnel pelves, but will be considered in their appropriate place. That contractions of the pelvic outlet may seriously affect the course of labor is shown by the fact that in 135 labors complicated by it and included in my paper of 1911, the following operations were necessary to effect delivery: namely, 17 forceps, 1 cesarean section, 3 pubiotomies, and 1 craniotomy upon the after-coming head. Moreover, even when the disproportion is not sufficiently great to give rise to serious dystocia, it may play an important part in the production of perineal tears. In such cases, with the increasing narrowing of the pubic arch, the occiput can not emerge directly beneath the symphysis pubis, and accordingly must stem itself further and further down upon the ischiopubic rami, and in extreme cases must rotate around a line joining the ischial tuberosities. Consequently the perineum must become more and more distended, and thus be exposed to greater danger of extensive rupture. 842 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT In view of the frequency and practical significance of outlet con- tractions, palpation of the pubic arch, as described in Chapter XXXIII, should form an integral part of the preliminary examination of every pregnant woman. If any abnormality be detected the various diameters of the pelvic outlet should be carefully measured. A shortening of the transverse diameter to 8 centimeters or less should be regarded as a danger signal; but, unfortunately, as Klien pointed out in 1896, the length of this diameter, either alone or in combination with that of the anteroposterior diameter, does not afford a sufficient basis for the formulation of an intelligent prognosis. Thus, it may hap- pen that serious dystocia may sometimes arise with a transverse diameter Fig. 605.—Diagram Illustrating Mensuration of the Anterior and Posterior Sagittal Diameters of Outlet by Means of Thoms’ Pelvimeter. X V*. of 7.5 centimeters, while on the other hand spontaneous labor may occur when it is reduced to 5.5 centimeters, as in one of my cases (Figs. 602- 605). This apparent discrepancy is readily understood when it is remem- bered that a decrease in length of the transverse diameter is associated with a progressive narrowing of the pubic arch, so that only a smaller and smaller segment of the head can pass beneath it, and in extreme cases only the portion of the outlet posterior to a line joining the ischial tuberosities is available for its passage. In such cases, it is evident that the possibility of delivery will depend not upon the actual length of the transverse or of the anteroposterior diameter, but rather upon the space available between the transverse diameter and the tip of the sacrum. Klien has designated this distance as the posterior sagittal diameter of the outlet, and devised a specially constructed pelvimeter for its mensuration. For years I obtained satisfactory results by the use of a modification of Klien’s instrument, which, however, had the disad- vantage that two persons were required for its manipulation, so that its employment was practically restricted to hospital patients. Thoms, LOCALIZED AND SYMMETRICAL ANOMALIES 843 while working in my clinic, devised the instrument described in Chapter XXXIII, which can be manipulated by one person, and can be used for measuring the distance between the tubera ischii, as well as the anterior and posterior sagittal diameters of the outlet. For the latter purpose, the transverse bar of the pelvimeter is held by the fingers of one hand in relation with the transverse diameter of the outlet, while the end of the free blade is brought in contact with the tip of the sacrum—this gives the length of the external posterior sagittal diameter. The pelvimeter is then rotated, and the distance to the lower margin of the symphysis is determined—anterior sagittal diameter (Figs. 605 and 606). This latter varies between 5 and 6 Fig. 606.—Showing Mensuration of Anterior Sagittal Diameter of Outlet by Means of Thoms’ Pelvimeter. X Vs- centimeters and is subject to comparatively little change; while the external posterior sagittal may vary greatly, and from it the length of the posterior sagittal may be estimated by deducting 1 centimeter—the average thickness of the tip of the sacrum. In order for spontaneous labor to occur it is apparent that this diameter must increase proportionally in length as the transverse diame- ter of the outlet is shortened, and my observations show that it is un- likely with measurements less than the following: Transverse diameter 8 cm., posterior sagittal 7.5 cm. << n 7 “ “ “ 8 “ “ “ 6.5 “ “ “ 8.5 “ “ “ 6 “ “ “ 9 “ “ “ 5.5 “ “ “ 10 “ ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 844 It should, however, be understood that these are only approximate esti- mates and by no means accurately indicate the necessity for radical interference, as spontaneous labor may occur when least expected. In multiparous women with a history of previous severe dystocia, they may aiford an indication for cesarean section or pubiotomy; while in primip- arous women, if spontaneous labor does not occur, they should lead us to substitute pubiotomy for brutal attempts at forceps delivery. In young women pubiotomy is the operation of choice whenever the dystocia is serious, as it not only permits delivery at the time, but also offers a reasonable prospect of permanently overcoming the ab- normality. In my article upon the effect of pubiotomy upon the course of subsequent labors, I have given details of several such cases, and have shown that as the result of the operation the funnel pelvis had become converted into a normal one, or if this did not occur that the softening and stretching of the fibrous union at the pubiotomy wound made pos- sible a temporary enlargement sufficient to permit spontaneous labor. On the other hand, in multiparous women who have al- ready lost one or more children, cesarean section at an appointed time should be chosen, as by so doing the birth of a living child will be assured, while with pubiotomy the child will be exposed to a slight, but definite, risk. In moderate degrees of outlet contraction the effect of postural treatment should be tested before resorting to the use of forceps, as I have found that by placing the patient in an exaggerated Sims’ position the innominate bones rotate upon the sacrum to such an extent that the length of the posterior sagittal undergoes an average increase of 0.75 centimeter, with extremes of 0 and 4 centimeters. In minor degrees of contraction, such an increase may be sufficient to do away with the necessity for the use of forceps. Fig. 607.—Diagram Illustrating Effect of Pubiotomy in a Pronounced Fun- nel Pelvis. Dotted lines show pubic arch before operation. X Vs- LITERATURE Betschler. Neue Zeitschr. f. Geb., 1840, ix, 121. Boeckh. Ueber Zwergbecken. Archiv f. Gyn., 1893, xliii, 347-472. Breus und Kolisko. Die patu Beckenformen, 1900, i. Spaltbecken, 107-139. Assiinilationsbecken, 169-256. Zwergbecken, 259-366. Budin. Recherches experimentales a propos de 1’ischio-pubiotomie. Femmes en couches et nouveau-nes, 1897, 468-482. Buttner. Beschreibung des inneren Wasserkopfs und des ganzen Beinkorpers einer von ihrer Geburt an bis im 31. Jahr krank gewesenen Person weiblichen Geschlechts. Konigsberg, 1873. LITERATURE 845 Deventer. Neues Hebammenlicht. II. Aufl., 1728, 196. Emmons. A Study of the Variations in the Female Pelvis, etc. Biometrika, 1913, ix, 34-57. Fabre et Bourret. Bassin h diametre antposterieure predominant. Bull, de la soe. d’obst. et de gyn. de Paris, 1913, xvi, 108-114. Gemmell and Paterson. Duplication of Bladder, Uterus, Vagina and Vulva, with Successive Full Term Pregnancy and Labor in Each Uterus. J. Obst. and Gyn. Brit. Emp., 1913, xxiii, 25-32. Gonner. Zur Statistik der engen Becken. Zeitschr. f. Geb. u. Gyn., 1882, vii, 314-331. Gurlt. Uebe,r einige Missgestaltungen des weiblichen Beckens. Berlin, 1854. Hart. On Inversion of the Ilium and Sacrum and Ischium and Pubis as Causes of Deformities of the Female Pelvis. Edinburgh Med. Jour., 1916, xvi, 9-32. Hohl. Das schragverengte Becken. Leipzig, 1852. Kaufmann. Untersuchungen iiber die sogenannte fotale Rachitis. Berlin, 1892. Klien. Die geburtshiilfliche Bedeutung der Verengerungen des Beckenausgangs. Volkmann’s Sainml. klin. Vortrage, 1896, N. F., Nr. 169. Kundrat. Quoted in full by Breus and Kolisko. Die path. Beckenformen, 1900, i, 147-153. Leisinger. Anat. Beschreibung eines kindlichen Beckens. D. I., Tubingen, 1847. Litzmann. Das schragovale Becken. Kiel, 1853. Das gespaltene Becken. Archiv f. Gyn., 1872, iv, 266-284. Ein durch mangelhafte Entwickelung des Kreuzbeines querverengtes Becken. Archiv f. Gyn., 1885, xxv, 31-39. Martin, E. De pelvi oblique ovate. Jena, 1841. Miller. Complete Exstrophy of the Bladder with Split Pelvis as a Complication of Pregnancy. Am. Jour. Obst., 1918, lxxvii, 267-273. Muller. Zur Frequenz u. Aetiologie des allg. verengten Beckens. Archiv f. Gyn., 1880, xvi, 155-173. Naegele. Das schragverengte Becken. Mainz, 1839. Olshausen. Schragverengtes Becken, etc. Monatsschr. f. Geburtsk., 1862, xix, 161-185. Paltauf. Quoted in full by Breus and Kolisko. Paterson. The Human Sacrum. Scientific Trans, of the Royal Dublin Society, 1893, v, 123-204. Pinard. De Uischio-pubiotomie ou operation de Farabeuf. Annales de gyn. et d’obst., 1893, xxxix, 139-143. Porak. De Uachondroplasie. Nouv. archives d’obst. et de gyn., Par., 1889, iv, 551; 1890, v., 19; and following. Richelet. Du bassin generalement retreci, etc. These de Paris, 1896. Risciibeith and Barrington. Dwarfism. Eugenic Laboratory Memoirs, London, 1912, xv. Robert. Beschreibung eines im hochsten Grade querverengten Beckens, etc. Karlsruhe u. Freiburg, 1842. Rosenberg. Ueber die Entwickelung der Wirbelsaule des Menschen. Morpho- logisches Jarbuch, 1876, i, 83-172. Bemerkungen fiber den Modus des Zustandekommens der Regionen in der Wirbelsaule des Menschen. Morphologisches Jahrbuch, 1907, xxxvi, 609-659. Schauta. Die Beckenanomalien. Midler’s Handbuch der Geb., 1889, ii, 220-496. Schickele. Beitrag zur Lehre des normalen und gespaltenen Beckens. Beitrage zur Geb. u. Gyn., 1901, iv, 243-272. Stein. Lehre der Geburtshfilfe, etc., 1825, i, 78. Tarnier et Budin. Traite de l’art des accouchements, 1898, iii, 314-318. 846 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT Thomas, S. Das schagverentge Becken, etc. Leipzig, 1861. Thoms. A Statistical Study of the Frequency of Funnel Pelves and the Descrip- tion of a New Outlet Pelvimeter. Am. J. Obst., 1915, lxxii, 121-132. Unna. Zur Gencse des schriigverengten Beckons. Hamburger Zeitschr. f. die ges. Med., 1843, xxiii, 281. Wagnee. Ueber familiare Chondrodystrophia. Archiv f. Gyn., 1913, e, 70-134. Williams. The Etiology and Clinical Significance of Contractions of the Pelvic Outlet. Surg. Gyn. and Obst., 1909, viii, 619-638. The Funnel Pelvis. Am. J. Obst., 1911, lxiv, 106-124. The Effect of Pubiotomy upon the Course of Subsequent Labor. Am. J. Obst., 1915, lxxii, 1-25. A Consideration of Some of the Factors Concerned in the Production of De- formed Pelves. Am. Jour. Obst., 1918, lxxvii, 714-758. CHAPTER XXXVI COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY AND LABOR COMPLICATED BY THE MORE COMMON FORMS OF CONTRACTED PELVIS Marked degrees of pelvic deformity exert a pronounced influence upon the course of pregnancy as as upon the mechanism of labor. Indeed, to be unaccompanied by more or less definite effects the con- traction must be minimal. EFFECT OF CONTRACTED PELVIS UPON THE COURSE OF PREGNANCY The Position of the Uterus.—Very exceptionally in the early months of pregnancy a pronounced degree of pelvic malformation may interfere with the normal rising up of the uterus, particularly if the promontory of the sacrum projects so far into the superior strait as markedly to overhang the pelvic cavity. In these rare cases as the uterus increases in size it may assume a position of pronounced retroflexion, which later may give rise to characteristic symptoms of incarceration. Later in pregnancy, when the deformity is sufficient to interfere materially with the descent of the presenting part into the pelvis, marked abnormalities in the position of the uterus are observed. Particularly in primiparae, the fundus occupies a higher position than usual, and serious respiratory and circulatory disturbances often result. At the same time, owing to the fact that the low'er portion of the uterus is not fixed by the engaged head, the entire organ is much more freely movable than usual. More important, however, is the sharply anteflexed position which the uterus may assume. This is particularly the case in small women presenting marked lumbar lordosis, whereby the capacity of the abdomen is so diminished that the growing uterus seeks to gain room by pushing forward the anterior abdominal walls. Consequently, the presence of a pendulous abdomen is a sign of considerable importance in primiparous women, and should always cause one to suspect the existence of marked pelvic deformity. The converse, however, does not necessarily indicate that no disproportion exists. On the other hand, the same condition may have no great significance in multiparous women, being generally due to a loss of tonicity of the uterine and abdominal walls as a result of previous pregnancies. Position and Presentation of Foetus.—A contracted pelvis plays an important part in the production of abnormal presentations. In normal 847 848 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY primiparous women, the presenting part, as a rule, descends into the pelvic cavity during the last six weeks of pregnancy; but when the superior strait is considerably contracted this does not occur at all, or not until after the onset of labor. Vertex presentations still predomi- nate; but since the head floats freely above the superior strait, or rests upon one of the iliac fossae, very slight influences may cause the foetus to assume other positions. According to Michaelis, vertex presentations are rarer by 10 per cent, in contracted than in normal pelves; while face, breech, and transverse presentations occur 2 or 3 times, and prolapse of the cord and the extremities 4 to 6 times more frequently. That abnormal presentations increase in frequency with the degree of contraction, is shown by the following figures of Michaelis, Litzmann, and Schwartz: Conjugata vera 9.5—8.5 cm., 93.1% vertex presentations “ “ 8.4—7.5 “ 83.8% “ “ 7.4 cm. or less, 64.7% “ “ Tarnier, in 1,030 cases of labor complicated by contracted pelvis, observed the following incidence for the various presentations: vertex, 85.13 instead of 96 per cent.; breech, 7 instead of 3 per cent.; face, 3 instead of 0.6 per cent.; and transverse, 4.2 instead of 0.5 per cent. Since abnormal presentations occur more frequently in multiparous than in primiparous women even under favorable conditions, they be- come still more common when the pelvis is contracted. Thus, Schauta estimated that they are 3 times more frequent in the fifth than in the first pregnancy. In primiparous women face and transverse presentations possess a peculiar significance, as their occurrence is nearly always associated with serious disproportion between the size of the head and the pelvis, so that whenever either variety is encountered one can feel certain that the head is unusually large or the pelvis abnormally small. Size of Foetus.—La Torre, Pinard, and others have stated that the children of women with abnormal pelves usually attain a larger size than usual. Pinard attributes this to the fact that the head does not become engaged during the last few weeks of pregnancy, and therefore cannot press upon the lower uterine segment, thus doing away with one of the I actors predisposing to the premature termination of pregnancy. Wilcke and biggs, after careful study, have concluded that such is not the case, but that the children, in such circumstances, are generally slightly below tbe in size. This is particularly the case with generally con- tacted pelves, as women possessing them are usually under-sized and would naturally produce smaller children than larger and better nour- ished individuals. MECHANISM OF LABOR IN RHACHITIC PELVES The possibility of the occurrence of spontaneous labor in flat pelves depends primarily upon the degree of contraction, and, when this is not excessive, upon the following additional factors: the size, compressibility, MECHANISM OF LABOR IN RHACHITIC PELVES 849 and malleability of the foetal head, and the character of the expulsive forces. The measurements of the pelvis can be determined with reason- able accuracy; with practice one can learn to estimate the size of the head with some degree of exactness, but there are no satisfactory methods of determining in advance the other properties of the head, and not until labor is well advanced can one predict even approximately what the uterus can do. In 701 cases of labor in contracted pelves, occurring in our service up to July, 1910, spontaneous delivery occurred in 74.76 per cent., and became progressively less frequent with increasing pelvic deformity. Thus, when the conjugata vera measured 10 —9.6 cm. spontaneous delivery occurred in 85.1% 9.5— 9.1 “ “ “ “ 78.5% 9 —8.6 “ “ “ “ 61.3% 8.5— 8.1 “ “ “ “ 37.8% 8 —7.5 “ “ “ “ 29.4% 7.5 cm. or less “ “ “ 13.3% Even when delivery is effected spontaneously and without any undue delay, certain characteristic abnormalities can be observed in the mechanism of labor, by which the experienced obstetrician is enabled to recognize the presence of a flat pelvis without resorting to pelvimetry. Inasmuch as in the varieties of pelves under consideration the con- traction is practically limited to the anterior posterior diameter of the superior strait, while the transverse diameter is relatively large, it is evident that the obstacle to the passage of the child’s head must be offered by the shortened conj ugata vera; and when this measures less than 9 centimeters it becomes out of the question for the biparietal diameter of the head to pass through it, unless it undergoes some dimi- nution in size. Accordingly, when engagement is occurring, the head slips to one side so as to bring the shorter bitemporal diameter in rela- tion with the con j ugata vera. As a result the long arm of the head lever becomes displaced to the side of the occiput, so that, under the influence of the uterine contractions, the anterior portion of the head descends, while the occipital portion rises up. Consequently the large fontanelle becomes more readily accessible to the examining finger on one side of the pelvis, and the small fontanelle less so on the other. At the same time the head tends to accommodate itself to the transverse diameter of the superior strait, so that its long axis, as indicated by the sagittal suture, comes to lie transversely. More characteristic still is the abnormal attitude which the head assumes when the disproportion between it and the pelvis is at all marked, when we may have what is known as an anterior parietal pres- entation. In this the head assumes an eccentric position, so that the anterior parietal .bone occupies the superior strait in such a manner that the sagittal suture lies just in front of the promontory. In such circumstances the anterior shoulder is readily distinguished upon ex- ternal palpation. According to the explanation generally accepted, this condition is brought about by the abnormal relation borne by the axis of the anteflexed uterus to the plane of the superior strait, as the result 850 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY of which the posterior portion of the head is arrested against the prom- ontory of the sacrum, while its anterior portion is forced into the pelvis. This presentation is simply an exaggeration of the so-Called Naegele’s obliquity, and the mechanism of descent is readily understood when we compare the passage of the head through the abnormal superior strait to the maneuver necessary to pass a stick of a certain length through a ring of a somewhat shorter diameter. To do so, one must depress one end of the stick so as to allow it to enter the ring obliquely, and after it has partially passed through its other end will descend without dif- ficulty. Sellheim suggests that this presentation provides a mechanism for effecting a diminution in the transverse diameter of the head. He considers that the sutures are so arranged that one lateral half of the head can be displaced to some extent beyond the other, just as in pushing one half of a jointed oval spring beyond its fellow the greatest transverse diameter will become considerably diminished. Fig. 608.—Showing Anterior Parietal Presentation. Fig. 609.—Showing the Passage of an Anterior Parietal Presentation THROUGH THE SUPERIOR STRAIT. In order for descent to occur, the j)osterior parietal bone is firmly pressed against the promontory of the sarcum, while under the influence of the uterine contractions the anterior portion of the. head is slowly forced down into the pelvis along the internal surface of the symphysis pubis; after this is accomplished the posterior portion passes over the promontory and enters the pelvis, the sagittal suture at the same time moving forward. Accordingly, when the contraction is marked, the posterior portion of the head must be subjected to considerable pressure, as is shown by the presence after birth of a more or less well-defined curved depression, just behind the coronal suture, upon the side of the head which was in contact with the promontory. After the posterior parietal bone has passed the superior strait, all resistance has been over- come, and, owing to the fact that the lower portion of the pelvis is relatively large, the rest of the labor is promptly accomplished. In about one-fourth of the labors occurring in flat pelves, according to Litzmann, the reverse condition—the posterior parietal presentation MECHANISM OF LABOR IN RHACHITIC PELVES 851 —is observed. The sagittal suture now lies almost in contact with the symphysis pubis, while the posterior parietal bone occupies the superior strait, and in pronounced cases the posterior ear of the child can be felt just above the promontory, so that the condition is sometimes spoken of as an ear presentation. The long axis of the child’s body forms an Fig. 610.—Showing Posterior Parietal Presentation. Fig. 611.—Showing the Passage of a Posterior Parietal Presentation through Superior Strait. obtuse angle with its head, and upon palpation the anterior portion of the latter can be felt as a prominent tumor lying above the symphysis. In this event, the head cannot enter the pelvis until its posterior por- tion is pushed down past the promontory of the sacrum, after which its anterior portion descends along the symphysis pubis, while at the same time the sagittal suture approaches the mid-line of the pelvis. After this has occurred labor takes place in the usual manner. The mode of production o f this abnormality is not definitely understood, al- though it is ob- served most fre- quently when the grade of contrac- tion is marked, the pelvic inclin- ation consider- ably increased, and the abdomen not pendulous It is generally considered as very unfavorable by the*Germans, as the line along which the uterine contractions are transmitted is given another direction at the neck, which is much less advantageous than when the spinal column and head form a continuous axis. Tarnier, and Yarnier, on the other hand, hold that the posterior parietal presentation occurs Fig. 612.—Engagement of Head in Reniform Superior Strait (Tarnier). 852 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY more frequently than the anterior, and is without ominous prognostic significance. In my experience, however, it has occurred far less fre- quently, although in certain cases it has not been associated with a particularly difficult labor. When the promontory of the sacrum protrudes into the superior strait in such a way as to render it reniform in outline, it is impossible for the head to assume its usual transverse position, and the sagittal suture must occupy an oblique diameter (Fig. 612). In rare instances the deformity is so great that the superior strait resembles the figure 8. In such circumstances only one side of it is available for the passage of the head, and Breisky has designated the condition as extramedian engagement. It naturally serves to exaggerate the degree of dispro- portion. Breech presentations likewise complicate matters to some extent, as the imperfect adaptation of the breech to the superior strait fre- quently facilitates prolapse of the cord or of one or more of the ex- tremities. In such circumstances, although the prognosis for the mother remains favorable, the child’s life is endangered. This is especially true when the contrac- tion is marked, as considerable difficulty may be experienced in ex- tracting the after-coming head, which, in passing through the con- tracted superior strait, follows a mechanism analogous to that ob- served in anterior parietal presen- tations. In other words, its posterior portion is arrested at the promon- tory, while its anterior portion passes down behind the symphysis, after which its posterior portion descends. In generally contracted flat pelves the mechanism of labor varies according to the extent of the deformity and the shape of the pelvis— that is, according as it approaches more closely to the flat or to the generally contracted type. In the former case, provided the contraction be not too marked, the mechanism of labor will be identical with that just desciibed for flat pelves, whereas in the latter the head will become «hai ply flexed and be born by the mechanism to be described below. In fhe generally and equally contracted rhachitic pelvis the mechan- ism coriosponds to that observed in the justominor pelvis; while in the pseudo-osteomalacic forms the contraction is usually so marked that the child cannot be born per vias naturales. The effect of the generally contracted, or justominor, pelvis upon e,,COjrse of ]abor ls very characteristic. Owing to the fact that all of the diameters of the superior strait are shortened, the head encounters more or less equal resistance from all sides of the pelvic outlet, conse- quently it enters it m an oblique diameter and in a sharply flexed Fig. 613.—Showing Passage of After- coming Head through Superior Strait; Darker Child Last. COURSE OF LABOR IN CONTRACTED PELVIS 853 position, so that on vaginal examination the small fontanelle is readily felt, while the large fontanelle is almost or quite out of reach. More- over, as the contraction involves all portions of the pelvic canal, labor is not rapidly completed after the head has passed the superior strait. The prolongation is due not only to the resistance offered by the pelvis, but also in many instances to the faulty character of the uterine con- tractions, incident to the imperfect development of the uterus, which frequently characterizes such patients. In typical funnel pelves no difficulty is experienced until the head reaches the pelvic floor and attempts to pass through the narrowed pubic arch. The details of this mechanism were considered in the preceding chapter and need not be recapitulated. COURSE OF LABOR IN CONTRACTED PELVIS When the pelvic deformity is not absolute, but is sufficiently pro- nounced to prevent the head from entering the superior strait during the last few weeks of pregnancy, or at the onset of uterine contractions, the course of labor is usually unduly prolonged. In the first stage this is due to imperfect dilatation of the cervix, and in the second to the time required so to mold and configure the head as to render possible its passage through to the pelvic cavity. Abnormalities in Dilatation of Cervix.—ISTormally, dilatation of the cervix is brought about by the unruptured membranes acting as a hydro- static wedge, and after their rupture by the direct action of the present- ing part. In contracted pelves, on the other hand, when the head is arrested at the superior strait, the entire force exerted by the uterus acts directly upon the portion of membranes in contact with the internal os, and, consequently, as the force is not broken by the intervening head, as in normal labor, premature rupture frequently results, occurring, according to Litzmann, in 26 per cent, of the cases. After rupture of the membranes, further dilatation cannot take place until the presenting part is able to exert a direct pressure upon the cervix, and this is out of the question until a succession of strong pains have molded the head sufficiently to permit its descent, or have led to the formation of a caput succedaneum upon its most dependent portion. Even after the cervix is completely dilated further delay may occur, and it sometimes requires hours to mold the head to the pelvis. In flat pelves the labor is promptly terminated as soon as the contracted superior strait is passed, but in the generally contracted varieties this is not the case, inasmuch as the hindrance persists throughout the entire pelvic canal. Abnormalities in Uterine Contractions.—In many instances the course of labor is still further prolonged owing to faulty uterine con- tractions. This is rarely the case in rhaehitic primiparae, in whom the pains are usually very efficient; but in multiparae, in whom previous difficult labors have weakened the uterine musculature, secondary uterine inertia frequently occurs as the result of exhaustion. 854 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY On the other hand, the uterus may become tetanically contracted. This is an extremely serious condition, as it cannot lead to the termina- tion of labor, and at the same time markedly increases the danger of uterine rupture. If this complication does not yield promptly to the administration of sedatives, it affords an imperative indication for the termination of labor. Danger of Uterine Rupture.—Abnormal thinning of the lower uterine segment frequently constitutes a very serious danger during a prolonged second stage. When the disproportion between the head and the pelvis is so pronounced that engagement and descent do not occur, the lower uterine segment becomes more and more stretched, and the danger of rupture becomes imminent. In such cases the contraction ring can be felt as a transverse or oblique ridge extending across the uterus some- where between the symphysis and the umbilicus, while sometimes its position is clearly visible. Thinning of the lower uterine segment is particularly liable to occur in the generally contracted variety of rhachitic pelvis, since the lower end of the cervix may be caught between the child’s head and the pelvic brim, and thus be prevented from retracting. Whenever this condition is noted prompt delivery is urgently indicated; but at the same time great caution is necessary on the part of the physician lest his maneuvers give rise to traumatic rupture. Production of Fistulae.—When the presenting part is firmly wedged into the superior strait, but makes no advance for a long time, portions of the birth canal lying between it and the pelvic wall may be subjected to undue pressure. As a result the circulation is so interfered with that necrosis follows, which may manifest itself a few days after labor by the appearance of vesicovaginal, vesicocervical, or rectovaginal fistulae. depending upon the part involved. These conditions are not to be feared so long as the membranes remain intact, but are liable to follow a very prolonged second stage. Intrapartum Infection.—Infection is another serious danger to which the patient is exposed in prolonged labors complicated by premature rupture of the membranes, particularly when examined repeatedly by those who do not observe stringent aseptic technic. If the amniotic fluid becomes infected, febrile symptoms appear during labor, while in other cases the microorganisms pass through the foetal membranes and invade the uterine walls, giving rise later to the characteristic manifesta- tions of puerperal infection. In other instances gas-producing bacteria may gain access to the uterus, which soon becomes distended Math gas as a result of their activity tympanites uteri or physometra. This condition usually fol- Ioms infection with bacillus aerogenes capsulatus, particularly when the child is dead. It was formerly attributed to the entrance of air into the uterus, but at present such an explanation must be regarded with skepticism. For further details the reader is referred to the chapter upon Puerperal Infection. Rupture of the Pelvic Joints.—In rare instances, particularly when the pelvis is contracted in its portion, spontaneous rupture of the symphysis pubis or of one or both sacro-iliac joints has been observed. COURSE OF LABOR IN CONTRACTED PELVIS 855 Such cases have been reported by Ahlfeld, Schauta, Braun-Femnwald, De Lee, Kehrer, and others, though in the majority the injury is pro- duced by injudicious methods of delivery. Kehrer in 1915 collected from the literature 100 cases of rupture of the symphysis pubis, 17 of which occurred during the course of spontaneous labor. He considers that the predisposing cause for the accident consists in unusual softening or the development of cavities in the pubic cartilage. Effect of Labor upon the Child.—So long as the membranes remain intact the child suffers but little from the prolonged labor; but after their rupture, continued uterine contractions may exert a deleterious influence upon it. This is due in great part to interference with the placental circulation, which sooner or later leads to manifestations of asphyxiation. Kow and again premature separation of the placenta occurs, causing certain death to the child. Particularly during the second stage of labor, prolonged pressure exerted upon the head is not without influence upon the child, in some cases leading to vagus stimulation with its resulting slow pulse and consequent gradual asphyxiation. Prolapse of the Cord.—A much more serious and frequent complication for the child is prolapse of the cord, the occur- rence of which is facilitated by imperfect adaptation between the presenting part and the pelvic inlet. The condition exerts no influence upon the course of labor, but in the majority of cases death of the child results from compression of the cord be- tween the presenting part and the pelvic wall, unless prompt delivery can be ac- complished. This must be regarded as one of the most frequent causes of foetal death in spontaneous labor in contracted pelves. Changes in Scalp and Skull.—As has already been stated, a marked caput is frequently developed upon the most dependent part of the head, and allusion has been made to the part which it sometimes plays in the dilatation of the cervix. In many instances it may assume very con- siderable proportions, and lead to serious diagnostic errors. For example, it may project almost to the pelvic floor while the head is still above the brim, so that an inexperienced physician may mistake it for the head and thus be tempted to resort to ill-timed operative measures. Such a caput is without significance so far as the life of the child is concerned, and disappears within a few days after birth. When the disproportion between the size of the head and the pelvis is considerable, it is apparent that the former can only pass through after a process of molding and accommodation, which is usually spoken of as configuration. In exceptional cases the head may descend into the pelvic cavity comparatively early in pregnancy, and, as it cannot Fig. 614.—Showing Molding of Head in a Generally Contracted Rhachitic Pel- vis. COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 856 readily escape, it undergoes further development in that position, and in consequence presents characteristic deformities at birth, the part within the pelvis being markedly flattened, while that above is unusually large, as shown in Fig. 614. Fig. 615.—Overlapping of Bones of Skull (Tarnier). Fig. 616.—Overlapping of Bones of Skull (Tarnier). Under the influence of the strong uterine contractions the various bones comprising the skull come to overlap one another at the various sutures. As a rule the median margin of the parietal hone, which is in contact with the promontory, be- comes overlapped by that of its fellow, and the same occurs with the frontal bones. The occipital bone, on the other hand, becomes shoved under the parietal bones, so that the posterior margins of the latter frequently overlap it. These changes are usually ac- complished without detriment to the child, though when the dis- tortion is marked they may lead to tentorial tears, and, when vessels are involved, to fatal in- tracranial hemorrhage. Coincident with the molding © of the head, the parietal bone, which was in contact with the promontory, may show signs of having been subjected to marked pressure, sometimes becoming very much flattened. Configuration is more readily accomplished when the bones of the head are imperfectly ossified, in rare instances the skull being so soft that it yields to pressure as readily as the shell of a soft crab. This process is of great importance, and serves to explain the difference in the course of labor in two apparently similar cases in which the pelvis and the head present identical measurements. In the one the head is soft and readily molded, so that spontaneous labor can Fig. 617.—Child Bohn Spontaneously through Generally Contracted Rha- chitic Pelvis, Conjugata Vera 7.25 Centimeters Showing Caput Succedan- eum and Depression of Skull. COURSE OF LABOR IN CONTRACTED PELVES 857 result; in the other the more resistant head retains its original shape, and radical operative interference becomes necessary for its delivery. Reference has already been made to the 'pressure marks upon the scalp covering the portion of the head which passes over the promontory of the sacrum. These are very characteristic in appearance, and from their location frequently enable one to determine the movements which the head has undergone in passing through the superior strait. Much more rarely similar marks appear on the portion of the head which has been in contact with the symphysis pubis. Such marks have no influence upon the well-being of the child, and usually disappear a few days after birth, although in exceptional instances the pressure may have been so severe as to lead to necrosis and sloughing of the scalp. Fractures of the skull are occasionally met with, and usually follow forcible attempts at delivery, though occasionally they may occur spon- taneously. The fractures are of two varieties, appearing either as a shallow gutterlike groove or as a spoon-shaped depression iust posterior Fig. 618.—Pressure Marks from Prom ontory. Fig. 619.—Spoon-Shaped Fracture of Skull (Tarnier). to the coronal suture. The former is relatively common, and, as it involves only the external plate of the bone, is not very dangerous : whereas the latter, if not operated upon, leads to the death of the child in about 50 per cent, of the cases; since it extends through the entire thickness of the skull and gives rise to projections upon its anterior, which exert injurious pressure upon the brain. In such cases it is advisable, as soon as convenient after labor, to elevate or remove the depressed portion of the skull, as may be indicated, in the hope of preventing pressure symptoms. Prognosis for the Mother.—The prognosis as to the outcome of labor complicated by contracted pelvis depends not only upon the degree of .contraction, but also upon the other factors to which we have already alluded. It may be said, however, that spontaneous birth of a fully developed child cannot occur when the conjugata vera measures 7 centi- meters or less, and is very unlikely when it measures 7.5 centimeters. Above the latter limit it becomes increasingly frequent as the degree of pelvic distortion diminishes. In our series of 701 cases studied in 1910, not including funnel pelves, 74.76 per cent, of the children were born spontaneously, and the COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY 858 incidence increased to 81.75 per cent, when the deliveries by low forceps were deducted, in which the operation had naturally no connection with the pelvic deformity. These results compare very favorably with those of other clinics, as is shown by the following figures: Valency 69 percent. Peham 72.4 per cent. Bar 76.5 per cent. Burger 77.8 per cent. Kronig 78.5 per cent. Baisch 80 per cent. The probability of spontaneous labor decreases rapidly with the degree of pelvic contraction, as is shown by the following analysis of our cases, in which the second column gives the total incidence, and the third column the corrected incidence, which was obtained by deducting all operations not due to pelvic indications: Conjugata Vera (Obtained by deducting 1.5 cm. from Diagonal Conjugata) Number of Cases Spontaneous Labor, Gross Spontaneous Labor, Corrected 10 -9.6 cm 248 85.1% 94.0% 9.5-9.1 cm 270 78.5% 84.3% 9 -8.6 cm 111 61.3% 67.6% 8.5-8.1 cm 37 37.8% 37.8% 8 -7.6 cm 17 29.4% 29.4% 7.5 cm. or less 15 13.3% 20.0% Furthermore, if the length of the conjugata vera be calculated by deducting 2, instead of 1.5, centimeters from the diagonal conjugate, as is done by most writers, our results appear still more favorable, as is shown by the following tabulation: Conjugata Vera Burger in 5,288 Cases Peham in 885 Cases Baisch in 927 Cases Williams in 701 Cases 10 -9.6 cm 89 % 89 % 94 % •• % 9.5-8.6 cm 80 % 80.5% 90 % 89.8% 8.5-7.6 cm 54.4% 63.8% 65 % 60.1% 7.5 cm. or less... 9.9% 14.8% 18 % 25 % Generally speaking, the probability of spontaneous labor is somewhat less in generally contracted than in flat pelves presenting the same con- jugata vera, it being customary to calculate that half a centimeter must be added to the conjugata vera of the former to make it comparable to the latter. This, however, is denied by Baisch, and Zangemeister, and in my own experience, the expected difficulty is usually compensated for by the somewhat smaller size of the children. The danger to the mother depends upon the course of labor, the perfection with which aseptic technic is observed, and the treatment pursued in operative cases. Speaking broadly, the maternal mortality after spontaneous labor should be hardly greater than in normal pelves, COURSE OF LABOR IN CONTRACTED PELVIS 859 if the case is conducted properly. On the other hand, if spontaneous labor does not occur, and the patient is left to herself, she will die undelivered, either from hemorrhage resulting from uterine rupture or from infection. In operative cases the prognosis depends entirely upon the choice of the operation, the surroundings of the patient, and the degree of perfection of the technic. In our 701 cases of labor complicated by contracted pelvis there were 11 maternal deaths (1.57 per cent.). It should be said, however, that 4 of these patients were profoundly infected when first seen, as the result of attempts at delivery outside of the hospital, and that uterine cultures taken at the time of delivery demonstrated the presence of the microoganisms which caused the fatal infection, leaving a net mortality of 1.0 per cent. Bar had one maternal death in 166 cases and Baisch four deaths in 809 cases, a mortality of 0.59 and 0.50 per cent, respectively. Ludwig and Savor reported a mortality of 0.8 per cent, in 706 spontaneous labors complicated by contracted pelvis, as compared with 5.2 per cent, in 591 operative cases. These results were obtained after aseptic technic had become so perfected that radical operations could be undertaken with comparative safety; previously they were impossible, as Michaelis, and Litzmann reported a mortality of 10 per cent, and 7.3 per cent., respectively. A very instructive comparison between the conditions existing then and now was furnished by Tarnier, who stated that in 334 cases occur- ring in the Maternite in Paris between the years 1860 and 1869, the maternal mortality was 22 per cent., as compared with 1.91 per cent, in 1,036 cases occurring between 1884 and 1892. In the latter series the mortality was 0.78 per cent, in spontaneous, and 5.15 per cent, in operative deliveries. Prognosis for the Child.—The prognosis for the foetus is always more serious in contracted than in normal pelves, even though labor occurs spontaneously. It likewise depends to a great extent upon the methods chosen for delivery, and, broadly speaking, increases with the degree of pelvic contraction, unless cesarean section or pubiotomy is frequently performed. This is clearly shown by the following table of Michaelis, Litzmann, and Schwartz: Coniugata vera 9.25—8.5 cm., foetal mortality 5 % “ “ 8.4 —7.5 “ “ “ 16.9% “ “ 7.4—7 “ “ “ 52.9% In a series of 1,297 cases studied by Ludwig and Savor, the mortality was 9.4 per cent, in spontaneous, and 46.3 per cent, in operative labors; while Bar, and Baisch reported a mortality of 11 and 23 per cent., and of 3.3 and 29.8 per cent., respectively, in similar series of cases. This striking difference is due to the fact that Ludwig and Savor resorted to craniotomy in the difficult cases, while Bar and Baisch performed cesarean section or pubiotomy whenever indicated. In our series of 701 cases, 68 children were born dead or died within two weeks after delivery, a gross mortality of 9.7 per cent. As 12 of 860 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY them were macerated and 21 others died from various conditions not connected with the pelvis, the actual number succumbing to the pelvic complication was 35. Of these 7 were dead when the mother was ad- mitted to the hospital, having succumbed as the result of operative measures undertaken outside, leaving 28, or 4 per cent., who died in our hands, as compared with Baisch’s corrected mortality of 4.5 per cent. TREATMENT OF LABOR COMPLICATED BY CONTRACTED PELVIS The treatment of labor complicated by contracted pelves varies ac- cording to the degree of contraction, the size of the child, and the history of previous labors. Generally speaking, a normally developed full-term child cannot be born spontaneously when the conjugata vera measures 7 centimeters or less, and only exceptionally when it falls below 7.5 centimeters; whereas, interference is rarely required when it measures 9 centimeters or more. We have therefore to consider in the first place the treatment of two great groups of pelvic deformities—those in which the conjugata vera measures 7.5 centimeters or less, and those in which it measures more. In the first group the problem is camparatively simple, whereas in the latter it is ofttimes extremely complex and requires the utmost nicety of judgment for its proper solution. Conjugata Vera of 7.5 Centimeters or Less.—It is customary to con- sider that a flat pelvis with a conjugata vera of a certain length gives rise to the same degree of dystocia as a generally contracted pelvis with one a half centimeter longer. For example, a flat pelvis of 7 centimeters would be equivalent to a generally contracted one of 7.5 centimeters; but, as this has not been my experience, I shall not make the distinction. If the deformity is recognized during pregnancy, the patient should be sent to a well-regulated hospital for the performance of cesarean section within a few days of the expected date of confinement or at the onset of labor, as the operator deems best. Such a procedure will give almost ideal results, and all of the children and 99 per cent, of the mothers should be saved, inasmuch as the maternal mortality following cesaiean section, when performed upon healthy women by competent operators at an appointed time, need not exceed that following the removal of uncomplicated ovarian cystomata. On the other hand, if the condition of the pelvis has not been lecognized until the woman is well advanced in labor, the treatment to be pursued will vary with circumstances. If the patient is uninfected, has not been examined repeatedly by the vagina, and is in suitable surroundings, cesarean section will offer every prospect for saving the child, provided it is in good condition, but the chances for the mother will be 5 or 10 per cent, less than if the operation had been done at an appointed time. But if the patient is infected or in poor condition, or the child is dead or dying, the treatment to he pursued will be determined by the degree of pelvic contraction. If the conjugata vera TREATMENT OF LABOR IN CONTRACTED PELVIS 861 be above 5.5 centimeters, craniotomy is the operation of choice; but with a measurement below this limit we have to deal with the absolute indication for cesarean section, which should be performed, no matter what the condition of the child or the mother, as in such circumstances the delivery of a mutilated child through the natural passages will be impossible, or at least quite as dangerous to the mother as a cesarean section done under unsatisfactory conditions. In infected cases the delivery of the child should be followed by a total hysterectomy. Pubi- otomy should not be thought of here, as its field of usefulness is limited to pelves in which the conjugata vera exceeds 7 centimeters, and to uninfected women with live children. Conjugata Vera above 7.5 Centimeters.—Here the question as to the proper treatment cannot be so readily disposed of, since definite rules cannot be laid down for the entire group, and each case must be con- sidered upon its own merits. We know in general that spontaneous labor will occur in many of these cases, and that its probability increases progressively with each half centimeter’s increase in length of the conjugata vera. But at the same time it may be difficult to predict what will occur in an individual case, as we have to reckon not only with the degree of pelvic deformity, but also with the size of the child’s head, the extent to which it may become molded and compressed, and the character of the labor pains. Moreover, although we can determine the size of the pelvis with considerable accuracy, and that of the child with some accuracy, unfortunately we can form only a very imperfect estimate concerning the other factors; and until methods are devised by which this becomes possible, the treat- ment of labor complicated by moderate degrees of contraction will remain a difficult problem. Of course, the ideal to be striven for is the attain- ment of such prognostic proficiency as to be able to determine with certainty before the onset of labor whether the disproportion can, or cannot, be overcome by the unaided efforts of Nature, and in the former event to count confidently upon a spontaneous outcome, or in the latter to perform cesarean section at an appointed time a few days before the calculated end of pregnancy. Naturally, this is out of the question, but it is nevertheless possible to develop such skill in prognosis that relatively few mistakes will be made. Methods of Determining the Size of the Head.—Despite the existence of numerous methods devised for determining the size of the head, we are still without one that is thoroughly satisfactory. In multiparous women, important information can occasionally be gained from the character of the heads of the children born in previous labors. If they were large and firmly ossified, it is probable that the child in question will possess a head showing similar characteristics, or may even be somewhat larger, as it is well known that the size is liable to increase with the age of the mother. Again, Muller s method of impression often affords material aid. In this procedure, the patient having been anesthetized, the obstetrician seizes the brow and occiput of the child with his fingers through the abdominal wall and makes firm pressure downward in the axis of the 862 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY superior strait, the effect of which may be controlled by the fingers of an assistant in the vagina. If there be no disproportion, the head will readily enter the pelvis and spontaneous labor may be predicted. On the other hand, the fact that the head cannot be forced into the superior strait does not necessarily indicate that spontaneous labor is out of Fig. 620.—Method of Determining Degree of Disproportion by Ascertaining the Extent to which the Head Overrides the Symphysis. the question, as we have no means of foretelling the extent to which molding and configuration will occur at the time of labor. Munro Kerr employs the following method, which has the advantage ol not requiring the services of an assistant. The obstetrician takes the Pawlik grip of the foetal head with his right hand and presses it TREATMENT OF LABOR IN CONTRACTED PELVIS 863 into the pelvis; while, with two fingers of the left hand in the vagina, he feels how the head engages. At the same time the thumb of the left hand feels along the brim and estimates the degree of overlapping. In Pinard’s palper mensurateur, the brow and occiput having been grasped by the two hands, the head is moved from side to side, so as to bring it into close contact with the pelvic brim. When this is accomplished, one hand is placed upon the child’s neck and the head pushed strongly downward and backward so as to bring its posterior portion into close contact with the promontory. An attempt is then made to insinuate the fingers of the other hand between the anterior surface of the head and the symphysis. If this can be done it indicates that there is no disproportion; but if it is impossible, and the anterior portion of the head forms a tumor which projects over the symphysis pubis, the probabilities are that engagement will not occur. I rely in great part upon a combination of the methods of Muller and Pinard, and after seizing the head through the abdominal wall, with the thumb over the occipital and the other fingers over the frontal region, make pressure downward in the axis of the superior strait. If the head enters, there can be no serious disproportion, whereas if it overrides the symphysis pubis to any extent disproportion exists, and with practice one learns to estimate its degree, and to differentiate between the cases in which it can be overcome spontaneously and those in which it will be impossible. Fig. 620 represents the conditions noted in a patient just prior to the performance of a fourth cesarean section. Ahlfeld believes that the biparietal diameter of the head bears a definite relation to the length of the child, and attempts to measure the latter in utero. To do this, one blade of the pelvimeter is placed upon the abdomen over the breech of the child, while the other is introduced into the vagina and applied to the vertex. The measurement thus obtained is taken to represent one half the length of the child, and from this the size of the head is calculated, as shown by the following table: For a child 50 cm. long, biparietal diameter 9.06 cm. “ “ 49 “ “ “ “ 8.72 “ “ “ 48 “ “ “ “ 8.56 “ “ “ 47 “ << “ “ 8 44 “ “ “ 46 “ “ “ “ 8.34 “ Perret, in 1899, and McDonald, in 1906, recommended measuring the fronto-occipital diameter of the head through the abdominal walls, and then estimating from it the length of the biparietal diameter. Perret devised a special cephalometer for the purpose, while McDonald attaches the tips of an ordinary pelvimeter to the index and second fingers of either hand by means of strips of adhesive plaster. The former estimates the length of the biparietal by subtracting 2.5 centi- meters from the measurement so obtained, while the latter contends that the amount to be subtracted averages 2.33 centimeters, but varies according to the length of the fronto-occipital diameter. Such figures, 864 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY Fronto-occipital diameter 10.00, subtract 1 centimeter 7< << “ 10 50, “ 1.55 centimeters “ “ “ 10.75’, “ 1.81 << “ “ 11.00, “ 1.91 ti << “ 11.25, “ 2.07 << “ “ 11.50, “ 2.26 “ “ “ 11.75, “ 2.50 u “ “ 12.00, “ 2.30 u << “ 12.25, “ 2.35 “ “ “ 12.50, “ 2.50 “ “ “ 12.75, “ 3.12 however, represent only the average obtained from the measurements of a number of children, but do not necessarily hold good for any given case. The methods of Muller, Kerr and Pinard frequently give us valuable information. But in the cases of moderate disproportion, iu which information is most desired, they give no clue as to the consistency of the head nor of the extent to which it may become molded. Information as to this point can be gained only by watching the course of labor during the second stage; but, unfortunately, if the decision that the disproportion is sufficiently great to require cesarean section is not made until that period, the optimum time for its performance will have already passed. Conjugata Vera from 10 to 9 Centimeters. — For conve- nience in considering the treat- ment of labor when the conjugata vera exceeds 7.5 centimeters, it is advisable to differentiate between pelves in which the conjugata vera varies between 10 to 9 centimeters; and those in which it falls be- low that limit. Spontaneous labor is the rule in the first category, un- less the head is unusually large or the expulsive forces are very deficient, since a moderate-sized head will usually become molded sufficiently to pass through the contracted superior strait. Accordingly, in pelves of this character the course of labor should be left to Nature as long as possible, and interference resorted to only when absolutely necessary. In most cases the head becomes engaged and then descends into the pelvis after Fig. 621.—Walcheb’s Hanging Position (Bumm). TREATMENT OF LABOR IN CONTRACTED PELVIS 865 an hour or so of second-stage pains, or at least becomes sufficiently molded to permit the safe application of mid forceps. On the other hand, if engagement fails to occur after complete dilatation of the cervix, the patient should he placed in Watcher’s position for as long a time as she will bear it. In many cases this procedure will bring about a lengthening of the anteroposterior diameter of the superior strait sufficient to permit engagement. As soon as the head has descended into the pelvis, the patient should he placed upon her back, as the hanging position tends to contract the pelvic outlet and thus retards delivery. If this does not bring about the desired result, or the child is unusually large, the treatment outlined in the following section should be adopted. If the child should die during the course of labor, craniotomy should be resorted to without hesitation, as it is safer for the mother than the application of high forceps. Conjugata Vera 9 to 7.5 Centimeters—It is in “border line” pelves, contracted within these limits, that the greatest difficulty is experienced in predicting the course of labor and in laying down rules for treatment. More than one half of such patients will be delivered spontaneously, the number decreasing as the lower limit is approached; but it is often impossible to foretell what will occur in a given case. Consequently, the patient should be examined most carefully at the end of pregnancy for the purpose of determining the existence and degree of disproportion. If it is clearly evident that the child’s head will not engage, or if the history of previous labors renders it probable that a spontaneous termi- nation is out of the question, cesarean section should be performed at an appointed time. On the other hand, if the disproportion appears to be so moderate that it is reasonably certain that a second stage of average intensity will bring about such configuration that the head will enter the pelvis, the labor should be left to ISiature in the hope that it will end spontaneously. It should always be remembered in this type of case that the ideal is to be able to differentiate before the onset of labor between the patients who require cesarean section and those in whom spontaneous labor can occur. Whenever a tentative course is pursued, the most rigorous aseptic technic should be employed, and the progress of labor followed by palpation and rectal touch, internal examination being restricted as far as possible. If the condition of the pelvis has been ascertained before labor, a vaginal examination need not be made, unless some emergency arises, or the second stage is unduly prolonged. The foetal heart, of course, should be auscultated at frequent intervals. In a large number of cases spontaneous delivery will occur after a longer or shorter second stage; but if the prognosis has been incorrect, and the head shows no tendency to descend after several hours of efficient second-stage pains, a spontaneous termination can scarcely be hoped for, and it then remains to determine what will be the most desirable method of delivery. If the patient is in a well-regulated hospital, and the head is still above the superior strait, and shows no sign of engaging, pubiotomy 866 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY or cesarean section should be considered, according to the preference of the operator; although my experience leads me to believe that in such circumstances the former is preferable, as its mortality at this time is considerably less than that of cesarean section. After the patient has been anesthetized, but before proceeding to operate, a thorough vaginal examination should be made with the entire hand, and the size and character of the head estimated. If there seems to be no likelihood of engagement occurring, the operation should be proceeded with, but in other cases it should be deferred. On the other hand, if the patient be in a tenement house and refuses to enter a hospital, or is in the country where the physician cannot command the necessary assistance and appliances for an aseptic opera- tion, the second stage should be allowed to continue until the appear- ance of definite signs of danger on the part of the mother or child. Occasionally spontaneous labor will occur contrary to all expectation. Failing such a fortunate outcome, high forceps should be applied obliquely to the head and a few tractions made. If the head shows a tendency to advance, they should be persisted in, but if not, the instru- ment should be removed and craniotomy performed. In such cases forceps should be employed only tentatively, it being understood that its employment is generally contra-indicated, and that prolonged traction and brutal methods of extraction are not permissible, as by their means the child is almost as surely lost as by craniotomy, while the life of the mother is unnecessarily endangered. Of course, if the patient is a devout Catholic, the well-known views of that Church concerning craniotomy must be recognized, and the physician may be called upon to perform pubiotomy or cesarean section when, from a purely professional point of view, its justifiability might be open to criticism. In all but the slightest grades of contracted pelvis, craniotomy should be performed whenever the child has died during the course of labor, as any other operation subjects the mother to increased danger for the purely sentimental consideration of not mutilating the child. Furthermore, if the patient has not been seen until far advanced in labor, and has been repeatedly examined by persons not skilled in aseptic technic, or if she presents symptoms indicative of a beginning infection, pubiotomy or conservative cesarean section is contra-indicated on account of their very high mortality in such circumstances. If, however, the patient is very anxious for a living child, cesarean section followed by supravaginal hysterectomy is justifiable, as experience shows that the results following it are excellent. It should always be remembered that this operation entails permanent sterility, so that in making a decision some thought should be exercised as to the future. Consequently, the operation will be resorted to more frequently in multiparae. If this is not done, tentative attempts at delivery with forceps should be made, and if these fail craniotomy should be performed. Not a few authorities advise pubiotomy or extraperitoneal cesarean section under these condi- tions, but in my opinion the results obtained are by no means com- mensurate with the added risk to which the patient is subjected. TREATMENT OF LABOR IN CONTRACTED PELVIS 867 If the line of treatment which we have outlined for hospital practice be rigorously carried out, the foetal mortality will hardly exceed that occurring in normal labor, while the maternal mortality will be reduced to a minimum. On the other hand, when the forceps is employed tentatively and is followed by craniotomy in unsuccessful cases, the foetal mortality will approach 50 per cent., but the danger to the mother will be only slightly increased. Breech and Face Presentations in Contracted Pelves.—The existence of a breech presentation in moderate degrees of pelvic deformity should be regarded as a complication especially unfavorable for the child, in- asmuch as in the early stages of labor prolapse of the cord is facilitated, and in the later stages serious delay may be encountered in the ex- traction of the after-coming head, which is almost uniformly followed by the loss of the child. Moreover, as the head is not in contact with the superior strait, it is difficult to determine the degree of disproportion. For these reasons, one is justified in being somewhat more liberal in the indications for cesarean section if the diagnosis is made early. On the other hand, if the patient is not seen until late in labor, and pre- sents any considerable disproportion, it is advisable to lay the Gigli saw prophylactically before attempting extraction. If the head passes the superior strait without difficulty, all is well; but, if not, the pubis should be sawed through, after which delivery can be readily effected. In my hands, this procedure has proved most satisfactory, and has given me a sense of security which was previously woefully lacking. So far as the mother is concerned, breech presentations are rather favorable, for the soft breech does not subject her soft parts to such injurious pressure as the hard head; and if delivery becomes imperative, ex- traction can usually be accomplished without great difficulty, unless the pelvic contraction is very marked. In frank breech presentations, when the pelvis is but slightly con- tracted and there is reason to believe that interference will become necessary, it is advisable, as a prophylactic measure, to bring down one foot soon after rupture of the membranes, so that extraction can be effected promptly when indicated. Face and brow presentations should be regarded as much more serious complications, as their existence usually indicates a marked degree of disproportion and an increased probability of the necessity for operative interference. If the pelvic contraction is at all serious, too much should not be expected from Nature, and radical measures should be promptly employed. On the other hand, when one feels fairly satisfied that the disproportion is not excessive and can be overcome, an attempt should be made to convert the presentation into a vertex by one of the recog- nized procedures. Use of Forceps in Contracted Pelves.—Generally speaking, the em- ployment of high forceps is contra-indicated in contracted pelves, espe- cially when the head is freely movable above the superior strait ; as the failure to engage after several hours of efficient second-stage pains indi- cates that the disproportion is too great to be overcome. In such cases forcible attempts to drag the head through the pelvis will lead to fatal COURSE, PROGNOSIS AND TREATMENT. OF PREGNANCY 868 injury of the child, and frequently to the death or to serious lesions on the part of the mother. Too many cases in hospital and consultation practice abundantly bear out the truth of this assertion. On the other hand, after the head has become well molded and is fixed at the pelvic brim, the tentative application of forceps is justifiable. If, however, a few tractions are not followed by descent, the obstetrician must be prepared to resort to craniotomy, rather than to a major operation. When the greatest circumference of the head has passed the superior strait, the employment of forceps is governed by the same rules as in normal pelves, for in such cases the operation is not performed on account of the contracted pelvis, but for one of the usual indications. Version in Contracted Pelves.—Version is frequently recommended as a satisfactory method of delivery in contracted pelves, and many authorities compare its advantages with those obtained with the forceps. Sir Janies Y. Simpson pointed out that the after-coming head offered more favorable conditions than the vertex for passing through a con- tracted pelvis, as smaller diameters are the first to encounter and over- come the resistance offered by the superior strait. But although version undoubtedly presents some advantages so far as the mother is concerned, these are more than counterbalanced by the dangers to which it exposes the child. Thus Lichtenstein stated that the foetal mortality in 154 operations performed in Leopold’s clinic from 1901 to 1905 was 26.62 per cent. Moreover, the advantages of version are markedly diminished by the fact that it must be performed soon after rupture of the mem- branes if satisfactory maternal results are to be obtained. This limits considerably its range of usefulness, as one is compelled to operate before the uterine contractions have had an opportunity to exert their full effect in molding the head; consequently it will be impossible to subject the patient to the test of labor, so that many cases will be delivered artificially, which, if let alone, would have terminated spon- taneously. Formerly many of the German authorities recommended the per- formance of so-called prophylactic version—turning at the onset of the second stage—in all cases of moderate disproportion. This practice does not appear justifiable for several reasons. In the first place, it does away Avith the possibility of the test of labor and conA'erts all into operative cases, and, on the other hand, when the operation is per- formed at the most favorable time, just after the rupture of the mem- bianes, the head has had no chance of becoming molded, and accordingly mnsi be dragged through the pelvis with only such diminution in size as results from a few minutes’ traction. Moreover, a mistake in the estimation of the degree of disproportion always results in foetal death; since if any serious obstacle to extraction is experienced, only a feAV minutes can elapse between the birth of the umbilicus and the delivery of the head, and in this event sufficient time is not available to permit of any other operation being performed in the hope of saving the child. Induction of Premature Labor.—In the past, in moderate degrees of peluc deformity many authorities recommended the induction of pre- mature labor at the thirty-fourth or thirty-sixth of pregnancy, and TREATMENT OF LABOR IN CONTRACTED PELVIS 869 some still do so in the hope that the smaller and softer head will be born more readily than at term. This is undoubtedly the case, and the operation, if properly performed, should have a maternal mortality of less than 1 per cent. Personally, I have never induced labor for this indication and do not recommend it. It is applicable only to the more moderate degrees of contraction, in which spontaneous labor at term is the rule; while the children frequently succumb to the operation, or, when born alive, are so imperfectly developed that even with the most careful attention hardly more than 50 per cent, survive the first year. Sarwey, in 1906, collected 2,200 cases from 50 operators, and found that 484 of the children were born dead, and that an additional 343 of those born alive succumbed before leaving the hospital—a net mortality of 37.3 per cent. Yoorhees reported, in 1905, a primary mortality of 21 per cent, from Cragin’s clinic, and Norris one of 13 per cent. These results, to my mind, are not so good as those following the expectant treatment at full term, and are far inferior to those following the more general performance of cesarean section or pubiotomy in the class of cases under discussion. Indeed, the foetal mortality, direct and indirect, attending the induction of premature labor is so great that it can scarcely be regarded as a means of saving foetal life. My own experience fully confirms the conclusions of Baisch con- cerning the great value of expectant treatment in contracted pelves. In his exhaustive study he clearly lemonstrated that the results for the child improve as the use of high forceps, prophylactic version, and the induction of labor is restricted, while at the same time the maternal mortality is not increased. This was also shown by studying the course of labor in 701 cases of contracted pelvis occurring in a series of 4,500 patients in our service. In the first 2,000, high forceps and version were frequently employed, while in the last 2,500 patients labor was conducted in a much more expectant manner, but cesarean section or pubiotomy was freely employed whenever radical interference was indi- cated, with the result that the total operative frequency fell from 32 to 21 per cent., while the gross and net foetal mortality fell from 11.3 to 8.3 per cent, and from 4.73 to 3.38 per cent., respectively. At the same time the maternal mortality was reduced nearly one half. Accordingly, it appears that intelligent expectant treatment, while reducing the total number of operations, necessitates the more frequent employment of radical procedures, but at the same time definitely re- duces both foetal and maternal mortality. It should always be remem- bered that a spontaneous outcome may be expected in from 75 to 80 per cent, of all contracted pelves, and that radical surgical interference will be necessary in less than one half of the operative cases, and to a still lesser extent in the class of cases in which the induction of labor is advocated. To my mind, the claims of the advocates of the induction of pre- mature labor may be disposed of by a reductio ad absurdum—namely, that better foetal results could be obtained by allowing all patients in whom it appears indicated to go to full term and performing crani- 870 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY otomy whenever spontaneous labor does not occur. For this reason it seems to me, whenever the induction of premature labor is frequently employed, that it must in many instances have been resorted to un- necessarily. On the other hand, in patients presenting moderate degrees of pelvic contraction without serious disproportion, labor should he induced as soon as the calculated end of pregnancy has been reached, as it seems irrational to stand idly by and to watch the child increase beyond the usual limits of size. In such cases, labor should be induced by Watson’s method, or, if it fails, by the introduction of a bougie. This, however, is not the induction of premature labor, but rather the termination of pregnancy after the child has attained full maturity. In conclusion, it cannot be too forcibly impressed upon the student that the repeated delivery of dead children in cases of contracted pelves is unjustifiable. The loss of a child may frequently be perfectly ex- cusable in a single labor, but its repeated occurrence indicates a neglect of human life which should not be tolerated, and physicians should learn that it is their duty, if they do not feel competent to cope suc- cessfully with such cases, to send them to a well-regulated hospital or to confide them to the care of a competent specialist for treatment. TREATMENT OF LABOR COMPLICATED BY OSTEOMALACIC PELVES The course of labor in osteomalacic pelves varies according to the stage of the disease and the degree of contraction. When the deformity is slight its influence upon the labor is minimal, but when marked it frequently gives an absolute indication for cesarean section. Some idea of the obstacle offered to labor by this class of pelves mav be gained from the figures of Litzmann, which were collected in 1861, at a time when the mortality attending cesarean section was so appalling that the operation was undertaken only under the most pressing indica- tions. lie tabulated 79 cases from the literature, and found that the following operations had been performed: 40 cesarean sections, 16 per- forations, 1 symphyseotomy, 2 inductions of premature labor; while 7 women had succumbed to rupture of the uterus, and 4 others had died undelivered. Latzo, in 1897, considered the effect of osteomalacia upon the course of labor in 85 patients who came under his observation. These women had gone through 290 labors before, and 169 after, the appearance of the disease. In the first group operative interference was necessary once in 48 cases, and in the second once in every 4.9 cases—in other words, labor had become ten times more difficult. If 1 he patient is seen during the early months of pregnancy and is suffering from the disease in its acute stage, she should be at once removed to a hospital where she can live under the best hygienic sur- roundings and be supplied with an abundance of suitable food. Phos- phorus or adrenalin should be administered tentatively. Latzo, Winckel, LITERATURE 871 and others state that the former in doses of 2.4 to 4 milligrams per day frequently leads to a permanent cure; while Bossi and others make similar claims for the curative properties of the latter, which is ad- ministered in large doses of 0.3 to 0.5 c.cm. of a 1 to 100 solution. Benzel and others claim that the use of the X-ray is sometimes followed by surprising results. If tentative treatment is not satisfactory, or the patient is not seen until the end of pregnancy or the time of labor, the treatment to be pursued depends altogether upon the degree of pelvic contraction. In such cases attention should be paid not only to the length of the conjugata vera, but more particularly to the dimensions of the inferior strait. In florid cases the bones may be so soft as to resemble leather in consistency, and the pelvis readily assumes various forms. This affords an explanation of the fact that one is occasionally surprised to sec delivery accomplished through a pelvis which at first glance appears to offer no possibility of such an occurrence. Quite a number of such cases are recorded in the older literature, but such an outcome should be regarded as very exceptional, and should not lead us to expect too much of Xature. If the pelvis is markedly contracted cesarean section should be per- formed without hesitation, followed by the removal of the uterus and ovaries, or by castration alone. Fehling has shown that either of these operations leads to the permanent cure of the disease in about 80 per cent, of the cases, and Seitz in 1913 collected 328 cases with 87 per cent, of cures. If, however, delivery occurs spontaneously, or has been effected by forceps or version, castration should be performed soon after the puerperium in the hope of checking the disease. LITERATURE Ahlfeld. Ueber die Zerreissung der Schamfuge wahrend der Geburt. D. I., Leipzig, 1868. Bestimmungen der Grosse und des Alters der Frucht vo.r der Geburt. Archiv f. Gyn., 1871, ii, 353-372. Baisch. Reformen in der Therapie des engen Becken. Leipzig, 1907. Bar. Logons de pathologie obstetricale. Paris, 1900. Benzel. Die Behandlung der Osteomalazie an der Strassburger Frauenklinik. Archiv f. Gyn., 1917, cvii, 268-282. Braun von Fernwald. Ueber Symphysenlockerung und Bymphysenruptur. Archiv f. Gyn., 1894, xlvii, 104-129. Breisky. Extramediane Einstellung des Kindeskopfes, etc. Archiv f. Gyn., 1870, i, 173-174. Burger. Die Geburtsleitung bei engen Becken. Wien, 1908. De Lee. Two Cases of Rupture of the Symphysis Pubis during Labor. Amer. Jour. Obst., 1893, xxxviii, 483-499; also 1901, xliii, 630-633. Ueber Wesen und Behandlung der puerperalen Osteomalacie. Archiv f. Gyn., 1891, xxxix, 171-196. Weitere Beitrage zur Lehre von der Osteomalacie. Archiv f. Gyn., 1895, xlviii, 472-498. Glaser. Ueber spontane Goburten bei engen Becken. D. I., Miinchen, 1898. 872 COURSE, PROGNOSIS AND TREATMENT OF PREGNANCY Kehrer. Symphysenlockerung und Symphysenruptur. Monatsschr. f. Geb. u. Gyn., 1915, xlii, 321-372. Kerr. Diagnosis and Treatment of Contracted Pelves. Trans. Am. Gyn. Soc., 1911, xxxvi. Kronig. Die Therapie bei engen Becken. Leipzig, 1901. La Torre. Le developpement du foetus chez les femmes a bassin vicie. Paris, 1887. Latzo. Beitriige zur Diagnose und Therapie de.r Osteomalacie. Monatsschr. f. Geb. u. Gyn., 1897, vi, 571-608. Lichtenstein. Ueber die Beeinllussung der Indication zur Wendung u. Extrac- tion durch die Hebotomie. Archiv f. Gyn., 1907, lxxxi, 626-647. Litzmann. Die formen des Beckens, nebst einem Anhange iiber die Osteomalacie. Berlin, 1861. Ueber die liintere Scheitelbeineinstellung. Archiv f. Gyn., 1871, ii, 433-440. Die Geburt bei engem Becken. Leipzig, 1884. Ludwig und Savor. Klin. Bericht iiber die Geburten beim engen Becken, Bericht aus der II. geb-gyn. Klinik in Wien. Wien, 1897, 120-353. McDonald. Mensuration of the Child in the Uterus with New Methods. J. Am. Med. Ass., 1906, xliii, 1979-1983. Menge. Zur Therapie des engen Beckens. Monatsschr. f. Geb. u. Gyn., 1910, xxxi, 687-701. Michaelis. Das enge Becken. Leipzig, 1851. Muller. Ueber die Prognose der Geburt bei engem Becken. Archiv f. Gyn., 1896, xxvii, 311. Norris. Intrapelvic versus Abdominal Method of Dealing with Mechanical Ob- struction to Delivery. Trans. Am. Gyn. Soc., 1908, xxxiii, 182-212. Peham. Das enge Becken. Wien, 1908. Perret. La cephalomet.rie externe, etc. L ’obstetrique, 1899, iv, 542-584. Pinard. Du palper mensurateur. Traite du palper abdominal, 2me ed., Paris, 1889, 202-222. Note pour servir a l’histoire de la puericulture pendant la grossesse. A-nnales de gyn. _et d’obst., 1898, 1, 80-89. Biggs. A Comparative Study of White and Negro Pelves. Johns Hopkins Hos- pital Beports, 1904, xii, 422-454. Sarwey. Besultate der wegen Beckenenge vorgenommenen kunstlichen Friihge- burten, etc. Winckel’s Handbuch d. Geburtshilfe, 1906, iii, 142-147. Schauta. Allg. Pathologie der Beckenanomalien. Miiller 's Handbuch der Geb 1889, ii, 265-284. Die Castration bei Osteomalacie. Wiener med. Wochenschr., 1900. Schwartz. Ueber die Haufigkeit des engen Beckens. Monatsschr. f. Geburtsh 1865, xxvi, 437-442. Seitz. Die Osteomalacie in ihren Beziehungen zur inneren Sekretion und zur Schwangerschaft. Innere Sekretion und Schwangerschaft. Leipzig, 1913. Sellheim. Ueber Geburtsvorgang und Geburtsleitung beim engen Becken. Yolk- mann’s Sainml. klin. Yortrage, 1912, Nr. 649. Simpson. Memoir on Turning, as an Alternative for Craniotomy and High Forceps, etc., 1850. Selected Obstetrical and Gynaecological Works. Edinburgh, 1871, i, 393. Tarnier et Budin. Traite de 1 ’art des aceouchements. 1898, t. iii, 70-135. Valency. De 1’accouchement spontane dans les bassins- retrecis rachitiques These de Paris, 1900. Varnier. Accommodation de la tete foetale au bassin maternal. L’obstetrique journaliere, Paris, 1900, 131-149. 4 oorhees. A Beport of Seven Caesarean Sections. Am. J. Obst., 1905, Iii, 161-190. LITERATURE 873 Wilcke. Das Geburtsgewicht der Kinder bei engem Beeken. Beit,rage zur Geb. u. Gyn., 1901, iv, 291-302. Williams. The Abuse of Cesarean Section. Surg. Gyn. and Obst., 1917. A Critical Analysis of Twenty-one Years’ Experience with Cesarean Section. Bull. Johns Hopkins Hosp., 1921, xxxii, 173-184. Winckel. Behandlung der Osteomalacie. Penzoldt u. Stintzing’s Handbuch der spec. Therapie, v. Abth., 1896, vii, 214-242 (full literature). Ueber die Erfolge der Kastration bei der Osteomalacie. Volkmann’s Sammlung klin. Vortrage, N. F., Nr. 28. Zaxgemeister. Beitrag zu.r Lehre vom engen Beeken. Zentralbl. f. Gyn., 1922, 1395-1406. CHAPTER XXXVII PELVIC ANOMALIES DUE TO DISEASE OF THE VERTEBRAL COLUMN KYPHOTIC PELVIS History.—Kyphosis or humpback, the result of spinal caries, pla} s an important part in the production of pelvic abnormalities, for when situated in the lower portion of the vertebra! column it is usually asso- ciated with a characteristically funnel-shaped pelvis. Fig. 622.—Longitudinal Section through Pelvis and Spinal Column in Dorso- lumbar Kyphosis (Breus and Kolisko). We are indebted to Rokitansky for the first accurate work upon the subject, although as early as 1759 Madame Boursier de Coudray reported a cesarean section performed upon a patient having a pelvis of this character. The most important contribution to our knowledge concerning the kyphotic changes was made by (1865), who clearly set forth the mechanical factors by which the alteration in shape was brought about. 874 KYPHOTIC PELVIS 875 Later, Chantreuil, Champneys, Barbour, Treub, and particularly Breus and lvolisko added materially to our knowledge of the subject. The effect exerted upon the pelvis by kyphosis differs according to its location. When the gibbus or hump is situated in the dorsal region, it is usually compensated for by marked lordosis beneath it, so that the pelvis itself is but little changed. On the other hand, when situated at the junction of the dorsal and lumbar portions of the vertebral column its effect upon the. pelvis becomes manifest, and is still further accentu- Fig. 623.—Kyphotic Pelvis Showing Elongation of Conjugata Vera. ated when the kyphosis is lower down, being most marked when it is at the lumbosacral junction. Klien analyzed 85 cases reported in the literature, and found that the kyphosis was dorsolumbar in 24, lumbar in 17, and lumbosacral in 37 cases, while in 7 other cases the vertebral column so overhung the superior strait as to produce a “pelvis oltecta” (Fig. 624). Characteristics.—4'he characteristic feature of the kyphotic pelvis is a retropulsion and rotation of the sacrum, by which the promontory becomes displaced backward and the tip forward. At the same time the entire bone becomes elongated vertically, and narrowed from side to side. These changes are associated with a rotation of each innominate bone about an axis, which extends through the symphysis pubis and the sacro-iliac articulation, so that the iliac fossae becomes flared outward while the lower portions of the ischial bones are turned in toward the middle line. When the kyphosis is in the dorsolumbar region, marked lordosis below it indicates an attempt at compensation, but as this is imperfect 876 PELVIC ANOMALIES DUE TO DKSEASE OF VERBEBRAL COLUMN the body weight is transmitted to the sacrum in such a manner that the latter becomes retroposed and lengthened, its promontory being farther backward and at a higher level than usual. At the same time its an- terior surface loses its normal vertical concavity and becomes straight or even convex; while its lateral concavity is obliterated by the projection of the vertebral bodies beyond their alae. The bodies themselves are considerably narrower than usual, and the alae of the first sacral vertebra appear to be drawn out and to extend obliquely upward to the prom- ontory. Owing to its backward displacement the posterior surface of the sacrum approaches the superior posterior spines of the ilium, thereby relaxing the iliosacral ligaments. At the same time the posterior ex- tremities of the innominate bones are pushed apart, and as a consequence their upper portions rotate outward and the lower portions inward, so that the crests are flared out and occupy a lower level than usual, while the ischial spines and tuberosities approach the middle line. This movement of rotation is still further accentuated by the increased tension exerted by the ilio- femoral ligaments re- sulting from a diminu- tion of the pelvic inclination. The ace- tabula also are shifted slightly and look more to the front than usual. Coincident with the displacement of the sacrum, the iliopectineal line becomes longer, par- ticularly in its iliac portion. these changes give rise to a funnel-shaped pelvis, in which, as the result of the increase in the length of the conjugata vera, the superior si iait becomes round or oval in shape, with the long diameter running anteroposteriorly, while the transverse diameter remains unchanged or may even be somewhat shorter than usual. There is also a gradual diminution of all the anteroposterior diameters of the pelvis below the supeiioi stiait, but the most characteristic change is the shortening of the distance between the ischial spines, and to a somewhat less extent of that between the ischial tuberosities. The pelvic inclination is usually decreased, though in some cases it is only slightly altered. in 18 kyphotic pelves described by Breus and Kolisko the conjugata aoiri varied from 10.7 to lfi.5 centimeters in length, the distance between the spines from 5.2 to 8.2 centimeters, and that between the ischial tuberosities from 6 to 12.1 centimeters. At the same time it should oe remembered that in not a few' cases the entire cavity is smaller than usual, Klien having pointed out that 30 per cent, of ail kyphotic pelves Fig. 624.—Pelvis Obtecta (Fehling). KYPHOTIC PELVIS 877 which he studied were also generally contracted, so that a conjugata vera which at first glance appears normal may in reality be relatively in- creased in length. When the kyphosis is situated at the junction between the last lumbar and the first sacral vertebrae, the pelvic changes are more marked than those just described, as the promontory of the sacrum is usually carious and takes part in the formation of the gibbus. In such cases there can be no attempt at compensation, as the body weight is transmitted directly to the anterior surface of the sacrum, so that its upper part is pushed far backward. It is not lengthened, and its alae are usually very small. In such cases the transverse contraction becomes still more marked, so that the distance between the ischial spines may be reduced to 3 or 4 centimeters, as in the cases described by Schroeder and Doktor. The pelvic inclination is always diminished, and in some cases is entirely obliterated. When the kyphosis is very marked, the lumbar vertebrae may so overhang the superior strait as effectively to prevent the child’s head from entering it. This condition was described by Fehling as pelvis obtecta. In his specimen the distance between the symphysis pubis and the nearest point on the vertebral column was 3.8 centimeters. A similar condition was noted in 8 per cent, of the cases analyzed by Ivlien, and has been described by Herrgott as sponclylizeme. Mode of Production.—A kyphosis in the dorsal region is usually com- pensated for by a marked lordosis below' it, so that the body weight is transmitted to the sacrum in the usual manner. On the other hand, as Breisky pointed out, when the hump is situated lower down, the body weight is transmitted through its upper limb, and on reaching the gibbus becomes resolved into two components, one of which is directed downward and the other backward. This latter force draws the prom- ontory of the sacrum backward and upward, thus leading to rotation and elongation of the entire bone (Fig. 625). Breus and Kolisko have showm that, owing to the necrosis of one or more of the vertebral bodies forming the gibbus, the body weight is not transmitted directly through the vertebral bodies below it, but through their arches and spinous processes. As a result the latter come into close contact, while the interior portions of the vertebrae become widely separated, thus leading to marked lordosis beneath the gibbus. This causes an upward drag upon the bodies of the sacral vertebrae, which become stretched and elongated. Coincident with these changes, and resulting from the backward displacement of the sacrum, as well as from the increased tension exerted by the iliofemoral ligaments, the innominate bones likewise undergo rotation, which brings about a nar- rowing of the lower portions of the pelvis. Frequency.—According to Klien’s statistical study a kyphotic pelvis is met with once in every 6,016 labors, although he himself believes that this estimate is too low, in view of the fact that humpbacked women are relatively numerous. On the w’hole, it is probable that any one who has an extensive obstetric practice is liable to meet with this abnormality. 878 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN Diagnosis.—The diagnosis is usually easy, as the external deformity is readily detected and should at once suggest the possible existence of a funnel pelvis. External pelvimetry is of great value, as it shows that the distance between the iliac crests is equal to or exceeds that between the tro- chanters, whereas normally the reverse is true. In a patient suffering Fig. 625.—Diagram Showing Forces Concerned in the Production of Kyphotic Pelvis (Tarnier). from this deformity, lines drawn through the iliac crests and trochanters will meet somewhere in the neighborhood of the feet, instead of near the head as is generally the case. On palpation of the pubic arch the transverse narrowing of the pelvic outlet will be noted, while internal examination will reveal the lengthening of the conjugata vera. In lumbosacral kyphosis the prom- ontory no longer exists, and the bodies of the lower lumbar vertebra KYPHOTIC PELVIS 879 overhang the superior strait. Accordingly, in this variety of pelvis particular attention should be devoted to estimating the length of the “pseudoconjugate”—the distance from the upper margin of the symphysis pubis to the nearest portion of the vertebral column. Occasionally the condition may be confounded with spondylolisthesis, and the differential diagnosis will be considered under the latter heading. Effect upon Labor.—Owing to the collapse of the vertebral column, the ribs approach the pelvic brim and thereby lessen the capacity of the Fig. 626.—Patient with Obliquely Contracted, Kyphotic, Funnel Pelvis. In A note that body weight is borne by right leg. In B note presence of double gibbus. The lumbo-sacral one is concerned in producing the funnel pelvis. abdomen, which in consequence becomes markedly pendulous at an early period of pregnancy. These mechanical conditions favor the occurrence of abnormal positions of the foetus, and Klien, in 103 cases, found 100 longitudinal and 3 oblique presentations. Of the former 90 were vertex, 4 face, and 6 breech presentations. It is interesting to note that left occipito-anterior presentations occur much less frequently than usual, being noted in only one-third of the cases, while the remainder are equally divided between right anterior and posterior presentations. It is difficult to give a satisfactory explana- tion for the unusual frequency of the right anterior position, but the 880 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN production of posterior positions is due to the pendulous abdomen, as in such circumstances the concave ventral surface of the child tends to apply itself to the convex inner surface of the anterior wall of the uterus. Except in cases of pelvis obtecta, the presenting part experiences no difficulty in entering the superior strait at the time of labor, and no obstacle is met with until it reaches the neighborhood of the ischial spines. If the transverse contraction be not too marked to prevent the descent of the head, further difficulty is encountered when the latter attempts to pass beneath the pubic arch, which, owing to the approach of the tubera ischii, has become more angular than usual, so that the head is prevented from coming in contact with the lower margin of the symphysis pubis and must descend lower than usual in order to be born. This fact readily explains the deep perineal tears so frequently observed. Generally speaking, it may be said that when the distance between the tubera ischii is less than 8 centimeters labor becomes difficult or impossible, according to the degree of transverse contraction of the outlet. In such cases the dystocia is more pronounced than in typical funnel pelves presenting identical measurements, for the reason that the anterior displacement of the tip of the sacrum is inevitably associated with shortening of the posterior sagittal diameter. Owing to the narrowing of the pubic arch, occipito-anterior are less favorable than occipitoposterior presentations, as in the former the wide hiparietal diameter has to accommodate itself to the pubic arch, whereas in the latter its place is taken by the smaller brow. According to Klien, face presentations are still more favorable for the same reason. Prognosis.—If the contraction is pronounced, the prognosis is bad unless cesarean section is resorted to. Klien has analyzed the histories of 175 labors occurring in 95 women, and found that 40 per cent, of the children died. The maternal mortality varied according to the degree of contraction; when the disproportion between the biparietal diameter of the child’s head and the distance between the spines was slight, it was 6.2 per cent., as compared with 17 per cent, in marked cases. Neugebauer has likewise analyzed the histories of 199 labors occur- ring in 118 women, and found that only 44 ended spontaneously. The maternal mortality was 24.3 per cent., and 49 per cent, of the children died. Treatment.—When the distances between the spines and tuberosities of the ischium do not fall below 8 centimeters, spontaneous labor, or at least a probable delivery with low or mid forceps, can be looked for, pro- vided the posterior sagittal diameter is not too shortened; but when the measurements are below this limit operative interference becomes necessary. Unless the child is very small, cesarean section is usually the operation of choice. Pubiotomy, however, may he considered if the dis- tance between the spines or tubera does not fall below 6 centimeters, as it will permit the passage of the head, and may lead to a permanent increase in the dimensions of the pelvic outlet. If the child is already dead, craniotomy is the operation of election. SCOLIOTIC PELVIS 881 KYPHORHACHITIC PELVIS Kyphosis is nearly always of carious origin, but when due to rhachitis it is usually associated with a greater or lesser degree of scoliosis. In the rare cases of pure rhachitic kyphosis, however, the pelvic changes are slight, as the effect of the kyphosis is counterbalanced to a great extent by that of the rhachitis, the former leading to an elongation and the latter to a shortening of the conjugata vera, while tending, respectively, to narrow and to widen the inferior strait. Thus it may happen that a woman presenting a markedly deformed vertebral column of this char- acter may still have a practically normal pelvis. The two processes, however, do not always counteract one another, and, as a rule, when the kyphosis is high up the pelvic changes are predominantly rhachitic. SCOLIOTIC PELVIS Pronounced scoliosis, or lateral curvature of the spine, is usually of rhachitic origin; but, on the other hand, minor degrees of the deformity Fig. 627. Fig. 628. Figs. 627-628.—Obliquely Contracted Non-rhachitic Scoliotic Pelvis (Breus and Kolisko). are often observed which have no connection with rickets. When the scoliosis involves the upper portion of the vertebral column,, it is usually compensated for by a corresponding curvature in the opposite direction 882 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN lower down, thus giving rise to a double or S-shaped curve. In such cases the body weight is transmitted to the sacrum in the usual manner. But when the scoliosis is lower down and involves the lumbar region, the sacrum takes part in the compensatory process and accordingly assumes an abnormal position which leads to slight asymmetry of the pelvis. Breus and Kolisko have devoted particular attention to the pelvic anomalies resulting from non-rhachitic scoliosis, but the changes in shape are usually so slight as to have little or no effect upon the course of labor. Figs. 629-630.—Scoliorhachitic Pelvis (Tarnier). Fig. 629. Fig. 630. When due to rhaehitis, the scoliosis may be very pronounced, and give rise to marked pelvic deformity, in which the characteristic changes due to the anomaly of the vertebral column are superadded to those resulting from rhaehitis. In such cases the scoliotic convexity is usually directed to the right side, as was noted in 7 out of the 9 eases described by Leopold. In such circumstances the sacrum takes part in the compensatory scoliosis, one side being compressed and the other elongated, so that its long axis becomes directed obliquely toward one side. At the same time it undergoes a partial rotation about its vertical axis, the spinous processes being directed toward the compressed side, a result which indi- cates the abnormal direction along which the body weight is transmitted to the iliac bones, and thence to the femurs. Owing to the abnormal pressure exerted upon one side, the pelvis becomes obliquely contracted, usually upon the side corresponding to the lumbar convexity; but, owing KYPHOSCOLIOTIC PELVIS 883 to the coexistence of rhachitic changes, the contraction is in great part limited to the superior strait. Owing to the pressure exerted upon the compressed side of the sa- crum, ankylosis at the sacro- iliac articulation often occurs. At the same time the innominate bone on the affected side is displaced upward, in- ward, and backward, while its acetabulum looks more forward than usual. The symphysis pubis is brought somewhat nearer to the opposite side, and owing to the rhachitic changes the pubic arch is widened, while the tubera ischii are directed outward instead of inward as in the Naegele pelvis. In pronounced cases the superior strait assumes an Figs. 631-632.—Kyphoscolioticheachitic Pelvis (Leopold). Fig. 631. Pig. 632. obliquely ovate appearance, and occasionally the acetabulum on the affected side may come almost in contact with the promontory. The location of the contraction can be determined by external ex- amination, as it always lies upon the side toward which the convexity of the scoliosis is directed. The contracted side is valueless from an obstetrical standpoint, and for practical purposes the superior strait be- comes generally narrowed. If, however, the head manages to pass through it, no further difficulty is experienced in its downward course, owing to the rhachitic widening of the lower nortion of the pelvis. KYPHOSCOLIOTIC PELVIS In this type, the distortion of the pelvis will vary according as the kyphosis or the scoliosis is the predominant factor in the deformity of the spinal column. When the former is more pronounced the pelvis will partake of the kyphotic character, and vice versa. When the two de- 884 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN formities are approximately equal, however, the kyphotic changes in the pelvis predominate, although the influence of the scoliosis tends to counteract, to a certain extent, the transverse narrowing of the inferior strait. KYPHOSCOLIORHACHITIC PELVIS This variety of pelvic deformity has been studied more particularly by Leopold, and Barbour. As has already been pointed out, a kyphosis due to rhachitis is nearly always complicated by a scoliosis and the latter usually predominates in the production of the pelvic de- formity, for the reason that the kyphosis and the rhachitis tend mutually to counteract one an- other in their effect upon the pel- vis. Accordingly, the resulting pelvis does not differ materially from that observed in scolio- rhachitis, except that the tend- ency to anteroposterior flattening is partially counteracted by the action of the kyphotic vertebral column. Nevertheless, owing to the presence of the scoliosis, the oblique deformity of the superior strait is usually quite marked. Generally speaking, this class of pelvis is more favorable from an obsteti ical standpoint than that due to scoliorhachitis alone. Fig. 633.—Vertical Section through Spondylolisthetic Pelvis (Kilian). SPONDYLOLISTHETIC PELVIS Ihe term spondylolisthesis (from o-ttovStAos vertebra, and oXurOrjois, slipping or sliding) was introduced by Kilian in 1853, in describing a pelvis in which the last lumbar vertebra had become displaced down- ward over the anterior surface of the sacrum. Characteristics.—The degree of displacement may vary greatly. W hen the deformity is slight the anterior inferior margin of the last lumbar vertebra merely projects a short distance beyond the anterior margin of the promontory of the sacrum; while in pronounced cases the entire body of the vertebra is displaced downward and forward into the pelvic cavity, so that its inferior surface comes in contact with, and more or less completely covers, the body of the first, and occasionally tlud o1 the second sacral vertebra. As a consequence, a greater or lesser portion of the lumbar column comes to occupy the upper portion of the sT™r strait >>«*>mi„g markedly obstructed aod assuming a remform shape. SPONDYLOLISTHETIC PELVIS 885 The lower lumbar vertebrae may overhang the pelvic inlet to such an extent that the obstetrical or pseudoconjugate will be represented by a line drawn from the upper margin of the symphysis to the lower margin of the fourth,, third, or even of the second lumbar vertebra, as the case may be. In the specimen which I described in 1899, it ex- tended to the lower margin of the third lumbar vertebra and measured Fig. 634. Fig. 635. Fig. 636. Figs. 634-636.—Williams’ Spondyliolisthetic Pelvis. 6.5 centimeters. The displacement of the last lumbar vertebra is due not to luxation, but to the lengthening and bending of its inter- articular portions. Its inferior articular processes still retain their normal relation to the superior articular processes of the first sacral vertebra, whereas its body and its superior articular processes, together with the rest of the vertebral column, become displaced forward and eventually downward. As a result of the new position assumed by the body of the last lumbar vertebra, the superior and anterior surfaces of the promontory become more or less worn away by friction, the defect being frequently followed by ankylosis which definitely checks 886 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN further displacement. In advanced cases the inferior articular processes of the last lumbar and the superior articular processes of the first sacral vertebra are usually firmly synostosed together, as are also the inferior articular processes of the fourth and the superior articular processes of the fifth lumbar vertebra. Owing to the collapse of the vertebral column into the pelvic cavity the center of gravity falls in front of instead of just behind the acetab- ula, and consequently the pelvis must be tilted backward in order that the individual may retain an upright position. In other words, the pelvic inclination must be dimin- ished, and when the deformity is marked the plane of the superior strait becomes parallel to, or even forms an obtuse angle with, the horizon. This is rendered possible by changes in the iliofermoral liga- ments, which are manifested on the one hand by a marked roughening of the portions of the pelvis to which they are attached, and on the other by characteristic changes in the gait of the patient. In my own case the pelvic inclination was obliterated; but, had it remained normal, the vertebral column would have formed a right angle with the legs, necessi- tating the patient’s going upon all- fours, where, as a matter of fact, she was able to walk erect. As the inferior surface of the last lumbar vertebra is in contact with the anterior instead of the su- perior surface of the first sacral vertebra, the action of the body weight tends to force the promontory of the sacrum backward, thereby causing it to rotate about its transverse axis, while its tip approaches the lower margin of the symphysis pubis. This rotation, together with the increased traction exerted by the iliofemoral ligaments, causes each innominate bone to rotate about an axis extending from the symphysis to the sacro-iliac joint, and tends to give the pelvis a funnel shape, just as in kyphosis, the inferior strait becoming contracted transversely. Etiology.—Kilian considered that the displacement of the last lumbar vertebra was rendered possible by inflammatory softening of the inter- vertebral disk. Later, various hypotheses were-advanced as to its mode of production. Robert, Lambl, and Konigstein showed that the dis- placement could not take place sc long as the inferior articular processes of the last lumbar were normal and in contact with the superior articular processes of the first sacral vertebra, unless the entire vertebra became lengthened. Fig. 637.—Spondylolisthesis; Ver- tical Section through Last Three Lumbar Vertebrae and Sacrum. XL}. SPONDYLOLISTHETIC PELVIS 887 Neugebauer devoted thirteen years (1882-95) to the study of this subject, and during that period published 15 journal articles and 3 monographs upon it, covering nearly 900 pages, not to mention the dis- cussions and demonstrations in which he took part. He showed con- clusively that in the vast majority of cases the deformity was rendered possible by a lengthening and thinning out of the interarticular por- tions of the last lumbar vertebra, by which its superior and inferior articular processes become separated by a long, thin lamina of bone in- stead of being almost in the same vertical line (Fig. 638). This condition he attributed to imperfect development of the inter- articular portion (spondylolysis) or to its fracture, with subsequent stretching of the callus. .He con- sidered that the former was the more frequent causes, as he was able to demonstrate it in many vertebrae which presented no signs of spondy- lolisthesis. When the displacement is marked the interarticular por- tion is not only lengthened and thinned out, but also becomes bent over the promontory of the sacrum, thus forming a dolicho-Tcyrto-platy- spondylus. In opposition to Neugebauer’s statement that the deformity always results from changes in the inter- articular portion, Chiari definitely showed that it can occasionally fol- low fracture of the articular proc- esses without the characteristic changes in the vertebra. At the same time, he considered that spondylolysis is the usual cause. Goldthwait holds that the deformity is usually due to luxation of the inferior articular processes of the last lumbar vertebrae over the superior articular processes of the sacrum. In this event, the spinal canal would be encroached upon and the cauda equina compressed, with resulting paralysis. The absence of the latter complication in most pronounced cases of spondylolisthesis argues against the correctness of his theory, and in favor of Neuge- bauer’s view, according to which the elongation of the interarticular portion of the last lumbar vertebra would lead to an increase in the size of the spinal canal, and thus lessen the probability of pressure upon the cauda. Arbuthnot Lane stated that the disease is more common than is generally supposed, as he observed several examples of it in coal-heavers. He considers that in such cases, at least, the changes in the interarticular portion ate due not to abnormalities in development but to excessive pressure, which results from carrying heavy burdens. Complete litcra- Fig. 638.—Fourth and Fifth Lum- bar Vertebrae from Author’s Case of Spondylolisthesis. X Yi- A, superior articular process; B, trans- verse process; C, inferior articular process; D, lamina of fourth lumbar vertebra; E, superior articular process; F, inferior articular proc- ess; G, transverse process; II, I, J, fissures in interarticular portion of last lumbar vertebra. 888 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN ture upon the subject will he found in my own article, and in those of Breus and Kolisko, and Chiari. Frequency.—Neugebauer, in 1893, was able to collect 115 cases of spondylolisthesis, most of which were clinical observations. In 1899 I collected 123 cases, which Chiari, in 1912, increased to 150, including 17 cases occurring in males—11.3 per cent. According to Breus and Kolisko only 20 indisputable anatomical specimens of this condition were in existence in 1900, including 2, which they described for the first time. I'ig. 639. Front and Back Views of Woman with Spondylolisthesis (Ahlfeld). Effect upon Labor.—When the condition is but slightly marked, its effect upon labor is similar to that of a flat pelvis, as the greatest con- traction is in the conjugata vera, although it should be remembered that it is likewise associated with considerable contraction of the inferior stiaii. "When the deformity is pronounced and the lower lumbar verte- brae overhang the superior strait, the degree of contraction, from an obstetrical point of view, is to reckoned not by the distance between the symphysis pubis and the anterior portion of the last lumbar vertebra, but by the length of the pseudoconjugate, whose posterior extremity may be at the fourth, third, or even second lumbar vertebra, and in many cases is so short as absolutely to preclude the possibility of the head entering the pelvis. Diagnosis.—In typical cases mere inspection of the patient should lead one to suspect the existence of this deformity, inasmuch as there SPONDYLOLISTHETIC PELVIS 889 is always marked lumbar lordosis and the entire trunk seems to have caved in, so that the ribs may come almost in contact with the iliac crests. When viewed from the front the abdominal walls appear un- usually redundant. Such patients have a peculiar ducklike walk or waddling gait, to which Neugebauer first directed attention. Since the posterior portion of the last lumbar vertebra retains its normal position while the rest of the vertebral column sinks forward, its spine will some times form a marked prominence just above the sacrum. The condition, however, may be confounded with a deep-seated kyphosis. On internal examination the diag- nosis, as a rule, is readily made, as, on attempting to measure the diagonal conjugata, the body of the last lumbar vertebra will be found lying in front of the anterior and upper portion of the sacrum. At the same time the iliopectineal line ends abruptly at the margins of the overhanging vertebral body, instead of continuing uninter- ruptedly to the promontory of the sacrum. Owing to the marked lordosis, which frequently accompanies the condition, the bodies of the lower lumbar vertebrae can readily be pal- pated and counted, and the bifurca- tion of the aorta, or at least the com- mon iliac arteries, are frequently readily accessible to the examining finger. Occasionally pronounced rhachitic changes in the sacrum may simu- late spondylolisthesis, but a correct diagnosis can usually be arrived at. In such cases, careful palpation, under anesthesia if necessary, will show that the iliopectineal lines terminate at the promontory of the sacrum instead of at the sides of the prolapsed body of the last lumbar vertebra. A somewhat similar condition is presented in certain cases of lumbo- sacral kyphosis, particularly in the pelvis obtecta. Under such circum- stances the promontory of the sacrum is destroyed, but a correct diag- nosis can usually be made by carefully palpating the anterior surface of the sacrum and tracing the alae to the body of the first vertebra, which, of course, is impossible in spondylolisthesis. The X-rav is a valuable aid in diagnosis, particularly in slightly developed cases. In such circumstances, it may make possible the recog- nition of a displacement of the last lumbar vertebra too slight to be Fig. 840.—Side View of Author’s Spondylolisthetic Patient, Show- ing Projecting Spine of Last Lumbar Vertebra. 890 PELVIC ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN detected on vaginal examination, as happened in the ease of a patient shown me by my assistant, John G. Murray, Jr. Prognosis.—Generally speaking, spontaneous labor can occur only when the deformity is minimal, and, accordingly, in pronounced cases the outlook is uniformly bad for both mother and child unless radical opera- tive measures be undertaken. Other things being equal, a spondylolis- thetic pelvis offers a worse prognosis than a rhachitic one with the same anteroposterior measurements, for the reason that in the former the inferior strait is also contracted, while in the latter it is usually enlarged. In considering the probable outcome of labor, one should measure the pseudoconjugate with particular care, inasmuch as it, rather than the anteroposterior diameter of the superior strait, usually offers the greatest obstacle to labor. The fact that a patient with spondylolisthesis has had one or more spontaneous labors does not necessarily imply that the labor in question will be uneventful, for the reason that the degree of de- formity frequently increases with age, as happened in my own case. Treatment.—With a pseudoconjugate of more than 8 centimeters, the possibility of spontaneous labor should he borne in mind; but when it falls below that limit cesarean section should be done at an appointed time. In slight degrees of contraction, in which spontaneous delivery has failed to occur, the propriety of pubiotomy may be considered; but in Morisani’s case, as well as in my own, symphyseotomy proved fatal. LITERATURE Barbour. Spinal Deformity in Relation to Obstetrics. Edinburgh, 3883. Boursier de Coudray. Abrege de l’art des accouchements. Paris, 1759. Breisky. Ueber den Einfluss dor Kyphose auf die Beckengestalt. Zeitschr. dor Gcsellsch. der Aerzte in Wien, i, 1865. Breus und Kolisko. Die path. Beckenformen. 1900. Bd. iii, I. Tlieil, Spondy- lolisthesis, 17-159. Kyphosen-Beeken, 163-307. Skoliosen-Becken, 311-352. Kyphoskoliosen-Becken, 355-359. Champneys. The Obstetrics of the Kyphotic Pelvis. Trans. Bond. Obst. Soc., 1883, xxv, 166-194. Ciiantreuil. Etude sur les deformations du bassin chez les cyphotiqucs. These de Paris, 1869. Chiari. Die Aetiologie und Genese der sogenannten Spondylolisthesis lumbo- sacral is. Zeitschr. f. Heilkunde, 1892. Spondylolisthesis. Bull. Johns Hopkins Hospital, 1911, xxii, 41-46. Pelikologische Mittheilungen. Yerh. d. deutschen path. Gesellsehaft, 1912, 318-337. Doktor. Ein Fall von conservativen Kaiserschnitt. Zentralbl. f. Gyn., 1893, xvii, 630-633. Fehling. Pelvis obtecta. Archiv f. Gyn., 1872, iv, 1-33. Goldthwait. The Lumbosacral Articulation, etc. Boston Med. and Surg. Jour., 1911, clxiv, 365-372. IIerrgott. Du spondylizeme. Archives de tocologie, 1877 (Fev.-Mars). Kilian. De spondylolisthesi gravissima; pelvangustiae causa nuper detecta. Bonn, 1853. Klien, Die Geburt beim kyphotischen Becken. Archiv f. Gyn., 1896, 1, 1-128, LITERATURE 891 Konigsteix. Entstehungsweise spondylolisthetischer Bccken. D. I., Marburg, 1871. Lambl. Das Wesen und die Entstehung Spondylolisthesis. Scanzoni’s Bei- trage, 1855, iii, 1-77. Lane. Some of the Changes Which Are Produced by Pressure in the Lower Part of the Spinal Column; Spondylolisthesis, etc. Trans. Loud. Path. Soe., 1885, xxxvi, 364-378. Leopold. Das skoliotische und kypho-skol. rachitische Beckcn. Leipzig, 1879. Weitere Untersuchungen iiber das skoliotische und kypho-skol. rachitische Becken. Archiv f. Gyn., 1880, xvi, 1-23. Morisani. Ancora della Sinfisiotomia. Annali di ost. e gin., 1886, viii, 345-391. Neugebauer. Zur Entwickelunsgesehichte des spondylolisthetischen Beckons und seiner Diagnose. Halle u. Dorpat, 1882. Spondylolisthesis et spondylizeme. Paris, 1892. Die heutige Statistik der Geburten bei Beckenverengerung infolge von Eiick- gratskyphose. Monatsschr. f. Geb. u. Gyn., 1895, 1, 317-347. Bobert. Eine eigenthiimliche angeborene Lordose, etc. Monatsschr. f. Geburtsk., 1855, v, 81-94. Bokitansky. Anomalien der Gestalt des Eiickgrats und seiner Thcile. Lehrbuch der path. Anat., Hi. Autl., 1856, ii, 162-172. Schroeder-Olshausen-Veit. Lehrbuch der Geb., XIIT. Aufl., 1899, 649. Treub. Eecherches sur le bassin cyphotique. Leyden, 1889. Williams. A Case of Spondylolisthesis, with Description of the Pelvis. Amer. Jour. Obst., 1899, xl, 145-171. Spontaneous Labor Occurring through an Obliquely Contracted, Kyphotic, Fun- nel Pelvis. Bull. Johns Hopkins Hosp., 1922, xxxiii, 190-193. CHAPTER XXXVIII PELVIC ANOMALIES RESULTING FROM THE ABNORMAL DIREC- TION OF THE FORCE EXERTED BY THE FEMORA—ATYPICAL DEFORMITIES Normally, in the case of an individual standing erect, the upward and inward force exerted by the femora is of equal intensity on either side, and is transmitted to the pelvis through the acetabula. In walking or running the entire body weight is transmitted alternately first to one and then to the other leg. On the other hand, in a person suffering from disease affecting one leg, the sound one has to bear more than its share of the body weight, and consequently the upward and inward force exerted by the femur is, as a rule, greater upon that side of the pelvis. To these mechanical factors are due the changes in shape which accom- pany certain forms of lameness, provided that the lesion, which gives rise to the latter, appears at an early period of life while the pelvic bones are still in a formative state. The defect may be either unilateral or bilateral; in the former case it is usually due to coxitis, luxation of the femur, infantile paralysis, or shortening of one leg from various causes, while in the latter case com- mon causes are luxation of both femora and double club-foot. These conditions have been studied in detail by Prouvost, in whose article, as well as in the chapters of Tarnier and Budin, and of Breus and Kolisko upon the subject, full literature is to be found. PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS Coxalgie Pelvis.—Coxitis occurring in early life nearly always gives rise to an obliquely contracted pelvis. If the disease makes its appear- ance before the patient learns to walk, or if the child is obliged to keep to its bed for a prolonged period, the entire organism may suffer from imperfect development, which also manifests itself in the pelvis and leads to the production of the generally contracted, or justominor type, to which are added the mechanical effects and atrophic changes resulting from the unilateral disease. These are manifested by imperfect develop- ment of the diseased side of the pelvis, the innominate bone being smaller than its fellow and the iliopectineal line forming the arc of a circle having a smaller radius than upon the well side. At the same time, the sacral alae are less developed upon the affected side, and the entire bone is somewhat rotated about its vertical axis, so that its anterior surface looks toward the well side (Fig. 641, A and B), 892 PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS 893 When the individual begins to stand, owing to the actual shortening of the diseased leg or to fear of placing it firmly upon the ground, the Fig. 641.—Diagram Showing Coxalogic Pelvis, A, before and, B, after the Individ- ual Has Walked. Fig. 643. Fig. 644. Figs. 642-644.—Coxalgic Pelvis with Ankylosed Femur. body weight is transmitted in great part to the well leg. As a result the pelvis become obliquely tilted, being higher on the well side, and a com- 894 PELVIC ANOMALIES—ATYPICAL DEFORMITIES pensatory scoliosis appears. At the same time the upward and inward force exerted by the femur tends to push the well side of the pelvis up- ward, inward, and backward, whereby the iliopectineal line is markedly flattened and the asymmetry of the sacrum still further increased, thus giving rise to an obliquely contracted pelvis. The contraction is not limited to the superior strait, but involves the lower portion of the Fig. 645. Figs. 645-647.—Obliquely Contracted Pelvis, Due to Unilateral Luxation of Femur. Fig. 646. Fig. 647. pelvis as well, the spine and tuberosity of the ischium being displaced toward the middle line. Not uncommonly these changes are accompanied by irritative proc- esses at the sacro-iliac articulations, which may eventually lead to anky- losis. As a general rule, the oblique contraction is to be found on the well side of the pelvis, but, according to Tarnier, and Briggs, the reverse is the case when the affected leg is ankylosed in a position of adduction and internal rotation (Fig. 642). Oblique contraction of the pelvis may also develop when unilateral luxation of the femur occurs in early life, although they are usually PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS 895 less pronounced than those following coxitis. Under such circumstances the head of the bone is displaced backward and upward upon the outer surface of the ilium, where a new joint surface may occasionally be formed. The affected leg becomes considerably shortened, and accord- ingly an undue share of the body weight is transmitted through the well leg, which forces the corresponding side of the pelvis upward, inward, and backward, and leads to an oblique contraction, just as in coxalgia. Unless the patient has had the benefit of proper orthopedic treat- ment in unilateral infantile paralysis, and in those cases in which disease at the knee- or ankle-joint or amputation early in life has caused shortening of one leg, similar changes occur in the pelvis, though it rarely assumes the extreme degree of obliquity which characterizes the coxalgic variety. Diagnosis.—A limping gait at once suggests an obliquely contracted pelvis, and when, upon questioning the patient, it is found that the con- dition has been present since early childhood, the existence of pelvic de- formity upon the side corresponding to the sound leg becomes highly probable. More accurate information can be obtained by careful examination and noticing the relative position of the iliac crests and the presence or absence of compensatory scoliosis, and finally an absolute diagnosis can be arrived at by the employment of the measurements suggested by Naegele for the detection of the obliquely contracted pelvis due to im- perfect development of the sacral alae. An accurate conception con- cerning the degree of contraction, however, can be obtained only by careful exploration of the interior of the pelvis, preferably with the patient under the influence of an anesthetic, although in many coxalgic patients this may be extremely difficult on account of the ankylosis of one leg. X-ray pictures, of course, afford valuable confirmatory infor- mation. Effect upon Labor.—The effect of this type of pelvis upon labor varies with the extent and position of the deformity. If the affected side is so contracted as to prevent its being occupied by a portion of the presenting part, we have for all practical purposes a generally contracted pelvis, and engagement, if it can occur at all, will take place more readily when the biparietal diameter of the head is in relation with the long oblique diam- eter of the superior strait. But even after descent has occurred, all ob- stacles to labor have by no means been overcome, since in many cases the inward projection of the ischium may lead to abnormalities in rotation. Generally speaking, these pelves are not excessively con- tracted, Prouvost reporting that 40 out of the 50 cases of labor com- plicated by them ended spontaneously. Treatment.—Although the pelvic contraction is usually not very pro- nounced, serious dystocia may occur. For this reason the patient should be examined under anesthesia during the last weeks of pregnancy and the entire interior of the pelvis carefully palpated. If it appears probable that engagement will not occur, cesarean section should be performed before the onset of labor. Fortunately, this is rarely indicated, unless the foetus is large, or the history of previous labors has shown that the 896 PELVIC ANOMALIES—ATYPICAL DEFORMITIES birth of a living child is out of the question. When the obstacle to the engagement of the head is not serious, version gives better results than forceps. This is especially true in coxalgic pelves when the ankylosed leg and asymmetry of pubic arch may make the application of the latter extraordinarily difficult. Pubiotomy is not a justifiable operation in coxalgic pelves, as we have no means of deter- mining in advance whe- ther the sacro-iliac syn- chondroses are synos- tosed; and if such be the case the operation cannot lead to a satisfactory in- crease in the capacity of the pelvic canal. Coxarthrolisthetic Pel- vis. Very exceptionally as the result of localized softening in the region of the acetabulum, the base of one or both acetabula yields to the pressure exerted by the head of femur, and projects into the pelvic cavity, thus leading to a uni- or bi- lateral transverse con- traction, which when pro- nounced may give rise to serious dystocia. Ep- pinger, who studied the condition exhaustively in 1903, designated such pelves as coxarthrolis- thetic, and attributed their production to de- layed and deficient ossification of the base of the acetabulum. The deformity was known to A. W. Otto as early as 1824, and Breus and Kolisko have shown that it is usually dependent upon gonorrheal coxitis, instead of upon arthritis deformans or tubercular processes, as was for- merly believed. Chiari, however, in 1912, described a specimen which he held resulted from tabetic arthritis. The condition is rare, and Waller succeeded in collecting only 16 cases up to 1922. PELVIC DEFORMITY DUE TO BILATERAL LAMENESS Occasionally children are born with luxation of both femora, the heads of the bones lying, as a rule, upon the outer surfaces of the iliac bones, above and posterior to their usual situation. In some cases the I'ig. 648.—-Side and Rear View of Patient with Bilateral Luxation of Femora. PELVIC DEFORMITY DUE TO BILATERAL LAMENESS 897 acetabula are entirely absent, but more frequently they are present in a rudimentary condition, new but imperfect substitutes being formed higher up. Strange to say, the condition does not usually seriously in- terfere with the individual in the matter of learning to walk at the usual age, though the gait is more or less wabbly. The pelvic changes resulting from this condition have been studied particularly by Kleinwachter, Schauta, and Sassmann, the latter writer having collected 27 cases from the literature. Owing to the fact that the upward and inward force exerted by the femora is not applied in its usual direction through the acetabula, the pelvis becomes unduly wide, and more or less flattened anteroposteriorly. The transverse widening is particularly marked at the in- ferior strait, while the flatten- ing, as a rule, is not very pro- nounced. Thus, the conjugata vera usually measures between 9 and 10 centimeters, and Del- mas, after studying 17 cases, concludes that the various di- ameters are usually enlarged unless the condition is compli- cated by some other abnormal- ity. Hence, this pelvis rarely offers any serious obstacle to labor. The patient presents a characteristic appearance, which is suggestive of that ob- served in spondylolisthesis. Owing to the displacement of the femora the trochanters are more prominent than usual, and the width of the buttocks is increased. At the same time, owing to the increase in the pelvic inclination, there is marked lordosis, the back of the patient appearing considerably shortened and presenting a marked saddle-shaped depression just above the sacrum. Meyer described a pelvis obtained from an individual who had double club-foot, and found that it was markedly funnel-shaped. This condition he attributed to the absence of the usual spring at the foot and ankle-joints, and to the fact that the knees were held fixed during walking. Accordingly, with each step a distinct shock was imparted to the acetabula, instead of the more gentle force which is exerted under ordinary circumstances. Fig. 649.—Obstruction of Pelvic Canal by Cystic Enchondroma (Zweifel). 898 PELVIC ANOMALIES—ATYPICAL DEFORMITIES ATYPICAL DEFORMITIES OF THE PELVIS In rare instances the pelvis may be more or less deformed by the presence of bony outgrowths at various points, and less frequently by tumor formations. Exostoses are most frequently observed upon the posterior surface of the symphysis, in front of the sacro-iliac joints, 01 upon the anterior surface of the sacrum, though in occasional cases they may be formed along the course of the iliopectineal line. Kalian, in 1854, directed attention to the fact that such structures may form sharp, more or less knifelike projections. He designated the condition as acananthopelys or pelvis spinosa. Such formations are rarely sufficiently large to offer any obstacle to labor, but owing to their peculiar structure may do considerable injury to the maternal soft parts. In fact, in several of the cases reported, they have cut through the lower portion of the uterus. In rare instances callus formation, resulting from inflammatory processes within the pelvis, may attain such proportions as to lead to serious pelvic ob- struction, as in a case reported by Ahlfeld. Tumor formations of various kinds may spring from the walls of the false or true pelvis and so obstruct its cavity as to render labor impossible. Fi- bromata, osteomata, enchondromata, carci- nomata, and osteosarcomata of the pelvis have been described, and some- times assume very considerable proportions, and occasionally become cystic. Stadfeld was able to collect 49 such cases in 1879, and Goder 81 cases in 1895. Enchondromata occur more frequently than other varieties of tumor formation, Schopping being able in 1907 to collect 33 well-described cases from the literature. He pointed out that such tumors grow especially rapidly during pregnancy and give rise to serious dystocia; 21 cesarean sections and 3 destructive operations being neces- sary in his series of cases. Unless cesarean section is performed, the prognosis is very grave when the pelvis is obstructed by tumors from its walls, 50 per cent, of the mothers and 89 per cent, of the children having perished in the cases collected by Stadfeld, while in only 11 cases was labor terminated by spontaneous delivery, forceps, or version. In rare instances healed fractures of the pelvis may offer an in- superable obstacle to the birth of the child, owing either to an excessive formation of callus or to the projection of the broken ends of the bones Fig. 650.—Fractured Pelvis (Mars). LITERATURE 899 into the pelvic cavity. This condition, however, is very rare, as it is stated that only 0.8 per cent, of all fractures involve the pelvis, and in such cases the internal injuries are usually so severe as to lead to the death of the patient, so that only a small proportion of such women survive, and very few of them become pregnant. The effect upon labor depends upon the location of the fracture and its manner of healing. Fig. 651 shows a pelvis described by Mars, and gives an idea of the extent of the changes which sometimes result. In a case reported by Neugebauer, in which there was a transverse fracture of the second sacral vertebra, the vertebral column prolapsed into the pelvic cavity and gave rise to a deformity suggestive of spondylolisthesis. For further details the reader is referred to the articles of Schauta, Tarnier, Meurers, and Breus and Kolisko. Ahlfeld. Das durch Knochenauswiichse vcrengte Becken. Lehrbuch der Geburts- hiilfe, II. Aufl., 1898, 336. Breus und Kolisko. Coxitis-Becken. Die path. Beekenformen. Leipzig u. Wien, 1912, iii, 474-593. Briggs. The Coxalgic Pelvis. J. Obst. and Gyn. Brit. Emp., 1914, xxvi, 212-215. Chiari. Pelikologische Mittlieilungen. Verh. d. deutschen path. Gesellsch., 1912, xi, 318-337. Delmas. Sur l’anatomie obst. du bassin a luxation coxo-femorale congenitale double. L’obstetrique, 1911, N. S. iv, 729-746. Eppinger. Pelvis-Chrobak, Coxarthrolisthesis-Becken. Beitrage z. Geb. u. Gyn. Wien, 1903, ii, 173-235 (Chrobak’s Festschrift). Goder. Yon dein Becken ausgehende Tumoren als Geburtshinderniss. D. I., Halle, 1896. Kilian. Das Stachelbecken (Akanthopelys) ; Schilderungen neuer Beekenformen. Mannheim, 1854, 59-114. Kleinwachter. Das Luxationsbecken, etc. Prager Vierteljahrsschr. f. Heil- kunde, cxviii, cxix. Mars. Schragverengtes Becken infolgc einer Fractur. Archiv f. Gyn., 1889, xxxvi, 289-300. Meurers. Beitrag zur geb. Bedcutung der Frakturbecken. D. I., Heidelberg, 1904. Prouvost. Etudes sur les bassins vicies par boiterie. These de Paris, 1891. Sassmann. Das Becken bei angeborener doppelseitiger Huftgelenksluxation. Archiv f. Gyn., 1873, v, 241-267. Schauta. Miiller’s Handbuch d. Geb., 1889, ii. Die Beekenformen bei doppelseitiger Luxation der Schenkelkopfe, 466-472. Die Beckenform bei Klumpfuss, 472-473. Schopping. Das Becken-enchondrom, besonders als Geburtshinderniss. Monats- schr. f. Geb. u. Gyn., 1907, xxv, 845-874. Stadfeld. Die Geburt bei Geschwiilsten des Beckens. Zentralbl. f. Gyn., 1880, iv, 417-420. Tarnier et Budin. Traite de l’art des accouchemerts. Paris, 1898, iii. Malformations du bassin dans la claudication, 229-278. Deformations atypiques du bassin, 338-352. Waller. Ein Becken von Otto-Chrobak mit fractura acetabuli. Deutsche Zeitschr. f. Chirurgie., 1922, clxviii, 19-36. LITERATURE CHAPTER XXXIX DYSTOCIA DUE TO ABNORMALITIES IN DEVELOPMENT OR PRESENTATION OP THE FOETUS EXCESSIVE DEVELOPMENT As was stated in Chapter V, the child at birth rarely exceeds 11 pounds (5,000 grams) in weight, though authentic accounts of much larger infants are to be found in the literature. Provided the pelvis is not contracted, it is very exceptional for a normally formed child, weighing less than 10 pounds (4,500 grams), to give rise to dystocia by its mere size. In overdeveloped children the difficulty is generally due to the fact that the head tends to become not only larger but harder, and consequently less malleable, with increas- ing weight; although it sometimes happens that after the head has passed through the pelvic canal without difficulty the dystocia may be due to the arrest of the unusually large shoulders either at the pelvic brim or outlet. Excessive development of the foetus can unusually be traced to one of four causes: prolongation of pregnancy, large size of one or both parents, advancing age, or multiparity of the mother. Cases in which three hundred days or more elapse between the last menstrual period and the onset of labor are not uncommon, and in the case of Gaskill versus Gaskill the English Courts in 1921, after hearing competent expert testimony, decided that a child was legitimate which had been born 331 days after the last coitus. Oyamada states that the possibility of prolonged pregnancy was present in 11 per cent, of the 932 children born in the Munich clinic between the years 1885 and 1910 whose weight exceeded 9 pounds (4,000 grams). In the majority of such cases, however, the prolongation is only apparent, and is dependent upon the forgetfulness of the patient concerning the date of the last menstruation. In this event, however, the size of the child does not greatly exceed the average. On the other hand, actual pro- longation occasionally occurs, and I can recall several cases in which eleven lunar months had elapsed between the last menstrual period and the birth of an excessively large child. In such circumstances serious dystocia may arise, inasmuch as the child may increase in size for each day beyond full term that it remains in the uterus. Accordingly, whenever labor fails to occur within a few days of the calculated date, the patient should be carefully examined twice each week, and labor induced as soon as one is convinced that full development has been attained. 900 EXCESSIVE DEVELOPMENT 901 More frequently the excessive size of the child is due to the fact that one or both of its parents are unusually large; moreover, it is a matter of common observation that the foetal head in many instances resembles that of its father, large-headed men usually producing children with similar characteristics. Likewise, the age of the mother may have an important influence upon the foetal development. Thus, the children of elderly primiparae frecpiently exceed the ordinary average, and in multiparae the children are often larger with each successive pregnancy, provided they do not follow in too rapid succession. As a rule, large children have well ossified skulls. This is more par- ticularly true for males, in whom the biparietal diameter is usually some- what greater than in female children of the same weight. In such cases the inability of the head to become molded not only interferes with its engagement, but predisposes to certain injuries, such as spoon-shaped depressions of the skull, if artificial delivery becomes necessary. Although, in the case of a normal pelvis, a moderate increase in the size of the child is usually without great practical significance, when any degree of contraction exists such a condition may make all the differ- ence between an easy and a difficult labor. At the same time, in mul- tiparous women the dystocia is often due in great part to the loss of tone of the uterine musculature incident to repeated childbearing. On the other hand, it should always be remembered that quite as serious dystocia may arise when an excessively large head attempts to pass through a normal pelvis, as when a head of average size is arrested by a markedly contracted superior strait. Inasmuch as our means of determining the size of the child, and par- ticularly of its head, are far from accurate, the diagnosis of excessive de- velopment is, as a rule, not established until after fruitless attempts at delivery have been made. Nevertheless thorough examination, in which careful palpation and Muller’s method of impression are employed, should ordinarily enable the trained obstetrician to arrive at fairly ac- curate conclusions and prepare him to meet this complication. If the pelvis is normal the failure of engagement in the last weeks of pregnancy in a primipara, or the existence of a face, brow, or transverse presenta- tion, should suggest the possibility of excessive size of the child. Treatment.—If the patient has apparently gone beyond term, and examination shows that the size of the child is above the average, there should be no hesitancy in the immediate induction of labor as a prophy- lactic measure. In multiparous women with normal pelves whose history shows that excessive foetal development was the cause of the previous difficult labors, the size of the child may occasionally be regulated by restricting the use of carbohydrates during the last two months of preg- nancy. If this does not have the desired result, labor should be induced as soon as the child has attained a normal size. On the other hand, if the pregnancy is not prolonged, the condition is rarely suspected by the ordinary practitioner before the outset of labor, and the diagnosis is made only after Nature has shown that she is unable to effect delivery. It is, however, exactly in this type of case that the benefits of efficient prenatal care becomes manifest. If the patient is carefully palpated 902 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS at intervals during the last months of pregnancy, and weekly if the child is not born within one week following the calculated date of de- livery, excessive size of the child will rarely escape recognition. In several instances, I have done cesarean section solely on that account, and every few weeks I induce labor when the child has attained some- what more than the average size, because I feel that it is irrational to allow it to grow sufficiently large to cause actual dystocia. Zangemeister and Lehn in 1918 studied the obstetrical significance of excessively large children, and, while they found that ordinarily a weight less than 4,500 grams (10 pounds) does not give rise to dystocia, they stated that the chances of the child being born alive decrease progressively with each additional 500 grams. Accordingly, prophylactic treatment is the ideal in these, as well as in so many other obstetrical, circumstances. If, however, the complication has not been recognized until the patient is well advanced in labor, it is often difficult to de- termine the best method of procedure. If examination shows that the head is not engaged and that the disproportion is excessive, the propriety of cesarean section or pubiotomy should be considered, provided that unavailing attempts at delivery have not been made. On the other hand, if physicians with questionable technic have failed to effect de- livery by forceps or version, radical surgical interference is contra- indicated, and craniotomy becomes our sole resource. When excessive size of the shoulders prevents the delivery of the child after birth of the head, labor can often readily be terminated after diminishing the size of the shoulder girdle by cutting through the clavi- cles with a pair of heavy scissors—cleidotomy. MALFORMATION OF THE FCETUS Double Monsters.—For practical purposes 3 groups of double mon- sters may be distinguished: (1) Incomplete double formations at the upper or lower half of the body (diprosopus, dipagus) ; (2) twins which are united together at the upper or lower end of the body (craniopagus, ischiopagus, or pygopagus) ; (3) double monsters which are united by the trunk (thoracopagus and dicephalus). The diagnosis of any one of these conditions is not made until diffi- culty experienced in attempting delivery has led to careful exploration under anesthesia with the entire hand in utero, although the existence of a multiple pregnancy may have been suspected. As such monstrosities frequently present minor deformities as well, the detection of a club- foot, hare-lip, etc., should direct one’s attention to the possible existence of some still more serious abnormality. Fortunately the delivery of many monstrosities is much more readily accomplished than would appear possible at first sight. In the first place, such pregnancies rarely go on to full term, so that the monstrosity rarely exceeds a normal child in size. In the second place, the connec- tion between the two halves is often of such a character as to permit of sufficient motility between the component parts as will make their successive delivery possible. DEFORMITIES OF FCETUS 903 On the other hand, in the first group the large size of the doubled portion of the monster may lead to serious mechanical obstacles at the time of delivery. The fused head in a diprosopus is, as a rule, much more readily delivered when it forms the after-coming part than when it presents primarily. In the second group a craniopagus presenting by the head usually causes only a moderate amount of difficulty; whereas, on the other hand, ischiopagi and pygopagi, as a rule, call for complicated and difficult maneuvers before delivery can be effected. In the third group, the delivery of dicephalic monsters is facilitated when they present by the breech, as in many cases first one and then the other head can be extracted. On the other hand, in cephalic presen- tations the two heads may mutually interfere with one another and thus prevent engagement until one has been diminished in size by craniotomy. When engagement of one head occurs delivery can be partially effected by forceps, but as a rule the head cannot be delivered beyond the pubic arch for the reason that further descent is prevented by the arrest of the second head at the superior strait. Under such circumstances it is advisable to amputate the first head, after which delivery of the rest of the monster is, as a rule, best accomplished by version. Thoracopagi usually offer a less serious obstacle to delivery, for the reason that they are frequently so loosely connected with one another that considerable motility is possible. Indeed, it is not unusual for the two children to present in a different manner. When possible, it is advis- able to bring down all four feet at the same time, and to effect extraction in such a way that the posterior head is first delivered. In cephalic presentations the head and body of the first child are expelled, and the second child is then born very much as in an ordinary twin pregnancy. If, however, the latter presents transversely, its delivery can be effected only by version and extraction. DEFORMITIES OF FfETUS In this place attention will be directed only to those abnormalities in foetal development which may give rise to difficult labor. An acardiacus is a monster which is sometimes developed in single-ovum twin pregnan- cies as the result of inequalities in the communicating placental circula- tion. One twin is well developed and normal, while the other is im- perfectly formed, and either possesses a rudimentary heart or no heart at all, being designated according to Kehrer as hemiacardius or holo- acardius, respectively. The genesis of such conditions was considered in the chapter on Multiple Pregnancy. The holoacardiac monsters may occur as acephali, amorphi, or acormi. Of these the most common variety is the acephalicus or headless foetus. Less common is the amorphous monster, which possesses neither a head nor extremities, but is round in shape and presents upon its surface a number of small nodules, which represent the rudimentary extremities. The umbilical cord may be attached to any portion of its surface. The interior of the monstrosity contains a rudimentary intestinal tract, 904 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS cystic cavities, vertebrae, etc., but no trace of a heart. The rarest variety of acardiacus is the acormus or trunkless monster, which consists of an imperfectly developed head and a rudimentary body, the umbilical cord being attached to the cervical region. As a rule such monsters do not attain any notable size, although ex- ceptionally, as the result of obstruction in the umbilical vein, they may become edematous and give rise to dystocia. The anencephalus or hemicephalus is a monster possessing a trunk, but only an imperfectly developed head, from which a large part of the brain and skull is lacking. Ordinarily such beings are of moderate size, but occasionally the shoulders may be so excessively developed as to give rise to serious dystocia. Owing to the absence of the cranial vault the face is very prominent and somewhat extended, the eyes often protrude markedly from their sockets, and the tongue hangs from the mouth. The brain is in a rudi- mentary condition, and the base of the skull is accessible to the examin- ing finger, so that the sella turcica can be distinguished. Owing to the exposed condition of the base of the brain and the upper part of the medulla, there is frequently a marked increase in the amount of amniotic fluid, its production being analogous to that noted in the picure experi- ments of the physiologists. In view of the abnormal shape of the head, face presentations are frequently observed, while those of the vertex are less common than with a normal foetus. Transverse and foot presentations are likewise not unusual. When the monstrosity presents by the face or head a correct diagnosis is frequently made by vaginal touch, the characteristic bulging of the eyes being noted in the former, and the absence of tbe cranial vault and the presence of the sella turcica in the latter presen- tation. Delivery, as a rule, occurs much more readily when the monster pre- sents by the breech, for the reason that the imperfectly developed head is not an efficient dilating agent, though in many cases rapid and spontaneous delivery is observed. Even when the enlarged shoulders give rise to dystocia, delivery can usually be accom- plished by means of version without any great difficulty. Fig. 651.—Anencephaltjs. HYDROCEPHALUS Ill this not very rare condition, the cerebral ventricles are distended by an excessive amount of cerebrospinal fluid (Fig. 652), which, accord- ing to the researches of Dandy and Blackfan, is due to the obliteration HYDROCEPHALUS 905 of Magendie’s foramen. As a result, the skull becomes much increased in size, frequently attaining several times its normal dimensions, while the brain substance forms a layer only a few millimeters thick beneath it, but occasionally it has entirely disappeared, except for a few tags of tissue in the neighborhood of the central ganglia. At the same time the cranial bones are imperfectly developed, the sutures and fontanelles being much wider than usual. If the enlarged head is not tensely filled with fluid, under the influ- ence of the uterine contractions it may undergo such changes in shape that its spontaneous expulsion becomes possible. This, however, is so rare a possibility that it should not be reckoned with in determining the treatment to be pursued in a given case. Still less frequently, owing to the pressure to which the head is subjected at the time of labor, the tissues forming a fontanelle or suture may give way, so that the cerebro- spinal fluid can escape, after which the head collapses and spontaneous delivery becomes possible. In the vast majority of cases, however, the condition gives rise to serious dystocia, which if not promptly relieved will lead to rupture of the uterus and the death of the patient from intra-abdominal hemor- rhage. Fig. 652.—Dystocia Due to Hydrocephalus (Bumm). In hydrocephalic children, although cephalic presentations predomi- nate, owing to the lack of accommodation between the head and the pelvic canal, the breech is often substituted. Diagnosis.—As a rule the condition is not recognized until several hours of fruitless second-stage pains have demonstrated the existence of an obstacle to delivery. On the other hand, careful examination should ordinarily lead to a correct diagnosis during the last weeks of pregnancy or soon after the onset of labor. In many cases the deformity can be detected by external palpation, the immensely large and movable head being isolated above the superior strait or in the fundus of the uterus. Furthermore, the examiner should always be on the lookout for the 906 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS presence of fluctuation, while a peculiar crackling sensation can be elicited by pressure upon the skull. I have made a positive diagnosis in this manner upon several occasions without an internal examina- tion. As soon as the cervix is dilated, vaginal examination will reveal a large head with widely gaping sutures, through which fluctuation can be obtained by appropriate maneuvers. Of course this does not hold good in breech presentations, hut here abdominal palpation will reveal the presence of the large fluctuant head in the fundus of the uterus, or just above the superior strait, in case attempts at extraction have been made. Prognosis.—For the child the outlook is uniformly bad, for even if born alive it usually succumbs within a few days, or, in the rare cases in which it survives, grows up a hopeless idiot. The maternal prognosis depends largely upon the obstetrician. If left to Nature the usual ter- mination is rupture of the uterus ; whereas, if the condition be detected and the proper treatment instituted, the results are almost universally favorable. Treatment.—As soon as the cervix has become completely dilated the head should be perforated through one of the wide sutures, in order that the cerebrospinal fluid can escape and the skull collapse, after which de- livery can be effected by the unaided efforts of Nature, or may be accelerated by the employment of the cranioclast. In breech presenta- tions, when the head has been arrested at the superior strait, evacuation of its contents can be readily effected by excising the arch of one of the cervical vertebrae and passing a catheter through the vertebral canal. On account of the nature of the disease and its effect upon the child, craniotomy may be undertaken without hesitancy, even by those who ordinarily do not consider it a justifiable procedure. In evacuating the hydrocephalic head, it should be borne in mind that, owing to the extreme thinness of the brain, mere perforation is not necessarily synonymous with foetal death. For this reason the perforator should be carried to the base of the skull and vigorously manipulated in order to destroy the medulla, as nothing could be more horrible than the extraction of a living child after such an operation. ENLARGEMENT OF THE BODY OF THE FOETUS Enlargement of the abdomen sufficient to cause grave dystocia is usually the result of ascites, a very much distended bladder, or of tumors of the kidneys or liver. Whenever the abdominal distention is excessive spontaneous labor is out of the question; but unfortunately the condition usually escapes de- tection until fruitless attempts at delivery have demonstrated the exist- ence of some obstruction and have led the obstetrician to introduce his entire hand into the uterus in the hope of discovering its nature. Occasionally a foetus affected with general dropsy may attain such immense proportions that spontaneous delivery is impossible. A number ENLARGEMENT OF THE BODY OF THE FCETUS 907 of such cases are recorded in the monographs of Ballantyne, Schumann, and Dorland. In very rare instances the ascites associated with fatal peritonitis may have a similar result, and exceptionally a child suffering from chondro dystrophia fatal in may become so edematous as to give rise to dystocia. As the result of the di- latation of the superficial lymphatics associated with edema of the subcutaneous tissues, the foetus may as- sume immense proportions and take on a bizarre shape. This condition, which is designated as elephantiasis congenita cystica, has been studied in detail by Ballan- tyne, and is a very rare cause of difficult labor (Fig. 653). Defective development of the lower portion of the urinary tract may lead to the retention of urine ac- companied by distention of the abdomen sufficient to render normal delivery im- possible (Fig. 654). Ex- amples of this condition have been reported by Walther, Schwyzer, and others, wffio also give details as to its etiology. A more frequent cause of abdominal enlargement is the presence congenital cystic kidneys. The growth, which is histo- logically an adenocystoma, may involve one or both organs, and give rise to tumors of immense size. The condition is frequently associated with dilatation of che ureters, and with dropsical effusions into the various body cavities. Fig. 655 gives an idea of the extent of the abdominal enlargement in a child which I delivered, and which was described by Lynch in 1906, together with an analysis of 50 other cases reported in the literature. In rare cases the abdominal enlargement may be due to tumors of the liver, Porak and Couvelaire having reported a case of congenital cystic liver associated with a similar condition of the kidneys. More- over, large tumors, arising from any of the abdominal organs, may give rise to dystocia. Thus, Bogers has described an immense fibrocystic testicle, and Phaenomenow an aortic aneurysm so large as to interfere with delivery. In rare instances foetal inclusions, such as the so-called Fig. 653.—Elephantiasis Congenita Cystica (Ballantyne) 908 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS foetus in fcetu, may be responsible. Occasion- ally the invasion by Bacillus aerogenes cap- sulatus may be followed by such an extensive production of gas that the size of the foetus be- comes more than doubled, when spon- taneous delivery is im- possible. In all of these con- ditions, if the dystocia is marked, delivery can be accomplished only after opening the body of the foetus and allow- ing the fluid to escape, or removing a portion, at least, of the offending tumor formation. The latter operation is not always easy, for, owing to the constrained position of the hand in utero and the dense consistency of the growth in many cases, great difficulty may be experienced. In rare instances abnormal growths aris- ing from various por- tions of the body of the foetus may inter- fere with delivery. Cases are on record in which lipomata, car- cinomata, angiomata, and various other tumors have given rise to such an en- largement that spon- taneous delivery be- came out of the ques- tion. Exceptionally, dermoid cysts and teratomatous tumors about the perineum and sacrum may offer a serious obstacle. Fig. 275 represents a foetus Fig. 654.—Fcetus with Immensely Distended Bladder (Hecker). Fig. 655.—Fcetus with Congenital Cystic Kidneys. DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 909 in which an adenoma of the thyroid gland necessitated a destructive operation. In rare instances, a large umbilical hernia, a spina bifida, and other growths give rise to difficult labor. DYSTOCIA DUE TO ABNORMAL PRESENTATIONS OF THE FCETUS Transverse Presentations.—In this condition the long axis of the foetus crosses that of the mother at about a right angle. When it forms an acute angle we speak of an oblique presentation. The latter, however, is usually only transitory, becoming converted into a longitudinal or transverse presentation when labor supervenes. In transverse presentations the shoulder usually occupies the superior strait, the head lying in one and the breech in the other iliac fossa Fig. 656.—Diagram Showing Left Acromion Dorsoposterior Presen- tation. Fig. 657.—Diagram Showing Right Acromion Dorso-anterior Presen- tation. (Figs. 656 and 657). Accordingly, such a condition is commonly spoken of as a shoulder, less frequently as a lateral plane, and technically as an acromion presentation. The latter designation is chosen for the reason that the acromion process is one of the most characteristic features of the shoulder, the position being right or left according to the side of the mother toward which the acromion is directed. Moreover, as, in either position, the back may be directed either anteriorly or posteriorly, it is customary to distinguish between the dorso-anterior and dorso- posterior varieties. The recognition of the position of the back is of great importance in connection with the proper performance of version— the treatment par excellence in this condition. According to Schroeder, the shoulder is directed toward the left side of the mother 2.6 times more frequently than toward the right, while the back looks anteriorly 2.5 times more frequently than posteriorly. Etiology.—The existence of a transverse presentation in a primipa- rous woman is prim a facie evidence of a lack of accommodation, usually the result of disproportion between the size of the head and the pelvis, though occasionally it may be due to hydramnios. In multiparae, on 910 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS the other hand, the most frequent etiological factor is abnormal relaxa- tion of the abdominal and uterine walls, the result of repeated child- bearing, which may be still further complicated by any of the causes already enumerated. Accordingly, transverse presentations are much more frequently observed in women who have borne a number of chil- dren, but in them, as a rule, the condition is less serious, for the reason that spontaneous reposition sometimes ensues after the onset of labor, the child assuming a longitudinal presentation—spontaneous version— whereas such an occurrence is very exceptional in primiparae. The occurrence of spontaneous version is very improbable after rup- ture of the membranes, and is still further hampered by any condition which interferes with the descent or engagement of the head; as, for example, a contracted pelvis, placenta previa, a pelvic tumor, or twin pregnancy. Very exceptionally, longitudinal may become converted into secondary transverse presentations at the time of labor, and such an occurrence is always indicative of disproportion between the size of the child and the pelvis. Diagnosis.—The diagnosis of a transverse presentation is usually readily made, inspection alone frequently causing one to suspect its existence. The abdomen is seen to be unusually wide from side to side, while the fundus of the uterus scarcely extends above the umbilicus. On palpation the first maneuver reveals the absence of a foetal pole from the fundus. On the second maneuver a ballottable head will be found in one and the breech in the other iliac fossa, while the third and fourth maneuvers are negative, unless labor has been in progress for some time and the shoulder has become impacted in the pelvis. At the same time the position of the back is readily determined. When it is situated anteriorly a hard resistant plane will be felt extending across the front of the abdomen; when it lies posteriorly irregular nodu- lations, representing the small parts, will be felt in the same location (Plate XY). On vaginal touch in the early stages of labor, the side of the thorax, readily recognizable by the “gridiron” sensation afforded by the ribs, can be made out at the superior strait. When dilatation is further advanced the scapula can be distinguished on one and the clavicle on the other side of the thorax, while the position of the axilla will indicate toward which side of the mother the shoulder is directed. Later in labor the shoulder becomes tightly wedged in the pelvic canal, and a hand and arm fre- quently prolapse into the vagina; whether it is the right or left can be readily determined by ascertaining to which one of the obstetrician’s it corresponds, just as in shaking hands. Course of Labor.—With very rare exceptions the spontaneous birth of a fully developed child is impossible in persistent transverse presenta- tions, since expulsion cannot be effected unless both the head and trunk of the child enter the pelvis at the same time, which is manifestly impos- sible. Accordingly, both the foetus and mother must almost inevitably perish if appropriate measures are not instituted. On the other hand, small premature, and particularly macerated, children are frequently born spontaneously. PLATE XV. PALPATION IN RIGHT ACROMIO-DORSO-ANTERIOR PRESENTATION. DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 911 Throughout the first stage, but particularly during the early period of the second stage of labor, preliminary, but futile, preparations are made for spontaneous delivery. These consist of a molding of the foetus in anticipation of the engagement of the presenting shoulder, which results in the approximation of the head to the ventral surface of the child, by which the transverse diameter of the foetal ovoid becomes diminished and the vertical diameter increased in length (Fig. 659). After rupture of the membranes, if the patient is left to herself, the shoulder is forced down into the pelvic cavity, and the corresponding arm Fig. 658.—Frozen Section through Woman Dying in Labor with a Neglected Transverse Presentation (Chiara). frequently prolapses. After a certain amount of descent, the shoulder becomes arrested by the margins of the superior strait, with the head in one iliac fossa and the breech in the other, and with the continuance of labor becomes firmly impacted in the upper part of the pelvic cavity (Fig. 658). The uterus then contracts vigorously in the attempt to overcome the obstacle, but in vain. After a certain time the contraction ring rises higher and higher, the lower uterine segment becomes more and more stretched and eventually gives way, when a part or the whole of the product of conception escapes into the abdominal cavity. In such circumstances the patient usually succumbs within a short time to intra- peritoneal hemorrhage, while in other instances death occurs after a longer or shorter period from infection. Possibly once in many thousand cases, the uterus may cease to con- tract before the membranes rupture, and the child, being retained within the uterus, may eventually become mummified. Such a missed labor is very rare in human beings, though it is well known to the veterinarians. On the other hand, such an occurrence would be out of the question had the amniotic sac been opened, as in such circumstances bacteria would gain access to the uterus and give rise to infection, which, if not ter- minating in the death of the patient, would lead to the gradual casting 912 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS off of the product of conception by suppurative processes, supposing that the woman could be so long neglected. In transverse presentations, now and again, spontaneous delivery ensues. Bartholin, in the seventeenth century, pointed out that a child that has lain transversely during the later months of pregnancy may spontaneously assume a longitudinal presentation at the time of labor. This so-called spontaneous version is not an infrequent occurrence. Its mode of production has already been referred to. Fig. 659.—Spontaneous Evolution by Douglas’ Mechanism. Moulding of Fcetus and Impaction of Shoulder. X 1A. A century later Roederer pointed out that in rare instances, if the child be very small and the pelvis large, spontaneous delivery might occa- sionally be accomplished in spite of the persistence of the abnormal pre- sentation. In such cases the child becomes compressed upon itself with the head tightly pressed against the abdomen, so that a portion of the thoracic wall below the shoulder becomes the most dependent part and appears at the vulva. The head and thorax then pass through the pelvic cavity at the same time, and the child, which is doubled upon itself, is expelled—conduplicato cor pore. Manifestly, such a mechanism is possible only in the case of very small children, and is occasionally observed when the second child in twin pregnancy is prematurely horn. In very rare instances, a dead child of moderate or average size may be expelled spontaneously by another mechanism, which is designated as spontaneous evolution. This, however, is met with so rarely, demands such peculiar conditions, and is attended by such risks to the mother that its occurrence should never be counted upon in actual practice, although very occasionally in neglected cases it may occur unexpectedly and even rapidly. Several cases have been observed in my service, two DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 913 of which are described in Stephenson’s article, and in one of them a 2,700 gram child was born eight hours after the onset of labor. Delivery by spontaneous evolution occurs once in every several hun- dred transverse presentations. It was first mentioned by Denman in 1772 and its mechanism was accurately described by Douglas in 1811. Since then a considerable literature has accumulated upon the subject, and the articles of Payer, Zangemeister, Franz, and Stephenson deserve particular mention. It is generally stated that spontaneous evolution Fig. 660.—Spontaneous Evolution by Douglas’ Mechanism. Prolapse of Arm and Elongation of Neck. X V3. may be effected by either of two mechanisms,—that of Denman or Douglas. Stephenson, however, after careful study of the original arti- cles, has concluded that only the latter occurs, and that the belief in the possibility of the former is based upon imperfect understanding of Denman’s casual and imperfect description of the process. In Douglas’ mechanism, the first stage consists in the molding of the foetus and impaction of the shoulder with prolapse of the arm, as described in a preceding paragraph. Then, under the influence of strong uterine contractions, the child rotates about its vertical axis, so that one side of the head comes to lie over the horizontal ramus of the pubis with the breech in the region of the opposite sacro-iliac joint, while the neck subtends the inner surface of the symphysis pubis (Fig. 660). Coin- 914 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS cident with excessive stretching of the neck, the prolapsed arm continues to descend until eventually the corresponding shoulder emerges under the pubic arch. The escape of the arm and shoulder affords room for the entrance of the rest of the body of the child into the pelvic cavity, and the lower side of the thorax, promptly followed by the breech, soon emerges from the vulva. Following the breech the anterior side of the thorax and the remaining arm are delivered, and finally the head is born spontaneously, or is extracted manually, according to the exigencies of the case (Fig. 6G2). Iug. 661. Spontaneous Evolution by Douglas’ Mechanism. Birth of Anterior Shoulder and of Buttocks. X 1 /z. In such cases the prolapsed arm is immensely swollen and a caput succedaneum develops over the presenting shoulder. From our studies it would appear that spontaneous evolution is possible only when the child is not unduly large and in the presence of strong uterine contrac- tions and an unusually elastic neck. Herrgott has reported an instance in which the child weighed 3,300 grams, and has collected the French liter- ature upon the subject up to 1918. Delivery by Douglas’s mechanism would probably have been effected in Chiari’s case had the patient sur- vived. Prognosis.—If spontaneous version does not occur within the first cw hours after the onset of labor, and operative procedures are not DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 915 instituted, spontaneous evolution offers the only possibility for spon- taneous delivery; and as this occurs so rarely as to be negligible the outcome for both mother and child is almost uniformly fatal, the child succumbing to asphyxia and the mother to hemorrhage or infection, as a result of rupture of the uterus. On the other hand, if appropriate measures are instituted, the prognosis for the child is fair, while for the mother it is excellent. In this class of cases prolapse of the cord is one of the most frequent causes of foetal death. Fig- 662.—Spontaneous Evolution by Douglas’ Mechanism. Birth of Body. X 1A Treatment.—If the diagnosis has been made in the last month of pregnancy and the pelvis is approximately normal, cephalic version should be effected by external manipulations, and the child held in its new position by means of a properly fitting bandage. On the other hand, if the pelvis is markedly contracted, such a procedure is useless, as cesarean section at an appointed time will be the operation of choice. If the patient is not seen until after labor has set in external cephalic version should likewise be attempted, provided the membranes have not ruptured. As a matter of fact, however, such manipulations will usually prove unsuccessful. In this event one should wait until the cervix is almost completely dilated, and then, after rupturing the membranes, perform internal podalic version, followed by prompt extraction. DYSTOCIA DUE TO ABNORMALITIES OF THE F(ETUS 916 On the other hand, if the patient be not seen until she is well ad- vanced in labor and the membranes have ruptured, the treatment will vary according to the degree of dilatation of the cervix, the condition of the patient, the degree of impaction of the shoulder, and the condition of the lower uterine segment. If the cervix is only partially dilated, while the child is alive and freely movable in the uterus, bipolar version may be attempted. After a foot has been brought down the cervix should be allowed to dilate still further before extraction is completed. On the other hand, if the condition is complicated by prolapse of the pulsating Fig. 663.—Frozen Section through Woman Dying at End of Pregnancy. Compound Presentation (Braune). cord, the cervix should be dilated manually, and the child extracted after internal podalic version. Whenever the cervix is fully dilated, internal podalic version should be performed at once, according to the rules already given, and followed by immediate extraction, provided the uterus is not so tightly contracted down over the child and the lower uterine segment so thinned out that such a procedure appears synonymous with rupture. Even in such cases anesthesia sometimes so relaxes the organ that version may be safely effected, although at first glance it had appeared to be out of the question. When the shoulder has become firmly impacted, the version appears to be contra-indicated, decapitation is the operation of choice, even if the child is alive; although very exceptionally cesarean section might be thought of. As such a condition is met with only in patients, who have been neglected by ignorant, and probably dirty, attendants, the danger of infection is so great that classical cesarean section should not be con- sidered. Consequently, if radical interference seems advisable, the body of the uterus should be amputated. For this reason, the procedure should DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 917 be limited to multiparous women; as in the case of primiparae it does not seem justifiable to destroy all future hope of childbearing for the sake of a child whose chances are already compromised. The treatment of transverse presentations again affords an admirable illustration of the advantages of efficient prenatal and intra-natal care. If the condition is recognized before or soon after the onset of labor, and intelligent medical care is available, the results for both mother and child are ideal; whereas if the patient is not seen until late in labor the mother is exposed to consider- able risk and the child will almost inevitably be lost; finally, if medical aid is not available, both mother and child will be lost. Compound Presentations.—By this term is understood the prolapse of an extremity alongside of the presenting part, both entering the pelvic canal simultaneously. It is not an infrequent occurrence, being observed about once in every 250 cases (Fig. 663). As a rule, a hand or an arm comes down with the head; much less commonly both arms, or a hand and a foot, or both feet may present together. Hahl has reported a case in which the neck of the child was girdled by its legs, so that the scrotum and head were felt upon vaginal examination (Fig. 665). Some idea of the relative frequency of the different combinations may be gained from the following table, taken from Pernice: Head and hand 26 cases Head and arm 8 “ Head, hand, and cord 5 “ Head and both hands 4 “ Head, one hand, and one foot 2 “ Head, two hands, one foot, and cord 1 case Face, hand, and cord 1 “ Such a condition is frequently associated with disproportion between the size of the head and the pelvis, owing to which early engagement has been interfered with, and as a result one or more of the extremities have prolapsed before the presenting part entered the pelvis. Treatment.—Whenever, during the first stage of labor, a hand is distinguished alongside of the head, it should be pushed up if possible; but if it be firmly fixed between the head and the pelvic wall it should be left alone, since it will usually not interfere with labor. On the other hand, if the entire arm is prolapsed alongside of the head, an effort should be made to replace it, provided serious disproportion is not present. 918 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS If, however, any considerable difficulty is experienced, the attempt should be abandoned, and version performed. This is more particularly indi- cated, since if the arm retains its position it may give rise to serious dystocia, more especially if it extends around the child’s neck, consti- tuting the so-called nuchal position. When, as happens only rarely, the foot prolapses, attempts to replace it are usually futile, and version should be promptly performed, after the hand in utero has determined the exact condition of affairs. LITERATURE Ballantyne. General Festal Cystic Elephantiasis. The Diseases of the Foetus. Edinburgh, 1892, i, 182-219. Bartholin. Quoted by Payer. Dandy and Blackfan. An Experimental and Clinical Study of Internal Hydro- cephalus. J. Am. Med. Assn., 1913, lxi, 2216-2217. Denman. Observations to Prove that in Cases where the Upper Extremities Present, at the Time of Birth, the Delivery may be Effected by the Spontaneous Evolution of the Child. London Med. J., 1785, v, 64-70 and 301-309. Dorland. Watery Accumulations in the Foetal Abdomen Obstructing Labor. Am. Jour. Obst., 1919, lxxix, 474-502. Douglas. An Explanation of the Real Process of the Spontaneous Evolution of the Foetus, etc. Dublin, 1819, ii, Ed. Franz. Zur Lehre von der Geburt mit gedoppeltem Koper. Gyn. Rundschau. Gaskill vs. Gaskill. The Law Reports, 1921, iii, Part XII, Dec. 5th., 1910, iv, 399-408. Hahl. Strietur des os internum als Geburtshinderniss. Arcliiv f. Gyn., 1901, Ixiii, 684-694. Herrgott. Un cas d ’evolution spontannee. Annales de gyn. et d’obst., 1918, xiii, 193-203. Kehrer. Zur Lehre von den herzlosen Missgeburten. Archiv f. Gyn., 1908, lxxxv 121-138. Lynch. Dystocia due to Cystic Kidney. Surgery, Gyn. and Obst., 1906, iii, 628-637. Oyamada. Ueber Riesenkinder. Beitrage zur Geb. u. Gyn., 1911, xvii, 93-128. I ayer. Zur Lehre von der Selbstentwickelung. Volkmann’s Sammlung klin. Vortrage, 1901, N. F., Nr. 314. Pernice. Die Geburt mit Vorfall der Extremitaten neben dem Kopfe. Leipzig, 1858. Phaenomenow. Bcitrag zur Casuistik der durch die Frucht bedingten Geburts- hindernisse. Archiv f. Gyn., 1881, xvii, 133-139. Porak et Couvelaire. Foie polykystique cause de dystocie. Comptes rendus soc. d’obst., de gyn. et de paed. de Paris, 1901, iii, 26-37. Roederer. Quoted by Payer. Schroeder, Olsiiausen, und Veit. Lchrbuch der Geburtshiilfe, XIII. Aufl., 1899, 737. , ’ ’ Schumann, a Study of Hydrops Universalis Foetus. Trans. Am. Gyn. Soc., 1915, xl, 12-32. eiwyzer. Uebe.i einen fall von Geburtshinderniss, bedingt durch hochgradige Erweiterung der fotalen Harnblase. Archiv f. Gyn., 1893, xliii, 333-346. LITERATURE Stephenson. The Mechanism of Labor in Spontaneous Evolution. Bull. Johns Hopkins Hosp., 1915, xxvi, 331-335. Walther. Dystokie infolge iibermassiger Ausdehnung der fotalen Ilarnblase. Zeitschr. f. Geb. u. Gyn., 1893, xxvii, 333-347. Zangemeister. Medianik und Therapie der in der Austreibungsperiode befind- lichen Querlagen. Leipzig, 1908. Zangemeister und Lehn. Die geburtshilfiiche Bedeutung iibergrosser Frucht- entwickelung. Archiv f. Gyn., 1918, cix, 500-533. 919 CHAPTER XL HEMORRHAGE Profuse hemorrhage occurring prior to or shortly after the birth of the child is always a dangerous and sometimes a fatal complication. Practically all varieties of antepartum hemorrhage, with the exception of those originating from lacerations of the genital canal, are due to a par- tial or complete separation of the placenta from its attachment to the uterine wall. This accident is an inevitable accompaniment of labor when the placenta is implanted in the neighborhood of the internal os—pla- centa previa, but occasionally occurs when the organ occupies its normal site in the upper portion of the uterus. PREMATURE SEPARATION OF THE NORMALLY IMPLANTED PLACENTA Antepartum hemorrhage due to the premature separation of the nor- mally implanted placenta has doubtless occurred from time immemorial, but its mode of production was first recognized by Louise Bourgeois in 1609. Particular attention was directed to it in 1776 by Rigby, who clearly differentiated it from the hemorrhage due to placenta previa, and designated it as accidental, in contradistinction to the unavoidable hemorrhage associated with the latter condition. R. W. Holmes of Chicago proposed in 1901 to designate the process as ablatio placentae, and many have accepted his suggestion. As will be indicated below, the placenta may be completely or only partially detached from the uterine wall, and the effused blood may be entirely retained within the uterine cavity, or may escape externally through the vagina—concealed or external accidental hemorrhage. The former is one of the most serious accidents of pregnancy and labor, and fortunately occurs but rarely; while the latter is less serious, and in my experience occurs more frequently than hemorrhage due to placenta previa. Goodell in 1875 collected from the literature 106 instances of concealed accidental hemorrhage, demonstrated its great gravitv, find indicated the impotence of the methods of treatment then in vogue. Indeed, it is in great part due to his teaching that it has been assumed that concealed hemorrhage and premature separation of the placenta are synonymous, with the result that the frequency of the latter has been underestimated and its seriousness exaggerated. Holmes in 1901 was able to collect 200 additional cases, but believed that his figures gave a very inadequate idea of the incidence of the accident. Subsequent in- 920 PREMATURE SEPARATION OF THE PLACENTA 921 vestigation has proved the correctness of his prediction, and Dorman, Colclough and Essen-Moller in large series of cases observed premature separation of the placenta once in every 115, 207 and 216 labors, re- spectively; although clinical symptoms were lacking in one half of their cases, while concealed hemorrhage occurred in less than one case out of ten. In the last 2,000 patients delivered in my service prior to July, 1915, 17 cases of premature separation were noted, but only one example of concealed accidental hemorrhage occurred in a series of 15,000 labors. Etiology.—Unfortunately the primary cause of premature separation of the placenta is imperfectly understood, and the following conditions have been invoked as etiological factors: traumatism, shortness of the umbilical cord, profound mental emotions, endometritis, nephritis, tox- emia, and torsion of the uterus. Formerly it was held that a fall or a blow upon the abdomen might cause it, and traumatism was noted in 67 of the cases collected by Holmes, but was mentioned less frequently in the statistics of subsequent writers, and was lacking in all of my own cases. For this reason, I believe, that its influence has been exaggerated, and, while it may occasionally be concerned, it cannot be regarded as the usual cause of the complication. In the classical specimen of Pinard and Yarnier, the accident was clearly due to traction exerted upon the placenta by an abnormally short umbilical cord. Gardiner has laid great stress upon its importance, but as such an abnormality is lacking in most instances, it is evident that it can only exceptionally be an etiological factor. The older writers laid great stress upon the part played by sudden and intense mental emotions, but at present no one believes in the efficacy of such causes. Many recent German authorities, particularly Weiss, Seitz and Schickele, hold that inflammatory or degenerative lesions in the decidua are responsible for the production of the accident. Doubtless, such changes are sometimes present; but as they were absent in all of my specimens, I feel that they should be regarded as accidental complica- tions. Since Winter in 1885 directed attention to the presence of albumin in the urine of patients suffering from this accident, nephritis has been regarded as its most common cause, and various writers have reported that albuminuria was present in one-half to seven-eighths of their cases. Plausibility is lent to the argument by the well-known association of red infarcts of the placenta with chronic nephritis, and it has been sug- gested that similar hemorrhagic lesions occurring in the decidua afford a satisfactory explanation for the inauguration of the placental separation. Although albuminuria was noted in 11 of the 17 cases mentioned in my article, chronic nephritis was present but once. Consequently, I believe that the latter is rarely an etiological factor, and that the albuminuria should be regarded as an accidental complication, or as a manifestation of a toxemic process. Bar, Couvelaire, Essen-Moller, Portes and others have observed the accident in eclamptic women, and the present tendency is to regard it as being due to a toxemic process. Notwithstanding the occasional asso- 922 HEMORRHAGE ciation with eclampsia, the toxemia is not of the typical preeclamptic variety, but is of a special type, concerning whose causation we are as yet ignorant. Justification for this belief is afforded by the findings in the only examples of concealed hemorrhage which I have examined. In these instances, albuminuria and all other symptoms of preeclamptic toxemia were absent, yet the intima of the smaller uterine arteries pre- sented degenerative lesions which could be explained only by the sup- position that certain toxic substances were circulating in the blood, and gave rise to the hemorrhagic changes which characterized the “utero- placental apoplexy,” which will be described in the following section. Multiparity would appear to be a predisposing cause, only 19.2 per cent, of the cases collected by Holmes having been noted in primiparae. Moreover, the frequency of the accident increases directly with the num- Fig. 665. Fig. 666. Figs. 665, 666.—Premature Separation of Placenta with External Hemorrhage (Winter). ber of pregnancies, and the advocates of the endometritis theory believe that these facts add to the force of their argument. Morse in 1918 was able to produce a somewhat similar condition in experimental animals by ligating certain uterine vessels or by producing torsion of one horn. He therefore attributed to a similar cause the lesions about to be described, but to my mind his argument is fallacious, foi the reason that torsion of the uterus was not present when the abdo- men of any of my patients was opened. Consequently, I believe that his experimental lesions are comparable to those with which we are so well acquainted following twisting of the pedicle of ovarian tumors. Most of the conditions just mentioned may come into play either during piegnancy or at the time of labor. On the other hand, certain other etiological factors cannot become operative until labor has set in. Among these may be mentioned traction exerted by an abnormally short PREMATURE SEPARATION OF THE PLACENTA 923 umbilical cord, as well as a sudden diminution in the bulk of the uterine contents following the birth of the first child in a twin pregnancy or the too rapid expulsion of a large amount of amniotic fluid in hvdramnios. Pathology.—Premature separation of the placenta is inaugurated by the effusion of blood into the decidua basalis, which then splits, so that a thin layer remains in contact with the maternal surface of the pla- centa, while a thicker layer adjoins the muscularis. Consequently, the process in its earliest stages consists in the development of a decidual hematoma, which leads to compression and ultimate throwing out of function of the portion of the placenta adjacent to it. In this stage there are no clinical symptoms, and the condition is discovered only upon examination of the freshly delivered organ, which will present on its maternal surface a sharply circumscribed depression, measuring a few centimeters in diameter, and containing dark and partially disorgan- ized, clotted blood. In most instances the decidual hemorrhage is more profuse, so that the area of separation becomes more extensive, and grad- ually extends to the margin of the placenta. As the uterus is still dis- tended by the product of conception, it is unable to contract and com- press the torn vessels in the decidua basalis, and, consequently, the escap- ing blood makes its way between the membranes and the uterine wall and eventually appears externally. Less often, the blood is retained within the uterus. This is designated as concealed accidental hemorrhage and is liable to occur (1) when there is an effusion of blood behind the placenta, its margins still remaining adherent; (2) when the placenta is completely separated, while the membranes retain their attachment to the uterine wall; (3) when the blood gains access to the amniotic cavity after breaking through the membranes; and (4) when the head is so accurately applied to the lower uterine segment that the blood cannot make its way past it. In the majority of such cases, however, the membranes are gradually dissected off from the uterine wall, and part of the blood eventually escapes from the cervix. Formerly, in considering the pathology of the condition, attention was centered upon the extent of the separation—partial or complete—- and whether the hemorrhage was external or concealed. Following the observations of Couvelaire, Fssen-Moller, myself, and others, it is now recognized that in many cases, at least, characteristic lesions occur in the uterus, which serve to explain not only the mode of origin of the separation, but also the failure of the organ to contract after being emptied of its contents. The uterus, and occasionally the tubes and ovaries as w'ell, take on a bluish, purplish coppery coloration and re- semble an ovarian cyst with a twisted pedicle (Plate XYI). The process may likewise involve one or both broad ligaments, which are then gorged with blood. In several instances, in which I performed cesarean section, the uterus failed to contract and retract after delivery, and, as it remained as soft and flabby as a piece of wet leather, I was forced to amputate it supravaginally. Microscopic examination showed extensive intramuscular hemorrhage, which had .so dissociated the muscle fibers as to destroy completely their contractile properties (Fig. 667). Fur- thermore, similar hemorrhagic changes in the decidua basalis afforded 924 HEMORRHAGE a ready explanation for the inauguration of the separation of the placenta. Couvelaire has designated the condition as uteroplacental apoplexy. Its mode of production is not yet clear, but as has already been indi- cated, it appears to he associated with a toxemic process; and in several FIof 6T6HE~No^?TNr ™«OUQH U™. Wall from a Case of Premature Separation Fibers b? PLACENTA’ Sh°WING Diss°ciation of the Muscle Light areas represent muscle, dark areas effused blood. X 40. o the uteri which I examined, endarteritic changes and lesions of con- tinuity m the smaller vessels afforded a satisfactory explanation for the production of the intramuscular hemorrhage. It is not yet known whether uteroplacental apoplexy is a constant lesion, or is' associated only with the more serious cases; but the fact that in the four years preceding the appearance of my article in 1915, twenty such specimens PLATE XVI. HEMORRHAGIC CHANGES IN UTERUS ASSOCIATED WITH PREMATURE SEPARATION OF THE PLACENTA. PREMATURE SEPARATION OF THE PLACENTA 925 had been described, and that Portes was able to collect 73 cases in 1923, makes it apparent that the lesion is not exceptional. Occasionally, as described by Knauer and Fraipont, superficial longi- tudinal fissures develop upon the surface of the uterus. These are usually multiple, a few centimeters in length, and extend only a slight distance into the muscularis. It is not yet known whether they are due to excessive distention of the organ or to the rupture of the superficial hemorrhagic areas; but, whatever their mode of production, they occa- sionally lead to fatal intraperitoneal hemorrhage, as recorded by McNair, Oldfield and Shaw. Clinical History.—Premature separation of the placenta may occur during the later months of pregnancy or at the time of labor. In the former case the resulting external or concealed hemorrhage is soon fol- lowed by the onset of uterine contractions. In either event, if the loss of blood is marked, the patient presents signs of acute anemia, and passes into a condition of profound shock which may end fatally if delivery is not effected promptly. Wright contends that the shock is more often the result of traumatism than of actual hemorrhage, and may pass off under appropriate medicinal treatment. In concealed hemorrhage the uterus gradually becomes of a size con- siderably larger than would normally correspond to the duration of the pregnancy, assumes an almost ligneous consistency, and does not alter- nate between contraction and relaxation, so that the outlines of the child can not be palpated. At the same time the patient complains of intense abdominal pain. As the child is dead, auscultation gives nega- tive results. On the other hand, when the hemorrhage is external, there is little or no enlargement of the uterus, and the pain is less severe. In the former case the pain and shock are often attributed to other con- ditions, and the patient sometimes dies before the condition is diagnosti- cated. When the premature separation of the placenta occurs at the time of labor as the result of traction upon an abnormally short cord, or of the sudden partial emptying of the uterine cavity in twin pregnancy or hydramnios, the hemorrhage is usually external, and the foetal heart sounds become imperceptible. In very exceptional instances the placenta may become separated from its attachment during the course of an otherwise normal labor, and be extruded in front of the child. No doubt most of the recorded cases were really instances of placenta previa, although now and again, as in the case reported by Munchmeyer, such an accident may occur even when the placenta is inserted normally—prolapse of the pla- centa. Diagnosis.—In the absence of external bleeding, the occurrence of sharp abdominal pain associated with a uterus of ligneous consistency, in a patient in the latter months of pregnancy, is almost pathognomatic of concealed accidental hemorrhage, and the diagnosis becomes assured when the patient presents signs of acute anemia with manifestations of shock. While the last-mentioned symptoms may follow the rupture of an advanced extra-uterine pregnancy, or the very exceptional spon- 926 HEMORRHAGE taneous rupture of the uterus, such conditions can be excluded if the uterus presents the characteristic board-like consistency. When, however, the hemorrhage is external, the diagnosis is rendered practically positive by the failure to demonstrate the presence of a placenta previa, by vaginal examination, though, of course, it is impos- sible to differentiate the rare cases of rupture of the circular sinus of the placenta to which Budin has directed our attention. When the accident occurs during labor and is attended by some loss of blood, the symptoms may be suggestive of those following rupture of the uterus, though the latter accident rarely occurs except late in an obstructed labor, and is not attended by the board-like consistency of the organ. In the exceptional instances in which the hemorrhage is entirely retroplacental a localized elevation of the corresponding portion of the uterine wall can occasionally be detected on palpation. Prognosis.—Concealed accidental hemorrhage is one of the most serious complications of pregnancy and labor, many of the mothers and practically all of the children perishing, Goodell having reported a maternal and foetal mortality of 50.9 and 94.4 per cent., respectively. Even now the results are not good, as in the 47 radical operations col- lected by Portes the mortality was 36 and 81 per cent., respectively. When the hemorrhage is external, the prognosis is usually dependent upon the amount of blood lost; although it should be remembered that slight vaginal bleeding does not necessarily preclude the possibility of profuse intra-uterine hemorrhage. Furthermore, the mere completion of delivery is not synonymous with safety, as a certain proportion of patients succumb to atonic postpartum hemorrhage, while others die from unrecognized intraperitoneal hemorrhage. Treatment.—In the more serious forms the life of the mother can be saved only by prompt evacuation of the uterus, as only then can the organ contract down and check the bleeding. On the other hand, when the separation is partial and the loss of blood but slight, the accident may be without serious significance. In the latter class of cases an ex- pectant treatment should be pursued, and labor allowed to take its natural course, interference being indicated only when the symptoms become urgent. On the other hand, if the patient presents signs of acute hemorrhage, whether of the concealed or external variety, the uterus should be emptied with the least possible delay. If labor has not yet set in, abdominal cesarean section should be performed; and the uterus retained or removed, according as it con- tracts satisfactorily or remains atonic. The same applies, even if labor is already in progress, unless the cervix is partially dilated and so softened that manual dilatation can be readily and safely effected, following which the child should be delivered by version or forceps, as seems advisable. Radical operative treatment is the more justified, for the reason that no one can predict to what extent the uterine muscle may be disorganized by hemorrhage, so that in many cases only the amputa- tion of the uterus can prevent death from postpartum hemorrhage. It of course goes without saying that the various measures appropriate PLACENTA PREVIA 927 for combating shock should be employed as adjuvants to the purely obstetrical treatment. In some instances, following delivery through the natural passages, the tonicity of the uterus has been so impaired by the disassociation of its fibers by intramuscular hemorrhage that it fails to contract and retract during the third stage of labor, and as a result profuse post- partum hemorrhage may follow. This possibility should always be borne in mind, and the operator should have in readiness the necessary ma- terials for packing the uterus at a moment’s notice. If, however, bleed- ing continues in spite of the pack, no time should be wasted in palliative expedients, but the abdomen should be opened at once and the uterus amputated. In such cases, the outlook is not so promising as if the uterus had been removed primarily. PLACENTA PREVIA It is generally stated that the most common cause of antepartum hemorrhage is the partial separation of a placenta implanted in the neighborhood of the internal os—placenta previa. Fig. 668. Fig. 669. CENTRAL Figs. 668, 669.—Showing Different Modes of Placental Insertion. (Modified from American Text-Book.) Our knowledge concerning this abnormality may be said to date from the end of the seventeenth and the beginning of the eighteenth centuries, Portal, in 1685, and Schacher, in 1709, having accurately described the condition from a clinical and an anatomical point of view. Notwithstanding the fact that Smellie, William Hunter, and Rigby were well acquainted with placenta previa and its dangers, very little advance 928 HEMORRHAGE was made in our knowledge concerning it until Barnes promulgated his views as to its mode of production and the methods of controlling the hemorrhage arising from it. Since then many investigators have busied themselves in determining its etiology and the most suitable treatment. An excellent historical resume is contained in the monographs of von Herff and Hofmeier. In this condition, the placenta, instead of being implanted high up upon the anterior or the posterior wall of the uterus, overlaps the internal os to a greater or lesser extent, thereby becoming accessible to the examining finger. Ordinarily, three varieties are distinguished: Placenta previa centralis, lateralis or partialis, and marginalis. In the first the internal os is completely covered by placental tissue, which is adherent to its margins; in the second the placenta encroaches more or less upon the internal os, but does not completely cover it; while in the third the placenta is implanted higher up, its lower margin just overlapping the internal os (Figs. (569 and 670). Strictly speaking, the differentiation between the several varieties should not be made until the cervix has be- come fully dilated, for the reason that the marginal variety cannot be felt until this has occurred; while what may appear to be a complete placenta previa during pregnancy or the first part of labor may prove to be only partial, and to en- I croach only slightly beyond the margin of the internal os when dilatation is complete. In both the central and partial varieties, partial separation of the pla- centa is an inevitable conse- quence of the formation of the lower uterine segment and the dilatation of the cervix. This is always associated with the tear- ing through of blood vessels, which cannot become constricted until after the uterus has been emptied, so that the resulting hemorrhage was appropriately designated by Rigby as unavoid- i, aWe- In placenta previa margi- ™l,s on the other hand, hemorrhage does not always occur, and, as the placental tissue can be felt only after dilatation has proceeded to Fig. 670.—Partial Placenta Previa, in which No Attempt at Delivery Had Been Made (Ahlfeld) PLACENTA PREVIA 929 a certain extent, the existence of the condition is frequently unrecog- nized. Such cases are closely related to the so-called vicious insertion of the placenta described by Pinard and his pupils, which is of frequent occurrence. Frequency.—Placenta previa is fortunately a comparatively rare com- plication, although the statements as to its frequency vary considerably. Thus, W. Muller, whose statistics were based upon 876,432 labors, stated that it occurs once in 1,078 cases; while Lomer, Tarnier, and Burger and Graf, on the other hand, estimated its incidence as once in 723, 207, and 130 labors respectively. In all probability it would be cor- rect to say that it is met with about once in 1,000 cases in private, as compared with once in 250 cases in hospital practice. Moreover, there is considerable variation in the statements concerning the relative incidence of the several varieties, though it is generally ad- mitted that the partial form is the most frequent. Thus, Koblanck, Strassmann, and Burger and Graf observed the central variety in 18.4, 23.8, and 18.4 per cent., the partial in 64.5, 61.5 and 36 per cent., and the marginal in 17.1, 15.2, and 45.6 per cent, of their placenta previa cases respectively. Pinard, on the other hand, states that he has never met with a placenta which was uniformly adherent to the margins of the internal os, and that the marginal is the most frequent variety. In favor of this view he adduces the fact that he had observed the so-called vicious insertion in 28.12 per cent, of all normal labors. His conclusions must, however, be accepted with reserve, since they are based upon the measurement of the distance of the margin of the placenta from the point of rupture of the membranes, as determined from the examination of the after-birth, and it is clear that such a mode of investigation is not beyond reproach. Etiology.—Concerning the etiology of placenta previa comparatively little is known. Two factors, however, appear to favor its occurrence— multiparity and endometritis. The abnormality occurs comparatively rarely in primiparae, and in- creases in frequency with the number of children which the individual has borne. This point is strikingly illustrated by the following figures of Doranth, which are based upon 30,796 labors occurring in Chrobak’s clinic. In these the incidence of placenta previa was 0.17, 0.48, 1.37, 1.28, 3.39, and 5.51 per cent., according as the patients had given birth to 1, 2, 3, 4, 5, 6, or 7 or more children respectively. The occurrence of placenta previa is not only favored by the absolute number of children, but also by the rapidity with which the labors have followed one another, Strassmann finding that the average age of his patients was 32.9 years, and that the average number of labors was 6.38. In 55 multiparous women with placenta previa in our service it was found that they had averaged 5.9 children each in the ten years follow- ing the first delivery. Strassmann also pointed out that one of the most important factors in its development was to be found in defective vascularization of the decidua, the result of iuflammatory or atrophic changes, the latter being favored by repeated and closely following pregnancies. Such conditions, 930 HEMORRHAGE he maintained, limit the amount of blood going to the placenta, so that in order to obtain its requisite supply of nutriment it becomes necessary for it to spread over a greater area of attachment, and in so doing its lower portion occasionally approaches the region of the internal os, completely or partially overlapping it as the case may be. Plausibility is lent to such a view by the fact that the placenta in this abnormality is at- tached over a greater area of the uterus than usual, while at the same time it is often considerably thin- ner. Thus, in one of my cases which came to au- topsy, the placenta was almost membranous, and its site occupied four-fifths of the interior of the uterus. The older authorities believed that placenta previa was due to the separation from its attach- ment of a normally im- planted ovum, which, fall- ing to the lower portion of the uterus, subsequently contracted new connections instead of escaping through the cervix. Later it was urged that such a view failed to explain the production of the central variety, as it was incon- ceivable that the escape of the minute ovum from the uterus could be delayed sufficiently long to permit the formation of attachments in the neighborhood of the internal os. The fallacy of this view is apparent when one recalls the fact that the uterus at the time of conception is normally so anteflexed that the region of the internal os is at a higher level than the fundus, hence the force of gravity would not necessarily aid in carrying the ovum towards the cervix. Further- more, Bumm contended that, in view of the congested condition of its margins, the internal os is smaller than the fertilized ovum. The gravitation theory was generally accepted until 1888, when Hofmeier and Kaltenbach advanced the theory that a part of the pla- centa developed from a portion of chorion in contact with the decidua reflexa. As pregnancy advanced this so-called reflexa placenta gradually bridged over the internal os and eventually came in contact and fused Fig. 671.—Right Half of Uterus with Central Placenta Previa and Velamentous Insertion of Cord. Note the Cup-like Form of the Pla- centa and ITS Varying Thickness. X 2/5. PLACENTA PREVIA 931 with the decidua vera, after which vascular connections with the uterine wail became established (Fig. 673). This view at once met with very favorable consideration, and Jolly, in 1911, advanced incontrovertible proof of its correctness in many cases. When Hofmeier advocated this mode of origin at the 1897 meet- ing of the German Gynecological Congress, he was careful to state that it was not the only manner in which a placenta previa might originate; inasmuch as in certain instances the extension of the placental area might be effected by a process of cleavage in the decidua vera, as the result of which the margin of the organ would ex- tend beyond the serotina. Should such cleavage extend downward, it was readily con- ceivable that the placenta might grow on either side of the internal os, a n d, eventually, completely cover it. At that time correct informa- t i o n concerning the mode of im- plantation of the ovum and of the growth of the placenta were not available, and Hofmeier was not aware that an analogous process occurs in every normal pregnancy. In view, therefore, of our present knowledge concerning the normal implantation of the ovum, as well as of Strassmann’s theoretical deductions, it appears prob- able that placenta previa results either from the primary implantation of the ovum in the lower portion of the uterus, associated with such exten- sive cleavage of the decidua vera that the extension of the placenta to the region of the internal os is facilitated, or it result from the development of a part of the placenta upon the internal surface of the deculua vera. Very exceptionally, as reported by von Weiss, Ponfick, Kermauner, and Labhardt, a part of the placenta is developed upon the upper portion of the cervix. The possibility of such an occurrence must be admitted, although Ahlfeld and Aschoff have shown that it is more apparent than real, as it is not due to a primary implantation, but rather to a secondary cleavage of the cervix by the extension of a placenta which had been primarily implanted above it. Symptoms.—The most characteristic symptom of placenta previa is hemorrhage, which usually does not appear until after the seventh month Serotina Reflexa Fig. 672.—Diagram Illustrating Hofmeier’s Theory of the Formation of Placenta Previa. 932 HEMORRHAGE of pregnancy. At the same time it is probable that many abortions are due to this abnormality, although the true state of affairs usually escapes observation. I have seen several abortions in the third month which were clearly due to it. The hemorrhage frequently comes on without warning in a pregnant woman who had previously considered herself in perfect health. Occa- sionally it makes its first appearance while the patient is asleep, so that on awakening and feeling the bedclothes moist, she is surprised to find that she is lying in a pool of blood. Ordinarily, the initial bleeding ceases spontaneously, to recur again when least expected, though the first hemorrhage is rarely so profuse as to prove fatal. In other cases the bleeding does not cease en- tirely, there being a continuous dis- charge of small quantities of blood- stained fluid, which eventually so weakens the woman that a comparatively slight acute hemorrhage may be suffi- cient to cause death. In a certain pro- portion of cases, particularly when the insertion is marginal, the bleeding does not appear until the time of labor, when it may vary from a slight, blood-stained discharge to a profuse or even fatal hemorrhage. As a rule, it is less copious in this than in the other varieties. The mode of production of the hemorrhage is readily understood when one recalls the changes which take place in the later weeks of pregnancy and at the time of labor. When the placenta is inserted centrally or partially, it is evident that as the formation of the lower uterine segment and the dilatation of the internal os progress its attach- ments must inevitably be torn through, the rupture being necessarily followed by a hemorrhage from the maternal vessels. Furthermore, the bleeding is favored by the fact that it is impossible for the stretched fibers of the lower uterine segment to compress the torn vessels, as is the case when the normally implanted placenta becomes separated during the third stage of labor. Moreover, when the placenta has developed in the capsularis, it is apparent that the thin tissue is devoid of all support where it bridges over the region of the internal os, and consequently a slight trauma will open up the intervillous space. As the placenta previa occupies the lower portion of the uterine Fig. 673. — Sagittal Section through Cervix and Posterior Wall of Uterus Showing Par- tial Placenta Previa. Note the area of separation just above in- ternal os, which was sufficient to cause fatal hemorrhage. X x/i- PLACENTA PREVIA 933 cavity, it interferes with the accommodation of the foetal head, and consequently abnormal presentations are unusually frequent, Muller having noted 272 transverse and 107 breech presentations in 1,148 cases. In normal labor all danger is ordinarily past with the completion of the second stage. In placenta previa, on the other hand, as a result of abnormal adhesions or an excessively large area of attachment, the process of separation is sometimes interfered with, so that profuse hemor- rhage frequently occurs after the birth of the child, and exceptionally continues even after the manual removal of the placenta. In other cases hemorrhage is due to the fact that the overstretched lower segment, which normally retracts but poorly, is unable to compress the vessels traversing its walls. Diagnosis.—In patients suffering from uterine hemorrhage during the last third of pregnancy, placenta previa or the premature separa- tion of the normally implanted placenta should always be suspected, and the possibility of the existence of the former should not be dismissed until careful examination has demonstrated its absence, in which event the latter condition should be diagnosticated. In the great majority of cases of placenta previa the cervix is softer and more succulent than usual, and its canal more patulous, so that but little difficulty is ex- perienced in carrying the finger through the internal os and feeling the characteristic spongelike placental tissue, or at least making out a soggy, thick substance lying between the finger and the presenting part. When, however, the cervix is not patulous it should be dilated, under anesthesia if necessary, sufficiently to permit the introduction of the finger, which is then passed through the internal os and swept around the adjacent portion of the lower uterine segment, when the presence or absence of the abnormality can be positively determined. It js true that such a procedure occasionally results in the induction of premature labor; but the risk is justifiable, since we possess no other means of arriving at a definite diagnosis, which should be made at any cost on account of the very serious menace which the existence of the con- dition offers to the life of the patient. Prognosis.—The prognosis is always serious. According to Muller, under expectant treatment the maternal mortality varied from 36 to 40 per cent., while for the children it was about 66 per cent., one half of those which were born alive perishing within the first ten days following delivery. The danger to the mother arises primarily from hemorrhage, which is usually the direct result of the condition, though frequently it may be increased by deep cervical tears resulting from too hasty artificial dilatation, or from the extraction of the child through an imper- fectly dilated cervix. Moreover, such patients are particularly prone to puerperal infection, which is favored by the presence of the thrombosed sinuses in the lower uterine segment. The foetal mortality is due in great part to the fact that the acci- dent so frequently comes on while the children are quite premature. In other instances they perish from asphyxiation, the result of placental hemorrhage, occasionally succumbing during attempts at extraction through an imperfectly dilated cervix. 934 HEMORRHAGE Nowadays the maternal mortality depends upon the variety of the placenta previa, the method of delivery, and the condition of the patient when first seen. Thus, in 178 cases reported by Hofmeier, Behm, and Lomer, and treated by 11 different obstetricians by Braxton Hicks’s method of combined version, the maternal mortality was 4.5 per cent. Jellett has reported a death rate of 3.69 per cent, in 138 cases treated at the Rotunda in Dublin, and Essen-Moller on of 3.7 per cent, in 132 cases. Pinard lost four mothers in 183 cases and Stratz one out of 110 patients whom he delivered personally. Kronig and Sell- heim, on the other hand, report that 8 to 10 per cent, of the patients die from hemor- rhage, if not treated by cesarean section. In hospital practice, where many patients are admitted after inefficient treatment by poorly trained practitioners, puerperal in- fection plays a large part in the production of maternal mortality. Thus, 40 per cent, of the deaths reported by Burger and Graf were attributable to infection; while in Bar’s series 71 per cent, were due to the same cause. The prognosis is much more serious in central placenta previa than in the other varieties. Furthermore, the mortality de- pends upon the condition of the patient when first seen, if being evident that women who have suffered from profuse and repeated bleeding have far less chance of recovery than those who come under observation after the first slight hemorrhage. Unfortunately, the foetal mortality has shown comparatively little decrease in recent years, Kiistner, Burger and Graf, and Strass- mann giving percentages of 35, 55, and Cl.22 respectively. A very great improve- ment in this respect is hardly to be antici- pated on account of the large number of pi emature children with which one has to deal, as I hompson’s analysis of our material showed that the proportion between pre- mature and mature children was as 8 to 1. h i mCn ‘ , 11 acc0lmt of the danger of profuse and unexpected nated iu tb’ pregnanCy or laboU as the case may be, should be termi- , the conservative manner as soon as possible after a pla- centa previa has been positively diagnosed. There is no single method leatment applicable to all classes, and the obstetrician who under- stands how to differentiate his cases will obtain the best results cieut v 44 fT?0818 18 -w?6 dUTing Pregnancv, and the cervix is suffi- ciently dilated to permit the introduction of two fingers, treatment will Fig. 674.—Famrs Partially Extracted from a Patient Dying of Placenta Pre- via, Showing how It Acts as a Tampon (Leopold). PLACENTA PREVIA 935 depend upon whether the child is viable or not. In the former case almost ideal results are obtained by the introduction of a Champetier de Fig. 675.—Left Half of Frozen Section through Uterus with Central Placenta Previa, Showing the Effect of Version. (Titus.) X x/i- Ribes balloon after rupture of the membranes or perforation of the placenta, according as one has to deal with a partial or central insertion, dilatation being hastened by attaching a 2-pound weight to the end of 936 HEMORRHAGE the tube by a string and suspending it over the foot of the bed. After the expulsion of the bag the child should be delivered by version tand extraction. On the other hand., if the child is not viable, equally good maternal results are more readily obtained by bringing down a foot by Braxton Hicks’s maneuver and using the breech of the child as a tampon to control further bleeding. If the hemorrhage ceases after the foot has been brought down, the expulsion of the child may be left to Nature; but if the oozing continues, gentle traction should he made upon the leg so as to compress the placenta with the child’s buttocks. Whichever method is employed, extraction should not be attempted until the cervix is completely dilated, or at least sufficiently so as to permit the ready passage of the head. Too great haste is liable to cause deep cervical tears, giving rise to additional hemorrhage and requiring the application of sutures, while in other instances serious difficulty may he encountered in delivering the child. Generally speaking, better results will be obtained in private practice by the employment of Braxton Hick’s bipolar version, no matter what may be the condition of the child, for the reason that the average practitioner will rarely be equipped with a suitable balloon and the necessary para- phernalia for its introduction. In hospital practice, however, its employment has un- doubtedly aided materially in diminishing the foetal mortality, and Thompson states that in 36 consecutive cases so treated in our service there was no maternal mortality. In very exceptional instances in primi- parous women the cervix may be so rigid that it is impossible to dilate it sufficiently to permit the employment of either of the above-mentioned procedures. In such cir- cumstances, in the hands of an expert sur- geon, cesarean section may be indicated, but in general practice a tight cervical and vagi- nal pack of sterilized gauze bandage should be applied. After remaining in place for a few' hours this will usually bring about sufficient dilatation to permit the employ- ment of whatever maneuvers may be deemed necessary. The use of the pack, however, should be restricted as far as possible, and should be regarded merely as a temporary expedient, partly because it may give rise to a false sense of security, but particularly on account of the danger of infection. At the time of labor the treatment depends upon the degree of dila- tation and the condition of the patient. If the cervix is fully dilated, immediate delivery by version or forceps is indicated. On the other hand, ii the dilatation is only partial, and the placenta is inserted marginally, good results very frequently follow rupture of the mem- Fig. 676.—Sketch to Elucidate Fig. 675. The median aspect of the half of foetus to left of vertical line is shown in the frozen section. PLACENTA PREVIA 937 branes, since the placenta is then able to follow the retracting uterine wall. In all other cases., provided the child is alive, I prefer to complete the dilatation by means of a large Champetier de Ribes balloon, which should be introduced into the amniotic cavity after rupturing the mem- branes or perforating the placenta, as the case may be. Dilatation is hastened by gentle traction exerted by the hand or by a weight attached to the end of the tube, and after extrusion of the bag delivery is usually best effected by version and extraction. If, however, a balloon is not available, equally satisfactory maternal results may be obtained by Braxton Hicks’s method of bipolar version, provided extraction is not attempted until the cervix is fully dilated. The practitioner is earnestly warned against the employment of rapid manual or instrumental dilatation of the cervix. In this class of cases it is particularly prone to laceration, and, no matter how gradually and carefully the dilatation may be effected, deep tears frequently result. These may extend far out into the base of the broad ligament or up into the lower uterine segment, and occasionally entirely through the uterine wall. I recall one of my own cases in which death resulted from a large broad ligament hematoma following a tear through the lower uterine segment, which I thought had been satisfactorily repaired, as well as several consultation cases in which laparotomy and amputation of the uterus were necessary to check intraperitoneal hemorrhage follow- ing extension of cervical tears. As already indicated, all danger has not passed with the delivery of the child, and great care should be exercised in the conduct of the third stage of labor. If there is no hemorrhage, expression should not be attempted until the placenta has been expelled into the vagina; but if bleeding is profuse, Crede’s method of expression should be immediately resorted to, and, if not effective, the placenta should be removed manually. If the loss of blood continues after the completion of the third stage, the cervix should be inspected, and immediately repaired if lacerated; but if no lesions are present, an intra-uterine pack should be introduced, so as to exert compression upon the flabby lower uterine segment. Whenever the hemorrhage has been profuse, and the patient presents the subjective symptoms of an acute anemia, one should resort to the therapeutic measure outlined under the treatment of post- partum hemorrhage. Occasionally, when the patient is markedly ex- sanguinated when first seen, but is losing little or no blood at the time, it is better to transfuse her before beginning any obstetrical manipu- lation. In view of the danger to the mother, but particularly because many children are sacrificed by extraction through an imperfectly dilated cervix, Tait, Palmer Dudley, and others recommended the performance of cesarean section, provided the child is viable and the patient in good condition. Ten years later, in 1908, Kronig and Sellheim stated that 8 to 10 per cent, of all placenta previa patients die from hemorrhage, and held that our methods of treatment were in urgent need of improve- ment. Furthermore, as they believed that any method associated with natural or artificial dilatation of the lower uterine segment still further 938 HEMORRHAGE agumented the danger, they advocated that all cases of partial or central previa should be treated by classical or extraperitoneal cesarean section, after which the lower uterine segment should be tightly packed with iodoform gauze. Their proposal was accepted by many operators, but called forth severe criticism on the part of more conservative obstetricians and has given rise to a voluminous literature. When we remember that .Jellet in 1910, and Essen-Moller in 1921, reported a maternal mortality from all causes of 3.69 and 3.7 per cent., respectively, and that Stratz lost only one of 110 personal cases, it is apparent that our German confreres have either greatly over-estimated the dangers of the condition, or had treated their patients badly prior to the employment of radical measures. This being the case, it seems doubtful whether trained and conservative obstetricians will endorse the extensive use of cesarean section, and I consider that its compara- tively frequent employment in this country aifords proof of the poor obstetrical training which our practitioners have received. Furthermore, its employment by any but expert operators will lead to a higher death rate than is obtained by the usual methods, and even in their hands it does not always give ideal results. For example, Stoeckel, who ad- vocates cesarean section, whenever as much as four centimeters of the internal os is covered by placental tissue and the patient is uninfected and the child viable, reports a mortality of 9.7 per cent, following it. For these reasons, I believe that the skillful obstetrican will rarely need to resort to cesarean section except under two conditions—first, in the very rare case of a primipara whose cervix is too rigid to permit the introduction of a balloon, and second in cases of complete placenta previa in women nearing the end of the childbearing period, who are especially desirous of a living child. Furthermore, I am prepared to admit that in many instances cesarean section done by a competent general surgeon will give better results than obstetrical treatment in unskilled hands, but that is not ideal obstetrics. Thus far, but two cesarean sections have been done in our service for placenta previa, and, as the results following the employment of the balloon have been extra- ordinarily satisfactory, I do not anticipate extending the employment of the former operation. The argument that wider use of cesarean section will increase the number of children born alive is plausible and attractive, but it should always be remembered that the majority of the children concerned are premature, so that even if they are delivered alive their chances for prolonged existence are not great, and consequently it seems the reverse of conservatism to expose the mothers to any additional risk on their account. POSTPARTUM HEMORRHAGE With the exception of the very rare cases incident to inversion of the uterus, a serious bleeding following the birth of the child is usually due to one of three causes. Of these the most common is defective function- ing of the uterine musculature or atony; less frequently it is due to re- POSTPARTUM HEMORRHAGE 939 tention of the partially separated placenta or of individual cotyledons; while occasionally it results from deep tears involving the tissues of the birth canal. Etiology.—As long as the placenta remains firmly attached to the uterine wall there can be no possibility of hemorrhage, but when it has become partially separated, the normal action of the uterine musculature is interfered with. As a result the torn vessels at the partially denuded placental site are imperfectly constricted, and more or less profuse hemor- rhage occurs. Incomplete separation of the placenta may be attributed to improper management of the third stage of labor, particularly the too early and energetic employment of Crede’s maneuver. Exceptionally, it may result from an abnormally intimate attachment of the placenta, due to defective development of the decidua, or some other morbid con- dition. The retention of isolated cotyledons or of a small succenturiate lobe interferes w'ith the normal contraction and retraction of the uterus in precisely the same manner as the partially separated placenta. The part played by deep tears of the generative tract is obvious, and will be considered in detail in the following chapter. In very rare instances serious hemorrhage may result from rupture of large varicose veins, of an aneurysm of the uterine artery, or the dis- turbance of areas of thrombosis in the cervix. Formerly, I held that atony of the puerperal uterus was a relatively infrequent cause of postpartum hemorrhage, but more prolonged ex- perience has convinced me that I was in error, and I now regard it as the most usual cause. This belief is based upon the fact that in most cases of moderate hemorrhage I have found no evidence of retention of placental tissue nor of tears, and the bleeding has persisted until vigorous contraction of the uterus was induced, when it ceased, never to return. The cause of such defective functioning of the uterine musculature is not known, but the condition is seldom primary; for, with the ex- ception of the instances in which it follows excessive distention of the uterus incident to twin pregnancy or hydramnios, serious abnormalities are often associated with some mechanical cause, such as retention of portions of the placenta, the presence of myomata, or in rare cases the existence of adhesions between the uterus and the surrounding organs. Occasionally atony may be associated with degeneration of the muscle fibers resulting from an abnormal invasion of foetal elements, as de- scribed by Kworostansky, Martin, and others. Moreover, the occasional instances in which patients bleed profusely after each labor without demonstrable cause likewise afford corroborative evidence. In a number of such cases Labhardt believes that he has been able to demonstrate the presence of an excessive amount of connective tissue between and within the muscle bundles. In view of our experience, it is certain that Areit went too far in denying in toto the possibility of a primary atony. The rare cases of hemorrhage following 'paralysis at the placental site, in which the rest of the organ remains firmly contracted, as in the cases reported by Chiari, Braun and Spaeth, Olshausen, and others, point to the possibility of a partial atony. HEMORRHAGE 940 Clinical History.—The loss of 600 or more cubic centimeters of blood was noted during and immediately following the third stage of labor in 13 per cent, of one thousand consecutive normal labors which 1 studied, while a loss of 1,500 or more cubic centimeters was observed about once in every one hundred labors, but with proper treatment a fatal issue should occur only once in 2,000 or 2,500 patients. Excessive bleeding may supervene either during or after the third stage of labor. In the first class of cases, as a rule, it is the result of tears or of partial separation of the placenta. Fortunately, hemorrhage dependent upon the latter cause is usually not serious, for the reason that the condition is only transitory, and ceases when complete separation has occurred, following which satisfactory uterine retraction checks the loss of blood. Exceptionally the bleeding may persist even after the placenta has be- come completely separated and lies free in the uterine cavity. In such cases it is due either to tears or to imperfect functioning of the uterus. Generally speaking, partial separation occurring during the course of placental expulsion by the Schultze mechanism is not accompanied by external hemorrhage until the placenta escapes from the vulva, when the large amount of blood collected behind it is suddenly discharged. In Duncan’s mechanism, on the other hand, the loss of blood continues throughout the entire placental period. A hemorrhage which persists after the extrusion of the placenta may be due to tears, retention of placental remnants, or to atony. In the first there is a steady flow of bright-red blood, which begins immediately after the delivery of the child. When due to retained placental tissue, the blood escapes in gushes, which are apt to be synchronous with the uterine contractions, and is frequently in large clots; whereas in cases due to primary atony there is a continuous flow of blood, which may be so abundant as to cause death within a very few minutes. In rare in- stances the hemorrhage may be concealed, several liters of blood some- times accumulating in the uterine cavity. The amount of blood lost during a postpartum hemorrhage may vary from 600 to 3,500 cubic centimeters, the latter extreme, however, being invariably incompatible with life, although upon several occasions I have seen recovery follow a loss of 2,500 cubic centimeters, and once after a measured loss of three liters. Generally speaking, the woman in labor can bear with comparative impunity the loss of an amount of blood which would seriously endanger the life of a well-developed man. This is attributed by Zuntz to the fact that a considerable increase in the amount of blood occurs during pregnancy, which has been confirmed by the as yet unpublished observations of Harris in our service. In any event, the effect of hemorrhage will depend more upon the general con- dition of the patient than upon the actual quantity lost. Thus, a woman who is already exhausted by a prolonged labor or weakened by antecedent disease may succumb after a loss of from 1,000 to 1,500 cubic centimeters, which others bear with impunity, but generally speak- ing the average woman can bear a loss of two liters without serious consequences. As a rule, the loss of a moderate amount of blood is not attended by serious symptoms; but when the hemorrhage is profuse POSTPARTUM HEMORRHAGE 941 the pulse becomes rapid and compressible, the face becomes pallid and assumes a drawn appearance, while at the same time the woman may complain of disturbed vision, chilliness, and shortness of breath. In extreme cases symptoms of air hunger appear, and the patient usually passes into unconsciousness before the fatal termination. Diagnosis.—The diagnosis offers no difficulty, except in the rare in- stances in which the hemorrhage has taken place into the uterine cavity and does not appear externally. It must, however, be distinctly stated that concealed hemorrhage should never occur if the condition of the uterus is conscientiously watched, although, if routine precautions are neglected, the first indication of the condition may be afforded by the pale and haggard appearance of the patient. On examination the pulse- rate will be found greatly accelerated, the uterus greatly increased in pize, and presenting a doughy consistence, instead of the characteristic firm, hard sensation offered by the normal puerperal organ. Pressure upon it is followed by a copious flow of blood from the vagina. As the decision concerning the proper treatment of the patient gen- erally depends upon the recognition of the source of the hemorrhage, a differential diagnosis is of the utmost importance. Generally speaking, if the bleeding commences immediately after the birth of the child, it is due either to tears of the genital tract or to partial separation of the placenta. In the latter case it usually ceases temporarily after energetic kneading of the uterus, but recurs as soon as it is allowed to relax. If such manipulations prove of no avail, it is probable that the hemorrhage comes from a tear, although this is not a universal rule, since in a certain number of instances the loss of blood will continue until the placenta is expressed by Crede’s method or is removed manually. Again, a hemorrhage persisting after the uterus has been emptied, while abdominal palpation shows that the organ itself is firmly con- tracted, suggests an extensive tear of the birth canal, which should be sought for, and closed with sutures when found. In order to accomplish this, the patient having been brought to the edge of the bed, the external genitalia are carefully inspected. If the perineum is intact, the cervix should be forced down toward the vulva by pressure upon the fundus, and if this fails to bring it into view, it should be exposed by means of a speculum and tenaculum forceps. If a cervical lesion cannot be detected, the vaginal walls should be spread apart by means of a speculum and thoroughly inspected. A hemorrhage which does not come on until ten or fifteen minutes after the birth of the child can hardly be due to this cause. On the other hand, if the uterus does not contract and retract firmly after the expulsion of the placenta, or if it remains so only so long as kneading is kept up, the cause of the hemorrhage must be sought for either in atony or in the retention of a placental cotyledon. Certainty with regard to the latter point is usually obtained by careful inspection of the after-birth, which should be made a matter of routine, a large defect upon its maternal surface indicating the retention of a cotyledon, while a more or less circular defect in the membranes a short distance from the placental margin shows that a succenturiate lobe has been left HEMORRHAGE 942 behind. At the same time one should be careful not to confound mere fissures with defects due to loss of tissue. The diagnosis of primary atony should be made only after every other explanation has been excluded. Treatment.—With proper management, serious hemorrhage during and directly following the third stage of labor should be extremely rare. The most important prophylactic measures consist in watching the condition of the uterus after the birth of the child, and not resorting to Crede’s maneuver until the rising up of the fundus indicates that the placenta has become completely detached. Premature attempts at ex- pression are a frequent cause of imperfect separation. Again, owing to the tendency toward relaxation following the birth of twins, as well as in hydramnios, concealed hemorrhage, and placenta previa, the condition of the uterus in such cases should be most carefully watched for the few minutes immediately following the birth of the child, and energetic kneading through the abdominal walls promptly resorted to upon the first sign of failing contraction. If examination of the placenta immediately after its expulsion re- veals any serious defect, immediate preparations should be made for the removal of the retained portion, whether symptoms supervene or not. In the presence of actual hemorrhage, the treatment varies according as the placenta is still within the uterus or has already been expelled. In the former case the uterus should at once be grasped through the abdominal wall and firmly kneaded. If firm contractions come on, all is well, but if the hemorrhage continues and the uterus relaxes as soon as the kneading is stopped, the placenta should be expressed by Crede’s method; and if this cannot be accomplished and the patient’s condition is alarming, it should be removed manually, when the directions given in Chapter XXIY should be conscientiously followed. If the hemorrhage does not cease after the delivery of the placenta, the cause should be ascertained and suitable treatment instituted. Tears should be located and their edges brought together by sutures. On the other hand, if the hemorrhage is the result of the retention of placental tissue, the gloved and disinfected hand should be carried up into the uterus in order to seek for and remove the retained cotyledon. In such circumstances the hand acts as a most efficient irritator, causing the uterus to contract energetically. After separating the retained portion of placenta, the hand should not be withdrawn at once, but should be allowed to recede gradually, as it is forced down by the contraction of the fundus. If the hemorrhage is due to atony, the uterus should be vigorously kneaded, and 1 cubic centimeter of pituitary extract followed by 30 minims of the fluid extract of ergot administered hypodermically. After careful disinfection of the skin, the needle should be plunged deep down into the tissues of the thigh, at right angles to the surface, since in this way the chances of abscess formation are greatly diminished. In my experience, pituitary extract acts within three minutes, but its effect is much more transient than that of ergot. Consequently, it is POSTPARTUM HEMORRHAGE 943 advisable to administer the former first, and to follow it by the latter if prolonged stimulation of the uterus is needed. If these measures are not attended with the desired result a very hot intra-uterine douche of several liters of sterile salt solution should be given. This usually acts as a most efficient hemostatic, effectively irri- tating the uterus and causing it to contract forcibly and permanently. If the hemorrhage persists in spite of the douche, our only hope of controlling it is by packing the uterus tightly with sterile gauze, which should be introduced according to the directions given in Chapter XXIY. Before resorting to the nse of the pack it is always advisable to palpate the interior of the uterus, as occasionally a portion of the placenta may have been retained, even though immediately after expul- sion the organ may have apparently been entire. Fieux has pointed out that postpartum hemorrhage is usually venous in character and occurs under very low pressure. Accordingly he states that placing the patient in the Trendelenburg posture, which can be improvised by adjusting the back of a chair under the mattress, over- comes the pressure and checks the bleeding. I have had no experience with the method, but he states that its results are sometimes marvelous. Should the loss of blood continue after the employment of these measures the aorta may be compressed by means of a stout rubber tube tied about the patient's waist, as recommended by Momburg. This emergency measure has been extensively employed in Germany, but has not found favor elsewhere. Occasionally in postpartum hemorrhage due to atony following pre- mature separation of the placenta, or placenta previa, slow bleeding will persist in spite of all these measures. In such circumstances, if the patient is in a hospital, life may be saved by opening the abdomen and removing the uterus. Formerly it was customary to recommend the introduction into the uterus of ice, or of solutions containing vinegar, the perchlorid of iron, or other astringent substances. Their employment, however, is not advis- able, since ice and ordinary vinegar are never sterile, while the iron solution accomplishes its purpose by the formation of dense coagula, which are later separated from the uterus by suppurative processes. Above all, none of them acts as promptly or efficiently as the pack, the employment of which, although comparatively rarely indicated, offers the most reliable means of coping with the condition. For this reason the obstetrician should always carry in his bag the materials necessary for it, as they cannot usually be obtained promptly in an emergency. Too great stress cannot be laid upon the importance of observing the most rigorous aseptic technic in every intra-uterine manipulation under- taken for the purpose of checking postpartum hemorrhage. The natural tendency of the physician is to forget all other risks in his attempts to check the bleeding promptly. Such neglect, however, is frequently at- tended by most serious consequences, the patient being saved from death from hemorrhage merely to perish of infection a few days later. For this reason, therefore, the obstetrician will usually best subserve the interests of his patient by taking the time necessary for carefully disin- 944 HEMORRHAGE fecting his hands, or at least for drawing on a fresh pair of sterile gloves, before beginning any manipulations. In view of the possibility of such emergencies, more than one pair of gloves should always be boiled and be ready for instant use even in what promises to be the simplest case. After the actual hemorrhage has been checked, attention must be directed to the general condition of the patient. When the shock is not profound and the pulse not particularly rapid, elevation of the foot of the bed and the application of hot bottles or bricks to the extremities will be all that is needed. In more severe cases, the administration of 1/30 grain of strychnin hypodermically, 3 doses being given in prompt succession, if necessary, is useful, and may be supplemented by hypo- dermic injections of whisky or ether. Hot rectal enemata of equal parts of black coffee and salt solution are also valuable. When the patient is seriously shocked, sterile normal salt solution in large quantities—500 cubic centimeters being injected under each breast, and repeated as soon as absorption has occurred—-will prove a useful temporary measure, and even more striking results may be obtained by administering it intravenously. In all such cases, however, preparations for actual transfusion should be made, and 500 to 750 of the donor’s blood injected, unless such improvement has resulted that its administra- tion appears needless. I am confident that by this means I have saved several lives, which otherwise would have been lost. INVERSION 0E THE UTERUS This condition is a very rare;, but important, cause of postpartum hemorrhage. According to Beckmann, not a single case occurred in 250,000 labors in the St. Petersburg Lying-in Hospital, while Madden noted it only once in 190,833 deliveries in Dublin. Many obstetricians in large practice have never seen a case, or have met with only a few examples of the condition. On the other hand, it is much more fre- quently noted in the practice of ignorant midwives. The historical and statistical aspects of the subject are fully dealt with in the articles of Beckmann, Browne, Holmes, and Vogel. Nowr and again the fundus of the uterus becomes inverted and comes into close contact with or may protrude through the external os; while in rare instances the entire organ appears outside of the vulva, the condi- tion being respectively designated as incomplete and complete inversion, and prolapse of the inverted uterus (Pig. 678). In not a few cases the placenta remains attached to the inverted organ. Etiology.—For the production of the accident three factors are neces- sary: marked laxity or thinness of the uterine walls, particularly at the placental site, pressure from above or traction on the cord or placenta, and a patulous cervical canal. Its occurrence is also favored by a fundal insertion of the placenta. Inversion may occur spontaneously as the result of the intra-abdominal pressure or from the mere weight of the intestines, but in most cases it is attributable to violence resulting from INVERSION OF THE UTERUS 945 the too vigorous employment of Crede’s maneuver or to traction upon the cord. In one of the cases which I saw in consultation it followed the manual removal of the placenta, while in two others it was due to too vigorous expression. Occasionally, inversion may recur in the same pa- tient, Fritsch having observed it in three successive pregnancies. Beckmann, who has carefully analyzed 100 cases reported in the literature, believes that in the majority of instances the accident occurs spontaneously, while Vogel, in a similar review, holds that most cases are due to violence. His contention appears to be confirmed by Beck- mann’s statistics, as only 3 of the 100 cases occurred in hospital practice. Fig. 677.—Prolapse of the Inverted Uterus (Bumm). Indeed, it is highly probable that the accident is excessively rare when labor is properly conducted, but that it occurs more frequently under the unfavorable conditions existing in private practice, particularly as conducted by midwives. The complication usually follows a full-term labor, although a num- ber of cases are recorded in which it was rioted after abortion. It is also an interesting fact that more than 50 per cent, of the cases recorded by both Beckmann and Yogel were in primiparous women. Symptoms.—As a rule, inversion of the uterus is promptly followed by alarming symptoms, the patient presenting evidences of shock out of proportion to the amount of blood lost, with a rapid pulse and a tendency to syncope. In other cases convulsions occur and profuse hemorrhage is 946 HEMORRHAGE frequently noted. On the other hand, the symptoms are sometimes very slight, and the condition may continue for several days without causing any serious annoyance to the patient. In rare instances the cervix may so retract about the completely in- verted uterus that strangulation occurs, followed by gangrene. In other cases this does not take place, but the condition becomes chronic, neces- sitating operative procedures later. Prognosis.—If the condition is detected promptly, and the uterus replaced immediately, the prognosis is fair, Beckmann reporting a mor- tality of 14 per cent. On the other hand, if strangulation or gangrene occur, the outlook is ominous. Treatment.—In very recent cases reposition can usually be effected without difficulty by pressure exerted by several fingers in the vagina, it being important to remember that the force should be directed upward in the axis of the superior strait. Neglect of this precaution undoubtedly accounts for a certain number of failures. As the procedure is generally painful, anesthesia should be employed. If the placenta is still attached to the uterus, it is generally advisable to defer its separation until reposition has been effected, because, the con- tractile function of the inverted uterus being in abeyance, there is always the risk of profuse hemorrhage. On the other hand, if the patient is not seen until several days after labor, the cervix may be so contracted that manual reposition cannot be accomplished, and operative procedures will become necessary. Full particulars concerning these will be found in the current works on gynecology. LITERATURE Ahlfeld. Ueber Placenta prsevia. Yerh. d. deutschen Gesell. f. Gyn., 1897, 268-277. Ahlfeld u. Aschoff. Neue Beitrage z. Genese der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1904, li, 544-556. Bar. Traitement chirg. des hemorrhagies de la grossesse, etc. Archives mens, d’obst. et de gyn., 1912, i, 162-176. Hemorrhagies retroplacentaires. Archives mens, d’obst. et de gyn., 1912, ii, 49. Barnes. .The Physiology and Treatment of Placenta Prarvia. London, 1858. Placenta Praevia. Lectures on Obstetric Operations, 4th ed. London, 1886, 398-422. Beckmann. Zur Aetiologie der Inversio uteri post partum. Zeitschr. f. Geb. u. Gyn., 1895, xxxi, 371-401. Behm. Die combinirte Wendung bei Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1883, ix, 373-419. Braun, Chiari, und Spaeth. Paralyse des Uterus. Klinik der Geb. u. Gyn., Erlangen, 1855, 202-204. Browne. Inversion of the Uterus. Amer. Gyn. and Obst. Jour., 1899, xv, 115- 129. Budin. Hemorrhagies uterines et rupture du sinus circulaire. Femmes en couches et nouveau-nes, 1897, 143-161. Bumm. Zur Frage der Eiimplantation auf dem inneren Muttermund. Zentralbl. f. Gyn., 1905, xxix, 4-7. XITERATURE 947 Burger u. Graf. Zur Statistik der Placenta praevia. Monatsschr. f. Geb. u. Gyn., 1907, xxv, 49-76. Colclough. The Treatment of Accidental Hemorrhage. J. Obst. and Gyn. Brit. Emp., 1902, ii, 153.' Couvelaire. Beux nouvelles observations d ’apoplexie utero-placentaire. Annales de gyn. et d’obst., 1912, ix, 416. Doranth. Statistisches iiber Placenta praevia. Chrobak’s Berichte aus der 2ten geb. gyn. Klinik in Wien, 1897, i, 77-119. Dorman. Premature Separation of the Normally Implanted Placenta, etc. Sloane Hospital Reports, 1913, i, 57. Dudley. The Modern Caesarean Section an Ideal Method of Treatment for Pla- centa Praevia. New York Med. Jour., 1900, lxxii, 754-760. Essen-Moller. L ’hemorrhagie retroplacentaire. Archives mens, d ’obst. et de gyn., 1913, iv, 145. Quelques remarques sur le traitment du placenta praevia. Acta Gyn. Scandi- navica, 1921, i, 1-9. Fieux. La position de Trendelenburg dans les hemorrhagies graves de la deliv- erance. Bull, de la soc. d’obst. de Paris, 1913, ii, 787-792. Fraipont. Fissures peritoneales des corps uterine dans les cas de decollemenl, premature du placenta, etc. Annales de gyn. et d’obst., 1914, xi, 200. Fritsch. Zur Aetiologie der puerperalen Uterusinversion. Zentralbl. f. Gyn., 1907, xxxi, 427-429. Gardiner. The Umbilical Cord. Surg. Gyn. & Obst., 1922, xxxiv, 252-256. Goodell. Concealed Accidental Haemorrhage of the Gravid Uterus. Amer. Jour. Obst., 1870, ii, 281-346. Gordon-Ley. Utero-placental (Accidental) Haemorrhage. Jour. Obst. & Gyn. Br. Emp., 1921, xxviii, 69-108. Harris. A Method of Performing Rapid Manual Dilatation of the Os Uteri, and Its Advantage in the Treatment of Placenta Praevia. Amer. Jour. Obst., 1894, xxix, 37-49. Herff. Zur Lehre von der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1896, xxxv, 325-372. Hofmeif.r. Ueber Placenta praevia. Yerh. d. deutschen Gesell. f. Gyn., 1888, 159-163. Zur Entstehung der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1894, xxxix, 1-17. Ueber Placenta praevia. Yerh. d. deutschen Gesell. f. Gyn., 1897, 204-225. Storungen der Schwangerschaft durch fehlerhaften Sitz der Placenta. Winckel’s Handbuch der Geb., 1904, ii, 1198-1259. Holmes. Inversio Uteri Complicating Placenta Praevia. Obstetrics, 1899, i, 297- 311. Ablatio Placentae. Amer. Jour. Obst., 1901, xliv, 753-784. Hunter. Anatomical Description of the Human Gravid Uterus. Birmingham, 1774. Jellett. The Place of Caesarean Section in the Treatment of Placenta Praevia. Lancet, 1910, i, 1271. Kaltenbach. Zur Pathogenese der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1890, xviii, 1-7. Kermauner. Placenta praevia cerviealis. Beitrage z. Geb. u. Gyn., 1906, x, 241. Knauer. Einige seltenere Falle von Gebarmutterzerreisung. Monatsschr. f. Geb. u. Gyn., 1903, xvii, 1279. Kronig. Zur Behandlung der Placenta praevia. Zentralbl. f. Gyn., 1908. Kustner. Ueber Placenta praevia. Yerh. d. deutschen Gesell. f. Gyn., 1897, 277- 283. 948 HEMORRHAGE Kworotansky. Ueber Anatomie und Pathologie der Placenta, etc. Archiv f. Gyn., 1903, lxx, 113-192. Labhardt. Ueber Placenta cervicalis. Gyn. Rundschau, 1908, ii, 702-707. Beitrage zur Kenntniss der anatomischen grundlagen der post-partum Blut- ungen. Zeitschr. f. Geb. u. Gyn., 1910, lxvi, 374-408. Lomer. On Combined Turning in the Treatment of Placenta Prjevia. Amer. Jour. Obst., 1884, xvii, 1233-1260. McNair. Concealed Accidental Hemorrhage with Intraperitoneal Bleeding. P.roc. Roy. Soc. Med., 1917, x, 13-16. Madden. Quoted by Browne. Martin. Zur Aetiologie lethaler Atonien post partum. Monatsschr. f. Geb. u. Gyn., 1906, xxiii, 207-217. Momberg. Blutleere der uteren Kdrperhalfte. Zentralbl. f. Gyn., 1909, 716. Morse. Premature Separation of the Normally Implanted Placenta. Surg. Gyn. & Obst., 1918, xxvi, 133-138. Muller, W. Placenta praevia. Stuttgart, 1877. Munchmeyer. Ueber den Yorfall der Nachgeburt bei regelmassigem Sitze derselben. Archiv f. Gyn., 1888, xxxiii, 486-497. Olshausen. Paralyse der Placentar-insertionsstelle. Schroeder’s Lehrbuch der Geb., XIII. Aufl., 1899, 775. Pinard. De la rupture prematuree, dite spontanee, des membranes, etc. Annale3 d’obst. et de gyn., 1886, xxv, 171-179; 321-345. Pinard et Varnier. Decollement premature par brievete du cordon de placenta normalement insere. Etudes d’anat. obst., 1892, 57. Ponfick. Zur Anatomie der Placenta praevia. Archiv f. Gyn., 1900, lx, 147-173. Portal. La pratique des accouchements, etc. Paris, 1685. Portes. Pathogenie et traitement de l’apoplexie utero-placentaire. Gyn. et Obst., 1923, vii, 56-74. Rigby. An Essay on the Uterine Haemorrhage which Precedes the Delivery of the Full-grown Foetus. London, 1776. Schaciier. De placentae uterime morbis. Lipsiae, 1709. Schickele. Die vorzeitige Losung der normal sitzenden Placenta. Beitrage zur Geb. u. Gyn., 1904, viii, 357-364. Seitz. Zwei sub partu verstorbene Falle von Eklampsie, etc. Archiv. f. Gyn., 1903, lxix, 71-99. Sellheim. Die Gefahren der natiirlichen Geburtsbestrebungen bei Placenta praevia, etc. Zentralbl. f. Gyn., 1908, 1297-1311. Smellie. A Treatise on the Theory and Practice of Midwifery, 1752. Spiegelberg. Die Inversion der Gebarmutter. Lehrbuch der Geb., 1891, III. Aufl., 599-607. Stoeckel. Zur Therapie du Placenta praevia. Monatsschr. f. Geb. u. Gyn., 1923, lxi, 52-62. Strassmann. Ueber Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1901, xliv, 529- 546. Placenta praevia. Archiv f. Gyn., 1902, xxvii, 112-275. Stratz. Behandlung der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1915, lxxvi, 713-728. Tait. On the Treatment of Unavoidable Haemorrhage by Removal of the Uterus. Med. Record, 1899, lv, No. 9. Tarnier et Budin. Hemorrhagie par insertion vicieuse du placenta. Traite de Part des accouchements, 1898, iii, 571-659. Thompson. The Treatment of Placenta Previa, together with the Anatomical Description of Two Specimens. Bull. Johns Hopkins Hosp., 1921, xxxii, 228-233. LITERATURE 949 Titus and Andrews. Frozen Sections through the Uterus of a Woman Dying from Central Placenta Previa. Am. Jour. Obst. & Gyn., 1923 (not yet pub- lished). Veit. Ueber die Behandlung der Blutungen unmittelbar nach der Geburt. Zeitschr. f. Geb. u. Gyn., 1895, xxxi, 214-225. Vogel. Beitrag zur Lehre von der Inversio uteri. Zeitschr. f. Geb. u. Gyn., 1900, xlii, 490-525. Weiss. Ueber vorzeitige Losung der normal sitzenden Placenta. Archiv f. Gyn., 1897, xlvi, 256-291. Zur Kasuistik der Placenta prsevia centralis. Zentralbl. f. Gyn., 1897, xxi, 641-649. Williams. Decidual Formation throughout the Uterine Museularis. Trans. Southern Surg. and Gyn. Ass., 1904, xvii, 119-132. Induction of Premature Labor and Accouchement Force, etc. Trans. Am. Gyn. Soc., 1906, xxxi, 316-333. Premature Separation of the Normally Implanted Placenta. Surg. Gyn. & Obst., 1915, xxi, 541-554. The Tolerance of Freshly Delivered Women to Excessive Loss of Blood. Am. Jour. Obst., 1919, lxxx, 1-17. Winter. Zur Lehre von der vorzeitigen Placentarlosung bei Nephritis. Zeitschr. f. Geb. u. Gyn., 1885, xi, 398-408. Wright. Some Points in the Diagnosis and Treatment of Accidental Haemorrhage. Am. Jour. Obst., 1906, liv, No. 5. Zuntz. Gesammtblutmenge in der Graviditat. Zentralbl. f. Gyn., 1911, 1365- 1369. CHAPTER XLI IN JUIHES TO THE BIliTH CANAL INJURIES TO THE VULVAL OUTLET In the chapter upon the Conduct of Normal Labor reference was made to the frequency of perineal lacerations, and emphasis was laid upon the necessity for repairing them immediately after the birth of the child. . More rarely tears occur about the anterior portion of the vulva. In spontaneous labor these seldom amount to more than slight abrasions upon the inner surfaces of the labia minora, but in forceps deliveries, especially when the handles have been unduly elevated, serious lesions may follow the compression of the tissues between the pubic arch and the blades of the instrument. Now and again the labia minora are completely severed or torn loose from their connections, or deep tears occur on either side of the urethra implicating the vessels supplying the clitoris and giving rise to profuse hemorrhage; Avhile following pubi- otomy, such tears may communicate with the pubic wound. INJURIES TO THE VAGINA With the exception of the most superficial varieties, which are limited to the mucous membrane of the fourchette, all perineal lacerations are accompanied by more or less injury to the lower portion of the vagina. Such tears rarely occur in the median line, but extend a variable dis- tance up one or both vaginal sulci, being sufficiently deep to involve some fibers of the levator ani muscle. Bilateral lacerations of this variety are usually unequal in length and are separated from one another by a tongue-shaped portion of mucosa which represents the lower end of the posterior column of the vagina (Big. 321). These injuries should always be looked for, and their repair should form a part of every operation for the restoration of a lacerated perineum. If this precaution is neglected and the external wound alone is sutured, the patient will eventually present symptoms due to relaxation of the vaginal outlet, even though the perineum proper may be in perfect condition. Isolated tears involving the middle or upper third of the vagina, and unassociated with lacerations of the perineum or cervix, are very rarely observed. They are usually longitudinal, and result from injuries, sus- tained during a forceps operation, though now and again they follow spontaneous delivery. They frequently extend deeply into the underlying 950 INJURIES TO THE VAGINA 951 tissues, and may give rise to a copious hemorrhage, which, however, is readily controlled by a few sutures. Their presence is readily overlooked, inasmuch as they can be recognized only after the vaginal walls have been spread apart by means of a speculum. More important are the injuries to the levator ani muscles, which are not associated with tears through the vaginal mucosa, and conse- quently usually escape immediate detection. As a result of overdis- tention of the birth canal, there may occur a submucous separation of certain fibers of the muscle, or at least so great a diminution in its tonicity, that it can no longer properly fulfill its function as the pelvic diaphragm. In such cases the patient sooner or later suffers just as severely from symptoms of relaxation as if a deeply lacerated perineum had been left unrepaired. Although the accident can sometimes be avoided by an intelligent use of forceps when the second stage of labor is unduly prolonged, it frequently follows spontaneous and rapid delivery. Lesions of the upper third of the vagina are extremely uncommon, unless they represent the extension of deep cervical tears into the fornix. In very rare instances, however, the cervix may be entirely or partially torn loose from its vaginal attachment, rupture in other cases occurring in either the anterior, posterior, or lateral fornix. Hugenberger, in 1875, collected 40 cases of this accident from the literature, and designated it as colpaporrhexis; while Kaufmann, in 1901, estimated that something more than 100 cases have been recorded altogether. The accident is somewhat analogous to rupture of the lower uterine segment, and follows energetic efforts on the part of the uterus to over- come some obstacle to the passage of the child. As a result of the retraction of Bandl’s ring, so great a strain may be exerted upon the cervix that it is torn loose from its vaginal attachment. It is commonly taught that colpaporrhexis is possibly only in those cases in which the lips of the cervix are not compressed between the presenting part and the pelvic wall, but are free to follow the retracting uterus. While colpaporrhexis sometimes occurs spontaneously, it more frequently fol- lows brutal and unskillful use of forceps. The symptoms are identical with those following rupture of the uterus, and will be considered under that heading. Immediately fol- lowing the rupture, the child may escape into the peritoneal cavity, after which the intestines may protrude into the vaginal canal, as in a case reported by Boss. The diagnosis is made solely by the sense of touch, as the clinical symptoms do not differ from those following rupture of the uterus. The prognosis is extremely unfavorable, 60 to 75 per cent, of the cases reported in the literature having ended fatally. Most authorities recommend treating the condition by means of a vaginal pack, a procedure which probably explains in part the high mortality. I, however, agree with Schick that laparotomy offers the best chance for successfully coping with this emergency, since in this way one can obtain an accurate idea of the extent of the injury, when the torn surfaces may be united by sutures, or, failing that, the uterus may be removed. 952 INJURIES TO THE BIRTH CANAL LESIONS OF THE CERVIX Slight degrees of cervical laceration must be regarded as an inevitable accompaniment of childbirth. Such tears, however, heal rapidly and rarely give rise to symptoms. In healing they cause a material change in the shape of the external os, and thereby afford us a means of determin- ing whether a woman has borne children or not. In other cases the tears are deeper, implicating one or both sides of the cervix and may extend up to or beyond the vaginal junction. In Fig. 678.—Annular Detachment of Cervix. Specimen Cast off before the Birth of Child, Showing Undulated and Rigid External Os and Obliterated Cer- vical Canal Seen from within. X 1. rarer instances the laceration may extend across the vaginal fornix or into the lower uterine segment, and occasionally open up the base of the broad ligament. Such extensive lesions frequently involve vessels of considerable size, and are then associated with profuse hemorrhage. Deep cervical tears occasionally occur during the course of sponta- neous labor, and under such circumstances their genesis is not always readily explainable. More usually, however, they follow rapid manual or instrumental dilatation, especially in eclampsia, placenta previa, or in the various types of cervical dystocia. Moreover, they are apt to result from attempts at delivery through an imperfectly dilated cervix, no matter whether forceps or version be employed. LESIONS OF THE CERVIX 953 Occasionally, even in spontaneous labors, the edematous anterior lip of the cervix may be caught between the head and the symphysis pubis and be compressed until it undergoes necrotic changes and separation occurs. In still rarer instances the entire vaginal portion may be torn loose from the rest of the cervix. According to Boudreau, this so-called annular or circular detachment of the cervix usually occurs in elderly primiparae when the pains are strong and a serious obstacle to delivery is offered by an imperfectly dilated os externum. Symptoms.—In all lesions involving the cervix there is usually no escape of blood until after the birth of the child, when the hemorrhage may be profuse. In many cases, however, the bleeding is so slight that the condition would pass unrecognized were it not detected upon vaginal examination. When one lip of the vaginal portion of the cervix is torn off, there is usually very little hemorrhage, for the reason that the tissues have been so compressed before the occurrence of the accident that the vessels have undergone thrombosis; likewise, circular detachment of the cervix is often not followed by bleeding. Slight cervical tears heal spontaneously, and extensive lacerations have a similar tendency, but perfect union rarely results. They afford to any pathogenic microorganisms which may be present a ready portal of entry into the lymphatics at the base of the broad ligament. Diagnosis.—A deep cervical tear should always be suspected in cases of profuse hemorrhage coming on during the third stage of labor, if the hand applied over the lower abdomen can feel that the uterus is firmly contracted. For a positive diagnosis, however, a thorough exami- nation is necessary. Owing to the flabby condition of the cervix imme- diately after delivery mere digital examination is often unsatisfactory, and the extent of the injury can be fully appreciated only after drawing the cervix down to the vulva and carefully subjecting it to direct in- spection. In view of the frequency with which deep tears follow artificial dilatation, and difficult breech extractions and forceps operations, the cervix in all such cases should be inspected at the conclusion of the third stage, even if there be no bleeding; and if a tear is discovered, it should be united by sutures as a prophylactic measure. Annular detachment of the vaginal portion of the cervix should be diagnosticated whenever an irregular mass of tissue having a circular opening in its center is cast off before or after the birth of the child. Treatment.—Deep cervical tears accompanied by hemorrhage should be immediately repaired, the introduction of a few sutures readily check- ing the flow of blood. On the other hand, if there be no hemorrhage, the condition usually escapes detection unless specifically looked for. 1 have already indicated the advisability of inspecting the cervix after certain operative procedures; but I consider its routine employment unnecessary after normal labor, as I hold that the benefits following the repair of all tears will be more than counterbalanced by the increased incidence of infection resulting from the necessary manipulations. More- over, the majority of such tears heal spontaneously, and ia the exceptional 954 INJURIES TO THE BIRTH CANAL cases in which this does not occur better results are obtained by a secondary operation performed in the latter part of the puerperium. The treatment of cervical tears associated with hemorrhage varies with the extent of the lesion. When the laceration is limited to the cervix, or even when it extends well into the vaginal fornix, satisfactory results are obtained by the introduction of sutures after bringing the cervix into view at the vulva. This is effected by having an assistant make firm downward pressure upon the uterus, while at the same time Fig. 679.—Lacerated Cervix Drawn down to Vulva, Preparatory to Repair (Bumm). the operator exerts strong traction by means of a bullet forceps inserted into either lip of the cervix, the vaginal walls being held apart by means of suitable retractors (Fig. 679). As the hemorrhage usually comes from the upper angle of the wound, it is advisable to apply the first suture in that situation, since if the suturing is begun at the free end of the tear a dead space is often left toward its upper extremity, from which subsequent hemorrhage may occur. Chromicized catgut sutures should be employed, as they do not have to be removed. The beginner is cautioned against too great a regard for appearances and attempting to give the cervix too normal a look, inasmuch as the retraction occurring within the next few days may lead to such constriction of its lumen as to cause retention of the lochial discharge. RUPTURE OF THE UTERUS 955 Many authorities recommend a tight vaginal pack in this class of cases. No doubt it will usually check the hemorrhage and may be em- ployed in an emergency, but it does not compare in efficiency with repair by suture. In the rare cases in which the wound extends through the broad ligament into the peritoneal cavity a tight pack may be introduced, provided there is no serious hemorrhage; but in all other cases the only satisfactory method of dealing wuth the condition is by laparotomy. The treatment of tears of the upper part of the cervix which involve the lower uterine segment will be considered in the follow-ing section. RUPTURE OF THE UTERUS This accident, which is one of the most serious with which the obstetrician can be confronted, seldom occurs except in prolonged and obstructive labors, although instances of spontaneous rupture during pregnancy are not unknown. While spontaneous rupture occurs more frequently in the last months, it may be met with at any period of pregnancy. Thus 31 out of 78 cases collected by Baisch were observed during the first five months of pregnancy. In the first half of gestation the accident is usually due to pregnancy in the interstitial portion of the tube or in a bicornuate or infantile uterus, or to excessive invasion of the uterine wall by foetal elements. In the latter months the condition is usually associated with the presence of scar tissue in the uterine wall, which yields gradually with the increasing distention of the organ. Accordingly it occurs in 1 or 2 per cent, of women who had previously been subjected to cesarean section, or in women whose uteri had been previously perforated or otherwise injured during curettage or some other operative procedure. Very exceptionally the accident may be attributed to lack of hypertrophy of the uterine wall at the fundal region; while Poroschin considers that it may be due to the scanty development or relative absence of elastic tissue. Alexandroff, Jellinghaus, and others are inclined to attribute certain cases to inherent weakness of the uterine walls resulting from the excessive formation of connective tissue following the removal of an adherent placenta in previous pregnancies. Schafer has reported a case due to diffuse adenomyometritis, and has collected the literature up to 1918. In spontaneous rupture occurring during pregnancy, the lesion is almost invariably situated in the upper portion of the uterus. This is in marked contrast to the conditions observed at the time of labor, when the rupture is usually limited to the lower segment, and clearly indicates that radically different etiological factors must be concerned. Contrary to the statement of Blind that the rupture nearly always occurs in the neighborhood of the fundus, Baisch found that it was situated upon the anterior or posterior wrnll in 32 out of 56 cases in which the location of the rupture has been accurately described. The symptoms, diagnosis, prognosis, and treatment of this condition are identical with those following rupture of the uterus occurring at the 956 INJURIES TO THE BIRTH CANAL time of labor. It should be noted, however, that in a number of the cases reported in the literature the hemorrhage following the accident was so slight as not to give rise to symptoms, the condition escaping recognition until operative procedures became necessary for the removal of the foetus lying free in the abdominal cavity. In very exceptional instances, as in the cases reported hy Leopold and Henrotin, the placenta remained in the uterus, while the foetus, surrounded by its membranes, escaped into the peritoneal cavity, where it went on to further development—utero-abdominal pregnancy. Such an occurrence is very unusual, as escape into the peritoneal cavity is ordinarily synonymous with foetal death. Etiology.—Eupture of the uterus at the time of labor occurs once in every 500 or 1,000 deliveries, and is a most serious complication, as it nearly always leads to the death of the foetus, and frequently to that of the mother as well. We are indebted to Bandl for the first clear explanation as to its mode of production, its etiology being inseparably connected with the doctrine of the lower uterine segment and the formation of the con- traction ring. Normally, under the influence of labor pains the uterus becomes differentiated into two portions, separated by a circular ridge of tissue, to which the term contraction ring is usually applied. The upper, by its contractions, serves to expel the child, while the lower undergoes dilatation and passively forms part of the canal through which the contents of the uterus are expelled. On the other hand, when a serious obstacle is opposed to the passage of the child, the active portion of the uterus is stimulated to more forcible efforts. As it contracts it likewise slowly becomes retracted, its lower margin—the contraction ring— eventually occupying a much higher level than usual. As a result, particularly if the lips of the cervix are caught between the presenting part and the superior strait, powerful upward traction is exerted upon the passive lower segment of the uterus, which becomes more and more stretched, and thinner and thinner. At the same time the contraction ring separating the two portions becomes thicker and more prominent, so that it can readily be palpated, and occasionally seen as a transverse or oblique ridge extending across the abdomen just below or perhaps on a level with the umbilicus. The round ligaments, likewise, are sub- jected to an abnormal strain and remain tense even in the intervals between the uterine contractions. As the process goes on the lower segment becomes extremely sensitive to pressure, and the contractions increase progressively in frequency and intensity, until eventually the upper segment of the uterus passes into a tetanic condition, and no longer alternates between contraction and relaxation. At the same time the contraction ring becomes more prominent on palpation. The pulse becomes more rapid, and as a result of the increased suffering the patient presents a worn and haggard appearance. Such a condition indicates that rupture is imminent and will occur unless delivery is promptly effected in a conservative manner. Generally speaking, rupture is more apt to take place when one RUPTURE OP THE UTERUS 957 side of the lower uterine segment is subjected to greater stretching than the other. In transverse presentations this condition is most marked on the side of the uterus occupied by the head. A similar danger threat- ens the posterior wall when the child presents by the head and the patient has a markedly pendulous abdomen. Excessive stretching of the lower uterine segment, with consequent danger of rupture, is favored by any factor which interferes with the birth of the child, and more particularly with the entrance of the pre- senting part into the pelvis. Such conditions are most frequently afforded by contracted pelves, neglected transverse presentations, hydro- cephalus, excessive size of the child, and, in fact, by any obstacle to labor. In recent years, the injudicious use of pituitary extract in cases of disproportion has resulted in the production of many uterine ruptures, which are frequently accompanied by unusually extensive injury. The following analysis by Merz shows the etiological factors concerned in the production of 160 cases of rupture of the uterus: Contracted pelvis 70 Neglected transverse presentation 26 Hydrocephalus 18 Large child or unfavorable presentation 10 Stenosis of birth canal 6 Trauma 5 Pelvic tumor 3 Ascites 1 Operative procedures 21 It is generally held that excessive stretching of the lower nterine segment can occur only after a prolonged second stage, but Goldner, in 1903, reported 19 instances in which rupture appeared imminent before the escape of the amniotic fluid. In these cases the condition was associated with oligohydramnios, very resistant membranes, or a rigid cervix. It is customary to distinguish between spontaneous and traumatic rupture of the uterus. In the former the accident occurs spontaneously, while in the latter it is the result of ill-judged manipulations on the part of the obstetrician in a uterus whose lower segment is so thinned out and distended that the slightest violence proves too much for its resisting powers. In other cases it may result from the upward exten- sion of cervical tears, following rapid manual or instrumental dilatation of the cervix. Traumatic rupture occurs relatively frequently when version is at- tempted in neglected transverse presentations. The proper treatment of this complication requires the utmost nicety of judgment, as it is oft- times extremely difficult to determine whether the lower uterine segment is so thinned out as to contra-indicate attempts at version, the operation being sometimes readily accomplished under anesthesia in cases in which, at first sight, it had appeared impracticable; whereas, in others, in which it seemed that the necessary manipulations would be without danger, rupture follows the mere introduction of the hand. Moreover, there is a marked difference in the rapidity with which overstretching of the lower uterine segment comes about, the condition supervening 958 INJURIES TO THE BIRTH CANAL very rapidly in some cases, while in others many hours of strong, second- stage pains may be necessary for its production. Certain women seem to possess a predisposition toward rupture of the uterus, this assumption being supported by the fact that not a few cases of repeated rupture appear in the literature. Thus, Mikhine found records of 13 patients, 6 of whom died as a result of a second rupture, the latter occurring in tissues already weakened by the previous accident. Pathology.—Spontaneous rupture of the uterus occurring at the time of labor is limited almost entirely to the lower uterine segment, the rent usually pursuing an oblique direction; although when it is in the Fig. 680.—Longitudinal Section through Woman Dying from Rupture of the Uterus (Zweifel). immediate vicinity of the cervix it frequently extends transversely. On the other hand, it is usually longitudinal when it occurs in the portion of the uterus adjacent to the broad ligament, and, according to Freund, when it occurs spontaneously in neglected transverse presentations. It is customary to distinguish between complete and incomplete rup- ture, according as the laceration communicates directly with the ab- dominal cavity or is separated from it by the peritoneal covering oi the uterus or broad ligament. The former is the more common, Merz having collected 118 complete as against 46 incomplete ruptures. Lobenstine noted 46 and 29 cases respectively in the New York Lying-in Hospital. Incomplete ruptures frequently extend into the broad ligament; in such circumstances the hemorrhage often occurs less rapidly than in the complete variety, the blood slowly accumulating between the leaflets and leading to the separation of the peritoneum from the surrounding viscera, with the consequent formation of a large subperitonenl hema- toma. Occasionally, an effusion of blood sufficiently copious to cause RUPTURE OF THE UTERUS 959 the death of the patient may be inclosed between the structures. More frequently, however, the fatal issue does not occur until rupture of the hematoma into the peritoneal cavity relieves the pressure which had previously, to some extent, restrained the bleeding. Although occurring primarily in the lower uterine segment, it is not unusual for the laceration to extend further upward into the body of the uterus or dowmward through the cervix into the vagina. The tear itself usually presents jagged, irregular markings which are stained with blood. Following complete rupture, the uterine contents may escape into the peritoneal cavity, while in the incomplete variety they may remain within the uterus, or come to lie beneath the serous covering of the uterus or between the leaflets of the broad ligament. When the pre- senting part is firmly engaged at the time of rupture, only a portion of the foetus may escape, the rest remaining in the uterine cavity. Symptoms .—The symptoms of actual rupture vary considerably. During the latter months of pregnancy, whether it occurs spontaneously or as the result of traumatism, the patient usually experiences sharp abdominal pain. In some cases marked symptoms of collapse immedi- ately supervene, but in many instances the patient merely complains of malaise, grave symptoms only occurring later as the result of infection or of putrefaction of the foetus. Thus, in one of my cases, two weeks elapsed before the appearance of alarming symptoms; wdiile in another, in which the scar of a previous cesarean section had given way and the entire product of conception had been expelled into the peritoneal cavity, the patient walked to the dispensary the day after the accident, and presented a pulse of only 80 when placed upon the operating table. In'the earlier months, on the other hand, profuse hemorrhage is the rule, and the patient rapidly succumbs to acute anemia if not operated upon. If the accident occurs at the time of labor, the patient, after pre- senting for some time the premonitory signs of the accident, suddenly, at the height of an intense uterine contraction or during an intra-uterine manipulation, complains of a sharp, shooting pain in the lower abdomen, and frequently cries out that something has given way inside of her. At the same time the lower uterine segment becomes much more sensitive to pressure. Immediately following these symptoms there is an absolute cessation of the uterine contractions, and the patient, who had previously been in intense agony, suddenly experiences great relief. At the same time there is usually some external hemorrhage, although in many cases it is very slight in amount. Palpation or vaginal examination shows that the presenting part has slipped away from the superior strait and has become movable, while a hard, round body, which represents the firmly contracted uterus, can he felt alongside of the foetus. Naturally, if the uterine contents have escaped into the abdominal cavity, the presenting part cannot be felt on vaginal examination. As a rule, shortly after the occurrence of complete rupture, the patient presents symptoms of collapse, the pulse increases greatly in rapidity, loses tone, and takes on a filiform character, the face becomes 960 INJURIES TO THE BIRTH CANAL pallid., assumes a drawn appearance, and is often covered with beads of sweat. If the hemorrhage has been copious, she may complain of chilliness, disturbances of vision, and air hunger, and eventually pass into an unconscious state. Symptoms of collapse, however, do not always appear immediately, but are sometimes deferred for several hours after rupture, being less marked when the child remains partially within the uterus. After incomplete rupture, on the other hand, the immediate symptoms are sometimes very slight, but increase in severity as the subperitoneal hematoma becomes larger, while actual symptoms of col- lapse sometimes do not appear until secondary rupture into the peri- toneal cavity has taken place. Occasionally after incomplete rupture, emphysematous crackling can be elicited in the tissues of the anterior abdominal wall, 14 cases of this character having been collected by Dischler. It is probably due to the invasion of the subperitoneal connective tissue by Bacillus aerogenes capsulatus. It is true that bacteriological proof has not been adduced in support of this statement, but the fact that the women had been in labor for many hours, and that many of the children were more or less putrefied, speaks strongly in favor of such a view. Diagnosis.—In cases of spontaneous rupture during pregnancy the diagnosis is not always easy. If the collapse is profound, it should at once lead to a provisional diagnosis of intra-abdominal hemorrhage, but in other cases the condition may escape detection until the appearance of peritonitic symptoms. Generally speaking, it may be said that a rapid pulse, slight elevation of temperature, and abdominal distention associated with very distinct palpation of the foetus, should always be regarded with grave suspicion, particularly when preceded by a history of traumatism. On the other hand, the diagnosis is usually easy when the accident occurs at the time of labor, especially if the patient has been under supervision during its course. If she is not seen until later the charac- teristic history and the collapse are almost pathognomonic, the only other conditions in which the latter is noted before delivery being in cases of rupture of an advanced extra-uterine pregnancy, or of the premature separation of the normally implanted placenta. If the child has escaped into the abdominal cavity it is much more readily felt on palpation than usual, while on one side of it the hard, rounded body of the uterus can be detected. Moreover, vaginal exami- nation sometimes reveals the existence of a tear in the uterine wall through which the fingers can be passed into the abdominal cavity, where they come in contact with the intestines, although failure to detect the tear by no means indicates its absence. Again, the fact that the presenting part can no longer be felt is conclusive evidence that the foetus has escaped from the uterus. Prognosis.—The chances for the child are almost uniformly bad, since it frequently succumbs before the occurrence of the accident. On the other hand, if it has survived up to that time, its only chance of living is afforded by immediate extraction, asphyxia, the result of the separa- tion of the placenta, being otherwise inevitable. If left to themselves, RUPTURE OF THE UTERUS 961 the vast majority of the mothers die from hemorrhage or infection, although spontaneous recovery has been noted in exceptional cases. In the 23 cases reported by Scipiades, which came to autopsy, death was due to infection in 52 per cent., to hemorrhage in 39 per cent., and to hemorrhage and shock in 44 per cent. Death from hemorrhage usually occurs within the first few hours, though ocasionally it may be deferred for forty-eight hours; in infection the fatal termination may not occur for some days. Spontaneous recovery is least likely when the child has escaped into the abdominal cavity, though isolated instances are on record in which the patient has survived even such an accident. In such circumstances the child is usually surrounded by foetal membranes, and after its death may undergo any one of the several eventualities mentioned in the chapter on Extra-uterine Pregnancy. So far as the women are con- cerned, even if properly treated, the mortality is very high, at least one-third succumbing. Treatment.— (a) Prophylactic.—Intelligent care of the lying-in woman should almost entirely do away with this accident. Accordingly, it occurs very rarely in well-regulated hospitals and comparatively fre- quently in the homes of the poor—in Scipiades’ series of 91 cases the respective incidence was 0.046 and 0.53 per cent. Whenever there is a possibility of the existence of an obstacle to the birth of the child, the obstetrician should always be on the alert for symptoms indicative of impending rupture. Transverse presentations should be promptly delivered by version as soon as the cervix is fully dilated; in head presentations failure of engagement after one hour of strong second-stage pains should be regarded with suspicion, and, if the contraction ring rises up, labor should be promptly terminated by the most conservative procedure. In neglected cases decapitation in transverse and craniotomy in head presentations often promise the best results. Such procedures are the more justifiable in the circumstances, as the children are usually either already dead or have been exposed to such danger that their chances of being delivered alive are very slight. (6) Curative.—If the child is alive and still within the ruptured uterus, or if it has already escaped into the abdominal cavity, no attempt should be made to extract it per vaginam, but laparotomy should be immediately performed, and followed, after removal of the child, by whatever operative procedures may be deemed necessary—suture of the tear, supravaginal amputation, or total removal of the uterus. On the other hand, if the child is dead and still within the uterus, certain authorities recommend its delivery through the natural passages by the most feasible and conservative procedure, after which, as well as in those cases which are not seen until after delivery per vaginam or in which the uterine rupture was not recognized until later, various procedures have been suggested by different authorities. I do not advocate delivering the child through the natural passages in any case, but I would especially warn against any attempt to do so after it had escaped into the peritoneal cavity, as the necessary manipulations will inevitably add to the shock from which the patient is suffering, and 962 INJURIES TO THE BIRTH CANAL lead to an increase in the size of the tear and render its repair more difficult when the abdomen is opened. I believe that in hospital practice the best results will follow lapa- rotomy, no matter what the character of the tear or the extent of the hemorrhage; for the reason that it is often difficult to determine the extent of the laceration, and furthermore that it is impossible to foretell whether the hemorrhage can be controlled by simple procedures. I therefore agree with Fritsch, Yarnier, Zweifel, and Munro Kerr, who hold that it is only by opening the abdomen that one can be assured against all further risk of hemorrhage. In general, the best results are obtained by amputating the uterus. At first glance it would appear very simple to repair the rent by sutures, and thus preserve the organ. But in practice it is not so simple, for in many instances the wound conditions are so complicated and the edges of the rent so damaged by hemorrhage and trauma, that accurate coaptation by means of sutures is out of the question. Furthermore, the fact that the patient has probably already been infected would contra-indicate any attempt to conserve the damaged tissues. On the other hand, if the patient cannot be removed to a hospital, and expert surgical aid is not available, one must be content with the employment of palliative measures after having delivered the child and placenta through the natural passages. In such circumstances, the results are usually disastrous following complete rupture, but are sometimes surprisingly good in the incomplete variety. Many authorities contend that, inasmuch as the danger to he ap- prehended in cases of incomplete rupture is hemorrhage, laparotomy should be performed only when the loss of blood is profuse, but that in all other cases equally good, if not better, results may be obtained by draining or packing the rupture from the vagina. Sehmit, Ivlien, Scipi- ades, and others have collected large series of cases which apparently bear out this contention. My own experience, however, leads me to believe it irrational to adopt such procedures as a matter of choice, as occasionally women who are apparently in excellent condition shortly after the occurrence of the rupture may begin to bleed profusely some hours later, and may die before operative measures can be instituted. Furthermore, I do not believe that the statistical evidence thus far adduced gives a correct idea of the relative merits of the two methods of treatment, for the reason that packing is usually employed in the milder and more favorable cases, whereas radical surgical measures have been practically limited to the desperate cases. INSTRUMENTAL PERFORATION OF THE UTERUS Reference has already been made to perforation of the uterus follow- ing attempts at criminal abortion or in the effort to remove placental tissue by means of curette or polypus forceps, after an incomplete abortion. Similar accidents likewise occasionally occur as the result of want of skill on the part of the obstetrician in full-term labor, when LITERATURE 963 either the uterus or the vaginal vault may be perforated. As has already been pointed out, in cases of this character, loops of intestine frequently prolapse through the rupture. In such circumstances laparotomy is the ideal treatment, though, in the absence of prolapse of the intestines cases are recorded in which recovery occurred spontaneously under what were apparently most unfavorable circumstances. PERFORATION OF THE GENITAL TRACT FOLLOWING NECROSIS In obstructed labor the tissues in various portions of the genital tract may be forcibly compressed between the head and the bony canal. If the pressure is transitory it is without significance; but if it is long continued necrosis results, and after a few days the area implicated sloughs away so that perforation follows. In most cases of this character the perforation occurs between the vagina and the bladder, giving rise to a vesicovaginal fistula. Less frequently the anterior lip of the cervix is compressed against the symphysis pubis, and an abnormal communication is eventually estab- lished between the cervical canal and the bladder—cervicovesical fistula. If the patient is not infected the fistulous tract frequently heals without further treatment. In other cases, however, it may persist, when a subsequent plastic operation becomes necessary for its cure. Occasionally the posterior wall of the uterus may be subjected to so much pressure against the promontory of the sacrum that necrosis re- sults, and a connection is established with Douglas’s culdesac. If infec- tion occurs the accident is usually followed by septic peritonitis. Fortu- nately, recovery usually follows without further complications, inasmuch as a localized peritonitis leads to the formation of adhesions between the posterior wall of the uterus and the pelvic peritoneum, thereby doing away with the possibility of a general peritoneal infection. It should be remembered that similar lesions may occur in the rare cases in which exostoses or bony spicules protrude from the walls of the birth canal, as in pelvis spinosa. LITEEATUEE Alexandroff. Ein Fall von Uterusruptur wahrend der Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1900, xii, 447-457. Baisch. Ueber Zerreissung der Gebarmutter in der Schwangerschaft. Beitrage. z. Geb. u. Gyn., 1903, vii, 248-283. Bandl. Ueber Euptur des Uterus und ihre Mechanik. Wien, 1875. Blind. Beitrag zur Aetiologie der Uterusruptur wahrend der Schwangerschaft und unter der Geburt. D. I., Strassburg, 1892. Boudreau. L’arrachement circulaire du col uterin pendant 1’accouchement. These de Toulouse, 1902. Uischler. Ueber subperitoneales Emphysem nach Euptura uteri. Archiv f. Gyn., 1898, lvi, 199-217. Freund. Neuere Arbeiten iiber die Zerreissung der Gebarmutter. Zeitschr. f. Geb. u. Gyn., 1910, Ixv, 735-759. 964 INJURIES TO THE BIRTH CANAL Fritsch. Ueber die Behandlung der Uterusruptur. Verh. d. deutschen Gesell. f. Gyn., 1895, 1-19. Goldner. Dehnung des unteren Uterinsegments bei stehender Blase. Monatsschr. f. Geb. u. Gyn., 1903, xviii, 491-512. Henrotin. Utero-abdominal Gestation. The Practice of Obstetrics by American Authors, 1899, 386. Hugenberger. Ueber Kolpaporrhexis in der Geburt. Petersburger med. Zeitschr., 1875, v, Heft, 5. Jellinghaus. Ueber Uterusrupturen wahrend der Schwangerschaft. Archiv f. Gyn., 1897, liv, 103-116. Kaufmann. Ueber die Zerreissung des Scheidengewolbes wahrend der Geburt. Monatsschr. f. Geb. u. Gyn., 1901, xiii, 464-470. Kerr. Rupture of the Uterus and Its Treatment. Jour. Ofcst. and Gyn. Brit. Empire, 1908, xiv, 1-22. Klien. Die operative und nicht operative Behandlung der Uterusruptur. Archiv f. Gyn., 1900, lxii, Heft 2. Leopold. Ausgetragene secundare Abdominalschwangerschaft nach Ruptura uteri traumatica, etc. Archiv f. Gyn., 1896, lii, 376-388. Lobenstine. Rupture of the Uterus during Labor. Am. Jour. Obst., 1909, lx, 810-852. Merz. Zur Behandlung der Uterusruptur. Archiv f. Gyn., 1894, xlv, 181-271. Mikhine. Un cas de recidive de rupture uterine. Annales de gyn. et d’obst., 1902, lvii, 403-410. Peham. Ueber Uterusrupturen in Narben. Zentralbl. f. Gyn., 19Q2, xvi, 87-94. Poroschin. Zur Aetiologie der spontanen Uterusruptur wahrend Schwangerschaft und Geburt. Zentralbl. f. Gyn., 1898, xxii, 183. Ross. Lacerated and Punctured Wounds of the Genital Tract. Amer. Jour. Obst., 1898, xxxvii, 449-469. Banger. Ruptura uteri. Verh. der deutschen Gesell. f. Gyn., 1895, 19-86. Schafer. Zur Aetiologie der Schwangerschaftsrupturen. Archiv. f. Gyn., 1918, cix, 284-301. Sciiick. Zerreissung des Scheidengewolbes wahrend der Geburt. Prager med. Wochenschr., 1893, xxiii, 355, 367. Schmit. Ein Beitrag zur Therapie der Uterusruptur. Monatsschr. f. Geb. u. Gyn., 1900, xii, 325-342. Scipiades. Ueber die Zerreissung der Gebarmutter. Tauffer’s Abhandlungen aus dem Gebiete der Geb. u. Gyn., 1909, i, 168-304. Varnier. Du traitement des ruptures de 1’uterus. Annales de gyn. et d’obst., 1901, Ivi, 249-279. Zweifel. Ueber die Behandlung der Uterusruptur. Beitrage z. Geb. u. Gyn., 1903, vii, 1-27. CHAPTER XLII PEOLAPSE OF THE UMBILICAL COED—ASPHYXIA NEONATOEUM— SUDDEN DEATH DUEING LABOE PROLAPSE OF THE UMBILICAL CORD It is customary to distinguish between presentation and prolapse of the funis or umbilical cord. In the former the cord can be palpated through the intact membranes, while in the latter a loop of it protrudes through the cervix into the vagina, and exceptionally emerges from the vulva. In general it may be said that any factor which interferes with the accurate adaptation of the presenting part to the superior strait predisposes to prolapse of the cord. Accordingly, the accident occurs most commonly in transverse and foot, and less often in frank breech presentations. On the other hand, it is rarely observed when the child presents by the head, unless accommodation is interfered with as a result of contracted pelvis, excessive development of the foetus, hydram- nios, or abnormal liaccidity of the lower uterine segment. For this reason it is much more common in multiparous than in primiparous women. Prolapse of the cord is without appreciable effect upon the course of labor so far as the mother is concerned. On the other hand, it is one of the frequent causes of foetal death, compression between the presenting part and the pelvic wall interfering with the circulation to such an extent that asphyxia and inevitable death often follow unless prompt delivery is effected. The danger is greater in vertex than in other presentations, for the reason that there is less likelihood that the cord will escape compression when the pelvic canal is filled out by the hard, rounded head than by the softer and more irregularly shaped part in other presentations. Presentation of the funfls is diagnosticated when on palpation a soft, pulsating, cordlike body can be felt through the membranes. In many instances, however, its recognition is only possible when the cord is in direct contact with the presenting part. Prolapse of the cord, on the other hand, is readily recognized, since on vaginal examination the fingers come directly in contact with a loop, while exceptionally it may be seen protruding from the vulva. In the former case mistakes are hardly possible if the foetus is alive, as distinct pulsations are felt, although in their absence the condition is sometimes overlooked on superficial examination. The possibility of prolapse of the cord should be particularly borne in 965 966 SUDDEN DEATH DURING LABOR mind in normal multiparous women in whom the membranes rupture while the head is still freely movable above the superior strait. In sueh cases the sudden cessation of the foetal heart-beat renders the diagnosis almost certain, even without vaginal examination. Treatment.—The treatment to be pursued in any given case depends mainly upon the degree to which the cervix is dilated, and to a lesser extent upon the presentation of the child. In cases of presentation of the funis there is no immediate danger of compression so long as the membranes remain intact, and for this reason every precaution should be taken to avoid their premature rupture, vaginal examinations being made with the utmost gentleness. Furthermore, the obstetrician should hold himself in readiness to effect delivery as soon as the cervix is sufficiently dilated. If the cord prolapses under the observation of the obstetrician, the cervix is fully dilated, and no great disproportion exists, the life of the child can usually be saved. No attempt at reposition should be made, but delivery should be effected at once. In cephalic and trans- verse presentations version is usually the operation of choice, but forceps are indicated when the head is already deeply down in the pelvic canal. In breech presentations a foot should be brought down and extraction promptly completed. On the other hand, when the cervix is only partially dilated, the chances of a favorable outcome for the child are greatly diminished. If the cervical canal is obliterated and resistance is offered only by the external os, manual dilatation followed by version and extraction may give excellent results. On the other hand, if the condition of the cervix precludes manual dilatation, the chances for the child are poor, and the only hope lies in replacing the cord, and retaining it in place until the cervix dilates. For this purpose, if the presenting part is not deeply en- gaged, the patient should be placed in the knee-chest position, the entire hand introduced into the vagina, and an attempt made to push the cord up into the uterus and, if possible, to carry it over some projecting por- tion of the child’s body. If the cord remain in place the patient should be made to lie upon the side toward which the child’s back is directed in the hope of avoiding compression, and all danger is past if the head engages. In the majority of cases, however, the prolapse recurs again as soon as the hand is removed. In such circumstances an improvised repositor will sometimes serve us in good stead, although the results attending its use are usually unsatisfactory. A piece of bobbin is firmly attached to the free end of a sterile bougie in such a manner as to leave a loop several inches long. This is then passed around the prolapsed cord and slipped over the tip of the bougie. By this means the cord can readily be carried up into the uterus, after which it may be freed from the repositor by bringing the loop in contact with a portion of the child and making traction upon it so as to cause it to slip off from the tip of the bougie. In the great majority of cases the condition recurs as soon as the repositor is removed; to insure against such an accident the bougie may be left in the uterus. ASPHYXIA 967 If, however, all such maneuvers prove ineffectual, as is usually the case, the death of the child becomes almost inevitable, unless cesarean section is performed, which is feasible only when the patient is already in a hospital. On the other hand, if the pulsations in the cord are weak or have ceased altogether, no attempt at reposition should be made, inasmuch as the child has either already perished or will die before delivery can be effected. If, however, the cervix is fully dilated, such limitations do not hold good, as occasionally a child that is apparently hopelessly lost may be rescued by immediate delivery. ASPHYXIA Normally the foetus while it remains in the uterus is in a condition of apnea, being satisfactorily supplied with oxygen by means of the placental circulation. As soon as delivery occurs, owing to the separa- tion of the placenta or to the great diminution in its area of attachment, this source of oxygen is entirely cut off, or so greatly reduced that the necessity for active respiration arises. Generally speaking, imperfect oxygenation should be considered as the primary factor in the establish- ment of this function, although numerous accessory causes come into play during the act of delivery and just after birth. Exceptionally, as the result of compression of the prolapsed cord, premature separation of the placenta, or much less commonly of tetanic contraction of the uterus, the normal supply of properly aerated blood through the umbilical vessels may be cut off or interfered with while the child is still within the uterus. Occasionally a similar condition may be brought about by compression against the symphysis of a cord which is wrapped around the neck of the child, while now and again asphyxia and even death may result when the head is on the perineum, owing to excessive retraction of the active segment of the uterus, with a conse- quent diminution in the area of placental attachment. As a result of the action of any of these factors the child may take it first breath while still in the uterus or in the lower portion of the birth canal. In the former case it may draw a certain quantity of amniotic fluid into its lungs, and when respiration begins while the head is in the vagina, a certain amount of mucus is liable to be aspirated. In either event the needed oxygen is not obtained, and the resulting air hunger leads to increased respiratory efforts, which are nevertheless of no avail. Gradually the accumulation of carbon dioxid and other ex- crementitious materials in the foetal organism leads to such a pronounced decrease in the irritability of the medulla that eventually the attempts at respiration cease, the intervals between the pulsations of the heart become longer and longer, and the child dies from asphyxia. Again, pressure exerted upon the brain in difficult labors or in opera- tive procedures may lead to vagus irritation and consequent slowing of the heart. As a result of the interference with the foetal circulation the blood becomes poorer in oxygen and richer in excrementitious material; this goes on until at last the irritability of the medulla becomes so 968 SUDDEN DEATH DURING LABOR lowered that the usual stimuli fail to call forth the first respiratory movement and asphyxia results. The most frequent causes of cerebral compression are attempts on the part of the uterus to force the head through a contracted superior strait, excessive pressure exerted by the blades of the forceps or during a breech extraction, and intracranial hemorrhage. When limited to the cerebral hemispheres a very considerable effusion of blood may occur without exerting an immediately deleterious effect upon the foetus; but if the base of the brain is implicated a much smaller amount may give rise to serious disturbances. Diagnosis.—The importance of watching for manifestations pointing to threatened intra-uterine asphyxia cannot be overestimated, inasmuch as their recognition frequently affords the indication for operative de- livery, without which the life of the child is inevitably lost. The most characteristic symptom is afforded by changes in the foetal pulse-rate. At first, as a result of momentary compression of the brain or interference with the placental circulation, it becomes slower with each uterine contraction, but regains its normal frequency in the intervals between the pains. As the condition becomes more serious, the remissions fail to occur and the pulse becomes slower and slower and eventually the heart ceases to beat. For practical purposes it is well to assume that a pulse-rate of 100 or less is incompatible with prolonged life for the foetus, and under such circumstances rapid delivery is indicated, provided it can be accomplished without too great risk for the mother. Excep- tionally, the first sign of asphyxia is a marked increase in the frequency of the foetal pulse, which may vary from 160 to 200. The acceleration, however, is only transient, and, as a rule, soon gives place to a marked slowing, which becomes still more perceptible as the fatal termination is approached. Such rules, however, have only an approximate value, and Baumm has pointed out their limitations, stating that the foetal pulse may retain its normal rate notwithstanding the existence of severe intracranial hemorrhage, while in other cases, in which delivery has been effected on account of a very slow heart beat, the child presents no signs of asphyxia or of any other abnormality. Notwithstanding these generally recognized limitations, the foetal heart rate constitutes the most available means of obtaining information concerning the condi- tion of the child, and should be counted occasionally during the first stage of labor, and at intervals of 30 minutes during the second stage. To neglect of this latter precaution can be attributed the death of many children, which otherwise could have been saved. In vertex presentations another- characteristic sign of impending asphyxia is the escape of meconium. This is due to relaxation of the sphincter ani muscle induced by faulty aeration of the blood. Accord- ingly, whenever the amniotic fluid presents a yellowish-green appearance and contains flakes of meconium, we may conclude that the child is in danger, and that the only hope for its safety lies in prompt delivery. In breech presentations, of course, this symptom is without significance, as it is a purely mechanical result of pressure applied to the abdomen of the foetus. ASPHYXIA 969 Especially in difficult breech extractions, when delay is experienced in delivering the head, signs of asphyxia may appear in a child which was apparently in excellent condition before the operation. In such circumstances the finger in the child’s mouth can readily appreciate the fact that vigorous inspiratory movements are being made. A similar phenomenon may occasionally be observed in vertex presentations, when the head is arrested on the pelvic floor, the movements of the mouth being felt or seen through the thinned-out perineum. Very exceptionally the child may not only make inspiratory efforts, but actually give utterance to sounds in uterovagitus uterinus. For the production of this phenomenon it is essential that air gain access to the foetus, its entrance into the uterus sometimes resulting from the introduction of the hand or instruments. A very characteristic example of this phenomenon has been recorded by Bucura, who has collated the literature bearing upon the subject up to 1904. After delivery the asphyxiated child may present one of two appear- ances—asphyxia pallida or asphyxia livida. In both respiration is in abeyance or occurs only in gasps, wffiile the heart beats slowly and feebly. In the former the surface of the body is pale and cold, the extremities hang limp, and the child fails to respond to the usual external stimuli. In the latter, on the other hand, it presents a congested or livid appearance, which is usually attributed to overdistention of the right heart and the inferior vena cava. This form of asphyxia is usually more amenable to treatment than the pallid variety, which is frequently associated with cerebral injury. Prognosis.—Asphyxia neonatorium is always serious. The prognosis is relatively favorable when the condition is due to mechanical interfer- ence with the placental circulation, but is far less so when it results from injuries to the brain, such as intracranial hemorrhage, fractures, or depressions of the skull. Treatment.—Normally, the child should make its first inspiratory movement a few seconds after it emerges from the vulva. If this does not occur, the feet being grasped by the fingers of one hand and the child suspended with its head downward, its body should be slapped gently with the other. If this maneuver does not prove immediately successful, and particularly if attempts at respiration are associated with a gurgling sound, a finger, covered with gauze, should be passed to the back of the pharynx for the purpose of removing any foreign material which may interfere with the free access of air to the laryngeal opening. Ordinarily, if the child is not deeply asphyxiated, these measures will bring about the desired results. In some instances, however, more radical measures will be found necessary. In such cases the cord should be ligated and cut through, and the child immersed in hot water, writh only its head protruding, and rubbed vigorously. As soon as it takes on a pink color, it should be immersed in cold water, and usually upon coming in contact with it, an inspiratory movement is made and it begins to cry. If there is any reason to believe that the trachea and larger bronchi contain mucous or amniotic fluid, a small, soft-rubber catheter should be introduced into. 970 SUDDEN DEATH DURING LABOR the larynx and the offending material re- moved by suction exerted by the obstetri- cian, or by the employment of a Kibemont- Dessaignes insufflator. If these measures do not lead to the establishment of respiration, the child should be wrapped in a piece of blanket or flannel to prevent too rapid cooling, and laid upon a table or chair, the head being allowed to hang over the edge. The tip of the tongue is then grasped by a small pair of artery forceps and drawn forward as far as possible and then allowed to recede, the maneuver being repeated at regular intervals 10 or 12 times to the minute. After the first few tractions an inspiratory movement usually follows, after which respiration goes on regularly, upon the principle that traction upon the tongue irritates the fibers of the superior laryngeal, glossopharyngeal, and lingual nerves, which in turn give rise to a reflex stimulation of the phrenic nerves with consequent con- traction of the diaphragm and the inter- costal muscles. Generally speaking, it is a most effective measure, and the prognosis becomes extremely gloomy if its employ- ment Is not attended by satisfoctory results within a few minutes. Occasionally, its efficiency may be heightened by practicing it with the child immersed in a hot bath. Before, however, despairing of saving the child’s life recourse may be had to Schultze’s method. In this maneuver, as shown in Figs. 682 and 683, the child is seized by both hands in such a manner that the index fingers of the operator lie under its axillae, the thumbs over the thorax, while the palmar surfaces of the remaining fingers are applied to its back, the head at the same time being fixed by the balls of the thumbs. The obstetrician stands with his legs apart and at first al- lows the foetus to hang down between them, he then slowly carries the child over his head in such a manner that the legs fall toward its face, so that the body becomes sharply flexed, after which he brings it back to its original position. The maneuver is repeated 5 or 6 times a minute. The rationale of the Fig. 681. Fig. 682. Figs. 681, 682.—Schultze’s Method of Resuscitation. ASPHYXIA 971 method is readily appreciated: the thorax is markedly compressed when the child is elevated, and expanded when it is lowered, the two positions ravoring expiration and inspiration respectively. Some idea of its efficiency may be gained by the fact that, when it is practiced upon a dead child, air can be distinctly heard to enter and leave the lungs with each movement, and Schultze, in 1911, still contended that it is the most efficient method at our disposal. The procedure, however, is not without disadvantages; for, if too violently employed, it sometimes gives rise to fracture of the clavicles or ribs, and occasionally to rupture of the liver or other serious lesions of the internal organs. Moreover, in view of the no small degree of violence associated with its use, the maneuver is contra-indicated when the clavicle or humerus has been fractured during a difficult extraction, inasmuch as the free ends of the bones are liable to cause serious injury to the soft parts. Byrd, in 1874, and Dew, in 1893, suggested a convenient substitute for Schultze’s method. The latter recommended that the child be grasped with the left hand, allowing the neck to rest between the thumb and forefinger so that the head falls far backward; while the right hand grasps the legs in such a way that the right knee rests between the thumb and forefinger, and the left between the fore and middle fingers, with the back of the thighs resting upon the palm of the hand. In order to bring about inspiration the child is gently bent backward, while the reverse movement compresses the thoracic contents and causes ex- piration. Dew claims that this method is quite as efficient as that of Schultze, and has the additional advantage that it is less likely to cause injury to the child, and is much less fatiguing to the operator. Recently several patented devices have been put upon the market by means of which it is possible to pump into and withdraw from the lungs of the asphyxiated child regulated quantities of oxygen gas or atmospheric air. It is claimed that they offer the most efficient means of stimulating respiration. In my experience, however, they are not superior to the methods generally employed. At the same time they are bulky and unnecessarily expensive, and are being advertised in so objectionable a manner that self-respecting practitioners should hesitate to advocate their employment. As asphyxia livida is associated with over-loading of the right side of the heart, it is sometimes advisable to loosen the ligature at the free end of the cord so as to allow the escape of 15 cubic centimeters of blood. In obstinate cases some authorities recommend the injection of a few drops of whiskey or ether, but I have not observed beneficial results following it. When the asphyxia is the result of a depressed fracture of the skull, the depressed portion should be elevated in the hope of removing the source of compression. Such an operation, however, should be attempted only when the heart still continues to beat strongly, though slowly. Efforts at resuscitation should be preserved in as long as the heart continues to beat, one method after another being given a trial. The necessity for persistence is shown by the fact that successful results are SUDDEN DEATH DURING LABOR 972 occasionally obtained after trials lasting for thirty to sixty minutes, or even longer. SUDDEN DEATH DURING OR SHORTLY AFTER LABOR Ordinarily, death occurring during labor, or in the first few hours immediately following it, is the result of some one of the abnormalities to which allusion has already been made, particularly pulmonary em- bolism, acute edema of the lungs, apoplexy complicating eclampsia, or acute anemia the result of postpartum hemorrhage, placenta previa, premature separation of the normally implanted placenta, or rupture of the birth canal. This subject was discussed in detail by E. P. Davis in 1905, to whose article the student is referred for an extensive bibli- ography. In rare instances incomplete rupture of the uterus is unattended by symptoms at the time of its occurrence, the blood slowly accumulating between the folds of the broad ligament with a gradual development of symptoms of shock. A subperitoneal hematoma formed in this way is liable to rupture into the peritoneal cavity at any time within the first forty-eight hours after delivery and lead to sudden death. Moreover, a woman in labor, or during the puerperium, may die suddenly from the effects of any condition which would give rise to a similar outcome under other circumstances. Thus, cases have been re- ported in which the fatal termination was due to rupture of an aortic or cardiac aneurism, hemorrhage from a gastric ulcer, or other accidents. Van der Velde has reported a case of a fatal retroperitoneal hemorrhage complicating an acute pancreatitis, while Node and Hines observed sudden death during labor following the rupture of an aneurism of the splenic artery. In the chapter dealing with the Pathology of Pregnancy reference was made to the consequences of labor in women suffering from valvular lesions of the heart, particularly stenosis of the mitral orifice. Less frequently sudden death may be due to fatty degeneration or to changes in the myocardium. Such accidents are to be particularly dreaded in elderly and corpulent women. Shock.—Formerly it was customary to attribute a certain number of deaths following labor to shock, which was supposed to occur occasionally after prolonged and very painful labors, the incidental loss of rest, imperfect nutrition, and mental excitement being looked upon as.pre- disposing causes. In the present state of our knowledge, however, this explanation is hardly permissible, since in the majority of such cases a carefully performed autopsy will reveal the existence of some condi- tion sufficiently serious to account for the unfavorable outcome, the most common being hemorrhage following injury to the genital tract. Syncope.—Faintness is not an uncommon result of exhaustion fol- lowing prolonged labor, and in neuropathic individuals may occur even after an easy and rapid delivery. In rare instances it may be due to cerebral anemia resulting from lack of blood in the nervous centers SUDDEN DEATH DURING OR SHORTLY AFTER LABOR 973 following the sudden diminution in the intra-abdominal pressure incident to the rapid decrease in the size of the uterus. The faintness usually passes off rapidly and does not lead to untoward results. On the other hand, it ocasionally gives cause for- serious alarm, the pulse becoming weaker and more rapid and the patient remaining in a condition of profound prostration. I have never seen a death from this cause, but can recall one patient who caused me the greatest anxiety, and who seemed to be in imminent danger for hours. Haig Ferguson reports 3 cases of serious exhaustion following labor in which he was inclined to attribute the condition to reflex irritation recovery, is to be found in the mental condition of the patient, since the ployment of Crede’s method of expressing the placenta, the organ being grasped laterally instead of anteroposteriorly. Profound Mental Depression.—In rare instances the only apparent explanation for death, or for a profound collapse which eventuates in recovery, is to be found in the mental condition of the patient, since the most careful examination, both at the bedside and at autopsy, may fail to reveal the slightest abnormality. I recall a case in my own practice which apparently belongs in this category. The patient, wdio was unhappily married, had already passed through two difficult labors. When I saw' her, in the latter part of the first stage of her third labor, she was about the room. Just before going to bed at the beginning of the second stage she asked the nurse and me to wdtness her will, as she said she felt sure she would not survive. The labor wrns rapid and uneventful, the placenta coming awray spon- taneously. An hour later, on approaching the bed to take leave of the patient, I was struck with her haggard appearance. Fearing the possi- bility of concealed hemorrhage I at once aplied my hand over the uterus and found it tightly contracted, while the pulse wras of excellent quality. Without any apparent reason, and in spite of energetic stimulation, the patient grew slowly worse, the pulse becoming rapid and weak, the eyes sinking back in their sockets, and the face assuming a drawn and Hippocratic expres-ion. Thorough examination failed to reveal the slightest cause for the condition. The hand introduced into the uterus could find no trace of rupture. Eight hours after delivery I requested a colleague to see her in consultation, but he also was unable to offer any explanation. It then occurred to me that the condition might possibly be the result of her morbid forebodings, and acting upon that supposition I administered a large dose of morphin hypodermically, which wrns promptly followed by sound sleep, a marked improvement in the character of the pulse, and some rapid change for the better in the general appearance. Upon aw'akening a few hours later the patient felt very comfortable and made an uninterrupted recovery. Pulmonary Embolism.—This accident, usually noted only later in the puerperium, but occasionally occurring shortly after labor, is due to the detachment of a small particle of thrombus situated in a uterine or pelvic vein or elsewhere, which is carried to the right side of the heart and leads to more or less complete occlusion of the pulmonary artery. 974 SUDDEN DEATH DURING LABOR It is usually associated with infective or thrombotic processes elsewhere in the body, though it may occur in women who were apparently per- fectly well. Davis considers it the most frequent cause of sudden death in the absence of definite disease. Under such circumstances the patient complains of intense and sudden precordial pain, becomes livid in ap- pearance, and presents symptoms of profound dyspnea and eventually of air hunger. These embolisms, however, are not always fatal, a certain proportion of the patients recovering. The treatment is purely palliative. The woman should be placed in the recumbent position, kept in absolute rest, and given the necessary sedatives, particularly morphia and bromide of potassium. When indi- cated, inhalations of oxygen may prove beneficial. Entrance of Air into the Uterine Sinuses.—Occasional cases of death following intra-uterine manipulations in women suffering from placenta previa or rupture of the uterus have been attributed by certain authori- ties to the entrance of air into the uterine sinuses, whence it is carried to the heart. The exact cause of death is not understood, some holding that the air bubbles enter the coronary arteries, and others that the right heart, being unable to rid itself of them, becomes paralyzed as a result of its fruitless efforts. The symptoms are analogous to those following pulmonary embolism. Cases of this character have been reported by Olshausen, Lcsse, Perkins, Eoger, and others. That such a condition occasionally occurs is clear from the fact that ' cases have been reported in which sudden death followed the pumping of air into the pregnant uterus for the purpose of producing abortion. On the other hand, it is probable that its frequency has been over- estimated, as most of the cases which have come to autopsy, and which were supposed to demonstrate such a possibility, are open to another and far more reasonable explanation. Thus, Dobbin was able to demonstrate the presence of Bacillus aerogenes capsulatus in the tissues from one of Perkin’s cases, in which the presence of air bubbles in the blood-vessels had been regarded as satisfactory evidence as to the cause of death. Wendeler had a similar experience, and it wxmld therefore seem permissible to regard with skepticism all cases of supposed air embolism unless death had occurred almost instantaneously, or in which careful bacteriological investigation had demonstrated the absence of gas bacilli. Acute Dilatation of the Stomach.—Very exceptionally following op- erative as well as spontaneous labor, the patient may pass into a con- dition of profound shock, associated with symptoms of acute dilatation of the stomach—great distention of that organ and the expulsion of immense quantities of dark fluid vomitus—and death may follow, or recovery ensue, just as in the similar condition, which is so well known to surgeons. I have encountered the complication upon one occasion. In this instance a healthy woman, one hour after the completion of a relatively easy spontaneous labor, passed into a condition of profound shock and hovered between life and death for 24 hours. The first manifestation wras a change in the character and rate of the pulse, but the true con- LITERATURE 975 dition was not suspected until the onset of the characteristic vomiting a few hours later. Audebert, in 1912, was able to collect 12 cases from the literature. As labor was spontaneous in three of them, he was inclined to attribute the condition to paralysis of the stomach due to the action of chloro- form. As my patient received only a minimal amount of the drug, I sought the etiological factor in an arterioduodenal occlusion following the acute diminution in the bulk of the abdominal contents, incident to the sudden decrease in the size of the uterus. Whatever the cause may be, the condition is most serious, and now that attention has been called to its possibility it should be recognized as one of the causes for sudden death following delivery. The best results are obtained by placing the patient in an inclined position, with the head considerably lower than the feet, emptying the stomach by a suitable tube, and stimulating according to the exigencies of the case. Post Mortem Delivery.—In the literature, which has been carefully searched by Aveling and Eeimann, a number of cases are recorded in which spontaneous birth of the child took place some hours or days after the death of the mother. Moreover, delivery sometimes occurs after burial, and, when the body has been exhumed for some reason, two individuals instead of one have been found in the coffin. These are instances of the so-called “coffin birth.” The phenomenon is usually observed in multiparous women in whom the birth canal is markedly relaxed, and is attributable to a marked increase in the intra-abdominal pressure produced by putrefactive changes, though certain authorities believe that rigor mortis of the uterine musculature is the causative factor. LITERATURE Audebert. La dilatation aigue de l’estomac chcz les accouchees. Annales do gyn. et d’obst., 1912, ix, 92-104. Aveling. On Post-mortem Parturition, with References to Forty-four Cases. Trans. London Obst. Soc., 1873, xiv, 240-258. Baumm. Etwas iiber kindlichen Herztone. Archiv. f. Gyn., 1917, cvii, 353-366. Bucura. Vagitus uterinus. Zentralbl. f. Gyn., 1904, xxviii, 129-136. Byrd. A Speedy Method in Asphyxia. The Obst. Jour, of Great Britain and Ireland, 1874, i, 65-69, Amer. Supplement. Davis. Sudden Death during or immediately after the Termination of Preg- nancy. Trans. Am. Gyn. Soc., 1905, xxx, 345-366. Dew. Establishing a New Method of Artificial Respiration in Asphyxia Neona- torum. Medical Record, Mar. 11, 1893. Dobbin. Bemerkungen zu den Arbeiten von Schnell, Wendeler, und Goebel: Ueber einen Fall von Gasblasen im Blute einer nach Tympania uteri gestor- benen Puerpera. Monatsschr. f. Geb. u. Gyn., 1897, vi, 375-379. Ferguson. On a Variety of Post-partum Shock, its Nature, Cause, and Preven- tion. Edinburgh Med. Jour., 1899, xxxv, 32-41. Laborde. Les tractions rhythmees de la langue, moyen rationnel et puissant de ranimer la fonction respiratoire et la vie. Paris, 1894. Lesse. Ein weiterer Fall von Luftembolie bei Placenta praevia. Zeitschr. f. Geb- u. Gyn., 1896, xxv, 184-191. 976 Nodes and Hines. Fatal Rupture of an Aneurysm of the Splenic Artery immedi- ately after Labour. Trans. London Obst. Soc., 1900, xlii, 305-310. Olshausen. Ueber Lufteintritt in die Uterusvenen. Monatsschr. f. Geburtsk., 1864, xxiv, 350-374. Perkins. Air Embolism, etc. Boston Med. and Surg. Jour., 1897, cxxxvi, 154-156. Reimann. Ueber Geburten nach dem Tode der Mutter. Archiv f. Gyn., 1877, xi, 215-255. Roger. £tude elinique sur la phenomene de 1’entree de Fair par les sinus uterins dans l’etat puerperal. These de Paris, 1899. Schultze. Ueber die beste Methode der Wiederbelebung scheintodt gebo.rener Kinder. Jenaische Zeitschr. f. Med. u. Naturwissensch., 1866, iii, Heft 4. Der Scheintod Neugeborener. Jena, 1871. Zur Behandlung des Scheintodes Neugeborener. Zeitschr. f. Geb. u. Gyn., 1911, lxviii, 591-596. Van der Velde. Ein Fall von todtlicher Pancreasblutung, etc. Ref. Frommel’s Jahresbericht, 1898, 764. Wendeler. Uebe.r einen Fall von Gasblasen im Blute einer nach Tympania uteri gestorbenen Puerpera. Monatsschr. f. Geb. u. Gyn., 1896, iv, 581-583. SUDDEN DEATH DURING LABOR SECTION VIII PATHOLOGY OF THE PUERPERIUM CHAPTER XLIII PUERPERAL INFECTION Under the general heading of “puerperal infection” are now included all the various morbid conditions which result from the entrance of in- fective microorganisms into the female generative tract during labor or the puerperium. The older term, “puerperal fever,” is at once too vague and misleading, and for many reasons should be discarded. In the first place it suggests the old idea of the essentiality of the affection so strongly urged by the late Fordyce Barker, and takes no account of the various etiological factors which may be concerned. Moreover, it em- phasizes the febrile phenomena of the affection, instead of laying stress upon its infectious nature and the consequent responsibility of the ob- stetrician and his assistants. Again, “puerperal septicemia” and “puer- peral sepsis,” which are often used as synonymous terms, are hardly less satisfactory, inasmuch as in many instances the infection results in perfectly localized inflammatory processes, to which such terms cannot be applied without violating the established rules of diction. It is probable that puerperal infection has occurred almost as long as children have been born, and passages in the works of Hippocrates, Galen, Avicenna, and many of* the old writers clearly have reference to it. As early as 1676 Willis wrote on the subject of febris puerperarum, but the English term “puerperal fever” was probably first employed by Strother in 1718. The ancients regarded the affection as the result of retention of the lochia, and for centuries this explanation was universally accepted. In the early part of the seventeenth century Plater showed that it was essentially a metritis, and was followed in the next century by Puzos with his milk metastasis theory. From the time of Plater, until Sem- melweiss proved its identity with wound infection, and Lister demon- strated the value of antiseptic methods, all sorts of theories were sug- gested concerning its origin and nature, which are comprehensively dealt with in the monographs of Eisenmann, Silberschmidt, and Burtenshaw. Bacteriology.—Although Charles White (1793) and Alexander Gordon (1795) clearly recognized the contagious nature of puerperal infection, and many other British observers had vague ideas upon the subject, it was not until the middle of the nineteenth century that such 977 978 PUERPERAL INFECTION views were strongly urged. In 1843 Oliver Wendell Holmes read a paper before the Boston Society for Medical Improvement, entitled “The Contagiousness of Cuerperal Fever,” in which he clearly showed that at least the epidemic forms of the affection could always be traced to the lack of proper precautions on the part of the physician or nurse. Four years later Semmelweiss, then an assistant in the Vienna Lying-in Hospital, began a careful inquiry into the causes of the frightful mor- tality attending labor in that institution, as compared with the com- paratively small number of women succumbing to puerperal infection when delivered in their own homes. As a result of his investigations he concluded that the morbid process was essentially a wound infection, and was due to the introduction of septic material by the examining finger. Acting upon this idea he issued stringent orders that the physi- cians, students, and midwives should disinfect their hands with chlorin water before examining parturient women. In spite of almost imme- diate surprising results—the mortality falling from over 10 to about 1 per cent.—his work, as well as that of Holmes, was scoffed at by many of the most prominent men of the time, and his discovery remained unappreciated until the influence of Lister’s teachings and the develop- ment of bacteriology had brought about a revolution in the treatment of wounds. It is now universally acknowledged that puerperal infection is wound infection, and is due to the invasion of the generative tract by various pyogenic bacteria. The principal microorganisms concerned are the following: (a) Streptococcus.—As early as 1865 this organism was discovered by Mayrhofer in the tissues of women who had died during the puer- perium, and confirmatory observations were made by Coze and Feltz, Recklinghausen, Waldeyer, Klebs, Orth, and Heibig. Pasteur, in 1880, however, was the first to cultivate streptococci from cases of puerperal infection, and he called them “chapelets en grains.” He was assisted by Doleris, who showed that they were the usual infectious agents, but that other bacteria were sometimes concerned. These researches were soon confirmed by Lomer, Bumm, Doderlein, Winter, Widal, and by all sub- sequent observers, so that the streptococcus is now believed to be the usual cause of the epidemic and fatal forms of puerperal infection. In 1903, Schottmiiller showed when streptococci, obtained from seri- ously ill patients, were grown upon blood-agar that each colony became surrounded by an area of hemolysis, which was lacking in the sapro- phytic varieties of the organism. His findings were confirmed by Fromme, Gonnet, and others, so that it was believed for a time that three types could be differentiated—streptococcus pyogenes, streptococcus mitior or gracilis, and streptococcus mucosus. It was held that the first, which is always hemolytic, was concerned in the production of virulent infections, while the other two varieties, which are lacking in hemolytic properties, were either saprophytic or only slightly pathogenic in char- acter. The work of Natwig, Lea and Sidebotham, and others has shown that these conclusions are too sweeping, and that Avhile hemolytic strep- BACTERIOLOGY 979 tococci are frequently highly virulent, they are not always so. Further- more, the non-hemolytic variety is occasionally very pathogenic; and, as the hemolytic property may either be lost or accentuated by various cultural methods, it would appear inadvisable to consider its existence as characteristic of a distinct species of streptococcus. Although Kronig, myself, and others had previously isolated an anaerobic streptococcus, it was not until 1910 that Schottmiiller demon- strated its practical importance. By the use of suitable anaerobic culture media, the latter was able to isolate it from many cases, and concluded that it was more frequently concerned in the production of puerperal infection than the ordinary aerobic variety. As the organism produces large amounts of sulphuretted hydrogen he designated it as the strep- tococcus putridus. Bondy, Briitt, and others have made similar ob- servations, but it appears that Schottmiiller’s conclusions were too sweeping. (b) Staphylococcus.—Further investigation gradually demonstrated the fact that the streptococcus is not necessarily the only organism which may be concerned, but that most of the pus producers, which give rise to wound infection in other parts of the body, may likewise at times be the exciting factors. Brieger, in 1888, reported that he had demonstrated Staphylococcus aureus in five fatal cases. Doleris stated, in 1880, that he had been able to cultivate in pure culture cocci arranged in groups or bunches, but it was not until 1894 that he stated definitely that they were staphylococci. The statement made by Fehling and Haegler that staphylococci usually give rise to mild forms of infection has not been borne out by the observations of other investigators. Occasionally mixed infections with the streptococcus or colon bacillus are observed. Staphylococcus aureus is the variety usually observed in puerperal infection, the albus and citreus playing little or no part in its production; while Rosowsky has shown that an anaerobic form is occasionally concerned. (c) Gonococcus.—Although clinicians had long suspected that gonor- rhea frequently plays a part in the production of puerperal infection, Kronig was the first to adduce bacteriological proof of its action. In 1893 he reported 9 cases of mild infection, in which he was able to obtain pure cultures of gonococci from the uterine lochia. In a later com- munication he stated that he had been able to cultivate the same organ- ism from the discharges of 50 out of 179 febrile puerperal patients, most of whom recovered spontaneously; while we have found it in approximately nine per cent, of our febrile patients. Krdnig’s experience has been confirmed by all subsequent investi- gators, and Taussig, and Stone and McDonald state respectively that one-sixth to one-tenth of all rises of temperature in the puerperium are the result of gonorrheal infection. As far as I am aware Foulerton and Bonney are the only recent writers who have not had a similar experience. Furthermore, I have repeatedly demonstrated the gonococcus in the tissues of cases of decidual endometritis, and others have made similar observations. As a rule, gonorrheal infection in the puerperium pursues 980 PUERPERAL INFECTION a favorable course, but occasionally fatal septicemia may result, as in two of my cases reported by Harris and Dabney, and J. T. Smith. (d) Bacillus Coli Communis.—In my first article upon puerperal infection (1893), it was stated that von Franque had cultivated the colon bacillus from a case of puerperal infection, and the belief was expressed that it would be demonstrated more frequently in the future. Time has amply verified this prediction, and there are now on record a long series of such cases. A priori, this is what would be expected when one takes into consideration the proximity of the genital tract to the rectum, and the enormous numbers of colon bacilli which are evacu- ated. As Vignal has shown that 1 decigram of feces contains about 20,000,000 colon bacilli, it is evident that the examining finger can hardly avoid contamination with them if it comes in contact with an imperfectly disinfected perineum. Gebhard demonstrated their presence in 7 cases of tympania utero, either alone or in combination with other organisms, and Galtier states that it is the organism most frequently concerned in the production of that condition. Ordinarily pure colon infections are relatively benign in character, but occasionally, as shown by Lenhartz and others, fatal septicemia may ensue. In most serious colon bacillus infections the organism is asso- ciated with the streptococcus, and it appears that such a combination tends to augment the virulence of both species of bacteria. (e) Bacillus Diphtheriae.—Formerly it was believed that the diph- theritic deposits upon the vagina and the interior of the puerperal uterus were due to the streptococcus alone, and were in no way connected with true diphtheria. That this is not always the case, however, has been shown by the observations of Nisot, Bumm, Lop, myself, and others, who have cultivated the Klebs-Loeffler bacillus from the diphtheritic membrane in the vagina, the affection yielding promptly to the use of the antidiphtheritic serum. Gide, in 1911, was able to collect 42 such cases. Wauschkuhn states that such infections are not uncommon, and that in a series of 200 apparently healthy women he found that diph- theria bacilli were carried nearly as frequently in the vaginal secretion as in the tonsils. (/) Bacillus Aerogenes Capsulatus (Gas Bacillus).—The gas bacillus ,of Welch is occasionally concerned in puerperal infection, especially when it follows criminal abortions. In 1896 I observed an instance of the kind, which was reported by Dobbin. Briefly stated, the case was as follows: An outdoor patient had been in labor for several days under the care of a midwife. When she came into our hands she was pro- foundly infected and the head of a macerated child was found firmly engaged in the contracted superior strait, the uterus being in a state of tetanic contraction. A fetid, dark-colored discharge, which contained many gas bubbles, was escaping from the vagina with a crackling sound. Delivery was effected by carniotomy, and death occurred the next day. Within a few hours the patient’s body had nearly doubled its size, as the result of the development of gas in the subcutaneous tissues. Similar changes were observed in the foetus and in the placenta, in both BACTERIOLOGY 981 of which, as well as in the uterine lochia, the presence of the gas bacillus was demonstrated. Unfortunately no autopsy was allowed upon the mother, and we were therefore unable to say to what extent the or- ganisms had penetrated into her tissues. Following this, many well-authenticated instances of infection with this organism have been reported, and the entire literature upon the subject was exhaustively reviewed by Welch in 1900, Fraenkel in 1904, Heinricius in 1908, and by Heynemann in 1911. Little, in 1905, re- ported ten cases in which it had been isolated in our service, and pointed out that in all probability the organism was identical with the “vibrion septique” of Pasteur, as well as with Bacillus perfringens described by various writers. In only one of our cases did the bacillus occur in pure culture, while in the others it was associated with various bacteria— particularly with streptococcus. As a rule, the gas bacillus exists merely as saprophyte upon dead material, and does not invade the deeper tissues until shortly before or just after death, but in one of my patients it gave rise to a true septi- cemia. Accordingly, the prognosis is usually favorable when the organ- ism occurs in pure culture, but becomes very serious when it is asso- ciated with the streptococcus, as it would seem that such an association tends to augment the virulence of both organisms. According to Welch, its presence in the puerperal uterus may give rise to emphysema of the foetus, endometritis, physometra, emphysema of the uterine wall, or gas sepsis. Moreover, it is important to remember, as was first pointed out by Welch and Dobbin, that the gas bubbles found in the blood vessels of women supposed to have perished from “air embolism” are frequently the product of the bacillus in question. (g) Bacillus Typhosus.—In 1898 Dobbin and I isolated Bacillus typhosus, Streptococcus, Staphylococcus aureus, and an unidentified anaerobic gas-producing bacillus from the uterine lochia of a Bohemian woman who was admitted to the Johns Hopkins Hospital on the fifth day of the puerperium with high fever. Her blood gave the character- istic Widal reaction, but all the usual symptoms of typhoid fever were absent. The temperature fell to normal on the thirteenth day, and did not rise again. We were inclined to believe that the bacilli were intro- duced into her uterus by the midwife, along with other organisms, since she was delivered upon the same bed upon which her husband had died of typhoid fever a few days previously. In a somewhat similar case reported by Blumer, in which the autopsy revealed an unsuspected typhoid fever, the presence of typhoid bacilli in the lochia should not be regarded as evidence of puerperal infection, but rather of typhoid septi- cemia. (h) Pneumococcus.—In rare instanses this organism may be found in the vaginal secretion of apparently healthy pregnant women, and may give rise to puerperal infection, which is particularly liable to eventuate in peritonitis. Foulerton and Bonney, and Natwig have re- ported cases in which it was found, and Hornung has collected the literature upon the subject up to 1920. Occasionally the presence of pneumococci in the uterine lochia is 982 PUERPERAL INFECTION merely a manifestation of a general septicemia originating from a focus outside of the generative tract, as reported by Czemetschka, and Burch- hardt, as well as by Johnston and Morgan from our clinic and others. Bondy has pointed out how difficult it may be in a given case to deter- mine whether such a finding should be regarded as evidence of external infection or of mere transportation by the blood stream. Still more occasionally the pneumobacillus of Friedlander may be isolated, as was shown by the observations of Howard, Fromme, Chirie, and others. (i) Bacillary Infections.—Perkins, Charrin, and others have recorded cases in which the bacillus pyocyaneus was the infectious agent. More- over, isolated observations of Fraenkel, Doleris, Widal, Mixius, Golds- cheider, Bumm, and others tend to show that certain cases of fatal infection may be due to unidentified bacilli with whose properties we are as yet unacquainted. Moreover, routine bacteriological examination of the uterine lochia in a considerable proportion of cases of puerperal in- fection clearly shows that various bacteria with which we are as yet unfamiliar may take part in the process. Thus, I have seen a case of phlegmasia alba dolens in which the infectious agent was a short, thick, anaerobic bacillus. (j) Sapremia.—Besides the cases in which the infection is due to the growth and extension of microorganisms within the body, there is a large group in which the symptoms are due to the absorption of toxins produced by bacteria which do not invade the uterine tissues nor make their way into the blood current. To this form of infection Matthews Duncan applied the term “sapremia.” It is usually thought to be due to putrefactive organisms with whose properties we are as yet almost totally unfamiliar. No doubt the term has been greatly abused, and many cases have been included under it which were really due to infection with the ordi- nary pyogenic organisms. This statement has been borne out by the observations of Bumm, who found streptococci in 8 out of 11 cases which were thought to present the clinical picture of sapremia. As von obtained similar results, he concluded that sapremic fever should be diagnosed only after an accurate bacteriological examination of the uterine lochia has demonstrated the absence of pyogenic organisms. The causative saprophytes are usually anaerobic, and consequently do not grow on the usual culture media. Many of them are gas producers, and thereby cause the frothy, ill-smelling secretion Avhich is so charac- teristic of these cases. Undoubtedly various bacteria may be concerned in its production, though only a few have as yet been isolated. Thus, Sackenreiter, in 1912, was able to isolate the causative factor in 88 per cent, of his cases of putrid endometritis, and found the colon bacillus, an anaerobic staphylococcus—staphylococcus parvulus, the streptococcus putridus, an influenzalike bacillus, various unidentified anaerobic bacilli, the gas bacillus and the bacillus pyocyaneus. Bacteriological examination of the uterine lochia in a series of 324 cases of my own, in which the temperature rose to 101° F., or higher, BACTERIOLOGY 984 during the first ten days of the puerperium, gave the following results: Streptococcus alone 60 cases ‘1 and bacillus coli 9 “ “ “ unidentified bacilli 7 “ “ “ bacillus aerogenes capsulatus 5 “ “ “ gonococcus 4 “ “ “ bacillus aerogenes capsulatus and bacillus coli.... 3 “ Streptococcus, anaerobic variety 3 “ staphylococcus, gas and typhoid bacillus 1 case ‘ ‘ “ “ “ cofon bacillus....... 1 “ Staphylococcus aureus 3 cases ‘ ‘ and gas bacillus 1 case “ “ “ albus and gas bacillus 1 “ ‘ ‘ albus 5 cases Bacillus coli communis 18 “ ‘1 and gas bacillus 2 “ “ “ gonococcus 1 case Gonococcus 29 cases and gas bacillus 1 case ‘ ‘ bacillus coli 1 “ “ unidentified bacillus 1 “ “ “ “ coccus 1 “ Bacillus aerogenes capsulatus 3 cases Unidentified anaerobic bacteria 22 “ ‘ ‘ aerobic bacteria 6 “ Bacillus diphtheriae 1 case ‘ ‘ typhosus 1 “ Bacteria on cover slip, cultures negative 63 cases Sterile 68 “ Contaminated 2 “ During the year ending July 14th, 1923, uterine cultures were taken from 75 patients in our service, all of whom recovered, and the following bacteria were found: Streptococcus hemolyticus, alone 5 cases “ “ with other bacteria 3 “ “ non-hemolyticus, alone 11 “ “ “ “ with other bacteria 9 “ Staphylococcus albus, alone 1 case “ “ with other bacteria 1 “ Bacillus coli communis, alone 2 cases “ “ with other bacteria 5 “ Gonococcus, alone 6 “ Saprophytes 23 “ Unidentified bacillus and coccus 1 case Sterile 8 cases Upon tabulating the 67 cases in which the presence of bacteria was demonstrated, the percentage incidence was as follows: Bacteria No. Cases Percentage Streptococcus, alone or in combination 28 41.8 Saprophytes 23 34.3 Bacillus coli, alone or in combination 7 10.4 Gonococcus 6 8.9 Various 3 4 5 67 99.9 984 PUERPERAL INFECTION Besides the organisms already mentioned, it is not unlikely that further research will show still others which may play a part in the production of isolated cases of puerperal infection; but, to summarize, it may be said that those most commonly concerned are the well-known pyogenic organisms (streptococcus, staphylococcus, bacillus coli, gonococ- cus, and pneumococcus) and the various putrefactive varieties. Pathological Anatomy.—The lesions may vary widely even in cases clinically similar, and these variations afford a probable explanation for the failure of the older authors to appreciate the true nature of the affection. Thus, there may be an almost infinite series of gradations from a slight membrane covering a small perineal tear to an inflam- matory process involving the entire generative tract, or extending beyond it to the parametrium or peritoneum, and sometimes resulting in a systemic infection. In other cases the infectious elements pass through the portal of entry with such rapidity that they do not excite local lesions, but produce a septicemia which is rapidly fatal—the sepsis foudroyante of the French authors. In the majority of cases the mor- bid process is limited to the endometrium, resulting in a puerperal endometritis. In other cases the lesions may be situated in any part of the generative tract, more than one region being frequently implicated. Thus, at different times we have to deal with a puerperal vaginitis, endo- metritis, metritis, parametritis, metrolymphangitis, metrophlebitis, sal- pingitis, oophoritis, peritonitis, pyemia, or phlegmasia alba dolens respectively. Lesions of the Vulva and Vagina.—In former times the puerperal ulcer was of very common occurrence, but with the introduction of aseptic methods its frequency has become greatly diminished. These ulcers appear on the surface of tears about the vulva and peri- neum, soon take on a dirty, greenish-yellow appearance, and are bathed in a foul-smelling secretion. As the result of necrosis they are some- times covered by a grayish-white membrane, and on this account were formerly designated as “diphtheritic ulcers,” but, except for their ex- ternal appearance, they have nothing in common with diphtheria. As a rule they give rise to very little systemic disturbance, and would fre- quently pass unnoticed were it not for ocular inspection. Puerperal Vagmitis.—Of this there are two forms, the one being characterized by general inflammation, the mucosa becoming thickened, soft, reddened, and bathed with an abundant purulent secretion. In the other type, especially when torn surfaces are present, the vaginal walls may be the seat of a pseudodiphtheritic membrane, which may vary in extent from a small patch covering a tear to a complete cast of the entire vaginal canal. Following the recognition of the predominant role played by the streptococcus, it was believed for a time that none of the so-called cases of diphtheria of the vagina were due to invasion by the Klebs-Loeffler bacillus; but the observations of Bumm, Nisot, myself, and others thow that the latter organism is occasionally the etiological factor. Endometritis.—The most common lesion in puerperal infection is an inflammation of the endometrium. When one recalls the condition of PATHOLOGICAL ANATOMY 985 the uterine cavity immediately after delivery, with its bleeding, raw surfaces and the large, gaping thrombosed placental sinuses, it becomes apparent that pathogenic bacteria introduced during labor can easily find entry. Again, when one considers the mechanism by which the decidua is normally removed during the puerperium, one can readily see that an ideal culture medium is prepared by Nature for their recep- tion and propagation. Fig. 683.—Uterus from Woman Dying Ten Days after Labor from Streptococcus Infection. X 2A. In puerperal infection the process may be limited to the placental site, or may extend over the entire interior of the uterus. When the for- mer alone is implicated, the organisms are usually found growing into the thrombi. They produce comparatively little local reaction, but give rise to the thrombophlebitic type of infection, which will be described below. On the other hand, when the entire internal surface of the uterus is affected, puerperal endometritis results. In this event, the lesions vary considerably according to the microorganisms concerned, and still more according to their virulence. When the infection is due to a virulent 986 PUERPERAL INFECTION streptococcus or staphylococcus, the local lesion may be comparatively slight, the discharge scanty, and comparatively free from odor (Fig. 083). In such cases the process tends to spread rapidly through the lymphatics or veins past the uterus, and gives rise to a peritonitis or a general systemic infection. On the other hand, when the infection is due to streptococci of lesser virulence, and particularly when they are associated with colon bacilli, the entire interior of the uterus is converted into a sloughing area made up of necrotic material and decidual debris Fig. 684.—Uterus from Woman Dying Ten Days after Labor from a Mixed Infec- tion with Streptococcus and Bacillus Coli. X V3. land bathed with a foul smelling, bloody, purulent discharge (Fig. 684). In some instances ulcerated areas appear, which are coated with fibrin and present the clinical picture of diphtheria. This was formerly desig- nated as diphtheritic endometritis, but, just as in the case of the vagina, the condition, as a rule, simply represents a fibrinous exudation, the result of intense necrosis. When the infection is due to putrefactive bacteria, to the colon bacil- lus, or to their association with the ordinary pus organisms of slight virulence, the process remains limited to the uterus, and results in so- called putrid endometritis. In this event large amounts of necrotic material may be produced, in which the bacteria lead a saprophytic existence, and give rise to a profuse foul-smelling bloody discharge, Avhich frequently contains gas bubbles. The amount of necrotic material pro- PATHOLOGICAL ANATOMY 987 duced is often enormous, and may recur with great rapidity after curet- ting. Eig. 684 represents a uterus infected with sttreptococcus and bacillus coli. The woman succumbed ten days after the birth of the child, the uterus having been scraped clean by means of a curette three or four days previously. A glance at the drawing, however, shows that the entire cavity is filled with necrotic material, which had been repro- duced in the interval following the curettage. Upon studying the microscopical features of puerperal endometritis, these differences are still further accentuated. Our original knowledge Fig. 685.—Puerperal Endometritis Due to Colon Infection, Showing Mark- ed Development of Leukocytic Wall. Fig. 686.—Puerperal Endometritis Due to Streptococcus Infection, Show- ing Slight Development of Leuko- cytic Wall. on this point we owe to Bumm and Doderlein, both of whom have shown that there are marked histological differences between the putrid and septic forms, and my own experience has amply confirmed their con- clusions. In sections through the wall of a uterus the seat of 'putrid, endometritis, a thick layer of necrotic material is found lining the uterine cavity, embedded in which are large numbers of the offending microorganisms. Beneath it is a thick layer of leukocytic infiltration—- the zone of reaction—and, under this again, more or less normal tissue. The microorganisms are limited almost entirely to the superficial necrotic layer; and although a few may he present in the reaction zone, none can be made out in the tissues beneath it, thus showing Nature’s mode of preventing the invasion of the body (Figs. 685 and 686). Similar pictures are also observed when the infection is due to 988 PUERPERAL INFECTION pyogenic organisms possessing only a slight degree of virulence. On the other hand, in septic endometritis, and especially when the organisms are virulent, a totally different appearance is noted. Although a layer of necrotic material containing organisms adjoins the uterine cavity, it is usually thinner than in the preceding case. The zone of leukocytic infiltration is either lacking or very imperfectly developed, and the microorganisms can be observed making their way down through the decidua and along the lymphatics of the muscular Avail of the uterus out towards its peritoneal surface (Figs. 687 and 688). Fig. 687.—Colon Bacillus Endometri- tis. Leukocytic Wall Not Invaded by Bacteria. X 800. Fig. 688.—Streptococcus Endometritis, Showing Invasion of Leukocytic Wall. X 800. It would appear, therefore, that Nature endeavors to confine the microorganisms to the inner surface of the uterus by interposing be- tween the necrotic la}rer and the deeper portions a barrier of leukocytic infiltration, which acts as an efficient filter when the bacteria are at- tenuated, but fails to restrain them when they possess a marked degree of virulence. As has already been pointed out, in a considerable proportion of cases the inflammatory process extends into the uterine musculature, and there gives rise to divers lesions of metritis, which may vary from small areas of leukocytic infiltration to definite abscess formation. As such PATHOLOGICAL ANATOMY 989 multiple abscesses are due to implication of the lymphatics, and, inas- much as these channels are most numerous beneath the peritoneal cover- ing of the uterus, such lesions are most abundant in that situation. Under the designation metritis dessicans, Garrigues described a vari- ety of severe puerperal infection in which not only the endometrium, but also a varying amount of the muscularis undergoes necrosis, and is ex- pelled in large shreds or even as a cast of the interior of the uterus. As Schmidlechner suggests, it should more properly be designated as gangrene of the uterus. Peritonitis.—In the majority of cases of puerperal infection which end fatally, death is due to peritonitis. As was pointed out when con- sidering the histological changes in puerperal endometritis, the strepto- cocci or other infecting agents may rapidly make their way by means of the lymphatics from the interior of the uterus to the peritoneal sur- face and there give rise to inflammatory changes. This is the usual mode of infection, but in rare instances it may be due to the escape of pus from the fallopian tubes; though in none of the autopsies which I have witnessed has such a mode of origin been observed. Occasionally, peritonitis may follow the rupture of a parametritic or ovarian abscess, while in other cases it may result from instrumental perforation of the uterus or vaginal culdesac during criminal abortion. Salpingitis.—In a small proportion of cases the infectious process extends directly from the uterine cavity to the fallopian tubes, and there gives rise to various inflammatory phenomena. Occasionally the sal- pingitis is due to infection through the lymphatics and not to direct extension from the endometrium. In most instances, however, the tubes are not involved, and when they are the lesions are more marked at their lateral ends, thus indicating that the infection is secondary to the peri- toneal improvement. Sometimes an oophoritis occurs, the ovaries being enlarged to several times their usual size and very edematous. The process may stop here or go on to typical abscess formation. The ovarian infection is usually due to lymphatic involvement, and may be associated with affections of the parametrium. Much more rarely it results from direct infection of a ruptured follicle by means of the peritonitic fluid. Parametritis.—One of the more frequent complications of uterine infection is parametritis. This frequently follows infected tears of the cervix, but in other cases is secondary to a puerperal endometritis; in either event it is due to the transmission of the microorganisms through the lymphatics to the peri-uterine connective tissue. The first effect of their invasion is a marked inflammatory edema, with very little or no suppuration. In mild cases the process goes no further, but in the severer types it rapidly spreads to the surrounding connective tissue and eventuates in abscess formation. In more severe cases the inflammatory process follows the course of the lymphatics and in many cases the abscess dissects the peritoneum off from the anterior pelvic and abdom- inal wall, and eventually points over Poupart’s ligament. Less fre- quently the process spreads posteriorly beneath the peritoneum, giving rise to retroperitoneal phlegmons, which may extend as high as the posterior mediastinum. In still another class of cases the bacteria fol- 990 PUERPERAL INFECTION low the lymphatics in the connective tissue surrounding the greater vessels of the thigh, and give rise to a rare form of phlegmasia alba dolens, the usual variety being due to the direct extension of a throm- botic process originating in the uterine veins. Pyemia.—The pyemic or thrombophlebitic form usually results from the infection of thrombi at the placental site with subsequent develop- ment of inflammatory changes in the veins. The thrombosis may be limited to a comparatively small area and be entirely within the uterine wall, or it may extend beyond the uterus, involving the internal iliac or ovarian veins, or both, so that occasionally all venous trunks leading from the pelvis are thrombosed as far up as the junction of the renal veins with the inferior vena cava. Its mode of production was exhaus- tively studied by Bardeleben in 1907. By the breaking down of the thrombi small particles escape into the circulation and are carried by the blood current in various directions, giving rise to endocarditis and metastatic abscesses, from which no portion of the body appears to be exempt. In this form of puerperal infection, such abscesses may develop in any of the internal organs, the synovial surfaces also being frequently implicated and giving rise to swellings about the joints, which, if not promptly treated, may lead to their complete destruction. In other cases blebs or bullae, due to the same cause, appear on the surface of the body, and in their contents the offending microorganisms are readily demonstrable. Less frequently, detached particles of thrombi may be arrested in one of the larger vessels of the lungs and give rise to pul- monary embolism and almost instantaneous death. When smaller vessels are involved the results are not so serious, though the portion of lung supplied by them becomes infarcted and gives rise to a secondary pleurisy or pneumonia, which may ultimately lead to death. It would appear from the observations of Mahler, Breuer, and Richter that a large part of the pulmonary affections occurring in puerperal women originate in this manner, and in not a few instances the appearance of a localized pleurisy may be the first manifestation of serious thrombotic process. Most cases of pyemia present comparatively little uterine involvement, and death, when it occurs, is due to general exhaustion following a pro- longed suppurative process. Phlegmasia Alba Dolens.—As was pointed out when considering the question of parametritis, this affection is sometimes due to the extension through the lymphatics of a parametritic process to the tissues sur- rounding the great vessels of the thigh. As a rule, however, it results from the extension of a thrombotic process from the pelvic veins; and in several of my autopsy cases the thrombophlebitis could be traced from the uterus to the common iliac veins, whence it extended upward to the vena cava and downward through the external iliac to the vessels of the leg. Occasionally, in cases which recover, the phlegmasia appears to he an isolated process, though it is probably only a part of a much more ex- tensive thrombosis. Moreover, it should be borne in mind that even widespread thrombosis may give rise to but slight clinical manifestations, as, in one of my cases which came to autopsy, the femoral vein and all PLATE XVII. SECTION THROUGH ENDOMETRIUM IN STREPTOCOCCIC PUERPERAL INFECTION. X 1000. ETIOLOGY 991 its branches were completely occluded, yet careful mensuration was necessary to detect any difference in the size of the legs. Clinically phlegmasia alha dolens should always be regarded as a manifestation of infection; although it is sometimes impossible to dis- cover its origin. Thus, I have seen it develop in several instances in which the patient had not been examined vaginally, and in which the first eleva- tion of temperature oc- c u r r e d during the course of the third week, as well as during the second half of pregnancy in appar- ently normal women. Furthermore, F. C. Goldsborough has de- scribed a case of complete occlusion of the common iliac, external iliac, and femoral veins, which occurred in my service, and was clearly the result of pressure. The inference, however, that the process is not of infective origin, is not permissible unless the patient comes to autopsy, and careful bacteriological examination demonstrates the absence of bacteria. An idea of the frequency of the various lesions in fatal cases of puerperal infection may be gained from the following figures of Kneise, which were based upon the findings in 89 autopsies: Peritonitis 43 cases Thrombophlebitis 20 “ Pyemia... 17 “ Parametritis 7 “ Sepsis foudroyante 2 “ Etiology.—As it has been conclusively demonstrated that the bacteria concerned in puerperal infection are identical with those with which we are familiar as causing ordinary wound infection, it must follow that puerperal infection is a wound infection resulting from the introduction of pyogenic bacteria into the generative tract either before, during, or immediately after labor. In other words, it is usually a direct infec- tion from without, the bacteria being brought to the woman by the hands, instruments, or any other object which may come in contact with her generative organs. Puerperal infection, then, is contact infection, this conception having been first definitely enunciated by Semmelweiss in the following words: “I consider puerperal fever, not a single case excepted, as a resorption fever, caused by the resorption of a decomposed animal-organic material. The first result of the absorption is a change in the blood, and the exudations are the result of this change. The decomposed animal- Fig. 689.—Section through Thrombosed Pelvic Vein, Showing Streptococci. X 800. 992 PUERPERAL INFECTION organic material, which, when resorbed, causes childbed fever, is brought to the individual from without in the great majority of cases, and this is infection from without. These are the cases which represent the epidemics of childbed fever. These are the cases which can be prevented. In the latter part of the eighteenth century puerperal fever began to be considered as a contagious malady in England. This conception ap- parently originated with Thomas Kirkland, of Ashby, in 1774, but was first clearly enunciated in 1795 by Gordon, of Aberdeen, in his treatise “On the Epidemic of Puerperal Fever, as it prevailed in Aberdeen from December, 1789, to March, 1792.” In this he gave an account of 77 cases which he had attended, and, among other things, stated: “It is a disagreeable declaration for me to mention that I myself was the means of carrying the infection to a great number of women.” In this country we are mainly indebted to Oliver Wendell Holmes for introducing the conception of the infectious nature of the affection. In an article entitled “Puerperal Fever as a Private Pestilence,” first published in 1843, he clearly showed that the epidemic form of the disease was preventable, and owed its origin either to the physician or midwife. His teachings, however, did not exert the influence which might have been expected, mainly because they opposed by the leading obstetri- cians of the country, notably Meigs and Hodge, the former stating that he preferred to consider the disease as due to the workings of Providence, which he could understand, rather than to an unknown infection of which he could form no conception. For many years the prevalent theory in Europe was that puerperal fever was due to miasmatic, telluric, or atmospheric influences. This view held its ground for years after the appearance of Semmelweiss’s book in 1801; although in 1864, Hirsch, after studying the matter from an historical standpoint, came to the conclusion that the malady was of infectious rather than of miasmatic origin. It was not, however, until after Lister had introduced antiseptic methods into surgery, and Stadfeld, of Copenhagen, had recommended the use of bichlorid of mercury in obstetrics, that the great mass of the profession began to understand that puerperal fever is due to contact infection, and can be prevented to a very great degree. The bacterio- logical work of Pasteur and his successors, and the almost constant pres- ence of streptococci in fatal cases, decided the question, and at present no one doubts the infectious nature of the disease. Modes of External Infection.—The most usual mode of infection is by the hands of the obstetrician or the midwife, and no one who has observed the way in which many medical men conduct labors can wonder that puerperal fever occasionally occurs. The employment of dirty instruments, as well as dirty hands, also plays an important part. Sources of infection, much rarer, it is true, but generally overlooked, especially among the lower classes, are self-inoculation by the patient fingering her genitalia or even making internal examinations, and copu- lation during the latter days of pregnancy. Liepmann states that bac- teriological examination of the prepuce of the penis reveals the presence of streptococci in 75 per cent, of all cases; while I have seen several ETIOLOGY 993 patients die, and a number of others seriously infected, who had not been examined internally, but who had copulated during the first stage of labor. Contact with wound secretion of any kind also plays an im- portant part, and whether the purulent material be from an external wound or elsewhere within the body, the result will be the same. Wounds on the hands of the physician or nurse, bone felons, and other affections of the fingers, such as a pustular eczema, are sometimes responsible. For many years it has been known that puerperal fever often occurred when a woman in labor was cared for by a physician who at the same time was attending a case of erysipelas. As has already been said, some of the old authorities held that the two affections were identical, but it was not until bacteriology had proved that erysipelas, as well as puer- peral infection, is due to the streptococcus that this relation was under- stood. At the present time it is generally believed that there is no essential difference between the streptococcus erysipelatis of Fehleisen and the ordinary streptococcus pyogenes. Puerperal fever has also frequently occurred in the practice of those attending diphtheria, scarlet fever, and occasionally typhoid patients. Although no essential relationship between these affections has been proven, it is well known that in both diphtheria and scarlet fever com- plications due to the streptococcus are frequently met with, and these organisms may be conveyed to the woman in labor. Air infection was formerly supposed to play an important etiological part, and many authors advise covering the external genitalia with an occlusive pad to prevent the entry of air into the vagina, and thus elimi- nate the danger source of infection. It is doubtful, however, whether air infection is ever the cause of the disease. Nevertheless, in England, and to a less extent in this country, sewer gas is believed to play a promi- nent part in its production. But I believe that the danger of infection from this source will be spoken of less and less frequently as medical men become better versed in aseptic technic. To show how accurate a conception Semmelweiss possessed of the various modes of contact infection, it may be interesting to quote what he said concerning it: “The bearer of the decomposed animal-organic material is the examining finger, the operating hand, instruments, bed- clothes, atmospheric air, sponges, the hands of midwives or nurses which come in contact with the excrement of women sick with puerperal fever, and afterwards handle pregnant or parturient women. In other words, the bearer of the decomposed animal-organic material is anything which is soiled by a decomposed animal-organic material and comes in contact with the genitalia of these patients.” Auto-infection - -At present it is universally accepted that the serious cases of puerperal infection are due almost without exception to the introduction from without of pyogenic bacteria into the genital canal of the pregnant or parturient woman. Nevertheless, many authorities teach that occasionally infection does not result in this manner., but owes its origin to microorganisms which were already within the genital tract before the onset of labor. To infection arising in this way the term 994 PUERPERAL INFECTION “auto-infection" is applied. The conception originated with Semmel- weiss, who stated: “In rare instances the decomposed animal-organic material, which causes childbed fever when absorbed, is produced within the patient herself. These are the cases of auto-infection, and cannot be prevented.” With the enthusiasm which attended the introduction of antiseptic methods into obstetrics, the possibility of auto-infection was lost sight of for a time, and it was only after the statistics of well-conducted lying-in establishments showed that a certain number of cases of infec- tion still occurred, despite the rigorous application of antiseptic prin- ciples, that the idea was rehabilitated by Ahlfeld and Kaltenbach (1883- 1889). Of course, with the recognition of the fact that puerperal fever is due to bacterial infection, the definition introduced by Semmelweiss fell to the ground, since the microorganisms could not originate spontaneously within the body of the woman. Kaltenbach then advanced the view that pathogenic bacteria are normally present in the vaginae of a consider- able proportion of healthy pregnant women, and that these might make their way into the uterus, or be introduced into it by the sterile examin- ing finger. Apparent proof of the possibility of auto-infection is afforded by the rare instances in which serious puerperal infection develops in women who had not been examined vaginally, and whose labors had been con- ducted in a thoroughly aseptic manner. Such cases undoubtedly some- times occur, but even in them the proof is not convincing; as it is im- possible to prove that the infection might not he due to the patient handling her genitalia, or to bacteria which were brought to the uterus by means of the blood current. Reference to the latter mode of infec- tion has already been made in connection writh the pneumococcus; and the streptococcus is sometimes similarly brought to the uterus in certain cases of angina, influenzal pneumonia, or other diseases. I was able to adduce convincing proof of its occurrence in influenza pneumonia, by demonstrating the presence of chains of streptococci in arterioles making their way through the uterine musculature to the decidua. Winter, in 1911, admitted the justice of these reservations, and held that one is justified in speaking of auto-infection only when bacterio- logical examination demonstrates that the bacteria found in the puer- peral uterus had existed in the vagina at the onset of labor. He con- siders that he has been able to adduce such proof, and therefore holds that auto-infection undoubtedly occurs. Accordingly, the solution of the question will depend upon the results of the bacteriological examina- tion of the generative tract during the last w'eeks of pregnancy. Un- fortunately, the investigations which have been undertaken for this purpose have not given uniform results, and consequently we are nearly as far from a scientific solution of the problem as when it was first broached; although in actual practice a constantly increasing number of obstetricians act on the supposition that auto-infection does not occur. All investigators are united in claiming that the cavity of the norma] uterus is free from microorganisms both in the pregnant and non- ETIOLOGY 995 pregnant condition. This fact has been amply demonstrated by the work of Gonner, Doderlein, and Winternitz in women, and by Strauss, Sanchez-Toledo, and Denzler in the lower animals. Prior to 1898 it was generally believed that the cavity of the normal puerperal uterus was also free from bacteria, and that the demonstration of their presence afforded indubitable evidence of infection. In that year, however, Franz stated that bacteria could frequently be found after the first few days of the puerperium in women who had presented no clinical signs of infection. His publication was soon followed by others; and at first it was believed that the bacteria in question were merely saprophytes, but Stolz, Schenk, and Schieb found streptococci in from 30 to 38 per cent, of their cases. On the other hand, Foulerton and Bonney, Brownlee, and others stated that streptococci were never present. In view of these contradictory statements, my former assistant, H. M. Little, investigated the question. For this purpose he studied the uterine lochia obtained from 50 women delivered consecutively in my clinic in 1901. In each case cultures were taken immediately after the expulsion of the placenta, and again on the third and ninth days of the puerperium. Xot counting the gonococcus, the uterus was found to be sterile in 96, 85, and 70 per cent, of the cases on the three days respectively, and in none of the 150 examinations were streptococci found. Little’s observations, indicate to my satisfaction that the normal puer- peral uterus at no time contains streptococci; but, on the other hand, it cannot be regarded as sterile except immediately after delivery, and becomes progressively more and more contaminated as the puerperium advances. The bacteria present are usually saprophytic in character, and while they may give rise to slight febrile disturbances they cannot be held responsible for the production of the grave forms of infection. In view of these investigations, it seems to me that the question of auto-infection must stand or fall with the demonstration of virulent streptococci in the vaginal secretion of healthy pregnant women. If they are even occasionally present, it must be admitted that they may be carried up into the uterus by the sterile examining finger, and give rise to infection; whereas if they are uniformly absent, such a con- tention must, be dismissed as untenable. Unfortunately, the bacteriological investigations which have been undertaken to determine this question have served rather to complicate than to settle it; one set of observers claiming that streptococci are frequently present, and the other contending that, with the exception of the gonococcus, pyogenic bacteria are always lacking. The monograph of Doderlein on the vaginal secretion, published in 1892, promised for a time to reconcile the conflicting results, but as his conclusions have not been confirmed by subsequent investigators, the question still remains an open one. He stated that the vaginal secretion might occur in one of two forms, which he designated as normal and pathological and which occurred in 55 and 45 per cent, of his patients, respectively. The former was a thick, dry, cheeselike material of a whitish color and a distinctly acid reaction. Microscopically it showed 996 PUERPERAL INFECTION epithelial cells, a pure culture of tolerably long, thin bacilli, and occa- sionally a few yeast fungi. The pathological secretion, on the other hand, was fluid, generally of a yellowish color, suggesting pus, and some- times contained gas bubbles. Its reaction was less acid than that of the normal secretion, occasionally neutral, and very rarely alkaline. In it were found large numbers of leukocytes and many microorganisms of various kinds, both bacilli and cocci. As pyogenic bacteria were never present in the normal, while streptococci were noted in 10 per cent, of the pathological secretions, he held that auto-infection was out of the question when the secretion was of the first, but might occasionally occur when it was of the second type. Following Doederlein’s investigations an immense literature has ac- cumulated upon the subject, but unfortunately the results obtained have been extraordinarily contradictory. Thus, Kronig and I, in 1897 and 1898 respectively, stated that streptococci could not be found in the vaginal secretion of normal pregnant women; whereas other investi- gators found them in a varying proportion of their cases—the extremes being represented by 4 per cent, in Burckhardt’s series, and by 74 and 100 per cent, in the series of Bumm and Sigwart, and Natwig, re- spectively. Naturally, such radical differences indicate that neither side has correctly faced all aspects of the problem, and that eventually a satisfactory solution must be attained. At one time, I thought that I had solved the problem, and that the contradictory results could be explained by differences in the technic employed for obtaining the secretion for examination, and that negative results were obtained when the secretion had been secured without con- tamination, while positive results were due to bacteria having been carried up from the vulva into the vagina when the sample of secretion was removed for examination. The correctness of this assumption was ap- parently substantiated by the examination of 25 pregnant women, from each of whom three sets of cultures were made. The first set was taken from the inner surface of the labia minora by means of an ordinary platinum loop; the second set was made from secretion obtained from the upper third of the vagina by means of a Menge tube, which effectively did away with the possibility of contamination from the external geni- talia, while in the third set, after introducing a speculum into the vagina, the secretion was taken from beyond its free end by means of a platinum loop. Pyogenic cocci or colon bacilli were present in 80 per cent, of the first, but were entirely absent from the second set, thereby indicating that the vaginal secretion, when obtained by a technic which precludes the possibility of contamination, is free from pyogenic bacteria. On the other hand, such bacteria were present in 48 per cent, of the third set of cultures, which apparently showed that they had been carried up from the vulva by means of the speculum. This explanation apparently settled the matter for a few years, but in 1904 Bumm and Sigwart stated that my negative results were to be attributed to the employment of solid, instead of fluid, culture media, so that streptococci escaped detection. They stated that by the use of fluid media they had been able to demonstrate their presence in from ETIOLOGY 997 38 to 74 per cent, of a series of pregnant women, according as cultures were taken upon one or several occasions. It should be mentioned that they employed a speculum for obtaining the secretion, taking the speci- men from a portion of the vaginal wall, which presumably had not come in contact with it. Since then various other investigators have studied the problem, and, as a rule have reported that streptococci could be found in a varying pro- portion of cases, Jotten, for example, in 1912, having demonstrated them in 67 out of 100 women at the time of labor, and found that they were frequently of the hemolytic variety. He, however, attached no practical significance to their presence, as he stated that the puerperium was more frequently febrile in their absence. He furthermore made the interesting statement that he believed that the conflicting statements concerning their incidence were due to internal conditions in the various clinics rather than to errors in interpretation or in technic. As I felt that it should be possible to discover at least a clue toward the solution of this complicated question, I requested Dr. Willa Fricke in 1914 to take it up once more, but I am sorry to say that, while she apparently discovered an explanation for certain phases of the subject, her findings added still further to the confusion. She studied the vaginal secretion in 50 women awaiting delivery in the clinic, employing the same technic for obtaining it as in my original work, but utilizing a greater variety of culture media—particularly glucose bouillon. She found streptococci upon the vulva and in the vaginal secretion in 14 and 8 per cent, of the cases respectively, and concluded that it made no dif- ference whether it was obtained by means of a Menge tube or a speculum. Her findings differed from mine in the occasional demonstration of streptococci, but more particularly by failing to demonstrate that bac- teria were carried up from the vulva into the vagina by the speculum. This 8 per cent, incidence of streptococci was so small in comparison to that recorded by many German investigators, that it seemed impor- tant to attempt to ascertain the cause of the discrepancy. It was, there- fore, tentatively suggested that the greater cleanliness of the patients in American hospitals might be a factor, and as a control, 47 out- patients were visited in their own homes without warning, and cultures were taken from the vulva, and from the vaginal secretion obtained by means of Menge’s tube. Streptococci were cultivated in 75 and 55 per cent, of the two sets of cultures, respectively, and approximately one third of them were of the hemolytic type. The difference between the two series is striking, and indicates that streptococci were demonstrated approximately seven times more frequently in the latter group, which is in close accord with the results obtained in the German clinics. As the only difference in the two series wras in the personal cleanliness of the patients, Fricke regards it as an impor- tant factor in explaining the incidence of streptococci, but we should hesitate to suggest that it is the sole explanation for the different results obtained in the German clinics and in Baltimore. Fricke did not attempt to determine the virulence of the streptococci which she isolated, but the fact that none of the women in either series were seriously sick PUERPERAL INFECTION 998 after delivery, and the further fact that the 10 women, whose vaginal secretion contained hemolytic streptococci, had afebrile puerperia, in- dicates that the cocci concerned were clinically harmless. What practical conclusions can be drawn from the evidence which has just been adduced concerning the doctrine of auto-infection? In the first place it appears that the vaginal secretion of normal healthy pregnant women does not contain streptococci which grow upon ordi- nary agar. On the other hand, the preponderance of evidence indicates that in a varying proportion of patients it does contain streptococci, which grow readily in glucose bouillon. Furthermore, it is probable that the incidence of the latter depends in great part upon the personal cleanliness of the patient; and finally there is no evidence that the presence of such streptococci plays any part in the production of puer- peral infection. In other words it may be concluded that while bacteriological re- search affords a certain amount of evidence in favor of the theoretical possibility of auto-infection, clinical observation speaks against it. Ac- cordingly, the occurrence of serious streptococci infection should always be regarded as evidence of external infection. At the same time it is possible that auto-infection may occur from other organisms, which are present in the vaginal secretion, and plausi- bility is lent to such a supposition by the increasing frequency with which bacteria are found in the uterus with the advance of the puerperium; but satisfactory evidence cannot be adduced in support of such a con- tention until methods have been devised which will enable us to isolate and cultivate in pure culture the organisms in question, many of which are anaerobes which will not grow upon the usual media. The gonococcus forms an exception in this regard, as it is the only pyogenic coccus which can live and thrive in the vaginal secretion. As already indicated, it is a frequent cause of puerperal endometritis. Such cases, however, should not be considered as supporting the doctrine of auto-infection, for the reason that they represent contact infections, which had occurred before conception or in the first few months of pregnancy, after which the gonococci had led a parasitic existence in the crypts of the cervical canal, until they found more suitable con- ditions for development during the first few days of the puerperium, when they made their way up into the uterine cavity and manifested their presence by the production of fever and an increased discharge. Likewise, one should not regard as auto-infection, in the strict sense of the word, those cases in which the bacteria are brought to the uterus from distant foci of disease by means of the blood current, nor those in which the process results from some preexisting affection of the genera- tive tract, such as an old pyosalpinx. An interesting fact in connection with the question of auto-infection is that those who believe most firmly in its possibility, and who employ the prophylactic vaginal douche for the destruction of the vaginal bac- teria, have been able to present less favorable statistics than their oppo- nents. The same may be said concerning the more recent proposals to employ a one-half per cent, solution of lactic acid as a prophylactic ETIOLOGY 999 measure, with the idea than an increase in the acid titre of the vaginal secretion will lead to the destruction of pyogenic bacteria and favor the growth of the characteristic vaginal bacillus. This question was considered in detail by Hamm in 1918. Frequency.—It is difficult to make accurate statements as to the fre- quency of puerperal infection, especially when it occurs outside of hospital practice. Concerning this condition the vital statistics of the health offices of the various American cities are of little value, inasmuch as many of the deaths from this disease are returned as being due to malaria, typhoid fever, pneumonia, or other causes. Dublin, in 1918, estimated that it was responsible for 43 per cent, of all deaths incidental to child-birth in this country; while Howard calculated, in 1921, that one out of every 406 women who become pregnant die from infection, and stated that “these rates are probably unparalleled in modern times in a civilized country.” Since the introduction of antiseptic methods into midwifery the mor- tality from puerperal infection has decreased very markedly in hospital practice. Formerly, in the old Maternity of Paris, and in the Lying-in Hospital in Vienna, it varied from 10 to 15 per cent., so that finally it attracted the attention of the public, and steps were being taken to abolish such institutions as a menace to public health. With the intro- duction of aseptic methods, however, all this was changed, so that at present in well-regulated lying-in hospitals the mortality from infection is usually only a small fraction of 1 per cent., Pinard, in 1909, having reported a mortality of 0.15 per cent, in 45,633 deliveries. Hence it happens that at the present time, in the discussions upon the subject, so far as hospitals are concerned, the question is rather one of mor- bidity than of mortality, and deals with the percentage of patients whose temperature rises above 38° C. or 100.4° F. during the puerperium. On the other hand, in private practice it is doubtful whether the results are materially better to-day than they were before the introduc- tion of antiseptic methods, for the reason that the doctrines of asepsis have not yet permeated the rank and file of medical men, much less of midwives, to whose care is committed a large proportion of obstet- rical cases. Though, at the same time, it must be admitted that we rarely hear of outbreaks of puerperal infection such as were mentioned in the historical work of Hirsch, wffio gave the particulars of 216 epi- demics occurring between the years 1652 and 1862. Boehr stated in 1875 that 363,324 women had died from puerperal infection in Prussia during the preceding 60 years, and calculated that every thirtieth married woman eventually perished from it; while Ehlers contended that outside of the wrell-regulated hospitals the results were equally bad in 1900. Furthermore, Fromme stated, in 1910, that at least 5,000 women succumb each year in Prussia to this preventable malady. Meigs stated that in the registration area, which includes somewhat less than two-thirds of our population, 4,542 deaths from-puerperal in- fection were recorded during the year 1913. She makes a still more startling arraignment by comparing the deaths from typhoid fever, diph- 1000 PUERPERAL INFECTION theria, tuberculosis and puerperal infection in the years 1900 and 1913 respectively. During this period the three first-mentioned diseases show a decrease of over one-half, as contrasted with a slight increase for puerperal infection. Howard, and Eichel in 1921 and 1922, respectively made impor- tant statistical studies and reached practically identical conclusions. The former studied the census figures for 1918 for the birth registration area, which includes 53 per cent, of the population, and found that one out of every 113 women delivered during that year died from some cause connected with childbirth—27.8 per cent, from infection. Howard stated that these results were 120 per cent, higher than in England and Wales, and then made the startling statement that, upon dividing the material into urban and rural, according as the women lived in localities having ten thousand inhabitants or less, the results were worse in the former group, the incidence of infection being one-fifth higher in the urban than in the rural population. Eichel studied the conditions obtaining in the State of New York for the five years ending with 1920. During this period he found that approximately one and a quarter million births had occurred, which were almost equally divided between the City and State of New York. In the former, one woman died in every 214 labors, while in the latter, the proportion increased to 1 to 151. He attributed the relatively good results in New York City to its well-conducted hospital facilities and to the presence of trained specialists. Upon analyzing more closely the figures for the State outside of the City of New York, he reached con- clusions similar to those of Howard, and found that labor was consider- ably safer in rural communities than in the cities and villages with more than 2,500 inhabitants. In other words, Eichel found that it was one-half again as dangerous to have a baby in the latter localities as in the City of New York, and one-fifth more dangerous than in the open country, where physicians were not always available. Furthermore, he stated that while the figures for the entire State for the years 1911 to 1916 showed a gradual decrease in the puerperal death rate from all causes, a progressive rise having occurred from 1916 to 1921, so that the risk-rate had become one-eighth greater in the latter year. This tendency, however, is not peculiar to America, as Eden has noticed it in England, and German writers refer to its occurrence in their country, but without giving actual figures in support of their con- tention. In general, it may be attributed to the disorganization of medical practice incident to the World War. Such figures seem to indicate that while preventive medicine has played a stupendous part in diminishing the incidence and mortality of the infectious diseases, that of puerperal infection has not been affected, except in the largest centers where well-conducted lying-in hospitals and trained specialists are available. The figures of Howard and Eichel, which set forth the appalling conditions obtaining in the smaller cities and towns of the country, constitute a striking arraign- ment of our system of obstetrical training, and indicate that the rank and file of medical practitioners are no better trained than their predeces- ETIOLOGY 1001 sors, and consequently with the single exception of tuberculosis, puerperal infection still constitutes the most important cause of death among women during the child-bearing period. The investigations of Boxall, Byers and Lea show a similar con- dition in Great Britain, where it may be said that outside of the lying-in hospitals this preventable scourge claims as many victims as forty years ago. Eden in 1922 pointed out that the mortality from childbirth had actually increased from 1911 to 1920, and that while the proportion of deaths from the complications of pregnancy and the accidents of labor had decreased, that from infection was actually greater. Moreover, in attempting to ascertain the frequency of puerperal infec- tion, one cannot be guided altogether by the mortality statistics, inas- much as the greater proportion of such cases do not end fatally. On the other hand, no one who has to deal with gynecological patients can fail to be impressed with the very large proportion whose troubles have originated from febrile affections during the puerperium, which in most instances were due to the neglect of aseptic precautions on the part of the obstetrician or midwife. Symptoms.—As was stated when considering the pathological anatomy of puerperal infection, the common lesion is an endometritis. This may be either of the septic, putrid or gonorrheal variety, each type present- ing a group of more or less characteristic symptoms. In the case of septic endometritis, after everything has gone smoothly for the first three or four days of the puerperium, the patient suddenly experiences some malaise, and complains of headache and a feeling of chilliness, or she may have a well-defined chill, the temperature rising to 103° F. or higher. Generally, only one rigor occurs, after which the temperature remains constantly elevated. At the same time there is some tenderness in the lower part of the abdomen, the uterus is larger and more doughy in consistency than it should be, and is sensitive on pres- sure. The lochial discharge is sometimes increased in quantity, and is partly bloody, partly purulent in character, and may be practically devoid of odor. If the temperature is very high the secretion may be diminished in amount, and occasionally disappears almost entirely. The character of the uterine discharges in these cases often leads to a mistake in diagnosis, for the average practitioner associates puer- peral infection with profuse and foul-smelling lochia; whereas, in reality in the more virulent streptococcus cases, there is very little, if any, odor, and its absence, therefore, is not necessarily a favorable indication, but rather the reverse. Another point of importance is the faulty involution of the uterus. This must be looked upon as an important factor in the further spread of the disease, for the microorganisms make their way through the mus- cular walls of the uterus by means of the lymphatics, and when the organ is markedly relaxed these channels are more patent and offer less resistance to the outward passage of the bacteria than when firm, normal contraction is present. The further history of septic endometritis varies according as the process remains limited to the cavity of the uterus or extends beyond it. 1002 PUERPERAL INFECTION In the former ease the temperature gradually falls, the secretion becomes less and less, and the patient is slowly restored to health. The mucosa, however, is not restored to its normal condition at once, but for some time remains the seat of a subacute or chronic inflammation. When the process has extended beyond the uterus the symptoms will vary according to the organs involved, and those belonging to a parametritis, peritonitis, or pyemia, as the case may be, are superadded. In putrid endometritis we may likewise have the initial chill and the high temperature, but the patient’s condition does not usually appear so serious as in the septic form. The main difference, however, is to be noted in the character of the uterine discharge, which, in the putrid cases, is abundant, very foul-smelling, and frequently has a frothy ap- pearance. These cases usually eventuate in recovery. Between these two well-marked types of cases, however, there exist all gradations, and not uncommonly we have to deal with a mixed infection due to pyogenic as well as putrefactive organisms. In gonorrheal puerperal endometritis the symptoms are usually very characteristic. The first days of the puerperium are normal, and about the end of the first week, just as one is congratulating one’s self that all is well, the temperature suddenly rises, usually without a chill, and remains elevated for a week or ten days, gradually falling to normal without treatment. Usually there is some abdominal tenderness and pain, which may become pronounced if the process extends beyond the tubes, which happens in only a small proportion of cases. In not a few cases, the diagnosis is facilitated by the development of ophthalmia neonatorum several days before symptoms appear in the mother. Ordi- narily only palliative treatment is required, and a few days additional rest in bed. Actual cure, however, can scarcely be expected, as the process tends to become chronic, and may lead to permanent sterility or to the development of chronic pelvic inflammatory disease, which may require operative interference months or years later. The extension of the infection from the uterine cavity, or from cervi- cal tears, to the parametrium produces an array of more or less character- istic manifestations. In many cases the initial rise of temperature lasts only for a few days, and we are congratulating ourselves that the patient has escaped so easily when suddenly another chill occurs, the tempera- ture rises again, to pursue a more or less irregular course, usually marked by evening exacerbations. Within a few days vaginal examina- tion or abdominal palpation will reveal the presence of a mass on one or both sides of the uterus, due to pus formation within the folds of the broad ligament. The abscess may be limited to this location, or, as it becomes larger, it may dissect ofi the peritoneum from the anterior portion of the pelvis and the abdominal wall, and form a tumor whose upper margin extends well above Poupart’s ligament ; in other cases, again, it extends backward toward the retroperitoneal region. The fever continues until the abscess has been opened or ruptures spontaneously, except in the few instances in which it undergoes gradual resorption, leaving a mass of cicatricial tissue to mark its former situation. If not operated upon, a parametritic abscess may burst spontaneously into the ETIOLOGY 1003 rectum or bladder, and occasionally through the abdominal wall in the region of the inguinal canal. Unless it ruptures into the peritoneal cavity the patient usually recovers with proper care. In rare instances the infection extends from the uterine cavity to the fallopian tubes, and gives rise to a salpingitis with its accompanying symptoms. A considerable proportion of the cases of pyosalpinx fol- lowing abortions, which come to operation months or years later, have originated in this manner. Unfortunately, it frequently happens that the infectious process does not remain limited to the uterus or to the parametrium, but the micro- organisms make their way through the lymphatics of the muscular wall of the uterus to the peritoneum, and there excite a peritonitis; though in exceptional instances the latter may result from an extension of the inflammation from the tubes, and occasionally from the rupture of a parametritic, ovarian, or tubal abscess. Particularly in gonorrheal infections, the peritoneal implication is limited to the portion lining the pelvic cavity—pelvic peritonitis—but in streptococci infections it tends to become generalized. In the former event, recovery is the rule, whereas in the latter death is almost inevi- table. The characteristic symptoms of peritonitis usually make their appearance during the first week of the puerperium, but rarely before the third or fourth day. If they occur at a later period the process is usually due to the rupture of an abscess. When very virulent streptococci are the infecting agents the endo- metritic implication is usually very slight, and practically the first sign of infection appears from the side of the peritoneum. A definite rigor occurs, the temperature rises rapidly and remains constantly elevated, the pulse becomes rapid, and later on very weak and thready in character. The patient may complain of intense pain, which is at first limited to the lower portion but gradually extends over the entire abdomen. At the same time there is marked tympanites, and the abdominal walls are rendered tense by the distended intestines. If a fatal issue ensues death usually occurs within ten days after delivery, the patient gradually sinking, although she may remain conscious to the last. In other cases, however, the clinical symptoms do not correspond to the gravity of the lesion; the temperature is but little elevated, the pain slight, and the abdominal symptoms slightly marked, or even absent, the serious char- acter of the condition being indicated only by the rapid and compressible pulse and the drawn and haggard facies. In the cases of pyemia, on the other hand, the clinical picture is very characteristic. Here the initial chill rarely occurs before the end of the first week, and the temperature does not remain constantly ele- vated, but instead we have a typical hectic fever, with the chill, high temperature, and remission recurring in succession. The symptoms vary very considerably, according as one has to deal with the disiodgment of a single thrombus or of the repeated entry into the blood of small infected particles. In the first instance a metastatic abscess develops at some one point, the symptoms depending upon the organ involved. 1004 PUERPERAL INFECTION On the other hand, if thrombi are being constantly dislodged we may have symptoms referable to various organs. One of the most constant manifestations of pyemia is an infectious bronchopneumonia, which contributes to the fatal termination. In other cases swellings occur at the various joints, which frequently eventuate in suppuration and lead to total destruction of the tissues implicated. Ab- scesses may also develop in the internal organs or appear upon the surface, and in several instances I have seen them lead to the destruction of the eye. The course of pyemia varies according to the organs attacked and the resisting powers of the patient, and weeks, or sometimes months, elapse before death occurs or recovery ensues. In general, it is less fatal than the peritonitic form of infection, but unless prompt resource is had to surgical intervention, its mortality is in the neighborhood of GO per cent. In rare instances the infection is so virulent that the bacteria do not have a chance to become localized in any one organ, and both they and their toxins are found in abundance in the circulating blood, with very slight implication of the uterus. This results in the so-called acute septicemia—the sepsis foudroyante of the French writers—which represents the most rapidly fatal form of infection, the patients occa- sionally dying on the second or third day after delivery in a condition of shock, and without the development of local symptoms. A case of streptococcus septicemia, observed in our out-patient department, ended fatally within eighteen hours after the initial rise of temperature. Occasionally, the thrombotic process involving the pelvic veins may extend to the femoral, and sometimes to the saphenous, vein on one or both sides, giving rise to phlegmasia alba dolens. This accident, as a rule, does not make its appearance until some time in the second or third week of the puerperium, or even later, the first symptom being pain along the course of the involved vessels, which, in thin individuals, may be felt as hard, sensitive cords. At the same time edema appears in the feet and soon extends upward, though occasionally it may appear first in the thigh. This swelling is associated with severe pain, and usually lasts for a considerable time, months sometimes elapsing before the patient can walk with comfort. The condition is rarely fatal unless some complication occurs. At the onset of phlegmasia many patients complain of severe pain about the chest. This symptom is attributed by Plnard and Wallich to the arrest of minute emboli in the smaller vessels of the lung, with subsequent infarction and the development of isolated areas of pleurisy. In a certain number of cases infection may occur before the birth of the child. This is designated as intrapartum infection, and usually oc- curs in slow labors in which the membranes have ruptured prematurely. In such circumstances the temperature may be markedly elevated and the patient present a profoundly septic appearance even before delivery. When the temperature during labor rises above 100.5° F., we should always think of this complication, and at once institute procedures to hasten the evacuation of the uterus. DIAGNOSIS 1005 Diagnosis.—The diagnosis of puerperal infection is usually made without difficulty, as the clinical history is very significant. If a patient, who has been doing well after delivery, has a rise of temperature on the third or fourth day exceeding 100.4° F. (38° C.), which persists for more than twenty-four hours, we may be practically sure that we have to deal with an infection, unless some other perfectly apparent condition will account for the symptoms. The occurrence of an initial chill adds to the probability of the diagnosis. In the old times it was believed that the onset of the lacteal secretion was accom- panied by fever, and the older observers were always ready to attribute a rise of temperature on the third or fourth day to this cause. At present, however, this so-called “milk fever” is no longer regarded as a morbid entity, as we know that the normal puerperium should be afebrile. In uncomplicated cases of puerperal endometritis usually very little pain is complained of, and it sometimes becomes a difficult matter to decide positively whether the temperature is due to a uterine infection or some other cause. After the infection has become well established, either as an endometritis, peritonitis, or one of the other forms, the diagnosis is generally easy, and it is hardly possible to mistake the symptoms produced by a peritonitis or by a pyemia. In the cases of parametritis and suppurative affections of the tubes and ovaries, biman- ual examination will demonstrate the presence of a mass on one or other side of the uterus, if the tumor has not already made itself evident to abdominal palpation. Occasionally a febrile movement may occur between the seventh and fourteenth days, which may possibly be ascribed to emotional causes, such as excitement, fright, or grief. In this event the temperature may rise suddenly, and after reaching a considerable height promptly fall to normal within a few hours. Such a diagnosis is not permissible if the temperature remains elevated for twenty-four hours. Now and again a somewhat similar rise is caused by auto-intoxication from the intestinal tract. The diagnosis, however, is readily arrived at by the administra- tion of a purgative, for after a copious movement of the bowels the temperature falls rapidly and remains normal. Again, fever occurring in the early part of the puerperium is sometimes due to inflammatory troubles about the breasts, but the subsequent history of the case readily clears up the question of diagnosis. In addition to the conditions just mentioned, many intercurrent dis- eases may be accompanied by chill and high temperature, temporarily making one suspect puerperal infection, although the subsequent history shows that one’s fears have been groundless. This is frequently so in angina, acute pulmonary affections and pyelitis. Occasionally prolonged suppurative processes in other parts of the body may be accompanied by symptoms which may be confounded with puerperal infection, but in the present state of our knowledge there is no reason why we should long remain in doubt as to the cause and origin of the fever in a given case. In the past malaria and typhoid fever were frequently confounded with puerperal infection, and were often made the scapegoat to shield PUERPERAL INFECTION 1006 the practitioner who had neglected aseptic precautions in the conduct of his case. While there is no doubt that either affection may occur during the puerperal period, in the vast majority of cases the diagnosis is open to question. If the symptoms be due to malaria one should be able to demonstrate the presence of the specific parasites in the blood; but in default of a positive finding one is not justified in making such a diagnosis. The diagnosis of typhoid fever is frequently made in prolonged cases of puerperal infection, being based on the long-continued fever and the general prostration of the patient. No doubt such a complication occa- sionally occurs, but in the present state of our knowledge we are not justified in making such a diagnosis unless a positive Widal reaction can be demonstrated. On the other hand, typhoid fever complicating the puerperium may simulate very closely a puerperal infection. Jung has described several cases in which the true nature of the malady was not discovered until autopsy, and I have had a similar experience. Likewise, an acute miliary tuberculosis, or the flaring up of a chronic process during the puerperium, may occasionally simulate an infection, or may mask its symptoms. To sum up, it may be said that it is a safe rule to regard every rise of temperature occurring in a puerperal woman as due to infection until it has been clearly demonstrated that some other exciting cause is respon- sible. Hence it follows that, in making a diagnosis of any febrile affec- tion complicating the puerperium, an accurate and complete physical examination of the patient is necessary, in which all the aids which the recent advances in diagnostic methods have placed at our command should be utilized. Bacteriological Examination of the Lochia.—As the most common lesion in puerperal infection is an endometritis, it is a matter of great importance to decide whether one has to deal with the septic, putrid or gonorrheal variety; but, although in many cases the clinical symptoms will give tolerably definite indications, a positive conclusion can be ar- rived at only after a bacteriological examination of the uterine lochia. In gonorrheal infections the development of a purulent ophthalmia on the part of the child justifies a positive diagnosis, but even in such cases one is not sure that other organisms may not be concerned. Cultures may be taken from the interior of the uterus with compara- tively little difficulty by means of a simple device first introduced by Doderlein and modified by II. M. Little. This consists of a glass tube 20 to 25 centimeters in length and 3 to 4 millimeters in internal diame- ter, with a slight bend at one end so as to conform to the anteflexed condition of the uterus. It is threaded with a piece of strong silk, to one end of which a folded rubber band is attached, which exerts suction when traction is made upon the free extremity protruding from the other end of the tube. When cultures are to be made the necessary instruments and lochial tube are sterilized by boiling, and the hands of the operator and the external genitalia having been thoroughly disinfected, the patient is placed in the Sims' or dorsal position and the cervix exposed by a suit- DIAGNOSIS 1007 able speculum. It is then seized with a volsellum forceps and, its vaginal portion having been carefully cleansed with a bit of sterilized cotton, the lochial tube is introduced as far as possible into the uterus, care being taken to avoid touching the external genitalia with it during the manipu- lation. On making traction upon the thread protruding from the free end of the tube, a partial vacuum is created and a certain amount of lochia is drawn up. The tube is then removed from the uterus and its ends hermetically closed with sealing wax. After being taken to the laboratory it is broken in its middle portion and cultures are made from the contents (Fig. 690). This method can be readily carried out by any practitioner, who is conversant with the ordinary rules of surgical technic, and if the tube be sent to a competent bacteriologist, it can be determined within twenty-four hours to what type of bacteria the in- fection is due. In my practice this procedure forms a part of the routine examina- Fig. 690.—Little’s Tube for Obtaining Uterine Lochia. tion in every puerperal patient presenting a rise of temperature above 101° F., and lasting for more than twenty-four hours. %It gives most reliable information if employed during the week following delivery, but after that period the results are not so decisive; as the uterine lochia in the latter part of the puerperium practically always contain putrefactive bacteria. I consider that this technic is preferable to the examination of the vaginal lochia obtained by means of cotton swabs, as recommended by many German authorities. The former method gives precise infor- mation concerning the bacterial contents of the uterus, while the latter necessitates the inference that the uterine and vaginal flora are identical, which is by no means always the case. As has already been indicated, it was for a time believed that the demonstration of the presence of hemolytic streptococci always indicated the existence of a virulent infection. This, however, is incorrect, as it has been demonstrated that such bacteria may give rise to benign infec- tions, or may even be present in healthy women. In general, it must be admitted that they are more frequently associated with serious infections than the non-hemolytic variety. Hirst believes that the examination of the uterine lochia may lead to erroneous conclusions, as it may give negative results, while at the same time bacteria can be cultivated from the blood. In my experience, how- ever, this is not the case in early infections, but after the first ten days of the puerperium, and especially in certain prolonged cases of pyemia, 1008 PUERPERAL INFECTION his contention is probably correct. On the other hand, if reliance were placed solely upon blood cultures, as he advised, practically all of the mild and some of the severe cases of infection would escape differentia- tion. In the former, bacteria rarely gain access to the circulation, while in the latter the reverse usually holds good; although I have seen several women die from infection in whom repeated examinations of the blood gave negative results both during life and at autopsy. In my opinion, therefore, the bacteriological examination of the blood is of secondary importance from a diagnostic point of view, although it should always be made in seriously sick patients, as the dem- onstration of streptococci adds to the gravity of the prognosis. It does not, however, necessarily indicate a fatal termination, as I have repeat- edly seen recovery occur in patients whose blood contained hemolytic streptococci, and in some instances they were but slightly sick. The macroscopic appearance of the lochia is also of considerable value, for in putrid endometritis the discharge is frothy and frequently very offensive in odor, while in pure streptococcic infections it is very little changed from the normal. This distinction needs to be especially emphasized, since the first question which the practitioner usually asks in the presence of fever during the puerperium is whether the lochia are foul-smelling, and if he receives a negative answer he is too apt to think that the fever is of other than uterine origin. As a matter of fact, the reverse is almost constantly true, and, as a rule, the foulness of the odor is in inverse proportion to the danger to which the patient is exposed. Prophylactic Treatment.—In considering the treatment of puerperal fever, prophylaxis should occupy the most important place. As has been repeatedly insisted, it is a wound-infection, due to the introduction of pyogenic microorganisms by the hands or instruments of the doctor or nurse. Hence, it follows that the most scrupulous asepsis immediately before and during labor is the means upon which we have mainly to rely to limit its occurrence. Every physician who conducts a labor case cannot feel too strongly his personal responsibility in this connection, and he fails to do his full duty to his patient unless he regards the rules of asepsis as carefully as when performing a capital surgical opera- tion. As long as vaginal examinations are made, infection will occasionally occur, even though the carefully disinfected hand be covered by a sterile rubber glove. As it is impossible to disinfect the vulva thoroughly, it must inevitably happen that bacteria are carried up into the vagina from it with each examination, and it is therefore not surprising that infec- tion sometimes occurs. For this reason vaginal exploration should be dispensed with as far as possible, and Avith this end in view the obstet- rician should perfect himself in the methods of rectal and external examination. All that has been said concerning the necessity of cleanliness and asepsis on the part of the physician applies equally well to the nurse, and in all her manipulations about the patient she should never forget her responsibility in this respect. Moreover, she should be strictly for- CURATIVE TREATMENT 1009 bidden to make vaginal examinations or give douches except at the direct request of the physician in charge. In view of what has already been said concerning practical sterility of the normal vaginal secretion, I strongly advise against the employment of the prophylactic douche as a routine procedure, believing that except when the vaginal secretion presents marked evidences of abnormality it does more harm than good. During the second stage of labor the vulva should be covered with an aseptic pad in the form of a towel soaked in bichlorid solution. This is done not so much for fear of air infection, as to prevent the possibility of contamination from the patient’s hands. The third stage of laboi likewise offers many facilities for infection, and too much stress cannot be laid upon its proper conduct. Speaking broadly, the generative tract after the birth of the child should be regarded as a noli me tang ere, unless an emergency, such as hemorrhage or an adherent placenta, necessitates the introduction of the hand. The recommendation that a routine vaginal examination is called for in order to detect cervical tears with a view to their immediate repair, cannot be too strongly depre- cated, and those who follow it will encounter a larger puerperal morbidity than when such examinations are reserved for exceptional and urgent cases. Another point in the prophylaxis of puerperal infection is to close with sutures immediately after the conclusion of labor all perineal wounds, unless the procedure is contra-indicated by profound exhaustion on the part of the patient, or by a very edematous condition of the tis- sues implicated. To save time, it is my practice to introduce the sutures immediately after the birth of the child, and while waiting for the expul- sion of the placenta. To recapitulate, the liability to puerperal infection will be materially lessened by the strict observance of the following: (1) The maintenance of strict asepsis by the obstetrician and nurse before, during, and after delivery; (2) the restriction of vaginal examinations within the narrow- est limits possible; (3) the greatest possible utilization of abdominal pal- pation and rectal examination; (4) the omission of prophylactic vaginal douches; (5) the immediate repair of perineal lacerations which might otherwise offer foci for infection; and (6) regarding the genital canal of the puerperal woman as a noli me tangere, into which neither linger nor instrument should be introduced except in emergencies. Curative Treatment.—The curative treatment of puerperal infection is a question concerning which there is much dispute, and it is probable that what is said here may be directly opposed to the usual practice of many physicians. If a puerperal ulcer is situated about the vulva or on the lower por- tion of the vagina, it should be occasionally touched with pure carbolic acid or tincture of iodin, and the parts kept as clean as possible. If the repaired perineum breaks down and suppurates, the stitches' should be removed in order that free drainage may be provided. As puerperal endometritis is the form of infection most frequently PUERPERAL INFECTION 1010 encountered, its treatment is most important; unfortunately the diree tions for it differ widely and are often contradictory. Whenever the temperature remains at 101° F. for more than 24 hours, unless a uterine infection can be excluded with a fair amount of certainty, the uterine lochia should be examined bacteriologically. Imme- diately afterwards an abundant saline douche should be given. Curettage as a routine measure in all cases of puerperal endometritis cannot be condemned too strongly, for the reason that in the most viru- lent infections there usually is nothing in the uterine cavity which can be removed, and its employment can only do harm by breaking down the leukocytic wall which serves to prevent the invasion of the deeper layers of the uterus by the offending bacteria. On the other hand, when the uterus contains a quantity of debris, its removal is quite as readily, and much more safely, effected by means of the finger. This teaching is directly contrary to that formerly given by many writers, who have enthusiastically recommended the use of the curette in puerperal infec- tion, although now, I am glad to say, much greater conservatism is practiced, and the dangers of the procedure are generally recognized. The routine use of intra-uterine douches containing bichlorid or other disinfectants in the treatment of these cases is contra-indicated on several grounds. In virulent streptococcus infection, histological examination shows that the organisms have penetrated deep down into the tissues by the time the initial chill and rise of temperature occur. In these circumstances the germicidal fluid cannot penetrate the uterine wall sufficiently deeply to reach the bacteria, upon which the further spread of the disease is dependent. How little penetration occurs was shown experimentally by Bumm. He soaked the liver of an animal dead of anthrax in a 1 to 1,000 bichlorid solution for thirty minutes, and then cut sections from it with a freezing microtome. After cutting off about 1/10 of a millimeter, he inoculated the next section into a laboratory animal, which suc- cumbed to anthrax, thus showing that the germicidal action had been exerted only upon the surface. If this be the case in the laboratory, where the tissues can be immersed in the antiseptic solution for any desired length of time, what effect can the transitory application of a few liters of weak bichlorid solution have upon bacteria, which are im- bedded in the depths of the decidua or even in the muscular wall of the uterus? Bumm likewise insisted that satisfactory results could be hoped for only when the douche was given simultaneously with the first appear- ance of symptoms, as he showed that streptococci could make their way through the uterus with great rapidity, being able to travel 2 centimeters or more in the space of six hours. On the other hand, the employment of antiseptic douches in putrid endometritis is even less rational, as in such cases simply cleaning out the uterus by a douche of sterile salt solution, will lead to a rapid fall of temperature and the amelioration of untoward symptoms. As the object of the douche is merely to wash away the debris, sterile salt solu- tion is superior to any antiseptic fluid for the purpose. In addition to these somewhat theoretical objections, there is this CURATIVE TREATMENT 1011 very practical one: namely, that the employment of antiseptics may in many cases do actual harm. Not a few cases of sudden collapse follow- ing the use of carbolic-acid douches are on record, while in some in- stances intra-uterine injections of bichlorid have been the direct cause of death. For example, at the autopsy upon a woman who was supposed to have died from puerperal sepsis, I found all the anatomical lesions of bichlorid poisoning, so that, to say the least, it remained doubtful whether the infection or the treatment instituted for its relief was responsible for the fatal issue. On reference to the literature, I collected a large number of cases in which death had followed the employment of intra-uterine bichlorid douches during the puerperium. In many instances, to be sure, exces- sive quantities had been employed, but in several a single injection of several liters of a 1 to 4,000 solution had resulted in fatal mercurial poi- soning. Consequently, when these facts are taken into consideration, it would appear that the benefit to be expected from their employment is at least very problematical, while the dangers are very real. The same considerations likewise apply to the various other anti- septic agents which have been recommended from time to time. Nor am I inclined to place great confidence in the disinfectant properties of injections of alcohol, as recommended by Wetherill, Sitsinsky, and others. At the same time it must be admitted that the uniform success obtained by the latter in 246 cases of infection speaks in its favor. The results thus far reported from the use of irrigations with Dakin’s solu- tion in the treatment of puerperal endometritis are not encouraging, and tend to indicate that the conditions are not identical with those obtaining in infected wounds in other parts of the body, in which such signal success has been obtained. So far as I am aware, Piper’s publi- cation is the only one dealing with the use of mecurochrome, and his results were not encouraging. At the same time, it should be said that the number of cases treated was too small to justify any conclusion as to its value, and it is to be hoped that wider experience may indicate that it will serve as useful a purpose in the treatment of puerperal infection as it has in other affections. The results following the somewhat nihilistic method of treatment just outlined are, to say the least, quite as good as those obtained by more radical measures, and this contention is sustained by the experi- ence of Bumm and Ivronig. By this means I have had a mortality of considerably less than 10 per cent, in my cases of streptococcic infec- tion, which would be still further reduced were to exclude the patients who were suffering from general peritonitis or severe pyemia at the time of admission. On page 983, attention was called to the fact that no fatalities occured in the 67 cases treated during the year ending July 14, 1923. At the same time it is not desired to give the impression that streptococcic infections are devoid of danger, as they are often serious and sometimes fatal, and I believe that our favorable results are probably attributable to the fact that many mild cases arO included in our series, which would have escaped detection except for the bacteriological examination of the lochia in all febrile cases. Nevertheless, our results 1012 PUERPERAL INFECTION would appear to indicate that too energetic treatment may be harmful, and that an equally good or better outcome will follow safer and more conservative measures. To recapitulate, in dealing with a case of puerperal endometritis after having removed some of the uterine lochia for cultures, the uterus should be douched with several liters of sterile salt solution. If the bacterio- logical examination shows the presence of streptococci all local treatment is contra-indicated. If, on the other hand, one has to deal with a putrid endometritis, and the symptoms do not yield to the first injection, addi- tional douches may be given. When the infection has extended beyond the uterus local treatment will only do harm in acute cases. Bumm has redirected attention to the observation made by Guerin in 1858 that in many instances involution had taken place very incom- pletely, and he therefore recommended the employment of ergot to secure better contraction, thereby occluding to some extent the lymphatics in the uterine wall. My own experience is in accord with this view, and whenever the uterus is larger than it should be at a given period of the puerperium the administration of one-half dram of the fluid extract four times a day for 48 hours is indicated. In gonorrheal endometritis active treatment is not required at the time, since in the vast majority of cases the moderate rise of temperature associated with the onset of the disease soon falls to normal, and the patients recover spontaneously, or are left with a chronic endometritis and disease of the appendages, which can be treated more advantageously at a later period. In all severe cases general tonic measures that w ill serve to keep up the strength of the patient and increase her resistance to the infec- tive virus are most valuable. Fresh air, easily digestible food, and fluids in large quantity are most important, while the most reliable drugs are strychnin and alcohol, and it is a matter of experience that these patients usually can bear much larger quantities of the latter than when in health. High fever should not be combated with antipyretics, the external appli- cation of cold, either in the form of spongings or cold baths, being preferable. Hydrotherapeutic measures have been enthusiastically ad- vocated by Runge and others, and in their hands have given satisfactory results. Occasionally, surprisingly good results are obtained in profoundly septic conditions by repeated subcutaneous injections of sterile salt solu- tion. Attention was first directed to this method of treatment by Bose, and subsequent experience has to some extent justified his predictions. If the process has extended beyond the uterus, and we have to deal with a parametritis or a pelvic peritonitis, dry or moist heat to the lower portion of the abdomen, in the form of poultices or other hot applications, is to be recommended. A great deal has been written on the operative treatment of puer- peral infection, nearly every prominent obstetrician and gynecologist having made some contribution to the subject. Every one is agreed as to the advisability of opening parametritic abscesses as soon as fluctua- tion appears rather than allowing them to rupture spontaneously. Occa- CURATIVE TREATMENT 1013 sionally in parametritis, on palpation a semifluctuant sensation is con- veyed to the examining finger which may lead one to imagine that one has to deal with pus, whereas upon opening the supposed abscess through the vagina or abdominal wall, as the case may be, the tumor turns out to be an inflammatory exudate without pus formation, and only a small amount of serous fluid escapes. Fortunately, incision into such masses frequently gives as good results as if a considerable quantity of pus had been evacuated, just as happens in cases of cellulitis elsewhere. When pus tubes or ovarian abscesses can be made out by bimanual palpation, their removal is indicated, for as long as they remain the patient will continue in a septic condition. At the same time it should be remembered that in streptococcic infections the bacteria may retain their virulence for long periods, so that abdominal operations are much more dangerous than at other times. For this reason interference should be delayed as long as possible, and in the early part of the puerperium should be undertaken only when urgently indicated. Whether such con- ditions should be dealt with by laparotomy or by puncture through the vagina will depend upon the particular case. If they are freely movable, laparotomy should be performed; whereas if they are adherent and readily accessible from below, vaginal puncture with subsequent packing of the abscess cavity with gauze is to be preferred. The chief point of discussion concerning the operative treatment of puerperal infection has been as to the advisability of removing the in- fected uterus. Here the various surgeons take quite opposite views, the more radical advocating its prompt removal, while the more con- servative do not regard this step with favor. For two reasons it would appear that hysterectomy is contra-indi- cated in the majority of cases. In the first place, if one operates at a period sufficiently early to prevent the extension of the process to other organs, many uteri will undoubtedly be removed from women who would have recovered spontaneously; on the other hand, if one waits until a later period, when other organs have become implicated, the operation only hastens the inevitable termination. Nevertheless, there is a re- stricted field for hysterectomy whenever the process has given rise to abscess formation within the uterine walls. Again, in a putrid endo» metritis, when all other attempts to check the disease have proved futile, the operation would appear to be justifiable, as well as the occasional instances in which the infectious process is associated with abnormal adherence of the placenta. Lusk in 1896 suggested that hysterectomy may sometimes be useful in the cases of pyemia in which infected thrombi are carried from the uterus to various portions of the body, giving rise to metastatic abscesses and to a hectic condition. As a rule, however, the thrombotic process has extended far beyond the uterus by the time symptoms appear, and consequently its removal is useless. Much more practical is the sug- gestion of Freund, Trendelenburg, and Bumm, that the thrombosed vessels be exposed by laparotomy, and excised or ligated distal to the thrombus, as may seem most expedient, just as is done in the case of infected thrombi complicating mastoid disease. In 1909 I reported 1014 PUERPERAL INFECTION five such operations with four recoveries and reviewed the literature up to that time; while Miller made a statistical study of the results of the operation up to 1916. In appropriate cases I regard the procedure as most valuable—an opinion in which Miller concurs. Formerly the development of general peritonitis was considered al- most necessarily fatal, and, therefore, in cases of this character the treatment was usually perfunctory. But Sourdille, Kownatski, Leopold, Boquel, and others have shown that recovery may occasionally follow after freely opening and draining the abdominal cavity. Cragin, on the other hand, reported that his results were not encouraging. In my experience good results are generally obtained when the infection is due to the gonococcus, but almost never when it is due to the streptococcus. In view, however, of the almost certainly fatal outcome of expectant treatment in the latter, such interference would seem justifiable in very exceptional cases. In certain cases of infection following criminal abortion Pryor, Bobb, Sourdille, and others have reported encouraging results following wide incision of the posterior fornix and packing Douglas’s culdesac with iodoform gauze. In many such cases serous or purulent fluid escapes from the incision, so that it would appear that the procedure may be of value in preventing a pelvic peritonitis from becoming generalized. In my limited experience this procedure has not appeared to exert an appreciable influence upon the course of the disease, but in view of the high standing of its sponsors it is worthy of trial. The prospects of coping more successfully with puerperal infection were greatly brightened in 1895 by Marmorek’s announcement of the discovery of an antistreptococcic serum. Unfortunately, the results of serum therapy in puerperal infection have not proved satisfactory. In May, 1899, a committee of the American Gynecological Society, of which I was chairman, made an exhaustive report upon the subject, giving the complete literature and collecting all the cases treated by serum which had been reported up to that time. It was found that 352 cases had been so treated, with 73 deaths—a mortality of 20.74 per' cent. In a large number of cases there was considerable doubt as to whether the infections wTere due to the streptococcus; but in 101 cases in which its presence was demonstrated the mortality was 32.69 per cent. This was a very discouraging showing, especially when compared to the results obtained by others without it. The question therefore arose as to whether the high mortality was due to the use of the antistrep- tococcic serum or to other attendant causes. Our investigations having indicated that the serum was practically harmless, the poor results fol- lowing its use can probably be explained in one of two ways: first, that many exceptionally severe cases had been treated; and, secondly, that a large number of the cases so treated had already been curetted—a pro- cedure which is often followed by untoward results. In view of these facts the committee reported that while there wras no evidence in favor of the therapeutic value of the serum, it apparently did not exert a dele- terious effect upon the patient, and therefore might be employed if the physician so desired. LITERATURE 1015 Following the report of our committee the general consensus of opinion has been that Marmorek’s serum is practically useless as u therapeutic agent in the treatment of puerperal infection. Later Aron- sohn, Tavel, Menzer and others have directed renewed attention to the subject. They showed that in order to produce an effective serum for use in human beings the streptococcus should not be passed through lowrer animals, but that as many strains as possible of virulent strepto- cocci, obtained from human sources, should be employed for immunizing the animal from which the serum is to be obtained. It was then shown that the serum did not neutralize the toxins, as is the case with antidiphtheritic serum, nor did it directly kill the bacteria, but merely gave rise to conditions which favored phagocytosis —in other w’ords, increased the opsonic power of the blood. Moreover, experimental work has demonstrated that while the serum might possess marked prophylactic value and be able to protect an animal against inoculation with many times the ordinarily fatal dose of streptococci, it is lacking in curative properties, or at most is of value only in the initial stages of infection. Modern antistreptococcic serum has been employed in large series of cases, but does not appear to have exerted an appreciable effect upon the course of the disease, although it has no deleterious effect upon the patient. The subject was exhaustively con- sidered by McLeod in 1914. Some hope was entertained that satisfactory results might be ob- tained by use of bacterial vaccines. Sir Almroth Wright, however, in- formed me that he had no such expectation as to streptococcic infec- tions, although improvement might be expected in certain chronic cases due to the staphylococcus or gonococcus. A collective investigation by a committee of the American Gynecological Society in 1910, has served only to confirm his conclusions. At the same time it should be men- tioned that Polak is more optimistic and believes the use of vaccines is sometimes followed by surprising results. Reference needs scarcely be made to the employment of intravenous injections of formalin, as advocated by Barrows, in 1903, as subsequent investigation has shown that they are not only of no value, but are absolutely harmful. A considerable literature has accumulated upon the employment of Crede’s ointment, and the intravenous injection of collargol or a solution of silver nitrate in puerperal infection. The report of Osterloh, however, shows that they are of but slight value, and act only by promoting phagocytosis. LITERATURE Ahlfeld. Beitrage zur Lehre vom Resorptionsfieber im Wochenbett und von der Selbstinfektion. Berichte und Arbeiten, 1883, 165. Beitrag zur Lehre der Selbstinfektion. Zentralbl. f. Gyn., 1887, xi, 729. Beitrage zur Lehre vom Resorptionsfieber in der Geburt und im Wochenbette und von der Selbstinfektion. Zeitschr. f. Geb. u. Gyn., 1893, xxvii, 466-519. Aronsohn. Ilntersuchungen fiber Streptokokken u. Antistreptokokkenserum. Berl. klin. Wochenschr., 1902, ii, 979-982, and 1903, 1006-1010. 101G PUERPERAL INFECTION Bar et Tissier. Serotherapie dans 1’infection puerperale. L’Obstetrique, 1896, 97-128, 204-217. Bardeleben. Streptococcus u. Thrombose. Archiv f. Gyn., 1907, lxxiii, 1-82. Barker. The Puerperal Diseases. 3d ed., 1874. Barrows. Intravenous Injection of Formalin Solution for Puerperal Septicaemia. Amer. Jour. Obst., 1903, xlvii, 366. Blumer. A Case of Mixed Puerperal and Typhoid Infection, in which the Strep- tococcus and Typhoid Bacillus were isolated both from the Blood and Uterine Cavity. Amer. Jour. Obst., 1899, xxxix, 42-50. Boehr. Untersuchungen fiber die Haufigkeit des Todes im Wochenbett in Preus- sen. Zeitschr. f. Geb. u. Gyn., 1878, iii, 16. Bondy. Ueber puerperale Infektion durch anaerobe Streptokokken. Monatsschr. f. Geb. u. Gyn., 1911, xxxiv, 536-549. Die Bedeutung der Pneumokokken fur die puerperale Infektion. Zeitschr. f. Geb. u. Gyn., 1912, lxxii, 631-644. Boquel. Sur le traitement des peritonites aigues au cours de la puerperalite. Archives mens, d’obst. et de gyn., 1912, i, 37-58. Bose. Injections de serum artificiel dans les maladies infectieuses et les intoxica- tions. Presse med., 1896, No. 49, 287-290. Boxall. The Mortality of Childbirth. Lancet, 1893, ii, 9-15. Breuer. Ueber puerperale Pleuritis u. Pneumonie. Chrobak’s Festschrift, 1903, i, 399-417. Brieger. Ueber bakteriologische Untersuchungen bei einigen Fallen von Puer- peralfieber. Charite-Annalen, 1888, xiii, 198. Brutt. Beitrage zur Kenntniss und zur chirurgischen Behandlung der puerperalen Gasbrandinfektion des Uterus. Archiv f. Gyn., 1922, cxvi, 1-25. Budin. La Semaine med., 1896, 155. Bumm. Die puerperale Wundinfektion. Zentralbl. f. Bakteriol., 1887, ii, 343. Histologische Untersuchungen iiber die puerperale Endometritis. Archiv f. Gyn., 1891, xl, 398. Ueber die verschiedenen Yirulenzgrade der puerperalen Infektion und die lokale Behandlung bei Puerperalfieber. Zentralbl. f. Gyn., 1893, xvii, 975. Ueber Diphtherie und Kindbettfieber. Zeitschr. f. Geb. u. Gyn., 1895, xxxiii, 126-136. Ueber die chirurgische Behandlung des Kindbettfiebers. Sammlung zwangloser Abhandlungen aus dem Gebiete der Frauenheilkunde und Geb., 1902, iv, Heft 4. Bumm u. Sigwart. Untersuchungen iiber die Beziehungen der Streptocoecen zum Puerperalfieber. Beitrage z. Geb. u. Gyn., 1904, viii, 329-336. Burckhardt. Ueber den Einfluss der Scheidenbakterien auf den Verlauf des Wochenbettes. Archiv f. Gyn., 1893, xiv, 71-94. Ueber den Keimgehalt der Uterushohle bei normalen Wochnerinnen. Zentralbl. f. Gyn., 1898, xxii, 686-689. Puerperal-infektion mit Pneumococcus Fraenkel. Beitrage zur Geb. u. Gyn.. 1901, v, 327-338. Burtensiiaw. The Fever of the Puerperium. New York Med. Jour., 1904, June 4. Byers. Mortality from Puerperal Fever in England and Wales. Amer. Jour. Obst., 1901, xliv, 433-441. ChiriL. Septicemie a pneumo-bacilles de Friedlander. Bull. Soc. d’obst. de Paris, 1906, ix, 357-362. Coze et Feltz. Experiences sur le sang de fievre puerperale. Gazette med. de Strasbourg, 1869, xxix, 29, 38. LITERATURE 1017 Cragin. The Treatment of Puerperal Infection. Amer. Jour. Obst., 1906, liii, 775-791. Czemetschka. Prager med. Wochenschr., 1894, xix, 233. Denzler. Die Bakterienflora des gesunden Genitalkanals des Rindes, etc. D. I., Zurich, 1904. Dobbin. Puerperal Sepsis Due to Infection with the Bacillus Aerogenes Capsu- latus. Bull. Johns Hopkins Hosp., 1897, viii, 24. A Case of Puerperal Infection in which the Bacillus Typhosus was found in the Uterus. Amer. Jour. Obst., xxxviii, 185-198. Doderlein. Untersuchung iiber das Vorkommen von Spaltpilzen in den Lochien des Uterus und der Vagina gesunder und kranker Wochnerinnen. Archiv f. Gyn., 1887, xxxi, 412. Das Scheidensekret und seine Bedeutung fur das Puerperalfieber. Leipzig, 1892. Vorlaufige Mittheilung iiber weitere bakteriologische Untersuchungen des Schei- densekretes. Zentralbl. f. Gyn., 1894, xviii, 779. Die Beziehungen der Endometritis zu den Fortpflanzungsvorgangen. Verh. d. deutschen Ges. f. Gyn., 1895, 224-242. Doderlein und Winternitz. Die Bakteriologie der puerperalen Sekrete. Beitrage zur Geb. u. Gyn., 1900, iii, 161-174. Doleris. Essai sur la pathogcnie et la therapeutique des accidents infectieux des suites de couches. These de Paris, 1880. Dublin. Mortality Among Women from Causes Incidental to Childbearing. Am. Jour. Obst., 1918, lxxviii, 20-37. Ehlers. Die Sterblichkeit im Kindbett in Berlin und in Preussen. Stuttgart, 1900. Eichel. The Geographical Distribution of Maternal Mortality in New York State. New York State Dept, of Health Bulletin, June, 1922. Eisenmann. Wund- und Kindbettfieber. Erlangen, 1837. Eehling. Ueber Selbstinfektion. Verh. d. deutschen Gesellsch. f. Gyn. Freiburg, 1889. Foulerton and Bonnet. An Investigation into the Causation of Puerperal Infec- tion. Jour. Obst. and Gyn. Brit. Emp., 1905, vii, 121-126. Fraenkel. Ueber die Aetiologie u. Genese der Gas-phlegmonen. Lubarsch- Ostertag, Ergebnisse der allg. Path. u. path. Anat., 1904, viii, 403-471. v. FranquL. Bakteriologische Untersuchungen bei normalem und fieberhaftem Wochenbett. Zeitschr. f. Geb. u. Gyn., 1893, xxv, 277. Franz. Bakteriologische und klinische Untersuchungen iiber leichte Fiebersteiger- ungen im Wochenbette. Beitrage zur Geb. u. Gyn., iii, 1900, 51-100. Freund. Ueber die Methoden und Indikationen der Totalexstirpation des Uterus. Beitrage zur Geb. u. Gyn., 1898, i, 344-404. Fromme. Physiologie u. Pathologie des Wochenbettes. Berlin, 1910. Galtier. De l’infection primitive du liquide amniotique apres rupture prematuree des membranes de l’oeuf humain. Th§se de Paris, 1895. Gebhard. Bacterium coli commune aus Fallen von Tympania uteri geziichtet. Verh. d. deutschen Gesellsch. f. Gyn., 1893, 305. Gide. De l’infection puerperale par le bacille de Loeffler. These de Lyon, 1911. Goldsborough. Thrombosis of the Internal Iliac Vein during Pregnancy. Bulle- tin of the Johns Hopkins Hospital, 1904, xv, 193-196. Goldscheider. Klinische und bakteriologische Mittheilungen iiber Sepsis puer- peralis. Charite-Annalen, 1893, xviii, 164-242. Gordon. A Treatise on the Epidemic Puerperal Fever, London, 1795. Gu£rin. Sur la fievre puerperale. Bull, de l’acad. de med., Paris, 1858, xxiii, 766-82. Hamm. Welche Aussichten bietet die prophylactische Antiseptik der Scheide, etc. Archiv f. Gyn., 1918, cviii, 110-136. 1018 PUERPERAL INFECTION Harris and Dabney. Beport of a Case of Gonorrhoeal Endocarditis in a Patient Dying in the Puerperium. Bull. Johns Hopkins Hosp., 1901, xii, 68-76. Heiberg. Die puerperalen und pyamischen Processe, 1873. Heinricius. Exp. Untersuch, iiber die Einwirkung des Bacillus aerogenes capsu- latus. Archiv f. Gyn., 1908, lxxxv, 216-250. Heynemann. Der E. Fraenkel’sche Gasbacillus, etc. Zeitschr. f. Geb. u. Gyn., 1911, lxviii, 425-443. Hirsch. Historisch-pathologische Untersuchungen iiber Puerpcralfieber. Er- langen, 1864. Hirst. Some Problems in the Diagnosis and Treatment of Puerperal Infection. Amer. Medicine, 1906, xl, 121-123. Holmes. Puerperal Fever as a Private Pestilence: Boston, 1855. Hornung. Zur Frage der primaren genitalen Pneumokokkeninfektion. Zentralbl. f. Gyn., 1920, 850-856. Howard. Importance of Bacillur. Mucosus Capsulatus (B. Friedliinder) as the Cause of Acute and Chronic Infections. Philadelphia Med. Jour., 1898, i, 336-338. The Beal Bisk Bate of Death to Mothers from Causes Connected with Childbirth. Am. Jour. Hygiene, 1921, i, 197-233. Johnston and Morgan. Acute lobar Pneumonia and Hematogenous Puerperal Infection. Bull. Johns Hopkins Hosp., 1922, xxxiii, 106-109. Jotten. Ueber die Bedeutung der Streptokolckenbefunde im Yaginalsekret Kreis- sender. Zentralbl. f. Gyn., 1912, 1529-1533. Kaltenbach. Zur Antisepsis in der Geburtsliiilfe. Volkmann’s Sammlung klin. Vortrage, Nr. 295. Ueber Selbstinfektion. Verh. d. deutschen Gesellsch. f. Gyn. Freiburg, 1889. Kirkland. Treatise on Childbed Fever, 1774. Kneise. Zur Kenntniss der reinen Septikiimie. Archiv f. Gyn., 1904, lxxiii, 333- 350. Kownatski. Zur Behandlung der freien puerperalen Peritonitis mit Laparotomie u. Drainage. Berliner klin. Wochenschr., 1905, Nr. 20. Kronig. Vorlaufige Mittheilung iiber Gonorrhoe im Wochenbett. Zentralbl. f. Gyn., 1893, xv, 157. Scheidensekretuntersuchungen bei ein Hundert Schwangeren. Aseptik in der Geburtshiilfe. Zentralbl. f. Gyn., 1894, xviii, 3-10. Ueber Fieber intra-partum. Zentralbl. f. Gyn., 1894, 749. Discussion iiber Endometritis. Yerh. d. deutschen Gesellsch. f. Gyn., 1895, 498-502. Klinische Versuche iiber den Einfluss der Scheidenspiilungen wahrend der Geburt auf den Wochenbettsverlauf. Miinchener med. Wochenschr., 1900, Nr. 1. Kronig und Menge. Bakteriologie des Genitalkanales der schwangeren, kreis- senden und puerperalen Frau. Leipzig, 1897. Kronig u. Pankow. Zur bakt. Diagnose des Puerperalfiebers. Centralbl. f. Gyn., 1909, 161-170. Lea. Puerperal Infection. London, 1910. Lea and Sidebotiiam. Bacteria of the Puerperal Uterus. Jour. Obst. and Gyn. Brit. Emp., 1909, xv, 26-41. Lenhartz. Die septischen Erkrankungen. Nothnagel’s Spec. Path, und Therapie, 1904, iii, Theil 2. Leopold. Yergleichen.de Untersuchungen iiber die Entbehrlichkeit der Scheiden- ausspiilungen bei ganz normalen Geburten und iiber die sogenannte Selbstin- fektion. Archiv f. Gyn., 1894, xlvii, 580-635. Zur operativen behandlung der puerperalen Peritonitis u. Pyaemie. Archiv f. Gyn., 1906, lxxvii, 1-33. LITERATURE 1019 Liepmann. Das geburtshilfliche Seminar. Berlin, 1910, 292. Little. A Simple Method of Obtaining Uterine Lochia for Bacteriological Ex- amination. Bull. Johns Hopkins Hospital, 1904, xv, 250-251. The Bacillus Aero genes Capsulatus in Puerperal Infection. Bull. Johns Hopkins Hospital, 1905, xvi, 136-146. The Bacteriology of the Puerperal Uterus. American Jour. Obst., 1905, lii, 815- 847. ’ Lower. Ueber den heutigen Stand der Lehre von den Infektionstragern bei Puerpcraltieber. Zeitschr. f. Geb. u. Gyn., 1884, x, 366. Lusk. Kecent Bacteriological Investigations concerning the Nature of Puerperal Fever. Amer. Jour. Obst., 1896, xxxiii, 337-347. Mahler. Thrombose, Lungenembolie u. plotzlicher Tod. Arbeiten aus der Frauenklinik in Dresden, 1895, iii, 72-120. Marmorek. Sur le streptocoque. Comptes rendus de la soc. de biol., 1895, lOme serie, ii, 122. Le streptocoque et le serum antistreptococcique. Annales de l’Institut Pasteur, 1895, ix, 593-620. Mayriiofer. Zur Frage nach Aetiologie der Puerperalprocesse. Monatsschr. f. Geburtskunde, 1865, xxv, 112-134. McLeod. On the Value of Antistreptococcal Sera. Lancet, 1914, clxxxvii, 837- 842. Meigs. On Childbed Fever. Philadelphia, 1854. Meigs, G. Maternal Mortality in Relation to Childbirth. Bulletin Children’s Bureau, 1917. Menzer. Das Antistreptokokkenserum und seine Anwendung beim Menschen. Miinchener med. Woehenschr., 1903, 1057-1061 and 1125-1129. Miller. Surgical Treatment of Puerperal Pyemia. Clin. Congress of Surgeons of North America. Nov., 1916. Mixius. Bakteriologische Untersuchungen einiger Falle puerperaler Sepsis. D. I., Berlin, 1892. Natwig. Bakteriologische Verhaltnisse im weibl. Genitalsekrete. Archiv f. Gyn., 1905, lxxvi, 701-859. Neumann. Ueber puerperale Uterusgonorrhoe. Monatsschr. f. Geb. u. Gyn., 1896, iv, 109-116. Nisot. Diphtherie vagino-uterine puerperale. Annales de gyn. et d’obst., 1896, xlv, 259. Oetii. Virchow’s Archiv, lviii, 441. Osterloh. Beitrag zur Behandlung des Puerperalfiebers mit intravenosen Collar- goleinspritzungen. Deutsches Archiv f. klin. Med., 1905, lxxxv, 227-233. Pasteur. Septicemie puerperale. Bull, de l’acad. de med., 1879, 260-271. Perkins. Report of Nine Cases of Infection with Bacillus Pyocyaneus. Jour. Med. Research, 1901, vi, 281-297. Pinard et Wallich. Traitement de 1’infection puerperale. Paris, 1896. Piper. The Treatment of Puerperal Sepsis by the Use of Mercurochrome In- travenously. Am. Gyn. Soc., 1922, xlvii, 233-246. Polak. Two Years’ Experience with Vaccines in Pelvic Infections. Jour. Am. Med. Assn., Nov. 25, 1911. Pryor. Treatment of Puerperal Streptococcus Infection by Curettage, the Cul- de-sac Incision, etc. Amer. Jour. Obst., 1889, xxxix, 584-596. Recklinghausen. Zentralbl. f. med. Wissenschaften, 1871, 713. Richter. Thrombose u. Embolie im Wochenbett. Archiv f. Gyn., 1905, lxxcvf 122-142. Robb. The Vaginal Incision in Sepsis following Abortion. Amer. Gyn.r 1903, ii 524-530. 1020 PUERPERAL INFECTION Runge. Die Allgemeinbehandlung der puerpcralcn Sepsis. Archiv f. Gyn., 1888, xxxiii, 39-52. Sackenreiter. Die Erreger der putriden Endometritis. Beitrage z. Geb. u. Gyn., 1912, xvii, 246-276. Schmidlechner. Gangraena uteri puerperalis (Metritis dessicans). Archiv f. Gyn., 1906, lxxviii, 525-538. Schottmuller. Zur Bedeutung einiger Anaeroben in der Pathologie, insbesondere bei puerperalen Erkrankungen. Mittheil. aus den Grenzgebieten der Med. u. Chir., 1910, xxi, 450-490. Semmelweiss. Die Aetiologie, der Begriff u. die Prophylaxis des Kindbettfiebers. Pest, Wien u. Leipzig, 1861. Sigwart. Die Streptokokken-forschung, etc. Monatsschr. f. Geb. u. Gyn., 1910, xxxi, 486-496. Silberschmidt. Historisch-kritische Darstellung der Pathologic des Kindbett- fibers, Gekronte Preissschrift. Erlangen, 1859. Sitsinsky. Die Behandlung des septischen Wochenbetterkrankungen. Monats- schr. f. Geb. u. Gyn., 1904, xx, Erganzunsheft, 640-677. Smith. Severe Puerperal Sepsis Due to Gonococcus Infection. Cleveland Med. Jour., 1911, x, 810-818. Sourdilee. Traitement de 1’infection puerperale grave par la laparotomie ou par la colpotomie sans hysterectomie. Revue de gyn., 1905, ix, 857-890. Stolz. Studien zur Bakteriologie des Genitalkanales in der Schwangerschaft u. im Wochenbett. Beitrage z. Geb. u. Gyn., 1903, vii, 406-421. Stone and McDonald. The Gonococcus in the Puerperium. Surg. Obst. and Gyn., 1906, ii, 151-162. Strauss et Sanchez-Toledo. Septieemie puerperale experimentale. Nouv. archives d’obst. et de gyn., 1889, cv, 277-295. Strother. Critical Essay on Fevers. London, 1718. Taussig. Gonorrhoeal Puerperal Infection. Amer. Gyn., 1903, ii, 334-345. Tavel. Exp. u. klinisches liber das Antistreptokokkenserum. Deutsche med. Wochenschr., 1903, Nr. 50. Trendelenburg. A Review of Surgical Progress. Jour. Am. Med. Assn., 1906, xlvii, 81-83. Vignal. Sur Faction des micro-organismes de la bouche et des matieres fecales. Comptes .rendus de la soc. de biol., aout, 1887. Waldeyer. Ueber das Yorkommen von Bakterien bei der diphthcritischen Form des Puerperalficbers. Archiv f. Gyn., 1872, iii, 293. Waltiiard. Bakteriologische Untersuchungen des weiblichen Genitalsekretes in der Graviditat und in Puerperium. Archiv f. Gyn., 1895, xlviii, 201-269. Walthard u. Reber. Beitrage zur Kenntniss der Natur u. klin. Bedeutung der Yaginalstreptokokken. Zeitschr. f. Geb. u. Gyn., 1905, liv, 304-442. Wauschkuhn. Ueber das Vorkommen von echten Diphtheriebazillen bei Gebaren- dcn und Neugeborenen. Zentralbt. f. Gyn., 1920, 820-824. Welch. Morbid Conditions caused by Bacillus Aerogenes Capsulatus. Boston Med. and Surg. Jour., 1900, cxliii, 73-87. Wetherill. The Rational Treatment of Puerperal Infection. Amer. Jour. Obst., 1903, xlvii, 590-598. Widal. Etude sur 1’infection puerperale. Th&se de Paris, 1889. Infection puerperale et phlegmasia alba dolens. Gaz. des Hop., 1889, 565. Williams. Puerperal Infection considered from a Bacteriological Point of View, with Special Reference to the Question of Auto-infection. Amer. Jour. Med. Sciences, July. 1893. The Cause of the Conflicting Statements concerning the Bacterial Contents of LITERATURE 1021 the Vaginal Secretion of the Pregnant Woman. Amer. Jour. Obst., 1898, xxxviii, 807-817. The Bacteria of the Vagina and their Practical Significance, based upon the Bacteriological Examination of the Vaginal Secretion in Ninety-two Pregnant Women. Amer. Jour. Obst., 1898, xxxviii, 449-483. Diphtheria of the Vulva. Amer. Jour. Obst., 1898, xxxviii, 180-185. Ein Pall von puerperaler infektion, bei dem sich Typhusbacillen in den Lochien fanden. Zentralbl. f. Gyn., 1898, xxii, Nr. 34. Ligation and Excision of Thrombosed Veins in the Treatment of Puerperal Pyaemia. Am. Jour. Obst., 1909, lix, 758-789. Williams, Cragin, and Newell. Report on the Employment of Vaccine Therapy in Gynecology and Obstetrics. Surg. Gyn. and Obst., 1910, x, 12-19. Williams, Pryor, Fry, and Reynolds. The Value of Antistreptococcic Serum in the Treatment of Puerperal Infection. Trans. Amer. Gyn. Soc., 1899, xxiv, 80-126. Winter. Ueber Selbstinfektion. Zentralbl. f. Gyn., 1911, 1495-1505. Zangemeister u. Kirstein. Zur Frage der Selbsinfektion. Archiv f. Gyn., 1915, civ, 1-27. CHAPTER XLIV DISEASES AND ABNORMALITIES OF THE PUERPERIUM We have already discussed in detail the more typical instances of puerperal infection. We shall now take up certain atypical varieties— tetanus, phlegmasia alba dolens, and cystitis—and shall then proceed to consider certain other diseases and abnormalities which may be en- countered in the puerperium, but which are not due to the introduction of infective material into the genital tract. Thus, we shall find that fever, associated with constitutional disturbances, is frequently met with as the result of pathological conditions in the breasts, disorders of the intestinal tract, and in very rare instances may he due to emotional causes. Moreover, it must be remembered that Nature has not rendered the puerperal woman exempt from the various disorders from which she might suffer at other times. Tetanus.—The undoubted development of tetanus during the puer- perium, although a very rare occurrence, has been fully established by the researches of Chantemesse and Widal, of Heyse, of Rubeska, and of others, who have isolated the characteristic bacilli from the uterine lochia. Spiegel in 1914 was able to collect 64 cases from the literature. The infection usually follows gross errors in aseptic technic, especially during operative procedures. Thus, in several of the reported cases, it is recorded that the operator placed the forceps upon the dirty floor by the side of the bed, and afterward carried it directly to the genital tract of the patient. Occasionally, however, such an explanation cannot be ad- duced, as in an epidemic in the Prague Lying-in Hospital, the disease, in one instance, at least, occurred in a woman who had not even been examined internally. Tetanus follows abortion more frequently than full-term labor, and as a rule gives rise to untoward manifestations between the sixth and tenth days of the puerperium, and sometimes later, though in rare in- stances the first symptom has been known to appear before the completion of labor. The prognosis is very grave. All of the 20 patients mentioned by Rubesca succumbed, while Vinay reports a similar result in 94 out of the 106 cases included in his statistics. Beyond affording means for temporarily controlling the symptoms, therapeutic measures are valueless, although the intralumbar injection of from 5 to 10 cubic centimeters of a 15 per cent, solution of magnesium sulphate is highly efficient in suppressing the convulsive seizures. Thus far the results obtained from the employment of antitetanic serum have not been encouraging, although its prophylactic employment has been attended by excellent results. In view of the hopelessness of other lines 1022 THROMBOSIS OF VESSELS OF LOWER EXTREMITIES 1023 of treatment, Pawlik and Rubeska removed the uterus in several of their eases, but without avail. Thrombosis of the Vessels of the Lower Extremities.—Thrombosis occurring in the crural, saphenous, or popliteal veins—Phlegmasia alba dolens—is usually a manifestation of puerperal infection, and follows the direct extension of a thrombotic process from the pelvic veins; occa- sionally it results from a localized phlebitis or periphlebitis, and in very rare instances may be due to purely mechanical factors. The lumina of the large veins rarely undergo complete obliteration, so that the cir- culation, while markedly interfered with, is not completely shut off. Symptoms do not usually make their appearance until the latter part of the second week of the puerperium, or even later. In most cases the first manifestation is pain in one leg extending along the course of one of the larger veins; this is soon followed by edema, which usually begins in the foot and extends upward, although occasionally it appears first in the neighborhood of the groin. The leg soon becomes much swollen, the skin being tightly stretched and presenting a glazed appearance, but at first pitting can be elicited only after prolonged pressure with the finger-tip. If the crural vein is implicated, a very sensitive cordlike structure can often be palpated just beneath Poupart’s ligament and can be followed for a certain distance down the thigh. The inflammatory changes are usually attended by some elevation of temperature, the pulse being more or less accelerated. High fever and a very rapid action of the heart usually indicate that similar processes exist in other portions of the body, and that the patient is suffering from a more generalized thrombophlebitis. In uncomplicated cases the pain, swelling, and temperature may continue for several weeks, and then gradually subside, though occasionally months elapse before the patient regains the full use of the leg. Ordinarily, the process is limited to one side, more rarely both ex- tremities are affected, an interval of a week or ten days elapsing before the second leg becomes implicated. If properly treated, most cases undergo spontaneous cure, the condition being dangerous only when it forms part of a generalized process, or wrhen the thrombus undergoes suppuration and softening, so that infected particles are carried to other parts, giving rise to metastatic abscesses. Occasionally the casting off of fragments lead to sudden death from pulmonary embolism. Treatment.—Complete rest is absolutely essential. The lower part of the leg should be elevated, and the entire member encased in absorb- ent cotton and protected from the weight of the bedclothes by a suitable contrivance. If the pain is severe morphin may be required, though ordinarily the application along the course of the thrombosed vein of cloths soaked in lead water and opium is followed by marked relief. Excellent results have been reported from painting the leg with a 15- or 20-per-cent, solution of ichthyol. On account of the danger of detaching portions of the thrombus, the leg should never be massaged. The patient should be kept in a horizontal position for at least a week after the temperature has subsided, and 1024 DISEASES AND ABNORMALITIES OF THE PUERPERIUM after being allowed to get up she should he cautioned against making sudden movements. Small varicose veins of the lower extremities sometimes undergo spontaneous thrombosis during pregnancy, hut more often during the first weeks of the puerperium. In pregnancy this occurrence is favored by the interference with the circulation due to the pressure exerted by the uterus upon the vessels returning from the extremities. During the puerperium its development may be incident to pressure exerted upon the intrapelvic veins by inflammatory exudates. This form of thrombosis is usually unattended by symptoms, although now and again the develop- ment of a localized phlebitis or periphlebitis may cause pain, and ex- ceptionally eventuate in the formation of a small abscess. Gangrene of the Extremities.—In very rare instances, as the result of extensive thrombosis of the venous channels or of embolism of the arteries, the circulation in the extremities may become so impaired that gangrene results. This accident, first described by Churchill and studied more particularly by Wormser and Burckhard, is a most serious com- plication, and usually ends fatally. ' Wormser, in 1904, collected 80 cases from the literature, 6 of which were apparently examples of Bay- naud’s disease, while of the remainder 66 cases occurred in puerperal, as compared with 6 in pregnant, women. The process usually involves one or both feet, although the hand or forearm may occasionally be implicated. Sixty-two per cent, of the 34 patients mentioned in Lafond’s thesis died, in spite of the fact that in several instances amputation was resorted to in order to check the further development of the process. Diseases of the Urinary Tract.—A cystitis occurring during the puer- perium is usually the result of infection following catheterization, during which the rules of asepsis have not been scrupulously followed. The occurrence of the condition is favored by the presence of slight lesions of the vesical mucosa which frequently accompany easy and spontaneous labors, and are almost universally associated with difficult deliveries. In rare instances it results from the direct extension of areas of in- flammation about the urethral orifice and vulva. In view of the constant presence of bacteria in the normal urethra, and of the impossibility of thoroughly disinfecting the vulva and urethral orifice, cystitis will occasionally occur, despite the most rigid precautions. For this reason catheterization should be restricted to the greatest pos- sible extent, and employed only when the patient is unable to evacuate the bladder after being placed in a sitting position. As long as it is continued, 10 grains of hexamethylenamin should be administered four times a day as a prophylactic measure. As the process demands a certain period of incubation, symptoms do not usually appear for several days. The patient first experiences a frequent desire to micturate, but passes only a small quantity of urine at one time, the act being accompanied by a burning sensation in the urethra, and a tendency to tenesmus afterward. At the same time, the bladder and the urethra become sensitive on pressure. The urine is usually cloudy, and upon microscopic examination is found to be loaded with mucus, leukocytes, epithelial cells, and bacteria. Occasionally it HEMORRHAGES DURING THE PUERPERIUM 1025 contains a large proportion of blood. The acid reaction is usually re- tained, although, more especially when the process is prolonged, the secretion may become alkaline, and very offensive in odor. Now and again cases are encountered in which the infection is so severe that larger or smaller portions of the mucosa become exfoliated and are cast off with the uterine, their expulsion being associated with cramplike pains. In these virulent types, as well as in the milder but obstinate proc- esses, the disease tends to extend up the ureters and to involve the pelvis of the kidney, giving rise to a pyelitis, which may be followed in a few weeks by a pyelonephritis or a pyelonephrosis. Thus, it sometimes happens that a patient, who had apparently recovered from a cystitis, may suddenly experience intense pain in one renal region, associated with the development of a temperature characterized by marked remissions and the passage of large quantities of urine laden with pus. The con- dition frequently apparently passes off to recur again when least expected. In mild cases of cystitis the treatment consists in the ingestion of large quantities of fluid, particularly milk and the carbonated and alkaline waters. The vesical irritability is often satisfactorily allayed by the administration of 10-grain capsules of hexamethylenamin repeated every four to six hours. Ordinarily, simple treatment leads to recovery in a comparatively short time, but if the process drags on, daily irri- gation of the bladder with a 2-per-cent, solution of boric acid or a very weak solution of silver nitrate should be practiced. Most cases of pyelitis recover spontaneously after rest in bed and the administration of large quantities of fluids and enough sodium bi- carbonate to render the urine alkaline; but whenever a pyelonephritis is accompanied by prolonged febrile manifestations, drainage and occa- sionally extirpation of the organ may be required, although this is fortunately rarely necessary. Retention of Urine.—In Chapter XVI, upon the care of the patient during the puerperium, reference was made to the retention of urine, which frequently causes annoyance during the first few days of that period. Incontinence of Urine.—In multiparous women, during the early part of the puerperium, coughing, sneezing, or other factors leading to a sudden increase in the intra-abdominal pressure often produce an involuntary discharge of a small quantity of urine. The condition usually passes off spontaneously, but cure is sometimes hastened by the admin- istration of 1/30 grain of strychnia four times a day. More marked incontinence at this time is usually the result of lesions about the neck of the bladder following operative delivery, though when the condition does not manifest itself until late in the first week it is usually the first sign of the development of a vesicovaginal fistula. In this event, scrupulous attention to cleanliness will frequently be followed by spontaneous recovery; but when the fistulous opening persists, a cure can be effected only by operative procedures at a later period. Hemorrhages during the Puerperium.—Ordinarily, if there has been no serious loss of blood during the first hour or hour and a half following 1026 DISEASES AND ABNORMALITIES OF THE PUERPERIUM delivery, it may be assumed that the danger of postpartum hemorrhage has passed. Occasionally, however, in the latter part of the first week, and more often still later in the puerperium, more or less severe uterine hemorrhages are encountered. They are nearly always due to the re- tention of portions of a placental cotyledon or of a succenturiate lobule, which may have been overlooked at the time of labor. If the retained tissue is not cast off spontaneously or removed manually, it undergoes gradual necrosis, while at the same time fibrin becomes deposited about its periphery, giving rise to a polypoid growth of varying size—placental polyp—which so interferes with the involution of the adjacent portion of the uterus that bleeding continues so long as it remains in utero. The retention of large portions of the foetal membranes rarely gives rise to serious hemorrhage, as the tissues gradually disintegrate and are cast off with the lochial discharge. The presence of a remnant of decidua of any considerable size, which has failed to undergo the usual regressive changes, may act as an irritant upon the regenerating endometrium, giving rise to a hyperplasia which is designated as endometritis decidua postpartum or postabortum, according as it follows full-term labor or abortion. It usually interferes with the process of involution, and may lead to more or less hemorrhage. The diagnosis of the retention of a placental remnant or the existence of a polyp can only be verified by the sense of touch. Therefore, when- ever a patient suffers from an acute loss of blood during the puerperium, the interior of the uterus should be carefully palpated, and any abnormal tissue promptly removed by means of the finger or curette. The treatment of the slight hemorrhage following retroflexion and subinvolution of the uterus will be referred to under those headings. The loss of blood associated with an endometritis postpartum demands curettage. If the patient bleeds excessively after the expulsion of an hydatidiform mole, similar treatment is indicated. And, on account of the possibility of the development of a chorio-epithelioma, the tissue removed should be subjected to careful microscopic examination. Puerperal Hematoma.—A tumefaction resulting from the escape of blood into the connective tissue beneath the skin covering the external genitalia or the vaginal mucosa is known as a vulval or vaginal hema- toma. This condition, first studied in detail by Deneux, in 1830, is a rare complication of labor and the puerperium, occurring about once in 1,500 or 2,000 cases. It occasionally originates during pregnancy, and may attain such proportions as to interfere with the descent of the child. Very exceptionally, if medical aid is not available, fatal hemor- rhage may follow its rupture at the time of labor, as in the cases reported by Kiinzig and others. The condition usually follows injury to a blood vessel during the act of labor without laceration of the superficial tissues, and may follow spontaneous, as well as operative, delivery. Now and again it does not occur until later, and is then attributable to the sloughing of a vessel which had become necrotic as the result of pro- longed pressure. Less frequently the torn vessel lies above the pelvic fascia. In this event the hematoma develops above it, and in its early stages gives rise HEMORRHAGES DURING THE PUERPERIUM 1027 to a rounded or sausage-shaped tumefaction, which projects into the upper portion of the vaginal canal and may completely occlude its lumen. If the bleeding continues, it spreads apart the broad ligament and separates the peritoneum from the adjacent tissues. In this way the effused blood may form a tumor palpable above Poupart’s ligament, or it may make its way into the iliac fossae, gradually invade the renal region and eventually reach the lower margin of the diaphragm. Yulval hematomata of moderate size are usually absorbed spontane- ously. In other cases the tissues covering the tumor may undergo pres- sure necrosis and give way, profuse hemorrhage resulting, or the contents may be discharged in the form of large clots. In either event the interior of the hematoma is very prone to become infected, the condition some- times ending fatally. If the tumor is large, it not only causes discom- fort by its mere size, but gives rise to great suffering, which becomes more intense the more rapidly it is formed, as the result of the tearing and stretching of the tissues. In the subperitoneal variety such quantities of blood may be effused beneath the peritoneum that the patient rapidly succumbs to acute anemia. In other cases a fatal issue follows secondary rupture into the peritoneal cavity. Occasionally rupture occurs into the vagina, in which event the hematoma becomes infected, the patient may perish if suitable treatment is not promptly instituted. In 33 cases of subperitoneal hematoma which I collected in 1904 the mortality was 56 per cent. It is interesting to note that more than 60 per cent, of the cases occurred in primiparae, and 71 per cent, after spontaneous labor. In my patient the hemorrhage came from a vessel at the base of the bladder, which had become torn through during the course of a spontaneous labor. A vulval hematoma is readily diagnosticated by the sudden appear- ance of a tense, elastic, fluctuating, and sensitive tumor of varying size, covered by discolored skin. When the mass develops in the vagina it may escape detection for a time, but the development of pressure symp- toms soon leads to a vaginal examination, when a round, fluctuant tumor is found, which encroaches upon the lumen. On the other hand, when the hematoma extends upward between the folds of the broad ligament, it is liable to escape detection, unless it gives rise to a tumor which can be felt upon abdominal palpation, or symptoms of anemia or infection appear. In my case the uterus was displaced upward by the effused blood, and on bimanual examination a fluctuant tumor of 15 centimeters in diameter could be palpated beneath it. Had the condition not been recognized until after infection had occurred, the differential diagnosis between it and an extensive pelvic inflammatory mass would have been very difficult. The prognosis is usually favorable, though very large hematomata occasionally lead to death from hemorrhage, whereas in rare cases the fatal termination is the result of infection. Treatment.—Small hematomata should be left alone, as spontaneous resorption usually takes place, provided the parts be kept clean and infection avoided. On the other hand, a steady increase in size indicates a continuance of hemorrhage, and in such cases the tumor should be laid 1028 DISEASES AND ABNORMALITIES OF THE PUERPERIUM widely open and packed with gauze. The strictest antiseptic precautions are imperative, inasmuch as infection is a frequent complication. In large subperitoneal hematomata, accompanied by acute anemia, lapa- rotomy should be promptly performed, the blood clots removed, and the hemorrhage controlled by ligature or by packing the cavity with gauze. Diseases and Abnormalities of the Uterus.—Sub involution.—This term is used to describe an arrest or retardation of the process of invo- lution, by which the puerperal uterus is normally restored to its original proportions. Involution is the result of an autolytic process, which leads to atrophy of the individual muscle cells, rather than to fatty degeneration, as was formerly supposed. Its proximate cause is to be sought in the liberation of certain, as yet unknown, ferments associated with the sudden and marked diminution of the blood supply to the uterus. As this can be brought about only by satisfactory contraction and retraction of the organ, it is apparent that any interference with the process may be followed by subinvolution. Among the most frequent factors concerned in its production are imperfect exfoliation of the decidua, retention of portions of the birth, inflammatory lesions of the endometrium, the presence of myoma- tous nodules in the uterine wall, abnormalities of circulation which accompany displacements of the uterus, existence of pelvic inflamma- tory lesions, and insufficient rest during the puerperium. In other words, subinvolution is the result of local conditions and not of consti- tutional disorders. Accordingly, careful investigation will usually reveal the underlying cause, and appropriate treatment, if undertaken suffi- ciently early, will lead to its cure. The existence of subinvolution is manifested by a prolongation of the lochial discharge beyond the usual period, its cessation being followed by persistent leucorrhea with pains in the back, a general feeling of draggi- ness, and a delayed return to perfect health. Similar symptoms accom- pany uterine displacements, but in all probability are in great part due to the coincident subinvolution. If the condition is not properly treated it may lead to permanent changes in the uterus, which are sometimes associated with such serious hemorrhage as eventually to necessitate the removal of the organ. According to E. F. Smith, and Otto Schwarz, such uteri are abnormally large, contain much more fibrous and less muscular tissue than normally, while the arterial walls are so altered that the normal mechanism for the regulation of the circulation is in abeyance. The diagnosis is established by bimanual examination, the uterus being found to be larger, softer, and more succulent than it should be at a given time following delivery. Inasmuch as subinvolution is dependent mainly upon local conditions, very little can be expected from medicinal treatment, although the administration of a half dram of the fluid extract of ergot every three or four hours, together with copious hot vaginal douches, for several days is sometimes followed by improve- ment. Local measures afford much better results. If the uterus is DISEASES AND ABNORMALITIES OF THE UTERUS 1029 displaced it should be put in proper position by bimanual manipulation and held in position by a suitably fitting pessary. When disease of the endometrium or retention of portions of the after-birth is responsible, prompt curettage offers the most efficient method of treatment. On the other hand, procrastination may lead to serious results, as the subinvo- lution may become permanent. Lactation Atrophy of the Uterus.—Ordinarily, in women who suckle their children, the uterus may undergo excessive involution, so that several months after delivery it may be smaller than in the virginal state. This condition is attributed to reflex irritation emanating from the breasts and incident to lactation and nursing. It usually disappears spontaneously after weaning, though when the child is nursed for a longer period than usual the uterus may begin to increase in size before the end of a year, even though lactation be continued. It is probable that the cessation of menstruation, which is usually observed during the early months of lactation, should be partly attributed to this form of atrophy. Lactation atrophy was first definitely described by Jacquet, in 1871, and since the publication of his paper has been carefully studied by numerous investigators, particularly Thorn, Gottschalk, Doderlein, and Yineberg. In rare instances it may persist after weaning and become permanent, the uterine cavity sometimes measuring only a few centi- meters in length. This abnormality, first described by Chiari, Braun, and Spaeth, in 1855, was later designated by Simpson as superinvolution. It is probable that it may occasionally be the causative factor in the production of future sterility, as well as in the unusually early appear- ance of the menopause. Displacements of the Uterus.—Immediately following the birth of the child, the lower uterine segment and cervix are represented by a flabby, collapsed structure which is freely movable upon the rest of the organ (see Fig. 328). In these circumstances a comparatively trivial cause, such as a slight increase in the intra-abdominal pressure or dis- tention of the rectum, may lead to an excessive bending forward of the body of the uterus—anteflexion. The condition is usually without significance, but occasionally the angle formed between the upper and lower portions of the organ may be so acute as to occlude the cervical canal and lead to the retention of the loehial discharge—lochiometra. As a rule the retention, when it occurs, is only transitory, but if it be prolonged the lochia may undergo putrefactive changes, when the absorp- tion of toxins may give rise to constitutional symptoms. The compli- cation is readily overcome by allowing the retained discharge to drain away through a douche-tube, after which the uterine cavity should be irrigated with sterile salt solution. So long as the body of the uterus lies above the superior strait, retrodisplacement cannot occur, as the falling backward of the enlarged fundus is prevented by the promontory of the sacrum. But as soon as the organ has become sufficiently involuted to descend into the pelvic cavity a retroflexion or retroversion becomes possible. The development of such displacements, which are rarely observed before the third week 1030 DISEASES AND ABNORMALITIES OF THE PUERPERIUM of the puerperium, is probably connected with excessive relaxation of some of the structures about the base of the broad ligaments, and appar- ently results from their overdistention by the presenting part. It is by no means always due to trauma incident to operative procedures, as in my experience retroflexion quite as frequently follows normal spontaneous labor during which no apparent injury was sustained. In other cases the retroflexion merely represents a recurrence of a similar condition existing prior to pregnancy, while occasionally it may be the result of extreme distention of the bladder. Backward displacement of the uterus rarely give rise to symptoms so long as the patient remains in bed, but as soon as she begins to move about their presence is apt to cause more or less inconvenience. The earliest and the most characteristic manifestation is an increase in the amount of lochial discharge or its reappearance if the flow has already ceased. Sometimes the patient suffers from pain in the back and lower abdomen, although in other cases she may only be conscious that she is not regaining her strength as rapidly as she had expected. In many instances, however, the displacement does not give rise to symptoms, so that the patient may have no idea of its existence until it is detected during the course of a pelvic examination months or years later. In my experience such displacements occur in every fourth or fifth puerperal woman. Lynch considered the subject in detail in 1922. A positive diagnosis can always be made upon vaginal examination, when the displaced uterus will be found to be larger and softer than normal—in other words, the condition is usually associated with sub- involution. The restoration of the uterus to its normal position by bimanual manipulations, and the introduction of a properly fitting pessary, as a rule will afford prompt relief, and on removal of the pessary three or four months later it will frequently be found that a permanent cure has resulted. On the other hand, if the pessary is not employed until after the conclusion of the puerperium, much less favorable results are ob- tained, while if deferred until some months later its employment is usually useless. This fact serves again to emphasize the necessity for making a final examination before discharging the puerperal patient. When the patient has suffered from retroflexion before pregnancy, a pessary should be introduced on the tenth day of the puerperium, before the uterus has returned to its abnormal position. Better results are obtained in this way than if the uterus is allowed to undergo involution in a retroflexed position; but in either event the prospects of a permanent cure are questionable. Relaxation of the Vaginal Outlet and Prolapse of the Uterus.—Refer- ence has already been made to the frequent occurrence of perineal lacera- tions at the itme of labor and the consequent relaxation of the vaginal outlet which follows neglect to repair them. Moreover, the changes following childbearing predispose to the occurrence of prolapse of the uterus, and an exacerbation should be expected during the puerperium in women who have presented moderate degrees of descensus uteri before labor. In order to obtain the best OBSTETRICAL PARALYSES 1031 results, and to prevent serious disability, an early operation is impera- tive, since the difficulty of rectifying the condition depends largely upon the extent of the prolapse and the length of time that it has been allowed to exist. Delayed Chloroform Poisoning.—Until very recently it was generally held that chloroform could be administered with impunity to the woman in labor. We now know that this is not the case, but that in rare instances symptoms of poisoning may set in several days after delivery and lead to death. The investigation of Howland and Kichards, and Whipple upon pregnant dogs shows that the process consists essentially in an autolysis of the hepatic cells, which may lead to almost total destruction of the secretory portion of the liver. In extreme instances the cells occupying the center of each lobule are completely destroyed, so that only a margin of approximately normal cells is preserved at the periphery. Associated with these changes is a pronounced perversion of metabolism. I have encountered the complication upon several occasions, and in one instance it ended fatally. This occurred in a primaparous woman whose cervix was dilated manually and forceps applied on account of threatened foetal asphyxia. The anesthetic was taken badly and was given for a little over one hour. The patient was in excellent condition for two days, but on the third day jaundice developed, and she passed into a torpid state, with occasional periods of excitement, and died in coma on the fifth day. At autopsy the liver presenting an appearance similar to that observed in the early stages of acute yellow atrophy of the liver, and identical with that produced experimentally in dogs. No doubt such cases were occasionally observed in the past, when death was attributed to some obscure toxemia. In view of our present knowledge it behooves us to inquire whether we are justified in continu- ing to use chloroform as an anesthetic. I believe that it may be safely employed for ordinary obstetrical anesthesia, but that it should be re- placed by ether whenever the operation and its preliminary preparations promise to last for longer than one half hour. Obstetrical Paralyses.—Paralytic conditions may develop in either mother or child during the puerperium. That branches of the sacral plexus sometimes suffer from pressure during labor is demonstrated by the fact that many patients complain of intense neuralgia or of crampliko pains extending down one or both legs as soon as the head begins to descend into the pelvic canal. As a rule, of course, the compression is rarely severe enough to give rise to grave lesions. In some instances, however, the pain continues after delivery, and is accompanied by the development of paralysis in the muscles supplied by the external popliteal nerve—the flexors of the ankles and the extensors of the toes—the gluteal muscles occasionally becoming affected to a lesser extent. The subject has been carefully studied by Hunermann, II. M. Thomas, and Hosslin. The investigations of the former supplied a very satisfactory explanation of the common localization of the paralysis by showing that the external popliteal nerve receives fibers from the fourth and fifth lumbar roots, and that these on their way downward to join 1032 DISEASES AND ABNORMALITIES OF THE PUERPERIUM the sacral plexus pass over the brim of the pelvis, where they are exposed to danger from compression, whereas the lower roots which lie upon the pyriformis muscle are more protected. Hiinermann considers that the chances of injurious pressure are greatest where the pelvis is generally contracted, and less so in the flattened varieties, inasmuch as the projecting promontory in the latter tends to prevent the head from coming in contact with the nerves. In the majority of cases the injury is the result of direct pressure exerted by the child’s head, and only exceptionally by the forceps. In view of the fact that only one oblique diameter of the superior strait is occupied by the greatest diameter of the head, it is readily understood why the paralysis is usually limited to one leg, Thomas’s case being the only instance in which both legs were affected, which had been recorded up to 1900. The paralytic symptoms usually appear immediately after delivery, and may become permanent unless suitable therapeutic measures, more particularly the use of electricity, are promptly instituted. In other cases paralytic symptoms, accompanied by intense neuralgic pains along the course of the sciatic nerve, follow pelvic inflammatory troubles. The condition is sometimes due to the development of a neuritis affecting certain branches of the sacral plexus, while in other cases pressure exerted by an inflammatory exudate is responsible. I have seen a case of the latter character, which had persisted for years in spite of continuous treatment, disappear as if by magic after laparot- omy and the separation of the adherent appendages from the posterior and lateral portions of the pelvic wall. Winsehied has directed particular attention to the rare cases of neuritis which follow delivery. The condition may be general or local- ized. In the latter only one or two nerves are affected—the median, ulnar, or crural—and atrophic symptoms soon make their appearance. In the former, since a number of nerves are implicated simultaneously, sometimes even those of the face not escaping, the symptoms may be manifold and the condition become most serious. In either event we are ignorant concerning the mode of production of the nerve lesions, although when generalized they are supposed to be due to toxemic in- fluences, being occasionally noted after toxemic vomiting and other toxic conditions. The prognosis is fair for the localized but poor for the generalized variety, although even the latter occasionally undergo spontaneous cure. It is also important to bear in mind that separation of the symphysis pubis, or of one or other sacro-iliac synchondrosis during labor, may be followed by pain, and by so marked an interference with locomotion as at first sight to suggest the existence of paralysis. Moreover, the disturb- ances in the function of the psoas muscles and the adductors of the thigh, which so frequently accompany the early stages of osteomalacia, might readily lead to a similar error. In addition to these more localized processes the puerperal woman may occasionally suffer from paralysis of central origin. In most in- stances these result from various varieties of apoplexy, and occasionally OBSTETRICAL PARALYSES 1033 from areas of cerebral degeneration incident to eclampsia and the other toxemias. As a result of a difficult labor, and exceptionally after an easy one, the child is sometimes born presenting an affection of the arm which is commonly known as Vuchenne’s paralysis. In this form, paralysis of the deltoid, infraspinatus, and the flexor muscles of the forearm causes the entire arm to fall close to the side of the body, and at the same time to rotate inward, while the forearm becomes extended upon the arm. The motility of the fingers is usually retained. Erb pointed out that such a paralysis could be due only to a lesion involving the fifth and sixth roots of the brachial plexus, and showed that electrical stimulation at a point from 2 to 3 centimeters above the clavicle and in front of the transverse process of the sixth cervical vertebra—now known as Erb’s point—produces contractions of the mus- cles involved. He considered that the paralysis frequently follows com- pression of the plexus by the clavicle in the Prague method of extraction more particularly when the arms have become extended over the head. In other cases its production is attributed to traction with the fingers in the axilla of the child, and occasionally to the use of forceps. That compression may be exerted during the employment of either of the first two of these maneuvers is at once evident from a consideration of the anatomical relations. On the other hand, the experiments of Stolper show that the plexus cannot possibly be compressed by the tips of the forceps so long as the child presents by the vertex, although it may occur in face or brow presentations. Carter, in 1893, was the first to direct attention to the fact that the condition is due to stretching of the upper roots of the brachial plexus more frequently than to abnormal pressure. His results were confirmed by the experimental work of Fieux, Schumaker, and Stolper, all of whom demonstrated that the plexus was readily subjected to extreme tension as a result of pulling obliquely upon the head, thus sharply flexing it toward one or other shoulder. As traction in this direction is frequently em- ployed in order to effect delivery of the shoulders in vertex presentations, it is readily seen that Duchenne’s paralysis may follow comparatively simple or even spontaneous labors. In view of these considerations, therefore, in extracting the shoulders care should be taken not to bring about too great lateral flexion of the neck. Moreover, in breech extrac- tions the Prague maneuver should be employed only when absolutely necessary, and particular attention should be devoted to preventing the extension of the arms over the head, as it not only materially complicates delivery, but adds considerably to the danger of infantile paralysis. The prognosis is usually fair, many of the children recovering. Occa- sionally, however, a case may resist all treatment and the arm may remain hopelessly paralyzed. All of the instances which I have person- ally observed ended in recovery, but in some of them prolonged treatment was necessary. In this form of paralysis the child should be promptly put under the care of a competent orthopedic surgeon, as the intelligent use of postural treatment will insure a useful arm, even if degenerative changes occur in the nerves and muscles. 1034 DISEASES AND ABNORMALITIES OF THE PUERPERIUM Abnormalities and Diseases of the Breasts.—Complete absence of both breasts is one of the rarest anomalies of development, while the absence of one and the normal development of the other breast have been noted in a few isolated cases. Hypertrophy of the breasts is more often observed, but abnormal enlargement is nevertheless an infrequent occurrence. In a large pro- portion of the recorded cases the condition developed rapidly in young unmarried women, both breasts being implicated and occasionally attain- ing such immense proportions that amputation became necessary. Cases have been reported in which a single breast weighed more than 50 pounds. The hypertrophy sometimes recedes during lactation, so that the abnormality does not always afford an absolute contra-indication to suckling the child. Overdevelopment of the mammae is sometimes ob- served in men, a number of cases having been collected by Laurent. Supernumerary Breasts.—Probably one in every few hundred women has one or more accessory breasts—polymastia. Reference to 262 such cases are to be found in Goldberger’s article. The supernumerary breasts are sometimes so minute as to be mistaken for small pigmented moles, and rarely attain any considerable size. They are often provided with distinct nipples, and are most commonly situated upon the anterior thoracic or abdominal walls, usually near the mammary line; less frequently they are found in the axillae, and occasionally upon other portions of the body—the shoulder, flank, or groin, and in rare instances the thigh. These supernumerary breasts vary greatly in number, Neugebauer having described a patient with ten. The condition is usually regarded as an atavistic reversion, though it is not associated with an increased tendency toward multiple pregnancy. In not a few instances an apparent hereditary influence can be traced. Not all observers, however, accept this view, Ahlfeld holding that the distribution of the mammary tissue is to be attributed to the transference at an early period of development by means of the amnion of some of the cells, which ordinarily go to form the breasts, to other portions of the body. The condition has no obstetrical significance, though occa- sionally the enlargement of supernumerary breasts occupying the axillae may result in considerable discomfort to the patient. Quite frequently a tongue of mammary tissue may extend out into the axilla from the outer margin of a normal breast, while sometimes an isolated fragment will be found in the same location. Such structures undergo hyper- trophy during pregnancy, and when lactation is being established become swollen and painful. Ordinarily, if let alone, they soon undergo regres- sion and give no further trouble. Abnormalities of the Nipples.—The typical nipple is cylindrical in shape and projects well beyond the general surface of the breast, its exterior being slightly nodular but free from fissures. Variations from the normal, however, are not uncommon, some of them being so pro- nounced as to interfere seriously with the act of suckling. In some women the lactiferous ducts open directly into an area which forms a depression at the center of the areola. In pronounced instances of this so-called depressed nipple nursing is out of the question, although ABNORMALITIES AND DISEASES OF THE BREASTS 1035 when the depression is not very deep the breast may occasionally be made available by the employment of a nipple-shield. More frequently, although not depressed, the nipple is so stunted that it hardly projects above the surface of the breast, and in consequence can be seized by the child’s mouth only with the greatest difficulty. In the presence of this anomaly daily attempts should be made during the last few months of pregnancy to draw the nipple out by traction with the fingers, and a wooden nipple-shield should be constantly worn in the hope that by exerting pressure upon the periphery of the areola the nipple itself may be gradually made to protrude through the opening of the shield. Again, it sometimes happens that nipples which are normal in shape and size may present so fissured or nodular a surface as to be especially susceptible to injury from the child’s mouth during the act of suckling. In such cases small cracks or fissures almost inevitably appear, and render nursing so painful that the mother dreads the approach of the child, and the mental distress so induced often has a deleterious influence upon the secretory function. Moreover, such lesions are still more serious in that they offer a convenient portal of entry for pyogenic bacteria which are liable to invade the breast and give rise to a mastitis. Abnormalities in the Mammary Secretion.—Marked individual varia- tions exist in the amount of milk secreted, many of which are dependent not upon the general health and appearance of the individual, but upon the degree of development of the glandular portions of the breasts. Thus we often find that a woman who possesses large, well-formed breasts, and who apparently should be an excellent milk-producer, secrets only a small quantity; while, on the other hand, one is often surprised at the abun- dant supply produced by another whose mammae are small and flat. It is a matter of common observation that stout women with redundant breasts usually have a very deficient secretion, the bulk of the organ being made up of fatty tissue while the glandular elements are poorly developed. Deficient secretion is likewise frequently noted in very young women and in elderly primiparae. In the former the defect is to be attributed to imperfect development; in the latter to regressive and atrophic changes in the breasts. In very rare instances there is an absolute lack of mammary secre- tion—agalacia. As a rule, however, the defect is not absolute, as it is nearly always possible to cause at least a small amount to exude from the nipple on the third or fourth day of the puerperium. On the other hand, relative deficiency is frequently observed, a large number of women secreting an amount of milk quite insufficient for the nutrition of the child. In Chapter XYII reference was made to the variations in the quantity of the milk as well as the various factors which may be con- cerned in their production. Occasionally the mammary secretion is excessive—polygalacia—and may even be so abundant that milk is constantly escaping from the nipples. This latter condition, which is known as galactorrhea, some- times continues for years after the birth of the child, and is extremely intractable to treatment. Nothing is known as to its cause. Although 1036 DISEASES AND ABNORMALITIES OF THE PUERPERIUM in rare instances the health of the woman may remain unimpaired, as a rule she soon begins to show evidences of the continuous drain upon her system, becoming irritable, querulous, and eventually developing symptoms of cachexia. Galactorrhea is best treated by not attempting to empty the breast, but by allowing it to become engorged, in the hope that the intramam- mary pressure will become so great as to compress the vessels and thus check secretion. At the same time the breasts should be supported by a bandage, and fairly large doses of potassium iodid should be admin- istered. Good effects are also said to have been obtained from the use of chloral. In a certain number of cases the condition is combined with atrophy of the uterus, and several observers have reported improve- ment following procedures which tend to bring about an increase in size of the uterus, such as the use of the vaginal douche, local applications to the cervix, or the employment of electricity. Diseases of the Nipples.—The mode of production and treatment of fissures of the nipples has already been considered in detail in Chapter XVII. Engorgement of the Breasts.—For the first twenty-four or forty- eight hours following the development of the lacteal secretion, it is not unusual for the breasts to become immensely distended, and to offer on palpation a firm, nodular resistance. This condition, which is commonly known as “caked breast/’ often gives rise to a considerable degree of pain, and is sometimes accompanied by a slight elevation of temperature. Within a day or so the engorgement usually passes off spontaneously, or as the result of appropriate treatment, though in some cases it persists in spite of all that can be done, and may be a forerunner of the develop- ment of a mammary abscess. It is probable that the excessive distention of the glandular portion of the breast leads to slight tissue changes, thereby offering a locus minoris resistentiae for invasion by bacteria, which are usually present in the lactiferous ducts. Whenever the breast becomes markedly engorged immediate steps should be taken to relieve the condition. This is most readily accom- plished by drawing the breasts firmly against the thorax by means of a tight binder, applying an ice bag, and if necessary giving % grain of codeia, which may be repeated in three hours if necessary. Usually this will relieve the condition within twenty-four hours, and the physician is cautioned not to be too hasty in resorting to other measures. If the engorgement does not show signs of subsiding within this period, and particularly when the child is unable to draw off a sufficient quantity of milk, an English breast-pump should be employed to remove the excess. Sometimes this procedure proves ineffectual, and relief can be obtained only by massage. The nurse having anointed the palmar surfaces of her hand with olive-oil, mixed with equal parts of laudanum if the breasts are very sensitive, makes stroking movements, beginning at the periphery of the breast and gradually approaching the nipple. At first the manipulations should be made very gently, but as the patient becomes accustomed to them more force may be employed, which will soon cause the milk to exude from the nipple. After the breast has ABNORMALITIES AND DISEASES OF THE BREASTS 1037 been emptied the bandage should be reapplied, as it not only relieves pain by preventing the overloaded organ from sagging downward, but at the same time serves to diminish the amount of secretion by diminishing the blood supply. That the engorgement is usually transient and the use of special treatment is unnecessary is clearly shown by the fact that I have not employed massage or the breast pump for years. In many instances I believe that the use of these measures often defeats the very purpose for which they are employed, as they stimulate rather than diminish the secretory activity of the breasts. Drying up the Breasts.—After the death of the child, or in cases in which for one reason or another the continuance of lactation is thought inadvisable, steps must be taken for checking the lacteal secretion, or “drying up the milk,” as it is usually designated. Formerly this was accomplished by the use of the binder, the application of belladonna ointment, and the employment of the breast-pump and massage wrhen the engorgement became pronounced. The process was frequently very painful to the patient, very troublesome to the nurse, and usually had to be employed for a week or ten days or even longer before the desired result was obtained. In 1904 Dr. E. R. Lewis, of Westerly, R. I., told me that much more satisfactory results could be obtained by the administration of 20 grains of potassium acetate every six hours. I immediately put his suggestion into practice, and found that the breasts dried up in the course of two to four days without other treatment. Further investigations, however, showed that the potassium acetate was of no value, as equally satisfactory results followed if drugs were not used. Accordingly, when it is desired to “dry up” the breasts, they are left absolutely alone. In the course of twenty-four hours they become more or less engorged, and sometimes very painful. If the pain is severe, % grain of codeia is administered, and repeated if necessary, but the breast- pump or massage is not employed. Within a few hours the engorgement begins to subside spontaneously and the amount of secretion to decrease, so that by the end of another twenty-four hours the breasts become soft and painless. With each succeeding day the secretion becomes less and less abundant, and practically disappears in the course of a week. II. J. Storrs, in 1909, published a report of the cases so treated in our clinic, and stated that not a single breast abscess had developed during the period of observation, and that less than one woman in ten complained of sufficient pain to necessitate the administration of a sedative. I have employed this method exclusively since 1915, and since then I have had no occasion to employ belladonna ointment, the breast- pump, massage, or the tight breast binder. Ice bags, however, are used, and when the breasts are large and pendulous they are supported by means of a binder, which does not exert pressure upon them. Inflammation of the Breasts—Mastitis.—Parenchymatous inflamma- tion of the mammary glands is a rare complication of pregnancy, but is frequently observed during the puerperium and lactational period. Whitcher in 1914 collected a number of cases of the former complication, and showed that it did not differ from the puerperal type except in the 1038 DISEASES AND ABNORMALITIES OF THE PUERPERIUM time of its appearance. The symptoms of mastitis rarely appear before the end of the first week of the puerperium, and as a rule not until considerably later. Marked engorgement usually precedes the inflamma- tory trouble, the first sign of which is afforded by chilly sensations or an actual rigor, which is soon followed by a considerable rise in tempera- ture and an increase in the rate of the pulse. The breast becomes hard, its surface is reddened, and the patient complains of acute pain. In many instances, by the end of twenty-four hours the condition disappears spontaneously without treatment, being often favorably influenced by the application of cold and of a tightly fitting bandage. But if the symptoms persist for longer than forty-eight hours, suppuration is to be expected. The process may remain limited to a single lobe if the abscess is opened promptly; but if left to itself the breast is liable to become undermined in all directions, and, as a result, the destruction of tissue is extensive, and the external surface may be left riddled with numerous fistulous tracts. In some cases the constitutional symptoms attending a mammary abscess are very pronounced, and very exceptionally lead to a fatal termi- nation. On the other hand, the local manifestations may be so slight as to escape observation. Such cases are usually mistaken for puerperal infection, and give rise to no little anxiety until the examination of cultures from the uterine cavity has demonstrated the absence of bac- teria. In still another group of patients the process pursues a subacute or almost chronic course, the breast being somewhat harder than usual and more or less painful, but constitutional symptoms are either lacking or very slight. Under such circumstances the first indication of the true state of affairs is often afforded by the detection of fluctuation. Etiology.—Mastitis is always the result of infection, pathogenic bac- teria from outside gaining access to the breast through fissured nipples by way of the lymphatics; or else some of those already present in the lactiferous ducts meet with conditions which enable them to invade the tissues. The researches of Bumm, Honigmann, Koestlin, and others have demonstrated that Staphylococcus albus is present in 80 to 94 per cent, of all breasts. Ordinarily this microorganism lives in the milk as a harmless parasite, but when the tissues are seriously altered as the result of engorgement, it is possible for it to become pathogenic. Rubeska reported the following bacteriological findings in 16 cases of mammary abscess: Staphylococcus aureus 9 cases Staphylococcus aureus and albus 3 “ Staphylococcus albus 3 “ Streptococcus 1 case Exceptionally, other bacteria are causative agents, Sarfert having demon- strated the gonococcus, Chassot the bacillus pvocyaneus, and Little the gas bacillus. When the infection occurs through fissured nipples the inflammation is usually phlegmonous in character. In some cases it involves only the connective tissue beneath the breast, a large collection of pus being formed between it and the thoracic wall—retromammary abscess. Again, ABNORMALITIES AND DISEASES OF THE BREASTS 1039 the infection may be limited to the areola, beneath which small abscesses, rarely exceeding 1.5 centimeters in diameter, may develop—subareolar mastitis. In rare instances the affection may be erysipelatous in charac- ter, and be limited to the superficial tissues. According to Winckel, 67.6 per cent, of all cases of mastitis occur in primiparae, but its actual incidence varies according to the care given the patients during pregnancy and the puerperium. Thus, the statistics of Kubeska show a frequency of 0.54 to 4.1 per cent, in the various Ger- man clinics. Generally speaking, it may be said that the frequent occur- rence of mastitis is indicative of neglect on the part of the physician or nurse. Treatment.—The occurrence of mastitis can be prevented in great part by suitable prophylactic measures, which mainly consist in prevent- ing the development of fissured nipples or treating them properly after they have appeared. The most suitable measures for treating the nipples during preg- nancy, so as to enable them to better withstand the strain of nursing, have already been mentioned in Chapter XVII. When lactation becomes established the strictest cleanliness should be observed and the nipples watched most carefully. As soon as a fissure begins to develop a nipple- shield should be employed, the child not being allowed to apply the mouth directly to the nipple until healing has taken place. In the intervals between the feedings the sore nipple should be covered with a piece of absorbent cotton soaked in a saturated solution of boric acid. The various applications which are usually recommended, however good in themselves, will prove practically valueless, unless the nipple can be placed at comparative rest, which is best afforded by the use of a suitable nipple-shield. If the condition becomes worse after some days’ trial of this treatment it is advisable to wean the child rather than take the risk of infection, which is so prone to follow if the deeply fissured nipple be used for any length of time. On the first symptom of mammary infection the breast should be put at rest as far as possible by not allowing the child to nurse it, and withdrawing the milk, if necessary, by means of a breast-pump. After being emptied the breast should be thickly covered with cotton, and by means of a tightly fitting bandage subjected to the greatest possible pressure consistent with the comfort of the patient, and an ice bag applied. In many cases such treatment apparently cuts short the process, the symptoms disappearing within twenty-four hours, after which the patient is able to resume suckling her child. Usually, however, the process sooner or later eventuates in abscess formation. In early cases Bier reported excellent results following the use of his method of artificial hyperemia, but in my service the procedure has been of little value. As soon as definite evidence of fluctuation can be obtained the breast should be incised. Procrastination is not permissible, delay being synonymous with extension of the process, which frequently leads to such extensive destruction of tissue as to destroy permanently the physiological function of the organ. The incision should be made radi- ally, extending from near the areolar margin toward the periphery of the 1040 DISEASES AND ABNORMALITIES OF TIIE PUERPER1UM gland, in order to avoid injury to the lactiferous ducts. In early cases a single incision over the most dependent portion of the area of fluctuation is usually sufficient, but when multiple abscesses are present several in- cisions may be required. The operation should always be done under anesthesia, and should not be considered as completed until the obstetri- cian has introduced a finger through the incision and carefully explored the interior of the breast, breaking down the partition walls between the various pockets of pus, so that only a single abscess cavity is left to be dealt with. This should then be loosely packed with gauze, and re- placed at the end of twenty-four hours by a smaller pack. If the pus has been thoroughly evacuated, the abscess cavity becomes obliterated with a rapidity which is sometimes surprising. Galactocele.-—Very exceptionally, as the result of the clogging of a milk duct by inspissated secretion, an accumulation of milk may take place in one or more lobes of the breast. Ordinarily this is limited in amount, but may become excessive and form a fluctuant tumor which may give rise to pressure symptoms. In many instances massage and the application of a tight bandage will cause it to disappear, and I have never seen the structure attain such size that puncture became imperative. Puerperal Psychoses.—Reference has already been made to the altera- tions in the mental condition which may accompany pregnancy. These vary from slight changes in disposition to actual insanity, though for- tunately the latter is of relatively rare occurrence. In the absence of the usual etiological factors or an hereditary taint, the insanity of pregnancy is usually a manifestation of auto-intoxication, and may be accompanied by melancholic or maniacal symptoms. It usually persists throughout the remainder of gestation, but disappears shortly after labor. Puerperal insanity, on the other hand, is more common, and accord- ing to the statistics compiled by Berkley and Jones is noted once in every 016 and 1,100 labors, respectively. In former times it was a com- paratively common complication, and it would seem that the introduction of aseptic methods into obstetrics is responsible for a reduction by one half in its incidence. The affection usually makes its appearance within the first two weeks following delivery. AVhen it occurs later it is desig- nated as lactational insanity. Puerperal psychoses may be due to one of three causes: infection, auto-intoxication, or direct lability of the nervous system. Of these, the former is by far the most important. This fact has long been recog- nized, but it is only of late that the bacteria concerned have been identi- field, and then only in a small proportion of the cases. In two instances which have come under my observation the infection was due to strep- tococcus, while in a third, it was due to the streptococcus and colon bacillus. Auto-intoxication is also a frequent etiological factor. According to Hansen and Picque, infection and auto-intoxication are responsible for more than 80 per cent, of all cases, while the remainder are to be attributed to other causes, and occur particularly in women afflicted with hereditary tendencies, the exciting cause of the insanity being shock, MALARIAL FEVER 1041 extreme mental depression, or the rapid loss of a large quantity of blood. Psychical disturbance is a well recognized, but fortunately rare, com- plication of eclampsia, usually appearing several days after the cessation of convulsions. In my experience it occurs about once in forty or fifty cases, though Olshausen observed it in 6 per cent, of his 515 eclamptic cases. The puerperal psychoses are usually characterized by great excite- ment during the first few days, associated with all sorts of hallucinations. Later the maniacal symptoms disappear, and the patient passes into a condition of depression, and frequently exhibits suicidal tendencies. The prognosis is most favorable in the cases following eclampsia, the majority of such patients recovering within a few weeks. On the other hand, those following infection are very tedious, and 20 to 40 per cent, of the women fail to regain their mental equilibrium. It is not unusual for the disturbance to last for from three to six months, although the prospect for recovery is poor if the latter period is exceeded. It is generally stated that from 5 to 10 per cent, of the patients afflicted with puerperal insanity die, this high mortality rate being due, of course, to the underlying infection and not to the mental derangement itself. In cases following infection the treatment should first be directed to the underlying condition, and the directions described in Chapter XLIII rigorously followed. The acute maniacal symptoms should be met by the administration of sedatives, and the patient should be watched most carefully throughout her entire illness, more particularly during the periods of depression, during Avhich she should never be left alone for fear that she may do an injury to herself. If prompt improvement does not follow the disappearance of the symptoms ascribable to infection, the patient should be placed in charge of a competent psychiatrist. Typhoid Fever.—This is not an infrequent complication of the puer- perium. Its course, however, varies but little from that observed under other conditions, although the prognosis is necessarily somewhat in- fluenced by the fact that the patient is already debilitated by the strain incident to labor. The diagnosis should never be made unless a definite Widal reaction can be demonstrated, inasmuch as all the other symptoms of the disease may be associated with a prolonged puerperal infection, especially when the endocardium is involved. Furthermore, the so-called typhoid condition is often encountered in various forms of pyemia. Malarial Fever.—In certain districts the puerperium is sometimes complicated by malarial infection. Although the course of the disease is not materially influenced by the fact that the patient has recently given birth to a child, it is interesting to note that labor, no less than surgical procedures, seems to predispose to a recrudescence of the dis- order in women who have already suffered from it, the typical phe- nomena often appearing during the first few days of the puerperium. Too many sins of omission and commission on the part of the obste- trician have undoubtedly been cloaked under the diagnosis of “malaria.” At the present day, whenever a puerperal patient presents a temperature characterized by marked remissions and possibly by chills, puerperal in- fection should be suspected, and the existence of malarial fever should not 1042 DISEASES AND ABNORMALITIES OF THE PUERPERIUM be seriously entertained unless all other possibilities have been practically eliminated and the characteristic parasites have been found in the blood. As soon as a positive diagnosis has been made, quinin should he given in sufficiently large doses to break up the attack, as the drug exerts no appreciable influence upon the mammary secretion or the well-being of the child. Pneumonia.—Croupous pneumonia is a rare complication of the puerperal state, unless the disease has existed before the onset of labor. The outlook is always serious. The lobular variety, or bronchopneumonia, is often a terminal process, and is one of the most common causes of death in patients who succumb within a few days following an eclamptic attack. The treatment does not differ essentially from that employed at other times. Scarlet Fever.—Although scarlet fever is rarely encountered during the puerperium, its occurrence has given rise to a great deal of dis- cussion and a very considerable literature. The interest manifested in the disease is largely to be accounted for by the fact that a scarlatini- form rash is occasionally observed during the course of a puerperal in- fection, so that in many cases a differential diagnosis becomes very difficult. Epidemics of scarlet fever in the puerperium have been reported by Boxall, Meyer, Ahfeld, and others. Nevertheless, it would appear that the puerperal woman is to a certain extent immune from the disease, inasmuch as statistics go to show that only a small proportion of those exposed to the contagion become infected. Thus, Meyer found the rate of morbidity to be about 1 per cent, among his patients. It is generally stated that infection may occur in the usual manner, as well as by the entrance of the specific poison through wounds about the genitalia. The belief in the possibility of the latter eventuality is based upon the fact that the rash occasionally appears first in the neigh- borhood of the vulva, and thence spreads to other portions of the body. Moreover, the frequent association of pelvic inflammatory troubles, and the occasional localization of diphtheritic patches in the vulva or vagina, instead of in the throat, are advanced in support of the view. Modern bacteriological investigation, however, has destroyed the force of this last agrument, since it has shown that the so-called diphtheritic deposits occurring in the throat in scarlet fever are due to a coincident strep- tococcic infection. Moreover, since such conditions about the genitalia usually have a similar origin, it would appear difficult to differentiate between those complicating scarlet fever and the varieties*occurring dur- ing the course of puerperal infection. It is also urged that the appear- ance of the disease on the third or. fourth day of the puerperium speaks in favor of transmission of contagion through the genitalia. In frank cases the diagnosis is readily made from the existence of a characteristic rash, which is later followed by desquamation. Moreover, the strawberry tongue, the development of pseudodiphtheritic patches in the pharynx, the appearance of albumin in the urine, together with a history of exposure to possible contagion, usually remove all doubt. On LITERATURE 1043 the other hand, in the absence of characteristic manifestations, the diagnosis cannot be made, it being often impossible to differentiate be- tween scarlet fever and puerperal infection, even when a distinct history of exposure to contagion can be elicited. The prognosis is largely the same as under other circumstances, mild forms, as a rule, ending in recovery, whereas patients affected with the hemorrhagic variety usually die. The puerperium appears to exert little effect upon the course of the disease, the death-rate not being higher than under ordinary conditions. The child may or may not be infected. Measles and smallpox occasionally occur during the puerperium, but their course does not differ materially from that observed in women who have not recently given birth to children. Diphtheria.—True diphtheritic patches, in which the Klebs-Loeffler bacillus can be demonstrated, occasionally occur upon denuded portions of the vulva and vagina. They may be due to a primary genital infec- tion, or be merely part of a process primarily localized in the throat. Such lesions, however, should be more frequently observed if the observations of Wauschkuhn are correct; as he stated that the vaginal secretion frequently harbors diphtheria bacilli; which he was able to isolate from eleven of a series of 200 women. Inasmuch as pseudodiph- theritic patches in the genital tract during, the course of puerperal in- fection are of frequent occurrence, the presence of fibrinous exudates about the vagina or vulva should lead to a diagnosis of diphtheria only when the characteristic bacilli can be demonstrated. If the process is limited to the genital tract, the constitutional symptoms are not severe, and the disease usually pursues a benign course, readily yielding to the employment of antidiphtheritic serum. LITERATURE Aiilfeld. Spaltung der Anlage der Brustdriise, Polymastie. Die Missbildungen des Mensehen. Leipzig, 1880, 110-113. Ueber Exantheme im Wochenbette, etc. Zeitschr. f. Geb. u. Gyn., 1893, xxv, 31-44. Berkley. The Insanities of the Puerperal Period. A Treatise on Mental Dis- eases, 1900, 307-328. Boxall. Scarlatina during Pregnancy and in the Puerperal State. Trans. Lond. Obst. Soc., 1889, xxx, 11-77; 126-154. Bumm. Zur Aetiologie der puerperalen Mastitis. Archiv f. Gyn., 1886, xxvii, 460-484. Burckhard. Gangran der unteren Extremitaten im Wochenbette. Zentralbl. f. Gyn., 1900, xxiv, 1381-1384. Carter. Obstetrical Paralysis, etc. Boston Med. and Surg. Jour., May 4, 1893. Chantemesse et Widal. Kecherches sur l’etiologie du tetanus. Le bull, med., 1889, No. 74. Chiari, Braun, und Spaeth. Acquirirte Yolumsabnahme des Uteruskorpers. Klinik der Geb., 1854, 371-372. Deneux. Memoire sur les tumeurs sanguines de la vulve et du vagin. Paris, 1830. 1044 DISEASES AND ABNORMALITIES OF THE PUERPERIUM Doderlein. Die Atrophia uteri. Veit’s Handbueh der Gyu., 3897, ii, 391-402. Duchenne. Paralysies obstetricales infantiles du membre superieur. De 1’elec- trisation localisee. Paris, 1872, 3me ed., 357. Fieux. De la pathogenie des paralysies brachiales chez le nouveau-ne. Annales de gyn. et d’obst., 1897, xlvii, 52-64. Goldberger. Ein seltener Fall von Polymastie. Archiv f. Gyn., 1895, xlix, 272- 277. Gottschalk. Beitrag zur Lehre von der Atrophia uteri. Volkmann’s Sammlung klin. Vortrage, N. F., Nr. 49. Hansen. Ueber das Verhaltniss zwischen der puerperalen Geisteskrankheit u. der puerperalen Infection. Zeitschr. f. Geb. u. Gyn., 1888, xv, 60-127. Heyse. Ueber Tetanus puerperalis. Deutsche med. YVochenschr., 1893, Nr. 14, 318. Honigmann. Bakteriologische Untersucliungen iibar Frauenmilch. D. I., Breslau, 1893. Hosslin. Ueber periphere Schwangerschaftslahmungen. Munchener med. YVoch- enschr., 1905, Nr. 14. Howland and Bichards-. An Experimental Study of the Metabolism and Pathology of Delayed Chloroform Poisoning. Jour. Exp. Med., 1909, xi, 344-72. Hunermann. Ueber Nervenliihmung im Gebiete des Nervus ischiadicus infolge von Entbindungen. Archiv f. Gyn., 1900, xlii, 489-512. Jacquet. Ueber Atrophia uteri. Berliner Beitrage zur Geb. u. Gyn., 1873, ii, 1-11. Jones. Puerperal Insanity. Jour. Obst. and Gyn Brit. Emp., 1906, iii, 109-125. Kostlin. Beitrage zur Frage des Keimgehaltes der Frauenmilch u. zur Aetiologie der Mastitis. Archiv f. Gyn., 1897, liii, 201-277. Kunzig. Ueber das Haematom der Vulva und der Vagina. D. I., Tiibingen, 1895. Lafond. De la gangrene des membres inferieurs dans les suites de couches. These de Bordeaux, 1901. Laurent. Gynakomastie, etc. Bibliothek fiir Socialwissenschaft. Leipzig, 1896, vi. Lynch. Betroversions of the Uterus following Delivery. Trans. Am. Gyn. Soc., 1922, xlvii, 177-192. Meyer. Ueber Scharlach bei Wdchnerinnen. Zeitschr. f. Geb. u. Gyn., 1888, xiv, 289-351. Neugebauer. Eine bisher einzig dastehende Beobachtung von Polymastie mit 10 Brustwarzen. Zentralbl. f. Gyn., 1886, x, 729-736. Olshausen. Beitrag zu den puerperalen Psychosen, speciell den nach Eklampsie auftretenden. Zeitschr. f. Geb. u. Gyn., 1891, xxi, 371-385. PiCQufi. Considerations sur les psychoses post partum. Bull, de la soc. d’obst. de Paris, 1905, viii, 19-38. Bubeska. Beitrage zum Tetanus puerperalis. Archiv f. Gyn., 1897, liv, 1-12. Zur Behandlung von wunden Warzen und Mastitiden im YVochenbett. Archiv f. Gyn., 1899, lviii, 177-184. Sarfert. Diplokokken im Eiter bei Mastitis. Deutsche med. YVochenschr., 1894, Nr. 8. Schumaker. Ueber die Aetiologie der Entbindungslahmungen, etc. Zeitschr. f. Geb. u. Gyn., 1899, xli, 33-53. Schwarz. The Pathology of Chronic Metritis and Chronic Subinvolution. Am. Jour. Obst., 1919, lxxix, 63-94. Smith. The Subinvoluted Uterus. Surg. Gyn. and Obst., 1910, x, 17-27. Spiegel. Zur Kenntniss des Tetanus puerperalis. Archiv f. Gyn. 1914, ciii, 367-392. Stolper. Ueber Entbindungslahmungen. Monatsschr. f. Geb. u. Gyn., 1901, xiv, 49-65. Storrs. Checking the Secretion of the Lactating Breast. Surg. Gyn. and Obst., 1909, ix, 401-405. Thomas. Obstetrical Paralysis, Infantile and Maternal. Bulletin Johns Hopkins Hospital, 1900, xi, 279. Thorn. Hie Laktationsatrophic des Uterus, etc. Volkmann’s Sammlung klin. Vortrage, 1910, Nr. 602 and 603. Vinay. Hu tetanus puerperal. Archives de tocologie, 1892, xix, 179. Vineberg. A Further Contribution to the Study and Practical Significance of Lactation Atrophy of the Uterus. Amer. Gyn., 1902, i, No. 2. Wauschkuhn. Ueber das Vorkommen von echten Hiphtheriebazillen bei Gebaren- den und Neugeborenen. Zentralbl. f. Gyn., 1920, 820-824. Whipple. Pregnancy and Chloroform Amethesia. Jour. Exp. Med., 1912, xv, 246-258. Whipple and Sperry. Chloroform Poisoning. Bull. Johns Hopkins Hospital, 1909, xx, 278-289. Whitcher. Mastitis in Pregnancy. Boston Med. & Surg. Jour., 1914, clxxi, 970-973. Williams. Subperitoneal Hsematoma following Labour, not associated with Lesions of the Uterus. Trans. Am. Gyn. Soc., 1904, xxix, 186-205. Winckel. Entziindung des Brustdriisenparenchyms, etc. Hie Pathologie u. Therapie des Wochenbetts. III. Aufl., 1878, 428-439. Winscheid. Neuritis gravidarum und Neuritis puerperalis. Graefe’s Sammlung zwangloser Abhandlungen auf dem Gebeite der Frauenheilkunde und Geb., 1898, iii, Heft 8. Wormser. Nochmals zur puerperalen Gangran der unteren Extremitaten. Zen- tralbl. f. Gyn., 1901, xxv, 110-112. Ueber puerp. Gangran der Extremitaten. Wiener klin. Rundschau, 1904, Nr. 5 u. 6. LITERATURE 1045 INDEX Abderhalden’s reaction, 213. Abdomen, discoloration of, in pregnancy, 190. enlargement of, during pregnancy, 210. foetal, enlarged, cause of dystocia, 900. pendulous, 220, 847. striae of, in pregnancy, 190. Abdominal binder, 381. pedicle, 123, 125, 131. pregnancy, 738, 741. wall, changes in, during pregnancy, 190, 570. during puerperium, 376, 381. emphysema of, 960. function of, during labor, 259, 277. Abortion, 701. changes in foetus in, 706. clinical history of, 708. complete, 709. criminal, 420, 701. curettage in, 421, 712. epidemic, 705. etiology of, 702. frequency of, 701. imminent, 709. in retroflexed pregnant uterus, 420, 646. in typhoid fever, 547. incomplete, 709. induction of, for contracted pelves, 421. for diseases of ovum, 420. for malignant growths, 421. for ovarian tumors, 421. for pernicious vomiting of pregnancy, 420. for renal insufficiency, 420. for retroflexed pregnant uterus, 420, 647. for tuberculosis, 422. for uterine hemorrhage, 421. for uterine myomata, 421. for vomiting of pregnancy, 587. methods of, 422. inevitable, 709. infectious, of cattle, 705. lithopedion in, 708. missed, 713. mole, formation of, in, 706. pathology of, 706. prophylaxis of, 709. repeated, 705. threatened, 709. treatment of, 709. tubal, 732. Abscess, in puerperal fever, 989. of Bartholin’s gland, 636. of breast, 1038. metastatic, 990. pelvic, 989. retromammary, 1038. Acanthopelys, 898. Acardiacus, 407, 903. Accessory fontanel, 165. Accessory ostium of tube, 59. Accessory ovaries, 64. Accessory tubes, 60. Accidental hemorrhage, concealed, 922. Accidents during pregnancy, 570. Accommodation theory as to production of presentations, 240. Accouchement force, 431. for hemorrhage due to premature sep- aration of placenta, 926. in eclampsia, 624. in placenta previa, 937. Acephalicus, 903. Acetonuria during pregnancy, 201. during puerperium, 380. Achondroplasia, 826, 907. Acormus, 904. Acromio-iliac presentations. (See Trans- verse Presentations.) Acute infectious diseases in pregnancy, 545. edema of cervix, 649. yellow atrophy of liver, 587. Adherent placenta, 683. Adhesions, amniotic, 672. Adipocere, 740. Adrenal gland, in pregnancy, 196. Afterbirth, 147. After-coming head, forceps to, 467, 481. perforation of, 529. After-pains, 378. Agalacia, 1035. Age of foetus, calculation of, 160. Agglutination, in eclampsia, 611. Air, entrance of, into veins, 974. entrance of, into uterine sinuses, 974. infection, 993. Albuginea, 63. Albuminometer, Esbach’s, 595. Albuminuria, changes in the placenta in, 679. Albuminuria during pregnancy, 194, 591, 593. during puerperium, 1047 1048 INDEX Albuminuria in eclampsia, 602. in labor, 379. relation to premature separation of pla- centa, 921. Albuminuric retinitis, 592. Allantois, 125. Amaurosis during pregnancy, 592, 602. Amenorrhea, conception during, 215. Ammonia coefficient, 584, 603. Amnesia, 363. Amnion, 111. adhesions of, 672. cysts of, 673. diseases of, 667. dropsy of, 667. fluid of, 133, 667. formation of, in bat, 116. in chicken, 111. in guinea pig, 115. in man, 114. in monkey, 116. inflammation of, 672. structure, 132. Amniotic adhesions, 672. caruncles, 132, 673. fluid, functions of, 173. origin of, 173. Amorphus, 903. Ampulla of tube, 56. Ampullar pregnancy, 726. Amputation, of leg, effect upon pelvis, 897. intra-uterine, 672. Anaerobic bacteria in puerperal infection, 982. Anaphylaxis, 612. Anemia, pernicious, 568. Anencephalus, 904. Anesthesia, 359. in eclampsia, 624. in heart disease, 556. in irregular pains of first stage, 759. in normal labor, 359. in painful labor, 759. Aneurysm of foetus, 907. Annular detachment of cervix, 953. Anteflexion, in contracted pelves, 847. of pregnant uterus, 642. of puerperal uterus, 1029. Antepartum hemorrhage, 876. Anteversion of pregnant uterus, 642. Anthrax during pregnancy, 548. Antistreptococcic serum, 1014. Antitetanus serum, 1022. Anus, laceration of sphincter of, 367. lesions of, during labor, 260, 282. Apoplexy during pregnancy, 567. in eclampsia, 607. of placenta, 678. uteroplacental, 923. Appendicitis during pregnancy, 571. Apron, Hottentot, 28. Arbor vitae uterina, 41. Area, embryonic, 107. germinativa, 107. opaca, 107. pellucida, 107. Areola, of pregnancy, 191. secondary, 191. Armadillo, multiple pregnancy, in, 405. Arterial pressure, 192, 256. Arteries. (See Blood-vessels.) Artificial feeding, 400. respiration. (See Asphyxia.) Ascites, of foetus, obstructing labor, 906. simulating pregnancy, 220. Asphyxia, from rupture of vasa previa, 684. intra-uterine, 967. livida, 969. neonatorum, 967. pallida, 969. trepanation for, 970. Assimilation pelvis, 835. Asthma during pregnancy, 557. Atony of uterus, 413, 939. Atresia of cervix, 768. follicular, 188. of vagina, 767. of vulva, 766. Attitude of foetus, 234. Auscultation, obstetrical, 207, 245. errors in, 246. foetal heart, 207. foetal heart murmurs, 208. funic souffle, 208. gas in maternal intestines, 208. in multiple pregnancy, 411. movements of foetal diaphragm, 208. placental souffle, 208. uterine souffle, 208. Auto-infection, 993. Auto-intoxication, intestinal, 610, 629, 1005. relation of, to eclampsia, 610. to insanity, 1040. Autolysis in eclampsia, 614. Axis of pelvis, 10. Axis traction forceps, 464. Bacillus abortus, 705. aerogenes capsulatus, cause of emphysema of abdominal walls, 980. infection with, cause of foetal dystocia, 908. infection with, simulating air embolism, 974. in puerperal infection, 980. Bacillus coli communis, in puerperal infec- tion, 980. in tympanites uteri, 980. Bacillus diphtheriae in puerperal infection, 980. Bacillus typhosus in puerperal infection, 981. Bacterial orgin of eclampsia, 610. Bacteriology of lochia, 379, 1006. of puerperal infection, 977. of vaginal secretion, 995. Bag of waters, 258, 276, 352. Balloon, Champetier de Ribes, 430, 433. Ballottement, 209. Bandl’s ring. (See Contraction Ring.) Barnes’s fiddle-bag, 430. Bartholin’s glands, 30. inflammation of, during pregnancy, 636. Basal plate of decidua, 143. Basilyst-tractor, 532. Basiotribe, 531. Bath, cold, in puerperal fever, 1012. during labor, 349. INDEX 1049 Bath of new-born child, 390. sweat, in eclampsia, 625. Battledore placenta, 683. Bauchstiel, 123. Baudelocque’s cephalotribe, 531. diameter, 786. pelvimeter, 784. Bed, preparation of, 351. Bichloride poisoning from intra-uterine douche, 539. Bicornuate uterus, cause of dystocia, 640. hernia of, 649. pregnancy in, 641. Binder, use of, during puerperium, 381. Bipolar version, 485. Bladder, changes in, during pregnancy, 195. calculus of, 777. ectopia of, 834. gangrene of, 645. rupture of, 645. tumor of, complicating labor, 777. Blastodermic vesicle, 107. Blecard’s sign of maturity of foetus, 161. Bleeding in eclampsia, 623. Blood, changes in, during menstruation, 86. agglutination in eclampsia, 611. chemistry, in eclampsia, 604, 616. in acute yellow atrophy, 589. in nephritic toxemia, 591. in preeclamptic toxemia, 594. in pregnancy, 193. diseases of, in pregnancy, 192, 568. during pregnancy, 192. during puerperium, 378. freezing point of, 170. lipoids of, 192. moles, 707. pressure in pregnancy, 192. serum, changes in, during pregnancy, 217. toxicity of, in eclampsia, 610. Blood-vessels of clitoris, 29. of ovaries, 63. of placenta, 146. of uterus, 50, 374. of vagina, 37. pudic, 280. umbilical, 149, 388, 684. vestibular bulbs, 30. Blood volume, 193. Blot’s perforator, 529. Blunt hook, 482, 534. Body stalk, 123, 131. Bones in pregnancy, 197. Bossi’s dilator, 433. Bougie, for induction of premature labor, 429. Bowels in pregnancy, 229 Bradycardia during puerperium, 377. Brain, changes in, in eclampsia, 607. Braun’s blunt hook, 534. cranioclast, 530. sign of pregnancy, 211. trepan, 529. Braxton Hicks’s method of version, 485, 491, 936. sign of pregnancy, 212. Breasts, absence of, 1034. anatomy of, 393. Breasts, areola of, 191. caked, 1036. care of, during nursing, 398. in pregnancy, 230. changes in, during pregnancy, 191. drying up secretion of, 398, 1037. engorgement of, 1036. hypertrophy of, 1034. inflammation of, 1037. supernumerary, 1034. Breech presentations, 236, 318. asphyxia in, 323. blunt hook in, 482. bringing down foot in frank, 324. causation of, 320. complicated by contracted pelves, 867. diagnosis of, 318. etiology of, 320. extraction of, 470, 477. fillet in, 482. forceps in, 467, 481. frequency of, 318. in hydrocephalus, 906. liberation of arms in, 474. mechanism of, 321. prognosis in, 322, 482. prolapse of cord in, 965. treatment of, during labor, 323. during pregnancy, 323. Bright’s disease. (See Nephritis.) Brim of pelvis. (See Pelvis.) Broad ligament, 47. hematoma of, 1027. pregnancy, 736, 738. Bronchopneumonia in puerperal infection, 990. Brow presentations, 236, 315. causation of, 315. configuration of head in, 316. diagnosis of, 315 frequency of, 315. mechanism of, 316. prognosis in, 317. treatment of, 317. Bruit, uterine, 208. Bryce and Teacher’s ovum, 118. Budin’s pelvimeter, 784. Bulb, vestibular, 30. Bylicki’s pelvimeter, 791. Byrd’s method of resuscitation, 970. Calcification of foetus, 708, 739. of placenta, 682. Callus formation, effect upon pelvis, 898 Canal, cervical, 41, 266. of Nuck, 28. Canalized fibrin, 143. Cancer. (See Carcinoma.) Capillary circulation in eclampsia, 920. Capsular membrane, 727, 732. Caput succedaneum, 244, 304, 853. Carbamic acid, relation to eclampsia, 615. Carbolic-acid poisoning from intra-uterine douche, 1011. Carbon dioxid, increase of, in blood, cause of labor, 249. Carcinoma of cervix, cesarean section for, 497. 1050 INDEX Carcinoma complicating pregnancy, 638. of rectum, cause of dystocia, 778. Carcinoma syncytiale, 662. Cardiac lesions in pregnancy, 554. Care, prenatal, 227. Carneous moles, 707. Carunculae myrtiformes, 376. Caruncles of amnion, 132, 672. of placenta, 672. Catheterization during puerperium, 383. Caul, 275. Causation of labor, 248. Cell layer of chorion, 132. Cell mass, internal, 106. Cell nodes, 141. Cellulitis in puerperal infection, 989, 1013. Celom, 121. Central placenta previa, 928. tear of perineum, 367. Centrosome, 105. Cephalalgia, during pregnancy, 593. in threatened eclampsia, 593. Cephalic version, 483. indications for, 483. methods of, 484. Cephalometer, 863. Cephalotribe, 531. Cervical endometritis, 638. Cervical ganglion, 52, 249. Cervicovesical fistula, 854, 963. Cervix, 40. acute edema of, 649. anatomy of, 40. annular detachment of, 953. apparent shortening of, in pregnancy, 264. arbor vitae uterina, 41. atresia of, 768. carcinoma of, 638. changes in, during labor, 266. during pregnancy, 266. during puerperium, 375. circular detachment of, 953. condition of, in latter part of pregnancy, 266. dilatation of, during labor, 258, 273, 853. manual, 431. with balloon, 433. with Bossi’s dilator, 433. with forceps, 444. diseases of, during pregnancy, 638. ectropion of, 42. external os, 40. ganglion of, 52. glands of, 41. hypertrophy of supravaginal portion dur- ing pregnancy, 648. incision of, 443. infravaginal portion of, 40. in normal labor, 258, 273. internal os, 41. lesions of, during labor, 952. mucosa of, 41. myoma of, 773. rigidity of, 755, 769. stenosis of, 768. stricture of, 768. supravaginal portion, 40. tears of, 952. Cervix, vaginal portion, 40. Cesarean section, 493. cervical, 495. choice of operation, 509. cicatrix following, 515. conservative, 494, 499, 865. contra-indications for, 498. extraperitoneal, 506. following vaginofixation, 772. ventrofixation, 770. for carcinoma of cervix, 497. of rectum, 778. for contracted pelves, 496, 865. for myoma of uterus, 497, 774. for old extra-uterine pregnancy, 743. for ovarian tumor, 497, 776. for placenta previa, 936. history of, 493. hysterectomy after, 504. in brow presentation, 318. indications for, 495. in eclampsia, 497, 627. instead of induction of premature labor, 869. in transverse presentations, 534, 916. Porro’s operation, 494, 504. post-mortem, 516. prognosis of, 511. repeated, 514. rupture of uterus after, 514. sterilizing patients after, 510. suprasymphyseal, 495. technic of, 499. vaginal, 434. Chadwick’s sign of pregnancy, 216. Chamberlen forceps, 441. Champetier de Ribes’ balloon, 430, 433. Child. (See New-born Child.) Chill, during puerperium, 376. following normal labor, 376. Chloroform in labor, 359. Chloroform poisoning, in puerperium, 1031. Cholera complicating pregnancy, 546. Cholesterin, increase in, 193. Chondrodystrophia foetalis, 826, 907. Chondrodystrophic dwarf pelvis, 826. Chorea, 426. during pregnancy, 567. Chorio-angioma of placenta, 681. Chorio-epithelioma, 662. Chorion, 111. abortion, from disease of, 702. angioma of, 681. canalized fibrin of, 143, 679. cell layer of, 132. cystic degeneration of, 656. decidual islands of, 130. diffuse myxoma of, 667. diseases of, 656. epithelioma of, 662. epithelium of, 129, 132. fastening villi of, 130. formation of, in chicken, 111. in man, 114. frondosum, 130, 142. giant cells of, 129, 140. laeve, 130, 142. Langhans’ layer of, 128, 132. INDEX 1051 Chorion, membrane of, 128. myxoma fibrosum of, 667. myxoma of, 656. Plasmodium of, 132. stroma of, 128, 132. structure of, 128. syncytium of, 132. trophoblast of, 114. villi of, 130. Zellschicht of, 132. Chorionic villi. (See Villi, Chorionic.) epithelioma, 662. Chromosomes, number of, 102. reduction of, 100. sex, 177. Chronic infectious diseases in pregnancy, 549. Cilia of ovaries, 69. of tubes, 58. of uterus, 43. Circular sinus of placenta, 147. detachment of cervix, 953. Circulation in foetus, 167. in new-born child, 388. Circumcision, girl, 29. Circumvallate placenta, 677. Cleidotomy, 535, 902. Clitoridectomy, 29. Clitoris, 29. amputation of, 29. anatomy of, 29. Cloasma, 197. Closing plate of decidua, 143. Clothing during pregnancy, 229. Club-foot, effect upon pelvis, 897. Cocain anesthesia in labor, 364. Coccygeus muscle, 278. Coccyx, 2. Coffee ground vomit, 583. Coffin birth, 975. Cohn’s method of inducing labor, 430. Coiling of cord, 149, 357, 684. Coitus during pregnancy, 229. Collapse during labor, 972. Collargol in puerperal infection, 1015. Colies’ law, 551, 686. Collision of twins, 413. Colostrum, 191, 394. Colpaporrhexis, 951. Colpeurynter in induction of premature labor, 430. Colpohyperplasia cystica, 637. Columns of vagina, 36. Coma in puerperium, 630. Combined pregnancy, 742. examination, 245. Compound presentation, 917. Concealed accidental hemorrhage, 922, 940. Concealed hemorrhage, 922. Conception, date of, 96, 222. during amenorrhea, 215, 224. Conduct of normal labor, 341. Conduplicatio corporis, 912. Configuration of head, 855. Confinement, estimation of date of, 223. Congenital cystic kidneys, 907. ectropion, 42. Conglomerate glandular body, 81. Conglutinatio orificii externi, 768. Conjugate. (See Pelvis.) Conservative cesarean section, 499. Constipation during pregnancy, 229, 559. during puerperium, 383. Constrictor vaginae, 280. Contracted pelvis, cesarean section in, 496, 860. cause of difficult labor, 780. classification of, 798. congenital, 803, 826. course of labor in, 847. craniotomy in, 861. diagnosis of, 783. due to abnormal malleability of bones, 801. to bilateral lameness, 893. to diseases of the vertebral column, 874. to generalized and symmetrical anom- alies in development, 823. to localized and asymmetrical anoma- lies in development, 829. to localized and symmetrical anoma- lies in development, 833. to tumors, etc., 898. to unilateral lameness, 892. effect of, upon course of pregnancy, 847. frequency of, 780. history of, 1, 780. in new-born child, 808, 826. induction of abortion in, 421. of premature labor for, 424, 868. mechanism of labor in, 848. pelvimetry in, 784. position of uterus in, 847. prognosis of labor in, 857. size of foetus in, 848. treatment of labor complicated by, 860. X-rays in diagnosis of, 794. Contraction, center for uterine, 252. hour-glass, of uterus, 763. of Bandl’s ring, 762. painless, 254. ring, 243, 269. cause of dystocia, 762. in dystocia, due to contracted pelves, 854. in threatened rupture of uterus, 854, 956. uterine, 250, 254, 271. Conversion in brow presentations, 317. in face presentations, 314. Convulsions. (See Eclampsia.) Cord. (See Umbilical Cord.) Cornu of uterus, 38, 641. Corona radiata, 74. Coronal suture, 164. Corpulence simulating pregnancy, 219. Corpus albicans, 78. fibrosum, 78. luteum, 75. cystic, 80. cysts in chorio-epithelioma, 665. cysts in hydatidiform mole, 659. evidence of pregnancy, 81. false, 80. internal secretion of, 80. of menstruation, 80, 91. of pregnancy, 80. structure of, 75. * true, 80. 1052 INDEX Corpus uteri, 42. Corrosive sublimate. (See Bichloride of Mercury.) Cortex of ovary, 63. Cotyledons of placenta, 147. Coxarthrolisthetic pelvis, 896. Coxitis, 892. Cranioclast, 530. Craniopagus, 903. Craniotomy, 527. for old extra-uterine pregnancy, 743. in collision of twins, 413. in contracted pelves, 861, 870. in face presentations, chin posterior, 315. in hydrocephalus, 906. in rupture of uterus, 961. indications for, 527. Cranium. (See Head, Foetal.) Cravings in pregnancy, 217. Crede’s method of expressing placenta, 336. ointment, 1015. Cretin dwarf pelvis, 827. Criminal abortion, 420, 701. Crotchet, 482. Culbute, 238. Culdesac, incision in puerperal infection, 1013. of Douglas, 35. Cumulus oophorus, 71. Curettage, 539. in abortion, 712. indications for, 540. in puerperal infection, 1010. Cycle, menstrual, 87. Cystic degeneration of chorion, 656. Cystitis, during pregnancy, 565. during puerperium, 383, 1024. Cystocele, complicating l£,bor, 777. Cyst, lutein, 659, 665. of umbilical cord, 686. of vaginal walls obstructing labor, 767. ovarian, 775. Cytolysis, 612. Dammerschlaf, 362. Date of confinement, estimation of, 223. Death of fcetus during pregnancy, 221. of mother during labor, 972. during pregnancy, 687. Decapitation, 533. in locked twins, 414. in transverse presentations, 533, 916. Decapsulation of kidneys, 628. Decidua, 132. bacteria in, 653. basal plate of, 143. basalis, 132, 138. capsularis, 132, 138. cells of, 134. cervical, 132. changes in, cause of labor, 249. in abortion, 704. closing plate of, 143. compact layer of, 134. development of, outside of uterus, 138 diffuse formation of, 138. thickening of, 651. diseases of, 650. ectopic, 138. Decidua, fatty degeneration of, 249. giant cells of, 139. glandular hyperplasia of, 651 layer of, 134. gonococci in, 653. hematoma mole of, 707. hyperplasia of, 651. in bicornuate uterus, 641. in extra-uterine pregnancy, 728, 732. in non-pregnant tube in intra-uterine pregnancy, 189. in ovaries, 138. in peritoneum, 138. inflammation of, 653. islands of, 130, 143. menstrual, 88. origin of, 136. polyposa, 651. pseudo-capsularis, 727, 730. reflexa, 132. reparation of, in puerperium, 374. serotina, 132. spongy layer of, 134. syphilis of, 693. tuberous subchorial hematoma of, 707. vera, 132, 134. Decidual cast in extra-uterine pregnancy, 732. cells, 134. endometritis. (See Endometritis.) islands, 130, 143. reaction in tubes, 189, 729. sarcoma, 662. septa, 143, 145. Deciduoma malignum, 663. in extra-uterine pregnancy, 740. Deformed pelves. (See Contracted Pelves.) Delivery, normal, 341. post-mortem, 975. Dental caries during pregnancy, 560. Deportation of chorionic villi, 143. in eclampsia, 608. Dermatitis herpetiformis, 569. Dermoid cysts of ovary, 775. Descent of foetus, causes of, 277. (See Me- chanism of Labor.) Deutoplasm, 75. Development of allantois, 125. of amnion, 110, 114. of chorion, 110, 114. of clitoris, 29. of cord, 151, 684. of foetus, 157. of hymen, 31. of ovaries, 66. of ovum, 105. of pelvis, 17. of placenta, 127. of tubes, 54. of uterus, 53. of vagina, 37. of vulva, 31. Diabetes during pregnancy, 561. during puerperium, 380. phloridzin, 174. Diagnosis, differential, of pregnancy. (See Pregnancy.) of life or death of foetus, 221. INDEX 1053 Diagnosis of presentation of foetus, 241. of sex during pregnancy, 207. Diameters of head, 165. of pelvis, 4. Diastasis of recti muscles in pregnancy, 650. in puerperium, 376. Dicephalus, 903. Dickinson’s sign of pregnancy, 211. Dietary alterations in eclampsia, 619. Diet during pregnancy, 228. during puerperium, 382. Differential diagnosis of pregnancy, 218. Dilatation of cervix, artificial, 422, 431. in normal labor, 273. Dilatation, acute, of stomach, 974. Dipagus, 903. Diphtheria, during puerperium, 1043. puerperal, 980, 984. Diprosopus, 903. Directions for obstetrical nurse, 342. for patients during pregnancy, 231. Disappearance of pregnancy, 714. Discus proligerus, 71. Diseases complicating pregnancy, 545. complicating puerperium, 1022. Disinfection of hands, 346. of vulva, 349. Displacements. (See Uterus.) Distinction between first and subsequent pregnancies, 220. Diverticula from tubes, 60, 721. from uterine cavity, 642. Dolichocephalic head, cause of face presen- tation, 309. Dolichokyrtoplatyspondylus, 887. Dolores praesagientes, 256. Double Naegele pelvis, 833. uterus, 639. Douche, intra-uterine, 538. prophylactic, 536. vaginal, 536. Douglas’ culdesac, 35. perforation of, 962. Douglas’ mechanism, 913. Dropsy of amnion. (See Hydramnios.) of foetus, 694, 906. of ovum, 706. Dry labor, 258, 756. Drying up breasts, 399, 1037. Duchenne’s paralysis, 1033. Duct3, Gartner’s, 48. lactiferous, 393. Mullerian, 54. para-urethral, 30. Skene’s, 30. Wolffian, 30, 48, 63, 66, 69. Ductus arteriosus, 168. venosus, 168. Duhrssen’s cervical incisions, 443. Duncan’s mechanism in extrusion of pla- centa, 331. Duration of labor, 262. pregnancy, 221. Duverney’s glands, 30. Dwarf, 826. pelvis, 826. Dyspnea during pregnancy, 557. Dystocia due to abnormalities of cervix, 768. to abnormalities of the expulsive forces, 754. to abnormalities of fcetus, 900. to abnormalities of vagina, 766. to abnormalities of vulva, 766. to contracted pelves, 847. to contraction of Bandl’s ring, 762. to levator ani muscle, 762, 768. to old extra-uterine pregnancy, 743. to size of child, 900. to tumors of birth canal, 772, 774. to uterine displacements, 769. following vaginofixation, 770. following ventrofixation, 770. Dysuria from incarcerated pregnant uterus, 645. Ear presentation, 851. Echinococcus cysts complicating labor, 777. Eclampsia, 597. albuminuria in, 602. bacterial origin of, 610. bleeding in, 623. blindness accompanying, 602. cesarean section in, 497. clinical history of, 598. diagnosis of, 620. etiology of, 609. frequency of, 597. hemoglobinuria in, 602. hydatidiform mole in, 598. immunity to, 622. in extra-uterine pregnancy, 598. in new-born child, 581. mania following, 602, 1040. metabolism in, 615. pathology of, 605. prognosis of, 620. recurrence of, 622. treatment of, 622. urine in, 602. without convulsions, 600. Ectoderm, 111. Ectopic pregnancy. (See Extra-uterine Pregnancy.) Ectropion, congenital, 42. Edema of cervix, acute, 649. of fcetus, 694. in pregnancy, 557. Egg nests, 66. Elastic ligatures in cesarean section, 501. Elderly primiparae, 262. Electricity in extra-uterine pregnancy, 742. Elephantiasis congenita cystica, 907. Embolism, air, 974. during pregnancy, 557. pulmonary, during labor, 973. Embryo, 157. anatomy of, 157. development of, 108. nourishment of, 169. Embryonic area, 107. shield, 108. Embryotomy, 533. Emesis in pregnancy, 216, 578. Emphysema complicating pregnancy, 557. foetal, causing dystocia, 908. 1054 INDEX Emphysema of abdominal walls following rupture of uterus, 960. Encephalocele, 672. Enchondroma of pelvis, 898. Endarteritis, compensatory, during puer- perium, 375. Endocarditis during pregnancy, 556. gonorrheal, 548. Endocervicitis, 638. Endocrine disturbances in eclampsia, 617. Endometritis, acute decidual, 653. atrophic decidual, 652. cause of abortion, 704. cause of placenta previa, 929. cause of premature separation of pla- centa, 921. cervical, 638. decidua cystica, 652. glandularis, 651. diphtheritic, 986. in pregnancy, 650. post-abortum, 1026. postpartum, 1026. puerperal, 984. putrid, 987. septic, 988. Endometrium, 43. in old age, 45. in young child, 45. lymphoid nodules of, 45. menstrual cycle, 44, 87. regeneration of, after curettage, 43. during puerperium, 374. reticulum of, 46. structure of, 43. Engagement. (See Mechanism of Labor.) extra-median, 852. Enterocele, complicating labor, 777. complicating pregnancy, 648. Enteroptosis during pregnancy, 560. Entoderm, 111. Entrance of air into uterine sinuses, 974. Entypie, 115. Epilepsy during pregnancy, 567. during puerperium, 567. Epiphyses in syphilis, 689. separation of, during extraction, 483. Episiotomy, 357. Epoophoron, 48. Erb’s paralysis, 1033. Ergot in postpartum hemorrhage, 942. use of, in labor, 365, 759. Erysipelas in pregnancy, 548. relation of, to puerperal infection, 993. transmission to foetus, 548. Esbach’s albuminometer, 595. Escutcheon, 26. Estimation of date of confinement, 223. Ether, 359. Eustachian valve, 168. Evisceration, 533. Evolution, spontaneous, 912. Examination, combined, 245. final, 384. preliminary, during pregnancy, 232, 326. rectal, 344. vaginal, during labor, 348. pregnancy, 243. Exanthemata in pregnancy, 545. Exercise during pregnancy, 229. Exostosis, producing pelvic deformities, 898. Expression of placenta, 336. Expression, Ritgen’s method of, 356. Expulsion. (See Mechanism of Labor.) Extension. (See Mechanism of Labor.) External generative organs, 26. External os, 39, 40. External rotation. (See Mechanism of Labor.) External version, 323, 484. Extraction, 471. in breech presentations, 471. indications for, 471. in frank breech presentations, 477. Mauriceau’s maneuver for, 475. Prag maneuver for, 477. Extra-uterine pregnancy, 719. abdominal, 738. abortion of, 732. anatomy of, 727. associated with intra-uterine, 742. attachment of ovum in, 727. broad ligament, 737. cause of dystocia, 741. chorio-epithelioma in, 740. decidual reaction in, 723, 732. diagnosis of, 741. eclampsia in, 740. effects upon subsequent childbearing, 743. etiology of, 719. fate of foetus in, 736, 739. frequency of, 719. hematoma mole in, 734, 740. hematocele in, 734, 741. hydatidiform mole in, 740. hydramnios in, 740. interstitial, 726. lithopedion formation in, 739. migration of ovum in, 722. multiple, 742. mummification in, 739. ovarian, 724. placenta in, 731. repeated, 742. rupture of, 735, 741. symptoms of, 740. terminations of, 732, 738. treatment of, 745. tubal, 726. Eyes of child, 391. Face presentations, 236, 307. abnormal mechanism in, 310. causation of, 308. complicated by contracted pelves, 867. craniotomy in, 315. diagnosis of, 307. frequency of, 307. mechanism of, 309. prognosis of, 312. prolapse of cord in, 965. treatment of, 313. Facial paralysis following forceps, 469. Fallopian tubes, 56. accessory, 59. lumina of, 59. INDEX 1055 Fallopian tubes, accessory, ostium of, 59 anatomy of, 56. changes in, during pregnancy, 189. ciliary current in, 59. decidua in, 189, 729. diverticula of, 60, 721. glands of, 59. False labor, 742. False promontory, 808. Fascia, pelvic, 280. perineal, 280. Fastening villi, 141. Fat in abdominal walls simulating preg- nancy, 220. Fatty degeneration of placenta, 677. Feces of infant, 392. Fecundation, 96. Feeding, artificial, 400. Female pronucleus, 101. Ferments in eclampsia, 617. Fertilization of ovum, 96, 103. Fever in eclampsia, 600. in labor, 756, 854, 1004. in puerperium, 376. Fibrin, canalized, 143. Fibromyomata of uterus, complicating labor, 772. Fiddle bag, Barnes’, 430. Fillet, 482. Fimbria ovarica, 57. Fimbriated extremity of tube, 56. Fissure of nipple, 398. Fistulae, production of, 854, 963. Flat, non-rhachitic pelvis, 801. rhachitic pelvis, 808. Fleshy mole, 706. Flexion. (See Mechanism of Labor.) Floating kidney during pregnancy, 564. spleen, 565. Foetal circulation, 167. diseases, 686. dropsy, 694. dystocia, 900. heart-beat, 207. leukemia, 568. membranes, 147. monstrosities, 902. peritonitis, 907. syphilis, 686. Foetus, abnormalities of, obstructing labor, 900. active movements of, 208. aneurysm of, 907. ascites of, 906. at full term, 161. attitude of, 234. bladder, distention of, 908. calcification of, 708, 739. centers of ossification, 161. circulation of, 167. compressus, 409. cranium of, 164. cystic kidneys of, 907. death of, 221. deformities of, 903. due to amniotic adhesions, 672. due to oligo-hydramnios, 672. development of, 157. Foetus, diameters of head of, 164. diet, effect upon size of, 228. digestive functions of, 176. diseases of, 686. dissolution of, 707. distention of bladder of, 907. dropsy of, 694, 906. edema of, 694. emphysema of, 908. enlargement of abdomen of, 907. estimation of age of, 160. excessively large, 162, 900. extraction of, 740. general dropsy of, 694, 906. habitual death of, 427. habitus of, 234. head of, 164, 304. headless, 903. heart-beat of, 207. heart sounds of, in asphyxia, 968. in pregnancy, 207. hydrocephalus of, 904. infection of, with Bacillus aerogenes capsulatus, 908. in fwlu, 908. lanugo of, 161. length of, 160. lesions of, in eclampsia, 581. maceration of, 707. malformations of, 902. meconium of, 392. metabolism of, 169. monstrosities, 903. movements of, in pregnancy, 208. mummification of, 707, 739. negro, 161. nutrition of, 167. over-development of, 162, 900. papyraceus, 409. passive movements of, 208. peritonitis of, 907. physiology of, 166. position of, 236. presentation of, 234, 847. pressure marks on head of, 856. respiration of, 176. sanguinolentus, 687. sex of, 176. signs of maturity of, 161. size of, in contracted pelves, 848. size of, in various months, 157, 160. syphilis of, 686. tuberculosis of, 549. tumor of testicle of, 907. of liver of, 907. of body of, 907. urine of, 174, 389. vernix caseosa of, 161 warmth of, 176. weight of, 160. Follicle, Graafian. (See Graafian Follicle.) Follicular atresia, 79, 188. epithelium, 69. Fontanels, 164. Footling presentation, 236. Foramen ovale, 168. Forceps, 439. application of, 448. 1056 INDEX Forceps axis traction, 463. cephalic application of, 450. Chamberlen’s, 441. choice of, 444. conditions necessary for application of, 446. contrasted with version, 868. delivery in oblique occipitoposterior posi- tion, 459. with head at vulva, 452. with high, 463. with mid, 455. with occiput in hollow of sacrum, 455. description of, 439. facial paralysis following, 469. functions of, 444. high, 448, 463. history of, 440. in breech presentations, 467. in brow presentations, 318. in collision of twins, 414. in contracted pelves, 867. in eclampsia, 624. in face presentations, 315, 466. in frank breech presentations, 467, 481. in heart disease, 445, 556. in occipitoposterior presentations, 459. in prolapse of cord, 966. in protracted second stage of labor, 759. in rupture of uterus, 961. in vertex presentations, 452. indications for, 441. Kielland’s, 462. Levret’s, 443. long, 443. low, 448, 452. mid, 448, 455. Osiander’s maneuver, 464. ovum, 422. Pajot’s maneuver, 464. Palfyn’s, 442. paralysis after, 469. perineal tears due to, 468. preparations for operation, 447. prognosis of, 467. prophylactic, 445. Saxtorph’s maneuver, 464. Scanzoni’s maneuver, 461. short, 443. Simpson’s, 439. Smellie’s, 439. Tarnier’s, 464. to aftercoming head, 467, 481. upon floating head, 463. Forces concerned in labor, 276. Formalin injections in puerperal infection, 1015. Fornix, vaginal, 35. rupture of, during labor, 951, 962. Fossa navicularis, 30. ovarica, 61. Fourchette, 28. Fractures of pelvis, 898. of skull. (See Skull.) Freezing point of blood, 170. Frenulum clitoridis, 28. Frontal suture, 164. Fundal incision in cesarean section, 502. Fundus uteri, 38. Funic souffle, 208. Funis. (See Umbilical Cord.) Funnel-shaped pelvis, 838. Galactocele, 1040. Galactogogues, 396. Galactorrhea, 1035. Gall stones in pregnancy, 559. Ganglion, cervical, 52. Gangrene of lower extremities during puer- perium, 1024. of puerperal uterus, 988. Gartner, ducts of, 48. Gas anaesthesia, 361. Gas bacillus. (See Bacillus Aerogenes Capsulatus.) Gasserian fontanel, 165. General metabolism in pregnancy, 198. Generally contracted, flat, rhachitic pelvis, 810. contracted pelvis, 823, 852. enlarged pelvis, 823. equally contracted rhachitic pelvis,811. Germ layers, 106. inversion of, 115. Germinal epithelium, 66. spot, 70. vesicle, 70. Giant cells of decidua, 139. of placenta in lungs, 608. placental, 143. Gingivitis in pregnancy, 560. organ of, 48. Glands, Bartholin’s, 30. cervical, 41. decidual, 135. Duverney’s, 30. interstitial, of ovary, 64. mammary, 191. Montgomery’s, 191. pituitary, 196. puberty, 64. salivary, changes of, in pregnancy, 560. thyroid, cause of face presentation, 308. changes of, in eclampsia, 618. in pregnancy, 195. foetal, cause of dystocia, 909. tubal, 58. uterine, 44. vaginal, 36. vestibular, 30. vulval, 30. Globulin, increase of, in eclampsia, 603, 617. Gloves, rubber, use of, 347. Glycerin, use of, in inducing labor, 430. Glycogen in decidua, 167. Glycosuria during pregnancy, 561. during puerperium, 380. Goiter in pregnancy, 567. Gonococcus in Bartholin’s glands, 637. in endometritis decidua, 653. in mammary abscess, 1038. in ophthalmia neonatorum, 391. in puerperal infection, 979, 998. Gonorrhea in pregnancy, 548. i in puerperium, 979. INDEX Gonorrheal endometritis, 998. ophthalmia, 391. Goodell’s cervical dilator, 422. Graafian follicle. (See Ovary.) atresia of, 79, 188. degeneration of, 79. rupture of, 75. Gravitation theory as to production of presentation, 238. Greater fontanel, 165. Guerin’s line, 688. Gumma of placenta, 692. Gut, primitive, 111. Gynecomastia, 1034. Habitual death of foetus, 427. Habitus of foetus, 234. Hair of pubis, 26. Halisteresis, 816. Hand disinfection, 346. Harris’ method for the dilatation of the cervix, 431. Head, foetal, changes in shape of, in brow presentations, 317. in face presentations, 312. in vertex presentations, 304. circumferences of, 166. diameters of, 165. estimation of size of, 861. fontanels of, 165. of new-born child, 164. scalp tumor on. (See Caput Succeda- neum.) sutures of, 164. Headache in pregnancy, 593. Head folds, 109. lever in face presentations, 309. in vertex presentations, 292. Heart, diseases of, in pregnancy, 426, 554. in pregnancy, 192. foetal, 207. means of diagnosing sex, 207. palpation of, 208. hypertrophy of, in pregnancy, 192. Hebostotomy, 518. Hebotomy, 518. Hegar’s sign of pregnancy, 211. Heine and Hofbauer’s ovum, 113. Hematokolpos, 42. Hematocele, diffuse, 741. pelvic, 734, 741. solitary, 741. Hematoma, of abdominal walls, 570. of broad ligament, 737. of decidua, 707. of liver, in eclampsia, 607. of placenta, 678. of sternocleidomastoid muscles, 483. of umbilical cord, 686. of vagina, 1026. of vulva, 1026. mole, 740. puerperal, 1026. subperitoneal, 958. Hematosalpinx, 734. Hematuria during pregnancy, 563. Hemianopsia following eclampsia, 602. Hemicephalus, 904. 1057 Hemoglobinuria in eclampsia, 602. Hemolysis in eclampsia, 611. Hemorrhage, accidental, 920. antepartum, 920. concealed, 922, 940. curettage in, 711, 1026, 1029. due to atony of uterus, 939. to inversion of uterus, 944. to paralysis of the placental site, 939. to placenta previa, 927. to premature separation of normal'y implanted placenta, 920. to retention of placenta, 939. to rupture of umbilical cord, 939. during normal labor, 335. puerperium, 1025. ergot in, 942. from velamentous insertion of cord, 684. in abortion, 709. in cholera, 547. in multiple pregnancy, 413. intraperitoneal, 736, 741, 959. intra-uterine douche in, 538, 943. pack in, 943. manual removal of placenta for, 942. pituitrin in, 942. postpartum, 938. puerperal, 1025. transfusion in, 944. unavoidable, 932. use of salt solution in, 944. Hemorrhagic hepatitis, 606. Hepatization of placenta, 677. Hepatotoxemia, 610. Heredity, explanation of, 104. Hermann’s forceps, 464. Hermaphroditism, 30. Hernia, abdominal, 650. congenital, of foetus, 672. inguinal, 649. of pregnant uterus, 649. umbilical, 649. vaginal, 777. Herpes gestationis, 569. Hicks’s sign of pregnancy, 212. High forceps, dangers of, 463, 866. Hilum of ovary, 61. Hirst’s pelvimeter, 792. Hodge’s inclined plane of pelvis, 3. parallel planes, 8. Holme’s packer, 542. Hook, blunt, 534. Hour-glass contraction of uterus, 763. Hubert’s forceps, 464. Hunger blockage, 229. Hyalin in ovary, 75. Hydatidiform mole, 656. destructive, 661. in eclampsia, 598. in extra-uterine pregnancy, 740. malignant, 661. ovaries in, 659. pathology of, 657. relation of, to deciduoma malignum, 658. treatment of, 662. Hydramnios, 667. eclampsia in, 598. in single-ovum twins, 407, 669. 1058 INDEX Hydramnios, in extra-uterine pregnancy, 740. treatment of, 671. Hydremia of pregnancy, 192. Hydrocephalus, 904. Hydrorrhea gravidarum, 651. Hydrosalpinx, 58. Hygiene of pregnancy. (See Pregnancy, Management of.) Hymen, 31. absence of injury at childbearing, 33 atresia of, 42, 767. carunculae myrtiformes, 33. development of, 31. imperforate, 31, 42. cause of difficult labor, 767. injuries at coitus, 32. injuries following childbearing, 33. operations upon, 32. structure of, 31. Hyperemesis gravidarum, 420, 578. Hyperplasia of chorionic villi, 667, 681. Hypertrophic elongation of cervix during pregnancy, 648. Hypertrophy of uterus during pregnancy, 183. Hypnotism in labor, 365. Hypophysis cerebri, 196, 618. Hypoplastic dwarf pelvis, 828. Hysterectomy during pregnancy, 773. for chorio-epithelioma, 667. for myomata, 773. for puerperal infection, 1023. supravaginal, after cesarean section, 504. total, after cesarean section, 504. Hysteria, cause of nausea of pregnancy, 582. in pregnancy, 566. Hysterotomy, abdominal, 423, 504. vaginal, 423, 434. Ice, use of, in hemorrhage, 943. Icterus of child, 393. during pregnancy, 559. gravis, 587. Identical twins, 404. Ileus due to retroflexed pregnant uterus, 645. Iliopectineal line. (See Linea terminalis.) Ilium, 3. Imaginary pregnancy, 219. Impetigo herpetiformis, 569. Implantation of ovum, 111. Impregnation, 95, 103. Incarceration of prolapsed pregnant uterus, 647. of retroflexed pregnant uterus, 645. Incisions of cervix, deep, 443. Inclination of pelvis, 8. Indigestion during pregnancy, 559. Induction of abortion. (See Abortion, In- duction of.) of premature labor. (See Premature Labor, Induction of.) Inertia uteri, 755. Infant. (See New-born Child.) Infantile paralysis, effect upon pelvis, 895. pelvis, 17, 826. Infarcts of placenta, 677. Infectious diseases complicating pregnancy, 545. Inferior strait, 5. contractions of, 793. Infibulation, 28. Influenza during pregnancy, 547. Infundibulopelvic ligament, 47, 61. Infundibulum, 56. Injuries to birth canal, 950. Inlet, pelvic, 5. Innervation of uterus, 52. Innominate bone, 21. Insanity, 1040. Insertio velamentosa, 683. Insufflation of lungs in asphyxia neonato- rum, 971. Interglandular tissue of uterus, 45. Intermittent contraction of uterus, 212. Internal cell mass, 107. Internal os, 39. Internal rotation. (See Mechanism of Labor.) Internal secretion of ovaries, 65, 80. Internal version, 485. Interstitial gland of ovary, 63. Interstitial pregnancy, 726. Intervillous blood spaces, 141. Intestinal obstruction, 572. Intrapartum eclampsia, 600. infection, 854, 1004. Intratubal rupture, 732. Intra-uterine douche, 538. indications for, 538. in postpartum hemorrhage, 943. in puerperal infection, 1010. pack, 542. pressure, 276. Inversion of germ layers, 107. of uterus, 944. Inverted yolk sac, 115. Involution of uterus, 373. Ischiocavernosus, 280. Ischiopagus, 903. Ischiorectal fossa, 280. Ischium, 3. spines of, 3. Isoagglutination, 611. Isthmic pregnancy, 726. Isthmus of tube, 56. Isthmus uteri, 39. Jaundice of child, 393. of mother, 559, 589, 602. Joints, motility of, during pregnancy, 11. pelvic, 11. pubic, 11. relaxation of, during pregnancy, 570. rupture of, during labor, 854. sacro-iliac, 11. Justo-major pelvis, 823. Justo-ininor pelvis, 823. Kerr, impression of head, 862. Kidney, changes in, during pregnancy, 194. in eclampsia, 605. cystic, of foetus, 907. dislocation of, during pregnancy, 564. dislocated, complicating labor, 777. INDEX Kidney, floating, during pregnancy, 564. of pregnancy, 194, 605. removal of, 564. tumor of, complicating labor, 564. Klien’s pelvimeter, 797. Knee presentation, 236. Knots of umbilical cord, 149, 685. Krause’s method of inducing labor, 429. Kyp ho rhachitic pelvis, 881. Kyphoscoliorhachitic pelvis, 884. Kyphoscoliotic pelvis, 883. Kyphosis, 874. Kyphotic pelvis, 874. Labium majus, 27. commissures of, 27. development of, 28. edema of, 557. hernia into, 28. Labium minus, 28. fossa navicularis, 30. fourchette, 28. frenulum clitoridis, 28. laborium, 28. infibulation, 28. nymphae, 28. preputium clitoris, 28. Labor, abdominal contractions during, 277. action of expellent forces in, 272, 276. acute dilatation of stomach in, 974. albuminuria in, 379. anesthesia during, 359. arterial pressure in, 192, 256. asepsis in, 346. bed, preparation of, for, 351. caput succedaneum, 304. cause of onset of, 248. changes in arterial tension during, 256. in perineum during, 280. in pulse during, 256. in rectum during, 282. in respiration during, 201, 256, 259. in shape of head in, 304. in temperature during, 256, 376, 756, 854. in uterus during first stage of, 271. in uterus during second stage of, 274. in vagina and pelvic floor during, 278. chill after, 376. clinical course of, 248, 256. collapse after, 972. complicated by bony tumors of pelvis, 898. by compound presentation of foetus, 917. by concealed hemorrhage, 922, 940. by coxalgic pelvis, 892. by deformities of foetus, 903. by eclampsia, 597. by enlargement of abdomen of foetus, 906. by excessive size of child, 900. by foetal monstrosities, 902. by flat pelvis, 801. by flat rhachitic pelvis, 807. by funnel pelvis, 838. by generally contracted pelvis, 823. by generally contracted, flat rhachitic pelvis, 810. by generally enlarged pelvis, 823. Labor, complicated by heart lesions, 554. by hydrocephalus, 904. by injuries to cervix, 952. by injuries to vagina, 950. by intra-uterine asphyxia, 967. by inversion of uterus, 944. by kyphotic pelvis, 879. by myoma of uterus, 772. by Naegele pelvis, 830. by osteomalacic pelves, 816. by ovarian tumor, 776. by paraplegia, 253, 565. by pelvis spinosa, 810. by placenta previa, 927. by postpartum -hemorrhage, 938. by premature separation of placenta, 920. by prolapse of placenta, 925. by prolapse of umbilical cord, 855, 965. by rhachitic pelvis, 848. by Robert pelvis, 833. by rupture of the uterus, 515, 761, 854, 955. by split pelvis, 818. by spondylolisthetic pelvis, 884. by transverse presentation of foetus, 909. by tumors of foetus, 907. by tumors of pelvis, 898. conduct of, 341. first stage of, 345. second stage of, 351, 353. third stage of, 336. contraction of uterine ligaments during, 48, 255. course of, in contracted pelves, 853. death during, 972. delivery of shoulders, 357. dilatation of cervix, 273. dry, 258, 756. duration of, 262. entrance of air into uterine sinuses during, 974. episiotomy in, 357. ergot during, 365, 759. examination in, 348. false, 742. first stage of, 257, 345. force exerted during, 253. forces concerned in, 266, 276. formation of contraction ring during, 267, 956. of lower uterine segment, 267. hand disinfection in, 446. hemorrhage during, 335. hypnotism in, 365. in elderly primiparae, 262. in young primiparae, 262. intra-uterine pressure during, 276. laceration of perineum during, 354, 369. mechanism of, in breech presentations, 321. in brow presentations, 316. in face presentations, 309. in vertex presentations, 285, 287, 300. mental depression, during, 973. missed, 764. molding of head in, 304, 312, 317. metabolism in, 252. nervous influences during, 252, 1059 1060 INDEX Levator injuries to, during labor, 950. Levret’s forceps, 443. Lex regia, 493. Life, 216. perception of, 216. Ligaments, broad, 47. cardinal, of Kocks, 48. iliosacral, 21. infundibulopelvic, 47, 61. of uterus, 47. ovarian, 61. pubic, 10. recto-uterine, 48. round, 49. sacrosciatic, 8. suspensory, of ovary, 47, 61. uterosacral, 49. Ligamentum arcuatum pubis, 11. latum, 47. ovarii, 61. teres, 49. transversale colli, 48. Linea terminalis, 3. Linzenmeier’s ovum, 114, 117. Lipoids in eclampsia, 614. Liquor amnii, 133, 667. folliculi, 71, 74. Lithopedion, 708, 739. Little’s lochial tube, 1007. Liver, acute yellow atrophy of, 587. changes in, in eclampsia, 606. in pernicious vomiting, 580. cystic, in foetus, 907. in pregnancy, 194. syphilitic, 687. Lochia, 378. bacteria in, 379. bacteriological examination of, 1006. in puerperal infection, 1006. retention of, 1001. Lochia-metra, 1029. Locked twins, 414. Longings in pregnancy, 217. Loops in umbilical cord, 685. Lott’s dilator, 434. Lower uterine segment, 267. during puerperium, 375. history of, 268. palpation of, 243. Lumbar anesthesia, 364. puncture in eclampsia, 628. Lungs, changes in, during pregnancy, 194. lesions of, in eclampsia, 608. Lutein cells, 73, 76, 79. Lutein cystoma, 659, 665. Luxation of femur, effect upon pelvis, 894, 896. Lymphatics of ovaries, 62. of tube, 58. of uterus, 45, 52. of vagina, 36. Lymphoid nodules in endometrium, 45. Macdonald’s sign of pregnancy, 212. Maceration of foetus, 687, 707. Macula embryonalis, 107. Malacosteon disease, 816. Labor, normal, 256, 341. obstructed. (See Dystocia.) painful, 755. painless, 254. pains of, 253. palpation in, 287, 299. perineal tears in, 365. phenomena, clinical, of, 256. physical changes during uterine contrac- tions, 253. physiology of, 248. pituitrin in, 760. placental period, 326. precipitate, 761. prediction of date of, 223. premature, 714. preparations for, on part of patient and nurse, 341. on part of physician, 344. prolonged, 754. protection of the perineum in, 354. pulmonary embolism during, 973. repair of perineal tears, 365. respiratory exchange, 252. rubber gloves, use of, during, 347. rupture of membranes in, 258, 352, 758, 853. second stage of, 259. shock during, 972. stages of, 256. syncope during, 972. tardy, 754. temperature in, 756, 854, 1004. third stage of, 262, 327. time of, 263. tying of cord in, 358. vaginal examination during, 350. Laborde’s method of resuscitation, 969. Lactation, 393. atrophy of uterus, 1029. Lactational insanity, 1040. Lactiferous ducts, 393. Lactosuria during pregnancy, 562. during puerperium, 380. Lambdoid suture, 164. Langhans’ layer of chorion, 132. Lanugo, 161. Laparo-elytrotomy, 495. Laparotomy, for colpaporrhexis, 951. for deep cervical tears, 955. for puerperal infection, 1013. for rupture of uterus, 962. in extra-uterine pregnancy, 745. in treatment of retroflexed pregnant uterus, 646. Lateral curvature of spine, 881. displacement of pregnant uterus, 647. placenta previa, 928. plane presentations. (See Transverse Presentations.) Laxatives in puerperium, 383. Lead poisoning during pregnancy, 568. Leg-holder, 419. Leopold’s ovum, 122. Leukocytosis in puerperium, 193, 378. Leukemia during pregnancy, 568. Levator ani muscle, 278. dystocia due to, 768. INDEX 1061 Malaria during pregnancy, 551. in puerperium, 1041. Male pronucleus, 103. Mammae. (See Breasts.) Mammary toxemia, 618. Management of pregnancy, 227. Mania. (See Insanity.) Manual dilatation of cervix, 431. Manual removal of placenta, 339, 543, 937. Marginal insertion of cord, 683. placenta previa, 928. Margo placentae, 678. Markstrange, 62. Martin’s pelvimeter, 784. Masculine pelvis, 825. Mastitis, 1037. Maturation of ovum, 100. Maturity of foetus, signs of, 161. Mauriceau’s maneuver, 475. Measles during pregnancy, 546. during puerperium, 1043. Meatus, urinary, 30. Mechanism of labor, complicated by foetal monstrosities, 903. in breech presentations, 321. in brow presentations, 316. in contracted pelves, 848. in face presentations, 309. in occipitoposterior presentations, 300. in transverse presentations, 910. in vertex presentations, 287. Meckel’s diverticulum, 152. Meconium, 392. Medulla of ovary, 63. Medullary cords, 63, 67. groove, 108. ridges, 109. Membrana granulosa, 71, 73. Membranes, foetal, 111, 114, 147. method of rupturing, 352. rupture of, 258. premature, 258, 758, 853. in contracted pelves, 853. Membranous placenta, 676. Memory, loss of, in eclampsia, 602. Menopause, 85. Menses, cessation of, in pregnancy, 215. persistence of, in pregnancy, 215. Menstrual cycle, 87. decidua, 90. wave, 92. Menstruation, 85. after ovariotomy, 92. after puerperium, 374. amount of blood lost in, 86. anatomical changes in, 86. causation of, 89. cessation of, in pregnancy, 215. in extra-uterine pregnancy, 740. in infants, 85. participation in, by tube, 90. persistent, 85. precocious, 85. relation of, to ovulation, 89. Mental and emotional changes during pregnancy, 217. depression during labor, 973. derangement following eclampsia, 602. Mental derangement’in pregnancy, 197, 217. Mento-iliac presentation. (See Face Pres- entations.) Mercurial poisoning from intra-uterine douche, 1011. Mesoblastic somites, 110. Mesoderm, 108. Mesodermic area, 108. Mesosalpinx, 48, 60. Mesovarium, 62. Metabolism at time of labor, 262. general, in pregnancy, 198. in eclampsia, 615. in puerperium, 380. of foetus, 169. Metritis dessicans, 988. in pregnancy, 653. Metritis, puerperal, 988. Meyer’s conjugate, 9. Michaelis’s rhomboid, 787. Migration of ovum, 93, 722. Milk, anatomy of, 394. corpuscles of, 394. cow’s, 400. drying up, 399, 1039. fever 376 1005. human 394. leg. (See Phlegmasia Alba Dolens.) modified 400. Miller’s ovum, 114 117. Miscarriage, 701. Missed abortion, 713. labor, 764. Modified milk, 400. Moellendorf’s ovum, 124. Mole, 707. blood, 707. carneous, 707. destructive, 661. fleshy, 707. hematoma, 707. hydatidiform, 656. tubal, 735. uterine, 707. Molecular concentration of blood, 170. Mollities ossium, 816. Monsters, 903. Mons veneris, 26. Montgomery’s glands, 191. Morales’s forceps, 464. Morning sickness, 216, 420, 578. Morula, 105. Movements of foetus during pregnancy, 209. Mulberry mass, 105. Mullerian ducts, 54. Muller’s method of impression of head, 861. Muller’s ring, 266. Multiple placenta in single pregnancy, 674. Multiple pregnancy, 402. acardia in, 407. course of labor in, 412. diagnosis of, 411. eclampsia in, 412. etiology of, 402. experimental production of, 405. foetus papyraceus in, 409. frequency of, 402. hemorrhage in, 413. 1062 INDEX Multiple hydramnios in, 407. in tubes, 742. mummification of foetus in, 409. relation of placenta and membranes in, 406. treatment of, 413. Murray’s forceps, 465. Muscle fibers of pregnant uterus, 184. rhomboids of uterus, 186. Muscular contractures in osteomalacia, 818. palsies in osteomalacia, 818. Musculature of non-pregnant uterus, 46. of pregnant uterus, 184. of tube, 56. Myocarditis during pregnancy, 556. Myoma of uterus, cesarean section in, 497, 774. complicating labor, 772. in pregnancy, 219, 421. Myomectomy during pregnancy, 774. Myxoma chorii, 656. fibrosum of placenta, 681. Nabothian follicles, 42. Naegele pelvis, 829. Naegele’s obliquity, 290. Nausea and vomiting in pregnancy, 216. Negro foetus, characteristics of, 161. Nephrectomy and pregnancy, 564. Nephritis, chronic, during pregnancy, 590. in acute yellow atrophy, 588. in eclampsia, 605. in toxemic vomiting, 583 Nerves of clitoris, 29. of ovaries, 63. of uterus, 53. Nervous system in pregnancy, 197, 565. Neuralgia during pregnancy, 565. Neurenteric canal, 128. Neuritis during pregnancy, 565. puerperal, 1032. Neurotic vomiting of pregnancy, 579. New-born child, artificial feeding of, 400. asphyxia of, 967. care of, 388 eyes of, 391. circulatory changes in, 388. ductus arteriosus of, 388. feeding of, 396. foramen ovale of, 168, 388. head of, 164. icterus of, 393. jaundice of, 393. length of, 161. loss of weight of, 393. meconium, 392. nursing of, 396. ophthalmia of, 391. sex of, 176. stools of, 392. umbilical cord of, 389. urine of, 392. weight of, 162, 393, 900. Nipples, abnormalities of, 1034. care of, during pregnancy, 230. during puerperium, 383, 1034. cracked, 398. depressed, 1035. Nipples, fissures of, 398. Nipple shield, 230, 398. Nitrogenous partition of urine, 581, 589, 604. Nitrous oxid analgesia in labor, 361. Nomenclature of presentation, 236. Nuchal presentation, 917. Nuck, canal of, 28. Nucleus, segmentation, 103. Number of spermatoza, 95. of ova, 69. Nursing, 396. Nymphae, 28. Obliquely contracted pelvis, 829. Obstetrical outfit, 344. paralysis. (See Paralysis, Obstetrical.) Obstetrical surgery. (See Operations, Ob- stetrical.) Obstructed labor. (See Dystocia.) Obstruction, intestinal, 572. Occipito-anterior presentations. (See Ver- tex Presentation.) Occipitoposterior presentations. (See Ver- tex Presentation.) Oligohydramnios, 671. Omphalomesenteric vessels, 152. Oocyte, 68, 70. Oogenesis, 67. Oogonia, 67, 69. Oophoritis, puerperal, 989. Operations, obstetrical, 417 accouchement forc6, 431. cesarean section, 492. cervical dilatation, manual, 431. cervical incisions, 443. cleidotomy, 535, 902. craniotomy, 527. curettage, 539. decapitation, 533. douche, 536. during pregnancy, 571. embryotomy, 533. evisceration, 533. extraction in breech presentations, 470. forceps, 439. hebotomy, 518. hysterectomy, 504, 773, 1023. hysterotomy, abdominal, 423. vaginal, 434. induction of abortion, 419. premature labor, 424. intra-uterine pack, 541, 943. laparo-elytrotomy, 495. manual removal of placenta, 542, 943. preparations for, 417. pubiotomy, 518. surgical, in pregnancy, 571. symphyseotomy, 517. tampon, 541. vaginal cesarean section, 434. version, 483. Braxton-Hicks, 485. cephalic, 483. combined, 485. external, 484. internal, 485. podalic, 485. Potter, 487. INDEX 1063 Ophthalmia, 391. neonatorum, 391. Organ of 48. of Rosenmuller, 48. Os externum, 40. innominatum, 2. internum, 39. tincae, 40. Osiander’s maneuver, 464. Ossification, of pelvis, 17. of child, 161. Osteochondritis syphilitica, 689. Osteomalacia, clinical history of, 816. pathology of, 817. pelvis in, 819. Osteomalacic pelvis, 817, 870. Osteophyte, 197. Outlet of pelvis, 6. contractions of, 793. Ova, early human, 113. Ovarian, artery, 51. epithelium, 65. fimbria, 57, 93. pregnancy, 724. tumors, cesarean section in, 497. complicating pregnancy, 219, 421, 774. Ovaries, 61. abscess of, 989. accessory, 64. anatomy of, 61. changes in, in pregnancy, 188. corpus luteum of, 75. cortex of, 63. cysts of, 774. decidual cells in, 138. development of, 66. epithelium of, 63. ganglion of, 64. Graafian follicle, 63, 70, 73. hilum of, 62. in osteomalacia, 818. internal secretion of, 65. interstitial glands of, 64. in young child, 69. ligament of, 62. medulla of, 63. medullary cords of, 63. microscopic structure of, 69. nerves of, 64. peritoneum, relations of, to, 62. position of, in pregnancy, 183. relation of, to wolffian body, 63. removal of, pregnancy after, 92. rete of, 63, 67. theca, 73. transplantation of, 64. Ovariotomy during pregnancy, 776. Ovate pelvis, 829. Over-rotation in breech presentation, 310. Ovula Nabothi, 42. Ovulation, 89. during pregnancy, 188. relation of, to menstruation, 89. Ovum, 74. abdominal pedicle, 123. allantois of, 125, 151. amnion of, 111, 114. area opaca of, 107. Ovum, area pellucida of, 107. Bauchstiel of, 123. blighted, 706. blastodermic vesicle, 106. body stalk, 123. Bryce and Teacher’s, 118. celom of, 126. centrosome of, 105. chorion of, 110, 114, 128. chromosomes of, 100. cleavage of, 105. corona radiata of, 74. deutoplasm of, 75. development of, 105. discharge of, from ovary, 75, 93. diseases and abnormalities of, 421. dropsical, 706. ectoderm of, 111. embryonic area of, 107. embroyonic shield of, 108. entoderm of, 111. entypie, 115. female pronucleus of, 103. fertilization of, 103. germinal spot, 75. germinal vesicle, 75. head folds of, 109. Heine and Hofbauer’s, 113. implantation of, 111, 727. impregnation of, 95, 103. internal cell mass of, 106. in transit through tube, 93, 112. inversion of germ layers of, 107. Leopold’s, 122. Linzenmeier’s, 114, 118. macula embryonalis of, 106. maturation of, 100. mature, 74. medullary groove of, 108. medullary ridges of, 109. mesoblastic somites of, 110. mesodermic area of, 108. mesoderm of, 108. migration of, 93, 722. external, 94. internal, 95. Miller’s, 113, 117. Moellendorf’s, 124. morula of, 105. neurenteric canal of, 128. parietal zone of, 109. parthenogenesis of, 104. perivitelline space of, 75. Peters’s, 118. physiology of, 89, 100. place of meeting with spermatozoa, 95. polar bodies of, 102. premature expulsion of. (See Abortion.) primary segments of, 110. primitive folds of, 108. primitive streak of, 108. primordial, 66. pronucleus, 103. protovertebrae of, 110. segmental layer of, 109. segmentation nucleus of, 103. segmentation of, 105, 106. sex of, 176. 1064 INDEX Ovum, size of, 74. somatopleure of, 110. Spee’s, 124. splanchnopleure of, 110. Streeter’s, 124. trophoblast of, 114. tuberculosum, 707. umbilical vesicle of, 118, 121, 151. vitelline membrane of, 72. with double nuclei, 70, 404. yolk of, 75. yolk-sac of, 118, 121, 151. zona pellucida of, 74. Oxytocics, indications for use of, 716. Pack. (See Tampon.) Painless labor, 254. Pajot’s maneuver, 464 Palfyn’s forceps, 442. Palpation, 241. in occipito-anterior presentations, 287. in breech presentations, 318. in brow presentations, 316. in face presentations, 308. in occipitoposterior presentations, 299. of cephalic prominence, 242. of contraction ring, 243. of foetal heart-beat, 208. of lower uterine segment, 243. of outlines of foetus, 209. of round ligaments, 243. through perineum, 352. Palper mensurateur, 863. Pampiniform plexus, 51. Paradoxical incontinence, 645. Paralysis, Duchenne’s, 1033. during pregnancy, 565. during puerperium, 1031. facial, following forceps, 469. obstetrical, 1031. of placental site, 939. Parametritis, 989. Parametrium, 48. Paraplegia complicating labor, 253, 565. during pregnancy, 565. Parathyroids in eclampsia, 618. in pregnancy, 195. Para-urethral ducts, 30. Parietal layer, 110. Parietal presentation, 849. Paroophoron, 48. Parovarium, 48. Parthenogenesis, 104. Partial placenta previa, 928. Parturient paresis, 618. Parturition. (See Labor.) Pathology of labor, 754. of pregnancy, 545. of puerperium, 977. Pelvic abscess, 989. axis, 10. cavity, 3. cellulitis following puerperal infection, 989, 1013. fascia, 280. floor, 278. anatomy of, 278. changes in, during labor, 278. Pelvic hematocele, 734, 741. joints, relaxation of, in pregnancy, 570. outlet, 3, 8, 793. peritonitis following puerperal infection, 989. Pelvigraph, 791. Pelvimetry, by use of X-ray, 797. external, 784. in pregnancy, 232. internal, 788. of outlet, 793. Pelvis, 1. acanthopelys, 898. anatomical conjugate, 6. anatomy of, 1. articulations of, 11. assimilation, 835. axis of, 10. bilateral luxation of femora in, 893. cavity of, 3. changes in size of, 11. child, 17. chondrodystrophic dwarf, 827, club foot, 897. coccyx, 2. comparison of, 12. conjugata diagonalis, 8, 789. conjugata vera, 5, 790. conjugate, anatomical, 6. contracted. (See Contracted Pelvis.) coxalgic, 892. coxarthrolisthetic, 893. cretin dwarf, 827. development of, 17. diameters of, 4. dolichopellic, 16. double luxation of femora, 896. double Naegele, 833. dwarf, 826. enchondroma of, 898. exostosis of, 898. external conjugate of, 786. false, 3. fibroma of, 898. flat non-rhachitic, 801. flat rhachitic, 806. fractures of, 898. funnel-shaped, 838. generally contracted, 823. flat rhachitic, 810. generally enlarged, 823. generally equally contracted rhachitic, 811. history of, 1. hypoplastic dwarf, 828. inclination of, 8. inclined planes of, 3, 295. infantile, 17, 826. paralysis, 895. inferior strait, 5, 793. inlet of, 5. innominate line, 3. ischial spines, 3. ischium, 3. joints of, 11, 570. justomajor, 823. justominor, 823. kyphorhachitic, 877. kyphoscoliorhachitic, 884. Pelvis, kyphoscoliotic, 883. kyphotic, 874. ligaments of, 11. linea terminalis, 3. male, 13. masculine, 825. mesatipellic, 16. middle flat rhachitic, 808. movements of, in joints, 11, 570. muscles of, 278. Naegele, $29. nana, 827. new-born child, 17. nimis parva, 823. normal conjugate of, 9. oblique conjugate of, 8. obliquely contracted, 829. obstetrical conjugate of, 7. obtecta, 875. ossification of, 17. osteomalacic, 816. outlet of, 3, 8, 793. ovate, 829. plana Deventeri, 801. plana osteomalacica, 819. planes, 4, 5, 8. platypellic, 16. pseudo-osteomalacic, 812. pubis, 4. racial differences in, 16. rhachitic, 804, 849. dwarf, 828. Robert, 833. sacrocotyloid diameter of, 6. sacro-iliac synchondrosis, 11. sacrum, 3. scoliorhachitic, 882. scoliotic, 877. second parallel of, 8. separation of, during labor, 1. sexual differences in, 13. simple flat, 801. soft parts of, 278. spinosa, 810, 898, 963. split, 834. spondylizc me, 877. spondylolisthetic, 884. straits of, 5. superior strait of, 5, 791. symphysis, absence of, 834. symphysis of, relaxation in, 570. symphysis pubis, 11. terminal, length of, 20, 809, 814. transformation of foetal into adult, 19. transversely contracted, 833. true, 3. conjugate of, 5, 790. dwarf, 827. walls of, 3. tumors of, 898. unilateral luxation of femur, 894. variations in, 12. Veit’s main plane of, 8. with imperfect development of sacrum, 835. Pendulous abdomen, 220, 847. Perforation. (See Craniotomy.) of Douglas’s culdesac, 963. INDEX Perforation of uterus, 962. Perineal fascia, 280. gutter, 282. muscles, 282. tears, after-treatment of, 369. central, 367. frequency of, 354. prevention of, 354. repair of, 365. Perineum, anatomy of, 280. changes in, during labor, 281. lacerations of, 354, 365. protection of, 354. rigid, 755. Peritonitis, foetal, 907. puerperal, 989. Peri-uterine inflammation in pregnancy, 653. Perivitelline space, 25. Pernicious anemia during pregnancy, 568. vomiting of pregnancy, 578. Perret’s cephalometer, 863. Pessary in treatment of retroflexed preg- nant uterus, 646. Peters’s ovum, 118. Pfluger’s ducts, 66. Phantom tumors, in diagnosis of pregnancy, 219. Phenolsulphonephthalein test in toxemia, 591. Phlebitis, femoral, 990. Phlebotomy in eclampsia, 623. Phlegmasia alba dolens, 556, 990, 1004, 1023. Phloridzin diabetes, 174. Phthisis of placenta, 677. complicating pregnancy, 549. Physiology of foetus, 166. of labor, 248. Physometra, 854. Pigmentation, changes in, during pregnancy, 197, 217, 570. in negro baby, 161. Pinard’s maneuver, 480, 863. Pituitrin in postpartum hemorrhage, 942. use of, in labor, 365, 758, 760. Pituitary gland, in pregnancy, 196. Placenta, 140, 142, 144. abnormalities in size of, 673. abnormalities in weight of, 673. adherent, 683. anatomy of, 127, 140. angioma of, 681. annular, 673. apoplexy of, 678, 923. artificial separation of, 543. at full term, 147. atrophy of, 679. autolysis in eclampsia, 614. basal plate of, 142. battledore, 683. bipartita, 674. bruit of, 208. calcification of, 682. canalized fibrin of, 142. cell nodes of, 141. changes in, in eclampsia, 613. chorio-angioma of, 681. circular sinus of, 147. circumvallata, 677. 1065 1066 INDEX Placenta, closing plate of, 142. cotyledons of, 147. cysts of, 680. decidual islands of, 142. development of, 127, 140. diagnosis of position of, by palpation of round ligaments, 243. dimidiata, 674. diseases of, 677. duplex, 675. edema of, 674. epithelium of, 132. expression of, 336. by author’s method, 338. by Credo’s method, 336. expulsion of, by Duncan’s method, 331. by Schultze’s method, 331. fastening villi, 141. fatty degeneration of, 677. fenestrata, 674. fibroma of, 681. functions of, 146, 169. giant cells of, 129, 140. gumma of, 692. hepatization of, 677. in albuminuria, 679. in eclampsia, 613. in extra-uterine pregnancy, 731 in latter half of pregnancy, 144. in multiple pregnancy, 406. in syphilis, 690. infarcts of, 677. inflammation of, 682. intervillous blood spaces of, 141, 145. lipoids of, in eclampsia, 614. manual removal of, 339, 543. marginata, 677. margo, 678. mechanism of separation of, 327. membranacea, 676. membranes of, 147. mode of delivery of, 330. mode of extrusion of, 330. multiple, in single pregnancy, 674. myxoma fibrosum of, 681. new growths in, 681. osmotic pressure in, 170. phthisis of, 677. polyp of, 1026. premature separation of, 498, 920. previa, 677, 927. prolapse of, 925. red infarcts of, 678. reflexa, 930. retention of, cause of hemorrhage, 339, 939. sarcoma of, 682. schirrus of, 677. senility of, 678. septuplex, 675. site of, postpartum, 374. situation of, in utero, 326. spuria, 676. succenturiata, 675, 939. syncytium of, 132. syphilis of, 690. transmission of substances through, 169. triplex, 675. trophoblast of, 114. Placenta, truff6, 678. tuberculosis of, 649, 682. tumors of, 681. velamentous, 683. vessels of, 147. vicious insertion of, 929. villi of, fastening, 141. weight of, 147. Placental bacteremia, 756. forceps, 402. period, 262, 326. amount of blood lost during, 335. clinical picture of, 334. hemorrhage during, 335. management of, 334. mechanism of separation of placenta, 327. mode of extrusion of placenta, 330. normal situation of placenta in utero, 326. polyp, 1026. souffle, 208. space, 142. transmission, 169. Placentitis, 682. Planes of pelvis, 4. Plasmodium, chorionic, 132. Pleurisy in puerperal infection, 990. Plexus, hypogastric, 53. pampiniform, 52. Plicae palmatae, 41. Pneumococcus in puerperal infection, 981. Pneumonia alba, 886. during pregnancy, 547. during puerperium, 1042. Podalic version, 485. indications for, 486. Potter, 487. technic of, 488. Polar body, 102. Polygalacia, 1035. Polymastia, 1034. Polypus, fibrinous, causing hemorrhage, 1026. Porro-cesarean section. (See Cesarean Sec- tion.) Portio vaginalis of cervix, 40. Position of foetus, 236. of uterus, 49. Positive signs of pregnancy, 206. Postmortem cesarean section, 516. delivery, 975. Postpartum hemorrhage, 938. Posture, in first stage of labor, 258, 350. in second stage of labor, 259, 353. Potter version, 487. Preputium clitoridis, 28. Prague maneuver, 477. Precipitate labor, 761. Pre-eclamptic toxemia, 593. Pregnancy, Abderhalden’s reaction in, 213. abdominal, 738. enlargement during, 210. abnormalities of pigmentation in, 570. abortion, 701. acardia in multiple, 407, 903. accidents during, 570. acute edema of cervix during, 649. INDEX Pregnancy, chorea in, 426, 566. | chorio-epithelioma, 662. chronic infectious diseases in, 549. I chronic nephritis in, 590. cloasma in, 197, 570. clothing during, 229. coitus in, 229. colpohyperplasia cystica during, 637. combined, 742. constipation during, 194, 229, 559. corpus luteum of, 78. cravings during, 217. cystitis in, 564. cytolysis, 612. death of foetus during, 427. decidua polyposa during, 651. dental caries in, 560. depressed nipples in, 1035. dermatitis herpetiformis in, 569. diabetes in, 426, 561. diagnosis of, 206. differential, 218. of death of foetus in, 221. diastasis of recti muscles during, 650. diet during, 228. diffuse thickening of decidua during, 651. directions for patients during, 231. disappearance of, 707. discoloration of mucous membrane in, 216. diseases of alimentary tract and liver in, 559. of blood in, 568. of cervix during, 638. of circulatory and respiratory systems in, 554. of decidua during, 650. of kidneys and urinary tract in, 561. of nervous system in, 565. of ovum during, 656. of skin in, 569. of vulva and vagina during, 637. dislocation of kidney in, 564. displacements of uterus during, 643. distinction between first and subsequent, 220. disturbances of vision in, 231, 567. duration of, 221. dyspnea in, 557. eclampsia in, 597. ectopic. (See Extra-uterine Pregnancy.) edema in, 557. emesis in, 216, 420, 578. emphysema during, 557. endocarditis in, 556. endometritis decidua cystica during, 652. endometritis during, 651, 653. enteroptosis in, 560. epilepsy in, 566. erysipelas in, 548. estimation of date of confinement, 223. estimation of duration of, 222. examination, preliminary, during, 232. exanthemata during, 545. exercise during, 228. extraperitoneal, 738. extra-uterine. (See Extra-uterine Preg- nancy.) floating spleen in, 565. 1067 ’regnancy, acute endometritis during, 653. acute infectious diseases in, 545. acute yellow atrophy of liver in, 587. after removal of kidney, 564. after removal of ovaries, 92. albuminuria during, 194, 591, 593. albuminuric retinitis, 592. amaurosis in, 592, 602. amenorrhea during, 90, 215. ampullar, 726. anemia, pernicious, in, 568. anomalies and diseases of ovum, 656. anteflexion of uterus during, 642. anteversion of uterus during, 642. anthrax in, 548. apoplexy in, 567. appendicitis in, 571. areola in, 191. asthma in, 557. atrophic endometritis decidua during, 652. auto-intoxication in, 610, 629. ballottement in, 209. bladder and rectum, changes in, 194. blood changes in, 192, 217. blood pressure in, 192. bowels in, 229. Braxton-Hicks’s sign of, 212. breasts, care of, during, 230. broad ligament, 736. changes in, during, 188. carcinoma of cervix during, 638. cardiac lesions in, 426, 554. cephalalgia in, 593. cervix in, 212. Chadwick’s sign of, 216. changes in abdominal wall during, 190. bladder during, 194. blood during, 192. blood serum during, 217. breasts during, 191. cervix during, 212, 266. digestive tract during, 194. ductless glands during, 194. heart during, 192. hypophysis, 196. kidneys during, 194. liver during, 194. lungs during, 194. maternal organism during, 183. metabolism, 198. nervous system during, 197. ovaries during, 188. pigmentation during, 197, 217, 570. respiratory tract during, 193. size, shape, and consistency of uterus during, 182, 210. skeleton during, 196. skin during, 197. teeth during, 196. thymus, 196. thyroid during, 195. tubes during, 188. urinary tract during, 194. uterus during, 183. vagina during, 188. voice, 194. weight during, 198. Cholera in, 546. 1068 INDEX Pregnancy, floating kidney in, 564. foetal heart in, 207. formation of lower uterine segment, 267. funic souffle in, 208. gall stones in, 559. gingivitis in, 560. glandular hyperplasia of decidua during, 651. glycosuria in, 561. goiter in, 567. gonorrhea in, 548. hematoma of abdominal walls in, 570. hematuria in, 563. hemoglobin during, 192. heart, hypertrophy of, in, 192. Hegar’s sign of, 211. hepatotoxemia in, 610. hernia during, 649. herpes gestationis in, 569. hydatidiform mole in, 656. hydramnios in, 427, 667. hydremia in, 192. hydroplasmia in, 193. hydrorrhea gravidarum during, 651. hymen in, 31, 767. hyperemesis in, 578. hypertrophic elongation of cervix during, 648. hypertrophy of cervix in, 212, 266. hypophysis cerebri in, 196. hysteria in, 566. icterus in, 559, 587. imaginary, 219. impetigo herpetiformis in, 569. incarceration of uterus during, 645. incontinence of urine in, 645. indigestion in, 559. induction of abortion in, 419. in diverticula from uterine cavity, 640. infection of uterine contents during, 712, 854, 1010. inflammation of Bartholin’s glands during, 636. influenza in, 547. inguinal hernia during, 649. in rudimentary horn of double uterus, 639. insanity during, 602, 1040. intermittent contractions of uterus during, 212. interstitial, 726. intestinal obstruction in, 572. in uterus bicornis, 641. in uterus unicornis, 641. isthmic, 726. joints, pelvic, relaxation of, 570. kidney of, 194, 605. lactosuria in, 562. lead poisoning in, 568. leukemia in, 568. localized thickening of decidua during, 651. lower uterine segment in, 267. malaria in, 551. mammae in, 191, 230. management of, 227. marital relations in, 229. maternal pulse in, 208. measles in, 546. menses, cessation of, during, 215. Pregnancy, menses, persistence of, during, 215. mental and emotional changes in, 217. mental derangements in, 602. metabolism in, 198. milk in, 216, 394. miscarriage in, 701. missed abortion in, 713. morning sickness in, 216. movements of foetus during, 209. multiple. (See Multiple Pregnancy.) myocarditis in, 556. myoma, 426. nausea and vomiting during, 216, 420, 578. nephrectomy, 564. nephritic toxemia in, 590. nervous irritability in, 197. neuralgia in, 565. neuritis in, 426, 565. neurotic vomiting in, 579. operations during, 571. osteophyte, 197. ovarian, 724. cyst complicating, 421, 427. ovulation during, 188. palpation during, 241. of foetal heart in, 208. paradoxical incontinence of urine during, 645. paralysis in, 565. paraplegia in, 565. pathology of, 545. pelvimetry during, 232. pendulous abdomen in, 220, 847. peri-uterine inflammation during, 653. pernicious anemia in, 427, 568. vomiting of, 578. pessary in, 646. phlegmasia in, 556. phthisis in, 549. physiology of, 183. pigmentation in, 217, 570. placenta previa in, 427. placental souffle in, 208. placentitis in, 677, 682. pneumonia in, 547. positive signs of, 206. pre-eclamptic toxemia in, 593. premature labor in, 714. presumptive signs of, 215. presumable toxemias, 628. probable signs of, 210. prolapse of uterus during, 647. prolonged, 222, 900. pruritus in, 569. pseudocyesis, 219. psychoses during, 602. pulmonary embolism in, 557. pyelitis, 563. pyelonephritis in, 427, 563. quickening in, 217. relapsing fever in, 173. relaxation of pelvic joints during, 570. of vaginal outlet during, 637, 950. renal insufficiency during, 194, 605. respiration in, 201. rest, effect of, on, 222. retroflexion of uterus during, 385, 643. Pregnancy, retroversion of uterus during, 643. rupture of uterus during, 955. sacculation of uterus in, 644. salivation in, 560. scarlet fever in, 546. sepsis in, 545. sexual intercourse during, 229. signs of, 215. signs of previous, 220. size of uterus in, 183, 210. smallpox in, 545. souffle, funic, in, 208. spleen, floating, 565. spurious, 219. striae of, 190. sugar tolerance in, 217. ' suppression of menses in, 215. surgical operations during, 571. symptoms of, 206. syphilis in, 551, 686. tachycardia in, 556. taste, perversions of, in, 197, 217. teeth, 197. termination of, 221. tetanus in, 548. tetany in, 566. thyroid in, 567. toothache in, 560. torsion of cord in, 685. toxemias of, 577. transmission of bacteria from mother to fcetus, 172. tubal, 726. tuberculosis in, 421, 426, 549. tubes and ovaries in, 188. tubo-abdominal, 738. tubo-ovarian, 738. tubo-uterine, 738. tumors complicating, 774. typhoid fever in, 547. umbilical hernia during, 649. umbilicus in, 218. urea, amount of, during, 200. urinary disturbances during, 217. urination during, 200. urine, examination of, during, 230. urine in, 200. uterine displacements in, 643. hemorrhage during, 920. myomata during, 421. souffle in, 208. utero-abdominal, 956. uterus in, 182. vaccination in, 546. vagina in, 189, 278. vaginal enterocele during, 648. examination during, 233, 243. vaginitis during, 548, 637. valvular lesions of heart in, 554. varices in, 557. varicose veins in, 557. variola in, 545. vomiting of, 420, 578. Wassermann reaction in, 551. weight in, 198. Preliminary examination during pregnancy, 232. INDEX Premature labor, 714. in chronic nephritis, 592. in heart disease, 556. in infectious diseases, 548. in lead poisoning, 568. in leukemia, 568. in malaria, 551. in ovarian tumors, 774. in pneumonia, 547. in syphilis, 551, 716. Premature labor, induction of, 424. for acute nephritis, 426. for cardiac lesions, 426. for chorea, 426. for contracted pelves, 424, 868. for diabetes, 426. for excessive size of child, 425, 901. for habitual death of foetus, 427. for heart disease, 556. for hydatidiform mole, 662. for hydramnios, 427. for neuritis, 426. for old extra-uterine pregnancy, 743. for ovarian tumors, 774. for pernicious anemia, 427. for placenta previa, 427, 937. for pyelonephritis, 427. for toxemia of pregnancy, 426, 597. for tuberculosis, 426. for uterine myomata, 427. methods of, 428. prognosis of, 428. Premature separation of normally implanted placenta, 920. Prenatal care, 217. Preparations for labor, 341. Prepuce of clitoris, 29. Presentation, 234. acromio-iliac. (See Transverse Presen- tation.) anterior parietal, 849. breech, 236. brow, 236. causation of, 238. cephalic, 235. compound, 917. diagnosis of, 241. ear, 851. face, 236. foot, 236. frank breech, 236. frequency of the several varieties of, 237. funic, 965. head, 235. knee, 236. lateral plane, 909. longitudinal, 235. mento-iliac. (See Face Presentation.) nomenclature of, 236. nuchal, 917. oblique, 909. occipito-iliac. (See Vertex Presentation.) pelvic, 235. posterior parietal, 850. reasons for predominance of head, 238. sacro-iliac. (See Breech Presentation.) shoulder, 235, 909. sincipital, 236. 1069 1070 INDEX Presentation, transverse, 235, 909. vertex, 236. Presentation and position, 234. diagnosis of, 241. frequency of, 237. in contracted pelves, 847. nomenclature of, 236. Presenting part, 235. Presumable toxemias, 628. Presumptive signs of pregnancy, 215. Primary segments, 110. Primiparae, elderly, 262. young, 262. Primitive folds, 108. groove, 108. streak, 108. yolk sac, 151. Primordial follicle, 65, 67. ova, 65. Probable signs of pregnancy, 210. Profeta’s law, 552. Prolapse of placenta, 925. of pregnant uterus, 647. of puerperal uterus, 1030. of umbilical cord, 855, 965. Prolonged labor, 754. pregnancy, 222, 900. Promontory, sacral, 4. Pronucleus, female, 103. male, 103. Prophylactic douche, 537. forceps, 445. version, 868. Protovertebrae, 110. Pruritus during pregnancy, 569. vulvae, 569. Pseudocyesis, 219. Pseudo-osteomalacic rhachitic pelvis, 812. Pseudoreflexa, 727, 732. Psychoses during pregnancy, 602. in eclampsia, 602. puerperal, 1040. Pubiotomy, 518. in brow presentations, 318. in contracted pelvis, 523, 844. in face presentations, 315. Pubis, 4. arch of, 4. palpation of, 793. symphysis, 2. Pudendum, 26. Puerperal infection, 977. antistreptococcic serum in, 1014. auto-infection, cause of, 993. bacteriological examination of lochia in, 1006. bacteriology of, 977, 1006. curettage in, 540, 1010. diagnosis of, 1005. etiology of, 991. frequency of, 999. hysterectomy for, 1013. intra-uterine douche in, 1009. operative treatment of, 1012. pathological anatomy of, 984. pyemia in, 990. sapremia in, 982. septicemia in, 977, 1004. Puerperal infection, sewer gas in, 993. symptoms of, 1001. treatment of, 1008. ulcer, 984. vaginitis, 984. Puerperium, 372. abdominal wall during, 376. acetonuria during, 380. after-pains in, 378, 382. ,albuminuria during, 379. anatomical changes in, 372. anteflexion of uterus during, 1029. atrophy of uterus during, 372. binder in, 381. bowels in, 383. bradycardia in, 376. Breasts, diseases of, during, 1034. care of patient during, 380. catheterization during, 383. cervix during, 375. changes in blood during, 378. in lower uterine segment during, 375. in uterine vessels during, 374. chill during, 376. chloroform poisoning in, delayed, 1031. clinical aspects of, 376. constipation during, 379. cystitis during, 1024. death during, 972. diabetes during, 380. diet during, 382. dilatation of stomach during, 974. diphtheria during, 1043. embolism in, 973. endarteritis in, 374. ergot in, 381, 942, 1028. examination during, 384. gangrene of lower extremities during, 1024. general functions during, 378 glycosuria during, 380. hematoma during, 1026. hemorrhage during, 1025. incontinence of urine during, 1025. infection during, 977. insanity during, 1040. involution of uterus during, 372. lactosuria during, 380. laxatives in, 383. leukocytosis during, 193, 378. lochia during, 378. lochiometra during, 1029. loss of weight during, 380. malarial fever during, 1041. management of, 380. mastitis during, 1038. measles during, 1043. menstruation in, reappearance of, 384. metabolism during, 380. milk fever in, 376. myoma in, 773. neuritis during, 1032. nipples, care of, in, 383, 1034. nursing in, 396. ovarian tumors in, 777. paralysis during, 1031. peritoneum during, 376. pessary during, 1030. phlegmasia alba dolens during, 1023. INDEX 1071 Puerperium, placental polyp, 1026. pneumonia during, 1042. prolapse of uterus during, 1030. psychoses during, 1040. pulse during, 376. pyelitis during, 1025. pyelonephrosis during, 1025. regeneration of endometrium during, 374. rest and quiet during, 382. retention of urine during, 1025. retroflexion of uterus during, 1029. scarlet fever during, 1042. smallpox during, 1043. subinvolution of uterus during, 1028. sweating in, 379. syncope in, 972. temperature during, 376, 382. tetanus during, 1022. thrombosis during, 1023. time for getting up, 383. typhoid fever during, 1041. urination during, 382. urine in, 378. uterine myomata in, 773. vagina during, 375. vulval toilet during, 381. weight, loss of, during, 380. Pulmonary embolism. (See Embolism, Pulmonary.) Pulmotor in asphyxia, 971. Pulse during puerperium, 377. Pyemia, 990, 1003. Pyelitis, 563, 1025. Pyelonephritis, 563, 1025. Pygopagus, 903. Pyriformis muscle, 278. Quadruplet pregnancy. (See Multiple Pregnancy.) Quickening, 216. Quinine as an oxytocic, 758. Quintuplet pregnancy. (See Multiple Pregnancy.) Ramsbotham’s sickel knife, 534. Receptaculum seminis, 96. Rectal examination, 344. Rectocele complicating labor, 777. Rectovaginal fistula, 854, 963. septum, 35. Rectum, carcinoma of, complicating preg- nancy, 778. in labor, 282. Red infarcts of placenta, 678. Reduction of retroflexed pregnant uterus, 643. Reflex vomiting of pregnancy, 579. Relapsing fever in pregnancy, 173. Relaxation of pelvic joints in pregnancy, 570. of vaginal outlet after labor, 950. of vaginal outlet during pregnancy, 637, 950. Renal decapsulation, 628. insufficiency, 420. Repeated cesarean section, 514. tubal pregnancy, 742. Repositor for prolapsed umbilical cord, 966. Respiration, artificial, 969. in pregnancy, 201. intra-uterine, 967. Rest cure, 586. effect of, upon pregnancy, 222. Restitution. (See External Rotation.) Resuscitation, 969. Retained placenta, 339, 543, 939. Rete ovarii, 63. Retention of urine, 383. in foetus, 907. Reticulum of endometrium, 46. Retinitis, albuminuric, 592. Retraction ring. (See Contraction Ring.) Retractores uteri, 49. Retroflexion, cause of abortion, 704. due to contracted pelvis, 847. of pregnant uterus, 420, 643. of puerperal uterus, 1029. Retromammary abscess, 1038. Retroperitoneal phlegmon, 989. Rhachitic dwarf pelvis, 828. Rhachitis, diagnosis of, 812. foetal, 815. mode of production of pelvic deformity in, 814. pathology of, 804. pelvis in, 806. Rhomboid of Michaelis, 787. Rima pudendi, 26. Ring of Bandl. (See Contraction Ring.) of Miiller, 266. Ritgen’s method of expression, 356. Robert pelvis, 833. Roentgen ray. (See X-ray.) Rosenmuller, organ of, 48. Rotation with forceps, 459. Round ligaments, 49. function of, during labor, 256. palpation of, 243. Rubber gloves, use of, 347. Rudimentary horn, 639. Rugae, vaginal, 36. Rupture of graafian follicle, 74. of pelvic joints, 854. ■ of tubal pregnancy, 735. of umbilical cord, 685. of uterus, 515, 761, 770, 854, 955. Rupture of uterus, at time of labor, 956. during pregnancy, 955. following cesarean section, 515. in contracted pelves, 854. in neglected transverse presentations, 915. in pregnancy in bicornuate uterus, 640. Sacculation of uterus, 645. Sacro-iliac synchondrosis, 11. rupture of, in labor, 788. synostosis of, 813. Sacrosciatic notch, 3. Sacrum, 3. assimilation of, to vertebral column, 835. imperfect development of, 835. not a keystone, 4. promontory of, 4. 1072 INDEX Sagittal diameter, 832. fontanel, 165. suture, 164. Salivation in pregnancy, 560. Salpingitis, follicular, cause of tubal preg- nancy, 720. puerperal, 989. Salt solution in eclampsia, 624. in hemorrhage, 944. Sapremia, 982. Sarcolactic acid in eclampsia, 615. Sarcoma uteri deciduacellulare, 663. Saxtorph’s maneuver, 464. Scanzoni’s maneuver, 461. Scarlet fever in pregnancy, 546. in puerperium, 1042. intra-uterine, 546. relation of, to puerperal infection, 1042. Schatz’s method of conversion, 314. Scheele’s method of inducing labor, 429. Schirrus of placenta, 677. Schultze’s mechanism of extrusion of pla- centa, 331. method of resuscitation, 970. Scoliorhachitic pelvis, 882. Scoliosis, 881. Scoliotic pelvis, 881. Scopolamin anesthesia, 362. Seat-worms, 570. Segmental layer, 109. cavity, 106. Segmentation nucleus, 105. of ovum, 105. Semen, 95, 103. Sepsis foudroyante, 984. in pregnancy, 548. Septicemia, puerperal, 1004. Sewer gas in puerperal infection, 993. Sex, determination of, 176. diagnosis by heart-beat, 207. Sexual intercourse in pregnancy, 229. organs, abnormalities of, 637, 754. Shock during labor, 972. Shortening of cervix, apparent, in pregnancy, 266. Shoulder presentation. (See Transverse Presentation.) delivery of, 357. Show, 257. Signs of pregnancy, 206. Simple flat pelvis, 801. Simpson’s basilyst, 532. cranioclast, 530. forceps, 439. Sincipital presentation, 236. Skene’s ducts, 30. Skin diseases, 569. Skin in pregnancy, 197. Skull, configuration of, 855. depression of, 857. fracture of, 857. pressure marks on, 857. Skutsch’s pelvimeter, 792. Slow pulse during puerperium, 376. Smallpox during pregnancy, 545. during puerperium, 1042. intra-uterine, 546. Smellie’s forceps, 439. Smellier’s scissors, 529. Somatopleure, 110. Souffle, funic, 208. placental, 208. uterine, 208. Spee’s ovum, 125, 12G. Spermatid, 103. Spermatocyte, 103. Spermatogenesis, 103. Spermatozoa, 95. entrance into ovum, 103. influence upon sex, 177. mode of entry into uterus, 95. number of, 95. Sphincter vaginae, 37. Spirochete, 552, 691. Splanchnopleure, 110. Spleen, enlarged, complicating labor, 777. floating, 565. Split pelvis, 834. Spondyliz6me, 877. Spondylolisthesis, 884. Spondylolysis, 884. Spontaneous amputation by amniotic ad- hesions, 672. evolution, 912. rupture of uterus, 955. version, 912. Spurious pregnancy, 219. Stages of labor, 256. Staphylococcus in puerperal infection, 979. Stein’s pelvimeter, 792. Stenosis of umbilical vessels, 668. Sterilization after cesarean section. 510. Sternocleidomastoid muscles, hematoma of, 483. Stigma folliculi, 73. Stomach, acute dilatation of, 974. Straits of pelvis, 5. Streeter’s ovum, 114, 124. Streptococcus in mammary abscess, 1039. in puerperal infection, 978. in puerperal insanity, 1040. Striae of pregnancy, 190. StroganofT’s treatment of eclampsia, 626. Subareolar mastitis, 1039. Subinvolution of uterus, 1028. curettage in, 1028. Subperitoneal hematoma, 958. Succenturiate placenta, 675. Sudden death during labor, 972. Sugar in urine, 380, 426, 561. Sugar tolerance in pregnancy, 4217. Sugar tolerance in pregnancy, 217. Superfecundation, 409. Superfoetation, 409. Superinvolution of uterus, 1029. Superior strait, 5. Suprasymphyseal cesarean section, 495. Surgical operations during pregnancy, 571. Sutures of head, 164. for perineal repair, 368. Sweating in puerperium, 379. Symphyseotomy, 517. Symphysis pubis, 2, 10. absence of, 834. relaxation of, 570. rupture of, in labor, 854. INDEX 1073 Symphysis pubis, separation of, during labor, 1. Synchondrosis, sacro-iliac, 10. Synclitism, 291. Syncope during labor, 972. Syncytioina malignum, 662. Syncytium, 132. in eclampsia, 608, 612. in lungs, in eclampsia, 612. Syncytolysin, 613. Syphilis, bone lesions in, 689. during pregnancy, 551, 716. foetal, 686. osteochondritis, 689. pathology of, 687. placental lesions,in, 690. transmission of, to foetus, 552. Tachycardia in pregnancy, 556. Tampon, 541. in abortion, 711. in placenta previa, 936. in postpartum hemorrhage, 943. in rupture of uterus, 962. Tardy labor, 754. Tarnier’s basiotribe, 531. cephalotribe, 531. excitateur ut6rin, 430. forceps, 464. Teeth in pregnancy, 197. Temperature during labor, 256, 376, 756, 854. during puerperium, 382. Temporal fontanel, 165. suture, 164. Teratoma of ovary, 775. of testicle, 666, 907. production of, 102. Terminal length of pelvis, 20. Tetanic contraction of uterus, 762. Tetanus during pregnancy, 548. in puerperium, 1022. of newly born child, 389. uteri, 762. Tetany in pregnancy, 566. Theca folliculi, 73. Third stage of labor. (See Placental Period.) Thom’s pelvimeter, 795. Thoracopagus, 903. Threatened abortion, 709. Thrill in uterine artery during pregnancy, 208. Thrombosis of uterine vessels, 374. of vessels of lower extremities, 990, 1004, 1023. Thyroid, cause of dystocia, 908. cause of face presentations, 309. toxemia of pregnancy, 195, 618. changes in, during pregnancy, 195. in eclampsia, 618, 627. Toothache in pregnancy, 560. Torsion of cord, 685. of uterus, 188. Touch, vaginal, during labor, 350. in pregnancy, 243. Toxemia, acute yellow atrophy, 587. eclamptic, 597. nephritic, 590. Toxemia, of pregnancy, 426, 577. preeclamptic, 593. presumable, 628. vomiting, 578. Trachelorhekter, 535. Transfusion, blood, 746, 944. Transfusion of salt solution in eclampsia, 624. in extra-uterine pregnancy, 746. in postpartum hemorrhage, 944. Transit of ovum, 94, 112. Transplantation of ovaries, 64. Transportation of chorionic villi, 143, 608. Transverse presentations, 235, 909. Transversely contracted pelvis, 833. Transversus perinei, 280. Traumatic rupture of uterus, 957. Trepanation for asphyxia neonatorum, 970. Triplet pregnancy. (See Multiple Preg- nancy.) Trophoblast, 114. True dwarf pelvis, 827. Tubal abortion, 732. pregnancy, 719. Tuberculosis during pregnancy, 422, 549. of placenta, 549. transmission of, to foetus, 173, 549. Tuberous subchorial hematoma of decidua, 707. Tubes, fallopian. (See Fallopian Tubes.) Tumors, abdominal, diagnosis of, in preg- nancy, 218. complicating pregnancy, 774. fibroid, of uterus, 421. of foetus, 907. of pelvis, 898. of placenta, 681. of umbilical cord, 686. osseous, deforming pelvis, 898. ovarian, 421, 774. phantom, differentiation of, from preg- nancy, 219. scalp, 244, 304, 853. vaginal, 767. Tunica externa of graafian follicle, 72. interna, 72. Turnipg. (See Version.) Twin Pregnancy. (See Multiple Preg- nancy.) Twins, collision of, 413. locked, 414. Twilight sleep, 362. Tympania uteri, 980. Tympanites uteri, 854. Typhoid bacilli, transmission to foetus, 173. Typhoid fever during pregnancy, 547. in puerperium, 1005, 1041. Typhoid icterus, 587. Ulcer, puerperal, 984. Umbilical arteries, 149, 169. hernia, 649. infection, 389. vesicle, 151. relation to velamentous insertion of cord, 683. Umbilical cord, 149. abnormalities of, 682. battledore insertion of, 683. 1074 INDEX Umbilical cord, care of, 389. coils of, about neck of child, 357, 684. compression of, in breech presentation, 323. cysts of, 686. dermoid of, 686. development of, 150, 684. edema of, 684. formation of, 150. hematoma of, 686. bernia of, 649. infection of, 389. inflammation of, 685. knots of, 149, 685. laceration of, 685. length of, 149, 684. ligation of, 358, 389. loops of, 685. marginal insertion of, 683. myxoma of, 686. prolapse of, 855, 965. reposition of, 966. rupture of, 685. sarcoma of, 686. shortening of, 685. souffle in, 208. stalk, 151. stenosis of vessels of, 668. strangulation of, by amniotic adhesions, 672. syphilis of, 693. tetanus of, 389. torsion of, 685. tumors of, 686. tying of, 358. variations in length of, 684. varices of, 686. velamentous insertion of, 683. vesicle, 151. Unavoidable hemorrhage, 932. , Uremia, 609. in retroflexion of pregnant uterus, 645. Urea in eclampsia, 603. in pregnancy, 200. Ureter, cause of eclampsia, 606. compression of, 194. Urethra, 30. Urethral opening, 30. Urinary disturbances in pregnancy, 194. Urine, ammonia coefficient of, 580. examination of, during pregnancy, 230. incontinence of, 1025. in acute yellow atrophy, 589. in eclampsia, 602. in pregnancy, 194. in puerperium, 379. in toxemia of pregnancy, 593. in vomiting of pregnancy, 580. of foetus, 174, 389, 907. retention of, during puerperium, 383, 1025. Uterine, atony, 413, 939. bruit, 208. glands, 44. inertia, 755. insufficiency, 755. milk, 172. paralysis, 939. souffle, 208. Uteroplacental apoplexy, 924. Uterosacral ligaments, 49. Uterus, non-pregnant, 38. anatomy of, 38. blood vessels of, 50. cervix of, 38, 40. development of, 53 ligaments of, 47. lymphatics of, 52. mucosa of, 43. musculature of, 46. nerves of, 52. position of, 49. weight of, 39, 183. Uterus, parturient, action of, in labor, 271, 853. anteflexion of, 769. changes in, 271. contractions of, 253. faulty contraction of, 757. hour-glass contraction of, 763. inertia of, 755. myoma of, 772. nerve supply of, 250. perforation of, 962. retroflexion of, 769. rupture of, 515, 761, 770, 911, 955. sacculation of, 644, 769. tetanus of, 762. Uterus, pregnant, abnormalities of, 769. anteflexion of, 641. anteversion of, 643. atrophy of decidua causing abortion, 704. atrophy of decidua causing placenta previa, 929. bicornis, 640. carcinoma of, 638. changes in cervix, 266, 648. changes in, during contractions, 271. changes in size and shape of, 183, 186. consistency of, 210. contractions of, 212. developmental abnormalities of, 639. diverticula of, 640. double, with rudimentary horn, 639. duplex, 640. hypertrophy of, 183. incarceration of retroflexed, 645. laceration of cervix of, 939, 952. lateral displacements of, 647. lower uterine segment of, 243, 267. malformations of, 639. muscle layers of, 185. myoma of, 421. nerve supply of, 250. perforation of, 962. prolapse of, 647. pseudodidelphys, 639. retrodisplacement of, 643. retroflexion of, 420, 643. retroversion of, 643. rupture of, 955. sacculation of, 644. sinking of, 224. suspension of, cause of dystocia, 770. torsion of, 188. tumors of, complicating pregnancy, 774. unicornis, 641. INDEX 1075 Uterus, pregnant, weight of, 183. Uterus, puerperal, anteflexion of, 1029. atony of, 939. atrophy of, 372. endarteritis of, 375. gangrene of, 988. hour-glass contraction of, 763. inversion of, 944. involution of, 372. lactation atrophy of, 1029. paralysis of, 1030. prolapse of, 1030. regeneration of, 374. removal of, after cesarean section, 494, 504. after'rupture, 962. for infection, 1013. retroflexion of, 1029. subinvolution of, 540, 1028. superinvolution of, 1029. weight of, 373. Vaccinia, 546. Vagina, 35. atresia of, 766. changes of, in labor, 278. in pregnancy, 189. in puerperium, 375. closer of, 37, 278. color of, in pregnancy, 216. development of, 37. diphtheria of, 984. double, 642, 768. fornix of, 35. functions of, 35. glands of, 36. hematoma of, 768, 1026. injuries of, during labor, 950. laceration of, during labor, 950. lymphatics of, 36. mucosa of, 36. neoplasms of, 767. prolapse of, in pregnancy, 637. relations of, 35. rugae of, 36. secretion of, 37, 189. septa in, 768. sphincter of, 37. stenosis of, 768. thrombus of, 1026. tumors of, 767. ulcer of, 984. vascular supply of, 37. Vaginal cesarean section, 434. douche, 536, 1009. enterocele, 648, 777. examination, during pregnancy, 233, 243. portion of cervix, 40. opening, 31. outlet, relaxation of, during pregnancy, 637, 950. secretion, 37, 189. in pregnancy, 189, 995. in puerperium, 995. tampon, 541. touch during labor, 350. in pregnancy, 243. Vaginismus, 768. Vaginitis, 548, 637. puerperal, 984. Vaginofixation, cause of dystocia, 771. Vagitus uterinus, 969. Varicose veins in pregnancy, 557, 637. Variety of presentation, 236. Vasa previa, 684. Veins. (See Blood Vessels.) Veit’s main plane, 8. Velamentous insertion of cord, 683. Venesection in eclampsia, 623. in heart disease, 555. Ventrofixation, cause of dystocia, 769. Veratrum viride in eclampsia, 627. Vernix caseosa, 161. Version, 483. bipolar. (See Bipolar Version.) cephalic. (See Cephalic Version.) combined, 485, 491. external. (See External Version.) in contracted pelves, 868. in transverse presentations, 916. podalic. (See Podalic Version.) prophylactic, 868. spontaneous, 912. Vertebrae, primitive, 110. Vertex presentations, 236. causation of, 238. diagnosis of, 286. frequency of, 285. mechanism of, 285, 300. occiput posterior, 302. t Vesical calculus complicating labor, 777. Vesicle, blastodermic, 107. umbilical, 151. Vesicocervical fistula, 963. Vesicovaginal fistula, 854, 963. septum, 35. Vesicular mole, 656. Vestibular bulbs, 30. Vestibule, 29. glandulae vestibulares majores, 30. minores, 30. Vibrion septique, 980. Villi, chorionic, 131. hyperplasia of, 681. metastases from, 661. syphilitic changes in, 692. transportation of, 143, 608, 661. Visceral arches, 158. clefts, 158. Vision, disturbances of, during pregnancy, 569. in eclampsia, 602. Vitelline membrane, 75. Volvulus, 572. Vomiting of pregnancy, 420, 578. Vulva, 26. atresia of, 766. clitoris, 29. commissure of, 27. diphtheria of, 984. edema of, 557. fourchette of, 28. frenulum of, 28. hematoma of, 766, 1026. hymen, 31. injuries of, during labor, 950. 1076 INDEX Vulva, labia majora, 27. minora, 28. pruritus of, 569. toilet of, during puerperium, 381. urethral opening, 30. vaginal opening, 31. varices of, 557, 639. vestibular bulbs, 30. vestibular glands, 30. vestibule, 29. Walcher’s posture, 11. in contracted pelves, 865. Wassermann reaction, 551, 691. Watson’s method of inducing premature labor, 428. Wegner’s bone disease, 689. Weight, changes in, during pregnancy, 198. loss of, during the puerperium, 380. of foetus at various months, 160. of newly born child, 162, 900. Wharton’s jelly, 149. White infarcts of placenta, 677. line, 278. Williams’s outlet pelvimeter, 794. Wolffian body, 63, 66. ducts, 30, 48, 63, 66, 69. X-ray in determining age of foetus, 161 in determining size of pelvis, 797. in diagnosis of pregnancy, 209, 219. in diagnosis of presentation, 241. in diagnosis of syphilis, 689. in diagnosis of twins, 411. Yolk, 75. Yolk-sac, 151. Young primiparae, labor in, 262. Zangemeister’s pelvimeter, 791. Zellschicht of chorion, 132. Zweifel’s trachelorhekter, 535. Zona pellucida, 74. APPLETON’S MEDICAL BOOKS A REVISION OF THE STANDARD Kelly and Burnam’s Diseases of the Kidneys, Ureters and Bladder The Only Urology of the Female Sex in English AS the author says in his preface, “All other works squint at urology from the standpoint of the female sex. We have frankly taken this aspect of the subject as our fundamental position and have done our squinting in the direction of the urological prob- lems of the male.” This most important work discusses the diseases of the kidneys, ureters and bladder from the urological standpoint, with the views of the Gynecologist super- imposed upon those of the Urologist. The ideas, the practical diagnostic methods and the description of non-operative and operative measures, make this work one of great value to both the urologist and the gynecologist. The new edition shows changes in the discussions of blood chemistry, cystos- copy, methods of functional diagnosis and in other fields and the large sale of the first edition presages an equal or even exceeding sale for the revised edition. 554 of the illustrations are by Max Broedel, which guarantees their value and relativity to the text. 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Holt, more than all other authors, has molded pro- fessional opinion as to methods of feeding and his views have been the accepted ones on the subject by the profession throughout the world. Though the general practitioner or the pediatrician may have all other books on pediatrics in his library, he can no more class that library as complete without Holt than can a library of English literature be complete without the Bible. In very truth, Holt’s book has been the "Bible” of the American medical profession in the field of pediatrics for many years. Dr. John Howland, Professor of Pediatrics at the Johns Hopkins University, appears as the co-author in this new edition with Dr. Holt. Dr. Howland was trained under Dr. Holt, and in the main, the revision of the present edition was in his hands, though all of the revised and new material was submitted to and accepted by Dr. Holt before printing. There is scarcely a page in the book that with the present edition has not been subjected to revision. Many new articles have been written. Many old illustrations have been omitted and many new ones added. Especial attention has been devoted by the authors to the newer methods of diagnosis and treatment. A NEW PORTRAIT OF DR. HOLT An Elaborate Revision, Containing Much Important New Material From the appearance of the first edition. Dr. Holt’s book has been notable as being highly scientific, but at the same time eminently practical—a combination of qualities too often lacking in medical literature. It is preeminently a book for the general practitioner. The author is firm in his belief but is not a hobby rider; authoritative, but not arrogant or dogmatic. Comparisons are said to be odious, but it is impossible to refrain from expressing the opinion that for the practising physician it is the most satisfactory work on pediatrics in the English language.—The New York Medical Journal. DISEASES OF INFANCY AND CHILDHOOD. By L. Emmett Holt, m.d., sc.d., ll.d., Professor of Diseases of Children in the College of Physicians and Surgeons, Columbia University; Attending Physician to the Babies' and Foundling Hospitals, New York, etc.; co-author with John Howland, a.m., m.d., Professor of Pediatrics in Johns Hopkins Medi- cal School, and in the Johns Hopkins University, Baltimore; Eighth Edition, completely Revised and Enlarged. Printed from New Plates. 1147 pages. With 7 full page plates, some in colors, and 172 text illustrations. Cloth. $7.50